Tooth Extraction/Alveoloplasty Procedure Note

Patient Name: [Full name]

DOB: [Date of birth]

MRN: [Medical record number]

Date of Procedure: [Date]

Location: [Clinic/OR location]

Operating Dentist/Oral Surgeon: [Name and credentials]

Assistant(s): [Name(s) and role(s)]

Referring Provider: [Name and credentials] (Only include if applicable.)

Procedure Summary

[1–3 sentence summary of procedures performed, teeth numbers, extraction technique types, alveoloplasty location/extent, and anesthesia used]

• Procedures: [Extraction(s) / Alveoloplasty / both]
• Teeth involved: [Tooth numbers using Universal Numbering System] (Use # for tooth numbers; include quadrants/regions for edentulous segments as needed.)
• Extraction type by tooth: [Tooth number: simple / surgical] (Group adjacent teeth with identical technique.)
• Alveoloplasty location/extent: [UR / UL / LR / LL quadrant; arch/region] (State if performed independently vs in conjunction with extractions.)
• Anesthesia: [local only / nitrous / moderate sedation / deep sedation / general anesthesia]

Indications and Diagnoses

• Indications: [caries/non-restorable / periodontal disease / fracture / preprosthetic ridge recontour / orthodontic / infection / other]
• Pre-procedure diagnosis: [Diagnosis(es) prior to procedure]
• Post-procedure diagnosis: [Diagnosis(es) after procedure] (Note if changed based on intraoperative findings.)

Pertinent History and Risk Review

(Include a focused review specific to this procedure. Omit this section only if a separate pre-operative evaluation note is referenced.)

• Medical history review: [Reviewed with no changes / Changes since last visit]
• Allergies/adverse reactions: [NKDA / Allergens and reaction types]
• Relevant medications impacting bleeding/sedation/infection: [Agent names and timing] (Include anticoagulants, antiplatelets, bisphosphonates, immunosuppressants, or state none.)
• Bleeding risk management: [Not applicable / INR value and date or DOAC timing, perioperative instructions, advising provider]
• Antibiotic prophylaxis: [Given / Not indicated] — [Rationale]
• Pre-procedure imaging reviewed: [Periapical / Panoramic / CBCT] — [Key findings relevant to procedure]
• Critical safety elements unable to obtain: [None / Element, reason, and mitigation]
• Reference to separate pre-op evaluation: [Not applicable / Note date] (Only include if applicable.)

Informed Consent

• Consent obtained from: [Patient / Legal guardian / Healthcare proxy] (Include name and relationship if not patient; note interpreter use if applicable.)
• Nature of procedure(s) discussed: [Procedures explained]
• Material risks/complications reviewed: [Risks discussed, tailored to case] (May include: bleeding, infection, pain, swelling, nerve injury/paresthesia, retained root, sinus communication, dry socket, need for additional surgery, anesthesia risks.)
• Alternatives discussed: [restoration / endodontic therapy / periodontal treatment / no treatment / referral]
• Patient questions addressed and agreement to proceed: [Yes / No — document informed refusal and plan if declined]

Pre-Procedure Verification

[Time-out performed with team present.]

• [Correct patient identity confirmed]
• [Correct procedure and site/tooth numbers verified]
• [Imaging available and reviewed]
• [Allergies confirmed]
• [Equipment and materials ready]

Anesthesia

(Include only the subsections that apply.)

• Local anesthesia: [Agent(s) and concentration] — [Total volume in mL] — [Injection technique(s)] — [Topical anesthetic: Yes with agent / No]
• Nitrous oxide/oxygen: [Start time] — [Stop time] — [Maximum concentration %] — [Patient response and recovery status] (Only include if used.)
• Moderate/deep sedation or general anesthesia: [Anesthesia provider name] — Separate time-based anesthesia record on file — [Baseline assessment completed; continuous monitoring performed; discharge criteria met] (Only include if used.)

Procedure Details

Extraction(s)

(Document each tooth separately or group adjacent teeth when identical technique was used.)

• Tooth #[number]: [simple / surgical] extraction.

  • Soft tissue management: [Flap type and extent] (Only for surgical.)
  • Bone management: [Ostectomy/osteoplasty performed; irrigation] (Only for surgical.)
  • Tooth sectioning: [Orientation and instruments] (Only if performed.)
  • Delivery method: [Elevators / forceps / other]
  • Socket management: [Curettage, irrigation, debridement performed]
  • Verification: [Tooth removed in entirety / Retained root tip with size, location, and management plan]
  • Sinus assessment: [No exposure / Exposure or communication with management] (Only for maxillary posterior teeth.)
  • Nerve proximity: [None / Suspected proximity or injury with assessment and plan] (Only for mandibular teeth near IAN/lingual nerve.)
• (Repeat for additional teeth as needed.)

Alveoloplasty

(Include this section only if performed.)

• Location and extent: [Arch/quadrant; tooth spaces or region]
• Indication: [preprosthetic ridge recontour / removal of sharp or irregular bone / denture comfort / other]
• Technique: [Flap elevation: yes/no with type] — [Bone reduction method: rongeur / bone file / bur] — [Contouring approach and irrigation]
• Relationship to extractions: [Performed with extractions / Performed independently] — [Extended beyond minor socket smoothing: yes / no]
• Final ridge assessment: [Smooth, rounded contours achieved and appropriate for planned prosthesis / Other findings]

Hemostasis and Socket Materials

• Hemostatic measures: [Pressure / gauze / local hemostatic agent with name / sutures / other]
• Socket fillers/grafts/membranes: [None / Material name and type; lot number if required by facility]

Closure

• Sutures: [None — healing by secondary intention / Material and size, technique, number placed]

Intraoperative Findings

(Include only if there were meaningful non-routine findings. Omit section entirely if none.)

• [Finding type] — [Description and management]

Complications and Estimated Blood Loss

(This section must never be left blank.)

• Complications: [None / Complication(s) with management, medications given, referrals, imaging, and follow-up plan]
• Estimated blood loss: [Numeric estimate in mL / Minimal]
• Specimens: [None / Teeth or tissue sent to pathology with destination]

Post-Procedure Status and Disposition

• Tolerance: [Tolerated procedure well / Other]
• Hemostasis at discharge: [Achieved / Ongoing bleeding with management]
• Status at discharge: [Local anesthesia: patient alert, oriented, stable / Sedation: discharge criteria met per anesthesia record, responsible adult escort present]
• Disposition: [Discharged home / Discharged with escort / Transferred with destination and reason]

Post-Operative Instructions, Medications, and Follow-Up

• Instructions: Written and verbal instructions provided to [patient / escort] — Domains covered: [bleeding control / diet / oral hygiene / activity restrictions / smoking cessation / sinus precautions]
• Medications prescribed:
  • [Drug name] — [Dose] — [Quantity] — [Directions] — [Refills] — [Indication]
  • (Add additional medications as needed.)
• Medications administered in-office: [None / Drug, dose, route, time]
• No prescriptions provided: [Reason, e.g., OTC regimen recommended] (Only include if no prescriptions given.)
• Follow-up plan: [Routine PRN / Scheduled visit date / Suture removal timing]
• Return precautions discussed: [Fever / uncontrolled bleeding / increasing swelling / difficulty swallowing or breathing / severe uncontrolled pain / suspected dry socket / persistent paresthesia]
• Communications: [Referring dentist/PCP to be updated: yes / no] (Include method and timeframe if yes.)

(If critical information is unavailable, use "Unable to obtain" with reason and mitigation, or "Not applicable" only when truly N/A. Never infer tooth numbers, anesthesia drugs/doses, whether consent occurred, complications, or pathology disposition.)