Extracting teeth

You should be able to extract a patient's teeth, either for severe toothache due to irritation of his dental pulp, or abscess formation, or less often, for periodontal disease. This makes teeth so loose that they almost fall out.

Try to remove his tooth with all its roots, and without damaging anything else in his mouth. The secret of success is to force the beaks of the forceps over the visible crown of his tooth, and under his gums, between the periodontal membrane and the alveolar bone, so as to grip its roots firmly. Then, while still grasping his tooth firmly, gently rock it or rotate it depending on the kind of tooth you are removing (as in D, or E, Fig. 26-5). This will break down the periodontal membrane, and widen its socket. The common idea of ''pulling teeth' is false[md]the important movement is the early one of pushing the beaks of the forceps into his jaw around the root of his tooth.

Each forceps has handles, a hinge and a pair of blades. Forceps for the upper jaw are straight, or slightly curved; those for the lower jaw have blades at right angles to their handles.

Ideally, forceps should avoid the crown, and fit the whole surface of the neck and root of a tooth. The blades must be sharp, so that they can easily slide between a tooth and its gum. If necessary, sharpen them on the outside of their tips.

If a tooth has one root, you can loosen it by twisting it (D, 26-5). The teeth which have one root are: the upper incisors and canines, and the lower incisors, canines, and premolars. All other teeth have more than one root, so you cannot twist them. Instead, you have to rock them (E, 26-5). You will need two forceps for upper molars[md]one for the right and another for the left. Upper molar forceps are curved, so as to avoid the lower lip. The buccal blade with a beak on it is designed to grip the two outer roots, and the palatal blade is designed to grip the one inner root. One pair of lower molar forceps is enough.

FORCEPS, dental, set of six with the following Ash numbers: (a) Upper anteriors (Nos. 1 or 2). (b) Upper right molars (Nos. 17 or 94). (c) Upper left molars (Nos. 18 or 95). (d) Upper premolars and roots (No.7). (e) Lower molars (Nos. 73 or 22). (f) Lower anteriors and roots (No. 74N). One only of each.

Alternatively, FORCEPS, dental, universal, set of two, upper universal (No. 36), and lower universal (No.74), one only of each. Dental forceps are expensive, so you may have to manage with these two universal forceps, but they are not so easy to use.

ELEVATORS, dental, (a) upper jaw, straight inclined plane, Coupland, (b) and (c) set of two lower jaw, Cryer's, mesial and distal. One only of each. Coupland's elevator is a small gouge on a metal handle. You will need it to remove roots; if you don't have one you may be able to use the narrow blades of anterior forceps.

PROP, dental, one only. You may find this useful to keep a patient's mouth open while you extract his teeth.

Fig. 26-3 TEETH AND FORCEPS FOR THEM. Forceps for the upper teeth are straight, and those for the lower teeth are cranked. There are separate forceps for the upper molars, right and left; all other forceps can be used on either side. The beak of a pair of molar forceps is always on the outside, where it fits between the two buccal roots. Kindly contributed by Hanif Butt.

EXTRACTING TEETH INDICATIONS. A patient with: (1) A painful, severely carious tooth. (2) A periapical abscess. (3) A periodontal abscess. (4) Severe periodontal disease.

If he has severe periodontal disease and his teeth are firm, but have swollen gums round them, leave them until other remedies have failed[md]you may be able to save them. But if one or more of his teeth are loose in their sockets, and his gums are red and swollen, and bleed easily on light pressure, remove them.

CONTRAINDICATIONS. Don't try to extract: (1) Buried or impacted teeth. Refer him. If you cannot refer him, see Section 26.4. (2) Displaced teeth. (3) Teeth which have no visible crown. (4) Teeth in very dense bone. Some of these will give you and most dentists much difficulty. (5) Teeth from a patient with a personal or family history of excessive bleeding, particularly bleeding after a previous tooth extraction[md]refer him. (6) A tooth with an apical abscess, from a patient with heart disease. Refer him; if impossible, proceed as below.

