Management of Traumatic Tooth Injuries in the Dental Office

Transcription

1 Management of Traumatic Tooth Injuries in the Dental Office John M. Coulter, D.D.S., O. Lee Wilson, D.M.D., Murray K. Marks, Ph.D. T D A EXAM #61 Introduction Pediatric and adult traumatic dental injuries can be challenging to treat by the dentist, because they are not routine. The nature of traumatic injuries necessitates time-sensitive treatment, often in an emergent, after-hours setting. Proper diagnosis, treatment and follow-up care are required to ensure the best possible outcome. With diagnosis and treatment planning of the dental emergency, it is of primary concern to consider the vitality and support of the periodontal ligament (PDL) and pulpal tissues. The correct immediate treatment can be administered and the anticipated future care plan can be communicated with the patient to achieve the predicted results. We provide an overview of the diagnosis and treatment of traumatic dental injuries encountered in the dental office setting. Protocol Assess the patient following a Where, When, and How questioning protocol. Where the injury occurred geographically will assist in determining bacterial contamination. When the injury occurred will aid in determining the necessary treatment and prognosis. Knowing How the injury occurred is necessary in identifying other facial or body parts that may be injured and require examination. Patient signs and symptoms such as headache, dizziness, nausea or loss of consciousness should be evaluated and appropriate referrals conducted. Lip or cheek lacerations may require an examination of those tissues to identify embedded tooth fragments or foreign bodies. Alveolar bone should be examined for pain, fracture, with or without lacerated mucosa, or segmental mobility. Evaluation of the teeth should focus on fractured, discolored, displaced or missing teeth. 1-3 Initially, oro-facial trauma is ABSTRACT categorized as involving soft tissue, hard tissue or both. Soft tissue injury includes lacerations and contusions to the face, particularly peri-oral, lips, tongue, gingiva, and remaining oral mucosa. Soft tissue wounds may indicate an underlying bony injury. Hard tissue trauma may present as damaged facial and/or alveolar bone including the teeth crowns and/or roots. Single or multiple tooth fracture(s) may include crown, root, crown-root, concussion, subluxation, lateral luxation, intrusion, extrusive luxation, and avulsion and may include multiple regions of a single tooth or multiple teeth 1,2 (Figure 1 and 2). Radiographs are essential to trauma assessment, especially to discern the degree of luxation, periodontal ligament (PDL) thickness, and crown/root developmental status. 4-7 Radiography is also essential in monitoring the healing process at subsequent appointments. A panoramic image provides the most practical structural view to assist in confirming horizontal and vertical ramus and condylar fractures. If a crown or root fragment or contaminating foreign body is suspected to be lodged in soft tissues, then a low exposure periapical radiograph is ideal for confirmation. For suspected crown or root fractures, radiographs using 94-2 Management of Traumatic Tooth Injuries in the Dental Office Dental trauma is sudden, unscheduled, and the dentist and staff must be adequately equipped to expeditiously and properly treat the patient to assure the best possible outcome. This paper reviews current dental trauma guidelines to provide the correct treatment protocol to ensure the best prognosis. The case report illustrates the technique of avulsion care, RCT care, and functional splinting in a successful manner. Keywords: dental trauma, avulsion, functional splinting, dental office emergencies, RCT, tetanus several different angulations should be used. 8 After examination and diagnosis, the dentist may initiate the appropriate treatment, following dental trauma guidelines by the American Association of Endodontists (AAE), American Academy of Pediatric Dentists, 9 and the International Association of Dental Traumatology. 10 Training received in dental school and practice experience increase predictable outcomes, while minimizing mistakes. No matter how much expertise one may possess, a thorough, well-designed checklist will improve treatment outcomes, especially for dental procedures not routinely practiced. The Recommended Guidelines of the American Association of Endodontists for The Treatment of Traumatic Dental Injuries 11 and the Dental Trauma Guide 12 offer guidance for confidently managing most dental trauma. The later site is excellent and contains primary and permanent teeth treatment guidelines and has been developed in cooperation with Copenhagen University Hospital and the International Association of Dental Traumatology (IADT). In treating traumatic dental injury, time is of primary concern. At presentation, the dentist should obtain a comprehensive history and should 31

