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Pulp Exposed
o RCT: Root Canal Therapy
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No
Dentin Exposed
No
Rough Edge Present
Primary Dentition
Yes
Yes
Pulp protection:
pulpotomy or
pulpectomy
GIC/composite
Use full coronal
coverage for seal
Provisional
restoration with
GIC/composite
“band-aid” if
symptomatic
Flowchart C: Crown Fracture Injuries
All treatment is ideal and
assumes patient has
manageable behavior.
Recommendations also assume
appropriate preoperative radiographic
survey has been accomplished
No
Direct pulp cap if <24
hours, partial pulpotomy
or pulpectomy / RCT
depending on restorative options
Injury <24 hours
Yes
No
Permanent Dentition
Open Apex
Yes
Consider need
for orthodontic
extrusion or crown
lengthening
surgery; if
nonrestorable then
consider decoronation
Pulp Exposed
Yes
No
Fracture
Subgingival
Yes
No
Dentin Exposed
Yes
No
No further treatment
required
Clinical follow-up in 1 week, clinical and radiographic
follow-up in 6–8 weeks and annually to monitor for
signs of pathology.
Advise parents of possible injury to permanent teeth
Yes
Smooth off edge
and if required
restore with
composite
Direct pulp cap
for small
exposure,
otherwise partial
(Cvek) pulpotomy
Restore with composite as appropriate
Clinical and radiographic follow-up in 4 weeks to monitor for signs of pathology.
Partial
(Cvek)
pulpotomy
Teeth with immature apices may require apexification
Provisional
“band aid”
if symptomatic
Smooth off rough
edge
Roughened Edge
Yes
No further treatment
No
No
required
o GIC: Glass Ionomer Cement
Reproduced with permission of the American Academy of Pediatric Dentistry
Anne O’Connell, Andrew Spading, Trauma and Sports Dentistry (Chapter 9), pg. 177–190. In: The Handbook of Pediatric Dentistry, AAPD, 5th Ed.,
Nowak and Casamassimo, 2018.
Trauma Treatment Algorithms, Chapter 9, Fig. 1-5, pg. 183–85
Clinical Cases inPediatric Dentistry 179
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Flowchart D: Lateral Luxation/Extrusion
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Primary Dentition
Tooth is aspiration risk
or severe extrusion or
severe luxation of crown
in labial direction (>3 mm)
Yes
No
Tooth causing occlusal
interference
Yes
No
Allow for spontaneous
repositioning or
reposition and splint or
consider extraction
Follow up in 2 weeks, 6–8 weeks, 6 months and annually.
Advise parents of possible injury/damage to permanent teeth
Extract and advise
parents of potential
damage to
permanent tooth
Reduce interference
by grinding,
reposition and
splint or extract
All treatment is ideal and assumes
patient has manageable behavior.
Recommendations also assume
appropriate radiographic survey
Permanent Dentition
Surgical or
orthodontic
repositioning.
Stabilize with splint.
Suture lacerations
Monitor response to sensibility tests.
In severe displacement, Ca(OH)
pulpectomy within 2 weeks then
endodontic therapy
Tooth can be
repositioned with digital
manipulation
No
Yes
Reposition tooth.
Use passive, physiologic splint
(e.g. fishing line or light stainless
steel wire) for 2–4 weeks.
Increase splinting time if significant
alveolar fracture.
Suture lacerations
No
2
Rx: chlorhexidine rinse, analgesics
Follow up in 2 weeks, 6–8 weeks, 6 months
and annually up to 5 years.
Monitor for signs of pathology.
Do not probe in area for 4 weeks
Apex open
Yes
Reproduced with permission of the American Academy of Pediatric Dentistry
Anne O’Connell, Andrew Spading, Trauma and Sports Dentistry (Chapter 9), pg. 177–190. In: The Handbook of Pediatric Dentistry, AAPD, 5th Ed., Nowak
and Casamassimo, 2018.
Trauma Treatment Algorithms, Chapter 9, Fig. 1-5, pg. 183–85
180 Clinical Cases inPediatric Dentistry
t.me/Dr_Mouayyad_AlbtousH
Flowchart E: Tooth Avulsion
o OHI: Oral Hygiene Instruction
o RCT: Root Canal Therapy
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Replant immediately
or 15 min-6 hrs
EO time in HBSS
or milk
No
Extra-oral dry time
(EODT) <60 min
No
EODT >60 min
Expect replacement
resorption
Yes
Yes
Open Apex (>1mm)
Yes
Rehydrate in
saline/HBSS
Apex Status
1. Local anesthesia
2. Replant and verify normal position of tooth with PA
3. Place physiological splint 2 weeks
4. Postoperative Instructions
- Rx chlorhexidine mouthrinse b.i.d. for 7 days
- soft food while splint on
- OHI
- avoid contact sports
- if splint loose, contact dentist immediately
5. Rx antibiotics-
- If <8 y/o: penV (20–50 mg/kg/day q 6h for 7 days
- if >=8 y/o and <45 kg: doxycycline (4 mg/kg/day divided
q 12h first day, then 2 mg/kg/day divided q 12h days
2 through 7)
- If >=8 y/o and >45 kg: doxycycline (100mg q 12h first
day, then 50 mg q 12h days 2 through 7)
