Odontogenic Infections in Pediatric Patients – PediaCast CME 110
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Show Notes
Description
Dr Homa Amini and Dr Beau Meyer visit the studio as we consider dental infections in children and teenagers. We explore their cause, symptoms, and management… along with prevention strategies and antibiotic stewardship. We hope you can join us!
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Topic
Odontogenic Infections in Pediatric Patients
Presenters
Dr Mike Patrick
PediaCast and PediaCast CME
Nationwide Children’s Hospital
Dr Homa Amini
Pediatric Dentistry
Nationwide Children’s Hospital
Dr Beau Meyer
Pediatric Dentistry
Nationwide Children’s Hospital
Learning Objectives
At the end of this activity, participants should be able to:
- Define odontogenic infections and explain their common causes in pediatric patients.
- Recognize the clinical signs and symptoms of early and advanced odontogenic infections.
- Describe strategies for management of odontogenic infections, including antibiotic therapy and stewardship.
- Discuss approaches for preventing odontogenic infection.
Links
Dental Care at Nationwide Children’s Hospital
School-Based Dental Care
Antibiotics for Dental Pain and Swelling Guideline
Infection Prevention Practices in Dental Settings
Dental Abscess – NIH Stat Pearls
Disclosure Statement
No one in a position to control content has any relationships with ACCME-defined ineligible companies.
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In support of improving patient care, Nationwide Children's Hospital is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the American Nurses Credentialing Center (ANCC), and the Accreditation Council for Pharmacy Education (ACPE), to provide continuing medical education for the healthcare team.
AMA Statement
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ADA CERP Statement
Nationwide Children’s Hospital is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to the Commission for Continuing Education Provider Recognition at CCEPR.ADA.org. Nationwide Children’s Hospital designates this activity for 1.0 continuing education credit.
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Episode Transcript
[Dr Mike Patrick]
This episode of PediaCast CME is brought to you by Pediatric Dentistry at Nationwide Children's Hospital.
Hello everyone and welcome once again to PediaCast CME. We are a continuing medical education podcast for healthcare providers.
This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. It's episode 110.
We're calling this one Odontogenic Infections in Pediatric Patients. We want to welcome all of you to the program. So, today's topic is an important one because dental infections are one of the more common things that we see in children.
And they can sometimes be serious. So, we don't want to overlook them because it is important to treat them appropriately. While many start as simple dental caries or gingivitis, they can quickly progress if not recognized and treated right.
This week we're going to explore the causes, symptoms, management, and prevention of odontogenic infections. From early signs to advanced complications and from antibiotic stewardship to prevention strategies, there is a lot to cover. So, whether you're a primary care provider, work in an emergency department, or you're a pediatric dental professional or a dental professional who sees kids.
You know, a lot of community dentists see kids. So, I think that this will be helpful information for you in terms of updated recommendations for taking care of little teeth. This episode will be packed with practical insight for keeping those young mouths healthy.
Our guest this week is a terrific one, Dr. Beau Meyer. He is a pediatric dentist at Nationwide Children's Hospital. We also have a returning host; guest host is Dr. Homa Amini. She's also a pediatric dentist and a professor of pediatric dentistry at the Ohio State University College of Dentistry. And she is also at Nationwide Children's Hospital. She always does a great job with dental topics.
We really appreciate her efforts in creating the dental episodes of our podcast. Dr. Beau and Dr. Homa will be with us shortly. I do want to remind you after listening to this episode, be sure to claim your free Category 1 continuing medical education credit.
Really easy to do. Just head over to the show notes for this episode at pdacastcme.org. You'll find a link to the post test in the show notes.
Follow that link to Cloud CME. Click on the materials tab. There you'll find the post test.
Take and pass that. And the Category 1 credit is yours. Really, really easy.
And we do offer, again, free Category 1 credit if you listen to this podcast and take the quiz. We offer that credit to many pediatric professionals, physicians, of course, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. And since Nationwide Children's is jointly accredited by all of those professional organizations, it's likely we offer the exact credits you need to fulfill your state's continuing medical education requirements.
Of course, you want to be sure the content of this episode matches your scope of practice. Complete details are available at pdacastcme.org. Also, the information presented in every episode of our program is for general educational purposes only.
We do not diagnose medical conditions or formulate treatment plans for specific individuals. Also, your use of this audio program is subject to the PediaCast CME Terms of Use Agreement, which you can find at pdacastcme.org. So, let's take a quick break.
We'll get Dr. Homa Amini and Dr. Beau Meyer settled into the studio, and then we will be back to talk about odontogenic infections in pediatric patients. It's coming up right after this.
Dr. Beau Meyer is a pediatric dentist at Nationwide Children's Hospital and an associate professor of pediatric dentistry at the Ohio State University College of Dentistry. He also serves as a research fellow with the Research and Policy Center at the American Academy of Pediatric Dentistry, and he serves on the editorial boards for the journals Pediatric Dentistry and the Journal of Dental Education. His research interests relate to the use of oral health services with a focus on improving access to dental care for Medicaid-enrolled children. So, let's offer a warm PediaCast CME welcome to our guest, Dr. Beau Meyer. Thank you so much for stopping by the studio today.
[Dr Beau Meyer]
Thanks for having me. I really appreciate the opportunity.
[Dr Mike Patrick]
And we appreciate you taking the time to do it. We also have a returning guest host this week. Dr. Homa Amini is a pediatric dentist at Nationwide Children's and a professor of pediatric dentistry at the Ohio State University College of Dentistry. Her research focuses on perinatal oral health, health literacy, and child advocacy. She's received numerous private and public grants aimed at improving access to dental care for low-income children and pregnant women. So, a warm welcome back to Dr. Homa Amini. With that, we'll let her take over the reins of the episode. Thanks, Homa, so much for putting this one together.
