Dr Irina Balieva / Registrar in Tropical Medicine, the Netherlands / Postgraduate Student in Global Health

Burjor is an Honorary Clinical Professor of Extreme Medicine, WED Module Lead on the University of Exeter’s MSc Extreme Medicine and travels the world running dental camps around his UK clinical practice. Irina is a doctor and postgraduate student in Global Health and Tropical Medicine based in the Netherlands. In this article they outline the importance and scope of expedition dentistry and routes into the field for both dentists and non-dentists. They also share the stories of their own initiations into WED, highlighting the immense value that dentistry can bring to the wilderness and expedition environment.

What is Wilderness Expedition Dentistry?

Are you a medic, paramedic, or dentist? Are you relatively fit? Do you enjoy lateral thinking and thrive in a challenging situation? Do you love travelling and exploring new places? If so, Wilderness Expedition Dentistry (WED) could be for you.

WED is a branch of medicine that addresses prevention, assessment and management of accidents and emergencies associated with the orofacial region in remote settings, where definitive care is often days or weeks away. This is a rapidly evolving field of increasing importance as more people engage in longer and potentially hazardous expeditions. WED includes:

• Expedition planning and clinical care
• Evaluation of experience and issuance of updated training to other expedition medics
• Epidemiological studies
• Humanitarian dentistry including organising and running emergency dental clinics in remote access areas for local populations or in refugee camps

How did we get into it?

Fresh out of dental school, doing his masters in Oral Surgery and madly interested in the outdoors, Burjor was invited to a dental camp in a rural area of Maharashtra, India in June 1986. There was a heavy monsoon and transport to the destination was a four-hour, back-breaking bus journey. The clinic was a classroom. Seven hours and 56 dental extractions later he was hooked. The communal team of medics, dentists and paramedics, went as strangers and left the best of friends. They are still in touch, still doing dental camps.

Irina’s first experience was as a medical doctor on a World Extreme Medical Expedition Course in Slovenia. There were several practicals on expedition dentistry. Realising how significant the impact of dental emergencies can be in remote settings and how much you can do with so little, made her excited to learn more.

What are the benefits of getting involved in Wilderness Expedition Dentistry?

WED can be extremely rewarding. Imagine yourself in your home country, as a patient vociferously complains about the 20-minute delay to be seen. You remember the patients you treated on your last expedition, many of whom may have waited months to access this care. Their gratitude reminds you that through WED, you can use your skills where they are most urgently needed, to help communities who lack regular access to dental care.

We have often been asked “can expedition dentistry be your full-time job?” Simply put, no. Though your financial rewards will be minimal, your payment in experiences, memories, skill improvements and mental wellbeing will more than make up for the monetary loss.

How can you balance your personal and professional life with expedition dentistry?

It is a compromise between professional ambitions, relationships with friends and family and the stimulation provided by going on expeditions. Essentially, it will vary depending on what stage of life you are in and where you want to go. You cannot consistently spend months taking a break from your training and sustainable income. However sometimes the opportunity will be well worth the sacrifice. To go or not to go? Only you can decide.

What advice do you have for anyone interested in becoming an expedition dentist?

The common themes of all WED expeditions are:

• Limited equipment
• Environmental extremes
• On the spot decision making/creative thinking and improvisation

There are many courses available. We recommend that you research well and check the reviews. We have had personal experience with:

World Extreme Medicine

Diploma & Masters in Expedition and Wilderness Medicine – RCPS of Glasgow

MSC in Extreme Medicine – University of Exeter

What extra qualifications are needed?

If you are a dentist reading this (and getting excited) you may be wondering what additional training is necessary. Some experience and working knowledge in oral surgery is definitely a plus. In addition, an Expedition Medicine course will give you various useful skills. On these courses you can meet and network with other like-minded medics. You will receive general outlines of expedition medical problems and how to deal with them, which is useful if you are supporting an expedition doctor.

If you are a medic or paramedic concerned with your lack of dental knowledge and want to round off your training so you can be prepared for every eventuality (including those irritating dental ones) there are many ways to improve your skills. You can attend the numerous wilderness expedition dental hands-on workshops available, shadow your local maxillofacial or dental teams and learn from the open-access articles and videos on Adventure Medic and Wilderness Expedition Dentistry. The importance of maintaining your physical fitness cannot be underestimated. You have to carry your medical and dental equipment on top of your regular kit and be prepared to do your work at the end of a physical day. It can be exhausting but you will be rewarded with unforgettable experiences.

Two main types of expeditions

The first type applies to qualified dentists. This is a dental camp. Here you volunteer to provide dental services to local people in remote areas, often in low-income regions. The organisation you go with will have spread the word, so a long line of patients will be waiting. These are usually rudimentary dental clinics and may actually have luxuries like a bright light and a portable chair. This is a good first introduction. They are easy to get onto, although you might have to pay for travel, boarding and lodging. The second type of expedition applies to medics, paramedics and dentists who have completed WED training. Here your goal is to provide dental emergency care as and when the need arises, mainly for participants of an expedition. You (or a team member) carry your dental emergency kit. Your clinic can become anywhere your patient can sit or lie.

Indemnity and medicolegal matters

First the good news: persons who participate in outdoor ventures are more likely to accept personal responsibility for their health, risky activities and the limitations of their remote location. They are grateful for the help they receive in difficult circumstances and therefore, are less likely to sue.

The Good Samaritan Act: technically this will apply only if you are somewhere as a lay person and an emergency arose which required you to exercise your medico-dental skills. If, however, you agreed to take part in an expedition in the capacity of a medic you would technically not fall into this category.

A court considering standard of care would not expect a medic to provide the same standard in remote wilderness as in a well-equipped emergency room, but would expect that medic to provide a similar standard to a competent medic in a similar emergency situation. The particular situation in which the incident occurred will be taken into account. You may be protected from legal liability for negligence if you do your job well and in accordance with the standards for the wilderness expedition medical professional. In our experience, as long as you will be performing standard dentistry procedures, i.e. fillings and extractions on your expedition, insurance is usually straightforward to obtain from the DDU. Further information is available for doctors on medicolegal aspects of expedition medicine, paramedics and by contacting your own indemnity provider.

Want to know more?

Dental emergencies account for 16% of all Medivacs.¹ In view of this, the Faculty of Prehospital Care, RCSEd² have stated the importance of basic dental training for all expedition medics. To help facilitate this we have created the Wilderness Expedition Dentistry website, an educational resource with no copyright restrictions. This allows medics worldwide free access to resources enabling them to run workshops and lectures to train expedition medics in managing dental emergencies. This is an evolving website where we aim to add videos and pictorial slides to reinforce this training.

All photographs courtesy of Eric Linder, Founder/ Team Leader, Team 5 Foundation.

1. Küpper, T., Hettlich, M., Horz, H.P., Lechner, K., Scharfenberg, C., Conrads, G., et al. Dental Problems and Emergencies of Trekkers – Epidemiology and Prevention. Results of the ADEMED Expedition 2008. High Altitude Medicine and Biology, 2014; 15: 39 – 45. DOI: 10.1089/ham.2013.1108.

2. Mellor, A., Dodds, N., Joshi, R., Hall, J., Dhillon, S., Hollis, S., et al. Faculty of Prehospital Care, Royal College of Surgeons Edinburgh guidance for medical provision for wilderness medicine. Extreme Physiology and Medicine, 2015; 4: 22. DOI: 10.1186/s13728-015-0041-x.

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Dr Burjor Langdana takes us through the problems with dental hygiene during endurance sports and expeditions. The Colgate Duraphat 5000 toothpaste’s high fluoride content helps to mitigate these risks and can help prevent both dental cavities and gum disease.

But I’m not an endurance athlete

If you are reading Adventure Medic you are likely to be involved in many outdoor pursuits already. Perhaps cycling to work, on your feet walking around the hospital (or other healthcare setting) all day and then any post-work sporting pursuits. At the weekend, a run, hill-walk or climb perhaps. In other words, you are directly or indirectly involved in endurance activities. Thus, you are sharing the oral insults these activities entail.

Do protractive frequent endurance activities affect my oral health?

