Chapter 24. Dental: Fillings, Extractions, and Trauma

Non-dental health care providers fear few things more than having to do dental procedures. The most common dental problems that non-dentists face in austere environments are filling cavities, extracting teeth, and managing oral trauma. The information in this chapter will help you manage these cases, even with limited or no formal dental equipment or training. (See also Chapter 23, Dental: Diagnosis, Equipment, Blocks, and Treatment, for basic information about filling teeth and how to improvise some of the equipment you will need.)

Depending on the materials used, a temporary filling will last from only a few weeks to a few months. It should be replaced, as soon as practicable, with a permanent filling. In the meantime, the temporary filling helps the patient to feel more comfortable.1

Never put a filling in an abscessed tooth. You can fill the cavity (it probably doesn't have an abscess) if:

• There is no swelling of the face or gums near the bad tooth.
• The tooth hurts only occasionally—such as when eating or breathing cold air.
• The tooth is not tender to percussion.

Filling Materials and Equipment

To fill a cavity, you first need material to use for the filling. The basic filling material is usually zinc oxide powder and oil of cloves liquid (eugenol). These materials come in a wide variety of brands, but are usually readily available. Intermediate restorative material (IRM) may be available, and provides more durable fillings. Often much easier to obtain is cyanoacrylate, which works well as a temporary filling, although it may not last as long as traditional materials.

While dentists routinely use drills to help fill teeth, these will usually not be available in austere circumstances. In addition, a dental drill is not a tool that the inexperienced practitioner should use. Instead, use any available dental hand tools to fill cavities. Such hand tools can easily be used by non-dentists, can be improvised or purchased at a relatively low cost, and can be easily sterilized between uses. Hand tools are also less painful for the patient than a low-speed drill, such as a foot-pedal-powered drill that may be available in remote or austere settings.

Chapter 23, Dental: Diagnosis, Equipment, Blocks, and Treatment, lists dental equipment you will need to fill a tooth and suggests ways to improvise these items.

How to Fill a Tooth

If your patient has a cavity that needs filling, these are the steps to do it.

1. The initial task is to isolate the tooth so you can keep the cavity dry. A dry cavity allows you to see what you are doing and, more importantly, strengthens the bond with the cement you are using. To keep the tooth and cavity dry, put cotton or other absorbent cloth between the cheek and gums. When working on a lower (mandibular) tooth, put some under the tongue. Change the cloth whenever it becomes wet and wipe the cavity itself while you work. Leave a piece of cloth inside the cavity if you mix the filler (unnecessary if using cyanoacrylate). Using continuous suction in the mouth helps reduce the saliva; give the suction to the patient to hold in the hand opposite the side on which you are working.

2. Then remove some of the decay from the cavity. As you remove the pieces, put them on a piece of cloth or cotton gauze that sits on the patient's chest. Removing them as you go along prevents the patient from swallowing them. Scrape the walls and the edge of the cavity to remove all decay from the cavity's edge. This prevents later enlargement of the defect when germs and food lodge in the space between the cement and the cavity. If the edge is thin and weak, you can break it with the end of your instrument, which will result in stronger sides to hold the cement; non-dentists need not do that. Use the spoon tool (or a large-bore needle) to lift out soft decay from inside the cavity, but don't try to remove decay at the cavity's bottom; it may be covering a nerve. There is no problem leaving some decay at the bottom of the cavity if you cover it with filling material so it stops growing. Enlarge the cavity just enough to give the cement a suitable bonding area. Use a mirror to carefully examine the cavity's edges for additional decay. Put some cotton (or cloth) inside the cavity and leave it there while you mix the cement.

3. If using cement that needs mixing (such as commercial dental filling material), mix the cement on a piece of smooth glass or plastic. To mix zinc oxide powder and eugenol, place some zinc oxide powder on the glass and, a distance away from it, a few drops of eugenol liquid. Use a mixing tool, such as a piece of a tongue depressor or a coffee stirrer, and add a small amount of the powder to the liquid, mixing them together. Continue adding small amounts of the powder until the cement mixture becomes thick. It helps to practice with the cement in advance to hone the mixing technique, determine the time it takes for the cement to harden, and see how best to manipulate it. Using this cement is much easier when it is thick and not too sticky. To test for "stickiness," roll some between your fingers; if it sticks to the fingers, it is not ready. Add more powder and then try it again.

