MEDICAL: Ditch Dentistry

I do my own dentistry

First the disclaimer.  What follows is for informational purposes only.  Nothing should be construed as dental advice.  Without a proper diagnosis by a qualified dentist, appropriate treatment cannot be recommended.  If you find yourself in the midst of a dental emergency/urgency, seek care from a qualified dentist as soon as possible.  If you read this and then think you are an expert, you are the author of your own demise and it’s not my fault.

No one wants to think about dental emergencies when “out and about” but emergencies happen nonetheless.  There are many possible scenarios that qualify as dental emergencies, and unfortunately, there are some things that just simply can’t be properly treated in the field.  There are other occurences, however, that do lend themselves to “ditch dentistry” to hold you together until you get back to a dentist.

Prevention is easier – “Going For The Gold”:

I have accepted the fact that no one likes to go to the dentist, I don’t even like to go to the dentist.  When working/living/traveling in hot zones, the open ocean, jungles, or other far away places, however, it is far better to have definitive dentistry completed prior going to your gig.  The last thing you want to deal with is a dental problem especially a dental problem that could have been prevented.

Definitive dentistry does not necessarily mean that you don’t have any new cavities and you’ve had your teeth cleaned.  Definitive dentistry means utilizing crowns, inlays, onlays, bridges, etc. to treat the teeth as comprehensively as possible to get the longest lifespan possible out of the teeth and the restorations.  This treatment is more expensive and more extensive than simple fillings, but if it is done properly, it will be worth the investment.

Just to make my point as clear as possible, I have five patients who are dentists themselves.  They had me replace their old fillings with gold crowns, inlays, and onlays.  I have had my fillings converted to gold inlays as well.  The gold standard is the gold standard.  It is my opinion, but it is also what I put in my own mouth, you cannot beat gold.

There are prettier restorations, but when it comes to functionality in the field, with lowest probability of failure, gold is where it’s at.  I made sure mine were solid before I moved to Honduras to do our NGO work in the rural interior of the country.  You do no one any good if you are taken out of commission, or if your awareness is diminished because your teeth hurt.  Also remember to not wait till the last minute to get things squared away.  There are complications that are possible and you want to be sure you are stable before taking off to the four corners of the globe.

Broken Tooth:

There are many variations when one considers a broken tooth.  Sometimes it is as simple as a small chip on the corner of a cusp, other times it is a through and through split that goes into the nerve and below the bone.  In the event a tooth is fractured, and the fractured component comes out, keep it if possible.  Not all pieces can be re-bonded to the tooth, but sometimes they can.  Since there is no way to know, without consulting a dentist, keep what you can.

If a tooth fractures beyond a small chip, significant symptoms can develop.  Exposed dentin (the hard yellowish inner component of a tooth) will be solid tooth structure to which a new restoration can be bonded or cemented, but it can be very sensitive, especially to cold and sweets.  If you have a fracture and you notice sensitivity to stimulus, you may have to moderate what you eat/drink and the temperature of it.

If you are out for an extended period of time, you will hopefully have brought a tooth brush and tooth paste with you.  Under these circumstances, I recommend that folks use a desensitizing toothpaste as their normal toothpaste.  There is a chemical that actually does help reduce dentin sensitivity in the toothpaste and if you already have it with you, it will do its job and start reducing the discomfort (notice I said reduce, not eliminate).

I actually carry/use a toothpaste made by Colgate that is called Prevident 5000 Plus-Desensitizing.  This is a prescription level toothpaste due to the fluoride content, but it is the most effective desensitizing toothpaste I have found to date.

If a fracture extends into the nerve of the tooth (also called the pulp) there will many times be significant pain on biting pressure and many times significant sensitivity to temperature and sweets.  Depending on the severity and extent of the fracture, the treatment could vary between a crown to extraction of a tooth.  Unfortunately, there is no easy temporary fix.

If a tooth breaks and doesn’t hurt, don’t assume nothing is wrong.  As soon as is feasible, get to a dentist to have it evaluated.  Many times a fracture occurs due to a large cavity having undermined healthy tooth structure.  The fracture can be a shot across the bow that is giving you one last warning before it blows up into a big big problem.

Toothache:

The majority of the time when a toothache develops, it is because decay has extended to the nerve of a tooth, or the nerve has died for some reason.  When this occurs, infection and abscess set in.  There are treatments that will help to alleviate the pain and infection, but the only way to stop it once and for all is to have the tooth properly treated by a dentist.  Treatments in these circumstances vary between root canals and extraction.

