In a survival scenario, the family medic will be called on to care not only for medical issues, but dental as well. Military medics during the Vietnam War reported that they dealt with dental problems almost as often as medical. While dental training was relatively informal back then, A special operations combat medic today may train to become a Special Operations Medical Sergeant, undertaking training not only in dental care (including extractions) but other outside-the-box skills, as well.
When the miracle of modern dentistry isn’t around to save a damaged tooth, we may have to return to tooth extraction as the treatment of choice for most dental emergencies. In any situation that involves long-term loss of power, the medic will eventually be confronted with a tooth that must be extracted. Indeed, the grand majority of dental emergencies can be resolved that way.
Tooth extraction is not an enjoyable experience as it is, and will be less so in a long-term survival situation with no power and limited supplies. Unlike baby teeth, a permanent tooth is unlikely to be removed simply by wiggling it out with your (gloved) hand or tying a string to it and the nearest doorknob and slamming. Knowledge of the extraction procedure with limited supplies, however, will be important for anyone expecting to be the family caregiver off the grid.
Note: Be aware that It is illegal and punishable by law to practice dentistry without a license. The lack of formal training or experience in dentistry may cause complications that are much worse than a bum tooth. If you are lucky enough to have access to modern dental care, seek it out.
Once a decision has been reached to remove a tooth, recent studies suggest that giving 800 mg of ibuprofen before dental procedures helps relieve post-extraction pain significantly. Have a good supply of this useful medication in storage.
Proper positioning will help you perform the procedure more easily. For an upper extraction (also called a “maxillary extraction”), the patient should be tipped at a 60-degree angle to the floor. The patient’s mouth should be at the level of the medic’s elbow. For a lower extraction, (also called a “mandibular extraction”), the patient should be sitting upright with the level of the mouth lower than the medic’s elbow.
Right-handed medics should stand to the right of the patient; left-handers stand to the left. For uppers and most front lower extractions, it is best to position yourself in front. For lower molars, some prefer to position themselves behind the patient.
The medic will want to wash hands and put on gloves, a face mask, and some eye protection. The area around the tooth should be kept as dry as possible, so that the area can be easily visualized. There will be some bleeding, so place cotton rolls or balls around the tooth to be removed (rolled gauze squares will also work in a pinch). These may have to be changed from time to time.
Teeth are anchored in their sockets by ligaments, which are fibrous bands of connective tissue. These ligaments must be severed to loosen the tooth. This goal is best accomplished with dental elevators, instruments which come in various shapes. Some may appear like a screwdriver with a very small head; others like a tiny chisel, shovel, or arrowhead.
Once loosened, instruments called extraction forceps are used to remove the tooth. These are specialized for each type of tooth (incisors, canines, premolars, molars). Indeed, there are more types of extractors than there are teeth.
Once positioned, the procedure goes as follows:
1) Separate the gum from the tooth: Use your spoon excavator between the tooth in question and the gum on all sides to separate the two. If this is not done, the gum may tear during the extraction, causing bleeding that will slow the healing process.
2) Loosen the tooth: Use a dental elevator to go between the tooth and the bony socket. Use your index finger for support against the tooth in front of the one being extracted, and apply pressure with the head of the elevator to get down to the root area. Your goal is to sever the ligaments holding the tooth in place. Expect some bleeding.
3) Extract the tooth: Take your extraction forceps and grasp the tooth as far down the root as possible. This will give you the best chance of removing the tooth in its entirety the first time. For front teeth (which have one root), exert pressure straight downward for uppers and straight upward for lowers. For teeth with more than one root, such as molars, a gentle side-to-side rocking motion will help loosen the tooth further as you extract. Once loose, avoid damage to neighboring teeth by extracting towards the cheek rather than towards the tongue. This is best for all but the lower molars that are furthest back (wisdom teeth).
4) Not uncommonly, a tooth might break during the extraction. In this case, use your elevator to identify and further loosen the root. Then, extract it from the socket using the instrument as a lever.
5) Control bleeding: Place some gauze on the bleeding socket and have the patient bite down. In most cases, bleeding should be light.
6) If excessive bleeding occurs, products such as ActCel or chitosan hemostatic gauze can be cut into small, moistened squares and placed directly on the bleeding area. It should form a gel which can be rinsed away with water in 24 hours. Alternatively, layers of 2-inch x 2-inch gauze (2x2s) can be used to place pressure into the socket by closing the mouth.
7) Occasionally, a suture may be required if bleeding is heavy and direct pressure with gauze fails. Use 4-0 chromic catgut or 4-0 polyglycolic acid (Vicryl) absorbable suture material.
Without some of these items, improvisations may be necessary. In a Cuban study, veterinary “Super-glue” (N-butyl-2- cyanoacrylate) was used (very carefully, we hope) in over 100 patients with good success in controlling both bleeding and pain. Dermabond, a prescription medical glue, has been used in some cases in U.S. emergency rooms.
Notice I haven’t mentioned anesthesia. I write about situations where there is no functioning medical or dental infrastructure, so this procedure was explained almost as if we were in an earlier era. It may sound unrealistic or even barbaric to you, but disasters happen and the medic may find themselves in austere settings. The materials used are available in unique specialty kits like the one below, which comes with a copy of “Where There Is No Dentist”:
Liquids and a diet of soft foods should be given to decrease trauma. Hot liquids and hard foods, however, should be avoided for 24-72 hours. Expect some swelling, bruising, and pain over the next few days. Cold packs will decrease swelling for the first 24-48 hours; afterwards, use warm compresses to help with jaw stiffness. Use medicines such as Ibuprofen 200-400 mg every 4 hours or 600-800 mg every 8 hours for pain. Alternatively, Acetaminophen 500 mg every 4 hours should also help for pain. Some stagger the two medicines. Begin warm saltwater rinses after six to eight hours.
Stay away from aspirin, as it may hinder the protective blood clot that naturally forms in the socket. That blood clot is your friend, so make sure not to smoke, spit, or use straws. These actions might dislodge it and cause a condition called “Alveolar Osteitis” or “dry socket.” With this condition, you will notice the clot has disappeared and that the patient has throbbing jaw pain and very foul breath. Antibiotics and warm saltwater gargles are useful here; a solution of 8 fluid ounces of water with 1-2 drops of Clove oil may serve to decrease the pain. Don’t use too much, however, as it could burn the mouth.
Although not all agree, antibiotics given just before and/or just after extraction may reduce the risk of infection and dry socket. Amoxicillin 500 mg, Cephalexin 500 mg, or Metronidazole 500 mg are options and are, at the time of this writing, available in veterinary equivalents.
Joe Alton MD
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