[Dr Homa Amini]
Thank you so much, Dr. Mike. It's a pleasure to be back, and I'm so happy to have Dr. Beau Meyer today with us. So, let's just jump in.
So, my first question for you is, Dr. Meyer, what are odontogenic infections and what are their primary causes in children?
[Dr Beau Meyer]
Yeah, thank you. So, we typically think of odontogenic infections as infections that originate from odontogenic structures. Those would be the tissues that support the teeth, that are the teeth.
So, infections that begin in the teeth and then disseminate to other parts of the body locally inside the mouth and in the head and neck region.
[Dr Homa Amini]
And what typically causes them in children? Like we see a lot of kids coming to our Dental Clinic at Nationwide Children's Hospital that present that. What are the causes, most common causes?
[Dr Beau Meyer]
Yeah, there was a recent paper in this month's edition of Journal of American Dental Association, actually, that suggests that about three quarters of odontogenic infections in a children's hospital originate from dental caries, and about a quarter of infections originate from failed previous dental work. There's a smaller proportion that are oral pathology related. There's a smaller proportion that are dental trauma related.
But the bulk of the source of that infection is dental caries or untreated dental caries, caries that has initiated them, progressed to the pulp of the tooth.
[Dr Homa Amini]
Great. And so how do they typically present? What are their signs that you see?
[Dr Beau Meyer]
Yeah, good question. The things that we would look for that kind of tip our hand to diagnose odontogenic infection would be some swelling around the tooth that can be intraoral, that can be extraoral, redness around the gums. You might see some pus in the area.
On the tooth itself, it's usually pretty obvious that there's a large hole in it, denoting the dental cavity. But sometimes those can be a little bit complicated or a little bit nuanced, especially if that tooth has had previous dental work. It can be sometimes tricky to identify where that source is coming from.
But typically, you're looking for a hole in the tooth and then some swelling, potentially some pus around the tooth, maybe some extraoral swelling involving the cheeks, going towards the eye, going underneath the chin, wherever it might be.
[Dr Homa Amini]
And what are the symptoms that the kids complain about?
[Dr Beau Meyer]
Another good one. So often there's pain initially. Sort of ironically, the pain can kind of dissipate in some instances.
We'll hear sometimes from parents that it used to bother them, but now it isn't bothering them so much, so I think it's better. And then we look in the mouth and we see the hole, we see the swelling, and it's like, oh, this has progressed beyond kind of the point of salvation, if you will. So that pain is a big one.
You'll often get disruptions to sleep or other daily life behaviors, disruptions to eating, things like that. They might just not feel themselves. Sometimes kids have a difficult time communicating that, so it can be tricky to identify what's really going on, especially if something isn't super obvious or if it's one of the more rare instances of infection.
So, pain is usually a good indicator, but not always. And changes to daily life behaviors is another tipping point for us.
[Dr Homa Amini]
I think that's a great point, especially with our children with special health care needs, that sometimes they have nonverbal patients, and they cannot verbalize. And parents wondering what's happening, and it's a good point to maybe think about, maybe there's something in the mouth.
[Dr Beau Meyer]
Yeah, and that reminds me too, sometimes with patients with special health care needs, they might be scratching at a particular part of their face or like really rubbing something, or they might have excessive drooling or things like that. So just the changes from normal baseline in and around the mouth are good indications that something might be going on.
[Dr Homa Amini]
So, what is the current prevalence of autogenic infections in children in the U.S.? If you have data on that.
[Dr Beau Meyer]
That's a good question. I don't have a solid answer on that, but let's step back and just think about dental caries prevalence for a second. We know that dental caries is, and has been for many decades now, a very common chronic condition.
Approximately 50% of 6- to 8-year-old children have had some type of dental caries experience in their life up to that point. And we know anywhere between 10% and 20% of that group has untreated disease. So, I don't know where to put the ballpark of the prevalence of odontogenic infection other than we see it a lot here at Children's, and I'm sure other Children's hospitals and dental practices also encounter it in their practice.
[Dr Mike Patrick]
I would interject and just say, working in the emergency department, it is rare that a shift goes by that we don't see a child who comes in because of dental pain, usually from caries, and often there's an infection associated with it. So, it's one of those things that you see really all the time. I would say one of them, other than viral upper respiratory tract infections, it's probably number two in terms of the most common things that we see in pediatrics.
[Dr Beau Meyer]
Anecdotally, I would tend to agree, based on our on-call experience, kind of rotating in and out of that.
[Dr Homa Amini]
So how are these odontogenic infections diagnosed? Are there imaging or lab tests usually required?
[Dr Beau Meyer]
Another good question. You're hitting the good ones. Often in a dental setting, we would rely on our clinical impression and maybe a local radiograph of that area, so our examination and the radiograph.
In an emergency department setting, there might be additional radiographic imaging that's obtained, a panoramic radiograph, for example. Sometimes, in some cases, a cone beam CT is ordered. Those are maybe less helpful for the mild to moderate cases of these infections, but for the more severe ones that do sort of look like they're compromising the airway or involving the eye or the orbit, those CBCTs can be helpful.
As far as lab testing goes, we don't typically recommend anything in particular, so we don't do culture and sensitivity testing. Those take a while to get back. The results of those take a while to get back.
We don't really do CBCs or blood counts. Those are not terribly reliable indicators for diagnostic purposes, so we're relying a lot on clinical impression, a symptom history, and that radiographic finding to kind of confirm everything, and often that's sufficient for our purposes.
