Dental care procedures

 

Putting on a protective cover

Used to treat pain in tooth (brief sharp pain OR sharp pain then dull throb) — see Dental and oral problems

Attention

  • Pain most likely due to dental nerve (pulp) inflammation if
    • Open hole in tooth
    • Pain made worse by hot or cold foods, drinks, air
    • No swelling or fever

What you need

  • Dental pain relief, oil of cloves (eugenol)
  • Large syringe for irrigation. Filled with warm water (cold will cause pain)
  • Sterile tweezers
  • Suction equipment OR cup and tissues to spit into 
  • Cotton pellets (small balls of cotton wool rolled between gloved fingers)
  • Temporary filling material (eg Cavit) — chewing gum or blu tak could also be used

What you do

  • Give dental pain relief — not required for brief sharp pain
  • Sit person in comfortable chair
  • Remove food or debris from hole. Syringe with warm water or use tweezers
  • Ask person to gargle and spit
  • Dry hole with cotton pellet held in tweezers
  • If pain not relieved — pick up hole-sized pellet of cotton wool, dip into oil of cloves, squeeze out excess, gently put in hole
    • Be careful, oil of cloves can sting gums or tongue
    • Do not use if pregnant, breastfeeding, under 12 years
  • If toothache — brief sharp pain OR severe sharp pain then dull throb (mostly painful after eating or drinking)
    • Put temporary filling on index finger, push in firmly to fill hole
    • Filling will set after few minutes, but will keep putty-like softness. Can be dug out if needed. Won’t last for more than a few weeks
  • If toothache — throbbing ache OR intense pain
    • Don’t fill tooth
    • Repeat oil of cloves application as needed
  • Refer to dental service

Dressing a dry socket

Alveolitis (dry socket) is due to poor healing, not infection. Treatment will give symptom and pain relief

Attention

  • Will need pain relief before procedure
  • Do not use oil of cloves (eugenol). Will burn, won't give pain relief

What you need

  • Paracetamol
  • Large syringe for irrigation, filled with warm sterile normal saline. Cold will cause pain
  • Suction equipment OR cup and tissues to spit into 
  • Sterile 
    • Cotton gauze
    • Tongue retractor, helper to retract tongue
    • Dental mirror
    • Tweezers
  • Pinch of dry socket dressing (eg Alvogyl)

What you do

  • Give paracetamol
  • Sit person in comfortable chair
  • Use syringe to irrigate (gently wash) socket with normal saline
  • Have person spit it out or use suction
  • Dry area with gauze
  • Use fingers or tweezers to push dry socket dressing (eg Alvogyl) into socket
    • Tell person it will smell and may taste bad, but they will feel a lot better
  • Tell person to use warm salt-water mouthwash morning, night, and after food
  • Check every 2–3 days. Repeat wash out, put in fresh dry socket dressing
  • Tell person dressing can be left in place. Dressing generally self-eliminates

Treating a bleeding tooth socket — compression

Attention

If prolonged bleeding

  • Check file notes for bleeding disorders, medicines that prolong bleeding
  • Check history of dental extraction. Talk with dentist who took out tooth
  • Usually occurs because blood in socket won’t clot normally. Likely causes are
    • Person taking medicine that slows clotting (eg warfarin, heparin, aspirin)
    • Blood vessel trauma that prolongs bleeding ― wide open sockets, soft tissue damage after difficult/multiple extractions
    • Bleeding at night. Large clot stops direct pressure, causes prolonged oozing
    • Kidney disease, especially if person has missed or delayed dialysis
  • Ensure following post operative instructions. Common mistakes that result in inadequate pressure at the site of bleeding include
    • Placing gauze over the adjacent teeth, rather than at the site of bleeding
    • Using excessive amounts of gauze
    • Removing the gauze too soon to look at the bleeding site
    • Rinsing and spitting

What you need

  • Paracetamol
  • Sterile cotton gauze

What you do

  • Give paracetamol
  • Sit person upright and comfortably in chair
  • Place a small folded gauze square or ball directly and firmly over the surgical wound 
  • Apply pressure — ask to bite down hard or otherwise press a finger firmly over the wound for 15 minutes, then check if the bleeding has stopped
  • Advise patient
    • Do not keep rinsing or spitting
    • Do not use paper tissues or cotton wool
    • Do not remove the gauze too soon to look at the bleeding site
  • If bleeding continues and you have skill needed — see Treating a bleeding tooth socket — suturing OR — medical/dental referral urgently

