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Pathologic conditions of mandibular third molar
Department of Oral Surgery PATHOLOGIC CONDITIONS OF MANDIBULAR THIRD MOLAR B ERNARD
T
G. "WAKEFIELD, D.D.S., B UFFALO, N. Y.
H E un erupted or partially erupte d mandibular third molar is often responsible for a large number of conditions, some of which have n o local symptoms. From pressure alone the symptoms may be many, varying from a cr owding of the other te eth and eroding of the second molar to mild referred pains, n eural gic symptoms, tinnitus, and even general nerve tension. In addition to its influ ence on the other t eeth and nerves, it may and of te n does develop a cyst. T his is because of the fact that the crypt possesses the nec essary t issu e r equirements and n eeds only an inflammatory influence over a period of time to start a cyst ic f orm ation. Thi s same inflammato ry influ ence may, in certain othe r instances, cause a r esor ption of the cry pt and bring about a true ankylosis and in turn a very "difficult ext r a ct ion. Again it may produce an active, acute infecti on, t he latter being our main interest at this time. The mandibular third molar, because of its anatomic position and adjacent st ru ct ures, presents more pathologie haz ards than d oes any other tooth in t he mouth. It is from th ese t eeth that most severe cases of celluliti s and osteo mye litis arise. Sometimes t hese complications are unavoidable, but many could be prevented if properly handled. 'I'he apices of t his tooth are close to the lin gual surface of the mandible below the myl ohy oid r idge and a lso closely approximat in g the canal, if not even enc roaching upon it. Th e f orm er condition permits easy passage of foreign sub stances and infection t o the subling ual and submaxillary area, while the latter invites complications within the canal. 'I'he close proximity to the anterior pillars and attachments of muscles of mastication invites early trismus and interference in swallowing; therefore the early dehydrati on and depleti on of t h e p atient's r eserv e. Then last, but by no means least, is the inaccessibility of mandibular third molar areas which makes their handling more difficult. With t hese facts in mind, let us first discuss the most common involvement, namely, the p ericorneal absc ess which so often accompanies a p artiall y erupted mandibular third molar. This condition, which starts with mild irritation of the flap , is often brought on by trauma from a maxillary third molar in the act of occlusion, and in a great many cases the extraction of the usually malposed maxillary molar should be considered in connection with the early treatment of the flap condition on the mandibular molar. Under this flap , anaerobic organisms usually are present and with a lowering of local tissue resistance as well as general resistance, they spring into 65
66
Bernard G. Wakefield
activity and create a local cellulitis which is many times termed a pericorneal abscess. It is, however, not an abscess at this time, but can either develop a localized soft tissue abscess and drain or go on to a diffuse cellulitis with extreme complications, including a periostitis from pressure. It is at this stage that surgical judgment may save both patient and dentist much trouble. Since surgery is contraindicated in the presence of a cellulitis, we must avoid surgery at this time, surgery here including any such procedure as lancing or extraction, for at this stage there is no pus to be drained. There may, however, later be a localized fluctuating pericorneal abscess which it is both permissible and good surgery to lance and drain. The tooth itself is usually a normal, healthy tooth surrounded by healthy bone and the removal of which will only allow the most virulent type of infection to enter deeply into the bone and set up an osteitis. In its removal, the soft tissue is involved and we are likely to create a diffuse cellulitis with the subsequent periosteitis. The stage would now be set for an osteomyelitis which could arise from either the surface or the interior, and this does occur all too often. In order to avoid these complications, let us follow some simple, common sense fundamentals. As the patients will usually delay visiting the dentist, they often present with some swelling, severe soreness, some pain and trismus, and with a slight temperature. If the delay has been greater, the patient is usually dehydrated, poorly nourished, and all symptoms are increased. Let us first have an x-ray examination and, if an intraoral film is impossible, then let us get an extraoral. Both are even better. This is to determine whether the condition is all pericorneal or possibly of apical origin, as well as to have a permanent record of conditions at the onset for future work and comparison especially in case of complications. Now, finding the condition to be both clinically and radiographically a pericorneal involvement, we should discuss it with the patient and preferably in the presence of another person, being very careful not to frighten the patient but equally careful to see that he has some conception of the condition, what we intend to do and the probable recovery, but also a glimpse of the possible complications. A statement here is diagnosis. The same words later may appear to be an alibi. For the chair treatment, I would suggest the following: First, spray the entire mouth with a 50 per cent hydrogen peroxide, spray with plenty of pressure to reduce the probable general mouth bacteria and clean it up. Then concentrate on spraying under the flap repeatedly, after which the medicament of choice should be worked under the flap. My choice of drug is Talbot's solution, but the manner of applying is of equal importance. To create the proper applicator, take an old contra-angle explorer or similar instrument with a very fine shaft and heat it to anneal the metal. Then bend to a slight curve. It is well to have the end either flat or notched, not pointed. Next, shove it through beeswax where it will collect a film of wax, which in turn will permit winding on a very small amount of cotton, thereby creating a very small applicator.
