Emergency dental for rural GPs

Chantelle: Welcome to the fourth webinar of the rural health webinar series.

Just one moment.

There we go. So welcome to our fourth webinar in our new rural health webinar series: Emergency dental for rural GPs. So this webinar will be presented by Associate Professor Tony Skapetis.

We'd like to start with an acknowledgement of country. RACGP would like to acknowledge the traditional owners of the lands on which this event is being broadcast and we pay our respects to their elders past and present. RACGP Rural would also like to thank our sponsor Access Telehealth. Access Telehealth provides GPs with free access to bulk billing specialists who conduct patient appointments via video. They have a wide range of specialists available and manage the entire process via a secure software platform. We greatly appreciate their support of this webinar series. 

I'd also like to quickly go over a few tips on using the webinar platform. You should be able to see a control panel like the expanded image to the left of your screen. If you can only see a few icons like the image on the far left, please click on the red arrow to open the control panel. The control panel provides you with the tools to select your audio options and is also the place to ask questions during the webinar. Those of you who have logged on will be using the mic and speakers option shown in the image on the screen.

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Now this webinar has been accredited for 2 category two QI&CPD points. In order to gain these points, we just ask for you to be present for the duration of the webinar and we would also ask you to complete the evaluation activity that will pop up at the conclusion of the webinar.

Now, the learning outcomes for this evening’s webinar are currently on screen but before handing over to our presenter I just want to let everyone know that a copy of this webinar presentation is also available in the handout section for you to download for your future reference. I'll now hand over to Tony.

Associate Professor Tony Skapetis: Chantelle, thank you very much and thank you to RACGP. More importantly thank you to all of you people that are listening and I sincerely hope we can add or illuminate a little bit about what to do in the mouth and really get some of the dental presentations. Now, I guess the first thing is we want to start to make sure that we've got some baseline knowledge and that may help you record some of your digital presentations and your dental problems.

And, the first thing is how do we describe teeth appropriately in the mouth? And, most of us would sometimes use words like a central incisor and this or that but the most correct way to do it is to use a two digit numbering system. This particular numbering system that you're seeing on screen is from the International Dental Federation and it's the most widely used system certainly throughout the world. The only problem is that if you do come across some of the emergency medicine, especially textbooks like the American ones, they will have a similar two-digit number existence, but the numbers are on different teeth. So please just ignore anything that's American, it will be a bit different to this. So, how does the numbering system work? And how will you remember this?

Very simple. If you think when someone presents with some facial injury you’d normally start to do a primary survey. And, if you remember that most people are right-handed. So this numbering system starts from the upper right-hand side of the person's head. The numbers start first of all with permanent teeth. No one's been able to tell me why you would start the numbering system with the teeth that appear after but nonetheless it does start with permanent teeth. So, every tooth in the upper right hand side of that person's head begins with the number 1. The second number is where the tooth lies in relationship to the centre line. So the tooth on the upper right-hand side closest to the centre line would be not tooth 11, but rather 1, 1 (11). Tooth number 1 in quadrant number 1.

As you move around in a clockwise direction we go to quadrant 2, quadrant 3. And, the lower right-hand side or the teeth line there would be quadrant number 4. And, the last permanent teeth or permanent tooth in each quadrant will be tooth number 8.

So, for example in quadrant number 2 would be 2, 8 (28). At the end if we're talking about moving towards deciduous teeth, and that's probably the best term you call them – primary teeth, baby teeth, milk teeth, first teeth, but deciduous or primary teeth are probably the most accurate terms.

The upper right-hand side, we start there and it becomes quadrant number 5. So 5, 1 (51) would be the tooth on the upper right-hand side closest to the centre line. And moving posteriorly, the last deciduous or primary tooth in quadrant number 5 would be 5, 5 (55) so four fives are twenty. There's 20 deciduous teeth in a child's mouth.

And you might say, ‘Hold on, this gets a bit complicated. How do I tell if there's a mix of both?’ Well, as a general rule, if the child is under 6, they’ll all be deciduous teeth. If the child is older than about 12, mostly you'll be seeing permanent teeth. It's only 6 to 12 you're going to get a mix of both of those numbers.

Okay Chantelle, next.

So here we've got an example of that mixed stage where this child probably would have been about 8 years old and I want to say probably, I should know better because this was my son, one of my sons when he was younger. But if you can see that we've got a combination of permanent teeth and deciduous teeth.

Now, you'll also see that the permanent teeth appear more yellow, and the reason why they appear more yellow is the thing that makes teeth up the most is a mineral material that's called dentine. Dentine is a yellow colour and it's coated by this thin two millimetre or so layer of very pearly white material when we smile that we see called enamel. It's the dentine that shines below, above the enamel that gives it that yellow appearance because there's more dentine in permanent teeth versus deciduous teeth they appear more yellow.

Now notice how in quadrant number 1, we've got a missing tooth. So what do you do if there's a missing tooth, you skip a number. If it looks like two teeth are missing, skip two numbers and so on.

Permanent teeth are wider and more yellow. Deciduous teeth are smaller and whiter.

Thanks next.

Now, this is a really good resource that you might want to use and this is a New South Wales Health government website, so you can trust it, and it's some of the material they have helped to put together. By all means you can, at your own leisure, have a look at this resource. Next, thank you.

So which anaesthetic should you use? If you're trying to numb something in the mouth you might be numbing it because of pain, you might be numbing it because there's some trauma and you want to do something about it, and more importantly like I said, the first thing about pain is don't underestimate how powerful getting someone out of pain is. You might say, ‘But hold on, why should I bother doing that? You know, I can't fix the problem. I am not a dentist. I can't do something about the teeth to actually definitively fix it.’ But, think about the situation.

