Headings
Tooth · Indication · Consent · Anesthetic · Procedure · Hemostasis · Post-operative instructions · Medications · Follow-up
When to use it
Use this for a simple or surgical tooth removal in the office. It puts the reason for extraction and the signed consent next to the procedure details, which matters if a complication comes up later. It also keeps post-operative medications and follow-up in view for the front desk.
Example
Fictional example
Tooth
#30.
Indication
Nonrestorable. Vertical root fracture with 9 mm isolated pocket on the distal.
Consent
Pain, swelling, dry socket and nerve numbness explained. Implant option discussed. Consent signed.
Anesthetic
Inferior alveolar and long buccal blocks, 2 carpules 2% lidocaine with 1:100,000 epinephrine, 72 mg.
Procedure
Sectioned between roots. Each root elevated and delivered. Socket curetted and irrigated with saline.
Hemostasis
Gauze pressure and one resorbable suture. Hemostasis achieved before dismissal.
Post-operative instructions
Bite on gauze 30 minutes. No straws, spitting or smoking for 72 hours.
Medications
Ibuprofen 600 mg every 6 hours, with acetaminophen 500 mg if needed.
Follow-up
Check in 1 week. Implant consult in 3 months.