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Dental conditions - non traumatic

  • 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
    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

    • 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 of age
    • Dental caries (tooth decay) 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 prolonged breast and bottle-fed children (>18 months) who continue to feed frequently at night or who comfort suck to sleep once teeth have erupted
    • Infants can have their teeth and gums wiped with a clean cloth or baby toothbrush
    • From 12 months twice daily brushing with a smear of paediatric fluoridated toothpaste supervised or performed by parents (for children under 8 years) and annual dental review helps prevent caries and complications
    • Routine dental care should be provided in the community rather than by hospitals, except for children with chronic illness that may be impacted by dental caries (eg cancer, cardiac disease, immunodeficiency, bleeding disorders, special needs) or where general anaesthetic is required

    Tooth Anatomy

    Teeth have three layers: enamel, dentine and pulp

    tooth anatomy

    Tooth Anatomy 2

    Primary teeth (20): small, very white, bulbous crowns, often worn with flat edges
    Permanent teeth (32): larger, creamier colour, jagged edges on newly-erupted teeth.

    tooth_anatomy4  tooth_anatomy5  tooth_anatomy6 
    <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 review and advice given
    • Previous dental trauma
    • Dental or facial pain
    • Chronic conditions which may impact saliva production or swallowing
    • Consider non-dental causes eg cervical lymphadenitis, parotitis

    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
        tooth_anatomy7

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

    Management

    Investigations

    • Blood tests are not required
    • In consultation with dentist consider orthopantogram (OPG) in children over 3 years who will cooperate to assess for early decay and other abnormalities

    Treatment

    • Treatment of dental abscesses in children usually involves tooth extraction with incision and drainage as needed
    • Refer for urgent dental review:
      • fever in setting of suspected dental abscess
      • facial cellulitis or swelling
    • Provide adequate analgesia
    • Antimicrobial recommendations may vary according to local antimicrobial susceptibility patterns; please refer to local guidelines
      • amoxicillin 25 mg/kg (max 500 mg) PO tds or benzylpenicillin 50 mg/kg (max 1.2 g) IV 6-hourly
    • Definitive treatment of the carious tooth will still be required after treatment of pain and infection

    Other Dental Conditions

    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 soaked in water or saline (bite down if able for 30 minutes)
      • if ongoing bleeding consider gauze soaked in tranexamic acid
      • 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

    Consider consultation with local paediatric dental team when

    Children with underlying medical, developmental or behavioural issues likely to benefit from specialist dental, anaesthetic or haematology input

    Consider transfer when

    Children requiring care beyond the comfort level of local services

    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

    Each state has its own eligibility criteria for access to public dental services in addition to the federal Child Dental Benefits Schedule (which can also be accessed through private dentists)

    Last updated October 2020

  • Reference List

    1. Australian Institute of Health and Welfare, 2020 Australia’s Children, viewed April 2020 <https://www.aihw.gov.au/reports/children-youth/australias-children/contents/health/dental-health>
    2. Department of Speech Pathology 2017, Oral Hygiene in Children with Feeding Difficulties, Queensland Children’s Hospital https://www.childrens.health.qld.gov.au/wp-content/uploads/PDF/factsheets/oral-health-feeding-hp-fs.pdf
    3. Oskouian R 2009, A Pediatric Guide to Children’s Oral Health, American Academy of Pediatrics, viewed April 2020 <https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Oral-Health/Documents/OralHealthFCpagesF2_2_1.pdf>
    4. RCH National Child Health Poll 2018, Child Oral Health: habits in Australian homes, viewed April 2020 <https://www.rchpoll.org.au/wp-content/uploads/2018/03/NCHP10_Poll-report_Child-oral-health.pdf>
    5. Schinkewitsch T 2014, Early Childhood Oral Health Guidelines for Child Health Professionals, Centre for Oral Health Strategy NSW, viewed April 2020 <https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2014_020.pdf>