How to Extract a Tooth
Many of our readers are often surprised that a medical doctor and nurse devote a portion of their writing to dental issues. Few people who are otherwise medically prepared seem to devote much time to dental health. History, however, tells us that problems with teeth take up a significant portion of the medic’s patient load. In the Vietnam War, medical personnel noted that fully half of those who reported to daily sick call came with dental complaints. In a long-term survival situation, you might find yourself as dentist as well as nurse or doctor.
The basis of modern dentistry is to save every tooth if at all possible. In the old days (not biblical times, I mean 50 years ago), the main treatment for a diseased tooth was extraction. If we find ourselves in a collapse situation, that’s how it will be in the future. If you delay extracting a tooth because it “isn’t that bad yet”, it will likely get worse. It could spread to other teeth or cause an infection that could spread to your bloodstream (called “sepsis”) and cause major damage. Like it or not, a survival medic, will eventually find himself or herself in a situation where you have to remove a diseased tooth.
Tooth extraction is not an enjoyable experience as it is, and will be less so in a long-term survival situation with no power and limited supplies. Unlike baby teeth, a permanent tooth is unlikely to be removed simply by wiggling it out with your (gloved) hand or tying a string to it and the nearest doorknob and slamming. Knowledge of the procedure, however, will be important for anyone expecting to be the medical caregiver in the aftermath of a major disaster.
Before we go any further, I have to inform you that I am not a dentist, just an old country doctor. Please note that this is an introductory article, and that tooth extraction can be a complex procedure. Also note: It is illegal and punishable by law to practice dentistry without a license. The lack of formal training or experience in dentistry may cause complications that are much worse than a bum tooth. If you have access to modern dental care, seek it out.
The anatomy of the tooth is relatively simple for such an important part of our body, and is worth reviewing. The part of the tooth that you see above the gum line is called the “crown”. Below it, you have the “root”. The bony socket that the tooth resides in is called the “alveolus”. Teeth are anchored to the alveolar bone with ligaments, just like you have ligaments holding together your ankle or shoulder.
The tooth is composed of different materials:
Enamel: The hard white external covering of the tooth crown.
Dentin: bony yellowish material under the enamel, and surrounding the pulp.
Pulp: connective tissue with blood vessels and nerves endings in the central portion of the tooth.
To extract a permanent tooth, you will, at the very least, need the following:
A dental extraction forceps (#150A is a good general one for uppers and #151 is reasonable for lowers; they get much more specialized for each type of tooth, however).
A periosteal (meaning “around the bone”) elevator instrument to loosen the ligaments holding the tooth in place.
A typical dental elevator ->
Gauze or cotton rolls or squares and a “pickup” forceps or tweezers.
A very cooperative patient or a good local anesthetic.
Proper positioning will help you perform the procedure more easily. For an upper extraction (also called “maxillary extraction”), the patient should be tipped at a 60 degree angle to the floor and the patient’s mouth should be at the level of the medic’s elbow. For a lower extraction, (also called a “mandibular extraction”), the patient should be sitting upright with the level of the mouth lower than the elbow. For right-handed medics, stand to the right of the patient; for left-handers, stand to the left. For uppers and most front lower extractions, it is best to position yourself in front. For lower molars, some prefer to position themselves somewhat behind the patient.
To begin with, you will want to wash your hands and put on gloves, a face mask, and some eye protection. Floss the teeth and give the patient an antibacterial rinse. Keep the area around the tooth as dry as possible, so that you can see what you’re doing. There will be some bleeding, so have cotton balls or rolled gauze squares available. These may have to be changed from time to time if you place them between the cheek and gum.
The teeth are held in place in their sockets by ligaments, which are fibrous connective tissue. These ligaments must be severed to loosen the tooth with an elevator, which looks like a small chisel. Go between the tooth in question and the gum on all sides and apply a small amount of pressure to get down to the root area. This should loosen the tooth and expand the bony socket. Expect some bleeding.
Take your extraction forceps and grasp the tooth as far down the root as possible. This will give you the best chance of removing the tooth in its entirety the first time. For front teeth (which have 1 root), exert pressure straight downward for uppers and straight upward for lowers, after first loosening the tooth with your elevator. For teeth with more than 1 root, such as molars, a rocking motion will help loosen the tooth further as you extract. Once loose, avoid damage to neighboring teeth by extracting towards the cheek (or lip, for front teeth) rather than towards the tongue. This is best for all but the lower molars that are furthest back.
Use your other hand to support the mandible (lower jaw) in the case of lower extractions. If the tooth breaks during extraction (not uncommon), you will have to remove the remaining root. Use your elevator to further loosen the root and help push it outward.
Afterwards, place a folded gauze on the bleeding socket and have the patient bite down. Occasionally, a suture may be required if bleeding is heavy. In a recent Cuban study, veterinary super glue (N-butyl-2-cyanoacrylate) was used in over 100 patients in this circumstance with good success in controlling both bleeding and pain. Dermabond has been used in some cases in the U.S. for temporary pain relief, but more research is needed.
Expect some swelling, pain, and even bruising over the next few days. Cold packs will decrease swelling for the first 24-48 hours; afterwards, use warm compresses to help with the inevitable jaw stiffness. Also, consider antibiotics, as infection is a possible complication. Liquids and a diet of soft foods should be given to decrease trauma to the area.
Use non-steroidal anti-inflammatory medicine such as Ibuprofen for pain. Some recommend staying away from aspirin, as it may hinder blood clotting in the socket. The blood clot is your friend, so make sure not to smoke, spit, or even use straws; the pressure effect might dislodge it, which could cause a painful condition called Alveolar Osteitis or “dry socket”. You will see that the clot is gone and may notice a foul odor in the person’s breath. Antibiotics and warm salt water gargles are useful here, and a solution of water with a small amount of Clove oil may serve to decrease the pain. Don’t use too much clove oil, as it could burn the mouth.
In a long-term survival situation, difficult decisions will have to be made. If modern dentistry is gone due to a mega-catastrophe, the survival medic will have to take on that role just as he/she may have to take on the role of medical caregiver. Performing dental procedures without training and experience, however, is a bad idea in any other scenario. Never perform a dental procedure on someone for any reason, if you have modern dental care available to you.
Here are some very useful links and references:
(slideshow on extraction techniques – important to review)
(an extraction performed at Mt. Everest base camp – note positioning of the dentist, use of the opposite hand for support, and improvisations)
(guide to extraction forceps and procedures)
Use of N-butyl-2-cyanoacrylate in oral surgery: biological and clinical evaluation. (Cuban Study)
Clínica Estomatológica Docente de Bauta, Provincia Habana; and Centre of Biomaterials of Havana University, Havana, Cuba.
N-butyl-2-cyanoacrylate based tissue adhesive, Tisuacryl, was employed as a nonsuture method for closing wounds in oral surgery. One hundred thirty patients were treated with the adhesive and 30 with suture. The surgical procedures were apicectomy, extraction of molars, and mucogingival grafting. The studied product was well tolerated by the tissue and permitted immediate hemostasis and normal healing of incisions. When Tisuacryl was used as dressing material for donor sites and mucosal ulcerations, pain relief was observed.