Textbook of Maritime Medicine

The pre-sea examination of seafarers does not always focus on the dental status. Also, seafarers may spend a long period of time at sea without access to dental health service. In the Danish telemedical service, dental problems are among the most frequent causes for consultation (Radio Medical Danmark, Annual report 2008, Esbjerg 2009). We therefore find it reasonable to give a rather detailed description of the diagnoses and treatment of dental injuries and dental infections.

The aim of dental first aid is to alleviate symptoms, to prevent spreading of infection from teeth to the adjacent tissues, and to prevent permanent damage.

To identify the affected tooth, an international system of numbering is used.

In  Fig. 10.2.1   the frontal aspect of the teeth is shown. Each half of the jaws is divided into quadrants. The front teeth are number 1 and the wisdom teeth number 8. For example, the wisdom tooth in the left upper jaw is designated 28, where 2 refers to the quadrant and 8 to the tooth.

A trauma to teeth may cause a tooth to break, to loosen, or to fall out. These injuries most often affect the upper or lower front teeth. If a jaw fracture is suspected, i.e. when the occlusion has become abnormal, the patient should be evacuated.

Fig. 10.7.1   Numbering of the teeth

10.7.1   Instruments, material and anaesthesia

Fig. 10.7.2 shows instruments for dental treatment. Excavators, formed as sharp spoons, are used for removing food residuals, soft caries affected dental tissue and excess dental cement. The excavator in the middle is stronger and may be used to remove loose fillings. The plastic instrument to the right is employed to place and to form dental cement, and to remove excess cement.

Fig. 10.7.2    Dental instruments for emergency intervention

Dental cements

There are two types of dental cements. One is soft and ready to use, the other (IRM) is hard and has to be prepared (mixed). Dental cements are used to replace a lost filling, or as first aid to cover exposed tooth structure after trauma or after removal of caries. It is important not to use too large amounts. The patient must bite firmly before the cement hardens. Too much cement may compromise the occlusion.

Fig. 10.7.3    Dental cements

Local anaesthesia

All kinds of medicine, including anaesthetics, may cause allergy. Such information is therefore necessary. Due to the complex anatomy of the face, local anaesthesia should only be used in the upper jaw and the in front of the lower jaw.

Local anaesthetic is injected in close proximity to the affected tooth, close to the point were the apex of the dental root is assumed to be.

Fig.10.7.4   Injection site for local anaesthetic

10.7.2  Injuries to the teeth

Broken tooth

If there is no exposure of the nerve, no icing and no pain, the patient should avoid chewing with the injured tooth and seek a dentist in first port of call. If the fracture has reached the nerve, or there is icing or pain, you may cover the fracture with dental cement IRMâ which will adhere to tooth substance.

Treatment

-         give painkillers or local anaesthetics  

-         put on gloves

-         cleanse the tooth (wound) with NaCl solution 0.9 %

-         dry the wound with cotton and pincer

-         cover the lesion with dental cement and gently press the cement in place with a wetted piece of
          cotton

-         remove excess cement with the plastic instrument

-         have the patient see a dentist in the next port of call

Loose tooth

If a tooth is loose, but in place, one should check that the patient is able to occlude without conflict with the other teeth. The patient should eat soft food only, and see a dentist as soon as possible.

If the tooth is out of position, it should be re-positioned. Put on gloves and press the tooth back  in position. If this is too painful, local anaesthesia may be given. When re-positioned, the tooth must be stabilised.

Fig. 10.2.5    Loose tooth stabilised with aluminium foil and cement

Treatment

-         put on gloves

-         form a piece of aluminium foil with 3-4 layers big enough to cover the loose tooth and one neighbour tooth on each side

-         mix cement (IRM) and apply a suitable amount to the aluminium foil. Move the cement to the border of the tooth and press upwards on each side, see Fig. 3.23

-         gently remove excess cement

-         the patient should eat soft food only,  and avoid chewing with the affected tooth and see a dentist in next port of call

Lost tooth

A tooth that has fallen out must not be allowed to dry, but should be stored in 0.9 % NaCl solution. If the tooth is soiled, it must not be scraped, but rinsed with saline solution. In case of major injuries, one should not try to rescue a single tooth. Instead, the tooth should be wrapped in gauze, wetted with saline solution, and follow the patient when evacuated.

If all other teeth are in place, and the socket of the lost tooth can be identified, the tooth should be replaced immediately.

Equipment

-         gloves

-         10 ml syringe

-         infusion solution (NaCl 0.9%)

-         dental cement IRM)

-         aluminium foil (1 x 3 cm, 3-4 layers)

Treatment

-         put on gloves

-         remove blood clots from the socket of the lost tooth by rinsing with saline solution

-         take the cleansed and moistened tooth (be careful not to harm the surface) and replace it

-         stabilise the tooth (se under “Loose tooth” above)

The patient should eat soft food only and avoid chewing with the affected tooth. He should receive antibiotics and possibly vaccination against tetanus. He should be told to see a dentist in first port of call.

