> ## Documentation Index
> Fetch the complete documentation index at: https://docs.bizaxl.com/llms.txt
> Use this file to discover all available pages before exploring further.
# Oral Surgery
> How to document tooth extractions, surgical extractions, wisdom tooth removal, implant procedures, and post-operative care using Clinical Procedures and Nursing Tasks.
Oral surgery is one of the most procedure-intensive and documentation-sensitive areas of dentistry. Every extraction, surgical removal, and implant placement must be fully documented: the anaesthetic given, the technique used, any complications, the post-operative instructions provided, and the follow-up plan. This page explains how to record oral surgery procedures from assessment through to post-operative review.
***
## Before You Start
* Clinical Procedure Templates for each surgical procedure must be set up.
* For sedation cases, the patient must have approved pre-surgical blood tests on file. See [Laboratory](/health-wellness/dental-clinic/laboratory).
* Consent must be documented before the procedure begins.
* You need the **Healthcare Practitioner** role to document surgical procedures.
***
## Setting Up Surgical Procedure Templates
Create a Clinical Procedure Template for each surgical procedure type:
| Template Name | Department | Notes |
| ---------------------------------------- | -------------------------- | --------------------------------------------------- |
| Tooth Extraction (Simple) | Oral Surgery | Single-rooted or easily elevated multi-rooted tooth |
| Tooth Extraction (Surgical) | Oral Surgery | Requires bony removal or sectioning |
| Wisdom Tooth Removal (Partially Erupted) | Oral Surgery | Soft tissue removal + flap |
| Wisdom Tooth Removal (Impacted - Bony) | Oral Surgery | Bone removal and tooth sectioning required |
| Apicectomy | Oral Surgery | Surgical endodontic procedure |
| Implant Placement (Single Implant) | Oral Surgery | Titanium fixture placement |
| Bone Graft | Oral Surgery | Socket preservation or ridge augmentation |
| Sinus Lift (Lateral Window) | Oral Surgery | Maxillary sinus floor augmentation |
| Implant Crown Fit (Single) | Oral Surgery / Restorative | Ceramic or zirconia crown on implant abutment |
| Suture Removal | Oral Surgery | Follow-up after surgical procedure |
| IV Sedation Administration | Oral Surgery | Sedation for anxious patients or complex surgery |
***
## Step 1: Pre-Surgical Assessment
The pre-surgical assessment is documented as a Patient Encounter with the appointment type set to "Oral Surgery Consultation".
In the Patient Encounter, record:
**History:**
* Reason for referral or self-referral
* Duration of the problem
* Previous attempts at treatment
* Dental anxiety level (relevant for sedation planning)
* Medical history review (diabetes, anticoagulants, bisphosphonates, immunosuppression)
* Bleeding history (excessive bleeding after previous procedures)
* Medications that affect surgery (Warfarin, Apixaban, bisphosphonates, steroids)
**Examination:**
* Tooth status (eruption, mobility, tenderness to percussion)
* Soft tissue assessment (swelling, sinus, pus)
* Mouth opening (normal, limited - if limited, affects access for lower wisdom teeth)
**X-Ray Review:**
Order an OPG or IOPA if not already available. See [Dental Radiography](/health-wellness/dental-clinic/dental-radiography) for how to document findings.
For impacted wisdom teeth, the OPG must show:
* Eruption status (soft tissue, partial, unerupted)
* Angulation (mesioangular, distoangular, horizontal, vertical)
* Relationship to inferior dental canal (for lower teeth)
* Root morphology (fused, divergent, dilacerated)
* Proximity to adjacent tooth
**Consent Discussion:**
Record in the encounter notes that consent has been discussed and the following risks explained:
* Pain and swelling post-operatively
* Bruising
* Dry socket (delayed healing after extraction)
* Numbness (inferior alveolar nerve or lingual nerve injury - for lower wisdom teeth)
* Sinus opening (for upper posterior extractions)
* Damage to adjacent teeth
Attach the signed consent form to the Patient Encounter record.
