3/4/2014 Dental Skills Lab Kip Benko MD FACEP Denise Ramponi, DCRNP Mary Jo Cerepani, DCRNP Joseph Mattis, CRNP Dental Skills Lab  Introductions  Models  Gloves/Latex Free  Garbage/sharps containers  Instruments  Evaluations  Format/partners/questions 1 3/4/2014 Objectives  Become familiar with equipment  Become comfortable with dental anatomy & dental regional anesthesia.  Become knowledgable about dental materials/medications/emergencies  Become confident with your skills when confronted with a dental emergency Equipment for use in Facial Anesthesia  Marcaine  Benzocaine  Syringes & Needle systems  Q-Tips Why know facial anesthesia? 1. Makes your job easier…. 2. Makes your patients more comfortable 3. Allows for better cosmesis 2 3/4/2014 Injection Techniques Rules of the Road  Wear Gloves  Keep needles sheathed.  Take Your Time/Ask questions!!  Have Fun & Be Safe--Always Aspirate! Topical Anesthetic  Remember, topical anesthetic decreases the pain of injection!  Check for allergies.  Open up benzocaine.  Put one glove on nondominant hand.  Get a small glob on your Qtip. Topical Anesthetic  Retract lip  Apply a small amount to the mucobuccal fold over 2 or 3 teeth.  Wipe mucosa dry in 12 minutes. 3 3/4/2014 Blocks You Should Know  Supraperiosteal Infiltration  Infraorbital Nerve Block  Greater & Nasopalatine Blocks  Inferior Alveolar Nerve Block  Mental Nerve Block Preparing Your Syringe  Advantages of Ring Syringes. --better control --aspiration  Remove the safety syringe from the wrapper. Preparing Your Syringe  Insert anesthetic carpule into the open end of the syringe barrel, metal end first. 4 3/4/2014 Preparing Your Syringe  Push the finger holder to the end of the plunger until it stops and covers the silicone O-ring.  Roll the “bull-nose” of the handle in behind the cartridge  Slide the sheath protecting the needle backwards. Make sure the sheath clicks into the black handle.  Remove the needle cover, inject a slight amount observing the “passive” aspiration after each injection. 5 3/4/2014 Locking the protective Sleeve  Slide the protective sleeve back over the needle until you feel two clicks. The sleeve should now be locked. Dismantling the Syringe  Pull the thumb ring completely back and gently tilt the end of the plunger out of the carpule. Assemble a new syringe again and leave intact. 6 3/4/2014 Supraperiosteal Injection  Indications  Review your Anatomy on Model  Practice on the models first.  Needle stays parallel to the root of the tooth, bevel toward the bone. Supraperiosteal Injection 7 3/4/2014 Supraperiosteal Injection Supraperiosteal Injection  NEEDLES COVERED!!  Retract Lip/shake (distraction)  Advance 3-4 mm.  Inject 0.5 cc to start.  Remember, more in the mandible. 8 3/4/2014 Infraorbital Nerve Block --indications Infraorbital Nerve  Review Anatomy Infraorbital Nerve  Retract lip with noninjecting thumb; index finger is on orbital rim.  Enter mucobuccal fold using premolars as your guide. 9 3/4/2014 Infraorbital Nerve Block  Advance needle to endpoint. --Approx. 1.5 cm.  Aspirate and inject. Infraorbital Nerve Block Infraorbital Nerve Block  Massage  Don’t poke finger!! 10 3/4/2014 Infraorbital Nerve Block Greater Palatine & Nasopalatine Block  Review anatomy  Indications 11 3/4/2014 Greater & Nasopalatine Nerve Blocks  Review the anatomy on the models. Palatine Blocks  Use “distraction” techniques. ---Vibration ---Pressure Nasopalatine Block 12 3/4/2014 Greater Palatine Block Nasopalatine Block  Perform the block on your partner.  Use the central incisors as your landmark. Greater Palatine Block --Perform the block on your partner. --Locate your landmarks by finding the second molar. 