RMP-ENT-002 Tooth pain, lost filling or lost crown: dental supplies, a sealed container for a loose crown, screen support for the CMO's mouth camera, relay to the flight surgeon and a ground dentist

1 · Identity and scope

When a crewmember reports tooth or jaw pain, a broken tooth, or a filling or crown that has come loose or come out, the robot tells the flight surgeon (who decides whether to bring in a ground dentist), asks short questions (red flags first), fetches the dental supplies from the medical kit on the CMO's request (a checked kit fetch, or an emergency fetch when an URGENT red flag has fired or a human states an emergency), hands over an empty labelled container so the crewmember can seal a loose crown or piece of tooth inside it, holds a display screen for the CMO's mouth camera, and sends images and the log to the flight surgeon. The CMO does any temporary repair, under the onboard checklist and the ground's direction. Any medicine is fetched only after a human order, through RMP-PHARM-001.

Why this protocol was chosen. NASA's review of spaceflight dental emergencies found no written record of an in-flight dental emergency in US astronauts, but a NASA dentist described a crown that came off in flight and was temporarily repaired by the crewmember with onboard supplies; cosmonauts lost fillings and crowns in flight (thought to be loosened by launch vibration), and one had disabling tooth pain on a 96-day flight. NASA's Integrated Medical Model estimates per person-year include a dental abscess 0.0230, an exposed tooth nerve (pulp) 0.0201, a crown replacement 0.00518 and a filling replacement 0.00511, and a dental abscess was the condition most likely to end in evacuation from the ISS in that model. A loose crown can be breathed in (aspirated), so it is kept out of the mouth and sealed in a container until the CMO decides what to do; fillings can be linked with tooth pain on a pressure change (Menon 2012). On Earth, a spreading swelling, trouble opening the mouth, fever, or signs of airway trouble or sepsis need emergency medical care; a possible spreading infection such as Ludwig's angina (under the tongue and jaw, the floor of the mouth) can block the airway (for clinicians only; the robot never names it); jaw pain can on rare occasions be a heart attack; and people with toothache often take more pain medicine than recommended (SDCEP 2026; StatPearls). A knocked-out adult tooth is a dental emergency; on Earth immediate re-implantation is advised where feasible, otherwise the tooth is kept moist (milk, saline or saliva) (SDCEP). For context for the CMO's checklist only, SDCEP advises a temporary dressing, or an emergency temporary repair kit, for an open cavity, and a crown that came off in flight was temporarily repaired by the crewmember with onboard supplies (Menon 2012); the robot never guides a repair. NASA-STD-3001 requires periodic monitoring and treatment of dental health [V1 3004 item f]. The dental supplies are fetched with a checked kit fetch (kit ID and seal checked before hand-over) unless an URGENT red flag has fired or a human states an emergency, when the emergency fetch applies (ISMP: overrides should be situation dependent, and there may be sufficient time for the normal check).

Autonomy: Max rung raised from 1 to 2 for supervised fetching, container hand-over and holding a display, as in batch 3. Tier 2 as in the library contents. The robot fetches supplies, hands over an empty container and holds a display; the CMO holds the mouth camera. Nothing robotic goes in or near the mouth.

Related: RMP-RESP-002 · RMP-CARD-002 · RMP-INF-001 · RMP-NEURO-001 · RMP-ENT-003 · RMP-EVA-001 · RMP-ENT-001 · RMP-INF-002 · RMP-PHARM-001 · RMP-PHARM-003

2 · Roles

Medical authority

Flight surgeon (ground). Holds medical authority for every run.

Onboard lead

Crew medical officer (CMO), acting under delegated care; uses the pre-approved onboard checklist when there is no link.