Pathologic Conditions of MU1lidibnlar Third Molar
67
Now dry underneath the flap with air and work the Talbot's solution well under and in back of the flap, as well as alongside the tooth. It is well to explain previously that it will hurt and cause discomfort for a short time afterward. Next comes the home care instructions, which are of utmost importance. See to it that the patient takes a saline cathartic to relieve toxicity and sluggishness. Advise the taking of large amounts of water and orange juice to build up the fluid content and to alkalinize the system. Nourishment as indicated. Inside the mouth advise a full glass of hot sodium perborate once every hour. This is for two reasons: first, to combat anaerobic bacteria, and, second, to cause, through the heat, a localizing and drainage. Then on the outside, have ice packs applied intermittently. This is to discourage the spread of infection. As already mentioned, if a maxillary third molar is actually causing trauma, its removal is indicated, but we do not advocate local anesthesia in those instances in which injecting would involve any inflammatory tissue. The patient is now instructed to return on the following day, and, unless the condition was hopelessly advanced, he will be much improved. It seems better judgment generally to allow these conditions to become rather normal before operating, but, of course, the hazard is a thousand times less as soon as the resolution is well under way. When the patient becomes comfortable, he may delay the removal of the tooth only to repeat the condition in a more serious form. This should be avoided. In those cases in which the condition has passed the abortive stage and the cheek is large and indurated, the latter condition having been present for a few days, we usually have to establish external drainage, but here again comes the question of surgical judgment, which is a simple phrase but an important factor. The localizing may be done in a number of ways, such as poultices, antiphlogistin, etc., but I prefer hot magnesium sulphate packs, which are a saturated solution of epsom salts. As soon as a point of fluctuation is noted, it should be opened with a sharp skin dissection followed by blunt dissection to avoid blood vessels and further complications. Then, either a lubricated gauze drain, oil silk, or rubber tube is inserted. Over this is placed a moist warm dressing, and each day as the dressings are changed, the drain is shortened by cutting off a bit of the projecting portion; this also frees the wound for drainage. Saturated solution of boric acid is preferred for wetting dressings during the period of heavy drainage. Allowing these conditions to come too close to the skin before opening, and leaving drains in too long, invite scars. It so happens that the patient may present with similar symptoms, which have a different etiology. The x-ray examination is for the purpose of differentiating. If the third molar is abscessed and sore to percussion as a result of pulp death, then we should follow the time-honored principle of drainage, the most complete and acceptable usually being extraction, but by all means under general anesthesia. After the removal of such a tooth, the patient should be given the same home care instructions as with the pericorneal involvement, except to use hot saline instead of hot sodium perborate.
