Evidence-Based

Oral Surgery

A Clinical Guide for the General

Dental Practitioner
Elie M. Ferneini
Michael T. Goupil
Editors

123
Evidence-Based Oral Surgery
Elie M. Ferneini · Michael T. Goupil
Editors

Evidence-Based Oral
Surgery
A Clinical Guide for the General Dental
Practitioner
Editors
Elie M. Ferneini Michael T. Goupil
Beau Visage Med Spa, Division of Oral & Maxillofacial Surgery
Greater Waterbury OMS University of Connecticut School of Dental
Cheshire, CT Medicine
USA Farmington, CT
USA
Division of Oral and Maxillofacial Surgery
University of Connecticut
Farmington, CT
USA

ISBN 978-3-319-91360-5    ISBN 978-3-319-91361-2 (eBook)

https://doi.org/10.1007/978-3-319-91361-2

Library of Congress Control Number: 2018965193

© Springer International Publishing AG, part of Springer Nature 2019

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Foreword

Evidence-based dentistry integrates a practitioner’s clinical expertise and judgment,

the needs, desires, and preferences of the patient, and current, clinically relevant
evidence. The intersection of these domains is a critical component of an effective,
patient-centered approach to care. The American Dental Association defines
evidence-based dentistry (EBD) as “an approach to oral healthcare that requires the
judicious integration of systematic assessments of clinically relevant scientific
evidence, relating to the patient’s oral and medical condition and history, with the
dentist’s clinical expertise and the patient’s treatment needs and preferences.” Since
introduced at McMaster University in the 1980s to improve the quality of healthcare
delivery by closing the gap between scientific-based knowledge and commonly
found practice patterns, evidence-based dentistry has continued to advance and is
now widely accepted as a best practice.
This text is intended to provide the general dentistry community with clear,
concise, focused guidance on the delivery of evidence-based, patient-centered
surgical management and care. Drs. Goupil and Ferneini are leaders in the practice
of evidence-based oral and maxillofacial surgery, with extensive experience in
academic, military, and private practice settings. The text covers a spectrum of
topics pertaining to oral and maxillofacial surgery, including patient assessment,
exodontia, pain management, oral pathology, trauma, temporomandibular joint
dysfunction, and implant therapy—all of which are discussed using the principles
and parameters of evidence-based healthcare. Collaborating with over twenty
authors, they have developed the quintessential guide for general dentists to apply
translational science and knowledge into everyday clinical practice. All general
dentists will find information in Evidence-Based Oral Surgery: A Clinical Guide for
the General Dental Practitioner to be of great value and relevance to their practice.

Farmington, CT, USA Steven M. Lepowsky

v
Contents

Part I Patient Assessment

1 Evidence Based Dentistry: What, Why, How������������������������������������������   3
Michael T. Goupil and Linda Elder
2 Office Environment������������������������������������������������������������������������������������ 23
Melissa E. Ing and Peter Arsenault
3 Medical Assessment of the Oral and Maxillofacial Surgery Patient ���� 49
Steve R. Ruiz, Steven Halepas, Jeffrey Bennett, and Elie M. Ferneini
4 Dental Radiography���������������������������������������������������������������������������������� 67
Aditya Tadinada
5 Complementary and Alternative Medicine���������������������������������������������� 91
Stephan Goupil and Michael T. Goupil
6 Medicolegal and Ethical Considerations in
Oral Surgery by the General Dentist ������������������������������������������������������ 103
Eric R. Bernstein and Zita Lazzarini

Part II Principles of Exodontia

7 Local Anesthetics in Dentistry������������������������������������������������������������������ 129
Christy Lottinger
8 Uncomplicated Exodontia ������������������������������������������������������������������������ 151
Roger S. Badwal and Andrew Emery
9 Complicated Exodontia ���������������������������������������������������������������������������� 173
Stuart Lieblich
10 Unerupted and Impacted Teeth: A Guide for
Assessment and Treatment������������������������������������������������������������������������ 183
Leon A. Assael
11 Surgical Complications������������������������������������������������������������������������������ 205
Christine Niekrash and Michael T. Goupil

vii
viii Contents

12 Acute Pain Management �������������������������������������������������������������������������� 223

Joseph F. Piecuch

Part III Management of Oral Pathology

13 Odontogenic Infections������������������������������������������������������������������������������ 239
Gabe Hayek, Morton H. Goldberg, and Elie M. Ferneini
14 Osteonecrosis���������������������������������������������������������������������������������������������� 263
Johanna M. Hauer, Mo Banki, and Elie M. Ferneini
15 Evidence-Based Principles of Antibiotic Therapy���������������������������������� 283
Thomas R. Flynn
16 Preprosthetic Surgery�������������������������������������������������������������������������������� 317
Riccardo I. Ambrogio and Daniel Beauvais
17 Soft Tissue Oral Pathology������������������������������������������������������������������������ 333
Easwar Natarajan and Michael T. Goupil
18 Dentoalveolar Trauma ������������������������������������������������������������������������������ 383
Richard T. Zhu, Frank Paletta, and Douglas L. Johnson

Part IV Advanced Oral Surgery

19 Disturbances of the Temporomandibular Joint Apparatus�������������������� 399
M. Franklin Dolwick and Danielle Freburg-Hoffmeister
20 Congenital Facial Deformities������������������������������������������������������������������ 423
Jeff Marschall Green, Eric D. Bednar, and Lewis C. Jones
21 Dental Implants������������������������������������������������������������������������������������������ 433
Martin A. Freilich, David M. Shafer, and Steven Halepas
22 Forensic Odontology���������������������������������������������������������������������������������� 461
Kevin Rand Torske

Part V Illustrative Case Reports

23 Case 1: Diagnostic Dilemma - White and Red lesion������������������������������ 479
Easwar Natarajan
24 Case 2: Diagnostic Dilemma - Crusty Lips���������������������������������������������� 485
Easwar Natarajan
25 Case 3: Diagnostic Dilemma - White Patch �������������������������������������������� 491
Easwar Natarajan
26 Case Studies Evidence-Based Treatment Planning�������������������������������� 495
Michael T. Goupil
Contributors

Riccardo I. Ambrogio Department of Oral and Maxillofacial Surgery,

The University of Connecticut School of Dental Medicine, Farmington, CT, USA
New York University College of Dentistry, New York, NY, USA
OMFS, Private Practice, Wethersfield, CT, USA
Peter Arsenault Division of Operative Dentistry, Department of Comprehensive
Care, Tufts University School of Dental Medicine, Boston, MA, USA
Leon A. Assael University of California San Francisco, San Francisco, CA, USA
Roger S. Badwal Division of Oral and Maxillofacial Surgery, Department of
Surgery, Western Connecticut Health Network, Danbury Hospital, Danbury, CT, USA
Division of Oral and Maxillofacial Surgery, University of Connecticut School of
Medicine, Farmington, CT, USA
Private Practice, Danbury, CT, USA
Mo Banki Artistic Contours and MSL Surgery, Warwick, RI, USA
Department of Surgery, Clinical Faculty, Warren Alpert Medical School of Brown
University, Providence, RI, USA
Division of Oral and Maxillofacial Surgery, Clinical Faculty, University of
Connecticut, Farmington, CT, USA
Daniel Beauvais Department of Oral and Maxillofacial Surgery, The University of
Connecticut School of Dental Medicine, Farmington, CT, USA
Eric D. Bednar Department of Orthodontics, University of Louisville, Louisville,
KY, USA
Jeffrey Bennett Indianapolis, IN, USA
Eric R. Bernstein University of Connecticut School of Dental Medicine,
Farmington, CT, USA
M. Franklin Dolwick Department of Oral and Maxillofacial Surgery, UF College
of Dentistry, University of Florida, Gainesville, FL, USA
Linda Elder Foundation for Critical Thinking, Santa Barbara, CA, USA

ix
x Contributors

Andrew Emery University of Connecticut School of Dental Medicine, Farmington,

CT, USA
Elie M. Ferneini Beau Visage Med Spa, Greater Waterbury OMS, Cheshire, CT,
USA
Division of Oral and Maxillofacial Surgery, University of Connecticut,
Farmington, CT, USA
Thomas R. Flynn Private practice (retired), Reno, NV, USA
Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine,
Boston, MA, USA
Danielle Freburg-Hoffmeister Department of Oral and Maxillofacial Surgery,
UF College of Dentistry, University of Florida, Gainesville, FL, USA
Martin A. Freilich Reconstructive Sciences, University of Connecticut School of
Dental Medicine, Farmington, CT, USA
Morton H. Goldberg Division of Oral and Maxillofacial Surgery, University of
Connecticut School of Dental Medicine, Farmington, CT, USA
Michael T. Goupil Division of Oral and Maxillofacial Surgery, Emeritus Faculty,
University of Connecticut School of Dental Medicine, Farmington, CT, USA
Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT,
USA
Stephan Goupil Department of Family Medicine, University of Massachusetts,
Worcester, MA, USA
Jeff Marschall Green Oral and Maxillofacial Surgery, University of Louisville,
Louisville, KY, USA
Steven Halepas University of Connecticut School of Dental Medicine, Farmington,
CT, USA
Johanna M. Hauer Department of Oral and Maxillofacial Surgery, University of
Connecticut School of Dental Medicine, Farmington, CT, USA
Gabe Hayek Division of Oral and Maxillofacial Surgery, Department of
Craniofacial Sciences, University of Connecticut School of Dental Medicine,
Farmington, CT, USA
Melissa E. Ing Division of Operative Dentistry, Department of Comprehensive
Care, Tufts University School of Dental Medicine, Boston, MA, USA
Douglas L. Johnson Private Practice, St. Augustine, FL, USA
University of Florida Shands, Jacksonville, FL, USA
Lewis C. Jones Department of Oral and Maxillofacial Surgery, University of
Louisville, Louisville, KY, USA
Contributors xi

Zita Lazzarini Community Medicine and Health Care, University of Connecticut,

Farmington, CT, USA
Stuart Lieblich University of Connecticut, Farmington, CT, USA
Avon Oral and Maxillofacial Surgery, Private Practice, Avon, CT, USA
Christy Lottinger Department of Oral and Maxillofacial Surgery, University of
Connecticut School of Dental Medicine, Farmington, CT, USA
Easwar Natarajan Section of Oral and Maxillofacial Pathology, University of
Connecticut School of Dental Medicine, Farmington, CT, USA
Christine Niekrash Frank H. Netter MD School of Medicine, Quinnipiac
University, North Haven, CT, USA
Frank Paletta Private Practice, MSL Facial & Oral Surgery, Warwick, RI, USA
Department of Surgery, Warren Alpert Medical School of Brown University,
Providence, RI, USA
Joseph F. Piecuch Division of Oral and Maxillofacial Surgery, University of
Connecticut School of Dental Medicine, Farmington, CT, USA
Steve R. Ruiz Division of General Dentistry, Department of Craniofacial Sciences,
University of Connecticut, Farmington, CT, USA
David M. Shafer Division of Oral and Maxillofacial Surgery, University of
Connecticut School of Dental Medicine, Farmington, CT, USA
Aditya Tadinada Oral and Maxillofacial Radiology, Oral Health and Diagnostic
Sciences, University of Connecticut School of Dental Medicine, Farmington, CT,
USA
Kevin Rand Torske Oral Pathology and Forensic Dentistry, Naval Medical Center,
Portsmouth, VA, USA
Richard T. Zhu Warren Alpert Medical School of Brown University, Providence,
RI, USA
 Part I
Patient Assessment
Evidence Based Dentistry:
What, Why, How 1
Michael T. Goupil and Linda Elder

“Now we will take another line of reasoning. When you follow

two separate chains of thought, you will find some point of
intersection which should approximate the truth.”
Sherlock Holmes in—The Disappearance of Lady Frances Carfax

Abstract
The concept of evidence-based medicine {EBM} and evidence-based dentistry
(EBD) is not new. EBM traces its origins back to the 1980s when the evidence-
based process was developed at McMaster University, Ontario, Canada. This
concept should be commonplace with the current generation of graduating den-
tists. Yet there continues to be barriers to fully implement EBD. This chapter
focuses on the what, why, and how of EBD.

1.1 Introduction: What Is EBD

The American Dental Association defines evidence-based dentistry as “an approach

to oral health care that requires the judicious integration of systemic assessments of
clinically relevant scientific evidence, relating to the patient’s oral and medical con-
dition and history with the dentist’s clinical expertise and the patient’s treatment
needs and preference” (Sakaguchi 2010). In other words dentists are expected to
provide the best possible health care for their patients as possible.

M. T. Goupil (*)
Division of Oral and Maxillofacial Surgery, Emeritus Faculty, University of Connecticut
School of Dental Medicine, Farmington, CT, USA
Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT, USA
e-mail: [email protected]
L. Elder
Foundation for Critical Thinking, Santa Barbara, CA, USA
e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2019 3

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_1
4 M. T. Goupil and L. Elder

The concept of EBD can best be demonstrated through a Venn diagram consist-
ing of three intersecting circles of equal value (Fig. 1.1). The circles represent (1)
the current clinical situation of the patient and the patient’s values, (2) current and
relevant scientific evidence, and (3) the clinical experience and judgment of the
dental provider. The area where all three of the circles intersect represents evidence-
based dentistry or more aptly labeled evidence-based practice. There is a miscon-
ception that evidence-based dentistry is based solely on the dental or medical
literature. Rather all three areas need to be considered, and depending on the
circumstance of a specific situation or patient, each of these areas may take on more
or less importance. There are a number of factors that need to be considered in each
of these domains.

1.2 The Patient

First consider the clinical patient circumstances. Obviously this includes an appro-
priate hard and soft tissue examination of the head and neck region. But one also
needs to consider the patient’s past dental history including past and current oral
hygiene practices and opportunities. Equally important is the past and current medi-
cal health history including past and current medications. Several questions need to
be addressed. How might the medical history have contributed to the patient’s oral
health? Will the patient’s medical status have an impact on any planned treatment?
Does the patient have any physical impairment that might affect the delivery of the
proposed treatment, and equally important, are there impairments in the patient’s
ability to maintain her or his oral health? (See Chap. 3.) Once the physical data have

Fig. 1.1 Venn diagram

demonstrating the
components of evidence-
based dentistry [EBD]
Patient Pertinent
Condition Literature
Values

Dentist
Abilities
Values
1 Evidence Based Dentistry: What, Why, How 5

been obtained, treatment plan options can be formulated for the patient, which
addresses their oral health in context with their more general medical health.
Next consider the patient’s preferences and their values. What is the patient’s
overall perception of oral health and its impact on general, overall health? Does he
or she eat to live or live to eat? What kind of esthetic concerns does the patient have?
Is a bright, white smile with straight teeth necessary? What is the patient’s financial
situation, and what time and financial investments do they want to make toward
their oral health?
There needs to be a recognition and acknowledgment that the patient’s value sys-
tem and the dental practitioner value system may be worlds apart. This does not mean
that the provider shouldn’t try to influence the patient’s value system through educa-
tion, but in the final analysis, it is the patient’s preferences that should drive the final
treatment choices. These preferences and values may change over time and need be
reassessed periodically. How patients view the world when they are young and on the
dating scene may be very different than when they are in their later years and enjoying
a few final pleasures like eating. From an ethical point of view, the dental provider is
not required to provide treatment that is not in the best interest of the patient just
because the patient wants a certain treatment plan, for example, the young adult
patient with a reasonable healthy and easily restored dentition that wants a full-mouth
extraction and complete dentures to avoid going to the dentist in the future. This is
really not a justifiable and ethical option despite the patient’s preference.

1.3 Scientific Evidence

As treatment plans are developed, it is paramount to consider what the literature

states about current materials and methods. Technology continues to advance
rapidly, providing ever-expanding options for providing health care. The literature
must be evaluated both critically and carefully, and especially for applicability,
before changing tried and true methods.
The notion of a “universally true” concept in dentistry is myth. Depending on
when an individual has graduated from dental school, some of the concepts that
were taught and “written in stone” have not survived the test of time. These
“universally true” concepts should be reassessed periodically in light of advanced
and advancing understandings of disease and the human condition.
The clinician should look for the best scientific literature available that represents
the clinical situation as closely as possible. This literature then needs to be evaluated in
a systematic fashion to assess both its value and applicability to the patient.

1.4 The Dental Provider

Lastly but equally important is the clinician’s experience and judgment. The scien-
tific literature is frequently based on looking at the results of an intervention on a
reasonably homogenous population. The results of a study must be assessed in the
6 M. T. Goupil and L. Elder

context of how closely a specific patient matches the population studied. As a

clinician gains more experience she/he is better able to make predictions on how
successful the treatment might be in a given situation.
Not all clinicians have an equal ability to perform certain specific tasks, although
there usually is an acceptable minimum standard that needs to be met. Frequently
one hears and perhaps even says “in my hands this works in such and such a way.”
That is a very important concept in assessing both the results in the literature and the
formulated treatment plan. Dental providers should accurately assess and honestly
face the results of their skills on a periodic basis. Treatment outcome assessments
should be part of every practice to ensure oral health care is provided at the highest
level. These outcome assessments can then be compared to current literature results.
In summary there are at least three components to evidence-based dentistry:
(1) the patient’s needs and desires, (2) what good current scientific literature states,
and (3) what the clinician knows that works well in her/his hands. Each of these
components is important and must be considered if one wants to deliver evidence-
based care. The relative importance of each of these components may change based
on circumstances for a specific patient. The influence of each of these components
may change and must be adjusted for each individual patient. The influence of the
literature may vary based on what is available and how applicable the literature is to
a specific patient. The clinician’s influence should improve over time, based on
experience and continuing education. Evidence-based dentistry entails using the
current literature within the context of one’s own expertise and applying this
knowledge to provide the best possible health care to dental patients.

1.5 Why Do EBD?

Evidence-based decision-making is the best approach to dentistry because it offers

the best chance at successfully helping our patients achieve reasonable goals in
terms of their dental care. The practitioner should continually ask the questions—
“What would I want if I were facing these dental issues?” “What would I want for
my family member?” One does need to be cautious though when applying this
dictum to specific patients. As mentioned, part of the evidence-based dentistry
model entails respecting the desires and values of the patient.
Oral health values are based on education and previous clinical experience and
modified by the practitioner’s own personal value system. This may lead the
practitioner to believe that a certain treatment plan is the “best” or the “ideal
treatment plan” and, indeed, the proposed plan may be the best for the provider, but
it may not be the best for the patient. The practitioner needs to again consider the
patient’s value system. As mentioned above the best procedure may be able to
modify the patient’s choice through education. In any case, the provider needs to be
mindful that current ethical philosophy focuses on patient autonomy, as opposed to
the “doctor knows best” paternalism of the past.
Another way of looking at evidence-based dentistry is that it represents or is part
of the informed consent process. Informed consent is a process that evolves over
1 Evidence Based Dentistry: What, Why, How 7

time through an open dialogue with the patient. Components of the informed
consent process include the patient’s condition as well as potential methods for how
this condition may best be addressed. What are the best treatment options, including
possibly no treatment at all? What risks and benefits of each of the reasonable
treatment options exist—including no treatment? How competent is the provider
ability to deliver these options?
In today’s litigiousness society, a recurrent theme is lack of informed consent.
Probably one of the best ways to avoid these legal consequences is to apply the
evidence-based dentistry model, incorporate EBD into the informed consent
process, and then, of course, document the process.

1.6 How Can EBD Be Accomplished?

In certain regards, evidence-based decision-making within dentistry can be imple-

mented relatively easily. In most cases the patient’s condition can be assessed
through the clinical examination and a review of the medical history that has been
captured earlier through questionnaires and verified through patient dialogue.
Directed questions to the patient to determine what he or she is looking for in terms
of health in general, and oral health more specifically, will help assess the patient’s
desires and personal values. Initial evaluation inferences may change, when various
treatment options are discussed with the patient as part of the informed consent
process. Individual practitioners are aware of their own experiences and expectations,
and they should realize, as mentioned previously, that these experiences and
outcomes must be evaluated objectively. Given the inherent problem of intellectual
arrogance in all human thought, it must be remembered that a provider’s success
rate may not be as high as one perceives it to be. Ideally, expectations change over
the course of time based on further experience, developed skills, and continuing
education. Periodic objective clinical practice outcome assessments should be part
of any EBD-based practice.
Incorporation of the scientific literature can be a little more complicated, but,
hopefully, with practice this need not be overly time-consuming. The scientific
evidence is limited to given research in reputable journals. But other essential infor-
mation is relevant to evidence-based dentistry. To name a few information sources
relevant to EBD (in addition to those already mentioned):

• Formal as well as informal learning and training through dental programs

and dental degree programs
• Discussions with colleagues
• Given Standards of Dental Societies
• Community Standards
• Professional Meetings
8 M. T. Goupil and L. Elder

None of these sources, in and of themselves, should be considered to offer defini-

tive “facts” and instead must be evaluated using a systematic critical thinking
approach.
To some, evaluation of the scientific evidence may be the most intimidating; but
there are ways to make the process less daunting. First and foremost, one should
already be taking an active approach to keep abreast of the current, as well as classic,
scientific literature. Most states and hospital organizations already require mandatory
continuing education hours, to encourage this process (ADA n.d.). There are
hundreds of medical/dental journals available, and in fact it is impossible to keep
abreast of all of them. For general dentists in the United States, the journal considered
by most scholars in the field to be required reading is the Journal of the American
Dental Association. This journal contains frequent updates on important changes in
the standards of the dental profession. We also recommend Dental Abstracts, a
journal that supplies easy-to-read summaries of potentially relevant articles from a
wide variety of journals that, in all likelihood, are not part of one’s routine reading.
Accordingly Dental Abstracts may offer exciting, new, and innovative ways of
thinking about dentistry and therefore can help keep you on the cutting edge of our
field.
In reviewing a patient’s medical history, the odds are that several disease entities
and/or medications will crop up where one’s knowledge base may be weak. A quick
Google Scholar search and a few minutes time in all likely will answer the
question—“Will this disease or medication have a modifying effect on the treatment
I am contemplating?” It would be beneficial to make a quick note in the patient’s
chart on the conclusions. An annotation of the information source and date is also
advisable. Again, remember that your conclusions may change with the development
of further information, given that, considered from one point of view, dentistry is
still in its infancy in terms of its potential.
As one considers an individual patient, certain key questions should also come to
mind:

• Is this the best treatment option?

• Is there another way?
• Is there a better way?
• How long will this last?
• Why didn’t that treatment work?
• Is there a more efficient way?
• Is there a more cost-effective way?

To effectively and efficiently address these questions, one needs to consider the
type of answer desired. Are we looking for generalities and opinion or, more likely,
specific, concrete information that will answer our questions and help direct the
patient’s care?
One method that is widely proposed is the use of the acronym PICO or more
commonly called the PICO statement. This method narrows the question and
1 Evidence Based Dentistry: What, Why, How 9

therefore should guide you to a more precise search of the literature, hopefully
resulting in the most relevant and significant articles, focused on the specific
information you are seeking.
“P” stands for the patient, problem, and the population with whom we are con-
cerned. Rather than looking for “What is the success rate of dental implants?”, the
search needs to be narrowed and focused on a specific relevant population, articu-
lated in a specific question, such as: “What is the success rate of dental implants in
a young, healthy male population?” “What is the success rate of dental implants in
a geriatric partially edentulous patient, with Type II diabetes, who is being treated
for osteoporosis?” You should be able to appreciate the differences in the responses
of search engines to each of these questions. The generalized question potentially
will return hundreds of responses, whereas the other two questions may only return
very few, but more relevant, articles.
“I” stands for intervention. What treatment options are you contemplating?
“C” stands for comparison. This is an optional component to the PICO state-
ment. Are reasonable alternative treatment options available?
“O” stands for outcomes, which refers to anticipated results for treatment option
options.

Example of a PICO Statement

P: For patients undergoing the removal of impacted third molars,
I: does the use of prophylactic antibiotics,
C: as opposed to no antibiotics,
O: help prevent postoperative complications, i.e. infection, alveolar osteitis

A variety of scientific sources are available for beginning to find answers.

Primary sources, such as research articles in scientific literature, are usually consid-
ered to have the best answers for EBD. A hierarchy exists in terms of value of the
literature; meta-analysis of randomized controlled trials (RCTs) is considered to be
at the top of the pyramid. Other significant and relevant sources of information
should be also considered. Textbooks, lectures, and input from colleagues may also
be utilized, providing a critical analysis and assessment of the information are
performed.
The more specific the question, the better the literature search is likely to answer
the question at the heart of the clinical process. The downside of an overly specific
question is that search engines might not find any literature that can answer the
question.
The type of question and the kind of information required will determine the best
place to start the search. When dealing with questions concerning the medical his-
tory of a client, a drug app on a smartphone may be all that is needed. A simple
Internet search, entering only the drug name or medical condition, will frequently
provide sufficient information. Even Wikipedia may provide the relevant answer,
but of course one must always use caution in using this source.
10 M. T. Goupil and L. Elder

The University of Texas at San Antonio has championed evidence-based practice

in a real practice environment for a number of years, and consequently they
developed the medical literature search engine SUMSearch [sumsearch.uthscsa.
edu]. SUMSearch 2 {http://sumsearch.org/} is now hosted by the University of
Kansas. The University of South Carolina hosts an evidence-based dentistry search
engine [http://musc.libguides.com/EBD/searching] that is designed to readily
accept your PICO question.
If the question at issue doesn’t readily adapt to using the PICO method, another
way of formulating questions is the use of WIN-, WIS-, and WIR-type questions
that are used in problem-based learning pedagogy. These stand for “What is the
nature of____________? What is the significance of_________? What is the
relation of_____________? Using this process entails selecting the most applicable
question and filling in the blank with the information relevant to the clinical case.
These questions can be easily used with other search engines.
PubMed is a frequently used and readily available search tool. Another search
engine to be considered is the Trip database [www.tripdatabase.com]. This database
will provide you with established practice guidelines which can help in the deci-
sion-making process.
Part of the acquisition of the evidence is ensuring that the source of the informa-
tion is reliable. It must be clear that any information acted upon will be in the best
interest of the patient. If the information is outdated or not from a trusted source,
there is significant potential that the information is no longer valid.
There are a couple of choices though that need to be made as part of the search
process. Some of the search engines noted previously should accommodate these
choices. One of the choices is “Do you want to select a specific journal?” Some
ranking systems attempt to assign a score to indicate the potential value of an
article found in a specific journal. One method commonly used is the “impact fac-
tor.” The impact factor (IF) is calculated on the number of times each article in a
journal is cited by authors for other articles. The impact factor is based on this
calculation over a 2-year period and obviously may change from year to year. One
implication is that the higher the IF, the more important is the value of an article
published in that journal. Thus, one would expect a journal like Cancer to have a
higher IF value than a throw away journal like Dental Economics. Remember
though this is a guideline and should be used with caution. Depending on the infor-
mation you are seeking, an obscure information source with a lower IF value may
be more relevant to a specific patient condition. The top five dental journals with
consistently high impact factors are the Journal of Dental Research, Journal of
Clinical Periodontology, Clinical Oral Implants Research, Dental Materials, and
Periodontology 2000 (Sillet et al. 2012).
A more recent method for ranking scientific journals is the Eigenfactor. In
this method the journal is still evaluated by the number of citations for each
article, but now the citations are weighted based on the relative importance of
where the citation is being used. The top five journals in this ranking system
have now changed to the Journal of Dental Research; Journal of Periodontology;
1 Evidence Based Dentistry: What, Why, How 11

Journal of Oral and Maxillofacial Surgery; Oral Surgery, Oral Medicine, Oral
Pathology, Oral Radiology, and Endodontology (quad O and E); and Dental
Materials. The Journal of the American Dental Association, which has an
impact factor of 1.9 and ranks #24 now moves to #14 using the Eigenfactor
(Sillet et al. 2012).
Just as journals may differ in relative value or significance, so may individual
articles within a specific journal. As mentioned previously a hierarchy exists of
study design or clinical evidence which is commonly described as “levels of
evidence,” ranking from Level 1 studies which contain the strongest evidence to
Level 5 which contain the weakest (Fig. 1.2). Level 5 entails editorials or opinions,
and Level 4 contains case reports; Level 3, case-controlled studies; Level 2, cohort
studies; and Level 1, randomized controlled trial and/or meta-analysis systematic
reviews. Several of the previously mentioned search engines can be judged according
to the level of evidence required. Obviously, one would prefer to have Level 1
evidence answer the question; but in many, if not most instances, this type of
evidence may not be available to answer the question. In most situations the provider
will have to settle for the best information currently available, at whatever level this
exists.
Cochrane reviews are an excellent source of high-level, comprehensive, clini-
cal-based literature. Their evaluations are designed to provide both the practitio-
ner and the patient relevant information for making informed health-care decisions
(Sandhu 2012).

Fig. 1.2 Hierarchy of

levels of evidence

Meta
Analysis

Randomized

Controlled

Cohort Studies

Case-controlled Studies

Case Series, Case Reports

Editorials or Expert Opinion

12 M. T. Goupil and L. Elder

Another choice that must be decided upon is how far back in the literature to go.
In most cases probably no more than 5 years would be appropriate. Decisions should
be made on the best and most current literature that is available.
Just because something is in print doesn’t necessarily make it true. A statistic to
keep in mind is that studies that have a significant difference are more likely to be
published than studies that don’t have a significant difference (Smyth et al. 2011).
Thus when reviewing the literature, be mindful that what is being read already
contains some form of bias. A critical evaluation of the information is of paramount
importance.
When reading a scientific article, there are a couple of things need to be checked
in the method section. Is the sample size large enough to truly indicate whether the
statistical difference is truly valid? Was a power analysis conducted to ensure that
the sample size is appropriate? Unfortunately, this is frequently missing in the
dental literature. Also note, if the test groups are compared over time, was the time
interval long enough? A difference noted may initially be found to be “statistically
significant,” but when followed for a longer more appropriate period of time, this
difference may in fact disappear, with the end result that indeed there was no
difference in the intervention being studied.
The p-value or statistical significance should be assigned before the study is
conducted. In most dental literature, a p-value of 0.05 is used to indicate significance.
A term creeping into the literature is “the results are approaching significant.” An
outcome is either significant or not. Significant results may also be indicated by a
confidence level (CL) that implies the probability that the true result falls within a
defined interval.
A large and varied body of literature is available, dealing with critical thinking.
Critical thinking is now required in the curriculum in all US dental schools. In the
field of dentistry, the concepts critical thinking and evidence-based dentistry are
essentially being used synonymously. However, while evidence is a significant part
of critical thinking, it represents only one part.
Further, some people believe that critical thinking is confined to given sub-
jects such as literature and the humanities. However this would be incorrect.
Critical thinking is in fact relevant to all subjects and disciplines in which peo-
ple reason, including dentistry; critical thinking can and should be applied to all
facets of life where best decisions need to be made and issues need to be rea-
soned through.
There isn’t a single definition capturing all components and complexities of criti-
cal thinking. According to Dr. Richard Paul, a world-renowned authority on this
subject, “critical thinking is thinking about your thinking while you are thinking in
order to improve your thinking.” This offers just one simple way into the concept.
In the remainder of this chapter, we will attempt to provide the basic format of the
Paul-Elder Critical Thinking Model™ (Fig. 1.3). It is up to dental professionals to
apply this method to our continuing education seminars and professional meetings
and even to other interpersonal interactions.
1 Evidence Based Dentistry: What, Why, How 13

Fig. 1.3 The Paul-Elder Critical thinkers routinely apply intellectual standards
Critical Thinking Model™ to the elements of reasoning In order to develop
(Paul and Elder 2015) Intellectual tralts.
The Standards
Clarity Precision
Accuracy Significance
Relevance Completeness
Must be
Logicalness Fairness applied to
Breadth Depth

The Elements
Purposes Inferences
Questions Concepts
As we learn Point of view Implications
to develop Information Assumptions

Intellectual Traits
Intellectual Humility Intellectual Perseverance
Intellectual Autonomy Confidence in Reason
Intellectual Integrity Intellectual Empathy
Intellectual Courage Fairmindedness

1.7 Paul-Elder Approach to Critical Thinking

The Paul-Elder Framework for Critical Thinking™ offers a unique approach to analyz-
ing an article, lecture, case study, patient interaction, etc. into eight component parts. The
eight component parts are based on reasoning and are as follows: purpose, key question,
point of view, assumptions, information, concepts, inferences, and implications (Fig. 1.4).
It is important to realize that there is no hierarchy to the eight parts of reasoning;
they all are open to analysis; and they function in a dynamic relationship with one
another in the mind of all humans. Therefore the provider need not analyze reasoning
(either one’s own or a patient’s) in a specific order. From a practical point of view
though, it may be easier to conduct the analysis in the order given above. Consistent
use in this order will ensure that all eight components have been considered when
reasoning through a given issue. An advantage of using this mode of analysis for
most peer-reviewed literature is that at least half of the components can usually be
identified in the article’s abstract.
This analysis is useful in analyzing any form of reasoning in any context—a
lecture, an article, a book, and a conversation. The use of the Checklist for Clinical
Reasoning taken from The Thinker’s Guide to Clinical Reasoning (Hawkins et al.
2010) simplifies the process (Fig. 1.5). The following helpful diagrams from this
guide illustrate the analysis and assessment process in clinical practice.
14 M. T. Goupil and L. Elder

Fig. 1.4 Elements of To Analyze Thinking We Must Learn to Identify and

critical thinking (Elder Question its Elemental Structures
and Paul 2010)
8 1

to answer a Whenever
question of we think
7 solve a we think for a 2
problem. purpose

based on
concepts and within a
theories point of view
Universal
Structures
6 of Thought 3
to make based on
inferences and assumptions
judgements

We use leading to
data, facts, implications and
and experiences consequences.

5 4

8 1

What is the What is my

key question I fundamental
7 am trying to purpose? 2
answer?
What is the What is my
most basic point of view
concept in the with respect to
the issue?
question? Universal
Structures
6 What are my of Thought 3
What
most fundamental assumptions am
inferences of I using in my
conclusions? What What reasoning?
information are the
do I need to implications
answer my of my reasoning
question? (if I am collect)?

5 4
1 Evidence Based Dentistry: What, Why, How 15

A Checklist for Clinical Reasoning A Checklist for Clinical Reasoning (cont.)

1 All clinical reasoning has a PURPOSE. 5 All clinical reasoning is based on DATA, INFORMATION, and EVIDENCE.
To what extent is your reasoning supported by relevant data?
Can you state your purpose clearly?
Do the data suggest explanations that differ from those you have given?
What is the objective of your clinical reasoning?
How clear, accurate, and relevant are the data to the clinical
Dose your reasoning focus throughout on your clinical goal?
question at issue?
Is your clinical goal realistic?
Have you gathered data sufficient to reach a valid conclusion?

2 All clinical reasoning is an attempt to figure something out, to settle 6 All clinical reasoning is expressed through, and shaped by,
some QUESTION, to solve some PROBLEM. CONCEPTS and THEORIES.
What clinical question are you trying to answer? What key concepts and theories are guiding your clinical reasoning?
Are there other ways to think about the question? What alternative explanations might be possible, given these
Can you divide the question into sub-questions? concepts and theories?
Is this a question that has one right answer or can there be more Are you clear and precise in using clinical concepts and theories in
than one reasonable answer? your reasoning?
Dose this question require clinical judgment rather than facts alone? Are you distorting ideas to fit your agenda?

7 All clinical reasoning contains INFERENCES or INTERPRETATIONS

3 All clinical reasoning is based on ASSUMPTIONS.
by which we draw CONCLUSIONS and give meaning to data.
What assumptions are you making? Are they justified?
To what extent do the data support your clinical condusices?
How are your assumptions shaping your point of view?
Are your inferences consistent with each other?
Which of your assumptions might reasonably be questioned?
Are there other reasonable inferences that should be considered?
4 All clinical reasoning is done from some POINT OF VIEW. All clinical reasoning leads somewhere, that is, has IMPLICATIONS
8
What is your point of view? What insights is it based on? What are and CONSEQUENCES.
its weaknesses? What implications and consequences follow from your reasoning?
What other points of view should be considered in reasoning If we accept your line of reasoning, what implications or
through this problem? What are the strengths and weaknesses of consequences are likely?
these viewpoints? Are you fairmindedly considering the insights What other implications or coclsequences are possible or probable?
behind these viewpoints?

Fig. 1.5 Checklist for clinical reasoning (Hawkins et al. 2010)

1.8 Reasoning Through the Logic of This Chapter

We can take the eight elements of reasoning and use them to figure out the logic of
this chapter we are writing for this book, as follows:
Purpose—What is the author trying to accomplish? For instance, the purpose of
this chapter is to give the dental practitioner a reasonable and defensible rationale
behind evidence-based dentistry and suggested ways to easily accomplish this goal.
Key Question—What essential question does this chapter, article, or lecture
address? For instance, a key question in writing this chapter was: What is a feasible
approach to addressing implementation of EBD?
Point of View—From what direction is the question being viewed and
answered? What are you looking at and how are you seeing it? Focusing on point
of view can help define potential bias when one is evaluating a piece of research,
lecture, or interaction. One of the authors [MG] has been a dentist for the past 40
plus years and in this capacity has provided direct patient care as an oral and
maxillofacial surgeon; for the past 15 years, he has been involved in teaching
critical thinking skills to dental students. The other author [LE] has made
16 M. T. Goupil and L. Elder

teaching of critical thinking her life’s work and is the one of the developers of
Paul-Elder Framework for Critical Thinking™. Each author therefore brings a
different point of view to this chapter, and both viewpoints enhance the other. To
take a different example, when considering the point of view in the context of
EBD, one must consider not only how a dental provider is looking at an issue but
very importantly how the patient may view the same issue; in many situations,
there also must be a consideration of how a third-party payer may be looking at
the same issue.
Assumptions—What is being, or should be, taken for granted in the clinical
context? One assumption being made by the authors of this chapter is that the
readers want to be more facile in applying evidence-based dentistry to their prac-
tice and therefore would see this chapter as useful and valuable. The readers, in
turn, should assume that the authors have been vetted and are therefore suffi-
ciently expert in their fields to write intelligently about the issues in this
chapter.
Information—What data is being used in the article or chapter? The informa-
tion used in this chapter offers the basics of what, why, when, and how of EBD. It
also offers a rich conception of critical thinking for the reader, through which EBD
can be best implemented.
Concepts—Concepts are the rules, laws, and principles used to interpret the
information in order to ultimately derive a conclusion. The primary concepts used
in this chapter include our idea of what constitutes EBD and how it may be reason-
ably understood in the dental field. This chapter also introduces the Paul-Elder
Framework for Critical Thinking™, as a primary conceptual tool for engaging in
EBD.
Conclusions—What primary conclusions do the authors of this chapter want the
reader to accept? At the end of this chapter, our expectation is that the reader will
conclude that evidence-based dentistry has value and that there are powerful
conceptual tools available for engaging in effective EBD.
Consequences—What happens if one acts or fails to act on the conclusions
offered in this chapter? A desired consequence of this chapter is that the reader will
incorporate critical thinking, not only throughout their practice in client care but
also in their daily life. If EBD is considered valuable, then as a result of using EBD,
one will be in a better position to make reasonable and sound decisions—based on
fact and not myth. If the concepts of EBD and critical thinking are not accepted by
the reader, the reader may not see the value of progressing as a thinker in dental care
and hence keep doing the same thing year after year, never advancing as a dental
provider.

1.9  nalyzing and Assessing Clinical Research Using

A
the Tools of Critical Thinking

The essence of this textbook entails the idea that the best treatment option for a
patient should be supported by the best available scientific data. The eight parts
of reasoning are very useful in analyzing and assessing research in the field of
dentistry (Fig. 1.6).
1 Evidence Based Dentistry: What, Why, How 17

Analyzing & Assessing Clinical Research

Use this template to assess the quality of any
clinical research project or paper.
1) All clinical research has a fundamental PURPOSE and goal.
Research purposes and goals should be clearly stated.
Related purposes should be explicitly distinguished.
All segments of the research should be relevant to the purpose.
All research purposes should be realistic and significant.
2) All clinical research addresses a fundamental QUESTION, problem or issue.
The fundamental question at issue should be clearly and precisely stated.
Related questions should be articulated and distinguished.
All segments of the research should be relevant to the central question.
All research questions should be realistic and significant.
All research questions should define clearly stated intellectual tasks that, being
fulfilled, settle the questions.
3) All clinical research identifies data, INFORMATION, and evidence relevant to its
fundamental question and purpose.
All information used should be clear, accurate, and relevant to the fundamental
question at issue.
Information gathered must be sufficient to settle the question at issue.
Information contrary to the main conclusions of the research should be explained.
4) All clinical research contains INFERENCES or interpretations by which conclusions are drawn.
All conclusion should be clear, accurate, and relevant to the key question at issue.
Conclusions drawn should not go beyond what the data imply.
Conclusions should be consistent and reconcile discrepancies in the data.
Conclusions should explain how the key questions at issue have been settled.
5) All clinical research is conducted from some POINT OF VIEW or frame of reference.
All points of view in the research should be identified
Objections from competing points of view should be identified and fairly addressed.
6) All clinical research is based on ASSUMPTIONS.
Clearly identify and assess major assumption in the research.
Explain how the assumptions shape the research point of view.
7) All clinical research is expressed through, and shaped by, CONCEPTS and ideas.
Assess for clarity the key concepts in the research.
Assess the significance of the key concepts in the research.
8) All clinical research leads somewhere (i.e., have IMPLICATIONS and consequences).
Trace the implications and consequences that follow from the research.
Search for negative as well as positive implication.
Consider all significant implications and consequences.

Fig. 1.6 Analyzing and assessing clinical research (Hawkins et al. 2010)

1.10  he Importance of Universal Intellectual Standards

T
in Evidence-Based Dentistry

Once the eight parts have been analyzed, then a critical assessment of the article,
lecture, event, etc. can be accomplished. For this, we must understand, internalize,
and adhere to universal intellectual standards on a daily basis. Essential intellectual
18 M. T. Goupil and L. Elder

standards include clarity, accuracy, precision, relevance, significance, depth,

breadth, logic, and fairness (Fig. 1.7). From a practical standpoint, certain parts of
the analysis and assessment can be accomplished at the same time. Using only a few
of the analysis and assessment items, a quick determination as to the potential value
of a given piece of research can often be accomplished.

Universal Intellectual Standards

Essential to Sound Clinical Reasoning
Universal intellectual standards are standards which must be applied to thinking
Whenever one is evaluating the quality of reasoning about a problem, issue, or
situation. To think cirtically one must have a command of these standards. While
there are a number of universal standards, we focus here on some of the most
significant:
Clarity
Could you elaborate further on that point? Could you express that point in another
way? Could you give me an illustration? Could you give me an example?
Clarity is a gateway standard. if a statements is unclear, we cannot determine
whether it is accurate or relevant. infact. In fact, we cannot tell anything about it (except
that it is unclear) because we don’t yet know what it is saying.
Accuracy
Is that really true? How could we check that? How could we find out if that is true?
What evidence is there to support the validity of your clinical thinking?
A statement can be clear but not accurate, as in “Most creatures with a
spine weigh more than 300 pounds.”

Precision
Could you give me more details? Could you be more specific?
A statement can be both clear and accurate, but not precise, as in “The solution
in the beaker is hot.” (We don’t know how hot it is.)
Relevance
How is that connected to the question? How dose that bear on the issue?
A statement can be clear, accurate, and precise, but not relevant to the
question at issue. If a person who believed in astrology defended his/her view by
saying “Many intelligent people believe in astrology.” their defense would be
clear, accurate, and sufficiently precise, but irrelevant to clinical reasoning.
Depth
How dose your answer address the complexities in the question? How are you
talking into account the problems in the question? Are you dealing with the most
significant factors?
A statement can be clear, accurate, precise, and relevant, but superficial (that
is, lacks depth). For example, the statement “Just Say No” which is often used to
discourage children and teen from using drugs, is clear, accurate, precise, and
relevant. Nevertheless, it lacks depth because it treats an extremely complex
issue, the pervasive problem of drug use among young people, superficially. It fails
to deal with the complexities of the issue.

Fig. 1.7 Analyzing and assessing clinical research (Hawkins et al. 2010)
1 Evidence Based Dentistry: What, Why, How 19

Breadth
Do we need to consider another point of view? Is there another way to look at this
question? What would this look like from the point of view of a conflicting
theory, hypothesis or conceptual scheme?
A line of reasoning may be clear, accurate, precise, relevant and deep, but lack
breadth (as in a well-reasoned argument from either of two conflicting theories which
ignores insights into the conflicting theory).

Logic
Does this really make sense? Is this consistent with what we know about this issue
or problem?
When we think, we bring a variety of thoughts together into some order.
When the combination of thoughts is mutually supporting and makes sense
in combination, the thinking is “logical.” When the combination is not mutually
supporting, is contradictory in some sense, or does not “make sense” the
combination is “not logical.” In clinical reasoning, new conceptual schemes
become working hypotheses when we deduce from them logical consequences
which can be tested by experiment. If many of such consequences are shown to
be true, the theory (hypothesis) which implied them may itself be accepted as true.
Significance
Is the most important problem to consider? Is this the central idea to focus
on? Which of these facts are most important?
When dealing with a complex issue it is essential to consider relevant variables
but some are more significant than others. The most significant variables should be
considered first. Secondary relevant variables come next in order of importance.

Fairness
Do we nhave a vested interest in this issue? Am I represnting the viewpoints of
others in a way that is fair and balanced?
We naturally think from our own perspective, from a point of view which tends
to privilege our position. Fairness implies the treating of all relevant viewpoints
alike without reference to one’s own feelings or interests. Because we tent to
be biased in favor of our own viewpoint, it is important to keep the standard of
fairness at the forefront of our thinking. This is especially important when the
situation may call on us to see things we don’t want to see, or give something up
that we want to hold onto.

Fig. 1.7 (continued)

In assessing the quality of this chapter, using essential intellectual standards, the
reader should find the following to be true:
Clarity—Hopefully the reader has found this chapter relatively straightforward
and easy to read. Diagrams and charts were included to illustrate the material to help
the reader better understand the text. The chapter itself has been used to provide an
example on how to use the Paul-Elder Framework for Critical Thinking™ in EBD.
Accuracy and Precision—Terms were defined, and figures were taken from
published materials. Appropriate literature was cited.
Depth and Breadth—The depth of the chapter is appropriate for the stated pur-
pose (see above). Should the reader desire more depth, there are numerous articles
20 M. T. Goupil and L. Elder

and texts devoted to the topic of evidence-based practice available through the
sources indicated in this chapter. Similarly the breadth of the chapter was limited to
only one literature review technique—the Paul-Elder Approach to Thinking™. This
is also in keeping with the stated purpose.
Relevance—The concept of evidence-based practice is now an established part
of contemporary dental practice. The Paul-Elder Critical Thinking Model provides
a structured method for analyzing and assessing the scientific literature.
Significance—EBD is essential for reasonable dental practice in today’s com-
plex information society.
Logic—The chapter starts with defining EBD and flows from why to how. EBD
is logically connected with the richer concept of critical thinking.
Fairness—Evidence and ideas in this chapter have been presented objectively
and without bias.

1.11 Conclusion

To sum up this chapter, we may return to our question: What is evidence-based

dentistry? First and foremost, it does not entail simply “doing an intervention” just
because some given piece of research may offer “correct” course of action. Rather,
evidence-based dentistry involves a critical appraisal of appropriate research and
other information that addresses a patient’s specific circumstances, as well as her or
his value system, interpreted through the clinician’s knowledge, experience, and
expertise.
Why do it? Because it takes into account the worldview of the dental patient as
well as the best knowledge available at a given time, in the field of dentistry.
How can EBD be reasonably accomplished?

1. Listen to patients to determine what they want.

2. Make an honest assessment of the dental situation in context.
3. Critically review the literature most relevant to the specific situation.
4. Then using personal experience, determine the best options to address the spe-
cific situation. There is usually more than one way to reach a satisfactory result.
Conduct a cost-benefit, risk-benefit discussion with the patient. This is the
informed consent process; make sure it is documented.

This chapter encourages the use of Paul-Elder’s Framework for Critical

Thinking™. It is one of the many ways to select and critically assess the literature.
But it has been chosen for inclusion here because it provides an excellent method
for reasoning through specific decisions, using the richest tools of criticality extant.
And we have recommended that the reader apply this approach to all aspects of life.
In starting this critical thinking process, consider beginning with assumptions. What
assumptions have you or others made about others that resulted in a course of action
detrimental or not in the best interest of your client?
1 Evidence Based Dentistry: What, Why, How 21

The tools of critical thinking can be easily documented in the best thinking in
dental practice. But dentists have yet to embrace, as a profession, a robust conception
of fair-minded critical thinking. This will be required if the best evidence-based
dental practices are to be achieved.

References
ADA. State CE Statutes and regulations dentist continuing education. n.d. http://www.ada.org/~/
media/ADA/Advocacy/Files/continuing_ed.pdf.
Elder L, Paul R. The thinker’s guide to analytical thinking. 2nd ed. Tomales, CA: Foundation for
Critical Thinking; 2010.
Hawkins D, Elder L, Paul R. The thinker’s guide to clinical reasoning. 1st ed. Tomales, CA:
Foundation for Critical Thinking; 2010.
Paul R, Elder L. The miniature guide to critical thinking. 7th ed. Tomales, CA: Foundation for
critical thinking; 2015.
Sakaguchi R. Evidence-based dentistry: achieving a balance. J Am Dent Assoc. 2010;141:496–7.
Sandhu A. The evidence base for oral and maxillofacial surgery: 10-year analysis of two journals.
Br J Oral Maxillofac Surg. 2012;50:45–8.
Sillet A, Katsahian S, Range H, Czernichow S. The Eigenfactor™ score in highly specific medical
fields: the dental model. J Dent Res. 2012;9(4):329–33.
Smyth RMD, Kirkham JJ, Jacoby A, Altman DG, Gamble C, Williamson PR. Frequency and reasons
or outcome reporting bias I clinical trials: interviews with trialists. BMJ. 2011;342(7789):155.
Office Environment
2
Melissa E. Ing and Peter Arsenault

“I fear that if the matter is beyond humanity it is certainly

beyond me.”
—The Adventure of the Devil’s Foot

Abstract
The dental profession is predisposed to various occupational hazards including
blood-borne pathogens, chemical agents, and particulate projectiles which can
cause skin and eye safety issues and musculoskeletal disorders. Oral surgery
procedures can cultivate these occupational hazards. This chapter discusses these
problems, their implications, and subsequent approaches to create a safe and
functional work environment. In addition, this chapter focuses on how to incor-
porate proper ergonomics to prevent musculoskeletal disorders, thereby helping
dentists maintain a healthy, long-term career.

2.1 Office Environment/Office Design

A dental office environment with thoughtful attention to details allows for patient
comfort as well as employer and employee satisfaction. The practice should look
professional and organized, with up-to-date technology, as superior office design
can be an excellent marketing tool. The workplace is an expression of the dentist’s
personality and should make a positive impression on the patient. Particular atten-
tion should be given to make the waiting area appealing and reassuring to anxious
patients. Furthermore, treatment areas should have soundproof walls to drown out
loud noises such as those from turbine-driven handpieces.
Dentists will always have their personal vision of what the office space should
consist of. However, an office’s clinical function will dictate its layout and ergo-
nomic considerations.

M. E. Ing (*) · P. Arsenault

Division of Operative Dentistry, Department of Comprehensive Care, Tufts University School
of Dental Medicine, Boston, MA, USA
e-mail: [email protected]; [email protected]

© Springer International Publishing AG, part of Springer Nature 2019 23

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_2
24 M. E. Ing and P. Arsenault

The floor plan should have good traffic flow. There should be areas that are
accessible to patients and private areas designated only for the staff.
Dental professionals can be exposed to numerous occupational hazards includ-
ing exposure to blood-borne pathogens, chemical agents, and musculoskeletal dis-
orders due to ergonomic setups. The office environment should provide protective
mechanisms and a systematic approach to safe practices.

2.2 Blood-Borne Pathogens

Dental offices must vigilantly follow the Centers for Disease Control and Prevention
(CDC) and the Occupational Safety and Health Administration (OSHA) guidelines
for proper infection control and safe work practices. While the CDC is a govern-
ment agency within the US Public Health Service, it is not a regulatory authority
(Cuny and Collins 2013). However, creating infection control recommendations
according to evidence-based research is one of the CDC’s many tasks. OSHA is part
of the US Department of Labor, and their duty is to protect the health and safety of
workers within the USA. OSHA creates regulations such as the Bloodborne
Pathogens standard to reduce the risk of occupational exposure to blood-borne
pathogens (Cuny and Collins 2013).
The blood-borne pathogens that are of concern to dental health-care personnel
(DHCP) are hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency
virus (HIV). HBV vaccinations became routine in 1982 and universal precautions
have been recommended since 1987.
Due to hepatitis B vaccinations and universal precaution recommendations,
transmission of blood-borne pathogens in the dental setting has rarely been reported
during the last decade. In the 1990s, there was one case where a dentist with
autoimmune deficiency disease (AIDS) was found to have transmitted HIV to five
of his patients after invasive procedures (Ciesielski and Marianos 1992). At this
time, there are no known patient to patient reports of HIV transmission.
Yet, a 2016 review of the literature cites three reports of blood-borne pathogen
transmissions of hepatitis B and hepatitis C from 2003 through 2015 (Cleveland
2016). The article described an incident from 2002 as a single HBV transmission
from one patient to another patient that occurred in an oral surgery office. The
article described a 2009 occurrence as the first documented patient to patient HBV
transmission which occurred in a large portable free dental clinic setting. The third
reported incident occurred in 2013 at an oral surgery office and is considered the
first documented case of patient to patient transmission of HCV in an American
dental setting. In the 2002 case, investigators speculated that there was a breach in
cleaning the environmental surfaces that resulted in cross contamination of blood
with the source patient who had chronic HBV with a high viral load at the time of
the surgery (Cleveland 2016). In the 2009 documented case, five HBV transmissions
occurred from a portable free dental clinic that was held in a gymnasium. Multiple
failures in infection control were cited retrospectively as the cause of the transmission
of HBV to three other patients as well as to two DHCP. It was reported that the
2 Office Environment 25

utilized handpieces were not heat sterilized; unwrapped sterilized instruments were
utilized, and patients were allowed to transport partially used anesthetic cartridges
in metal syringes to another station for later reuse (Cleveland 2016). Investigators
speculate that the 2013 patient to patient transmission of HCV occurred due to the
failure to administer IV sedation by licensed, trained dental personnel, due to the
use of improperly sterilized equipment, and due to the reusing of contaminated
medication vials, needles, and syringes (Cleveland 2016).
Lesson gleaned from the above reporting is that even though blood-borne patho-
gen transmissions are infrequent, they can happen from routine restorative and oral
surgery procedures. There are several potential routes for the spread of infection in
the dental clinic. These include (1) direct contact with bodily fluids of an infective
patient, (2) contact with contaminated instruments or environmental surfaces, and
(3) contact with infectious airborne particles from an infective patient (Harrel and
Molinari 2004).
HBV and HCV can survive on blood-contaminated environmental surfaces for
long periods of time. Bond et al. demonstrated that the HBV virus can survive in
dried blood at room temperature on environmental surfaces for at least 1 week
(Bond et al. 1981). Furthermore, Paintsil et al. demonstrated that HCV infectivity
can remain on dry surfaces for up to 6 weeks (Paintsil et al. 2014). HIV can survive
in dried blood at room temperature for 5–6 days if placed in an ideal pH level. For
long-term survival, HIV cannot have a pH below 7 nor a pH above 8 (Tjotta 1991).
In 2003 the CDC published the Guidelines for Infection Control in Dental Health
Care Settings. To this day, this remains the standard for offices and institutions to
follow (CDC 2003). More recently, the CDC also published the Summary of
Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care.
This includes a handy infection prevention checklist that DHCP can use to evaluate
infection control compliance (CDC n.d.-a). Offices should designate an infection
control officer to be in charge of assessing annual safe practice policies and updating
a written manual. Dental offices should ensure each DHCP hire and current
employees have yearly OSHA training.
Clinicians should always keep in mind that all patients could be carriers of an
infectious disease. Therefore, universal precautions should always be followed.
Since oral surgical procedures can increase the risks of local or systemic infection,
it would be prudent to have an extra vigilant infection prevention routine in place.

2.3 Spatter and Aerosols

In the dental operatory, a visible spray is created each time high-speed rotary hand-
pieces, ultrasonic scalers, or air-water syringes are utilized. Water is often used as
coolant with handpieces and ultrasonics to prevent overheating of tooth structure.
Studies show that when high-speed rotary handpieces are used, the air can be
contaminated for a period of time until the particles settle (Harrel and Molinari
2004). In oral surgery, Hall drills, Stryker drills, and high-speed and low-speed
drills are often used to section teeth for easier extraction and for implant placement.
26 M. E. Ing and P. Arsenault

The water spray alone that is generated from the rotary equipment may not be
harmful, but once mixed with the patient’s oral fluids such as saliva, blood, bone
fragments, human tissue, bacteria, and debris, it can turn into a potential health
hazard.
This visible spray contains larger and smaller particles. The larger particles, in
the size of 50 μm or more, are called “spatter” (Harrel and Molinari 2004; Micik
et al. 1969). Since spatter particles are large and heavy, they traverse short distances,
landing fairly quickly on operatory surfaces, equipment, the clinician, and the
patient.
In contrast, aerosols are defined as a collection of solid or liquid particles
which are less than 50 μm in size (Harrel and Molinari 2004; Micik et al. 1969).
Since aerosols are much smaller particles, they remain suspended in air much
longer than spatter before finally contacting surfaces (Harrel and Molinari 2004).
In fact, aerosols can stay suspended in the operatory air for up to 30 min (Harrel
and Molinari 2004). Some of the smaller aerosols that range in size from 0.5 to
10 μm can potentially travel to and penetrate into the pulmonary passages (Harrel
and Molinari 2004). Harrel and Molinari noted that if DHCP remove face shields
upon completing the procedure to talk with the patient, there is potential contact
with aerosol contaminants which are floating in the environment (Harrel and
Molinari 2004).
Studies have demonstrated that the ultrasonic scaler produces the greatest amount
of airborne contamination followed by the high-speed handpiece. The air-water
syringe also produces a great deal of aerosols (Harrel and Molinari 2004).
Investigators have demonstrated that during scaling and root planing, blood is
always present in the ultrasonic scaler aerosols (Harrel and Molinari 2004). Harrel
and Molinari deduced that blood is most likely present in aerosols where any rotary
instrumentation was used within an operating field containing blood. This would
include any subgingival, periodontal, and oral surgery procedures (Harrel and
Molinari 2004).

2.4 Infection Control Measures

The most logical and first precautionary measure to reduce spatter and aerosols is to
ensure that DHCP wear OSHA-approved personal protection equipment (PPE)
while treating patients as well as when preparing and breaking down the operatory.
PPE consists of and should be donned in the following sequence: (1) fluid resis-
tant clinic gowns, (2) face masks, (3) safety eyewear, and (4) gloves.
Clinic gowns should have high necks and long sleeves, with ribbed cuffs at the
neck and at the wrists. The gowns should at least cover the operator’s knees when
seated. Rutala et al. studied the cost differences between disposable and reusable
gowns and found that reusable gowns did not always save money due to the fact that
the gowns would be damaged during the handling and laundering process thus
rendering them useless (Rutala et al. 2001). Rutala also demonstrated that some
2 Office Environment 27

reusable gown materials proved more superior than others. Gowns with a laminated
coating of polypropylene provided the most superior resistance to blood and other
liquids seeping through. A single-layered non-woven fabric was found to be the
next best performing reusable gown fabric. 50 cotton/50 polyester was not very
effective in preventing blood strike through, and 100% cotton offered the least
amount of protection (Rutala et al. 2001).
If masks become soiled or wet during the procedure, they should be replaced.
Clinicians should always avoid touching masks during the course of treatment to
prevent cross contamination. All dental mask styles provide protection of covered
facial areas (nose, mouth, and portions of the cheeks) against splash and projectiles.
Dental masks are available in a variety of designs and profiles. Pleated-type den-
tal masks are preferred by dental practitioners since they are easy to wear and have
low resistance to breathing. Most pleated masks contain an inner layer of melt-­
blown filtration material (Arsenault and Tayebi 2016). However, since there is no
effective seal between the perimeter of the mask and the wearer’s face, air leakage
occurs through the perimeter of the mask, and hence, the mask fails to provide
effective respiratory system protection. The National Institute for Occupational
Safety and Health (NIOSH), which is part of the CDC, utilizes research to promote
safer recommendations for workers. In comparison to NIOSH-approved respirators,
most pleated masks lack the seal between their perimeter and the wearer’s face and
hence would not meet NIOSH approval requirements (Arsenault and Tayebi 2016).
Masks that are fitted with a full-face transparent shield such as an up visor or a full
down visor may be particularly desirable when an oral surgery procedure generates
excessive blood splashes, fluids, or particulates.
The CDC recommends that prior to oral surgical procedures, a fast-acting anti-
microbial soap with a broad spectrum of bactericidal activity is utilized for hand-
washing. For oral surgery procedures in the operating room, sterile gloves should be
used. If gloves become wet and torn or are deemed defective, they should be
promptly replaced. Scrupulous handwashing after the procedure is completed must
take place.
In 2006, Rautemaa et al. studied how far aerosols travel from a patient after the
use of high-speed rotary instrumentation is utilized in the operatory. Investigators
placed agar plates in distances varying from 0.5 to 2 m from the patient. The agar
plates were samples before and after dental procedures. At the same time, they
also sampled the facial masks of the DHCP before and after the procedure. The
most commonly found bacteria in the agar plates were Viridans streptococci and
staphylococci. Significant contamination was found from agar plates at all dis-
tances. Face masks were found to be equally contaminated when high-speed
rotary instruments were used. Rautemaa’s study substantiates how aerosols spread
beyond the area and equipment used for the procedure (Rautemaa et al. 2006).
Thus, all PPE needs to be removed as soon as the DHCP leave the operating area
to prevent cross contamination. This study also substantiates the need to wear PPE
when cleaning, preparing, and breaking down operatory surfaces and equipment
(Rautemaa et al. 2006).
28 M. E. Ing and P. Arsenault

In addition, Rautemaa’s work demonstrates that all environmental surfaces, even

if not used for the procedure, must be thoroughly disinfected at the beginning of the
workday, in between each patient, and at the end of the workday. Rautemaa’s study
also suggests that only necessary equipment items needed for the procedure at hand
be placed within the operatory work surfaces to minimize contamination and that all
other items be placed within a closed cupboard (Rautemaa et al. 2006). Furthermore,
Rautemaa et al. (2006) suggest protection of the exposed skin and hair to prevent
bacterial spread.
As a second precautionary measure, having patients use an antiseptic preopera-
tive rinse such as 0.01% chlorhexidine for 1 min prior to the procedure can lower
overall bacterial counts in the operating environment (Harrel and Molinari 2004).
A third essential method in reducing airborne aerosols is to use an efficient high-­
volume evacuator (HVE) to prevent aerosols and bacteria from escaping the imme-
diate operating site. An HVE suction system is defined as one that removes a large
volume of air within a short period of time. Most HVE used in dentistry are attached
to an evacuation system and will have an 8 mm or greater opening and are able to
remove up to 100 cubic feet of air per minute. Since a saliva ejector has a very small
opening, it cannot remove enough volume of air to be classified as an HVE. Studies
demonstrated that an HVE with a good suction system can reduce up to 90% of
operatory area contamination (Harrel and Molinari 2004; Micik et al. 1969). A
study done by Noro et al. in Japan demonstrated that the use of a high-­speed vacuum
aspirator effectively reduced the spread of streptococci bacteria (Micik et al. 1969;
Noro et al. 1995).
It is important that each dental unit suction hose be flushed twice daily with dis-
infecting agent and routinely cleaned according to manufacturer’s instructions. The
water in each unit should be flushed for any utilized handpieces, ultrasonic scalers,
and air-water syringes for 30 s after each patient.
Whenever possible, single-use devices such as aspirator tips and drill burs should
be used. Disposable instruments and equipment eliminate the risk of patient to
patient contamination once it is discarded after one-time use. Items such as patient
bib clip chains are sources of cross contamination. The University of North Carolina
cultured bib chains in a study and found strains of Pseudomonas, E. coli, and
Staphylococcus aureus. These bacteria can put immunocompromised populations at
even greater risk for respiratory disease transmission. Disinfecting the napkin
holders does not eradicate the bacteria completely, so disposable holders should be
considered instead (Molinari 2010). The CDC recommends that one-time-use
gauze, irrigating syringes, syringe needles, and scalpel blades used for oral surgery
procedures be sterile (CDC n.d.-b).
At the end of the appointment, the CDC recommends the following sequential
order for instrument processing (Cuny and Collins 2013; CDC 2003). Sharps,
including syringe needles, burs, and scalpel blades, need to be carefully discarded
into specially marked puncture-resistant sharps containers. Next, single-use
disposable materials and waste should be discarded. Biohazard waste must be
disposed of in specially marked biohazard containers in accordance with state
2 Office Environment 29

regulations. The equipment and instrument cassettes should be transported to a

centrally located cleaning and sterilization area that fosters one-directional work
flow which will prevent cross contamination (Cuny and Collins 2013). There should
be separate areas for receiving dirty instruments and cassettes as well as areas for
decontamination, packaging for sterilization, and sterilization. There should be a
separate storage area to place sterile packaged instruments until ready for the next
procedures.
The CDC has made three categories of criteria to determine how instruments
should be sterilized. These categories are (1) critical, (2) semi-critical, and (3) non-
critical. Critical instruments are those that penetrate soft tissue, contact the bone, or
have entered the bloodstream. Critical instruments used in oral surgery procedures
would include dental burs, elevators, forceps, and scalpel blades. Semi-­critical
instruments are those that contact mucous membranes but have not penetrated soft
tissue or bone and have not entered the bloodstream. These instruments would
include dental mouth mirrors and dental handpieces. Noncritical instruments are
those that contact intact skin, and this equipment would include blood pressure
cuffs, pulse oximeters, and radiographic tube heads. The CDC stipulates that all
critical instruments be heat sterilized as well as all dental handpieces even though
they are considered semi-critical (Cuny and Collins 2013; CDC 2003).
Utilized handpieces should be lubricated after use to prolong the life of the
equipment prior to sterilization. Hand instruments should be cleaned thoroughly
with either a washing disinfecting machine or an ultrasonic soak. The pre-cleaning
helps to remove blood or debris that could potentially harm the DHCP that is
packaging the cassettes for sterilization. Used handpieces and hand instruments
must be inspected thoroughly for any left on particles of blood, tooth, and bone
debris. Debris must be removed so as not to compromise the sterilization process. A
metal cleaning brush can be used to clean off caked on debris. Equipment should
then always be prepared for sterilization by wrapping and sealing in special pouches
or bound in sterilization appropriate sheeting that are labeled to show the date of
sterilization, which sterilizer was used, and the load or cycle.
Quality assurance of the instrument sterilization process must be upheld for
patient safety. It is crucial that sterilization machines are not improperly loaded.
Overloading is a common reason for sterilization failure. Utilizing a combination of
biological and chemical indicator methods ensures that adequate sterilization condi-
tions have been achieved (Cuny and Collins 2013).
The biological indicator method is also commonly referred to as “spore testing.”
Spore testing is recommended at least once a week for private practice offices and
institutions. Spore testing is the most widely accepted method of testing sterilization
efficacy since it can kill highly resistant microorganisms such as Geobacillus and
Bacillus (Cuny and Collins 2013; CDC 2003).
Since spore testing might only be done once a week and takes some time to
obtain the results, it is prudent to also utilize a chemical indicator method. Chemical
indicators can provide more timely indications if sterilization equipment malfunc-
tion were to occur (Cuny and Collins 2013; CDC 2003).
30 M. E. Ing and P. Arsenault

Peel and seal sterilization pouches specially marked with sensitive chemical
indicators will change color if the contents have been sterilized to correct temperature
and time. It is also possible to place chemical indicating tape over wrapped
instruments. If a color change does not occur after the sterilization process, this
indicates that the sterilization process has been compromised, so the instruments
should be repackaged and sent through sterilization again (Cuny and Collins 2013;
CDC 2003).
Furthermore, chemical indicating devices, called “multiparameter integrators,”
are highly suggested to be placed within the instrument pouches to determine
optimal sterilization conditions. The integrators verify that the sterilization process
has penetrated the instruments within the packaging (Cuny and Collins 2013; CDC
2003). Multiparameter integrators indicate if the contents of the peel and seal pouch
have been exposed to the correct time, temperature, and pressure during autoclaving
procedures (see Photo 2.1).

Photo 2.1 Example of a

chemical multiparameter
integrator (courtesy of
Vapor Line)
2 Office Environment 31

2.5 Eyewear Safety Considerations

OSHA Standard 1910.133(a) (1) states:

“The employer shall ensure that each affected employee uses appropriate eye or face
protection when exposed to eye or face hazards from flying particles, molten metal, liquid
chemicals, acids or caustic liquids, chemical gases or vapors, or potentially injurious light
radiation.”

By their nature, dental procedures involving drilling at very high speeds

(180,000–500,000 rpm) generate debris that can travel at speeds of up to 50 mph
(Arsenault and Tayebi 2016). Such debris could include pieces of amalgam, tooth
enamel, calculus, pumice, and broken dental burs. In the absence of a protective
means, such debris may find its way to the eyes of the practitioner, the staff, or the
patient.
CDC and OSHA mandate that dentists wear protective eyewear (either glasses or
loupes, prescription or nonprescription) while performing dental procedures. Most
often, dental assistants wear either prescription or nonprescription safety eyewear.
Masks with full-face shield or a mask and visor combination provide the most
effective facial and eye protection to date against projectile and spatter hazards (see
Photos 2.2 and 2.3). However, their use by dental practitioners is limited due to their
higher cost, reflective glare, fogging, and optical distortion caused by the unavoid-
able curvature of the face shield when the mask is worn and hotness of the air in the
zone between the face shield and the wearer’s face. This results in discomfort and
inconvenience.
There are three possible routes dental debris may follow in order to reach the eye
of a practitioner not wearing a full-face shield mask or mask and visor
combination.

(a) Frontal entry route by debris traveling perpendicular to the dental professional’s
face. Glasses provide the necessary protection against such debris. Not only do
the glasses need to meet OSHA Standard 1910.133(a) (1), but they also must
meet ANSI Standard (Z87.1) (Arsenault and Tayebi 2016). ANSI is the
American National Standards Institute which supervises the development of
safety standards from products, systems, and services in the USA. By choosing
eyewear that meets both OSHA and ANSI, fewer eye injuries are caused by
flying debris.
(b) Sideway (right to left or left to right) entry routes by debris traveling tangential
to the face. Side shields provide effective protection against such debris and are
specifically required by OSHA Standard 1910.133(a) (2), which states:

“The employer shall ensure that each affected employee uses eye protection that provides
side protection when there is a hazard from flying objects. Detachable side protectors (e.g.
clip-on or slide-on side shields) meeting the pertinent requirements of this section are
acceptable.”
32 M. E. Ing and P. Arsenault

Photos 2.2 and 2.3

Up visor and down visor
prevent bottom gap space
breach

(c) Bottom gap entry routes (see Photo 2.4) by debris traveling vertically and tangen-
tial to the face. Such debris may reach a practitioner’s eye through the open gaps
(bottom gaps) between the lower rims of the lenses of the protective eyewear and
the upper edge of the mask worn by the practitioner (Arsenault and Tayebi 2016).

Since frontal entry route and sideway entry routes are effectively blocked by the
use of OSHA-required protective eyewear (OSHA Standard 1910.133(a) (1)) and
side shields (OSHA Standard 1910.133(a) (2)), the bottom gap entry routes are the
most frequent, yet unaddressed, routes of eye-injury-causing debris.
2 Office Environment 33

Photo 2.4 Bottom gaps

Arsenault and Tayebi demonstrated in their studies that there is a major inade-
quacy and breach in protecting the dental care provider’s eyes using the present den-
tal mask and standard/typical eyewear combination. Closing the bottom gaps is
essential and should be considered “appropriate” when defining adequate or appro-
priate personal protective equipment standards as noted by OSHA (Arsenault and
Tayebi 2016).
It is inherent and unavoidable in the process of wearing a non-full-face shield
dental mask or mask/visor combination and deforming the mask’s nose clip to fit
over the wearer’s nose that bottom gaps are generated; therefore, the currently used
combination of protective eyewear and standard dental mask does not provide the
“appropriate” eye protection required by OSHA. Also, the unavoidable generation
of the bottom gaps renders the combination of regular protective eyewear and stan-
dard mask combination to be a potentially dangerous combination since it is reason-
ably foreseeable that dental debris may reach the eyes of the dental practitioner or
dental personnel through such open bottom gaps.
It is also important to consider protection for the patients’ eyes. Instruments
can be sharp and heavy and could inadvertently fall into the patient’s face or
eyes so it is imperative to provide appropriate safety eyewear with side shield
protection for all patients. It would be prudent to pass instruments either around
the back of the patient’s head or below their chin areas instead of over their
faces.
At the end of the procedure, all protective eyewear should be wiped down with a
hospital-approved disinfectant, then rinsed off, and allowed to air-dry.

2.6 Extracted Teeth

The CDC guidelines state that extracted teeth can be returned to patients upon
request (CDC n.d.-c). If a tooth is returned to a patient, then OSHA regulations do
not apply since OSHA regulations are set forth to protect the employees. If the tooth
34 M. E. Ing and P. Arsenault

is given to the patient, OSHA does not consider it a risk to DHCP since they do not
need to transport, clean, or dispose of human tissue. However, if extracted teeth are
to be discarded in the dental office, then OSHA compliance must be followed as the
teeth would be considered potentially infectious waste. Extracted teeth must be dis-
posed of in specially marked medical waste containers (CDC n.d.-c).
Teeth containing amalgam must not be disposed of in the same medical waste
containers that use an incineration process. Clinicians should be familiar with their
state laws regarding amalgam disposal.
Often, dental offices will be approached by dental students who wish to collect
teeth to be used in educational and research settings. The CDC suggests that
collected teeth be stored in 1:10 bleach to water in a sealed container upon leaving
the dental office. Per CDC recommendations, the students should autoclave the
teeth prior to using for the teaching exercises or research purposes (CDC n.d.-c).

2.7 Handling and Shipping of Biopsy Specimens

Often tissue is biopsied at the dental office and sent to a laboratory facility for
pathology evaluation. Any time materials are handled in the dental laboratory,
OSHA-approved PPE should be worn. The preservatives used to store the tissues
are considered potentially hazardous materials by the US Federal Department of
Transportation (DOT) or the International Air Transport Association (IATA), so
great care must be given to packaging and shipping.
Most clinicians use 10% formalin as a tissue preservative. 10% formalin is pre-
pared by diluting a 37% formaldehyde solution. A 10% formalin solution contains
3.7% formaldehyde. It is considered within regulatory limits to store a specimen in
a solution that contains 10% or less of formaldehyde.
The shipper is responsible for any spills while in transit. Should the package
break open and require an emergency cleanup, the DOT or the Federal Aviation
Administration will fine the shipper. Dental offices should triple package the
specimens using leakproof containers with watertight lids. The specimen must be
placed in a primary leakproof container, affixed with a biohazard label, which
goes into a secondary leakproof container. In between the primary and secondary
containers, there should be enough absorbent materials and bubble wrap to absorb
all the liquids in case anything breaks. This should all be placed inside a rigid box
that is concisely marked with the number of items contained within. In addition,
the outside of the box needs to be labeled with the following specific words for
biopsy specimens: “Exempt Human Specimens” along with the addressed “To”
and “From.” In addition, there should be arrows indicating the orientation of the
test tubes or containers upright position. Once packaging is completed, the box
should be able to sustain a drop of several feet without the container boxes break-
ing apart. It is important that the outside packaging not be contaminated.
Consideration should be given to the shipping personnel that will be handling the
package and not wearing PPE once the package leaves the office premises (see
Fig. 2.1).
2 Office Environment 35

Wrap absorbent material

around biohazard labeled
specimen container (with snap
on/secure lid) before being
placed in the secondary leak-
proof container. Wrap securely
in enough absorbent materials

Secondary
Leak proof
Container
Wrap leak-proof secondary container
in enough absorbent materials and in
bubble wrap securely in case container
breaks. Place inside rigid specially
marked box.

Exempt Human
Specimens

Up

Fig. 2.1 Triple packaging of biopsy specimens. Drawn by Melissa E. Ing, D.M.D., and Ms.
Patricia DiAngelis

The shipper should use their best practices professional judgment and always
follow the triple packaging principles.

2.8 Musculoskeletal Disorders and the Dental Surgeon

Musculoskeletal disorders (MSDs) are injuries or disorders of the soft tissues that
can include the muscles, tendons, ligaments, joints, cartilage, and nerves. DHCP are
prone to work-related MSDs, which are MSDs that are made worse when exposed
to certain work conditions and risk factors. Dentists commonly report MSDs in the
areas of the neck, shoulders, back, and arms (Valachi and Valachi 2003a). While
treating patients, dental surgeons tend to work in static seating or standing postures,
often bending over to peer into the patient’s oral cavity. In addition, dentists are
36 M. E. Ing and P. Arsenault

prone to tightly grasp small hand instruments and use vibrating handpieces for pro-
longed periods. Repeatedly straining to visualize with little movement of joints and
muscles while working in a very confined oral cavity spaces predisposes dentists to
MSDs.
MSDs can result in reduced productivity and lost wages due to healing time.
Michalak-Turcotte estimated that American dental professionals report an annual
income loss of approximately 41 million dollars due to MSDs (Michalak-Turcotte
et al. 2000).
MSDs have long been described by dental clinicians. In 1946, at a time when all
dentistry was done in an upright standing position, F.E. Biller reported that 65% of
dentists reported back pain (Biller 1946). Decades later, the advent of four-handed
dentistry has decreased operator stress and increased office efficiency. Dental equip-
ment has ergonomically evolved as well, yet, there is no less reporting of MSDs
(Valachi and Valachi 2003a; Shaik et al. 2011; Ayatollani et al. 2012). Studies con-
ducted from 1987 until 2000 showed that up to 81% of dental professionals report
pain in the back, neck, shoulders, or arms (Shaik et al. 2011). Most clinicians favor
a standing rather than sitting position without back support when performing pres-
ent-day oral surgical procedures such as extractions. Anecdotally, when oral sur-
geons are asked why they choose standing over sitting, they most often will answer:
“It’s tradition.” Most general dentists prefer a seated position when performing
restorative procedures. Valachi and Valachi (2003a) compared pain statistics of the
1946 standing dentists to the present-day seated clinicians and found that the seated
position made little difference in how frequently MSDs were reported. Instead, the
investigators found that pain reporting fluctuates to different areas of the body
depending on whether clinicians chose a seated or standing position. Clinicians that
favored a seated position reported pain in the back, neck, shoulders, and arms.
Clinicians that favored a standing position reported lower back pain, varicose veins,
and flat foot (Valachi and Valachi 2003a).
Pejcic et al. demonstrated that it is best to alter sitting and standing positions
while performing dentistry (Pejcic et al. 2016). Different sets of muscles are used
when standing versus sitting, so alternating the positioning will give one set of
muscles the chance to rest while the workload is turned over to another set of
muscles (Biller 1946). Furthermore, Catovic et al. (1991) found that a seated
position is preferred when visually intensive or precise work is being done, while a
standing position may be more ideal for maximizing gripping forces.
In addition, the University of California at Los Angeles Ergonomics Group dem-
onstrates that alternating standing and sitting during a workday of tasks is a better
way to prevent MSDs of the back and may help to maintain a neutral spine position.
Neutral spine is also referred to as a healthy spine or good posture. When viewed
from the side of the body, there are three natural curves in maintaining a healthy
spine. These consist of the neck or cervical spine area which gently curves inward,
the mid-back or thoracic area which curves outward, and the lower back or lumbar
area which curves inward (see Photo 2.5).
The dental professional spends much of their day in a forward leaning posi-
tion. While trying to get closer to the patient for better access and vision, the
2 Office Environment 37

Photo 2.5 Operator chair

with five castor wheels and
proper lumbar support
allowing neutral spine.
Operator thighs at approxi-
mately 110° waterfall

Neutral
spine

tendency is to slouch. Due to the forward flexion slouching assumed during most
of the workday, many DHCP report back pain. It is important to work on building
strong core muscles which can help stabilize and protect the spine (Valachi and
Valachi 2003b).
Arm, wrist, and hand ailments are commonly reported by dental professionals.
Common complaints to hand surgeons include carpal tunnel discomfort, trigger
finger, and wrist tendonitis.
The median nerve and several tendons loop through a small passageway in the
wrist called the carpal tunnel. The median nerve controls movement and sensitivity
in the thumb and the first three fingers. Prolonged wrist flexure positioning and grip-
ping instruments too tightly can cause carpal tunnel syndrome (CTS). CTS can
cause pressure and swelling of the median nerve. Symptoms can include numbness,
tingling, weakness of the thumb area, and pain that can run from the hand, up the
wrist, and to the elbow. It is reportedly mostly in the dominant hand but can also be
bilateral (Ashworth 2016).
In addition, exceedingly firm and awkward ergonomic grips on instruments can
cause a stenosing tenosynovitis of the digits, which is also called “trigger finger.”
Trigger finger is characterized by pain on the palm side of the hand involving the
metacarpal heads of the digits. A true trigger finger can cause the fingers to lock up
so that movement is staggered and painful. Furthermore, there is wrist tendonitis.
The most common is De Quervain’s tendonitis which consists of inflammation of
the first dorsal compartment tendons located behind the thumb area. Prolonged
deviation and repetitive activity increase the risk of ulnar neuropathy. Other tendon-
itis ailments affecting dentists involve the radial, ulnar, and dorsal regions of the
wrist (Shehab and Mirabelli 2013; Tallia and Cardone 2003).
38 M. E. Ing and P. Arsenault

Due to long procedures where dentists are engaged in static and repetitive strain,
the best advice is to give hands and arms a rest in between procedures. Rotating
tasks and releasing forceful instrument grasps may prevent CTS, trigger finger, as
well as wrist ailments.

2.9 Selecting Equipment to Fit Clinicians’ Ergonomic Needs

Ergonomics is the science of fitting the environment to the worker. Ergonomic

equipment and office design can impact MSDs. Properly selected operator chairs,
patient chairs, and delivery systems can promote better posture. The physical stature
of the clinician should be considered when purchasing these three pieces of
equipment so as to maintain neutral spine (Michalak-Turcotte et al. 2006).
The operator chair should be sturdily supported on five castor wheels. It should
provide back support and seat contour to allow for a neutral spine position at all
times. When seated, the clinician’s buttocks should be snug against the back of the
chair (Valachi and Valachi 2003b). The clinician’s feet should be positioned flat on
the floor, and they should not be resting on the castor wheels for support. The seat
height should be adjusted high enough so that the thighs make a gentle downward
waterfall (Valachi and Valachi 2003b). It is important that the operator chair is
adjusted prior to adjusting the patient position (Valachi and Valachi 2003b;
Michalak-Turcotte et al. 2006) (see Photo 2.5).
The patient chair should allow the clinician close proximity to the patient, so
they do not have to overreach to get to his or her equipment. It is crucial that the
dentist does not need to lean into the oral cavity. The patient chair should also
consist of a small and thin headrest so that the clinician’s legs and thighs can fit
comfortably under the patient chair without obstruction (Valachi and Valachi 2003b;
Michalak-Turcotte et al. 2006).
Delivery systems can be side mounted to the patient chair or rear mounted. Most
delivery systems are designed for four-handed dentistry. Operators that work on
their own may find themselves twisting their torsos or overreaching to obtain desired
instruments (Michalak-Turcotte et al. 2006).
Clinicians should research, try out, and then invest in the best equipment to pro-
tect their muscles and spines.

2.10 Magnification Aids

Most dentists have the tendency to lean their heads and necks forward by 30° for
about 85% of the time while operating, thereby accounting for the approximate 70%
of reported neck pain (Marklin and Cherney 2005; Lehto et al. 1991). The forward
positioning results in an unsupported spine as well as muscles that can easily fatigue
and can cause a painful disorder called tension neck syndrome (TNS). TNS can
include headaches and pain that radiates through the neck and shoulders and down
the arms (Valachi and Valachi 2003b).
Magnification aids such as loupes can improve vision of the operating field as
well as clinician posture, if chosen properly. It is important to understand several
2 Office Environment 39

concepts before purchasing magnification devices. Prior to ordering a pair, the

clinician should try out different brands of magnifying loupes. Glass frames may
rest differently on each operator depending on facial features. Manufacturers should
calculate the proper working distance and angle of declination for clinicians.
Working distance is defined as the distance from the clinician’s eyes to the work-
ing area. Working distance can vary based on the dentist’s height. If the clinician is
shorter, then the working distance will probably be around 14 in. away, whereas a
very tall provider may have a working distance of 20 in. or more (Valachi and
Valachi 2003b). Declination angle is defined as that angle the eyes are inclined
downward toward the work area (see Photos 2.6 and 2.7) This is a very important
aspect for cervical health. Well-designed magnification loupes prevent the head
from leaning forward more than 25°. If loupes have a steep enough declination
angle, there is minimal need to lean forward. Valachi et al. believe that in general,
flip-up style loupes allow for a steeper angle of declination and therefore less neck
flexion (Valachi and Valachi 2003b).

2.11 Illumination Considerations

Proper illumination of the operating field enhances critical details and prevents eye
strain. Operatory lights are offered in different configurations. Those that are
mounted on a ceiling track or wall unit may be less cumbersome as they allow clini-
cians’ arms to have free movement as opposed to those lights that are self-­mounted
to patient chairs. Lights that are attached to chairs could cause clinicians to over-
reach when adjusting.
Dr. Lance Rucker, an ergonomic specialist from the University of British
Columbia, gives the following advice to eliminate shadows while working with

Photo 2.6 Less

declination angle

Forward
neck
40 M. E. Ing and P. Arsenault

Photo 2.7 Steeper

declination angle with
flip-up loupes

Neck is
less
Forward

illumination sources. Dr. Rucker advises that the operatory light should always
be parallel to or within 15° of the operator’s line of sight (Rucker et al. 1999).
In many cases, this would necessitate the operatory light be behind the
operator’s head, which may be difficult with ceiling track systems. Headlamps
mounted to loupes or to the forehead can provide direct and parallel lighting
to the operator’s line of sight, significantly minimizing shadows (Rucker
et al. 1999).
By the year 2020, it is estimated that most light sources will consist of light-­
emitting diode (LED) lighting. LEDs have advantages over incandescent as well as
other light sources. LEDs have a longer life span and better energy efficiency and
are more cost-effective. Currently, loupe headlamps are mostly of the LED variety,
and overhead lighting is also switching over to LED.
However, LEDs contain blue light, which at 445 nm is part of the visible light
spectrum. Blue light affects the back of the eye, and research has shown that it could
cause retinal damage, possibly leading to macular degeneration, over time. The
macula is the central portion of the retina which is responsible for the ability to
focus, to read, and to see objects in fine detail. The eye responds easily to LED
exposure. Clinicians have reported blurry vision, headaches, and eye strain while
using LED headlamps (Ing et al. 2015).
It is recommended to turn off the headlamp when not in use. In addition, it is
recommended to purchase loupes with adjustable headlamp settings and to keep
it on the lowest intensity that allows for the most comfortable illumination (Ing
et al. 2015).
2 Office Environment 41

2.12 Prevention Before Intervention

In addition to selecting proper ergonomic equipment, clinicians should adopt an

injury prevention program. This should include the incorporation of proper seating
and positioning while working, stress reduction, and regular aerobic and daily
ergonomic exercises as part of their routine.
To maintain neutral spine and to prevent MSDs, it is important to position the
patient in a position far enough back so that the patient’s face is at the operator’s
elbow. The elbows should not be elevated more than 30° to prevent the dentist’s
shoulders and arm muscles from elevating and fatiguing (Valachi and Valachi
2003b).
In general, when performing mandibular procedures, the patient should be placed
in a semi-supine position. In general, when performing maxillary procedures, the
patient should be placed in a supine position (Valachi and Valachi 2003b).
When performing precise tasks, arm rests can be used to stabilize the hands
and help maintain the static position without causing fatigue. Dentists should not
grip or grasp handpieces and hand instruments such as extraction forceps with
undo force while performing procedures. After griping instruments for periods of
time, clinicians should shake out the hands, to allow the hand, wrist, and arm
muscles to relax. After intense gripping, stretch the hand, especially the area
between the thumb and first finger. Experts agree that rotating tasks will give
muscles a break.
Prevention before intervention is key. Clinicians should seek medical assistance
before pain and muscular symptoms get worse. A physician, a physical therapist, or
a trainer can make helpful evaluations and recommendations for preventative
exercises to target the neck, shoulder, arms, and upper and lower back regions.
Exercise programs should be preapproved by a physician. As people age, muscle
mass is lost. Muscle loss typically starts around age 35 or 40 and picks up speed by
the age of 50. Weights or resistance training at the local gym can help maintain
stronger muscles. The following are good exercises for strength and resistance train-
ing that can be done at the gym.

1. The seated row machine: This works the upper and mid-back muscles (rhomboids,
trapezius, with assistance of rear deltoids, and the biceps.) sit in upright neutral
spine and pull bar straight back, holding.

8-10 repetitions position for 5-10 seconds. Do

42 M. E. Ing and P. Arsenault

2. The rear deltoid machine: This works on the upper back muscles including the
deltoids and the trapezius. Sit upright with chest up against the pad to stabilize,
and with hands on machine, steadily pull back and then hold for approximately
5–10 s. Do 8–10 repetitions.

Below are two floor exercises that help with stabilization/hyperextension.

1. Cross crawl core stability exercise: Get onto hands and knees with knees directly
under hips and hands placed under shoulders. Ensure that there is equal amount
of weight at all four points. Slowly extend one arm out in front toward the ceiling
while at the same time lift the opposite leg up behind toward the ceiling. Hold
position for about 10 s and then repeat on other side.
2 Office Environment 43

2. The superman exercise: This is a great exercise for working out the back as well
as strengthening the shoulders, glutes, and hamstrings. Lay down on the floor
with legs extended behind and arms stretched out in front. The neck should be
relaxed. Gaze should be a few feet in front. Lift up chest, arms, and legs off the
floor all at once, aiming to balance only on the pelvis. Hold position for about
10 s. Lower body. Do 8–10 repetitions.

The following preventative exercises are designed to open up the chest muscles
and can be done while you are in the dental office. They are simple to do and
require little to no special equipment and should be done with neutral spine posi-
tioning and with the chin tucked in. It is recommended to do the exercises several
times a day.

1. The door frame stretch to open up chest muscles: Have arms at shoulder level
against the sides of the door. The head should be gently tucked down. Lean into
the door, and at the same time squeeze the shoulder blades together as if there is
a ball between the trapezius muscles. This should stretch the pectorals. Count to
30 and repeat.

2. The cervical rotations to help stretch neck muscles: Sit in upright neutral spine
position. Keep the chin tucked gently and turn the head to the left and hold for
10–15 seconds and then back to the center. Then turn the head to the right and
hold for 10–15 seconds and repeat.
44 M. E. Ing and P. Arsenault

3. The upper trapezius stretch: Sit in upright neutral spine position and ensure that
the chin is gently tucked. Start with arms at the side and then place the hand
under the chair seat to anchor the arm from raising. Bend the ear toward the
shoulder and hold for 30 s. Repeat on the alternate side.
2 Office Environment 45

4. The chin tuck strengthens muscles that pull the head back into alignment over
shoulders: This will stretch the suboccipital muscles. Assume upright neutral
spine position. Place the finger on the chin to dip the chin gently. This is only a
10–15° movement. Making a “double chin” is also correct. You should feel the
muscles of the upper cervical spine engage.

2.13 Conclusions

The general dentist spends an average of 35 plus hours in the office performing a
variety of procedures including oral surgery. The dental profession is predisposed to
occupational hazards. Self-awareness of these hazards and understanding how to
handle them will allow for an optimally functional office environment as well as a
healthy, prolonged career.

Acknowledgments The authors would like to thank Dr. David Frantz and Ms. Patricia
DiAngelis for their assistance with graphics; Ms. Kathy Craig from Tufts University
Environmental Health and Safety for her expertise as chemical safety officer, in area of han-
dling and shipping of human specimens; and Mr. Max Herault for his expertise as an American
Council on Exercise certified personal trainer. The following people posed in chapter photo-
graphs: Ms. Erica Kleinbaum, Mr. Kevin Campbell, Mr. Patrick Choi, Mr. Max Herault, Mr.
Steven Boucher, and Dr. David Frantz.
46 M. E. Ing and P. Arsenault

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Medical Assessment of the Oral
and Maxillofacial Surgery Patient 3
Steve R. Ruiz, Steven Halepas, Jeffrey Bennett,
and Elie M. Ferneini

“It is a capital mistake to theorize before one has data.

Insensibly one begins to twist facts to suit theories, instead of
theories to suit facts.”
—A Scandal in Bohemia

Abstract

Gathering data: the preoperative medical assessment is arguably the most impor-
tant visit for proper patient care. The dentist should review the patient’s medical
history and do a thorough review of systems and a proper physical exam. If nec-
essary appropriate testing should be done such as blood glucose or INR. This
chapter is designed to improve outcomes by teaching clinicians how to perform
a proper medical assessment through evidence-based guidance and provide rec-
ommendations for altering care with certain medical conditions.

S. R. Ruiz
Division of General Dentistry, Department of Craniofacial Sciences, University of
Connecticut, Farmington, CT, USA
e-mail: [email protected]
S. Halepas
University of Connecticut School of Dental Medicine, Farmington, CT, USA
e-mail: [email protected]
J. Bennett
Indianapolis, IN, USA
E. M. Ferneini (*)
Beau Visage Med Spa, Greater Waterbury OMS, Cheshire, CT, USA
Division of Oral and Maxillofacial Surgery, University of Connecticut, Farmington, CT, USA

© Springer International Publishing AG, part of Springer Nature 2019 49

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_3
50 S. R. Ruiz et al.

3.1 Introduction

An accurate and effective medical assessment is necessary with every patient. A

thorough understanding of the patient’s medical history is invaluable while treating
and managing intermediate- and high-risk patients, especially those with
cardiovascular issues, bleeding disorders, compromised immune status, and
endocrine disorders. This chapter is designed to improve outcomes by teaching and
guiding clinicians how to perform a proper medical assessment through evidence-­
based guidance.
The goal of a medical assessment is to gather information about the patient in
order to formulate an appropriate treatment plan. As always, the clinician must
weigh the risks of each treatment option with the benefits, as well as educate the
patient as to his/her options. An accurate medical assessment allows the clinician
the ability to identify patient needs and foresee potential complications. A good
medical history interview is tailored to the individual patient, but the basic rubric
has been well accepted across the medical community. Interestingly, although the
basic components are cited in many books and journals, few studies explore the
effectiveness of these components. More importantly is to follow a format that
allows the patient to tell his/her story and ensure the clinician does not forget
important questions/topics (Haidet and Paterniti 2003). A proper medical assessment
includes a thorough medical history, review of systems, and physical exam.

3.2 Medical History

Medical care starts with the patient’s story, and thus the diagnosis tends to hide
within the patient’s history. Information in the medical history is subjective.
Although the patient’s story is subjective, the medical history has objective
components. Although the story is subjective, it is a clinician’s most useful
information; it allows the provider to predict how any medical condition could
potentially interfere with patient’s ability to tolerate a certain procedure. The risk
for serious medical complications from surgery is reported as less than 0.1% in
healthy patients but increases significantly in medically complex patients (Cohn
2016). Closer attention is needed for patients with a more complex medical history
(Miloro et al. 2012). High-risk patients who undergo medical optimization prior to
surgery have decreased mortality rates (Kern and Shoemaker 2002; Williams and
Bergin 2009; Cecconi et al. 2013). Interestingly, dentists are routinely asked to
eliminate dental disease before the patient has stents placed or other procedures.
The general dentist is often asked to provide care prior to patient optimization
because of the concern of postoperative infections associated with the dental disease
after the non-dental procedure.
Medical history should be updated at each patient encounter. Any inconsistencies
in a patient’s history should be reviewed further with a proper discussion with the
patient. Most practices use health history forms as an initial means of collecting the
medical history. These forms are a good starting point but discussion with the
3 Medical Assessment of the Oral and Maxillofacial Surgery Patient 51

patient is vital. The forms should be written in layman terms and in a concise
fashion. When conducting the medical history interview, consider using the
following formula:

1. Identify the source of information.

2. Biographic data.
3. Chief complaint.
4. History of present illness.
5. Past medical history.
6. Past surgical history.
7. Social/family history.

3.3 Review of Systems

The review of systems is a technique used to structure and organize a complete

head-to-toe review of the body to hopefully identify any underlying issues not
already diagnosed or those missed in the medical history as well as define the extent
of a known disease (Hupp et al. 2014; Collins et al. 1995):

1. General examination: alert and oriented x4 (to person, time, place, event)
2. Head: fainting spells, headaches, and dizziness
3. Ears: otorrhea, tinnitus, and changes in hearing
4. Eyes: ocular movements, pupil accommodation, double vision, and blurry
vision
5. Nose: epistaxis and rhinorrhea
6. Throat: oral pain, pathology, dental evaluation, and jaw range of motion
7. Cardiovascular: chest pain, orthopnea, and exercise tolerance quantified by
metabolic equivalent of tasks (METs), murmurs, or rheumatic fever
8. Respiratory: cough, wheeze, and shortness of breath
9. Gastrointestinal: abdominal pain, unintentional weight loss, difficulty swal-
lowing, and any nausea/vomiting
10. Genitourinary: incontinence and menses
11. Neurologic: special senses
12. Psychiatric: depression and sleep patterns
13. Hematologic/lymphatic: anemia, history of excessive bleeding after extrac-
tion, and anticoagulant/antiplatelet therapy
14. Allergies: history of anaphylaxis and allergic reactions

3.4 Physical Examination

The physical exam starts to collect objective information. The examination should
start with vital signs; this both serves as a screening device for unsuspected medical
problems and gives a good baseline for future assessments. Next follows a systemic
52 S. R. Ruiz et al.

approach that contributes to a smooth, flowing process that gathers information that
is pertinent to the patient’s status. The provider should be observant and ensure that
signs are not overlooked, e.g., lower extremity edema, evidence of IV drug abuse in
the arms, gait when they walk to the office, abdominal girth, skin lesions, etc.
Physical examination usually involves four primary means of evaluation:

1. Inspection: facial symmetry and proportions, eye size, sclera color, movements,
nares patency, skin lesions, skin turgor, oral mucosa, the tongue, and floor of the
mouth
2. Palpation: TMJ function and range of motion, presence of enlarged lymph nodes,
and areas of swelling or tenderness
3. Percussion: nasal sinuses resonance, dental fractures, and periodontal status
4. Auscultation: TMJ derangements (click, crepitus, pop)

Table 3.1 American Society of Anesthesiologists classification of physical status (American

Society of Anesthesiologists 2017)
Classification Definition Examples, including, but not limited to:
ASA I A normal healthy Healthy, nonsmoking, no or minimal alcohol use
patient
ASA II A patient with Mild diseases without substantive functional limitations.
mild systemic Examples include (but not limited to) current smoker, social
disease alcohol drinker, pregnancy, obesity (30 < BMI < 40),
well-controlled DM/HTN, mild lung disease
ASA III A patient with Substantive functional limitations; one or more moderate to
severe systemic severe diseases. Examples include (but not limited to) poorly
disease controlled DM or HTN, COPD, morbid obesity (BMI ≥40),
active hepatitis, alcohol dependence or abuse, implanted
pacemaker, moderate reduction of ejection fraction, ESRD
undergoing regularly scheduled dialysis, premature infant
PCA <60 weeks, history (>3 months) of MI, CVA, TIA, or
CAD/stents
ASA IV A patient with Examples include (but not limited to) recent (<3 months)
severe systemic MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia or
disease that is a severe valve dysfunction, severe reduction of ejection
constant threat to fraction, sepsis, DIC, ARD, or ESRD not undergoing
life regularly scheduled dialysis
ASA V A moribund Examples include (but not limited to) ruptured abdominal/
patient who is not thoracic aneurysm, massive trauma, intracranial bleed with
expected to mass effect, ischemic bowel in the face of significant cardiac
survive without pathology, or multiple organ/system dysfunction
the operation
ASA VI A declared
brain-dead
patient whose
organs are being
removed for
donor purposes
3 Medical Assessment of the Oral and Maxillofacial Surgery Patient 53

Once the practitioner has gathered all of this data, it is important to classify the
patient. The more medically complex the patient is, the greater the risk for
perioperative complications. Most surgeons use the American Society of
Anesthesiologists classification of physical status (Cohn 2016; Dripps et al. 1961)
(Table 3.1).

3.5 Common Medical Problems

3.5.1 Cardiac Issues

The Centers for Disease Control and Prevention states that heart disease is the lead-
ing cause of death globally. Cardiac issues may be congenital and asymptomatic but
can cause serious complications. The underlying pathophysiology varies greatly
depending on the disease. The general dentist must be mindful of his/her limitation
and level of comfort. Patients with very complex medical conditions, especially
complex cardiac conditions, might be better suited in a hospital setting (Table 3.2).

3.5.1.1 Hypertension
One of the most common medical conditions the general practitioner will run into
is hypertension. One third of the US population has hypertension (defined as systolic
blood pressure >139 mmHg or a diastolic blood pressure >89 mmHg) (Mozaffarian
et al. 2015). It is vital that the provider recognizes hypertension before treatment in
order to foresee potential medical emergencies such as hypertensive crisis. The risk
of stroke increases as blood pressure rises from >115/75 mmHg. The practitioner
must also be mindful of true hypertension vs white coat hypertension. White coat
hypertension is a situation in which a person experiences high blood pressure at a
doctor’s office. It is recommended to defer treatment and refer the patient to the
primary care physician, emergency room department (ER), or cardiologist if the
patient presents with severe hypertension.
The use of local anesthesia with vasopressors is shown to be safe for patients
with controlled hypertension (Uzeda et al. 2014). The only true contraindications

Table 3.2 Hypertension classification according to the American Heart Association 2017
Guidelines
Systolic mmHg Diastolic mmHg
Blood pressure category (upper #) (lower #)
Normal Less than 120 and Less than 80
Prehypertension 120–139 or 80–89
High blood pressure (hypertension) 140–159 or 90–99
stage 1
High blood pressure (hypertension) 160 or higher or 100 or higher
stage 2
Hypertensive crisis (emergency care Higher than 180 or Higher than 110
needed)
© 2017 American Heart Association, Inc.
54 S. R. Ruiz et al.

of using epinephrine are uncontrolled hyperthyroidism, uncontrolled diabetes,

unstable angina, and pheochromocytoma (Pérusse et al. 1992). It is important to
aspirate before injecting local anesthesia to ensure the vasopressor is not injected
directly into the blood vessel. Although epinephrine is found to leak into the sys-
temic vasculature, local anesthesia with vasopressors has been demonstrated to
cause only transient hemodynamic alteration (Patil and Patil 2012; Serrera Figallo
et al. 2012; Bader et al. 2002; Nakamura et al. 2001). When epinephrine is contra-
indicated, anesthetics such as carbocaine or prilocaine should be considered
(Milam and Giovannitti 1984). More information on local anesthetics will be dis-
cussed in Chap. 7.

3.5.1.2 Ischemic Heart Disease and Acute Myocardial Infarction

Ischemic heart disease is defined as a partial or total reduction in coronary blood
flow. Chest pain arises when there is occlusion of the vessels but prior to myocardial
necrosis. Coronary artery disease (CAD) progresses silently. Acute myocardial
infarction (MI) usually develops from a rupture of a vulnerable atherosclerotic
plaque. Myocardial necrosis is therefore the consequence of ischemia (Ambrose
et al. 1988).
A patient experiencing chest pain is a true medical emergency. The provider
should immediately contact emergency medical services and the patient be
transported to the emergency department. Current guidelines recommend
supplemental oxygen, 162–325 mg aspirin, and administration of sublingual
nitroglycerin (0.3–0.4 mg may be repeated in 5 min two times if needed) (Anderson
and Morrow 2017; Antman et al. 2008; Braunwald et al. 2000). Monitoring patient
vitals is important; do not give a second dose of nitroglycerin if blood pressure falls
under 90 mmHg. If the patient becomes unresponsive, assess for a pulse. If the
patient has no palpable pulse, do CPR.
According to the most recent literature, dental care appears to be safe 30 days
after an ischemic vascular event in optimal conditions and suggests the traditional
recommendation of delaying care 6 months should be reassessed (Niwa et al. 2000).
The time the provider should wait for safe care of a patient post MI depends on the
procedure being performed. More invasive procedures may require more healing
time following an ischemic vascular event. Although most practitioners still choose
to defer for at least 6 months after an MI episode although little evidence exists to
support this decision. Patients with a past medical history of an MI are at an
increased risk for a subsequent episode, and therefore supplemental oxygen and
nitroglycerin should be readily available (Skaar et al. 2012).

3.5.1.3 Congestive Heart Failure (CHF)

This disease occurs when the heart is unable to pump efficiently to maintain blood
flow and blood begins to pool up. Most congestion is seen in the lungs and liver.
Signs and symptoms commonly include shortness of breath, chest pain, swelling in
ankles and legs, pleural effusion, coughing, and excessive fatigue. Patients with
CHF are usually on an assortment of medications to limit fluid resorption. Chronic
management of these patients includes diuretics, digoxin, ACE inhibitors,
3 Medical Assessment of the Oral and Maxillofacial Surgery Patient 55

beta-blockers, and calcium channel antagonists in an attempt to control and main-

tain blood flow (Neubauer 2007).
Ejection fraction is an important measurement via echocardiogram to determine
the severity of systolic heart failure. It measures the fraction of blood ejected from
a ventricle with each heartbeat, i.e., an ejection fraction of 60% means that 60% of
the total amount of blood in the left ventricle is pushed out with each heartbeat.
A normal ejection fraction ranges between 50% and 70%, and measurement of
<40% may be evidence of congestive heart failure (Redfield 2016). Patients that are
being treated with digoxin may be at higher risk of complications when undergoing
an extraction. It is recommended to use cardiac monitoring in these high-risk
patients (Malamed 2009). Monitoring is likely not required for all patients on
digoxin therapy but may be beneficial especially in those patients with other
comorbidities. Before prescribing/recommending postoperative NSAIDs, the
practitioner must be mindful that patients taking long courses of NSAIDs can have
renal impairment that can lead to dangerous increases in digoxin levels.

3.5.1.4 Arrhythmias
Patients who are at risk of or have cardiovascular arrhythmias more often than not
have a background marked by ischemic coronary disease requiring different dental
management techniques. Patients who suffer from atrial fibrillation typically are on
blood thinners, which will be discussed later. It is important for the dentist to make
this association.
A large number of patients have pacemakers/defibrillators and pose no contrain-
dication to oral surgery other than limiting the use of electrocautery.
Common medications and adverse effects on dentoalveolar surgery are the
following:

• Non-cardio-selective beta-blockers: increased risk for accentuation of epineph-

rine effect.
• Calcium channel blockers: increased risk of gingival hyperplasia.
• Central agents: clonidine—risk of xerostomia.
• Alpha blockers: epinephrine reversal; vasodilation with resultant excessive
bleeding and decreased efficacy and duration of local anesthetics.
• NSAIDs can diminish the therapeutic effects of antihypertensive medications
(Pavlicević et al. 2008).

