Tooth Care – PediaCast 189

Welcome back to another PediaCast!  Today Dr. Mike discusses tooth care in infants and children with special guest Dr. Elizabeth Gosnell, a pediatric dentist at Nationwide Children's Hospital.


  • Tooth Care


  • Dr Elizabeth Gosnell
    Pediatric Dentist
    Nationwide Children's Hospital



Announcer 1: This is PediaCast.


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!

Mike Patrick: Hello, everyone, and welcome to PediaCast, a pediatric podcast for moms and dads. It's Dr. Mike coming to you from the campus of Nationwide Children's in Columbus, Ohio. Is it Episode 189 for November 15th, 2011. We're calling this one 'Tooth Care' because we have a pediatric dentist with us in the studio today.

Before we get started, I have to prep us. I still have a cold, still dealing with what we call the 'kiddie crud' around here, it's just one of the side effects of working in the emergency department and in the urgent cares, but just bear with me. So if there's some awkward coughing or pauses as I need to get a drink, you'll understand.


I also want to remind you that PediaCast is really your show, and if there's a topic you'd like us to talk about, it's easy to get a hold of me. Just go to and click on the Contact link. You can also email and we have a voice line at 347-404-KIDS. That's 347, 404, K-I-D-S. So if you have a comment or a question, you can leave a message there and we can get you on the show that way as well.

I also want 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, as always, if you have a concern about your child's health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also, your use of this program is subject to the PediaCast Terms of Use Agreement, and you can find that over at


All right. Our guest today is Dr. Elizabeth Gosnell. Did I say that right? Is it Gosnell?

Elizabeth Gosnell: Yes, you did.

Mike Patrick: All right.

Dr. Gosnell is an assistant professor in the Division of Pediatric Dentistry in Community Oral Health at the Ohio State University College of Dentistry. She's also Director of the Pre-Doctoral Dentistry Program at Ohio State, I'm sorry, the Pre-Doctoral Pediatric Dentistry Program. She earned her dental medical degree from the Medical University of South Carolina and completed additional training in pediatric dentistry at the Ohio State University and Nationwide Children's Hospital.

Welcome to PediaCast, Dr. Gosnell.

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

Mike Patrick: Now what is the difference between a DMD, so you have a dental medical degree, correct?

Elizabeth Gosnell: I do.

Mike Patrick: What's the difference between that and DDS?

Elizabeth Gosnell: Unfortunately, there is no difference. I'm not sure why we have two different degrees, but there is no difference in treating.


Mike Patrick: Because sometimes you see dentists with a DMD and sometimes with the MD.

Elizabeth Gosnell: Exactly. That's Doctor of Dental Surgery.

Mike Patrick: Interesting. I know in the physician industry, there's MDs and DOs and there is kind of a tradition, I mean, they're very similar now in terms of training, but once upon a time they were different. But that's not the case with this.

Elizabeth Gosnell: That is not the case. There is probably a historical reason why, but now there is no difference.

Mike Patrick: And it just kind of depends on the university, which degree that they give.

Elizabeth Gosnell: Exactly. That's right.

Mike Patrick: But you take the same boards and you do the same training and all that business?

Elizabeth Gosnell: We do. Yeah, same training.

Mike Patrick: Great.

So let's start. When should kids, and this is what pediatricians get asked a lot when babies are coming in for their well-child visits, parents ask, 'When should I take my baby to see a dentist for the first time?' What do you think?

Elizabeth Gosnell: Sure. Our governing body, the American Academy of Pediatric Dentistry, recommends that all children see a dentist by the age of one to establish a dental home, which actually came from the idea of pediatrics where we have a medical home.


However, there are some children, some populations like with children with special health care needs, so we may recommend an earlier visit prior to the age of one. It kind of depends on the risk assessment as well as the patient's needs.

Mike Patrick: Should that be a regular dentist or a pediatric dentist? Does it make a difference?

Elizabeth Gosnell: Unfortunately, there aren't enough pediatric dentists in the country to see all of the children, so a general dentist that feels comfortable seeing children is perfectly fine. A general dentist may, however, refer patients to see a specialist, and that's what we're here for.

