Field dentistry- fractured tooth

[Bandaid]

You and your team are training some indigenous forces in small arms. One of your teammates is standing behind a local as he fires downrange. The neophyte gets excited at hitting his target and swings around...... squarely smacking the side of his barrel into the mouth of your teammate. After a few choice words of encouragment on proper control of the weapon and situational awareness, your teammember walks over to you for "a look".

You see the following:
http://www.smilesensation.com/smile-cos-bond2a.jpg


He was intially in moderate pain, but since then it has gone"numb".
You gaze at the new appearance of his smile, suppress a chuckle, and then....


***edited to remove hiijack potential from my use of humerous slang

[ussfpa]

subscribing...:D
And lets remember the sticky at the top of the medical thread...
not ONE POST about BLING BLING and gold caps...:p

Primum non Nocere

[SOTB]

Originally posted by ussfpa
....And lets remember the sticky at the top of the medical thread...
not ONE POST about BLING BLING and gold caps....

Man, you medical guys take away ALL of the fun....

[Bandaid]

Well, the first thing to do is examine for other signs of not so obvious injury.
1. rule out concussion (very unlikely in this incident)
2. Examine mucosa including lips, buccal mucosa, palatal area for lacerations/bleeding
3. Rule out a Lefort I type fracture of maxilla if blow was with great force(simply place one hand and stabilize patients forehead while using other hand to attempt to move entire maxilla as a complete unit separately from the midface)
4. Palpate alveolar bone around area of fractured tooth by gently manipulating the area to see if a segment of the maxillary teeth move independantly of the rest of the arch.
5. Evaluate the actual tooth or teeth. Evaluate them by lumping it into one of three basic catagories of tooth fracture:
A. Fractured teeth
B. luxated teeth (displaced from normal position)
C. avulsed teeth (actually "knocked out")

6. will skip C in this instance. Now you have confirmed a fractured tooth. That breaks down into three main catagoriesbased on the layers of tooth involved:
a. enamel only
b. enamel and dentin layers
c. enamel/dentin/pulp

From what we have in the picture, there is definitely at least two layers of tooth involved (outer enamel layer and the inner yellowish dentin layer). Exam also determines that the tooth is slightly intruded into its bony socket. Any treatment needed to reposition it? How can you tell if the pulp layer is affected from the fracture? What to do next?

[RIT_MEDIC]

...when it comes to diagnosing dental emergencies, but I enjoy these varying scenarios.

Now on subject, looks like this soldier will be needing a bit of bonding on that tooth. Will he undergo a root-canal prior to the asthetics?

James D

[ussfpa]

Originally posted by Bandaid
Well, the first thing to do is examine for other signs of not so obvious injury.

From what we have in the picture, there is definitely at least two layers of tooth involved (outer enamel layer and the inner yellowish dentin layer). Exam also determines that the tooth is slightly intruded into its bony socket. Any treatment needed to reposition it? How can you tell if the pulp layer is affected from the fracture? What to do next?

OK...as this is not my general arena...please keep my leash fairly tight.

Looking at the tooth, it LOOKS like either an Ellis II or III. I would probably have the guy suck a breath over the tooth to check the exquisiteness of his sensitivity, then apically numb the guy with 1:100,000 lido and epi for the initial eval and Tx.
The tooth SHOULD then be ok to swab with a dry gauze or sterile cotton tipped applicator to see if there is either blood droplets or the "blue dot" charaterizing the root.
If the root is open, this is bad...emergent referral, probable root canal as the tooth may die or an abcess may develop.
I carry a small wad of parafin wax in a film canister for this type of thing...once the tooth is gently cleaned, I mold the parafin over top of the tooth to prevent food, air, or temperature exposures from the wound until he gets to COMPETENT dental care.
In the most extreme of environments, where Dental referral within about 72 hours is not avail...would you consider extraction?

Thanks for reading my dribble, may I please have a spit cup now?:D

Primum non Nocere

[medicchick]

I have no idea what to do in this case, but I am wondering if you'd want to try and find the rest of the tooth, or not worry about it. What about if he has it? I know that probably isn't a big concern right now in the scenario, and sorry if it's a stupid question.