3.5.2 Bleeding Disorders

Bleeding is one of the most common complications that occur in most minor oral
surgery procedures the general dentist will perform. A patient can have genetic
bleeding disorders, decreased platelet production, splenic sequestration of platelets,
or increased destruction of platelets. For most patients the reason for their increased
bleeding is medication induced.
56 S. R. Ruiz et al.

3.5.2.1 Anticoagulants
There is a growing number of patients who are prescribed anticoagulation therapy.
Evidence strongly suggests no indications to discontinue anticoagulant therapy for
dental extraction (Beirne 2005; Jeske et al. 2003; Alaali et al. 2012). Although many
new medications exist, many patients are still taking warfarin. Warfarin inhibits
synthesis of vitamin K-dependent factors. Many conditions are managed with an
INR between 2 and 3. This range is generally considered safe for exodontia and
should be checked within 24 h (Nematullah et al. 2009; Salam et al. 2007). The INR
should be checked within 24 h because different foods/medications can alter
warfarin’s effects (Table 3.3).
Many of the newer direct thrombin inhibitors do not have a test such as the INR,
so it is difficult to assess the patient’s anticoagulant state (Curto et al. 2017; Turpie
et al. 2012). However, little evidence suggests delaying or stopping these newer
medications (Napeñas et al. 2013).
Some of the newer medications are listed below (Table 3.4).

3.5.2.2 Decreased Production of Platelets

Decreased production can be caused by dehydration, vitamin deficiencies, or bone
marrow disorders. The general dentist should be watchful for hereditary syndromes
such as von Willebrand, hemophilia, and Wiskott-Aldrich. A medical consult with a
hematologist is always recommended. Consider delaying treatment if platelet count
is decreased until the patient’s condition is stabilized to minimize bleeding.

3.5.2.3 Medication-Induced Platelet Destruction/Inhibition

Thrombocytopenia is defined as a low concentration of platelets <150,000 per mm3
either inherited or acquired. Abnormal or spontaneous bleeding can occur if platelets
fall below 50,000. Some patients may show signs of external bleeding that can be
manifested through nosebleeds, gingival bleeding, bruising, or in some women

Table 3.3 Medications that Increased warfarin effect Decreased warfarin effect
may alter the therapeutic Acetaminophen Carbamazepine
effects of warfarin Allopurinol St. John’s wort
Azithromycin Barbiturates
Celecoxib Vitamin K
Ciprofloxacin Rifampin
Erythromycin Sucralfate
Metronidazole Phenytoin −/+
SSRIs
Omeprazole
Ethanol
Fluconazole
Amiodarone
Cefazolin
Phenytoin ±
Rosuvastatin
Trimethoprim-sulfamethoxazole
3 Medical Assessment of the Oral and Maxillofacial Surgery Patient 57

Table 3.4 Assessment methods for patients on medications that may affect coagulation
Drug class Drug names
Anticoagulant • Warfarin
Pt/INR is the standard for monitoring effect (Coumadin®)
Antiplatelet agents • Clopidogrel
Ivy bleeding time, optical aggregometry, VerifyNow®, and PFA100 may (Plavix®)
offer some assessment • Ticlopidine
No good gold standard for monitoring (Ticlid®)
• Prasugrel (Effient®)
• Ticagrelor
(Brilinta®)
• Aspirin
Target-specific oral anticoagulants • Dabigatran
Efficacy of these drugs can be measured by ECT (ecarin clotting time) (Pradaxa®)
Doses are modified by renal and liver function • Rivaroxaban
(Xarelto®)
• Apixaban (Eliquis®)
• Edoxaban
(Savaysa®)

abnormal menses. Some medications may induce thrombocytopenia which is a

relatively common disorder. Rapid identification and discontinuation of certain
medications can prevent significantly lower risk of infection.
Aspirin irreversibly inhibits platelet binding to cyclooxygenase. Aspirin in most
cases does not need to be discontinued (Eapen et al. 2017). There is a rebound
hypercoagulability when antiplatelet medications are discontinued.

3.5.2.4 Increased Destruction of Platelets

Increased platelet destruction may be related to some immune or infectious condi-
tions, for example:

• Idiopathic thrombocytopenic purpura.

• Thrombotic thrombocytopenic purpura.
• Hemolytic-uremic syndrome.
• Disseminated intravascular coagulation (DIC): factors are depleted from exces-
sive clotting that block small vessels that usually evolves from toxic substances
in the bloodstream.
• Paroxysmal nocturnal hemoglobinuria.
• Systemic lupus erythematosus: as an autoimmune chronic inflammatory disease,
bleeding can occur because of antibodies reacting to lipids involved in the
coagulation cascade known as antiphospholipid syndrome.
• Posttransfusion purpura: production of alloantibodies to the introduced platelets’
antigens. These alloantibodies destroy the patient’s platelets leading to
thrombocytopenia.
• Dengue fever.
• Gaucher’s disease.
58 S. R. Ruiz et al.

• Zika virus: limited evidence shows Zika may also be transmitted through platelet
transfusion.
• Septicemia.
• HIV/AIDS: immune-mediated destruction and toxic effects of medication cause
generalized myelosuppression.

3.5.3 Patients on Bisphosphonates

The United States in the past decade has seen a surge of bisphosphonates prescribed.
Bisphosphonate-related osteonecrosis of the jaw (BRONJ) was first reported by
Marx in 2003 (Marx 2003). It is defined by exposed bone in the maxillofacial region
for 8 or more weeks and a history of bisphosphonates with the absence of radiation
therapy. The incidence of BRONJ increases with age and is more prevalent in the
mandible. Patients who were on bisphosphonates for greater than 3 years are also at
higher risk (Jeong et al. 2017). The AAOMS position paper reclassified BRONJ as
medication-related osteonecrosis of the jaw (MRONJ) (Ruggiero et al. 2014). For
patients at high risk of MRONJ, it is recommended to give antibiotic prophylaxis
especially if the patient has a history of MRONJ. For patients who are taking oral
and/or IV bisphosphonates and who have no prior history of osteonecrosis, current
research indicates that antibiotic prophylaxis may help reduce the risk of developing
osteonecrosis (Bermúdez-Bejarano et al. 2017).
Whenever possible, the patient should receive his/her dental care at least 3 months
before starting bisphosphonate therapy. Vandone et al. reported that the incidence of
developing ONJ was reduced by 50% in patients who received preventive dental
care before initiating drug therapy (Vandone et al. 2012). The ADA Council on
Scientific Affairs stated in 2011 and suggested that patients receiving lower
cumulative doses of bisphosphonate (<2 years) or denosumab may continue
antiresorptive therapy during invasive dental treatment (Hellstein et al. 2011).
According to the AAOMS position paper, there is currently no evidence that
interrupting bisphosphonate therapy alters the risk of ONJ in patients following
tooth extraction (Ruggiero et al. 2014) (Table 3.5).
Reports indicate late implant failure can be caused by oral bisphosphonates.
Failure is associated with a sort of localized osteonecrosis. Theories include a
greater mastication force displaced across the implant and surrounding bone due to
the absence of a periodontal ligament. This increased force requires greater bone
turnover which can be inhibited by the initiation of bisphosphonate therapy (Pogrel
and Ruggiero 2018). If dental implants are placed, informed consent must be
obtained related to the possible long-term implant failure and the low risk of
developing osteonecrosis of the jaw (Ruggiero et al. 2014). The patients should be
placed on regular recall schedule.
3 Medical Assessment of the Oral and Maxillofacial Surgery Patient 59

Table 3.5 Recommendations for patients with a medical history of oral bisphosphonate usage
Oral bisphosphonate for No alteration or delay in the planned surgery is necessary. This
less than 4 years and includes any and all procedures common to oral and maxillofacial
have no clinical risk surgeons, periodontists, and other dental providers
factors
Oral bisphosphonate for The prescribing provider should be contacted to consider
less than 4 years and discontinuation of the oral bisphosphonate (drug holiday) for at least
have also taken 2 months prior to oral surgery, if systemic conditions permit. The
corticosteroids or antiresorptive therapy should not be restarted until osseous healing
antiangiogenic has occurred. These strategies are based on reports that corticosteroid
medications and antiangiogenic agents, in combination with antiresorptive
concomitantly therapy, may increase the risk of developing MRONJ and that a drug
holiday may mitigate this risk. Long-term, prospective studies
however are still required to establish the efficacy of drug holidays in
reducing the risk of MRONJ for these patients
Oral bisphosphonate for The prescribing provider should be contacted to consider
more than 4 years with discontinuation of the antiresorptive therapy for 2 months prior to
or without any oral surgery, if systemic conditions permit. The bisphosphonate
concomitant medical should not be restarted until osseous healing has occurred. The risk
therapy of long-term oral bisphosphonate therapy requires continued analysis
and research
Adapted from the AAOMS © 2014 Position paper on MRONJ

3.5.4 HIV Status

According to the Americans with Disabilities Act of 1990, adult or pediatric HIV-­
positive patients are able to receive routine dental care at any dental practice. Most
if not all patients with HIV are able to tolerate routine dental care. HIV virus and
antiretroviral therapies have a myelosuppressive effect and may be associated with
abnormal bleeding, glucose intolerance, hyperlipidemia, reduced platelet count, or
white blood cell neutrophil.
Indiscriminate use of antibiotics may predispose patients to adverse drug reac-
tions, superinfection, and drug-resistant microorganisms. Especially in this patient
population, the use of antibiotics must be judicious. Baseline viral load and CD4
counts are the most commonly referred to values and can be useful in determining
stability of treatment and susceptibility for opportunistic infections, but neither test
is necessary to provide care. Both values do not predict how well a patient will toler-
ate a dental procedure and must not be used to determine the need for antibiotic
prophylaxis before dental therapy.
Currently there are no specific guidelines in the literature regarding the need for
antibiotic prophylaxis; some authors state that patients with severe neutropenia
(<500 cells/mm3) might benefit from a therapeutic antibiotic regimen starting with
a loading dose at the time of the procedure and followed by 5–7 days of postoperative
antibiotics (Patton et al. 2002). There is little evidence to support use of antibiotics
in these patients despite the risks of oral complications after dental procedures.
There are no restrictions on the dental treatment of stable patients on regular
antiretroviral therapy (Robbins 2017). This is similar to rehabilitation using dental
60 S. R. Ruiz et al.

Table 3.6 Important blood count values that would determine modification to surgical treatment
plan
Type Normal Minimum
Absolute neutrophil 2500–7000 cells/ 500 cells/mm3 <500 cells/mm3 antibiotic
count (ANC) mm3 prophylaxis recommended
Platelets 150,000– 50,000 cells/ 100,000–70,000: local hemostatic
450,000 cells/mm3 mm3 measures are indicated
70,000–50,000: transfusion may
be needed and considered

implants regardless of CD4+ counts. The literature has shown no increased rate of
infection and indistinguishable osseous integration in patients with well-controlled
HIV as compared with a non-HIV population as well as similar healing from sinus
lifts and bone augmentation surgeries (Diz et al. 2013) (Table 3.6).
Most other HIV-associated oral conditions are caused by opportunistic infec-
tions. These may include candidiasis, bartonellosis, cryptococcosis, cryptosporidi-
osis, and histoplasmosis. Opportunistic viral infections may predispose patients to
human papilloma virus (condyloma or cancer); Epstein-Barr virus can lead to oral
hairy leukoplakia; human herpesvirus may develop into Kaposi’s sarcoma; cyto-
megalovirus may lead to cytomegalovirus oral ulcers. Herpesvirus infection may
also lead to necrotizing periodontitis. Conventional periodontitis is found in up to
30% of HIV-positive adults.

3.5.5 Pregnancy

Dentoalveolar surgery for the pregnant patient should be focused on the relief of
pain and elimination of any infection or malignant neoplasm. If treatment must be
performed, the patient should not be placed in the supine position (especially in the
third trimester). The supine position increases the risk of developing deep vein
thrombosis by compression of the inferior vena cava. The ideal position for pregnant
patients in the dental chair is the left lateral decubitus position with the right hip
elevated by 15°.
Some elective and dentoalveolar surgery procedures are more safely performed
in the second trimester (Dellinger and Livingston 2006).
Multiple NSAIDs including ibuprofen, naproxen, and ketoprofen are the most
common medications used, but utilization of these medications in early pregnancy
has been related with an increased risk of cardiac septal defects (Flynn and Susarla
2007). Also, short-term use of NSAIDs in the third trimester is associated with a
significant increase in the risk of premature closure of ductus arteriosus (Koren
et al. 2006). Contrary to NSAIDs, opiates have not been related with fetal abnor-
malities, although they may cause neonatal opiate withdrawal disorder when the
mother is dependent on opiates (Pryor et al. 2017).
Infections are the most well-known reason an oral and maxillofacial specialist is
approached to treat a pregnant patient. The teratogenic potential has a wide range
3 Medical Assessment of the Oral and Maxillofacial Surgery Patient 61

depending on the antibiotic of choice. It is recommended to use antibiotics such as

amoxicillin or clindamycin in the pregnant patient (Donaldson and Goodchild
2012).

3.5.6 Seizure Disorders

Seizures are reported as the second most common medical incident encountered in
the dental chair. These disorders are characterized by an episode of alteration of
mental activities, involuntary muscle contractions, and changes in consciousness
secondary to abnormal synchronous neuronal activity. The most encountered types
of seizures are tonic-clonic and absence attack. These two also present the highest
potential for morbidity (Sanders et al. 1995).
Knowledge of the patient’s typical seizure triggers, duration, and type allows the
provider to recognize early signs of a seizure episode and take precautions.
Reduction in fibrinogen and/or an increase in prothrombin time has been reported
with the use of sodium valproate, usually without associated clinical signs and
particularly with high doses as it has an inhibitory effect on the second phase of
platelet aggregation.

3.5.7 Adrenal Insufficiency

Diseases of the adrenal cortex may cause adrenal insufficiency. Symptoms of pri-
mary adrenal insufficiency include weakness, weight loss, fatigue, and hyperpig-
mentation of skin and mucous membranes. However, the most common cause of
adrenal insufficiency is chronic therapeutic corticosteroid administration (second-
ary adrenal insufficiency). Often patients who regularly take corticosteroids have
moon facies, buffalo humps, and thin translucent skin. Their inability to increase
endogenous corticosteroid levels in response to physiologic stress may cause them
to become hypotensive, syncopal, nauseated, and feverish during surgery. They do
not respond to the typical agents administered to correct these signs/symptoms.
If a patient with primary or secondary adrenal suppression requires complex oral
surgery, the primary care physician should be consulted about the potential need for
supplemental steroids. In general, minor procedures require only the use of an
anxiety reduction protocol. Thus, supplemental steroids are not needed for most
dental procedures (Miller et al. 2001).

3.5.8 Diabetes

Several chronic microvascular complications have been reported in connection to

diabetes including increased risk for periodontal disease, change in subgingival
microbiota, alterations in immune response, altered collagen metabolism, alteration
62 S. R. Ruiz et al.

in oral vascularization, hereditary patterns, altered neutrophil function, reduced

phagocytic capacity, and chemotaxis (Fernandes et al. 2015).
The patient is advised to seek urgent medical attention as soon as possible if
blood sugar levels continue to rise. If left untreated, this can result in diabetic
ketoacidosis and death. Preoperative serum glucose should always be taken at the
time of the appointment. As a rule, treatment should be deferred if medical conditions
are not well controlled. Certain exceptions are met on an individual patient basis. If
the blood glucose is low (<70 mg/dl) or extremely high (>300 mg/dl), the general
dentist should consider deferring treatment, if possible, and focus on helping the
patient seek appropriate medical treatment to get better glycemic control. The
provider should refer the patient to their primary care doctor or endocrinologist and
see the patient when their blood sugar becomes more controlled. Helpful values that
demonstrate glucose control are the HbA1c that measures a 3-month average of
serum glucose levels. The American Diabetes Association’s Standards of Medical
Care in Diabetes recommends an HbA1c of <7.0% in most patients to reduce the
incidence of microvascular disease, i.e., mean plasma glucose of ∼150–160 mg/Dl
(Evert 2014). High blood glucose is associated with delayed healing (Lalla and
D’Ambrosio 2001). Some research suggests that antibiotic prophylaxis can be used
in patients with poorly controlled diabetes mellitus. Although the current data is not
very strong, antibiotics might be indicated in invasive dental procedures (Lockhart
et al. 2007; Ship 2003). Obviously delaying care is not always possible, such as
instances of pain or infection.

3.6 Antibiotic Prophylaxis

There is a lack of evidence for antibiotic prophylaxis in third molar extractions

(Marchionni et al. 2017). A meta-analysis conducted by Moreno-Drada and Garcia-­
Perdomo did conclude that antibiotic prophylaxis is effective in decreasing the
incidence of infections post-tooth extraction and can be considered for high-risk
patients (Moreno-Drada and García-Perdomo 2016). Infections following tooth
extraction are quite low, and antibiotic prophylaxis is not indicated for most patients
(Prajapati and Sathaye 2016; Aragon-Martinez et al. 2016). Antibiotic prophylaxis
also shows no apparent difference in postoperative infection for patients who receive
dental implants (Keenan and Veitz-Keenan 2015). However, many practitioners will
prescribe antibiotics when grafts are placed. Although controversial, some studies
have concluded that failure rates of implants are significantly reduced when
antibiotic prophylaxis is given. A single dose of preoperative antibiotic therapy is
usually sufficient. It is therefore up to the individual practitioner on whether to use
antibiotic prophylaxis for implant placement until better research is conducted
(Sharaf and Dodson 2011; Deeb et al. 2015; Mazzocchi et al. 2007; Dent et al.
1997). The practitioner must be mindful as to the risks of prescribing antibiotics.
One must consider the role in increasing antibiotic resistance as well as the cost to
society when prescribing antibiotics.
3 Medical Assessment of the Oral and Maxillofacial Surgery Patient 63

3.7 When to Postpone Surgery?

Unfortunately, medicine is not an exact science, and outcomes cannot always be

guaranteed. Patients will always have different reactions to surgical procedures. The
decision to defer patient care should be driven by concern for the safety of the
patient. The clinician needs to ask whether the patient would be better managed by
a specialist or in a more advanced facility such as a hospital setting. If the patient is
suffering from a self-limiting disease, the clinician should consider delaying care
until the patient’s condition improves.

3.8 Conclusion

“First do no harm” is one of the first things practitioners are told when they embark
on their careers. In order to provide safe patient care, it is vital to perform an accurate
medical assessment. The goal of this chapter is to help the general dentist realize
when he/she needs to change in order to maximize safety in patients with certain
medical conditions. It is also important for the general dentist to realize his/her
limitations and always act in the best interest of the patient.

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Dental Radiography
4
Aditya Tadinada

“It is the scientific use of the imagination, but we always have

some material on which to base our speculation.”
—The Hound of Baskervilles

Abstract
Radiographic imaging is an important complement to clinical evaluation in diag-
nosis and treatment planning of most dental procedures. The appropriate imag-
ing modality for radiographic evaluation should be chosen based on the specific
diagnostic task at hand. Several conventional two-dimensional and three-dimen-
sional imaging options are available to the clinician to evaluate the area of inter-
est. Radiographic imaging exams must only be ordered after a comprehensive
clinical examination and must follow the guiding principle for radiation safety:
“as low as reasonably achievable” (ALARA). It means making every reasonable
effort to maintain exposures to ionizing radiation as far below the dose limits as
practically possible. Clinicians must perform radiographic imaging on patients
only when they expect that the information provided by the radiographic exami-
nation will provide additional diagnostic information and meaningfully contrib-
ute to the treatment plan.
This chapter will focus on an evidence-based approach to imaging the maxil-
lofacial structures for routine dental conditions commonly encountered in the
dental office.

A. Tadinada (*)
Oral and Maxillofacial Radiology, Oral Health and Diagnostic Sciences, University of
Connecticut School of Dental Medicine, Farmington, CT, USA
e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2019 67

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_4
68 A. Tadinada

4.1 Dentoalveolar Structures

4.1.1 Routine Radiographic Evaluation of Teeth

The guidelines recommended by the American Dental Association (ADA) and the
Food and Drug Administration (FDA) are the recommendations most states use for
prescribing dental radiographs (The American Dental Association Council on
Scientific Affairs and the US Department of Health and Human services 2012). The
guidelines clearly articulate that radiographic exposure should be need based and
dependent on clinical judgment. For a new adult dentate or partially edentulous
patient being evaluated for oral diseases, the recommendation is to do a panoramic
exam with posterior bitewings or selected periapical radiographs and posterior
bitewings (Fig. 4.1). A full mouth intraoral radiographic exam (FMX) is
recommended when the patient has clinical evidence of generalized dental disease
or if an area is being monitored for specific conditions. The recommendation for
patients with a high risk for clinical caries is posterior bitewings at 6–18-month
interval. Recall patients with no clinical caries and not at increased risk for caries
can be imaged using posterior bitewing at 24–36-month intervals. FDA guidelines
clearly indicate that if the patient has established clinical conditions like periodontal
disease or dental implants, craniofacial pathoses, and restorative or endodontic
needs, then the radiographic examination and time intervals between exams are
determined based on clinical judgment. The clinician must always consider the risk

Fig. 4.1 Routine radiographic evaluation of teeth. (a) Panoramic radiograph. (b) Bitewing
radiographs
4 Dental Radiography 69

versus benefit analysis and make decisions based on the best outcomes for the
patient while strictly following the principles of “ALARA”.

4.1.2 FDA-ADA Recommendation (Table 4.1)

Most dental offices will have patients who present with pain that can arise from hard
tissues like the tooth and bone or soft tissues like the gingiva and the periodontium.
Pulpal inflammation and associated infections leading to severe pain are frequently
a reason for an emergency dental visit. The first step in diagnosis is gathering
adequate history about the problem followed by a comprehensive clinical
examination. An intraoral periapical radiograph is the initial radiographic exam
done to evaluate the tooth, the surrounding periodontal ligament (PDL) space, and
the periapical area (The American Dental Association Council on Scientific Affairs
and the US Department of Health and Human services 2012). Based on the clinical
and the initial two-dimensional radiographic evaluation, the clinician must choose
whether it is adequate to make a diagnosis or if there is a need to further evaluate the
area by either making a panoramic radiograph or recommending a three-dimensional
acquisition like the cone beam CT (CBCT) exam (The American Dental Association
Council on Scientific Affairs 2012). If the associated infection warrants a more
detailed three-dimensional examination including a study of the soft tissues, a
computerized tomography (CT) exam should be considered.

4.1.3 Imaging with Portable X-Ray Units

Dental radiographic examination has traditionally been done in an office setting

with the patient sitting upright on a dental chair. A wall mounted X-ray unit with the
help of position indicator device is the most common method of intraoral
radiographic exposure. With the advent of several procedures that require an
intraoperative check radiograph or a postoperative radiograph when the patient is
not fully able to follow instructions, a relatively newer option is the portable X-ray
unit. These units are battery operated and are typically handheld. Their applications
extend from intraoperative imaging and emergencies and on the field where a typical
dental office setup is not available. While an entire full mouth series can be acquired
with these devices, for ergonomic reasons, it is best to limit the use of these devices
to a few exposures. The use of these devices may need additional radiation safety
training and certification.

4.1.4 Imaging of the Third Molars

Third molar teeth often fail to erupt due to lack of adequate space and could end up
being impacted. Pericoronitis involving erupting, partially erupting, or impacted
third molar teeth is a common inflammatory condition that leads to significant pain
70 A. Tadinada

Table 4.1 American Dental Association Guidelines for selecting radiographic imaging
Type of
encounter Patient age and dental developmental stage
Child with Child with Adolescent
primary transitional with
dentition (prior dentition permanent
to eruption of (after eruption dentition Adult,
the first of the first (prior to dentate, or
permanent permanent eruption of partially Adult,
tooth) tooth) third molars) edentulous edentulous
New patient Individualized Individualized Individualized Individualized
Being evaluated radiographic radiographic radiographic exam radiographic
for oral diseases exam exam consisting of posterior exam, based
consisting of consisting of bitewings with panoramic on clinical
selected posterior exam or posterior signs and
periapical/ bitewings with bitewings and selected symptoms
occlusal views panoramic periapical images. A full
and/or exam or mouth intraoral
posterior posterior radiographic exam is
bitewings if bitewings and preferred when the patient
proximal selected has clinical evidence of
surfaces periapical generalized oral disease or
cannot be images a history of extensive
visualized or dental treatment
probed.
Patients
without
evidence of
disease and
with open
proximal
contacts may
not require a
radiographic
exam at this
time
Recall patient Posterior bitewing exam at 6–12-month Posterior Not applicable
with clinical intervals if proximal surfaces cannot be bitewing
caries or at examined visually or with a probe exam at
increased risk 6–18-
for caries month
intervals
Recall patient Posterior bitewing exam at Posterior Posterior Not applicable
with no clinical 12–24-month intervals if bitewing bitewing
caries and not at proximal surfaces cannot be exam at exam at
increased risk examined visually or with a 18–36-month 24–36-
for caries probe intervals month
intervals
(continued)
4 Dental Radiography 71

Table 4.1 (continued)

Type of
encounter Patient age and dental developmental stage
Child with Child with Adolescent
primary transitional with
dentition (prior dentition permanent
to eruption of (after eruption dentition Adult,
the first of the first (prior to dentate, or
permanent permanent eruption of partially Adult,
tooth) tooth) third molars) edentulous edentulous
Recall patient Clinical judgment as to the need for and type of radiographic Not applicable
with periodontal images for the evaluation of periodontal disease. Imaging
disease may consist of, but is not limited to, selected bitewing and/
or periapical images of areas where periodontal disease
(other than nonspecific gingivitis) can be demonstrated
clinically
Patient (new Clinical judgment as to the Clinical Usually not indicated for
and recall) for need for and type of judgment as monitoring of growth and
monitoring of radiographic images for to the need development. Clinical
dentofacial evaluation and/or monitoring of for and type judgment as to the need for
growth and dentofacial growth and of and type of radiographic
development development or assessment of radiographic image for evaluation of
and/or dental and skeletal images for dental and skeletal
assessment of relationships evaluation relationships
dental/skeletal and/or
relationships monitoring of
dentofacial
growth and
development
or assessment
of dental and
skeletal
relationships.
Panoramic or
periapical
exam to
assess
developing
third molars
(continued)
72 A. Tadinada

Table 4.1 (continued)

Type of
encounter Patient age and dental developmental stage
Child with Child with Adolescent
primary transitional with
dentition (prior dentition permanent
to eruption of (after eruption dentition Adult,
the first of the first (prior to dentate, or
permanent permanent eruption of partially Adult,
tooth) tooth) third molars) edentulous edentulous
Patient with Clinical judgment as to the need for and type of radiographic images for
other evaluation and/or monitoring of these conditions
circumstances
including, but
not limited to,
proposed or
existing
implants, other
dental and
craniofacial
pathoses,
restorative/
endodontic
needs, treated
periodontal
disease, and
caries
remineralization

and limitation in mouth opening with a high possibility of becoming a serious infec-
tion. Since it is challenging to image the third molars using intraoral periapical
examinations, and mouth opening could be a major limitation in many patients, an
extraoral examination like the panoramic is recommended (Smith et al. 1997).
Panoramic radiographs provide a general overview of the area of interest and its
surrounding structures (Fig. 4.2). Based on the panoramic image, a decision about
the surgical procedure is often made. Modifications to the surgical approach and
evaluation of the location and inclination can be studied with panoramic radiography.
Evaluation of the proximity to vital structures like the maxillary sinus in the maxilla
and the inferior alveolar nerve canal in the mandible is key to a successful surgical
outcome. A white paper written by the American Association of Oral and
Maxillofacial Surgeons (AAOMS) states that along with critical anatomic struc-
tures, the distal aspect of the second molar and the periodontal health of that tooth
are important areas to evaluate and consider prior to third molar removal (Pogrel
et al. 2007; Haug et al. 2009). To evaluate these relationships better, a small-volume
CBCT is often recommended (Figs. 4.2 and 4.3), but when it is clinically determined
that all the four third molars are in very close proximity to a critical anatomic
4 Dental Radiography 73

Fig. 4.2 Panoramic radiograph showing impacted third molars. Relationship to the IANC is chal-
lenging to evaluate

Fig. 4.3 Horizontally impacted tooth #32 in contact with the distal root of tooth #31, clearly
demonstrates proximity with lingually positioned inferior alveolar canal

structure or by position are located in a position that is challenging to access, then a

bigger field of view CBCT with all the four third molars in one image can be
acquired (Haug et al. 2009).
74 A. Tadinada

4.1.5 Imaging Dental Infections

The most common dental disease is dental caries. Although the prevalence of dental
caries has been steadily decreasing, it continues to be a significant public health
problem. Dental caries cannot be detected by clinical examination alone and often
needs radiographic evaluation using bitewing radiography to evaluate the crown and
interproximal surfaces. Clinically incipient carious lesions are challenging to
diagnose, especially if they are located interproximally where direct visual access is
challenging. An established carious lesion is seen as an area of demineralization,
and the breakdown of the enamel can be clinically observed as a “catch” upon
probing with a probe. On radiography carious lesions appear as a dark zone or a
radiolucent area with varying radiographic patterns of spread toward the pulp
(Wenzel 1998; Wenzel 2004). From a practical perspective, approximately 60–70%
demineralization needs to be present for a carious lesion to be visible on radiographic
examination. The more severe the clinical involvement is, the more obvious is the
radiographic appearance. Radiographic examinations are also representations of a
specific time point in the disease process. Unless there are sequential images at
regular time intervals, it is not possible to determine if a lesion is active or not.
While routine dental caries appears as a radiolucent area with varying degrees of
darkness, certain patterns of decay are specific to postradiation therapy cancer
patients and in patients having Sjogren’s syndrome where the buffering action of
saliva compromises the oral environment leading to significant dental decay.
Poor dental hygiene can cause gingival inflammation known as “gingivitis,” and
when not addressed, it could lead to underlying alveolar bone loss and periodontitis.
The hallmark of periodontitis is alveolar bone loss and widening of the periodontal
ligament space, which is an important radiographic finding to evaluate periodontal
health (Armitage 1999; Douglass et al. 1986). Presence of radiographic calculus is
an important radiographic feature indicative of compromised periodontal health.
Overhanging restorations are areas that specifically need to be evaluated in assessing
the status and prognosis of the periodontium. Bone loss in periodontitis could range
from mild to moderate to severe forms and could be localized or generalized. Dental
caries in combination with periodontal involvement can lead to endo-perio lesions
that involve the pulp and the periodontal tissues leading to dental infections ranging
from mild periapical infections to a full-blown abscess or a space infection.
While the key to effective management starts with astute clinical judgment and
early detection, radiographic evaluation plays a critical role in determining the
extent and severity of the problem and helps in diagnosis, treatment planning, and
management. The choice of choosing the appropriate radiographic imaging modality
largely depends on the clinician who will determine the purpose of the radiographic
examination (Åkesson et al. 1992; Persson et al. 2003). If the task at hand is localized
to a single tooth, a vertical bitewing to show the extent of bone loss and an initial
periapical radiograph may be adequate, but if the clinical evaluation shows that a
larger area is involved, a panoramic radiograph should be made to study the area of
interest and to determine the extent of the infection. Panoramic radiography is an
extraoral examination, and the resolution of the image is not ideal to assess bone
4 Dental Radiography 75

levels, but a general idea about the overall bone levels and extent of an infection if
present can be observed. Based on the panoramic radiograph, a further judgment
about the necessity to do any advanced imaging is made. CBCT is adequate to
evaluate the bone levels when three-dimensional views of the alveolar bone and
periodontal defect are being studied (Misch et al. 2006; Vandenberghe et al. 2007).
If the clinical evaluation appears to be a more complicated condition and a space
infection is suspected, then a computed tomography (CT) will help in determining
the extent and spread of the pathology and also to show the effect on adjacent
structures.
Pulpal inflammation leading to infections is a common challenge encountered in
the dental office; the American Association of Endodontists (AAE) and the American
Academy of Oral and Maxillofacial Radiology (AAOMR) (Patel et al. 2014; Fayad
et al. 2015; Special Committee to Revise the Joint AAE/AAOMR Position Statement
on use of CBCT in Endodontics 2015) in a joint position paper state that when the
evaluation of the area of interest cannot be achieved by conventional dental radiog-
raphy, CBCT must be considered. When imaging with CBCT, it is recommended
that the smallest possible field of view (FOV) and smallest voxel size and lowest
mA must be used to best avail the benefits of the technology while addressing the
issue of exposing the patient to ionizing radiation in the most meaningful way
(Fayad et al. 2015; Special Committee to Revise the Joint AAE/AAOMR Position
Statement on use of CBCT in Endodontics 2015).

4.1.6 Imaging of Inflammation Associated with the Jaws

4.1.6.1 O  steomyelitis, Osteoradionecrosis, and Medication-Related

Osteonecrosis of the Jaw (MRONJ)
The strict definition of osteomyelitis is inflammation of the bone marrow.
Functionally, osteomyelitis is generally used to indicate a major infection of the
bone. Osteomyelitis is always reflected in increased bone destruction and increased
bone deposition. The mandible is more susceptible than the maxilla and is likely due
to the nature and quality of the bone and blood supply. There are several types of
osteomyelitis and can be broadly divided into acute, chronic, Garre’s (proliferative
periostitis), sclerosing, focal or diffuse, radiation-related, drug-related, rarefying, or
condensing osteitis (related to a local periodontal problem). The sources for
osteomyelitis in the jaws could be from a dental infection, chronic pericoronitis,
fracture, systemic seeding, and radiotherapy or could be drug induced.
In acute stages of osteomyelitis, no early changes are evident on radiographs, at
least 30–60% demineralization of the bone to detect on conventional radiographs.
The first changes perceptible on conventional radiographs are “unsharpness” of
bone trabeculae and overall loss of bone density, reflecting the primary effect as loss
of bone mineral content through bone resorptive mechanisms. Occasionally, the
first changes will manifest as increased thickness of trabeculae and increased bone
density, reflecting the primary effect as increase of bone mineral content through
reactive bone formation (Fig. 4.4).
76 A. Tadinada

a b

Fig. 4.4 (a) PA radiograph showing caries, widened PDL space and a pericarpial radiolucency
involving the mesial root of #19. (b) Endodontically treated #18 and grossly decayed #19 showing
apical pathology/infection with sclerotic changes involving the surrounding trabecular bone

Fig. 4.5 White arrow points to sequestrum formation

Chronic osteomyelitis may or may not be related to acute phase, it is typically

longer in duration, and the patient has intermittent to recurrent painful episodes.
Paresthesia in the involved area and a draining sinus are common features.
Radiographically the hallmark of osteomyelitis is “sequestrum” formation, and
indication of a repair process is periosteal new bone formation (Figs. 4.5 and 4.6).
The pathological process of osteomyelitis is when an infection in the bone leads to
an increase in intramedullary pressure due to inflammatory exudates; the perios-
teum becomes stripped from the ostium, leading to vascular thrombosis; bone
necrosis follows due to lack of blood supply; and sequestra are formed. As this
process continues, involucrum formation may occur as a reparative process; it is a
4 Dental Radiography 77

Fig. 4.6 Axial section of

head CT sat the level of the
mandible showing buccal
and lingual bone
destruction along with
multiple specks of
sequestrations

layer of new bone growth outside the existing bone seen in osteomyelitis. It results
from the stripping off of the periosteum by the accumulation of pus within the bone
and new bone growing from the periosteum.
Osteomyelitis is far more common than osteoradionecrosis and the medically
related osteonecrosis (Fig. 4.7) of the jaws (MRONJ) (Fig. 4.8). A thorough clinical
history can help in understanding the etiology of the condition. In all of these
clinical scenarios, panoramic imaging can help serve as an initial examination, but
three-dimensional imaging using cone beam CT will help in understanding the
extent of the condition. Nuclear medicine exams using a radiopharmaceutical like
technetium-99 will help in understanding the mitotic activity at the site and also in
differentiating between an acute phase and a chronic phase and also between
osteomyelitis and osteoradionecrosis (Fig. 4.9). Medically related osteonecrosis of
the jaws is a fairly recent challenge that general dentists must learn to recognize and
be familiar in the management of such cases along with appropriately referring
those cases in a timely manner. Conventional 2-D imaging often does not completely
show the full extent of involvement of the osteonecrosis. A CBCT scan can help in
the staging and treatment planning of the condition; when the infection has a more
extensive and deeper involvement, then a multi-slice medical CT should be
considered (Fig. 4.6).

4.1.7 Imaging of Cysts

A cyst by definition is a pathological cavity having fluid and is lined by an epithe-

lium surrounded by a connective tissue wall. Cysts are more common in jawbones
than in any other bone of the body because of the numerous rests of odontogenic
epithelium that remain in the tissues. Most cysts etiologically arise from these cells.
78 A. Tadinada

At the time of screening

3Months later

Fig. 4.7 Osteoradionecrosis (“ORN”) (radiation osteomyelitis)

Odontogenic cysts affect the tooth-bearing areas; non-odontogenic cysts are usually
developmental and are most common in the anterior maxilla. Upon clinical evalua-
tion, odontogenic cysts are noted to be the most common cause of swelling in the
jawbones. Patients typically do not have pain unless the cyst is secondarily infected.
Cysts in the jaws are most often associated with unerupted teeth. Upon radiography,
cysts appear as well-defined, radiolucent lesions arising in the tooth-bearing areas.
Cysts are radiolucent entities; they could be unilocular or multilocular. The periph-
ery is a well-defined, well-corticated, and thin radiopaque line. When the cyst gets
secondarily infected, this radiopaque rim thickens and appears more sclerotic. Most
cysts behave similarly and usually grow slowly and thought to expand by hydro-
static pressure. They usually expand and cause resorption of adjacent structures.
The most common type of cyst is the radicular cyst (65–70%) (Fig. 4.10) followed
4 Dental Radiography 79

Fig. 4.8 Medication related osteonecrosis of the jaw (MRONJ). This patient was on biphospho-
nate therapy

Area of
increased
radiolabel
uptake -
mandibular
Osteomyelitis

Fig. 4.9 Bone scan to detect acute osteomyelitis

by a dentigerous cyst (15–18%). Odontogenic keratocysts are also a frequent occur-

rence in older individuals. Panoramic radiography is recommended as the initial
image for evaluation (Fig. 4.11). Further imaging like CBCT or a CT is often done
to evaluate the full extent in three dimensions, to study the effects on adjacent struc-
tures, and also to plan the surgical approach.

4.1.8 Imaging of Benign Tumors and Malignant Tumors

A time-sensitive and key pointer for the general dentist to notice is understanding
the clinical and radiographic presentation of a benign and malignant tumor and
distinction from an infection and appropriate timely referral to a specialist. It is very
valuable for the clinician to recognize the difference between these entities. While a
panoramic radiograph may be adequate to do an initial analysis, imaging using
CBCT will help in evaluating the characteristics of the lesion to observe the nature
80 A. Tadinada

Fig. 4.10 Sagittal CBCT

section showing a radicular
cyst. Arrow showing the
raised floor of the sinus

Fig. 4.11 An odontogenic keratocyst involving tooth # 32. Note the undulating cortication

and behavior of the lesion. Based on these observations, a CT exam may be ordered.
Radiographically an important point to note is that benign tumors only resorb struc-
tures by growth, whereas malignant tumors destroy structures and are fairly quick
to cause significant destructive changes. A well-designed approach would be to start
with a panoramic radiograph, based on the behavior of the lesion; other advanced
imaging options may be considered like CBCT, CT, and a positron emission tomog-
raphy (PET)-CT. Since timing is critical for the prognosis in these cases, appropri-
ate referrals must be made in a timely fashion.
4 Dental Radiography 81

4.1.9 Imaging of the Paranasal Sinuses

There a total of four paired sets of paranasal air sinuses. Maxillary and ethmoid
sinuses are of particular interest to dentists because of the shared borders and proxim-
ity to dental structures (Fig. 4.12). Maxillary sinus in particular is of significant impor-
tance. The floor of the maxillary sinus is in very close proximity to the premolar and
molar teeth. The floor of the maxillary sinus appears as a thin radiopaque line on
radiography. It is commonly observed in intraoral radiographic exams and on pan-
oramic radiographs and in 3-D imaging of the maxillofacial complex. Over time
pneumatization of sinuses occurs and this is most marked in the maxillary sinus. It has
been observed that with loss of a posterior tooth, the pneumatization of the maxillary
sinus is more obvious, and the floor of the sinus drops down toward the alveolar bone
causing further expansion or pneumatization of the sinus. This aspect is of particular
value in dental implant therapy where it is of utmost value to have as much natural
bone volume available as possible. One common method of preparing a potential
implant site after extraction of the tooth is to graft the site and is referred to as the
socket preservation procedure. If the site happens to be a long-standing edentulous
site, and pneumatization of the bone has occurred causing inadequate availability of
bone volume, a technique called “sinus-lift” procedure is done where the sinus floor
is augmented and raised up and grafted to gain adequate bone volume.
Several diseases are associated with the sinuses; the most important sinus that is
of interest to the dentist is the maxillary sinus. While the pathology associated with
the sinuses can be classified in many ways, a simple way to distinguish the etiology
that is meaningful for the dentist is to classify the diseases as those arising from

Fig. 4.12 Coronal CBCT

image showing maxillary
Ethmoidal Sinusitis
and ethmoid sinuses with
marked mucosal thickening

Maxillary Sinusitis Maxillary Sinusitis

82 A. Tadinada

within the sinus tissues (intrinsic) or originating outside the sinus (extrinsic) such as
those with an odontogenic origin. Upon clinical examination, pressure and pain
during bending and head movement are common signs associated with maxillary
sinus disease. Diseases involving the maxillary sinus include inflammation due to
infection, allergies, trauma, etc. Since sinuses are air filled, the radiographic
appearance is radiolucent, any changes including mucosal thickening to any mass in
the sinus will radiographically appear radiopaque, but the density varies depending
upon the condition. Sinusitis is a common condition radiographically noted as a
radiopaque lining on the floor of the sinus, it could be inflammatory or allergic, and
several cases may have an odontogenic involvement. When the infection is due to an
odontogenic cause, there may be an oroantral communication and a breach in the
continuity of the maxillary sinus. While sinusitis, polyps, antroliths, and mucoceles
constitute the inflammatory group of conditions affecting the maxillary sinus,
benign neoplasms like a papilloma or an osteoma affect the paranasal sinuses. The
most important pointer for clinicians is to identify squamous cell carcinoma largely
because they are rare and importantly because they are silent and often are mistaken
for inflammatory conditions and are diagnosed at an advanced stage. Malignancy in
the maxillary sinus will have facial swelling and nasal obstruction. In most cases the
medial wall of the sinus is eroded first leading to nasal involvement and spread.
From a dental perspective, it is valuable to know that if there is no odontogenic
involvement and there’s unexplained swelling, altered sensation of teeth, ill-fitting
prostheses (when present), and pain with no obvious odontogenic cause, it is prudent
on the part of the dentist to identify the condition as a malignancy arising from the
floor of the sinus and that it undergoes a complete workup till proven otherwise.
Several extrinsic conditions may involve the maxillary sinus including odonto-
genic cysts like dentigerous cyst or an odontogenic keratocyst or an inflammatory
cyst like the radicular cyst. All of them push the floor of the maxillary sinus superi-
orly and when there is a superimposed infection could cause breach or discontinuity
of the sinus floor. Another important condition for the clinician to be aware of in this
region is fibrous dysplasia which is a condition that alters bone metabolism and
turns normal bone into dysplastic bone. This condition is more observed in the pos-
terior maxilla and blends into the adjacent area and may appear as a poorly defined
radiopaque entity involving the maxillary sinus.
Intraoral radiography shows the tooth root and floor of the sinus area very well
but does not provide the full picture necessary for complicated cases where
knowledge of the type and extent of the lesion is important. An extraoral projection
known as the “Waters’ view” was typically used to compare air-fluid levels in the
sinus and internal components of the sinuses in the same image but is slowly
becoming obsolete. Panoramic radiography is helpful in studying both the maxillary
sinuses and the sinonasal areas in the same image, but the challenge of
superimpositions inherent to its acquisition technique may lead to a 3-D examination
if the panoramic image is not adequately able to depict the entire sinus and the
spread of the condition. CBCT (Fig. 4.13), CT, and MRI are being increasingly used
to evaluate the extent and spread of fibrous dysplasia or a malignancy.
4 Dental Radiography 83

Ethmoidal Sinusitis

Maxillary Sinusitis Maxillary Sinusitis

Fig. 4.13 Panoramic and CBCT images showing sinusitis

4.1.10 Imaging of the TMJ

Imaging of the temporomandibular joint is based on clinical findings. Diagnostic

imaging of the TMJ is an important adjunct to clinical evaluation. The osseous
components of the TMJ can be imaged by panoramic radiography, but because of
the unique location of the TMJ, several superimpositions can be noted in this area
and often make it challenging to do a complete evaluation of the joint structures.
Three-dimensional imaging using computed tomography (CT) or cone beam
computed tomography (CBCT) can provide high-resolution images of the condyle
and the fossa (Fig. 4.14). It is challenging to image the disc using plain films, CT, or
CBCT, and so magnetic resonance imaging is used to evaluate the disc. Several
conditions affect the TM joint complex that have a direct impact on esthetics and
function, and so it is valuable for the clinician to know and recognize these conditions
and to make appropriate and timely referrals. Condylar hyperplasia, condylar
hypoplasia, juvenile arthrosis, and bifid condyle are the more common developmental
challenges involving the joint complex. The articular disc could be displaced
anteriorly or medially or laterally leading to pain and limitation in mouth opening
and the range of motion. Disc displacement could be because of a number of reasons
like arthritis, trauma, or temporomandibular dysfunction. All changes involving the
disc and fluid effusion in the joint space is best recognized on magnetic resonance
imaging (MRI) (Fig. 4.15).
84 A. Tadinada

Fig. 4.14 High resolution CBCT images of the TMJ

Bone marrow inside mandibular condyle

(Fat is a bright signal in T1-weighted MRI)
Articular disc (dark grey)
Lat Pterygoid muscle

Head of
mandibular condyle

Maxillary
sinus Inferior alveolar
(mandibular) nerve

Sagittal, mouth closed Sagittal, mouth open Coronal, mouth closed

Fig. 4.15 T1-weighted magnetic resonance imaging (MRI) of the TMJ

4.1.11 Imaging of the Salivary Glands

Salivary glands play several important functions including buffering action to

enzymatic production. Adequate quantity and quality of salivary flow is critical
for normal functioning of many physiological processes in the body. There are
4 Dental Radiography 85

2 submandibular, 2 sublingual, and more than 400 minor salivary glands in the
mouth. Upon clinical evaluation the presentation of salivary gland symptoms
includes pain and swelling, sometimes associated with eating and drinking. It
could also be a painless mass, dry mouth, or bad taste in the mouth. Salivary
gland enlargements can be inflammatory, cystic, neoplastic, or nonneoplastic.
The most common condition for pain involving the salivary gland is sialolithia-
sis or formation of a stone in the salivary gland. One way to test the origin of
pain when salivary gland involvement is suspected is to administer lime/lemon
juice to the patient, and if the salivary gland is involved, typically there is sali-
vary production that could be obstructed by a sialolith and could elicit pain due
to obstruction within the gland. Sialoliths are most common in the subman-
dibular gland at its duct known as the Wharton’s duct. The high rate of involve-
ment could be because the duct is longer and has a larger caliber and a slower
salivary flow rate. Higher pH and calcium circulation could also be possible
reasons that could be contributing to the formation of salivary gland stones.
Occlusal radiographs are recommended as an initial examination to study the
floor of the mouth when a submandibular gland sialolith is suspected. A func-
tional imaging exam known as sialography was very popular to both diagnose
and partially treat the obstructed salivary gland, but because of many contrain-
dications like inability to use in acute infections, sensitivity to iodine-based
dyes used in the procedure, and evolution of better techniques, this method is
slowly being replaced by other advanced imaging methods like magnetic reso-
nance sialography (MR sialography). Sialadenitis is another important condi-
tion that the clinician must recognize. It is an acute or chronic bacterial
infection; upon clinical evaluation, it presents as a swelling with redness, ten-
derness, fever, and possible regional lymphadenopathy. Computerized tomo-
graphic exams of the salivary gland are valuable when the clinical need is to
study the gland in 3-D and also to understand the extent and involvement of the
condition. CT exams also have a good contrast resolution that is necessary to
study the subtle soft tissue layers. MRI is also being extensively used to study
the soft tissues in this area including the salivary gland proper especially to
study masses in the salivary gland and also to study the ductal system. While
access to the salivary glands using conventional ultrasonography probes is
challenging, it is used frequently to differentiate between cystic and solid
lesions and is very sensitive for detection of superficial lobe parotid masses. A
functional imaging test that is of significant value to the clinician is scintigra-
phy using 99mTc-pertechnetate. Because of the poor resolution of the image,
it cannot accurately depict small tumors and cannot differentiate between
benign and malignant tumors, but it is very valuable in diagnosis, treatment,
and follow-up of Sjogren’s syndrome. CBCT- and CT-guided surgical proce-
dures are fast becoming the preferred method of surgical management. Data
generated from the 3-D scans is used as a roadmap to navigate a sophisticated
instrument into the area of interest and perform several different surgical pro-
cedures (Figs. 4.16 and 4.17).
86 A. Tadinada

Fig. 4.16 Normal parotid

sialogram—water based
contrast

Fig. 4.17 Parotid punctate sialoadenitis with retention of contrast in gland. This is a characteristic
appearance of Sjogren’s Syndrome
4 Dental Radiography 87

4.1.12 Imaging Involving Dental Implants

With a significant shift in the restoration of edentulous spaces with dental implants,
general dental offices are involved in many ways in the treatment planning, placement,
and restoration of dental implants. Implant therapy is a multistep process that requires
careful planning, case selection, and execution. Several aspects need to be carefully
evaluated to facilitate the success of dental implants. Radiographic imaging is key to
successful implant placement. While a panoramic radiograph and intraoral radiographs
provide adequate initial details, cone beam CT (CBCT) must be considered in cases that
require three-dimensional views of the proposed implant site. The International Congress
of Oral Implantologists in its consensus report establishes the value and limitations of
CBCT in implant treatment planning and also provides guidelines regarding the use of
CBCT in implantology. Cone beam CT provides high-resolution, three-dimensional
images of the proposed implant site. The most important advantage of CBCT is the abil-
ity to provide cross-sectional images of the implant site without any superimpositions.
The radiation dose is significantly lower compared to a conventional 3-D imaging option
using a multi-slice medical CT. The American Academy of Oral and Maxillofacial
Radiology (AAOMR) in its position paper on the use of dental radiography in dental
implantology, based on available literature and current evidence, states that cross-sec-
tional imaging should be used for the assessment of all dental implant sites. CBCT scans
provide information regarding the proximity of critical structures to the potential implant
site and often help in making and/or modifying the treatment plan and surgical approach.
There are several ways CBCT scan data is utilized in implant therapy. Typically a radio-
graphic guide is fabricated prior to the CBCT acquisition indicating the desired site for
implant placement. The patient is scanned with the radiographic guide in place, and
cross-sectional images of the potential implant site are generated using a post-process-
ing CBCT reconstruction program. Height and width measurements of the implant site,
morphology of the buccal, lingual/palatal cortical bone contours, and trabecular pattern
are recorded along with proximity to any critical structures to aid in implant treatment
planning. Since dental implant placement is dependent on the location of the final pros-
thetic component, many times bone grafting procedures need to be done to gain ade-
quate bone volume at the desired location. CBCT can help determine the location, size,
and volume of graft necessary to manage the site. When guided surgery is being consid-
ered for implant placement, the DICOM data from the CBCT scan is used in the fabrica-
tion of the surgical stent. Overall, radiographic imaging especially cross-sectional
imaging using CBCT can contribute toward evaluation of the implant site, need for any
grafting procedures at the site, and choosing the type, size, and number of implants
providing significant value addition (Figs. 4.18 and 4.19).
88 A. Tadinada

Fig. 4.18 CBCT image of maxillary implant site with radiographic guide

Fig. 4.19 CBCT images showing an implant treatment planning program that allows virtual
implant placement
4 Dental Radiography 89

4.2 Summary/Conclusion

Radiographic evaluation of the oral and maxillofacial structures is an important

complement to clinical evaluation in diagnosis and treatment planning of most den-
tal procedures. Ionizing radiation in the form of X-rays is the most commonly used
source of radiographic imaging. The challenge with ionizing radiation is that it
leads to radiation and body tissue interactions that could potentially cause cancer-
ous transformation of cells even at low doses. Because these interactions cannot be
predicted easily, due diligence and responsible use of ionizing radiation are advised.
Benefits of a radiographic exposure should outweigh the risks, and the information
gathered should meaningfully contribute toward the patient’s treatment. A key point
to remember as a rule of thumb is that younger patients are more sensitive to ion-
izing radiation and so are some organs like eyes, salivary glands, thyroid gland, etc.
No dose is too low to completely avoid the risk induced by ionizing radiation.
Proper selection criteria must be followed for radiographic examination. A 2-D
examination like an intraoral periapical, a bitewing, or a panoramic must be the
initial exam of choice, and if deemed necessary, a 3-D exam with the lowest dose
that yields diagnostic quality images must be selected. It is the responsibility of the
dental office acquiring the radiographic images/scans to interpret the exams and do
the necessary timely referrals. When needed the services of an oral and maxillofa-
cial radiologist may be sought to interpret the images/scans.
Overall it is advisable to have a system in place for a standardized work flow
involving selection criteria, image acquisition, patient protection using shielding,
electronic health record management, interpretation, and archival of patient data.
All the processes in place should help in responsible management of the dental
office that follows evidence-based decision-making to enhance patient-centric
outcomes.

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Complementary and Alternative
Medicine 5
Stephan Goupil and Michael T. Goupil

“Let us get a firm grip of the very little which we do know, so

that when fresh facts arise, we may be ready to fit them into
their places.”
Sherlock Holmes in—The Adventure of the Devil’s Foot

Abstract
Complementary and alternative medicine (CAM) techniques are used by a sig-
nificant part of the population worldwide. Many of these techniques have been
used successfully for thousands of years. Current research has tried to evaluate
the basis and success of these techniques with mixed results. This chapter pro-
vides an overview of this vast topic and provides examples of where these tech-
niques might be employed into contemporary dental practice.

5.1 Introduction

The National Institutes of Health defines complementary and alternative medicine

(CAM) as “a group of diverse medical and health care systems, practices, and
products that are not presently considered to be part of conventional medicine”

S. Goupil
Department of Family Medicine, University of Massachusetts, Worcester, MA, USA
M. T. Goupil (*)
Division of Oral and Maxillofacial Surgery, Emeritus Faculty, University of Connecticut
School of Dental Medicine, Farmington, CT, USA
Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT, USA
e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2019 91

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_5
92 S. Goupil and M. T. Goupil

(Little 2004). It is used by approximately 40% of the US population, and herbalism

is the most common medical practice in the world (Barnes et al. 2008; Kummet
et al. 2014). A considerable number of patients do not inform their healthcare
provider that they are utilizing CAM. The use of CAM, especially the use of herbal
products, can have an interactive effect on more traditional Western medicine
practices. This chapter provides an overview of many of the popular CAM practices
that the dental practitioner may encounter. CAM practices are commonly used in
the treatment of chronic pain (Lee and Raja 2011; Ossendorf et al. 2009). Some of
these practices can be incorporated into the overall dental treatment plan especially
in the area of chronic pain management (Spector et al. 2012). Studies indicate that
patients utilize CAM practices in alleviating their temporomandibular dysfunction
(TMD) (Myers et al. 2002; Raphael et al. 2003).

5.2 Common CAM Systems

1. Traditional Chinese Medicine (TCM) is a broad range of medicine practices

sharing common concepts which have been developed in China and are based on
a tradition of more than 2000 years, including various forms of herbal medicine,
acupuncture, massage (Tui na), exercise (qigong), and dietary therapy.
2. Ayurvedic Medicine is a system of healing that originated in ancient India. In
Sanskrit, ayur means life or living, and veda means knowledge, so Ayurveda has
been defined as the “knowledge of living” or the “science of longevity.” It
includes dietary therapy, herbal medicine, and meditative poses that are
individualized to the patient’s specific medical situation.
3. Naturopathy is a system of treating diseases, largely employing natural agents,
such as air, water, sunshine, etc., and rejecting the use of drugs and medicines. It
uses complementary and conventional medicine techniques to support and
promote self-healing.
4. Homeopathy is a system of medical practice that treats a disease especially by
the administration of minute doses of a remedy that would when given in larger
amounts to healthy persons would produce symptoms similar to those of the
disease.
5. Chiropractic is a system of noninvasive therapy which holds that certain mus-
culoskeletal disorders result from nervous system dysfunction arising from mis-
alignment of the spine and joints. Treatment focuses on the manual adjustment
or manipulation of the spinal vertebrae.
6. Osteopathy was developed as a manual therapy involving manipulation of the
spinal and peripheral joints and soft tissues. Currently in the USA, it includes
most of the allopathic therapeutic methods and is considered as part of mainstream
healthcare. In some other countries, osteopaths are still considered complementary
medicine therapists.
5 Complementary and Alternative Medicine 93

5.3 Herbal Therapy

Herbal therapy may be prescribed by a healthcare provider but is more commonly

self-prescribed. In the USA, herbals are considered dietary supplements rather than
drugs and are used by approximately 20% of the population (Bent 2008; Kennedy
et al. 2008). As dietary supplements, herbals are required to be safe but not
necessarily proven to be effective.
One of the problems in conducting research on herbals, and consequently in
interpreting the available research, is the “purity” of the herb. Plants are affected by
a variety of growing conditions such as weather, soil conditions, geography, etc.
Also, the effects of the herbal may differ depending on what part of the plant is
being used—root, stem, leaf, or flower. In addition, there are other confounding
factors such as when was the herb harvested, how it has been prepared, and how
long has it been stored. Despite these drawbacks, there is a considerable amount of
literature available on a variety of herbal products; but this literature, both positive
and negative, needs to be interpreted with care. An objective assessment as illustrated
in Chap. 1 becomes very important. This is also true when looking at other CAM
techniques that are discussed later in this chapter.
The quantity of plants used for medicinal purposes worldwide numbers in the
tens of thousands. Some of the more commonly used herbals that might be
encountered in a dental practice will be covered in this chapter. As part of a patient’s
medical history, they must be specifically asked if they are taking any herbal
products or dietary supplements. In a dental school patient population, Abede et al.
reported that only 12.6% of the patients reported using an herbal within the past
month (Abede et al. 2011). There are several informational sources available that
can be utilized to determine whether these herbs/supplements may influence the
treatment planned (see Table 5.1).

5.3.1 Common Herbals

• Arnica (Arnica montana), also known as wolf’s bane, is considered to have both
anti-inflammatory and analgesic properties and is applied topically immediately
following injury to reduce bruising and swelling. It has been advocated to reduce

Table 5.1 Complementary National Center for Complementary and Alternative Medicine—
and alternative medicine www.nccam.nih.gov
information resources US Food and Drug Administration—www.fda.goc/consummer
Alternative Medicine Foundation—www.herbmed.org
US National Library of Medicine—www.medlineplus.gov/
druginfo/natural
94 S. Goupil and M. T. Goupil

pain and swelling following tooth extraction. It may be a valid alternative to

nonsteroidal anti-inflammatory medications (Iannitti et al. 2016). When taken
orally it should be in diluted homeopathic doses, as arnica, when taken
systemically, can cause cardiac arrhythmias and increase blood pressure (Leonard
2017).
• Black cohosh (Actaea racemosa, Cimicifuga racemosa) is one of the top-selling
herbs for the treatment of menopausal symptoms. The widespread belief has
been that black cohosh acts by way of phytoestrogens. Studies indicate that,
instead, it has neurotransmitter-like activity (Wuttle and Seidlová-Wuttke 2015).
Case reports have raised a concern about hepatotoxicity. The results of a meta-
analysis by Nauser et al. demonstrated that there is no evidence that isopropano-
lic black cohosh has any adverse effect of liver function (Naser et al. 2011).
• Chamomile (Matricaria recutita) has anxiolytic properties (Amsterdam et al.
2009) most likely working at the benzodiazepine receptor sites and is considered
to have both antibacterial and anti-inflammatory action. It is used for a variety of
inflammatory conditions including the mouth and pharynx and has been
advocated for the treatment of oral lichen planus (Jornet and Aznar-Cayuela
2016). It is also used for teething pain. Patients may be encountered that use
chamomile tea as an antioxidant or as part of their diabetic control (Zemestani
et al. 2016). Chamomile contains coumarins and may have anticoagulant effect
(Izzo 2013).
• Echinacea (Echinacea purpurea and related species) also known as the cone-
flower is in the aster family and grows wild in North America and Europe. It is
commonly used to prevent and treat infections including mouth ulcers. It is con-
traindicated in patients with autoimmune diseases and may decrease the effects
of immunosuppressants. Meta-analysis suggests that Echinacea may be associ-
ated with a reduction in common colds but not of shortening its duration (Karsch-
Völk et al. 2015).
• Feverfew (Tanacetum parthenium) has analgesic and anti-inflammatory proper-
ties and is used in the treatment of migraine, arthritis, and rheumatic diseases. A
number of trials have been conducted that indicate feverfew may have a preven-
tive effect on migraines (Ernst and Pittler 2000). It may interfere with coagula-
tion and the effects of nonsteroidal anti-inflammatory agents.
• Garlic (Allium sativum) is a common aromatic herb frequently used in cooking.
Although for medicinal purposes, it should be eaten raw or taken in capsule
form. Garlic is reported to lower cholesterol and blood pressure and has the
potential for cardiac protection (Varshney and Budoff 2016). It interferes with
platelet aggregation and can increase bleeding especially when combined with
other herbals like Ginkgo.
• Ginger (Zingiber officinale) root is primarily used for its antiemetic properties to
treat nausea, vomiting, and loss of appetite. Research has demonstrated that it is
more effective than a placebo for the treatment of postoperative problems
(Chalayakunaprul et al. 2006). It increases the effects of anticoagulants and may
enhance the effects of central nervous system depressants.
5 Complementary and Alternative Medicine 95

• Ginkgo (Ginkgo biloba) is one of the oldest known trees with a fossil record dat-
ing back millions of years. It has been extensively researched for a variety of
conditions most notable for intermittent claudication and dementia where it
appears to have a positive effect (Brondino et al. 2013). Its primary methods of
action are increasing microcirculation blood flow and inhibition of erythrocyte
aggregation. It has an inhibitory effect on platelet-activating factor and may have
an additive effect with aspirin, antiplatelet agents, and other anticoagulants
which may lead to postoperative bleeding issues.
• Ginseng (Panax ginseng or Asian ginseng and Panax quinquefolius or American
ginseng) is used to prevent illness and promote health, in other words a “cure-all”
tonic. According to Bach et al., there is “insufficient clinical evidence to support
the use of ginseng supplements on reducing fatigue and enhancing physical per-
formance” (Bach et al. 2016). Ginseng appears to have neutral effects on the
vascular system but may have favorable effects on the systolic blood pressure of
individuals with diabetes and obesity (Komishan et al. 2016). It has antiplatelet
activity and should not be used in combination with aspirin, nonsteroidal anti-
inflammatory medications, or other blood thinners.
• Goldenseal (Hydrastis canadensis) is a member of the buttercup family. It is
widely used in folk medicine as an antimicrobial and antiseptic (Asmi and
Lakshmi 2013). When used as a mouthwash, it has the potential to inhibit
cariogenic and periodontal pathogen growth. It may have cardiovascular effects
and potentiate the risk of bleeding when taken with other blood thinners (Leonard
2017).
• Green tea (Camellia sinensis) is a common beverage used throughout the world.
It is considered to have antioxidant properties and is used in dentistry because of
its antimicrobial activity. Studies have demonstrated that mouthwash containing
green tea is effective in treating periodontal and cariogenic pathogens (Hirasaawa
et al. 2006; Radafshar et al. 2017). Its vitamin K content may interfere with the
anticoagulation effect of Coumadin.
• Kava (Piper methysticum) is native to the South Pacific and is used as primarily
as an anxiolytic and sedative. It has been banned by many countries because of
its hepatotoxicity. The kavalactones modify binding at the GABA receptors and
this could potentiate the effects of benzodiazepines and barbiturates (Sarris et al.
2012; Rowe and Baker 2009).
• Saw palmetto (Serenoa repens) is a popular herbal remedy primarily used for
urinary problems associated with benign prostatic hyperplasia. According to
Barry et al. in the Journal of the American Medical Association, increasing doses
of saw palmetto were no more effective than placebo (Barry et al. 2011). Wyatt
found similar findings in patients being treated with radiation therapy for prostate
cancer (Wyatt et al. 2016).
• St. John’s wort (Hypericum perforatum) grows throughout the world and is one
of the oldest of the medicinal herbs originally used to ward off evil spirits.
Current research indicates that it is effective in the treatment of mild to moderate
depression (Gupta and Möller 2003; Ng et al. 2017). It most likely acts as a
96 S. Goupil and M. T. Goupil

serotonin reuptake inhibitor and thus may have an additive effect with drugs with
a similar action and may result in serotonin syndrome.
• Valerian (Valeriana officinalis) dates back to Hippocrates and is used for insom-
nia and anxiety. It most likely affects the GABA receptors. Several studies indi-
cate that Valerian is effective both as a sedative/hypnotic and an anxiolytic
(Hadley and Petry 2003). Like Kava, Valerian could potentiate the effects of
benzodiazepines and barbiturates (Lauder 2009).

5.4 Supplements

• Chondroitin is commonly used for joint-related pathologies and is used for the
promotion and maintenance of cartilage. It appears to be useful especially in
patients with osteoarthritis. It has anti-inflammatory properties and reduces
inflammation by the inhibition of TNF-α. Meta-analyses have concluded that
chondroitin sulfate obtained from natural sources is safe (Heller et al. 2006).
Although because of the similarity of its chemical composition to heparin, it has
been speculated that bleeding complications can occur when chondroitin is taken
with other blood thinners (Dahmer and Schiller 2008).
• Glucosamine occurs naturally in cartilage and has become a popular treatment
for arthritis frequently in combination with chondroitin. Most clinical trials have
been for osteoarthrosis of the knee. Its usefulness has not been confirmed, but no
significant drug interactions have been reported (Dahmer and Schiller 2008).
Highlight et al. have reported that glucosamine sulfate is more effective and safer
than the use of ibuprofen in the treatment of temporomandibular joint osteoar-
thritis (Haghighat et al. 2013).
• Melatonin is a naturally occurring neurohormone produced in the pineal gland
and is involved in the regulation of sleep. Meta-analysis has disagreed on the
effectiveness of melatonin as a sleep modifier. These results may have to do with
differences in dosing regimens (Arendt et al. 2008). Because of melatonin’s
sedation properties, it has been studied as a possible premedication for the
management of dental anxiety (Perez-Heredia et al. 2015). According to Permuy
et al., melatonin “may have important implications for dental disorders, such as
periodontal disease, as well as osseointegration of implants, due to its anti-
inflammatory and osteoconductive effects” (Permuy et al. 2017).

A variety of herbals and food supplements can interact and alter the effectiveness
of many medications that many dental patients routinely take or that the dentists,
themselves, may prescribe (see Tables 5.2, 5.3, and 5.4).
5 Complementary and Alternative Medicine 97

Table 5.2 Botanicals and Arnica Horse chestnut

supplements that may Bilberry Kelp
increase bleeding potential Coleus Papaya
Chamomile St. John’s wort
Feverfew Turmeric
Fish oil Watercress
Garlic Willow
Ginger Yarrow
Ginseng
They may have an additive effect when used with warfarin, non-
steroidal anti-inflammatories, and aspirin

Table 5.3 Botanicals that Chamomile Lavender

can potentiate central nervous Hawthorne Marigold
system depressants Henbane Parsley
Feverfew Queen Anne’s lace
Ginger Valerian
Horehound Yarrow
Kava Yerbe mate
They may have an additive effect when used with muscle relax-
ants, narcotic pain relievers, and benzodiazepines

5.5 Adjunctive Therapies

1. Skeletal/muscle manipulations form the basis of both osteopathy and chiro-

practic. They may have a place in the care of the chronic pain population. In the
Cuccia et al. randomized controlled study, the osteopathic manipulative treat-
ment group required less muscle relaxant and nonsteroidal medications than the
conventional therapy group (Cuccia et al. 2010). Osteopathic manipulative treat-
ment has been used for chronic neck pain as well as trigeminal neuralgia and
burning mouth syndrome (Haller et al. 2016; Campbell et al. 2012).
2. Acupuncture is a Traditional Chinese Medicine (TCM) technique and consists
of inserting fine, sharp needles into the skin at specific points to provide preven-
tive or therapeutic therapy. The original concept on how acupuncture works is
that acupuncture allows correction of the body’s energy flow or qi. Acupuncture
does release neurotransmitters like opioid peptides and serotonin, and this may
account for some of its positive effects. According to Aung “acupuncture man-
ages pain, controls anxiety…and is a viable treatment of choice for patients who
are allergic to anesthesia…” (Aung 1998). Research does support that acupunc-
ture may have a role and a positive influence on the signs and symptoms of
temporomandibular joint disorders (Smith et al. 2007; Jung et al. 2011).
98 S. Goupil and M. T. Goupil

Table 5.4 Botanicals that All spice Flaxseed

may alter glucose metabolism Bay leaf Korean ginseng
Burdock Oregano
Cinnamon Teas—green and black
Clove Sage
Dandelion Witch hazel
They may improve the utilization of glucose and the function of
insulin

3. Yoga consists of a variety of gentle stretching poses, breath control, and medita-
tion. It has a history dating back over 5000 years. It has proven to be more effec-
tive than other modes of physical activity in alleviating musculoskeletal pain in
dentists (Koneru and Tanikonda 2015).
4. Biofeedback is the use of instruments to monitor and provide feedback on phys-
iologic response to events thus providing information that would allow the
patient to modify those responses. According to Crider and Glaros’s meta-anal-
ysis, five of six controlled trials found electromyographic biofeedback to be
superior to no treatment or psychological placebo controls (Crider and Glaros
1999). An exploratory study found that a respiratory rate biofeedback device
may be helpful in reducing dental anxiety (Morarend et al. 2011).
5. Massage is one of the oldest forms of treatment and consists of treating the soft
tissue of the entire body using pressure and traction. For the dental practitioner,
this may be an excellent way to combat neck and back pain affecting many
practitioners. This is a method that could be considered in the treatment of the
chronic pain patient. Although it may not provide a lasting effect, it may be
useful in providing immediate pain relief effects (Kong et al. 2013). Massage
therapy had no significant effect on electromyographic activity in selected
masticatory muscles in patients with temporomandibular disorders. When used
in combination with occlusal splint therapy, massage reduces the intensity of the
signs and symptoms of temporomandibular disorders and sleep bruxism (Gomez
et al. 2014).
6. Relaxation therapy consists of a variety of techniques, such as deep breathing,
visualization, progressive muscle relaxation, meditation, and guided imagery,
used to invoke the relaxation response of the autonomic nervous system. It is
frequently used to treat anxiety, stress, and musculoskeletal pain (Atterbury
1984; Kirschneck et al. 2013; Appukuttan 2016).

5.6 Conclusion

The question is not whether a patient is using a CAM practice or taking food supple-
ments, but rather which practices are they using and which supplements are they
taking. The botanicals in particular may have significant negative effects on the care
the dental provider is going to provide. It is imperative that a thorough heath history
5 Complementary and Alternative Medicine 99

is accomplished and specifically inquiring about food supplements. Many of the

CAM techniques available may be used to enhance overall health especially in the
area of chronic pain management.

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Medicolegal and Ethical Considerations
in Oral Surgery by the General Dentist 6
Eric R. Bernstein and Zita Lazzarini

“Watson here will tell you that I never can resist a touch of the
dramatic.”
—The Naval Treaty

Abstract
Medicolegal and ethics issues that face the general dentist in their practice of oral
surgery frequently overlap with those issues faced throughout the practice of
general dentistry. Given that overlap, this chapter discusses medicolegal and
ethical issues in two broad ways: first, those issues that are traditional medicolegal
or ethical issues across practice areas that have special implications regarding
oral surgery in the practice of general dentistry and second, those emerging
issues related to technology and to the regulatory environment that, while in
some less specific to the oral surgery context, are nonetheless apt because of their
changing nature. In the first half of this chapter, we consider those traditional
issues with special implications for oral surgery in the general dentistry practice.
These include informed consent, standard of care, and scope of practice. The
second half of the chapter explores the current regulatory environment, the
medicolegal implications of new technologies, and the interplay between
technology and compliance. This consists of discussions around opioid analgesic
prescribing, HIPAA and HITECH compliance, electronic health records, and

E. R. Bernstein (*)
University of Connecticut School of Dental Medicine, Farmington, CT, USA
e-mail: [email protected]
Z. Lazzarini
Community Medicine and Health Care, University of Connecticut, Farmington, CT, USA
e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2019 103

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_6
104 E. R. Bernstein and Z. Lazzarini

other related privacy and security issues involving software, hardware, and the
emerging Internet of Things.

6.1  pecial Implications of Traditional Medicolegal

S
and Ethical Issues

Three specific medicolegal and ethical issues are worthy of discussion in the context
of oral surgery performed by the general dentist: informed consent, standard of care,
and scope of practice. These three interrelated issues have broad and generalized
application within all of healthcare practice, and the special implications discussed
here are not exclusive to oral surgery procedures. Rather, they are noteworthy in the
oral surgery context because they may have added complexity or may require
additional considerations in those instances; none of the implications discussed here
would hinder or harm the provider across their practice. It is apt to mention that
patient knowledge and expectations have changed in the information age as patients
come to providers with more information, whether from mass media, marketing,
and/or online resources. These new lenses that patients bring to their interactions
with providers impact the medicolegal and ethical landscape of healthcare practice.

6.1.1 Informed Consent

Informed consent is both an ethical and legal construct. With respect to ethics,
“informed consent reflects respect for patient autonomy and, as mentioned above, is
a process that, from a practical perspective, reduces provider liability. In either case,
the essence of informed consent is “a conversation between physician and patient
about a proposed treatment, alternative treatments, nontreatment, and the risks and
benefits of each of these options” (Whitney et al. 2004). Informed consent is also
significantly impacted by the new knowledge and expectations that patients bring to
their relationships with providers in the information age. However, the fundamental
informed consent process, and it is a process—not a form or a signature, is not
altered by patient knowledge or expectations, nor does it vary in premise from one
type of procedure to the next.
Broadly, informed consent involves the communication between patients and
their care providers about treatments, treatment options, and treatment decisions.
The primary goal of the informed consent process is to make sure that patients fully
understand the procedures that will be performed (and/or the care that will be
provided). A full understanding requires understanding the expected benefits and
risks and any alternatives to the proposed procedure that may be available; the
opportunity to discuss their treatment choice, to ask questions, and to reflect on the
decision; and, finally, to provide a clear indication of their ultimate decision free
from coercion or pressure (Mukherjee et al. 2017). All of these elements, together,
indicate informed consent.
6 Medicolegal and Ethical Considerations in Oral Surgery by the General Dentist 105

Despite its critical importance in providing high-quality, safe healthcare that is

patient-centered, the informed consent process in practice is very often insufficient.
This is a high-risk inadequacy on many levels, as failure to obtain adequate informed
consent is not only an ethical conflict because it compromises patient autonomy but
it places patient safety at risk and could constitute negligence or even battery from
a legal perspective.

6.1.1.1 Fundamental Elements of Informed Consent

Informed consent should include five basic elements: decisional capacity, informa-
tion, understanding, voluntarism, and a final decision by the patient (Mukherjee
et al. 2017).
Decisional Capacity: Patients must be able to participate in all aspects of the
informed consent process in a complete and meaningful way. This includes both the
legal maturity and cognitive ability necessary to understand the information the
dentist provides and to make a reasonable and independent decision based on the
way that information interacts with their own values and beliefs. Put simply, a
patient must be able to understand, deliberate, and communicate about the issues
related to the proposed treatment.
Information: The knowledge a patient needs in order to make an informed
decision about the management of their dental problems includes information
about the nature of the problems and the proposed treatment by the dentist. The
nature of the proposed treatment should include both the benefits of the treat-
ment and the risks associated with it. In addition, patients must have informa-
tion related to the risks and benefits of alternative treatments, if available, and
of nontreatment. One way to ensure that all appropriate information is discussed
is the acronym BARN: B—benefits, A—alternatives, R—risks, and N—no
treatment.
As mentioned earlier, in the information age, patients will often have conducted
their own research prior to a final decision. That research can be both an advantage
in helping the patient understand their problem and the treatment options and a
challenge for the provider who may need to help a patient make sense of incomplete
or inaccurate information that they have found in their own search. In either case,
the patient should be heard with respect to their own research and the dentist should
take seriously their response to that information.
Understanding: Merely having information is not sufficient for informed con-
sent. Patients must comprehend the information for consent to be valid. Active con-
versation between the dentist and patient is needed to ensure and assess
understanding. This includes clarifying issues for the patient, answering their
questions, and verifying, through the conversation, that they have an understanding
of the information provided and discussed.
Voluntarism: Ensuring voluntariness protects the participant’s right to make his
or her own decisions. A consent decision should not be coerced or manipulated
either by the dentist or by family members. Nevertheless, if the dentist thinks that
the course chosen by the patient will do more harm than good to the patient, the
dentist should communicate his or her concerns and reasons in an attempt to
106 E. R. Bernstein and Z. Lazzarini

persuade the patient to reconsider. If the dentist knowingly fails to do so, it is a

violation of the ethical principle of beneficence.
Final Decision: To complete the act of giving consent, it is essential that the
patient make a final decision. While the final decision does not necessarily need to
be communicated in writing, it should always be documented in writing by the
dentist. With increased risks and complexities, comes an increased advantage to
capturing the final decision in writing that is signed by the patient.

6.1.1.2 Additional Aspects of Informed Consent

The fundamental elements of informed consent have nuanced aspects when the pro-
cess is put into practice and in the application to dental medicine in particular.
Treatment Planning: Dental medicine often carves out two additional elements
from the five basic elements of the informed consent process related to treatment
planning. With respect to “information,” dentists should ensure that the proposed
treatment plan is clear to the patient. Regarding the “final decision,” the patient must
then authorize the treatment plan.
Waiver of Informed Consent: Patients have both the right to be informed prior
to consenting to treatment and the right to refuse treatment, with limited exceptions.
Two circumstances may arise that place the dentist in a difficult situation with
respect to those patient rights.
Rights are inherently waivable—think, for example, of the right to free speech
which does not require speech but protects the right to it. Individuals may, then,
choose not to exercise a right. If a patient says “I don’t need any more information
and I don’t care what the risks are, Doc…I am going to do whatever you suggest,”
it places the dentist in a tricky position. While it has been long held that patients
may decline the information while retaining the right to decide to undergo treatment
(Meisel 1979), it should be carefully documented when a patient does so and it is
prudent to inform the patient that they have the right to know the risks, benefits, and
alternatives before making a decision.
“Informed Refusal”: The other challenge to informed consent arises when a
patient decides to refuse treatment while declining to be informed. A theory of
“informed refusal” has been articulated in some instances, which would require
patients to have the same information required to consent to treatment before
declining. However, similarly to declining information and giving consent, one can
decline information and decline treatment—for example, “No matter what you say,
Doc, I will not have surgery.” In such instances, it is still important for the waiver
and the refusal to be documented and prudent for the dentist to clearly inform the
patient that they have a right to the information before deciding against treatment
(Ridley 2001).
It is also worth noting that informed consent, as a process that may span multiple
visits, may involve multiple conversations over an extended period of time. This is
particularly true as the circumstances and/or treatment options change. Take the
extraction of a third molar as an example. A patient may indicate that they will not
6 Medicolegal and Ethical Considerations in Oral Surgery by the General Dentist 107

consent to the prophylactic removal of the third molar or molars and decline to hear
the benefits of such removal. Over time and at subsequent visits, the dentist may
revisit the discussion and the patient may decide to hear more information. If the
condition of the patient changes over time—such as the emergence of evidence of
disease in the third molars—the revisited conversation now becomes obligatory, not
optional (Gray et al. 2017). In either case, the continued conversations and the
patient’s responses should be documented appropriately.

6.1.1.3 Informed Consent and Oral Surgical Procedures

While informed consent always has the same underlying framework and elements,
certain aspects of informed consent merit additional discussion in the context of oral
surgery procedures, especially when performed by the general dentist.
First, oral surgery procedures likely have some inherent increased risks and com-
plexities that may impact certain aspects of the consent process. Decisional capacity
and voluntarism are particularly impacted by the nature of the procedure being pro-
posed. A patient with decreased cognitive ability (e.g., a mildly intellectually dis-
abled patient) may be able to understand and have decisional capacity with respect
to tooth cleaning and polishing, but may not have the decisional capacity to provide
informed consent to the extraction of multiple teeth. Similarly, issues may arise
when the stressors around higher risk procedures create an undue pressure that can
undermine the voluntariness of a patient’s consent (Roberts 2002).
When engaging in the consent process for more complex or anxiety-inducing
procedures—like oral surgical procedures—the dentist must take additional time to
ensure that patients are not under duress in making their decision and that they
maintain the capacity to decide, despite the complexity of the procedure. In addition,
the amount of information necessary for a less routine procedure increases with the
complexity. Thus, the information that must be provided for a restorative procedure
may be more than needed to gain valid consent for prophylactic care but less than
necessary for a surgical extraction or implant.
Coupled with the increased risks of the procedures are increased potential for
malpractice claims resulting from adverse procedural outcomes and complications.
While informed consent is and should always be equally important from an ethical
perspective, when the risk of legal liability increases, the legal importance of
appropriate and documented informed consent increases, as well.
General dentists benefit from their ongoing relationships with patients when
helping a patient navigate the decision-making process, values, and care preferences.
In the context of performing a surgical procedure, however, where the risks or
complexity are increased, care must be taken not to gloss over or rush through the
informed consent process, relying on the inferred consent from the ongoing
relationship. The historical treatment patterns, especially with respect to lower risk
and less complex treatments, may help the general dentist interpret the patient’s
questions or reactions but should not impact the nature and extent of the informed
consent process for the more complicated surgical procedure on the whole.
108 E. R. Bernstein and Z. Lazzarini

6.1.2 Standard of Care and Scope of Practice

Standard of care and scope of practice are inextricably linked, especially at the
intersection of the generalist and the specialist. Whether the standard of care,
defined as the “duty of a [dentist] to use the care and skill ordinarily used by
reputable members of the profession practicing under similar circumstances” (Dym
2012), can be met by the generalist in performing a procedure is one of the primary
considerations in determining the appropriate scope of practice for the generalist.
Along with informed consent, discussed earlier, standard of care and scope of
practice form an interrelated triad of which at least one component provides the
basis of the vast majority of malpractice claims.

6.1.2.1 Standard of Care

Perhaps the most significant legal consideration with respect to standard of care
when the general dentist practices oral surgery is the consistency with the standard
of care for the same procedure performed by the oral surgeon. The standard of care
is not simply “doing it the way [you] were taught in dental school, doing it the best
[you] can, or doing it the way everyone else is doing it” (Graskemper 2004). The
standard of care is also not static. It evolves with new materials, procedures, and
legal decisions.
The phrase “reputable members of the profession” that forms the basis of the
definition of the standard of care refers to the profession of dental medicine (or even
of medicine beyond oral medicine, in some cases related to surgical procedures).
That is to say, regardless of whether a procedure is performed by a specialist or a
general dentist, the standard of care does not change. Additionally, “reputable
members” does not merely mean “everybody else,” but rather those professionals
who have the most current training and experience, including the understanding and
consideration of new materials and treatment modalities available for the instant
condition.
It is notable that studies have found higher incidence of postoperative complica-
tions in certain procedures where the operator is a general dentist compared with
oral surgeons. Moreover, in either the case of the general dentist or the oral sur-
geons, the extent of experience of the operator was inversely correlated to the inci-
dence of complications—greater experience resulted in fewer incidents (Bui et al.
2003; Sisk et al. 1986).

6.1.2.2 Scope of Practice

Scope of practice can be broken into two distinct aspects: professional scope of
practice and legal scope of practice. Professional scope of practice is often referred
to as professional competence and in healthcare it is rooted in the way the specific
healthcare profession itself defines the type and extent of care that members of that
profession are trained to provide. Legal scope of practice emerges from the statutory
and regulatory definitions and limitations of the care that may legally be provided
by licensed practitioners. The dental practice acts of each state are the basis for the
legal scope of practice in each state. Legal scope of practice and professional
6 Medicolegal and Ethical Considerations in Oral Surgery by the General Dentist 109

competence have significant overlap; however, the legal limitations in the practice
acts vary from state to state, and while, for example, dental hygiene programs may
instruct hygienists in anesthesia administration, the dental practice acts of many
states do not include anesthesia within the scope of the practice of hygienists (Dower
et al. 2013).
The professional scope of practice of dentistry has been defined by the American
Dental Association as “the evaluation, diagnosis, prevention and/or treatment
(nonsurgical, surgical or related procedures) of diseases, disorders and/or conditions
of the oral cavity, maxillofacial area and/or the adjacent and associated structures
and their impact on the human body; provided by a dentist, within the scope of his/
her education, training and experience” (Passi and Bhalla 2012). This broad
definition leaves a great deal of space for the general dentist, with the requisite
education, training, and experience, to engage in a broad dental practice that includes
surgical procedures. Clearly, though, the primary limitation is the sufficiency of the
individual dentist’s education, training, and experience to perform particular
procedures.
Most states do not limit the scope of practice of dental medicine significantly
from the definition of professional competency. This makes it incumbent upon the
general dentist to appropriately limit the scope of their own practice. The most
important consideration is the need for the general dentist to ensure competency in
the procedures that are performed in their practice. Therefore, when considering
surgery in the general dental office, case selection is of vital importance, continuous
professional learning and development with respect to the procedures to be
performed is required, and considerations of practical experiences necessary when
deciding whether to perform a surgical procedure (Lam 2014). The general dentist
performing surgical procedures must be keenly aware of when they have reached
the bounds of their skills, training, and abilities and make sure that they refer cases
out that exceed those limitations.
Emergence of Mid-level Providers: In recent years, there has been a marked
increase in the authorization of mid-level providers in dental medicine practice.
Indeed, exploring the expansion of these types of providers in dentistry has support
from many deans of US dental schools, and the existence of these providers in other
countries has become more widely accepted and valued (Aksu et al. 2013; Koppelman
2017). Whether called advanced dental hygiene practitioners (ADHP), advanced den-
tal therapists (ADT), or other titles created in enabling legislation, like mid-level pro-
viders in medicine (advanced practice registered nurses, physician assistants, etc.),
mid-level providers have the potential to impact the way dentistry is practiced.
Though the primary aim of the movement for mid-level dental practitioners is to
expand access to dental care, particularly in high-need areas, the eventual inclusion
of those providers in traditional dental practices may be likely. This is a relevant
consideration in the context of the scope of practice of the general dentist as the
inclusion of mid-level providers within a general dental practice may provide
opportunities for the general dentist to focus on more complicated restorative
procedures or oral surgical procedures including extractions or implants (Evans
et al. 2007).
110 E. R. Bernstein and Z. Lazzarini

This is both an opportunity for the general dentist’s scope of practice and a risk.
The elements of competency do not change merely because there are now providers
who address the lower risk and less complex patients. Dentists should be careful not
to assume that the addition of a mid-level provider to their practice necessarily
makes them competent to expand their own scope of practice. That said, there is
increased potential for the dentist to gain more experience and increase participation
in continuing professional development opportunities regarding the performance of
more complex procedures and surgeries if they have additional time available where
revenue continues to be generated by the mid-level practitioner. Such additional
experience and training may facilitate the expanded scope of practice at a competent
level by the general dentist.

6.1.2.3 Risk Management

Ensuring a complete informed consent process, practicing at the standard of care,
and engaging in the appropriate scope of practice are all essential to an ethical
practice of dental medicine and to ensure the highest level of patient care. On an
additional practical note, these three concepts are also crucial components of a
liability risk reduction strategy.
In some respects that have been discussed, especially regarding standard of care
and scope of practice, general dentists may face slightly elevated liability risks when
they perform surgical procedures. However, one area where the general dentist often
has a distinct advantage is in the doctor-patient relationship. Patients often see an oral
surgeon only for the consultation, the procedure, and the follow-up, and the nature of
the practice provides little time for relationship and rapport building (Holmes and
Udey 2008). The general dentist tends to have a more comprehensive, longer-term
relationship with patients than the oral surgeon, and that relationship may, in itself,
serve as a mitigating factor in a patient decision to pursue legal action in the face of an
adverse outcome. In addition, the persistent relationships that general dentists typi-
cally have with patients give them a “prior understanding of a patient’s values and
preferences” (Moskop 2006) that supports key aspects of the consent process.
Relying on the existing doctor-patient relationship alone to mitigate the risk of
liability or to serve as a primary basis for consent is not sufficient. Moreover, to
maintain the best doctor-patient relationships and to ensure an overall ethical
practice, the general dentist should engage in a comprehensive, procedure-specific
informed consent process, adhere to the appropriate standards of care, and ensure
the scope of their practice remains consistent with their training, skills, experience
level, and abilities.

6.2  he Regulatory Environment, Compliance,

T
and Technology

On the other side of the medicolegal page, dentists must be aware of the regula-
tory environment that is designed to protect the privacy and safety of patients.
There are practice-based compliance issues that arise in that context and there are
6 Medicolegal and Ethical Considerations in Oral Surgery by the General Dentist 111

also unexpected considerations that emerge from the use of new technologies in
the dental practice. Some elements of the regulatory environment relate directly
to patient care and safety, such as those involving opioid analgesic prescribing
while others involve compliance with standards to protect the privacy of patient
information. The regulatory environment is constantly reacting, albeit often
slowly, to research, public health issues, and the advent of new treatments and
technologies.
Bridging the span between ethical practice issues and the regulatory environment
is the prescription of opioid analgesics by dentists. This is of particular interest in
this chapter because the highest rates and greatest increases in rates over time of
prescribing opioids in dental practice have been following surgical, root canal, and
implant procedures (Steinmetz et al. 2017).
The requirements of the HIPAA and the HITECH Act, as well as specific regula-
tory rules associated with their enactment, create a compliance structure that impacts
all healthcare providers and agencies. The provisions of the HITECH Act are inte-
grated into the HIPAA compliance framework. That integration, along with a flow
of almost constant technological advances, poses new challenges related to patient
privacy and adherence to legal mandates. Some of the technological advances have
specific implications with respect to the expansion of oral surgery in the general
dentistry practice and some of the advances apply broadly to all dental practice
areas.

6.2.1 Opioid Analgesic Prescribing

Dental providers have developed prescribing practices and beliefs around the man-
agement of acute dental pain that have unintentionally contributed to the prescrip-
tion opioid epidemic. This necessitates a reexamination of those reflexive treatment
habits and consideration of the evidence from a fresh perspective regarding dental
pain management. Specifically, approaches should be adjusted where alternative
pain management options exist that may be as or more effective than opioid analge-
sics, with less potential for misuse. From an ethical perspective, this ensures that
dental providers “do no harm in the doctor-patient interaction and at the societal
level” (Dionne et al. 2016).
This ethical imperative related to opioid analgesics intersects with the regulatory
environment as government agencies at the state and federal levels have attempted
to combat the opioid epidemic, as well. Two key statutory and regulatory issues
have emerged from those attempts: changes to prescribing processes and dispensing
limits as well as increased training for prescribers and consolidated tracking of
patient opioid prescriptions.
In 2010, the Drug Enforcement Administration issued an interim final rule that
revised existing regulations to “provide practitioners with the option of writing
prescriptions for controlled substances electronically. The regulations will also
permit pharmacies to receive, dispense, and archive these electronic prescriptions”
(Drug Enforcement Administration 2010).
112 E. R. Bernstein and Z. Lazzarini

Along with improving care for patients, electronic prescriptions of controlled

substances (EPCS) have proven to be effective tools for initiative by public health
and law enforcement agencies to address diversion and misuse of opioid analgesics
(Gabriel et al. 2016). As a result, many states have made the significant switch to not
only permit but require electronic prescribing of controlled substances or opioid
analgesics specifically (see Table 6.1 for state policy as of 2017 regarding EPCS).
Furthermore, as of 2017, at least 17 states had enacted laws limiting the duration
and/or dosage of opioid prescriptions. Some states have limited initial prescriptions
to as few as 3 to 5 days. Federal legislation has also been proposed that similarly
limits initial prescriptions of opioids for acute pain management. These limits are
evolving and the requirements vary from state to state, creating particular challenges
to those providers with patient populations from multiple states.
Electronic prescribing and dosage limits have fed another correlated regulatory
response to the opioid epidemic. As of 2016, every state except for Missouri had
established prescription monitoring programs (PMPs). Many of these programs
have been created with federal grant funding, but PMPs vary by state in the
requirements placed on providers. They may range from simply registering with the
PMP to mandated training for providers and/or their staff to requiring access to the
PMP database when prescribing controlled substances (Deyo et al. 2017). The

Table 6.1 States with existing or pending electronic prescribing requirements (EPCS 2017)
State Policy Effective date
Connecticut All controlled substances must be January 1, 2018
prescribed electronically
Illinois All medication to be electronically January 1, 2022
prescribed
Maine All controlled substances must be July 1, 2017
prescribed electronically
Massachusetts All controlled substances must be a

prescribed electronically
Minnesota All controlled substances must be January 1, 2011
prescribed electronically
New Jersey All medication to be electronically a

prescribed
New York All medication to be electronically March 27, 2016
prescribed
North Carolina All controlled substances must be July 1, 2018
prescribed electronically
Oklahoma Bill consideration, not yet proposed or b

passed
Pennsylvania All controlled substances must be a

prescribed electronically
Rhode Island All controlled substances must be January 1, 2020
prescribed electronically
Virginia All controlled substances must be July 1, 2020
prescribed electronically
a
E-prescribing legislation has been drafted and proposed in these states but has not yet passed.
Effective dates are anticipated to be 1 or 2 years after passage
b
E-prescribing legislation has been under consideration but has not yet been drafted or proposed
6 Medicolegal and Ethical Considerations in Oral Surgery by the General Dentist 113

National Alliance for Model State Drug Laws (http://www.namsdl.org) has compiled
information regarding each state’s laws and has, historically, linked to specific state
statutes and regulations.
Although the evidence is mixed regarding the efficacy of these approaches to the
opioid epidemic (Finley et al. 2017), they nonetheless place an onus on providers to
be aware of and be compliant with the statutes and regulations of their locales.
Given the increased potential for consideration of opioid analgesic prescriptions by
general dentists performing oral surgery procedures, it is essential for those
providers to remain familiar with the latest statutory and regulatory factors
associated with opioids analgesic prescribing.

6.2.2 HIPAA Compliance and Technology

Technology poses several broad (and generally relevant) areas of concern for patient
privacy and HIPAA compliance. Public concerns about the disclosure of confidential
health information contributed to the structuring of the Health Insurance Portability
and Accountability Act (HIPAA) of 1996. Although the original intent of HIPAA
was to ensure that employees could continue to receive health insurance if they left
or changed jobs, the Act became a vehicle for Congress to address a variety of other
healthcare matters ranging from healthcare fraud and abuse to the growing public
concern over the confidentiality and security of their health information.
The HIPAA Privacy Rule and the security regulations under HIPAA protect indi-
vidually identifiable health data, known as “protected health information” (PHI) in
any form, written or electronic. All “covered entities” are subject to these provi-
sions. Covered entities include all health plans, healthcare clearinghouses, and
healthcare providers who transmit any health information in electronic form in
connection with any healthcare transaction. Dentists and dental practices, as covered
entities, must protect the confidentiality, integrity, and availability of the PHI that
they create, store, maintain, or transmit. With respect to HIPAA compliance,
confidentiality means ensuring the privacy of the information, integrity means
ensuring the information is not altered or destroyed improperly, and availability
means that the information is accessible to and usable by authorized individuals.
Integrity, confidentiality, and availability, as required under HIPAA must be
addressed from all of three different perspective: administrative, physical, and
technical. Policies must be in place administratively to ensure that PHI is accurately
maintained and accessible only to the proper individuals. Physical measures must
be practices to prevent the physical theft or loss of devices that contain PHI and
other sensitive data. Technical processes must be utilized to protect devices and
networks from unauthorized access and breaches (Rinehart-Thompson and
Reynolds 2012; Brown 2005; Davis and Having 2006; McGowan et al. 2012).
Nearly every function of a dental practice is impacted and covered by these
requirements: policies, recordkeeping, technology, and building safety. Under
HIPAA, the protection of patient data is a pervasive and comprehensive organizational
responsibility.
114 E. R. Bernstein and Z. Lazzarini

In addition to the protection of the confidentiality, integrity, and availability of

PHI, compliance with HIPAA privacy and security rules requires:

1. Practices to maintain a Notice of Privacy Practices, which is a confidentiality

statement posted in a prominent place in their office and, if applicable, on the
website of the practice
2. Patients to consent to the release of their health information, as necessary, to
conduct the business of the practice
3. Staff to be trained and periodically updated about confidentiality rules and
regulations

HIPAA has been effective in raising awareness and sensitivity to patient privacy
concerns. Virtually all healthcare organizations and providers have faced the initial
compliance responsibilities under HIPAA (Brown 2005; Davis and Having 2006).
The challenge that is most pressing now is related to the pervasive use of technology
and the constant emergence of new technologies in healthcare practices and the
expanding and less “obvious” business associates who interact with covered entities.
Business Associates: Covered entities, like dental practices, have many interac-
tions with other entities, organizations, and/or individuals who they share PHI with
for nonclinical functions, like billing and claims processing or information technol-
ogy services—which we will discuss further. Whether or not these other entities are
themselves required to be HIPAA-compliant for their own core business function,
as business associates of the dental practice (or other covered entity), they must
agree to be compliant with HIPAA on behalf of that practice. In order to comply
with these provisions of HIPAA, a practice must enter into a direct “business associ-
ate agreement” (BAA) with each entity that creates, receives, maintains, or trans-
mits PHI on their behalf. This means that it is not enough that the entity states or
guarantees that they are “HIPAA-compliant.” The US Department of Health and
Human Services provides detailed guidance on the requirements (Services USDoHH
2017) of and for the direct BAAs that practices must have with those entities.
The HITECH Act: Since HIPAA passed into law in 1996, the United States and
the world have seen year-over-year exponential growth in Internet usage and the
explosion of the information age. For perspective, according to the US Census,
fewer than 18% of US households had Internet access when HIPAA was passed,
compared with more than 85% by 2015, and “Google.com” was not even registered
as a domain until 1997 (Newburger 2001). As a result, HIPAA did not originally
contemplate the emerging health information technology (HIT) opportunities and
risks.
The Health Information Technology for Economic and Clinical Health Act of
2009 (HITECH) was a sweeping “commitment to digitizing the U.S. health [care]
system” (Blumenthal 2011). The two underlying motivations for passing the
HITECH Act were the potential that HIT could improve health and healthcare
outcomes and that major systemic inhibitors would likely have impacted the spread
of HIT in ways that only government remedies could overcome. Two of the most
significant barriers were the economics of digitization and concerns over security
6 Medicolegal and Ethical Considerations in Oral Surgery by the General Dentist 115

and privacy. HITECH set aside billions of dollars to support movement toward the
universal adoption and “meaningful use” of electronic health records (EHRs) and
other HIT across the healthcare sector and amended HIPAA to address the
management of privacy and security in the digitization of PHI, including increased
penalties for violations.
Whether outsourced or internal, HIPAA and the HITECH Act provisions require
providers to formally designate a security officer who is responsible for managing
systems users and technologies. The security officer also identifies security
weaknesses and threats and makes risk assessments related to those threats,
ultimately addressing any security concerns of the organization (Office of the
National Coordinator for Health Information Technology 2015a).
Audit Trails: The HITECH Act added a requirement to HIPAA for audit trails of
electronic information. Regardless of the type of security measures used to protect
electronic PHI and other sensitive data, a comprehensive audit trail system must
also be in place. Audit trails are defined as “record[s] that show[s] who has accessed
a computer system, when it was accessed, and what operations were performed”
(Rinehart-Thompson and Reynolds 2012). These trails allow systems activity to be
reviewed in the course of a security audit and, in particular, “precisely monitor who
had access to patient information,” what information was viewed, for how long, and
from what computer, among other details.
Cyberattack Threats: Audit trails are a powerful way to detect and respond to
the threat of cyberattacks. HIPAA and the integrated HITECH security requirements
require covered entities to secure PHI from such threats. Internal or external users
can hack, manipulate, or destroy data—including PHI—so all users of technology
in a practice must be included in security measures and provided with ongoing
educational programs regarding appropriate use and threats. Hacking can best be
defended through security measures like firewalls, intrusion detection software, and
antivirus software. These measures may protect data integrity and digital threats
coming into the system. However, phishing and other schemes are another way that
malicious users can attack systems.
Phishing is a “form of fraud in which an attacker masquerades as a reputable
entity or person in email or other communication channels… to distribute malicious
links or attachments that can perform a variety of functions, including the extraction
of log-in credentials or account information from victims” (Rouse 2017). While
phishing can move into more technical methods of extracting security-breaching
information from victims, they are frequently more direct acts of trickery that cause
victims to simply provide the credentials necessary for the attacker to access the
secure system.
The best defense against phishing and similar schemes is the education of all
employees and secure system users. Users should be educated about how to
identify suspicious contacts and never to share their credentials to secure sys-
tems with any other user or entity, even if it looks legitimate. If voice calls are
received and requests are made for log-in information and/or other usernames or
passwords from “technical support” or other official seeming “vendors” or indi-
viduals, such information should never be provided. Rather, the contact
116 E. R. Bernstein and Z. Lazzarini

information of the caller should be taken and provided to the practice’s HIPAA
security officer. That individual can then follow up directly with the purported
vendor to determine if there is a valid request for system access for an approved
reason.
Similarly, links in emails from outside entities or that may even seem to come
from internal individuals or requests in such emails should not be responded to.
Rather, such requests or suspicious links should be forwarded to the security officer
for assessment. Staff should be warned that emails may seem to come from an
internal person and may even appear to have internal (or official-looking external—
e.g., FBI, IRS, or HHS) logos and email addresses but should still not be responded
to.
Smaller, low-profile healthcare providers may believe that they are safe from the
threat because cyberattackers will generally target only the largest organizations.
However, every day, there are cyberattacks in the forms of hacking and phishing that
specifically target small- and mid-sized organizations. Smaller organizations have
been targeted—and successfully attacked—for the very reason that they are less
likely to be fully or effectively protecting themselves (Office of the National
Coordinator for Health Information Technology 2015b).

6.2.2.1 Electronic Health Records

According to the American Dental Association, most dental practices are not obli-
gated, by law, to adopt an EHR. A small number of states have added dentists to
their EHR mandates (beginning with Minnesota in 2015), and while HITECH
mandated the adoption of EHR by virtually all medical practices, only those dentists
who are Medicare-eligible are compelled by the federal law to shift to EHRs.
Voluntary adoption, however, can improve quality and patient safety by building in
protocols and reminders as well as enhancing the quality of documentation and the
accuracy of recordkeeping; reducing paperwork and paper storage issues; improving
office efficiency with respect to scheduling, billing, and reimbursement; and
addressing the e-prescribing options and/or requirements discussed earlier (Foisey
2016).
Voluntary adoption of an EHR by a dental practice would still trigger the privacy,
security, and compliance requirements associated with the implementation of an
EHR by those providers otherwise mandated under HITECH (Fernández-Alemán
et al. 2013). These compliance matters are not significantly different from the
protection and securing of any forms of electronic PHI, including, for example,
stand-alone billing systems. The voluntary adoption of an EHR by dentists also has
patient information security advantages.
One benefit to the adoption of an EHR is the inclusion of secure online patient
communication options. The current environment of online accessibility for
consumers broadly has led patients to develop expectations of online communications
with healthcare providers. As explained in the next section of this chapter, email and
text are not generally secure mechanisms to communicate with patients, particularly
when communicating about PHI. The communication modules of EHR systems
offer a secure alternative.
6 Medicolegal and Ethical Considerations in Oral Surgery by the General Dentist 117

The “carrot” contained in the HITECH Act to promote adoption of the EHR is a
financial incentive related to Medicare reimbursements. In order to qualify, providers
must not only adopt an EHR but also demonstrate “meaningful use” of the
EHR. Essentially, meaningful use means that the EHR is used to improve the
delivery of care. The most consequential opportunity for meaningful use is the
inclusion of clinical decision support systems (CDSS). CDSSs can provide general
references regarding a condition or, potentially, specific suggestions that take into
account a patient’s individual clinical data. This includes the integration of evi-
dence-based decisional factors (Menachemi and Collum 2011; Berner 2009).
Such a system, integrated with the EHR, has the potential to ensure that the
appropriate standard of care is met, as discussed earlier in this chapter. Moreover,
individualized information that connects a specific patient’s clinical data to the
research-based treatment guidelines that is readily available within the CDSS that is
integrated into the EHR can also support the informed consent process and the
adequacy and accuracy of treatment information provided to the patient.

