Dentists serve as officers in the military to provide preventative and specialty dental care to...

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