Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2018; 63:(1 Suppl): S11–S18

doi: 10.1111/adj.12586

Contemporary exodontia
PJ Sambrook, AN Goss
Oral & Maxillofacial Surgery Unit, Faculty of Health Sciences, The University of Adelaide, Adelaide, South Australia, Australia.

ABSTRACT
Exodontia is a cardinal skill of all dentists. Patients expect extractions to be skillfully and painlessly accomplished every
time. It’s not necessarily so simple and can be challenging. In this paper we explore contemporary issues of the full pro-
cess of exodontia including diagnosis, technique, complication minimization as well as management of medically com-
promised patients with appropriate post-operative care, including pharmacotherapy.
Keywords: Complications, dentoalveolar surgery, exodontia, medically compromised, pharmacology, ridge preservation.
Abbreviations and acronyms: AF = Atrial fibrilation; GA = General anaesthetic; INR = International normalising ratio; IV = Intra-
venous; LA = Local anaesthesia; MRONJ = Medication related osteonecrosis of the jaws; NICE = National Institute for Health and
Care Excellence; Nm = Newton meters; NOAC = Novel oral anticoagulant agent; NSAIDS = Non steroidal anti inflammatory drugs;
OMS = Oral & Maxillofacial Surgery; ORN = Osteoradionecrosis.
Accepted for publication October 2017.
[Correction added on 18 May 2018 after first online publication: Table 2 has been added.]

advanced periodontal disease or fracture. It is more

INTRODUCTION
Exodontia is a cardinal skill of all dentists
In this paper, we present contemporary issues related
to exodontia. Patients expect extractions to be skill-
fully and painlessly accomplished every time. Extrac-
tions are not necessarily simple and can be
challenging. Diagnosis, technique, complication mini-
mization as well as management of medically compro-
mised patients with post-operative care, including
pharmacotherapy will be presented.
Decision to extract or not
Any surgical procedure requires careful consideration
of the harm and benefits (Table 1). This requires a full
diagnostic process of history and examination and
special tests. Pre extraction radiographs will confirm
the diagnosis and indicate factors of potential diffi-
culty (Figs 1a–1c). Pulpal sensibility and assessment of
the periodontium can be invaluable additional pieces
of information.
Teeth may be considered for extraction at the level
of the individual tooth, the patient’s mouth or the
overall patient’s health. It is a common failing that
inexperienced dentists only look at the individual
tooth. The decision to extract individual teeth can be
straightforward in the presence of gross decay,
difficult in the presence of an insistent patient wanting
an apparently painful tooth extracted when clinical
and radiographic examination shows an intact tooth.
It is mandatory that a proper history and examination
are undertaken to exclude referred pain from cramped
masticatory muscles or sinus disease as causes of max-
illary tooth pain. Both of these are common mistakes.
Similarly trigeminal neuralgia will do a very good imi-
tation of toothache.1 Dentists should not take out
teeth on the insistence of patients in the absence of a
clear cut diagnosis. A surgeon who removed a normal
body part because the patient demanded it would jus-
tifiably be sued. Absolutely if the patient returns and
demands another extraction or root filling because the
pain is still there, they mandatorily need to be care-
fully reevaluated or referred for advice.
Common indications for extraction of normal teeth,
but at a mouth level, include orthodontic extractions
where there is a tooth size/jaw size discrepancy or as
part of a prosthodontic plan. What contribution to
mastication does the malposed tooth make? These
extractions require careful workup and a fully
informed consent process to the patient’s or their par-
ent for orthodontic patients. Showing them the study
models will often facilitate the process.
There are circumstances where extractions need to
be considered as part of the overall management of
the patient’s health. Management of oncology patients