4. Once the filler is prepared or you're ready to use the cyanoacrylate, remove any cotton or cloth from the cavity and make certain that the cavity is dry. Then press (or drip, in the case of cyanoacrylate) some filling material into the cavity. The method for dental filler is, while keeping the area dry with cotton or absorbent cloth around the tooth, to put a small ball of cement on the end of a filling tool (or a small, thin flat screwdriver) and spread it over the floor of the cavity. Be sure that it gets into the corners of the cavity. Add another ball of cement, pressing it against the cement already in the hole and against the sides of the cavity. The key is to pack the cavity completely and tightly to stop the growth of decay. Keep adding cement until the cavity is over-filled. Then, smooth the extra cement against the edge of the cavity. If a cavity goes down between two teeth, one other step is necessary. You need to take care that the cement does not squeeze and hurt the gum. Before you spread the cement, place something thin between the teeth. You can use the soft stem from a palm leaf, a toothpick, or a tooth from a comb, but be sure it has a rounded end to prevent damage to the gums.2 If you are using cyanoacrylate, no filling tool is needed, but you must avoid leaving air bubbles in the cement.

5. Remove the extra cement before it gets too hard. Press the flat side of the filling tool against the cement and smooth it toward the edge of the cavity. As you smooth the cement, shape it to look like the top of a normal tooth. This way, the tooth above or below it can fit against the filling without breaking it. If you are using cyanoacrylate, work fast to smooth the filling, since it dries very quickly. Do not touch it with your finger or you may get stuck to the patient! After you take out the object you have placed between the teeth, smooth the cement. Remove any pieces of cement that stick out, are in the gum pocket, or are not smooth. These may injure the patient's gums and may break off, allowing food and bacteria to enter the cavity. Check carefully that no pieces of cement are in the gum pocket below the tooth.

6. After removing the cotton or cloth used to absorb saliva from around the tooth, ask the patient to gently bring his teeth together. (Too much pressure on the filling may break it.) The teeth should come together normally and not first hit against the filling. Always check to see if part of the filling is high: (a) If the cement is still wet, you can see the smooth place where the opposite tooth bit into it. Scrape the cement away from this place. (b) If the cement is dry, have the patient bite on a piece of carbon paper. (If you have no carbon paper, darken some paper with a pencil.) If there is too much cement, the carbon paper will darken the cement. Scrape away that extra cement. The patient must not leave your clinic until the filled tooth fits properly against the other teeth.3

7. Does the tooth hurt more than before? If the tooth hurts more after the filling is in place, there is probably an abscess. Extract the tooth now or, if there is too much swelling, extract it after the swelling has been treated.

8. After-care instructions: So that the temporary filling does not break or loosen, ask the patient not to eat anything for 1 hour so that the cement has time to harden. The patient should try not to use that tooth for biting or chewing until there is a permanent filling, since the cement and sides of the cavity are weak.

Teeth should be extracted only when absolutely necessary. However, extraction may represent the only possible care that can be delivered in austere circumstances.4 The general reasons to extract a tooth are5:

• The patient has constant pain from the tooth.
• The tooth is loose and painful when moved.
• The tooth is already broken with an exposed nerve root.

General Extraction Techniques

In old movies, extractions appear to be a simple procedure. But in reality, the extraction of a tooth is difficult and painful to accomplish without breaking the tooth. A dental, preferably a regional, anesthetic block is required. (See the section on blocks in Chapter 23, Dental: Diagnosis, Equipment, Blocks, and Treatment.)

Rather than simply pulling a tooth out, the basic principle is to break the periodontal ligaments holding the tooth to the bone and then rock/lever the tooth out. Generally, the ligaments holding the tooth to the gum and jaw are loosened using a tiny sharp instrument inserted between the tooth and the gum all the way around the tooth.

The keys to successful extractions are patience and finesse. Don't simply try to yank the tooth out; this will only break it off. A number of techniques have proved successful most of the time, but the main requirement is not to hurry the procedure. Michael A. Grossman, DDS, of Tucson, AZ, says that one method is to push down and rotate or move the tooth in a figure-eight pattern, with movement in any direction lasting 8 seconds. (Personal communication, received May 9, 2008.)

Another experienced dentist, Dr. Manuel Bedoya, gently rocks the tooth outward and inward until it can be levered out. He has found that this technique of leveraging the tooth and rocking it back and forth is the easiest way to remove a tooth. Once the tooth rocks back and forth, he advises letting it "rest" for 20 to 30 minutes and then returning to pull the tooth out. During the rest period, enzymes are generated that further help to loosen the tooth. (Personal communication, received December 23, 2007.)

If a tooth breaks (as it often does) when being extracted by non-dentists or with makeshift extractors, pry out the remaining fragments using small metal instruments. Or, send the patient to a dentist later, since the key element, drainage, is accomplished when the tooth breaks.

