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You and your group are sitting around a roaring campfire enjoying the end of a long days hunting. You bite down on some trail mix and suddenly get a shooting pain in your mouth. You’ve just broken your first molar and are four hours from the nearest dentist. Now what? Believe it or not, this happens more often than we would like to believe. In a survival scenario, it may be days or weeks or never that you get to a dentist. So, what do you do? 

The most important thing to do is to prepare for a dental emergency, just like you have prepared for food, electricity, shelter and self-defense. Prevention is the key to avoiding these situations.   What does that mean? We have heard it since we were kids, “Brush twice a day, floss, and see your dentist twice a year.” Routine visits to the dentist can often times prevent those emergencies from happening. Often times those small cavities can be taken care of before they get out of control requiring crowns, root canals or extractions.

Brushing and flossing regularly make the difference. When under stress the body will tend to develop inflammation more easily, including gingivitis, an inflammation of the gum tissue. So, when prepping for the worst-case scenario, be sure you have multiple toothbrushes and plenty of floss. In a pinch, you can use your finger or a washcloth to wipe the teeth clean.  Even a twig can be used to stimulate the gums and clean the teeth.

So, what should you pack in your medical kit for dental emergencies? Here are some basics that need to be included:

1. Dental floss- also good for tying things down in a pinch.
2. Dental wax- can be melted down and used to make a candle if needed. Should be a soft type of wax.
3. Some type of Temporary filling material such as Cavit
4. Temporary dental cement such as Den-temp for re-cementing crowns.
5. Cotton pellets for use with;
6. Oil of cloves, which is a substitute for Eugenol
7. A set of dental tweezers
8. Tight fitting latex or vinyl gloves. The mouth carries more bacteria than any place in the body.

What causes a toothache and what should you do about it? A toothache is the result of injury to the nerve of the tooth. This can be the result of trauma or a deep cavity. If the nerve becomes infected, it can result in an abscess, which is an infection of the bone around the tooth that can be extremely painful. Often times an abscess can cause swelling around the tooth. The infection can spread to other parts of the head and neck resulting in difficulty swallowing and even in the ability to breath.  This type of infection, if left untreated, can eventually cause an infection of the blood, which can lead to death. Don’t mess around with it.

How do we treat this on our own? First, figure out which tooth is causing the problem. Be sure the area in the tooth  is cleaned out.  Take a cotton pellet and soak it in Oil of Cloves, and place it in the cavity. Be sure you don’t get it on the soft tissue because it can burn.  Other products you can use include Dent’s Toothache Drops, Orajel and Red Cross Toothache Medicine. When you have the cotton in place, cover it up with some Cavit or other temporary dental filling.

For pain, I highly recommend using 400mg of Ibuprofen taken with 800 mg of Tylenol at the same time, every 4-6 hours. If that doesn’t do the trick then a narcotic such as Codeine or Vicodin can be taken every 4-6 hours. Be sure to take these with food. If infection is present, an antibiotic should be taken for 5-7 days. Under no circumstances should you place aspirin on or next to the tooth. It can cause serious burns to the gum tissue.

What about treating gum inflammation, commonly known as gingivitis? This is usually the result of poor oral hygiene. Proper brushing and flossing can prevent it. If pain and bleeding are taking place, increasing your brushing and flossing can often help.  Be sure that you are getting enough Vitamin C in your diet, a deficiency can also have a negative impact on the gums. A side note on gum inflammation: Studies have shown that people with bleeding gums have a substantially higher incidence of heart attack and stroke.

So, you bite into a nice leg of venison and break off a filling, what now? If you have access to a dentist, get to them as soon as possible. If that is not possible, you can use a small amount of temporary filling material such as Cavit to fill the hole. Be sure to bite down on the material while it is soft so it will not interfere with your bite after it hardens. In a pinch you can use some soft dental wax to fill the cavity.

Crowns (caps), inlays and onlays can come out when you eat sticky foods such as caramels or taffy. If the tooth isn’t sensitive, save the restoration and take it to a dentist as soon as you can. If that is not possible, or the tooth is sensitive, it may be necessary to try and re-cement the crown temporarily. To do this, clean out any material on the inside of the restoration.  Mix a thin layer of temporary dental cement such as Den-temp and place it inside the restoration.  Carefully align the restoration with your tooth and gently bite it down all the way to place. Since the crown is only in temporarily, be very careful about chewing on it, so that you don’t jar it lose and swallow it. See a dentist as soon as possible.

What happens to a tooth if you fall or get hit in the mouth? Usually this can result in injury to the upper front teeth. The teeth can be knocked out of position, either forward or backward. They can be loose or hanging out of their sockets. Or they can be knocked out completely. If possible, see a dentist immediately. If this isn’t possible, the tooth can gently be repositioned to line up with the other teeth. Be aware that this process can be extremely painful.  Biting on a piece of gauze gently can help hold it in position.  Get to a dentist as soon as you can so that the tooth can be splinted to other teeth. 
           
