PREPARING FOR DENTAL EMERGENCIES

PREPARING FOR DENTAL EMERGENCIES

Countless articles have been written on the need for emergency medical preparedness. Many of us have devoted considerable time, effort and money to paramedical training and elaborate provisions for medical self-sufficiency. Indeed, many survivalists have concentrated on acquiring arcane knowledge of herbal medicine, believing that homeopathic (so-called natural) medicine is somehow superior to allopathic (scientific) medicine, or that Western-style health care will cease to be accessible after the crash.Either way, practically all survivalists recognize the need to be medically reliant insofar as possible. Unfortunately, one aspect of health care is almost always overlooked in these preparations dental care.

The human body is remarkably resilient. Bandages and antiseptics and splints help the body to heal. However, except for life-saving techniques like hemostasis, and perhaps antibiotics for really nasty infections, medical interventions tend to assist the body's own healing processes. Not true for dental health! Let me be emphatic here; dentists are, and always will be, vitally important. Dental emergencies seldom, if ever, solve themselves. Worse, left alone they often get much, much worse. Painful teeth can prevent you from taking in adequate nutrition and hydration, and infections in this area can have dire consequences.

The purpose of this article is to familiarize you with basic concepts of both routine and emergency dental care and oral health. These measures are meant to assist you only until you can reach a qualified dentist; make no mistake, even in the event of an all-out collapse, you should still seek out a dentist as soon as possible. Never fear, they'll still be here if you are. Only dentists have the necessary skill and equipment to properly treat dental problems. They are unsung heroes, so take the time to become friends with yours. I myself am not a dentist, so this article will not pretend to make you a dentist, either. Except in truly desperate situations (e.g., making it to the other side of a nuclear war), laymen have no business giving nerve blocks or pulling teeth. Leaving aside the obvious risks inherent in injecting anesthetics into somebody's head, improper technique in extracting teeth, risks fracturing the tooth or jaw, leaving bits of root or other bone fragments in the jawbone, hemorrhage, etc. Although none of us are immune to dental problems, a more prudent course is to make sure your mouth is in good condition to begin with. Once that's accomplished, preventive maintenance and a few specialized first aid techniques should be sufficient.

First and most importantly, get in good dental health now. Of course this is expensive. However, if you're really serious about survival, you should see this as an important investment. Delay getting that new weapon or year's supply of overpriced storage food if you have to, but attend to your teeth right away. If there are fillings, crowns, or root canals you've been putting off, get them done as soon as possible. Have your dentist carefully check any amalgam fillings that are over ten years old. Although these are very durable, age and the acid conditions of the mouth will eventually erode them. Contrary to the ill-informed ravings of "eco freaks", there is little evidence that amalgam fillings release toxic amount of mercury into your system, so don't be concerned about having them put in. Teeth that have extensive fillings will probably eventually require crowns, a procedure in which most of the tooth is ground away and replaced with an artificial tooth made of gold and porcelain. Crowns are expensive but tend to last much longer than fillings. I have known people who would rather pull a tooth rather than spend the money necessary to repair it; this is lazy at best and foolish at worst.

Next, keep your teeth and gums in good condition. Brush and floss your teeth regularly and properly. If you're not sure what I mean by "properly", your dentist or dental hygienist will be glad to show you. While you're at it, take a few minutes to make sure the kids are brushing properly. Most commercial toothbrushes and toothpastes are pretty much equivalent, regardless of their extravagant claims, so find ones you like and stock up. (By the way, both toothbrushes and toothpaste would make excellent barter items). The variety of emergency roles for dental floss, make it a good idea to keep plenty on hand, as well. For example I have heard of situations where injured people were sutured with dental floss, although that's a pretty extreme example. A more mundane use for floss is as thread to repair things like leather, since dental floss has a relatively high tensile strength. Your imagination is the only limit for floss's other uses.

In an emergency situation, or if you're a die-hard do-it-yourselfer, it's easy to make you own toothpaste. Probably the simplest recipe is to mix equal parts of baking soda and table salt. To use, moisten a toothbrush and dip it into this mixture and scrub away. To be honest this tastes as bad as it sounds, but it does an excellent job of cleaning your teeth and gums. A little fancier version omits the salt and includes a small amount of calcium carbonate (ground chalk, an abrasive), water, glycerin, and a drop of flavoring oil such as spearmint or peppermint. Vary the proportions of water and glycerin until you active a slightly thick paste. Keep this mixture in a small container until needed.