[Doctor_Doom]

Just subscribing, I am totally out of my league here.

[Bandaid]

RitMedic-
Two schools of thought on the need for root canal for this one. Assuming the pulp is not exposed, then someone can temporize and then restore the tooth following the "watch, test periodically, and wait" technique. The other option is that the dentist can perform root canal asap and then restore the tooth. For a SF soldier who is likely to be redeployed soon after treatment, I would probably go ahead and perform the root canal after explaining to him that he would have about a 30-60% chance of having an emergency abscess within the next 1-4 years if the RC wasn't performed. As my civilian patient, I would restore and test periodically at recall for need to perform the root canal in the future. Different needs dictate the treatment IMO.

Ussfpa-
A few points to consider when evaluating this case.
1. A positive/negative pain test on teeth is not very diagnostic either way when evaluating someone immediately after a traumatic event. Exposed dentin can be just as painful as pulpal tissue for some patients. For that matter, pulp exposures can be asymptomatic from the disruption of nerve endings at the apex. Your visual examine is a more selective method for determining pulpal access from trauma (classIII).
2. Use gauze or cotton tip applicator to clear any existing blood/fluid off of the tooth first. Then examine for one of two things:
a. Bleeding from "inside" surface of tooth-not the gingiva
b. a visible PINK/RED blush from the inner portion of the tooth. Blue is usually not seen in my experience, if anything you may see a ruddy brown in older patients but not blue.
Either or both of these conditions confirms pulp involvement (classIII).
3. If class III, then as stated, refer for definitive treatment. Usually, any exposure greater than the "pinpoint" in size or one that is not sealed properly within 1-2 hours will require a root canal for treatment. If not treated, the tooth will become necrotic and will become an abcess risk that Mr. murphy determines when to initiate.
4. If class II, then your wax treatment is sufficient for temporary relief of symptoms. Also, I have read literature from Japan for the use of cyanoacrylate (superglue) as a temporary liner to shield from cold/air/tactile stimulations. I can't recommend it personally, as I only use accepted treatments and materials in my practice.....but I would try it on myself if I was hurting out in the middle of nowhere and didn't have anything else! Its supposed to work on class III fractures, too. If you try it on a CL III, you need to use a cotton pellet to control hemorrage of pulp before placement or it will not seal or set properly. If you can't control the hemorrage after 5 minutes of constant pressure, then I would leave it open to the mouth for drainage and relief of pressure. Otherwise, you better have lots of pain meds around!:eek:
5. I would not extract the tooth at this point. Even in an environment where longer time will pass than 72 hours. Here is the reasoning. Some teeth will become necrotic without pain or clinical infection giving time for possible treatment in the future. I would anesthitize as you suggest, dry and place liner, evac asap for follow-up care while placing him on amox 500 tid for prevention. Extraction would be the last option, and after I ran out of 2% lido for anesthesia (it only takes .5 cc or so to infiltrate at apex for 2 hrs of pain free sleep). Its much easier to fix with a root canal/crown than an implant or bridge after the extraction. Also a continous dose of IBU 800 tid for the next few days may allow him to handle it w/o the extraction.
Another note- you may want to look at bringing a carpule or two of marcaine with you. Gives mod. to deep anesthesia and gives 4-6 hours of relief per injection verses the 1-2 hours for lido.

Med chick-
If the tooth fragment is in one piece, the Japanese studies I suggested above were using the cyanoacrylate to "reglue" the pieces of tooth back together. I, personally, would not worry about it. If brought to me for Tx, I would simply throw away the fragment and fix the tooth. Not a dumb question, there is research being performed overseas on that right now. :)
***one extra note med chick- it is worth looking for the fragment to rule out possible lodging of it in either the gingiva or the soft tissue around the injury site. That falls under the general CYA protocal. :D

[Bandaid]

Sorry for the long winded post with numerous grammar mistakes. My hands and eyes got tired trying to get this posted during my hectic day!!!! :eek:
Ussfpa, do you want more or do you need six months to rest your eyes after reading all that? LOL
Just advise me as to the level wanted.... believe it or not, I left off a few Tx items that could have developed :o I will save them for later topics.

