✅ Abstract
Tooth extraction is a common procedure in pediatric dentistry and requires adaptation of adult techniques to the child’s unique anatomy, behavior, and medical needs.
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Emphasis is placed on safety (weight-based dosing, avoidance of contraindicated drugs), minimizing trauma, and family-centered communication. Key practice statements are drawn from recent AAPD guidance and contemporary systematic reviews and clinical guidelines.
✅ Introduction
Extractions in children range from simple removal of non-restorable primary teeth to surgical removal of first permanent molars or retained roots. Pediatric exodontia differs from adult exodontia because of developing dentition, thinner cortical bone, presence of succedaneous tooth buds, behavioral considerations, and differing pharmacologic safety profiles. High-quality guidance aims to minimize trauma, preserve future occlusion, and ensure safe pain control and healing.
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Common indications for extraction in children include: non-restorable carious primary teeth causing pain or infection, presurgical removal for orthodontic reasons, supernumerary or ectopic teeth, trauma with poor prognosis, and first permanent molar extractions when indicated by severe disease and orthodontic planning. Preoperative assessment should document medical history, allergies, developmental status, current medications, and any bleeding or immune problems that might alter management (for example, immunosuppression, anticoagulants). For medically complex children, consult appropriate medical specialists and consider antibiotic prophylaxis per established guidance.
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Obtain age-appropriate informed consent and assent as applicable; explain the procedure to caregivers and the child using simple, honest language and visual aids. Use previsit imagery, tell-show-do, and distraction techniques for cooperative behavior; for anxious or special-needs patients, consider nitrous oxide, protective stabilization, sedation, or general anesthesia following AAPD and sedation safety guidance. Behavior guidance should be individualized and documented.
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Use weight-based dosing and select agents recommended for children. Topical anesthetic can reduce injection pain; choose needle size appropriate for age and site. Avoid agents and formulations contraindicated for certain ages or medical conditions (e.g., avoid benzocaine in infants under 2 years with methemoglobinemia risk; be cautious with articaine in very young children). Aspiration before injection and slow injection technique reduce complications. Always document agent, dose (mg/kg), injection site, and any adverse responses.
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➤ Atraumatic principles: Aim to minimize trauma to alveolar bone and soft tissues to preserve the developing dentition and future eruption paths. Luxation and controlled rotational forces (for single-rooted deciduous teeth) are commonly used, followed by forceps retrieval. For multi-rooted primary molars or retained roots, surgical techniques (elevation, careful sectioning, and minimal bone removal) may be required.
➤ Forceps use and innovations: Use pediatric-sized forceps designed to adapt better to primary teeth. Conventional extraction forceps and elevators remain standard; newer instruments such as “physics forceps” have been studied—some trials suggest reduced extraction time or reduced soft-tissue trauma, but systematic reviews conclude current evidence is low quality and insufficient to claim clear superiority. Clinicians should be trained in any new instrument and apply it only when appropriate for tooth shape and root anatomy.
➤ Technique tips:
• Visualize and protect the developing permanent tooth bud; avoid excessive apical pressure.
• Use controlled buccolingual luxation for single-rooted teeth and careful sectioning for multirooted teeth when necessary.
• Ensure adequate access and visualization; consider suturing if soft-tissue flaps are raised.
• Always check the socket for retained fragments and confirm hemostasis before discharge.
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For postoperative pain after simple or surgical extractions, nonopioid analgesics—particularly ibuprofen—are recommended as first line; combining ibuprofen with acetaminophen is effective when single agents are insufficient. Avoid codeine and tramadol in children under 12 years. Use weight-based dosing and counsel caregivers on dosages and maximum daily limits. Antibiotics are not routinely indicated for uncomplicated extractions; reserve for systemic involvement (fever, cellulitis), immunocompromised status, or where local infection cannot be controlled—follow AAPD/AHA guidance for prophylaxis in specific medical conditions.
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Give clear verbal and written instructions to caregivers covering: expected duration of numbness (avoid lip/cheek/tongue biting), control of bleeding (bite on gauze for 20–30 minutes; call if heavy bleeding), pain control (weight-based analgesic schedule), diet (soft foods for 24–48 hours), oral hygiene (gentle rinsing after 24 hours as tolerated; avoid vigorous rinsing), and signs of infection or complications (fever, persistent swelling, severe pain). Arrange follow-up or emergency contact information. Postoperative instruction templates from AAPD are practical to adapt for local use.
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➤ First permanent molars (FPMs): Extraction timing for FPMs influences spontaneous space closure; multidisciplinary discussion with orthodontics is important when considering extraction of severely compromised FPMs. Recent reviews outline orthodontic and developmental consequences—plan timing according to the child’s dental age and occlusal development. MDPI
➤ Ankylosed primary molars or retained roots: Surgical approach with careful bone removal and preservation of the follicle is often required.