6.2.2.2 E  lectronic and Mobile Communication, the “Cloud,”

and Compliance
The ubiquity and relative convenience of electronic communication has led to an
increasing number of patients to expect to be able to communicate with their
providers using electronic communication methods. Deciding what and how to
securely and competently integrate electronic communications into the doctor-
patient relationship is a more complicated decision than it may seem on its face.
Furthermore, both electronic communication and mass data storage now take place,
at least in part, in an increasingly virtual space—where physical servers are not
located on-site for organizations. More and more data and applications are hosted in
the “Cloud” which raises privacy, security, and compliance issues in its own way.
Indeed, many EHRs utilize Cloud-based applications and data storage. This
increased reliance on virtual environments has challenges but also affords the
potential for enhanced data integrity and comprehensive, failure-resistant data
backup solutions.
Email: In any discussion about communication with patients and patient privacy,
it is essential to clarify that the obligations are not bilateral. Rather, providers and
their associates are required to ensure privacy and confidentiality in their
communications with patients, but patients may communicate however they wish
and through whatever channels they wish. It is never a HIPAA violation when a
patient communicates with a provider about her or his own care—regardless of
whether it is in the grocery store, on Facebook, or through telephone, email, or text
message. It is the providers’ initiation of communication and responses to patients
that must comply with ethical and regulatory standards and the handling of any
information received from the patient that is also protected—once it has been
received by the provider.
The HIPAA Security Rule requires that when a provider sends PHI to a patient,
it is sent through a secure method. The provider must have a reasonable belief that
it will be delivered to the intended recipient. With increasing demands for online
118 E. R. Bernstein and Z. Lazzarini

access and near real-time communications from patients, providers must be careful
to use communications mechanisms that allow for the appropriate security rule
safeguards. This can include things like an email system that encrypts messages or
requires patient log-in, such as the patient portal integrated into an EHR.
In order to comply with HIPAA regarding email communication with patients,
three elements must be in place. First, there must be strong security. This includes
secure email sending that is encrypted when PHI is included, the automatic scanning
of outbound emails for sensitive data, and appropriate email use policies. Second,
the HIPAA Omnibus Final Rule released March 18, 2013, requires that patients
consent to communications via email after being provided with information about
the risks related to sending PHI through email prior. Finally, there must be a business
associate agreement with any third-party email provider (e.g., Gmail, Microsoft,
Yahoo, or any Internet hosting company used) (Menachemi et al. 2011; Murray
et al. 2011). To be clear, this means that a provider may not simply start using a
Gmail email address to communicate with patients via email. While Gmail offers
secure email options that meet HIPAA standards, and even after patient consent, a
BAA is still required to be specifically signed by Google for your own practice prior
to using a Gmail account for patient communication.
Text Messaging: Similar to email communication consideration is text messag-
ing. Texting and emailing, because of the expanded use of multifunctional mobile
devices, are extremely commonplace. Text messaging, like all communication tech-
nologies, needs to be managed appropriately with assurances of both security and
privacy of the information transmitted and stored.
One of the considerations with respect to text messages is that they may reside
on mobile devices indefinitely and, due to theft, loss, or device exchange, the
information can be exposed to unauthorized third parties at various points in the
lifecycle of a device. Depending on the security measures set up on the mobile
device, the text messages may be accessible without any level of authentication.
This means that, for example, if a secure passcode is not set up, anyone who has
access to the device may have access to all of the text messages that are on the
device at that time.
Another complication of text messaging is the HIPAA privacy rule provision that
gives individuals the right to access and amend PHI about themselves that is
maintained in a “designated record set.” The designated record set includes PHI
“used, in whole or in part, by or for the covered entity to make decisions about
individuals” (HIPAA 2018). This means that if a dental assistant in the office sends
the dentist a text message that Ms. Smith is still experiencing pain the day after a
procedure and asking whether to refill Ms. Smith’s prescription, for example, that
text message may be subject to the right of access and amendment. If the practice
cannot later provide Ms. Smith with access to the text message, there is a risk of
noncompliance with the privacy rule.
Security controls that may mitigate the risks of noncompliance associated with
texting include administrative policies prohibiting texting of PHI or placing limits
on the type of information that may be shared via text message (e.g., information
identifying a patient), training on appropriate and approved use of work-related
6 Medicolegal and Ethical Considerations in Oral Surgery by the General Dentist 119

texting, employing mobile device security measures (as described later in this
section), implementing policies that require annotation of the patient record with
any PHI that is received via text and used to make a decision about a patient, or
using alternative technology, such as a vendor-supplied secure messaging
applications.
One interesting and important difference between text messaging and email or
other online methods of communication is the way that the US Department of
Health and Human Services has classified telecommunications providers, because
telecommunications providers are “entities acting only as conduits of ePHI and that
do not access the information other than on a random or infrequent basis as necessary
for the performance of the transportation service do not qualify as business
associates” and, thus, do not require a business associate agreement with the covered
entity to be HIPAA-compliant (Greene 2012; Office for Civil Rights 2006).
While both text messaging and email may be convenient forms of communica-
tion with or regarding patients, it is imperative to avoid online or electronic com-
munication unless the communication method meets, or is exempt from, the HIPAA
Security Rule.
Mobile Devices: With the increased power and presence of mobile devices for
computing purposes, including and beyond the messaging and email use discussed
earlier, providers’ and other staff have an increasing likelihood of accessing,
maintaining, transmitting, or receiving PHI on business-issued or personal mobile
devices. Precautions must be taken to secure those devices, which are easily lost or
stolen, leaving the potential for exposures of PHI and breaches of patient privacy
requirements. The Centers for Medicare and Medicaid Services have provided a list
of 11 steps that can be taken to secure health information on mobile devices (see
Fig. 6.1).
The “Cloud”: In its earliest iterations, email servers and other networking serv-
ers were local to organizations. That is to say, the hardware and storage devices
were physically located and under the control of the organization itself. However,
for many reasons, electronic communications, data storage, and even many software
applications now reside on virtual storage solutions that have come to be known,
collectively, as the “Cloud.” Cloud-based storage solutions include tools like
Dropbox and Google Drive, and Cloud-based applications can range from standard
office software like the Microsoft Office 365 suite or Google Apps to billing
software up to a Cloud-based EHR.
All of the same security and privacy requirements apply to Cloud-based tools as
have been discussed with respect to other local technology and resources. It is
critical to note that any Cloud-based service provider used by a dental practice that
has a product or tool that will have secure information or PHI within that resource
must have a business associate agreement with between the practice and the Cloud-
based service provider.
When using Cloud-based tools to support patient care in any way, dental prac-
tices must guarantee the security of patient data on the Cloud. This including ensur-
ing that the Cloud platform has the needed security mechanisms in place. In addition,
security in the transmission of data between the Cloud and devices that are used to
120 E. R. Bernstein and Z. Lazzarini

How Can You Protect and Secure Health Information

When Using a Mobile Device?

1 Use a password or other user authentication

2 Install and enable encryption

3 Install and activate remote wiping and/or remote disabling

4 Disable and do not install or use file sharing applications

5 Install and enable a firewall

6 Install and enable security software

7 Keep your security software up to date

8 Research mobile applications (apps) before downloading

9 Maintain physical control

Use adequate security to send or receive health information over

10
public Wi-Fi networks
Delete all stored health information before discarding or reusing
11
the moblie device

Fig. 6.1 Centers for Medicare and Medicaid Services recommendations for protecting and secur-
ing mobile devices (Medical Learning Network 2017)

access the cloud must be maintained, including appropriate network security

protocols that protect against external attacks on the data (Rodrigues et al. 2013;
Zhang and Liu 2010). Practices should be very selective when choosing Cloud
services and have assurances that the Cloud service provider understands the
sensitivity of patient data and is experienced with PHI security standards.

6.2.2.3 Technology Security and Embedded PHI

Technical issues raise some persistent HIPAA concerns in both the hardware and
software spheres related to issues including security patches, upgrades, and the
maintenance or expiration of support services. With respect to both software and
hardware, network and Internet connectivity have created a constantly evolving
threat to security ranging from vulnerability to viruses, malware, and attacks to the
compromising of network systems and services. Protection from and mitigation of
these threats require both diligence and state-of-the-art information and hardware
security practices. Inadequate security may result in compromised confidentiality,
data integrity, and data availability resulting from unauthorized, often malicious
access.
6 Medicolegal and Ethical Considerations in Oral Surgery by the General Dentist 121

Digital Images: One of the most common digital technologies in dental offices
are digital imaging devices. From digital radiography to intraoral cameras, digital
images abound in dental practices. For storage and management purposes, patient
identification data is often included in the metadata embedded in the images.
Metadata is data about other data, and images commonly have various metadata
tags with the latent image information (Yee et al. 2003). Among the data that may
be stored along with digital images in a dental context are patient names, billing
identification information, or patient/medical record numbers. All of these can make
digital images, on their own, constitute PHI, even if the image does not visibly
identify the patient, either by printed name or by photographic recognition.
Therefore, digital images taken, received, stored, or used in the treatment of patients
should generally be considered PHI and treated with the appropriate security and
privacy precautions as other PHI would be.
Clinical Devices: There are a variety of new and emerging technologies that may
be utilized by any dental practice and especially when performing oral surgery in
the general dentist’s office. The American College of Prosthodontists has issued a
position statement that describes the use of “Advanced Digital Technologies in
Dentistry” with respect to digital diagnostics, design, and manufacturing. They
discuss the use of medical and dental digital imaging, including computed
tomography (CT), cone-beam CT (CBCT), and magnetic resonance imaging (MRI),
to “develop implant planning, Orthognathic surgical planning, orthodontic planning
and design of guides, maxillofacial prosthetic devices, and single and multiple tooth
restorations, and dentures” (American College of Prosthodontics 2014).
The pervasion of digital dental device research is opening opportunities for “all
aspects of production of dental prostheses and include customized implants, full
denture construction, and orthodontic appliances. In fact anything that you might
expect a dental laboratory to produce can be done digitally and potentially more
consistently, quicker and at a reduced cost” (van Noort 2012). The equipment that
will be used for this production will inevitably be highly connected and integrated
with both the Internet and the other technology in dental offices. This means that all
of the existing and emerging technologies in the dental office must be considered in
the protection of private patient information and also in ensuring network and device
security from breaches and attacks.
Digital Copiers and Nonclinical Devices: One of the most common examples
of network-enabled nonclinical devices are the digital copiers in many dental
offices. The Federal Trade Commission has described digital copiers as “today’s
generation of networked multifunction devices” that copy, print, scan, email, and
fax. If a dental office uses digital copiers and/or similar devices, they must include
those devices in their information security plans. These devices use hard drives and
other memory storage components to manage jobs and increase production speeds.
Most of these devices are Internet enabled and/or integrated and often unprotected.
They can, therefore, become targets for information attacks.
Security of Internet-Enabled “Things”: If a practice uses an Internet-enabled
devices, whether clinical or nonclinical, ranging from digital copiers to radiography
equipment, from lasers to 3D printers, and anything in between, it is likely that these
122 E. R. Bernstein and Z. Lazzarini

devices to create, receive, maintain, or transmit PHI, those devices are subject to the
same HIPAA security standards and requirements as any other device in the office.
The Federal Trade Commission recommends several steps to ensure the security
of digital copiers and similar devices (Commission FT 2017). These steps may also
be applied when considering a privacy and security plan for other Internet-enabled
clinical or nonclinical devices:

1. The same individuals in a practice who have expertise and responsibility for
securing computers and servers should be responsible for securing data and
network interactivity for all Internet-enabled devices.
2. All mechanisms of device connectivity should be secured appropriately, includ-
ing Wi-Fi that will need to be secured like any other Wi-Fi capable devices in the
practice’s network.
3. All devices should be configured to comply with the practice’s PHI security and
privacy policies.
4. Understand and utilize data security features available either as standard equip-
ment or as optional add-ons for connected devices. These include features like
encryption and overwriting, as well as hardware passcode protection.
5. If a device is removed from an office for maintenance, treat the device the same
as any other transportation of PHI, such as a laptop computer with PHI being
taken out of the office.
6. Have a plan for the secure and appropriate disposal of accumulated data on
devices over time; in particular, understand the lease or purchase contract
provisions for ownership of hard drives and disposal of data at the end of life of
the device or component.
7. Be aware that, especially in the case of leased devices, vendors may be business
associates under HIPAA and require a BAA for compliance.

The Internet of Things: The US National Intelligence Council has defined the
Internet of Things (IoT) as “the general idea of things, especially everyday objects,
that are readable, recognizable, locatable, addressable, and controllable via the
Internet - whether via RFID, wireless LAN, wide-area network, or other means”
(Swan 2012). While the most familiar Internet-connected devices are computers or
obviously computer-based, such as laptops, servers, smartphones, and tablets, the
IoT concept encompasses far more technology-embedded tools. Even stand-alone
devices often have network connectivity, and there are an increasing number of
healthcare applications of sensor-based technology that shares data from wearable,
ingested, installed, or injected miniature microprocessors. These “things” collect
and often transmit data that could be classified as PHI and certainly will be classified
as such if the devices are increasingly used to help inform treatment and treatment
decisions.
Internet-enabled devices and the IoT have an almost unlimited potential to
impact the future of healthcare quality and practice. However, as these technologies
become more ubiquitous, it may be easier to overlook them as potential threats to
patient privacy and health information security. Such technology should not be
6 Medicolegal and Ethical Considerations in Oral Surgery by the General Dentist 123

avoided solely because of the risks, but appropriate attention should be paid to the
way technology is used and secured so as to maximize the benefit to health outcomes
and mitigate the risks to the PHI of patients (Swan 2012; Peppet 2014).

6.3 Closing Remarks

The medicolegal issues discussed in this chapter share a core common characteris-
tic, to best serve the interests of patients. Whether through traditional ethical and
legal practice issues, such as informed consent, standard of care, and scope of prac-
tice or through the attention to patient privacy rights in general administrative prac-
tices and use of technology, the center of these issues is and should be patients. At
the same time, that attention to these important issues supports a patient-centered
approach to practice, such attention has the dual benefit of reducing risks of liability
for care-related outcomes and statutory and regulatory compliance violations.
It is important to note that the medicolegal issues that face dentists—and all
healthcare providers—often have common characteristics that foster the types of
suggestions and considerations raised by this chapter; however, laws and regulations
vary from state to state and local counsel should always be sought for their familiarity
with malpractice laws and the legal landscape of the particular jurisdiction. This
chapter does not purport to establish, impact, or effect standards of care, nor is this
chapter intended to serve as a substitute for competent legal advice on any specific
issue.

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 Part II
Principles of Exodontia
Local Anesthetics in Dentistry
7
Christy Lottinger

“It is, of course, a trifle; but there is nothing more important as

trifles.”
—The Man with the Twisted Lip

Abstract
Since the advent of their use over a hundred years ago, local anesthetics have
continued to shape the field of dentistry and its specialties by providing the
means with which to accomplish a multitude of procedures in an office setting
without the need for a general anesthetic. In oral and maxillofacial surgery, local
anesthetics have the added benefit of providing hemostasis to the surgical field,
resulting in increased visualization and attenuation of blood loss. In addition,
long-acting local anesthetics have become increasingly popular for the control of
postoperative pain, mitigating the need for the prescription of narcotic pain
medication. A variety of agents, both for topical use and for injection, are
available on the market in the United States. While the mechanism of action of
these local anesthetic agents is similar, each drug offers its own unique
characteristics, allowing the practitioner to tailor his or her selection of local
anesthetic to the needs of the patient and the demands of the procedure. The aim
of this chapter will be to introduce the basic pharmacology of local anesthetic
agents and to familiarize the reader with the variety of drugs currently available
on the market, their unique properties, and potential risks and complications
associated with their use.

C. Lottinger (*)
Department of Oral and Maxillofacial Surgery, University of Connecticut School of Dental
Medicine, Farmington, CT, USA
e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2019 129

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_7
130 C. Lottinger

7.1 Introduction

The use of local anesthetic agents is so intimately tied to the field of dentistry that it
is difficult to imagine a modern practice without them. With some exception, den-
tistry as a whole relies heavily on the ability to perform minimally to moderately
invasive procedures on conscious patients, and it is because of this practice model
that it has been so important to develop agents that are capable of controlling painful
stimuli. Prior to the development of local anesthetic agents, painful procedures
would require the use of general anesthetic agents, most often ether, which was
developed in 1846 by a dentist by the name of W.T.G. Morton who first publicly
demonstrated its effectiveness by performing a tooth extraction of a patient under its
influence (Calatayud and Gonzalez 2003). However, general anesthesia carries
inherent risks to the patient and can prove to be impractical, particularly in an out-
patient setting.
It was not until the late 1800s when surgeons began to use cocaine as a topical
analgesic for surgery and dentists began using subcutaneous injection of cocaine-
containing solutions with a hypodermic needle for tooth extraction. However, the
unwanted side effects of injected cocaine caused dentists to adhere solely to using
cocaine as a topical anesthetic. Later, with the addition of epinephrine to cocaine-
containing solutions, and the concept of nerve blockade, introduced by William
Halsted and William Hall, the injection of smaller amounts of local anesthetic at
distal sites was able to provide longer-lasting local anesthesia with fewer
unwanted side effects. Soon thereafter, the invention of a synthetic analog of
cocaine, procaine, was introduced onto the market as “Novocaine.” Novocaine
had fewer unwanted side effects compared to cocaine, but it was a vasodilator as
opposed to a vasoconstrictor, so it spread easily away from the site of administra-
tion. The agent was subsequently combined in solution with vasoconstrictor,
which counteracted its vasodilating properties, and enjoyed revolutionary suc-
cess in the world of both medicine and dentistry (Calatayud and Gonzalez 2003;
Nathan et al. 2016).
Further advances over the past several decades have been made in both the
development of dental syringes and cartridges as well as in the development of
new and different local anesthetic agents (Nathan et al. 2016). Today, the ability
to provide temporary sensation loss intraoperatively without the need for gen-
eral anesthetic agents provides a safe and comfortable working environment
enjoyed by dentists and dental specialists everywhere. Local anesthetics are
frequently used in dentistry and medicine not only as primary surgical anesthe-
sia via infiltration or nerve blockade but combined with general anesthetics and
as agents for the control of postoperative pain (Ganzberg and Kramer 2010).
This chapter focuses on the basic pharmacology of local anesthetic agents, the
specific drugs and their availability in dental cartridges in the United States,
their selection and proper administration, as well as potential complications of
their use.
7 Local Anesthetics in Dentistry 131

7.2 Pharmacology of Local Anesthesia

7.2.1 Neurophysiology

Information throughout the body is carried by nerve fibers from one region to
another in the form of electrical action potentials, which are propagated along the
cell membranes of neuronal axons via transient depolarizations. These
depolarizations affect the permeability of neurons to sodium ions by producing
conformational changes in membrane proteins that serve as ion channels.
Specifically, excitation along a nerve will disrupt the electrochemical gradient,
allowing an influx of Na+ ions across the cell membrane, which is essentially
impermeable to sodium ions at rest. The influx of sodium will continue until a firing
threshold is reached, at which point further rapid sodium ion influx results in
initiation of an impulse, or action potential. This depolarization process takes only
about 0.3 ms. Afterward, the neuron undergoes a process of repolarization, whereby
the cell membrane’s permeability to sodium ions, and thus the resting membrane
potential, is once again restored (Malamed 2013a).
Local anesthetics work by reversibly blocking ion channels along the nerve fiber,
which lowers the rate of depolarization and results in failure to produce an action
potential along the nerve. They bind to specific sites within sodium channels to
prevent the conformational change that would allow the passage of sodium necessary
to produce an action potential. When a critical length of a nerve fiber is exposed to
local anesthetic, the result is conduction blockade. Myelination of a nerve fiber or
an increase in the diameter of a fiber produces a greater intermodal distance, thereby
increasing the critical length and decreasing the nerve fiber’s sensitivity to the local
anesthetic agent. It is for this reason that small, unmyelinated fibers such as those
that transmit pain signals are more easily blocked by local anesthetics than large,
myelinated fibers such as those of motor neurons. Because local anesthesia diffuses
through a nerve bundle from the outer mantle of the axon to the inner core, the
structures innervated by the outer axons will display a loss of sensation first,
followed by the structures innervated by the core. This is why in the case of the
inferior alveolar nerve block, loss of sensation proceeds from proximal to distal,
with the lip being the last to be anesthetized. Recovery also occurs proximal to
distal, with the lip being the last to regain sensation as well (Giovanitti et al. 2013).

7.2.2 Pharmacology of Clinical Agents

7.2.2.1 Local Anesthetics

Most local anesthetics used in dentistry are tertiary amines. Injected local anesthet-
ics possess a lipophilic aromatic ring connected to a hydrophilic amino group by an
intermediate hydrocarbon chain. They are classified according to their intermediate
chain into ester and amide groupings. Ester-linked local anesthetics such as procaine
are easily hydrolyzed in aqueous solution, whereas amide-linked local anesthetics
are hydrolyzed much more slowly (Becker and Reed 2006).
132 C. Lottinger

Local anesthetics are available for clinical use as acid salts. After injection into
the tissues, the acidic solution is buffered by the body and dissociates into an
uncharged base and a cation. The degree of ionization after injection determines
the anesthetic’s rate of onset, as it is the uncharged base form that is able to diffuse
across the nerve membrane to block an action potential. The amount of base form
present after injection is dependent on the pKa of the local anesthetic and the pH
of the tissue, with lower pKa values resulting in faster onset. presence of inflam-
mation or INFECTION in the tissue results in a relative abundance of H+ mole-
cules, which causes more of the local anesthetic to be present in its cationic form.
As this form cannot readily diffuse through the nerve sheath, the onset of local
anesthesia will be delayed. Once inside the nerve fiber, the drug once again is able
to dissociate back to its cationic form, and it is this form that performs the sodium
ion channel binding that is necessary for conduction blockade (Calatayud and
Gonzalez 2003).
Duration of action of local anesthetic agents relies on their protein-binding capa-
bilities, as sodium ion channels and binding sites are primarily protein. In addition,
protein-bound local anesthetic molecules serve as a reservoir for the drug that can
be made available as it is moved from the active site by uptake from local vascula-
ture. The potency of a local anesthetic agent is dependent on its lipid solubility,
which is determined by its aromatic ring. Drugs with greater lipid affinity will dem-
onstrate greater potency (Giovanitti et al. 2013; Becker and Reed 2006).
The biotransformation of amide local anesthetics occurs primarily in the liver
and therefore may be impaired in patients with severe liver dysfunction. By con-
trast, the biotransformation of esters occurs in the plasma by pseudocholinesterase.
Therefore, patients with pseudocholinesterase deficiency will be at an increased
risk for toxic effects from ester local anesthetics. However, duration of action is
largely unaffected even when biotransformation is slowed, as it relies more on the
redistribution effect of the drug from the site of injection into the bloodstream
(Haas 2002). Articaine, although classified as an amide, does possess an ester side
chain and therefore undergoes biotransformation both in the liver and by plasma
esterases.

7.2.2.2 Vasoconstrictor
It is the absorption of the local anesthetic into the vasculature that removes it from
the injection site and precipitates a return of clinical sensation. Of note, all clinically
effective local anesthetics with the exception of cocaine work as vasodilators, which
speeds this redistribution effect. At the outset of the use of local anesthesia for the
performance of surgical procedures, it was suggested that a tourniquet be applied to
delay the absorption of the anesthetic agent and to prolong its effect (Giovanitti
et al. 2013). Today, that effect is achieved by the addition of vasoconstrictor to
constrict blood vessels, which slows redistribution and prolongs anesthesia. As a
result, the blood concentration of these drugs is lowered, effectively reducing their
systemic toxicity, and their effects are prolonged. Vasoconstrictors also aid in
providing hemostasis at the surgical site, reducing the loss of blood during surgical
procedures and increasing the visibility of the surgical field.
7 Local Anesthetics in Dentistry 133

In dental cartridges, the vasoconstrictors that are available for use in conjunction
with local anesthetics are epinephrine and levonordefrin. Both these agents have
similar effects both locally and systemically; however, levonordefrin is approximately
15% times less potent than epinephrine (Malamed 2013b). Their desired effect is
agonism of alpha adrenergic receptors in small arterioles and capillaries, causing
blood vessel constriction and consequently a reduction in local blood flow. However,
they will be ultimately absorbed from the site of injection and can exert their effects
on both alpha and beta agonists throughout the body. The use of vasoconstrictors in
patients with cardiovascular disease remains controversial. Some investigators
maintain that the risk of the use of vasoconstrictors is very small, given their
seemingly minimal effects on the cardiovascular system (Cawson et al. 1983).
However, there has been evidence that vasoconstrictors can produce a significant
effect on stroke volume, heart rate, and both systolic and diastolic blood pressures
in the same fashion that strenuous exercise might (Haas 2002; Dionne et al. 1984).
Physiologic responses may include an increase in heart rate, stroke volume, blood
pressure, ischemic changes, and incidence of dysrhythmias (Brown and Rhodus
2005; Goldstein et al. 1986; Mochizuki et al. 1989; Hughes et al. 1966; Ryder 1970;
Hasse et al. 1986; Vanderheyden et al. 1989). However, there is incomplete data to
suggest what the maximum dosage of vasoconstrictor should be in patients with
cardiovascular disease (Niwa et al. 2001). While Malamed (2013c) has proposed a
maximum dosage of 40 μg of epinephrine in these patients, Little (2013) has
proposed no more than “one or two carpules” or 36 μg maximum dose of epinephrine
if using local anesthetic solutions with 1:100,000 parts of epinephrine. Additional
studies are probably needed to more clearly elucidate these guidelines. It is, however,
generally accepted that small doses of vasopressor-containing local anesthetics are
well tolerated in patients with cardiovascular disease (Niwa et al. 2001; Malamed
2013c; Davenport et al. 1990).

7.2.2.3 Other Dental Cartridge Components

Local anesthetic agents containing vasoconstrictors also contain an antioxidant,
usually sodium bisulfite, to prolong their shelf lives. Although rare, allergy to
sodium bisulfite is possible, and therefore the use of local anesthetic solutions
containing sodium bisulfite is contraindicated in patients with a true sulfite allergy
(not to be confused with allergy to sulfonamides or “sulfa drugs” (Haas 2002)). The
standard dental cartridge will also contain distilled water for volume and sodium
chloride to achieve tonicity, neither of which should be of any risk to patient
(Malamed 2013d).

7.3 Topical Anesthetics

In dentistry, topical anesthetics are commonly used to improve patient comfort with
injection of local anesthesia; however, they may also be used in place of injected
local anesthetics to relieve discomfort from oral mucosal lesions such as aphthous
ulcers or for certain dental procedures such as gingivectomy, extraction of exfoliating
134 C. Lottinger

deciduous teeth, placement of rubber dam clamp, or scaling and root planning. For
a topical anesthetic to be effective, it must be active when applied to the mucosa,
which can be achieved by both ester- and amid-type local anesthetics. Some local
anesthetic agents, such as mepivacaine, articaine, and procaine, are not effective for
use as topical agents, as they would require unacceptably high doses to produce
topical anesthesia (Malamed 2013e; Meechan 2000). Topical anesthetics are
transferred through the mucous membrane by diffusion over a period of 30 s to
2.5 min depending on site of administration, and they penetrate to a depth of 2–3 mm
(Meechan 2000; Golan et al. 2012). Because their action requires diffusion across
this distance, they typically require higher concentrations to achieve clinical effect
than injected anesthetic agents. Additionally, they may not contain vasoconstrictors
and may undergo rapid vascular uptake. Therefore, care must be taken to avoid over
administration resulting in local and systemic toxicity, particularly when used in
conjunction with injected local agents.
Several studies have attempted to determine whether or not the application of
topical anesthetic is effective at alleviating the discomfort of local anesthetic
injection. Results are equivocal but appear to vary based on site of administration
and whether or not needle penetration was accompanied by the injection of local
anesthetic (De Freiras et al. 2015; Nakanishi et al. 1996; Alqareer et al. 2006;
Rosivack et al. 1990; Vickers and Punnia-Moorthy 1992a; Gill and Orr 1979; Keller
1985; Martin et al. 1994). Effectiveness of topical anesthesia is undoubtedly affected
by proper administration. When topical anesthetic is being administered prior to
injection of local anesthesia, it should be applied in small quantity to dried mucosa
only at the site of needle penetration. The topical should remain in contact with the
mucosa for at least 2 min to allow sufficient time for it to diffuse across the mucous
membrane, thus providing anesthesia to a depth of 2–3 mm and improving pain on
injection (Malamed 2013e; Meechan 2000).
The two most commonly used topical anesthetics in dentistry, lidocaine and ben-
zocaine, are not water soluble and therefore poorly absorbed into circulation, which
reduces the likelihood of toxicity (Golan et al. 2012). However, compound agents,
which employ a combination of topical anesthetic agents with or without vasoactive
agents, have been implicated as potentially harmful if used without caution due to
their low therapeutic index, variations in composition, and difficult dosing (Kravitz
2007).

7.3.1 Benzocaine

Benzocaine is one of the most widely used topical anesthetic agents in dentistry and
is available most commonly as either a spray or a gel, although gel patches,
ointments, and solutions of benzocaine have also been developed. It is frequently
used as either a single agent or in concert with other topical anesthetics and is
available in concentrations of 10–20%. Benzocaine is an ester local anesthetic that
is mostly insoluble in water and poorly absorbed into the systemic vasculature,
making systemic toxicity possible but unlikely at clinically relevant levels. However,
7 Local Anesthetics in Dentistry 135

methemoglobinemia with topical application of benzocaine has been documented,

with the elderly and neonates being especially susceptible. Therefore, unmetered
spray devices should be used with caution intraorally, if at all, with careful
monitoring of the patient (Malamed 2013e; Kravitz 2007; Guerriero 1997; Aronson
2016). Few reports of allergic reaction have also been reported with topical use of
benzocaine, with incidence of contact dermatitis being about 2% in the North
American literature (Marks et al. 2000).

7.3.2 Lidocaine

Lidocaine is commonly used for topical application in both dentistry and medi-
cine and is available in many different forms, from sprays and eye drops to gels,
ointments, and patches. Lidocaine is also available in viscous solution at con-
centrations of 0.5%, 1%, and 2%, which are commonly used in preparations of
“magic mouthwash” for symptom relief from conditions such as radiation
mucositis and aphthous ulcers (Boyce et al. 2016). As a single agent ointment,
lidocaine is available in either a 2% water-soluble form or a 5% base form and
is commonly used by pediatric dentists in lieu of injected local anesthetic for
simple procedures such as exfoliation of primary teeth. Systemic absorption is
greater with the water-soluble form, and care must be taken to avoid overdose,
particularly in the pediatric population (Malamed 2013e). Lidocaine is an
amide, and therefore risk of allergy is very low; however, the prevalence of con-
tact allergy to lidocaine in North America has been reported as 0.7% (Mackley
et al. 2003).

7.3.3 Tetracaine Hydrochloride

Tetracaine is a long-acting ester that can be applied topically for local anesthesia.
It is supplied in several forms and can be used as a topical agent on mucosal
membranes such as is common for dental procedures or on the skin, for instance,
to ameliorate the pain of insertion of an intravenous catheter. It is commonly
encountered in dentistry compounded with other agents, such as in TAC 20 per-
cent Alternate, which is a compound of 20% lidocaine, 4% tetracaine, and 2%
phenylephrine. A similar tetracaine-containing compound originally formulated
for use in soft tissue laser surgery is Profound, which contains a mixture of 10%
lidocaine, 10% prilocaine, and 4% tetracaine (Kravitz 2007). It has also been
developed as a nasal spray in 3% concentration compounded with oxymetazoline
for the achievement of anesthesia of maxillary teeth (Malamed 2013e; Hersh
et al. 2016). Tetracaine is a highly potent, water-soluble ester with a slow onset
of action given relatively high pKa compared to many other local anesthetics
(Covino 1971). It is rapidly absorbed through the mucosa and has a potential for
systemic toxicity; therefore, it may not be an appropriate agent for use over large
areas.
136 C. Lottinger

7.3.4 EMLA

Another commonly used compound topical anesthetic is EMLA (Eutectic Mixture

of Local Anesthetics) cream, which is an emulsion of lidocaine and prilocaine both
in concentrations of 2.5% in the form of a eutectic oil, which enhances its ability to
penetrate intact skin (Fiala et al. 2016). EMLA is effective and popular for use prior
to venipuncture particularly in pediatric patients but is additionally employed as a
topical anesthetic agent in a variety of minor soft tissue procedures. To achieve
desired results, EMLA cream should be applied to the desired site and covered with
an occlusive dressing for at least 60 min, although maximum effect occurs at 2–3 h
(Rogers and Ostrow 2004). Superficial dermal anesthesia lasts approximately 1 h
after removal of the cream (Malamed 2013e). EMLA appears to be a potent topical
anesthetic when used on oral mucosa as well, although this use remains “off-label,”
as the manufacturer guidelines state that EMLA is indicated for intact skin and
genital mucous membranes only (Vickers and Punnia-Moorthy 1992b; Bernardi
et al. 1999; Munshi et al. 2001; AstraZeneca 2013).
The use of compound topical anesthetics in general may pose a significant risk
of toxicity due to their varying composition, difficult dosing, and low therapeutic
index. Therefore, caution should be exercised in their use, particularly when used in
conjunction with injected local anesthetic (Kravitz 2007).

7.4 Injected Local Anesthetics

7.4.1 Effectiveness and Proper Administration

A number of local anesthetic agents with varying onset, duration of action, and
maximum dose are available in dental cartridges either with or without the addition
of a vasoconstrictor. Therefore, the choice of anesthetic will depend upon the
demands of the patient and procedure with focused attention on efficacy and safety.
Currently, the anesthetic agents available in North America are lidocaine,
mepivacaine, bupivacaine, articaine, and prilocaine. These are all amide-type local
anesthetics that are often offered with epinephrine in concentrations of either
1:50,000, 1:100,000, or 1:200,000. Selection of a particular anesthetic is therefore
important, as there are a variety of options with clinically relevant differences.
The practitioner must always remember that the time of onset and duration of a
drug’s anesthetic action can be affected by many factors, such as accuracy and
method of administration, individual patient response, anatomic variations, and
tissue conditions. Therefore, these values are reported as approximations. The
practitioner must also take into account the maximum allowable dose of the
anesthetic agent, which is a weight-based calculation and therefore of particular
concern to clinicians who provide care to small children or frail, elderly patients.
Biotransformation and distribution of local anesthetics may also be affected by liver
function, plasma protein binding, and blood volume. Therefore, maximum dosages
should be decreased in the medically compromised, debilitated, or elderly patient as
7 Local Anesthetics in Dentistry 137

well as patients with significant liver dysfunction. There is no clear formula for this
dosage decrease, however, and it must be determined on an individual basis. Another
confounding variable often encountered in determining the maximum allowable
dosage of anesthetic is the use of two or more local anesthetic agents in the same
patient. When this situation is encountered, the maximum allowable dosage of
anesthetic can best be determined by ensuring that the total dose of each agent not
exceed the lowest maximum doses for the individual agents. Of course, using the
lowest dose necessary to achieve clinical success is of paramount importance to
limit the risk of side effects and toxicity (Malamed 2013f).

7.4.2 Procaine

Procaine is the first synthetic anesthetic agent, introduced in 1904 and marketed
under the trade name of Novocaine. It is an ester local anesthetic that is no longer
available in North America but is worth mentioning due to its historical significance
and impact on the field of dentistry. Due to its high pKa and potent vasodilating
properties, procaine has a low potency, slow onset, and short duration of action.
Additionally, because procaine is an ester-type local anesthetic agent and is
metabolized to para-aminobenzoic acid, it has a higher allergic potential than the
amide anesthetics. Procaine has now been replaced by newer local anesthetic agents
with more desirable properties and fewer potential side effects (Haas 2002).

7.4.3 Lidocaine

Lidocaine is the most widely used local anesthetic in both dentistry and medicine
and the first amide local anesthetic to be marketed to clinicians as an alternative to
procaine in 1943. Lidocaine has been extensively studied and is regarded as safe,
reliable, and effective. As such, it remains the standard against which other local
anesthetics are measured. Lidocaine is currently available in North America in two
preparations, 2% with 1:100,000 epinephrine and 2% with 1:50,000 epinephrine.
The 1:50,000 preparation has been shown to be of use in circumstances that warrant
more significant hemostasis, such as surgical procedures, as it provides a greater
attenuation of blood loss than the 1:100,000 epinephrine preparation (Buckley et al.
1984; Shorogui et al. 2008). Onset, duration of action, and maximum recommended
dosages for each of the two preparations are the same. When used for local
infiltration, onset of anesthesia is less than 2 min. Pulpal anesthesia can be expected
for at least 1 h, and soft tissue anesthesia for approximately 2.5 h. When administered
for nerve blockade, onset averages between 2 and 4 min, and pulpal and soft tissue
anesthesia is extended to 90 min and approximately 3 h, respectively (Dentsply
2011). Although the American Academy of Pediatric Dentistry still recommends a
maximum dosage of lidocaine with epinephrine of 4.4 mg/kg in the pediatric patient,
the FDA lists a maximum dosage of 7.0 mg/kg for both adult and pediatric patients,
not to exceed a maximum total dose of 500 mg (AAPD 2015).
138 C. Lottinger

7.4.4 Mepivacaine

Mepivacaine, which is pharmacologically similar to lidocaine, was introduced into

dental cartridges in 1960 as a 2% solution containing levonordefrin. The following
year, a 3% solution was introduced without the addition of vasoconstrictor (Su et al.
2014). Because of mepivacaine’s less potent vasodilating properties compared to
lidocaine, it does not rely as heavily on the addition of vasoconstrictor in order to
provide clinically acceptable duration of anesthesia. Therefore, mepivacaine 3%
without vasoconstrictor is still on the market and is used frequently in patient
populations where the practitioner may wish to limit the use of vasoconstrictor.
However, studies have shown that 3% mepivacaine has an inferior success rate in
terms of duration and depth of anesthesia compared to lidocaine with epinephrine,
whereas mepivacaine performs similarly to lidocaine when each local anesthetic is
combined with vasoconstrictor (Su et al. 2014). Therefore, 3% mepivacaine plain
may best be reserved for procedures that are short in duration and do not require
profound pulpal anesthesia. In addition to 3% plain solutions, mepivacaine is
currently available as a 2% solution with the addition of either 1:50,000 epinephrine,
1:100,000 epinephrine, or 1:20,000 levonordefrin. There is no significant difference
in depth or duration of anesthesia among the different concentrations or type of
vasoconstrictor. The maximum recommended dose of mepivacaine 2% with
vasoconstrictor and mepivacaine 3% without vasoconstrictor is 6.6 mg/kg, with an
absolute maximum dosage of 400 mg (Malamed and Yagiela 1998).

7.4.5 Bupivacaine

Bupivacaine is an amide local anesthetic agent similar to lidocaine but with a slower
onset time (6–10 min) and a prolonged duration of action. It may be the anesthetic
of choice for lengthy dental procedures and/or for controlling postoperative pain, as
pulpal anesthesia can last anywhere from 90 to 180 min and soft tissue anesthesia
from 4 to 9 h. As such, bupivacaine is not recommended in young children or in the
developmentally delayed, as unintentional self-mutilation due to prolonged soft tis-
sue anesthesia is a concern. It is routinely used, however, for postoperative pain
control and if used properly can reduce or even eliminate the need for postoperative
opioid analgesics, particularly if supplemented with nonsteroidal anti-inflamma-
tory drugs. Bupivacaine is available in dental cartridges in a 0.5% solution with
1:200,000 epinephrine, and its maximum recommended dosage by the FDA is 90 g
in a healthy adult patient, which is unique in that this recommended maximum dos-
age is not weight-based (Hospira, Inc. 2017). Of note, bupivacaine has been associ-
ated with particularly severe reactions upon accidental overdose. This is believed to
be due to its increased cardiotoxicity compared to other local anesthetics due to
several factors including a negative chronotropic and ionotropic effects on the heart,
a decrease in coronary blood flow, potential disruption in conduction through the
heart, and an inhibition of cardiovascular control at the level of the brainstem. The
reason for its negative cardiac effects may be due to its increased lipid solubility
7 Local Anesthetics in Dentistry 139

and thus ability to penetrate cell membranes (Tanz et al. 1984; Pitkanen et al. 1992;
Bourne et al. 2010).

7.4.6 Articaine

Articaine has enjoyed profound popularity in the United States only recently com-
pared to other countries such as Germany and Canada, as it has only been approved
for use in the United States since 2000. Articaine is similar in structure to the other
amide local anesthetics on the market except that it is the only agent with a thio-
phene rather than a benzene ring, which increases its liposolubility and makes it
more effective at crossing lipid barriers. Articaine is also unique in that it contains
an ester group, which causes it to be metabolized both in the liver and in the blood
by plasma esterases. Due to its ability to diffuse quickly through both hard and soft
tissues, articaine has a short onset of action (1–9 min) and reaches peak blood
levels in as little as 25 min (Ogle and Mahjoubi 2011). It has also been suggested
to have superior anesthetic effect compared to lidocaine on buccal infiltration, both
in the maxilla and mandible (Malamed et al. 2000; Katyal 2010; Shurtz et al.
2015); however, 2% lidocaine and 4% articaine may not be significantly different
in terms of onset, duration, and quality of anesthesia when used for local infiltra-
tion for minor dental procedures in the maxilla (Vahatalo et al. 1993). Adding to
its attractive features, there is evidence to support that maxillary buccal infiltration
with 4% articaine may be capable of achieving palatal anesthesia as well, obviat-
ing the need for additional palatal injections, which are notoriously painful
(Al-Mahalawy et al. 2018).
Several studies have been conducted on the safety and efficacy of articaine as
compared to lidocaine, and caution has been suggested in the use of articaine with
nerve blockade owing to a possible increased risk in paresthesia compared to
lidocaine. An epidemiological study by Haas and Lennon in Ontario over a 20-year
period reported a 2.5-fold increased risk in paresthesia with the use of 4% articaine
compared to 2% lidocaine (Haas and Lennon 1995). To further this point, data from
the FDA Adverse Event Reporting System over a 10-year period was published by
Garisto and Gaffen (2010), implicating articaine with significantly higher risk of
paresthesia than all other available local anesthetics with exception of 4% prilocaine,
thus proposing that the more concentrated formulation may contribute to
neurotoxicity when used for nerve blockade. In contrast, a 2001 study by Malamed
comparing the use of 4% articaine with 1:100,000 epinephrine and 2% lidocaine
with 1:100,000 epinephrine in 1325 subjects failed to show a significantly higher
rate of paresthesia or other clinical complications with the use of articaine (Malamed
et al. 2001). However, as suggested by Hillerup et al. in a 2011 epidemiological
review of neurosensory deficits associated with local anesthetic injection compared
to market share, the incidence of neurosensory disturbance with local anesthetic
injection is uncommon enough to render inconclusive results from prospective trials
even with 1300+ participants. In this review, the authors calculated a 3.1–8.6-fold
increase in risk of neurosensory deficit with the injection of 4% articaine relative to
140 C. Lottinger

its market share (Hillerup et al. 2011). Therefore, while the use of 4% articaine for
nerve blockade has not been eradicated, it is suggested that clinicians consider
avoiding its use for nerve blockade when there are viable alternatives. This caution
may also be prudently applied to 4% prilocaine for similar reasons.

7.4.7 Prilocaine

Prilocaine is another amide-type local anesthetic that is available in dental car-

tridges. While biotransformation of all amides occurs in the liver, prilocaine is
unique in that metabolism also takes place in the kidney and plasma. Of note, prilo-
caine has been implicated in the development of acquired methemoglobinemia
through a metabolite (orthotoluidine) that inhibits the methemoglobin reductase
pathways. Peak levels of methemoglobin occur 3–4 h after administration and may
manifest as weakness, tachycardia, respiratory distress, nausea, and vomiting. At
further increased blood concentrations of methemoglobin, lethargy and stupor can
occur, and levels above 70% are often fatal if untreated. A cyanotic patient that is
unresponsive to administration of supplemental oxygen as well as a chocolate-
brown appearance of the blood indicates that a patient is suffering from methemo-
globinemia, and this should be treated with administration of 1% methylene blue
(1.5 mg/kg). The practitioner should remember that a patient with methemoglobin-
emia may have normal partial pressures of oxygen and that oxygen saturation as
measured by pulse oximetry is falsely elevated. Though methemoglobinemia is
unlikely to develop at or below the manufacturer’s guidelines for maximum dosage
of prilocaine with or without epinephrine (8.0 mg/kg up to 600 mg), it is relatively
contraindicated in patients with a history of congenital methemoglobinemia (Kreutz
and Kinni 1983; Rehman 2001).
Because prilocaine is metabolized in multiple sites, plasma levels decrease more
rapidly than lidocaine and are therefore considered to produce less systemic toxicity.
Prilocaine is available in dental cartridges as a 4% concentration both without
epinephrine and as a solution with 1:200,000 epinephrine. The non-vasoconstrictor
containing solution is popular among practitioners wishing to limit the dosage of
epinephrine, as in the treatment of patients with severe cardiovascular disease.

7.5 Complications

The statistics regarding incidence of complications from administration of local

anesthesia for dental procedures are not well reported on but may be anywhere from
4% to 26% and are generally transient and relatively minor (Daublander et al. 1997;
Kaufman et al. 2000; Moore and Hersh 2010). A 1997 study by Daublander et al. of
2731 patients evaluated by questionnaire after receiving dental anesthesia reports
only a 4.5% incidence of complication, 0.07% of which were severe adverse events
(Daublander et al. 1997). It can be reasonably assumed from the prolific use of local
anesthetic agents in the field of dentistry and oral surgery that they are safe, effective,
7 Local Anesthetics in Dentistry 141

and reliable. However, the injection or administration of any drug is not without
risk, and the prudent dental practitioner should be well aware of the potential
adverse events as well as the appropriate strategies for their management.

7.5.1 Local Complications

7.5.1.1 Paresthesia
The most common cause of paresthesia associated with the administration of local
anesthesia is with a mandibular nerve block. The incidence of trigeminal nerve
injury varies wildly in the literature, although it is probably between 1:20,000 and
1:785,000 (Moore and Haas 2010). It is also believed that all but 10–15% of these
patients recover full sensation over the course of a few days up to several months
(Moon et al. 2012). Paresthesia may be caused from mechanical injury from the
needle, pressure from edema or hematoma, or from neurotoxicity of the local
anesthetic agent. As discussed previously, there may be an association with certain
local anesthetic agents and higher incidence. When paresthesia does occur, a
neurosensory exam should be performed and repeated at each follow-up in order to
document the extent and degree of injury. Steroids and NSAIDs may be useful in
treating acute nerve injury by alleviating edema around the affected nerve but do
little to improve persistent paresthesia beyond 10 days after injury. Painful
dysesthesias that do not resolve within 1–2 weeks after injury may be treated with
tricyclic antidepressants or gabapentin, but these medications are for symptom
relief only (Moon et al. 2012).

7.5.1.2 Prolonged Anesthesia and Soft Tissue Injury

Particularly in children and in the mentally disabled, prolonged soft tissue anesthe-
sia can result in inadvertent biting of the tongue, lips, or cheek, resulting in minor to
potentially severe soft tissue damage in the form of laceration, ulceration, and/or
contusion. Even in the normally mentating adult, self-inflicted trauma is a
complication of dental treatment under local anesthesia if care is not taken to prevent
it. These injuries occur in as many as 18% of children and are more common in
young children, although children 12 years and older are still at a risk of about 7%
(College et al. 2000).
The treatment for soft tissue as a result of inadvertent self-mutilation is generally
aimed at treating and protecting the affected soft tissue until sensation is restored.
Largely, the focus is on prevention. Many practitioners, particularly as it relates to
the pediatric population, argue against the use of bilateral mandibular block
anesthesia as a prevention strategy for managing soft tissue injuries; however, the
rate of injury has not been shown to significantly differ between patients receiving
unilateral versus bilateral blocks (College et al. 2000).
Another prevention strategy to reduce the frequency of soft tissue injury after
local anesthesia is the selective use of short-acting local anesthetic agents such as
plain mepivacaine. Even so, soft tissue anesthesia can last several hours, leading
dental practitioners to seek other options (Chi et al. 2008). Since its FDA approval
142 C. Lottinger

in 2008, phentolamine mesylate (OraVerse), a nonselective competitive antagonist

of alpha adrenergic receptors, has been used to reverse the effect of conduction
blockade and return sensation to anesthetized soft tissue. Phentolamine mesylate
acts as a potent vasodilator, which enhances the clearance of local anesthesia from
the site of delivery and results in a recovery of normal sensation in about 50–60%
of the normal recovery time (Tavares et al. 2008; Hersh et al. 2008). OraVerse is
available in standard dental cartridges as a solution with 0.4 mg phentolamine
mesylate. Its recommended dosage is not weight-based; rather it is recommended to
administer the same number of cartridges of OraVerse as were administered for
local anesthesia, with a total dosage of 0.2 mg (1/2 carpule) maximum in children
weighing between 15 and 30 kg. It is not recommended for use in children under the
age of 3 or weighing less than 15 kg (OraVerse 2016).

7.5.1.3 Hematoma
Injection into an area of high vascularity can result in hematoma formation due
to inadvertent damage to a nearby vessel with the needle. Most often, this
occurs during injection of local anesthetic in the posterior maxillary region, as
for a posterior superior alveolar nerve block, and is likely due to injury of the
pterygoid plexus of veins, although injury to the posterior superior alveolar
artery or its gingival branch is also possible. Hematoma formation can also be
caused by inferior alveolar nerve block if the needle is directed too high
(Blanton and Jeske 2003). Hematoma formation can occur rapidly after vessel
injury and will result in cheek swelling on the affected side followed by several
days of ecchymosis as the hematoma resolves. Although bleeding is generally
self-limiting, the goals of initial treatment are to achieve hemostasis with pres-
sure and minimize inflammation in the area by application of an ice pack. The
patient should be reevaluated in 24–48 h to assess for recurrent bleeding or
signs of secondary infection. Hematomas generally resolve on their own in
1–2 weeks, although the healing process is often accompanied by trismus and/
or ecchymosis. The frequency of hematoma formation after injection is higher
with maxillary posterior injections, but the overall incidence is around 0.1%
(Kuster and Udin 1984).

7.5.1.4 Trismus
Trismus is an uncommon complication of local anesthetic injection, but it has
been known to be associated with inferior alveolar nerve blocks and posterior
maxillary injections. The likely etiology is intramuscular edema and hemorrhage,
both of which are worsened by multiple needle passes (Stone and Kaban 1979).
Hematoma and needle-track infection from contaminated needles can also cause
postinjection trismus. Acute pain and inflammation are accompanied by muscle
spasm, resulting in limitation in mandibular range of motion. Treatment is aimed
at addressing pain and inflammation and improving range of motion, often with
NSAIDs, moist heat, and physiotherapy. Movement of the jaw prevents fibrosis,
which can lead to long-term hypomobility. If infection is suspected, antibiotics
should be initiated early.
7 Local Anesthetics in Dentistry 143

7.5.1.5 Ocular Complications

Diffusion of local anesthetic agents through myofascial spaces or inadvertent intra-
vascular injection has the potential to directly affect both the motor and autonomic
neurons that supply the eye, resulting in various ophthalmologic consequences.
These are rare but may present as blurry vision, temporary blindness, mydriasis,
ptosis, diplopia, or ophthalmoplegia. These symptoms generally occur immediately
after administration of local anesthesia and are self-limiting, although visual impair-
ment may be permanent as much as 8% of the time (Alamanos et al. 2016). Ocular
complications are best prevented by aspiration prior to injection of local anesthetic
and proper injection technique. If visual disturbances develop after injection, the
patient should be monitored and reassessed frequently for resolution of symptoms.
If symptoms do not resolve within 6 h, referral to an ophthalmologist is warranted
to assess for damage to the eye and associated structures (Boynes and Echeverria
2010).

7.5.1.6 Palsy of CN VII

Palsy of the facial nerve is possible with injection of local anesthetic and most often
presents immediately but can present in a delayed fashion, typically within hours to
days. The common etiology is inadvertent administration into the parotid gland, as
from a mandibular nerve block where the practitioner has injected too posteriorly
(Cummings et al. 2011). Additional anesthetic techniques that may inadvertently
anesthetize the facial nerve are auriculotemporal nerve block or intra-articular
injection of local anesthetic into the temporomandibular joint space.
On clinical presentation, patients will display unilateral facial weakness on the
side of injection. This can include lagophthalmos of the eye on the affected side,
asymmetrical smile, and/or an inability to raise the eyebrow. Immediate palsy of the
facial nerve after administration of local anesthesia is a result of direct blockade of
neural conduction and should resolve within a few hours, depending on the duration
of action of the local anesthetic agent. Delayed-type palsy, however, may take
anywhere from 24 h to several months to fully resolve, and the etiology is not well
understood. Akin to Bell’s palsy, the standard treatment is systemic steroid therapy
as well as proper protection and lubrication of the eye in the case of lagophthalmos
(Tzermpos et al. 2012). It has been proposed that a possible etiology for delayed
facial nerve palsy after local anesthesia injection is reactivation of latent herpes
simplex virus. Therefore, some practitioners also elect to prescribe an antiviral
medication such as acyclovir, although this remains controversial (Chevalier et al.
2010).

7.5.2 Systemic Complications

7.5.2.1 Overdose
In dentistry, the incidence of local anesthetic overdose is not well known, but severe
consequences are very rare. However, the signs and symptoms of toxicity must be
diligently surveilled for, particularly in young children with low body mass and in
144 C. Lottinger

the elderly or medically compromised patient, whom may have delayed absorption,
metabolism, and excretion as well as impaired plasma protein binding. Dysfunction
of the cardiovascular, hepatic, and renal systems may all increase the incidence of
toxicity in different ways. Even pregnancy may predispose the patient to toxicity at
lower doses, given the reduction in protein binding and more rapid absorption from
higher cardiac output (Byrne and Engelbrecht 2013). The maximum dosages of
local anesthetic agents provided by the manufacturer in accordance with the FDA
and ADA are generally weight-based and formulated for the “average” patient.
These suggested dosages do not take more specific patient considerations into
account; therefore, some patients may experience signs of local anesthetic systemic
toxicity at lower doses than the proposed maximum dose. Overdose of local
anesthesia may occur even when local anesthesia is properly administered in
appropriate amounts, but it is more likely to occur with intra-arterial injection or
with dosages exceeding the recommended maximum.
In the early stage of local anesthetic toxicity, the patient may complain of tinni-
tus, light-headedness, and circumoral tingling. Initial cardiovascular and central
nervous system response to local anesthetic toxicity is excitatory, as inhibitory neu-
rons within the central nervous system are targeted and blocked by the systemic
absorption of the drug. The signs that may be encountered in this excitatory phase
are tremors, shivers, twitching, and even convulsions. Hypertension and tachycardia
may also be evident, and the patient may become unusually talkative, apprehensive,
agitated, or disoriented. What follows is a generalized depression phase characterized
by myocardial depression, ectopic cardiac rhythms, bradycardia, and hypotension.
Decreased cardiac output is accompanied by central nervous system depression
resulting in drowsiness and loss of consciousness (Moore and Hersh 2010).
Respiratory and circulatory collapse are the end points of severe local anesthetic
overdose and present a dire situation for the patient.
Management of local anesthetic overdose will depend on the severity of the reac-
tion and is aimed at providing support to the patient until symptoms subside or help
arrives. The practitioner should administer supplemental oxygen to the patient and
monitor their vital signs carefully while continuing to assess the patient’s airway,
breathing, and circulation. Tonic-clonic convulsions are common with overdose. If
present, the patient should be placed in a supine position and protected from injur-
ing themselves. The administration of an anticonvulsant, such as midazolam or
diazepam, may be required in cases where convulsions are prolonged but are not
often necessary (Cummings et al. 2011). The emergency response team should be
notified early, and the principles of basic life support should be adhered to until help
arrives. Maintenance of a patent airway and adequate ventilation is paramount to
successful patient recovery, and if properly managed, the patient generally suffers
no long-term sequelae (Malamed 2013g).

7.5.2.2 Methemoglobinemia
Methemoglobinemia is a condition that occurs when iron atoms contained within
hemoglobin are oxidized from their normal ferrous form to a nonfunctional ferric
form that has a much higher affinity for bound oxygen and therefore impaired
7 Local Anesthetics in Dentistry 145

ability to release oxygen to and remove carbon dioxide from peripheral tissues (Hall
et al. 2004). In dentistry, the most common causes of acquired methemoglobinemia
are application of topical anesthetics such as benzocaine and the injection of
prilocaine, in which peak levels of methemoglobin occur 3–4 h after administration
(Rehman 2001). The degree of cyanosis is affected by the fraction of hemoglobin
molecules oxidized, with signs and symptoms apparent at a methemoglobin level of
15–20%. Mental changes such as headache, fatigue, and syncope may be noted at
levels of 20–30%, and physiologic signs of tachypnea, tachycardia, dysrhythmia,
and seizure may be evident at concentrations above 30%. At further increased blood
concentrations of methemoglobin, lethargy and stupor can occur, and levels above
70% are often fatal if untreated (Trapp and Will 2010).
A diagnosis of methemoglobinemia should be considered in a cyanotic patient
that is unresponsive to administration of supplemental oxygen with unexplained
decreased SpO2 despite adequate ventilation. Another hallmark feature is a
chocolate-brown appearance of the arterial blood. Upon diagnosis or high suspicion,
immediate treatment should be instituted in the form of 1% methylene blue 1–2 mg/
kg administered over a period of 5–10 min, which can be redosed after 1 h up to a
maximum of 7 mg/kg. In patients with NADPH and/or G6PD deficiencies,
methylene blue is ineffective for treatment of methemoglobinemia, and alternate
strategies for treatment include hyperbaric oxygen, charcoal, transfusions, or
hemodialysis (Hall et al. 2004).
The practitioner should remember that a patient suffering from methemoglobin-
emia may display falsely elevated SpO2 readings on pulse oximetry, as pulse
oximeters misinterpret fractional arterial oxygen saturation at high levels of met-
hemoglobin. SpO2 readings will be expected to fall with rising levels of methemo-
globin but only to a plateau of approximately 85%. They therefore should not be
relied upon to estimate the level of methemoglobin in patients with methemoglo-
binemia (Barker et al. 1989).

7.5.2.3 Allergy
True allergy to local anesthetic is estimated to account for only 1% of all adverse
reactions during dental anesthesia, and 80–90% of these cases are allergic contact
dermatitis. Most patient-reported history of allergy to local anesthetic are actually
adverse events not related to allergy and can be elucidated from a thorough medical
and dental history. In patients who do report true allergy to local anesthetic agents,
intracutaneous testing has been suggested as a strategy to identify safe agents that
can be used in their treatment. However, intracutaneous testing has been shown to
be of no value in this circumstance due to its propensity toward both false-negative
and false-positive results (Tomoyasu et al. 2011). Instead, the challenge test,
whereby a small amount of local anesthetic is deposited into the mucosa as the
patient is monitored for adverse effects, is thought to be the best strategy to determine
if an allergic response is present (Berkun et al. 2003). Challenge testing carries a
risk of anaphylaxis, however, and therefore should be undergone with caution, in a
setting with a proper emergency response team, and with continuous monitoring.
For patients with true allergy to local anesthetics, 1% diphenhydramine has been
146 C. Lottinger

used as an alternative to more traditional local anesthetic agents with reportedly

good success and no cross-reactivity (Pavlidakey et al. 2009).
Patients have been told they are “allergic to dental anesthetics” when instead they
exhibited signs and symptoms of epinephrine sensitivity. Thus a careful history
must be taken when a patient reports a local anesthesia allergy.

7.6 Summary

Local anesthetic agents represent a class of drugs that are capable of providing
safe and reliable loss of sensation and control of painful stimuli, allowing for
patient comfort during dental and surgical procedures without the need for gen-
eral anesthesia. A variety of local anesthetic agents are available for use in mul-
tidose vials or, as is more common in dentistry, dental cartridges. While all local
anesthetic agents exert their effects similarly, they each display their own unique
characteristics and are therefore selected with care and special attention to the
needs of the patient and the procedure. Complications associated with the
administration of dental anesthesia are uncommon and almost always self-lim-
iting, but untoward events can occur in relation to their use. As such, judicious
and cautious use of any drug is the standard of care in both medicine and
dentistry.

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Uncomplicated Exodontia
8
Roger S. Badwal and Andrew Emery

“Mediocrity knows nothing higher than itself: but talent

instantly recognizes genius.”
Sherlock Holmes in—The Valley of Fear

Abstract
Although the mission of dentistry is to save teeth, dental practitioners must be
prepared to extract non-restorable dentition effectively when the need arises.
This chapter will detail the equipment and techniques employed to perform sim-
ple dental extractions.

8.1 Introduction

The practice (or rather learned proficiency) of extracting teeth (aka exodontia) is a
part of medicine that dates back thousands of years. Although other areas of den-
tistry have evolved considerably over time, the basic tenets of tooth extraction have
remained relatively stable. The idea is to free the tooth from its attachments within
the alveolar socket and remove it from the jaw while preserving as much bone as
possible. Depending on the location and anatomy of the tooth, different instruments
are more useful and desirable. In addition to performing the procedure itself, there
are a number of ancillary pre-op and post-op requisites that must be done, which are
discussed in this chapter.

R. S. Badwal (*)
Division of Oral and Maxillofacial Surgery, Department of Surgery, Western Connecticut
Health Network, Danbury Hospital, Danbury, CT, USA
Division of Oral and Maxillofacial Surgery, University of Connecticut School of Medicine,
Farmington, CT, USA
Private Practice, Danbury, CT, USA
A. Emery
University of Connecticut School of Dental Medicine, Farmington, CT, USA
e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2019 151

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_8
152 R. S. Badwal and A. Emery

8.2 Preoperative Issues

Arguably the most important step of any procedure, and especially for one that is
irreversible such as a dental extraction, is assuring the patient is adequately informed
and the provider is suitably prepared. To do this, the correct diagnosis must be made
based on collected diagnostic information, full disclosure must be provided to the
patient regarding treatment options and risks/rewards, and the provider must
document consent as provided by the patient, both verbally and written.
Correct Records: Preventing mistakes in dentistry starts with having the right
records. Prior to extracting a tooth or performing any procedure, the dental provider
must first confirm that they have the correct patient. Items used for confirming the
correct patient include but are not limited to patient name, date of birth, phone num-
ber, address, and any previous patient photos on file. Medical record numbers are
also helpful as an additional measure of confirmation. Additionally, emergency con-
tact information can also be an additional security check in confirming the correct
patient is being selected (Charangowda 2010).
The next step is to verify the procedure planned. This is frequently done by
reviewing treatment notes from previous visits, comments from presurgical con-
sults, and radiographs and can be further verified by conducting a brief oral exam
to confirm the previous diagnostic impression. If there is a discrepancy with the
patient’s presentation and previous notes, adequate patient records should be
taken, including a full extraoral exam, intraoral exam, radiographs, and any other
records deemed necessary for each case. Part of verifying the procedure is assur-
ing that the operator is on the correct side of the mouth and addressing the tooth
of interest. Measures to reduce wrong-sided surgery include marking the correct
side of the patient (e.g., on the cheek) in accordance with patient records, with a
witness auditing the process to catch any potential mistakes. The correct side can
also be initially confirmed by asking the patient to point to the tooth they believe
they are having extracted or area of pain/concern, but it is ultimately up to the
provider to use their own discretion to determine where the surgery is to be
performed.
A time tested and universal methodology for preventing surgical mistakes is to
take a few moments before a procedure to conduct a “time out” (Lee 2010). A “time
out” involves a member of the surgical team verbally reviewing the patient’s identity
and surgical plan with all participants listening to screen for discrepancies and
confirm the correct information for patient and procedure about to begin.
Diagnosis Based on Objective Criteria: Evidence-based decision-making is an
important part of every procedure. It is not enough to merely suggest a treatment or
procedure, but instead one must arrive at a decision systemically and objectively. In
fact, every treatment should be tied to a proper diagnosis. To do this, it is important
to use preset criteria or guidelines for determining what the diagnosis is and thus
what the recommended course of treatment should be given to that diagnosis.
There are several factors or checkpoints to consider prior to extracting a tooth.
Often the first step is to take a good history, which is often gleaned by asking the
right questions. For example, start by determining if the tooth is painful or not. If the
tooth is painful, is pain spontaneous or is the pain elicited with certain stimuli? Has
8 Uncomplicated Exodontia 153

the patient noted any drainage or signs of swelling? These questions can give the
clinician an idea of which type of tooth pathology the patient is presenting with.
Once a thorough history is acquired, the next step is often a clinical exam. To do
this well, the provider will examine both extraorally and intraorally, making note of
any pain on palpation or percussion, swellings, asymmetries, or marked erythema.
The tooth itself is assessed for periodontal health via periodontal probing, assess-
ment of mobility, and assessment of structural soundness. Specifically, one should
determine the likelihood of extraction forces breaking the crown and need for more
advanced surgical techniques for removal of the remaining roots. If the tooth is
decayed or has been treated endodontically leading to a higher risk of crown fracture,
the provider should consider the need for a surgical approach to gain better access,
typically by making an incision and reflecting the soft tissue. For more information
on surgical approaches to extractions, see Chap. 9 on complicated exodontia.
Following a clinical exam, radiographic assessment should be done to correlate
with clinical findings. Radiographs should clearly demonstrate the tooth in question,
particularly in relation to important nearby anatomy. Examples of important
anatomic considerations are the shape of the roots, proximity to anatomic structures
such as the maxillary sinuses and inferior alveolar nerve canal, and the quality or
quantity of surrounding bone. Reviewing older radiographs and comparing to more
recent ones is also valuable in creating a timeline for the tooth. It is also necessary
to plan ways for replacing teeth prior to their removal in order to prepare for any
socket preservation or immediate implant placement, which would be required at
the time of extraction. For more information on implant treatment planning and
preprosthetic considerations, see Chap. 21 on dental implants.
Once data is collected, the clinician will then take a systematic and evidenced-
based approach to planning treatment. There are many reasons to extract teeth,
including the following (Hupp et al. 2008):

• Teeth are diseased:

–– Caries, particularly those that extend through a significant portion of the
crown.
–– Non-vital teeth.
–– Vertical root fracture or cracked tooth.
–– Periodontal compromise.
–– Treatment plan necessitates extraction (i.e., in preparation for complete den-
ture or partial denture).
–– Pericoronitis or teeth erupting such that it compromises the health of other
teeth (e.g., that which is commonly seen with erupting third molars and their
effect on second molars).
–– Teeth associated with other pathology such as cysts and cancer, along fracture
lines (see Chap. 9 on Complicated Exodontia for more information on
advanced surgical techniques).
–– Teeth associated with fractures or part of planned resections are consequently
also frequently extracted.
• Elective reasons
–– Nonsurgical orthodontic treatment for arch length discrepancies
154 R. S. Badwal and A. Emery

–– Impacted teeth in anticipation of future complications with that tooth or adja-

cent teeth
–– Supernumerary teeth (e.g., mesiodens)
–– Financial reasons

There are many stories of patients being treated with root canal therapy for pain
associated with undiagnosed trigeminal neuralgia. There are also cases of teeth
being extracted unnecessarily with radiographic suspicion of periapical abscess, but
actual presence of focal or periapical cement-osseous dysplasia. Unfortunately,
many pathological conditions can present similarly but often require vastly different
treatment plans. As such, it is paramount to take an objective and scientific approach
to working up teeth in question.
In the end, a risk-benefit conversation must be had with the patient regarding extract-
ing a tooth and whether doing so maximizes patient benefit. Since patients have differ-
ent values, this decision cannot be made without discussing with the patient the
prognosis of taking out a tooth or leaving it in and the prognosis of treatment options
(e.g., implant with crown vs. root canal therapy with post, core, and crown). Although
the literature is refute with articles comparing root canal therapy and implant longevity,
more high-quality research is necessary to make definitive distinctions or more clearly
define the best way to select treatment options depending on how the case presents.
Informed Consent: Informed consent for tooth extractions typically involves a
review of the risk and rewards of different treatment options, including no treatment.
Most notably is the risk of simple exodontia on adjacent teeth and nearby skeletal
anatomy, such as nerves and maxillary sinuses. The patient should also be informed
about post-op risks and expectations, including swelling, bleeding, bruising, infec-
tion, dry socket, potential paresthesia, etc. The patient should consent both verbally
and on paper to provide adequate documentation of this discussion, which may be
required if a complication did occur and the patient wished to seek retaliation through
the court. For more information on informed consent, see Chap. 6 (Medical-Legal).

8.3 Operative Considerations

8.3.1 Adequate Visualization

Light: Proper visualization is not possible without an adequate light source. Whether
you use a headlamp, dental loupe light, or dental chair light, it is important to see
where you are working and that instruments are functioning. Discriminating
between bone and tooth is not always as obvious by feel as it is by visualization.
Thus, an adequate light source is especially important for helping the operator
accurately perform dental extractions.
Suction: There are several different types of suction available for keeping the
operative field dry. The Yankauer suction is a large bore suction that is especially
useful for high-volume suction, particularly when using copious irrigation. By
contrast, the surgical suction has a smaller diameter tip, which may be more
8 Uncomplicated Exodontia 155

desirable for suctioning up a piece of tooth or bone, but not aspirating it into the
suction. The narrow tip of the surgical suction also has the benefit of fitting into
smaller spaces, such as alveolar sockets.

8.3.2 Protect Patient

–– Eye protection (e.g., glasses, towel head wrap, etc.)

–– Pharyngeal curtain (Fig. 8.1)
–– Bite block or mouth prop (Fig. 8.1)

Available Instruments: Dental surgery has come a long way since the advent of
the dental pelican and other now outdated dental instruments. However, many of the
functions have been preserved with increased ergonomics and instrument variety.

8.3.2.1 Tray Setups

A tray setup for a simple extraction can vary but frequently involves several of the
most commonly used instruments. For example, Fig. 8.2 shows a common tray

Fig. 8.1 Patient with bite

block and pharyngeal
curtain in place

Fig. 8.2 Tray setup for

simple extraction
156 R. S. Badwal and A. Emery

setup with a local anesthetic syringe and needle, scalpel and blade, Molt curette,
periosteal elevator, small straight elevator, large straight elevator, offset elevator,
bone file, Minnesota retractor, bite block, aluminum foil used as a sterile barrier for
light handles, hemostat, needle holders, suture scissors, and a suture. This setup
allows for most dental extractions to be carried out effectively. Depending on the
tooth being extracted, different forceps can also be added to the tray to aid in tooth
removal.

8.3.2.2 Types of Forceps

Dental forceps are multipronged instruments used to grasp teeth. There are many
different iterations of dental forceps that are designed for different functions. The
following section will describe the most commonly used dental forceps and explain
how form dictates function.
The basic anatomy of dental forceps consists of a handle, hinge, and beak. The
handle is used to provide the operator with an adequate grip and control over the
instrument. Depending on the instrument and location of use, the handle can be
gripped differently (e.g., overhand vs. underhand) to provide the operator better
ergonomics and improved leverage. The hinge, located where the handle transitions
to the beak, allows for pivoting and instrument function. The beaks are designed to
grab and hold onto the tooth. Specifically, the beaks are designed to adapt to the root
form, not the crown. Maxillary forceps are designed with the beaks parallel to the
handle, while mandibular beaks are perpendicular to the handle. To optimally use
forceps, it is important to also have proper patient positioning where the maxilla is
perpendicular to the floor when extracting maxillary teeth and the mandible is
parallel to the floor when extracting mandibular teeth.
One of the most common dental forceps is the No. 150 forceps, which is seen in
Fig. 8.3. These forceps, also known as universal, are used for extracting maxillary
teeth, particularly maxillary anteriors and premolars. The beak tip is well suited for
single rooted teeth. The beaks notably have no serrations and are rounded at the tip.
The analogous instrument to the No. 150 forceps used for the mandible is the No.
151 forceps (Fig. 8.4). These forceps, also called universal, are best used for
mandibular anterior and premolar teeth. The difference between the No. 150 and
No. 151 is that the beak of the No.151 is bent to accommodate the perpendicular
position of the mandibular teeth to the floor and forceps handle.
Mandibular molars, which are positioned posteriorly in the mouth, are often
more easily extracted with the No. 17 forceps (Fig. 8.5). These forceps have pointed
tips that are able to better engage the buccal and lingual furcations. The bent beak,

Fig. 8.3 No. 150 forceps

8 Uncomplicated Exodontia 157

Fig. 8.4 No. 151 forceps

Fig. 8.5 No. 17 forceps

Fig. 8.6 Cowhorn forceps

similar to the No. 151, allows for better operator positioning for a more comfortable
and effective extraction technique.
Similar to the No. 151 and No. 17 forceps, the Cowhorn forceps—aka No.
87—(Fig. 8.6) are also useful for extracting mandibular molars. Like other for-
ceps used for lower molars, the beaks are bent in relation to the plane of the han-
dle. These forceps are designed with sharp beaks that when closed are squeezed
into the furcation leading to elevation of the tooth out of the socket. Notably, these
forceps create a lot of force and can impose a lot of damage if not used with
caution. If enough force is applied or the teeth are fragile, the tooth may fracture,
often buccal-lingually. This amount of potential force, however, may be advanta-
geous for teeth better suited for extraction in pieces as the forceps may split the
tooth.
One of the most popular instruments for extracting anterior teeth is the English
Style 74N forceps (Fig. 8.7). These forceps have beaks positioned at a 90-degree
angle to the long axis of the instrument. Like other forceps designed for taking out
anterior teeth, the beaks are narrow (as designed by the “N”) which helps grip
smaller diameter teeth. The beaks are also serrated for improved grip of teeth.
Similar to the English Style 74N forceps is the English Style 13 forceps
(Fig. 8.8). These forceps are designed for extracting anterior teeth but have larger
beaks. Like the English Style 74N, they also have serrated beaks for improved grip
(Fig. 8.9).
158 R. S. Badwal and A. Emery

Fig. 8.7 English Style 74N

Fig. 8.8 English Style 13

Fig. 8.9 English Style

74N (left) vs. 13 (right)

A newer type of dental forceps is the physics forceps (Fig. 8.10). These forceps
were originally introduced by Dr. Richard Golden in 2004 as a way to extract teeth
more “atraumatically” than traditional forceps. They are designed with one beak
that has a blunt plastic guard and the other beak that is sharp and hook shaped. The
blunt plastic guard is used to brace against the alveolar process, while the sharp
beak engages the tooth or tooth root and directs extraction forces vertically, instead
of horizontally as often occurs with traditional extraction forceps. Conventional
forceps function as two first-class levels that are connected by a hinge, which acts
as a fulcrum to magnify and transfer the forces exerted on the handles to the beaks
and ultimately to the tooth. By contrast, the physics forceps work as one first-class
lever, in much the same way that an elevator is inserted between tooth and a bony
margin and rotated works, but work on a larger scale. One study by El-Kenawy and
Ahmed reported statistical significance for a sample size of 200 patients in favor of
the physics forceps extracting teeth with fewer crown and root fractures than con-
ventional forceps. Although the design of physics forceps prevents universal
8 Uncomplicated Exodontia 159

Fig. 8.10 Physics forceps (WAMkey n.d.)

Fig. 8.11 Rongeurs

application to all extraction scenarios, it appears to have support for its use in many
simple extraction cases and may be a nice complement to oral surgery armamen-
tarium (El-Kenawy and Ahmed 2015).
Another type of forceps that is used frequently for removing bone and occasion-
ally soft tissue are rongeurs (Fig. 8.11). These forceps are easily manipulated with
one hand due to the spring mechanism between the forceps handles. They are typi-
cally designed with either side cutting only or side and end cutting functions (aka
Blumenthal rongeurs). They are often used to trim sharp pieces of bone or remove
interradicular bone. However, they are not designed to remove teeth and should
never be used for that purpose.
160 R. S. Badwal and A. Emery

8.3.2.3 Types of Elevators

One of the most commonly used instruments for extracting teeth are dental eleva-
tors. They are designed with a handle that connects to a blade via a shank. Despite
the variety of blade and shank designs, they all function to help luxate teeth by
transferring rotational forces from the operator to the tooth.
One of the most commonly used elevators is the small straight elevator, aka
301 (Fig. 8.12). This instrument is often inserted between tooth root and bone, and
rotational forces are delivered to the instrument to engage the tooth resulting in
coronal forces that help elevate the tooth out.
Similar to the small straight elevator is the straight elevator, aka 34S (Figs. 8.13 and
8.14). The main difference between the two instruments is that the blade size of the
34S is larger. It is common to begin elevating with the 301 followed by the larger 34S.
Another useful elevator, particularly for posterior teeth like upper molars, is the
offset 92 elevator (Fig. 8.15). This elevator has a bent shank that offsets the blade
from the plane of the handle. This allows for the blade to gain access to the tooth
without being impeded by the cheek. The blade of the offset 92 elevator is not as
concave as the 34S allowing for a broader contact with tooth surface. Also, the blade
of this elevator is serrated, which aids in gripping teeth during elevation.
A visually distinct set of elevators that are often used to remove broken roots in
sockets are the Cryer elevators (Figs. 8.16 and 8.17). The east is the elevator that
has a blade pointing to the right or east when the instrument is laid on the ground

Fig. 8.12 Small straight

elevator (301)

Fig. 8.13 Straight elevator

(34S)

Fig. 8.14 301 elevator

(top) vs. 34S elevator
(bottom)
8 Uncomplicated Exodontia 161

Fig. 8.15 Offset 92 elevator

Fig. 8.16 Picture on left has the above Cryer elevator (east) and below elevator (west). The pic-
ture on the right is a close-up of the east elevator

Fig. 8.17 Cryer elevator

(west)

Fig. 8.18 Crane pick elevator

edge with the handle positioned superiorly. Both cryers have triangular-shaped
blades that curve and can be placed within sockets to engage more mesial or distal
tooth roots or fragments.
Similar to the east, the west Cryer elevator has a blade that points to the left or
west when the instrument is placed on its ground edge, and the handle is positioned
superiorly.
The Crane pick elevator (Fig. 8.18) is used to remove broken root fragments in
the tooth socket. The blade is bent and pointed, which can often be utilized by
inserting it into a hole drilled into the root or tooth surface.
162 R. S. Badwal and A. Emery

8.3.2.4 Miscellaneous Instruments

In addition to elevators and forceps, there is also an assortment of ancillary instru-
ments that are used in oral surgery. One of these instruments is the hemostat
(Fig. 8.19). These are narrow, curved-beak forceps that have horizontal serrations
and used to grip bone and tooth fragments or remove loose soft tissue. The design
of the beaks is such that they are not intended for use to grasp suture needles and
should not be used for suturing. That function should be reserved for needle holders.
Other functions of hemostats include controlling bleeding by clamping blood ves-
sels. The handles are designed with two finger holds that are often occupied by the
thumb and ring finger, with the operator’s index finger resting along the handle
length and pointing toward the beaks. Finally, the handles have a locking mecha-
nism that helps to retain the closed position of the instrument without the operator
needing to maintain force to keep the beaks closed.
Often confused with hemostats (Fig. 8.19) by the unfamiliar operator are needle
holders (Fig. 8.20). These instruments are designed with shorter beaks than hemo-
stats, and also have locking handles, but have a crossed-hatch serration pattern that
aids in gripping suture needles in any orientation.
Suture scissors, aka Dean scissors (Fig. 8.21), are also important for cutting
excess suture material or removing non-resorbable sutures after soft tissue has
approximated. They are uniquely designed with bent, short beaks and long handles
to allow for adequate reach of the instrument in small spaces far back in the mouth.
The short beaks are also designed to avoid damaging surrounding structures since
they open and function in the isolated area of interest only. Although they may work
for cutting tissue, they are not designed to do so.

Fig. 8.19 Hemostat

Fig. 8.20 Needle driver

8 Uncomplicated Exodontia 163

Fig. 8.21 Suture scissors

Fig. 8.22 Tissue forceps

Fig. 8.23 Bone file

Fig. 8.24 Molt curette (straight)

Along with needle holders and suture scissors are the tissue forceps (Fig. 8.22).
These are either called the Adson forceps (when short) or Stillies forceps (when
long). These forceps have teeth on one end and are used to grasp soft tissue for
suturing or dissecting. Since the metal teeth are sharp, they can crush or tear tissue
easily so caution should be exercised while using them.
Another instrument that is used for smoothing out sharp bony spicules is the
bone file (Fig. 8.23). This instrument has two ends, one large and one small, and has
sharp horizontal serrations that are angled to cut or remove small amounts of bone
with pulling strokes. Pushing the instrument leads to crushing or burnishing bone,
which is not suggested.
One instrument that is often used to remove soft tissue from bony surfaces is the
Molt curette, aka straight curette (Fig. 8.24). This curette has a straight handle with
164 R. S. Badwal and A. Emery

straight shanks and small and large spoon-shaped blades at each end. This instru-
ment often helps to remove soft tissue from bony surfaces like granulation tissue
from a socket or granulomas and small cysts from periapical lesions. The curettes
can be used in a pulling motion for scooping or often in a pushing motion for blunt
dissection, such as cyst enucleation.
Another type of dental curette that is used during the extraction process of teeth
is the periapical curette (Fig. 8.25). This doubled-ended curette has bends in the
shank at both ends that aid in reaching all aspects of teeth. For example, they are
often used to reach tooth sockets to remove granulation tissue or to relieve soft tis-
sue around teeth, particularly molars.
A scalpel is an essential part of any extraction setup (Fig. 8.26). It consists of a
handle and a scalpel blade. To attach the blade to the handle, it is often recom-
mended to grasp the scalpel blade with a hemostat and line up the oblique lower
border of the blade with that of the handle. Blades are straight with a curvature,
which helps them to cut when held in different orientations. It is suggested to cut
with the belly of the blade or the bend in the curve. Scalpel blades are disposable
and should be thrown out after each procedure, but the handles are reused after an
autoclave cycle.
A frequent favorite for any dental extraction is the very versatile number 9 peri-
osteal elevator (Fig. 8.27). This straight double-ended instrument has one small
end that is more pointed and one larger end that is more rounded. This instrument is
best known for its utility in elevating soft tissue off the bone, especially during the
initial phase of dental extraction. The smaller end is frequently used first followed
by the rounded end.
An instrument uniquely special to oral surgery is the Minnesota retractor
(Fig. 8.28). This offset retractor has one end with an acute turn that is best fitted for
hooking on to the operator’s thumb with the other end that is straighter and more
round that is well suited for retracting soft tissue, especially flaps. The offset allows
the instrument to reach farther back into the patient’s mouth with less impedance by

Fig. 8.25 Periapical curette

Fig. 8.26 Scalpel and scalpel blade

8 Uncomplicated Exodontia 165

Fig. 8.27 Number 9 periosteal elevator

Fig. 8.28 Minnesota

retractor

Fig. 8.29 Weider retractor

the tongue than if it were straight. It is particularly helpful during third molar extrac-
tions. It can also be used to protect tissues from cutting instruments like drills or
chisels.
Another common retractor in oral surgery is the Weider retractor, aka sweet-
heart retractor (Fig. 8.29). This retractor has a heart-shaped end that is useful for
retracting the patient’s tongue when working near it. The serrations are used to more
aptly grip and engage retracting tissues such as the tongue. The other end has a
curvature that helps the operator hold it with minimal hand skills since it can merely
hook around a finger or hand. It is important to not push this instrument too far into
the patient’s mouth as doing so may trigger a gag reflex.
The mouth mirror is an absolute necessity, especially when working on poste-
rior maxillary teeth (Fig. 8.30). The instrument consists of a handle into which
166 R. S. Badwal and A. Emery

Fig. 8.30 Mouth mirror

Fig. 8.31 Aspirating syringe

Fig. 8.32 Irrigation tip

screws a small round mirror that can be replaced when scratched or damaged. The
mirror also doubles as a retraction tool for the cheek or soft tissue.
Another very important instrument that is key to nearly every procedure in oral
surgery is the aspirating syringe (Fig. 8.31). This instrument consists of a chamber
into which local anesthetic carpules are loaded. There is a threaded end to the cham-
ber onto which screws the anesthetic needle via a plastic hub. After the carpule is
loaded, the metal harpoon on the end of the handle is pushed into the silicone
plunger of a local anesthetic carpule and confirmed to be adequately engaged prior
to use. This allows the operator to aspirate during local anesthetic injection.
To aid in visualization and remove debris during extraction, the operator must
have adequate irrigation. Irrigation tips (Fig. 8.32) are attached to plastic syringes
and often used to direct sterile saline into a socket to remove debris. This larger bore
tip allows for enough water or sterile saline to be dispersed to provide proper irriga-
tion for cleaning out a socket or lubricating a dental drill.
8 Uncomplicated Exodontia 167

Fig. 8.33 Suction

Fig. 8.34 SteriGage

Another instrument that cannot be spared during dental procedures is suction

(Fig. 8.33), particularly surgical suction when extracting teeth. This instrument has
a long bent metal tube with a depression halfway down that allows air in unless
covered. When using it, the operator can put his or her finger over the opening on
the body of the suction to increase suction forces, while not doing so will result in
weaker suction, which may be better at certain times, such as when suctioning
around soft tissue. Also, the smaller diameter of the suction allows for it to suck up
small pieces of tooth or bone or soft tissue, which is useful when using hemostats or
another instrument for picking up pieces proves more difficult.
Lastly, any operator should be familiar with the SteriGage indication strip
(Fig. 8.34), which is found in each cassette. As pictured, a SteriGage that has under-
gone a proper autoclave cycle will result in the black indicating strip extending into
the accept end. If it does not, then the autoclave cycle was not successful, and the
instruments were not properly sterilized.

8.3.3 Proper Use of Elevator and Forceps

Exodontia is a deliberate and controlled process of loosening a tooth from its alveo-
lar socket and removing it from the mouth with as little collateral damage or bone
removal as possible. There are many instruments for this process that are often used
in a typical sequence.
After confirming the records are correct, including the patient, tooth, and proce-
dure, the first step is to anesthetize the patient properly (see Chap. 7 for more infor-
mation). Before doing so, first make sure the patient is wearing appropriate
protective eyewear on to prevent iatrogenic trauma to their eyes. After local anesthe-
sia is achieved, the patient’s throat should be protected with pharyngeal curtain,
often done so by opening up a 4 × 4 piece of gauze. If working on the patient’s lower
jaw, this is also a good time to insert a rubber bite block on the opposite half of the
168 R. S. Badwal and A. Emery

mouth in order to protect the patient’s temporomandibular joint and reduce fatigue
from staying open for a while.
At this point, a number 9 periosteal elevator or double-ended periapical curette
may be used to release the attached gingiva and mucosa from around the tooth.
Once the tooth is successfully freed from soft tissue, an elevator is usually inserted
perpendicular to the facial side of the tooth, between tooth and alveolar process,
with the concave face toward the tooth. The elevator should be held with the opera-
tor’s index finger along the length of the shank and blade. Caution should be taken
to make sure the elevator is between tooth and bone, not between teeth. Once in
place and a purchase is found, the elevators are turned either clockwise or counter-
clockwise, which helps to break PDL fibers and luxate the tooth.
Finally, once luxation has been achieved and the tooth has gained mobility, or
elevating is no longer effective, the correct forceps, which depends on the tooth
being extracted, can be selected and used. The forceps’ beaks are placed parallel to
the tooth, one beak at a time (i.e., typically palatally or lingually first then followed
by buccally). The first direction of force is apical in an attempt to seat the forceps as
apically on a tooth as possible, which provides counter pressure and helps expand
the alveolar process. Slow and steady buccal or lingual pressure is applied followed
by similar pressure in the opposite direction. A controlled amount of force should
be used in order to feel and respond to tactile feedback from the tooth or alveolus
and avoid sequelae of uncontrolled forced such as fractured teeth, fractured alveolar
bone, or instrument slipping causing collateral trauma. A slow figure-8 motion can
also be used to help break more PDL fibers and better luxate the tooth. Anterior
teeth that are single rooted and often conical and straight are often successfully lux-
ated with rotational forces using forceps. However, caution should be exercised to
avoid applying excessive rotational forces to teeth with roots that are possibly dilac-
erated (as may be radiographically evident) or multi-rooted as that may lead to
unfavorable fracturing of tooth roots. As a result, providers would be left with a
more difficult extraction as they attempt to remove a piece of tooth that has poorer
access, visibility, and leverage points.
Once the tooth is extracted, it should be inspected thoroughly for any signs of
root fracture that may indicate part of the root was left behind. For more information
on management of root tips, see Chap. 11 on surgical complications.

8.3.4 Postextraction Toilette

A rather historical and often overlooked step of exodontia is postextraction curet-

tage of the alveolar socket (Fig. 8.35). Many surgeons instinctively or reflexively
perform curettage, but recent literature and old principles challenge that practice. Is
curettage always necessary?
A study from 2014 by Wahl et al. found that postextraction curettage carries a
number of inherent risks but few benefits (Wahl et al. 2014). They report that com-
plete radiographic healing occurs without postextraction curettage in teeth with peri-
apical radiolucencies. An interesting point raised by the study was that periapical
8 Uncomplicated Exodontia 169

Fig. 8.35 Surgical

“toilette” or result of
socket curettage following
tooth extraction

lesions of endodontic teeth heal well after root canal therapy, suggesting that the
same should happen for periapical lesions following tooth extraction. Given the risks
of perforating through sinus walls, injuring nerves, excessive bone removal, and
increased postoperative pain, curettage should be done much more selectively.
Although little literature exists on the exact indications for postextraction curettage,
doing so is generally recommended when there is loose soft granulation tissue along
socket walls and when easily accessed apically, but excessive pressure or force
should not be exerted to avoid the previously mentioned risks.
In addition to curettaging after tooth extraction, the alveolar socket is often irri-
gated with sterile normal saline. This is typically done to wash out debris and bac-
teria. As stated by Dr. Sherry Rogers, a medical doctor specializing in environmental
medicine, “The solution to pollution is dilution.” That being said, irrigating a socket
often helps to dilute out unwanted pollutants in the socket. However, this postex-
traction curettage routine has been reconsidered by some. One study by Tolstunov
found that the rate of alveolar osteitis in patients undergoing mandibular third molar
170 R. S. Badwal and A. Emery

removals was less when the socket was not irrigated (Tolstunov 2012). The study
found that it was easier for younger patients to reform blood clots following socket
lavage than older patients. Although the literature is light on the benefits and risks
of socket irrigation and the study presented focused specifically on mandibular third
molars, postextraction irrigation should be considered more on a case-by-case basis.
In particular, it is important to consider the patient’s age and health, tooth being
extracted, and difficulty of extraction when deciding whether to irrigate or not.
After the tooth is removed, it is important to control bleeding which is most often
done by having the patient bite on moist gauze. Biting on moist gauze helps to
prevent the blood clot from being removed when the gauze is taken out or changed,
and the pressure the gauze provides helps achieve adequate hemostasis. Patients
should typically bite down for about 20–30 min, with more or less time depending
on extent of bleeding. The operator may also wish to straddle the alveolar ridge
around the edentulous tooth socket with their thumb and index fingers and apply
compressive forces to push the expanded alveolar socket walls back in and facilitate
quick wound closure.
Special Considerations: Patients on anticoagulants or with conditions that pro-
long bleeding time or coagulation may benefit from having Gelfoam, surgical, or
another resorbable hemostatic agent in the socket to reduce prolonged bleeding risk.
After the socket is filled or packed with these agents, a figure-8 suture is typically
used to help re-approximate soft tissue and retain the Gelfoam or other hemostatic
agent.

8.4 Post-Op

Oral Hygiene: There are a number of postoperative hygiene recommendations to

follow after tooth extractions. Patients are encouraged to avoid any motion that
creates suction such as sucking (e.g., using a straw, spitting, smoking, or using
alcohol). Also, patients should brush their teeth gently avoiding the extraction
socket so as to avoid disrupting the blood clot or granulation tissue. Lukewarm salt
water rinses are also helpful to facilitate healing and can be done several times a day
during the healing phase. However, caution should be taken to not spit, but rather let
the salt water passively empty from one’s mouth.
Diet: After extraction, patients should have a soft diet (e.g., yogurt, soup, etc.).
Patients should drink lots of fluids, especially water, and avoid very hot or cold
foods and liquids. Also, it is best to avoid carbonated beverages and alcohol.
Analgesics: For more information, refer to Chap. 12 (Acute Pain Management).

8.5 Summary

Simple exodontia is fundamental to dentistry and one of the longest practiced pro-
cedures of the profession. Over the years, a lot of progress has been made to improve
patient outcomes, but there is still a lack of evidenced-based support for much of the
8 Uncomplicated Exodontia 171

clinical decisions that are made. It is important to always take a logical, stepwise
approach to dentistry, especially dental extractions, with justification for each step
from diagnosis to decision to irrigate or curette alveolar sockets. As more time and
research is invested in understanding the benefits or consequences of different treat-
ment options, more evidence will be available to justify treatment recommendations
and will better direct dental practitioners in decision-making.

References
Charangowda BK. Dental records: an overview. J Forensic Dent Sci. 2010;2(1):5–10.
El-Kenawy MH, Ahmed WMS. Comparison between physics and conventional forceps in simple
dental extraction. J Oral Maxillofac Surg. 2015;14(4):949–55.
Hupp JR, Ellis E, Tucker MR. Contemporary oral and maxillofacial surgery. 6th ed. St. Louis:
Elsevier Mosby; 2008. p. 91.
Lee SL. The extended surgical time-out: does it improve quality and prevent wrong-site surgery?
Perm J. 2010;14(1):19–23.
Tolstunov L. Influence of immediate post-extraction socket irrigation on development of alveolar
osteitis after mandibular third molar removal: a prospective split-mouth, preliminary report. Br
Dent J. 2012;213(12):597–601.
Wahl MJ, Wahl JA, Schmitt MM. Dental extractions, antibiotics, and curettage. Global J Med Res.
2014;14(1):1–7.
WAMkey. n.d. http://www.wamkey.com/images/gmxps_zoom.jpg.
Complicated Exodontia
9
Stuart Lieblich

“The plot thickens.”

—A Study in Scarlet

Abstract
Planning for the extraction of teeth involves not only preparing the appropriate
dental treatment plan for the patient but an appreciation of what potentially makes
a case more complicated. Anticipating that a procedure may be more complicated
than usual often is achieved via experience. The general dental practitioner that
may be comfortable with some aspects of exodontia still may need to understand
when a case may need to be referred to a specialist. This chapter will present some
aspects of extractions as well as patient issues that may indicate that the procedure
may be more complicated or present unusual circumstances.

9.1 Assessment

The initial aspect of planning for surgery is to determine if the patient is an appro-
priate candidate. Certainly emergency procedures may dictate that cases need to be
done more urgently, but in general extractions can usually be deferred until the
patient’s health status is optimized. The intake of the patient needs to include certain
aspects of their medical history and vital signs (Table 9.1). The surgeon must
determine if the patient can safely undergo the surgical procedure. Most practitioners
will primarily be treating with local anesthetics, but even these medications can
cause an adverse outcome if the patient is not in optimal health.
One important screening tool is the patient’s ability to undergo some basic levels
of physical activity. Simple questions such as what tasks they can accomplish such

S. Lieblich (*)
University of Connecticut, Farmington, CT, USA
Avon Oral and Maxillofacial Surgery, Private Practice, Avon, CT, USA
e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2019 173

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_9
174 S. Lieblich

Table 9.1 Basic patient • Vital signs

evaluation for extractions  – Blood pressure
 – Heart rate and rhythm
• Medical history
 – Comorbid diseases?
 – How have you been feeling lately?
 – Which medications do they take?
• Can they go up a flight of steps? (METs >4)
• Can they take deep breath and hold it for 5–10 s?
• Can they extend head/open mouth wide?

as walking upstairs, playing tennis, etc. gives an indication of the patient’s meta-
bolic equivalents (METs). METs are scaled from 1 (just sitting in a chair) to 10
(able to play single’s tennis for an hour). A patient that can walk up a flight of stairs
has some basic level of cardiac and respiratory reserve that should be an acceptable
risk for treatment in an office setting with local anesthesia (Eagle et al. 1996).
Some of the patient evaluation issues will alert the practitioner to a situation that
complicates extraction. For example, the use of anticoagulant medications can
create postoperative bleeding issues. In general, the risk of a stroke with stopping
these medications is greater than the potential for postoperative bleeding, and
typically these medications are continued. Although there is no absolute maximal
INR that is thought to be safe, values of 3.5 or less are usually not associated with
significant postoperative hemorrhage. Concerns may be greater for patients under
dual anticoagulant therapy than just a single agent (Lillis et al. 2011; Lu et al. 2016).
It is interesting that periodontally involved teeth are often associated with more
bleeding in patients taking anticoagulants. Also the ability to control any
postoperative bleeding will depend on the anatomical site involved. For example,
simple intraoral oozing is more easily observed and treated than occult bleeding into
the maxillary sinus or the floor of the mouth.
The use of intrasocket hemostatic agents is indicated for use in these patients
along with suture closure. Other local measures that can be used are tranexamic acid
rinses. Cessation of anticoagulant medications should not be done without consulta-
tion with the prescribing physician. Other coagulopathies such as von Willebrand’s
disease or the various presentations of hemophilia necessitate collaboration between
the dentist and the hematologist. Patients need to be advised of the likelihood of
significant ecchymosis forming following even a relatively simple extraction
(Fig. 9.1a, b).
Other medication issues are the use of the medications known to be associated
with MRONJ (medication-related osteonecrosis of the jaws). There are no specific
guidelines in these cases other than to try to avoid extractions if at all possible with
endodontic treatment and root retention. With the use of the oral bisphosphonates,
some have recommended a 3-month drug holiday prior to extractions (Ruggiero
et al. 2009). There is little evidence to support this, and current recommendations
for patients that have been taking oral bisphosphonates or an anti-resorptive such as
denosumab for less than 2 years can have invasive oral surgery and continue their
medications (Ruggiero et al. 2014). If they have been on these medications for
9 Complicated Exodontia 175

a b

Fig. 9.1 (a) Ecchymosis following simple extraction in a patient taking warfarin. (b) Severe floor
of mouth ecchymosis that can become life-threatening due to impingement of the airway

greater than 4 years, there may be some theoretical advantage to a 2-month drug
holiday (Damm and Jones 2013).
However, if active infection is present with fistula formation, extractions may be
necessary. Although there is no evidence that antibiotics are indicated, in these cases
the preoperative administration is often considered. The term “atraumatic” extraction
is often used in these cases, although this is a goal in every patient population.
In evaluating the patient for extraction, access to the tooth planned for extraction
must also be considered. A limited range of opening can severely hinder the dentist’s
vision to the region as well as the ability to place necessary instrumentation. The
surgeon should evaluate the access especially in posterior areas of the mouth along
with malaligned adjacent teeth that can hinder visualization or placement of
necessary instrumentation. Other anatomical barriers can be tipped adjacent teeth
which hinder access. Adjacent prosthetic restorations that may be failing (Figs. 9.2
and 9.3) can easily be dislodged during the extraction of the planned tooth creating
secondary damage and/or be aspirated by the patient.
The availability of three-dimensional imaging, e.g., cone beam CT (CBCT) scans,
will often provide additional information regarding the location of the teeth to be
extracted and the proximity to other roots, nerves, and the sinus cavity. Although not
typically indicated for most extractions, the dentist should consider if the information
provided by the CBCT will aide in the extraction or reduce the risk to the patients. A
principle of ALARA (as low as reasonably acceptable) should be followed in order to
determine if the additional radiation exposure to the patient could improve the out-
come. Figure 9.4 shows an impacted mandibular canine that on the panoramic image
cannot be determined if it is on the buccal or lingual aspect. Using a CBCT to evaluate
the tooth in all three dimensions, the surgeon can localize the tooth to the buccal
aspects as well as determine the proximity to the incisor roots in this region.
176 S. Lieblich

a b

Fig. 9.2 Clinical and radiograph of a failing bicuspid indicated for extraction. Although there is
only a single conical root, the proximity to other potentially failing and overhanging prosthesis
complicates this case

Fig. 9.3 The presence of

this dental implant in
contact with the failing
molar makes extraction
more difficult. The risk of
creating a bone defect on
the distal aspect of the
implant might indicate a
need for grafting of the
molar extraction site, along
with attempts at primary
closure

a b

Fig. 9.4 A cone beam CT provides important three-dimensional information in more complicated
extraction cases. (a) Mandibular impacted canine showing buccal position. (b) Maxillary
supernumerary tooth demonstrating palatal position and proximity to the central incisor root
9 Complicated Exodontia 177

Fig. 9.5 Use of a

periotome type of elevator
to preserve bone around
the site anticipated for
subsequent dental implant
placement

9.2 Anatomical Issues

Complicated extractions are often described as requiring more bone removal. An

example is the disto-angular or full bony impacted lower third molar. These teeth
typically require substantial bone removal. The additional time and bone removal
associated with these cases can lead to an increased rate of postoperative discomfort
and swelling as well as a higher rate of infection. The rate of infection is noted to be
increased with the complexity of the extraction and most likely the time necessary
to extract the tooth (Piecuch et al. 1995). Although in general antibiotics are not
indicated for routine extractions, if a complex extraction is anticipated, a consider-
ation for prophylactic antibiotics (i.e., administered prior to surgery) can be enter-
tained. Intraoral surgery is considered “clean-contaminated” surgery in most cases,
yet as noted routine antibiotics are not proven to be effective (Krishnan et al. 2017).
Cases where it is anticipated that a dental implant will secondarily be placed into
the site may entail other considerations. Careful sectioning of the teeth with main-
tenance of the buccal plate and interradicular bone (in multirooted teeth) may pro-
vide more predictable sites for the upcoming implant placement. Even with
conical-shaped anterior maxillary teeth, a more precise extraction technique should
be considered to avoid creating a postsurgical defect. The use of fine elevators,
known as periotomes (Fig. 9.5), can be used to expand the sockets and typically
preserve the surrounding boney socket. The dentist may also consider planning to
graft the sockets to preserve the local anatomy.

9.3 Maxillary Issues

The maxillary sinus can complicate extractions due to risk of bone fractures creating
an oral-antral communication (Fig. 9.6). When the maxillary molar is lone standing
or there is significant pneumatization of the sinus, there is a significant risk of associ-
ated bone fracture. If expected the tooth should be sectioned and removed as indi-
vidual roots. During an extraction palpation of the alveolar crest will often indicate if
178 S. Lieblich

a b

Fig. 9.6 (a) Extraction of a maxillary first molar that created oral-antral communication. (b)
Horizontal mattress suture to attempt primary closure between the oral cavity and the maxillary
sinus

Fig. 9.7 Significant

tuberosity bone on the
distal of the third molar
can complicate extraction
due to potential fracture of
the bone

a fracture is occurring. Once noted, care should be taken to dissect the mucoperios-
teum off the bone to maintain a maximal amount of tissue for primary closure.
It is not important to reestablish a bony separation from the oral cavity to the
maxillary antrum. Soft tissue should be adequate once the tooth is removed as long
as the mucosa is not torn and carefully dissected from the bone. A horizontal mat-
tress suture is used to attempt a “water-tight” closure. Patients are instructed to not
blow their nose for 2 weeks to avoid causing a dehiscence in the incision and a
secondary oral-antral communication. If primary closure cannot be achieved, most
small communications (less than 5 mm) will spontaneously close.
Other often overlooked anatomic issues are the maxillary tuberosity. The pres-
ence of a significant tuberosity is subject to fracture during the extraction. The
cleavage plane can extend up the lateral aspect of the maxilla to the infratemporal
space (Fig. 9.7). When this situation is recognized, preoperative sectioning of the
9 Complicated Exodontia 179

tooth and slow, careful expansion of the socket is indicated. If a significant fracture
occurs, cessation of the procedure and stabilization of the tooth to the adjacent tooth
until the fracture heals (4–6 weeks) are indicated.

9.4 Mandibular Extraction

The increased density of mandibular bone and the issues associated with the course
of the inferior alveolar nerve can create issues unique to this area of the oral cavity.
Proximity of the apical regions of mandibular molars with the inferior alveolar
nerve may dictate that a coronectomy procedure would provide a better outcome by
reducing risk of damage to the neurovascular bundle (Fig. 9.8).
The dense bone of the mandible and often multirooted molar teeth can present a
challenge to even the most experienced surgeon. As noted in Fig. 9.9, the mandibular
third molars are anticipated to be a relatively complicated extraction. The surgeon
will often need to remove a significant amount of bone as well as section these teeth
to enable removal. Late infections and even fractures of the mandible can occur due
to excessive forces during the extraction or overheating the bone during surgery.
Consistent irrigation with the use of sterile solutions is indicated throughout cutting
the bone and teeth.
It is important to be aware of the risks of subcutaneous/submucosal emphysema
(Miller and Lieblich 2012) with the use of conventional dental handpieces. The air
and air/water spray can dissect under raised flaps creating substantial tissue
emphysema (Fig. 9.10). Most surgical handpieces are a combination of rear exhaust
along with the use of nitrogen gas. If nitrogen gets under the tissues, it is rapidly
absorbed due to its solubility. In contrast forced air continues to dissect under the
tissue planes and may not be recognized by the practitioner or initially felt by the
patient due to local or general anesthesia. In severe cases the air has dissected into
the periorbital regions causing visual changes as well as inferiorly creating acute
airway compromise.

a b

Fig. 9.8 Deeply impacted lower second molar with radiographic evidence of contact with the
inferior alveolar nerve. (a) Preoperative view. (b) Coronectomy procedure with intentional
retention of the roots to reduce risk of nerve injury
180 S. Lieblich

Fig. 9.9 The posterior ramus of the mandible provides an anatomic hinderance to the extraction
of these lower third molars

a b

Fig. 9.10 (a) Facial swelling immediately following extractions with the use of a conventional
dental handpiece with air/water spray being used. (b) The CAT scan shows extensive free air
(arrows) in the submucosal tissues that has dissected to the orbital region causing visual defects

9.5 Conclusion

The extraction of teeth can range from relatively simple to extremely complex. It’s
incumbent upon the dentist to start with a careful evaluation of the patient to assure
they are physically able to withstand the procedure. Although complicated extrac-
tions cannot always be predicted in advance, there are certain anatomic factors that
can indicate the surgery may be more complicated. Preparing the patient for the
complexity as well as an honest assessment of the practitioner’s experience with
these cases may help determine which cases can be treated or which ones need to be
referred.
9 Complicated Exodontia 181

References
Damm DD, Jones DM. Bisphosphonate related osteonecrosis of the jaws: a potential alternative to
drug holidays. Gen Dent. 2013;61:33.
Eagle KA, Brundage BH, Chaitman BR, Ewy GA, Fleisher LA, Hertzer NR, et al. Guidelines
for perioperative cardiovascular evaluation for non-cardiac surgery. Report of the American
College of Cardiology/American Heart Association Task Force on practice guidelines
(Committee on Perioperative Cardiovascular Evaluation for Non-cardiac Surgery). J Am Coll
Cardiol. 1996;27:910–48.
Krishnan D, Lieblich SE, Swift JQ, et al. Multicenter report of antibiotic usage for third molar
surgery. San Francisco, CA: AADR/IADR/CADR General Session; 2017.
Lillis T, Ziakis A, Kostinas K, et al. The safety of dental extractions during uninterrupted single or
dual antiplatelet therapy. Am J Cardiol. 2011;108(7):964–7.
Lu S-Y, Tsai C, Lin L, Lu s-N. Dental extraction without stopping single or dual antiplatelet
therapy: results of a retrospective cohort study. IJOMS. 2016;45(10):1293–6.
Miller JM, Lieblich SE. Cervicofacial subcutaneous emphysema after surgical extraction: report of
cases and review of literature. J Oral Maxillofac Surg. 2012;70(9 Suppl 2):e50–1.
Piecuch JF, Arzadon J, Lieblich SE. Prophylactic antibiotics for third molar surgery: A supportive
opinion. J Oral Max Surg. 1995;53(1):53–60.
Ruggiero SL, Dodson TB, Assael LA, et al. American Association of Oral and Maxillofacial
Surgeons position paper on bisphosphonate-related osteonecrosis of the jaws—2009 update. J
Oral Maxillofac Surg. 2009;67:2.
Ruggiero SL, Todson TB, Fantasaia J, et al. American Association of Oral and Maxillofacial
Surgeons position paper on medication-related osteonecrosis of the jaws-2014 update. J Oral
Maxillofac Surg. 2014;72:1938–56. https://www.aaoms.org/docs/govt_affairs/advocacy_
white_papers/mronj_position_paper.pdf. Accessed 12 Dec 2017
Unerupted and Impacted Teeth: A Guide
for Assessment and Treatment 10
Leon A. Assael

“How often have I said to you that when you have eliminated
the impossible, whatever remains, however improbable, must be
the truth.”
—The Sign of the Four

Abstract
This chapter provides a comprehensive review of patient assessment and treat-
ment recommendations for patients with unerupted and/or impacted teeth. Risk
assessment for treatment options is provided.

