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Slide 1JSOMTC, SWMG(A)
SOCMDental Emergencies and Splinting, Fractured Cusp, and Ivy Loops
PFN: SOMDSL0A
Hours: 1.0
Slide 2JSOMTC, SWMG(A)
Terminal Learning Objective
Action: Communicate knowledge of “Dental Emergencies and Splinting, Fractured Cusp, and Ivy Loops”
Condition: Given a lecture in a classroom environment
Standard: Received a minimum score of 75% on the written exam IAW course standards
Slide 3JSOMTC, SWMG(A)
References Color Atlas of Common Oral Diseases, Langlais, Robert P., Miller, Craig S. 2d ed. Williams & Wilkins, 1998
Contemporary Oral and Maxillofacial Surgery, Peterson, et al, 2d ed, Mosby 1993
Medical Subjects ‐ Dental, JSOMTC, as issued.
Medical Subjects ‐ Dental, JSOMTC, as issued
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Slide 4JSOMTC, SWMG(A)
Reason
As a SOF Medic you will diagnose and treat dental conditions
You will manage fractured and avulsed teeth
You will manage infections and periodontal disease
Slide 5JSOMTC, SWMG(A)
Agenda Identify assessment and management guidelines for dental emergencies
Understand the pathophysiology, clinical presentation and management of dental injuries
Identify the clinical presentation and management of mandibular dislocation
Slide 6JSOMTC, SWMG(A)
Agenda
Understand the pathophysiology, clinical presentation and management of odontogenicinfections
Identify the pathophysiology, clinical presentation and management of fascial space head and neck infections
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Identify Assessment and Management Guidelines for Dental
Emergencies
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Management of Dental Emergencies
Considerations with limited equipment, you will rely on four factors to diagnose:
Chief Complaint limit care to “cc” or you may limit your availability to others
Examination
Amount and type of pain
Systemic manifestations
cervical lymphadenopathy, fever and malaise
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Questions to Ask:
How did it happen?
Where did it happen?
When happened?
Previous injury?
Cold or air elicit symptoms?
Change in the “bite”? (jaw fracture)
Allergies?
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Clinically Examine Soft and Hard Tissues:
ABC’s and C spine first, when cleared, focused evaluation
Clean patient’s face and mouth to give an unobstructed view during evaluation
Examine soft tissue for bleeding, lacerations, deformity…
Examine hard tissue for deformity: wiggle teeth and palpate bone to locate mobile and missing segments
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General Guidelines for Dental Injury
Record evaluation of injury (SOAP)
Examine both hard and soft tissue
Treatment as indicated for the situation
Refer as needed for definitive treatment
One SF Dental Surgeon per Group
Five Dental Surgeons per Division (situational)
Corps level: Area Support Dental Company
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Medications for Dental EmergenciesPain medication
IBUPROFEN: anti‐inflammatory
800mg: 1 tab TID
Narcotics (in the absence of head injury)
Tylenol#3: 1 tab q 4‐6h prn pain
Percocet 5: 1‐2 tabs q 4‐6h prn pain
Your choice as provider of other Narc
Local injection of Marcaine® or Lidocaine
(Acetominophen is efficacious but not anti‐inflammatory and is compounded with most Narc selections)
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Antibiotic Therapy
Seriousness of infection
cellulitis vs abscess
Can adequate surgical treatment of infection be achieved
Young and healthy or medically compromised
12 hour replication cycle of oral bacteria
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Antibiotic Therapy
Penicillin VK 500mg QID x 10‐14 days
(250mg is insufficient)
For true Penicillin allergy:
Clindamycin 300 mg TID x 10 days
Azithromycin: 500mg the first day, then 250mg each day for four days
Flagyl as indicated
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Understand the Pathophysiology, Clinical Presentation and
Management of Dental Injuries
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Dental Injuries
Cusp Fracture
Avulsed Tooth
Crown Fracture
Root Fracture
Extrusion and Fractured Alveolus
Alveolar Fracture
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Manage Fractured Cusps
Very common large posterior restorations
Lessen risk by placing cuspal coverage, “crowns”, too large restorations
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Fractured Cusps
Restored First and Second molars with amalgam
Field treatment: 3M dental company’sAdper Prompt L‐Popand Transbond XT
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Fractured Cusps
Annoying to debilitating
Ensure adequate pre‐deployment to Class I
Request cuspalcoverage as needed
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Manage Fractured & Avulsed Teeth
Rule out more serious injury
Examine soft and hard tissue
Ask questions: Lose consciousness
Rule out: C‐Spine or Closed Head Injury check LOC
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Avulsion
Tooth completely out of socket Time is critical and must be insert <30‐60 min
Rinse tooth gently
Do not scrub
Flush socket
Place tooth back in socket to same height as contralateral tooth
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Avulsion
Treatment
Adper Prompt L‐Popwith Transbond light cured plastic over a 24 or 25 gauge wire
The wire should extend to cover two unaffected teeth on either side of the affected tooth (teeth)
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Avulsion
If can’t place tooth in socket, use storage media:
Under tongue (adults)
IV solution
Water
Milk widely quoted due to osmotic equality. But kicks off immune response so do not use
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Crown Root Fracture
Can involve:
Enamel
Enamel & Dentin
Enamel & Dentin & Pulp
Paint from impact object
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Crown FractureTreatment
Enamel: none necessary
Dentin: none or can paint Adper Prompt L‐Pop®, cure with MiniMag for 60 seconds
Pulp: Paint with eugenol, clean, cover with AdperPrompt L‐Pop®, cure with MiniMag for 60 seconds
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Root Fracture
Horizontal blow
Difficult to diagnose
Internal hemorrhage
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Root Fracture
Reapproximate fragments
Ideal: Adper Prompt L‐Pop
w/ Transbond light cured
composite over a wire
that extends to cover two
unaffected teeth on either
side of the affected teeth.