Someone comes to your rooms, hasn't slept the last 2, 3 days because of an aching tooth ache. No pain killers seem to work for dental pain. If you can get them out of pain and get them out of pain especially for say 6 to 8 hours, they can go home, they can rest, they can sleep. They wake up. Suddenly the pain killers work better. They've had a chance to potentially seek dental treatment and bit more time. If there was a need to give antibiotics, they've had a bit more time to work. You change the course and the management of that pain by the person, so I really do encourage you guys to try anaesthetising inside the mouth when you get a dental presentation of pain. It really is amazing what you can do and it's not rocket science. It’s really quite simple and we'll cover that in a minute. 

So, as far as the anaesthetics that you should use, when you go to the normal dentist most of the time we're using just Lignocaine with adrenaline and that's great. It gives us one hour of numbing so we can go fix a tooth or what have you. But, it's probably not so good for someone that hasn't been able to sleep the last couple of nights. I suggest that you’d be using some Marcaine. Probably Marcaine plain. There's really no benefit using adrenaline unless you want some basic restriction at the same time. But Marcaine plain gives you quite an extended duration of anaesthesia. It really changes the course of how that pain is managed by the patient.

Next, thanks.

Now, hold on. Tammy, you're saying we can go in and start numbing inside the mouth. Sure, we numb the rest of the body, but after all the mouth is that part of the body we have this impenetrable halo, don’t we? You guys are happy to do anything - do spinal taps, do central lines. No problem. But once you get into the mouth, you think it's a different world and it's not. Quite simply, if you would even close your eyes and approach someone with a needle, as long as you don't get it in an eye in the orbit you’re pretty well safe. It really is almost foolproof. So let's have a look though at the evidence. We want to base our decisions on evidence and I'm certainly going to be trying to do that throughout the presentation. So have a look how safe it is. So this particular study looked at all sorts of dental anaesthesia that was done for non-surgical reasons. The reason why is that you don't want to include surgical activities because the surgery (for example taking wisdom teeth) that has got a morbidity attached to the actual surgical intervention itself. Not just the anaesthesia. So if you look at the safety margins here, look at this. There's one chance in a hundred and eighty-one million using Lignocaine that you can have a problem. Now, I think you've got a better chance of winning Powerball quite frankly. So then you might say, ‘But hold on you're saying Marcaine.’ And well, sorry. It doesn't drop a little bit. It's one in a hundred twenty four million.

It just goes to emphasise how safe giving general anaesthesia using these materials are. They’re super-duper safe. Now, let's have a look at some other literature and here it's reporting some nerve damage again, very low risks. We're talking about 160,000 but the interesting thing is that if you look at that study in more detail, they claim that the majority of those incidences were related to neurotoxicity because of a use of a material called Articaine, which is a an anaesthetic that's used. It is used reasonably popularly around the world. It's starting to get a bit of penetration here in Australia, but it's certainly not what you guys are going to be using. So I don't think you need to consider that. You should be focusing on the safety shown in that first study that I showed you.

Next. Thanks.

So how do we know? So, inside the mouth any tooth, if someone comes up with a toothache from the top and the top arch. Let's focus just on the front part of the mouth for the time being in the maxilla. You pull the lip back. Now, to make this injection a bit more comfortable you might want to put a bit of Lignocaine gel on the end of a Q-tip and just put the Q-tip cotton up there. Just let it sit there for a couple of minutes before you come and a load of the syringe and start doing this.

I recommend you use a 5ml syringe. Of all the sort of volumes I'm going to be talking about within the range, you don't really need any more than that. If you want to sort of really try to scare somebody you can use a 10 ml syringe, but it's not necessary. And as far as the needles go, it doesn't really matter.

If you're using something in the order of probably about 23, 25 gauge, around anything between about 14 and 20 millimetres is fine for these types of injections.

Now after you've numbed that tissue with a bit of Lignocaine gel (so this is that vestibule area), when you pull the lid back above the tooth you’re trying to numb, that deepest part of the gutter or vestibule, that's where you should have placed the gel. You take your needle and barrel, load it up with a couple of mls of solution.

So assuming you’re using Marcaine and let's just say you put 3 full mls in there, you then go in, penetrate with the needle and barrel parallel to the long axis of the tooth, two millimetres of penetration into the mucosa and two mls volume per tooth you're trying to anaesthetise and therefore adult doses. So, if I was trying to anaesthetise 3 teeth in the same quadrant, I'd probably put 2 mls above one. Skip the next one and do 2 mls above the third tooth and it will capture the one in between with just the 4 mls.

Next. Thank you.

So still applying that simple principle these are maxillary or posterior teeth further back. You would anaesthetise them in exactly the same way. You pull the lip back, aim for the deepest part of the vestibule or concavity formed out there with needle and barrel parallel to the long axis of the tooth. Two millimetres penetration of the needle goes into the mucosa and 2 mls volume of anaesthetic per tooth you’re trying to anaesthetise.

Thank you next.

Now what about in the mandible? Well, the mandible is a little bit different in that in the anterior part of the mandible the principles apply exactly the same. As you move further back in the mandible though, the bone surrounding the posterior teeth in the mandible tends to be thicker. So depositing anaesthetic just on the side tends not to work as well. It'll still work but not as predictably and as profoundly as I'll show you here at the front. So if you want to get predictable anaesthesia further back in the mouth, you can do it up to the age of about 12 or 14 year olds as long as the child is not too big. It will work using this same technique. As you move into adults where the bone now is thickening more you will get some anaesthesia, but not perfect anaesthesia.

