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Author:

Dr Callum Durward

Service: Paediatric Dentistry
Editor: Dr Patrick Kelly Date Issued: Reviewed August 2005

 

ORO-FACIAL PROBLEMS, EMERGENCY MANAGEMENT OF

 

 

The Oral Health Team        é

 

A+ runs a regional hospital dental service.  The main bases are at Greenlane and Middlemore Hospitals, with other clinics at Starship, Buckland’s Rd (Mangere), Waitakere Hospital and the Mangere Refugee Center.  There will also soon be a small inpatient clinic at Auckland Hospital.

 

Our staff include 25 full and part-time dentists/oral surgeons (and one dental therapist) covering almost all dental specialities. The two services that you are most likely to communicate with are:

  • Oral and Maxillo-Facial surgery - 1 full-time consultant; 3 part-time consultants; 1 registrar; 1 house surgeon.

  • Paediatric Dentistry - 1 full-time consultant; 1 part-time consultant; 3 part-time dentists; 1 senior dental house surgeon; and 1 part-time dental therapist.

 

Names and Contact Numbers For The Staff:

Greenlane Oral Health Unit                                           623-6494 or ext 3499/4894

Middlemore Dental Department                                     276-0145 or ext 902-8696

Starship Hospital Dental Clinic                                      ext 6527

 

Oral & Maxillo-Facial (OMF) Team

Chris Sealey                                                                 025-2858661

John Edwards                                                               025-941514

Lance West                                                                  025-923372

Neil Luyk                                                                      025-973852

Nigel Parr                                                                     021-555490

Peter Hill (Registrar)                                                      93-5242  or  025-866748

House Surgeon On-Call. Ring switch-board

 

Paediatric Dentistry Team

Callum Durward                                                            021-442051

Nina Vasan (on leave)                                                   025-773-806

Nisreen Faris                                                               025-469258

Wanda Gaynor                                                            902-8696

Yaso Ramadas (Snr Dental House Surgeon)                  025-2751406

 

Obtaining Advice

One of our dentists is often working at SSH in the Dental Clinic at Level 3 Outpatients on Tuesday (pm), Wednesday (pm), Thursday (am), and Friday (am).  The phone number for the SSH Dental Clinic is ext 6527.  Advice can also be sought day and night from the Dental House Surgeon on-call.   Only the oral surgery team provides an after-hours service.

 

Treatment Services for Children Outside the Hospital       é

 

The School Dental Service

·         Enrol children from birth

·         Provide free treatment up until Form 2 (limited range of treatment)

·         Usually should be the first port of call for a child with a dental problem during school hours or school holidays

        (some clinics remain open throughout the holidays).  You can find out which clinics are open by calling 839-0565.

·         Dental Therapists however:

o        do not provide an after-hours or weekend service

o        do not manage trauma

o        do not extract permanent teeth

o        do not carry out pulp therapy (soon to change)

o        do not prescribe drugs

 

Contracting Private Practice Dentists (see list)

·         Some dentists have a contract with the DHB to provide free dental services for:

o        adolescents, and

o        for younger children who: 1) are referred to the dentist by the School Dental Service for something beyond the training of the Dental Therapist, or, 2) turn up at the dentist with an acute problem eg trauma, infection or toothache (especially if it is after normal school dental clinic hours). 

·         Parents must pay for any orthodontic treatment.

 

Non-Contracting Dentists

·         Other dentists will only provide treatment for children on a fee-for-service basis

·         There are two private paediatric dentists in Auckland (Nina Vasan tel:  025-773-806) and Kahtan Yaghot tel: 570-2572) who will treat children for specialist fees.  There are two other dentists with postgraduate qualifications in paediatric dentistry (Nisreen Faris: tel: 570-2572 or 025-469258 and Wanda Gaynor: tel: 576-6720 or 902-8696).

Children with Toothache        é

For preschool and primary school children, treatment can be sought from the local school dental therapist during work hours and school holidays.  However, each dental therapist visits several schools.  To find out the phone number and location of the nearest open dental clinic call the School Dental Service (Tel: 839-0565). After hours and at weekends the child can be taken to the family dentist or an Emergency Dental Clinic.

 

Children who for some reason cannot see their local dental therapist or dentist may attend the Relief of Pain service at the Oral Health Unit, Green Lane Hospital between 8.15am and 11am. After hours, the hospital dental service is usually not involved with simple toothache cases, unless there is an associated facial swelling or systemic signs, or unless the child is a regular patient of the department (eg medically compromised) etc.  Most children with after-hours toothache can be seen at one of the private Emergency (A&E) Dental Clinics around Auckland or by their family dentist.

