Simple Extraction Notes Template for UK Dentists
Nosht
Published by Nosht Limited
Extraction notes are often scrutinised after a complication — dry socket, retained roots, IAN paraesthesia, complications. Below is a template for UK clinicians to paste into their PMS — Montgomery consent in full, no patient demographics (PMS captures those), defensible against every common complaint head.
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 IR(ME)R justification, A/N quality grade, and report — satisfies IR(ME)R 2017 reg 11 and reg 12(9) in one line.
- Tooth integrity recorded explicitly — whole / crown fracture / retained root with management decision (a retained root is a common trigger for post-extraction complaints).
- Aftercare prompts BOTH verbal AND written leaflet given — discharges GDC Principle 4 duty of after-care and is a key defensive line if a complication follows.
The template (paste into your PMS notes field)
Paste the simple extraction template below into your PMS notes field. Patient demographics are left out because your PMS already holds them.
TOOTH: [FDI] REASON: [Caries / periodontal / orthodontic / fractured / other:] PRE-OP ASSESSMENT: [Mobility / root morphology / access / pre-op pain] Pre-op radiograph: [Type — date — quality A/N — report: roots / periapical / proximity to IAN / sinus] MHx: [Reviewed — anticoagulants / antiplatelets / bisphosphonates (MRONJ risk) / diabetes / steroids / bleeding disorder] BP: [If indicated] CONSENT (Montgomery): Risks explained specific to this tooth — - Common: pain, swelling, bruising, trismus (2-5 days) - Uncommon: dry socket [~5%, higher in smokers], bleeding, infection - Rare: IAN/lingual paraesthesia (where relevant: ~__%), retained root fragment, oro-antral communication (where relevant), jaw fracture Benefits: [resolution of pathology / pain relief]. Alternative: [restore / RCT / antibiotics only / no treatment — consequences]. Patient understands and consents. LA: [Agent — total volume — cartridges — technique (infiltration/IDB/long buccal/lingual/mental)]. Profound anaesthesia confirmed. PROCEDURE: [Luxation — instrument (Coupland's/elevator) — direction of force / delivery — forceps used / approach]. Tooth delivered [intact / with crown fracture / with root fracture — retained: __mm — decision: leave/surgical retrieval]. No excessive force. INTRA-OPERATIVE FINDINGS: [Complications / socket walls intact / bone fracture: Y/N] SOCKET / HAEMOSTASIS: Socket inspected — [no retained fragments / fragment left — informed]. Irrigated saline. Pressure pack — haemostasis achieved end of appointment. Sutures: [None / Vicryl 3-0 / silk 3-0 — n=__] POST-OP INSTRUCTIONS (verbal + written leaflet provided): Bite on gauze 30 min. No vigorous rinsing 24h. Warm salt-water rinses from 24h. Soft diet. Avoid smoking. Analgesics — ibuprofen 400mg + paracetamol 1g PRN (no contraindications). Contact practice immediately if uncontrolled bleeding. Dry socket symptoms discussed (onset 2-4 days, dull aching, radiating to ear — return for management). FOLLOW-UP: [No routine review / suture removal at __ days / specific review for complications]. Next exam per recall.
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What good looks like — a worked example
The same simple extraction template, completed for a realistic case.
