Many believe that they can handle any emergency if the grid goes down. For those who are trained to stabilize and transport, that may be true for typical injuries due to trauma. Experienced medical professionals faced with dental trauma, however, are often unsure how to proceed. In a long-term austere setting, the group medic must be ready to deal with as many dental problems as medical.
Dental trauma may appear in various forms. After an injury to the oral cavity, a person may have a:
Dental Fracture: a portion of a tooth chipped or broken off.
Dental Subluxation: a loose tooth.
Dental Avulsion: a tooth knocked out completely.
Dental Fractures (Broken Teeth)
When a portion of a tooth is broken off, its categorization is based on the number of layers of the tooth that are exposed. Classically, dentists have referred to these as Ellis class 1, 2, and 3 fractures.
Ellis 1 fractures: In an Ellis 1 fracture, only the enamel has been broken and no dentin or pulp is exposed. This is a problem only if there is a sharp edge to the tooth. The medic can consider filing the edge smooth or using pre-mixed commercial filling cement, Also, a mixture of oil of cloves, also known as eugenol, and zinc oxide powder can be improvised to make temporary cement. Brand names that are commercially available are called “Dentemp” and “Cavit.“
Ellis 2 fractures: Ellis 2 fractures show yellow or beige dentin under the enamel. This area may be sensitive and should be covered if possible. The composition of dentin is more porous than enamel and allows bacteria to enter and infect the tooth. This is especially the case with pediatric dental trauma.
Ellis 3 fractures: Here the pulp and dentin are both exposed. Ellis 3 fractures can be quite uncomfortable. If the pulp is exposed, there may be some bleeding. The risk of permanent damage is most likely here, so protective coverings will be very important.
When you identify a fracture of a tooth due to external trauma, you should:
- Evaluate the patient for associated damage to the face, inside of the cheek, tongue, and jaw. On occasion, a tooth fragment may be lodged in the soft tissues and require removal or soft tissue lacerations sutured. Use an absorbable suture like 4-0 or 5-0 plain catgut, polydiaxanone (PDS), or polyglycolic acid for the inside of the cheek.
- Use water to thoroughly flush and rinse the inside of the mouth with an irrigation syringe for easier evaluation.
- Place a bite block; even a large eraser will do (pain may cause the patient to reflexively bite down).
- Using your gloved hand or a cotton applicator, lightly touch the injured tooth to see if it is loose.
- For sensitive Ellis II fractures of dentin, thoroughly dry the exposed surface and cover with temporary cement as described above or a prescription calcium hydroxide composition (commercially sold as “Dycal”). If these products are unavailable, improvisations include a fluoride dental varnish, clear nail polish, or a cyanoacrylate glue gel to decrease sensitivity (avoid the gums).
- Provide pain medications and cold packs (a thin cloth should be placed between the pack and the skin).
- Instruct the patient to avoid hot and cold food or drink.
Ellis III fractures into pulp are more problematic, partially due to the high risk of infection. Calcium hydroxide on the pulp surface coupled with additional temporary cement can be used as protective coverings. Alternatively, a commercially-available product from India known as Prevest Fusion Flo is a composite material that is effective but must be “cured” with a UV dental curing light (available online) to harden.
If the pulp is breached, antibiotics may be appropriate. Penicillin 500 mg orally every six hours or Doxycycline 100 mg orally twice a day for a week are acceptable options. Pain relief will be required in many cases as well.
Particularly difficult dental fractures involve the root. Sometimes, it is not until the gum is peeled back that the damage to the root is identified. If this is the case off-grid, the tooth is likely unsalvageable (especially in vertical fractures) and should be extracted (discussed in previous articles).
Prevent dental fractures by:
- Not chewing on hard objects such as ice or hard candies.
- Not using your teeth as a cutting tool or to open packaging.
- Avoiding the clenching or grinding of teeth (sometimes called “bruxism“).
Of course, in normal times, use mouth guards when playing contact sports.
