Sujatha S. Sivaraman BDS, DMD
May 16
th2014
Pediatric Dental
Emergencies
36th Annual Common Childhood
Problems Conference
Disclosures: None
Objectives
¾
•
Identify Dental Emergencies
¾
•
Best methods to address emergencies in
the Clinic and ED
Dental Anatomy
¾
Primary Teeth
Primary Teeth
¾
Usual age 6 months - 6 years
¾
20 teeth total-2X ( 4 Incisors, 2 Canines, 4 Molars)
¾
AKA “baby teeth”, “milk teeth” “deciduous teeth”
¾Teeth are very white, square, and spaced apart.
Primary Teeth
Mixed Dentition
Mixed Dentition
Usual age 6 -12 yrs
Primary and Permanent Dentition present
“Ugly duckling stage”
Around ages 6-7 and 10-11 yrs
lots of “loose teeth”
Permanent Teeth
zBegin formation 3-4 mo
z
Eruption 7-21 yrs
z
32 teeth ( including wisdom teeth)
z
2x ( 4 incisors, 2 canines, 4 premolars, 6 molars)
Dental Anatomy
Dental Emergencies in ED
¾
Increase in ED visits for dental care in the last two
decades (Needleman, 2013).
¾
66% of dental ED visits are Traumatic dental injuries.
¾
Few hospitals have onsite and/or off site coverage.
Role of Physicians
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Dental emergency during–weekend and evening hours.
¾
Emergency dental insurance coverage.
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Uncontrolled or complex medical problems.
¾
Behavioral management issues needing sedation.
¾
Concomitant serious maxillofacial trauma.
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Lack of dental professionals on ED staff
Pediatric Dental Emergencies
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Dental Caries - 6%
¾Gingivitis - 5%
¾Toothache - 9%
¾Others - 10%
It includes
zFacial cellulitis
zDental abscess
zFacial pain
zLoose teeth
z
Dental Brace problems.(Oliva et al, 2008)
Pediatric Dental Emergencies
¾
Caries (cavity) related emergencies
¾Trauma related emergencies
¾I. Primary (baby) teeth
¾II. Permanent teeth
This is what healthy dentition looks like
Early Childhood Caries: “Baby bottle tooth decay”
Management
¾
Referral to a general or pediatric dentist ASAP.
¾Pain management PRN.
¾
Antibiotics if systemic involvement
¾
Based on age, extent of decay, patient will need
dental rehabilitation under G.A or sedation.
Full tooth coverage with stainless steel crowns
Odontogenic Infections
Localized to immediate area surrounding tooth and roots
- Spreading to soft tissue and musculature
- Can lead to severe swelling and cellulitis
Can be:
-
Caries-related: oral bacterial invasion
- Trauma-related: pulpal injury leading to necrosis and
aseptic inflammation
Localized Abscess
¾ Manifests as abscess or fistula local to affected tooth
¾ Primary teeth: Extraction & space maintenance ¾ Permanent teeth: Root canal therapy or extraction ¾ No antibiotics needed unless there is systemic
Space maintainers
Periapical Abscess
Cellulitis
Management of Cellulitis
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Extensive swelling and Inflammation.
¾
Can be life threatening if left untreated especially in
lower arch.
Treatment includes
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IV Antibiotics and
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Possible Hospitalization initially &
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Extraction of the offending tooth ASAP
Complications
¾
Dental infections can progress to life threatening
complications such as
z
Facial or buccal cellulitis
z
Submandibular space infections (Ludwig’s angina)
zParapharyngeal space infections
z
Airway compromise
zOrbital infections
zCNS infections
zMediastinal infections
zCavernous sinus thrombosis
Complications
¾ Signs of more serious illness
z Systemic symptoms – fever/chills
z Trismus
z Displacement of tongue z Altered LOC/delirium z Eye pain
¾ Requires systemic ABX ¾ ENT consult ¾ Possible CT imaging ¾ Airway management
Antibiotics
Broad range of pathogens
z
Mainly Streptoccocal
zBacteroides sp.
zAnaerobes
Simple infections
z
Pen V or amoxil
z
I prefer Amox/Clav or clinda
Infections extending to facial or buccal cellulitis
¾
IV 2
ndgeneration Cephalosporin + Metronidazole
¾
HPTP
Prevention
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Age one visit.
¾
Caries risk assessment and appropriate referrals.
¾
Fluoride varnish applications.
Pediatric Dental Emergencies
¾
Caries (cavity) related emergencies
¾Trauma related emergencies
¾I. Primary (baby) teeth
¾II. Permanent teeth
¾
Uncommon dental emergencies
¾
Occur commonly in summer months particularly June
and July.
