Oral and maxillofacial surgery: extractions and minor oral surgery

In short

Exodontia is the planned removal of a tooth from the alveolar bone, and minor oral surgery covers the day-care surgical procedures a general dentist performs under local anaesthesia — surgical removal of impacted teeth, pre-prosthetic surgery, biopsies, cyst enucleation, apicectomy, frenectomy and management of alveolar trauma. It is the most hands-on, medico-legally exposed part of BDS clinical practice: every BDS graduate must be independently competent at it under NCISM/DCI-prescribed training before internship ends. The subject is examined in the final-year Oral and Maxillofacial Surgery paper, in viva on armamentarium and complications, and in NEET-MDS/INI-CET/AIIMS-style entrance MCQs. In interviews — clinic chains (Clove, Sabka Dentist, Apollo White, FMS), hospital OPDs and MDS admissions — the questions are overwhelmingly about anaesthesia dosage, medically compromised patients, consent and complication management.

Explained

Patient assessment, consent and the medico-legal frame

• History first: chief complaint, duration, drug history (anticoagulants, bisphosphonates, steroids, antiepileptics), allergy (penicillin, lignocaine, NSAIDs), bleeding/transfusion history, diabetes, hypertension, cardiac disease, pregnancy, smoking and tobacco/gutkha habit.
• ASA classification guides where you operate: ASA I–II (healthy / mild controlled disease) safely in the dental chair; ASA III (severe disease limiting activity) only with physician clearance; ASA IV–V refer to a hospital setting.
• Local examination: tooth mobility (Miller grade), caries extent, crown integrity, periodontal support, access, mouth opening, adjacent teeth, opposing occlusion.
• Radiographs: IOPA for routine teeth; OPG/panoramic for impacted third molars, multiple extractions and pathology; CBCT when the root is close to the inferior alveolar canal or maxillary sinus, or for impacted canines. Read root number, curvature, dilaceration, hypercementosis, ankylosis, bone density, canal/sinus proximity.
• Informed consent must be written, in a language the patient understands, naming the tooth, the procedure, alternatives and specific risks (pain, swelling, bleeding, infection, nerve injury/numbness, sinus communication, jaw fracture, root retention, TMJ problems). For a minor, the guardian consents; the Supreme Court standard (Samira Kohli v. Prabha Manchanda, 2008) requires real, prior, specific consent — consent for one tooth does not cover another.
• Statutes and standards in Indian practice: Dentists Act, 1948 and DCI/NCISM regulations on registration and professional conduct; the Clinical Establishments (Registration and Regulation) Act, 2010 in adopting states; Bio-Medical Waste Management Rules, 2016 (as amended) — red bag for contaminated plastics/suction tips, yellow for human tissue/extracted-tooth-with-tissue and soiled gauze, white puncture-proof container for needles and scalpel blades, blue for glass; AERB licence, lead shielding and no hand-holding of films for dental X-ray; Drugs and Cosmetics rules for schedule H drugs; records retained (commonly 3 years, longer if litigation is possible).
• Pre-operative checks: blood pressure, random blood sugar/HbA1c in diabetics, INR in patients on warfarin, platelet count where indicated.

