Burjor Langdana / Adventure Medic Resident Expedition Dentist
Matt Edwards / Registrar / London Air Ambulance
You are out on an oil rig. The weather is foul and will be for the next few days. You are faced with a patient in excruciating pain. The lower front tooth is mobile, there is redness and swelling in the surrounding gums. If only you could take that tooth out, it would establish drainage and provide immediate relief from pressure pain. From our past articles you would have located the problem and selected the appropriate local anaesthetic. This article and the slide show below will give you the basics of a simple dental extraction.
When you are in a remote area and a great distance from help, dental extraction may be contemplated to avoid evacuation. It may also be an emergency procedure when evacuation is not likely in the near future. It is highly recommended that appropriate training and practice has been completed prior to departure, as the worst case scenario if an extraction goes wrong is a patient who is still in pain, still has an abscess but now has a fractured tooth that will require oral surgery.
Indications for extraction under these circumstances would include:
Loose teeth associated with a dental abscess / Extraction of which would provide drainage and relief of severe pressure pain.
Loose teeth on side of a jaw fracture / Removal to facilitate reduction and haemorrhage control.
Excruciatingly painful tooth / That can’t be made pain free medically but responds well to LA and is within your skill levels to attempt extraction.
Upper Extraction / You stand in front and to the right of the patient.
Lower Extraction / You stand slightly to the back and right of the patient
Support / Head and Jaw must be well supported
These look like flattened screw drivers and are wedged in the ligament space between tooth and surrounding bone. They are used as levers to compress the soft bone around the tooth thus increasing the size of the socket. This increases the tooth mobility allowing the forceps a better purchase.
All forceps are made such that their beaks would be parallel to the long axis of the tooth. This allows force to be applied precisely along that long axis, as tangential force will increase likelihood of tooth fracture.
Lower Forceps / Have a sharp bend to allow force to be applied without damaging the lower lip
Upper Forceps / Are straighter as they can achieve the required angle of force without the need of a sharp bend.
If you can only take one, take the lower forceps and don’t be tempted to use pliers. While it is possible to perform an extraction with them, they are highly likely to fracture the tooth as they are too bulky and cannot grip it in the correct spot.
1 / First push towards the root. Push the beaks of the forceps towards the root apex, below the gum margin as far as possible. This lowers the centre of rotation decreasing force on the root apex and reducing likelihood of root fracture.
2 / Then, using slow but firm focused force, exert pressure towards the cheek/lip followed by pressure towards tongue/palate. It’s like slowly removing a tent peg from the ground, by moving it back and forth to widen the hole in which it is lodged.
3 / The tooth is slowly rotated out following the line of least resistance.
Pressure Pack / Within five minutes of extraction advise patient to bite hard on a small firm pack of cotton roll or absorbent paper placed over the socket to achieve haemostasis for at least fifteen minutes. Continued bleeding is mostly because pressure has not been applied for long enough. Fifteen minutes can get quite boring. Some recommend soaked teabags bitten and held into the socket to stop bleeding, as tea supposedly contains some mildly antiseptic and vasoconstrictive agents.
Post-Extraction Patient Instructions
15- 30 mins / Gently rotate out the pressure pack.
12 hours / Avoid eating anything hot/hard.
24 hours / Avoid vigorous spitting, rinsing and smoking.
Oral Hygiene / Mouth washing, gentle brushing after every meal strongly advised even though this may be uncomfortable.
(Cover Photo: AfroBrazilian / Wikimedia Commons)