2 Figure 1: Permanent dentition trauma (after Andreasen 2010; used with permission). Figure 2: Primary dentition trauma (after Andreasen 2010; used with permission.) Continuing Education Exam #61 32 Journal of the Tennessee Dental Association 94-2

3 Figure 3: Patient presentation in the emergency room after replanting of avulsed maxillary right central incisor #8). Figure 4: Fixture of physiologic splint securing tooth #8 to lateral incisor #7 and left central incisor #9. thoroughly evaluate extent of injury, and the precise time the injury occurred should be noted Management of an avulsed tooth is the most techniquecritical of dental injuries, with a primary goal to preserve and support the tooth root tissues. The most critical component in PDL preservation is the duration extraoral dry time Ideally, when avulsion occurs the tooth should be gently rinsed and immediately replanted in the alveolus. If this is not possible at the site of the incident, then it is crucial to store the tooth in an appropriate medium until treatment can be initiated by Emergency Room or dental office personnel. 18,19 Ideally, the surviving cells, primarily fibroblasts and fibrocytes, will produce new cells to differentiate and reform the supporting tissues A Hanks Balanced Salt Solution (HBSS) is the preferred transport medium with milk being a suitable alternative. 23 The value of a balanced salt solution will maintain ph and osmotic balance as well as provide cells with water and essential ions. A normal saline solution is an adequate substitution but does not have essential ions and does not provide cell nutrients. Since sporting events are typical dental trauma locations, often sports drinks such as Gatorade are readily available. Gatorade has a low ph preventing cell growth and is also hypertonic which results in cell dehydration. Compared to HBSS and milk, Gatorade is not as effective in maintaining cellular vitality; however, it is a preferable alternative when the aforementioned transport Figure 5: Periapical radiograph showing tooth #8 one week after being replanted. Figure 6: Periapical radiograph showing tooth #8 with Calcium Hydroxide dressing four weeks after being replanted. Figure 7: Periapical radiograph showing tooth #8 at obturation Management of Traumatic Tooth Injuries in the Dental Office 33

4 Continuing Education Exam #61 mediums are unavailable. Tap water storage should be avoided due to its low osmolality which may cause cell lysing. In fact, the cellular effects of storage in tap water have been found comparable to dry storage. 14 Treatment of the apical and surface root tissue of an avulsed tooth is dependent on the stage of root development, the extraalveolar time and the storage medium used. If the tooth has a closed apex and has been stored in a physiologic or osmotically balanced medium, or has been dry for less than sixty minutes, the tooth should be rinsed with saline and replanted without root manipulation. 16 Current recommendations by the AAE and the IADT recommend soaking the root surface with a 2% sodium fluoride solution for twenty minutes if the tooth has been dry for greater than sixty minutes. Avulsed teeth with an open apex have the potential for pulpal revascularization If the tooth has an open apex and has been stored in a physiologic or osmotically balanced medium or has been dry for less than sixty minutes, the AAE recommends that the root be soaked in doxycycline or minocycline (1mg per 20 ml of saline) solution for five minutes. The recommendation to soak the tooth is based on the anti-inflammatory and antibacterial properties of doxycycline, which may promote revascularization, promote PDL healing, and mediate processes that cause inflammatory root resorption. For any cells that survive, ideally they will reproduce new cells, which then differentiate and reform the supporting tissues. 