Unfortunately yes, this is true. Oral health gets a right beating before, during and after exercise. This is how it happens:

Saliva

a) Viscosity – Sympathetic activity during strenuous exercise increases the mucinous, sticky saliva secretion.¹

b) Volume – is decreased due to dehydration and mouth breathing.

c) Composition – IgA concentration is decreased, reducing mucosal and upper respiratory tract immunity.¹

Diet

A change in regular diet, increased snacking or energy supplements can result in:

a) Increased quantity and frequency of carbohydrate intake.

b) Increase in acid exposure, which causes increased dental corrosion due to the chelating action of the acids present in saliva.¹

Immunosuppression

Studies show that after intense frequent physical activity for 3-24 hours, immune function is affected in the following ways:²

a) Neutrophil respiratory burst.

b) Lymphocyte proliferation.

c) Monocyte antigen presentation.

This results in increased soreness of the throat and mouth.

So, what does all this mean?

This means that your active fun-filled lifestyle puts you in a high-risk group of individuals predisposed to dental decay and gum disease.

Duraphat 5000 Toothpaste

But I go for regular dental check-ups and brush twice a day. What else can I do? A simple addition to your regime is Duraphat 5000 Toothpaste.

What is it? – Colgate Duraphat 5000 ppm toothpaste contains four times the amount of fluoride found in regular toothpaste.

What does it do? – Over-the-counter fluoride toothpaste (1000 ppm) reduces cavities by approximately 23% while a toothpaste in the range of 2400-2800 ppm reduces cavities by about 36%. A 5000 ppm high fluoride toothpaste reduces the cavity risk even more – estimated to be about a 42% reduction.³

How does it work? – The active ingredient sodium fluoride prevents the build-up of plaque that can cause tooth decay and cavities (dental caries). It works by strengthening and remineralising enamel to help resist acid erosion.³

a) Decreases the formation of new cavities.

b) Slows down the progress of any existing dental decay to a certain extent.

c) Helps to decrease dental sensitivity.

d) Decreases the progression of gum disease to a certain extent.

How do I use it? – Ideally, brush for three minutes three times a day and then do not rinse. Try not eating or drinking or rinsing for 30 minutes after that.

Where can I get it? – For those in the UK, if your dentist agrees that you are in the high-risk category for dental decay then you can get up to four tubes on a single NHS prescription.

Practical advantages for the outdoors

• Colgate Duraphat 5000 comes in a small tube and you only need a pea-sized quantity on your toothbrush; saving both weight and space in your pack.
• Its minimal foaming action helps to keep your kit clean and tidy when brushing teeth in a tent.
• Due to its high fluoride content, Colgate Duraphat 5000 can also be used for sensitive teeth – by rubbing and leaving it on sensitive teeth.
• Bottom line: By making Colgate Duraphat 5000 your regular toothpaste, its beneficial effects will make up for the inevitable temporary lapses in oral hygiene maintenance when out in the field.

References

1. Influence of intensive training on salivary flow, on salivary pH and on salivary lactate concentration: consequences for oral health. Reis N, et al. 2015. International Congress of CiiEM.
2. Immune function in sport and exercise. Gleeson M. 2007. Journal of Applied Physiology.
3. The Anticariogenic Efficacy of 5000 ppm Fluoridated Toothpaste: A Systematic Review. Chaudhary D, et al. Journal of Clinical and Diagnostic Research. 2018 Jan, Vol-12(1): ZE04-ZE10.

The post Duraphat 5000 – The Secret Dental Elixir For Endurance Athletes appeared first on Adventure Medic.

Fortunately our resident expedition dentistry expert, Dr. Burjor Langdana, has started uploading free to access educational videos to the YouTube channel Wilderness Expedition Dentistry. There are already some excellent educational videos covering common dental presentations, with more to come in the future.

We have included one of the videos below but you can access the full library here.

The post Expedition Dentistry Teaching Videos appeared first on Adventure Medic.

Dr Burjor Langdana explains why routine use of antibacterial mouthwash, such as 0.2% chlorhexidine may reduce the beneficial effects of training; especially in the recovery phase.

Newsflash – Routine use of antibacterial mouthwash like 0.2% chlorhexidine may reduce the beneficial effects of training especially is the post-training phase ¹.

Mechanism – Oral bacteria play a key role in the cardiovascular effects of exercise, specifically the vasodilation and low blood pressure seen after exercise. When you exercise, cells in your blood vessels and muscles produce nitric oxide, which widens blood vessels and increases blood flow to working muscles. The nitrate formed during exercise is then absorbed by the salivary glands and secreted in the mouth during the recovery period after exercise ¹. After nitrate is secreted into the mouth, oral bacteria reduce this to nitrite which is then swallowed. After swallowing, a small portion of nitrite is rapidly absorbed into the bloodstream and forms new nitric oxide; helping to sustain optimal blood supply to active tissues. This causes a blood pressure lowering response termed ‘post-exercise hypotension’.

Bottom Line – Antibacterial mouthwashes such as Corsodyl (active ingredient: chlorhexidine) may be detrimental to recovery. By killing the ‘good’ oral bacteria, less nitrates are converted into nitrites and thus less nitric oxide is available to widen the diameter of blood vessels after exercise. Therefore, tissue perfusion is reduced as well as post-exercise hypotension.

References

1. Post-exercise hypotension and skeletal muscle oxygenation is regulated by nitrate-reducing activity of oral bacteria. C Cutler et al. Free Radical and Biology Medicine. 2019. 1;143:252-259. Accessed at: https://pubmed.ncbi.nlm.nih.gov/31369841

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Matt Edwards / Emergency Medicine Consultant / Air Ambulance Kent Surrey Sussex / Contributor Wilderness Expedition Dentistry

This article is the sixth of our series and aims to provide you with some guidelines on managing acute non-traumatic temporomandibular joint (TMJ) dislocation in the field. For more in the series, check out the Adventure Medic Dental page.

Background

Most medics will have had little experience with TMJ dislocation, which only represents 3% of all joint dislocations.¹ While it is not uncommon for these to be relocated under sedation or anaesthesia, they are very treatable without sedation, especially if attempted early.² Therefore, all expedition medics should be comfortable to assess, diagnose and manage a dislocated temporomandibular joint.

There is a shriek around the campfire. “She can’t close her mouth!” You rush over, finding this frightened young woman in acute pain. She has saliva drooling from her mouth. Her mouth appears to be locked open. You are in the middle of nowhere. There is no access to anaesthesia or sedation. What can you do?

This article and slideshow aim to:

1. Describe how to diagnose acute temporomandibular joint (TMJ) dislocation.
2. Demonstrate the various treatment options, with a stepwise escalation for when treatment options fail.
3. Describe the considerations and management of prolonged dislocation.

Diagnosis

The Patient

1. Acute Pain (especially anterior to the ear) due to major myospasm associated with the dislocated joint.
2. Difficulty in speaking due to the inability to open or close mouth. Give them a means to write so they can tell you how it happened.
3. Excess salivation as they may find swallowing impossible. This will make taking any oral medication difficult.
4. No difficulty in breathing or stridor. If this is the case, consider alternative diagnosis such as retropharyngeal swelling and/or infection.

What you see

1. Normally the jaw is displaced anteriorly with bilateral dislocations. The mouth will be held open, lower jaw appears prominent with midline maintained.
2. Occasionally dislocation could be unilateral and the midline of the jaw will deviate to the side opposite to the dislocation i.e. to the normal side. Look at the relationship of the upper and lower incisors as a reference point.
3. Rarely, dislocations can occur posteriorly, laterally or even superiorly. ^3,4,5 This tends to be more common with trauma and can be more easily missed.
4. You should not see neck swelling or haematomas under the tongue.

What you feel

1. Hollowing in front of the tragus.
2. You should not feel any crepitus or instability of the jaw or swelling in the neck.

Why did this happen?

Wide-open mouth (yawning, eating, laughing, singing) and an underlying susceptibility. It is even possible during routine dental checks!

• Condyle (The rounded projection of the lower jaw that fits into the fossa of the temporal bone) moves onto the articular eminence (the raised area of bone at the anterior limit of the temporal fossa)
• Condyle slips forward, preventing the mouth from closing
• Powerful masticatory muscles tighten/spasm
• These biting muscles easily overpower the weaker mouth opening muscles
• The mandible is then held in this new ‘open and protruded’ position
• Causes a reinforcing cycle and muscles contract further
• The mandible becomes ‘locked’ in this position.