Bandaid silently drags himself from the keyboard and goes to get a coke

[ussfpa]

Originally posted by Bandaid
Sorry for the long winded post with numerous grammar mistakes. My hands and eyes got tired trying to get this posted during my hectic day!!!! :eek:
Ussfpa, do you want more or do you need six months to rest your eyes after reading all that? LOL
Just advise me as to the level wanted.... believe it or not, I left off a few Tx items that could have developed :o I will save them for later topics.

Bandaid silently drags himself from the keyboard and goes to get a coke
Saca Muelas,
Appreciate the short leash, the info is great. Long winded with grammatical errors??? You must not remember some of MY posts :rolleyes:
I don't feel TOO AWFUL bad about my response...I didn't get the double play, but think I at least had the lead runner pegged.

Primum non Nocere

[Sneaky SF Dude]

Really good stuff Saca Muelas. Thanks.

[Stampee]

No claims to any knowledge about this, except for first hand experience. I had my left lateral incisor broken in just about the same spot as the photo of that persons central incisor, while I was in Basic Training. I spent about 10 hours in the ER waiting for a dentist to come fix me up because it happened on the weekend, and well they just don't care too much about BCT kids, but that's a whole different discussion.

Anyway, upon initial diagnosis it was determined that all three layers were involved, all the way to a tiny little yellow exposed nerve ending (pulp). It was covered with some form of a bonding agent until I could see the real dentist on the following Monday. When the doc looked at me he told me I would need a root canal but due to my training status it would have to wait. So he capped it and sent me on my marry way. One month later that cap fell off from eating hard MRE food crap stuff, and they re-capped it. This was last February and I still have that second cap. Yes I am still in training so I haven't had it looked at for a permanent fix. However, this cap which is on now seems to be working out just fine.

[Bandaid]

Originally posted by Bandaid
someone can temporize and then restore the tooth following the "watch, test periodically, and wait" technique. As my civilian patient, I would restore and test periodically at recall for need to perform the root canal in the future. Different needs dictate the treatment IMO.
If class III, then as stated, refer for definitive treatment. Usually, any exposure greater than the "pinpoint" in size or one that is not sealed properly within 1-2 hours will require a root canal for treatment. If not treated, the tooth will become necrotic and will become an abcess risk that Mr. murphy determines when to initiate.
Here is the reasoning. Some teeth will become necrotic without pain or clinical infection giving time for possible treatment in the future.

Stampee-
See above, I condensed it to fit your history.... Your tooth may in fact be DEAD already and slowly eroding your alveolar bone as I type!!! :eek: LOL If your worried, go get " a PA of #10 and a series of endo vitality tests performed (both cold and EPT tests)." Tell that same history you gave me to your dentist and tell him your dentist friend told you that you ought to get this done just to be safe before being deployed. :cool:

See there Ussfpa, can't extract those teeth..... This gentleman is still doing SF training and PT with his tooth. BTW, I was impressed with your last post. I was going to recommend gum or something as I do not know what you carry with you when out in the field (wax is much better).
I will do a follow up on what could happen to Mr. Stampee concerning infection and possible death due to cavernous sinus thrombosis from his abscessed tooth in the future. :D

[RIT_MEDIC]

...but wanted to say thank you for the case. It is refreshing to learn from a different angle. Keep it coming Bandaid.

James D

[medicchick]

Thanks for the informative posts. I found them interesting to read. Teeth are something I don't deal with much.:)

[Bandaid]

Thanks for kind words everyone.... I will post more topics in the future if no one has any lingering questions or what if's on this one.

SneakySF-
I believe my response should be written as .... " de nada"

ok, I couldn't find it in the spa/eng dictionary. That is how it sounds when I say it!!! ROTFLMAO at myself :D As a wiseman once said " a linguist you are not"

[Stampee]

I will do a follow up on what could happen to Mr. Stampee concerning infection and possible death due to cavernous sinus thrombosis from his little abscessed tooth in the future.Death huh? Well, we all gotta go sometime. What better way than from a bum tooth.

[Bandaid]

BTW, Congrats and welcome back Stampee.

