BOH Part4

Training of basic oral health workers

Part 4 - Special problems

Abscesses

Submucosal abscesses

Causes

We have learned that after caries attacks a tooth the nerve can die and a periapical abscess may develop. This abscess, if left untreated, might spread through the bone. It usually takes the easiest way out of the bone; it goes through the bone and comes

out under the mucosa next to the tooth.

Progress

When the swelling starts next to the tooth there is no immediate pus. After 3 days you should expect pus. if no treatment is

given, sooner or later the abscess will open by itself. Pus comes out and the patient might have a bad taste. The swelling goes

down very quickly now, but leaves a pimple. This pimple we call FISTULA. Every now and then pus will come out of the fistula, as

long as the cause is not removed. The cause is the decayed tooth.

Treatment should be aimed at:

-removal of the cause (extraction, rootcanal treatment)

-release of pus

When giving an injection of local anaesthesia we should be careful NOT to inject into the swelling. The local anaesthesia does not

work in an abscess as the injection as such will be more painful. It can also cause the spread of the infection into other areas.

If the submucosal abscess is present for less than 3 days, an extraction will suffice. INSTRUCT the patient to report to your

clinic if the swelling has not subsided in 3 days. Than refer to a dental clinic.

If the submucosal abscess exists for longer than 3 days, you should expect pus. Again do an extraction. Do not inject into the

swelling. After the extraction, you should manipulate the swelling in order to make the pus come out through the socket. If

no pus comes out. leave it. INSTRUCT the patient to report to your clinic if the swelling has not subsided in 3 days. Then

refer to a dental clinic. Only if the patient is unable to visit a dental clinic can you start giving antibiotics first. Give: PROCAINE PENICILLINE 2 ml. intramuscular daily for 5 days. If the swelling has still not gone by then: REFER. If there is a known allergy for Procaine Penicillin you should refer to a dental clinic. Children should get a dose according to age and weight. Consult a medical

assistant.


Relation of tooth to submucosal abscess.	Relation of a tooth to a submandibular abscess

Submandibular abscess

Causes

After the nerve of a tooth has died a periapical abscess might develop. When the abscess spreads through the bone a submucosal

abscess may develop, but if the pus spreads to the area below the mandible, the so-called submandibular region, a submandibular

abscess develops.

When pus has entered the submandibular region a large swelling of the face will appear. After 3 days pus will be present in the

swelling. If no treatment is given, pus might find its way to the skin and come out, forming a FISTULA on the skin. The pus might

also spread further into other tissues around the throat, thus causing breathing problems. A submandibular abscess is a serious

condition.

Treatment

Treatment of submandibular abscesses is aimed at:

-treatment of the abscess itself

-treatment of the cause

The best thing to do is to refer patients with a submandibular abscess right away. if this is impossible you can give

antibiotics first. Give procaine penicillin 2 ml intramuscular daily for 5 days. Children should get a dose according to age and

weight. In case of a known allergy to Procaine penicillin, you should refer. Many times a submandibular abscess cause TRISMUS

(patient is unable to open his mouth) This trismus prevents you from removing the cause. As soon as the trismus has gone, due to

antibiotic therapy, the cause should be removed. If antibiotics and/or removal of the cause do not make the

submandibular abscess subside, you should refer.

Symptoms of abscesses

When a patient has a swelling, a very careful examination should be made. important questions are:

-how long has the patient had the swelling?

-has it happened before?

-did the patient have a toothache?

In general the symptoms of abscesses are:

-pain

-swelling

-redness or tenderness of tissue

-warm swelling

-trismus

-rise in body temperature

Abscesses have a short history.

If a swelling exists for longer than 2 weeks, it is not usually an abscess. If it exists for less then 2 weeks it might be an abscess.

A swelling is an abscess when:

-it is painful

-it feels warm

-it exists for less than 2 weeks

-it developed very quickly

-there has been a tooth ache or you see a very seriously decayed tooth

If a swelling does not subside when the tooth is remove or when you have prescribed antibiotics for days: REFER. If the trismus

does not go away, so that you are unable to treat the cause: REFER.

When giving local anaesthesia when there is an abscess, you should NEVER inject the swelling. Warn the patient that local anaesthesia does not work well in abscesses, so the extraction might be a little painful.

PERICORONITIS

PERICORONITIS is an inflammation around the crown of a tooth. Pericoronitis is a special condition and refers to a tooth coming

through in the mouth which has, at that particular time, an inflammation of the gums around it. In fact pericoronitis is only

associated with the eruption of a 3rd molar in the lower jaw.

Causes.

If a tooth erupts at some stage an opening in the gums occurs. A tooth which is in the jawbone has a sack around the crown. Fig.32

shows the stages from the tooth being completely within the jawbone (a), to the tooth opening the gums (c).

