Leukoplakias (also called keratoses; see Chapter 5). The diagnosis should be confirmed by taking a biopsy and sending it for histological examination prior to cryosurgery, in case it is a malignancy

Warts and papillomas

Mucus extravasation cysts (mucoceles)

Haemangiomas (see Chapter 5).

• Palliation (producing some relief) of:

Severe ulcers

Cancerous lesions.

Procedure

Liquid nitrogen (N₂) or nitrous oxide (N₂O) is applied to the diseased area. This is done either by spraying it directly or circulating it through a probe called a cryoprobe. The very low temperatures –about –70°C – achieved with liquid N₂ make this particularly useful in the management of intractable lesions. Liquid N₂ probes and sprays can cause full-thickness skin necrosis, and therefore must be handled very carefully.

• Local analgesia is given if required.

• The clinician ensures good contact of the cryoprobe with the lesion by coating it with a jelly such as KY jelly.

• The clinician freezes the lesion.

• The freezing is turned off. The cryoprobe is left on the lesion until it thaws and de-frosts.

• Multiple freezes, with thawing between each freeze, maximise the effect. The ice crystals formed in the tissue spaces between the cells kill the cells.

Laser surgery

Lasers can be used for surgery but can also damage normal tissues, especially the eyes. The hard laser, especially the carbon dioxide laser, is the most useful (see Subchapter 1.1).

Advantages

Laser surgery usually:

• Causes little bleeding. Haemostasis occurs during vaporisation to coagulate small vessels in the wound bed

• Is followed by less pain and swelling than that which follows surgical excision or cryotherapy

• Results in little post-operative scarring

• Is particularly helpful for surgery close to important anatomical structures, e.g. lesions affecting the floor of the mouth.

Disadvantages

Laser surgery usually:

• Is best conducted under general anaesthesia (GA)

• Requires expensive equipment

• Can damage the eyes, skin, mucosae and teeth.

Also, because laser light travels in straight lines, access to some lesions can be difficult.

Surgery Involving Hard Tissues (Bone and Teeth)

Bone and teeth are usually cut with rotating instruments (burs) in a surgical handpiece. This involves the production of heat, so simultaneous cooling by constant running sterile water or sterile saline (irrigation) is important. Air-rotors are less commonly used as they can contaminate wounds unless using a sterile coolant, and occasionally cause surgical emphysema (see Chapter 16). Laser and ultrasonic cutting are uncommonly used. Piezosurgery is a new but expensive technique that cuts only hard tissues, increasingly used in apical and implant surgery as the danger of damage to nerves or arteries or the sinus membrane is less. However, this kind of surgery can generate significant heat, and cutting is slower than with many high-speed drills.

Identify and Learn

Identify two surgical handpieces in your workplace. Note the fitted tube for irrigation.

Wound Closure

Incisions are usually an integral part of surgery. The wound thus created needs to be closed so that it heals by primary intention. The would is closed usually with cyanoacrylate tissue adhesive or tapes (e.g. Steri-Strip), or sutures (stitches) (Box 10.2). This results in a small line of scar tissue, which is the goal whenever a wound is closed. In some circumstances, an open wound is left to heal by secondary intention. In the mouth it is then protected by a dressing such as Coepak. Wounds in bone are sometimes protected by BIPP (bismuth iodoform paraffin paste), or Whitehead’s varnish (compound iodoform paint).

BOX 10.2 Closing a Wound

Skin Tapes

• Closure of skin wounds by adhesive tapes is convenient.

• It produces a strong wound with little infection and with good cosmetic results.

• The skin and wound should be thoroughly cleaned as above, and all bleeding within the wound must cease before tapes are applied.

• The tapes are left in place for seven to 10 days and then gently removed by traction.

Sutures

• Atraumatic needles are generally preferred.

• Monofilament materials are associated with a lower rate of wound infection compared with multifilament sutures.

• Sutures (stitches) are used for most:

Oral wounds – 3.0 Vicryl (resorbable) or black silk (non-resorbable but pliable and easily seen)

Facial wounds – 5.0 or 6.0 polypropylene or nylon

Other skin wounds – 3.0 nylon or Prolene (polypropylene).

