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panoramic view), sialography, CT, MRI, ultrasonography, and scintigraphy of the gland are useful in
showing tissue changes of the salivary gland tissue. Chest X-ray, tuberculin test, and salivary gland
biopsy may be necessary when involvement of the gland by systemic disease is suspected.
58. What is the treatment of sialadenitis?
If stones are present in the submandibular gland duct, a ductoplasty is indicated. If the stones are
large, beyond the mylohyoid flexure of the duct, or intraglandular, the gland must be removed.
Parotid gland infection is more serious and must be drained or treated by superficial parotidectomy.
Antibiotics should be administered to cover Streptococcus and Staphylococcus spp. Escherichia
coli and Haemophilus influenzaearealsooccasionallyimplicated.Hydrationwithintravenous(IV)
fluid, especially in the elderly and children, is often a necessary part of the treatment of acute
sialadenitis.
59. What are the most commonly used antibiotics for treatment of salivary gland
infection?
Empirically, or if Gram stain shows gram-positive cocci, administration of penicillinase-resistant
antistaphylococcal antibiotics, such as methicillin, is advisable. In patients who have a history of allergy
to penicillin, cephalosporins can be used. Aminoglycosides (gentamicin) could also be used. Antibiotics
should be administered in high doses and intravenously in patients who are hospitalized or seriously ill.
60. Which cranial nerves pass through the cavernous sinus?
CranialnervesIII,IV,V(ophthalmicdivisionofV),andVIpassthroughthecavernoussinus.
61. What is cavernous sinus thrombosis?
Itisanuncommonbutpotentiallylethalextensionofodontogenicinfection.Valvelessveinsinthehead
and neck allow retrograde flow of the infection from the face to the sinus. The pterygoid plexus of
veins and angular and ophthalmic veins may contribute to retrograde flow. The first clinical signs of
cavernous sinus thrombosis include vascular congestion in periorbital, scleral, and retinal veins. Other
clinical signs include periorbital edema, proptosis, thrombosis of the retinal vein, ptosis, dilated pupils,
absent corneal reflex, and supraorbital sensory deficits.
62. What are the pathways of odontogenic infection to the cavernous sinus?
An orofacial infection can reach the cavernous sinus through two routes: an anterior route via the
angular and inferior ophthalmic veins, and a posterior route via the transverse facial vein and the
pterygoid plexus of veins.
63. What is the flora of acute and chronic sinusitis?
Acute sinus infections are caused by Streptococcus pneumoniae (30% to 50%) and Haemophilus
influenzae (20% to 40%). Other organisms associated with acute sinusitis include Moraxella
catarrhalis, S. aureus, Streptococcus pyogenes, and beta- and alpha-hemolytic streptococci.
Chronic sinusitis is due to S. aureus, alpha-hemolytic streptococci, Peptostreptococcus,
Pseudomonas, Proteus, and Bacteroides. The flora of chronic sinusitis is usually a mixture of aerobic
and anaerobic organisms.
64. What is the treatment for maxillary sinus infections?
Treatment for maxillary sinus is based on a combined approach of medical treatment and, if neces-
sary, surgical treatment. The medical treatment includes use of antibiotics, topical or oral decongestants, antihistamines, and topical or oral steroids. Commonly prescribed antibiotics for the treatment
of maxillary sinusitis include ampicillin, amoxicillin, amoxicillin plus clavulanic acid, cefaclor, cefuroxime axetil, and trimethoprim-sulfamethoxazole.
Surgical treatment is indicated when the underlying cause of the infection cannot be corrected
with medical therapy. The goal is to reestablish drainage and remove the underlying cause (if identified) using minimally invasive techniques, such as functional endoscopic surgery.
65. What are the most common bacterial and fungal infections affecting patients with
diabetes mellitus?
Mucormycosis (phycomycosis) is the most common infection in patients with diabetes mellitus,
especially those with diabetic ketoacidosis. Of patients with rhinocerebral mucormycosis, 75% have
ketoacidosis. Mucormycosis is a fungal disease, possibly caused by phycomycetes organisms of the
Zygomycetes class.
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66. Which organisms are associated with infections from human and animal bites?
