Data from Wilson W, Taubert KA, Gewitz M, et al: Prevention of infective endocarditis: Guidelines from the American Heart Association—A guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group, J Am Dent Assoc 139:3S, 2008.

BOX 30-2

Dental Procedures for Which Prophylaxis Is Reasonable in Patients With the Cardiac Conditions Listed in Box 30-1

All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth, or perforation of the oral mucosa

Antibiotic prophylaxis is NOT recommended for the following dental procedures or events:

Routine anesthetic injections through noninfected tissue

Taking dental radiographs

Placement or adjustment of removable prosthodontic or orthodontic appliances

Placement of orthodontic brackets

Shedding of deciduous teeth

Bleeding from trauma to the lips or oral mucosa

BOX 30-3

Antibiotic Prophylactic Regimens for Dental Procedures (Single Dose 30 to 60 Minutes Before Procedure)

Oral Amoxicillin

Adults: 2 g

Children: 50 mg/kg

If Unable to Take Oral Medication

Adults: ampicillin 2 g IM or IV, or cefazolin or ceftriaxone 1 g IM or IV

Children: ampicillin 50 mg/kg IM or IV, or cefazolin or ceftriaxone 50 mg/kg IM or IV

^* Or other first- or second-generation oral cephalosporin in equivalent adult or pediatric dosage.

Begin with open-ended questions before focusing attention with more specific questions. As information is collected, one can begin to focus attention on the more specific characteristics of pain to help attain a diagnosis. It is useful to know when symptoms started, frequency, severity, duration, how they change over time, what brings them on, and what allows relief.

The examination focus depends somewhat on the examiner’s suspicions. However, in all cases a systematic approach to examination in oral and maxillofacial emergencies allows efficient collection of all relevant data. Begin the examination with a general appraisal of the victim that optimally includes temperature, blood pressure, and pulse rate. How sick is the patient? Observe the head, neck, and face, especially noting any asymmetry. Palpate to appreciate point tenderness, crepitus, foreign bodies, or swelling. Palpate the temporomandibular joints, muscles, lymph nodes, and areas of suspected injury. Observe the victim slowly open and close his or her mouth, observing for degree of opening, range of motion, and deviation on opening.

Begin the intraoral examination with the lips, then move back to the cheeks, floor of the mouth, tongue, hard palate, soft palate, and pharynx. In addition to inspection, palpation is very important. Swelling may turn out to be rock hard (bone) or fluctuant (abscess). Bimanual palpation is helpful when examining the lips, cheeks, and floor of the mouth. The gingiva is observed for color, firmness, recession, and swelling. Gentle probing reveals the depth of the gingival pocket and the presence or absence of bleeding. The teeth are inspected for caries, fractures, presence of plaque and calculus, wear, and loose restorations. Test for tooth mobility by using moderate force in a side-to-side direction. Gentle percussion of the teeth with a metal instrument reveals injury or disease of the supporting structures. Inspect occlusion by retracting the lips and then having the victim occlude the teeth (bite). The victim may feel pain when biting on a specific tooth, or you may see that the teeth do not come together normally. Radiographs and other technology-dependent diagnostic tests are valuable but for purposes of this chapter are assumed to be unavailable. Gather the results of your history, examination, and tests to formulate the proper diagnosis.

Maxillofacial Pain

The causes of maxillofacial pain are myriad, and the diagnosis of head and neck syndromes can be exceedingly difficult.^32,³³ The most common painful conditions are covered below. If the victim’s symptoms do not seem consistent with a dental origin, other causes should be suspected. Examples of disorders that are sometimes confused with dental pain are myofascial pain, maxillary sinusitis, temporal arteritis, and trigeminal neuralgia. Box 30-4 lists others. Table 30-1 shows the characteristics of specific types of tooth-related pain that can assist the examiner in sorting out a diagnosis.

TABLE 30-1 Characteristics of Dental Conditions That Cause Pain

Pulpitis

The common toothache is caused by inflammation of the dental pulp. It may be difficult for the victim to identify the offending tooth due to convergence of neurons in the trigeminal spinal tract nucleus.^9,²⁶ The painful tooth is rarely sensitive to percussion or palpation. An obvious cause, such as a large carious lesion, is sometimes found on examination of the mouth, but often all of the teeth appear intact. If inflammation is mild, the condition is characterized by pain that is elicited only by cold or sweets and disappears within seconds when the stimulus is removed. Moderate pulpitis is characterized by sensitivity to hot as well as cold, greater discomfort, and an increasing interval between the removal of the stimulus and resolution of the pain. In its most severe form, pulpitis causes intense, continuous, and debilitating pain.^6,^9,³³ Emergency treatment recommendations are given in the following sections.

Mild Pulpitis (Characterized by Transient Thermal Sensitivity)

Examine the mouth visually. Structures will likely appear within normal limits. However, if a defect is found in a tooth, it can be temporarily filled. Reassure the victim that although this condition is annoying, rapid progression is unlikely.

Moderate Pulpitis (Longer Episodes of Pain)

Proceed as for mild pulpitis. Treat with a non-narcotic analgesic (ibuprofen 600 mg orally [PO] every 6 hours as needed for pain), and reduce physical activity. If a large defect (cavity) is found in the offending tooth, a cotton pellet with eugenol can be applied to the exposed pulp. Then fill the defect with zinc oxide/eugenol cement (Intermediate Restorative Material [IRM]) or Cavit.

Severe Pulpitis (Intense, Continuous Pain)

The preferred approach is pain relief using a local anesthetic, followed by evacuation of the victim.^35,⁴⁷ A nerve block with bupivacaine (Marcaine) 2% with 1 : 200,000 epinephrine can provide up to 8 hours of excellent pain relief without central nervous system depression (see Local Anesthesia, later). Nonsteroidal antiinflammatory drugs (NSAIDs) will probably give little relief. Large doses of narcotics should not be used because they are likely to compromise the victim’s ability to participate in evacuation. Sometimes application of cold (continuously sipping cold water) provides relief to the hyperemic pulp. In an extraordinary circumstance, an experienced rescuer could locate the offending tooth, expose the pulp, remove the inflamed pulpal tissue with a barbed broach, and cover the opening with a temporary filling material. Extraction is also an option in a case of severe pulpitis but is usually contraindicated for a number of reasons (see Exodontia, later).

