Extraction of the Teeth

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, B, C, D, E, F, G, H, I, L, M, N, O, P, R, S, T, U, W.

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.
———
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CLAUDIUS ASH & SONS, Limited,

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