McGraw-Hill Specialty Board Review Pediatrics, 2nd Edition

Chapter 19. DENTISTRY

CASE 143: A 4-YEAR-OLD WITH DENTAL TRUAMA

DENTAL TRUAMA

The mother of a previously healthy 4-year-old girl calls your office and reports that her daughter had an accident while playing in the backyard. The child was running and fell to the ground hitting her face on the concrete. Mom reports no loss of consciousness, but the child is in pain and is crying. One of her front teeth has been “knocked out,” and they have the tooth. She has no drug allergies.

SELECT THE ONE BEST ANSWER

1. What would be the age-appropriate number of erupted teeth for a normally developed child at age 4 years?

(A) 8

(B) 12

(C) 20

(D) 24

(E) 32

2. What should you instruct the mother to do with the “knocked-out” tooth?

(A) place the tooth in milk and seek care at the nearest emergency department (ED)

(B) replant the tooth as soon as possible and seek care at the nearest ED

(C) discard the tooth; it should not be saved

(D) place the tooth in a buccal vestibule for safekeeping and go to the nearest ED as soon as possible

(E) place the tooth in tap water and seek care at the nearest ED

3. If in the same scenario, the mother reports that no teeth have been “knocked out,” but the webbing inside the mouth extending from between the two middle top front teeth is “bleeding like crazy.” What should the mother be instructed to do?

(A) go to the nearest ED

(B) apply a compress to the area until the bleeding has stopped

(C) have the mother bring the child to the office immediately

(D) have the child rinse her mouth with peroxide

(E) none of the above

4. If the child’s age is 9 years, in the same scenario, and the mother reports that an upper middle tooth has been “knocked out,” what should the mother be instructed to do with the tooth?

(A) replant the tooth in the socket immediately and go to the ED or the dentist

(B) place the tooth in milk and go to the ED or the dentist

(C) store the tooth in a warm dark environment (ie, pants pocket) and go to the ED or the dentist

(D) do nothing with the tooth; it should not be saved

(C) place the tooth in tap water and go to the ED or the dentist

5. The patient has had a tooth splinted by a dentist on call at the ED and has come to your office immediately afterward for follow-up. The antibiotic of choice would be which one of the following?

(A) amoxicillin

(B) clindamycin

(C) doxycycline

(D) phenoxymethyl penicillin (penicillin V)

(E) no antibiotic is indicated; the tooth is not infected

6. A 2-year-old boy comes to your office for a routine physical examination. You notice a dark-colored front primary tooth. He is in no pain and the parent does not care if it is discolored. What would be the appropriate next step?

(A) Have the parent see a dentist as soon as possible

(B) Reassure the parent that the tooth is a baby tooth and will fall out

(C) Have the parent see a dentist within 1 month

(D) Prescribe an antibiotic

(E) Recommend an over-the-counter tooth bleaching kit

ANSWERS

1. (C) Figure 143-1 shows the eruption of the primary dentition.

2. (C) In a normally developed child of this age, the tooth is a primary tooth. The tooth is not replanted. If the tooth is reimplanted, the risk of a negative outcome for the forming of the permanent tooth is very high.

3. (B) The labial frenum is very vascular and bleeds heavily when torn. The frenum is not sutured when torn. The bleeding should be stopped with a compress, and the child can consult with a dentist within 48 hours.

4. (A) The tooth should be replanted immediately. The sooner the tooth is implanted, the greater the chance of a favorable outcome. Being placed back into the socket is the closest to the tooth's natural environment and will facilitate the best outcome. If the parent is unable to replant the tooth, it should be placed in the buccal vestibule. If the parent is unable to replant the tooth or place it in the mouth, it should be placed in a solution to keep it moist until it can be replanted in the ED. The best storage solution is Hanks Balanced Salt Solution, followed by milk, and then tap water.

5. (D) Phenoxymethyl penicillin is the best choice in this scenario. In children younger than 9 years at risk for tetracycline staining, phenoxymethyl penicillin is recommended. Amoxicillin would be an appropriate alternative choice if the patient is unable to tolerate the taste of the phenoxymethyl penicillin. If the child is older than 9 years, doxycycline is the antibiotic of choice.

6. (C) The dark tooth is not an emergency. However, a dentist should evaluate it. It is possible that a dark tooth is a sign of a localized infection that could affect the developing permanent tooth.

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FIGURE 143-1 Eruption of the primary dentition.



SUGGESTED READING

Guidelines for the management of traumatic dental injuries— 2007. International Association of Dental Traumatology Web site. www.iadt-dentaltrauma.org

CASE 144: A NEONATE WITH AN ERUPTED TOOTH

A full-term newborn is delivered with no complications. The newborn is healthy, and no developmental or heritable disorders are noted. The child has a single tooth present near the midline of the mandibular alveolar ridge. The tooth appears to be normally developed with only slight mobility.

SELECT THE ONE BEST ANSWER

1. What should be done with this tooth?

(A) remove the tooth because it is most likely an extra tooth and will not be needed

(B) if there is little risk of aspiration, leave the tooth as is

(C) apply fluoride to strengthen the tooth

(D) B and C

(E) support the tooth with a suture to the gingiva

2. Another full-term newborn is delivered with no complications. There are hard raised nodules on the labial maxillary alveolar ridge. What would be the best course of action?

