Doc, My mouth hurts

[NousDefionsDoc]

So, the scenarios continue...

[Sacamuelas]

That pic reminds me of one of my favorite smart ass responses...

"Sir, do you use a toothbrush to clean your teeth?"

typical response... " Of course, I brush every day"

My rebuttal... "You may want to try putting the toothbrush IN your mouth while you brush then. "

Good typical indig. poverty case NDD. I will defer posting for a while until others have had a chance to post/ask questions.

[Sacamuelas]

How many are we getting today NDD? How much time can we spend on any one patient?

For all:
What treatment is required? How do you determine whether to put this patient on antibiotics post op? How would you perform the actual treatment you decide upon?

[Sacamuelas]

Concerning my question about antibiotics:
Routine/general use of antibiotics pre-op on patients that do not have a documented medical need ( ex. hx of Rheumatic fever, mitral valve prolapse WITH regurg., recent joint replacement, Prosthetic heart valve) is not indicated. To me, that would be wasting precious and limited quantity meds. You are also putting the patient at an unnecessary risk for an allergic reaction.
The reasoning behind not needing Ab's post-op after standard extractions... you are taking the etiology or cause of the infection out of the patient when you remove the tooth. The normal immune response can then handle the residual bacteria left in the socket.

Now, if they are showing systemic signs of infection (fever, malaise), then I would agree with Ab useage. Also, a clinically large fluctuant or any size cellulitis infection would also dictate use of Ab, IMO.
Note on premed- If I was working on a fellow US soldier. If I had the time, I might pre-med the patient with 800mg of IBU 2 hours before. That way, when the anesthesia wears off , the med is in place. It also cuts down on postop inflammation IMO. That is not a "guideline", just my personal choice though.

[Sacamuelas]

Looking at the case NDD has provided, multiple teeth will need to be extracted.
If any of you want, we can go over a few common principles/anatomy basics.
I have placed red numbers to indicate different areas in the mouth that we will be extracting teeth in this exercise.

To standardize, we will be using 2% Lidocaine 1:100,000 Epi with standard 28 gauge long dental needles.

A short reminder on needles in case you have been misinformed. I only stock long dental needles as they can be used anywhere that short can be used. However, there are injections that require the long variety. Also, I only stock 28 ga. not 30 ga. needles. Studies have shown that patients cannot tell the difference in sensitivity between the two. This info follows the K.I.S.S. principle, the fewer number of items you need to inventory and pack, the better

Now, back to the case. Let's start with the three teeth that are indicated with the #1(max right molars) in my attached pic. What techniques are used for anesthesia? What major complications are watched for/protected against during extraction of these teeth? If severely infected (abscessed), are their certain techniques or other injections that might obtain anesthesia better? Does anatomy affect how you extract these teeth as far as technique is concerned?

Here is a radiograph (x-ray) of the teeth in question. Look at anatomy for help with one of the complications. hint..hint
http://www.tip-edge.com/images/fa98f2a.jpg

[Sacamuelas]

Starting with anesthesia/nerve supply:

For all maxillary (upper) teeth we generally need to perform two separate injections to extract teeth. This is because there are always two different nerves that need to be anesthetized for upper teeth. One nerve runs to the actual tooth and outside (buccal) gums, the other to the roof of the mouth (palatal) gingiva.

The easiest and safest way to numb any upper tooth and it's outside (buccal) portion of gingiva is through local infiltration. This puts anesthetic directly over the bone where the nerve supplying the tooth enters the apex (bottom) of the root. As a general rule, this technique is only effective in maxillary teeth. Mandibular (lower) teeth have a dense cortical bone layer over the bony surface, which prevents diffusion through the bone.
Technique:

1. You perform an infiltration just over the apex (where you think the bottom of the root would be inside the bone/the ending or tip of the root) of the tooth you want to extract on the "outside" of its gums.
The aiming point for placing the needle is identified by placing your finger inside the patient’s cheek and slightly retracting out away from the patient’s teeth. This creates tension on the mucosa, and a trough can be identified where the mucosa attached to the bone joins with the mucosa covering the inside of the cheek. This trough (mucobuccal fold) is where the needle is placed and advanced into the mucosa a few mm. You are trying to angle the needle parallel with the angle of the tooth into the bone. I diagrammed a photo showing the Aiming point (dotted line) and the needles angle that would be taken to numb up a first molar (blue star).
2. Then you simply aspirate then inject 1/2 carpule SLOWLY... and wait a few minutes

3. This technique is used on all top teeth with a success rate of @95%. There is very little complication risk.

[Sacamuelas]

One still has to anesthetize the palatal gingiva to extract these teeth.