Dislocations and fracture-dislocations can occasionally occur with trauma ⁵ and in these cases, it is important to ensure:

• The airway is not compromised
• C-spine injury is considered
• Tooth avulsions are located (if they cannot be found, assume they are in the right main bronchus)
• Tooth avulsions are relocated (see the AM Guide to Dental Trauma)
• Mandibular fractures are considered (look for gum-line bleeding, sublingual haematoma)
• External auditory meatus is examined for bleeding or occlusion (posterior fracture/dislocations) ³
• Mastoid area is examined for bruising (Battle Sign) – basilar skull fracture due to posterior dislocation) ¹⁶

It is likely these patients with traumatic dislocation/fracture-dislocation will require medevac and operative reduction. The techniques described below are not suitable for these types of dislocations.

What can you do?

Relocation options:

1. Hippocratic ⁶ / Traditional intraoral method ⁷

a) Reposition mandible both sides at the same time

1. Seat patient lower than you
2. Place your thumb inside the mouth. Your thumb will rest on the top (occlusal surface) of the lower molar teeth
3. Your remaining fingers are outside the mouth. They will extend along the lower border of the mandible from angle to chin
4. Exert downward, steady, constant pressure on patients’ lower molars with your thumb while the remainder of your fingers and hand around chin are levering upwards
5. As myospasm is overcome you will feel a give sensation
6. Then guide the mandible posteriorly and upwards

b) Reposition mandible one side at a time ⁸

1. Fix the patients head between your body and non-dominant hand
2. Place the thumb of your dominant hand onto the occlusal surface of the last molar of the side of the jaw to be repositioned
3. Grip the mandible with the rest of your hand
4. Apply gentle but increasing downward pressure
5. Gradually increase the force for up to five minutes until you feel the condyle move
6. Guide upwards and backwards very slightly until you feel condyle slide into fossa.
7. After reducing one TMJ, hold it in position with your non-dominant hand by positioning a finger in front of the reduced condyle.
8. Then reposition the other TMJ in the manner stated above.

How to avoid getting bitten

• Instruct the patient that you will guide the jaw in its closed position and they should not contribute by attempting to bite
• Gauze wrap around thumbs
• Place thumb on bony ridge present on the cheek side of mandibular molars, rather than on the top surface of the molars
• Consider using the Syringe Technique (see below)
• Consider using the Extra Oral Technique (see below)

2. ‘Syringe’ or Lever Technique for reducing TMJ dislocation ^9,10

This technique had a 97% success rate in one series when the patients presented within two hours of dislocation.⁹ It utilises the patient’s own strong masseter to pivot the jaw around a fulcrum pushing the mandibular condyle down and back into place.

1. Choose the right size of syringe (5 to 10 ml) or similar sized rigid cylindrical-shaped item. Wide enough for the patient to rest/bite on in the dislocated position i.e. 2-3cm. This could even be a roll of gauze, as described in the ‘lever’ technique.
2. Place it between the upper and lower molars on one side.
3. Tell the patient to gently bite down.
4. The patient is then encouraged to roll the syringe back and forth. By protruding mandible forwards and retruding it backwards. Gradually more and more movement will be tolerated.
5. Simultaneously you assist by grasping the end of syringe protruding from the side of the mouth. And rotating it forwards and backwards.
6. Syringe acts as a rolling fulcrum translating the force of the biting muscles to pivot the back of the jaw back into its socket.
7. The opposite side reduces spontaneously. If this does not occur, the syringe should be placed on that side as well.

3. Extra-Oral Technique for reducing TMJ dislocation ¹¹

1. Patient in sitting or supine position
2. You stand in front of the patient.
3. You place your thumb on the patient’s cheek, on the coronoid process of the dislocated mandible. Your thumb then applies persistent posterior pressure. The rest of the fingers of this hand are placed behind this same mandible, posterior to the mastoid process, stabilising the grip.
4. Simultaneously on the opposite side. You then place your thumb on the malar eminence (cheek prominence) and your fingers around the angle of the mandible. Applying an anterior force (Like jaw thrust manoeuvre.)
5. Then, by pulling the mandible anteriorly and simultaneously using your other hand to push the coronoid posteriorly, the jaw rotates facilitating contralateral TMJ reduction.
6. Once one side is reduced, the other side will usually go back spontaneously.
7. If this does not work apply posterior force on both coronoid processes at the same time.

Problem-solving: prolonged dislocation

You have been away from the campsite. The dislocation is now 24 hours old and myospasm has set in. The traditional method of reduction is not working. You don’t have access to sedation or GA. What can you do?

In this scenario, you could try:

• Ensure adequate analgesia. If possible, use IM medication as oral medications will be extremely difficult to swallow.
• Ask the patient to open widely against resistance, through reciprocal inhibition, the muscle tone of the elevator muscles is reduced and then manual reduction can be attempted.
• Syringe or Extra-Oral technique. It’s claimed that they have a higher success rate in the presence of excessive myospasm.
• The Wrist Pivot Method (see below)
• If available, attempting regional nerve blocks (see below)
• If none of these methods succeed there will be no option but to arrange a medevac.

Wrist Pivot Method ¹²

1. Grasp the mandible at the mentum with both thumbs
2. Place your fingers on the inferior molars
3. Apply upward force on thumb and downward pressure with fingers
4. The forces should be applied bilaterally to avoid mandibular fracture.

Deep Temporal Nerve block ^13,14

1. You will need a 30 gauge needle to inject approximately 0.5 to 0.8 ml of 2% Lignocaine with 1;100,000 adrenaline
2. Take your index finger run it on the top surface of the zygomatic arch anteriorly until the horizontal arch meets the vertical zygomatic process. This is the area of anterior temporalis muscle
3. Insert the needle parallel horizontally to the index finger through the temporalis muscle to contact the bone ( greater wing of sphenoid)
4. Aspirate and inject and wait at least two minutes

Masseteric Nerve block ^13,14

1. You will  use a 30 gauge needle to inject approximately 0.5 to 0.8 ml of 2% Lignocaine with 1;100,000 adrenaline
2. Take your thumb and middle finger. Grasp the anterior and posterior border of the ramus of the mandible, extra-orally, visualising the width of the ramus with your index finger.
3. Locate the zygomatic arch. Follow to a point midway between thumb and index finger.
4. Slide index finger inferiorly until it reaches the mandibular notch.
5. Insert needle posteriorly, hitting the neck of the condyle approximate depth 7-10 mm
6. Aspirate and inject and wait at least two minutes.

Patient care post-reduction

1. Verify normal bite/occlusion i.e. midline of upper and lower teeth match. The patient may feel that the bite is good but not exactly right. This is frequently just some residual swelling around the TMJ.
2. Cool compress
3. Barrel bandage (check slide show for method) The patient may find the use of a cervical spine collar helpful ¹⁵
4. Liquid diet for 48 hours
5. Soft iedt for subsequent seven days
6. NSAID for three days
7. Follow up with their dentist when they return home

References

¹ Lovely FW, Copeland RA. Reduction eminoplasty for chronic recurrent luxation of the temporomandibular joint. J Can Dent Assoc. 1981;47:179–184.

² Liddell A, Perez DE. Temporomandibular joint dislocation. Oral Maxillofac Surg Clin North Am. 2015 Feb;27(1):125-36.

³ Albilia, Weisleder, and Wolford. Technique for Posterior Condylar Dislocation. J Oral Maxillofac Surg 2018.

⁴ Srinath N et al. Superolateral dislocation of the intact mandibular condyle: report of a rare case with a review. Int. J. Oral Maxillofac. Surg. 2017; 46: 1424–1428

⁵ Akinbami BO. Evaluation of the mechanism and principles of management of temporomandibular joint dislocation. Systematic review of literature and a proposed new classification of temporomandibular joint dislocation. Head Face Med. 2011 Jun 15;7:10.

⁶ Forshaw RJ. Reduction of temporomandibular joint dislocation: an ancient technique that has stood the test of time. Br Dent J. 2015 Jul;218(12):691-3.

⁷ DeAngelis AF et al. Review article: Maxillofacial emergencies: dentoalveolar and temporomandibular joint trauma. Emerg Med Australas. 2014 Oct;26(5):439-45.