10.1 Introduction

Among the normal developmental and pathologic conditions of note in dental prac-
tice is the presence of unerupted teeth. While the most common unerupted tooth is
the mandibular third molar at all stages of life, mandibular canines are next in fre-
quency of impaction. However, every deciduous and permanent tooth has been
noted to be unerupted sometimes with associated pathology and sometimes without
any discernable health consequence. Supernumerary teeth also are noted to be
impacted, about 70% of which are mesiodens in the anterior maxilla in the incisive
foramen region (McBean and Miloro 2018). The comprehensive oral health
assessment of the patient always must consider unerupted teeth and their potential
health consequences.
Seventy-nine percent of all young adults have four third molars present, while
only 12% have no impacted third molars (Hugoson and Kugelberg 1988). In addition
to third molars, every deciduous and permanent tooth has been noted to exhibit
delayed eruption or impaction due to associated pathology and sometimes with
important adverse health consequences. These adverse consequences of impaction

L. A. Assael (*)
University of California San Francisco, San Francisco, CA, USA
e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2019 183

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_10
184 L. A. Assael

may be local, causing damage to vital structures or system, due to the effects of
inflammation or neoplasm. Thus, the comprehensive oral health assessment of the
patient always must consider unerupted teeth and their potential health consequences.
Patients depend upon their general dentist for assessment of their personal oral
health, which includes assessment of pathology and prognostic assessment. If the
dentist determines the removal of an impacted tooth is required, does the patient
with an unerupted tooth require referral to a surgeon or will the dentists carry out the
procedure themselves? An understanding of difficulty assessment and relative risk
of morbidity assessment is needed to determine that plan. Can the plan for a patient’s
impacted teeth also be based upon all determinants of health: concomitant oral
health status, systemic health, and the social determinants of health? The general
dentist, with their long-term relationship with the patient, may be in the best position
to bring the presence of impacted teeth into the context of what is of greatest benefit
to the patient. Thus, the need for detailed knowledge of impacted teeth is critical to
optimal general dental practice.

10.2 Assessment of Unerupted and Impacted Teeth

The role of the general dentist as the leader of the oral health-care team is essential
in the assessment and considerations for management of impacted teeth. Patients
will expect their family dentist to be able to advise on the presence of impacted teeth
as well as their need for either observation or removal.
Physical examination involves the counting of each tooth and determination of
the status of missing teeth, including all 20 deciduous and all 32 permanent teeth.
Palpation of the jaws and dental arches will determine areas of hard or soft tissue
swelling that might represent the presence of unerupted or impacted teeth.
Displacement of erupted teeth, translocation of erupted teeth, and crowding of
erupted teeth are associated with concomitant impacted teeth. Inflammation
including redness, tenderness, swelling, or warmth may represent infection
associated with an impacted tooth. Soft displacement of the tissues during palpation,
termed ballotability, is a sign associated with impacted teeth. In the case of third
molars, partial eruption may result in pericoronitis and infection of the pericoronal
tissues characterized by pain, trismus, fetor, and purulent discharge. Due to the
ectopic position of some impacted teeth, they may not be visible on routine intraoral
radiographs, so determination of their status will help determine the need for further
imaging evaluations.
Imaging: Utilization of comprehensive imaging of the dental patient now
includes the assessment of dental growth and development and pathology of the
jaws for every patient. Due to contemporary imaging techniques, with the common
use of the panoramic radiograph in general practice, and more recently with cone
beam CT scan, every general dentist should have access to comprehensive imaging
assessment of impacted and unerupted teeth, and their associated pathology, during
the course of growth and development as well as throughout life. The use of full
mouth series, periapical radiographs, does not adequately detect or evaluate
10 Unerupted and Impacted Teeth: A Guide for Assessment and Treatment 185

impacted teeth and is a known risk for false-negative findings as a diagnostic tool
for this purpose. Full mouth series will result in false negatives when determining
the presence or characteristics of impacted teeth. Panoramic radiographs are
adequate to identify essentially all impacted teeth as well as their location and
associated pathology for purposes of surgical decision regarding the need for
removal and as a guide to removal method in most cases (Figs. 10.1 and 10.2). Cone
beam CT provides a comprehensive three-dimensional evaluation of the impacted
tooth and is a consistently useful guide as to best methods for removal with
minimized surgical trauma and risks to vital anatomic structures including the
inferior alveolar nerve.
Evidence-based assessment: Patients depend upon the general dentists for their
assessment which includes assessment of pathology and prognostic assessment.
Simply stated, does the patient with an unerupted tooth require its removal? In a

Fig. 10.1 Panoramic radiograph reveals impacted tooth #1, impacted #17 with hypercementosis,
Pell and Gregory type 2B and impacted #32, also with hypercementosis and Pell and Gregory
type 1A

Fig. 10.2 This periapical radiograph does not adequately evaluate the relationship of this impacted
tooth to the inferior alveolar nerve or the associated osseous pathology demonstrated in the panorex
186 L. A. Assael

practical sense, referral to a surgeon usually indicates a plan to remove the tooth.
Although an assessment by the specialist can be requested, a bias toward tooth
removal will be commonly made by the specialist as their life experience, seeing the
complications of retention of impacted teeth, and practice model may be a guide
toward treatment. Surgeons who reject a dentist’s plan for the removal of an
impacted tooth usually do so for assessment of medical comorbidities or assessment
of increased risk of surgically related complication such as nerve injury or damage
to adjacent teeth. Despite a predilection toward removal of impacted teeth, not all
impacted teeth need to be removed. Decision to remove an impacted tooth needs to
be made on sound diagnostic criteria and indications for care. Fortunately, there is a
broad scientific body of knowledge regarding the indications for care in the
management of impacted teeth that can guide the general dentist toward knowing
which cases should be referred and how patients should be informed of risks and
benefits of unerupted teeth. These decision points may be delineated according to
the following criteria:

1. Is the tooth simply unerupted, or is it impacted?

2. Is the tooth ankylosed during growth, or are there other etiopathologic reasons
for failure of eruption?
3. Does the tooth demonstrate a threat to periodontal health of adjacent teeth?
4. Is the tooth carious, is the distal of the second molar carious, or has it under-
gone internal resorption?
5. Is an abnormal pericoronal or periradicular radiolucency present?
6. Are there signs of acute or chronic infection?
7. Does the patient exhibit pain associated with the impacted tooth?
8. Is the tooth contributing to a malocclusion or skeletal facial deformity?
9. Does the tooth impinge on vital structures?
10. Does the impacted tooth have an effect on systemic health?
11. Does the patient have a syndromic or developmental problem associated with
unerupted teeth?
12. Does the unerupted tooth represent a potential important functional component
of the masticatory system?

10.2.1 Is the Tooth Simply Unerupted, or Is It Impacted?

Teeth that are unerupted during normal growth and development are not impacted.
There are predictors of impaction that might indicate future impaction. For example,
Ricketts arcial growth analysis of mandibular vertical and horizontal ramus growth
demonstrated that persistence of the third molar in the vertical ramus might be a
strong predictor of impaction (Ricketts 1972). His demonstration of the downward
and forward growth of the mandible showed that lower mandibular plane angles and
longer horizontal ramus length resulted in less impaction of third molars. Third
molars that remain above the occlusal plane in the vertical ramus by age 12 nearly
always remain impacted, while those unerupted teeth in the horizontal ramus nearly
always erupt. On the other hand, Kugelberg’s work demonstrated that the period
10 Unerupted and Impacted Teeth: A Guide for Assessment and Treatment 187

between ages 20 and 30 surprisingly resulted in eruption of nearly half of teeth that
would have been presumed to be impacted in a longitudinal third molar observation
study (Kugelberg et al. 1991). The 60% of third molars that were mesial or verti-
cally impacted at age 20 and followed without extraction had an overall impaction
rate of 32% at age 30. Thus, with 100% of third molars impacted at age 15 and
observed, just a third of retained third molars remained unerupted at age 30.
Nonetheless, many unerupted teeth are removed in midteens/late teens, though
they are not yet determined to be impacted, but justifiable removal may be carried out
for orthodontic purposes, to prevent later greater risk of inferior alveolar nerve injury,
or because of the decreased risk of complications in removal in younger patients.
In 1933, Pell and Gregory attempted to define third molar impaction based upon
a classification system describing the length of the dentoalveolar process and the
location of the vertical ramus, whereby inadequate arch length produced impaction
(Pell and Gregory 1933). Teeth entirely in the horizontal ramus are Class 1, those
less than half in the vertical ramus are Class 2, and those in with a majority in the
vertical ramus are Class 3. The subclassification is type A for at the occlusal plane,
type B for a tooth above the cementoenamel junction (CEJ) of the second molar, and
type C for a tooth apical to the CEJ of the second molar (Fig. 10.1). Anatomically,
a Class 1A tooth would have the greatest ease of removal with the lowest morbidity,
and a Class 3C would have the highest difficulty and risk for morbidity. This
classification system has now been adapted for assessment with cone beam CT
(Maglione et al. 2015). For impacted premolars, loss of arch length due to pediatric
caries is the most common reason for impaction.
As a practical matter, impaction is a diagnosis made on the basis of the prepon-
derance of evidence in a clinical situation. Is there an anatomic obstruction to erup-
tion? Is there adequate arch length to permit eruption into a functional aspect of the
dentoalveolar process?

10.2.2 I s the Tooth Ankylosed During Growth, or Are There Other

Etiopathologic Reasons for Failure of Eruption?

Deciduous molars and permanent first and second molars in the mandible are the
most commonly ankylosed teeth causing failure of eruption as well as diminished
vertical growth of the dentoalveolar process in the affected region (Fig. 10.3a).
Ankylotic failure of eruption is often identified by the progressive impaction of the
tooth over time, by dilacerations of the root, and by the absence of a portion of the
periodontal ligament with associate direct alveolar bone contact with the tooth
(Fig. 10.3b). Unerupted maxillary canines that do not respond to exposure and
orthodontic traction can be noted to be ankylosed (Plaisance et al. 2017).

10.2.3 D
 oes the Tooth Demonstrate a Threat to Periodontal
Health of Adjacent Teeth?

Analysis of the regional and general periodontal health of patients with impacted
third molars has been an object of assessment in multiple longitudinal third molar
188 L. A. Assael

a b

Fig. 10.3 (a) Impaction of a deciduous second molar due to ankylosis. (b) Impaction with anky-
losis is noted for teeth numbers #4, 5, and 31. Note progressive impaction of these teeth due to
ankyloses in the dental arch during vertical development of the jaws

studies. Increased pocket depth, increased levels of inflammatory mediators, and

increased gingival index have been noted in the second and first molar and to a
lesser extent in the entire quadrant where a partially erupted third molar is present
in the mandible. Substantial periodontal pathology has been observed in patients
with asymptomatic impacted third molars, and that pathology has been noted to be
progressive (Blakey et al. 2002). The microorganisms in the gingival crevicular
fluid of impacted third molars have been noted to express orange and red organisms
according to Socransky’s criteria, meaning that they are those organisms associated
with progressive bone loss (Socransky and Haffajee 2002). The prevalence of those
organisms in impacted third molars has demonstrated colonization by invading
neutrophils resulting in chronic inflammation and bone loss due to periodontal
pathogens. This can also be measured by levels of inflammatory mediators,
cytokines in the pericoronal tissues. White demonstrated elevated levels of IL-1B
and PGE2, two cytokines associated with periodontal bone loss in partial bony
impactions (White et al. 2002). Additional longitudinal studies on impacted third
molar retention show a greater risk of periodontal bone loss progressive over time
in the quadrant where the partially erupted impacted third molar remains, at least for
mandibular teeth. Kugelberg et al. noted that extraction of the third molar during the
course of impaction prior to the age of 25 results in recovery of pocket depth and
bone loss, while removal later in life does not accrue that benefit. (Kugelberg et al.
1991). Early removal of mesioangular impacted third molars had beneficial effects
on pocket depth and periodontal health (Fig. 10.4).

10.2.4 I s the Tooth Carious, Is the Distal of the Second

Molar Carious, or Has It Undergone Internal/External
Resorption?

During development, impacted third molars do not gain the functional anatomic
resistance to caries equivalent to other teeth. This is due to the variable deep pits and
fissures in the crown and decreased extent of enamel development. The result is a
10 Unerupted and Impacted Teeth: A Guide for Assessment and Treatment 189

Fig. 10.4 Normal osseous recovery after removal of third molars for orthodontic purposes

high caries rate in erupted and partially erupted third molars noted to be high in
White’s studies with a progressive extension of caries in observational studies.
Erupted third molars have a higher risk of cervical caries in the older patient as well.
Resorption of the cervical portion or roots of adjacent teeth is associated with
impaction as well as internal and external resorption of the impacted tooth. In young
adults, the risk of caries on the distal of the second molar more than doubles if a
partial bony impacted third molar is present (Assael 2002). This may result in pulpal
necrosis of the impacted or adjacent teeth with subsequent symptoms. Resorption of
the impacted tooth is also associated with the neurovascular bundle in the mandible
and may also be associated with narrowing of the neurovascular bundle.

10.2.5 I s an Abnormal Pericoronal or Periradicular Radiolucency

Present?

All impacted teeth will exhibit a pericoronal radiolucency. This represents the coro-
nal dental follicle which envelops the enamel of the unerupted tooth. The epithelial
attachment of this follicle should be at the cervical margin of the tooth in the
unerupted state such that the developing periodontal ligament has a direct interface
with adjacent alveolar bone. When the unerupted tooth is in a pathologic state,
inflammation and epithelial migration of the pericoronal cap cause expansion of the
pericoronal radiolucency to both enlarge its pericoronal components and to encom-
pass a portion of, or all of, the root of the impacted tooth. This process results in a
dentigerous cyst, which will undergo osmotic expansion until it is disrupted by erup-
tion of the tooth or surgical decompression or removal. When pericoronal expansion
occurs in an erupting tooth, it is termed an eruption cyst which once broken will
through gingival apoptosis allow the eruption of the tooth and development of the
gingival crevicular epithelium.
Other pathologic conditions also can produce periradicular radiolucency. These
include most commonly keratocystic odontogenic tumor (aka odontogenic keratocyst)
190 L. A. Assael

or other odontogenic tumors such as ameloblastoma. Adenomatoid odontogenic tumor

is also noted to occur nearly exclusively in association with impacted maxillary canines
(Al-Shimari et al. 2017).
The prevalence of pericoronal pathology should encourage the submission of all
such tissue removed during the course of impaction removal to the pathologist, but
this is by no means a routine standard of practice. The overall risk of pathology has
been evaluated associated with the submission of otherwise normal pericoronal
tissue to oral pathology services where all removed soft tissue is submitted. A study
of 2646 such specimens reveals that 67% were non-pathologic, while 28%
represented dentigerous cysts and 3% keratocysts, and the remaining were various
other tumors most notably 13 ameloblastomas and 6 carcinomas (Curran et al.
2002). Overall in just under 1 in 20 cases, the pathologic diagnosis resulted in a
need for subsequent clinical action due to the risk of progressive disease.

10.2.6 Are There Signs of Acute or Chronic Infection?

Anamnestic assessment (patient history) should assess a recent history of signs of

infection.
In addition to physical evaluation noted above, objective findings of the clinical
examination should be recorded, including range of motion, swelling, pain, fever,
and fetor. In the adolescent and young adult, tonsillitis with beta-hemolytic strep is
also associated with pericoronal inflammation in third molars. Radiographic signs
of chronic infection such as mottling of bone or focal bone loss should be noted.

10.2.7 D
 oes the Patient Exhibit Pain Associated
with the Impacted Tooth?

Pain associated with impacted teeth is one of the frequent reasons for their removal.
In the ramus of the mandible, myofascial pain is often noted in chronic impaction.
Bone pain is noted as well, but the reasons for this when no infection is present have
not been discerned. Of note as a possible cause is the increased levels of osteolytic
cytokines associated with impacted teeth including proinflammatory cytokines that
could even in the absence of infection elicit pain. While this pain commonly associ-
ated with eruption (aka teething) is a temporary phenomenon that ceases with the
eruption of the tooth, patients with impacted teeth may suffer from periodic exacer-
bations of bone pain associated with the impaction.

10.2.8 I s the Tooth Contributing to a Malocclusion or Skeletal

Facial Deformity?

The role of impacted teeth as etiologic in malocclusion is, after numerous studies,
remains unclear. Lower incisor crowding and maxillary crowding are associated
with the presence of impacted teeth especially mesioangular impacted teeth
10 Unerupted and Impacted Teeth: A Guide for Assessment and Treatment 191

(Beeman 1999). This association has caused orthodontics for decades to recommend
the removal of impacted third molars especially when young adults are going into
retention therapy after full-banded orthodontics. There is however scant evidence
that this association is one of the causes and effects. There are some interesting
studies in this regard.
Early studies indicated the reasons for incisor crowding after orthodontics to be
non-impaction related. An Iowa study of models with a split-mouth design took
post-retention orthodontic patients and removed third molars unilaterally. Less
crowing was noted on the extracted side. Attempts to use pressure transducers after
extraction actually showed lower interdental forces on the non-extraction side. The
effect of impacted teeth on occlusion is multifactorial and has not been categorized
sufficiently to be a guide to treatment decisions. Impacted mandibular third molars
are associated with more mesial angulation of mandibular first and second molars
and more incisor crowding assessed with contemporary imaging methods (Hasegawa
et al. 2013).

10.2.9 Does the Tooth Impinge on Vital Structures?

Impingement on adjacent teeth is associated with external root resorption and peri-
odontal bone loss. The lingual nerve is impinged upon by lingually inclined and
vertical/distoangular impactions of the mandible third molars. Chronic pericoronitis
of these teeth is associated with adherence of the lingual nerve to the follicle
markedly increasing the risk of lingual nerve injury at the time of removal.
Determination of the risk of inferior alveolar nerve injury is dependent upon the
factors indicating direct impingement. These have been noted radiographically by
Rood and others to include loss of the white line of the inferior alveolar canal,
narrowing of the inferior alveolar canal, darkening of the root of the impacted tooth
as seen on panorex, and deflection of the root. Periapical film is inadequate to
evaluate this risk (Fig. 10.2). While the background risk of inferior alveolar nerve
injury is noted to be about 1%, multiple positive radiographic features noted here
increase the risk to as high as 24%. Thus, radiographic and clinical assessment of
the risk of nerve injury will guide a decision to carry out elective removal of
impacted mandibular third molars.
Impacted canines occur far more frequently in the maxilla where damage to the
lateral incisor and less so to the central incisor can result in the loss of these teeth.
Such teeth are variously observed, exposed and orthodontically erupted, or removed.
The relationship of the impaction on vital structures including teeth and the floor of
the nose can guide treatment decisions.

10.2.10 D
 oes the Presence of an Impacted Toot Have an Effect
on Systemic Health?

If inflammatory mediators are present producing local inflammation and immune

response, does this have an impact on systemic health. Such impacts have been
192 L. A. Assael

studied for untreated periodontal disease and caries in populations such as those
with atherosclerotic disease and pregnant patients with remarkable associations
noted. Moss reported on the systemic impact of impacted third molars with
periodontal pathology (Moss et al. 2006). This study found that third molars with
greater than 4 mm of pocket depth had association with more negative health
outcomes including gestational age less than 37 weeks and elevated serum levels of
C-reactive protein during the study. It should be noted that this was an observational
study in which the association does not demonstrate cause and effect; however
levels of these inflammatory mediators drop after the removal of such impacted
teeth including in the adjacent second molar. The recommendation is that for
systemic purposes early third molar removal is recommended when pocket depth is
greater than 4 mm.

10.2.11 D
 oes the Patient Have a Syndromic or Developmental
Problem Associated with Unerupted Teeth?

Cleidocranial dysplasia is associated with impacted and supernumerary teeth, often

with major failure of eruption and not functional dentition. Other syndromes are
associated with failure of eruption or delayed eruption. Multiple unerupted or
supernumerary teeth should initiate a genetic consultation to determine whether
there is an inherited underlying cause.

10.2.12 D
 oes the Unerupted Tooth Represent a Potential
Important Functional Component of the Masticatory
System?

Unerupted teeth can be successfully brought into good function in the oral cavity
by surgical exposure, assisted eruption, and uprighting. This is commonly done
for canines and mesioangular molars (Magkavali-Trikka et al. 2018). Erupted
teeth can also be removed to facilitate the eruption of delayed teeth. This is espe-
cially the case for first bicuspids associated with impacted second bicuspids and
blocked-out canines. Loss of first molars during growth due to caries will often
permit the facilitated eruption of third molars in order to achieve a two molar
occlusion in the affected quadrant. In the past this was sometimes done with
third molar to first molar transplant, but more contemporary therapy allows for
the mesial orthodontic movement of the second and third molar. The removal of
impacted third molars or other impacted teeth may be deferred when the adja-
cent teeth in function exhibit advanced caries (or rarely early aggressive peri-
odontal disease). Even the late loss of a first or second molar due to caries can
permit the subsequent assisted or spontaneous eruption of the impacted third
molar.
10 Unerupted and Impacted Teeth: A Guide for Assessment and Treatment 193

10.3 Risk Assessment in Third Molar Removal

A fundamental question in risk assessment is “Should asymptomatic third molars be

removed?” This question relates to risk since it is clear if there was no morbidity,
risk, or mortality associated with the removal of asymptomatic nonfunctioning
impacted teeth, then they should all be removed. However notable risk for temporary
disability, permanent injury, and even death can result from this surgical intervention.
Thus, indications for care must take into account a demonstrated benefit that
outweighs these real if rare substantial complications.
What is the risk of surgical catastrophe after third molar removal? Every experi-
enced surgeon has seen hospitalization for bleeding or infection after impacted
tooth removal, and many have seen severe systemic complications including death
associated with anesthesia and surgery for removal of third molars. Risk of death
during ambulatory anesthesia for oral surgery has been variously reported in ranges
from 3 in 5,000,000 to as high as 1 in 50,000 cases. Hospitalization from bleeding
occurs in about 1 in 10,000 cases and permanent lingual or inferior alveolar nerve
injury in about 1% of cases.

10.3.1 Indications for Third Molar Removal

When all the indications for removal are assessed, the evaluation of third molars has
driven most health systems toward removal either electively or as a result of
pathology. Indeed, even in societies where elective third molar removal is not usual
as in Norway, 85% of elder patients have no third molars present (Hugoson and
Kugelberg). Reasons for removal most commonly include pericoronal inflammation,
periodontitis, caries, jaw pathology, and for preprosthetic reasons.
All surgical procedures must include a statement of the indications for care.
While at minimum, this includes a diagnostic code, a narrative indicating the
pertinent findings from assessment as noted in the previous assessment is needed to
justify what will be a substantial surgical procedure, the removal of an impacted
tooth. An evidence-based assessment of the benefits of removal that are more
influential in guiding treatment than acceptable risk should be noted. This is an
individualized process that should respect the individual needs and desires of the
patient and patient autonomy.

10.3.1.1 Findings and Indications for Care

Example 1: This 22-year-old male presents because of mesioangular impaction of a
left mandibular third molar associated with inadequate arch length, chronic
pericoronal inflammation, and 6 mm. pocket depth on distobuccal of the mandibular
second molar.
Example 2: This 40-year-old clarinet player presents for assessment of a full
bony impacted mandibular third molar with a 3 mm pericoronal radiolucency. Rood
classification indicated deflection of the root and narrowing of the inferior alveolar
194 L. A. Assael

canal. Treatment plan is to inform the patient of symptoms to be on alert for and to
return in 1 year for examination and radiographs part of routine dental follow-up.
No extraction indicated at this time.
Indications for third molar removal have been assessed by consensus and evi-
dence and vary among health systems. In Europe impacted teeth are retained if they
are fully impacted with no oral cavity communication and no associated osseous
pathology. If erupted they are retained if gingival tissue is keratinized and pocket
depths are less than 4 mm with no bleeding or drainage on probing and no caries
(Wower and Nielsen 1989).
As a practical matter, those factors that affect the clinical decision to remove an
impacted tooth include the presence of symptoms, age of the patient, health status
of the patient, concomitant risk factor assessment, pocket depth, presence of
inflammatory signs, proximity of vital structures, and presence of additional
pathology.

10.3.2 E
 vidence-Based Assessment of Surgical Technique
and Perioperative Care

A Cochrane review of surgical techniques for removal of mandibular wisdom teeth

was performed in 2014 which demonstrated a cacophony of methods for removal
(Coulthard et al. 2014). This review of 35 trials indicated a high risk of bias due to
the observes and the preferred methods of the operators. Triangular and envelope
flaps were compared; irrigation methods, technique of bone removal, use of
retractors closure technique, and use of surgical drains and coronectomy were
compared. No conclusions would be made that would support in changing preferred
practice of the operating surgeon with regard to comparative techniques.
Decision points in the operative technique for removal of impacted teeth include:

1. Adjunctive medical management: steroids, analgesics, antibiotics

2. Access incisions
3. Ostectomy and osteotomy
4. Sectioning of the tooth
5. Preservation of vital structures
6. Management of the osseous defect
7. Closure
8. Postoperative instructions

10.4  djunctive Medical Management: Steroids, Analgesics,

A
and Antibiotics

Steroids are a class of anti-inflammatory drugs based upon the steroid ring of cor-
tisol, a hormone that modulates inflammation by decreasing movement of fluid
into the extracellular space, thereby decreasing edema, and inhibiting the
10 Unerupted and Impacted Teeth: A Guide for Assessment and Treatment 195

migration through chemotaxis of inflammatory cells, thus reducing the effects of

inflammatory mediators in the surgical site. In the removal of impacted teeth, they
are demonstrated to reduce trismus, swelling, and pain in the immediate postopera-
tive days.
Analgesics: Postoperative opioids have been the bulwark of pain management
following impacted tooth removal for decades. Recent attention to the adverse
effects of these drugs have included an understanding that prescription opioids,
especially in the young adults, carry substantial risk of subsequent abuse and
potential addiction risk. In addition, recent analgesic studies demonstrate that
nonsteroidal anti-inflammatory drugs, most prototypically ibuprofen, demonstrate
equivalent or even superior analgesic effect, especially when used preemptively, as
a preoperative dose of 400–600 mg of ibuprofen followed by scheduled postoperative
dosing. Effectively addressing postoperative patient has the additional advantages
of supporting adequate postoperative oral intake and return to activities of daily
living, both of which are associated with more rapid recovery from surgical
interventions.
Recently nonsteroidal anti-inflammatory drugs have been injected into the surgi-
cal site concurrent with impacted tooth removal with good effect (Gorecki et al.
2018). The use of rescue medication increased by 16 h for the highest dose of sub-
mucosal diclofenac.
Antibiotics: While antibiotics are commonly prescribed in conjunction with
impacted tooth removal, no standardized approach to this has reached the prac-
ticing community. Antibiotics are given preoperatively or during the procedure
or postoperatively or not at all. Morrow examined whether postoperative antibi-
otic use had an impact on inflammatory complications through a practice-based
research model. Inflammatory complications were low in both groups 4.3% in
the antibiotic group and 7.5% in the no antibiotic group, a 40% drop in risk
(Morrow et al. 2018). Contemporary assessment of antibiotic use associated with
removal of teeth indicates it is overused and not in an evidence-based fashion
(Kim et al. 2018). Evidence-based interventions have substantially reduced the
utilization and improved the quality of utilization of antibiotics in association
with impaction surgery, while the use of antibiotics remains well established
(Piecuch et al. 1995).

10.5 Access Incisions

Access incisions for removal of impacted teeth must address the need to preserve or
reconstruct adequate attached gingival tissue abutting the surgical site and for the
adjacent teeth (Fig. 10.5). There is no single correct flap designed for any given
surgical situation, and planning should involve a balance between the need for
complete access to the surgical site and the need to preserve critical components of
soft tissue associated with osseous defects and the dentition. Indeed, studies
comparing flap designs have not demonstrated appreciable differences at 90 days
after exodontia, though releasing incisions have been associated with higher initial
196 L. A. Assael

Fig. 10.5 Triangular flap

(with anterior release) for
removal of mandibular
third molar

symptoms and swelling (Ottria et al. 2017). Gingival margin incisions have the
advantage of permitting replacement without the risk of vertical defect, while
releasing incisions can give more substantial access to the surgical site for ostectomy
and tooth sectioning. For third molars, releasing incisions are always performed
lateral posteriorly, but if the flap is released anteriorly as well, it is referred to as a
triangular flap. Triangular flaps can offer greater visibility of deep impactions but,
due to incising of the buccinator muscle, result in greater buccal swelling and
trismus.

10.6 Ostectomy and Osteotomy

Cutting of bone (osteotomy) and removal of bone (ostectomy) are performed in

order to gain access to the impacted tooth for removal. Small areas of very thick
bone, such as on the external oblique ridge of the mandible, normally undergo
ostectomy, wherein the cut bone is removed, while areas where a thin bone layer
may be covering the impacted tooth as in the maxilla for an impacted third molar or
canine can undergo osteotomy with osteoperiosteal flap, preserving the thin layer of
buccal bone attached to the overlying periosteum. Bone that is removed in association
with impacted teeth should remove cortical bone in direct apposition to the
periodontal ligament or crypt of the impacted tooth of a sufficient thickness to
permit placement of an elevator. Too aggressive removal of bone may result in an
excessive loss of anatomic integrity of the bone and increase the risk of fracture of
the jaw during elevation of the tooth (Fig. 10.6).
Due to the risk of tissue emphysema or venous air embolism, routine high-speed
dental handpieces are not suitable for removal of bone or sectioning impacted teeth.
Such air embolisms have been demonstrated to be a fatal outcome of their misuse of
the handpiece in the dental operatory. A designated surgical handpiece such as the
Hall air drill does not permit the anterior escape of air that can result in air embolism
or tissue emphysema.
10 Unerupted and Impacted Teeth: A Guide for Assessment and Treatment 197

Fig. 10.6 Appropriate

defect associated with
removal of mandibular
third molar

10.7 Sectioning of the Tooth

Impacted teeth may be sectioned prior to removal for several purposes: to provide
removal of the tooth through a more limited osteotomy access, to allow the
manipulation of curved roots separately to permit a pathway for removal, and to
protect vital structures such as the inferior alveolar nerve from the pressure of
luxation. Teeth are sectioned in two basic fashions, to separate the crown from the
roots or to separate roots from one another. Maxillary third molars are very rarely
sectioned due to the softness of maxillary bone the path of removal along a
distobuccal track. Maxillary canines often benefit from sectioning the crown from
the root to facilitate removal in a dentoalveolar site of crowding, especially adjacent
to the maxillary lateral incisor. Mesioangular third molars are routinely sectioned
vertical separating the mesial from the distal crown and root, while vertical and
distoangular impacted third molars in the mandible generally have the crown
sectioned from the root followed by crown delivery and root delivery in one or two
root segments.

10.8 Preservation of Vital Structures

For maxillary impacted teeth, violation of the maxillary sinus with disruption of the
Schneiderian membrane can result in sinusitis or an oral antral fistula. During
removal of mandibular third molars, a lateral posterior flap design must be used to
protect the lingual nerve which is coursing just directly distal to the second molar
and on the lingual crest of the mandible. Some surgeons advocate the retraction of
lingual tissues to prevent lingual nerve severing, while others prefer to not manipulate
lingual tissues due to the risk of traction nerve injury of the lingual nerve. Removal
of the roots of impacted teeth should be done with judicious force understanding the
risk to the inferior alveolar nerve and toward displacement of roots beyond the
boundary of the mandible, especially into the submandibular space.
198 L. A. Assael

10.9 Management of the Osseous Defect

Removal of impacted teeth necessarily results in a substantial osseous defect in

a region where regeneration is often needed to regain osseous strength and to
restore periodontal health. Various bone preservation and guided tissue regen-
eration techniques have come into common use to regain healthy bone and soft
tissue. These have included the use of platelet-rich plasma, cadaver bone, bone
substitutes, bone morphogenic proteins, and other bone-promoting substances
among others. Membranes have also been used to enhance gingival epithelial
reattachment. While all of these are reports, study of the impaction site in heal-
ing without these methods indicates that they are not routinely desirable or nec-
essary where normal health can be anticipated. Such normal healing can be
anticipated in patients under the age of 25, with no medical comorbidities and
no preexisting pathology such as greater than 4 mm. pocket or coexisting osse-
ous pathology.

10.10 Closure

Primary closure of surgical sites after odontectomy can result in increased swell-
ing due to contained hematoma and greater postoperative edema due to fluid
retention. On that basis, adaptation of critical portion of the wound such as gin-
gival attachment at ling angles is performed while permitting partially open
socket to permit the egress of blood and extracellular fluid. As a technique for
this in mandibular third molar removal, a single suture to adapt the distal buccal
line angle of the second molar is often performed after envelope flap with distal
release. Drains may be used after deep impaction, and these have shown some
benefit but require greater maintenance and follow-up which has limited their
routine use (Fig. 10.7).

Fig. 10.7 Single suture on

distobuccal line angle of
second molar to close third
molar site
10 Unerupted and Impacted Teeth: A Guide for Assessment and Treatment 199

10.11 Postoperative Instructions

Postoperative instructions after impaction surgery include the following domains:

Activity: Can the patient drive, operate machinery, and make decisions?
Diet: What food and liquids and in what quantity should be consumed?
Medications: Does the patient understand their analgesic use and other medica-
tions that may have been prescribed?
Medical comorbidities: Does the patient know how to manage systemic diseases
and associated medications during the postoperative period?
Precautions: Does the patient know what to expect regarding swelling, bleeding,
and pain, and do they know self-care plans regarding packs, ice, and analgesia?
Contact: Do they have 24/7 contact information to get help or answer queries?

10.12 Complications of Care

10.12.1 M
 ethods to Mitigate and Treat the Risks of Third Molar
Removal

The overall risk of complications after removal of impacted third molars is substan-
tial. Ons sing;e-center reported a complication rate of 17% with dry sockets account-
ing for the majority of cases. Interestingly, since most surgeons are right-handed,
the incidence of complications is higher on the left (contralateral side) of the operat-
ing surgeon, indicating a potential iatrogenic aspect of surgical complications
(Schwartz-Arad et al. 2017).

10.12.2 Dry Socket

Dry socket is an acute localized osteitis of the extraction site in which the initial clot
fails to organize and undergo fibrinogenesis, leaving bacterially contaminated exposed
bone with associated fetor and pain. It is never a simple dry socket when pus is present
or when it is associated with regional cellulitis. Dry socket is not an infection, and it
does not respond to antibiotics; however if an infection is misdiagnosed as a dry
socket, it may progress dangerously if treated with packing rather than drainage.
Essential ways to differentiate dry socket from postoperative infection include
the following, increased redness, tenderness/pain, temperature, and swelling (rubor,
dolor, calor, tumor), which are more indicative of postoperative infection than dry
socket. Laboratory values may be useful in which a leukocytosis with a shift to the
left is noted on CBC with infection and not with dry socket and increase in systemic
temperature is noted in infection but not dry socket.
Dry socket has been associated with various factors that could cause the failure
in the formation and retention of fibrin in the extraction site. Some of these include
cigarette smoking, use of birth control pills, menses stage, presence of pathogenic
bacteria, and food impaction.
200 L. A. Assael

Prevention has been promoted through the use of topical antibiotics, prophylac-
tic systemic antibiotics, copious saline irrigation, and chlorhexidine irrigation and
the use of steroids. Information on these methods has contrary assessments includ-
ing some that demonstrate increased risk for the use of steroids and antibiotics.
Treatment of dry socket is based upon reduction of the bacterial and inflammatory
product burden in the socket via irrigation with normal saline. Such irrigation often
removes much detritus form the site including necrotic clot, food, and bacterial film.
If pus is noted during examination or irrigation, it is NOT a dry socket. Instead a post-
operative infection is present which needs to be treated with drainage and appropriate
antibiotic. If, after exam and irrigation, a dry socket remains the working diagnosis,
gentle packing of the site with quarter inch plain or iodoform gauze along with a topi-
cal local anesthetic and an obtundent is often used. While eugenol is a very effective
obtundent, it is also neurotoxic and tissue toxic when concentrated. Thus, other obtun-
dents such as balsam of Peru are often used in dry socket dressings. FDA-approved
dry socket dressings, commercially available, attend to these issues adequately.

10.12.3 Postoperative Cellulitis and Abscess

Acute postoperative infection after third molar removal, like other infections after
surgery, typically occurs 3–5 days after the procedures. While normal swelling after
a surgical procedure typically peaks at 1–3 days after surgery, the patient with a
postoperative infection will have a further increase in swell typically at days 3–5
postoperatively. Additionally, fever, dehydration, trismus, redness, pus, difficulty
swallowing, tachypnea, and dyspnea may be noted.
Postoperative infection after impaction surgery is often a surgical emergency
requiring imminent drainage of the infection, parenteral antibiotics, fluid resuscita-
tion, and airway management.

10.12.4 Osseous Defect, Fracture, and Osteomyelitis

The osseous defect after removal of impacted teeth can be substantial so that mea-
sure to minimize this defect has included the use of bone grafts and tissue-guided
regeneration. Osteomyelitis after impaction removal is more frequent in older
patients and those with medical comorbidities such as osteomyelitis. While fracture
of the mandible can occur during removal, it is more frequent in the weeks and
months following removal due to progressive osteolysis associated with recovery or
subsequent osteomyelitis.

10.12.5 Oral Antral Fistula

Maxillary third molar removal is fairly commonly associated with oral antral com-
munication that is difficult to diagnose since its presenting finding may simply be a
deep periodontal pocket to the distal of the maxillary second molar along with
10 Unerupted and Impacted Teeth: A Guide for Assessment and Treatment 201

sinusitis. Communication with the sinus can be considered routine for any deeply
impacted maxillary tooth, so that careful attention to adequate closure and sinus
precautions in postoperative instructions is needed.

10.12.6 I nferior Alveolar Nerve Injury, Buccal Nerve Injury,

and Lingual Nerve Injury

Temporary or permanent damage to the inferior alveolar or lingual nerve can result
in loss of sensation in the lip, chin, tongue, and cheek and loss of taste in the affected
area and neuropathic pain. Such injuries require appropriate referral to an expert in
the surgical management of maxillofacial nerve injuries since early treatment is
often effective (Figs. 10.8 and 10.9).

Fig. 10.8 Lingual nerve

exposure and injury at the
time of third molar
removal

Fig. 10.9 Inferior alveolar

nerve in mandibular third
molar site, partially
severed
202 L. A. Assael

10.13 Summary

Careful diagnostic evaluation of unerupted teeth is needed to determine if they are

impacted and whether they exhibit the presence or the risk of associated pathology.
A decision to remove an impacted tooth should be evidence-based. Removal of
impacted teeth is an in-depth surgical procedure with structured procedural,
follow-up, and assessment components.

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Surgical Complications
11
Christine Niekrash and Michael T. Goupil

“There is nothing more stimulating than a case where

everything goes against you.”
Sherlock Holmes in—The Hound of the Baskervilles

Abstract
If a dental practitioner performs surgery, he or she will have complications. This
chapter will describe the evaluation and management of the most common surgi-
cal complications that might occur when performing dentoalveolar surgery.

11.1 Introduction

A surgical complication can be defined as an unanticipated problem that arises fol-

lowing, and is a result of, a provided treatment or procedure. Since pain and swell-
ing following a surgical procedure is expected, technically they should not be
considered surgical complications. But they would be considered complications if
there is an inordinate amount of pain and/or swelling, meaning more than antici-
pated for a particular surgical procedure.
This chapter is divided into three sections: preoperative, intraoperative, and post-
operative issues. This chapter covers treatment options and, when possible, preven-
tion strategies. Though most of the surgical complications are well known, there is
not necessarily a significant amount of published literature concerning these issues.
Much of the available information is anecdotal in nature, being passed from one

C. Niekrash
Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT, USA
e-mail: [email protected]
M. T. Goupil (*)
Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT, USA
Division of Oral and Maxillofacial Surgery, Emeritus Faculty, University of Connecticut
School of Dental Medicine, Farmington, CT, USA
e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2019 205

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_11
206 C. Niekrash and M. T. Goupil

generation to the next. The best way to minimize surgical complications is attrib-
uted to Harold Kent in 1947: “Know your patient, know yourself’” (Holland 1948).
This advice, seven decades later, continues to be valid.

11.2 Preoperative Issues

The goal of preoperative preparation is to prevent adverse events by excellent prepa-

ration and identification of possible threats to patient safety. Provider team members
should also be encouraged to speak up if they observe a problem or a potential one.
Review Medical History, Family Medical History, and Medications, Including
Over-the-Counter Pharmaceuticals and Herbal Supplements: The goal is to
recognize a compromised patient and initiate appropriate adjunct therapy. Past and
present illnesses, medications presently taken (prescription and over-the-counter),
allergies, tobacco use, and possible need for premedication before dental treatment
(antibiotics, sedation, pain control) should be identified. The patient should confirm
medications taken the day of the dental procedure, including aspirin. Examples of
diseases that could affect a patient’s treatment include cardiovascular diseases,
hypertension, hypotension, diabetes, blood or clotting disorders, and respiratory
disorders. If necessary, the patient’s physician should be contacted to provide a
medical consultation. The dentist must also identify patients with special medical
conditions affecting treatment, such as pregnancy or transmissible diseases, includ-
ing HIV-/AIDS-positive individuals, active tuberculosis patients, and hepatitis car-
riers. Medically compromised individuals are associated with increased postoperative
complications (Pierse et al. 2012).
Review Dental History: The patient should be asked about his or her primary
dental concern, the chief complaint. Addressing patient’s concerns improves patient
compliance. Patients should report any history of dental, temporomandibular,
periodontal, or oral surgery problems.
Review Radiographs: The area affected by the dental procedure should be ade-
quately imaged prior to the procedure. All aspects of the roots should be visualized,
and the restorations analyzed, including those in neighboring teeth. The radiographs
should be confirmed to be properly mounted.
Clinical and Oral Examination of the Patient: The clinician should perform an
overall appraisal of the patient, including the patient’s emotional and mental state,
attitude and ability to cooperate, and capacity to open the mouth sufficiently to
provide access to the involved teeth. Vital signs should be obtained prior to the
dental procedure and monitored during the appointment. It should be noted that
anxiety and pain may induce transient hypertension.
Intraoral jewelry should be removed before dental procedures begin.
Avoid Wrong-Site Surgery: This avoidable complication can occur through per-
forming a procedure on the wrong patient, on the wrong tooth, or the wrong side of
the mouth, viewing the wrong patient record, or performing the wrong procedure.
At the start of the patient visit before any treatment occurs, the patient should state
their full name and date of birth, and the provider then confirms that it matches the
11 Surgical Complications 207

dental record. Review the dental record, medical history, radiographs, charts, and
laboratory results. Record the tooth number(s) to be treated, and mark the tooth or
surgical site on a diagram and radiograph to be included in the patient record.
Record a description of the condition of the tooth to be extracted and of adjacent
teeth and the reason for extraction. The site may be photographed for additional
documentation. Inform the patient (or parent/guardian) of the condition and the
location of the tooth and the reason for extraction. Verify which tooth is affected and
obtain and document informed consent for treatment. The patient should understand
the risks, benefits, and alternatives for treatment before consent is obtained.
Reconfirm that the radiographs are properly mounted, and visually confirm that the
proper tooth has been indicated and charted and is adequately visualized in the
radiographs. Utilize a “time-out” to validate correct patient, correct tooth, and
correct procedure with the dental assistant present at the time of extraction (check
and recheck) (Lee et al. 2007). Clinically, count the teeth before applying forceps on
the tooth. If a dental prosthesis is to be delivered, validate prior to extraction that the
prosthesis design is compatible with the planned extraction.
Comfort of Practitioner with Procedure and Potential Complications: Procedures
beyond the scope of the practitioner’s competency and comfort should be referred
to the appropriate specialist.
Proper Conditions: All instruments necessary for the procedure should be read-
ily available, sterilized, and carefully examined before use for wear or fragility and
sharpness and be replaced as necessary.

11.3 Intraoperative Issues

Any dental procedure can result in complications. The difficulty of tooth extraction
is increased when there is a large restoration or carious lesion in the tooth,
endodontically treated teeth, curved or dilacerated roots, and dense supporting bone
(Le and Woo 2007). This increased challenge can lead to intraoperative complications
as well as an increase in postoperative problems.
Anesthetic Concerns: Inadequate anesthesia is probably the most common “anes-
thetic concern” that one would encounter. This more frequently occurs in the man-
dible and most likely is technique related. A conventional Halstead technique block
has an inadequate anesthesia rate of 31–81% of the time (Malamed 2013a). The
practitioner needs to first determine whether the problem is technique related or a
patient perception issue. Technique issues include anatomical variation, insufficient
time to allow the anesthetic to take effect, and improper technique. Repeating the
delivery of the anesthetic usually will correct the problem. Patient perception issues
may require the addition of sedation such as nitrous oxide or preoperative oral
sedation.
Frequently, the lack of adequate anesthesia is attributed to an infection in the area
that may alter the local pH. This may be true when a local infiltration technique is
used but not when a nerve block has been performed. The site for performing a
nerve block should be sufficiently distant from the “infected tooth,” so pH change
208 C. Niekrash and M. T. Goupil

should not be a factor as long as the infection is localized. In the case of local
infiltration anesthesia where the tissue pH may be a concern, a local anesthetic with
a more favorable pKa should be considered such as mepivacaine with a pKa of 7.6
as opposed to lidocaine with a pKa of 7.9 (Malamed 2013b).
Broken anesthetic needles are rare, but they can occur. When providing local
anesthesia, the anesthetic needle should be of sufficient length so that the needle
never penetrates to the hub. Should the needle inadvertently break, there should be
a sufficient length of needle remaining to allow the provider to calmly grasp the
broken end of the needle with a hemostat and remove it. When performing an
inferior alveolar nerve block, the needle only penetrates 2/3 to 3/4 of the length of a
long (35 mm) needle (Malamed 2013c). The best way to avoid the problem of
unrecoverable broken needles is to avoid using short (25 mm) anesthetic needles.
Most dental local anesthetic procedures can be provided with a long needle, but they
cannot all be safely provided with a short needle.
Fracture of Adjacent Tooth or Restoration: This complication can occur but is
usually avoidable and most likely is caused by excessive, uncontrolled, and/or
improper use of an elevator (Oliver 2014). A thorough clinical and radiographic
examination preoperatively should indicate the probability of this complication
occurring. If it is a potential complication, then this risk needs to be covered in the
informed consent. If a fracture occurs, the use of a posterior pharyngeal curtain will
prevent aspiration of any tooth or restoration material. A temporary restoration can
be placed after the planned surgery has been completed. In the case of a cast
restoration, recementing the restoration may be all that is required.
Fracture of Tooth Being Extracted: Tooth fracture is the most common complica-
tion of exodontia (Venkateshwar et al. 2011). This may be an unavoidable complica-
tion, but as stated above, a thorough clinical and radiographic examination
preoperatively should indicate the probability of this complication occurring. In
particular, the amount of unsupported tooth structure remaining is usually the
determining factor of crown fracture. Also, note curvature and divergence of the
roots. The patient needs to be made aware in advance of the potential risk of fracture
and the need for a more extensive procedure. Consideration for sectioning of the
tooth as described in Chap. 9 should be entertained.
In the case of fracture of the roots, small root tips (<3 mm) may be retained
with minimal associated infection (Matocha 2000). This is especially true if sig-
nificant bone would be lost in attempting to remove the root tip. The patient needs
to be made aware of the situation and advised that the root tip could potentially be
perceived by the immune system as a foreign body and cause problems in the
future.
Bone Fractures: Even the extraction of a single tooth should be considered pre-
prosthetic surgery, and the treatment plan should include the future proposed treat-
ment of the edentulous space. In the case of plans for an implant restoration, every
effort needs to be made to preserve all alveolar bone at the extraction site. Whereas,
if the treatment plan calls for no restoration or a removable prosthesis, then bone
removal may be desirable because of the need to remove an undercut.
11 Surgical Complications 209

Fracture of the mandible is always caused by excessive force. When the radio-
graph demonstrates an extremely large radiolucency associated with a tooth that
needs to be removed, the risk of jaw fracture increases and extreme care is required.
In that circumstance, it would be more prudent for the patient to be referred to a
specialist. In the rare instance when a mandibular fracture does occur, the patient
should be immediately referred for treatment.
Excessive force and/or an unusual root formation could result in the fracture on
the maxillary tuberosity especially when removing a third molar. When this occurs,
there are two issues to consider: (1) this is an alveolar bone fracture and (2) there is
a high probability of a maxillary sinus exposure. In most cases of a tuberosity
fracture, the planned tooth extraction should not continue. The fractured segment
needs to be stabilized, and the tooth planned for extraction might be utilized to
obtain the stabilization. This tooth might be fixated to the adjacent tooth with
composite resin. A similar situation could occur with other teeth that are being
extracted. The occurrence of an alveolar bone fracture needs to be detected while
the bone is still attached to the periosteum.
Alveolar fractures, including tuberosity fracture, can potentially be avoided by
placing the fingers/thumb of the non-dominant hand along the alveolus of the tooth
being extracted when using an elevator and/or forceps. This technique can help
identify the potential of alveolar bone fracture and necessitate consideration for an
alternative extraction technique, such as tooth sectioning before any damage is
done.
Small fracture of the alveolar bone may occur and may not be detected until the
extracted tooth is delivered from the oral cavity and inspected to ensure that the
entire tooth has been removed. Once the tooth has been removed along with a
portion of the alveolar plate, the extraction needs to be examined in the context of
the restorative treatment plan. Depending on the restorative plan, no further
treatment may be required, and the removal of bone may even be desirable. In those
situations when restoration of the site is being considered, especially where an
implant restoration is planned, then a bone grafting material and/or membrane may
be required to maintain critical alveolar dimensions.
Displaced Tooth, Root Fragment, or Broken Instrument: The displacement of a
tooth part or an entire tooth is more likely secondary to excessive force or lack of
attention to detail during the exodontia procedure. This is also true of breaking
instruments, i.e., elevators and curettes. The use of a pharyngeal screen will help
prevent the aspiration or accidental swallowing of these foreign bodies (Photo 11.1).
When removing a maxillary third molar, it is prudent to place a retractor behind the
tooth, distal to the tuberosity. This will prevent the displacement of the tooth into the
pterygomaxillary space. Uncontrolled use of an elevator can result in the
displacement of roots into the maxillary sinus (Photo 11.2), into the lingual space,
or into the inferior alveolar canal.
Once a tooth has been extracted, it should be carefully examined to ensure that
the entire root has been removed. Each root end must be examined to ensure that the
root apex is intact and indeed has been removed. Fracturing a tooth during removal
is always a potential complication. If a tooth or tooth segment is missing, a thorough
210 C. Niekrash and M. T. Goupil

Photo 11.1 Pharyngeal

curtain

Photo 11.2 Root tip in

sinus

examination must be conducted and may include radiographs. First, everything

should be removed from the oral cavity. The posterior pharyngeal curtain should be
spread out and inspected. The entire oral cavity should be examined with a good
light and suction, looking especially under the tongue. Carefully palpate the alveo-
lar ridge in the area of the extraction site. Root tips can be displaced through the
alveolar plates. Tooth fragments that have perforated the alveolar plate can usually
be easily retrieved by elevating an envelope flap.
If the tooth or tooth segment cannot be located on clinical exam, then dental
radiographs are indicated. A panoramic radiograph is initially helpful to locate
the missing tooth/fragment. Since this will only locate the missing tooth/frag-
ment in two dimensions, additional films are required for accurate localization.
Displacement of a foreign body into the maxillary sinus, inferior alveolar canal,
11 Surgical Complications 211

lingual space, or similar areas has significant consequences, and immediate

referral to a specialist is recommended. These displaced teeth/fragments can
move deeper into the spaces of the head and neck and result in life-threatening
infections.
Maxillary Sinus Exposure: It has been proposed that when maxillary teeth are
removed, perforation of the maxillary sinus may be a common occurrence ranging
between 0.13% and 4.7% (Krishanappa et al. 2016). In the immune-competent
patient, this is usually not a problem and treatment may not be indicated. Checking
for a sinus perforation by having the patient perform a Valsalva maneuver may not
be a good idea. What may have been only a small perforation requiring no treatment,
potentially, could be converted to a larger perforation requiring a complex closure
procedure.
Small perforations of less than 3 mm (the size of a small elevator) normally heal
well without intervention (Krishanappa et al. 2016). The blood clot in the extraction
site provides an adequate barrier between the sinus membrane and the surface oral
mucosa. Perforations between 3 and 5 mm in size require minimal intervention. The
use of a Gelfoam® plug secured with a “figure 8” suture over the extraction site (Le
and Woo 2007) will bring the oral mucosal edges closer together which enhances
healing. This, potentially, can also help protect and preserve the clot that is required
to act as a barrier between the sinus and the oral cavity. The use of nasal decongestants
and antibiotics should be considered. Antibiotics such as amoxicillin or amoxicillin
and clavulanate potassium may be preferred as they have a broader coverage that
includes sinus cavity organisms, i.e., Haemophilus influenzae. The patient should
also be placed on sinus precautions, avoiding all types of Valsalva-type maneuvers
such as blowing the nose.
Perforations larger than 5 mm require an airtight closure that usually necessitates
a flap procedure. A number of flap procedures have been described, including
palatal rotation flaps, buccal mucosa advancement flaps, and buccal fat pad flaps
(Borgonovo et al. 2012). There are advantages and disadvantages to each technique,
but the final result of an air-/watertight closure must be obtained.
The buccal mucosa advancement flap can be performed by most general dentists.
A buccal flap is raised using anterior and posterior vertical relaxing incisions. The
periosteum may be scored in a horizontal fashion to allow the mucosa to stretch.
The buccal flap is then sutured to the palatal mucosa. Once the closure is completed,
the patient should be instructed to perform a light Valsalva maneuver to ensure that
an air-/watertight closure has been obtained. The patient should be placed on
appropriate antibiotics and decongestants. Sinus precautions are required and oral
hygiene measures could include a chlorhexidine mouth rinse. Close follow-up is
required until satisfactory healing is obtained, and there is no evidence of an oral-
antral communication.
Aspiration and Ingestion of Foreign Bodies: Inadvertently swallowed foreign
objects enter the GI tract 92.5% of the time and the tracheobronchial tract 7.5%
(Wevv et al. 1984). Individuals at higher risk are young children under 2 years old,
elderly, sedated, inebriated, mentally handicapped, or traumatized with loss of
212 C. Niekrash and M. T. Goupil

conscious, patients with functional impairment of swallowing, and denture wearers

(Fields and Schow 1998). A patient under local anesthesia and a patient in a supine
or semi-recumbent position are also at increased risk in the private practice setting.
Many objects can be aspirated or swallowed. The most common aspirated objects
are teeth and root tips. Impression material may be aspirated and may not be seen
clinically or on radiographs. Therefore, impressions should be obtained with the
patient in an upright position and only after the patient has recovered sufficiently
from sedation.
Signs of aspiration are varied and often subtle. Early signs include coughing,
gagging, choking, inspiratory stridor, paradoxical breathing, hoarseness, cyanosis,
decreased oxygen saturation, tracheal shift, and dullness to auscultation. Aspiration
may also result in complete airway blockage or respiratory compromise (Fields and
Schow 1998). Dental procedure aspiration is reported to be the second most common
reason for foreign body aspiration in the lung (Tiwana et al. 2004).
Ingestion of foreign objects is usually asymptomatic and confirmed after com-
plete passage and identification in the stool. A swallowed object may result in bowel
perforation, abscesses, fistula, or obstruction.
Prevention of aspiration or ingestion is key. Place a 4 × 4 in. gauze screen poste-
rior to the surgical site to protect the oropharynx. Patient position may be adjusted
to place the patient more upright with the head turned to the side. In addition, small
devices should be fastened to a long length of dental floss hanging out of the mouth
to allow retrieval if necessary. Instruments should be properly maintained and
examined. Broken burs and instruments should be retrieved and pieced together to
make sure that all parts have been removed.
Intraoral jewelry and removable dental prostheses should be removed from the
mouth before dental procedures are initiated.
If aspiration or ingestion occurs, determine the patient’s stability. If the patient
is stable, determine whether the object was aspirated or ingested, usually by radio-
graphic examination of the abdomen by PA and lateral radiographs. The patient
should be informed and reassured. If the patient is unstable with respiratory dis-
tress, summon emergency personnel. An algorithm for treatment has been pub-
lished by Abusamaan et al. (Abusamaan et al. 2014) and is shown in Fig. 11.1.
Soft Tissue Laceration or Puncture: This complication should be avoided by
proper use of elevators and forceps with controlled forces and proper instrument
placement. Tearing of soft tissue may be prevented by performing vertical relaxing
incisions. However, vertical incisions should be avoided on the posterior lingual
surface of the mandible to avoid damage to the lingual nerve. Trauma and force
should be minimized and adequate luxation should be performed. Copious irrigation
with saline and chlorhexidine should be performed with adequate suction for
visualization and patient comfort.
Excessive Intraoperative Bleeding: The source of excessive bleeding should be
determined by careful observation. The major source of bleeding is nutrient vessels
in the alveolar process. The causes are usually failure to adequately debride granula-
tion tissue in the socket, tissue tearing, or rebound vasodilation after epinephrine
injection.
11 Surgical Complications 213

Lost dental
instrument,
prosthesis, or
dental material

Obtain chest radiograph, abdominal radiograph, or both

Aspirated Ingested
Object Object

Perform urgent
bronchoscopy

Blunt object with regular edges Sharp object or > 2.5 cm in diameter
And <2.5 cm in diameter and or > 6 cm in length
<6 cm in length

If object has not passed within 7 days Refer patient immediately for
or patient becomes symptomatic, endoscopic removal-ideally within
confirm with imaging, and refer 4 hours-while object is still in the
patient for endoscopic removal stomach

Fig. 11.1 Algorithm for the evaluation and treatment of aspirated or ingested objects. Adapted
from Abusamaan M, Giannobile WV, Jhawar P, Guaratnam NT (2014). Swallowed and aspirated
dental prostheses and instruments in clinical dental practice. JADA 145(5):462

To treat bleeding, apply pressure by placing a folded 2 × 2 in. gauze in the socket
and asking the patient to bite down firmly for at least 15 min. The patient should be
in an upright position to diminish venous pressure in the head. The socket is then
reexamined. If bleeding persists, then consider placing coagulant materials into the
socket. Ligation of a bleeding artery should be performed with resorbable sutures.
Some authors recommend burnishing of osseous structures with a curette. Several
materials may be placed in the socket to assist in coagulation. Gelfoam® (absorbable
gelatin sponge) may be saturated with topical thrombin to form a scaffold for the
developing blood clot. It is placed in the socket and a resorbable suture is placed over
the top. Gauze is placed on top and pressure is then applied. Surgicel® (resorbable
214 C. Niekrash and M. T. Goupil

oxidized regenerated cellulose) or Oxycel® (resorbable oxidized cellulose) may be

packed into the socket and held in place with sterile gauze to promote coagulation.
Alternatively, bovine purified collagen may promote and stabilize clot formation by
promoting platelet adhesion and aggregation. Epinephrine should be used with cau-
tion as bleeding may be temporarily controlled with rebound hemorrhage. Tissue
may also be cauterized with electrocautery. In this circumstance, profound local
anesthesia by block should be obtained. Avoid burning adjacent tissue when cauter-
izing and alert the patient to expect a noxious odor.
In cases of excessive bleeding, monitor vital signs for hypotension. Do not dis-
charge the patient until hemostasis is successful. Also, advise the patient to avoid
rinsing and spitting.
Post-extraction Instructions: Clear, simple postoperative instructions should be
delivered to the patient and other adults accompanying him or her. These instructions
should be provided orally and in written form. Any questions should be answered
prior to discharge.

11.4 Postoperative Issues

Pain: Postoperative pain is an expected risk of any surgical procedure and should
not necessarily be considered a surgical complication. For dental extractions, pain
will normally peak around 12–24 h postoperatively and should not be an issue after
72 h. The acronym
H+I+S = A
is a useful formula to determine whether a patient requires any analgesic and, if
they do, what analgesic should be prescribed. The H represents the pertinent medical
history including current medications, drug allergies, and liver and kidney function.
The I represents how the patient interprets a painful stimulus. Pain response is very
variable and is related to both the physiology and the psychology of the patient. The
S represents the stimulus of the procedure and includes the procedure complexity,
difficulty, and duration. When the H, I, and S are added together, the end result is
the A representing analgesics.
Pain becomes a complication when it exceeds the level that has been predicted
for a particular procedure. Patients complaining of more pain than expected should
be examined to determine whether another type of complication has occurred such
as an infection or alveolar osteitis which is not treated by prescribing additional or
stronger analgesics. The patient should still be evaluated in the context of the
HIS = A formula. The surgical trauma may have been underestimated. A significant
amount of an analgesic’s effect is placebo in nature. Thus, the patient may not have
interpreted the pain correctly. The potential that the patient is a “drug seeker” must
always be kept in mind.
Acute pain management is addressed in Chap. 12. By using the formula HIS = A,
the dental provider has an evidence-based and defensible approach to analgesic
prescribing. This is extremely important with the current concerns of opioid overuse
and abuse.
11 Surgical Complications 215

Swelling: Postoperative swelling is an expected risk of any surgical procedure

and should not necessarily be considered a surgical complication. The amount of
postoperative swelling is directly related to the associated trauma of the surgery
(Matocha 2000). For dental extractions, swelling will normally peak around 24 h
postoperatively and should start to resolve around day 3 postoperatively. Patients
are usually instructed to use cold/ice compresses for the first 24–48 h to minimize
the swelling (Le and Woo 2007) and then switch to warm compresses to help reduce
the swelling that has occurred. An inordinate amount of swelling may be considered
a complication. A significant amount of swelling can restrict the patient’s ability to
open his mouth. This may lead to alteration of diet and the inability to perform
adequate oral hygiene procedures.
The patient should be examined to ensure that the swelling is secondary to surgi-
cal trauma edema. There is the possibility that the swelling is related to a postopera-
tive infection, but one should not jump to this conclusion and should not immediately
prescribe antibiotics. Watchful waiting is an appropriate course in an immune-com-
petent patient. Surgical edema is self-limiting and should start to decrease around
the third or fourth postoperative day especially if warm compresses are being used.
Bleeding: Many oral surgical procedures may result in a wound that is not or
cannot be closed primarily. Subsequently, some postoperative bleeding should be
expected. Clot formation usually takes 6–12 h (Pierse et al. 2012). This may be
extended for patients that are on anticoagulant therapy including aspirin. Currently,
the use of anticoagulant medication is not considered an increased risk factor, and
they are usually not discontinued prior to uncomplicated office oral surgery
procedures (Malmquist 2011; Verna 2014). When a patient presents and there is a
concern about postoperative bleeding, an initial assessment includes a review of the
medical history especially current use of medications or herbal supplements that
may contribute to prolonged bleeding. An assessment needs to be made of the
amount of bleeding that may have occurred, ranging from a small amount of blood
mixed with saliva to spitting out blood clots. It should be determined how often the
gauze pressure packings were changed and how much blood was on them because
the frequent changing of gauze packs can aggravate rather than enhance the
coagulation process.
Next, a thorough clinical examination is conducted with good lighting and suc-
tion. All visible blood, clots, and saliva need to be removed to determine the exact
source of bleeding—bone, soft tissue, or both. Large “liver” clots need to be
removed. “Liver” clots are so named because they look like raw liver. These are
clots that extend beyond the confines of the surgical site. If granulation tissue is
noted in the extraction site, it should be removed (Malmquist 2011).
Most bleeding can be stopped by applying pressure to the area for a sufficient
length of time. A 4 × 4 in. gauze sponge dampened with saline is folded and placed
directly over the bleeding site and held firmly in place for at least 5 min. The area is
reexamined and the bleeding should have decreased. If this is the case, then the
procedure is repeated and the pressure applied for a longer period of time (in the
range of 15–20 min). It is important to maintain constant pressure. This will usually
correct most cases of postoperative bleeding. It is important to make sure the patient
216 C. Niekrash and M. T. Goupil

knows precisely where to place the pressure pack and to maintain constant pressure
for at least 15–20 min each time. The patient needs to be reminded not to rinse, spit,
or do any sucking activity for the next 24 h.
A wet tea bag is an excellent substitute for a 4 × 4 in. gauze sponge. This is espe-
cially useful when responding to a patient who is at home. The “soggy” tea bag is
placed over the bleeding site, and pressure is applied as described above. There is a
potential that the tannic acid in the tea may act as an astringent or coagulation agent
(Soltani et al. 2014).
When direct pressure does not resolve the problem, there are a variety of other
measures that can be utilized. The same measures would be indicated even if the
patient has an underlying coagulation problem.
Soft Tissue: Bleeding from capillaries and very small vessels can be cauterized.
Soft tissue lasers and electrocautery units may be readily available in many dental
offices. Chemical cautery, such as the use of silver nitrate, may be available in the
office or hospital emergency room. The injection of a vasoconstrictor, such as epi-
nephrine, has been advocated to control the bleeding by injecting local anesthesia
containing epinephrine directly into the bleeding site. There are two reasons why
this should not be done. The vasoconstrictor indeed may stop the bleeding, but the
source can no longer be identified. Additionally when the epinephrine wears off,
the bleeding may start again. There is also a rebound phenomenon with epineph-
rine, and the vessels may vasodilate, thus increasing the amount of bleeding
(Matocha 2000).
Bone: Using an instrument such as a dental curette or ball burnisher has been
described to burnish or crush the alveolar walls to stop bleeding. However, this has
the potential to cause a larger bleeding site. An alternative would be to heat the
instrument, and then with great care, bony bleeding site can be heat cauterized.
A variety of agents have been described to pack into the bleeding site such as an
resorbable oxidized regenerated cellulose (Surgicel®) or absorbable gelatin sponge
(Gelfoam®) or a coagulating agent (Hemodent®—a buffered, aluminum chloride,
epinephrine-free hemostatic liquid) in a resorbable carrier (Matocha 2000). It is
advisable to have at least one of these products available in any office that performs
dental extractions. The primary function of any of these agents is to stop localized
bleeding and promote clot formation.
In the case of very brisk bleeding from a posterior mandibular extraction site,
there is the potential that the bleeding is coming from the inferior alveolar
neurovascular bundle. One must be mindful that pressure and some chemical agents
may cause nerve damage. Caution also needs to be exercised when treating bone
bleeding in the posterior maxilla. Excessive/uncontrolled pressure within the
extraction socket may result in a sinus communication.
Clinicians must rely on their experience as there is a lack of reliable evidence on
this topic (Sumanth et al. 2016). In the rare case that the above measures do not
control the bleeding situation, then an underlying coagulation problem needs to be
entertained. Consultation with a hematologist should be considered. The patient
needs to be evaluated for factor deficiencies as well as a low platelet count or inef-
fective platelets. Blood product placement may be required.
11 Surgical Complications 217

Nerve Damage: Oral surgical procedures can result in a neurodeficit. When per-
forming a procedure in the area of a named nerve (i.e., inferior alveolar, mental,
lingual), during an extraction or biopsy, every effort needs to be made to avoid
damaging the nerve. In the case of a biopsy, small terminal nerve branches may be
cut, and the patient may notice an alteration of sensation adjacent to the biopsy site.
No treatment is indicated, and the patient should be reassured that normal feeling
should return once healing has taken place.
Damage to the inferior alveolar nerve and/or the lingual nerve can occur when
third molars are removed, especially if the tooth was impacted or the surgery was
difficult. In these instances, a neurologic exam needs to be accomplished. If there is
no improvement within a couple of weeks, that patient must be referred to a
specialist for further assessment and possible nerve repair procedure.
There is a potential for damage to the mental nerve when mandibular premolar
teeth are removed or some type of buccal flap procedure or biopsy is performed in
the area. This is a terminal nerve branch and further treatment is not required. The
deficit needs to be documented, and the patient needs to be reassured that clinically
normal sensation should return. There is always the possibility of a permanent
deficit.
Infection: There is always the possibility of a postoperative infection developing
after any oral surgical procedure. The use of antibiotics for routine dentoalveolar
procedures in healthy patients may not have any effect of wound healing (Gbotolorum
et al. 2016). Inadequate irrigation with consequent accumulation of debris beneath
a flap is a frequent cause of postoperative infection (Matocha 2000). The infection
usually will occur 3–4 days after the procedure (Adeyemo et al. 2006). The
presenting signs and symptoms are usually increasing swelling, foul ­ tasting/
smelling drainage, and possibly a decrease in oral opening or difficulty in swallow-
ing depending on the location of the surgery.
The treatment for infection is always removal of the source and/or drainage
(Lypka and Hammoudeh 2011). If the complaint is post-extraction, radiographic
imaging may be required to rule out any residual tooth fragments that are triggering
a foreign body reaction. Antibiotics may be indicated if the patient is immune-com-
promised or the infection is not locally confined, meaning it is spreading or involv-
ing deeper spaces of the head and neck region. A useful acronym for guiding therapy
is
A = S+H+O
S stands for the patient’s presenting signs and symptoms, H stands for the past
and current medical history, and O stands for the organism most likely causing the
infection. When all three of these are considered, then a decision can be made if an
Antibiotic is indicated and which one should be selected.
When signs and symptoms persist, then the potential of osteomyelitis needs to be
a concern. This is uncommon in patients with a competent immune system
(Krakowiak 2011). The diagnosis and management of osteomyelitis are covered in
Chap. 14.
Alveolar Osteitis (Dry Socket): An alveolar osteitis (AO) or dry socket “is an
acute inflammation of the alveolar bone around an extracted tooth, and it is
218 C. Niekrash and M. T. Goupil

characterized by severe pain and breakdown of the clot formed within the socket,
making the socket empty (devoid of clot) and often filled with debris. There is mild
swelling and redness of the gingiva, halitosis, bone exposure, and severe tenderness
on examination” (Akinbami and Godspower 2014). The overall incidence of AO is
around 3–5%, with most AO being related to the surgical removal of third molars
occurring up 30% of the time (Akinbami and Godspower 2014; Blum 2002). There
is a higher incidence of AO associated with surgery performed by a less experienced
operator (Parthasarathi et al. 2011) due to the longer surgery times and/or more
bone trauma. AO also occurs more commonly in patients with a history of a previ-
ous AO or when teeth are extracted that are related to infection, non-vital pulp, or
periodontitis (Bowe et al. 2012). This may be related to the theory that the cause of
AO is a bacterial-related breakdown of the clot (Mudali and Mahomed 2016).
Regardless of the exact etiology of AO, it does not represent an infection and
antibiotics should not be considered as part of the treatment. Patients with AO typi-
cally complain of an increasing and/or radiating pain occurring 3–4 days after an
extraction. The treatment goal is to keep the patient comfortable until the extraction
site undergoes healing by secondary intention, and the exposed bone is covered by
soft tissue and no longer exposed to the oral cavity. Pain management can usually
be obtained with the use of an obtundent dressing placed in the extraction site. The
extraction site is gently irrigated to remove any food or residual clot debris. This
irrigation may be accomplished using 0.12% chlorhexidine that has antimicrobial
properties (Fomete and Saheeb 2015). The socket is then packed with ¼ in. gauze
of sufficient length to fill the socket entirely to the apex. The gauze packing is used
as a carrier for the obtundent medication. There are several commercially available
“dry socket” dressings. The dressing should contain eugenol which acts as a topical
local anesthetic (Krakowiak 2011). The dressing will need to be changed every
1–3 days for a period of 7–10 days. Local anesthesia may be required to accomplish
the AO treatment, especially the first time when the patient is extremely sensitive
and apprehensive. Additional analgesics may need to be prescribed, but opioids can
usually be avoided. Since AO is a local inflammation of bone (osteitis), prescribing
an anti-inflammatory medication makes more sense.
Chlorhexidine (0.12%) rinses prior to surgery as well as postoperatively for a
week have been shown to decrease the incidence of AO (Blum 2002; Bowe et al.
2012; Caso et al. 2005; Hedström and Sjögren 2007; Daly et al. 2012).
Oral-Antral Communication/Fistula: An antral perforation may not be noted at
the time of the original maxillary tooth extraction or may develop at a later date
secondary to increased sinus pressure, i.e., nose blowing. The patient may complain
of fluid draining from the nose, foul drainage intraorally, or air escaping into the
mouth and, perhaps, symptoms consistent with a sinus infection. The intraoral
examination will usually demonstrate a mucosal perforation in the area of the
extraction site. When the patient performs a Valsalva maneuver, an air leak will be
noted with or without purulent drainage. A dental radiograph may demonstrate a
discontinuity of the sinus floor.
Nasal decongestants and antibiotics should be prescribed. An antibiotic such as
amoxicillin would be preferred as it has a broad coverage that includes sinus cavity
organisms, i.e., Haemophilus influenzae.
11 Surgical Complications 219

The oral/antral communication requires an airtight closure that usually necessi-

tates a flap procedure. A number of flap procedures have been described including
palatal rotation flaps, buccal mucosa advancement flaps, and buccal fat pad flaps.
There are advantages and disadvantages to each technique, but the final result of an
air-/watertight closure must be obtained. In planning the repair, the operator needs to
keep in mind that the boney defect will be significantly larger than the mucosal fis-
tula (Borgonovo et al. 2012).
The buccal mucosa advancement flap can usually be performed by most general
dentists. A buccal flap is raised using anterior and posterior vertical relaxing
incisions connected by an alveolar crest incision that includes the mucosal fistula
opening. The periosteum may be scored in a horizontal fashion to allow the mucosa
to stretch. The entire fistulous tract must be removed prior to the closure. The free
edge of the buccal flap is then sutured to the palatal mucosa. Once the closure is
completed, the patient should be instructed to perform a light Valsalva maneuver to
ensure an air-/watertight closure has been obtained. The patient should be placed on
appropriate antibiotics and decongestants. Sinus precautions are required, and oral
hygiene measures could include a chlorhexidine mouth rinse. Close follow-up is
required until satisfactory healing is obtained, and there is no evidence of an oral-
antral communication.
Loss to Follow-Up: Losing patients to follow-up should also be considered a
complication. This is of special concern when a biopsy has been performed or a dry
socket dressing has been left in place. Attempts to reestablish contact with a patient
for the purpose of follow-up care should be attempted both by telephone and written
communication emphasizing the importance of follow-up. These attempts to fol-
low-up should be well documented in the patient’s dental record.

11.5 Documentation

Record documentation is always important but especially so when a complication

has occurred. The patient record should reflect the nature of the complication,
what measures have been made to correct the situation or may be needed in the
future, and that the patient has been made aware of the complication with a full
and complete explanation. Claims of negligence related to the postoperative
course have been made due primarily to poor documentation (Curley 2011).
Follow-up is necessary and should be well documented as to the resolution of the
problem.

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Acute Pain Management
12
Joseph F. Piecuch

“For me, there still remains the cocaine-bottle.”

Sherlock Holmes in—The Sign of the Four

Abstract
Dentists are frequently called upon to provide short-term acute pain manage-
ment. Traditional over-the-counter medications such as acetaminophen, ibupro-
fen, and similar drugs are generally effective. Yet the prescription of opioid
medications has steadily grown, with dentists now prescribing 12% of the initial
opioid prescriptions written in the United States.
As the use of opioids has grown, the country has experienced a growing epi-
demic of opioid-related deaths, due primarily to respiratory depression. Recent
studies indicate that a small percentage of patients who begin opioid medication
for legitimate reasons continue their use of these drugs long term. A national
effort is aimed at decreasing opioid prescriptions.
Multimodal analgesia using local anesthetics and nonsteroidal anti-inflamma-
tory medications is very effective, both in relief of pain as well as elimination of
need for opioids.

12.1 Introduction

Dentists are frequently called upon to provide acute pain management. The term
“acute” signifies recent onset and generally a type of pain that is limited in duration
and will not become a long-term issue. Such situations include trauma, infections,
and posttreatment pain, particularly after invasive surgical procedures.
Chronic or long-term pain management, on the other hand, is typically managed
by pain specialists and is not managed by the dentist. However dentists should be
aware that when a patient mentions that he or she is in a pain management program,

J. F. Piecuch (*)
Division of Oral and Maxillofacial Surgery, University of Connecticut School of Dental
Medicine, Farmington, CT, USA
e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2019 223

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_12
224 J. F. Piecuch

that person has usually signed a contract with a pain specialist. Typically such con-
tracts specify the drug and the number of doses that will be prescribed each month,
particularly for opioids. In addition, such contracts typically specify that there will be
a single provider, the pain management specialist. Thus, for the patient who has
signed such a contract, the dentist should not prescribe additional opioid doses
(American Society of Anesthesiologists Task Force on Pain Management 2010).
In dentistry, a variety of options are available for acute pain control, including
local anesthetics, aspirin, acetaminophen, nonsteroidal anti-inflammatory drugs
(NSAIDS), and opioids. Local anesthetics, typically used for procedural pain
control, may also be used for post-procedural pain. Since virtually all of the
medications used for pain control do have other potential systemic effects and can
be harmful to some patients, it is critical that the dentist be knowledgeable
concerning the patient’s health history. Of particular importance are cardiac and
pulmonary function, renal disease, hepatic disease, psychiatric issues, current
medications, and allergy history. If the prescribing dentist is not familiar with the
possible drug interaction with the patient’s current medications, the dentist must
look up the medication prior to prescribing pain control. If not certain about possible
interactions with the patient’s medical condition or medications, the dentist should
contact the patient’s physician for guidance.
Special considerations are pregnancy and the nursing mother. Generally if there
are any questions the patient’s obstetrician should be consulted. A brief review of
the use of pain medications in these specific conditions follows.

12.2 Postoperative Pain and Analgesic Medications

Acute postoperative pain occurs following tissue trauma, which activates sensory
receptors, nociceptors, that detect noxious stimuli and which conduct the painful
sensation to the CNS via A delta and C fibers. The noxious input, arriving in the
CNS, increases nociceptive neurons in the CNS, thus creating central sensitization.
Local and systemic mediators, such as cytokines, are released at the site of injury.
Cytokines are extracellular polypeptides which have multiple actions. These include
interleukins (IL-1 to IL-35) and tumor necrosis factor (TNF). These “pro-inflamma-
tory” mediators increase production of prostaglandins, which produce hyperalgesia,
inflammation, and pain. Cyclooxygenase isoenzymes (COX-1 and COX-2) are
important in the synthesis of prostaglandins (PG), which increase blood flow and
thus permit edema and inflammation. Prostaglandin E2 (PGE2) promotes blood
flow and microvascular permeability, causing redness and edema. PGE2 also
directly affects sensory neurons causing pain. TNF-alpha produces inflammation,
pain, and hyperalgesia. Substance P is a peptide which is rapidly released following
noxious stimuli and causes vasodilation, promotes expression of the cytokines, and
assists transmission of pain to the CNS (Barrow de Oliviera et al. 2011).
Modification of this inflammatory response by means of blocking the effects of
cyclooxygenases is the goal of pain management. COX-1 has effects on the gastric
mucosa, where it produces protective prostaglandins for gastric epithelial cells.
12 Acute Pain Management 225

COX-1 also decreases platelet aggregation. COX-2 effects are antipyretic, analgesic,
and anti-inflammatory. Traditional nonsteroidal anti-inflammatory medications
(NSAIDs) are nonselective and inhibit both cyclooxygenase isoenzymes COX-1 and
COX-2, thus inhibiting synthesis of prostaglandins and other mediators and decreas-
ing edema, inflammation, and pain. NSAIDS also block the effects of substance P,
decreasing chemotaxis of inflammatory cells. But the nonselective NSAIDS also
have COX-1-mediated undesirable gastric and platelet effects. The COX-1 effects for
most of these agents are reversible, except for aspirin. Specific COX-2 inhibitors
(coxibs) do not inhibit COX-1 and therefore have fewer effects on the gastric mucosa.

12.2.1 Acetaminophen

Is not considered an NSAID and acts primarily in the CNS. It is useful for mild-to-
moderate pain. The mechanism of action is not completely understood, but it does
act centrally to inhibit cyclooxygenase (COX) enzymes with selective COX-2 activ-
ity (Graham et al. 2013). It does not do so peripherally. It also modulates the endog-
enous cannabinoid system, centrally. Peak activity is reached in ½ to 2 h, and overall
duration is 4–6 h (Ghanem et al. 2016). It is available in doses of 325 and 650 mg
and typically is dosed every 4 h.
Acetaminophen can be hepatotoxic, and as a result it should be avoided in
patients with hepatitis or other liver disease. The maximum adult daily dose as rec-
ommended since 2011 by the manufacturer is 3000 mg per 24 h period.

12.2.2 Nonsteroidal Anti-Inflammatory Agents (NSAIDS)

Act by inhibition of prostaglandin synthesis. Their action is local, at the site of

inflammation, where they prevent the development of pain pathways during their
period of activity. A large number of NSAIDS have been studied for post-proce-
dural pain, including several selective COX-2 inhibitors, such as rofecoxib (Vioxx)
and valdecoxib (Bextra), which have been taken off the market, in 2004 and 2005,
respectively, due to an association with negative cardiac outcomes and other serious
side effects. The most commonly NSAIDS currently used in dentistry are ibuprofen
and naproxen.
Aspirin (acetylsalicylic acid, ASA) is classed with the nonsteroidal anti-inflam-
matory agents, with effects on both COX-1 and COX-2, blocking prostaglandin
production and producing both analgesic and antipyretic effects. The anti-inflam-
matory effects are achieved only at very high doses (4–8 g per day) which risk audi-
tory and gastrointestinal toxicity. It is useful for mild-to-moderate pain at doses of
325–650 mg every 4–6 h. The higher dose should be spaced out every 6 h to reduce
total daily amount.
The gastric effects of aspirin are irreversible, in contrast with other NSAIDS,
which have reversible gastric mucosal effects. Aspirin also produces irreversible
inhibition of platelet aggregation, which lasts for the life of the platelet (7–10 days).
226 J. F. Piecuch

COX-1 inhibitory effects of ASA include blocking the formation of thromboxane

A2, which is necessary for platelet aggregation. This does occur at lower doses, and
for this purpose 81 mg per day is usually recommended for persons at risk for
thrombotic events. Other side effects include allergy, gastrointestinal pain and
ulceration, as well as hepatotoxicity. Aspirin is not generally recommended as first-
line therapy for post-procedural pain.
Ibuprofen achieves peak activity in 1–2 h, with a half-life of 2–4 h. It is poten-
tially nephrotoxic, and thus the Food and Drug Administration (FDA) has limited
the recommended daily dosage to 3200 mg. It should not be used for patients with
renal compromise. Ibuprofen is available without prescription as 200 mg tablets,
and usual adult doses for post-procedural pain are 400 or 600 mg every 4–6 h.
Naproxen, like ibuprofen, is an NSAID of the propionic acid class and is a non-
selective COX inhibitor, similar to ibuprofen. It has the smallest potential cardiovas-
cular risk (Angiolillo and Weisman 2017) of all NSAIDS. On the other hand, its
relative risk for gastrointestinal complications such as peptic ulcer and GI bleeding
is significantly higher than that of ibuprofen (Castellsague et al. 2012). The active
life of naproxen is longer than ibuprofen, and it is generally prescribed as 250–
500 mg every 8–12 h.
Celecoxib (Celebrex) is a selective COX-2 inhibitor usually prescribed as a
long-term analgesic for chronic arthritic pain. Because it has no effects on the gas-
tric mucosa, it is better tolerated over time than the nonselective NSAIDS. A
Cochrane review of its use in immediate post-procedural pain, first published in
2013 and updated in 2017, identified ten studies with 1785 participants. Celecoxib
in 200 and 400 mg doses were compared with placebo. The time till need for res-
cue medication was 6.6 h for the 200 mg dose and 8.4 h for the 400 mg dose. The
authors concluded that celecoxib 400 mg is similar in effect to 400 mg of ibuprofen
(Derry and Moore 2013).

12.2.3 Opioids

Opioids as a class of drugs have been used for analgesia for thousands of years,
yet the modern formulations, other than morphine and heroin, have appeared
mostly in the last century. Opioids act centrally on mu opioid receptors in the CNS
to dull the perception of pain. Opioids also act to decrease transmission of noci-
ceptive stimuli by the spinal cord. They do not have a significant local effect and
do not decrease inflammation at the site of injury. It is thought by some that when
such drugs bind to central receptors they release other mediators which are associ-
ated with euphoria, and this explains some of the effects that chronic users obtain
from these drugs.
Opioids are primarily absorbed in the gastrointestinal tract. Lipid-soluble opi-
oids can be absorbed through buccal or nasal mucosa, and those with the greatest
lipid solubility can even be absorbed transdermally. All opioids are metabolized in
the liver and excreted by the kidneys. They should be used with caution in patients
with hepatic or renal compromise.
12 Acute Pain Management 227

Tolerance, dependence, and addiction can occur with opioids. Tolerance is

defined as a gradual decrease in effectiveness after repeated doses, over days to
weeks, and can result in doses becoming less effective over time. Cross-tolerance
can occur between drugs of the same class, such as those affecting mu receptors.
Dependence is an adaptation to chronic use which produces significant physical and
emotional symptoms upon withdrawal of the drug. Addiction is the compulsive use
of a drug. While the euphoric effects of opioids during recreational use may lead to
addiction, the most common motivation for addiction is the avoidance of withdrawal
symptoms.
Currently the most commonly used opioids for dental pain are codeine, hydroco-
done, and oxycodone. Codeine has a low affinity for opioid receptors, but about
10% of an administered dose is metabolized to morphine, which is responsible for
the analgesic effect. Hydrocodone and oxycodone are codeine analogs which act in
a similar manner.
The major difference between codeine, hydrocodone, and oxycodone is
potency. One milligram of codeine is equivalent to 0.15 mg (0.15 M.E.) of mor-
phine, while 1 mg of hydrocodone equals 1 morphine equivalent (1.0 M.E.), and
1 mg of oxycodone provides 1.5 M.E. All three of these opioids have an onset
between 1/2 and 1 h and durations of 3–5 h. Oxycodone should only be prescribed
in its immediate release (IR) form for dental-related pain. It also has delayed
release forms (marketed primarily as OxyContin) which last up to 12 h. Such
drugs are inappropriate for dental post-procedural pain and should not be pre-
scribed by dentists.
Opioids are usually prescribed as combination drugs with acetaminophen or
ibuprofen as the other component. A listing of commonly prescribed commercial
combinations is found in Table 12.1. Notably, combinations which include acet-
aminophen limit that drug to 300 mg in order to decrease the possibility of
hepatotoxicity.
Other opioids occasionally used in dentistry include propoxyphene, meperidine,
tramadol, and fentanyl. Propoxyphene is a weak opioid, formerly marketed as
Darvon, which was commonly used for post-procedural pain. It was taken off the
market in 2010 due to the risk of cardiac toxicity. Meperidine is sometimes used in

Table 12.1 A listing of commonly prescribed commercial combinations of opioids and acet-
aminophen or ibuprofen
Commercial drug name Opioid dose in mg Combination drug dose
Tylenol # 2 Codeine 15 mg Acetaminophen 300 mg
Tylenol # 3 Codeine 30 mg Acetaminophen 300 mg
Tylenol # 4 Codeine 60 mg Acetaminophen 300 mg
Vicodin Hydrocodone 5 mg Acetaminophen 300 mg
Vicodin ES Hydrocodone 7.5 mg Acetaminophen 300 mg
Vicodin HP Hydrocodone 10 mg Acetaminophen 300 mg
Vicoprofen Hydrocodone 7.5 mg Ibuprofen 200 mg
Percocet Oxycodone 5 mg Acetaminophen 300 mg
Percodan Oxycodone 5 mg Aspirin 325 mg
Tylox Oxycodone 5 mg Acetaminophen 500 mg
228 J. F. Piecuch

this setting if the patient has had significant side effects (nausea) from codeine and
related drugs. Tramadol is another synthetic codeine analog not commonly used in
this setting. Fentanyl is a powerful short-acting and rapidly metabolized opioid with
poor gastric absorption. It is rapidly absorbed transbuccally and transdermally and
has been used as oral lozenges and as skin patches, mostly in cancer patients with
chronic pain. Due to significant side effects, it should not be used in this fashion for
dental post-procedural pain. Fentanyl is used as an adjunct to anesthesia due to its
rapid onset and rapid termination when used intravenously. The risk of respiratory
depression in this setting is significant.
When prescribing opioids, the dentist must be cognizant of the ongoing opioid
epidemic which currently takes the lives of 33,000 Americans per year.

12.3 Special Considerations in Prescribing

12.3.1 Pregnancy

Continuation of dental care throughout pregnancy is recommended by both the

American Dental Association and the American College of Obstetrics and
Gynecology. One study (Hagai et al. 2015) compared 210 patients given local
anesthesia for dental care during pregnancy (53% during the first trimester) with
794 pregnant women who did not have such treatment. Although three quarters
of the treatment group had invasive procedures such as endodontics or extrac-
tions, only 8% used postoperative pain medication, either acetaminophen or
NSAIDS. There were no differences in pregnancy outcomes between the two
groups.
In general when pain medication is contemplated for posttreatment care for preg-
nant patients, it is recommended that the dentist obtain consultation with the
patient’s obstetrician concerning appropriate medications. For patients who have
been scheduled in advance for the procedure, this consultation should be obtained
prior to the appointment.

12.3.2 The Nursing Mother

Clinical guidance of the use of pain medications in the nursing mother has been
provided by the American Academy of Pediatrics (Sachs and Committee on Drugs
2013) as well as by a number of scholarly publications. The following comments
provide a brief overview of this topic.
Aspirin: Salicylate excretion into human milk is low, approximately 4–8%. A
study which included low-dose aspirin (Bell et al. 2011) showed that low doses
(<100 mg per day) did not produce any adverse effects. However higher, therapeutic
doses have resulted in complications including neonatal purpura and metabolic
acidosis (Bar-Oz et al. 2003). Thus aspirin is not recommended for the nursing
mother.
12 Acute Pain Management 229

Acetaminophen: The maximum dose passed to the nursing infant is estimated to

be only about 1.5% of the daily maternal dose. Consequently use of acetaminophen
is compatible with breastfeeding.
Ibuprofen: Maternal doses of this drug do not appear to pass to the infant in
detectable amounts, so it is also compatible with breastfeeding.
Naproxen: Less than 1% of the maternal dose is excreted into human milk, con-
sequently Naprosyn is acceptable in this setting.
Codeine: This drug definitely passes to the nursing infant and should be avoided.
Some studies suggest that it can cause neonatal respiratory depression only in high
doses (60 mg every 4–6 h) (Sachs and Committee on Drugs 2013), but another study
(Lam et al. 2011) specifically measuring CNS depression in neonates whose mothers
were using codeine and other opioids found that 16.7% of the babies exhibited CNS
depression. This paper also cited an FDA warning that codeine is not safe for infants
in this setting. A systematic review by Madadi et al. (2008) concluded from available
evidence that respiratory depression will occur in infants whose mothers use
codeine. These authors had previously reported a fatality of a breastfed infant whose
mother had been taking codeine (Madadi et al. 2007).
Hydrocodone: Timed breast milk samples from 30 nursing mothers were tested,
and only 1.6% of the maternal dosage passed to the infant. Thus these authors
considered hydrocodone to be safe in this setting (Sauberan et al. 2011).
Oxycodone: Infants of nursing mothers taking oxycodone for postpartum pain
had a 20.1% rate of infant CNS depression (Lam et al. 2011). These authors
concluded that oxycodone is not safe in this setting.
The above should not be taken as definitive recommendations as new informa-
tion may contradict previous publications. In any event when prescribing pain medi-
cations for the nursing mother, the dentist should strongly consider contacting the
patient’s obstetrician or the child’s pediatrician for advice.

12.4 The American Opioid Epidemic

While opioid addiction, and overdose death, is certainly not confined to the United
States, it is clear that the steady rise in the death rate has reached epidemic propor-
tions. In the year 2014, there were 47,055 drug overdose deaths, with 28,647 due to
opioids. In 2015 these numbers had increased to 52,407 and 33,091, respectively
(Centers for Disease Control and Prevention 2016). In October 2017 it was
announced that overall drug overdose deaths had reached 64,000 in 2016, (Centers
for Disease Control and Prevention 2017) many now due to powerful synthetic opi-
oids such as fentanyl. How did this happen?
Opioids have been used for pain control for several millennia, yet as recently as
the late twentieth century, they were not commonly prescribed. In the 1980s and
1990s, many practitioners became concerned about pain control, and pain manage-
ment groups and associations proliferated. Meetings were cosponsored by the phar-
maceutical industry, which of course had an interest in the topic. Pain control is an
admirable goal. Based on a small number of relevant publications which purported
230 J. F. Piecuch

to show that addiction was rare after medical use of these drugs, pain management
groups emphasized the use of opioids, spurred on by drug manufacturers which
sponsored scientific presentations favoring their lucrative products. These papers,
referred to as “landmark studies” by some, were repeatedly cited in the literature by
authors who perhaps, in the pre-Internet age, did not make the effort to actually read
them and perhaps just repeated the praises of others. By 1996, pain, a subjective
symptom, was redefined as “the fifth vital sign,” along with objective measurement
of heart rate, blood pressure, respiratory rate, and temperature (Van Zee 2009).
Simultaneously drug manufacturers aggressively promoted their products. One
company funded all or part of over 20,000 educational programs focusing on
OxyContin, a sustained release oxycodone formulation, between 1996 and 2002.
Prescriptions of this drug increased from 670,000 nationally in 1997 to 6.2 million
in 2002 (Van Zee 2009).
In 2000, accrediting standards for healthcare organizations were changed to
include statements requiring documentation of pain assessment and appropriate
pain management for all patients. As a result control of pain became a major focus
in the care of hospitalized patients, and the use of immediate release opioids prolif-
erated. The concept rapidly spread to outpatient facilities, including dental offices,
and the result was a significant increase in opioid prescriptions, as well as the
amounts prescribed. It remains common for postsurgical patients to receive pre-
scriptions for large numbers of opioids upon discharge to home. Based on the 2015
National Survey on Drug Use and Health (NSDUH), it was estimated that over a
third of the adult civilian non-institutionalized population of the United States used
prescription opioids in 2015 (Han et al. 2017).
Thus in the early twenty-first century, medical use of opioids became very com-
mon. As addiction and drug overdose deaths increased, studies have belatedly been
done to assess the risk of addiction from post-procedural use. Not surprisingly these
new studies contradicted previous assumptions and beliefs. Using de-identified
insurance claims data, one study of 36,177 opioid-naïve (never used before) adults
undergoing surgery who filled an opioid prescription following surgery found that
6% were still filling opioid prescriptions 6 months later (Brummett et al. 2017). A
similar study found that some patients become habituated or addicted after the first
prescription (Sun et al. 2016). Another study found that “legitimate opioid use
before high school graduation is independently associated with a 33% increase in
the risk of future opioid misuse after high school.” (Miech et al. 2015) This associa-
tion seemed to be concentrated among persons with no history of opioid use and
strong disapproval of drug use at baseline.
Belated review of two of the best-known early papers supporting opioid use
without need for concern about addiction revealed they were not studies at all. One
paper was a retrospective chart review of 38 patients maintained on opioids for
nonmalignant pain, and it actually showed that 5% developed a “drug management
problem” (Portnoy and Foley 1986). The other, cited in the scientific literature over
900 times, was neither an article nor research but an 11-line “Letter to the Editor”
in which the authors simply expressed an opinion (Porter and Jick 1980).
In 2016 the Joint Commission issued a “Statement on Pain Management” (Joint
Commission 2016) clarifying current accreditation standards regarding pain. The
12 Acute Pain Management 231

Statement pointed out that the standard “Pain is assessed in all patients” had been
removed in 2009 and that it had not required that pain be treated until the pain
score is zero. The Commission felt that the 2001 pain standards did not require
only use of opioids and denied that the 2001 standards caused a rise in opioid pre-
scriptions. A graph of yearly US opioid prescriptions accompanying this Statement
showed opioid prescriptions nationally to be 126 million in 2000 and 219 million
in 2011.
These comments are not meant to imply that the medical and dental professions
are solely responsible for the opioid epidemic. Certainly industry marketing (Van
Zee 2009), illegal drug distribution, and new synthetic narcotics smuggled into the
country play a very large role.
For physicians, dentists, and other providers, however, prescribing patterns must
be relearned. Many states have taken a lead role in requiring mandatory opioid edu-
cation for licensure, mandatory registration in prescription monitoring programs,
and limiting the amount of drug which may be prescribed. In some states opioid
prescriptions may be sent only electronically, eliminating the possibility of duplica-
tion of prescriptions or changing the amounts. The recent declaration of a National
Opioid Emergency (October 2017) hopefully will amplify a multifaceted approach
to the problem.

12.4.1 Role of Dentists in the Opioid Epidemic

Although dentists likely do not initially see themselves as part of this problem, one
should be aware that over 12% of all narcotics prescribed in the United States are
prescribed by dentists (Denisco et al. 2011). Of patients prescribed opioids by den-
tists, 72% had leftover medications, and 71% of the group with leftover pills kept
them. Further, 41% of the prescribing dentists expected leftover medications
(Denisco et al. 2011).
A recent study of opioid prescriptions after surgical extraction of teeth (Baker
et al. 2016) evaluated a de-identified Medicaid database of all Americans covered
by Medicaid over an 11-year period (2000–2010). Of the 2,757,273 patents who
underwent these procedures, 42% of this total filled opioid prescriptions. The drugs
prescribed were hydrocodone (78%), oxycodone (15.4%), propoxyphene (3.5%),
and codeine (1.6%). The range of morphine equivalents (M.E.) in this group was
75–225 M.E., with a mean of 120 M.E. This dose is equivalent to 24 tablets of 5 mg
hydrocodone or 16 tablets of 5 mg oxycodone.
Another study evaluated opioid prescribing in a single state in the previous
2 years. All patients recorded in that state’s drug monitoring program who were
given at least one opioid prescription by a dentist were studied (McCauley et al.
2016). A total of 653,650 patients fit this parameter. Although dentists had written
only 8.9% of the opioid prescriptions in that state over the 2-year span, dentists
wrote 44.9% of those patients’ initial opioid prescriptions.
While dentists certainly are not the primary cause of the opioid epidemic, they
do play a role. Each practitioner must become familiar with their state’s guidelines,
including any recent changes, for opioid prescribing.
232 J. F. Piecuch

12.4.2 Alternatives to Opioids for Postoperative Pain

The American Dental Association has published a “Statement on the Use of Opioids
in the Treatment of Dental Pain,” which was adopted by the ADA House of Delegates
in October 2016 (American Dental Association 2017). This statement emphasizes
the need for a thorough medical history, for consulting state prescription drug moni-
toring programs (PDMP), and for coordination with other prescribers when consid-
ering opioids. In addition the statement urges dentists to consider nonsteroidal
anti-inflammatory analgesics as first-line therapy for acute pain management
(American Dental Association 2017).
The American Association of Oral and Maxillofacial Surgeons has issued its own
statement on opioid prescriptions (American Association of Oral and Maxillofacial
Surgeons 2017). This statement emphasizes the use of NSAIDS as first-line analge-
sic therapy, with acetaminophen as a substitute when NSAIDS are contraindicated.
These AAOMS guidelines also encourage adjunctive pain control treatments such
as presurgical NSAIDS, long-acting local anesthetics, and perioperative steroids.
An example of the use of these multiple techniques is illustrated in a 2013 article in
JADA (Laskin 2013).
Daniels et al. (2011) evaluated 678 patients who underwent third molar extrac-
tion using 2% lidocaine with 1/100,000 epinephrine. The patients were randomized
into five groups:

• Ibuprofen 400 mg plus acetaminophen 1000 mg

• Ibuprofen 200 mg plus acetaminophen 500 mg
• Ibuprofen 400 mg plus codeine 25 mg
• Acetaminophen 1000 mg plus codeine 30 mg
• Placebo

The results of this study showed that both ibuprofen and acetaminophen combi-
nations were more effective than the combinations that included codeine.
A similar randomized study evaluated effectiveness of pain medication given in
emergency departments for extremity pain while waiting for radiographs.
Acetaminophen was combined with one of four other drugs: ibuprofen, codeine,
hydrocodone, and oxycodone. At 2 h, the acetaminophen and ibuprofen combina-
tion was equally effective to the opioid combinations (Chang et al. 2017).
A systematic review of randomized controlled trials compared acetaminophen
plus an NSAID drug (ibuprofen, diclofenac, ketoprofen) versus one or both drugs
alone. The results of this review showed that the combination was more effective
than either acetaminophen alone or the NSAID drug alone (Ong et al. 2010). Moore
and Hersh (2013) published a critical analysis of published scientific evidence for
avoiding narcotics and using a combination of ibuprofen and acetaminophen for
dental pain relief, using primarily evidence-based systematic reviews published by
the Cochrane Collaboration. These reviews demonstrate improved efficacy of the
combinations without an increase in adverse effects, which might occur with large
doses of a single drug. Several of their references showed more frequent adverse
drug reactions when opioids were added to the combinations.
12 Acute Pain Management 233

12.5 Preemptive Analgesia

Preemptive analgesia is a technique of decreasing pain perception by preventing the

establishment of central sensitization caused by incisional injury and by postsurgical
inflammation. To be preemptive, pain must be addressed prior to the start of the
procedure and continued through the initial postoperative period.
This concept is not new. In 1913 Crile published his observations of human
patients as well as animal studies suggesting that surgical procedures might
cause permanent changes in the brain. Specifically he noted that inhalational
general anesthesia did not protect against CNS changes. Yet these changes could
be reduced by applying a regional (local) anesthetic prior to the procedure (Crile
1913). Prospective studies in the early 1990s confirmed that modern techniques
of local anesthesia decreased short- and long-term surgical pain. Jebeles et al.
(1991) compared pre-tonsillectomy bupivacaine infiltration of the surgical site
with placebo (saline) infiltration. All patients were operated with general anes-
thesia. On the second postoperative day, pain scores were four times lower in the
bupivacaine group, and this difference persisted through the tenth postoperative
day. Tverskoy et al. (1990) compared patients undergoing inguinal herniorrha-
phy under general anesthesia with patients under general anesthesia who also
received bupivacaine injections in the line of incision 5 min prior to surgery. In
the general anesthesia only group, the first request for pain medication averaged
1 h after the conclusion of the procedure, while the general plus local group
asked for pain medication on average 9 h postsurgery. In the general plus local
group, incisional pain was almost completely absent at 24 and 48 h, and signifi-
cantly lower pain persisted in this group through the tenth postsurgical day. A
summary of early studies concerting preemptive analgesia was published in 2000
by Kirsin, who was a co-author of the Jebeles and Tverskoy papers cited above
(Kissin 2000).
A systematic review of 66 studies with data from 3261 patients undergoing a
variety of operations has shown that the most effective methods involve epidural
anesthesia started prior to the procedure, local anesthesia given prior to surgery,
and systemic NSAIDS begun either before or immediately after the procedure
(Ong et al. 2005). Opioids showed the least proof of efficacy. Subsequently studies
involving oral surgery began.
Gordon et al. (2002) presented four groups of oral surgery patients undergoing
surgical extraction of lower third molars under general anesthesia:

• Pre-op lidocaine and post-op saline

• Pre-op lidocaine and post-op bupivacaine
• Pre-op saline and post-op bupivacaine
• Pre-op saline and post-op saline

Measurement of circulating endorphins during the procedure showed a signifi-

cant increase in the two groups receiving a preoperative saline injection, while
there was no increase in the two groups with preoperative lidocaine. At 1 h after
completion of the procedures, there was still a decrease in in circulating
234 J. F. Piecuch

endorphins in the three groups which had local anesthesia in comparison with sig-
nificant elevation in the saline/saline group. At 48 h the pain intensity was similar
in the saline/saline and lidocaine/saline groups, while both groups receiving bupi-
vacaine (lidocaine/bupivacaine and saline/bupivacaine) showed a significantly
decreased pain intensity.
Nayyar and Yates (2006) reported a comparison of patients undergoing third
molar surgery under general anesthesia. On one side the patient did not receive local
anesthesia, while on the other side the patient received bupivacaine 0.5% with
epinephrine 1/200,000. These authors found a significant decrease in pain on the
local anesthesia side at 6, 12, and 72 h and also at 7 days. In summary preemptive
local anesthesia is effective in the dental setting, and longer-acting agents appear to
be more effective. Nonsteroidal anti-inflammatory agents decrease the inflammatory
response and thus act in concert with the local anesthesia as the most effective
measure.
In 2011 the FDA granted approval for use of liposomal bupivacaine injectable
solution for several soft tissue procedures (Chahar and Cummings 2012; Charous
and Ilfeld 2015). In 2015 approval for use was extended to several other sites, includ-
ing intraoral infiltration. A recent Cochrane review of nine studies with 1377 patients
undergoing five procedures (none were oral surgery) suggested that liposomal bupi-
vacaine was better than standard bupivacaine for postoperative pain control (Hamilton
et al. 2017). This form of bupivacaine has been used to date by many oral surgeons
with reported excellent results, although actual controlled studies are still ongoing. It
is important for the dentist to understand the restrictions on intraoral use: it may not
be used for nerve blocks; it should not be used in patients under age 18, and the den-
tist must be aware of interactions with other local anesthetics.
Preemptive analgesia becomes multimodal analgesia when additional agents are
utilized in the postoperative period to decrease pain as well as to prevent central
sensitization. Such techniques are advocated by many as an approach which will
limit the use of postoperative opioids, which simply become unnecessary. Such
methods were formalized in the early 2000s as ERAS (enhanced recovery after
surgery) pathways and promulgated by the ERAS Society, founded in 2001 (ERAS
n.d.). Current postoperative multimodal options for use in ERAS pathways are
found in the 2017 review article by Wick et al. (2017). Current pathways from the
ERAS Society focus primarily on general surgery procedures. The following path-
way for dental and oral surgical procedures is suggested:

Preoperative: Lidocaine with epinephrine

Immediate postoperative: Bupivacaine with epinephrine or
Liposomal bupivacaine
Early postoperative: Begin, NSAID, typically ibuprofen 400 or 600 mg
Add, acetaminophen 325 mg

In this pathway the oral medications can either be taken together every 4 h (Hersh
and Moore 2015) or alternated in an overlapping pattern at 2-h intervals, one pill
every 2 h. The latter is this author’s preference, as the peak effect of one drug occurs
when the other is wearing off.
12 Acute Pain Management 235

In summary it is now recognized that opioids are not necessary for many dental
conditions and procedures. However when they are prescribed, the dentist should
make efforts to ensure that proper disposal guidelines be followed, in order to
prevent diversion. The most important method of prevention is to prescribe only the
amount the patient will likely use, to decrease the possibility of leftover medication.
Then, at the next appointment, the patient should be asked how many pills are left
over and given instructions for proper disposal.

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 Part III
Management of Oral Pathology
Odontogenic Infections
13
Gabe Hayek, Morton H. Goldberg, and Elie M. Ferneini

“It is of the highest importance in the art of detection to be able

to recognize, out of a number of facts, which are incidental and
which vital.”
—The Reigate Puzzle

Abstract
Odontogenic infections are caused by the normal commensal oral flora that
spread, most often, through a pathway from the roots of the teeth to enter the
periapical region and can subsequently spread to the deeper fascial spaces of
the head and neck. The main principle of treatment is to establish drainage of the
abscess, either through endodontic therapy or removal of the tooth, and incision
and drainage may be required as well. Antibiotics are an adjunctive therapy to
surgical intervention. This chapter discusses the basic approach to the evaluation
and treatment principles in the management of odontogenic infections. An
overview of the microbiology and the deep fascial spaces is also provided to
understand the rationale for treatment decisions.

