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PEDIATRIC
Emergency Medicine PRACTICE
AN EVIDENCE-BASED APPROACH TO PEDIATRIC EMERGENCY MEDICINE s EBMEDICINE.NET
Initial Assessment and Management of Pediatric Dental
Emergencies
In the middle of a busy shift in the ED, a nurse tells you she has just
placed a 5-year-old boy with a mouth injury in an examining room. The
boy reports that less than an hour ago he was playing basketball and lost a
tooth when he was accidentally “elbowed” by his older brother. His mother
reports that an adolescent nephew had a similar incident last year, and the
dentist recommended that they place the tooth in milk, and she produces a
small jar of milk containing the lost tooth. On physical examination, the
child denies having any jaw pain or swelling, but the socket where the left
central maxillary incisor should be is empty and oozing blood. Can this
tooth be saved? What sort of dental injuries might this child have suffered
in addition to the lost tooth? How does the management of dental trauma
change in light of a patient’s age or the location of the traumatized tooth? Is
there something else a parent should have done prior to arrival in the ED to
help save the tooth?
Meanwhile, one of your patients has just been taken to the cardiac
catheterization laboratory since you diagnosed his myocardial infarction.
After intubating a woman with lung cancer and respiratory failure secondary to acute H1N1 influenza, her condition has finally stabilized. You
have even managed to administer moderate sedation to reduce the shoulder
dislocation of a young skateboarder who fell on his outstretched hand. You
are hoping for an easy case when the nurse tells you there’s a 6-year-old girl
with dental pain in the next room. You think you’ve caught a break until
your review of this patient’s previous visits to the ED for several episodes
of dental pain. Her record contains several notes from emergency clinicians
as well as from social workers instructing the parents to follow-up with
AAP Sponsor
Michael J. Gerardi, MD, FAAP,
FACEP
Martin I. Herman, MD, FAAP, FACEP Clinical Assistant Professor of
Professor of Pediatrics, UT
Medicine, University of Medicine
College of Medicine, Assistant
and Dentistry of New Jersey;
Director of Emergency Services,
Director, Pediatric Emergency
Lebonheur Children’s Medical
Medicine, Children’s Medical
Center, Memphis, TN
Center, Atlantic Health System;
Department of Emergency
Editorial Board
Medicine, Morristown Memorial
Jeffrey R. Avner, MD, FAAP
Hospital, Morristown, NJ
Professor of Clinical Pediatrics
and Chief of Pediatric Emergency Ran D. Goldman, MD
Associate Professor, Department
Medicine, Albert Einstein College
of Pediatrics, University of Toronto;
of Medicine, Children’s Hospital at
Division of Pediatric Emergency
Montefiore, Bronx, NY
Medicine and Clinical Pharmacology
T. Kent Denmark, MD, FAAP,
and Toxicology, The Hospital for Sick
FACEP
Children, Toronto, ON
Medical Director, Medical Simulation
Mark A. Hostetler, MD, MPH Clinical
Center; Associate Professor of
Professor of Pediatrics and
Emergency Medicine and Pediatrics,
Emergency Medicine, University
Loma Linda University Medical
of Arizona Children’s Hospital
Center and Children’s Hospital,
Division of Emergency Medicine,
Loma Linda, CA
Phoenix, AZ
Alson S. Inaba, MD, FAAP, PALS-NF
Pediatric Emergency Medicine
Attending Physician, Kapiolani
Medical Center for Women &
Children; Associate Professor of
Pediatrics, University of Hawaii
John A. Burns School of Medicine,
Honolulu, HI; Pediatric Advanced
Life Support National Faculty
Representative, American Heart
Association, Hawaii and Pacific
Island Region
Andy Jagoda, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Mount
Sinai School of Medicine; Medical
Director, Mount Sinai Hospital,
New York, NY
Tommy Y. Kim, MD, FAAP
Assistant Professor of Emergency
Medicine and Pediatrics, Loma
Linda Medical Center and
Children’s Hospital, Loma Linda;
Attending Physician, Emergency
Medicine Specialists of Orange
June 2010
Volume 7, Number 6
Authors
Derya Caglar, MD
Assistant Professor, University of Washington School of Medicine;
Attending Physician, Division of Emergency Medicine, Seattle
Children’s Hospital, Seattle, Washington
Richard Kwun, MD
Attending Physician, Department of Emergency Medicine,
Swedish Medical Center, Issaquah, Washington
Peer Reviewers
Alan B. Douglass, MD, FAAFP
Associate Director, Family Medicine Residency Program,
Middlesex Hospital, Middletown, CT
Joanna Douglass, BDS, DDS
Associate Professor, Division of Pediatric Dentistry, University of
Connecticut School of Dental Medicine, Farmington, CT
Martin I. Herman, MD, FAAP, FACEP
Professor of Pediatrics, UT College of Medicine; Assistant
Director of Emergency Services, Lebonheur Children’s Medical
Center, Memphis, TN
CME Objectives
Upon completion of this article, you should be able to:
1. Identify differences between types of dental trauma/dental
infections and how they appear clinically in your patients.
2. Apply evidence-based treatment of primary versus
permanent teeth in cases of dental trauma in your patients.
3. Recognize and treat/refer dental trauma and infections
in your patients that require emergent or urgent dental follow-up.
Date of original release: June 1, 2010
Date of most recent review: May 10, 2010
Termination date: June 1, 2013
Medium: Print and Online
Method of participation: Print or online answer form and
evaluation
Prior to beginning this activity, see “Physician CME Information”
on page 19.
County and Children’s Hospital of
Orange County, Orange, CA
Gary R. Strange, MD, MA, FACEP
Professor and Head, Department
of Emergency Medicine, University
of Illinois, Chicago, IL
Brent R. King, MD, FACEP, FAAP,
FAAEM
Professor of Emergency Medicine
Christopher Strother, MD
and Pediatrics; Chairman,
Assistant Professor,Director,
Department of Emergency Medicine,
Undergraduate and Emergency
The University of Texas Houston
Simulation, Mount Sinai School of
Medical School, Houston, TX
Medicine, New York, NY
Robert Luten, MD
Adam Vella, MD, FAAP
Professor, Pediatrics and
Assistant Professor of Emergency
Emergency Medicine, University of
Medicine, Pediatric EM Fellowship
Florida, Jacksonville, FL
Director, Mount Sinai School of
Medicine, New York, NY
Ghazala Q. Sharieff, MD, FAAP,
FACEP, FAAEM
Michael Witt, MD, MPH, FACEP,
Associate Clinical Professor,
FAAP
Children’s Hospital and Health Center/ Medical Director, Pediatric
University of California, San Diego;
Emergency Medicine, Elliot Hospital
Director of Pediatric Emergency
Manchester, NH
Medicine, California Emergency
Research Editor
Physicians, San Diego, CA
V. Matt Laurich, MD
Fellow, Pediatric Emergency
Medicine, Mt. Sinai School of
Medicine, New York, NY
Accreditation: EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. A. Douglass, Dr. J. Douglass, and their related parties
report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Commercial Support: This issue of
Pediatric Emergency Medicine Practice did not receive any commercial support.
the dental clinic. The reports also document transport
assistance provided to the family as well as their need for
financial aid. Before you enter the examining room, you
ask yourself several questions. Are this child’s primary or
permanent (secondary) teeth affected? What is the likely
cause of her dental pain? If there is an infection, what are
the indications for antibiotics? Given the repeated history
of visits to the ED without appropriate follow-up, should
you report her parents to Child Protective Services?
teeth from falls and collisions with stationary objects, whereas among older adolescents and adults,
injuries to the permanent teeth are inflicted mostly
during sports, traffic accidents, and some forms of
violence (eg, fights, assaults, battery).4-7
Anatomic features can increase the risk of injury.
The central maxillary incisors are the most commonly injured teeth.2,8-10 Protrusion of the upper teeth
(ie, overbite) and inadequate coverage by the lips
double the risk of injury to these teeth, particularly if
the protrusion is greater than 5 mm.11-13
Human factors also play a role in trauma risk.
Boys are 2 to 3 times more likely than girls to sustain
injury to their permanent teeth.3,8,14,15 Hyperactivity
and increased risk-taking behavior heightens this
risk.16 Not surprisingly, victims of bullying sustain
more dental trauma. Oral piercings with metal
jewelry are increasingly more common and can lead
to dental injuries. Research has shown that lip and
tongue piercings may lead to chipping and fracturing of teeth and restorations, pulp damage, the
cracked tooth syndrome, tooth abrasion, pain, swelling, and infections.8,17,18
W
hat is the evidence base for the assessment
and treatment of dental emergencies in
children? The emergency clinician must be able to
quickly recognize injury patterns in the pediatric
population and must be familiar with the anatomy
unique to this group. Of specific concern is the
emergency treatment of primary teeth versus permanent (secondary) teeth. This article is divided into 2
sections: dental trauma and dental infections. This
review of available evidence in the literature will
equip the emergency clinician with the information
needed to provide the most up-to-date care.
Part I. Dental Trauma
Pathophysiology
Critical Appraisal Of The Literature
In order to understand the pathophysiology of
dental injuries, one must have a basic understanding of the anatomy of the tooth and its surrounding
structures. (See Figure 1.) The tooth has 2 regions:
the crown is the part of the tooth covered by enamel
that develops below the gingiva and then erupts into
place and becomes visible in the mouth. The root
is the part of the tooth covered by cementum that
remains below the gumline.
Four major tissues make up the tooth: enamel,
dentin, cementum, and dental pulp.
The enamel is the hardest and most mineralized
layer of the tooth, designed to withstand decades
of chewing (incising and grinding) and tearing of
food. It is important to note that the enamel has no
regenerative capacity and must be supported by the
underlying dentin.