Treating a bleeding tooth socket — suturing

Stopping bleeding using adrenaline (epinephrine) injection and suturing

What you need

  • Cotton bud
  • Topical anaesthetic cream
  • Local anaesthetic with adrenaline (epinephrine), dental syringe, dental needles
  • Helper to retract tongue, cheek etc
  • Sterile equipment
    • Tongue retractor
    • Dental mirror
    • Tweezers
    • Cotton gauze
    • Suture kit
  • 3.0 plain gut suture
  • Haemostatic agent, to stop blood flow (eg Gelfoam)

What you do

  • Paint topical anaesthetic over injection site/s with cotton bud. Wait 1 minute
  • Inject local anaesthetic + adrenaline (epinephrine) into surrounding soft tissue
  • Wipe dry, remove any large clots, look for torn tissue or source of bleeding
  • Put in suture by pushing needle right through soft tissue only from outside to inside of socket, then from inside to outside of socket — Figure 8.60
  • Pull socket sides toward each other, knot suture firmly, and cut — Figure 8.61

Figure 8.60   

Figure 8.61   
  • If haemostatic agent (eg Gelfoam) available. Use tweezers to gently push into socket and under suture to hold in place. Will mould into position
  • Watch for 10 minutes
  • If still bleeding — reapply finger pressure and gauze pack
  • Recheck medical history — dental consult

Lancing a pointing abscess

Attention

  • Only lance abscess if sure it is needed, skilled and confident to do so
  • Make sure abscess is clearly pointing. Can see pus just under skin (mucosa)
  • Do not give local anaesthetic unless trained/skilled to do so
  • Do not inject local anaesthetic into swelling. Will not anaesthetise area, can cause dangerous spread of infection
  • Nerve block injections away from site of infection can be safe and effective
  • Important that there is immediate dental follow-up care after this procedure to make sure the source of infection is removed, and to prevent a more serious and dangerous infection

What you need

  • Sterile cotton gauze
  • Cotton bud
  • Topical anaesthetic cream
  • Local anaesthetic (LA) for dental use, if required and trained/skilled
  • Sterile No. 11 scalpel blade and handle
  • Suction equipment OR cup and tissues to spit into
  • Sterile suture kit
  • 3.0 plain gut suture

What you do

  • Give pain relief
  • Check medical history
    • Bleeding disorders, medicines that prolong bleeding
    • If RHD, artificial heart valve, heart transplant, history of bacterial endocarditis, congenital heart problem — medical/dental consult about preventive antibiotics before starting procedure
  • If signs of spreading dental infection start antibiotics straight away — see Dental and oral problems
    • If person has trouble opening their mouth due to spreading infection — medical consult and send to hospital urgently
  • Sit or lie person down
  • Dry area to be lanced with sterile gauze
  • If using LA — use cotton bud to paint topical anaesthetic over lancing site or injection site. Wait 3 minutes before giving LA, if required
  • Tell person you are about to lance abscess, ask them to keep calm and still
    • Plunge scalpel quickly in and out exactly where abscess is pointing
    • Use suction and gauze to soak up pus and blood
    • Let person relax, then ask person to rinse and spit
    • Put gauze pack over incision, have person close their mouth to hold in place
    • If bleeding doesn't stop — use simple suture to loosely close incision. Small incision should not need a suture
  • Tell person to rinse with warm salty water 3–4 times a day
  • Check daily
  • Dental consult for extraction or root treatment within few days to prevent abscess reoccurring

Minor swelling or soreness after extraction

  • Some pain and swelling is expected after extraction and/or oral surgery
  • Infection is uncommon
  • Swelling usually peaks 48–72 hours after extraction
  • Sometimes retained tooth or bone fragments can cause symptoms

Attention

  • Give pain relief first — may be all that is needed

What you need

  • Paracetamol
  • Sterile tweezers
  • Warm sterile normal saline

What you do

  • Give paracetamol
  • If problem continues — dental consult
  • May need to
    • Sit person in comfortable chair
    • Remove any bony fragments or debris with tweezers
    • Have person gargle with warm salt water and spit
  • Tell person to use warm salt-water mouthwash morning, night, after food

Dental trauma

Tooth may be loosened, displaced, fractured by trauma

Attention

  • Treatments for primary (baby) teeth and secondary (adult) teeth are different
  • Dental consult first if possible
  • Put tooth or tooth fragments to be taken to dentist in container of milk — cow's milk (fresh, powdered, long life) or breastmilk
  • If milk not available — use saline or wrap in cling wrap

Broken tooth (fractured tooth crown)

What you need

  • Sterile specimen jar
  • Milk

What you do

  • Give pain relief if needed
  • Look for tooth fragment/s — may be in soft tissues
  • If adult — broken pieces of tooth can be stuck back on by dentist at any time so keep safe and wet, in specimen jar containing milk
  • If milk not available — use normal saline or wrap in cling wrap
  • If child 
    • Primary (baby) tooth — no immediate treatment, send for dentist follow-up
    • Secondary (permanent) tooth — send to dentist follow-up with broken pieces of tooth
  • If tooth very sensitive — may help to mould (press) temporary filling over what is left of tooth in mouth
    • If no temporary filling material available — try chewing gum or blu tak

Loose or displaced tooth — adult or child

Attention

  • Person will need pain relief before this procedure
  • Tooth may be partially intruded (pushed up) or extruded (hanging down)
  • Baby teeth usually left as they are. Baby teeth pushed back up into gum will usually re-erupt (grow out again) without help
  • Displaced adult tooth must be put back in place or extracted (taken out)
  • Loosened but undisplaced teeth are left alone
  • Root canal treatment often needed later

What you need

  • Paracetamol
  • Hand mirror
  • Small strip of aluminium foil

What you do

  • Give paracetamol
  • Sit person in comfortable chair
  • Hold tooth firmly, move back to proper position
  • Check bone and gum are in position
    • Ask person to close teeth together gently
    • Check that bite and appearance are normal, ask person to check too
  • If both seem normal. Splint tooth in place with aluminium foil. Cut and mould single layer of foil over inside and outside of tooth and teeth next to it
  • Send person for dental follow-up as soon as possible

Replacing knocked out adult tooth

Attention

Before starting procedure

  • Dental consult — about whether local anaesthetic needed
  • If RHD, artificial heart valve, heart transplant, history of bacterial endocarditis, congenital heart problem — medical/dental consult about preventive antibiotics before starting procedure.
  • Person may need pain relief before this procedure

Replacing teeth

  • Put tooth back as soon as possible, best within 1 hour
  • Do not replace baby (primary) teeth. If not sure whether baby or adult tooth — try to put back, dental consult
  • If you can’t replace tooth — have person hold tooth between cheek and gum, or put in container of milk and send with person to dentist within 12 hours
    • Do not store in water
  • Only replace whole tooth with root attached. If fragments — see Fractured tooth crown

What you need

  • Cotton bud
  • Topical anaesthetic
  • Local anaesthetic, syringe, dental needles, if needed
  • Normal saline, if tooth very dirty
  • Milk
  • Sterile
    • Mirror
    • Tweezers
    • Suture kit
  • 3.0 plain gut suture
  • Small strip of aluminium foil

What you do

  • Give pain relief
  • Sit person in comfortable chair
  • Paint topical anaesthetic over injection site with cotton bud. Wait 1 minute
  • Give local anaesthetic if needed, if skilled
  • Do not touch root, only crown
  • If tooth very dirty — hold crown, gently shake in normal saline to clean
    • If normal saline or milk not available — rinse tooth in water for less than 10 seconds
  • If need to store before replacement
    • Have person hold tooth in mouth between cheek and gum OR put in container of milk or normal saline OR wrap in cling wrap
    • Do not let tooth dry out. Do not store in water
  • Look at shape of tooth, and teeth beside gap
  • Make sure tooth is right way around (eg front of tooth is to the front)
    • Firmly push tooth all the way back into gap
    • Gently shape (press) gum back around tooth
    • Hold tooth in place for a few minutes
    • Ask person to close teeth together, check tooth in right place, ie looks right, teeth meet properly
  • Suture lacerations in gum if needed
  • Splint tooth in place with aluminium foil. Mould (fold) single layer of foil all the way over tooth and teeth next to it
  • Give antibiotics — see Dental and oral problems
  • Immunisation status — tetanus
  • Tell person to use chlorhexidine 0.2% mouthwash – 10mL. Rinse for 1 minute, 3 times a day
  • Send person to dentist urgently