Dental Emergencies in the Wild Presented by: Dr. Natali Schindler, DDS bite Family Dentistry Banff, AB Common Dental Emergencies • Toothache from a cavity or lost/broken filling (especially important when travelling in high altitudes or scuba diving) • Dental or periodontal abscess • Pericoronitis (wisdom tooth) • Loose crown/bridge • Avulsed or dislodged (tooth (knocked out) • Fractured tooth • Fractured jaw Prevention and Preparation • Mouth guard • Helmet with a jaw guard • Having regular dental exams or an exam prior to going on an expedition • Packing a dental emergency kit and preventive supplies The Dental Emergency Kit Including: Dental examining gloves, dental mirror, dental tweezers or cotton pliers, dental spatula, dental wax, dental floss, temporary filling material-zinc oxide powder and eugenol or Cavit, temporary crown & bridge cement, topical analgesics (Orajel), cotton tip applicators, cotton rolls, sterile cotton gauze pads, oral analgesics/anti-inflammatories, antibiotics, toothbrush with toothpaste, sugarless gum Emergency Medications Analgesics/Anti-inflammatories Antibiotics Ibuprofen 200-400mg, 6-8 hours, prn Rx: pain, do not exceed 1.2g/day. Penicillin V (600mg or 300mg), qid for Acetaminophen 325-650mg, 4-6 hours 7 days. or 1000mg 3-4 times a day, do not exceed 4g/day If allergic to Penicillin: Ibuprofen and Acetaminophen taken Clindamycin (300mg or 150 mg), qid together are more effective than when for 7 days taken individually. Toothache from decay, broken or leaking fillings A toothache is a common dental emergency that is often caused by a cavity in the tooth. Bacteria inside the mouth use food particles left on the teeth to produce an acid, which destroys the enamel and dentin resulting in a hole in the tooth. The pulp tissue often becomes inflamed eliciting a pain response. Broken fillings can occur from an active process of decay under an existing restoration or trauma. Broken fillings are often sharp to the tongue and cheeks and may or may not be sensitive, depending on whether the dentin is exposed. Exposed dentin may cause the tooth to be sensitive to pressure, air or temperature of foods. Signs and Symptoms - Pain from the tooth which is intermittent and often hot or cold sensitive. Hot or cold sensitivity often lasts for a few seconds and goes away. Sharp tooth surfaces can cause pain to the soft tissues such as the tongue and cheek. • Locate the offending tooth and moisten a piece of cotton or cotton pellet with eugenol. Apply the cotton to the tooth or soft tissue to ease pain. • Fill the cavity with temporary filling material such as Cavit, zinc oxide and eugenol cement, or dental wax. Cavit requires no premixing and is applied directly over the tooth. Intermediate restorative material is prepared by adding a few drops of Treatment eugenol to powdered zinc oxide to make as dry a mix as possible. (Zinc oxide and eugenol combination cements are advantageous in that they have an anesthetic effect and can be mixed to different consistencies, depending upon whether they are to be used as filling material or adhesives. However, the liquid can leak from its container, and the cement is sticky and more difficult to work with than Cavit). • Smooth the temporary filling material with your finger or a wet cotton roll. Bite down on the material when it is soft to ensure a comfortable occlusion once set. • Use pain medication as needed. • Temporary fillings set after exposure to saliva and usually have to be replaced every few days. Follow-Up See a dentist after your trip and have the tooth filled with a permanent filling. Dental Abscesses A dental abscess can cause unbearable pain, swelling and discomfort. Dental abscesses are a complication of tooth decay or gum disease. It may also result from trauma to the tooth, such as when a tooth is broken or chipped. Infections may spread out from the root of the tooth and to the bones and soft tissue surrounding the tooth. If not treated, the infection can spread from the tooth to the floor of the mouth, the face and neck resulting in severe illness. Dental Abscess cont’d Signs and Symptoms Toothache -Severe and continuous pain, sharp and shooting pain, throbbing pain, pain when biting and chewing. The pain may keep the person up at night Redness and swelling around the gums and at the root of the tooth Presence of a gum boil near the root of the tooth that may or may not drain General malaise and discomfort Bad breathe and foul taste in the mouth Lymphadenopathy Trismus Swollen face and neck indicating a very serious condition Fever may be present Administer oral antibiotics. (PenV or Clindamycin) Treatment Rinse with warm salt water (1teaspoon of salt in 1 cup of warm water) a few times a day. If there is a soft, pointing abscess adjacent to the