Dentin is the substance between the enamel or
cementum and the pulp chamber. It is produced by
the dental pulp and acts as a protective layer to support the crown of the tooth. More dentin is produced
when the tooth is subjected to trauma, excessive
wear, or decay (caries). It is deposited along the
pulpal wall to protect the pulp from injury. However, it is a softer tissue than enamel, with a higher
organic content, making it more susceptible to caries
if not properly treated.19
Cementum is a specialized bony substance that
covers the root of a tooth and serves as a medium
by which the periodontal ligaments can attach to the
tooth, providing stability. It helps prevent the tooth
from becoming fused to or resorbed by the adjacent
The literature search was performed in November 2009 using MEDLINE, the National Guideline
Clearinghouse, the Database of Abstracts of Reviews
of Effects (DARE), and the Cochrane Database of
Systematic Reviews. The articles chosen for review
included those published after 1995 and in the
English language, with children and adolescents
as subjects; articles published before 1995 were
included as needed to provide background information. Search terms included dental trauma, oral
trauma, dental intrusion and extrusion, dental avulsion,
emergency dental care, dental subluxation, dental injury,
dental fracture, crown fracture, and root fracture. After
careful review, a total of 40 articles were selected; in
addition, textbooks on dentistry, trauma, radiology,
and emergency medicine were reviewed. Few large,
prospective clinical trials on dental injuries have
been carried out, especially in children; large trials
that were reviewed were primarily observational or
retrospective. Case reports have been included to
illustrate rare but important outcomes in children.
Epidemiology And Etiology
Dental trauma occurs in 7% to 50% of all children,
peaking between 18 and 36 months of age and
between 7 and 15 years of age.1,2 Physical activity at home, in kindergartens, at playgrounds, and
in schools accounts for a significant proportion of
dental injuries in young children.2,3 The unsteady
gait of the toddler leads to injuries of the primary
Pediatric Emergency Medicine Practice © 2010
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EBMedicine.net • June 2010
alveolar bone. In conjunction with the periodontal
ligament and surrounding alveolar bone, the cementum allows for flexibility and movement of the
tooth, which helps it withstand the powerful forces
generated by chewing.
The dental pulp is a specialized tissue that
contains odontoblasts, fibroblasts, blood vessels, and
nerves. The pulp provides the neurosensory function
of the tooth and allows for repair. It is important to
maintain a healthy dental pulp until the walls of the
root become thick enough to sustain traumatic forces
transmitted from the crown during mastication. If the
root is not completely formed, the pulp may become
nonvital and tooth retention is diminished. Therefore,
prompt treatment of dental trauma and caries in children is critical to maintaining oral health.
Tooth eruption begins when a child is about 6
months old and continues until they are approximately 2 years of age, at which time they typically
have 20 primary teeth (incisors and molars). (See
Figure 2.) Adult or permanent (secondary) teeth begin to erupt (initially the central incisors) when the
child reaches 7 or 8 years of age, and they continue
to erupt into adolescence, with the arrival of the
molars.20 (See Figure 3.) Anatomically, the permanent anterior teeth develop in close proximity to the
apices of primary incisors; thus, periapical infection
caused by necrotic pulp tissue or intrusion injuries
of the primary dentition can irreversibly damage the
permanent tooth.
There are important differences between primary and permanent teeth. In primary teeth, the crown
tends to be shorter and narrower, and the enamel
and dentin layers are thinner relative to those of
the permanent teeth. Also, the pulp of the primary
tooth is larger and closer to the outer surface.21 These
characteristics make the primary tooth susceptible to
more significant injury compared with a permanent
tooth that sustains an equal force.
Traumatized teeth are at substantial risk for devitalization because relatively minor blows can easily
injure the small inner chamber of pulp tissue at the
root apex. Disruption of the neurovascular supply to
the tooth results in ischemic necrosis of the pulp and
can become manifest externally by a color change in
the tooth crown. Left untreated, these teeth may form
an abscess or undergo inflammatory resorption of
the roots. When a primary tooth becomes infected,
inflammation can extend to developing tooth buds
and impair development of the permanent dentition.
Trauma to primary teeth must be evaluated for problems involving not only the injured tooth but also the
developing tooth yet to erupt.
Differential Diagnosis
The differential diagnosis of dental trauma includes
concussion, subluxation, luxation, intrusion, extrusion, avulsion, and fracture.22,23
Concussion And Subluxation
Dental concussions result from mild trauma and
cause slight injury to the periodontal ligament
without causing tooth mobility or displacement.
There is usually no significant injury to the tooth or
surrounding tissues, but often there is mild inflammation of the periodontal ligament. Patients may
complain of mild dental pain on biting or may have
no pain at all. Subluxation occurs from slightly more
significant trauma and leads to loosening of the
tooth, without displacement, because of damage
to the periodontal ligament and inflammation. On
examination, the tooth is mobile, and bleeding from
the gum may be present.
Figure 1. Dental Anatomy And Surrounding
Structures
Crown
Luxation is the loosening and displacement of a
tooth from its normal anatomic position that occurs
when the periodontal ligament is torn. The tooth
is often nontender and immobile and may be fixed
in its new position. Lateral luxation is an angular
displacement of the tooth while it is still within the
socket. Since there is usually an associated fracture
of the supporting alveolar bone, especially with
labial and palatal luxations, it is prudent for the
emergency clinician to search for additional occult
injuries. Since the alveolar bone surrounding the
primary tooth is relatively elastic, dental luxation
is a common injury during the toddler years. The
primary upper incisors are often pushed in toward
the palate when the child falls forward.
An intrusion injury is the most severe type of
luxation injury. Intrusion occurs when a tooth is
Dentin
Pulp cavity
Gingival sulcus
Gingiva
Periodontal
ligament
Root
Luxation, Intrusion, Extrusion, And Avulsion
Enamel
Alveolar
bone
Cementum
Attachment
apparatus
Root canal
Reprinted with permission from: Amsterdam JT. Oral Medicine.
Chapter 68, figure 68.2 In: Marx JA, Hockberger RS, Walls RM, et al.
Rosen’s Emergency Medicine: Concepts and Clinical Practice, 7th
ed. 2009; Mosby: Philadelphia.
June 2010 • EBMedicine.net
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Pediatric Emergency Medicine Practice © 2010
driven apically into the socket, often fracturing the
alveolar bone. The tooth appears shortened, or even
absent and, when visible, is not mobile or tender.
The forces that drive the tooth into the socket wall
crush the periodontal ligament and rupture the
blood and nerve supply to the tooth. When the
intruded tooth cannot be seen, the injury may be
mistaken for an avulsion (description follows). Some
studies have shown that intrusions of up to 3 mm
have an excellent prognosis, whereas the prognosis
of severely intruded incisors (> 6 mm) is hopeless.
If a permanent tooth is involved, radiographs may
show an alveolar fracture or displacement of the
tooth into the nasal cavity. Pulpal necrosis occurs in
a vast majority of cases of intruded permanent teeth.
Extrusion occurs when a tooth is incompletely
displaced from its socket. The tooth appears elongated and is mobile owing to tearing of the periodontal
ligament.
Avulsed teeth are completely displaced from the
socket and alveolar ridge. The periodontal ligament
is lacerated, often with significant bleeding from
the gum, and the alveolar bone may or may not be
fractured.
Fracture of the enamel and dentin combined may
cause pain on light pressure and a sensitivity to air.
Pale-yellow discoloration of the tooth indicates dentin
exposure. Patients younger than 12 years of age have
immature teeth, so much less dentin spans the space
between the pulp and the enamel layer. The chance
of infection and damage to the pulp is much greater
in this age group because the pulp area is larger and
the distance across the dentin is shorter, allowing the
infection to reach the pulp more rapidly.24
A complicated fracture involves the enamel,
dentin, and pulp. Patients often complain of pain on
manipulation or exposure to air or hot or cold temperatures. This injury may present as pinkish markings on the outside of the tooth, with the surrounding
dentin appearing yellowish, or blood may be seen in
the center of the tooth from the exposed pulp.
A root fracture involves the dentin, pulp, and
cementum and is difficult to diagnose clinically.
These fractures are almost always seen in permanent
teeth, and patients may notice abnormal mobility
and sensitivity to percussion.
Prehospital Care
Fracture
Patients with dental trauma in association with
significant head injury should first be evaluated for
life-threatening injuries, airway compromise, and
neurologic deficits. Airway, breathing, and circulation, in addition to cervical spine stability, should be
Fractures of the permanent teeth are more commonly seen, since the primary teeth tend to become
displaced only with more significant trauma. Crown
fractures may be uncomplicated or complicated.
Uncomplicated crown fractures result from injuries
to the enamel alone or to both enamel and dentin. An
enamel fracture alone is not considered a dental emergency and often goes unnoticed by the patient, who
might feel roughness when running the tongue over
the chipped tooth. The injury is often asymptomatic
and discovered during a routine dental examination.