A tooth that has been completely knocked out is known as an avulsion.  The first 30 minutes of a knocked out tooth are the most important. If treated correctly, the tooth can often be saved. If the tooth can be replaced in the socket within the first 30 minutes, there is a good chance that the body will accept it. After about 30 minutes the body will treat it as a foreign object and reject the tooth. 
           
Once the tooth has been found, pick it up by the crown, not the root and gently clean it off using sterile water or milk.  Use gauze to stop any bleeding from the socket in the mouth.  Gently place the tooth back in the socket and using steady pressure, push it back into place.  Have the person use gentle biting pressure on some gauze and get to a dentist ASAP to have the tooth stabilized. If for some reason the tooth can’t be immediately placed back in the mouth, place it in a container of Hank’s solution, designed specifically for this situation. If this is unavailable, use a container of sterile saline or milk and get the person to the dentist immediately.

As with any other type of prepping, preparation for dental emergencies is extremely important and needs to be well planned out. The nice thing about preparing for a dental emergency is that it is not very expensive to do. See your dentist regularly, brush and floss, and Keep Smiling.

Introduction
There seems to be a lot of talk among the survivalist community regarding dental care and particularly dental extractions.  I am a practicing dentist at an urgent care facility and have addressed thousands of patients in varying situations that have had abscessed teeth that require extraction, and have subsequently extracted thousands of teeth.  I would like to provide some insight on dental care and in particular on the subject of tooth extraction and the materials required to perform a successful extraction without complicating the existing dental problem.  Also note that many medical problems particularly those relating to bleeding, stress, blood pressure, etc will additionally complicate things.

Prevention
First, I will point out the obvious due to a nagging sense of professional obligation.  Prevention is the best medicine.  Topical application of fluoride is critical to preventing a cavity that may put you in a bad situation.  Brushing your teeth with an abrasive (toothpaste or otherwise) that does not contain fluoride will be of marginal benefit, however, the real bulk of the cavity prevention will be significantly diminished.  If your retreat location is supplied by a natural water source (spring, pond, well, etc) it might be prudent to have it tested for fluoride content.  If your water is high in fluoride then you could utilize it as a topical mouth rinse (i.e. hold it on your teeth, the longer the better) .  If not consider stockpiling fluoride containing toothpaste or mouth rinse.  I know this is stretching it a bit, but flossing: would it really kill you?  The natural reduction in the amount of refined sugar that you consume will also benefit you.

Equipment
Now that that is out of the way, here is a list of the things I would consider necessary for taking out a tooth.

1. Anesthetic-  Obviously this is not “necessary” but will make the experience must more enjoyable for all parties involved.  Lidocaine and septocaine are both common local anesthetics and sufficient for all dental work.  Septocaine is my preference because it comes in 4% formulations that just plain work better.  Upper anesthetic is applied to both the check and palate side of the tooth in question.  For the lower numbing is much more difficult.  Anesthetic must be applied high in the jaw bone.  As a general rule, have the patient open as wide as possible and you should see a fold on the cheeks posterior to the teeth.  Put the needle just anterior to that fold and aim toward the TMJ.  Injecting adjacent to the tooth is also helpful but will not be sufficient for complete anesthesia.  Assuming you have access and intend to stockpile these things (a syringe, needles, and anesthetic) I would recommend reviewing and perhaps printing for your survival library the following web pages (not mine, just nice pictures): http://www.fice.com/course/FDE0010/c12/p01.htm  http://www.fice.com/course/FDE0010/c12/p02.htm
2. Dental mirror- being able to see is good.
3. Bite block- This is just a piece of rubber that is designed to prop the person’s mouth open.  It will come in especially handy if you don’t have anesthetic.
4. Straight elevators- One with a small tip (2mm-3mm wide), one with a medium tip (3mm – 4.5mm wide)
5. Extraction forceps- #150 – Universal upper, #151 Universal lower, #23 Cowhorn

One additional thing you could do to potentially make your life easier.  Have every member of your retreat group obtain a copy of their latest panoramic x-ray from their dentist.  This is the big x-ray they take that images all of your teeth and the jaw bones.  In particular take note of any upper teeth that have roots that approximate the sinuses, any teeth with extra or curved roots, or any teeth with bulbous roots.  Don’t worry too much about keeping these records up to date.  What you are concerned with is the root structure of the teeth which doesn’t change over time.

With these basic tools you should have the equipment required to extract almost any tooth. 

Dental Assessment
When one of your retreat members presents with a dental problem first evaluate your situation.  Teeth with large cavities, cracked, or broken teeth will likely require extraction.  If you try to put off extracting a tooth because it “just isn’t that bad yet” it will likely be abscessed and be exponentially worse (with or without anesthetic) when you actually do get the tooth extracted.  As much as you won’t want to do it at the time, act early.  When a tooth starts to hurt and no dental care is available, take care of it before it gets infected and threatens your life rather than just your tooth. 

