Dental Injuries – PediaCast 266

Dr Elizabeth Gosnell returns to the PediaCast Studio to talk about dental injuries. Join us as she and Dr Mike discuss the emergency and long-term treatment of chipped, fractured, dislodged, and knocked-out teeth.


  • Dental Injuries

  • Chipped / Fractured Teeth

  • Dislodged Teeth

  • Knocked-Out Teeth

  • Gum Injuries

  • Tooth Injury Prevention

  • Tooth Injury Research

  • Treating Pediatric Cancer with Viruses





Announce 1: This is PediaCast.


Announce 2: Welcome to PediaCast, a pediatric podcast for parents.& And now direct from the campus of Nationwide Children's, here is your host Dr. Mike.

Dr. Mike Patrick: Hello everyone and welcome once again to PediaCast, it is a pediatric podcast for moms and dads, this is Dr. Mike coming to you from the campus of Nationwide Children's Hospital.& We're in Columbus, Ohio, it is October 2, 2013 and we're going to talk about dental a injury today, that's the title of the program, "Dental Injuries".& I want to welcome all of you to the show, we have a practical one lined up for you this week.& If you have kids at home it's likely to experience some sort of dental injury.


Little kids fall down and go boom, their faces hit the ground or whatever other objects happen to be close by.& Older kids gets struck in the face by all sorts of things, baseballs, basketballs, handle bars like cross sticks, other kid's elbows, really the list could go on and on.& The examples of some of the dental injuries that we see, chipped and fractured teeth, loose teeth, dislodge but not quite knocked out teeth, and lacerations or cuts of the gums, lips, the lining of the mouth which we call the oral mucosa, and the tongue.& So what do you do in these situations?& I mean what does immediate at home emergency care look like?& And which injuries truly need immediate treatment, and which ones can wait?& Who do you call?& And what treatment can you expect both on the short term, maybe in the emergency department for instance and the long term?& So for instance, by your child's dentist.  


And here's a popular question, what exactly should you do with the tooth that's been completely knocked out?& Also, how can you prevent tooth injuries from happening in the first place?& And what is the latest news in the world of pediatric dental injury research.& So lots to cover, and I do have a great dental expert joining me in the studio today to talk through these issues, Dr Elizabeth Gosnell is a pediatric dentist here at Nationwide Children's Hospital.& We'll get to her in a moment before we do quick reminder, PediaCast is the place for evidence based answers to parenting questions.& So if you have a question, or a topic idea, or a comment, or suggestion, maybe you have a bit of advice that you'd like to share with other parents on a particular topic that we've covered, maybe you disagree with something you've heard me say, I'd love to hear you or hear from you and be able to share your thoughts with the rest of the audience and it is easy to get in touch.


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You can also incorporate them into your own custom talk radio station with other content providers of your choosing, you can even add your local news weather and traffic in to the mix, and PediaBytes are also included in a couple of pre-program stations on iHeart Radio Talk including the Parenthood and Moms Sippy Cup.& One more thing before we get started, the information presented in all of our episodes is for general educational purposes only.& We do not diagnose medical conditions or formulate treatment plans for specific individuals, so if you have a concern about your child's health, make sure to call your doctor and arrange a face to face interview and hands on physical examination.& Also your use of this audio program is subject to the PediaCast terms of use agreement which you can find at Alright let's take a quick break, we'll get Dr. Gosnell settled in to the studio so we can talk pediatric and dental injuries, and be sure to stick around at the end of the show because my final word this week involves an interesting new approach to treating pediatric cancer with viruses, so it's all coming your way right after this.



Dr. Mike Patrick: Dr. Elizabeth Gosnell returns to the PediaCast studio this week as our resident dental expert, she's a dentist at Nationwide Children's Hospital and an assistant professor at the Ohio State University, College of Dentistry.& Dr. Gosnell joined us back in episode 189 to talk about routine tooth care during childhood, she returns now as we shift gears and talk about dental injuries, welcome back to the studio Dr. Gosnell.

Dr. Gosnell: Thank you, I'm glad to be here.

Dr. Mike Patrick: Really appreciate you stopping by.& PediaCast 189 and I did put a link to it in the show notes for this episode which is 266 over at


We covered, when kids should have their first dental visit?& How often they should go?& How to care for baby teeth, basically as soon as they erupt?& When to start brushing with toothpaste?& We talked fluoride, and water, and mouth rinses, and as a tooth application, and we discuss cavities and their treatment, and we touched base on dental injuries but we didn't go on to too much detail with trauma because, really the focus was routine care and I would encourage parents to go back and listen to episode 189 in the archives at, and again I'll put it in the show notes for this episode as well.& Because it really was full of great information I think and none of that's change that you can think of.

