Difficulties, Complications and Sequelæ of Extraction of the Teeth.
Like all other surgical operations, the extraction of teeth is at times
attended with certain difficulties, complications and sequelæ which for
the sake of description will be considered under the following headings:
(1) Difficulties, complications and sequelæ connected with the teeth
themselves.
(2) Difficulties, complications and sequelæ connected with the jaws.
(3) Difficulties, complications and sequelæ connected with the soft
parts.
(4) Difficulties, complications and sequelæ arising during extraction
under anæsthetics.
(5) Miscellaneous complications, difficulties and sequelæ.
(1) DIFFICULTIES, COMPLICATIONS AND SEQUELÆ CONNECTED WITH THE TEETH
THEMSELVES.
(_a_) =Undue Resistance of the tooth and= =alveolus.=--Considerable
resistance to our efforts to remove a tooth at times occurs. This is
naturally most often, though by no means always, met with in those of
strong physique. Teeth isolated are always firmer than those in series;
this is accounted for by a consolidation of the bone around them.
Experience will act as a guide, and it is to a certain extent possible,
after a little observation, to gather from the general appearance of a
tooth if it will give more than normal trouble in removal. Should undue
resistance be met with, steady attempts to move the tooth slightly in
different directions should be made and persevered with; if this
precaution is not taken and too much force is used in any one direction,
fracture of the tooth or alveolus is sure to result. It may, perhaps, be
found impossible to remove the tooth; when this is the case it is best
to dismiss the patient and to make a fresh attempt two or three days
later; the tooth will then probably be loose, as a result of the
inflammation which has been set up by the previous attempt at
extraction, and can be easily removed.
The causes of undue resistance are:--
(i.) Abnormal density of the alveolar process.
(ii.) Divergent and twisted roots.
(iii.) Alteration in the shapes of the roots brought about by
periodontal inflammation (exostosis).
(_b_) =Fracture of the tooth.=--The principal causes of this accident
are:--
(i.) The use of badly fitting forceps.
(ii.) The use of unnecessary or wrongly applied force in attempting to
loosen the tooth in its socket.
A tooth having been fractured, the patient should be made to rinse the
mouth until the bleeding has ceased, the socket should be dried with
cotton-wool, and the position and edge of the root defined with a probe
before attempting to remove the fractured portion. It is neglect of
these steps that so often leads to failure to remove the remaining
portion of a fractured root. Too many attempts to remove a fractured
root should not be made; if a second endeavour proves fruitless, the
patient should be dismissed and a fresh attempt, if necessary, made
after a period of one or two days, as the tooth will probably then be
looser from inflammatory trouble, moreover, the hæmorrhage having
ceased, it will be possible to obtain a clearer view of the root.
Before, however, dismissing the patient, an anodyne mouth wash should be
prescribed, and the pulp if exposed touched with carbolic or nitric
acid. The lower third of a root may generally be left without fear of
unpleasant consequences; but it is always well to inform the patient
when any portion of a tooth is allowed to remain in the jaw, as such
knowledge may be of assistance should any trouble arise at a subsequent
date.
(_c_) =Crowded and irregular teeth.=--The removal of these has already
been referred to in Chapter III.
(_d_) =The Removal of the wrong tooth.=--The removal of the wrong tooth
may occur and is naturally due to carelessness on the part of the
operator. Should this accident arise, the tooth must be immediately
replaced and if necessary secured with a ligature. If the pulp
subsequently shows signs of degeneration or inflammation it should be
removed and the canal treated and filled.
(_e_) =Removal of a neighbouring tooth.=--This may occur and is generally
due to a crowded arrangement of the teeth. The accident seems to occur
most frequently with the removal of the first permanent lower molar, the
neighbouring tooth usually involved being the second bicuspid which is
simultaneously dislocated from its socket. This accident can be avoided
by placing the thumb on the tooth which shows a tendency to move, and
exerting only as much force in the removal of the tooth which is being
extracted as can be controlled by the thumb. If a neighbouring tooth is
removed it must be replaced and treated in the same manner as described
above.
(_f_) =Removal of an unerupted bicuspid.=--This may be an avoidable or an
unavoidable accident. At times the developing bicuspid is so firmly
embraced by the roots of the deciduous molar that during the extraction
of the latter tooth the bicuspid is removed--such an accident cannot be
avoided. It is an avoidable accident when it occurs during the
extraction of the roots of a temporary molar and arises from using too
much force. As previously pointed out it is best to leave the fractured
roots of temporary molars alone unless they can be easily removed.
(_g_) =Breaking one tooth in extracting another.=--In the extraction of
lower teeth with hawk’s-bill forceps the upper teeth may be fractured.
This accident is most likely to occur to the inexperienced, and arises
from the tooth leaving its socket suddenly, due frequently to the
extracting force being used in an upward rather than an outward
direction. It may, however, occur when a lower tooth has been more than
normally resistant. In all such cases it is well for the operator to be
on guard by keeping the thumb or a finger of the left hand over the
joint of the forceps.
Also in using the elevator an adjacent tooth may be fractured.
(2) DIFFICULTIES, COMPLICATIONS AND SEQUELÆ CONNECTED WITH THE JAWS.
(_a_) =Fracture.=--The fracture and removal of a small piece of the
alveolus is not an unfrequent accident which is fortunately by no means
serious. It is sometimes unavoidable but at other times is due to
getting the blades of the forceps on the outer sides of the alveolus
instead of between the bone and the root of the tooth.
Extensive fracture is sometimes seen, for instance in a case that came
under my notice at the Dental Hospital of London an unqualified person
in removing the first lower right permanent molar fractured the bone in
a horizontal direction so that the second and first bicuspids with the
canine were completely separated from the body of the bone. Mr.
