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 A dental problem occurring in an environment where access to professional care is limited or absent may progress to a point which seriously degrades the functioning of the afflicted individual. A dental emergency would be defined as a medical emergency where pain or swelling originates from the teeth, jaws or gingiva (gums). The vast majority of dental emergencies arise from either tooth decay or periodontal disease commonly referred to as gum disease. Both are a result of a bacterial infection but follow different pathologic paths.

Tooth decay has its humble beginnings when certain bacteria, ever present in the mouth, adhere and colonize on teeth or exposed root surfaces. As we eat, the bacteria on our teeth metabolize the same sugars that are in our foods and excrete acid and/or toxins. The teeth and their supporting bone and gums respond in different ways to bacteria.  The teeth which we see when looking in a mirror are most susceptible to being affected by bacterial acid and will slowly dissolve when subjected to repeated bacterial acid attack. The bacteria adherent to the tooth wall, referred to as a bacterial plaque, is responsible for the initial event which leads to tooth cavitation and the propagation of the decay process. The most common sites to decay are those areas on the teeth which are the most difficult to clean, for example, the pit and fissure biting surface of molars and bicuspids, in-between the teeth and around the margins of existing dental fillings or crowns. At first, cavities are small and painless, but over a two to three year time interval will increase in size and depth until symptoms such as tooth fracture, tooth pain or swelling occur. Once the tooth has become painful or abscessed, the infected or inflamed nerve must be removed by either tooth extraction or root canal treatment.

The second major cause of dental emergencies is Periodontal or gum disease. It is caused by the immune system’s response to bacterial plaque adherent to the root surface of teeth and necessarily located below the gum line.  The actual causal agent of periodontal disease is once again a bacterial plaque but a second component is necessary and that is an exaggerated immune response. According to a 2004 National Institute of Health (NIH) study the prevalence of periodontal disease in a general population aged 20 to 64 years of age is 8.52%. In my experience I find this number low. In any event, susceptible individuals exhibit an exaggerated inflammatory response to the bacterial plaque (anaerobes, in this case) and endotoxins causing bone loss around the root of the tooth. The initial stages of gum disease, like tooth decay, are painless, with symptoms usually occurring at more advanced stages. Periodontal disease can start in third decade of life (20’s) and go unnoticed until the fifth or sixth decade (40s-50s) of life when the teeth and gums become symptomatic. Generally, periodontal disease will affect the entire dentition and progress at a slower rate than decay induced dental disease. Symptoms of advanced periodontal disease include loose or mobile teeth, pus and bleeding from the gums around the teeth, bad breath, pain and swelling of the gums. Current treatment for periodontal disease returns excellent results, in terms of teeth retained when combined with ultrasonic scalars, lasers, bone regeneration, surgical and non-surgical methods. Although current delivery of treatment of dental diseases requires professional care in a fully equipped office, including a trained staff, an alternate plan should be available if the above mentioned services and facilities are no longer available.  It would be prudent to plan for dental treatment in a post TEOTWAWKI world for symptomatic teeth caused by decay or periodontal disease as well as planning to avoid, slow down and reduce the likelihood of dental disease and emergencies.

Modern dentistry has reached a technologically advanced state and the standard of care is indeed high. In a post TEOTWAWKI situation, the current standard of care will no longer exist and dental treatment, if it exists at all, may be limited to basic care such as treating infection and relieving pain. Even with the lowered standard of care, dental treatment delivered by a dentist will be difficult but not impossible. First, let’s dismiss the idea that the current emergency dental kits will be anything more than a short term temporary fix at best. They cannot and do not address the problem of a toothache other than placing a topical anesthetic on the large cavity found in the tooth. Placing the temporary cement, which is included with the kits, in decayed teeth, does nothing to alter the disease course.  The myth that modern restorative dentistry and periodontal treatments can be done under such adverse conditions is just that, a myth. Just taking out the decay will not cure an abscessed tooth! Treating a toothache in these circumstances, no matter the cause, should be done with a goal of (1) definitively solving the problem and (2) relieving pain and suffering.  In most cases this is best done by extracting the tooth. Probably greater than 90% of serious dental emergencies could be treated by extraction i.e. forceps extraction of the painful tooth under local anesthetic. The procedure itself requires a minimum of instruments, materials, personal and equipment. Once it is determined that there are no dentists or dental clinics available and the status quo will not be changing in the foreseeable future, the task of diagnosis and treatment will fall to the medical officer of your group or someone so inclined. Simple tooth extraction has been done with no anesthesia numerous times by untrained personal because the patient decided that the extraction procedure was a better alternative than living with the increasing facial swelling and continuous dental pain. The more desirable plan, of course, is to use local anesthesia and make the procedure as pain free as possible as well as to develop the knowledge to attempt such treatment.

