Teething

The eruption of the primary teeth (around 6 months old) is usually accompanied by inflamed and sore gingiva. There may be irritability, disturbed sleep and drooling. Teething does not cause high fever or convulsion.

Treatment

Analgesic/anti-inflammatory such as elixir paracetamol “Teething ring” or something hard to chew on, like hard biscuits

Trauma to Soft Tissue and Primary (milk) Teeth . Small superficial oral lacerations heal spontaneously and no antibiotic is indicated. Dirty lacerations need surgical debridement and antibiotic if infected.

Antibiotics used are:

-                  Phenoxy methyl penicillin 12.5mg/kg qid for 5-7 days OR

-                  Amoxicillin 25mg/kg tid for 5-7 days OR

-                  Benzyl penicillin, 15-30mg/kg IV every six hours If hypersensitive to penicillin, use:

-                  Erythromycin 10-20mg/kg orally bd OR

-                  Cephalexin 6.25mg/kg orally every 6 hours OR

-                  Clindamycin (child: 5mg/kg up to) 300mg orally, q8H for 5 days Alveolar bone in a child is elastic and rarely fractures.

Injuries to the primary teeth are usually loosening with/without displacement. Fractures to crown or root can happen.

Treatment includes elixir paracetamol for pain/fever, oral penicillin or amoxicillin if infected and referral for dental assessment.

Trauma to Secondary / Permanent Teeth

Permanent teeth start to erupt into the oral cavity at 5-6 years and continue up to the age of 21.

After the initial eruption, root formation/development continues for a period of 18-30 months. Injuries during this phase have the potential to interrupt root development.

Injuries involved are mostly fractures of the root or crown and displacement (luxation, intrusion, extrusion or avulsion).

Treatment includes oral paracetamol for pain and immediate dental referral. Successful outcome depends on timely re-establishment of a normal periodontium (supporting structures around tooth).

Toothache

Toothache in a child is usually caused by either caries impacted with food, abscess, root infection or an erupting tooth.

Treatment includes paracetamol for pain/fever, phenoxy methyl penicillin or amoxicillin for infection and referral for further dental treatment.

INFECTIONS

Bacterial Infections

Causative organisms are usually a mixture of aerobic and anaerobic oral flora. All cases should ideally be referred to a dentist or dental therapist for appropriate treatment.

Gingivitis

Presents as red swollen gums, that easily bleed on brushing teeth Antibiotic is normally not indicated in most cases

Local dental care such as regular tooth brushing to control bacterial plaque is usually sufficient

Acute Necrotising Ulcerative Gingivitis (ANUG)

This is a painful yellowish-white ulcer of the interdental papillae and gingival margins which bleeds easily. Causative bacteria are a mixture of the anaerobes: Borrelia vincentii, Fusobacterium fusiform, Bacteroidis and Treponema species. The appearance of ANUG in an otherwise healthy individual may be the presenting sign of HIV infection.

Treatment

Advise

Adequate oral hygiene 0.2% chlorhexidine gluconate mouthwashes (if available), adjunct to tooth brushing

Metronidazole (10mg/kg up to) 400mg tds for 5 days Refer for dental debridement

Periodontal Abscess

Localised collection of pus in a periodontal pocket of a tooth There is pain on lateral movement of the tooth and it may be quite mobile Treatment

Oral Amoxicillin 500mg tds and metronidazole 400mg orally tds for 5 days Refer for dental treatment

Chronic Periodontitis

This is usually caused by gram negative anaerobes which are also prominent in active disease. Teeth involved are usually mobile and painful.

Treatment

0.2 % chlorhexidine gluconate mouthwash (if available) bd Doxycycline 100mg orally bd for 5 days

OR

Phenoxy methyl penicillin (child 12.5mg/kg) up to 500mg orally 6- hourly for 5 days,

PLUS

Metronidazole 400mg orally tds for 5 days (in moderately severe cases)

Use erythromycin (child: 10 mg/kg up to) 500 mg orally, q6H for 5 days in place of penicillin in penicillin allergy

Pocket dental treatment for localised pus formation

Pericoronitis

This is an inflammation / infection of a gum flap (operculum) overlying a partially erupted tooth, usually a lower wisdom tooth (or lower three molars) - often traumatised by an overerupted upper wisdom tooth (or upper three molars)

Treatment

Removal of the opposing upper third molar Adequate oral hygiene Chlorhexidine gluconate 0.2% mouth wash Irrigation with 3% hydrogen peroxide

Phenoxy methyl penicillin 12.5mg/kg four times daily for 5-7 days OR Amoxicillin 25mg/kg three times daily for 5-7days If penicillin hypersensitive- Erythromycin 10-20mg/kg orally twice daily OR

Cephalexin 6.25 mg/kg orally 6-hourly

Facial Swelling and Infection

Facial swelling can either be due to odontogenic causes (e.g. caries, retained roots, periodontitis) or non-odontogenic causes (e.g. soft tissue infection, fractures, osteomyelitis, sialoadenitis, foreign body).

Infections can spread to the soft tissue around jaws, neck and cause cellulitis and suppuration.

This can easily be life-threatening.

In the absence of systemic signs and symptoms, odontogenic causes can be usually treated by local dental care, such as removal of the infected pulp tissue.

If accompanying systemic signs and symptoms are present, the following treatment should be given:

Oral amoxicillin and metronidazole for 5 days

Patients hypersensitive to penicillin should be given either erythromycin or cephalexin.