Local anaesthesia for oral surgery

• Agents: lignocaine (lidocaine) 2% with adrenaline 1:80,000 is the Indian workhorse; articaine 4% with adrenaline 1:100,000 for infiltration (good bone diffusion); mepivacaine 3% plain for short procedures and cardiac patients; bupivacaine 0.5% with adrenaline for long procedures and post-operative analgesia.
• Maximum safe doses (adult, by body weight): lignocaine with adrenaline 7 mg/kg up to 500 mg absolute; lignocaine plain 4.4 mg/kg up to 300 mg; articaine 7 mg/kg; bupivacaine 1.3 mg/kg up to 90 mg. One 2 mL cartridge of 2% lignocaine = 40 mg.
• Adrenaline limits: healthy adult up to about 0.2 mg (≈ 1:80,000 in 2 mL = 0.025 mg per cartridge); significant cardiac disease limited to about 0.04 mg (roughly 1–2 cartridges) — this is the classic viva number.
• Techniques: maxilla — buccal infiltration (supraperiosteal) plus greater palatine/nasopalatine blocks; posterior superior alveolar and infraorbital blocks for multiple teeth. Mandible — inferior alveolar nerve block (IANB) with lingual, plus long buccal for molar buccal soft tissue; Gow-Gates and Vazirani-Akinosi (closed-mouth) blocks when IANB fails or mouth opening is limited; mental/incisive block for anteriors.
• IANB landmarks: needle 6–10 mm above the occlusal plane of lower molars, at the coronoid notch/pterygomandibular raphe, barrel over the opposite premolars, advance ~20–25 mm to bony contact, withdraw 1 mm, aspirate, deposit slowly.
• Signs of success: lower lip and tongue tingling (IANB); absence of lip numbness means failure, not slow onset.
• Failures and causes: accessory innervation (mylohyoid nerve), bifid canal, infected/inflamed tissue lowering pH, intravascular or too-low deposition, dense bone.
• LA complications: needle breakage (never bend the needle, don't bury to the hub), haematoma (PSA block), trismus from medial pterygoid haematoma, facial palsy from deposition into the parotid (needle too posterior with no bony contact), transient paraesthesia, self-inflicted lip bite in children, and systemic toxicity (excitation then CNS depression) or adrenaline reaction (palpitation, tremor, pallor).

Indications, contraindications and the extraction techniques

• Indications: grossly carious/unrestorable teeth, pulpal or periapical infection where RCT is not feasible or has failed, advanced periodontal disease with grade III mobility, impacted or malpositioned teeth causing pericoronitis or caries, retained deciduous/supernumerary teeth, orthodontic extraction (commonly first premolars), teeth in a fracture line or in a cyst/tumour, prosthetic reasons, pre-radiotherapy clearance of non-restorable teeth, and root-stump removal.
• Absolute/relative contraindications: uncontrolled diabetes, recent myocardial infarction (defer about 6 months where elective), uncontrolled hypertension, bleeding disorders and untreated leukaemia, head and neck radiation field (osteoradionecrosis risk), IV bisphosphonate therapy (MRONJ risk), acute pericoronitis/acute infection with spreading cellulitis in some situations, first and third trimesters of pregnancy for elective work (second trimester is the preferred window), patients on antiplatelet/anticoagulant therapy without planning.
• Intra-alveolar (closed/forceps) extraction steps: (1) check the correct tooth against the record and radiograph; (2) achieve adequate anaesthesia and test it; (3) sever the gingival attachment with a periosteal elevator or BP blade; (4) luxate with an elevator to expand the socket and break the periodontal fibres; (5) apply forceps as far apically as possible, beaks parallel to the long axis, under the gingival margin; (6) deliver with controlled buccolingual and rotational movements plus traction — buccal expansion first in most sites, rotation only for conical single roots (upper central incisor, lower premolar); (7) inspect the tooth for completeness and the socket for bone spicules; (8) compress the socket, irrigate, place a gauze pack and give post-operative instructions.
• Mechanical principles: forceps and elevators work as lever (first-class, wheel-and-axle, wedge) mechanisms; the fulcrum is adjacent bone, never an adjacent tooth. Elevator types — straight (Coupland's No. 1,2,3), Cryer's right/left (triangular, for interradicular bone and roots), Warwick James (straight, right, left), Apexo and root-tip picks, Winter's cross-bar elevators (high force — risk of jaw fracture, avoid in inexperienced hands).
• Forceps: upper straight (anteriors), upper premolar (curved, no beak spike), upper molar right/left (buccal beak pointed for the buccal bifurcation), upper third molar bayonet, upper cowhorn root forceps; lower anterior/premolar, lower molar (both beaks pointed), lower cowhorn (No. 86/23) engaging the bifurcation, lower root forceps. Also periosteal elevator (Howarth/Molt), bone file, chisel and mallet, rongeur, surgical curette, Allis/tissue forceps, needle holder, suture scissors, Austin/Minnesota retractor, straight/contra-angle surgical handpiece with saline irrigation.
• Transalveolar (open/surgical) extraction is indicated for ankylosed teeth, hypercementosis, dilacerated or divergent/curved roots, retained root tips, deeply carious crowns, thick dense bone, and failed closed extraction. Steps: flap design and reflection → bone guttering/removal with a bur under copious saline → tooth sectioning/odontectomy → delivery → socket debridement and irrigation → bone edge smoothing → haemostasis → suturing without tension.
• Flap principles: broad base with adequate blood supply, base wider than the free margin, flap resting on sound bone, incision not over the mental nerve or crossing a frenum, vertical limb at the line angle of a tooth, no sharp angles. Common flaps — envelope (crevicular), triangular (with one vertical release), trapezoidal, semilunar (for apicectomy), Y-shaped and lingual-sparing designs.