Figure 3. Permanent (Secondary) Teeth
9
10
8
7
11
6
12
Figure 2. Primary Teeth
5
13
4
14
Upper Teeth Erupt
Central Incisor 8-12 months
Lateral Incisor 9-13 months
Cuspid
16-22 months
First Molar
3
15
2
16
1
17
32
13-19 months
Second Molar 25-33 months
31
18
First Molar
29
20
28
21
14-18 months
22
Cuspid
17-23 months
Lateral Incisor 10-16 months
Central Incisor 6-10 months
Pediatric Emergency Medicine Practice © 2010
30
19
Lower Teeth
Second Molar 23-31 months
4
25 26
23
24
27
Upper Teeth
Erupt
Central Incisor
7-8 Years
Lateral Incisor
8-9 Years
Canine (Cuspid) 11-12 Years
First Premolar
10-11 Years
(First Bicuspid)
Second Premolar 10-12 Years
(Second Bicuspid) First Molar
6-7 Years
Second Molar
12-13 Years
Third Molar
17-21 Years
Lower Teeth
Third Molar
(Wisdom Tooth)
Second Molar
Erupt
17-21 Years
First Molar
11-13 Years
11-13 Years
Second Premolar 11-12 Years
(Second Bicuspid)
First Premolar
10-12 Years
(First Bicuspid)
Canine (Cuspid) 9-10 Years
Lateral Incisor
7-8 Years
Central Incisor
6-7 Years
EBMedicine.net • June 2010
evaluated while emergency medical services is notified to transfer the patient to the hospital for more
advanced care.
Pain control and tooth preservation are the goals
of prehospital care for isolated dental trauma. Acetaminophen can be given for analgesia and an ice pack
may help reduce local swelling and stop bleeding to
facilitate evaluation of the oral tissues in the emergency department (ED). Avulsed teeth and fragments
should not be wrapped in tissue or cloth or be allowed to dry, and they should be handled only by the
crown to avoid damaging the periodontal ligament at
the root. Debris should be removed with gentle rinsing in saline or water; scrubbing should be avoided
because it may cause further damage.
An avulsed permanent tooth should be reimplanted as soon as possible and maintained in position with gentle pressure until the ED evaluation. If
it cannot be reimplanted within 5 minutes, the tooth
should be stored, in order of preference, in UW-Belzer solution, Hanks’ balanced salt solution, cold milk,
saliva, physiologic saline, or clean water.25
Through-and-through lip lacerations are not uncommon with dental trauma and should be evaluated
with the possible need for cosmetic repair in mind.
The intraoral examination begins with visual
inspection of the soft tissues. Debris and clots should
be gently removed to allow a thorough evaluation.
Intraoral lacerations should be explored to detect
foreign material, avulsed teeth, or tooth fragments.
Frenulum tears heal well with no intervention. The
patient should be asked to bite down and report any
feelings of misalignment or malocclusion that could
indicate luxation. The emergency clinician should
also palpate the alveolus for any evidence of a stepoff or other type of fracture.
Evaluation of the dental structures begins with
visualization to look for any gross abnormalities (eg,
fractures, missing teeth, displacements). The emergency clinician should note any gingival or sulcal
bleeding as a sign of sustained trauma even if the
tooth itself appears normal. Each tooth should be
palpated for movement, and percussion may elicit
pain in a traumatized tooth that otherwise appears to
be uninjured.
Emergency Department Evaluation
Diagnostic Studies
The ED evaluation should begin with a complete assessment for closed head injury, quickly determining
whether there are any life-threatening injuries. Once
airway, breathing, and circulation have been assured
and stabilized, the emergency clinician can proceed
to a more thorough dental examination.
Since management differs between primary and
permanent (secondary) teeth that have sustained a
traumatic injury, it is crucial for the practitioner to
first determine which type of tooth has been affected
and then what type of injury has occurred. The
mechanism and time of injury are particularly important aspects of the history because they are used
to stratify the risk of associated injuries, the available treatment options, and the ultimate viability of
the tooth. The patient’s tetanus vaccination status
should be determined as well as the need for spontaneous bacterial endocarditis prophylaxis based on
the patient’s medical history.
The dental examination should begin with an
evaluation of the extraoral structures. Any bruising,
swelling, and lacerations should be noted. The emergency clinician should also maintain a high level of
suspicion for abuse when examining young children
who have oral injuries. Particular attention should be
paid to any pattern of bruising or bruises in various
stages of healing. Jaw movement should be assessed
by having patients open and close their mouths; any
evidence of difficulty or pain may suggest a mandibular fracture or dislocation at the temporomandibular joint (TMJ). Palpation of the bony structures
may reveal step-off fractures. Lacerations should be
explored for foreign bodies (eg, dirt) or avulsed teeth.
June 2010 • EBMedicine.net
Dental films can be obtained to further assess the
type and extent of injury. When possible, a panoramic radiograph (also known as an orthopantomogram) can help identify fractured, avulsed, intruded,
and extruded teeth. Injuries to the maxillary or
mandibular teeth are best assessed with an occlusal
radiograph. If a root fracture is suspected, radiographs taken from 2 different angles are required for
a definitive diagnosis but would be better obtained
in a dental office. A computerized tomographic (CT)
scan may be obtained when additional injury is
suspected, such as in LeFort fractures of the maxilla
and/or facial bones.
Treatment
Injuries To Primary Teeth
The management of injuries to the primary teeth
should focus on controlling pain and preventing
damage to the permanent teeth that are developing
in close proximity to the apices of the primary incisors or molars.26,27 With dental concussions and subluxations of the primary teeth, the risk of injury to
the underlying permanent teeth buds is low. These
injuries can typically resolve spontaneously and can
generally be treated with supportive care, pain control, and outpatient dental follow-up. Radiographs
may be advised to detect any damage to the surrounding alveolus, although bone injury is unlikely.
A soft diet is recommended for comfort.
The most common injuries to primary teeth are
luxation injuries, in which the teeth become loose,
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Pediatric Emergency Medicine Practice © 2010
are displaced, or are completely avulsed. Luxated primary teeth may be allowed to passively
reposition, although consultation with a dentist is
recommended in cases of significant angulation
and displacement to ensure that the developing
permanent teeth have not been harmed.28 (See Table
1.) An intruded primary tooth may be allowed to
spontaneously erupt over a 2- to 3-month period, as
long as the developing permanent tooth bud has not
been injured.29 If eruption does not proceed within 2
months, it will be necessary to extract the intruded
primary tooth. Extraction of intruded primary teeth
is indicated in the ED when the apex is displaced
toward the permanent tooth bud, as determined by
radiography. Injured primary teeth may be removed
by the emergency clinician if a dentist is not immediately available for consultation and there is the possibility of aspiration. The premature loss of primary
anterior teeth does not irreversibly affect the child’s
speech or the position of the permanent teeth.30,31
Extruded teeth should be repositioned and allowed to heal unless the tooth is severely injured or
near exfoliation (natural loss), in which case extraction is necessary. If the tooth is splinted, the patient
should be seen by a dentist within 7 to 10 days to
re-evaluate the tooth’s vitality.
Avulsed primary teeth should not be reimplanted because of the potential for injury to the underlying tooth bud.28,32 The tooth should be examined to
be sure that the entire crown and root are present.
Obtaining radiographs of the head, chest, or abdomen are occasionally necessary to locate the avulsed
primary tooth, which might have been swallowed or
aspirated or have intruded into the alveolus.33,34
Crown fractures of the primary teeth require a
thorough dental evaluation to determine the risk
of further injury and infection. Uncomplicated
fractures of the enamel alone do not require emergent dental evaluation and can be followed up by
a dentist, who can then smooth the rough edge of
the tooth to prevent additional injury to adjacent
soft tissues.28,35 Exposed dentin should be restored
with dental cement to prevent infection, and urgent
referral to a dentist should be made within 24 hours.
Complicated fractures involving the pulp are treated
with pulpotomy or pulpectomy. Root fractures of the
primary teeth are rare occurrences. If the tooth cannot be restored, it should be removed unless removal would cause injury to underlying tooth buds.25
emergency clinicians could become proficient at
placing a temporizing splint with minimal training.23
Dental follow-up, with radiographic monitoring at 4
weeks, is recommended to detect any inflammatory
resorption or pulp necrosis, which may lead to tooth
discoloration. (See Table 1.) Parents should be informed about the possibility of future discoloration.
Luxation injuries of permanent teeth constitute
true dental emergencies and should be managed
immediately to achieve the best possible outcome.
Management should be focused on maintaining the
vitality of the periodontal ligament. For lateral luxation
and extrusion injuries, the tooth should be repositioned
with a semirigid (flexible) splint for 2 to 3 weeks.
Intrusion injuries of a permanent tooth found to
have an immature root on radiography may be allowed to re-erupt over 3 to 6 weeks, whereas injured
teeth with mature roots require prompt orthodontic
or surgical extrusion and eventual root canal therapy
by a dentist.22
The prognosis for avulsed permanent teeth worsens in direct proportion to the length of time they are
outside the mouth. Permanent teeth require urgent
reimplantation because success is time-dependent.36
There is an 85% to 97% survival of permanent teeth
when they are replaced within 5 minutes, but survival is near zero after 1 hour.37 The avulsed tooth
should be handled by the crown only and simply
rinsed, with no excessive handling or scrubbing of the
root, which would remove any of the remaining live
periodontal cells. The tooth should be re-implanted
with gentle pressure and held in place. A flexible,
functional splint should be placed for 7 to 10 days (as
previously described). If an alveolar fracture is also
present, a rigid splint should be applied and kept in
place for 4 to 6 weeks. The patient’s tetanus vaccination status should be updated, and a 10-day course
of antibiotics should be prescribed to prevent oral
infections.22 A follow-up visit to a dentist should be
scheduled for 7 to 10 days after the injury to determine the need for root canal therapy.