Others

• Crewmember with symptoms: answers questions and can stop at any time; places any loose piece in the container themselves
• Ground dentist: brought in by the flight surgeon; advises through the flight surgeon
• Second trained CMO: receives alerts if the CMO is the patient

Commercial flights

On commercial flights, 'flight surgeon' and 'CMO' mean the operator's designated medical authority and trained onboard responder. If no trained responder is aboard, this protocol is not used. (NASA-STD-3001 requires two CMOs per vehicle for NASA programs [V1 3006]; FAA rules set no medical standards for spaceflight participants.) [14]

3 · Preconditions and consent

• PRE-1 A crewmember (the one with symptoms, or the CMO) started the log by command.human_start == trueV2 10174
• PRE-2 The crewmember is awake and answering. If not, stop and alert at once (X7).crew_responsive == true
• PRE-3 Robot self-test passed; it knows the stowage location of the medical kit and its dental supplies, and has an empty labelled container.V2 10161
• PRE-4 Robot and supplies restrained when not moving.V2 7046
• PRE-5 Link status and current delay known.link_state in [live, delayed, down]

Consent

The crewmember agrees to questions by voice and to any images. They can decline any question; an explicit "no" is logged as declined for that question only. Mouth images are sent only to the flight surgeon and the ground dentist the flight surgeon names.

Emergency consent

If the crewmember cannot answer, the robot asks no more questions; it sends an URGENT alert and a crewmember checks in person (X7).

Withdrawal

The crewmember can stop questions or images at any time; an alert already sent is not withdrawn.

4 · Required sensor inputs

5–6 · Steps and decision points

Each step names who acts. Decision points sit after the step they follow and say who decides: Robot Crew Ground. Any stop rule in section 7 can interrupt any step.

1. S1RobotRung 2

   On a crewmember's command, open the log, tell the CMO, and send a "tooth pain or lost filling or crown" note to the flight surgeon, asking whether a ground dentist should join (queued if the link is down).

   Done when: CMO acknowledges; note delivered or queued.

   V2 10174V1 6003

2. S2RobotRung 2

   Ask the red-flag questions first, then the pain questions and what came loose. Log answers word for word with clock times. D1 is checked after every answer.

   Done when: Answers logged, or "no response" logged.

   D1DecisionRobot decides

   Checked after every answer and at any point in the run (even mid-question or mid-step): does any answer, reading or observation meet a red flag?

   • Yes → Stop the current question or step at once and apply the action listed for each matching red flag (URGENT alert, flag, or stop), with the answer or reading itself, never a cause. Every URGENT alert goes to the CMO and the flight surgeon at the same time (queued for the flight surgeon if the link is down). If the CMO is the patient, is busy treating, or does not answer, the alert goes to the second trained CMO, or the crewmember named before flight [V1 3006]. An URGENT alert that is not acknowledged within <set by validation> seconds is repeated and sent to the next named crewmember.
   • No → Continue.
   D2DecisionRobot decides

   Did the crewmember answer the question?

   • Yes → Continue.
   • Declined explicitly (the crewmember says no to a question) → Log "declined" for that question only; the alert already sent stands.
   • No response, or the answer does not make sense → URGENT: log "no response" (never "declined"); the CMO, or the second trained CMO if the CMO is the patient, checks the crewmember in person at once.
3. S3RobotRung 2

   If something came loose, hand the crewmember an empty labelled container and ask them to put the piece in it and close it (the robot never handles the piece). Take the container back only when the crewmember says it is sealed, and stow it in the medical stowage.

   Done when: Sealed container stowed and logged, or "nothing to keep" logged.

   V2 7046

4. S4RobotRung 2

   On the CMO's request, fetch the dental supplies from the medical kit, closed, and restrain them within reach outside the CMO's work area. It never opens them. If an URGENT red flag has fired, or a crewmember or the CMO states an emergency, this is an emergency fetch on a human command (CMO): no barcode check runs before hand-over and nothing waits for one. The robot reads the kit's own label and seal status only if that adds no delay, says "EMERGENCY FETCH – NOT VERIFIED (CMO command)", and "seal not intact" if so, and hands the kit over anyway. The fetch is logged as an override: time, who asked, the reason as stated, kit ID and seal status. It never says "verified". Otherwise this is a checked kit fetch: before hand-over the robot reads the kit ID and seal status and matches them to the kit list in RMP-PHARM-001. On a match it says "KIT ID AND SEAL MATCH. Not a check of the contents." and hands the kit over closed. On a MISMATCH, a seal not intact or CANNOT VERIFY it says so, does not hand the kit over, and the kit stays sealed in quarantine as in RMP-PHARM-001. Any medicine inside goes only through RMP-PHARM-001 after a human order.

   Done when: Supplies restrained within reach; emergency fetch logged as an override, or checked kit fetch result logged (D3).