Approximately 25% of animal bite infections are caused by Pasteurella multocida. Approximately 10%
are caused by S. aureus, 40% are caused by alpha-hemolytic streptococci, and 20% are caused by
bacteroides and fusobacteria. About 25% of human bite infections are caused by S. aureus from the
skin of the victim; 10% are caused by alpha-hemolytic streptococci; 50% are caused by anaerobic
bacteria including gram-positive cocci, fusobacteria, and Bacteroides species; and 15% are caused by
Eikenella corrodens. The latter organisms are mostly associated with severe infections.
67. What is the treatment for animal and human bites?
Treatment includes antibiotic therapy and surgical intervention. Good surgical technique involves
debridement of the devitalized tissue and thorough irrigation with copious quantities of saline. Oral
ampicillin and amoxicillin are the antibiotics of choice for both types of bites. Also provide prophylaxis
against rabies virus, if deemed necessary.
68. What is actinomycosis?
Actinomycosis is a bacterial infection caused by a gram-positive, facultative, anaerobic rod bacte-
ria called Actinomyces israeli. The organism is part of the normal oral flora. The infection presents
as a hard swelling of the jaw and drainage characterized by sulfur granules. The treatment of
actinomycosis includes 10 to 20 million U of penicillin daily for 2 to 4 weeks, followed by
5 to 10 million U for 3 to 4 months. Surgical debridement of the area may accelerate resolution of
the infection.
69. Which diseases are associated with Epstein-Barr virus?
Mononucleosis,Burkitt’slymphoma,nasopharyngealcarcinoma,andhairyleukoplakiaareassociated
with the Epstein-Barr virus.
70. What is a Jarisch-Herxheimer reaction?
It is a transient, increased discomfort in an erythematous skin lesion plus temperature elevation
occurring within 2 hours after starting antibiotic therapy in treatment of secondary syphilis and Lyme
disease (penicillin or tetracycline).
71. What are the various fungal infections that may affect the head and neck?
The various fungal infections of the head and neck include candidiasis, zygomycosis, histoplasmosis,
blastomycosis, aspergillosis, and coccidiomycosis.
72. What are the common antifungal agents?
The most common antifungal agents are nystatin, clotrimazole, ketoconazole, and amphotericin B.
73. What are the common antiviral agents?
The common antiviral agents are acyclovir, zidovudine, vidarabine (ara-A), and idoxuridine.
74. What are the most common agents used in HIV-positive patients?
See Table 28-11.
75. Is the following statement true or false? Osteomyelitis can be classified into three
major groups.
False. Osteomyelitis is generally classified as two major groups: suppurative and nonsuppurative.
76. What is the most common classification of osteomyelitis of the jaws?
Suppurative osteomyelitis is classified as acute, chronic, or infantile osteomyelitis. Nonsuppurative
osteomyelitisisclassiedaschronicsclerosing(focalanddiffuse),Garré’ssclerosingosteomyelitis,
and actinomycotic osteomyelitis.
77. What is Garré’s osteomyelitis?
Garré’sosteomyelitisischaracterizedbylocalized,hard,nontender,bonyswellingofthelateraland
inferior aspects of the mandible. It is primarily present in children and young adults and is usually
associatedwithcariousmolarandlow-gradeinfection.TheradiographicfeaturesofGarré’s
osteomyelitis include a focal area with proliferative periosteal formation, most often seen as a carious
mandibular molar opposite the hard bony mass, and periosteal bony outgrowth seen on occlusal films.
Treatment of this condition includes extraction of the tooth and removal of potential sources, which
leads to gradual remodeling of the area involved. Long-term postoperative antibiotics generally are not
necessary.
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Table 28-11. Common Drugs Used to Treat HIV-Positive Patients
DRUG MAIN ACTION COMPLICATIONS
Immunosuppressive
Glucocorticoids Decrease circulating lymphocytes Infection
Diabetes mellitus
Impair delayed hypersensitivity Adrenal suppression
Alter lymphocyte–macrophage interaction Peptic ulcer disease
Impaired wound healing
Cause monocytopenia
Impair neutrophil chemotaxis
Azathioprine Interferes with DNA/RNA synthesis, leading
Antithymocyte
globulin
Cyclosporine Inhibits T-cell proliferation and activation Nephrotoxicity
Cyclophosphamide Depletes circulating T-lymphocyte pools Leukopenia
Adapted from Miyasaki SH, Perrott D, Kaban LB: Infections in immunocompromised patients, Oral Maxillofac
Surg Clin 3:393–402, 1991.
to lymphocytopenia
Lymphocyte-selective immunosuppression Infection
Inhibits T-cell function and proliferation
Hepatitis
Agranulocytosis
Infection
Predisposition to tumor
development
Thrombocytopenia
Hemolysis
Leukopenia
Hepatotoxicity
Lymphoma
Gingival hyperplasia
78. Which conditions are associated with periosteal thickening?
InadditiontoGarré’sosteomyelitis,infantileosteomyelitis,corticalhyperostoses(Caffey’sdisease),
syphilis,leukemia,Ewing’ssarcoma,metabolicneuroblastoma,andfracturecallusareallassociated
with periosteal thickening.
