1. Morehouse Pediatrics EM Lecture Series November 23,2009 Taryn R Taylor, MD

2.  Epidemiology  Tooth Eruption & Shedding Schedule  Clinical Evaluation  Dental Concussion & Subluxation  Avulsion Injuries  Tooth Displacement  Tooth Fractures  Dental Abscesses

3.  Epidemiology ◦ 30% of children experience dental injuries ◦ Peak period of trauma to primary teeth is 18 to 40 months of age ◦ Trauma to permanent teeth  School aged boys suffer trauma twice as frequently as girls  Upper (maxillary) central incisors are most frequently injured

4.  Tooth Eruption & Shedding Schedule

5.  Clinical Evaluation ◦ Medical History  Assess need for SBE prophylaxis  Determine if child has a bleeding disorder or is immunocompromised  Record current medications and medication allergies  Obtain history of previous surgeries  Determine if tetanus immunization is up to date  Determine if child lost consciousness due to injury ◦ Dental History  How the injury occurred: provides info regarding severity  When injury occurred: prognosis for injured tooth worsens with every minute of delay in treatment  Where injury occurred: helps determine whether tetanus prophylaxis is warranted

6.  Clinical Evaluation ◦ Physical Examination  General assessment includes review of vital signs, evaluation of potential head and cervical spine injury as well as ocular damage  Extra oral evaluation  Palpate mandibular condyles, maxilla, zygoma & TMJ  Anterior open bite, malocclusion or limited mandibular opening suggests condylar fractures or dislocation  Note extra oral lacerations, bruises or swelling  Lacerations must be inspected for foreign bodies i.e. gravel or tooth fragments & be debrided if foreign body present

7.  Physical Exam cont. ◦ Intra oral evaluation  Remove all clots and debris  Palpate alveolus to detect fractures  Have patient clench teeth to detect dental occlusion  Examine each tooth for damage or mobility  Examine labial mucosa, maxillary frenulum, gingival tissues and tongue for bruising or lacerations  Lacerations must be cleaned & explored for presence of foreign body  Frenulum will heal without long term consequences  Most tongue lacerations will heal on their own, unless tissue edges are not self-approximating

8.  Dental Concussion & Subluxation ◦ Concussion: Mild injury to periodontal ligament without tooth mobility or displacement ◦ Subluxation: Significant injury to periodontal ligament resulting in some tooth mobility ◦ These injuries may result in tooth discoloration ◦ Initial management  Tylenol as needed for pain  Ice as needed for swelling  Soft diet  Follow up with dentist ◦ Dental office management  Radiographs of primary tooth to evaluate for root fracture  Splinting of permanent tooth if extremely mobile

9.  Avulsion Injuries ◦ Occurs when a tooth is completely displaced from the dental socket ◦ Radiographs may be necessary if tooth cannot be found ◦ Primary Teeth  Not reimplanted, as the risk of injury to developing permanent tooth bud is high ◦ Permanent Teeth  Best way to preserve an avulsed tooth is to replace it in its socket as quickly as possible  Periodontal ligament is protective layer surrounding the root, which suffers irreversible damage if allowed to dry  Do not touch root of tooth, handle by crown only  Rinse only if there is dirt covering it, don’t scrub or scrape tooth  Gently dislodge any clots, & reintroduce tooth into the dental socket slowly

10.  Avulsion Injuries cont. ◦ Post Reimplantation care  Dental consult immediately for splinting & tooth stabilization  10 day course of prophylactic penicillin  Tetanus vaccination if wound is dirty or vaccination requires updating  Chlorhexidine gluconate rinses, oral hygiene & soft diet instructions  Analgesics for pain control  Dental follow up within one week

11.  Tooth Displacement ◦ Luxation: Displacement of tooth in any direction, while remaining in the socket  Lateral luxation is usually associated with fracture of alveolar bone  Primary teeth: analgesia, proper dental hygiene, prompt dentist follow  Permanent teeth: gently reposition tooth, additional care similar to primary teeth

12.  Tooth Displacement ◦ Extrusion: tooth is only partially removed from socket  Care similar to other luxation injuries ◦ Intrusion: tooth is impacted into alveolar bone with associated fracture  Intrusions of up to 3 mm have excellent prognosis  Care similar to other luxation injuries

13.  Tooth Fractures ◦ Crown fractures are described by Ellis Classification  Ellis class I: involves enamel only, rarely painful, cosmetic implications only  Ellis class II: involves enamel as well as dentin  Sensitivity to cold air & fluids  Emergency treatment aimed at protecting the pulp by applying calcium hydroxide product  Dentist follow up in 48 hours  Ellis class III: dental pulp involved, often appears red  Exposure of nerve endings causes extreme pain  Exposure of pulp will lead to pulpal necrosis from bacterial infection if left untreated  Emergency treatment aimed at protecting the pulp by applying calcium hydroxide product  Dentist follow up within 24 hours

14.  Dental Abscess ◦ Results when inflammation of the pulp is left untreated ◦ Pain, tenderness, red, swollen gingiva with areas of fluctuance ◦ Complications include localized cellulitis, fistula formation ◦ Emergency management includes pain control and oral penicillin ◦ Prompt dental follow-up ◦ Emergent ENT consultation for patients requiring incision and drainage due to severe pain or with extension of infection into deeper tissues