68
Bernard G. Wakefield
If the patient presents with the pain, swelling, and fever, but no trismus, we should be suspicious of an adenitis or peritonsillar abscess and not of a dental condition, for trismus almost invariably accompanies these symptoms if they are of dental origin. When such cases present and are recognized as nondental, the patient should be advised to consult his physician, and you should call him to explain your diagnosis, for these are invariably of dental appearance to the physician until dental involvement is ruled out. In passing, I might mention that these conditions often follow measles. These facts should be kept in mind in connection with the removal of all mandibular third molars whether impacted or not; and, when trouble starts within the socket, prompt and adequate dressings should be used and home care instituted. When trouble is present in these sockets with the usual painful symptoms, the following treatment is suggested: Spray out the entire mouth and with curettes and irrigations, remove all debris from the socket, but do not curette the walls as this only invites trouble at this stage. Next, dry the socket and insert a pledget of cotton saturated with a sedative of choice, to stop pain immediately. Then mix the dressing, which is a powder and liquid incorporated, to a very sloppy mixture on a slab. The powder is equal parts parathesin and aristol, while the liquid is equal parts tincture of iodine and oil of cloves. This mixture is spatulated into quarter-inch iodoform gauze until the gauze will take no more. This gauze is carefully carried well down into the socket as the cotton pledget is removed and the socket is lightly filled but not packed. The patient is instructed to return in twenty-four to forty-eight hours for irrigations and further dressing. This dressing may now be repeated if deemed necessary or a lighter sedative dressing may be used thereafter; this one being used only in those really very troublesome sockets. In those postoperative, third molar sockets in which pain and swelling have persisted for some time in spite of dressings, we should be suspicious that the osteitis may be becoming an osteomyelitis. In making such a diagnosis, the clinical picture will precede x-ray evidence by many days, for it is only after the calcium salts are dissolved out that the x-ray will reveal an osteomyelitis. The clinical picture which should put us on our guard is that of continued pain in spite of dressing, some fever, swelling, trismus, and very brilliant reddened appearance to the overlying mucosa which may show signs of thickening and lifting. As these symptoms and the x-ray examination have completed the picture of an osteomyelitis, we then have another subject which the space allotted will not permit discussing at this time.
T
G. "WAKEFIELD, D.D.S., B UFFALO, N. Y.
H E un erupted or partially erupte d mandibular third molar is often responsible for a large number of conditions, some of which have n o local symptoms. From pressure alone the symptoms may be many, varying from a cr owding of the other te eth and eroding of the second molar to mild referred pains, n eural gic symptoms, tinnitus, and even general nerve tension. In addition to its influ ence on the other t eeth and nerves, it may and of te n does develop a cyst. T his is because of the fact that the crypt possesses the nec essary t issu e r equirements and n eeds only an inflammatory influence over a period of time to start a cyst ic f orm ation. Thi s same inflammato ry influ ence may, in certain othe r instances, cause a r esor ption of the cry pt and bring about a true ankylosis and in turn a very "difficult ext r a ct ion. Again it may produce an active, acute infecti on, t he latter being our main interest at this time. The mandibular third molar, because of its anatomic position and adjacent st ru ct ures, presents more pathologie haz ards than d oes any other tooth in t he mouth. It is from th ese t eeth that most severe cases of celluliti s and osteo mye litis arise. Sometimes t hese complications are unavoidable, but many could be prevented if properly handled. 'I'he apices of t his tooth are close to the lin gual surface of the mandible below the myl ohy oid r idge and a lso closely approximat in g the canal, if not even enc roaching upon it. Th e f orm er condition permits easy passage of foreign sub stances and infection t o the subling ual and submaxillary area, while the latter invites complications within the canal. 