If progressive trismus arises and airway is compromised, admit case and give: Penicillin G 1.2-2.4g IV qid OR

Ampicillin 1-2g IV qid PLUS Metronidazole 1-2g IV tds PLUS

Gentamicin 3-5mg/kg/day IV (ideally not exceeding 48 hours; in patients with poor renal function serious damage to the vestibular apparatus may result from gentamicin. Get an estimate of renal function before prescribing)

Pus must be drained surgically by the dentist

Be careful of poorly controlled diabetic and hypertensive patients, who may need antibiotic cover

Septicaemia

Septicaemia due to skin infection or cellulitis is usually caused by Staphylococcus aureus or Streptococcus pyogenes.

Treatment is with IV cloxacillin 1-2 g, 4 to 6-hourly.

Patients hypersensitive to penicillin, give Clindamycin (child:10 mg/kg up to) 450- 900 mg IM/IV, every 6-8 hours

In children, facial or periorbital cellulitis may be caused by Haemophilus influenzae or Streptococcus pneumonia in addition to the above pathogens, add one of the following to the above:

Ceftriaxone 100mg/kg (max. 2g/day) IV once daily Children hypersensitive to penicillins or cephalosporins, give

Chloramphenicol 100mg/kg/day (max 3g/day) IV in 3 or 4 divided doses Viral Infections

Primary Herpetic Stomatitis

Causative agent is Herpes Simplex Virus 1 (HSV 1). It presents with multiple oral ulcers accompanied by fever, malaise, anorexia and irritability. In children, they may have drooling of saliva.

Treatment

For symptomatic relief; soft diet and adequate fluid intake, since this is a self limiting illness

Antipyretic such as paracetamol

Local antiseptic mouthwashes such as chlorhexidine 0.2% solution Aciclovir, 10mg/kg qid orally for 7-10 days

Herpes simplex labialis (cold sore)

Causative agent is HSV 1. The virus is latent in the trigeminal ganglia and is reactivated as herpes labialis. It is precipitated by sunlight, trauma, systemic disease or stress. Papules are followed by blisters then pustules.

Treatment

Aciclovir cream (5%) applied qid early, before blisters appear.

Herpes zoster (shingles)

Causative agent is Varicella Zoster Virus (VZV), the same one that causes chicken pox. It presents as an acute painful, vesicular rash along the dermatomal distribution of the sensory nerves; commonly of the trigeminal or the intercostal nerves.

Treatment

Aciclovir 800mg oral 5 times daily OR valaciclovir 1g oral, q8H for 7 days; beneficial only if started within 72 hours from the onset of the vesicles.

Ophthalmic herpes zoster should be referred to the Eye clinic. FUNGAL

ORAL CANDIDIASIS

A white creamy plaque which leaves a red base when wiped off. Causative agent is usually Candida albicans, when triggered off by the use of antibiotics, steroids, unhygienic dentures, smoking and in immunocompromised hosts. It can be seen in neonates too.

Treatment

Eliminate predisposing factors

Nystatin 100,000 U/mL suspension 1mL oral, q6H for 7-14 days. For severe cases in immunocompromised hosts, give itraconazole 100-200 mg oral, daily for 14 days OR nystatin suspension 2mL orally qid.

ODONTOGENIC PAIN

Odontogenic pain refers to pain initiating from the teeth or their supporting structures, the mucosa, gingivae, maxilla, mandible or periodontal membrane.

‘A toothache, or a violent passion, is not necessarily diminished by our knowledge of its causes, its character, its importance or insignificance.’ TS Eliot

Toothache is caused by inflammation of the dental pulp, most commonly as a result of dental caries (tooth decay), the most common human infective disease worldwide, affecting 60–90% of school children worldwide. Periodontal disease (gum disease) is the second most common infection, and similar to chronic mycobacteria infections, for example Leprosy, is painless. The two bacteria appear to be particularly likely to cause aggressive periodontal disease. Both P gingivalis and A. actinomycetemcomitans, along with multiple deep pockets in the gum, are associated with resistance to standard treatments for gum disease. Other risk factors include smoking and there is very likely a genetic predisposition to developing this silent painless disease, which is the leading cause of tooth loss, and is found in 5–400% of middle-aged adults. The diagnosis and management of this condition remain outwith this article's remit.

The role of all medical personnel in improving oral health in children is being recognised. Caries is preventable using fluoride toothpaste and simple dietary advice such as reducing the frequency of sugar intake. Despite this, the numbers of children undergoing general anaesthetic for dental extractions due to caries continues to increase.

PROTOCOL FOR PAINFUL TOOTH/TEETH

Where possible, refer case to the dental department for identification and treatment of cause of pain. Variation in an individual’s response to pain is affected by fatigue, anxiety and sometimes depression.

While one is waiting for definitive dental treatment, the following analgesics could be given:

Mild Pain

Paracetamol 500mg-1g orally 4 to 6-hourly OR

Aspirin® 300-600mg 4 to 6-hourly (avoid in children, breast feeding mothers, people with gastric diseases and those with bleeding tendencies)

OR

Other NSAIDS such as ibuprofen 400mg-1.6g bd Moderate Pain

ADD codeine 15-60mg qid oral to the above medications Severe Pain Pethidine 25mg-100mg SC/IMI 2 to 3-hourly PRN OR

Morphine 2.5mg-10mg SC/IMI 2 to 3-hourly PRN