Dr. Gosnell: No.

Dr. Mike Patrick:& Any new recommendations since then?

Dr. Gosnell: No, none have has changed.

Dr. Mike Patrick: But we're going to turn our attention to injuries this time around.& Dr. Gosnell, what are the most common types of dental injuries that you see in kids?

Dr. Gosnell: I'd probably say the most common dental injury that we see in kids is broken teeth.  


Now whether or not the tooth has been moved too, that's beside the point, but really, broken teeth is the most common type of dental injury, and the most common reason for that type of injury is from falls.& It's we usually see a peak of dental injury around toddler age, because they're getting mobile and they're not quite coordinated and they fall.& It's a time where will you see a peak, and then around age 10 or so, exactly as you said earlier they're getting in to contact sports and more active.& Whether it's contact sports or just playing outside we see a peak of dental injury then too.

Dr Mike: Sure.& And in addition to actual teeth problems too, you take care of the gums as well?

Dr. Gosnell: Yes.

Dr. Mike Patrick: Do you see lacerations to the gums very often?& I mean the teeth I guess are sticking up and are the ones that are more exposed to the trauma.& But do you see gum injuries as well?

Dr. Gosnell: We see gum injuries very commonly associated with the tooth injury and not always associated with the tooth injury.& But gum injuries don't always need a specific type of treatment because the gum injuries heal very well.& As you mention, the oral mucosa inside the mouth has a pretty fast turnover rate, so the healing rate is fast, and sometimes they do need to be re-treated, but a lot of times they heal very well on their own.


Dr. Mike Patrick: That's great.& I guess it goes along too with like when you burn your mouth on a piece of pizza or something, it's amazing how fast it gets better in just a day or two sometimes.

Dr. Gosnell: Right.

Dr. Mike Patrick: Now which dental injuries are true medical emergencies?& So, when kids have a fractured, broken tooth, parents get very upset about this and understandably so.& But what sort of things have to be seen immediately, and what could wait till you call your pediatric dentist the next day let's say?

Dr. Gosnell: The number one type of dental trauma that needs to be seen immediately is when permanent teeth are moved or they're knocked out.& The term for moved permanent teeth is luxated.  


So if they are knocked, and as you mention they're knocked but they're not quite knocked all out all the way, those need to be treated immediately, meaning that night, as well as the permanent that's not completely out needs to be treated immediately.& And there are several other types of treatment that we'll talk about that don't need to be seen immediately and can wait till the next day.

Dr. Mike Patrick: Pretty much just about anything else.& If there's like a piece of the tooth is missing, that's something that could wait, but it's really the position.& If you look at the bottom of the tooth, if that is not in proper position then that's an emergency.

Dr. Gosnell: Right, exactly.

Dr. Mike Patrick: But you mentioned permanent teeth, so that could same is that true for baby teeth?

Dr. Gosnell: For baby teeth, the same is true for baby teeth, however if a baby tooth is knocked completely out we don't re-implant baby teeth.& But if the parent is not quite sure if it's out of the way, or if they're not quite sure if other teeth have been hit and knocked, then the child should be evaluated if they're not quite sure.& And if the tooth is same for permanent teeth if it's broken but it's not moved, that can wait till the next day.  


If it is knocked and luxated and that the child's now not able to close down all the way, that should be treated immediately as well.

Dr. Mike Patrick: Sure.& Now one of the things that I've come across in my own practice is, we're kind of spoiled here in Columbus because we have a pediatric emergency department here at Nationwide Children's, we have dental residents who are basically at our call 24 hours a day which is fantastic.& But when I was in private practice, and also when I worked in pediatric urgent care in Florida, it was sometimes very difficult to get in touch with a dentist to figure out what to do with some of these kids.& Do you have any suggestions on resources that maybe I'm not aware of?

Dr. Gosnell: That's a really good question.& So, what I would say, we get a lot of calls from physicians out two, three hours away from here just because they're not quite sure what to do and they show up on a local emergency room.