Impacted third molars and other minor oral surgery

• Causes of impaction: inadequate arch space, dense overlying bone/soft tissue, ectopic position, obstruction by adjacent tooth, phylogenetic jaw reduction, syndromes (cleidocranial dysplasia).
• Winter's classification (angulation of the long axis to the second molar): mesioangular (commonest, usually easiest for lower 8s), distoangular (most difficult in the mandible because the tooth is removed against the ramus), vertical, horizontal, buccoangular, linguoangular, inverted.
• Pell and Gregory classification: relation to the ramus — Class I (enough space between the second molar and ramus), II (about half covered), III (entirely within the ramus); relation to the occlusal plane — Position A (occlusal surface at or near the occlusal plane), B (between the occlusal plane and the cervical line), C (below the cervical line). Higher class/position = more difficult.
• Maxillary third molars are classified similarly by angulation and depth (A/B/C), and by relation to the maxillary sinus and buccal/palatal displacement; the main risks are tuberosity fracture, displacement into the infratemporal fossa or sinus.
• Difficulty indices: Pederson difficulty index (angulation + depth + ramus relation; score 3–4 slightly difficult, 5–6 moderately, 7–10 very difficult) and the WHARFE assessment.
• Indications for removal: recurrent pericoronitis, distal caries in the second molar, periodontal pocketing, unrestorable caries in the third molar, cyst or tumour, root resorption of the adjacent tooth, tooth in a fracture line, orthodontic/prosthodontic need. Asymptomatic, disease-free impacted teeth may be kept under review (NICE-style guidance; practice in India is moving away from routine prophylactic removal).
• Other minor oral surgical procedures: apicectomy with retrograde filling (MTA) for a failed RCT with a persistent periapical lesion; enucleation, marsupialisation (Partsch) or decompression of cysts; incisional and excisional biopsy (adequate depth, include normal margin, avoid the centre of a necrotic ulcer, do not crush the specimen, store in 10% formalin at about ten times the specimen volume, label and send for histopathology — vital in a country with India's oral cancer burden); frenectomy (labial for a midline diastema, lingual for ankyloglossia); operculectomy; alveoloplasty and pre-prosthetic surgery (tori removal, tuberosity reduction, mylohyoid ridge reduction, vestibuloplasty); incision and drainage of abscesses; coronectomy where the root is intimately related to the inferior alveolar canal; exposure of impacted canines for orthodontics; implant site surgery; management of oro-antral communication (buccal advancement, palatal rotation or buccal fat pad flap).
• Suturing: 3-0 to 4-0 silk (non-resorbable, removed day 5–7) or resorbable vicryl/catgut; interrupted, continuous, figure-of-eight (over a socket), mattress and sling sutures; bite from mobile to fixed tissue, 2–3 mm from the edge, no tension and no suture over a bony defect.

