Medical preparedness is an important part of surviving a disaster scenario and, indeed, 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. The true survival medic, however, is the end of the line for medical care, not a way-station to a modern medical facility.

That means long-term care. I often encounter folks who believe that they’re medically prepared, and they are, for a disaster that means a few days or even weeks without power. There are issues that crop up after months or longer off the grid; some of those are dental issues.

If you’ve spent a day at work with a toothache, you know that you weren’t at 100% efficiency, which is where you need to be in a survival situation. The medic needs to be able to handle dental emergencies as well as medical ones.

Despite this, few people who are otherwise medically prepared seem to devote much time to dental health. Today’s dentists have high technology on their side, but this technology will not be available if things go South. Therefore, we look to historical methods of treating these problems. Of these issues, some will be related to trauma

Dental trauma may appear in various forms. After an injury to the oral cavity, a person may have:
· a portion of a tooth chipped or broken off (a dental fracture)
· a loose tooth (a dental subluxation)
· a tooth knocked out completely (a dental avulsion)

The anatomy of the tooth is relatively simple for such an important part of our body and is worth reviewing. The part of the tooth that you see above the gum line is called the “crown”. Below it, you have the “root”. The bony socket that the tooth resides in is called the “alveolus”. Teeth are anchored to the alveolar bone with ligaments, just like you have ligaments holding together your ankle or shoulder.

• The tooth is composed of different materials:
• Enamel: The hard white external covering of the tooth crown.
• Dentin: bony yellowish material under the enamel that surrounds the pulp.
• Pulp: connective tissue with blood vessels and nerves endings in the central portion of the tooth.

DENTAL FRACTURES

When a portion of a tooth is broken off, it is categorized 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 only a problem if there is a sharp edge to the tooth. You can consider filing the edge smooth or using a mixture of Oil of Cloves, also known as Eugenol, and Zinc Oxide powder as a temporary cement.

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 different than enamel and bacteria may 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, and Ellis 3 fractures can be quite uncomfortable. If the pulp is exposed, it may bleed. Protective coverings will be most necessary here, and the risks of permanent damage most likely, especially in a collapse.

When you identify a fracture of a tooth, you should evaluate the patient for associated damage, such as to the face, inside of the cheek, tongue, and jaw. Sometimes, a tooth fragment may be lodged in the soft tissues and must be removed with instruments. There is likely to be blood due to the trauma, so thoroughly clean out the inside of the mouth so you can fully assess the situation. Then, 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, cover the exposed surface with a calcium hydroxide composition (commercially sold as “Dycal”), a Fluoride varnish (Fluoride is rarely beneficial in drinking water, in my opinion, but is acceptable as a direct application to the tooth defect) or even clear nail polish to decrease sensitivity. Provide pain medications and instruct the patient to avoid hot and cold food or drink.

Ellis III fractures into pulp are trouble, due to the risk of infection, among other reasons. Calcium hydroxide on the pulp surface with an additional temporary cement can be used as coverings. Provide analgesics and antibiotics. Penicillin and Doxycycline are options. Despite all this, the prognosis is not favorable without modern dental intervention.

A particularly difficult dental fracture involves the root. Sometimes, it is not until the gum is peeled back that a fracture in the root is identified. If this is the case, the tooth is likely unsalvageable (especially in vertical fractures) and, in a power-down situation, should be extracted.

TEETH KNOCKED LOOSE OR OUT

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 it. 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. If you can, use enough wax to anchor the loose tooth to neighboring teeth both in front and in back.

Prevent further trauma by placing your patient on a liquid diet for a time. Puddings, gelatins, or soft cereals are also ok. Occasionally, the trauma may be severe enough to completely knock the tooth out of its socket. This is called an “avulsion”.

The most favorable situation when a tooth is knocked out is when it comes out in one piece, including the root and ligaments. In this circumstance, time is a very important factor in possible treatment success. If the tooth is not replaced or 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”.

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.
-If you don’t have preservation solution, place the tooth in milk, saline solution, or saliva (put it between your cheek and gums or under your tongue). This will keep the ligament cells viable longer than plain water.

If the tooth has been out for less than fifteen minutes, you may attempt to re-implant it. Flush the tooth and the empty socket with Hank’s solution (Save-a-Tooth). Replace the tooth, hold in place for five minutes, and make sure the tooth is level with its neighbors. Cover with cotton or gauze, and have the patient bite down firmly to keep it in place. After a while, splint the tooth with soft wax to the teeth on either side for support.

Place your patient on a liquid diet and consider antibiotics such as Penicillin (Veterinary equivalent: Fish-Pen) or doxycycline (Bird-Biotic) to prevent infection. Antibiotics and their veterinary equivalents are discussed in detail in The Survival Medical Handbook: The Essential Guide for When Medical Help is Not on the Way or at Doom and Bloom. 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, the more painful it will likely be to replace, so make sure you have pain meds available in your supplies.

After a couple of hours of being out, the ligament fibers dry out and die, and 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 does.

This causes a chronic inflammation causing 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”. Don’t replace “baby teeth”,
because the scarring process may prevent the permanent teeth from emerging.

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.

In the end, some cases of dental trauma may result in an unsalvageable tooth. Dental extraction may be necessary. Indeed, 90% of dental emergencies were, in the past, dealt with by extraction. In a survival situation, this may be your best option to prevent complications.

In future articles, I will go over the process by which a tooth may be extracted. For this, a good dental kit will be an important tool in the medical woodshed.

Joe Alton MD