To successfully anesthetize a tooth depends upon its location. All upper teeth are anesthetized for an extraction by first injecting the anesthetic solution in the mucobuccal fold (the fold formed by the oral mucosa as it transitions from the upper jaw to the cheek) directly opposite the tooth to be extracted. I typically inject 1.8cc of a 2% Lidocaine with 1:100,000 epinephrine solution in a dental aspirating syringe (a regular 3cc medical syringe would work also) using a 30 or 27 gauge short needle. Incidentally, a 1.8ml dose is the standard dose in a pre-loaded dental anesthetic carpule which is used with a dental aspirating syringe. This is an infiltration injection and once the mucosa is penetrated the needle is advanced approximately 10mm, aspirate to be sure you are not in a blood vessel and then inject the anesthetic solution close to the maxillary bone. The Lidocaine will diffuse through the maxillary bone and anesthetize the tooth, surrounding bone and buccal gingiva. A second injection, to anesthetize the palatal gingiva, is given on the roof of the mouth about 10 mm above the given tooth/gingiva junction. The needle is advanced about 2mm through the palatal mucosa until bone is reached, aspirate, and inject a small amount of solution (0.1ml) until the palatal tissue slightly blanches (turns white in an area 2mmx2mm).

A visual representation will best explain what I have described.

The first link is a You Tube video of the of the Maxillary infiltration technique described above. The second link shows the palatal component of the Maxillary infiltration technique. Note that in this link multiple palatal injections are given.

http://www.youtube.com/watch?v=n0z5n8HoQ9s&feature=related

http://www.youtube.com/watch?v=e9xQbVWp7mA&feature=related

Anesthesia is achieved in 5 to 10 minutes and lasts 90 to 120 minutes.

Mandibular (lower jaw) teeth require an entirely different type of injection technique to obtain anesthesia for tooth extraction.  An infiltration technique will not work on mandibular teeth or bone because mandibular bone has a thick outer covering (named cortical plate) which hampers diffusion of the anesthetic through the bone and into proximity with tooth nerves.  To circumvent this limitation of infiltration anesthesia in the mandible another type of anesthetic delivery is chosen namely a nerve block. The target of the block injection, in this case, is the Inferior Alveolar Nerve (IAN).  Each IAN provides sensation to the lower jaw, teeth and the gingiva on their respective side of the mouth. Since the dense mandibular cortical bone shields the IAN from the anesthetic solution, our strategy is to anesthetize the nerve trunk before it enters the mandible. This can best be accomplished by an understanding of mandibular landmarks and mentally visualizing the location of the IAN before it enters the mandible.  This type of injection is technique sensitive and is more of a challenge to administer than an infiltration injection.  An aspirating syringe with a long (because it has approximately 25 mm of tissue to traverse) 25 to 27 gauge needle is used. Aspiration is of particular importance with this injection  to verify that the anesthetic solution (e.g. 2%lidocaine with epinephrine 1:100,000) is not inadvertently administered into the IA artery or IA vein which are located in close proximity to the IA nerve.  My best recommendation is to study multiple videos on the anatomical landmarks and the technique of this injection.  Dentists give tens of thousands of these injections in their career and with attention to detail, complications are minimized.  I still pay close attention to the following when I give an IAN block.  (1). Correct positioning of the patient.   (2) Reviewing and palpating the land marks intraorally on every patient. (3) Use an aspirating syringe and if blood is aspirated, reposition the needle and aspirate again. Also, if a mandibular molar is being extracted, a separate injection (an infiltration injection) of the Long Buccal (a branch of IAN) nerve must also be given. This nerve provides sensation to the buccal (cheek side) gingiva of the mandibular molars.  Alternately, sensory innervation of the gingiva on the tongue side and the anterior 2/3 of the tongue are provided by the lingual nerve (also a branch of IAN) however this nerve, due to proximity, is usually anesthetized along with the Inferior Alveolar Nerve when the IAN block is given. To be complete, when extracting mandibular incisors, an infiltration injection in the muccobuccal fold adjacent to the tooth to be extracted is given in addition to the IAN block. The infiltration injection is to anesthetize cross over nerve fibers from the contralateral (opposite side) IAN. Anesthesia is profound and lasts 3-5 hours.

