INTRODUCTION
Non-dental health care providers fear few things more than having to do dental procedures. The most common dental problems that non-dentists face in austere environments are filling cavities, extracting teeth, and managing oral trauma. The information in this chapter will help you manage these cases, even with limited or no formal dental equipment or training. (See also Chapter 26 for basic information about nerve blocks and how to improvise some of the equipment you will need.)
FILLING CAVITIES
Depending on the materials used, a temporary filling will last from only a few weeks to a few months. A dentist should replace this temporary filling as soon as practicable with a permanent filling. In the meantime, the temporary filling helps the patient to feel more comfortable.1
Never put a filling in an abscessed tooth. You are probably safe filling the cavity if:
There is no swelling of the face or gums near the bad tooth.
The tooth hurts only occasionally—such as when eating or if breathing cold air.
The tooth is not tender to percussion.
The basic filling material for cavities is usually zinc oxide powder and oil of cloves liquid (eugenol). These materials come in a wide variety of brands, but are usually readily available. Intermediate restorative material (IRM) may be available; it provides more durable fillings. Often much easier to obtain is cyanoacrylate, which works well as a temporary filling, although it may not last as long as traditional materials.
While dentists routinely use drills to help fill teeth, these will usually not be available in austere circumstances. In addition, a dental drill is not a tool that the inexperienced practitioner should use. Instead, non-dentists can use dental hand tools, which are easy to use. If there are none available, they can be improvised or purchased at a relatively low cost. Hand tools are also less painful for the patient than a low-speed drill, such as a foot-pedal-powered drill, which may be available in remote or austere settings. Dental tools should be sterilized after each use.
Chapter 26 lists dental equipment you will need to fill a tooth and suggests ways to improvise these items.
The initial task is to isolate the tooth so you can keep the cavity dry. A dry cavity allows you to see what you are doing and, more importantly, strengthens the bond with the cement you are using. To keep the tooth and cavity dry, put cotton or other absorbent cloth between the cheek and gums. When working on a lower (mandibular) tooth, put some under the tongue. Change the cloth whenever it becomes wet, and wipe the cavity itself while you work. Leave a piece of cloth inside the cavity if you mix the filler (unnecessary if using cyanoacrylate). Using continuous suction in the mouth helps reduce the saliva; give the suction to the patient to hold in the hand opposite the side on which you are working.
Then remove some of the decay from the cavity. As you remove the pieces, put them on a piece of cloth or cotton gauze that sits on the patient’s chest. Removing them as you go prevents the patient from swallowing them. Scrape the walls and the edge of the cavity to remove all decay from the cavity’s edge. This prevents later enlargement of the defect when germs and food lodge in the space between the cement and the cavity. If the edge is thin and weak, dentists can break it with the end of their instrument, which will result in stronger sides to hold the cement; non-dentists need not do that. Use the spoon tool (or a large-bore needle) to lift out soft decay from inside the cavity, but do not try to remove decay at the cavity’s bottom; it may be covering a nerve. There is no problem leaving some decay at the bottom of the cavity if you cover it with filling material so it stops growing. Enlarge the cavity just enough to give the cement a suitable bonding area. Use a mirror to carefully examine the cavity’s edges for additional decay. Put some cotton or cloth inside the cavity, and leave it there while you mix the cement.
If using cement that needs mixing, such as commercial dental filling material, mix the cement on a piece of smooth glass or plastic. To mix zinc oxide powder and eugenol, place some zinc oxide powder on the glass and, a distance away from it, a few drops of eugenol liquid. Use a mixing tool, such as a piece of a tongue depressor or a coffee stirrer, and add a small amount of the powder to the liquid, mixing them together. Continue adding small amounts of the powder until the cement mixture becomes thick. It helps to practice with the cement in advance to hone the mixing technique, determine the time it takes for the cement to harden, and see how best to manipulate it. Using this cement is much easier when it is thick and not too sticky. To test for “stickiness,” roll some between your fingers; if it sticks to the fingers, it is not ready. Add more powder and then try it again.
