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