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P A R T

9
Guidelineess
for Dental
tal Care Onboard Merchant Ships
Ships

1. Introduction
The International Se
eafarers' Welfare and Assistanc
ce Network
has launched DENT
TAL CARE as one of the topics in the

Content Seafarers' Health an

nd Information Programme (SHIP).

To
Toothache may rang
ge from a distressing inconvenie
ence to
1. Introduction
intense, miserable pain,
p ¿cult to treat with only the
that is diff¿
2. Risks for Seafarers
medication and instrruments in the ship’s medical ch
hest.
3. To
Tooth Anatomy
4. The Right Way to Brush
To
Toothache may adve
ersely affffect a seafarer ’s performance,
5. Fluorides
up-set their concenttration and generally present a risk to safety.
6. Emergency T
To
oothache
7. To
Tooth Filling
Consequently, the im
mportance of good dental care a
and regular
8. To
Tooth Extraction
checkups at the den
ntist, cannot be overestimated, e
especially
9. Root Canal Treatment
before embarkation.
10. Crowns and Bridges
11. Bleaching, Whitening and Bonding
Prevention of tooth decay
d can indeed prevent a lot of pain and
12. Dry Mouth
suffffering while onbo
oard.
13. Bad Breath
14. Tips for the Successful Implementation
It should also be rem
membered that dental care syste
ems and
of a Dental Care Campaign
n ports may be very difffferent from what the
the quality of care in
15. Where to Find Advice?
seafarer is used to. In some cases, treatment in ports may
have to be carried out very quickly because of the ffast turna-
round times of todayy’s ships. This may lead to hasty
y decisions
and treatments such
h as an extraction, where other measures
could have saved the tooth.

Dental care may be expensive in ports and treatme

ents are
not always covered by the seafarer ’s company or m
medical
[email protected]
insurance especiallyy when crowns, bridges or denttures are
www.seafarershealth.org
needed.

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International Committee Welfare
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Welfare

2. Risks for Seafarers

Modern dentistry has succeeded in reducing the incidence Root Canal Problems occur when the tooth’s pulp, a small,
of dental caries through water fluoridation, oral hygiene thread-like tissue in the centre of the tooth is damaged or
education, and preventive dental care. diseased. The most common causes of pulp damage or
disease are:
Cavities are far less prevalent than they were several • a cracked tooth
decades ago and may now be managed by advanced • a deep cavity
technology. • an injury, such as a severe knock to the tooth,
either recently or in the past
However, the risk of dental problems is increased for
seafarers because of their limited access to advanced Once the pulp is infected or dead, if left untreated, pus can
dental care and regular control whilst at sea. build up at the root tip in the jawbone, forming an abscess.
An abscess can destroy the bone surrounding the tooth
Some of the most frequent Dental Problems are: and cause pain.

Tooth Decay (dental “caries”) which is the decomposition of Severe, emergency dental pain may be as unrelenting
tooth structure caused by the destructive toxins created by as kidney stones or even labour contractions. Onboard,
Plaque, a combination of natural bacteria and food debris pain treatment is limited and therefore prevention is most
left on the teeth by inadequate oral hygiene. important!

Dental caries has been described as a “disease of civiliza-

tion,” especially in relation to the last hundred years, as
man has strayed from a diet rich in fruit and vegetables to
one with a high intake of refined sugars.

Gum Disease is an inflammation of the gums that can

progress to affect the bone that surrounds and supports the
teeth. It is caused by the bacteria in Plaque that constantly
forms on the teeth. If not removed through daily brushing
and flossing, plaque can build up and the bacteria may
infect not only the gums and teeth, but eventually the gum
tissue and bone that support the teeth. This can cause
teeth to become loose, fall out or have to be removed by a
dentist.

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Guidelines for Dental

Guidelines Care
for Dental CareOnboard Merchant
Onboard Merchant Ships Ships

3. Tooth Anatomy

Different Parts of a Tooth Different Types of Teeth

Crown: the top part of the tooth, and the only part which Every tooth has a specific job or function (the dental
can normally be seen. The shape of the crown determines diagram at the end of this section may help to locate and
the tooth’s function. For example, front teeth are sharp and identify each type of tooth)
chisel-shaped for cutting, while molars have flat surfaces
for grinding. Incisors: the sharp, chisel-shaped front teeth (four upper,
four lower) used for cutting food.
Gumline: where the tooth and the gums meet. Without
proper brushing and flossing, plaque and tartar can build Canines: sometimes called cuspids, these teeth are
up at the gumline, leading to gingivitis and gum disease. shaped like points (or cusps) and are used for tearing food.