Here’s a link to a video which describes the anatomy and technique of the IAN block on a model as well as a patient. It is an excellent video and covers the basics of the technique. The second link is a short video covering the Long Buccal infiltration injection

http://www.youtube.com/watch?v=39kPPBbrM1c&feature=related

http://www.youtube.com/watch?v=rrzUL_61hLU&NR=1

Despite what you think or may have heard, extracting teeth is not an act of brute force but rather correct application of moderate forces and adequate preparation of the tooth to be extracted. Using excessive force or inadequate tooth preparation commonly leads to root fracture and an overall more complicated extraction. With this in mind, let’s look at the extraction process of a fully erupted painful tooth. This technique would be applicable to a non-surgical extraction. A discussion which encompasses surgical extraction is beyond the scope of this essay. The overview of simple tooth extraction involves severing and widening the bone and tissue attachments which hold the tooth in the jaw. Specifically, after adequate anesthesia has been achieved and in a stepwise fashion, the gingival/tooth attachment is severed. The attachment is about 2mm in width and extends 360 degrees around the tooth. I use a periosteal elevator (Molt 9) placed in the gingival sulcus (gum line around the tooth), and in the long axis of the tooth. The instrument is advanced in an apical (toward the root apex) direction in a short, steady motion until the 2mm tissue band is severed. This action is repeated until the gingiva is reflected 360 degrees around the tooth and to the level of the bone.  Remember this severing is done only around the gingiva closely adherent to the tooth root because you are only separating the gingiva from the root of the tooth to be extracted. There will be some minor bleeding, which can be blotted with some sterile gauze or surgical suction if available. Next is the crucial step in the extraction. Failure to adequately loosen the tooth with dental elevators (either 301 which has a smaller concave blade or 34S) can turn a simple extraction into one which may be beyond your skill level. The dental elevator is an instrument which resembles (but isn’t) a common flat bladed screwdriver.  During an extraction the elevator tip or concave blade is placed in between the tooth and the gingiva/surrounding bone. Once in place, the handle of the elevator is rotated in a fashion (clockwise or counter clockwise) to engage the root surface of the tooth with the blade and attempt to elevate it out of the socket. This process is repeated a few times moving the elevator to different interproximal locations as it gradually widens and separates the boney socket and ligament from the root of the tooth to be extracted. Skillful use of the elevator will render the tooth visibly mobile, that is, noticeable movement of the tooth can be visualized. I have extracted many teeth with an elevator alone. A word of caution, this is not an instrument that is used with much force. The force applied is mostly rotational and is never a strong pushing force or directed in the long axis of the tooth. A strong vertical pushing force has the tendency to slip and become redirected towards other anatomic structures which would best be avoided, such as the floor of the mouth, cheek or maxillary sinus.