Salter[5] gives an account of an extensive fracture of the jaw which
occurred in a lady æt. 35. The fracture occurred in connection with the
removal of the superior central incisors. The right central incisor
required some force for its removal, and when it came away the whole of
the front of the alveolus was firmly attached to the root. In removing
the left central incisor considerable force was required during the
exertion of which the bone was fractured. On examination of the parts
the mass of bone corresponding to the intermaxillary bone was found to
be merely held in place by the soft tissues. “A vertical fracture
extended from the side of the canine up to the root of the nose, then
nearly horizontally across to the opposite side, being connected there
with another vertical fracture. The lesion passed completely through the
jaw from before backwards, and there was a wound in the palate three
quarters of an inch from the alveolar border, through which was
considerable hæmorrhage.” A still more severe example of fracture during
extraction of teeth is recorded by Mr. Cattlin,[6] where in an attempt
to remove a third upper molar with an elevator the tuberosity of the
maxilla, a portion of the floor of the antrum and part of the sphenoid
were fractured.
Fracture of the maxilla tuberosity may occur during the removal of the
third upper molar, and Mr. Nicol[7] records such an accident during the
removal of the second upper permanent molar. In a case recorded by Mr.
L. Matheson[8] a transverse fracture of the maxilla occurred in a line
between the first and second permanent molars during the removal of the
first-named tooth.
Direct transverse fracture of the horizontal ramus of the mandible due
to extraction of the teeth has also been recorded.
_Treatment._--In fracture of small portions of the alveolar process, no
special treatment is called for except that all loose fragments should
be removed. When the fracture is of a more extensive character, the
fragments must be retained in position by a suitable form of splint, a
description of which will be found in most works on dental surgery.
(_b_) =Necrosis= of the alveolus may result from extraction and is
generally the result of undue violence or of some septic process
occurring in the wound. The _treatment_ to be followed consists of the
use of antiseptic and deodorant mouth washes; the necrosed bone when
quite separated from the living tissue should be removed with a pair of
suitable forceps.
(_c_) =Dislocation of the mandible.=--The use of too much force in
extracting a lower tooth and not at the same time counteracting the
force by supporting the chin, may lead to unilateral or bilateral
dislocation of the mandible. This accident may also be brought about by
forcing the mouth open too much with a Mason’s gag during the
administration of an anæsthetic. It may likewise occur without the
employment of undue force in those who have previously met with or are
liable to dislocation.
_Reduction_ may be brought about by placing the thumbs, carefully
wrapped in a napkin, on the molar teeth and the palmar surfaces of the
fingers below the chin. If downward pressure is then made with the
thumbs, and upward pressure with the fingers, the condyles of the
mandible will generally pass back easily into the glenoid cavity. In
cases where more difficulty than this is experienced, the patient should
be placed in a recumbent position, and corks should be inserted between
the back teeth. Upward pressure should then be applied on the under
surface of the chin. It is advisable, after reduction, for the patient
to wear a four-tailed bandage for about a week.
(_d_) =Forcing a root into the antrum.=--This accident occurs mostly in
connection with the extraction of the second upper bicuspid root and
buccal roots of the first upper permanent molar. If a root has been so
dislocated into the antral cavity as to still partly remain in its
socket, the best course to pursue is to leave it alone and not to
attempt removal as the attempt might only result in complete dislocation
of the root into the antrum. The socket should be kept quite clean by
the continual use of antiseptic washes. As a rule the root gives rise to
no subsequent trouble.
When a root has been forced completely into the antrum, the latter
should be enlarged and the antral cavity thoroughly syringed. For this
purpose it is well to use an aural syringe of five or six ounce
capacity. The rationale of this form of treatment is that the root may
pass out with the return current from the antrum. If this treatment
fails, an attempt may be made to remove the root with a little scoop of
gutta-percha fixed on to a flexible wire. When it cannot be removed in
this manner, the cavity should be thoroughly irrigated with an
antiseptic solution and the root left alone, as it will in all
probability become encysted and not give rise to any subsequent
trouble. If, however, the patient has a history of epitheliomatous
disease of the jaws further attempts should be made to remove it. A case
where a tooth was forced into the antrum in a patient with a family
history of epithelioma of the jaw is recorded in the Transactions of the
Odontological Society, vol. ii., page 15, old series.
(_e_) =Forcing a tooth into an abscess cavity.=--This accident may occur;
if it does, it requires similar treatment to the accident just described
in connection with the antrum.
(_f_) =Trismus.=--Inability to open the mouth naturally renders extraction
of the teeth more difficult than usual. When, however, the closure is
the result of inflammatory trouble in connection with the lower molars,
an anæsthetic should be given and the mouth opened forcibly with a
Mason’s gag. If the trismus is the result of tonic contraction of the
muscles closing the jaw, ether should be used in order to overcome the
resistance of the muscles, as nitrous oxide would not have the desired
effect.
(3) DIFFICULTIES, COMPLICATIONS AND SEQUELÆ IN CONNECTION WITH THE SOFT
TISSUES.
(_a_) =Extensive laceration of the gum.=--In cases where a tooth has given
rise to much trouble in removal, the soft tissues naturally suffer, but
apart from this they may be severely lacerated when the gum is more
than usually adherent to a tooth. This is most frequently seen in the
removal of the lower third molar, but it is also sometimes met with in
the removal of loose teeth. When the gum is found more than usually
adherent the tooth should be left in the socket until the gum attachment
has been divided with a pair of scissors or a lancet. Continued attempts
to remove the tooth with the forceps before the gum has been divided
will only lead to undue laceration.
In all cases where the gums have been badly lacerated, an anodyne mouth
wash should be prescribed.
(_b_) =Wounding the tongue.=--This is most likely to occur under nitrous
oxide, as the tongue during anæsthesia is generally swollen, and is,
moreover, not under the control of the patient. Wounding the tongue is
nearly always due to carelessness, and arises generally in using the
elevator. When the tongue is _much lacerated_, the overhanging portions
should be trimmed off with scissors and the surface kept clean with
antiseptic mouth washes. If the _tongue is punctured and the wound does
not involve a large branch of the lingual artery_, but yet bleeds
freely, the tongue should be drawn forward; if this does not prove
successful the insertion of a stitch will generally cause the hæmorrhage
to cease. _If the tongue is punctured and a large branch of the lingual
artery is involved_, the finger should be placed on the back of the
tongue and the organ drawn forward; this compresses the lingual artery
against the hyoid bone. The bleeding point must then be sought for and,
if found, an attempt made to twist the wounded vessel. If this fails
cauterisation may be tried, and as a last resource, if cauterisation
does not stop the bleeding, the lingual artery must be tied.
(_c_) =Bruising the lower lips.=--This may occur in the removal of upper
bicuspids and molars, and is due to having the mouth insufficiently
opened, and using forceps of too straight a pattern.
(_d_) =Injury of the mandibular nerve.=--The mandibular nerve may be
injured during the removal of the lower molars and bicuspids. Loss of
sensation over the parts supplied by the nerve, with dribbling of
saliva, generally follows the accident. Sensation is, however, usually
restored, and in cases of laceration the nerve generally unites.
Mr. Sewill records a case in which “the roots of a lower wisdom tooth
contained a groove and a foramen, through which the inferior dental
nerve had evidently passed.”
(_e_) =Hæmorrhage following tooth extraction= is a most important
complication, and one which needs prompt treatment. Hæmorrhage is
predisposed to by a diathesis known as hæmophylia. Of its pathology but
little seems to be definitely known. The blood in this condition is said
by Walsham to be deficient in fibrin. Hæmorrhage may occur in people not
predisposed to the above-named diathesis; in some instances it is
probably due to pathological changes in the artery supplying the tooth,
these changes being frequently induced by inflammation around the apex
of the root, and the vessel becoming adherent to its bony surrounding,
and thus prevented from contracting. Another condition, which may or may
not have any practical bearing, is the occurrence of hæmorrhage during
the menstrual period. I have, on two occasions, had under notice
patients for whom teeth have been extracted during this period, and in
whom hæmorrhage followed, but ceased at the termination of the period.
Teeth had been extracted for both these patients on previous occasions,
without undue hæmorrhage following.
Hæmorrhage is generally divided into three stages, viz.:--primary,
intermediate and secondary. In the mouth we often find the primary
running into the intermediate. The treatment of primary hæmorrhage, or
that occurring at the time of the operation, is not of serious import.
If it is at all sharp a useful plan is to give the patient some tincture
of hamamelis in the water used for rinsing the mouth. At the same time
about fifteen grains of gallic acid[9] should be given, and the patient
should be ordered to take a similar quantity every two or three hours
until the hæmorrhage ceases. The socket should also be loosely plugged
with cotton-wool dipped in some styptic, such as gallic acid.
Intermediate and secondary hæmorrhage is of a more serious nature, and
generally sets in at night. When a case of intermediate hæmorrhage is
first seen, these two important points should be ascertained before
treating it:--first, whether the bleeding is coming from the gums or the
socket of the tooth; secondly, whether the blood shows a tendency to
coagulation. The latter point will act as a guide in the choice of drugs
for internal administration.
In hæmorrhage from the gum search should be made for any small vessels
that may be the cause of it, and if found they should be twisted or
compressed. If the vessel is only partially divided it should be
completely severed, as this will probably allow contraction to take
place. If the bleeding is capillary in character, a pad of gutta-percha
lined with lint dipped in some styptic and applied with firm pressure is
usually sufficient to stop it.[10]
When the bleeding proceeds from the socket the following mode of
procedure is adopted: some small cone-shaped pieces of non-absorbent
cotton-wool are prepared (each about ⅓ to ½ inch long and ¼ inch broad
at the base), also a pad of lint and a four-tailed bandage; a syringe, a
pair of conveying forceps, some cold water and the chosen styptic are
likewise placed ready for use. The socket is first freed from clot, then
syringed, then dried out with a pledget of cotton-wool, and directly
afterwards one of the cone-shaped pieces of cotton-wool dipped in the
styptic (the most useful being tannin) is placed in the socket and
forced to the apex, with a fair amount of pressure; the hæmorrhage is
arrested far more by pressure than by the styptic. More pledgets of wool
are inserted until the socket is quite full; a plug of lint is then
placed over all and kept in position by antagonism with the upper teeth,
a four-tailed bandage being used for this purpose. An excellent method
of keeping the plug in the socket if the approximal teeth are standing
is to wedge a piece of wood between them. Excellent as this plan is,
however, if the hæmorrhage is at all sharp it is better to use the
four-tailed bandage to make more certain of retaining the plug in
position. The number of pledgets of wool inserted in the socket should
be counted.
The general directions to be given to the patient, though apparently
trivial, are most important and should never be forgotten. He or she
should be advised to go home very quietly, to avoid all forms of
excitement, to assume the sitting position usual during the day, and to
use a high pillow at night. The patient should be fed through a bent
tube, and all fluids should be given cold.
In addition to plugging the socket, hæmostatics should be administered
internally.
In _cases where there is_ a thin watery blood and _no tendency to
coagulation_ it may be fairly assumed that the cause of the hæmorrhage
lies in the blood, and such drugs as gallic acid[11] and perchloride of
iron[12] are indicated, _but when the blood shows a marked tendency to
coagulate_ in the mouth, as often happens, and the bleeding still
continues, such drugs as ergot[13] are indicated; in this latter
condition it may be assumed that the cause of the hæmorrhage lies in
some want of contractility of the vessel wall, and ergot causes
contraction of unstriped muscular tissue.
At the time of plugging the socket a dose of gallic acid, perchloride of
iron or ergot should be given, and its administration continued at
intervals until the bleeding ceases. Mr. Morton Smale prefers a
hypodermic injection of ergotine.[14]
The patient should be seen within twenty-four hours after treatment, and
if the bleeding has ceased the plugs may be removed and an antiseptic
mouth wash prescribed. This course is not recommended when the
hæmorrhage has been severe; under such circumstances the plugs should be
allowed to work themselves out. If the hæmorrhage has not then ceased,
the socket should be replugged tighter than before with a plug of wood
wrapped in non-absorbent cotton-wool. Should this prove of no avail the
actual cautery may be tried; if this fails, and the bleeding is from the
mandible, the canal should be trephined and a plug of ivory inserted,
so as to compress the artery against the inner plate of the bone. In
uncontrollable hæmorrhage from the maxilla digital pressure on the
common carotid opposite the transverse process of the sixth cervical
vertebra may be tried; should this fail to stop the hæmorrhage, ligature
of that vessel must be resorted to.