But if the child has a regular dentist, that dentist should have an emergency protocol in place that they should be able to be seen, and if you're not sure what that is, then you should just ask your dentist.& If you don't have a dentist and you go to your local emergency room or your local urgent care and then the resources available to that physician they could probably call, I'm asking you this, I think they can call our emergency room.& Here we can give over the phone advice and see if they need to be transported at that point.& But there are lots of resources available to physicians and dentist, that's probably another topic.

Dr. Mike Patrick: Yes, it's sometimes frustrating depending on where you are.& Like I said, here we're spoiled but I can remember times when it's been difficult to get in touch with someone, and especially when I was in Florida, I mean do you call Nationwide Children's?& You could but we don't want your folks to be inundated with nationally, all the calls from everyone.  


I think that take home for moms and dads here is to get established with a dentist early before there's ever any problems so that you do have a point person that you can connect to and talk to them ahead of time, like what do we do in an emergency if it's after hours and really need to get in touch with you.

Dr. Gosnell: And that's the best thing to do is to really become aware of what type of prevention protocol there is, so that when you are in the situation that's midnight, you know exactly who to call and what to do.

Dr. Mike Patrick: Yup, absolutely.& So let's talk about some of these individual injuries a little bit and what the treatment looks like, kind of in the immediate period and then sort the long term treatment as well.& You mention that broken, chipped, fractured teeth are the most common things.& What kind of stuff do dentists do for those, especially in permanent teeth immediately following an injury?

Dr. Gosnell: If it's just broken or chipped and it hasn't been moved, if it's a permanent tooth and it's either enamel, which is the outer layer of the tooth or the enamel, and then dentin which is the second layer of the tooth, we can restore pretty simply with a composite resin, which is the filling type material.  


If it has exposed the nerve of the tooth and it's a permanent tooth that may lead pressure root canal treatment at that point.& If it's a baby tooth and it has exposed the nerve, we have a decision to make whether or not we will do root canal treatment for the child, or if it's a situation where the child's not able to tolerate that type of treatment we may elect to remove it early.

Dr. Mike Patrick: Sure.& I do understand that I want moms and dads out there to understand too.& We're really talking generally because each specific injury is going to be unique, and so you got to look at what tooth's involved? What's the extent of the injury?& How old is the child?& How cooperative is the child?& I mean there're so many data points to filter through that we can't say this is what should be done.& But in just general, these are some of the options that we have.& Is there a time factor in terms of repairing a broken tooth?& So you talked about applying the resin, is there a certain period of time when that should be done, or it's better to be done?     &  


Dr. Gosnell: I mean it's best just see the child and do a full evaluation within the first couple of days especially if the nerve is exposed.

Dr. Mike Patrick: And you're going to know that because they're having pain?  

Dr. Gosnell:& They're having pain and the parent may see a little bleeding point which is where the nerve and the vascularity would be showing in the end of the tooth.

Dr. Mike Patrick: Sure.& And I mentioned to you before we got started recording, that as physicians I think a lot of times dentistry as pediatricians I should say, a lot of times dentistry is like this mystery black box and so please forgive me if I ask any silly questions, because I very well may.& Let's say that the tooth is loose, but it hasn't been knocked out and it's not necessarily even mal-aligned or the positioning is not wrong, but the kid can maybe move it with their tongue and they can tell that the tooth is loose, what about those situations?


Dr. Gosnell: So let's talk about for permanent teeth, for permanent teeth it's significantly loose, we may place a splint on that to allow the ligament that attaches the tooth to the bone to heal.& And that splint would probably stay on there for a couple of weeks, but again that's depending on the type of instance, and it's usually a flexible splint.& And now for baby teeth, if the tooth is significantly loose and it's a choking hazard, we may decide to remove that at that point.& Now we don't place flexible splints for baby teeth because the risk is such that the permanent tooth may be damaged in that instance.& If the tooth is moderately loose and not a choking hazard for baby teeth, we'll just let watch, monitor the child and see them back on a regular basis to make sure the ligament has healed appropriately.

Dr. Mike Patrick: As the ligament heals, is the tooth expected to tighten back up in the socket?

Dr. Gosnell: Yes.

Dr. Mike Patrick: And then when you talked about splint, is this kind of like braces?


Dr. Gosnell:& it's similar to braces, there're different types of fractures and the tooth is loose, so if the actual bone around the tooth is fractured in making the tooth loose, we'll use what's commonly used in braces, which is a metal wire.& But if it's not, we'll use what's similar to like an acrylic type of flexible splint, if that's just the tooth being loose.& So it's very similar to what looks like braces, kids think they have braces.