13.1 Introduction

One of the most common presenting problems in general dentistry office is

odontogenic infections (Christensen et al. 2013a, b). These tooth-borne infec-
tions can arise from caries, periodontal disease, or pulpitis and potentially spread

G. Hayek
Division of Oral and Maxillofacial Surgery, Department of Craniofacial Sciences, University
of Connecticut School of Dental Medicine, Farmington, CT, USA
M. H. Goldberg
Division of Oral and Maxillofacial Surgery, University of Connecticut School of Dental
Medicine, Farmington, CT, USA
e-mail: [email protected]
E. M. Ferneini (*)
Beau Visage Med Spa, Greater Waterbury OMS, Cheshire, CT, USA
Division of Oral and Maxillofacial Surgery, University of Connecticut, Farmington, CT, USA

© Springer International Publishing AG, part of Springer Nature 2019 239

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_13
240 G. Hayek et al.

to tissues deep in the head and neck or beyond. Although odontogenic infections
have the ability to quickly become severe and life threatening, the vast majority
are readily treatable in the early stages by the general dentist. An understanding
of the signs, symptoms, microbiology, and the fascial planes and spaces is criti-
cal to understanding the basic decision-making necessary for the treatment of
odontogenic infections. Management of the infection can then be performed
with definitive treatment of the source of infection, incision and drainage, and/or
antibiotics, and referral to a qualified oral and maxillofacial surgeon, when
appropriate.

13.2 Microbiology

Like most infections, the bacteria that cause odontogenic infection are most com-
monly part of the normal commensal oral flora (Hupp and Ferneini 2016; Hupp
et al. 2014). These bacteria are primarily aerobic gram-positive cocci, anaerobic
gram-positive cocci, and anaerobic gram-negative rods. These bacteria cause the
everyday dental pathologies of dental caries, gingival, and periodontal disease;
however, they may gain access to deeper tissue through means such as a necrotic
pulp or a deep periodontal pocket, causing the presenting infection. The changing
environment of these deeper tissues also changes the predominant type of organism
taking hold as they thrive in the now oxygen-depleted space.
The literature on the profile of odontogenic infections has been well established
for decades and is important when making antibiotic choices. The underlying prin-
ciple is that odontogenic infections are generally polymicrobial, mixed aerobic-
anaerobic infections. The laboratory is able to identify an average of five species of
bacteria in a sample and sometimes much more. A mere 6% of infections are aerobic
alone, 44% are pure anaerobic, and 50% are mixed. Despite recurrent questioning
as to whether the microbiologic flora of odontogenic infections is changing, multiple
studies, including systematic reviews, have concluded that this is not the case as
highlighted in Tables 13.1 and 13.2 (Sakomoto et al. 1998; Heimdahl et al. 1985;
Haug 2003). Instead, perceived changes are attributed to changes in nomenclature
and an increased ability to isolate organisms. Although less extensive in sample size

Table 13.1 Major pathogens in odontogenic infections

Microorganism Heimdahl et al. (1985) Sakomoto et al. (1998)
Streptococcus milleri group 31 65
Peptostreptococcus species 31 65
Other anaerobic streptococci 38 9
Prevotella species 35 74
Porphyromonas species – 17
Fusobacterium species 45 52
From: Hupp, J., Ellis, E., Tucker, M. Principles of Management and Prevention of Odontogenic
Infections. Contemporary Oral and Maxillofacial Surgery 2014; p 297
13 Odontogenic Infections 241

Table 13.2 Major pathogens through the decades show no statistical changes
Number isolated from Number isolated from Chi-square
1980s patients (%) 1990s patients (%) statistic P-value
Gram-positive 56 70 5.357 0.021
cocci
Other gram- 5 4 0.066 0.8
positive bacteria
Gram-negative 23 13 4.323 0.038
anaerobes
Other gram- 16 13 0.520 0.5
negative bacteria
From: Storoe W, Haug RH, Lillich TT. The changing face of odontogenic infections. J Oral
Maxillofac Surg 2001;59:739–48

Table 13.3 Increasing Year Penicillin resistance (% of cases) Country

penicillin resistance rates 1991 33 United States
among oral pathogens 1992 38 Sweden
1995 55 United Kingdom
1999 54 United States
From: Hupp, J., and Ferneini, E. Principles of Antibiotic
Therapy for Head, Neck, and Orofacial Infections. Head, Neck,
and Orofacial Infections 2016; p 143

and only single studies, newer literature from the 2010s continues to show no statis-
tical changes in the microbial flora of odontogenic infections (Yuvaraj et al. 2012;
Farmahan et al. 2014).
On the other hand, antibiotic resistance has been shown to be changing. Table 13.3
shows that the percentage of odontogenic infections yielding one or more penicil-
lin-resistant strains increased from 33% to 55% during the 1990s (Flynn et al.
2006a; Brook et al. 1992; von Konow et al. 1992; Lewis et al. 1995). Of note,
clindamycin resistance is also increasing in peritonsillar abscesses, with resistant
strains noted in as many as 33% of cases.
The predominant aerobic bacteria in odontogenic infections are the Streptococcus
milleri group composed of S. viridans bacteria that include S. anginosus, S. interme-
dius, and S. constellatus (Hupp and Ferneini 2016; Hupp et al. 2014). These bacteria
are facultative organisms, meaning they can grow in the presence or absence of
oxygen. Numerous studies have been consistent in showing that these bacteria make
up approximately 65% of odontogenic infections. Other less common aerobic bac-
teria include staphylococci, group D Streptococcus organisms, other streptococci,
Neisseria species, Corynebacterium species, and Haemophilus species.
The anaerobic bacteria of odontogenic infections include a greater variety of spe-
cies; however, the gram-positive cocci, specifically Streptococcus and
Peptostreptococcus, predominate in 65% of cases. Gram-negative anaerobic rods,
Prevotella, and Porphyromonas are found in nearly 75% of cases. Fusobacterium
organisms are found in more than 50% of cases.
242 G. Hayek et al.

13.3 Fascial Planes and Spaces

As a general rule, infection erodes through the thinnest adjacent bone (most com-
monly the buccal plate, except for mandibular molars which most commonly perfo-
rate the lingual plate), to cause infection in the adjacent tissue. While most infections
penetrate the cortical plate to become a vestibular abscess, depending on the anat-
omy of adjacent muscle attachments relative to where the infection erodes, the
abscess may spread into the deeper fascial spaces. The fascial spaces are fascia-
lined tissue compartments filled with loose, areolar connective tissue that serve to
provide a cushion for the adjacent muscles, vessels, nerves, glands, and other sur-
rounding structures. It is important to recognize that these are only potential spaces
and do not exist in normal anatomy. When microorganisms invade the tissue, the
resulting inflammatory process results in an edematous response and corresponding
tissue exudate; and eventually the tissue becomes indurated as the polymorphonu-
clear leukocytes, lymphocytes, and macrophages migrate into the interstitial spaces.
The final step of this process is a liquefactive necrosis of white blood cells and con-
nective tissue, resulting in an abscess formation. These stages are what are clinically
referred to as edema (bacterial inoculation), cellulitis (intense inflammatory
response), and abscess formation (pus formation). Table 13.4 provides a compari-
son of the clinical parameters of the stages of infection, while Table 13.5 provides
an overview of the potential spaces.

13.3.1 Infections Arising from Maxillary Teeth

Maxillary incisors and the palatal root of maxillary first molars whose apices may
lie toward the palate may perforate the palatal cortical plate causing a palatal space
infection (Hupp and Ferneini 2016; Hupp et al. 2014; Flynn and Topazian 1987).
The buccal space is commonly infected from maxillary molars (Fig. 13.1). This will
clinically be apparent as swelling below the zygomatic arch but above the inferior
border of the mandible.

Table 13.4 Comparison of the clinical stages of infection

Characteristic Edema (inoculation) Cellulitis Abscess
Duration 0–3 days 1–5 days 4–10 days
Pain, borders Mild, diffuse Diffuse Localized
Size Variable Large Smaller
Color Normal Red Shiny center
Consistency Jellylike Board-like Soft center
Progression Increasing Increasing Decreasing
Pus Absent Absent Present
Bacteria Aerobic Mixed Anaerobic
Seriousness Low Greater Less
From: Hupp, J., Ellis, E., Tucker, M. Principles of Management and Prevention of Odontogenic
Infections. Contemporary Oral and Maxillofacial Surgery 2014; p 298
13 Odontogenic Infections 243

Table 13.5 Potential spaces involved in odontogenic infections

Deep fascial space infections associated with any tooth
• Vestibular
• Buccal
Deep fascial space infections associated with maxillary teeth
• Infraorbital
• Infratemporal
• Canine
• Palatal
• Periorbital
• Orbital
• Cavernous sinus (venous plexus)
• Peritonsillar
• Maxillary or other paranasal sinus
Deep fascial space infections associated with mandibular teeth
• Space of the body of the mandible
• Submandibular
• Sublingual
• Submental
• Masticator
• Submasseteric
• Pterygomandibular
• Superficial temporal
• Deep temporal
Deep fascial spaces of the neck (most commonly mandibular)
• Lateral pharyngeal
• Retropharyngeal
• Pretracheal
• Danger space
• Prevertebral
From: Hupp, J., and Ferneini, E. Anatomy Relevant to Head, Neck, and Orofacial Infections.
Head, Neck, and Orofacial Infections 2016; p 71

Posterior maxillary teeth may also erode through the floor of the maxillary sinus.
This route accounts for almost 20% of maxillary sinusitis cases. Rarely, these
infections may spread superiorly through the ethmoid sinus or orbital floor to cause
periorbital or orbital infections. These cases require prompt surgical intervention
and can be recognized by vascular and neural involvement of the orbit in addition to
the traditional signs and symptoms of infection. Also rare, maxillary odontogenic
infections can erode into the infraorbital (via the infraorbital space) or inferior
ophthalmic vein (via the maxillary sinus). These vessels are part of the pathway
through the superior orbital fissure directly into the cavernous sinus (Fig. 13.2). This
is the one pathway of potential cavernous sinus thrombosis.
Deeper infections from maxillary teeth may include the infratemporal space,
which lies just posterior to the maxilla and is continuous with the deep temporal
space. It is rare for this space to become infected, most commonly from maxillary
third molars, but this space contains a number of important structures including
branches of the internal maxillary artery and the pterygoid venous plexus. The
pterygoid plexus contains emissary veins that pass through the foramina of the skull
244 G. Hayek et al.

Fig. 13.1 Patient with a

left buccal space infection

Fig. 13.2 Patient with a

left cavernous sinus
infection
13 Odontogenic Infections 245

to connect with the intracranial dural sinuses and can result in cavernous sinus
infection. These rare but serious cases highlight the importance of recognizing the
potential seriousness of the spread of infections.

13.3.2 Infections Arising from Mandibular Teeth

In the mandible, infections spreading beyond the vestibular space tend to enter the
space of the body of the mandible and the submandibular, sublingual, submental, or
masticator spaces and may subsequently enter the deep fascial spaces of the neck
and, rarely, can extend to the mediastinum, causing a threat to the heart, lungs, and
great vessels (Fig. 13.3).
The space of the body of the mandible is a subperiosteal space, and as such, an
infection may simply lift the periosteum and clinically appear as if the mandibular
bone itself is enlarged. If an infection of this nature penetrates the buccal cortical
bone and the periosteum inferior to the attachment of the buccinator muscle, a buc-
cal space infection ensues.

Fig. 13.3 Patient with a

submental space infection
246 G. Hayek et al.

Sublingual and submandibular space infections are usually the result of a lin-
gual cortical plate perforation from mandibular molars and occasionally premo-
lars. The attachment of the mylohyoid muscle on the mylohyoid ridge of the
medial aspect of the mandible is the separation of these two spaces with the sub-
lingual space (usually from premolars and first molars) being above this demarca-
tion and the submandibular space (usually from third molars) below. Infections
from the mandibular second molars may involve either space, depending on the
length of the roots. It should be noted that clinically, a sublingual space infection
would appear as floor of mouth swelling with the tongue elevated. Swelling below
the border of the mandible can identify an infection of the submandibular space.
The posterior portion of the sublingual space is in open communication with the
submandibular space. The submandibular space similarly communicates posteri-
orly freely with the deep fascial spaces of the neck. The third component of the
“perimandibular space” is the submental space just adjacent to the mandibular
midline. Though rarely seen as an isolated infection, it is most commonly the
result of mandibular incisors. It is much more common to see this develop as a
submandibular space infection that has passed around the anterior belly of the
digastric muscles.
When all three perimandibular spaces (submandibular, sublingual, submental)
are involved bilaterally, it is known as Ludwig’s angina. This is a surgical emergency
that can quickly obstruct the airway and spread to the deep fascial spaces of the
neck. These patients clinically present with severe swelling, elevation of the tongue,
and a bilateral induration of the submandibular space. Patients often have trismus,
drooling, and difficulty and pain to swallowing and may have difficulty breathing.
Prompt, aggressive treatment is required to secure the airway and provide surgical
intervention, or death can ensue.
Numerous studies have shown that the most commonly infected spaces are the
submandibular and masticator spaces in 54–78% of non-vestibular infections, with
the third molar being the most common offending tooth. The masticator space can be
further divided into four compartments: the submasseteric space (between the mas-
seter muscle and the lateral surface of the ascending ramus), the pterygomandibular
space (between the medial pterygoid muscle and the medial surface of the ascending
ramus), the superficial temporal space (between the temporalis fascia and the tempo-
ralis muscle), and the deep temporal space (between the temporalis muscle and the
skull). The zygomatic arch separates the submasseteric and superficial temporal
spaces, while the lateral pterygoid muscle separates the pterygomandibular and deep
temporal spaces. The commonly referred to infratemporal space is the inferior por-
tion of the deep temporal space.
Generally, only one of these four subspaces is infected, though long-standing or
severe infections may involve multiple. The submasseteric space most commonly
results from the spread of a buccal space infection or a mandibular third molar
pericoronitis infection. The resulting inflammation of the masseter muscle results in
trismus. Pterygomandibular space infections generally arise from mandibular third
molars. It should be noted that this is the space into which local anesthetic solution
is deposited when providing inferior alveolar nerve blocks, and this space may thus
13 Odontogenic Infections 247

be infected via needle tracking. Clinically, an infection of this space does not result
in much, if any, swelling; however, there will be significant trismus, and the lack of
swelling in the presence of trismus can be a diagnostic sign. It may also be possible
to identify swelling and inflammation of the anterior tonsillar pillar on the affected
side with deviation of the uvula. The superficial and deep temporal spaces are rarely
infected, and their involvement is generally indicative of a severe infection.
Clinically, swelling will be observed in the temporal region, superior to the
zygomatic arch, and posterior to the lateral orbital rim.

13.3.3 Infections Spreading to the Deep Cervical Spaces

Involvement of the deep cervical spaces, though rare, can have life-threatening con-
sequence as the airway can become compressed, deviated, or even completely
obstructed; vital structures, such as the great vessels, can become invaded; and exten-
sion into the mediastinum and its contents can occur (Flynn et al. 2006a). As
described above, the perimandibular spaces extend posteriorly into the deep cervical
spaces, with the lateral pharyngeal space being the first to encounter the spread of
infection (Hupp and Ferneini 2016; Hupp et al. 2014).
The lateral pharyngeal space includes a relatively benign anterior compartment
containing loose connective tissue and a posterior compartment, which contains the
carotid sheath and cranial nerves IX (glossopharyngeal), X (vagus), and XII
(hypoglossal). Clinically, an infection of this space will include trismus and lateral
neck swelling. Patients often have difficulty swallowing and will appear sick with a
significant fever. An infection of this space indicates a severe infection that is often
rapidly spreading. The contents of the lateral pharyngeal space put the patient at risk
for internal jugular vein thrombosis, carotid artery erosion, and interference with
the functions of the associated cranial nerves.
Beyond the lateral pharyngeal space lies the retropharyngeal space, just posterior
to the pharynx. This space contains only loose connective tissue and lymph nodes.
As such, there are essentially no barriers to the spread of infection from one lateral
pharyngeal to its contralateral side, effectively surrounding the airway.
Involvement of the retropharyngeal space is most concerning for rupture of the
alar fascia posteriorly, thus allowing the infection to invade the danger space. The
danger space extends from the skull to the diaphragm, continuous with the medias-
tinum. The mediastinum runs between the lungs and contains the heart, lungs, and
trachea, in addition to the phrenic and vagus nerves, main stem bronchi, esophagus,
and great vessels such as the aorta and inferior and superior vena cava. Infection of
the mediastinum puts the patient at risk for compression of the heart and lungs,
neurological interference with the control of heart rate and respirations, and rupture
of the lungs, trachea, or esophagus with potential resulting spread to the abdominal
cavity. The mortality rate in mediastinitis is high.
Table 13.6 highlights the anatomy of the above-described potential spaces, while
Table 13.7 summarizes the clinically relevant information, including the most likely
offending tooth and optimal approach for surgical drainage.
Table 13.6 Borders of the fascial spaces of the head and neck
248

Superficial or
Space Anterior Posterior Superior Inferior medial Deep or lateral
Buccal Corner of the mouth Masseter muscle, Maxilla, Mandible Subcutaneous Buccinator muscle
pterygomandibular infraorbital tissue and skin
space space
Infraorbital Nasal cartilages Buccal space Quadratus labii Oral mucosa Quadratus labii Levator anguli oris muscle,
superioris superioris muscle maxilla
muscle
Submandibular Anterior belly Posterior belly digastric Inferior and Digastric tendons Platysma muscle, Mylohyoid muscle,
digastric muscle muscle, stylohyoid medial surfaces investing fascia hyoglossus muscle,
muscle, of mandible superior constrictor
stylopharyngeus muscle muscles
Submental Inferior border of Hyoid bone Mylohyoid Investing fascia Investing fascia Anterior belly of digastric
mandible muscle muscle
Sublingual Lingual surface of Submandibular space Oral mucosa Mylohyoid Muscles of tongue Lingual surface of
mandible muscle mandible
Pterygomandibular Buccal space Parotid gland Lateral Inferior border of Medial pterygoid Ascending ramus of
pterygoid mandible muscle mandible
muscle
Submasseteric Buccal space Parotid gland Zygomatic arch Inferior border of Ascending ramus Masseter muscle
mandible of mandible
Lateral pharyngeal Superior and middle Carotid sheath, scalene Skull base Hyoid bone Pharyngeal Medial pterygoid muscle
pharyngeal muscles fascia constrictors and
retropharyngeal
space
Retropharyngeal Superior and middle Alar fascia Skull base Fusion of alar and Carotid sheath and lateral
pharyngeal prevertebral fascia pharyngeal space
constrictor muscles at C6-T4
Pretracheal Sternothyroid- Retropharyngeal space Thyroid Superior Sternothyroid- Visceral fascia over trachea
thyrohyoid fascia cartilage mediastinum thyrohyoid fascia and thyroid gland
From: Hupp, J., Ellis, E., Tucker, M. Principles of Management and Prevention of Odontogenic Infections. Contemporary Oral and Maxillofacial Surgery 2014;
G. Hayek et al.

p 323
13 Odontogenic Infections 249

Table 13.7 Clinical findings relevant to fascial space anatomy

Approach
Space Likely causes Contents Neighboring spaces for I&D
Buccal Upper Parotid duct Infraorbital Intraoral
premolars Anterior facial Pterygomandibular (small)
Upper molars artery and vein Infratemporal Extraoral
Lower Transverse facial (large)
premolars artery and vein
Buccal fat pad
Infraorbital Upper canine Angular artery and Buccal Intraoral
vein
Infraorbital nerve
Submandibular Lower molars Submandibular Sublingual Extraoral
gland Submental
Facial artery and Lateral pharyngeal
vein Buccal
Lymph nodes
Submental Lower anterior Anterior jugular Submandibular (on Extraoral
teeth vein either side)
Fracture of Lymph nodes
symphysis
Sublingual Lower Sublingual gland Submandibular Intraoral
premolars Wharton’s ducts Lateral Intraoral-
Lower molars Lingual nerve Pharyngeal extraoral
Direct trauma Lingual artery and Visceral (trachea
vein and esophagus)
Pterygomandibular Lower third Mandibular Buccal Intraoral-
molars division of Lateral pharyngeal extraoral
Fracture of trigeminal nerve Submasseteric
angle of Inferior alveolar Deep temporal
mandible artery and vein Parotid
Peritonsillar
Submasseteric Lower third Masseteric artery Buccal Intraoral
molars and vein Pterygomandibular Intraoral-
Fracture of Superficial temporal extraoral
angle of Parotid
mandible
Infratemporal and Upper molars Pterygoid plexus Buccal Intraoral
deep temporal Interior maxillary Superficial temporal Extraoral
artery and vein Inferior petrosal Intraoral-
Mandibular sinus extraoral
division of
trigeminal nerve
Skull base foramina
Superficial temporal Upper molars Temporal fat pad Buccal Intraoral
Lower molars Temporal branch of Deep temporal Extraoral
facial nerve Intraoral-
extraoral
Lateral pharyngeal Lower third Carotid artery Pterygomandibular Intraoral
molars Internal jugular Submandibular Intraoral-
Tonsils vein Sublingual extraoral
Infection of Vagus nerve Peritonsillar
neighboring Cervical Retropharyngeal
space sympathetic chain
From: Hupp, J., Ellis, E., Tucker, M. Principles of Management and Prevention of Odontogenic
Infections. Contemporary Oral and Maxillofacial Surgery 2014; p 324
250 G. Hayek et al.

Table 13.8 Relative severity of deep fascial space infections

Low severity—low risk to airway or vital structures
• Vestibular
• Subperiosteal
• Buccal
• Space of the body of the mandible
• Infraorbital
Moderate severity—hinders airway access
• Submandibular
• Sublingual
• Submental
• Masticator
• Submasseteric
• Pterygomandibular
• Superficial temporal
• Deep temporal
High severity—direct threat to airway or vital structures
• Perimandibular
• Lateral pharyngeal
• Retropharyngeal
• Pretracheal
• Danger space
• Mediastinum
• Intracranial infection
From: Hupp, J., and Ferneini, E. Principles of Antibiotic Therapy for Head, Neck, and Orofacial
Infections. Head, Neck, and Orofacial Infections 2016; p 127

Whichever deep fascial space is infected, it is important to understand that the

risk to the airway is real and compromise can occur quickly. Thus, it is important to
quickly recognize the affected space so that treatment can be initiated. The relative
severity of each potential space infection can be classified by the likelihood of
threatening the airway or other vital structure (see Table 13.8). Low-severity infec-
tions are not likely to threaten any vital structure. Moderate-severity infections can
hinder access to the airway via trismus or tongue elevation, potentially making
endotracheal intubation difficult. High-severity infections can compress or deviate
the airway or damage vital organs such as the heart, lungs, or brain.

13.4 Management and Treatment

When treating infections, the clinician must keep in mind all of the preceding infor-
mation. Applying this information to a series of principles can be used stepwise to
make treatment decisions.

13.4.1 Determine Severity of Infection

Though the above discussion on fascial planes can be intimidating, as previously

mentioned, most odontogenic infections are mild and require only minor surgical
therapy. The severity of infection can be determined with a complete history and
13 Odontogenic Infections 251

physical examination to evaluate airway patency, anatomic location, and rate of

progression. The history should be obtained as any other history would be, by start-
ing with the chief compliant in the patient’s own words. The provider should then
determine the onset of the infection. This can be obtained by asking the patient
when they first began to experience symptoms such as pain, swelling, or drainage.
The provider will want to know if the infection has been constant, waxed and waned,
or steadily grown worse. These questions will help the practitioner determine the
rate of progression of the infection.
The signs and symptoms of the infection should be assessed at this time as well.
An infection is the body’s response to severe inflammation, and as such, the cardinal
signs of inflammation are what to look for in on examination. These include dolor
(pain), tumor (swelling), calor (warmth), rubor (erythema), and functio laesa (loss
of function).
Pain is generally the most common complaint from patients. The clinician will
want to know where the pain started and where the pain has spread. Swelling can
range from subtle and difficult to notice to quite obvious. In cases of subtle swelling,
the patient may be able to point out an area of their own body that doesn’t look right
to them better than the practitioner, and as such the patient should be specifically
asked if they have noticed any swelling. Similarly, the patient should be asked whether
they have noticed any warmth over the area in question or whether they perceive a
color change. Loss of function can be assessed by checking for trismus (limited mouth
opening), as well as asking the patient if they are having any difficulty chewing, swal-
lowing (dysphagia), or breathing (dyspnea). Finally, the patient should be asked how
they feel in general. Malaise is a feeling of fatigue, fever, weakness, or just “sickness”
and is often indicative of the body’s general reaction to infection.
Any history of treatment for the current infection should be discerned at this
time. This can include self-treatments such as taking previously leftover antibiotics
or professional treatment by other dentists or physicians. The patient’s complete
medical history should be obtained.
The physical exam should include the patient’s vital signs (temperature, blood
pressure, pulse rate, and respiratory rate). Patients with systemic involvement will
have elevated temperatures (a temperature of 101.5 °F or 38.6 °C is considered a
true fever). The pulse will increase with temperature, and 100 beats/min is a poten-
tial sign of a severe infection requiring more aggressive treatment. Blood pressure
is the vital sign that will deviate from baseline the least due to infection. Its increase
is generally due to patient pain or anxiety; however, hypotension is a sign of septic
shock. Respirations are important for the assessment of partial or complete airway
obstruction. A normal respiratory rate is between 14 and 16 breaths/min. If the
only vital sign that is altered is a mild temperature elevation, this is indicative of a
mild infection that can be readily treated. Alterations of other vital signs are poten-
tial indicators of a more severe infection that may need a higher level of care.
The physical exam should then continue with an inspection of the general appear-
ance of the patient. Patients with more severe infections will appear more “toxic”
with apparent fatigue and general malaise.
The head and neck should be closely examined for the cardinal signs of infec-
tion. The patent should be asked to open wide, swallow, and take deep breaths as the
252 G. Hayek et al.

dentist inspects for trismus, dysphagia, and dyspnea. These are signs of more severe
infections that may require referral.
Areas of swelling should be examined by palpation, gently touching the area to
check for tenderness, warmth, and consistency. The consistency may range from
indurated (hard) to fluctuant (soft, fluid-filled balloon feeling). The latter is indicative
of purulent accumulation.
An intraoral exam should be completed in an attempt to identify the source of
infection. The exam should include inspection for carious teeth, severe periodontal
disease, infected fracture of tooth or bone, or any combination of the above. The
dentist should also feel for areas of gingival swelling and for localized vestibular
swellings or sinus tracts.
The next step of the initial exam is radiographic. This may consist of periapical
or panoramic radiographs, which are especially useful in patients with limited
mouth opening or tenderness. Deep cervical space infections will require evaluation
with computed tomography (CT).
At this point, the dentist should have a sense of the presenting stage of the infection
and severity of the infection. Soft, mildly tender, edematous swellings indicate inocula-
tion; induration represents cellulitis; and central fluctuance indicates abscess. Cellulitis
is generally acute, painful, with more swelling than edema, and with diffuse borders.
They are hard, do not contain visible pus, and can rapidly spread. Abscesses are a more
mature infection with more localized pain, less swelling, and well-circumscribed bor-
ders. They represent the body’s host resistance in an attempt to wall off the infection. It
is often difficult to distinguish between cellulitis and abscess, and both may be present
in a given area or different spaces may be at different stages of infection.

13.4.2 Evaluate Host Defenses

One of the reasons it’s so important to take a complete and accurate medical history
is the opportunity for the dentist to evaluate the patient immune system’s ability to
defend itself against infections. Several common disease states and medications can
significantly alter the patient’s ability to do so. Not only are immunocompromised
patients more likely to get infections, but the infection is also more likely to become
serious and spread rapidly.
Uncontrolled metabolic diseases result in decreased function of leukocytes. The
most common of these disorders are type 1 (insulin-dependent) and type 2 (insulin-
independent) diabetes but also include end-stage renal disease with uremia, malnu-
trition, and severe alcoholism. It should be noted that worsening control of
hyperglycemia is directly correlated with lowered resistance to infection. The sec-
ond significant category of immunocompromised patients is those that suppress the
immune system in general and includes malignancies, HIV, and immunologic dis-
ease. In these disease states, the patient will have decreased white blood cell func-
tion and decreased antibody synthesis and production.
Patients taking certain medications can also be immunologically compromised.
These include chemotherapeutic agents that decrease circulating white blood cells
13 Odontogenic Infections 253

and patients taking immunosuppressive drugs, most commonly for organ

transplantation, which decrease T and B lymphocyte and immunoglobulin
production. If the medical history indicates a history of disease state that may have
required these drugs, the dentist should inquire as to not only current use but past
use of these drugs as the immunosuppressive effects of certain chemotherapeutic
agents can last for up to 1 year after cessation.
When the patient’s history indicates any of the above concerns, the risk of rapid
spread is much greater, and the patient will need to be treated more aggressively.
Consideration should be given for prompt referral to an oral and maxillofacial
surgeon for treatment and initiation of parenteral antibiotics, as well as the possibility
of prophylactic antibiotics for even routine oral surgical procedures.

13.4.3 Determine the Care Setting

The vast majority of odontogenic infections can be treated by the general dentist
with minor surgical intervention and antibiotics if indicated. However, the previous
discussion should highlight that severe infections do have the potential to become
life threatening. The dentist needs to know when to refer cases to an oral and
maxillofacial surgeon for care in an outpatient or hospital inpatient basis, summarized
in Table 13.9. The dentist should use the following set of criteria to quickly evaluate
the severity of infection. If some or all of these criteria are met, immediate referral
should be considered.
There are three main criteria that should indicate immediate referral to a hospi-
tal emergency department due to an impending airway threat. The first is a history
of rapidly progressing infection—that is, one that began only 1 or 2 days ago and
has rapidly gotten worse with increasing swelling, pain, and other signs and symp-
toms. These patients are at increased risk of infection involving the deep cervical
spaces and compressing the airway. The second criterion is difficulty breathing
(dyspnea), which may be due to the infection encroaching on the soft tissue sur-
rounding the airway. The dentist can recognize this by looking for obvious signs of
breathing difficulties, patients who refuse to lie down, or those with muffled or

Table 13.9 Oral and • Difficulty breathing

maxillofacial surgeon referral • Difficulty swallowing
criteria • Dehydration
• Moderate-severe trismus (MIO <20 mm)
• Swelling extending beyond the alveolar process
• Fever (>101.5 °F)
• Severe malaise and toxic appearance
• Immunocompromised patient
• Need for general anesthesia
• Failure of prior treatment
From: Hupp, J., Ellis, E., Tucker, M. Principles of Management
and Prevention of Odontogenic Infections. Contemporary Oral
and Maxillofacial Surgery 2014; p 303
254 G. Hayek et al.

distorted speech. The third criterion is difficulty swallowing (dysphagia), which is

also a sign of deep cervical space involvement. True dysphagia can be identified by
the presence of drooling, as a patient’s inability to handle his or her own secretions
is a sign of a narrowed oropharynx. In all three of these cases, the immediate con-
cern is monitoring the airway and, if necessary, securing with endotracheal intuba-
tion or surgical intervention. The infection can then be dealt with appropriately.
There are other criteria that the dentist needs to be aware of that may require
referral to an oral and maxillofacial surgeon. The first is that certain spaces are more
appropriately treated by a transfacial incision and drainage procedure for drainage
by gravity, as was seen in Table 13.7. The second is a temperature greater than
101.5 °F, which indicates a greater severity of infection. The third criterion is severe
trismus—an inability to open the mouth fully due to inflammation of the muscles of
mastication. Trismus can be defined as mild, moderate, or severe by a maximum
incisal opening (MIO) of 20–30 mm, 10–20 mm, and <10 mm, respectively.
Moderate-severe trismus is a potential sign of involvement into the masticator space
and beyond to the deep cervical spaces. Infection of these spaces may require
evaluation by an oral and maxillofacial surgeon to determine airway patency.
Systemic involvement is another reason for referral, which can be identified by the
previously described “toxic” appearance. Lastly, an oral and maxillofacial surgeon
may be more appropriate to treat patients with severely compromised host defenses,
as the surgeon has the ability to admit these complicated patients to the hospital for
more definitive care.

13.4.4 Treat Surgically

Once the first three factors have been evaluated and the dentist has decided to treat
the patient, the first step in the management of odontogenic infections is removal of
the source of infection and surgical drainage, which can range from simple
endodontic access to soft tissue dissections in the neck or mediastinum in truly
severe, life-threatening situations.
The primary goal of surgical management is to remove the source of infection,
most commonly a necrotic dental pulp, with a secondary goal of draining any
accumulated purulent or necrotic debris. If the dentist chooses to save the tooth,
endodontic therapy should be initiated to remove the necrotic pulp, which is the
source of infection. Extraction of the tooth both removes the source of infection and
provides drainage from the periapical region. If the infection has spread beyond the
periapical region, an incision and drainage (I&D) should be performed. This
decreases the bacterial load, and the removal of the purulent and/or necrotic debris
will decrease the pressure in the region, thus decompressing the tissue and increasing
local blood flow to deliver host defenses and antibiotics to the region. Given that the
goal of surgical intervention is to achieve adequate drainage, it should be noted that
if endodontic access does not provide adequate drainage, an I&D is still indicated.
Lastly, the dentist should consider insertion of a drain to prevent premature closure
of the mucosal incision, allowing the abscess to reform. It should be noted that
13 Odontogenic Infections 255

removal of the source and evacuation of the bacterial and necrotic debris is the
treatment that must be performed. Antibiotics are an adjunctive treatment, and fail-
ure to perform surgical intervention for infections beyond the inoculation stage may
result in the lack of resolution or worsening of the infection.
Generally, infections in the inoculation stage can generally be cured with removal
of the source of infection with or without supporting antibiotics, whereas cellulitic
or abscessed patients are at a more advanced stage requiring removal of the source,
as well as incision and drainage and antibiotics.
Within the surgical community, there continues to be disagreement as to whether
cellulitis cases require incision and drainage versus removal of the source and antibi-
otics alone. Literature suggests that if a true cellulitis exists, intravenous antibiotics
alone, with empiric coverage against aerobic and anaerobic pathogens, are enough
for treatment in addition to source removal (Flynn et al. 2006b; Shanti and Shahid
2011). However, one landmark study by Flynn and colleagues noted that clinical
examination was able to identify a drainable collection only 63% of the time; other
studies show this percentage as low as 33%. Flynn’s same study found the presence
of pus in 76% of cases. Even the accuracy of CT scans in the evaluation of deep neck
infections has been shown to have variable accuracy, with false positives for abscesses
ranging from 11.8% to 25%. Literature suggests that a combination of CT scan and
clinical examination together is the most accurate method of identifying a drainable
collection. Given that clinical examination often underestimates suppuration, this
may be a reason to drain even suspected cellulitis, which at the very least changes the
environment of the often-facultative anaerobes living in the infection (Hupp and
Ferneini 2016; Hupp et al. 2014).
Figure 13.4 outlines the suggested algorithm for the treatment of odontogenic
infections. The optimal site for a straightforward vestibular abscess or cellulitis is
directly over the area of maximum swelling and inflammation; however, the dentist
should take care to note relevant anatomy such as a frenum or the mental nerve and
alter their incision site appropriately in such cases. The site should be anesthetized
either locally or with a regional block, and the needle subsequently discarded so as
not to infect other tissue if it is used again.
Before starting, the dentist should determine whether a culture and sensitivity
(C&S) test of the specimen should be obtained. Table 13.10 outlines the indications
for such a procedure. As the previous discussion on microbiology of odontogenic
infections highlighted, the microbes of these infections are highly consistent, and
C&S is not needed for routine odontogenic infections. If the test is to be obtained,
after anesthesia, the dentist should disinfect the mucosal surface with a solution
such as povidone-iodine (Betadine) and dry the tissue with sterile gauze. A large-
gauge needle (e.g., 18 g), with a small syringe (3 mL is usually sufficient), will be
used to collect the specimen. The needle should be inserted into the abscess or cel-
lulitis and 1 or 2 mL of fluid aspirated. Even if no apparent pus is obtained, there is
usually a sufficient bacterial load to suffice. The specimen should then be trans-
ferred to an appropriate culturette, which is a sterile tube that contains a swab and
bacterial transport medium. This will be sent to the lab with a request for gram stain,
aerobic and anaerobic cultures, and antibiotic sensitivity testing.
256 G. Hayek et al.

Follow-up
preventive and
restorative care

History and
physical examination Remove dental cause
extraction Improvement
Pain by 72h
Inoculation endodontics
Swelling ↓temperature
Caries stage debridement
↓fever
Periodontitis ↓swelling
Pericoronitis
Assess Severity
airway compromise
anatomic location Oral antibiotics
rate of progression supportive care
Odontogenic Outpatient
evaluate host defenses control systemic disease
infection therapy
medical comorbidities hydration, nutrition
immune compromise
systemic reserve

Xray examination Failure to

periapical pathosis improve by
periodonatal bone loss Cellulitis or Incision and drainage 72h
impacted tooth abscess stage
Remove dantal cause
extraction
endodontics
debridement

Referreal to
oral and
maxillofacial
surgeon

Fig. 13.4 Management algorithm for odontogenic infections. From: Hupp, J., Ellis, E., Tucker,
M. Principles of Management and Prevention of Odontogenic Infections. Contemporary Oral and
Maxillofacial Surgery 2014; p 305

Table 13.10 Indications for • Infection spreading beyond the alveolar process
culture and antibiotic • Rapidly progressing infection
sensitivity testing • Previous, multiple antibiotic therapy
• Nonresponsive infection (after 48 h)
• Recurrent infection
• Immunocompromised patient
From: Hupp, J., Ellis, E., Tucker, M. Principles of Management
and Prevention of Odontogenic Infections. Contemporary
Oral and Maxillofacial Surgery 2014; p 304

A scalpel blade should be used to incise through mucosa, submucosa, and peri-
osteum to bone. The incision should be short, around 1 cm. A closed curved hemo-
stat is then inserted through the incision and opened in several directions to explore
the space and breakup and loculations (cavities of pus) that weren’t incised by the
original incision. Care should be taken not to close the hemostat within the wound
so as not to crush any tissue. The cavity should then be thoroughly irrigated with
solution, most commonly normal sterile saline, in order to fully wash out any
remaining debris.
Once the abscess cavity has been fully opened and evacuated, a small drain
should be inserted to ensure that the access stays open. For intraoral I&Ds, this is
most commonly a ¼″ Penrose drain, but anything that will keep the mucosa open
will suffice. The drain should be of adequate length to reach the depth of the abscess.
13 Odontogenic Infections 257

It is then inserted into the cavity with a hemostat and sutured to one edge of the inci-
sion with a non-resorbable suture. The drain should remain in place until drainage
has stopped, usually 2–5 days. The drain can be removed by simply cutting the
suture and gently pulling on the end of the drain.

13.4.5 Support Medically

Although the mainstay of infection management is surgical therapy, supportive

medical therapy cannot be overlooked. Medical therapy should be aimed at support-
ing the host’s systemic response to the infection through appropriate antibiotic ther-
apy, management of comorbidities, and special attention to appropriate hydration
and nutrition. For example, diabetics may require insulin adjustment as the infec-
tion raises the blood sugar level; cardiovascular disease decreases the ability of the
patient to respond to stress, thus potentially necessitating the need for hypertension
or cardiac arrhythmia control; and patients on Coumadin may require reversal prior
to surgical intervention. Patients with compromise of the cardiovascular, respira-
tory, hematologic, or metabolic systems may need appropriate medical support
from a team of specialists.
Even healthy patients can have reduced or altered physiologic reserves required
for the body to fight the infection. Children, for example, are much more susceptible
to dehydration and high fevers, while the elderly are less able to mount a fever but
are also susceptible to dehydration (Chi et al. 2014). Fever increases daily fluid
requirements and daily caloric requirements. Fevers up to 103 °F may help to fight
the infection; however, it is important to monitor this closely so that dangerous lev-
els are not reached. Dentists can help patients in this regard with thorough postop-
erative instructions, as patients often need to be encouraged to have adequate fluid
and caloric intake in the face of pain and/or difficulty swallowing.

13.4.6 Choose and Administer Appropriate Antibiotics

Antibiotics are an often-needed adjunctive agent in the management of odontogenic

infections that need to be carefully chosen and used in the appropriate situations,
especially given the growing concerns regarding antibiotic resistance. The following
discussion serves as a guideline for appropriate antibiotic prescribing.
It is commonly assumed that all infections require antibiotics, though this is
certainly not the case—there are even situations in which they are contraindicated.
Antibiotics, in short, should be used when there are clear indications of bacterial
invasion into deeper tissues, in patients with compromised immune systems, in
patients not able to receive immediate surgical intervention, and in patients with a
systemic response (Rosenthal et al. 2011; Flynn 2011). The following three factors
should be considered when deciding whether to prescribe an antibiotic, and
Table 13.11 further lists indications.
258 G. Hayek et al.

Table 13.11 Antibiotic • Swelling extending beyond the alveolar process

indications • Cellulitis
• Trismus
• Lymphadenopathy
• Fever >101.5 °F
• Severe pericoronitis
• Osteomyelitis
From: Hupp, J., Ellis, E., Tucker, M. Principles of Management
and Prevention of Odontogenic Infections. Contemporary Oral
and Maxillofacial Surgery 2014; p 307

Table 13.12 Situations in • Patient demand

which antibiotics are not • Pain, toothache
indicated • Periapical abscess
• Alveolar osteitis (dry socket)
• Extractions in non-immunocompromised patients
• Mild pericoronitis (inflammation of the operculum only)
• Successfully drained alveolar abscess
From: Hupp, J., Ellis, E., Tucker, M. Principles of Management
and Prevention of Odontogenic Infections. Contemporary Oral
and Maxillofacial Surgery 2014; p 307

1. The seriousness of the infection. Infections that have caused swelling, rapidly
progressed, or is a diffuse swelling all have literature support for antibiotics in
addition to incision and drainage.
2. Failure to obtain adequate drainage. As previously stated, removal of the tooth—
or source of infection—does not spread the infection but rather aids in the resolu-
tion of infection and limits complications. Multiple studies have supported this
statement and also shown that antibiotics are not necessary prior to extraction. If
extraction fails to achieve appropriate drainage, an I&D will be indicated in addi-
tion to antibiotics.
3. The state of the patient’s host defense response. Aggressive antibiotics are indi-
cated in patients with an immunocompromised state, as has been discussed
previously.

Antibiotics are not indicated for minor, chronic, well-localized abscesses in

which removal of the source of infection will result in complete evacuation of the
infectious material, provided that the other factors previously discussed, such as an
immunocompromised state, are not met. Alveolar osteitis (dry socket) is not an
infectious process, and thus treatment should be limited to palliative care. Patients
with mild pericoronitis with minor gingival edema and pain also do not require
antibiotics and can be treated with light irrigation with hydrogen peroxide or
chlorhexidine and removal of the tooth. Patients who demand antibiotics also should
not be prescribed unless clinically indicated. Table 13.12 further describes situa-
tions in which antibiotics are not indicated. Antibiotics do not increase wound heal-
ing, nor do they play a role in nonbacterial infectious processes. Patients with
13 Odontogenic Infections 259

Table 13.13 Antibiotics Narrow-spectrum antibiotics Broad-spectrum antibiotics

used for odontogenic • Penicillin • Amoxicillin with
infections clavulanic acid
(Augmentin)
• Amoxicillin • Azithromycin
• Clindamycin • Moxifloxacin
• Metronidazole
From: Hupp, J., Ellis, E., Tucker, M. Principles of
Management and Prevention of Odontogenic Infections.
Contemporary Oral and Maxillofacial Surgery 2014; p 308

significant pain of pulpal origin, without spread into deeper tissues, also are not
indicated for antibiotics treatment, as this is a local inflammatory response.
The earlier discussion on odontogenic infection microbiology highlights the pre-
dictability of these infections; thus antibiotic therapy should be directed at these
organisms with proven medications in an empiric fashion. Oral antibiotics that have
been proven to be effective include penicillin, amoxicillin, clindamycin, azithromy-
cin, metronidazole, and moxifloxacin. Systematic reviews have shown that none of
the newer antibiotics have a greater efficacy than the traditional amoxicillin or peni-
cillin. Metronidazole should be reserved for situations in which there are significant
numbers of anaerobes and should be given in addition to an antibiotic with antiaero-
bic properties. With the exception of metronidazole, which targets anaerobes only,
these antibiotics all cover aerobic and facultative streptococci in addition to oral
anaerobes.
When choosing an antibiotic, the dentist should note to use the narrowest-spec-
trum antibiotic possible and with the lowest toxicity and side effects, as well as
using the least complicated dosing schedule possible to encourage patient compli-
ance. Using a narrow-spectrum antibiotic ensures that the therapy is targeting only
the offending organisms and not other bacteria that may be part of the GI tract, skin,
etc. and are part of the patient’s normal flora and can lead to other problems. See
Table 13.13 for a list of narrow- versus broad-spectrum antibiotics, all of which
have been proven effective in the treatment of odontogenic infections. Note that
simple odontogenic infections are ones in which the swelling is limited to the alveo-
lar process or vestibule, has not been treated before, and is not taking place in an
immunocompromised patient. Complex odontogenic infections include those in
which the swelling has extended beyond the vestibular space, has failed previous
therapy, and is attached to an immunocompromised patient.
Toxicities range from mild to severe. It should be noted that the time-tested anti-
biotics used in dentistry have a relatively benign side effect profile. The most com-
mon side effect of penicillin is allergy with approximately 2–3% of the population
affected. Azithromycin and clindamycin also have generally benign side effect pro-
files. Clindamycin is most commonly associated with severe diarrhea and pseudo-
membranous colitis, though any antibiotic can cause this condition. This is a rare side
effect with appropriate prescribing patterns. Moxifloxacin, a fluoroquinolone, is
rarely used in dentistry and should be limited to severe infections. It has significant
260 G. Hayek et al.

potential toxicities including muscle weakness, mental clouding, and potential life-
threatening drug-drug interactions. It is contraindicated in children and pregnant
females. Cephalosporins are no longer commonly used in dentistry as many of them
have lost much of their effectiveness against oral bacteria. They should be used with
caution, if at all, in penicillin allergic patients due to a 10–20% cross-reactivity.
Similarly, tetracyclines are no longer considered effective for the treatment of odon-
togenic infections with the exception of their use as topical agents in periodontal
infections. Tetracyclines can cause GI upset and photosensitivity and also should not
be used in pregnant patients or children. Lastly, metronidazole has only mild side
effects, most commonly GI disturbances. Patients must refrain from all alcohol
intake due to the disulfiram-like reaction of this drug in which even a small amount
of alcohol can cause violent abdominal cramping and vomiting.
Dentists should try to choose bactericidal antibiotics when possible. These
types of antibiotics kill bacteria themselves, whereas bacteriostatic antibiotics
interfere with bacterial reproduction and rely on the body’s host defenses to kill
the organism. The use of bactericidal antibiotics is thus especially important in
immunocompromised patients. Bactericidal antibiotics include the penicillins,
cephalosporins, fluoroquinolones, and metronidazole.
Antibiotics should be prescribed in the least taxing dosing schedule as possible in
order to encourage compliance—that is, patients are more likely to be compliant if
they have to take a pill less often. Current literature suggests that for routine odonto-
genic infections, antibiotics are not required beyond 3–5 days, when combined with
appropriate surgical intervention (Rosenthal et al. 2011). If the infection is not
resolving at follow-up, additional antibiotic courses may be necessary.

13.4.7 Reevaluate Frequently

Patients should be closely monitored following infection intervention to monitor for

response to treatment and complications. For routine odontogenic infections, a
follow-up at 2–3 days should suffice. Patients who are improving will exhibit a
dramatic decrease in pain and swelling. If there is no purulent output from the drain,
it can be removed at this time. The dentist should evaluate the patient’s temperature,
trismus, and subjective feelings of improvement at this time, in addition to inquiring
about drug toxicities and side effects.
If the patient is not showing significant signs of improvement, the dentist should
evaluate for possible causes of failure, summarized in Table 13.14. Most commonly,
this is due to inadequate surgery, especially if the tooth was endodontically accessed
and not removed—it should then be evaluated for extraction. It is also possible in
this situation that the area of infection covered a wider amount of tissue and an
additional I&D may be necessary.
Other causes of failure may be a more immunocompromised patient than origi-
nally suspected, in which the dentist should carefully question the patient to make
sure a complete medical history was elicited. Foreign bodies are rarely a cause of
odontogenic infection but should be considered in the setting of non-resolution of
13 Odontogenic Infections 261

Table 13.14 Common • Inadequate surgery

reasons for treatment failure • Immunocompromised state
• Foreign body
• Antibiotic problems
 – Non-compliance
 – Antibiotic not reaching site
 – Dose too low
 – Wrong identification of bacteria
 – Wrong antibiotic
From: Hupp, J., Ellis, E., Tucker, M. Principles of Management
and Prevention of Odontogenic Infections. Contemporary Oral
and Maxillofacial Surgery 2014; p 311

infections. Radiographic exam can help identify this, and dental implants should be
considered a source of bacterial harbor.
Lastly, the dentist should consider the chosen antibiotic. The dentist should first
question the patient on appropriate compliance with the prescribed drug regimen
including dose and scheduling. Patients often misunderstand dentist directions and
may not even fill the prescription due to cost or other reasons. The dentist will also
need to determine whether the antibiotic is reaching the infected tissue as penetra-
tion of antibiotics into abscess cavities is poor due to the walled-off nature of the
abscess. This highlights the need for appropriate I&D, allowing maximal blood flow
to the area in question. Another reason for the antibiotic not reaching the infected
tissue is an inappropriately low dose. Incorrect identification of the causative bacte-
ria will also need to be considered, and as has been discussed, a C&S should be
obtained for failed resolution, if it wasn’t before.
Lastly, even once the infection appears to be resolving, the dentist should perform
additional follow-up to check for recurrent infection. Even if the infection appears
almost resolved, it is possible that, for example, the patient may end their antibiotic
regimen too early or the drain was removed too early, thus reestablishing the infectious
process. If reinfection occurs, the dentist should again begin the treatment algorithm.

13.5 Conclusion

Dentistry has made significant advances over the years in the prevention and early
treatment of odontogenic infections. Although most odontogenic infections are
simple in nature and discovered early, they can become complex and potentially life
threatening. It is thus important to follow an organized, meticulous approach to the
evaluation and care of these patients: (1) determine the severity of infection, (2)
evaluate host defenses, (3) decide on the setting of care, (4) treat surgically, (5)
support medically, (6) appropriate antibiotic choices, and (7) evaluate the patient
frequently. The dentist must be cognizant to the possibility of treatment failure,
whether through an error in diagnosis, antibiotic resistance, or medical compromise,
among other reasons. Although there are no guarantees in surgery, following these
principles will ensure the highest quality of care for patients.
262 G. Hayek et al.

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treatment course last? Oral Maxillofacial Surg Clin N Am. 2011;23:519–36.
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Osteonecrosis
14
Johanna M. Hauer, Mo Banki, and Elie M. Ferneini

“I remain an unknown factor in the business, ready to throw in

all my weight at a critical moment.”
—The Hound of the Baskervilles

Abstract
This chapter explores three different, yet interrelated, topics essential for the prac-
tice of oral and maxillofacial surgery. It addresses the current evidence-based
treatment recommendations for osteomyelitis, medication-related osteonecrosis
of the jaw (MRONJ), and osteoradionecrosis (ORN). Additionally, this chapter
addresses the etiology, diagnosis, and staging of MRONJ/BRONJ and ORN, as
well as the subcategories of osteomyelitis of the jaws, including acute suppurative
osteomyelitis, chronic suppurative osteomyelitis, chronic sclerosing osteomyeli-
tis, and juvenile mandibular chronic osteomyelitis (JMCO).

14.1 Introduction

This chapter encompasses three interrelated topics within the field of oral and
maxillofacial pathology—osteomyelitis, medication-related osteonecrosis of the
jaw (MRONJ), and osteoradionecrosis (ORN). All of these conditions warrant

J. M. Hauer
Department of Oral and Maxillofacial Surgery, University of Connecticut School of Dental
Medicine, Farmington, CT, USA
M. Banki
Artistic Contours and MSL Surgery, Warwick, RI, USA
Department of Surgery, Clinical Faculty, Warren Alpert Medical School of Brown University,
Providence, RI, USA
Division of Oral and Maxillofacial Surgery, Clinical Faculty, University of Connecticut,
Farmington, CT, USA
E. M. Ferneini (*)
Beau Visage Med Spa, Greater Waterbury OMS, Cheshire, CT, USA
Division of Oral and Maxillofacial Surgery, University of Connecticut, Farmington, CT, USA

© Springer International Publishing AG, part of Springer Nature 2019 263

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_14
264 J. M. Hauer et al.

intervention by the oral and maxillofacial surgeons, and this chapter explores the
current recommendations based on the literature available to date. Ultimately, each
of these conditions involves destruction of the bony structures within the
maxillofacial skeleton, and management falls firmly within the scope of oral and
maxillofacial surgeons.

14.2 Osteomyelitis

Osteomyelitis is the inflammation of the osseous medulla or cortical bone which

may be acute or chronic and encompasses a variety of disease processes (Neville
2009). This disease process dates as far back as the Pleistocene era approximately
1.6 million years ago, but with the advent of modern antibiotics, the frequency of
presentation has been dramatically reduced (Krakowiak 2011; Hudson 1993). Due
to the highly vascularized nature of the head and neck, healing in this region tends
to proceed without complication. However, sometimes, surgical sites or areas
exposed by injury or other odontogenic conditions may become infected, and host
factors may predispose patients to development of such infections. The mandible is
more susceptible to infection due to its dense cortical plates and primary vascular
supply from the inferior alveolar artery and limited anastomoses with the facial
artery. By contrast, the maxilla has significantly less dense bone and multiple vessels
for perfusion, making it less susceptible to infection (Bagheri et al. 2008).
Whereas osteomyelitis in the long bones typically becomes established from
local or hematogenous spread, osteomyelitis of the jaws spreads through local
extension from the skin, sites in the oral cavity, or the sinuses, but rarely
hematogenously. Neonatal osteomyelitis of the jaws typically has a hematogenous
source and can be treated by parenteral antibiotics exclusively (Ecury-Goossen
et al. 2009). Unlike any other bone in the body, the mandible and maxilla have a
direct connection to the external environment by way of the teeth and periodontium,
creating a pathway for infection without an obvious source (Krakowiak 2011;
Landesberg et al. 2011).

14.2.1 Acute Suppurative Osteomyelitis

Patients with acute suppurative osteomyelitis typically present with acute pain,
swelling, purulent drainage, lymphadenopathy, and fever as well as leukocytosis
which can differentiate this from the chronic form of disease (Case 1, Fig. 14.1).
Additionally, there is a temporal component, where diagnosis is within 1 month of
onset of symptoms. Osteomyelitis is a polymicrobial infection, with colonization
by microbes comprising “normal oral flora” including Fusobacterium,
Porphyromonas, and Streptococcus (Santosh et al. 2017). However, osteomyelitis
is distinguished from other odontogenic infections by also featuring colonization
by Staphylococcus aureus, Staphylococcus epidermidis, Actinomyces, and
Eikenella (Krakowiak 2011; Koorbusch et al. 1992). Increasingly, cases of
14 Osteonecrosis 265

a b

Fig. 14.1 (a) Panoramic X-ray showing impacted mandibular third molars. (b) Panoramic X-ray
reveals a nondisplaced fracture involving the right mandibular angle. (c) Panoramic X-ray after
debridement, sequestrectomy and saucerization and placement of maxillo-mandibular fixation

osteomyelitis are seeing infection with clindamycin-resistant S. aureus, as well as

MRSA, with overall presentation with Staphylococcus species of upward of
70–90%. For this reason, cultures are important when selecting an antimicrobial
agent for treatment. Until culture results are returned, treatment with empirically
selected agents is appropriate (Helm et al. 2016).
Unfortunately radiographic signs on conventional radiographs require as much
as 50% bone mineral density loss for detection. Plain radiographs may be interpreted
as normal for at least 4–8 days and as many as 3–4 weeks. When visualized on
orthopantomogram, signs of osteomyelitis include ill-defined radiolucency, which
may be closely associated with an extraction socket or radiolucency (Fig. 14.2).
Rarely, pathologic fracture may be seen. As the disease state progresses, bony
sequestrum may appear as radiodense areas surrounded by irregular radiolucency.
In the interim, additional methods of imaging may be used including computed
tomography (CT), magnetic resonance imaging (MRI), and radionuclide imaging
using technetium. When plain radiographs, orthopantomograms, and CT imaging
have negative results in the setting of high clinical suspicion, MRI often demonstrates
more extensive subperiosteal disease with high signal on T2 imaging and low signal
on T1, while sequestra will appear like cortical bone with low signal in both T1 and
T2 (Schuknecht and Valavanis 2003). Radiolabeled technetium Tc99m scintigraphy
can show hyperemia associated with osteomyelitis as early as 2–3 days. Typically,
early osteomyelitis appears on CT as osteolysis within the cancellous bone, but later
changes like sequestration formation will not be visualized for 3–4 weeks
(Schuknecht and Valavanis 2003; Koorbusch and Deatherage 2011). Additionally,
periostitis ossificans or Garre’s osteomyelitis may be visualized on radiographs or
CT. However, this finding, while associated with chronic osteomyelitis, actually
represents a feature of acute osteomyelitis (Schuknecht and Valavanis 2003).
266 J. M. Hauer et al.

Fig. 14.2 (a) Osteomyelitis subsequent to a dental infection in the left posterior mandibular area
(Courtesy of Dr. Aditya Tadinada, University of Connecticut). (b) 3-week follow-up with a
significant increase in size of the involved area (Courtesy of Dr. Aditya Tadinada, University of
Connecticut)

Increasingly cone-beam computed tomography is used in the field of oral and max-
illofacial surgery. Cone-beam computed tomography (CBCT) findings of osteomy-
elitis include osteosclerosis and irregular radiolucencies, just as on panoramic or
plain films and conventional CT (Fig. 14.3). Despite additional differential diagno-
ses with similar radiographic presentation, CBCT has a place in the imaging of
osteomyelitis (Schulze et al. 2006).
The goal of treatment for osteomyelitis is the removal of the nidus of infection
and elimination of the offending pathogens. While antibiotic therapy is a cornerstone
of osteomyelitis treatment, surgical therapy is typically required for resolution. The
literature reflects a variety of surgical options for approaching acute suppurative
osteomyelitis, including debridement, incision and drainage, resection,
sequestrectomy, and decortication. Debridement is typically the first line of surgical
14 Osteonecrosis 267

Fig. 14.3 CBCT images showing Osteomyelitis of the right posterior mandibular region (Courtesy
of Dr. Aditya Tadinada, University of Connecticut)

intervention, along with stabilization to prevent pathologic fracture (Koorbusch

et al. 1992; Hjorting-Hansen 1970). Sequestrectomy may also require saucerization,
and typically decortication is reserved for refractory cases (Koorbusch and
Deatherage 2011). These surgical techniques function to increase the vascular
penetrance of the bone and allow antibiotic therapy access to the infection site.
Ideally, antibiotic therapy should not be initiated until after a specimen is obtained
from the affected site, and therapy should be tailored once cultures are returned
(Hudson 1993). The duration of treatment remains debatable, but it appears that
most infections resolve with 3–6 weeks of antibiotic therapy (Helm et al. 2016).

14.2.2 Chronic Osteomyelitis

Chronic osteomyelitis is an overarching term that encompasses a variety of disease

states lasting at least 1 month, some of which may be confused with osseous
dysplasias (Koorbusch et al. 1992). Chronic suppurative osteomyelitis is a
smoldering form of disease that may be attributed to an inadequately treated acute
osteomyelitis, whereas primary chronic osteomyelitis, also known as chronic
nonsuppurative osteomyelitis, is not associated with any acute presentation (Neville
2009; Hjorting-Hansen 1970; Dym and Zeidan 2017). Patients typically present
with deep pain, and malaise, and may exhibit lymphadenopathy, fever, or swelling.
Fistulas and sequestrum formation may also be present (Koorbusch and Deatherage
2011). On radiographic examination, there are significant findings on both plain
films and CT/MRI. Chronic suppurative osteomyelitis will appear with patchy
268 J. M. Hauer et al.

radiolucent and radiodense lesions that are contiguous, which is also in contrast to
primary chronic osteomyelitis, which will present with multifocal areas of mixed
lucency/density (Schuknecht and Valavanis 2003).
Treatment of chronic suppurative osteomyelitis involves removal of all necrotic
and affected bone, as well as long-term antibiotic therapy. Persistence of disease
after treatment is usually due to incomplete removal of diseased tissue. Tetracycline
administered for 48 h prior to surgery or doxycycline administered for 10 days
prior to surgery may be of assistance, as it allows for fluorescence of unaffected
bone (Hjorting-Hansen 1970). Decortication, with removal of any involved corti-
ces, with the exception of the lingual cortex, and exposure of the cancellous bone
should be performed. Cortical removal is aggressive and should extend 1–2 cm into
the bleeding bone. Some advocate packing the site and allowing for healing by
secondary intention, while others suggest primary closure. Despite perforations in
the lingual cortex, it is left intact, as the lingual of the mandible typically exhibits
improved vascularity due to the mylohyoid muscle attachments (Neville 2009).
Treatment for chronic suppurative osteomyelitis is similar to that of acute osteo-
myelitis, but often use of intravenous antibiotics can be limited to 2 weeks before
switching to oral antibiotics. In general, chronic disease should be treated with a
longer duration of antimicrobial therapy, and, as always, an infectious disease spe-
cialist should be consulted regarding therapy duration. Surgical techniques for
removal of affected tissues are the same as for acute forms of disease, with debride-
ment and sequestrectomy being most frequently used, but more aggressive decor-
tication for intractable cases (Krakowiak 2011).
Chronic diffuse sclerosing osteomyelitis is a much debated condition that is
poorly understood. In the literature, chronic diffuse sclerosing osteomyelitis is also
referred to as chronic nonsuppurative osteomyelitis or primary chronic osteomyelitis
(PCO). This condition is often confused with florid osseous dysplasia, as it can
present with only radiographic findings, but patients typically have pain. Florid
osseous dysplasia, on the other hand, typically presents as a painless condition that
is confined to the alveolus (Schneider and Mesa 1990). It has long been hypothesized
that there is a low-grade bacterial pathogen etiology to chronic diffuse sclerosing
osteomyelitis with no identified pathogen. However, Marx et al. have identified
Actinomyces and Eikenella species in patients with chronic diffuse sclerosing
osteomyelitis. This research suggests that chronic diffuse sclerosing osteomyelitis
progresses without pus formation and by evading host defenses as a result of a
mutualism between Actinomyces species or Arachnia species and E. corrodens
(Marx et al. 1994). Unfortunately, this finding is considered dubious by some, and
there has been insufficient research to corroborate this finding (Jacobsson 1994).
Juvenile mandibular chronic osteomyelitis [JMCO] has been thought to be the
presentation of chronic diffuse sclerosing osteomyelitis in children, but some
authors suggest this may be a distinct entity of aseptic osteomyelitis (Sammut
et al. 2014). However, some patients treated as adults for primary chronic osteo-
myelitis that began in childhood have findings of normal oral flora and skin con-
taminants in surgical specimens (Bevin et al. 2008). These children typically
present with pain and swelling of the mandible, and do not respond to antibiotic
14 Osteonecrosis 269

therapy or nonsteroidal anti-inflammatory agents, but do have improved pain con-

trol with high-dose steroids. Debridement, decortication, and resection have all
been employed with success rates around 50% (Renapurkar et al. 2015; Bevin
et al. 2008; Sammut et al. 2014).
Hyperbaric oxygen therapy (HBO) is often a beneficial adjunct therapy for all
types of osteomyelitis. HBO has been shown to enhance host immune response, as
well as produce reactive oxygen species that may prove toxic to pathogens. In
addition, HBO has a neoangiogenic response, which allows for superior penetration
of host defenses and antimicrobial therapy into the affected site (Hudson 1993; Van
Merkesteyn et al. 1984). HBO is helpful for refractory cases.

14.3 Medication-Related Osteonecrosis of the Jaws

MRONJ is defined by the American Association of Oral and Maxillofacial Surgeons

as exposed bone or bone that can be probed by way of intraoral or extraoral fistulas
that has been present for 8 or more weeks in a patient with history of or current use
of antiresorptive/anti-angiogenic agents without previous radiotherapy to or
metastatic disease of the jaws (Ruggiero et al. 2014). Oral bisphosphonates were
introduced into the US market in the early 1990s for treatment of osteoporosis, and
intravenous formulations were introduced to treat cancer metastases to bones.
Bisphosphonates are beneficial for these conditions due to their ability to suppress
osteoclasts and increase bone density, which thereby reduced the risk of SREs or
skeletal-related events like fracture or additional metastases. Some patients treated
with oral bisphosphonates experienced esophageal or gastrointestinal sequelae and
are therefore switched to intravenous infusions despite requiring therapy for
osteoporosis and not metastatic disease (Assael 2011). The first reports of
medication-related osteonecrosis of the jaw [MRONJ] came to light in 2003 with a
case series presented by Marx of 36 patients with exposed bone in the oral cavity.
Each of the 36 patients was taking intravenous bisphosphonate medications, in this
case pamidronate [Aredia] or zoledronate [Zometa]. Of these, 80% had painful,
necrotic lesions in the mandible, 14% with lesions in the maxilla, and 6% in both.
Seventy-eight percent of these lesions appeared after tooth extraction, while the
remainder were spontaneous (Marx 2003). Just a year later, Ruggerio reported 63
similar cases, all with patients taking intravenous bisphosphonates (Ruggiero et al.
2004). Initially, this condition was described as bisphosphonate-related osteonecrosis
of the jaw. Over the next several years, cases appeared in the literature associated
with additional bisphosphonates, including oral preparations, as well as other
antiresorptive and anti-angiogenic medications including denosumab, bevacizumab,
and long-term steroids and have subsequently been renamed medication-related
osteonecrosis of the jaw (Ruggiero et al. 2014; Qi et al. 2014; Neto et al. 2016; Kim
et al. 2014; Kyrgidis and Toulis 2011).
The inhibition of osteoclasts by bisphosphonate medications is well documented,
although it is unclear why this phenomenon occurs exclusively in the jaws or what
the precise etiology entails (Williams 2015; Landesberg et al. 2011). Additionally,
270 J. M. Hauer et al.

the inhibition of angiogenesis resulting in avascular necrosis is a much hypothesized

concept regarding development of MRONJ (Williams 2015). Histologically,
specimens will be devoid of osteocytes, indicating necrosis, while absence of
osteoclasts lends credence to the concept of osteoclast apoptosis prior to development
of disease (Ruggerio 2015).
Hundreds of millions of prescriptions for bisphosphonates and other antiresorp-
tive agents have been written in the United States, yet MRONJ remains relatively
uncommon (Shintani et al. 2015; Assael 2011; Lo et al. 2010). Unfortunately
uncommon diseases are difficult to study in terms of incidence, as the population
sizes studied must be very large before disease is seen. As a result the literature
reflects overall risk ranges from 0% to 6.7% (Dodson 2015). In general, the incidence
of MRONJ in patients receiving intravenous bisphosphonates or other implicated
agents for cancer therapy is approximately 1%, while patients receiving denosumab
see approximately 1.9% incidence (Dodson 2015; Ruggiero et al. 2014; Lo et al.
2010). Patients taking denosumab for metastatic prostate cancer also seem to have
higher rates of MRONJ (Qi et al. 2014). Bevacizumab alone is associated with
MRONJ incidence around 0.2% but increases to about 1% when combined with
zoledronate (Ruggiero et al. 2014; Lo et al. 2010). Some of the highest rates of
MRONJ reported in the literatures are in renal cell cancer patients with bone
metastases who are treated with bisphosphonates and tyrosine kinase inhibitors
concurrently at 10% (Beuselinck et al. 2012). Given that 7 in 100 patients receive
bisphosphonates for osteoporosis, it is reassuring that the prevalence of MRONJ in
patients taking oral bisphosphonates is just 0.1%, and just 0.21% if taking agents for
more than 4 years (Lo et al. 2010).
The low incidence of MRONJ may be reassuring; however, as many as 80% of
MRONJ cases are related to tooth extraction (Ruggerio 2015; Goodday 2015;
Dodson 2015; Tsao et al. 2013; Scoletta et al. 2013). Patients exposed to IV
bisphosphonates treated with tooth extraction had many times [with studies showing
as much as 16- to 44-fold] the risk of developing MRONJ as patients who did not
have tooth extractions (Dodson 2015; Kim et al. 2017; Ruggiero et al. 2014;
Kyrgidis et al. 2009). With reports ranging from 1.6% to 14.8%, cancer patients
with IV bisphosphonate use are certainly not at low risk for MRONJ when
undergoing extraction. Additionally, use of complete dentures was associated with
a nearly five times the risk of developing MRONJ (Dodson 2015; Kyrgidis et al.
2008; Holzinger et al. 2013). Studies disagree on whether periodontitis is a
significant risk factor for development of osteonecrosis, but there is no question that
periodontitis often leads to extraction or surgical therapy, and periodontal disease is
found in 71–84% of MRONJ cases. Cases of MRONJ have also been associated
with endosteal implants, with and without periimplantitis (Holzinger et al. 2013). It
is also possible that pain, drainage, and edema leading to extraction of a tooth could
actually reflect osteonecrosis and not an odontogenic source (Ruggerio 2015;
Dodson 2015; Tsao et al. 2013; Scoletta et al. 2013; Vahtsevanos et al. 2009). A
wide range of incidence rates apply to patients undergoing extraction when taking
oral bisphosphonates, with reports ranging from 0% to 3.9%. The current thought is
that MRONJ might be seen in about 0.5% of extractions from patients on oral
14 Osteonecrosis 271

bisphosphonates (Dodson 2015; Yamazaki et al. 2012). At this time, it remains

unknown what risk exists for these patients when undergoing other procedures like
dental implants or apicoectomy (Dodson 2015). Ideally, providers should avoid
extractions when possible, as patients receiving dental treatment prior to initiating
bisphosphonate treatment experience three times fewer rates of MRONJ (Goodday
2015). When extractions or other surgical interventions are required, initiation of
bisphosphonate therapy should ideally be delayed until there is sufficient bone
healing and full mucosal coverage (Ruggiero et al. 2004).

14.3.1 Staging and Appearance

The American Association of Oral and Maxillofacial Surgeons released updated

staging criteria in 2014, designating four stages of MRONJ ranging from “at risk”
to stage 3. At-risk patients have been identified in the staging criteria and include
patients with no evidence of necrotic bone but with a history of bisphosphonates and
other associated medications. Stage 0 represents patients without clinical evidence
of disease, but are symptomatic and have radiographic changes noted. Stage 1
encompasses patients without symptoms but have exposed or necrotic bone. Once
patients become symptomatic with pain, erythema, and possibly purulent discharge,
a patient has progressed to stage 2. In stage 3, patients have symptomatic exposed
bone that extends beyond tooth-bearing regions to include the inferior border of the
mandible or the ramus, the maxillary sinus, or the zygoma. Pathologic fractures
may be present in this patient (Ruggerio 2015; Ruggiero et al. 2014) (Fig. 14.4).
MRONJ can appear with lesions in the maxilla, mandible, or both jaws, while
there is a clear predilection for the mandible, which is twice as likely to develop areas
of necrosis (Marx 2003; Chiandussi et al. 2006; Neto et al. 2016). However, patients

Fig. 14.4 Medically Related Osteonecrosis of the Jaw (MRONJ) in a patient with bisphosphonate
exposure. Osteonecrosis is most prominent in the left posterior mandibular region with a
pathological fracture
272 J. M. Hauer et al.

may present with symptoms before areas of exposed bone are detectable, like dis-
comfort, mobility of teeth, or mucosal changes, hence the designation of stage 0
patients (Ruggerio 2015). Stage 1 patients will have no symptoms but visible necrotic
bone, while stage 2 patients will have clinically evident disease and symptoms.
Areas of osteonecrosis can be visualized in multiple imaging modalities.
Panoramic radiography will demonstrate these lesions as ill-defined patchy radiolu-
cencies with possible radiopaque sequestra, and sometimes previous extraction sites
will be visualized. On CT, the lesions will show irregular cortical margins with
destruction of cortical bone. Again, sequestra are often demonstrated. MRI pro-
duces enhancement of T2-weighted images and low signal intensity on T1-weighted
images and will also clearly demonstrate soft tissue changes. Scintigraphy will also
show areas of increased uptake of technetium in affected locations and may show
decreased uptake associated with sequestrum formation. This imaging modality
will show increased uptake in symptomatic patients, as the radionuclide uptake cor-
responds to osteoblast hyperactivity in subchondral areas, while asymptomatic
patients will show decreased activity that reveals decreased osteoblast activity. For
this reason scintigraphy is an advantageous imaging type for evaluating early or
asymptomatic lesions (Assael 2011; Chiandussi et al. 2006). It is also important to
note that changes may be seen on imaging prior to development of classic findings
of osteonecrosis. Thickened lamina dura, osteosclerosis, and reduced healing or
trabeculation over previous extraction sites may indicate early stages of disease
(Ruggerio 2015).

14.3.2 Management

While there is no definitive consensus on managing patients with MRONJ,

AAOMS recommends medical management of these lesions prior to attempting
any surgical intervention. Often used treatments include antibiotics [used intrave-
nously, orally, and/or topically], adjunct medications like teriparatide, and hyper-
baric oxygen [HBO]. Prevention of MRONJ is essential, and AAOMS recommends
that patients who might benefit from agents associated with MRONJ receive a
comprehensive dental evaluation before initiating therapy (Ruggiero et al. 2014).
Incidence of MRONJ can be reduced by 50% by evaluation and treatment of oral
health and dental needs prior to starting therapy (Lo et al. 2010). Symptomatic
stage 0 patients should be managed carefully, with close evaluation and treatment
of oral health, including caries management and management of periodontal dis-
ease (Ruggiero et al. 2014).
Drug holidays in anticipation of dental treatment have been much debated, but
AAOMS no longer recommends drug holidays, as the research does not support the
efficacy of this method in patients with osteoporosis (Holzinger et al. 2013).
Evidence is minimal for patients taking antiresorptive agents for cancer treatment
but may be considered in this setting (Ruggiero et al. 2014). Overall, discontinuation
of therapy [with other treatments] results in 35.2% of patients experiencing com-
plete healing (Fliefel et al. 2015).
14 Osteonecrosis 273

Topical antimicrobial agents such as 0.12% chlorhexidine gluconate are widely

used in oral and maxillofacial surgery and are a mainstay in treatment of MRONJ
(Williams 2015). Often, chlorhexidine is used to aid in the reduction of bacterial
load, as well as the development of biofilm, which contributes to the overall disease
process (Goodday 2015; Kumar et al. 2010). Topical antimicrobial rinses alone are
suggested for the treatment of asymptomatic, stage 1 MRONJ, but are also part of
the treatment therapy for both stage 2 and stage 3 diseases (Williams 2015; Ruggiero
et al. 2014). When extractions are performed in at-risk patients, use of chlorhexidine
two or three times daily until full mucosal healing is achieved is recommended
(Goodday 2015).
Oral antibiotic therapy is a critical component of MRONJ treatment and should
be tailored to pathogens implicated in MRONJ. Selection should also be tailored
based on patient tolerance and previous exposures. Typically, penicillins are first-
line therapy, as most normal oral flora involved in MRONJ are susceptible to this
class of antibiotics (Ruggiero et al. 2014; Hinson et al. 2014). Specifically, stage 2
and stage 3 will require antibiotics, and stage 0 patients will likely need them as
well (Ruggiero et al. 2014). When oral antibiotics fail or particularly pathogenic
bacteria are found, intravenous antibiotics are often used with increased success.
Typically 6 weeks of IV antibiotics are used, but colleagues in infectious disease
should be consulted (Williams 2015).
Teriparatide is used as an adjunct therapy in the management of MRONJ when
patients are taking or have taken bisphosphonates for osteoporosis. Use is
contraindicated in patients with metastatic bone disease. This medication is a
parathyroid hormone analogue and promotes bone remodeling. It is believed to
stimulate both osteoblasts and osteoclasts, allowing for improved bone remodeling
(Williams 2015), and is also believed to have angiogenic properties (Spanou et al.
2015). Teriparatide [TPTD] is especially useful for patients with intractable
MRONJ. A 2014 study by Kim et al. showed that 62.5% of patients receiving
teriparatide, vitamin D, and calcium for 6 months had one-stage improvement in
presentation while 37.5% improved by two or more stages, including complete
healing of the lesions (Kim et al. 2014).
Hyperbaric oxygen therapy [HBO] has recently been used to augment surgical
intervention in MRONJ treatment. While 26.7% of patients saw complete healing,
37.8% experienced worsening lesions, casting doubt on the efficacy of this treatment
(Fliefel et al. 2015). HBO is also very time-consuming for the patient and expensive
and may not provide statistically significant improvement in patients with MRONJ
(Williams 2015; Spanou et al. 2015). Ozone treatment is another treatment that may
show good healing results [up to 57.8%], but small study populations limit the
generalizability of the result (Fliefel et al. 2015).
Surgical intervention for MRONJ based on the 2014 AAOMS guidelines is stage
specific, and conservative therapy is recommended for all stages before attempting
surgical intervention. Stage 0 and 1 patients usually do not require surgery, and
medical management is the recommended treatment. However, stage 2 patients
have a wide spectrum of presentation, and some of these patients may benefit from
localized surgical intervention based on the extent of disease and patient-specific
274 J. M. Hauer et al.

factors. Most commonly, debridement, marginal resection, and segmental resection

are utilized, based on patient presentation (Assael 2011). Overall, minimally
invasive approaches see 39.2% of patients with complete healing, while upward of
80% of patients undergoing major surgery experience full healing (Williams 2015;
Ruggiero et al. 2014; Holzinger et al. 2013). Holzinger et al. reported 59% of
patients treated with surgical procedures saw improvement or healing of lesions
(Holzinger et al. 2013). While surgery typically results in high success rates, patients
taking oral bisphosphonates are more likely to heal than patients taking intravenous
bisphosphonates, and maxillary resections are the most likely to result in success
(Carlson and Basile 2009).
Because it is essential to remove all necrotic bone and remove sharp edges or
bony spicules that may interfere with healing, the use of tetracycline fluorescence
may be beneficial in determining the extent of affected bone intraoperatively.
Primary closure is recommended when possible, and all specimens should be sent
for microbial analysis to more appropriately direct therapy and to rule out under-
lying malignancy. Stage 3 patients who present with extensive disease often
require segmental resection or wide areas of debridement (Williams 2015;
Ruggiero et al. 2014).
Research shows that comprehensive care prior to beginning bisphosphonates as
well as more frequent monitoring while taking bisphosphonates results in reduced
rates of disease and earlier intervention for MRONJ (Vandone et al. 2012). In fact,
prevention of MRONJ with close monitoring of oral health and noninvasive manage-
ment of oral health concerns can reduce the incidence of MRONJ by threefold
(Dimopoulos et al. 2009). Many patients often start bisphosphonates before receiv-
ing dental care and do not have adequate monitoring of oral health. Scoletta et al.
have published a protocol for preoperative management of patients taking intrave-
nous bisphosphonate medications or other anti-angiogenic agents that require extrac-
tion. In 62 out of 63 patients, Scoletta reported normal healing after extraction
following the protocol which involved periodontal scaling and oral hygiene instruc-
tion, beginning a 6-day regimen of amoxicillin/clavulanate potassium or erythromy-
cin the night before the procedure, a split thickness vestibular incision, and primary
closure over extraction sockets packed with PRGF [plasma rich in growth factors]
(Scoletta et al. 2013). Other studies show that use of platelet-rich plasma and bone
morphogenic protein can result in healing in 81.5% of patients. These studies, while
limited in number, represent similar results to major surgical treatment (Fliefel et al.
2015). Despite Scoletta’s recommendation for primary closure, there is debate
whether primary closure is actually beneficial (Goodday 2015).
The 2009 version of the AAOMS guidelines, but not the most recent 2014 ver-
sion, discourages immediate reconstruction with vascularized or nonvascular bone,
as disease may not have been eliminated at resection margins and result in failure of
the reconstruction. Nevertheless, there are a variety of case reports in the literature
reporting success with this strategy (Neto et al. 2016; Vercruysse et al. 2014).
Recently, Kim et al. published results that patients undergoing extensive surgery
had better outcomes. This study utilized curettage, sequestrectomy, saucerization,
and mandibulectomy for management of these patients. Patients receiving curettage
14 Osteonecrosis 275

had the poorest outcomes, with 57% relapsing and requiring additional surgery.
Nearly 30% of patients treated with sequestrectomy required additional surgery,
while only 21% of patients who underwent saucerization did. While only five
patients were treated with radical mandibulectomy, 100% of those patients saw
complete healing of their lesions (Kim et al. 2017).
There are a plethora of options available in the treatment of medication-related
osteonecrosis of the jaw, and typically resolution requires use of multiple treatment
modalities. Complete resolution is the goal with any and all of these therapies, but
“success” is defined as complete mucosal healing and radiographic healing for
1 year after treatment (Fliefel et al. 2015). Of patients with MRONJ, those treated
with oral bisphosphonates are more likely to see healing with treatment. Thirty-four
percent of patients taking oral bisphosphonates and treated for MRONJ with
antibiotics [topical and systemic] saw healing of lesions, while only 19% of patients
receiving IV bisphosphonates did when treated the same way. When invasive
treatment is performed, this difference persists, as 94% of patients taking oral
bisphosphonates and treated with sequestrectomy had complete healing, while just
50% of IV bisphosphonate patients healed (Shintani et al. 2015).

14.4 Osteoradionecrosis

Since the first report of osteoradionecrosis in 1922, ORN has had a much debated
history in the literature. In the 1970s, ORN was thought to be an infection caused by
the introduction of bacteria [by way of unintentional trauma or intentional trauma-
like extractions] into bone that has reduced defenses to bacterial onslaught after
irradiation (O’Dell and Sinha 2011; He et al. 2015; Schwartz and Kagan 2002;
Marx 1983). Initially, treatment for ORN was penicillin. However this concept was
challenged by Marx, when he proposed his “three H” theory that osteoradionecrosis
arises from tissue hypoxia, hypovascularity, and hypocellularity. He also found that
bacteria were only located in the most superficial aspect of exposed bone and had
not invaded deeper layers, nor did the features of ORN follow the course of an
infection. Furthermore, Marx argued that the previously accepted “radiation,
trauma, and infection” theory could not explain the high percentage [35% in his
study] of cases that lacked a traumatic episode (Marx 1983). Marx’s hypoxic-hypo-
cellular-hypovascular theory stood until recent development in research supported a
new radiation-induced fibroatrophic theory (O’Dell and Sinha 2011). This new
theory proposes that radiation results in endothelial cell injury, free radicals, and
cytokine release, which in turn cause fibroblast deregulation. Tissues then become
vulnerable to inflammation as they become progressively hypocellular and fibrosed
(O’Dell and Sinha 2011; Lyons and Ghazali 2008).
Osteoradionecrosis [ORN] is defined as exposure of irradiated bone exposed by
a skin or mucosal wound that persists for 3–6 months (O’Dell and Sinha 2011; He
et al. 2015; Moon et al. 2017; Schwartz and Kagan 2002; Lyons and Ghazali 2008).
This diagnosis excludes any recurrence of malignancy, metastasis, or tumor necrosis
during treatment. While disease has been reported in the mandible, maxilla, hyoid,
276 J. M. Hauer et al.

and temporal bones, ORN is most commonly found in the mandible. The mandible
has less vascular supply than other bones in the head and neck, as it is only supplied
by the inferior alveolar and facial arteries. Additionally, the mandible is more likely
to be exposed in the field of radiation for oropharyngeal cancer (O’Dell and Sinha
2011). This condition can be exceedingly painful with significant impact on patient
quality of life (Schwartz and Kagan 2002; Bruins et al. 1998).
Several decades ago, incidence of ORN approached 20%, and rates have been
declining with advances in radiotherapy (Moon et al. 2017). Recent studies have
shown slight variation in incidence rates from 5.5% (Moon et al. 2017) to 6.6% (Lee
et al. 2009) to 7.7% (Kojima et al. 2007) of patients who have undergone head and
neck radiotherapy, for neoplasms in this region go on to develop ORN.
Primary tumors of the tongue, floor of mouth, alveolus, retromolar pad, and ton-
sils are most likely to result in a large volume of radiation to the mandible, and thus
patients are at increased risk for developing ORN. Additionally, the more advanced
the primary tumor, the more likely patients are to develop ORN (O’Dell and Sinha
2011; Kluth et al. 1988). ORN is rarely seen at less than 50 Gy of radiotherapy.
Doses of more than 60 Gy increase the risk for ORN (O’Dell and Sinha 2011; Lyons
and Ghazali 2008). Trauma, extractions, or other dental procedures may precede
development of osteoradionecrosis; however, as many as 48% of patients report no
previous trauma (O’Dell and Sinha 2011). The existence of periapical radiolucen-
cies prior to beginning radiotherapy predisposes patients to develop ORN (Kojima
et al. 2007). Patients who have poor oral hygiene are significantly more likely to
develop ORN, as are tobacco users and heavy drinkers [six drinks or more per day]
(Lyons and Ghazali 2008; Kluth et al. 1988).

14.4.1 Staging and Classification

There have been multiple proposals for classification of osteoradionecrosis (O’Dell

and Sinha 2011; He et al. 2015), but Schwartz and Kagan (2002) have proposed a
staging system that is widely accepted. Stage I is superficially exposed bone that has
small soft tissue defects and necrosis confined to the exposed cortical bone. Stage II
features necrosis of cortical and cancellous bone. Lesions in stage IIA would feature
small soft tissue defects, while stage IIB would have more extensive soft tissue
involvement and cutaneous fistula formation. Stage III has more widely involved
including basal bone and possibly pathologic fracture. Stage IIIA is associated with
small soft tissue defects, while stage IIIB also has soft tissue necrosis and possibly
cutaneous fistula formation (Fig. 14.2, O’Dell and Sinha 2011).
While ORN is diagnosed and staged based on symptoms, clinical exam, and his-
tory, radiographic evaluation is also important (O’Dell and Sinha 2011). Panoramic
radiographs are often the first imaging obtained when evaluating for possible osteo-
radionecrosis, and these lesions typically appear as heterogeneous radiolucency with
areas of radiodensity. As with the appearance in osteomyelitis, sequestra may be
14 Osteonecrosis 277

visible, but in contrast, early lesions may be visualized radiographically before dis-
ease becomes clinically evident, with osteolytic lesions (Owosho et al. 2015). Stage
III lesions may be associated with pathologic fractures, and these may be visualized
on orthopantomogram. CT imaging will assist with visualizing perforation in the
cortical plates, as well as sequestration formation. On MRI, lesions will appear with
low intensity on T1, and some changes may be seen in T2 as well. Development of
these lesions distant from the primary tumor or more than 2 years later strongly sug-
gests ORN over tumor recurrence but cannot be excluded without biopsy (O’Dell
and Sinha 2011). Both gallium and technetium scans have proven to be of little addi-
tional benefit, except that technetium scanning may help identify early lesions and
gallium scans may aid in evaluation of treatment (O’Dell and Sinha 2011).

14.4.2 Treatment

Prevention of ORN is important, as ORN typically worsens over time and is difficult
to manage (Kojima et al. 2007; Delanian et al. 2005). Poor oral hygiene during and
after radiotherapy with increasing rates of caries is associated with three times
greater odds of developing osteoradionecrosis. Ideally, teeth with moderate-severe
periodontitis or probing depths of more than 5 mm, teeth with periodical
radiolucencies, partially impacted or partially erupted teeth, root tips, and teeth with
extensive caries should be extracted, and extractions should be completed 2 weeks
prior to initiation of radiotherapy (O’Dell and Sinha 2011; Kojima et al. 2007;
Bruins et al. 1998). However, pre-radiation extractions are an independent risk
factor for developing ORN (Moon et al. 2017). Persistent vigilance should be
practiced, as osteoradionecrosis can develop at any time after undergoing
radiotherapy to the head and neck. The majority of cases will be diagnosed within
1 year of radiation; however, a significant number may develop longer than 5 years
after treatment (He et al. 2015).
Conservative management of ORN includes avoiding irritating the exposed site.
Denture wearers should refrain from wearing prostheses, and tobacco users should
be counseled regarding cessation (Wong et al. 1997). Topical antimicrobial agents
like chlorhexidine are often used. Unlike osteomyelitis, systemic antibiotics are
reserved for acute infection of exposed necrotic bone (O’Dell and Sinha 2011).
Debridement and sequestrum removal can be very effective in producing mucosal
coverage of defects (O’Dell and Sinha 2011).
Hyperbaric oxygen is also routinely used in cases of osteoradionecrosis, but its
use is currently controversial (Ceponis et al. 2017). Pressurized oxygen results in
increased oxygen in tissues, which leads to angiogenesis. HBO can be used both as
prophylaxis for patients with a history of head and neck radiation who must undergo
extraction, but it can also be used to promote wound healing in existing lesions
(O’Dell and Sinha 2011). However, HBO is typically unsuccessful when used as the
sole treatment modality (Lyons and Ghazali 2008; Ceponis et al. 2017). Currently,
278 J. M. Hauer et al.

the recommended treatment is 20–30 dives for 90–120 min and 20–30 preoperative
dives followed by 10 postoperative dives when extraction is planned. Ultrasound is
another therapy that can promote angiogenesis, and 40–50 ten-min sessions can be
used until mucosal coverage is achieved (O’Dell and Sinha 2011).
Medical management is less common with ORN than with osteomyelitis, but
treatment with pentoxifylline, tocopherol, and clodronate [available as Pentoclo] to
stimulate osteogenesis has shown promising results. In an attempt to combat the
vascular necrosis that occurs early in the initiation of ORN, pentoxifylline has been
used to dilate remaining blood vessels in the bone and prevent continuing fibrosis
while reducing inflammation. It has been paired with vitamin E [tocopherol],
which scavenges reactive oxygen species during oxidative stress, for a synergistic
treatment option. Clodronate is a nonnitrogenous bisphosphonate that inhibits
bone resorption and has been used in the most severe cases of ORN, but pentoxifyl-
line and tocopherol may also be used alone (O’Dell and Sinha 2011; Lyons and
Ghazali 2008). In this protocol, 800 mg pentoxifylline and 1000 IU tocopherol
were administered for 6 months and continued as long as healing progressed. If
ORN was severe, 1600 mg clodronate was added daily five times per week. This
regimen resulted in complete healing for 89% of patients (Delanian et al. 2005).
Pentoxifylline may also be used for 6 weeks prior to extraction, with the addition
of tocopherol 1 week prior to extraction or surgery for prophylaxis. If the response
is insufficient, clodronate can be added 3 months postoperatively (Lyons and
Ghazali 2008).
When patients have failed conservative therapy or have current or impending
pathologic fracture [with involvement of the inferior border of the mandible],
surgery is indicated. Resection should be continued until bleeding bone is
encountered at the margins (O’Dell and Sinha 2011). While stage II lesions typi-
cally heal with conservative management or surgery, stage III requires more sig-
nificant surgical procedures. With extensive resections, free flaps may be
required. These patients have an increased risk of complications with free flap
surgery, but often it is the only remaining option. Despite the increased compli-
cation risk, free flap reconstruction still has a 91% success rate (O’Dell and
Sinha 2011).

14.5 Conclusion

Despite the varied etiology of osteomyelitis, medication-related osteonecrosis of

the jaw (MRONJ), and osteoradionecrosis (ORN), all of these conditions ultimately
stem from cellular destruction within the bony skeleton of the maxillofacial region.
This chapter has explored the current recommendations based on the literature
available, but investigations into the pathogenesis and treatment of these diseases
are ongoing. Due to the significant economic, psychosocial, and physiologic damage
these conditions wreaked on patients, this further investigation is absolutely neces-
sary in order to provide curative treatment for all of those affected.
14 Osteonecrosis 279

Case 1
A 65-year-old male was referred to us for the management of a right mandibu-
lar third molar with a history of recurrent pericoronitis (Fig. 14.1a). The
patient was otherwise in good general health. He denied tobacco or alcohol
use. The patient underwent an uncomplicated surgical extraction of the third
molar and was placed on a 7-day course of amoxicillin. Postoperative course
was only remarkable for pain and trismus mostly due to muscle spasm. A
panoramic radiograph obtained on postoperative week 4 revealed the mandi-
ble to be intact and devoid of any obvious signs of osseous pathology. On the
eighth postoperative week, patient returned to clinic with a complaint of sud-
den return of right mandibular pain and malocclusion of 3-day duration. The
patient denied any history of trauma and was afebrile. Examination of man-
dible was difficult due to trismus and presence of focally intense pain.
Additionally, a small quantity of purulent exudate was noted at the sight of the
previous extraction. Culture of the drainage was obtained and submitted to the
laboratory for culture and sensitivity studies. A radiograph obtained revealed
a non-displaced fracture involving the right mandibular angle region
(Fig. 14.1b). Radiolucencies consistent with osteolysis as well as ragged
osseous borders and presence of a sequestrum were noted. Patient underwent
exploration of the wound along with debridement, sequestrectomy, and
saucerization, and he was placed into maxillomandibular fixation (MMF)
(Fig. 14.1c). Two days postoperatively, patient reported increased malaise,
and decision was made to have the patient admitted for further workup. The
patient had a low-grade fever with a slight leukocytosis (13,000 mm−3
consisting of 78% polymorphonuclear leukocytes and 16% bandemia).
Computed tomography (CT) scan was interpreted as being most consistent
with a diagnosis of osteomyelitis of the mandible due to the presence of soft
and hard tissue changes. An infectious disease consultation was obtained to
assist with the management of the patient. The patient was treated
presumptively for osteomyelitis pending the results of the biopsy and the
culture and sensitivity studies. He was empirically placed on intravenous
broad-spectrum antibacterial coverage. Vancomycin and ampicillin/sulbactam
(Unasyn) were recommended by the infectious disease consultant and imple-
mented. Rigid fixation was also applied to the fracture site on post-admission
day 4. Bone biopsy result returned was consistent with osteomyelitis, and the
culture revealed mixed oral flora. Patient was placed on a 4-week course of
intravenous penicillin followed by a 3-month regimen of amoxicillin/clavula-
nate (Augmentin). The patient tolerated the antibiotic course and had a full
recovery from the infection. The pathological fracture of the mandible fully
healed without any sequelae. He has been symptom-free for 12 months since
the initial presentation.
280 J. M. Hauer et al.

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Evidence-Based Principles of Antibiotic
Therapy 15
Thomas R. Flynn

“I have no desire to make mysteries, but it is impossible at the

moment of action to enter into long and complex explanations.”
Sherlock Holmes in—The Adventures of the Dancing Men

Abstract
Oh, for the days when I could just write a prescription for penicillin and know
that it would be effective for my patient! Those days are over. Now, I have to
worry about whether the antibiotic will cover the usual organisms in the infec-
tion; if there are highly antibiotic-resistant bacteria present; if my prescription
will select for resistant organisms in the patient, or her family, or his community;
if the patient will have a toxic or allergic reaction; or if it will interact with one
of the many other drugs the patient is taking. What if my patient can’t afford the
antibiotic or doesn’t take it as prescribed? How long will he really take the anti-
biotic for? Just until he feels better? Should I be prescribing this antibiotic at all?
Modern antibiotic therapy for odontogenic infections has become quite com-
plex. This chapter will provide the available evidence that answers the above
questions as well as is possible with our current knowledge. It lists the ten prin-
ciples of the modern use of antibiotics and provides the evidence supporting
those principles. Some of these principles apply to the issue of antibiotic selec-
tion and others to proper administration of antibiotics.

15.1 The Principles of Modern Antibiotic Therapy

The modern evidence-based use of antibiotics can be summarized in the following

ten principles:

T. R. Flynn (*)
Private Practice, Department of Oral and Maxillofacial Surgery,
Harvard School of Dental Medicine, Boston, MA, USA

© Springer International Publishing AG, part of Springer Nature 2019 283

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_15
284 T. R. Flynn

1. Surgery to remove the cause and establish drainage is primary; antibiotics are
adjunctive treatment.
2. Use therapeutic antibiotics only when clinically indicated.
3. Use specific antibiotic therapy as soon as possible, based on culture and sensi-
tivity testing.
4. Use the narrowest-spectrum empiric antibiotic effective against the most likely
pathogens.
5. Avoid the use of combination antibiotics, except in specific situations where
they are shown to be necessary.
6. Use the least toxic indicated antibiotic, considering interaction with concurrent
medications.
7. Minimize the duration of antibiotic therapy, as appropriate to the presenting
type of infection.
8. Use the most cost-effective appropriate antibiotic.
9. Use prophylactic antibiotics only when proved effective or according to profes-
sional guidelines.
10. Follow the guidance of evidence-based recommendations and professional
guidelines when they are available.

Each of these principles will be discussed, and the evidence supporting them will
be cited. In some cases there are highly reliable scientifically obtained data
(randomized clinical trials and meta-analyses) to support each usage, and in other
cases, data such as the pharmacologic profile of given antibiotics are used to guide
usage recommendations.

15.1.1 P
 rinciple 1: Surgery to Remove the Cause and Establish
Drainage Is Primary; Antibiotics Are Adjunctive Treatment

In the 1940s, two landmark studies of the treatment of Ludwig’s angina provided
the first evidence supporting this principle in severe odontogenic infections.
Dr. Williams (1940) presented a retrospective case series of 37 consecutive cases of
Ludwig’s angina treated at Boston City Hospital. The airway management policy at
the time was emergency tracheotomy when necessary. Fifty-four percent of those
patients died. Three years later, Williams and Guralnick (1943) published the first
prospective study of severe odontogenic infections. In this study, the airway man-
agement protocol was changed to immediate stabilization of the airway by endotra-
cheal intubation or tracheotomy as appropriate. Necessarily, general anesthesia was
induced immediately after the airway was secured, so the surgeons also performed
aggressive surgical incision and drainage of all infected spaces. In those 3 short
years, before penicillin was available to civilians because of World War II, the mor-
tality of this dreaded infection was reduced to 10% (N = 20). Thus, in one of the
most severe of all odontogenic infections, early airway security and aggressive sur-
gery provided a dramatic decrease in mortality without the benefit of antibiotics.
The importance of surgical treatment in odontogenic infections may be related to
the flora of these infections and to the anatomy of the teeth, jaws, and deep fascial
15 Evidence-Based Principles of Antibiotic Therapy 285

spaces of the head and neck. The bacteria that have been associated with severe
odontogenic infections are abscess formers, and many of them also form biofilms.
The blood supply of an abscess is nil; antibiotic penetration into abscesses is by
diffusion from surrounding vascularized tissues. Further, biofilms forming on hard
or tough surfaces, such as teeth, bone, and fascia are not well penetrated by
antibiotics. Bacteria found in biofilms are also less metabolically active than
planktonic bacteria, rendering them less susceptible to the action of antibiotics.
Therefore, surgical drainage and physical debridement of necrotic tissues and
biofilms may be of special benefit in odontogenic infections, because they reduce
the bacterial bioburden in the deep tissues of the face, neck, and jaws (Socransky
and Haffajee 2002).
More recent evidence supports principle 1 as well. Igoumenakis et al. (2015)
compared extraction of the involved teeth with nonextraction in patients with severe
infections requiring hospitalization. Patients with non-restorable teeth were assigned
to the extraction group, and those with restorable teeth did not have any teeth
extracted during or just prior to hospitalization. All underwent incision and drainage.
On postoperative day 2, temperature, white blood cell count, and C-reactive protein
(an inflammatory marker) were all significantly less in the extraction group on the
second postoperative day. Further, the length of hospital stay was significantly less
in the extraction group. This study indicates that extraction of the causative teeth,
even in the presence of acute infection, resulted in decreased overall inflammation
and a shorter time to the clinical endpoint (resolution of swelling, pain, and fever).
When patients present to a hospital emergency room with toothache, the emer-
gency room physician will commonly prescribe an antibiotic in order to prevent the
spread of infection beyond the tooth, plus an analgesic. Brennan et al. (2006) per-
formed a study of 134 patients presenting with toothache and randomized them into
antibiotic and non-antibiotic (placebo) groups. Thirteen patients (10%) developed a
spreading infection, defined as swelling, fever, pus drainage, or trismus, but there
was no difference between the two groups. On multivariate analysis of the outcome
of spreading infection, the only parameters predicting spreading infection were
periapical pathosis larger than 1.5 mm on periapical X-ray and the presence of an
amalgam filling in a causative tooth. This study indicates that antibiotics used for
toothache do not play a role in preventing subsequent infection spreading beyond
the tooth.
In emergency medicine, there are two meta-analyses, Fahimi et al. (2015) and
Singer and Thode Jr (2014), that found no difference in the outcome of skin and
soft tissue infections treated with incision and drainage comparing effective vs.
noneffective or no antibiotic (Fahimi et al. 2015) or an antibiotic vs. no antibiotic
(Singer and Thode Jr 2014). A noneffective antibiotic was defined as one to which
the cultured organism(s) were not sensitive. These two high-quality studies indi-
cate that surgery alone is also effective in skin and soft tissue infections not related
to the teeth.
There is one randomized clinical trial comparing two antibiotics in odontogenic
infection that used a control group receiving no antibiotic. Matijević et al. (2009)
compared patients with spreading odontogenic infections, all receiving incision and
drainage plus extraction or root canal therapy, in three groups, amoxicillin,
286 T. R. Flynn

cephalexin, and no antibiotic. There was no significant difference among the groups.
The two antibiotic groups had a statistically insignificant shorter time to clinical
resolution, but all patients were considered resolved by 1 week after surgery. This
clinical trial indicates that surgery alone is effective in the treatment of odontogenic
infections that have spread beyond the tooth itself.
The Infectious Diseases Society of America recommends clinical follow-up and
reexamination of the patient at approximately 3 days after a course of antibiotics has
begun (Bartlett et al. 2005). Since odontogenic infections inherently require a surgi-
cal approach, close clinical follow-up is required after incision and drainage, tooth
extraction, and root canal therapy in the setting of acute infection. At the same visit,
evaluation of the effectiveness of and continuing necessity for the antibiotic regi-
men is performed.
In summary, significant high-quality evidence indicates that surgical therapy of
odontogenic infections can lead to desired clinical outcomes (practically speaking,
the resolution of the infection) without the use of antibiotics at all. This confirms
what dentists observed even before antibiotics were discovered. In fact, it is ethi-
cally impossible to design a study comparing surgery alone with antibiotics alone in
the management of odontogenic infections, because we know that some type of
surgery, extraction, root canal therapy, gingival curettage, or incision and drainage,
or combinations of these, is necessary.

15.1.2 P
 rinciple 2: Use Therapeutic Antibiotics Only When
Clinically Indicated

The indications for antibiotic therapy for odontogenic infections are listed in Box
15.1. This section discusses the use of antibiotics for established infections. Sections
15.1.9 and 15.1.10 discuss the use of prophylactic antibiotics.
When an odontogenic infection spreads beyond the immediate periapical region into
the bone of the jaw, or through the cortical plate into the soft tissues of the oral vestibule,
or the deep fascial spaces of the head and neck, therapeutic antibiotics are indicated. The

Box 15.1 Indications for Antibiotic Therapy in Odontogenic Infections

Fever
Swelling
Lymphadenopathy
Prophylaxis of infection following dental procedures:
Endocarditisa
Immunocompromised patientsa
Surgical site infectionb
a
Guidelines from professional associations apply
b
High-quality evidence supports prophylactic antibiotics for third molar and
periodontal surgery
15 Evidence-Based Principles of Antibiotic Therapy 287

clinical signs of such a spreading infection include fever, swelling, and lymphadenopa-
thy. Trismus (limited mouth opening) is seen in 73% of severe odontogenic infections
requiring hospitalization, and dysphagia (difficulty swallowing) is seen in 78% of them
(Flynn et al. 2006); so these are ominous signs as well. An unfortunate diagnostic error
is made when trismus due to infection is diagnosed as temporomandibular disorder. The
resulting treatment delay can allow a virulent infection to spread deeply into the fascial
spaces of the head and neck, with potentially life-threatening consequences.
This principle of antibiotic therapy, like the first one, was established by decades
of clinical experience before randomized clinical trials became the scientific stan-
dard by which new clinical approaches are validated. The one study by Matijević
et al. (2009), compared amoxicillin, cephalexin, and no antibiotic in patients
receiving appropriate surgical therapy for odontogenic infections. There was no
significant difference among the three groups, although time to clinical resolution of
the infection was shorter in the two antibiotic groups. This is the only high-quality
evidence that supports the use of therapeutic antibiotics for dental infections, but the
result was not statistically significant. Ethical considerations may preclude directly
testing the hypothesis that such therapeutic antibiotics are clinically beneficial.
When a dentist writes a prescription for antibiotics, he or she is causing the selective
survival of antibiotic-resistant bacteria. That course of antibiotics selects for resistant
bacteria not only within the patient but also within the patient’s family. In 1988 Brook
took throat swab cultures of children with sore throats before a 7-day course of penicil-
lin. At the end of treatment, he cultured the throats again, not only of the patients but
also of their parents and siblings. Before treatment, 12% of the children harbored one
or more penicillin-resistant organisms. After treatment, carriage of resistant organisms
increased to 46%. Interestingly, however, 45% of the parents and siblings carried at
least one penicillin-resistant species, even though they had not received the antibiotic.
This figure had not returned to baseline by 3 months after treatment, when 27% of the
subjects carried penicillin-resistant bacteria. Thus, prescribing antibiotics selects for
resistant bacteria not only in the patient but also in the patient’s family.
In a follow-up study, Brook and Gober (1997) took monthly throat swab cultures
of children in a metropolitan school system for 2 consecutive years. In September,
the mean carriage of one or more penicillin-resistant bacteria was at its trough, in
13% of children. That figure increased to its peak in April, at 60% of children. The
explanation for these results is that at the beginning of the school year, the children
are relatively healthy, but as the weather declines in the colder months, more children
are given courses of antibiotics for ear and throat infections and other common ill-
nesses. By springtime, even children who may not have taken antibiotics during the
school year have acquired resistant bacteria from their schoolmates. As the weather
improves, the need for antibiotics decreases, and then the children disperse for sum-
mer vacation. This allows the rate of carriage of antibiotic-resistant bacteria to
decline in the study population. This study demonstrates that by prescribing antibiot-
ics, we are affecting entire communities, such as schools and workplaces.
In fact, the rate of penicillin resistance has been increasing over the past decades.
Table 15.1 shows that penicillin resistance has increased from 33% of patients with
severe odontogenic infections (those with head and neck or oral swelling) to 63% in
288 T. R. Flynn

2017. Clindamycin resistance has increased also, from 13.7% of strains in 2006
(Rega et al. 2006) to 32% in 2017 (Kim et al. 2017).
In summary, therapeutic antibiotics do provide added benefit when combined
with appropriate dental and surgical treatment. Rigorous observance of the indica-
tions for antibiotic therapy, such as swelling, fever, and lymphadenopathy can mini-
mize the development of antibiotic-resistant strains, which are increasing among
patients with odontogenic infections.

