See also

Dental trauma
HSV gingivostomatitis

Key points

1. Opportunistic education for families on good oral hygiene practices and how to access dental services can prevent dental caries and odontogenic infection
2. Once a dental abscess or infection has formed, extraction or root canal therapy is usually required to remove the source of the infection

Background

• Dental caries occurs in more than 40% of Australian children and can begin as soon as teeth erupt during infancy
• Early childhood caries mainly affects the upper front teeth, and is seen in both breast and bottle-fed children who continue to feed/comfort suckle at night
• Oral hygiene practices should start from infancy. Infants can have their teeth and gums wiped with a clean cloth or baby toothbrush. Children >12 months old should have twice daily brushing with a smear of paediatric fluoridated toothpaste, performed or supervised by parents until competent
• Annual dental review is recommended

Tooth anatomy

Teeth have three layers: enamel, dentine and pulp

 Tooth development

• Children’s lower front teeth are the first to erupt, usually between 6-10 months (range 4-15 months). Children have 20 teeth by about 3 years old. See also eruption dates and tooth numbering
• Although the primary (baby) teeth exfoliate (fall out), the primary molars teeth do not exfoliate until 11-12 years of age
• Primary dentition (20 teeth): small, very white, bulbous crowns, often worn with flat edges
• Permanent dentition (32 teeth): larger, creamier colour, jagged edges on newly-erupted teeth

<6 yo - primary dentition	6-13 yo - mixed dentition	>13 yo - permanent dentition

Assessment

Dental history

• Frequency, duration and who performs tooth brushing
• Exposure to sugary and high acidity foods and drinks (including processed fruit juice and cordial)
• Frequency of bottles or sleeping with bottle teat or breast in mouth
• Previous dental treatment and advice given
• Previous dental trauma
• Dental or facial pain
• Chronic conditions which may impact dental development, saliva production or swallowing
• Medications which impact saliva production (eg antihistamines, anticonvulsants, antidepressants) or cause gum hypertrophy (eg phenytoin)
• Cardiac conditions which may indicate need for infective endocarditis prophylaxis for dental procedures

Examination

• ‘Lift the lip’ to ensure thorough examination of upper front teeth and gums
• Look for early signs of decay including white or brown spots/lines along the top of the tooth adjacent to the gum line which don’t brush off (see picture below)

• Check for loose or tender teeth
• Abscess may be indicated by
• tender gingival swelling or erythema
• draining sinus from the gingiva
• erythema and cellulitis of facial skin overlying tooth, submandibular or periorbital areas
• trismus
• fever and systemic symptoms may be absent

Management

Dental abscess

• Antibiotics should be prescribed in cases of spreading infection and/or systemic signs of infection, or where definitive dental treatment is likely to be delayed >24 hours
  
  
  • Localised infection: eg amoxicillin 25 mg/kg (max 500 mg) orally TDS
    
    
  • Spreading infection without systemic features: eg amoxicillin/clavulanate 22.5/3.2mg/kg (max 875mg/125mg) orally BD for 5 days
    
    
  • Spreading infection with severe or systemic features: eg. amoxicillin/clavulanate 25/5 mg (max 1/0.2 g) IV 6 hourly
    
    
• Antimicrobial recommendations may vary according to local antimicrobial susceptibility patterns, please refer to local guidelines
• Definitive treatment of the carious tooth ie extraction will still be required after treatment of pain and infection

Dental socket bleeding

• Can occur after treatment if child disturbs blood clot or due to a bleeding disorder
• Management
• Assess and manage haemodynamic status
• Clean mouth with cold water
• Provide local pressure with gauze (bite down if able for 30 minutes)
• If ongoing bleeding, consider gauze soaked in tranexamic acid
• Treat bleeding disorder if applicable
• May need surgical dressing and suturing
• Severe bleeding: IV access, FBE, coags, cross match, IV fluids, firm pressure, discuss with maxillofacial surgery and haematology

Natal teeth

• Usually do not require intervention
• Indications for extraction: very loose, inhalation risk, difficulties breastfeeding or traumatic ulcerations of the tongue/frenulum/lip

 Thumb-sucking and dummies

• Prolonged thumb-sucking and dummy use can cause problems with front teeth alignment, open bite and a “V-shaped” palate
• Dental consultation and cessation counselling is recommended for children with persisting habits after 3 years of age

Consider consultation with specialist paediatric dental team when

• Dental abscess with severe or systemic features requiring admission  
• Children with underlying medical, developmental or behavioural issues likely to benefit from specialist dental, anaesthetic or haematology input

Consider transfer when

Specialist dental or maxillofacial assessment and management is required and is not locally available

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services.

Consider discharge when

• Suitable for oral therapy
• Cellulitis improving and extraction planned or complete

Parent information

Dental care

Additional notes

Access to dental services

Each state has eligibility criteria for access to public dental services

• New South Wales
• Queensland
• South Australia
• Victoria
• Western Australia

Some children will also be eligible for the Child Dental Benefits Schedule which subsidises dental treatment through public or private dental services

Last updated June 2024