DN11 - provide chairside support during the extraction of teeth and minor oral surgery

Question 1

BEFORE THE PROCEDURE

Answer 1

• correct identification of the patient
• correct identification of the procedure
• knowledge of the records and images required by the operator for the procedure
• knowledge of the correct setting up of the area for the procedure
• knowledge of the instruments, materials and equipment that may be required for the procedure
• knowledge of the actions to take if the dental nurse is unable to fully prepare for the procedure

Question 2

THE RECORDS TO BE SET OUT:

Answer 2

• notes written at the previous appointment or when the decision was made to carry out the particular procedure
• medical history form, to be checked to highlight any potential concerns - for example, is a certain local anaesthetic required, or does the patient have an allergy to latex
• consent form, indicating that the patient has given valid consent to the procedure
• radiographs of the relevant tooth - these will allow the operator to plan the procedure and the technique used and to show any potential difficulties such as curved roots or lateral canals on the tooth involved

Question 3

CORRECT IDENTIFICATION OF THE PROCEDURE:

Answer 3

SIMPLE EXTRACTIONS - of roots or whole teeth, where no soft tissue or bone removal is required
SURGICAL EXTRACTIONS - of roots or whole teeth, where soft tissue alone or with bone has to be removed to gain access to the root or tooth
IMPLANT PLACEMENT - the replacement of a missing tooth (or teeth) by the surgical placement of a titanium implant into the alveolar bone
APICECTOMY - the amputation of a root apex and any associated pathology as a surgical endodontic procedure
FRENECTOMY - the surgical removal of the frenal soft tissue attachment between the lip and the alveolar ridge
ALVEOLECTOMY - the surgical adjustment and a removal of bone spicules from the alveolar ridge after tooth extraction, to produce a smooth base for denture seating
SOFT TISSUE BIOPSIES - the partial or complete removal of soft tissue oral lesions for pathological investigation and diagnosis

Question 4

EXTRACTIONS

Answer 4

• simple extraction
• surgical extraction involving dissection of the tooth in its socket and removal in sections
• surgical extraction involving soft tissue removal to expose an unerupted tooth or buried root
• surgical extraction involving the raising of a mucoperiosteal flap and bone removal to gain full access to a tooth or root

Question 5

FUNCTION OF FORCEPS:

Answer 5

range of sterile hand instruments used to grip a tooth or root at its neck before applying appropriate wrist actions to loosen the tooth/root in its socket during the extraction procedure.

Question 6

FUNCTION OF LUXATORS:

Answer 6

sterile hand instruments used to widen the socket and sever the periodontal ligament attachment as they are pushed towards the apex, lifting the tooth out of the socket

Question 7

FUNCTION OF ELEVATORS:

Answer 7

sterile hand instruments used to prise the tooth/root out of the socket

Question 8

FUNCTION OF FINE-BORE ASPIRATOR:

Answer 8

disposable suction tip used to suck away all the blood and maintain good moisture control throughout the procedure

Question 9

FUNCTION OF HAEMOSTATS:

Answer 9

gelatine sponges or oxidised cellulose packs, which are inserted into the socket after extraction to aid blood clotting and achieve haemostasis - can be used with or without a suture

Question 10

PATTERNS OF FORCEP:

Answer 10

• UPPER INCISOR AND CANINE FORCEPS are straight with single rounded blades and have both wide and narrow patterns
• UPPER ROOT FORCEPS are similar in appearance, with narrow, straight blades
• UPPER PREMOLAR FORCEPS have slightly curved handles and single rounded blades
• UPPER LEFT MOLAR FORCEPS have curved handles, a beaked blade to the right of the instrument, and a rounded blade to the left to grip the buccal roots and the palatal root
• UPPER RIGHT MOLAR FORCEPS have curved handles and the beaked blade is to the left of the instrument
• UPPER BAYONET FORCEPS have extended handles and angled blades to gain access to third molars or have angled pointed blades to gain access to fractured roots
• LOWER ANTERIOR FORCEPS have single rounded blades at right angles to the handle that are particularly useful for extracting lower premolars
• LOWER ROOT FORCEPS are similar, with narrow and straight blades that are also particularly useful for extracting small or crowded incisors
• LOWER MOLAR FORCEPS have beaked blades to right angles to the handles, to grip the furcation of the two roots
• LOWER “COWHORN” FORCEPS have curved and pointed blades at right angles to the handles, to grip the furcation of lowar molar teeth
• SMALLER VERSIONS of most patterns exist, for deciduous tooth extractions

