Advanced Pediatric Emergency Medicine Assembly. March 11 14, 2013 Lake Buena Vista, FL

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1 Michael Witt, MD, MPH, FACEP Medical Director, Pediatric Emergency Medicine, New Hampshire's Hospital for Children Elliot Health System Advanced Pediatric Emergency Medicine Assembly March 11 14, 2013 Lake Buena Vista, FL Dental Injuries in Children: Latest Guidelines and Creating a Dental Kit for Your ED Dental trauma is fairly common in the pediatric population, and the management of dental injuries depends on the nature and severity of the injuries as well as the child s stage of dental development. As 24/7 emergency access to a pediatric dentist may be limited in many settings, emergency care providers should understand which injuries warrant on-site consultation and/or emergent referral to a dental specialist, what patient assessment data dental professionals will need when contacted, and what temporizing measures should be available in the ED. Explain dental development and anatomy. Perform assessment and classification of dental trauma in children. Assess injuries that require immediate dental consultation, and how to communicate this to the dentist. Apply acute interventions that can be performed by ED professionals, and identify components of an ED dental kit. 3/13/2013 1:15pm 2:00pm (+)No significant financial relationships to disclose

2 Advanced Pediatric Emergency Medicine Assembly Disney s Contemporary Resort March 12-14, 2013 Dental Injuries in Children MICHAEL WITT, MD, MPH, FACEP, FAAP MEDICAL DIRECTOR, PEDIATRIC EMERGENCY MEDICINE Disclosures I have no personal financial or other interests in any diagnostic or therapeutic modalities discussed in this lecture I am more than happy to entertain offers There may be trade name use and off label use of certain medications in this lecture 1

3 Uh Oh! Ryan vs. His Sister Primary teeth Basic Dental Development Central incisors first to erupt Typical range, age 6 to 15 months All 20 teeth present by age 3 Tooth loss range: 6 to 12 yrs Permanent teeth Begin to erupt: 5 6 yrs 32 teeth by adolescence All but 4 wisdom teeth 2

4 Dental Anatomy/Lingo If you must call, you might as well sound like a dentist Central incisors Lateral incisors Canines Premolars 0 in primary 2 in permanent dentition Molars 2 in primary, 3 in permanent dentition More Dental Anatomy/Lingo Labial or buccal: outer tooth surface Palatal: interior surface of uppers Lingual: interior surface of lowers Occlusal: bite surface of tooth Apical: position close to tooth root Coronal: position close to tooth crown 3

5 Tooth Anatomy Crown: visible portion Root: portion below the gingival line Pulp: center, provides for circulation and innervation Dentin: microporous structure, surrounds pulp Enamel: extremely hard substance, covers dentin Periodontal Structures Cementum calcified collagenous tissue, covering the tooth root, attaches tooth to the periodontal ligament Periodontal ligament thin fibrous ligament, attaches tooth to bony socket key supportive structure with neural and vascular components Alveolar bone bony structure of the maxilla and mandible forms the bony socket Gingiva tough insoluble protein mucosa, surrounds the tooth, attaches to cementum and alveolar bone, helps hold tooth in place 4

6 Epidemiology of Dental Trauma Occurs in 50% of children 30% of pre school aged no sex difference 23% of males & 13% of females ages 6 20 yrs Prevalence and incidence peaks at 2 4 & 8 10 yrs Males >> females (nearly 2:1) Anterior teeth most likely affected Causes related to motor development Learning to walk, bike, sports Errant projectiles Dental Trauma Why Important Traumatized teeth lose vitality over a short time Leads to discoloration or abscess Can result in permanent damage Can interfere with occlusion Can be a result of abuse 5

7 Concussion Trauma to the supporting structure of tooth Tooth maintains stability Not displaced, not mobile Bleeding usually not evident Tenderness to percussion & with chewing Management (1 0 or 2 0 teeth) Analgesia Soft diet Refer to dentist Subluxation Mobility or loosening of the tooth without displacement <2mm displacement in socket Blood may be present in gingival sulcus Pain with percussion Management Soft diet If tooth is very mobile splinting Splint all mobile injuries in 2 0 teeth 6

8 Luxation Loosening and displacement of a tooth from normal position Periodontal ligament is torn Intrusion Lateral Luxation Extrusion Avulsion Intrusion Tooth is driven into socket Crown height shortened Bleeding usually present Periodontal ligament lacerated Root & alveolar fx s may occur Must determine if the tooth is intruded and not fractured Pearl: Missing tooth = consider complete intrusion 7