Table 1. Need For Follow-Up By A Dentist
According To Type Of Injury
Injuries To Permanent (Secondary) Teeth
Concussed permanent teeth generally require no
intervention. Subluxed permanent teeth may require
splinting if there is more than 2 mm of movement.22
Several splinting options exist in the ED, including
periodontal packing, the use of bondable reinforcement ribbon, and placement of a flexible wire. A
recent randomized cross-over study showed that
Pediatric Emergency Medicine Practice © 2010
6
Type Of Injury
Dental Follow-up
Concussion
As needed
Subluxation
As needed
Intrusion
Within 24 hours
Extrusion
Within 24 hours
Avulsion
•
Primary
•
Permanent
As needed
Emergent
Fracture
•
Enamel only (Ellis I)
•
Enamel and dentin (Ellis II)
•
Enamel, dentin, and pulp (Ellis III)
•
Root fracture
As needed
Within 24 hours
Within 24 hours
Within 24 hours
EBMedicine.net • June 2010
The treatment of uncomplicated fractures of permanent teeth should focus on maintaining pulp vitality, tooth function, and appearance. Small fractures
that involve the enamel only are not emergent, and a
dentist could smooth out any rough edges to prevent
injury to surrounding soft tissues on an outpatient
basis. Larger injuries or fractures that involve the
dentin or pulp should be restored with dental cement
to reduce the risk of infection, and urgent referral to
a dentist should be made within 24 hours. Definitive treatment of complicated fractures involving the
pulp involves pulpotomy, pulpectomy, or root canal,
preferably, by an endodontist. The prognosis depends
on the extent of injury to the periodontal ligament,
the extent of dentin and pulp exposure, and the stage
of tooth development at the time of injury.25
Treatment of a root fracture should focus on stabilizing the coronal fragment. If the fracture is in the
apical one–third of the tooth and the crown segment
is stable, the tooth can be left in place. However,
when the root is fractured in the middle or coronal
one-third of the tooth, extraction is necessary because the crown segment is unstable and the fracture
site will become contaminated with bacteria from
the saliva. This allows for possible abscess formation
and extension of infection into the bone.
should be advised to follow a soft diet until outpatient dental follow-up has been arranged. Long-term
sequelae to traumatized teeth include pulp death,
root resorption, and displacement or developmental
defects of permanent tooth successors, all of which
should be discussed with the patient and parents.
Special Circumstances
The literature search was performed in November 2009
using MEDLINE, the National Guideline Clearinghouse, the Database of Abstracts of Reviews of Effects
(DARE), and the Cochrane Database of Systematic
Reviews. Reviewed articles included those published
after 2000 and in the English language, with children
as subjects. Search terms included dental infection, dental
caries, gingivitis, pulpitis, periapical abscess, periodontitis,
periodontal abscess, pericoronitis, and peri-implantitis.
After careful review, a total of 56 articles were selected
for inclusion. Articles published before 2000 were
included as needed for background information; in
addition, textbooks on dentistry, infectious disease,
and emergency medicine were reviewed. Not many
large, prospective clinical trials have focused on dental
infections, especially in children. The large trials described here were observational or retrospective. Case
reports and anecdotal articles in the literature were
not included, and the majority of published guidelines
focused on the prevention of dental infections rather
than their treatment.
Summary
Dental trauma is common in children. To properly
manage dental injuries, the emergency clinician
must first determine whether the traumatized tooth
is primary or permanent and the length of time since
the injury occurred. Management of injuries to the
primary teeth should focus on controlling pain and
preventing damage to developing permanent teeth,
whereas the focus in injuries to the permanent teeth
should be on maintaining the viability of the periodontal ligament and dental pulp. Regardless of the
extent of care provided in the ED, the patient should
always be referred for outpatient dental follow-up.
Part II. Dental Infections
Critical Appraisal Of The Literature
As with any injury in the pediatric patient, nonaccidental trauma must be considered. Up to 75%
of abused children have orofacial injuries.38,39 In
addition to traumatic injury to the maxillary incisors and mandible, children subjected to abuse may
sustain a variety of perioral and intraoral injuries,
including bruises, lacerations, and broken bones.
The presence of bruises in various stages of healing, with or without dental trauma, may indicate
multiple traumatic incidents. A torn upper labial
frenulum and bruising of the labial sulcus in young,
preambulatory patients should alert the emergency
clinician to possible abuse. Accidental falls are more
likely to cause bruising on the skin overlying bony
prominences of the forehead or chin.40 Children with
bruising to the softer areas of the cheeks or neck
should be thoroughly evaluated for possible abuse.
The emergency clinician must maintain a high index
of suspicion when evaluating young children for
dental trauma and report possible abuse to Child
Protective Services.
Epidemiology, Etiology, And Pathophysiology
Epidemiology
Disposition
In the United States (US), 50% of children 6 to 8
years of age have dental caries.41 Among children
2 to 11 years of age, 41% have caries of the primary
teeth; among those 6 to 19 years of age, 42% have
caries of the permanent teeth.42 These statistics have
improved compared with a century ago, when 60%
All patients with traumatized teeth ultimately need
a follow-up appointment with a dentist for a more
complete diagnosis and decisions about long-term
care. In the ED, adequate pain control should be
achieved with oral analgesics, and the patient
June 2010 • EBMedicine.net
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Pediatric Emergency Medicine Practice © 2010
of the adult population eventually lost all 32 of their
permanent teeth.43 Today, children who receive
regular appropriate dental care can expect to maintain an entire set of healthy teeth over a lifetime. As
a consequence of poor oral hygiene, gingivitis affects
2% to 34% of 2 year olds.44
In 2007, the amount of money spent on dental
services alone in the US was $95.2 billion — a 5.2%
increase over the previous year and representing
4.3% of the $2.2 trillion spent in total on healthcare.45
The cost of hospital care for caries-related visits
is between 3 and 10 times the cost of outpatient
preventive services, as based on Medicaid reimbursement data.46 The median charge of admitting a
patient to the hospital following a visit to the ED for
caries-related problems is $3,223.47
While it is generally known that an ED is not
usually the best venue to obtain dental care, given the
absence of dentists and the lack of dental training in
emergency clinicians, ED visits for dental problems
from 1992 to 1999 nevertheless increased 14%.48 From
1997 through 2000, the average number of visits per
year to an ED for the treatment of dental pain or
injury was 738,000.49 The uninsured appear to be disproportionately represented, with 4.2 million children
having unmet dental needs because their families
could not afford dental care50; in many cases, parents considered the ED the child’s primary source of
dental care.51 There are social disparities as well, with
the strongest positive association being between tooth
loss and low educational level. The highest rate of
caries has been reported to be among Mexican-American children (54.9%) and in families whose income is
below 100% of the federal poverty level (55.3%).42
it the oral cavity,53 Streptococcus mutans is the only
organism found to have an etiologic association with
caries formation.54 Prolonged and frequent exposure
of the mouth to dietary sugars allows bacteria such
as S mutans to metabolize these carbohydrates and
convert them into weak organic acids, leading to
decay of the tooth surface.
Gingivitis may be caused by local trauma or by
a shift in the normal bacterial composition of plaque
from gram-positive organisms to anaerobic gramnegative rods, such as Prevotella intermedia, Capnocytophaga species, and Peptostreptococcus species.54 It is
the most common form of periodontal disease.43
Periodontitis involves the loss of connective tissue and alveolar bone support to teeth. The chronic
presence of anaerobic bacteria in plaque, in addition to the host’s inflammatory response, can lead
to a periodontal pocket, at which point the process
is irreversible.55 Risk factors associated with periodontitis include the presence of specific subgingival
bacteria, diabetes, obesity, poor oral hygiene, tobacco
use, male gender, age, and diet.56,57 Individuals that
maintain normal weight, engage in regular exercise,
and have a high-quality diet are 40% less likely to
develop periodontitis.58 It has been shown that periodontal disease, as measured by clinical attachment
loss and bone loss, progresses in a 52-month period
without preventive dental care.59
Early-onset (or aggressive) periodontitis affects the
young and although the childhood form is typically
differentiated from adult periodontitis, there appears
to be no obvious bacteriologic distinction between the
two. Invariably, these infections contain Porphyromonas
gingivalis, Treponema denticola, and Tannerella forsythia,
although other bacteria may be isolated.60
Inflammation of the dental pulp occurs when
bacteria encroach upon the pulp, either through the
apical foramen or through fracture or caries via the
dentin. Irreversible pulpitis occurs with ischemia and
necrosis of the pulp. A periapical abscess may ensue.
Pericoronitis is an infection of the gingiva that
overlies partially erupted teeth or impacted wisdom
teeth. It is the result of food particles and microorganisms that become trapped within the gingiva.
Peri-implantitis refers to inflammation of the tissue surrounding dental implants.
Etiology
In the pediatric population, infections range from
dental caries to periodontitis. Dental caries is the
most common and preventable infectious disease in
childhood.52 Until recently, parents were counseled
not to seek dental care for their children until the
child reached 6 years of age or later, around the time
when the first permanent tooth erupted. However,
painful and preventable infections can and do occur
in the deciduous teeth. Despite public education, the
prevalence of caries in children 2 to 11 years of age
has not improved.42
Differential Diagnosis
Pathophysiology
Dental Caries
The cause of dental caries is multifactorial and
involves the composition of the biofilm (also known
as plaque), the extent of exposure of the teeth to
fluoride and dietary sugars, and the effectiveness
of preventive behaviors such as toothbrushing and
flossing. Biofilms are microenvironments on the
tooth surface that are composed of highly organized
microorganisms encased in an extracellular matrix.
Although an estimated 500 species of bacteria inhabPediatric Emergency Medicine Practice © 2010
In the earliest stage, caries appear as a chalky white
spot on the surface of the tooth, at which point the
lesion is still reversible. Surface defects that manifest golden-brown to black discoloration are irreversible but are sometimes difficult to distinguish
from unrelated staining of the enamel, for example
from nicotine use. More serious decay may extend
to the pulp.