MEET YOUR TEETH

Now that your teeth are healthy, take a close look at them. To effectively deal with emergency dental problems you must be familiar with tooth structure and function. This knowledge will also allow you to have intelligent conversations with your dentist or emergency personnel. To begin with, the tooth is divided into a crown and a root. The crown is covered with enamel, one of the hardest substances in nature. Under the enamel is a softer material, the dentin. Finally, at the heart of the tooth is the collection of blood vessels and nerves known as the pulp. The tooth's root anchors it in the jaw, and is covered with material known as cementum. This material is softer than enamel and is sensitive when it is exposed to the oral cavity or air. There are normally 32 teeth in the adult (adult, or permanent teeth) and 20 in children (primary teeth, also known as deciduous or "milk" teeth). Adults have (starting from the back) 3 molars, 2 premolars, 1 canine and 2 incisors per side in each jaw. As you are probably aware, the third set of molars (wisdom teeth) may not find enough room to erupt from the jaw, requiring extraction.

There are two specialized techniques used in dental examination, namely percussion and transillumination. Percussion refers to tapping the tooth with a hard blunt object (such as a tongue depressor) in a vertical direction. Painful sensitivity to percussion generally indicates root problems such as periapical (around the root) inflammation. Transillumination takes a little more practice. In this technique, a high intensity light (a small penlight works best) is applied directly on the enamel surface of the tooth. Often, damage or other defects will show up as irregularities in the light which is transmitted through the tooth.

THE SURVIVALIST'S DENTAL INFIRMARY

A number of items necessary for emergency dentistry are already in your general infirmary. However, there are also some specialized items which will be required. The items listed here should be kept together in a small pouch ready to travel, but also accessible as needed when you're at home:

  • Dental mirror and dental probe for examining the teeth and mouth. These are available in either plastic or metal from many of the survival supply companies. Alternatively, your dentist may be able to get them for you.
  • Plastic mixing tool or several flat toothpicks
  • Temporary dental filling material: (Cavit or Dentemp, available at most pharmacies)
  • Sterile 2x2 gauze pads (8-10 should be enough)
  • Sterile cotton pellets and cotton rolls. You can probably beg some from your dentist if he/she's friendly.
  • Dental wax, available at most pharmacies. Used to temporarily cover sharp tooth edges.
  • Anesthetic for oral tissues. Orabase B and Anbesol are readily available from almost all pharmacies. Another option is to get some sample packs of products offered by Zila, Inc.,5227 North 7th Street, Phoenix, Arizona 85014 Phone: 602-266-6700, Fax:602-234-2264. Zila carries a number of products including Zilactin and Zilactol. These products sting like crazy when they first go on, but work (for me) better than anything else I've tried. Try the sample packs, decide which of the products works best for you, and then get a larger size for your infirmary.
  • Kenalog in Orabase, a prescription item, is good for problems such as aphthous ulcers (canker sores). You can get a prescription for this from either your physician or dentist.
  • Calcium hydroxide resin paste (optional; may be available from your dentist, but don't count on it).
  • Eugenol, also known as oil of cloves (anesthetic for teeth).
  • Ibuprofen or acetaminophen for dental pain.
  • Toothbrush, toothpaste, and dental floss (small sample packs are available at most drugstores).
  • One or two pairs of latex gloves and a small plastic waste bag (Ziplocs bag).

If your funds are limited, one approach is to purchase a basic dental emergency kit from a company such as Nitro-Pak; then expand on it. Why this approach? Temporary filling materials available at pharmacies generally have minimal mixing tools supplied, if any. On the other hand, the basic emergency dental kits usually have filling material, a dental mirror, a probe/mixing tool, and often a mixing tray. By expanding on such a basic kit, you can customize it to your specific needs. If you choose to buy a pre-stocked kit, an excellent unit containing everything listed above (with the exception of Kenalog) in a nice nylon pouch is available from Adventure Medical Kits (P.O. Box 43309, Oakland, CA 94624, Phone: 800-324-3517, Fax: 510-632-1284).