15.1.3 P
 rinciple 3: Use Specific Antibiotic Therapy as Soon
as Possible, Based on Culture and Sensitivity Testing

Almost all oral disease is infectious. Caries, pulpitis, periodontitis, periapical

abscess, and deep fascial space infection are all caused by oral pathogens. Over its
history, dentistry has developed surgical therapy for each of these manifestations of
infectious disease. Table 15.2 lists the most frequent pathogens that have been iso-
lated from odontogenic infections.
In the earlier phase of the antibiotic era, often called “The Golden Age of
Antibiotics,” dentists were able to prescribe penicillin for most patients with oral
infection and erythromycin for penicillin-allergic patients. In recent years we have
entered the age of increasing antibiotic resistance, as demonstrated for oral infec-
tions in Table 15.1. Therefore, the need for culture and sensitivity testing, even for
dental infections, is likely to increase in coming years. In fact, culture and sensitiv-
ity testing is now being used in periodontitis as well as swellings extending beyond
the alveolar process. With routine oral infections, often the infection is completely
resolved before the culture results become available. Culture and sensitivity testing
in a hospital microbiology laboratory can be quite expensive. Therefore, reasonable
indications for culture and sensitivity testing are listed in Box 15.2.

Table 15.1 Increasing rates Year % of cases PCN resistant Country

of antibiotic resistance in Brook et al. (1991) 33 USA
odontogenic infections von Konow et al. (1992) 38 Sweden
Lewis et al. (1995) 55 UK
Flynn et al. (2006) 54 USA
Kim et al. (2017) 63 USA
PCN penicillin, UK United Kingdom, USA United States of
America

Table 15.2 Most frequent Microorganism % of cases

pathogens in odontogenic Streptococcus milleri group 65
infections Peptostreptococcus species 65
Other anaerobic streptococci 9
Prevotella species (oralis, melaninogenica, etc.) 74
Porphyromonas species (gingivalis, etc.) 17
Fusobacterium species 52
Data from: Sakamoto H, Kato H, Sato T, Sasaki J (1998)
Semiquantitative bacteriology of closed odontogenic abscesses.
Bull Tokyo Dent Coll. 39:103–7
15 Evidence-Based Principles of Antibiotic Therapy 289

Box 15.2 Indications for Culture and Sensitivity Testing

Serious, potentially life-threatening infections
Chronic, recalcitrant infections
Previous, multiple antibiotic therapy
Immunocompromised patient:
• Diabetes
• IVDA
• HIV

Practical considerations for dentists taking cultures include that both aerobic and
anaerobic specimens should be harvested, which in general requires separate aero-
bic and anaerobic culturettes. Modern microbiology laboratories will not perform
anaerobic cultures on a specimen that has not been transported in anaerobic media,
because the anaerobes will not likely have survived. Further, such culturettes have a
short shelf life, and outdated culturettes will be rejected as well.
It is not necessary to harvest pus for valid cultures. Serosanguineous fluid
obtained from a cellulitis yields viable bacteria that can successfully be grown in the
microbiology laboratory. In suspected osteomyelitis, a specimen of affected bone
from the jaw should be cultured aerobically and anaerobically. Specific antibiotic
therapy, meaning that the choice of antibiotic is guided by the results of culture and
sensitivity testing, is required for osteomyelitis of the jaws.
Molecular methods for identification of oral pathogens have been used for some
time now, especially in periodontology and endodontology (Haffajee et al. 2009;
Sassone et al. 2007). In severe odontogenic infections, such as deep fascial space
infections (Flynn et al. 2012) and pericoronitis (Mansfield et al. 2012), we have
found that a large percentage of the species identified are unculturable. This means
that species identification can be performed using the genetic material of the patho-
gens involved, but that the appropriate culture methods for growing live specimens
of those species have not yet been found. Completely novel species have also been
identified using molecular methods. Developing applications of this technology
include the rapid identification of pathogens, especially the most virulent and anti-
biotic-resistant species, such as methicillin-resistant Staphylococcus aureus
(MRSA) in emergency departments and hospitals (Palavecino 2014).

15.1.4 P
 rinciple 4: Use the Narrowest-Spectrum Empiric
Antibiotic Effective Against the Most Likely Pathogens

In 2004, the American Dental Association Council on Scientific Affairs published a

policy on the use of antibiotics in dentistry, with the purpose of reducing antimicrobial
resistance. The American Dental Association acknowledged in this publication that
increasing antibiotic resistance is a problem that must be managed in dentistry, and
it recommended the use of narrow-spectrum antibiotics in simple cases. Penicillin,
metronidazole, and clindamycin (in penicillin-allergic patients) were classified as
narrow-spectrum agents. For complex cases, broader-spectrum antibiotics could be
290 T. R. Flynn

used, which were amoxicillin, ampicillin, cephalosporins, macrolides (erythromycin

family), and tetracyclines. Amoxicillin-clavulanate (Augmentin®) was recommended
for sinus infections only. However, the policy did not define simple and complex
cases. Box 15.3 defines the characteristics of simple and complex cases.
The Infectious Diseases Society of America (IDSA) has also recommended that
the antimicrobial agent selected should be the most cost-effective, least toxic, and
most narrow in spectrum (Bartlett et al. 2005).
The narrow-spectrum antibiotics that are useful for odontogenic infections are
generally effective against the major oral pathogens, consisting of the viridans
group of streptococci, anaerobic streptococci, and the oral anaerobic Gram-negative
pathogens, primarily members of the genera Fusobacterium, Prevotella, and
Porphyromonas. They generally are not effective against enteric Gram-negative
bacteria found primarily in the gut flora, such as Escherichia coli, Klebsiella pneu-
moniae, Enterobacter species, Enterococci, Pseudomonas aeruginosa, and Serratia
marcescens. Many of the most virulent Gram-positive pathogens, such as
Staphylococcus aureus, are also resistant to the narrow-spectrum antibiotics useful
in dentistry. Thus, when narrow-spectrum antibiotics, such as the penicillins, are
used for odontogenic infections, the most worrisome pathogens that cause complex
systemic infections while being resistant to many antibiotics are not affected. They
are already resistant to penicillin V, amoxicillin, and clindamycin.
Other advantages of using narrow-spectrum antibiotics are that superinfection,
pharmacologic toxicity, and, for the most part, the cost of treatment are reduced.
Superinfection is the overgrowth of members of the resident flora that are resistant
to the antibiotic being used. The bacteria involved are not causing the infection
being treated, and in fact, they may be distant from the infected site. An example is
overgrowth of vaginal yeast organisms, such as Candida, when an oral infection is
being treated. In many sites in the body, the normal resident flora of that location is

Box 15.3 Simple vs. Complex Odontogenic Infections

Simple
• Swelling limited to the alveolar process and vestibular space
• First attempt at treatment
• Non-immunocompromised patient

Complex
• Swelling extending beyond the vestibular space
• Failed prior treatment
• Immunocompromised patient

From: Flynn TR (2008) Principles of management and prevention of odon-

togenic infections. In: Ellis E, Hupp JR, Tucker MR (eds) Contemporary oral
and maxillofacial surgery, 5th edition. Mosby, St. Louis, MO. p. 308. Used
with permission
15 Evidence-Based Principles of Antibiotic Therapy 291

at an equilibrium state among a large number of species, whose interactions tend to

keep the relative proportion of each species fairly stable. When an antibiotic is
introduced, the susceptible organisms are killed, and the balance is disrupted,
allowing resistant organisms to overgrow, causing disruption of the function of the
organ system they inhabit. Another example is the overgrowth of Clostridium
difficile in the gut flora, causing antibiotic-associated colitis. When their numbers
increase to a certain level, these Clostridia release an exotoxin that causes diarrhea
that can be severe and difficult to treat (Lübbert et al. 2014).
Fortunately, the narrow-spectrum antibiotics in common use in dentistry have
low pharmacologic toxicity as well. The major toxicity of the penicillin family, for
example, is allergy. Severe allergic reactions to penicillins are best prevented by
careful history taking.
As the American population ages and suffers from more chronic diseases, the
need for lifelong medications increases. With the newer antibiotics currently
available, drug interactions have become a mounting problem, many of which are
severe. For example, both the macrolides (erythromycin family) and the
fluoroquinolones (e.g., cipro-, gemi-, and moxifloxacin) are metabolized by
CYP3A4, a liver microsomal enzyme in the cytochrome P450 system, which
metabolizes 60% of prescribed drugs. CYP3A4 is responsible for about half of that
function, and it is associated with more than half of known interactions between
prescribed drugs (Zanger and Schwab 2013). When certain macrolide or
fluoroquinolone antibiotics are prescribed in combination with a wide range of
other drugs, some of which are listed in Box 15.4, cardiac dysrhythmias and even
torsades de pointes, a form of ventricular fibrillation leading to death can occur.
Narrow-spectrum antibiotics can also cost less than broad-spectrum antibiotics.
Although many factors contribute to the cost of antibiotics, the narrow-spectrum
ones tend to be older and can therefore be marketed generically. Certain new

Box 15.4 Selected Categories and Examples of Drugs That Prolong the QT
Electrocardiographic Interval
Antibiotics: macrolides; fluoroquinolones; TMP-SMX; flu-, itra-, vori-, keto-
conazole; pentamidine; quinine
Antiarrhythmics: amiodarone, procainamide, sotalol, disopyramide,
quinidine
Psychiatric drugs: TCAs (amitriptyline), SSRIs (citalopram Celexa®, esci-
talopram Lexapro®, fluoxetine Prozac®, paroxetine Paxil®, sertraline Zoloft®),
phenothiazines, lithium, butyrophenones (Haldol®, Risperdal®)
Anticonvulsants: felbamate, fosphenytoin
Miscellaneous: diphenhydramine, droperidol, tacrolimus, tamoxifen, sero-
tonin receptor agonists (Imitrex®, Zomig®), smoking
Legend: SSRIs = selective serotonin reuptake inhibitors; TCAs = tricyclic
antidepressants; TMP-SMX = trimethoprim-sulfamethoxazole
292 T. R. Flynn

narrow-spectrum antibiotics, aimed specifically at highly resistant pathogens, such

as S. aureus, can be quite expensive, however. The cost of antibiotic therapy is dis-
cussed more thoroughly in Sect. 15.1.8.
The effectiveness of the commonly used antibiotics for oral infections has been
compared in several well-designed randomized clinical trials. These were reviewed
systematically by Flynn (2011), who found eight trials comparing a penicillin with
another antibiotic for severe odontogenic infections. Appropriate surgical treatment
was also used in all patients, consisting of root canal therapy, extraction, and incision
and drainage, as appropriate. The outcome was clinical resolution (decrease in pain,
swelling, fever) at 5–7 days after treatment. Table 15.3 lists the results. Interestingly,

Table 15.3 Systematic review of antibiotics in odontogenic infections

Significant
difference
Intervention Comparator Surgical between
Reference Year N group group control groups? Comment
Gilmore 1988 49 PCN CLI N N Only surgery was
et al. (1988) I&D; EXT/RCT
performed only
after study
completion
von Konow 1983 60 ORN PCN N N Only surgery was
and Nord I&D; two subjects
(1983) in each group did
not receive
surgery. Fewer
days of pain in
ornidazole group
(p < 0.05); more
failures in PCN
group (NSD)
Mangundjaja 1990 106 CLI AMP N N Only surgery was
and I&D; EXT/RCT
Hardjawinata performed only
(1990) after study
completion. Not
all subjects were
cured by 7 days
Lewis et al. 1993 78 AM/CL PCN N N Surgery was either
(1993) I&D or EXT or
RCT. Greater pain
reduction at 1–2
and 2–3 days in
amoxicillin/
clavulanate group;
otherwise NSD in
swelling,
temperature,
lymphadenopathy,
or pain
15 Evidence-Based Principles of Antibiotic Therapy 293

Table 15.3 (continued)

Significant
difference
Intervention Comparator Surgical between
Reference Year N group group control groups? Comment
Davis Jr and 1969 49 LIN (im and PCNG (im N N Nine patients had
Balcom 3rd po) and po) trauma and
(1969) fractures,
including
osteomyelitis
Matijević 2009 90 AMOX CEPH Y N Antibiotic groups
et al. (2009) had shorter
treatment time
than surgery alone
(not statistically
significant)
Ingham et al. 1977 37 MET PCNG (im N N Subjects received
(1977) once daily) “appropriate
surgery when
necessary.” at
24–48 h, “marked
clinical
improvement”
was noted in all
subjects
Al-Nawas 2009 19 MOXI AM/CL N N Only study of
et al. (2009) hospitalized
patients, requiring
extraoral and/or
intraoral I&D.
Cure = improving
trismus, no pain on
palpation, afebrile
AM/CL amoxicillin/clavulanate; AMOX amoxicillin, AMP ampicillin, CEPH cephalexin, CLI
clindamycin, EXT extraction, im ilntramuscular, I&D incision and drainage, LIN lincomycin, MET
metronidazole, MOXI moxifloxacin, N no, NSD no statistically significant difference, ORN ornida-
zole, PCN penicillin V, PCNG penicillin G, RCT root canal therapy, Y yes
Adapted from: Flynn TR (2011) What are the antibiotics of choice for odontogenic infections, and
how long should the treatment course last? Oral Maxillofac Surg Clin North Am 23:519–36

none of the studies found a significant difference in outcome between the control
antibiotic (a penicillin) and the test antibiotic (another antibiotic, usually with a
broader-spectrum than the penicillin control).
This review allows us to conclude that the usual empiric antibiotic choices for
severe odontogenic infections (those causing orofacial swelling) are equally effec-
tive, given the appropriate surgery. Thus, antibiotic selection should be based upon
pharmacologic safety, cost, and the patient’s past medical history, including concur-
rent medications. Further, one of the studies reviewed in Flynn 2011, found that
surgery alone, without antibiotic therapy, was effective, but the time to resolution
may be shorter when an antibiotic is added (Matijević et al. 2009).
294 T. R. Flynn

15.1.5 P
 rinciple 5: Avoid the Use of Combination Antibiotics,
Except in Specific Situations Where They Are Shown
to Be Necessary

Most odontogenic infections are polymicrobial. Using conventional culturing meth-

ods, four to six species can be isolated. Using molecular methods, as many as 18
species have been identified from a single sample (Flynn et al. 2012). Nonetheless,
a single antibiotic can usually be selected that is effective against the most likely
pathogens. Even when one or more of the species identified is resistant to the anti-
biotic used, clinical resolution is achieved when appropriate surgery is performed
(Flynn et al. 2006). For almost all odontogenic infections, a single antibiotic is
effective when the appropriate surgical treatment is provided (Flynn 2011).
Combinations of antibiotics may rarely be indicated in severe infections of
unknown cause, in severe (hospitalized) polymicrobial infections for which no sin-
gle antibiotic is effective against all of the pathogens and to prevent the emergence
of resistance to a single antibiotic.
However, combining antibiotics can increase toxicities and costs, select for resis-
tant organisms, and cause antagonistic interactions between the antibiotics. For exam-
ple, vancomycin has minimal renal toxicity when used alone, but in combination with
an aminoglycoside, such as gentamicin, renal toxicity is significantly increased.
Combining a bactericidal antibiotic with a bacteriostatic one can reduce or elimi-
nate the effectiveness of the bactericidal antibiotic. Many bactericidal antibiotics,
like the penicillins, inhibit cell wall synthesis and are thus effective during the active
growth and cellular division phases of the bacterial cell cycle. Bacteriostatic antibi-
otics, like the macrolides, inhibit protein synthesis, and slow bacterial growth and
multiplication. This reduces the number of bacteria that must be destroyed by the
immune system. Because bacteriostatic antibiotics restrict bacterial growth, cell
wall synthesis, the target of the penicillins and other beta-lactam antibiotics is not
active, thus rendering the bactericidal antibiotic largely ineffective. Table 15.4 lists
common bactericidal and bacteriostatic antibiotics.

Table 15.4 Bactericidal and bacteriostatic antibiotics

Bactericidal Bacteriostatic
Beta-lactams Macrolides
 Penicillins  Erythromycin
 Cephalosporins  Clarithromycin
 Carbapenems  Azithromycin
 Monobactams Clindamycin
Aminoglycosides Tetracyclines
Vancomycin Doxycycline
Metronidazole  Tigecycline
Fluoroquinolones Sulfa antibiotics
 Ciprofloxacin Oxazolidinones
 Moxifloxacin  Linezolid
Aminoglycosides  Tedizolid
Glycopeptides
 Vancomycin
 Telavancin
Daptomycin
15 Evidence-Based Principles of Antibiotic Therapy 295

Some antibiotics antagonize each other because they compete for the same
receptor sites. Examples are the combinations of clindamycin and the macrolides,
such as erythromycin, and the combination of linezolid and vancomycin. Such com-
binations should be avoided.
Combined antibiotics have been shown to be effective in a few diseases. For
example, in endocarditis, the combination of a penicillin with an aminoglycoside
allows reduction in the duration of therapy to 2 weeks from 4 weeks, with less fre-
quent relapse and no increase in antibiotic resistance among initially susceptible
isolates (Baddour et al. 2005; Bliziotis et al. 2005).
One head and neck infection that is treated with combined antibiotics, at least
initially, is necrotizing fasciitis, the dreaded “flesh-eating bacteria” infection. Some
head and neck cases of necrotizing fasciitis are odontogenic, and they can result in
the loss of large amounts of skin and subcutaneous tissue of the face and neck.
When this infection arises in a deeper plane, the necrotizing bacteria can follow the
fascial layers of the neck into the mediastinum, the space between the lungs that
contains the heart.
There are five subtypes of necrotizing fasciitis, based on the causative bacteria.
Since this severe infection progresses rapidly, initial empiric antibiotic therapy is
directed at all five bacterial subtypes, requiring a combination of a carbapenem,
such as imipenem, plus vancomycin. At emergency surgical debridement, the sur-
geon samples the infection for culture and sensitivity testing and for histopathologic
examination (biopsy). When culture and sensitivity results are available, the antibi-
otic regimen may be deescalated from the broad-spectrum combination of a car-
bapenem plus vancomycin to more narrow-spectrum specific antibiotic therapy that
is effective against the subtype that has been identified by culturing. Figure 15.1
illustrates the empiric therapy of necrotizing fasciitis and the bacterial subtypes
responsible for this infection.

ANTIBIOTICS FOR NECROTIZING FASCIITIS

POLYMICROBIAL (odontogenic)
Carbapenem (imi-, mero-, doripenem)

EMPIRIC THERAPY: STREPTOCOCCAL (Group A, C, G)

Penicillin G + Clinda?
Carbapenem Gram stain CLOSTRIDIAL
+ Vancomycin + C&S + Bx Penicillin G + Clinda
MRSA
Imipenem + vanco-or daptomycin

KLEBSIELLA
Carbapenem (+ Colistin if KPC/ESBL+)

Fig. 15.1 Antibiotic therapy for necrotizing fasciitis. Empiric therapy is with a carbapenem, such
as imipenem or meropenem plus vancomycin. After Gram stain, culture and sensitivity testing, and
histopathologic examination of involved fascial tissue results are available, specific antibiotic
therapy is directed toward one of the five bacterial types of necrotizing fasciitis shown on the right
side of the image. Bx biopsy, C&S culture and sensitivity testing, MRSA methicillin-resistant
Staphylococcus aureus
296 T. R. Flynn

Certain bacteria undergo frequent mutations that can confer antibiotic resistance.
Fortunately, this is not yet common among the usual dental pathogens. Combinations
of antibiotics are sometimes used in order to prevent the survival of antibiotic-resis-
tant mutant strains of these bacteria. For such organisms, combining two antibiotics
that have independent bactericidal mechanisms can provide impressive synergy in
suppressing antibiotic resistance. Specifically, if the frequency of mutation confer-
ring resistance to the first antibiotic is 10−5, and it is 10−8 for the second antibiotic,
then the probability of both of those mutations occurring simultaneously is 10−13.
This strategy is used in staphylococcal osteomyelitis, endocarditis involving pros-
thetic heart valves, and tuberculosis (Flynn and Shanti 2016).
In summary, there are few, if any, indications for combination antibiotic therapy
in dentistry at this time. The only exceptions may rarely occur in the most severe
infections, such as necrotizing fasciitis or staphylococcal osteomyelitis of the
mandible.

15.1.6 P
 rinciple 6: Use the Least Toxic Indicated Antibiotic,
Considering Interaction with Concurrent Medications

The various antibiotic families in use today can be ranked in order of their major
and most common toxicities, as shown in Table 15.5. The salient pharmacologic
features of antibiotics commonly used in dentistry are listed in Table 15.6. Selected
antibiotic-drug interactions are listed in Table 15.7. The pregnancy-associated risk
categories for various antibiotics can be found in Table 15.8.
The penicillins and cephalosporins are among the best-tolerated antibiotics, as
long as allergic reaction is not likely by history. The most commonly used
lincosamide is clindamycin. Its major toxicity is antibiotic-associated colitis, due to
the overgrowth of C. difficile. This complication is most frequent in females and
hospitalized patients, after gastrointestinal tract surgery and with a history of
inflammatory bowel disease, renal disease, and cancer chemotherapy. Fortunately,
these risk factors are not common in dental patients, except for female gender.
The newer macrolides, clarithromycin (Biaxin®) and azithromycin (Zithromax®),
are much better tolerated by the digestive tract than are the various other forms of
erythromycin. The major toxicity of the macrolides is drug interactions involving
the CYP3A4 microsomal enzyme, many of which can lead to or worsen

Table 15.5 Relative toxicity Antibiotic family Major toxicity

of antibiotic families Penicillins Allergy
Cephalosporins Allergy, superinfection
Carbapenems Seizures
Lincosamides Antibiotic-associated colitis
Oxazolidinones Serotonin syndrome, thrombocytopenia
Macrolides Drug interactions, ↑QT
Fluoroquinolones Drug interactions, ↑QT, chondrotoxicity
Glycopeptides Nephro-/ototoxicity
Aminoglycosides Nephro-/ototoxicity
 15

Table 15.6 Pharmacology of antibiotics commonly used in dentistry

Dosage (po
Antibiotic Spectrum unless stated) Mode of action Side effects Comments
Penicillin V Oral streptococci 500 mg qid Bactericidal Allergy—may cause Produces lower blood
Oral anaerobes Children: Interferes with cell wall anaphylactic shock levels than IV PCN G
Resistant: 25–50 mg/kg/ synthesis of bacteria in (~0.05%) Excreted by kidneys
Staph day their growth phase Rare GI disturbances Administer before meals
Enteric flora Superinfection by
Bacteroides fragilis resistant bacteria may
occur. Rash in 3% of
patients, serum sickness in
4%
Amoxicillin Oral streptococci 500 mg qid, Bactericidal Allergy—may cause Less effective against
(semisynthetic penicillin) Oral anaerobes 875 mg bid, Interferes with cell wall anaphylactic shock oral streptococci than
Actinomyces 1000 mg qd synthesis of bacteria in Most common cause of PCN V; more effective
Resistant: Children: their growth phase antibiotic-associated against oral anaerobes
Staphylococci 20–50 mg per colitis
Pseudomonas sp. kg/day Diarrhea in 10% of
Evidence-Based Principles of Antibiotic Therapy

patients
Amoxicillin + clavulanic Oral streptococci 500 mg qid; Bactericidal Allergy may cause Not effective against
acid Oral anaerobes 875 mg bid; Interferes with cell wall anaphylactic shock MRSA
(Augmentin®) Actinomyces 2000 mg bid synthesis of bacteria in Common cause of Improved coverage for
Staphylococci Children: their growth phase antibiotic-associated staphylococci, oral
Enteric Gram-negative 20–40 mg per Clavulanic acid inhibits colitis anaerobes, and enteric
rods kg/day; penicillinase made by Diarrhea in 9% of flora
H. influenzae 2000 mg bid staphylococci and some patients; less frequent
(high dose) Gram-negative rods with bid dosing (less
clavulanate)
(continued)
297
Table 15.6 (continued)
298

Dosage (po
Antibiotic Spectrum unless stated) Mode of action Side effects Comments
Azithromycin Some oral streptococci 500 mg on day Bactericidal or GI upset: less common Fewer drug interactions
(Zithromax®) Atypical pathogens in 1, then 250 mg/ bacteriostatic than with other macrolides than with the other
HIV+ patients day for days Interferes with protein Prolongs QT interval macrolides; concentrates
Resistant: 2–5 synthesis during growth Fewer drug interactions in phagocytes at up to
Most staphylococci Children: phase. Active uptake of the than with other macrolides 15× concentration in
B. fragilis 10–12 mg/kg on antibiotic by phagocytes serum
Fusobacteria day 1, then may improve coverage over
5 mg/kg/day for in vitro data
days 2–5
Clindamycin Oral streptococci 150–600 mg qid Bactericidal or Common cause of C. Does not cross
(Cleocin®) Some staphylococci Children: bacteriostatic difficile colitis blood-brain barrier some
Anaerobes 15–30 mg per Interferes with protein streptococci are
Resistant: kg/day synthesis becoming resistant
Enteric flora
Eikenella corrodens
Cephalexin Streptococci 500 mg qid Bactericidal Allergy: may cross-react Does not cross
(Keflex®—first-generation Resistant: Children: Interferes with cell wall with those that have had blood-brain barrier in a
cephalosporin) Oral anaerobes 25–50 mg per synthesis of bacteria in an anaphylactoid reaction predictable fashion
Enteric flora kg/day their growth phase to penicillins
B. fragilis
Cefdinir Streptococci 300 mg bid, Bactericidal Allergy: may cross-react Does not cross
(third-generation Oral anaerobes 600 mg qd Interferes with cell wall with those that have had blood-brain barrier in a
cephalosporin) Resistant: Children: synthesis of bacteria in an anaphylactoid reaction predictable fashion
Staphylococci 14 mg/kg/day their growth phase to penicillins
T. R. Flynn
 15

Metronidazole Obligate anaerobes only 500 mg qid Bactericidal Metallic taste Crosses blood-brain
(Flagyl®) Resistant: Children Interferes with folic acid Antabuse-like effect barrier. Can be used with
All facultative and >1 year: metabolism Carcinogenic in rats: use other antibiotics
aerobic bacteria 30 mg/kg/day in only when indicated
four doses
Moxifloxacin Oral streptococci and 400 mg qd Bactericidal Possible ↑QT interval, Chondrotoxic in
(Avelox®) anaerobes, E. corrodens Children: Interferes with especially if used with pregnancy and children.
Actinomyces, B. fragilis, Do Not Use DNA synthesis quinidine, procainamide, May cause Achilles
staphylococci, including Pregnancy: amiodarone, sotalol, other tendon rupture. Mental
some MRSA, most Do Not Use drugs, or if hypokalemic clouding and decreased
enteric flora energy are common
Resistant: enterococci,
P. aeruginosa
Linezolid MRSA 600 mg bid Bactericidal to streptococci Epinephrine Weekly CBCs for
(Zyvox®) Streptococci Children: Bacteriostatic to hypersensitivity; bone monitoring; monitor BP
Vancomycin-resistant 30 mg/kg/day in staphylococci, enterococci. marrow suppression; for hypertension; may be
enterococci three doses Interferes with protein serotonin syndrome; toxic to fetus
Resistant: synthesis Stevens-Johnson (insufficient data)
Evidence-Based Principles of Antibiotic Therapy

Enterobacteriaceae syndrome; seizures

Abbreviations: bid twice daily, BP blood pressure, CBC complete blood count, GI gastrointestinal, HIV human immunodeficiency virus, IM intramuscular, IV
intravenous, kg kilograms, mg milligrams, MRSA methicillin-resistant Staphylococcus aureus, PCN penicillin, po by mouth, qd once daily, ↑ QT increased
electrocardiographic QT interval, sp. species, qid three times per day, X times
Adapted from: Flynn, TR, Shanti, RM (2016) Principles of antibiotic therapy for head, neck, and orofacial infections. In: Hupp JR, Ferneini (eds) Head, neck,
and orofacial infections: a multidisciplinary approach. Elsevier, St Louis, MO. p. 141–63
299
300 T. R. Flynn

Table 15.7 Selected interactions between antibiotics and other drugs

Antibiotic Second drug Adverse effects Mechanism
Erythromycin Theophylline Seizures, Antibiotic inhibits
Clarithromycin dysrhythmias cytochrome P450
Ketoconazole metabolism of the second
Itraconazole drug; ketoconazole not
implicated
“ Cisapride Dysrhythmias Antibiotic inhibits
(torsades de pointes) cytochrome P450
metabolism of the second
drug
“ Alfentanil ↑ Respiratory Antibiotic inhibits
depression cytochrome P450
metabolism of the second
drug; ketoconazole not
implicated
“ Bromocriptine ↑ CNS effects, Antibiotic inhibits
hypotension cytochrome P450
metabolism of the second
drug
“ Carbamazepine Ataxia, vertigo, Antibiotic inhibits
drowsiness cytochrome P450
metabolism of the second
drug
“ Cyclosporine ↑ Immunosuppression Antibiotic inhibits
and nephrotoxicity cytochrome P450
metabolism of the second
drug
“ Felodipine Hypotension, Antibiotic inhibits
Possibly other tachycardia, edema cytochrome P450
calcium channel metabolism of the second
blockers drug
“ Methylprednisolone ↑ Immunosuppression Antibiotic inhibits
Prednisone cytochrome P450
metabolism of the second
drug
“ Lovastatin Muscle pain, Antibiotic inhibits
Possibly other statins rhabdomyolysis cytochrome P450
metabolism of the second
drug
“ Triazolam ↑ Sedative depth and Antibiotic inhibits
Oral midazolam duration cytochrome P450
metabolism of the second
drug
“ Disopyramide Dysrhythmias Antibiotic inhibits
cytochrome P450
metabolism of the second
drug
Erythromycin Clindamycin ↓ Antibiotic effect Mutual antagonism
Erythromycin Digoxin Digitalis toxicity, Antibiotic kills Eubacterium
Tetracyclines dysrhythmias, visual lentum, which metabolizes
disturbances, digoxin in the gut
hypersalivation
15 Evidence-Based Principles of Antibiotic Therapy 301

Table 15.7 (continued)

Antibiotic Second drug Adverse effects Mechanism
Erythromycin Warfarin ↑ Anticoagulation Antibiotic interferes with
Clarithromycin Anisindione metabolism of the second
Metronidazole drug
Tetracycline Warfarin ↑ Anticoagulation Antibiotic kills gut flora that
Cefamandole Anisindione synthesize vitamin K, which
Cefotetan antagonizes the second
Cefoperazone drug; poor vitamin K intake
Sulfonamides a factor
Aminoglycosides
Metronidazole Alcohol Flushing, headache, Antibiotic inhibits
Cephalosporins Ritonavir palpitations, nausea acetaldehyde
dehydrogenase, causing
accumulation of
acetaldehyde; ritonavir
preparations contain alcohol
Metronidazole Disulfiram Acute toxic psychosis
Metronidazole Lithium Lithium toxicity: Antibiotic inhibits lithium
Tetracyclines confusion, ataxia, excretion by kidney;
kidney damage tetracycline interaction not
well established
Tetracyclines Di- and trivalent ↓ Absorption of Second drug interferes with
Fluoroquinolones cations antibiotic absorption of antibiotic;
(dairy, antacids, didanosine is formulated
vitamins) with calcium carbonate and
Didanosine magnesium hydroxide
buffers
Clindamycin Neuromuscular ↑ Depth and duration Additive effect due to
Aminoglycosides blocking agents of paralysis inherent minor
Tetracyclines neuromuscular blocking
Bacitracin effect of the antibiotic; seen
with clindamycin in the
presence of low
pseudocholinesterase levels
and abnormal liver function
tests
Clindamycin Erythromycin ↓ Antibiotic effect Mutual antagonism
Penicillins Estrogen- and Contraceptive failure Interference with
Cephalosporins progestin-containing enterohepatic recirculation
Metronidazole oral contraceptives of estrogen caused by
Erythromycin killing of gut flora; rifampin
Clarithromycin is the only antibiotic in
Tetracyclines which this has been
Rifampin clinically proven
Ampicillin Allopurinol Rash Unknown, possibly due to
Amoxicillin hyperuricemia in patients
taking allopurinol
Cephalosporins Aminoglycosides ↑ Nephrotoxicity Additive or potentiating
effect
(continued)
302 T. R. Flynn

Table 15.7 (continued)

Antibiotic Second drug Adverse effects Mechanism
Trimethoprim/ Thiazide diuretics Purpura, bleeding in Thrombocytopenia
sulfamethoxazole elderly patients
Vancomycin Aminoglycosides ↑ Renal toxicity Additive effect
Fluoroquinolones Oral hypoglycemic Hypoglycemia Antibiotic displaces the
Sulfonamides agents second drug from plasma
Chloramphenicol proteins
Fluconazole
Itraconazole
Ciprofloxacin Phenytoin ↑ Serum level of Interference with phenytoin
Sulfonamides phenytoin, confusion, metabolism
Chloramphenicol delirium
Fluconazole
Ketoconazole
Itraconazole
Sulfonamides Methotrexate ↑ Methotrexate Antibiotic displaces
concentration methotrexate from plasma
proteins
↑ increased, ↓ decreased
Note: This list of antibiotic-drug interactions is only partial and selected according to the interests
of dentists. Drug prescribers remain responsible to ascertain the complete drug interactions of any
medications they may prescribe
From: Flynn, TR, Shanti, RM (2016) Principles of antibiotic therapy for head, neck, and orofacial
infections. In: Hupp JR, Ferneini E (eds) Head, neck, and orofacial infections: a multidisciplinary
approach. Elsevier, St Louis, MO. p. 154–5. Used with permission

prolongation of the QT interval on the electrocardiogram and possibly life-threaten-

ing cardiac dysrhythmias (Box 15.4). Azithromycin, however, is not metabolized by
CYP3A4, and it therefore is much safer than the other macrolides. Further, azithro-
mycin’s pregnancy risk category is B (no evidence of animal toxicity and studies in
humans are inadequate; or animal toxicity but studies show no human toxicity),
while the other macrolides’ pregnancy risk category is C (animal toxicity; studies in
humans are inadequate). Azithromycin is therefore the safest of the currently avail-
able macrolides. The disadvantage of the macrolides, however, is that most oral
anaerobes and many oral streptococci have become resistant to them.
The most useful fluoroquinolone for dentists is moxifloxacin, because its spec-
trum includes the usual oral pathogens. In occasional cases caused by Eikenella
corrodens, which is uniformly resistant to clindamycin, the fluoroquinolones are the
antibiotics of choice. The major toxicities of the fluoroquinolones, however, are
chondrotoxicity and serious drug interactions. These drugs are toxic to growing
cartilage especially and are contraindicated in pregnancy and children under
18 years of age. There is also a low incidence of tendonitis and tendon rupture in
adults, especially after 60 years of age. Because the fluoroquinolones are metabolized
by CYP3A4 and can cause prolongation of the QT interval even when given alone
(Yan et al. 2010), their many interactions with other drugs are particularly
concerning. The potential for torsades de pointes exists when the fluoroquinolones
are combined with other antibiotics including the macrolides, antiarrhythmic drugs
15 Evidence-Based Principles of Antibiotic Therapy 303

Table 15.8 Pregnancy risk categories of selected antibiotics

Pregnancy risk
Antibiotic category Pregnancy risk
Penicillins
 Penicillin G and V B
 Ampicillin B
 Amoxicillin B
 Amoxicillin/Clavulanate B
Cephalosporins
 Cephalexin B
 Cefuroxime B
 Cefdinir B
Macrolides
 Erythromycin B
 Clarithromycin C Increased risk of miscarriage
 Azithromycin B Fetal defects in mice and monkeys
Antianaerobic
 Clindamycin B
 Metronidazole B
Fluoroquinolones
 Ciprofloxacin C Chondrotoxic in growing rats
 Moxifloxacin C Chondrotoxic in growing rats
Antifungals
 Fluconazole D Teratogenic at high doses
 Itraconazole C Teratogenic at high doses
 Voriconazole D Teratogenic at high doses
Others
 Vancomycin C Potential ototoxicity in human
fetuses
 Tetracyclines D Intrinsic dental staining
 Doxycycline D Intrinsic dental staining
 Linezolid C Fetal toxicity in rodents
 Trimethoprim/ C Increased risk of cleft palate
sulfamethoxazole
A studies in pregnant women, no risk, B animal studies no risk, human studies inadequate; OR
animal toxicity, but human studies no risk, C animal studies show toxicity, human studies
inadequate, benefit may outweigh risk, D evidence of human risk, benefit may outweigh risk, X
fetal abnormalities in humans, risk outweighs benefit
Adapted from: Flynn, TR, Shanti, RM (2016) Principles of antibiotic therapy for head, neck, and
orofacial infections. In: Hupp JR, Ferneini E (eds) Head, neck, and orofacial infections: a
multidisciplinary approach. Elsevier, St Louis, MO. p. 141–63

such as amiodarone and sotalol, psychiatric drugs including the selective serotonin
reuptake inhibitors commonly used for depression, and tamoxifen, a drug used to
prevent the recurrence of breast cancer (Box 15.4). A common sequela of the fluo-
roquinolones is fatigue and mental clouding.
In summary, the antibiotic families that have been routinely used for decades in
dentistry are not only effective when combined with appropriate surgery but also
fairly safe. The newer antibiotics that are effective against oral pathogens seem to
have increased toxicities, especially drug interactions and increased risk of fetal
damage in pregnancy.
304 T. R. Flynn

15.1.7 M
 inimize the Duration of Antibiotic Therapy,
as Appropriate to the Presenting Type of Infection

In the past, dentists and physicians were taught that if a patient did not complete the
entire duration of a prescribed antibiotic course, increased microbial antibiotic resis-
tance would result. The rationale for this approach was that a shortened antibiotic
course would allow the survival of partially sensitive strains of bacteria, while elimi-
nating the completely sensitive ones. Thus, over time, the minimal inhibitory con-
centration of antibiotic necessary to kill those strains would gradually rise.
More recent investigations, however, suggest that in many instances, the acquisi-
tion of antibiotic resistance occurs in a single-step transition. Figure 15.2 illustrates

Conjugation

Transformation

Transduction

Mutation

Fig. 15.2 Mechanisms of antibiotic resistance acquisition. DNA from the environment containing an
antibiotic resistance gene (pink) can be transferred into a recipient bacterium by several paths: bacte-
rial cell-to-cell conjugation; transformation by free DNA (on plasmids or as uncoiled DNA) that is
released by dead bacteria; or viral phage-mediated transduction. Resistance can also arise by de novo
mutation (indicated by a red cross). From: Andersson DI, Hughes D (2010) Antibiotic resistance and
its cost: is it possible to reverse resistance? Nat Rev. Microbiol. 8:260–71. Used with permission
15 Evidence-Based Principles of Antibiotic Therapy 305

the mechanisms by which bacteria can transfer genetic material containing antibi-
otic resistance genes to each other.
With stepwise acquisition of antibiotic resistance, shortening the duration of
antibiotic exposure may limit the opportunities for antibiotic-resistant strains
to pass resistance mechanisms on to other members of their own species or
even bacteria from unrelated species. The carriage of antibiotic resistance
mechanisms appears to impose a metabolic cost to bacteria. By not having to
develop and maintain these mechanisms, “wild” strains of bacteria can devote
more energy to their own metabolism and reproduction. In the absence of anti-
biotic selection pressure, the wild strains gradually outcompete the resistant
strains in a given population. Therefore, shortening the period of antibiotic
exposure may reduce the survival of antibiotic-resistant strains (Andersson and
Hughes 2010).
The four major types of antibiotic resistance mechanisms are listed in Table 15.9,
with examples of bacterial species known to exploit them. Some of these mechanisms
are found among oral pathogens, such as beta-lactamases in Prevotella and
Porphyromonas; altered penicillin receptors (penicillin-binding proteins) in
Streptococcus sanguis, a frequent pathogen in endocarditis; and efflux pumps that
allow the antibiotic to be removed from within the bacterial cell in enterococci and
staphylococci (Li and Nikaido 2009).
High-quality randomized clinical trials of the duration of antibiotic therapy in
odontogenic infections have been performed by Lewis et al. (1986) and by Chardin
et al. (2005). Lewis et al. (1986) compared two 3 g oral doses of amoxicillin 8 h
apart on the day of surgery with a 5-day course of penicillin V, 250 mg four times
per day. Chardin et al. (2005) compared 3- and 7-day regimens of amoxicillin 1 g
orally twice per day. There was no difference in clinical parameters of swelling,
fever, and lymphadenopathy at 7 days after surgery between groups in either study.
Although the Chardin et al. (2005) study claimed that the shorter course of antibiotic
would result in less antibiotic resistance, there was no significant difference in the
carriage of amoxicillin-resistant organisms between the long and short regimen
groups at 30 days after intervention.
In summary, the two included studies found no significant difference in clinical
cure at 7 days when either a 1–3 days or a 5–7 days course of antibiotics was used,
in combination with appropriate surgery (Table 15.10).

Table 15.9 Antibiotic resistance mechanisms, with examples of pathogenic species known to
have them
Mechanism Pathogens
Beta-lactamases S. aureus, S. epidermidis, H. influenzae, Prevotella,
Porphyromonas, Capnocytophaga, Eikenella, Fusobacterium
Altered PBPs (trans-, carboxy-, MRSA, S. pneumoniae, S. sanguis
and endopeptidases)
Reduced permeability K. pneumoniae, P. aeruginosa, S. marcescens, E. coli
Active transport pumps S. aureus, Enterococcus faecalis, C. difficile, K. pneumoniae,
S. pneumoniae, E. coli
Underlined = member of the oral flora
306 T. R. Flynn

Table 15.10 Clinical trials of the duration of antibiotic therapy in odontogenic infections
Significant
difference
Title/ Intervention Comparator between
reference Year group group groups? Comment
Lewis 1986 AMOX 3 g PCN 250 mg Less swelling No significant difference in
et al. q8h × 2 doses qid × 5d at 24 h in pain, swelling, temperature,
(1986) amoxicillin or lymphadenopathy at day
group 7
Chardin 2009 AMOX 1 g AMOX 1 g N No difference in carriage of
et al. bid × 3d, then bid × 7d AMOX-resistant
(2005) placebo streptococci between
groups at 30 days
posttreatment
AMOX amoxicillin, PCN penicillin V
Adapted from: Flynn TR (2011) What are the antibiotics of choice for odontogenic infections, and
how long should the treatment course last? Oral Maxillofac Surg Clin North Am 23:519–536

15.1.8 Use the Most Cost-Effective Appropriate Antibiotic

Cost is not the primary criterion on which antibiotics should be selected for our
patients, yet clinicians should be aware of the costs of the antibiotics they prescribe.
Table 15.3 lists the results of a systematic review of various antibiotics in dental
infections (Flynn 2011). The available randomized clinical trials all found that,
given appropriate surgery, no one antibiotic is superior to its comparator antibiotic.
Therefore, patient medical history, pharmacologic toxicity, and cost become the
major criteria that are used in antibiotic selection in odontogenic infections.
Table 15.11 compares the cost to an uninsured patient of 1 week of oral therapy
with selected antibiotics at the usual doses and intervals. The cost of a 7-day pre-
scription for amoxicillin 500 mg, to be taken three times per day, is compared to the
other antibiotics listed in the right column, the amoxicillin cost ratio. Thus, the cost
of a week prescription for penicillin V, at $18.59, is 55% greater than the cost of
amoxicillin. An interesting comparison can be made among different formulations
of clindamycin. The cost of generic clindamycin, 150 mg, given four times a day for
1 week is $27.69, more than twice as much as amoxicillin. When the dose is raised
to 300 mg by giving two 150 mg capsules four times a day, the cost increases to
$52.59 per week, which is 4.39 times the cost of amoxicillin. When, however, that
same 300 mg dose, four times per day, is given as one generic 300 mg capsule four
times a day, the cost is $79.99 per week, 6.67 times the cost of amoxicillin, over
50% greater than when the same 300 mg dose is given as two capsules, instead of
one. Therefore, when cost is a primary concern, the 300 mg dose can be given as
two 150 mg capsules instead of one 300 mg capsule. The cost savings may be offset,
however, by a decrease in compliance (the patient’s actually taking the medication
as prescribed) due to the increased number of capsules per dose.
The newer antibiotics tend to be more expensive than older ones. For example,
generic amoxicillin/clavulanate (brand name Augmentin®), 875 mg given twice per
day, costs $69.99 per week, 5.84 times the cost of amoxicillin, yet its clinical effective-
ness is not significantly different than penicillin V, when appropriate dental treatment is
performed (Lewis et al. 1993). Moxifloxacin is over nine times the cost of amoxicillin,
15 Evidence-Based Principles of Antibiotic Therapy 307

Table 15.11 Costs of oral antibiotic therapy

1-week
Usual Usual retail Amoxicillin
Dose Interval
Antibiotic (mg) (h) Cost 2017 Cost ratio
Penicillins
Amoxicillin 500 8 $11.99 1.00
Penicillin V 500 6 $18.59 1.55
Augmentin 875 12 $48.99 4.09
Augmentin XR (1000 mg X2) 2000 12 $119.99 10.01
Amoxicillin/clavulanate XR generic(1 g 2000 12 $178.99 14.93
X2)
Dicloxacillin 500 6 $39.59 3.30
Cephalosporins (generation)
Cephalexin caps (first) 500 6 $17.99 1.50
Cefadroxil (first) 500 12 $35.29 2.94
Cefuroxime (second) 500 8 $82.99 6.92
Cefaclor ER (generic) 500 12 $264.99 22.10
Cefdinir (third) (300 mg X2) 600 24 $61.59 5.14
Erythromycins
Erythromycin base 500 6 $464.99 38.78
Clarithromycin (Biaxin XL) 500 24 $34.99 2.92
Azithromycin (Zithromax) 250 12 $74.99 6.25
Fidaxomicin (Dificid) 200 12 $3034.99 253.13
Antianaerobic
Clindamycin (generic) 150 6 $27.69 2.31
Clindamycin (2 T generic) 300 6 $52.59 4.39
Clindamycin (generic) 300 6 $79.99 6.67
Metronidazole 500 6 $29.69 2.48
Others
Trimethoprim/Sulfamethoxazole 160/800 12 $11.99 1.00
Vancomycin 125 6 $376.99 31.44
Ciprofloxacin 500 12 $17.19 1.43
Moxifloxacin (Avelox) 400 24 $102.99 8.59
Doxycycline 100 12 $50.59 4.22
Linezolid (Zyvox) 600 12 $2223.99 185.49
Notes: Usual doses and intervals are for moderate infections and are not to be considered
prescriptive. Amoxicillin cost ratio = retail cost of antibiotic for 1 week/retail cost of amoxicillin
for 1 week

yet it is not more effective than amoxicillin/clavulanate (Al-Nawas et al. 2009).

Doxycycline (Vibramycin®), a broader-spectrum drug than amoxicillin, is 3.54 times
the cost of amoxicillin. Well-done clinical trials failed to demonstrate any significant
advantage of these newer, broader-spectrum drugs over the older narrow-spectrum
penicillin family antibiotics, such as penicillin V or amoxicillin (Flynn 2011).

15.1.9 U
 se Prophylactic Antibiotics Only When Proved Effective
or According to Professional Guidelines

Antibiotics can be used to prevent systemic complications of dental procedures,

such as endocarditis and late prosthetic joint infection, and to prevent surgical site
308 T. R. Flynn

infection (SSI) in the oral wound left by an oral surgical procedure. Prophylactic
antibiotics are given to prevent infection; therapeutic antibiotics are given to treat an
established infection.
The use of prophylactic antibiotics to prevent distant infections after routine den-
tal procedures, such as scaling and root planing or endodontic therapy, is discussed
in Sect. 15.1.10. Prophylactic antibiotics to prevent SSI (wound infection) are dis-
cussed here.
There is no evidence to support the use of prophylactic antibiotics for extraction
of erupted teeth. Expert recommendations exist to support this practice in
immunocompromised patients, such as in patients undergoing cancer chemotherapy
or taking immunosuppressive drugs (Tong and Rothwell 2000).
A mounting body of reliable evidence supports the use of prophylactic antibiot-
ics for the removal of impacted mandibular third molars. One randomized clinical
trial (Halpern and Dodson 2007) compared one intravenous dose of antibiotic before
third molar surgery and found a significant reduction in SSI and alveolar osteitis
(dry socket). Several meta-analyses have also found a significant reduction in SSI
and alveolar osteitis when an antibiotic is administered 2 h or less preoperatively
and some additional benefit when the antibiotic is continued for 3–4 days postop-
eratively (Ren and Malmstrom 2007; Lodi et al. 2012; Moreno-Drada and García-
Perdomo 2016; Marcussen et al. 2016).
The value of using prophylactic antibiotics in third molar surgery may be ques-
tioned, however, because in these studies it was found that the number needed to
treat (the number of third molar patients that must be given an antibiotic in order to
prevent one infection) ranged from 12 to 40. The number needed to treat raises con-
cerns of adverse or allergic reactions, expense, and increased antibiotic resistance.
On the other hand, the costs, morbidity, and professional liability of postoperative
infection and its treatment can be considerable, especially when hospitalization
becomes necessary.
In periodontal surgery, adjunctive antibiotic therapy with tetracycline or metro-
nidazole provides marginal improvement in attachment levels, according to a meta-
analysis by Haffajee et al. (2003).
Even though many dental implant manufacturers recommend prophylactic anti-
biotic therapy before dental implant placement, a recent meta-analysis of random-
ized clinical trials on this topic found no significant risk reduction of SSI following
dental implant surgery when prophylactic antibiotics were used (Moreno-Drada and
García-Perdomo 2016). In addition, these authors found no benefit of prophylactic
antibiotics in endodontic surgery.
In summary, there is high-quality evidence to support the use of prophylactic
antibiotics for prevention of SSI in otherwise healthy patients for removal of
impacted mandibular third molars and for improved results in periodontal surgery,
but not for other common dental procedures, such as routine extractions, dental
implant placement, or periapical surgery. Concerns about adverse reaction to
prophylactic antibiotics, costs, and antibiotic resistance remain, even when
prophylactic antibiotics show benefit in reduction of SSI.
15 Evidence-Based Principles of Antibiotic Therapy 309

15.1.10 F
 ollow the Guidance of Evidence-Based
Recommendations and Professional Guidelines When
They Are Available

When conclusive evidence-based guidelines are not feasible, whether due to lack of
available high-quality evidence or to ethical considerations that preclude clinical trials
directly testing alternative treatments, professional associations, such as the American
Dental Association, the American Heart Association, the American Academy of
Orthopaedic Surgeons, and the Infectious Diseases Society of America, join forces to
convene expert panels charged with providing guidelines for clinicians. Their guide-
lines are periodically reevaluated, based on new basic research and studies of clinical
outcomes, resulting in revisions. Such has been the history of guidelines for the preven-
tion of endocarditis and late prosthetic joint infections following dental procedures.
Bacteremia following dental procedures, often caused by Streptococcus viridans, an
oral streptococcus, has been suspected as the cause of some cases of subacute bacterial
endocarditis since the 1930s (Weiss 1934). Bacteremia occurs in up to 100% of dental
extractions, 70% of root planing, and 20% of root canal procedures (Li et al. 2000).
Prophylactic antibiotics, administered before tooth extraction, can prevent bacteremia,
according to the meta-analysis by Moreno-Drada and García-Perdomo (2016), by up to
80% in one trial (Vergis et al. 2001). A reasonable strategy, therefore, would be to use
antibiotics to prevent bacteremia and its resultant endocarditis or late prosthetic joint
infection. Since the 1950s, the antibiotic regimens for preventing endocarditis have
ranged from intramuscular penicillin administered for 5 days, including 2 days before
and after the procedure, to a large dose of amoxicillin given shortly before surgery, with
no follow-up dose (Wilson et al. 2008). The regimens have evolved as our understanding
of the oral flora, the timing of bacteremias, the effectiveness of antibiotics in preventing
bacteremias, the antibiotic sensitivities of the oral flora, and the actual risk posed by the
predisposing conditions has evolved. We can expect continued evolution of our under-
standing of these factors and accordingly updated antibiotic regimens.
The most recent revision of the endocarditis guidelines was published in 2008
(Wilson et al. 2008). The committee took into account recent information that only a
very small proportion of cases of endocarditis might be prevented by the use of antibi-
otic prophylaxis before dental procedures, even if the antibiotic were 100% effective.
The committee recommended prophylaxis only for those patients with cardiac condi-
tions with the highest risk of adverse outcomes, and not for all patients having an
increased lifetime risk of endocarditis. The dental procedures for which antibiotic pro-
phylaxis is recommended are “All dental procedures that involve manipulation of gingi-
val tissue or the periapical region of teeth or perforation of the oral mucosa.” Specifically
excluded procedures, however, include local anesthetic injections through uninfected
tissue, taking dental radiographs, placement of removable orthodontic or prosthodontic
appliances, adjustment of orthodontic appliances, and bleeding from trauma to the lips
or oral mucosa. The 2008 recommended antibiotic regimens are shown in Table 15.12.
Antibiotic prophylaxis for the prevention of late prosthetic joint infection has
been much more controversial than for endocarditis. In 1994, a survey of orthopedic
310 T. R. Flynn

surgery and general dentistry program directors found that the majority of both
groups felt that dental diseases can affect joint prostheses and that antibiotic prophy-
laxis should be used in such patients before dental procedures (Shrout et al. 1994). In
2003, the American Dental Association and the American Academy of Orthopaedic
Surgeons published updated guidelines recommending cephalexin, cefazolin, amox-
icillin, or clindamycin for antibiotic prophylaxis before dental procedures in pros-
thetic joint patients with certain risk factors, such as recent placement of the prosthetic
joint, immunocompromised patients, or those with comorbidities, such as type 1
diabetes or a history of prosthetic joint infection (American Dental Association and
the American Academy of Orthopaedic Surgeons 2003).
However, in 2009, the American Academy of Orthopaedic Surgeons unilaterally
published online a guideline that recommended antibiotic prophylaxis for all
patients with prosthetic joint replacements before indicated dental procedures. After
considerable debate in the literature among orthopedic surgeons, dentists, infectious
disease specialists, and others, the American Dental Association and the American
Academy of Orthopaedic Surgeons published a joint clinical practice guideline

Table 15.12 Antibiotic prophylaxis regimens for prevention of endocarditis following dental
procedures
Single dose: 30–60 minutes
Situation Agent before procedure
Oral Amoxicillin Adults, 2 g; children, 50 mg/kg
Unable to take oral medications Ampicillin Adults, 2 g IM or IV; children,
50 mg/kg IM or IV
OR
Cefazolin Adults, 1 g IM or IV; children,
50 mg/kg IM or IV
OR
Ceftriaxone Adults, 1 g IM or IV; children,
50 mg/kg IM or IV
Allergic to penicillin Clindamycin Adults, 600 mg; children, 20 mg/
kg
OR
Cephalexina Adults, 2 g; children, 50 mg/kg
OR
Azithromycin or Adults, 500 mg; children, 15 mg/
clarithromycin kg
Allergic to penicillin and unable to Clindamycin Adults, 600 mg; children, 20 mg/
take oral medications kg IV
OR
Cefazolina or Adults, 1 g IM or IV; children,
ceftriaxonea 50 mg/kg IM or IV
Total children’s dose should not exceed adult dose
IM intramuscular, IV intravenous
From: Flynn TR (2008) Principles of management and prevention of odontogenic infections. In:
Ellis E, Hupp JR, Tucker MR (eds) Contemporary oral and maxillofacial surgery, fifth edition.
Mosby, St. Louis, MO. p. 315. Used with permission
a
Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or
urticaria with penicillins or ampicillin
15 Evidence-Based Principles of Antibiotic Therapy 311

acknowledging the lack of evidence to support the use of antibiotics to prevent late
prosthetic joint infection following dental procedures and recommended in general
against antibiotic prophylaxis for this purpose. However, the guideline also
recommended that practitioners consult their best judgment and give the patient a
say in whether antibiotic prophylaxis is used (American Academy of Orthopaedic
Surgeons and American Dental Association 2012).
Most recently, in 2015, the American Dental Association’s Council on Scientific
Affairs published an evidence-based guideline for dentists on the use of prophylactic
antibiotics. The expert panel convened by the Council on Scientific Affairs judged
that the current best evidence failed to demonstrate an association between dental
procedures and late prosthetic joint infection. The panel cited evidence that antibiotic
prophylaxis is not effective in preventing prosthetic joint infections. Because of
mounting concerns about antibiotic resistance, adverse drug reactions, opportunistic
infections, and costs associated with prophylaxis, the panel did not recommend
antibiotic prophylaxis prior to dental procedures for this purpose. In fact, the panel
judged that the benefits of antibiotic prophylaxis may not exceed the harms for most
patients. The panel did allow that special clinical circumstances may present
significant risk in providing care without antibiotic prophylaxis, which may require
the dentist to use his or her professional judgment, in consultation with the patient
and the orthopedic surgeon. If antibiotics are deemed necessary, the panel stated
that it is most appropriate for the orthopedic surgeon to choose the regimen and
write the prescription (Sollecito et al. 2015).

15.2  mpiric Antibiotics of Choice for Odontogenic

E
Infections

The evidence presented thus far in this chapter can be integrated to allow evidence-
based selection of the empiric antibiotics for odontogenic infections that require
antibiotic therapy, in addition to appropriate dental treatment.
Table 15.13 lists the empiric antibiotics of choice for outpatient odontogenic
infections.
The antibiotics usually chosen for odontogenic infections are not significantly
different in their clinical effectiveness when appropriate dental treatment is given
(see Table 15.3). Therefore, empiric antibiotics can be chosen based on their

Table 15.13 Empiric Antibiotic of choice

antibiotics of choice for Amoxicillin
outpatient orofacial infections Clindamycin
Azithromycin
Penicillin allergy Clindamycin
Azithromycin
Moxifloxacin
312 T. R. Flynn

pharmacologic safety, the patient’s medical history (such as allergy or interaction

with concurrent medications), and cost.
In the absence of penicillin allergy, amoxicillin is the antibiotic of first choice for
odontogenic infections. The penicillins are among the least toxic of antibiotics and
have few drug interactions. Besides hypersensitivity reactions, antibiotic-associated
colitis, suppression of hematopoietic tissues, hepatitis, cholestatic jaundice, and sei-
zures are rare adverse reactions to amoxicillin. As shown in Table 15.11, amoxicil-
lin is the least expensive among the antibiotics dentists may have occasion to use,
nowadays even cheaper than penicillin V.
Clindamycin has been used effectively by dentists for decades. However, recent
overuse may be the cause of an alarming rise in the carriage of clindamycin-resistant
pathogens among patients with odontogenic infections. A recent study found that 32%
of strains isolated from severe odontogenic infections were clindamycin resistant
(Kim et al. 2017). Further, clindamycin’s major adverse reaction is antibiotic-associ-
ated colitis caused by Clostridium difficile. The treatment of C. difficile colitis has
become more challenging in recent years due to increasing resistance to the usual
antibiotic management, resulting in common recurrence of the condition. Fidaxomicin
is a new member of the macrolide family that is effective against C. difficile, but it is
extremely expensive. Other adverse reactions of clindamycin include gastrointestinal
intolerance, metallic taste, hypersensitivity reactions including Stevens-Johnson syn-
drome, erythema multiforme, and toxic epidermal necrolysis, as well as suppression
of the blood-forming tissues. Clindamycin can interfere with the effectiveness of con-
traceptive pills and may prolong the effect of non-depolarizing muscle relaxants used
during general anesthesia. Its cost is 4.39 times that of amoxicillin.
Among the macrolide family of antibiotics, azithromycin has the best safety pro-
file because, unlike the other macrolides, it is not metabolized by CYP3A4, the liver
microsomal enzyme responsible for a large proportion of known drug interactions.
This avoids the interaction between clarithromycin, for example, and the statin drugs
commonly used to treat hyperlipidemia, resulting in increased breakdown of skeletal
muscle due to elevated statin levels. A similar reaction between most macrolides and
the warfarin anticoagulants, which results in unwanted bleeding, is avoided with
azithromycin. Azithromycin does have a life-threatening interaction with the psychi-
atric drug, Orap® (pimozide), which can result in a form of ventricular fibrillation
called torsades de pointes. Adverse reactions include hypersensitivity reactions, hep-
atotoxicity, pancreatitis, prolongation of the QT electrocardiographic interval, and
exacerbation of myasthenia gravis. While the other macrolides carry pregnancy risk
category C (toxicity in animals; human studies insufficient data), azithromycin has
been assigned pregnancy risk category B (no toxicity in animals; human studies
insufficient data). The cost of azithromycin is 6.25 times that of amoxicillin.
Moxifloxacin is a fourth-generation fluoroquinolone with increased effective-
ness against oral streptococci and anaerobes, as compared to ciprofloxacin. The
toxicities of moxifloxacin are considerable, however. Like other fluoroquinolones,
it is toxic to growing cartilage and is therefore contraindicated in pregnancy and in
children younger than 18 years. Its adverse reactions include hypersensitivity reac-
tions, phototoxicity, seizures, mental clouding and fatigue, nephrotoxicity,
15 Evidence-Based Principles of Antibiotic Therapy 313

hepatotoxicity, suppression of hematopoietic tissue, exacerbation of myasthenia

gravis, and tendon rupture. Achilles tendon rupture, especially in individuals older
than 60 years, has occurred. C. difficile-associated colitis can also occur. Further,
moxifloxacin prolongs the QT interval, and when combined with other drugs that
prolong the QT interval, it can result in torsades de pointes and death. Some of those
drugs are methadone, tramadol, amitriptyline, trazodone, macrolide antibiotics,
antiretroviral drugs, and halogenated inhalation anesthetics (Box 15.4). Moxifloxacin
is 8.59 times the cost of amoxicillin.

15.3 Conclusion

The available evidence strongly supports the primacy of appropriate dental treat-
ment interventions, such as tooth extraction, gingival curettage and scaling, root
canal therapy, and incision and drainage in the management of odontogenic infec-
tions. The modern era of antibiotic therapy is characterized by increasing antibiotic
resistance, drug interactions, toxicities, and cost. Well-performed studies, however,
indicate that older antibiotics, when combined with appropriate dental treatment,
are equally as effective as the newer ones, with increased safety and lower cost.
Figure 15.3 is an algorithm for the use of antibiotics in dentistry.

Ampicillin/Sulbactam*
Culture and
Clindamycin
Inpatient sensitivity
Indications for Ceftiaxone**
therapeutic antibiotics Specific antibiotic
Moxifloxacin
Swelling therapy based on:
Fever
Penicillin* Culture and
Osteomyelitis Failure of Culture
sensitivity
Outpatient Clindamycin empiric and
results
antibiotic sensitivity
Azithromycin
Response to
Orofacial empiric
infection Clindamycin antibiotic
present Culture and
Ampicillin/Sulbactam*
Osteomyelitis sensitivity at
Moxifloxacin debridement

Penicillin*
USE OF ANTIBIOTICS Transoral Clindamycin

Infection-
Transcutaneous Cefazolin**
prone
Clindamycin
surgery
Risk of
infection

Endocarditis
Indications for prophylactic Follow AHA/ADA guidelines
Risk
antibiotics
Endocarditis risk
Prosthetic joint *Avoid in Penicillin Allergy
infection risk
Infection-prone Prosthetic ** Caution in PCN Allergy
surgery Joint Infection Follow AAOS/ADA guidelines*** ***No prophylaxis currently
Risk
recommended

Fig. 15.3 Algorithm for the use of antibiotics in dentistry. PCN penicillin, AAOS American
Academy of Orthopaedic Surgeons, ADA American Dental Association, AHA American Heart
Association. Adapted from: Flynn TR (2007) Use of antibiotics. In: Laskin DM, Abubaker AO,
eds. Decision making in oral and maxillofacial surgery. Chicago, Quintessence
314 T. R. Flynn

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Preprosthetic Surgery
16
Riccardo I. Ambrogio and Daniel Beauvais

“I will compress the story as far as may be done without

omitting anything vital to the case.”
Sherlock Holmes in—The Crooked Man

Abstract
Proper performance of preprosthetic surgery entails a systematic and detailed
review of the patient’s medical and dental history, appropriate imaging, preop-
erative models, and a thorough understanding of the patient’s goals for prosthetic
treatment. This chapter will provide an overview of preprosthetic surgery.
Surgical techniques will be reviewed and complications will be discussed.

16.1 Introduction

The primary goal of preprosthetic surgery is to establish a functional and healthy

platform for support and retention of prosthetic devices. Preprosthetic surgery per-
formed by the general dentist is a service that can be comfortably and efficiently
provided to the dental patient. It alleviates patient scheduling and traveling to
another practitioner’s office and allows continuity of care with the primary dental
provider. When prostheses are to be delivered at time of surgery, this allows for
immediate adjustments of the removable or fixed prosthetics at time of delivery. As
the prevalence of edentulism among American adults is noted to be as high as 16.3%
(rural settings), with predictions that 8.6 million Americans will be edentulous in

R. I. Ambrogio (*)
Department of Oral and Maxillofacial Surgery, The University of Connecticut School
of Dental Medicine, Farmington, CT, USA
New York University College of Dentistry, New York, NY, USA
OMFS, Private Practice, Wethersfield, CT, USA
D. Beauvais
Department of Oral and Maxillofacial Surgery, The University of Connecticut School of
Dental Medicine, Farmington, CT, USA

© Springer International Publishing AG, part of Springer Nature 2019 317

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_16
318 R. I. Ambrogio and D. Beauvais

2050, the current and future needs for preprosthetic surgery continue to exist (Miloro
et al. 2011; Vargas et al. 2002; Slade et al. 2014).
Radiographic imaging may guide the practitioner with treatment planning and
surgical options. The panoramic radiograph serves as the best initial image for
evaluation of hard tissue and any existing pathology. This initial radiograph can
serve as a tool for making measurements for potential bony reduction, identifying
anatomic variants, evaluating of the maxillary sinuses, locating root tips or impacted
teeth, and identifying the location of the inferior alveolar canal and mental foramina.
The use of cephalometric analysis used in conjunction with mounted models serves
as a tool for aiding the practitioner in establishing an appropriate path of insertion
for prostheses and identifying interarch relationships that may complicate the
prosthetic treatment plan. Additionally, computed tomography (CT) radiographs
may be used for some cases where detailed evaluation of bone quality and contour,
precise neurovascular location, and sinus anatomy are of interest.
Preoperative models not only assist in treatment planning, e.g., for the reduction
of a soft tissue tuberosity, but can also be used for model surgery, e.g., for the
fabrication of clear stents to be used either postoperatively or to judge appropriate
reduction of the surgical site.
Paramount to preprosthetic surgery is a thorough evaluation of the hard and soft
tissue form in the maxilla and mandible. The practitioner should carefully visualize,
palpate, and examine the soft tissue overlying the alveolar ridges and the associated
muscle attachments. Ideally, the maxilla and mandible should be in a normal rela-
tionship. The alveolar processes should be as large as possible without the presence
of protuberances or undercuts. The arches should be broad and U-shaped, the width
of the maxilla should be as similar to that of the mandible as possible to provide good
stability, and the jaws should be oriented in a dental Class I position Starshak and
Sanders (1980). Bone and soft tissue should be free of disease, with uniform gingival
thickness and consistency. The vestibules should be free from scar tissue or pathol-
ogy. The tongue should be freely moveable without disease or a restricting frenum.
Adequate salivary gland function must be intact so as to keep the mouth, and subse-
quent prostheses, moist and lubricated. All of these characteristics must be noted
prior to the initiation of preprosthetic surgery. A thorough initial examination will
help the practitioner create a clear and concise plan for subsequent surgery.
It also must be stressed that successful surgery involves appropriate expectations
from the patient. Proper preoperative discussion of goals, including risks and benefits
of the preprosthetic procedure, will ultimately assist with patient understanding of
successful surgery.

16.2  actors to Consider When Performing Preprosthetic

F
Surgery

16.2.1 Local Anesthesia

The practitioner should be thoroughly knowledgeable in the administration of local

anesthesia, as discussed in Chap. 7. The principles of administering local anesthesia
for preprosthetic procedures are the same as for other routine dental procedures;
16 Preprosthetic Surgery 319

profound analgesia is best obtained by nerve block technique, and soft tissue
hemostasis is best achieved by using the local anesthetic with a vasoconstrictor
applied locally to the surgical site El-Kholey (2013). It is important to take into
account the distorting effect of local anesthesia on soft tissues when performing
preprosthetic surgery. Applying direct pressure to the site and waiting for several
minutes after administration will help minimize this tissue distortion while maxi-
mizing the effect of the vasoconstrictor. As a simple technique, soft tissue prepro-
sthetic surgery tends to be performed with administration of local anesthesia directly
in the surgical field, whereas bony surgery frequently relies on nerve block anesthe-
sia with some local infiltration to assist in dissection and/or hemostasis.

16.2.2 Surgical Technique

When creating access for hard or soft tissue surgery, full-thickness flaps are the
preferred method of access in most bony surgery, especially in simple preprosthetic
surgery. Partial thickness flaps are used in more advanced and specific surgical
techniques, which are not covered in this chapter.
Proper flap technique allows for adequate blood flow to the entirety of the flap,
thereby decreasing the incidence of flap necrosis. Flap access to the surgical site
should offer adequate exposure, whether with a direct flap or with the addition of
releasing incisions. Flaps should be kept moist, noting the longer the flap is open,
the more likely the chance of injury to the flap, suboptimal healing, or infection.
When performing bony preprosthetic surgery, consider trimming any redundant
mucosal tissue and/or using a surgical splint to reinforce any areas of potential dead
space. If a properly relieved postoperative stent is available, this will help protect
the wound from direct trauma and decrease the chance of hematoma formation.
Clear (transparent) stents are recommended so that the wound site is visible in the
postoperative period.

16.3 Hard Tissue Removal

16.3.1 Alveoloplasty

Alveoloplasty is the recontouring of the bone in an area that previously was dentate,
specifically involving the alveolar bone. The immediate goal in performing an
alveoloplasty is to provide adequate ridge contour in order to facilitate fabrication
of a well-fitting and esthetic prosthetic device. In evaluating alveolar ridges for
alveoloplasty, the practitioner should aim to leave the ridges as broad as possible to
distribute masticatory load. Undercuts should be identified and removed if their
presence would hinder in denture retention. Sharp edges should be rounded, and the
mucosa overlying the alveolus should be uniform in thickness and compressibility
for even transmission of masticatory forces. Care must be taken not to over-reduce
the alveolus, as resorption occurs over time. Furthermore, if implants are being
considered for restoring the alveolar ridge, alveoloplasty should be performed judi-
ciously to allow for a broad site with adequate bone height for implant placement.
320 R. I. Ambrogio and D. Beauvais

Alveoloplasty may be performed at the time of dental extractions or anytime fol-

lowing exodontia. For efficiency and patient comfort, alveoloplasty should be ideally
performed immediately following exodontia in most cases. There are scenarios,
however, in which delayed alveoloplasty is indicated. If the immediate removal of
the bone will result in a narrow, V-shaped ridge, it is advisable to wait for the bone to
fill the extraction sockets prior to performing alveoloplasty (4–6 weeks). Additionally,
in cases of advanced periodontitis with severe resorption of the alveolar and interra-
dicular bone, allowing for bony healing prior to performing alveoloplasty will pre-
vent over-reduction of the alveolus.

16.3.2 Technique

During exodontia, the full-thickness mucoperiosteal flap must be maintained, and

consideration should then be given to extending the flap or performing releasing
incisions to fully expose the surgical site. The practitioner must be cognizant of
areas of anatomy to avoid when creating the flap, e.g., mental foramina. Releasing
incisions should avoid neurovascular structures, and in the edentulous, possibly
atrophic mandible, the mental foramina may be on or close to the alveolar ridge,
and the incisive papilla may also be positioned in a similar fashion. Preoperative
radiographs can aid in locating the mental foramina. A bone file, irrigated rotary
bur, or rongeur forceps are then used to reduce the areas of the irregular bone. The
surgical site is then inspected with the gingiva reflected back into place and pal-
pated with a gloved finger to evaluate any irregularities or sharp edges. When sat-
isfactory reduction is complete, the wound is closed primarily with silk or
resorbable sutures.
For alveoloplasty performed at a later date than the exodontia, a full-thickness
flap is initiated at the occlusal aspect of the alveolar ridge. Proper exposure may
involve elongating the incision and/or adding releasing incisions. Once the bone is
properly exposed, a bone file, irrigated rotary bur, and/or rongeur forceps are used
to shape the areas of the irregular bone. The surgical site should then be inspected,
palpated, and closed primarily as described above.

16.3.3 Palatal Torus

A palatal torus is a benign, slowly growing bony projection on the maxilla that is
prevalent in the adult population. Palatal tori have a dense cortical surface with a
cancellous core, and they vary in shape and size. A palatal torus can be comfortably
removed in the office with local anesthesia. The anxious patient may require some
anxiolytic intervention, and the patient with a strong gag reflex might require nitrous
oxide supplementation or sedation.
Palatal tori serve no useful purpose, yet they do not need to be routinely removed.
Indications for removal of a palatal torus include interference with the tongue,
speech and/or mastication, chronic trauma, biopsy or evaluation for pathology, a
source of autogenous bone for grafts, or preparation for delivery of dental prosthesis.
16 Preprosthetic Surgery 321

Preparation for any preprosthetic surgery entails appropriate review of medical

and dental history and evaluation of radiographs for bone-related surgery. Radiographs
for soft tissue surgery are not always necessary but are recommended for bone-
related surgery. Preoperative models of the maxilla are very helpful in planning torus
surgery. The torus can be conservatively reduced on the models, and an interim ther-
moplastic splint can be fabricated from the model surgery. This splint will act as a
guide, assisting in evaluating the amount of bony reduction sought surgically.

16.3.4 Technique

Local anesthesia is recommended via bilateral greater palatine block, nasopalatine

block, and infiltration. The infiltration should be attempted in a subperiosteal fashion
in an attempt to freely elevate the soft tissue off of the torus. This aids the dentist in
flap dissection and decreases the chance of flap perforation. A “Y” or “double Y”
(−< or >−<) incision is made over the torus. Careful incisions are made in an
attempt to avoid the palatine vasculature. Once the flap is reflected and the torus is
exposed in its entirety, surgical removal can commence (Fig. 16.1).
A fissure bur with saline irrigation can be used to score the torus. Once scored, a
chisel or elevator can be used to remove the bony fragments. A round bur and bone
file are then used to smooth the surface of the palate. If the palatal torus is small, it
can be removed via chisel, reduced with round bur, and filed with a bone file or any
combination thereof. Copious irrigation is recommended throughout the procedure.
Once the torus is completely removed, the soft tissue flap edges should be
approximated, and the surgical site should be evaluated for bony irregularities or
redundant soft tissue.
If a bony irregularity can be felt, a bone file can be used to file the rough edges.
Failure to do this may contribute to wound dehiscence. It is also important to ensure
not to over-reduce the bony torus. A good strategy for proper reduction without
over-reduction is to intentionally leave a miniscule amount, e.g., less than half a
millimeter, of bony torus during reduction, and then complete the remainder of the
reduction with a bone file.

Fig. 16.1 Double “Y” flap design for removal of a palatal torus
322 R. I. Ambrogio and D. Beauvais

If the torus is large, there may be a significant amount of redundant soft tissue
remaining following bony reduction. This tissue has a large area of potential dead
space, which can lead to hematoma formation under the flap. It is recommended to
conservatively trim excessive mucosa, while still maintaining a primary, linear clo-
sure. Once the wound is closed, the dentist may consider placing a clear denture
type stent for wound protection. The stent should be relieved so as not to place pres-
sure on the wound. If not properly relieved, this can lead to pressure necrosis.
The patient should begin a soft diet postoperatively and advance the diet slowly
as tolerated.

16.3.5 Complications

Despite appropriate patient selection, the practitioner may experience the occa-
sional patient that cannot commence with surgery once they have a completely
anesthetized palate. Anxiety, gagging, and or nausea may be so profound that the
surgery may require rescheduling and/or pharmacologic assistance.
Infection is relatively rare, but clean incisions and dissection assist in wound
healing. Inadequate cooling/irrigation while using rotary instruments can cause
bone necrosis, thus increasing possibility of wound dehiscence or infection.
Perforation into the nasal or maxillary sinus, or fracture of bone in these regions,
is a potential unexpected outcome. A small perforation can be managed by applying
firm pressure with gauze in order to achieve hemostasis. In rare cases, it may be
necessary to pack the nasal cavity with gauze strips to achieve hemostasis.
Hemorrhage is a potential complication that can be avoided by clean incisions
that avoid the greater palatine and nasopalatine vasculature. In the event of persistent
bleeding, injecting a small amount of local anesthetic with vasoconstrictor and
application of firm pressure usually resolve the bleeding. In instances of persistent
bleeding, electrocautery may be required to achieve hemostasis.
Wound dehiscence can occur from many ways, including flap dissection with
tears, a palatal splint with excessive pressure on the mucosa, or attempted removal
of a torus with improper access. If dehiscence does occur, the wound should be
covered with a temporary stent to facilitate application of tissue conditioner until
wound healing has occurred.

16.3.6 Mandibular Tori and Maxillary/Mandibular Exostoses

A mandibular torus is a benign bony growth of the mandible that usually occurs
bilaterally on the medial (lingual) surface of the body and alveolar process of the
mandible. Like palatal tori, the overlying mucosa is typically very thin. Indications
for mandibular tori removal include interference with speech, interference with
comfortable chewing, ulceration and poor healing of the overlying mucosa, and
facilitation of removable denture construction.
16 Preprosthetic Surgery 323

Buccal exostoses occur on the buccal aspect of the either the maxilla or mandi-
ble. They occur near the crest of the alveolar process, most commonly in posterior
areas. Exostoses typically present problems for the prosthetic patient, as they can
interfere with retention and stability, and they may pose difficulty in obtaining accu-
rate impressions.

16.3.7 Principles of Torus and Exostosis Removal

A full-thickness mucoperiosteal flap offers proper wound protection at closure and

is the recommended approach to removing bony growths of the jaws. Consider
releasing incisions if appropriate for exposure and to avoid encroaching on
neurovascular structures.
Lingual mandibular flaps or releasing incisions can create additional morbidity
to the patient, and caution should be used in deciding to attempt surgery on the
lingual aspect of the mandible for multiple reasons. The abundance of salivary
glands and ductal structures are at risk for direct and indirect damage. The lingual
nerve and artery vary in anatomic location in all patients, and in part this is related
to changes in alveolar architecture in the edentulous alveolar segment as well as
muscle pull caused by tongue movement. Lingual flaps have greater potential for
injury to the mylohyoid muscle and lingual nerve and artery. In the third molar
region, variants in the course of the lingual nerve are not uncommon, and studies
have noted the presence of the lingual nerve at the height of the mandibular third
molar in a significant percentage of patients. Therefore, surgical access in this
location, including lingual releasing incisions, is not advised (Pogrel et al. 1995).
In the edentulous mandible, the location of the mental foramina migrates superi-
orly, and exiting mental nerve branches may limit the extent of soft tissue surgery.
In the edentulous patient, the mylohyoid muscle and lingual nerve also move supe-
riorly. Careful clinical and radiographic examination can assist the dentist in evalu-
ating these parameters.

16.3.8 Technique

A full-thickness mucoperiosteal flap is the access of choice for bony growths of the
mandible and maxilla. Keeping in mind key anatomic areas to avoid, the bony
growth is fully exposed, by linear ridge incision in the edentulous patient or an
intrasulcular flap in the dentate patient (Fig. 16.2). Releasing incisions are
recommended if the linear/intrasulcular incision is of adequate length, but exposure
is still inadequate (Fig. 16.3).
Lingual releasing incisions of the mandible are not advocated for reasons previ-
ously discussed. The flap is reflected and protected with a retractor of the practitio-
ner’s preference (Fig. 16.4).
The retractor will keep the surgical field exposed and also act as a protective barrier
to the surrounding anatomical structures. A combination of one or many devices can
324 R. I. Ambrogio and D. Beauvais

Fig. 16.2 Sulcular

incision with small anterior
releasing incision (Avoid
splitting the papilla at the
junction of the release.
This diagram has the
release too close to the
papilla)

Fig. 16.3 Large posterior

relaxing incision in an
edentulous area

be used to remove the exostosis/torus. A fissure bur can be used to score the growth,
followed by removal by chisel or elevator. With the lingual torus, the fissure bur can
be used to create a linear channel into the cancellous region of the bony growth, at the
interface of the alveolus and the torus. This linear channel, placed mesial to distal, will
allow the placement of a chisel or elevator to chip off/elevate the exostosis. If the
exostosis is small, a round bur or bone file can be used to physically reduce and
remove the growth, rather than creating the channel. It is important to note that copi-
ous sterile saline irrigation is recommended when using rotary instruments to alter
bony structures. Excessive heat will create postoperative bone necrosis, increase the
risk of infection, and contribute to increased postoperative discomfort for the patient.
Once the bony growth is removed, the surgical site should be inspected and palpated
to feel for any sharp edges or bony excess. With mandibular tori, the practitioner will
frequently need to file a small step at the inferior-most aspect of the wound. One must
be very careful to protect adjacent soft tissues when working in this anatomic area, as
soft tissue injury here may be very dangerous. Hemorrhage, glandular obstruction,
nerve injury, and airway embarrassment are some of the potential complications that
could occur with soft tissue injury at the floor of the mouth.
16 Preprosthetic Surgery 325

Fig. 16.4 Lingual flap for

removal of torus using a
crestal incision and no
relaxing incisions

As with most bone-related preprosthetic surgery, care should be taken to not

over-reduce the bony protuberance. Once the surgery is completed, the underly-
ing bone will continue to undergo some degree of bone resorption and remodel-
ing. One technique for completing bony reduction involves using a bone file:
this allows for tactile sensation while smoothing off rough edges and clinically
visualizing proper bone reduction. If the majority of a bony prominence is
removed via handpiece, the remaining finishing touches can be performed with
the bone file.
Primary closure with either silk or resorbable sutures is recommended. Postoperative
thermoplastic splint protection is not necessary for these procedures, but fabricating a
clear surgical stent as a surgical guide may be helpful.
Removal of exostoses of the maxilla and mandible will create some postopera-
tive discomfort for the patient. This tends to be localized and well-tolerated.
Removal of lingual tori tends to be locally painful in the postoperative period and
may also cause some discomfort with swallowing. Diet may be more affected with
the lingual tori patient, and bruising of the neck, and later dependent bruising dis-
coloration to the chest, will usually be more evident. In light of these postoperative
findings, proper preoperative patient teaching will better prepare the patient for a
better postoperative recuperation.
326 R. I. Ambrogio and D. Beauvais

16.4 Soft Tissue Removal

Following tooth loss, muscle and frenum attachments may interfere with prosthetic
fit, esthetics, and function. It is therefore necessary to carefully evaluate soft tissue
interferences prior to fabricating prostheses. It is important to remember, however,
that hard tissue remodeling must be performed prior to removal of soft tissue. Soft
tissue is often used to aid in grafting and augmentation procedures, so preservation
of soft tissue should be attempted when possible.

16.4.1 Frenectomy

Frenum attachments consist of thin mucosa overlying fibrous tissue bands, which
extend from the buccal, labial, or lingual mucosa to the alveolar periosteum.
Following tooth removal, frenum attachments commonly become more prominent
and may interfere with the fit of removable prostheses.
There are multiple techniques available for performing frenotomy, including
simple excision and Z-plasty for narrow frenum attachments, and vestibuloplasty
for wider frenum attachments.
The following technique describes the surgical removal of the maxillary midline
frenum (Fig. 16.5). Other modalities include laser and electrosurgery, which are not
discussed in this chapter.

16.4.2 Technique

One must consider the tissue distorting effects of local anesthetics prior to injecting
the soft tissue. Regional anesthesia has the benefit of avoiding tissue distortion at
the site of excision. However, local infiltration affords the benefit of hemostasis.
When administering local anesthesia via infiltration, gentle direct pressure with
gauze should be placed on the frenum and lip for several minutes so as to help
dissipate the soft tissue distortion. The upper lip is then everted to allow for

Fig. 16.5 Maxillary

midline frenum
16 Preprosthetic Surgery 327

Fig. 16.6 Remove triangular wedge from the maxillary frenum

Fig. 16.7 After removal of tissue from the maxillary frenum, with underlying periosteum. Closure
with simple interrupted sutures. With permission: Hupp JR, et al. “Preprosthetic Surgery.”
Contemporary Oral and Maxillofacial Surgery, 5th ed., Mosby Elsevier, 2008

adequate visualization. A hemostat can be used to hold tension on the frenum, while
an elliptical incision is made around the frenum in a supraperiosteal fashion. Sharp
dissection is then performed, ensuring that the underlying mucosa and connective
are removed, while preserving the periosteum (Fig. 16.6). Upon removing the
hemostat with the excised frenum still engaged, one will notice a triangular- or
diamond-shaped wound, as the elastic fibers will pull the mucosal edges apart. At
this time, the wound edges should be inspected to determine if adequate soft tissue
has been removed. If there is a superior edge of puckered frenum mucosa, this tri-
angular tissue can be excised with a scissor. Occasionally, dense, fibrous, mucosal
tissue will be remaining at the alveolar ridge. This soft tissue will also require exci-
sion, noting that it is removed while leaving the underlying periosteum intact on the
alveolar ridge. The incisive papilla should not be involved in the palatal-most extent
of the dissection.
Following complete dissection of the frenum and underlying connective tissue,
there are two methods of achieving primary closure. If wound edges are approxi-
mated and vestibular depth is adequate, simple closure can be performed with
resorbable sutures in an interrupted fashion (Fig. 16.7). It is important to note that
the sutures should encounter the periosteum in order to preserve alveolar ridge
height and anatomy Hupp et al. (2008).
If there is concern for shallow vestibular depth, Z-plasty can be performed. Two
releasing incisions are made: one from the superior-most point of the wound, angled
328 R. I. Ambrogio and D. Beauvais

Fig. 16.8 Horizontal

releasing incisions for
Z-plasty in labial frenum
repair

Fig. 16.9 The mucosa

underlying the flap margins
is freed to relieve tension

laterally and inferiorly, and the other from the inferior-most point of the wound, angled
in the opposite lateral direction and superiorly (Fig. 16.8). The mucosa under each side
of the flap should be freed with either sharp scissors or a periosteal elevator to relieve
tension on the flaps (Fig. 16.9). The resulting two flaps are then rotated, creating a
Z-shape, which allows for horizontal closure of the vertical wound (Fig. 16.10).
Localized vestibuloplasty can be performed for broad-based frenum attach-
ments. An incision is made along the superior aspect of the frenum attachment, and
dissection is made to expose the underlying periosteum. The mucosa is then reposi-
tioned more apically and sutured to the underlying periosteum. Healing occurs via
secondary intention.
Lingual frenum attachments are unique in that they may interfere with speech or
tongue range of motion. Like labial frenum attachments, they often interfere with
denture stability. Local anesthesia for a lingual frenectomy can be achieved through
bilateral lingual nerve blocks and local infiltration. The tongue can be retracted
16 Preprosthetic Surgery 329

Fig. 16.10 Incision following a labial frenectomy with horizontal releasing incisions, prior to
closure. The flap margins (marked A and B) are rotated inferiorly and superiorly, respectively,
closing the soft tissue. The resulting Z-shaped incision can then be closed primarily with sutures

Fig. 16.11 Incision of

lingual frenum attachment
with scalpel blade,
followed by closure with
simple interrupted sutures.
With permission: Hupp JR,
et al. “Preprosthetic
Surgery.” Contemporary
Oral and Maxillofacial
Surgery, fifth ed., Mosby
Elsevier, 2008

either via a suture through the tip of the tongue or by manual retraction with gauze.
A linear incision is then made transversely through the frenum at the base of the
tongue, releasing the connective tissue attachments. Closure is performed in a linear
direction, thereby releasing the ventral aspect of the tongue from the alveolar ridge
Hupp et al. (2008). Care must be taken to avoid Wharton’s ducts and superficial
vessels on the floor of the mouth (Fig. 16.11).
330 R. I. Ambrogio and D. Beauvais

The patient should be instructed to maintain a soft diet for several days to mini-
mize strain on the wound and also should be advised that some swelling will be
noticeable for a few days. Ice packs in the postoperative period will aid in patient
comfort and may decrease swelling.

16.4.3 Soft Tissue Tuberosity of the Maxilla

Tuberosity reduction tends to be more often a soft tissue procedure than a hard tis-
sue endeavor. Preoperative radiographic evaluation will assist in initial treatment
planning. A quality panoramic radiograph may be sufficient to evaluate the soft and
hard tissue in the area of surgery. Mounted models of the maxilla and mandible are
invaluable planning aids for tuberosity reduction, both for hard and soft tissue sur-
gery. The goal is to achieve adequate interarch distance between the maxillary and
mandibular denture, while not reducing the entire tuberosity.
The mounted models can be manipulated so as to reduce the tuberosity on stone
via model surgery. The altered model of the maxilla can then be used to create a
clear thermoplastic surgical guide to assist the surgeon intraoperatively. This will
guide the surgeon with appropriate reduction of the tuberosity.
The objective of the soft tissue surgery is to decrease the occlusal height of the
tuberosity without disrupting the distal hamular notch region. It is important to pre-
serve landmarks that make up part of the denture borders. An elliptical incision is made
in the fibrous tuberosity, starting just anterior to the hamular notch (not involving the
notch). The incisions are extended anteriorly in an elliptical shape, meeting at a point
on the center of the alveolar ridge just anterior to the area of the intended reduction
(Fig. 16.12). It is important that the initial incision is full thickness. In order to achieve
optimal wound approximation and minimize soft tissue injury, it is prudent to aim the

Fig. 16.12 Elliptical

incision over the alveolar
ridge for soft tissue
tuberosity reduction
16 Preprosthetic Surgery 331

Fig. 16.13 Undermining of the soft tissue following tissue removal to facilitate wound edge
approximation. Closure with simple interrupted sutures

scalpel with a slight bevel toward the center of the alveolar ridge. Once the elliptical
incision is completed, a periosteal elevator or curette is used to free the underlying
periosteum of the elliptical wedge and remove the wedge. Once the wedge is removed,
the wound is inspected for any soft tissue tears or fragments. A periosteal elevator is
then used to undermine the periosteum bordering the wedge defect so as to mobilize
soft tissue. This will aid in bringing wound edges together. The wound edges are suture
closed, and the interocclusal clearance is then inspected (Fig. 16.13). A surgical stent/
guide would be used at this time to evaluate amount of reduction. In some instances,
the practitioner will find adequate reduction but will be unable to get complete primary
closure of the wound edges. The edges should be sutured as close as possible to each
other without tension on the edges. This will granulate and close with time.

16.4.4 Complications

Potential complications of soft tissue tuberosity reduction include perforation of pala-

tine vessels and oral-antral communication. Palatine vessels can be avoided by keep-
ing the incision within the tuberosity and beveling the scalpel toward the center of the
alveolar ridge. This will also help keep the shape of the tuberosity, a vital landmark in
denture fabrication. If excessive pressure or aggressive reduction takes place on the
underlying alveolar bone, it is possible to perforate the bone and expose the maxillary
sinus. This iatrogenic oral-antral communication may require further treatment.

16.5 Conclusion

Preprosthetic surgery is a service that the general dentist can provide to their patients
to facilitate the transition to removable and/or fixed prostheses. Reduction of both
hard and soft tissues can be performed in the office setting and, when appropriate,
can minimize trips to other providers for additional procedures. It is essential to
appreciate the patient’s medical and dental history, utilize appropriate imaging, and
consider the use of preoperative models for predictable surgical planning.
332 R. I. Ambrogio and D. Beauvais

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Miloro M, et al. Preprosthetic and reconstructive surgery. In: Peterson’s principles of oral and
maxillofacial surgery. 3rd ed. USA: People’s Medical Pub. House-USA; 2011.
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Res. 2014;93(10):959–65.
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2002;133(12):1672–81.
Soft Tissue Oral Pathology
17
Easwar Natarajan and Michael T. Goupil

“We balance probabilities and choose the most likely. It is the

scientific use of the imagination.”
Sherlock Holmes in—The Hound of the Baskervilles

Abstract
Once a complete oral exam has been completed, coupled with an appropriate
patient history, then a systematic approach should be utilized to develop a dif-
ferential diagnosis for any abnormalities noted during the exam. This chapter
provides a framework to obtain a focus patient history, accomplish an appropri-
ate oral examination, and develop a differential diagnosis and recommendations
for the management of specific entities using simple algorithms.

17.1 Introduction

Diagnostic science relies on the ability of the practitioner to obtain a detailed focus
history and to accurately describe the oral pathologic condition of concern. This
history and clinical examination must include both positive and negative findings.
Once the complete history and examination have been obtained, and then and only
then, a differential diagnosis is developed and a provisional diagnosis made.
This purpose of this chapter is to provide a systematic method to obtain a complete
focused history and a descriptive framework that will allow the clinician to develop
a system-based differential diagnosis. This systematic method will be demonstrated

E. Natarajan
Section of Oral and Maxillofacial Pathology, University of Connecticut School of Dental
Medicine, Farmington, CT, USA
e-mail: [email protected]
M. T. Goupil (*)
Section of Oral and Maxillofacial Pathology, University of Connecticut School of Dental
Medicine, Farmington, CT, USA
Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT, USA
e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2019 333

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_17
334 E. Natarajan and M. T. Goupil

in the oral pathologic conditions most likely to be encountered by the general dental
practitioner. Once a provisional diagnosis is made, further laboratory tests, including
some form of biopsy, may be required to confirm the diagnosis. Appropriate directed
care can only be provided when a definitive diagnosis is obtained.

17.2 Focused History

Time Line—A focused history should be obtained in the form of chronological events
related to the present pathological condition of concern. When was the condition first
noted? Was there an obvious cause at the time? What is the growth rate? Unfortunately,
the patient is frequently unaware of the condition until it has been identified by the
dental provider and thus may only be able to provide limited historical data.
Medical History—Both current and past medical histories including medications
that may be relative. Certain medications may produce allergic-type reactions and
mucosal alteration. A variety of chronic diseases, especially dermatologic conditions
such as lichen planus, have oral manifestations. A review of systems is an excellent
way to ensure that all pertinent medical information has been collected (see Chap. 3).
Habits—The use of alcohol and tobacco products is an obvious question as part
of the focused history, and this information can be easily obtained through a ques-
tionnaire. But questions concerning hobbies, holding objects in the mouth, chewing
on pencils, etc. can be equally as important.
Related Information—If the patient has been aware of the condition, then more
specific information can be obtained. What makes it better? Worse? Has it changed
over time? What treatments have been attempted including complementary and
alternative medicine? Have any dental procedures been performed prior to the onset
of the current problem?

17.3 Focused Examination

General—When conducting an examination, keep in mind that the findings will

need to be recorded in the patient record, and these findings will need to be com-
municated as part of a consultation referral. The description should convey a
description so complete that the reader should be able to mentally visualize the
pathologic condition. Taking photographs is another excellent way of accurately
documenting an area of concern. Most mobile phones can be used for this
purpose.
Location—It is very important to be very specific as to the location of the condi-
tion of interest. White lesions on the floor of the mouth may be of greater signifi-
cance than those along the occlusal line. Multifocal bilateral mucosal alterations
may be suggestive of an autoimmune process or merely a patient-specific normal
variation. The location of the lesion is an important consideration for performing a
biopsy. If the lesion is close to vital structures, i.e., salivary gland duct orifices, it
may be prudent to refer the patient to a specialist.
Size—The size of the lesion should be measured. There may be a tendency to over-
or underestimate the size of the lesion depending on other characteristics. A periodontal
probe is a very convenient way to accomplish this and is usually very readily available.
17 Soft Tissue Oral Pathology 335

Texture—Is the lesion flat or raised? Is it rough or smooth? Is the mucosal intact?
Ulcerated? Is there a lack of adherence of the mucosa? In the case of a nodule is it
firm? Soft? Dough-like? Feel like a water balloon?
Color—Does the lesion have a distinct color change from the surrounding or
“normal” mucosa? Red, velvety lesions may carry a higher index of suspicion. Are
there color changes noted throughout the oral cavity, and might they represent nor-
mal, ethnic variation?
Borders—Are the edges of the lesion very distinct and demarcated from the sur-
rounding normal tissue? Or do the edges merely blend in to more appearing tissue
making an accurate measure difficult?
Surrounding Effect—Is the lesion having an effect of surrounding tissue? In the
case of bony lesions, are teeth being moved or eroded? Is the body attempting to
wall off the pathologic condition? This, walling off, may be represented by a scle-
rotic border in bony conditions or a firm nodule in the case of soft tissue lesion. Has
salivary flow, amount or consistency changed?
Related Information—In the case of white lesions, it is important to note whether
the lesion is wipeable or not. Are there radiographs already available that may pro-
vide information? In the case of bony lesions, this may have been the first presenting
sign. Old radiographs should be obtained and compared to help determine length of
duration. Rapidly growing lesions causing tooth destruction are usually of greater
concern than slow-growing lesions that move teeth.

17.4 Differential Diagnosis

The development of a differential diagnosis should be done in a systematic and

orderly fashion and not merely a list of best guesses. One way to approach this task
is to consider potential diagnoses within specific diagnostic groups.

1. Congenital/developmental
2. Reactive/inflammatory
3. Infection
(a) Bacterial
(b) Viral
(c) Fungal
4. Immune mediated
(a) Localized
(b) Systemic
5. Neoplastic
6. Oral manifestations of systemic disease

The use of these diagnostic groups should result in a list of the more probable
diagnoses that the area of interest might be. This should also help reinforce the fun-
damentals of oral pathology. The resulting list of diagnoses can then be ranked
ordered using information from the history and clinical examination. This rank
ordered list can then be used to decide on how to best manage the area of concern.
Certain conditions, such as geographic tongue, will not require any management
other than informing the patient and reassuring them that nothing needs to be done.
336 E. Natarajan and M. T. Goupil

Other conditions, such as an ulcer, may be followed for a brief period of time to see
if it heals or may need to be biopsied especially if there is any suspicion of a malig-
nant condition.

17.5 White Lesions

In daily practice, the discovery of a white oral lesion often raises concern and in
many cases can present the clinician with a diagnostic dilemma. Encountering a
white lesion may bring a planned dental appointment to a grinding halt. Clinicians
are understandably concerned about potential epithelial dysplasia (premalignant
change) or oral squamous cell carcinoma. While this concern is justified, the fact is
that the vast majority of white lesions that occur on oral mucosal surfaces are
benign. The diagnosis of white lesions, or any other oral/extraoral lesion, should
always be approached in a disciplined and logical manner. The clinician should
gather all relevant data regarding the finding, including history, symptoms, location/
distribution, and clinical features, and then proceed to build a differential diagnostic
list based on his/her understanding of pathological processes. White lesions, as with
all other pathological lesions, can be categorized by pathological process as shown
in Table 17.1.
Given that white oral lesions represent a range of pathological processes, it is
essential that clinicians approach the diagnostic process in a stepwise manner as it
is discussed below and as shown in the accompanying diagnostic flow diagram
(Flowchart 17.1).

Table 17.1 White lesions of the oral cavity. Pathological processes and selected examples
1. Variants of normal/physiological
 • Linea alba
 • Geographic tongue
2. Reactive
 • Frictional/reactive hyperkeratosis
 • Cheek/tongue chewing (morsicatio)
 • Ridge keratosis
3. Infectious diseases (viral, fungal)
 • Candidiasis—pseudomembranous, hyperplastic
 • Oral hairy leukoplakia (EBV)
4. Immune-mediated conditions
 • Lichen planus
5. Neoplastic
 • Benign—verruca vulgaris/squamous papilloma
 • Premalignant—epithelial dysplasia, actinic cheilitis/actinic keratosis
 • Malignant—squamous cell carcinoma
6. Developmental/Genetic
 • White sponge nevus
 • Hereditary benign intraepithelial dyskeratosis
17 Soft Tissue Oral Pathology 337

WHITE NON-WIPEABLE PLAQUE

(Non-wipable = keratotic)

Findings suggestive of Findings that warrant an

a benign process incisional/ excisional biopsy
NON-WIPEABLE PLAQUE THAT CANNOT BE
1. Obvious source of chronic friction:
DIAGNOSED ON CLINICAL GROUNDS
- Hx of trauma or biting area
2. Location: 1. Location (Oral cancer prone locations):
- Buccal mucosa - Lateral and ventral tongue
- Dorsal tongue - Floor of mouth
- Lower labial mucosa - Soft palate, tonsillar pillars
- Attached gingiva & Hard palate 2. No obvious source of trauma or friction
3. Distribution: - Persistence of lesion even after elimination
- Bilateral on buccal mucosae, gingiva of potential sources of irritation/ trauma
- Adjacent to sharp tooth, restoration, 3. Distribution:
prosthesis, appliance - Unilateral
- Away from sources of chronic irritation
- Lesion larger than 200 sq. mm.
4. Patient history:
Benign Benign Lesions - Current tobacco/ alcohol habit
Hyperkeratosis Red + White - Recent or distant history of tobacco use
- Obvious source of 1. Geographic tongue 5. Appearance:
chronic irritation/ friction - Dorsal and lateral - Diffuse white/ homogeneous
- Location on trauma tongue - Heterogeneous/ red & white/ speckled
prone sites - Serpentine/ annular - Pebbly / leathery/ verrucous surface
- Lesion fades/ responds - Discrete - Persistent ulceration / nodularity
to removal of potential - Migratory
source of irritation 2. Lichen planus
- Painless - Chronic
1. Clinical follow-up at defined intervals
- Bilateral, buccal
2. Rebiopsy if lesion persists or evolves:
mucosa, gingiva
- Cutaneous lesions BIOPSY - Heterogeneous/ red & white
- Pebbly/ nodular/ verrucous
- Ulceration, Mass

Clinical Dx &
Diagnosis Epithelial Atypia
management
EPITHELIAL ATYPIA COULD REPRESENT:
1. Evolving epithelial dysplasia
OR
2. Epithelial change secondary to benign
reactive process

Epithelial dysplasia
1. Epithelial Dysplasia = premalignant lesion.
Grade of dysplasia (mild/ moderate/ severe) is not a consistent predictor of
malignant transformation potential or rate
2. Management of small lesions: Surgical excision followed by indefinite
clinical follow-up at defined intervals (see below)
3. Management of extensive lesions: Selective surgical excision of “suspicious” areas
followed by indefinite clinical follow-up:
- “Suspicious” findings: Increase in size > 200 sq. mm.. Change in color: heterogeneous, erythema.
Change in surface texture: ulceration, pebbly, verrucous, nodular.
Change in patient symptoms: pain, paraesthesia.
4. Clinical follow-up recommendations (indefinite due to the genetic nature of the condition):
- Establish defined monitoring schedule (3-6 month recall).
- Evaluate lesion for suspicious evolutionary changes described above.
- Photographic documentation of lesions is recommended.
- BIOPSY LESION IF WARRANTED. Obtain multiple biopsies if lesion is
extensive and/ or multiple areas appear suspicious.

Flowchart 17.1 White non-wipeable plaque. A step-by-step approach to the diagnosis of a clini-
cally indeterminate non-wipeable white plaque
338 E. Natarajan and M. T. Goupil

17.5.1 D
 iagnosis of White Lesions: History of the Presenting
Lesion

The diagnostic process must always begin with a patient’s presenting complaint and
relevant history taking. Most patients who present with white oral lesions are
unaware of these findings until they are discovered incidentally, either by them-
selves or by a healthcare provider at a routine visit: hygienist, dentist, or physician.
Lesions that present on the buccal mucosa, dorsal and lateral tongue, labial mucosa,
and gingivae are generally discovered by patients as these areas are easily accessible
and illuminated. However, white lesions on the ventral tongue, floor of the mouth,
retromolar pad, vestibules, and palatal mucosa are discovered by healthcare provid-
ers who are able to examine these areas with better illumination and instruments and
after having dried these areas appropriately. When a white lesion is reported or
discovered, it is essential for clinicians to gather additional data by asking pointed
questions to flesh out the history of the presenting complaint as listed below:

1. Duration:
(a) When did you/your provider discover this lesion/lesions?
(b) How long have you been aware of this lesion?
2. Discovery: How did you discover this lesion?
3. Distribution:
(a) Focal/unilateral
(b) Multifocal—intraoral and/or extraoral sites
4. Stimuli/triggers:
(a) Do you recall a history of trauma?
(b) Do you have a habit of grinding your teeth/biting your tongue/cheek/lip?
5. Symptoms: Do you have pain or discomfort associated with this lesion?
(a) Character of symptoms: persistent/intermittent
(b) Quality of symptoms: intense pain, burning, scales of pain
6. Progression:
(a) Has the lesion grown in size or reduced in size since discovery?
(b) Has it spread to other oral sites or is it localized?
(c) Do the lesions move around?
7. Factors that alleviate symptoms or make the lesions change in character

17.5.2 Examination: Wipeable and Non-wipeable White Plaques

Oral examination should always be preceded by a thorough neck, extraoral and

perioral exam. Intraoral examination should be conducted with appropriate illumi-
nation, instruments, and gauze sponges to properly dry oral surfaces. Examination
is followed by thorough visualization and palpation of all of the oral surfaces.
A plaque is a lesion that is characterized by a broad, raised thickening of the
surface epidermis or mucosa. During examination, if a white plaque is detected, the
clinician should attempt to wipe or scrape it away with gauze or a tongue depressor.
17 Soft Tissue Oral Pathology 339

If the white plaque is wipeable, it likely comprises surface debris and is not the
result of epithelial proliferation, hyperkeratosis, or maturational irregularity. On the
other hand, if the white plaque is non-wipeable, it represents an increase in thick-
ness of the oral surface epithelium with or without attendant hyperkeratinization,
i.e., epithelial hyperplasia. Non-wipeable white plaques may also represent hyper-
keratosis of the surface epithelium resulting increased keratinization (para- or
orthokeratinization). In addition to hyperplasia and hyperkeratosis, non-wipeable
white plaques may demonstrate epithelial maturational irregularities.

