Deciduous dental damage

As my youngest daughter continues to her quest for her two front teeth, my eldest has lost two of hers. They came out naturally with minimal fuss though as they were hanging on by a (peri-odontal) thread she asked me lots of questions about teeth. Given that I was not trained as a dentist I thought I had better do a little more research on the matter.

The first question I was asked after “How much is the Tooth Fairy going to leave?*, was “When am I going to get my grown up teeth?

If nature takes its course then the deciduous teeth will fall out in time to be replaced by their more permanent counterparts.

Unfortunately children are inquisitive creatures. prone to tripping over, falling off bikes and colliding in mid-air on the trampoline. First up – let’s get a handle on the language used to describe dental injuries.

Concussion – just like receiving a bump on the head, the tooth is tender to touch or tapping but does not move

Subluxation – the tooth is tender and is mobile

Extrusion – the tooth is almost pulled from the socket so appears longer and is very wobbly

Intrusion – the tooth is impacted into the alveolar bone

Avulsion – the tooth is not in the socket but in the hand

Infraction – this is a crack through the enamel without the structural integrity of the tooth being impacted

Now that we are speaking the same language, how should we manage these injuries? Given that deciduous dental damage may disrupt the development of their successors in up to 69% of cases, we should be able to say a little more than “You should go to the dentist.” Intrusion and avulsion are the biggest culprits. This disruption may manifest as anything from discolouration or enamel opacities to non-eruption of permanent teeth.

Concussion

Parents may not be aware of the inciting trauma but become concerned when they notice a grey discolouration of the tooth. There may be underlying pulp necrosis but this may be asymptomatic. As the damage is only cosmetic no real treatment is needed, other than regular follow up to ensure that osteitis is detected early.

Subluxation

The wobbly tooth requires observation only. It should settle down within a couple of weeks provided no apples or hard toffees are eaten. If it becomes painful and more loose then a localised infection may have taken hold.

Extrusion

With the tooth already half way out there are two options – take it out or push it back in and splint it in position.

Intrusion

Because the growing maxilla/mandible is relatively demineralised compared to that of an adult, when a toddler falls flat on their face they are more likely to push the tooth into the soft bone (intrusive luxation) than to fracture the jaw. Management of the intruded tooth depends on the direction and degree of intrusion as well as the presence or absence of an underlying alveolar fracture.

Because the intruded teeth – most commonly the incisors –  follow the line of the roots. i.e. in a labial direction – they are pushed away from the waiting secondary dentition. A watchful waiting approach, in a case series by Altun et al.  found that 78% re-erupted, 15% partially erupted and only 7% remained impacted. The majority re-erupted within 6 months. If they intrude towards the underlying permanent teeth then they should be removed to avoid permanent disfigurement.

Avulsion

Once a deciduous tooth has come out there is no point in replacing it. Trying to force it back into the socket may lead to damage to underlying tissue and subsequent problems with permanent tooth eruption. If it is a permanent tooth then it should be handled with care, by the crown. If it is replanted then there is a chance it will take but it might be some time before this becomes obvious.

If it has come out and the parents and child have no idea where it is then consider taking a chest radiograph. You may not find the tooth but missing an inhaled incisor could be disastrous.

Infraction

These microcracks require no acute treatment but indicate underlying brittle enamel. They may require resin sealing at a later stage.

 

So what sort of dental hygiene should the parents perform?

  • A soft diet for 14 days
  • Brush the teeth (with a soft brush) after every meal
  • Use chlorhex mouthwash twice a day for the first week
  • Avoid dummies (pacifiers) and feeding bottles in the case of intrusive injuries so that spontaneous re-eruption may take place.

 

And what about dental fractures?

First of all, let’s review the normal anatomy of a tooth.

Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. (Own work) [CC BY 3.0], via Wikimedia Commons

Those of you who have gone on to study for Fellowship exams may be aware of the Ellis classification system of dental fractures – something that no dentist would actually use. To avoid confusion it might be better to refer to:

  • Enamel fractures
  • Enamel-dentin fractures
  • Enamel-dentin-pulp fractures

 

 

Enamel fractures just require the smoothing and sanding down of sharp edges.

Enamel-dentin fractures  should be sealed if possible and should be followed up in 3-4 weeks

Enamel-dentin-pulp fractures are the most serious of the three. If the pulp cavity is not capped off with something like calcium hydroxide paste apical periodontitis and failure of root maturation may occur. The alternative is just to remove the tooth and be done with it – not a viable option in the case of permanent teeth.