TOOTH: LR8 REASON: Recurrent pericoronitis — third episode this year. Grossly carious, non-restorable. PRE-OP ASSESSMENT: Partially erupted, mesially impacted. Grade 1 mobility. OPG [date] reviewed — parallel roots, no curvature, adequate bone density. IAN canal inferior to roots with apparent separation. Complexity: straightforward simple extraction anticipated; patient counselled re: possible referral if resistance encountered. Pre-op radiograph: OPG ([date]) — quality A — report as above. MHx: Reviewed. No anticoagulants. No bisphosphonate history (MRONJ risk nil). No bleeding disorder. BP normal. CONSENT (Montgomery): Risks explained specific to LR8 — - Common: pain, swelling, bruising, trismus (2-5 days) - Uncommon: dry socket ~5%, post-op bleeding, infection - Rare: IAN paraesthesia of lip/chin <1% (based on OPG anatomy); lingual paraesthesia; retained root fragment Benefits: resolution of recurrent infection, pain relief. Alternative: antibiotics alone (temporising, doesn't resolve cause), no treatment (further episodes expected). Patient understands. Elects extraction. Consented. LA: IDB — articaine 4% w/ adrenaline 1:100,000, 1.7ml (1 cartridge). Long buccal infiltration — articaine 4% 1:100,000, 0.5ml. Total 2.2ml. Profound anaesthesia confirmed. PROCEDURE: Luxation with Coupland's elevator — buccal and mesial application. Tooth delivered with lower molar forceps (Ash 22). No excessive force. Single-rooted specimen — roots intact. INTRA-OPERATIVE FINDINGS: No complications. Socket walls intact. No bone fracture. Irrigation with saline. SOCKET / HAEMOSTASIS: Socket inspected — no retained root fragments. Irrigated saline. Pressure pack — haemostasis achieved end of appointment. Sutures: None. POST-OP INSTRUCTIONS (verbal + written leaflet provided): Bite gauze 30 min. No vigorous rinsing 24h. Warm salt-water rinses from 24h. Soft diet. Avoid smoking. Ibuprofen 400mg + paracetamol 1g PRN (no contraindications). Contact immediately if uncontrolled bleeding. Dry socket symptoms discussed. FOLLOW-UP: No routine review. Patient to contact if bleeding doesn't stop, signs of infection, or dry socket symptoms. Next exam per recall.
Compliance: the medico-legal angle
- SDCEP — Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs (2nd edition, March 2022). The MH field prompts the explicit assessment SDCEP requires before any extraction.
- SDCEP Oral Health Management of Patients at Risk of MRONJ (2017, reviewed and extant March 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.
- IR(ME)R 2017 reg 11 — justification before exposure; reg 12(9) — a clinical evaluation of the outcome recorded. Quality grading (A/N, 2020 Guidance Notes) is a QA-programme addition, not an IR(ME)R requirement. The pre-op radiograph line covers all three.
Common documentation mistakes
- 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.
Sources
- GDC Standards for the Dental Team, Principle 3: Obtain valid consent (accessed 18 October 2026)
- GDC Standards for the Dental Team, Principle 4: Maintain and protect patients’ information (accessed 18 October 2026)
- The Ionising Radiation (Medical Exposure) Regulations 2017 (SI 2017/1322) (accessed 18 October 2026)
- Montgomery v Lanarkshire Health Board (UK Supreme Court, 2015, UKSC 11) (accessed 18 October 2026)
- SDCEP: Oral Health Management of Patients at Risk of Medication-related Osteonecrosis of the Jaw (March 2017) (accessed 18 October 2026)
- SDCEP: Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs (2nd edition, March 2022) (accessed 18 October 2026)
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 — IR(ME)R 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 TDS 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?
In Bulletproof mode, recording a retained root apex or a suspected or confirmed oro-antral communication opens follow-on fields: risks explained, radiograph monitoring and patient acceptance, or OAC management and follow-up (and size, if confirmed). The complication is recorded in structured fields at the time, instead of forgotten in the rush after a difficult appointment.
Guides that cover this
- Dental Indemnity for New UK Graduates Compared
- Antibiotic Prescribing in Dentistry: SDCEP Guide & Doses (UK 2026)
- Local Anaesthetic Maximum Doses in Dentistry: A UK Reference
- Dental Drug Interactions: A UK Reference
- Montgomery in Dentistry: the Legal Test and Material Risks
- Record-Keeping for Dentists (UK): A Dento-Legal Guide
Patient leaflets for this treatment
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Nosht
Published by Nosht Limited
Nosht Limited makes structured clinical note templates for UK dental professionals. Articles refer to guidance from the GDC, CGDent, BSP, SDCEP and NICE. Check the current version of a source before relying on it.