Survival Dentistry, by The Army Dentist

Friday, Dec 19, 2008

Dentistry may be one of the least exciting topics under preparedness. You will never see a television show on the daily life and death struggles in a dental office and you won’t find too many stories “from the front” on the dental team. But a dental emergency can quickly complicate or even bring to a standstill, daily living and tasks. In a SHTF scenario, this is not something you want to deal with. The confederate army was the first army to recognize this and fielded a dentist for their troops. In Vietnam, dental disease accounted for 11% of Disease and Non-Battle Injury (DNBI). Today, the military recognizes this and has provided more and more dental support closer to the forward line of troops (FLOT ) in an effort to keep troops on duty and out of sick call.

I have been practicing dentistry for 12 years now. I am currently in private practice but I served on active duty in the army for four and one half years and have been in the reserves the balance of my career. I have performed dental procedures in the third world as both a civilian and a soldier in places such as rural Jamaica, Guatemala and Kosovo (and in a few months I will add Iraq to the list but I doubt I will ever leave the wire to treat civilians). Most of these procedures involved nothing more than tooth extractions because it is the fastest way to help the most people. And most of these people recognized that follow up dental care was tenuous at best, and were not willing to gamble on a questionable tooth. On each of the medical civilian aid missions (MEDCAPs) in which I participated, the line to see the dentist was always at least as long as the line to see the physician's assistants (PAs) and physicians.

I would like to present a summary of the caries process and the best way to prevent dental pathology in the first place, a simple way to recognize and or loosely categorize dental symptoms, and some simple treatment alternatives until definitive care can be reached.

The first place I would start, would be to go to your dentist and have everything taken care of immediately. Think of Tom Hank’s character in the movie “Lost” who ended up extracting an abscessed tooth with an old ice skate. Need I say more? Sometimes in dentistry, we will treat a questionable tooth in an effort to save it but the tooth has a poor prognosis and we instruct the patient to return if problems persist. If you feel that you will be remote to dental care for an extended period of time, then I would attempt to limit these “watch and wait” procedures. Always ask for the dentist’s prognosis. You don’t want to find out that the procedure has failed after you no longer have access to the dentist.

After all existing problems have been addressed, begin and maintain (make it a habit) a preventive dental program. It is not a very difficult thing to do and you can save untold thousands of dollars and a lot of pain by doing it. Believe me, I’ll take your money to fix the problems but its better if you just avoid the problems in the first place.

Caries begins when bacteria in your mouth, digests sugar and creates acid, which dissolves tooth structure. As this process progresses towards the pulp of the tooth, you will experience pain. I know you all have heard this a million times but I’ll say it again because if you do this, you will have very few problems. Brush your teeth nd limit your sugar intake. . It really does work. If you can remove the bacteria, which predominantly resides in plaque, from your mouth, you will limit its ability to create acid. Also, the sugar intake frequency is more important than the amount of sugar. Every time you put sugar in your mouth, the bacteria will create acid for thirty minutes. If you drink one soda in 10 minutes, and then consume no more sugar the rest of the day, then you will only have acid in your mouth for about 40 minutes. If you take the same soda, and sip on it all day long, then you will have acid in your mouth all day long. Certainly limit the amount of sugar you ingest, but more importantly, limit the frequency with which you ingest it. Also, use a fluoride rinse every night. You should brush your teeth, then rinse your mouth, drink water if you want, and then rinse with the fluoride. Then don’t put anything else in your mouth and go to bed. The fluoride will sit on your teeth and make the enamel less soluble. It works.|

Toothpaste is not necessary in this regimen either. It is good but not necessary. Toothpaste is nothing more than a mild abrasive, flavoring and fluoride. If you want to make your own, you can use fluoride rinse and baking soda although baking soda is much more abrasive than commercially made tooth paste and can irritate your tissues. It is fine to use every now and then and just use fluoride rinse or water if that’s all you have the rest of the time.

If you do develop a carious lesion (a cavity), you can expect the following, which can take months or years to fully develop. These symptoms are never written in stone and vary greatly between individuals and even between teeth in the same person. But this should provide a general guideline so you can estimate what you are dealing with, what symptom may be expected with time and what treatment you may need.

When the tooth structure has been sufficiently weakened, it will break and leave a hole (the cavity). At first you may have no pain and only experience a gingival irritation as food gets packed in it. You may have trouble getting all of the food out. Soon it will start to ache when you chew and possibly will be very cold sensitive. This decay is approaching the pulp of the tooth and is starting to irritate the nerves within the tooth. This is called reversible pulpitis, literally a reversible irritated pulp. This can be treated with a filling. When the tooth begins to hurt spontaneously, wakes you up at night and is sensitive to hot, then you most likely have an irreversible pulpitis. At this point, the tooth requires a root canal or an extraction. The toxins from the decay have reached the nerve and essentially have mortally wounded it. This may last for several weeks and if you gut it out, the pain will eventually go away. When the pain goes away, the nerve has died. Do not leave this tooth untreated! As the nerve decomposes, the body is unable to get inside the tooth to take care of it and you will eventually end up with an abscess. The pain will return with a vengeance. This tooth will no longer be sensitive to hot and cold but it will be extremely painfully to the touch. You may begin to run a fever and experience swelling. Some people say it feels like the tooth has “raised up”. It has. The infection is pushing it up. The infection will seek the path of least resistance in an effort to relieve pressure. If you are lucky it will establish drainage toward your cheeks or lips through the gums. Once the drainage is established, the pain may resolve somewhat. Again, don’t leave this untreated. If the infection, however, travels toward the tongue, neck or sinuses, to name a few places, it can become very dangerous, very quickly. Possible sequelae include septicemia, airway obstruction and pericardial infections. These complications are not common but are very dangerous and need to be treated by a medical professional. Some of the symptoms of these very serious infections will include increased temperature, swelling under your jaw, under your tongue and around your chin, swelling extending toward your neck, swelling in your throat that may begin to push your uvula aside, difficulty swallowing and/or breathing. Do not ignore these! Seek medical care immediately!

As far as field dentistry for non-dental personnel, you are pretty much limited to prevention, and possibly temporarily treating a reversible pulpitis. I have in the past taught 18Ds [The Army MOS for Special Operations Medical Sergeants] to extract teeth and even perform root canals but they are exceptional men in exceptional circumstances and we had a lot of time to work on it. In this venue I will suggest the names and techniques and perhaps you can fill in the gaps with a willing local dentist.

Two long-standing temporary filling materials are Cavit and IRM. Both of these are a powder and liquid that when mixed will become very hard. The benefit of IRM is that it contains eugenol (clove oil), which is a sedative and can sooth a sensitive tooth. These will keep food and “cold” out of a cavity until you can reach definitive care. If you are somehow able to secure it, Fuji IX is a wonderful restorative material that will also release fluoride and can slow down/stop the decay process. I don’t know how you can get it without a dental license but if you are resourceful…please, I am not advocating non-dentists treating tooth pathology in any way, shape or form (i.e. don’t sue me if you try something and it doesn’t work). I am simply offering some observations from my own experiences that may be helpful when dental care is not available. In the end, you will need to find a dentist but hopefully these tips can help you prevent, treat or recognize the severity of dental pathology that you may encounter in remote areas. This is about four years of school crammed into a few pages so there are huge gaps of course, and there are as many ways to treat disease as there are dentists. Others may have different opinions and better treatment alternatives but I think this can at least organize a discussion or be a good stimulus for questions.


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