If a small hole in the tooth seems to be responsible for the pain, consider non-operative treatment, and refer him. Clean out the cavity. Use a mixing spatula on a glass surface to make a paste of zinc oxide powder, clove oil and cotton wool fibres. Dry the hole and pack it off with cotton wool to keep it dry. Pack the mixture into the cavity with a plastic hand instrument (D, 26-1), or some substitute for it.

CHILDREN'S TEETH. If he is aged 6 to 12, be very careful when you remove a deciduous tooth, lest you remove or damage the permanent tooth under it.

MEDICAL HISTORY. Don't forget this. If he has any form of heart disease, extract his teeth under antibiotic cover.

WHICH TOOTH? If he has toothache, he usually knows which tooth is causing it. Occasionally, when the pain is referred, he is wrong even about which jaw it is in. So don't necessarily remove the tooth which he thinks is at fault. The offending tooth may: (1) Have a large hole in it. If you cannot immediately see any carious areas, use a dental mirror to look for them on the adjacent surfaces of his teeth. (2) Be broken, black, or brown. (3) Look grey under its enamel. (4) Be loose, and surrounded by severe periodontal disease. (4) Be tender on gentle tapping. Tap each tooth in turn with the handle of a dental mirror. The most sensitive one is likely to be the cause of his toothache.

X-RAYS. If a tooth is displaced or impacted, X-ray it.

ANTIBIOTICS. If he has an apical abscess (5.8), give him an antibiotic for 24 hours beforehand, and continue it for three days afterwards.

ANAESTHESIA. Use local anaesthesia (A 6.3). Make sure that a tooth is properly anaesthetized, by pushing a blunt probe into the gingival crevice on its buccal and lingual surfaces. If he feels pressure but not pain, anaesthesia is adequate. If he feels pain, inject more anaesthetic.

POSITION. Sit him down so that his head is level with your chest as you stand. Position yourself and him correctly. The stance of the operator in B, Fig. 26-5 is ideal.

IF YOU ARE EXTRACTING A LOWER TOOTH, use right-angled forceps and press downwards. First, where to stand and how to position him:

If you are extracting a lower front tooth or a lower left molar or premolar, sit him upright in the chair, and low enough for his mouth to be level with your elbow. If he is too high stand on something. Grip his alveolus between the first and second fingers of your left hand, and put your thumb under his mandible.

If you are extracting a lower right premolar or molar tooth, stand behind him (B, Fig. 26-4).

If you are left handed, stand behind him for extracting all lower left premolar and molar teeth. For all others, stand in front of him, but to the left of his legs.

Fig. 26-4 EXTRACTING A LOWER RIGHT TOOTH. Stand behind the patient. If you cannot get low enough, stand on a box or something stable. Support his jaw with one finger inside it and one outside it. From ''Common oral diseases', Fig. 2.9.3. WHO, with the kind permission of Martin Hobdell.

Lower teeth. The beaks of lower molar forceps are both pointed to fit between the two flattened roots. Use small rotating movements combined with a sideways movement between his tongue and his cheek. Use constant downward pressure, and support his jaw in your other hand.

To extract a lower incisor tooth, stand in front of him, push the beaks of the forceps down round the root, and apply a gently backwards and forwards movement.

To extract a lower canine, which has a more rounded root, use gentle rotating movements (D, 26-5).

To extract lower left premolars, turn his head towards you and use gentle rotating movements.

To extract lower right premolars, move to his right, or even stand behind his right shoulder.

To extract a lower right molar, stand behind his right shoulder, and use a side-to-side rocking action (E, 26- 5).

If you have difficulty extracting his lower third molar, this may be because its roots are deformed, and need to be dissected out with bone chisels[md]see Section 26.4.

IF YOU ARE EXTRACTING AN UPPER TOOTH, tilt his head backwards. If your chair does not have a head rest, support his head against a wall, or ask your assistant to support it. Stand in front and to the right of the patient's legs. For all upper teeth, put the finger and thumb of your left hand on either side of his gums.

CAUTION ! (1) Make sure that the long axis of the blades is in the long axis of the tooth. (2) Don't grasp his tooth and his gum together. (3) Carious teeth are brittle and will break, if you put too much sideways pressure on them[md]don't use the forceps as a ''nut cracker'. (4) Don't start extracting movements when you have only grasped the crown of his tooth. (5) When you rock a tooth, feel if it is responding to reasonable pressure; if it does not respond and seems very firmly fixed, refer him.