Oh, I wouldn't temp the dental Gods. Mr. Murphy could still be at work in your mouth as I type this. I agree, death is extremely rare but wishing for death during a severe abscess is all too common. :D LOL

Since you have called out the dental God's wrath with your dismissive comment, I will attempt to enlighten on his potential power.:D Actually its just a good transition to the next topic.

Maxillary teeth complications are not life threatening nearly as often as a mandibular molar. Anyone know why? There are two main processess that can cause death from oral infections. Any guesses?

Edited to note: Please read above post with a heavy dose of sarcasm..... No disrespect is meant in any way to you Stampee

[Bandaid]

Everyone must be tired of this????
Alright, enough for this month :cool:

[RIT_MEDIC]

Originally posted by Bandaid
Everyone must be tired of this????
Alright, enough for this month :cool:

Quite the contrary Bandaid. I think it is more that the ones of us who are usually commenting have no basis to comment and are subscribing/learning.

I think I can speak for everyone here when I say we are thankful to have your knowledge expressed here on the board.

James D

[medicchick]

Originally posted by RIT_MEDIC
Quite the contrary Bandaid. I think it is more that the ones of us who are usually commenting have no basis to comment and are subscribing/learning.

I think I can speak for everyone here when I say we are thankful to have your knowledge expressed here on the board.

James D

I don't think I could have said it better, so I'm not going to try.

I would like to read more cases of yours, as it is an area that's new to me, and I like to learn new things. That's if you don't mind, I'm just a little nobody here.:)

[Doc T]

back from vacation...

excellent post. We do not have dentists on call here despite being a level I center... don't believe any of the centers I have been at do except in Miami where there was an oral surgery residency. Great information for me.

We had a kid come in before I left with his entire tooth out...root and all...we just stuck it back in as the books say to do but none of us had done it before... what is the chance of survival for the tooth? It was returned to the socket after about 30 minutes...the paramedics brought it in but didn't think to place it back themselves but we were happy they thought to bring it.

sorry if I should have posted this as a new thread...let me know and i"ll change it.

Doc t.

[Bandaid]

Welcome Back Doc T:D

Need to clarify tooth success... All avulsed teeth will necrose and need treatment. They will die due to loss of the internal blood supply, but the overall success depends on reattachment and long term survival of the tooth. I will answer the reimplant question as that is probably what you are asking.

Well, the prognosis of the reimplantation depends on several factors. I will list them:
1- Condition of Tooth itself ( is it cracked or fractured)
2- Condition of alveolar bone surrounding tooth (it has to be fractured to allow the tooth to be avulsed)
3- Time elapsed before treatment (<30 minutes unless using #1 or #2 techniques below)
4- Condition of PDL fibers ( connective tissue fibers that attach the root to the alveolar bone)
5- Storage technique of tooth until treatment
6- Luck

For this case, I will assume it was just placed into gauze until reimplanting it. The prognosis is poor. The reason is that even after the tooth gets a root canal, the healing phase will usually involve an unfortunate process of root resorption due to damage of the PDL fibers. This can either be an internal resorption or external resorption of the root, but both are basically untreatable and lead to failure of the tooth.

Looking for ways to prevent this and give the patient the best chances? OK, here are some ways.... #1 being best.

1. Take tooth,gently rinse with h20 or saline, do NOT scrub or damage PDL on outside of root, do NOT curette out socket, place tooth back into socket ASAP (pt is usually temporarily "numb" from trauma), get to professional help ASAP
2. Take tooth, place tooth into special mixture of fluid that is designed to allow viability of tooth, get to help ASAP
3. Take tooth, rinse off gently, place tooth into patient’s mouth under lip (like a dip), get help ASAP {not performed on little ones or patients at risk for aspiration}
4. Take tooth, rinse gently, place into milk. get help ASAP
5. Let tooth dry, scrub outside of root surface, curette socket, or take over one hour and you will drastically reduce chances for a good long term outcome.

