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:
- Twice a day 2 minute brushing
- 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.
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.
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.
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:
|Short trip, evacuation reasonably quick and straightforward e.g. Kilimanjaro||No prior training required, expedition medicine course with a dental session advised||Advise dental checks||Basic dental kit: a few instruments, some temporary cement and oil of cloves|
|Long trip, evacuation likely to be a few days e.g. Greenland Crossing||Sit with a local dentist or attend an expedition medicine course with a dental session||Strongly request participants have dental checks||More extensive dental kit, plus: Duraphat, Ledermix, matrix bands, local anaesthestic. Preferably some remote access dental back up.|
|Remote clinic, difficult or impossible evacuation e.g. British Antarctic Survey||Formalised dental training course and visit a local maxillofacial surgeon or attend an expedition medicine course with a dental session and a maxillofacial trauma session||All participants must have regular dental checks before and during deployment||Advanced dental kit with basic dental extraction and interdental wiring kit. A reliable remote access dental back up. Radiology and telemedicine capabilities would be an added bonus|
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.
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:
- Co-amoxiclav 375-625mg three times daily for 5 days
- Amoxicillin 250-500mg and metronidazole 200-400mg three times daily for 5 days
If the patient is penicillin allergic:
- Metronidazole alone, 200-400mg three times daily for 5 days, doubled in severe infection. Avoid alcohol as they may interact rather unpleasantly.
- Erythromycin 250-500mg four times daily for 5 days; may cause nausea, vomiting and many organisms are nowadays resistant.
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.
- Warm salty water: half teaspoon salt in half a cup warm water, temperature of tea.
- Chlorhexidine gluconate 0.2% mouthwash: 1-2 min, two to three times daily.
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:
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:
- Isolating and drying the cavity.
- The exact ratio of powder to liquid is critical.
- The mixing time is about 1 min and the setting time is similar.
- Mix on a glass/shiny plastic slab with a flat spatula into a dough-like consistency.
- 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.
- IRM may be colour-coded: white for a clean cavity, blue for decay present, red for pulpal symptoms.
- 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.
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
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
Temporary filling materials: Glass Ionomer powder + liquid or Intermediate restorative material (IRM), Cavit
Chlorhexidine 0.2% mouthwash
Duraphat (high fluoride varnish)
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
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)
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
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.