An upper incisor, or an upper canine has a single conical root, so rotate the tooth at the same time as you press it firmly in the direction of its tip (D, 26-5). Finally, tilt it outwards.

An upper premolar has delicate roots (the first premolar often has two), so be as gentle as you can. So make small side to side and rotating movements while you push upwards with considerable force. When the tooth is loose, pull it downwards.

An upper molar has three roots, two on the buccal side, and a single large one on the inside next to the palate. The roots of the third molar are sometimes fused together. Choose the correct molar forceps (right or left), so that the pointed blade slips down outside the crown between the roots on the buccal side. Press upwards firmly until the beaks are beside the roots, while you make slight side-to-side rocking movements to loosen it (E, 26-5). Finally, increase these movements, and exert pressure in an outward direction, until you can draw the tooth out of its socket into his cheek.

CAUTION ! Make sure you support his alveolus firmly between your finger and thumb, because you can easily break off part of it, especially when you extract a third molar, and break his maxillary tuberosity.

AFTER ANY EXTRACTION, examine the tips of the roots you have removed. If they are not complete, see below.

POSTOPERATIVELY [s7]AFTER TOOTH EXTRACTION Allow him to rinse out his mouth once only. Remove loose bits of bone and tissue. Push the lingual and labial sides of his empty socket together. Place a tight ball of gauze over his socket, and tell him to bite on this for 15 or 30 minutes[md]make sure it presses on to the socket. When you remove it 15 minutes later, bleeding should have stopped. If it has not, see below.

Ask him not to spit, or wash to out his mouth again for 24 hours[md]it may wash away the blood, which should be clotting in his empty socket. The following morning, he can start rinsing out his mouth with saline, using a small spoonful of salt to a cup of water. If his empty socket does not bleed after you have removed his tooth, use a dental probe to scratch around inside it until it does bleed. A socket which does not bleed is more likely to become infected (see below under ''dry socket'). Tell him not to meddle with the socket.

CAUTION ! If you have extracted his tooth for an abscess, make sure he returns for antibiotic treatment if his swelling does not rapidly improve.

Fig. 26-5 EXTRACTING TEETH FROM THE UPPER JAW. A, support the patient's gums between the finger and thumb of your left hand. B, tilt his head backwards and support it against a wall, or ask an assistant to support it. Note the excellent stance of the operator in this figure. C, the teeth to rotate (those with single roots), and the teeth to rock (those ]]with more than one root). D, rotating a tooth with a single root. E, rocking a tooth. From ''Common oral diseases', Fig. 2.9.2, WHO, with the kind permission of Martin Hobdell.

DIFFICULTIES [s7]DURING TOOTH EXTRACTION If there is a constant OOZING during the operation, swab, suck, and apply packs. If necessary, press a dry pack over the wound for 2 minutes timed by the clock.

If his tooth is IMMOVABLE, and fails to yield when you apply reasonable force with forceps, or an elevator, it probably needs dissection. So stop and refer him: it may have curved roots or be ankylosed.

If the crown or a ROOT BREAKS as you extract a tooth, examine it carefully to see how much you have left behind. What you should do depends on how much is left.

If it is only a root apex, less than 5 mm in its greatest dimension, removing it is going to need much dissection. Leave it. If he is healthy, the retained apex of a vital tooth is unlikely to cause trouble.

If the root is larger than 5 mm, try to extract the fragment of the broken root with a Coupland's inclined plane elevator as in Fig. 26-7. Wiggle the elevator between the root and its socket.

CAUTION ! (1) Hold the elevator with your index finger near its tip in case it slips. (2) The roots of the upper premolar and molars are very close to the antrum, so that you can easily push a root into it.

If his ALVEOLUS BREAKS as you remove his tooth, examine the socket. Remove any bony fragment which has lost over half its periosteal attachment. Grip it with haemostatic forceps, and dissect off the soft tissues.

If you DISPLACE A TOOTH INTO HIS ANTRUM, refer him. If you cannot refer him, see below.

