Spot Treatment for Pediatric Dental

Emergencies

Fadi Kass DMD, Msc, FRCD(c)‏

May 9, 2015

1426 McPhillips St

R2V 3C5

888-KIDS

2107 Pembina Hwy

R3T 5L1

888-5437

Toothache

“mother is on

the line saying

her 6 year old

has been

having pain

from a tooth

for the past

week”

Is it really a toothache?

- better oral hygiene

- consider prescribing chlorhexidine

mouthwash to be brushed on

Rx Chlorhexidine 0.12% Mouthwash

Dispense 1 Bottle (475ml)

Brush affected area BID x 5 days

DO NOT SWISH

DO NOT SWALLOW

Is the tooth vital?

Yes No

Operative

Management

Pharmacological

Management

Vital tooth NO Antibiotics

- overly prescribed

- not effective on teeth that are vital

Symptoms:

- no spontaneous pain

- pain from eating

- Pain from cold and sweet

- Pain in winter, colder day

2 Doctors:

PH Keyes

[1960]

Eva Mertz-

Fairhurst

[1998]

Keyes Triad

Mertz-Fairhurst

- Frank cavitated lesions

- Just removed superficial caries

- Beveled enamel

- Restored tooth

- 10 years later teeth were fine

- The seal of the tooth is the key more than the

removal of the decay

the seal of the

filling is the

most

important

best sealing

dental material?

Back to the kid . . .

glass ionomer cement

Interproximal decay trickier

- Remember can be gingival irritation

- Place ionoseal to cover decay

- Likely touch neighbouring tooth.

- Do not floss area till you get them back

- Consider prescribing chlorhexidine

mouthwash

Non-vital

- Spontaneous pain

- Sometimes gingival pain may mimic this

- Up all night

- If PA is available, intraradicular or

perioapical radiolucency

- Buccal swelling

- Draining fistula (pain not as bad)

Antibiotics

- amoxicillin (40mg/kg TID)

- erythromycin if allergic

Pain medication

Just dealt with a

toothache

emergency in

about 10

minutes

Fractured tooth

“Dr. Kass there’s

a father on the

phone who says

his child fell at

the playground

and wants to

come in”

Question

How old?

- Under 5, likely primary tooth

- Over 8, likely permanent

- 5-8, unpredictable (most parents will likely

tell you if child’s already lost incisor)

“Is the tooth still in the mouth?”

- Unless child is <5 or we are certain that

this is primary tooth, we need to rule out

avulsion

- If the tooth is completely out and we are

not sure it is a primary tooth. Get here

NOW! Place in milk.

- If fractured, take a few minutes to find

piece.

Class I

- take PA to rule out root fractures

- smooth off rough areas

- consider adding layer of bond to reduce

sensitivity

- avoid incising into food

- keep area clean

Class II

- take PA to rule out root fracture

- smooth off rough areas

- add touch of GI to deepest

- add layer of bond

- avoid incising into food

- keep area clean

Send to oral

surgeon

Class III – Pulp exposure

Remove small

layer of

exposed pulp

Calcium

Hydroxide

GI cement

followed by

bond

Cvek

Pulpotomy

Avulsed tooth 60 mins is key

- brave parent, wash tooth with running water

and place back into socket

- place in milk

- re-implant tooth

- doxicycline BID x 7 days

- closed apex NSRCT within 7-10 days

- prognosis poor if >60mins

Erupting 8's

- long term, OMFS referral

- for now, CHX mouthwash with monoject

syringe

- if showing signs of systemic infection, then

considering antibiotics (amoxicillin)

Loose baby teeth “parent on the

phone. 11 year old

girl with pain from

her back teeth”

Immediate treatment

- if child is cooperative, extract

- if child is uncooperative then prescribe CHX

to use in that area and keep wiggling

Shark Tooth

Syndrome

“Tooth

growing

behind the

other tooth

in front”

- sorry, simply not an emergency

- concern yes, “same day” emergency it is not

- bring child back within a few days

Pearls of wisdom

Pediatric dentistry = Efficiency

- children have a short attention span

- the quicker you do treatment, the better so

long as outcome is not compromised

- sealing the tooth important aspect of

restoration

- GI cement is the best sealing restorative

material

What do we know?

Stainless steel crowns cemented with Glass

ionomer cements are the best restorations

for primary molars.6

Best from durability standpoint

Best seal formation

Don't always have to do

pulpotomies!

AAPD guidelines on pulp therapy for

primary and immature permanent teeth:

“Indirect pulp capping has been

shown to have a higher success

rate than pulpotomy in long

term studies. It also allows for a

normal exfoliation time.

