Procedure to be carried out: Simple Extraction of Lower Left Second Premolar Tooth

Patient details: age 82, Female,

Social Habits: no smoking, no drinking alcohol

Medical history: High Blood Pressure – tacking Ramipril 5 mg 1x day

No other medical concerns, no allergies

Last visit and last treatment: 11th June 2024, Routine Examination

Clinical area: NHS Dental Practice

Preparation of the clinical area for Simple Extraction of LL5:

I am wearing my scrubs, I have short nails, I am not wearing any jewellery, I washed
my hands in line with HTM 01-05 regulations, as stated in the handwashing poster
found above each handwashing sink and after that I used rinse-free hand
disinfection gel on my hands and wrists. I am wearing Personal Protective
Equipment (PPE) that I put in the following order: first I put on the plastic apron and
tied at the waist, second, I put on the disposable face mask and made sure it covers
my nose, mouth and chin, then I got the visor and lastly the disposable nitrile
powder-free examination gloves.

I made sure that surgery is kept dry and adequately ventilated at all times to
eliminate exposure of airborne materials, toxic hazards and improve the comfort of
dental staff and patients. Temperature, humidity, and ventilations systems are
regularly maintained/checked following HTM 03-01 specialised ventilation for
healthcare premises guidance. Natural light combination with ambient lighting is
used to establish a comfortable environment in a way that helps the patients feel
confident and calm.

 I switched on and visually checked all the equipment required for the
procedure according to the manufacturer’s guidelines:
 Air compressor, which is located downstairs, I switched on the power by
pressing the switch button on the wall, and then pulled on the safety valve to
test it which released a hiss of escaping air. After I had done that, I watched
the pressure gauge, waiting for the needle to stop moving. This signifies that
the air inside has reached optimum pressure.
 X-ray Machine, I switched on the power by pressing the red switch button on
the wall, and visually checked if the equipment works within diagnostic
reference levels (DRL), checked if warning lights and alarms functioning
correctly, checked if isolation switch is working, and I checked if the arm is not
loose and moving, and if the head is in good working condition with the
collimator on, recording the findings in the Log in record sheet.
 Dental chair- I switched on the power by pressing the green switch button
from the bottom of the dental chair unit, and I filled a reservoir bottle with
freshly made distilled water and water lines decontamination solution
( tosylchloramide sodium solution), in a concentration of 10ml solution to
 990ml distilled water, according to manufacturer guidelines, for preventing the
biofilm in dental unit waterlines I attached it to the chair securely and flushed
all dental unit water lines (DUWL) like 3 in1 syringe, slow and fast speed hand
pieces and scale and polish, for 2 minutes and flushed again for 30 seconds
between each patient (HTM01-05). This is done to remove stagnant water
and to also reduce the microbiological count within the water lines and to
prevent cross contamination. I am aware that Legionella and Pseudomonas
bacteria can be spread through the handpieces to the patient or staff and can
cause mild to severe illness.
 The Suction line was switched on together with the dental chair, and now
used my finger to completely cover the Regulator Port to check the suction
strength.
 Amalgamator- I switched on the power by pressing the switch button on the
wall, hearing the beep sound confirming that the amalgamator is on.
 Light cure- I switched the power on and checked it was working by removing
the light cure and placing it back on the charging unit watching the charging
light come on.
 switched on the computer from the plug and pressed the on/off button at the
bottom of the screen which then brought power to the computer and logged
into the system.

All the equipment was in good working condition for the day.

All staff in our practice are responsible for checking and setting up the
Decontamination room every morning, by turning all the equipment on - the lights
pressing the swich on, the fun extractor, that is very important because ensures a
good ventilation taking out the air from the room and bringing in fresh air, the
illuminated magnifier by pressing the switch on, and the Autoclave type N that I filled
with freshly distilled water and I run an autoclave test cycle using TST strip to test
the sterilising conditions. Before the cycle starts, I do the safety checks looking if the
door seal is intact and checking for the door pressure interlock and door closed
interlock. During this cycle the air is sucked out of the vacuum chamber which
creates a steam which allows it to contact all surfaces, including any hollow
instruments. The autoclave heats to 134 degrees Celsius and holds a bar pressure
of 2.25 for 3 minutes. A full cycle length is 15 minutes, and I knew the test was
successful when the yellow circle present on the TST strip had turned to purple once
the cycle had complete. I write down all the findings in the Log sheet, and signed
with my initials, together with the cycle number, the Autoclave model and serial
number. There are no other automatic cleaners in my practice. I scrubbed the dirty
washing sink and the instruments rinsing sink with cream cleaner paste, the taps as
well, making sure there is no limescale deposits, and then I cleaned them with warm
water. I sprayed all the flat work surfaces with disinfectant spray 2 in 1 anti -microbial
non- alcoholic surface cleaner and wiped them with paper towels.