Complications and their management

• Intra-operative: root fracture (retrieve with root forceps/Cryer's or raise a flap; a small, non-infected apical fragment deep near the canal or sinus may be left with documentation and review), alveolar bone or maxillary tuberosity fracture, luxation of the adjacent tooth, soft-tissue laceration and burns from the bur, extraction of the wrong tooth (replant immediately and splint, disclose, document, inform), oro-antral communication (confirm clinically — nose-blowing test used cautiously — and close primarily if > 2 mm; antibiotics, decongestants, no nose blowing), displacement of a root into the sinus, antral floor or submandibular space, fracture of the mandible (angle region, atrophic mandible), needle breakage, swallowing or aspiration of a tooth (chest/abdominal radiograph), TMJ dislocation (reduce by Hippocratic manoeuvre), and haemorrhage.
• Bleeding management ladder: pressure with gauze 15–20 minutes → local measures (socket compression, figure-of-eight suture, resorbable gelatin sponge, oxidised cellulose, collagen plug, tranexamic acid 4.8% mouthwash, bone wax for bony bleeders, electrocautery or ligation for a vessel) → systemic measures and referral for a bleeding disorder. Causes are grouped as primary (during surgery), reactionary (within 24 hours, as the vasoconstrictor wears off) and secondary (after about 5–7 days, usually infection).
• Post-operative: pain peaking at 6–12 hours, swelling peaking at 48–72 hours, trismus, ecchymosis, dry socket (alveolar osteitis) — severe throbbing pain 2–4 days later, empty/denuded socket with bare bone, foul odour, no pus or pyrexia; more common in mandibular molars, smokers, oral contraceptive users and after difficult extractions; managed by gentle irrigation with warm saline, a medicated obtundent dressing (zinc oxide-eugenol or Alvogyl), analgesia and review — *curettage is contraindicated*. Also infection/abscess, osteomyelitis, paraesthesia or anaesthesia of the inferior alveolar/lingual/mental nerve (classify as neurapraxia, axonotmesis, neurotmesis; most neurapraxias recover in weeks to months), sequestration of bone spicules, and delayed healing.
• Socket healing stages: clot (first 24 hours) → granulation tissue by days 4–7 → connective tissue and epithelialisation by 2–3 weeks (soft tissue closes by about 3–4 weeks) → woven bone fill by 6 weeks, radiographic bone trabeculation by 6 months, with about 40–60% ridge width lost in the first 6 months.
• Post-operative instructions: bite on gauze for 30–45 minutes, no spitting, rinsing, smoking or straws for 24 hours, cold compress on day 1, soft cold diet, warm saline rinses from day 2, take prescribed medicines, do not probe the socket with the tongue, report excessive bleeding or swelling.
• Pharmacology: analgesia — paracetamol 500–1,000 mg (max 4 g/day), ibuprofen 400 mg 8-hourly, the paracetamol-ibuprofen combination, diclofenac, tramadol for severe pain. Antibiotics only when indicated (spreading infection, immunocompromise, prolonged surgical removal, osteomyelitis) — amoxicillin 500 mg 8-hourly, amoxicillin-clavulanate 625 mg, metronidazole 400 mg for anaerobes, clindamycin or azithromycin in penicillin allergy. Routine antibiotic cover for a simple extraction in a healthy patient is not justified and feeds antimicrobial resistance (ICMR treatment guidelines and the National Action Plan on AMR).
• Antibiotic prophylaxis for infective endocarditis is now limited to high-risk cardiac patients (prosthetic valve, previous IE, certain congenital heart disease) undergoing procedures involving gingival/periapical manipulation: amoxicillin 2 g orally (50 mg/kg in children) 30–60 minutes before, or clindamycin 600 mg if penicillin-allergic. Guidance has narrowed over the years and differs slightly between AHA, ESC and NICE — check the current local protocol.
• Medically compromised patients: diabetes — morning appointment, do not skip the meal/insulin, ensure glycaemic control (random blood sugar broadly under ~200 mg/dL and HbA1c ideally < 7–8% for elective surgery); hypertension — defer elective extraction if BP is very high (commonly above about 180/110 mmHg) and refer; anticoagulants — do not stop warfarin for a simple extraction if INR ≤ 3.5–4.0, use local haemostatic measures; DOACs are usually continued or the morning dose delayed for simple procedures on physician advice; low-dose aspirin is continued. Bisphosphonates/denosumab/antiangiogenics — assess MRONJ risk, prefer non-surgical options, atraumatic technique, primary closure, chlorhexidine; "drug holidays" are debated. Pregnancy — second trimester, left lateral/semi-recumbent position, lignocaine with adrenaline and paracetamol are acceptable, avoid NSAIDs in the third trimester and tetracyclines throughout, shield for radiographs.

