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

• 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

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