Up to this point, the soon to be extracted tooth has obtained anesthesia, had its gingiva reflected with a periosteal elevator, been adequately loosened with a 301 or 34S elevator and ready for the forceps delivery. Forceps are special pliers which dentists use to remove the loosened tooth from the gingiva severed, widened boney socket. There is a specialized forceps for almost every tooth in the mouth but, in a pinch, you really only need two, an upper universal forceps (no. 150S) for all maxillary teeth and a lower universal for all mandibular teeth (no. 151S). One thing to keep in mind is the forceps extraction will differ slightly in technique depending if the extraction is of a multi rooted tooth or a single rooted tooth. Let’s assume that we don’t have access to x-rays and classify all maxillary and mandibular molars and maxillary bicuspids as multi rooted teeth and all the remaining teeth are single rooted. This of course is not always the case but we’re in a post TEOTWAWKI environment. The forceps technique differs slightly if the tooth to be extracted has a single conical root or has two or more roots. The main difference is that a slight 15 degree rotational force is not used at all on a multi rooted tooth because the multiple roots will resist rotation and most likely fracture. Going on, once the appropriate forceps is chosen, the concave beaks of the forceps are placed around the loosened tooth and advanced as far apically (towards the root tip) as possible. The further up the root the forceps’ beaks can be placed, the better. The goal is to apply the holding force of the beaks to the root and not the crown of the tooth. After a solid purchase is attained I will firmly move the forceps in a controlled small figure “8” and also a firm but small cheek to tongue directed rocking motion gradually expanding the boney socket and expanding the periodontal ligament (which is holding the tooth root to the bone socket). I will increase the size of the figure “8” and rocking motion as the bone expansion permits. Only after I have achieved noticeable tooth mobility with the forceps will I exert some lifting force to remove the tooth from the socket. If I am patient and don’t rush the forceps extraction, the tooth will gently release from the socket. Excessive upward pulling force is undesirable and often leads to a sudden unexpected release of the tooth from the extraction site with the undesirable result of the accelerated forceps hitting and damaging the opposing teeth. Once the tooth is extracted, attention is directed to the extraction site. Our goal now is to return the post extraction boney socket to its original shape and to control the bleeding. If needed, I  will first compress the expanded socket using my thumb and index finger in a pinching motion and control the bleeding by placing a few folded 2×2( 2 inch square) gauze on the extraction site and instructing the patient to bite and apply pressure. Pressure is what will control and stop the bleeding. Bleeding is usually controlled quickly with pressure and limiting physical activity until a clot forms. The patient is given gauze to use as necessary and also instructed not to rinse or forcefully spit for 24 hour, soft food diet, no alcohol or smoking (good luck with this one!)
 
An excellent video is available showing a dental extraction at a Mount Everest base camp.  The dentist uses a makeshift 301 elevator and has a 151 forceps which were found in the dental kit at the base camp. Tooth #28 is a lower right, single rooted, first bicuspid. It’s a great video of an extraction under marginal conditions.

http://www.youtube.com/watch?v=o_DPqhQl4AM

There are many more instructional videos posted on the internet which go into detail about extracting teeth. Don’t misunderstand what I’m writing, extracting teeth is difficult and there is a long learning curve to develop the skill but it is a learnable skill for a nurse, EMT, PA, or dental hygienist. It is likely that a dental emergency will arise post TEOTWAWKI and being a  real medical emergency where no dentist is available reasonable action should be taken by those available and most qualified.

Three points to note: 

1. Gloves are worn mostly to protect against transmission of blood borne diseases such as HIV and Hepatitis B, I have switched to Nitrile rather than latex because there are a significant number of patients who will present with latex allergies.