Once the filler is prepared or you are ready to use the cyanoacrylate, remove any cotton or cloth from the cavity and make certain that the cavity is dry. Then press (or drip, in the case of cyanoacrylate) some filling material into the cavity. Keeping the area dry with cotton or absorbent cloth around the tooth, put a small ball of cement on the end of a filling tool (or a small, thin flat screwdriver) and spread it over the floor of the cavity, in particular into the corners. Add another ball of cement, pressing it against the cement already in the hole and against the sides of the cavity. The key is to pack the cavity completely and tightly to stop the growth of decay. Keep adding cement until the cavity is overfilled. Then, smooth the extra cement against the edge of the cavity. If a cavity goes down between two teeth, one other step is necessary: You need to take care that the cement does not squeeze and hurt the gum. Before you spread the cement, place something thin between the teeth. You can use the soft stem from a palm leaf, a toothpick, or a tooth from a comb, but be sure it has a rounded end to prevent damage to the gums.2 If you are using cyanoacrylate, no filling tool is needed, but you must avoid leaving air bubbles in the cement.
Remove the extra cement before it gets too hard. Press the flat side of the filling tool against the cement and smooth it toward the edge of the cavity. As you smooth the cement, shape it to look like the top of a normal tooth. This way, the tooth above or below it can fit against the filling without breaking it. If you are using cyanoacrylate, work fast to smooth the filling, because it dries very quickly. Do not touch it with your finger or you may get stuck to the patient! After you take out the object you have placed between the teeth, smooth the cement. Remove any pieces of cement that stick out, are in the gum pocket, or are not smooth. These may injure the patient’s gums and may break off, allowing food and bacteria to enter the cavity. Check carefully that no pieces of cement are in the gum pocket below the tooth.
After removing the cotton or cloth used to absorb saliva from around the tooth, ask the patient to gently bring his or her teeth together. (Too much pressure on the filling may break it.) The teeth should come together normally and not first hit against the filling. Always check to see if part of the filling is too high: (a) If the cement is still wet, you can see the smooth place where the opposite tooth bit into it. Scrape the cement away from this place. (b) If the cement is dry, have the patient bite on a piece of carbon paper. (If you have no carbon paper, darken some paper with a pencil.) If there is too much cement, the carbon paper will darken the cement. Scrape away that extra cement. The patient must not leave your clinic until the filled tooth fits properly against the other teeth.3
If the tooth hurts more after the filling is in place, there is probably an abscess. Extract the tooth now or, if there is too much swelling, extract it after treating the swelling.
After-care instructions: Ask the patient not to eat anything for 1 hour so that the cement has time to harden and the temporary filling does not break or loosen. The patient should try not to use that tooth for biting or chewing until there is a permanent filling, because the cement and sides of the cavity are weak.
EXTRACTIONS
Extract teeth only when absolutely necessary. However, extraction may represent the only possible care that can be delivered in austere circumstances.4 The general reasons to extract a tooth are5:
The patient has constant pain from the tooth.
The tooth is loose and painful when moved.
The tooth is already broken with an exposed nerve root.
In old movies, extractions appear to be a simple procedure. In reality, tooth extraction is painful and difficult to accomplish without breaking the tooth. A dental, preferably a regional, anesthetic block is required. (See the “Anesthesia and Analgesia” section in Chapter 26.)
The keys to successful extractions are patience and finesse. Do not try to yank the tooth out; this will only break it off. The basic principle is to first break the periodontal ligaments holding the tooth to the bone and then rock/lever the tooth out. Generally, the ligaments holding the tooth to the gum and jaw are loosened using a tiny sharp instrument inserted between the tooth and the gum all the way around the tooth. A number of techniques have proved successful most of the time, but the main requirement is not to hurry the procedure.