'I'he close proximity to the anterior pillars and attachments of muscles of mastication invites early trismus and interference in swallowing; therefore the early dehydrati on and depleti on of t h e p atient's r eserv e. Then last, but by no means least, is the inaccessibility of mandibular third molar areas which makes their handling more difficult. With t hese facts in mind, let us first discuss the most common involvement, namely, the p ericorneal absc ess which so often accompanies a p artiall y erupted mandibular third molar. This condition, which starts with mild irritation of the flap , is often brought on by trauma from a maxillary third molar in the act of occlusion, and in a great many cases the extraction of the usually malposed maxillary molar should be considered in connection with the early treatment of the flap condition on the mandibular molar. Under this flap , anaerobic organisms usually are present and with a lowering of local tissue resistance as well as general resistance, they spring into 65
66
Bernard G. Wakefield
activity and create a local cellulitis which is many times termed a pericorneal abscess. It is, however, not an abscess at this time, but can either develop a localized soft tissue abscess and drain or go on to a diffuse cellulitis with extreme complications, including a periostitis from pressure. It is at this stage that surgical judgment may save both patient and dentist much trouble. Since surgery is contraindicated in the presence of a cellulitis, we must avoid surgery at this time, surgery here including any such procedure as lancing or extraction, for at this stage there is no pus to be drained. There may, however, later be a localized fluctuating pericorneal abscess which it is both permissible and good surgery to lance and drain. The tooth itself is usually a normal, healthy tooth surrounded by healthy bone and the removal of which will only allow the most virulent type of infection to enter deeply into the bone and set up an osteitis. In its removal, the soft tissue is involved and we are likely to create a diffuse cellulitis with the subsequent periosteitis. The stage would now be set for an osteomyelitis which could arise from either the surface or the interior, and this does occur all too often. In order to avoid these complications, let us follow some simple, common sense fundamentals. As the patients will usually delay visiting the dentist, they often present with some swelling, severe soreness, some pain and trismus, and with a slight temperature. If the delay has been greater, the patient is usually dehydrated, poorly nourished, and all symptoms are increased. Let us first have an x-ray examination and, if an intraoral film is impossible, then let us get an extraoral. Both are even better. This is to determine whether the condition is all pericorneal or possibly of apical origin, as well as to have a permanent record of conditions at the onset for future work and comparison especially in case of complications. Now, finding the condition to be both clinically and radiographically a pericorneal involvement, we should discuss it with the patient and preferably in the presence of another person, being very careful not to frighten the patient but equally careful to see that he has some conception of the condition, what we intend to do and the probable recovery, but also a glimpse of the possible complications. A statement here is diagnosis. The same words later may appear to be an alibi. For the chair treatment, I would suggest the following: First, spray the entire mouth with a 50 per cent hydrogen peroxide, spray with plenty of pressure to reduce the probable general mouth bacteria and clean it up. Then concentrate on spraying under the flap repeatedly, after which the medicament of choice should be worked under the flap. My choice of drug is Talbot's solution, but the manner of applying is of equal importance. To create the proper applicator, take an old contra-angle explorer or similar instrument with a very fine shaft and heat it to anneal the metal. Then bend to a slight curve. It is well to have the end either flat or notched, not pointed. Next, shove it through beeswax where it will collect a film of wax, which in turn will permit winding on a very small amount of cotton, thereby creating a very small applicator.
