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Friday, January 15, 2010

Sections of tooth undergoing development.

Survival Dentistry, by Dr. Dent

There seems to be a lot of talk among the survivalist community regarding dental care and particularly dental extractions.  I am a practicing dentist at an urgent care facility and have addressed thousands of patients in varying situations that have had abscessed teeth that require extraction, and have subsequently extracted thousands of teeth.  I would like to provide some insight on dental care and in particular on the subject of tooth extraction and the materials required to perform a successful extraction without complicating the existing dental problem.  Also note that many medical problems particularly those relating to bleeding, stress, blood pressure, etc will additionally complicate things.
First, I will point out the obvious due to a nagging sense of professional obligation.  Prevention is the best medicine.  Topical application of fluoride is critical to preventing a cavity that may put you in a bad situation.  Brushing your teeth with an abrasive (toothpaste or otherwise) that does not contain fluoride will be of marginal benefit, however, the real bulk of the cavity prevention will be significantly diminished.  If your retreat location is supplied by a natural water source (spring, pond, well, etc) it might be prudent to have it tested for fluoride content.  If your water is high in fluoride then you could utilize it as a topical mouth rinse (i.e. hold it on your teeth, the longer the better) .  If not consider stockpiling fluoride containing toothpaste or mouth rinse.  I know this is stretching it a bit, but flossing: would it really kill you?  The natural reduction in the amount of refined sugar that you consume will also benefit you.
Now that that is out of the way, here is a list of the things I would consider necessary for taking out a tooth.
  1. Anesthetic-  Obviously this is not “necessary” but will make the experience must more enjoyable for all parties involved.  Lidocaine and septocaine are both common local anesthetics and sufficient for all dental work.  Septocaine is my preference because it comes in 4% formulations that just plain work better.  Upper anesthetic is applied to both the check and palate side of the tooth in question.  For the lower numbing is much more difficult.  Anesthetic must be applied high in the jaw bone.  As a general rule, have the patient open as wide as possible and you should see a fold on the cheeks posterior to the teeth.  Put the needle just anterior to that fold and aim toward the TMJ.  Injecting adjacent to the tooth is also helpful but will not be sufficient for complete anesthesia.  Assuming you have access and intend to stockpile these things (a syringe, needles, and anesthetic) I would recommend reviewing and perhaps printing for your survival library the following web pages (not mine, just nice pictures): http://www.fice.com/course/FDE0010/c12/p01.htm  http://www.fice.com/course/FDE0010/c12/p02.htm
  2. Dental mirror- being able to see is good.
  3. Bite block- This is just a piece of rubber that is designed to prop the person’s mouth open.  It will come in especially handy if you don’t have anesthetic.
  4. Straight elevators- One with a small tip (2mm-3mm wide), one with a medium tip (3mm - 4.5mm wide)
  5. Extraction forceps- #150 – Universal upper, #151 Universal lower, #23 Cowhorn
One additional thing you could do to potentially make your life easier.  Have every member of your retreat group obtain a copy of their latest panoramic x-ray from their dentist.  This is the big x-ray they take that images all of your teeth and the jaw bones.  In particular take note of any upper teeth that have roots that approximate the sinuses, any teeth with extra or curved roots, or any teeth with bulbous roots.  Don’t worry too much about keeping these records up to date.  What you are concerned with is the root structure of the teeth which doesn’t change over time.
With these basic tools you should have the equipment required to extract almost any tooth. 
Dental Assessment
When one of your retreat members presents with a dental problem first evaluate your situation.  Teeth with large cavities, cracked, or broken teeth will likely require extraction.  If you try to put off extracting a tooth because it “just isn’t that bad yet” it will likely be abscessed and be exponentially worse (with or without anesthetic) when you actually do get the tooth extracted.  As much as you won’t want to do it at the time, act early.  When a tooth starts to hurt and no dental care is available, take care of it before it gets infected and threatens your life rather than just your tooth. 
If, however, you miss the early action window and are presented with an abscessed tooth (and here be abscessed I am referring to draining puss/visibly swollen) consider a course of antibiotics or making a small incision into the swelling to allow the infection to drain before attempting tooth extraction.  Contrary to popular belief, this isn’t because there is an increased risk of infection (the chance of infection is 100% it’s already infected).  The real reason is twofold.  First, it will be a lot less painful to have the tooth extracted.  Second, if the patient is more comfortable it will make it easier for the operator to get the tooth out.