⁸ Shun TA et al. A case series of closed reduction for acute temporomandibular joint dislocation by a new approach. Eur J Emerg Med. 2006 Apr;13(2):72-5.

⁹ The “syringe” technique: a hands-free approach for the reduction of acute nontraumatic temporomandibular dislocations in the emergency department. (J Emerg Med. 2014 Dec;47(6):676-81. doi: 10.1016/j.jemermed.2014.06.050. Epub 2014 Sep 30.)

¹⁰ Yeşiloğlu N et al. The lever technique for the external reduction of temporomandibular joint dislocation. J Plast Reconstr Aesthet Surg. 2015 Jan;68(1):123-5.

¹¹ Gonai S et al. Extraoral autoreduction of temporomandibular joint dislocation: a preliminary clinical study. Am J Emerg Med. 2015 Apr;33(4):588-9.

¹² Refractory Temporomandibular Joint Dislocation – Reduction Using the Wrist Pivot Method. ( Clin Pract Cases Emerg Med. 2017 Nov; 1(4): 380–383)

¹³ Woodall CE et al. The use of intraoral local anaesthetic to aid reduction of acute temporomandibular joint dislocation. J Stomatol Oral Maxillofac Surg. 2019 Apr;120(2):152-153

¹⁴ Use of Masseteric and Deep Temporal Nerve Blocks for Reduction of Mandibular Dislocation. ( Anesth Prog. 2009 Spring; 56(1): 9–13.doi: 10.2344/0003-3006-56.1.9)

¹⁵ Jaisani MR et al. Use of Cervical Collar in Temporomandibular Dislocation. J. Maxillofac. Oral Surg. (Apr–June 2015) 14(2):470–471

¹⁶ https://www.reliasmedia.com/articles/4144-the-facial-trauma-patient-in-the-emergency-department-review-of-diagnosis-and-management-part-iii

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Matt Edwards / Registrar / London Air Ambulance

You are out on an oil rig. The weather is foul and will be for the next few days. You are faced with a patient in excruciating pain. The lower front tooth is mobile, there is redness and swelling in the surrounding gums. If only you could take that tooth out, it would establish drainage and provide immediate relief from pressure pain. From our past articles you would have located the problem and selected the appropriate local anaesthetic. This article and the slide show below will give you the basics of a simple dental extraction.

Dental Extractions

When you are in a remote area and a great distance from help, dental extraction may be contemplated to avoid evacuation. It may also be an emergency procedure when evacuation is not likely in the near future. It is highly recommended that appropriate training and practice has been completed prior to departure, as the worst case scenario if an extraction goes wrong is a patient who is still in pain, still has an abscess but now has a fractured tooth that will require oral surgery.

Indications

Indications for extraction under these circumstances would include:

Loose teeth associated with a dental abscess / Extraction of which would provide drainage and relief of severe pressure pain.

Loose teeth on side of a jaw fracture / Removal to facilitate reduction and haemorrhage control.

Excruciatingly painful tooth / That can’t be made pain free medically but responds well to LA and is within your skill levels to attempt extraction.

Positioning

Upper Extraction / You stand in front and to the right of the patient.

Lower Extraction / You stand slightly to the back and right of the patient

Support / Head and Jaw must be well supported

Elevators

These look like flattened screw drivers and are wedged in the ligament space between tooth and surrounding bone. They are used as levers to compress the soft bone around the tooth thus increasing the size of the socket. This increases the tooth mobility allowing the forceps a better purchase.

Forceps

All forceps are made such that their beaks would be parallel to the long axis of the tooth. This allows force to be applied precisely along that long axis, as tangential force will increase likelihood of tooth fracture.

Lower Forceps / Have a sharp bend to allow force to be applied without damaging the lower lip

Upper Forceps / Are straighter as they can achieve the required angle of force without the need of a sharp bend.

If you can only take one, take the lower forceps and don’t be tempted to use pliers. While it is possible to perform an extraction with them, they are highly likely to fracture the tooth as they are too bulky and cannot grip it in the correct spot.

Extraction Technique

1 / First push towards the root. Push the beaks of the forceps towards the root apex, below the gum margin as far as possible. This lowers the centre of rotation decreasing force on the root apex and reducing likelihood of root fracture.

2 / Then, using slow but firm focused force, exert pressure towards the cheek/lip followed by pressure towards tongue/palate. It’s like slowly removing a tent peg from the ground, by moving it back and forth to widen the hole in which it is lodged.

3 / The tooth is slowly rotated out following the line of least resistance.

Pressure Pack / Within five minutes of extraction advise patient to bite hard on a small firm pack of cotton roll or absorbent paper placed over the socket to achieve haemostasis for at least fifteen minutes. Continued bleeding is mostly because pressure has not been applied for long enough. Fifteen minutes can get quite boring. Some recommend soaked teabags bitten and held into the socket to stop bleeding, as tea supposedly contains some mildly antiseptic and vasoconstrictive agents.

Post-Extraction Patient Instructions

15- 30 mins / Gently rotate out the pressure pack.

12 hours / Avoid eating anything hot/hard.

24 hours / Avoid vigorous spitting, rinsing and smoking.

Oral Hygiene / Mouth washing, gentle brushing after every meal strongly advised even though this may be uncomfortable.

(Cover Photo: AfroBrazilian / Wikimedia Commons)

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Maintaining a diet that is good for our teeth may be a struggle in wilderness or extreme athletic situations. It can be difficult to keep up our fluid intake, as well as brushing and flossing regularly. Choosing the right toothpaste can help mitigate these issues, but the choice can be confusing. Fear not however, as Adventure Medic’s Resident Extreme Dentist Burjor Langdana swings in to the rescue.

Dental problems can wreck an expedition and be a source of considerable stress for medic and patient. Fortunately, it has never been so easy to prevent dental decay or control sensitivity as it is today. However, there is such a wide variety of toothpastes out there that the choice can be confusing. Indeed, not to choose the right one would be similar to an asthmatic climbing K2 without the right inhaler, and the best choice will depend on the activity, the location as well as the state of the mouth in question.

Choosing a Toothpaste

Here is some general guidance, followed by some real life case studies below.

Spit or rinse? / Always spit out excess toothpaste, rather than rinse, as they act better the longer they stay on the teeth.

Whitening / Whitening toothpastes are usually more agressive and in expedition settings may predispose to increased sensitivity.

Anti-sensitivity / Don’t chop and change different toothpastes, stick to the one that works for you and don’t stop once sensitivity is reduced.

Tender gums after brushing? / May indicate allergy to the foaming agent sodium lauryl sulphate. Use non-foaming toothpastes such as Sensodyne Repair & Protect or Sensodyne Pronamel.

Herbal / Herbal toothpastes are generally more aggressive and have a lower concentration of active fluoride so in an expedition setting they may be of limited protective effect.

Freeze Resistance

We were curious as to how these toothpastes perform in the cold, so Burjor tried them out in -18-20ºC.

Case Study 1 – The Extreme Athlete

An Iron Woman competitor notices that her front teeth are getting translucent. She is forming little caves on the top surface of her teeth, they are looking more yellow and flatter. Gradually her sensitivity is getting worse.

Why / High acid in her diet from energy drinks is dissolving her teeth enamel. This exposes the dentine which then cavitates.

Toothpaste / Sensodyne Pronamel: its low abrasive action will prevent further tooth loss. Its high active fluoride delivery system will harden exposed tooth structure. It will numb the ongoing sensitivity to improve comfort.

Case Study 2 – The High Altitude Climber

You are planning to climb a Himalayan peak. You have always had sensitive teeth but in cold weather your gums get tender and the sensitivity gets worse.

Why / Recession of gums exposing the inner dentine, close to gum line. This part of the tooth (dentine) is rich in tubes that end in nerves. When fluid touches the tubes, nerves are stimulated leading to sensitivity.

Toothpaste / Sensodyne Repair and Protect: needs to be started a few weeks before the expedition. The toothpaste contains Novamin which will form a resistant coating on the sensitive portion of the teeth. This coating is hard and resistant but needs repetitive exposure to Novamin to keep it intact. Hence, continued brushing with Sensodyne Repair and Protect is needed even after sensitivity disappears. It does not contain the toothpaste foaming agent (sodium lauryl sulfate) so it’s kinder to sore gums, as well as avoiding a mouth full of foam while high on a mountain. It does not contain water (as water activates Novamin) so it performs nicely in very low temperatures.

