Tips for Dental Emergencies while Traveling Abroad

Are you planning a vacation outside the U.S.? Don’t have your vacation ruined by a toothache. Prior to traveling abroad a thorough dental examination is important especially if traveling to developing countries or remote areas without access to safe dental care.

Emergency dental care abroad may be hard to find, uncomfortable, expensive, or even dangerous. Most of us take for granted the high U.S. standards for infection control and safety. We seldom think about the fact that sterile instruments, gloves, disposable needles and safe water are not always routine in parts of the world. Dentists practicing in the U.S. are held to high standards of care and must follow infection control guidelines for disease prevention. The standards for educating and licensing dental professionals also vary in foreign countries. In the U.S., dentists have been educated in accredited schools and have taken national and state boards prior to receiving a license to practice.

Before you travel…
Schedule an appointment with your dentist giving adequate time to complete any necessary dental treatment. Pressure changes especially during air travel can cause pain in an untreated tooth.

• Have decayed or cracked teeth treated
• Congested with sinus problems? It may be from or affecting your teeth
• Schedule a cleaning, especially if you have any type of periodontal (gum) disease or bad breath
• Sensitive teeth should be checked before you travel
• Complete all root canal treatments

Seeking safe emergency dental care while you’re traveling…
Along with your passport, carry travel information including names and phone numbers of organizations to contact in case of a dental or medical emergency. Some good sources to contact in an emergency are:

• A local hotel concierge.
• Americans living in the area or American military personnel.
• The International Assoc. For Medical Assistance To Travelers — a network of doctors and medical institutions around the world – (www.iamat.org) (716) 754-4883.
• American Consulate or American Embassy in the country you are visiting.
• In Europe – American Dental Society of Europe (ADSE) (www.adse.co.uk) Phone: 011 44 141 331 0088.

To obtain A Traveler’s Guide To Safe Dental Care visit The Organization For Safety and Asepsis Procedures (www.osap.org)

Don’t let a dental emergency dampen your vacation. Be sure to have your teeth in great shape prior to leaving home.

Watch Dental Video about Dental Implants

There exists a series of clinical and radiological criteria for the identification of an implantation success.

Of course, the patient counts freedom from pain as a success, but pain is a very unreliable partner in medicine. For example, as a rule, malignant tumors are only painful shortly before the end. A general rule in medicine is that slow changes are rarely painful, while only acute changes are noticed as pain.

So what constitutes a successful implant? The doctor does not just evaluate pain, he has a series of negative criteria whose absence is a condition for success and at whose occurrence a failure must be admitted. A successful implant must be clinically fixed in the jaw, be free of any inflammation and pain, and not show any loss of bone.

In most implant systems, a loss of bone around the implant can be observed in the first two years. This is probably due to the implant superstructures, the so-called abutments.

However, since most implant systems do not have a conus, but a plug connection, the initial bone resorption is defined as “normal”. In this process, the decrease of the height of the bone around the implant should not be more than 0.2 mm after the second year following the implantation. The majority of the loss is registered in the first year, both in toothless jaws as well as in partially edentulous jaws, with a decrease of around 0.4 – 0.5 mm / year, while only 0.1 – 0.2 mm / year are measured in the second year and the years following that. Implants performed in combination with bone augmentations show a significantly higher resorption rate in the first year (1.1 mm), but approaching that of the area bone in the subsequent progress.

Conical connection between implant and abutment

Physicians use standardized analytical processes in order to assess the success rate of an implant system. A common procedure is the analysis of the retention period: Contrary to the frequently used ratio calculated between all failed implants and all placed implants (“Input-Output Statistics”), the analysis of the retention period results in a realistic representation of the failures. In this case, the probability of the loss of an implant is calculated based on its retention time. Since the effect relating to the retention period is missing in the simple “input-output statistics”, their failure rates are significantly lower. However, in the calculation of corrected failure rates, there is also a degree of uncertainty due to the fact that the individual implant, the patient, or the implant-supported construction can be subject of the success assessment as a “calculation unit”.

So when you read an implant statistic, it is important that the correct analysis method was used. At the present time, hundreds of thousands of implants of varying kinds are placed worldwide every year. Unfortunately, the evaluation of the life span and thus the success rate of implants in the various areas of application are conducted in very different ways! The multitude of possible approaches mentioned above, the definition of the inclusion and exclusion criteria of different studies, as well as the variable definition of what constitutes an implant success complicate the assessment of the results and the comparability of the surveys among them.

