Preoperative Testing for Tooth Extraction
For routine tooth extractions in healthy patients, obtain a focused medical history and periapical or panoramic radiograph—routine laboratory tests are not indicated without specific clinical risk factors. 1
Medical History Assessment
Complete a thorough medical history focusing on conditions that increase surgical risk: 1
- Bleeding disorders and anticoagulation therapy (verify INR <2.50 and platelets >30 × 10^9/L for low bleeding risk) 1
- Immunosuppression status 1
- Diabetes mellitus 1
- History of head/neck radiation therapy (particularly if extraction site received ≥50 Gy, as this dramatically increases osteoradionecrosis risk) 2, 1
- Liver disease (affects coagulation) 1
- Congenital heart disease (patients with prior Fontan procedure, severe pulmonary arterial hypertension, cyanotic disease, or malignant arrhythmias require tertiary center management) 1
Clinical Oral Examination
Perform intraoral assessment evaluating: 1
- Periapical tissue swelling (justifies intraoral radiograph with dedicated film holder) 2
- Signs of infection (fistula, marginal gingival inflammation, periodontal disease) 2
- Tooth mobility and periodontal status 2
- Adjacent tooth integrity 2
Radiographic Evaluation
Standard Imaging Protocol
Obtain orthopantomography (panoramic radiograph) as the first-line diagnostic examination for tooth extraction planning. 2, 1 This provides sufficient information for treatment planning in the majority of cases. 2
For impacted third molars, panoramic imaging efficiently defines the risk of injuring the alveolar nerve and may be considered sufficient for treatment planning in non-critical cases. 2
Advanced Imaging Indications
Order CBCT imaging only when: 2, 1
- Panoramic films suggest contact between third lower molars and the mandibular canal (to assess relationship with mandibular canal and surrounding anatomical structures, preventing nerve injury) 2, 1
- Third upper molars appear to contact the maxillary sinus floor (to assess sinus perforation risk) 2, 1
- Complex impactions require detailed anatomical assessment 2, 1
CBCT is essential for assessing the relationship between third molars and critical anatomical structures, but should not be used routinely as this violates the ALARA principle. 2, 1
Laboratory Testing
Do not order routine preoperative laboratory tests without specific clinical indications. 1 Laboratory work is only warranted when the medical history reveals:
- Active anticoagulation (obtain INR and platelet count) 1
- Known or suspected bleeding disorder 1
- Liver disease (obtain coagulation studies) 1
- Congenital heart disease (obtain full blood count, coagulation screen, ECG, chest x-ray, transthoracic echocardiography, and systemic arterial oximetry) 1
Special Population Considerations
Radiation Therapy History
If the extraction site received ≥50 Gy radiation, dental extractions should be avoided when possible. 2, 1 When extraction is unavoidable:
- Review the radiation therapy plan with particular attention to dose delivered to mandible and maxilla 2
- Consider alternatives to extraction (root canal, crown, filling) unless the patient has recurrent infections or intractable pain 2
- Prescribe oral antibiotics before and after the procedure 2
Pediatric Patients
Do not perform level I radiological examination before age 6 for suspected dental impaction. 2, 1
Common Pitfalls to Avoid
- Ordering CBCT as initial imaging for routine extractions exposes patients to unnecessary radiation 1
- Ordering routine laboratory tests in healthy patients without clinical indication is not cost-effective and does not improve outcomes 1
- Failing to identify prior radiation therapy can lead to catastrophic osteoradionecrosis 2, 1
- Delaying necessary extractions in cancer patients to perform dental work—if rapidly progressing tumor is present, extractions should be deferred and not delay radiation therapy initiation 2