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Dental Problems in the Field Setting Roy L. Alson, PhD, MD, FACEP CO DMAT NC-1.

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Presentation on theme: "Dental Problems in the Field Setting Roy L. Alson, PhD, MD, FACEP CO DMAT NC-1."— Presentation transcript:

1 Dental Problems in the Field Setting Roy L. Alson, PhD, MD, FACEP CO DMAT NC-1

2 Thanks Herb Johnson, DDS Numerous Authors, etc whose photos on the web I borrowed NC-1 for putting up with me

3 Objectives Identify and Discuss Common Dental Problems seen in Primary Care Setting Describe management of Common Infections of the Mouth and Face Describe Management of Dental Trauma Assemble a Basic Kit for DMAT to Care for Dental Issues in the Field Setting.

4 Incidence Common ED Complaint 1% of visits to DMAT NC-1 on deployments post hurricane, have been dental related Common complaint for pain medication seekers Physicians have little training in management of dental problems

5 Epidemiology of Mouth Pain Infectious Trauma Post Procedure Dental Blocks Non Oral Causes Many Americans have poor dental hygiene

6

7 Assessment History –MOI –Other significant trauma –Airway Status –C-spine Onset of Pain Location of Pain

8 Assessment Radiation of Pain Fever, other Systemic Signs Malocclusion Temperature Sensitivity? Recent Surgery Loss of appliance? History of Rheumatic Fever, etc?

9 Exam

10 Radiographs

11 Waters View From:

12

13 Anatomy of The Mouth 32 Adult Teeth

14 Terminology Buccal (labial): Lingual (palatal) Occlusal

15 Anatomy of aTooth Root –Gingiva: Gum –Periodontal Ligament Anchors tooth Crown –3 layers –Enamel –Dentin –Pulp

16 Development Primary or Baby Teeth –Erupt from 6 months to 3 years –Teething pain –Treat symptomatically Secondary or Permanent Teeth –Begin Erupting at 6 years –Complete in Teens: Wisdom Teeth

17

18 Analgesia Dental Problems Hurt People seek care because of the pain Blocks improve patient care May need conscious sedation Will need analgesics after visit Common complaint for seekers

19 Analgesia Relief of the perception of pain –sedation not intentional –sedation may be a secondary effect of medications administered for analgesia –Opioids –Nonopioids Local Anesthetics block pain and temperature –The Patient will Feel PRESSURE!!

20 Conscious/Light Sedation Controlled lessening of a patients awareness of the environment and/or pain perception. Able to maintain stable vital signs, independent airway, and adequate spontaneous respirations.

21 Conscious Sedation Who is at high risk for poor procedural analgesia and sedation? –Patients at extremes of age Its only an LP, she wont remember Hes a gome, he wont even know he hurts –Patients with cognitive limits –Ethnicity! Communication and cultural biases

22 Sedation Have a protocol in place Monitor the patient Recover the patient Benzodiazepine and Opioids Ketamine for Pediatrics Etomidate?? Nitrous oxide!! –Lack scavenger, little familiarity

23 Dental Blocks Apply topical to mucosa –Benzocaine –Lidocaine Introduce needle ASPIRATE SYRINGE Inject slowly and use smallest effective volume –Usually need only 1 to 2 cc +/- Bicarbonate

24 Anesthetic Agents Addition of Epinephrine prolongs anesthetic effects by decreasing absorption Rarely causes palpitations and hypertension DMAT has –Marcaine (bupivicaine) 0.5% w/o –Lidocaine 1% w and w/o

25 Duration of Analgesia Anesthetic Duration without Epinephrine (min) Duration with Epinephrine (min) Maximum Dose without Epinephrine (mg/kg) Maximum Dose with Epinephrine (mg/kg) Esters Cocaine Procaine Chloroprocaine Tetracaine Amides Lidocaine Mepivacaine Bupivacaine Etidocaine Prilocaine

26 Dental Blocks Multiple Sites Useful for many facial injuries Risk of Hitting Nerve or Vascular Injection Hematoma at Site Do Not Inject into Infected Tissue

27 Local Infiltration Works better for maxillary teeth than mandibular teeth –Thickness of bone

28 Trigeminal Nerve Branches

29 Maxillary Block: Mandibular Branch

30 Inferior Alveolar Block Palpate the retromolar fossa with the index finger and identify the convexity of the mandibular ramus. Hold the syringe parallel to the occlusal surfaces of the teeth so that its barrel is in line between the first and second premolars on the opposite side of the mandible. Retract the soft tissue towards the cheek and find the pterygomandibular triangle. Puncture the triangle, making sure the needle passes through the ligaments and muscles of the medial mandibular surface. Stop advancing the needle when it reaches the bone, withdraw it a few millimeters, aspirate to be sure the tip is not in a vein, and deposit 1-2ml of local anesthetic

31 Inferior Alveolar Block

32 Dental Caries Break down of Enamel by acids Poor Dental Hygiene contributes Occlusal and between teeth Dark spot or hole Pain, tender to tooth percussion Remove Food particles Temporary Filling?