Technique

The simple interrupted stitch is most commonly used because it allows good approximation of the wound edges, and is easy to place. Various other suturing techniques can be used. The surgeon will often ask the dental nurse to cut the stitch once placed.

1. Care of sutures

• Clean wounds twice daily with chlorhexidine 0.1% aqueous solution.

• Apply Polyfax ointment (antibiotics – polymyxin and bacitracin) twice daily to prevent scab formation, facilitate suture removal and reduce scarring.

2. Suture removal

• Facial sutures should be removed within three to five days, to keep scarring to a minimum.

• Mucosal sutures are usually resorbable, but otherwise are removed at five to seven days.

• Many patients are apprehensive and need reassurance.

• Clean the wound and surrounding mucosa or skin with aqueous 0.2% chlorhexidine.

• Lift the suture with sterile forceps and cut the stitch on one side, as close to the skin or mucosa as possible (this avoids pulling contaminated suture material through the wound).

• Pull the suture out using traction on the long end, across the wound so as to avoid pulling apart the edges.

• Clean the area again with an antiseptic solution.

• Remove alternate sutures first to see if wound has healed adequately. If yes, remove the remaining sutures a day later.

• If wounds tend to gape a little, use tapes (but not in the mouth).

Terms to Learn

Healing by primary intention: when the wound edges heal directly touching each other.

Healing by secondary intention: when the wound is left open to fill with granulation tissue, which will subsequently turn into scar tissue.

Key Point

The suture (stitch) should be cut about 5 mm away from the knot.

Find out More

Look at some wound closure materials in your workplace and try to think of a situation each of them could be used in.

Surgical operations: safeguards

Operating on the Wrong Patient

Causes

• Tiredness or lack of care.

• Notes attached to the wrong patient following emergency admission.

• Last-minute changes in operating lists.

Prevention

• Taking general care.

• Patients should have one identifying number, which should always be quoted on every paper.

• All patients should have a wristband.

• The wristband should bear the patient’s surname, forenames and accident or in-patient number.

• Providing the patient with a wristband should be the responsibility of the sister or their deputy, or, at night, by the nurse in charge or their deputy.

• All unconscious patients admitted through the accident department should be given a wristband before being taken to the ward.

• The surgeon or accident officer should see that unconscious patients are escorted by a nurse to the ward or theatre.

• The dental surgeon who is to operate should check the patient before operation; check that the medical or dental record relates to the patient; and ask the patient their name and the operation they are to have.

• The anaesthetist should check that the medical record relates to the patient.

• The operations list should carry the patient’s surname in full, forenames, hospital number, and the operation planned.

• The list should be displayed in the surgery or theatre, in the anaesthetic room, and in every ward which has a patient on the list or is to receive a patient from the list.

• When sending from theatre for a patient, the theatre porter should bring a slip bearing the surname, forenames and number of the patient.

• The ward sister or deputy should be responsible for seeing that:

The correct patient is sent to theatre

The patient has signed a consent form

The patient has received the prescribed pre-medications

Where appropriate, the side of the operation has been marked

The correct records and radiographs accompany the patient.

• In theatre, the theatre superintendent or deputy should be responsible for sending for patients.

• Day patients who are undergoing minor operations, and out-patients undergoing any operation under GA should be labelled in the same way as in-patients.

Operating on the Wrong Side or Area

Prevention

• It is the responsibility of the surgeon who explains the operation to the patient to witness the patient signing the correct consent form.

• The surgeon should mark the side or area with an indelible skin pencil before the patient is sent to theatre.

• Nurses should inform the operating surgeon if they find that a patient due to be sent to theatre has not been so marked, but they should not undertake the marking themselves.

• The words LEFT and RIGHT should always be written in full and in block letters, at least on operating theatre lists.

• When extracting teeth, especially for orthodontic reasons (where the teeth may not be carious), the clinician should count the teeth carefully, and double-check/confirm with a colleague. This elementary exercise can prevent the patient losing a tooth unnecessarily (which can become a medico-legal problem).