There is no evidence that prophylactic antibiotics need to be given in these dental fractures.

 

If you are not sure then you should consult your local maxillo-facial service.

But perhaps the stubborn baby teeth will not come out despite all the tongue wiggling and face pulling the child can muster. Is there anything they can do to tempt the Tooth Fairy? Once it has been worried to the extent that it is literally dangling by a thread you can grab the tooth with clean hands and twist it out. Alternatively you can loop a piece of dental floss around the tooth, as far down as possible, and quickly yank it out – kind of like this…

 

*Finally, how much should the Tooth Fairy leave under the pillow when they come out?

The Tooth Fairy is not just an awful film starring Dwayne ‘The Rock” Johnson (it scored a grand 18% on Rotten Tomatoes) but a tall tale that has only been around for about 90 years. Before she (?he) flitted into our children’s bedrooms slipping shiny coins and more under pillows, parents told stories of La Petite Souris (in France) or Ratóncito Pérez (in Spain). This creature would sneak in like a rodent Indiana Jones swiping his shiny enamel treasure and replacing with a slightly weightier monetary equivalent.

I ran a Twitter poll to find out just how much La Petite Souris would have to leave behind. For children in Australia the almost unanimous vote came out in favour of a shiny two dollar coin (unless it was a first tooth then some recommended five dollars). For our international readers that works out as £1.19 or US$1.52.

 

References

The Dental Trauma Guide – This is a great online reference for kids and adult teeth alike

Miranda C, Luiz BK, Cordeiro MM. Consequences of dental trauma to the primary teeth on the permanent dentition. RSBO (Online). 2012 Dec;9(4):457-62.

Gupta M. Intrusive luxation in primary teeth–Review of literature and report of a case. The Saudi Dental Journal. 2011 Oct 31;23(4):167-76.

Altun C. Traumatic intrusion of primary teeth and its effects on the permanent successors: a clinical follow-up study. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 2009;107(4):493–498.

Flores MT. Traumatic injuries in the primary dentition. Dental Traumatology. 2002 Dec 1;18(6):287-98.

Arx T. Developmental disturbances of permanent teeth following trauma to the primary dentition. Australian dental journal. 1993 Feb 1;38(1):1-0.

Fried I, Erickson P. Anterior tooth trauma in the primary dentition: incidence, classification, treatment methods, and sequelae: a review of the literature. ASDC journal of dentistry for children. 1994 Dec;62(4):256-61.

Malmgren B, Andreasen JO, Flores MT, Robertson A, DiAngelis AJ, Andersson L, Cavalleri G, Cohenca N, Day P, Hicks ML, Malmgren O. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition. Dental Traumatology. 2012 Jun 1;28(3):174-82.

Dummett Jr CO. Dental management of traumatic injuries to the primary dentition. Journal of the California Dental Association. 2000 Nov;28(11):838.

Kramer PF, Onetto J, Flores MT, Borges TS, Feldens CA. Traumatic Dental Injuries in the primary dentition: a 15‐year bibliometric analysis of Dental Traumatology. Dental traumatology. 2016 Feb 1.

Feldens CA, Borges TS, Vargas‐Ferreira F, Kramer PF. Risk factors for traumatic dental injuries in the primary dentition: concepts, interpretation, and evidence. Dental traumatology. 2016 Dec 1;32(6):429-37.

Teething trouble

As the smallest member of the clan grows older it’s time for my reality based revision to move on from normal neonates to something else. We’ve made it through neonatal nasties and tourniquets on toes. It’s something more commonplace that keeps us up at night – something we’ve all been through – teething.

Only about 1 in 2000 babies are actually born with teeth, most of us had to wait a while before they came through. Cutting through the gingiva from their origin in the mandible/maxilla causes localized trauma and inflammation as well as a number of systemic effects such as a low grade fever and lose stools. Local effects and systemic effects are mediated by cytokine and prostaglandin release as well as by the possible translocation of oral bacteria through the gingival breach.

The embryology of teeth

Teeth develop from the ectoderm of the first pharyngeal arch and elements of the neural crest at around 6 weeks of embryonic development. Layers of cells develop as epithelial thickenings before moving through the stages of bud, cap, bell and then terminal differentiation into individual teeth. The odontoblasts (derived from the neural crest) form the predentin before calcifying to dentin.  It’s the ameloblasts that produce the tooth enamel.