   Limit: <set by validation>

   V2 7046V2 7059

   D3DecisionRobot decides

   Which kit fetch was it, and what did the checked kit fetch show?

   • EMERGENCY FETCH (an URGENT red flag had fired, or a crewmember or the CMO stated an emergency) → Hand-over already done as an emergency fetch, logged as an override; reconciled afterwards (not a check before use).
   • KIT ID AND SEAL MATCH → Hand the kit over closed; log "KIT ID AND SEAL MATCH. Not a check of the contents." and the clock time.
   • MISMATCH, seal not intact or CANNOT VERIFY → Shown with the reason. No hand-over under this protocol: the kit stays sealed in quarantine (the RMP-PHARM-001 default), and the robot never hands it over unprompted or to anyone but the CMO. The robot does not offer or suggest an override. Only if the CMO explicitly makes the two-step override request inside RMP-PHARM-001 can the kit go to the CMO, logged there as an override with the reason, and flagged to the flight surgeon. If the need becomes an emergency, a crewmember or the CMO states it and the emergency fetch applies.No hand-over
5. S5RobotRung 2

   When the CMO asks and the crewmember agrees, hold its display screen still at the CMO's side, outside the keep-out zone, showing the image from the mouth camera the CMO is holding, and stream or queue the images to the flight surgeon and the named ground dentist. It never moves the screen toward the face.

   Done when: Images shown and streamed or queued.

   V1 6003V2 10172

6. S6Crew

   The CMO examines the mouth and does any temporary repair or other care under the onboard checklist, as the flight surgeon and ground dentist direct. Any medicine is ordered by the CMO or flight surgeon.

   Done when: CMO entries logged.

   V1 3004

7. S7RobotRung 2

   Only after the CMO or flight surgeon has placed an order, run RMP-PHARM-001 for the ordered item (fetch, barcode match to every order field, recipient check). This protocol adds nothing to that check, never suggests an order, and never hands anything over outside RMP-PHARM-001.

   Done when: RMP-PHARM-001 run logged with its result.

   V2 7059

   D4DecisionRobot decides

   What did RMP-PHARM-001 show for the ordered item?

   • MATCH TO ORDER → RMP-PHARM-001 completes its own recipient check and hand-over; this protocol only logs "MATCH TO ORDER. Not a dose, interaction or allergy review." and the clock time.
   • MISMATCH or CANNOT VERIFY on any field, or a failed scan or recipient check → MISMATCH or CANNOT VERIFY shown with the fields named. No hand-over under this protocol: the item stays sealed in the NOT VERIFIED bag in quarantine (the RMP-PHARM-001 default), and the robot never hands it over unprompted or to anyone but the CMO. The robot does not offer or suggest an override. Only if the CMO explicitly makes the two-step override request inside RMP-PHARM-001 can the item go to the CMO, logged there as an override with the reason and the mismatched fields, and flagged to the flight surgeon.No hand-over
8. S8RobotRung 2

   Hand the CMO a fresh waste bag; take only waste bags the CMO has sealed, and stow them as biohazard waste. Clean its own surfaces afterwards (RMP-INF-002).

   Done when: Sealed waste stowed; cleaning logged.

   V2 10172

9. S9RobotRung 2

   After any URGENT alert: After an URGENT alert the robot does not leave on its own: it stays at its rest position in the module, with its screen and voice link available, until a human has taken over or tells it to go. It never follows, blocks or touches anyone. It keeps time-stamping what humans say they did, and repeats the alert if it is not acknowledged.

   Done when: Robot at rest in the module until a human releases it; alert acknowledged or escalated.

   V2 10173V1 3006

10. S10RobotRung 2

    Send the flight surgeon one package: answers with clock times, CMO entries, images, what was sealed and stowed, RMP-PHARM-001 results and alerts. When the CMO says the event is over, run RMP-PHARM-001 reconciliation on each kit fetched: record the items the CMO or crew state were used, the remaining contents against the kit list, seal status and expiry, labelled "inventory reconciliation after emergency use – not a check before use". Flag the override to the flight surgeon and the pharmacy lead, and show each kit as "opened – not restocked" until a human restocks and reseals it.

    Done when: Package delivered or queued; kit reconciled or shown as opened – not restocked.

