Dental Problems in the Field Setting

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

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Epidemiology of Mouth Pain

• Infectious
• Trauma
• Post Procedure
• Dental Blocks
• Non Oral Causes
• Many Americans have poor dental hygiene

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Assessment

• History
• MOI
• Other significant trauma
• Airway Status
• C-spine
• Onset of Pain
• Location of Pain

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Assessment

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

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Exam
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Radiographs
11
Waters View
From http//www.ghorayeb.com/ImagingMaxillarySinu
sitis.html
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Anatomy of The Mouth

• 32 Adult Teeth

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Terminology

• Buccal (labial)
• Lingual (palatal)
• Occlusal

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Anatomy of aTooth

• Crown
• 3 layers
• Enamel
• Dentin
• Pulp

• Root
• Gingiva Gum
• Periodontal Ligament
• Anchors tooth

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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

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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

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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!!

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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.

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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

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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

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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

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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

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Duration of Analgesia
http//www.emedicine.com/derm/topic824.htm
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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

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Local Infiltration

• Works better for maxillary teeth than mandibular
  teeth
• Thickness of bone

http//www.septodont.ca/Septodont/english/other/ce
a_di01.html
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Trigeminal Nerve Branches
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Maxillary BlockMandibular Branch
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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

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Inferior Alveolar Block
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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?

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Lost Filling

• Clean area out
• Apply ZOE or IRM
• Scrape excess
• Dental Referral

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Lost Crown

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

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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?

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Dry Socket

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

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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

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Odontogenic Infections

• Mucosal
• Apical
• Deep Space

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Pericoronitis

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

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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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Diagnosis

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

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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

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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

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Gingivitis
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ANUG

• Acute Necrotizing Ulcerative Gingivostomatitis
• Trench Mouth or Vincents Angina
• Fusospirochettal infection
• Antibiotics
• Will need debridement

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Herpangina
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Thrush
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OMF Trauma

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

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Oral Soft Tissue Injuries

• Lacerations
• Cheek
• Tongue
• Gums
• Vascular Structures
• Bleed Profusely
• Airway at Risk
• Manage Airway

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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

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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

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Frenulum Laceration

• Face Plant
• No need to repair
• Anxious Parents

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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

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Gingival Lacerations

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

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Cheek Lacerations

• Look for Facial Nerve Injury
• Look for Parotid Duct Injury

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Lip Lacerations

• Close Through and Through lacerations
• Mucosa First, then skin
• If small, leave mucosa open
• Align Vermillion Border!!!

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Dentoalveolar Trauma

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

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Luxation of Teeth

• Avulsion
• Intrusion
• Extrusion
• Luxation
• Alveolar Ridge Fractue

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Mandibular Anatomy
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Assessment

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

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Assessment

• Tongue Blade Test
• Palpate oral lacerations
• Step off
• Check for loose teeth
• Tooth tap for pain

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Radiographs

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

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LaForte fractures

• Higher Force Blunt Face Injury

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Alveolar Ridge Fracture
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Tooth Fractures

• Ellis Classification
• 1-Enamel Only
• White
• 2- Enamel and Dentin
• Yellow tint
• 3- Enamel, Dentin and Pulp
• May see blood

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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

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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

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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

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Luxation with Alveolar FX

• Reposition tooth
• Then repair Gingiva
• Splint

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Intrusion

• Usually stable
• gt 6mm will require surgical repair
• Primary teeth
• Allow to grow out
• Permanent tooth may be damaged

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Laterally Luxated Tooth
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Treating Avulsed Tooth

• Tooth transport and storage
• Socket is the best place.
• Save-A-Tooth lt 24 hours.
• Hanks Balanced buffer solution.
• Cold milk lt 6 hours.
• Saliva, saline or water lt ½ hour.

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Tooth Replantation

• Time is tooth
• Analgesia
• Clean out clot
• Gently but firmly insert tooth
• Splint tooth

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Tooth Replantation
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Tooth Replantation
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TMJ Syndrome

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

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Dental Kit

• Home made
• Cheaper
• Choose what you want
• Commercial
• More expensive
• Easier to obtain and maintain

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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

• 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 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 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. 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
  TextphotographsDepicting 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
  Items Manufacturers 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)

94
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 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 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. 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
  TextphotographsDepicting 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
  Items Manufacturers 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)

95
Resources

• International association for Dental
  Traumatology www.iadt-dentaltrauma.org/site_2005/g
  uidelines/index_guidelines.htm
• Academy for Sports Dentistry http//www.sportsdent
  istry-iasd.org/trauma.htm
• http//www.septodont.ca/Septodont/english/other/ce
  a_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/ce
  a_di01.html dental anesthesia