Key points

• Exodontia - painless removal of a tooth in toto with minimal trauma to the investing bone and soft tissue, leaving a wound that heals uneventfully.
• ASA II ceiling - routine dental-chair surgery; ASA III needs physician clearance, ASA IV–V a hospital.
• Lignocaine maximum - 7 mg/kg with adrenaline (cap 500 mg); one 2 mL cartridge of 2% = 40 mg and carries 0.025 mg adrenaline at 1:80,000.
• Cardiac adrenaline limit - about 0.04 mg, i.e. roughly 1–2 cartridges of 1:80,000.
• IANB failure sign - no lower lip numbness; anaesthetise again rather than wait.
• Facial palsy after IANB - needle advanced too far posteriorly into the parotid with no bony contact.
• Elevator principles - lever, wedge and wheel-and-axle; fulcrum on bone, never on an adjacent tooth.
• Rotation is allowed only for conical single-rooted teeth (upper central incisor, lower premolar); multirooted teeth need buccolingual expansion.
• Winter's classification - angulation: mesioangular, distoangular, vertical, horizontal (distoangular is the hardest lower third molar).
• Pell and Gregory - ramus relation Class I/II/III and depth Position A/B/C.
• Transalveolar extraction - flap, bone removal, tooth sectioning, delivery, debridement, suture; for ankylosis, hypercementosis, curved roots and root stumps.
• Flap rule - base wider than the apex, flap on sound bone, avoid the mental nerve and frenum.
• Dry socket - painful empty socket at day 2–4 with no pus; irrigate and dress, never curette.
• Bleeding types - primary (intra-operative), reactionary (within 24 h), secondary (5–7 days, infectious).
• Oro-antral communication - close surgically if more than ~2 mm; give antibiotics, decongestants and nose-blowing precautions.
• Warfarin - continue for simple extraction when INR ≤ 3.5–4.0; rely on local haemostasis.
• No routine antibiotics for uncomplicated extraction in a healthy patient — ICMR/NAP-AMR position.
• Biopsy fixative - 10% formalin at roughly 10× the specimen volume; include a margin of normal tissue.
• Waste segregation - yellow (tissue, extracted tooth with tissue, soiled gauze), red (contaminated plastic), white (sharps), blue (glass) under BMW Rules, 2016.

Formulas and examples

Example 1 — maximum lignocaine for a 60 kg adult.

• Allowable dose = 7 mg/kg × 60 = 420 mg (below the 500 mg absolute cap, so 420 mg governs).
• Per cartridge of 2% in 2 mL = 2 × 10 × 2 = 40 mg.
• Maximum cartridges = 420 / 40 = 10.5, i.e. 10 cartridges.
• Adrenaline check: 10 × 0.025 = 0.25 mg — this exceeds the 0.2 mg healthy-adult ceiling, so adrenaline limits you to 8 cartridges (0.2 mg), not 10. The lower of the two limits always rules.