¾
Fridays and Saturdays were the busiest days of the
week.
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Most common cause of trauma are Falls, accidents,
violence and sports activities.
Dental Trauma
Dental Trauma
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Most common age group: 2-3 yrs
¾
Most commonly affected teeth are
z Permanent Maxillary central incisors
z Lateral incisors and z Mandibular central and z Lateral incisors.
¾
Most common injuries are Luxations and Avulsions.
¾
Most common displacements lateral luxations,
extrusions and intrusions.
Dental Trauma
¾Fractures of teeth
¾Alveolar Fractures
¾Luxation
¾Intrusion or concussion
¾Avulsion
¾Primary vs Permanent
History Of Injury
¾ Medical and dental history ¾ Where did the injury occur ? ¾ How did the injury occur ? ¾ When did the injury occur ?
¾ Was there a period of unconsciousness?
¾ History of dizziness, headache, nausea and vomiting. ¾ Tetanus Vaccination.
History of Injury
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Rule out Abuse.
¾
Is there any disturbance in the bite?
¾
Is there any reaction in the teeth to cold and/or heat
exposure?
Clinical Examination
¾ Cranial nerve examination.
¾ Examine the face, lips and oral muscles for soft tissue lesions. ¾ Palpate the facial skeleton for signs of fractures.
Inspect intra-orally for ¾ Fractures
¾ Abnormal tooth position ¾ Tooth mobility
¾ Abnormal response to percussion ¾ Identify injured teeth as primary or permanent
Radiographic Examination
Ideally an Intra-Oral radiograph at least in 3 different angles. In case of Maxillary or Mandibular fracture
¾ Panoramic film ¾ Cone-beam CT or ¾ CT scan may be indicated.
¾ Basic goal is ALARA (As low as reasonably achievable ) ¾ Digital photographic examination.
Primary Vs Permanent
Tooth Fractures
¾
Enamel Fracture (Ellis 1)
zChipped tooth
z
Painless unless associated with other injuries
z
Large chips can be saved for reattachment
z
Non urgent dental referral for cosmetic purposes
Enamel and Dentin Fracture
Tooth Fractures
¾ Enamel and Dentin ( Ellis 2)
z 70 % of dental fractures
z Pain with hot or cold and air. z Dentin is yellow colored z Panaromic to r/o other injury
z Increased risk of pulp infection/desiccation z Dental evaluation in 24hrs
Complicated Fractures
Pulp involvement
z May be visible (Ellis 3) •Can see blood
z May be below gums (root fracture) •Only seen with x-ray
z Very painful as nerve exposed
z Treatment as Ellis 2
z Will need extraction or root canal
Root Fracture
A fracture confined to the root of the tooth involving Cementum, Dentin & Pulp. Can be further classified by if the coronal fragment is displaced
Alveolar Fracture
Mobility of the alveolar process:
Several teeth typically will move as a unit when mobility is checked. Occlusal interference is often present.
Fractures of Permanent Teeth
Alveolar Fractures
z Associated with fractures, luxated or avulsed teeth
z Small fractures involving 1 or 2 teeth can be treated by a dentist z Large areas of alveolar bone damage can cause significant
cosmetic deformity & oral surgery should be consulted
Alveolar segment fractures
Can contain single or multiple teeth Usually determined by
- Stepping” of the teeth (or) - Mobility of the entire segment of
displaced bone
Other things to think about
If tooth appears fractured, ensure pieces of tooth are not
embedded in the soft tissue such as
- Tongue
- Lips
- Cheeks
Other things to think about cont.,
Concussion
¾
Displacement of tooth into socket
¾
Concussion – pain with no movement
Subluxation
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Tooth has abnormal mobility but no displacement.
¾
Sulcular bleeding is present.
Luxation
¾ “Loose tooth”
¾ Extrusion – dislodgement from alveolar bone
¾ Lateral luxation – lateral displacement with alveolar fracture ¾ Both should have x-rays
¾ Reposition with firm pressure – may require L.A ¾ Temporary splinting in ED
¾ Permanent splinting/treatment by dentist - 4 wks
Lateral Luxation
Displacement of the toothother than axially.
Displacement is accompanied by comminution or fracture of either the labial or the palatal/lingual alveolar bone.
Extrusion
Partial Vertical displacement of the injured tooth from its socket.
Discoloration of tooth
Intrusion
¾ Intrusion – more severe displacement involving root fracture and/or alveolar fracture forced in to alveolus, no mobility.