Nevertheless, scientifically substantiated long-term results have been documented for the most common implant systems that are anchored in the bone by now, while such data has not yet been presented for other systems such as, for example, implants underneath the periosteum or ceramic implants.

Depending on the implant system used, the success probability for implants in toothless lower jaws for bar-supported provisions in implant-related statistics after 8-10 years is given with 88-97% and in patient-related statistics after 5 or 8 years with 95 and 97%. For fixed, conditionally removable replacements, the success rate in implant-related statistics after 8 years is between 92 and 98% and in patient-related analyses 86%.

Thanks to such analyses, news findings are still being arrived at. Thus, for example, a perforation of the osseous sinus cavity floor during the placement of the implant in the upper jaw apparently does not influence the prognosis for the placed implants. Nevertheless, one should be careful not to injure the sinus cavity during the implantation. It is postulated that implants, which are projecting into the sinus cavity, can be more easily infected in a sinus cavity infection within the course of a simple infection. However, there are still very few studies regarding this point.

A lack of a stable anchoring after the healing phase of the implants or a loss due to functional stress express themselves clinically through a mobility of the implant and would necessitate a removal. Reasons for such a failure during the healing phase could be an improper action during bone preparation with a thermal injury to the bone, an infection of the implant bedding during the healing phase, premature mechanical stress, or structurally weak bone bedding.

mplant?

Every person is unique, and so is their smile. A smile serves as an invitation to our fellow human beings to get to know us. Stars show us how it’s done: Julia Roberts, George Clooney, etc., have particularly attractive smiles.

Not everyone is naturally blessed with beautiful, even, white teeth. Do you only smile and laugh with your hand covering your mouth or with your lips closed? This can be a thing of the past now. Smile and laugh spontaneously, joyously, confidently, and in a relaxed way! With the aid of orthodontic treatments, veneers (ceramic covers) and/or ceramic crowns, unattractive gaps, misalignments, or dark teeth that can no longer be brightened (due to older root canal treatments) can be removed, and an appealing and favorable look can be created – it’s easier than you think!

Bleaching the teeth prior to reconstructive and beautifying procedures can further improve results.

Beautiful people with flawlessly white teeth beam at us from magazines, billboards, TV, and other media. Is it even possible to have teeth that are that white? Yes, an uncomplicated method makes it possible for everyone: It’s called bleaching.

Red / White Aesthetics

Teeth become darker or spotty due to consumption of tea, coffee, red wine, tobacco, and coca cola, or simply as a result of the natural ageing process. Through bleaching, your own teeth can be brightened without any complications.

Usually, the results last for two to three years or longer, depending on your personal oral hygiene and eating habits. If necessary, you can have another professional dental bleaching done after two years.

“Freshly squeezed orange juice affects the dental enamel more than modern bleaching.”

Professional brightening is done with active oxygen, which decolorizes the unattractive color pigments present in the teeth. Through this process, no dental enamel is removed, cut, or etched away. The extent of the brightening is individual and depends on the base tone of your teeth. Depending on the degree of discoloration, a brightening of about 1 – 14 shades is possible.

Prior to bleaching, the dentist should check the teeth and fillings and, if necessary, professional cleaning (oral hygiene) should be performed. Furthermore, it should be noted that only one’s own teeth can be brightened (no crowns, bridges, or veneers can be brightened). This is another reason why bleaching is the optimal starting point before inserting a ceramic-technical provision.

So is it possible to measure, categorize, and standardize smiles?

Aesthetics of the Gums

Yes, we can show you a way.

The gums should be pale pink, lie flat on the tooth and, when observed closely, show a stippling pattern (similar to that of an orange). The first upper tooth is the lightest, the second one is a bit darker, and the third one is the darkest.

A smile is considered young and dynamic when we see more upper jaw teeth than lower jaw teeth. Of particular importance for a harmonic appearance is the symmetry of the upper teeth; a slight asymmetry of the teeth in the lower jaw, on the other hand, promotes a natural appearance. Furthermore, the proper interaction of saturation, surface, and spatial contrasts, as well as translucency and opalescence, is important in order to obtain a natural appearance.

Other parameters for a charming smile are dental geometry and red-white aesthetics. With the aid of modern dentistry, it’s possible to face life with a flawless white smile nowadays. The range of possibilities for “polishing up” your personal dental image is broad. Body care, hygiene, and “taking time out for oneself” are all becoming a bigger and bigger priority in today’s society.

“Wellness” is the name for the new magic formula for feeling well and for satisfaction in your private as well as in your professional life. Dental aesthetics doesn’t just consist of beautiful white teeth; above all, it consists of healthy teeth in a healthy body. According to a Thai proverb, “a smiling person shows teeth.”