Periapical Osteitis

Inflammation of the supporting structures at the root of a tooth is characterized by constant, often throbbing, pain. Unlike pulpitis, the affected tooth is easily located. The victim can usually point to the exact source of the pain, or the examiner may gently tap individual teeth, observing for tenderness. The area over the apex of the tooth is usually tender to palpation, but there is no frank swelling. Although trauma to a tooth can result in periapical inflammation, the most common cause is egress of bacteria and breakdown products from the necrotic pulp. Minor swelling around the apex extrudes the tooth slightly, causing increased forces on the tooth during occlusion, and thus intensifies the pain. Emergency treatment includes an analgesic (ibuprofen 600 mg PO every 6 hours as needed for pain) or a local anesthetic and a soft diet. Ideally, the contacting areas of the opposing tooth are reduced to relieve occlusal forces.^6,⁹ Because this usually is impractical in the field, the victim can be given a strip of webbing or something similar to place between the teeth on the nonpainful side. This will keep the offending tooth out of occlusion and reduce the pain.

Cracked Tooth Syndrome

The victim complains of momentary, sharp pain when chewing certain foods or on releasing the bite. Often the victim reports that the tooth feels “weak” or that “it only hurts when I bite on something hard just the right way.” These symptoms occur when forces of the proper magnitude and direction open the incomplete fracture in the tooth.³⁷ The pain can vary with a cracked tooth depending on how deep the crack is and how close it comes to the pulp. Significantly, there is no pain on chewing soft foods. Often the victim has large restorations or a habit of chewing ice or clenching and grinding.²² This condition usually progresses slowly. Reducing the occlusion on the cracked tooth will relieve some pain but again is often impractical in the field. The victim should be advised to avoid chewing on the affected side and to seek definitive dental treatment as soon as possible.

Odontogenic Referred Pain

Pain originating in the pulp of the tooth can sometimes be referred to distant sites. Common referral patterns are the following: maxillary incisors to the forehead, maxillary canine to the infraorbital area, maxillary molars to the temple or ear area, mandibular anterior teeth to the mental foramen area, mandibular premolars to the posterior jaw, and mandibular molars to the angle of the jaw, the ear, or the neck. Sometimes the victim swears the pain is coming from a tooth several teeth in front or behind the source of pain. Pulpitis pain can be referred from an upper tooth to a lower tooth, or vice versa, but never crosses the midline. Many cases have been presented in the dental literature detailing how experienced practitioners have treated the wrong tooth or performed multiple dental treatments when the source of pain was not a tooth.^26,³⁰ If in doubt about the diagnosis, ensure that you do no harm.

Maxillary Sinusitis

The pain of maxillary sinusitis can be referred to a maxillary posterior tooth. It is usually described as a relatively continuous throbbing ache that is intensified by postural change. A typical statement is, “My tooth really hurt when we were hiking down the hill. I could feel it pound with every step. When we got to camp, I lay down, but it got even worse.” The pain may be unilateral or bilateral. It is usually located in the infraorbital region and is often referred to the cheeks, frontal region, and the maxillary premolars and molars. A complaint of multiple toothaches in the maxilla, with no evidence of carious teeth, should immediately raise suspicion for maxillary sinusitis. In addition to pain, there is tenderness elicited by pressure infraorbitally or over the bony prominence above the first molar. The victim also generally has an elevated temperature and nasal or postnasal discharge.

Treatment of maxillary sinusitis includes an analgesic (ibuprofen 600 mg PO every 6 hours as needed for pain), inhalation of steam, oxymetazoline (Afrin) 0.05% 1 spray in each nostril twice a day to shrink the nasal membranes and improve sinus drainage, and an antibiotic. Appropriate choices include amoxicillin 875 mg with clavulanic acid 125 mg (Augmentin) PO twice a day for 10 days or trimethoprim 160 mg with sulfamethoxazole 800 mg (Septra DS) PO twice a day for 10 days. Azithromycin (Zithromax) 500 mg PO the first day and then 250 mg PO for 4 days is a convenient alternative.^1,¹⁹

Temporomandibular Disorder

Temporomandibular disorder (TMD) is a cluster of conditions, multifactorial in origin, and with overlapping symptoms that often respond to a variety of therapies, including placebos.³¹ If the victim answers “yes” to any of the following questions, he or she may suffer from TMD: Does it hurt to open the mouth widely or yawn? Do you have earaches or pain in front of your ear? Is your pain worse in the morning? Have you had trauma to your face or jaw? Do you have temporal pain or headaches? Has your jaw ever gotten stuck open or closed? Does your jaw pop or click on opening or closing?

Included under the term TMD are two groups of sufferers: those with primary masticatory muscle involvement (myofascial pain and dysfunction [MPD]) and those with internal derangements of the temporomandibular joint (TMJ). Patients also may present with a combination of both types. Internal derangements, traumatic injuries, and dislocation of the joint are covered in Chapter 31.

Myofascial Pain and Dysfunction

Muscle hyperactivity is an important etiologic factor in MPD. In some persons this may result from parafunction (gum chewing, clenching or grinding the teeth). Occlusal interferences can also cause muscle hyperactivity. This occurs when a lower tooth contacts an upper tooth prematurely during mouth closure and a reflex causes jaw muscle contraction that shifts the mandible in such a way as to avoid the premature contact. For this reason this condition is often referred to as an “occluso-muscle disorder.” Psychological stress is also an important factor in causing excessive muscle tension.²⁵

Participants in wilderness activities are exposed to many of the risk factors for MPD. The high physiologic and psychological demands of many expeditions lead to considerable stress. Increased jaw function, such as that required to chew granola, beef jerky, and other dried foods common on wilderness expeditions, is another factor that may precipitate an acute episode of MPD.

Symptoms of MPD include pain in the muscles of mastication that is usually unilateral and increased with chewing, headache, earache, limitation of jaw movement, and a change in the bite. Pain originating in the muscles of mastication is often referred to the teeth, so the chief complaint may be a toothache.^26,⁴⁰ The victim may have a history of acute onset, or a long saga of exacerbation, remission, and various treatments.

The examiner may find objective signs, such as tenderness of the jaw muscles to palpation, muscle spasm or “knots,” and abnormal jaw movements, such as inability to open the mouth widely, or deviation of the chin to one side on opening. Tenderness to palpation of the TMJ or joint noise suggest the victim has an internal derangement of the joint.²⁵

Emergency treatment consists of resting the muscles (soft diet and control of tooth clenching and grinding habits) and the application of moist heat. Holding a soft material such as a folded gauze between the front teeth or use of an athletic mouth guard often gives immediate relief because it keeps the teeth from touching and allows the muscles to relax. An analgesic should be given on a scheduled basis (ibuprofen 600 mg PO every 6 hours), rather than as needed, to break the cycle of muscle pain and spasm. A muscle relaxant, such as cyclobenzaprine hydrochloride (Flexeril) 10 mg PO 3 times a day, or sedatives, such as diazepam (Valium) 2 to 10 mg PO 3 times a day, may be helpful if the primary treatment is ineffective. Muscle relaxants and sedatives, especially in higher doses, can cause significant central nervous system depression, so they should be used in the lowest effective dosage and only if more conservative therapy has failed.^10,^31,⁴²

Miscellaneous Lesions

Aphthous Ulcers

It is thought that aphthous ulcers may represent a local immune response with various triggers such as stress; trauma; immunosuppression; nutritional deficiencies of vitamin B₁₂, folic acid, or iron; acidic foods; and food allergies; to name a few. The lesions are round or ovoid in shape with a yellowish center and a red border and usually occur on nonkeratinized, movable mucosa (Figure 30–1). They can be quite painful. The victim usually gives a history of similar ulcerations. There are three types of aphthous ulcers. Minor aphthae are less than 0.6 cm (0.2 inch) in size and usually last 10 to 14 days. Major aphthae are larger than 0.6 cm (0.2 inch) and may last weeks or months. Herpetiform aphthae are clusters of small, shallow ulcers that resemble intraoral herpes.