***
## Step 2: Pre-Operative Nursing Checklist
On the day of surgery, the dental nurse completes a pre-operative checklist before the procedure begins:
1. Go to Healthcare workspace → Nursing card → **Nursing Task**
2. Complete the pre-operative tasks for the surgical patient:
| Task | Check |
| -------------------------------------------------------------------- | ----------------------------------- |
| Patient identity confirmed (name, date of birth) | Ticked |
| Consent form on file | Ticked |
| Nil by mouth confirmed (for sedation cases) | Ticked |
| Escort confirmed (for sedation cases) | Ticked |
| Blood pressure recorded | Recorded |
| Blood glucose recorded (for diabetic patients) | Recorded |
| Pre-surgical blood test result approved (for sedation cases) | Confirmed |
| Surgical site confirmed with patient (which tooth / teeth) | Confirmed |
| Allergies reviewed | No new allergies |
| Patient has not taken anticoagulant medication today (if applicable) | Confirmed or discussed with dentist |
***
## Step 3: Recording Vital Signs
Before any surgical procedure and before sedation is administered:
1. Go to Healthcare workspace → Consultation card → **Vital Signs** → New
2. Link to the patient
3. Record:
| Measurement | Notes |
| ----------------------------------- | ----------------------------------------------- |
| Blood Pressure (systolic/diastolic) | Defer elective extraction if systolic >180 mmHg |
| Pulse | Baseline pre-sedation |
| Blood Oxygen Saturation (SpO2) | Baseline pre-sedation |
| Blood Glucose | For diabetic patients |
| Weight | For sedation drug dosing |
***
## Step 4: Performing and Documenting the Procedure
After the procedure is completed, the dentist completes the Clinical Procedure record:
1. Open the Clinical Procedure record (created from the encounter or appointment)
2. Record the procedure details in the Notes field:
**For Simple Extraction:**
```
Tooth: 45
Anaesthetic: Lignocaine 2% with 1:80,000 adrenaline, 2 cartridges (3.6 mL),
inferior alveolar block + long buccal infiltration.
Extraction: Tooth elevated with Warwick James elevator, removed with
lower straight forceps. Socket inspection - no retained root or bone fragments.
Haemostasis: Pressure pack applied. Good haemostasis achieved.
Post-operative instructions given verbally and in writing.
```
**For Surgical Extraction (e.g., Impacted Wisdom Tooth):**
```
Tooth: 38
Pre-op OPG reviewed: Mesioangularly impacted, inferior dental canal appears
adjacent to apex, roots fused.
Anaesthetic: Lignocaine 2% 1:80,000 adrenaline, 3.6 mL, IDB and lingual
block + infiltration.
Flap design: Three-sided buccal flap, papilla preserved.
Bone removal: Bur on surgical handpiece, 9mm of buccal bone removed.
Tooth sectioning: Tooth divided at CEJ, crown removed, roots removed
in sections.
Socket management: Irrigated with saline, no active bleeding.
Closure: 3x 3-0 Vicryl Rapide sutures placed. Good closure.
Post-op radiograph: IOPA taken - no retained fragments.
Instructions: Written post-operative instructions given. Escort present.
Review in 7 days for suture removal and healing check.
Complications: None intraoperatively.
```
**For Implant Placement:**
```
Tooth site: 16 (missing tooth)
Pre-op planning: OPG reviewed, 10mm bone height confirmed on CBCT.
Anaesthetic: Lignocaine 2% with adrenaline, palatal infiltration + buccal block.
Flap: Crestal incision, full-thickness mucoperiosteal flap raised.
Implant site preparation: Sequential osteotomy, 3.5 x 10mm site prepared.
Implant placed: [Brand] 3.5 x 10mm implant, primary stability achieved.
Flap closure: 3 x 4-0 Prolene sutures.
Post-op IOPA taken: Implant position satisfactory.
Instructions: Soft diet 2 weeks. No smoking. Review in 2 weeks.
Loading planned: 3 months osseointegration before crown.