There is another technique that is a little bit beyond of what we're doing within the time frames, but nonetheless as I said, this still will work. So, you pull the lip back. Assuming you've anaesthetised that area a little bit or prep the area with a bit of Lignocaine gel on the end of a Q-tip. After that you pull the lip back, needle and barrel parallel to the long axis of the tooth, 2 millimetres penetration and 2 mls volume of anaesthetic.

Now the other thing to keep in mind as you’ve anaesthetised the teeth, when you're putting this technique to use - same with the top lip as the bottom lip, you also anaesthetise the surrounding lip. So one of the usefulness of not only to manage some teeth into dental pain using these anaesthetic techniques is to consider if you've got a lip laceration in the upper lip or lower lip, to think - rather than injecting into the lip laceration distorting it and then trying to bring it all back together again, especially if it's through the Vermilion border, might it be better to pull the lip back, do this sort of technique (exactly what I've shown you) and then without distorting the orbital you can suture it now better. Just a thought. This works very well for lip lacerations this technique.

Next, thanks.

Now, let's move a little bit onto some other sorts of useful bits of information involving some injuries now. Now, this particular link that I put up there, and you'll be able to download a PDF and it has active links in the PDF as well. This particular link is very useful because it will give you access to a spreadsheet. It's a very valuable, useful spreadsheet that in the past until February of last year was free to everyone and it certainly was widely used. It's from the International Association of Dental Traumatology, which are the leading group in the world in relation to producing evidence based material for both clinicians and the public on how to manage trauma - dental trauma specifically.

Now unfortunately, they did have a bit of a financial squeeze and they subsequently as often as I said to you February last year, they license now access and for example, the Australian Dental Association to access it is paying 30 nearly $30,000 a year.

So this is a bit of a way to get to that material without obviously paying any of that money and it's certainly legal, and it's gives you just about the same material. So I really would advise you to just try out this link.

Next. Thank you.

So let's start firstly with deciduous teeth. Now an avulsion is where the tooth has come out of the mouth, that’s separated from the mouth. What do we do with deciduous teeth? Well, first of all, if you get a deciduous avulsion, we covered what sort of ages you’re likely to see that in. Now, it's very simple with deciduous teeth and generally with deciduous tooth injuries.

First of all, if you can reimplant it, you should never consider that when a deciduous tooth is involved. Permanent teeth. Absolutely. Let's re-implant it but deciduous teeth absolutely not because you might damage the permanent successor underneath and sometimes parents will be very pushy and ask you to try it anyway. Please resist and don't put it back in. You might damage the permanent tooth. Now, what about if the tooth is not actually completely avulsed but sort of hanging on there. Well, if the child can close their teeth together, their back teeth together. Therefore their by function, you know, they can eat. I really think you shouldn’t touch it.

If the tooth is interfering and the child isn't able to close the back teeth together and therefore eat or function. I think you should probably be extracting it.

So, you know how to anaesthetise now. If the child's younger, of course you would use less volume of anaesthetic and you just grab it with a piece of gauze or tissue and remove the tooth.

Now keep in mind that the gag reflex completely forms after about three years old. So, children younger than three are more predisposed to suffering inhalation. So if you can’t account for where the tooth has gone, you might want to consider a chest x-ray for young children. Really young children.

Now as far as what to you do as far as referring to the dentist. Well, if you've extracted the tooth that's not an issue. You might want to get the child to go to the dentist just to have a look at things in case there was some other injuries that you've missed. In short, these injuries certainly don't need too much management if you've managed it quite capably.

Next. Thank you.

So what about permanent teeth? What do we do with permanent teeth? Now permanent teeth are very time-critical so if we have an avulsed permanent tooth, you should consider putting it back in the mouth. So if you ever get that phone call where somebody says, ‘Look we're on the football field’ or something and the tooth has just been knocked out. ‘Dr, what do we do?’ You say to them ‘Take the tooth’ and you re-implant it. You then ask them to just get a tissue or a hanky. Just put it between their teeth keeping things together.

And, make sure they go somewhere where that tooth can be somehow supported or splintered in a better way.

If they've got a mouth guard as a lot to do in various sports, ask them to reimplant their tooth, put their tooth back in and then just put the mouth guard on top. It's a fabulous splint just in itself. Now, it's interesting what does the literature say? If you give that advice to people would they tend to re-implant their tooth and the answer is no. Most, about 83% will not re-implant their own tooth even given that that's the best advice to do so. Which means now you've got to think, well okay, how do I manage this tooth in the meantime whilst we transport that tooth somewhere to somebody that can do something for them?

So then we'll talk a little bit about that transportation medium in a minute. But critically if you can get them to re-implant their own tooth if possible. Now if they reimplant it back to front don't worry too much about it. It's interesting, not too long ago I was talking to a rural GP, this is a medical GP, who when he was young (he was now in his late 50s) had knocked out his two front teeth when he was about 17 or so during a sports injury.