If you have small children at home who frequently participate in violent sports, or just tend to fall down a lot, a handy item to keep on hand is called Save-A-Tooth, (3M Health Care, St. Paul, MN 55144, Telephone: 800-5378-2191). This is a small plastic jar filled with a nutrient solution for preserving teeth that have been avulsed (knocked out). 3M claims that 90% of teeth preserved in this solution have been successfully re-implanted. I have occasionally seen Save-A-Tooth stocked in pharmacies, but chances are you'll have to have the pharmacist order it for you. Tooth avulsion is covered in greater detail below.

PROBLEMS WITH THE TEETH

Dental caries (cavities) is a microbial disease which is associated with destruction of the tooth; it is the most prevalent chronic disease afflicting humans. Several species of bacteria normally found in the human mouth feed on the natural, and more practically the added, sugars found in our food. Acids are produced as a waste product by the bacteria and these acids attack the enamel of the tooth, demineralizing it. If not treated, the bacterial infection progresses to the dentin and eventually the pulp, destroying the tooth. A toothache usually precedes complete destruction of the tooth, acting as an early warning of trouble. Minor toothaches may be treated with NSAIDS such as ibuprofen, or by applying a small amount of oil of cloves (both of these items belong in your dental infirmary). However, once the process of decay has begun, it cannot be reversed and the damaged tooth must be restored (filled). Tooth restoration is not a do-it-yourself job as it requires tools, materials and skills most of us don't possess. In extreme survival situations, a severely decayed tooth may require extraction. Since I advocate prevention rather than treatment, I won't explain the process of dental extraction here.

Dental fractures are often the result of trauma to the face. Tooth fractures are traditionally classified according to the Ellis scale depending on severity. A Class I fracture affect only the enamel of the tooth, is not painful (although it may be sensitive to heat or cold), and is not really an emergency. If a sharp edge is present and damaging oral tissue, it may be smoothed over with some wax from you dental infirmary, or carefully filed with an emery board. Class II fractures affect both the enamel and the dentin. This condition may be recognized easily, as the dentin is more yellowish or pink, as compared to the white enamel. Class II fractures are more serious in younger children, who have less dentin in relation to pulp than do adults. Immediate treatment consists of sealing off the dentin, which may be accomplished with dental wax. If you have a more complete infirmary, you may dry the tooth off with a gauze pad and apply a dressing of calcium hydroxide resin paste. Dental attention is more urgent here, since the goal is to prevent contamination of the pulp and the subsequent need for a root canal treatment. Next up in seriousness is a Class III fracture, a true dental emergency in which the pulp is exposed and pain may be severe. Emergency treatment consists of covering the tooth with cotton or gauze moistened with saline and administering analgesics. It is extremely important with these fractures to prevent contamination, which may result in abscess formation.

Subluxation refers to loosening of teeth in their socket following trauma. Subluxation is diagnosed by any movement of the tooth upon manipulation; it may also be suspected if a ring of blood surrounds the tooth at the gum line following trauma to the face or jaw. If the surrounding structures are sound, subluxated teeth will usually stabilize, although they may require some help from a dentist. In an extreme situation, the loose tooth may be stabilized by applying emergency dental compound (e.g., Cavit) to the margins between the loose tooth and its neighbors. Have the patient refrain from eating with this portion of the teeth until the tooth is stronger and be sure to practice good oral hygiene during this period. Once the tooth has stabilized, remove the dental cement to facilitate proper cleaning. Although Subluxation generally requires little or no treatment, treatment of luxation, which is gross displacement of the tooth in its socket, is best left to the professionals.

Avulsion refers to the loss of a tooth from its socket following trauma. If handled properly, avulsed permanent teeth can often be re-implanted and regain function. The key phrase here is "handled properly". First, find the tooth, not as trivial a statement as it sounds at first. If a tooth can not be accounted for, there is a possibility that it has been swallowed, or it may even be embedded in the soft tissue of the mouth. Once you have found the tooth, pick it up by the CROWN ONLY, never by the roots! The periodontal ligaments along the root may be damaged by pressure, making re-implantation difficult or impossible. Rinse the tooth off, preferably with saline although cool water will also work; do not use alcohol, Betadine or other antiseptics, which will damage the tooth. Finally, transport the tooth (along with the patient) to the dentist. The best transport container for the tooth is the socket it came out of. It is often an easy matter to simply reinsert the tooth in its socket, place a sterile gauze pad over it and have the patient hold the tooth in using either her finger or a light biting pressure.