    V1 6003V1 7001V1 7003V2 7059

11. S11Ground

    The flight surgeon, with the ground dentist, decides care, follow-up, work limits and whether evacuation needs to be considered [V1 3007]. The robot logs the decisions.

    Done when: Decision logged.

    V1 3004V1 3007

    D5DecisionGround decides

    What is the plan (care, follow-up, work limits, evacuation)?

    • Link live → Flight surgeon decides; robot logs.
    • Link down or delay too long → The CMO decides under the pre-approved onboard checklist; the flight surgeon reviews the log at the next contact.
12. S12RobotRung 2

    Offer a check-in every <set by flight surgeon> hours until the crewmember and flight surgeon close the log. At each scheduled time the robot prompts the crewmember on their own screen; it approaches only when the crewmember (or the CMO) accepts, and a prompt never starts the robot. A routine check-in never wakes a sleeping crewmember.

    Done when: Each prompt accepted, postponed or answered; log closed by a human.

    V2 10174

7 · Stop and escalate rules, red flags

Red flags

The robot reports the sign or value only, never what it means. Numeric thresholds are placeholders for the clinical lead.

8 · Safety limits

9 · Logs and audit

• LOG-1 Every input, robot action, decision (with who made it) and hand-off, time-stamped to the second.V2 10163V2 10164
• LOG-2 Mode changes and safety-limit events are announced to the operator as they happen and logged.V2 10162V2 10172
• LOG-3 Records are stored and sent as private medical data, encrypted, with access limited to the medical team.V1 6003V1 7003
• LOG-4 Results are kept in a permanent, retrievable format so the flight surgeon can see trends.V1 7001
• LOG-5 Each answer, image, sealed container and waste bag stowed, and alert, with clock times.
• LOG-6 Each URGENT alert, who received it, the time it was acknowledged (or the escalation to the next named crewmember), and the time a human released the robot.V2 10163
• LOG-7 Each emergency fetch as an override (time, who asked, reason as stated, kit ID, seal status) and the later inventory reconciliation, labelled "not a check before use".V2 7059
• LOG-8 Each RMP-PHARM-001 run started from this protocol: order ID, result (MATCH TO ORDER, MISMATCH or CANNOT VERIFY with the fields), quarantine, and any CMO override logged by RMP-PHARM-001 (reason and mismatched fields), at clock time. No running counter of doses.V2 7059
• LOG-9 Each checked kit fetch: time, who asked, kit ID, seal status and result (KIT ID AND SEAL MATCH, MISMATCH, seal not intact or CANNOT VERIFY), and any quarantine.V2 7059

10 · Links to NASA-STD-3001

IDs as published in Volume 1 Revision C [9] and Volume 2 Revision F [11]. NASA-STD-3001 binds NASA programs; it is not a regulation for commercial flights. Its robot rules are general automation requirements, not medical-device rules.

11 · Validation

1. Simulation. Scripted runs covering every red flag, no response, a loose piece that cannot be found, a knocked-out tooth, a CMO who is the patient, an RMP-PHARM-001 MISMATCH, a kit with a broken seal, and lost link. Pass: Every red flag acts as listed; zero hand-overs after a MISMATCH; zero robot movement inside the head keep-out zone; every emergency fetch logged as "EMERGENCY FETCH – NOT VERIFIED" and reconciled afterwards; every other fetch checked (kit ID and seal) before hand-over, with zero hand-overs of a mismatched kit.
2. Earth analog. Volunteers and a trained CMO use the container hand-over and the held display with a mouth camera (no patient care). Pass: Zero handling of the test piece by the robot; image stream usable for the ground dentist at or above <set by validation>.
3. Parabolic or station demonstration. Container hand-over, sealed-container stowage and held display in weightlessness, without a patient. Pass: Zero escapes of the test piece; zero contacts.
4. Flight use under flight surgeon supervision. First use alongside the usual medical conferences. Pass: No safety events; the flight surgeon and ground dentist find the images and log useful.

No stage has been run. Pass and fail criteria must be fixed in advance by the clinical lead and safety board.

12 · Human sign-off

Before any use

• Clinical lead for the specialty (sets every clinical threshold marked <set by clinical lead>)
• Flight surgeon, as medical authority
• Robotics and medical-device safety board
• Program approval for the mission

Each run

Started by a crewmember. The flight surgeon reviews the log and images with the ground dentist; red flags go to the CMO and flight surgeon at once.

Restart after a stop

Human only. After any emergency or protective stop, a crewmember must restart the robot; the robot never restarts itself.

None of these sign-offs has happened. This is a Draft v0.6.

13 · Change control for learning

• Every change gets a new version number and a written reason; earlier versions are kept.
• Any change to steps, thresholds, limits or software that touches the patient repeats validation from the simulation stage before use.
• Software and learned-skill updates follow a pre-agreed change plan (what may change, how it is tested, how to roll back), modeled on the FDA predetermined change control plan approach.
• If a new version misbehaves, the robot rolls back to the last validated version and the event is reviewed by the flight surgeon and safety board.
• The robot never changes its own protocol, thresholds or limits.

Change-plan model: FDA guidance [13].

Loss of signal and Mars delay

Live link

Low Earth orbit: the flight surgeon sees summaries at the private medical conference and can be alerted at any time.

Loss of signal

• Only the robot pauses; crew care never waits for the link or the robot.
• The robot pauses any movement and tells the CMO; on the CMO's confirmation it keeps logging offline.
• Red flags go to the CMO (or the second trained CMO) at once; the CMO decides under the pre-approved onboard checklist.
• At the next contact the robot sends one package: the log, alerts and decisions.

Mars-class delay

• Replies may take up to about 21-23 minutes each way, with blackouts of about 2-3 weeks; red-flag thresholds and the check-in schedule are set before flight and the CMO acts on them.

[12]