He re-implanted his own 2 upper front teeth back in so that's the 1,1 (11) and the 2,1 (21) if you remember your numbers. He re-implanted them after having them knocked out and he said, ‘Tony, you know what, one of them when I re-implanted it I put it in back to front, and subsequently we could do cosmetic work on that. We could make any tooth look like anything else you want just as long as obviously you can pay for it. But, irrespective he put his tooth in back to front. And, he says, ‘Look, I've still got one of those two teeth. I lost the other one a few years ago.’ He said, ‘You won't believe the one that I’ve still got is the one I re-implanted back to front.’ So put it back in. As far as how soon do you put them back in or how soon do you put them in in their correct storage medium. The answer is as soon as possible. Teeth are very susceptible to drying. What happens is when the tooth is knocked out of the mouth it has these fibres on the root system called the periodontal membrane fibres or periodontal membrane. It's keeping these fibres alive during the period of transport until you re-implant the tooth that's critical, and these fibres or this periodontal ligament is very susceptible to dehydration. So strictly speaking if the tooth is left completely dry out of the mouth most of those periodontal ligament fibres are probably not viable now. So re-implanting the tooth back in the mouth or putting it in the right medium is critical ASAP.

Now you might say well, hold on. What if somebody leaves, doesn't get to put it in something, then finds the right thing after about 15-20 minutes, but then someone tells them, ‘No, you should put it in this.’ Then they do that. It gets to you after a couple of hours, can you still re-implant it? The answer is yes. I think if it's stored in the correct medium even the day after I will try re-implanting it.

But, tell the person that ‘Look, you did the right thing. But the fact that it was dry for quite a long time before you put it in the right medium and the fact that it's been in the medium for quite some time reduces its success rate.’ But nonetheless, I would re-implant those teeth anyway, as long as it was stored in the right medium. I will try. If it's stored dry for more than a couple of hours, I probably wouldn't.

Now splinting, we will talk a little bit about the splinting and as I said to you this can be done, but we're going to look at some of the things that you can do with just the things that you may have available to you in your rooms, or for example nursing department if some of you are doing a VMO or something like that at the local hospital. Any of these things where you do do something probably as far as re-implanting a tooth or something like that, you need to follow it up at the dentist as soon as they can. Now, if you're able to splint it with something more permanent, then you can probably follow it up one to two weeks later. If you're just doing something very simple like putting a mouth guard on top of it, it probably needs to go to the dentist if you can within the same day, or at least the next day to be managed.

Next. Thanks.

So, you get that phone call and the person says ‘No, I'm not happy to put it back in. What do I do with the tooth?’ You ask them to store it in one of the appropriate mediums. Fresh milk is great. Most people have access to fresh milk. Can it be long life milk? Yes, it can be. Can it be skim milk? Absolutely. So these are all evidence-based. Can it be chocolate milk? The answer is no. It’s not because of the sugar that's bad for you. Take notes. It’s not that. In fact, it's the osmolality that changes because of the chocolate flavouring. Can it be soy milk? Yep, it can be. It's not much good for anything else, although I was vegan at one stage, I’ve seen the light since then but soy milk is okay. It's actually as good as milk, fresh milk. Egg albumin is actually okay. So, can you break it, just break an egg and throw it into the egg white? Yeah, you can. The egg is sterile. And in fact, the albumen is essentially a hundred percent protein and it helps keep those periodontal membrane cells alive.

One thing I didn't mention earlier is that with any of these mediums just try to keep it cool. The number of teeth I've had to pull out of curdled milk due to our hot climate in different parts of Australia, you can imagine, and I'm sure all that extra bacteria doesn't do the periodontal membrane any good. I've yet to tell you whether it'll work when I pull a tooth out of an omelette because someone's put it in some egg white but one of these days I'll find out. Breast milk, very good. So, certainly seems to be good for everything else. So, very good but where you can find a willing lactating mother without getting an injury of your own is another story. A lot of people wear contacts and have the solution that they store contacts in. That's also very good. Saliva. Can you put it in saliva? And, some of the textbooks and other things will say to you put it into your patient's mouth and the answer is yes, you can do that, but it's not as good as milk because of the extra bacterial load.

The other thing is I have had times (a couple, only about two or three in the many years I've been practicing dentistry) where I've had patients actually swallow the tooth. So that's not much good. And, the other thing is I've had people bring it to me in saliva in a little container, which is what I suggest that you spit into the container put the tooth in. Now I always ask, ‘Look is that your saliva or somebody else's?’ and sometimes it’s their mate’s saliva. Unless they’re pretty close to them, you’ve got to worry about that. So their own saliva in a little container, they spit the saliva out and put the tooth in the container and bring it to you.

Water, no it's not good. It swells the periodontal membrane cells. It's not a good idea. Baby milk formula? A lot of parents that might have other children, young children where one of them suffers an injury, an avulsion injury, baby milk formula is also good. If you mix it up you can do it, and as well as powder milk, by the way, is exactly the same as long as you follow the instructions. Mix it at the right concentration. It's as good as a normal milk, fresh milk.

Next. Thank you.

Okay. So what do we do, what are the steps of managing the avulsion? We talked about the storage, we talked about the importance of trying to put it in the correct storage medium. We talked about putting it in as soon as possible.

So those of you that have ability to take an OPG, which is an orthopantomograph, by all means do that. Now, is an x-ray essential? The answer is no. What the x-ray will do is it can help you pick up potentially also a fracture, for example in the mandible, or a fracture in the maxilla if it was there. Also, if you're not sure whether it's a permanent tooth or a deciduous tooth, you can see that in the x-ray. For example, you would be able to see that the permanent tooth is underneath if you're trying to work out if that's a baby tooth or not.

You would anaesthetise. We've talked about how to do that now. You would take the tooth handling it from the crown part up. So you try to avoid touching the root. The reason why is soon as you touch the root you're starting to damage some of those periodontal membrane cells, that we said was so valuable that we want to keep healthy. Otherwise if we don't keep those cells alive when we reimplant it, these cells can't therefore reattach and heal.