Osteopathy

How is the dental care of patients done during and after administering bisphosphonates?

Bisphosphonates (BP) have been used successfully in certain tumor diseases (multiple myeloma) and in the bone metastasis of other tumors, but also in case of osteoporosis and other bone metabolism disorders for more than 20 years. Even quickly progressing diseases can be treated successfully.
Chemically, BP’s are similar to pyrophosphate, which, among other things, plays a significant role as an autologous regulator in bone mineralization.

The big difference between these two substances is the chemic bond between them; pyrophosphate has a phosphorus-oxygen-phosphorus bond (P-O-P bond), while all BP’s have a phosphorus-carbon-phosphorus bond (P-C-P bond). This bond is more resistant to the enzymatic cleavage of osteolytic cells since BP’s are bound to the hydroxylapatite of the bone; this slows down the resorption of bone by osteoclasts (bone-destroying cells).

Depending on the drug, the half-life period may be between a few months and years. BP’s are administered through the vein or the mouth. The side effect profile has been appraised as favorable for years, while it has only been in recent years that osteonecrosis of the jaw, i.e. non-healing wounds of the jawbone, has been brought to the fore.

At first, it was believed that these are normal wound infections, but a pathogenic contamination of the bone (dentogenic infections) or a jaw-related soft tissue bone wound (tooth extractions, jaw surgeries) could not be found in all patients. Since then, case histories have been accumulating, giving the impression of a progressing disease rate. Based on the scientific case collections, there is a generally strengthening view that a relevant risk for a BP-induced osteonecrosis of the jaw exists in patients who are given high doses of an intravenous BP medication over a longer period of time due to a malignant primary disease.

It is interesting to know that similar osteonecroses of the jaw were already found in the 19th and 20th centuries in factory workers who had been breathing in vapors of yellow and white phosphorus over extended periods in the manufacture of match heads. These osteonecroses of the jaw led to suppurations in the bone – including the formation of fistulas. The smell and the inability to eat normally caused the affected persons to be socially isolated, and, in 20-50% of the sufferers, the osteonecrosis of the jaw led to their death, in part, due to suicide. The ban of yellow phosphorus in the production of matches in 1912, led to the extinction of the disease given the nickname, “phossy jaw” and thus, to the extermination of an occupational disease.

The exact reason for the osteonecroses of the jaw caused by bisphosphonate is still unclear. However, there are clues for a multifactorial etiology – in other words, is it assumed that multiple causes are responsible for the occurrence of this disease. Bad oral care, periodontitis, bad toot canal treatment and the foci/fistulas frequently associated with them, certain metabolic diseases such as, for example, diabetes mellitus, might promote the development of the osteonecroses of the jaw! Radiation therapy of jaw metastases while being medicated with BP’s constitutes a particularly high risk.

Besides the factors already mentioned, the individual risk profile is substantially influenced by the type of application of the bisphosphonates (intravenously versus orally), the dosage, the duration of the therapy, and the BP type.

So what does an osteonecrosis of the jaw look like? Osteonecroses of the jaw, which are associated with BP’s, show a clinical and radiological resemblance to normal osteoradionecrosis (ORN), which is caused by excessive radiotherapy. In such cases, too, the leading symptom of the exposed bone is the lack of any tendency to heal. A striking feature in BP-associated osteonecroses of the jaw is the often strong mouth odor (halitosis), which may point to an infection.

There may be a total lack of pathological changes in the X-ray. One conspicuous detail is the radiological and intraoperative findings of “persistent alveoles;” normally, new bone develops within 8-12 weeks of a tooth extraction – but this is not the case in osteonecroses of the jaw. Since BP’s reduce the activity of the osteoclasts and osteoblasts, the overall result is decreased bone remodeling, so that the suspension of reparative and resorptive processes in the alveole becomes quite plausible.

Apart from that, there is often a widening of periodontal gaps. If necessary, further diagnostic measures such as a CT, an MRI, or a scintigraphic examination are indicated. The care concept involves prophylaxis prior to and the early detection during/after a BP therapy, as well as the treatment of manifest BP-associated osteonecroses of the jaw.

