This chapter will train you to evaluate and treat oral and dental conditions that occur in the wilderness, according to the following criteria:

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Chapter 11 Wilderness Dentistry This chapter will train yu t evaluate and treat ral and dental cnditins that ccur in the wilderness, accrding t the fllwing criteria: T understand basic tth anatmy T be
Chapter 11 Wilderness Dentistry This chapter will train yu t evaluate and treat ral and dental cnditins that ccur in the wilderness, accrding t the fllwing criteria: T understand basic tth anatmy T be able t describe etilgies and treatment f painful pulpitis. T be able t recgnize and treat failed dental restratins. T be able t describe and treat varius types f ral infectins. T be able t describe and treat a fractured tth T be able t describe and treat an avulsed tth. 110 Case 1 A 38 year-ld male is attempting t summit Munt McKinley when he injures a tth while biting dwn n a piece f hard candy. He cmplains f sensitivity t cld and liquids and pain when he bites n the invlved tth, which is his upper left canine. On examinatin, yu nte a missing filling and part f the tth lst n the buccal side. There is n bleeding. 1. What is the mst likely cmplicatin, ther than pain, that this climber will have if the tth is nt repaired? 2. What is the best way t repair the tth? 3. Des this situatin require antibitics? Case 2 A 56 year-ld wman is backpacking the Appalachian Trail when she develps a cnstant ache in her lwer left first mlar, with sensitivity t cld and pressure. She denies trauma t the tth. On examinatin, the tth has an intact large filling, with pain n percussin. There is n evidence f tth fracture r gum swelling. 1. What is the mst likely etilgy fr her symptms? 2. What is the best way t manage this situatin, ther than pain management? 3. Des this situatin require antibitics? If yu were ging t use an antibitic, which ne wuld yu select? Case 3 A 16 year-ld climber is struck in the face by a falling rck, which kncks ut his right frnt permanent upper incisr. Frtunately, the rck kncked the tth back int his muth, s the victim pssesses the avulsed tth. 1. What is the first step in the management f this tth avulsin? 2. Is this a tth that shuld be replanted? 3. Hw wuld yu clean this tth if it fell int the dirt? 4. What is the best way t transprt this tth if yu d nt replant it? 5. Wuld yur management be different if this was a primary tth in a 4 year-ld male? 111 Basic Dental Anatmy There are three primary regins f the tth; enamel, dentin and pulp. The supprting tissue cnsists f the gingiva (gum), peridntal ligaments (PDL), and bne. Enamel Enamel is the uter layer f the tth and cnstitutes the crwn (part f the tth ne sees when lking in the muth). It is the hardest substance in the human bdy and devid f nerve endings. Dentin The dentin, while still a fairly hard substance, is made up f tiny fluid-filled tubules. The dentin prvides nutrients t maintain tth viability and the ability fr a tth t handle stress lads. If the stress lad is t great r a tth becmes brittle because it has lst vitality, it can break r crack. If dentin is expsed, a persn can experience pain when an applied stimulus makes the fluid in the dentinal tubules mve and thus elicit a respnse frm the nerve. Pulp The inner layer f the tth is the pulp chamber, which cnsists f the neurvascular bundle, ften referred t as the pulp. When this area is affected, a persn can experience pain. If a tth is fractured dwn t the pulp, ne may ntice bleeding frm the tth. Clinical Presentatin & Management Pulpitis Inflammatin f pulp tissue (neurvascular bundle) is the primary cause f mst tthaches. Pain can range frm mild t debilitating and can be steady r intermittent. The etilgy f inflammatin can arise frm: Bacterial invasin (cnsequences f the tth decay ( cavity ) prcess) Lcal irritatin (e.g., a restratin being placed in clse prximity t the pulp chamber) Physical trauma, first causing inflammatin f the pulp, and then reducing r eliminating bld supply t the tth, which causes necrsis f pulp tissue. Pulpitis