Example 2 — a 20 kg, 6-year-old child.

• Lignocaine with adrenaline at 7 mg/kg → 7 × 20 = 140 mg = 140/40 = 3.5 cartridges.
• Many paediatric protocols use a more conservative 4.4 mg/kg → 4.4 × 20 = 88 mg = 2.2 cartridges; take the conservative figure in a child.
• Warn the guardian about lip/cheek biting while the lip is numb for 2–3 hours.

Example 3 — cardiac patient (stable angina, 70 kg).

• Adrenaline ceiling 0.04 mg; 1:80,000 in 2 mL gives 0.025 mg per cartridge → 0.04/0.025 = 1.6, so a maximum of 1 cartridge safely (or 2 cartridges of 1:200,000, each 0.01 mg = 0.02 mg total).
• Better choice: mepivacaine 3% plain, 2 mL = 60 mg (no vasoconstrictor); limit 6.6 mg/kg → 462 mg, capped at 400 mg, so dosage is not the constraint.
• Use slow aspirating injection, short appointment, morning slot, BP monitoring.

Example 4 — difficulty index for a mandibular third molar.

• Findings: distoangular angulation (score 4), Position B depth (score 2), Pell and Gregory ramus Class II (score 2).
• Pederson index = 4 + 2 + 2 = 8 → very difficult; plan a transalveolar approach with sectioning, longer chair time and a pre-operative CBCT if the canal is superimposed.

Example 5 — warfarin patient for two mandibular extractions.

• INR measured on the morning of surgery = 2.8 → within the ≤ 3.5–4.0 window, so do not stop warfarin.
• Plan: single quadrant, atraumatic technique, gelatin sponge in each socket, figure-of-eight sutures, 4.8% tranexamic acid mouthwash 10 mL four times daily for 2 days, paracetamol (not NSAIDs, which add bleeding and interact with warfarin), written emergency contact.

Where it is used

• Government and teaching hospitals: OMFS OPD and minor OT in dental colleges, district hospitals and CHCs — extractions, I&D, biopsies and trauma triage under the National Oral Health Programme.
• Private general practice and corporate dental chains (Clove Dental, Sabka Dentist, Apollo White, FMS, Partha Dental): extraction and surgical removal of third molars are among the highest-volume, highest-revenue chairside procedures; implant site preparation depends on atraumatic extraction and socket preservation.
• Oral cancer screening and tertiary care: Tata Memorial, AIIMS, regional cancer centres — incisional biopsy of leukoplakia, OSMF and suspicious ulcers by the general dentist feeds the referral chain; India carries a very large share of the world's oral cancer burden, largely tobacco-related.
• Armed Forces Dental Corps, Railways, ESIC and CGHS dental units, and dental officers in state health services, where exodontia is the bulk of daily work.
• Medico-legal and insurance work: age estimation from third molars, documentation of dental injuries, consent and record audits under the Clinical Establishments Act; NABH-accredited clinic protocols for sterilisation and biomedical waste.
• MDS specialisation and academia: entry to OMFS residency, orthognathic surgery, maxillofacial trauma, cleft and TMJ surgery, implantology — all built on minor oral surgery fundamentals.