Back in surgery room, I sprayed all the flat work surfaces with disinfectant spray 2 in
1 anti -microbial non- alcoholic surface cleaner and wiped them with paper towels.
For the dental chair, dental light, control panels and for the bracket table that holds 3
in 1, slow and fast speed hand pieces and Ultrasonic scaler. I used anti-microbial
surface cleaning pre-saturated and alcohol-free wipes following manufactures
guidelines (we don’t apply disposable covers to the dental chair handles and
headrest in the surgery room I worked this day, but we do it in other surgery rooms
were the dental chair have any sign of wear or tear, and I am aware that the best
practice according to HTM 01-05 guidelines Best Practice there should be
disposable covers applied to the aspirator tubes, control panels and handles dental
light). Computer keyboard is covered with protective silicone cover. I clean these
areas in between each patient with anti-microbial cleaning wipes following
manufactures instructions. I prepared the dirty instruments box, which is lockable,
rigid and puncture proof by spraying it with disinfectant spray 2 in 1 anti -microbial
non- alcoholic surface cleaner and wiped it with paper towels.

The patient is an existing patient, and I opened her file records, where I
could see that her last visit was on 11th May 2024, for her routine
examination, when the dentist saw that her lower left second premolar
tooth is severely decayed and mobile, and because already had a
pulpectomy procedure in the past, recommended an extraction for that
specific tooth, removable prosthesis procedure, a treatment plan that the
patient agreed with. I checked the last radiograph taken and displayed it on the
screen for the dentist to have another look at it, before the procedure, and I opened
patient's medical history to check for any allergies or red flag warnings, to inform the
dentist accordingly. Any change in patient's medical history was documented and
electronically signed and dated at the reception, as for each patient. The patient is
taking High Blood pressure medication, but no other known existing health problems
or allergies of any kind, and I made the dentist aware of this. The planned procedure
is confirmed with the dentist. I made sure I have got the consent from the patient as
a trainee dental nurse to use the information about the treatment for my RoE
records. Patients consent was gained for a trainee dental nurse to assist the clinician
prior to treatment.

On the dentist side I placed the tray with: mirror, straight probe, college tweezers,
upper premolar forceps (after consulting with the dentist, no other extraction forceps
been prepared; I am aware of other extraction forceps that may be required for an
upper premolar such as bayonet extraction forceps, root extraction forceps, eagle
beak extraction forceps), Coupland elevator (size 4 mm) and luxator (D4503 - 3mm
size), sharp surgical scissor, handle needle-holder, anaesthetic safety (blue) needle
hypodermic syringe (27G) and Prilocaine hydrochloride 4% anaesthetic cartridge
B337582AA - 2025/09 (following the dentist guidance, after checking patient's
medical history, solutions without vasoconstrictor can be safely used in hypertensive
patients), synthetic absorbable sterile surgical suture composed of a copolymer
made from 90% glycolide and 10% L-lactide, cotton wool rolls, gauze pieces,
disposable 3 in 1 tip. On the nurse side I placed: the topical anaesthetic gel (5%
lidocaine) and cotton roll, a disposable aspirator tube, a cup of fresh mint mouthwash
and a box with soft tissues. Written post operative instructions and two extra pieces
of gauze into a sterile pouch, been prepared on nurse side before the procedure to
begin, to be handed over to the patient after the extraction.
I changed my gloves and prepared PPE for the dentist and for the patient, as follow:
for the dentist prepared disposable nitrile powder-free examination gloves, plastic
apron, disposable face mask and visor, and for patient prepared the safety googles
and bib.
I politely invited the patient into the surgery room and asked them to have a seat on
the dental chair. I provided the safety googles and covered her with the bib, always
making sure and asked if the patient is comfortable to start the procedure. After got
the consent from the patient to start the procedure, I put a small amount of topical
anaesthetic gel (5% lidocaine) on a cotton roll and handed to the dentist to numb the
oral tissue prior to anaesthesia injection, to reduce the sensation of pain. In the
meantime I removed the anaesthetic safety holder and the long needle hypodermic
syringe from their sterile package, the anaesthesia cartridge as well, and handed
over to the dentist for the anaesthetic injection to be delivered, and after
manufacturer’s recommended waiting time (after 3 to 5 minutes, the numbing agent
will take full effect), when the patient felt confident to carry on, the dentist delivered
the inferior dental (ID) block injection. After manufacturer's recommended waiting
time, when the patient said she feels no pain sensation while dentist is checking the
gingiva using straight probe, the dentist asked the patient consent to begin
extraction. Then, the dentist used the luxator, parallel to the root surface of the tooth
and after incising the gingival attachment, the blade of the luxator is inserted into the
periodontal ligament space and pushed apically, severing the collagen fibers and
acting as a wedge. The periodontal ligament was already widened by the
inflammation of the gingiva and has been disrupted sufficiently, so the dentist
inserted the elevator now, between the bone and tooth roots and rotated to elevate
them out of the sockets. The patient was advised that she may feel some pushing,
wiggling and pulling taking place, but if she feels any pain, to rise her hand. I was
always reassuring and monitoring the patient for signs of medical
emergencies/stress, anxiety, fear.