FIGURE 30-1 Aphthous ulcer on the tongue.

Many treatments have been proposed, but none has been found predictably effective. The best approach appears to be application of a topical corticosteroid to reduce pain and hasten healing by 3 to 4 days. Mix fluocinonide (Lidex) 0.05% ointment with Orabase and place the mixture gently over each ulcer 6 to 8 times per day, especially after meals and before bedtime. Do not mix the medications until you are ready to apply them, and do not rub the mixture into the lesions. Other options include premixed preparations, such as Kenalog in Orabase, applied to the ulcer 6 to 8 times per day, which is more convenient but delivers only about 10% of the antiinflammatory effect, or dexamethasone (Decadron) elixir (0.5 mg/5 mL, rinse with 5 mL for 2 minutes and expectorate 4 times a day). Finally, a systemic corticosteroid (prednisone, 40 mg PO once daily for 3 days, then taper) may be used for a very severe case. If these preparations are not available, tincture of benzoin or a topical anesthetic (viscous lidocaine 2%) can be applied to the dried surface of the ulcer before meals and at bedtime to control the pain.^15,⁴⁵

Traumatic Ulcers

Traumatic ulcerations are similar to aphthous ulcers but are usually more irregular in outline and lack the red border. They occur from chronic rubbing such as from a sharp tooth against the tongue or an ill-fitting denture against the palate. Topical anesthetic (viscous lidocaine 2%) can be used, but the most important treatment is to remove the source of irritation.

Bisphosphonate-Related Osteonecrosis of the Jaws

Oral bisphosphonates such as alendronate (Fosamax) are widely used to treat osteoporosis, and intravenous bisphosphonates, such as zoledronic acid (Zometa) are used to manage skeletal involvement in various cancers. A side effect of these medications can be delayed healing of exposed bone in the maxillofacial region. Altered bone metabolism persists long after the medications have been discontinued. Bisphosphonate-related osteonecrosis of the jaws (BRONJ) may occur after bone is exposed by acute trauma, by chronic trauma such as from an ill-fitting dental prosthesis, from dental surgery, or after tooth extraction. The incidence after tooth extraction in patients that have taken oral bisphosphonates is less than 1%. The risk for BRONJ in patients that have received intravenous therapy is estimated between 0.8% and 12%.³

The diagnosis of BRONJ is made when exposed, necrotic bone persists for at least 8 weeks in a patient currently or previously treated with a bisphosphonate who has no history of radiation treatment to the jaws. Small lesions may be asymptomatic (Figure 30-2, online), whereas some exposed areas become infected, as evidenced by pain, erythema of the surrounding soft tissue, and possible purulent drainage. Prevention of BRONJ focuses on avoiding bone exposure in patients at risk. Emergency management consists of eliminating pain, controlling infection, and limiting the progression of bone necrosis. Asymptomatic lesions are treated with an antibacterial mouth rinse such as chlorhexidine. BRONJ that is painful and infected is treated with an antibacterial mouth rinse as well as an antibiotic, such as penicillin V potassium 500 mg PO 4 times a day, cephalexin (Keflex) 500 mg PO 4 times a day, or clindamycin 150 mg PO 4 times a day, and pain control. Evacuation for surgical care is indicated in cases of BRONJ complicated by any one of the following: pathologic fracture, extraoral fistula, or necrosis extending to the inferior border of the mandible.^3,^27,³⁸

FIGURE 30-2 Two small areas of bisphosphonate related osteonecrosis of the jaw (BRONS).

Mucocele

Mucocele, or mucous retention phenomenon, occurs when the duct of a minor salivary gland is blocked or traumatized, resulting in accumulation of saliva beneath the mucosa. It most commonly occurs in the lower lip. A mucocele in the floor of the mouth is called a ranula. Most mucoceles are a few millimeters in diameter, lie just under the surface, and have a translucent or bluish tint. They often form, spontaneously drain, then reform again and again. Most will eventually disappear without surgical intervention. No emergency treatment is necessary (Figure 30-3).

FIGURE 30-3 Mucocele commonly occurs on the inside of the lower lip.

Maxillofacial Infections

Viral Infections

Herpes labialis (cold sore, fever blister) is the most common oral viral infection. It is characterized by yellow, fluid-filled vesicles that rupture to leave ragged ulcers on the lips (Figures 30-4 and 30-5). Other locations for recurrent herpetic outbreaks include the palate, tongue, and buccal mucosa. The victim can be given valacyclovir (Valtrex) 2 g PO twice daily for 1 day, with doses taken about 12 hours apart.⁴³ It is important to begin treatment as soon as the victim becomes aware of a prodromal “tingle” or paresthesia. There is some evidence that the same regimen of valacyclovir can prevent outbreaks from occurring.^8,²⁹ However, more conservative methods, such as the use of sun-blocking agents on the lips, are preferred.⁴⁴

FIGURE 30-4 Herpes labialis in the healing stage.

FIGURE 30-5 Herpes labialis showing vesicles.

Primary herpetic gingivostomatitis is characterized by a thin zone of very red, painful gingiva just next to the teeth. Other areas of mucosa, such as the tongue, may also be involved, and close inspection may reveal tiny vesicles or ulcers. Sore throat, lymphadenopathy, and low-grade fever are also present. This and other viral infections of the oral cavity are self-limited. The victim should be reassured that the condition will resolve in about 10 days. Treatment involves the use of an analgesic (ibuprofen 600 mg PO every 6 hours as needed for pain and fever) and soothing mouth rinses, such as warm saline or a mixture of equal amounts of diphenhydramine (Benadryl) elixir 12.5 mg/5 mL with kaolin-pectin (Kaopectate) and viscous lidocaine 2% (rinse and expectorate 5 mL every 2 hours).