Root: the part of the tooth that is embedded in the jaw- Premolars: these teeth have two pointed cusps on their
bone. The root makes up about two-thirds of the tooth and biting surface and are sometimes referred to as bicuspids.
holds it in place. The premolars are for crushing and tearing.

Enamel: the outermost layer of the tooth. Enamel is the Molars: used for grinding, these teeth have several cusps
hardest, most mineralized tissue in the body - yet it can be on the biting surface.
damaged by decay if teeth are not cared for properly.

Dentine: the layer of the tooth under the enamel. If decay

is able to make its way through the enamel, it next attacks
the dentine - where millions of tiny tubes lead directly to the
dental pulp. CROWN

Pulp: the soft tissue found in the centre of all teeth, where
the nerve tissue and blood vessels are. If tooth decay rea- ENAMEL
ches the pulp, it usually causes pain.
DENTINE
GUMLINE
PULP

ROOT
3

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TOOTH DEVELOPMENT : Permanent Teeth

ERUPT UPPER TEETH

Lateral Incisor
7 - 8 yrs.
8 - 9 yrs. Central Incisor

11 - 12 yrs. Canine (cuspid)

10 - 11 yrs. First Premolar

10 - 12 yrs. Second Premolar

6 - 7 yrs. First Molar

12 - 13 yrs. Second Molar

Third Molar
17 - 21 yrs.

LOWER TEETH
ERUPT

17 - 21 yrs. Third Molar

11 - 13 yrs. Second Molar

6 - 7 yrs. First Molar

11 - 12 yrs. Second Premolar

10 - 12 yrs. First Premolar

9 - 10 yrs. Canine (cuspid)

Lateral Incisor
7 - 8 yrs.

6 - 7 yrs. Central Incisor

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Guidelines for Dental

Guidelines Care
for Dental CareOnboard Merchant
Onboard Merchant Ships Ships

4. The Right Way to Brush

Proper brushing takes at least two minutes, but no more!

However, most seafarers (and other people) do not brush
for nearly that long. To get a feel for the time involved, a
stopwatch can be used. For the teeth to be brushed pro-
perly, short, gentle strokes should be used, paying extra at-
tention to the gumline, hard-to-reach back teeth, and areas
around fillings, crowns or other restoration work. Each
section should be thoroughly cleaned as follows:
• first the outer surfaces of the upper teeth,
then the lower teeth
• next the inner surfaces of the upper teeth,
then the lower teeth
• finally the chewing surfaces should be brushed
• for fresher breath, the tongue should be brushed too

Toothbrush The outside, inside and chewing surface of each

Most dental professionals agree that a soft-bristled brush tooth should be gently brushed using short back-and-
is best for removing plaque and debris from the teeth. forth strokes.
Small-headed brushes are also preferable, since they can
better reach all areas of the mouth, including hard-to-reach
back teeth. For many, a powered toothbrush is a good
alternative. It can do a better job of cleaning teeth, parti-
cularly for those who have difficulty brushing or who have
limited manual dexterity.

Toothpaste
It is important that an appropriate toothpaste is used. Today
there is a wide variety of toothpaste designed for many
conditions, including cavities, gingivitis, tartar, stained teeth
and sensitivity. The dentist or hygienist can advise on the
most suitable one.

Replace Toothbrush
A toothbrush should be replaced when it begins to show
5
wear, or every three months, whichever comes first. It is
also very important to change toothbrushes after having a
cold, since the bristles can collect germs that can lead to
reinfection. The tongue should be gently brushed to remove
bacteria and freshen breath.

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5. Fluorides 6. Emergency Toothache

Fluor is a so-called trace element, necessary for the growth If there is a lost filling or defect in the enamel (surface
and normal function of the body. Only small quantities are of the tooth), oil of cloves should be applied to the tooth
needed; larger doses may be harmful to health. surface.
Fluor does not exist as a free molecule in nature, it is linked
to other elements to form Fluorides. Fluorides are found in If there is a large defect in the tooth, a temporary dressing
fish, bones and tea, and sometimes also in drinking water. should be inserted into the cavity as follows:

The bacteria in tooth plaque metabolise the sugar we eat • the tooth should be isolated by putting a 5X5 cm piece
to form acids. These acids may demineralise the teeth and of gauze on each side of it
cause cavities if remineralisation is slow or insufficient. Flu- • the cavity should be dried with a cotton bud or pellet
orides slow down demineralisation and make remineralisa- • a drop of oil of cloves on cotton wool should be gently
tion faster. Tooth tissue that has incorporated Fluor is more pressed into the cavity and left in place
resistant to acidity. Fluor in the saliva makes teeth stronger • the isolating gauze should then be removed
to resist the negative effects of sugars.
This procedure may be repeated two to three times a day
Since the effect of Fluor is local, it is advisable to have a as necessary
small quantity of Fluoride in the saliva about three times
per day. This can be done by brushing the teeth three times To relieve the pain, 1000mg paracetamol may be taken
a day with a toothpaste containing Fluoride. orally to start with.
If a stronger analgesic is necessary, which is often the
Too much Fluor can cause white spots and stripes on the case, the paracetamol may be replaced with tramadol 50
teeth, so Fluoride drops or tablets should only be taken on mg orally, or an equivalent analgesic in the medical chest,
the recommendation of a dentist! twice a day.
The patients should rinse out their mouth with warm saline
solution for five minutes every waking hour, until they can
see a dentist.

If infection or abscess formation is suspected, amoxicillin/

clavulanate 875/125 mg orally, should be taken three times
a day for seven days, after the patient has been checked
for allergies.

Medical advice should be sought urgently if there is:

• difficulty opening the mouth
• difficulty swallowing
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• drooling
• difficulty breathing
• swelling in the neck
• pain much beyond the area of the infected tooth

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Guidelines for Dental

Guidelines Care
for Dental CareOnboard Merchant
Onboard Merchant Ships Ships

If a crew member loses a tooth after a blow to the face or

jaw, emergency dental care may not only relieve unneces-
sary suffering, but may actually save teeth, such as those
which are partially, or totally dislodged. Should a tooth
be knocked out, it should be handled only by the crown,
rinsed with tap water (not scrubbed) and an attempt made
to place it back in its socket; the patient should keep it in
place with a finger or by biting it. If this is unsuccessful, the
tooth should be placed in milk or water. Medical advice and
dental care should then be sought urgently!

7. Tooth Filling
A filling is a way to restore a tooth damaged by decay back If the dentist decides to fill a cavity, he or she will first remo-
to its normal function and shape. The dentist removes the ve the decay and clean the affected area. The cleaned-out
decayed tooth material, cleans the affected area, and then cavity will then be filled with any of the variety of materials
fills the cavity with a filling material. described above.

By closing off spaces where bacteria can enter, a filling Only the dentist can detect whether a cavity needs to be
helps prevent further decay. Materials used for fillings filled. During a checkup, the dentist will use a small mirror
include gold, porcelain, a composite resin (tooth-colored fil- to examine the surfaces of each tooth.
lings), and an amalgam (an alloy of mercury, silver, copper,
tin and sometimes zinc). Anything that looks abnormal will then be closely checked.
The dentist may also X-ray the entire mouth or a section of
The type of filling that is best is determined by the extent of it. The type of treatment the dentist chooses will depend on
the repair; potential allergies to certain materials; where in the extent of damage caused by decay.
the mouth the filling is needed; and the cost.

If decay or a fracture has damaged a large portion of the

tooth, a crown or cap may be recommended. Decay that
has reached the nerve may be treated in two ways: through
root canal therapy (in which damaged nerve is removed) or
through a procedure called pulp capping (which attempts to
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keep the nerve alive).