The dentist used the extraction forceps now, to extract the tooth out, while I was
assisting the dentist by keeping the patient’s head still. Once the tooth has been
removed, the clinician inspected it to ensure all the roots are intact and a rolled-up
sterile gauze piece was placed in the socket area. The patient was asked to bite
down on the swab for 1-2 minutes to stop the bleeding. Then I opened the sterile
surgical suture and handed to the dentist using the ‘’no touch’’ technique, to suture
the gingivae using the handle needle-holder, and after he finished, he used the sharp
surgical scissor to cut off the synthetic absorbable sterile surgical suture. The patient
was constantly monitored and reassured through the entire procedure. Now, the
dentist placed another piece of gauze in the socket are and asked the patient to bite
down on that, for the next 30 to 45 minutes, to stop the bleeding and to help the
blood cloth to form.

Wearing my PPE, after I checked that the extracted tooth is free from amalgam, I
disposed it into the yellow sharp disposal container (rigid and puncture proof, close
to the operator side), using a tweezer, and following HTM07-01 guidelines for best
practice clinical waste management.

I ensured the patient was clean and tidy after the procedure was done, I asked if I
could remove the bib and if can have the googles back and handed over the post
operative verbal and written instruction, as such:

- to avoid poking the socket with their tongue or fingers or bite their cheeks and lips,
as this will result in trauma.
- to avoid eating hard or spicy foods or those which could easily become trapped
within the socket.

- to avoid rinsing their mouths out for 24 hours to avoid clot disturbance.

- to have warm salty mouth washes after every meal, starting the next day, for at
least a week to keep the socket clean and promote healing.

- to rest when at home, but to avoid taking a hot bath or sitting by a fire or in an over-
heated room.

- to refrain from exercise or drinking alcohol or hot drinks for at least 24 hours after
the procedure, as this will raise the blood pressure resulting in clot disturbance and
possible haemorrhage.

- to refrain from smoking for as long as possible to prevent a dry socket occurring.

- if bleeding occurs, to roll up the swab provided and bite down hard for 20 minutes.
If the bleeding persists, contact the dental surgery.

When the patient left the surgery room, I escorted her to the Reception.

A simple dental extraction is where a tooth or its roots are removed from its socket
within the alveolar ridge. The tooth being removed could be a deciduous or a
permanent tooth. Most dental practices undertake the removal of straightforward
extractions on a daily basis using a local anaesthetic to provide pain-free treatment.
Some patients will not tolerate a tooth being removed with a local anaesthetic only.
In this instance the clinician will either refer the patient to another specialist dental
surgery or local hospital where the patient can receive either a form of conscious
sedation or a general anaesthetic. Naturally, if the dental surgery provides conscious
sedation in house the patient may be treated within. Patients have teeth extracted for
various reasons but for today's patent the reason was severe decay, to prevent a
recurrence of the infection.