Dental Extraction Notes with Post-Extraction Care Instructions

Pre-Operative Assessment: Medical and Dental History: The patient has a history of mild dental anxiety and has undergone previous extractions without complications. No bleeding disorders or anticoagulant use were reported. Tooth Assessment and Diagnosis: Examination and radiographs revealed that tooth number 36 was severely decayed with signs of infection and moderate mobility. The root anatomy appeared normal with no significant bone involvement. Consent Documentation: "Verbal and/or written consent was obtained from the patient and/or guardian prior to extraction. The procedure, risks, benefits and alternatives were discussed." Anaesthesia: Type of Anaesthetic Used: Lidocaine 2% with epinephrine 1:100,000 was administered via local infiltration. Onset and Effectiveness: Anaesthesia took effect within 5 minutes, providing adequate numbness for the extraction procedure. Extraction Procedure: Tooth/Teeth Extracted: Tooth number 36 was extracted using the Universal system. Technique Used: A simple extraction technique was employed. Instruments and Materials Used: Forceps and elevators were used during the extraction. Intraoperative Observations: No granulation tissue or cystic changes were observed. The extraction was uncomplicated. Complications (if any): No complications were noted during the procedure. Post-Extraction Management: Haemostasis Achieved: Haemostasis was achieved using gauze pressure. Post-Operative Instructions Given: The patient was advised to apply pressure with gauze for 30 minutes to control bleeding, avoid rinsing or spitting for 24 hours, and maintain a soft diet. Pain management with over-the-counter analgesics was recommended, and the patient was instructed to contact the clinic if excessive bleeding or pain occurred. Medications Prescribed (if any): Ibuprofen 400 mg was prescribed for pain management. Follow-Up Plan: The patient was advised to return for a follow-up appointment in one week to assess healing. Provider Details: Dentist Name and Credentials: Dr. Emily Carter, DDS Dental Assistant (if applicable): Sarah Johnson, Dental Assistant