Dr. Mike Patrick: Yes, they kind of get excited about it.

Dr. Gosnell: Yes they do.

Dr. Mike Patrick: Let's go beyond this loose tooth thing and say that it is now, it hasn't been knocked out completely but it's not straight, I mean it's been dislodged or it's mal-positioned, what do you do in addition in those cases?

Dr. Gosnell: So again we're going to break it down to permanent teeth and baby teeth.& So for permanent teeth, most important part of that is we need to reposition the tooth as soon as possible for the ligament to heal appropriately and if the tooth isn't fully developed, it has a more of a chance of healing that nerve and the vascularity to the tooth.


So we really have to monitor the child and see them back on a regular basis after it's repositioned and splint in afterwards.& Now for baby teeth, if it's moved so that they're in cross bite, meaning their teeth don't come down into occlusion or the bite correctly, we'll decide to go ahead and take that tooth out.& Because if we have to reposition the tooth, there's too much of a risk of damaging that permanent tooth that's developing underneath it.

Dr. Mike Patrick: Now has there been a change in practice especially for maybe the older kids in terms of maybe you work quicker to pull out mal-aligned tooth, and then do like a root canal and the crown kind of situation?& Has there been a change in the practice there, or has it always been you really try to keep the natural tooth in this if it's going to work?

Dr. Gosnell: I think there has been more of a shift towards retaining the permanent tooth as long as possible.  


And there's some new treatment that we'll talk about dental research that allow us to do that and give them a better long term success rate.

Dr. Mike Patrick: Yes, it's interesting.& And then what about when the tooth is actually knocked out?& So now this is really time is of the essence here, is that correct?

Dr. Gosnell: That is correct, yes.

Dr. Mike Patrick: What should parents do?

Dr. Gosnell: So if it's a permanent tooth and it's been knocked out whether it's in your backyard, or at a basketball game, the best thing you can do if that area is free of debris and the tooth is free of debris to re-implant it on sight.& Now if it is have a lot of debris, like sometimes if the kid falls on gravel and it's pretty messy, if you don't feel comfortable, or if it's not safe to re-implant, then you can put it in cold milk and transport it to your dentist immediately.

Dr. Mike Patrick: So the best place is back in the socket unless it's really dirty, and then a glass of milk, cold milk is it?& OK, and you want to see a dentist as soon as possible, so this is a situation where if you have, of course you want to call your dentist would be the first option.


If your dentist is not available or not answering the phone, I guess you could call your pediatrician to see if maybe they have a dental resource.

Dr. Gosnell: That would be great.

Dr. Mike Patrick: There're also some cities that have 24 hour emergency dental facilities.& Will they see kids?& Well I guess it depends on the place right?

Dr. Gosnell: Depends on the place, right.

Dr. Mike Patrick: And then of course, pediatric emergency department or a local community emergency department if you don't have a pediatric facility nearby.& That's kind of the process that parents should go down, and I'm on target with that.

Dr. Gosnell: Yes you are, that sounds good.& So but like you said the timing is very significant here, so we were trying to keep the ligament vital which is on the root surface, so you don't want to handle the root if possible and put it immediately in that cold milk if you can't put it right back in the socket and then go straight to your dentist.


Dr. Mike Patrick: What if folks don't have milk, are there other options for what to put the tooth thing?

Dr. Gosnell: Yes, you know the best thing that you can put it, there's a solution called Hank's Balanced salt solution.& The absolute best thing use, you can put it in organ transplant solution like Viaspan, nobody has that of course.& So Hank's Balanced salt solution a lot of people don't have that, some sports teams now own that so they may have that available.& But if it just happens in your back yard and you don't have cold milk, you can put your own spit into a cup and put it in your own saliva, that's probably the next best thing.

Dr. Mike Patrick: Sure.& There are emergency tooth preservation kits that like sports team will have, but that may be a little overkill for a parent to have on hand, they probably expired too I would imagine.

Dr. Gosnell: They do expire pretty fast actually, so.

Dr. Mike Patrick: But spit is an option, if it's a kid and you know, cooperation and they're upset and could it be the parents spit, or should it be that child's spit?  

Dr. Gosnell:& Not necessarily, just spit.

Dr. Mike Patrick: And in general, great.& Ok so you heard it here folks, if you don't have milk, you spit, but milk is going to be preferable.  