In one case of hæmorrhage from the region of the third right lower molar
Mr. Boyd[15] divided the lip in the median line and reflected the cheek
from the jaw. The mandibular canal was then laid open by excising the
outer plate of the bone, and the bleeding was arrested by plugging the
mesial and distal ends of the canal.
_In extreme cases, with sign of collapse_, normal saline solution[16]
must be infused into the median basilic vein.
In _patients predisposed to hæmorrhage_ extraction should be if possible
avoided; but, if the removal of the tooth be absolutely necessary,
prophylactic treatment should be pursued for three or four days previous
to the operation by the administration of one or other of the remedies
previously mentioned.
A new styptic, consisting of fibrin ferment 1 to 10 to which 1 per cent.
of calcium chloride has been added, is said by Walsham to act only on
the blood, not on the tissues, and to be perfectly aseptic. It was found
to be effectual in arresting hæmorrhage after the division of all the
veins except the common jugular in a dog’s neck.
The tooth should be extracted in the early morning, as we then have the
day before us should hæmorrhage occur. Some hæmostatic should be
administered at the time of the operation and the socket plugged at
once; for it is most important to remember that in these cases it is far
easier to prevent the hæmorrhage occurring than to arrest it when once
it has commenced. The subsequent treatment will consist in the continued
administration of hæmostatic drugs.
(_f_) =Injury of the arteries in the neighbourhood of the teeth.=--Wound
of the _lingual_ artery has been referred to under the heading of
injuries to the tongue. Laceration of the _ranine_, _anterior and
posterior palatine_ arteries may also occur. Such accidents are usually
the result of the forceps slipping and are therefore avoidable.
Treatment consists in pressure or in twisting or tying the divided
vessel. In the case of the _anterior or posterior palatine artery_ it
may be found necessary to plug the foramina which give passage to these
vessels.
(_g_) =Pain following tooth extraction.=--The causes giving rise to pain
following the extraction of a tooth are:--
(1) _Incomplete extraction of the tooth_, more especially when the
remaining portion contains an exposed pulp.
(2) _Too rapid healing of the orifice of the socket._--It sometimes
happens that the margins of the wound left after extraction unite very
early, and when this occurs the discharges which naturally come away
from the granulating surface at the base of the socket, have no exit;
the consequence is that they are retained and set up a local traumatic
inflammation, leading to swelling of the surrounding tissue.
(3) _Suppuration in the tooth socket._--This may be due in the first
instance to the use of dirty forceps, and under such circumstances it
may be classed as a poisoned wound. An examination will reveal the
presence of greenish putrid pus, while the tissue around will be much
inflamed, and the portion immediately bordering the wound will have a
tendency to slough. A condition of this kind is often seen in hospital
nurses and medical students and is no doubt due to infection met with in
their daily duties.
Suppuration in the socket may be due to a lowered vitality of the
tissue, produced by some such local causes as acute or chronic
inflammation, and is especially well seen in cases of extraction for
the relief of periodontitis, or where the operation has been performed
in patients suffering from general debility, syphilis, struma or in fact
any of those systemic diseases which tend to lower the vitality of the
organism.
(4) _Extensive laceration of the hard and soft tissues_ in the
neighbourhood of the socket; and
(5) _Necrosis of the socket of the tooth_ are also fruitful sources of
pain following tooth extraction.
(6) _The presence in the wound of a foreign body._--A curious example of
this came under notice a few years ago. A patient applied for the
extraction of the left first permanent molar. During the operation a
portion of one of the cusps disappeared; a search was made for it but,
as it was not found, the natural supposition was that it had been
removed in rinsing the mouth. The patient for the next three weeks
complained of slight pain in the socket for which remedies were tried
but proved of little use. Eventually the patient discovered the cusp on
the top of the granulation tissue which had filled up the socket. In
another case of the same character which came under notice, the
offending material was a piece of an amalgam filling. A fractured blade
of forceps may likewise act as the offending body.
(7) _Injury to the nerve._--Direct injury to the trunk of the nerve is
more likely to occur during extraction of the lower third molar than
with any other tooth. It is more than probable that many obscure cases
of pain following tooth extraction are due to exposure and irritation of
the nerve at the apex of the socket. An interesting case of this
character was lately reported by Mr. Storer Bennett.[17] The patient, a
lady æt. 23, had had the third upper molar dislocated through the use of
a Wood’s gag, and, as it was considered hopeless to restore the
dislocated tooth, it was extracted without difficulty. The socket in
spite of treatment remained painful for the next twelve days, but in the
meanwhile granulated healthily, except at its apex, where by the aid of
a mirror and probe a spot about the size of a pin’s head was noticed
which caused the greatest agony on being touched. Incision of the nerve
produced permanent relief.
_Treatment._--The treatment naturally depends very much upon the cause.
A thorough examination of the socket should be made with probe and
mirror. When due to incomplete extraction, another attempt, if
considered advisable, may be made to remove the tooth. This proving
unsuccessful, the socket should be swabbed with an anodyne drug and, if
there is an exposed pulp in the remaining portion of the tooth, the pulp
should be touched with fuming nitric acid or strong carbolic acid. The
patient should also be advised to use some poppy head fomentation.[18]
In _too rapid healing of the orifice of the socket_, the freshly healed
surface must be separated, the socket syringed out, and a small tent of
lint allowed to remain in the orifice for about twelve hours. An
antiseptic mouth wash should also be prescribed.
In those cases _where the pus is putrid_ and there is reason to suspect
infection, the socket should be thoroughly syringed with some antiseptic
such as hyd. perchlor. 1 in 1,000, carbolic acid 1 in 40; following this
the parts should be carefully dried with cotton-wool. A small piece of
chloride of zinc should then be introduced and allowed to dissolve in
the socket, which must be subsequently kept aseptic by constant
irrigation with some antiseptic solution.