33

34 Lost Filling Clean area out Apply ZOE or IRM Scrape excess Dental Referral

35 Lost Crown Clean restoration and tooth surface Dry with cotton Apply small amount ZOE or IRM Place on tooth Bite on gauze

36 Post Extraction Hemorrhage Prior Aspirin or Anticoagulants –Coagulopathy? Sucking on Straw, etc. Clot partially retracted Have pt. apply pressure for 30 min Suction out and clean socket –? Retained fragments Gelfoam +/- Thrombin –Expensive Tea bag?

37 Dry Socket Alveolar Osteitis –Loss of clot post extraction exposes alveolar bone Local Infection –Days 2-4 –Painful –Smoking, Use of Straws, Molars

38 Dry Socket Management Pain Relief: Local Block Irrigate Socket and Remove Debris Fill Open Socket –Commercial Products: Alvogyl, Dry Socket Paste –Iodoform gauze or gauze with Eugenol may need replacement at 48 hours –Eugenol on Gel foam Antibiotics may be needed: OMFS preference

39 Odontogenic Infections Mucosal Apical Deep Space

40 Pericoronitis Operculum of erupting wisdom teeth becomes filled with impacted food, debris –Cellulitis follows Irrigate area out Oral Hygiene +/- Antibiotics Analgesics

41 Dentoalveolar Infection Usually arises in Dental Pulp Periapical Abscess forms –Pain and possibly swelling –+ / - Fever Follows path of least resistance –Abscess tracks through alveolar bone into oral mucosa or skin –Superficial abscess –Dissects into deep spaces

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43 Diagnosis Swelling of face or jaw Swelling or fluctuance in gingiva Panorex if available, may show apical origin Consider CT for Deep Space infections

44

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46 Treatment Antibiotics –PCN or Clindamycin for the infection –May require multiple agents if deep spaces involved –Surgical Drainage Dependent drainage of gingival lesions Deep space lesions should be managed by experienced surgeon. Extraction or root canal for periapical abscess

47

48 Mucosal Infections Ginigivitis –Inflamation –Clean Debris out of sulci –Mouth rinses Thrush Ginigivostomatitis –Children most common –Wont eat or drink due to pain –Nystatin for thrush –Magic Mouthwash

49 Gingivitis

50 ANUG Acute Necrotizing Ulcerative Gingivostomatitis –Trench Mouth or Vincents Angina –Fusospirochettal infection Antibiotics Will need debridement

51 Herpangina

52 Thrush

53 OMF Trauma Common –Assaults, MVC, Falls Significant Morbidity Potential for airway compromise Blunt versus penetrating Other associated Trauma –Chest, Head, Neck

54 Oral Soft Tissue Injuries Lacerations –Cheek –Tongue –Gums Vascular Structures Bleed Profusely Airway at Risk –Manage Airway

55 Lacerations Airway and Life Threats First Repair of Teeth before Soft Tissue Repair Classically: Given Prophylactic Antibiotics –Newer Literature suggest not necessary –With large amounts of devitalized tissue, give antibiotic coverage –PCN or Clindamycin

56 Buccal Lacerations Less than 2 cm: will heal on own Close larger lacerations with absorbable sutures Through and Through Lac –Check for injury to salivary ducts Stensons exits by upper second molar –Check for Nerve Injury Close mucosa first then skin –If tooth puncture, close only skin

57

58 Frenulum Laceration Face Plant No need to repair Anxious Parents

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60 Tongue Laceration Most small Lac heal on own Challenge to repair, especially in child Edge Lac or gaping Lac should be repaired –Prevent Bifid Tongue

61 Gingival Lacerations Skin is thin Hard to close Usually heal without repair Often associated with Fractures Flaps will require closure

62

63 Cheek Lacerations Look for Facial Nerve Injury Look for Parotid Duct Injury

64 Lip Lacerations Close Through and Through lacerations –Mucosa First, then skin If small, leave mucosa open Align Vermillion Border!!!

