Dental problems arising while travelling abroad are, in general, given little thought and consideration both by prospective travellers and by those responsible for emergency treatment.
Travellers on short visits or holidays abroad are unlikely to face a dental emergency (other than an accidental one) if they have had a careful examination within a few months of their journey, and any necessary treatment has been completed. The initial appointment should be booked a sufficient time before departure to permit treatment to be completed without haste. People with heavily restored mouths, or large complex restorations should seek advice on how to cope with any particular problems that might arise.
Travellers intending to spend a long time abroad should consider treatment for any conditions likely to cause trouble in the future for example currently symptomless impacted teeth or the replacement of a just adequate but ancient denture. Dental problems in long-term expatriates are surprisingly common. In American Peace Corps Volunteers (who each spend two years overseas), they consistently represent the third or fourth most frequently reported of all health problems.
Emergencies tend to fall into three categories: pain; lost or broken fillings and other restorations; and more serious emergencies (infection or traumatic injury).
A relatively trivial dental problem can give rise to a totally disproportionate amount of pain, and make life quite miserable. Extreme sensitivity to hot and cold may be the first sign of trouble; if treated at this stage, the tooth may settle down. If left untreated, the pain may become spontaneous and long lasting; the nerve in the tooth may eventually die, and act as a focus for infection and abscess formation.
A dental abscess can cause severe persistent pain, exacerbated by pressure on the tooth. In all cases, a swollen face should be taken seriously; it is wise to seek treatment early, as there is a small but significant risk of life-threatening spread of infection.
The usual treatment for an abscessed tooth in many countries would be extraction; however if the abscess is caused by death of the nerve, it is often possible to perform root canal treatment to save the tooth. Where a high standard of dental treatment is available, baby teeth may be treated in a similar fashion; otherwise it may well be more sensible to accept loss of a milk tooth, rather than risk a spreading infection.
If treatment is unavailable antibiotics should be taken, although every effort must be made to see a dentist as soon as possible.
Another type of abscess may develop where teeth are badly affected by gum disease. Such an abscess may sometimes be treated by deep cleaning of the tooth to remove infected deposits under the gum. However once again, the only treatment offered in some countries may be extraction of the tooth. A similar abscess may develop around the crown of an impacted tooth, usually a lower wisdom tooth, and this is quite common in young adults. Extraction of the impacted tooth will eventually be necessary, although antibiotics, hot saline mouthwashes, and good tooth brushing may help control the infection until the traveller returns home.
It is sensible for individuals, who have heavily restored dentitions, or who have suffered any kind of dental abscess in the past, to discuss the management of such problems with us; we may well recommend travelling with a supply of antibiotics.
Though often a source of great inconvenience, the loss or breakage of a dental restoration cannot be considered to be a true emergency; the freshly exposed tooth surface is often sensitive to hot or cold, and jagged edges may irritate the soft tissues of the mouth. It is not, however, absolutely essential to seek immediate treatment unless there is considerable discomfort. The survival and fate of a tooth are unlikely to be affected by a delay even of a few weeks; this means that it is almost always possible to wait until you can see your own dentist, or can find a dentist on personal recommendation.
If extreme sensitivity or a toothless smile necessitate treatment in the absence of adequate facilities, it is wise to seek provisional treatment only. It is often a simple matter for a dentist to insert a temporary filling, or temporarily recement a crown or bridge, but in many countries even the most basic dental materials may prove to be unobtainable. "Do-It-Yourself" repairs and repair kits are not to be recommended without advice from us on how to use them as there is a risk that restorations may be inhaled or swallowed if they become loose in the mouth during sleep; once a restoration has become de-cemented it should be removed.
Fractured jaws and spreading infections need hospital dental treatment by an appropriate dental specialist. Standards of skill in treating jaw and facial bone fractures probably vary more from country to country than for any other injury.
If it becomes clear that skilled treatment is not available locally, and if after emergency care the patient is fit enough to travel and is not at risk from obstruction of the airway, it is be best to return home for further treatment.
A front tooth that has been broken as a result of a blow (particularly in a child) may not always seem to need urgent care: in fact, expert treatment within a matter of hours may make all the difference between conserving the tooth or losing it.
If a child's permanent front tooth is knocked out, it may be possible to re-implant it. The roots of some re-implanted teeth are subsequently eaten away by the body, like those of baby teeth, and the tooth is lost again; but others survive and give good service. If there is to be a chance of success, the tooth must be reasonably clean when picked up and it must be rinsed in cold water or milk. Hold the tooth only by the crown, and do not touch, rub, or scrub the root.
