Pediatric Dental Emergencies

“TOOTH” AND CONSEQUENCES Diagnosis and Management of Dental Pain and Trauma in the Urgent Care Setting October 8, 2020

Presented by: Dr. Lori Barbeau, DDS Medical Director–Children’s Dental Center Program Director–Pediatric Dental Residency Program

 Dental Pain  Dental Trauma  Teething  Tooth Fracture  Decay  Lateral luxation ○ Toothache  Intrusion ○ Abscess  Extrusion ○ Facial Swelling ○ Role of  Avulsion Antibiotics  Alveolar  Dental Fracture Appliances  Jaw Fracture

 Primary Dentition  Permanent Dentition  smaller, squarer, whiter  larger, longer, darker  Mandibular primary incisors  Mandibular permanent incisors begin exfoliation at ~6/7 years begin eruption at ~ 6/7 years of of age age  Maxillary primary incisors  Maxillary permanent incisors begin exfoliation at ~ 7/8 begin eruption at ~7/8 years of years of age age  **impact on the underlying permanent teeth always dictates treatment

 Most common with primary teeth  Appear blue or translucent  Soft upon palpation  Fluid and blood accumulation within the eruption follicle  No treatment: tooth erupts and hematoma resolves  If painful can encourage eruption with teething rings, spoons and/or minor incision

© Children’s Hospital of Wisconsin. All Rights Reserved 4 Teething Pericoronitis  Inflamed soft tissue covering part of the crown of a partially erupted tooth  Usually suppuration & tenderness  Most common site is mandibular permanent 3rd molar  Most common cause of 3rd molar pain and infection

 If swelling/suppuration is present consider irrigation and antibiotics  Chlorhexidine Rinse  Antimicrobial mouth rinse given for moderate/severe inflammation or when brushing is difficult  Chlorhexidine Gluconate Oral Rinse .12% ○ Disp: 1- 16 oz bottle ○ Sig: Swish or brush on with toothbrush with ½ oz 2 times per day for 2 weeks  Need to f/u with dentist to evaluate  Treatment: Debridement +/- gingivectomy or extraction

 Decay can occur on any tooth & on any surface that is exposed to saliva  Discomfort increases as bacteria gets closer to the pulp/nerve  Can vary in color  White spot lesions  Yellow/brown  Black

 Bacteria is causing inflammation of the pulp tissue = pain  Understanding the severity of the inflammation will help determine if antibiotic is warranted  Reversible Pulpitis = mild inflammation  Irreversible Pulpitis = severe inflammation

 How long has the tooth been hurting?  Is the child waking up at night with pain?  Does anything provoke the pain?  Ex: hot/cold or sweet foods  Can the child eat & drink normally?  Have you noticed any swelling?  Medications taken for pain relief?

 Signs of MILD inflammation  Pain provoked by hot, cold or sweets  Pain goes away once the stimulus is gone  Intermittent  Tooth may be saved if treated soon

 Signs of SEVERE inflammation  Pain that wakes them up at night (Nocturnal)  Constant throbbing  Spontaneous (unprovoked)  Usually the pt had previous toothache that went away . . . “it wasn’t this bad”  Tooth becoming necrotic – requires pulp therapy or extraction  Abscess is inevitable or already forming

 Bacteria invasion of pulp tissue leading to an immune response = swelling  Tooth is necrotic = pain is from pressure and inflammation

 Infection takes the path of least resistance and looks to drain  Clinical Presentation  Parulis (gum boil)  Draining Fistula  Facial Swelling

 Dental pain with severe inflammation (irreversible pulpitis)  antibiotic may help relieve symptoms and prevent further swelling  Systemic Involvement  fever or facial swelling  Dental pain without inflammation (reversible pulpitis)  antibiotics are not indicated  Visible parulis or fistula w/o fever or swelling  antibiotics are usually not indicated because infection is draining & localized

 In early dental infections (symptoms <3 days), aerobic streptococci predominate  Penicillin VK is the #1 choice for dental infections  Pediatric Dosage = 50mg/kg per day (q6h)  Alternatives: Amoxicillin or Clindamycin

 In severe or mature dental infections, anaerobic bacteria predominate; penicillin resistance rate is 35- 50%  Clindamycin is a better choice for facial swelling, especially if it is >3 days  Pediatric Dosage = 25mg/kg/day (q6h or q8h)  Horrible taste!!!  “Mix with Kool Aid”, says the dentist . . .

 Fever? Oral Intake?  Airway Evaluation  Difficulty swallowing & constant drooling- indicates pharyngeal swelling  Difficulty sleeping in supine position  CT scan to evaluate deep head & neck infections  Trismus- inability to open wide  Caused by inflammation in the muscles of mastication  + indicates masticator space infection  May be the only external visible sign of pterygomandibular space infection ○ Seen with mandibular 3rd molar infections ○ Airway can be compromised quickly if infection spreads to lateral pharyngeal space

 Extensive facial swelling that could hinder airway or threaten vital structures  Fever >101  Inability to eat or drink/vomiting  Inability to comply with oral medication  Need for inpatient control of systemic disease (ex: diabetes)  Immune system compromise

 “Pokey” wires treated with dental wax or clip the end; f/u with dentist  Broken space maintainer- bend to relieve discomfort and/or remove mobile piece; f/u with dentist  Loose space maintainer- remove with band remover; f/u with dentist

© Children’s Hospital of Wisconsin. All Rights Reserved 21 Band Remover Noises when band pulls off due to cement cracking— warn and reassure child. Give appliance to parent. Need f/u with dentist to remove cement