Case Study 3 – Jungle trekking

You are planning a long walk through the jungles of Burma. You have excellent teeth but have been told that you have weak gums. You have had gum treatment and are doing your best to maintain them.

Why / Aggressive gum disease is multifactorial. Good oral hygiene needs to be reinforced with the antiseptic provided by Corsodyl mouthwash and toothpaste.

Toothpaste / Corsodyl toothpaste: it contains ingredients to maintain gum health and fluoride.

Case Study 4 – Field workers or shift workers

Energy rich diets, hit and miss oral hygeine, more tooth decay is noted every dental check.

Toothpaste / Duraphat 2800: available on prescription, this toothpaste has a much higher fluoride content. The added protection helps overcome high decay rate.

Case Study 5 – You are planning a long desert walk

Maintenance of fluid intake and maintenance of oral hygiene is hard. Diet is energy rich in sugars.

Toothpaste / Duraphat 5000: small sized toothpaste tube with a big punch of fluoride. You only need a great pea sized amount to provide high protective fluoride boost on teeth.

Case Study 6 – Dentally fit and planning a long climbing trip to the Alps

Toothpaste / Colgate Total: contains Triclosan, helping increase its duration of protective action.

Case Study 7 – Dentally fit and backpacking around India for six months

You want to carry one toothpaste that will do everything.

Toothpaste / Oral B Pro-Expert: a good multifunctional toothpaste (or use Oral B Complete if you prefer something less gritty.

Case Study 8 – Sudden sensitivity

You are in the Alps. Suddenly you develop sensitivity on a few localised teeth. It’s getting progressively more painfully and sensitive.

Toothpaste / Sensodyne Rapid Relief or Colgate Pro Relief: these act rapidly when they are first rubbed gently onto the sensitive teeth. Follow by a normal two minutes brushing with the same toothpaste. Repeat this procedure twice a day and the toothpaste will rapidly block the exposed tubes of sensitive dentine.

Authors’ note: this article should be taken as a guideline based on our clinical experience and knowledge while working in the field. The best toothpaste is the one that works well for you. Sometimes (for reasons unknown) the suggested toothpaste does not help reduce your sensitivity but another one will. The article is written on the premise that the teeth are essentially healthy without evidence of fractures or leaky fillings.

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Matt Edwards / Registrar / London Air Ambulance

This article is the third of our series and aims to provide you with some guidelines on providing effective regional anaesthesia for dentistry in the field. For more in the series: check out Expedition Dentistry for Medics and the AM Guide to Dental Trauma.

Most medics will have had little experience with the specific regional blocks used in dentistry. That said, everyone should be happy to provide local infiltration of local anaesthetic and many of us will also be familiar with performing various peripheral nerve blocks. Dental anaesthesia is no different and builds on these basic skills.

One of the team is complaining of severe dental pain. He has been unable to eat or sleep. He will not let you touch the tooth and is extremely anxious about the pain getting worse. He beseeches you, “Doc, can you please numb the tooth before you go anywhere near it?” As he winces in pain, you feel far, far out of your comfort zone…

In essence, we need to locate the area with the problem, select an appropriate local anaesthetic, decide on a dose and then carefully direct our needle using anatomical landmarks.

This article and slideshow will describe the use and loading of a ‘dental syringe’ as well as number of different anaesthetic options. Dental syringes give excellent control when down deep in holes such as the mouth. They also come with specific screw-on long, thin needles and purpose-built cartridges of lidocaine and adrenaline. The disadvantages are that they are a lot of extra kit and require a little practice to use effectively. If your expedition is large or lengthy, we recommend taking a kit along.

No specific dental kit? Here are the options.

Standard needle and syringe / Can be used for blocks towards the back of the mouth, but it will be more difficult than a dental needle. The standard short 25g orange needle is not long enough for inferior alveolar block. However the blue 23g needle, while more painful and slightly more likely to cause direct damage to the nerve, should be able to reach it.

Topical anaesthetic agents / Such as Xylonor 5% lignocaine gel to numb the oral mucosa for injections. Again this may well not be carried in your kit. EMLA cream, a commonly used lidocaine and prilocaine mix, is not licensed for the use on the oral mucosa or wounds, but a number of studies have demonstrated its efficacy and safety in practice. Apply it to the mucosa under gauze for approximately 20-30 minutes. The absorption of the drugs is greater than when applied to broken skin but has still been shown to be far lower than toxic thresholds. With that in mind, it is still advisable to be very conservative with the dose of anaesthetic used for the block if EMLA has been used to numb the mucosa first. Fortunately, the amount required for any given dental block will be small.

We recommend you also use adrenaline (epinephrine) to reduce the systemic spread of local anaesthetic even further. You can mix your own quite easily. Add 50mcg of adrenaline into 10ml of 1% lidocaine and you will have a 1:200,000 mix. 50mcg is 0.05ml of 1:1000 adrenaline (the 1ml ‘anaphylaxis’ ampoule) or 0.5ml of 1:10,000 (the 10ml ‘arrest dose’ ampoule).

To block or infiltrate?

You can’t work on mandibular molars without a nerve block. They are held in very thick bone that will not be affected by local infiltration. For tooth extractions, injections on both sides are required (buccal/labial and palatal black.

However, maxillary bone and the front of the mandible bone (up to the first premolar) is porous and therefore injected anaesthetic will infiltrate around the affected tooth.

Aim for the apices of the roots of the teeth which will be approximately 20mm from the occlusal surface (the biting end) and remember canines are longer ~ 30mm.

At the front of the mouth there is little room for anaesthestic volume so infiltration should be slow or it will be extremely painful, especially on the palatal side.

Mandibular nerve block (the ‘Inferior Dental’ block)

The mandibular branch of the trigeminal nerve becomes the inferior alveolar nerve, running within the bone of the mandible itself. It enters along the medial aspect of the ramus through the mandibular foramen, supplies all the teeth of the lower half of the jaw and then exits the mental foramen supplying cutaneous sensation to the lower lip and chin. Before it enters the bone, it throws off two relevant branches, the buccal nerve and then the lingual nerve. It is not uncommon (and occasionally desirable) to block these nerves as well.

Complications are rare but worth bearing in mind:

Toxicity / Direct intravascular injection can easily be avoided by aspirating prior to injection.

Neurological complications / Short-lived but can cause considerable anxiety if the patient and the medic are not prepared for them. Most commonly, the local anaesthetic agent may act on the facial nerve causing a palsy, or even on the optic nerve. A ‘direct hit’ on the nerve is possible, as is the barbing of a needle – hitting the mandible then causing damage to the nerve as it is withdrawn. Unfortunately the classic ‘electric shock’, warning the clinician of direct contact with a nerve, actually only occurs in about 5% of patients. Larger needles are more likely to cause damage and careful assessment of the anatomy is key to avoiding problems.

As with any procedure: you must do your best to gain informed consent from the patient and you should also first gain some experience with a dentist or maxillofacial department before trying these blocks on your own in the field.

The Procedure

See the slideshow above for diagrams.

Preparation / Kit, gloves and informed consent.

Position / Stand in such a way that you can see the site of injection clearly. Ask the patient to open their mouth as wide as possible. If you are right-handed, then position yourself behind patient to anaesthetise the lower-left quadrant and in front of the patient for the lower-right.

Target / Understand and visualise that you are aiming to place the LA just above the canal entrance (lingula). Find the intersection of the horizontal line (height of injection) and the vertical line (anteroposterior plane) on the medial aspect of the ramus.

Height of Injection / Put your thumb beside the last molar tooth. Feel the jaw bone as it turns upwards to the head. Rest your thumb in the depression there – the coronoid notch. It is about 6-10 mm above the occlusal table of the mandibular teeth. That defines your horizontal plane.

Anteroposterior Plane / Find the pterygomandiblar raphe (the muscular pillar that connects the lower third molar region to the upper third molar region) and go just lateral to it.

Angle of Approach / Approach from over the contra-lateral premolars which will be a 45 degree angle. Angle the needle backwards towards and just above the lingula.