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Resorption SequelumRoot Fracture stabilize 2‐4 months and resorption of root may occur over years
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Extrusion andFractured Alveolus
Extrusion
Oblique force
Tooth extruded
Bone fractured on one side due to horizontal force
Apex may be locked out
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Extrusion & Fractured Alveolus Treatment
Reposition using slow and steady pressure
Attempt to free apical lock and reposition tooth with alveolus
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Fracture of Alveolar Process
Fractures bone on all sides of tooth (compared to one bone surface)
Can see two or more teeth move together when checking mobility
Move fragments to correct position, splint in place.
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Tooth Stabilization: Splinting
Adper Prompt L‐Pop (by 3M ESPE)
Transbond XT composite (Light cure with MiniMag for 60 seconds)
24 or 25 gauge wire
7‐10 days for teeth only
3‐4 weeks teeth & bone
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Splinting
Fishing line or light wire Endodontic therapy to be expected
Deployed dental officer should have this capability
18D has this capability 7‐10 days for mature root
3‐4 weeks for immature root
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Identify the Clinical Presentation and Management of Mandibular
Dislocation
Slide 35JSOMTC, SWMG(A)
Reduce a Mandibular“Open Lock”
Initial episode: Excessive opening of mouth (ie yawn) followed by attempted quick closure.
Subsequent episodes become easier to initiate
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Reduce an “Open Lock”
Reassure the patient, have the patient relax Manipulate the mandible down and forward to clear the eminence. You must go down and forward
Then gently allow the mandible to return to its normal posterior position. Now have patient maintain muscle closure to prevent re‐open lock.
Do not merely push back as this could fracture the condylar necks
NSAIDS, Warm compresses
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Slide 37JSOMTC, SWMG(A)
Understand the Pathophysiology, Clinical Presentation and
Management of OdontogenicInfections
Slide 38JSOMTC, SWMG(A)
Odontogenic Infection
Odont = tooth
Genic = to start
Periodontal ‐ infection starts in the tissue surrounding the tooth
Periapical ‐ infection starts inside the pulp and expresses out the apex
Slide 39JSOMTC, SWMG(A)
Manage a Periodontal Abscess Localized purulent inflammation in the periodontal tissues due to infection or foreign body
Dull pain, mobility, slightly sensitive to percussion; fistula
Treatment
Anesthetize, perio probe to locate pocket, drain by scaling, irrigate, possible extraction if truly hopeless
Administer antibiotics
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Slide 40JSOMTC, SWMG(A)
Acute Necrotizing Ulcerative Gingivitis: ANUG
“Punched out” papillae, gray pseudomembranethat sloughs, radiating pain, bleeding, sensitive to touch, fetid “metallic” taste;
Causes
Change in living habits, inadequate rest, stress; spirochetes and fusiform bacilli
Treatment
Anesthesia, scale, Peridex if available, pain meds (antibiotics: Flagyl 250 mg tid x 4‐5 days)
Slide 41JSOMTC, SWMG(A)
Manage a Periapical Abscess
Appears similar to periodontal abscess
Localized purulence may not be at root apex; fistula can travel
Pulpal death by
caries or trauma
Throbbing pain, sensitive to percussion
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Periapical abscessWeakest path will display sinus tract
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Manage a Periapical Abscess
When fistula forms
Foul taste and odor
Little pain since pressure relieved
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Manage a Periapical Abscess
Treatment
Anesthesia (may be difficult)
I&D with Penrose drain
Antibiotics
Endodontics and restoration
Extraction as a last resort
Slide 45JSOMTC, SWMG(A)
Pulpitis
Reversible Pain of short duration [< 30 sec] due to thermal stimulus or sweets
Missing restoration (“filling”) Decay
Treatment Place IRM® then Adper Prompt L‐Pop® andTransbond XT® or IRM
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Pulpitis
Irreversible Fatal infection of pulpDecay Trauma with subsequent invasion of transient bacteria
Treatment Pain meds Endodontic therapy preferred Extract only if necessary
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Pericoronitis
Inflamed operculumover lower 3rd molar
Painful swelling
Trismus (infection spreads)
Dysphagia
Lymphadenopathy
Fever
Malaise
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Pericoronitis
Treatment Pain meds Irrigate under the operculum
Antibiotics Pt to brush over area Extract opposing molar if causing traumatic occlusion
Refer to dental officer to extract offending impacted tooth regardless of resolution of symptoms
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Identify the Pathophysiology, Clinical Presentation and