22 The Figure 8: Incisal edges of the maxillary central incisors were contoured with Super-Snap Rainbow disks. Figure 9: Periapical radiograph at the 3 month recall. Figure 10: Photograph at the 3 month recall. worst prognosis is given for a tooth with an open apex an extraoral dry time greater than sixty minutes or the periodontal ligament is necrotic and there is not a chance for revascularization or regeneration. Due to the open apex, it is advised to complete root canal therapy prior to replantation. Treating the root with antibiotics or fluoride is not indicated. The likely outcome will be ankylosis or resorption of the root, so the goal of treatment is to maintain the alveolar contour and to achieve a positive esthetic, functional, and psychological outcome, if only for a temporary basis. 16,19 For patient comfort, a local anesthetic may be applied if the tooth is being replanted in a dental office. Prior to the tooth being replanted, blood in the socket may begin to coagulate. Coagulum may make tooth repositioning more difficult, but it is not detrimental to healing. The coagulum may be removed with a gentle rinse using sterile saline. Once any coagulum is removed, the alveolar bone may be examined for collapse of the socket wall. The walls may be repositioned with a blunt instrument, such as a mirror. This will allow the tooth to be replanted without damage to PDL cells that remain on the root. 16 The tooth should only be held by the crown and never by the root, thereby safeguarding cementoblasts and PDL cells. The crown should be gently washed with chlorhexidine, saline, or water, and replanted into the socket with slight pressure. Clinical and radiographic verification of proper tooth position should be made, with application of a flexible splint to stabilize 34 Journal of the Tennessee Dental Association 94-2

5 the tooth. 16,19 Current International Association for Dental Trauma 10 and American Association of Endodontists 11 guidelines outline the use of a functional splint for luxated and avulsed teeth. Splinting stabilizes and restores roots in their anatomical position, protects hard and soft tissues from traumatic forces, facilitates oral hygiene and prevents accidental ingestion or inhalation. The type of splint is determined by the extent of the injury. While treatment outcomes are not directly linked to splinting specifications, it is best to splint when indicated so that teeth are retained in the correct position for patient comfort. 19,27 A flexible split will maintain the teeth in their original position and allow PDL regeneration as well as provide for patient comfort and hygiene. The recommended 2013 American Association of Endodontists treatment guidelines advocate a flexible splint to stabilize teeth. However, this reference does not specify what is considered flexible. When splinting, both material type and size of the stint determine flexibility. When choosing splint material, the dentist should consider using composite to fix either 30 pound nylon monofilament fishing line or millimeter (mm) diameter stainless steel or nickel-titanium wire. Direct composite splints and splints using wire greater than 0.4 mm diameter are considered rigid and prohibit normal physiologic movement. Hard tissue injury, such as an alveolar process fracture, may require a more rigid splinting device. 28 Few studies have examined splint extension. Two studies advocate a design that incorporates only one uninjured mesial and distal tooth to the injured tooth. Extending the splint past one uninjured tooth on either or both sides increases horizontal rigidity but makes hygiene more difficult and potentially increases the risk of damaging enamel during splint removal. 29 The IADT and AAE guidelines advise Figure 11: Periapical radiograph at the 6 month recall Management of Traumatic Tooth Injuries in the Dental Office up to the clinician to evaluate the injury and recommend an appropriate length of 30, 31 splinting time. Post-op Care It is well documented that antibiotic coverage is best provided by systemic Doxycycline 2 times per day for 7 days at an age and weight appropriate dose. 11,16,19 Penicillin or Amoxicillin can be given as an alternative for patients with a tetracycline contraindication. If the avulsed tooth has contacted soil or tetanus coverage is in uncertain, then a tetanus booster is advised. 11,19 Generally, for a clean wound, a tetanus booster is required if more than ten years have passed. For contaminated wounds, a tetanus booster is required if more than five years have elapsed. 