Avulsion
The tooth is completely displacedoutof its socket. Clinically the socket is found empty or filled with a coagulum.
Avulsion
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If Primary tooth, do not reimplant.
¾
Breathing difficulties - Chest X-ray to rule out aspiration.
Avulsion
¾ Most time sensitive Traumatic dental injury. ¾ Complete displacement of tooth from alveolar socket ¾ Best chance of saving tooth if re-implanted under 60 mts.
Management at Site of Injury
Management at Site of Injury
-
Replant immediately, if possible
-If contaminated, rinse
- When cannot be replanted, place tooth in transport medium.
Transport Media
Transport Media
¾Hank’s Balanced Salt Solution (HBSS)
¾Milk ¾Saline
¾Saliva (buccal vestibule) ¾Water, if none available
Management of the Socket
Management of the Socket
- Gently aspirate without entering socket - If clot present use saline irrigation - Do not curette socket- Do not vent socket
- If alveolar bone collapsed, use blunt instrument to reposition
- Manually compress bony plates.
Tightly suture any soft tissue lacerations, especially in the cervical region
Splinting
Splinting
Use fish line/acid-etch resin: soft arch wire/resin: Ortho brackets with passive arch wire Suture as last resort
Circumferential wire splints contraindicated Maintain splint 7-10 days; longer if tooth
demonstrates excessive mobility
Post trauma Instructions
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Good oral hygiene for first 10 days after an injury.
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Soft diet.
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Avoid sucking on a pacifier or digit.
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No need for routine antibiotics except avulsion.
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Watch for Parulis, swelling & necrosis.
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Avulsion of permanent teeth - needs RCT in 7-10 days.
Prevention Of Dental Trauma
Counsel caregivers about :-¾ Participation in sports activities ¾ Household safety measures ¾ Trip hazards.
Primary Vs Permanent
¾ Avulsed primary teeth should not be re-implanted to avoid damage to underlying teeth
¾ Primary teeth have more pulp and less dentin - more at risk for infection
¾ Luxations in young children are at greater risk of avulsion and aspiration – consider urgent dental splinting.
¾ Enamel injuries can cut mucosa in young children and may need to be filed down
Final Thoughts
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Pen or amoxicillin usually sufficient
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Consider clindamycin if allergic
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Don’t forget Tetanus immunization
Stock Mouth Guards
¾ Not Well adapted.
¾ Least expensive and least protective. ¾ The prices range ~ $3 to $25. ¾ Interferes with Speech and Breathing.
Boil and Bite Mouth Guard
¾ Mouth formed or Boil and Bite Mouthguard
¾ Most commonly used mouthguard
Custom Made Mouth Guards
Good adaptation, retention, comfort, and stability of material. Interfere the least with speaking and no effect on breathing. Superior to the store bought stock and boil and bite Mouthguard
Other Emergencies
¾
Pericoronitis
¾Dry socket
¾Palatal trauma.
Pericoronitis
¾ Most common in wisdom teeth
¾ Bacterial plaque and food debris accumulate beneath the flap of gum covering the partially erupted tooth.
¾ Pain, bad taste, pus, local inflammation can progress to cellulitis ¾ Salt mouthwashes, irrigate under flap
¾ ABX
Pericoronitis
Dry Socket- Alveolar Osteitis
¾Complication of tooth extraction
¾
Clot covering alveolar bone is displaced
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Exposed alveolar bone becomes inflamed
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Normal post extraction pain decreases over 48hrs
Dry Socket
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Analgesia – NSAIDs, Narcotics, Nerve block
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Referral back to dentist in 24 hrs
zWill need frequent packing
¾
ABX ?
z If caught early
z Timely f/u is available, probably not needed
Resources & Recommendations
¾
Develop and have a dental emergency protocol in place.
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List of dental professionals in community for consult
treatment - referral.
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www.dentaltraumaguide.org
.
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Guidelines for trauma in AAP.
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Guidelines for management of trauma in AAPD .
References
¾ Needleman,H.L. et al.(2013).Massachusetts emergency departments resources and physicians knowledge of management of traumatic dental injuries.Dental Traumatology ; 29: 272-279 ¾ Oliva et al (2008). Nontraumatic dental comlaints in a pediatric
emergency department. Pediatric Emergency Care ; 24(11): 757-60. ¾ Bruns,T.& Perinpanayagam ,H.(2008).Dental trauma that require
fixation in a children’s hospital. Dental traumatology;24: 59-64 ¾ http://www.sportsdentistry.com/mouthguards.html