Suppuration is most frequently seen after extraction of the lower teeth
owing to the fact that drainage is less easily effected than in the
upper, owing to the dependent position of the socket. In many cases it
will be found necessary to plug the socket tightly with non-absorbent
cotton-wool dipped in an antiseptic solution; this prevents the
accumulation of _débris_ which would act as an irritant. In cases of
_suppuration occurring in patients of diminished vitality_ a tonic form
of treatment should be prescribed;[19] the dressing in the socket should
be removed two or three times a day and the socket syringed.
Care must be exercised in applying escharotics to sockets to which the
nerve may be in close proximity; this is especially necessary in dealing
with impacted lower third molars. Two cases illustrating this point have
come under my notice. In the first a second lower bicuspid with a long
standing chronic abscess had been removed. The patient complained of
pain, the socket was syringed out and a small piece of chloride of zinc
inserted. Intense agonizing pain followed which all local anodynes
failed to relieve. In the second case an impacted right lower third
molar had been removed. The socket suppurated, and the pain although
severe was not intense. Treatment similar to that used in the first case
was adopted with similar results. Since then in all cases where it is
possible that the trunk of the nerve may be in close proximity to the
socket, I have used non-irritating antiseptic injections and plugged
the socket with cotton-wool dipped in tincture of opium with much more
satisfactory results.
It is advisable to inform the patient of the possibility of pain
following the extraction of a tooth, especially after periodontitis, and
in all cases where a large number of teeth have been extracted a
mouth-wash[20] should be prescribed; for, even if there is no pain, it
will prevent the discharge from the sockets of the teeth undergoing
putrefactive changes.
_In pain due to necrosis of the socket_ deodorant antiseptic injections
must be used, while in extensive laceration of the soft and hard parts
an anodyne mouth-wash[21] may be tried. In all _obscure cases_ an
application should be made to the socket of some local anodyne such as
tincture of opium or cocaine, and a mouth wash having similar
properties should at the same time be prescribed.
(4) DIFFICULTIES, COMPLICATIONS AND SEQUELÆ ARISING DURING EXTRACTION
UNDER ANÆSTHETICS.
(_a_) =Tongue slipping back.=--During extraction under anæsthetics the
tongue not being under control may slip over the larynx, or may be
forcibly pushed back by the fingers of the operator. Symptoms of
difficult breathing or even arrest of respiration will follow this
accident. It is not enough to watch the chest walls, as respiratory
movement may continue without air entering the lungs. Treatment consists
in pulling the tongue forcibly forward with a suitable instrument and
forcibly extending the head on the spinal column.
(b) =Forcing out a tooth with a prop or a Mason’s gag.=--With a prop this
accident may arise from resting it upon teeth which are loose or from
placing it in such a way that undue leverage is brought to bear on the
teeth. It is an accident most likely to occur when the prop is fixed on
the front teeth and the mouth opened to its widest extent. Under such
conditions undue leverage at right angles to the long axis of the tooth
is brought to bear upon the palatal surfaces of the upper teeth and they
are consequently forced outwards. With a Mason’s gag the accident is
due at times to clumsiness; great care should therefore be exercised
when using this very powerful instrument. If a tooth is forced out it
should if possible be immediately replaced.
(_c_) =Passage of a foreign body through the isthmus of the fauces.=--A
foreign body, such as a tooth, a broken piece of forceps or a prop,
passing through the isthmus of the fauces may become impacted in either
the air or food passages.
In the air passages it may lodge (1) over the entrance of the larynx,
(2) in the larynx, (3) in the trachea or bronchus.
In the food passages it may lodge (1) in the pharynx, (2) in the
œsophagus, (3) at the pyloric opening of the stomach.
_In the air passages._--Should the foreign body lodge _over the entrance
of or in the larynx_ the patient will be seized with a violent fit of
coughing which may expel it; but, should this not happen, symptoms of
asphyxia will supervene. With regard to treatment; the head should
immediately be brought forward and the finger inserted along the side of
the mouth into the pharynx, and then given a forward sweeping movement;
by this means the foreign body, if lodged at the back of the tongue,
will probably be removed. This failing, the patient must if possible be
inverted and a forcible slap given on the back. If the foreign body is
not dislodged by this method, laryngotomy should be immediately
performed. There must be no hesitation about the performance of this
operation and it must be carried out promptly, for the longer it is
delayed the less becomes the chance of saving the life of the patient.
_A foreign body in the trachea or bronchus_ may give rise to no
immediate symptoms, but generally a violent fit of coughing, with signs
of impending asphyxia, takes place at the time of the accident. These
signs pass away, to be followed at intervals by fresh attacks of
coughing and eventually by symptoms of collapse of the lung or lungs.
In a case recorded by Sir William MacCormac,[22] during the removal of
an upper bicuspid the palatine blade of the forceps snapped off close to
the joint and disappeared. The patient immediately suffered from great
dyspnœa and appeared to be dying. The symptoms passed away, and for the
following six weeks the patient’s condition gave no great cause for
anxiety, although she suffered from a constant hacking cough accompanied
by bloody expectoration. Seven weeks after the accident she was admitted
into St. Thomas’s Hospital, the foreign body was with difficulty removed
from the right bronchus, and the patient made an excellent recovery.
_The diagnosis of a foreign body in one bronchus_ is made by an absence
of signs of respiration over the whole or part of the lung on that side,
with exaggerated sounds (puerile breathing) over the opposite side.
Treatment consists in performing tracheotomy and removing the foreign
body.
_In the food passages._--_A foreign body impacted in the pharynx_ will
give rise to pain, symptoms of dysphagia and dyspnœa. A hacking cough is
generally present.
Should a foreign body be suspected in the pharynx, its presence can
usually be ascertained by digital exploration; this failing, the cavity
should be examined by the aid of a laryngoscope.
An attempt should first be made to remove the body with the fingers, and
if this is unsuccessful pharyngeal forceps must be called into use. In
some cases where the impaction is very firm it may be necessary to
perform pharyngotomy.