8
EBMedicine.net • June 2010
Early Childhood Caries
Peri-implantitis
Formerly known as nursing-bottle or baby-bottle
caries, prolonged and frequent bottle-feeding can
lead to caries in early childhood. This condition is
also associated with the use of training cups, breastfeeding on demand, or the use of sweetening agents
applied to the pacifier.61 The upper anterior and
posterior teeth are mainly affected, since the lower
teeth are protected from direct exposure to milk and
other substances by the pooling of saliva, as well as
by the position of the bottom lip and tongue. Early
childhood caries are typically found on the anterior
surfaces of the exposed teeth.
Erythema of the tissues surrounding dental implants
constitutes peri-implantitis. This condition may or
may not involve loss of alveolar bone adjacent to the
implant.
Prehospital Care
Patients typically treat themselves at home with
over-the-counter medications such as acetaminophen and nonsteroidal anti-inflammatory drugs.
Only when the pain becomes severe or progresses,
as in fascial plane infections, do patients resort to
visiting the ED for evaluation and treatment.
Gingivitis
Gingivitis is the most common form of periodontal
disease. Early in its course one might detect only a
bluish-red discoloration of the gingiva, with swelling
and thickening at the margins. This condition is typically painless, but bleeding may be triggered easily by
eating, toothbrushing, or probing by the examiner. Of
special note is a condition known as Vincent’s angina,
or acute necrotizing ulcerative gingivitis (ANUG).
Patients with ANUG may report malaise and pain,
and examination of the oral cavity may reveal the
presence of a grayish pseudomembrane, along with
halitosis, fever, and lymphadenopathy.54
Emergency Department Evaluation
As with any emergency, the child’s airway must be
assessed first. The presence of trismus may portend
a difficult intubation (should such a step become
necessary) and secondary airway intubation devices
should be readily available. In babies, turning back
the child’s lips should allow the examiner to detect
early childhood caries. Any staining of the teeth,
from white spots to black discoloration, warrants referral to a dentist for further evaluation. Phlebotomy
is not usually indicated, since a thorough physical
examination and radiography, when indicated, can
be used to diagnose any dental infections.
Periodontitis
Gingivitis is a precursor of periodontitis,62 which
occurs when the gingiva surrounding the affected
teeth become erythematous, bleed easily, and form
periodontal pockets. Supporting tissues, such as the
periodontal ligament, cementum, and alveolar bone,
become eroded, leading to a loosening and loss of
teeth. Periodontal abscesses may drain spontaneously or may be expressed using external digital pressure and probing. These lesions usually present as
erythematous, tender, fluctuant masses of the gums.
Diagnostic Studies
An orthopantomogram can reveal caries, periodontal abscesses, and bone loss due to periodontitis.
(See Figure 4.) Computed tomography (CT) is the
modality of choice for the evaluation of odontogenic
Figure 4. Panoramic Dental Radiograph
Pulpitis
Pain may be mild early in the course of pulpitis
and may be elicited by thermal changes, especially
contact with cold drinks. Persistent, severe throbbing and poor localization may indicate irreversible
pulpitis, by which time necrosis has developed.
Tenderness to percussion of the tooth and regional
lymphadenopathy may indicate the development of
a periapical abscess.
Pericoronitis
In pericoronitis, the tissue overlying impacted teeth
or over the wisdom teeth (teeth #1, 16, 17, 32) appears erythematous and edematous. Exudate may
be expressed when pressure is applied. Trismus may
be present owing to localized inflammation of the
adjacent masseter muscle and/or medial pterygoid
muscle.54
June 2010 • EBMedicine.net
Panoramic dental radiograph showing caries (white arrows), periapical
abscess (solid arrow), and periodontal bone loss (open arrow).
Reprinted with permission from: Flynn TR. The swollen face: severe
odontogenic infections. Emerg Med Clin North Am. 2000;18(3):481519.
9
Pediatric Emergency Medicine Practice © 2010
Clinical Pathway For Treatment Of Traumatic Dental Injuries
Type of injury
Analgesics
Soft diet
YES
Concussion — is tooth
primary?
NO
Analgesics
Soft diet
YES
Subluxation — is
tooth primary?
NO
Splint, if severe
Analgesics
Soft diet
YES
Intrusion — is
tooth primary?
NO
Allow to re-erupt
If no re-eruption after
3 to 6 weeks: extract,
splint, root canal
Allow to re-erupt
If no re-eruption after 2
months: extract
Reposition
Splint
YES
Do not re-implant
YES
Pulpectomy or
pulpotomy
YES
Extrusion, lateral
luxation — is
tooth primary?
Avulsion — is
tooth primary?
Fracture of the crown
(primary and permanent) -- Is the fracture
complicated (ie, involves enamel, dentin,
and pulp)?
Fracture of the root,
primary and permanent
Analgesics
Soft diet
NO
Reposition
Splint
NO
Re-implant immediately
NO
Enamel only:
analgesics
Enamel and dentin:
cap, restoration
If apical: restoration
If coronal or middle:
extract
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2010 EB Practice, LLC d.b.a. EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of
EB Practice, LLC d.b.a. EB Medicine.
Pediatric Emergency Medicine Practice © 2010
10
EBMedicine.net • June 2010
infections.63 Guidelines are now being developed for
the use of cone-beam CT. As with any study, radiographs should be obtained only when the findings are
expected to affect patient care.64
progression. Chlorhexidine gluconate 0.12% oral
rinse or hexetidine 0.1% rinse is sufficient for treating gingivitis in most cases.52 Antibiotics may be
required when the disease is progressing rapidly
or in patients with ANUG, which should be treated
with local debridement and lavage using oxidizing
agents.62 Antibiotic choices to treat ANUG include
penicillin, amoxicillin, amoxicillin–clavulanate, metronidazole, and clindamycin.
Acute infections of the periodontium and oral
mucosa require immediate referral and treatment by
a dentist.79 Dental interventions may include plaque
removal, root debridement, surgical removal of inflamed periodontal tissues, and chlorhexidine rinses,
as well as education regarding primary prevention.
In the absence of systemic signs of infection such as
fever and facial swelling, antibiotics are usually not
indicated.80 However, in a study of treatments for
advanced periodontitis, 81% of the patients who received metronidazole or doxycycline in combination
with locally delivered antimicrobials (metronidazole,
chlorhexidine) did not require periodontal surgery
or tooth extraction.81 If an antibiotic is prescribed,
the choice of agent should be guided by the duration
of symptoms, since odontogenic infections contain
primarily aerobic, penicillin-sensitive bacteria in the
first 3 days. Infections that persist for longer than 3
days harbor anaerobic bacteria, which are frequently
penicillin-resistant.82 Commonly prescribed antibiotics include metronidazole, clindamycin, doxycycline or minocycline, ciprofloxacin, azithromycin,
metronidazole plus amoxicillin, and metronidazole
plus ciprofloxacin. Periodontal abscesses should be
referred to a dentist for incision and drainage.
Patients diagnosed clinically with pulpitis and
periapical abscesses should be referred to a dentist
for definitive surgical treatment, which may involve
pulp removal and/or tooth extraction. Antibiotics
do not appear to significantly decrease dental pain
caused by irreversible pulpitis, and they offer no
significant benefit in the concurrent treatment of
periapical abscesses that are drained.83,84
Depending on its severity, pericoronitis should
be treated with removal of food particles, mouth
rinses using warm saltwater or chlorhexidine, and
referral to a dentist. Antibiotics may be indicated in
patients with overlying facial cellulitis or when the
infection extends along fascial planes.
Antibiotics may be started in cases of periimplantitis, although this treatment appears to be no
more beneficial than other modalities, which include
polishing or scaling of the teeth; the local application
of antibiotics; ultrasonic, laser, or manual debridement; chlorhexidine irrigation; resective surgery,
smoothing of the implant surface or its decontamination with abrasive powder; autogenous bone
grafting, with or without resorbable membrane; and
the use of bone graft substitutes. To date, no specific
Prevention And Treatment
Prevention is key to maintaining healthy teeth,
whether they are primary or permanent (secondary). The American Academy of Pediatric Dentistry
(AAPD), the American Dental Association, and the
American Association of Public Health Dentistry all
recommend that children have their first dental evaluation within 6 to 12 months of eruption of the first
primary tooth.65-67 The American Academy of Pediatrics recommends that a dental “home” be established
within the child’s first year of life where a primary
pediatric dentist can provide continuity of care.68 It
is estimated, however, that there are only about 4000
pediatric dentists currently practicing in the US.69
Pediatricians, primary healthcare providers, and
even emergency clinicians are in a unique position to
provide anticipatory guidance for dental care and have
been called upon to do so, especially for disadvantaged
families.70 After 2 to 5 hours of training, it has been
found that physicians, nurses, and physician assistants
are able to identify caries almost as accurately as dentists can and, subsequently, can refer patients appropriately for definitive dental treatment.49,71,72
Although primary prevention of dental caries
cannot usually be provided in the ED, many of the
same treatments can be recommended to patients
with reversible conditions and to arrest progression
of existing disease. Topical fluorides, in the form of
varnishes applied professionally 2 to 4 times yearly,
as well as mouth rinses, used in conjunction with
fluoride-containing toothpaste, have been reported
to reduce caries.73-75 There is clear evidence that
the application of fluoride gels a few times a year
reduces the development of caries in children and
adolescents.76 It has now been firmly established that
children who brush their teeth at least once daily
with a fluoridated toothpaste have less tooth decay.77
Parents should wipe their infant’s tooth with a
brush or washcloth at the first sign of eruption. Such
brushing without toothpaste is recommended for
children under 2 years of age. Between the ages of
2 and 6 years, children should use no more than a
pea-size amount of fluoridated toothpaste to avoid
possible enamel fluorosis. Children 6 years of age
and older can safely use fluoridated toothpaste and
should brush twice daily.78 Any caries should be referred to a dentist for definitive restorative treatment.