Alright, so let's move kind of down the tooth in and talk about gum injuries.& I think we did talked about his a little bit, they heal quickly you said, do you perhaps to saw those?

Dr. Gosnell: Sometimes, just depends on that instance but sometimes we do have to put some sutures in, or stitches in, but the vast majority of them we don't need to.

Dr. Mike Patrick: Because they're minor and stitches heal so nicely.& When you do have to do emergency work kind of kid, this kind of a good time just talk about sedation, what sort of sedation techniques do you use to get a child to be cooperative and open their mouth and let you do emergency work?

Dr. Gosnell: That's a good question, so you know the best thing that we can give them is something that they all tolerate to take for us, so it's either a liquid medicine that we can flavor so that they can tolerate it, or a nasal spray that they don't have to really cooperate a whole lot for, and something that's pretty quick acting.


If we need something that last a lot longer, that's when we talk to our emergency physician friends about maybe doing an IV sedation in the emergency room if that's needed.& And that would be really for, well we'll talk about it, they have a significant laceration that needs sutures or stitches on the outside of the face as well as the inside, re-implanting teeth, but really that's what we're talking about as far as sedation's concern.

Dr. Mike Patrick: Yup.& Do you do much with nitrous oxide or laughing gas, because when i think about dental sedation in kids, that's the kind of first thing I think about, or is that more for routine procedures?& Or is there a difference between when you would use that routinely versus injuries?

Dr. Gosnell: Yes, we use laughing gas which is nitrous oxide, we use that for routine procedures like I could bet.& We also do that for, we combine that with that oral sedative medication to give them a little bit more anxiety relief.  


But we do use that in the emergency room if needed to help them relax and that's useful for the child that will tolerate it having on their nose that they could actually breath it in.

Dr. Mike Patrick: Yup.& And I think a lot of parent reads stories now and then about a kid that goes in to see the dentist and they got their sedation,& and then there were some emergency that the dentist wasn't equipped to handle, and then there was a bad outcome, or a child arrested something like that.& I mean you hear about these stories now and then so it is important to have this done in a place that's used to doing this, and I guess that's where I would say, if you have the time to get to a pediatric emergency department, or to see a pediatric dentist then that's your best choice especially if your child's going to need sedation.

Dr. Gosnell: Yes I absolutely agree.

Dr. Mike Patrick: Another thing that I know that I see quite frequently practicing in pediatric urgent care and then in the emergency department are tears of the frenulum that are between the upper gum and the upper lip, there's kind of a piece of tissue there and I think a lot of moms and dads will know what I'm talking about, and it seems like that rips pretty frequently when kids hit their mouths, but do you need to do anything with those?&  


Dr. Gosnell: You know vast majorities of those don't need any type of treatment, it does tear pretty easily and it's pretty friable or a tissue that attaches the lip to the gum, and that does tear often when you're bumped right in the mouth.& But a lot of times it doesn't need any additional treatment and it'll heal very well.

Dr. Mike Patrick: And then while I've got you here, I want to ask you about this because I hear a lot of parents ask, sometimes there's a little gap between the two front teeth and that frenulum is coming up through it and then they want to know, does that need to be snipped?& And would that gap go away?& And what's the natural progression?& And do you have any words, I know this is not injuries but it comes up.

Dr. Gosnell: That's one of the most common questions, so I understand.& Parents always want to know if we can go ahead and snip that and close the teeth, but I will tell you, it just depends on the dental age of the child.


When their permanent K9's come in about age 11, a lot of times the spaces will close and at that point if that frenulum or that attachment goes all the way through the teeth and on to the palette and at such it doesn't allow the teeth to all the way close, that's when we would be talking about potential orthodontics to close them and then snip that if needed, but that's later on, that's into adolescents.

Dr. Mike Patrick: Sure.& And there is a possibility that it'll just go away on its own?

Dr. Gosnell: Yes.

Dr. Mike Patrick: And the gap would close?

Dr. Gosnell: Yes.

Dr. Mike Patrick: Which is what happened with my son, yes, it happens very often, and we didn't do anything.& But then when I see in my own kid, yes it went away it closed, you kind of hesitate to tell other people that, because I don't know if that's the usual thing and or if he was an exception?

Dr. Gosnell: Yes, a lot of them close on their own.

