BASIC DENTAL EXAMINATION SETUP
a. The Setup. The basic dental examination setup (figure 1-13) consists of a mouth mirror, cotton pliers, explorer, periodontal probe, cotton dispenser with cotton, Two by two inch gauze pads, and a saliva ejector. This equipment is used in almost every dental treatment procedure. The water and air syringes are frequently used to remove debris and fluids from tooth surfaces so that they may be examined more accurately. A good light source is also essential to adequate vision in performing any oral diagnostic procedures.
b. The Sterile Pack.
(1) Certain instruments are required for each type of dental procedure. In order to facilitate the work being done, these instruments can be prepared in advance. Possibly days, or even weeks, before the actual operation is performed, the dental assistant can wrap the proper instruments in a pack (usually paper or muslin) and autoclave them. These sterile packs can then be stored and used whenever necessary. This method will save both time and space in the dental clinic. The pack used most frequently contains the basic examination instruments, with the exception of the saliva ejector. These could be prepared long in advance since a basic examination is common procedure for all types of dental work. Remember, though, that the type of material in which the instruments are autoclaved determines how long they will remain sterile.
(2) The instruments found in the basic examination sterile pack is the explorer, (number 6, number 17, or number 23), the mouth mirror, the periodontal probe, cotton pliers, and 2x2-inch gauze pads.
Figure 1-13. Instruments and materials for basic examination.
1-13. MEDICAL HISTORIES
a. General. Any dental examination includes taking and recording the patient's medical history. The medical history may be brief or detailed, depending upon the findings and observations made during the examination. The history consists mainly of information pertinent to the conditions revealed during the examination and is obtained from the patient from questions asked by the dental officer. A medical history should be updated at every appointment.
b. Importance of Medical Histories. The following are four important functions of patient medical histories:
(1) Provide important information that assists the dental officer in arriving at a diagnosis.
(2) Provide information on conditions that might lead to complications during treatment procedures if not previously recognized.
(3) Establish good rapport with the patient.
(4) Provide a good opportunity for patient education.
c. Taking and Recording Histories. Pertinent information brought out while taking the patient's history should be recorded in writing. In taking a history, the dental officer often has an established routine, which he conscientiously follows so that no possible information is overlooked. He may take brief notes and later write the summary to be recorded or transcribed as part of the patient's record.
d. Ethical Aspects. Information given by the patient to the dental officer is confidential and is used to enhance professional care. The dental specialist will not reveal confidential information to any person not concerned with the patient's medical or dental health.
e. Medication. The dental officer, during an initial examination and before starting any dental treatment, routinely asks a patient if he is taking any medication. If so, a notation is made on the record as to the type and amount of drug being taken. Special considerations in providing dental treatment and in prescribing additional drugs will be determined from this information.
f. Medical Treatment. During a dental examination, the dental officer asks the patient if he is under medical treatment and, if so, for what particular condition. This will enable the dental officer to determine the best plan for dental treatment.
g. Systemic Conditions. There are a number of oral manifestations of systemic diseases, if discovered while taking the medical history, which must be considered carefully in planning and carrying out the course of treatment. Because of physical standards for active military duty, these conditions are not as common in the military community as in other segments of the population. Some of these conditions, including potential dangers and precautions to be taken, are as follows:
(1) Congestive heart failure. Patients with congestive heart failure have hearts that have been weakened to the extent that they can no longer fulfill the body's demands. A physician is usually consulted before oral surgery or other dental treatments are performed.
(2) Rheumatic heart disease. Rheumatic fever is a disease that may affect the valves of the heart. Heart valves that have been damaged (rheumatic heart disease) by rheumatic fever are susceptible to infections from bacteria, which may be forced into the bloodstream during extraction of teeth or other dental procedure. Should a patient with a history of rheumatic fever require dental care, the dental officer normally will consult the patient's physician and institute prophylactic antibiotic treatment before performing the indicated treatment.
(3) Coronary artery disease. Patients with coronary artery disease (disease of the arteries that supply blood to the heart) may experience pressure or pain in the chest called angina pectoris. Pressure or pain occurs when narrowing of the coronary arteries prevents adequate oxygen to the heart muscles. Attacks may be brought on by nervousness and physical or emotional stress. Patients with a known history of angina pectoris should be treated only after every precaution has been taken to minimize nervousness and stress. Usually a physician is consulted before these patients are treated. The patient who has angina pectoris usually carries his own supply of nitro- glycerin.
(4) High blood pressure (hypertension). The dental officer normally will consult the patient's physician before surgery or any extensive dental treatment on a patient with elevated blood pressure. Premedication, selection of the anesthetic agent, and the duration and nature of anticipated surgery or dental manipulation all require careful consideration.
(5) Diabetes mellitus. Diabetes is a systemic disease in which the body is unable to utilize sugars in the diet because of the lack of insulin in the system. Diabetes may be controlled by periodic injections of insulin, oral medication, or diet, depending on its severity. Periodontal disease is often associated with uncontrolled diabetes. Special consideration must be given in performing surgery or any dental treatment on diabetics because of their tendency to bleed easily and their high susceptibility to infections. The dental officer normally will not perform extractions on uncontrolled diabetics unless the patient's physician assumes responsibility and supportive measures have been employed.