79. What are the general treatment principles of osteomyelitis of the jaws?
Treatment of osteomyelitis of the jaws usually includes both surgical intervention and medical
management of the patient, as well as sensitivity testing. Medical management involves administration of empirical antibiotics, performing Gram stain, administration of culture-guided antibiotics, use
of appropriate imaging to rule out other causes such as tumors, and evaluation and correction of the
patient’simmunedefenses.Surgicaltreatmentincludesremovaloflooseteethandforeignbodies;
sequestrectomy; debridement; decortication; resection; and reconstruction, if necessary.
80. How does the management of severe odontogenic infections in pregnant patients
differ from that in normal patients?
The principles of treatment of odontogenic infections in pregnant patients are the same and include
removal of the source of infection, incision and drainage, antibiotic therapy and medical support.
However, the physiologic changes associated with pregnancy as well as the status of the fetus have to
be carefully considered and make medical, surgical, and anesthetic management of these infections
in the pregnant patient very challenging. Although the details of physiologic changes associated with
pregnancy have been discussed elsewhere, it is worth emphasizing that when treating these patients,
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such physiologic changes can impact the outcome of the infection treatment as well as the viability of
the fetus. Such changes include:
• Cardiovascular:changesinbloodpressure,cardiacoutput,heartrate,etc.
• Respiratory:changesinrespiratorydrive,tidalvolume,respiratoryrate,andminuteventilation
• Endocrine:increasedincidenceofgestationaldiabetes
• Urinary:changesinkidneyoutputandriskofurinarytractinfections
• Hepaticfunction:changesinserumalkalinephosphate,bilirubin,andperipheraledema
• Hematological:increasesinerythrocyteandleukocytecountsandincreasesinplasmavolumewith
resulting hypercoagulability
81. What is meant by generations of antibiotics, as in third-generation cephalosporins?*
The earliest antibiotics were bacteriostatic, largely through interference in protein synthesis, so
that they might keep a microorganism from reproducing even if they did not kill it. The difference
between infestation (presence of living microbes in the host) and infection (replication and
spread of microorganisms in the host) may be useful in understanding how earlier drugs possibly controlled infection but were less capable of eliminating organisms in any brief period of
therapy.
Penicillin changed all that. It may be the first antibiotic with a legitimate claim to the title wonder
drug, because it has the microbicidal capability of eradicating sensitive organisms. Penicillin was the
first generation of the beta-lactam antibiotics, joined by the congener first-generation cephalosporins
(e.g., cefazolin). They shared beta-lactam structure and had good gram-positive coverage with less
range in any effect over gram-negative microbes.
The second-generation beta-lactam antibiotics (e.g., cefoxitin) covered new classes of microbes
beyond gram-positive aerobes, such as many of the Bacteroides species, but had little effect on gramnegative aerobic microbes. Because the third-generation cephalosporins covered some of the latter
microbes, they were touted as single-agent therapy for all principal-risk flora.
As with penicillin, the original wonder drug, the wonderment waned with failures of the new
agents because of rapidly induced antimicrobial resistance. The most easily measured and calculated
difference in the generations is cost: wholesale values are about $2.00/g for the first generation,
$5.00/g for the second, and $30.00/g for the third. Despite this bracket creep in cost, the higher
generations lose some of their potency against the original gram-positive organisms for which the
first-generation agents were truly wonderful. Therefore, it takes 2 g of moxalactam to be half as good
as 1 g of cefazolin for gram-positive coverage. It does not take a pharmacoeconomist to ask, “What
have I got in return for this sixtyfold surcharge?”
82. Are two prophylactic doses better than one in preventing infection? Are three
doses better still?