© 2018 Australian Dental Association S11

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PJ Sambrook and AN Goss

Table 1. Harm benefit analysis for surgical proce- extracted is discarded but the residual alveolus must
dures – Exodontia last the patient for the rest of their life.
The tooth is secured to the jaw by a thin periodon-
Benefit Harm
tal membrane composed of multiple interconnected
Procedure performed collagen fibres inserted into the tooth and bone
Exodontia control pain incomplete procedure
resolves problem dry socket
(Figs 2a and 2b). Teeth, particularly with multiple
damage flared roots are further held within the bony socket
Procedure not performed (Fig. 2c). The traditional method of extracting the
No Extraction saves tooth spreading infection
avoids procedure later complications
tooth requires various forces; gripping, rocking and
avoids complications twisting to be applied to the tooth by means of for-
ceps or elevators. The forces involved are quite large;
gripping – 146Nm (126–167), rocking 200Nm (74–
266) and twisting 20Nm (3–13). Nine point eight
Nm (9.80) is approximately 1 kg.5 Multiple roots and
stronger bone all contribute to the force required. If
too great a force is used then either the tooth or the
alveolus will break. Although breaking the alveolus

(a) (b)

Fig. 1 Preoperative radiographs showing potential difficulty in extrac-

tion. (a) Cemental hyperplasia and condensing osteitis. (b) Enostosis. (c)
Dilacerated roots.

does sometimes involve the extraction of compro- (c)

mised but individually savable teeth for patients
undergoing head and neck radiotherapy or chemother-
apy including intravenous antiresorptive agents. These
will be further discussed later in the paper under the
management of medically compromised patients.

Technique
Once the decision to extract has been made the first
issue is the method of pain control for the procedure.
There are multiple choices, local anaesthesia (LA);
LA + oral sedation; LA + IV sedation in rooms or in
hospital or day stay general anaesthetic (GA). A
harm/benefit analysis needs to be applied to each.
Most commonly local anaesthesia is the technique
employed but this is not without complication.2–4
The objectives of exodontia are clear cut; to remove
the whole tooth whilst preserving the alveolus for Fig. 2 (a) Normal periodontal membrane, dentine and cementum left,
future prosthetics or implants. Again it is all too easy alveolar bone right. (b) True boney ankylosis bridge between the tooth
for the inexperienced dentist and their patient to and bone. This is rare and usually there is a history of dental trauma. (c)
Maxillary molar with divergent palatal and buccal roots. Note the thin
emphasise the removal of the whole tooth at the buccal plate at risk of fracture (see Fig. 9a) and the large close maxillary
expense of the alveolus. Remember the tooth once sinus with risk of oroantral communication (see Fig. 9c).
S12 © 2018 Australian Dental Association

will facilitate removal of the tooth it is at the expense
of the final shape of the alveolus. This has lead to the
development of fine periotomes which are carefully
inserted down the periodontal membrane to split it
and gently expand the socket (Fig. 3). If the tooth is
multirooted then the tooth should be sectioned into
its component parts. Although this may take longer it
conserves the alveolus.
Careful conservation of the alveolus must be consid-
ered at the time of extraction. If the buccal plate frac-
tures and comes away with the tooth, as it commonly
does with maxillary canine and molar extractions, it
can be replaced. It is best firmly fixed with mini screws
and a mucosal flap covers the graft (Fig. 4). Alterna-
tively a small bone graft can be taken from the lower
third molar or maxillary tuberosity area. The mini
screws are removed some 3–4 months after the extrac-
tion at the time the implant is placed. This primary
replacement is always preferable to secondary grafting
at the time of later implant placement.
There are two components to the alveolus, the hard
and soft tissues. With the soft tissue it is essentially
that there is a wide area of keratinised attached gin-
giva (Figs 5a and 5b) at the alveolar crest with soft
pliable mucosa in the vestibule. Careful attention to
these simple reconstruction principles, at the time of
Fig. 3 Periotone inserted into the periodontal membrane.
Fig. 4 Immediate bone graft to the alveolus placed at time of extraction.
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Contemporary exodontia
Fig. 5 (a) Well formed alveolus with broad keratinised mucosa. (b)
Alveolus with deficient buccal plate and high non keratinised mucosa.
extraction, will always make subsequent prosthetic
management easier.
So what happens if the tooth breaks or can’t be
removed? This should be considered as a failure of
the decision making process as much as a technique
failure. More experienced surgeons will often start
out an extraction as a surgical procedure, raising a
mucoperiosteal flap and sectioning the tooth. This
gives much greater control, is usually swifter and puts
the patient through much less pressure. What happens
if a root tip fractures? Firstly consider leaving it there
if it is vital, less than 5 mm and in proximity to a
vital structure such as a nerve. If you can, remove it
through a small boney window thus maintaining alve-
olar bone height (Fig. 6).
At the time of the extraction one should also care-
fully consider the residual shape of the alveolus. Are
there bony frenae, flabby tuberosity or bony exostoses
and tori (Figs 7a–7e).
Addressing these is all part of the objective of
exodontia, removing the tooth AND preserving the
alveolus for future prostheses or implant.
Complications
Complications are unforeseen and unexpected adverse
sequelae from a surgical procedure. Thus a patient
who bleeds after an extraction but has a known
Fig. 6 Root tip being approached via a buccal window to conserve the
alveolus.
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PJ Sambrook and AN Goss

