Using the Modified Dental Aid Bag

LTC Steven Eikenbergt LTC Robert Meyertt Purpose To describe the need for and modifications to the Dental Instrument Supply Set (DISS) Emergency Treatment Field (ETF), LIN F95504, UA 7039. Dental officers of the 257th Medical Company (Med Co) (Dental Service (DS)) have used a Modified Dental Aid Bag (MDAB) on multiple deployments. Most recently, the MDAB was utilized during relief efforts after Hurricane Marilyn on St Thomas, U.S. Virgin Islands.
Introduction

* When a dental officer is a member of a rapidly deployed force package and cargo space is not allocated for dental equipment. * During initial deployment, convoy operations, and redeployments within theater, when a clinic cannot be established. * On-site awaiting the establishment of a dental treatment facility or prior to redeployment after the dental treatment facility has been closed. * As a back-up treatment capability when equipment malfunctions or electrical power is not available. * During operations when personnel are unable to join with equipment at a predetermined location. Without equipment, dental personnel are incapable of performing the mission. 1 * During civilian assistance missions or visits to remote troop locations. Except for the Forward Surgical Teams (FST), most medical and dental personnel arrive in an area of operations before their equipment. After medical and dental personnel are reunited with their equipment, they may have to ground convoy for days to the site where the medical facility is to be established. Although some treatment facilities can be established almost immediately, a Deployable Medical Systems (DEPMEDS) facility may require 3 or more days to be established. The Modified Aid Bag (MAB) will enable the dentist to render emergency care when a dental treatment facility has not or cannot be established. If required, a forward deployed medical facility can provide an exam light and a portable suction unit. Local Civilians, Allied Military Personnel, Volunteer Relief Workers, and Civilian Contract Workers may present with odontogenic infections and pain of a dental origin as soon as the military dentist arrives in theater. 2 Most recently, the Dental Aid Bag was utilized in the Virgin Islands during the mission to provide relief after Hurricane Marilyn. Civilian dental offices were destroyed, or were inoperable, due to the interruption of electrical power. The St Thomas Hospital Dental
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The 257th Med Co (DS) at Fort Bragg, NC, is an airborne-capable unit that provides area dental support within the XVIII Airborne Corps area of operation. The 25th Med Co (DS) provides the dental component of the 44th Medical Brigade (Airborne) Medical Readiness Force I. The 25th can reinforce or reconstitute division level dental assets. The unit provides additional combat care capabilities to medical treatment facilities by utilizing the alternate wartime roles of the dental officer. This article describes how the MDAB has been utilized on multiple deployments and training missions in which the 257th has participated. The MDAB replaces the present DISS UA 7039 (Dental Emergency Treatment Bag). It also details the modifications of the DISS that increase the treatment capability of a deployed dental officer.
Deploying with a Dental Aid Bag

Dental officers from the 257th have accumulated a wide range of experience providing dental care during various types of deployments, both real world missions, and to the Joint Readiness Training Center. In a rapid deployment scenario, dental equipment is usually not placed high on the time phased deployment list. Utilizing a dental aid bag, early dental casualties and emergencies can be treated without evacuation. A dental aid bag can be utilized:

tDental Corps. LTC Eikenberg is assigned to the U.S. Army Dental Research Detachment with duty at the U.S. Navy Institute of Dental Research, Great Lakes, IL. ttDental Corps. LTC Meyer is the Commander, 257th Med Co (DS), Fort Bragg, NC.

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Clinic was without full electric power until the 10th day after the hurricane. The 257th Dental Officer arrived in St Thomas with the advance party of the 28th Combat Support Hospital (CSH), 7 days after the hurricane. Thirty-five civilians, Federal Emergency Management Agency Employees, Red Cross Volunteers, and Military Personnel were treated utilizing the instruments and materials in the aid bag, before the DEPMEDS dental clinic of the 28th CSH was established. Because of the large number of patients treated with the aid bag, additional gloves, masks, sterilization bags, and local anesthetic were obtained from the staff at St Thomas Hospital. The hospital dental clinic sterilizer, utilizing emergency generator power, was employed to sterilize instruments. The supplies in the aid bag, in addition to the 32 pound Kevex Handheld X-ray, gave the dental officer the capability to perform Forensic Dental Identification exams. Dental officers deploying on future "disaster relief missions" may need to modify the aid bag to meet this mission requirement. In the Virgin Islands, the aid bag was also used to provide mobile dental care to elderly civilian personnel who were staying in a temporary shelter. The DEPMEDS Dental Clinic ofthe 28th CSH was packed for redeployment 6 days before the main party of personnel redeployed to Fort Bragg. Utilizing the dental aid bag, the dentist treated an additional 15 patients during that time. The MDAB was utilized in Haiti during Operation Uphold Democracy. When the 82d Airborne Division prepared for a forced entry into Haiti, in September 1994, the division dental officers were to "jump in" with a dental aid bag. If dental equipment and treatment sets were needed, they were to follow at a later date. Before an Army Dental Clinic was established on Haiti, dental emergencies were medically evacuated to the Navy Hospital ship positioned offshore. These personnel were lost to their unit for up to 12 hours. The 257th personnel, attached to the 28th CSH, arrived on the island on D+6. The 28th CSH personnel waited 2 days for the DEPMEDS hospital to arrive in country. The dental clinic was not established until D+1 1.From D+6 until D+ 11, five soldiers and three United States civilians were treated, utilizing the MDAB. Without the capability provided by the MDAB, these patients would not have received dental treatment unless they were also medically evacuated. The MDAB was also used during visits to civilian hospitals and orphanages. During Operation Desert Storm, several dental officers improvised "dental aid bags" for use during the ground offensive into Iraq. Dental officers with the