Let me add a few points of interest:
1. The emerg. kits with the liquid discussed in #2 is commercially available. I think it should be recommended for emerg. kits for all coaches, emt's, school offices, etc. where likelihood of this problem being faced is high. Small container, not very $$$, and it could save you or your kids tooth if its available.
2. AS to the tooth itself, All avulsed teeth will require a root canal and SEMI-rigid splinting. The semi-rigid splinting helps prevent the resorption process from occurring... Rigid splinting is contraindicated. Make sure your dentist remembers. :D

hope that helps...

[Sneaky SF Dude]

Can you give a link to an example of the kit, please.

[Doc T]

Originally posted by Bandaid

Well, the prognosis of the reimplantation depends on several factors. I will list them:
1- Condition of Tooth itself ( is it cracked or fractured)
2- Condition of alveolar bone surrounding tooth (it has to be fractured to allow the tooth to be avulsed)
3- Time elapsed before treatment (<30 minutes unless using #1 or #2 techniques below)
4- Condition of PDL fibers ( connective tissue fibers that attach the root to the alveolar bone)
5- Storage technique of tooth until treatment
6- Luck


the tooth was in perfect condition... having never seen a tooth in its entirety i was pretty impressed. No fractures were seen in the alveolar bone on CT scan... and no pain or symptoms from the patient (15 year old)... the tooth was stored in saline soaked gauze until we replaced it. The kid has luck on his side...he survived being ejected from a car through the windshield, landing on the street and only receiving facial lacs, missing teeth and a bad femur fracture.

I will look into getting some of that solution.... do you have a name??

thanx again.... very informative for me.

doc t.

[Bandaid]

SneakySF-
Will do...I must add that the thread where you scared the FNG about marines, navy guys paying him a visit for talking imaginary smack about them was priceless. I almost inhaled my coke (yes, the drink smart@$$) several times when reading that. :cool:

Got to go look it up a link....

[RIT_MEDIC]

Originally posted by Doc T
back from vacation...

...excellent post. We do not have dentists on call here despite being a level I center... don't believe any of the centers I have been at do except in Miami where there was an oral surgery residency. Great information for me.

We had a kid come in before I left with his entire tooth out...root and all...we just stuck it back in as the books say to do but none of us had done it before... what is the chance of survival for the tooth? It was returned to the socket after about 30 minutes...the paramedics brought it in but didn't think to place it back themselves but we were happy they thought to bring it.

Doc t.


Doc T:

Glad to have you back. Pray you enjoyed your time away and feel rested and anew.

To address placing the tooth back. I know I was taught a tooth was not to be returned to its socket in the field, just as we would not try to repack ones eviscerated abdomen. They may not have thought of it or were just following their training.

Everyone knows we(paramedics) never work outside our scope of practice.:rolleyes:

James D

[medicchick]

Originally posted by RIT_MEDIC
Doc T:

Glad to have you back. Pray you enjoyed your time away and feel rested and anew.

To address placing the tooth back. I know I was taught a tooth was not to be returned to its socket in the field, just as we would not try to repack ones eviscerated abdomen. They may not have thought of it or were just following their training.

Everyone knows we(paramedics) never work outside our scope of practice.:rolleyes:

James D


I was taught to put the tooth in a glass of milk if avaliable, or to try and keep it moist, but to not handle it too much.

RIT- I thought we were just there to drive the ambulance to the hospital..LOL

[RIT_MEDIC]

Originally posted by medicchick
...RIT- I thought we were just there to drive the ambulance to the hospital..LOL

Oh Taxi!!

I have never head of the milk idea. We were just taught to bring it with, to the ED.

James D

[Sneaky SF Dude]

Milk does a body good.

[Axe]

Besides lidocaine and marcaine, can you use longer-acting drugs for local anesthesia in the mouth? Also, what if you find yourself with only lidocaine + epi?

[Doc T]

Originally posted by Axe
Besides lidocaine and marcaine, can you use longer-acting drugs for local anesthesia in the mouth? Also, what if you find yourself with only lidocaine + epi?

we use lido with epi in the mouth.... the only places we are taught not to use it is on the ear, nose tip and penis...

the gums were never contraindicated....

doc t.

