Wisdom Tooth Extraction Notes Template for UK Dentists

NICE TA1 still prohibits prophylactic third molar removal — pathology must be present and documented. Below is a template for UK clinicians to paste into their PMS for any third molar extraction, with NICE TA1 indication, BAOMS-aligned consent, and IAN risk assessment.

Why this wisdom tooth (third molar) extraction template wins

• NICE TA1 indication documented EXPLICITLY — without this, the extraction is prophylactic which NICE prohibits. A frequent gap in wisdom tooth complaints.
• Pell-Gregory + Winter classification — universal taxonomy that any specialist can interpret.
• IAN distance assessment from OPG/CBCT — quantifies the risk for Montgomery consent.
• Lingual flap NOT raised explicitly noted — defends lingual nerve preservation if patient reports tongue numbness.
• Written post-op leaflet given — confirmed in note. GDC Principle 4 + indemnity defence.

The template (paste into your PMS notes field)

Paste the wisdom tooth (third molar) extraction template below into your PMS notes field. Patient demographics are left out because your PMS already holds them.

TOOTH: [FDI — 18 / 28 / 38 / 48]
NICE TA1 INDICATION (mandatory documentation): [Second or subsequent episode of pericoronitis — episodes recorded / unrestorable caries / non-treatable pulpal or periapical pathology / cellulitis, abscess or osteomyelitis / resorption of the tooth or adjacent 7 / fracture / follicle disease incl. cyst or tumour / impeding surgery. NOT prophylactic per NICE TA1. Orthodontic, prosthetic or periodontal reasons are not TA1 indications — record separately.]

PRE-OP ASSESSMENT:
- Pre-op radiograph: [OPG mandatory — date — quality]
- Classification:
  - Pell & Gregory: [Class I/II/III — depth relative to occlusal plane / A/B/C — relationship to ramus]
  - Winter: [Vertical / mesioangular / horizontal / distoangular]
  - Follicle: [Size — normal / enlarged]
- IAN relationship: [Inferior to roots — separation visible / superior / lingual / no clear separation — CBCT may be indicated]
- CBCT taken: [Y/N — IR(ME)R justification if Y]
- MHx: [MRONJ risk (bisphosphonates), anticoagulants, bleeding disorder, immunosuppression]
- BP: [If indicated]
- Sedation considered: [N / Inhalation / IV — cross-reference sedation record]

CONSENT (Montgomery, written): Risks specific to third molar removal —
- Common: pain (peaks 24-48h, manageable), swelling (peaks 48-72h), bruising, trismus (3-7 days), sutures
- Uncommon: dry socket (~15-20% lower 8s, higher in smokers), bleeding requiring return
- Rare but specific:
  - Lower 8s: temporary IAN paraesthesia (~5%, permanent <1% — adjust per CBCT proximity); lingual nerve injury (~0.5% temporary, <0.1% permanent — if lingual flap)
  - Upper 8s: sinus communication (~5-10% depending on root position), oro-antral fistula if not closed
  - Both: jaw fracture (very rare; atrophic mandible / large cyst contexts)
Alternative: leave in situ + monitoring (if no pathology — but NICE TA1 mandates pathology before removal). Coronectomy (if very high IAN risk on CBCT). Patient understands and consents in writing.

LA: [Agent + total volume — IDB / infiltration / long buccal / lingual / supplemental]. Profound anaesthesia confirmed. [If sedation — cross-reference sedation note]

SURGICAL PROCEDURE:
- Incision: [Buccal sulcular + distal relieving / envelope]
- Flap: [Full-thickness mucoperiosteal buccal — NO lingual flap unless specifically indicated]
- Bone removal: [Round bur / piezo — buccal + distal exposure / volume]
- Sectioning: [Crown + roots / coronectomy if IAN risk + sectioning to leave roots]
- Delivery: [Elevation — Coupland's / Warwick James / Cryers / luxator]
- Lingual nerve protection: [Retractor used Y/N / lingual flap NOT raised — explicit]

INTRA-OP FINDINGS: [IAN exposed Y/N / sinus exposure Y/N / smooth — none]

SOCKET MANAGEMENT: [Inspected, irrigated saline, follicle removed, sharp bone smoothed, debris removed]

CLOSURE:
- Sutures: [Vicryl 3-0 / silk — number — sites — interrupted]
- Haemostatic adjunct: [Pressure pack / collagen / tranexamic acid mouthwash]

POST-OP INSTRUCTIONS (verbal + written leaflet given): Standard extraction aftercare + specific re: trismus (jaw exercises if persistent), CHX mouthwash from day 2 if available, contact for paraesthesia review.

PRESCRIPTIONS: [Per SDCEP — typically no antibiotic unless indicated]

REVIEW: [Suture removal at 7-10 days. Paraesthesia review at 1 week, 6 weeks, 6 months if presents.]

Try the wisdom tooth (third molar) extraction note in the live demo → No account needed.

What good looks like — a worked example

The same wisdom tooth (third molar) extraction template, completed for a realistic case.

