Children frequently present to the emergency department (ED) complaining of oral problems, primarily due to oral trauma or related to dental caries. Many of these can be diagnosed and treated by the ED physician, with subsequent referral to a dentist for consultation and/or definitive treatment.
Dental Anatomy
A basic knowledge of dental anatomy is necessary for evaluating and treating dental emergencies. The tooth itself is composed of four primary layers. The dental enamel, a mineralized, crystalline material, covers the coronal portion of the tooth. It is the hardest material found in the human body. A somewhat softer material, cementum, forms the outer surface of the root. Underneath the enamel and/or cementum is a less mineralized layer called dentin. The innermost portion of the tooth is the pulp chamber, which contains nerve tissue, as well as the vascular supply for nourishing the tooth structure. Periodontal ligament fibers attach the roots of the tooth to the surrounding alveolar bone. These structures are shown in Figure 4.1.
Complaints Associated With Dental Eruption
Clinical Presentation
Teething
Teething can be associated with irritable behavior (due to minor discomfort) and increased drooling. Teething infants often present to the ED with fever and diarrhea, although there is no conclusive evidence that tooth eruption is truly the cause. Therefore, evaluate the patient appropriately and consider teething a diagnosis of exclusion.
Treat teething pain with a frozen teething toy, but advise the parents to avoid using toys with multiple parts. For more significant pain, recommend acetaminophen (15 mg/kg q 4h), ibuprofen (10 mg/kg q 6h), or an over-the-counter non-irritating topical anesthetic. Be judicious when prescribing topical anesthetics for infants, as systemic absorption is rapid, so toxicity can occur if the product is misused.
Eruption Cyst or Hematoma
An eruption cyst is a fluctuant, fluid-filled sac overlying an erupting primary or permanent tooth. An eruption hematoma will have a bluish-purple appearance due to blood filling the sac. Eruption cysts and hematomas are benign findings and will resolve spontaneously, either through biting pressure or upon eruption of the tooth.
Natal and Neonatal Teeth
Natal teeth are primary teeth that are present at birth. Neonatal teeth refer to teeth that erupt in the first 30 days of life. Both usually erupt in the mandibular incisor area and, in most cases, are part of the normal primary dentition and not supernumerary. Natal and neonatal teeth pose a theoretical aspiration risk, although no cases of aspiration have been reported in the literature.
Traumatic injury to the infant’s tongue may be caused by the sharp incisal edges of these teeth, while trauma to a nursing mother’s breast may interfere with feeding. Both of these conditions are indications for extraction and require referral to a dentist.
Bibliography
Dental Caries and Odontogenic Infections
Dental caries is the most common chronic childhood disease in the United States and is frequently the cause of dental pain and oral infection. The caries process is initiated by the interaction of the bacteria Streptococcus mutans with fermentable carbohydrates, primarily sucrose. The acid that is produced as a byproduct of the bacteria’s digestion of carbohydrates can dissolve the highly mineralized enamel that covers the tooth surface. Once the enamel is destroyed, further destruction of tooth structure can proceed fairly quickly until bacteria infect the innermost layer of pulp tissue. Lactobacilli may play a role in the progression of the lesions. Once organisms have reached the pulp, the infection can spread through the root into the adjacent periapical tissue, resulting in a dentoalveolar infection.
Most odontogenic infections are polymicrobial, with anaerobes predominating. Under healthy conditions, most of these organisms are not pathogenic. However, local (caries, trauma, foreign body, vascular insufficiency) and/or systemic factors (immune deficiencies) can facilitate the development of dental abscesses.
Clinical Presentation
Cavities
Dental caries commonly occur in the pits and fissures of the occlusal (chewing) surfaces of posterior teeth, interproximal surfaces of molars, and smooth tooth surfaces close to the gingiva. They initially appear as dull, opaque, white discolorations, which then cavitate and appear as brown holes. Although these lesions may be visible upon oral examination, they often remain asymptomatic until the infection spreads into the pulp tissue, and then present as pain upon eating sweet or cold foods. As the infection spreads, patients frequently report spontaneous pain, often interfering with sleep and eating.
Early Childhood Caries
Previously termed nursing bottle caries or baby bottle tooth decay, early childhood caries (ECC) is a form of rampant caries found in some young children. Typically, the labial and palatal surfaces of the primary maxillary incisors are the first teeth affected. If not treated, the caries can spread to the primary molars. The mandibular incisors are typically spared, except in the most severe cases. Children will often present with gross destruction of the maxillary incisors.
Dental Abscess
This is a localized, purulent infection caused by dental pulp necrosis, secondary to either dental caries or trauma to a non-carious tooth. An abscess can be chronic or acute. A chronic abscess is often asymptomatic, but can become an acute, symptomatic lesion. Some painful acute abscesses are not clinically evident and require a radiograph for diagnosis. Others may present with gingival erythema, tooth mobility, tenderness to tooth percussion, soft tissue swelling, and lymphadenopathy. Sometimes, a fistulous tract develops and opens onto the gingival mucosa, forming a parulis/abscess. This is more common in younger children, whose alveolar bone is relatively less dense.