Slow gradual luxation (i.e., dislocation/rocking) of the tooth with either an elevator (screwdriver) or forceps (pliers) is crucial. The bone will expand and the inflammatory process in the periodontal ligament that follows luxation further loosens the tooth. The steps in a dental extraction are (a) position the patient, (b) administer anesthesia, (c) position yourself, (d) separate the tooth from alveolar bone, (e) apply leverage, (f) grasp the tooth, (g) luxation, (h) rest period, (i) extract the tooth, (j) hemostasis, (k) tooth inspection, and (l) post-extraction care.6
Michael A. Grossman, DDS, of Tucson, Ariz., says that one method is to push down and rotate or move the tooth in a figure-eight pattern, with movement in any direction lasting 8 seconds. (Personal communication, May 9, 2008.) Another experienced dentist, Dr. Manuel Bedoya, gently rocks the tooth outward and inward until he can lever it out. He has found that this technique of leveraging the tooth and rocking it back and forth is the easiest way to remove a tooth. Once the tooth rocks back and forth, he advises letting it “rest” for 20 to 30 minutes and then return to extract the tooth. During the rest period, enzymes are generated that further help to loosen the tooth. (Personal communication, December 23, 2007.)
If a tooth breaks, because it often does when being extracted by non-dentists or with makeshift extractors, pry out the remaining fragments using small metal instruments. Or, send the patient to a dentist later, because the key element, drainage, is accomplished when the tooth breaks.
Root fractures are particularly common in nonmobile molar teeth. However, most retained roots are not a problem, and experienced dental practitioners know that they will eventually come out on their own, will remain in place without causing a problem, or, especially if surrounded by infected tissue, will be the focus of an abscess that can be drained through the gum and the root removed.
Although commonly suggested, using regular pliers wrapped in gauze for extractions generally just pulverizes the tooth at the gum line—especially if the tooth is diseased. Use either a dental extractor (a pediatric universal extractor should work in most situations) or cut off the end of an awl, file it flat, and put a tiny notch on the side of the filed tip. A large-gauge needle with the sharp end filed down also works. Push it between the tooth to be extracted and the gum, breaking the ligaments. Then, carefully lever the tooth out of the socket. (Michael Grossman, DDS. Personal communication, December 22, 2006.)
Dental forceps are designed to fit the shape of the teeth, including their roots. The inexperienced operator will find it simpler to rely on one pair of universal forceps for the upper jaw and one pair for the lower jaw.7 If channel-lock pliers or a bone rongeur that has jaws curved inward like dental pliers is available, use that. There is less chance of breaking off the enamel, especially if you pad the tool’s ends with gauze or other suitable cloth. Dr. Bedoya adds that even a screwdriver, if used gently, can help to pry the tooth from the socket. (Personal communication, December 23, 2007.) (Also see the “Dental Instruments and Equipment” section in Chapter 26 for improvising dental tools.)
Experience shows that if you take your time, you can successfully use even electrician’s tools to extract teeth. In a remote environment—on a rocking ship, I had to improvise not only appropriate dental tools, but also personal protective equipment (plastic bags and painters’ masks), a functional suction machine, medications for a dental block (compounded epinephrine and lidocaine), a dental chair (a tall office chair covered in plastic), and dental consent forms and follow-up instructions in the patients’ language.6
If the tooth is abscessed, try to extract it. Tooth extraction is the best way to drain an apical abscess when no facilities are available for root canal treatment. Removing a tooth is appropriate if it cannot be preserved, is loose and tender, or causes uncontrollable pain. In these circumstances, according to Barnett R. Rothstein, DMD, even if you must use pliers or a similar instrument that breaks the tooth, opening the abscess in this manner will allow it to drain, thus avoiding the severe complications (e.g., Ludwig’s angina, airway compromise, sepsis) that might otherwise occur. (Personal communication, April 9, 2007.)
According to Dr. Manuel Bedoya, the abscess will still drain even if part of the tooth remains, and the rest of the tooth will eventually work its way out without complications. (Personal communication, December 23, 2007.) One benefit is that it is easy to extract loose teeth with periodontal laxity/destruction.
The first step is to position the patient correctly. Patients needing a lower tooth extracted should be sitting lower than the clinician, because the extraction technique for the lower jaw is to push down and then to pull up on the tooth. Standing on a stable platform, such as a box, may be useful for the practitioner. Position patients who need an upper tooth removed higher than the clinician, because the extraction technique for the upper jaw is to push up and then pull down on the tooth. Sitting the patient on several cushions often accomplishes the necessary height adjustment.8 It also helps to have a dental chair that prevents the patient from pulling his or her head back during the procedure. A dental chair can be fashioned from a straight-back chair, two broomsticks, tape, and some webbing (see the “Dental Instruments and Equipment” section in Chapter 26).