17.5.3 Wipeable White Plaques

Clinicians must always try to wipe or scrape away detected white plaques with a
gauze sponge or tongue blade. As a general rule, wipeable white lesions are over-
whelmingly suggestive of a benign process. They are generally representative of
surface debris. They can include accretions of food debris, fungal microorganisms,
desquamated keratin, the fibrinopurulent pseudomembrane that covers an ulcer
base, and necrotic tissue resulting from a chemical burn or a collapsed bulla.
Scraping away necrotic tissue or debris that covers an ulcer base often causes pain.
If possible, any white material that wipes away should be examined under the
microscope in order to identify it. The salient features of selected common and
clinically significant entities are discussed below:

(a) Hairy tongue/coated tongue: Hairy tongue/hairy coated tongue manifests as a

thick, hairy/matted white/yellow/pigmented change on the dorsal surface of the
tongue. It is characterized by the accumulation of keratin and food debris likely
resulting from the elongation of filiform papillae (Fig. 17.1). Although the spe-
cific cause of hairy tongue is uncertain, possible factors that result in hairy
tongue include oral dryness, poor oral hygiene, lack of filiform clearing in the
setting of other painful oral conditions (lack of debridement), aggressive tongue
scraping/brushing, or general debilitation. Although hairy tongue does not

Fig. 17.1 Hairy tongue/

coated tongue. A result of
filiform papillary
hyperplasia often the result
of aggressive tongue
brushing and not the result
of candidal infection
340 E. Natarajan and M. T. Goupil

present as a white “plaque,” the clinical presentation can be quite striking and
alarming to patients. The keratin debris that builds up on the tongue can be
wiped or scraped off with a tongue blade or gauze. Patients may complain of a
bad taste in the mouth. It is important for clinicians to recognize that this is a
benign condition and not the result of oral candidiasis. Proper oral hygiene and
addressing the predisposing factors listed above often address this benign clini-
cal finding. No diagnostic tests or biopsies are indicated.
(b) Pseudomembranous candidiasis (thrush): Candidiasis is an opportunistic fungal
infection that can manifest itself on the oral mucosal surfaces of patients with cer-
tain predisposing factors (e.g., dry mouth, poor appliance hygiene, anticholinergic
use, asthma inhalers, antibiotic use, immunosuppression/depletion, etc.). Clinically,
oral candidiasis is characterized by a wide distribution of lesions. Patients may
present with the various clinical forms of candidiasis including the erythematous
(atrophic) form, angular cheilitis (commissures), hyperplastic (non-wipeable/can-
didal leukoplakia), and the abovementioned pseudomembranous form simultane-
ously. It is the pseudomembranous form, commonly referred to as thrush, that
presents with wipeable curd-like accretions on an atrophic mucosal background
(Fig. 17.2). Patients presenting with oral candidiasis are typically asymptomatic or
may complain of mild discomfort, and they seldom report pain. Oral candidiasis is
typically diagnosed based on a patient’s clinical history and presentation. In
selected cases lab tests may be required: cytological smears to demonstrate fungal
organisms, fungal cultures, or biopsies. Oral candidiasis can be managed with anti-
fungal agents. Additionally, it is essential for clinicians to investigate and address
the underlying systemic factors leading to this opportunistic infection.
(c) Other wipeable white lesions: Food debris, fibrinopurulent ulcer membranes,
and necrotic oral mucosal tissue may also present as wipeable white plaques. In
each case, clinical correlation with patient history, symptoms, and oral mucosal
findings will enable clinicians to arrive at a diagnosis.

Fig. 17.2 Pseudomembra-

nous candidiasis. Wipeable
curd-like white patches on
an atrophic, erythematous
background. Note the
widespread distribution
17 Soft Tissue Oral Pathology 341

17.5.4 N
 on-wipeable White Plaques: Findings Suggestive
of a Benign Process

(a) Benign reactive hyperkeratoses: White plaques located along oral mucosal
sites that are subject to chronic friction or trauma are most likely a result of
reactive hyperplasia and hyperkeratosis and are termed benign reactive hyper-
keratosis (Flowchart 17.1). This is a common benign response to local irrita-
tion and is equivalent to calluses seen on palms and soles resulting from
chronic friction. Typically, these plaques appear as rough-surfaced, asymp-
tomatic lesions and arise directly opposite the source of friction or irritation.
The most common locations include the buccal mucosa, dorsolateral tongue,
labial mucosa, gingival mucosae, and hard palate. In most cases, if the pre-
sumptive source of irritation is eradicated, then these epithelial changes will
resolve within a few weeks. If the irritant persists or reintroduced, the white
plaque can return. Regardless, reactive hyperkeratoses are fundamentally
benign mucosal lesions; they are not predisposed to malignant transforma-
tion. In the oral cavity, benign reactive hyperkeratoses are most commonly
seen in the following forms:
–– Linea alba: Linea alba or “white line” corresponds to asymptomatic, bilat-
eral linear white plaques seen exclusively on the buccal mucosa along the
occlusal plane at the site of dental intercuspation. This white oral finding is
extremely common, benign, and is considered a variant of normal (Fig. 17.3).
It is a result of physiological hyperplasia and keratosis of the buccal mucosal
epithelium in response to daily function and intercuspation. It is widely rec-
ognized and requires no further diagnostic testing.
–– Cheek and tongue chewing/biting (Morsicatio): Patients who have a his-
tory of chronic cheek and/or tongue chewing/biting or other parafunctional
habit that results in chronic friction/irritation of the buccal mucosa and
dorsolateral surfaces of the tongue present with bilaterally distributed,
painless, diffuse and ill-defined, rough, or shaggy-surfaced white plaques

Fig. 17.3 Linea Alba. A

common finding noted on
the buccal mucosa along
the interocclusal plane
342 E. Natarajan and M. T. Goupil

(Fig. 17.4a, b). These plaques are typically directly opposite the source of
irritation and may extend superiorly or inferiorly depending on the indi-
vidual patient’s chewing habit. Some patients may present with interven-
ing areas of erythema or atrophy that correspond to areas of trauma. In rare
instances, focal areas within the plaque corresponding to frayed surface
keratin may be wipeable leaving behind intact mucosae. The diagnosis of
“Morsicatio” is established based on a patient’s history and the typically
bilateral distribution of shaggy white plaques on the buccal mucosa and
dorsolateral tongue. There is no need for further diagnostic testing, includ-
ing tissue biopsies.
–– Alveolar ridge/gingival keratosis: Areas along the attached gingival sur-
faces, palate, and partially/completely edentulous alveolar ridges that are
subject to chronic friction can present with epithelial hyperplasia and hyper-
keratosis. Clinically, these lesions appear as asymptomatic non-wipeable
white plaques that typically have a corrugated/rough surface texture and cor-
respond to a local/specific source of friction. The most common causes of
gingival keratoses include aggressive toothbrushing techniques, appliance
clasps, or parafunctional habits, while the most common cause of

Fig. 17.4 (a, b) Cheek a

chewing (morsicatio).
Benign reactive
hyperkeratosis that is a
result of habitual cheek
chewing/biting. Note the
bilateral distribution with
foci of erythema

b
17 Soft Tissue Oral Pathology 343

hyperkeratosis along edentulous alveolar ridges is friction from mastication.

The borders of these white lesions can be either discrete or ill-defined. The
diagnosis is typically made by correlating patient history, distribution and
location of the plaque, and identification of specific irritant. If these lesions
do not correspond to a specific physical irritant then a biopsy/ biopsies may
be warranted, especially as there is no specific stimulus.
(b) White and Red Lesions
–– Erythema migrans/benign migratory glossitis: This is a benign condition that
is typically seen on the tongue (geographic tongue). It is an extremely com-
mon finding (1–3% of the population) that is thought to be a variant of normal.
The lesions are clinically asymptomatic and are frequently discovered inciden-
tally by the patient or on routine clinical examination. The clinical presentation
of erythema migrans/geographic tongue is characterized by multiple, well-
demarcated areas of erythema surrounded by s­ erpiginous/annular/scalloping
yellow-white linear plaques on the dorsal and lateral borders of the tongue
(Fig. 17.5a, b). Erythematous areas on the dorsolateral tongue correspond to
areas of filiform papillary atrophy. Geographic tongue often occurs in the
background of the fissured tongue. Patients are generally asymptomatic; a few

Fig. 17.5 (a, b) Benign a

migratory glossitis
(geographic tongue). Well
demarcated, serpiginous,
annular areas of mucosal
atrophy rimmed by
yellow-white linear
mucosal changes with a
history of migration.
Fissuring of the dorsal-
lateral tongue is a common
finding in these patients

b
344 E. Natarajan and M. T. Goupil

patients may report sensitivity to hot/spicy foods. In some patients, the lesions
of erythema migrans may be seen in other oral sites including the buccal
mucosa, ventral tongue, floor of the mouth, and other sites. Although its
appearance can be clinically alarming, erythema migrans/geographic tongue
should be recognized for what it is—a benign, noninfectious, non-cancerous
condition that requires no further management or diagnostic tests.
–– Lichen planus: Is a benign cell-mediated autoimmune disease characterized by
multifocal, symmetrical, papulosquamous dermatosis and mucosal lesions.
Lichen planus is the result of a T lymphocyte-mediated cytotoxic destruction
of basal keratinocytes that results in compensatory surface hyperkeratosis
(Cheng et al. 2016). Clinically, the lesions of classic reticular oral lichen pla-
nus are characterized by papules, plaques, and delicate lacy white striations
distributed bilaterally within the oral cavity (Fig. 17.6a, b). The buccal mucosa
is affected in >80–90% of patients followed by the gingiva, tongue, and lip
surfaces (mucosa and vermilion). Patients with the reticular form of lichen
planus are generally asymptomatic. Patients may present with intervening
areas of erythema and erosion in areas where cytotoxic basal cell destruction
has not been sufficiently compensated with surface hyperkeratosis. Patients

Fig. 17.6 (a, b) Oral

lichen planus. Classic
a
bilateral, multifocal
distribution of reticular
white striations with
intervening areas of
erythema. This patient was
asymptomatic given the
lack of erosions/ulceration

b
17 Soft Tissue Oral Pathology 345

with erosive lichen planus may present with symptoms of sensitivity and/or
pain. The diagnosis of lichen planus and lichenoid stomatitis should be made
ONLY if specific clinical (i.e., multifocality, symmetric distribution of cutane-
ous/mucosal lesions) and microscopic criteria (i.e., normal epithelial matura-
tion, basal cell liquefaction, lymphocytic infiltration of the stroma) are satisfied
(Cheng et al. 2016). Lesions that appear red and white and clinically lichenoid
that are unilateral or in cancer-prone locations (ventral tongue, floor of the
mouth, lateral tongue, soft palate, etc.) must be biopsied to rule out epithelial
maturational irregularities.

17.5.5 N
 on-wipeable White Plaques: Findings That Warrant
Biopsy/Biopsies

Before the emergence of an oral squamous cell carcinoma (oral cancer; malignant
neoplasm of oral squamous epithelium), clinically visible precancerous oral muco-
sal surface changes precede the appearance of a tumor (Fig. 17.7). These findings
present as white non-wipeable plaques and are often the first signs of cancer devel-
opment (Natarajan and Eisenberg 2011). Given that the oral mucosal surfaces are
readily accessible to exam and visualization, clinicians can detect these lesions dur-
ing a thorough oral examination. White non-wipeable plaques that meet one or more
of the following criteria must be biopsied:

1. White plaques in oral locations that are relatively protected from friction or
trauma—floor of the mouth, lingual mandibular vestibules, ventral-lateral
tongue, soft palate, uvula, and tonsillar pillars. These locations are referred to as
the oral cancer-prone locations (Natarajan and Eisenberg 2011).
2. White plaques for which there is no identifiable inciting agent and for which a
presumptive clinical diagnosis cannot be made with confidence (i.e., no obvious
inciting agent, no history of trauma, no features characteristic of other specific
keratotic diseases).

Fig. 17.7 Non-wipeable

white plaque that warrants
multiple biopsies. A large
white plaque on the right
ventral tongue. Note the
leathery surface texture on
the anterior portion and the
diffuse milky white surface
changes extending to the
posterior ventral tongue
346 E. Natarajan and M. T. Goupil

3. White plaques in trauma protected locations that are unilateral and are larger
than 200 sq. mm. Large lesions (200 sq. mm. or more) require multiple biopsies
(Natarajan and Eisenberg 2011; Holmstrup et al 2006; Arduino 2009; Ho
et al. 2012; Ho et al. 2013).
4. White plaques in patients with a current or past history of tobacco use (smoking/
smokeless) or heavy alcohol use. Plaques in patients with a distant history of
smoking must not be dismissed and should be evaluated similarly.
5. White plaques with the following surface changes must be regarded with suspi-
cion and biopsies obtained—diffuse borders, heterogenous (red + white)/speck-
led surface changes, pebbly/leathery/verrucous surface changes, and areas of
ulceration/nodularity/induration (Natarajan and Eisenberg 2011; Holmstrup et al
2006; Arduino 2009; Ho et al. 2012; Ho et al. 2013).
6. White plaques with surface nodularity/ulceration/erythema accompanied by
patient symptoms of pain/paresthesia or bleeding must be biopsied (Natarajan
and Eisenberg 2011).

Full thickness tissue biopsies of non-wipeable white plaques are required to

establish a definitive biopsy. Only an incisional (scalpel) or punch biopsy will per-
mit proper evaluation of the full thickness of the epithelium and its relationship to
the underlying connective tissue. While a majority of the clinically indeterminate
white lesions demonstrate benign features on biopsy, a small but significant subset
of white lesions that demonstrate one or more of the above clinical characteristics
demonstrate histopathological evidence of epithelial maturational disturbance (epi-
thelial atypia/epithelial dysplasia) or squamous cell carcinoma.

(a) Squamous cell carcinoma: Oral squamous cell carcinoma is a malignant neo-
plasm arising from the oral mucosal lining. It is a disease of protracted genetic
deregulation within the stratified squamous epithelial cells of the oral cavity.
While these mutations typically occur in the setting of genetic predisposition, it
is well known that this deregulatory process can be accelerated by chemical
carcinogens (risk factors), primarily smoking tobacco. The resulting genetic
mutations cause an uncoordinated and unregulated proliferation of squamous
cells. This cellular proliferation and maturational disturbance causes epithelial
thickening and manifests clinically as a white, non-wipeable mucosal plaque
defining the evolutionary process of epithelial dysplasia during carcinogenesis.
The altered epithelial cells acquire additional mutations and eventually alter the
homeostatic equilibrium between the epithelium, the basement membrane, and
the underlying stromal tissue. Genetically “rogue” epithelial cells acquire the
ability to breach the basement membrane and infiltrate the underlying stromal
tissue—this violation of natural tissue barriers manifests itself clinically as an
irregular, ulcerated, indurated, red, and white mass and defines a squamous cell
carcinoma (Natarajan and Eisenberg 2011). For the clinician, it is important to
understand that the cumulative mutations leading to oral cancer affect all epi-
thelial cells within a field within the oral cavity—this accounts for the known
risk for recurrence of oral cancer but also accounts for new primary tumors
elsewhere within the oral cavity.
17 Soft Tissue Oral Pathology 347

Classically, oral squamous cell carcinomas present as ulcerated, white, and

red masses (Fig. 17.8) usually with a variegated surface appearance (i.e., cor-
rugation, verrucous, speckled, lobulated, pebbly) on classic cancer-prone loca-
tions (e.g., floor of the mouth, ventral-lateral tongue, soft palate, etc.). The
tumors are typically indurated (hard) on palpation and tend to tether down the
affected tissues. Patients may report being aware of the tumor growing over
weeks to months and may report symptoms of pain and paresthesia. Tumor
infiltration of the surrounding jawbones may result in bone destruction and
manifest as tooth mobility. The ulcerated tumor masses are frequently sur-
rounded by non-wipeable white plaques that exhibit microscopically diagnos-
able epithelial dysplasia. This is consistent with the genetically devolutionary
process of carcinogenesis (Natarajan and Eisenberg 2011). When clinicians
discover a non-wipeable white plaque in an oral cancer-prone location, it is
important for them to recognize and characterize the surface changes (e.g.,
ulceration, variegation, pebbly texture) and lesion characteristics (e.g., nodular-
ity, induration, mass lesion) that make it suspicious for squamous cell carci-
noma (see Flowchart 17.1). It is essential that any lesion that exhibits the above
characteristics be biopsied (multiple biopsies if necessary) and submitted for
histopathological examination.
Patients diagnosed with oral squamous cell carcinoma should be referred to
an appropriate specialist for further staging and appropriate management.
(b) Epithelial dysplasia: Epithelial dysplasia is a potentially malignant (premalig-
nant/precancerous) mucosal lesion that usually precedes the emergence of oral
squamous cell carcinoma. Epithelial dysplasia typically presents clinically at a
relatively late stage in the evolutionary process of carcinogenesis and is repre-
sentative of the protracted accumulation of genetic defects within the oral squa-
mous epithelium (Natarajan and Eisenberg 2011). As described above, the
unregulated epithelial proliferation in oral mucosal fields susceptible to chemi-
cal carcinogens manifests itself as a non-wipeable white plaque on oral cancer-
prone mucosal surfaces (Fig. 17.9). These mucosal alterations are often
described using the clinical descriptor “leukoplakia.” It is important for clini-
cians to understand that not all lesions described as “leukoplakia” exhibit

Fig. 17.8 Oral squamous

cell carcinoma. A
heterogeneous ulcerated
mucosal mass on the
posterior ventral tongue.
Note the location, surface
irregularity and the white
leathery non-wipeable
plaque anterior to the mass
348 E. Natarajan and M. T. Goupil

Fig. 17.9 Epithelial

dysplasia, clinical features.
A large white plaque on
the right ventral tongue.
The anterior portion of the
lesion is milky white with
a leathery surface quality.
The posterior portion
extent of the lesion on the
ventral tongue is diffuse
and indescernable

features diagnostic for epithelial dysplasia, i.e., “leukoplakia” is not synony-

mous with epithelial dysplasia (Natarajan and Eisenberg 2011). Epithelial dys-
plasia as a diagnosis refers to a composite of architectural, maturational, and
cytomorphological changes noted in biopsies of clinically detected white
plaques. Pathologists require a specimen that captures the full thickness of the
epithelium and some underlying connective tissue to arrive at this diagnosis;
detection of cytological abnormalities by themselves is not sufficient to make
this diagnosis. By definition, lesions diagnosed with epithelial dysplasia exhibit
maturational irregularities confined within the stratified squamous epithelium
and above the basement membrane (i.e., there is no infiltration beyond the base-
ment membrane). Pathologists grade oral dysplastic lesions as being mild (sub-
tle basal cell changes), moderate, severe, or carcinoma in situ (top-bottom
epithelial change) based on the extent of maturational abnormality as it presents
from the basal cell layer to the surface of the oral epithelium. Grading oral epi-
thelial dysplasia enables pathologists to categorize lesions by degree of micro-
scopic severity. However, it is important for clinicians to understand multiple
studies have demonstrated that the grade of microscopic dysplasia does not
necessarily predict or correlate with the likelihood of progression to squamous
cell carcinoma (Holmstrup et al 2006; Arduino 2009; Ho et al. 2012; Ho et al.
2013; Arnaoutakis et al. 2013; Mehanna et al. 2009). It is important to under-
stand that microscopic findings do not provide objective information on the
specific genetic defects harbored by cells within the dysplastic epithelium, nor
does it predict its stage in carcinogenic evolution. Irrespective of degree, it is
important for clinicians to recognize the significance of epithelial dysplasia. A
diagnosis of epithelial dysplasia constitutes a risk for progression to squamous
cell carcinoma. Patients diagnosed with epithelial dysplasia must be appropri-
ately educated about the genetic basis of the disease and must be monitored/
managed in an ongoing, indefinite manner.
(c) Epithelial atypia: Epithelial atypia is a term used by pathologists to describe
deviations from normal observed in epithelial architecture or cytomorphology
that indicate disturbances in epithelial maturation (Flowchart 17.1). In compari-
son to epithelial dysplasia which is clearly precancerous, the findings seen in
epithelial atypia do not meet all the criteria for epithelial dysplasia (Natarajan
17 Soft Tissue Oral Pathology 349

Fig. 17.10 Non-wipeable

white plaque, epithelial
atypia. Large white plaque
on the left buccal mucosa
with intervening area of
pebbly erythema/erosion.
The plaque exhibits a
verrucous texture. Given
the patient’s smoking
history, multiple biopsies
were obtained revealing
epithelial atypia and
recommendation for
continued monitoring

and Eisenberg 2011). The maturational disturbances of epithelial proliferation,

architecture, and differentiation may represent unusual epithelial responses to
local inflammatory or physical insults (chronic friction) and infectious or other
unspecified stimulus. For instance, the margins of healing ulcers or epithelial
tissues with candidal infection can demonstrate significant epithelial atypia. It is
important for clinicians to recognize that in some instances, epithelial atypia
may be seen in an evolving dysplastic lesion. Given that there are no predictive
genetic biomarkers to distinguish between “benign” atypias and “evolving pre-
cancerous” atypias, the pathologist uses the term atypia to alert the clinician
about microscopic findings that are deviant from normal epithelium. When
pathologists diagnose a non-wipeable plaque as “epithelial atypia,” they typi-
cally include a comment that alerts the clinician to the diagnosis, recommending
further clinical correlation (rule out local reactive/inflammatory factors) and
continued monitoring of the lesion (Fig. 17.10). Clinical follow-up of atypical
lesions is mandatory. On follow-up examination visits, any clinical evidence of
persistence, increase in the size of the lesion, progressive heterogeneity in sur-
face character (pebbly change, corrugation, ulceration, erythema, nodularity,
change in symptoms), or evolution of the lesion should trigger a biopsy (see
Flowchart 17.1).
(d) Management of patients diagnosed with epithelial dysplasia:
• Patient education: Patients diagnosed with epithelial dysplasia, irrespective
of histopathological grade, must be educated about the potentially cancer-
ous nature of the lesion and about the underlying acquired genetic deregula-
tory basis of the disease. From the outset, and given the lack of genetic
biomarkers that predict progression to squamous cell carcinoma, clinicians
must strongly emphasize the need for continued clinical follow-up at regu-
lar intervals (Natarajan and Eisenberg 2011; Smith et al. 2009). Patients
must also be educated about the “field effect” of genetic change that is
likely present in normal-appearing oral mucosal tissues that surround the
clinically detectable white plaque. Patients may be offered surgical man-
agement options including excision of visible lesions. However, clinicians
must advise patients that excision of all clinically abnormal tissue will nei-
ther eliminate nor predictably “cure” a disease characterized by underlying
350 E. Natarajan and M. T. Goupil

genetic deregulation further emphasizing the need for ongoing clinical vigi-
lance (Holmstrup et al 2006; Ho et al. 2012; Ho et al. 2013; Arnaoutakis et
al. 2013; Mehanna et al. 2009; Warnakulasuriya et al. 2008; Field et al.
2015).
• Surgical management (see Flowchart 17.1): Complete surgical excision is
recommended for small dysplastic lesions measuring <200 sq. mm. in area
followed by clinical follow-up at defined 3–6 months of intervals. For large
and extensive dysplastic lesions measuring >200 sq. mm., multiple biopsies
are recommended from the outset. Complete surgical excision of all clini-
cally visible areas in extensive dysplastic lesions can pose a surgical and
clinical challenge. In these patients, clinicians may elect to follow a conser-
vative and selective approach. One recommendation based on findings in the
literature includes complete surgical excision of clinically “suspicious”
areas followed by indefinite follow-up (Holmstrup et al 2006; Ho et al. 2012;
Ho et al. 2013; Smith et al. 2009; Field et al. 2015). Clinically “suspicious”
findings that warrant full surgical excision include areas within a white
plaque that exhibit the following features:
–– Increase in size > 200 sq. mm. between clinical visits.
–– Color—erythema, variegation of color, change in color between visits.
–– Surface texture—pebbly (red + white), verrucous, nodular, ulceration,
induration (palpation), or changes between visits.
–– Patient symptoms—discomfort, pain, paresthesia, increase in size.
• Clinical follow-up recommendations: Ongoing and indefinite clinical follow-
up must be emphasized at every patient visit given the genetic basis of epithelial
dysplasia and squamous cell carcinoma (Natarajan and Eisenberg 2011).
Patients diagnosed with epithelial dysplasia must be monitored following a
defined schedule (every 3–6 months)—a general dentist can examine these
patients along with their hygiene team every 6 months. At these visits, it is
important to evaluate the lesion for the presence/absence of the clinically suspi-
cious findings described above. Photographic documentation of the lesion,
original biopsy site, and the surrounding tissues is strongly recommended
(Natarajan and Eisenberg 2011; Field et al. 2015; Kanatas et al. 2011). If a
clinically suspicious finding is detected at these monitoring visits, selective
biopsies/re-biopsies are recommended. If multiple evolutionary changes are
noted, then multiple biopsies are recommended.

17.6 Oral Ulcers

Oral ulcerative conditions are common. Patients suffering from oral ulcers present
with much pain, discomfort, and functional compromise. On initial presentation,
oral ulcers resulting from a wide array of pathological conditions can look alike and
pose a clinical diagnostic challenge. Regardless of pathological process, number,
distribution, or size of the ulcers, patients who suffer from these lesions experience
significant pain and are understandably concerned. Fortunately, the majority of oral
17 Soft Tissue Oral Pathology 351

ulcerative conditions, solitary or otherwise, are benign and can be diagnosed using
specific criteria.

17.6.1 Oral Ulcerative Lesions: The Diagnostic Process

The diagnostic approach to oral ulcerative lesions should be disciplined and must
begin with a thorough clinical history, followed by examination of extraoral and
oral surfaces. Oral ulcerative conditions can be categorized as being either acute
(<2–3 weeks of duration) or chronic (> 2–3 weeks of duration). While obtaining a
history of the presenting complaint, clinicians must address the factors listed in
Table 17.1 in order to determine the type of pathological process causing the ulcers.
There is a range of pathological processes associated with oral ulceration, including
ulcerations due to reactive physical/chemical (e.g., traumatic ulcers), infectious dis-
eases (e.g., herpes), local immune dysregulation, manifestations of systemic
immune-mediated conditions, and malignant neoplasia. Although there is a range of
oral ulcerative lesions, it is important for clinicians to recognize that ulcers caused
by direct physical trauma (traumatic ulcers) are the most common of all oral ulcer-
ations. The salient features of each type of pathological process and examples of
ulcerative conditions are listed in Table 17.2.

Table 17.2 Oral ulcers, blisters and desquamation. Questions to guide the clinical diagnostic
process
Onset/Duration
 – Acute (<2 weeks)
 – Chronic (>2 weeks)
Number of lesions
 – Solitary ulcers
 – Multiple
Distribution
 – Localized (unilateral/bilateral/multifocal)
 – Oral mucosal distribution: keratinized (attached gingiva, hard palate, vermilion) vs.
unkeratinized surfaces (ventral tongue, buccal mucosa, labial mucosa)
 – Extraoral: cutaneous lesions, mucosal lesions (conjunctiva, genital, nasal mucosae)
Local factors
 – Trauma: restorations, sharp teeth, appliances, foreign objects
 – Dry mouth
 – Chemical agents, medications etc.
Frequency
 – Single episode
 – Persistence/progression
 – Recurrent/overlapping episodes/previous hx of similar lesions
Systemic factors
 – Cutaneous lesions/mucosal lesions—rashes, hives, pruritic, scaly, vesiculo-bullous lesions
 – gastrointestinal symptoms—cramping, diarrhea, gluten sensitivity, blood in stools, Hx of
IBS
 – general health—anemia, fatigue
352 E. Natarajan and M. T. Goupil

Given the range of pathological processes associated with oral ulcerative lesions,
clinicians must approach the diagnostic process in a stepwise manner as discussed
below and in Flowchart 17.2. The first step in the diagnostic process is to establish
whether a patient’s ulcerative lesions/condition is acute or chronic, and the second
step is to establish the number/distribution of the ulcerative lesions. Additional
information on local/systemic precipitants, frequency, and systemic/extraoral

ULCERS
Acute/ short duration Chronic/ recurrent/ > 3
< 3 weeks duration weeks duration

Traumatic Aphthous Herpetic Other Solitary Multiple

ulcers ulcers ulcers Ulcers Ulcer ulcers
- Location - Unkeratinized, 1º infection: Examples:
- Trauma Hx moveable mucosa - Gingivostomatitis 1. Coxsackie virus
- Generally - Dorsal tongue - PAIN 2. Erythema
solitary - PAIN - Vesicles & ulcers multiforme:
- Pain - Round ulcers - Constitutional - Identify cause
signs, symptoms
- Duration - Recurrence - Manage episodes
- 2 weeks duration
- Resolution - Duration 2º infection:
3. OTHERS
2-3 weeks - Resolution - Prodrome
7-10 days - Keratinized
mucosa Other Immune
- Pain/ no pain
- Vesicles/ ulcer systemic mediated
conditions conditions
1. Crohn’s disease 1. Lichen planus:
- Aphthous ulcers - Lacey white striae
- Hx of Crohn’s - Bilateral
or - Buccal & gingival
Hx of GI symptoms mucosae
- Lip swelling - Cutaneous lesions
Traumatic Squam. cell Other 2. Lichenoid
- Epulis-like growth
Ulcer carcinoma ulcer - Cobblestones/ stomatitides:
granulomatous - White/ red striae
Clinical Dx and Tx - Location - Ca prone Location 1. Malignant lesions - Erosions
- Trauma Hx - Tobacco Hx neoplasm 2. Other systemic - Medications?
- Generally solitary - White/Red 2. Granulomatous conditions with - PAIN
- Can be painless - MASS ulcer oral ulcers: - bilateral or not
- Repeated trauma - Ulcer > 3 weeks 3. Deep fungal - Appropriate Hx or 3. Mucosal
- Scarring - Induration ulcer clinical work-up Pemphoid:
- Depth of ulcer - No trauma source 4. OTHERS - Gingival redness
- Dry mouth? - Painless - Mucosal sloughing
Ulcers persist - Underlying - Paraesthesia - Conjunctiva
- Pebbly, irregular - Discomfort
> 4 weeks systemic cond.
surface - Rare vesicles
4. Pemphigus:
- PAIN
- Irregular ulcers
- Sloughing mucosa
- Skin lesions

2 Biopsies for immune-mediated

BIOPSY chronic ulcerative conditions:
1. Conventional H&E:
submit in Formalin
2. Direct Immunofluorescence
submit in special transport medium
(Michel’s/ Zeus preservative medium)

Flowchart 17.2 Oral ulcers. A step-by-step approach to the diagnosis of clinically indeterminate
oral ulcers, blisters and desquamation with selected examples
17 Soft Tissue Oral Pathology 353

manifestations guides a clinician’s diagnostic work-up. As seen in Flowchart 17.2,

determining whether an ulcerative condition is acute or chronic is the single most
important step as it immediately guides clinicians’ differential diagnostic consider-
ations. Clinicians can use their knowledge about salient features of ulcerative enti-
ties as shown in Table 17.3 to guide this diagnostic process.

Table 17.3 Oral ulcers. Pathological process, general features and selected examples
Pathological process and clinical features Examples
1. Reactive 1. Traumatic ulcers
 – Local factors—restorations, margins, sharp teeth, irritant 2. Chemical burns (pizza burn,
 – Generally acute/patient recalls specific cause aspirin burn)
 – Heal within 10–14 days
 – Can be chronic if irritant/agent persists
 – Generally painful
 – Heal if irritant is removed/scarring with chronic ulcers
 – Predisposing factors—oral dryness
2. Infectious diseases (viral,a fungal,a bacterial infection) 1. Herpetic infection (primary
 – Children or secondary)
 – Primary and recurrent episodes 2. Coxsackie virus infection
 – Acute onset—last 10–14 days
 – Multiple ulcers; distribution depends on type of infection
 – Pain
 – Constitutional signs/symptoms: fever, malaise,
lymphadenopathy
 – Recurrences
3. Local immune-dysregulation/immune-reaction pattern 1. Recurrent aphthous stomatitis
 – Acute onset 2. Erythema multiforme (E.M)
 – Duration—10–14 days
 – Pain
 – Multiple ulcers
 – Distribution—oral mucosal (aphthous); oral + extraoral
(E.M.)
 – Recurrent episodes (aphthous; E.M. if trigger persists)
4. Immune-mediated conditions (systemic) 1. Erosive lichen planus
 – Adults 2. Mucosal pemphigoid
 – Chronic and progressive 3. Pemphigus vulgaris
 – Multiple ulcers—unrelated to local physical factors 4. Irritable Bowel Syndrome
 – Distribution—oral + extraoral (skin, conjunctiva, genital
etc.)
 – Persistent ulcers; recurring and overlapping episodes
 – Hx of underlying systemic condition
5. Neoplastic—Malignant 1. Squamous cell carcinoma
 – Clinically obvious mass/tumor 2. Malignant salivary gland
 – Solitary ulceration; persistent; chronic ulceration neoplasms
(>3–4 weeks)
 – Unrelated to local physical factors
 – Cancer prone oral locations—ventral/lateral tongue,
floor of mouth, soft palate
 – Pain, paresthesia
*
Benign neoplasms are generally non-ulcerated, unless secondarily traumatized
**
Ulcers due to underlying developmental/genetic disorders are extremely uncommon
a
Oral ulcers due to fungal and bacterial infections are extremely uncommon and generally associ-
ated with severe immune-depletion and tend to be solitary non-healing ulcers
354 E. Natarajan and M. T. Goupil

17.6.2 Acute Ulcerative Conditions

(a) Traumatic ulcer: Traumatic ulcers are the most common oral ulcerations and
typically present as acute, painful, focal/solitary ulcers. Classically, patients
report a history of recent trauma to the oral mucosa. The traumatic insults range
from self-inflicted cheek/tongue bite, denture irritation, irregular teeth/restora-
tions, oral appliances, pizza burn, iatrogenic injury, or other traumas. The
majority of traumatic ulcers occur in so-called trauma-prone sites, i.e., the buc-
cal mucosa, lower labial mucosa, lateral and dorsal tongue, and gingival sur-
faces. It is unusual to see traumatic ulcers on the floor of the mouth, ventral
tongue, and soft palatal surfaces as they are naturally protected from direct
trauma (so-called cancer-prone sites). Traumatic ulcers are typically painful
and solitary (unless there are multiple areas of physical trauma, e.g., denture
flange) and appear as shallow yellow-white ulcers with irregular, erythematous
borders (Fig. 17.11a, b). The vast majority of traumatic ulcers heal within
2–3 weeks of the initial injury. If the initial stimulus persists (e.g., overextended
denture flanges, fractured tooth structure, improperly contoured/fractured res-
toration), then the ulcer can persist for longer than 3 weeks. In this setting,

Fig. 17.11 Traumatic

ulceration. (a) A shallow a
ulcer on the left lateral
tongue in a patient with a
history of recent trauma to
the area. (b) A deep painful
ulcer on the left lateral
tongue. The patient
reportedly inadvertently bit
his tongue. Note the
buildup of debris on the
dorsal tongue secondary to
oral pain

b
17 Soft Tissue Oral Pathology 355

traumatic ulcers can be chronic in duration and present as deep ulcers with
hyperplastic borders and appear clinically worrisome. It is essential for clini-
cians to determine the source of trauma and address the initial stimulus accord-
ingly. Once the stimulus/source of trauma is addressed, the patient must be
followed up in 2–4 weeks depending on the size of the initial traumatic ulcer.
Solitary ulcers that persist beyond 2–4 weeks despite having addressed the
source of physical trauma must be viewed with suspicion. These ulcers must be
biopsied to rule out other diagnostic possibilities, including oral squamous cell
carcinoma. Complete surgical excision may be required for large traumatic
ulcers with surrounding hyperplastic tissue.
(b) Recurrent aphthous stomatitis (RAS): Aphthous ulcers (RAS/“canker sores”)
are among the most common oral ulcerative conditions, second only to trau-
matic ulcers. RAS is an acute ulcerative disease of local immune dysregulation
and the result of localized T lymphocyte-mediated vasculitis and epithelial
necrosis. Transient deposition of cytokines like tumor necrosis factor alpha
(TNF-α) and interferon γ (IFN-γ) is among the chemotactic factors within local
blood vessel and epithelial basement membranes, and the subsequent oral epi-
thelial necrosis results in clinical ulcers (Al-Samadi et al. 2015; Natah et al.
2000).
Clinically, patients with RAS present with painful ulcers almost exclusively on
moveable, unkeratinized mucosal lining surfaces, i.e., buccal mucosa, labial
mucosa, floor of the mouth, ventral tongue, soft palate, alveolar mucosa, vestibules,
and the dorsal tongue (exception; heavily keratinized surface). Aphthous ulcers do
not present on the attached gingiva, hard palate, and the labial vermilion. Given that
RAS is an acute process, aphthous ulcers can present suddenly (no prodrome), typi-
cally running a 7- to 10-day course, with some patients aware of specific inciting
triggers. Classic aphthous ulcers present as round-to-ovoid ulcers surfaced by a
yellow-white fibrinonecrotic center and erythematous borders (Fig. 17.12a).
Aphthous ulcers may be classified by size with minor aphthae measuring less than
1.0 cm in diameter. Major aphthae are 1.0 cm or greater in diameter and, because of
their width and depth, could run a more protracted course in excess of 2 weeks
(Fig. 17.12b). Herpetiform aphthae present as clusters of very small ulcers measur-
ing 0.1 or 0.2 cm in diameter. Individual patients may have one or several types of
aphthous ulcers in a single episode. Patients with aphthae may present with one or
multiple ulcers within the oral cavity. Irrespective of lesion size, number, and distri-
bution per episode, RAS is very painful and can cause significant morbidity, espe-
cially in patients presenting with major aphthae or with multiple overlapping
episodes (Sciubba J.J. 2007; Staines & Greenwood 2015; Porter & Scully Cbe
2007). While the immunological basis of RAS is well established, the triggers that
precipitate this localized immune dysregulation are not as clear. The best-character-
ized predisposing factors that have been implicated in the etiopathogenesis of RAS
are (1) genetic susceptibility (~35–40% patients present with a +ve family history),
(2) local factors (e.g., trauma, stress, exposure to certain foods/materials), (3)
immune deficiency, and (4) systemic immune-mediated conditions (e.g., Behcet’s
disease, Crohn’s disease, celiac disease, ulcerative colitis).
356 E. Natarajan and M. T. Goupil

Fig. 17.12 (a) Aphthous

ulcer, minor. A round
a
0.5 cm ulcer with a
yellow-white central
pseudomembrane
surrounded by erythema on
the lower labial mucosa
(an unattached,
unkeratinized surface). (b)
Aphthous ulcer, major. A
irregularly shaped >1 cm
ulcer with yellow-white
center and erythematous
surrounding on the right
posterior buccal mucosa
(unattached, unkeratinized
surface) b

For clinicians, it is important to emphasize a critical concept: recurrent aphthous

stomatitis is a disease of localized immune dysregulation. It is not the result of a
viral infection (e.g., herpes, coxsackie), nor is it associated with specific dietary
deficiencies (Sciubba J.J. 2007; Staines & Greenwood 2015; Porter & Scully Cbe
2007). The vast majority of patients (~95%) have recurrent aphthous stomatitis as
an isolated oral mucosal disease, with no underlying systemic condition or predis-
position. However, given that RAS is a potential feature of some systemic disorders
(e.g., Crohn’s disease, ulcerative colitis, Behcet’s disease, celiac disease), it is
important for clinicians to ask patients with RAS questions about potential gastro-
intestinal symptoms, extraoral mucosal involvement, and cutaneous lesions. A posi-
tive history of systemic signs/symptoms associated with an underlying systemic
condition should trigger an appropriate referral and work-up (Sciubba J.J. 2007;
Porter & Scully Cbe 2007).
It is essential for clinicians to understand that the diagnosis of recurrent aph-
thous stomatitis is based almost entirely on correlation of patient’s history, the
clinical course (acute), and the distribution and appearance of oral mucosal
ulcerative lesions. Laboratory studies and biopsies are non-revelatory and tend
to be diagnostically nonspecific. With regard to treatment options for aphthous
stomatitis, it is important to understand that there is no “cure” for this condition.
17 Soft Tissue Oral Pathology 357

The treatment objective should be to manage the localized underlying immune-

mediated condition and individualize immunomodulatory therapy taking into
consideration the following factors: (1) frequency of ulcerative episodes (sin-
gle/overlapping), (2) number and distribution of ulcers/episodes, and (3) pres-
ence of underlying systemic complaints/conditions or triggers (Sciubba J.J.
2007; Staines & Greenwood 2015; Porter & Scully Cbe 2007; Montgomery-Cranny
et al. 2015).
(c) Herpes simplex infection (primary or reactivated/secondary)
Herpes simplex infections (primary or reactivated) are attributable to herpes sim-
plex viruses 1 and 2 (HSV-1 and HSV-2) which are part of the α group of human
herpes viruses (large DNA viruses). As with most human herpes viruses, HSV-1
and HSV-2 exhibit the phenomenon of primary and latent infection whereby a
virus has the ability to remain dormant in a host following the initial infection,
with the potential for intermittent reactivation. Epithelial cells are the preferential
primary target for HSV-1 and HSV-2 with local neurons/ganglia serving as the
site for viral latency (Woo & Challacombe 2007; Westley et al. 2011).
–– Primary herpes simplex virus infection in the orofacial region is often a clini-
cally silent event that occurs fairly early on in life. Following viral entry into
epithelial cells, the host’s cell-mediated immune response abrogates viral rep-
lication and cell lysis and almost immediately sends the virus into a latent
phase. Therefore, the vast majority of patients do not present with clinical
manifestations of a viral syndrome (subclinical primary infection). In a small
proportion of patients, HSV replication and epithelial cell lysis (acantholy-
sis = vesicle formation) proceed unabated. These patients present with an
acute vesiculoulcerative clinical syndrome. In the orofacial region, this pres-
ents as primary acute herpetic gingivostomatitis. The classic patient is a child
or teenager who presents with constitutional signs of a viral infection—fever,
lymphadenopathy, chills, nausea, anorexia, and malaise—which often pre-
cede visible oral lesions. Within a matter of hours to a day, patients present
with an acute, painful, vesiculoulcerative eruption (blisters that quickly ulcer-
ate) that involves multiple oral mucosal sites. The characteristic manifestation
of primary HSV infection is generalized, extremely painful ulcerative gingi-
vitis (Fig. 17.13a, b). In addition, ulcerative lesions may be seen involving the
skin and vermilion of the lip and oral mucosal surfaces that are both keratin-
ized (attached gingiva, hard palate, etc.) and unkeratinized (buccal mucosa,
tongue, soft palate, labial mucosa, etc.). Due to severe pain, patients are often
unable to eat or drink anything—children are especially at risk of hydration.
In otherwise healthy individuals, the primary disease resolves within
2–3 weeks of onset. Following the primary infection, the virus goes into a
latency phase within the local ganglion (trigeminal ganglion—oral infection)
with the potential for future reactivation (Woo & Challacombe 2007; Westley
et al. 2011). The ulcerative lesions of primary HSV infection of the oral cavity
can mimic the presentation of recurrent aphthous stomatitis. However, they
can be distinguished from aphthous stomatitis based on the history (constitu-
tional signs of fever, etc.), the type of lesions (HSV presents as vesicles that
358 E. Natarajan and M. T. Goupil

Fig. 17.13 Primary

herpetic gingivostomatitis.
a
(a) A young patient with
multiple ulcerative lesions
involving attached and
unattached oral mucosal
membranes. The patient
reports acute onset and
accompanying
constitutional signs. (b) A
young patient with
widespread ulcerative
lesions on attached and
unattached oral mucosa
with fever and
lymphadenopathy. Note the
generalized gingival b
erythema, ulceration and
necrotic debris in the
interdental papillae

ulcerate), and most importantly the distribution of lesions. Primary HSV

lesions can be seen on both attached and moveable surfaces, whereas RAS is
seen almost exclusively on moveable, unkeratinized surfaces.
–– Secondary (recurrent) herpetic lesions represent the reactivation of latent
HSV virus from the native ganglion (oral cavity = trigeminal ganglion) fol-
lowed by viral replication and epithelial cell lysis (acantholysis). Reactivated
orofacial HSV infection presents almost exclusively on keratinized/attached
mucosal surfaces (i.e., vermilion/skin of the lip, attached gingiva, hard pal-
ate). The classic manifestation of reactivated (secondary/recurrent) HSV
infection is herpes labialis (“cold sore”). This is characterized by an outbreak
of localized cluster of small vesicles that ulcerate along the vermilion or skin
of the lips. Lesions are localized, cause mild discomfort to pain, and last for
around 10–14 days before they crust over and heal. Recurrent outbreaks are
typically preceded by a prodrome (tingling, burning, pain) in the area where
vesicles emerge. Recurrences can be precipitated by several triggers—stress,
febrile illness (fever blister), immune dysregulation, intense heat/cold, men-
struation, etc. Some patients can present with intraoral reactivated HSV infec-
tion which is seen almost exclusively on the attached gingiva or hard palate
(keratinized surfaces) in a unilateral distribution (Fig. 17.14). In addition to
17 Soft Tissue Oral Pathology 359

Fig. 17.14 Secondary/

reactivated intraoral
herpes. Painful 1–5 mm
ulcerations on the left hard
palate (attached mucosa).
Note the clustered,
unilateral distribution and
lack of soft palatal
involvement

some of the above triggers, intraoral HSV reactivation has also been precipi-
tated by local anesthetic injections or dental procedures. The lesions are simi-
lar and present as small clusters of painful ulcers that heal within 2–3 weeks
(Westley et al. 2011).
HSV infections (primary and reactivated) are acute, self-limiting viral
infections that present with oral ulcerations and may be confused for RAS or
coxsackie infection. The diagnosis of orofacial HSV infections is made almost
exclusively on clinical grounds alone correlating a patient’s history (constitu-
tional signs, acute/short duration) and clinical presentation (distribution,
appearance of ulcers). Laboratory tests and biopsies are of limited value and
are diagnostically nonspecific. Cytological smears looking for virally modi-
fied epithelial cells (Tzanck cells) may be a useful adjunct in selected patients
who present with intact ulcers; however, given that oral vesicles quickly rup-
ture, the value of this test is limited. Diagnosis based on clinical manifesta-
tions as described above tends to be more reliable. Management of patients
with HSV infections is conservative: analgesics-antipyretics, soft diet, and
pain management with topical agents (viscous lidocaine). In selected patients
with multiple, overlapping reactivated HSV infections, antiviral medications
(systemic or topical) may be considered (e.g., acyclovir, valacyclovir, etc.).
(d) Oral coxsackie viral infection (herpangina, lymphonodular pharyngitis, hand-
foot-and-mouth disease): Oral coxsackie viral infections are attributable to
group A coxsackieviruses which are typically spread via the fecal-oral route.
The incubation period for coxsackieviruses is typically 1 week, and resulting
viral syndrome is typically acute running a short 7–10 days of course. Coxsackie
viral infections are usually seen in children, adolescents, and less often in
adults. Patients with coxsackie viral infections typically present with constitu-
tional signs of fever, lymphadenopathy, malaise, headache, nausea, and anorexia
reflective of a self-limiting systemic viral infection. Orofacial lesions are seen
in all three forms of coxsackie infection, i.e., herpangina (localized), lympho-
nodular pharyngitis, and hand-foot-and-mouth disease (systemic). Patients
typically complain of pharyngitis, dysphagia, and a modest degree of oral
mucosal pain. Coxsackievirus infections can be acquired multiple times in an
individual patient but occur only once in a single season.
360 E. Natarajan and M. T. Goupil

Clinically, the lesions of coxsackievirus infection present as widely distrib-

uted vesicles and ulcers. The ulcers are typically clustered and small, ranging
from 1 to 3 mm. The classic distribution is around the posterior oral cavity and
oropharynx (soft palate, tonsillar pillars, base of the tongue, etc.) with a few
lesions seen toward the anterior oral cavity. Lesions may be seen on both kera-
tinized and unkeratinized locations. In some instances, oral and oropharyngeal
lesions may be accompanied by cutaneous vesicles located on the hands, feet,
and other cutaneous sites (hand-foot-and-mouth disease).
Oral coxsackie infections are common and therefore are important for clini-
cians to recognize. Coxsackie infections are acute, self-limiting viral infections
that present with oral ulcerations and may be confused for RAS or herpes infec-
tion. The diagnosis of oral coxsackie infections is made almost exclusively on
clinical grounds alone correlating a patient’s history (constitutional signs, acute/
short duration) and clinical presentation (distribution, appearance of ulcers).
Laboratory tests and biopsies are of limited value and are diagnostically non-
specific. Management of patients with coxsackie viral infections is conserva-
tive: analgesics-antipyretics, soft diet, and pain management with topical agents
(viscous lidocaine).
(e) Erythema multiforme: Erythema multiforme (EM) is an acute, noninfectious,
immunologic mucocutaneous reaction resulting from a T-cell-mediated vascu-
litis. The explosive clinical manifestation of EM is often the result of a precipi-
tant to which a patient has become immunologically sensitized through prior
exposure. Typical precipitants include medications (prescribed/over-the-coun-
ter), drugs (recreational), alcohol, or certain microbial infections (mycoplasma
and herpes simplex viruses). The chemical or infectious agents have the poten-
tial to trigger a systemic Type-III (immune complex mediated) or Type-IV
(delayed/cell-mediated) hypersensitivity reaction. It is essential for clinicians to
recognize that this is not a true “allergic” response (Type-I hypersensitivity); it
is not the result of mast cell-mediated histamine release. Patients sensitized to a
specific precipitant have the potential to present with progressively more severe
manifestations with subsequent exposures.
Clinically, EM can present involving multiple cutaneous and mucosal sites
(e.g., oral, nasal, genital, conjunctival). On the skin, patients may present with
lesions in multiple forms (multiforme): vesicles/bullae, maculopapular rashes,
ulcers, urticaria, purpura, or classically described “target lesions.” Although the
lesions can affect any cutaneous surface, lesions are often seen involving the
palms, soles, and the perioral cutaneous surfaces. Orofacial manifestation is
seen in a significant number of patients (>60–70%) diagnosed with EM. Patients
typically present with acute swelling, vesicles/bullae, ulcerations, and hemor-
rhagic crusting of the vermilion, skin, and mucosa of the upper and lower lips.
Widely distributed intraoral ulcers may be seen. The ulcers are typically irregu-
lar and ragged, and they can mimic the clinical appearance of lesions seen in
chronic conditions like pemphigus or pemphigoid. The extremely painful oral
lesions may preclude a patient’s ability to eat or drink fluids with potential for
dehydration and morbidity.
17 Soft Tissue Oral Pathology 361

The differential diagnosis for erythema multiforme includes acute primary

herpes infection, pemphigus/pemphigoid, recurrent aphthous stomatitis, and
herpangina. The diagnosis of EM is typically made on clinical grounds in rec-
ognition of its acute, self-limiting presentation (ruling out chronic conditions),
correlating a patient’s history (acute/explosive onset, pain, precipitants), and
clinical presentation (distribution, appearance of lesions). The clinical presenta-
tion of erythema multiforme may trigger biopsy studies with conventional and
direct immunofluorescence (DIF) analyses; histopathological and DIF analyses
are diagnostically nonspecific. Although the clinical course of EM episodes is
acute and self-limiting, it is essential that clinicians address this explosive, often
debilitating immune-reaction syndrome. Immunomodulatory intervention (sys-
temic/topical) may be indicated in addition to pain management. Additionally,
and more importantly, clinicians must try and identify and address the inciting
agents that cause EM in patients. A significant proportion of EM is associated
with reactivated herpes simplex infection, providing the rationale for prophy-
lactic antiviral therapy in those patients.

17.6.3 Chronic Ulcerative Conditions

17.6.3.1 Solitary Chronic Ulcers

(a) Chronic traumatic ulcer: As described in the section above (traumatic ulcers),
traumatic ulcers typically heal within 1–2 weeks. If the initial stimulus that led
to the ulcer persists (e.g., overextended denture flanges, fractured tooth struc-
ture, improperly contoured/fractured restoration), or if a patient has certain pre-
disposing factors (e.g., extremely dry mouth, immunosuppression/depletion),
then a traumatic ulcer can persist for longer than 3 weeks. In this setting, trau-
matic ulcers can be chronic in duration. These lesions are clinically worrisome
and present as deep ulcers with areas of hyperplasia, underlying scarring, symp-
toms, and surrounding white and red changes (Fig. 17.15a, b). The ulcers may
present with areas of induration as a result of underlying scar tissue. Chronic,
long-standing traumatic ulcers may present with pain or in some patients be
painless or associated with persistent discomfort. Just as with self-limiting trau-
matic ulcers, it is essential for clinicians to determine the source of trauma and
address the inciting stimulus accordingly. Solitary chronic ulcers that persist
beyond 2–4 weeks despite having addressed the source of physical trauma must
be viewed with suspicion. These ulcers must be biopsied to rule out the possi-
bility of oral squamous cell carcinoma (see Flowchart 17.2). Complete surgical
excision may be indicated for chronic traumatic ulcers with surrounding hyper-
plastic tissue in an attempt to achieve healing/repair by primary intention.
(b) Squamous cell carcinoma: Oral squamous cell carcinoma (OSCC) is a malig-
nant neoplasm arising from the oral mucosal lining and is the result of pro-
tracted genetic deregulation within the stratified squamous epithelium
(Natarajan and Eisenberg 2011). The most common clinical presentation of
OSCC is as a solitary, progressive, chronic, ulcerated mass in classically
362 E. Natarajan and M. T. Goupil

Fig. 17.15 (a, b)

Traumatic ulcers, chronic. a
Longstanding (>1 month)
ulcers on the left lateral-
ventral tongue. These
patients reported a history
of trauma. If these ulcers
do not show signs of
healing 2–3 weeks after
addressing local traumatic
factors, a biopsy is
indicated

cancer-prone locations (e.g., lateral tongue, ventral tongue, floor of mouth,

soft palate, etc.) and in locations in contact with tobacco and tobacco products
(e.g., buccal vestibules). Patients are often aware of a “sore” or “lump” in
these locations for several weeks or months and may report progressive
growth. The ulcer is often painless but in some patients can present with
symptoms of severe pain and paresthesia (i.e., numbness, tingling, burning).
The growth rate of the ulcer and/or mass is variable but is relatively rapid
when compared to benign processes. As described previously in the section
on “White Lesions,” the ulcerated masses exhibit prominent red and white
plaques with a variegated surface appearance (i.e., corrugation, verrucous/
papillary, speckled, lobulated, pebbly) (Figs. 17.16 and 17.8). The ulcerated
tumors are typically indurated (hard) on palpation and tend to tether down
affected tissues (tumor infiltration, desmoplastic scarring). The surrounding
white plaques exhibit microscopically diagnosable epithelial dysplasia. In
addition to oral changes, patients with OSCC may present with palpable
regional lymphadenopathy at the time of presentation. As with the tumor,
these nodes are typically indurated and tethered/matted to adjacent tissues
(Natarajan and Eisenberg 2011).
17 Soft Tissue Oral Pathology 363

Fig. 17.16 Squamous cell

carcinoma. A large painful,
ulcerated, indurated (hard)
mass on the right ventral
tongue surrounded by
white surface changes

As a general rule, any oral ulcerative lesion that is solitary in a cancer-prone

location or otherwise that persists for more than 3–4 weeks despite having
addressed potential traumatic stimuli must be biopsied. Multiple representative
biopsies may be indicated for lesions that are large and heterogeneous in
appearance.
(c) Other solitary chronic ulcers: Although trauma and OSCC account for the vast
majority of solitary chronic ulcers of the oral cavity, there are chronic ulcers
representative of the following pathological processes:
• Other malignant neoplasms—salivary gland malignancies (lateral palate),
metastatic disease (bone + soft tissue), other primary malignancies (lym-
phoma, melanoma)
• Infections—granulomatous ulcers (e.g., tuberculosis, deep fungal infections,
syphilis)
• Granulomatous ulcers—foreign body granulomas with ulceration

17.6.3.2 Multifocal Chronic Ulcers

Patients who present with a combination of chronic, multifocal oral ulcerations pose
diagnostic challenge. Patients often present with pain, tissue fragility, and func-
tional compromise. They are often the result of an underlying chronic immune-
mediated mucocutaneous condition. As described above, the diagnostic process for
such complaints must begin with a disciplined clinical history (Table 17.1), fol-
lowed by thorough examination. In addition, clinicians may ask the following key
questions that are pertinent to patients presenting with a potential immune-mediated
condition:

1. Does the patient have any scaly, pruritic, popular, vesicular, or ulcerative cutane-
ous lesions anywhere on the skin surfaces?
2. Does the patient experience any discomfort, pain, redness, stinging/irritation, or
gritty sensations involving the eyelids? History of nasal epistaxis? Genital muco-
sal, pharyngeal, or esophageal discomfort/pain?
364 E. Natarajan and M. T. Goupil

3. Does the patient experience any gastric discomfort, diarrhea, bloating, flatu-
lence, hematochezia (blood in the stools)?
4. Is there a temporal relationship between the onset of lesions and introduction of
new medications (prescriptions/over-the-counter)/supplements?

(a) Erosive lichen planus: As described in the section on “White Lesions,” oral
lichen planus (OLP) is a benign cell-mediated autoimmune disease character-
ized by multifocal, symmetrical, papulosquamous dermatosis and mucosal
lesions. Lichen planus is the result of a T lymphocyte-mediated cytotoxic
destruction of basal keratinocytes that results in compensatory surface hyper-
keratosis resulting in the classically described reticular white striations, pap-
ules, and plaques (Cheng et al. 2016). Foci of erosion/ulceration of the
epidermis/mucosae correspond to areas where sustained cell-mediated destruc-
tion overwhelms or abrogates compensatory epithelial proliferation. Patients
with the reticular form are generally asymptomatic. The erosive/ulcerative
form of OLP, although less common, is clinically significant as patients are
often symptomatic; the symptoms may include sensitivity (to acidic/abrasive
food), discomfort, general soreness, pain, or combinations of the above (Cheng
et al. 2016; Park et al. 2012). In addition to widely distributed chronic ulcer-
ations/erosions, foci of erosive OLP are usually surrounded by characteristic
non-wipeable white striations or papular lesions (Fig. 17.17a, b). Patients often
present with progressively uncomfortable/painful oral mucosal surfaces.
Gingival involvement is often a prominent feature of erosive lichen planus
(Fig. 17.17c). In addition to widespread mucosal fragility, patients may report
bleeding during professional manipulation and/or home oral hygiene care.
Additionally, lichenoid stomatitides (similar to lichenoid dermatoses), a
large group of clinically and/or histologically diverse conditions, can have fea-
tures similar to that of classic OLP. Since there is a range of clinical situations
(clinical/histological) that mimic LP (e.g., direct contact hypersensitivity, drug-
related lichenoid lesions, other autoimmune conditions, etc.), it is more appro-
priate to view them as chronic immune-mediated processes that share the
pathogenetic mechanisms of chronic T-cell activation with degrees of basal cell
and basement membrane complex destruction. This explains the spectrum and
overlap in clinical presentation of lichenoid stomatitides. For that reason,
lichenoid stomatitis should be considered as a diagnostic possibility in patients
presenting with multifocal chronic oral ulcers (Park et al. 2012; Patel et al.
2016).
The clinical presentation of erosive lichenoid oral lesions can be indistin-
guishable from other chronic immune-mediated ulcerative/erosive mucocu-
taneous conditions like mucosal pemphigoid and pemphigus posing a diagnostic
challenge. In this setting, biopsies are indicated to establish a definitive diagno-
sis (Patel et al. 2016). The recommended diagnostic work-up for chronic ero-
sive/ulcerative immune-mediated mucocutaneous conditions is provided below.
(b) Mucous membrane pemphigoid: Mucous membrane pemphigoid/mucosal pem-
phigoid/cicatricial pemphigoid (MMP) is one among a number of chronic auto-
immune vesiculobullous (blistering) conditions which can present with
17 Soft Tissue Oral Pathology 365

Fig. 17.17 (a–c) Oral a

lichen planus, erosive/
ulcerative. Bilateral,
multifocal distribution of
reticular white striations
with intervening areas of
erosion and ulceration.
Note the areas of
ulceration on the buccal
mucosae surrounded by
radiating striations. Also,
note the prominent gingival
involvement—lichenoid
striations on the interdental
papillae and vestibule, and
erosive changes along the
posterior attached gingivae b
preventing oral hygiene
maintenance

multifocal chronic oral ulcerations/erosions (Taylor et al. 2015). As the name

indicates, there could be simultaneous involvement of multiple other mucous
membranes, particularly conjunctival mucosa and nasal, genital, and esopha-
geal mucosa. MMP is typically not accompanied by corresponding cutaneous
involvement. MMP is the result of an autoimmune antibody-mediated destruc-
tion of the hemidesmosomal-basement membrane complex (BHMC). IgG and
C3 mediated reaction against elements of the BHMC in the disruption of the
366 E. Natarajan and M. T. Goupil

attachment which anchors the epithelium to the basement membrane zone

(BMZ), resulting in separation and complete “lifting off” (desquamation) of the
surface epithelium from the underlying lamina propria (Kasperkiewicz et al.
2012; Schmidt & Zillikens 2013; Jascholt et al. 2017). The separation of the
basal epithelium from the underlying basement membrane complex is often
described as being “clean” with intact basal epithelium seen along the roof of a
blister. Therefore, MMP is among the mucocutaneous diseases characterized
clinically by a positive Nikolsky sign: tactile-induced fragility and/or bulla for-
mation which results in sloughing of the mucosal (or skin) surface. The Nikolsky
sign is diagnostically nonspecific and is a clinical indicator of weakness in
attachments between epithelial cells or the epithelial-stromal interface
attachment.
MMP is often described as a disease that classically affects perimenopausal,
middle-aged women. However, it must be noted that MMP is a chronic condi-
tion that can affect any adult, regardless of sex. Clinically, the most common
initial presentation of patients with oral MMP is chronic, progressive gingival
discomfort with notably “red gums” which are typically nonresponsive to pro-
fessional and/or home oral hygiene measures (Fig. 17.18a). Patients often report
a prolonged course with pain/discomfort that varies considerably over time and
from patient to patient. The clinical manifestation of MMP is characterized by
desquamative gingival lesions, erosions, ulcers, and tissue fragility; intact oral
vesicles/bullae are rarely observed as they tend to rupture easily (Fig. 17.18b).
Although the gingival involvement is most prominent, other oral mucosal sites
can also be involved. Disease activity and degrees of discomfort vary consider-
ably with every patient. Patients often report symptomatic exacerbations aggra-
vated by the introduction of spicy/acidic or abrasive/sharp foods. The repeated,
overlapping vesiculoulcerative lesions of MMP are associated with aberrant
repair and scarring (cicatrix formation). In the oral cavity, repeated gingival/
alveolar mucosal scarring may manifest as reduced vestibular depth.
This tendency for cyclical erosion and scarring is especially significant when
other mucosal sites are involved, most of all the conjunctival surfaces. MMP
involving the conjunctival mucosae can result in the formation of progressive
band-like adhesions between the palpebral and bulbar conjunctiva (symblepha-
ron) and potential inversion of the eyelid (entropion) (Kasperkiewicz et al.
2012; Schmidt & Zillikens 2013). Erosive and ulcerative lesions affecting other
mucosal sites including the genital mucosa, nasal mucosa, and esophageal
mucosa can cause significant morbidity. It is for this reason that clinicians must
ask directed questions about extraoral mucosal and cutaneous involvement
while documenting a patient’s clinical history.
Bullous pemphigoid (BP) is an entity within the pemphigoid group of disor-
ders and is similarly characterized by autoantibody-mediated destruction of ele-
ments of the BHMC (protein BP180) (Schmidt & Zillikens 2013). While the
condition may bear some similarity to MMP, bullous pemphigoid is primarily a
cutaneous condition with few patients exhibiting oral mucosal involvement. BP
is considered a disease of older adults, typically 60 years of age or older.
Cutaneous lesions on the trunk and extremities present as erythematous
17 Soft Tissue Oral Pathology 367

Fig. 17.18 (a) Mucous a

membrane pemphigoid,
oral. Generalized gingival
erythema and erosion
involving the margins,
attached gingiva and
alveolar mucosal surfaces.
Similar findings noted on
the palatal aspect, and
mandibular arch. The
patient had concomitant
conjunctival involvement.
(b) Mucous membrane
pemphigoid, vesicle.
Generalized gingival
erythema with
b
desquamation. Note the
intact vesicle on the
gingival surface between
teeth # 26 and 27

papules, tense bullae, and vesicles which rupture and ulcerate. The oral lesions
of BP are indistinguishable from those seen in MMP, affecting the gingival tis-
sues as well as other oral sites. Other mucosal sites may be involved in patients
with BP.
As with erosive lichenoid stomatitides, MMP and BP can be indistinguish-
able from other chronic immune-mediated ulcerative/erosive mucocutaneous
conditions (Patel et al. 2016). In this setting, biopsies are indicated to establish
a definitive diagnosis. The recommended diagnostic work-up for chronic ero-
sive/ulcerative immune-mediated mucocutaneous conditions is provided below
(diagnostic work-up). Furthermore, patients diagnosed with MMP must be
referred to appropriate specialists (e.g., ophthalmology, otolaryngology, derma-
tology, etc.) for further evaluation and management.
(c) Pemphigus vulgaris: Pemphigus is a group of chronic, antibody-mediated auto-
immune mucocutaneous disorders characterized by acantholysis and vesicu-
lobullous lesions (blistering) that can involve both cutaneous and mucosal
tissues, including the oral cavity (Sultan et al. 2017; Feller et al. 2017). The
pemphigus group of disorders consists of four subtypes of which pemphigus
vulgaris is the most common. Pemphigus vulgaris is characterized by autoan-
tibody-mediated destruction of cell-to-cell adhesion in the supra-basal kerati-
nocyte layers (spinous cells). The sensitized immune system generates
368 E. Natarajan and M. T. Goupil

antibodies (IgG) that target the desmosomes, specifically desmoglein 3, a gly-

coprotein cadherin linked to the intermediate filaments of epithelial cells.
Destruction of desmosomes by IgG and resulting complement activity (C3)
causes the spinous cells to separate from one another (acantholysis), compro-
mising the integrity of the epithelium (Feller et al. 2017). In the clinical set-
ting, acantholysis presents as cutaneous and/or mucosal blisters, mucosal/
epidermal fragility, desquamation, and painful ulcerations. Untreated pem-
phigus can predispose patients to serious skin infections and can be a devas-
tating and potentially fatal. Oral mucosal involvement can precede cutaneous
involvement in some patients. Clinically, oral pemphigus is characterized by
extremely painful ulcers involving any and all oral mucosal surfaces. Unlike
the round, symmetrical appearance of aphthous ulcers, the oral ulcers seen in
pemphigus are markedly irregular, ragged, and extremely friable (Fig. 17.19a–
c) (Sultan et al. 2017). The surrounding mucosal surfaces are prone to slough-
ing on pressure (+Nikolsky sign). Intact vesicles/bullae are almost never seen
within the oral cavity. Patients may be aware of or may report cutaneous
lesions and/or other mucous membrane involvements (genital, nasal, etc.). A
thorough history with relevant questions that address other areas of involve-
ment as listed above should help guide a clinician toward an appropriate diag-
nostic work-up.
As with pemphigoid, biopsies with special immunofluorescence analysis are
indicated to establish a definitive diagnosis. The recommended diagnostic
work-up for chronic erosive/ulcerative immune-mediated mucocutaneous con-
ditions is provided below (diagnostic work-up). Furthermore, patients diag-
nosed with pemphigus must be referred to appropriate specialists (e.g.,
dermatology, gynecology, etc.) for further evaluation and management as indi-
cated below (management).

17.6.4 Diagnostic Work-Up for Oral Ulcerative Conditions

17.6.4.1 Acute Ulcerative Conditions

1. Conditions/entities diagnosed on clinical grounds: traumatic ulcers, aphthous
ulcers, primary and/or reactive herpes simplex infections, coxsackievirus
infections
2. Conditions requiring biopsies: large potentially traumatic ulcers that persist
beyond 3–4 weeks
3. Conditions potentially requiring additional diagnostic tests:
–– Recurrent aphthous stomatitis with inflammatory bowel-related symptoms
(Crohn’s disease, celiac disease, ulcerative colitis)—gastroenterology
evaluation
–– Recurrent aphthous stomatitis with mucocutaneous lesions (Behcet’s dis-
ease)—rheumatology evaluation
–– Herpes simplex infections with intact vesicles—cytological smear to detect
virally modified epithelial cells (Tzanck cells)
17 Soft Tissue Oral Pathology 369

Fig. 17.19 (a) Pemphigus a

vulgaris, bulla. Patient with
pemphigus vulgaris
presents with an intact
bulla on the right posterior
buccal mucosa. This bulla
ruptured shortly after this
photograph was taken
leaving behind a painful,
ragged oral ulcer. (b)
Pemphigus vulgaris,
ruptured bulla. This is the
same patient as (a)
presenting with a ruptured
bulla. Note the irregular,
ragged appearance of the
ulcer in the right lower b
vestibule and labial
mucosa. (c) Pemphigus
vulgaris, ulcer. Ragged
appearing ulcers
characteristic of
pemphigus vulgaris

17.6.4.2 Chronic Ulcerative Conditions

1. Conditions that require biopsies for specific diagnosis—chronic/long-standing
traumatic ulcers that have not healed/resolved after elimination of potential local
sources of trauma/irritation. As discussed above, chronic solitary ulcers must be
regarded with caution and must be biopsied to rule out the possibility of a malig-
nant neoplasm or other pathology.
370 E. Natarajan and M. T. Goupil

2. Conditions/entities that require conventional biopsies and direct immunofluores-

cence analysis: Long-standing/persistent multifocal oral ulcerative lesions that
may or may not be accompanied by other mucosal and/or cutaneous involvement
are generally suggestive of a chronic immune-mediated ulcerative mucocutane-
ous condition. In this setting, it is essential to analyze the affected and surround-
ing oral/cutaneous tissue under light microscopy and direct immunofluorescence
(Suresh & Neiders 2012; Yih et al. 1998; Amber et al. 2016). Diagnostic confir-
mation of autoantibody-mediated immunological ulcerative conditions requires
obtaining two tissue specimens during the same surgical procedure: (1) a repre-
sentative tissue biopsy taken adjacent to an active mucosal lesions for conven-
tional light microscopic examination submitted in 10% neutral buffered formalin
and (2) a specimen from a relatively intact mucosal specimen which is adjacent
to an active lesion for direct immunofluorescence (DIF) analysis. DIF analysis is
essential for determining diagnostic specificity. It discloses (1) the presence or
absence of immune reactants (e.g., antibody, antibody-antigen complexes, com-
plement, fibrinogen, etc.); (2) the specific anatomic location of immune reactants
within the epithelium, subepithelial zone, and perivascular regions; and (3) the
specific immune reactants identified (e.g., IgG, C3, IgA, etc.). Specimens sub-
mitted for DIF analysis must be submitted in an appropriate transport medium
(Zeus or Michel’s preservative solution) to allow for analysis of immune
reactants.

17.7 Oral Mucosal Masses/Tumors

The discovery of oral soft tissue masses can present clinicians with a diagnostic
challenge, as they could be the result of epithelial and/or mesenchymal prolifera-
tion. These swellings can have varied clinical appearances, present in various oral
locations, and represent a range of pathological processes: reactive/inflammatory,
benign neoplasm, malignant neoplasms, developmental/genetic, or the manifesta-
tion of an underlying systemic condition. Fortunately, the vast majority of oral soft
tissue masses are the result of the first three processes, namely:

1. Reactive/inflammatory—exuberant inflammatory and/or reactive hyperplastic

lesions
2. Benign neoplasms—genetic mutations leading to benign proliferation of epithe-
lial/mesenchymal tumor tissue
3. Malignant neoplasm—genetic mutations leading to malignant proliferation and
infiltration of epithelial/mesenchymal tumor tissue

17.7.1 Oral Soft Tissue Masses/Nodules: The Diagnostic Process

When clinicians develop a differential diagnosis for a given oral soft tissue mass,
clinicians must approach the diagnostic process in a stepwise manner as discussed
below and as shown in Flowchart 17.3. As with any other abnormal finding, the
17 Soft Tissue Oral Pathology 371

Oral Mucosal Mass/ Nodule

Benign reactive hyperplasia Benign neoplasm Malignant neoplasm

Location: Location:
- Sites of acute/ chronic friction FACT: Oral Squamous cell carcinoma is
- Any intraoral mucosal site the MOST COMMON ORAL MALIGNANCY
- Lower lip, buccal mucosa, gingiva, - Salivary gland neoplasms: upper lip,
lateral tongue postero-lateral hard palate, General features of Oral Malignancy
buccal mucosa Location:
Clinical history: - Squamous papilloma: any oral site,
- Hx of trauma; agent of trauma/ - Oral SCC - lateral/ventral tongue, floor of
preferentially soft palate, tongue mouth, soft palate, vestibule (tobacco)
friction in area
- Painless - Salivary gland - posterolateral palate
Clinical history:
- Slow/ rapid growth (depends on - MASS - Lymphoma - posterior palate
stimulus) - SLOW GROWTH - Years - Metastatic disease - intraosseous in the
- Painless mandible canine/premolar region
Clinical appearance: - Persistent/ progressive growth
- MASS - No local traumatic factor Clinical history of cancer (generally):
- Painless - RAPIDLY GROWING MASS over weeks/
- Smooth surface, mucosa colored Clinical appearance: months
- Occasional ULCERS - MASS - Pain/ paresthesia/ painless
- Discrete, not encapsulated - Discrete, often mobile, pedunculated, (on occasion)
symmetrical - No obvious local factors (trauma/ friction)
Examples: - Smooth surface. NON-ULCERATED - Weight loss, fatigue, lymphadenopathy
1. Traumatic fibroma - Mucosal colored or color of tumor - Rapid tooth mobility
2. Pyogenic granuloma, peripheral content e.g. White/ pink SCC specifically: Hx of tobacco/
giant cell granuloma (Squamous papilloma), alcohol use Metastatic Disease -
3. Epulis fissuratum Lipoma (yellow), Hemangioma Hx of primary cancer
4. Exuberant gingival hyperplasia (red, blue)
- Encapsulation Clinical appearance of Oral Malignancy:
- MASS
Examples: - RAPID GROWTH
1. Papilloma/ verruca vulgaris - ULCERATION, ERYTHEMA,
Exuberant reactive hyperplasias: 2. Hemangioma telangiectasia
- DO NOT resolve spontaneously 3. Lipoma - INDURATION on palpation
4. Schwannoma/ neurofibroma - Irregular borders, diffuse
- persist and can progress if inciting
5. Leiomyoma SCC specifically: WHITE &
traumatic agent persists RED SURFACE CHANGES
- can affect oral hygiene SURROUNDING TUMOR
- management must include Examples:
addressing the inciting agent 1. Oral squamous cell carcinoma
2. Mucoepidermoid carcinoma
3. Malignant lymphoma
4. Metastatic carcinoma of the breast/ lung etc.

Incisional Biopsy

Reactive hyperplasia Benign neoplasm Malignant neoplasm

Management: Management: DIAGNOSIS AND STAGING and further
- Surgical excision - Complete surgical excision evaluation for all malignancies
- Address local inciting factors Oral Squamous cell carcinoma - specific
1. Margins are generally dysplastic
2. Patient education - genetic mutations may be
present in surrounding tissues
3. Indefinite follow-up after initial management

Flowchart 17.3 Oral mucosal mass/nodule. A step-by-step approach to the diagnosis of clini-
cally indeterminate oral mucosal masses. Selected examples of reactive hyperplasias, benign and
malignant neoplasms

diagnostic process must begin with a patient’s presenting complaint and relevant
history taking. Most patients who present with a mass are aware of it, often present-
ing with it being the chief complaint. Oral soft tissue growths can be alarming to
patients, especially if they have grown rapidly and potentially associated with
372 E. Natarajan and M. T. Goupil

symptoms of discomfort/pain/bleeding. On the other hand, patients with slow-

growing, asymptomatic oral masses may be aware of them but overtly concerned.
Regardless, clinicians should approach the diagnosis of masses/nodules by fleshing
out the history of the presenting lesion.

1. Duration:
(a) When did your provider discover this lesion/lesions?
(b) How long have you been aware of this lesion?
2. Discovery: How did you discover this lesion?
3. Stimuli/triggers:
(a) Do you recall a history of trauma?
(b) Do you have a habit of grinding your teeth/biting your tongue/cheek/lip?
4. Signs/symptoms:
(a) Do you have pain/discomfort/paresthesia associated with this lesion?
• Character of symptoms: persistent/intermittent
• Quality of symptoms: intense pain, burning, scales of pain
(b) Any history of bleeding? Any discharge?
5. Progression:
(a) Has the lesion grown in size or reduced in size since discovery?
(b) Are you aware of any surface changes on this mass? Ulcer? Color change?
6. Factors that alleviate/aggravate symptoms (if any)

Each of the above parameters provides valuable information in developing a dif-

ferential diagnosis. Among these, the following parameters are of paramount impor-
tance in determining whether a discovered mass represents a benign growth
(exuberant hyperplasia or benign neoplasm) or a malignant neoplasm:

Location: certain pathological processes occur in specific locations.

Duration: benign growths are generally long-standing and painless. Malignant neo-
plasms tend to be more recent in history.
Rate of growth: benign growths typically grow slower than malignant neoplasms.
Surface characteristics: benign growths are typically non-ulcerated and smooth sur-
faced, while malignant tumors are often ulcerated.
Symptoms: benign growths tend to be painless. Malignant tumors are often associ-
ated with pain, paresthesia, and functional compromise.

Gathering the above information should help clinicians determine the appropri-
ate diagnostic and management approach (see Flowchart 17.3).

17.7.2 Exuberant Reactive Hyperplasias

Nodules/masses that are reactive/inflammatory in origin are typically masses of

submucosal (mesenchymal components) tissue that arise in response to a local incit-
ing agent, inflammatory source, or chronic traumatic injury. Patients are generally
aware of an underlying parafunctional habit or report a local traumatic agent. These
17 Soft Tissue Oral Pathology 373

lesions tend to be painless and tend to grow very slowly over months to years. The
surface mucosa is typically intact and the color of surrounding mucosa. Ulcerations
and white surface plaques may be seen if these lesions are secondarily traumatized.
Examples include traumatic fibromas (Fig. 17.20a, b) on the buccal or labial mucosa
secondary to biting (Savage and Monsour 1985) and epulis fissuratum secondary to
denture flange impingement. Exceptions to this slow growth rate include exuberant
granulation tissue responses to local irritants. Examples include pyogenic granu-
loma (Fig. 17.21) in response to trauma/local plaque/ill-fitting restoration/extrac-
tion sockets and peripheral giant cell granulomas (PGCGs) on the gingiva secondary
to plaque/rough restoration margins (Fig. 17.22) (Bhaskar & Jacoway 1966). Given
their relatively rapid growth rate, pyogenic granulomas and PGCGs tend to present
with ulcerated surfaces and occasional bleeding (Jafarzadeh et al. 2006; Katsikeris
et al. 1988; Barker and Lucas 1967).
Although benign, it is important for clinicians to recognize that these lesions do
not resolve spontaneously. These exuberant reactive hyperplastic nodules frequently
require surgical excision as they can persist and progress to grow if a local inciting
agent persists. Furthermore, it is essential that clinicians attempt to address the
inciting agent. Failing to do so can result in these masses reappearing/recurring in

Fig. 17.20 (a, b)

Traumatic fibroma.
a
Painless, longstanding,
discrete, sessile, smooth
surfaced and mucosa-
colored nodules on the
lower labial mucosa
(trauma prone location)

b
374 E. Natarajan and M. T. Goupil

Fig. 17.21 Pyogenic

granuloma. Painless,
exophytic, ulcerated
nodule on the upper labial
mucosa. Note that
pyogenic granulomas can
occur on locations other
than gingiva. Also, this is
an older gentleman—PGs
are not exclusive to
pregnant women

Fig. 17.22 Peripheral

giant cell granuloma.
Painless, longstanding,
firm, focally ulcerated
nodule on the maxillary
anterior attached and
marginal gingiva. PGCGs
are comprised of
hyperplastic granulation
tissue with giant cells and
occur exclusively on the
gingival tissues

the same location. For instance, pyogenic granulomas on the gingiva tend to recur if
the local plaque/calculus that stimulated the exuberant granulation tissue hyperpla-
sia is not addressed. Such patients may require additional scaling/root planing in
addition to surgical excision of the pyogenic granuloma.
Excised specimens must be submitted for histopathological examination and
specific diagnosis.

17.7.3 Benign Neoplasms

Benign neoplasms are caused by genetic mutations (acquired/germ line) that

result in a benign, often clonal proliferation of the affected tissue (­ epithelial/
mesenchymal). Unlike exuberant reactive hyperplasias, benign neoplasms can
arise in any oral mucosal location and are not associated with a specific trau-
matic insult/chronic irritant. Benign neoplasms present as slow-growing, pain-
less masses with intact surface mucosal tissue. Patients are often aware of a
slow-growing mass for several months to years and report no symptoms associ-
ated with them.
17 Soft Tissue Oral Pathology 375

Fig. 17.23 Verruca

vulgaris, multiple.
Painless, discrete,
exophytic, white,
rough-surfaced/verrucous
nodules on the right
anterior buccal mucosa.
Benign oral warts can
present as solitary masses
or can be multiple

Clinically, benign neoplasms are discrete, often mobile (encapsulation), and

may be pedunculated (stalk). They tend to be symmetrical and smooth surfaced.
Benign neoplasms may be ulcerated if patients have secondarily traumatized
them. Depending on the tumor cell composition, benign neoplasms can range
from being mucosal colored (e.g., leiomyoma, true fibroma, neurofibromas), or
white/pink (e.g., HPV-associated squamous papilloma/verruca vulgaris)
(Fig. 17.23), or yellow (e.g., lipoma, lymphoid proliferation), or red/blue (e.g.,
hemangioma), or other colors depending on the underlying proliferative compo-
nent (Ethunandan & Mellor 2006; Fregnani et al. 2003; Friedman et al. 1987;
Gonsalves et al. 2007; Kaban and Mulliken 1986; Toida et al. 2003).
As with exuberant reactive hyperplasias, these lesions must be completely surgi-
cally excised. They often lend themselves to easy excision given their discrete, often
encapsulated nature.

17.7.4 Malignant Neoplasms

Malignant neoplastic processes are the result of cumulative genetic defects over
years/decades. As described in the section on squamous cell carcinoma, the cumula-
tive genetic deregulation within cells and tissues is often driven/accelerated by the
presence of risk factors. There is a wide range of malignant neoplasms that can
present as soft tissue masses on the oral mucosa, including squamous cell carcino-
mas, salivary gland malignancies (e.g., mucoepidermoid carcinoma, adenoid cystic
carcinoma), malignant lymphoma, and oral manifestation of metastatic disease.
With this in mind, it must be emphasized that the most common oral malignancy is
squamous cell carcinoma (OSCC) that arises from the mucosal lining that lines the
oral cavity. OSCC comprises more than 95% of all oral malignancies.
Regardless of the individual entity, malignant neoplasms of the oral cavity share
certain general clinical features that are important for clinicians to recognize and act
on. Almost all oral malignant neoplasms present as masses that grow fairly rapidly.
Due to their rapid and infiltrative character, tumors are often ulcerated and exhibit
376 E. Natarajan and M. T. Goupil

varying degrees of erythema and/or necrosis on the surface (Fig. 17.24a, b). Malignant
tumors are frequently ill-defined and asymmetrical and have a lobulated/lumpy-bumpy
character. Various surface changes that may be noted include prominent white/red
plaques surrounding the masses (as seen in OSCC), bluish hue with secretions (as seen
in mucoepidermoid carcinoma), or vascular surface m ­ arking/surface bleeding (result-
ing from the underlying angiogenesis and desmoplastic stroma associated with malig-
nancies). Malignant tumors are frequently hard/indurated on palpation. Patients may
present with symptoms of pain/paresthesia (i.e., numbness, tingling, burning), weight
loss, lymphadenopathy, rapid tooth mobility, and difficulty swallowing. They may also
report unintentional weight loss and fatigue, which may be an indication of systemic
disease (metastatic spread). When clinicians encounter ulcerated masses on oral muco-
sal surfaces, it is essential to gather information on the duration of the lesion and to rule
out local inciting factors. It is also important to ask patients if they have a history of
other primary cancers currently or in the past. If an ulcerated mass has persisted longer
than 3–4 weeks and the surface exhibits changes that are suspicious, representative
incisional biopsy/biopsies must be obtained. Based on the specific diagnosis, patients
diagnosed with malignant neoplasms must be referred to specialty teams for further
evaluation, staging, and management. Furthermore, patients diagnosed with malignant
neoplasms of the oral cavity must be followed up indefinitely following management.

Fig. 17.24 Oral mass a

suspicious for malignancy,
salivary gland malignancy.
(a) This ulcerated mass on
the right posterior hard-soft
palate junction warrants
biopsies. The biopsy
revealed a mucoepidermoid
carcinoma which is typical
for this location. (b) A
painful, fungating,
ulcerated mass on the left
anterior maxillary alveolar
ridge with ill-defined
radiographic destruction of
the underlying bone.
Biopsies revealed a
squamous cell carcinoma
that infiltrated the floor of
b
the maxillary sinus and
surrounding gnathic
structures
17 Soft Tissue Oral Pathology 377

17.8 Biopsy Considerations

Several decisions need to be made by the dentist prior to performing a biopsy. First
and foremost, does a biopsy even need to be performed? The primary reason to per-
form a biopsy is to obtain tissue to establish a diagnosis once the differential diagnosis
has been developed. Not infrequently the area of concern may be a normal anatomical
variation, or the history and clinical exam may be so characteristic or pathognomonic
that the diagnosis is obvious, and no further investigation is warranted. Even in these
situations, a biopsy may be warranted to satisfy the patient’s concern.
The next obvious question is who should perform the biopsy? Can the biopsy be
performed by the general dentist or would a specialist be preferred? The author’s
(MG) preference is that if there is a high probability that the condition is malignant,
then the biopsy may be better performed by the practitioner that most likely will be
providing the definitive care. Other considerations in answering this question
include comfort level of the dentist, location of the lesion within the oral cavity, and
even the dental practice location. For example, lesions located on the tonsil pillar
are much more difficult to biopsy than ones on the lip. Specialty referral may be
more difficult for the patient when the patient is treated in a very rural practice as
opposed to an office in a medical arts building.
Once the practitioner has decided to perform the biopsy, the next decision is what
kind of biopsy? There are two primary biopsy types, an excisional biopsy where the
entire area of concern is removed and an incisional biopsy where a representative
sample is obtained. An excisional biopsy in most cases should be reserved for well-
demarcated lesions 1 cm or less in the greatest diameter and not closely related to
other significant anatomical entities, i.e., the lip commissure region. Incisional
biopsy probably should not be considered for vascular lesions due to the potential
difficulty in obtaining hemostasis. In the past one may have been advised not to
incisional biopsy pigmented lesions that have a high probability of being a mela-
noma. Phlugfelder et al. state that “incisional biopsies of malignant melanoma do
not negatively influence prognosis (Pflugfelder et al. 2010).”
There are a few subcategories within incisional biopsy. A fine needle aspirate
(FNA) involves using a large bore needle on a syringe with the goal of aspirating
diagnostic cells from within a nodule. This is frequently used for deep-seated
nodules and is best performed by a specialist. A brush biopsy is used to obtain
cells from the surface of a lesion. This technique has been recommended as part
of a routine dental examination but is of questionable value and may lead to a
false sense of security (Bhoopathi & Mascarenhas 2011; Bhoopathi et al. 2009).
A punch biopsy is a special technique for an incisional biopsy that can be per-
formed quite easily by most dental providers. Biopsy specimens should be
obtained using sharp instruments. The soft tissue must be handled carefully to
avoid distortion. This includes methods that may cause thermal damage.
A final consideration to be made is the transportation of the biopsy specimen to
the pathologist. Biopsy specimens are usually transported in 10% buffered forma-
lin. There is one significant exception to this and supports the importance of devel-
oping a differential diagnosis. In the case of vesicular-bullous lesions, where an
underlying immune process is highly probable, different tissue preservation tech-
niques are required. When performing a biopsy on an immunological based process,
378 E. Natarajan and M. T. Goupil

a minimum of two biopsy specimens are required. One specimen is placed in the
standard formalin solution and will undergo routine H&E examination. The other
specimen is placed in saline gauze for quick freezing and can then be used for spe-
cialized immunofluorescent studies. An alternative to performing two biopsies is to
take a slightly larger specimen and divide it in two.
Specimens can be delivered to the local hospital for histological evaluation
which most likely will be conducted by a general pathologist who may not be
knowledgeable in the nuances of oral pathological conditions. The alternative is to
mail the specimens to an oral pathologist, but special precautions are required as
formalin is a hazardous chemical.

17.8.1 Excisional Biopsy Technique

Local anesthesia should be obtained with regional anesthesia and not directly into
the area of the lesions. Injecting directly in the lesion can distort the tissue and make
it difficult for the pathologist to make an accurate diagnosis. The standard incision
for an excisional biopsy is an ellipse that is approximately three times longer in
length than width. The incision is “V” shaped from the superior aspect to the base
of the lesion. There must always be an adequate border of normal tissues in all
directions surrounding the pathologic condition. This normal tissue boarder can
vary from a couple of millimeters for a benign condition to a centimeter or more for
a malignant condition. The need for adequate margins reinforces the suggestion for
referral to a specialist when the condition in question is most likely malignant.
The rationale behind the use of the elliptical incision is to allow tension-free
closure. Since this technique is being recommended for lesions of 1 cm or less, the
adjacent mucosa does not need to be undermined. The tissue is placed immediately
in the transport medium.

17.8.2 Incisional Biopsy Technique

An incisional biopsy is indicated for larger lesions and/or where more than one
representable sample is required. The basic principles are the same as for an exci-
sional biopsy, whereas the specimen is elliptical in nature and undermining is not
required (Fig. 17.25). Local anesthesia is the same as for an excisional biopsy. The
sample should include both normal and abnormal tissues as this interface is impor-
tant for the pathologist to make an accurate diagnosis. Multiple representative sam-
ples are taken especially for larger diffuse conditions, different textures, and/or
color differences, i.e., red vs. white. The one disadvantage to an incisional biopsy is
that a diagnosis can only be made on the tissue submitted. Therefore, it is very
important to choose representative samples. Also, when multiple samples are taken,
the biopsy lab requisition must be specific about where each specimen was obtained
and only one specimen is placed in each bottle.
17 Soft Tissue Oral Pathology 379

Fig. 17.25 An elliptical

incision is made to remove
all or a portion of a
suspicious area. The length
should be approximately
three times the width
which allows primary
closure

Fig. 17.26 4- and 5-mm

biopsy punches

A punch biopsy is a specialized type of incisional biopsy that uses a circular cut-
ting blade as opposed to a conventional scalpel. The incision is circular as opposed
to the more ideal elliptical incision, but since the diameter of the incision is small
and is being performed on mucosa, closure of the wound is not difficult and heals
well. Punch biopsy blades come in a variety of diameters with a 4- or 5-mm-diam-
eter punch being very adequate (Fig. 17.26).
A circular cut is made with the circle encompassing both normal and abnor-
mal tissues (Fig. 17.27a, b). The depth of the cut in most cases needs to be only
a few millimeters unless an excisional biopsy is being performed. The tissue core
can then be picked up gently with a tissue forceps and cut off at the base with a
sharp scalpel or tissue scissors. Closure can usually be accomplished with one or
two sutures.
380 E. Natarajan and M. T. Goupil

a b

Fig. 17.27 (a) Making the circular “punch” incision. (b) The resultant “punch” biopsy
specimen

17.9 Conclusion

The need for accurate diagnosis of oral pathologic conditions cannot be overempha-
sized. Common oral lesions can frequently be diagnosed and managed. A system-
atic approach to data collection and development of an appropriate differential
diagnosis is the responsibility of very general dentist.

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Dentoalveolar Trauma
18
Richard T. Zhu, Frank Paletta, and Douglas L. Johnson

“In solving a problem of this sort, the grand thing is to reason

backward. That is a very useful accomplishment, and a very
easy one, but people do not practice it much.”
—A Study in Scarlet

Abstract
Dentoalveolar injuries occur commonly in pediatric and adult populations and
account for up to 5% of all traumatic injuries for which people seek medical
treatment. These injuries present a significant challenge to dental practitioners
and require proper diagnosis, treatment planning, and follow-up to ensure a
favorable outcome. Dentoalveolar injuries span the full clinical spectrum from
luxation injuries in primary dentition to tooth avulsions in permanent dentition.
Guidelines have emerged to formulate a systematic approach for the appropriate
and urgent care of these injuries and associated complications. This chapter
focuses on the common causes, patient evaluation, classification system, and the
medical, dental, and surgical management of dentoalveolar injuries.

R. T. Zhu
Warren Alpert Medical School of Brown University, Providence, RI, USA
e-mail: [email protected]
F. Paletta (*)
Private Practice, MSL Facial & Oral Surgery, Warwick, RI, USA
Department of Surgery, Warren Alpert Medical School of Brown University,
Providence, RI, USA
D. L. Johnson
Private Practice, St. Augustine, FL, USA
University of Florida Shands, Jacksonville, FL, USA

© Springer International Publishing AG, part of Springer Nature 2019 383

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_18
384 R. T. Zhu et al.

18.1 Introduction

The growing patient population with dentoalveolar injuries presents the dental prac-
titioner with a series of thought-provoking challenges and opportunities to enhance
diagnostic and treatment strategies. Dentoalveolar injuries are especially important
to understand because of the potential complications related to aspiration risk, tooth
eruption, alveolar stability, malocclusion, infection, bleeding, and facial asymmetry.
The evaluation and management of dentoalveolar injuries differ among children and
adults as commensurate with the different developmental stages of dentition. Timely
diagnosis, classification, and appropriate management are critical to ensure salvage
of the teeth and surrounding tissues to improve patients’ overall masticatory func-
tion and quality of life. In this chapter, we discuss the common causes of dentoal-
veolar trauma, outline the key aspects of focused history and physical exam,
delineate the indications for radiographic studies, discuss appropriate classification
system, and highlight evidence-based treatment strategies for injuries to the teeth,
alveolus, and surrounding soft tissues.

18.2 Causes

Traumatic dentoalveolar injuries are not uncommon and can occur from various
causes that differ between adults and children. Among adults, these injuries are
frequently the result of motor vehicle and motorcycle accidents as well as physical
assaults, contact sports, and work-related accidents (Leathers and Gowans 2013).
Iatrogenic injuries to dentoalveolar structures are potential complications of
intraoral procedures such as dental and maxillofacial surgery and endotracheal
intubation (Ozcelik et al. 2005). On the contrary, among younger children and
toddlers, dentoalveolar injuries are most often caused by falls, especially during the
first few years of life. The general prevalence of dentoalveolar injuries among
children with primary dentition is approximately 30% and among children with
mixed and permanent dentition is 5–20% (Leathers and Gowans 2013). Among
adolescents with sport-related trauma, the incidence of dentoalveolar injuries is
reported to be 36%. Among children, boys are affected almost twice as often as girls
with a peak incidence at 2–4 years and 8–10 years (Leathers and Gowans 2013).
Another cause of dentoalveolar injuries among children can result from child abuse.
In fact, more than 50% of all physical injury associated with child abuse occurs in
the head and neck region, of which roughly 7% of injuries involve the oral cavity
(Cairns et al. 2005). Among children of school age, dentoalveolar injuries occur
mostly in the playgrounds and from accidents related to bicycles, tricycles, and
scooters (Hall et al. 2016). At the teenage years, these injuries are most often caused
by contact sports, motor vehicle accidents, and relationship violence (Nesiama and
Sinn 2010). Violent teeth grinding during seizures has also been documented to
cause dentoalveolar injury in both children and adults (Lagunju et al. 2016). Finally,
certain medical conditions and comorbidities may predispose one to dentoalveolar
18 Dentoalveolar Trauma 385

trauma, such as radiation-induced osteonecrosis, osteoporosis, vitamin D defi-

ciency, oral cavity cancer, and odontogenic infections.

18.3 Patient Evaluation

Meticulous and systematic diagnostic evaluation is critical to ensuring timely and

appropriate management of dentoalveolar injuries. The pivotal importance of a
focused history and physical examination cannot be overstated. Foremost in the
initial evaluation is the primary trauma survey with particular attention to airway,
breathing, and circulation. Injuries to dentoalveolar structures can result in
fragmented pieces that are potential aspiration risk, mandating the priority toward
securing the airway. Once airway and breathing are safeguarded, any uncontrolled
bleeding must be staunched to provide better visualization and assessment of the
oral cavity. Because the prognosis of dentoalveolar injuries depends on the timeliness
of evaluation and management, it is imperative for diagnosis to commence
immediately. However, definitive repair of dentoalveolar injuries may be delayed
until the primary trauma survey is completed, and life-threatening injuries are
controlled. Results of the history and physical examination will inform the diagnosis
and guide the dental practitioner toward further diagnostic testing and appropriate
management strategies.

18.3.1 History

Obtaining a thorough and pertinent history can provide invaluable information for
the diagnosis and management of dentoalveolar injuries. However, children and
individuals with impaired consciousness often do not offer a reliable history,
especially after a traumatic event. In this situation, one must depend on the
accompanying adult or other eyewitnesses. The history obtained should include the
time interval between the dentoalveolar injury and presentation to the clinic or
emergency room. This information is important since studies have shown that the
success of treatment of many dentoalveolar injuries including dislocated teeth,
crown fractures with and without pulp exposure, and alveolar bone fractures may be
impaired by delayed treatment (MacLeod and Rudd 2012). In addition, the location
surrounding the accident provides insight into the severity of bacterial infection and
possible need for tetanus prophylaxis. Likewise, the nature of the accident can offer
clues to the type of injury to be suspected. For example, a fall can cause injury to the
anterior dentition, whereas a blow to the chin will often cause crown-root fractures
of the premolar region with concomitant mandibular symphysis or condyle fractures
(Murray 2013). The nature of the injury may also provide information regarding
other associated occult injuries. For example, if the patient is thrown against the
vehicle dashboard as an unrestrained passenger or against the guardrail from a
bicycle accident, an injury to the neck should be suspected and ruled out during the
initial trauma survey evaluation.
386 R. T. Zhu et al.

Additional pertinent history should include whether there have been teeth or
teeth fragments noted at the site of the accident. If there is high suspicion for avulsed
or fractured dentition, radiographic examination of the neck, chest, and abdominal
region is warranted. Radiographic images provide visual guidance to unaccounted
foreign bodies or fragments of teeth in body tissues and cavities. Dentoalveolar
injuries can also disrupt normal occlusion. Such changes may indicate tooth
displacement or dentoalveolar or jaw fractures. A pertinent medical and dental
history as well as any previous oral and maxillofacial trauma and surgical procedures
must be documented to establish any medical conditions or dental factors that can
influence the treatment plans.
Moreover, information of the events surrounding the accident should include
whether the patient had loss of consciousness, sustained potential head injury, or
experienced confusion, nausea, vomiting, or visual disturbances after the accident.
If any of these symptoms occurred, intracranial injury with or without cervical spine
instability should be suspected and the patient referred for neurological evaluation
(Straus 2015). If these symptoms persist or worsen, the patient should be taken to
the emergency department immediately for urgent cranial imaging to assess for
hematoma and cervical spine subluxation or fracture. In the event of potential life-
threatening head and neck trauma, the treatment of the dentoalveolar injury should
be delayed until more pressing assessment is completed. Finally, in children,
women, and the elderly, any discrepancy between the history and severity of the
injury should raise suspicion for abuse. In such circumstances, it behooves the
practitioner to carefully document the finding with the patient and report to the
appropriate authorities.

18.3.2 Physical Exam and Radiographic Correlates

The physical exam must prioritize the stability of the patient’s overall physical sta-
tus as guided by the principles of ABCDE taught by advanced trauma life support.
The history can inform the examination and direct the examiner to anticipate injury
patterns, thereby promoting a more comprehensive examination. For instance,
abnormalities in vital signs, difficulty breathing, and visible contusions and
ecchymoses may indicate intracranial injury, cervical spine injury, chest or
abdominal injury, or even aspiration of an avulsed tooth (Dale 2000). The mental
status of the patient should also be assessed by asking specific questions and by
observing the patient’s reaction and behavior during the history and examinations.
Once a general examination is completed and a concomitant injury is ruled out, a
thorough oral and maxillofacial examination is performed that focuses on injuries to
extraoral and intraoral soft tissues, teeth, and alveolus.
Because dentoalveolar trauma does not always result in visible manifestations
and can cause occult trauma, radiographic studies are warranted to provide additional
information regarding injuries affecting the root portion of the tooth such as root
fracture, periodontal ligaments, and status of the bone. Radiographic images can
also detect the presence of pre-existing periapical disease, maxillary and mandibular
18 Dentoalveolar Trauma 387

fracture, tooth fragment, or foreign bodies lodged in surrounding soft tissue. In

children and young adults, radiographic examination is an indispensable method to
evaluate the extent of root development, size of the root canal, and proximity of
succedaneous teeth to the injured primary tooth. Radiographic imaging of
dentoalveolar trauma consists of multiple radiographs at different projects such as
periapical, occlusal, and panoramic (Woodward 2009). Correctly positioned
periapical radiographs provide the most detailed information to adequately evaluate
root fracture and dislocation of the teeth. Occlusal radiographs are also useful to
diagnose a root fracture and examine the floor of the mouth, tongue, cheek, or lip
and are also often made for patient comfort because they place minimal pressure on
the traumatized area. Panoramic radiographs are perhaps the most useful of
dentoalveolar films as they provide a broader overview of the teeth, alveolus,
maxilla, and mandible. Taken together, these three radiographs are indispensable
tools to a comprehensive assessment of dentoalveolar trauma in patients that can
tolerate such procedures.
Radiographic interpretation requires a methodical approach to the evaluation of
soft tissue and teeth, alveolus, and bone (Holan and Yodko 2017; Beeching 1981).
Extruded teeth may appear as periapical radiolucency and subluxation of the teeth
as a widening of the periodontal ligaments. Intruded teeth often will show minimal
radiographic findings or only as blurred periodontal space. If alveolar ridge or
mandibular fractures are suspected, extraoral radiographs such as panoramic view
of the mandible should be taken. Although panoramic radiographs can demonstrate
fractures of the jaw, alveolar ridges, and teeth, they are best suited as a screening
tool. For fractures involving the condyle, subcondylar region, angle or body of the
mandible, or other facial trauma, computed tomography scans produce sharper
detailed images in 3D that enhance diagnosis and surgical management strategies.

18.4 Classification of Dentoalveolar Fractures

Following the diagnosis of dentoalveolar trauma, the practitioner subsequently uses

a classification system to provide a universal depiction of the injury for more readily
communication and surgical planning purposes. Over the years many classifications
of dentoalveolar trauma and surrounding structures have been developed (Diangelis
and Kland 1998; Kirthiga et al. 2015). These systems are based on a variety of
factors such as etiology of injury, pathology, and therapy. The Andreasen’s
classification encompasses the system originally adopted by the World Health
Organization (WHO) and is the most widely used classification in the literature.
This classification system includes detailed portrayal of injuries to the teeth, alveolar
bone, supporting structures, gingiva, and oral mucosa as well as incorporates
anatomic, therapeutic, and prognostic considerations (Da Feliciano and de Caldas
2006; Andreasen 1981). The classification can be applied to both the permanent and
primary dentition for evaluation of injury to both succedaneous and deciduous teeth.
In this classification, dentoalveolar injuries are divided into four major categories:
388 R. T. Zhu et al.

Table 18.1 Classification of dentoalveolar injuries

Dental hard tissue Periodontal Gingival
injury Alveolar bone injuries injuries injuries
Enamel infraction Intrusion of teeth into alveolar Concussion Contusion
socket wall
Enamel fracture Alveolar socket wall fracture Subluxation Abrasion
Enamel dentin fracture Alveolar wall fracture Extrusive Laceration
luxation
Complicated crown Lateral luxation Degloving
fracture
Crown root fracture Intrusive luxation
Root fracture Avulsion

dental hard tissue injury, alveolar bone injury, periodontal injury, and gingival injury
(Table 18.1).

18.5 Treatment of Dentoalveolar Injuries

Once the appropriate diagnostic information and classification have been estab-
lished, a treatment plan tailored to each patient’s specific surgical needs can be
formulated. Factors that influence the treatment plan include the age and coopera-
tion of the patient, whether the injury tooth is a primary, mixed, or secondary denti-
tion, the location and extent of the injury, and any concomitant injuries or medical
comorbidities. The overall goal of treatment of dentoalveolar injuries is to preserve
the function of the teeth, bone, and gingiva. Although every attempt should be made
to maintain all of these structures, it is sometimes necessary to only temporarily
maintain the teeth for the overall benefit of the patient. Therefore, the final restorative
plan should guide the decision to remove or preserve teeth and bony segments at the
initial phase of evaluation and treatment. Accordingly, the teeth not useful in the
final restorative plan should be jettisoned. On the other hand, the teeth designated
for extraction in alveolar fractures may be retained provisionally to maintain
vulnerable alveolar bone. Preserving proper alveolar contour, volume, and bulk will
allow for a more efficacious dental rehabilitation. Likewise, avulsed teeth that have
an extremely poor prognosis when associated with alveolar fractures may be
replanted for a period of time in order to mitigate additional fracture development
and maintain alveolar stability.

18.5.1 Soft Tissue Injuries

Dentoalveolar injuries can cause collateral damage to surrounding soft tissues. For
instance, depending on the force of the impacted trauma, direct injury mechanism
can affect the upper or lower lip, causing laceration of the lip as well as alveolar
fractures (Dale 2000; Diangelis and Kland 1998). Dentoalveolar injury from indirect
trauma results from direct impact against the chin forcing the mandibular teeth to
18 Dentoalveolar Trauma 389

collide with the maxillary teeth. The impact of this force can cause fractures in
condylar and/or symphysis regions of the mandible as well as intraoral soft tissue
and submental laceration. Palpation of both of the temporomandibular joints and
assessment of jaw range of motion are necessary to rule out mandibular condylar
fracture. Examination of these injuries in addition to abrasions and contusions of the
face, chin, forehead, and scalp is needed. A thorough analysis of these injuries is
important because the site of soft tissue trauma is a key predictor of associated hard
tissue injuries. Inspection of intraoral injuries must also include evaluation for
deeply penetrating soft tissue wounds with embedded teeth or teeth fragments,
which can be associated with occult hematoma (Leathers and Gowans 2013).
Following extraoral assessment, intraoral soft tissue examination should include
assessment of any injury to the buccal and alveolar mucosa, gingiva, lips, tongue,
soft palate, and floor of the mouth. If present, such injuries should be carefully
evaluated for the presence of foreign bodies, debris, and teeth fragments implanted
within such tissues. As described by Leathers et al., intraoral injuries are often
associated with neurovascular complications, such as Stenson duct and/or facial
nerve damage following buccal mucosal injury (Leathers and Gowans 2013). When
visual access to the oral cavity is occluded, it is necessary to perform adequate
debridement and staunch any active bleeding before evaluation. Bleeding from lac-
erated gingiva often indicates tooth displacement, whereas bleeding from non-lac-
erated gingiva suggests periodontal ligament damage or mandibular fracture. It is
imperative that the practitioner accounts for all teeth at this time. Any missing teeth
or teeth fragments should be considered to have been aspirated, swallowed, or
displaced into the surrounding soft tissues, the nasal cavity, or the maxillary sinus.
Therefore, a systematic radiographic examination of the head and neck with
panoramic radiographs and chest and abdominal radiographs are warranted to rule
out presence of teeth or teeth fragments that have dislodged and embedded in these
tissues and organs.
The overall goal of soft tissue injury treatment is to reestablish sufficient soft
tissue bony coverage in a timely manner so as to not jeopardize underlying bony
tissue devitalization. Injuries to the gingival and alveolar mucosa mainly comprise
of laceration, contusion, and abrasion. Laceration of the mucosa involves damage to
the superficial epithelial layer including epidermis, dermis, and part of hypodermis.
Treatment requires comprehensive cleansing of healthy tissues, debridement of
devitalized tissues, and re-approximation of tissue edges with sutures. Because the
gingival and alveolar mucosa linings are well vascularized, isolated soft tissue
lacerations do not require antibiotic or tetanus prophylaxis administration. Contusion
injury results when trauma impacts a region of tissue or skin that injures underlying
capillaries with a resulting subcutaneous hematoma. Treatment for contusion
injuries often is conservative and involves thorough cleansing and observation. An
abrasion injury is less severe than either laceration or contusion injuries and is a
superficial wound involving only the upper layers of the epidermis that can result
from wearing, grinding, or rubbing by friction. As with contusion injuries, abrasion
injuries are best managed with adequate irrigation and local cleansing, consisting of
disinfectant soap for the external skin and 0.12% chlorhexidine mouth rinse for the
390 R. T. Zhu et al.

gingiva. Soft tissue injuries in children are managed with similar principles of close
examination, thorough cleaning and debridement, and meticulous alignment of
wound edges. Frequently, young children might not tolerate the repair process even
when given local anesthesia and sedation and might require general anesthesia for
repair in the operating room.

