Spot Treatment for Pediatric Dental Emergencies

Transcription

1 1426 McPhillips St R2V 3C5 888-KIDS 2107 Pembina Hwy R3T 5L Spot Treatment for Pediatric Dental Emergencies ( FRCD(c Fadi Kass DMD, Msc, May 9, 2015

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6 mother is on the line saying her 6 year old has been having pain from a tooth for the past week Toothache

7 Is it really a toothache?

8 - better oral hygiene - consider prescribing chlorhexidine mouthwash to be brushed on

9 Rx Chlorhexidine 0.12% Mouthwash Dispense 1 Bottle (475ml) Brush affected area BID x 5 days DO NOT SWISH DO NOT SWALLOW

10 Is the tooth vital? Yes No Operative Management Pharmacological Management

11 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

12 2 Doctors: PH Keyes [1960] Eva Mertz- Fairhurst [1998]

13 Keyes Triad

14 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

15 the seal of the filling is the most important

16 best sealing dental material?

17 Back to the kid...

18 glass ionomer cement

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20 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

21 - Spontaneous pain Non-vital - 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)

22 Antibiotics - amoxicillin (40mg/kg TID) - erythromycin if allergic

23 Pain medication

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25 Just dealt with a toothache emergency in about 10 minutes

26 Fractured tooth Dr. Kass there s a father on the phone who says his child fell at the playground and wants to come in

27 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)

28 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.

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30 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

31 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

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33 Send to oral surgeon

34 Class III Pulp exposure

35 Remove small layer of exposed pulp Cvek Pulpotomy Calcium Hydroxide GI cement followed by bond

36 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

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38 Erupting 8's - long term, OMFS referral - for now, CHX mouthwash with monoject syringe - if showing signs of systemic infection, then considering antibiotics (amoxicillin)

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40 Loose baby teeth parent on the phone. 11 year old girl with pain from her back teeth

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43 Immediate treatment - if child is cooperative, extract - if child is uncooperative then prescribe CHX to use in that area and keep wiggling

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45 Shark Tooth Syndrome Tooth growing behind the other tooth in front

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47 - sorry, simply not an emergency - concern yes, same day emergency it is not - bring child back within a few days

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49 Pearls of wisdom

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51 Pediatric dentistry = Efficiency

52 What do we know? - 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

53 Stainless steel crowns cemented with Glass ionomer cements are the best restorations for primary molars. 6 Best from durability standpoint Best seal formation

54 Don't always have to do pulpotomies!

55 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

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57 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

58 5 minutes on a screaming child

59 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.

60 Hall Technique no local minimal preping high success rate

61 Behaviour Management

62 Read this article David Nash -- Engaging children's cooperation in the dental environment through effective communication.

63 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

64 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.

65 scenario... Child: I'm scared Dentist: There's nothing to be scared about

66 Wrong!

67 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.

68 Child: I m scared. 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.

69 It is OK to be scared. Then follow up with explanation why what we are going to do next is not so bad.

70 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

71 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.

72 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

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74 Thank you

75 Referenes 1) McDonald, Avery. Dentistry for Children and Adolescent, 6 th ed. CV Mosby, Philadelphia ) Keyes PH: The infectious and transmissible nature of experimental dental caries: Findings and implications. Arch Oral Biol 1960;1: ) 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): ) Neville, Brad et al. Oral and Maxillofacial Pathology, 3 rd ed. Elsevier, St. Louis ) Addy M, Moran J. Mechanisms of stain formation on teeth, in particular associated with metal ions and antiseptics. Adv Dent Res 1995; 9: ) Seale NS. The use of stainless steel crowns. Pediatr Dent Sep-Oct;24(5): Review.

76 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 Jan;129(1): ) American Academy of Pediatric Dentistry. Clinical guide-lines on pulp therapy for primary and young permanent teeth: reference manual Pediatr Dent 2006; 28: ) Paddick, J.S., Brailsford, S.R., Kidd, E.A.M. and Beighton, D., Phenotypic and genotypic selection of microbiota surviving under dental restorations. Applied and Environmental Microbiology, 71(5), pp ) 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 Dec;145(12): doi: /jada ) Nash DA. Engaging children's cooperation in the dental environment through effective communication. Pediatr Dent Sep-Oct;28(5): ) 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., The Hall Technique for managing carious primary molars. Dental Update, 36: