Extraction of the Teeth

by Frank Colyer

When the bleeding proceeds from the socket the following mode of procedure is adopted: some small cone-shaped pieces of non-absorbent cotton-wool are prepared (each about ⅓ to ½ inch long and ¼ inch broad at the base), also a pad of lint and a four-tailed bandage; a syringe, a pair of conveying forceps, some cold water and the chosen styptic are likewise placed ready for use. The socket is first freed from clot, then syringed, then dried out with a pledget of cotton-wool, and directly afterwards one of the cone-shaped pieces of cotton-wool dipped in the styptic (the most useful being tannin) is placed in the socket and forced to the apex, with a fair amount of pressure; the hæmorrhage is arrested far more by pressure than by the styptic. More pledgets of wool are inserted until the socket is quite full; a plug of lint is then placed over all and kept in position by antagonism with the upper teeth, a four-tailed bandage being used for this purpose. An excellent method of keeping the plug in the socket if the approximal teeth are standing is to wedge a piece of wood between them. Excellent as this plan is, however, if the hæmorrhage is at all sharp it is better to use the four-tailed bandage to make more certain of retaining the plug in position. The number of pledgets of wool inserted in the socket should be counted.

The general directions to be given to the patient, though apparently trivial, are most important and should never be forgotten. He or she should be advised to go home very quietly, to avoid all forms of excitement, to assume the sitting position usual during the day, and to use a high pillow at night. The patient should be fed through a bent tube, and all fluids should be given cold.

In addition to plugging the socket, hæmostatics should be administered internally.

In cases where there is a thin watery blood and no tendency to coagulation it may be fairly assumed that the cause of the hæmorrhage lies in the blood, and such drugs as gallic acid[11] and perchloride of iron[12] are indicated, but when the blood shows a marked tendency to coagulate in the mouth, as often happens, and the bleeding still continues, such drugs as ergot[13] are indicated; in this latter condition it may be assumed that the cause of the hæmorrhage lies in some want of contractility of the vessel wall, and ergot causes contraction of unstriped muscular tissue.

At the time of plugging the socket a dose of gallic acid, perchloride of iron or ergot should be given, and its administration continued at intervals until the bleeding ceases. Mr. Morton Smale prefers a hypodermic injection of ergotine.[14]

The patient should be seen within twenty-four hours after treatment, and if the bleeding has ceased the plugs may be removed and an antiseptic mouth wash prescribed. This course is not recommended when the hæmorrhage has been severe; under such circumstances the plugs should be allowed to work themselves out. If the hæmorrhage has not then ceased, the socket should be replugged tighter than before with a plug of wood wrapped in non-absorbent cotton-wool. Should this prove of no avail the actual cautery may be tried; if this fails, and the bleeding is from the mandible, the canal should be trephined and a plug of ivory inserted, so as to compress the artery against the inner plate of the bone. In uncontrollable hæmorrhage from the maxilla digital pressure on the common carotid opposite the transverse process of the sixth cervical vertebra may be tried; should this fail to stop the hæmorrhage, ligature of that vessel must be resorted to.

In one case of hæmorrhage from the region of the third right lower molar Mr. Boyd[15] divided the lip in the median line and reflected the cheek from the jaw. The mandibular canal was then laid open by excising the outer plate of the bone, and the bleeding was arrested by plugging the mesial and distal ends of the canal.

In extreme cases, with sign of collapse, normal saline solution[16] must be infused into the median basilic vein.

In patients predisposed to hæmorrhage extraction should be if possible avoided; but, if the removal of the tooth be absolutely necessary, prophylactic treatment should be pursued for three or four days previous to the operation by the administration of one or other of the remedies previously mentioned.

A new styptic, consisting of fibrin ferment 1 to 10 to which 1 per cent. of calcium chloride has been added, is said by Walsham to act only on the blood, not on the tissues, and to be perfectly aseptic. It was found to be effectual in arresting hæmorrhage after the division of all the veins except the common jugular in a dog’s neck.