1
Only one dose of prophylactic antibiotic can be proved, beyond statistical or clinical doubt, to be
efficacious—the dose in systemic circulation at the time of the inoculum. Whether the dose needs to
be repeated one or more times during the 24 hours after the inoculum depends on the blood levels
of the drug, which are largely a function of protein binding and clearance rate. We also know for sure
that 10 days of the same prophylactic drug that is efficacious if given immediately before the inoculum
results in a higher risk of infection than no antibiotic at all.
83. What factors determine the timing of antibiotic administration under the criteria of
prophylaxis?
1
The one immutable principle has been set out above—the most important element in timing of
prophylaxis is that the drug be circulating before the inoculum. When should it stop? When the
reduction in infection risk is no longer provable and before continued use will defeat the prophylactic
purpose (as explained above). To summarize with an arbitrary rule of thumb: There is no justification
for prophylactic antibiotic 24 hours after the inoculum of an invasive procedure.
What does this rule imply? Should we not continue prophylaxis for weeks to cover the presence
of a prosthetic hip joint? Presumably, the prosthetic hip will be in the patient for many years, but
surely you do not argue that the antibiotic should continue on a daily basis as long as the hip is in
place. What is “prophylaxed” is not the prosthetic hip but the procedure of implantation. And it is not
only implantation that poses a risk to the patient with a prosthesis—so does hemorrhoidectomy done
years later, for which prophylaxis is made mandatory by the presence of the hip prosthesis.
The prosthetic or rheumatic heart valve is a risk, but the indication for the use of prophylactic
antibiotics is an invasive procedure; a root canal is an example in which an inoculum is unavoidable.
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Operations are covered by prophylactic antibiotics; the conditions that are risk factors during the
operation are not.
84. To be safe, why not administer prophylactic antibiotics to all patients undergoing
any kind of operation?
Can you give me the indication for a prophylactic antibiotic in a patient undergoing a clean elective
surgical procedure that implants no prosthesis, such as hernia repair?
“Sure,” one of my brighter students once responded, “the patient who has a serious impairment
in host response, such as acute granulocytic leukemia in blast crisis.”
I responded, “Why on earth are you fixing his hernia? That is a clean error (hopefully not a clean
kill) in surgical judgment that has nothing to do with antibiotics at all. A patient with that degree of
host impairment does not undergo an elective surgical procedure.”
Rule of thumb: If you can provide the indication for a prophylactic antibiotic to cover a
clean elective nonprosthetic operation for a patient, you have provided the contraindication for the
operation.
85. What is the drug of choice for the treatment of an abscess?*
A knife. Surgically drain the abscess. Abscesses have no circulation of blood within them to deliver an
antibiotic. The antibiotic, even if injected directly into the abscess, would be worthless because the
abscess contains a soup of dead microorganisms and white blood cells (WBCs). Even if the organisms
were barely alive, they would not be reproducing and incorporating the antibiotic. The drug most likely
wouldnotworkatallatthepHandpKaconditionsoftheabscessenvironment.
If there is an indication for an antibiotic, it would be in the circulation around the compressed
inflammatory edge of the abscess and the cellulitis (at the vascularized “peel of the orange”) and
uncontaminated tissue planes through which the necessary drainage must be carried out. A focal
infection is managed by a local treatment, which is both necessary in all abscesses and sufficient
treatment in many. Adjunctive systemic antibiotics are occasionally indicated for protection of the
tissues through which drainage is carried out. If it helps to make this fundamental surgical principle
clear, here is the rule of thumb for management of abscesses: Where there is pus, let there be steel.
Perhaps one of the most gratifying procedures in all of medicine is the drainage of pus with immediate relief of local and systemic symptoms (e.g., a perirectal abscess).
86. Are antibiotic drug combinations always superior to a single antibiotic agent?
Monotherapy is superior to combination antibiotic treatment regimens, but this is provable probably
only in the highest risk patients. With the carbapenem-class antibiotic agents, a large multicenter
clinical trial proved imipenem therapy superior to aminoglycoside and a macrolide antibiotic, with
survival demonstrably superior only in the patients with the highest APACHE scores. Ertapenem monotherapy was the equivalent of ceftriaxone and metronidazole in a smaller, more recent trial.
More is not always better, and the R and S on culture reports does not translate directly to the
M and M (morbidity and mortality) at the Death and Complications Conference reports. It is not just
important that the effective antibiotic regimen kills the bacteria; also important are how this microbicidal effect is carried out and what effect it may have on the patient in quenching or prolonging the
systemic inflammatory response.
