Third World Dentistry (Belize and Haiti)

& Dental Emergencies in the Wilderness

Dr. Eric Parsons - DDS

Dr. Elsa Hui-Derksen, DMD

Winnipeg, Manitoba

Kindness in Action - Belize 2004

The objectives of Kindness in Actions are as follows:

•  To provide dental health services, doing as much as we can with what we have.

•  To honor, support and empower those with less and assist them in becoming self-sufficient.

•  To educate and raise awareness of Developing World Issues.

Kindness in Action has been in existence for 11 years and sends teams to the countries of Guatemala, Honduras, Nicaragua, Mexico, Belize, Peru, Phillipines, India and Thailand. KIA focuses on the relief of pain for the greatest number of people and serving communities.

The 2004 trip to Belize was the first of its kind for Kindness in Action. I was involved with a team of 23 individuals on a one week trip to a small village in the north eastern part of Belize called Sartenja.

Discussion for today:

a) History of the country and need for dentistry

b) The making of a makeshift dental clinic

c) The need for a reliable liaison when volunteering in a foreign country

d) Risks and rewards

Dental Emergencies Statistics - How much at risk are you?

1. Dental health prevention for the traveller :

a) Need for regular dental visits

b) Mouthguard

2. Management and treatment of dental emergencies in the wilderness:

a) Toothache from a Cavity and Lost/Broken Fillings

b) Tooth Abscess

c) Pericoronitis

d) Loose crown

e) Dental Injuries

Fractured tooth

Avulsed tooth (Knocked Out Tooth)

3. Know what to include in an emergency dental kit

1. Dental health prevention for the traveller

Dental emergencies can happen when leased expected. You could be in the middle of a hike on the West Coast Trail, mountain climbing in Alaska, or camping in Banff National Park where access to a dentist may not be readily available. It is important to know which dental emergencies can be temporarily treated in the wilderness and which ones require immediate attention.

The best prevention is to have regular dental visits and/or to visit your dentist prior to going on a long trip. A leaky filling can cause a problem at high altitudes or below sea level. This is especially applicable to mountain climbers and scuba divers. Bring essential dental care supplies on your trip - toothbrush, toothpaste, and floss. Floss and brush after every meal to avoid food being lodged into the gums, which can result in an aggravating gum infection.

Sugarless chewing gum can also become a good friend during long trips. When brushing and flossing are not ideal, chewing sugarless gum helps to promote saliva flow and clear the teeth and gums of excess food particles.

Mouthguards can be important for those travelling and enjoying high impact sports. Mouth protectors, which typically cover the upper teeth, can cushion a blow to the face, minimizing the risk of broken teeth and injuries to the soft tissues of the mouth.

2. Management and treatment of dental emergencies in the wilderness

Toothache from a cavity and broken 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 inflammed eliciting a pain response.

Broken fillings can occur from an active process of decay under an existing restoration. 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 which is intermittent and often hot or cold sensitive. Hot or cold sensitivity often lasts for a few seconds and goes away.

Treatment

1. Locate the offending tooth and moisten a piece of cotton or cotton pellet with eugenol. Apply the cotton to the tooth.

2. 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 clove oil to powdered zinc oxide to make as dry a "dough" 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®).
3. Smooth the temporary filling material with your finger or a wetted toothpick.

4. Give pain medication as needed. (Ibuprofen 600 mg q4-6h prn)

5. Such fillings set after exposure to saliva and usually have to be replaced every few days.

Follow-up Treatment

See your dentist after your travel and have the tooth filled with a permanent filling.

Abscesses and gum infections

A tooth abscess is a collection of infected material (pus) resulting from bacterial infection of the center (pulp) of a tooth. A tooth abscess can cause unbearable pain and discomfort to the traveler. Tooth abscesses are a complication of tooth decay. It may also result from trauma to the tooth, such as when a tooth is broken or chipped. Openings in the tooth enamel allow bacteria to infect the center of the tooth (the pulp). Infection may spread out from the root of the tooth and to the bones supporting the tooth.

Infection results in a collection of pus (dead tissue, live and dead bacteria, white blood cells) and swelling of the tissues within the tooth. This causes a painful toothache. If the pulp of the tooth dies, the toothache may stop, but the infection remains active and continues to spread and destroy tissue. If not treated, the infection can spread from the tooth to the floor of the mouth, the face and neck resulting in severe illness.

Signs and Symptoms

1. Toothache

- Severe and continuous pain

  - Sharp, shooting pain

  - Throbbing pain

2. Pain upon biting and chewing to the effect the tooth feels longer

3. Redness and swelling around the gums and at the root of the tooth

4. Presence of a gum boil near the root of the tooth that may or may not drain

5. General malaise and discomfort

6. Bad breath and foul taste in the mouth

7. Swollen glands in the neck area - lymphadenopathy

8. Swollen face and neck indicating a very serious condition

9. Fever may be present

Complications

•  Loss of the tooth

•  Spread of infection to soft tissue (facial cellulitis, 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

Treatment

1. Administer oral antibiotics.

  Pen V 500 mg

  2 tabs stat then 1 tab qid until finished

2. Rinse mouth with warm salt water (1 teaspoon of salt in 1 cup of warm water) every 4 hours. Salt water rinses are good as they alkalinize the mouth creating an environment less favorable for bacteria.

3. If there is a soft, pointing abscess adjacent to the offending tooth, apply orajel and then puncture the boil with a sharp scalpel if available. This will help relieve the pressure and the pain.