[Dr Homa Amini]
How is this typically managed? When you have a child with odontogenic infection, what are the standard treatment options, and when should a parent take their child to an emergency department?
[Dr Beau Meyer]
Some good ones there too. The primary treatment for odontogenic infection is to remove that source of infection, and we think of that as primarily surgical, but surgical doesn't necessarily always mean to go to sleep, to go to surgery to take the tooth out, or to take the tooth out as an oral surgeon might do. Surgery just in this particular case means remove that source of infection, so that can be an extraction, that can be a root canal in a tooth that is restorable or salvageable, anything to kind of get that infection out, and those would be procedures that are frequently reserved for the dental specialist and profession.
Things that our physician colleagues can do when access to a dentist is challenging or difficult, we can do some antibiotic therapy to sort of control that infection or the spread of that infection, but we would want that to be accompanied by a referral to a dental service. As far as when a parent should take their child to an emergency department, I think if there's fever that is maybe unexplainable, if there's that pain, if there's that swelling that's noticeable on the face or along the gums, those would be nice times to at least go get evaluated in the emergency department, and that's, I think, what we see in our emergency department when patients arrive.
[Dr Mike Patrick]
If I could jump in again really quick, what is your first-line antibiotic that you would use? So, if I'm a physician and I see a kiddo with dental abscess, maybe they have some cheek swelling and they can't get in to see a dentist until the next day or the day after, depending on the challenges in the community, I'm going to start an antibiotic just until they at least get in there. Do you just start with amoxicillin?
Do you have to think about anaerobes in the oral cavity and add clavulanic acid to the amoxicillin?
[Dr Beau Meyer]
Yeah, that's a great question. I think the guidelines would suggest us to try amoxicillin. I would say if you're concerned about an aggressive infection or one that seems to be progressing fairly rapidly or the swelling has gotten worse throughout the day, you might consider adding that anaerobe coverage, so something like Augmentin might be preferable in patients who are not allergic to penicillin.
If there is an allergy, clindamycin is our preference, and then follow those dosing schedules, and I would prescribe a five- to seven-day course. We do want to be responsible about our antibiotic prescriptions, so try not to prescribe too much or use them too often or for too long, and that's where that referral or connection to a dentist can be super helpful for these individuals.
[Dr Homa Amini]
That was actually my question about the dosages and the length of antibiotics. Sometimes we have patients who have been prescribed antibiotics by their physician since they came to the emergency department or their office, and they come to us and they're in the middle of the course of their antibiotic treatment, and we take the source of infection out. We extract the tooth out and get it out.
What recommendation do you make to the patient? Because I always ask this question, shall I continue with my antibiotic, or can I stop it? Do I still need to take this?
What is the current practice?
[Dr Beau Meyer]
I recommend that they finish the course that was prescribed and take it as prescribed, so if it's two or three times a day for five to seven days, they should finish that course of antibiotics. I won't say never, but very rarely would prescribe an additional course and would usually require some type of reevaluation after the surgical procedure if I needed to consider an additional course, but if they get started on the antibiotic by the physician, we see them a couple days later to get the tooth out or remove the source of infection, I still recommend that they finish the original course of antibiotics that was prescribed.
[Dr Mike Patrick]
Okay, I have another question. I'm so sorry. No, you're good.
Because this is really, as I said, it's one of the more common things that we see. If a kid comes in with just the dental pain and you don't really see much swelling and they don't have a fever and they're going to be able to get in to see the dentist the next day, then do you really need to do an antibiotic at all?
[Dr Beau Meyer]
This is a perfect question, and I love it. We do not recommend antibiotics in those instances. So, we typically like to reserve our antibiotic prescriptions when there are signs of systemic involvement.
So, if you see that swelling or if they're febrile, those would be sort of the two indicators that trip us towards an antibiotic prescription. If it's just dental pain, we try to do pain management until they can get to the dental clinic or the dentist that next day. And there are recent guidelines on odontogenic pain and pain management, postoperatively even, and both of those from the American Dental Association and sort of a well-done clinical guideline group suggests using NSAIDs or nonsteroidal anti-inflammatories like ibuprofen as the first-line agent.
And if that is not cutting it, to give ibuprofen and Tylenol together every six to eight hours as needed. And if that can manage that pain until they can get to the dentist, that's usually sufficient and also avoids the antibiotic coverage that may be not indicated.
[Dr Homa Amini]
I think along the talking about the pain management, so the opioids are not something that we consider in dentistry because it's not indicated, correct?
[Dr Beau Meyer]
Correct, correct.
[Dr Homa Amini]
Yeah, I think this is like two great points here. One is like toward antibiotic stewardship to make sure we do not misuse it and also with the pain management. Something that I see a lot in our clinic that with kids that have been in pain for a long time and they come in and the parents have been giving them pain medication for a long time and I think like the Tylenol and like what are the concerns with the prolonged use of those pain medication for the families and for the children?
[Dr Beau Meyer]
I think the chronic use of those medications should probably be avoided. We don't want to upset gut metabolism or liver metabolism so they can cause a lot of GI or liver issues if we're using them for a long time. So, we want to kind of limit the use of this to three, maybe five days.
We don't want them to be on this pain management protocol for a super long time. We'd rather get them in and try to address the source because if we can get rid of that source, then they can stop taking the medicine. They can be free of that pain, free of that infection.
They can go on with their life. We can manage the other things that might happen after that tooth is taken out. We can manage that later.
But I think addressing that concern as close to the moment as it's actually happening is probably the best way to go.