in early stages can be reversed. Early n, the tth will be sensitive t a stimulus such as heat r cld, r sweet r sugary fd placed n the tth. Once the nxius stimulus is remved, the tth returns t its nrmal status. With irreversible pulpitis, the tth will frequently remain achy r painful after the stimulus has been remved. Pulpitis can be classified int mild, mderate, and severe. The amunt f treatment needed varies with severity f tthache. Mild pulpitis is ften reversible and can be treated simply by aviding any stimulus. Severe pulpitis requires remval f pulp tissue r extractin f the tth. This is usually nt feasible in the backcuntry and therefre warrants evacuatin. Until that time, the patient must be managed t reduce pain and t prevent the situatin frm wrsening. Signs and symptms Tth sensitivity r pain t stimulus (cld, ht, sweets) Transient sensitivity t debilitating pain In early stages, it may be difficult t identity the ffending tth Radiating pain may make it seem as if ther teeth are invlved Pain intensity may increase when the victim lies dwn Rarely, sensitive t percussin r biting pressure Lk fr tth decay r a vid (hle) in the tth Remve any irritant r debris Temprarily fill any defect in the tth 112 Avid stimulus that makes the tth respnd with pain Pain management using NSAIDs fr mild t mderate/severe pain and piate analgesics fr mre severe pain. If the pain is severe, a lcal anesthetic can be used Antibitics at the first sign f swelling r abscess Cmplicatins If necrtic pulp tissue escapes int surrunding tissue utside f the tth, the infectin can begin t develp int an abscess. Abscesses in the backcuntry need t be mnitred very clsely because f delay t treatment and the pssibility f their spreading int deeper and mre serius anatmical areas. Nte: The percussin test is tapping n the tth with a hard bject such as the handle f a spn. Respnses that elicit pain indicate inflamed tissue surrunding the tth. Failed Dental Restratins There are several reasns why a restratin (filling r crwn) may fail. With the restratin gne, the tth may be sensitive r fd may get packed between the teeth and irritate and inflame the gingiva (gums). Temprary filling materials can be used t make repairs until a dentist can be fund and a mre permanent restratin created. Lst filling Signs and symptms f a lst filling: Tth sensitivity t stimulus (cld, ht, sweets). The tth is usually fine withut any stimulus present. Missing filling Sre tngue frm rugh r sharp tth edge Fd impactin between teeth, making tth and gums sre Remve any debris in r arund the tth Temprarily fill any defect Temprary filling material There are several cmmercially available temprary filling materials Cavit cmes pre-mixed and will harden nce placed in the muth. Cavit can be thinned, if necessary, by mixing it with petrlatum jelly (Vaseline). IRM cmes in a pwder/liquid frm that requires mixing. The advantage f IRM is that it can be mixed t any cnsistency. Smth rugh r sharp edges Cmplicatins Left untreated, bacterial invasin can begin the decay prcess that eventually leads t irreversible pulpitis and the need fr enddntic therapy (rt canal). Lst Crwn r Bridge Symptms f a lst crwn r bridge Tth sensitivity t stimulus (cld, ht, sweets) Fd impactin arund tth Clean ut ld cement frm inside f crwn Remve any debris arund the tth Check t make sure that the crwn still fits Place a thin film f sft temprarily filling material in the crwn and place the crwn back n the tth. Have the patient bite dwn t squeeze ut excess cement. Nte: Yu may need t thin the temprary filling material if it is t thick. 