Yeast Infections

Oral yeast infections occur most commonly in persons who are debilitated, immunocompromised, suffer from xerostomia, or are taking an antibiotic or corticosteroid. Classic oral candidiasis (thrush) is characterized by white patches on the mucosa that can be rubbed off, leaving a red and raw surface (Figure 30-6). Candidiasis can also manifest as erythematous mucosa, without any white patches, or as chronic angular cheilitis (Figures 30-7 and 30-8; Figure 30-8, online). Candidiasis is treated with an antimycotic mouth rinse (nystatin oral suspension 100,000 U/mL, rinse with 5 mL for 2 minutes and swallow, 4 times a day for 10 days) or lozenges (clotrimazole [Mycelex] troche, 1 troche 4 times a day, leave in mouth 5 minutes, and expectorate remains). In the field, nystatin preparations meant for vaginal treatment (Nystatin vaginal suppository used as an oral lozenge 3 times a day for 10 days) can be used.

FIGURE 30-6 Thrush.

FIGURE 30-7 Angular cheilitis.

FIGURE 30-8 Close-up of angular cheilitis, a yeast infection.

Bacterial Infections

A bacterial infection in the maxillofacial region can become a serious health threat. In a wilderness setting, it should be taken seriously. Most odontogenic infections are caused by mixed populations of aerobic and anaerobic bacteria. These organisms are almost always present as normal oral flora, but because of a change in the relative numbers of various bacteria or because of a change in the oral environment, an infection can become aggressive.

The behavior of an organism, such as the production of collagenase or hyaluronidase, determines the clinical presentation. Thus an infection may manifest as diffuse cellulitis or localize as an abscess. Oral infections usually spread slowly, but rapid spread to a deep facial space can occur. Regional lymphadenopathy is common, whereas severe systemic symptoms are rare. Although bone is often involved, osteomyelitis is uncommon.³⁹

Acute Apical Abscess/Cellulitis

An acute apical infection begins with bacteria invading the dental pulp. The infection then spreads to surrounding bone through the apical foramen and then along the path of least resistance. Because the apices of most teeth are located closer to the facial aspect of the jaw, swelling is much more common in the facial soft tissues, as opposed to those on the lingual or palatal side.

The victim presents with pain and swelling, often fluctuant and usually in the buccal vestibule (Figure 30-9). There is often a history of prior toothache, but at this stage tooth pain is often absent. The offending tooth can be localized by percussion, site of the swelling, condition of the teeth, and by radiographs if available. The affected tooth does not respond at all to hot or cold. The victim may be dehydrated because of decreased fluid intake.

FIGURE 30-9 An apical abscess manifesting with swelling in the buccal vestibule.

Primary treatment for an apical abscess is drainage.^28,⁴¹ This can be accomplished with incision, extraction, or endodontic therapy. The treatment chosen depends on the equipment and personnel available, advisability of retaining the offending tooth, and ultimately on clinical judgment. An antibiotic is necessary only if complicating factors exist^11,^28,^41,⁴⁶ (Box 30-5). Penicillin V potassium 500 mg PO 4 times a day is the most commonly used antibiotic in dental practice, but a cephalosporin, such as cephalexin (Keflex) 500 mg PO 4 times a day, typically carried on wilderness expeditions, is acceptable. Clindamycin 150 mg PO 4 times a day is a good alternative.^23,^41,⁴⁶ Combination antibiotic therapy is not indicated except for life-threatening sepsis or when organisms particularly sensitive to combination therapy have been identified. There is some evidence that hesitation to obtain drainage combined with overreliance on chemotherapy can lead to serious exacerbation of dental infections.¹¹

Incision and Drainage

Incision and drainage (I&D) is often the treatment of choice in an emergency situation. An I&D procedure can be performed by a nondentist using commonly available supplies. It is indicated for fluctuant swelling due to an apical abscess and may also be effective for nonfluctuant swelling associated with infection. Infiltration of a local anesthetic helps to reduce the pain of incision. If unavailable, adequate anesthesia can often be obtained by applying cold to the area to be incised, using ice, snow, or frigid water. An incision is made down to the bone in one swift motion, and a knife handle or the beak of a hemostat is used to spread the incision. A T-shaped drain may be improvised from a piece of latex glove and retained without sutures (Figure 30-10). Hydration, a soft diet, an analgesic (ibuprofen 600 mg PO every 6 hours as needed for pain), and warm saline rinses are helpful postoperative measures.

FIGURE 30-10 Incision and drainage technique. A, Fluctuant abscess. B, Abscess incised with scalpel. Purulent drainage is removed by suction or caught in gauze sponges. C, Cross section showing incision carried to the bone. D, The incision is spread with a hemostat. E, A T-shaped drain often stays in place without sutures. F, Drain in place.

(Redrawn from Ingle JI, Beveridge EE: Endodontics, ed 2, Philadelphia, 1976, Lea & Febiger, with permission.)

Deep Fascial Space Infections

An acute apical infection occasionally spreads beyond the local region. The rescuer should be suspicious of any dental infection that causes swelling or tenderness in the floor of the mouth, swelling of the tongue, dysphagia, breathing difficulty, or trismus, or that fails to respond to appropriate therapy. The most commonly involved fascial spaces are the canine, buccal, masticator, and submandibular spaces.¹²

The canine space is located lateral to the nose. Infection originates in the maxillary canine tooth and swelling causes the eye to close. The infection is drained through an intraoral approach over the root of the canine tooth.

Buccal space infection is characterized by rounded swelling of the cheek (Figure 30-11). The offending teeth are the maxillary and mandibular molars. Drainage is obtained extraorally through an incision below the lower border of the mandible, so that the scar will eventually be hidden or minimal.

FIGURE 30-11 A buccal space infection.

The masticator space is divided into the masseteric, pterygoid, superficial temporal, and deep temporal spaces, all of which communicate. The hallmark of involvement is trismus. Swelling may be minimal owing to the deep location of the abscess. The masseteric and pterygoid spaces are drained at the angle of the mandible, whereas the temporal space may be drained from an intraoral approach or through an incision just superior to the zygomatic arch.

The mylohyoid muscle divides the floor of the mouth into the sublingual and submandibular spaces. These communicate posteriorly and with their counterparts across the midline. An infection originating in a mandibular tooth can involve these spaces. If only the sublingual space is infected, an intraoral approach is used for drainage, avoiding damage to Wharton’s duct. If the submandibular space is involved, an extraoral approach is used. All incisions in the facial area are made parallel to branches of the facial nerve.^12,²⁴

Fascial space infections are potentially life threatening. The likelihood of widespread sepsis increases, cavernous sinus venous thrombosis and mediastinitis are possible, and the airway may become compromised.^13,¹⁷ The most feared infection is Ludwig’s angina, a bilateral submandibular space infection that elevates the tongue, obstructs breathing, and is associated with a high mortality rate (Figure 30-12). A mild dental infection can progress to a life-threatening emergency in as little as 48 hours.¹⁷

FIGURE 30-12 Ludwig’s angina.

Treatment of fascial space infections includes airway management, proper hydration and electrolyte balance, aggressive incision and drainage, intravenous antibiotics, and pain control. Because these objectives are best met in a controlled environment, any person with a suspected fascial space infection should be evacuated immediately.