If the abscess is severe enough (lots of facial swelling), it can actually become a life threatening medical emergency and surgical drains may be required.  About the only thing that can be done, without definitive treatment, is to try to fight the infection back for a temporary reduction in symptoms.

The drug of choice for treating an abscess is Amoxicillin.  If a patient is allergic to the pennicillin family of antibiotics, I generally recommend Zithromax.  I will repeat that these do not eliminate symptoms completely and they do not cure the abscess, they just take the edge off until it can be properly treated.  Some common dosing regimens for Amoxicillin are 500mg capsules three times per day for seven to fourteen days.

I prefer Amoxicilling 875mg tablets twice per day for seven to fourteen days (fewer pills to deal with and easier to remember to take your meds when you wake up and when you go to bed).  Zithromax 250mg should be taken as follows:  Two tablets on the first day at the same time followed by one tablet per day for the next four days.

Lost filling/crown:

If a filling or crown (cap) comes loose, there is no permanent field solution but you can use the drugstore emergency temporary filling kits to fill in the hole or get the crown to stay put until you can get to a dentist.  If the filling or crown came out due to a cavity forming around the old restoration, these filling kits may be limited in their effectiveness (go back to the PREVENT problems section at the beginning).

Once again I will say that you need to get to a dentist if a filling or crown are lost as soon as possible, even if it doesn’t hurt.  There could be bigger problems looming.

Avulsion:

In the event of a traumatic loss of the tooth (knocked out completely for whatever reason) and the root is intact, the options will be limited.  If you are able, put the tooth back in the socket from which it came or put it in a cup of milk (yeah I know everyone is always carrying milk with them).

Do not scrub the root of the tooth and if you must, just rinse the root of debris with clean water or milk.  There is a chance it can be re-implanted by a dentist, but this all needs to happen in a matter of hours at the most.  If you are too far away from a dentist and/or are not going to be able to seen rather rapidly, you will not get the tooth put back in and you will require other treatment to replace it in the future, after you heal up a bit.

In the ditch and you have to pull a tooth:

If things have gone very south and you are in a position to need to extract your own or someone else’s tooth, your day is going to suck and I’m sorry.  The old ice skate/tooth/rock combination made famous in the move “Castaway” is not to be confused as a tutorial.  I would recommend looking over the shoulder of a dentist/oral surgeon and getting a few pointers BEFORE this becomes a necessity, especially if you think you may find yourself in the position to have to do it (medic/permanent remote NGO worker).

You may also want to get the book “Where There Is No Dentist,” published by the Hesperian Foundation.  For what it’s worth they also publish a book titled “Where There Is No Doctor” which is excellent as well.  Youtube also has ample videos of dental extractions so you can get an idea of what is involved.  Some are educational, some are friends wanting to be sure the moment was captured for all eternity, either way, the teeth come out.

Dental emergency extraction kit:

Dental emergency extraction kit:

I will not go into technique here (it would take a looooong time to put that into words) but a basic backpack emergency extraction kit that I carry into the bush consists of:

– Dental Syringe
– 30 gauge short dental needles (5)
– 27 gauge long dental needles (5)
– Dental cartridges of anesthetic 2% Lidocaine 1:100,000 epinephrine (10 cartridges)
– 2×2 gauze (30)
– Dental Bone Currette
– Small straight elevator
– Large straight elevator
– 150 Forcep
– 151 Forcep
-23 forcep
– Hemostat
– Needle driver
– 4-0 Chromic Gut suture with cutting needle (two packs)
– Suture Scissor
– Alcohol wipes (just to clean instruments after an extraction, this DOES NOT sterilize instruments)

If I am planning on doing lots of dental work (like with our NGO work) I obviously will have a much bigger list of equipment that will do lots of stuff, but this is a decent minimal list for a medic to have on hand.

I hope you are never faced with any of these scenarios, but  if you do find yourself in the unenviable position of having a dental emergency, I  hope some of this info can help put you on the right track to getting out of pain as quickly as possible.

DVM Recommends the Following Emergency Dental Supplies:

Emergency Dental Kit >>>

Where There Is No Dentist (Book) >>>

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~Dr. David Sperow
Dental Medicine Correspondent

David is a US based dentist that works through La Cima World Missions to lead medical and dental relief teams to Honduras and Southeast Asia.  Prior to founding La Cima, he and his wife ran a small mission clinic in the mountainous interior of Honduras in 2001 and 2002.