(A) place the child on antibiotics

(B) perform an immediate excisional biopsy

(C) incise the lesions

(D) instruct the parent to scrub the lesions with a toothbrush until they resolve

(E) observe; no treatment is necessary at this time

3. A 6-month-old reports to the office with a lesion near the midline on the mandibular alveolar ridge. There are no teeth present. The lesion is asymptomatic, dome shaped, and fluctuant. The best treatment would be which of the following?

(A) observe; no treatment is necessary at this time

(B) perform immediate excisional biopsy

(C) incise the lesion

(D) place the child on antibiotics

(E) perform a brush biopsy

4. What systemic conditions could be associated with a child who has no teeth present at 12 months?

(A) ectodermal dysplasia

(B) hypothyroidism

(C) malnutrition

(D) Down syndrome

(E) all of the above

5. A mother reports to the office with questions regarding fluoride. The family has well water that has been tested and contains no fluoride. The child is 14 months old. What would be the appropriate fluoride supplementation?

(A) 0.25 mg

(B) 0.5 mg

(C) 1 mg

(D) no fluoride supplementation

(E) none of the above

6. Dental fluorosis can be caused by ingestion of too much fluoride while the permanent teeth are developing. What can cause fluorosis?

(A) fluoride supplements

(B) fluoridated tap water used to mix powdered infant formula

(C) drinking water

(D) ingestion of toothpaste

(E) all of the above

7. At what approximate age do the earliest permanent teeth normally begin developing?

(A) birth

(B) 6 months

(C) 12 months

(D) 18 months

(E) none of the above

8. A 14-month-old child has black stains on the anterior teeth that could possibly be dental caries. A child should be normally referred to a pediatric or family dentist at what age?

(A) at birth

(B) 12 months

(C) when the permanent teeth erupt

(D) 6 years

(E) none of the above

9. How do children become colonized with the bacteria that cause dental caries?

(A) they are naturally colonized at birth

(B) pacifier

(C) inoculation from saliva of primary caregiver

(D) thumb sucking

(E) all of the above

10. Which of the following are risk factors that can contribute to early childhood caries (baby bottle caries)?

(A) frequent bottle feeding at night

(B) breastfeeding ad libitum

(C) excessive use of sippy cup for feeding

(D) active caries in mother

(E) all of the above

11. A child reports to the office with a swelling on the left cheek that is tender to palpation and has been present for 1 day. What could be the etiology of the swelling?

(A) mumps

(B) infection secondary to cheek bite

(C) obstructed salivary gland

(D) infection of dental origin

(E) all of the above

ANSWERS

1. (B) Natal teeth are present at birth. The teeth are the true primary teeth 90% of the time. Natal teeth should be removed only if their mobility would cause a risk for aspiration. Fluoride should not be applied to the tooth of a newborn to avoid possible fluorosis in the permanent dentition.

2. (E) No treatment is required. They are developmental and will resolve. They can be found on the middle of the hard palate or on the labial surface of the maxillary alveolar ridge.

3. (A) No treatment is required. The lesion is an eruption cyst. The cyst may appear right before a primary tooth erupts. This cyst is consistent with the timing of the eruption of the mandibular incisor. The cyst resolves as the tooth enters the oral cavity.

4. (E) Delayed eruption of the primary teeth can be caused by all of these conditions. A child with any of these conditions should be evaluated by a dentist by 12 months.

5. (A) 0.25 mg. The American Academy of Pediatrics (AAP) and American Academy of Pediatric Dentistry (AAPD) recommend fluoride supplementation as per the nearby chart (see Table 144-1).

TABLE 144-1

 

FLUORIDE CONCENTRATION IN LOCAL WATER SUPPLY

 

AGE OF CHILD

<0.3 ppm

0.3-0.6 ppm

>0.6 ppm

DAILY DOSAGE OF FLUORIDE

 

6 months to 3 years

0.25 mg

None

None

3-6 years

0.50 mg

0.25 mg

None

6-16 years +

1.0 mg

0.50 mg

None

 

6. (E) All of these can cause fluorosis. Determining a child’s total fluoride intake from all sources is important when deciding if a child will need more fluoride.

7. (A) The first molars begin developing at birth. From this point forward, the teeth can be susceptible to development or environmental anomalies.

8. (B) The AAP and AAPD recommend a first dental visit within 6 months of the eruption of the first tooth. This is usually around 12 months.

9. (C) Infants are colonized by bacteria that originate from the saliva of their primary caregiver, usually the mother (eg, sharing a spoon).

10. (E) All of the choices can contribute to early childhood caries. Other factors to be aware of are malformed primary teeth (weak enamel), frequent in between meal snacking and drinking of foods and drinks with fermentable carbohydrates.

11. (E) All of these items can cause facial swelling. Depending on the tooth that has become infected, any of the facial spaces can be involved. These infections can be secondary to caries or trauma to a tooth.


S
UGGESTED READING

2010-11 Definitions, oral health policies, and clinical guidelines. American Academy of Pediatric Dentistry Web site. http://www.aapd.org/media/policies.asp.

http://www.cdc.gov/FLUORIDATION/safety/infant_formula.htm.

http://jada.ada.org/cgi/content/full/133/1/93.