113 Have patient bite dwn t ensure that the replaced crwn desn t interfere with his r her bite Remve excess filling material Check the bite again Cmplicatins Left untreated, bacterial invasin can begin the decay prcess that eventually leads t irreversible pulpitis. If decay is present under the crwn, it may have gne unnticed. If it is severe enugh, the tth may break ff at the gum line and there wn t be enugh retentin t cement the crwn back int place. In this case, ne culd place a small amunt f temprary filling material ver the remaining part f the tth t make it smth, s that the tth is less sensitive and the tngue wn t becme irritated. Oral Infectins Muth infectins can be viral, fungal r bacterial. The first tw are less frequent and generally nt a majr health threat in the backcuntry. Bacterial infectin can becme a serius prblem if nt treated, in part because they have the ptential t spread. Viral While there are several viruses that have ral manifestatins, herpes virus is the ne mst cmmnly encuntered in the backcuntry. Herpes simplex virus generally presents with small vesicles in lcalized clusters, which may calesce t frm a large lesin. When the vesicles rupture, they leave a shallw, ragged, and extremely painful ulcer cvered by a gray membrane and surrunded by an erythematus hal. Herpes labialis manifests as blistering fllwed by a brwn crust n the lips. One may reduce the incidence f recurrent herpes labialis (cld sres r fever blister) by using sun blck. Symptms Prdrmal paresthesia r tingle Lymphadenpathy Sre thrat Lw grade fever Analgesics Acyclvir r valacyclvir Sthing muth rinses, such as warm saline slutin Diminish the incidence by using sunscreen Fungal Fungal infectins are mst cmmnly fund in individuals wh are immuncmprmised, debilitated, r taking antibitics. The fungal infectin mst likely t be encuntered is candidiasis, therwise knwn as thrush. Symptms White patches n the mucsa that can be rubbed ff, leaving a raw, red surface : Nystatin r cltrimazle (Mycelex Trche) Bacterial A bacterial infectin in the maxillfacial regin can becme a serius health threat. In the backcuntry, such an infectin shuld be treated aggressively. Oral infectin generally spreads slwly, but rapid spread t deep fascial spaces may ccur. Reginal lymphadenpathy is cmmn. Ostemyelitis is uncmmn even thugh bne is ften invlved 114 Where definitive treatment is delayed, antibitics shuld be started If the swelling is sft and fluctuant, drainage will relieve pressure and prevent further spread Odntgenic Abscesses Odntgenic infectins can be caused by dental caries (cavity), deep restratins that apprximate the pulp chamber, pulpitis, and peridntitis (gum disease). An abscess frm a tth will fllw the path f least resistance. Generally, it will stay lcalized and drain int the ral cavity. Hwever, in sme cases it may spread alng fascial planes and int deep tissue spaces. All abscesses shuld be mnitred and treated. Any increased swelling r spread f infectin is reasn t evacuate the patient t btain prper treatment. Acute Apical Abscess The swelling in this abscess is cnfined t the apex area f the tth. Swelling is mre cmmn n the facial aspect f the jaw and the buccal vestibule adjacent t the ffending tth. Signs & Symptms Pain Swelling (lcalized) Tth sensitive t percussin The affected tth may be unrespnsive t thermal changes because f pulpal necrsis The patient may have a prir histry f a tthache Antibitics Drainage Drainage is accmplished by extractin, incisin, r enddntic therapy (rt canal) Extractin r enddntic therapy are generally impractical in the backcuntry setting Incisin and drainage becme the treatment f chice in an emergency situatin Pericrnitis This infectin is fund in the tissue arund a partially erupted tth. The mst cmmn site is the mandibular third mlars ( wisdm teeth ). This infectin seldm prduces purulent drainage. Signs & Symptms Trismus (difficulty pening the muth) Symptms mimicking pharyngitis r tnsillitis Cmmn in cllege age patients because this is the age range during which wisdm teeth erupt Warm saline rinses (¼ tsp salt in 8 z water) every tw hurs Irrigate the area arund the tth and under the tissue flap Antibitics Peridntal Abscess Prliferatin f bacteria between the tth and gingiva (gums) Signs & Symptms Swelling is near the gingiva where it meets the tth, rather than in the vestibule The tth is sensitive t percussin The affected tth respnds t thermal changes 115 N incisin is necessary. Drain thrugh the gingival sulcus (between the tth and gums) with a blunt instrument Fllw up with warm t ht saline rinses Fascial Space Abscesses