Tools

Although commonly suggested, using regular pliers wrapped in gauze for extractions generally just pulverizes the tooth at the gum line—especially if the tooth is diseased. Use either a dental extractor (a pediatric universal extractor should work in most situations) or cut off the end of an awl, file it flat, and put a tiny notch on the side of the filed tip. A large-gauge needle with the sharp end filed down also works. Push it between the tooth to be extracted and the gum, breaking the ligaments. Then, carefully lever the tooth out of the socket. (Michael Grossman, DDS, Tucson, AZ. Personal communication, received December 22, 2006.)

Dental forceps are designed to fit the shape of the teeth, including their roots. The inexperienced operator will find it simpler to rely on one pair of universal forceps for the upper jaw and one pair for the lower jaw.6 If channel-lock pliers or a bone rongeur that has jaws curved inward like dental pliers is available, use that. There is less chance of breaking off the enamel, especially if you follow Dr. Manuel Bedoya's advice and pad the tool's ends with gauze or other suitable cloth. Dr. Bedoya adds that even a screwdriver, if used gently, can help to pry the tooth from the socket. (Personal communication, received December 23, 2007.) (Also see Chapter 23, Dental: Diagnosis, Equipment, Blocks, and Treatment, for improvising dental tools.)

Extracting Abscessed Teeth

If the tooth is abscessed, try to extract it. Tooth extraction is the best way to drain an apical abscess when no facilities are available for root canal treatment. Removing a tooth is appropriate if it cannot be preserved, it is loose and tender, or it causes uncontrollable pain. In these circumstances, according to Barnett R. Rothstein, DMD, even if you must use pliers or a similar instrument that breaks the tooth, opening the abscess in this manner will allow it to drain, thus avoiding the severe complications (e.g., Ludwig's Angina, airway compromise, sepsis) that might otherwise occur. (Personal oral communication, received April 9, 2007.)

According to Dr. Manuel Bedoya, the abscess will still drain even if part of the tooth remains, and the rest of the tooth will eventually work its way out without complications. (Personal oral communication, received December 23, 2007.) One benefit is that it is easy to extract loose teeth with periodontal laxity/destruction.

Positioning the Patient

The first step is to position the patient correctly. Patients needing a lower tooth extracted should be sitting lower than the clinician, since the extraction technique for the lower jaw is to push down and then to pull up on the tooth. Standing on a stable platform, such as a box, may be useful for the practitioner. Position patients who need an upper tooth removed higher than the clinician. That is because the extraction technique for the upper jaw is to push up and then pull down on the tooth. Sitting the patient on several cushions often accomplishes the necessary height adjustment.7 It also helps to have a dental chair that prevents the patient from pulling his head back during the procedure. A dental chair can be fashioned from a straight-back chair, two broomsticks, tape, and some webbing (see "Dental Instruments and Equipment" in Chapter 23, Dental: Diagnosis, Equipment, Blocks, and Treatment).

Tooth Extraction: Procedural Steps

1. Seat the patient in a chair with a high back that will support his head. After he has rinsed his mouth, swab the gum with 70% ethanol. Do a supraperiosteal or other dental block, as described in Chapter 23 under "Blocking Individual Teeth." Wait 5 minutes for the anesthetic to work, and then test to be sure the tooth is numb. If the patient still feels pain, give another injection.8

2. Position yourself to best work on the tooth you are extracting. Right-handed clinicians should stand behind and to the right of the patient when extracting lower right molar or premolar teeth. Face the patient, to the patient's right, when working on all other teeth.

3. The first step is to separate the gum from the tooth. This is vital so that the gum does not tear when the tooth is removed. Torn gums bleed more and take longer to heal. Slide the end of the instrument along the side of the tooth and into the gum pocket alongside the tooth. At the deepest part of the pocket, you can feel the place where the gum attaches to the tooth. The attachments are strong, but thin. Push the dental instrument or blunted needle between these attachments and the tooth. Then separate the tooth from the gum by moving the tool back and forth. Do this on both the buccal (cheek) and the lingual (tongue) side of the tooth. Take care not to go too deep and to cut only the attachments to the tooth.8

4. Next, loosen the tooth. While a loose tooth may not break when you extract it, a strong one will if you don't loosen it first. While a dentist will use an elevator to loosen the tooth, you may need to use a small flat screwdriver. Either tool can cause harm if not used carefully. The blade goes between the bad tooth and the good one in front of it. Put the face of the blade against the tooth you are removing and slide it down the side of the tooth, as far as possible under the gum. Turn the handle so that the blade moves the top of the bad tooth backward and loosens it. Rest your first finger on the adjacent tooth while you turn the handle. This will control it.8 Now that you have loosened the tooth, waiting about 20 minutes will allow the tooth to loosen even more, according to Dr. Manuel Bedoya. (Personal communication, received December 23, 2007.) You may want to get a cup of coffee or do any required paperwork for this patient.

