Chapter 12: Orodental Problems

If a permanent (second) tooth is knocked out (i.e. in an accident or fight) but is intact, it can be saved by the following, immediate procedure. The tooth should not be out of the mouth for longer than 20 to 30 minutes from the time of injury.

Method

1. Using a sterile glove hold the tooth by its crown and replace it in its original position, preferably immediately (Fig. 12.1); if dirty, put it in milk before replacement or, better still, place it under the tongue and ‘wash’ it in saliva. Alternatively, it can be placed in contact lens saline or the solution in the ‘Dentist in a Box^®’ kit (www.dentistinabox.com.au). Note: Do not use water, and do not rub (it removes dentine) or wipe it or touch the root.

2. Fix the tooth by moulding strong silver foil (e.g. a milk bottle top or cooking foil) over it and the adjacent teeth. Moulding foil can be difficult: an alternative is to suture with a figure-of-eight silk suture to encompass the tooth. It can also be secured to the two adjoining teeth with a strip of tape cut from a disc in the ‘Dentist in a Box^®’ kit.

3. Refer the patient to his or her dentist or dental hospital as soon as possible. Tell the patient to avoid exerting any direct biting force on the tooth.

Note: If a blood clot is present, remove it after a nerve block. Teeth replaced within 20 to 30 minutes have a 90% chance of successful reimplantation.

Loosening is excessive movement of a permanent tooth with no displacement.

Splint the mobile tooth to a neighbouring tooth with the splinting material from the kit (see above). Alternatively, use chewing gum or Blu-Tack. Refer the patient to a dentist.

Rinse the mouth with warm water. Cover the exposed area, which is usually painful, with dental tape. Recover and store the tooth fragment for use by the dentist. If possible, secure the broken fragment with splinting material from the kit. Refer the patient to a dentist.

A temporary measure is to stick a piece of chewed sugarless gum into the filling or use an OTC dental cement. Refer to the dentist ASAP.

Make appointment to visit dentist ASAP.

If area is sensitive, apply a little clove oil. Slip crown back over the tooth after coating the inner surface with OTC dental cement (or from Box kit). Do not use ‘superglue’.

This may present as an impacted tooth in the molar region, with pain and swelling, possible local infection and ‘frozen’ jaw. Rinse with warm salt water, applying an ice pack, and organise a dental appointment ASAP. Prescribe antibiotics if dental care is delayed.

Dental attention—if severe:

• amoxycillin.

If unresponsive:

• amoxycillin/clavulanate and metronidazole.

First aid treatment method

Enquire about blood-thinning medication. Wipe away the blood on top of the socket. Instruct the patient to bite very firmly on a gauze swab moistened with saline or water or a rolled-up moistened clean cotton handkerchief over the bleeding socket. Bite hard for up to 30 minutes. This simple measure is sufficient to achieve haemostasis in most instances. Biting on a recently used tea bag is another suggestion.

Surgical treatment for persistent bleeding

1. Remove excess blood clot, using a piece of sterile gauze.

2. Bite on a firm gauze pack (as above).

3. If still bleeding, infiltrate LA with adrenaline, insert an absorbable suture.

4. Using a reverse suture, approximate the anterior and posterior mucosal remnants (Fig. 12.2). The idea is not to close the socket but to tense the mucoperiosteum against the bone.

If a vessel in soft tissue is bleeding, either ligate or cauterise it.

Avoid aspirin, rinsing and alcohol.

Clinical features

• Tooth extraction 1 to 3 days earlier especially a wisdom tooth.

• Very severe pain, unrelieved by analgesics.

• Continuous pain on the side of the face.

• Foetid odour.

• Mainly in the lower molars, especially the third (wisdom teeth).

Examination shows a socket with few or no blood clots, and sensitive bone surfaces covered by a greyish-yellow layer of necrotic tissue.

Treatment method

1. Self-limiting healing 10 to 14 days.

2. Refer to the dentist for special toilet and dressing (palliative).

If you have to treat:

• irrigate with warm saline in a syringe

• pack socket with 1 cm ribbon gauze in iodiform paste or pack a mixture of a paste of zinc oxide and oil of cloves or (usual dental formulation) zinc oxide and eugenol dressing. Leave 10 days.

• analgesics

• mouth wash.

Note: Antibiotics are of no proven value unless infection supervenes.

The differential diagnosis for the dry tooth socket is descending infection.

Dentists utilise codes in which the teeth are numbered from 1 to 8 from the midline.

International notation

Each of the four quadrants are numbered:

Permanent teeth (n = 32; Fig. 12.3)

Deciduous teeth (n = 20)

There are five teeth in each quadrant, and the four quadrants are notated 5 to 8.

Examples:

• 1.6 = upper right first molar

• 3.2 = lower left lateral incisor

• 6.3 = upper left deciduous canine.

Palmer notation

In this notation a cross is drawn to represent quadrants, but the numerals are used as above for permanent teeth. Deciduous teeth are represented by the letters A–E.

The quadrants are noted by four right angles:

Examples:

• 5 = upper left second premolar

• C = lower right deciduous cuspid.

Wisdom teeth

These are the third molars. They are usually normal teeth, but are prone to troublesome eruption usually in the late teens and difficult extraction when impacted.

These acutely painful ulcers on the mobile oral mucosa are a common problem in general practice and puzzling in their cause and response to treatment. Their cause is unknown, but several factors indicate a localised abnormal immune reaction.

Minor ulcers: < 5 mm in diameter—last 5 to 10 days.