_A foreign body in the œsophagus_ will cause dysphagia, and will
probably give rise to constant pain; if it is situated in the upper part
it will in all probability give rise to dyspnœa. On applying the
stethoscope over the region of the œsophagus, a gurgling sound will be
heard when the patient swallows fluids. The presence of a foreign body
may be definitely ascertained by passing a bougie; this step will also
enable the surgeon to determine the position in which the foreign body
is lodged.
_If impacted in the upper part of the œsophagus_, an attempt may be made
to remove the impacted body with forceps; this failing, œsophagotomy
must be performed.
_If lodged near the cardiac end of the œsophagus_ an attempt may be made
with a bougie to push the foreign body into the stomach; this failing,
gastrotomy should be performed.
_If a foreign body becomes impacted at the pyloric opening_ of the
stomach, it will give rise to gastric dilatation. Under such
circumstances the stomach must be emptied of its contents, and
gastrotomy then performed.
A foreign body going through the isthmus of the fauces will as a rule
pass into the œsophagus, then into the stomach, and will give rise to no
trouble.
The details of such operations as gastrotomy, œsophagotomy, &c., do not
lie within the scope of this book, and should be sought for in works
dealing with general surgery.
The necessity of being ready for such emergencies as the above cannot be
too fully emphasised, and all who administer anæsthetics should be
provided with the instruments necessary to perform laryngotomy. These
should be kept in a little case, and no anæsthetic should be
administered without the case being near at hand. Adherence to this rule
is important.
(5) MISCELLANEOUS DIFFICULTIES, COMPLICATIONS AND SEQUELÆ.
(_a_) =Uterine pain.=--A case is quoted by Mr. Sercombe where extraction
of a tooth was followed by paroxysmal uterine pain, followed by the cure
of an obstinate leucorrhœa.[23]
(_b_) =Shock.=--The fact that _tooth extraction is a surgical operation_,
and may be followed by shock, is often overlooked. The amount of shock
which follows as a rule is practically _nil_, but at times, especially
in the weak, it may be well marked. This is not taken sufficiently into
account when a question arises as to the number of teeth to be extracted
at one sitting, and it should be clearly borne in mind that what a
strong, able-bodied person, can stand, one of weaker physique cannot
bear. The _wholesale extraction of teeth at one sitting_ which is
carried out by some operators is not advisable, and the amount of
prostration that follows is sometimes very severe.
_Syncope at the time of the operation_ sometimes occurs. Should it
supervene during the extraction of the tooth the operator should
immediately desist until recovery ensues. Fainting is best treated by
bending the head down towards the knees, at the same time loosening
anything tight about the neck and applying ordinary salts of ammonia to
the nose. _In severe cases_ the patient should be removed from the chair
and laid on the floor, and the chest should be exposed and flipped with
a towel dipped in cold water. _In more severe cases_ it may be necessary
to inject ether or some other stimulant, such as brandy. _Fatal syncope_
following tooth extraction has occurred, and a case which took place at
Marseilles in 1881 is mentioned by Tomes.[24] The patient was a female,
and an attempt was made to remove a tooth, but was desisted in owing to
alarming syncope. A second attempt was made, or rather about to be made,
when fatal syncope ensued. _Post-mortem_ examination showed nothing
beyond a slight amount of cerebral congestion.
(_c_) =Epilepsy.=--In those pre-disposed to epilepsy an attack often
commences immediately after the extraction of a tooth. In the event of a
fit occurring the patient should be removed from the chair and placed on
the floor, the clothes being at the same time loosened, and a wedge of
wood or some suitable material placed between the teeth to prevent
injury to the tongue.
(_d_) =Hysteria.=--Manifestations of this disorder at times follow tooth
extraction, but do not call for any special treatment beyond that
usually adopted for this disorder.
(_e_) =Septic and infective sequelæ.=--Scattered through dental literature
will be found a large number of records of septic and infective diseases
which have followed the extraction of teeth. In many of these cases it
would be difficult to say that the infection was always the result of
the operation; in a number of them the actual cause was due to the
neglected condition of the tooth which called for extraction. Infection
can, however, at times undoubtedly be traced to the operation, and once
again attention cannot be too strongly drawn to the fact that antiseptic
precautions should be carried out as far as possible.
Suppuration of the socket and its appropriate treatment has already been
dwelt upon (page 82). Cases of syphilis having been acquired through the
use of infected forceps are recorded, while septicæmia, sapræmia,
cellulitis, osteitis, osteomyelitis, periostitis, pyæmia, tetanus, have
all been known to follow the removal of a tooth, but the treatment of
these conditions hardly lies within the scope of this book.
INDEX.