5. You are now ready to remove the tooth. While supporting the gum and underlying bone with the thumb and finger of your nondominant hand, apply the forceps to either side of the crown, parallel with the long axis of the tooth. Push your grasping tool (extractor, pliers, etc.) as far toward the roots as possible. The idea is for the forceps to grasp the tooth's root under the gum. Your fingers will feel the bone expanding a little at a time as the tooth comes free. Rather than "pulling" the tooth, think about rocking it back and forth or levering it out.6 To decide which way to move a tooth, think about how many roots it has. If a tooth has one root, you can turn it. If a tooth has two or three roots, you need to tip it back and forth. Take your time. If you hurry and squeeze your forceps too tightly, you can break a tooth. As Dr. Dickson wrote in Where There Is No Dentist, "Removing a tooth is like pulling a post out of the ground. When you move it back and forth a little more each time, it soon becomes loose enough to come out."9 If the tooth does not begin to move, loosen the forceps, push them deeper, and repeat the rocking movements. Avoid excessive lateral force on a tooth, as this can lead to its fracture.6 After you extract the tooth, examine its roots to be certain that you haven't broken any part.

6. Stop the bleeding. Apply direct pressure by squeezing the sides of the socket for 1 to 2 minutes and covering it with cotton gauze or absorbent cloth. Have an adult patient bite firmly against it for 30 minutes; a child should continue biting for 2 hours.9 After the patient has rinsed his mouth, inspect the cavity for bleeding. If the bleeding continues, if you have removed two or more teeth, or if the gums are torn or loose, suture the extraction site with absorbable (if available) mattress sutures across the cavity.6,10

7. Carefully inspect the extracted tooth to confirm its complete removal. A broken root is best removed by loosening the tissue between the root and the bone with a curved elevator. After the tooth has been completely removed, squeeze the sides of the socket together for a minute or two and place a dental roll over the socket. Instruct the patient to bite on it for a short while.

8. Instruct the patient6,10:

   • Not to rinse his mouth again for the first 24 hours: if he does, the blood clot may be washed out, leaving a dry socket. But after 24 hours, he should rinse his mouth frequently with warm saltwater during the next few days.
   • To bite on cotton gauze or absorbent cloth if bleeding starts again.
   • To take acetaminophen or, if there has not been much bleeding, nonsteroidals for pain, if needed.
   • Not to explore the cavity with his finger.
   • To drink lots of cool fluids. He should not drink hot liquids like tea or coffee, because they promote bleeding.
   • To eat soft food that is easy to chew. He should try to chew food on the side opposite from where the tooth was removed.
   • To keep his mouth clean, especially the teeth near the extraction site.

Extraction Problem: Broken Tooth

Even when handled with care, extractions sometimes lead to a broken tooth. If you can see the root, try to remove it. If you leave a broken root inside the bone, it can become the nidus for an infection. However, small broken roots are better left inside the socket. They will loosen over the next week or so, and will be easier to remove.11

If you do try to remove a tooth root, use one of the techniques below.

To remove a broken upper root11: Slide the blade of a straight elevator or thin flat screwdriver along the wall of the socket until it meets the broken root (Fig. 24-1). Then,

1. Force the blade between the root and the socket.

2. Move the root away from the socket wall.

3. Move the root further until it is loose.

4. Grab the loose root and pull it out.

To remove a broken lower root11: Use a straight elevator (or a curved elevator if you have one). If the broken root is from a molar tooth, slide the blade into the socket beside the broken root.

1. Break away the bone between the root and the blade.

2. Force the blade between the root and the socket.

3. Move the root away from the socket wall.

4. Grab the loose root and pull it out.

If dental equipment is not available, this technique is recommended if you have a bright light to work under: Dry the socket with gauze and then firmly wedge a 26-gauge needle into the root canal of the errant piece. "With gentle manipulation it is possible to retrieve the root fragment impaled onto the stainless steel needle."12

Post-Extraction Problems

Bleeding

Post-extraction bleeding usually occurs in the small vessels. If the patient presents with persistent bleeding after a tooth extraction, remove any clots extending out of the socket with gauze. Then take a small folded gauze pad or a moist (regular) tea bag wrapped in a thin cloth or gauze, place it over the socket, and have the patient gently bite on it for 1 hour. The tea contains a procoagulant as well as tannic acid, which helps relieve pain. This should be repeated as necessary; it often takes two or three times. Patients should be told to wait at least 1 hour before checking the site so they do not disrupt clot formation. If bleeding continues, give a local anesthetic block and then curette and irrigate the socket with normal saline to remove the existing clot and to freshen the bone. If this does not stop the bleeding, suture the area with gentle tension.13 If bleeding is excessive, including in anticoagulated patients, drying the area as much as possible and then applying cyanoacrylate has been effective.14