This procedure is performed by giving what is called a Greater Palatine nerve block. I will post a pic of where the nerve exits the palate and supplies the gingiva. The exit point (foramen) or slightly anterior to it is where you will give the injection. It is located clinically about .5-1 cm toward the midline from the inside of the second molar. It's location can be confirmed by using a cotton tipped applicator to palpate the area. You will feel a softer fluctuant area when you are over the foramen compared to hard palate bone. This is you aiming point. Here is a pic that we can use for anatomy.

The injection is given by placing the needle straight up vertically approx. 3-4 mm in depth. If you give it in the wrong place (you obtain bony contact with the needle), as long as you are in the area or slightly anterior to the foramen, the injection will still work fine.

This injection actually gives palatal anesthesia all the way from the soft palate junction forward to the canine teeth.
1. Have patient open very wide for your visibility
2. Locate foramen with palpation
3. Insert needle 3-4 mm
4. Aspirate (important as Greater Palatine artery runs through that foramen as well), then inject 1/2 carpule VERY slowly to prevent unnecessary discomfort

Only palatal anesthesia major complication is caused by not aspirating the needle, which would allow for injection of the lido/epi directly into an artery. Bleeding/eccymosis is not a real concern for injection into such a small vessel. FWIW, If you get bloody aspirate, pull out and reinsert slightly anterior.

That completes the technique on basic/common anesthesia for these three teeth.

[Sacamuelas]

Things to note:
1. Maxillary molars have at least three roots. Two are side by side on the outside (buccal) portion and one is on the palatal side of the tooth. You always want to attempt to get the palatal root out in one piece if possible. I will cover how to do that in the technique part.

2. In about 30% of people, the upper First molar has secondary innervation by another nerve to its outside root towards the midline of the face side (Mesio-buccal root). This means that sometimes an extra infiltration injection is needed slightly towards the midline of the first molar.

3. Major Complication: The maxillary sinus lies directly above the teeth in question. In some cases, the roots are in the sinus itself. Something to remember when chasing after small fragments or when using your elevators to "push up" and wedge a root out (which can push the fragment up into the sinus).

I will post the same x-ray as before with the maxillary sinus identified by a blue dotted line. I will also label roots to make more sense of the above description in red. As you can see, the roots in the example could definitely be in the maxillary sinus. You can also see the two smaller buccal roots with superimposed over the larger palatal root.

[Sacamuelas]

Common questions relating to extractin maxillary (upper) molars:

What happens if you push a fragment of the molar into the maxillary sinus?

Leave it alone. Deduce/Observe how much fragment is left and document which root it came from. Document all that info (if he is a US soldier) and place on antibiotics.

The removal of a fragment is outside the capabilities of a SF medic. You are better off leaving the area, without further attempts once you see the root fragment disappear "up" into the socket.

Where is the "soft palette junction" that is referred to in the anesthesia portion of the above explanation?

Hard palate has underlying palatal bone underneath it. The soft palate is the posterior continuation of the mucosa that forms the upper/posterior roof of the oral cavity.

Easy way to distinguish the line... Hold patients nose pinched closed with his mouth open wide. Observe the roof of the mouth. While focusing on the roof of the mouth, have the patient attempt to blow air out of his nose. You will observe the more posterior area of the mouth drop/pivot down from the pressure building in the nasopharynx. It will look as if it bends down in a perfect little crease from one side of the mouth to the other. That crease line is the hard/soft palate junction. This is because the hard palate will not pivot from the pressure due to its bony support. The soft palate is only mucosa, therefore it will move with the air pressure influence above it.

Provide some insight into other problems that root fragments into the sinus could create and S/S for additional problems? Any ideas on post op instructions for the patient if this happens?

As for the S/S after the root fragment is displaced, you usually observe none initially. The effects are a potential for sinus infection, continuous sinus congestion/inflammation, creation of oral/sinus fistula, and cyst formation around fragment. Frequently, you will observe blood/fluid drainage through the nose as well.

Also a connection between the nasal sinus and the mouth can be made which is evident by seeing air bubbles come from up through the empty socket when the patient blows pressure into his nose while pinching it shut. If this is observed, place a figure eight suture over the socket with a little surgical/gelfoam in the socket if available.