2.  A complete medical history is taken prior to administering any local anesthetics, antibiotics or extractions.  Persons with certain cardiac conditions such as prosthetic heart valves, certain congenital valve defects, past history of bacterial endocarditis or those who have had prosthetic joint replacement surgery such as a total hip, knee or shoulder joint replacement will require prophylactic antibiotic coverage for any dental procedure which causes gingival bleeding. This prophylactic regimen is followed to reduce the likelihood of bacteria, introduced into the blood by the dental procedure, lodging on the prosthetic hip or damaged heart valve and causing a very troublesome life threatening infection. A common prophylactic regimen is to have the patient take 2 grams (2000mg) of Amoxicillin (assuming no allergy) by mouth one hour before the dental procedure. Some other concerns to extraction are bleeding disorders, allergies to any of the drugs or classes of drugs you are administering, anti-coagulants (Coumadin, Plavix) the patient may be taking and the class of drugs known as bisphosphonates. The bisphosphonates are commonly used to treat osteoporosis and some advanced cancers (palliative treatment) by inhibiting bone remodeling at the extraction site leading to bone death and infection. Of the bisphosphonates (such as Reclast), the intravenous route of administration exerts the most effect on the remodeling bone and can exert bone inhibition for many years after the drug has been discontinued. This is not a complete list and to proceed while not taking these contraindications into account may leave the patient worse off than they are initially. If a patient history or current condition is given and you are not familiar or unsure of the ramifications of the history or condition, STOP, take a step back and reassess the situation and obtain more information. A dental emergency of the type we have been discussing almost never requires an instant decision or action. Risk vs. benefit must be weighed and the question asked “Will this patient be better or worse off if I continue with my treatment.”

3. Often decayed teeth will not only be painful but will be accompanied by an acute dental infection.  Antibiotics such as Penicillin VK and Azithromycin, if available, are two first line antibiotics useful for treating acute dental infections and can be given orally. If there is an allergy to any of the Penicillins then Azithromycin can be given in its place. An Erythromycin allergic person is also allergic to Azithromycin. Dosages for Pen VK are 250mg to 500mg every 6 hours for 7 to 10 days. Azithromycin (Z-Pak) is usually dosed at two 250mg tabs the first day followed by one 250mg tab on each of the next 4 to 5 days. Antibiotics will work on bacterial infections only and should be administered as necessary. If no antibiotics are available an infected tooth, gum swelling or jaw pain will usually respond favorably once the source of the infection, namely the tooth is extracted and drainage of the infection can be established through the extraction site. If a fluctuant intraoral abscess is present it should be drained and followed with a course of antibiotics.

There is a potential shortfall to this entire dental emergency scenario and our proposed model of treatment namely, all local anesthetic necessary to anesthetize the teeth for dental treatment has a shelf life of ~ 18 – 24 mos. It can’t freeze either, if it does, it no longer works. I don’t know how the anesthetic was kept from freezing at the Everest base camp, but during Vermont winters, if the dental anesthetic freezes (usually in transit from the dental supply house) it no longer works effectively. A patient faced with an extraction without the benefit of local anesthesia knows intuitively that it is a very painful procedure and probably wouldn’t allow it until the dental pain becomes worse than the dreaded future extraction.  As long as local anesthetic is available, extractions can be done painlessly by a trained individual. Keep in mind that many general dentists don’t take out impacted wisdom teeth because of their degree of difficulty and most impacted third molars would be above the skill level of the TEOTWAWKI trained individual. There is also the issue of obtaining a supply of antibiotics and local anesthetic as well as the surgical instruments necessary for tooth extraction. Once legally obtained, the shelf life clock on the antibiotics and anesthetics begins. There are no studies that I am aware of which test the clinical efficacy of expired anesthetic or antibiotics on humans. Ethically, I couldn’t envision a clinical test structured to treat active infections with long expired vs. not expired antibiotics.  Along with drug potency, drug sterility can also degrade over time. Regardless of the expiration date, a liquid injectable anesthetic should be clear and free from floating debris and if isn’t, discard the vial or carpule.  Sterility of the anesthetic is not guaranteed, even though it may appears non contaminated, once past the expiration date.  On the other hand, dental extraction instruments, if properly maintained will last a lifetime. I should mention that surgical equipment needs to be sterilized before each use. Ideal sterilization is done in an autoclave under steam and pressure. If an autoclave is not available, a through scrubbing of all visible blood and debris from the instruments is done followed by a stay in 5% Sodium Hypochlorite(household bleach) and followed by 30 minutes in a pressure cooker @240 degrees F. The instruments are then dried, wrapped in sterile cloth and stored until the next use.  Up to this point, I’ve described one method of treating definitely most post TEOTWAWKI dental emergencies, let’s now examine how most of us can slow down and reduce the risk of dental disease and emergencies to a minimum.