32 The AAE recommends a soft diet for two weeks to reduce further trauma to the supporting tissues and to allow healing. A soft brush should be used on the dentition after each meal, and the patient should be prescribed to use a 0.12% Chlorhexadine mouthrinse 2 times per day for 1 week. Follow-up visits should be discussed and re-evaluated at the time of splint removal. Conclusion Acute dental trauma will present in the dentist s office Figure 12: Photograph at the 6 month recall. in a variety of situations, each with different treatment modalities. Trauma may range from a light impact causing an Ellis Class I fracture to a heavy force resulting in the avulsion of a deciduous central incisor. Regardless of the type of dental trauma, they all splinting avulsed or luxated teeth for 7-14 present unexpectedly. Since days. Splinting times do not differentiate these patients are sporadic in presentation, between the degree of trauma, stage of the practitioner must be adequately root development (immature/short vs prepared to deliver the appropriate mature/long), and the extent of alveolar treatment. Choosing and expeditiously bone or root fracture. Essentially, it is delivering the correct treatment modality 35

6 Continuing Education Exam #61 36 will predictably save a traumatized tooth and ensure that the best care is provided for the patient. Case Report A twelve-year-old female patient presented to the University of Tennessee Medical Center Emergency Room for evaluation and treatment of an avulsed and replanted maxillary central incisor (#8). A dental hygienist at the scene of the accident witnessed the avulsion and immediately rinsed the root and replanted the tooth. A history and physical was obtained by the Emergency Room physician, and dentistry was consulted for treatment approximately three hours post-avulsion. A panoramic image showed no hard tissue fracture. Dental occlusion was normal. A small gingival laceration not requiring sutures was the only soft tissue trauma. Developmentally, the crown height of tooth #8 is 2 millimeters (mm) greater than tooth #9 (Figure 3 and 4). The patient was anesthetized with 1cc of 0.5% Bupivacaine with 1:200,000 epinephrine. Since no further intrusion could be obtained, tooth #8 was splinted to the adjacent incisor teeth using a 30 lb monofilament line bonding, the labial surface of teeth #7, 8 and 9 with Adper Easy- Bond (3M ESPE) self-etch adhesive and SureFil SDR Flow (DENTSPLY Caulk). The patient was instructed to follow up in 7-10 days for root canal therapy, eat a soft diet, and maintain good oral hygiene by using a soft toothbrush. Penicillin VK 500 mg for 7 days QID and 0.12% chlorhexidine BID was prescribed. One week later the patient returned for assessment and treatment. A periapical radiograph was obtained to determine apical root maturation and to gain a baseline for recall appointments (Figure 5). At this appointment, extirpation of the pulp and placement of calcium hydroxide in the canal was completed. A cotton pellet and TERM fill was placed in the Figure 13: Periapical radiograph at the 12 month recall. Figure 14: Photograph at the 12 month recall. pulp chamber. To achieve better stability of the tooth and prevent occlusal trauma, the existing splint was removed and replaced with a flexible one. Tooth #8 was splinted for another 4 weeks to extend decreased mobility. A periapical radiograph confirms healing of the periodontal ligament (Figure 6). Due to the patient s schedule, she returned two weeks later for obturation, some five weeks after the initial injury. The splint was removed. The patient was anesthetized with isolation via a rubber dam across teeth #7-9. Tooth #8 was accessed with removal of the cotton pellet and CaOH. The canal was instrumented using ProTaper Universal treatment files (DENTSPLY), and between each active file, the canal was irrigated with NaOCl confirming patency and reirrigation. The canal soaked in EDTA for two minutes, and EndoREZ sealer was expressed into the canal, and an F5 cone placed to working length. The coronal portion and excess removed leaving approximately 5mm in the apical portion. A DENTSPLY Calamus 3D obturation system was used for warm vertical backfill to the CEJ (Figure 7). The access was sealed with TERM, and the patient was instructed to return for tooth contouring and evaluation for any color modification. Two weeks after obturation, the patient returned for evaluation of tooth esthetics. The maxillary central incisal edges were contoured with Super-Snap Rainbow disks (Shofu) (Figure 8). The shade was stable and the access was sealed with composite. The patient returned for a 3 month (Figures 9 and 10), 6 month (Figures 11 and 12) and one-year recall (Figures 13 and 14). The patient was made aware that in the next 4-5 years, a veneer or full-coverage crown may be needed to restore any weakened or fractured enamel. She was also informed that if the Journal of the Tennessee Dental Association 94-2