While mst dental abscesses lcalize arund a tth, there is ptential fr the infectin t spread int areas f the head and neck in such a manner that they may becme life threatening. Due t prximity f the central nevus system and airway t the rpharynx, timely effrts are required t treat this situatin. In the backcuntry, immediate evacuatin is indicated. Sign & Symptms Severe swelling Pain Trismus (difficulty pening muth) Elevated temperature Rapid and weak pulse Difficulty swallwing Difficult r shallw breathing Antibitics Airway management Immediate evacuatin Antibitic Use Odntgenic infectins are typically plymicrbial. Anaerbes are prevalent, s penicillin has histrically been the first chice fr these infectins. Even thugh penicillin has a narrw spectrum, many dntgenic infectins fit within that spectrum. Hwever, increasing rates f resistance have led t recmmendatins t use clindamycin. Indicatins fr antibitic use fr ral infectins Antibitics are warranted in lcal infectins fr patients wh are immuncmprmised, r if the infectin has inadequate drainage, r if delay t definitive care is anticipated. A patient wh shws signs f disseminated infectin, such as lymphadenpathy, fascial space invlvement, r systemic symptms, shuld be treated with antibitics. Cmpund maxillfacial fractures invlving tth-supprting bne warrant treatment with antibitics. Dental Trauma Injuries t the tth and supprting tissues are mre likely t ccur during high adventure activity mishaps, such as muntain biking, skiing, climbing, r rafting. Trauma can be islated t nly the tth, but mre likely invlves sft tissue and supprting tissue as well. Sft tissue cnsists f the lips, tngue, and cheeks, while supprting tissue is made up f bne, ligaments, and gingiva (gums). Histry & Exam Prper evaluatin and histry are helpful in a trauma situatin. In additin t examinatin f the dental arches and surrunding tissue, the victim shuld be asked abut lss f cnsciusness, nausea, vmiting, and dizziness, t identify any pssible head injury. Clean the regin well t unmask injuries hidden by bld r debris. Evaluate laceratins fr any freign material, including parts r pieces f brken teeth. Examine teeth fr fractures and pulp expsures. Evaluate the mandible and facial bnes fr any fractures. 116 Injuries t the Tth Tth injuries cnsist f fractured r chipped teeth. A fracture can vary frm just lsing a crner f a tth t an entire tth breaking ff at the gum line. Uncmplicated Crwn Fracture Signs & Symptms Visible chip n tth N visible pulp tissue r bleeding Sensitive t stimulus (ht, cld, sweets) Smth sharp edges by placing temprary filling (IRM, Cavit, sft wax, r tape) ver the tth Avid any stimulus that may aggravate the tth Uncmplicated Crwn-Rt Fracture This fracture usually ccurs with pre-mlar and mlar teeth, when part f the cusp has brken away but remains in the muth because it is still attached t gingiva. Signs & Symptms Lse piece f tth Pain r irritatin n biting Remve lse fragment Cver the tth with a temprary filling Avid any stimulus that may aggravate the tth Cmplicated Crwn Fracture Signs & Symptms Fracture invlving expsure f pulp Sensitive t air, cld and ther stimuli because f expsed nerve Stp bleeding by biting n gauze Because the nerve has been expsed, the tth is very sensitive, s the sner the victim is taken t a dentist, the better Cver the tth with a temprary filling Cmplicated Crwn-Rt Fracture Signs & Symptms Fracture that expses pulp Sensitive t air, cld, etc. Lse fragment f tth attached t gingiva Remve r stabilize fragment Prceed as fr a cmplicated crwn fracture Rt Fracture This injury may be difficult t differentiate frm an extruded tth (next sectin) withut a radigraph. Hwever, treatment in the field is the same. 117 Signs & Symptms Slight t severe mbility Generally anterir teeth Repsitin the tth and splint Injuries t Peridntal Tissues Trauma t the ral cavity may nt fracture a tth. Hwever, damage may ccur in the supprting structures arund the tth, in which case the tth will be displaced frm its nrmal psitin. The fllwing are pssible scenaris that can affect teeth and supprting tissues. Cncussin