Wilderness MedicineWilderness MedicineBackcountry DentistryBackcountry Dentistry

James Strohschein, DDSJames Strohschein, DDS

Assistant ProfessorAssistant Professor

UNM Division of Dental ServicesUNM Division of Dental Services

Treatment is limited:Treatment is limited:

Dentistry is an equipment Dentistry is an equipment intensive medical specialtyintensive medical specialty

Tooth MorphologyTooth Morphology

In the field you will be addressing In the field you will be addressing two primary concerns with two primary concerns with respect to the dentition:respect to the dentition:

1.1. TraumaTrauma

2.2. InfectionsInfections

TraumaTrauma

Any trauma to the dentition will produce Any trauma to the dentition will produce pulpitispulpitis::

•Temperature sensitivityTemperature sensitivity

•Percussion sensitivityPercussion sensitivity

•Palpation sensitivityPalpation sensitivity

•Acute / non-lingering painAcute / non-lingering pain

FracturesFracturesTypes:Types:1.1. Enamel / Dentinal Fractures Enamel / Dentinal Fractures (uncomplicated)(uncomplicated)

2.2. Pulpal Involvement Fractures Pulpal Involvement Fractures (complicated)(complicated)

3.3. Root Fractures – Root Fractures – Difficult to evaluate in the fieldDifficult to evaluate in the field

Note:Note:• Symptoms very for each typeSymptoms very for each type• Diagnosis is related to symptomsDiagnosis is related to symptoms

Enamel / Dentinal FracturesEnamel / Dentinal Fractures

Symptoms:• + sensitivity to cold (air / liquids)• Acute / Non-lingering

Diagnosis: Reversible Pulpitis

Treatment: Will require restoration or temporary coverage depending

on severity of pain

Pulpal Involvement FracturesPulpal Involvement FracturesSigns and Symptoms:• + sensitivity of hot and/or cold• Dull constant ache• Possible heme from the fractured tooth

Diagnosis: Irreversible Pulpitis

Treatment: • Temporary restoration• Will require endodontic therapy to alleviate

discomfort and prevent future infection

Dislocations / Mandibular FracturesDislocations / Mandibular FracturesFirst step is to evaluate occlusion:• Ask patient to bite teeth together to evaluate if teeth are

reapproximating• Evaluate for any facial paresthesia

Treatment: • Will require splinting• May attempt with perio-pack or floss• Difficult to do in the field• Future endodontic therapy will be needed• Evacuate patient ASAP for radiographic evaluation

Note: Any displaced teeth may involve bony fractures

AvulsionsAvulsionsDefinition: Complete loss of tooth

Imperative that tooth be kept moist:• Best solutions: saline, milk, mouth• If tooth dries out it can not be reimplanted• Never discard tooth! (dental evaluation, future uses)

Treatment: • Reimplant immediately (if possible)

• Rinse with water or saline but DO NOT SCRUB! - periodontal fibers important

• Will require splinting and future endodontic therapy

InfectionsInfectionsUsually a result of an existing condition

Many times difficult to diagnose:• Sinusitis can produce similar symptoms• Teeth usually sensitive to percussion and palpation

Clinical Evaluation:• Look for chronic / throbbing pain• Swelling• Draining fistula• Bad taste in the mouth• May be febrile

Dental AbscessDental AbscessEvaluation:• Related to necrotic pulpal tissue• Extends to the periodontium• Seeks path of least resistance• 90% of sinus tracts will travel to the buccal (cheek side)• Evaluate by extending the cheeks and lips

Treatment: • Oral antibiotics

Pen VK (500mg x 30)Clindamycin (300mg x 30)

• Will require endodontic therapy or extraction

Note: If symptoms do not improve within 48 hours consider evacuation of the patient

Facial CellulitisFacial CellulitisDefinition: Infections of odontogenic origin diffusing throughout facial planes

Locations:• Buccal Space

Source: Maxillary or Mandibular posterior teethEvaluation: Swollen cheek

• Submandibular SpaceSource: Mandibular teethEvaluation: Swollen under chin, may have difficultly swallowing,

can progress into neck planes and into the mediastinum if not aggressively treated

• Canine SpaceSource: Maxillary anterior teethEvaluation: Periorbital swelling, difficulty with vision

Treatment: IV antibiotics (if possible) then immediate evacuation

Other Dental Emergencies / ConcernsOther Dental Emergencies / Concerns

1. Loss of fillings

Treatment: Place temporary restorative material (Cavit)

2. Loss of crowns

Treatment: Re-cement with IRM

(Intermediate Restorative Material)

Note: Both restorative materials contain eugenol which will

provide coverage and pain relief

Field Dental KitField Dental Kit

Minimal kit:• Cavit, dental floss, Benzocaine gel (Orabase),

mouth mirror, head lamp or small flashlight

More extensive:• Dental syringe w/ anesthetic, IRM, temporary

filling carrier instrument, universal extractors and elevators