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8. Tooth Extraction
Teeth are extracted for a variety of reasons: A certain amount of pain and discomfort may be expected
following an extraction. In some cases, the dentist will
• decay has reached deep into the tooth recommend a pain killer. An ice pack to the face for 15
• infection has destroyed a large portion of the tooth minutes at a time, may help. Strenuous activity should be
or surrounding bone limited, and hot liquids avoided; use of a straw may help
• there is not enough room for all the teeth in the mouth with drinking. The day after the extraction, the dentist may
suggest that the mouth may be gently rinsed with warm
Many dentists recommend extracting impacted teeth salt water (which should not be swallowed). If there is pro-
that are only partially erupted. Impacted teeth continue longed or severe pain, swelling, bleeding or fever, medical
trying to break through the gum tissue even if there is not advice should be sought.
enough room to accommodate them. Removing a tooth
that is impacted can often prevent infection, damage to
adjacent teeth and bone, and save pain in the future.
9. Root Canal Treatment
Before a tooth is removed, the dentist will review the pa-
tient’s medical and dental history and take the appropriate Root canal treatment involves several procedures that
X-rays. may require a number of dental appointments, depending
on the situation. These procedures are as follows:
X-rays reveal the length, shape, and position of the tooth
and surrounding bone. • First an opening is made through the back of a front
tooth or the crown of a molar or pre-molar.
Before removal, the dentist uses a local anesthetic to • After the diseased pulp is removed (a pulpectomy), the
numb the area of the mouth where the extraction will take pulp chamber and root canals are cleaned, enlarged
place. and shaped in preparation for being filled.
• If more than one visit is needed, a temporary filling
For a simple extraction, once the area is anaesthetized, is placed in the crown opening to protect the tooth
the tooth is loosened with the help of a tool called an between dental visits.
elevator, then extracted with dental forceps. • The temporary filling is removed and the pulp chamber
and root canal permanently filled. A tapered, rubbery
It is critical to keep the area clean and prevent infection material called gutta-percha is inserted into each of
immediately following the removal of a tooth. The dentist the canals and is often sealed into place with cement.
will ask the patient to bite down on a piece of dry, sterile Sometimes a metal or plastic rod is placed in the canal
gauze to limit bleeding while clotting takes place. For the for structural support.
next 24 hours, smoking or vigorous rinsing of the mouth • In the final step, a crown is usually placed over the
should be avoided. tooth to restore its natural shape and appearance.
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If the tooth is very broken down, a post may be
required to build it up prior to fitting a crown.

A treated and restored tooth/teeth can last a lifetime with

proper care. However, as tooth decay can still occur in
treated teeth, good oral hygiene and regular dental exams
are still necessary to prevent further problems.

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Guidelines for Dental

Guidelines Care
for Dental CareOnboard Merchant
Onboard Merchant Ships Ships

10. Crowns and Bridges

Unlike removable devices such as dentures, which can Using this impression, the crown or bridge is then made
be taken out and cleaned daily, crowns and bridges are by a dental lab. A temporary crown or bridge will be put
cemented onto existing teeth or implants, and can only be in place to cover the prepared tooth while the permanent
removed by a dentist. one is being made. When it is ready, the new crown or
bridge is cemented over the prepared tooth or teeth.
A crown is used to entirely cover or “cap” a damaged
tooth. Besides strengthening a damaged tooth, a crown While crowns and bridges can last a lifetime, they do
can be used to improve its appearance, shape or align- sometimes become loose or fall out. The most important
ment. A crown can also be placed on top of an implant to step which can be taken to keep them as long as possible
provide a tooth-like shape and functional structure. is to practice good oral hygiene.

Porcelain or ceramic crowns can be matched to the colour A bridge can lose its support if the teeth or bone holding it
of the natural teeth. Other materials include gold and in place are damaged by dental disease. Gums and teeth
metal alloys, acrylic and ceramic. should therefore be kept healthy by brushing with Fluoride
toothpaste twice a day and flossing daily.
A crown is recommended to:
• replace a large filling when there isn’t enough tooth
remaining
• protect a weak tooth from fracturing
• restore a fractured tooth
• attach a bridge
• cover a dental implant
• cover a discoloured or poorly shaped tooth
• cover a tooth that has had root canal treatment

A bridge may be recommended if one or more teeth are

missing. Gaps left by missing teeth eventually cause the
remaining teeth to rotate or shift, resulting in a bad bite.

Bridges span the space where the teeth are missing and
are cemented to the natural teeth or implants.
As with crowns, there is a choice of materials for bridges.
The dentist can advise which to use, based on the loca-
tion of the missing tooth (or teeth), its function, aesthetic
considerations and cost.
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Before either a crown or a bridge can be made, the tooth
(or teeth) must be reduced in size so that the crown or
bridge will fit over it properly. After reducing the tooth/
teeth, the dentist will take an impression to provide an
exact mould for the crown or bridge.