As we discussed, most dental disease is caused by oral bacteria. So anything which reduces the amount of bacteria in our mouths will reduce our susceptibility to dental disease. By routinely maintaining impeccable oral hygiene a person will absolutely lower their risk of developing cavities and gum disease and avoiding the post TEOTWAWKI dental office.  This approach would be applied in a situation where dental care is extremely limited or non-existent. Implement a daily effective brushing and flossing routine, identifying and perhaps limiting the foods which are high in sugar and/or sticky such as raisins and granola bars. Why high sugars and sticky? Because studies show the two most important factors in cavity development are the number of times per day and the duration of time the teeth are exposed to bacterial acid.

In regard to the former, drinking a 12 ounce can of Mountain Dew, two ounces at a time, over 6 hours is far worse for dental health than drinking the entire 12 ounce can at one sitting. It was shown from clinical studies that bacteria on the teeth produce acid each time they are exposed to sugar and the recovery time to return to a normal mouth pH is similar for both the 12 ounce exposure and the 2 ounce exposure. So the incremental drinking exposes the tooth to 6 separate acid attacks rather than just one.

The latter, duration, is a factor when the high sugar food is sticky and becomes stuck between teeth or impacted into natural anatomic pits and crevices. In this case there is a steady supply of sugar for bacteria to metabolize because the sugar source is adherent on the teeth. The pH will stay in the acidic range for a longer time. As we discussed, tooth decay once started, if unchecked, will progress to nerve involvement with all its consequences.

Effective treatment which you can do to avoid or limit the initiation and progression of tooth decay is three fold and is directed at the known mechanism of the tooth decay process.
1. Develop and maintain a high level of home care by effective brushing and flossing. Young children who have teeth and cannot brush or floss effectively should have the parent brush and floss all teeth as they erupt in a child’s mouth. Daily brushing and flossing mechanically removes the bacteria adherent to the teeth. The goal is to remove and disrupt the bacterial plaque and thereby reducing the quantity of bacterial acid available for the decay process. Flossing is very important because it is the only way the surface area between the teeth is cleaned. If floss is not available, double thickness sewing thread can be used. In post TEOTWAWKI times I would advise flossing morning and night along with brushing after each meal.
2. Limit the number of times the teeth are exposed to sugar.  Brushing after each meal or if brushing is not possible, rinse the mouth with water. This will dilute the acid and aid in the rapid return to a more favorable oral pH.
3. Avoid sticky sugary foods. To adequately neutralize the acid the adherent food must to be mechanically removed with floss or brushing.

Here’s a link to showing effective brushing and flossing and provides a visual for what was discussed.

http://www.youtube.com/watch?v=bR7rPFuyeBE

It would be good preparation (if you haven’t done so already) to develop good oral hygiene skills   which could be checked for technique by your dentist or hygienist. Also, your teeth/gums should be brought to optimal condition while there is a functioning health care delivery system.  If you have broken teeth that need repair or extraction do it now, while it’s still relatively simple. Ask your dentist about potential future tooth problems and what can be done to minimize them.
 
For most of us, a tooth free of bacteria won’t develop decay or periodontal disease…our two main concerns regarding dental disease. Keep in mind that before antibiotics and local anesthetics, people routinely died or suffered severely from dental infections. We know the cause of dental disease is bacteria and mechanically removing it with brush and floss will interrupt or mitigate the disease process. Impeccable oral hygiene doesn’t leave you immune to dental disease but will go a long way in preventing or prolonging its’ onset.