dentists serve as officers in the military to provide preventative and specialty dental care to...
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Dentists serve as officers in the military to provide preventative and specialty dental care to soldiers and their families. Dental careers are available in many specialty areas including orthodontics, oral surgery and pediatrics. Dentists on active duty receive special pay in addition to their officer basic pay.
Short DescriptionDental care is one of the health services provided to all military personnel. It is available in military dental clinics all over the world. Dental specialists assist military dentists in examining and treating patients. They also help manage dental offices.
What They DoDental specialists in the military perform some or all of the following duties: Help dentists perform oral surgery
Prepare for patient examinations by selecting and arranging instruments and medications
Help dentists during examinations by preparing dental compounds and operating dental equipment
Clean patients’ teeth using scaling and polishing instruments and equipment Operate dental X-ray equipment and process X-rays of patients’ teeth, gums, and jaws Provide guidance to patients on daily care of their teeth Perform administrative duties, such as scheduling office visits, keeping patient records, and ordering dental supplies
Helpful AttributesHelpful school subjects include biology and chemistry. Helpful attributes include: Ability to follow spoken instructions and detailed procedures
Good eye-hand coordination Interest in working with people
Training ProvidedJob training consists of classroom instruction, including practice in dental care tasks. Further training occurs on the job and through advanced courses. Course content typically includes: Preventive dentistry
Radiology (X-ray) techniques Dental office procedures Dental hygiene procedures
Work EnvironmentDental specialists in the military usually work indoors in dental offices or clinics. Some specialists may be assigned to duty aboard ships.
Civilian CounterpartsCivilian dental specialists work in dental offices or clinics. Their work is similar to work in the military. They typically specialize in assisting dentists to treat patients, provide clerical support (dental assistants), or clean teeth (dental hygienists).
Emergency management Facial exam Fractures
Major Minor
Soft tissue injuries Unusual injuries
Acute Airway compromise Exsanguination Associated intracranial or cervical-spine injury
Delayed Meningitis Oropharyngeal infections
Estimated 3,000,000 facial trauma cases per year in USA
Estimated 40 to 50% of motor vehicle victims have facial injury
No uniform reporting or registry of cases
Respiratory upper airway Visual Olfactory Mastication Cosmetic Communication Individual recognition
Airway control / immobilize cervical spine Bleeding control Complete the primary survey Secondary survey
Consider NG or OG tube placement
Plain radiographs if fractures suspected CT if suspect complex fractures
Repair soft tissue immediately if no other injuries
Delay soft tissue repair until patient in OR if surgery for other injuries necessary
Step 1: Airway control Oxygen for all patients May need to keep patient sitting or prone Stabilize C-spine early Large bore (Yankauer) suction available
Step 1: Airway control Orotracheal intubation preferred over
nasotracheal if possible midfacial fracture and invasive airway needed
Combitube®, retrograde wire, or cricothyroidostomy if unable to orotracheally intubate
Step 2 : Bleeding control Can be major threat to life Use universal precautions Direct pressure dressings initially Contraindicated: blind vessel clamping
Step 2 : Bleeding control Rapid nasal packing may be necessary
Be sure blood is not just running down posterior pharynx
Step 2 : Bleeding control Rarely: emergent cutdown and ligation of
external carotid artery needed to prevent exsanguination
Note: Although shock in facial trauma patient is usually due to other injuries, it is possible to bleed to death from a facial injury
Blood in airway “Debris” in airway
Vomitus, avulsed tissue, teeth or dentures, foreign bodies
Pharyngeal or retropharyngeal tissue swelling
Posterior tongue displacement from mandible fractures
Scalp Check for lacerations, hematomas,
stepoffs, tenderness Bleeding maybe brisk until sutured Can use stapler for rapid closure
Ears Examine pinnae, canal walls, tympanic
membranes Suction gently under direct vision if blood
in canal Put drop of canal fluid on filter paper for
“ring sign” CSF leak Assess hearing
Eyes Pupils, anterior chamber, fundi,
extraocular movements Conjunctivae for foreign bodies Palpate orbital rims
No globe palpation if suspect penetration
Eyes Lid injury can leave cornea exposed
Use artificial tears or cellulose gel
Overall facial appearance Assess for symmetry, deformity,
discoloration, nasal alignment Palpate forehead & malar areas
Nose Check septum for hematoma & position Check airflow in both nares Palpate nasal bridge for crepitus Check fluid on filter paper for “ring sign”
(for CSF leak)
Mouth Check occlusion Reflect upper & lower lips Check Stenson's duct for blood Palpate along mandibular and maxillary
teeth (be careful !)