87. What are triple antibiotics? What are the doses?
A shotgun approach to potentially life-threatening infections when the patient is seriously ill and the
surgeon is seriously concerned:
1. Gram-positivecoverage(e.g.,ampicillin):1gevery6hoursIVinadults;40mg/kgevery6hoursIV
in children
2. Gram-negativecoverage(e.g.,gentamicin):7mg/kgIVevery24hours(thissingledailydoseisless
nephrotoxicthan2mg/kgIVevery8hours)
3. Anaerobiccoverage(e.g.,metronidazole[Flagyl]):500mgIVevery6hoursinadults;7.5mg/kgIV
every 6 hours in children. To avoid overgrowth of yeast and resistant bacteria, focus on the culprit
bacteria as soon as the cultures define it.
1
1
†
* Reprinted from Geelhoed GW: Surgical infectious disease. In Harken AH, Moore EE, editors: Abernathy’s surgical secrets,
ed 5, Philadelphia, 2005, Mosby.
†
Reprinted from Harken AH: What does postoperative fever mean? In Harken AH, Moore EE, editors: Abernathy’s s urgical
secrets, ed 5, Philadelphia, 2005, Mosby.
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88. How do I use antibiotics correctly to prevent surgical wound infection?*
First by knowing what organism you are targeting, and then by choosing an appropriate antibiotic
and delivering it at the appropriate time via the appropriate route. Because you usually will not have a
preoperative culture to guide therapy, you need to base your choice of antibiotic on predicted organisms. Staphylococci are the most common skin organisms and the most common etiologic agents in
surgical site infections (SSIs). Cefazolin, a first-generation cephalosporin, is usually the recommended
antibiotic for prophylaxis in clean surgical procedures. In circumstances in which known contamina-
tionhasoccurred,initialantibioticsshouldbetailoredbasedontheviolatedorgan’scommonora.
If the gut was entered, Enterobacteriaceae and anaerobes are common; biliary tract and esophageal
incisions yield these organisms plus enterococci. The urinary tract or vagina may contain group D
streptococci, Pseudomonas, and Proteus.
89. If prophylactic antibiotics are used, how and when should they be administered?*
Maximal benefit is obtained when tissue concentrations are therapeutic at the time of contamination.
EfcacyisenhancedwhenprophylacticantibioticsareadministeredIV20to30minutesbeforesurgical incision; late administration is similar to no administration. Multiple-dose regimens have no proven
benefit over single-dose regimens. Indiscriminate antibiotic selection outside recommended hospital
protocols may increase the incidence of SSIs. In special circumstances, administration routes other
thanIVmaybeindicated.
90. What can the patient do to help decrease surgical wound infection?*
Stop smoking. Although obesity, poor nutritional status, advanced age, and diabetes are risk factors
for SSIs, cigarette smoking is probably the leading preventable patient factor for SSIs, just like it is the
leading preventable cause of death and disability in the United States. Half of all people who smoke
eventually die from a smoking-related illness. Smoking not only kills, but also more than triples the
risk of incisional wound breakdown; in one study, smoking increased the incidence of SSIs in clean
operative procedures sixfold, from 0.6% to 3.6%. Tobacco use results in decreased blood flow and
decreased oxygen delivery to the wound. Toxic tobacco by-products also directly impede all stages of
wound healing. Despite this knowledge, surgeons continue to operate electively on smokers, and most
smokers continue to smoke up until the day of surgery.
BiBliography
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1:79–105, 1994.
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DIAGNOSIS AND MANAGEMENT
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OF DENTOALVEOLAR INJURIES
Jason A. Jamali, A. Omar Abubaker
1. What is the prevalence of dentoalveolar injuries?
The prevalence of dentoalveolar injuries varies widely depending on factors such as age, the cause of
injury, and gender. The general prevalence of these injuries among pediatric patients is reported to be 5%
of all facial fractures. Among adolescents with sport-related trauma, the incidence of dentoalveolar injuries is reported to be 36%. Overall, the prevalence of dentoalveolar injuries among children with primary
dentition is 11% to 30%, and among children with permanent dentition is 5% to 20% of the time. Boys
also are affected almost twice as often as girls with a peak incidence at 2 to 4 years and 8 to 10 years.
