Subspecialist Consult

Management of Dental Emergencies


 

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As general pediatricians, you should feel confident in your ability to diagnose and manage dental trauma and emergencies. Bumped teeth that are not loose, bruised gums, and aphthous ulcers are dental emergencies that you can evaluate and treat in your office, for example.

In contrast, referral is warranted after trauma loosens a tooth, breaks it, or causes the tooth to come out (avulsion). In addition, a child who presents with extreme pain, an abscessed tooth, or a tooth pushed out of position should be referred to a specialist. Dental cellulitis and severe soft tissue injuries of the mouth are other reasons I typically see these children.

An avulsed permanent tooth should be replaced quickly, within seconds or minutes. The longer the tooth is out of the mouth, the poorer the prognosis. Do not handle the root surface, but do rinse lightly and quickly to remove foreign material. If it is impossible to reimplant the tooth immediately, instruct parents to store the tooth in milk or saline for transport to the dentist.

Once the child reaches a specialist, treatment may include reimplantation with a splint to stabilize the tooth, prescriptions for systemic antibiotics and oral antimicrobials, and pulp therapy. Inform parents that most displaced permanent teeth undergo pulpal necrosis and require initiation of root canal therapy 1 week after stabilization.

In contrast, primary teeth usually are not reimplanted. If a patient comes in with a “baby tooth” that has been knocked out, then just pass it on to the tooth fairy.

The good news is most tooth injuries are self-evident. Signs of trauma include discoloration and patient reports of pain associated with tooth movement, chewing, palpation, and/or sensitivity to hot or cold food or drinks.

If you see facial swelling, however, expand your differential diagnosis to include etiologies beyond the teeth or gingival tissue. Infections and allergic reactions, for example, also can cause substantial gingival swelling. Rule out ear infections, swollen lymph nodes, and strep throat and viral infections, because these can mimic dental concerns.

If a child presents after trauma with a fractured tooth, make sure to remove any tooth fragments before suturing nearby tissue, including lacerated lips. Hemorrhage control, cleansing, and suturing, as indicated, are important management tips for such soft tissue wounds. Antibiotics are recommended for all “through and through” lacerations.

Establish a working relationship with pediatric dentists and oral surgeons in your community. When a child requires immediate care, these specialists can provide telephone advice on how to handle the emergency and/or be a source of immediate referral for the patient.

A dentist never wants to see a child for the first time during a traumatic situation. Instead, each patient should see a dentist by age 1 to establish a dental home. A child who visits the dentist on a regular basis will become familiar with the provider and more comfortable in the event of a dental emergency. Education of parents on optimal oral health, prevention of problems, and appropriate dental development are other benefits of early, routine dental care.

I recommend the American Academy of Pediatrics Section on Pediatric Dentistry and Oral Health's new curriculum called Protecting All Children's Teeth (PACT): A Pediatric Oral Health Training Program (www.aap.org/oralhealth/pact.cfm

Some dental emergencies can be evaluated and treated in your office, according to Tonya Fuqua, D.D.S.

Source Courtesy Cook Children's Hospital

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