[Dr Homa Amini]
I think here at Children's Hospital, our Poison Center probably see a lot of, Dr. Mike, correct me, liver toxicity because of the overuse of Tylenol and acetaminophen. I think that's something that we have a lot of concern about with the prolonged use of that.
[Dr Mike Patrick]
Yeah, especially an acute overdose is particularly worrisome for the liver. I don't know that we have as much information about prolonged use. You know, there are a lot of kids with chronic pain stuff.
And I think the jury's out on that one. But certainly, taking too much Tylenol at one time can damage the liver in a real quick fashion. We want to avoid that.
Yeah, yes.
[Dr Homa Amini]
So, what are the potential complications if an odontogenic infection is left untreated?
[Dr Beau Meyer]
Oh, this is a wide-ranging response. But I think sort of in that early untreated stage, the initial spread will spread to other anatomic spaces. So, involving the buccal space of the cheek, the infraorbital space or canine space below the eye, the submental or submandibular space underneath the chin.
If those start to cross the midline or involve the eye, that can be some serious problem. If untreated or unaddressed, that can progress to cavernous sinus near the brain and cause lots of problems with brain abscess and those kinds of things. It's sort of at the extreme end, but there are very well-documented cases of that happening with a tooth infection being the originating source.
Decades ago, now, the Deamonte Driver story got a lot of attention, and that was a brain abscess as a result of a dental infection. I saw within the last couple of years, there was an NFL player, a former NFL player who died, and one of his listed on his cause of death was an odontogenic infection or brain abscess secondary to odontogenic infection. So, these things do happen.
They are thankfully rare, but that's the extreme end of what can happen. I think those are the main things that if it goes untreated. And if I can pivot to what some of the things that can happen if a following treatment are kind of that swelling, if there is some can linger a little bit, it might take a little bit longer to resolve.
If it's a primary tooth, you risk space loss in that area, so you might introduce sort of orthodontic problems down the road. If it's a permanent tooth, you've got to think about a static replacement. If it's a front tooth, what's the space management plan?
If it's a back tooth, those are some of the main ones, I think. And then on the extreme end of that, following a procedure sometimes, in the rare example, you might get osteonecrosis or unexplained sort of bony pain, and that can be a thing that happens after tooth extraction. So again, those are more rare things that happen, but those kind of are related to the odontogenic infection.
[Dr Homa Amini]
And I get this question asked by the families, like if the kid had abscess, is it going to affect their permanent tooth that is developing?
[Dr Beau Meyer]
Yeah, so that's kind of well documented in the history of dental textbooks that we learn in dental education. But there are some potential disruptions to tooth development of the permanent tooth, if the primary or baby tooth is infected. Those can be any number of things, from color disturbances as the tooth is developing, you know, when it erupts into the mouth and we see it for the first time, it might have a slightly yellow or brownish hue that the other permanent teeth don't have.
Some infections can alter the eruption path of permanent teeth, so it can send it in a different direction than it otherwise was going. Those, I think, are two of the more common ones that I would see as far as disturbances to the permanent teeth. I have encountered cases of infected primary teeth in altering the eruption path have changed sort of the shape of the root.
So sometimes those, I would count that as rarer, but that can be a potential thing as well. So, it's not to neglect the treatment of the primary tooth infection, we want to address that. So, we can potentially avoid or mitigate some of these possibilities.
[Dr Homa Amini]
Thank you. I think you made a couple of great points about in children, because of the differences in anatomy, the spread of infection can happen really quickly and fast and can become a life-threatening situation. And I think those are the cases that we typically admit.
And most of the time they come to the emergency department and Dr. Mike sees them and get them admitted for us so we can take care of them. But it can become serious quick and fast. And thank God we have antibiotics to manage it.
But I think if we didn't have it, many people probably would have died more than what we currently have like back in the ages. So sometimes we see patients that come into our clinic, and they have signs and symptoms of odontogenic infection. But when you look in their mouth, you don't see anything.
So, what are potential, maybe not odontogenic conditions that can have similar presentations that we should be aware of?
[Dr Beau Meyer]
Yeah, this is an interesting one. We see this more often than I might think in our clinics. But you're right, sometimes they'll have a facial swelling near their cheek, and you look inside their mouth and the teeth look pristine and you're like, I'm struggling to think of something here.
Some of the things that kind of raise towards the top of that differential might include things like lymphadenitis, if there's a lymph node bundle in that area. Maybe some viral infection that is presenting as a facial swelling. If it's near the cheek, maybe like a parotitis, salivary gland inflammation.
Sometimes that may or may not be related to having like a stone blocking the duct, not an actual stone, but like a blockage of the salivary duct. So, the saliva is just backing up and that can be acutely painful too. And then one of the things that we learn in residency is cat scratch disease and it's not something that I think I give a lot of like thought to a lot, but I've seen it more often than I care to admit where patients, they come in with swelling in their cheek, again, their teeth look pristine.
We can't explain anything from an odontogenic thing. We're trying to figure out what's going on and you might have a little tiny nick on their face or somewhere else and you're really just trying to figure out like what's happening. And you ask the question; do you have any pets?
And they say, yes, we have a cat. Did the cat scratch you recently? Yes.
Or did you tussle with the cat? Sometimes that can happen. And again, it kind of, it doesn't seem like a real thing to me sometimes, but I've seen it more than I care to admit.
[Dr Mike Patrick]
It's actually more kittens than adult cats that are more likely to do it because you think, oh, it's a cute little kitten that can't cause any problems. But yeah, we definitely do see that in quite large lymph nodes often when that happens. Yeah, that's very interesting.
[Dr Homa Amini]
Great. So, what are the most effective prevention strategies that we have?
[Dr Beau Meyer]
So, considering that three quarters of odontogenic infections are related to dental caries and an additional almost a quarter are related to failed dental treatment, which was probably initiated because of dental caries, preventing dental caries seems to be like a good starting point. And this is where in our new patient exam visits or our hygiene preventive visits where we like to hammer home a couple things for prevention, things that we can do at home that can help us prevent cavities from forming. And one of the best ways we know how to do that is the use of twice daily use of fluoride toothpaste over the counter.
You can pick your favorite flavor, your favorite brand, your favorite variety. Use that, but make sure that it has fluoride in the toothpaste. That's, I think, the number one thing, like home care thing that I would recommend.
And then another home care thing that we typically talk about, or I typically talk about with patients is establishing good routines and that includes dietary routines and healthy bedtime routines for our infants and toddlers. So, for dietary routines, there are obviously exceptions to this rule. But one of the things I like to address is trying to limit the amount of grazing we do in terms of how often we're eating or consuming things and focus our consumption on well-defined periods of time within our day.
And for infants and toddlers, that can be five or six times as they're transitioning to new diets or solid foods. That's the breakfast, the morning snack, the lunch, the afternoon snack, dinner, and then maybe something after dinner. But if you can avoid that after dinner snack, then you really are setting yourself up with a good sort of consumption pattern that can promote oral health.
There are certainly exceptions to that rule based on medical needs or nutritional needs or other things. But that, as a starting point for discussion, is usually where I begin. And then as far as healthy nighttime routines, I subscribe to the brush book bed routine recommended by AAP, and I add two Bs on front of it.
So, it's the bath, it's the bottle or breastfeeding, then it's the brush book and bed. So, the five Bs rather than the three, but it's easier to remember the three. So, establishing some sort of routine so that there's a nighttime feeding if you need it, and that can be bottle feeding or breastfeeding, then the bath time.
And those two things don't have to happen in a particular order, but then after that, brush book bed, and that's a good routine. And those can set kids up for good behaviors, good patterns, kind of ward off early onsets of disease. And a lot of parents will ask, well, why do I have to do this for my child who only has a couple teeth?
And the real purpose, I think, is just to establish that routine. Kids and infants don't like it. My son, he was notorious for hating me brushing his teeth for the solid first 18 months of his life, but now he'll sit, and he'll just let me do it, and there's no real crying, no real fighting through it.
So, establishing that routine is what I attribute to be somewhat successful in doing that. So those routines are helpful. And beginning that fluoride toothpaste use at the time that the first tooth erupts.
So, when you start to see teeth, you can use just a little bit. A little bit goes a long way but using that grain of rice size amount or that smear on the first three bristles of the toothbrush to start brushing that teeth. Again, you're just setting routines, and if you can get into that habit, it's a nice way to go about that.
And my last tip on this is parents have a lot of questions. Well, what if I'm a single parent or if I'm the only one responsible for this child's nighttime routine? How do I wrangle that?
How do I brush their teeth? When they're infants, I like using a diaper pad or a changing pad just on the floor after the bath. So, you pop them out of the bath, set them on the floor to dry them off.
You're changing their diaper, you're putting their pajamas on, you're brushing their teeth, and they're already on that changing pad. Just keep them laid back and then set their head in your lap or orient yourself so that their head is in your lap and you can brush their teeth pretty easy. So, the diaper changing pad is pretty effective.
Cooler adjunct to developing those routines.
[Dr Mike Patrick]
You know, a lot of information is out there on fluoride, and parents, I'm sure, have lots of questions for you. You know, using that small amount of fluoride toothpaste is a great idea, as you mentioned. What about fluoride supplements, fluoride in the drinking water?
Is that safe? I'm sure parents have lots of questions, and pediatricians actually get asked those questions. And we want to say, well, ask your dentist.
But we also want to be helpful and provide some guidance.
[Dr Beau Meyer]
Yeah, very good. You ask the tough questions, which are good. I'll answer the supplements first because I think it's technically easier.
The guidelines still have supplements listed in them as a recommendation for children who live in non-fluoridated communities, which may be on the rise in the near future. But if they live in a community with water fluoridation, they likely do not need fluoride supplementation. And for most of Ohio, not all of Ohio, for most of Ohio, their community water fluoridation still exists.
I know it's on the table for discussion at the legislative level, but so most of Ohio children probably don't need that fluoride supplementation. But if they live in a community or are using well water, if they live in rural areas, you might ask to have that tested. And if it comes back with no fluoride in it, you might consider prescribing.
And there's a table in our guidelines that recommends the dosing schedule for that.
[Dr Mike Patrick]
If you live in an area with well water, there is the possibility that there's a lot of fluoride in the drinking water, which is, it's not common, but it can happen. And then if you supplement it on top of natural fluoride, then you really could get fluorosis of the teeth.
[Dr Beau Meyer]
And that would be a concern. So having that water tested, and my experience has been that most people with well water have had it tested at some point, and they know, but if they've just purchased that house, they might not have that report and they might not know. So having it tested, just making sure that they know what's in their water, if they're on a well water system.
Also buy water in the store that has fluoride in it, correct? Correct. And that is usually very clearly marked as well.
And it's often branded or sold as nursing water or infant water. But you would see it on the packaging that it has fluoride in it.
[Dr Mike Patrick]
And that would be okay to do as long as you're using exclusively that water for making bottles and such.