Once you’ve decided there is a problem (whether you are early or late) the first step is to decide which tooth is the problem.  Sometimes it will be obvious to the patient via pain when pressure is applied to a particular tooth.  Sometimes it is obvious to the operator via swelling or a small “blister” on the gums beside the tooth.  However if it is not obvious, the most convenient way to decide which tooth is the problem will be to apply cold to each tooth individually.  A tooth that is dying or dead will either give intense pain which lingers for ten or more seconds or will have no feeling at all.  Whatever the result of this test is, compare to known healthy teeth to verify your result is indeed abnormal.
Extraction Procedure
When you are ready to begin tooth extraction, get your tools ready by sterilizing them (in this scenario boiling may be the best you can do).  Always clean your mirror, elevators, bite block, and the forceps required for the particular tooth in question (for upper teeth you will be utilizing the 150 forcep only, for lower teeth that are incisors, canines, or bicuspids you will be using the 151 forcep only, for lower molars you will be using either the 151 or 23 forcep). 
All teeth extractions will begin the same way.  Prop the patient’s mouth open.  Insert the small straight elevator between the tooth and the gum in the space between the tooth to be taken out and the tooth in front of it.  While applying firm downward pressure, slowly turn the elevator and begin to move the tooth to be removed.  Do not use excessive force at any point.  When you can get no additional movement switch to the medium elevator and repeat.  The key to easy tooth extractions is getting them loose before you grab them with the elevator.  Be careful not to put pressure on other adjacent teeth, your elevator should leverage the tooth to be removed against the bone.  If the tooth does not loosen at any point you may consider peeling the gum tissue back on the cheek/lip side a bit and chipping away some of the bone on that side only (the small straight elevator can double as a half decent chisel).  When the tooth in question has a little movement to it you are ready for the forcep.
For removing an upper tooth: Use the 150 forcep and place it as far down the tooth as possible (well above the gum).  Slowly wiggle the tooth back and forth while putting pressure downwards (toward the bone).  Every few wiggles choke the forcep up on the tooth.  The tooth should be really moving at this point.  Rotate it towards the cheeks/lips with firm pressure and remove it. 
For removing a lower incisor, canine, or bicuspid: Use the 151 forcep and use the same technique described for upper teeth. In addition to the rocking motion described above you can also typically (meaning as long as these teeth have no extra roots) rotate these (twist rather than rock) to remove them more easily and less traumatically.
For a lower molar:  Examine the x-ray.  If the molar has two separate roots the 23 forcep would be appropriate.  If the roots of the tooth are fused together then use the 151 and follow the instructions for removing an upper tooth and disregard what follows.  Note that the vast majority of the time there will be 2 separate roots.  Place the points of the forcep in the middle of the tooth as far below the gums as you can get them.  The attempt is to get the points right into the area where the tooth roots separate.  Once you believe the forceps are in place, lightly squeeze the handles together while moving the forcep up and down.  If it doesn’t slip it is probably in the right place.  Next, continue light pressure on the handles together and move the forcep in a figure 8 [motion].  As you move it, you should naturally feel that every so often, the handles will close slightly.  This will slowly lift the tooth up.  Continue this motion until it feels like the handles are closed together, then rotate the forceps toward the cheek (twist) and remove the tooth.  If you have difficulty with the 23 try the 151 and follow the directions for removing an upper tooth.  Having said that, the denser bone in the mandible will be harder to chisel away, and slower to loosen the tooth.  Take your time and don’t break it.
Always examine the extracted tooth!!  Make sure the tooth looks like it does on the x-ray and that none of the roots broke and/or are missing.
Only one thing remains, what if it breaks?
First, don’t feel bad, you are in good company.  Even if you do everything right, you still have a decent chance at breaking the tooth.  If you act early and it’s a small portion that broke you may choose to leave it and see if it heals.  If the tooth is really abscessed when you act, the broken piece will perpetuate infection if not removed.  In order to remove a residual root, some bone may need to be removed.  If this is attempted it should be done from the cheek/lip side only.  Often a forcep (150 or 151) can be used to grab the bone adjacent to the root on either side crush it, grab the root, and remove it.  This is a difficult technique, but if it’s that or dealing with infection, give it a shot.
Post op
After 24-48 hours rinse with warm salt water a few times per day.  Don’t spit, smoke, or perform any serious chores or exercise for several days.
Note that in most jurisdictions it is illegal to do any of these things to another person unless you are a licensed dentist, but in TEOTWAWKI that probably won’t matter to you.
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