Using the Modified Dental Aid BagLTC Steven Eikenbergt

LTC Robert Meyertt

Purpose

To describe the need for and modifications to theDental Instrument Supply Set (DISS) EmergencyTreatment Field (ETF), LIN F95504, UA 7039. Dentalofficers of the 257th Medical Company (Med Co)(Dental Service (DS)) have used a Modified DentalAid Bag (MDAB) on multiple deployments. Mostrecently, the MDAB was utilized during relief effortsafter Hurricane Marilyn on St Thomas, U.S. VirginIslands.

Introduction

The 257th Med Co (DS) at Fort Bragg, NC, is anairborne-capable unit that provides area dental supportwithin the XVIII Airborne Corps area of operation. The25th Med Co (DS) provides the dental component ofthe 44th Medical Brigade (Airborne) MedicalReadiness Force I. The 25th can reinforce orreconstitute division level dental assets. The unitprovides additional combat care capabilities tomedical treatment facilities by utilizing the alternatewartime roles of the dental officer.

This article describes how the MDAB has beenutilized on multiple deployments and training missionsin which the 257th has participated. The MDABreplaces the present DISS UA 7039 (Dental EmergencyTreatment Bag). It also details the modifications of theDISS that increase the treatment capability of adeployed dental officer.

Deploying with a Dental Aid Bag

Dental officers from the 257th have accumulateda wide range of experience providing dental care duringvarious types of deployments, both real worldmissions, and to the Joint Readiness Training Center.In a rapid deployment scenario, dental equipment isusually not placed high on the time phased deploymentlist. Utilizing a dental aid bag, early dental casualtiesand emergencies can be treated without evacuation. Adental aid bag can be utilized:

* When a dental officer is a member of a rapidlydeployed force package and cargo space is not allocatedfor dental equipment.

* During initial deployment, convoy operations, andredeployments within theater, when a clinic cannot beestablished.

* On-site awaiting the establishment of a dentaltreatment facility or prior to redeployment after thedental treatment facility has been closed.

* As a back-up treatment capability whenequipment malfunctions or electrical power is notavailable.

* During operations when personnel are unable tojoin with equipment at a predetermined location.Without equipment, dental personnel are incapable ofperforming the mission. 1

* During civilian assistance missions or visits toremote troop locations.

Except for the Forward Surgical Teams (FST), mostmedical and dental personnel arrive in an area ofoperations before their equipment. After medical anddental personnel are reunited with their equipment, theymay have to ground convoy for days to the site wherethe medical facility is to be established. Although sometreatment facilities can be established almostimmediately, a Deployable Medical Systems(DEPMEDS) facility may require 3 or more days tobe established.

The Modified Aid Bag (MAB) will enable thedentist to render emergency care when a dentaltreatment facility has not or cannot be established. Ifrequired, a forward deployed medical facility canprovide an exam light and a portable suction unit. LocalCivilians, Allied Military Personnel, Volunteer ReliefWorkers, and Civilian Contract Workers may presentwith odontogenic infections and pain of a dental originas soon as the military dentist arrives in theater.2

Most recently, the Dental Aid Bag was utilized inthe Virgin Islands during the mission to provide reliefafter Hurricane Marilyn. Civilian dental offices weredestroyed, or were inoperable, due to the interruptionof electrical power. The St Thomas Hospital Dental

PB 8-96-9/10 September-October 21

tDental Corps. LTC Eikenberg is assigned to the U.S. Army Dental ResearchDetachment with duty at the U.S. Navy Institute of Dental Research, Great Lakes, IL.

ttDental Corps. LTC Meyer is the Commander, 257th Med Co (DS), Fort Bragg, NC.