Chronic Apical Abscess

The hallmark of chronic apical infection is a draining fistula or “gum boil” (Figure 30-13, online). Because the bacteria have a route to escape, they do not cause pressure or pain, although the tooth may be mildly sensitive when eating. Such an abscess is not an emergency except in the unlikely event of an acute flare-up. Antibiotics are not indicated.

An infected deciduous tooth also usually manifests with a fistula and a mild amount of swelling at most. Happily for the child, severe pain is rarely present. Emergency care involves an antibiotic, with the dosage adjusted for the child’s weight, and I&D only if the abscess is not draining. Extract the tooth only if it is very loose and it will be weeks until comprehensive care is available.

Exodontia

A dental extraction is considered definitive treatment and should be attempted in the field only under extraordinary circumstances (Box 30-6). Extraction requires training, specialized instruments, and profound anesthesia, which may be difficult to obtain. As discussed above in the section on facial pain, symptoms that seem to be coming from a maxillary molar may actually originate in a lower molar or from a muscular trigger point. Never extract a tooth without a definitive diagnosis. Premedication with a sedative or narcotic may be necessary, as may dental radiographs. Intraoperative and postoperative complications are common. Providers of emergency care should focus on treating pain and infection with local anesthetics, analgesics (ibuprofen 600 mg PO every 6 hours as needed for pain, or hydrocodone 7.5 mg and acetaminophen 750 mg [Vicodin ES] PO every 4 to 6 hours as needed for pain), I&D, and antibiotics (see Acute Apical Abscess/Cellulitis, earlier) as appropriate for each case.^6,^35,⁴¹ Extraction or other definitive care can then be rendered after evacuation; the tooth can often be saved.

Other factors to consider before exodontia are degree of mouth opening possible, relationship of the root to the maxillary sinus, condition of the clinical crown, alignment of the tooth in the dental arch, and history of previous endodontic treatment (after root canal treatment, a tooth is usually very brittle).²¹ Along with the considerations for extracting the tooth, weigh the possible complications arising from extraction, such as fractured roots, fractured alveolus, fractured mandible or tuberosity, damage to adjacent teeth and restorations, soft tissue injury, loss of root tip in sinus, prolonged bleeding, and infection.

If, after careful consideration of all factors, extraction is deemed the best course of treatment, proceed as follows.

Review the victim’s medical history. There are dental implications for many frequently prescribed medications.⁷ Chapter 34 discusses chronic diseases and wilderness activities. Do not assume that the victim is free of bleeding disorders, severe cardiovascular disease, and the like. A discussion of dental surgery for the patient on anticoagulant therapy and maximum international normalized ratio (INR) values for various procedures is beyond the scope of this chapter. Suffice it to say, you do not want to exceed those values in a wilderness setting! Persons with certain cardiac conditions or recent prosthetic implants should be premedicated with an antibiotic^2,⁵⁰ (see Boxes 30-1 to 30-3). Consider the emotional state of the victim, and decide if sedation is prudent.

Plan the procedure, and gather all necessary equipment. Secure a good light source and a means to keeping the field dry—either suction or plenty of gauze. It is important to have the victim’s head supported. Therefore it may be best to place the victim in a supine position with the head slightly elevated. Obtain good local anesthesia, and test by touching the soft tissues with a sharp instrument. A 10 × 10-cm (4 × 4-inch) gauze curtain placed in the rear of the victim’s mouth prevents aspiration of teeth and debris.

Teeth are inflexible and brittle. Heavy forces, especially if applied quickly (high acceleration), break teeth. Bone has more flexibility, the degree of which depends on the individual patient. Judiciously applied, moderate forces slowly expand the bone. The tooth will eventually be delivered in the same direction as if it continued to erupt. However, do not attempt to “pull” the tooth in that direction initially. The direction of force needed to loosen a tooth depends on the anatomy of the root. A straight, conical root can be loosened by twisting forces. This technique often works well on the upper front teeth. Sometimes a tooth can be removed by alternating 30 seconds of steady pressure toward the cheek with 30 seconds of steady pressure in the opposite direction, until the root gradually loosens.⁵²

A variety of instruments can be used to apply force to the tooth. Elevators are firmly wedged between tooth and bone in the interproximal area. Avoid putting pressure on the adjacent tooth. Forceps should be applied as far apically as possible. Spend plenty of time working the forceps well under the gingiva. Lower molars are often removed with “cowhorn” forceps, which, in addition to applying the usual forces, are designed to apply force to the tooth in a coronal direction simply by squeezing the handles. However, an experienced exodontist using careful technique and a single forceps (the No. 151 universal extraction forceps) (Figure 30-14) will have success extracting almost any nonimpacted tooth, whereas a reckless operator using dozens of specialized instruments will have difficulty.^21,⁵²

FIGURE 30-14 No. 151 universal mandibular forceps.

Despite the utmost care, a tooth may break during the extraction procedure. If this occurs, stop and take a minute to reevaluate the situation. The root canal will probably now be exposed. If you are treating a case of infection, perhaps drainage can be obtained through the root canal. If you are treating a case of severe pulpitis, perhaps the pulpal tissue can now be removed. Remember that you are rendering emergency care, and it may not be necessary to remove the remaining root at that time. Some teeth are impossible to remove without sectioning or can be removed in only one direction.

Once the tooth has been removed, look at the end of the root to confirm that the entire root was extracted. Any remaining fragments can be removed at another time if necessary. Compress the expanded socket using the thumb and forefinger. If the gingiva is quite loose, placing a suture may help speed healing. Have the victim apply direct pressure to the wound by biting firmly on a gauze pack for 30 minutes while sitting in an upright position. Complete hemostasis may require several hours of steady pressure. Caution the victim to avoid rinsing, spitting, toothbrushing, and smoking for 24 hours. Apply cold packs for 15 minutes on and 15 minutes off for the first day, and use an appropriate analgesic to reduce swelling and pain. Beginning the day after surgery, have the victim rinse with warm saline to cleanse the area.

A common postoperative complication is persistent bleeding several hours after the extraction, accompanied by a poorly organized clot that looks like a piece of raw liver growing out of the socket. Remove the “liver clot,” and have the victim apply firm, uninterrupted pressure to the socket by biting on a gauze pack or a wet tea bag (tannic acid in the tea helps to promote clotting) for 20 minutes. If the victim cannot do this, the rescuer will have to apply manual pressure. If bleeding continues after 20 minutes, consider packing the socket (Gelfoam, Surgicel, or sterile gauze) or suturing. Then resume direct pressure.