Fig. 7 Surgical indication for corrections of alveolar bone shape. (a) Low set frenum. (b) Thick lingual frenum onto an atrophic ridge. (c) Large flabby
tuberosities. (d) ulcerated genial tubercles. (e) Surgical removal of a torus palatines.

The most common complication of exodontia is

Fig. 8 Gross mandibular atrophy in proximity to a pericoronitic third
molar. An invitation to fracture.
bleeding diathesis is not really a complication but a
failure of planning. Similarly, mandibular fracture
after an attempt at elevator only extraction of the
molar, in an elderly patient, with a grossly atrophic
jaw, is a failure of planning and consent (Fig. 8). If a
mandibular premolar is close to the mental foramen
unless care is taken the patient may have residual
paresthesia, or worse still, dysesthesia of the lower
lip. Hence is it a complication or known risk?
alveolar osteitis or dry socket.6 In this common condi-
tion the blood clot undergoes fibrinolysis and the
bony walls of the socket become exposed (Fig. 9a).
This is a painful but self limiting condition which
resolves in 2–3 weeks. The incidence is 3–5% of
extractions with risk factors being traumatic extrac-
tion, smoking, posterior teeth and mandible more
than maxilla, but it is usually unpredictable.6 If there
are signs and symptoms beyond the alveolus then the
diagnosis needs to be reviewed as it’s not a ‘dry
socket’ but a spreading infection. Excessive granula-
tion tissue usually is as a result of residual pieces of
tooth or bone (Fig. 9a and 9b).
Penetration into or loss of tooth roots into the sinus
must always be considered in the extraction of poste-
rior maxillary teeth (Fig. 9c). After extraction of such
teeth check carefully that they are complete. Check
for the presence of an oro-antral communication by
holding the patient’s nose and getting them to blow,
listen for any passage of air or bubbles. If the tooth is
intact and the communication small, compress the

Fig. 9 Complications. (a) Traumatic extraction of a maxillary molar. Unreduced fractured buccal plate and alveolar osteitis. (b) Exuberant granulation tis-
sue in response to a residual non viable root fragment. (c) Large chronic oroantral communication. (d) Endodontic accident. Not only root tips can end up
in the maxillary sinus. (e) Displaced molar into the intratemporal fossa.