(6) Hemophilia. Hemophilia is a rare hereditary condition appearing in males. In hemophilia, there is profuse bleeding due to an inadequate clotting mechanism resulting in prolonged uncontrollable bleeding, even from the slightest cut. Any necessary surgical procedures should be done only with the cooperation of the patient's physician to minimize and to control bleeding.
(7) Pernicious anemia. Pernicious anemia is a severe form of anemia characterized by lowering red blood cell count, weakness, and other forms of debilitation. One frequent early symptom is a painful, fiery red inflammation of the tip and sides of the tongues. The wearing of dentures or any other mild mechanical irritations cannot be tolerated by some patients with pernicious anemia.
(8) Allergy and hypersensitivity. Patients may be allergic or hypersensitive to any of a number of drugs or materials used in dentistry. The dental officer must take a thorough history, so that he may avoid the use of drugs and materials to which the patient may have an unfavorable reaction.
(9) Hyperthyroidism. Hyperthyroidism is a disease in which the thyroid gland is abnormally active and produces marked systemic effects. Among these effects are pronounced nervousness and emotional instability, cardiovascular changes, weakness, and other symptoms. Extensive or painful oral operations or the use of agents containing adrenalin is contraindicated in the active hyperthyroid cases. The patient's physician normally will be consulted before an oral operation is performed on the patient. The hyperthyroid patient on adequate medication can become a well-stabilized dental patient.
(10) Hepatitis B. Patients with active hepatitis, or who are carriers of the Hepatitis B virus, can infect the dentist, staff, and other patients. To reduce risk to everyone, strict barrier protection procedures must be enforced (masks, gloves, gowns, and protective eyewear) along with strict aseptic techniques. Hepatitis is a very debilitating disease and causes death in a small percentage of the cases. Therefore, it is recommended that all dental personnel receive the heptavax vaccine to eliminate risk of infection with the Hepatitis B virus.
(11) HIV Infection. Human Immunodeficiency Virus (HIV) infection, or AIDS as it was originally called, causes death by destroying the patient's immune system. More simply, the patient dies from an infection because the body's defense system does not work. This virus is very difficult to transmit from one person to another. A dental care provider cannot contract an HIV infection through daily contact at the workplace. The HIV infection enters the bloodstream by having sex with an infected person or by shooting drugs with a needle or syringe that has been used by an infected person. If you work on an HIV positive patient, the patient is many more times at risk than you are. The reason is the their immune system cannot easily control new and different infections. It is important, then, to have extremely strict aseptic procedures before, during, and after patient care. This reduces the risk to the HIV patient and the possibility of risk to other patients and the dental care providers.
ORAL EXAMINATIONS
a. Classification. Direct examination of the teeth and oral tissues is the procedure used most in determining the status of oral health. Four classifications are used to describe the dental health of active duty service members. Dental classifications are described in more detail in AR 40-66, Medical Record and Quality Assurance Administration.
(1) Class 1. Personnel who require no dental treatment.
(2) Class 2. Personnel whose existing condition is unlikely to result in a dental emergency within 12 months.
(3) Class 3. Personnel that require dental treatment to correct a dental condition that is likely to cause a dental emergency within 12 months. Class 3 includes patients who have deep caries, a fractured tooth, or pericoronitis (infection around a wisdom tooth).
(4) Class 4. Personnel who have missed two annual exams or whose status is unknown.
b. Records. As in all patient treatment areas, the dental specialist in the oral medicine and treatment planning service should assure, when treating the patient, that the correct records for the patient have been provided. As the dentist conducts the examination, he will state his initial findings and the dental specialist will record these findings on applicable charts and sections of the various forms used. The dental specialist in the oral medicine and treatment planning service must be proficient in recording examinations and know the provisions of publications which cover prescribed forms, authorized terms and abbreviations, methods of recording, and dental classifications.
RADIOGRAPHS (X-RAYS)
a. General. Radiographs are indispensable aids in diagnosing many conditions existing within the teeth, bone, or tissues that are not apparent on clinical examination. Information revealed by radiographs includes the following:
(1) Infection and abscesses within the bone and about the roots of the teeth.
(2) Size and shape of roots of teeth to be extracted.
(3) Carious lesions, which cannot be detected in other ways.
(4) Condition of the periodontal bone.
(5) Condition of teeth and bone that have been considered for the support of fixed or removable prosthodontic appliances.
(6) Presence of impacted teeth, supernumerary teeth, or retained roots.
b. Recording Radiographic Findings. Radiographs are usually completely processed before they are interpreted. This often takes place after the examination. If emergency treatment is indicated, the dental officer may request a "wet reading." At such times the radiographs are processed enough to obtain suitable image for interpretation and diagnosis, and remain attached to the radiograph hanger. Radiographs that have been completely processed and mounted are interpreted by the dental officer, when he is not engaged in examination or treatment procedures. The dental specialist must see that the radiographs are properly mounted and available for the dental officer for interpretation and must be able to record radiographic findings on dental health records. Radiographs should be kept in the dental health record until they are no longer needed.
