BOOK 3

DENTAL CARE

CHAPTER 7

DENTAL CARE

M any of our readers are frequently taken aback that a survival medicine book includes a dental problems section. However, history teaches us that the majority of the patients who seek medical attention have dental issues. Medical professionals observed that oral symptoms were presented by half of all sick call patients during the Vietnam War.

To be clear, neither of us is a dentist, and practicing dentistry without a license is against the law and punishable by fines. Dental problems that are considerably worse than a bad tooth may result from a lack of professional training or expertise. If you can, seek out contemporary dental care.

Anyone who has tried to complete a task while also managing a severe toothache will attest to the drop in productivity brought on by the issue. It only makes sense that you should become familiar with fundamental dental care and techniques to tackle typical dental emergencies.

According to the survival medic's guiding principle, an ounce of prevention is worth a pound of cure. When it comes to your teeth, this way of thinking is extremely relevant. You can prevent your loved ones from suffering a great deal of discomfort by establishing a basic dental hygiene routine (and yourself from many headaches).

The tooth's anatomy is very straightforward for such a vital component of our bodies. Thus it is important to examine. The "crown" is the portion of the tooth that is visible above the gum line. The "root" lies beneath it. The "alveolus" is the bony cavity that houses the tooth. Similar to how ligaments hold your ankle or shoulder together, teeth are attached to the alveolar bone utilizing them.

The tooth is made up of a variety of substances:

Enamel is the tooth's crown's exterior, hard and white.

Dentin is the bony, yellowish substance surrounding the pulp beneath the enamel.

Located in the middle of the tooth, the pulp is a connective tissue that contains blood vessels and nerve endings.

Bacteria are the main cause of dental disease. They're everywhere in your mouth, so anything lessens the number of bacteria there will lessen the likelihood of complications.

Although maintaining a daily brushing practice is important, you will eventually run out of toothbrushes. You can also apply some toothpaste with your finger in a circular motion as an option. You may also use a piece of cloth for this.

Another choice is to use the fibrous end of a twig you've been chewing on to clean your teeth. Any bent twig will do (living wood), so long as it is bendable. The other end of this twig can be used as a toothpick; therefore, it has two uses.

Commercially produced toothpaste will eventually become unavailable. Take baking soda into consideration as a cheap substitute. Compared to toothpaste made with produced silica, it is less abrasive to dental enamel.

You should wash your teeth or, at the very least, rinse your mouth after each meal and, especially, before going to bed. Infection risk will be reduced, and gum irritation will be reduced.

An efficient and affordable method would be to use a mixture of half water and half hydrogen peroxide (3 percent). Swish it in your mouth for a minute or two to get the best effect. Mouthwashes are sometimes overlooked when planning a survival kit, even though they are an excellent way to guard against dental problems. Higher hydrogen peroxide concentrations should be avoided because they can cause tongue burns.

Reliable flossing is another way to stop dental decay. Although some people might find it uncomfortable, many bacteria buildup occurs between your teeth. By flossing and then smelling the floss, you can demonstrate this. Due to the substantial amount of bacteria you just ejected, it will smell bad if you don't floss frequently. Removing unwanted things from between teeth, such as food particles, is another benefit of dental floss.

 

TOOTH DECAY

 

Understanding how germs cause dental disease is crucial. Your teeth are colonized by bacteria that dwell in your mouth. They typically gather around where the gums and teeth contact and the notches on your molars. The tartar or plaque that results from these colonies forming at the enamel's base is thick and erratic. Your gums and teeth are less healthy the more tartar you have.

These bacterial colonies eat with you when you eat; they digest the sugars you consume and release a poisonous acid. Your teeth's enamel will slowly dissolve as a result of this acid.

After the enamel has deteriorated, a "cavity" is produced. The process quickens and begins to produce pain because each tooth has living nerves when the cavity gets deep enough to infect the tooth's soft inside (the pulp). Once the germs have penetrated sufficiently deep into the nerve or the surrounding gum tissue, the cavity may become infected if it is not treated.

When your gums are inflamed, they will seem red and puffy and bleed when you wash your teeth. This condition, known as gingivitis, is quite typical in adults. Infection is a simple consequence of the condition's deterioration. If the gums are affected, they could spread to the tooth roots or even the bone socket.

Once the tooth's root is affected, you could get a bad infection (abscess). This swelling of the gums and accompanying inflammatory fluid buildup can be extremely painful. Once you develop an abscess, you will require antibiotic therapy and possibly surgery to drain the collected pus. At this time, it's probably too late to save the tooth.

