Sore Tooth

sore_toothWhat is this?  Child has no real signs of trauma or infection but complains of toothache.  The pain is vague and not specified to a single tooth.  Pain may be elicited with biting pressure and may be hot/cold sensitive.  Oral hygiene may be very poor in area.

Situation: A sore tooth, the most common childhood dental “emergency”.

What else it could be:  Erupting permanent tooth behind row baby tooth (blue gum),  food debris stuck betwen teeth or under red gums, cavity in between teeth, not readily seen, trauma to teeth from recent hard bite or hit to face, small canker sore (aphthous ulcer) low on the gum.

Is this an emergency, urgency, or problem?  PROBLEM.

Usually, if you cannot readily identify the problem in the mouth looking with a mirror and a good light, the problem is not urgent, despite the child’s concern.  Take your time in asking about the duration, onset, location, and “story” behind the pain.  The child may need a pat on the head and ibuprofen.  If you can find the source of pain and remove it (e.g., floss out the popcorn husk) or explain it, that treatment goes a long way.  A child who is “dying” of pain can transform into a happy big kid once he knows his big molar is coming in and he is just having “growing pains”.

Tell the parent:  Explain your investigation into the pain and the child’s story; often the parent is aware but did not give it importance or thought the child was bluffing.  Suggest follow up by a dentist unless it was an obvious fix.  Give over-the-counter analgesia if taht will help the child return to class.  Urge regular dental care and a relationship with a dentist.

First Aid:  As needed.

Follow up:  As needed or suggest new patient check-up for children without a dentist.

Dental Abscess

dental_abscessWhat do you see? Child has swelling above teeth on gum. It is fluctuant and may or may not hurt when touched.  The teeth hurt to biting pressure and may be hot/cold sensitive.

This is a:  This is a dental abscess.

What else it could be: Erupting permanent tooth over baby tooth. Aphthous ulcer (would be white but flat and very painful to touch)

Is this an emergency, urgency, or problem?  Problem
An abscess is a bacterial infection that is feeding off a dead pulp and pushing its way into the bone. The body tries to wall off the infection by surrounding it in pus.  If the pus pocket bursts, it relieves pressure and the child gets out of pain temporarily. Untreated the pus pocket grows and the infection can get into the spaces between facial muscles, growing serious.

What to tell the parent:  Explain the tooth is dead.  That gets their attention. Explain this is a bacterial infection that will not go away but become more serious, especially at night.  Press upon them the need to get an antibiotic started to limit the infection size until the tooth can be treated or removed.  Call the on call dentist for an emergency appointment and arrange for payment assistance if necessary.  Put a course of action in motion to make it easier for the parent to follow.  Over the counter pain medication will help; ice or topical anesthesia (ambesol) will not help.

First Aid:  Give the child ibuprofen at 10mg per kg. That is one tsp of liquid for a first grader and one 200mg pill for a fifth grader.  Restrict biting on tooth. Distract with candy (NO!)

Follow up:  A dentist will numb the lips, gums and tooth and remove the infected, necrotic tissue from the tooth or remove the tooth.  Space maintenance my be necessary.

Dental Abscess with Facial Cellulitus

dental_abscess_faceWhat do you see? Child has swelling seen outside mouth with possible distortion near eye or below angle jaw.  Fever and maliase present as well a swollen lymph nodes on effected side. The  teeth hurt to biting pressure and may be hot/cold sensitive.  Sometimes it is a rapid onset.

This is a:  This is a dental abscess spread into the planes of the face – facial cellulitis

What else it could be: Trauma, look for outside bruise at point of contact. Look at history. Gland infection or saliva gland blockage

Is this an emergency, urgency, or problem?  Emergency
An abscess is a bacterial infection that is feeding off a dead pulp and pushing its way into the bone. The infection may get into the spaces between facial muscles if the infection comes out the roots under the attachment of muscles to jaw. This spread can be very fast and may impact a child’s airway. If it is rapidly treated with IV antibiotics it usually quickly goes down.  If delayed treatment, bone loss, tooth loss and surgical intervention may be necessary. Children die from facial cellulitis in this country.

The family physician should work with the family dentist to admit this patient to the hospital and have the tooth removed. A pediatric dentist is trained for this scenario and may be able to save the family thousands in unnecessary medical work up if alerted early.

What to tell the parent: Explain the tooth is dead.  That gets their attention. Explain this is a bacterial infection that will become more serious.  Call emergency services if the child has convulsions or trouble breathing. Call a pediatrician or pediatric dentist to see child in ER or office depending on the judgment of the dentist.

First Aid: Not much can be done.  OTC analgesia should be given with DDS consultation.

Follow up:  A dentist will often be able to remove the tooth and get pus drainage which provides immediate pain relief and accelerates healing.  Medical treatment without tooth extraction usually is not effective.