Pain

If a patient presents with severe pain about 2 to 3 days after a tooth extraction, it is most probably due to alveolar osteitis, a "dry socket." A dry socket occurs most commonly after wisdom tooth extraction, in patients using oral contraceptives, and in smokers. It is due to losing the clot from the socket, with a subsequent growth of anaerobic organisms leading to a localized alveolitis. The pain can be localized to the tooth or extend throughout the dentition on that side. While it generally resolves spontaneously in about 2 weeks, the patient will be in so much pain that treatment should be instituted to resolve the problem.

Treatment

Block the tooth. Then gently rinse the socket with warm saline or potable water. Gently place a piece of gauze or cloth soaked in iodine or a saline/anesthetic solution (or with a 1- to 2-inch iodoform gauze strip saturated in eugenol or coated with an anesthetic ointment, such as lidocaine 0.5%) in the socket. A piece of gauze with eugenol, oil of cloves, or a local substitute (damp, but not wet) can also be used, as can cyanoacrylate (not the best choice in this case). The patient should bite down on a piece of dry gauze, cotton, or cloth over the tooth dressing. That cloth can be discarded after 1 hour. The dressing gauze should be changed every 1 to 3 days until symptoms do not return when the gauze is left out for a few hours. This procedure eliminates the need for systemic analgesics. If the symptoms last a month, suspect osteomyelitis and evaluate the patient for long-term antibiotic treatment.

Root (Pulp) Extraction

Dentists use a thin barbed wire to extract the pulp. While a thin wire like a filament will get down the canal, removing the pulp requires a hook or lateral projections to pull or scrape the soft tissue out. However, Daniel Kemmedson, DMD, suggests that making a very small bend on the bevel portion of a thin (25-, 27-, or 30-gauge) hypodermic needle might work. (Personal written communication, received June 7, 2008.)

Gum Lacerations

Many gum lacerations need no treatment other than keeping them clean. They can, of course, be sutured. Alternatively, apply cyanoacrylate directly to the wound.

Tooth Injuries: Spectrum

Multiple methods exist for describing injuries to teeth. The simplest that has clinical applicability is that teeth may be:

• Subluxed (loose, but without change in position)
• Luxated (loose and in a different position than normal)
• Fractured (missing a part of the tooth)
• Avulsed (missing)

Loose Teeth: General Approach

A common presenting complaint is that a patient's tooth is loose. Table 24-1 describes the symptoms, complications, and treatment for various causes of loose teeth. These are described in more detail in subsequent sections of this chapter.

Subluxed: Loosened Tooth

If the tooth is minimally loose but in normal position, patients should be placed on a liquid or soft diet progressing slowly to a normal diet. Follow-up with a dentist is rarely required. If the teeth need to be stabilized, dental follow-up is recommended within 48 hours, if possible.

Luxation

A luxated or displaced tooth is shifted out of normal position but remains intact. (Whether it is really intact may be unclear without radiographs.) The surrounding alveolar bone is normally fractured. Luxated teeth, usually the upper front teeth (incisors), may either be in normal position or loose (subluxed), pushed back, or partially or completely out of the socket. When communicating with a dentist, they are described as extrusive = coming out; intrusive = pushed inward; or lateral = to the side.

The treatment depends on the tooth's position. If the tooth appears longer than the others (extrusion), try to push it back firmly into the socket with steady, gentle pressure. You can get a better grip on the tooth if you use a piece of gauze to hold it. If the tooth seems to be pushed ahead of or behind the other teeth (lateral displacement), also try to firmly realign it. If it is loose, the patient can gently bite on a piece of gauze or cloth. The tooth should then be splinted in position, as described in "Splinting/Wiring" later in this chapter. If it seems shorter than surrounding teeth (intruded), it probably won't survive and there is little that can be done in adults without advanced dental equipment.16 In children, intruded teeth are allowed to re-erupt.

Tooth Fractures

If a tooth breaks (generally the crown, which is the part of the tooth above the gum line), treatment is often necessary to reduce pain. Tooth fractures may initially seem to have significant bleeding, although much of this may be a mixture of saliva and blood. If the patient can bite down on a gauze or cloth, the bleeding generally stops. Although the following classifications seem obvious, if it is unclear how much damage was done to the tooth, watch it over several days. If it changes color or if signs of an abscess develop, extract it.

