SOCM Dental Emergencies and Splinting, Fractured Cusp, and ...

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Slide 1JSOMTC, SWMG(A)

SOCMDental Emergencies and Splinting, Fractured Cusp, and Ivy Loops

PFN: SOMDSL0A

Hours: 1.0


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


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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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


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


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


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


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


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


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


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


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


Manage Fractured Cusps

Very common large posterior restorations

Lessen risk by placing cuspal coverage, “crowns”, too large restorations


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


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


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)


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


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


Root Fracture

Horizontal blow

Difficult to diagnose

Internal hemorrhage


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


Extrusion andFractured Alveolus

Extrusion

Oblique force

Tooth extruded

Bone fractured on one side due to horizontal force

Apex may be locked out


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.


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


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


Reduce a Mandibular“Open Lock”

Initial episode: Excessive opening of mouth (ie yawn) followed by attempted quick closure.

Subsequent episodes become easier to initiate


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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Understand the Pathophysiology, Clinical Presentation and

Management of OdontogenicInfections


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


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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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)


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


Periapical abscessWeakest path will display sinus tract

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When fistula forms

Foul taste and odor

Little pain since pressure relieved



Treatment

Anesthesia (may be difficult)

I&D with Penrose drain

Antibiotics

Endodontics and restoration

Extraction as a last resort


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


Pericoronitis

Inflamed operculumover lower 3rd molar

Painful swelling

Trismus (infection spreads)

Dysphagia

Lymphadenopathy

Fever

Malaise


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


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


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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Mandibular spaces

Infection tracks the pathway of least resistance

Emergent routes

Infraorbital to Intracrainal

• encroachment on airway Space (pharyngeal and

parapharyngeal)


Life‐Threatening Infections

Cavernous Sinus Thrombosis

Pharyngeal Abscess

Ludwig’s Angina

Mediastinal Abscess


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


Ludwig’s Angina

Airway Obstruction: Emergency

Maintain airway

Evac priority is “Urgent ”

Relieve pressure extraorally

Major IV antibiotics


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


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


Floor of the Mouth

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Floor of the Mouth


Floor of the Mouth

Buccal

Space


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)


I & D

Portion of surgical glove can be used

Suture in place

ABX


Questions

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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.


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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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


Agenda

Understand the pathophysiology, clinical presentation and management of odontogenicinfections

Identify the pathophysiology, clinical presentation and management of fascial space head and neck infections


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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SOCM Dental Emergencies and Splinting, Fractured Cusp, and ...

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