Post-operative care:
No forceful blowing of the nose
No use of straws
No smoking
Keeping mouth open when sneezing
Soft diet for several days
Antibiotics (Amoxicillin, or Clindamycin)--- I would give Amox 500, 21tabs , 1 Po tid
Nasal decongestants: Systemic: Sudafed Local: Neosynephrine
Bite on 2x2 gauze for twenty minutes
No spitting

[Sacamuelas]

Some tips/tricks on technique when extracting upper molars:

1. Use surgical currette/#2 molt to detach gingiva from the tooth completely around its circumference. Then begin to gently luxate the tooth with the instrument by placing the working end directly parallel to the tooth and into the crevice (sulcus) that exists between the root and the bone. You can do this from the sides as well as the palatal and buccal surfaces of the root. This will begin the process of loosening (luxating) the tooth by expanding the bony socket that it sits in.

2. Then use your straight elevators to perform this same luxating motion. They are designed to work in the same manner as a flathead screwdriver is used when prying off a lid to a paint can. You leverage the tooth by applying pressure between it and the bone. As the tooth begins to move a little, apply more pressure press apically (up into the bone) to get as deep as you can on the root for better leverage. Before you pick up a forcep, you want to have the tooth in question moving within its socket.

3. It is generally easier to get the farthest tooth back out first. This allows you to rock it out in a general direction towards the back of the mouth (which actually coincides with the normal curvature of the roots on max. molars) which will enable an easier extraction with less chance for root fragments breaking. After the posterior tooth's removal then you can move to the next molar in front of that socket and perform the same leveraging force towards the back. The bony socket towards the back will compress much easier than the original solid bone would have. You continue this process for all three molars.

4. If getting out multiple teeth, Use the currette and elevators on all the teeth before you actually go to extract the first tooth. The reason you do this is to allow for hydrostatic pressure to build in the PDL space under the roots of the teeth you have traumatized/loosened with the elevators. When you come back to the original tooth, you will have the benefit of this natural process helping to actually "push" the tooth out. It works... that is one reason taking a break actually seems to help on the tough cases.

5. The procedure for max molar extraction with forceps is to compress( up with slight pressure toward palatal)-expand (hard up with firm to buccal)-then repeat.....slow deliberate movements holding at the extreme of the movement for five seconds before changing directions, repeated slowly and progressively increasing the amount of movement until its loose, then remove with a traction force. The entire time until the very end, you actually use pressure exerted up into the bone (pushing towards tooth as if to push it into the mouth). This compresses and expands the socket but most importantly by using the laws of physics it decreases the chances for root fracture by lowering the axis of rotation within the socket.

6. You will not be able to rotate (twist) a max molar when extracting. You use a gentle upward/palatal movement, then a harder upward/buccal (toward outside). This causes the likely hood of fracturing the longer palatal root to decrease compared with the two buccal roots.

No tips work for all teeth you will deal with in the field. Hopefully, these should help for most that you run into though.

Any questions on molars... please don't refrain from asking.

[Sacamuelas]

To anesthetize the teeth labeled #2(premolars), the same two injections will be used. The only changes being that the buccal infiltration injection will be given over the tops of these teeth instead of the molars.

Some things to remember concerning maxillary premolars:
1. In @70% of the cases, they have two roots. (one buccal and one palatal)
2. The teeth are taken out with a buccal to palatal rocking motion with the forceps. This is due to the shape of the roots making a rotation or twisting action of the teeth unfavorable (likely to break off the roots). Same motion as with molars except a slight twist can be used periodically to expand the socket.

[Doc T]

just reading all this stuff reminds me why I hate to go to the dentist :D

but thank you for the information...

I should get CME for this!

[Eagle5US]

Saca...you be da man.
Outstanding information. Great visuals too.
Thanks...

The Eagle

[Sacamuelas]

The next teeth that need to be taken out are the canine/lateral & central incisors. These teeth are generally the easiest and least complicated extractions that you will face in the upper arch.

Things to note:
You can use a similar technique of anesthesia concerning local infiltration over the apex of the roots on the buccal mucosa. This will anesthetize the teeth and outside gingiva.

You will need to use a different palatal gingiva anesthesia technique on these three teeth however. These three teeth are innervated on the palatal gingiva by a nerve (nasopalantine nerve) that runs through the incisal foramen. This canal (incisive canal) is also labeled on the already posted/attached pic above on palatal bony anatomy.

The easy way to find this opening clinically is to locate the soft tissue "hump" immediately behind the central incisors on the palate. This marks the location of the incisive foramen and sphenopalatine artery/nasopalantine nerve that run through it.

The palatal injection is given with the following technique for maximum comfort during the process.


