Facebook tracking pixelNotes on Tooth Extraction with Aftercare Guidelines
Back to Templates
Dental Practitioner
15-20 minutes

Notes on Tooth Extraction with Aftercare Guidelines

The s10.ai Dental Extraction Notes template with Post-Extraction Care Instructions is expertly crafted for dental professionals to meticulously document every aspect of the extraction process. This comprehensive template features sections for pre-operative evaluation, anesthesia specifics, detailed extraction procedure, and post-extraction management. Dentists can efficiently record patient medical and dental history, tooth assessments, anesthesia administered, and any encountered complications. Additionally, it offers dedicated space for post-operative care instructions and follow-up strategies. Perfect for enhancing patient care and communication, this template ensures thorough documentation and improved treatment outcomes. Implement this template in your practice to optimize dental extraction documentation and elevate patient care.

2,482 uses
4.4/5.0
D
Dr. Jonathan Harris
Template Structure

Organized sections for comprehensive clinical documentation

Pre-Surgical Evaluation:
Health and Dental Background: [insert relevant health and dental history including bleeding disorders, anticoagulant use, history of infection, dental anxiety, or prior extractions] (only include relevant history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Write as a full paragraph in complete sentences.)
Tooth Evaluation and Diagnosis: [insert findings from examination and any radiographs including tooth number, condition of the tooth, presence of infection, mobility, root anatomy, or bone involvement] (only include findings if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Write as a full paragraph.)
Consent Documentation: "Verbal and/or written consent was obtained from the patient and/or guardian prior to extraction. The procedure, risks, benefits and alternatives were discussed."
Anesthesia:
Type of Anesthetic Used: [insert type of anesthetic agent, dosage, concentration, and method of delivery] (only include anesthetic details if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Write in a sentence.)
Onset and Effectiveness: [insert observations on how quickly anesthesia took effect and the adequacy of numbness achieved before extraction] (only include onset and effectiveness if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Write as a short paragraph.)
Extraction Process:
Tooth/Teeth Removed: [insert the tooth number(s) extracted using FDI, Palmer, or Universal system as applicable] (only include tooth numbers if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Technique Employed: [insert whether extraction was simple, surgical, or required sectioning or flap elevation] (only include extraction technique if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Write as a sentence.)
Instruments and Materials Utilized: [insert list of dental instruments used during the extraction such as forceps, elevators, scalpel, sutures, or curettes] (only include instruments or materials used if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. List in a sentence.)
Intraoperative Observations: [insert any findings such as granulation tissue, cystic changes, ankylosis, or root fracture observed during the extraction] (only include intraoperative findings if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Write as full sentences.)
Complications (if any): [insert any complications such as root fracture, excessive bleeding, sinus perforation, or difficulty in extraction] (only include complications if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Write as a paragraph.)
Post-Extraction Care:
Haemostasis Achieved: [insert method used to achieve haemostasis, including gauze pressure, sutures, or haemostatic agents] (only include haemostasis method if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Write in sentence format.)
Post-Operative Instructions Provided: [insert instructions provided regarding bleeding control, pain management, oral hygiene, activity restrictions, diet, and what to do if complications arise] (only include post-operative instructions if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Write as a full paragraph.)
Medications Prescribed (if any): [insert medications prescribed such as analgesics, antibiotics, or antiseptic rinses] (only include medications if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. List in a sentence.)
Follow-Up Plan: [insert any advice regarding review appointments, suture removal, or further treatment required] (only include follow-up plan if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Write as a sentence.)
Provider Information:
Dentist Name and Credentials: [insert full name and professional designation of the clinician performing the extraction] (only include clinician information if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Dental Assistant (if applicable): [insert name and role of dental assistant present during the procedure] (only include assistant information if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Sample Clinical Note

Example of completed documentation using this template

Pre-Operative Assessment:  
Medical and Dental History: The patient has a history of mild dental anxiety and has previously undergone extractions without any complications. No bleeding disorders or use of anticoagulants were reported.  
Tooth Assessment and Diagnosis: Examination and radiographs indicated that tooth number 36 was severely decayed, showing signs of infection and moderate mobility. The root anatomy appeared normal with no significant bone involvement.  
Consent Documentation: "Verbal and/or written consent was obtained from the patient and/or guardian prior to extraction. The procedure, risks, benefits, and alternatives were discussed."
Anaesthesia:  
Type of Anaesthetic Used: Lidocaine 2% with epinephrine 1:100,000 was administered via local infiltration.  
Onset and Effectiveness: Anaesthesia took effect within 5 minutes, providing adequate numbness for the extraction procedure.
Extraction Procedure:  
Tooth/Teeth Extracted: Tooth number 36 was extracted using the Universal system.  
Technique Used: A simple extraction technique was employed.  
Instruments and Materials Used: Forceps and elevators were used during the extraction.  
Intraoperative Observations: No granulation tissue or cystic changes were observed. The extraction was uncomplicated.  
Complications (if any): No complications were noted during the procedure.
Post-Extraction Management:  
Haemostasis Achieved: Haemostasis was achieved using gauze pressure.  
Post-Operative Instructions Given: The patient was advised to apply pressure with gauze for 30 minutes to control bleeding, avoid rinsing or spitting for 24 hours, and maintain a soft diet. Pain management with over-the-counter analgesics was recommended, and the patient was instructed to contact the clinic if excessive bleeding or pain occurred.  
Medications Prescribed (if any): Ibuprofen 400 mg was prescribed for pain management.  
Follow-Up Plan: The patient was advised to return for a follow-up appointment in one week to assess healing.
Provider Details:  
Dentist Name and Credentials: Dr. Emily Carter, DDS  
Dental Assistant (if applicable): Sarah Johnson, Dental Assistant
Clinical Benefits

Key advantages of using this template in clinical practice

  • The Pre-Operative Assessment template is an essential tool for clinicians aiming to streamline and enhance the efficiency of pre-surgical evaluations. This comprehensive template covers critical areas such as medical and dental history, tooth assessment, and consent documentation, ensuring thorough preparation before any dental extraction procedure. By incorporating detailed sections on anaesthesia, extraction techniques, and post-extraction management, this template aids in minimizing complications and optimizing patient outcomes. Clinicians can benefit from its structured format, which facilitates accurate documentation and adherence to best practices, ultimately improving patient care and satisfaction. Explore and implement this template to elevate your clinical workflow and ensure meticulous pre-operative planning.
Frequently Asked Questions

Common questions about this template and its usage

Ready to transform your practice?

Join thousands of clinicians already using S10.AI to reduce administrative burden and improve patient care.

Cookie Preferences

We use cookies to enhance your browsing experience, analyze site traffic and personalize content.