So handle it from the crown. Then you should give it a quick rinse while handling it from the crown, give it a quick rinse with some saline, just flush the root if there's any bits of obvious dirt or something, give it a flush. Those of you that are very pedantic about cleanliness, you are not to try to say ‘I can see bit of dirt there and let me get a bit of gauze and scrub that dirt away.’ No, please don't do that. Obviously if there's obvious big blades of grass or a bit of glass or something, take it away. But don't try to clean it beyond giving it a good flush with some saline. Be careful to do that over the sink. I've done that. I've had a patient come in with he was about 17/18 with his mother. I've said ‘Look guys, if you're at here, this is after hours in an ED’ and said ‘Look, you're here. You've done all the right things. We're going to save this tooth, you know, you’ve come to an expert. I know what I'm doing. This is going to be great.’ and then after saying that I gave the tooth a rinse over the sink and it slipped out of my fingers and went down the drain. We subsequently also use that room for sexual assault and I thought we might use it as well. So, look - very embarrassing. Don't rinse it over the sink unless you've covered the sink up. I've covered cleaning with a bit of saline and then what about in the socket itself?

So give the socket a bit of flush with some saline, you grab the tooth which you've now rinsed under a bit of saline and running water and you reimplant the tooth into the socket. You then get the patient to close their back teeth together so that the tooth you've re-put into position isn’t interfering. It doesn't matter if it's hanging a little bit below the tooth next door or above the tooth next door, if it's a lower tooth. It doesn't matter if it's a bit to the left or to the right or a little bit rotated, it doesn't matter. Then you'll try some sort of splinting mechanism that we cover in a moment.

Next. Thanks.

So here's a bit of a pictorial view of what I was saying earlier. So after you've anesthetised, I'm just using a monoject syringe there with some saline. I'm flushing the socket to wash the blood clot out. Otherwise, if you find it hard to put the two through that coagulation their of blood, don't stick instruments up there to try to get the coagulum out, you're going to damage the socket or damage the cells that are up there because there's cells on the tooth root, but there's also sells up inside the socket.

After you've rinsed it with some saline handling it from the crown, you re-implant that tooth.

Next. Thank you.

So what about splinting? What can we do as far as splinting materials go? So assuming you haven't got really any other materials, what can you use? We talked about mouth guards. That's really great. That's handy. You slip a mouth guard on top. Now, a lot of people that have had braces have got these clear looking retainers and you can see it on the upper left-hand side of your slide.

That's our orthodontic retainer which helps maintain teeth during they wear them at night to hold their teeth back into position. But because they’re very accurately fitting you can use one of these as a split and they work very well. Now assuming you haven't got that either. Well, most of us have got a bit of blu-tac hanging around the house and I'll explain to you how I come about this. What is useful is rather than using foil as a lot of the textbooks say, just grab a bit of foil and roll it up and use it.

We've all got access to the back of our suture materials, you know our suture packs, if you open up one of the suture materials, Viper, Chromic or even just plain gut. Open a suture and that aluminium is just the right thickness. And if you cut a bit of a sort of a sausage out of it, I suggest that after you've reimplanted the tooth you get a bit of blu-tac, and now blu-tac is made by Bostic you can eat the stuff, that's totally non-toxic and we published on this. That's why I know about it and yellow-tac which is what you see in that picture is made by Selleys.

You can get this material just like plasticine, it's non-toxic. You can mould it a little bit around the tooth you've now repositioned or reimplanted and then you take the backing of that suture material and push it around and it doesn't fall off and it's a fabulous temporary splint for at least several hours whilst that person goes somewhere to get more permanent splinting done.

So the picture on that same slide on the right hand side lower shows the yellow-tac below and we now put the aluminium backing on top of that as this splint. Now, if you haven't got any of those as well, another thing is you'll be aware that people who have a colostomy bag would attach the bag with some adhesive. These are like adhesive pads that have got a backing to them.

They're totally non-toxic. If you cut again a small sausage size you can take this piece, peel the backing off after you've repositioned the re-implanted the tooth and you can mould it around. It sticks to the adjacent teeth and will keep the tooth there and it takes several hours before the stomahesive wafer actually melts. So that's very useful as a temporary splint as well. Now, if you're worried what the dentist is going to say, they're going to say, ‘Oh you shouldn’t have done this’ or ‘You should have used this other splinting material’ or you some of the fancy stuff that they've got. Well that's actually not evidence based.

The systematic review done here looked at all different types of splinting materials for all different types of injuries and found it really didn't matter what you splinted it with as long as you splinted it with something.

So just keep that in mind as well.

Next one. So, once you've taken a tooth, you’ve splintered it and you put it back into position, is there any particular post-operative instructions you would do? Well, bit of common sense. You want to transport that to get some more permanent splinting. That's the first thing that makes sense. Now. The other thing is, the next point here, I've talked about doxycycline. It's interesting that when you re-implant a tooth one of your biggest problems, we have as a sequelae of a re-implanted tooth or reposition is that the periodontal membrane when it's damaged it's the barrier that stops surrounding bone osteoclasts from actually eating into the root’s surface. And, that's just resorption and that process of resorption that is fundamentally underpinned by osteoclast activity, that's what destroys a lot of our re-implanted or repositioned teeth. Some of the studies are now saying that well, in their animal studies, unfortunately, I think that if we give some doxycycline it's not because of the antibacterial effect, but it's because it has an inhibitory effect on collagenase which is part of the osteoclastic pathway. And, by inhibiting the osteoclast, it tends to reduce the rate of root resorption, which is a good thing. So subsequently we say if you've done one of these it's an adult person because you don't want to get some tetracycline staining on their tooth. As long as the kids over about 12, 100 milligrams twice a day for seven days of doxycycline in order to help reduce the risk of resorption or root resorption. Chlorhexidine mouthwash – fabulous, an interesting thing. I've got a PhD student at the moment working with me that’s saying that maybe one of the upcoming things is we may be seeing using coconut oil may be as good as chlorhexidine. So watch that space. That's very interesting because chlorhexidine can stain the teeth if it's used for more than about two weeks and it tastes horrible and so forth, but at this stage let’s use chlorhexidine, that's what the evidence says. And, obviously they should eat a softer diet follow up with the dentist if they can.

