Indications for extractions (2)

• Gross caries– Not all teeth can be saved, e.g insufficient ferrule
• Advanced periodontal disease. 
• Peri-apical infections
• Cysts and Tumours – they can expand causing pathological fractures and/or become infected.
• Vertical root fractures
• Terminal prognosis teeth in cancer patients, this will be discussed in future lessons
• Orthodontic spacing
• Prophylactic removal (historically this was more commonly carried out on sound wisdom teeth). 
• Patient preference, some patients are unwilling to have endodontic treatment
• Supplementary and malformed teeth
• Supernumerary teeth,
• Teeth in fracture line of jaws.

Consent

Consent is a requirement by law and is the 3^rd GDC principle [1]. Consent is the permission of the patient to be examined or treated by the clinician. It can be verbal or written. Informed consent is more involved, especially since the Montgomery case (2015). This means patients must be aware of the ‘material risk’ which they may attach significance to. The process of gaining consent should provide all the necessary information about the procedure involved, and invite the patient to ask any questions as well as being free of dental jargon so the patient can understand. 

In line with the mental capacity act (2005), for patients to have the necessary capacity to give valid consent they must be able to [3]:

• Understand information relevant to the decision
• Retain that information
• Use and weigh up the information, as part of a decision, AND
• Communicate their decision effectively, by any means.

What should be explained and discussed?

• Diagnosis and Prognosis 
• Potential complications of not having an extraction (e.g. infection)
• The treatment options XLA and Gap replacement
• What the procedure entails:
• Benefits of treatment
• Risks, especially those specific to the patient
• Complications of treatment
• Cost and timeframes
• Post-operative instructions

Alternative treatment options

1. Do nothing
2. Coronectomy (removal of the crown, leaving the root in situ)
3. Root canal treatment (This is when a tooth is restorable - see lesson: tooth by tooth prognosis for more)

Discussing what the procedure will entail

Extraction is the permanent removal of a tooth. This is usually done under local anaesthetic, but other options are available, such as sedation and general anaesthetics (case-by-case selection). It is important to communicate and reassure the patient as well as determining, how much of the specific details of the procedure they wish to know. Some common examples are mentioned below:

The patient will experience some pressure in both a downward direction and some pulling/ stretching of the cheek and soft tissues will occur. During the procedure they may hear some noises, making patient reassurance a key aspect throughout the extraction procedure.

The patient's bite may alter after the extraction, especially if the space is not filled with a replacement option.

If the tooth were to break, surgical options should be discussed and pre-warned; that a small incision (cut) of the gum may be needed alongside some bone removal to gain accessed to any fragments. The patient may need sutures (stitches), and if not resorbable, booked in appropriately for removal.

Numbness of the local anaesthetic will be experienced for round 2-3 hours; therefore, it is important to include in the post-op instructions (see record keeping lesson), the avoidance of cheek/lip biting, and hot foods and drinks, to prevent trauma and burns. 

Bleeding is to be expected and the area might be painful after the anaesthetic wears off; management of this is again included in the post-op instructions and care.

Gap replacement options

The patient may ask what the options for gap replacement are, following an extraction. All of this should be discussed as part of the consent process as some of the treatment may require multidisciplinary intervention by an implantologists, prosthodontists and/or oral surgeon. This is because after the extraction the socket undergoes internal and external changes leading to alveolar ridge resorption [4] and this may result in inadequate bone volume and ridge architecture for implant placement [4]. Therefore, a referral may be the most appropriate option for the patient, to see an implantologist for a pre-operative assessment of the site, to plan for any future implant placement if deemed appropriate.

A useful acronym to remember the options for gap replacement is NDBI, the treatment options are also arranged from least to most invasive options:

1. Nothing: replacing the gap may not be of great benefit. 
2. Denture: patients may not know what this is and it is important that patients understand this isn’t like having their own tooth.
3. Bridge: there are various prosthodontic designs; the most appropriate bridge should be discussed.
4. Implants: even if not in our scope, it should still be offered as a treatment option to refer. 