Gingivitis rarely progresses to periodontitis in
children with primary teeth. Good hygiene should
be emphasized, since these habits can be carried
over into late childhood and for the care of permanent teeth, which are more susceptible to disease
June 2010 • EBMedicine.net
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Pediatric Emergency Medicine Practice © 2010
treatment appears to be significantly more effective
than any other, but all appear to be beneficial.85
of oral health essential for adequate function and
freedom from pain and infection.”86 Caregivers who
do not understand the importance of dental care
must be distinguished from those whose knowledge
of such care is adequate. Those caregivers who understand the need for dental care and who, despite
having received assistance with transportation
and costs and having been directed to low-cost or
Special Circumstances
Dental neglect is defined by the AAPD as the “willful failure of parent or guardian to seek and follow
through with treatment necessary to ensure a level
Risk Management Pitfalls To Avoid In Pediatric Dental Emergencies
1. “The patient must have an avulsion and lost
his tooth with the injury because the socket is
empty and they weren’t able to find the tooth.”
A severe intrusion injury can appear to be an
avulsion in the setting of significant swelling
and bleeding. It is prudent to maintain a high
level of suspicion for a retained tooth and obtain
radiographs of the maxilla and mandible whenever the location of the tooth is unknown.
ity. The tooth should simply be rinsed with clean
water, gently reinserted in the socket, and held
in place until a splint can be applied.
6. “I think I saw a case of child neglect last
night.”
Even if no evidence of physical abuse is found,
emergency clinicians are mandated reporters
and must inform Child Protective Services when
a case of child neglect is suspected.
2. “The tooth looks fine.”
A dental concussion, mild subluxation, or root
fracture can all have a relatively normal appearance on examination. Pay close attention to any
slight movement of the tooth, pain on palpation,
or pain with chewing, since these findings may
indicate more significant injury to the tooth.
7. “My patient with gingivitis is back and looks
worse.”
Antibiotics are not usually indicated in patients
with gingivitis, except in those with ANUG. The
presence of a grayish pseudomembrane should
be a clue to this diagnosis.
3. “The primary tooth was knocked out, but the
family put it back in place.”
An avulsed primary tooth should not be reimplanted, since doing so may cause damage to
the underlying tooth buds and impair development of the permanent teeth. Although some
families find it hard to accept the cosmetic effect
of a missing tooth, the patient will have the best
outcome if the avulsed tooth is removed.
8. “How can a 12-month-old have cavities?
Should the patient be using a fluoride toothpaste?”
Fluoridated toothpaste is not indicated for
children under 2 years of age, since they tend
to swallow the toothpaste and are at increased
risk for fluorosis and permanent staining of
the enamel. Daily brushing without toothpaste
should be sufficient for a child who is 12 months
of age.
4. “The parents don’t know how the baby injured
himself.”
Be wary of nonspecific or unknown circumstances of injury or a mechanism of injury that
is incongruent with the patient’s developmental
stage, especially in very young children. Oral
and dental injuries are often seen in children
who are abused and, if deemed suspicious, must
be evaluated and reported to Child Protective
Services.
9. “I told the patient to wrap the tooth in gauze
before it can be re-implanted.”
An avulsed tooth should not be allowed to dry.
If it cannot be re-implanted within 5 minutes,
the tooth should be stored, in order of preference, in UW-Belzer solution, Hanks’ balanced
salt solution, cold milk, saliva, physiologic
saline, or clean water.
10. “It wasn’t a dirty wound.”
Patient with an avulsion injury should be
screened to determine their tetanus vaccination
status. If the patient has not received a tetanus
booster within 5 years, their vaccination status
should be updated.
5. “We scrubbed the tooth clean before putting it
back in.”
An avulsed tooth should not be cleaned and
scrubbed vigorously before being re-implanted
because the removal of any surviving periodontal ligament cells will compromise tooth viabilPediatric Emergency Medicine Practice © 2010
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EBMedicine.net • June 2010
public facilities for follow-up, continually fail to seek
proper care for their children should be reported to
Child Protective Services.
confounders (such as age), exposure to mercury was
found to be independently associated with periodontitis.94 Bone preservation in periodontitis may
be achieved with the inhibition of tissue-destructive
enzymes, such as matrix metalloproteinases, and the
inhibition of alveolar bone destruction with the use
of bisphosphonates.95
Controversies/Cutting Edge
Vaccines to prevent dental caries that specifically
target S mutans have shown promise in animal models; however, their clinical application in humans is
not likely to take place in the near future.62 Teledentistry may offer access to regular dental care for the
disadvantaged and may be as efficient as a visual
examination in screening for caries.87,88
Periodontal disease has been linked to preterm
birth, cardiovascular disease, the metabolic syndrome, and ischemic stroke.89,90 Although certain
studies have demonstrated such links, other researchers have not found significant associations.
In one study of 1859 patients with periodontitis,
the increase in risk for coronary heart disease was
found to be insignificant.91 A meta-analysis of 9
cohort studies showed a 19% increase in risk of
cardiovascular disease, including stroke, in patients
with periodontal disease; this association was more
prominent in patients 65 years of age or younger,
among whom the risk increased to 44%.92 One study
of 41,380 men suggested an increased risk of stroke
in those with periodontal disease and 24 or fewer
teeth.93 Because patients with periodontal and cardiovascular disease share the same risk factors (ie,
body fat content, tobacco use, increasing age, stress,
and socioeconomic status), this research may be
subject to confounding bias.
In a cross-sectional study of 1328 participants
in which the analysis was controlled for potential
Disposition
In the absence of fascial plane extension, patients with
odontogenic infections can usually be discharged
home from the ED, with arrangements made for
adequate dental follow-up. The presence of trismus
or findings suggestive of airway compromise, such as
tracheal deviation or stridor, may warrant admission
to the hospital for observation, intravenous antibiotic
therapy, and in-house consultation.
Summary
With minimal training, the emergency clinician
should be able to identify carious lesions and refer
these patients to dental providers. Antibiotics are
not usually warranted except in cases of ANUG,
advanced periodontitis, reversible pulpitis, and pericoronitis, all of which may be difficult to diagnose
clinically in the ED. The selection of antibiotic(s) is
based on empiric treatment rather than on evidencebased research.96
Case Conclusions
Your thorough evaluation of the 5-year-old-boy reveals
no concerns about significant intracranial injury, so you
obtain an orthopantomogram, which reveals that the
patient has no injuries other than the avulsed tooth. The
mother’s report, the boy’s age, and close examination of
the tooth support your conclusion that this is a primary
tooth. You review the radiograph with his mother and
explain that the primary tooth should not be reimplanted
because of possible deleterious effects on the development of his permanent tooth. The patient’s immunization
status is up-to-date, and a tetanus booster is not required.
You recommend a short course of penicillin and advise
the mother to arrange a follow-up appointment with the
child’s dentist for the following week.
Your second patient appears to have diffuse periodontitis, with obvious luxation of the primary teeth
and alveolar bone loss. At this point, dental follow-up
for probable surgical debridement of devitalized tissue is
required. Antibiotic therapy is not warranted. The parents
tell you that they have just been too busy to take their son
to the dentist. You discharge the patient home with his
parents after having informed them that Child Protective
Services will be contacting them to arrange for a home
assessment and follow-up. Although there does not appear
to be any abuse, this is a case of dental neglect.
Cost- And Time-Effective
Strategies
The first treatment of trauma to the primary or
permanent dentition, as well as of odontogenic
infections, is prevention. Mouthguards and helmets
should be used during sports and regular dental
checkups should begin within 6 to 12 months of
eruption of the first primary tooth. As a child learns
to cruise and walk, protective covers should be
placed over sharp edges and on corners of furniture
within the home.
When possible, parents should seek emergency
care for their children primarily from a dentist.
This is obviously difficult outside of regular business hours and for the uninsured. Before seeking
emergency care, parents should contact the ED for
help in determining which local hospital, if any, has
a dentist on staff or at least know one who will be
available for consultation.
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Pediatric Emergency Medicine Practice © 2010
Practice Recommendations
1979;37:47-50. (Retrospective; 1,614 patients)
11. Baccetti T, Antonini A. Dentofacial characteristics associated
with trauma to maxillary incisors in the mixed dentition. J
Clin Pediatr Dent. 1998;22:281-284. (Prospective; 169 patients)
12. Glendor U. Aetiology and risk factors related to traumatic
dental injuries — a review of the literature. Dent Traumatol.
2009;25:19–31. (Review)
13. Roberts G, Longhurst P. The problem: classification, epidemiology and aetiology. In: Oral and Dental Trauma in Children
and Adolescents. Oxford: Oxford University Press; 1996.
(Textbook)
14. Bruns T, Perinpanayagam H. Dental trauma that requires fixation in a children’s hospital. Dent Traumatol. 2008;24(1):5964. (Retrospective; 79 patients)
15. Lombardi S, Sheller B, Williams BJ. Diagnosis and treatment of dental trauma in a children’s hospital. Pediatr Dent.
1998;20:112–120. (Retrospective; 487 patients)
16. Sabuncuoglu O. Traumatic dental injuries and attention-deficit/hyperactivity disorder: is there a link? Dent Traumatol.
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17. Price SS, Lewis MW. Body piercing involving oral sites. J Am
Dent Assoc. 1997;128:1017–1020. (Case report)
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21. Ingle JI, Bakland LK. Endodontics. 5th ed. Loma Linda: B.C.
Decker; 2002. (Textbook)
22.* American Academy of Pediatric Dentistry. Guideline on
management of acute dental trauma. http://www.aapd.org/
media/Policies_Guidelines/G_Trauma.pdf. Last accessed
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23. McIntosh MS, Konzelman J, Smith J, et al. Stabilization and
treatment of dental avulsions and fractures by emergency
physicians using just-in-time training. Ann Emerg Med.
