Dental Health International Nederland
Training of basic oral health workers


Part 3 - Treatment of common dental diseases

Introduction

Treatment of dental diseases is only possible if we have a good understanding of the patient, his problem and our skills in diagnosing the problem.

First of all we consider the patient.
The patient who attends your clinic only does so because he is in pain. People, in general, are very afraid of anything a dental
worker may do. Awful stories about dental treatment are often told so that when a patient develops toothache he is only
visiting you because his pain is worse than his fear. Therefore we have to accept the fact that patients are attending our clinic
are scared. We should therefore act friendly. In order to reduce the fear of a patient it is important that we receive a patient
in a good, clean and well light room. No blood stained bandages, syringes or other frightening instruments should be shown. We can
chat with the patient, specially children are sensitive to this way of acting. Adults may suppress their emotions but children
will not. If they are scared they will shout and scream. Be patient and act swiftly and with confidence.

A patient comes to you with a wish to be relieved of the problem he has. Usually the patient is quite accurate in indicating where
the cause of the problem is. Sometimes you will find that the patient feels his upper molar is the cause, while you find there
is nothing wrong. However, you find that at the same side the lower molar does have a big cavity and you believe that lower
molar causes the pain. In such cases you should consider the following: A patient has certain rights. The patient has the
right on the best possible dental care. He has the right to be informed on your diagnosis and your proposed treatment. The
patient has the right to disagree with your proposal. For example: you want to propose a filling while the patient wants an
extraction. The patient has the right to refuse a filling. The dental worker has certain duties. He has the duty to provide
the best care he can give. He has to do a proper examination of the patient before he comes with his diagnosis and his treatment
proposal. As indicated before the patient has the right to refuse a proposal, but the dental worker has the duty to do what is
best. If the patient does not agree with the dental worker, the dental worker should not treat. The patient can never force the
dental worker to give treatment which the dental worker does not think best for that very patient.

Examination

The patient who visits you has a problem for which you should find a solution. In order to propose and execute proper treatment
you have to give a name to the problem of the patient. This we call : MAKING A DIAGNOSIS. Only if we have a diagnosis we can
give proper treatment.
In order to make a diagnosis we should follow a procedure which consists of:
observation 
The moment the patient enters your clinic, you may observe signs which maybe connected to the patient's problem. does the patient
have bruises or cuts. Does he have a swelling. Does he look healthy or sick? All these signs may be observed at a glance but
they are important.

questioning 
Before we look into the mouth we have to ask the patient some relevant questions:
     -Could you tell what your problem is?
     -When did it start?
     -What is its nature? E.g. intermittent or continuous pain, dull or sharp pain.
     -Is it getting better, stable or worse?
     -Do you have medical problems? Patient with heart problems may need some special precautions.

extra-oral examination 

We examine the face. Are there any bruises or cuts. Is there swelling? How are the bruises etc. caused?

oral examination 
Now we take a look into the mouth. Check the mucosa, the gums, the tongue etc. Look for things which appear to be abnormal. Is
the mouth clean? Did the patient brush his teeth? Now check each and every tooth. We have to find each and every problem. Look for
cavities, for calculus and for gum-problems. Be aware that you may notice something which is not normal but
what you cannot put a name to.
Usually the patient complains about 1 problem only while on examination you find more problems. In such cases treatment for
all problems has to be proposed.

After finishing the examination we should combine all the information we have. When we are able to put all signs and
symptoms together we are able to recognise the problem and we can give a name to the problem. We than can make a DIAGNOSIS.
E.g. pain for several days, a big cavity in the molar. The molar hurts when you taper on it. These signs and symptoms lead to the
diagnosis peri-apical abscess due to caries.

Now it is very important to remember that: When we are unable to make a diagnosis we will be unable to perform proper treatment.
In such cases we have to refer to someone more experienced. Never do anything without a proper diagnosis!

Treatment

scaling
When we have diagnosed: gingivitis, our treatment is: Oral hygiene instruction and scaling.

Scaling is the removal of calculus.
Calculus is a hard stony layer which has to be scraped off the teeth with a special instrument which is called SCALER.
The scaler is triangular in cross section. With the sharp angles we can scrape off the calculus by placing the scaler in between
the gums and the teeth underneath the calculus. With a slow scraping motion we remove the calculus. Proper removal may take
quite some time. Calculus is tough and the gums bleed easily, which make it difficult to get proper sight. After removal of the
calculus the teeth ought to be polished. Usually this is only possible in dental clinics. Scaling is always possible. Make sure
your patients leave the clinic with a clean mouth and instructions on how to keep the mouth clean.

- a scaler (11A-12A)
- the form of the tip and the cross-section
- how to use the instrument

anesthesia
In order to remove a tooth we have to give anaesthesia. Anaesthesia is an injection fluid which numbs the nerve so that a patient
does not feel anything of your treatment. In chapter I (Anatomy) we have learned that the tooth has a
nerve. The gums have also nerves. In order to perform a painless extraction we have to anaesthetise both the teeth and the gums.
The technique for anaesthesia in the mandible (premolar/molars) is called MANDIBULAR BLOCK. The technique for the mandible
(incisors/canines) and the maxilla is called INFILTRATION ANESTHESIA.

necessities
The drug which we use for dental anaesthesia is LIGNOCAINE 2% with or without ADRENALINE 1:100.000. Lignocaine with adrenaline works better than lignocaine plain, but if we only have LIGNOCAINE 2% PLAIN this will also work.
We need about 2 ml anaesthetic fluid per tooth to be extracted. We need a syringe of 2 ml and thin needles of 3 cm (1") length.

infiltration anesthesia

This technique aims at putting the anaesthetic fluid near the tooth to be extracted.
When we pull away the cheek or the lip we see where it joins the gums. This fold we call sulcus.



For infiltration anaesthesia we pull away the cheek/lip and insert the needle in the sulcus while aiming at the root tip of the
tooth to be removed. Here we inject 1 1/2 ml. This suffices for anaesthesia of the tooth and the gums at the outside. For the gums
at the inside we have to inject into the soft tissue at the inside next to the tooth. Here we put 1/2 ml.
Tooth, cheek and sulcus; a) maxilla, b) mandible
Position of the needle during infiltration anaesthesia
in the mandible.
Position of the needle during infiltration anaesthesia in the maxilla

mandibular block anesthesia
The bone of the mandible where the molars and premolars are is too dense for infiltration anaesthesia to be effective. Therefore
we use the mandibular block anaesthesia. The technique of mandibular block anaesthesia aims at blocking the mandibular nerve before it enters the mandible through the mandibular foramen.
Procedure: Place your thumb in the very back of the mandible where you feel the mandible going up. Your thumb should feel the
inner ridge. Now insert the needle at the level of your thumbnail. The syringe should be in line with the chewing
surfaces of the teeth, while the barrel is in the premolar area of the opposite side.
Position of the thumb on the mandible, the syringe is in proper position.
When the needle touches bone and it is almost completely in the tissue you can be sure you are in good position. Now inject 1 ml.
This is to anaesthetise the tooth itself. While withdrawing you inject another 1/2 ml. Just before the needle is out of the
tissue. This is to anaesthetise the gums at the inside and the tongue (you block the lingual nerve). The gums at the outside are
anaesthetised using infiltration anaesthesia next to the tooth to be extracted. This requires 1/2 ml.
As part of the tongue also gets anaesthetised we only can safely use block anaesthesia at 1 side at the time. In case you need
anaesthesia at both sides we treat one side and wait about 4 hours for the first anaesthesia to finish before we start the other
side.
In  5 - 10 minutes the anaesthesia
starts working.      We can test this by:
- asking for a numb feeling in the lip and tongue
- asking whether the pain has stopped
- testing the gums with a probe to check for numb feeling when pricking
Only when the anaesthesia is working properly we can start with the necessary treatment.

EXTRACTION
In order to perform an extraction we need:
- proper anaesthesia
- proper instruments
- proper technique
Proper anaesthesia has been discussed before. Proper instruments will be discussed now.

INSTRUMENTS

An extraction we do by placing an instrument on the tooth to make it loose and come out. In principle there are 2 instruments which
we use for extraction. A forceps and an elevator.
Fig. Forceps(a) and elevator (b)
Forceps: A forceps consists of a handle, a joint and blades or beaks. The blades are shaped according to the shape of the root.
At the level where the crown and the root of a tooth join (CERVIX), the various teeth have different shapes. The shape of
the root at the CERVIX is shown in fig.
In order to get a good grip on the teeth the shape of the blade has to fit properly. The design of the blades of the essential
forceps and its relation to the teeth is shown in fig.
The shape of the root at cervix level
Because the position of the teeth in maxilla and mandible is different we also have forceps specially for the maxilla and the
mandible. In the mandibular forceps the blades and the handle make a right angle, maxillary forceps have the handle and blade
more or less in a straight line.
 Difference between upper forceps
 and lower forceps
A special type of forceps is the root forceps. Normal forceps have blades which don't touch when the handle is closed. In
rootforceps the blades do touch. Because of the difference between upper and lower teeth, and between the various teeth we
need 8 forceps.


ELEVATORS

An elevator is an instrument which can be pressed in between two teeth or in between a tooth and the jaw bone. By rotating the
elevator will come loose. An elevator consists of a handle and a blade.
There are 3 types of elevator (from left to right)

- a straight elevator
- a curved elevator (left and right)
- a triangle elevator (left and right)

Proper technique.

The major thought for proper technique when extracting teeth can best be explained with an example from day to day life.
In your garden you have an old pole from a fence which needs to be removed. The pole should be removed completely. You can easily
give a jerk, break the pole where it enters the soil and leave the rest. To remove the rest is tiresome. If you want to remove
it completely you start carefully. First you push and pull a bit to find out which way it moves. After some trying you feel that
it is moving slightly. You move a bit more and at some stage you feel it is loose enough to pull. Now you grip the pole as near to
the soil as possible (maybe you even take away some soil) and then you lift out the pole completely.
When extracting teeth we do exactly the same thing. We take the best fitting forceps. Place it as deep as possible on the tooth
and we start moving very gentle. Hold the tooth with you other hand so that you feel the movements. We move towards the inside,
then towards the outside. When it moves better to one side or another we press a bit more. We do this as long as necessary to
make it move easily. At that stage we start pulling and remove the tooth. The aim of the extraction is by making these careful
movements to break the fibres which connect the tooth to the jawbone.