Retraction / Using the non-dominant hand to retract the cheek with your thumb positioned in coronoid notch of mandible as above and index finger along the posterior border of the mandible from outside the mouth.

Depth / Make a visual note on the needle of 3cm. The needle should gently touch bone at 3 cm deep. Too shallow indicates you are in front of the lingula and in the wrong place. Too deep and the needle will be passing towards the posterior aspect of the mandible and all the vital neurovascular structures that will be waiting.

Aspirate and Administer / Check you are not in a blood vessel – if you are, reposition the needle and reaspirate. Once you are happy, deliver a full cartridge slowly over one minute.

Withdraw / Continue to inject slowly on withdrawal to anesthetise the lingual branch.

Consider Anaesthetising the Buccal Branch / To perform a long buccal nerve block, inject another cartridge of anaesthetic into coronoid notch region of the mandible, found in the mucous membrane distal and buccal to most distal molar.

Watch and Wait / Wait for a clear indication of anaesthetic taking effect as far as the midline of the mandible and along the full length of the side of the tongue. This may take seconds or minutes. Only start your dental work when there is a clear sensory distinction across the mandibular midline.

References

Larijani GE, Cypel D, Gratz I, Mroz L, Mandel R, Afshar M, Goldberg ME. The efficacy and safety of EMLA cream for awake fiberoptic endotracheal intubation. Anesth Analg. 2000 Oct;91(4):1024-6.

Smith MH, Lung KE. Nerve injuries after dental injection: a review of the literature. J Can Dent Assoc. 2006 Jul-Aug;72(6):559-64.

Vickers ER, Marzbani N, Gerzina TM, McLean C, Punnia-Moorthy A, Mather L. Pharmacokinetics of EMLA cream 5% application to oral mucosa. Anesth Prog. 1997 Winter;44(1):32-7.

The authors have made efforts to ensure that the pictures and diagrams in their slideshow are licensed for modification and dissemination. However, please contact Adventure Medic with any specific requests for attribution.

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Following on from their excellent Guide to Expedition Dentistry for Medics, Burj and Matt present a more detailed article on how to deal with an avulsed tooth and dental trauma in the field.

Dental Trauma

Anyone who has worked night shifts in an inner-city Emergency Department will know that dental injury is common, with the majority being due to alcohol and/or interpersonal violence at the weekend. When we are on expeditions, we are generally spared the incapable inebriates and yet the incidence of dental trauma is still high. Whether it has been due to slips, trips, climbing equipment, rock-hard frozen chocolate or opening beer bottles, we would expect at least one incidence of dental trauma per expedition. Mostly these will be minor and simple to sort out but, like any other injury, there is a large spectrum of severity from a tooth that has taken a single blow but otherwise looks fine (the so-called tooth concussion) to a smashed, bloody mouth with the teeth sitting in the patient’s hand.

Given that most doctors will have had little experience dealing with the aftermath of dental trauma beyond referring to the Maxfax SHO, hopefully this summary will guide some decision making and initial treatment in the field.

Notes

Findings – sensitivity should be tested with all teeth. Insensitive teeth are at over double the risk of pulp death.

Standard Management – all dental trauma will need analgesia, soft diet, careful oral hygiene with a soft brush and regular chlorhexidine wash (if available) and a formal dental review with Xrays on their return home.

Prognosis – our prognosis estimates are generated from dentaltraumaguide.org but prognosis is always difficult. Dentists will all tell of teeth they thought would survive but didn’t and vice versa. Prognosis is significantly worse if associated with an insensitive tooth, poor dental hygiene or concomitant tooth fracture. Also REMEMBER pulp death does not necessarily mean the tooth will fall out. The tooth may still remain in place but will probably require root canal treatment if the pulp dies.

Associated Tooth Fractures

Enamel only ‘chipped tooth’ / Assess for luxation injury as above. Sharp edges should be filed(nail file). If you have good resin you could build up a restoration but often this is more trouble than it is worth on an expedition. A drop of surgical glue can be used to cover exposed tooth to reduce sensitivity.

Crown and/or root but no pulp / The fragment will lose sensitivity and, if mobile, should be gently removed. Then just like a lost filling, a new cement filling should be placed (see our previous article). If not available then a drop of surgical glue can be used to cover exposed tooth to reduce sensitivity.

Crown and/or root with a pulp fracture / This will be tender on percussion and the fracture line will either extend below the gingival margin or be invisible as it is at the level of the root. Without Xrays it is virtually impossible to distinguish this from subluxation/extrusion. If undisplaced, it should be left alone, splinted and dealt with upon return. Two weeks untreated will not really effect the prognosis. If the fractured fragment has been avulsed, cement the fragment back on and splint.

Alveolar fracture / This is a fracture of the alveolar part of the maxilla or mandible bone and will likely involve two or more teeth. This will be fairly obvious, normally involving more severe trauma, gingival lacerations and two or more teeth moving together. Use local anaesthetic if you have it. Once restored to normal position by simple manipulation, a longer splint will be required and a dental surgeon will need to be consulted in the next few days.

Dental Avulsion: Reimplantation of a Tooth That’s Been Knocked Out

Reimplantation stands a worthwhile chance of success (up to about 80%) if the accident occurred within the past hour and the tooth was stored correctly. Teeth displaced for over than an hour are much less likely to recover (<20%). Please refer to the slides above for a pictorial demonstration.

The Laws of Tooth Transport

Preparation for Reimplantation

Your working environment / positioning for yourself and the patient, appropriate location, excellent lighting, assistance etc.

Available equipment / Ideally the affected tooth is splinted to the teeth on either side of it by means of a wire stuck on with filling material. We would advise getting hold of some appropriate splinting material if you can from your MaxFax dept or local dentist if you ask nicely. It is very lightweight and very small. The alternative is a temporary measure – use cyanoacrylic tissue adhesive (wound glue), with supplementary steristrips if needed.

Assess strength of adjacent teeth / Strong solid adjacent teeth will be able to support the avulsed tooth on their own. If the supporting teeth have been concussed or subluxed, more teeth may need to be involved in the splint.

Examine for clot in the socket / This will need to be removed prior to reimplantation.

Consent / Talk your assistant and the patient through what you are going to do.

Local anaesthetic / if available, discuss with patient and use it.

The Process

Follow up

The patient will need to attend a dentist within a week of injury for possible root canal treatment. The pulp is likely to die but the tooth may still survive functionally with good follow up. This may not be possible due to environmental issues. That would reduce long term prognosis . Suggest dental review as soon as realistically possible.

If you want more detail on these conditions with some fantastic animations and an excellent ‘prognosis calculator’ then visit www.dentaltraumaguide.org. See also Part I of this series: Expedition Dentistry for Medics.

The post AM Guide to Dental Trauma appeared first on Adventure Medic.

We are proud to present the first part of a series on expedition dentistry for wilderness medics by Burjor Langdana, Dental Surgeon at the British Antarctic Survey Medical Unit and Matt Edwards, Registrar at London Air Ambulance. In this article, they cover: prevention, preparation, dental history taking and examination, diagnosis and management of common conditions. They also include a kit list at the end. The slide show at the below of the article expands on some of the key points – you can click on an image to enlarge it.

Dental problems are common on expeditions and anxiety provoking for the lone practitioner. This is generally because there is a lack of exposure to dental presentations and procedures in clinical practice. Patients, on the whole, go to dentists if they have a dental issue. Doctors employed for prolonged remote placements, e.g. the British Antarctic Survey, undergo formalised dental training prior to deployment. Luckily dental issues on expeditions can be made very simple for the non-dental practitioner and the purpose of this article is to help create a framework to help you decide what you can deal with, what you cannot, what kit to take and the relative urgency of any medevacs that may be required.

Consider this scenario: it is the end of day four of your expedition. Your team has just reached base camp. A team member complains of throbbing pain in his mouth. You are all exhausted and dental problems are a little out of your comfort zone. The questions you should be asking at this stage are:

1) Why did this happen?

Dental problems are common on expeditions. Diets change with increase in amount and, most importantly, frequency of sugar intake. Participants often have dry mouths with increased respiratory rate and inadequate fluid intake. Oral hygiene often becomes a secondary consideration when people are tired. There may be exposure to extreme cold (or heat) so teeth sensitivity becomes a major issue. Finally, teeth may be subject to trauma e.g. frozen chocolate is a common culprit.