Pathologic Conditions of MU1lidibnlar Third Molar
67
Now dry underneath the flap with air and work the Talbot's solution well under and in back of the flap, as well as alongside the tooth. It is well to explain previously that it will hurt and cause discomfort for a short time afterward. Next comes the home care instructions, which are of utmost importance. See to it that the patient takes a saline cathartic to relieve toxicity and sluggishness. Advise the taking of large amounts of water and orange juice to build up the fluid content and to alkalinize the system. Nourishment as indicated. Inside the mouth advise a full glass of hot sodium perborate once every hour. This is for two reasons: first, to combat anaerobic bacteria, and, second, to cause, through the heat, a localizing and drainage. Then on the outside, have ice packs applied intermittently. This is to discourage the spread of infection. As already mentioned, if a maxillary third molar is actually causing trauma, its removal is indicated, but we do not advocate local anesthesia in those instances in which injecting would involve any inflammatory tissue. The patient is now instructed to return on the following day, and, unless the condition was hopelessly advanced, he will be much improved. It seems better judgment generally to allow these conditions to become rather normal before operating, but, of course, the hazard is a thousand times less as soon as the resolution is well under way. When the patient becomes comfortable, he may delay the removal of the tooth only to repeat the condition in a more serious form. This should be avoided. In those cases in which the condition has passed the abortive stage and the cheek is large and indurated, the latter condition having been present for a few days, we usually have to establish external drainage, but here again comes the question of surgical judgment, which is a simple phrase but an important factor. The localizing may be done in a number of ways, such as poultices, antiphlogistin, etc., but I prefer hot magnesium sulphate packs, which are a saturated solution of epsom salts. As soon as a point of fluctuation is noted, it should be opened with a sharp skin dissection followed by blunt dissection to avoid blood vessels and further complications. Then, either a lubricated gauze drain, oil silk, or rubber tube is inserted. Over this is placed a moist warm dressing, and each day as the dressings are changed, the drain is shortened by cutting off a bit of the projecting portion; this also frees the wound for drainage. Saturated solution of boric acid is preferred for wetting dressings during the period of heavy drainage. Allowing these conditions to come too close to the skin before opening, and leaving drains in too long, invite scars. It so happens that the patient may present with similar symptoms, which have a different etiology. The x-ray examination is for the purpose of differentiating. If the third molar is abscessed and sore to percussion as a result of pulp death, then we should follow the time-honored principle of drainage, the most complete and acceptable usually being extraction, but by all means under general anesthesia. After the removal of such a tooth, the patient should be given the same home care instructions as with the pericorneal involvement, except to use hot saline instead of hot sodium perborate.
68
Bernard G. Wakefield
If the patient presents with the pain, swelling, and fever, but no trismus, we should be suspicious of an adenitis or peritonsillar abscess and not of a dental condition, for trismus almost invariably accompanies these symptoms if they are of dental origin. When such cases present and are recognized as nondental, the patient should be advised to consult his physician, and you should call him to explain your diagnosis, for these are invariably of dental appearance to the physician until dental involvement is ruled out. In passing, I might mention that these conditions often follow measles. These facts should be kept in mind in connection with the removal of all mandibular third molars whether impacted or not; and, when trouble starts within the socket, prompt and adequate dressings should be used and home care instituted. When trouble is present in these sockets with the usual painful symptoms, the following treatment is suggested: Spray out the entire mouth and with curettes and irrigations, remove all debris from the socket, but do not curette the walls as this only invites trouble at this stage. Next, dry the socket and insert a pledget of cotton saturated with a sedative of choice, to stop pain immediately. Then mix the dressing, which is a powder and liquid incorporated, to a very sloppy mixture on a slab. The powder is equal parts parathesin and aristol, while the liquid is equal parts tincture of iodine and oil of cloves. This mixture is spatulated into quarter-inch iodoform gauze until the gauze will take no more. This gauze is carefully carried well down into the socket as the cotton pledget is removed and the socket is lightly filled but not packed. The patient is instructed to return in twenty-four to forty-eight hours for irrigations and further dressing. This dressing may now be repeated if deemed necessary or a lighter sedative dressing may be used thereafter; this one being used only in those really very troublesome sockets. In those postoperative, third molar sockets in which pain and swelling have persisted for some time in spite of dressings, we should be suspicious that the osteitis may be becoming an osteomyelitis. In making such a diagnosis, the clinical picture will precede x-ray evidence by many days, for it is only after the calcium salts are dissolved out that the x-ray will reveal an osteomyelitis. The clinical picture which should put us on our guard is that of continued pain in spite of dressing, some fever, swelling, trismus, and very brilliant reddened appearance to the overlying mucosa which may show signs of thickening and lifting. As these symptoms and the x-ray examination have completed the picture of an osteomyelitis, we then have another subject which the space allotted will not permit discussing at this time.