Next. Thank you.

Now the next thing what happens if someone comes in and they've got bleeding from the mouth. Usually it's because they've gone to see the dentist that day. They might be on some blood thinners. Usually it'll be warfarin, maybe on clopidogrel as well. So what do you do with this situation now? I'm going to give you a recipe that works every single time. There's never been a case where I've had even people with on multiple different types of new oral anticoagulants as I said to you the warfarin that’s all sorts of levels, it will work every single time but don't take shortcuts. You've got to do the whole recipe as I am about to go through it. So the first thing is you anaesthetise, you use some lignocaine with adrenaline this time. You’d only need lignocaine because we don't want to get numbness for 4-6 hours, just a short time, but it's more the vasoconstrictor part that we want and where you inject is not where I mentioned earlier, but around the peripheries of the socket. 

So right around the peripheries of the socket you inject and maybe 4,5 points around the periphery of the socket. Put a little bit in that soft tissue surrounding that bleeding socket of some lignocaine with adrenaline. You'll see a blanche. Hopefully it'll slow a little bit down with that, but the point is, one you’re trying to numb it so we can suture it. Two is also you're trying to get the vasoconstrictor in there. Next thing, you take a bit of oxidised cellulose, which is Surgicel or a lot of you would be familiar with Kaltostat, which is in a lot of EDs. Just take a piece, cut a piece off. This is totally resorbable material and doesn't cause foreign body reaction and you pack it into the bleeding socket.

The next thing and that stabilises the fibrin clot. The next thing is I would be using some probably vicryl rapide 40 and take a suture needle and put a suture across the wound. Don't take too big a bite because if you take too big a bite your hip bone below because the socket, their bony socket around there around the bleeding site. So take a bite of about 2 millimetres, go across the bleed across the socket and all you're trying to do there is don't try to get primary closure. You won't be able to you're just tear tissues. So all you're trying to do is stabilise the stuff that you've put below. So you're trying to get a passive suture on top of it to help stabilise the Kaltostat of the Surgicel that you’ve put below, and the last thing take a tranexamic acid tablet that you've all familiar with, 500 milligram tablet, crush it in 10 mls of saline. You now have a 5% solution. Roll up a piece of gauze into a little square, dunk it into the solution that you've made up now of tranexamic acid, you put it above the sutured wound that's been previously packed with Surgicel or Kaltostat. It's obviously been anaesthetised before that with the vasoconstrictor and you ask the patient to bite down on that for 20 minutes. You will stop every single bleed that way. Then I normally give the rest of the tranexamic acid solution to the patient. So and with some spare gauzes just in case it uses a bit they can do that themselves at home.

Next. Thank you.

So, a couple of pointers about infections that might be useful to you. Now out of these two papers, I specifically picked these two papers only because they're both Australian papers and especially I recommend that you have a look at the second one which has some great algorithms of how to manage some dental problems as well. So really good paper and that's quite recent.

So I have a look at that if you get a chance. Next. Thank you.

So things to look at for with dental infections. Now, first of all, how has the progress of infection occurred? So for example, if someone comes up they've got some dental pain and it hasn't changed the last couple of days, a little bit of a swelling there - facial swelling that hasn't really changed much and it's been there three, four days. They're pretty healthy. They are a febrile they've got no comorbidities. They've just generally feeling not too bad except for the pain.

Well, probably I don't think you should give them some antibiotics. You should consider maybe controlling the pain the way we talked about, giving them some pain relief and encouraging them to seek some more permanent treatment, definitive treatment, but I don't think you should be reaching for a prescription pad. Comorbidities, of course, you know, that's something you really need to take into account. The same patient with several comorbidities, you may think, well I need I need to pay a bit more attention to you and may consider giving you antibiotics.

Yeah, what about the degree of swelling in the number of spaces? So if the swelling is singular space, it's only mild to moderate, it hasn't changed the last couple of days. Well that's going to be quite a different way of managing the swelling that presents itself in 24 hours. It's huge, the patient looks quite ill and you’re thinking, well, in the next 24 hours what's going to happen? It's spread potentially up and down the different spaces involved and even the airway. So yeah. Look at the number of spaces involved

The degree of trismus, assess that. Can the patient open their mouth? How wide can they open their mouth? Is there an airway issue? Now normally a person can open three fingers wide of their own fingers on a vertical way. Up to two fingers are still okay. Less than two fingers, you've now got a compromised airway and you should be considering this as an emergency.

Ability to protrude the tongue as you’re getting more posterior swelling towards the back of the mouth and especially in the floor of the mouth as well. You're going to find that the person can’t protrude their tongue, that's a bit of a warning sign as well. But you may have some airway involvement – dysphonia and dysphagia. You're pretty good with those things, you can see that could be spreading now through the pharyngeal spaces. And of course if the person had been given some antibiotics beforehand or a couple of courses hasn't worked, well, that may ring some alarm bells as well.