[Dr Beau Meyer]
Yep. And to your question about is fluoride in the water safe? The overwhelming science on this topic is that yes, it is in the United States because we use it at the EPA regulated level of 0.7 parts per million. That level of fluoride is safe and effective as a community or population health strategy for preventing areas where things kind of get a little bit concerning. As you point out, is when those concentrations get higher and are maybe unregulated or they're too much, that's when we would be concerned. But at the current regulated level, it is safe, it is effective.
And if I may tangent or divert off this a lot right now is a lot of the discussion that seems to happen or a lot of the questions or maybe pushback I get on this is not necessarily that families or parents are disagreeing with the strength of the evidence or what the benefits of fluoride. It comes down to sort of a navigating a conversation of personal choice of them choosing what they want to include in their diets or what they're consuming. And that can be a very difficult conversation to have, and it can take a long time to have that conversation.
So, I have patients in my practice who are like this, and I don't kick them out. It's like, okay, we're going to have this conversation over the course of months, and we'll try to work within these guardrails that we've kind of set up. And there may come a time where, you know, I might not be able to help you within those guardrails and I can try to find somebody who can, but I'm willing to kind of walk that tightrope with you.
This is what the evidence says. This is what the child's presenting condition is like. How can we navigate that within the context of your overall wishes?
And often there's a solution, but sometimes there's not. And that's just a really hard thing to do. And, you know, as pediatricians, I'm sure you feel like your visits are already very packed information and that these conversations probably can't happen for very long.
But I would try as much as you can to not squash that conversation, to use it as a starting point for future conversations. And that can be a pretty helpful strategy and makes, I think, parents feel like their voices are being heard.
[Dr Mike Patrick]
Because at the end of the day, the parent is just trying to do the right thing for their kid. Absolutely. We encounter that with vaccines all the time, you know, where we are definitely pro immunizations and it can be frustrating talking to parents who come across anti-vax literature, anti-science stuff.
But at the end of the day, they're really just trying to do what's best for their kid. And in our opinion, and I think it's evidence-based, that would be fluoride and immunizations.
[Dr Beau Meyer]
Yeah, I think there's a lot of overlap with the fluoride conversation or the fluoride hesitancy, if we'll call it that. So, yeah, we're in the same boat. And you want to respect that they're just trying to do the best.
But sometimes the best is murky.
[Dr Homa Amini]
Yeah, I think maybe note that you talked about the home instructions and things that family can do at home. But strategies that are more community-based or professionally delivered-based. I mean, you talked about community-based community water fluoridation, which is one of the top 10 public health instruments for us.
What other strategies are community-based available?
[Dr Beau Meyer]
Yeah, so for decades now, since early 2000s, late 1990s, the specialty organizations within dentistry and pediatrics have recommended that children establish a dental home early in life. And we recommend the age one visit. And I get a lot of questions like, why do I need to do this?
And often that is to establish this relationship so that we can have these conversations about how to take care of teeth, how to establish good dietary patterns and practices. It's a lot of conversation and communication rather than it is technical skill or technical procedural elements. And that can be a really helpful strategy.
So, we like to establish that early visit by age one or shortly thereafter. And that can be a good thing to do and set children on the right path or the right trajectory for optimal oral health. If that is a difficult thing to accomplish because access to dental care is challenging, we know that, then working with pediatricians to provide those preventive oral health services that are within the realm of medicine, I think, are a good alternative to not being able to get to a dentist.
So, there are a lot of pediatric practices that are applying fluoride varnish within the well child visit setting. And we recommend that too, especially if they can't get to a dentist. So, we support our pediatrician colleagues providing these preventive oral health services.
I also have an affiliation with Partners for Kids. And one of the things that we're trying or testing right now is to integrate a dental hygienist within a primary care medical team. And we have to sort of flex but follow the scope of practice regulations for hygienists in the state of Ohio.
And I am very excited about our pilot project. And we've been pretty successful at doing this. And it's really exciting because we're, as part of the regulation, we have to schedule that patient with the dentist for a six-month follow-up.
So, our focus has been on the one- to three-year-old children, the group that's sort of chronically underserved or has challenges with access. And in a day-week capacity, the hygienist has basically been able to integrate herself into the medical care team and see what would be a full schedule of hygiene patients in a dental practice. So, she's been able to see eight to ten patients in an integrated setting.
And the most exciting thing is she's scheduling the visits. And we've been doing the pilot long enough that the kids are starting to show up at the dental clinic here at NCH. And we're starting to see sort of the benefits of this integrated project to try to get that connection to the dentist earlier.
So, it's really exciting. I think there's just a lot to like about that. And, you know, we're interested at PFK to try to scale that to other practices.
It can probably be a little bit challenging in a private practice setting to find that dental partner. But we're lucky here at Children's that we have a dental division that works with the primary care division and the two. There's a lot of synergy there.
So, all of that to say that this early access to dental care is important to establish these good habits, these good behaviors, these good trajectories to prevent all the bad things that we let off this podcast with today. We're trying to ward off these infections. We're trying to prevent these things from being problems for families and children.
[Dr Mike Patrick]
You know, since we're really have a target audience for this podcast of pediatric providers, what are your thoughts of collaborations between community physicians and community dentists in terms of that model? Like here in Columbus and as we think about Medicaid populations and it's a little easier, I think, to integrate those two. But when they're both like, you know, the medical side is a private practice and the dental side is a private practice, it does seem like you could have some kind of relationship there.
You know, stick a dental chair in the primary care office and let the dentist send their dental hygienist over, you know, a couple days a week or something like that. Is that doable?
[Dr Beau Meyer]
That's what we want to test. We really, we have a couple practices lined up who are interested in this with Partners for Kids, and we want to test can this actually work. Because I think the services that we're providing in our integrated setting right now don't actually even require a dental chair.