STUDY CASTS
a. Definition. Study casts are another aid in examination and diagnosis. They are plaster or artificial stone casts poured in accurate impressions of the dental arches. These are often mounted on an anatomic articulator (articulator which may be adjusted to reproduce the movement of the jaw).
b. Function. Study casts are used to:
(1) Permit study of alignment and occlusal relationships of the teeth outside the confines of the patient's mouth.
(2) Permit coordinated study of the teeth and radiographs after the patient has left the office and the radiographs have been processed and dried.
(3) Provide a duplication of the mouth, which is useful in consultations with other dental officers.
(4) Provide a permanent record of oral conditions as they existed prior to treatment.
(5) Provide a media upon which proposed treatment procedures, such as spot grinding for occlusal equilibration or the fabrication of prosthetic appliances may be studied.
GENERAL
a. Introduction. Following the basic examination, the anesthetic is administered, when required. There are a few situations, such as an oral prophylaxis, in which an anesthetic is not necessary. However, in most restorative or surgical procedures, the dental officer will administer some type of anesthesia.
b. Uses. Anesthesia is the loss of sensation. It may be partial or complete. Certain drugs are used in dentistry to achieve anesthesia for the prevention of pain during surgical and restorative procedures. Local anesthesia, or anesthesia limited to small areas of the body, is used for most dental operations. General anesthesia, or insensibility of the entire body, is sometimes used for extensive oral surgery and cases in which local anesthesia is contraindicated. See paragraph 1-13 for systemic conditions requiring special precautions during anesthesia and surgery.
c. Local Anesthesia. Local surface (topical) anesthesia may be achieved by application of certain drugs to the skin or mucous membrane. (See figure 1-14.) Examples are: Xylocaine® (lidocaine hydrochloride) and Benzocaine® (ethylamine benzoate). Another type of agent used for topical anesthesia is known as refrigerants (ethyl chloride). These are sometimes employed to relieve gagging tendencies during dental operations and to anesthetize the tissues over an abscessed area before incision for drainage. For local anesthesia of deeper tissues, such as the nerves of teeth, muscles, and alveolar bone, an anesthetic solution is injected into soft tissues.
Figure 1-14. Materials for application of topical anesthetic.
INSTRUMENTS FOR LOCAL ANESTHESIA
a. Anesthetic Syringe (Syringe, Cartridge) (figure 1-15). The anesthetic syringe is designed to support and expel anesthetic solution from a commercially prepared glass cartridge called a Carpule™. (The trademark name is Carpule.) The cartridge syringe available for local anesthesia has a thumb-ring handle at the outer end and a harpoon at the cartridge end of the plunger. The harpoon is designed to engage the rubber stopper plunger of the cartridge. The thumb-ring is used to draw back on the plunger to determine whether the needle has penetrated a blood vessel. This procedure is called "aspirating," and the syringe is an aspirating syringe.
Figure 1-15. Anesthetic syringe (aspirating).
b. Disposable Needles (Needles, Disposable). Disposable needles are packaged to keep them in a sterile condition. Once used, they are discarded. They are attached to the syringe by a plastic hub, which is part of the disposable needle. They are supplied in lengths of thirteen-sixteenths of an inch and one and three-eighths of an inch. Disposable needles are always sterile, always sharp, and less likely to break than other needles. Hypodermic needles should be disposed of in such a way that they cannot injure clinic personnel or will not be available for pilferage or theft.
ANESTHETIC INSTRUMENT SETUP
a. Sterilized Instruments. As in the basic examination, the anesthesia also requires a certain setup. (Look in Annex A for typical instrument setups for various dental procedures.) One instrument in the setup that always requires autoclaving is the syringe. The other items are sterilized by the manufacturer and packaged in this condition.
b. The Topical Anesthetic. The first item in the setup is topical Xylocaine®. This anesthetic is produced in a jelly-like or ointment form. It is most often used to anesthetize the area where the actual injection is to be made. Two-inch by two-inch gauze or cotton tip applicators will be necessary when administering topical Xylocaine®. A small amount is placed on the applicator and applied over the area to be injected. The purpose of this topical anesthesia is to lessen the discomfort to the patient during the actual injection.
c. The Syringe. The syringe (side-loading cartridge syringe) is the only item in the setup that will require autoclaving after each patient. This syringe is used to administer local anesthetics. Syringe needles are the disposable type. The length and gauge needle used will vary depending on the preference of the dental officer. You will be handling two different needles: an infiltrative and a conductive needle. The infiltrative needle is 13/16" long and is used for maxillary injections. It is used to anesthetize a small area of possibly two or three teeth. The conductive needle is 1-3/8" long. Block injections are made with this, anesthetizing an entire area.