TOOTH: LR8 (FDI 48)
NICE TA1 INDICATION: Recurrent pericoronitis — 3 documented episodes in past 12 months (March, August, today). Plus distal caries on LR8 making it non-restorable. NICE TA1 criteria fully met.

PRE-OP ASSESSMENT:
- Pre-op radiograph: OPG today (quality A)
- Classification: Pell & Gregory Class II / B (depth at occlusal plane, partial ramus relationship). Winter: mesioangular impaction.
- Follicle: Slightly enlarged but within normal range.
- IAN relationship: IAN canal inferior to roots with apparent separation ~2mm. Low-risk for IAN involvement.
- CBCT: Not taken — OPG adequately shows separation. ALARP (IR(ME)R 2017) justified.
- MHx: Fit and well. No MRONJ risk. No anticoagulants. No bleeding disorder.
- BP: 118/76. Normal.
- Sedation: Not required — patient comfortable with LA only.

CONSENT (Montgomery, written): Risks specific to LR8 —
- Common: pain (peaks 24-48h, manageable), swelling, bruising, trismus 3-7 days, resorbable sutures
- Uncommon: dry socket ~15-20% lower 8s (non-smoker so lower end of range)
- Rare: IAN paraesthesia temporary ~2-3% given OPG separation (permanent <0.5%), lingual nerve injury <0.5% (no lingual flap planned), jaw fracture very rare in fit young adult
Alternative: leave in situ — not viable given recurrent pericoronitis + non-restorable. Coronectomy not indicated (IAN risk low per OPG). Patient understands, consents in writing.

LA: IDB articaine 4% w/ adrenaline 1:100,000 — 1.7ml (1 cartridge). Long buccal — articaine 4% 1:100,000 — 0.5ml. Lingual topical via diffusion. Total 2.2ml. Profound anaesthesia confirmed.

SURGICAL PROCEDURE:
- Incision: Sulcular LR8 + relieving incision distal to LR7, blade #15
- Flap: Full-thickness mucoperiosteal buccal only. NO lingual flap (preserves lingual nerve).
- Bone removal: Round bur (#6) buccal cortex exposure. Distal bone removal to expose CEJ.
- Sectioning: Vertical section through crown, then between mesial and distal roots. Crown removed first, then each root separately.
- Delivery: Mesial root — Coupland's elevator. Distal root — Cryers elevator.
- Lingual nerve protection: Lingual retractor placed at all times during distal bone removal. Lingual flap NOT raised.

INTRA-OP FINDINGS: No complications. IAN not exposed. Socket walls intact. No bone fracture.

SOCKET MANAGEMENT: Inspected — no retained roots. Follicle removed. Irrigated saline. Sharp bony edges smoothed.

CLOSURE:
- Sutures: Vicryl 3-0, 2 sutures — 1 along sulcular, 1 closing relieving incision (interrupted)
- Haemostatic adjunct: Pressure pack 5min — haemostasis achieved

POST-OP INSTRUCTIONS (verbal + written leaflet): Standard extraction aftercare. Specific re: trismus expected 3-7 days — gentle mouth-opening exercises from day 3. CHX 0.2% mouthwash twice daily from day 2 (rinse only). Sutures resorb 2-3 weeks. Contact immediately if uncontrolled bleeding, dry socket symptoms (onset day 2-4), or any lip/chin numbness persisting beyond 24h.

PRESCRIPTIONS: Analgesia — ibuprofen 400mg + paracetamol 1g PRN, alternate. NO antibiotic — patient immunocompetent, no systemic signs. SDCEP-compliant.

REVIEW: No routine review (resorbable sutures). Contact if complications. Specific note: if any persistent numbness, contact immediately for review.

Compliance: the medico-legal angle

• NICE TA1 Guidance on the Extraction of Wisdom Teeth (2000, reviewed 2015) — pathology must be present. Prophylactic removal NOT recommended.
• BAOMS 2020 Lower Third Molar Surgery update — current UK specialist guidance.
• Montgomery — IAN/lingual nerve risk is material to wisdom tooth consent and must be quantified.
• IR(ME)R 2017 — CBCT justified ONLY when 2D shows IAN proximity that needs 3D clarification. IRR 2017 ALARP principle.

Common documentation mistakes

• Removing a wisdom tooth without documenting NICE TA1 pathology — a significant indemnity gap; extraction-related claims are a frequent category of UK GP dental indemnity claims.
• Lingual flap raised routinely for lower 8s — exposes lingual nerve unnecessarily.
• IAN paraesthesia risk not quantified in consent — Montgomery breach.
• CBCT taken without IR(ME)R justification — radiation dose breach.
• No written post-op given (or not documented) — GDC Principle 4 + indemnity weakness.

Sources

• 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)
• NICE TA1: Guidance on the extraction of wisdom teeth (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)

Frequently asked questions

Patient leaflets for this treatment

• After Your Wisdom Tooth Removal
• Your Guide to Wisdom Tooth Removal
• Caring for Stitches After Dental Surgery
• Soft Food Guide After Dental Surgery

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