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14 thoughts on “MEDICAL: Ditch Dentistry”

  1. Great article and books referenced.
    You can download both: Where there is no doctor and Where there is no dentist here…

    http://www.hesperian.org/publications_download.php

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  2. Wow, I have never been more glad in my life that I have never had a cavity or really anything wrong with my teeth. But great info Doc, thanks. Now I am going to go and floss again.

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  3. ..why milk?

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  4. Great article Doc, and thanks for writing it man

    I have also wondered about the milk thing – I heard you can do the same thing if you lob off a finger

    ~James G

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  5. I’ve heard that when you lob off a finger or knock a tooth out, you shouldn’t put it straight into milk or ice, that you should wrap it in cellophane to keep it from getting dehydrated and to protect the skin from frost bite. I’ve heard that with teeth you should just put somewhere cold until you can get to a doc. But that’s just me, I could be wrong.

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  6. I’m glad you liked it.

    The root of a tooth is covered with cells that are connected to a ligament. The ligament connects that cell to a corresponding cell attached to the bone in a tooth socket. Teeth are not actually directly connected to bone (most of the time), they are suspended/held in place by the ligament (called a periodontal ligament). When a tooth is knocked out, this ligament is torn but is still half connected to the bone and half connected to the tooth root.

    Milk is better at keeping the cells on the root surface alive longer (there is another solution that can be used, but it’s not something anyone would ever carry with them or mix up in the field). If the cells die then the ligament can’t grow back together and the tooth will fall out, even if it has been put back in place. The longer the tooth is out, the more of these cells die and the lower the likelihood the tooth will be successfully re-implanted.

    This is all an oversimplification but it gives you an idea of why milk is used.

    As far as fingers, I have no idea, I’ve only heard of ice. I reattached a toe once, but it was right after the kid chopped it so everything was still fresh and warm (things that make me glad I’m a dentist ;)

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  7. I had an avulsion happen to a cadet in my care 5 years ago. FMF Corpsman training told me milk, we did that and hoofed it to the E.R.
    It was the weekend so pickings were the B team I guess as no one knew what to do, was referred to a dentist on Monday. this being a Friday I knew the Cadet was probably going to lose the tooth if we waited. Back to Field Medical specialist School training. I had him grab my shoulders, and I braced behind his neck and I pushed it back up into place, gave him a rag and told him to bite down and keep pressure.
    Saw the cadet a few ears later and asked him how “My” tooth was doing. He smiled and said great Sgt. Hewett.
    This is some good knowledge to have as you never know when you might be called upon to use it.
    “Doc” up!

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  8. Outstanding Doc! Sometimes you do what ya gotta do! When you know the outcome is 100% failure (medically speaking) if you don’t do anything, you have nothing to lose to give it a whirl. Glad it worked out for the cadet.

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  9. I gotta go find me a dentist now. Ive been putting off routine visits. You just gave me the e b g b’s. Good info.

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  10. DanL is at least correct about not putting a lopped off appendage directly on ice. It will cause cell damage / frost bite & you will not be able to reattach. Wrap it in something like a paper towel, put in plastic bag & keep it cool. As for putting it in milk, I have never heard this & wouldn’t recommend it.

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  11. EMR/EMT training ’round these parts say to deal with an amputation: dust off debris, put it in a ziplock baggie, wrap that baggie in a triangular bandage and put all that in another, larger plastic bag of ice. Then wait for the cavalry (air ambulance) to arrive to evac to the hospital.

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  12. We had a guy in our scouts canada group who was jerking around, he fell off the cliff edge (about a 20 foot drop maybe less, on a slight incline) and broke 3 teeth.

    We used ASA i think to burn off the tip of the exposed nerve on each tooth, I was 16 at the time so i don’t quite remember, but it was something like that.

    I don’t remember the follow up after they got him off the mountain (Adirondacks in NY state) but it didn’t sound like something that was any kind of fun.

    Is using ASA in an emergency acceptable or no?

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    1. I would not recommend putting it directly on the tissues. Aspirin will cause chemical burns and they are definitely not fun (look for some pics on the web and it will be obvious that they hurt). In the event of a situation as you described, you can count on it hurting bad no matter what, burned surface of the nerve or not. Temperature changes and contact stimulation will hurt the most. The best thing to do (if they are headed for care right away) is for the victim to keep their mouth shut to maintain body temperature in the mouth and of the nerve. They should try to prevent air, fluid, and food from moving over the exposed nerve tissue.

      People also sometimes bite on an aspirin when they have a toothache. It damages the tissues when they do that too.

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      1. Aspirin will cause chemical burns? – Hmmm… I didn’t know that, interesting

        ~James G

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