The root must be kept moist, so put the tooth in a clean container, in cold drinking water to which salt has been added (one teaspoon to a glass), or some milk. The tooth may then be pushed back fully into its socket, straight away. Be sure that the crown is the right way round!
Surprisingly the procedure will not be too painful. Baby teeth should not be re-implanted. Ideally a dentist should then splint the re-implanted tooth in place, give antibiotics, and arrange for a tetanus booster injection. If a dentist is not immediately available a temporary splint may be improvised using softened chewing gum (preferably sugar free), pressed around the tooth and its neighbours, and covered with metal foil. It is best not to re-implant a tooth that has fallen on to pasture grazed by animals, because of the increased risk of tetanus infection.
Teeth successfully replaced within half an hour are most likely to reattach normally. If the tooth is kept moist there is a reasonable chance of success for up to two hours. Beyond two hours results are poor. The splint should normally remain in place for about 2 weeks. In all cases the tooth should be checked by a dentist upon returning home, and subsequently at regular intervals.
Non-sterile instruments and needles may be a source of Hepatitis B or AIDS and you should satisfy yourself that any dentist you consult uses instruments that have been adequately sterilized. "Cartridge" syringes are the safest for giving local anaesthetic.
These are made of metal, and a fresh glass vial, closed with a bung at each end and filled with sterile local anaesthetic solution by the manufacturer, slides into the barrel for each patient. A fresh needle from an intact plastic tube should be used for each patient. The syringe should be sterilized between patients, autoclaving is preferable, but boiling the metal part is acceptable. Absolute sterility is less critical than with syringes in which the solution has to be drawn up into the barrel itself.
Needles and plastic syringes should come from intact original packages, and should be discarded after each patient. Beware of needles re-sterilized by soaking in antiseptic or by boiling. Beware also of plastic syringes that have been "re-sterilized" by soaking in antiseptic. Be wary also of bottles of solution from which doses for other patients have been withdrawn. Needles that have been used on patients can easily contaminate the contents.
Bear in mind that high-speed drills use water as a coolant, and this water (and any other water used in your mouth) is likely to be only as clean as the local supply. Personal recommendation is usually the best basis for choosing a dentist.
Patients who are taking anticoagulant drugs or who have had trouble with excessive bleeding from cuts etc. or who suffer from haemophilia should make sure that the dentist understands the situation.
Naturally you should tell the dentist about any serious illnesses you have had and any medicines, injections, or tablets that you take as a routine. If you are allergic to any drugs, (e.g. penicillin or aspirin), or dressings, it is essential that the dentist or pharmacist knows about this. Language problems may make this difficult.
Remember also that not all cultures attach a great deal of importance to saving teeth. You must make your own feelings on this subject quite clear!
When travelling in a hot country, it is sometimes tempting, and often necessary (when safe drinking water is unobtainable) to drink large amounts of canned or bottled soft drinks. In some countries it may also be customary to serve guests with heavily sweetened tea or coffee. Frequent consumption of sugary food or drink is especially damaging to the teeth. It may take only a few months for early decay to develop in a previously unaffected tooth; small quiescent or reversing lesions may become active and irreversible.
Tooth cleaning becomes even more important when sugar consumption is high. Using dental tape or an interdental brush every day in the way that we have shown you will help to prevent decay of otherwise inaccessible surfaces. Dental floss has been found to be a versatile and indispensable travelling companion by one of the authors, who has had cause to use it on occasion as a clothes line, for repairing a tent, and for hanging a hammock. The possibilities are limitless!
A small amount of fluoride (one part per million in temperate climates) in drinking water undoubtedly reduces the likelihood of tooth decay, particularly in children; however an excessive fluoride intake (greater than two parts per million in a temperate climate), can lead to mottling and discolouration of developing teeth. In countries that have a well - developed mains drinking supply, the fluoride content is carefully controlled to the proper level. Not only is the appropriate small amount added where it is required, but a natural excess of fluoride is removed.
Unless it is known for certain that fluoride is absent from the local water supply or is present only in a very low concentration (much less than one part per million), the use of fluoride supplements for children is unwise. In any case, supplements should be used only when prescribed by us, or a knowledgeable local dentist or doctor. Where fluoride levels are high, it may be wise to use alternative sources of drinking water for babies and small children, bearing in mind that water intake and thus total fluoride intake is much higher in hot countries.
Young children often swallow a significant amount of toothpaste when they brush their teeth. If the toothpaste contains fluoride, and fluoride levels in the drinking water are already on the high side, this may result in an excessive total fluoride intake. Only under these circumstances is it better for babies and young children to use fluoride-free toothpaste.
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