Expedition Doctor Heather Reynolds recently caught up with oral surgeons Harriet Tweedale and Paul Hudson to ask them about how they manage dental problems in the mountain environment. Here's what they said...
Heather and Paul before we start, can I ask you to tell us about your careers so far?
Harriet: I graduated from Newcastle University 6 years ago. I did a year in a general dental practice in Nottingham (my home city) before moving onto a Maxfax job in Lincoln. I really enjoyed it in Lincoln and worked there for just over 3 years. During my time there I obtained my MFDS with the RCS of Edinburgh and my dental sedation diploma with King’s College, London. I then moved back to Nottingham and split my time between general dental practice and providing emergency dental care in the community before moving to Sheffield to do another Maxfax post (my current job). My long term plan is (hopefully) to become a Specialist Oral Surgeon (like Paul!).
Paul: I’ve now been in the tooth business for the last 23 years having graduated from Leeds in 1996, WOW amazing how time flies. I started out in general practice before taking flight for adventures overseas - India, Nepal, Thailand, Indonesia and Australia. Sadly, all adventures come to an end and somehow I found myself back in the UK. I took up a position at Sheffield's Charles Clifford Dental Hospital in 2000. Following a few changes of roles and with considerable support from others, the General Dental Council registered me as a Specialist Oral Surgeon in 2010. I now work as an Oral Surgery Associate Specialist delivering service provision and training to both undergraduates and post graduates.
What has been your involvement in remote dentistry?
Harriet: The only time I was involved in truly remote dentistry was on my dental elective as a student. My buddy and I went to Kenya. We visited isolated villages in and around Migori, a town in Southwest Kenya. We had a little ambulance to take us to schools in the most remote areas and we examined hundreds of children’s teeth each day. We had one “dental chair” and we would numb up about 5 children at a time and they would then take it in turns to sit on the said dental chair for their fillings/extractions (mainly extractions!). A big Kenyan chap called Kevin (who introduced himself as the local sugar cane farmer) would come and help us when we were struggling with an extraction and I don’t think there was a single tooth/root that guy couldn’t remove. It wasn’t until the end of our elective that he told us he was a trained dentist but it didn’t pay as well as growing sugar cane (!!).
Paul: Anyone who has spent some time in Australia will know just how vast and remote it is. I spent some time working there in my early years in a tiny remote town. Being isolated you do not have access to expert opinion or the option of a referral for management by more experienced dental and medical colleagues. Telephone case discussion and advice is as good as it gets. An appointment with a specialist was a 9 hour drive or 3 hour flight away. Internet communication and advanced social media were developing platforms in their infancy. Working in this environment you have to rapidly grow to deliver the service the locals expect of you. You need to be resourceful, resilient, develop people skills and above all learn to work as a team.
Left untreated a dental abscess can cause extensive soft tissue swelling and result in septic shock.
I also recall an unusual experience whilst climbing in Nepal. I was recovering from a very acute stomach upset in the remote Langtang Valley having been left there by my climbing pals whilst they forged ahead. On the second day of convalescence a porter from the next village, a day’s walk away, presented himself, having been sent to collect me. Apparently a resident of his village needed a tooth pulling with some urgency. Still totally wiped out and unable to walk the porter essentially carried me the whole way in a makeshift harness - he refused to wait a few days for me to recover. The unfortunate villager whom I had been summoned to attend had a severe facial abscess and spreading cellulitis from an upper molar tooth. The swelling had closed his eye and was spreading well into his lower face. His pulse was raging, he was profusely sweating and he was effected by rigors. As we had no local analgesia or dental equipment the abscess was lanced and the tooth removed with a hot water sterilised - you’ve got it, Swiss army knife! Analgesia provided by copious volumes of local rice wine, patient compliance achieved with the help of lots of restraining friends. Within 24 hours the swelling was subsiding, my GI symptoms eased and quite possibly the villager’s life was saved.
What are the most common dental problems you might expect to deal with in a remote environment?
Harriet: Provided those on expeditions heed standard dental advice, dental decay and abscesses (as a result of untreated dental decay) are likely to be very rare in a remote environment.
Dental trauma however, is much more likely. Fractured teeth, loose teeth, teeth knocked out of position and teeth completely knocked out of the mouth can all occur whilst in a remote environment. Breaking of the bone around teeth (dento-alveolar fractures) can also happen as well as fractured mandibles (not ideal!). We will discuss how to deal with these scenarios later on.
Pericoronitis (inflammation around the crown of a tooth) – usually associated with a partially erupted lower wisdom tooth (the buggers!) could be a potential problem whilst away. It is generally caused by food packing under the gum (next to the tooth) or trauma from the opposing tooth biting onto the gum (operculum) over the partially erupted tooth. Symptoms include: pain/tenderness and swelling around the tooth, pain on swallowing, halitosis and sometimes pus discharge and reduced mouth opening. The best way to deal with pericoronitis is by maintaining good oral hygiene. Warm, salty rinses can also be helpful. If symptoms fail to improve a course of antibiotics (metronidazole 400mg tds for 5 days) may be required. If you suffer with recurrent episodes of pericoronitis prior to going on expedition it may be worth having the offending wisdom tooth (or that opposing it) removed. Your dentist can advise you further.
Fillings may be lost or fractured and these are quite easy to deal with in a remote environment provided you have the right materials! A temporary filling material (e.g. Cavit) can be put in place and easily moulded to fit the defect until appropriate dental treatment can be sought.
What advice would you give to those going into a remote environment about dental care pre-expedition?
Harriet: Before departure it is important to have a full dental check-up (with radiographs). Ideally this should be done 3 months prior to the start of your expedition so if there are any issues they can be dealt with promptly before you go.
For people going on expedition in areas of extreme temperatures it may be worth stocking up on Sensitive toothpastes e.g. Sensodyne Rapid Relief, Colgate Sensitive Pro-Relief before you go. I would advise starting to use these prior to the start of your trip and then everyday whilst on expedition.
A soft or medium toothbrush is recommended and should last you a couple of months. Maybe take one or two extra, just in case!
Can you recommend the best analgesia to use for dental-related injuries and problems?
Harriet: Generally for dental pain we would recommend staggering paracetamol or co-codamol 30/500 with ibuprofen.
Administration of local anaesthetic next to a symptomatic tooth (discussed later) can provide temporary relief from toothache.
Can you talk us through the basics of recognising and managing dental infection, including appropriate antibiotics to use?
Harriet: Usually a dental abscess is preceded by toothache from a decayed or broken tooth. A small lump/abscess can develop in the gum next to the problematic tooth. Sometimes these drain themselves through a sinus tract. This is the best case scenario because the infection has somewhere to escape and therefore causes little/no discomfort. Worst case scenario is the infection has no release and spreads and you develop a big fat face. Ideally, before it gets to this stage if there is a fluctuant swelling adjacent to the tooth then it needs incising and draining under local anaesthetic and a course of antibiotics starting.
Co-amoxiclav 625mg tds for 5-7 days
(If allergic to penicillin then clindamycin 300mg (up to 450mg) qds for 5-7 days)
If someone on the expedition with a dental infection develops a large facial swelling, trismus, difficulty in swallowing or are systemically unwell their expedition is over! They will probably need admission to hospital for IV antibiotics, dental extraction(s) and incision and drainage of surrounding abscess (intraorally vs extraorally) either under local or general anaesthetic depending on how bad it is. Hence highlighting the importance of a pre-expedition dental check up!
What dental equipment (including drugs and other kit) would you advise an expedition medic with a basic level of dentistry training to take on a remote expedition?
Harriet: I’ve tried to be useful and taken a photograph of the essentials. These include...
Dental equipment for remote practise.
Local anaesthetic (Lignospan Special - lidocaine (2%) + adrenaline (1:80,000))
Long dental needle (yellow)
Temporary dental materials (including glass ionomer cement (GIC), Coltosol and Cavit plus a mixing pad and spatula)
Materials for splinting (titanium splint, scissors, cotton rolls, gauze, etch/bond lollipop sticks and composite (and composite gun) for gluing the splint in place).
Sachets of saline
0.5mm or 0.45mm soft pre-stretched wire (for bridling fractured mandibles!), wire cutters and curved artery clip
Universal dental forcep (lower premolar forcep)
Analgesia - paracetamol, ibuprofen and cocodamol (30/500)
Antibiotics - coamoxiclav, metronidazole and clindamycin
A method of sterilising instruments
What advice would you give an expedition medic about management of dental trauma?
Paul: Wow! That’s a whole day’s tutorial right there, tricky to get the info into a short blog. Keeping it simple, I would advise the following:
-Asymptomatic broken teeth are probably best left well alone until you return from your adventure. Any sharp edges should be smoothed if possible to avoid developing ulcers which can often become infected and debilitating.
-The management of symptomatic broken teeth is very much dependent upon the symptoms which present. A simple sedative temporary filling may ease the situation (e.g. sedan/kalzinol)
-Teeth that are fractured due to trauma can have temporary fillings placed to stop them becoming sensitive and debilitating.
-Avulsed (Knocked out) and luxated teeth (moved but not knocked out) need to be repositioned and splinted. Temporary splints can be fashioned with creativity and some form of dental adhesive. Teeth which are avulsed should obviously have the roots cleaned before being re implanted. Immediacy of treatment is key to good long term outcomes. A course of antibiotics should also be given (antibiotic of choice: co-amoxiclav 625mg tds 5 days)
What advice can you give to us about dental extractions in the field (when should it be done, and how would you do it?)
Harriet: Unless you have had prior training, I would avoid dental extractions in the field except if the tooth is ridiculously loose or an obvious airway risk and you can remove it quite simply with your fingers!
Can you talk us through the basics of using local anaesthetics for dental extractions or other procedures?
Paul: The most common dental anaesthetic is 2% lignocaine with 1:80,000 adrenaline (lignospan). I would imagine any emergency medical kit might have some sort of similar anaesthetic available. Most dental procedures can be carried out with deposition of about 2 ml in the sulcus next to the affected tooth. For lower molar teeth Inferior dental blocks are the norm, but some training is desirable if these are to be delivered safely and effectively. The use of dental local analgesia techniques could also be utilised to provide pain relive and management of maxillofacial hard and soft tissue injuries.
If you would like any further information regarding dental issues and how to manage them please get in touch.
Many thanks to Heather, Harriet and Paul for writing this fascinating post!
Paul and Harriet will be speaking at the Hathersage Mountain Medicine Festival (6-9th June 2020).
Disclaimer: The information provided above is intended for reference only and we strongly advise that healthcare delivery is only provided by those with the skills and training to do so effectively.