Pericoronitis
Pericoronitis refers to inflammation or infection of the soft tissues adjacent to a partially erupted tooth. The teeth most commonly associated are the mandibular third molars (wisdom teeth). The condition is caused by food and bacteria becoming trapped under gingival tissue that partially covers the tooth. Symptoms can include localized swelling, pain, and a bad taste in the mouth due to suppuration. Frequently, there is localized lymphadenopathy, and cellulitis and trismus can also develop.
Cellulitis
Localized infection from a carious or traumatized tooth can spread through soft tissues, causing cellulitis. This may be accompanied by fever, pain, trismus, and regional lymphadenopathy. Include a thorough oral examination of any patient presenting with cellulitis of the face or neck, as the infection may be of odontogenic origin.
Deep Fascial Space Infections
Oral infections can also spread to the deep fascial spaces of the head and neck. Depending on the tooth and drainage area involved, varying degrees of pain, swelling, and trismus occur. In severe cases, involvement of the sublingual, pharyngeal, retropharyngeal, or pretracheal areas can occur, leading to dysphagia and/or respiratory compromise.
Ludwig’s angina is a condition in which a mandibular dental abscess expands rapidly, causing diffuse swelling to the floor of the mouth, which then leads to airway compromise. This is usually associated with the permanent molars and is therefore uncommon in young children who have only primary teeth.
Diagnosis
A thorough intraoral evaluation is necessary for any patient with oral pain or face and neck swelling. In the absence of obvious dental caries, inquire about a history of dental trauma or past dental treatment. Inspect the oral cavity for obvious caries, gingival swelling and erythema, possibly from an infected tooth or an abscess. Palpate the gums for swelling and tenderness, and tap the molar occlusal surfaces of each tooth with a tongue blade to identify percussion sensitivity, and check for tooth mobility. Radiographs are indicated only if there is no obvious etiology for a swelling, or when numerous carious teeth are present.
ED Management
Caries
Refer asymptomatic children with dental caries and no evidence of acute infection to a dentist for comprehensive care. If the patient has dental-related pain, but no soft tissue inflammation or swelling, give analgesics and refer to a dentist as soon as possible, preferably the next day. Do not prescribe antibiotics for such patients.
Localized Dental Abscess
Consult with a dentist to perform incision and drainage of any fluctuant area. Prescribe analgesia with ibuprofen (10 mg/kg q 6h), or if severe, acetaminophen with codeine (0.5 mg/kg of codeine q 6h), although satisfactory pain relief is often achieved by the drainage procedure. Also prescribe oral antibiotics, either penicillin (25–50 mg/kg/day div q 6–8h) or clindamycin (20–30 mg/kg/day div q 6h). Treat localized pericoronitis in the same way as other localized dental abscesses. Additionally, irrigation with saline under the gingival flap that covers the affected tooth may help to alleviate discomfort.
Facial Cellulitis or Deep Fascial Space Infections
Admit the patient, consult an oral and maxillofacial surgeon, and start IV antibiotics. Use either penicillin 100,000–250,000 units/kg/day div q 4 h or clindamycin 25–40 mg/kg/day div q 6h). Carefully assess the airway; any suggestion of compromise is an indication for early intubation. After initiation of antibiotic therapy, if there is a concern about the extent of a deep fascial space infection, obtain either a computerized tomography (CT) scan or magnetic resonance imaging (MRI).
Indications for Admission
Facial cellulitis involving periorbital region
Evidence of deep space infection (sublingual, submandibular, parapharyngeal) with potential for airway compromise
Systemic involvement, including fever and/or dehydration due to inability or unwillingness to eat and drink
Patients with immune compromise (HIV, diabetes, steroid therapy, cancer chemotherapy)
Concern about outpatient adherence to the medical and/or follow-up recommendations
Bibliography
Oral Trauma
Oral trauma is quite common in childhood, with injuries occurring in approximately 25% of school-age children. Causes include falls, seizures, sports injuries, motor vehicle accidents, fights, and inflicted injury. Lacerations, contusions and abrasion of facial soft tissues, gingiva, and intraoral mucosa are often associated with dental injuries. Fractures to facial bones and the bones that support the dentition can also occur. In a multiple-trauma victim, be sure to evaluate for dental injuries, which can easily be overlooked and potentially result in permanent damage.
Clinical Presentation
Dental Fractures
Treatment of dental fractures in the ED is rarely definitive, and any patient presenting with acute dental trauma requires referral to a dentist or oral surgeon within 24 hours. Appropriate intervention provided in a timely manner in the ED, however, is vital to prevent subsequent tooth loss and infection. See Table 4.1 for classification of dental fractures, along with appropriate management. Recommendations for treatment of fractured primary teeth do not differ markedly from those for permanent teeth. Depending on the age of the child at the time of trauma, and the expected longevity of the primary tooth, many dental practitioners will choose to be less aggressive in attempts to maintain a primary tooth.
