diagnosis and management of dental pain and trauma in the

© Children’s Specialty Group. All rights reserved.

“TOOTH” AND CONSEQUENCESDiagnosis and Management of Dental Pain and Trauma in the

Urgent Care Setting October 8, 2020

Presented by:

Dr. Lori Barbeau, DDSMedical Director–Children’s Dental CenterProgram Director–Pediatric Dental Residency Program

© Children’s Hospital of Wisconsin. All Rights Reserved

Things that will walk into Urgent Care

Dental Pain

Teething

Decay

○ Toothache

○ Abscess

○ Facial Swelling

○ Role of Antibiotics

Dental Appliances

Dental Trauma

Tooth Fracture

Lateral luxation

Intrusion

Extrusion

Avulsion

Alveolar

Fracture

Jaw Fracture

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Primary vs. Permanent

Primary Dentition smaller, squarer, whiter

Mandibular primary incisors

begin exfoliation at ~6/7 years

of age

Maxillary primary incisors

begin exfoliation at ~ 7/8

years of age

**impact on the underlying

permanent teeth always

dictates treatment

Permanent Dentition larger, longer, darker

Mandibular permanent incisors

begin eruption at ~ 6/7 years of

age

Maxillary permanent incisors

begin eruption at ~7/8 years of

age

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Teething

Eruption Hematoma/Cyst

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

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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

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Pericoronitis

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

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Dental Decay

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

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Toothaches

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

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Questions to ask parents…

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?

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Reversible Pulpitis

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

10


Irreversible Pulpitis

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

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Dental Abscess

Bacteria invasion of pulp tissue leading to an immune

response = swelling

Tooth is necrotic = pain is from pressure and

inflammation

12


Dental Abscess

Infection takes the path of least resistance and looks

to drain

Clinical Presentation

Parulis (gum boil)

Draining Fistula

Facial Swelling

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Dental Abscess

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When to give RX for Antibiotics

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

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Penicillin VK

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

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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 . . .

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Facial Swelling 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

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Admission considerations

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

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Facial Swelling

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Dental Appliances

“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

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

22


Cemented Bands

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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

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Tooth Fractures

Uncomplicated – no pulpal involvement

Complicated – pulpal involvement

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Uncomplicated Fracture

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

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

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Associated Soft Tissue Injury

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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

29


Displacement Injuries

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”)

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Displacement - Luxation

May not be mobile due to associated bone fracture

Neurovascular bundle is severed

Apex is “locked”

Areas of both periodontal ligament tearing and

compression

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Displacement - Luxation

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

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Displacement-Luxation

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Displacement - Intrusion

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

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Displacement-Intrusion

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Primary Dentition

36



Permanent Dentition

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Displacement - Extrusion

Tooth appears elongated, is very loose and

shows bleeding from the sulcus

Neurovascular bundle is stretched/torn

Periodontal ligaments are torn

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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

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Displacement-Extrusion and Luxation

Primary Dentition

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Displacement-Extrusion

Permanent Dentition

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Avulsion

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

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Avulsion-

Permanent Dentition 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 days43


Avulsion-Permanent Dentition

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Fracture of the Alveolar Process

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

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Alveolar Fracture

Bite Compensation

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Alveolar Fracture

TX: reposition & splint

5 interrupted 4-O chromic gut sutures

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Jaw Fracture: “Pearls”

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

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Mandibular Fracture

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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

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Questions?

References• Dentaltraumaguide.org

• Andreasen et al. Guidelines for the Management of Traumatic Dental Injuries

• (University Hospital of Copenhagen)

• AAPD – American Academy of Pediatric Dentistry

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