- if splint loose, contact dentist immediately
6. Tetanus booster required if >5 years since booster
7. Follow up 7–10 days, 4 weeks, 3 months, 6 months, 1 year.
8. Monitor open apex teeth for apexogenesis – if pulp
necrosis apparent, begin revascularization technique
or apexification
9. For closed apex teeth, CaOH pulpectomy within
2 weeks then endodontic therapy
Debride/remove PDL cells gently with scaler or place in
2% NaF for 20 minutes before replanting to slow down
osseous replacement of the tooth
Closed Apex
Rehydrate in
saline/HBSS
Yes
Yes
Replant immediately
or 15 minutes–6 hours EO time
in HBSS or cold milk
Yes
EODT <60 min
EODT >60 min
Expect replacement
resorption
No
No
Splint 2 weeks
Or Do not replant
o PA: Periapical Radiograph
o EO: Extra-oral
o HBSS: Hank’s Balanced Saline Solution
o EODT: Extra-oral Dry Time (it is actually defined in
one of two of the diamond-shaped boxes
Follow up in 2–4 weeks, 3, 6 12 months and annually
Monitor for replacement resorption
Decoronation may be necessary when
infraposition (>1 mm) is seen
o NaF: Sodium Fluoride
o PDL: Periodontal Ligament
o penV: Penicillin
o Rx: Prescription
o y/o: Years Old
RCT with CaOH now or after replantation
Splint 4 weeks
Reproduced with permission of the American Academy of Pediatric Dentistry
Anne O’Connell, Andrew Spading, Trauma and Sports Dentistry (Chapter 9), pg. 177–190. In: The Handbook of Pediatric Dentistry, AAPD, 5th Ed., Nowak
and Casamassimo, 2018.
Trauma Treatment Algorithms, Chapter 9, Fig. 1-5, pg. 183–85
Clinical Cases inPediatric Dentistry 181
t.me/Dr_Mouayyad_AlbtousH
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t.me/Dr_Mouayyad_AlbtousH
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5
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Oral Medicine andOrofacial Pathology
Denise A. Trochesset
Case 1: Eruption Cysts in a Newborn, Natal/Neonatal Teeth ............................................................................... 184
Angus C. Cameron
Case 2: Primary Herpetic Gingivostomatitis ........................................................................................................ 189
Angus C. Cameron
Case 3: Mucocele ................................................................................................................................................195
Denise A. Trochesset
Case 4: Candidiasis .............................................................................................................................................199
Denise A. Trochesset
Case 5: Celiac Disease ........................................................................................................................................205
Denise A. Trochesset
Case 6: Acute Odontogenic Infection .................................................................................................................. 209
Angus C. Cameron
Case 7: Amelogenesis Imperfecta ......................................................................................................................215
Sam Gue
Clinical Cases in Pediatric Dentistry, Second Edition. Edited by Amr M. Moursi.
© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/moursi/pediatrics
183
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CHAPTER 5
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Case 1
Eruption Cysts inaNewborn, Natal/Neonatal Teeth
G. Extraoral Examination
• Minor bruising on the face and scalp due to the
delivery by forceps, but the mouth is not involved
H. Intraoral Examination
Soft Tissues
Figure 5.1.1 Intraoral photograph showing two well circumscribed lesions (arrows).
A. Presenting Patient
• Two‐day‐old Caucasian male
• Newborn infant presenting as an emergency
• There are two well‐circumscribed lesions on the
lower alveolus on either side of the midline. They are
symmetrically placed and identical in size, measuring
approximately 4 mm in diameter (Figure5.1.1)
• The lesions are dark purple but do not blanch on pressure. They are soft and fluctuant, and the base appears
to extend into the bone and is not pedunculated
B. Chief Complaint
• The mother and obstetrician have noticed two purplish
swellings on the mandibular anterior alveolar ridge
following delivery. There are no feeding difficulties at the
moment. The pediatrician requested a dental consult
C. Social History
• Only child to nonconsanguineous parents
Middle class family
•
D. Medical History
• Review of medical history reveals no significant
findings, no known drug allergies, no medications.
