Dental therapist Melanie Joyce summarises advice on the treatment of pain and sepsis in the primary dentition
If left untreated, dental caries in deciduous teeth can lead to pain and infection. The acute phase of infection can have systemic effects on the child and, in rare cases, can be fatal. Fayle et al 2001 state that caries and the subsequent pain can have a detrimental effect on the child’s nutrition, sleep patterns, behaviour and aesthetic appearance. Managing pain should be the first priority when providing care for paediatric patients. The SDCEP 2010 advise to avoid an extraction for a child – if it is their first visit – to prevent future anxiety surrounding dental treatment and to ensure the child returns for definitive treatment.
Assessment and treatment
A thorough history of the presenting pain should be taken. To determine whether the pulp has been reversibly or irreversibly inflamed, it should be asked if there is pain to cold or sweet, does the pain go after the stimulus has been removed?
If the answer is yes to those questions – and the tooth is not tender to percussion and it is difficult to localise the pain – it is likely the pulp is reversibly inflamed and therefore the advised treatment would be to restore the tooth or place a temporary dressing with a view to restore the tooth at a later date.
However, if the answer to the initial questions was no – and the tooth is tender to percussion with a well-located spontaneous pain to hot or cold that does not resolve when the stimulus is taken away, it is likely that the pulp is irreversibly inflamed.
This is also the case if the pain wakes the child in the night. To decide the best treatment, it should be considered whether the child is co-operative enough to have operative treatment. If the child is pre cooperative, the tooth should be dressed with a lining of corticosteroid antibiotic paste, then a temporary dressing; pain relief can be prescribed by the dentist and a referral made for the child to be seen for extraction under sedation or general anaesthetic.
If the child is cooperative, then the tooth should be dressed with a lining of corticosteroid antibiotic paste, then a temporary dressing and pain relief can then be prescribed by the dentist.
The options for the tooth should then be discussed with the parent and child, if appropriate, and an appointment for either pulp therapy or extraction made. If the child presents with a swelling around a tooth tender to percussion, spontaneous pain that awakens the child in the night and sometimes malaise, then this is a dental abscess and should be treated initially with antibiotics and pain relief by the dentist.
Again the co-operative ability of the child should be assessed. If the child is pre co-operative or has multiple abscesses, they should be referred for extractions under sedation or general anaesthetic and, if the child is co-operative, pulp therapy or extraction can be carried out in the general dental environment.
It’s not just caries that can cause pain and infection in children. Acute pericoronitis can occur when teeth are erupting. Acute pericorinitis is caused by infection under the gingival tissue covering a partially erupted tooth. Pain can be associated with erupting teeth in both primary and permanent teeth in children.
The SDCEP advise initially on presentation to determine if the child’s airway is compromised by the swelling. If the child is unable to swallow their own saliva or they are unable to push their tongue forward out of their mouth, this indicates that the airway is compromised and the child should be sent immediately to emergency care via NHS 24 or call 999.
If the airway is not compromised, pain relief should be advised, along with soft tooth brushing around affected area and rinsing the mouth after food.
The SDCEP (2011) suggest that most dental pain can be relieved effectively by non-steroidal anti-inflammatory drugs (NSAIDs) due to their ant inflammatory activity. Paracetamol is also effective in the management of dental or post-operative pain, but has no demonstrable anti-inflammatory activity.
Aspirin is a potent and useful NSAID but should be avoided in children. Pyrexia in children can be managed using paracetamol or ibuprofen. Both drugs can be given alternately to control ongoing pyrexia without exceeding the recommended dose or frequency of administration for either drug.
Avoid the use of all NSAIDs in children with a history of hypersensitivity to NSAIDs, including those in whom attacks of asthma, angioedema, urticaria or rhinitis have been precipitated by an NSAID.
All NSAIDs cause gastrointestinal irritation and therefore avoid in patients with previous or active peptic ulcer disease. NSAIDs might impair renal function and so use with caution in patients with renal, cardiac or hepatic impairment.
Dental pain is one of the most common reasons a child presents at the dental practice and can have a detrimental effect on the child’s life. It is important that the dental team manage the child’s pain and disease appropriately.
Treatment of the child’s pain will depend of the aetiology of the pain although the initial management is often the same. It is important that the dental therapist understands the different aetiological causes of dental pain to aid its correct management.
Fayle, S. A., Welbury, R.R., Roberts, J.F. 2001. British Society of Paediatric Dentistry: a policy document on management of caries in the primary dentition. International Journal of Paediatric Dentistry, 11, pp.153-157.
Scottish Dental Clinical Effectiveness Programme. 2010. The Prevention and Management of Dental Caries. Dundee, SDCEP.
Scottish Dental Clinical Effectiveness Programme. 2011. Drug Prescribing For Dentistry
Dental Clinical Guidance. Dundee, SDCEP.
Currently, the dental therapist cannot prescribe pain relief, however it is useful for the dental therapist to know what drugs are relevant for the relief of a child’s dental pain.
Melanie Joyce qualified as a dental therapist in 2010 after six years as a dental nurse and currently works in a mixed general practice in Leeds. She is an opinion leader for Ivoclar Vivadent and is also the North East representative and secretary elect for the British Association of Dental Therapists (BADT). Melanie is currently furthering her studies by completing a BSc in Dental Studies at UCLan.