[ussfpa]

Originally posted by Doc T
we use lido with epi in the mouth.... the only places we are taught not to use it is on the ear, nose tip and penis...

the gums were never contraindicated....

doc t.
Hey DocT / saca muelas...
- dental syrettes contain 1:100,000 epi with lido...I understand that epi isn't conta'ided in the suck, but are there concerns using cutaneous concetrations???
-I don't have a bottle of lido w/ epi in front of me to check the concentration at the moment, but seeing as how the gums are essentially huge capillary beds, and toofer blood supply easily compromised, does restriction of blood flow by buccal administration of epi to the apex of a tooth may generate some concern???

Just throwing this one out there, understand using lido w/ epi in the mouth, no question there...just wondering about using the mulit-dose vial of lido w/epi ON THE TOOTH.

BTW DocT...welcome back ;)

Primum non Nocere

[Doc T]

Originally posted by ussfpa
Hey DocT / saca muelas...
- dental syrettes contain 1:100,000 epi with lido...I understand that epi isn't conta'ided in the suck, but are there concerns using cutaneous concetrations???
-I don't have a bottle of lido w/ epi in front of me to check the concentration at the moment, but seeing as how the gums are essentially huge capillary beds, and toofer blood supply easily compromised, does restriction of blood flow by buccal administration of epi to the apex of a tooth may generate some concern???

Just throwing this one out there, understand using lido w/ epi in the mouth, no question there...just wondering about using the mulit-dose vial of lido w/epi ON THE TOOTH.

BTW DocT...welcome back ;)

Primum non Nocere

Its good to be back... not easy traveling with two small ones...

as for epinephrine and mucosal absorption:

Epinephrine-Containing Anesthetic Safe for Patients

Lidocaine with epinephrine has been widely used as a local anesthetic in dentistry. It purpose is to cause constriction of the blood vessel around the area where the lidocaine/epinephrine solution is injected. By decreasing the blood flow, the anesthetic is not "washed out' of the area as quickly and the area stays "numb" longer. Absorption of epinephrine-containing anesthetics may cause unwanted side effects in patients with cardiovascular disease. A study by Niwa et al investigated the hemodynamic changes resulting from injection of 1.8 ml of 2% lidocaine with 1:80,000 epinephrine in 27 patients with cardiovascular disease, in order to examine the safety of epinephrine-containing local anesthesia for use on such patients.

The study monitored systolic blood pressure, diastolic blood pressure, mean arterial pressure, and heart rate after lidocaine with epinephrine was administered into the operative site over a period of sixty seconds, using aspirating technique to avoid injecting into blood vessels. The study found that there was a 4.1% increase in systolic blood pressure and a 5.1% increase in heart rate immediately after injection. Diastolic blood pressure and mean arterial pressure remained unchanged. There were no complaints of cardiac symptoms among the patients and no significant differences in hemodynamic responses related to the extent of the cardiac functional capacity. The study concluded that lidocaine-epinephrine was safe, with few, if any, hemodynamic consequences in patients with cardiovascular disease.

[ussfpa]

but it is obvious I didn't phrase my question right :(
Is there a difference in the epi concentration in dental syrettes vs the epi concentration of the multi-dose vials traditionally used for infiltration or nerve blocks outside of the gum line?

Am I making sense yet??? If not, no worries...I'll rephrase it later :D

Primum non Nocere

[Doc T]

Originally posted by ussfpa
but it is obvious I didn't phrase my question right :(
Is there a difference in the epi concentration in dental syrettes vs the epi concentration of the multi-dose vials traditionally used for infiltration or nerve blocks outside of the gum line?

Am I making sense yet??? If not, no worries...I'll rephrase it later :D

Primum non Nocere

gotcha now.... the typical concentration we use is 1% also with a 1:100,000 concentration. That is what you said the dental dosing was so it is all the same....

i should also have added fingers and toes to my areas not to use epi on......

[ussfpa]

Originally posted by Doc T
gotcha now.... the typical concentration we use is 1% also with a 1:100,000 concentration. That is what you said the dental dosing was so it is all the same....

i should also have added fingers and toes to my areas not to use epi on......
:D
Cool...thanks.