If, however, you miss the early action window and are presented with an abscessed tooth (and here be abscessed I am referring to draining puss/visibly swollen) consider a course of antibiotics or making a small incision into the swelling to allow the infection to drain before attempting tooth extraction.  Contrary to popular belief, this isn’t because there is an increased risk of infection (the chance of infection is 100% it’s already infected).  The real reason is twofold.  First, it will be a lot less painful to have the tooth extracted.  Second, if the patient is more comfortable it will make it easier for the operator to get the tooth out.

Once you’ve decided there is a problem (whether you are early or late) the first step is to decide which tooth is the problem.  Sometimes it will be obvious to the patient via pain when pressure is applied to a particular tooth.  Sometimes it is obvious to the operator via swelling or a small “blister” on the gums beside the tooth.  However if it is not obvious, the most convenient way to decide which tooth is the problem will be to apply cold to each tooth individually.  A tooth that is dying or dead will either give intense pain which lingers for ten or more seconds or will have no feeling at all.  Whatever the result of this test is, compare to known healthy teeth to verify your result is indeed abnormal.

Extraction Procedure
When you are ready to begin tooth extraction, get your tools ready by sterilizing them (in this scenario boiling may be the best you can do).  Always clean your mirror, elevators, bite block, and the forceps required for the particular tooth in question (for upper teeth you will be utilizing the 150 forcep only, for lower teeth that are incisors, canines, or bicuspids you will be using the 151 forcep only, for lower molars you will be using either the 151 or 23 forcep). 

All teeth extractions will begin the same way.  Prop the patient’s mouth open.  Insert the small straight elevator between the tooth and the gum in the space between the tooth to be taken out and the tooth in front of it.  While applying firm downward pressure, slowly turn the elevator and begin to move the tooth to be removed.  Do not use excessive force at any point.  When you can get no additional movement switch to the medium elevator and repeat.  The key to easy tooth extractions is getting them loose before you grab them with the elevator.  Be careful not to put pressure on other adjacent teeth, your elevator should leverage the tooth to be removed against the bone.  If the tooth does not loosen at any point you may consider peeling the gum tissue back on the cheek/lip side a bit and chipping away some of the bone on that side only (the small straight elevator can double as a half decent chisel).  When the tooth in question has a little movement to it you are ready for the forcep.

For removing an upper tooth: Use the 150 forcep and place it as far down the tooth as possible (well above the gum).  Slowly wiggle the tooth back and forth while putting pressure downwards (toward the bone).  Every few wiggles choke the forcep up on the tooth.  The tooth should be really moving at this point.  Rotate it towards the cheeks/lips with firm pressure and remove it. 

For removing a lower incisor, canine, or bicuspid: Use the 151 forcep and use the same technique described for upper teeth. In addition to the rocking motion described above you can also typically (meaning as long as these teeth have no extra roots) rotate these (twist rather than rock) to remove them more easily and less traumatically.

For a lower molar:  Examine the x-ray.  If the molar has two separate roots the 23 forcep would be appropriate.  If the roots of the tooth are fused together then use the 151 and follow the instructions for removing an upper tooth and disregard what follows.  Note that the vast majority of the time there will be 2 separate roots.  Place the points of the forcep in the middle of the tooth as far below the gums as you can get them.  The attempt is to get the points right into the area where the tooth roots separate.  Once you believe the forceps are in place, lightly squeeze the handles together while moving the forcep up and down.  If it doesn’t slip it is probably in the right place.  Next, continue light pressure on the handles together and move the forcep in a figure 8 [motion].  As you move it, you should naturally feel that every so often, the handles will close slightly.  This will slowly lift the tooth up.  Continue this motion until it feels like the handles are closed together, then rotate the forceps toward the cheek (twist) and remove the tooth.  If you have difficulty with the 23 try the 151 and follow the directions for removing an upper tooth.  Having said that, the denser bone in the mandible will be harder to chisel away, and slower to loosen the tooth.  Take your time and don’t break it.

Always examine the extracted tooth!!  Make sure the tooth looks like it does on the x-ray and that none of the roots broke and/or are missing.

Only one thing remains, what if it breaks?
First, don’t feel bad, you are in good company.  Even if you do everything right, you still have a decent chance at breaking the tooth.  If you act early and it’s a small portion that broke you may choose to leave it and see if it heals.  If the tooth is really abscessed when you act, the broken piece will perpetuate infection if not removed.  In order to remove a residual root, some bone may need to be removed.  If this is attempted it should be done from the cheek/lip side only.  Often a forcep (150 or 151) can be used to grab the bone adjacent to the root on either side crush it, grab the root, and remove it.  This is a difficult technique, but if it’s that or dealing with infection, give it a shot.

Post op
After 24-48 hours rinse with warm salt water a few times per day.  Don’t spit, smoke, or perform any serious chores or exercise for several days.

Note that in most jurisdictions it is illegal to do any of these things to another person unless you are a licensed dentist, but in TEOTWAWKI that probably won’t matter to you.