and Subluxatin The tth is prperly psitined but tender t tuch and percussin with pssible increased bleeding frm gums. cnsists f a sft diet, rest and NSAIDs fr pain management if necessary. If the patient keeps biting n the tth, thus causing pain, have them hld smething between their teeth t prevent biting. Intrusive Luxatin The tth has been pushed int the scket. There is n mbility. Field treatment is palliative because the tth is ut f cclusin. Enddntic and rthdntic treatment shuld be initiated within tw weeks f the incident. Extrusin Luxatin The tth is extruded partially frm its scket and extremely mbile. Use gentle steady pressure t repsitin the tth, allwing time t displace any bld that has cllected in the scket area. After reductin, the tth shuld be nnrigidly splinted. Lateral Luxatin The tth is displaced laterally because f bne fracture and can get lcked int a new psitin. If this happens, the tth will nt be mbile. Reduce the tth using the tw finger technique: ne finger ver the apex pushing tward the crwn while the ther finger places a small amunt f pressure utwards t help psitin the tth back int its scket. The tth may snap back int psitin and be quite stable. Splint if mbility is present after reductin. Exarticulatin (Avulsin) Quick actin is needed t increase survival f the tth. The lnger the tth is ut f the muth, the less the chance fr survival f the tth. Prgnsis als depends n the health f the peridntal ligament (PDL) cells, sme f which are n the rt f the tth (thers are in the scket). D nt scrub, curette, disinfect, r let the rt surface dry ut; rinse the tth with saline t remve debris befre replanting it back in the scket. When remving cltted bld frm the scket, use gentle irrigatin and suctin; avid scraping the scket walls. Replace the tth gently with steady pressure t displace any accumulated bld. If cntaminated, rinse the tth befre replanting. If immediate replantatin is nt pssible, place tth in the best transprtatin medium available. Transprt media (in rder f effectiveness) Save-A-Tth (Hank's balanced salt slutin, which is a physilgically ph balanced saline) Milk Saliva 118 Saline and water d nt wrk well as transprt slutins because they can damage the PDL cells. They shuld nly be used t clean the tth fr immediate replantatin and nt fr transprtatin. Management f the rt surface Keep the tth mist at all times. D nt handle the rt surface (hld by the crwn). D nt scrape r brush the rt surface. If the rt appears clean, replant the tth. If the rt surface is cntaminated, rinse with HBSS r saline (use water if saline is nt available). Persistent debris can be remved with tweezers and then rinsed. Management f the scket Gently aspirate withut entering the scket. If a clt is present, use light irrigatin t remve it. D nt curette the scket. D nt make a surgical flap unless bny fragments prevent replantatin. If the alvelar bne is cllapsed and prevents replantatin, carefully insert a blunt instrument int the scket t repsitin the bne t its riginal psitin. After replantatin, manually cmpress facial and lingual bny plates (nly if spread apart). Splint r stabilize the tth Splinting Once a tth has been repsitined back int the scket it will need t be splinted s that the ligaments can reattach. There are tw types f splinting: rigid and nn-rigid. Rigid splinting is best fr the bny segment fractures r jaw bne fractures. Nn-rigid is the splinting f chice fr tth stabilizatin. In a backcuntry envirnment, it may be necessary t imprvise with material n hand. Fishing line r even flss culd be bnded t splint teeth. Sutures can als be used t supprt the tth by running the suture thrugh the gingiva n the facial aspect f the tth and then thrugh t the lingual gingival, making a sling that will stabilize the tth. Injuries t Primary Teeth Primary teeth, baby teeth, and deciduus teeth are all different terms fr the same thing. When dealing with first aid fr primary teeth, the general rule is t remve the tth if it is in the way. If a yung child has sustained an injury that results in a tth be
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