Toothache

Finding the problematic tooth is the first step in treating a toothache. Ask your patient to open his or her mouth so you can look inside. A toothpick and mirror are useful starter items. You will first look closely for any noticeable cracks or cavities. However, even if there isn't anything visible, you could still have extensive decay beneath the gum line or in between the teeth.

So how do you identify the problematic tooth if nothing is immediately apparent? Use something cold to massage the teeth where the pain is occurring. The damaged tooth will be extremely vulnerable to cold. Now contact it with a hot object. The tooth is possibly still salvageable if there is no sensitivity to heat.

Putting something hot on a tooth that is likely beyond saving will hurt a lot (only touching the tooth). After you turn off the heat source, it will hurt for around 10 seconds more. This is a result of irreparable nerve injury. You cannot feel hot or cold if the nerve is destroyed at the root level. However, even the slightest touch will be unpleasant.

If at all possible, contemporary dentistry aims to save every tooth. Extraction was the primary method of treating a bad tooth in the past—even as late as fifty years ago. We might need to use that tactic once more in a survival situation.

A severely decaying tooth will likely worsen if you put off extraction. Other teeth could get affected by decay, or it could result in septicemia, an infection that could enter your bloodstream and do serious harm.

The most crucial fact to be aware of is that tooth extraction can effectively treat 90% of dental crises.

What more should the medic's dental kit include except a mirror and a dental pick?

 

Health and Dental Kit

       Toothbrushes and floss.

       Dental or orthodontic wax, such as that used for braces; in a pinch, even a candle can do. A loose tooth can be secured to its neighbors using wax.

       A rubber bite block to maintain an open mouth. Thanks to this, you'll be able to observe the dentition and avoid getting bit. The task would be perfectly accomplished by one of those big pink erasers.

       Cotton swabs, Q-tips, and cloth sponges (cut into small squares).

       A material used as a temporary filler, such as Tempanol, Cavit, or DentempTM.

       Eugenol is a natural anesthetic found in clove oil. Eugenol should only be used on teeth as it burns the tongue, so keep that in mind.

       When combined with two drops of clove oil, zinc oxide powder can be used to secure loose crowns or create a temporary filling cement.

       Dental pick, dental mirrors, and tweezers.

       Forceps for extraction. These have curled ends and resemble pliers. There are variations for upper and lower teeth. Dental extractors come in various shapes and sizes, but you should have at least two of each: the number 151 or 79N for lower teeth and the number 150A or 150 for upper teeth. The number 23 can also be used for some molar extractions.

       Two elevators, one medium and one little. By separating the ligaments that keep teeth in their sockets, these tiny, chisel-like tools aid in loosening teeth. (A few components from a Swiss army knife might come in handy.)

       Painkillers and antibiotics; a dental scaler and dental pick to remove tartar.

 

Temporary Fillings

Crowns that are loose or missing fillings are common dental problems. Creating a combination that can quickly harden and offer a passable seal, these can be fixed, at least temporarily.

Make a paste by combining two drops of clove oil with zinc oxide powder. Apply it to the region after rolling it into a ball. In addition to reducing discomfort, it will harden.

Scrape any black deterioration with your dental pick, paying great attention to the cavity's margins. Your paste should cover the entire region that the initial filling once occupied. Scrape away any extra so the person can normally bite with their teeth closed. To locate spots where more cement has been applied, use carbon paper or paper that has been penciled on. The patient bites down so the carbon can darken the extra filling material.

It should be remembered that they are only short-term solutions. You'll probably need to repeat the filling procedure several times unless modern dentistry becomes once more accessible.

 

Dental Trauma

       Dental trauma can take many different forms. A person may have any of the following symptoms following an oral cavity injury:

       Dental fracture: A chipped or broken piece of a tooth

       a loose tooth or dental subluxation

       Dental avulsion: the total knocking off of a tooth

The number of layers exposed when a piece of a tooth is broken off determines what type of tooth it is. These are typically referred to as Ellis classes I, II, or III fractures by dentists:

Injury to Ellis I: Here, no pulp or dentin is visible because just the enamel has been fractured. This is only a concern if the tooth has a sharp edge. You can think about filling the edge smoothly or applying a temporary cement made of powdered zinc oxide and clove oil (eugenol).