The role of a dental nurse in oral surgery

Before the Procedure

• Retrieve patient notes, radiographs, consent form.

• Prepare the dental environmental ensuring infection control.

• Prepare the surgical tray or trolley using an aseptic technique.

• Greet and reassure the patient in the waiting area.

• Ensure pre-operative advice has been followed.

• Inform the clinician of any changes/comment from the patient.

• Assist the patient to the dental chair.

• Provide the patient with protective equipment (bib and glasses).

• Provide a bowl with water for dentures.

Basic Surgical Tray (Figure 10.4)

Instrument	Purpose
Scalpel blade (Nos 11,12,15)	To cut the flap
Scalpel handle (e.g. Swann Morton)
Mitchell’s trimmer	To raise the flap
Periosteal elevator (e.g. Howarth’s)	To raise the flap and protect soft tissues
Surgical handpiece	To remove bone or cut tooth
Surgical selection of burs
Retractors: flap; cheek; tongue	To retract flap for visibility to operative site, and protect tissues
Surgical aspirator	To remove saliva, blood, water and debris
Irrigation syringe	To irrigate the site with sterile saline or water
Suture	To reposition and fix mucoperiosteal flap
Needle holders	To hold the suture needle
Rat-toothed tissue dissecting forceps	To hold the flap while suturing
Suture scissors	To cut sutures
Gauze swabs
Cotton wool rolls

After the Procedure

• Provide a mirror and tissues for the patient to wipe their face and assist if necessary.

• Assist patient to the recovery room or waiting area.

• Ensure the patient has another appointment and has the post-operative instruction sheet.

• Make a follow-up appointment as required.

• Decontaminate the environment and sterilise instruments.

• Dispose of the local anaesthetic needle in the correct sharps container.

• Dispose of the clinical waste in the yellow bags.

Extraction of teeth (exodontia)

Instruments Used

Figures 10.1–10.3 show a selection of forceps and elevators used for extraction of teeth, both straightforward and impacted teeth. Figure 10.4 shows a selection of other surgical instruments.

FIGURE 10.1 Forceps for extracting deciduous teeth: (A) upper straight; (B) upper root; (C) upper molar; (D) lower root; (E) lower molar.

FIGURE 10.2 Forceps for extracting permanent teeth: (A) upper straight; (B) upper root; (C) upper right molar; (D) upper left molar; (E) bayonet; (F) lower root; (G) lower molar.

FIGURE 10.3 (A) Warwick James elevators; (B) Coupland chisels; (C) Cryer elevators.

FIGURE 10.4 A selection of surgical instruments and items.

Identify and Learn

Write down the names of all the items shown in Figure 10.4 and get it checked by your supervisor.

Extraction of Deciduous Teeth

There is seldom a case for the removal of only one deciduous tooth, unless it:

• Is close to being shed naturally

• Has been retained so long that it impedes the eruption of its successor

• Is infra-occluded.

Term to Learn

Infra-occluded: a tooth whose incisal edge or occlusal surface appears ‘sunken’ in comparison with the rest of the teeth in the arch. So for an upper tooth this would mean the incisal edge or occlusal surface is ‘higher’ than the rest of the teeth, and in the lower teeth it would appear to be lower down. Conversely, teeth can also supra-occlude (over-erupt) in comparison with the rest.

Enforced extractions of deciduous canines or molars are usually balanced by extraction of a contralateral tooth in the same arch. This is to prevent a centre-line shift. Radiographs are usually taken to ensure that there are no other problems (e.g. a midline supernumerary tooth), which may also require attention.

Extraction of Permanent Teeth

Many orthodontic treatments require the extraction of premolars. However, in some patients there may be indications for the removal of a different tooth.

Checks Required Before Extraction of a Tooth

• Check that the name of the correct tooth to be removed is written down clearly in the notes.

• Check that the patient (or in the case of a child, both patient and parent) understands that a permanent tooth is being removed – and the reason for removal.

• Check that any orthodontic appliance (see Chapter 11) that is meant to be worn is being worn satisfactorily before orthodontic extractions are performed.