Technique for anterior palatal anesthesia

Use a cotton tipped applicator/or mirror handle to apply FIRM pressure on the actual hump just behind the centrals. Hold this pressure firm enough to cause blanching of the tissue in the area.
After approx. 10 seconds, inform the patient that you will now give them a quick pinch. While still holding pressure, insert the needle right beside your instrument applying the pressure. Do this quick and with intention as the tissue in this area is thickly epithelium and requires a little force to penetrate.
Now, release the pressure from the instrument and VERY slowly begin placing anesthetic into the area. I do this with a short burst type technique as the tissue is firm/tight and requires a lot of pressure on the plunger to get anesthesia to flow. The slow pumping then relaxing allows time for the anesthetic to begin working on the tissues as it expands out away from the needle. This vastly decreases the sensitivity to this injection.

BTW- It really hurts if you just pump it in fast. It is by far the most sensitive injection to give when performing Sacamuelas activities.
FWIW, don't waste your time using topical on the palatal injections, as it does not work. The keratinized gingiva on the palate will not allow it to soak in like it will on the outside (buccal) mucosa. Use the pressure technique to cause slight local anesthesia properties from the ischemia produced from the pressure.

Back to a few things to note about these particular teeth:
These three teeth are single rooted and conical in root shape. This allows for an extraction technique that involves slow rotational force to be put on the teeth while placing firm upward force with the forceps. Take your time and they will generally come out with no problems.

Before forceps, use the same elevating techniques and gingival separation as described for the other maxillary teeth. Remember, a little time spent loosening the teeth (elevating and luxating) will save you a LOT of time chasing after root tips and fragments.

The maxillary canine has the longest root in the mouth. It also tends to be difficult to extract not because of root shape but because of the bony anatomy of the maxilla. If you feel with your finger on the outside of your lip that covers your upper canine's root you will feel a prominence or boney lump. This is an extra cortical bone thickness(canine prominence) that covers the canine root for added strength. It was nature's way to provide for chewing/tearing/shreading of meat back when we were cavemen and not loosing out canine teeth due to the forces.
For this reason, when extracting on a patient like in NDD's example, I will take out the lateral incisor before attempting to take out the canine. The reason I do this is to create a hole/opening in the bone next to the canine so that I can luxate the canine towards/into this hole to help loosen it before I try to extract it with forceps. That extra cortical bone definetly makes an extraction of that tooth more difficult, and this technique allows you to luxate the canine in a direction away from that extra boney support on the outside.

A special helpful thing to remember when taking out all of an indig. patient’s dentition as in NDD's example pic:

You can use the adjacent teeth themselves as a fulcrum to lever against each other with your elevator when you are taking out all the teeth in an area. You do this with your elevators (large straight) and it will really luxate them quickly. You can NOT use this technique if you are not removing the tooth that you are using as the fulcrum of the lever as it WILL loosen that tooth as well and put unhealthy forces on its support.

[Sacamuelas]

Here is a pic of the basic instruments needed for extractions in the field. The 150 forcep is for all maxillary teeth and the 151 is for lower teeth. ***sorry about the quality of the pic...

[Roguish Lawyer]

So you really are a dentist, eh, Saca?

[Sacamuelas]

Originally posted by Roguish Lawyer
So you really are a dentist, eh, Saca?

Yes, some have accused me of having such skill sets in my bad of tricks. :D

[Sacamuelas]

pulled from the depths of the archive due to a recent article focused on just this aspect of SF medicine.
http://www.professionalsoldiers.com/forums/showthread.php?t=10457

[mugwump]

Necropost redux:

Mother of mercy, I hope someone straps my mouth shut when I reach droolin' age.

6148

[Roguish Lawyer]

Yuck!

[jfhiller]

I can think of better ways to get my protein.

[mugwump]

Yuck!

Yeah, I figured if I had to live with that image burned into my brain I'd share the wealth.

[paramedicfred]

All I have to say is CRAP! that was a very interesting CME Class. Thank you.

[JMH85]

What’s the procedure to deal with the larva in the above photo? Can the teeth be saved? Any guess how long he's been like that?

John

[Sacamuelas]

The teeth are hopeless. From the photo, it is obvious that the teeth exhibit severe periodontal infection. There is most likely <20% of the bone surrounding the teeth that originally existed which leaves them mobile and non-restorable. The periodontal condition/bone loss is a chronic and progressive condition that has probably existed for years/decades. The acute necrotizing ulcerative periodontitis (ANUP) that is present in the picture which created the environmental conditions for the maggots is most likely that.... acute.

The teeth between canines would be extracted due to the perio condition... then debride the wound. I marked them in the picture. The bone loss in most cases like this makes it pointless to leave the teeth which are the etiology(cause) of the infection.

You won't see this condition in American troops. You might rarely see it's baby brother sans maggots though. It's called ANUG or acute necrotizing ulcerative gingivitis. aka trench mouth.

[JMH85]

Very interesting. Thanks for the information Sacamuelas.