Natal teeth (those present at birth) have a genetic predisposition with up to 60% of cases reporting a family history. They are also associated with an increased incidence of cleft lip/palate. Natal teeth are a known feature of :-

  • Ellis-van Creveld syndrome (chondroectodermal dysplasia)
  • Jackson-Lawler syndrome (pachyonychia congenital 2)
  • Steatocystoma multiplex with natal teeth
  • Hallerman-Streiff syndrome (oculomandibulofacial syndrome with hypotrichosis)

Teeth erupt in a predictable order.

 

How do you number the primary teeth?

There are almost as many numbering schemes as there are teeth. In Australia we use the Fédération Dentaire Internationale – take a look at the graphic below to refresh your memory.

If you work in the US you might choose the universal numbering system, which is not, as you might think, used universally.

Common symptoms of teething

Macknin et al. convinced some of their co-workers at the Cleveland Clinic to keep an 8 month log of 125 of their children. They recorded twice daily temperature measurements as well as filling in a daily symptom report and a record of their dental eruptions. Despite the fact that it seems that my children were teething all of the time they found that symptoms increased 4 days before an eruption, the day of and 3 days after – just an 8 day window. The parents reported drooling, sucking and general grumpiness coupled with the presence of a facial rash and ear or gum rubbing.

Though teething has been shown to raise ones temperature, it is only by a miniscule amount, around 0.6°C and that will be dependent on how it accurately it is measured. The parents in the Macknin cohort all used tympanic thermometers and whilst they are not overly accurate for individual measurements there were used to compare like with like.

Myths surrounding teething

The Macknin et al survey also refuted some common misconceptions. Teething was NOT associated with looser stools, vomiting or high temperatures. The problem is that these myths persist, not only in the general population but also amongst healthcare professionals. Admittedly, I was taught nothing about teething in medical school (or since, hence this post). A survey carried out in New Zealand found that 31% of health care professionals though that teething could cause nappy rash, 27% thought it could cause diarrhoea, 19% a runny nose and  though that teething could cause mouth ulcers.

So how should we treat the pain of erupting teeth?

Teething isn’t the life threatening illness that we once thought it was, but it certainly is sanity threatening for a parent.

Some infants achieve some degree of pain relief by chewing on anything they can.  Solid, silicone based teething rings are probably safer than the water filled variety as they cannot leak. Other parents swear by frozen veggies.

Most of the over-the-counter teething gels contain lignocaine hydrochloride.

Other teething gels, such as Bonjela® contain choline salicylate. These have a local anti-inflammatory as well as local anaesthetic effect. The salicylate component was removed from the UK formulation back in 2002 though there have been case reports of chronic salicylate toxicity in Australia.

There is also the option of using systemic analgesia in the form of appropriate weight-based doses of paracetamol.

And, more importantly, should we NOT treat teething pain?

Whilst it was not until the mid 19th century that teething stopped being listed as a cause of death in young infants it is now more likely that some of the treatments are more deadly.

Lancing (forming a cross-shaped incision over the troubling tooth) was a popular form of treatment in 16th century Europe and persisted until the late 19th century where it fell out of favour. Despite this a similar practice takes place in sub-Saharan Africa today. Removing the budding ‘tooth worms’ with non-sterile implements like knitting needles and bicycle spokes is a form of infant oral mutilation. Healers think the ‘tooth worms’ cause some of the common diarrhoeal illnesses – the erupting tooth bud looks similar to parasitic worms found in stools. If the child does not suffer from serious infection then they may still go on to develop permanent facial disfigurement.

Whilst we know that homeopathy is of no benefit, Hyland’s baby teething tablets were withdrawn in the US after concerns that non-homeopathic does of belladonna extract may have led to around 400 adverse events and 10 deaths. Whilst the alkaloid has not been found in the Australian product, the supplier, in conjunction with the TGA initiated a recall.

Amber necklaces, all the rage with a certain sector of the populace, have a number of health benefits (allegedly) – including reducing inflammation and the pain of teething. I’ve not found any high, medium, or low level evidence to confirm these claims but I have found a number of case reports detailing near strangulation events. Teething toddlers are inquisitive creatures. As they clamber over the furniture in their quest for something else valuable to break the necklace may get caught, leading to near-fatal consequences. One of our roles in emergency medicine is to advocate for those patients that cannot speak for themselves. As Tim Horeczko would say “You are the champion of the child in front of you.

 

Next time I’ll look at some basic dental anatomy, dealing with dental damage and how much you should leave for the Tooth Fairy.

References

Macknin ML, Piedmonte M, Jacobs J, Skibinski C. Symptoms associated with infant teething: a prospective study. Pediatrics. 2000 Apr 1;105(4):747-52.