9 Management of Intrusion Primary Tooth Observation if < 50% intruded, re erupt in 3 4 wks If 100% intruded, or in contact with underlying tooth bud, may require extraction Need dental follow up to monitor for damage to underlying tooth bud Secondary Tooth Monitor for injury to root structures & neurovascular supply Allow tooth to re erupt, close dental follow up Tooth may require re positioning and splinting Lateral Luxation Displacement of tooth laterally in socket Lingual displacement most common Periodontal ligament is torn Usually accompanied by alveolar fx Primary Tooth Gentle repositioning No intervention necessary, unless extreme mobility Permanent Tooth Dental referral for repositioning and splinting 8

10 Extrusion Vertically displaced from bony socket Periodontal ligament torn May be associated with root fracture Primary Tooth Reposition if partial & stable tooth Extract if very mobile or nearly avulsed Permanent Tooth Reposition if partial & stable tooth Discuss with dentist Avulsion Tooth is completely detached from the socket Periodontal ligament severed, possible alveolar bone fracture Need to find the tooth!!! Rule out aspiration/intrusion/fracture Determine primary vs. permanent tooth 9

11 Primary Tooth Avulsion Avulsed primary teeth NEVER replaced Children under 6 years of age Control bleeding Small lacerations to tongue, lips, gums typically do not require repair Dental referral to evaluate potential injury to permanent tooth bud Permanent Tooth Avulsion True dental emergency time is essential Best outcome if < 30 min to reimplantation Viability dependent upon vitality of root periodontal ligament (PDL) Goal is to avoid further damage to PDL cells Minimize handling, DO NOT SCRUB 10

12 Permanent Tooth Avulsion If tooth cannot be immediately re implanted, place it in transport media Commercial Solution, fresh cold milk, saline, saliva (buccal vestibule), water Extra oral time <1 hr: Rinse off debris and re implant Immediate splinting by dentist Extra oral time > 1 hr: Soak transport media min. Re implant with immediate splinting Classification of Dental Crown Fractures Ellis Class I Injury to enamel only (white) painless Ellis Class II Injury to enamel and dentin (gray or yellow) painful Ellis Class III Injury to enamel, dentin, pulp (pink) painful & bleeds 11

13 Management of Crown Fractures Ellis Class I Do not require immediate Rx Rough edges may need filing Ellis Class II Exposed dentin must be covered Calcium hydroxide paste (time?) Subsequent composite repair Don t forget the missing fragment! Management of Crown Fractures Ellis Class III Exposed pulp will become infected More likely if exposed > 6 hrs If primary tooth, may need to extract to prevent further injury If permanent tooth Urgent referral to dentist Calcium hydroxide paste Root canal for prolonged exposure 12

14 Root Fractures Suspect with crown luxation, pain, excessive mobility, malocclusion Confirm location with radiographs Prognosis is better for apical vs. coronal location of fractures Apical fracture urgent referral for splinting Coronal fracture usually extracted Alveolar Fractures Segment containing one or more teeth is displaced or mobile Urgent dental or maxillofacial surgery referral 13

15 Dental Kit Dental Mirrors Storage Medium (Hank s Balanced Salt Solution, EMT Toothsaver) Gauze on Strings Syringes & Needles Lidocaine Topical Anesthetic Gel (20% Benzocaine or 5% Lidocaine) Hemostatic Product (e.g. Gelfoam) Calcium Hydroxide Paste (with spatulas, bowl) Dry Socket Paste (Eugenol & Zinc Oxide) When To Follow up? Type of Injury Follow Up Concussion As needed Subluxation As needed (Within 24 hrs if very mobile) Intrusion Within 24 hours Extrusion Within 24 hours Avulsion Primary As needed Permanent Emergent Fracture Enamel only (Ellis I) As needed Enamel & Dentin (Ellis II) Within 24 hours Enamel, Dentin, & Pulp (Ellis III) Within 24 hours Root Fracture Within 24 hours 14

16 No Dentist? Find a friend! Who has privileges? Who takes Medicaid? Who has a charitable mission? Mandibular Fractures Clinical findings Intra or extra oral swelling, sublingual hematoma, dental trauma/asymmetry, malocclusion, trismus, facial asymmetry 15

17 Mandibular Fractures Unilateral subcondylar fracture Most common injury, conservative management All other fractures require surgical fixation Consider injury to permanent teeth A Word About Child Abuse Head, face and neck injuries occur in 50% of abuse cases Careful intra oral and peri oral exam is indicated in all suspect cases 16

18 Summary Review anatomy with Primary & Permanent teeth Discussed tooth luxions, avulsions, and fractures Timing of referral to Dentistry Dental Box Don t forget abuse! Thanks to you!... 17

19 Thank You! Dr. Steve Krug, Lurie Children s Hospital of Chicago Dr. Nina Casaverde, Lindner Dental Associates QUESTIONS??? 18

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