If, while you are extracting an upper molar, you feel SUPPORTING BONE MOVE WITH HIS TOOTH, you have FRACTURED HIS MAXILLARY TUBEROSITY, and are in danger of opening his antrum. If only a small piece of tuberosity has broken off, remove it. If a larger piece has broken, refer him. Removing the tooth and the detached fragment will open his antrum. He will need to have a mucoperiosteal flap made to cover the gap. Warn him that if he has the same teeth extracted on the other side, the same thing may happen again.

If, when you remove his upper molar, YOU SUSPECT YOU HAVE MADE A FISTULA, ask him to grip his nose and to try to blow air through it. This will raise the pressure in his antrum, make blood in his socket bubble, and deflect a wisp of gauze if you hold it over the socket. Refer him to have the fistula closed with a flap. If you cannot refer him, see below. Meanwhile, don't allow him to rinse out his mouth until the defect has been repaired, and don't put any instrument through the fistula[md]you may infect his antrum.

If extraction of a tooth has CAUSED A FISTULA, you see him within 24 hours, and cannot refer him, close it immediately, by incising the periosteum, and advancing a buccal mucoperiosteal flap over the defect, as in E, Fig. 26-7, and sew it in place. Postoperatively, give him an antibiotic and inhalations of tincture of benzoin.

If you see him after 24 hours, the edges of the wound will probably be infected, so that if you close it now, the suture line will probably break down. Allow the area to heal, excise the fistulous tract, and close the fistula with a buccal flap.

You can remove most teeth or roots from the antrum through the original defect enlarged if necessary. Failing this, the Caldwell[nd]Luc approach will give you better access (25-7).

If you LOSE A TOOTH while you are extracting it, immediately bring his head forwards, and hope he will cough it out. X-ray the socket and his chest. If he has inhaled it, refer him to have it removed by bronchoscopy during the next few days, before a lung abscess develops. If you cannot refer him, you may have to bronchoscope him yourself (25.12).

If you BREAK HIS MANDIBLE (62.7) or dislocate it (62.6), treat these injuries as described elsewhere.

If you INJURE HIS TONGUE, and the wound is small, it needs no treatment except mouth washes. If it is larger, pull it forwards and suture it.

If he has an EXTRA TOOTH, it is usually conical, and may present almost anywhere on his jaw, and even in a nostril. Removing it may call for skill and ingenuity. If necessary use a dental elevator to clear away the soft tissues of his gum before you apply forceps.

Fig. 26-6 SUTURING A BLEEDING SOCKET. A, a ball of haemostatic gauze (1), soaked in adrenalin and plugging a clot filled socket (2), which is closed by stitches (3). B, the equipment. C, how to hold the needle. B, and C, from ''Common oral diseases'. WHO, with the kind permission of Martin Hobdell.

BLEEDING [s7]AFTER TOOTH EXTRACTION His socket may bleed too much or, more rarely, not enough. If it fails to bleed adequately, it is more likely to become infected (see below). Bleeding during the first few hours is likely to be reactionary haemorrhage. Later bleeding is the result of infection.

After any tooth extraction, squeeze his gums between your finger and thumb for a few minutes. Then allow him to rinse gently with clean water. If he continues to bleed, follow these steps in order. If one fails, try the next.

(1) Ask him to bite on a pad of damp cottonwool, or gauze, for 15 minutes.

(2) Ask him to bite on it for a further 30 minutes. Make sure the pad really does press on to the socket this time.

(3) Soak a small ball of cotton wool in the contents of a 1 mg ampoule of adrenalin. Press this into his bleeding socket for 30 minutes.

(4) Stitch his gums. Use a half-circle cutting needle in a needle-holder and 3/0 black waxed silk, or any suitable suture material, to hold a plug of haemostatic gauze over his bleeding socket, as in A, Fig. 26-6. If you don't have haemostatic gauze, use cotton wool; but be sure to remove it in 48 hours.

Alternatively, bring the edges of his gum together. If they will not come together, chip away the bone from the crests of the socket until they do. This will put his gum under tension, and make it less likely to bleed. Send him home biting on the pack.

CAUTION ! Don't be content with inadequate suturing, it will only cause more problems later.