7 root canal fails or root resorption occurs, then #8 will need to be restored with an implant/crown. Acknowledgements We thank Jens Ove Andreasen, First President of the International Association of Dental Traumatology, for permission to reproduce his internationally recognized illustrations and two anonymous reviewers for helpful comments. Disclosure: The authors did not report any disclosures. References: 1. Andreasen JO, Andreasen FM. Essentials of traumatic injuries to the teeth, 2nd edition. Mosby: St. Louis, Berman LH, Blanco L, Cohen S. Introduction, Chapter 1, pp In: A Clinical Guide to Dental Traumatology, Berman LH, Blanco L, Cohen S (eds.). Mosby Elsevier: St. Louis, Tsukiboshi M. Treatment planning for traumatized teeth, 2nd edition. Quintessence Books: Chicago, Andreasen JO. Luxation of permanent teeth due to trauma: a clinical and radiographic follow-up study of 189 injured teeth. Scan J Dent Res 78;1970: Laine FJ, Conway WF, Laskin DM. Radiology of maxillofacial trauma. Curr Probl Diagn Radiol 22;1993: Lam EWN. Trauma, Chapter 30, pp In: Oral Radiology, Principles and Interpretation, 7th edition, White SC, Pharoah MJ (eds.). Mosby Elsevier: St. Louis, Newman J. Medical imaging of facial and mandibular fractures. Radiol Technol 69;1998: Kullman L. Guidelines for dental radiography immediately after a dento-alveolar trauma: a systematic literature review. Dent Traumatol 28;2012: American Academy of Pediatric Dentistry ( 10. International Association of Dental Traumatology ( 11. American Association of Endodontics ( 12. Dental Trauma Guide ( 13. Fuss Z, Shaul L, Tsesis I. Patient assessment, Chapter 2, pp In: A Clinical Guide to Dental Traumatology, Berman LH, Blanco L, Cohen S (eds.). Mosby Elsevier: St. Louis, Gomes MC. Study of storage medium for avulsed teeth. Braz J Dent Traumatol 1(2);2009: Lipton H. The psychological impact of dental injuries. Chapter 10, pp In: A Clinical Guide to Dental Traumatology, Berman LH, Blanco L, Cohen S (eds.). Mosby Elsevier: St. Louis, Sigurdsson A, Bourguignon C. Avulsions, Chapter 6, pp In: A Clinical Guide to Dental Traumatology, Berman LH, Blanco L, Cohen S (eds.). Mosby Elsevier: St. Louis, Trope M, Clinical management of the avulsed tooth: present strategies and future directions. Dent Traumatol 18;2002: Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM Replantation of 400 avulsed permanent incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol 11(2);1995: Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 28(2);2012: Isaka J, Ohazama A, Kobayashi M, Nagashima C, Takiguchi T, Kawasaki H, Tachikawa T, Hasegawa K. Participation of periodontal ligament cells with regeneration of alveolar bone. J Periodont 72(3);2001: Nyman S, Gottlow J, KarringT, Lindhe J. The regenerative potential of the periodontal ligament: An experimental study in the monkey. J Clin Periodont 9(3);1982: Shaul L. Root surface conditioning in closed apex avulsed teeth: a clinical concept and case report. Oral Surg, Oral Med, Oral Path, Oral Radiol, and Endodont 108(3);2009:e125-e Trope M, Friedman S. Periodontal healing of replanted dog teeth stored in Viaspan, milk and Hank s balanced salt solution. Dent Traumatol 8(5);1992: Cvek M, Cleaton-Jones P, Austin J et al: Pulp revascularization in reimplanted immature monkey incisors- predicatability and the effect of antibiotic systemic prophylaxis, Endod Dent Traumatol 6;1990: Kling M, Cvek M, Mejare I: Rate and predicatability of pulp revascularization in therapeutically reimplanted permanent incisors, Endod Dent Traumatol 2;1986: Skoglund A, Tronstad L: Pulpal changes in replanted and autotransplanted immature teeth of dogs, J Endod 7;1981: DiAngelis AJ, Andreasen JO, Ebeleseder KA, Kenny DJ, Trope M, Sigurdsson A, ANdersson L, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Pohl Y, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol 28(1);2012: Kwan S. The effect of splint material and thickness on tooth mobility after extraction and replantation using a human cadaveric moel. Dent Traumatol 28(4);2012: Berthold CA. Influence of wire extension and type on splint rigidity evaluation by a dynamic and a static measureing method. Dent Traumatol 27(6);2011: Hinckfuss S. Splinting