A
PAGE
Abnormality of upper molars, 26
ACCIDENTS UNDER ANÆSTHETICS:--
Forcing out a tooth with a prop or a Mason’s gag, 88
Passage of a foreign body through the isthmus of the fauces, 89
Tongue slipping back, 88
Alveoli of the teeth, disposition of the, 12
Alveolus, fracture of the, during extraction, 67
“ “ “ “ treatment of, 69
“ necrosis of the, following extraction, 70
Anæsthetics, the use of, during the extraction of teeth, 56
Arteries, injury to the, in the neighbourhood of the
tooth during extraction, 81
B
Bicuspids, the extraction of lower, 34
“ “ “ “ misplaced lower, 51
“ “ “ “ “ upper, 49
“ “ “ “ upper, 22
Breaking one tooth in extracting another, 67
Bruising the lower lips during extraction, 74
C
Canines, the extraction of lower, 34
“ “ “ “ upper, 21
Central incisors, the extraction of lower, 33, 51
“ “ “ “ “ upper, 19
Chloride of ethyl, 61
Chloroform, the use of, during the extraction of the teeth, 56, 57
Cocaine, mode of employment, 60
“ toxic effects, 61
COMPLICATIONS, DIFFICULTIES AND SEQUELÆ OF EXTRACTION OF THE TEETH:--
Complications, difficulties, and sequelæ arising during extraction,
miscellaneous, 94
Complications, difficulties and sequelæ arising during extraction
under anæsthetics, 88
Complications, difficulties and sequelæ of extraction of the teeth
connected with the jaws, 67
Complications, difficulties and sequelæ of extraction of the teeth
connected with the soft tissues, 72
Complications, difficulties and sequelæ of extraction of the teeth
connected with the teeth themselves, 63
Coryl, 61
D
DIFFICULTIES, COMPLICATIONS AND SEQUELÆ ARISING DURING EXTRACTION,
MISCELLANEOUS:--
Epilepsy, 94
Hysteria, 94
Septic and infective sequelæ, 95
Shock, 93
Uterine pain, 93
DIFFICULTIES, COMPLICATIONS AND SEQUELÆ ARISING DURING EXTRACTION
UNDER ANÆSTHETICS:--
Tongue slipping back, 88
Forcing a tooth out with a prop or Mason’s gag, 88
Passage of a foreign body through the isthmus of the fauces, 89
DIFFICULTIES, COMPLICATIONS AND SEQUELÆ CONNECTED WITH THE JAWS:--
Dislocation of the mandible, 70
Forcing a root into the antrum, 71
Forcing a tooth into an abscess cavity, 72
Fracture, 67
“ treatment of, 69
Necrosis, 70
Trismus, 72
DIFFICULTIES, COMPLICATIONS AND SEQUELÆ CONNECTED WITH THE TEETH
THEMSELVES:--
Breaking one tooth in extracting another, 67
Crowded and irregular teeth, 65
Fracture of the tooth, 64
The removal of a neighbouring tooth, 66
“ “ an unerupted bicuspid, 66
“ “ the wrong tooth, 66
Undue resistance of the tooth and alveolus, 63
DIFFICULTIES, COMPLICATIONS AND SEQUELÆ IN CONNECTION WITH THE
SOFT TISSUES:--
Bruising the lower lips, 74
Extensive laceration of the gum, 72
Hæmorrhage following tooth-extraction, 74
“ “ “ treatment of, 76
Injury of the arteries in the neighbourhood of the teeth, 81
Injury of the mandibular nerve, 74
Pain following tooth extraction, 81
Wounding the tongue, 73
Disposition of the alveoli of the teeth, 12
E
Elevator, 7
Epilepsy, attack of, following tooth extraction, 94
Ethyl, chloride of, 61
Extraction of impacted lower third molars, 54
“ “ individual teeth, 19
“ “ lower bicuspids, 34
“ “ “ canines, 34
“ “ “ incisors, 33
“ “ “ molars, 35
“ “ “ teeth, 30
“ “ misplaced lower bicuspids, 51
“ “ “ “ incisors, 51
“ “ “ teeth, 46
“ “ “ upper bicuspids, 49
“ “ “ “ canines, 48
“ “ “ “ central incisors, 47
“ “ “ “ lateral “, 47
“ “ temporary teeth, 17, 43
Extraction of upper bicuspids, 22
“ “ “ canines, 21
“ “ “ incisors, 19
“ “ “ molars, 23
“ “ “ teeth, 19
“ “ the teeth, general principles of, 1
“ with forceps, 14
F
Forceps, holding of, 6
Forceps, the, 3
Forcing a root into the antrum during tooth extraction, 71
“ “ tooth into an abscess cavity during tooth extraction, 72
“ out a tooth with a prop or a Mason’s gag, accidents
under anæsthetics, 88
Fracture of the alveolus during tooth extraction, 67
“ “ “ “ treatment of, 69
“ “ “ tooth during tooth extraction, 64
Freezing agents, local anæsthetics, 61
G
General principles of extraction of the teeth, 1
Gum, extensive laceration of the, during tooth extraction, 72
H
Hæmorrhage following tooth extraction, 74
“ “ “ “ treatment of, 76
Hewitt, Dr., on the toxic effects of cocaine, 61
“ “ “ “ use of chloroform in operations, 57
Holding of elevator, 9
“ “ the forceps, 6
Hysteria, attack of, following tooth extraction, 94
I
Impacted lower third molars, the extraction of, 54
Incisors, the extraction of lower, 33
“ “ “ “ misplaced lower, 51
“ “ “ “ “ upper central, 47
“ “ “ “ “ “ lateral, 47
Incisors, the extraction of upper, 19
Individual teeth, the extraction of, 19
Injury of the arteries in the neighbourhood of the tooth during
extraction, 81
“ to the mandibular nerve during tooth extraction, 74
Instruments, 3
Irregular and crowded teeth, difficulties during extraction through, 65
L
Laceration of the gum through tooth extraction, extensive, 72
Lateral incisors, the extraction of misplaced upper, 47
Lips, bruising the lower, during tooth extraction, 74
Local anæsthetics, 59
Lower bicuspids, misplaced, the extraction of, 51
“ incisors, misplaced, the extraction of, 51
“ “ the extraction of, 33
“ teeth, the extraction of, 30
“ third molars, impacted, the extraction of, 54
M
Mandible, Dislocation of the, during tooth extraction, 70
Mandibular nerve, injury to the, during tooth extraction, 74
Miscellaneous complications, difficulties and sequelæ, 93
Misplaced lower bicuspids, the extraction of, 51
“ “ incisors, the extraction of, 51
“ teeth, the extraction of, 49
“ upper bicuspids, the extraction of, 49
“ “ canines “ “, 48
“ “ central incisors, the extraction of, 47
“ “ lateral “ “, 47
Molars, impacted lower third, 54
