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Dental Problems in the Field Setting
Roy L. Alson, PhD, MD, FACEP
CO DMAT NC-1
Thanks
• Herb Johnson, DDS
• Numerous Authors, etc whose photos on the web I “borrowed”
• NC-1 for putting up with me
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.
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
Epidemiology of Mouth Pain
• Infectious
• Trauma
• Post Procedure
• Dental Blocks
• Non Oral Causes
• Many Americans have poor dental hygiene
Assessment
• History– MOI– Other significant trauma– Airway Status– C-spine
• Onset of Pain
• Location of Pain
Assessment
• Radiation of Pain
• Fever, other Systemic Signs
• Malocclusion
• Temperature Sensitivity?
• Recent Surgery
• Loss of appliance?
• History of Rheumatic Fever, etc?
Exam
Radiographs
Water’s View
From: http://www.ghorayeb.com/ImagingMaxillarySinusitis.html
Anatomy of The Mouth
• 32 Adult Teeth
Terminology
• Buccal (labial):
• Lingual (palatal)
• Occlusal
Anatomy of aTooth
• Root– Gingiva: Gum– Periodontal Ligament
• Anchors tooth
• Crown– 3 layers– Enamel– Dentin– Pulp
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”
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”
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!!
Conscious/Light Sedation
• Controlled lessening of a patient’s awareness of the environment and/or pain perception.
• Able to maintain stable vital signs, independent airway, and adequate spontaneous respirations.
Conscious Sedation
• Who is at high risk for poor procedural analgesia and sedation?– Patients at extremes of age
• “It’s only an LP, she won’t remember” • “He’s a gome, he won’t even know he hurts”
– Patients with cognitive limits– Ethnicity!
• Communication and cultural biases
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
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
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
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 45 - 2.8 -
Procaine 15-30 30-90 7.1 8.5
Chloroprocaine 30-60 - 11.4 14.2
Tetracaine 120-240 240-480 1.4 -
Amides
Lidocaine 30-120 60-400 4.5 7.0
Mepivacaine 30-120 30-120 4.5 7.0
Bupivacaine 120-240 240-480 2.5 3.2
Etidocaine 200 240-360 4.2 5.7
Prilocaine 30-120 60-400 5.7 8.5
http://www.emedicine.com/derm/topic824.htm
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
Local Infiltration
• Works better for maxillary teeth than mandibular teeth– Thickness of bone
http://www.septodont.ca/Septodont/english/other/cea_di01.html
Trigeminal Nerve Branches
Maxillary Block:Mandibular Branch
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
Inferior Alveolar Block
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?
Lost Filling
• Clean area out
• Apply ZOE or IRM
• Scrape excess
• Dental Referral
Lost Crown
• Clean restoration and tooth surface
• Dry with cotton• Apply small
amount ZOE or IRM
• Place on tooth• Bite on gauze
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?
“Dry Socket”
• Alveolar Osteitis– Loss of clot post extraction exposes
alveolar bone • Local Infection
– Days 2-4– Painful– Smoking, Use of Straws, Molars
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
Odontogenic Infections
Mucosal
Apical
Deep Space
Pericoronitis• Operculum of erupting wisdom
teeth becomes filled with impacted food, debris– Cellulitis follows
• Irrigate area out• Oral Hygiene• +/- Antibiotics• Analgesics
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
Diagnosis
• Swelling of face or jaw
• Swelling or fluctuance in gingiva
• Panorex if available, may show apical origin
• Consider CT for Deep Space infections
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
Mucosal Infections
• Ginigivitis– Inflamation– Clean Debris out of sulci– Mouth rinses
• Thrush• Ginigivostomatitis
– Children most common– Won’t eat or drink due to pain– Nystatin for thrush– “Magic Mouthwash”
Gingivitis
ANUG
• Acute Necrotizing Ulcerative Gingivostomatitis– Trench Mouth or
Vincent’s Angina– Fusospirochettal
infection
• Antibiotics• Will need
debridement
Herpangina
Thrush
OMF Trauma
• Common– Assaults, MVC, Falls
• Significant Morbidity
• Potential for airway compromise
• Blunt versus penetrating
• Other associated Trauma– Chest, Head, Neck
Oral Soft Tissue Injuries
• Lacerations– Cheek– Tongue– Gums
• Vascular Structures• Bleed Profusely• Airway at Risk
– Manage Airway
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
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• Stenson’s exits by upper second molar
– Check for Nerve Injury
• Close mucosa first then skin– If tooth puncture, close only skin
Frenulum Laceration
• Face Plant
• No need to repair
• Anxious Parents
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
Gingival Lacerations
• Skin is thin
• Hard to close
• Usually heal without repair
• Often associated with Fractures
• Flaps will require closure
Cheek Lacerations
• Look for Facial Nerve Injury
• Look for Parotid Duct Injury
Lip Lacerations
• Close Through and Through lacerations– Mucosa First, then
skin
• If small, leave mucosa open
• Align Vermillion Border!!!