Child was born at term with a birth weight of 4200 g
(9.25 lb). Delivery by forceps with a prolonged labor
but good APGAR scores (8 and 10)
E. Medical Consult
• Not applicable
F. Dental History
• Not applicable
Hard Tissues
• No significant findings
I. Diagnostic Tools
• No other investigations are required
J. Differential Diagnosis
Inflammatory Hyperplasias
•
Fibrous epulis/pyogenic granuloma
Neoplasias/Tumors
• Congenital epulis/granular cell tumor of infancy
• Melanotic neuroectodermal tumor of infancy
• Congenital epithelial tumor
Developmental Anomalies/Hamartomas
• Eruption cyst/hematoma
• Bohn’s nodules/dental laminar cysts
• Dentigerous cyst/odontogenic keratocyst
• Lymphangioma
• Hemangioma
• Vascular malformation
• Natal/neonatal teeth
184 Clinical Cases inPediatric Dentistry
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BACKGROUND INFORMATION 1
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Natal andNeonatal Teeth
• A natal tooth is present at birth (Figure5.1.2),
whereas the neonatal tooth erupts within a
month of delivery. In almost every case, it is the
normal primary tooth that has appeared early
and not a supernumerary tooth. Therefore, the
loss of a natal or neonatal tooth represents the
loss of the primary tooth but should not affect
the development of the permanent successor
• The incidence of natal teeth is between 1 : 2000
and 1 : 3500 live births. There are no accurate
figures on the incidence of neonatal teeth
• Treatment options depend on the degree of
mobility of the tooth and the risk that the tooth
will exfoliate. It is important to remember that
only five‐sixths of the crown of a primary
incisor has formed at birth; hence, the mobility
of the tooth. Despite the theoretical risk, there
has never been a reported case of aspiration of
natal or neonatal teeth
• If the tooth is excessively mobile, if there is
ulceration of the tongue, or there are feeding
difficulties, then it may be extracted
• When extracting natal or neonatal teeth, it is
essential to remove the dental papilla (pulp). If this
is left behind, hard tissue or even a root may form
• Local anesthesia is usually not required and the
airway must always be protected
• See Chapter1, Case 1 for more on natal teeth
ORAL MEDICINE ANDOROFACIAL PATHOLOGY
K. Provisional Diagnosis andProblem List
Provisional Diagnosis
• Eruption cysts (see Fundamental Point 1)
• Natal/neonatal teeth (see Background Information 1)
Problem List
• Bilateral swellings on the alveolar ridge in a newborn
L. Comprehensive Treatment Plan
• Reassurance and monitoring
• If teeth erupt, extraction or monitoring
M. Prognosis andDiscussion
• The cyst will typically resolve with the eruption of the
new tooth and there is usually little need to surgically
drain these lesions unless there is an acute infection.
Chronically infected eruption cysts are rare because
drainage would allow for eruption of the tooth and
resolution of any infection. Parents are usually more
worried about the appearance of the condition and
are best reassured that the condition will resolve
spontaneously
• The premature emergence of a primary tooth is of
little cause for concern except that root development will not be accelerated and so the tooth is
likely to show increased mobility. A major concern is
to ensure that the mother can adequately breastfeed the infant without pain or trauma to the nipples. This is usually not a problem if the tooth is in
the mandibular arch as the tongue will protect the
nipple during feeding. If there is ulceration of the
ventral surface of the tongue or the tooth is excessively mobile, then consideration should be given
toits removal
Figure 5.1.2 Intraoral photograph of natal tooth.
Complications
N.
• Infection of the cyst
• Misdiagnosis with the possibility of a vascular lesion
and massive hemorrhage when the primary tooth
erupts or if there is surgical intervention
• Aspiration or swallowing of mobile teeth
• Riga–Fede disease: an ulceration affecting the ventral
surface of the tongue in infants, caused by continual
protrusive and retrusive movement of the tongue over
the lower incisors or natal/neonatal teeth. It typically
presents between one month and one year of age.
Treatment options include monitoring the ulcer only,
smoothing of the incisal edge of the offending tooth,
or extraction. See Chapter1, Case 1 for more on
Riga–Fede disease
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Clinical Cases inPediatric Dentistry 185
CHAPTER 5
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FUNDAMENTAL POINT 1
Diagnosis ofEruption Cysts
• The eruption cyst or hematoma is an extremely
common variation of normal eruption and not
considered to be pathological unless the lesion is
infected. The cyst represents an enlargement of
the follicle around a newly erupting tooth.
Because natal and neonatal teeth are common, it
is not unusual to see an eruption cyst in a newborn infant. An eruption cyst must not be confused with a vascular lesion. To test this, apply
pressure to the lesion to determine whether the
area changes in color because of any blood
emptying. Lesions that are bilateral and symmetrical are almost invariably benign and histopathology is not required
• The most common lesions that may mimic eruption cysts in a newborn include vascular anomalies
(hemangiomas or lymphangiomas), neuroectodermal tumors of infancy, or other odontogenic cystic
lesions. A case has been reported of an odontogenic keratocyst mimicking an eruption cyst in a
19‐month‐old infant (Chiang and Huang 2004)
186 Clinical Cases inPediatric Dentistry
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Self‐Study Questions
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ORAL MEDICINE ANDOROFACIAL PATHOLOGY
1. What is the difference between a natal tooth and
a neonatal one?
2. What happens if a neonatal tooth is lost soon
after birth?
3. How is a natal tooth extracted?
4. What is Riga–Fede disease? How is treated?
Answers are located at the end of the case
Clinical Cases inPediatric Dentistry 187
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