duration and periodontal outcomes for replanted avulsed teeth: a systematic review. Dent Traumatol 25(2);2009: Kahler B. An evidence-based appraisal of splinting luxated, avulsed and root-fractured teeth. Dent Traumatol 24(1);2008: Rhee P. Tetanus and trauma: a review and recommendations. J Trau Inj Infect and Crit Care 58(5);2005: John M. Coulter, D.D.S., Department of General Dentistry, University of Tennessee Medical Center, Knoxville, Tennessee O. Lee Wilson, D.M.D., Department of General Dentistry, University of Tennessee Medical Center, Knoxville, Tennessee Murray K. Marks, PhD, Department of General Dentistry, University of Tennessee Medical Center, Knoxville, Tennessee. Contact Professor Marks at mmarks@utmck.edu or Management of Traumatic Tooth Injuries in the Dental Office 37

8 Questions for Continuing Education Article - CE Exam #61 Publication date: Fall/Winter Expiration date: Fall/Winter This exam is also available online. If you take the exam online, you can pay with a credit card and print out your certificate in a matter of minutes. Visit the TDAs website at 1. The goals of physiologic splinting an avulsed tooth are to: a. Maintain the teeth in their original position b. Allow PDL regeneration c. Provide for patient comfort d. Facilitate good oral hygiene e. All of the above 2. If an avulsed tooth cannot be re-implanted and must be transported to a dental professional, the best transport medium is: a. Saline b. Milk c. Energy drinks d. Hanks Balanced Salt Solution 3. What factor is most important in preserving the PDL of an avulsed tooth: a. Root surface treatments b. Extra-oral dry time c. Direction of force applied to the tooth d. Characteristics of the gingival biotype 4. Which of the following drug therapies are indicated in treatment of an avulsed tooth: a. Systemic antibiotics b. Chlorhexidine rinses c. Referral to a physician for tetanus consultation d. All of the above 5. Re-implantation success of avulsed teeth is greatest when the tooth is replanted under: a. 60 minutes b. 90 minutes c. 120 minutes d. Avulsed teeth cannot be re-implanted 6. A hard-tissue injury, such as an alveolar process fracture, requires: a. No splinting b. A physiologic splint c. A rigid splint d. Maxillo-mandibular fixation screws ADA CERP Recognized Provider Continuing Education Exam #61 38 The Tennessee Dental Association is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by the boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at Journal of the Tennessee Dental Association 94-2

9 Answer Form for TDA CE Credit Exam #61: Management of Traumatic Tooth Injuries in the Dental Office Publication date: Fall/Winter Expiration date: Fall/Winter Circle the correct letter answer for each CE Exam question: Date exam taken: T D A EXAM #61 1. a b c d e 2. a b c d 3. a b c d 4. a b c d 5. a b c d 6. a b c d Please complete the following course evaluation. These answers do not affect the grading process. Assess your mastery of the material Full Partial No Your comprehension of material Excellent Fair Poor Appropriateness of the material Excellent Fair Poor Was the material adequately in-depth? Yes No Additional feedback should be ed to the TDA at tda@tenndental.org Cost per exam per person is $ If you correctly answer four of the five questions, you will be granted one (1) continuing education credit. Credit may not apply toward license renewal in all licensing jurisdictions. It is the responsibility of each participant to verify the CE requirements of his or her licensing or regulatory agency. This page may be duplicated for multiple use. Please print or type. ADA ID Number (Dentist Only): License Number of RDH: Registration Number if RDA: Name (Last/First/Middle): Office Address: City/State/Zip: Daytime Phone Number : ( ) Component Society (TDA Member Only): Dr. (Auxiliary Staff: Please provide name of Employer Dentist) All checks should be made payable to the Tennessee Dental Association. Return the Exam Form and your check or credit card information to: Tennessee Dental Association at 660 Bakers Bridge Ave., Suite 300 in Franklin, TN The form may be faxed to if using a credit card (use your TDA/Bank of America card, MasterCard or Visa ONLY): Signature: Card #: Three-digit CVV2 Code (on back of the card following the card number): Name as it appears on the card: Exp. Date: Do not write in this space - for TDA Administration purposes only Check #: CC Paid w/doctor s CC 94-2 Management of Traumatic Tooth Injuries in the Dental Office - Answer Form 39