Pediatric Dental Emergencies

Transcription

1 Pediatric Dental Emergencies 36th Annual Common Childhood Problems Conference Sujatha S. Sivaraman BDS, DMD May 16 th 2014 Disclosures: None Objectives Identify Dental Emergencies Best methods to address emergencies in the Clinic and ED Strategies to prevent dental emergencies 1

2 Primary Teeth Dental Anatomy Primary Teeth Usual age 6 months - 6 years 20 teeth total-2x ( 4 Incisors, 2 Canines, 4 Molars) AKA baby teeth, milk teeth deciduous teeth Teeth are very white, square, and spaced apart. Mixed Dentition Usual age 6-12 yrs Primary and Permanent Dentition present Ugly duckling stage Around ages 6-7 and yrs lots of loose teeth teeth falling out - very common 2

3 Permanent Teeth Begin formation 3-4 mo Eruption 7-21 yrs 32 teeth ( including wisdom teeth) 2x ( 4 incisors, 2 canines, 4 premolars, 6 molars) Dental Anatomy Dental Emergencies in ED Increase in ED visits for dental care in the last two decades (Needleman, 2013). 66% of dental ED visits are Traumatic dental injuries. Few hospitals have onsite and/or off site coverage. Very few have written dental trauma protocol. 3

4 Role of Physicians Dental emergency during weekend and evening hours. Emergency dental insurance coverage. Uncontrolled or complex medical problems. Behavioral management issues needing sedation. Concomitant serious maxillofacial trauma. Lack of dental professionals on ED staff Pediatric Dental Emergencies Dental Caries - 6% Gingivitis - 5% Toothache - 9% Others - 10% It includes Facial cellulitis Dental abscess Facial pain Loose teeth Dental Brace problems.(oliva et al, 2008) Pediatric Dental Emergencies Caries (cavity) related emergencies Trauma related emergencies I. Primary (baby) teeth II. Permanent teeth Uncommon dental emergencies 4

5 This is what healthy dentition looks like Early Childhood Caries: Baby bottle tooth decay Management Referral to a general or pediatric dentist ASAP. Pain management PRN. Antibiotics if systemic involvement Based on age, extent of decay, patient will need dental rehabilitation under G.A or sedation. 5

6 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 Manifests as abscess or fistula local to affected tooth Primary teeth: Extraction & space maintenance Permanent teeth: Root canal therapy or extraction No antibiotics needed unless there is systemic involvement 6

7 Space maintainers Periapical Abscess Cellulitis 7

8 Cellulitis Management of Cellulitis Extensive swelling and Inflammation. Can be life threatening if left untreated especially in lower arch. Treatment includes IV Antibiotics and Possible Hospitalization initially & Extraction of the offending tooth ASAP Complications Dental infections can progress to life threatening complications such as Facial or buccal cellulitis Submandibular space infections (Ludwig s angina) Parapharyngeal space infections Airway compromise Orbital infections CNS infections Mediastinal infections Cavernous sinus thrombosis 8

9 Complications Signs of more serious illness Systemic symptoms fever/chills Trismus Displacement of tongue Altered LOC/delirium Eye pain Requires systemic ABX ENT consult Possible CT imaging Airway management Antibiotics Broad range of pathogens Mainly Streptoccocal Bacteroides sp. Anaerobes Simple infections Pen V or amoxil I prefer Amox/Clav or clinda Infections extending to facial or buccal cellulitis IV 2 nd generation Cephalosporin + Metronidazole HPTP Prevention Age one visit. Caries risk assessment and appropriate referrals. Fluoride varnish applications. Diet and Oral hygiene Instructions 9

10 Pediatric Dental Emergencies Caries (cavity) related emergencies Trauma related emergencies I. Primary (baby) teeth II. Permanent teeth Uncommon dental emergencies Dental Trauma Occur commonly in summer months particularly June and July. Fridays and Saturdays were the busiest days of the week. Most common cause of trauma are Falls, accidents, violence and sports activities. Dental Trauma Most common age group: 2-3 yrs Most commonly affected teeth are Permanent Maxillary central incisors Lateral incisors and Mandibular central and Lateral incisors. Most common injuries are Luxations and Avulsions. Most common displacements lateral luxations, extrusions and intrusions. 10

11 Fractures of teeth Dental Trauma Alveolar Fractures Luxation Intrusion or concussion Avulsion Primary vs Permanent History Of Injury Medical and dental history Where did the injury occur? How did the injury occur? When did the injury occur? Was there a period of unconsciousness? History of dizziness, headache, nausea and vomiting. Tetanus Vaccination. Rule out Abuse. History of Injury Is there any disturbance in the bite? Is there any reaction in the teeth to cold and/or heat exposure? 11

12 Clinical Examination Cranial nerve examination. Examine the face, lips and oral muscles for soft tissue lesions. Palpate the facial skeleton for signs of fractures. Inspect intra-orally for Fractures Abnormal tooth position Tooth mobility Abnormal response to percussion 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 Panoramic film Cone-beam CT or CT scan may be indicated. Basic goal is ALARA (As low as reasonably achievable ) Digital photographic examination. Primary Vs Permanent Abi, Meenu teeth photo. 12