Mike Patrick: And that's going to be more of an issue, really, in smaller communities and rural America where you might not pediatric dentists around.

Elizabeth Gosnell: Exactly. There isn't access to care problem in rural communities, exactly like you said, so we see a lot of patients from hundreds of miles away, which needs to be addressed.

Mike Patrick: Yes, yes. Now, let's say, obviously if there are special needs, it's going to be dictated patient by patient exactly how often that they should go in to see the dentist, but how often sort of routinely should kids be seen? Is it every six months like adults or is it more often, less often?


Elizabeth Gosnell: The most common period recall that we recommend is six months. Depending on the child's needs and their risk for cavities, we may recommend every three months. And we may change that period depending on if things change. Like if a diet or hygiene of a child changes, or if their physical condition changes, we may change that period recall.

Mike Patrick: Now, once the teeth erupt, how should parents start caring for the baby's teeth? Let's say it erupts before they get in to see the dentist for the first time. Do they need to do anything?

Elizabeth Gosnell: We would like them to go ahead and start brushing the child's teeth as soon as they start seeing them erupt. They can use a small amount of fluoridated toothpaste with the toothbrush and then just wipe off the excess afterwards.

Mike Patrick: Just a small amount, and it should have fluoride in it?

Elizabeth Gosnell: It should have fluoride in it.

Mike Patrick: So these pediatric toothpastes that say 'does not have fluoride in it', those should not be used.

Elizabeth Gosnell: Correct, yes. We recommend just a small amount. Unfortunately, some people believe that they should not be using fluoride, but we recommend that just a very small amount is used, and then wipe off the extra.


Mike Patrick: Got you. What if they swallow some of it?

Elizabeth Gosnell: If they swallow, just that small amount is going to be no harm.

Mike Patrick: Yup. So on the toothpaste tube, it will say, 'use a pea-size amount'. You see that a lot.

Elizabeth Gosnell: Exactly.

Mike Patrick: Even for an infant, is that about what you would put on the toothbrush?

Elizabeth Gosnell: For an infant, we would recommend just a smear, meaning you can just see a small layer on the tip of the bristles of the brush.

Mike Patrick: So just a film.

Elizabeth Gosnell: Exactly, a film.

Mike Patrick: And how many times a day should they do that?

Elizabeth Gosnell: Twice a day.

Mike Patrick: Does it matter how that relates to their feeding schedule?

Elizabeth Gosnell: It does. If they are feeding at will, we may recommend brushing more often, or at least wiping off the excess of formula or milk.

Mike Patrick: Just with the wash rag?

Elizabeth Gosnell: Just with the wash rag.

Mike Patrick: Got you. And they should do that every time they feed?

Elizabeth Gosnell: It kind of depends. Exactly like you said, if they're frequent feeders or at-will feeders, we may recommend more frequent, if they're more at risk for getting cavities. However, if not, then just twice a day is fine.


Mike Patrick: Got you. I wonder, too, if, I'm getting off of what we agreed to talk about, but it just came to mind. It seems that sometimes more cavities run in families, and I don't know if that's because of the genetics of the tooth, the shape of the tooth and pits and grooves and that sort of thing. I'm not a dentist, so you've got to bear with me a little bit.

Would it make sense if there's sort of a family history of more cavities that you would be more careful about wiping the teeth off after every feeding, whereas if you have a family where Dad's never had a cavity and Mom had one, and there's a sibling that maybe had one, you know what I'm saying, then you wouldn't worry about it so much.

Elizabeth Gosnell: We do ask parents about their own oral health during their visit, because the bacteria in the parent's mouth can be transmissible to the child, and the bacteria in the parent's mouth, if it's more virulent and have caused aggressive cavities, it can do the same in the child's mouth. So yes, that is something that we consider.


Mike Patrick: All right. Now, I guess a lot of parents would be asking, if we're going to start fluoride before my baby's even a year old, is that going to be harmful? I guess a good place to start would be just to describe how fluoride helps with dental health, and then we can talk about what the risks are, just so we get a well-rounded conversation.

Elizabeth Gosnell: Sure. No problem.

So fluoride. Fluoride is a wonderful thing when used correctly. Fluoride can prevent cavities, it can stop cavities from progressing, and it can even reverse the process of cavities. How fluoride works is actually incorporates into the outer layer of the tooth, the enamel, and makes it less susceptible for forming cavities. So it makes it a little bit harder.

Mike Patrick: Does it replace calcium?

Elizabeth Gosnell: It does, yes.

Mike Patrick: So the outer surface of the tooth loses the calcium and fluoride takes it place, and then that makes it stronger?

Elizabeth Gosnell: Exactly. Yep.


Mike Patrick: Is that because the chemicals that the bacteria, or is it an acid issue?

Elizabeth Gosnell: It is. Fluoride actually alters the bacterial metabolism as well, so basically how cavities work, bacteria are in everyone's mouths. They metabolize sugars and they produce acid as a by-product, and as acid attacks the tooth, and the fluoride component of the fluorapatite in the outer layer of the tooth is less susceptible from that acid.

Mike Patrick: And that's what makes it stronger?

Elizabeth Gosnell: Yes.

Mike Patrick: Now, some of these groups that are anti-fluoride that you hear about, this is like your MMR-autism issue for us. Yours is the fluoride myths and concerns that are out there.

I remember, once upon a time I practiced in a medium-sized community, and every couple of years the city would try to put fluoride in the water and the citizens would, there would be a ballot, well, actually I think a group would come to town and stir up fear about fluoride, and then they'd put it up for a vote whether we want to add fluoride to the water and it would always fail, despite our best efforts to convince people that it was a good thing.


Elizabeth Gosnell: Yeah. This is a touchy subject, because I know that over 20 communities in Ohio alone are not advocating fluoride in their community water.

Mike Patrick: Yep. I guess one of the fears is that there have been some reports of increased cancers associated with increased fluoride, at least one of the issues. But as I recall, it was like a tea or something in India or China and there was like a ton of fluoride in this stuff.

Elizabeth Gosnell: Yeah. In the United States, there has not been an appreciable increase in cancers from the addition of fluoride in the community water when used at the recommended level. However, when seen, exactly what you said, like the tea in India, it's usually from an incredibly increased amount from fluoride, or from naturally occurring fluoride, which is well over the recommended limit as well.

Mike Patrick: Sure. In addition to those kind of health issues, excess fluoride can also cause some what we call fluorosis, which is too much fluoride in the teeth. Talk about that a little bit.


Elizabeth Gosnell: Yes. Fluorosis is actually caused by excess fluoride during the enamel development of the tooth. The severity of the fluorosis is dependent upon the age of the child when they're exposed to this excess amount if the teeth are developing at that stage, how much fluoride they are exposed to, as well as the individual response of the child.

It can show up clinically as either opaque white spots, so an aesthetic concern, a brown or black stain. In the worst circumstances, it can cause modeling of the enamel, so it's actually a disfiguration of the enamel.

Mike Patrick: But if they're just using a fluoridated toothpaste, a small film of it, a couple of times a day, fluorosis is not going to be a worry?

Elizabeth Gosnell: This is absolutely not a concern for that. Exactly.

Mike Patrick: Great. My next definition was going to be, should cities add fluoride to their water supply, but you're definitely on board with that.

Elizabeth Gosnell: I am, I am. Fluoride addition to the water supply is one of the great public health successes that we've had in the last 50 years that's shown, when they've done studies in communities where they've added fluoride, it's shown a significant decrease in cavities in those communities.


Mike Patrick: Only 20 communities in Ohio that don't add fluoride?

Elizabeth Gosnell: I think it's 23.

Mike Patrick: Wow. So even small towns, most of them are on board and doing this now.

Elizabeth Gosnell: Yes.

Mike Patrick: So people, if folks out there who are listening that live in Ohio, we have listeners all over. Actually, not just if you live in Ohio; if you live anywhere and you're on the city water supply, make sure you contact your city government and ask, 'Do we have fluoride?' and if not, why not.

Obviously the dentists and probably pediatricians in town would be on board if your city doesn't do it, but they need folks in the community to educate neighbors and friends and family, so you may be the catalyst for getting fluoride added to the water in your community if you don't already have it.

Elizabeth Gosnell: Yeah, that would be great.

Mike Patrick: Now, what about folks on well water? They don't have fluoride in the water. What about them?


Elizabeth Gosnell: Those children are at increased risk for getting cavities, no doubt. All of our dentistry governing bodies do recommend an optimal level of fluoride.

However, I personally find it very difficult to calculate exactly how much the child is intaking from different locations and food sources as well, so what I recommend to my own patients is they get the recommended amount of toothpaste fluoride, they spit out the excess and don't rinse afterwards, and if they are so inclined, they can buy bottled water that has fluoride added in it.

Mike Patrick: That's what we did. We lived in a rural area for about 10 years. Our house was like a half-mile from the city water supply and we had a well, and that's what we did. We just bought the big five-gallon with the fluoridated water. It really was not very expensive to do that.

Now, what about fluoride supplements? I guess a lot of pediatricians out there probably still do this where we start giving infants fluoride drops or a multivitamin that has fluoride in it. Is that a good idea?


Elizabeth Gosnell: It is a good idea. We have supplementation tables that you can follow. Like I said, though, it's difficult to calculate exactly how much fluoride they are taking in. You need to get a sample from the water company to see how much fluoride they are actually getting in that way, as well as get a dietary log of what kind of foods they're taking in that may have fluoride in it as well. If your pediatrician or local dentist can do that, then they can supplement correctly.

Mike Patrick: So the issue is that a baby might be getting sources of fluoride that you don't know about. You think that they're not getting enough fluoride so you put them on a supplement, and really what you're doing is giving them too much fluoride because of the natural fluoride that they're getting.

Do babies who are definitely getting fluoridated water, do they need supplementation?

Elizabeth Gosnell: They don't. If babies are on infant formula as well, it adds fluoride to their diet as well. There are lots of food sources and community water and toothpaste alone that has fluoride in it, so they don't need supplements.


Mike Patrick: So if they're using bottled water that has fluoride added to it because they don't have fluoride in their own water, and they're mixing up formula, then they don't need the supplements.

Elizabeth Gosnell: Correct.

Mike Patrick: But if they're nursing, I would suspect that mom drinking fluoridated water is not going to be, that fluoride probably doesn't get into the breast milk, does it?

Elizabeth Gosnell: Probably not.

Mike Patrick: At least not enough.

Elizabeth Gosnell: So they may want to have that conversation with their dentist or pediatrician.

Mike Patrick: Sure. That becomes a little more difficult if you're in a rural area and you breast-feed, then those are the kids that may need the supplement added. Got you. And we do encourage breast-feeding.

Elizabeth Gosnell: Yes.

Mike Patrick: Right. We talked a little bit about cavities. Let's go back to that for a second. You said that there are some bacteria that tend to be more cavity-causing than others, so that can be an issue, and then I had mentioned, too, the anatomy of the tooth, if you have more pits and grooves. I guess just kind of take us back to how the cavity forms and what other issues might be involved.


Elizabeth Gosnell: Sure. Exactly like you said, the anatomy of a tooth can make that particular tooth more susceptible for getting cavities. If it has deep grooves, or the anatomy when it was forming the enamel didn't form correctly, then this tooth is going to be more at risk for getting cavities.

Each person has millions of bacteria in our mouths. Some bacteria, like I said, are more indicated and causing cavities than others. Some people have more virulent forms of that bacteria than others. When people take in sugars or simple carbohydrates, the bacteria break this down, they feed off of that, and their by-product is an acid, it's lactic acid, and that acid attacks the tooth structure, and that's what can cause cavities.

Mike Patrick: So it's not the bacteria itself, and it's not the sugar or carbohydrate substrate itself, but it's that the bacteria's feeding on the sugar and then that produces an acid, and that's what dissolves enamel and causes the cavity.

Elizabeth Gosnell: Correct. And they need a plaque surface to attach itself to as well. So you need to clean your teeth in order to decrease that risk.


Mike Patrick: Got you. What symptoms do cavities cause in children? Now, I know in adults there may not be any symptoms at first, and that's why you want to go to the dentist every six months so they can try to identify those early, but obviously in adults, our teeth hurt. How do you know in a young baby if they're starting to get cavities, because they can't tell you, 'Hey, my tooth hurts'?

Elizabeth Gosnell: Exactly. That's tricky in a young child. They can't voice what's hurting.

You may find that their eating habits have changed or their sleeping habits have changed. So the symptoms could be they have pain when they're eating spontaneously or it could wake them when they're sleeping. Children's teeth, their nerves are much larger than adults', so the cavity can progress much quicker. That's why we advocate very frequent follow-ups to keep this on track.

Mike Patrick: Sure. What about bad breath or foul taste in the mouth, that sort of thing? That would only come if they actually then have a cavity that then gets infected, correct?


Elizabeth Gosnell: Exactly, yeah. If the cavity is not addressed, the infection can go through the tooth and out the end of the tooth and cause a facial swelling, and this is a really serious condition in kids, and you may see these kids in the emergency room when you work there, and they may be cause for hospital admission.

Mike Patrick: Right. How do you deal with dental caries or cavities in children? Would you just fill them like you do adults? Do you do root canals? What do you do?

Elizabeth Gosnell: It depends on a lot of things. It depends on the child's risk factors, their age, is the tooth about to exfoliate or has it just erupted, how is the child's behavior. It depends on a lot of things. So we try to take in a lot of those factors and formulate a treatment plan for that child.

But to answer your question, we do do some fillings. We do do crowns, root canal treatments or extractions, depending on the situation.

Mike Patrick: So really the same spectrum of things that you would do in an adult, but what you do for a specific kid and a specific tooth really depends upon the situation.

Elizabeth Gosnell: Exactly.

Mike Patrick: Got you. How can cavities be prevented, then?


Elizabeth Gosnell: Well, it kind of boils down to a very simple plan. As long as you're trying to get enough fluoride, so you try to make the child less at risk, will limit your amount of sugar intake for your child. If you do give them juice, try to limit it to four to six ounces a day, only at meals. Between meals, try to have them drink water. The less frequently that they are taking in sugar, the less at risk they are for getting cavities.

Mike Patrick: And obesity. Less risk for obesity, too.

Elizabeth Gosnell: Exactly. It helps with multiple areas of the child's health.

As well as helping your child brush their teeth. Until the child is about 10 or 11, they don't really have very good dexterity in their hands to move the toothbrush to all the tooth surfaces, so we would like an adult to go behind them, make sure they're doing a very good job.

Mike Patrick: Great. So it's really an issue of you want to avoid the sugar as much as possible. Obviously you need that to grow, you need some of it, but you want to avoid excess sugar on the teeth so the bacteria can't have that action.


And then the hygiene part of it, you want to try to, are you trying to decrease the numbers of bacteria that are there or the formation of the plaques?

Elizabeth Gosnell: The formation of the plaques.

Mike Patrick: Is really what you're trying to eliminate. Because that plaque, is it made up of bacteria?

Elizabeth Gosnell: It is. It's made up of bacteria as well as the sugars that attach to the tooth surface.

Mike Patrick: OK, sure. And then, what about flossing? When would you start flossing a child's teeth, in between their teeth?

Elizabeth Gosnell: Ideally, children have spaces between all of their teeth, but when their baby teeth start erupting in the back of their mouths, if you see that they have contact between those teeth, I would go ahead and start flossing, make sure you're cleaning.

Mike Patrick: Now, some parents are going to really do a good job at this. They're going to brush their child's teeth as recommended, they're going to floss, they're going to avoid too much sugar, they're not going to put their kids to bed with the bottle, and yet their kid still gets a cavity. Should they feel guilty that they didn't do enough or is it sometimes just inevitable?


Elizabeth Gosnell: They should not feel guilty. No. Sometimes it is inevitable, sometimes it is genetics, like you mentioned. There is not enough research to understand completely what all is going into why kids get cavities and why other children in the family don't. As long as they are seeing a dentist, we can take care of that.

Mike Patrick: My son just went to the dentist not too long ago. He actually had his first cavity, he's 14. That's pretty good to have your first cavity at 14. The dentist was very specific to say, 'This is not your fault. There's a deep groove right here. Otherwise the hygiene looks good.'

Of course, it may be this is the same dentist who, when my daughter was, how old was she, she was probably two, we took her in, and we had been seeing a dentist every six months, but it was an adult dentist and we switched over to a pediatric dentist, and she had like six cavities that he found that the other dentist didn't, and my wife literally started crying because she just felt so bad. So I think that this dentist, even though that was so many years ago, he was like, 'This is not your fault,' in front of Mom. [Laughter]


Elizabeth Gosnell: Yeah. I understand there is a certain level of guilt that some parents do feel.

Mike Patrick: Yeah, because you think, 'This is something I could've prevented, and now they're going to have to go through this pain.' Although dentistry now, really, kids aren't in a lot of pain when you're fixing things, right?

Elizabeth Gosnell: No, they shouldn't be.

Mike Patrick: There's creams that you can put on the gums before you do injection.

Elizabeth Gosnell: Exactly.

Mike Patrick: Do you still use a lot of nitrous oxide?

Elizabeth Gosnell: We do. We do use laughing gas for a good number of our kids when they are anxious. It really helps.

Mike Patrick: Definitely. And this is, I think, one of the advantages of pediatric dentistry is because you can use those modalities, but you're also prepared if there's an emergency, too, and know what to do.

Elizabeth Gosnell: Oh, exactly.

Mike Patrick: All right. Well, let's move on from cavities a little bit and talk trauma. What are some of the common dental trauma that you see in kids?

Elizabeth Gosnell: Unfortunately, we see a lot of trauma in kids, and most of them that I have seen are related to sports injuries or injuries around the household, like when they're playing with their sibling or they're just running through the house and fall on a coffee table. Those are probably the most common injuries.


Mike Patrick: And it never happens at a convenient hour.

Elizabeth Gosnell: No, it doesn't. It always happens at 1 am.

Mike Patrick: So what do you do for some of these?

Elizabeth Gosnell: The biggest thing for you to know, if a tooth is knocked out and it's a baby tooth, we do not recommend putting that tooth back in.

Mike Patrick: Just leave it.

Elizabeth Gosnell: Just leave it alone and leave it out, because if you put it back in, it puts more at risk for the developing tooth underneath the baby tooth. So we recommend leaving those out.

However, if this is a permanent tooth, we do recommend putting the tooth back in immediately. That way, it helps the tooth have more of a chance of long-term prognosis.

Mike Patrick: Is that something parents can do at home?

Elizabeth Gosnell: It is something that parents can do at home.

Mike Patrick: When the tooth comes out, you just put it back in the socket?

Elizabeth Gosnell: Exactly.

Mike Patrick: You don't put it in a glass of milk and take it with you?

Elizabeth Gosnell: Right. If they don't feel like they can put it back in themselves, then we'd recommend putting it in cold milk and calling your dentist.

Mike Patrick: OK. How long can a tooth survive like that in milk?


Elizabeth Gosnell: Ideally, we'd put it back in within an hour. The quicker we put it back in, the more chance that it's going to survive. And really what we're talking about is the ligament that's on the root. But if they cannot get to a dentist within a few hours, the viability of it, probably within 10 to 12 hours.

Mike Patrick: That's not going to take…

Elizabeth Gosnell: It's probably not going to do a whole lot after a day.

Mike Patrick: Got you. Now, having worked in emergency departments and urgent cares, more often than not, the tooth doesn't come all the way out and it just becomes dislodged or displaced or it may be pushed back, pushed forward. What do you do with those?

Elizabeth Gosnell: This is a baby tooth that is displaced or dislodged. If it's at risk for the child aspirating it or it becomes all the way out at home, then we may recommend removing the tooth. Or if the child isn't able to close their teeth all the way, if this is impeding their feeding or function, we may recommend taking the tooth out. However, if it's just a slight dislodgement, we may reposition the tooth and then follow it closely.


Mike Patrick: And then, what about if a tooth is cracked or fractured? Is that something that you leave or do those come out, too?

Elizabeth Gosnell: No. We try to restore those. It kind of depends if the nerve of the tooth is exposed or not. If it is and this is a permanent tooth, we will do everything we can to save it. It may need root canal treatment or it may not, just kind of depending on how mature the tooth is.

Mike Patrick: But baby teeth, you'd be a little more quick to say, 'We can take this tooth out.'

Elizabeth Gosnell: Exactly.

Mike Patrick: And then what about lacerations? You get cuts in the gum; do those have to be sutured or do those usually heal up without needing anything?

Elizabeth Gosnell: If it's a small cut or a laceration on the gums, a lot of times those heal just fine without any stitches at all. The tissues in the mouth are very quick to heal. They heal over in about seven days.


However, if it's a type of laceration where the entire gum tissue is what we call 'degloved' or it all lifts away from the bone, that's something that does need to be sutured.

Mike Patrick: Sure. And then we also see a lot of kids who have the little frenulum. It's the little flap of skin in between the upper top teeth. That's something that gets lacerated very often.

Elizabeth Gosnell: It is.

Mike Patrick: But generally nothing needs to be done with that.

Elizabeth Gosnell: Correct, that's right.

Mike Patrick: I've also seen, my son had a frenulum that was really quite large when he was young and it sort of separated the upper front teeth and there was a space there. Our dentist said, 'No, it will go away,' and you think, how is that big flap of skin going to go away? But it did.

Elizabeth Gosnell: Yeah, it does. As the child develops, that's very common in a young child to have this very broad frenulum or attachment from the lip to the gums. When they grow, the lip kind of separates and the gum tissue elongates so that the frenular piece of tissue, it shrinks.

Mike Patrick: Sure. And we're talking at the middle of the upper…


Elizabeth Gosnell: Upper front teeth, yes.

Mike Patrick: Teeth, yeah. Just so parents have a mind where we're talking about this flap. Parents who have kids that have this, they know what we're talking about.

We're really spoiled here in Columbus. We have a pediatric dentistry residency, so dentists who have earned their dental degree and now they want to specialize in pediatric dentistry, they can come to Nationwide Children's and there's a training program here, and we have those in-house, 24-hours-a-day/seven-days-a-week access to them.

Elizabeth Gosnell: Exactly.

Mike Patrick: So here in Central Ohio, if there is a dental trauma at an inconvenient hour, they can go to the emergency room and see a pediatric dentist. But this is not typical of most people in communities. Before I came here, the audience knows I spent some time in Orlando, and in Orlando, Florida, there is not this convenient way to get in touch with a pediatric dentist at any hour of the day.


So what should parents do if trauma occurs at home and they aren't in Central Ohio where they can come to Nationwide Children's and see a pediatric dentist? What should they do?

Elizabeth Gosnell: Well, if they have a local dentist, the best thing they can do is call them if they access to after-hours care. If not, they can go to their local emergency room and see a physician there. If they have a dentist there, then that would be unique. They probably wouldn't. They would see a physician. If they do recommend that they have treatment, they may recommend transporting the patient somewhere else.

Mike Patrick: This is a tough one, because I saw a lot of kids and really, you have to kind of fly by the seat of your pants a little bit sometimes as a physician because a lot of the dentists in town wouldn't talk to you if it wasn't their established patient. And I think this is another reason to really establish that dental home ahead of time as young as you can so that if something like that comes up, you are plugged in with a dentist who knows you and you have a doctor-patient relationship with them, so you don't have to go see a doctor who doesn't really know a lot about dentistry.


Elizabeth Gosnell: Exactly, and that's something that should be discussed at your visits, prevention of dental trauma and what to do if this does occur.

Mike Patrick: Yeah, absolutely. Now, there's a dental clinic here at Nationwide Children's Hospital as well, and as I understand it, you have walk-in hours?

Elizabeth Gosnell: We do, we do. We have walk-in emergency hours. They are Monday through Thursday from 9 to 11 in the morning, 1 to 3 in the afternoon, and then Friday, 8 to 11 in the morning and 1 to 3 in the afternoon.

Mike Patrick: So people can just basically come to Nationwide Children's Hospital, just show up at the dental clinic, and they're going to be able to see a dentist?

Elizabeth Gosnell: Exactly.

Mike Patrick: Now you said "emergency."

Elizabeth Gosnell: Yes. Emergency during the day is a very loose term. We consider any child in pain to be an emergency.

Mike Patrick: So it's not walk-in hours for a cleaning.

Elizabeth Gosnell: Exactly. No, it's not.

Mike Patrick: OK, this is if they're having pain, having an issue. But they can schedule a cleaning through the dental clinic here?

Elizabeth Gosnell: Yes, they can.

Mike Patrick: OK. We'll have a link in the show notes to Pediatric Dentistry here at Nationwide Children's Hospital, so if there's any questions or you need a reminder on their walk-in, I imagine your walk-in hours are on the website?


Elizabeth Gosnell: They are.

Mike Patrick: So if you just go to, click on the Show Notes for this episode, this is 189, there will be a link to the Pediatric Dentistry page here at Nationwide Children's.

I'm also going to put a link to the American Academy of Pediatric Dentistry's page because they have a lot of resources and educational tools for parents as well. So I'll have a link to that, too.

Well, I want to thank Dr. Gosnell for stopping by. Before you leave, we ask all of our guests as sort of our 2011 question, and then we're going to tally up all of the results at the end of the year, what is your favorite board game?

Elizabeth Gosnell: Oh, my favorite board game.

Mike Patrick: Because we're encouraging families to do things together that don't always involve watching a screen, and I just, from my own childhood and now with my kids, we play a lot of board games.


Elizabeth Gosnell: I enjoy a good game of Clue.

Mike Patrick: Oh, we love Clue. Do you play just the traditional Clue? Have you played any of the special versions of it?

Elizabeth Gosnell: I have it, I still have my board game from when I was a kid, so it's pulling apart. It's the traditional.

Mike Patrick: Oh, yeah. The classic.

Elizabeth Gosnell: Yes.

Mike Patrick: We lived in Orlando and we're kind of Disney buffs, and they have a "Haunted Mansion" version and a "Tower of Terror" version. Those are both pretty fun, too.

Elizabeth Gosnell: Oh, I bet. I'll try them.

Mike Patrick: They don't involve murder.

Elizabeth Gosnell: Oh. Well, that's probably better for kids.


Mike Patrick: They involve either just who's spooked who.

Elizabeth Gosnell: That's good.

Mike Patrick: Yeah. Right. Exactly. We love Clue, too.

Great. All right, well, we appreciate you stopping by.

I also want to thank listeners like you for tuning in to PediaCast and making it a part of your day. We really appreciate it.

As always, reviews on iTunes are helpful. If you haven't done that, it only takes a few moments of your time. If you could also mention PediaCast in your blogs and on Facebook and in your tweets, we appreciate that as well.

And make sure you let your pediatrician or your family doctor know about PediaCast so they can spread the news to other patients. We encourage you to do that not just if you live here in Central Ohio but anywhere in the country or around the world. We're happy to have listeners from any place.


Also, to sort of help out with that, if you go to, there is a tab that says 'Resources' and there is a flyer that you can download that just has information about PediaCast. It's great for bulletin boards at doctor's offices, daycares, churches, nurseries, YMCAs, all that kind of stuff.

I also want to remind you, if there's a topic you'd like to hear about, just go over to and click on the Contact link. You can also email or, again, the voice line is 347-404-KIDS, 347, 404, K-I-D-S.

And until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everyone!



Announcer 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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