When the tooth is very fixed in the jawbone or when it is the last tooth in the row we can also use a straight elevator to
loosen up the tooth. Carefully press a straight elevator in between the teeth, with the hollow side towards the tooth to be
removed.
Place the forceps deep around the tooth. The other hand supports the jaw bone.
Extraction of the last molar.
a) press the elevator inbetween the teeth,
b) rotate until the tooth is lifted out.
Rotate gently until you feel the tooth getting loose. When you feel the tooth is loose, rotate further to lift out the tooth out
of the jawbone (out of its SOCKET) or when it is loose take a forceps to remove it.

PROBLEMS WITH EXTRACTION

Problems with extraction may arise when the crown is seriously decayed or when the crown breaks while extracting.
First of all it is important to realise that most problems arise because of "speed". When you are in a hurry do not perform an
extraction. Speed will cause breaking of crowns and roots so that in the end it will take much more time to solve the problem.
When the tooth breaks at crown-level, at first you may try to remove some jawbone around the tooth by pressing the beak of the
forceps in between the gums and the jawbone. After pressing carefully you close the forceps and while rotating you break away
some bone.

Fig 26. Remove bone to get grip on the tooth.

     a) take the bone margin in the beak of the forceps and rotate
     b) after having removed the broken bone, place the root forceps on the root

Now you clean the forceps with a gauze and you may attempt to remove the root.

In such cases we also can try a straight elevator. The elevator is pushed carefully in between the root and the jawbone. While
pressing you rotate so that the pressure may move the root. The hollow side of the elevator should be directed towards the root
to be removed.
When the root breaks at a deeper level it is impossible to remove jawbone with the forceps as described above. Now we can try the
curved elevator. Try to push the elevator-tip in between the jawbone and the root.

Position of the curved elevator when removing a root. Be carefull with this instrument, it can easily slip away in an undesired direction and cause wounds.

Now manipulate until the root comes loose. You may have to use the left and right curved elevator alternating.
If you are trying to remove a two or three rooted tooth (e.g. molars) and you succeed in removing 1 root than you can take
the triangle elevator to remove the second root. Place the tip of the elevator in the empty socket and rotate the tip through the
jawbone into the remaining root.
Use of the triangle elevator
Use of an excavator


Fig 28.

Now continue rotating thus lifting the root out of its socket.
If you fail to remove the root you can best refer to a dental clinic where they are also specialised in difficult cases. Often
this is a problem for the patient as he may have to travel a long distance. In such cases you may also wait 3 or 4 days and than
try again. A tooth or root, which does not have any function, will come a bit loose by itself.

In any case remember what has been said before: NEVER HURRY Try to prevent problems with extraction by careful diagnosing and
treating. Give proper anaesthesia, select well-fitting instruments and work confidently without haste.


POST EXTRACTION CARE
After the tooth has come out you should press the gums over the socket so that there is a minimal chance for bleeding.


Fig. 29 Pressing the gums over the socket.

Take a piece of gauze on which the patient can bite. He should bite for 1/2 hour so that bleeding stops. When bleeding does not
stop or restarts the patient should bite firmly on a piece of gauze for at least 1 hour. If after 1 hour bleeding still has not
stopped another gauze should be put over the socket with firm pressure for 1 hour. If after 2 hours of pressure there is still
bleeding, a suture should be made.
Information to the patient.
After you have finished your treatment you should tell the patient what you have done e.g.2 teeth extracted, calculus
removed, no roots remaining. Instruct the patient bite on the gauze for about 1/2 hour. Advise him not to rinse his mouth the day of the extraction. If pain persists he may take painkillers of which Paracetamol (e.g. Panadol) is the best.


Dry socket
Sometimes a few days after you have done a proper extraction the patient may return complaining about toothache at the very spot
where you have done your extraction. In such cases first check whether there are neighbouring teeth with a cavity. If not the
patient may have developed DRY SOCKET. Normally after an extraction the socket fills up with blood which
forms a bloodcloth. If for some reason the bloodcloth disappears food remnants may enter the empty socket and cause an
inflammation of the bony wall. You can easily diagnose dry socket by taking some cottonwool in a pair of tweezers. Dip the
cottonwool into the socket and smell. When it is a bad smell, the diagnosis is dry socket. Dry socket is very painful, but
harmless. Reassure the patient by explaining the situation. With a thick blunt needle and saline water you can rinse the socket.
Advise the patient to take painkillers. within 3-5 days the pain will disappear and the wound will heal. Antibiotics are of no
use. Even without any treatment dry socket will heal without any problem.