2) Could this have been prevented?

Prevention is certainly possible for the vast majority of dental issues. Often pre-existing problems suddenly get worse due to the environmental stressors, and remember, this can happen to you as well.

Three months before the expedition: advise a proactive dental check up with chartings and necessary radiographs. Follow this up one month later and request dental chartings.

In your pre-expedition briefing, reinforce:

1. Twice a day 2 minute brushing
2. Flossing
3. To spit out excess toothpaste, not rinse it out

Finally, when you are on expedition, for those with any known sensitivity advise Anti-Sensitivity Toothpastes (Sensodyne,Colgate, OralB).

What questions help you in the history?

As in medicine, if you suspect a dental problem, first take a history including:

Previous dental history / Hopefully you will know this already

Location / Teeth or gums? Can he localise it at all?

Sensitivity / To what? Does it disappear immediately when stimulus removed or persists for a few minutes or longer?

Character / Is it constant or throbbing ache? Can biting down help localise the correct tooth?

Performing an examination

Next, examine the patient.

Lighting / During the day, position the patient facing the sun and leaning against a good back rest. At night, use a head torch within a closed tent. Bugs rarely help dental examinations.

Positioning / Make life easy and comfortable. Get padding for patient and for your knees. Get a willing volunteer to help you, preferably two. If examining the lower teeth, then position the patient sitting up with lower teeth parallel to the floor, uppers at an angle of 45 degrees to floor. If you are looking at the upper teeth then lie the patient supine, with the neck fully extended.

Achieving dryness / Position multiple cotton rolls on the cheek side of upper first molars (i.e. next to the parotid duct), under the tongue for the submandibular ducts and to attempt to hold the tongue out the way and on the buccal side of the tooth needing treatment. Rotate head to the opposite of the working side, to reduce poolage. Suction is great if you have it, otherwise a rubber camera lens-blower can be helpful. Don’t forget to use your assistants and ask the patient politely to try to control their tongue.

Equipment / See the list at the end of the article.

Diagnosis and Management

Managing these problems will, for the vast majority, be a temporising measure, buying time before the patient can get to a dentist. But seeing as there are rarely ‘expedition dentists’ coming along with you, then you will likely need to do something.

In order of seriousness of the problem, the most common issues on expedition will be these:

Caries and Infection

Initial caries, not down to dentine, will leave the patient sensitive to cold (less than one minute) with a brown spot (demineralised patch) on the tooth. Manage with a high fluoride toothpaste (Duraphat) and/or anti-sensitivity toothpastes, alongside oral hygiene advice. Follow up with a dental hygienist. Dentine caries causes more severe sensitivity and pain, with a darker, deeper and softer lesion. Clean away the soft debris and fill the hole with filling material, then follow up with a dentist for a formal restoration.

Pulpitis / Apical Abscess

These cause pain over side of face, prolonged periods of sensitivity and the patient will be unable to eat on the effected side, though it may be difficult to locate the responsible tooth. There are no proprioceptive receptors in the pulp, only outside. Once it infiltrates local tissues or forms an apical abscess then it will become easier for the patient to localise. It is likely to have caries, or previous large restorations and may be tender to percussion. If you can, get ice and place it on each tooth. The diseased tooth should respond painfully.

You should seriously consider evacuating the patient. First line treatment is antibiotics, analgesia, no eating on that side and urgent dental review. Second line is Ledermix temporary filling (antimicrobial steroid dressing). Finally, third line would be tooth extraction, though this is a last resort and should be avoided. For follow up, standard UK treatment for this would be is either root canal treatment or extraction.

Abscesses

Severe pain and swelling on a gum. It is very difficult to differentiate between a tooth abscess (a decayed tooth and a dead pulp causing an apical abscess) and a gum abscess (food debris in the periodontal pocket, forming an abscess to point on the gum). Management is incision and drainage (see slide show above for technique), trimodal analgesia (NSAIDS, paracetamol, opiates) and antibiotics (see below). Follow up with an urgent dentist review for tooth abscesses. Gum abscesses should settle with simple management at home but prompt dental review is still important.

Gingivitis

Bleeding on brushing, mild discomfort from the gums with inflamed friable gums on examination. Remember to always check behind back molars, as debris often collects there. Manage by encouraging more brushing, not less, flossing and mouthwashes. Follow up with a dental hygienist.

Pericornitis

Severe pain, facial swelling, restricted mouth opening. Look for swelling around and posterior to back molars. There is little you can do in the field here with established infection – evacuate the patient. In the meantime, examine thoroughly behind molars and irrigate with mouthwash. Give regular trimodal analgesia and antibiotics. Once evacuated, follow up with a dentist or potentially maxillofacial surgeons.

Preparing for dental issues on expedition

Your preparations for dental issues on expedition will depend on multiple factors. A qualified dentist with good equipment can still perform complex treatments in the middle of nowhere and they regularly do. A non-dentally qualified practitioner working where evacuation might be impossible for prolonged periods might be expected to perform some reasonably complex dental procedures. That, however, assumes that they have had the appropriate pre-expedition training and can get some advice remotely. In the case of smaller trips or where evacuation is reasonably straightforward, advanced training and equipment cannot really be justified. Still, basic diagnosis and simple symptom management and will greatly help patients until evacuation or definitive care can be arranged. A way of thinking about the level of dental capabilities we would recommend are as follows:

Analgesia

Oral analgesia according to the standard pain ladder is normally sufficient. Need for strong opiates is rare. Use regular trimodal dosing i.e. NSAIDS, paracetamol and opiates.

Anti-sensitivity toothpastes can be used if increasingly uncomfortable twinges of pain are being generating by contact between hot, cold or sweet stimuli and an area of a tooth where temporary filling is not possible. Retaining the toothpaste in that area for as long as practical helps to reduce the sensitivity.

Clove oil on a cotton plug placed into a cavity is often temporarily soothing.

Duraphat, a high fluoride varnish applied to dry tooth surfaces reduces sensitivity.

Local anaesthesia, either as a nerve block or infiltration around the tooth can provide temporary respite.

Ledermix paste – contains the broad spectrum antibiotic demeclocycline and triamcinolone acetonide as an anti-inflammatory, can be used when there is an unremitting pulsating toothache, such as that associated with a large deep cavity, a lost filling, or a loose filling that can be easily be removed. The tooth is cleaned of all the soft debris, Ledermix paste is applied with a small cotton pledget to the depth of the cavity, and the cavity then sealed with a temporary dressing, such as Cavit.

Antibiotics

Dental infections are typically caused by anaerobic bacteria and require treatment with a broad spectrum antibiotic. When in remote locations strongly consider higher doses than routinely prescribed. Antibiotics will generally reduce swelling and associated pain in 2–3 days. At this point the dose of anti-inflammatories can also be significantly reduced.

When there is an acute dento-alveolar infection, the treatment of choice is to drain the pus, by means of a gum incision into pointing abscesses or by extracting the affected tooth. If these local measures have proved ineffective or there is evidence of cellulitis, spreading infection or systemic involvement, one of the following first-line antibiotics can be prescribed. Local gum disease can be treated by debridement and irrigation together.

The antibiotics of choice if patient can take them are:

1. Co-amoxiclav 375-625mg three times daily for 5 days
2. Amoxicillin 250-500mg and metronidazole 200-400mg three times daily for 5 days

If the patient is penicillin allergic:

1. Metronidazole alone, 200-400mg three times daily for 5 days, doubled in severe infection. Avoid alcohol as they may interact rather unpleasantly.
2. Erythromycin 250-500mg four times daily for 5 days; may cause nausea, vomiting and many organisms are nowadays resistant.

Mouthwashes

Dental pain may also arise from infections of the gum structure associated with poor oral hygiene around buried or partly erupted third molars. The gums will appear swollen reddish-purple in colour, may bleed spontaneously or on touch with an instrument, and may smell foul. Having diagnosed periodontal infection,. it is essential to minimize bacteria between the teeth and along the gum margins.

Mouthwashes are used as an adjunct to improved oral hygiene in the treatment of gum disease in particular. The patient should be encouraged to brush the painful area vigorously despite bleeding and discomfort. A case of being cruel to be kind.