Acute Facial Swelling              é

  • Make contact with Dental House Surgeon or Oral Surgery Registrar On-call

  • If severe, child may require admission, IV antibiotics (usually amoxycillin +/- metronidazole), and incision and drainage (often with tooth extraction)

  • Swelling which could compromise the airway (e.g. sub-lingual) or is causing trismus must be treated without delay

  • Mild facial swellings not causing pyrexia/malaise can often be managed with tooth extraction (or pulpectomy), and antibiotics

Dental Trauma        é

All dental trauma should be reviewed as soon as possible by a dentist.  Some can be referred to the local family dentist or Emergency Dental Clinic. If  the child presents at SSH between 8.15am and 11am they can be sent to the Oral Health Unit at Greenlane Hospital where they will be seen on the Relief of Pain clinic. At other times the dental house surgeon on-call can be contacted.

 

INITIAL MANAGEMENT OF SPECIFIC TYPES OF DENTAL TRAUMA

 

The Avulsed Tooth

 

Instructions on the phone

  • handle by crown only

  • rinse gently with cold water and put tooth back into socket

  • hold in place by gently biting on a folded handkerchief or piece of gauze

  • go to dentist immediately

 

Note:  

  • avoid letting the tooth root "dry out"

  • if unable to reinsert tooth immediately, put it in milk and send to the dentist

  • storage media, in order of preference, are cold milk, saline and saliva (keep tooth inside cheek).

  • if tooth is missing, need to establish where it is (Radiographs?)

 

At the hospital, if tooth not yet re-implanted:

  • place tooth in milk - call the dental house surgeon

  • irrigate tooth (and socket) with saline and replant as soon as possible (this may require local anaesthesia)

  • gently bite on gauze to keep tooth in place until dental house surgeon arrives (or send to their dentist, an Emergency Dental Clinic, or Greenlane Oral Health Unit)

  • antibiotics (eg amoxycillin) are recommended and a tetanus booster if necessary

  • the dentist will place a splint to hold the tooth in place for about 1 week

 

Reimplantation may not be appropriate in some situations –

·         primary tooth

·         where other injuries warrant preferential treatment / intensive care

·         where the tooth is immature with a short root and wide open apex and the extra-oral time is long and the periodontal ligament has been allowed to dry out

·         children who are medically compromised eg at risk of infectious endocarditis or on immunosuppressive therapy

 

Mature teeth with closed apices which have been out of the mouth for over an hour and have been allowed to dry out, need special treatment by the dentist before reimplantation.   This involves:  scraping the periodontal ligament off the root and soaking the tooth in a fluoride solution/gel, and possibly carrying out root canal treatment on the tooth before reimplanting it.  The tooth will eventually be lost after some months or even years. 

 

If the initial and follow-up management of the tooth is not good, in many cases the tooth root will resorb, and the tooth will eventually be lost.

 

Note: The pulps of immature teeth (eg in children under 10) if reimplanted quickly may survive. 

 

The Fractured Tooth

 

  • keep fragment if found (store in water) - can sometimes be reattached

  • check soft tissues for fragment if it is missing (may need radiographs)

  • if fragment cannot be found, consider CXR and abdominal film

  • refer to own dentist, Greenlane Oral Health Unit, or dental house surgeon

  • child should be seen by a dentist the same day

  • the fracture may involve the crown, the root or both

  • the fracture may expose the pulp, which can become infected

  • if the dentine or pulp is exposed, the tooth will be very sensitive, and measures to cover the dentine and the pulp should be carried out within 2 days

 

The Luxated Tooth

 

  • the tooth may be extruded, intruded or have a lateral luxation

  • even teeth with a minor "knock" can become non-vital, so follow-up with a dentist is highly recommended

  • tooth may need to be repositioned (or extracted - especially if it is a very mobile primary tooth)

  • refer to own dentist, Greenlane Oral Health Unit, or dental house surgeon

  • child should be seen the same day if possible

 

Maxillofacial Trauma           é

  • examine the child for other injuries and ensure they are in a stable condition, then call the dental house surgeon

  • examination should include looking for signs of: bony tenderness or steps in bony margins (palpate facial bones); mobility of facial bones; paraesthesia eg of lip, chin or cheek; malocclusion; haematoma or swelling (intra-oral or extra-oral); soft tissue injuries; deviation on opening and closing; pain

 

Child Abuse            é

Where this involves injury to the oro-facial region the paediatric dentists and/or oral surgeons are willing to be involved. Such children should also be discussed with the Paediatrician on call for child abuse (see Abuse and Neglect Guideline).

Children Requiring a General Anaesthetic             é

Although some oral and maxillo-facial emergencies can be treated on the Acute List at SCH, the Oral Health Service also has several elective GA lists each week.  It may be possible to put a child who requires an urgent extraction or I&D etc on one of these booked lists as an extra patient.  The lists are:

 

Monday am           - GLCC

Tuesday am          - SCH

Tuesday pm          - GLCC

Wednesday am     - GLCC

Wednesday pm     - GLCC

Thursday pm         - GLCC