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66 Dentoalveolar Trauma Blunt trauma Disrupts Dentoalveolar complex Common Pediatric Problem –Toddlers falling –Sports Injuries –Prevent with Mouth Guards

67 Luxation of Teeth Avulsion Intrusion Extrusion Luxation Alveolar Ridge Fractue

68 Mandibular Anatomy

69 Assessment ABCs Clear Airway Look for Extruded Teeth –If not Found: Get Chest Xray Palpate TMJ –Assess ROM Palpate Mandible –Malocclusion sensitive for Fracture

70 Assessment Tongue Blade Test Palpate oral lacerations –Step off Check for loose teeth Tooth tap for pain

71 Radiographs Panorex and CT are best Not available in Field Plan films of mandible –Should not change Field management

72 LaForte fractures Higher Force Blunt Face Injury

73 Alveolar Ridge Fracture

74 Tooth Fractures Ellis Classification –1-Enamel Only White –2- Enamel and Dentin Yellow tint –3- Enamel, Dentin and Pulp May see blood

75

76 Treatment of Tooth Fracture Pain Relief Prevent Infection of Dentin Dental Block for Analgesia Cover Exposed tooth –CaOH Paste –Zinc Oxide Coe-Pak Dry Area off Place Agent on Area and allow to set Patient should eat soft food till seen by dentist – 48 hr

77 Coe-Pak Tooth and surrounding gum must be dry Moisten your glove Silly putty feel Make sure material gets into sulci between teeth Soft Diet

78 Luxation Extrusive – Partially out of socket Lateral – displaced laterally, mesially, facially or lingually –Often with associated Alveolar FX Intrusive: tooth pushed in Complete or avulsed tooth

79 Luxation with Alveolar FX Reposition tooth Then repair Gingiva Splint

80 Intrusion Usually stable > 6mm will require surgical repair Primary teeth –Allow to grow out –Permanent tooth may be damaged

81

82 Laterally Luxated Tooth

83 Treating Avulsed Tooth Tooth transport and storage: Socket is the best place. Save-A-Tooth: < 24 hours. –Hanks Balanced buffer solution. Cold milk: < 6 hours. Saliva, saline or water: < ½ hour.

84 Tooth Replantation Time is tooth Analgesia Clean out clot Gently but firmly insert tooth Splint tooth

85 Tooth Replantation

86

87 TMJ Syndrome Pain at TMJ Click or Pop with Chewing May have crepitus Soft Diet Analgesics Consider occlusal problem –New Filling?

88

89 Dental Kit Home made –Cheaper –Choose what you want Commercial –More expensive –Easier to obtain and maintain

90 NC-1s Ultimate Dental Kit for DMATs

91 Dental Kit Goals –Control Pain –Stabilize Loose Teeth –Cover exposed Pulp –Secure Lost Restorations

92 Dental Kit Table 5. Dental equipment needed in the ED. Packing gauze Dental roll gauze Calcium hydroxide paste or glass ionomer cement or zinc oxide cement Dry Socket Paste or eugenol Topical anesthetic gel (20% benzocaine or 5% lidocaine) Topical bactericidal intraoral solution (Ora-5) Periodontal paste (Coe-Pak) or self-cure composite Bupivacaine cartridges with epinephrine EMT ToothsaverTM Preservation System or fresh milk Zinc oxide/eugenol temporary cement (Temrex) Ringed injection syringe Stainless steel spatula and mixing pads Oral surgery tray with arch bars and ligature wires Tongue blades and cotton-tipped applicators Disposable electrocautery (optional) Acute Dental Emergencies In Emergency Medicine (May 2003) Emergency Medicine Practice

93 Dental Kit tray Cantilever Style Heavy Duty Plastic Utility Box (1) 2. TOPICAL ANESTHETIC 20% BENZOCAINE GEL 30GM BOTTLES (2)used For Topical Mucosal Anesthetic 3. CALCIUM HYDROXIDE PASTE (CATALYST AND BASE) STANDARD PACKAGE (1)used For Covering Fractured Teeth. 4. Zinc Oxide/Eugenol Temporary Cement Powder 25 Gms (1) 5. Zinc Oxide/Eugenol Temporary Cement Liquid 1 Oz. (1)--#4 & #5 Are Used In Combination To Fill Deep, Painful Caries Or To Cement Loose Fillings, Caps, Or Bridges. 6. Periodontal Dressing Standard Pkg. 90 GM BASE AND 90 GM CATALYST (1)used For Stabilizing Loose Or Subluxed Teeth 7. Bupivocaine/Epinephrine Cartridgescanister Of 50. (1)used As A Local Anesthetic For Odontalgia (Tooth Pain). For Use By Injection. 8. REUSABLE RINGED ASPIRATORS FOR USE WITH DISPOSABLE ANESHETIC SYRINGES (2) for Use With #9 9. Dental Injector Disposable Syringes With 27 Gauge 1.5 NEEDLES FOR USE WITH CARTRIDGE ANESTHETIC AND RINGED ASPIRATORS (100) used To Inject Local Anesthetic. For Use With # Topical Oral Bactericidal Solution 1oz. MULTI- DOSE BOTTLE (1)for Use As A Topical Antibacterial Agent In The Mouth Or Buccal Mucosa. 11. Cotton Gauze Rolls 50 Per Pkg (4) 12. Dry Socket Medicament 1 Oz Size. (1)for Use In Sealing Dry Sockets (Alveolar Osteitis) 13. 3x 3 Mixing Pads 100 Sheets/Pkg (2) 14. Stainless Steel Cement Spatula For Mixing Medicaments, Glues, Dressings, Etc. (1) 15. Stainless Steel Plastic Filling Instrument For Application Of Cements, Dressings, Etc. (1) 16. Laminated Quick-reference Cards With Instructional Text&photographs Depicting Use Of Each Medication And Of Each Tooth Block Type. ( The Instruction Cards Are To Be Used As A Clinical Reference Only And Are Not Designed To Replace The Individual Items Manufacturers Instructions. The Procedural Descriptions/Depictions Are Not Substitutes For Adequate Training Under A Professional Who Is Proficient In Said Procedure. ) 17. Cotton Tipped Applicators For Application Of Topical Anesthetic (50) 18. Wooden Tongue Depressors For Mixing Of Periodontal Dressing(50) 19. EMT Toothsaver, Tooth Preservation Kit (1) 20. Fax/Phone Reorder Forms (2)