Next, thank you. I've got 15 minutes left. So what about when to use antibiotics? Now, you can read through this yourself. I'm not going to go through each individual case because I'm going to focus more on when not to use antibiotics coming up soon. So next. Thank you.

So a couple of highlights from some recent evidence. These are good papers for some strong evidence that there's insufficient evidence to suggest you should be giving antibiotics thinking that you're going to help with the pain and or the rates of infection when it comes to a dental infection. So there's not really good evidence to support that and also don't forget with antibiotic stewardship, the infectious disease people are always on our backs, you should be thinking that dental antibiotic prescribing also contributes to that you can see the evidence there.

Next. Thank you.

Choice of antibiotics. So again putting it a little bit in a summary, if the infection is less than three days old probably aerobic mostly so good old penicillin V will work best most of the time. Once the infection goes beyond three days duration, probably you’re starting to get anaerobes in there. I'd probably add some metronidazole. You can consider giving clindamycin not only for allergy patients, but because of its good bonding penetration, it also works on its own.

And, also consider this that even where there's a fair bit sometimes of antibiotic resistance, for example, this was a study that I showed you there. One of the studies looked at penicillin even with up to quite significant 37% resistant strains, the antibiotic still worked anyway despite that. Some of the recent literature saying maybe we should be considering using second generation cephalosporins with metronidazole in preference to penicillin because it has better, stronger activity against the beta lactams and the anaerobes.

And of course IV AB’s, you should know that but I've got that for reference next. Thank you.

So conclusions where you can drain it like anywhere else in the body, grab yourself a needle, puncture it if it looks like it's suitable for drainage. There's obvious looking like puss especially in the vestibule area, stick a needle into it.

Get some drainage, you would do that anywhere else, why not do it in the mouth? You know how to numb now to numb on either side of that swelling and try to puncture it. Following some treatment, the antibiotic duration is important and the type of antibiotic is really secondary. So don't get too bogged down on antibiotics and the choice of antibiotics, keep it simple, but make sure that the person tries to get some treatment or try to where you can puncture that swelling if you can.

Now some of the things that have been drummed into us. We should stop antibiotics early, no, you know, they say we should finish the whole course. Well, that's probably not true. And there's not good evidence to support that we should be giving antibiotics for a lot of these infections beyond two to three days and we certainly don't develop resistance strength.

And, the duration of antibiotics. So I've got here treatment depends on the clinical presentations the organism, source control and host response, and so fundamentally what that’s saying is the antibiotic choice should be dependent on the diagnosis and just because of this is febrile, that's not a diagnosis. That's a symptom, there should be a diagnosis.

Next. Thank you. So here are some references.

Now, please feel free to put any questions up. And while we're waiting. I'm just going to go through some of the questions that were put forward by some of you. Now. The first question here is, so Chantelle, I'm not sure, can participants actually see the questions or not?

Chantelle: No, they can't. So read the question out as well. 

Associate Professor Tony Skapetis: I guess. All right fine. So the first question is when babies are teething and in pain, is there any role for Lignacaine gel or some equivalent?

The answer is, look since the beginning of mankind we've all had teething and we've had some teething pain. I would suggest that probably I prefer not to use any sort of chemicals of any kind. I'd be preferring to use something like rusks, something that's cold that will help numb the pain and look the reality is everybody's gone through it for thousands of years. It's not going to harm them at the end of the day.

Now the next question, just wondering regarding dental avulsions. What if it's landed on a dirty surface like the ground of a sports field? Do I advise the patient to just re-implant it without trying to clean it?

Now the answer is no, you should tell them that look if it's obviously dirty they should just quickly run it under running water. Now just running it under running water, although I said not to store it in water, running it under running water for a couple of seconds is not a problem whatsoever. So just quickly run it under running water, but try not to handle it from the root before they re-implant it. That's the answer to that.

Now how many OPGs are allowed in six months?

Well, that's a very interesting question. I don't think I've ever come across it but why would you need to take so many OPGs in six months is a good question. I would say normally, look OPGs are big X-ray exposures that are quite large. I would say you can certainly take (if you really had to and you had a good reason) within 2 to 3 OPGs within six months, but that's got to be clinically relevant, and I can't see why you would need that many OPGs within six months quite frankly.

How should we manage a dry socket? Yes. Well, we were just talking about that. We might be doing this in another presentation. Maybe next year. Very quickly dry sockets. Incidence of dry sockets are somewhere between 1 and 4 percent. They occur usually 3 to 4 days, sometimes even up to 5 days post extraction. They are not an infection. They are a breakdown of the clot and it leaves the bare boning walls around and that's why they hurt a lot. They can smell a bit. So patients often will present saying, ‘Look I had this tooth removed because it was aching. The pain got better 2-3 three days later. Now I'm so much more pain than I even had before I took the tooth out.’ That's a typical dry socket. You open up, you see it looks white bare looking, nothing in it, maybe bits of food. What you should do with that is probably give it a good flush with some saline. What to do? We as dentists have some materials, some chemicals that we can put it on it.

Is there anything to say evidence based that can support something that you could do outside? Interestingly enough green tea - green tea bags. If you take a green tea bag, soak it in some warm water, put it on that area and leave it, and the patient could do that as many times as they want through the day has been shown to be quite effective. Especially after people have had a wisdom tooth surgery removal and was as effective as paracetamol.