```
***
## Step 5: Post-Operative Prescriptions
After surgical procedures, raise a prescription from the Patient Encounter:
| Procedure | Typical Post-Op Prescription |
| ------------------------------- | -------------------------------------------------------------------------------------------------------- |
| Simple extraction | Ibuprofen 400mg TDS x 3 days (if no contraindication) |
| Surgical extraction | Ibuprofen 400mg TDS x 5 days + Amoxicillin 500mg TDS x 5 days (if clinically indicated) |
| Wisdom tooth removal | Ibuprofen 400mg TDS x 5 days + Amoxicillin 500mg TDS x 5 days + Chlorhexidine 0.2% mouthwash BD x 7 days |
| Implant placement | Amoxicillin 500mg TDS x 5 days + Ibuprofen 400mg TDS x 3 days |
| Patient with penicillin allergy | Metronidazole 400mg TDS x 5 days (instead of Amoxicillin) |
***
## Step 6: Post-Operative Review
Book the post-operative review appointment before the patient leaves:
* Simple extractions: usually no formal review needed unless patient has concerns
* Surgical extractions and wisdom teeth: Day 7 for suture removal and healing check
* Implant placement: Day 14 for suture removal, then 3-month review for osseointegration check
Document the review in a new Patient Encounter:
| Finding at Review | Record As |
| -------------------------------- | -------------------------------------------------------------------------------------------------------------------------------------------------------- |
| Normal healing, sutures in situ | "Socket healing satisfactory. Sutures removed." |
| Dry socket (alveolar osteitis) | "Dry socket: socket irrigated, alvogyl placed. Review in 3 days." |
| Infection / swelling | "Infected socket: drainage, irrigation. Antibiotic course extended / changed. Review in 5 days." |
| Paraesthesia (nerve involvement) | "Persistent lower lip numbness since surgery. Inferior alveolar nerve likely involved. Monitoring. Refer to oral surgeon if no improvement in 3 months." |
| Excellent healing for implant | "Soft tissue healed well. Implant stable on percussion. Proceeding to impression for crown in 4 weeks." |
***
## Field Guide: Clinical Procedure (Surgical)
| Field | Description |
| ----------------------- | ----------------------------------------------------------------------------------- |
| Patient | Linked patient |
| Procedure Template | Type of surgical procedure |
| Healthcare Practitioner | Operating dentist |
| Appointment | Linked appointment |
| Start Date / Time | Time surgery began |
| Completion Date / Time | Time surgery ended |
| Notes | Full operative note: tooth, anaesthetic, technique, findings, closure, instructions |
| Consumable Items | Sutures, bone graft material, implant fixture |
| Status | Initiated / In Progress / Completed |
| Invoiced | Ticked when invoiced |
***
## Best Practices
* Never extract a tooth without radiographic evidence of the root and surrounding bone, unless it is a clearly mobile, rootless primary tooth - underbones, extra roots, and proximity to adjacent structures are invisible clinically but visible radiographically
* For lower wisdom teeth, always discuss the risk of inferior alveolar nerve injury before surgery, record the discussion in the notes, and obtain signed consent
* For patients on bisphosphonates, document this clearly before any extraction and discuss medication-related osteonecrosis of the jaw (MRONJ) risk with the patient. Consider a specialist referral for patients on IV bisphosphonates
* Always book the post-operative review before the patient leaves - patients who are in pain or have complications must be able to return promptly, and an unbooked follow-up is frequently missed
* Record every incidence of post-operative complication (dry socket, nerve involvement, sinus opening) in the clinical record - complications that are managed promptly and documented properly rarely become complaints; complications that are hidden or undocumented become serious liability risks
***
## Troubleshooting
**The pre-operative checklist cannot be completed because the blood test result has not been approved**
Contact the LabTest Approver urgently. Do not proceed with sedation until results are approved and in range. Document the delay and reschedule the patient if results are not available in time.
**The patient's blood pressure is too high to proceed**
Record the blood pressure reading in Vital Signs. Do not proceed with elective extraction if systolic is persistently above 180 mmHg. Refer the patient to their GP for blood pressure management. Document the decision in the encounter notes.
**A tooth has been extracted but the patient is requesting the tooth back**
This is a patient rights matter. If your clinic policy permits, the extracted tooth can be given to the patient after appropriate handling. Document the request and the outcome in the procedure notes.
***
## Related Features
* [Dental Examination](/health-wellness/dental-clinic/dental-examination): Surgical assessments are documented as Patient Encounters
* [Dental Radiography](/health-wellness/dental-clinic/dental-radiography): OPG and IOPA are essential for surgical planning
* [Laboratory](/health-wellness/dental-clinic/laboratory): Pre-surgical blood tests for anticoagulated patients and sedation cases
* [Billing and Finance](/health-wellness/dental-clinic/billing-finance): Surgical procedures and anaesthetic fees are billed after completion