Clinic was without full electric power until the 10thday after the hurricane. The 257th Dental Officerarrived in St Thomas with the advance party of the 28thCombat Support Hospital (CSH), 7 days after thehurricane. Thirty-five civilians, Federal EmergencyManagement Agency Employees, Red CrossVolunteers, and Military Personnel were treatedutilizing the instruments and materials in the aid bag,before the DEPMEDS dental clinic of the 28th CSHwas established. Because of the large number ofpatients treated with the aid bag, additional gloves,masks, sterilization bags, and local anesthetic wereobtained from the staff at St Thomas Hospital. Thehospital dental clinic sterilizer, utilizing emergencygenerator power, was employed to sterilize instruments.

The supplies in the aid bag, in addition to the 32pound Kevex Handheld X-ray, gave the dental officerthe capability to perform Forensic Dental Identificationexams. Dental officers deploying on future "disasterrelief missions" may need to modify the aid bag to meetthis mission requirement. In the Virgin Islands, the aidbag was also used to provide mobile dental care toelderly civilian personnel who were staying in atemporary shelter. The DEPMEDS Dental Clinic of the28th CSH was packed for redeployment 6 days beforethe main party of personnel redeployed to Fort Bragg.Utilizing the dental aid bag, the dentist treated anadditional 15 patients during that time.

The MDAB was utilized in Haiti during OperationUphold Democracy. When the 82d Airborne Divisionprepared for a forced entry into Haiti, in September1994, the division dental officers were to "jump in"with a dental aid bag. If dental equipment and treatmentsets were needed, they were to follow at a later date.

Before an Army Dental Clinic was established onHaiti, dental emergencies were medically evacuatedto the Navy Hospital ship positioned offshore. Thesepersonnel were lost to their unit for up to 12 hours. The257th personnel, attached to the 28th CSH, arrived onthe island on D+6. The 28th CSH personnel waited 2days for the DEPMEDS hospital to arrive in country.The dental clinic was not established until D+1 1. FromD+6 until D+ 11, five soldiers and three United Statescivilians were treated, utilizing the MDAB. Without thecapability provided by the MDAB, these patients wouldnot have received dental treatment unless they were alsomedically evacuated. The MDAB was also used duringvisits to civilian hospitals and orphanages.

During Operation Desert Storm, several dentalofficers improvised "dental aid bags" for use duringthe ground offensive into Iraq. Dental officers with the

87th Medical Detachment (Med Det) utilized an aidbag and provided dental care from the tailgate of aM1008 pickup truck. A dental officer attached to the3d Armor Division provided dental care on convoyoperations utilizing a modified equipment chest.3

On Joint U.S. Honduran Medical Assistancevisits to villages on the isolated northeast coast ofHonduras, the aid bag, augmented by a duffle bag ofdisposable supplies, was employed for 7-day missions.An average of 20 patients a day were treated. The 257thperformed similar missions in Columbia, Costa Rica,and Guyana.

The 257th Med Co Dental Officers have "jumped"with the MAB on Airborne Emergency ReadinessDeployment Exercises. The contents of the aid bag haveremained intact. Utilizing a patient examination lightand a portable suction machine from a FST, the dentalofficer can provide a wide range of treatment optionsto the emergency dental patient.

Justification for Aid Bag Modifications

The present DISS, ETF, gives the dental officerlimited treatment capability. One of the antibioticslisted in the packing list, erythromycin, is no longera drug of choice for odontogenic infections. Filesfor endodontic debridement are not included.4Recognizing the limitations of the present dentalemergency treatment bag, the officers of the 257th havecreated a MDAB. A proposed packing list for MDABis shown below.