“ the extraction of lower, 35
“ “ “ upper, 23
N
Necrosis of the alveolus following tooth extraction, 70
Nitrous oxide, the use of, during the extraction of the teeth, 56, 57, 58
Nitrous oxide with air, the use of, during the extraction of
the teeth, 56, 57, 58
O
“Oblique rooted” molars, 26
Operations requiring a long anæsthesia, 57
Order of removal of teeth, 59
P
Pain following tooth extraction, 83
Passage of a foreign body through the isthmus of the fauces,
accidents under anæsthetics, 89
Points in the anatomy of the teeth and jaws, 11
Position of the operator and patient, 10
R
Removal of a neighbouring tooth during extraction, 66
“ “ an unerupted bicuspid “ “, 66
“ “ teeth, the order of, under anæsthetics, 59
“ “ “ with straight elevator, 15
“ “ the wrong tooth during tooth extraction, 66
S
Screw, the, 9
Septic and infective sequelæ following extraction, 95
Sequelæ, difficulties and complications arising during
extraction, miscellaneous, 93
Sequelæ, difficulties, complications and, arising during
extraction under anæsthetics, 88
Sequelæ, difficulties, complications and, of extraction
of the teeth connected with the jaws, 67
Sequelæ, difficulties, complications and, of extraction
of the teeth connected with the soft parts, 72
Sequelæ, difficulties, complications and, of extraction
of the teeth connected with the teeth themselves, 63
Shock following extraction, 93
T
Teeth, general principles of extraction of the teeth, 1
“ which require extraction, 1
Temporary teeth, the extraction of, 17, 43
Tongue slipping back, accidents under anæsthetics, 88
Treatment of fracture of the alveolus during tooth extraction, 69
Treatment of hæmorrhage following tooth extraction, 76
Trismus, treatment of, 72
U
Undue resistance of the tooth and alveolus, 63
Upper bicuspids, misplaced, the extraction of, 49
“ canines, misplaced, the extraction of, 48
“ central incisor, misplaced, the extraction of, 47
“ lateral “ “ “ “ “, 47
“ teeth, the extraction of, 19
Use of anæsthetics during the extraction of the teeth, 56
Uterine pain following tooth extraction, 93
W
Wounding the tongue during tooth extraction, 73
Wound resulting from removal of a tooth, 16
* * * * *
DISEASES AND INJURIES
OF THE TEETH,
_Including Pathology and Treatment_,
A Manual of Practical Dentistry for Students
and Practitioners.
BY
MORTON SMALE, M.R.C.S., L.S.A., L.D.S.,
Dental Surgeon to St. Mary’s Hospital; Dean of the
School, Dental Hospital of London; Member of Board
of Examiners in Dental Surgery, Royal College of
Surgeons of England.
AND
J. F. COLYER, L.R.C.P., M.R.C.S., L.D.S.,
Dental Surgeon and Lecturer on Dental Surgery to
Charing Cross Hospital and to the Dental Hospital
of London.
334 illustrations. 407 pp. and Index. 8vo, cloth.
Price 15s.
SUPPLIED BY
CLAUDIUS ASH & SONS, Limited,
5, 6, 7, 8, & 9, BROAD STREET, GOLDEN SQUARE, LONDON, W.
ENGLAND.
FOOTNOTES:
[1] A description of the different instruments in general use for the
removal of the various teeth will be found in chapter ii.
[2] A description of the form of each tooth, with respect to its
bearing upon the construction of forceps and its removal, will be
found in chapter ii.
[3] The following is a useful formula:--
℞ Liquoris potassæ Ʒvi.
Acidi carbolici glacialis Ʒij.
Aquam ad. ℥viii.
_M._ One teaspoonful to be used with half a tumbler-full of warm water
as a mouth wash.
[4] “A System of Surgery” (edited by Frederick Treves), vol. i., page
292.
[5] “Dental Pathology and Surgery,” page 340.
[6] _Transactions Odontological Society_, vol. iii., page 138.
[7] _Transactions Odontological Society_, vol. xxviii., page 3.
[8] _Journal British Dental Association_, vol. xiv., page 727.
[9]
℞ Acidi gallici Ʒij.
Ft. pulv. viij.
One powder every two hours until the hæmorrhage ceases.
[10] Perchloride of iron should be avoided as a styptic, it nearly
always contains some free acid, and is therefore detrimental to the
teeth; in addition to this it leads to extensive clotting in the
veins, as well as to a certain amount of sloughing of the gums.
[11]
℞ Acidi gallici Ʒij.
Ft. pulv. viij.
One powder every two hours until the hæmorrhage ceases.
[12]
℞ Liq. ferri perchloridi ♏xxv.
Aquæ chloroformi Ʒij.
Aquam ad ℥j.
Mitte ℥viij.
M. Two tablespoonfuls every three hours until the hæmorrhage ceases.
[13]
℞ Ext. ergotæ liquidi ♏xx.
Acidi sulphurici diluti ♏x.
Aquam rosæ ad. ℥j.
Mitte ℥viij.
M. Two tablespoonfuls every three hours until the hæmorrhage ceases.
[14] Injectio ergotini hypodermica B.P.: 1 of ergotine to 2 of camphor
water. Dose 3 to 10 minims, made as required.
[15] _Dental Record_, vol. xi., p. 425.
[16] Common salt, Ʒj., water 0j. at 99° F.
[17] _Transactions of the Odontological Society_, vol. xxvii., page
123.
[18] Two ounces of poppy heads should be placed in one pint of boiling
water, the water being boiled down to half a pint.
[19]
℞ Ferri et quiniæ citratis gr. vi.
Aquæ chloroformi Ʒij.
Infusum quassiæ ad. ℥i.
Mitte ℥viij.
M. Two tablespoonfuls three times a day after meals.
[20] The following will be found useful:--
℞ Boro-glyceride (Barff) }
Eau de Cologne } aa. Ʒiv.
Tinct. krameriæ }
Spirit vini. rect. ad. ℥iv.
♏ Fiat lotio.
To be used with water as a mouth wash. Shake before using.
[21]
℞ Zinci sulphatis gr. viij.
Zinci chloridi gr. vi.
Morphinæ acetatis gr. ij.
Aquam ad. ℥viij.
♏ Fiat lotio.
To be used with an equal quantity of water as a mouth-wash.
[22] _The Journal of the British Dental Association_, vol. vii., page
32.
[23] _British Journal Dental Science_, vol. iii., page 221.
[24] “A System of Dental Surgery,” 3rd edition, page 626.
End of Project Gutenberg's Extraction of the Teeth, by J. F. Colyer