d. Local Anesthetics. Currently, two types of local anesthetics are available through routine supply: lidocaine hydrochloride (Xylocaine®) with epinephrine (1:50,000 to 1:100,000); and mepivacaine hydrochloride (Carbocaine®) without epinephrine. These types can be identified by their stopper color and by the color of their containers. For example: lidocaine hydrochloride with epinephrine, one part to fifty thousand, is recognized by a green stopper and green stripe on the container; lidocaine hydrochloride with epinephrine 1:100,000, has a red stopper and a red striped can; and mepivacaine hydrochloride has a white stopper and a brown container. The epinephrine is the controlling factor as to how long the anesthetic will last. The more epinephrine, the longer the area will stay anesthetized. The epinephrine is a vasoconstrictor that causes the tissue around the capillaries to swell and thus constricts the capillaries and slows the blood flow. The decreased blood flow slows diffusion of the anesthetic throughout the body thus prolonging its action. It also aids in controlling bleeding.
e. Aspiration Required. The assembly and usage of the aspirating syringe is quite simple. The syringe is equipped with a device enabling the dental officer to determine if he is injecting into the blood stream. The accidental injection of the agent into the circulatory system may produce undesirable symptoms or death. Notice the thumb ring and the barbed plunger. The barb penetrates the rubber stopper of the anesthetic cartridge, permitting aspiration when the dental officer retracts the syringe plunger by means of the thumb ring.
f. Instrument Setup. For the instrument setup for local anesthesia, see figure 1-16.
Figure 1-16. Instrument setup for anesthesia.
PROCEDURES
a. Loading the Syringe. When a disposable needle is used, the plastic hub is threaded on to the syringe without breaking the seal or removing the outer protective plastic cylinder. The first step is inserting the proper needle. The next step is to withdraw the plunger of the syringe and insert the Carpule™ (cartridge) of the anesthetic. After inserting the Carpule™, release the plunger and secure the barb in the rubber stopper by striking the thumb ring in the palm of the hand. The protective cylinder may be removed at the discretion of the dental officer. This usually will be done after the Carpule™ of anesthetic solution has been and inserted just before the injection is made. The needle and hub are discarded after use, following standard precautions, and in accordance with local policy.
b. The Injection.
(1) When the dental officer is ready to inject the anesthetic solution, he will dry the injection area with 2-inch by 2-inch or 4-inch by 4-inch gauze. He may then apply an antiseptic solution to the area with an applicator. The tissue is then ready for the injection. The specialist may hand each item to the dentist as needed and receive them from him as each step is accomplished. The dental specialist will be expected to assist by retracting tissues, reassuring the patient, and observing the patient for signs of fainting or any other reaction to the anesthetic.
(2) Local anesthetics are undoubtedly the most frequently used drugs employed in the practice of dentistry. The local anesthetic most commonly used in the Army is Xylocaine®, also called lidocaine hydrochloride (two per cent concentration with epinephrine 1:50,000 or 1:100,000). The manner of packaging these anesthetics, in disposable cartridges, makes their use in the dental syringe quick and simple. Anesthetic needles come in different gauges and lengths. The long needle is used primarily for "block" type injections and the short needle for infiltration type injections; however, the long needle may be used for both types. The 25-gauge, long needle is the one provided in the dental field kit.
c. Possible After Effects. Although the techniques are followed, and drugs are used which have a very high margin of safety, and equipment is used which is efficient and easily sterilized, complications do occur. The most common is syncope (fainting), which is caused by cerebral anemia (which is usually psychogenic in nature), and normally lasts from 30 seconds to 2 minutes. If the patient does not injure himself (that is, by falling or aspirating a foreign body and obstructing his airway), no problem of any consequence will arise. Syncope is treated by placing the unconscious patient in the shock position, using a cold, damp towel on his forehead, and/or allowing him to inhale the irritating fumes from an ammonia ampule. Occasionally, allergic reactions to the drugs used may arise, but these are extremely rare.
THE DENTAL ASSISTANT AS AN ASSISTANT IN ORAL SURGERY
In addition to some general clinical duties, the dental assistant in oral surgery performs a number of specialized duties. The nature of many of his duties will depend upon his capabilities, the technical procedures followed by the dentist, and the ways in which the dentist wishes his assistant to participate. The effective assistant is the one who takes an interest in his work and tries to become familiar with instruments, equipment, procedures, and techniques. He establishes rapport with patients, maintains personal and area cleanliness and appearance, and anticipates and carries out the dentist's needs so that unnecessary delays are avoided. Thorough familiarity with instruments and materials used for specific operative procedures is of particular importance in the oral surgery section. One reason for this is that surgical setups are commonly prepared, packed, and autoclaved ahead of time. From an examination of the patient's record, the experienced oral surgery assistant can usually determine what instruments and materials will be required for the operation and have them ready when needed. Many oral surgeons perform certain operations in a surgical operating room of a hospital, often using general anesthesia. The dental assistant may be expected to perform preparatory procedures, assist in surgery, and clean the operating room after surgery. Therefore, he must be familiar with pertinent basic and local hospital operating room procedures
ASEPSIS AND CLEANLINESS
Because surgical procedures expose susceptible areas of tissues to invasion by bacterial organisms, strict attention must be paid to cleanliness and aseptic techniques. All instruments, equipment, dressings, and medication must be carefully sterilized and protected from any contamination that might later be introduced into a surgical site. Possible sources of contamination must be minimized through continual attention and adherence to cleanliness of area, equipment, and personnel. Any time we deal with open wounds, proper sterilization and handling of instruments cannot be over emphasized.