4. Reduce pain and fever with oral analgesics (Ibuprofen 600mg every 4-6 hours).

Follow-up Treatment

Upon returning from your trip, visit your dentist for definitive treatment. Root canal treatment is most likely required to remove the infected pulp tissue and decay. The tooth is then restored with a core and crown after the root canal treatment.

Pericoronitis

Pericoronitis is an infection of the gum flap that overlies a tooth that has only partially advanced ("erupted") into the mouth. This is most common with a lower third molar and usually indicates an infection with Streptococcus bacteria.

Signs and Symptoms

1. Bad taste or foul breath

2. Pain resulting in limited range of motion and inability to open completely (trismus)

3. Pain may be mild but is usually quite intense and may radiate to the external neck, the throat, the ear, or the oral floor

4. Cervical lymphadenopathy, fever, and malaise are common signs and symptoms

Treatment

1. Rinse with warm salt water rinses every 4 hours.

2. If hydrogen peroxide is available, attempt to irrigate the area with a syringe to remove food debris, plaque and pus.

3. Administer oral antibiotics.

Pen V 500mg

2 tabs stat then 1 tab qid until finished

3. A soft diet is advisable.

Follow-up Treatment

Visit your dentist immediately after your trip to have a referral to an oral surgeon. The condition will persist until the tooth is removed.

Loose or lost crowns

Loose crowns can also pose a problem while travelling. A loose crown is dangerous as it can be aspirated or even swallowed if not careful. A loose crown should be recemented to prevent sensitivity and further bacterial contamination.

Signs and Symptoms

1. A loose crown may feel like you are not biting like you normally do

2. Hot and cold sensitivity due to exposed dentin

Treatment

1. Wash away any debris and food particles around the tooth with a cotton tip applicator or toothbrush.

2. Remove remainder of cement in the crown

3. Mix zinc oxide and eugenol into a temporary cement consistency and place into the crown. Alternatively, prepared dental cements, such as Dentemp®, are premixed and are simple to carry and place.

4. Place crown back on the tooth in the correct position and bite down until the cement is set.

5. Clean off any excess cement with a toothpick and floss between the teeth.

Follow-up Treatment

Visit your dentist as soon as your travel 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.

Complications

Crowns that are not recemented will cause further problems as the occlusion will be affected and the adjacent and opposing teeth will shift out of position. The tooth is vulnerable and weak and needs to be restored immediately to prevent loss of the tooth.

Traumatic dental injuries

Fractured tooth

A fractured tooth can be saved depending on where the fracture occurs and if the nerve is exposed. Most teeth fractures occur in the front teeth, however some fractures occur on posterior teeth such as the molars.

Signs and Symptoms

1. Pain and sensitivity when breathing in air

2. Hot and cold sensitivity

3. Bleeding around the gums at the injured site

4. Mobility may or may not be present

Treatment

1. Place temporary restorative filling material into the fractured area of the tooth if it will hold.

2. Avoid hard foods and maintain a soft diet.

3. Avoid very hot and very cold drinks.

4. Check other areas of the mouth for lacerations or broken teeth fragments.

Follow-up Treatment

If the no pulp exposure occurs the tooth can be restored with a simple filling upon returning to civilization. If the nerve is exposed and a pinpoint bleed can be seen at the site of the fracture, the tooth can sometimes be restored with a base and filling. Larger exposures will require root canal treatment.

Dislodged and avulsed teeth (knocked out tooth)

A dislodged tooth involves a tooth that has come out of position in its socket. An avulsed tooth is one that is completely knocked out of its socket and requires immediate attention in order to save it. The single most important factor in the success of reimplantation of an avulsed tooth is the speed of reimplantation. The first 15-20 minutes are crucial, after that the periodontal ligament cells lose their normal physiological function.

Treatment

1. Clean any dirt and debris off the tooth by gently rinsing with saline. Do not scrub the root surface, as it will damage vital cells required for reimplantation.

2. Irrigate the socket gently of any debris or dirt.

3. Carefully place the tooth back into the socket in the correct position and orientation.

4. Remember to hold the tooth at the crown portion to avoid disrupting the periodontal ligament cells.

5. See your dentist immediately to have the tooth splinted into place.

6. If seeing your dentist is impossible, splint the tooth to the adjacent teeth by placing a strip of wax across a span of two teeth to the right and left of the affected tooth. Do the same on the inside surface of the teeth.

7. Soft diet is advisable for at least two weeks.

If the tooth cannot be reimplanted easily, the best transport media to place the tooth in is milk, followed by saliva. Milk maintains vitality of the periodontal ligament cells for up to 3 hours whereas saliva maintains cells for 2 hours. Immediate dental treatment should be sought.

3. Emergency dental kit

An emergency dental kit may prove handy during long trips in the wilderness. Dental emergencies can cause a lot of grief and take away the enjoyment of a trip. An emergency dental kit is easy to pack and lightweight. They can be purchased or made at home.

Essential items to include:

Dental examining gloves

Dental mirror

Dental tweezers or cotton pliers

Dental spatula

Dental wax

Dental floss

Temporary filling material - zinc oxide powder and eugenol

Temporary crown & bridge cement

Topical analgesics

Cotton tip applicators

Cotton rolls

Cotton gauze pads

Toothbrush with toothpaste

Resources:

Cohen S, Burns RC, Pathways of the Pulp, 8 th Edition, St. Louis: Mosby, 2002:636-637.

Peterson LJ, Ellis E, Hupp JR, Myron RT, Contemporary Oral and Maxillofacial Surgery, 3 rd Edition. St. Louis: Mosby, 1998:219.

Weiss, EA., Backpacker Wilderness 911. 3 rd Edition, Seattle: The Moutaineers, 2003.

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