Classification of Tooth Fractures

Fractured Enamel

The most common dental injuries are those of the tooth's crown, involving the enamel and the enamel-dentin without pulp involvement. These usually involve a child or young adult's anterior maxillary incisors. About one in four children worldwide will have such an injury before age 18 years, with most occurring between the ages of 6 and 13 years.4

If only the tooth enamel is fractured, the tooth will not be sensitive to temperature or touch and has a very small (<3%) chance of pulp necrosis. Although the tooth may later need filling, no treatment is required immediately. If no dental care is available, smooth any sharp edges with sandpaper, a small file, an emery board, or a hard stone.4

Reattaching the tooth fragment is the ideal treatment when the piece is available, since it can improve both the appearance of the tooth and its function. While dentists can use a variety of techniques to accomplish this reattachment, including the use of special preparations and cements, using a simple adhesive, such as cyanoacrylate, can restore 25% or more of the tooth's pre-injury strength. This method provides immediate cosmetic improvement and allows a dentist to provide more definitive care at a later time. Until the tooth fragment is reattached, it can be kept in sterile water, milk, or Hank's Balanced Salt Solution (see the formula under "Preservation" later in this chapter).17,18 Gently dry both the tooth and the fragment before applying the cement. If the fragment is not reattached and the patient will see a dentist, immerse it in a preservative solution (see "Avulsed Tooth" in this chapter) and send the piece to the dentist with the patient. The patient should be placed on a liquid or soft diet until seen by a dentist and told not to pick at the adhesive. The tooth or the cement may irritate the patient's tongue or lip. If this irregularity bothers the patient, it can be smoothed with a variety of instruments, as described in steps 5 and 6 under "How to Fill a Tooth" earlier in this chapter.

Dentin Fracture

If the dentin is fractured, it will usually be visible as a deep, golden yellow inside the tooth. The tooth will be very sensitive to percussion, temperature, and air. Pulp necrosis (dead tooth) occurs in 7% to 10% of these patients. After blocking the tooth, dry it and cover it with calcium hydroxide (CaOH) paste or cyanoacrylate. The CaOH paste will stay in place for about a week if the patient is on a soft/liquid diet. To apply cyanoacrylate, drop it onto the tooth and, with a metal tool or the top of the adhesive tube, rapidly try to smooth it. Have the patient keep their mouth open for a few minutes to let it dry. For CaOH paste, use a flat instrument, such as a knife blade (cover the cutting edge), ice pop (e.g., Popsicle) stick, or similar tool to place dental filling material or wax over the area. Have the patient bite down gently, and remove the excess material. They will have to avoid using that tooth to eat; the piece may come loose.

Pulp Exposed

A tooth's pulp space may be fractured with the tooth in place or with a piece missing. If the tooth remains in place and the root is broken, the tooth will move if you firmly grasp the alveolar bone (by holding the gum over the bone) and try to move the tooth. Of course, the bone doesn't move unless it is broken. If the pulp is exposed, a piece of the tooth is missing and blood will be visible coming from the pulp cavity. This is generally quite painful since the nerve is exposed also. But, if the nerve is concussed, it may not hurt. In that case, pulp necrosis (dead tooth) is likely.

Treatment

The first priority is to help control the pain and bleeding. These teeth can be gently treated without anesthetic or after using one of the blocks discussed in Chapter 23, Dental: Diagnosis, Equipment, Blocks, and Treatment. The specific block to use depends on which tooth is involved.

The basic principle is to dry and cover the tooth. The tooth can be covered using either standard dental materials or cyanoacrylate. If using standard dental materials, cover the tooth with a mixture of cotton fibers in a zinc oxide and eugenol paste. This paste should be very thick. It is applied over both the injured tooth and several adjacent teeth. If possible, leave the gum line clear so the patient can keep it clean. Caution the patient not to bite into food with these teeth until seen by a dentist.19 If dental supplies are not available, use cyanoacrylate to stabilize the tooth.

Adequate pain control may require removing the tooth pulp from the chamber. If the tooth fracture has exposed the pulp space and a very tiny pulp removal tool is available, remove the pulp. A lightbulb filament with a tiny drop of cyanoacrylate may suffice in a pinch. Whether or not the pulp can be removed, use a small piece of gauze or cotton to seal the hole and avoid contamination. Cover it with oil of cloves or zinc oxide. If only cyanoacrylate is available, use that to cover the hole.