Question 11

PATTERNS OF ELEVATORS

Answer 11

• CRYER’S ELEVATORS are available as left and right patterns, but can be used on either side of the mouth, depending whether they are engaged mesially or distally - the tips are triangular-shaped and pointed
• WINTER’S ELEVATORS have a similar blade design as Cryer’s, but have a corksscrew style handle to give more leverage
• WARWICK JAME’S ELEVATORS are available as left, right and straight patterns - the tips are a similar shape to the round blade of forceps

Question 12

FUNCTION OF SCALPEL BLADE AND HANDLE:

Answer 12

• to make the initial incision through the full-thickness mucoperiosteum and around the necks of the teeth to create the flap

Question 13

FUNCTION OF OSTEOTRIMMER:

Answer 13

• to raise the corners of the flap off the underlying alveolar bone
• to scoop out any pathological debris from the bony cavity at the periapical area during an apiectomy procedure

Question 14

FUNCTION OF PERIOSTEAL ELEVATOR:

Answer 14

• to complete the elevation of the flap off the bone, by pushing the instrument over the bone surface beneath the flap and efffectively peeling it off the bone
• to be held lingually during a lower third molar surgical extraction, to retract the lingual tissue and protect the lingual nerve

Question 15

FUNCTION OF HANDPIECE AND SURGICAL BURS:

Answer 15

• to remove any alveolar bone necessary to gain access to the tooth or root
• to drill a notch between the roots of multi-rooted teeth, so that they can be seperated before extraction
• the handpiece and burs used during implant procedures are specialised for this purpose alone

Question 16

FUNCTION OF IRRIGATION SYRINGE:

Answer 16

• to irrigate the surgical field with sterile saline or sterile water, although the handpiece often ahs its own irrigation supply from the bracket table bottle
• the irrigation system used during implant procedures is supplied as a drip-type bottle of sterile saline, which connects directly to the handpiece

Question 17

FUNCTION OF AUSTIN AND KILNER RETRACTORS:

Answer 17

• to protect and retract cheeks, lips and tongue from the surgical field, providing clear access for the operator

Question 18

FUNCTION OF RAKE RETRACTOR:

Answer 18

• to hold and retract the mucoperiosteal flap itself, so that the immediate surgical field is clear

Question 19

FUNCTION OF BONE RONGEURS:

Answer 19

• to nibble away bony spicules and produce a smooth bone surface for healing

Question 20

FUNCTION OF DISSECTING FORCEPS:

Answer 20

• to hold the loose flap edges taut during suturing

- to hold and remove solid debris from the surgical area

Question 21

FUNCTION OF NEEDLE HOLDERS:

Answer 21

• to hold the pre-threaded needle firmly while suturing. some designs also have a dual function as suture scissors

Question 22

FUNCTION OF SUTURE PACK:

Answer 22

• half-moon shaped needle, pre-threaded with either black braided silk or a resorbable suture material such as vicryl, to suture the flap back into position over the alveolar bone

Question 23

FUNCTION OF SUTURE SCISSORS:

Answer 23

to cut the suture ends after each stitch, using the notched blades

Question 24

COMPLICATION THAT MAY OCCUR UNEXPECTEDLY DURING THE PROCEDURE ARE:

Answer 24

• NERVE DAMAGE - by trauma during instrumentation
• UNEXPECTED TOOTH FRACTURE - especially if the tooth is heavily filled or root-filled, and this may result in a simple extraction becoming a more complicated one
• ACCIDENTAL TOOTH LOSS - either into the respiratory or digestive tracts or out of the mouth, and as a result of it slipping out of the operator’s grip while pushing the tooth out of the socket or lifting it out of the mouth
• HAEMORRHAGE - primary haemorrhage is normal during extraction and surgical procedures, but a damage to a local blood vessel may cause unexpected and profuse bleeding
• ORO-ANTRAL FISTULA - due to a perforation of the maxillary sinus lies over their roots and is often only seperated by a membrane which can be easily perforated
• PATIENT COLLAPSE - due to medical emergency
• EQUIPMENT FAILURE - either actual faliure or loss of the electricity supply

Question 25

ACTIONS TO TAKE IN EVENT OF - NERVE DAMAGE:

Answer 25

this may be identified as witnessing the actual cutting of the nerve during the procedure by the operator, but it can also occur by careless soft tissue retraction by the dental nurse, causing trauma to the nerve, the actions are:

• use the correct retraction technique at all times
• do not remove or adjust the retractor without informing the operator first
• be prepared to retrieve any additional instruments and equipment that the operator may require

Question 26

ACTIONS TO TAKE IN EVENT OF - UNEXPECTED TOOTH FRACTURE:

Answer 26

this will be identified by the snapping of the tooth (often audibly) and its disintegration into pieces; the actions are:

• collect all loose pieces with the aspirator and remove them from the mouth
• reassure the patient
• be prepared to retrieve any additional instruments and equiment that the operator may require
• be prepared to proceed to a surgical procedure

Question 27

ACTIONS TO TAKE IN EVENT OF - ACCIDENTAL TOOTH LOSS:

Answer 27

this may be identified as witnessing the actual loss from the operative field at the time; the actions are:

• if it is visible in the mouth, apsirate and remove it from the mouth
• help to locate it if it was seen to come out of the mouth
• assist the patient if they begin choking, as the tooth is inhaled
• monitor the patient to see if they swallow it, and confirm this with them
• reassure the patient

Question 28

ACTIONS TO TAKE IN EVENT OF - HAEMORRHAGE:

Answer 28

this will be sudden and either red and spurting if an artery is involved or purple and welling if a vein is involved; the actions are:

• apply immediate pressure to the area, using gauze
• aspirate to clear the field if possible, while still applying pressure
• reassure the patient
• be prepared to retrieve any additional instruments and equipment that the operator may require
• be prepared to fetch help

Question 29

ACTIONS TO TAKE IN EVENT OF - ORO-ANTRAL FISTULA:

Answer 29

this will be identified by the sudden visual loss of the tooth from the socket; the actions are:

• assist the operator if requested to do so
• be prepared to retrieve any additional instrument and equipment that the operator may require
• reassure the patient

Question 30

ACTIONS TO TAKE IN EVENT OF - PATIENT COLLAPSE:

Answer 30

this will be identified by monitoring the patient to notice any skin colour change, any alteration in their breathing, that they have slumped in the chair, that they have become unresponsive; the actions are:

• determine the cause of the collapse from the signs and symptoms
• carry out the necessary basic life support techniques
• be prepared to fetch help

Question 31

ACTIONS TO TAKE IN EVENT OF - EQUIPMENT FAILURE:

Answer 31

this will be identified by the item’s malfunction and may be accompanied by electric flashes or burning smells, or be as simple as a blocked aspirator tube; the actions are:

• stop using the equipment immediatley
• switch off the appliance and disconnect it from the mains
• reassure the patient and ensure their safety
• unblock the aspirator if possible
• check to determine if a duplicate portable item can be seconded from elsewhere, or if a spare surgery s availible
• abandon the procedure if it cannot be safely completed without the item

Question 32

POSTOPERATIVE INSTRUCTIONS:

Answer 32

postoperative instructions are given to advise the patient on how to avoid disturbing the blood clot, and how best to look after the wound to encourage healing, and should include the following points:

• pain, swelling or bruising may occur after the procedure - this is especialy likely after a surgical procedure and is quite normal
• analgesics (except aspirin) may be taken as required - these may be started as soon as the patient arrives home, if required
• alcohol, hot drinks and excersice should be avoided for 24 hours after the procedure - all of these activities make loss of the bllod clot more likely
• food can be taken once the local anaethtic has completely worn off, nut should be kept away form the wound and should consist of bland foods only on the day of the procedure
• patients who smoke should be advised to refrain from doing so for at least 24 hours after the procedure - smoking make the disintegration of the blood clot more likely and then a post-operative infection will occur
• no mouth rinsing should be carried out on the day of the procedure - this will wash out the blood clot and result in reactionary haemorrhage
• hot salt water mouthwashes should be carried out after each meal, from the day after the procedure for up to 1 week later - these will wash away any food debris from the wound and encourage the soft tissues to heal
• if bleeding does occur, bite onto the moistened spare bite pack or a cotton pack for up to 30 minutes, without removing the pack - in most instances this will succeed in stopping the bleeding
• give an emergency telephone number for care and advice if problems occur out of hours, and ensure they have the surgery number in case problems occur during opening hours
• give details of further appointments if necessary