The document discusses patient assessment for exodontia procedures according to the American Society of Anesthesiologists (ASA) physical status classification system. It also covers techniques for closed and open extractions, indications and contraindications for tooth removal, preoperative assessment using x-rays, and post-extraction instructions and notes. A variety of hemostatic agents and systemic treatments that can be used to manage post-extraction bleeding are also outlined.

1. EXODONTIA
Htay Htay Yi ( Mandalay )

2. Patient assessment

3. ASA – American Society of Anesthesiologists
established in 1940 , modified in 1961
 System of classifying patients according to their physical status and guiding
judgement decisions
 ASA I – Normal healthy patient
 ASA II – A patient with mild systemic disease that does not interfere with day to
day activity or that has a significant health risk factor
 ASA III- A patient with moderate to severe systemic disease that is not
incapacitating but that may alter day-to-day activity; may have significant drug
concerns; may require special patient care; would generally require dental
management alterations
 ASA IV- A patient with severe systemic disease that is a constant threat to life;
definitely requires dental management alterations; best treated in special
facility
 ASA V – Moribund , not expected to live 24hrs regardless of operation
 e – emergency operation

4.  ASA II , III , IV – consultation , specialist
opinion
 Fit to do extraction /surgery - justification

5. PMH – Past Medical history
any hospitalization
 Where? , When? , Why?
 How ? medical/surgery , GA , LA
 What ? procedure , complications
any medication
any illness
 health status
any complication with the previous dental treatment –

6. Check vital sign
 BP
 PR
 RR
 Temperature

7. Extraction techniques ;
 Closed
 Open

8. Crowding
Difficult extraction

9. Periodontal disease

10. Impacted toth

11. Malposed tooth

12. Techniques
 Closedtypeof exodontia; Simple or forceps
technique
 Open typeof exodontia; Surgical or flap
technique , Complicated exodontia

13. Clo se d type o f e xo do ntia ;
 Simple or forceps technique
 Primary consideration for almost every
extraction. Intra- alveolar extraction which
require either forceps or elevator without
surgical flap

14. Procedure of closed extraction ;
 loosening of soft tissue attachment from the tooth
 gently first ,increasing force
 check for profound anaesthesia
 luxation of the tooth with elevator
 adaption of the forceps
 beaks of the forceps must be held parallel to the long axis of
the tooth
 forceps must be seated apically as far as possible , below CEJ

15. O pe n type o f e xo do ntia ; Surgical or
flap technique , Complicated exodontia
 Transalveolar extraction is commonly known
as surgical extraction or open extraction of
tooth
 The method is employed when forceps
extraction is not possible due to various
difficulties

16.  Generally if a tooth fracture during a regular
extraction, surgical approach is necessary to
remove the root fragment
 The reflection of an adequate muco-periosteal
flap for adequate access and visualization of
the field of surgery
 The Ostectomy ( removal of bone) or/and
Odontectomy ( coronal and root section) is for
an unimpeded pathway for removal of the
tooth

17.  Alveolar purchase is when the crest of the
alveolar bone is purchased by the forceps
along with the coronal portion of the root and
removal in totoo .


18.  luxation of the tooth with forceps
 expansion of the alveolar bone and tearing of the periodontal
ligament
 bone direction towards the thinnest and therefore the
weakest bone
 bucco-lingually not jerky wiggles , bone time to expand
 removal of tooth from the socket – slight traction force
usually directed buccally


19. Indications for surgical extraction;
 Open extraction may be less morbid than closed extraction
 When they perceive a possible need for excessive force to
extract the tooth – the force will probably result in fracture
of the bone , tooth , root
 After initial attempt at forceps extraction have failed , divide
and conquer

20.  Short clinical crown with severe attrition , bruxism ( a
grinding habit )
 excessive caries , especially root caries , large amalgam
restorations
 nonvital tooth , RCT treated tooth
 Heavy or dense bone especially on buccocortical plate
 Older patient has denser and more calcified bone that is less
likely elastic