S14 © 2018 Australian Dental Association


socket and suture closed. Tell the patient not to blow
their nose or create a negative pressure. Discuss fully
with the patient the reason for this sometimes distress-
ing complication. If the communication is large, more
than 4 mm or a piece of tooth is missing, promptly
refer to an Oral and Maxillofacial Surgeon (OMS).
(Fig. 9c and 9d) A two layer mucoperiosteal flap with
a buccal fat pad graft is useful for large communica-
tions.
Tooth or root displacement, beyond the alveolus
into the soft tissues, is usually a sign of excessive or
misdirected force, don’t ignore this as the probability
of infection is high. Promptly refer to an OMS for
imaging to localize the tooth and retrieve it (Fig. 9e).
If there is a delay in the patient being seen a short
course of antibiotics is appropriate.
Medically compromised patients
In this fortunate age of increased longevity and better
medical management of chronic disease the interac-
tion of dental and medical compromises plays an
increasing role. Knowledge of the patient’s current
medical conditions including their current medications
is essential. Interaction with the patient’s medical
practitioner is important but it must be noted that
medical practitioners have minimal exposure to oral
and dental conditions so that aspect is the dental
practitioner’s sphere of expertise.
Full discussion of the dental interactions with medi-
cal conditions is beyond the scope of this paper. All
dentists should keep up to date with contemporary
medical practice beyond their undergraduate educa-
tion.7 Useful references are Therapeutic Guidelines,
Oral & Dental8 and the others in the series, also the
Australian Prescriber monthly series.9 Some specific
current conditions with direct impact include those
which may affect healing, such as diabetes, steroids,
antiresorptives and head and neck radiotherapy as
well as those which may result in increased bleeding,
including anticoagulants, antiplatelet and haemato-
logic diathesis. In all these conditions a careful harm/
benefit analysis needs to be performed.
What is the nature of the underlying medical condi-
tion? What is the problem or particular medicine for?
How stable is the condition and what are the local
and general consequences of your planned procedure?
Can you minimize the risk of harm?
DIABETES
Diabetes is commonly considered by dentists and
patients as a single condition which will result in
increased infection and poor healing. This view is
incorrect. Diabetes covers a broad spectrum of condi-
tions, mainly a metabolic consequence of obesity for
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Contemporary exodontia
Type 2 but a few Type 1 and some Type 2 are a con-
sequence of failure of insulin production in the pan-
creas. The condition can be readily characterised by
knowing how long they have had it, their current
medication, blood glucose levels and HbA1c. In a
landmark study of a large series of Type 2 diabetics
on oral hypoglycaemics having extractions, we found
that they had less extraction complications than the
control group. The result showed a much higher inci-
dence from smoking in the control group. Thus most
well controlled Type 2 diabetics on diet control or
oral hypoglycaemics can be treated the same as non
diabetic patients.10 Type 1 and those Type 2 diabetics
requiring insulin are a different proposition, having
both problems of local healing and the effect of
change in diet from both local wound pain and fast-
ing are more easily destabilised. Specialist referral for
insulin dependent diabetics requiring extraction
should be considered.
STEROIDS
Patients are placed on steroids, particularly pred-
nisolone, for a wide range of medical conditions and
the particular indication for your patient must be first
identified. There has been a major change in that
more patients are on short pulses of steroids rather
than a continued dose. This reduces the risk of
cushingoid changes and adrenal suppression. Thus the
need to double dose prior to procedure is less. The
consequence of long term steroid on wound healing
and osteoporosis must be considered. Is the patient
also on an antiresorptive drug for osteoporosis?
Antiresorptive drugs
The introduction of the antiresorptive bisphosphonate
drugs in the late 1990’s were a major advance in the
management of bone diseases such as osteoporosis,
Paget’s disease and primary and secondary bone can-
cer. However, in 2003 the risk of bisphosphonate
related osteonecrosis of the jaws was identified.11 This
is of particular importance to dentists as dental proce-
dures, particularly extractions, are the major factor
for this painful non healing condition. The manage-
ment of this condition has been discussed in a number
of publications.12–14 A key finding is that the risk of
medication related osteonecrosis of the jaws
(MRONJ) relates to bone turnover which can be
assessed by the use of the simple blood test, fasted
serum beta cross laps test.15 Current management is
presented in Table 2. There are newer antiresorptive
drugs which are not bisphosphonate, the most com-
mon of which is Denosumab which is an antibody
which acts directly to cease the action of osteoclasts.