[Bandaid]

Back from weekend trip to New Orleans.... Caution- my answers may be affected slightly from a mild hangover! :D

First off, the solution originally came out as Hanks Balanced salt solution. I believe there are several trade brands. I did a quick internet search and found a supply house that sells the ADA accepted brand (Save-a-tooth). I am sure most emergency supply wharehouses sell it too. Here is the link....
http://www.life-assist.com/phoenix/md393.html


To the questions from Ussfpa-

Doc T is right, but the standard concentration for dental use is 2%lido w/1:100,000 epi . Understand that we also use lido w/ epi 1:50,000 for some surgeries,etc. When using proper technique(aspiration before injection/slow administration) the limiting drug dosage for normal patients is actually the lido not the epi. Approximately 10 1.8 ml carpules of 2% lido 1:100,000 epi can be given.

In cardiac patients, the limiting drug becomes the epi... usually limited to .04 mg of epi in any 30 minute period. Therefore, can only give 2 1.8 ml carpules of 2% lido 1:100,000epi.

Why use the epi if it can be a risk? Because it has been shown to produce much more profound anesthesia with longer results than without it. And lets be realistic... If they are not numb, your treatment hurts and the patient will release a LOT more epinehrine naturally due to the pain than any dental cartridge contains. For that matter, endogenous epi causes much more of a cardica response when I walk in with the white coat and the needle than any shot I have ever given. :D

The rule I learned, Never use vasoconstrictive anesthetics on "ending" appendages or areas that have no concurrent bloodflow. That is why you never use on tips of noses, fingers, toes, penis, etc. The mouth is highly vascular and bloodflow is never truly blocked so this is not a concern.

Axe- What anesthetics are you referring to? I use lido, articaine, bupivacaine, and mepivacaine. Just now starting to use septocaine regularly in dentistry. To my knowledge, bupivicaine (marcaine) is the longest acting option available and more than suffices for the treatment times that we require in my profession

Hope that helps

[Axe]

Originally posted by Bandaid

Axe- What anesthetics are you referring to? I use lido, articaine, bupivacaine, and mepivacaine. Just now starting to use septocaine regularly in dentistry. To my knowledge, bupivicaine (marcaine) is the longest acting option available and more than suffices for the treatment times that we require in my profession

Hope that helps

You named the three I was thinking of, Sir. Articaine, bupivicaine, and mupivicaine. Thank you.

[Bandaid]

Axe, you made me get out the old textbooks and do some research. :eek: memories......oh memories
There is one other amide type long lasting anesthetic. Its called etidocaine. Never used it, came out in 1985, don't know anyone using it either. Just a FYI

That was a good question, for field medics a longer lasting anesthetic could be very beneficial.
Doc T, do you know of any local anesthetics that last longer than 3-6 hours?

[Bandaid]

RitMed and medicChick-
I would definitely follow your standards for CYA purposes. But this is the best treatment for you or your loved ones if it happens around you in the civilian world. Taxis? I always thought of you as glorified medicaid Chauffeurs :D :D




Originally posted by Bandaid
Exam also determines that the tooth is slightly intruded into its bony socket. Any treatment needed to reposition it?

Just to finish my original post's questions, If a tooth is "pushed into" or intruded the socket (looks like a shortened tooth), no treatment is usually attempted to extrude it back out. The tooth itself usually erupts back to its previous position over time. Note, however, that treatment is still given and referral made as the tooth will very likely need a root canal due to the disruption of the blood supply.

For luxated teeth (loose and/or repositioned teeth) treatment is usually attempted to place back into the original position. This will definitely require anesthesia as the bone will still have innervation. Then refer as obviously this is is higher on the emergency list than a simple fractured tooth.

[medicchick]

Quick question on the "Save -A-Tooth" product. Is it a one time use deal, or a multiple use fluid? I looked, but couldn't really find the answer. Thanks:)

[Sneaky SF Dude]

saca muelas - What's is TX in a UW environment? I'm thinking yank that bad jackson and drive on.