Dr. Mike Patrick: Great.& And then what about other injuries in the mouth?& So the tongue, the lips, the palette, is that in the realm of being fixed by pediatric dentist, or is there a difference between seeing like your nose and throat doctor or oral surgeon, so what are the differences and who does what?


Dr. Gosnell: That's a great question.& If it's the tongue or the inside of the lips or the inside of the cheeks, that's the pediatric dentist.& If it goes into the posture throat or the soft palette, then we may involve our plastic surgeon colleagues or the oral surgeon.& If the cut or the laceration goes on to the outside of the lip and on to the face, that would not be your pediatric dentist, you would really want somebody who's very good at aesthetic type of stitches which would be the plastic surgeon.

Dr. Mike Patrick: Yes, got you.& Or the suture techs, if you are at Nationwide Children's because they do, and it's funny because a lot of people, you know they come in, their child has a laceration that involves their lip or their face and it's like " I want the plastic surgeon", but you know, you may get the plastic surgeon intern as opposed to the suture tech who, that's all they do all day long.

Dr. Gosnell: Yes, and we work with suture technicians a good bet in the EDE, they are our friends.


Dr. Mike Patrick: Yes.& What about folks who do wait to have dental injuries looked at by pediatric dentist?& So you said for a knocked out tooth or one that's dislodged, you want them to be seen right away if it's got a chip or fracture or broken in some way, then at least the first day or two.& But for folks who may be way a week, or two weeks and then their child starts complaining of pain, what are the complications that can arise from untreated dental injuries?

Dr. Gosnell:& Probably the most severe complication that can occur from an untreated dental injury is a facial swelling which results from either the nerve and or the vasculature being severed when it's been bumped.& You'll notice either a bump on the gum or the worst case scenario, the whole cheek or face gets swollen.& And if it's in the front of the upper front teeth, that area if it becomes swollen can progress pretty fast to the eye area, and that's a significant concern for kids, so you don't want to take that too lightly.


Dr. Mike Patrick: Yes, absolutely.& What about infection, do you see infection as a complication very often?

Dr. Gosnell: Infection would result in this facial swelling that I'm talking about, that's probably the number one cause of that.

Dr. Mike Patrick: OK, got you.& So not just inflammation but actual infection from organisms that are living in the mouth that get into the soft tissues.

Dr Gosnell: Yes, it's just such a common complication for the inflammation and all the bacteria that normally live in our mouths, they combine and they form the swelling.

Dr. Mike Patrick: Yup, absolutely.& Now what can parents do to prevent dental injuries from happening in the first place?

Dr. Gosnell: So the best thing that you can do if your child is involved in a contact sport is make sure they're wearing a mouth guard, when they're practicing, as well as when they're actually playing the game.& But for kids that just fall down at home, or fall down when they're playing outside, there's not a whole lot that you can do to prevent that.& You can't put your child on a bubble, you can't really prevent it however you can come up with a really good plan in case it does happen to you.


Dr. Mike Patrick: Yes, and I think that's really the' like I said the take home here is to think about what you would do if this happens and who you need to sort of be in touch with right now to prepare the way for that end up happening.& And I think here in Columbus it's pretty easy, you just come to the emergency department 24/7 and we've got pediatric dentist that's going to take a look at you, but if you live in a community that doesn't have a children's hospital around the corner, then it's something that you definitely want to think about.& In terms of mouth guards for sports, there's some different kinds that are out there, there're ones that you just buy and just goes in their mouth, there's different sizes, there's the ones that you boil and kind of bite in to and then you can even get custom fitted mouth guards.& Do you have any recommendations on what the better way to go?& Obviously you should go up that ladder to get more expensive, is the expense worth it?


Dr. Gosnell:& As you go up the ladder, it does get more expensive to the custom made, however the custom made does distribute the forces if they are bumped, better.& They have a better chance of not having significant issues if they are bumped into during a contact sport if they do have a custom made one.& The next best one is the boil and bite which you can buy at any sporting goods store, and the least, the one on the lowest part of the ladder is the stock made mouth guard.

Dr. Mike Patrick: Do you folks in the dental clinic here at Nationwide Children's do the custom fitted ones?

Dr. Gosnell: Yes.

Dr. Mike Patrick: And then couple of the other questions I have I think we really already covered, the benefits in seeing a pediatric dentist as suppose to a general dentist when a dental injury occurs, it's just in terms of experience, I mean seeing the same things over and over again, although I'm sure there're plenty of community dentists who see lots of kids if there's not a pediatric dentist.& So I don't want to bad mouth the adult dentists because I'm sure there're plenty of them that feel comfortable seeing kids.


