Dental conditions - non traumatic

  • See also 

    Dental injuries

      Background

      The RCH Department of Dentistry only provides 'routine' dental care for children with chronic illness that may be impacted by dental caries (eg cerebral palsy, cardiac disease, bleeding disorders).

      Assessment

      • Age
      • Relevant medical history
      • History of presenting complaint
      • Pain history
      • Any associated swellings - extra or intra-orally.

      Toothache/ dental caries

      Background

      Tooth caries (decay) are common in Australian children and can begin soon after the eruption of the first incisors (around 7 months).

      'Nursing caries' are frequently seen (18 months onwards), mainly affecting the upper front teeth.

      Caries are often easy to recognize by the medical practitioner and this provides an important opportunity for education about dental care. Encouragement of good dental hygiene and dental review are important in preventing progression of decay and subsequent complications.

      Management

      Dental caries noted incidentally:

      Refer to a dentist (see services below) and provide dental care advice:

      Diet:

      • Minimise exposure to sugary floods and drinks, and limit sugary snacks to mealtimes (when saliva flow is optimal).
      • Minimise exposure to high acidity drinks (eg. carbonated, fruit & sports drinks) as they cause erosion of enamel.
      • For nursing caries, provide advice regarding feeding practices including change to a sipper cup from a bottle and avoiding demand or bottle feeding over-night.

      Toothbrushing and fluoride:

      • Toothbrushing should commence within 6 months of eruption of first tooth and should be supervised until the child is 8 years of age.
      • Use a small headed soft toothbrush for infants.
      • Toothbrushing should occur twice daily.
      • Use only a smear of toothpaste (size of a pea) and encourage children to spit out toothpaste.
      • Use low-fluoride (Junior) toothpaste for children under 5 years of age.
      • Drink plenty of water, ideally fluoridated tap water.

      Regular dental check-ups

      • Infants should see a dental professional within 6 months of eruption of the first tooth, as a 'well baby' anticipatory guidance visit.
      • Check-ups should take place at least annually.

      Children presenting with toothache:

      • Provide adequate analgesia
      • Exclude complications of dental abscess or systemic symptoms (see dental abscess below)

      Referral for dental care:

      • The RCH Department of Dentistry only provides 'routine' dental care for children with chronic illness that may be affected by dental disease (eg cerebral palsy, cardiac disease, bleeding disorders). Contact the dental registrar.
      • Otherwise healthy patients with uncomplicated dental caries or toothache should be referred to community dental services.

      Dental abscesses presenting with facial swelling / cellulitis

      Treatment of dental abscesses in children almost always involves tooth extraction +/- incision and drainage, particularly if primary dentition.

      Antibiotics will help to treat infection and pain but will only be a temporisingmeasure until definite treatment of the underlying carious tooth can occur.

      Assessment

      Consider non-dental causes (eg. cervical lymphadenitis, parotitis) for facial swelling/ cellulitis.

      Consider dental causes (toothache will not necessarily be a presenting complaint):

      • Enquire about recent dental trauma or hx of caries.
      • Examine for caries in association with a loose or tender tooth or an abscess (localised tender gingival swelling or erythema).
      • Fever and systemic upset may or may not be present.

      Management

      Treatment usually involves tooth extraction +/- incision and drainage.

      Dental registrar referral is required for:

      • Fever in the setting of suspected dental abscess
      • facial cellulitis/ swelling

      Fast patient until dental review

      Adequate analgesia

      Consider OPG (discuss with ED consultant or dental registrar); Generally children under 3 years are not able to cooperate for OPG.

      Antibiotics - IV penicillin or oral amoxicillin (if well enough for discharge).

      If well enough for discharge from ED, the patient needs review by a dentist in next 5-7 days.

      Dental socket bleeding

      May be after dental treatment, or due to underlying bleeding disorder or vascular anomaly.

      For bleeding disorders, also see:

      VonWillebrands Disease

      Haemophilia

      Assessment and management

      • Assess and manage haemodynamic status
      • Clean the mouth with cold water
      • Identify the source of the bleeding
      • Apply local pressure with a moist gauze pack soaked in Tranexamic acid (using a 500mg tablet crushed dissolved in 50ml of water)
      • Contact the on-call dentist
      • Socket may need suturing

      For severe bleeding

      • Circulation: IV access x2, FBE, coagulation screen, cross-match blood, IV fluid resuscitation.
      • Keep firm pressure on the site of bleeding as above.
      • ED Consultant/ ICU/ Anaesthetic input.
      • Contact maxillo-facial team

      Gum pathology

      • Gum pathology can be a local problem (eg. ulcers, viral gingivostomatitis, oral thrush, eruption cysts) or indicate systemic disease (eg leukaemia, immune-deficiency)
      • At risk of dehydration
      • HSV stomatitis

      Assessment

      • Appearance and tenderness of oral/gum lesion
      • Look for signs of dehydration, systemic infection or disease

      Management

      • Analgesia: topical anaesthetic gels /mouthwashes (suggestions would be good)
      • Maintain hydration
      • Antifungals for thrush
      • The dental registrar can be contacted for advice.

      Natal teeth

      • Do not usually require any intervention.
      • Indications for extraction include hypermobility, difficulties during breast-feeding, traumatic ulcerations on tongue/frenulum/lip, inflammation

      Resources

      Accessing dental services for Victorian children

      Dental Health Services Victoria

      Royal Dental Hospital, 720 Swanston Street, Melbourne: will accept emergency patients with a health care or pension card, open daily until 9pm (03 9341 1000).