Case Medical Instrumentand Supply Set No. 17 6545-01-161-7145

Compartment 1Atropine, anaphylaxis kitIbuprofen tabs, 800 mg, bottle of 100Penicillin, 500 mg tabs, bottle of 100Clindamycin, 250 mg tabs, bottle of 100Lidex gel 15 gr tubeAirway, pharyngeal lg adultMarcaine 1:200,000 can of 50Xylocaine 2% 1:100,000 pack of 10Envelope, self-seal, polyethyleneFloss, waxed, individual sizeStethoscopeSphygmomanometerToothbrush, individual

21112113

15111

10

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Compartment 2Gloves, sterile, pair, size (Dr choice) 10Gloves, exam, vinyl, pair, size (Dr choice) 30Mask, surgical 30Protective eyewear 1Autoclave tape, 1 in diameter roll 1Cut segments of 2 in sterilization roll 20

Compartment 3Tray instrument with lid 8x8x2 1Monojet syringe irrigating 10 cc 2Handpiece, battery operated with straight

nose and contra angle attachments(Bell Model RX100) 1

Compartment 45% iodoform sterile packing strip 1Sterile alcohol pads, individual 50Surgical scalpel blade No. 15 4Individually bagged and sterilized;

syringe, aspirating, anesthetic 2Forcep, tooth No. 23 1Forcep, tooth No. 150s 1Forcep, tooth No. 151s 1Elevator, 34s 1Elevator, 301 1Curette, miller No. 10 2Elevator, periosteal molt No. 9 2Handle, surgical scalpel blade 2Surgical suction tip 1Forceps, dressing 6 in 2Holder, suture needle collier 1Scissors, iris, curved 1Tissue forceps, addison 4.5 in 1Scissors, Dean angular 6 3/4 in 1 in cut 1Mouth mirror with handle 6Explorer-probe dental No. 23 explor

No. 4 probe 6Bagged and sterilized perio pack consisting

of Curette perio gracey 11-12 1Curette perio gracey 5-6 1Scaler dental No. U15 and 30 dbl end 1

Compartment 5Wire 25 gauge wire 1 oz, for oral sxSplint set, arch wire dentalPliers, diag cutting surgical wireBacitracin ointment

1213

Suture sz 4-0, absorb, polyglycolicSuture sz 4-0, nonabsorb, ethiconBandaids pk of 10Adhesive tape lin x 10 yds, porous4x4 sterile gauze, packs

Compartment 6Cement, ZOE, IRM ivory, kit powder & lqGlass ionomer cement, kit powder & lqMatrix band, dental No. 1 pk of 10Matrix band, dental No. 2 pk of 10Fuji IX, glass ionomer restorative materialSpatula dental flat, mixingArticulating paper, bookBur, surgical No. 702 pk of 10Bur, latch type No. 4 pk of 10Bur, latch No. 8 pk of 10Bur, latch No. 557 pk of 10Endo files, 25 mm set 1-35Endo files, 25 mm set 40-70Gates glidden burs size 4-6, eachBagged and sterilized operative pack

consisting of excavator dental black'sNos. 38 & 40

Forceps, dressing tweezer type 6 in 1 gPlugger plastic fillin Ladmore No. 3 dbl endCarver dental hollenback No. 12Carver dental tanner No. 5Tofflemire, retainer, matrix, bandOrtho pack consisting of elastic ligaturesWire ligatures

10532

10

11111111111222

111112

1010

Compartment 7 - side pocketPen, black ink 2SF Form 603 20Small memo pad 1

The MDAB weighs just 23 pounds and can beplaced in a large All-Purpose, Lightweight IndividualCarrying Equipment (ALICE) Pack, or attached to theframe below the ALICE Pack. The MDEAB utilizesa different bag or case. The M5 bag (6545-00-912-9890), on the present equipment listing, has severaldeficiencies. The bag has one large compartment andinstruments cannot be packed so that they may be easilylocated. The case for the MDAB (6545-01-161-7145),surgical case instrument No. 17, enables dentalinstruments and supplies to be placed in smaller

PB 8-96-9/10 September-October 23

compartments. These compartments are used tosegregate the instruments based on the procedure beingperformed (Figures 1 thru 4).