87th Medical Detachment (Med Det) utilized an aid bag and provided dental care from the tailgate of a M1008 pickup truck. A dental officer attached to the 3d Armor Division provided dental care on convoy operations utilizing a modified equipment chest. 3 On Joint U.S. Honduran Medical Assistance visits to villages on the isolated northeast coast of Honduras, the aid bag, augmented by a duffle bag of disposable supplies, was employed for 7-day missions. An average of 20 patients a day were treated. The 257th performed similar missions in Columbia, Costa Rica, and Guyana. The 257th Med Co Dental Officers have "jumped" with the MAB on Airborne Emergency Readiness Deployment Exercises. The contents ofthe aid bag have remained intact. Utilizing a patient examination light and a portable suction machine from a FST, the dental officer can provide a wide range of treatment options to the emergency dental patient. Justification for Aid Bag Modifications The present DISS, ETF, gives the dental officer limited treatment capability. One of the antibiotics listed in the packing list, erythromycin, is no longer a drug of choice for odontogenic infections. Files for endodontic debridement are not included. 4 Recognizing the limitations of the present dental emergency treatment bag, the officers ofthe 257th have created a MDAB. A proposed packing list for MDAB is shown below. Case Medical Instrument
and Supply Set No. 17 6545-01-161-7145

Compartment 1 Atropine, anaphylaxis kit Ibuprofen tabs, 800 mg, bottle of 100 Penicillin, 500 mg tabs, bottle of 100 Clindamycin, 250 mg tabs, bottle of 100 Lidex gel 15 gr tube Airway, pharyngeal lg adult Marcaine 1:200,000 can of 50 Xylocaine 2% 1:100,000 pack of 10 Envelope, self-seal, polyethylene Floss, waxed, individual size Stethoscope Sphygmomanometer Toothbrush, individual

2 1 1 1 2 1 1 3
15

1 1 1 10

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Compartment 2 Gloves, sterile, pair, size (Dr choice) Gloves, exam, vinyl, pair, size (Dr choice) Mask, surgical Protective eyewear Autoclave tape, 1 in diameter roll Cut segments of 2 in sterilization roll Compartment 3 Tray instrument with lid 8x8x2 Monojet syringe irrigating 10 cc Handpiece, battery operated with straight nose and contra angle attachments (Bell Model RX100) Compartment 4 5% iodoform sterile packing strip Sterile alcohol pads, individual Surgical scalpel blade No. 15 Individually bagged and sterilized; syringe, aspirating, anesthetic Forcep, tooth No. 23 Forcep, tooth No. 150s Forcep, tooth No. 151s Elevator, 34s Elevator, 301 Curette, miller No. 10 Elevator, periosteal molt No. 9 Handle, surgical scalpel blade Surgical suction tip Forceps, dressing 6 in Holder, suture needle collier Scissors, iris, curved Tissue forceps, addison 4.5 in Scissors, Dean angular 6 3/4 in 1 in cut Mouth mirror with handle Explorer-probe dental No. 23 explor No. 4 probe Bagged and sterilized perio pack consisting of Curette perio gracey 11-12 Curette perio gracey 5-6 Scaler dental No. U15 and 30 dbl end Compartment 5 Wire 25 gauge wire 1 oz, for oral sx Splint set, arch wire dental Pliers, diag cutting surgical wire Bacitracin ointment