INFECTION [s7]AFTER TOOTH EXTRACTION He may return some days after a tooth extraction complaining of:

(1) PAIN AND BLEEDING. His empty socket is probably infected. Irrigate it, remove clot and food debris, pack it with haemostatic gauze, and suture it. Place a firm gauze pack on it and ask him to bite on this. Give him an antibiotic. Don't let him rinse out his mouth, which may restart the bleeding; instead, clean it with wet gauze. If you don't have any haemostatic gauze, suturing it without gauze is probably better than suturing it over ordinary gauze.

(2) An acutely PAINFUL EMPTY SOCKET, without any clot in it. He has a DRY SOCKET. This is a local osteitis of the condensed bone that lines it. The danger is that osteomyelitis may follow. If you cannot refer him, irrigate it with warm saline and remove any food and degenerating blood clot. Under local anaesthesia, scratch around inside it to make it bleed. Try to excise any sharp bone spurs. When it has bled, and a clot has formed, it will probably heal. A dry socket is very painful, so make sure you give him adequate analgesics.

(3) FEVER and a very painful socket, a mandible which is exquisitely tender, and perhaps numbness of his lips (due to involvement of his mental nerve). He has acute OSTEOMYELITIS. Admit him and treat him as in Section 7.14a.

Fig. 26-7 DIFFICULTIES WITH ROOTS. A, Coupland's inclined plane dental elevator (not to scale with the tooth socket). B, how to hold this with your finger close to the end, to act as a guard. C, the roots of a patient's upper teeth are close to his maxillary antrum. D, be careful not to cause an oro-antral fistula. E, a relieving incision being made through the periosteum (only) on the under surface of a mucoperiosteal flap, which will be moved across to close an oro-antral fistula. A, to D, kindly contributed by DJ Halestrap. E, after ''Hamilton Bailey's Emergency Surgery' edited by HAF Dudley, Fig. 16.45 (John Wright), with the kind permission of Hugh Dudley.

BROKEN ROOTS [s7]AFTER TOOTH EXTRACTION If a ROOT BREAKS OFF as you remove a tooth, leave a small piece (less than a third of a root) in place. Remove a larger piece. You may be able to do this with the narrow blades of a pair of anterior forceps, or by passing Coupland's inclined plane elevator between the root and its socket, as in A, Fig. 26-7. Try to push the elevator towards the bottom of the socket, while you press it firmly and rotate it a little each way. As you do so, hold it with your thumb near its tip, to prevent it doing any unnecessary damage (B). It should act like a wedge and move the root out of the socket. You can also use this elevator for loosening very firm teeth.

If you FAIL TO REMOVE A ROOT, destroy its pulp by pushing a dental probe down it, cover it with a zinc oxide and oil of cloves dressing, and explain that you have left a root behind. Ask him to return in a few weeks time. Then try again; removing it this time may be easier.

CAUTION ! Don't try to remove a fractured maxillary root by passing instruments up the socket. You may enter his antrum and cause a fistula (D, 26-7). This is much more likely to occur with molars and premolars, than with incisors and canines.

OTHER DIFFICULTIES [s7]WITH CARIOUS TEETH If he presents with a SMALL GRANULOMA with a discharge and underlying thickening, on his lower face, jaw, or chin, or inside his mouth on the surfaces of his alveoli, it is probably a DENTAL SINUS. An abscess around an infected residual root has caused an abscess in the bone under it, which has tracked through his soft tissues, to discharge on his gums or on the surface of his face. X-rays show a carious tooth, or a residual root, opposite the sinus. Give him a general anaesthetic, or ketamine, and remove the root with a dental elevator and forceps. Curette away the granulation tissue on his face. The discharge will stop in 48 hours, and the granuloma will not recur. If X-rays show signs of osteomyelitis, give him an antibiotic.

Fig. 26-8 THREE DENTAL SINUSES. A dental sinus is caused by a chronically infected residual dental root which has caused an abscess in the bone around it. This erupts on the gums, or, less often, on the surface of the cheek. After Charles Bowesman. ''Surgery and Clinical Pathology in the Tropics'. E and S Livingstone, permission requested.