An alternative is to gently wash the tooth and try to reattach it with cyanoacrylate. A splint is normally required to keep it in place (see "Splinting/Wiring" later in this chapter). The tooth can be splinted in place until a dentist can do a root canal or the tooth can be extracted. (Extracting this type of fractured tooth is very difficult, especially for the novice.) Occasionally, a tooth may split vertically and, after drying, may be able to be glued together with cyanoacrylate in situ. This, however, may be only temporary, since such teeth may have too much intrinsic damage to be retained.20

Fractured Bone

If the bone moves when you attempt to move the teeth after an injury, the alveolar bone is most likely fractured. Do not take those teeth out until the bone is healed. Otherwise, bone will come out with the teeth and there will be a big hole in the patient's jaw. Instead, support the teeth in order to hold both sides of the bone steady. Stabilize the tooth with a splint (e.g., interdental wires) or cyanoacrylate to attach it to the adjacent tooth. If more than the alveolar bone is fractured (a substantial maxillary or mandibular fracture), wiring may be the only option. See "Splinting/Wiring" and Fig. 24-2.

Avulsed Tooth

Avulsion means that the entire tooth has come out of the socket. If the tooth is out, the ligaments that hold the tooth as well as the nerve and blood vessels for that tooth have been completely torn. Handle the tooth only by the enamel (crown), since the root structures can be damaged easily and this would prevent the tooth from being successfully reimplanted.

Preservation

If the tooth cannot be reimplanted immediately, store it for up to 4 hours in sterile saline, potable water, milk (better), or Hank's Balanced Salt Solution (HBSS; best). The practice of placing the tooth between the patient's gum and lip is not as good. Use this method only if there is no risk of the patient aspirating the tooth. A chemist or pharmacist can compound HBSS in advance. To make a 100 mL solution, add to distilled water: 0.80 g NaCl, 0.04 g KCl, 0.014 g CaCl2 anhydrous, 0.01 g MgSO4-7H2O, 0.01 g MgCl2-6H2O, 0.006 g Na2HPO4-1H2O, 0.006 g KH2PO4, 0.1 g Glucose, 0.035 g NaHCO3, and usually, 20 mg Phenol red.21 Sterilize the solution, if necessary, by filtering rather than heating it. For dental work, no sterilization is needed.

Treatment

If the tooth is whole, reimplant it within 30 minutes after the injury, if possible. Hold the tooth only by the crown (enamel) so as not to injure the periodontal ligament covering the root. Gently rinse it off with sterile saline, potable water, milk, or HBSS. Don't scrub it or use any chemicals. Gently rinse the socket with warm water to clean out any debris and clot. After doing a supraperiosteal, alveolar, or Gow-Gates block, push the tooth into the socket with firm, gentle, steady pressure; it often "snaps" into place. (See Chapter 23, Dental: Diagnosis, Equipment, Blocks, and Treatment, for dental blocks.) Hold it in place for about 5 minutes. Then have the patient bite down lightly on a piece of gauze or cloth. If dental care is not readily available, the tooth then can be stabilized by splinting or wiring it to adjacent teeth (see "Splinting/Wiring" below). The tooth may still darken and die months or years later. In that case, the option is to extract it or for a dentist to do a root canal.

Children

Deciduous teeth, also known as milk teeth, baby teeth, temporary teeth, and primary teeth, need not be reimplanted, since if they are replaced, they typically become necrotic, and then infected. They may also become fused to the bone (ankylosed) and not fall out, or they can fuse to the erupting adult teeth, interfering with the eruption of the permanent tooth.22,23

Splinting/Wiring

Teeth and surrounding boney structures can be stabilized with glue, glue and wire, splints, or interdental wiring.

Glue Only

To stabilize a tooth, cyanoacrylate or dental cement may the easiest and best makeshift method. After drying the affected tooth and the adjacent teeth and gums, apply the adhesive to the teeth and to the gingiva below them. Apply the adhesive to both the labial (exterior) and lingual (interior) sides of the teeth.

Glue or Wire and Splint

Simpler than using wires alone to stabilize teeth, an effective temporary method, suggested by Barnett R. Rothstein, DMD is to combine adhesive and wire. (Personal communication received May 7, 2007.) Cut a piece of wire to the length necessary to cover multiple teeth. If used for loose or avulsed teeth, the wire need only cover four or five teeth; if used for a mandibular or maxillary fracture, cover as many teeth as possible. The wire can be thin orthopedic wire; a small-gauge spinal needle with the ends clipped; a thin paperclip; or similar thin-gauge, malleable, but relatively rigid, wire. Bend the wire so it conforms to the convexity of the normal tooth configuration.

Beginning with four teeth on either side of the fracture line—or all the teeth that will be used in the case of a loose or avulsed tooth—dry the teeth thoroughly. Hold the lip away from the teeth manually or by using gauze or absorbent cloth between the lip and gum. Put cyanoacrylate or dental cement on the anterior tooth and embed the wire in the glue. Be certain that the teeth are aligned as well as possible. Continue the same process until the entire wire is cemented.24

A more secure alternative is to use wires or heavy nonabsorbable sutures around the teeth to secure the stabilizing wire (Fig. 24-2).

These are only temporary fixes. The patient must be placed on a liquid or soft diet and be seen by a dental professional as soon as possible.

Makeshift Splints

Wax Splint

Another alternative to stabilize a loose tooth is to use beeswax. According to Dr. Dickson, in Where There Is No Dentist, the method is to

Soften some beeswax and form it into 2 thin rolls. Place 1 roll near the gums on the front side of five teeth: the loose tooth and the two teeth on each side of it. Press the wax firmly, but carefully, against these teeth. Do the same with the second roll of wax on the back side of the same teeth, again near the gums. It is good if the wax on the back side is touching the wax on the front side. This helps the wax hold the teeth more firmly. To do this, you can push the wax between the teeth with the end of your cotton tweezers.25

Splint from Dental Filling Material

Cotton fibers can be mixed in with standard temporary filling mix to form a fibrous mix. This then can be molded to make a splint between the injured tooth and its healthy neighbors.24

Interdental Wires for Dental Stabilization

Interdental wire fixation simply means tying wires around stable and unstable teeth, and then affixing these to a heavy wire splint laid across the involved teeth. This can be used for unstable teeth or fractures of the mandible or maxilla. Since extracting teeth when the alveolar bone is fractured can leave a big hole in the jaw, supporting the teeth with a splint until the bone heals is the optimal treatment.

Interdental wiring is much easier to do on anterior teeth than on others, especially with limited equipment. If dental equipment is not available, a pair of scissors and small pliers can be used to cut and manipulate the wire.

Alternative Techniques

A basic method is to place a double strand of wire around several teeth (one to three teeth) and twist it tight. Place the wires so that, if possible, they do not touch the gums. Tuck the cut ends between the teeth.4

Another method for applying interdental wires is to use your thumb and finger to gently move the loose teeth and bone back into normal position.26 Cut a wire to use as a splint. It should be long enough to lie across two strong teeth on each side of the loose tooth or teeth. The splint can be a thin orthopedic wire; heavy electrical wire with the insulation removed; a small-gauge spinal needle with the ends clipped; a thin paperclip; or thin-gauge, malleable, but relatively rigid wire. Curve the wire so that it fits the curve of the teeth. If using a needle, smooth the sharp end with a file or stone. Then tie each tooth to the splint wire using short pieces of 20-gauge ligature wire or, if that is not available, heavy surgical suture, dental floss, or nylon fishing line. Put one end of the ligature under the splint. Bring it around the back of one tooth and out to the front again over the needle. Use the end of a small instrument to hold down the ligature at the back of the teeth. Then twist or tie the ends together. Tighten the ligature around each of the six teeth. If using wire ligatures, cut the ends and bend them toward the teeth, so they will not cut the lip. If using wire ligatures, tighten them the next day, and then once each week. But be careful: Only half a clockwise turn usually is needed ("Righty tighty; lefty loosey"). More, and the wire will break.

Patient Aftercare Instructions

Explain to the patient that it takes 4 weeks for the bone to heal. The wires must remain on the teeth for this time. To help the teeth to heal, ask the patient to use other teeth for chewing, to clean both the teeth and the wires with a soft brush frequently, to rinse with 2 cups warm saltwater every day, and to return to have the wires tightened every week.

After 4 weeks, cut and remove the ligatures. Ask the patient to watch those teeth. A dark tooth and gum bubble are signs that the tooth is dying. If those appear, the patient must return for the tooth to be extracted or be referred for specialized dental treatment.

Dental Wiring for Facial Fractures

To wire teeth to treat a maxillary or mandibular fracture, an adequate number of teeth must be included. With facial fractures, wires are placed on both upper and lower teeth and then tied together for increased stability.

With a fracture of either bone, tie the wires around at least six teeth in the maxilla and the same number of mandibular teeth. Twist the wires to attach them to the teeth. Try to adjust the teeth so that they appear aligned. This will place the facial fracture segments in correct position. Tie the upper and lower wires together, tying the lateral ones together first, then others, crossing some ties over the fractured area. Tie them loosely at first, and then tighten them.27 A specific contraindication for interdental wiring for facial fractures is poorly controlled seizures, since the patient could easily vomit and, without the ability to open their mouth, aspirate.

Wiring for mandibular/maxillary fractures should remain in place for 6 weeks. During that time, the patient will be on a liquid diet and should carry a wire cutter on a string around his neck in case there is a need to emergently cut the wires—such as if he has an airway problem.