(See prosthodontic topic area for space replacement)

Benefits of treatment (5)

• Alleviate or reduce pain from the offending tooth.
• To alleviate or prevent the spread of infection. 
• Restore function and improve oral health as the source of infected tissue is removed. 
• This may also preserve bone levels of adjacent teeth, if the tooth in question has existing advanced periodontal disease
• Create space - orthodontic extractions

Patient specific risks

• Smoker: increased post-operative risk of alveolar osteitis (dry socket) [6].
• Anticoagulants/antiplatelet medications: Increased bleeding risk
• Midline shift and occlusal changes if space not replaced. [7]
• Loss of anterior tooth e.g. could be significant for musicians that play wind instruments. 
• Permanent paraesthesia of lower lip e.g. could be significant for musicians who play wind instruments.
• MRONJ/Osteonecrosis of jaw e.g. patients taking particular bisphosphonates.
• Infection in immunosuppressed patients. 

Peri-operative complications and risks

Some risks occur more commonly and are shared by all oral surgical procedures post operatively, for example:

• Pain
• Swelling
• Bleeding
• Bruising
• Infection

Specific to extractions:

• Developing a dry socket is a painful condition in the socket where the blood clot fails to develop, which is more likely to occur if the patient smokes and/ or a disturbance of the extraction site occurs. Dry socket is the most common complication post-extraction [5]. It has an incidence in the range of 0.5-5% in routine dental extractions [6] and as high as 1%-37.5% in third molar extractions [6]. The risk of alveolar osteitis is documented to be tenfold higher in surgical extractions [6]
• Fracture of the tooth during extraction, this could turn a simple extraction into a minor oral surgical procedure, requiring an incision and possible removal of bone to remove the tooth fragment.
• Loss of tooth, this will create a gap where the tooth was.

Specific to site: Mandibular extractions:

• Trismus – this means limited mouth opening and can occur as a result of inflammation around the muscles of mastication or the development of a haematoma in the medial pterygoid muscle when administering an inferior dental block (IDB) [5].
• An awareness of the mental nerve anatomy is needed when making a surgical incision (see rare risks).

Specific to site: Maxillary extractions:

• Fracture of maxillary tuberosity, this is risk is higher with a lone standing maxillary tooth and/or older patients [5].
• Oro-antral communication (OAC) the risk of causing an OAC is higher if the radiographic appearance of the teeth appear to be in close proximity of the maxillary sinus, and/or a difficult extraction [5]. Signs of an OAC include, bone attached to the root of extracted teeth and bubbling in the socket.

Complications if the space is not replaced:

• Over eruption of opposing teeth.
• Localised bone resorption and remodelling, this is important and must be discussed as it could affect future implant potential/ procedures.
• Tilting and rotating of neighbouring teeth; as a consequence this may cause change in occlusion.

Rare risks

• Risk of permanent/ temporary damage to Inferior dental nerve. This has been reported to occur around 3.47% [5] and is one of the rare risks worth discussing, for example it may lead to permanent paraesthesia (feeling of burning or numbness) in the lips affecting patient quality of life. 
• Damage to the lingual, mental and buccal nerves is rare and is more a risk during surgical extractions.
• Bone fracture
• Osteonecrosis of the jaw can occur, if the site of surgery has been irradiated or if the patient is/ has taken medications implicated in medication related osteonecrosis of the jaw (MRONJ).

Cost of treatment

All appropriate alternative treatments costs should be discussed with the patient prior to commencing treatment, as this may influence the patient’s preferences of choice. At the time this lesson was created, under the NHS band 2 treatment is £62.10 (subject to change). In addition any further treatment that would incur extra cost e.g. replacing the space, also needs discussed.

World Health Organisation (WHO) Form

The WHO surgical checklist initially developed in 2009, aims to reduce errors and adverse events; optimising patient safety [8]. It helps to mitigate complications of extraction by considering the relevant aspects of the medical history. It also helps prevent wrong site extraction (WSE) by reconfirming which tooth is to be extracted. WSE is classed as a never event by the NHS. The WHO form will be discussed in more detail in the following lesson.