Management of Fascial Space Head and Neck Infections
Slide 50JSOMTC, SWMG(A)
Maxillary spaces
Canine spaces: a thin, potential space between the levator anguli oris and the levator labiisuperioris muscles
Buccal spaces: bound by the overlying skin of the face on the lateral aspect and the buccinatormuscle on the medial aspect
Infratemporal spaces: lies posterior to the maxilla, bounded medially by the lateral plate of the pterygoid process of the sphenoid bone and superiorly by the base of the skull
Slide 51JSOMTC, SWMG(A)
Maxillary Spaces
Submental spaces: between the anterior bellies of the digastric muscle and between the mylohyoidmuscle and the overlying dermis
Buccal spaces: dermis on the lateral, buccinatormuscle on the medial
Sublingual spaces: between the oral mucosa of the floor of the mouth and the mylohyoid muscle, and laterally by the medial border of the mandible
Submandibular spaces: between the mylohyoidmuscle and the dermis, and laterally by the medial border of the mandible
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Slide 52JSOMTC, SWMG(A)
Mandibular spaces
Infection tracks the pathway of least resistance
Emergent routes
Infraorbital to Intracrainal
• encroachment on airway Space (pharyngeal and
parapharyngeal)
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Life‐Threatening Infections
Cavernous Sinus Thrombosis
Pharyngeal Abscess
Ludwig’s Angina
Mediastinal Abscess
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Cavernous Sinus Thrombosis
No valves in ocular veins
Upper tooth infection involving the infraorbital area could progress intracrainial
Fatal
Admit: IV Antibiotics
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Pharyngeal Abscess
Molar infection or other dissecting infection can progress to close airway
Treatment:
Airway
IV antibiotics
Treat cause
Evacuate with dependable airway
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Ludwig’s Angina
Airway Obstruction: Emergency
Maintain airway
Evac priority is “Urgent ”
Relieve pressure extraorally
Major IV antibiotics
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Ludwig’s AnginaTrach. is the Airway of choice for Protection
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Mediastinal Abscess
Extension of odontogenic infection
Can be fatal
Evac Urgent Surgical
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Floor of the Mouth
Mylohyoid line attaches to mandible
Allows infections under the floor of the mouth, down potential spaces of the neck
Think Airway
Note were third molars would drain
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Floor of the Mouth
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Floor of the Mouth
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Floor of the Mouth
Buccal
Space
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Treatment of Oral Infections
I & D if pointed infection
Intraoral incision preferred
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Treatment of Oral Infections
Blunt dissection
Penrose drain
remove when non‐productive (drain keeps area open for drainage not to provide duct/tube for passage)
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I & D
Portion of surgical glove can be used
Suture in place
ABX
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Questions
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Slide 68JSOMTC, SWMG(A)
QuestionsA dental avulsion occurs when
a. The crown is fractured off of the root.
b. The tooth comes completely out of the socket.
c. The maxilla is fractured distal to tooth #17.
d. The infection erodes the cortical bone.
Slide 69JSOMTC, SWMG(A)
Terminal Learning Objective
Action: Treat a dental emergency to include a fractured, dislodged, or avulsed tooth; a fractured cusp; and a fractured mandible. Place a bonded wire on maxillary teeth, two teeth either side of the identified avulsed/displaced teeth; place a bonded temporary with Transbond XT ® for a fractured cusp; place four Ivy Loops and appropriate elastics.
Condition: Given a lecture in a classroom environment
Standard: Received a minimum score of 75% on the written exam IAW course standards
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Slide 70JSOMTC, SWMG(A)
Agenda Identify assessment and management guidelines for dental emergencies
Understand the pathophysiology, clinical presentation and management of dental injuries
Identify the clinical presentation and management of mandibular dislocation
Slide 71JSOMTC, SWMG(A)
Agenda
Understand the pathophysiology, clinical presentation and management of odontogenicinfections
Identify the pathophysiology, clinical presentation and management of fascial space head and neck infections
Slide 72JSOMTC, SWMG(A)
Reason
As a SOF Medic you will diagnose and treat dental conditions.
You will manage fractured and avulsed teeth
You will manage infections and periodontal disease
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Slide 73JSOMTC, SWMG(A)
Break