A Modern Approach to Exodontia, Part 1: Helping to Ensure Successful Implant Outcomes

Dr. Steven L. Rasner
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It is estimated that 21 million teeth are removed each year in the United States alone.1 Add to that fact the meteoric rise in implant dentistry, and the importance of bone-preserving exodontia techniques becomes rather clear. The literature suggests that while only 2% of general dentists are involved in surgical implant dentistry, 7% of clinicians routinely remove teeth.2 Most clinicians would agree that successful implant placement begins with sufficient available bone following tooth removal. A review of the literature reveals that the last textbook dedicated to exodontia, Tooth Extraction: A Practical Guide, by Paul D. Robinson, PhD, BDS, MBBS, FDS, was published in 2000 by Elsevier Health Sciences in the United Kingdom.

This 2-part article is dedicated to the vast changes in armamentarium and technique over the past 20 years, all in the interest of sharing clinically relevant information on bone preservation and the safe care of your patient. Most of the material found in this presentation comes from 30 years of private practice with an emphasis on oral sedation and, hence, a plethora of surgical extractions. Adhering to a protocol that refers out marginally healthy patients still leaves more than enough work to keep a clinician busy for a career. The successful avoidance of a 911 call, or a post-surgical outcome that required hospitalization, over those 30 years was not an accident. It resulted from abiding by the principles set forth in this article.

PRE-SURGICAL RECOMMENDATIONS
It should be clear by the conclusion of this article that the best way to treat a complication is to avoid the complication! The intent of this article is to help the clinician minimize complications. A useful guide for frontline clinicians to be mindful of is “The Rule of Four:”

1. No ASA IIIs or IVs; only ASA I and II patients (Table 1)
2. No children
3. No thirds
4. Not sure? Then no!

Now, before you fill up my inbox with hate mail, I am sure many of you are accomplished in exodontia for some or all of the above. However, I stand firm in the belief that there exists a plethora of challenging extractions with which to fill one’s career. One lawsuit, or even a single disgruntled patient spreading bad will, should be enough to discourage the astute clinician from including these higher-risk patients for even minor oral surgery.

Preoperative Assessment
One could dedicate a book to the importance of gathering an adequate medical history and detailed record taking for successful exodontia. Be certain you carefully review the history with the patient, and call the patient’s doctor if there is anything you feel uncertain about. I will repeat my strong recommendation to limit your services to ASA 1 and ASA 2 patients. There is no prudent reason that you could give a State Board for a complication your patient encountered in your chair when your patient would have been better served in a hospital setting.

MEDICAL MANAGEMENT
It is the responsibility of the clinician to understand the potential complications found in any medically compromised patients and to determine when pre- and/or post-treatment medication(s) or emergency care might be indicated.

It is beyond the scope of this paper to cover all possibilities, but we will review the most common medical conditions seen in the operatory.

Hypertension: Hypertension is the most commonly diagnosed disease worldwide (30% to 45% of the general population)3 and is associated with increased cardiovascular risk and mortality. Alarmingly, up to 49% of these cases are undiagnosed, and as many as 80% are not controlled!4 The dentist has an important role in screening for undiagnosed and undertreated hypertension. Blood pressure should be checked at the initial visit and at each recall visit. It is generally recommended that emergency dental procedures be avoided in patients with a blood pressure greater than 180/110 mmHg.5 It is also the clinician’s responsibility to be aware of the oral side effects of antihypertensive medications.

Diabetes: More than 20% of patients over the age of 65 have diabetes.6 In patients with controlled diabetes, no special treatment is required for routine dentistry, including prophylaxis and dental restorative care (Table 2).

Recommendations for exodontia would include:

1. Continuing with their normal eating; in particular, they should not skip their morning meal
2. Maintaining their usual/prescribed insulin injection protocol
3. Making morning appointments, because cortisol levels are highest at this time and will provide the best blood glucose level
4. That no more than 2 carpules of lidocaine (1:100,000 epinephrine), prilocaine HCL (1:200,000 epinephrine), or bupivacaine (1:200,000 epinephrine) should be delivered for anesthesia7
5. That an antibiotic should be prescribed following therapy
6. That following surgery, the patient’s food intake should include the proper caloric content and protein/carbohydrate/fat ratio to maintain glucose balance.

The most common in-office complication with treatment of the diabetic patient is hypoglycemia. Frequently, this is the result of a depressed glucose level. The clinician should look for mood changes, hunger, and weakness as well as sweating, tachycardia, and mental disturbance.

The Take-Away
It is patently clear that a long list of systemic conditions exists that impact the extraction procedure. Respiratory, liver, endocrine, and renal disease, as well as blood dyscrasias, neurogenic disease, STDs, pregnancy, and breastfeeding all impact our care. Remember and abide by The Rule of Four listed above. If you are not certain whether you need more information or medical clearance, then this rule states that you don’t treat until you are clear. There is no one case worth treating with an unsure approach.

AVOID THIRD MOLAR EXTRACTIONS
That’s exactly what I said! I don’t care if you are the second coming of Karl Koerner. By the way, he is a prosthodontist and, by far, the exception. The return on investment for third molar removal is just not worth it. There is a host of anatomical differences between the second and third molar regions. It will only take one paresthesia case or an airway-compromising hematoma to have you hanging up your forceps forever. It is worth noting that, of the 10 million wisdom teeth removed yearly in the United States, more than 11,000 people suffer permanent paresthesia (numbness of the tongue, lip, and/or cheek) as a consequence of nerve injury during the surgery. This constitutes a silent epidemic of iatrogenic injury that afflicts tens of thousands of people with lifelong discomfort and disability.1

CLOSING COMMENTS
Now that we have addressed the safety of your surgical patients, part 2 of this article, in next month’s issue, will provide the procedural steps and recommended armamentarium for easy and bone-preserving exodontia.


References

  1. Friedman J. The prophylactic extraction of third molars. Am J Public Health. 2007;97(9):1554–1559.
  2. Christensen G. Who should direct and coordinate dental implant placement? Dentaltown. 2007(9)10-14.
  3. Danon-Hersch N, Marques-Vidal P, Bovet P, et al. Prevalence, awareness, treatment and control of high blood pressure in a Swiss city general population: the co laus study. European Journal of Cardiovascular Prevention and Rehabilitation. 2009;16(1)66-72.
  4. Hogan J, Radhakrishnan J. The assessment and importance of hypertension in the dental setting. Dental Clinics of North America. 2012;56:731–745.
  5. Popescu SM, Scrieciu M, Mercut V, et al. Hypertensive patients and their management in dentistry. International Scholarly Research Notes. 2013;410740.
  6. Burgess J. Dental Management in the Medically Compromised Patient Updated Jan 06, 2015; http://emedicine.medscape.com.
  7. My next patient is diabetic: what are the implications for the dental treatment I provide? Canadian Dental Association. 2012. Retrieved from http://oasisdiscussions.ca/2012/10/31/diabetes-dental-treatment/.

Dr. Rasner earned his DMD degree at the University of Pennsylvania. He has completed the Misch International Implant Institute curriculum and the Pikos Institute continuum. Dr. Rasner has been teaching for 19 years. His courses, “Atraumatic Extractions for the GP” and “The Bulletproof Guide to Implant Success,” have been popular at ADA and AGD component society meetings as well as at the national ADA meeting. His newest course, “Hands-on Atraumatic Extractions for the GP,” features 2 days of live-patient experience in his office. He has authored 3 books and more than 50 industry and journal publications. He can be reached via email at drrasner@aol.com.

Disclosure: Dr. Rasner reports no disclosures.

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