Like they can be done in an exam room. And that is a really, I think, powerful thing for the project because it makes use of existing resources rather than having to outfit clinical space for new resources. But what I think it comes down to is kind of the workflow of that hygienist and how engaged or the word champion comes up a lot.
How much of a champion the hygienist is and the physician practice is in making it work. Because I think if people want to make this work, if people want to address the issue, they're going to make it work. So, I think that if there are champions, I think it can be pretty successful.
But it seems like from a resource perspective, we could do it and using existing resources and supply chains and whatnot, that it would really come down to sort of a logistics issue and a time issue and potentially billing issues. But I think there's ways to address that relatively easy. But we want to work through a lot of those questions as we test this in that community relationship, that private physician practice with the private dental practice.
Can we match them together? What agreements are needed? How does billing work?
That kind of thing.
[Dr Mike Patrick]
If we have physicians listening right now, especially in the central Ohio area who might be interested in that sort of collaboration, can they reach out to you?
[Dr Beau Meyer]
Yeah, absolutely. So, you can reach out to me. And we have a dental hygienist.
Her title is a dental hygiene educator with Partners for Kids. And she would likely be the one to coordinate a lot of this. And she's fantastic at what she does.
And we do the project through a quality improvement lens or methodology. So, there'd be a lot of QI support and project management support that we could offer in doing that. But yes, reach out to me.
I would be more than happy to talk with the practices to see if there's some kind of project that we could come up with that's grounded in the data and the framework and the goal to improve access to oral health for kids.
[Dr Homa Amini]
This is all so exciting, Dr. Boe. Because that was my question about how we can do more integration, like interprofessional. And this sounds like the path to go.
And I'm excited to see about the success of this project.
[Dr Beau Meyer]
It's been one of the things that I've been most proud of. And I'll say I'm entering the mid-stages of my career. So, I don't know if I'm still junior or mid.
But in my 10 years or so, it's been the thing I think I've been most proud of is testing this model of integrated care. It's not terribly innovative or novel, but it is to Ohio. Like the state of Colorado has been doing this for a while.
The state of Wisconsin has been doing this for a while. People or groups in Michigan have been doing this for a while. But it seems like it's new to Ohio.
And that is really exciting. And if we could implement that, we could solve an access problem or address an access problem. And that's just really exciting to me.
I think there's a lot of benefits that may take, you know, five years to actually realize. But doing the work now seems to set things up and set kids up for better trajectories, better use of services, better oral health for a lifetime.
[Dr Homa Amini]
And prevention of the autogenic infections. I think that's the whole point of early prevention. That's the path to go.
I think we've been kind of focusing on the prevention in younger kids. But for older kids, like when permanent teeth start coming in, what are like the prevention things that are available that we can offer families?
[Dr Beau Meyer]
Yes, great question. We, I think your question is maybe directed towards permanent for smallers. And that would be, those would be teeth that we would recommend for dental sealants.
So having that evaluation, once those, around age six, kindergarten is typically an age we think about. But it could be a little bit earlier. It could be a little bit later.
Each kid's unique in that regard. But around that time, think about what are the permanent teeth, permanent molars, coming in. Can we put sealants on them?
Can we prevent the cavities from forming? That being said, there seems to be mounting evidence and suggestion that some permanent molars don't develop normally. And this is a great proportion.
So, teeth might come in that are hypomineralized or brown or chalky. And those teeth might not be suitable candidates for sealant. They could be.
The variability in that presentation can be very wide. So having that dental evaluation around age five, six, seven, somewhere in that ballpark, as these teeth are coming in, we can try to prevent disease from happening and support teeth that are, I'll call them malformed or maybe not completely normal. Defective is maybe another term that's thrown out there.
But they're just different and they require different supports and management. So, I just want to kind of throw that out there as something that we also can see.
[Dr Homa Amini]
And my last question is related to what are community-based programs or resources that are available to families or for our pediatrician colleagues who want to refer? What are the places that they can send children for their dental care?
[Dr Beau Meyer]
That can be a lot of different things. There are a lot of that probably depends on insurance status and what kind of insurance they have. If you have a relationship with an existing dental practice, I would obviously talk to them.
Or if the dentist is in your social groups, talk to them. Try to identify if they would be willing to take some of your children or if some proportion of those children. I think that's a good start.
We at Partners for Kids maintain a list of practices that participate in Medicaid. And that's across our geography, which is 47 counties. So, we've been able to collect this list and develop it and sort of validate that these providers have treated Medicaid-enrolled children in the last couple years.
So, we have that as an available or existing resource. If the child has an active infection and you know that it is dental pain or dental in origin and they have a swelling and you're struggling, our dental clinic here at Children's has a walk-in emergency clinic every day, both the morning and the afternoon. It's first come, first serve.
That being said, if you are swollen and you're after the cutoff times, we usually find ways to get you in if you're swollen, whether that be that day or go over to the emergency department and we can treat you there. But we typically, we can triage the higher acuity patients to be seen that same day. But that can be an option.
It's not, it can be a challenge if you live far away, but if parents are listening or pediatricians from outside of Columbus are listening and need to find a place to send a kid with an active infection, that walk-in clinic at Children's might be your best bet. And if you are in a practice setting or community that has an FQHC with a dental clinic, I know each one operates a little bit differently, but I might suggest reaching out to them as well to see if they can work them in, in the same day capacity or the next day capacity. But those might be some options or places that I might look towards.
What about school-based programs? Another great question. These are on the rise and there are a number of different school-based organizations out there, school-based clinic organizations out there.