➤ Traumatic injuries: Immediate assessment of tooth viability, root formation stage, and adjacent structures guides extraction versus conservative management.
馃搳 Table: Indications for Tooth Extraction in Pediatric Dentistry
| Indication | Clinical Rationale | Considerations |
|---|---|---|
| Extensive caries with pulp involvement | Prevents spread of infection and pain when restoration is not feasible | Assess proximity to permanent tooth germ; consider pulpectomy first |
| Severe dental trauma | Extraction when the tooth is non-restorable or poses aspiration risk | Evaluate soft tissue healing; radiograph for root fragments |
| Orthodontic reasons (space management) | Facilitates eruption guidance or alignment correction | Coordinate timing with orthodontist to preserve arch balance |
| Retention or ankylosis of primary teeth | Allows eruption of permanent successor and prevents malocclusion | Radiographic evaluation required to confirm ankylosis or absence of permanent tooth |
| Supernumerary or ectopic teeth | Prevents impaction or displacement of adjacent permanent teeth | Surgical extraction may be indicated with careful bone preservation |
| Infection or abscess unresponsive to endodontic treatment | Eliminates chronic infection source and discomfort | Ensure systemic infection control and follow-up for healing |
| Impacted or malformed teeth | Prevents cyst formation or adjacent root resorption | Use radiographic guidance; consider referral to oral surgeon |
馃挰 Discussion
Pediatric exodontia is both a technical and behavioral challenge. Recent AAPD guidance emphasizes individualized planning, conservative pharmacology, and thorough behavior support and documentation to reduce adverse events and improve the patient experience. There is growing interest in instruments and techniques that claim to be more atraumatic (e.g., physics forceps), but the systematic evidence is currently limited and of low quality—clinicians should weigh potential benefits against training needs and patient selection. Analgesic strategies favor NSAIDs like ibuprofen, alone or combined with acetaminophen, and explicitly discourage opioids such as codeine and tramadol in young children. Finally, good outcomes depend on clear caregiver communication and easy access to emergency advice if complications arise.
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Extractions in pediatric dentistry must combine sound surgical technique adapted to developing dentitions with age-appropriate pain management and behavior guidance. Key recommendations for practice are: thorough preoperative assessment and medical review; use of pediatric-appropriate instruments and atraumatic techniques; weight-based local anesthesia and analgesia following current guidelines; individualized behavior management strategies; avoidance of opioids like codeine/tramadol in young children; and explicit, written postoperative instructions for caregivers. Where evidence is evolving (e.g., novel forceps), apply new tools cautiously and prioritize training and case selection. Adhering to contemporary AAPD and evidence-based guidelines improves safety and clinical outcomes.
馃摎 References
✔ American Academy of Pediatric Dentistry. (2024). Behavior guidance for the pediatric dental patient (Reference Manual of Pediatric Dentistry). American Academy of Pediatric Dentistry. https://www.aapd.org/globalassets/media/policies_guidelines/bp_behavguide.pdf
✔ American Academy of Pediatric Dentistry. (2025). Management considerations for pediatric oral surgery (Latest revision 2025). American Academy of Pediatric Dentistry. https://www.aapd.org/globalassets/media/policies_guidelines/bp_oralsurgery.pdf
✔ American Academy of Pediatric Dentistry. (2023). Use of local anesthesia for pediatric dental patients (Best practices). American Academy of Pediatric Dentistry. https://www.aapd.org/globalassets/media/policies_guidelines/bp_localanesthesia.pdf
✔ Carrasco-Labra, A., Polk, D. E., Urquhart, O., Aghaloo, T., Claytor, J. W., Dhar, V., ... & Pilcher, L. (2023). Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in children. Journal of the American Dental Association, 154(9), 814–825.e2. https://doi.org/10.1016/j.adaj.2023.06.014
✔ Janani, K., Teja, K. V., Alam, M. K., Nagy, A. I., Basheer, S. A., Srivastava, K. C., Hosni, H. A., Jose, J., & Shrivastava, D. (2022). Physics forceps in tooth extraction—A systematic review of randomized controlled trials. Applied Sciences, 12(1), 254. https://doi.org/10.3390/app12010254
✔ Fayaz, Y., et al. (2024). Analysis of primary tooth extractions and associated factors: implications for pediatric dental care. [Journal]. (Available via PubMed Central).
✔ Baillargeau, C., et al. (2020). Postoperative discomforts in children after extraction of primary teeth under local anesthesia: a prospective observational study. International Journal of Paediatric Dentistry. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7745079/
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