1. Warm salty water: half teaspoon salt in half a cup warm water, temperature of tea.
2. Chlorhexidine gluconate 0.2% mouthwash: 1-2 min, two to three times daily.

Fillings

Temporary filling materials are used to insulate the pulp from temperature, hypertonic solutions, chemicals or irritating foods. It will make the tooth feel much better. If a tooth is damaged during an expedition – whether through a lost or broken filling, decayed dentine, or cracked or broken enamel – but is not giving symptoms, then a temporary filling can still be useful as a preventive measure. Temporary filling materials suitable for placement when in a remote location fall into three categories:

Premixed

Supplied in a sealed tube; squeeze out and apply. The premixed materials (e.g.‘Cavit’) are easier to use but have less structural strength. They requires a mechanically retentive cavity to stay put. i.e. a hole with walls. The material also erodes and may require replacing as often as every few days. The cavity can be a little damp but not wet.

Materials requiring mixing

Examples include IRM (Intermediate Restorative Material) or any glass ionomer filling material which is fussy, but also very sticky and retentive.

Consider the following before starting:

1. Isolating and drying the cavity.
2. The exact ratio of powder to liquid is critical.
3. The mixing time is about 1 min and the setting time is similar.
4. Mix on a glass/shiny plastic slab with a flat spatula into a dough-like consistency.
5. Apply and compress into a dry cavity, immediately removing all excess material from the biting surface. A Vaseline coated finger in ease of smoothening and shaping the filling.
6. IRM may be colour-coded: white for a clean cavity, blue for decay present, red for pulpal symptoms.
7. The same glass ionomer filling materials, if mixed into a ‘double cream-like’ consistency, are excellent for reseating and cementing crowns. For greater effectiveness, after removing excess cement, seal the margins of the cement around the crown, whilst setting, with vaseline to protect from saliva erosion.

Improvised materials

Improvisation can be attempted. Dip cotton pellet into oil of cloves or Eugenol. Swab the depth of the cavity. Then seal the cavity with candle wax, ski wax or sugarless chewing gum. Expect limited success, of a very short duration.

Expedition Dentistry Kit List

Instruments

Dental mirror
Flat-plastic spatula (for placing dental filling material onto tooth)
Pair of tweezers or forceps
Spoon excavator (medium) – for scraping out soft caries
Fine curved surgical scissors
Cement mixing spatula
Glazed mixing paper pad/or glass slab

Medicaments

Temporary filling materials: Glass Ionomer powder + liquid or Intermediate restorative material (IRM), Cavit
Chlorhexidine 0.2% mouthwash
Duraphat (high fluoride varnish)
Ledermix paste
Antibiotics: Co-amoxiclav 625 mg, Metronidazole 400mg
Painkillers: ibuprofen, paracetamol, codeine-phosphate
Dental local anaesthetic cartridges: 2% Lidocaine with 1:80,000 adrenaline
Toothpaste for sensitive teeth
Eugenol( oil of cloves) Topical Analgesic

Others

Sterile gloves
Cotton wool rolls
Stainless steel wire for eyelet wiring (24G for eyelets, 26G for ligatures) or electrical cord for harvesting copper wire
Safety-plus disposable syringes: 27G long (can be used in upper and lower jaw)
5ml syringe with blunt needles (for irrigation and flushing out debris below operculum)

Practicals

Gas aerosol suitable for camera cleaning – ideal for drying teeth and cavities

Optional equipment for the experienced

Upper single root extraction forceps
Upper molar extraction forceps left and right
Lower molar extraction forceps
Lower single root extraction forceps
Fine Luxator or Elevator-Coupland

Next time

Still to come in this series: dental anaesthesia, trauma and management of an avulsed tooth, and dental extrations.

Featured image: Roadside false teeth seller, Nepal, Matt Wilkes.

The post AM Guide to Expedition Dentistry for Medics appeared first on Adventure Medic.

The World Health organisation rates Myanmar’s health system as the worst in the world, with respect to access and equity of care. In January 2012, Derek Goodisson, fellow New Zealand surgeon Rajan Patel and anaesthetist Gavin King joined Singapore plastics surgeon TC Lim and his anaesthetist for a week long surgical mission to Yangon (formerly Rangoon).

Our mission followed recent visits by William Hague, the British Foreign Minister, and Hillary Clinton in the months after the announcement of elections in Myanmar. These were to be the first since the annulled elections of 1990 when Ang Sun Suu Kyi was placed in house arrest.

For me, this was my second surgical mission, and the changes in Myanmar were dramatic. It also was an opportunity for Gavin King and I to see a little of the country. The mission had been announced to the public six weeks in advance throughout the Yangon region. We were told later that hundreds had turned up, often travelling days hoping that they would be chosen for the clinic, and take a step closer to receiving the surgery they needed.

The Clinic

Our first day was an outpatient clinic, assessing those able to get through the initial screening process for the next three days of surgery.  Perhaps 15 of the 30 of so of those assessed would be operated on. The spectrum of craniofacial deformity was extreme: from congenital facial deformity and severe post-traumatic disfigurement, to neglected benign and malignant pathology.

In stark contrast to these cases, we were also presented with several patients for minor cosmetic procedures. The previous year I had come to understand that these cases were the price we paid to operate here; that there would be a few patients, usually children of middle ranking officers (the more powerful would be treated in Singapore), who would demand minor cosmetic operations. Nasal tip implants were popular and interest had increased significantly since the previous year.

The clinic took us back to the fundamentals of medicine: history, examination and differential diagnosis. Special tests were not so special: CT scanning although available, would turn up at the least expected, but always welcome, time.

It was here that several charming Asian characteristics were on show. The first, a desire for all things European.  Both Rajan (UK Indian) and TC (Singapore Asian) are internationally renowned surgeons. Yet it was Gavin and I, the white Caucasians who were the stars. This was quite justifiable for Gavin, a skilful anaesthetist (we often work together), but quite flattering for me.

The second was the time-honoured tradition of respecting elders, regardless. The Chief of Surgery was a venerable, very old and Yoda-like civilian surgeon, regarded by many as the founding father of craniofacial surgery in Mynamar. His status reflects having trained all of Myanmar’s top medical brass and his diagnostic skills put ours to shame, most of the time.  However, where our opinions differed, etiquette, and the concept of saving face made further discussion problematic.

Surgery

The week went well. Through intermittent powercuts, improvised surgical equipment and an ever-attentive bevy of local surgeons we operated, hoping to make a difference.

The day would start and finish with a ward round. Apart from wound checks, it was hard to tell how things were going; when asked, patients had no pain, and felt well. This may have not been simply lost in translation: these patients, despite what we had done to them, seemed genuinely quite comfortable. The same procedures back home would not have been nearly so well-tolerated.

We were well looked after. The military had catered for every detail, from facilitating the customs process, with our mini-mountain of medical supplies, through to our own dining room and military cooks and waiting staff. There was no doubt that the army remained top dog still.

On our last day, we had a ritualistic handing-over of the remaining medical equipment, including a craniofacial plating set, provided by Stryker-Leibinger.  It was all very well received and we hoped that it would be put to good use.

Travel in Myanmar

Having completed our surgery, Gavin and I then headed up to Inle Lake, Myanmar’s largest lake.  Villagers here spend their whole lives afloat: homes, schools markets and gardens.

Our guide was a pleasant local man, who spoke very good English; Gavin and I were his third tour group ever.  He and his colleague lead us into the mountains around the lake where we spent the night in a local house, asleep on the floor. The open fire served as stove and heater. There were no windows and it was the middle of winter.

We were the first tourist party through here, they told us, and something of a novelty. We even managed to continue the medical theme, examining an old lady with a hemi mandibular resection and dispensing penicillin for a man with impressive tonsillitis.

Final word

The week went well. I’m sure we made a positive difference to those we operated on.  Yet I hope our greatest legacy will be to the local surgical staff – that they will keep in contact and evolve their specialties. There is no doubting their abilities, it is only their knowledge and the tools they have that need improving.

Myanmar has been described as the undiscovered Asia.  It shares the Andaman coastline with Thailand, with its unspoilt beaches.  The food is all that you would expect and the hospitality generous and sincere.  But things are changing, quickly, as Myanmar heads inexorably towards capitalism. Visit now.

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