The MDAB gives the dentist expanded capabilities.Trained dental officers have the capability to place archbars on fractured jaws or dental alveolar fractures,suture oral facial trauma, extract teeth (includingimpactions), debride sites of periodontal infections,place temporary fillings, and start endodontictreatment. The ability to treat oral facial trauma isimportant. Ten percent of hospital admissions inVietnam involved facial injuries. 5 According to theNorth Atlantic Treaty Organization Emergency WarSurgery Handbook, the initial management of

maxillofacial injuries include hemorrhage control,airway maintenance, fracture reduction, and infectionprevention.

The MDAB contains a Bell Electric DentalHandpiece, Model XR100, that can operate on arechargeable battery. The handpiece provides thedentist with the capability to remove the bone aroundteeth and to section teeth for extraction. The latchtype contra angle enables the dentist to remove caries

Fig. 3. M17 bag open to show its 6 equalsize compartments(l x 5 x 8 inch side

pocket not visible).

Fig. 1. Modified Dental Aid Bag (M17)on left, DISS (M5) on right.

Fig. 2. Open M5 bag demonstrating its onelarge open area and four small pockets.

Fig. 4. Modified Dental Aid Bag placedunderneath large rucksack.

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from teeth, or provide access for endodonticprocedures.

Presterilized instruments are packed in the aid bag.The bag receives quarterly preventive maintenancechecks and services to insure that the expiration datefor instrument sterility and medications are at least 4months in the future.

The principle limitation of the bag is theincapability to sterilize instruments. A total ofapproximately 10 patients can receive invasivetreatment before the presterilized instruments must beutilized. This limitation can be overcome by the useof a sterilizer belonging to a medical treatment teamthat may be in the area. At other times, dirtyinstruments were separated from the aid bag andsterilized after the dental clinic was established.Although not ideal, in isolated situations, instrumentshave been sterilized by boiling. The present DISScontains a liquid sterilization solution (2%glutaraldehyde); this has not proven to be practical.Plastic bottles containing any solution will often leakduring deployment due to the rough handling the bagwill encounter.

A future development that may overcome thesterilization limitation is a sterilization powderpresently under development. When this powderedmaterial is mixed with water at a minimum temperatureof 68F, the solution can sterilize instruments within20 minutes.6

There are a limited amount of disposable suppliesin the MAB. There are enough nondental specificsupplies such as gloves, masks, and cotton gauzeto treat approximately 20 patients. There are enoughlocal anesthetic capules and needles to treatapproximately 50 patients. Historically, it has beenmore difficult to be resupplied with these dentalspecific items.7

Paper sterilization bags are not adequate for theMDAB. The paper tends to seat or accumulate moistureduring a deployment. The contents in the MDAB aresubjected to rough handling in a field environment. Theinstruments easily tear through the paper side of thesterilization bag. A two-inch wide plastic sterilizationroll is superior for this purpose. Cotton rolls are placedover the points of sharp instruments. During fieldtesting, sterile instruments have not punctured throughthe all-plastic bag.

Bottles containing liquid or powder should besealed with tape if the factory seal has been broken.This will help to prevent materials from spilling or

leaking in the bag. Measuring scoops for materialsshould be taped to the material container.

A series of endodontic files should be placed in a2-by 2-inch gauze and sterilized in a section of 2-inchplastic sterilization roll. All burs should be groupedand placed in one sealable baggie (envelope, self-seal,polyethylene (8105-01-099-0355)). Matrix bands andendodontic burs are grouped into separate baggies.Medication can also be dispensed to a patient usingthese baggies.

A field expedient exam light is the flashlightthat each soldier takes on a deployment. Dentaltreatment can also be performed using sunlight. Ifa medical treatment facility is already established,an exam or treatment lamp is usually available.Treatment can be accomplished with the patients in aconventional chair or on a stretcher with the patient'shead raised.

The 257th has included Fuji IX glass ionomer fora traumatic restorative treatment as part of the aidbag.This material provides a semipermanent way to fixcarious teeth. 8

There is space in the MAB for a dental officerto pack extra supplies or instruments specific tothe mission. Additional disposable supplies maybe required for civilian assistance missions.Additional restorative supplies may be required forvisits to remote areas where U.S. soldiers arestationed.

