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Aims: To evaluate osteoradionecrosis (ORN) incidence in a cohort of patients undergoing tooth extraction (TE) before radiotherapy (RT) for head and neck cancers. Methods: The study protocol was approved by the Ethics Committee of Università Cattolica del Sacro Cuore (ID‐2132) and registered at clinicaltrials.gov (ID: NCT04009161). TE was performed in case of signs of pericoronitis, periapical lesions, restorative impossibility, severe periodontitis. ORN was defined as exposed bone at an unhealed post‐extraction socket in the absence of oncological recurrence. The RT plans were reviewed, and each post‐extractive socket was contoured to calculate the received radiation dose. Results: In total, 156 patients with 610 TE were enrolled. The mean follow‐up was 567 days. ORN was diagnosed in four patients (2.6% of patients and 0.7% of TE). Need for osteotomy and radiation dose at the extraction site were associated with ORN (OR for osteotomy: 21.9, 95% CI: 2.17–222.2, p = 0.009; OR for RT dose: 1.1, 95% CI: 1–1.15, p = 0.05). Conclusions: TE appears to be a significant risk factor for ORN, particularly when osteotomy is required, and post‐extraction sockets receive a high RT dosage. This study proposes a decision‐making algorithm for TE and outlines a straightforward surgical protocol. [ABSTRACT FROM AUTHOR]