It has this effect for 6 months after which the
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PJ Sambrook and AN Goss
Table 2. Management of patients who are on antire-
sorptive agents and requiring extraction
Determine the type of bone disease
• Osteopenia
• Osteoporosis
• Paget’s disease
• Multiple myeloma
• Metastatic bone cancer
Determine the antiresorptive agent
• Type
• Dose
• Duration
Arrange fasted serum beta cross laps*
• If above 150pg/ml proceed
• If below 150pg/ml cease drug†
Until level reaches over 150pg/ml
Then extract
*Dentist can request this test from a pathology lab. Need to state
antiresorptive drug and bone problem e.g. Fosamax for osteoporosis.
†
For oral bisphosphonates the level rises at 25 pg/mL per month.
osteoclasts become reactivated.16 Hence management
is simple, avoid bone invasive dental treatment until
the seventh month and prior to further injection.
Extraction site will heal well and then drug usually
can be resumed within 2 weeks of the extraction.16
Patients with bone malignancy on antiresorptive medi-
cations and patients with established MRONJ are best
managed by referral to OMS specialists.
Radiotherapy
Head and neck cancer patients who have had radio-
therapy are at risk of osteoradionecrosis (ORN)
another non healing bone wound. Prevention is better
than cure so all patients should have their teeth care-
fully evaluated before radiotherapy commences. This
is an example of where the emphasis of treatment
planning is at the whole body level and not the indi-
vidual tooth. If a patient who has had the mandible
therapeutically irradiated then the correct approach is
pre extraction hyperbaric oxygen for 20 treatments.17
Established ORN which most sufferers describe as
being worse than their original cancer similarly need
more hyperbaric oxygen therapy and surgery.18 Such
patients are best treated by specialist experienced in
management of this condition. Failure to follow these
requirements may result in chronic pain and suffering
for the patient and medico legal consequences for the
dentist.
Anticoagulants and antiplatelet drugs
An increasing number of patients are on medications
to decrease the coagulation of their blood. This may
be both prevention and therapeutic management of a
wide range of cardiovascular and haematologic condi-
tions. Hence again the first issue is what is the patient’
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underlying medical condition and what are the poten-
tial consequences of altering their drug regimen? In
the last decade there has been a fundamental philo-
sophic shift away from being concerned about the risk
of bleeding to the risk of stopping the anticoagulant
medication. Oral bleeding is troublesome but a stroke
is a catastrophe.19
Management of patients on Warfarin is straightfor-
ward, determine the INR and if this is between 2.0
and 4.0 leave the Warfarin dose alone and use local
haemostatic measures for the extraction site.19 If the
level is below 2.0 or above 4.5 then the dose is not
therapeutic and needs to be adjusted by the prescrib-
ing medical practitioner. In our extensive studies on
patients taking Warfarin we found about one-third of
patients were not in the therapeutic range.20 We also
found many continued the use of Warfarin beyond
the recommended time for the management of the
underlying medical condition. The most likely extrac-
tion site to have post operative bleeding was a peri-
odontally involved maxillary molar.20
In some conditions Warfarin has been replaced by
antiplatelet agents including aspirin and clopidogrel.
For a patient in the 6 months following placement of
a metal coronary stent then stopping clopidogrel,
there is a fifteen percent chance of death.21 Hence,
leave the antiplatelet agent dose as is and use local
haemostatic methods. More recently there have been
a range of Novel Oral Anticoagulant Agents (NOAC),
these have replaced Warfarin for management of
atrial fibrillation (AF) and certain thrombo-embolic
conditions.22 Local haemostatic measures consist of
careful management of the soft tissue without tearing
during the extraction; placement of haemostatic agent
such as surgicelâ or gelfoamâ in the socket and sutur-
ing. The practitioner performing the procedure must
carefully explain the procedures involved to the
patient, stressing that they must not unilaterally cease
their medication. The more medically complex the
patient is and the more extensive the procedure then
the more the general dental practitioner should con-
sider specialist referral.
Medication related hyposalivation
With our aging population the issue of medication
related reduction in salivation is an increasing issue.23
The consequences of this dry mouth are increased
smooth surface decay and periodontal disease.23
Extractions and dentures are not necessarily the
answer because the dry mouth results in difficulties in
denture wearing. This may be complicated by
increased cognitive decline with consequential effects
on oral hygiene and difficulty learning how to use a
prosthesis. An important subgroup of patients with
medication related salivary flow reduction have
© 2018 Australian Dental Association