[Bandaid]

SneakySF-

I honestly have to defer to you on that one. I don't have any experience making that type of call. I am speculating, but I would think there are many times when your situation warrants NOT referring for evac.
At that point, you have a decision. I would probably just anestitize, manipulate the tooth back into position, splint with wax, compress the bone around to tooth itself from inside and outside gums/bone together (like a pinching action) to REcompress the bone to tighten the tooth up. Give Ab and pain meds, try to allow the soldier to finish his mission. You always can extract if infection/severe pain become issues later.

Then then let me steal a line from Teutates...
after treatment then tell him to quit his crying and "to move out and draw fire. " LOL:D

[Sneaky SF Dude]

Originally posted by Bandaid
SneakySF-

I honestly have to defer to you on that one. I don't have any experience making that type of call. I am speculating, but I would think there are many times when your situation warrants NOT referring for evac.
At that point, you have a decision. I would probably just anestitize, manipulate the tooth back into position, splint with wax, compress the bone around to tooth itself from inside and outside gums/bone together (like a pinching action) to REcompress the bone to tighten the tooth up. Give Ab and pain meds, try to allow the soldier to finish his mission. You always can extract if infection/severe pain become issues later.

Then then let me steal a line from Teutates...
after treatment then tell him to quit his crying and "to move out and draw fire. " LOL:D

Sounds good. Especially since you added in that "you can always extract..." Thanks.

[Bandaid]

Originally posted by medicchick
Is it a one time use deal, or a multiple use fluid? Thanks:)

Come on now MedicChick...
Click your heals three times and say:
Infection control
Infection control
Infection control

J/K ;) :D

I am just goofing off, I had to think about it for a second too. I don't have a kit myself so this is just "off the cuff" . But you are placing that bloody tooth back into someone's mouth, so I wouldn't want to be the second person to use the container and get my tooth soaked in someone elses blood. HAHA No, I don't think it is reuseable. Sorry to play smart@$$, just had a sarcastic kind of day:cool:
Please forgive me? I know you will, your so tolerant of others (spilled spit cup tragedy) ;)

[medicchick]

Originally posted by Bandaid
Come on now MedicChick...
Click your heals three times and say:
Infection control
Infection control
Infection control

J/K ;) :D

I am just goofing off, I had to think about it for a second too. I don't have a kit myself so this is just "off the cuff" . But you are placing that bloody tooth back into someone's mouth, so I wouldn't want to be the second person to use the container and get my tooth soaked in someone elses blood. HAHA No, I don't think it is reuseable. Sorry to play smart@$$, just had a sarcastic kind of day:cool:
Please forgive me? I know you will, your so tolerant of others (spilled spit cup tragedy) ;)

All right, you're forgiven since I kinda walked into that one. I should have clarfied, I meant multi use for the same person. I'm thinking if it's their olld and junk, who's going tocare, but what about stuff growing in the fluid? Hmm, I might just have to e-mail the maker of the stuff.

If the spit cups spill again, who knows what I might need...j/k

:D :D :D

[Bandaid]

If you knock his teeth out on MORE than one separate occasion:eek: ...... do him the favor and at least buy him some new solution!!! ;) :D
He is a BTDT according to your profile... I will buy it for him on round two. The least I could do...poor guy.;):D

Sorry folks, back to the thread.

[RIT_MEDIC]

Originally posted by Bandaid
...Taxis? I always thought of you as glorified medicaid Chauffeurs :D :D


Bandaid:

Dont get me started on having to pay my own salary to treat/transport those individuals milking society.


James D

[medicchick]

Originally posted by RIT_MEDIC
Bandaid:

Dont get me started on having to pay my own salary to treat/transport those individuals milking society.


James D

Like a ride to the hospital for a pregancy test. Oh yeah, don't get me started either, I'll talk about the swollen testical the size of a water balloon. Yeah, you heard me.:D :D :D

[mac3982]

seeing that most of you know where i work ....DON'T GET ME STARTED!!!!!!

[medicchick]

Originally posted by mac3982
seeing that most of you know where i work ....DON'T GET ME STARTED!!!!!!

OK, you'd win hands down. One call in Detroit was more than enough for me.:cool:

[mac3982]

:D

[heatersbu11]

We used a product called Dentall. It was a paste you form and stick on the tooth. It turned hard and protected nerve and tooth until you could be seen by Dentist.