The Tooth Extraction Notes Template UK Dentists Use

A simple extraction notes template is a structured framework for recording a routine forceps extraction — covering pre-op assessment, medical history considerations (anticoagulants, bisphosphonates), Montgomery consent with all relevant risks, anaesthetic record with batch numbers, technique, socket status, sutures, and post-operative aftercare — meeting GDC, FGDP(UK), SDCEP, and CQC documentation standards.

Extraction notes get scrutinised more than any other dental record — dry socket, retained roots, IAN paraesthesia, complications. Below is the template UK dentists paste into their PMS — Montgomery consent in full, no patient demographics (PMS captures those), defensible against every common complaint head.

Download the free Simple Extraction template — plain text, GDC/FGDP(UK)-aligned.

Why this simple extraction template wins

  • Full Montgomery consent including all standard extraction risks — dry socket, IAN/lingual paraesthesia (with realistic likelihood), sinus communication — so you can't be accused of failing to warn.
  • Medical-history considerations explicitly prompted for anticoagulants, bisphosphonates (MRONJ risk under SDCEP 2024), bleeding disorders, immunosuppression — the flags that change extraction management.
  • Pre-op radiograph prompt includes IRMER justification, quality score, and report — satisfies IRMER 2017 Reg.11 in one line.
  • Tooth integrity recorded explicitly — whole / crown fracture / retained root with management decision (retained root is the #1 source of post-extraction GDC complaints).
  • Aftercare prompts BOTH verbal AND written leaflet given — discharges GDC Principle 4 duty of after-care and is the single most-cited defence line in MDDUS / Dental Protection case reviews.

Compliance: the medico-legal angle

  • SDCEP — Management of Dental Patients Taking Anticoagulants/Antiplatelets 2024. The MH field prompts the explicit assessment SDCEP requires before any extraction.
  • SDCEP MRONJ 2024 — bisphosphonate/denosumab risk screen documented before extraction is mandatory; the dedicated MHx flag prevents this being missed.
  • Montgomery v Lanarkshire (2015) — material risk disclosure. Risks are tooth-specific (IAN paraesthesia for lower posteriors, sinus communication for upper posteriors).
  • GDC Standards Principle 3 + 4 — informed consent documented and written information confirmed.
  • IRMER 2017 Reg.11 — every radiograph needs documented justification, report, and quality score. The pre-op radiograph line covers all three.

Common mistakes UK dentists make

  • Recording "LA, extracted, no complications" — totally indefensible. Needs consent, technique, socket status, aftercare.
  • Forgetting to record paraesthesia warning for lower 8s and lower premolars near the IAN canal — even if risk is low, must be discussed.
  • No MRONJ / anticoagulant screen documented — SDCEP non-compliance and a defence-killer if a complication arises.
  • Written aftercare not given (or not documented as given) — GDC Principle 4 breach if a post-op complication arises.
  • No "return if" criteria — patient doesn't know when to come back, complications escalate, GDC files in.

Frequently asked questions

What risks must I discuss before any extraction?

Under Montgomery, you must disclose all material risks a reasonable patient would want to know: pain, swelling, bruising, bleeding, infection, dry socket, retained roots, adjacent tooth damage, and — where relevant to the tooth — IAN paraesthesia (lower posterior teeth) and sinus communication (upper posterior teeth). Record the discussion in the note.

Do I need a pre-op radiograph for every extraction?

For any tooth where roots, periapical pathology, or proximity to anatomical structures (IAN, sinus) are uncertain, yes — IRMER 2017 requires clinical justification. For a clearly mobile, end-stage periodontally-involved tooth where roots are visible, a recent radiograph may suffice. Either way, the template prompts you to record what radiograph (and when) you reviewed.

How do I handle anticoagulant patients?

Follow SDCEP guidance — most warfarin and DOAC patients can have routine extractions in primary care without stopping medication, with local haemostatic measures (suturing, packing, tranexamic acid mouthwash). The template prompts you to record the MH consideration so your management approach is justified.

What aftercare advice is mandatory?

Bite firm gauze 30 min, no rinsing for 24h, salt rinses from day 1, avoid smoking and alcohol 48h, soft diet, analgesia (ibuprofen 400mg QDS unless contraindicated), return if pain >day 3, swelling, bleeding, or paraesthesia. Verbal AND written information must be given — the template prompts both.

What if I leave a retained root?

Record it explicitly: "Root fracture, apical 3mm retained, decision to leave (close to IAN / minimal risk / extraction would cause more morbidity)." The note must document WHY it was left, that the patient was informed, and the post-op surveillance plan. Hiding a retained root is the single fastest way to lose a GDC case.

How does Nosht handle complications mid-extraction?

The structured form lets you tick "Root fracture" or "Sinus communication" and a branching sub-form opens — capturing the size, management taken, patient informed, follow-up planned. The whole complication is documented in 30 seconds instead of forgotten in the rush after a difficult appointment.

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