1. Wilderness Medicine Backcountry Dentistry James Strohschein, DDS Assistant Professor UNM Division of Dental Services

2. Treatment is limited: Treatment is limited: Dentistry is an equipment intensive medical specialty

3. Tooth Morphology

4. In the field you will be addressing two primary concerns with respect to the dentition: 1.Trauma 2.Infections

5. Trauma Any trauma to the dentition will produce pulpitis: Temperature sensitivityTemperature sensitivity Percussion sensitivityPercussion sensitivity Palpation sensitivityPalpation sensitivity Acute / non-lingering painAcute / non-lingering pain

6. Fractures Types: 1.Enamel / Dentinal Fractures (uncomplicated) 2.Pulpal Involvement Fractures (complicated) 3.Root Fractures – Difficult to evaluate in the field Note: Symptoms very for each typeSymptoms very for each type Diagnosis is related to symptomsDiagnosis is related to symptoms

7. Enamel / 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

8. Pulpal Involvement Fractures Signs 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

9. Dislocations / Mandibular Fractures First 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

10. Avulsions Definition: 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

11. Infections Usually 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

12. Dental Abscess Evaluation: 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

13. Facial Cellulitis Definition: Infections of odontogenic origin diffusing throughout facial planes Locations: Buccal Space Source: Maxillary or Mandibular posterior teeth Evaluation: Swollen cheek Submandibular Space Source: Mandibular teeth Evaluation: Swollen under chin, may have difficultly swallowing, can progress into neck planes and into the mediastinum if not aggressively treated Canine Space Source: Maxillary anterior teeth Evaluation: Periorbital swelling, difficulty with vision Treatment: IV antibiotics (if possible) then immediate evacuation

14. Other 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

15. Field 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