Pressure Points

Prophylaxis before the administration of bisphosphonates: As long as the pathogenesis of the BP-associated osteonecroses of the jaw has not been further clarified, all patients should be clinically and radiologically examined prior to a BP therapy, and chronically inflammatory processes in the area of the mucosa and the jaw should be rehabilitated. To do so, the doctor prescribing BP’s transfers the patient to a dentist and/or a cranio-maxillofacial surgeon. He will evaluate the individual risk profile (taking into account the abovementioned criteria), conduct a radiological examination, and define a rehabilitation plan – which must consider the following issues:

• Consultation and education about the risk of an osteonecrosis of the jaw before and after a bisphosphonate therapy.
• Rehabilitation of potentially inflammatory processes in the area of the jaw and the oral cavity.
• Smoothing of sharp bone edges.
• Restorative measures on teeth worthy of conservation.
• Intensification of the oral hygiene.
• Check of the patient’s dental prosthesis for the risk of pressure points.
• Integration into a continuous recall.

In this process, invasive prophylactic measures, in particular prophylactic tooth extractions, should be limited to patients with a high risk profile. Therefore, a decision for the removal of teeth is subject to different criteria than in a pre-radiotherapeutic tooth restoration. The decisive aspect regarding the prognosis are not carious lesions on predilection areas (tooth neck, cutting edges), but the periodontal condition. While the bacterial flora in the periodontium has largely returned to normal 1-2 years after a radiological therapy, patients with BP-associated osteonecroses of the jaw mention frequent spontaneous losses or removals of loose teeth.

Therefore, teeth with periodontal damages that cannot be restored in the foreseeable future should be removed prior to beginning the administration of BP’s with a relevant risk profile. In high-risk patients, the tooth restoration should be completed prior to the start of the treatment with BP’s. An interval of 14 days between the restoration and the start of the BP treatment would be desirable here; however, there is very few resilient data in medical literature.

Prevention and early detection during an ongoing bisphosphonate therapy

Patients taking BP medication should regularly report to their dentists every 6 months. In case of discomfort, in particular regarding pressure points due to a dental prosthesis or due to progressively loosening teeth, the dentist must be consulted early. With regard to prevention, preference should be given to the conservative therapy, compared to the operative therapy (in particular in case of periodontal diseases). However, necessary surgical interventions should not be delayed and, in high-risk patients, should be conducted under the same conditions as after a radiological treatment of tumors in the cranio-maxillofacial area.

Regarding this issue, the following recommendations may be given:

• Long-term continuation of the recall (at least every 3 months, in particular prior to a renewed BP infusion or in case of need);
• A detailed instruction and sensitization of the patients so that any corresponding symptoms can be subjected early to a targeted diagnosis and therapy;
• Conservative restoration of changes that may potentially be threatened by an infection;
• Conservative therapy including an individually adjusted intensive oral care and cautious tooth cleaning;
• Early exact endodontic therapy of devitalized teeth;

If surgeries are required: As a rule, interventions are to be conducted by a cranio-maxillofacial surgeon, oral surgeon, or a dentist familiar with the disease pattern, subject to the following provisions:

• If possible, an atraumatic surgical technique is to be used;
• Systemic anti-infective prophylaxis;
• No secondary healing, as is otherwise common in dento-alveolar interventions (tooth extractions!!), but a plastic covering of the wound areas;
• Possibly, epiperiostally prepared cloth for a plastic covering in order to prevent a further reduction in the periosteal provision of the jawbone.

Therapy of the osteonecroses of the jaw associated with BP

An osteonecrosis of the jaw caused by bisphosphonates is difficult to treat; the course of the therapy is uncertain. In case of small findings, a therapy may be attempted with a local revision and/or a long-term open after-care. If this is not successful or if there are extensive findings, a bone resection is required. Currently, the following recommendations apply in such cases:

• Therapy through a surgical facility with the possibility of a treatment under general anesthesia, inpatient care, and parenteral, anti-infective therapy, in which the respective therapy indication is determined by the practitioner;
• Gentle, but complete removal of the necrotic bone – insofar as intraoperatively recognizable – and (obligatory!) histological reconditioning (also to exclude metastases and relapse);
• Safe plastic covering under a tension-free mobilization of sufficient soft tissue or – if required – plastic cloth;
• Mechanical rest of the surgery area (liquid to passed food, possibly nasogastric tube or PEG (percutanous endoscopic gastrostomy));
• Since bisphosphonates may remain tied to the hydroxylapatite of the bone for years, there is, according to current knowledge, no evidence for an interruption of the therapy with bisphosphonates.

Dental implant care of patients with a bisphosphonate therapy

To date, there is only isolated data in the medical literature pointing toward an increased risk profile for the development of a BP-related osteonecrosis of the jaw due to dental implants. A patient, with implants that were already inserted prior to the BP therapy, will surely require intensified follow-up care. It is unknown up to what point in time it is possible to implant safely prior to a planned BP therapy. An implantation at the time on an ongoing BP therapy must be determined individually depending on the existing risk profile (primary disease, type, duration of the administration and dosage of the medication, cofactors, etc.).