Seat the patient in a chair with a high back that will support his or her head. After rinsing the mouth, swab the gum with 70% ethanol. Do a supraperiosteal or other dental block, as described in Chapter 26 under “Blocking Individual Teeth.” Wait 5 minutes for the anesthetic to work, and then test to be sure the tooth is numb. If the patient still feels pain, give another injection.9
Position yourself to best work on the tooth you are extracting. Right-handed clinicians should stand behind and to the right of the patient when extracting lower right molar or premolar teeth. Face the patient, standing on the patient’s right, when working on all other teeth.
The first step is to separate the gum from the tooth so that the gum does not tear when the tooth is removed. This is vital because torn gums bleed more and take longer to heal. Slide the end of the instrument along the side of the tooth and into the gum pocket alongside the tooth. At the deepest part of the pocket, you can feel the place where the gum attaches to the tooth. The attachments are strong, but thin. Push the dental instrument or blunted needle between these attachments and the tooth. Then separate the tooth from the gum by moving the tool back and forth. Do this on both the buccal (cheek) and the lingual (tongue) side of the tooth. Take care not to go too deep and to cut only the attachments to the tooth.9
Next, loosen the tooth. While a loose tooth may not break when you extract it, a strong one will if you do not loosen it first. While a dentist will use an elevator to loosen the tooth, you may need to use a small flat screwdriver. Either tool can cause harm if not used carefully. The blade goes between the bad tooth and the good one in front of it. Put the face of the blade against the tooth you are removing and slide it down the side of the tooth, as far as possible under the gum. Turn the handle so that the blade moves the top of the bad tooth backward and loosens it. Rest your first finger on the adjacent tooth while you turn the handle. This will control it.9 Now that you have loosened the tooth, waiting about 20 minutes will allow the tooth to loosen even more, according to Dr. Manuel Bedoya. (Personal communication, December 23, 2007.) You may want to get a cup of coffee or do any required paperwork for this patient.
You are now ready to remove the tooth. While supporting the gum and underlying bone with the thumb and finger of your nondominant hand, apply the forceps to either side of the crown, parallel with the long axis of the tooth. Push your grasping tool (extractor, pliers, etc.) as far toward the roots as possible. The idea is for the forceps to grasp the tooth’s root under the gum. Your fingers will feel the bone expanding a little at a time as the tooth comes free. Rather than “pulling” the tooth, think about rocking it back and forth or levering it out.7 To decide which way to move a tooth, think about how many roots it has. If a tooth has one root, you can turn it. If a tooth has two or three roots, you need to tip it back and forth. Take your time. If you hurry and squeeze your forceps too tightly, you can break a tooth. As Dr. Dickson wrote in Where There Is No Dentist, “Removing a tooth is like pulling a post out of the ground. When you move it back and forth a little more each time, it soon becomes loose enough to come out.”10 If the tooth does not begin to move, loosen the forceps, push them deeper, and repeat the rocking movements. Avoid excessive lateral force on a tooth, because this can lead to its fracture.7 After you extract the tooth, examine its roots to be certain that you have not broken any part.
Stop the bleeding. Apply direct pressure by squeezing the sides of the socket for 1 to 2 minutes and covering it with cotton gauze or absorbent cloth. Have an adult patient bite firmly against it for 30 minutes; a child should continue biting for 2 hours.10 After the patient has rinsed his or her mouth, inspect the cavity for bleeding. If the bleeding continues, if you have removed two or more teeth, or if the gums are torn or loose, suture the extraction site with absorbable (if available) mattress sutures across the cavity.7,11
Carefully inspect the extracted tooth to confirm its complete removal. A broken root is best removed by loosening the tissue between the root and the bone with a curved elevator. After completely removing the tooth, squeeze the sides of the socket together for a minute or two and place a dental roll over the socket. Instruct the patient to bite on it for a short while.
Instruct the patient to do the following:7,11
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