Ellis II fracture: Under the enamel, this fracture reveals yellow or beige dentin. If possible, cover up this region since it can be sensitive. Since dentin is distinct from enamel, bacteria may infiltrate and infect the tooth.

The pulp and dentin are exposed in an Ellis III fracture, which can be very unpleasant. The pulp may bleed if it is exposed. Here, covers for protection will be most important, and the likelihood of lasting harm will be greatest.

When a tooth is broken, you should check the patient for any other injuries, such as those to the face, or the interior of the cheek, tongue, or jaw. Sometimes a tooth fragment gets stuck in the soft tissues and needs to be extracted using tools.

Because of the trauma, blood is probably present; therefore, completely rinse out the mouth's interior so you can fully evaluate the situation. Then, check if the damaged tooth is loose using your gloved hand or a cotton applicator. Remember to bring your bite block.

To lessen sensitivity in Ellis II dentin fractures, the exposed surface should be covered with a calcium hydroxide composition (marketed as DycalTM), a fluoride varnish, transparent nail polish, or a medical adhesive like DERMABONDTM (super medical glue). Give the patient pain medication and advise them to avoid hot and cold foods and beverages.

Ellis III fractures into the pulp are problematic for several reasons, including the potential for infection. Coverings made of calcium hydroxide on the pulp surface and additional temporary cement can be employed. Analgesics and antibiotics are appropriate possibilities; penicillin or doxycycline come to mind. Despite this, without contemporary dental intervention, the prognosis is not good.

The root is a particularly challenging dental fracture. Sometimes a fracture in the root is not visible until the gum is peeled aside. If this is the case, the tooth is routinely extracted as it is probably beyond repair (particularly in vertical fractures).

 

DENTAL SUBLUXATIONS AND AVULSIONS

 

A tooth that has been knocked loose but is still in its alveolar socket is said to have subluxated. To find out if the tooth is loose and how much, lightly push it with your gloved palm or a cotton swab. A minor trauma might not need any serious treatment.

To stabilize a loose tooth, it should be forced back into its alveolus (socket) and "splinted" to nearby teeth. Dentists utilize wire or other specialized materials for this, but you may use soft wax if a dentist is unavailable. Use enough wax to secure the protruding tooth to its front and neighboring rear teeth if possible. Put the patient on a diet of liquids and soft meals until the tooth appears to be well fixed to prevent further stress.

When a tooth is knocked out (an avulsion), the best-case scenario is that it was extracted intact, including the ligaments and root. Time is crucial in this situation for the potential efficacy of the treatment. The success of reimplantation decreases by 1% per minute when a tooth is not in its socket if it is not replaced or at least placed in a preservation solution. Don't try to replace baby teeth, please.

Hanks' solution is an effective tooth preservation solution for teeth that have been knocked out. For a while, it helps shield undeveloped ligament fibers. Commercially, this solution is offered under the name Save-a-tooth.

What to do if a tooth is knocked out is as follows:

Locate the tooth.

Avoid contacting the root when picking it up by the crown to prevent further injury to the ligament fibers.

Use water or saline to rinse the tooth free of dirt and debris. Scrubbing it will only cause the ligament more injury.

Place the teeth in milk, saline solution, or saliva if you don't have preservation solution (put it between your cheek and gum or under your tongue). This will prolong the life of your ligament cells longer than just drinking water.

You can try to reimplant the tooth if it has been out for less than 15 minutes. Use Hanks' solution (Save-a-Tooth) to clean the tooth and the empty socket before replacing it and covering it with cotton or gauze. The patient should then make a strong bite to maintain it. Placing your patient on a liquid diet after splinting it with soft wax to the adjacent teeth. To avoid infection, antibiotics like penicillin (veterinary equivalent: Fish Pen) or doxycycline (Bird Biotic) will be beneficial.

If the tooth has been out for longer than 15 minutes, you might need to soak it in Hanks' solution for around 30 minutes before replacing it. Make sure you have painkillers in your supplies because the longer you wait to replace the tooth, the more painful it will probably be to do so.

The ligament fibers dry out and die after a few hours of exposure to air, and the tooth is essentially dead at this point. It would be difficult to replace it at this point since the pulp would decompose as all dead soft tissue does. The dead tooth then scars down into its bony socket, behaving like a dental implant, and may even turn dark in color. Ankylosis is the term for this.

It's crucial to understand that even if the ligament survives the lesion in mature permanent teeth, the pulp does not. As a result, even your greatest efforts might not succeed if there is no access to contemporary dental care to remove dead tissue. Your patient can be in more danger than just losing a tooth if there is a serious infection in the dead pulp.