Wake M, Hesketh K, Lucas J. Teething and tooth eruption in infants: a cohort study. Pediatrics. 2000 Dec 1;106(6):1374-9.

Jaber L, Cohen IJ, Mor A. Fever associated with teething. Archives of Disease in Childhood. 1992 Feb 1;67(2):233-4.

Wake M, Hesketh K. Teething symptoms: cross sectional survey of five groups of child health professionals. Bmj. 2002 Oct 12;325(7368):814.

McIntyre GT, McIntyre GM. Teething troubles?. British Dental Journal. 2002 Mar 9;192(5):251-5.

Zone CP, Guide S. Teething pain in babies. Sign. 2017 Jan 13;3531(937).

Hudson A, Blake K, McLaughlin R. Amber jewellery: A dangerous popular trend for toddlers during their teething months and beyond. Journal of paediatrics and child health. 2016 Apr 1;52(4):470-.

Voelker R. Safe Relief for Teething Symptoms. JAMA. 2016 Nov 15;316(19):1957-.

Ispas RS, Mahoney EK, Whyman RA. Teething signs and symptoms: persisting misconceptions among health professionals in New Zealand. New Zealand Dental Journal. 2013 Mar 1;109

Williams GD, Kirk EP, Wilson CJ, Meadows CA, Chan BS. Salicylate intoxication from teething gel in infancy. Med J Aust. 2011 Feb 7;194(3):146-8.

Girgis S, Gollings J, Longhurst R, Cheng L. Infant oral mutilation–a child protection issue?. British dental journal. 2016 Apr 8;220(7):357-60.

 

Supervision

I’ve been lucky enough to be one of the few paediatric registrars allocated to an Adolescent Inpatient Mental Health ward for a 6 month rotation. Although I’d worked in (adult) Psych wards before, I had few well formed ideas about psychiatric theory or practice past how to “do a takedown”. In Shem’s House of God, the future psychiatrist repeatedly states that “Good medicine as doing as much nothing as possible”. Until this term, I wasn’t entirely sure what that was, and knew even less about what to expect when it came to the care of young people.

As this opportunity is becoming rarer by the year and the rarefied air of Inpatient Adolescent Psychiatry is far removed from most paediatric practice; this is the second post in a series aiming to help understand the work (and underpinning theories) seen on the inpatient unit. 

Several months in advance of my rotation through Adolescent Psychiatry, there was much made of term supervisor allocation. I was pleasantly surprised on arrival into psych that the approach to mentoring and clinical supervision is quite different from that in paediatric training.

It’s worth pausing to reflect on the origins of medical training; until Osler introduced the intern/resident medical officer – style system we use today, much of medicine was a 1 on 1 apprenticeship. Some, including Dornan, have argued in favour of a “new apprenticeship model”; but for most trainees, as we change rotations, roles or hospitals on a regular basis, a longstanding, whole-of-training supervisor might feel like a pipe-dream. In this respect, psychiatry was not particularly different to paediatrics, but, in general, the approach to supervision was quite apart from what I’d previously experienced.

What happens?

Each member of the team, from case manager to consultant psychiatrist is allocated a senior supervisor. The pair is scheduled one hour of protected one-on-one time on a weekly basis. This is enshrined in the RANZCP program, which stipulates “Of [the 4 hrs/wk clinical supervision], a minimum of 1 hour per week must be individual supervision of a trainee’s current clinical work.” I can’t think of any other clinical job I’ve done where there is this kind of opportunity, let alone mandatory requirement!

 

What is this mean?

This tremendously augmented my education and overall experience from what could easily have been a paediatrics trainee “just muddling through” to being a functional member of the team, able to work independently in clinically challenging situations. Although I’m speaking of my experience, the general principles that this kind of supervision fosters, include establishing and maintaining an active/mentoring role, frequent contact, open dialogue, identifying opportunities for learning and discussion about multiple domains of practice.

A good mentor and active supervisor means much more than reducing the likelihood of the awkward end-of-term assessment most of us have endured in our junior years. By it’s nature, my experience of supervision in psychiatry was more immediate and active. The supervisor and trainee would see several patients together each week and discuss the clinical interaction.

I believe it possible to parallel this in medical specialities, as it is a key part of a consultant ward round. It is, however, something that must be actively held in mind by the supervisor, in addition to patient care. Interestingly, in 2004, a Danish group published a validated checklist assessing ward round performance in internal medicine. Although this kind of tool, along with other standardised forms, undoubtedly have their place for objectively measuring skill attainment and improvement, the many aspects of medicine that are learned from mentoring are often numerically elusive.