Mouth Palpate along exterior of mandible Pull forward on maxillary teeth
Neurologic Skin fold symmetry at rest Motor: each division of CN-VII Sensation: 3 divisions of CN-V Sensation on tongue Gag reflex
Major Lefort I, II, III Mandibular
Minor Nasal Sinus wall Zygomatic Orbital floor Antral wall Alveolar ridge
Nasal fracture 30 g Zygoma fractures 50 g Mandibular (angle) fractures 70 g Frontal region fractures 80 g Maxillary (midline) fractures 100 g Mandibular (midline) fractures
100 g Supraorbital rim fractures 200 g
Lefort fractures can coexist with additional facial fractures
Patient may have different Lefort type fracture on each side of the face
Pull forward on maxillary teeth Lefort I: maxilla only moves Lefort II: maxilla & base of nose move: Lefort III: whole face moves:
Horizontal fracture extending through maxilla between maxillary sinus floor & orbital floor Crepitus over maxilla Ecchymosis in buccal vestibule Epistaxis: can be bilateral Malocclusion Maxilla mobility
Closed reduction Intermaxillary fixation: secures maxilla to
mandible May need wiring or plating of maxillary
wall and / or zygomatic arch Antibiotics: anti-staphylococcal
Subzygomatic midfacial fracture with a pyramid-shaped fragment separated from cranium and lateral aspects of face
Signs & symptoms Midface crepitus Face lengthening Malocclusion Bilateral epistaxis Infraorbital paresthesia Ecchymoses: buccal vestibule,
periorbital, subconjunctival
Hemorrhage or airway obstruction may require emergent surgery
Treatment can often be delayed till edema decreased
Usually require Intermaxillary fixation Interosseous wiring or plating of
infraorbital rims, nasal-frontal area, & lateral maxillary walls
May need additional suspension wires Antibiotics
Craniofacial dissociation Bilateral suprazygomatic fracture
resulting in a floating fragment of mid-facial bones, which are totally separated from the cranial base
Signs and Symptoms Face lengthening: “caved-in” or “donkey
face” Malocclusion: “open bite” Lateral orbital rim defect Ecchymoses: periorbital, subconjunctival
Signs and Symptoms Bilateral epistaxis Infraorbital paresthesia Often medial canthal deformity Often unequal pupil height
Usually associated with major soft tissue injury requiring emergent surgery for bleeding control
Surgery can be delayed till edema resolves
Intermaxillary fixation
Transosseous wiring or plating Frontozygomatic suture Nasofrontal suture May need extracranial fixation if concurrent
mandibular fracture Antibiotics
Nasal fracture 30 g Zygoma fractures 50 g Mandibular (angle) fractures 70 g Frontal region fractures 80 g Maxillary (midline) fractures 100 g Mandibular (midline) fractures
100 g Supraorbital rim fractures 200 g
Airway obstruction from loss of attachment at base of tongue
>50 % are multiple Condylar fractures associated with ear
canal lacerations & high cervical fractures
High infection potential if any violation of oral mucosa
Signs and symptoms Malocclusion Decreased jaw range of motion Trismus Chin numbness Ecchymosis in floor of mouth Palpable step deformity
Tongue blade test: have patient bite down while you twist. If no fracture, you will be able to break the blade.