The dental care delivered in those is highly variable. I know the, the school-based clinics that are operated by NCH that have dental provide comprehensive care and services. You know, that could be an option.
Some of the school-based clinics are only doing the preventive visits or are only equipped to do preventive work. So, your exams, your cleaning, fluoride sealants, that kind of stuff, they're not necessarily equipped to do or address dental cavities or extractions or things like that. So that can be an option.
It just depends on kind of what that clinic looks like in that local area.
[Dr Homa Amini]
Thank you so much for a lot of great information today, Dr. Beau. We appreciate you taking the time to be with us. And I'm going to hand it off to Dr. Mike.
[Dr Mike Patrick]
This was a really fascinating conversation. And again, as a pediatrician that works in an emergency department, we do see a lot of dental caries and dental injuries. And I have worked at places before that did not have nearly the extensive dentistry presence that we have here in Columbus in terms of pediatric dentistry.
And that's so appreciated. I worked in a city at one point that literally had nothing. And so, you just had to have relationships with the community dentist, you know, to send someone the next day, even with a dental injury.
And so, we really do appreciate you guys and your presence in the community. And to offer walk-in hours every weekday in the morning and the afternoon is just incredible, really. And again, those are walk-in hours for emergencies, so injuries and, you know, like facial swelling or fever, not just dental pain without any other thing.
You know, in that case, you would want to make an appointment and use some over-the-counter pain medicine until you can get in, which hopefully is in a few days, not in a few weeks. We certainly don't want to wait that long. So anyway, thank you so much for a really enjoyable conversation.
We are going to have some links in the show notes for everyone over at pediacastcme.org. This is episode 110. We'll have a link to dental care at Nationwide Children's Hospital, and there is a contact mechanism through that page to reach out.
So, we had mentioned practices wanting, you know, if you are interested in exploring the possibility of a collaboration, you can get in touch with Dr. Beau again through the dental care website because we do have a contact page there. And if you can't find it there, just the general contact and find a physician at nationwidechildrens.org. You can direct a question to the dental program, and it'll find its way to you.
We also have information about the school-based dental care that we provide here at Nationwide Children's Hospital. Another is antibiotics for dental pain and swelling guideline. So, if you're a physician or other pediatric provider and you want to dive a little deeper into the recommendations from the American Dental Association and the American College of Emergency Physicians, I think they were involved in this guideline as well, and we'll have a link to that in the show notes.
Because our emergency medicine colleagues also want to sort of rein in unnecessary antibiotic use and so that we're all good stewards of antibiotics. And we also have a link to a document from the CDC on infection prevention practices in dental settings. And then from the National Institutes of Health, they have a stat pearls series on dental abscess.
We'll put a link to that. Those are all updated references and resources in case you want to dive a little bit deeper. So once again, Dr. Beau Meyer, Pediatric Dentist at Nationwide Children's Hospital and our guest host this week, who always does a fantastic job. And we're so lucky to have her at our institution as well. Dr. Homa Amini, Pediatric Dentist and Professor of Pediatric Dentistry at The Ohio State University and Nationwide Children's Hospital. Thank you both so much for stopping by today.
[Dr Beau Meyer]
Yes, thank you for having me. It's been a better than I was really nervous about it, but I hope it went OK.
[Dr Homa Amini]
You did a great job. And thank you, Dr. Mike, for hosting us again. It's always a pleasure and I always enjoy and learn every time.
Thank you.
[Dr Mike Patrick]
We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast CME a part of it. Really do appreciate that. Also, thanks again to our guests this week, Dr. Beau Meyer and Dr. Homa Amini, both pediatric dentists at Nationwide Children's Hospital. Don't forget, you can find us wherever podcasts are found. We're in the Apple podcast app, Spotify, iHeartRadio, Amazon Music, Audible, YouTube and most other podcast apps for iOS and Android. Our landing site is PediacastCME.org.
You'll find our entire archive of past programs there, along with show notes for each of the episodes, our CME information, the terms of use agreement and the handy contact page. If you would like to suggest a future topic for the program, you can also reach out and just say hi. I read everything that comes through the contact page and would love to hear from you.
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Simply search for PediaCast. So, you have listened to the podcast. Now be sure to claim your free category one continuing medical education credit.
Really easy to do. Just head over to the show notes for this episode. Again, at PediacastCME.org.
You'll find a link to the post test in the show notes. Follow that link to Cloud CME. Click on the materials tab.
Take and pass the post test and the category one credit is yours. Super easy, right? And you can even download a transcript of your credit if you need, you know, written documentation of your participation.
And again, we do offer that credit to many pediatric professionals, doctors, nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. Of course, you want to be sure the content of this episode matches your scope of practice. And again, complete details are available at PediacastCME.org.
Also, remember we have an evidence-based podcast for moms and dads. Lots of pediatricians and other medical providers also tune in as we cover pediatric news and interview pediatric and parenting experts. Shows are available at the landing site for that program, Pediacast.org.
Also available wherever podcasts are found. Just search for PediaCast. And an additional podcast that I host because, you know, two is not enough.
It is a faculty development podcast from the Center for Faculty Advancement, Mentoring, and Engagement at the Ohio State University College of Medicine. It's called FAMEcast. So, if you are a teacher in academic medicine or a faculty member in any of the health sciences, then this is a podcast for you.
And you can find FAMEcast at FameCast.org and wherever podcasts are found by simply searching for FAMEcast. Thanks again for stopping by. And until next time, this is Dr. Mike saying stay informed, keep it evidence based, and take care of those kids. So long, everybody.