Interview questions

• Q: Define an ideal extraction. A: Painless removal of the whole tooth with its root, with minimal trauma to investing bone and soft tissue, so that the socket heals uneventfully and no prosthetic problem is created.
• Q: How many cartridges of 2% lignocaine with 1:80,000 adrenaline can you give a healthy 60 kg adult? A: Lignocaine allows about 10 cartridges (420 mg at 7 mg/kg), but adrenaline caps it at about 8 cartridges (0.2 mg), so the adrenaline limit governs.
• Q: A patient develops facial asymmetry and cannot close one eye right after an IANB. What happened? A: The anaesthetic was deposited into the parotid gland, blocking the facial nerve — a transient palsy; reassure the patient, protect the eye with a pad and lubricant, and it resolves as the drug wears off.
• Q: Which mandibular third molar impaction is the most difficult and why? A: Distoangular, because the tooth has to be removed against the ascending ramus, which means more bone removal and sectioning.
• Q: Differentiate dry socket from post-extraction infection. A: Dry socket presents at day 2–4 with severe pain, an empty socket and no pus or fever; infection shows pus, swelling, fever and a retained clot. Dry socket is dressed, infection is drained and treated with antibiotics.
• Q: Would you stop warfarin before a single extraction? A: No — if the INR is 3.5 or below on the day, continue it and control bleeding locally with sutures, a haemostatic sponge and tranexamic acid mouthwash; stopping risks thromboembolism.
• Q: Do you give antibiotics for every extraction? A: No. A simple extraction in a healthy patient needs none; antibiotics are for spreading infection, immunocompromise, prolonged surgical removal or specific prophylaxis, in line with ICMR guidance on antimicrobial resistance.
• Q: State the four principles of flap design. A: A base wider than the free margin for blood supply, flap margins resting on sound bone, adequate size for access without tension, and avoidance of vital structures such as the mental nerve, lingual nerve and frena.
• Q: How do you manage a 3 mm oro-antral communication found after extracting an upper first molar? A: Close it the same day with a buccal advancement flap, prescribe antibiotics and a decongestant, and instruct the patient not to blow the nose, sneeze with the mouth closed or use straws.
• Q: When is it acceptable to leave a root fragment behind? A: When the fragment is small (about 3–4 mm or less), non-infected, deeply placed and intimately related to the inferior alveolar canal or sinus, so that retrieval would cause more harm — the decision, the reason and the radiograph must be documented and the patient informed and reviewed.
• Q: What is a coronectomy and why do it? A: Deliberate removal of only the crown of a lower third molar, leaving the roots in situ, when the roots are intimately related to the inferior alveolar nerve — it greatly reduces the risk of permanent nerve injury.
• Q: Why is the second trimester preferred for extraction in pregnancy? A: Organogenesis is complete, the miscarriage risk of the first trimester has passed and the patient is not yet so gravid that supine positioning and preterm labour are concerns; lignocaine with adrenaline and paracetamol are acceptable, NSAIDs in the third trimester are not.
• Q: How do you dispose of an extracted tooth and a used scalpel blade? A: The tooth with attached soft tissue goes in the yellow bag (a clean tooth may be treated as sharps/general per local protocol) and the blade in the white translucent puncture-proof container, as per the Bio-Medical Waste Management Rules, 2016.

Common mistakes

• Quoting the lignocaine maximum but forgetting that adrenaline is usually the binding limit, or confusing mg per cartridge with mL.
• Writing "wait for the block to act" when the lip is not numb — a failed IANB must be repeated or switched to Gow-Gates, not waited out.
• Using an adjacent tooth as the elevator fulcrum, or rotating a multirooted molar — both cause avoidable fractures.
• Curetting a dry socket, or prescribing antibiotics for it, instead of irrigating and placing an obtundent dressing.
• Stopping anticoagulants or antiplatelets routinely before a simple extraction, which risks a thromboembolic event far more serious than the bleeding.
• Mixing up Winter's classification (angulation) with Pell and Gregory (ramus relation and depth), or reversing Class I/II/III with Position A/B/C.
• Vague consent — naming no tooth, no specific risk of nerve injury or sinus communication — and poor records; this is where most dental litigation in India succeeds.
• Operating without reading the radiograph for root curvature, canal proximity or a bifid canal, then being surprised by a fracture or paraesthesia.

Related topics

Medical emergencies in the dental clinic · Endodontics: root canal treatment · Periodontology · Fixed prosthodontics: crowns, bridges and dental implants · Oral pathology and oral medicine · Oral radiology and imaging