Sometimes blood clots or small bits of tooth or bone will make this difficult. In such cases, rinsing the socket with saline may remove enough debris to facilitate placing the tooth in the socket. In a situation where it is not possible or practical to replace the tooth in its socket, the Save a Tooth kit (mentioned above) is the next best thing. If neither of these options is available, the tooth may be transported in a container of cold milk, which is similar enough to the mouth's chemistry to nourish the tooth. Finally, the patient may hold the tooth under her tongue until reaching the dentist; this is the least favored option since the tooth is not nourished as well, and especially since the tooth may be inadvertently swallowed this way. In a true survival situation, however, it will be best not to try re-implantation yourself, since a re-implanted tooth requires proper alignment and stabilization. Moreover, although the re-implanted tooth itself may live, the pulp will usually die, requiring a root canal. In this situation, it will be best to do without the tooth. By the way, primary teeth are almost never re-implanted, since they tend to fuse to the jawbone, preventing the permanent teeth from erupting.

Damage to dental appliances may result from either trauma or (primarily in the case of lost fillings), deterioration of the tooth or cement resulting from age, wear, or tooth disease.

Many of these temporary filling compounds are a binary mixture of zinc oxide powder and eugenol. To make an emergency repair for a lost filling, first gently remove any loose debris from the tooth cavity, drying the cavity as thoroughly as possible with cotton pellets. Following instructions provided with the filling material, mix the binary components well using flat toothpicks or a spatula, which is usually included in emergency dental kits. Quickly, but carefully, pack the filling material into the cavity, trying to avoid any bubbles or loose spaces. Once the cavity is full, smooth the top and have the patient bite down gently for a moment to ensure proper mating of the upper and lower teeth. Allow the temporary filling to dry, and have the patient avoid vigorous chewing until a permanent replacement filling can be made. Another problem arises when a crown falls off, usually resulting in substantial pain. An expedient treatment is to rinse off the tooth (use cotton pellets soaked in lukewarm water to reduce sensitivity) as well as the inside of the crown. Apply a small amount of petrolatum (Vaseline) to the inside of the crown and then reposition the crown on the tooth. Have the patient bite down gently to seat the crown; this will generally reduce sensitivity and allow the patient to seek professional treatment. In a wilderness situation, you can use the emergency dental cement in your infirmary to make a stronger bond until you can reach civilization.

PROBLEMS WITH OTHER ORAL TISSUES

Gingivitis refers to inflammation of the gingivae (gums) and is diagnosed by swelling, bleeding and redness of the tissues around the teeth. The swelling often enlarges the pockets around the teeth. Although gingivitis may signal any number of disease conditions (diabetes or leukemia, for example), it is usually the result of poor dental hygiene and the development of dental plaque. Treatment is simple: brush and floss better. A word to the wise: toothbrush, toothpaste and floss don't take up much room in your gear. Pericoronitis is a common problem around erupting teeth, particularly the third molars (wisdom teeth) in adults. It is recognized by red, swollen and very sensitive gingivae (gums).With wisdom teeth, the problem is often associated with a partial flap of tissue covering the tooth/teeth. Food or other debris may become trapped under this tissue, leading to microbial growth and inflammation. Symptomatic relief may be provided by saline irrigation using a syringe, followed up by thorough cleaning of the tooth itself (if it is visible). Warm saline rinses usually help until the patient can seek professional help. While we're on the subject of erupting teeth let's take a moment to discuss teething in babies. Teething can be very painful. When babies begin teething between the ages of four months and two and a half-years old, they often have sore and tender gums. The breaking through of these teeth often causes a child to become irritable. Gently rubbing your baby's gums with a clean finger, a small, cool spoon, or wet gauze can usually soothe this pain. You can also give the baby a clean teething ring to chew on. You may also want to include an anesthetic gel in your infirmary; there are special gels available for babies, which contain a lower concentration of lidocaine than is found in adult preparation, although this is probably more of a marketing ploy than a necessity; just use less. Contrary to common belief, teething does not cause fevers. If a fever does exist, it needs to be addressed as a separate medical concern. If the baby continues to be cranky and uncomfortable after your attempt to ease the teething pain, consult your dentist or physician.