Discussion

The present DISS, ETF, LIN F95504, UA 7039should be improved to provide better dental care tosoldiers in the field. The Defense MedicalStandardization Board is slow to produce changes tothe packing list of any sets, kits, and outfits. Field dentalunits and officers should not hesitate to upgrade theDISS ETF

Army dentists have the responsibility to providethe soldiers the best dental care possible under avariety of circumstances. Dentists are deployed tosupport the soldier. The well-being of a soldier is notenhanced when he is told "your discomfort is not a trueemergency and can wait, we'll evacuate you later toa facility in the rear." The delivery of modem dentalcare affects not only unit readiness, but individualsoldier morale. 9Even if every soldier deploys in perfectdental health, emergencies can and do occur. The

PB 8-96-9/10 September-October 25

expanded dental mission has increased our potentialpatient population. Recently in Somalia, Haiti,Guantanamo, and the Virgin Islands, U.S. MedicalPersonnel have been responsible for providing care topersonnel who are not in the U.S. military. Theseforeign military, civilian contract workers, and localcivilian patients often have a greater need foremergency dental treatment.

Some healthcare professionals state that adequateemergency care consists of relieving pain with long-acting local anesthetic and codeine. Simply relievingpain with a long-acting anesthetic, such as Marcaine,is not in the soldier's best interests. The lack ofproprioception, resulting from local anesthetic, caninterfere with the soldiers ability to eat, communicate,wear the Kevlar, or wear the M40 protective mask.Eventually, the soldier must be evacuated from his unitarea. The soldier's unit must often provide the vehicleand driver used in the evacuation. The patient, the driveror escort, and the vehicle, may be lost to the unit foran extended period of time.

The MDAB can replace the DISS, ETF, LINF95504, UA 7039. The MDAB should be distributedon a basis of one bag to each Division Dentist, SpecialForces Dentist, and Dentist in a separate medicalcompany. One aid bag should be carried by the generaldentist in a table of organization and equipmenthospital. Since a Med Co (DS) may deploy up to 10separate clinics, 10 bags should be distributed to each.Four bags should be distributed to each Med Det (DS).

Summary

This article is intended to express the need to placea MDAB in the hands of the Army's Field Dentists.On deployment, the dental officer will discover thatdental emergencies will arise when a dental treatmentfacility is not established. Soldiers, who mightotherwise be evacuated far from their unit, can beproperly treated by dental officers utilizing a modified,self-contained, lightweight dental aid bag.

References1. Mitchell WL, Knowles MJ. Emergency Dental Deployment Bag and Supportof Air Land Battle. JMil Med. March-April 1991;25-26.

2. Eikenberg S, White K. Report of Dental Emergencies Treated by the 257thMed Co in Haiti. Med Dept J. September-October 1995;17-21.

3. Baker WP, Pietz D. The Experience of a Unit Dental Officer During the GulfWar. Med Dept J May-June 1995;20-24.

4. GR 27. Dental Officers Field Guide. U.S. Army Medical Department Centerand School, Fort Sam Houston, TX, August 1993;p F-24.

5. King JE, Brunner DG. Theater of Operations, Dental Workload Estimates.U.S. Army Health Services Command, May 1984.

6. Conversation with COL Robert Vandre. U.S. Army Dental Research Institute.Fort Meade, MD, November 6, 1995.

7. Baker WP, Pietz D. The Experience of a Unit Dental Officer During theGulf War. Med Dept J May-June 1995;20-24.

8. Frencken JE, et al. A traumatic Restorative Technique. Int Den J.November-December 1994;19-22.

9. Conversation with MAJ Keith Cipriano. 528th Combat Stress Detachment,Fort Bragg, NC, November 20,1995.

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