2009;54(4):585-592. (Randomized cross-over study; 25 participants)
24. Andreasen J, Andreasen F, Andersson L, eds. Textbook and
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25. Kargul B, Welbury R. An audit of the time to initial treatment in avulsion injuries. Dent Traumatol. 2009;25(1):123-125.
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26. Flores MT. Traumatic injuries in the primary dentition. Dent
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27. Fried I, Erickson P, Schwartz S, et al. Subluxation injuries of
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(Retrospective; 134 patients, 207 teeth)
28. Da Silva Assuncao LR, Ferelle A, Iwakura ML, et al. Effects
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30. Brin I, Fuks A, Ben-Bassat Y, et al. Trauma to the primary
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31.* Wilson, CF. Management of trauma to primary and developing teeth. Dent Clin North Am. 1995;39:133-167. (Review)
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33. Luna AH, Moreira RW, de Moraes M. Traumatic intrusion of
maxillary permanent incisors into the nasal cavity: report of
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References
Evidence-based medicine requires a critical appraisal of the literature based on study methodology and
number of subjects. Not all references are equally
robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight
than a case report.
To help the reader judge the strength of each
reference, pertinent information about the study,
such as the type of study and the number of patients
in the study, will be included in bold type following
the reference, when available. In addition, the most
informative references cited in this article, as determined by the authors, are designated by an asterisk
(*) next to the number of the reference.
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6.* Lin S, Levin L, Goldman S, et al. Dento-alveolar and maxillofacial injuries: a 5-year multi-center study. Part 1: General
vs facial and dental trauma. Dent Traumatol. 2008;24(1):53–55.
(Retrospective cohort; 5886 patients)
7. Perez R, Berkowitz R, McIlveen L, et al. Dental trauma in
children: a survey. Endod Dent Traumatol. 1991;7(5):212-213.
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8. Tzigkounakis V, Merglova V, Hecova H, et al. Retrospective
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Pediatric Emergency Medicine Practice © 2010
14
EBMedicine.net • June 2010
a case. Dent Traumatol. 2008;24(2):244-247. (Case report)
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35. Harding AM, Camp JH. Traumatic injuries in the preschool
child. Dent Clin North Am. 1995;39:817-835. (Review)
36. Al-Jundi SH. Type of treatment, prognosis, and estimation
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37. Pohl Y, Filippi A, Kirschner H. Results after reimplantation
of avulsed permanent teeth. II. Periodontal healing and the
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38. Jessee S. Orofacial manifestations of child abuse and neglect.
Am Fam Physician. 1995;52:1829-1834. (Review)
39. da Fonseca MA, Feigal RJ, ten Bensel RW. Dental aspects of
1248 cases of child maltreatment on file at a major county
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40. Welbury R, Murphy J. The dental practitioner’s role in protecting children from abuse: 2. The orofacial signs of abuse.
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of Oral Disease: Tool for Creating State Documents.http://
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42. Beltrán-Aguilar ED, Barker LK, Canto, MT, et al. Surveillance
for dental caries, dental sealants, tooth retention, edentulism, and enamel fluorosis — United States, 1988–1994 and
1999–2002. MMWR Surveill Summ. 2005;54(3):1-44.
43.* Selwitz RH, Ismail AI, Pitts NB. Dental caries. Lancet.
2007;369:51-59. (Review)
44. Delaney JE, Keels MA. Pediatric oral pathology: soft tissue and periodontal conditions. Pediatr Clin North Am.
2000;47(5):1124-1147. (Review)
45. Centers for Medicare and Medicaid Services. National Health
Expenditures 2007 Highlights. http://www.cms.hhs.gov/
nationalhealthexpenddata. Last accessed April 25, 2010.
46. Pettinatto ES, Webb MD, Seale NS. A comparison of Medicaid
reimbursement for nondefinitive pediatric dental treatment in
the emergency room versus periodic preventive care. Pediatr
Dent. 2000;22:463-468. (Retrospective; 97 patients)
47. Ettelbrick KL, Webb MD, Seale NS. Hospital charges for
dental caries-related emergency admissions. Pediatr Dent.
2000;22:21-26. (Retrospective; 52 patients)
48.* Cohen LA, Magder LS, Manski RJ, et al. Hospital admissions
with nontraumatic dental emergencies in a Medicaid population. Am J Emerg Med. 2003;21(7):540-544. (Retrospective;
4326 claims)
49. Lewis C, Lynch H, Johnston B. Dental complaints in emergency departments: a national perspective. Ann Emerg Med.
2003;42:93-99. (Retrospective; 693 visits)
50. Bloom B, Cohen RA. Summary Health Statistics for U.S.
Children: National Health Interview Survey, 2007. National
Center for Health Statistics. Vital Health Stat. 2009;10(239):180.
51. Graham DB, Webb MD, Seale NS. Pediatric emergency
room visits for nontraumatic dental disease. Pediatr Dent.
2000;22:134-140. (Retrospective; 149 patients)
52. Nguyen DH, Martin JT. Common dental infections in the primary care setting. Am Fam Physician. 2008;77(5):797-802,806.
(Review)
53. Paster BJ, Boches SK, Galvin JL, et al. Bacterial diversity in
human subgingival plaque. J Bacteriol. 2001;183:3770-3783.
(Basic science)
54. Chow AW. Infections of the oral cavity, neck and head. In:
Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas and
Bennett’s Principles and Practice of Infectious Diseases. 7th ed.
Philadelphia: Churchill Livingstone, Inc. 2009. (Textbook)
55. Pihlstrom BL, Michalowicz BS, Johnson NW. Periodontal
June 2010 • EBMedicine.net
diseases. Lancet 2005;366:1809-1820. (Review)
56. American Dietetic Association. Position of the American Dietetic Association: oral health and nutrition. J Am Diet Assoc.
2007;107:1418-1428. (Review)
57. American Academy of Periodontology. Treatment of plaqueinduced gingivitis, chronic periodontitis, and other clinical
conditions. J Periodontol. 2001;72:1790-1800. (Review)
58. Al-Zahrani MS, Borawski EA, Bissada NF. Periodontitis
and three health-enhancing behaviors: maintaining normal
weight, engaging in a recommended level of exercise, and
consuming a high-quality diet. J Periodontol. 2005;76:13621366. (Retrospective; 12,110 participants)
59. Costa FO, Cota LOM, Costa JE, et al. Periodontal disease
progression among young subjects with no preventive
dental care: a 52-month follow-up study. J Periodontol.
2007;78:198-203. (Prospective; 44 patients)
60. Loesche W. Dental caries and periodontitis: contrasting two
infections that have medical implications. Infect Dis Clin
North Am. 2007;21:471-502. (Review)
61. Caufield PW, Griffen AL. Dental caries: an infectious and
transmissible disease. Pediatr Clin North Am. 2000;47(5):10011019. (Review)
62. Oh TJ, Eber R, Wang HL. Periodontal disease in the child
and adolescent. J Clin Periodontol. 2002;29:400-410. (Review)
63. Hurley MC, Heran MKS. Imaging studies for head and
neck infections. Infect Dis Clin North Am. 2007;21:305-353.
(Review)
64. American Academy of Pediatric Dentistry. Guideline on
prescribing dental radiographs for infants, children, adolescents, and persons with special health care needs. http://
www.aapd.org/media/Policies_Guidelines/E_Radiographs.
pdf. Last accessed April 25, 2010. (Guideline)
65. Council on Clinical Affairs, American Academy of Pediatric
Dentistry. Policy on the dental home. http://www.aapd.
org/media/Policies_Guidelines/P_DentalHome.pdf. Last
accessed April 25, 2010. (Policy)
66. American Dental Association. Current policies. http://www.
ada.org/2057.aspx. Last accessed April 28, 2010. (Policy)
67. American Association of Public Health Dentistry. First oral
health assessment policy. http://www.aaphd.org/default.
asp?page=FirstHealthPolicy.htm. Last accessed April 25,
2010. (Policy)
68. Keels MA, Hale KJ, Thomas HF, et al. Preventive oral health
intervention for pediatrics. Pediatrics. 2008;122(6):1387-1394.
(Policy)
69. Nield LS, Stenger, JP, Kamat D. Common pediatric dental
dilemmas. Clin Ped. 2008;47(2):99-105. (Review)
70. Cohen LA. The role of non-dental health professionals in
providing access to dental care for low-income and minority
patients. Dent Clin North Am. 2009;53(3):451-468. (Review)
71. dela Cruz GG, Rozier RG, Slade G. Dental screening and referral of young children by pediatric primary care providers.
Pediatrics. 2004;144:642-652. (Review)
72. Bader JD, Rozier RG, Lohr KN, et al. Physicians’ roles in
preventing dental caries in preschool children: a summary
of evidence for the U.S. Preventive Services Task Force. Am J
Prev Med. 2004;26(4):315-325. (Review)
73. Marinho VCC, Higgins JPT, Sheiham A, et al. Combinations
of topical fluoride (toothpastes, mouthrinses, gels, varnishes)
versus single topical fluoride for preventing dental caries in
children and adolescents. Cochrane Database Sys Rev. 2004;1
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74. Marinho VCC, Higgins JPT, Logan S, et al. Fluoride mouthrinses for preventing dental caries in children and adolescents. Cochrane Database Sys Rev. 2003;3 CD002284. (Review)
75. Marinho VCC, Higgins JPT, Logan S, et al. Fluoride varnishes for preventing dental caries in children and adolescents.
