Dental Trauma and Emergency Tooth Care – PediaCast 429

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Show Notes

Description

• Dr Janice Townsend returns to the studio as we consider dental trauma and emergency tooth care. We explore common dental injuries and their treatment, including what to do when teeth are chipped, knocked loose or fall out. We hope you can join us!

Topics

• Dental Trauma
• Emergency Tooth Care
• Chipped, Fractured and Broken Teeth
• Loose Teeth
• Knocked-Out Teeth
• Gum Injuries
• Tooth Injury Prevention
• Tooth Injury Research

Guest

• Dr Janice Townsend
  Chief of Dentistry
  Nationwide Children’s Hospital

Links

• PediaCast on SoundCloud
• RODECaster Pro Podcasting Console
• Infant Teething and Toddler Tooth Care – PediaCast 423
• Pediatric Dentistry at Nationwide Children’s Hospital
• American Academy of Pediatric Dentistry
• Can You Handle A Dental Emergency? (AAPD)

Transcription

Announcer 1: This is PediaCast.

[Music]

Announcer 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 Episode 429 for April 11th, 2019. We're calling this one "Dental Trauma and Emergency Tooth Care". I want to welcome everyone to the program. 

So we are covering dental topics this year. Sort of in-depth series within a podcast, if you will, because issues surrounding teeth are very important to moms and dads. It comes up often from the time kids are babies. They're teething, when do you start brushing their teeth? How do you take care of toddler teeth? 

0:01:17

And then, injuries, injuries to teeth are very common and sometimes require emergency tooth care. So it's been a few years since we covered dental topics. It's a good year to revisit them. Dr. Janice Townsend, she's our chief of Dentistry here at Nationwide Children's Hospital. A few weeks ago, she stopped by the studio and we talked about infant teething and caring for toddler teeth. 

We talked about the symptoms of teething, how you comfort babies as teeth erupt, how you do that safely, what things you should avoid, brushing guidelines for young kids, the use of fluoride and other cavity prevention measures. And I'll put a link to that particular episode in case you're just hearing about it for the first time, you're like, "Oh, I didn't know that they covered teething and toddler tooth care on PediaCast." 

We did. It was Episode 423. And to help you find it easily, I'll put a link to it in the show notes for today's episode, which is 429, over at pediacast.org.

0:02:16

So, Dr. Janice Townsend is back in the studio today again, as we consider dental injuries and emergency tooth care. And a little foreshadowing for you, she'll be back later in the year to talk about routine care of school-aged and adolescent teeth, including cavity prevention and treatment, braces, wisdom teeth, that sort of thing as we wrap up the Year of the Tooth here on PediaCast.

Before we get started with our dental topic, a few housekeeping items are in order. First, last week, we answered a full plate of listener questions. Which means the question bank is running low. So if you have a topic you'd like to hear us chat about, if you have a particular question about child health or parenting, maybe you've seen something in the news that you'd like us to consider, now would be a good time to write in since we'll be looking for content for upcoming shows. 

0:03:11

Easy to get in touch, just head over to pediacast.org and click on the Contact link. I do read each and every one of those that come through. And we'll try to get your question, or your topic, your suggestion on the program. 

We also have a Skype line, which I've not been promoting lately, but we still have it. And I'm happy to play an audio version of your question or a topic suggestion if you'd rather say it than write it. Phone number is 347-404-KIDS. That's 347-404-5437.

Another quick reminder, we are now on SoundCloud. We've been wherever podcasts are found for a very long time. And sometimes, we say that, look for PediaCast wherever podcasts are found. But we weren't in SoundCloud, so you weren't able to find us there. But we are there now and we'd appreciate it if you'd stop by and like our page. 

0:04:00

We have 23, I think this will make 24 episodes there. Kind of a mixture of the regular PediaCast programs. We also have some of the CME shows. And there's an app that you can listen. You can download the app free, listen for free. 

The cool thing about SoundCloud is they have playlists. So you don't just get the episodes in chronological order. You can actually kind of group them together, which I'm really excited about. So we have a couple of playlists there now. One is our Pediatrics in Plain Language Panel, their collection of podcasts that we've done. It's a fun group. We have a lots of fun in the studio. And I think folks enjoy listening to those particular episodes. 

And then, all of our CME episodes for Category 1 Continuing Medical Education. Not all of them, I think we have the last ten or so. And moving forward, we will add all of those to that playlist. Again, you can find that at SoundCloud.

I think once we record our third dental program, we can make a playlist, Dentistry for Parents. Or maybe I ought to make that now and just always put these two and we'll add the third one. Why wait? 

0:05:05

And I think our sports medicine episodes, we also have a very nice collection of those. I think they are ripe for a SoundCloud playlist. 

So please do consider liking us on SoundCloud. I think we have three likes right now. So if you come, it's a pretty empty place at this point, you can sort of hear the crickets a little bit, but we would appreciate you, if you are in SoundCloud, stopping by. If you're not, it may be a convenient way for you to listen to the program and see what our current content is, then see where we're putting shows together in the playlists. 

And by the way, something else about SoundCloud, you can actually form a little bit of a community there. It's kind of a message board. It's really a little more intuitive and I think you'll be able to see what folks are writing about individual episodes a little bit better than at the website. Sometimes, those comments get lost below the transcription.

So I think SoundCloud would also be a great place to form a little bit of a community. This show certainly attracts a unique combination of parents and pediatric providers and it will be great to foster some community interactions between these two groups. And who knows, SoundCloud may be a place where that could happen.

0:06:17

So moms and dads, doctors, nurses, whether you're a parent or a medical professional, please look for PediaCast on SoundCloud, like us and chime in from time to time. That'd be really cool. 

We're also in traditional social media outlets, Facebook, Twitter, and Instagram and also love when you connect with us there. 

One more thing I wanted to mention for the audio lovers in the crowd, you may have noticed a subtle, hopefully it's subtle and not real obvious. But there has been a little bit of a shift in our sound in terms of quality and tone over the last of couple of episodes. No one has mentioned it, so I think we're okay. I have a new piece of gear that I am absolutely loving. But with any new piece of technology, there's a learning curve.

0:07:06

Sometimes, I think maybe there's a little bit too much bass boost in our last couple of episodes. We'll see if that rings true today, too. And there may be more little adjustments coming. But I would value your feedback. How are we sounding?

The new piece of equipment is called the RODECaster Pro, and boy, this thing makes podcasting easy. And I just want to say upfront, I am not getting any paid endorsement. They didn't send me a free piece of hardware, nothing like that. 

But this thing is really an all-in-one podcasting board. It's got your mixer board. It's got four XLR microphone channels. And I knew there are fellow podcasters who listen to this program, so it's the reason you'll bear with me here. It's got audio processors in each channel, compression, noise-gate, DSR, high pass filter, Aphex Big Bottom. Seasoned podcasters will know what I'm talking about. 

The unit is also a digital recorder. It will also send multi-channel signals to your computer for additional recording options. It's got a telephone hybrid with mix-minus for doing telephone interviews. And even the USB connection to the computer is mix-minus so it makes it easy to record Skype interviews right on the unit. Plus, it has an eight-pad cart player to play your intro and outro and interludes and all the music with your podcasts.

0:08:28 

And this is all in one unit. So that's why I'm really excited because this thing has replaced a ton of analog components in the studio. And the studio is small, and with all that, it would heat up pretty fast, as many PediaCast interviewee can attest to. But this thing's all digital and it runs cool without, in my opinion, sacrificing on sound. Although we're still playing with the settings a bit. 

So if you're a podcaster or you're thinking of becoming a podcaster, and I know some of you are, I highly recommend this gear. And again, no paid ads here. It's the RODECaster Pro. And I'll put a link to it in the show notes. And maybe I'll even put a picture of it in action here from the studio on Instagram. So, if you're interested, check that out. 

0:09:16

All right, one final item of business, and that's to remind you that the information presented in every episode of PediaCast 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, be 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 pediacast.org.

So let's take a quick break. And then, I will be back with Dr. Janice Townsend as we consider dental drama and emergency tooth care. That's coming up, right after this.

[Music]

0:10:26

Dr. Mike Patrick: Dr. Janice Townsend is chief of Dentistry at Nationwide Children's Hospital and associate professor of Pediatric Dentistry at the Ohio State University College of Dentistry.

Spring is here with warmer temperatures around the United States, which means outdoor sports are underway and kids are outside, running, jumping, falling, colliding into things, all of which means we are in a season of increased dental injury. That's what Dr. Townsend is here to talk about, dental trauma and emergency tooth care. So let's give a warm welcome back to Dr. Janice Townsend. Thanks so much for joining us again today. 

Dr. Janice Townsend: Thank you for having me. 

Dr. Mike Patrick: Really appreciate you stopping by. Dr. Townsend was here a few weeks ago. We did infant teething and toddler tooth care. That was Episode 423. We talked about the symptoms of teething, how to comfort babies as teeth erupt, brushing, tooth brushing guidelines for young kids, the use of fluoride, and other cavity prevention measures. So lots of information for moms and dads in that episode, again, 423 over at pediacast.org.

0:11:28

So we're going to turn our attention this week to dental injuries. So what are the most common dental injuries that we see in kids? 

Dr. Janice Townsend: People are surprised to hear this, but it actually depends on the age of the child. Severe young children or toddlers, three-year-olds, four-year-olds, their bone is very soft. So when they fall and hit their teeth, the teeth are more likely to get moved in the bone, which we call luxation injury, or to get knocked out altogether, which is an avulsion. 

As you get older, your bone gets more dense, so in the permanent dentition, especially our teenagers, their teeth are more likely to break or fracture. 

0:12:07

Dr. Mike Patrick: This was a new word for a lot of people, luxated. So that's when the tooth moves, but it doesn't fall out, correct? 

Dr. Janice Townsend: Exactly.

Dr. Mike Patrick: Just isn't where it's supposed to be anymore. 

Dr. Janice Townsend: Isn't where it's supposed to be or could be loose.

Dr. Mike Patrick: And we'll talk more about what you do for those things momentarily. I suspect that you see some common grouping age-wise of this kind of injuries. Talk about that. 

Dr. Janice Townsend: Yeah, so almost always, with the little ones that are starting to cruise, usually our two to three year olds, those are usually falls. They're up against furniture, coffee tables, things like that. And the teeth are moved in the bone, so sometimes they push the tooth into the bone. Sometimes, at the point you can't barely see the tooth and that's called an intrusion. Sometimes, they hit at a different angle and push it back towards the tongue. Kids are very creative. 

0:13:00

Dr. Mike Patrick: Yeah. And then, when sports seasons get started, I suspect that that's middle school and high school. You see a lot of teeth injuries at that point as well. 

Dr. Janice Townsend: Exactly. And those again, creative. They can either break them. We see more breaks or fractures in the permanent teeth but they can still move the tooth in the wrong direction or knock it out. So wide range.

Dr. Mike Patrick: And then, the teeth themselves can cause injury inside the mouth, so we see gum injuries and lip injuries and oral mucosa stuff. You guys deal with that, too? 

Dr. Janice Townsend: Exactly. So if the patient falls in a way or child falls in a way where their lips come in contact with their tongue or their gum, sometimes the lips can go through the tongue, through the gum, through the lower lip, and need to get stitches. 

Dr. Mike Patrick: Now, which of these injuries that you mentioned are really medical emergencies. So these things always happen in opportune times, right? Doctor's office is closed, dentist's is close. So parents are thinking, "Do I go to an urgent care? An emergency room? Is this something that can wait till the next day?" How do you know when it needs to be dealt with now? 

0:14:08

Dr. Janice Townsend: The most emergent type of injury is an avulsion or when a tooth is knocked out completely. So the losing of permanent tooth completely, that's an injury that every minute that goes by hurts the prognosis of the tooth. So those are medical emergencies for sure. That's the most emergent.

Dr. Mike Patrick: So if the tooth is out completely...

Dr. Janice Townsend: Permanent tooth.

Dr. Mike Patrick: Permanent tooth out completely, you're going to want to see someone right away. And we're going to talk more as we get into individual injuries exactly what you do for this. But this is where you would then just go to a pediatric emergency department or an urgent care center if it's after hours. How do you know where you're supposed to go if a tooth comes out? 

Dr. Janice Townsend: Well, parents actually, this is one knowing a little a bit of first aid that we're going to talk about can be very helpful and can save a tooth. Unfortunately, most medical providers don't get a lot of training in teeth injuries. So, having a dentist that has emergency hours or has a plan for what to do if your child falls is the best thing and to sort of have that plan in place before the injury happens. 

0:15:17

Dr. Mike Patrick: So this may be something that parents want to think about before they actually need this service. Just look up in your area, is there an emergency dentist available? If you have a pediatric emergency department near you, do they have pediatric dentists that are available? And if you're not sure what the answer is, talk to your doctor, right? Because they deal with these things and know where they have sent people in the past and where folks get good pediatric dental care. 

Dr. Janice Townsend: Yeah, our hospital does have a pediatric dental resident on call 24 hours a day, every day of the year, and that's rare. Most hospitals don't.

Dr. Mike Patrick: So beyond the permanent tooth coming completely out, are there any other emergencies that you want sooner rather than later?

Dr. Janice Townsend: Yeah. Anytime a permanent tooth is moved. Those luxation injuries, if we can treat those early before the bone has started to heal, it's a lot easier to treat. We're going to have a better prognosis.

So permanent tooth avulsion, most important. A permanent tooth displaced or in the wrong place, or very loose, that's also a medical emergency. 

And then, finally, primary teeth if it's interfering with function, if it's causing pain, if the child can't bite down all of the way, those also should be evaluated. 

0:16:31

Dr. Mike Patrick: And by primary tooth, you mean baby tooth.

Dr. Janice Townsend: Baby teeth.

Dr. Mike Patrick: And so if they're displaced, luxated, and to the point that then they can't really close their mouth because the tooth's in the way, then that can be a problem. 

And also, what about if they're really loose, we worry about those being kind of a choking hazard in young kids. Is that something, for the baby tooth, just go ahead and pull it out if it's really loose.

Dr. Janice Townsend: I would get a dentist to look at it because it might seem like it's really loose but might have a longer root than you expect. We don't want to cause unnecessary discomfort. But yes, if there's one just sort of hanging on, it needs to see, yes.

0:17:08

Dr. Mike Patrick: And that'd be sooner rather than later because again, you don't want your child necessarily sleeping, and then it does fall out and they choked on it. I've never actually heard of that happening. But we always worry about it and tell people that that's a possibility. 

And then, I would guess too if there's persistent bleeding in the mouth. It could be a sign that there's more of an injury, maybe a bone fracture, or lacerated gum, and so that might need to be seen sooner rather than later as well. 

But the chips and the cracks and those things in the teeth, those can wait?

Dr. Janice Townsend: They can wait but not long, probably until office hours. And again, if it's causing pain that can't be controlled with analgesics, things like that, maybe even the same day or night. 

Dr. Mike Patrick: So sooner is better than later, but if you can't get in to see anyone, at least the next day is going to be okay on the chips and fractures? 

Dr. Janice Townsend: Yes.

Dr. Mike Patrick: Now, when I talk to a dentist, so I work in the emergency department in our urgent care centers. And sometimes, dental stuff will come in and I'll ask to talk to a dentist. And the first thing they ask me is it a baby tooth or an adult tooth? Tell us why that makes a difference.

0:18:09

Dr. Janice Townsend: Primary teeth are meant to come out. So we do try to save teeth of all kinds. But if we lose the primary tooth early, there's really not a major problem. It's the opposite for permanent teeth. There's no good replacement for a natural tooth, and especially with the immature or the growing child's front permanent teeth. 

I think now that implants have become so popular, people think, "Oh, I could just get an implant." And you really can't get an implant until you're finished growing. So that's about age 22 or 23. And even in a young adult, as they continue to grow, you can see changes with implant. So we want to preserve that natural tooth when at all possible. 

So any permanent tooth injury, especially getting knocked out, getting displaced, we would like to see them and try to provide some kind of first aid for it right away. 

0:19:09

Dr. Mike Patrick: And I can tell you from personal experience that getting a dental implant, it's a long process. It's not necessarily a fun process. It can be expensive. So if you can preserve that tooth, that's definitely the better way to go than the implant.

Dr. Janice Townsend: Yeah. And psychologically, it's not good for kids to go for years and years without a tooth in the front. It can cause problems with braces. It's best to try to save that tooth. Now, there are permanent front teeth that we can't save but first aid is the best treatment for this. 

Dr. Mike Patrick: So how do you go about treating a chip or a fractured tooth? So it has a piece out of it or there's a fracture line. What do you do for those?

Dr. Janice Townsend: We almost always place a composite or a tooth-colored resin filling for those. And that's a great question because we treat those primary teeth or baby teeth and permanent teeth in a growing child differently that you or I as adults would get treated. 

0:20:07

So as an adult, if you are missing a big part of your tooth, you would probably get a permanent crown or something that's made in the lab to go over your tooth. But as your child is still growing, the tooth length is changing over time, the gum levels are changing over time. So instead, we would replace those with fillings and then when growth is complete, that's something that an adult dentist and the patient could discuss getting a permanent tooth. But we usually put a tooth-colored filling there. 

Dr. Mike Patrick: Do you ever have to do a root canal and a crown? Do you do those with baby teeth or is that just something that you would do with an adult tooth? 

Dr. Janice Townsend: We do primary root canal therapy with baby teeth. We only do that if we have a really good chance of saving the tooth. Also, if the child's cooperative. We don't want to unnecessarily have to sedate a child or put them to sleep for sort of a temporary tooth in the front.

0:21:04

And in permanent teeth though, yes, we do root canals. They're very routine. We don't do them unless they're necessary, but they're pretty straightforward procedures. I think sometimes the name gets people nervous, but it's really just like getting a filling done. 

Dr. Mike Patrick: Yes, tell us, what is exactly done on a root canal? You're right, a lot people, you hear this word but it's kind of a black box. What exactly is happening?

Dr. Janice Townsend: I think you could think of it as a deep filling. So whenever you've got a tooth, you've got the hard outer layer. It's the strong part we all see, but inside there's living tissue. It's like a nerve. It's sort of similar to your gum tissue, but it lives inside the tooth. When that nerve becomes exposed or when it dies, we go in there and remove it so that it can't cause an infection. And we put a filming material inside the tooth and then close it up. So it's like getting a deep filling.

0:22:00

Dr. Mike Patrick: That's a great way to put it. And then sometimes with this, if it's extensive fracture, sometimes you just have to extract the tooth? Especially if it's a baby tooth. 

Dr. Janice Townsend: Yes, baby tooth, when in doubt, it's better to remove it because if we leave a baby tooth and it's compromised and it gets an infection, that infection can actually affect negatively that developing permanent tooth that's below the gums. So when in doubt with the front tooth, we're usually more likely to take it out if it's a baby tooth.

Dr. Mike Patrick: And again, it's really good idea to get the opinion of a dentist, not just get it out yourself if it's pretty loose. 

Dr. Janice Townsend: Yeah. 

Dr. Mike Patrick: Not like you would when the tooth naturally becomes loose.

Dr. Janice Townsend: Yeah.

Dr. Mike Patrick: So let's talk about loose teeth with injuries. What do you do for those?

Dr. Janice Townsend: So normally, if it's loose or if it's been positioned a little bit in the wrong way, we'll put it back where it's supposed to go and then we'll place a splint. So a splint is sort of like braces. And we have different ones. I can tell you the best kind of splint for an injured tooth is actually a piece of fish line. 

Dr. Mike Patrick: Oh!

Dr. Mike Patrick: Right. So it's nice because it's clear. It adapts to the teeth well. And after the splint, you actually want the teeth to move a little bit. It's normally for teeth to move. We call it p physiologic mobility. And if we put like a big heavy wire in there where the tooth isn't moving at all, it's actually making the tooth more at risk to fuse to the bone. And that means that it won't grow down normally like the other teeth will. 

0:23:32

So we put on a flexible splint. We usually fix it in place with some of that composite resin material that I was talking about. And the teeth are a little loose and that's okay. The splint make kids more comfortable. And then, when the tooth is firmed up, then we take the splint off. 

Dr. Mike Patrick: So the splint, so it's connected from one tooth to an adjoining tooth, is that right? 

Dr. Janice Townsend: Yeah. And we try to usually sort of save that. The front teeth are loose, we usually will want to anchor the splint with two teeth that aren't loose on either side. 

Dr. Mike Patrick: And so it kind of looks like braces, other than it's more of a plastic if you're not using metal. Although, you said fish line. 

0:24:13

Dr. Janice Townsend: Mm-hm, it's a fish line, so the clear fish line. A 40-pound line one [24:18 XX] if you want to be precise for people who are fishermen. Again, what...

Dr. Mike Patrick: Yeah, and that's what you're attaching from one tooth to the other with just a little bracket or something with glue? Or...

Dr. Janice Townsend: Well, actually, we just glue it straight on the teeth. And there's different ways to do it. Some people do use metal wires. And if it's a very flexible wire, that's okay. I think sort of intuitively, you would think I want something big and heavy and strong to make sure this tooth stays really in place. And that, we found out, is called a rigid splint and it can actually be dangerous for teeth.

Dr. Mike Patrick: So you put glue on the tooth and fishing line. This is great, okay. But don't try this at home. 

Dr. Janice Townsend: Don't try this at home. 

Dr. Mike Patrick: This is not Elmer's Glue kind of stuff, right? You would want to see the dentist to have this done. 

Dr. Janice Townsend: And this is not something that I just invented. There's study after study, I promise that.

[Laughter]

Dr. Mike Patrick: Yeah, no, no, no. I trust you, you're chief of Dentistry at Nationwide Children's Hospital. I completely trust what you're saying.

And then, you mentioned if the tooth has moved, you want to reposition it and put it back. Is time of the essence with that? Is that something that you should do, especially with an adult tooth kind of at the scene? Or can that wait till you get in to see the dentist and let them do it?

0:25:23

Dr. Janice Townsend: I would wait and let the dentist do it, but time is of the essence. Now, if it looks like if you just leave the tooth the way it is, if it's hanging out of the socket and this is a permanent tooth, a permanent tooth that's hanging out of the socket, you could gently have the child bite down on a wash rug or paper towel just so it doesn't fall off. But the dentist can reposition it as well. 

So I would only do this at home, if you feel like I don't do anything, the tooth's going to be knocked out because we don't want to knock out a tooth. Otherwise, the dentist can do it. 

But yes, the sooner that we can see them, this is easier. The bone hasn't started to heal yet. The socket's still soft. Unfortunately, I've had patients over the years that could not access the dentist because, like I said, many emergency departments don't have dentistry. I would see them two days later. And it was almost impossible to reposition those teeth the way it should be and also very uncomfortable. 

0:26:21

Dr. Mike Patrick: And it makes a really big difference for adult teeth, right? 

Dr. Janice Townsend: Yes, adult teeth. 

Dr. Mike Patrick: Because worst case with the baby tooth or primary tooth, it's knocked or it's moved and its blood supply's compromised, it's going to fall out. But it was going to fall out anyway. But the adult teeth really, you want to avoid permanent damage to those. 

And this may be a good reason, too, to have a good working relationship with a dentist that you're seeing every six months because they probably have some sort of on-call system, anyway. And it's much more difficult to maybe find a dentist after hours if you don't have a relationship with one already. So that will be a good reason to be in and seeing someone on a regular basis. 

0:27:04

Dr. Janice Townsend: Yeah, I feel very strongly that one of our obligations as dentists is to have some kind of access for emergency after-hour patients. Now, does that mean that every dentist is going to get up in the middle of the night because somebody's tooth hurts? No, but again, for these types of permanent teeth that are getting knocked out, severely injured.

And what a lot of offices will do is they'll have a group where maybe you cover call for one week. So you might even be going to a different office than the person you normally see, but at least you have someone after hours. But I think that is great question for every parent listening that next time they go to the dentist or maybe even call up and say, "Hey, you know, what would I do if my child were to knock out a tooth?" 

And the parents of Columbus are very fortunate that we do have Nationwide Children's Hospital here. Like I said, most general hospitals don't have this. And if their answer is "Oh, go to the urgent care, go to the hospital," you have to wonder what kind of treatment are you getting. And you're an emergency physician, did you get a lot of dental training in med school?

Dr. Mike Patrick: No.

[Laughter]

0:28:13

Dr. Mike Patrick: That is easy, no. And I have worked in other places too where there was not the strong dental presence that there is here. And it is wonderful. I have worked in an urgent care in Florida where there was no dental program associated with any of the children's hospitals and most of the dentists would not take any phone calls if it wasn't their established patient. So there is definitely a challenge in some places for sure. 

One thing I came across as I was researching this episode was this idea that you can stimulate stem cells in the pulp when some of these teeth are kind of loose or they're misplaced and you're manipulating them. Tell us what that's all about. 

Dr. Mike Patrick: This is an emerging area. So I might get a little deep here. But when kids are only seven, eight, nine years old, their tooth hasn't fully formed. So you might be able to see the whole tooth in the mouth but the root of the tooth maybe has only formed half of it or a third of it. And if that tooth dies or becomes necrotic and we have to do a full root canal, the tooth isn't going to grow any longer. So it's not going to be a forever tooth, because there's not enough root to anchor it in the mouth.

0:29:29

One of the therapies that we do is called regenerative endodontics. And this is an area Nationwide Children's Hospital has historically had a very strong dental trauma program led by our faculty member, Dr. Dennis McTigue. And this is an area that we were some of the first people to be doing this procedure.

But we go in there and instead of taking out the nerve and putting out a filling like we normally do, we put in an antibiotic or a medication to kill all the bacteria, and then we stimulate those stem cells to regrow back in. And the tooth can go from being a dead tooth to alive again. 

0:30:11

And the advantage of that in a growing child is instead of only having half a root, you can have a full root. So regenerative endodontics, definitely using stem cell therapy. And we're very excited about that. And it's a procedure that we do perform in our dental clinic here. 

Dr. Mike Patrick: Yeah, that is fantastic. Now, I'm sure there's some parents who are hearing this and thinking how do you stimulate a stem cell? What does that look like? 

Dr. Janice Townsend: Well, I wish I could say it a little more fancy but we poke it. 

[Laughter]

Dr. Janice Townsend: You take something longer than your root and you poke beyond the root of the tooth. And when you do that, that blood brings in the healing cells, brings in the stem cells. And the bleeding is what forms a matrix for the new nerve tissue to grow in. 

Dr. Mike Patrick: Yeah. And I can just imagine like how someone stumbled upon that this works. Maybe they were probing a little too deep and they started to notice, hey, when I do that, things are actually better, not worse. And it's just kind of interesting how sometimes new therapies emerge. I'm sure there's a story there somewhere. 

0:31:15

So let's move on to knocked-out teeth. So now, a tooth actually comes out. If it's a baby tooth, just ...

Dr. Janice Townsend: Leave it out.

Dr. Mike Patrick: Just leave it out.

Dr. Janice Townsend: And don't put it back in. 

Dr. Mike Patrick: Okay.

Dr. Janice Townsend: Because as I said, the permanent teeth that are forming up there especially in children in ages two to four, think of it like wet concrete. So if you go in there and if you shove something in that wet concrete, it's going  to leave an imprint. So if we push that baby tooth back in, the force of the root going in, of the blood going in is going to come in contact with that developing tooth. And you can injure the tooth. It could have either a defect on it. There's cases where the permanent tooth never fully forms. 

So I have some parents that had not been happy that my recommendations is we're not putting the baby tooth back in. But again, you've got a risk benefit. We've got a temporary tooth that's only supposed to last till age five versus a tooth we want these kids to be a 100 with his front tooth. And I'm not going to put that permanent tooth at risk. So baby tooth out, it's time for the tooth fairy.

0:32:18

Dr. Mike Patrick: And really good advice, so folks remember this. Baby tooth comes out, you leave it out. But if a permanent secondary tooth or adult tooth comes out, that's a whole different story. 

Dr. Janice Townsend: Then you put it right back in. And that's something that this is where parents, grandparents, knowing that appropriate first aid can make the difference between losing a tooth or not. So permanent tooth comes out, the best thing that anyone can do is put it right back in and have them bite on something like a wash cloth or a paper towel and go to see a dentist to get that brace put on. If you put it on the wrong socket, if you put it in backwards, that's still better than it being out. 

0:33:03

These teeth are covered in a very fragile kind of cell. It's called a periodontal ligament cells but those cells, every minute they're exposed to air that they don't have a blood supply, they're going to die. And once those cells die, then that tooth is going to fuse with the bone. 

And as you grow, when you're eight, it might be okay. But by the time, they're 12, there's going to be about half an inch difference between one of the front teeth and the tooth that's fused to the bone. 

So we want to keep those cells alive and happy. And so, the best thing is to take it and put it right back in. If it's covered with a lot of dirt, you can do the quickest rinse with water, but not a lot. Water's actually very dangerous to those cells. They can cause them to break or rupture. 

So don't go in there and scrape them off, we want to keep the cells. You could do a very light rinse with water, but the key is to get those teeth right back in. 

Dr. Mike Patrick: Yeah, warm water. Cold water, room temperature water, it doesn't matter. 

Dr. Janice Townsend: Honestly, if you could rinse it out with milk, that would be better. Because like I said, the cells, if they come into contact with water, the water will flood the cells and make them burst and die. So that's the 100% best thing, put it right back in.

0:34:19

If you can't, then that's when you can put it in what we call a physiologic solution or something that's sort of similar to the blood supply. Cold milk is the thing that most people have at home. So right back in is the best. If you're worried with other injuries, things like that, that you're afraid to put it right back in, you can put it in cold milk and go to the dentists or to a medical facility immediately. 

Every minute it's out of the mouth, the cells are more likely to die. If the tooth is scraped, their cells are scraped off, they're almost always going to fuse with the bone and the tooth will be only be a temporary tooth. If you store them in water, the cells are all going to sort of explode and the same thing's going to happen. So it's very important that everybody knows that first aid.

0:35:14

Dr. Mike Patrick: As we think about cells exploding, it's a great opportunity to say, "Hey, science matters." Because kids in biology class, you learn about osmosis where water moves across the semi-permeable membrane from where there are less particles, where there's more particles. And so, the water is actually going to go into the cell and then it explodes because water is moving where there are no particles in the plain water. That's cool. I love science.

So the rinse is only if you see a lot of debris.

Dr. Janice Townsend: Yeah.

Dr. Mike Patrick: I mean, otherwise... 

Dr. Janice Townsend: Just put it back in. 

Dr. Mike Patrick: Just put it back in. You really don't need... And if you're going to do the rinse, it's going to be really general, really quick, and just to try to get any dirt and gravel or whatever off of it. If you don't feel comfortable and you don't have to orient it just right, just stick it in there. 

Dr. Janice Townsend: Again, if you could get it to be the way it was before, that would great. 

Dr. Mike Patrick: But don't spend a lot of time. 

Dr. Janice Townsend: Don't spend lots of time. And the dentist, I've had that happen where physicians who weren't doing the right thing put the right tooth in the left socket, and the left tooth in the right socket. It was just a matter of seconds to take them back out and put them in the right place. And that's easy for the dentist to do. What we can't do is once those cells are dead, we don't have any therapies to bring them back to life.

0:36:26

Dr. Mike Patrick: Now, emergency medical folks, there's some kind of special dental solution that people can buy, right? And emergency rooms and urgent cares might have them on hand or maybe EMS. Is that necessary? 

Dr. Janice Townsend: It's called Hanks Balanced Salt Solution. Honestly, you can go online and look for it. I can't remember the trade name it's sold under. If you have it, wonderful. But I wouldn't want to keep the tooth out and dry and let those cells die so you could go to the store and buy it. Then, just use the cold milk.

Dr. Mike Patrick: And then I've also heard, so you're at the playground. There's no cold milk around. I've heard you can use spit. 

Dr. Janice Townsend: You can. Spit's not a...

0:37:09

Dr. Mike Patrick: You don't sound enthused about this.

Dr. Janice Townsend: I don't sound enthused about it. The spit seems very natural because your teeth are already in spit. But only the crowns of the teeth or the teeth parts that are visible are in spit. The roots in spit, that's not really ideal. And our saliva or spit has a lot of bacteria. So it's not ideal but if it's better than dry, and it's better than water.

Dr. Mike Patrick: And it doesn't have to be the child's spit, right? It could be the parent's spit. 

[Laughter]

Dr. Janice Townsend: Let's just put the tooth back in. 

Dr. Mike Patrick: Okay.

[Laughter]

Dr. Mike Patrick: All right. I can see the kid with bleeding and the tooth's out is probably not going to be really excited about spitting into it. If you're in the playground, you probably don't have a Dixie cup or something to stick the spit in anyway. So stick it back in the socket.

Dr. Janice Townsend: Stick it back. 

Dr. Mike Patrick: Let's move on to gum injuries. Do you see those very often with trauma? 

0:38:06

Dr. Janice Townsend: Yeah, we definitely do. The nice thing about the inside of the mouth is that it's very forgiving. So we'll have cases where the kids will have what we call laceration, to be all fancy. That the kids  will have a laceration, it looks really bad. And then, they come in a week and a half later, and it's perfectly healed over. 

You don't scar inside your mouth. All the cells inside your mouth turn over about every two weeks. So if it's something very deep, that may be food to get stuck in, that would just be uncomfortable, we might do a stitch. Most of the time, we don't even stitch it up and it heals very nicely on its own. 

Dr. Mike Patrick: Yeah, the mouth is amazing that way, isn't it?

Dr. Janice Townsend: It is. 

Dr. Mike Patrick: In just how quickly it heals. And then, if you have prolonged bleeding or the gum is gaping, those might be some reasons that you would have that sewn up. And the dentist do that, correct? 

Dr. Janice Townsend: Yes.

Dr. Mike Patrick: You deal with gums and teeth. 

And then, we talked about this a little bit in our last podcast that we did together. Some kids have that little flap of skin called the frenulum that kind of connects between their upper gum and between their two front teeth. What if that's injured?

0:39:18

Dr. Janice Townsend: It's not a problem. And again, the only time we would ever stitch that is just like you said, if it wouldn't stop bleeding. If it was a deep gap that may be something could get stuck. But that's a common target for injuries. And it normally heals on its own within a week and a half and it's fine. 

Dr. Mike Patrick: You just leave it alone? 

Dr. Janice Townsend: Mm-hm. 

Dr. Mike Patrick: Gotcha. And maybe it won't be there after. 

Dr. Janice Townsend: Yeah. 

Dr. Mike Patrick: It just kind of reabsorb and... 

Dr. Janice Townsend: You just save yourself a surgery. 

Dr. Mike Patrick: Yeah, yeah. Although, there's [39:44 XX] always have to have [39:44 XX]... We talked about that last time, right? 

Dr. Janice Townsend: Not at all.

Dr. Mike Patrick: Sometimes, they just go away on their own.

Dr. Janice Townsend: And a lot of kids take care of it themselves [39:50 with their XX], I promise. 

Dr. Mike Patrick: There you go.

[Laughter]

Dr. Mike Patrick: And then, what about structures inside the mouth -- tongue, palate injuries -- who treats those, when things are more extensive?

Dr. Janice Townsend: We treat. A lot tongues, ourselves, pediatric dentists. And the tongue is another one that I've seen some terrible looking injuries. Tongues are really hard to stitch. Try to stick out your tongue and hold it still. It's impossible. It's always in motion. It's hard to stitch. And it's a lot of it is injuries we don't do anything to and they're fine.  

0:40:22

So you would still want to get it examined. But tongues, usually, pediatric dentist, if it's something a little more intense, then we may consult an oral surgeon. But usually, they should heal up on their own. The roof of the mouth, again, very rarely needs any kind of treatment. But if it were something in the back, the soft palate -- I've had kids who are running with pencils and things in their mouths fall -- an injury back there, we would probably consult either our oral surgeons or our ENT colleagues. 

The one thing you do want to be careful about, and I've seen this happen where kids will go somewhere and get some stitches placed in their lip at an urgent care, at emergency room, and then, they'll come the next day and see the dentist, and they're missing half a tooth. They've got a big laceration on their lip. We're wondering where's the rest of that tooth? 

0:41:17

We'll take an X-ray, and I have had to cut out some stitches, remove the piece of tooth that was embedded either in the tongue or in the lip and then resuture them again. 

So if there's a broken tooth, it's always good to know where that is before you get any lacerations sutured or stitched up because sometimes you can stitch the piece of tooth in there and that's not ideal. We need to remove it so it doesn't cause an infection. 

Dr. Mike Patrick: This is a word of awareness and warning to urgent care and emergency medicine staff. If a tooth, if part of it is missing, try to figure out where it is before your sew something close. And you could do that for just exploring the wound but you can get an X-ray if you need to.

Dr. Janice Townsend: X-ray's ideal. And the dental X-rays, we take an extremely low radiation. They show it and I've had plenty of cases where I'll go in there and pretty easy to get the piece of tooth out and then I'll glue the tooth right back on. 

Dr. Mike Patrick: Oh, nice. 

Dr. Janice Townsend: And actually, that's a good point. I failed to mentioned that. When you break a tooth, we do tooth-colored fillings. But if you have that piece of tooth, we can glue that back on in a lot of situations. And that's ideal because it's already the right shape and the right color. 

0:42:25

Dr. Mike Patrick: And that's for both baby teeth and adult teeth or just adult teeth? 

Dr. Janice Townsend: Just adult teeth. Baby teeth don't tend to just break. They tend to shatter into a lot of pieces. So every once in a while, we'll have a kid come in there, just a chip is off the baby tooth. But usually, if it's a big injury, you'll see lots of cracks all through the baby tooth, and it usually needs to be removed. 

Dr. Mike Patrick: Going back to tongues, just very quickly. Sometimes, we do see lacerations that are kind of big in the middle of the tongue. I always tell people, there are folks who pay for that, right? I mean, people poke holes on their tongue on purpose. And if you take out that tongue ring, it will start to heal even then. So those do heal just fine on their own most of the time. 

0:43:13

Dr. Janice Townsend: Yeah, we're very fortunate the mouth heals so well and doesn't leave scars. 

Dr. Mike Patrick: Yes, great. And then, let's say that you have a dental injury that you do wait too long or you don't go at all. What kind of complications can arise if you don't seek treatment in fast fashion. 

Dr. Janice Townsend: So pain, obviously. Pain can happen. And then, also infections. So with the baby teeth again, kids bump their baby teeth. Maybe their gums bled a little bit but stopped. They decided not to do anything about it. And we have kids four weeks later that will come in with little pimples, pain, and infection from the tooth dying.

So some of these emergencies are not middle-of-the-night emergencies. But they should see a dentist ideally the next day or within a week, even if it doesn't seem like a severe injury because you can have long-term effects.

Same thing, it's a permanent tooth and you've knocked off a piece of it, it may not be something that needs to be seen in the middle of the night, but we do want it seen the next day or within a couple of days to get sealed up so it doesn't cause any kind of infection that could require a root canal. 

0:44:27

Dr. Mike Patrick: Yeah, we want to avoid infection at all cost. And then, there's the cosmetic issues, too. It's easier to get a good fix if you do it quicker rather than waiting longer. 

And then, in terms of prevention, what are just some things that parents can do to sort of prevent this from happening in the first place? 

Dr. Janice Townsend: You mean other than bubble wrapping the kid?

Dr. Mike Patrick: Yeah. 

[Laughter]

Dr. Mike Patrick: Yes. 

Dr. Janice Townsend: So the little kids and coffee tables and fireplaces are culprits. So baby-proofing the house, not just for dental safety but for overall safety for falls. So having all those sharp corners and covered with something that's forgiving so you don't have those types of injuries. They are sort of inevitable in some ways in the little kids that they are going to fall and bump their teeth. 

0:45:12

In the permanent dentition, we most commonly associate dental trauma with sports. So wearing mouth guards do protect teeth. Now, most of the injuries I see are not during competitive sports where mouth guards are required. It's usually just the pick-up basketball game. 

So having a mouth guard for basketball and little games, even just learning to ride the bike, we see a lot of bicycle accidents, it's okay to have the kids wearing mouth guards just like they wear helmet. Having them wear that mouth guard can help protect those teeth. 

And usually, that seven-year-old stage as the teeth are coming in, they may be sort of jutting out a little forward. And we call that Ugly Duckling stage. That's a common stage for dental trauma. It's also one of the most dangerous stages because the teeth haven't fully formed. And as we talked about, if the teeth get knocked out or die early, it can be hard to get them to be their full size and shape of the root. 

0:46:17

Dr. Mike Patrick: Speaking of mouth guards, there's so many options. There are ones that are free formed. There are ones that you boil and bite. You could get custom fitted ones. What do you recommend?

Dr. Janice Townsend: I think that kids who are playing competitive sports, especially high risk sports such as basketball, football, baseball, I don't know. I feel like cheerleading, I've seen a lot of cheerleading... 

Dr. Mike Patrick: Yeah, just [46:36 XX]. 

Dr. Janice Townsend: Yeah, all of those, when they're really a good investment in a professionally made mouth guard. We invest in all kinds of other sports equipment, like the best bat, the best mitt, the best basketball, best shoes, why wouldn't we want to invest in protecting our teeth? So I think that's ideal. 

Now, if you got kids that the teeth are coming in, falling out every other week, and you want to protect them for learning to ride a bicycle, the scooters, the corner game of basketball, you could buy one of the boil and bite ones and just carefully adjust it. Sometimes, if they're too bulky and they don't fit, that's when the kids just take them out. 

0:47:18

So getting a fitted one or getting that you fit as well as you can is going to make it more likely for the kids to wear it. 

Dr. Mike Patrick: And the custom fitted ones, is that something the service you provide in the dental clinic here, or no? 

Dr. Janice Townsend: Most dentist will make the mouth guards. That's something that you definitely should speak to your dentist about. And they're pretty easy to make. And again, even if they're more expensive than the boil-and-bite ones, if it's something that the kids will actually wear, and if it can protect their teeth a long-term, it's worth the investment.

There's some estimates out there. We don't have the best data on this, but there's estimates out there that show that loss of a permanent tooth cost about $20,000 over the lifetime of the tooth. And it's one of those things, it's just a body part that's really hard to replace. I'll worry again that we make it seem like there's this easy solutions and they're not. 

So even getting a cap on a tooth, it will eventually have to get replaced over the years, things like that. So investing in prevention is money well spent. 

0:48:24

Dr. Mike Patrick: Got you. Is there a benefit in seeing a pediatric dentist specifically for these injuries compared to a family dentist?

Dr. Janice Townsend: I don't want to make generalizations because I think that there are some family dentists who have a big interest in sports dentistry, things like that. But as part of almost every pediatric dentistry program, they're expected to take that after-hours trauma call. And that's not part of dental school. 

This is something that I've actually done research in that we developed a special program at my  old dental school. But dental schools are open between 8 and 5, and they're usually very structured about who can go there. 

0:49:05

So almost no dental students see a kid walk in to dental school with a mouth injury. At my own dental school, it maybe happened twice a year. So that's only about two to four students learning from it. The way you really get to learn how to manage injuries is being on call in a busy emergency room where you're seeing lots of them. And that should be an activity that pediatric dentists do in their training. 

Now, again, not to brag, but I feel like the residency program here at Nationwide Children's Hospital, we see as much if not more trauma than anyone in the country. That's why we have the internationally recognized program in dental trauma. So I did my residency here, I feel like within the first month, whatever walked in the door, I was like, "Yeah, I can do that."

So I feel incredibly confident. Some residency programs that may be are based in dental schools or community care clinics, maybe don't have that same high volume. 

0:50:07

So again, if it's a general dentist that's done a special general practice residency, maybe has a special interest in sports dentistry, they may be well trained in this. But it's not part of the normal dental school curriculum. 

Dr. Mike Patrick: Do the dental students at Ohio State rotate through with you, guys? Or is it pretty much just the fellows or the ones doing the residency? 

Dr. Janice Townsend: They rotate here through the day. And then, certain ones who have a special interest can come in and just observe at night. 

Dr. Mike Patrick: It would seem that if you're going to going into family dentistry especially if you are in a small town, that might be a good idea to take advantage of that part of the program. 

Tell us really quickly, so someone's listening and they've been interested in becoming a dentist, what does that look like? How do you become a dentist, then a pediatric dentist? 

Dr. Janice Townsend: Well, that's a great question. We always like to recruit. So dentistry is a post-doc degree. So what you do is you typically go to undergraduate, to college for four years. So you go to four years, there are certain classes that are required to take in college. And then, usually, the end of your junior year, sort of summer before your senior year is when you apply to dental school.

0:51:24

It's gotten quite competitive. And it's a great career, I love what I do. And I think a lot of people want to do it, so it's gotten quite competitive that you would apply before your senior year and then you would interview and go to school. 

Now, we have other people who finished college maybe before they go to dental school. They want to get an advanced degree in something else, so we have people that come in with other types of degree such as masters of public health, about other things. 

We also have people that maybe had one career already and feel attracted to some of the benefits of being a dentist offer, such as really getting a good relationship with your patients, getting to be a business owner, things like that. So I've had dental students with a lot of different backgrounds. 

0:52:09

And then, in dental school, you get exposure to lots of different specialties. So our goal is for our dental students to be able to go out and do a little bit of everything. But along the way, some of those dental students really develop a passion for treating kids and help making the lives of children better. And they may want to specialize and only see children. So that's when you do a pediatric dental residency. 

Again, I would say the majority apply before their last year of dental school, but we have people that have gone out, been in practice for years, realized that they really would be more fulfilled only treating children and come back to our residency program. 

Dr. Mike Patrick: Really, I've mentioned this before, but it's such a great service in having the dentist being willing to come in and see these kids with dental trauma. It really does make a big difference. And it really is a shame that there isn't that kind of support in lots of other places. 

0:53:12

Well, Dr. Janice Townsend, thank you so much for stopping by today. We're going to have a lot of links in the show notes for you over at pediacast.org for this episode, 429. Of course, we'll have a link to Pediatric Dentistry here at Nationwide Children’s Hospital. 

We talked last time about some of the services that you guys offer. Remind us what those are. 

Dr. Janice Townsend: Yeah, so we are the dental home for some patients. And what I mean by dental home is some kids, they come and see us ideally by age one. They get their first exam. They come back every six months for their cleanings. And if they have needs, such as needing fillings, if they have trauma, we're their place that they go. So we're their dental office. 

We have other families that have to travel a long way. And maybe because either that patient at that point time maybe has a lot of needs. Maybe they have a trauma that needs a specialist to see them. Or they're very young and have a lot of cavities. Their general dentist may refer them to our clinic, sort of for a limited treatment with the understanding that we're not going to be their forever dental office, but we're going to take care of their needs then. 

0:54:21

So we welcome children of all ages up to age 18. And we do like to see the really little ones because most other dentists won't see them. So we're willing to see them. 

Also, families that have children with special healthcare needs. Maybe they're getting treatment at Nationwide, or just somewhere families would feel more comfortable with their children getting seen in a hospital setting. We welcome those families as well, and we have families that drive across the state from different states just to be seen at Nationwide Children's in this hospital environment. 

Dr. Mike Patrick: It really is that good. Really. And we'll put a link to the Pediatric Dentistry program here at Nationwide Children's. Of course, we'll also have a link to the previous episode that you did on infant teething and toddler tooth care. 

And then, the American Academy of Pediatric Dentistry has a great website with information for parents. One of the resources that they have is an article called Can You Handle a Dental Emergency. And it's got a lot of pictures and great information there. And we'll put a link to that in the show notes as well. 

0:55:23

So once again, Dr. Janice Townsend, chief of Pediatric Dentistry here at Nationwide Children's Hospital, thanks so much for being here today. 

Dr. Janice Townsend: Thank you. 

[Music]

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 a part of it. I really do appreciate that.

0:56:09

Also, thanks to our guest, Dr. Janice Townsend, chief of Pediatric Dentistry at Nationwide Children's. Always a pleasure having her stop by the studio and sharing her expertise on everything tooth here on PediaCast. Because as she pointed out, pediatricians do not get a lot of training on dentistry. And she was right about that. So it's always great having her stop by and sharing her knowledge with us. 

Don't forget, you can find PediaCast in all sort of places. We are in the Apple podcast app, iTunes, Google Play, iHeartRadio, Spotify, and now, SoundCloud where we have some playlists. And we'd love for you to like us on SoundCloud and maybe start a little community action with the parents and the pediatric providers in the crowd. That would be super fantastic. We'll see, we'll see if that happens. 

We also have our landing site where you will find our entire archive of past programs, show notes, transcripts, our Terms of Use Agreement and a handy Contact page to ask your questions or suggest a topic for the program.

0:57:10

Reviews are always helpful wherever you listen. Always do appreciate that.

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And that does include your child's pediatric healthcare provider so that they can raise some awareness about the program. Maybe they'd like to listen, share it with their other families that they take care of. 

And while you have their ear, let them know we have a podcast for them as well. It's called PediaCast CME, stands for Continuing Medical Education. Very similar to this program. We turn the science up a couple notches and offer free Category 1 Continuing Medical Education Credit for those who listen. Shows and details are available at the landing site for that program, which is pediacastcme.org. 

That one's also in Apple Podcast, Google Play, iHeart Radio, Spotify, wherever you find podcasts. Oh, SoundCloud, too! Simply search for PediaCast. 

0:58:17

Thanks again for stopping by, and until next time, this is Dr. Mike, saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.

[Music]

Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.