Another postextraction complication is acute alveolar osteitis, or “dry socket.” The victim reports moderate to severe pain, foul odor, and a bad taste, beginning about 3 days after a dental extraction. Examination reveals an empty socket and exposed bone due to loss of the blood clot, but no suppuration. Treatment consists of anesthetizing the area, gentle irrigation with warm saline, followed by packing with a strip of gauze dipped in eugenol. Administer an oral analgesic. Change the pack every 24 to 48 hours until the symptoms subside, which may take up to 10 days. The victim should avoid alcohol, smoking, and carbonated beverages during treatment.

Dental Trauma

Wilderness recreation creates many opportunities for traumatic injury. One recent survey of 9543 consecutive trauma patients registered with an oral and maxillofacial surgery service found that 31% were sports related. Of those, 44% could be considered “backcountry” trauma, mostly resulting from skiing and snowboarding. The study was done in Innsbruck, Austria.⁴⁹

It is essential to quickly evaluate the general condition of an injured victim (see Chapter 21). The primary survey identifies and corrects any inadequacy in respiration or circulation. The mouth and pharynx should be examined for foreign bodies such as blood clots, tooth or bone fragments, or dentures. If the airway is still obstructed, it may be necessary to perform a chin lift or jaw thrust or insert an oropharyngeal airway to hold the tongue forward (see Chapter 20). Care should be taken not to hyperextend the neck because of the possibility of a cervical spine fracture. If there is no indication of a neck fracture, sometimes merely placing the victim on his or her side rather than in a supine position facilitates respiratory exchange. If all these measures fail, endotracheal intubation or performance of a cricothyrotomy or, less commonly, a tracheotomy may be necessary.⁵ Once a victim’s airway is secured and he or she is hemodynamically stable, perform a secondary survey.

Question the victim about the time and nature of the accident, symptoms, loss of consciousness, nausea, vomiting, visual disturbances, and headache. A baseline mental status examination and cranial nerve assessment may be warranted. Clean the face, mouth, head, and neck of blood and debris. This unmasks soft tissue injuries and facilitates diagnosis. Gently reflect the lips with teeth closed to examine soft tissues and occlusion. Examine any lacerations carefully to determine if they penetrate through the lip or contain foreign material. Examine all of the teeth for fractures. A blow to the chin or whiplash injury may produce fractures of the posterior teeth as the mandible is forcibly closed. Examine fractured teeth carefully for pulp exposure. This will require drying the tooth with gauze. Tap each tooth with an instrument handle. Tenderness denotes injury to the periodontal ligament, whereas a high-pitched, metallic sound indicates ankylosis as occurs in lateral luxation or intrusion. Test each tooth for abnormal mobility. Electrical pulp vitality testing, dental radiographs, and soft tissue radiographs should be obtained if available.^4,¹⁶

See Chapter 31 for injuries to the face, head, and jaws.

A classification of traumatic injuries to the teeth and supporting structures is given in Box 30-7. Note that these injuries often occur in combination, with one tooth exhibiting two or more injuries, or several teeth exhibiting various sequelae of trauma. Each injury requires definitive treatment, but proper emergency care improves the prognosis and makes the victim more comfortable. Treatment of most injuries requires, or is at least facilitated by, infiltration of a local anesthetic.

BOX 30-7

Classification of Dental Trauma

Injuries to the hard dental tissues and pulp

Crown infraction

Uncomplicated crown fracture

Complicated crown fracture

Uncomplicated crown–root fracture

Complicated crown–root fracture

Root fracture

Injuries to the periodontal tissues

Injuries to the supporting bone

Comminution of alveolar socket

Fracture of alveolar socket wall

Fracture of alveolar process

Fracture of jaw

Injuries to soft tissues

From Andreasen JO, Andreasen FM: Textbook and color atlas of traumatic injuries to the teeth, ed 3, St Louis, 1994, Mosby.

Specific Dental Injuries

Crown Infraction

Blows to the teeth sometimes produce small craze lines in the enamel. These superficial fractures look like tiny surface cracks on an old porcelain dish. Reassure the victim that minimal damage has occurred and treatment is not necessary.

Uncomplicated Crown Fracture

The tooth has been fractured, but no pulp tissue is visible. The tooth may be sensitive to cold, but otherwise all test results are within normal limits. Account for and save the missing fragment if possible. No emergency treatment may be necessary. Irritating sharp edges can be smoothed with a fingernail file. If thermal sensitivity is moderate to severe, a soothing topical antiinflammatory dressing (IRM) can be held in place with aluminum foil or adhesive tape.

Uncomplicated Crown–Root Fracture

Diagnosis and treatment of this condition are identical to the uncomplicated crown fracture, except that the fracture is nearly vertical, leaving a small, chisel-shaped fragment attached only by the palatal gingiva (Figure 30-15). Removal of this mobile fragment makes the victim much more comfortable.

FIGURE 30-15 Crown-root fracture. The mobile fragment (A) should be removed. The larger fragment (B) should be left in place.

Complicated Crown Fracture

In this injury, the pulp has been exposed. A small exposure that has not been grossly contaminated is capped with calcium hydroxide (Dycal) or IRM. If the exposure is larger than 1 mm or if the pulp tissue has been exposed for more than 24 hours, amputate approximately 2 mm of tissue with a sharp, sterile instrument. If bleeding continues for more than a few minutes, use a cotton pellet soaked in local anesthetic solution, hydrogen peroxide, or Dycal to obtain hemostasis. Fill the top of the canal with Dycal or IRM, and protect the tooth as for a crown fracture (Figure 30-16).

FIGURE 30-16 A, Complicated crown fracture. B, Treated with a temporary filling.

Complicated Crown–Root Fracture

The tooth has been fractured obliquely, resulting in a mobile fragment attached to the palatal gingiva as well as a pulp exposure. First, remove the mobile fragment as in a crown–root fracture, then treat the pulp exposure as in a complicated crown fracture.⁴ It is possible to glue tooth fragments together with 2-octyl cyanoacrylate (Dermabond) for a day or two.²⁰

Root Fracture

A root fracture may be difficult to diagnose without radiographs. There is slight to severe malposition of the crown, but this could be caused by extrusion of the entire tooth or a root fracture with luxation of the coronal portion. Reposition the tooth as precisely as possible, and splint rigidly (see Splinting, later). Hard tissue union of the fragments usually occurs within 3 months. If the coronal portion of the tooth proves impossible to stabilize and definitive treatment is days away, remove the mobile fragment, but do not attempt to extract the apical fragment.^4,¹⁶

Concussion and Subluxation

Injuries to the tooth’s supporting structures (periodontal ligament, bone, and gingiva) cause sensitivity to percussion. The tooth remains in its proper position. In subluxation the tooth is abnormally mobile, whereas mobility is normal with concussion. Hemorrhage from the gingival crevice sometimes occurs. Emergency treatment consists of shortening the opposing tooth so that the victim can occlude comfortably.