15.  Landmarks of the eye  Different types of eye injuries  Emergency care for eye injuries  Orbital Cellulitis

16.  The globe of the eye, or eyeball is a sphere approximately 1” in diameter  Five most important landmarks of the eye: ◦ Sclera- the “white” of the eye ◦ Cornea- clear, front portion of the eye that covers the pupil ◦ Pupil- opening in which light enters ◦ Iris-colored portion of the eye ◦ Retina- back of the eye

17.  Ocular trauma is the leading cause of noncongenital unilateral blindness in children younger than 20  Most eye trauma occurs during sports activities  Clinical Assessment ◦ Mechanism: blunt or sharp object, foreign body present ◦ Symptoms: pain, photophobia, eye movements, visual acuity ◦ Exam: Pupil size, shape, reaction to light: orbital rims, floor, extra ocular motion

18.  Eye injuries are usually not life-threatening  Time is of the essence in your treatment  Six different types of eye injuries: ◦ Foreign object in the eye ◦ Corneal Abrasions ◦ Lid injury ◦ Injury to the globe ◦ Injury to the orbits ◦ Chemical burn to the eye

19.  Extra ocular Foreign Objects ◦ Dust, dirt, sand or fine pieces of metal can be blown into the eye & lodged on conjunctiva or cornea  Signs & Symptoms  Pain, foreign body sensation  Excessive tearing  Reddening of conjunctiva  Decreased visual acuity

20.  Extra ocular Foreign Body ◦ Flush eye for at least 20 minutes ◦ If object cannot be flushed, attempt to remove ◦ Evaluate for possible corneal abrasion  To remove object:  Pull down lower lid while patient looks up, or evert upper lid while patient looks down  Remove object with sterile gauze

21.  Corneal Abrasions ◦ Most common eye injury in all ages ◦ Scraping away of the corneal surface, caused by :  Injury  Blowing dust, sand, debris  Extended contact lens wear  Ocular foreign bodies, embedded under an eyelid ◦ Signs and symptoms  Red, irritated eye  Foreign body sensation  Increased tearing  Photophobia  Fluorescein uptake under Woods lamp ◦ Treatment  Polytrim antibiotic ointment or gtts

22.  Eyelid Lacerations ◦ Control bleeding with LIGHT pressure ◦ Ocular injury should always be suspected ◦ Lids should be everted and conjunctival surface examined ◦ Orbital CT if suspected ocular penetration ◦ Laceration repair with 6-0 nonabsorbable suture ◦ Optho referral for repair:  Lacerations involving nasolacrimal duct  Full thickness lacerations  Eyelid margin lacerations ◦ Lacerations from animal or human bites require tetanus prophylaxis

23.  Injuries to Globe ◦ Subconjunctival Hemorrhage  Blood between conjunctiva & sclera, stops at cornea  Not an emergency  Heals like any other bruise ◦ Hyphema  Accumulation of blood in the anterior chamber  Complications include inflammation and increased IOP  Patients with sickle cell disease or trait & thalassemia are at risk for central retinal artery and optic nerve damage  Patients are at risk for rebleeding 3-5 days after initial injury  Initial treatment: bed rest, elevation of head of bed 30 degrees, optho referral  Hyphemas > 50% should be admitted  Avoid aspirin & NSAIDS

24.  Injuries to Globe ◦ Globe Rupture  Can occur after significant laceration of cornea or sclera due to sharp objects, or blunt trauma  Visual loss, bloody chemosis, soft globe  Protective shield should be placed over the eye AVOIDING direct pressure on globe  Broad-spectrum IV antibiotics against skin flora & tetanus prophylaxis should be administered  Analgesics, sedatives and antiemetics to decrease IOP from vomiting  Immediate ophthalmologic consultation required

25.  Orbital Fractures ◦ “Blowout” Fracture  Following blunt trauma, eye is pushed through floor of orbit, causing fracture of orbital wall  Trapping of intraocular muscle prevents movement of eye away from fracture site  Facial asymmetry, sunken eye, paralysis of upwards gaze, double vision ◦ Orbital roof fractures  Occur mostly in children under 5 years  Possibility of communication between orbit & intracranial cavity  Pulsating proptosis ◦ CT scan with immediate ophthalmologic consultation

26.  Chemical Burns ◦ Represent a DIRE emergency ◦ Permanent damage can occur within seconds ◦ Burning and tissue damage will continue to occur as long as substance is left in eye ◦ Signs and Symptoms  Irritated, swollen eyelids  Redness of the eye  Blurred/diminished vision  Irritated, burned skin around the eyes

27.  Chemical Burns ◦ Emergency Care  Immediately begin irrigation with NS or LR  Continuously irrigate for a minimum of 20 minutes  Remove contact lenses-may trap chemicals  Wash your hands afterward to prevent contamination to yourself  Contact Poison Control Center for further information  Referral to ophthalmologist

28.  Orbital Cellulitis ◦ An infection of the orbit itself, which occurs  As a complication of sinusitis with extension of the infection to the orbit  Secondary to penetrating trauma  As an extension of a nearby facial infection ◦ Signs & Symptoms  Erythema, edema, induration and tenderness to peri orbital tissues  Decreased eye movement  Proptosis, chemosis, decreased visual acuity and papilledema

29.  Orbital cellulitis ◦ CT scan of orbit ◦ Prompt treatment with IV antibiotics ◦ Inpatient admission for frequent monitoring ◦ Ophthalmologic consultation

30. Questions?