Major ulcers: > 8 mm in diameter—last weeks and heal with scarring.

Associations to consider

Blood dyscrasias, denture pressure, Crohn disease, pernicious anaemia, iron deficiency.

Precipitating factors

Stress and local trauma.

Treatment methods

These treatments should be used early when the ulcer is most painful. Several optional healing methods are presented.

Symptomatic relief

Apply topical lidocaine gel or paint, e.g. SM-33^® adult paint formula or SM-33^® gel (children) every 3 hours. If applied before meals, eating is facilitated.

Alternatively, use a mixture of:

• diphenhydramine (Benadryl^® mixture) 5 mL plus

• Mylanta^® 15–20 mL.

Gargle well and swallow 4 times a day.

Healing

One of the following methods can be chosen.

The teabag method

Consider applying a wet, squeezed out, black teabag directly to the ulcer regularly, such as 3 to 4 times daily. The tannic acid promotes healing and alleviates pain. Another method is to prepare a strong cup of tea (concentrated), cool and dip in a cotton bud or ball and hold it against the ulcer for 3 minutes.

Topical corticosteroid paste

Triamcinolone 0.1% (Kenalog in orobase^®) paste. Apply 8 hourly and at night.

Topical corticosteroid spray

Spray beclomethasone on to the ulcer 3 times daily.

Topical chloramphenicol

Use 10% chloramphenicol in propylene glycol. Apply with a cotton bud for 1 minute (after drying the ulcer) 6 hourly for 3 to 4 days.

Tetracycline suspension rinse for multiple ulcers

1. Empty the contents of a 250 mg tetracycline capsule into 20–30 mL of warm water and shake it.

2. Swirl this solution in the mouth for 5 minutes every 3 hours.

An alternative method is to apply the solution soaked in cotton wool wads to the ulcers for 5 to 10 minutes.

Note: This has a terrible taste but reportedly shortens the life of the ulcers considerably. We recommend spitting out the rinse, although some authorities suggest swallowing the suspension.

Topical sucralfate

Dissolve 1 g sucralfate in 20–30 mL of warm water. Use this as a mouth wash.

Treatment

Explanation and reassurance.

• No treatment if asymptomatic.

• Cepacaine^® gargles, 10 mL tds, if tender.

• If persistent and troublesome, low dose spray of glucocorticoid (e.g. beclomethasone 50 mcg tds). Do not rinse after use.

Brush tongue with a toothbrush to remove stained papillae. Use pineapple as a keratolytic agent.

Method

1. Cut a thin slice of pineapple into eight segments.

2. Suck a segment on the back of the tongue for 40 seconds and then slowly chew it.

3. Repeat until all segments are completed.

4. Do this twice a day for 7 to 10 days. Repeat if symptoms recur.

Alternate: sodium bicarbonate mouthwash.

The most common site for a salivary calculus is in the duct of the submandibular gland (Wharton duct). Obstruction to the gland by the calculus causes the classic presentation of intermittent swelling of the gland whenever the patient attempts to eat. The following method applies if the clinician can easily palpate the calculus with the finger under the tongue.

Method

1. Localise the calculus in the duct by finger palpation.

2. Anaesthetise the area with a small bleb of LA or surface anaesthetic (preferable if available), e.g. 5% cocaine placed under the tongue.

3. Insert a stay suture around the duct immediately behind the calculus (Fig. 12.4), and use this to steady the stone by elevation.

4. Make an incision over the long axis of the duct (the calculus easily slips out).

5. Remove the stay suture and leave the wound unsutured.

1. Fast for about 6 hours.

2. Squeeze an unripe lemon and drink the juice.

3. Place a slice of lemon on the tongue. The calculus usually appears at the opening—it may then be possible to extract it using the preceding or following methods.

If the calculus is visible at the opening of the duct it can be removed using the round end of a Jacob–Horne probe.

The round end of the probe is placed over the meatus and firmly pressed inwards.

Digital pressure is then applied from the opposite side of the frenulum. The calculus may ‘pop out’ quite readily.

The ideal time to release a tongue tie (ankyloglossia) is in infancy, when it may cause breastfeeding problems and maternal nipple pain.

Early signs

• Tongue may appear as heart-shaped.

• Infants should be able to lift the tongue halfway to the roof when the mouth is open.

• Infants should be able to protrude the tongue over the lower lip.

However, the condition is often not noticed until later in life, when it causes such symptoms as speech defects (e.g. a lisp), dental problems with the lower teeth, inability to protrude the tongue, and accumulation of food in the floor of the mouth.

Treatment in infants (usually under 4 months, best at 3 to 4 months)

Note: The frenulum is thin and avascular and there is minimal or no bleeding.

1. Ideally, a frenulum spatula should be used.

2. When the spatula is in place the tongue is stretched upwards.

3. Use a scalpel blade or sterile iris scissors to slit the frenulum just above the floor of the mouth.

Alternative to frenulum spatula

The infant is held by an assistant on the examination table with arms positioned either side of the head. The operator holds the frenulum between the index finger and thumb of the non-dominant hand and stretches it firmly (Fig. 12.5). The frenulum is then snipped with sterile scissors, taking care not to damage structures in the floor of the mouth and under the tongue.

Treatment in adults or older children

1. Perform the procedure under local or general anaesthesia.

2. When the tongue is elevated, use a no. 15 scalpel blade to incise the frenulum horizontally, taking care to avoid the Wharton ducts.

3. Tongue traction will then convert the horizontal incision into a vertical one, which can be closed in a vertical plane with interrupted plain catgut sutures.