Treatment Prompt fixation: intermaxillary fixation
(arch bars), +/- body wiring or plating
Can occur from direct blow to mandible Can occur “spontaneously” from yawning
or laughing Mandible dislocates forward & superiorly Concurrent masseter & pterygoid spasm
Symptoms Patient presents with mouth open, cannot
close mouth or talk well Can be misdiagnosed as psychiatric or
dystonic reaction
Treatment Manual reduction: place wrapped thumbs
on molars & push downward, then backward
Be careful not to get bitten Usually does not require procedural
sedation or muscle relaxants
Nasal fracture 30 g Zygoma fractures 50 g Mandibular (angle) fractures 70 g Frontal region fractures 80 g Maxillary (midline) fractures 100 g Mandibular (midline) fractures
100 g Supraorbital rim fractures 200 g
Often diagnosed clinically: x-ray not needed
Emergent reduction not necessary except to control epistaxis
Usually do not need antibiotics Early reduction under local anesthesia
useful if nares obstructed
Nasal septal hematoma: incise & drain, anterior pack, antibiotics, follow-up at 24 hours
Follow-up timing for recheck or reduction: Children: 3 to 5 days Adults: 7 days
Nasal fracture 30 g Zygoma fractures 50 g Mandibular (angle) fractures 70 g Frontal region fractures 80 g Maxillary (midline) fractures 100 g Mandibular (midline) fractures
100 g Supraorbital rim fractures 200 g
Tripod (tri-malar) fracture Depression of malar eminence Fractures at temporal, frontal, and
maxillary suture lines
Isolated arch fracture Less common Shows best on submental-vertex x-ray
view Painful mandible movement Usually treat with fixation wire if arch
depressed
Tripod S & S Unilateral
epistaxis Depressed malar
prominence Subcutaneous
emphysema Orbital rim step-
off
Altered relative pupil position
Periorbital ecchymosis
Subconjunctival hemorrhage
Infraorbital hypoesthesia
Nasal fracture 30 g Zygoma fractures 50 g Mandibular (angle) fractures 70 g Frontal region fractures 80 g Maxillary (midline) fractures 100 g Mandibular (midline) fractures
100 g Supraorbital rim fractures 200 g
Frontal sinus fracture Often associated with intracranial injury Often show depressed glabellar area If posterior wall fracture, then dura is torn
Ethmoid fracture Blow to bridge of nose Often associated with cribiform plate
fracture, CSF leak Medial canthus ligament injury needs
transnasal wiring repair to prevent telecanthus
“Blow out” fracture of floor Rule out globe injury
Visual acuity Visual fields Extraocular movement Anterior chamber Fundus Fluorescein & slit lamp
Symptoms and signs Diplopia: double vision Enophthalmos: sunken eyeball Impaired EOM’s Infraorbital hypesthesia Maxillary sinus opacification “Hanging drop” in maxillary sinus
Diplopia with upward gaze: 90% Suggests inferior blowout Entrapment of inferior rectus & inferior
oblique Diplopia with lateral gaze: 10%
Suggests medial fracture Restriction of medial rectus muscle
Sometimes extraocular muscle dysfunction can be due to edema and will correct without surgery
Persistent or high grade muscle entrapment requires surgical repair of orbital floor (bone grafts, Teflon, plating, etc.)
Before repair, rule out injury to: Facial nerve Trigeminal nerve Parotid duct Lacrimal duct Medial canthal ligament
Remove embedded foreign material to prevent tattooing
For lip lacerations, place first suture at vermillion border
Never shave an eyebrow: may not grow back
If debridement of eyebrow laceration needed, debride parallel to angle of hairs rather than vertically
Antibiotics for 3 to 5 days for any intraoral laceration (penicillin VK or erythromycin) and if any exposed ear cartilage (anti-staphylococcal antibiotic) – no evidence
Remove sutures in 3 to 5 days to prevent cross-marks
Most face bite wounds can be sutured primarily
Clean facial wounds can be repaired up to 24 hours after injury
Place incisions or debridement lines parallel to the lines of least skin tension (Lines of Langer)
Assess ABC's first Do complete exam as part of secondary
survey Obtain standard X-rays and / or CT scan
as indicated Decide if specialist referral and / or
operative repair indicated
Arrange followup after repair to assess for delayed complications or cosmetic problems