So the only evidence thing base that I could say you use is to soak a green tea bag on top of a dry socket after you've probably flushed it a little bit, washed any food that's obvious in there when they present to you and I would use just some lignocaine with adrenaline just so you numb it a bit while you're doing it.

And now let's see, I may have missed this but how do you inject local anaesthesia into adult molars? So exactly the same way, you would pull the lip back, try to aim for the vestibule or the deepest part of the gutter that's formed down adjacent to that molar whether it be top or bottom 2 millimetres penetration, 2 mls volume, needle and barrel parallel to the long axis of the tooth.

Another question that came up. How long can we store the air valves too thin milk? Do we have to refrigerate it? The answer is that you should keep it cool. So by all means you can put it in the refrigerator. And by the way once ever I've received a tooth back that's actually come in an ice cube. No, that's not good. So yes, cool milk will keep it cool and I would say that if you do that, even if you get that tooth the day after I would re-implant it.

So how to manage sharp teeth? That's interesting, sharp teeth. Well again sharp teeth use a little bit of common sense and I have had this literally in the field where I say to them, ‘Look if you've got nothing else just take this off a little bit of sandpaper to smooth that or a nail file and smooth it and usually that won't affect anything that the dentist has to do.

Now that maybe not a perfect answer, but it's practical answer.

Any other questions guys, we've got a couple more minutes. Just fire off some questions that might be useful to you. It doesn't necessarily have to be directly related to well, hopefully dental.

What do you do with a chipped tooth? 

If it's a small chip, nothing quite frankly. if it's a larger chip, ask them to keep the tooth piece and take it with them to the dentist because sometimes we can glue these chips back. Beyond the level of what we're discussing today. And I do do quite a few other workshops where I show you how to repair those broken teeth if you've got some dental material, but from the point of view of if you haven't got anything there, I would suggest to you that you say look ‘I would just be so take the broken piece with you, try to avoid hot and cold things because that's going to make that broken or chipped tooth sensitive.’ And that's basically what I would do as far as the emergency management.

Now what about drugs for dental pain?

Interestingly for drugs for dental pain, the first thing is the most common cause of paracetamol overdose resulting in ED presentations around the world is because of dental pain and then popping paracetamol, so interestingly enough, so be careful with paracetamol. Generally, with dental pain a lot of things don't work.

Well, if I was to say what works the best and evidence-based, I'd be saying that I tell the patients to take the normal standard dose of paracetamol assuming they have got obviously stomach ulcers or bleeding issues. I also asked them to take the standard dose of neurofen at the same time. So they ignore that they taking the two lots of drugs, rather they take both as if they were taking them independently and that seems to combat the pain the best way.

Now if the amalgam falls out from the tooth, what should we do? 

Well again within the limits of what we've got I would say to you that as an interim, I'd get a bit of blu-tac and put it in there. Get a bit of chewing gum and put it in there. At least it's stopping more food going in there. It's stopping the hot and cold going in there. It's not going to fix it, but it's at least something and I think it's probably the safest thing to use.

 What are the other dental emergencies you recommend GPs be equipped to deal with? 

Well, look, I think with your scope of practice you should do a lot more. Now, normally I was just saying to Chantelle who's coordinating this, I've just come back from teaching down in Victoria (in rural Victoria) where we spent six hours with some doctors teaching them with some basic materials how they can literally repair broken teeth, fix up polyps that are exposed, re-implant teeth, splint teeth permanently. You can do heaps of stuff. Of course, you can control pain, all those sorts of things you should be able to. I don’t think it's beyond the scope of what we can expect a rural GP to do just given a little bit of help on how to do it. 

Next one. What's the evidence of clove oil in the cavities?

None. So cloves are not so good. So, although we do use cloves in some older materials , dental materials, we used to mix some of the filling materials that we used to use and you could remember those if you are older. As soon as you walked in a dental surgery, you could smell it by the clove oil but there's really no good evidence that we probably should be putting clove oil. Some people will say ‘I have a bit of scotch and so forth.’ That probably helps because only because they've drunk it and it's gone down.

But, look again I think you should be concentrating on a combination type of analgesics where you're giving them some paracetamol and giving them some nurofen together.

I heard a tip from someone, another question. I heard a tip from someone about poking a hole into an ibuprofen gel capsule and squeezing the gel into the site. Is this dangerous? Probably wouldn't do any harm but I can't say I've got any evidence that I've read or seen that actually squeezing the gel directly onto the site helps with anything in particular in the mouth. So I don't think that's evidence based. I think if you’ve got an ibuprofen gel capsule, get them to swallow the capsule.

Any other questions that came up?

Chantelle: That seems to be all the questions and we actually look to be out of time so we might wrap up for this evening. So thank you Tony and thank you to all of our attendees for joining us. Just a reminder for the attendees to complete the evaluation form that will pop up in a new window in just a moment once this webinar session closes. So this will take just a minute or two to complete and also certificates of attendance will become available in your QI&CPD statements within the next few days. For any non RACGP members who would like a certificate of attendance, please email rural@racgp.org.au and finally, I'd like to let you all know that our rural health webinar series will continue next year on the first Thursday evening of every month starting in February, so, please keep an eye on your inbox for details. So thank you again, Tony. 

Associate Professor Tony Skapetis: Thank you very much Chantelle and thank you to all of you, and please if you get nothing else out of today, get people out of pain, numb them up. Don't be scared going inside the mouth. Thank you Chantelle. Thank you everyone. 

Chantelle: Thanks, Tony and thank you and goodnight to everyone.