2. Is there a difference between dentoalveolar injuries in children to that in adults?
The nature of dentoalveolar fracture varies with age possibly due to the anatomic differences between
the teeth and supporting structures of adults and pediatric patients. Such differences are reflected
by the fact that trauma to the primary dentition affects mostly the supporting structure (luxation and
exarticulation), while trauma to the permanent dentition affects mostly the teeth themselves (causing
crown fractures). Trauma to primary dentition result in only 10% of crown or crown-root fractures,
and 75% involves luxation or exarticulation of the tooth compared to incidence of mostly crown and
crown-root fracture involvement in the permanent dentition.
3. What is the difference between an injury that is a result of direct trauma to the
dentoalveolar structures compared to that of indirect trauma?
If the injury is caused by a direct trauma, the most likely teeth to sustain injury are the anterior teeth
because of their relatively exposed position. This occurs most commonly to the maxillary incisors
when these teeth are protruding, as in patients with Class II division I malocclusion or in patients
with insufficient lip closure. Depending on the force of the impacted trauma, direct injury can affect
the upper or lower lip, occasionally causing laceration of the lip as well as dental or osseous alveolar
fracture (Fig. 29-1). Dentoalveolar injury from indirect trauma usually results from force applied to
the chin forcing the mandibular teeth against the maxillary dentition. The impact of this force often
results in crown or crown-root fracture, condylar and/or symphyseal mandibular fracture, and anterior
intraoral soft tissue and submental lacerations.
4. What should be included in the history of assessing a dentoalveolar trauma patient?
The history obtained from patients with dentoalveolar injury should include the following information:
• Biographic and demographic data of the patient including name, age, sex, race, address, and
phone number
• When did the injury occur? The time interval between the injury and presentation to the clinic or
emergency room (such time will determine prognosis).
• How: The mechanism of injury—the nature of the accident can provide insight into the type of
injury to be suspected.
• Where: The environment where the injury occurred may lead to contamination of the injury site;
have the missing teeth been located (aspiration, embedded within tongue/lip)? If missing teeth
haven’t been accounted for, imaging (CXR, AXR, pan) may be considered.
• What: What treatment has been rendered so far? What type of media teeth have been stored dur-
ing transfer?
• Other: The patient or parent should also be asked for information regarding any changes in the
occlusion as a result of the injury, and a short medical and dental history to delineate any systemic
or dental factors that can influence the immediate and later treatment plans. Such factors include
the presence of major systemic illnesses, especially those that may influence the treatment such
as bleeding disorders and epilepsy.
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Figure 29-1. Example of an alveolar ridge fracture. (From Baren JM, Rothrock SG, John Brennan: Pediatric emergency
medicine, Philadelphia, 2008, Saunders.)
5. What should be included in the physical examination of a dentoalveolar injury
patient?
• An important aspect of the physical examination is the overall evaluation of the physical status of
the patient as well as a detailed oral and maxillofacial examination (intraoral and extraoral).
• The general examination should include measurement of vital signs such as pulse rate, blood pres-
sure, and respiration. Significant changes in these measurements may indicate intracranial injury,
cervical spine injury, chest or abdominal injury, or even aspiration of an avulsed tooth. The mental
status of the patient should also be assessed by both asking specific questions and by observing
the patient’s reaction and behavior during the history and examinations.
• The oral and maxillofacial examination should include extraoral soft tissue examination, intraoral
soft tissue examination, examination of the jaws and alveolar bone, examination of the teeth for
displacement, and mobility and reaction to percussion.
6. What physical finding may suggest fracture of the alveolus?
During palpation of an involved tooth, movement of adjacent teeth as well may suggest an alveolar fracture.
7. What is the role of pulp testing immediately after dental trauma?
Pulp testing can result in false negative results immediately after injury. Retesting several weeks later
is beneficial to determine any need for an endodontic treatment.
8. What is the role of radiographic examination in evaluation of dentoalveolar fractures?
The purpose of radiographic examination is to provide information regarding injuries affecting the root
portion of the tooth, periodontal ligaments, and status of the surrounding alveolar and based bone.
Such information includes presence of root fracture, root infraction, and root dislocation. It also serves
to provide data on the presence of preexisting periapical disease, presence of jaw fracture, degree
of extrusion or intrusion, and tooth or tooth fragment or foreign bodies lodged in the soft tissue. In
children and young adults, radiographic examination serves to provide information regarding extent
of root development, size of the pulp chamber, and root canal and proximity of succedaneous teeth to
the injured primary tooth. Because a single radiograph may not be sufficient to show a crown or root
fracture, radiographic imaging of dentoalveolar trauma usually consists of more than one radiograph
and occasionally more than one projection (periapical, occlusal, and panoramic).