Dental Subluxations (Loose Teeth)
A tooth that is knocked loose but not out of its socket is called a “subluxation”. Use your gloved fingers or a cotton applicator lightly to identify any mobility. Often, these injuries will appear to bleed slightly from the border between the tooth and gum.
Minimal trauma may require no major intervention, although the tooth may benefit from support. The loose tooth should be pressed back into the alveolus (socket) and “splinted” to neighboring teeth for stability. Dentists use wire or special materials for this purpose, but you might have to use soft wax if professional help is not at hand. Use enough to anchor the loose tooth to neighboring teeth both in front and in back. Dental wax is an option. Prevent further trauma by placing your patient on a liquid diet for a time. Puddings, gelatins, or soft cereals are also ok.
Dental Avulsions (Teeth Knocked Out)
Occasionally, the trauma may be severe enough to completely knock the tooth out of its socket. This is called a “dental avulsion”. The most favorable situation is when a tooth is knocked out in one piece, including the root and ligaments.
In this circumstance, time is a very important factor in treatment success. If the tooth is not replaced or, at least, preserved in a solution, the success of re-implantation drops 1% every minute the tooth is not in its socket.
A good preservative for teeth that have been knocked out is “Hank’s Solution”. This is a balanced salt solution that has been used to culture living cells, and it helps protect raw ligament fibers for a time. Hank’s Solution is available commercially as “Save-a-Tooth”. Although you can make your own Hank’s Solution, it’s a fairly complex process.
If you are not at your retreat at the time of injury:
- Find the tooth
- Pick it up by the crown; avoid touching the root as it will damage already-compromised ligament fibers.
- Flush the tooth clean of dirt and debris with water or saline solution. Don’t scrub it, as it will further damage the ligaments.
- Place in preservative solution. If you don’t have Hank’s solution, place the tooth in milk, normal saline, egg white, or saliva (put it between your cheek and gums or under your tongue). This will keep the ligament cells viable longer than plain water would.
If the tooth has been out for less than fifteen minutes, you may attempt to re-implant it. Replacing a tooth isn’t always successful, but it’s worth a shot. You should:
- Flush the tooth and the empty socket with Hank’s solution (Save-a-Tooth).
- Replace the tooth.
- Hold in place for five minutes, making sure the tooth is level with its neighbors.
- Cover with cotton or gauze.
- Have the patient bite down firmly to keep it in place.
- Splint the tooth to the teeth on either side for support for two weeks with soft dental wax (some suggest aluminum foil or even Blu Tack adhesive putty). Another improvisation utilizes thin wire and cyanoacrylate glue gel, almost like making a “brace.”
Place the patient on a liquid diet and, to prevent infection, consider antibiotics such as Penicillin 500 mg orally every 6 hours for 7-14 days or doxycycline 100 mg twice a day for 7-14 days. Antibiotics and their veterinary equivalents will be discussed later in this book.
If the tooth has been out longer than 15 minutes, you may have to soak the tooth for a half hour or so in Hank’s Solution before you replace it. The longer you wait to replace the tooth, however, the more painful it will likely be to replace due to swelling and other factors. Make sure you have pain meds and cold packs available in your supplies.
After a couple of hours of being out, the ligament fibers dry out and die; the tooth is, for most intents and purposes, dead. Replacing it at this point is likely to be unsuccessful, as the pulp will decay like all dead soft tissue. Chronic inflammation may develop that causes the dead tooth (which may turn dark in color) to scar down into its bony socket, almost like a dental implant. This is called “ankylosis”.
It’s important to know that, in mature permanent teeth, the pulp rarely, if ever, survives the injury even if the ligaments do. As such, without the availability of root canal procedures to remove dead tissue, even your best efforts may be unsuccessful. If a serious infection arises in the dead pulp, your patient may be in a worse situation than just missing a tooth. It should also be noted that avulsed “baby teeth”, should not be replaced. This is because the scarring process may prevent the permanent teeth from emerging.
Of course, none of the techniques mentioned above should take the place of a full evaluation by a qualified dental professional anywhere a functioning modern dental system exists.
Joe Alton MD
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