Dr. Gosnell: Right, but yes exactly like you said where you'll see a lot of it and there're residents see a lot of it when they're advance training for two years.& They also review all the up to date literature in this two year training program that would help them become more equipped to be able to handle in their private practice.

Dr. Mike Patrick: I do want to put a plug in for that as well.& In order to be a pediatric dentist you first go to dental school, well actually first you go to under grad school and have a bachelor's degree, and then you go to dental school which is competitive to get into.& Anyone out there listening who wants to be a dentist, make sure you take school seriously, and then you do dental school four years?

Dr. Gosnell: Four years.

Dr. Mike Patrick: And then the pediatric dental residency is a couple years?

Dr. Gosnell: It's an additional two years.

Dr. Mike Patrick: Great, and then you're a board certified as a pediatric dentist at that point?

Dr. Gosnell: Well the board certification is another couple of exams after you graduate your fourth year certificate of pediatric dentistry, but yes, all of our department, all of our faculty are board certified.


Dr. Mike Patrick: And those pediatric training programs, there are a ton of them are there?

Dr. Gosnell: No there aren't.

Dr. Mike Patrick: I mean this is kind of the unique program that we have here.

Dr. Gosnell: Yes, there aren't enough pediatric dentists to serve all of our children in the country, that's for sure.

Dr. Mike Patrick: Are you working on improving that? that you personally?

Dr. Gosnell: We as a whole, yes.


Dr. Mike Patrick: We talked briefly on research, what are some of the hot topics right now in pediatric dental injury research?

Dr. Gosnell: Probably the hottest topic and the most difficult challenge for us is when a child is bumped and their permanent tooth isn't fully developed.& So when a permanent tooth erupts into the mouth, it takes an additional about three years for the root to fully develop, meaning the wall thickens and the apex, meaning the end of the root closes.  


If that happens and the tooth becomes infected or if it's bumped and the vascularity goes away and it's non vital, we have to do root canal treatment that the long term success rate is very low because the root walls aren't thick enough and to be a stable as it would as a fully matured tooth.& There's a lot of research now devoted to stimulating stem cells to re-grow that tooth tissue so that it can fully mature and close and the root walls will thicken so that it is stable and has much higher long term success rate.

Dr. Mike Patrick: What does it look like when the root canal fails?

Dr. Gosnell: When the root canal fails, you may see a, what looks like an abscess or a bump on the gums, you may see the person may become in pain again, or you may see that the tooth just becomes significantly loose, so you would need to see somebody about that.

Dr. Mike Patrick: Yup, absolutely, so that's interesting.& Now how do you stimulate stem cells?


Dr. Gosnell: Our department is working on re-vascularization which is what I'm talking about.& You basically have to stimulate them in a procedure, you have the nerve as open, the tooth is open and you're simulating at the end of the root where the stem cells would be so that it would influx into the tooth space, the root canal space and then reform that tooth structure, so it's kind of how that works.

Dr. Mike Patrick: What are you using to stimulate?

Dr. Gosnell: It's actually a root canal file that we put down into the end of it where the root end would be.

Dr. Mike Patrick: So you're kind of causing more damage and because you want to stimulate the body to heal itself and so, that's very interesting, good. I kind of wanted to wrap up just to talk a little bit specifically about our dental clinic here because it's really a great resource not just for on call emergency department, but also for the community.& You have some walk-in hours that so folks can just show up?


Dr. Gosnell: We do have walk-in hours.& You know our hospital clinic is extremely busy, we could use more space to accommodate our patients for sure, but we do have walk-in hours for those children that have a history of pain, with kids that have had trauma, and with kids that have a facial swellings.& So for injuries and true emergencies.

Dr. Mike Patrick: So the walk-in hours are not for to get your teeth cleaned, you would want an appointment for that?

Dr. Gosnell: Yes, you need an appointment for that.

Dr. Mike Patrick: But the walk-in hours, if you do have a child with significant pain or an injury, you are able to accommodate? And there's just some peace of mind I think living in Central Ohio to have that as a resource because I lived in some other places and practice in some other places where that just not a possibility so that's fantastic.& Alright, is there anything else that I didn't cover on pediatric tooth injuries that moms and dads should know about, that you can think of?