Intrusion

A tooth that has been driven into the bone by a vertical force demonstrates little mobility and a high-pitched, metallic tone on percussion. Emergency treatment is palliative only. Endodontic treatment (to prevent inflammatory root resorption) and orthodontic extrusion should begin within 2 weeks of injury. Intrusion is associated with a poor long-term prognosis.⁴

Extrusion

The extruded tooth is partially displaced from its socket and extremely mobile. Gentle, steady pressure is used to reposition the tooth, allowing time to displace the blood that has collected in the apical region of the socket. After reduction, the tooth is nonrigidly splinted for 2 to 3 weeks.

Lateral Luxation

In this injury, the tooth is often displaced by a horizontal blow, yet it is not mobile because the apex is locked into its new position in the alveolar bone. A high, metallic tone on percussion is another clue that this has occurred. This injury and its treatment are painful. Figure 30-17 shows how two fingers are used to reduce the tooth. One finger guides the apex down and back, while the other repositions the crown. This requires judicious, but sometimes quite firm, application of force. The tooth may snap back into position and be quite stable. Check the tooth the next day. Breakdown of marginal bone and inflammation may cause the tooth to become mobile. Splinting is necessary if mobility is present, whether this occurs immediately after reduction or is detected later.¹⁶

FIGURE 30-17 Two fingers are used to reduce lateral luxation.

Exarticulation

When a tooth is totally avulsed from bone, the prognosis after replantation depends on the health of the periodontal ligament cells, some of which are still attached to the root surface and some of which line the socket wall.^14,³⁶ To preserve the vitality of these cells, certain guidelines should be observed. Keep the time before replantation to a minimum. Immediate replacement is ideal (Figure 30-18). If the tooth must be stored, keep it moist. Less than 20 minutes in air is associated with a good prognosis and longer than 1 hour with a poor prognosis.^4,¹⁴ If possible, the tooth should be stored in a Save-A-Tooth, which uses a soft mesh to suspend the tooth in Hanks’ balanced salt solution. Alternative transport mediums are whole milk, saline, the victim’s saliva, sports drinks, and water, in that order of preference. The concept is to preserve the health of the periodontal ligament cells in the most isotonic, pH-balanced solution at hand. If no container is available, use a plastic bag, plastic wrap, or saturated cloth to keep the tooth from drying. Handle the tooth by the crown only. Never scrub, curette, or use a disinfectant on the root surface; gently rinse with saline to remove debris. When removing clotted blood from the socket, use gentle irrigation and suction, and avoid scraping the socket walls. Examine the socket for fracture of the alveolar wall. If present, reduce the fractured bone with a blunt instrument. Ease the tooth back into place with slow, steady pressure. After replantation, splint the tooth nonrigidly for 1 week. Suture any gingival lacerations after splinting. Administer an antibiotic for 5 days, and give appropriate antitetanus prophylaxis. Endodontic therapy should be instituted within 2 weeks.^4,³⁶

FIGURE 30-18 A, Two teeth have been avulsed. B, The teeth have been replanted.

The preferred approach to tooth avulsion or severe luxation is immediate reduction in the field, followed by evacuation for definitive treatment. The next most desirable option is to store the tooth properly and transport victim and tooth for replantation within a few hours of injury. If the extraoral dry time exceeds 60 minutes, the periodontal ligament cells are presumed necrotic and should be removed by curettage. The root is then treated before replantation. Sodium fluoride 2.4% with a pH of 5.5 has been shown to improve prognosis, as have enamel matrix proteins (Emdogain).⁴⁸

If field conditions prevent all of the aforementioned treatments, a delayed replantation procedure is indicated. Store the tooth dry. Three weeks after the injury, the necrotic pulp tissue is removed and the tooth is disinfected, fluoridated, and surgically replanted. The aim of delayed replantation is to produce ankylosis between tooth and bone.⁴

Comminution of Alveolar Socket or Fracture of the Alveolar Socket Wall

The bone of the alveolar socket is fractured into one or more segments. Stabilize the associated teeth.

Alveolar Segment Fracture

This condition is characterized by displacement of two or more teeth as a unit. The teeth are not mobile with respect to one another. The apices may be locked into their abnormal position as in lateral luxation. The segment is repositioned (this may be painful even with local anesthesia), and rigid splinting is placed for 4 to 6 weeks.

Soft Tissue Injuries

Wounds of the oral mucosa and face should be treated after repair of the dental injuries and jaw fractures. Time is more critical when treating intraoral, hard tissue injuries. Also, lacerations are likely to be reopened if closed before intraoral manipulations. See Chapter 31 for diagnosis and treatment of facial soft tissue injuries and Chapter 22 for wound care.

Patient Instructions

After all of the preceding intraoral injuries, the patient should be placed on a soft diet for 10 to 14 days and instructed to brush gently but thoroughly with a soft toothbrush after every meal. The patient should also rinse twice each day with a chlorhexidine-containing mouthwash if available, or warm saline if not.

Proper Reduction

It is sometimes difficult to know when a displaced tooth has been returned to its proper position. Usually a tooth should be positioned similarly to its contralateral mate. Sometimes asking the victim can help; it may be that one tooth has always been longer than the others, or in a different position. However, occlusion is always the best guide to proper position. If the victim bites and contacts only the injured tooth, further positioning is necessary. In many cases, it is not possible to reposition the tooth completely because of swelling or organized clot formation. Therefore some adjustment of the opposing tooth (try using an emery board or pocket knife file) may be necessary to allow proper occlusion. If the injured tooth receives additional trauma each time the victim bites, it will be uncomfortable and healing will not occur.

Splinting

When the goal of splinting is to establish a normal, fibrous union between the tooth and the bone, a short-term, nonrigid technique is used. When hard tissue union is desired (e.g., root fracture or alveolar segment fracture), longer-term rigid splinting is used.⁴ Ideally, a single avulsed or loosened tooth is usually bonded to the adjacent tooth or teeth with the acid etch and composite technique.^4,¹⁶ For fractures of the jaws or alveolar segments, arch bars and wire splints are often used. The rescuer lacking adequate materials must use ingenuity and improvisation to splint teeth. During a very short evacuation, the victim could hold the tooth in approximate position by closing (biting gently) on a gauze pad. Softened wax can be adapted to a loosened tooth and the teeth on either side to lend support. If the victim has an athletic mouth guard with him or her, this can also be used. Figure 30-19 shows how a suture can be used to hold a tooth in place for a period of a few days. For a sturdier splint, a crude arch bar can be cut from a SAM Splint or made from a paper clip and dead-soft wire obtained from copper wiring or twist ties.

FIGURE 30-19 A suture can be used to hold a replanted tooth in place.