Therefore, indirect pulp

treatment is preferable to a

pulpotomy when the pulp is

normal or has a diagnosis of

reversible pulpitis.” 8

Treatment time

- it takes me between 4-8 minutes to do a

pulpotomy properly

- prep the chamber

- remove pulp tissue

- place formocresol for at least 4 mins

- wait for IRM set

- final prep for crown

5 minutes on a screaming child

If you're not sure, then you have to pulp

looking for signs of irreversible pulpitis or

necrosis.

If you are sure that this tooth is vital, you do

not have to enter the chamber.

Hall

Technique

no local

minimal preping

high success rate

Behaviour Management

Read this article

David Nash -- Engaging children's

cooperation in the dental environment

through effective communication.

“When children are in the midst of strong emotions, they cannot listen to anyone…they want us to understand what is going on inside of them—what they are feeling at that particular moment.”

Haim Ginott

a child's feelings

What a child feels is what they feel. It is a

fact.

Often we try to deny children their feelings,

rather than accept them.

Want child to know that you understand.

Child: “I'm scared”

Dentist: “There's nothing to be scared about”

scenario . . .

Wrong!

Child: “I'm scared”

Dentist: “There's nothing to be scared about”

We are denying the child their feelings.

We are implying that they are not normal for

feeling this way.

Dentist: “I understand. Sometimes new things

are scary. It is okay to be scared.

Sometimes I am scared of things I do not

understand or things I have not done

before.”

Child: “I’m scared.”

“It is OK to be scared.”

Then follow up with explanation why what

we are going to do next is not so bad.

“I message”

Nash states that if the dentist/assistant

describing phrases in the first person, it is

more effective.

“When you open your mouth really wide, the

tooth doesn't get wet”

“I can see better when you open your mouth

wider”

“Ouch! It hurts me when you bite down”

Children are inherently

very nice mini humans

and they do not want to

cause you any harm.

I use this technique very

often to gain moisture

control.

In Summary . . .

- selectively choose to avoid pulpotomies

- sympathize with child's feelings

“It is ok to be scared”

- speak in terms of I messages

“ouch, please don't do that it hurts me”

Thank you

Referenes

1) McDonald, Avery. Dentistry for Children and Adolescent, 6th ed. CV Mosby, Philadelphia. 1994.

2) Keyes PH: The infectious and transmissible nature of experimental dental caries: Findings and

implications. Arch Oral Biol 1960;1:304–320.

3) Farooq NS, Coll JA, Kuwabara A, Shelton P. Success rates of formocresol pulpotomy and indirect

pulp therapy in the treatment of deep dentinal caries in primary teeth. Pediatr Dent 2000;22(4):278-

86.

4) Neville, Brad et al. Oral and Maxillofacial Pathology, 3rd ed. Elsevier, St. Louis. 2009.

5) Addy M, Moran J. Mechanisms of stain formation on teeth, in particular associated with metal ions

and antiseptics. Adv Dent Res 1995; 9: 450–456.

6) Seale NS. The use of stainless steel crowns. Pediatr Dent. 2002 Sep-Oct;24(5):501-5. Review.

7) Mertz-Fairhurst EJ, Curtis JW Jr, Ergle JW, Rueggeberg FA, Adair SM. Ultraconservative and

cariostatic sealed restorations: results at year 10. J Am Dent Assoc. 1998 Jan;129(1):55-66.

8) American Academy of Pediatric Dentistry. Clinical guide-lines on pulp therapy for primary and young

permanent teeth: reference manual 2006-07. Pediatr Dent 2006; 28:144–8.

9) Paddick, J.S., Brailsford, S.R., Kidd, E.A.M. and Beighton, D., 2005. Phenotypic and genotypic

selection of microbiota surviving under dental restorations. Applied and Environmental

Microbiology, 71(5), pp. 2467-2472

10) Ludwig KH, Fontana M, Vinson LA, Platt JA, Dean JA. The success of stainless steel crowns placed

with the Hall technique: a retrospective study. J Am Dent Assoc. 2014 Dec;145(12):1248-53. doi:

10.14219/jada.2014.89.

11) Nash DA. Engaging children's cooperation in the dental environment through effective

communication. Pediatr Dent. 2006 Sep-Oct;28(5):455-9.

12) Bark JE, Dean AA, Cairns AM. Opinion and usage of the “Hall Technique” amongst paediatric

dental specialists in Scotland. Int J Paediatr Dent 2009; 19(Suppl. 2):11.

13) Innes NPT, Evans DJP. Hall N., 2009. The Hall Technique for managing carious primary molars.

Dental Update, 36:472-478.