Preoperative Examination for Teeth Extraction
For routine tooth extractions, perform a focused clinical examination including medical history, oral/dental assessment with documentation of existing dental damage, and obtain appropriate radiographic imaging based on the clinical scenario—panoramic radiography for impacted teeth or intraoral periapical films for routine extractions.
Essential Components of Preoperative Assessment
Medical History and Risk Stratification
Complete a thorough medical history focusing on conditions that increase surgical risk: bleeding disorders, anticoagulation therapy, immunosuppression, diabetes, history of radiation therapy to head/neck, liver disease, and congenital heart disease 1, 2.
Document all current medications, particularly anticoagulants like warfarin, as PT/INR determination is recommended just prior to any dental procedure 3. For patients on warfarin with INR <2.50, the bleeding risk after tooth extraction is low 2.
Identify patients requiring specialized management at tertiary centers: those with prior Fontan procedure, severe pulmonary arterial hypertension, cyanotic congenital heart disease, complex heart disease with residua, or malignant arrhythmias 1.
Clinical Oral Examination
Perform a focused dental examination documenting any pre-existing loose teeth, crowns, dentures, or damaged dentition 4, 5. This documentation is critical as dental damage represents the most common anesthesia-related complication and the largest source of malpractice claims 4, 5.
Assess the upper incisors specifically, as these are the teeth most likely to be injured during the perioperative period if general anesthesia is required 5.
Evaluate the span of edentulous regions and lateral wall thickness, as short-span edentulism (e.g., missing bicuspids) is more difficult to treat than long-span edentulous areas 1.
Examine the patient's facial profile: patients with short faces tend to have thicker sinus walls and more coronally-canted zygomatic processes, making treatment more challenging 1.
Radiographic Evaluation
For impacted teeth:
Obtain orthopantomography (panoramic radiograph) as the first-line diagnostic examination for suspected dental impaction 1.
Order CBCT imaging when panoramic films suggest contact between third lower molars and the mandibular canal, or between third upper molars and the maxillary sinus floor, to assess risk of nerve injury or sinus perforation 1.
Use periapical intraoral imaging for dental impaction in the upper incisor-canine region 1.
For routine extractions:
Obtain intraoral periapical radiographs using dedicated film holders and beam aiming devices for assessment of root morphology and periapical pathology 1.
Avoid CBCT as an initial diagnostic examination unless level I radiographic investigations (panoramic or periapical films) cannot provide adequate information 1.
Special Population Considerations
Patients with head and neck cancer history:
Identify if the extraction site received ≥50 Gy radiation, as dental extractions in these areas should be avoided when possible to reduce osteoradionecrosis risk 2.
Consider root canal, crown placement, or dental filling as noninvasive alternatives to extraction for problematic teeth in high-risk irradiated areas 2.
Patients with liver disease/cirrhosis:
Verify INR values and platelet counts: for INR <2.50 and platelets >30 × 10^9/L, bleeding risk after tooth extraction is low 2.
Do not routinely administer blood products or factor concentrates before procedures in stable cirrhosis patients 2.
Patients with congenital heart disease:
Obtain basic preoperative assessment including systemic arterial oximetry, ECG, chest x-ray, transthoracic echocardiography, full blood count, and coagulation screen 1.
Ensure patients understand their specific endocarditis prophylaxis regimen and verify this knowledge at every visit, as fewer than 50% of families have adequate knowledge about endocarditis prevention 1.
Common Pitfalls to Avoid
Do not order routine preoperative laboratory tests without specific clinical indications, as "preop status" or "surgical screening" are not considered specific clinical purposes 1.
Do not assume all patients require formal dental clearance before procedures; recent evidence suggests routine formal dental clearance for all surgical patients may not be necessary, and preoperative tooth extraction may represent an unnecessary step in some cases 6.
Do not perform level I radiological examination before age 6 for suspected dental impaction 1.
Do not use CBCT as initial imaging for routine extractions or tooth transposition, as this violates the ALARA principle and exposes patients to unnecessary radiation 1.
Do not overlook documentation of pre-existing dental damage, as this is essential for medicolegal protection given the high frequency of dental injury claims 4, 5.