Extraction of the Teeth

by Frank Colyer

(7) Injury to the nerve.—Direct injury to the trunk of the nerve is more likely to occur during extraction of the lower third molar than with any other tooth. It is more than probable that many obscure cases of pain following tooth extraction are due to exposure and irritation of the nerve at the apex of the socket. An interesting case of this character was lately reported by Mr. Storer Bennett.[17] The patient, a lady æt. 23, had had the third upper molar dislocated through the use of a Wood’s gag, and, as it was considered hopeless to restore the dislocated tooth, it was extracted without difficulty. The socket in spite of treatment remained painful for the next twelve days, but in the meanwhile granulated healthily, except at its apex, where by the aid of a mirror and probe a spot about the size of a pin’s head was noticed which caused the greatest agony on being touched. Incision of the nerve produced permanent relief.

Treatment.—The treatment naturally depends very much upon the cause. A thorough examination of the socket should be made with probe and mirror. When due to incomplete extraction, another attempt, if considered advisable, may be made to remove the tooth. This proving unsuccessful, the socket should be swabbed with an anodyne drug and, if there is an exposed pulp in the remaining portion of the tooth, the pulp should be touched with fuming nitric acid or strong carbolic acid. The patient should also be advised to use some poppy head fomentation.[18]

In too rapid healing of the orifice of the socket, the freshly healed surface must be separated, the socket syringed out, and a small tent of lint allowed to remain in the orifice for about twelve hours. An antiseptic mouth wash should also be prescribed.

In those cases where the pus is putrid and there is reason to suspect infection, the socket should be thoroughly syringed with some antiseptic such as hyd. perchlor. 1 in 1,000, carbolic acid 1 in 40; following this the parts should be carefully dried with cotton-wool. A small piece of chloride of zinc should then be introduced and allowed to dissolve in the socket, which must be subsequently kept aseptic by constant irrigation with some antiseptic solution.

Suppuration is most frequently seen after extraction of the lower teeth owing to the fact that drainage is less easily effected than in the upper, owing to the dependent position of the socket. In many cases it will be found necessary to plug the socket tightly with non-absorbent cotton-wool dipped in an antiseptic solution; this prevents the accumulation of débris which would act as an irritant. In cases of suppuration occurring in patients of diminished vitality a tonic form of treatment should be prescribed;[19] the dressing in the socket should be removed two or three times a day and the socket syringed.

Care must be exercised in applying escharotics to sockets to which the nerve may be in close proximity; this is especially necessary in dealing with impacted lower third molars. Two cases illustrating this point have come under my notice. In the first a second lower bicuspid with a long standing chronic abscess had been removed. The patient complained of pain, the socket was syringed out and a small piece of chloride of zinc inserted. Intense agonizing pain followed which all local anodynes failed to relieve. In the second case an impacted right lower third molar had been removed. The socket suppurated, and the pain although severe was not intense. Treatment similar to that used in the first case was adopted with similar results. Since then in all cases where it is possible that the trunk of the nerve may be in close proximity to the socket, I have used non-irritating antiseptic injections and plugged the socket with cotton-wool dipped in tincture of opium with much more satisfactory results.

It is advisable to inform the patient of the possibility of pain following the extraction of a tooth, especially after periodontitis, and in all cases where a large number of teeth have been extracted a mouth-wash[20] should be prescribed; for, even if there is no pain, it will prevent the discharge from the sockets of the teeth undergoing putrefactive changes.

In pain due to necrosis of the socket deodorant antiseptic injections must be used, while in extensive laceration of the soft and hard parts an anodyne mouth-wash[21] may be tried. In all obscure cases an application should be made to the socket of some local anodyne such as tincture of opium or cocaine, and a mouth wash having similar properties should at the same time be prescribed.

(4) DIFFICULTIES, COMPLICATIONS AND SEQUELÆ ARISING DURING EXTRACTION UNDER ANÆSTHETICS.

(a) Tongue slipping back.—During extraction under anæsthetics the tongue not being under control may slip over the larynx, or may be forcibly pushed back by the fingers of the operator. Symptoms of difficult breathing or even arrest of respiration will follow this accident. It is not enough to watch the chest walls, as respiratory movement may continue without air entering the lungs. Treatment consists in pulling the tongue forcibly forward with a suitable instrument and forcibly extending the head on the spinal column.