10 30 30 1 1 20 1 2 1

Suture sz 4-0, absorb, polyglycolic Suture sz 4-0, nonabsorb, ethicon Bandaids pk of 10 Adhesive tape lin x 10 yds, porous 4x4 sterile gauze, packs Compartment 6 Cement, ZOE, IRM ivory, kit powder & lq Glass ionomer cement, kit powder & lq Matrix band, dental No. 1 pk of 10 Matrix band, dental No. 2 pk of 10 Fuji IX, glass ionomer restorative material Spatula dental flat, mixing Articulating paper, book Bur, surgical No. 702 pk of 10 Bur, latch type No. 4 pk of 10 Bur, latch No. 8 pk of 10 Bur, latch No. 557 pk of 10 Endo files, 25 mm set 1-35 Endo files, 25 mm set 40-70 Gates glidden burs size 4-6, each Bagged and sterilized operative pack consisting of excavator dental black's Nos. 38 & 40 Forceps, dressing tweezer type 6 in 1 g Plugger plastic fillin Ladmore No. 3 dbl end Carver dental hollenback No. 12 Carver dental tanner No. 5 Tofflemire, retainer, matrix, band Ortho pack consisting of elastic ligatures Wire ligatures Compartment 7 - side pocket Pen, black ink SF Form 603 Small memo pad

10 5 3 2 10 1 1 1 1 1 1 1 1 1 1 1
2 2 2 1 1 1 1 1 2 10 10

1 50 4 2 1 1 1 1 1 2 2 2 1 2 1 1 1 1 6 6 1 1 1 1 2 1 3

2 20 1

The MDAB weighs just 23 pounds and can be placed in a large All-Purpose, Lightweight Individual Carrying Equipment (ALICE) Pack, or attached to the frame below the ALICE Pack. The MDEAB utilizes a different bag or case. The M5 bag (6545-00-9129890), on the present equipment listing, has several deficiencies. The bag has one large compartment and instruments cannot be packed so that they may be easily located. The case for the MDAB (6545-01-161-7145), surgical case instrument No. 17, enables dental instruments and supplies to be placed in smaller
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compartments. These compartments are used to segregate the instruments based on the procedure being performed (Figures 1 thru 4). The MDAB gives the dentist expanded capabilities. Trained dental officers have the capability to place arch bars on fractured jaws or dental alveolar fractures, suture oral facial trauma, extract teeth (including impactions), debride sites of periodontal infections, place temporary fillings, and start endodontic treatment. The ability to treat oral facial trauma is important. Ten percent of hospital admissions in Vietnam involved facial injuries. 5 According to the North Atlantic Treaty Organization Emergency War Surgery Handbook, the initial management of

maxillofacial injuries include hemorrhage control, airway maintenance, fracture reduction, and infection prevention. The MDAB contains a Bell Electric Dental Handpiece, Model XR100, that can operate on a rechargeable battery. The handpiece provides the dentist with the capability to remove the bone around teeth and to section teeth for extraction. The latch type contra angle enables the dentist to remove caries

Fig. 3. M17 bag open to show its 6 equal size compartments(l x 5 x 8 inch side pocket not visible).

Fig. 1. Modified Dental Aid Bag (M17) on left, DISS (M5) on right.

Fig. 2. Open M5 bag demonstrating its one large open area and four small pockets.
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Fig. 4. Modified Dental Aid Bag placed underneath large rucksack.

from teeth, or provide access for endodontic procedures. Presterilized instruments are packed in the aid bag. The bag receives quarterly preventive maintenance checks and services to insure that the expiration date for instrument sterility and medications are at least 4 months in the future. The principle limitation of the bag is the incapability to sterilize instruments. A total of approximately 10 patients can receive invasive treatment before the presterilized instruments must be utilized. This limitation can be overcome by the use of a sterilizer belonging to a medical treatment team that may be in the area. At other times, dirty instruments were separated from the aid bag and sterilized after the dental clinic was established. Although not ideal, in isolated situations, instruments have been sterilized by boiling. The present DISS contains a liquid sterilization solution (2% glutaraldehyde); this has not proven to be practical. Plastic bottles containing any solution will often leak during deployment due to the rough handling the bag will encounter. A future development that may overcome the sterilization limitation is a sterilization powder presently under development. When this powdered material is mixed with water at a minimum temperature of 68F, the solution can sterilize instruments within 20 minutes. 6 There are a limited amount of disposable supplies in the MAB. There are enough nondental specific supplies such as gloves, masks, and cotton gauze to treat approximately 20 patients. There are enough local anesthetic capules and needles to treat approximately 50 patients. Historically, it has been more difficult to be resupplied with these dental specific items. 7 Paper sterilization bags are not adequate for the MDAB. The paper tends to seat or accumulate moisture during a deployment. The contents in the MDAB are subjected to rough handling in a field environment. The instruments easily tear through the paper side of the sterilization bag. A two-inch wide plastic sterilization roll is superior for this purpose. Cotton rolls are placed over the points of sharp instruments. During field testing, sterile instruments have not punctured through the all-plastic bag. Bottles containing liquid or powder should be sealed with tape if the factory seal has been broken. This will help to prevent materials from spilling or