When the opening occurs there is a possibility that plaque enters this sack through the opening. As the patient cannot clean in

this space, irritation and subsequent inflammation arises. This inflammation we call PERICORONITIS. In fact it is the same

process as gingivitis, only around an erupting tooth. Normally no pericoronitis develops when a tooth erupts, only if eruption is

delayed for some reason. A delayed eruption we see mainly with 3rd lower molars.

Progress

When the inflammation starts the patient feels a slight pain in the back of the mouth. As the inflammation gets worse, a trismus

may arise. Because of the pain, the patient usually does not clean the area properly, thus making the inflammation worse. If

no treatment is carried out, a pericoronitis may cause a submandibular abscess.


Erupting tooth	Rinsing the sack with a blunt needle

Treatment

The aims of treatment are:

-to clean the area and the sack

-to prevent new dirt from entering the sack

You should clean the sack. This can be done by taking a 20 ml. syringe and a thick blunt needle. Push the needle carefully into

the opening and rinse with 20 - 40 ml saline water. Even with severe trismus this can be done. Advise the patient to mouthwash

with saline water 4 times daily. The patient should come back for rinsing until the acute phase has passes. The figure above shows

the position of the needle when rinsing.

Sometimes the patient is in a poor condition with fever, swelling of the throat and of the submandibular region. In this case it is

better to refer. If the patient cannot be referred you can give antibiotics. Give Procaine Penicillin 2 ml daily for 5 days. If

the condition does not improve: REFER.

When pain and trismus are gone, you have to prevent new plaque from entering the sack.

A careful examination of the area and the sack should give you an idea whether:

-the tooth is sound or decayed

-the position of the tooth is such that there is a chance of it erupting properly or not

-there is much tissue overlying the tooth or not

After this you have to answer the question whether the tooth is worthwhile saving or not.

-If it is worthwhile saving, some of the overlying tissues might have to be removed. This should be done at a dental clinic.

Explain to the patient and refer.

-If it is not worthwhile saving, the tooth needs to be removed.

Removing of 3rd lower molars may cause problems. Check carefully whether you think you will be able to extract the tooth. If you doubt, you better refer.

ACUTE ULCERATIVE GINGIVITIS.

Acute ulcerative gingivitis is a severe inflammation of the gums. Acute ulcerative gingivitis causes a lot of pain. It is so

painful that brushing the teeth or even eating, might be impossible. Generally we see acute ulcerative gingivitis in

patients with poor general health; mainly patients who are malnourished. Children are often affected. If this condition is

neglected it may affect the cheeks as well and cause large defects (noma).

Causes.

Acute ulcerative gingivitis is caused by PLAQUE. Plaque is the cause of the inflammation. because the patient is in poor general health the inflammation develops into acute ulcerative gingivitis, instead of ordinary gingivitis. Mainly malnourished children between the ages of 3 to 7 years are affected.

Treatment.

Treatment of acute ulcerative gingivitis is aimed at the removal of the cause of the condition. This means:

-removal of the plaque

-treatment of poor general health

Brushing the teeth might be very painful, therefore we start with MOUTHWASH with saline water 4 times a day. GENTIAN VIOLET should be applied once a day.

If the situation is so severe that the patient cannot eat you can prescribe antibiotics. Preferably you should prescribe

METRONIDAZOLE. Dose: 200 mg, 3 times a day to be taken during meals, for 3 days.

If no metronidazole is present, you can prescribe Procaine penicillin intra muscular for 5 days, dose depending in the patients weight. Consult a medical assistant for the proper dose.

As soon as possible you should do scaling and the patient should start brushing. Together with treating acute ulcerative

gingivitis locally, the underlying cause, being malnutrition, should be treated. Refer to a malnutrition clinic. If the

condition does not improve in 7 days, Refer to a dental clinic.

TEETHING PROBLEMS

When the child starts growing teeth, the teeth need to open the gums. This happens when the erupting teeth press themselves

through the gums. This pressure usually causes pain for 1 or 2 days. The child will be crying and will feel uncomfortable. The

best thing to do is to give the child something hard to bite on, like a wooden ## This should be large enough so that the child

cannot swallow it by accident. The biting on this hard thing helps to open the gums faster. Parents often believe that

teething also causes fever, coughs or even diarrhoea. This is not true. Teething is a problem on its own without any complications.

Of course the child may have any of these problems as well during the teething period, but they have another cause.

Persisting baby teeth.

We know that we have two sets of teeth. The baby set is complete at the age of 2 1/2 years. The first baby teeth get lost at about

6 years. The adult teeth are formed under the baby teeth. As can be seen in fig.34 (a), at first, just the crown is present. Later on the

root starts forming. The root does not grow downwards, but the crown grows upwards (fig.34. (b)). When the crown touches the

root of the baby tooth, this root will dissolve. At some stage, so much of the root of the baby tooth is gone that it will fall

out (fig.34 (c)). Some time later the adult successor will erupt.