offending tooth, apply orajel and then puncture the boil with a sharp sterile scalpel if available. This will help relieve the pressure and the pain. Reduce pain and fever with oral analgesics (Ibuprofen, Acetominophen). Loss of tooth Spread of infection to soft tissue (facial cellulitis, Complications Ludwig's angina). Spread of infection to the jaw bone (osteomyelitis of the mandible or maxilla). Spread of infection to other areas of the body resulting in cerebral abscess, endocarditis, pneumonia, or other disorders. If the swelling is localized to the soft tissues of the cheek or the submandibular area, begin oral antibiotics and monitor. If the infection spreads to the infra-orbital space or is starting to affect the airway, the patient has a persistent fever or are lethargic management in the hospital setting will be necessary – GO TO THE NEAREST HOSPITAL. Follow Up Visit a dentist for definitive diagnosis and treatment. Pericoronitis Pericoronitis is an infection of the gum tissue that overlaps a partially erupted tooth. It is most common around lower erupting or impacted wisdom teeth. Bacteria and food debris get trapped under the tissue and cause swelling, pain and infection. Pericoronitis cont’d Signs and Symptoms Treatment Bad taste or bad breathe. Oral antibiotics Pain - may be mild but is Irrigate with salt water usually quite intense and my radiate to the external neck, Oral anti-inflammatories and the throat, the ear, or the oral analgesics floor. Soft diet Trismus If the infection spreads and Cervical lymphadenopathy, affects the airway, there is fever, and malaise continued malaise and fever or the symptoms worsen – GO THE Swelling localized around the NEAREST HOSPITAL impacted or erupting tooth. Follow up: Visit a dentist - the tooth may need extraction Loose Crowns or Bridges Loose crowns or bridges can pose a problem while in the back country. A loose crown is dangerous as it can be aspirated or even swallowed if not careful. A loose crown should be re-cemented to prevent sensitivity and further bacterial contamination. The tooth may feel sensitive to temperatures or the bite might feel different and the crown is loose or comes off. Remove the crown/bridge from the mouth. Wash away any debris and food particles around the tooth by rinsing with water or with a cotton tip applicator or toothbrush. Remove the remainder of cement in the crown. Treatment Check to see that the crown goes back on and the bite is comfortable (if the bite is off – this can lead to pain in the tooth and jaw pain) Mix zinc oxide and eugenol into a temporary cement consistency (runny) and place into the crown. Alternatively, prepared dental cements, such as Temp Bond can be used. Place the crown back on the tooth in the correct position and bite down until the cement is set. Clean off any excess cement with a toothpick, toothbrush and floss between the teeth. Follow-Up Visit your dentist as soon as your trip is over for definitive treatment. The tooth may require a new crown or may simply need to be re-cemented with permanent cement and adjusted into occlusion. Dislodged or Avulsed Tooth When a tooth is dislodged or knocked out, timing is everything. The tooth has a better chance of surviving the sooner it is placed back into the socket. When possible, gently rinse the root and socket with water and remove any debris (do not scrub the root) and place back in the socket immediately. Pack with temporary material to splint in place. Eat a soft diet. See a dentist as soon as you can. Delayed Treatment For delayed treatment of an avulsed tooth (5 minutes – 60 minutes), the tooth should be stored in a physiologic medium such as chilled milk, saliva, tissue culture medium). Usually ankylosis will be the outcome. Over 60 minutes of time out of the mouth will predictably result in ankylosis. The decision to replant a tooth is reversible: it allows for more time to assess other available options and plan for eventual loss of the replanted tooth. The tooth will require endodontic therapy and a more rigid splint for 7-14 days. Seeing a dentist as soon as possible will provide the most favorable outcomes. Implants or dental bridges are long term treatment options if tooth must be extracted or is not replanted. Traumatic Dental Injuries A fractured tooth, for the most part, can be saved depending on where the fracture occurs and if the nerve is exposed. Most dental fractures occur in the front teeth, however some fractures occur on posterior teeth such as the molars. Fractured Teeth Signs and Symptoms Treatment Broken tooth Place temporary restorative filling material into the fractured area of the Pain and sensitivity when breathing in tooth (if it will hold). air. Avoid hard foods and maintain a soft Hot and cold sensitivity when eating.