Even while going without a dentist occasionally might be uncomfortable, most dental crises would leave us with few other options. In such cases, the preferred course of therapy may need to be tooth extraction.

 

DENTAL EXTRACTION

 

One day, as a medical professional, you might have to pull a tooth because it is infected. Tooth extraction is not a pleasant procedure in its current form, and it will be even less so in a long-term survival scenario with no power and few resources. A permanent tooth can't usually be pulled out by merely wriggling it with your gloved hand or by tying a thread to the nearest doorknob and slamming that. However, anyone planning to provide medical care in the wake of a severe tragedy will need to be familiar with the method.

Your ability to complete the process will increase with proper placement. For an upper extraction, the patient should be tilted at a 60-degree angle to the ground (also called a maxillary extraction). The medic's elbow should be level with the patient's mouth. A lower extraction, also known as a mandibular extraction, requires the patient to sit upright and have their mouth below the doctor's elbow. Standing to the right of the patient for right-handed medical personnel and the left for left-handed personnel. Standing in front of the patient when doing upper and the majority of front lower extractions is advisable. Some people like to stand behind the patient when extracting lower molars.

Wash your hands first, then wear gloves, a face mask, and eye protection. Keep the region around the tooth as dry as possible to see what you're doing. There will be some bleeding, so you might wish to wrap the tooth in cotton balls or pieces of rolled gauze that you can remove and replace as needed.

The ligaments, fibrous connective tissue, keep the teeth in their sockets. To release the tooth, these ligaments must be cut. An elevator—which resembles a small-headed flathead screwdriver or chisel—is used to do this.

 

Dental extractors and elevator

Apply little pressure around the tooth in question and between the gums to descend to the root region. The tooth ought to get loose as a result. There may be bleeding.

Grab the tooth as far down the root as you can with your extraction forceps. This will increase your chances of successfully extracting the tooth the first time. After first loosening the tooth with your elevator, apply pressure straight downward for the upper teeth and straight upward for the lower teeth for the front teeth (which have one root). When removing teeth with multiple roots, such as molars, shaking the tooth will aid in further loosening it. When a tooth becomes loose, extract it away from the tongue and toward the cheek (or lip if it's a front tooth). All teeth benefit from this except the backmost lower molars (wisdom teeth).

Use the opposite hand to support the mandible (lower jaw) for lower extractions. You will need to extract the remaining root if the tooth breaks during extraction (this happens frequently). To assist, press the root outward and loosen it further; use your elevator.

Then, apply gauze to the bleeding socket and ask the patient to bite. To stop excessive bleeding, cut an item called ActCel hemostatic gauze into small squares, moisten them, and apply them directly to the bleeding location. In 24 hours, it ought to solidify into a gel that may be removed with water.

Occasionally, if bleeding is severe, a suture may be needed. In this situation, use 4-0 chromic catgut absorbable suture material. N-butyl-2-cyanoacrylate also referred to as veterinary "super glue," was successfully employed in a recent study conducted in Cuba on more than 100 patients to control both bleeding and discomfort. In some situations, DERMABOND adhesive has been applied in US emergency rooms for short-term relief. For 24 to 72 hours, stay away from hot beverages and crunchy meals.

Over the next few days, discomfort, bruising, and swelling are expected. Applying cold compresses will reduce swelling for the first 24 to 48 hours; after that, warm compresses can improve jaw stiffness. Consider medications as well because the infection is another potential problem. To lessen trauma to the area, the patient should be placed on a diet of liquids and soft foods.

Use ibuprofen, acetaminophen (Tylenol TM), or another non-steroidal anti-inflammatory drug to treat pain (or stronger meds, if you have them). Avoid taking aspirin since it can prevent blood clotting in the socket. Don't smoke, spit, or even use straws because the blood clot is there to protect you; doing so could develop alveolar osteitis, sometimes known as "dry socket," which is a painful ailment.

In this scenario, the clot will have disappeared, and the person's breath may smell bad. Here, antibiotics and warm saltwater gargles are helpful, and a water solution infused with a tiny bit of clove oil may help to lessen the discomfort. Avoid using too much oil because it could cause tongue burns.

To survive over the long term, tough choices must be made. The survival medic will also need to serve in the capacity of dental care provider if modern dentistry is rendered obsolete due to a mega-catastrophe. If you have access to contemporary dental care, you should never perform a dental procedure on someone.

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