Stages of formation of adult teeth in relation to baby teeth.	The adult tooth grows behind the baby tooth.

Sometimes the crown of the adult tooth does not touch the root of the baby tooth, but it will grow behind it. This is shown in the figure above.

As the root does not get absorbed, the baby tooth will persist. In the mouth we see two teeth behind each other. The adult tooth

on the inside, the baby tooth on the outside. The parents usually want you to remove the tooth which is out of

line. If we do not give any treatment, the tongue will eventually push the adult tooth into line with the other teeth. At that time

the baby tooth will come out by itself. Therefore: the baby tooth will come out, but it will take some time. The best thing to do

is to explain to the parents that the problem will solve itself. If in two years time the tooth still persists, you can remove it.

The reason for not doing anything is that if we want to extract the baby tooth, we have to give anaesthesia and this will upset

the child very much. He will be scared of the dentist for the rest of his life.

DISLOCATED JAW.

First we to describe the normal situation. As can be seen from fig.36, the joint of the mandible is positioned against the skull

just in front of the ear. When a patient opens his mouth the joint rotates; when closing it rotates back. Note that at the

side of the joint away from the ear there is a small bone extension.

Dislocation.

When a patient opens his mouth very wide (yawning, biting large pieces of food, singing) the joint may move across the bone

extension. This is shown in fig. When the joint has moved across the bone extension we call it a DISLOCATION OF THE LOWER JAW. The joint will not usually move back from its dislocated position without treatment. Some patients frequently have dislocated jaws. They know how to move the joint back into its proper position.


Joint, normal position.	Joint, dislocated	Supporting the mandible; position of the thumbs

Symptoms.

-the patient is unable to close his mouth

-the patient feels pain in the area of the joint

Treatment

Place the patient on a low chair. He should sit upright with his head supported against a backrest or wall. Now place your thumb

on the mandible as far as possible in the back of the mouth. The fingers should support the chin. The figure above shows how to hold the mandible.

Now press the jaw down on one side. This may require considerable force. When the jaw is pressed downwards it will jump back into

its proper position. Now you can do the same on the other side. The patient should be instructed not to open his mouth wide. He

should only bite small bits of food. When yawning he should support his chin to limit the mouth opening.

DENTAL DISEASES AND PREGNANCY.

A woman who is pregnant can have the same dental problems as any other patient. Therefore a pregnant woman should care for her

teeth at least twice a day and she should reduce her intake of sugar and sweet food and drinks. If a pregnant woman fails to

care for her teeth and gums properly, she will develop dental diseases. A pregnant woman might develop caries and gingivitis

and caries; the causes being PLAQUE and SUGAR. Because of gingivitis and caries and their consequences, a

pregnant woman might attend your clinic with toothache.

Causes of dental diseases in pregnant women.

As already explained before, the cause of dental problems is the same for everybody, including pregnant women. However, the

resistance of the gums against attack by waste materials, as produced by the bacteria in the plaque is controlled by chemical

components which we call HORMONES. A pregnancy is also controlled by hormones and these hormones interfere with the hormones of the gums. As a consequence the resistance to waste materials is less, which means: A PREGNANT WOMAN WILL DEVELOP GINGIVITIS MORE EASILY AND MORE SERIOUSLY IF SHE DOES NOT BRUSH HER TEETH!. Plaque

removal (proper oral hygiene) will prevent the rise of gingivitis.

The development of caries is not controlled by hormones. A pregnancy therefore does not change the pattern of caries. Only

the sugar intake and the presence of plaque does.

Treatment of dental diseases in pregnant women

As we know, gingivitis and caries might cause serious toothache. Traditional belief in many parts of the world is that during

pregnancy teeth should not be extracted. However, DENTAL TREATMENT DOES NOT AFFECT THE UNBORN BABY.

Therefore, we should treat any pregnant woman who comes for help, WITHOUT delay, just like anybody else.

You should give ORAL HYGIENE INSTRUCTION and perform SCALING if necessary.

You can use Lignocaine local anaesthesia without any problem in the normal dosage. Do not remove more than 2 teeth at the time,

because there might be a bit more bleeding due to the pregnancy.

A PREGNANCY IS TO CONTRA-INDICATION FOR DENTAL TREATMENT.

Prevention of dental diseases in pregnant women.

Prevention is better than cure. You should go to the ante-natal clinic regularly to teach women on proper oral hygiene. You could

also perform examinations and suggest treatment if necessary. Of course the woman has the right to refuse treatment if she

believes in traditional values of dental treatment during pregnancy. However, dental treatment should never be refused

because of pregnancy. The midwives at your clinic should know about this as well. You should also teach them about the relation

between dental diseases and pregnancy and on possibilities of treatment during pregnancy.