13 3/4/2014 Inferior Alveolar Nerve Block  Indications  Review Anatomy Inferior Alveolar Nerve Block  Review Injection Points 14 3/4/2014 Inferior Alveolar Nerve Block  Review Models Mandibular Sulcus (under the pterygomandibul ar raphe) is the Needle Endpoint Inferior Alveolar Nerve Block  Retract Lip  Place thumb on anterior surface of the ramus  Approach from opposite premolars. Inferior Alveolar Block 15 3/4/2014 Inferior Alveolar Nerve Block Let’s Do It! Questions? Mental / Incisive Nerve Block  Indications  Review Anatomy  Exits beneath the roots of the premolars 16 3/4/2014 Mental//Incisive Nerve Block  Review the models.  Notice the alignment of the foramina over the premolars. Mental/Incisive Nerve Block Mental/Incisive Nerve Block --Perform the Block. -- Use the premolars as your guide. 17 3/4/2014 Injection Tips  Ask about allergies  Know your landmarks  Use topical anesthetic/vibration  Aspirate always  Reconsider if patient is on coumadin. Questions about Dental Blocks?? Onward to other dental emergencies!! 18 3/4/2014 Deep Painful Caries  Cover if painful.  Block the tooth first.  Cover with Temrex. --bactericidal --contains eugenol (anesthetic) Deep Painful Caries  Mix temrex as follows: place one scoop (~0.51 cm on spatula) powder and two drops liquid on your mixing pad. Mix with spatula. Deep Painful Caries  Apply to affected carie. (on your plaster model, not on your partner) 19 3/4/2014 Fractured Teeth  You only need to act if the dentin or pulp is exposed.  Components Fractured Teeth 20 3/4/2014 Fractured Teeth…. Why do anything??  Dentin fractures--relieves pain, prevents further contamination, may prevent root canal.  Pulp fractures--prevents further contamination, relieves pain. Calcium Hydroxide is preferred for the ED  Cheap & Easy  Sets up Fast  Watertight  PH neutral  Easy for the f/u dentist to work with. Covering the Tooth  Anesthesia First!  Dry the Tooth  Place equal drops of Dycal catalyst & base on your mixing pad.  Mix your Dycal with spatula. 21 3/4/2014 Covering the Tooth The Next Day Tips  Make sure the tooth is dry.  Don’t allow the dycal to get too thick before applying  Don’t allow eating of hard foods prior to follow up.  No evidence to support routine use of antibiotics for fractured teeth. 22 3/4/2014 Stabilizing Teeth Stabilizing Teeth--Luxation/Subluxation 23 3/4/2014 Periodontal Paste  Applied to gingiva and the enamel.  Should really apply it to both facial and oral gingiva. Periodontal Paste 1. Squeeze out equal lengths (approx. 1 inch) of catalyst and base onto your mixing pads. 2. Mix until completely mixed--about 20 -30 secs. 3. Grab coe-pak off of tongue blade with wet hands & roll into small cigar. Periodontal Paste  Keep hands WET!  Keep gingiva and teeth DRY!!  Apply to enamel and gingiva and “work” into inter-proximal spaces. 24 3/4/2014 Periodontal Paste Apply to the oral surface ( inside the mouth) as well, if needed. Tips  Apply with wet hands to dry teeth and gums.  Follow up the next day or ASAP  Do not pick at the periodontal dressing or eat hard foods. 25 3/4/2014 Avulsed Teeth  The trick is be to be fast, careful, and have the right stuff. 3 How Fast? 3 How Careful? 3 What Stuff? Avulsed Teeth  Rinse the root of the tooth…GENTLY!  Suction the socket….GENTLY!!  Replace the tooth…FIRMLY!! Avulsed Teeth  Stabilize tooth once you’ve replaced it.  No hard foods until seen the next day.  Antibiotics? 26 3/4/2014 Alveolar Osteitis  Loss of Clot after extraction.  Sxs. begin several days later.  Localized Osteomyelitis 3 Severe Pain Alveolar Osteitis (Dry Socket)  Block the Tooth  Suction/Irrigation  Pack the Socket Dry Socket  Follow up 24-36 hours.  No straws and no smoking.  No antibiotics. 27 3/4/2014 Loose Appliances/Deep Caries  Caps, Crowns, Fillings, etc.  Cyanoacrylates (Dermabond) not approved for mouth….yet. Dental Stuff  THEDENTALBOX.com  PATTERSONDENTAL.COM  HENRYSCHEIN.COM 28