Injuries to Primary Teeth

Injuries to the deciduous teeth offer unique challenges, not the least of which is behavioral management of a young child. Splinting is very difficult because of the small amount of tooth structure available. In general, heroic efforts should not be made to save primary teeth.^4,¹⁶ Exarticulated deciduous teeth should not be replanted. Severely extruded teeth, infected teeth, or those intruded into the developing permanent tooth should be extracted. Because the permanent tooth follicle lies to the lingual side of the primary tooth root, the typical frontal impact displaces the crown toward the palate, but levers the root apex away from the permanent tooth (Figure 30-20). Most minor subluxations and luxations require only symptomatic treatment. As long as the displaced tooth does not interfere with occlusion, reduction is contraindicated. Spontaneous repositioning often occurs over a period of weeks. Fragments of primary roots need not be extracted because normal resorption will still occur.

FIGURE 30-20 When a child falls forward, the typical direction of force is shown by arrow A, and the apex of the deciduous tooth is levered away from the developing permanent tooth bud, as shown by arrow B.

Dislodged Fillings, Crowns, and Bridges

No emergency treatment is necessary for a dislodged filling, small piece of tooth, crown, or bridge in the absence of other symptoms. Often the best course of action is to file off any excessively sharp areas of the tooth that are irritating the victim’s soft tissues, and otherwise leave the tooth alone. If you are going to attempt a temporary filling or crown recementation procedure, make sure you do not create an occlusal problem by leaving the restoration too high. This will only make the patient more uncomfortable.

Appliance Sores

Complete dentures, removable partial dentures, retainers, mouth guards, and the like can cause mucosal sores if their fit changes even a small amount. The mucosa will appear red or even ulcerated. Often the patient can do without the appliance until definitive treatment is available. If not, it is necessary to file or scrape away a small amount of material where the appliance is rubbing the mucosa. Finding the proper area of the appliance to relieve can be a challenge. Mark the sore spot (a tiny piece of adhesive tape, sticky side out, or a slurry of water and grape drink mix are options), insert the dried appliance, and remove. Hopefully the mark will have transferred to the appliance, showing the proper place to adjust.

Orthodontic Emergencies

Orthodontic appliances can cause soft tissue irritation or ulceration. Cover the offending fixture with soft wax. Sometimes a protruding wire can be bent until the sharp portion faces away from the soft tissues. If a bracket or wire becomes excessively loose, it can usually be removed with judicious tinkering. If a wire needs to be cut and small wire cutters are unavailable, try fingernail clippers or repeatedly bending the appliance until the metal fatigues and breaks.

Local Anesthesia

Local anesthesia is a prerequisite to many emergency dental, oral, and maxillofacial procedures. Anesthesia of any upper tooth and the associated buccal soft tissues can be obtained by infiltration. Approximately 2 mL of a local anesthetic solution is placed as close to the apex of the tooth as possible, just above the periosteum. By holding the syringe parallel to the long axis of the tooth, the needle tip is guided in the proper direction (Figure 30-21). Articaine (Septocaine) 4% with 1 : 100,000 epinephrine has become the most widely used local anesthetic in dentistry.⁵¹ Two percent lidocaine with 1 : 100,000 epinephrine is also commonly used, and bupivacaine (Marcaine) 2% with 1 : 200,000 epinephrine is useful for long-term pain relief. Other available local anesthetics can be substituted.

FIGURE 30-21 Technique for infiltration of a local anesthetic.

The mental nerve block is a simple method for obtaining anesthesia of the teeth and buccal mucosa from the second premolar forward. Proceed as for the infiltration, except that the target area is the mental foramen, located between apices of the lower first and second premolars (Figure 30-22). After depositing the solution, gently massage the area for about 30 seconds.

FIGURE 30-22 Technique for blocking the inferior alveolar nerve near the mental foramen. The shaded teeth will be anesthetized.

The inferior alveolar nerve block is more difficult to learn but produces anesthesia of all the lower teeth up to the midline, as well as the buccal soft tissues forward of the mental foramen. The lingual nerve is also blocked by this injection, producing numbness of the anterior two-thirds of the tongue and lingual gingiva. Figure 30-23 shows how the deepest concavity on the anterior border of the mandibular ramus is palpated by the thumb while the deepest concavity on the posterior border is palpated by the index finger. The target area is then halfway between the rescuer’s thumb and index finger.⁴⁷ Figure 30-24 shows how the syringe is kept parallel to the plane of the lower teeth and how to puncture the mucosa just medial to the rescuer’s thumbnail. When bone is contacted in the target area, the anesthetic solution is deposited. Experienced dentists miss the target area, and thus fail to produce adequate anesthesia, in approximately 10% of injections.

FIGURE 30-23 When administering the inferior alveolar block, the target area lies on the medial surface of the mandibular ramus, halfway between the rescuer’s thumb and forefinger.

FIGURE 30-24 Keep the syringe parallel to the plane of the lower teeth.

Dental First-Aid Kit

Most supplies needed to treat dental emergencies can be found in a good, general purpose first-aid kit. These include antibiotics and analgesics, gauze, tweezers, scalpel, hemostat, and sutures. Items specific to dental emergencies can be added to a wilderness first-aid kit without a large sacrifice of space or weight. Cavit is temporary filling material that requires no mixing and is easy to use. Squeeze a small amount of the material from the tube and place it in the tooth. Wet a dental packing instrument (or cotton-tipped applicator or toothpick) to prevent sticking and pack the Cavit well. Then remove any excess. Have the victim bite to displace material that would interfere with occlusion. The filling material will set in a few minutes after contact with saliva.

Zinc oxide/eugenol cements (IRM) consist of a liquid and powder. Start with two drops of the liquid and begin mixing in the powder. Keep adding powder to make a dough that is not sticky yet will hold together. Dip the instruments in some powder to keep the mixture from sticking. Insert and shape the filling material as explained previously. Zinc oxide/eugenol cements have several advantages compared with Cavit. They are significantly stronger and can be mixed to a doughy stage for filling or slightly thinner for use as cement. Most important is the soothing effect of eugenol on teeth with pulpitis. However, the liquid often leaks from its container, lending a pervasive odor to the backpack and tent; wind tends to blow the powder away; and the material is difficult to mix and is a sticky mess to insert into the tooth.

A more complete kit for extended expeditions should include a No. 151 universal extraction forceps (see Figure 30-13, online) and a straight elevator for extracting teeth. A mouth mirror, Orabase with benzocaine, orthodontic wax, dental floss, dental syringe, 30-gauge needles, and anesthetic cartridges complete the kit. These items fit in a small case and weigh about 14 oz. A custom dental first-aid kit is preferred over commercial dental “travel kits,” which contain unnecessary items and lack essential ones.

In an outdoor situation, techniques must often be adapted or improvised depending on the items available. For example, Figure 30-18 shows how a suture can be used to splint an avulsed or extruded tooth. A temporary filling can be fashioned from softened candle wax, an emery board can be used to smooth a sharp tooth, or a pocket knife can be used to perform a drainage procedure.