Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Dentistry
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If it is not possible for the patient to access a dental surgeon then extraction will
be necessary to prevent further decay and pain. There are a few dental and medical
contraindications to extraction:
1. A history of severe bleeding after previous extractions or a family history of
bleeding disorders, require referral to a specialists.
2. A history of heart disease (Congenital, Rheumatic valve disease or a prosthetic
valve) requires antibiotic cover (amoxycillin 3g po, 1 hour preop). A
large dental abscess will produce extensive bacteraemia after extraction, refer
to a specialist if possible.
3. Teeth which are buried, impacted, displaced or ankoylosed (attached directly
to bone) are difficult to extract and should be left to a dental surgeon.
4. Removal of diseased milk teeth must be followed by insertion of a spacer by
a dental surgeon within three months.
5. Hyperthyroidism is an absolute contraindication to tooth extraction.
6. Patients with diabetes should have their blood sugar levels well controlled
before attempting any dental surgery.
Local Anaesthesia
This is vital to prevent the patient experiencing severe pain during the procedure.
The nerve supply to the teeth is located on the lingual and labial side of the
tooth and through the pulp. All three sets of nerves must be anaesthetized.
Materials
2% Lidocaine with Epinephrine (1:200,000), max dose 20 ml for 70 kg patient.
This is equivalent to 6mg/kg. For known hypertensives and diabetics, epinephrine
is contraindicated and 2% Lidocaine should be used (max dose 10 ml for 70 kg
patient or 3 mg/kg). Although dental cartridge syringes with a 26-gauge needle are
ideal, other types of syringes can be used along with a narrow gauge needle (24/26
gauge).
Method
The usual precautions regarding local anaesthesia apply. Never insert the needle
completely into the tissue, as it may break off and become extremely difficult to
remove. Test the anaesthesia by probing the gum adjacent to the tooth to be extracted.
If pain is still felt, repeat the infiltration, without exceeding the maximum
dosage.
Infiltration Method
Two injections are necessary at the inner (lingual) and outer (labial) aspects of
the tooth adjacent to the root of the tooth to be extracted.
Labial Injection
Insert the needle at the point where the gum joins the cheek, to a depth level
with the base of the root of the tooth. For the third molar, insert the needle at the
proximal molar and insert diagonally. Inject 1.25 ml of lidocaine + epinephrine.
Lingual Injection
Insert the needle opposite and 1 cm towards the center of the palate, at a shallow
depth. Inject enough anaesthetic solution to change the color of the gum to white
(Fig. 5).
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