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.
Before departure
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.
Dental emergencies
Emergencies tend to fall into three categories: pain; lost
or broken fillings and other restorations; and more serious
emergencies (infection or traumatic injury).
Toothache
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.
Fillings, crowns, bridges and dentures
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 decemented it should be removed.
More serious emergencies
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 reimplant it. The roots of some reimplanted
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 reimplanted. Ideally a dentist
should then splint the reimplanted 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 reimplant 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.
Choosing a dentist abroad
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.
Important points to mention
If you have had rheumatic fever, St Vitus's dance (chorea),
have a heart valve defect or disease, or a hole in the heart,
a heart murmur or have had heart valve surgery, then you should
have antibiotic cover for any extraction and should make this
plain to any dentist you see. Antibiotic cover is also advisable
for extractions if you have an artificial joint or a heart
pacemaker.
You should also tell the dentist about any
steroid treatment that you have had, even many months before,
as it may be necessary for you to have additional steroid
treatment at the time of a tooth extraction or similar surgery.
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!
Looking after your teeth
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!
Fluoride and living abroad
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.
NOTE: This is an abridged excerpt from the
book "Travellers
Health", Oxford University Press, Editor Dr
Richard Dawood.
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