Before using these instruments, they should be properly sterilized and maintained in a sterile condition throughout the operation. The sterile instrument forceps should always be used when transferring sterile instruments from one point to another. A sterile towel should be under all instrument setups. When the operation is completed, the instruments should be washed thoroughly. If they are not to be sterilized immediately, they should be thoroughly dried to prevent rusting.
EXTRACTION FORCEPS
a. General. Extraction forceps are used in the removal of teeth. Variations in these instruments are caused by differences in root shape, size, number, alignment of the tooth, and location in the mouth. Except for those designed for some specific operations, forceps generally follow certain basic principles. They are distinguished by the angles of the beaks, the notches on the beaks, the contour, and the number engraved on the forceps.
b. Maxillary Anterior Forceps.
(1) Forceps number 65 is a bayonet-shaped forceps with pointed nibs used primarily to remove crowded maxillary incisors and root fragments (figure 3-1).
Figure 3-1. Forceps No. 65.
(2) Forceps number 150S is an S-shaped forceps designed for maxillary anterior and bicuspid teeth and roots (figure 3-2). The Universal Forceps number 150A also is S-shaped and used to extract all maxillary teeth.
Figure 3-2. Forceps No. 150S.
(3) Forceps number 286 is a bayonet-shaped forceps (figure 3-3). It is used primarily for extracting maxillary anterior teeth and roots. It may be used for bicuspids.
Figure 3-3. Forceps No. 286
(4) Forceps #1 (Winter) is no longer in the Medical Supply Catalog, but you may see it in clinics.
c. Maxillary Posterior Forceps.
(1) Forceps number 150S may also be used for maxillary bicuspids.
(2) Forceps numbers 53R and 53L are bayonet-shaped forceps designed for maxillary first and second molars. Number 53R is designed for teeth on the right side of the maxillary arch, number 53L for teeth on the left side (figure 3-4).
Figure 3-4. Forceps numbers 53R and 53L.
(3) Forceps number 210 has a hooked handle. It is a bayonet-shaped forceps designed for maxillary third molars (figure 3-5).
Figure 3-5. Forceps number 210.
d. Mandibular Anterior Forceps.
(1) Forceps number 151S is a canoe-shaped universal forceps used to extract all mandibular anterior teeth (figure 3-6).
Figure 3-6. Forceps number. 151S.
(2) Forceps number 203 is used for extracting mandibular anterior teeth, bicuspids, and roots (figure 3-7).
Figure 3-7. Forceps number 203.
e. Mandibular Posterior Forceps.
(1) Forceps numbers 151S, and 203, as noted above may be used for mandibular bicuspids. See figures 3-6 and 3-7.
(2) Forceps number 15 has a hooked handle (figure 3-8). It is designed for mandibular first and second molars.
Figure 3-8. Forceps number 15.
(3) Forceps number 222 has L-shaped beaks. It is designed for mandibular third molars (figure 3-9).
Figure 3-9. Forceps number. 222.
(4) Forceps number 217 has cow horn-shaped beaks and a hooked handle (figure 3-10). It is designed for mandibular molars.
Figure 3-10. Forceps number 217.
(5) Forceps number 16 is generally obsolete, but you may see it in clinics.
ROOT ELEVATORS
Root elevators are instruments designed to loosen or remove roots, root fragments, or teeth. As with forceps, a variety of designs are available to suit different teeth, techniques, and locations in the mouth.
a. Stout A Elevator. This elevator's nib is flat on one side and rounded on the other. The nib has straight tapering walls and a rounded end (figure 3-11).
Figure 3-11. Stout A elevator.
b. Straight Elevator Number. 34-S. This elevator is straight and shaped like a gouge (figure 3-12). In cross-section its nib is crescent-shaped. It is one of the most commonly used elevators.
Figure 3-12. Straight elevator number 34-S.
c. Straight Elevator Number 301. This elevator is similar in shape to but smaller than number 34-S (figure 3-13).
Figure 3-13. Straight elevator number 301.
d. Apical Fragment Root Elevators. These are used to remove apical root fragments (figures 3-14 and 3-15).
Figure 3-14. Miller root elevators numbers 73 and 74.
Figure 3-15. Apical fragment root elevators.