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76. Marinho VCC, Higgins JPT, Logan S, et al. Fluoride gels
for preventing dental caries in children and adolescents.
15
Pediatric Emergency Medicine Practice © 2010
CME Questions
Cochrane Database Sys Rev. 2002;1 CD002280. (Review)
77. Marinho VCC, Higgins JPT, Logan S, et al. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database Sys Rev. 2003;1 CD002278. (Review)
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Pediatric Emergency Medicine Practice © 2010
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Category 1 credits, and 4 AAP Prescribed credits.
1. Which of the following does NOT increase the
risk of dental trauma?
a. Female sex
b. Hyperactivity
c. Involvement in sports
d. Overbite
2. Proper handling of an avulsed permanent
tooth includes:
a. Holding the tooth by the root only
b. Drying the tooth with gauze
c. Scrubbing the root clean
d. Re-implanting the tooth as soon as possible
3. Which teeth are most likely to be involved in
dental trauma?
a. Molars
b. Canines
c. Mandibular incisors
d. Maxillary incisors
4. Treatment of an avulsed tooth includes all the
following EXCEPT:
a. Handling by the root
b. Tetanus immunization booster as needed
c. Oral antibiotics
d. Re-implantation
e. Outpatient dental follow-up
5. A concussed primary tooth should be managed
with:
a. Supportive care
b. A flexible splint for 7 to 10 days
c. A rigid splint for 4 to 6 weeks
d. Pulpectomy/pulpotomy
6. Which dental tissue has no regenerative capacity?
a. Enamel
b. Dentin
c. Cementum
d. Periodontal ligament
16
EBMedicine.net • June 2010
7. Findings in Vincent’s angina include:
a. Shortness of breath
b. Diffuse arthralgias
c. Erythematous rash
d. Grayish pseudomembrane
e. All of the above
11. Antibiotics are indicated in the treatment of:
a. Irreversible pulpitis
b. Dental caries
c. Vincent’s angina
d. Dental concussion
12. Risk factors associated with periodontal disease include which of the following:
a. Hyperlipidemia
b. Pregnancy
c. Diabetes
d. Ischemic stroke
8. In early childhood caries, which side of the
tooth is most commonly affected?
a. Medial
b. Lateral
c. Anterior
d. Posterior
13. Avulsed permanent teeth can be stored temporarily in all of the following EXCEPT:
a. Saliva
b. Milk
c. Saline
d. Orange juice
9. Which organism has an etiologic association
with dental caries?
a. Treponema denticola
b. Streptococcus mutans
c. Prevotella intermedia
d. Tannerella forsythia
14. A chalky white spot on teeth indicates what
condition?
a. Periapical abscess
b. Acute necrotizing ulcerative gingivitis
c. Dental caries
d. Periodontitis
10. Periodontal disease has a clear and established
association with which of the following diseases:
a. Cardiovascular disease
b. Metabolic syndrome
c. Preterm birth
d. None of the above
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Date of Original Release: June 1, 2010. Date of most recent review May 10,
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Pediatric Emergency Medicine Practice (ISSN Print: 1549-9650, ISSN Online: 1549-9669) is published monthly (12 times per year) by EB Practice, LLC. 5550 Triangle Parkway, Suite 150, Norcross, GA
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Pediatric Emergency Medicine Practice © 2010
EVIDENCE-BASED PRACTICE RECOMMENDATIONS
Initial Assessment and Management of Pediatric Dental Emergencies
Caglar D, Kwun R. June 2010; Volume 7, Number 6
The emergency clinician must be able to quickly recognize dental injury patterns in the pediatric population and must be familiar with the anatomy unique to this group.
Of specific concern is the emergency treatment of primary teeth versus permanent (secondary) teeth. This review of available evidence in the literature will equip the emergency clinician with the information needed to provide the most up-to-date care. For a more detailed and systematic look at pediatric dental emergency injuries, see the
full text article at www.ebmedicine.net.
Key Points
Comments
First determine which type of tooth has been affected. (The
management of dental trauma in children differs between primary and permanent teeth.)
The mechanism and time of injury are particularly important aspects of the history
because they are used to stratify the risk of associated injuries, the available
treatment options, and the ultimate viability of the tooth. The patient’s tetanus vaccination status should be determined as well as the need for spontaneous
bacterial endocarditis prophylaxis based on the patient’s medical history.
The management of injuries to primary teeth should be focus
on controlling pain and preventing damage to the permanent
teeth that are developing in close proximity to the apices of the
primary incisors and molars. Intruded teeth should be removed,
and avulsed primary teeth should not be re-implanted. 26,27
Acetaminophen can be given for analgesia and an ice pack may help reduce local
swelling and stop bleeding to facilitate evaluation of the oral tissues in the emergency
department (ED). With dental concussions and subluxations of the primary teeth, the
risk of injury to the underlying permanent teeth buds is low. These injuries can typically resolve spontaneously and can generally be treated with supportive care, pain
control, and outpatient dental follow-up. Radiographs may be advised to detect any
damage to the surrounding alveolus, although bone injury is unlikely. A soft diet is
recommended for comfort.
Luxation injuries to the permanent teeth are true dental emergencies. The tooth should be repositioned in an anatomically
correct position, if possible, and splinted with a flexible splint.
The patient should have outpatient dental evaluation within the
following week to assess the viability of the injured tooth.
Management should be focused on maintaining the vitality of the periodontal ligament. For lateral luxation and extrusion injuries, the tooth should be repositioned with
a semirigid (flexible) splint for 2 to 3 weeks. Intrusion injuries of a permanent tooth
found to have an immature root on radiography may be allowed to re-erupt over 3 to 6
weeks, whereas injured teeth with mature roots require prompt orthodontic or surgical
extrusion and eventual root canal therapy by a dentist.22
An avulsed permanent tooth should be handled only by the
crown and re-implanted as soon as possible to improve the
tooth’s viability. The tooth should not be allowed to dry and
should not be scrubbed, which would remove the remaining
periodontal cells that are critical to tooth viability.
The prognosis for avulsed permanent teeth worsens in direct proportion to the length
of time they are outside the mouth. Permanent teeth require urgent reimplantation
because success is time-dependent.36 There is an 85% to 97% survival of permanent
teeth when they are replaced within 5 minutes, but survival is near zero after 1 hour.37
If the tooth cannot be reimplanted within 5 minutes, the tooth should be stored, in
order of preference, in UW-Belzer solution, Hanks’ balanced salt solution, cold milk,
saliva, physiologic saline, or clean water.25
Child abuse should always be a consideration in cases of facial
and dental trauma, especially in young infants and toddlers.
Up to 75% of abused children have orofacial injuries.38,39 An inconsistent history or
the presence of atypical bruising or developmentally inappropriate injuries should
alert the ED clinician to possible abuse. A torn upper labial frenulum and bruising of
the labial sulcus in young, preambulatory patients should alert the emergency clinician to possible abuse. Accidental falls are more likely to cause bruising on the skin
overlying bony prominences of the forehead or chin.40 Children with bruising to the
softer areas of the cheeks or neck should be thoroughly evaluated for possible abuse.
Preventive measures must be incorporated in the home care of
primary and permanent teeth in order to maintain good dental
health.
Since patients often present to the ED only after symptoms of progressive disease
have become severe, it is crucial to provide anticipatory guidance for dental hygiene
at each opportunity.
See reverse side for reference citations.
5550 Triangle Parkway, Suite 150 • Norcross, GA 30092 • 1-800-249-5770 or 678-366-7933 Fax: 1-770-500-1316 • [email protected] • www.ebmedicine.net
REFERENCES
These
references are
excerpted from
the original
manuscript.
For additional
references and
information
on this topic,
see the full text
article at
22.* American Academy of Pediatric Dentistry. Guideline on management of acute dental trauma. http://www.aapd.org/media/Policies_Guidelines/G_Trauma.pdf. Last accessed April 25, 2010. (Guideline)
25. Kargul B, Welbury R. An audit of the time to initial treatment in avulsion injuries. Dent Traumatol. 2009;25(1):123-125. (Retrospective; 79 patients, 120 teeth)
36. Al-Jundi SH. Type of treatment, prognosis, and estimation of time spent to manage dental trauma in late presentation cases at a
dental teaching hospital: a longitudinal and retrospective study. Dent Traumatol. 2004;20(1):1-5. (Review)
37. Pohl Y, Filippi A, Kirschner H. Results after reimplantation of avulsed permanent teeth. II. Periodontal healing and the role of physiologic storage and anti-resorptive-regenerative therapy. Dent Traumatol. 2005;21(2):93-101. (Retrospective)
38. Jessee S. Orofacial manifestations of child abuse and neglect. Am Fam Physician. 1995;52:1829-1834. (Review)
39. da Fonseca MA, Feigal RJ, ten Bensel RW. Dental aspects of 1248 cases of child maltreatment on file at a major county hospital.
Pediatr Dent. 1992;14:152-157. (Retrospective)
40. Welbury R, Murphy J. The dental practitioner’s role in protecting children from abuse: The orofacial signs of abuse. Br Dent J.
1998;184:61-65. (Review)
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Pediatric Emergency Medicine Practice (ISSN Print: 1549-9650, ISSN Online: 1549-9669) is published monthly (12 times per year) by EB Practice, LLC. 5550
Triangle Parkway, Suite 150, Norcross, GA 30092. Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute
endorsement. This publication is intended as a general guide and is intended to supplement, rather than substitute, professional judgment. It covers a highly technical
and complex subject and should not be used for making specific medical decisions. The materials contained herein are not intended to establish policy, procedure, or
standard of care. Pediatric Emergency Medicine Practice is a trademark of EB Practice, LLC. Copyright © 2010 EB Practice, LLC. All rights reserved.