© Children’s Hospital of Wisconsin. All Rights Reserved 23 Pediatric Dental Trauma  Most common etiologies: falls, accidents (bike/car), sports, acts of violence  Dental trauma accounts for 5% of all injuries for which people seek treatment  Peak incidence ages 2-3  Males > Females  Risk Factors  Hyperactivity  Compromised protective reflexes  Abuse  Substance abuse  Malocclusions  Nearly half of all children will suffer some type of tooth injury by the time they reach adolescence

 Uncomplicated – no pulpal involvement  Complicated – pulpal involvement

 Generally non-urgent for primary and permanent teeth unless tooth is also mobile  May be sensitive to temperatures/air pending depth of fracture  Advise lukewarm foods/drinks  Advise f/u with dentist on next business day

© Children’s Hospital of Wisconsin. All Rights Reserved 26 Complicated Fracture Pulp Exposure  Look for bleeding from the center of the tooth (not gingival bleeding)  Often extremely sensitivity to air/temperature  Requires immediate treatment

© Children’s Hospital of Wisconsin. All Rights Reserved 28 Tooth Mobility  Typically associated with other injuries (tooth fracture, soft tissue lacerations)  Permanent teeth – urgency if moderate/severe mobility or displacement (> 2mm or depressible)  Primary teeth – urgency if occlusal interferences or aspiration risk

 Tooth is displaced and may or may not be mobile  “Ugly Duckling Stage”….is that the way they always look??  Get a “before” picture from the parents  Typical to have a tooth displaced in many directions (“down and out”, “in and rotated”)

 May not be mobile due to associated bone fracture  Neurovascular bundle is severed  Apex is “locked”  Areas of both periodontal ligament tearing and compression

 Primary teeth  Biggest concern is that the primary tooth root can contact the permanent tooth bud ○ primary tooth appears like it is sticking out at you  Primary teeth are extracted if severely luxated; left to spontaneously reposition if mild/moderate luxation  Consultation with dentist  Permanent teeth  Needs urgent treatment  Reposition & splinting is required

 WORST prognosis of all tooth injuries  Ligaments around the teeth are crushed  Non-mobile with bleeding from the sulcus  Primary teeth  May be wrongly diagnosed as an avulsion  Risk for damage to underlying permanent tooth  Consult with dentist to determine urgency  Permanent teeth  Consult with dentist ○ Treatment depends on age and degree of intrusion ○ Severe >7mm needs immediate treatment ○ 4-7mm have dentist determine urgency ○ < 3mm possible f/u with dentist the next business day

 Tooth appears elongated, is very loose and shows bleeding from the sulcus  Neurovascular bundle is stretched/torn  Periodontal ligaments are torn

© Children’s Hospital of Wisconsin. All Rights Reserved 38 Displacement - Extrusion  Primary teeth  Look for occlusal interference….if yes, urgent treatment is needed  Is it an aspiration risk?  For minor extrusion (< 3mm) either reposition or leave the tooth for spontaneous alignment  Primary teeth are generally extracted if >3mm extrusion  Permanent teeth  Requires urgent treatment  Reposition & splinting

 Was the tooth recovered?  R/O aspiration, Chest x-ray?  Primary teeth  Never re-implant, risk to permanent tooth bud  f/u with dentist the next business day  Permanent teeth  The most TIME SENSITIVE dental injury  Storage Medium: Natural socket > HBSS > Milk > Saliva > Saline > Water > Dry

 Permanent Teeth  < 60 minutes since injury is the best prognosis  If tooth is dirty, rinse for max of 10 seconds with saline. Don’t scrape or wipe tooth!  Re-implant immediately (esp < 60 min), can re-implant w/o anesthetic  Have pt bite on gauze until splint can be placed  Tooth will need root canal in 7-10 days  When in doubt….re-implant:  Tetanus Coverage ○ If tetanus coverage is uncertain consider a tetanus booster if wound is dirty  Antibiotic Coverage ○ > age 12 Doxycycline q 12 hours for 7 days ○ < age 12 Amoxicillin or Pen VK q 8 hours for 7 days © Children’s Hospital of Wisconsin. All Rights Reserved 43 Avulsion-Permanent Dentition

 Fracture may occur at any level  Segment containing one or more teeth displaced axially or laterally  Teeth are displaced as a “unit”  Often results in occlusal interferences  Gingival lacerations are common  Primary and Permanent Teeth  Requires immediate treatment  The rare instance when primary teeth are splinted

TX: reposition & splint 5 interrupted 4-O chromic gut sutures

 Blunt trauma to chin - suspect body fracture  Open mouth posture - suspect condylar fracture  Sublingual Ecchymosis is a common finding with a mandibular body fracture  Steps in occlusion often present  Facial series with Panorex/Oral Surgery consult  Tongue blade test  Wooden tongue blade over the molars and instruct them to bite down firmly. Twist the blade while they are biting…..tolerance = usually no fracture

© Children’s Hospital of Wisconsin. All Rights Reserved 49 Rules to live by . . .  Best resource is dentaltraumaguide.org  Time is generally a critical factor in dental trauma  Pulpal bleeding – always needs immediate treatment  Displacement/Avulsion in permanent teeth requires immediate treatment  Displacement/Avulsion in primary teeth sometimes requires immediate treatment – consider photo for dental consult  Always check occlusion/bite  Rule out aspiration  Look for fragments in soft tissues  When in doubt, call—often times a phone consult can help decide definitive management

References • Dentaltraumaguide.org • Andreasen et al. Guidelines for the Management of Traumatic Dental Injuries • (University Hospital of Copenhagen) • AAPD – American Academy of Pediatric Dentistry