9. What method can be used to improve detection of the root in dentoalveolar trauma?
The beam of X-ray should be parallel with the line of fracture. Multiple angulations should be taken to
improve detection. Cone beam CT can be useful for this purpose.
CHAPTER 29 DIAGNOSIS AND MANAGEMENT OF DENTOALVEOLAR INJURIES 321
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10. What is the purpose of dentoalveolar injury classification?
The purpose of such classification is to provide a comprehensive and universal description of the
injury for communication and treatment planning purposes. Many classifications of traumatic injuries
to the teeth and supporting structures have been developed. These systems are based on a variety
of factors such as etiology, anatomy of injury, pathology, and therapy. All systems of classification of
dentoalveolar injuries have advantages or disadvantages. The three most commonly used systems
for simple and comprehensive classification of dentoalveolar injuries are those developed by Ellis, by
Saunders et al., and by Andreasen.
11. What is the Ellis classification system of dentoalveolar fractures?
• Class I: confined to enamel
• Class II: enamel and dentin
• Class III: enamel, dentin, and pulp
• Class IV: root fracture
• Also can be described as complicated (involving pulp) and uncomplicated (not involving pulp)
12. What are the different types of injuries to hard dental tissues and pulp?
These injuries include crown infraction (an incomplete fracture or crack of the enamel without loss of
tooth substance); uncomplicated crown fracture (a fracture confined to the enamel or involving the
enamel and dentin without exposing the pulp); complicated crown fracture (a crown fracture involving enamel and dentin with exposure of the pulp); uncomplicated crown-root fracture (a fracture
involving enamel, dentin, and cementum without exposure of the pulp); complicated crown-root
fracture (a fracture involving enamel, dentin, and cementum with exposure of the pulp); and root
fracture (a fracture involving dentin, cementum, and the pulp).
13. What are the different types of injuries to the periodontal tissues?
These injuries include concussion (an injury to the tooth-supporting structures without abnormal
loosening or displacement of the tooth, but with marked reaction to percussion); subluxation
(loosening) (an injury to the tooth-supporting structures with abnormal loosening, but without displacement of the tooth); intrusive luxation (central dislocation) (displacement of the tooth into the
alveolar bone with comminution or fracture of the alveolar socket); extrusive luxation (or peripheral
dislocation, partial avulsion) (partial displacement of the tooth out of the alveolar socket); lateral
luxation (displacement of the tooth in a direction other than axially, accompanied by a comminution
or fracture of the alveolar socket); retained root fracture (a fracture with retention of the root segment, but loss of the crown segment out of the socket); and exarticulation (complete avulsion) (a
complete displacement of a tooth out of the alveolar socket).
14. What are the different injuries to the supporting bone in dentoalveolar injuries?
These injuries include comminution of the alveolar socket (crushing and comminution of the
alveolar socket occurring most commonly with intrusive and lateral luxation); fracture of the alveolar
socket wall (confined to the facial or lingual socket wall); fracture of the alveolar process (which
may or may not involve the alveolar socket); and fractures of the mandible or maxilla (involving the
basal bone of the mandible or maxilla and often the alveolar process).
15. How does location of the root fracture affect prognosis?
In general, the more apical the fracture, the better the prognosis.
16. What are the treatment options for an intruded tooth with either a closed or open
apex?
The three options are observation for spontaneous eruption, orthodontic repositioning, and surgical
repositioning.
For an intruded tooth with an open apex, observation should be considered if the tooth is
intruded up to 7 mm. Otherwise, surgical versus orthodontic repositioning should be considered.
For an intruded tooth with a closed apex, observation should be chosen if the amount of intrusion is limited to 3 mm. If there is greater than 3 mm of intrusion with a closed apex, surgical versus
orthodontic repositioning should be planned.
Evaluation for endodontic therapy should be planned at 3 to 4 weeks.
17. What is the treatment for tooth avulsion?
The tooth is replanted and splinted for 2 to 4 weeks in addition to a week of systemic antibiotics.
In situations where the extraoral dry time is greater than 60 minutes, a root surface treatment with
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