Dr. Gosnell:& I don't think so.


Dr. Mike Patrick: Again, for some of the other topics, it's a lot easier for me to know which question to ask, but for teeth, I don't know, because we just don't learn a lot about them, because you do.

Dr. Gosnell: You know, in every trauma like you said is different, so every instance we learn something new, and we see something different so the best thing to do if you have an additional question is to ask your local dentist.

Dr. Mike Patrick: Great, we really appreciate you stopping by, there is some great links in the show notes for you so head over to and look for the show notes for episode 266 and I'll have a link to PediaCast 189 which was our tooth care episode that we did, and then I also have a link to the dental clinic here at Nationwide Children's Hospital, and also the American Academy of Pediatric Dentistry, they have some interesting stuff not only for pediatric dentist and for those who refer to pediatric dentist, but there's some interesting information for parents on child tooth care and tooth injuries there as well, so I'll put a link to that too.& Alright let's take a quick break and I will be back with a final word on something completely different, treating pediatric cancer with viruses.& A quick word on that right after this.


Dr. Mike Patrick: Alright my final word today is a complete departure from pediatric dentistry, but an interesting topic that I wanted to put out there for you.& You know as parents and doctors, we do our best to children from viruses, but viruses can also be useful.& Doctors and researchers at Nationwide Children's Hospital are looking into the role viruses may play in treating certain types of cancers.& This novel approach is called viral therapy, and it involves the slight alteration of a virus in the laboratory and then injecting the virus directly into a solid cancer tumor which causes the tumour to shrink and disappear all together.


Several years of study into this approach have lead scientists to find more and more evidence that so called oncolytic viruses show promise as anti-cancer agents with variations of the herpes simplex virus among the most commonly used.& Viral therapy's been studied in an adult, but only a few institutions have studied it in kids.& Dr Timothy Cripe, chief of hematology, oncology and bone marrow transplant at Nationwide Children's Hospital says, "Virus therapy is a very promising area of cancer treatment.& By injecting the tumour directly with the virus, it will cause the body's immune system to react and attack that tumour while preserving the body's healthy cells.& With Viral Therapy, the immune system damage is limited to the tumour cells, it does not affect the healthy tissues surrounding the tumour or other cells throughout the body, that means there are very few, if any side effects from the treatment.


Viral therapy could make a world of difference for pediatric cancer patients who would otherwise require chemo therapy and its common side effects including hair loss, fatigue, nausea, and weight loss".& Dr. Cripe and his team will soon launch a phase one clinical trial at Nationwide Children's which will study viral therapy for solid cancer tumors in kids starting with treatment for neuroblastoma and sarcoma.& So, this is cutting edge stuff folks, and as we progress down this road of viral therapy for solid tumors, we'll get Dr. Cripe in the PediaCast studio to talk more about it.& I've already been in touch with him and he's excited to come on the program so we have to arrange that down the road.& In the meantime I have a nicely produced YouTube video to share which takes a sneak peek into Dr. Cripe's laboratory and I'll put a link to that in the show notes for this episode 266 over at So treating cancer with viruses, interesting stuff and that's my final word.


I want to thank all of you for taking time out of your day to make PediaCast a part of it and being one of our listeners, also thanks to Dr. Elizabeth Gosnell for stopping by and chatting it up about pediatric dental injuries.& Don't forget PediaCast and our single topic short format programs, PediaBytes single topic they're available on iHeart Radio Talk and you also find those on the web at iHeart Radio, it's actually is how you get to iHeart Radio, and then the iHeart Radio app for mobile devices, those have the PediaBytes in them as well.& Reviews and comments on iHeart Radio and in iTunes are most helpful as our links, mentions, shares, re-tweets, re-pens, all those things on your favorite social media site.& PediaCast is on Facebook, Twitter, Google Plus and Pinterest and be sure to tell your family, friends, neighbors, co-workers, and your child's doctor about the program.& We do have a poster available under the resources tab at Again the contact link is available at so you can ask your question and or provide a comment or suggest a show topic.  


And then we also have the connect with the pediatric specialists link which you'll find over at As for referrals and appointments it's just a way to get you in touch with the specialists at Nationwide Children's a little easier and a little quicker.& Alright that wraps things up for this week and until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids.& So long everybody.

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Announce 2: This program is a production of Nationwide Children's, thanks for listening.& We'll see you next time on PediaCast.  





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