Sources

1. Menon A. Review of Spaceflight Dental Emergencies. NASA/TM-2012-217368 (NASA Johnson Space Center, September 2012). ntrs.nasa.gov/api/citations/20120002807/downloads/2012000280… Supports: No written record of an in-flight dental emergency in US astronauts, but a NASA dentist described an in-flight crown displacement temporarily repaired by the crewmember with onboard supplies; cosmonauts reported lost fillings and crowns in flight, thought to be dislodged by launch vibration, and incapacitating dental pain on a 96-day flight; repair must weigh the risk of aspiration (inhaling) of a loose crown; Integrated Medical Model estimates (events per person-year) include dental abscess 0.0230, exposed pulp 0.0201, crown replacement 0.00518 and filling replacement 0.00511, and a dental abscess was the condition most likely to end in evacuation from the ISS in that model; fillings can be linked with tooth pain on pressure change (barodontalgia).
2. Scottish Dental Clinical Effectiveness Programme (SDCEP). Management of Acute Dental Problems, 2nd edition (March 2026): Management of spreading or systemic infection; Timescales for treatment; Pain pathway (guidance website, read Oct 20, 2026). www.acutedentalproblems.sdcep.org.uk/guidance/overarching-pr… Supports: Management of spreading or systemic infection: check for the cardinal signs of spreading infection (cellulitis, lymph node involvement, swelling, trismus [trouble opening the mouth]) and systemic infection (fever and malaise); cervicofacial infection such as Ludwig's angina is associated with acute illness and death; be alert to signs of sepsis. Timescales for treatment: a dental problem with signs of airway compromise or sepsis needs immediate contact with appropriate medical services.
3. Scottish Dental Clinical Effectiveness Programme (SDCEP). Management of Acute Dental Problems, 2nd edition (2026): Pain pathway (guidance website, read Oct 20, 2026). www.acutedentalproblems.sdcep.org.uk/guidance/pathways-to-pr… Supports: Pain in the mouth or jaw is most commonly related to the teeth, but a heart attack (myocardial infarction) may present with pain in the jaw on rare occasions; patients suffering from toothache often self-medicate and might have exceeded the recommended dose of pain medicine.
4. Scottish Dental Clinical Effectiveness Programme (SDCEP). Management of Acute Dental Problems, 2nd edition (2026): Cracked, fractured, loose or displaced tooth fragments and restorations (guidance website, read Oct 20, 2026). www.acutedentalproblems.sdcep.org.uk/guidance/management-of-… Supports: If it is known or suspected that the patient has inhaled a piece of tooth, filling or restoration, send the patient immediately to emergency care; for an open cavity, provide a temporary dressing if available, or advise an emergency temporary repair kit.
5. Scottish Dental Clinical Effectiveness Programme (SDCEP). Management of Acute Dental Problems, 2nd edition (2026): Injuries to the mouth, face and jaws (guidance website, read Oct 20, 2026). www.acutedentalproblems.sdcep.org.uk/guidance/management-of-… Supports: Emergency medical attention is needed for, for example, severe bleeding that will not stop within 15-30 minutes, significant facial trauma, a head injury or loss of consciousness, inhalation of a tooth or tooth fragment, or airway obstruction; an avulsed (knocked-out) permanent tooth with no other complications is a dental emergency but not a medical emergency; advise immediate reimplantation of the tooth, if feasible, otherwise place it in milk, saliva or saline for transport to the dentist.
6. Al Ghabra Y, Brizuela M, Winters R, Singhal M. Ludwig Angina. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2025 (updated June 22, 2025). PMID 29493976. www.ncbi.nlm.nih.gov/books/NBK482354/ Supports: Ludwig angina is a rare, life-threatening, spreading infection of the soft tissues of the floor of the mouth and neck; involvement of the deep spaces presents the greatest risk of airway compromise; early recognition and treatment are critical, including emergent airway management. Only the PubMed abstract was read (the full page blocked the fetch).
7. NASA Human Research Program. Evidence Report: Risk of Adverse Health Outcomes and Decrements in Performance due to In-Flight Medical Conditions (2017). humanresearchroadmap.nasa.gov/evidence/reports/Medical.pdf Supports: Dental emergencies have been documented among astronauts (Berry 1974, as cited in the NASA evidence report).
8. Institute for Safe Medication Practices. Guidelines for the safe use of automated dispensing cabinets (2019). www.ismp.org/system/files/resources/2019-11/ISMP170-ADC%20Gu… Supports: An override occurs when a practitioner bypasses the pharmacist's review because a delay would harm the patient; the use of overrides should be situation dependent and justifiable, and not based merely on a list of medications; there may be some situations when there is sufficient time for the normal review (section 3.3 and the override definition). Used by analogy for the two kit-fetch patterns (a robot fetching a sealed kit is not a dispensing cabinet).
9. NASA. NASA-STD-3001, Space Flight Human-System Standard, Volume 1: Crew Health, Revision C (2023). www.nasa.gov/wp-content/uploads/2023/11/nasa-std-3001-vol-1-… Supports: NASA-STD-3001 Vol 1 Rev C: V1 3004 items b (medical kits), d (history), f (periodic monitoring and treatment of dental health), m (medicines) and s (private transmission of medical data, including imaging); V1 3007 (medical evacuation).
10. NASA OCHMO. Medical Operations. Technical Brief OCHMO-TB-044 (2025). www.nasa.gov/wp-content/uploads/2025/08/ochmo-tb-044-medical… Supports: The crew surgeon keeps medical authority when care is delegated; crew medical officers train on the JSC 48522 medical checklist.
11. NASA. NASA-STD-3001, Volume 2: Human Factors, Habitability, and Environmental Health (Rev F, 2026), including Section 10.6 Automated and Robotic Systems. standards.nasa.gov/standard/NASA/NASA-STD-3001_VOL_2 Supports: Requirement IDs beginning V2.
12. NASA. Mars communications disruption and delay (fact sheet, 2023 Moon to Mars Architecture Concept Review). www.nasa.gov/wp-content/uploads/2024/01/mars-communications-… Supports: One-way Earth-Mars delay up to about 21-23 minutes, plus blackouts of about 2-3 weeks near solar conjunction.
13. U.S. Food and Drug Administration. Marketing submission recommendations for a predetermined change control plan for artificial intelligence-enabled device software functions (guidance). www.fda.gov/regulatory-information/search-fda-guidance-docum… Supports: A model for planning, validating and rolling back software updates.
14. U.S. Code of Federal Regulations, Title 14, Part 460: Human space flight requirements. www.ecfr.gov/current/title-14/chapter-III/subchapter-C/part-… Supports: Federal rules for crew and spaceflight participants on licensed commercial flights; they set no medical standards for spaceflight participants.

Checked on 2026-10-20: links opened (HTTP 200 or publisher redirect), DOIs and PubMed IDs matched, NASA documents read in full text. The framework comes from Part 1.