Lost filling

Fillings are most often lost during chewing and rarely give rise to strong pain. A fragment of a fractured tooth is often confused with a lost filling by the patient. The aim of first aid is to prevent pain and cover underlying tissue. This is achieved by covering the defect with dental cement. The patient will normally be able to point out the tooth where the filling is missing.

Treatment

-         put on gloves

-         localise the affected tooth by means of light and dental mirror

-         with the excavator  clean the defect where the filling is lost

-         rinse with sterile infusion fluid (use a syringe and a large canulla)

-         place a cotton roll between the tooth and the cheek

-         dry out the defect with a pincer and a small amount of cotton

-         close the defect with  a small amount of cement,  using the plastic instrument. The cement can be pressed into place with a small, wetted piece of cotton. Excess
cement should be removed with the plastic instrument

-         let the patient bite firmly to secure that the filling is not too large

-         the patient should see a dentist in next port of call

Lost jacket crown

The loss of a jacket crown or a porcelain crown should be treated only when there is pain. In the case of pain, the condition is treated as a fractured tooth (see above).

If the tooth is tender, an infection is likely to be present and antibiotics should be administered. . The patient must be advised to see a dentist in the next port of call.

10.7.3   Dental Pain and Infections in the Teeth and the Oral Cavity

Signs of infection are swelling, increased redness, tenderness and increased temperature locally or generally (fever). Infected teeth should be watched carefully since spread of infection to eyes or neck may be serious. If there is progression towards an eye, the patient must be evacuated. By spread of infection to the throat, the patient may experience locked jaw, and respiratory problems may arise.

Dental pain

Dental pain and the clinical findings do not always agree. Dental pain is most often caused by caries with inflammation of the nerve, or by an infection in the nerve that has progressed to the adjacent tissue. In the first case, the patient may have problems to localise the pain. If the tooth is tender to light tapping with an instrument, it often indicates that infection has progressed to the surrounding tissues. To localise the lesion, a thorough case history is necessary. The different modes of intervention are described for each of the most common causes of toothache. Toothache may be a symptom of a disease or an injury. You will find equipment to give first aid in both cases (See “Injuries to the teeth” above)

Hole in a tooth (caries)

A dental cavity does not always cause pain, but if present, the pain tends to be constant and is often worsened by heat or cold, or by intake of sugar or sweets. Covering the defect with cement, without removing dental caries may result in spread of infection.

First line treatment should be limited to pain relief in consultation with Radio Medico. The patient is advised to see a dentist in the first port of call.

If the pain is not relieved by analgesics, emergency treatment may be given.

Emergency examination and treatment

-         have the patient point at the affected tooth. Observe that there may be problems with accurate localisation

if pain derives from an apparently intact tooth, treatment must be limited to pain killers.
The   same is the case if the pain comes from at tooth with a filling which
cannot be removed

-         if there is pain from a tooth showing a cavity that lacks filling, examine tenderness by tapping on the tooth with the shaft of a dental mirror.

-         if the tooth is not tender and the bottom of the cavity is firm and clean, treatment may be given as under “Lost filling”  (see above)

-         if the tooth is tender, this  may indicate that infection has spread and antibiotics should be given.

Dental root infection

Infection of the dental root is often a consequence of an insufficiently treated dental cavity. The infection has spread to the jawbone via an infected dental nerve. The tooth consequently feels tender during chewing, or if tapped with the shaft of a dental mirror. First line treatment should be limited to pain relief until the patient is seen by a dentist. If the infection appears to be spreading, the condition should be treated as a root abscess (see below).

Dental abscess

Infection of the dental root may progress to an abscess (gum boil).

The gum then becomes red, swollen and tender. The tooth is usually also tender, and may be felt as “too high”. Occasionally, fever may occur.

Fig 10.7.6    Gum boil from an infected tooth

Examination

-         put on gloves

-         locate the origin of the pain with a dental mirror and ample light

-         look for swelling and other signs of infection (Fig. 3.21)

-         if pus is running from the spot when light pressure is applied (Fig.3.22) drainage has started and   
          symptoms may be expected to decrease rapidly

-         look for signs of serious spread of infection (see above)

Fig.10.2.7    Gum boil with pus

Treatment

-         have the patient rinse the mouth with chlorhexidine (0.2%) 3-4 times daily

-         after consultation with Radio Medico give antibiotics (e.g. phenoxymethylpenicillin 1320   mg 3 times
          daily)

-         the patient should see a dentist in first port of call

-         in cases of serious spread of infection, the patient should be evacuated

Infection of the gum (gingivitis and periodontitis)

Gum infection rarely causes pain, but in some cases a gum boil may develop (see above)

Examination

See above

Treatment

Common gum infections rarely cause pain, but bleeding from the gum may be seen. Good dental hygiene with the use of a brush and dental sticks are recommended. In addition, the patient may rinse the mouth with chlorhexidine (0.2%) 2 times daily.

If an abscess has developed, see “dental abscess” (above).