13 Tooth Fractures Enamel Fracture (Ellis 1) Chipped tooth Painless unless associated with other injuries Large chips can be saved for reattachment Non urgent dental referral for cosmetic purposes Enamel and Dentin Fracture Enamel and Dentin ( Ellis 2) 70 % of dental fractures Tooth Fractures Pain with hot or cold and air. Dentin is yellow colored Panaromic to r/o other injury Increased risk of pulp infection/desiccation Dental evaluation in 24hrs Protection with dental cement Consider OTC pain medications. 13

14 Complicated Fractures Pulp involvement May be visible (Ellis 3) Can see blood May be below gums (root fracture) Only seen with x-ray Very painful as nerve exposed Treatment as Ellis 2 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. 14

15 Fractures of Permanent Teeth Alveolar Fractures Associated with fractures, luxated or avulsed teeth Small fractures involving 1 or 2 teeth can be treated by a dentist 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 Alveolar segment fractures cont., 15

16 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 Displacement of tooth into socket Concussion pain with no movement No bleeding at the margin of the tooth and gums. 16

17 Subluxation Tooth has abnormal mobility but no displacement. Sulcular bleeding is present. Luxation Loose tooth Extrusion dislodgement from alveolar bone Lateral luxation lateral displacement with alveolar fracture Both should have x-rays Reposition with firm pressure may require L.A Temporary splinting in ED Permanent splinting/treatment by dentist - 4 wks Lateral Luxation Displacement of the tooth other than axially. Displacement is accompanied by comminution or fracture of either the labial or the palatal/lingual alveolar bone. Tooth may be mobile or firmly locked into the displaced position. 17

18 Extrusion Partial Vertical displacement of the injured tooth from its socket. Discoloration of tooth Intrusion Intrusion more severe displacement involving root fracture and/or alveolar fracture forced in to alveolus, no mobility. Intrusion is differentiated on x-ray and requires repositioning 18

19 Avulsion The tooth is completely displaced out of its socket. Clinically the socket is found empty or filled with a coagulum. Avulsion If Primary tooth, do not reimplant. Breathing difficulties - Chest X-ray to rule out aspiration. Opposite is true for Permanent teeth!! 19

20 Avulsion Most time sensitive Traumatic dental injury. Complete displacement of tooth from alveolar socket Best chance of saving tooth if re-implanted under 60 mts. Management at Site of Injury - Replant immediately, if possible - If contaminated, rinse - When cannot be replanted, place tooth in transport medium. Transport Media Hank s Balanced Salt Solution (HBSS) Milk Saline Saliva (buccal vestibule) Water, if none available 20

21 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. Soft Tissue Management Tightly suture any soft tissue lacerations, especially in the cervical region 21

22 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 Good oral hygiene for first 10 days after an injury. Soft diet. Avoid sucking on a pacifier or digit. No need for routine antibiotics except avulsion. Watch for Parulis, swelling & necrosis. Avulsion of permanent teeth - needs RCT in 7-10 days. Prevention Of Dental Trauma Counsel caregivers about :- Participation in sports activities Household safety measures Trip hazards. Mouth guards Ice hockey, Lacrosse, Field hockey, Football. 22

23 Primary Vs Permanent Avulsed primary teeth should not be re-implanted to avoid damage to underlying teeth Primary teeth have more pulp and less dentin - more at risk for infection Luxations in young children are at greater risk of avulsion and aspiration consider urgent dental splinting. Enamel injuries can cut mucosa in young children and may need to be filed down Final Thoughts Pen or amoxicillin usually sufficient Consider clindamycin if allergic Don t forget Tetanus immunization Stock Mouth Guards Not Well adapted. Least expensive and least protective. The prices range ~ $3 to $25. Interferes with Speech and Breathing. 23

24 Boil and Bite Mouth Guard Mouth formed or Boil and Bite Mouthguard 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 Pericoronitis Other Emergencies Dry socket Palatal trauma. 24

25 Pericoronitis Most common in wisdom teeth Bacterial plaque and food debris accumulate beneath the flap of gum covering the partially erupted tooth. Pain, bad taste, pus, local inflammation can progress to cellulitis Salt mouthwashes, irrigate under flap ABX Pericoronitis Dry Socket- Alveolar Osteitis Complication of tooth extraction Clot covering alveolar bone is displaced Exposed alveolar bone becomes inflamed Normal post extraction pain decreases over 48hrs Dry socket pain increases at hrs Can progress to osteomyelitis 25

26 Dry Socket Analgesia NSAIDs, Narcotics, Nerve block Referral back to dentist in 24 hrs Will need frequent packing ABX? If caught early Timely f/u is available, probably not needed Resources & Recommendations Develop and have a dental emergency protocol in place. List of dental professionals in community for consult treatment - referral. Guidelines for trauma in AAP. Guidelines for management of trauma in AAPD. Latest Resources 26

27 References Needleman,H.L. et al.(2013).massachusetts emergency departments resources and physicians knowledge of management of traumatic dental injuries.dental Traumatology ; 29: Oliva et al (2008). Nontraumatic dental comlaints in a pediatric emergency department. Pediatric Emergency Care ; 24(11): Bruns,T.& Perinpanayagam,H.(2008).Dental trauma that require fixation in a children s hospital. Dental traumatology;24: Thank You 27