PERIOSTEAL ELEVATORS
Periosteal elevators are used to separate and raise periosteum from the surface of the bone and retract the tissue flap (see figure 3-16).
a. Woodson Plastic Instrument Number One. This is a restorative instrument often used as a periosteal elevator in oral surgery.
b. Spatula Number Seven. This wax instrument also is often used as a periosteal elevator. It is blunt on one end and pointed on the other.
c. Molt Periosteal Elevator Number Nine. This elevator has a curved, blunt blade at each end.
d. Seldin Periosteal Elevator Number 22. This elevator has a flat handle with a small blade at each end. The blades are angled and shaped to give easy access to all locations in the mouth. All edges are rounded slightly to avoid needless injury to the tissues.
Figure 3-16. Periosteal elevators.
CURETTES
Curettes are instruments designed to remove extraneous material from tooth sockets and other spaces in the alveolar bone. Their nibs are spoon- shaped and their shanks are angled to reach different areas of the mouth. Standard curettes include Molt curettes 1, 2, 4, (anterior) and 5L, 6R, 9L, 10R (posterior) (figure 3-17).
Figure 3-17. Curettes.
RONGEUR FORCEPS
Rongeur forceps are cutting instruments designed to cut and contour bone (figure 3-18). Springs located between their handles separate their beaks when closing pressure is not being applied. The dentist may ask for a single rongeur.
a. Rongeur number 1A is both a side and end cutting instrument.
b. Rongeur number 4A is a side cutting rongeur.
Figure 3-18. Rongeur forceps.
BONE FILES
Bone files are made in various sizes. They are used to smooth the edges of bone. Seldin bone file number 11 (figure 3-19) is double-ended, with the file surface at one end being larger than the file surface at the other end.
Figure 3-19. Bone file.
BONE CHISELS
Bone chisels are used to remove bone or section teeth. Some are designed for use with a hand mallet. Another type is driven by a special handpiece, described in paragraph 3-12 as an engine-driven oral surgical mallet. Chisels must be kept sharp to be effective.
a. Stout chisels numbers 1, 2, and 3 are straight bone chisels used with a hand mallet. They differ in the size of their blades.
b. Chisel points used with the engine-driven surgical mallet are made in different shapes, designed for various surgical procedures. These include two bone removing points, one unibevel and one bibevel, one gouge and two tooth elevator points.
SURGICAL MALLETS
The oral surgical hand mallet (figure 3-20) is a double-headed mallet resembling a gavel or wood mallet. The engine-driven oral surgical mallet (impactor) fits on the arm of the dental engine like a straight handpiece. It is equipped with five detachable impactor points.
Figure 3-20. Surgical mallets.
SURGICAL BURS
Specially designed surgical burs (figure 3-21) are used by many oral surgeons to remove bone and to groove teeth for controlled sectioning. They are made for both the straight and contra-angle handpiece. Steel bur number 41 is available for AHP or SHP. The tungsten carbide bur is available for SHP only. To avoid excessive heat while cutting, sterile water should be dripped over the bur.
Figure 3-21. Surgical burs.
SCISSORS
Utility scissors (figure 3-22) are ordinary scissors usually made of stainless steel and used for miscellaneous cutting. Suture scissors have curved, small blades and are used to cut suture material in the mouth. Tissue (saw-tooth) scissors have long curved handles and short serrated jaws suitable for cutting soft tissue.
Figure 3-22. Scissors.
SURGICAL KNIVES
Surgical knives (figure 3-23) are used to cut soft tissue and incise localized abscesses. A surgical knife is comprised of a handle and interchangeable blades. Four sizes and shapes of detachable blades and three types of handles are available.
Figure 3-23. Surgical knife handle and blades.
SUTURE NEEDLES
Many different types of suture material can be attached to different shapes and sizes of needles. Suture needles are use to carry suture material through soft tissue which, when tied, will hold tissue parts together for initial healing.
Figure 3-24. Suture material and needle
GINGIVAL RETRACTORS
Gingival retractors are used to hold gingival flaps back and out of the way to expose operative areas. Thoma gingival retractors 1 and 2 are two-pronged, fork-like retractors. Instruments designed for other purposes, such as periosteal elevators (figure 3-16), are also used as retractors.
IRRIGATING SYRINGE
Irrigating syringes (figure 3-25) are used to wash pus, debris, and other extraneous material from tooth sockets, cavities, or inflamed gingival flaps. The tip is usually metal and should be blunt. If a syringe with a glass barrel is used, particular care must be exercised; the glass barrel could shatter if it is hit with a surgical bur.
Figure 3-25. Irrigating syringes.
DENTAL ASPIRATOR
The dental aspirator (figure 3-26) is an electrically operated vacuum suction unit used to maintain a clear operating field by removing blood, bone chips, debris, and other materials. The unit is fitted with a tube running from a vacuum bottle, which ends in a handle and suction tip. The handle fitted with a suction tip is controlled by the oral surgery assistant in the removal of extraneous material from the surgery site.
Figure 3-26. Dental aspirators.
DRESSING FORCEPS
Dressing forceps (figure 3-27) have the appearance of large tweezers. They are used to handle sterile dressings inside the mouth.
Figure 3-27. Dressing forceps.