94 Dental Kit tray Cantilever Style Heavy Duty Plastic Utility Box (1) 2. TOPICAL ANESTHETIC 20% BENZOCAINE GEL 30GM BOTTLES (2)used For Topical Mucosal Anesthetic 3. CALCIUM HYDROXIDE PASTE (CATALYST AND BASE) STANDARD PACKAGE (1)used For Covering Fractured Teeth. 4. Zinc Oxide/Eugenol Temporary Cement Powder 25 Gms (1) 5. Zinc Oxide/Eugenol Temporary Cement Liquid 1 Oz. (1)--#4 & #5 Are Used In Combination To Fill Deep, Painful Caries Or To Cement Loose Fillings, Caps, Or Bridges. 6. Periodontal Dressing Standard Pkg. 90 GM BASE AND 90 GM CATALYST (1)used For Stabilizing Loose Or Subluxed Teeth 7. Bupivocaine/Epinephrine Cartridgescanister Of 50. (1)used As A Local Anesthetic For Odontalgia (Tooth Pain). For Use By Injection. 8. REUSABLE RINGED ASPIRATORS FOR USE WITH DISPOSABLE ANESHETIC SYRINGES (2) for Use With #9 9. Dental Injector Disposable Syringes With 27 Gauge 1.5 NEEDLES FOR USE WITH CARTRIDGE ANESTHETIC AND RINGED ASPIRATORS (100) used To Inject Local Anesthetic. For Use With # Topical Oral Bactericidal Solution 1oz. MULTI- DOSE BOTTLE (1)for Use As A Topical Antibacterial Agent In The Mouth Or Buccal Mucosa. 11. Cotton Gauze Rolls 50 Per Pkg (4) 12. Dry Socket Medicament 1 Oz Size. (1)for Use In Sealing Dry Sockets (Alveolar Osteitis) 13. 3x 3 Mixing Pads 100 Sheets/Pkg (2) 14. Stainless Steel Cement Spatula For Mixing Medicaments, Glues, Dressings, Etc. (1) 15. Stainless Steel Plastic Filling Instrument For Application Of Cements, Dressings, Etc. (1) 16. Laminated Quick-reference Cards With Instructional Text&photographs Depicting Use Of Each Medication And Of Each Tooth Block Type. ( The Instruction Cards Are To Be Used As A Clinical Reference Only And Are Not Designed To Replace The Individual Items Manufacturers Instructions. The Procedural Descriptions/Depictions Are Not Substitutes For Adequate Training Under A Professional Who Is Proficient In Said Procedure. ) 17. Cotton Tipped Applicators For Application Of Topical Anesthetic (50) 18. Wooden Tongue Depressors For Mixing Of Periodontal Dressing(50) 19. EMT Toothsaver, Tooth Preservation Kit (1) 20. Fax/Phone Reorder Forms (2)

95 Resources International association for Dental Traumatology dentaltrauma.org/site_2005/guidelines/index_guidelines.htm dentaltrauma.org/site_2005/guidelines/index_guidelines.htm Academy for Sports Dentistry iasd.org/trauma.htmhttp://www.sportsdentistry- iasd.org/trauma.htm tmlhttp://www.septodont.ca/Septodont/english/other/cea_di01.h tml : Local anesthesia in Dermatology tml dental anesthesiahttp://www.septodont.ca/Septodont/english/other/cea_di01.h tml


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