Abscesses are often localized to the firm tissue of the gums close to the teeth and can form in either healthy or diseased tissues. They are very painful, and can be easily recognized. Abscesses are sometimes formed by trauma (toothbrush!), dental appliances such as braces, and by certain foods such as popcorn in which a small foreign body can become lodged in the soft tissue. Treatment of abscesses is generally by incision with a #15 scalpel blade, followed by gentle probing of the tissue to enhance drainage of pus. A local anesthetic may be necessary since this is a painful procedure. The patient is advised to use warm saline rinses for several days, and antibiotics are usually unnecessary. In most cases this treatment will solve the problem; if the abscess does not resolve, or if it returns quickly, it may be symptomatic or a more serious condition. As an important note, this treatment regimen applies only to abscesses of the gums. A dental abscess, one involving a compromised tooth or tooth root, is a truly serious condition which may lead to systemic infection and worse. Treatment of such a condition in the field would require extraction of the tooth and systemic antibiotics, after which the patient would still be at risk of dying. Bottom line: it's not something most people could handle. The possibility of a situation such as this is all the encouragement you should require to make sure your teeth are healthy NOW.

Vincent' Disease, or Trench mouth is a noncontiguous bacterial infection associated with poor oral hygiene, stress, insufficient rest or nutritional deficiencies; in other words, survival-related situations. Symptoms of this condition include painful bleeding gums, excessive salivation, bad breath, and ulceration of the gums covered by a graying membrane. Treatment of this condition in the field includes warm saline or peroxide rinses, improved oral hygiene, and possibly therapy with penicillin, erythromycin or tetracycline.

Thrush is an infection of the oral membranes with Candida albicans, the yeast also responsible for vaginal infections. It is recognized as white raised patches which resemble milk curds; when these plaques are removed from the tissues, the area underneath often bleeds slightly. The infection usually begins on the tongue and the oral cavity, but may spread to the throat, gums, palate and beyond. Thrush is treated with the antibiotics Nystatin and Amphotericin B, which should be included in your general infirmary.

Aphthous ulcers, (canker sores), are small painful sores which occur inside the mouth or on the gums. Approximately 20% of the population are affected by recurring canker sores, which are usually associated with stress, tissue damage or diet. They begin as small circular reddish swellings that rupture within a day. The ruptured sores are covered by thin whitish areas that are surrounded by reddish (hyperemic) inflammation. Luckily, canker sores are not contagious and will resolve themselves within a week or two. The pain of canker sores may be relieved to some extent by using one of the topical anesthetics in your infirmary, especially those that form a film over the lesion. If Kenalog is applied to the sore when it first starts, the infection may be aborted and the sore may dry up before becoming painful.

Fever blisters (cold sores) are lesions that occur around the lips, often at the margin of the pink part of the lip (known as the vermillion) and the skin of the face. Approximately 80% of the population are afflicted with fever blisters, which are caused the contagious herpes simplex I virus. Once a person is infected, this virus remains in the body even following healing of the lesion. In some people it remains inactive. However, with most people, it occasionally travels down the nerve located near the cheek bone to the lips. This results in a breakout around the lips. After the initial infection the virus may remain dormant, although factors such as emotional stress, fever, illness, sunlight, fatigue and menstruation may trigger a recurrence of the infection. Many people who get recurring cold sores feel tingling or burning at the location about a day before the sore erupts. After the initial stage of the outbreak, there is a reddening and swelling of the area. The sore or sores are usually fluid-filled and can be painful, and will seep fluid and crack for several days. After this stage, the sores dry up and form scabs. Treatment of fever blisters consists primarily of pain relief. Topical anesthetic gels or diphenhydramine (Benadryl) elixir are good choices. A mouthwash of ½ teaspoon baking soda in 8 oz of warm water is also soothing. Applying 70% isopropyl (rubbing) alcohol to the lesions appears to soothe the initial burning or tingling which signals the onset of fever blisters, and may also help dry up the oozing of lesions after the infection starts. Following the drying up of the lesions and scab formation, keeping the area lubricated with petrolatum may also provide some relief.

SUMMARY

Although many medical emergencies can be handled by a well-prepared individual, dental problems often require specialized training and supplies that most of us just don't have access to. Nevertheless, recognizing potential problems represents a good start to dealing with these conditions until proper treatment can be obtained. Again, let me stress that the key to solving dental problems is to treat them before they start, by prevention. Regardless of whether or not we are faced with a complete breakdown of all social services, good dental health is an emergency preparation that pays daily rewards.

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Wednesday, 04 August 2021

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