SPONGE FORCEPS
Sponge forceps (figure 3-28) are large and doughnut-shaped nibs. They are used to handle sterile dressings or linen outside the mouth.
Figure 3-28. Sponge forceps.
INSTRUMENT FORCEPS
Instrument forceps have prong-like nibs resembling a knife and fork. They are used to handle sterile instruments.
Figure 3-29. Instrument forceps.
HEMOSTATS
Hemostats (figure 3-30) are small forceps designed to stop the flow of blood by clamping blood vessels. A hemostat is used for holding material and tissue.
Figure 3-30. Hemostats.
3-24. NEEDLE HOLDERS
Needle holders (figure 3-31) are forceps resembling straight hemostats. Each jaw has a groove on its inner surface, which is used to hold and manipulate the suture needle during suturing.
Figure 3-31. Suture needle holder.
NEEDLE HOLDERS
Needle holders (figure 3-31) are forceps resembling straight hemostats. Each jaw has a groove on its inner surface, which is used to hold and manipulate the suture needle during suturing.
TOWEL CLAMP
Towel clamps (figure 3-32) are small forceps with curved, claw-like jaws used to hold surgical drapes in place.
Figure 3-32. Towel clamp.
PREPARATION TO RECEIVE THE PATIENT
Preparation to receive a patient begins with the cleanup and sterilization of instruments used during the treatment of the preceding patient. All evidence of treatment of that patient should be removed. Traces of blood should be removed from the dental unit and instrument trays. The cuspidor, aspirator bottles, handles, tips, and tubes should be cleaned. Instruments should be scrubbed and either sterilized or set aside for sterilization. Linens, headrest covers, and bracket table covers should be replaced. The dental chair should be lowered and set in an upright position, with the bracket table and operating lamp pushed back, out of the way. The next patient's records and radiographs should be set out for the dentist to examine. A basic examination setup should be placed on the bracket table. Instrument setups, sterile towels, and dressings (as indicated by the dentist) should be on hand and their need anticipated.
PREOPERATIVE TREATMENT
In some cases, the dentist may wish the next patient to have some form of medication before surgery and may have the patient come in early for this purpose. The dental assistant may be expected to make a record of patients requiring such medication, notifying the dentist of the patient's arrival, reminding him of the need for medication, and recording the medications given. The oral surgery assistant should be familiar with the uses, doses, and effects of these and other drugs importa EXTRACTIONS
a. General. Extraction in oral surgery refers to the removal of teeth. That phase of oral surgery that deals with extractions is called exodontia. Teeth can frequently be removed simply through proper application of force using extraction forceps or elevators. Other teeth, because of the curvature of roots, the divergence of roots, and excessive cementum, called hypercementosis, density of bone, or alignment of the teeth, may be harder to extract. In these cases, the use of elevators, the removal of bone, the sectioning of teeth with burs or chisels, or combinations of these procedures may be necessary. Instruments and techniques used will vary with the tooth, with the presence of complicating conditions as described above, and with the techniques favored by the dentist.
b. Instrument Setups.
(1) Uncomplicated extraction. See figure 3-34.
Figure 3-34. Instruments and materials for uncomplicated extraction.
(2) Surgical extraction and bone removal. See figure 3-35.
Figure 3-35. Instruments and materials for surgical extraction and bone removal.
REMOVAL OF IMPACTED TEETH
a. General. Impacted teeth are those that are so located and inclined within bone that they fail to erupt and cannot erupt normally. Impacted teeth may be completely embedded or partially erupted. Mandibular third molars (wisdom teeth) are the most commonly impacted teeth. Impaction of other teeth may occur, with the maxillary third molars and cuspids most frequently observed. Supernumerary teeth, retained roots, and foreign bodies embedded in the jaws present problems of location and removal similar to those encountered with impacted teeth. Surgical extraction involving bone removal is often necessary.
b. Instrument Setup. The instrument setup for the removal of impacted teeth is similar to that for surgical extraction and bone removal.
PREPARING INSTRUMENT SETUPS
A working knowledge of oral surgical procedures is a necessity for the dental specialist. The nature of the work done in oral surgery requires that everything that may be needed during an operation be available immediately. The dentist will be at the chair-side with the patient; therefore, it is imperative that the specialist understands the operation and is able to recognize instruments in order to save time.
a. Variation in Procedures. Procedures followed in sterilizing, storing, and preparing instruments for oral surgery will depend upon the desires of the oral surgeon, the extent and volume of surgery done, and the facilities available. Most oral surgery services have sterilizing facilities adequate to handle all their needs; others must depend upon medical service sterilizing facilities for autoclaving. Some oral surgeons have complete sets of instruments and materials autoclaved in packs to meet the needs of each commonly performed surgical procedure. Some have the items sterilized and stored separately but have them assembled into sets before each operation. Others have just the minimum number of instruments set out and additional ones obtained as needed. In some oral surgery services, the sterile items are stored in cabinets. In others, they are stored on shelves or on tables covered with sterile drapes. In any case, aseptic procedures must be carefully followed to maintain sterility. Scrupulous cleanliness of the oral surgical suite is an absolute necessity to prevent any contamination.
b. Steps of Procedure. In arranging the surgical tray or other work areas, the first step is to drape the area with sterile (autoclaved) towels. The next step is to lay out the instruments and other materials in the order in which they are to be used. The final step is to cover the setup with a sterile towel until the dentist is ready for its use
ALVEOLECTOMY
a. General. Alveolectomy is the contouring of alveolar bone. It may be done to smooth the bone after removal of teeth or other surgery, to contour irregular ridges, to remove bone undercuts, or to increase the space between the maxillary and mandibular ridges before the fabrication of dentures.
b. Instrument Setup. See figure 3-36.