chronic pain, are on extensive amounts of narcotics
and antidepressants. They are usually younger, so
have more time for their dentition to fail. Again pre-
vention is better than cure. Discussion with the
patient’s prescribing medical practitioner about the
oral consequences of the medication; dry mouth man-
agement with local pharmacologic agents; strengthen-
ing the tooth resistance with fluoride and ongoing
oral hygiene training, involving the family and nursing
home as necessary. Careful consideration of individual
teeth for conservation or extraction is at a whole
patient level. Remember implants are not necessarily
the answer as the patient may be physically incapable
of withstanding the procedure and caring for the
reconstruction. Cost is a significant barrier also.
Pharmacologic management of patients undergoing
extraction
Appropriate prescription of medications is an essential
accompaniment of exodontia although sometimes this
involves the avoidance of medications, knowing what
not to prescribe is often more important than know-
ing what to prescribe. The key areas relate to seda-
tion, analgesics and antibiotics. Besides local
anaesthetic, oral sedation with the benzodiazepines is
a useful adjunct. The dose relates to the patient’s anx-
iety, previous benzodiazepine experience and the
extent of the procedure. The patient should be
escorted and must not drive.
Gaseous agents such as nitrous oxide and oxygen
has a role but there are question marks over pen-
throx.24 Commonwealth rules are changing concern-
ing the use of intravenous sedation in rooms with the
need to meet a full operating suite standard.
Analgesia
The pain associated with extractions is usually tran-
sient and well covered by either the over the counter
medication paracetamol, which acts centrally and/or
the non-steroidal anti-inflammatory drugs (NSAIDS)
which act peripherally. The patient needs to be
advised on the appropriate usage. Most patients can
tell you what analgesic works best for them and what
they don’t like. Patients should be advised against
over the counter medications containing codeine as
the dose is sub therapeutic. Generally codeine, even in
therapeutic doses is not recommended as it doesn’t
work for 1 in 10 patients has a high side effect profile
and about 1% of patients are rapid metabolizers and
has a high risk of dependence. It is for these reasons
that codeine containing medications are now only
available on a prescription.25 For similar reasons the
use of prescription paracetamol codeine combination
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Contemporary exodontia
is best used sparingly. If the patient asks for narcotics
by name – beware.
Antibiotic prophylaxis
The indications for prophylactic antibiotics in Aus-
tralia have been greatly restricted for extractions, they
are not required for patients with artificial joints and
the number of indicated cardiac conditions is greatly
reduced.8 In the United Kingdom the NICE guidelines
indicate no cardiac condition requires antibiotic pro-
phylaxis.26 This has results in a 75% reduction in the
prescription of Amoxicillin 2 g prescription and no
discernible increase in endocarditis.27
There is no indication for antibiotics after routine
extractions in healthy patients and there is no evi-
dence that antibiotics reduce post extraction infection
even in immunocompromised patients. Dentists do
have an important role in reducing the prescription of
antibiotics as part of overall antibiotic steward-
ship.8,28 The last seventy years of over prescription of
antibiotics has resulted in the rise of antibiotic resis-
tant microorganisms.
Exodontia is the cornerstone procedure in den-
toalveolar surgery. Care and maintenance of the alve-
olus is paramount. Other dentoalveolar procedures
are discussed in the papers on impacted teeth,29 and
single tooth replacement implants.30
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Address for correspondence:
Assoc. Prof. Paul J Sambrook
Director, Oral & Maxillofacial Surgery Unit
Faculty of Health Science
The University of Adelaide
Adelaide, SA 5005
Australia
Email: paul.sambrook@adelaide.edu.au
© 2018 Australian Dental Association