Frequent contact leads to both the supervisor having a better handle on how the trainee is going, and running counter to this, the trainee establishing a greater chance of understanding the supervisor’s philosophies of practice, and hopefully the opportunity to humbly question and challenge them!

This increased overall fidelity (rather than one tired afternoon as a chore), enables the opportunity to discuss not only clinical work but also system issues, learning points and more grand theories of practice and professionalism.

Much has been written in recent weeks about physician well-being, and I’d speculate regular meetings might also enable a supervisor to become both aware and active at an earlier stage for a doctor struggling with burnout or overwork, rather than picking up the pieces of an upset, overburdened registrar mid-term, or much worse. Supervision is a key part of a culture of care.

Barriers?

With some months of hindsight, I perceive the main barriers for this kind of supervision in paediatric training are threefold:-

Firstly, and most profoundly, the culture of making time, and the will to include this as paid work. Many departments battle to have protected teaching time, reasonable hours and a safe clinical workload. Non-clinical time is at a premium for everyone in a service and, in this context, supervision might strike many as an inefficient, unproductive use of time to have both a trainee and a consultant unavailable for an hour each week. There is strong argument to the contrary; as Bradfield observes “[t]here is overwhelming evidence that closer clinical supervision of junior doctors results in better patient outcomes, in the same way that double-checking reduces medication errors in a nursing context.

Secondly, the immediacy of supervision may be heavily diluted. I’ve alluded to check-box supervision above, but additionally, one or two sessions in a three-month rota often equates to a global impression that is simply too diluted to utilise pragmatically. I imagine it quite frustrating to know an observed ward round is more likely to terminate with the consultant dashing off to clinic, rather than a thoughtful, timely discussion about the morning’s caseload.

Thirdly, the goodness of fit between the supervisor and trainee probably plays a role. It’s understandable that not everyone gets on with everyone. Not all physicians are, by their nature, extroverts, teachers or energised by their work; qualities which may be more or less helpful for mentoring. This isn’t something to modify aggressively, but more an observation of personality, culture and the world, and bears consideration as a barrier to close supervision.

This topic isn’t a new one, having been more comprehensively reviewed in Bradfield’s take on the 2008 Garling Report into the provision and governance of Acute Care Services in New South Wales Public Hospitals.

Taussig & Blalock; senior peers.

What about senior staff?

Everyone benefits from senior supervision, irrespective of experience. The consultants in the Adolescent Unit also had supervision on a weekly basis. As a junior observing, this seemed to evolve with a clinician’s experience; from the outside, depending on the experience differential, this appeared as either a grandparent-parent interaction, and, as the age and experience of the pair narrowed, two older professional siblings discussing their work thoughtfully and with joy.

The further I extend this metaphor, the more supervision strikes me as being about communication between generations of clinicians. That is, interns (consciously or subconsciously) model their thinking and behaviour on their immediate peers and seniors, often those whom they have the most contact.

Within this framework, registrars are the adolescents of the medical world; they have developed sufficiently as clinicians to think and act, and are often looking for guidance about the transition to (clinical) adulthood.

Having senior peers effectively in the role of parents and grandparents are indispensable in guiding, modelling and nurturing the “adolescent” clinician through these tricky years. Further, the parallel key roles of the consultant and the parent; to be bigger, wiser, stronger and kind, are equally applicable in mentoring. Like parenting, the most important thing to have someone who is willing and able to supervise and hold the younger in mind.

References and Further Reading:

Dornan T., Osler, Flexner, apprenticeship and ‘the new medical education’ J R Soc Med. 2005 Mar; 98(3): 91–95.

Nørgaard K, Ringsted C, & Dolmans D., Validation of a checklist to assess ward round performance in internal medicine. Medical Education 2004; 38: 700–707

Bradfield, O.M. “Ward rounds: the next focus for quality improvement?” Australian Health Review, 2010, 34, 193–196 

Garling P . Final report of the Special Commission of Inquiry: Acute Care Services in NSW Public Hospitals. Sydney: NSW Government, 27 November 2008. http://www.dpc.nsw.gov.au/?a=34194 Accessed June 2017.

Royal Australian and New Zealand College of Psychiatrists (RANZCP), Supervisor Manual. 2012. https://www.ranzcp.org/Files/Resources/Assessor-Supervisor/Supervisor-Manual.aspx Accessed Feb 2017

Pelling, N., Barletta, J. and Armstrong, P. The practice of clinical supervision. Bowen Hills, Qld. : Australian Academic Press, 2009.