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11. Bleaching, Whitening 12. Dry mouth

and Bonding Everyone has a dry mouth once in a while, especially
when they are nervous, upset or under stress. But a dry
Some people are born with teeth that are more yellow mouth all or most of the time, can be uncomfortable and
than others. Others have teeth that yellow with age. The can lead to further health problems or indicate that a more
natural tooth colour can also be affected by many factors serious medical condition may exist.
such as:
• tobacco (whether smoked or chewed) Symptoms of dry mouth include:
• coffee, tea, or red wine • a sticky, dry feeling in the mouth
• highly pigmented foods such as cherries and • trouble swallowing
• blueberries • a burning sensation on the tongue
• accumulation of tartar, resulting from plaque • a dry feeling in the throat
• cracked lips
But also: • reduced ability to taste things or a metallic taste
• treatment with the antibiotic tetracycline in childhood, in the mouth
when the teeth are forming • mouth sores
• yellowing or greying of the teeth as part of the aging • frequent bad breath
process • difficulty chewing/speaking
• trauma to the teeth resulting in the death of the tooth’s
nerve, giving the tooth a brown, grey or black colour There are several reasons why the glands that produce
saliva, called the salivary glands, might not function pro-
Thorough cleaning by a dental professional will remove perly, resulting in a dry mouth. These include:
most external staining caused by food and tobacco. • the side effects of over 400 medicines , including
Using a whitening toothpaste can also help remove these antihistamines, decongestants, pain killers, diuretics
surface stains between dental visits. If stains have been and medicines for high blood pressure and depression
present for years, teeth may need to be professionally • diseases such as diabetes, Hodgkin’s, Parkinson’s
whitened to remove these more stubborn external stains. disease, HIV / AIDS and Sjogren’s syndrome,
Internal stains can be bleached, bonded or capped • menopause- changing hormone levels affect the
(crowned). While each of these methods is safe and effec- salivary glands
tive, the dentist will recommend which treatment is appro- • smoking — many pipe, cigar and heavy cigarette
priate depending on the state of the teeth and the desired smokers experience dry mouth.
results. Bonding uses composite resins or porcelain/com-
posite veneers to cover the surface of stained teeth and The only permanent way to cure a dry mouth is to treat
give a good, even appearance to broken or misshapen its cause. If a dry mouth is the result of medication, the
teeth. To help prevent stains from coming back, smoking patient’s doctor might change their prescription or the
and consumption of coffee, tea, red wine and heavily dosage. If the salivary glands are not working properly but
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coloured foods should be avoided. Teeth should also be are still producing some saliva, the doctor might prescribe
brushed twice a day with a whitening toothpaste. a medicine that helps the glands work better.

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Guidelines for Dental

Guidelines Care
for Dental CareOnboard Merchant
Onboard Merchant Ships Ships

13. Bad Breath

If the cause of a dry mouth cannot be eliminated, or until Bad breath (Halitosis) may be caused by many factors,
it can be, moisture can be restored to the mouth in a num- including certain diets and inadequate oral hygiene. If die-
ber of different ways. The dentist may recommend mouth tary adjustments do not help, the dentist should be consul-
moisturizers, such as a saliva substitute and rinsing with ted! If improved oral hygiene does not help, stomach and
mouthwashes specially formulated to help dry mouth, may intestinal problems, or disorders such as diabetes may be
also bring relief. the cause.

In addition, the following may help: Poor oral hygiene, advanced tooth decay or periodontal
• water or sugarless cordials should be drunk frequently disease may result in bad breath that may range from of-
• drinks containing caffeine, such as coffee, tea and fensive to fetid. For many, bad breath is caused by the ac-
some sodas, should be avoided cumulation of bacteria lodging in the ridges of the tongue.
• sugarless gum may be chewed or sugarless hard The inclusion of a small plastic rake (tongue scraper) into
candy sucked to stimulate saliva flow (if some salivary a regular oral hygiene programme will prove effective for
gland function exists) those who experience this problem. A germicidal mouth
• tobacco or alcohol, which dry out the mouth, should be rinse, containing chlorine dioxide, may also be beneficial.
avoided
• spicy or salty foods which can cause pain in a dry Poor dental hygiene may result in acute necrotizing ulce-
mouth should be avoided rative gingivitis (ANUG). Once called trench mouth, this
• a humidifier should be used at night condition is fairly uncommon in advanced countries, but
may develop in teenagers and young adults. Though not
contagious, it can, and should, be treated.

14. Tips for the Successful

Implementation of
a Dental Care Campaign
The ship, where seafarers not only work but spend all
their time during a voyage, is the best place for health
intervention. The following measures may therefore be
considered to encourage a sensible approach to dental
care.
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Encourage and stimulate the crew members to prevent
dental problems. Draw attention to the prevention of den-
tal problems in meetings, at medical check-ups etc.

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