Figure 3-36. Instruments and materials for alveolectomy.
FRACTURES
a. Treatment of Fractures. Definitive treatment and care are normally performed by the oral surgery service of a hospital's department of dentistry. In treating any fractured bone, the objective is to bring the fragments of bone as near to their normal relationship as possible and to immobilize them in that position long enough for a bony union to occur and normal function to return. In most fractures of the jaw, proper apposition of the fragments can be achieved by restoring teeth to their normal occlusal relationship with teeth of the opposing jaw. Immobilization may be achieved by any of several methods. The most common method is to apply wires or special arch bars to the teeth in each jaw to provide hooks for the anchorage of small rubber bands. The rubber bands are stretched from hooks of one jaw to those of the other jaw in such a way as to maintain the correct occlusal relationship of the teeth by elastic traction. Some fractures are immobilized by metallic or acrylic splints made to fit over the teeth. Some are held in position by wires passed through the bone. Other fractures may require complex means of immobilization or even bone grafts or prosthetic restorations to correct defects.
b. Postoperative Treatment. Following fracture reduction, the postoperative treatment during the weeks of immobilization may consist of:
(1) Daily evaluation of the efficiency of the chosen method of immobilization.
(2) Irrigation of the patient's mouth to aid in oral hygiene.
(3) Instruction in methods of good oral hygiene and the use of a device that delivers a pulsating stream of water, if one is available.
(4) Instruction in the use of a child's toothbrush to aid in oral hygiene.
ASSISTING DURING SURGERY
a. Operative Techniques. One of the most helpful procedures performed by the dental assistant in oral surgery is the manipulation of the suction apparatus or the use of gauze sponges in such a way as to keep the surgical field free of blood, saliva, and tissue while interfering as little as possible with the view of the dentist. To perform oral surgery properly, the surgeon must be able to see the tissue he is manipulating. Other ways in which the oral surgery assistant helps to afford good vision of the operative site is by keeping the operating lamp adjusted for maximum illumination, by wiping blood and other material from the mouth mirror as it accumulates, and by careful retraction of cheeks, lips, and other tissues. Efficiency of the operation is further enhanced by keeping the instrument tray in order, removing instruments and materials no longer needed, preparing other instruments and materials for use before needed, and being ready to take each instrument as the dentist finishes using it and to replace it with the one he will need next. The assistant must also learn how to use the surgical mallet. Proper malleting technique requires working with the dentist in a coordinated rhythmic pattern and knowing how much force to apply, at what angle the mallet must strike the chisel, and when to begin and when to discontinue malleting. During the placement of sutures, the assistant will be expected to help by cutting the suture material after each knot is tied.
b. Caring for the Patient. The oral surgery assistant should be ever mindful of the patient, seeing to his comfort and preventing accidental soiling of his clothes. During surgical procedures, the assistant should carefully observe the patient for signs of syncope (clammy or pale skin and lips) or apprehension and notify the dentist of the change. When surgical procedures are prolonged, he can often lessen the patient's discomfort by supporting his head and mandible. When the operation is completed, the oral surgery assistant should remove blood and other traces of the operation from the patient's face and lips. Before the patient is dismissed, the assistant should be alert to remind the dentist of needed postoperative instructions or medications and to re-emphasize the dentist's instructions to the patient
POSTOPERATIVE CARE OF THE PATIENT
a. Dismissing the Patient. The patient should not be dismissed until blood or any other evidence of the operation has been removed from his face or lips. He should receive the necessary postoperative instructions and medications and future appointments, if needed. If he has been given medication that leaves him with incomplete control of his faculties, someone should take them home. This should be arranged beforehand. The dentist may want to detain the patient in the clinic for observation or recovery.
b. Suture Removal. Following surgery, the patient will be instructed in home care. Generally, he is instructed not to rinse on the day of surgery, in order to avoid disturbing the clot. The following day he should rinse gently with warm salt water to promote healing. He will receive exact instructions concerning any medication that he is to use. Another appointment is given at least 48 hours later for the removal of sutures. Other special instructions may be given as well, and he must always receive instructions to return to the clinic as soon as possible if any complications develop. The specialist should observe the patient postoperatively until all instructions have been given to the patient and he has left the clinic. Many dentists will ask dental assistants to remove sutures. See figure 3-37 for steps of suture removal.
Figure 3-37. Suture removal.