21. Preoperative Xray assessment
 ankylosis
 noperiodontal space , absent of laminadura
 widely divergent root
 accessory root

22. Hypercementosis
hypercementosis - large
bulbous root

23. Concrescence

24. Dilacerated tooth

25. Accessory root

26. Contraindications for the removal of teeth ;
 some situations that the tooth should not be
removed
 relative and can be modified by the additional care
and treatment
 so significant and should not be removed until the
severity of the problem has been resolved

27. Systemic ;
 severe , uncontrolled
 pregnancy – all female of reproductive age
( relative contraindication )

28. Known case of ITP – PC – 16,000

29. Local;
 teeth of the irradiated jaws
 tooth in the line of fracture
 teeth that are located within an area of tumour ,
unknown lesion
 teeth at the vascular lesion , AV aneurysm
 Severe infections ; Ac. pericoronitis , cellulitis ,
ANUG



30. Teeth of the irradiated jaws – to prevent ORN
- high radiation dosage ( >60 Gy ),radiation technique
(interstitial ) , fraction size and number , bone involved
in the field of radiation
- anatomic site of the primary tumour ( H&N )
- higher risk – mandibular bone is denser and blood
supply poorer than maxilla
- dentulous - dental status - caries , periodontal ,
impaction
ORN

31. Tooth in the line of fracture

32. Teeth that are located within an area of tumour
, unknown lesion
 Locally – spread
 Regionally spread to
lymph node
 Distant – metastasis
 R/T - exo at the
time of biopsy ,
before R/T
 S/T – exo at the
time of surgery

33. Teeth at the vascular lesion , AV aneurysm

34. Severe infections ; Ac. pericoronitis , cellulitis ,
ANUG

35. Consent
 Procedures under LA is commonly obtained verbally
 Consent to the procedure and full explaination of the
options and consequences
 Recognises a patient's right of autonomy

36. Post extraction instructions
 The swab over the socket must be bit firmly for one hour
 Avoid rinsing and spitting for 24hs after extraction
 Avoid taking hot food and drink for 24 hrs
 Do not explore the wound with tongue ,fingers , lips and cheeks
 Avoid smoking , alcohol drinking and also excessive physical exercise for
24 hrs
 If bleeding occur , place sterile swab over the socket and bite firmly without
releasing the pressure for another one hour
 If the problem persists , come back or contact to the Dental surgeon
 Prescribed medicine should be taken as directed
 Brush other teeth , but avoid the wound or socket
 TCA according to the instruction

37. Post extraction note;
 Dx - Tooth , Dx - Indicated for extraction
 Tx - ELA ( what LA ? How many cartridge is used ? )
 Rx - medicine ,types , ? mgm ,frequency , route ,
duration
 eg. Paracetamol tab 500mgm 1qid po x 2days
 Further Tx - TCA , Refer etc.

38. Post exo bleeding
 Suture

39. Haemostatic agent
 Mechanical measures
 pressure - pack , suture , splint ,
plug( Whitehead varnish , BIPP on ribbon gauze )
 bone wax

40. Topical agents
 adrenaline ( 1:1000)
 Monsel's sol ( Ferric sulphate)
 Thrombin
 Russel viper venom (stypven)
 Tannic acid

41.  Gelatin sponge ( Gel foam)
 Oxidised cellulose ( Oxycel )
 Oxidised regeneraqted cellulose ( Surgicel )
 Topical thrombin
 Collagen

42. Systemic agent
 Vit K – 10 mgm cap/ IM
 Vit C - 500 - 1000mgm
 Carbazochrome (Adona) - 30mgm t.d.s / 25-100mgm IV
 Naftazone
 Etamstylate
 Aminocaproic acid (EACA )
 Reptilase
 Aprotinin
 Desmopressin acetate ( DDAVP)
 Tranexamic acid (azeptil) – 500-1000mh 8hrly,slowIV
1ml/min
