Sink Your Teeth Into this TIME SENSITIVE Topic!

http://www.dentaltraumaguide.org/permanent_avulsion_treatment.aspx

******PLEASE ALSO REVIEW VIA THE REX WEBSITE LIBRARY THE TOOTH AVULSION CHAPTER IN UPTODATE, WHICH HAS SUPERB PICTURES******

While we are obviously not dentists, facial and dental trauma are a part of urgent care practice. I will be the first to admit that a medical provider can quickly get lost in the dental terminology of dental concussion, subluxation, intrusion, extrusion, and avulsion. Here are the imperative points though:

• With a facial trauma, and a "knocked out tooth", in the mayhem of patient and understandable parent panic, don't lose sight of the forest for the (tooth) trees. In other words, make sure that the c-spine is alright, assess for loss of consciousness and intracranial injury risk factors that take precedence over the tooth, and do a quick body survey and history for potential child abuse.
• The most dreaded and time sensitive is a full tooth avulsion. These injuries, for PERMANENT TEETH, need care within 1 hour and if not placed in proper medium, the tooth and its essential periodontal ligament have a zero percent survival rate. 

      As such, our main focus is:
1. Is this a permanent tooth? Here is a basic guide:
-All teeth are primary for kids less than 5.
-Permanent incisors usually erupt around age 6-7. Note the frontal maxillary incisors are the 2 most commonly injured teeth.
- Mixed dentition occurs in ages 6-12. As such, this will be the "tough group."
-Most kids over 13 have all permanent teeth.

2. Is this an avulsion? Again, I suggest the UptoDate pictures, but in non dental language the tooth is totally knocked out at the gumline, the periodontal ligament is severed, and a fracture of the alveolar ridge may also be present. AVULSION NEEDS REIMPLANTATION AS SOON AS POSSIBLE. NOTE THAT FROM THE TRAUMA UNTIL REIMPLANTED AND SEEN BY A DENTIST, COLD MILK IS THE BEST TRANSPORT SOLUTION, OR IF THE CHILD IS OLD ENOUGH TO NOT ASPIRATE IT, INSIDE THE BUCCAL MUCOSA.
Per UptoDate, here is the basic-and doable-guide to reimplant the avulsed tooth and quickly being sent to the ER or dentist. Again, the 1 hour window applies to reimplantation, so you can make a big difference here...

• handle the tooth carefully by the CROWN and avoid the ligament
• remove debris by gentle rinsing with saline or tap water (again, milk is the preferred storage medium over saline for transport). DO NOT ATTEMPT TO STERILIZE OR SCRUB THE TOOTH, as you want to keep the periodontal microfibers.
• manually reimplant the tooth in the socket- see picutre 8 in up to date.
• keep the tooth in place by having the child bite down on a clean gauze or towel.
• see the dentist or pediatric ER as soon as possible.   

Again new things are always intimidating, but here is the cheat sheet summary:
1. SEE ALL DENTAL INJURIES ASAP IN THE CLINIC. 
2. IF A PARENT CALLS IN ROUTE, OR IF THE PATIENT HAS THE TOOTH IN HAND, PLACE IT IN COLD MILK OR THE BUCCAL MUCOSA. NO SCRUBBING.
3.IF A PERMANENT TOOTH, REIMPLANT IT TO MAINTAIN VIABILITY AND SEND TO THE DENTIST ASAP. 

 

Enter the Enterovirus D68

http://www.cdc.gov/non-polio-enterovirus/about/EV-D68.html?s_cid=cdc_homepage_whatsnew_001

Above is the link to the CDC website for enterovirus D68. Note that at least as of September 22, 2014 the CDC says it is not in North Carolina yet, but given its spread and proximity it is safe to say it is here and just undetected, or will be soon. A few salient urgent care points for this after reviewing the current information on EV-D68.

• Recall this is an enterovirus, which technically is the same grouping as polio. Recall that with these enteroviruses, while droplet spread is typical, a large amount of organism is shed in the stool.  As such, a valuable pearl for prevention in families is to remind family members to be especially diligent about washing hands (for at least 20 seconds) after diaper changes.
• Perspective is a key ally against the fear mongering in the news media. So far,  175 people in 27 states were confirmed to have EV-D68. Most of these patients were tested due to a need for hospitalization. For comparison, think how many children and adults are hospitalized in an average flu season.
• EV-D68 especially attacks babies, infants, children and teens. Most adult immune systems have already seen an immunologic plethora of enteroviral infections, and as such more immunity is present in older people. 
• MOST CRUCIAL POINT- FEVER, ESPECIALLY HIGH FEVERS, ARE NOT TYPICAL FOR EV-D68.  Almost subconsciously, like a pneumonia, one would expect respiratory severity to correlate with fever, but this is not the case. Yes, fever can cause tachypnea but EV-D6 can cause respiratory distress without fever.
• SECOND MOST CRUCIAL POINT: RESPIRATORY DISTRESS IS THE ATTACK MODE FOR THIS VIRUS. AS SUCH, IT IS IMMENSELY HELPFUL TO GAUGE THE CHILD'S RESPIRATORY STATUS BY SITTING AT THE BEDSIDE- SHIRT OFF (TO SEE ABDOMINAL BREATHING, NECK, AND RIB RETRACTIONS)- AND THEN TIME THE RESPIRATORY RATE FOR A FULL 30-60 SECONDS. USE A CLOCK, AS OTHERWISE YOU WILL STOP AT 15 SECONDS BECAUSE IT FEELS  LIKE 30 SECONDS.  This "old school" physical diagnosis pearl yields a veritable cornucopia of information. Plus, to the concerned parents this shows concern as this exam exudes thoroughness and an attention to detail. Try it- you will be amazed how a simple task can go so far. I have lost count of the number of times I thought a patient would need the hospital at triage, or conversely was unimpressed at triage, only to pull a "complete 180" after doing this maneuver. 

Obviously, much like Ebola, I suggest checking with the CDC website about every 2 weeks, especially as these are fluid epidemiological situations that are very much in the public mind.