As long as there are alternatives, sufficient possibilities for a dental provision, high-risk patients receiving an intravenous administration of BP’s due to a malignant primary disease, should currently abstain from getting implants.

Grinding of the teeth can lead to dental issues

The grinding of teeth is also know by the Latin name bruxism and usually happens when the patient is sleeping.

People deal with stress differently, when the jaws and teeth are used this is known as bruxism.

When we talk of stress in this case we mean so-called distress. Eustress rarely causes tension which requires release. The difference between eustress and distress can be illustrated in the following story: The fox is hunting a rabbit, the fox has eustress as he thinks to himself that if he catches the rabbit he has a fine meal, the rabbit on the other hand suffers from distress as it is a matter of life and death.

Many people use their jaws and teeth to relive stress when sleeping. They usually don t realize that they are grinding their teeth and may only wake up with some muscular pain in the jaw. Bruxism in young people can lead to jaw joint problems when then grow up. Therefore, it is important to identify young people who suffer from this problem and help them with psychotherapy. Children generally grind their teeth and usually do not require therapy.

Using the jaw and teeth to relive stress is not all bad; problems arise when the grinding of the teeth talks place over many years and damages the teeth. In the picture you can see how grinding of the teeth has affected the teeth and how the teeth have shortened. Other problems are jaw joint problems, ear pain, parodontal damage and facial pain.

The dental therapy for bruxism is usually only a symptomatic therapy i.e. a mouth guard which slows down the rate at which the teeth are ground down. Behavior such as no food before going to bed, no alcohol, no nicotine or caffeine can help the patient sleep better but do not offer a cure for bruxism. A psychotherapy can help shortened the bruxism phases and many patients learn to live and deal with bruxism very successfully. When there are problems in the patient’s private life or work environment then the patient can start to use the mouth guard before going to sleep to help cope with the stress.

Teeth which have been sanded down as a result of bruxism can only be built-up in combination with a mouth guard as without the guard the teeth will be ground down again.

“We will also celebrate, proudly, BRA’s establishment of its first Food Security system that will help produce long-term food independence and economic self-sufficiency for more than 35,000 rural batey residents and farmers through USAID and USDA-funded food distribution and agricultural/cooperative development projects,” said Ulrick Gaillard, BRA’s founder and CEO. According to Gaillard, the organization’s newest food security milestone is credited to the continuing support and collaboration of the Dominican government.

With the financial and technical assistance of the USAID, through a Food for Peace/IFRP program, within a period of four years from 2007-2011, BRA distributed 656.48 metric tons (equivalence of 33million servings) of food rations at a value of $2.3 million to 986,800 impoverished and vulnerable people living with HIV/AIDS and Tuberculosis, vulnerable/orphaned children, Cholera patients, earthquake-affected Internally Displaced People, pregnant women, the elderly who are without a pension or health coverage living in more than 17 provinces and 168 vulnerable and impoverished Dominican Republic Batey communities, rural and urban slums and Haiti’s border regions.

Meanwhile the organization partnered with USDA in 2009, through a two-year Food for Progress-funded program of $1.2 million, to create the first major Batey-run cooperative Food Security System, by producing crops and animal and developing community infrastructures for 35,000 beneficiaries within seven Batey communities in the province of Monte Plata, involving 7,700 cooperative members/farmers and community health promoters in skills training and technical assistance, veterinarian and health services, sharing of equipment and provision of credit.

BRA will present its 2011 “TRUE PARTNERS AWARDS” to USAID, USDA and Charlie Mariotti, Senator for the Monte Plata province, at the 14-year anniversary celebration festivities to be held on Friday, October 21st at 2:30pm at the organization’s Medical Center complex located inside Batey Cinco Casas in the province of Monte Plata.

More than 1,000 people are expected to attend the event, including government, diplomatic and media officials, foreign and local partners and local residents. Dominican President, Dr. Leonel Fernandez Reyna, US Ambassador to the DR, Raúl Yzaguirre and USAID Interim Director to the DR, James Watson have been invited to be our Guests of Honor.

BRA is member of the Clinton Global Initiative (CGI)—collaboration between the private sector, non-governmental organizations and other global leaders committed to effectively confront the world’s most pressing issues and identifying groundbreaking solutions that reduce poverty, improve the environment, and increase access to health care and education.