leaking in the bag. Measuring scoops for materials should be taped to the material container. A series of endodontic files should be placed in a 2-by 2-inch gauze and sterilized in a section of 2-inch plastic sterilization roll. All burs should be grouped and placed in one sealable baggie (envelope, self-seal, polyethylene (8105-01-099-0355)). Matrix bands and endodontic burs are grouped into separate baggies. Medication can also be dispensed to a patient using these baggies. A field expedient exam light is the flashlight that each soldier takes on a deployment. Dental treatment can also be performed using sunlight. If a medical treatment facility is already established, an exam or treatment lamp is usually available. Treatment can be accomplished with the patients in a conventional chair or on a stretcher with the patient's head raised. The 257th has included Fuji IX glass ionomer for a traumatic restorative treatment as part of the aidbag. This material provides a semipermanent way to fix carious teeth. 8 There is space in the MAB for a dental officer to pack extra supplies or instruments specific to the mission. Additional disposable supplies may be required for civilian assistance missions. Additional restorative supplies may be required for visits to remote areas where U.S. soldiers are stationed. Discussion The present DISS, ETF, LIN F95504, UA 7039 should be improved to provide better dental care to soldiers in the field. The Defense Medical Standardization Board is slow to produce changes to the packing list of any sets, kits, and outfits. Field dental units and officers should not hesitate to upgrade the DISS ETF Army dentists have the responsibility to provide the soldiers the best dental care possible under a variety of circumstances. Dentists are deployed to support the soldier. The well-being of a soldier is not enhanced when he is told "your discomfort is not a true emergency and can wait, we'll evacuate you later to a facility in the rear." The delivery of modem dental care affects not only unit readiness, but individual soldier morale. 9 Even if every soldier deploys in perfect dental health, emergencies can and do occur. The

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expanded dental mission has increased our potential patient population. Recently in Somalia, Haiti, Guantanamo, and the Virgin Islands, U.S. Medical Personnel have been responsible for providing care to personnel who are not in the U.S. military. These foreign military, civilian contract workers, and local civilian patients often have a greater need for emergency dental treatment. Some healthcare professionals state that adequate emergency care consists of relieving pain with longacting local anesthetic and codeine. Simply relieving pain with a long-acting anesthetic, such as Marcaine, is not in the soldier's best interests. The lack of proprioception, resulting from local anesthetic, can interfere with the soldiers ability to eat, communicate, wear the Kevlar, or wear the M40 protective mask. Eventually, the soldier must be evacuated from his unit area. The soldier's unit must often provide the vehicle and driver used in the evacuation. The patient, the driver or escort, and the vehicle, may be lost to the unit for an extended period of time. The MDAB can replace the DISS, ETF, LIN F95504, UA 7039. The MDAB should be distributed on a basis of one bag to each Division Dentist, Special Forces Dentist, and Dentist in a separate medical company. One aid bag should be carried by the general dentist in a table of organization and equipment hospital. Since a Med Co (DS) may deploy up to 10 separate clinics, 10 bags should be distributed to each. Four bags should be distributed to each Med Det (DS).

Summary This article is intended to express the need to place a MDAB in the hands of the Army's Field Dentists. On deployment, the dental officer will discover that dental emergencies will arise when a dental treatment facility is not established. Soldiers, who might otherwise be evacuated far from their unit, can be properly treated by dental officers utilizing a modified, self-contained, lightweight dental aid bag. References
1.Mitchell WL, Knowles MJ. Emergency Dental Deployment Bag and Support of Air Land Battle. JMil Med. March-April 1991;25-26. 2. Eikenberg S, White K. Report of Dental Emergencies Treated by the 257th Med Co in Haiti. Med Dept J. September-October 1995;17-21. 3. Baker WP, Pietz D. The Experience of a Unit Dental Officer During the Gulf War. Med Dept J May-June 1995;20-24. 4. GR 27. Dental Officers Field Guide. U.S. Army Medical Department Center and School, Fort Sam Houston, TX, August 1993;p F-24. 5. King JE, Brunner DG. Theater of Operations, Dental Workload Estimates. U.S. Army Health Services Command, May 1984. 6.Conversation with COL Robert Vandre. U.S. Army Dental Research Institute. Fort Meade, MD, November 6, 1995. 7. Baker WP, Pietz D. The Experience of a Unit Dental Officer During the Gulf War. Med Dept J May-June 1995;20-24. 8. Frencken JE, et al. A traumatic Restorative Technique. Int Den J. November-December 1994;19-22. 9. Conversation with MAJ Keith Cipriano. 528th Combat Stress Detachment, Fort Bragg, NC, November 20,1995.

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