Dentoalveolar Trauma
• Blunt trauma
• Disrupts Dentoalveolar complex
• Common Pediatric Problem– Toddlers falling– Sports Injuries– Prevent with Mouth Guards
Luxation of Teeth
• Avulsion
• Intrusion
• Extrusion
• Luxation
• Alveolar Ridge Fractue
Mandibular Anatomy
Assessment
• ABC’s• Clear Airway• Look for Extruded Teeth
– If not Found: Get Chest Xray
• Palpate TMJ– Assess ROM
• Palpate Mandible– Malocclusion sensitive for Fracture
Assessment
• Tongue Blade Test• Palpate oral
lacerations– Step off
• Check for loose teeth
• Tooth tap for pain
Radiographs
• Panorex and CT are best• Not available in Field• Plan films of mandible
– Should not change Field management
LaForte fractures
• Higher Force Blunt Face Injury
Alveolar Ridge Fracture
Tooth Fractures
• Ellis Classification– 1-Enamel Only
• White
– 2- Enamel and Dentin
• Yellow tint
– 3- Enamel, Dentin and Pulp
• May see blood
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
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
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
Luxation with Alveolar FX
• Reposition tooth• Then repair
Gingiva• Splint
Intrusion
• Usually stable• > 6mm will
require surgical repair
• Primary teeth– Allow to grow out
– Permanent tooth may be damaged
Laterally Luxated Tooth
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.
Tooth Replantation
• Time is tooth• Analgesia• Clean out clot• Gently but firmly
insert tooth• Splint tooth
Tooth Replantation
Tooth Replantation
TMJ Syndrome
• Pain at TMJ
• Click or Pop with Chewing
• May have crepitus
• Soft Diet
• Analgesics
• Consider occlusal problem– New Filling?
Dental Kit
• Home made– Cheaper– Choose what you want
• Commercial– More expensive– Easier to obtain and maintain
NC-1’s Ultimate Dental Kit for DMATs
Dental Kit
• Goals– Control Pain– Stabilize Loose Teeth– Cover exposed Pulp– Secure Lost Restorations
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
Dental Kit• www.dentalbox.net• 1. 2-tray Cantilever Style Heavy Duty Plastic Utility Box
(1)2. TOPICAL ANESTHETIC 20% BENZOCAINE GEL 30GM BOTTLES (2)—used For Topical Mucosal Anesthetic3. 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 Teeth7. Bupivocaine/Epinephrine Cartridges—canister 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 #99. 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 #8.
•10. 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. 3”x 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&photographsDepicting Use Of Each Medication And Of Each Tooth Block Type. ( TheInstruction Cards Are To Be Used As A Clinical Reference Only And Are Not Designed To Replace TheIndividual Item’s Manufacturer’s Instructions. The Procedural Descriptions/Depictions Are NotSubstitutes 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)
Dental Kit• www.dentalbox.net• 1. 2-tray Cantilever Style Heavy Duty Plastic Utility Box
(1)2. TOPICAL ANESTHETIC 20% BENZOCAINE GEL 30GM BOTTLES (2)—used For Topical Mucosal Anesthetic3. 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 Teeth7. Bupivocaine/Epinephrine Cartridges—canister 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 #99. 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 #8.
•10. 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. 3”x 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&photographsDepicting Use Of Each Medication And Of Each Tooth Block Type. ( TheInstruction Cards Are To Be Used As A Clinical Reference Only And Are Not Designed To Replace TheIndividual Item’s Manufacturer’s Instructions. The Procedural Descriptions/Depictions Are NotSubstitutes 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)
Resources
• International association for Dental Traumatologywww.iadt-dentaltrauma.org/site_2005/guidelines/index_guidelines.htm
• Academy for Sports Dentistry http://www.sportsdentistry-iasd.org/trauma.htm
• http://www.septodont.ca/Septodont/english/other/cea_di01.html
• http://www.emedicine.com/derm/topic824.htm • : Local anesthesia in Dermatology• http://www.rxroots.com/Downloads.htm#• http://www.aafp.org/afp/20030201/511.html• http://www.septodont.ca/Septodont/english/other/
cea_di01.html dental anesthesia