18.5.2 Injuries to the Teeth

Dental trauma is a commonly encountered event both in the clinic and in the emer-
gency department. Appropriate management of dental injuries including fractures,
avulsions, and displacement is a necessary skill attained in the career of every dental
practitioner. Prompt and comprehensive care in the acute setting is instrumental to
not only avoid adverse complications such as bleeding, aspiration, and infection, but
more importantly allow for the salvage of viable tooth structure and achieve better
patient outcomes. Following timely and astute diagnosis of the acute dental injury,
many patients frequently require follow-up with a dentist or an oral surgeon within
24 h. Nonetheless, proper medical and surgical intervention should not be delayed.
The original Ellis and Davey classification of dental trauma (1970) provides a suc-
cinct and systematic numerical categorization of dental injuries according to a vari-
ety of factors including etiology, anatomy, and management recommendations
(Ellis and Davey 1970).
This dental trauma classification scheme was initially created for pediatric popu-
lations and has since been modified and adopted for adult populations as well
(Table 18.2). Class I injury involves fractures to the tooth enamel only without
dentin or pulp exposure. Injured teeth are non-tender to palpation and are
characterized by their uneven and jagged edges which reflected the fragmented
pieces. These teeth can be left alone or smoothed to mitigate rough edges. Class I
dental trauma usually does not require urgent treatment and can be followed up

Table 18.2 Ellis Classification of dental fractures

Fracture class Clinical presentation Management
I. Enamel No visible color change, rough edges Elective
referral
II. Enamel and dentin Tender to touch, exposed yellow-white Dental consult
dentin
III. Enamel, dentin, and pulp Tender to touch, exposed pink-red pulp Dental consult
IV. Devitalized tooth with or Tender to touch, may show sign of Dental consult
without crown loss necrosis
V. Luxation and or tooth loss Tooth dislocation or loss Dental consult
VI. Root Separation of tooth from alveolus, root Dental consult
fractured fragments
VII. Displacement Displaced tooth without fracture of Dental consult
crown or root
VIII. Crown En-bloc fracture of crown Dental consult
IX. Deciduous teeth Fracture of deciduous teeth Dental consult
18 Dentoalveolar Trauma 391

within 24–48 h by a dentist or oral surgeon. On the other hand, class II through class
II injuries warrants immediate dental consultation to optimize tissue viability and
healing. Class II injury includes fractures that involve both enamel and dentin.
These teeth can be tender and are detected as a layer of yellow dentin on examination.
Class III injury frequently involves fractures through enamel, dentin, and pulp,
resulting in tender teeth and exposed pinkish-red pulp at the center of the tooth. As
the hub of vital structures including neurovascular bundle, connective tissue, and
odontoblasts, the pulp of the tooth is susceptible to infection from intraoral flora
(Zero et al. 2011). Active inflammation and infection of the pulp, termed pulpitis,
can lead to chronic infection, abscess formation, and potential tooth loss (Zero et al.
2011). In Ellis and Davey III fractures, in which pulp is exposed, it behooves the
dental practitioner to create a calcium hydroxide sealant layer followed by an
appropriate pulpal therapy either pulpotomy or pulpectomy to protect the pulp from
further insults. The indications for type and duration of antibiotic regimen for class
III dental injuries remain controversial.
Class IV injury involves traumatized tooth that has resulted in devitalized tissues.
Thorough extirpation of nonviable tooth and surrounding structures followed by
debridement is necessary to ensure proper healing and to prevent the necrotic tissue
from serving as a nidus for infection. Class V injury includes root luxation and
subluxation. Class VI injury includes root fractures with or without concomitant
crown fractures and tooth avulsion. For classes V and VI injuries, the management
goal is to restore the tooth to its correct anatomical position as securely and
expeditiously as possible, without incurring further damage to the tooth, alveolus,
or gingiva (Kirthiga et al. 2015). Multiple radiographic images including panoramic
views are essential to enhance visualization of the root fragments and their
anatomical position within the alveolus (Holan and Yodko 2017). It is recommended
that root fragments firmly entrenched in the alveolus be left alone unless they are
impinging upon neurovascular bundle and are destabilizing the alveolus (Henley
2006; Jackson et al. 2005). On the other hand, clearly mobile root fragments should
be carefully removed by their coronal and apical portions (Jackson et al. 2005;
Henley 2006). Class VII injury involves displaced tooth. It is critical to employ a
meticulous search for the mobile tooth and/or tooth fragments in nearby soft tissue
as unaccounted pieces are suspected to be aspirated. Class VIII injury includes en
bloc crown fractures that require prompt intervention to achieve a quick and
appropriate seal to protect underlying dentin and pulp. Finally, class IX injury
involves deciduous teeth fractures in children and is managed with similar principles
as in adults with special care paid to not damage succedaneous teeth.
Injuries to teeth as a result of dentoalveolar trauma can be readily identified by
intraoral examination. Assessment of occlusion provides additional insight into the
detection tooth displacement. Although shift of teeth as a result of dentoalveolar
trauma can occur in any direction, the most common movement is in a buccolingual
direction (MacLeod and Rudd 2012). Displaced tooth can impinge on surrounding
teeth and encroach upon soft tissues such as buccal and alveolar gingiva. In any
dentoalveolar trauma event, all teeth should be tested for both horizontal and axial
stability by manual palpation. If a tooth is very mobile but does not appear to be
392 R. T. Zhu et al.

displaced, a root fracture or periodontal ligament injury should be suspected. In the

absence of tooth displacement, increased sensitivity to palpation is suggestive of
injury to the periodontal ligament. This test is performed by gentle percussion of the
tooth in adults or by ginger fingertip pressure when examining smaller children
(MacLeod and Rudd 2012; Dale 2000).
Injuries to the tooth and pulp include crown infractions, which are microcracks
seen within the dental enamel and are visualized by transillumination (Leathers and
Gowans 2013). No treatment is necessary as they heal well on their own. More
severe trauma can cause crown fracture, which involves cracks crossing the enamel-
dentin border (Leathers and Gowans 2013). Any fractures of the crowns should be
meticulously explored. Crown fractures should be evaluated for extension into the
dentin and the pulp. Increased translucency in a traumatized tooth may indicate a
pulp exposure (MacLeod and Rudd 2012). It is also important to note that trauma
leading to crown-root fractures on one side of the jaw is frequently associated with
similar fracture patterns on the ipsilateral side. When no root is involved in crown
fractures, treatment entails smoothing the crown edges or repairing the entire crown
with composite restoration. However, if crown fracture compromises pulp, then it is
necessary to perform conventional root canal treatment (RCT) with future repair.
Children ages 12 and under may not need root canal treatment since their teeth are
still developing. It has been suggested that stem cells present in the pulps of children
can be stimulated to complete root growth and heal the pulp following injuries or
infection (Potdar and Jethmalani 2015). Multiple follow-up appointments are
needed to monitor the healing process with intervention if any unfavorable changes
appear.
For uncomplicated root fractures that encompass the enamel, dentin, and cemen-
tum but do not expose the pulp, buildup with full-coverage crown placement is
recommended. For root fractures with pulp exposure, RCT with crown lengthening
and full-coverage crown replacement is recommended (Leathers and Gowans 2013).
If root fractures are severe, the involved teeth should be extirpated without
compromising the alveolar segment. This is important because the fractured
periapical root is a potential nidus of infection as well as serves to destabilize the
neurovascular integrity of the surrounding alveolus. Accordingly, root fracture
injuries can result in pulp necrosis and subsequent metaplastic replacement of pulp
tissue into nonfunctional cancellous bone (Leathers and Gowans 2013). Otherwise,
minimally displaced root fractures without major complications can be left in place
for removal at a later date after the alveolar segment has fully healed.
Injuries to periodontal ligament tissue from traumatic forces that cause tooth
dislodgment can cause a secondary resorptive process that can heal through normal
physiologic manner or through pathologic fashion such as ankylosis and
inflammation. Inflammatory resorption can be best treated by RCT. Pulpal
revascularization and periodontal ligament healing can also be achieved through
splinting. The goal of splinting is to immobilize traumatized teeth or bony segments
into proper occlusion that is consistent with preinjury alignment. Indeed, as
delineated by Berthold et al., current guidelines recommend that flexible or semirigid
splints are best used to stabilize teeth with dislocation injuries or root fractures,
18 Dentoalveolar Trauma 393

whereas rigid splints such as titanium ring splint are more effective in the treatment
of alveolar fractures (Berthold et al. 2009).
In the pediatric population, the practitioner must keep in the mind the large pulp
chamber to tooth ratio and the possibility that the succedaneous teeth might be
compromised. Much of the principles of teeth repair in adults can be applied to
children. For crown fractures that involve the enamel, smoothing rough edges is the
essential treatment. For fractures involving enamel and dentin, calcium hydroxide
or composite resin restoration is recommended. For teeth fractures that involve pulp
exposure, coronal coverage is required. In the event of root fractures in deciduous
teeth that does not involve cervical third, no treatment is needed as the apical site
sprouts new tooth bud. However, when root fractures compromise formation of
permanent tooth buds, the root fragments should be removed. Moreover, for
luxations, subluxations, and lateral luxations, conservative management is
recommended with close monitoring and follow-up. For extrusion or intrusion
injuries, the treatment involves realignment and removal if the tooth impinges upon
the permanent successor or becomes infected.

18.5.3 Injuries to Alveolus

Thorough visual examination can readily detect fractures of the alveolar bone pro-
truding through the overlying alveolar mucosa. In the event that the overlying
mucosa is not lacerated, manual palpation for mobility and crepitation of the
alveolar fracture can confirm the underlying alveolar bone injury. Not uncommonly,
severe impact causing alveolar bone fractures can also result in jaw fractures. Visual
inspection for the floor of the mouth, ecchymoses and manual percussion for gross
malocclusion, step-off deformities, and pain can detect maxillary and/or mandibular
fractures. First and foremost, when dealing with alveolar and/or concomitant jaw
fractures, systematic debridement of the bone is necessary to prevent necrosis and
bacterial contamination as well as enhance visualization.
Fractures of the alveolar process most commonly occur in the incisor and premo-
lar regions. The hallmarks of alveolar fracture treatment involve early reduction and
stabilization. Reduction can be achieved through either open or closed technique.
The closed method minimizes additional incisions and trauma and involves physical
manipulation and rigid splint immobilization for 4 weeks (Leathers and Gowans
2013). On the other hand, the open method is indicated in cases of severe tooth
displacement and/or comminuted fractures, which precludes closed reduction.
Treatment requires creating an incision below the fracture line to achieve adequate
exposure of fractured segments. The alveolar fractures are subsequently reposi-
tioned, reduced, and secured with a miniplate. Any mobile teeth can be stabilized by
a secondary acid-etch/resin splint, and proper occlusion, teeth alignment, and pri-
mary splint placement are attained. The ideal splint must be able to stabilize the
injured tooth in the normal pre-injured position, provide adequate fixation through-
out the immobilization period, and not interfere with occlusion, articulation, or end-
odontic physical therapy. Following splint placement, copious irrigation is needed
394 R. T. Zhu et al.

to cleanse the open wound prior to closure by sutures. For severe blunt facial
trauma resulting in significant alveolar fracture with bony exposure, adequate soft
tissue coverage with mucosal advancement and interpolation flaps is recommended
(Herford 2004). Alveolar fractures in the pediatric population are quite rare and
involve the same treatment paradigms as for adults.

18.6 Conclusion

Dentoalveolar injuries are among the most serious emergencies that require the
expertise of an experienced dental practitioner for judicious diagnosis and
management. Examples of such injuries include lacerations, contusions, and
abrasions to the surrounding soft tissues, infractions and fractures to the teeth, and
fractures of the alveolar process. These injuries commonly arise from motor vehicle
accidents, assaults, falls, contact sports, and interpersonal violence. Dentoalveolar
injuries also accompany life-threatening complications such as aspiration and
bleeding. Time from dentoalveolar trauma to treatment is a major factor in the
outcome of many of these injuries. Focused history and physical examination should
be further corroborated with pertinent radiographic findings to arrive at the correct
diagnosis. Classification of the dentoalveolar trauma provides a common platform
for implementing appropriate care plans according to the class of injury. Treatment
is tailored specifically to the nature and severity of dentoalveolar injury and involves
debridement, removal of nonviable teeth fragments, stabilization, realignment, and
splint fixation. Finally, adequate follow-up is important for dental practitioners to
improve functional and aesthetic outcomes and provide the best longitudinal care to
patients.

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 Part IV
Advanced Oral Surgery
Disturbances of the Temporomandibular
Joint Apparatus 19
M. Franklin Dolwick and Danielle Freburg-Hoffmeister

“Let us get a firm grip of the very little which we know, so that
when fresh facts arise we may be ready to fit them into their
places.”
Sherlock Holmes in—The Adventure of the Devil’s Foot

Abstract
This chapter focuses on diagnosis and treatment of temporomandibular joint dis-
orders (TMD) including myofascial pain disorder (MPD) and disorders of the
joint itself. Noninvasive treatments include physical therapy, pharmacotherapy,
massage, thermotherapy, and occlusal appliance therapy. Lastly minimally
invasive procedures such as arthrocentesis and arthroscopy as well as surgical
procedures such as arthroplasty and total joint replacement will be discussed.

19.1 Introduction

Temporomandibular joint disorder (TMD) is a broad term that encompasses a

wide array of pain which is localized to the head and neck region. It can present
as tension, pressure, or aching in the head and neck region. TMD is more com-
mon in females versus males with age range from 20 to 40 (premenopausal
women) (Liu and Steinkeler 2013). It has been shown that approximately 5% of
the total population seek medical treatment for TMD, but over 30% of the

M. F. Dolwick (*) · D. Freburg-Hoffmeister

Department of Oral and Maxillofacial Surgery, UF College of Dentistry, University of
Florida, Gainesville, FL, USA
e-mail: [email protected]; [email protected]

© Springer International Publishing AG, part of Springer Nature 2019 399

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_19
400 M. F. Dolwick and D. Freburg-Hoffmeister

general population experience at least one finding of TMD and never seek treat-
ment (Dolwick and Dimitroulis 1996). Therefore it is clear to see that the general
dentist will encounter and need to understand how to screen and treat patients
with TMD. To simplify temporomandibular joint disorders, it will be discussed
in two general categories: disorders of the muscles of mastication and disorders
of the joint itself. Disorders of the masticatory muscles include myofascial pain
associated with parafunctional activities, myositis, and neoplasia.
Temporomandibular joint disorders include disk derangement disorders, osteoar-
thritis (noninflammatory disorders), inflammatory disorders hypermobility,
hypomobility, traumatic disorders, congenital or developmental disorders, and
neoplasia of the TMJ. This chapter will focus on the history and physical exami-
nation of the patient who suffers from TMD and will discuss ways to help dif-
ferentiate muscular versus joint disorders. Often times TMD is caused by both
muscular and joint disorders. Once the classifications have been clarified, the
treatments will be discussed.

19.2 Clinical Evaluation

19.2.1 History from Patient

Prior to ordering tests and radiographic studies, it is important to perform a his-

tory and physical. Much of the patient’s symptoms will help differentiate disor-
ders within the actual joint versus muscles surrounding the joint (this may also
be termed intra-articular and extra-articular). It is important to have the patient
fill out a preexamination questionnaire as shown (Fig. 19.1). As shown in the
figure, a patient circling the area of pain will help determine the cause of pain.
Generally a patient who circles a wide section of the head will suffer from mus-
cular dysfunction, whereas a patient who circles directly over the joint will tend
to have a dysfunction limited to the TMJ. Other clues in the preexamination
questionnaire which will differentiate joint dysfunction from muscular include
joint noises.
After review of the questionnaire, it is important to interview the patient and
find out the patient’s chief complaint. The history of present illness should
include onset of pain and the exact location of pain. The patient should point
with one finger to the area of most perceived pain. The history also should
include review of any changes in patient’s living situation, recent trauma, and
recent stressors. All prior medications should be reviewed as well as current
medications. This is important as several medications may cause bruxism. Ask
the patient about prior use of corticosteroids systemically as well as steroid
injections to the TMJ in other joints. It is important to discuss all surgeries the
patient has undergone in addition to surgeries involving the head and neck and/
or TMJ.
19 Disturbances of the Temporomandibular Joint Apparatus 401

Please use the figure below to draw a circle around those areas where you
WHAT DOES YOUR PAIN FEEL LIKE? have pain.

b
Right Left
Some of the words below describe your present pain. Circle ONLY those words
that best describe it. Leave out any category that is not suitable. Use only a
single word in each appropriate category– the one that applies best.

1 2 3 4 a
Flickering Jumping Pricking Sharp
Quivering Flashing Boring Cutting
Pulsing Shooting Drilling Lacerating
Throbbing Stabbing
Beating Lancinating
Pounding PLEASE CIRCLE THE CORRECT RESPONSE WHERE INDICATED: c
5 6 7 8
1. Do you have any pain now? Yes No
Pinching Tugging Hot Tingling
Pressing Pulling Burning Itchy a. If YES, please answer Question #2, otherwise go directly to Question #3

Gnawing Wrenching Scalding Smarting 2. On a scale of 1 -10, please rate your pain by placing an “X” on the line indicating,
(A) your present pain and (B) your usual pain. Mark each “X” with the
Cramping Searing Stinging corresponding letter:
Crushing
9 10 11 12
No Pain Most Intense
Dull Tender Tiring Sickening Pain Imaginable
Sore Taut Exhausting Suffocating
3. Are you awakened from sleep with pain? Yes No
Hurting Rasping
Aching Splitting 4. Are you aware of clenching or grinding of your teeth? Yes No
Heavy
5. Is your pain worse on functioning (chewing, talking)? Yes No
13 14 15 16
6. Do you have limited opening? Yes No
Fearful Punishing Wretched Annoying
Frightful Grueling Blinding Troublesome 7. Do you have any dietary limitation related to your jaw problem? Yes No

Terrifying Cruel Intense 8. Does your jaw make noises on functioning? Yes No
Vicious Unbearable
9. Have you experienced jaw locking? Yes No
Killing
17 18 19 20 10. Please rate your ability to chew by placing an “X” on the line indicating your

Spreading Tight Cool Nagging present ability to chew:

Radiating Numb Cold Nauseating

Penetrating Drawing Freezing Agonizing
Piercing Squeezing Dreadful
Tearing Torturing No Difficulty Unable to Chew

Fig. 19.1 (a–c) Example of pre-examination questionnaire packet received by every patient
which aid in differentiating muscular from joint pain

19.2.2 Physical Examination

The examination is an important part in differentiating masticatory muscle from

joint disorders. You should always perform the exam in the same order to avoid
missing findings which could contribute to diagnosis. If starting with the extraoral
exam, it should include palpation of all muscles of mastication and palpation of the
head and neck verifying that no lymphadenopathy or masses are present. While
palpating the muscles, pay attention to trigger points as well as masseter and
temporalis enlargement, both of which will favor a diagnosis of myofascial pain
disorder (Fig. 19.2). A very important and simple test to help with differentiating
muscular pain versus joint disorder is to test pain on occlusal loading. As seen in the
photo, if the patient has pain on the same side as the side which is being loaded, the
source of pain is likely muscular. Conversely, should pain be present in the opposite
joint as demonstrated (Fig. 19.3), this is called Mahan’s sign and would be consistent
with joint dysfunction (McCain and Stroia 2012). It is important to palpate over the
joint capsule and ask patient if they experience tenderness to palpation. While
palpating over the joints, ask the patient to open and close. You should listen for
402 M. F. Dolwick and D. Freburg-Hoffmeister

a b

Fig. 19.2 Palpation of the temporalis in picture (a) and of the masseter in photo (b)

clicking (single sound) and crepitus (multiple sounds which are gravel like) (Tucker
and Dolwick 1993).
Next attention should be directed intraorally. Examine the oral cavity assessing
the teeth for decay, recession, or other sources which may be contributing to
orofacial pain. Wear facets may be present and are consistent with bruxism. One

a b

Fig. 19.3 (a) Example of Mahan’s sign: occlusal load causes pain in the opposite TMJ indicating
an intrinsic joint dysfunction. (b) Testing MIO: maximum incisal opening. (c) Lateral excursion
19 Disturbances of the Temporomandibular Joint Apparatus 403

should note the patient’s Angle classification, presence of cross bite or open bite,
occlusal interferences, and occlusal stability. If the patient has a class II malocclusion,
the examiner should find out if this has always been present or if it has gradually
changed with time. A class II malocclusion which has gradually developed should
raise suspicion of idiopathic condylar resorption and prompt further imaging
(Mercuri 2008). The vertical opening should be assessed. The patient should actively
open to the maximum extent without pain and then where they perceive pain. Joint
noises should be observed.

19.2.3 Diagnostic Imaging

After the complete history and physical is performed, the next step is to perform any
imaging which may aid in diagnosis. The choice of imaging is based on the clinical
findings and should always be selected based on the exam findings.

19.2.4 Panorex

Generally, a panoramic radiograph serves well as a screening tool (Fig. 19.4). It will
help assess the dentition and rule out any possible lesions which were missed on
physical exam. It will also aid in assessing for any bony pathology which may
possibly be contributing to the orofacial pain. The panoramic radiograph allows the
clinician to assess for a narrowed joint space, flattening of the condyle, and/or
osteophytes all of which may be signs of osteoarthritic changes.

Fig. 19.4 Panorex demonstrating osteoarthritic joint changes

404 M. F. Dolwick and D. Freburg-Hoffmeister

19.2.5 Magnetic Resonance Imaging (MRI)

If soft tissue joint abnormalities (internal derangement of the joint) are suspected,
an MRI would be indicated. It is important to inform the radiology technician that
the exam is to assess the TMJ disk movement as well as joint effusion. The slices
should be perpendicular in the sagittal plane and parallel to the coronal plane (Moore
2006).
A T1-weighted and T2-weighted image should be performed with the patient
open and closed. While the disk position and morphology may be better assessed
with a T1 image, the T2 is better for displaying joint effusions as seen below
(Fig. 19.5).
The included images are T1-weighted images and will display disk position.
Figure 19.6a shows the closed joint with the disk in the correct location with regard
to the fossa and articulator eminence. Image b shows the condylar after translation
forward. The disk remains superior to the condyle and translates down the eminence
with the condyle. Conversely Fig. 19.6c and d shows pathology. Figure 19.6c shows
the patient in a closed position, but the disk is anterior to the condyle. When the
condyle comes forward (Fig. 19.6d), the disk is reduced and superior to the condyle.
Figure 19.6e and f shows an example of disk displacement without reduction in
which the disk is anterior to the condyle in closed position and remains so as the
condyle moves anteriorly along the eminence. Gadolinium-based contrast agents
may be used in the T-1 weighted image to differentiate joint effusion versus synovial
proliferation which may suggest a more severe inflammatory process. The joint
effusion will not light up with contrast, but the synovial proliferation will.

Fig. 19.5 Joint effusion in superior joint space demonstrated on T2 weighted image
19 Disturbances of the Temporomandibular Joint Apparatus 405

a b

c d

e f

Fig. 19.6 (a) Closed normal condyle and disk relationship. (b) Open, normal position. (c, d) Disk
displacement with reduction, (e, f) disk displacement without reduction

Rheumatoid arthritis is an example of a condition with severe inflammation result-

ing in synovial proliferation (Bag et al. 2014).

19.2.6 Computerized Tomography (CT)

A CT is best to assess bony changes and offers the ability to use 3-D reconstruction
(Bag et al. 2014). This would be indicated if the panorex showed concern for
possible joint ankyloses or condylar radiolucency. If infectious process is considered,
406 M. F. Dolwick and D. Freburg-Hoffmeister

CT with contrast is indicated. A CT is also necessary if patient requires total joint

reconstruction (Moore 2006).

19.2.7 Nuclear Medicine Bone Scan

If there is concern for condylar hyperplasia or another lesion causing rapid bone
growth, a bone scan should be ordered. The most common radiolabeled marker is
technetium-99M (Tc-99m). This is injected intravenously and will display areas of
the bone with rapid turnover consistent with condylar hyperplasia, infectious
process, or neoplasia (Moore 2006).

19.3 Developing a Differential Diagnosis

After the history and physical as well as imaging or other diagnostic aids, it is then
time to review the information and begin to make a diagnosis for the patient. The
most straightforward approach to the TMJ is to assign the pain into either intra-
articular or extra-articular causes. Extra-articular causes include muscular pathol-
ogy (myopathy) or myofascial pain disorder. Intra-articular causes of TMJ
disturbance are disk dislocation, disk morphologic changes such as perforation, or
inflammatory changes resulting in osteoarthritis. The cause of pain may also be a
combination of the aforementioned conditions.

19.3.1 Myofascial Pain and Dysfunction

Myofascial pain and dysfunction (MPD) generally presents as diffuse, poorly local-
ized pain. Patients cannot isolate the pain with one finger but rather point to a region
or several regions of their head and neck. Generally patients will draw their pain in
a muscle region rather than over the joint itself as with internal derangement of the
joint. Patients will generally describe their pain in a cyclic fashion with pain worse
in the morning which is related to muscle strain associated with bruxism during
sleeping hours. Another symptom patients may report is tiredness and fatigue, again
emphasizing the importance of patient history and pre-appointment paperwork. On
exam of the patient, you will notice trigger points or areas that the clinician palpates
and causes radiation of pain throughout a muscle region as well as tight, hypertro-
phied muscular bands (Clark 2008). Patients will also demonstrate decreased range
of motion, possibly have joint noises, and have wear facets. The patient will have
ipsilateral pain on occlusal loading.
The leading cause of MPD is parafunctional activity, namely, tooth clenching
and/or grinding. It is important to find out when the patient grinds or clenches in
order to attempt to treat. The occlusal guard should be worn at times when patient
is known to grind whether during stress of the day or while sleeping. Muscular pain
and parafunctional activity can also be caused by a cyclic pattern of pain involving
19 Disturbances of the Temporomandibular Joint Apparatus 407

the internal derangement of the TMJ. As patients continue to grind and clench, they
place excessive load on the TMJ. This results in hypoxia of the joint thus leading to
free radical production on reperfusion of the joint. The free radicals break down
hyaluronic acid which leads to decreased joint lubrication (Leeuw 2008). Ultimately
the disk morphology is altered, and disk displacement and degeneration then occur.
With the joint breakdown, the patient’s parafunctional activities hence affect the
masticatory muscle function completing this cycle of pain.
While MPD is similar to fibromyalgia with regard to painful symptoms and trig-
ger points, it is different in that MPD is a regional myalgia and fibromyalgia involves
the entire body. Fibromyalgia also is associated with central sensitization of pain
which means that elevated neurotransmitter levels and modulation of neuro-recep-
tors exist in the central nervous system in response to chronic noxious stimuli. This
neuromodulation makes the patient more susceptible to pain in other sites, thus
developing generalized pain (Clark 2008).
Another cause of muscular pain surrounding the TMJ may be due to myositis.
This may be from direct trauma to the muscle such as following a motor vehicle
collision or may be due to muscular irritation after injection of local anesthesia
(Clark 2008). This transient pain generally will resolve with noninvasive interven-
tion such as nonsteroidal anti-inflammatory agents (NSAIDs) and rest.

19.3.2 Internal Derangements and Osteoarthritis

Internal derangement is a very broad category and includes any abnormality within
the TMJ. Pain is frequently described as continuous, worsening with function and
localized to the joint itself. Joint noise may or may not be present. The condition
also is associated with alteration in the joint mechanical function such as deviation
on opening, intermittent locking, and a closed lock. As stated in the physical exam
portion, there will be tenderness over the temporomandibular joint, there will be
pain on the ipsilateral TMJ on occlusal loading, and there will be joint noise or a
history of joint noise. The cause of internal derangement is thought to be related to
trauma in the form of macro (direct blow) versus micro (clenching or grinding
repeatedly). This results in force onto the joint which causes hypoxia which leads to
free radical generation. Free radicals regrade hyaluronic acid which leads to
decreased joint lubrication. It is thought that this process causes adhesions in the
superior joint space as well as disk displacement. The stages of internal derangement
were quantified by Wilkes and are summarized in the following table (Table 19.1)
(Wilkes 1989).
The disease-free condyle and disk move together with opening and closing. In a
closed position, the disk’s posterior band lies directly over the condylar as seen in
the MRI (Fig. 19.6a, b). Just anterior to that is the intermediate zone of the disk
which is a superior and anterior position. The disk then moves forward with the
condyle with opening but to a lesser degree thereby remaining over the condyle for
the entirety of the opening and closing movement. With disk displacement with
reduction, the disk is anteriorly positioned with respect to the condyle in the closed
408 M. F. Dolwick and D. Freburg-Hoffmeister

Table 19.1 Wilkes staging

Radiographic findings Surgical/anatomic
Stage Clinical findings (MRl/CT) findings
Early Reciprocal click, no Anterior disk Normal morphology
pain, full range of displacement (ADD)
motion (ROM)
Early/ Increased joint noises, Early disk changes and ADD, thickening
intermediate episodic pain, early ADD posterior band
ROM limits, decreased
MIO
Intermediate Increased episodic pain ADD with major disk ADD, adhesions, disk
further ROM limitations, changes, thickening intact without bony
closed lock, decreased posterior band changes
MIO
Intermediate/ Chronic pain and Increased changes in disk Morphologic changes
late functional limitations, morphology, ADD with without disk perforation,
decreased MIO bony changes on CT bony changes, adhesions
Late Crepitus, variable pain, Disk perforation, bony Disk perforation, bony
functional limitations changes on CT erosions
Modified from Table 1 of Criteria internal Derangements of the Temporomandibular joint. Arch
Otolaryngol Head Neck Surg—Vol 115. April 1989

position. On opening, a click is heard when the posterior band is passed and the
condyle is able to sit beneath the disk (Leeuw 2008). When closing, a reciprocal
click is heard when the disk resumes to its malposition anterior to the condyle
(Tucker and Dolwick 1993). Generally in these patients, an opening over 40 mm is
observed, and pain is minimal.
Disk displacement without reduction occurs when the disk is anterior to the joint
in closed position. When attempts are made to open, the condyle is never able to
pass the posterior bands, and therefore the disk never sits over the top of the condyle
as in a disease-free state. The history of patient will include that they used to have a
click on opening and that the clicking went away and their maximum interincisal
opening (MIO) decreased. The clinical exam for patients with displacement without
reduction will include a lack of clicking/popping, MIO <30 mm, and pain to the
ipsilateral joint on loading.
Generally no imaging is required for diagnosis of displacement. A plain film
(panoramic radiograph) may be taken and will show normal appearance with very
mild flattening of the superior condyle (Leeuw 2008). If confirmation of the
displacement is required, then an MRI is indicated.
Whether disk position and pain are related is a matter of debate. It has been
shown that 30–50% of people may experience clicking without ever experiencing
pain. It does not appear that surgeries to reposition the disk reduce pain but rather
that simple procedures like joint lavage (arthrocentesis) and arthroscopy with lysis
of adhesions have more success with pain reduction. Mandibular dysfunction
(limited opening) has also been associated with disk displacement, but it has been
shown that lavage and lysis of superior joint space adhesions during arthroscopy or
arthrocentesis have effectively treated closed lock. There is an unclear relationship
19 Disturbances of the Temporomandibular Joint Apparatus 409

between osteoarthritis and joint position with theories that the disk helps to protect
the condyle and displacement expedites joint degeneration. It is also unclear as to
whether disk position may interfere with growth of the joint as there are limited
studies comparing symptomatic versus asymptomatic patients with disk
displacement (Dolwick and Dimitroulis 1996).

19.3.3 L
 ow Inflammatory Disorders (Degenerative Joint Disease
and Osteoarthritis) and High Inflammatory Disorders
(Systemic Arthritic Conditions)

The TMJ is affected by conditions which are low inflammatory processes which
develop slowly and are isolated to the TMJ. These conditions include osteoarthritis
and degenerative joint disease of the TMJ. These conditions are generally detectable
on clinical exam with decreased range of motion, joint popping, and crepitus.
Patients will have a history of joint pain which worsens through the day and with
function as well as joint noises. In severe osteoarthritic changes, the resorption of
the condyle can decrease the vertical height of the ramus and therefore cause
apertognathia (anterior open bite). Osteoarthritic changes of the TMJ noted
radiographically on panoramic imaging may be flattening or irregularity of the
condyle, decreased joint space, or osteophytes. A CT may show areas of radiolucency
indicating degeneration (Mercuri 2008). Degenerative joint disease, namely, joint
perforation, can be visualized with diagnostic arthroscopy or open joint surgery.
MRI T2-weighted images will show joint effusion which is suggestive of disk
perforation (Fig. 19.5). Low inflammatory disorders are associated with low
leukocytes values on lab examination (Mercuri 2008). Move sentence up to the
previous paragraph.
Conversely in high inflammatory states such as idiopathic juvenile arthritis,
rheumatoid arthritis, or gouty arthritis, there will be elevated inflammatory factors
which will aid in diagnosis. The patient will have bilateral TMJ involvement as well
as bilateral joint involvement elsewhere in the body (knees, wrists) with erosive
changes present on panoramic imaging. If patients present with multiple affected
joints, it is important to send them to their primary care provider for additional
investigation into their disease process to aid in systemic treatment.

19.3.4 Hyper- and Hypomobility Disorders

Hypermobility of the TMJ can be divided into acute dislocation, chronic recurrent
dislocation, and chronic dislocation. Acute dislocation can occur following wide
opening such as eating or even during dental procedures. This is very painful and
should be treated as soon as possible. The treatment consists of the dentist’s thumbs
being applied to the posterior mandible, either over the teeth or on the ramus, and
fingers to be along the anterior aspect of the inferior border of the mandible. Then a
clockwise rotational pressure is applied to overcome the articular eminence
410 M. F. Dolwick and D. Freburg-Hoffmeister

a b

Fig. 19.7 (a) Anterior dislocation of the condyle from fossa, (b) reduction of the condyles mov-
ing in a clockwise direction with thumbs over posterior teeth and fingers supporting inferior sur-
face of mandible, (c) jaw support for post-reduction care

(Fig. 19.7). Post-op imaging can be performed to verify reduction, but the clinical
exam should be sufficient as the patient is able to occlude again (panoramic
radiograph from slide #9). Post-op care includes limited opening for 3–4 weeks
with aid of a jaw bra, NSAIDs, and muscle relaxants. Patients with chronic recurrent
dislocations will experience dislocation as described above multiple times a week or
even day. A chronic dislocation is when a patient dislocates and remains so for
several weeks without reduction. These cases should be referred to an oral surgeon.
TMJ ankylosis may be caused intra- vs extra-articular sources. True ankylosis
(intra-articular) is caused by fibrous or osseous tissue which eliminates the joint
space thus fusing the condyle to the fossa space. This prevents any movement of the
mandible. False (extra-articular) ankylosis occurs generally with coronoid
hyperplasia in which treatment is coronoidectomy (Fig. 19.8). It may also occur
following facial trauma in the case of a zygomaticomaxillary complex impingement.

19.4 Noninvasive Treatment

The majority of patients will not require surgical intervention and will recover with
conservative treatment. Muscular disorders do not benefit from surgical intervention.
They require a combination of pharmaceuticals, physical therapy, cognitive
behavioral therapy, occlusal therapy, massage and thermal therapy, stress reduction,
and occasionally psychological counseling (Clark 2008). The majority of patients
with disk derangement will recover without surgical intervention. After diagnosis of
disk displacement which is made clinically and/or radiographically (MRI), patients
are instructed to avoid parafunctional activities (grinding/clenching) and to maintain
space between their teeth unless swallowing. They are encouraged to have a soft
diet to avoid loading the joint and exacerbating pain.
19 Disturbances of the Temporomandibular Joint Apparatus 411

a b

Fig. 19.8 (a) Coronoid hypertrophy, not true TMJ ankylosis, (b) CT with 3D reconstruction
showing true (osseous) ankylosis, (c) panorex showing left TMJ osseous ankylosis

19.4.1 Physical Therapy (Professional and Home Directed)

Physical therapy (PT) is very important for both MPD and internal derangement
as well as for post-op rehabilitation as in total joint replacement. PT is important
to improve range of motion and alleviate symptoms. Patients will then be placed
on home exercise routines which may be assigned by the physician, dentist, or
physical therapist. The physical therapist will review the patient’s history, posture,
and habits which may be altered in order to decrease pain and increase range of
motion (ROM) (Wright and North 2009). PT also involves manipulation and
stretching of muscles and tension bands. A therapist or dentist may suggest a daily
regimen. One recommended exercise to aid with masticatory muscle strain
involves the patient placing their tongue to the roof of their mouth and attempting
to open without disengaging the tongue. The neck should also be addressed with
chin to neck exercises. It is important to stress to the patient that the stretching
must be repeated once every few hours rather than once per day for a longer ses-
sion (Clark 2008).
412 M. F. Dolwick and D. Freburg-Hoffmeister

19.4.2 Thermal and Massage Therapy

It has been shown that ice packs, moist heat, and heating pads are effective in the
management of pain for MPD by increasing vascularity into the muscles of
mastication. Patients are instructed to perform local treatments with hot or cold
packs onto the affected muscles for 20 min twice daily (Clark 2008). Patients may
seek professional massage therapy or perform their own massage of muscular
trigger points with moist warm towels.

19.4.3 Occlusal Splints

Another form of therapy is fabrication of a custom-made occlusal splint. Patient

may have their general dentist fabricate the appliance or may be referred to a dentist
who consistently treats patients with TMJ discomfort. The patient must be counseled
on consistent use of occlusal guards and wearing it at times of known bruxism.
Patients with painful anterior disk displacement with reduction may benefit from an
anterior repositioning appliance which protrudes the condyle in a closed mouth
position. This reduces pressure on the retrodiscal tissues thereby allowing
remodeling and decreased pain. This is not meant to eliminate clicking (Leeuw
2008). The full coverage stabilization splint (Fig. 19.9) is effective for patients with
osteoarthritis, internal derangement, and MPD. Relief occurs in taking some of the
load off of the joint as well as achieving a more balanced occlusion, thereby
decreasing muscle hyperfunction (Al-Ani et al. 2005).
A systematic review was performed comparing splint therapy to other noninva-
sive treatments in MPD. It did not show statistical significance of splint therapy
being more effective when compared to other noninvasive treatments but did con-
clude that splint therapy was more effective than no treatment at all (Al-Ani et al.
2005). Another systematic review found inconclusive data to support one type of
splint versus another and found no difference between hard and soft splints but
agreed with the first review that splint therapy was more effective at pain reduction
than no treatment (Turp et al. 2004).

Fig. 19.9 Full coverage occlusal appliance

19 Disturbances of the Temporomandibular Joint Apparatus 413

19.4.4 Life Modifications

It is important to talk to the patient about their diagnosis and discuss the need for
conservative treatment prior to considering surgery. Patients who clench when
stressed or chew on gum continuously need to recognize these activities as painful
stimuli, so they may be avoided. In addition to avoiding certain behaviors, it is
important to encourage patient to channel their stress in a more productive way such
as aerobic exercise. It is important to counsel patient on exercise that will not
exacerbate their symptoms however (Clark 2008). Another simple modification is to
have the patient plan timed reminders in their day to have lips together and teeth
apart.

19.4.5 Pharmacotherapy

The first-line treatment for both musculoskeletal pain as well as internal derange-
ment is nonsteroidal anti-inflammatory agents (NSAIDs). These drugs do not have
risk of dependency and are very effective at analgesia and anti-inflammatory prop-
erties if they are taken scheduled rather than as needed. NSAIDs should be avoided
in patients with history of gastrointestinal ulcers or patients taking anticoagulation
agents as this may lead to a life-threatening bleed. Short-term corticosteroids and
intra-articular injections are effective in reducing inflammatory agents and thereby
reduce pain. Steroid injections should be used with caution as frequent repeated
injections, as well as injections in developing joint, may result in osteoarthritic dam-
age (Mercuri 2008). Opioids should be reserved for postoperative use only and in
absence of surgery should be avoided to prevent dependency.
Tramadol which is an opioid agonist is effective in pain management, especially
in cases of fibromyalgia, and would do well with musculoskeletal pain, but this drug
causes dependence and therefore should also be reserved for postoperative pain
only (Clark 2008). Patients with myofascial pain disorder (MPD) may benefit from
a benzodiazepine or other sedative hypnotics. This is related to muscle relaxing
activity as well as increased sleep architecture. These medications run the risk of
being dependence however and should not be used for long durations. Muscle
relaxants such as flexeril (cyclobenzaprine) are useful as they act centrally to reduce
muscle spasm. They do cause fatigue which is why several patients do not tolerate
the medication despite pain reduction (Hersh et al. 2008). Botox has an off-label use
in MPD when injected into trigger points. The research to date has inconsistent
study models as well as results and therefore offers no conclusion as to Botox’s
effectiveness in MPD (Chen et al. 2015).
Topical medications are not well studied, but available agents include capsaicin
and transdermal lidocaine patches. Antidepressants are also effective at pain
reduction, but the mechanism of action with regard to analgesia is not known. The
most effective of these is tricyclic antidepressants, but due to side effects, these
agents generally are not tolerated well by patients. While selective serotonin receptor
inhibitors (SSRIs) have a better side effect profile, their utility in pain management
414 M. F. Dolwick and D. Freburg-Hoffmeister

is disputed (Clark 2008). Anticonvulsants are useful as neuropathic pain modulators;

they also reduce muscle spasm and pain perception at trigger points. Again, side
effects including fatigue limit their use (Hersh et al. 2008).

19.5 Surgical Procedures

If conservative treatments do not decrease pain or aid with function, then further
procedures are indicated. Treatment for internal derangement may be arthrocentesis,
arthroscopy, or arthroplasty. Treatment for noninflammatory and inflammatory
conditions may be the above in addition to gap arthroplasty and total joint
replacement. Hypermobility of the TMJ may be treated with hemarthrosis
conservatively or eminectomy.

19.6 Invasive Procedures

19.6.1 Arthrocentesis

After a patient has an occlusal guard for at least 2 months as well as taking sched-
uled NSAIDs, and if they are still experiencing pain and limited MIO, then arthro-
centesis may be effective. Arthrocentesis has a very low risk profile and has success
rate of 83.2% according to literature review by Al-belasy and Dolwick (Al-Belasy
2007). The procedure may give benefits of lysis of adhesions, lavage of inflamma-
tory agents, and injection of steroids which may reduce pain (Al-Belasy 2007). The
act of washing out an inflamed joint will decrease pressure thus decrease pain
(Nitzan 2006). It can be performed in a clinic setting with local anesthesia, poten-
tially augmented with conscious sedation. The procedure consists of two 18 gauge
needles placed into the superior joint space (Fig. 19.10). The first needle is placed
following an imaginary line connecting the tragus to the lateral canthus. 10 mm
anterior to the tragus and 2 mm inferior are the approximate location of the first
needle. The second needle is then inserted just anterior to the first as shown.
It is advised to use an actual needle rather than catheter to prevent breakage of
the catheter tip into the joint space or tissues. Prior to needle insertion, an
auriculotemporal nerve block and local anesthetic infiltration are performed for
patient comfort. In one needle lactated ringer (LR) solution is pushed, and in the
second needle, the irrigation is expelled. The pressure of the lavage aids to break
down superior joint adhesions. This is augmented by intermittently blocking the
outflow tract which temporarily increases intra-articular pressure. After irrigation
with up to 300 ml of LR, steroids are injected into the joint space. Then the needles
are removed and pressure applied over the puncture sites for 5 min. Range of motion
is examined and recorded. The patient should be manipulated to MIO, protruded,
and test lateral excursive movements (Dimitroulis et al. 1995). Postoperative
analgesia may consist of NSAIDs with narcotics for breakthrough pain. The patient
19 Disturbances of the Temporomandibular Joint Apparatus 415

Fig. 19.10 (a) Shows an auriculotemporal block, (b) insertion of first 18 gauge needle into supe-
rior joint space, (c) insertion of second needle

should have a soft diet for 3 weeks and begin range of motion exercises the day
following the procedure (Al-Belasy 2007; Dolwick 2007).
This procedure has been found to be effective in several studies at increasing
MIO and decreasing pain in patients who have failed conservative therapy including
NSAIDs and consistent occlusal guard use. Dolwick, Dimitroulis, and Martinez
showed an increase in MIO following procedure of 24.5 mm ± 5.2 mm to
42.3 mm ± 6.1 mm in a 21-month follow-up and reduction of pain from 8.8 ± 2.0 to
2.2 ± 0.6 (Dimitroulis et al. 1995). This procedure has few risks which include
infiltration of LR into surrounding tissues, hematoma, or infection; these risks are
very low however. A transient risk is facial paralysis causing weakness of eye
closure. This will last a few hours and require an eye patch until the eyelids have
regained function.
In addition to showing that arthrocentesis is highly effective, further studies have
shown that arthrocentesis plus occlusal therapy produces the most effective pain
reduction for cases of internal derangement and osteoarthritis (Lee et al. 2013;
Machon et al. 2011). In a study by Machon, 80 patients with unilateral TMJ
symptoms were divided into four groups. The first group received rest therapy plus
nonsteroidal scheduled anti-inflammatory drugs (NSAIDs), the second group had
splint therapy plus NSAIDs, the third group had arthrocentesis with analgesics as
needed, and the forth group had arthrocentesis plus splint therapy with NSAIDs.
This study showed the best results in group 4 (arthrocentesis, NSAIDs, and occlusal
splint therapy) with an 86% pain and function improvement. Another study demon-
strates the importance of combined therapies from Lee which compared three
groups. The first group had occlusal therapy delivery, the same day as arthrocente-
sis, the second group wore the occlusal guard 8 weeks prior to arthrocentesis, and
the third group wore occlusal guard as sole treatment. All three groups showed
improvement, but the fastest improvement was in the simultaneous arthrocentesis
416 M. F. Dolwick and D. Freburg-Hoffmeister

plus occlusal guard group and slowest improvement in the group that received
occlusal guard treatment only (Lee et al. 2013).

19.6.2 Arthroscopy

Arthroscopy can be performed for diagnosis as well as treatment and may be per-
formed in an oral surgeon’s office with intravenous sedation or in the operating
room. In a diagnostic arthroscopy, the superior joint space is entered similarly with
arthrocentesis. An arthroscopic telescope (1.8–2.6 mm diameter) is placed into the
superior joint space as well as a second access instrument anterior to the arthroscope.
The joint is then examined from posterior to anterior looking for inflammation,
capillary hyperemia, adhesions, disk perforation, and cartilaginous degeneration
(Fig. 19.11) (Dolwick 2007).
A diagnostic arthroscopy can achieve breakdown of adhesions, but if performing
discectomy, plication, or other procedure, general anesthesia in an operating room
setting should be considered. Postoperative care is similar to arthrocentesis. The
benefit of this surgery is the lack of an incision while allowing visualization of the
joint with expense being the main drawback.

19.6.3 Arthroplasty (Open Joint Surgery)

If conservative procedures including arthrocentesis are unable to alleviate pain

and improve range of motion, arthroplasty may be considered. This procedure
requires general anesthesia through a preauricular incision. Disk repositioning
may be performed if the disk is intact and may provide better motility with
decreased mechanical interferences. If the disk is diseased or perforated, a discec-
tomy is indicated (Fig. 19.12). The bone may be re-contoured to remove mechani-
cal interferences, but care should be taken to manipulate bone as little as possible
as it can lead to heterotopic bone formation. An abdominal fat graft may help
prevent heterotopic bone and ankylosis. Postoperative care consists of range of
motion exercises the day following surgery and soft diet for 6 weeks. Pain may be
addressed with NSAIDs primarily and 1–2 weeks of narcotics for breakthrough
pain. The benefits of the procedure are direct visualization of the joint and access
for treatment.
The main risk of this procedure is damage to the facial nerve which could result
in weakness and elevating eyebrows. This procedure is not performed frequently
due to invasiveness and great results with conservative procedures like arthrocentesis;
however, it is highly effective. It was shown by Abramowicz and Dolwick in a
20-year follow-up of internal derangement treated with disk repositioning that there
was a reduction of pain at rest (77% reduction) and reduction of pain in function
(56%), less dietary restrictions, and a 94% improved quality of life for patients who
participated in postoperative survey (Abramowicz and Dolwick 2010).
19 Disturbances of the Temporomandibular Joint Apparatus 417

a b

c d

e f

Fig. 19.11 (a, b) Normal arthroscopic upper joint space, (c, d) synovitis and inflammatory
changes, (e, f) joint adhesions

19.6.4 Total Joint Replacement

Alloplastic joint replacement has changed much over the years with current FDA-
approved products: TMJ Concepts which is a custom-fitted prosthesis and the
Biomet stock joint. Previous failed products include the Proplast-Teflon and silastic
implants. They had good short-term success but were later taken off the market. The
418 M. F. Dolwick and D. Freburg-Hoffmeister

a b

Fig. 19.12 (a) Preauricular incision with dissection to joint, (b) direct visualization of joint, (c)
debridement of the joint, discectomy with removal of diseased portion of disk. Through this
approach osseous recontouring also performed to remove interferences with movement

functional load placed on the joint was too great which caused breakdown as well
as foreign body reactions (Dolwick and Dimitroulis 1994). For the custom
prosthesis, a CT of the head is required from which an acrylic model is made and
the prosthesis is designed (Fig. 19.13). The stock joint (Biomet) comes in three
sizes for the condylar and fossa components. The surgery requires a preauricular
and retromandibular incision. The procedure requires two surgical fields: a sterile
19 Disturbances of the Temporomandibular Joint Apparatus 419

a b

Fig. 19.13 (a) Example of Biomet stock joint in which the patients bone is modified to fit the
prosthesis, (b) example of TMJ concepts custom joint which is fabricated from the patient’s CT
that is made into a 3D reconstruction model

field for entering the joint and a non-sterile field for accessing the mouth. The mouth
is covered with Tegaderm, and the joint is accessed first. A gap arthroplasty is
performed to remove the condyle and smooth irregularities of the bone in the fossa.
Additional bone may require removal to allow the prosthesis to fit in function. The
benefit of the Concepts custom joint is the need for less modification of the native
mandible and fossa. The bone that does require removal is marked on the acrylic
model which further reduces surgical time. Next the sterile field is isolated, and the
mouth is accessed, and patient is placed in maxillomandibular fixation. Finally the
joints are placed and secured. In some cases such as ankylosis, previous prosthesis,
or other pathologies, a two-stage procedure will be required with the custom joint
prosthesis. While the benefits of the custom joint are clear, it does delay surgery as
the fabrication process may take 3–4 months (Dolwick 2007).

19.7 Conclusion

In conclusion, disorders of the TMJ may be categorized as either musculoskeletal or

intra-articular (involving the joint itself). Treatment of musculoskeletal disorders
and myofascial pain is through noninvasive therapy and will not benefit from
surgical intervention. Management of intrinsic joint disorders may be noninvasive
and/or surgical. The examination findings of both categories were discussed as well
as the noninvasive treatments. Radiographic exam involves panoramic imaging for
screening, MRI for disk morphology and movement evaluation, and a CT for
arthritic changes. Physical therapy, thermal therapy, massage therapy, and occlusal
splints have all been shown to be effective in the treatment of TMD. Regarding
pharmacotherapy, NSAIDs are the first-line medication for treatment of TMJ both
musculoskeletal and intra-articular disorders. Opioids should only be given for a
short duration to manage postoperative pain. Surgery is indicated for patients with
420 M. F. Dolwick and D. Freburg-Hoffmeister

intra-articular disorders who have failed noninvasive therapy. Arthrocentesis is the

first-line minimally invasive procedure for internal derangement, followed by
arthroscopy. Arthroplasty is used to improve function and decrease pain by removing
movement interferences. Severe osteoarthritis and ankyloses must be treated with
total joint replacement with either a stock Biomet or Concepts custom joint
prosthesis. If surgery is indicated, it should be stressed that the noninvasive therapies
must continue postoperatively to achieve optimal results regarding pain and
function.

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Congenital Facial Deformities
20
Jeff Marschall Green, Eric D. Bednar, and Lewis C. Jones

“My eyes have been trained to examine faces and not their
trimmings. It is the first quality of a criminal investigator that
he should see through a disguise.”
Sherlock Holmes in—The Hound of the Baskervilles

Abstract
Craniofacial deformities encompass a wide array of congenital and acquired syn-
dromes of the head, neck, face, and jaws. The care of these complex patients
requires a team-based approach with multiple providers, including but not
limited to surgeons, pediatricians, and dentists. Understanding normal growth
and development of the maxillofacial complex and the deciduous and
succedaneous dentition is essential as it has a profound influence on the timing
of surgical and nonsurgical interventions. This chapter is designed to introduce
the general dentist who practices on the craniofacial team of the basic principles
in the care of these patients.

J. M. Green
Oral and Maxillofacial Surgery, University of Louisville, Louisville, KY, USA
e-mail: [email protected]
E. D. Bednar
Department of Orthodontics, University of Louisville, Louisville, KY, USA
e-mail: [email protected]
L. C. Jones (*)
Department of Oral and Maxillofacial Surgery, University of Louisville, Louisville, KY, USA

© Springer International Publishing AG, part of Springer Nature 2019 423

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_20
424 J. M. Green et al.

20.1 Introduction

Congenital facial deformities (CFDs) consist of a wide array of phenotypes that

consist of deviations in varying degrees from “normal” facial proportions and dental
relationships. CFDs range from almost imperceptible defects to extremely
disfiguring anomalies. Underlying skeletal, soft tissue, and dental abnormalities can
result in malocclusion, esthetic deformities, speech impediments, and psychosocial
difficulties—each of which may result in decreased quality of life (Proffit et al.
2003).
Optimal care for patients with CFDs requires a team approach to achieve appro-
priate timing for intervention and ensure that no aspect of care is neglected. A typi-
cal craniofacial team includes a craniofacial surgeon (often a maxillofacial, ENT, or
plastic surgeon—each of which may be required separately depending upon the
craniofacial surgeons background), dentist, speech-language pathologist, audiolo-
gist, prosthodontist, psychologist, geneticist, and social worker. The roles of the
various practitioners in the team approach are outlined in Table 20.1.

Table 20.1 The personnel of the craniofacial team

Craniofacial surgeon Usually an oral and maxillofacial surgeon, plastic surgeon, or
otolaryngologist with additional fellowship training in cleft and/or
craniofacial surgery
Otolaryngologist Perform tympanostomy and ear tube placement, which is often required
in CFD patients
Oral and Perform dental extractions, bone grafts, dental implant placement, and
maxillofacial surgeon corrective jaw surgery (orthognathic surgery) which is often required in
CFD patients
Speech pathologist Help the team decide if speech therapy, prosthetic devices, or surgery is
needed to help improve the patient’s spoken communication
Orthodontist Instrumental in the nonsurgical management of maligned jaws and help
monitor growth and development via cephalometrics
Audiologist Often works in conjunction with the speech pathologist, this individual
is responsible for completing the hearing test for the patient
Pediatrician Often the coordinator of care, this individual has a hand in all aspects of
care including diagnosis, medical management, and communication
between other healthcare providers
Pediatric dentist This individual coordinates the children’s dental care with emphasis on
prevention and maintenance of oral health
Prosthodontist Dental specialist who fabricate prosthesis to replace missing teeth or
obturators to close soft-tissue or bony defects that surgery cannot
correct
Psychologist Instrumental on monitoring the mental health of the patient and how to
teach the patient to cope with the social aspects of a facial deformity
Clinical geneticist Helps delineate the genetic etiology of disease and advise on heredity if
a specific syndrome is suspected
Social worker Patient and family counselor and often helps with communication
between healthcare teams
Nurse During hospital stays, the nurse is responsible for the daily healthcare of
the patient and carries out physician orders
20 Congenital Facial Deformities 425

20.2 Normal Growth/Development

This chapter is designed for the dental provider on the craniofacial team. The dental
provider must be well versed in normal craniofacial and dental development to
ensure that the interventions are timed appropriately. In brief, bone development
can be separated into three general processes: bone growth, remodeling, and
displacement. Bone growth and remodeling occur simultaneously—striking a
balance between bony resorption and deposition. Displacement occurs as the facial
bones grow away from each other from their articular junctions. These processes
occur in concert and produce dynamic three-dimensional changes. The
maxillomandibular complex enlarges in a downward and forward direction that has
been described as an “expanding pyramid” (Enlow and Hans 1996). Disruptions in
these processes during growth can result in anomalies. These disruptions can occur
as inherited abnormalities (i.e., TCOF1 gene with Treacher Collins syndrome,
which is autosomal dominant), spontaneous mutations (i.e., GNAS1 gene mutations
resulting in fibrous dysplasia), intrauterine events (i.e., mandibular growth
restrictions resulting in Pierre Robin sequence), or environmental factors (i.e., facial
clefting resulting from anti-seizure medications such as valproic acid).
The maxillofacial complex encompassing the maxilla, mandible, alveolus, and
dentition is an ever-changing region beginning in utero (dental lamina in the maxilla
and mandible are evident as early as 8 weeks in utero) and extending into late
adolescence/early adulthood when the mandible reaches growth completion
(DeAngelis 1975). In the interval between birth and adulthood, primary teeth
develop, erupt, and exfoliate as their succedaneous counterparts erupt into occlusion.
Teeth start entering the oral cavity at approximately the sixth postnatal month. The
primary dentition is completed by 2.5 years of age. The first teeth to exfoliate are the
primary incisors at ages 6–7. The permanent dentition begins to emerge as the
incisors and first molars first pierce the oral mucosa at about this same age. The
permanent dentition is completed by ages 12–14; however, third molars will
continue to develop until approximately 17 years of age (Fig. 20.1). During this
process, the supporting alveolus grows and is remodeled to support the dentition.
The maxilla and mandible should grow in concert to allow for the final result of
class I occlusion with appropriate projection and expansion of the maxilla and
mandible. Deviation from these normal developing processes can result in
malocclusions (Angle’s class II or III; Fig. 20.2), crossbite, and/or anterior open bite
to name of few. Data extrapolated from the National Health and Nutrition
Examination Survey (NHANES III) demonstrated about 2% of the population of the
United States suffered from a DFD resulting in a debilitating malocclusion requiring
surgical correction (Proffit et al. 1998). The appropriate timing of interventions
including maxillary expansion, headgear, orthodontics, and implant therapy is
imperative to optimize the care delivered.
426 J. M. Green et al.

Baby Teeth Erupt Lose Permanent Teeth Erupt

8-12 mos. 6-7 yrs. 7-8 yrs.
Upper Teeth Upper Teeth
9-13 mos. 7-8 yrs. 8-9 yrs.
Front 16-22 mos. 10-12 yrs. 11-12 yrs.
Front 10-11 yrs.
13-19 mos. 9-11 yrs.
25-33 mos. 10-12 yrs. 10-12 yrs.
6-7 yrs.
Back 12-13 yrs.
Erupt Lose 17-21 yrs.
23-31 mos. 10-12 yrs. Erupt
Back
14-18 mos. 9-11 yrs. 17-21 yrs.
Front 17-23 mos. 9-12 yrs. 11-13 yrs.
10-16 mos. 7-8 yrs. 6-7 yrs.
Lower Teeth
6-10 mos. 6-7 yrs. 11-12 yrs.
Front 10-12 yrs.
9-10 yrs.
Lower Teeth 7-8 yrs.
6-7 yrs.

Fig. 20.1 Primary and permanent dental eruption pattern

20.3 Timing of Interventions

Interventions directed by the dentist on the craniofacial team are mainly comprised
of dental treatments (including exams, cleanings, imaging, restorations, and
extractions), growth modification (headgear, palatal expansion, appliances), and
surgical interventions (orthognathic, dental implant, and distraction osteogenesis
surgeries). In general, each patient should have appropriate exams with a dental
provider on a semi-annual basis at a minimum. Increased frequency of visits will be
required in scenarios where an increased risk of dental caries exists. This could be
due to a variety of reasons. Patients with cleft lip and/or palate have demonstrated
an increased incidence of dental caries over control groups in both primary and

Fig. 20.2 Angle classification of malocclusion

20 Congenital Facial Deformities 427

permanent dentition (Bokhout et al. 1996; Kirchberg et al. 2004; O’Neill 2007).
Hygiene may be difficult to optimize for some craniofacial patients with extremity
and/or digital anomalies (such as Apert syndrome). Judicious fluoride treatments
can aid in caries prevention in addition to repeated encouragement and reinforcement
of good habits with the patient.
Outside of exams, cleanings, and restorations, one of the first interventions with
regard to growth modification in many cleft and craniofacial patients is maxillary
expansion. Placement of a stable and effective maxillary (tooth-borne) expander
requires adequate eruption of the first molars, which occurs at or around age 6. The
midpalatal suture ossifies at ages 12–13; therefore, intervention should occur prior
to this, or the expansion will require a surgical midpalatal osteotomy (and associated
osteotomies) in order to facilitate expansion of the maxilla. The routine exam
administered at each team clinic visit should include analysis of the existence (and
degree when it exists) of posterior crossbite and eruption of the first molars to
facilitate possible orthodontic intervention. When required, the appropriate referral
for extractions due to decay or impaction should be made as soon as detected and
prior to development of symptoms. This allows for flexibility in the timing of a
procedure. Many cleft and craniofacial patients require multiple procedures
throughout their growth and development. All efforts should be made to combine
procedures when possible to consolidate the number of general anesthetics a patient
must undergo. Extractions can often be performed in conjunction with other
procedures. One example of this is the extraction of third molars in conjunction with
orthognathic surgery.
Palatal expansion is one type of growth modification—growth modification tech-
niques require that the patient is still growing. Preadolescent referral of patients
who exhibit a class II or class III malocclusion will allow the orthodontist flexibility
in regard to the timing and method of growth modification. Growth modification
techniques strive to apply orthopedic forces to growing skeletal structures to
improve jaw position and relationships. Ideal timing of growth modification depends
on skeletal maturity and growth potential. Attempts at growth modification that take
place after skeletal maturity can alter dental relationships if forces are placed on the
dentition but are less effective at altering skeletal relationships. For patients without
clefts or syndromes, typical class II growth modification is completed during the
adolescent growth spurt. Orthodontic headgear places a distal force on the maxilla
and maxillary dentition to restrain maxillary growth while the mandible is growing
downward and forward, thus correcting class II dental relationships and improving
jaw relationships while the mandible is growing at peak velocity. Other inter-arch
tooth-borne appliances (Herbst, MARA, Twin-Block) can be used which transmit
distal force through the maxillary dentition to the maxilla and transmit mesial force
through mandibular dentition to the mandible. These appliances have a restraining
effect on maxillary growth. For patients without clefts or syndromes, ideal class III
growth modification takes place in the early mixed dentition, typically before age 9
when the circum-maxillary sutures are still pliable. Treatment is typically done with
a reverse pull face mask, in which elastics are attached from the face mask to a
tooth-borne appliance on the maxillary dentition, transmitting force to cause suture
428 J. M. Green et al.

separation and maxillary protraction. When considering growth modification for

patients with clefts and other dentofacial deformities, adaptation of these general
principles may be required to fit the unique conditions and circumstances of each
patient.
Surgical interventions for dentofacial deformities include distraction osteogene-
sis, orthognathic surgery, bone grafting, bone contouring, and dental implant sur-
gery. Timing of the surgery will take into account the risks, benefits, alternative
treatments including the limitations of surgery, timing of the surgery with respect to
growth maturation, and the psychosocial well-being of the patient.
Distraction osteogenesis is performed for various reasons. A patient with severe
mandibular retrognathia at birth (such as a severe Pierre Robin sequence patient)
may require early distraction osteogenesis of the mandible to translate the mandible
and associated muscular attachments forward, thus opening the airway and
(hopefully) obviating the need for tracheostomy (Images 20.1, 20.2, 20.3). Early
mandibular distraction is performed with an attempt to place osteotomies proximal
to the developing dentition/tooth buds. This is not always accomplished and so
monitoring of the developing teeth for appropriate interventions (orthodontics/
extractions/etc.) is paramount. A patient requiring distraction osteogenesis to
achieve symmetry (such as a hemifacial microsomial patient) may elect to wait until
growth completion with the hope that the surgery will be a “one-and-done.” With a
single intervention after growth is completed to achieve the symmetry. However, the
asymmetry may impact the psychosocial well-being of the child, and earlier
intervention with distraction osteogenesis may be “outgrown” as the patient
continues to develop, but the phenotypical presentation of the patient will be less
severe and this can certainly have a positive impact on the psychosocial well-being

Image 20.1 Lateral scout film of patient with Pierre Robin sequence: total closure of posterior
airway and maxillomandibular discrepancy with mandibular retrognathia is observed. This patient
was unable to maintain his airway in prone position with supplemental oxygen
20 Congenital Facial Deformities 429

Image 20.2 Internal distractors (KLS Martin Micro Zurich 2) in place immediately post-op.
Patient remains intubated during initial distraction

of the patient. Thus it is difficult to assign a timeline to many of these interventions,

and it requires each patient be reviewed by the team and include all the appropriate
providers to determine the optimal timing of intervention.
Bone grafting to the alveolus is timed differently depending upon the intent for
use of the graft. Grafted bone can (and will) resorb if not utilized. Thus, the timing
for the graft will depend upon when it will be utilized. An alveolar bone graft in a
cleft patient with an oronasal fistula present will need the surgery for alveolar cleft
repair prior for several reasons. Indications for alveolar bone grafting include the
following: consolidation of the maxillary dental arch, closure of the fistula, provide
bone to support erupting dentition and existing dentition on either side of cleft, and

Image 20.3 Patient is now 5 days post placement of distraction with a 1 cm mandibular advance-
ment (2 mm/day—1 mm twice daily). He underwent successful intubation and distraction contin-
ued at 1 mm/day for additional 8 days
430 J. M. Green et al.

nasal base support (Coots 2012). Bone grafting in this population is done at different
stages depending on the theories to which the operating surgeon subscribes. The
majority of surgeons will ensure that the grafting has been performed prior to
development and eruption of the canine on the affected side (most often when the
root of the canine is 2/3 formed). This is usually around ages 9–10 and the procedure
is tolerated very well. Bone used is often harvested from the iliac crest, but other
bone utilized may include symphysis, cranial, allogeneic, or rh-BMP2 (Images 20.4
and 20.5). Once the canine is erupting into the cleft, the level of difficulty of surgery
increases and quality of bone remaining after grafting is decreased due to exposed
cementum, which may exhibit external resorption after exposure to an autogenous
graft. Annual visits to the craniofacial team and examination by those with dental
backgrounds will help avoid late, compromised grafting in the cleft/craniofacial
patient population.
Other bone grafts may be placed to facilitate implant placement. Implants (in
most cases) will not be placed until the patient has reached skeletal maturity. (17–
18 years of age is usually a “safe” age, but longitudinal observation and exams will
help aid in determining cessation of growth prior to placement.) Grafts placed
several years prior to utilization often resorb and require additional augmentation
prior to (or at the time of) implant placement. For this reason, it is recommended
that grafting for implants takes place approximately 6 months prior to placement of
the implants. This will help ensure that the grafted bone is stimulated under the
stresses of mastication and does not atrophy.
Orthognathic surgery is best timed after growth completion—with the mandible
being the final bone to reach growth completion in the craniofacial skeleton. This is
especially significant in the class III patient, as early intervention with a LeFort I
advancement can correct the occlusion and dentofacial esthetics initially only to
“relapse” as the patient’s mandible continues to grow and results in a class III

Image 20.4 Alveolar cleft intraoperative view: a 9-year-old female with near-complete alveolar
cleft present
20 undefined 431

Image 20.5 Alveolar bone graft present and ready for mucosal closure

malocclusion. A thorough understanding of the normal facial growth timeline is

essential for treatment planning. Maxillary growth in the transverse plane is
complete by 12 years of age (Bjork and Skieller 1977). Anterior-posterior growth of
the maxilla is completed by 14 years of age (Savara and Singh 1968). On average,
mandibular ramus height increases 1–2 mm per year, and mandibular body length
increases 2–3 mm per year. Mandibular growth is completed by 14–15 years of age
in females (Foley and Mamandras 1992) and 18 in males (Love et al. 1990)
(Table 20.2). Decisions with regard to timing of growth completion may include
evaluation of hand/wrist films or serial cephalometric images. These can be used to
aid in the decision-making process with regard to surgical timing.

20.4 Conclusion

Thus the dental provider on the craniofacial team can aid in the coordination and
care of each patient. The end goal of the team is unified in its desire to rehabilitate
the patient’s form and function. Much of the function that is desired centers around
the ability to masticate and speak—both of which are facilitated by dentition. The
dental practitioner is paramount in ensuring that milestones and opportunities to

Table 20.2 Approximate Bone Age

completion of craniofacial Cranial vault 8
bone development Anterior cranial base 10
Posterior cranial base 20
Nasomaxillary complex 16–18
Orbits 11 in females; 15 in males
Maxilla 12–14
Mandible 14–15 in females; 18 in males
432 J. M. Green et al.

maximize the patient’s outcome are not overlooked. Frequent exams, both in team
clinic and in the dental chair at follow-up visits, are important interactions to ensure
that high-quality, well-timed care is delivered in a method that is tailored to each
patient’s circumstance and presentation.

References
Bjork A, Skieller V. Growth of the maxilla in three dimensions as revealed radiographically by the
implant method. Br J Orthod. 1977;4(2):53–64.
Bokhout B, Hofman FX, van Limbeek J, Kramer GJ, Prahl-Andersen B. Increased caries preva-
lence in 2.5-year-old children with cleft lip and/or palate. Eur J Oral Sci. 1996;104(5-6):518–22.
Coots BK. Alveolar bone grafting: past, present, and new horizons. Semin Plast Surg.
2012;26(4):178–83.
DeAngelis V. Dentofacial growth and development/orthodontics, vol. 2. Williams and Wilkins
Company: Baltimore; 1975.
Enlow DH, Hans MG. Essentials of facial growth. Philadelphia: Saunders; 1996.
Foley TF, Mamandras AH. Facial growth in females 14 to 20 years of age. Am J Orthod Dentofac
Orthop. 1992;101(3):248–54.
Kirchberg A, Treide A, Hemprich A. Investigation of caries prevalence in children with cleft lip,
alveolus, and palate. J Craniomaxillofac Surg. 2004;32(4):216–9.
Love RJ, Murray JM, Mamandras AH. Facial growth in males 16 to 20 years of age. Am J Orthod
Dentofac Orthop. 1990;97(3):200–6.
O’Neill J. More caries in primary teeth of children who have cleft lip and palate. Do children who
have cleft lip and palate have elevated caries levels in the primary and permanent dentition?
Evid Based Dent. 2007;8(4):106.
Proffit WR, Fields HW Jr, Moray LJ. Prevalence of malocclusion and orthodontic treatment need
in the United States: estimates from the NHANES III survey. Int J Adult Orthodon Orthognath
Surg. 1998;13(2):97–106.
Proffit WR, White RP, Sarver DM. Contemporary treatment of dentofacial deformity. St. Louis,
MO: Mosby; 2003.
Savara BS, Singh IJ. Norms of size and annual increments of seven anatomical measures of maxil-
lae in boys from three to sixteen years of age. Angle Orthod. 1968;38(2):104–20.
Dental Implants
21
Martin A. Freilich, David M. Shafer, and Steven Halepas

“There is nothing new under the sun. It has all been done
before.”
Sherlock Holmes in—A Study in Scarlet

Abstract
Implants are rapidly becoming the gold standard for replacing missing teeth.
With new technology related to the planning of implant placement, alveolar bone
anatomy can be evaluated in 3D facilitating the reliable differentiation between
simple and complex sites. This allows for better case selection to perform surgi-
cal procedures by general dentists, thereby relying less on specialists. It is critical
for the dentist to properly treatment plan the procedure. Case selection and
patient expectations are crucial. Implants are only useful if they can be properly
restored and should not just be placed “where the bone is.” This chapter provides
information on prosthetic planning, implant placement strategies, bone augmen-
tation techniques, and prosthetic principles and addresses frequently asked ques-
tions related to dental implant placement and restoration.

M. A. Freilich (*)
Reconstructive Sciences, University of Connecticut School of Dental Medicine,
Farmington, CT, USA
e-mail: [email protected]
D. M. Shafer
Division of Oral and Maxillofacial Surgery, University of Connecticut School of Dental
Medicine, Farmington, CT, USA
e-mail: [email protected]
S. Halepas
University of Connecticut School of Dental Medicine, Farmington, CT, USA
e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2019 433

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_21
434 M. A. Freilich et al.

21.1 Introduction

Humankind’s battle against edentulism spans back centuries. Although implants

have been around for ages, they continue to become a larger part of modern dental
practice (Block 2018). Branemark et al. can be credited with bringing the modern-
day implants to North America in 1982 (Branemark et al. 1985). Since that time,
evidence shows that implants have had high levels of success for long-term tooth
replacement (Adell et al. 1981). As technology has advanced, treatment planning
and surgical implant placement have become easier. With the utilization of cone-
beam computed tomography (CBCT) and radiographic and surgical guides, implant
placement has become more predictable and reliable. An increasing number of
general practitioners have become comfortable placing implants for many of their
cases. It is widely understood that proper treatment planning of implant placement
and restoration is critical for surgical and prosthetic success. It cannot be
overemphasized that the characteristics (e.g., screw- vs. cement-retained), functional
requirements, and esthetics of the implant restoration drive implant selection and
the manner of placement where clinical success is attained.

21.2 Discussion

21.2.1 Planning Treatment

Implant success requires integration with the adjacent alveolar bone, which pro-
vides for long-term stability and a functional restoration. Implant biocompatibility
is a major determinant of osseointegration success. Most implants today are com-
posed of commercially pure titanium or a titanium alloy, where the titanium oxide-
bone interface defines the extent of bone integration. Other factors that facilitate
consistent integration are the use of graduated sharp size drills, cooling irrigation,
and relatively low speed drilling (generally less than 1000 RPM) minimizing heat
application to the adjacent bone (temperature below 47 °C) (Friberg et al. 1999).
Bone density of the site may aid in obtaining initial implant stability, which is an
important factor in achieving successful bone to implant integration (Elias et al.
2012; Lages et al. 2018). Cortical bone is denser than cancellous bone. Implants
placed in the anterior mandible with its thick cortical bone layer are managed differ-
ently than implants placed in the less dense posterior mandible or maxilla (Heo
et al. 2017). Maxillary bone has a thin cortical layer and a high percentage of can-
cellous bone resulting in less overall bone density (Jensen et al. 1994; Gupta et al.
2017). Nevertheless, achieving primary implant stability in the maxilla is a routine
given the current surgical techniques and modern implant design. As with any diag-
nosis and treatment plan, the initial aspect of the treatment planning process includes
determining the patient’s chief complaint, expectations, and budget. Patient selec-
tion and addressing patient expectations are important considerations. The practitio-
ner should always review the medical history and ensure that there are no major
contraindications to implant placement or bone augmentation surgery. Major
21 Dental Implants 435

a b

Fig. 21.1 The basic components needed for proper treatment planning of implant cases. (a)
Mounted diagnostic casts with denture teeth waxed into correct position of the final implant
crowns. (b) A panoramic view of a CBCT showing the radiographic guide with radiopaque
material within the image. (c) Surgical guide made through modification of radiographic guide by
removing radiopaque material and placing holes at implant placement sites

contraindications generally include uncontrolled systemic diseases that need to be

managed prior to implant placement. Minor contraindications to implant surgery
include particular medical conditions, the use of some medications, and behavioral
habits such as smoking which will be discussed in detail toward the end of this
chapter. Planning for less complex cases can be generally accomplished with 2D
panoramic and/or periapical radiographs. The evaluation of these radiographs and
careful clinical examination may illustrate anatomic challenges where proximity to
large undercuts and important anatomic structures, such as the inferior alveolar
nerve canal or maxillary sinus, may indicate the use of a CBCT 3D scan (Christman
et al. 2014). Figure 21.1 demonstrates the basic components needed for proper treat-
ment planning.

21.2.2 Prosthetic Implant Placement Considerations

21.2.2.1 Implant Restorations

Implant restorations such as crowns and fixed prostheses are attached to the
implant via a screw-retained abutment. This abutment may be separate or continu-
ous with a single implant crown. As seen in Fig. 21.2, the abutment and crown can
be joined together, and the entire unit is screw-retained. Abutments that are sepa-
rate from crowns may be premade by the manufacturer or custom-made in the
436 M. A. Freilich et al.

a b

c d

Fig. 21.2 Screw-retained implant crowns are retrievable and having no cement line or potential
for excess cement often demonstrate outstanding soft tissue health. (a) Single-piece screw-retained
abutment/metal ceramic crowns. (b) Implant sites demonstrate excellent peri-implant gingival
health. (c) Final placement of screw-retained implant restorations. (d) Periapical radiograph of
metal ceramic screw-retained crowns restoring tapered bone level implants at sites #19 and #20
(Photos courtesy of Dr. Florian Kernan)

dental laboratory building upon a manufacturers’ foundation (Vigolo et al. 2012).

Custom abutments may be made from a metal alloy, ceramic material, or a com-
bination of alloy and ceramic. Various cement-retained abutments can be seen in
Fig. 21.3. Cement-retained implant crowns are placed over abutments that have
the “resistance form” and “retention form” requirements similar to taper and axial
wall length of crown preparations of natural teeth. Examples can be seen in
Fig. 21.4.

21.2.2.2 Implant Selection and Placement

A variety of different designs and sizes of implants are seen in Fig. 21.5. Implant
selection is dependent upon many factors, including esthetics, biomechanical
strength, available vertical prosthetic space, buccolingual ridge width, and mesiodis-
tal edentulous space dimension. Figure 21.6 shows apico-coronal, buccolingual, and
mesiodistal landmarks for optimal implant placement (Buser et al. 2004). Implant
design and shape also has substantial impact on the emergence profile of implant
restoration and gingival embrasure size. Figure 21.7 shows the implant path of place-
ment (MD should be general parallel to adjacent tooth roots and compatible with
adjacent proximal surfaces). On occasion, modifications may be required to these
21 Dental Implants 437

a b

Fig. 21.3 (a) Prefabricated abutment placed into a rough surface-tapered implant. (b) Two cus-
tom cement-retained abutments, one made from metal alloy and the other from a combination of
ceramic and metal alloy

a b

Fig. 21.4 Cement-retained implant crowns have potential for optimal esthetics. Given no screw
access hole also exhibits excellent durability and good control over the occlusal surface. (a)
Cement-retained metal ceramic implant crowns on final cast made to restore tissue level implants
at sites #30 and #31. (b) Follow-up periapical radiographs (Photos courtesy of Dr. Konstantinos
Vazouras)
438 M. A. Freilich et al.

Straumann® Dental lmplant System

Tissue Level Implants Bone level Implants

S SP TE BL BLT

Straumann® Straumann® Straumann® Straumann® Straumann®

Standard Standard Plus Tapered Effect Bone level Bone level
Implant (S) Implant (SP) Implant (TE) Implant (BL) Tapered
Implant (BLT)

Abutments for use with Abutments for use with

WN (Wide Neck) implants RN (Regular Neck) implants

6º

4.0 mm 5.5 mm 4.0 mm 5.5 mm 7.0 mm

048.545 048.546 048.540 048.541 048.542

green brown yellow grey blue
WN WN RN RN RN

Fig. 21.5 Various implant designs and diameters with various prefabricated abutment heights
available for a popular implant system. Available vertical and MD space may influence selection
of: Soft tissue level vs. bone level implant, selection of implant with taller vs. shorter smooth col-
lar, selection of optimal implant diameter for edentulous space, selection of pre-fabricated or cus-
tom abutment, selection of screw- or cement-retained implant crown

adjacent surfaces in order to allow the path of implant placement with adequately
long proximal contacts with the adjacent teeth. Figure 21.8 shows that buccolingual
angulation may be somewhat dependent upon angulation of alveolar bone, whether
the surgical provider is able to repair any apical buccal plate fenestrations that are
made trying to minimize buccal flare. This may be a particularly important consider-
ation when trying to optimize abutment shape or planning for a screw-retained
restoration.

21.2.2.3 Prosthetic Space

For restoration of an implant crown or fixed implant prosthesis, there should be a
minimum prosthetic vertical height of 8–10 mm space depending on the type of
abutment and size of the adjacent teeth. Justification for prosthetic height needed for
21 Dental Implants 439

a b c

Fig. 21.6 This schematic shows the optimal zone of implant placement in three planes: (a) mesio-
distal, (b) buccolingual, and (c) apico-coronal (Buser et al. 2004)

Fig. 21.7 A 3D view of a

CBCT scan simulation
showing the icon of a
Straumann regular neck,
tissue level implant with its
path of placement parallel
to the adjacent tooth roots
of the missing maxillary
second premolar

a single cement-retained implant crown can be seen in Fig. 21.9. In some cases, the
alveolar crest at the implant site may need reduction prior to implant placement, or
the opposing tooth should be modified in order to achieve this space requirement.
Occlusal plane problems and the lack of adequate prosthetic height can result in
ceramic failure and loss of cementation to abutments that exhibit inadequate resis-
tance and retention form. These negative outcomes can be seen in Fig. 21.10, where
a four-unit implant prosthesis has failed. As noted above, available mesiodistal
440 M. A. Freilich et al.

a b

Fig. 21.8 Simulation using CBCT imaging to plan implant placement for a maxillary lateral inci-
sor site showing an edentulous ridge with a pronounced facial undercut. The red line shows the
path of the abutment screw channel. (a) Acceptable buccolingual implant angulation following the
cross-sectional shape of the ridge for a cement-retained implant crown. (b) Although more complex
for the surgeon, proper buccolingual implant angulation for a screw-retained implant crown. This
path of placement likely results in the need to repair an apical fenestration with guided bone
regeneration (GBR) methods

7 mm
from
10 mm from head of
implant
4mm 4-7 mm 2 mm bone

With shortest solid abutment,

minimal vertical height required

Fig. 21.9 Demonstration of soft tissue level implant components and needed prosthetic vertical
height to make a single cement-retained implant crown

(MD) space may determine design and diameter of implant. On occasion, the
amount of MD space or angulation of the adjacent teeth may require orthodontic
treatment or modification of adjacent tooth surfaces. Examples of various outcomes
from efforts at managing the available MD space and teeth adjacent to implant
placement are seen in Fig. 21.11.
Figure 21.12 summarizes the approach to prosthetically driven implant planning
and placement. These photos show an example of diagnostic and treatment procedures
carried out to replace a single mandibular first molar with a metal ceramic implant
crown. As seen in this and previous figures, diagnostic casts and diagnostic wax pat-
terns or denture teeth can be used to fabricate a radiographic ­and/or surgical guide. A
21 Dental Implants 441

Fig. 21.10 Mandibular posterior metal ceramic-cemented implant bridge failure. The prosthesis
failed due to limited vertical prosthetic height with the abutments lacking adequate resistance/
retention form. Note the shape of the occlusal plane and limited height due to extrusion of the
opposing teeth. Negative outcomes include partial occlusal ceramic failure and loss of cementation
(Photos courtesy Dr. Hujuan Xiao)

radiographic guide can be used during 2D or 3D imaging to help best place the implant
to support a properly shaped and well-positioned implant restoration. The surgical
guide also helps with proper implant location and axial positioning/angulation.

21.2.3 The Implant/Bone Interface Post-Implant Placement

Modern dental implants are most often solid screws that have a rough surface.
Manufacturers create this surface with a variety of methods. Upon placement of the
implant, its surface should be in close proximity to the adjacent bone with extent of
initial or “primary” stability affected by operator skill and bone density, as noted above.
Over days and weeks, the bone adjacent to the implant resorbs and is replaced by newly
regenerated bone resulting in increasing bone to implant contact area and final or sec-
ondary stability. This process can take from 4 to 8 weeks, depending on the nature of
the implant surface, patient-related factors, length of implant, initial bone density, and
extent of adaptation of the implant to the bone surrounding the osteotomy. Consequently,
loading time to place an abutment or provisional restoration after implant placement
generally occurs within 8 weeks but may be longer when bone volume and initial sta-
bility are compromised (Chidagam et al. 2017; Esposito et al. 2013a).
442 M. A. Freilich et al.

a b

d e

Fig. 21.11 (a) Tipped adjacent tooth can lead to difficulty in implant placement and restoration.
(b) Implant crown with less than optimal emergence profile, gingival embrasure size, and
interproximal contacts. (c) Panoramic radiograph of a case with mesial drifted first molar limiting
the size of the edentulous space. (d) Periapical radiograph after orthodontic correction. (e)
Periapical radiograph showing symmetrical implant crown shape exhibiting good emergence
profile and smaller gingival embrasures
21 Dental Implants 443

a b

10 mm

7 mm

c d

e f

Fig. 21.12 These images show planning, surgical, and prosthetic treatment to replace a missing
mandibular molar. (a) Diagnostic wax-up showing mesiodistal width for a molar tooth. (b)
Adequate pretreatment vertical prosthetic height is determined. (c) Implant placement and
angulation verified with surgical guide during surgery. (d) Non-submerged wide neck tissue level
implant with healing abutment. (e) Placement of prefabricated abutment for cement-retained
crown. (f) Final metal ceramic restoration (Photos courtesy of Dr. Tyler Thomas)
444 M. A. Freilich et al.

21.2.4 Surgical Considerations

Skillful soft tissue management enhances implant and bone graft placement out-
comes, increases safety, and minimizes pain. This is accomplished by making well-
located incisions, full-thickness flap elevation allowing for good visualization of the
implant site, maintenance of flap vascularization and tissue volume at interproximal
areas, and obtaining primary flap closure with well-placed sutures. Figure 21.13
shows the location and extension of incisions made for placement of an implant in
the mandibular first molar site with simultaneous bone grafting on the buccal aspect.
Prior to beginning the procedure, the operator should determine whether implants
will be submerged, requiring a second minor surgical procedure prior to prosthetic
treatment. Alternatively, transgingival healing abutments may be placed prior to flap
closure for “non-submerged” implant placement. With regard to proximity to ana-
tomic structures, implants should if possible be placed inferior to the sinus cavity. If
this is not feasible, the need for a sinus elevation would be considered. Implants

Fig. 21.13 The incision

design shows a midcrestal
incision extending to
intrasulcular incisions of
adjacent teeth, terminating
with a papilla-sparing
incision toward the mesial
between premolar and
canine (buccal surface
only) and a vertical
releasing at the distobuccal
of the molar. The objective
of this flap design is to
create a full-thickness flap
that contains both the
mucosa and periosteum.
The flap should offer
adequate access for
implant and bone graft
placement while
maintaining a proper blood
supply
21 Dental Implants 445

should be positioned at least 5 mm anterior to the mental foramen and 2 mm above

the inferior alveolar nerve canal. At least 3 mm space should be maintained between
adjacent implants and 1.5 mm between implants and adjacent roots.

21.2.5 Timing of Dental Implant Placement and Loading

It is possible to place implants directly into the extraction sites of single-rooted teeth
in areas of moderate or low esthetic importance and where critical anatomic
structures such as the mental foramen or maxillary sinus are not in close proximity.
“Immediate” implant placement is technique sensitive with outcomes largely a
function of operator skill and careful case selection (Esposito et al. 2007). In areas
of high esthetic importance, implant placement at the time of the extraction can
prove to be an advantage or additional risk. While the implants may minimize bone
and tissue resorption, there is evidence of buccal plate loss in the presence of
implants placed into extraction sockets (Araújo et al. 2011). Consequently, the final
location of the hard and soft tissues adjacent to the implant cannot be predicted.
This can lead to potential for substantial esthetic problems in patients with a high
smile line (Rodriguez and Rosenstiel 2012). With implants placed into an extraction
socket, it is important to minimize the trauma of the extraction. This includes
avoidance of elevating a flap, which would remove periosteal vascularization to the
buccal plate and the use of any instruments, which can create defects in the adjacent
bone. The use of a thin periotome and forceps is often most helpful. Risks of poor
esthetic result are increased in the presence of thin, missing, or damaged buccal
plate post extraction. It is important to note that the implant osteotomy will not
likely be an extension of original extraction site, particularly at anterior areas. In
these cases, the osteotomy is located to the lingual aspect of the extraction site
avoiding implant contact with the buccal plate also avoiding the creation of a
fenestration in the bone forming an undercut to the alveolar ridge apical to the buc-
cal plate (Chen et al. 2009).
Care must also be taken to avoid a buccolingual angulation of implant placement
with excessive buccal flare. This allows for easy fabrication of cement- or screw-
retained crowns and creation of an osteotomy that results in good implant primary
stability. There are many references that describe the aforementioned techniques in
detail including the use of soft and hard tissue grafting simultaneous with immediate
implant placement (Chappuis et al. 2017, 2018; Benic et al. 2017; Benic and
Hämmerle 2014). As an alternative to immediate dental implant placement, slowly
resorbing “bone graft” substitutes can be placed into extraction sites to minimize
tissue resorption, with dental implants placed after a period of soft tissue and bony
healing. Please see additional detail below.
Delayed or early implant placement that occurs 4–12 weeks post extraction is
generally simpler and more predictable (Kohen et al. 2016). By 4–5 weeks, there is
soft tissue closure, and between 8 and 12 weeks (depending upon the size of the
446 M. A. Freilich et al.

socket), bone regeneration has occurred within the socket with resorption found at
the periphery of the site. This more clearly defines the position of the hard and soft
tissues at implant placement and allows the operator to elevate flaps to better
visualize the remaining alveolar ridge, thereby simplifying the osteotomy, placement
of the implant, and any needed graft materials.
Immediate loading of implants has shown to be quite successful (Boedeker
et al. 2011; Kacer et al. 2010). This is a particularly well-supported approach
when multiple implants with good initial stability are placed in dense bone sup-
porting a splinted prosthesis. In a systematic review assessing the current litera-
ture, multiple studies were found to have success rates of 95.7% at 2-year
follow-up for immediate loaded implants (Nkenke and Fenner 2006). Immediate
loading allows a patient to receive a provisional fixed prosthesis at the time of
implant placement, generally eliminating the need for a removable interim pros-
thesis. Immediate loading of an implant has the potential to decrease bone resorp-
tion and maintain proper gingival contouring. However, immediate loading also
carries the risk of placing load on the implant at the time period when initial sta-
bility is diminishing and prior to establishment of “secondary” stability resulting
from integration of the implant with newly regenerated bone at the implant sur-
face interface (Singh et al. 2015). This can lead to early implant failure. A graphic
representation of the decrease in primary stability while secondary stability
increases is seen in Fig. 21.14.

Primary stability Secondary stability

(old bone) (new bone)
100

75
Stability (%)

50

25

0
1 2 3 4 5 6 7 8
Time (wks)

Fig. 21.14 It shows a decrease in primary stability, while secondary stability increases over the
first 2 months of implant integration (Raghavendra et al. 2005)
21 Dental Implants 447

21.2.6 Socket Preservation

“Socket preservation” (actually we do not really want to preserve the socket but
rather obliterate it with regenerated bone) is a technique used to theoretically reduce
bone resorption after extraction and, hopefully, provide a better foundation for a
future implant. Socket preservation is accomplished by placing a slowly resorbing
osteoconductive biomaterial serving as a bone graft substitute into the extraction
site immediately after the tooth is extracted. The types and derivation of these
biomaterials are described in the next section. Ideally, the biomaterial preserves the
height and width of the adjacent alveolar bone and resorbs allowing for enhanced
formation of newly regenerated bone into the socket. The evidence on the efficacy
of socket preservation is very weak. Although several studies exist that support the
use of socket preservation, many contain insufficient evidence to draw such a
conclusion or have a high degree of bias (Brignardello-Petersen 2018; Moraschini
and Barboza 2016). A systematic review was performed to validate the efficacy of
socket preservation. Six randomized controlled trials and three controlled clinical
trials were reviewed. The authors concluded that evidence shows that although
socket preservation may alter the bony dimensional changes after tooth extraction,
this procedure does not prevent ridge resorption (Byrne 2012). In a recent study
from 2016, a meta-analysis was performed to determine if bone grafting after tooth
extraction provides alveolar ridge preservation. This study concluded that socket
preservation may prevent bone loss in both the horizontal and vertical dimension
after extractions of non-molar teeth (Cheng 2016). The author concluded that the
studies analyzed supported that there was a statistically and clinically significant
increase in midbuccal height of 2.07 mm. The question then becomes whether
socket preservation has a clinical difference beyond just a statistical difference, and
this is still yet to be determined. Socket preservation most likely has minimal effect
on long-term implant success; however, the esthetics is often a critical factor of
clinical success, and it is generally agreed that the placement of bone graft substitutes
in the extraction site results in greater overall tissue volume, thereby enhancing the
esthetic outcomes. Socket preservation in many clinical situations is likely not to aid
in the future stability of the implant but to aid in the overall esthetics of the restored
implant. A particularly clinical relevant study compared 40 patients who underwent
socket preservation for a single anterior implant with 20 control patients who had
single anterior implants placed without socket preservation. Clinical and CBCT
analysis demonstrated that ridge preservation was more effective in preserving at
least 6 mm alveolar ridge width at the time of implant placement than in the control
group in the anterior maxillary zone (Lee and Poon 2017). In instances of high
esthetics, many studies have shown great benefit of an immediate implant placement
with simultaneous bone grafting at the time of the extraction instead when possible.
We do know that placement of slowly resorbing biomaterial graft material into the
extraction site will delay implant placement, since the manufacturers generally
expect biomaterial resorption and replacement with new bone to occur from 5 to
12 months. At this point with current evidence, one cannot recommend routine
socket preservation for all extractions. The determination for placing a biomaterial
448 M. A. Freilich et al.

into an extraction site is a function of clinical judgment for a particular case. The
anatomy and location of the site along with planned timing of implant placement
and restoration will have great impact on this decision.

21.2.7 Bone Grafting

Bone regeneration through grafting procedures may be undertaken months prior to

implant placement or when there is adequate bone volume to stabilize the implant,
but not enough width to provide coverage of all implant surfaces, simultaneous with
implant placement (Benic et al. 2017; Benic and Hämmerle 2014). “Guided bone
regeneration” (GBR) constitutes grafts that are primarily particulate in nature, while
“block grafts” are fastened with stabilization screws (Joshi et al. 2017). Guided
bone regeneration can be done months prior to implant placement to develop the site
or simultaneous with implant placement as seen in Fig. 21.15. Regardless of the
source of the graft material, the primary purpose is to serve as a scaffold and
maintain a volume of space (preventing soft tissue collapse) for new bone formation
while slowly resorbing and being replaced by newly regenerated bone. At this time,
numerous bone graft materials exist. Autologous (or autogenous) bone grafts are
bone grafts derived from the patient. Depending on its shape and size, an autogenous
bone graft has varying amounts of structural capacity and osteoinductive capacity.
Common donor sites include the edentulous ridge during modification prior to
dental implant osteotomy, bone removed from the osteotomy, the ramus or
symphysis of the mandible, and the nasal spine and lateral wall of the maxillary
sinus for the maxilla. The selected donor location generally depends on the type of
bone needed (particulate vs. block), the volume needed, and the expected recipient
site. Block grafts can often be obtained in the ramus or symphysis regions of the
mandible as seen in Fig. 21.16. Particulate grafts can be obtained from all of the
potential donor sites. Implants placed after or simultaneous with bone grafting show

Fig. 21.15 It shows

guided bone regeneration
simultaneous with implant
placement with particulate
graft material placed at the
facial aspect of an implant
replacing a maxillary
central incisor (Photo
courtesy of Dr. Cho)
21 Dental Implants 449

a b

Fig. 21.16 (a) Autologous block graft harvested from the mandibular symphysis. (b) Block graft
secured with titanium screw into defect at recipient site 5–6 months prior to implant placement

excellent outcomes (Benic et al. 2017; Jensen and Sindet-Pedersen 1991). Only
clinicians with extensive surgical training should undertake cases requiring more
invasive bone grafting procedures.
There are three types of bone graft substitutes: allografts are biomaterials com-
posed of cadaver bone. An important difference from autogenous bone is the loss
of endogenous cells and growth factors resulting from processing and sterilizing
the allograft, thereby reducing or eliminating osteoinductive capacity.
Consequently, the allograft will exhibit varying amounts of bony osteoinduction
while also serving as an effective osteoconductive scaffold for new bone regenera-
tion (Sheikh et al. 2017). A xenograft is a graft that is obtained from another spe-
cies. The most common xenografts used in alveolar bone regeneration are
osteoconductive bone graft substitute made of inorganic components but derived
from nonhuman sources. Alloplasts are synthetically derived biomaterials that are
generally derived from calcium phosphate (CaP) such as beta-tricalcium phos-
phate (beta-TCP), hydroxyapatite (HA), or combinations of various CaP materials
(Choo et al. 2013; Kniha et al. 2018; Singh and Suresh 2012; Gahlert et al. 2016).
The different formulations of the alloplasts primarily alter how quickly they are
resorbed and replaced. The use of bone graft substitutes allows for the eliminating
the harvesting of autogenous bone or harvesting a smaller volume of autogenous
bone while providing structure and slow resorption characteristics that stabilize
and “protect” the autogenous component of the bone graft. In addition, the use of
bone graft substitutes eliminates and donor site morbidity. To take best advantage
of these characteristics, clinicians often mix and/or layer autogenous bone and
biomaterial bone graft substitute components (Wang et al. 2004). It is expected
that implants can be placed into previously placed block or particulate bone grafts
450 M. A. Freilich et al.

5–6 months post-graft placement; however, there is older data that shows implant
stability may be more predictable when placed 6–9 months following bone graft-
ing (Triplett and Schow 1996; Anitua et al. 2015; Levin et al. 2005, 2007).
Implants placed into bone-grafted sites tend to have slightly decreased survival
rates but still have been demonstrated to be quite stable (Lekholm et al. 1999).
When particulate grafting occurs simultaneously with implant placement, the
implant will often begin prosthetic treatment approximately 3–4 months after
implant placement.

21.2.8 Sinus Elevation

As stated earlier, the maxillary edentulous arch creates its own challenges. The
maxillary bone tends to resorb in the apical and palatal direction. In the posterior
maxilla, the lack of vertical bone height may prevent implant placement. When
minimal vertical bone height exists between the crest of the edentulous ridge and
the maxillary sinus, choices need to be made (Kent and Block 1989). One option
is to use “short” implants. As currently defined, short implants (4–8 mm) have
been demonstrated to have similar success rates to longer implants (Atieh et al.
2012; Guljé et al. 2013). One paper reviewed 18 studies comparing sinus eleva-
tion (lifts) vs. using short implants. The study found that sinus lifts had more
complications than using a shorter implant (5–8.5 mm) but that the data could not
support the use of one or the other (Marchionni et al. 2017). Therefore, the clini-
cian can consider using a shorter implant as a possible alternative to sinus lifts in
certain situations. Sinus elevation is the alternative to placement of a short implant.
Boyne and Jones described that if space was maintained between an implant and
an elevated sinus membrane, the bone will eventually grow in its place (Boyne
and James 1980). In contrast, implants placed directly into the sinus membrane
tend to form a fibrous tissue interface without any new bone growth to support the
apical aspect of the implant (Brånemark et al. 1984). Depending on the bone
height and extent of sinus elevation needed, an “internal” sinus elevation may suf-
fice (Pal et al. 2012). Internal sinus lifts can be performed when there is already at
least 5 mm of bone between the ridge and the maxillary sinus. There must be
adequate bone height below the sinus for the implant to be stable when it is
inserted in the alveolar bone. This approach is executed by making the osteotomy
just short of the sinus floor. Hand osteotomes can then be used to “up-fracture” the
remaining cortical bone at the sinus floor. Typically, 3–5 mm of sinus elevation
can be predictably obtained by this technique, with greater vertical bone gain if
graft material is placed at the apex of the osteotomy site (Schleier et al. 2008;
Summer 1994; Romero-Millán et al. 2012; Chen and Shi 2017). Minimizing the
extent of the elevation decreases the risk of creating a hole in the sinus floor and
perforating the sinus membrane. The implant can then be placed as soon as sinus
floor elevation is completed to the desired extent.
An “external” lateral window sinus elevation is generally considered a more
advanced surgical technique, and clinicians with extensive surgical training
21 Dental Implants 451

should undertake this more invasive type of procedure. This procedure is per-
formed using a window that is created in the lateral sinus wall after reflecting an
extensive mucoperiosteal flap with releasing incisions. After flap elevation, the
sinus may be visible through the lateral wall showing as a transparent/blue appear-
ance. A rectangular- or oval-shaped window is created with a large round diamond
bur or now more commonly with an ultrasonic piezotome using great care to
prevent perforating the underlying sinus membrane (Lin et al. 2016). When the
osteotomy is completed, the membrane can be visualized and gently elevated with
curettes. Bone graft material is spaced into the new space created between the
apical aspect of the edentulous ridge and the sinus membrane. A clinical example
can be seen in Fig. 21.17. Autogenous bone can be harvested from the iliac crest,
chin, ramus, or tuberosity (Block and Kent 1997). Other techniques utilize bone
graft substitutes alone or in combination with autogenous bone. The provider
should wait 5–6 months after sinus augmentation and then 3 months after implant
placement prior to prosthetic treatment. If the sinus elevation is not extensive and
enough bone height exists to achieve primary stability, the implant can be placed
at the time of the sinus augmentation.

a b

Fig. 21.17 (a) Lateral window osteotomy exposing maxillary sinus and elevated sinus mem-
brane. (b) Particulate bone grafting placed between sinus membrane and superior aspect of eden-
tulous ridge. (c) Sinus augmentation with implant placement showing guide pins used to gauge
implant depth and assess potential initial stability
452 M. A. Freilich et al.

21.2.9 Overdentures

Implants can be used to aid in retention of conventional dentures. In the mandible,

two implants, both placed in the lateral incisor region, are generally effective to
stabilize and better retain the prosthesis while minimizing anterior/posterior
rotation. In the maxilla, four implants optimally placed in the lateral incisor and
premolar sites will reliably retain the prosthesis and eliminate the need for palatal
coverage (Raghoebar et al. 2014; Sadowsky 2007; Slot et al. 2016; Zitzmann and
Marinello 2000). Converting dentures to overdentures is a relatively easy procedure
that can be extremely beneficial to your patients (Boerrigter et al. 1995). For the
maxilla and placement of four implants, the distance between the anterior and pos-
terior implants is called the anterior-posterior (AP) spread (Jensen and Adams
2009). The greater the AP spread, the greater the potential stability of the prosthesis.
For the overdenture prosthesis, is it critical that there is adequate vertical prosthetic
space for the implant abutment, housing, and prosthetic material (need photos). This
would measure approximately 10 mm from the alveolar crest to the outer (cameo)
surface lingual to the anterior denture teeth and from the alveolar crest to the occlu-
sal surface of posterior teeth. From a planning and prosthetic view, the conventional
denture should be made prior to implant placement. This allows for fabrication of a
surgical guide and well-located surgical implant placement. Planning, surgical
guide fabrication, and guide pins placed into implant osteotomies during implant
surgery can be seen in Fig. 21.18. There are two important surgical notes related to
implant placement for the mandibular overdenture: (1) do not minimize the impor-
tance of careful full-thickness lingual flap elevation identifying possible intraosse-
ous vessels moving through lingual foramina to the soft tissues, and (2) prevent the
osteotomies from making any perforation through the lingual plate near the floor of
the mouth.

21.2.10 Anticoagulants

Many dentists are still not questioning how to handle anticoagulants and implant sur-
gery. The literature suggests that 0.6% of patients required more than positive hemo-
static pressure such as reducing their anticoagulant dose postoperatively (Wahl et al.
2018). Therefore, the risk of significant/uncontrolled postoperative bleeding is
exceedingly low in dental procedures performed on patients who take anticoagulant
medications and who are maintained in a normal therapeutic range. The risk of stop-
ping a patient’s anticoagulant medication outweighs the benefit of minimizing postop-
erative bleeding. The vast majority of the literature states that patients on oral
anticoagulants in the appropriate therapeutic range can be treated the same as healthy
patients (Wahl et al. 2018; Beirne 2005; Jeske and Suchko 2003; Alaali et al. 2012;
Mauprivez et al. 2016). If a patient is taking warfarin, it is important to know the
patients INR prior to surgery. The 2016 American Academy of Oral Medicine recom-
mends the INR be checked “within a few days” of the procedure (Lockhart 2016).
Some providers are worried about the newer medications, such as dabigatran that does
21 Dental Implants 453

a d

Fig. 21.18 (a) Surgical guide fabrication by duplicating complete denture with clear acrylic. (b)
Surgical guide with window at lingual aspect allowing site visualization, access for drills to make
osteotomies, and placement of guide pins. (c) The vertical line represents the distance from the
head of the implant to the cameo surface on the lingual aspect of the denture base, which should
be at least 10 mm. If the distance is less than 10 mm, alveolar bone should be reduced in order to
create additional prosthetic space and a wider platform (indicated by the horizontal dotted line).
The reduction of alveolar bone height just prior to implant placement allows for adequate space for
the overdenture abutment on the implant and overdenture housing within the tissue side of the
prosthesis. (d) Clinical photo showing bone reduction and guide pins placed into implant
osteotomies
454 M. A. Freilich et al.

not have routine monitory tests. If worried about postoperative bleeding in these cases,
the provider can plan the surgery between dosing. Plan to have the implant surgery
after 12 h from last dose, and resume 8 h after implant surgery for patients taking dabi-
gatran (Gómez-Moreno et al. 2016). Still little evidence suggests stopping or delaying
these newer medications for routine dentoalveolar surgery (Napeñas et al. 2013).

21.2.11 Smoking

Although smoking can be considered a relative contraindication, it does not pre-

clude a patient from dental implant placement. Smoking has been demonstrated to
increase failure rates (Abt 2009; Hinode et al. 2006). The failure rate appears to be
greater in the maxilla than the mandible of smokers. In addition, there is some evi-
dence that the negative effect of smoking may be less critical with dental implants
having roughened surfaces such as ones that are sandblasted and/or acid etched. If
possible, the provider should counsel the patient on the benefits of smoking cessa-
tion, both the dental and the systemic benefit. It is important to explain the increased
risk of failure of implants in patients who use tobacco. Patients who smoke need to
maintain prestige oral hygiene to minimize the risk of implant failures.

21.2.12 Bisphosphonates

Evidence on the effects of oral bisphosphonates on dental implants still lacks real
conviction. Some studies have suggested that oral bisphosphonates initially increase
implant stability. Other studies suggest oral bisphosphonates can lead to late implant
failure. These late implant failures in patients on bisphosphonate appear to be of a
different type than that typically seen in patients not on bisphosphonates. Rather than
seeing the typical loss of osseointegration at the bone implant interface in failures
associated with bisphosphonate use, implants remain integrated to the bone on their
surface. However, this surrounding bone becomes necrotic essentially creating a
bony sequestrum with implant attached to it. This type of late implant failure maybe
associated with the inability to have adequate bone turnover and bone integration
leading to a localized osteonecrosis. Pogrel and Ruggiero suggest that this late
implant loss is related to the lack of a periodontal ligament. The masticatory forces
placed on the surrounding bone become high enough to cause localized bony necro-
sis and implant loss. This increased force requires greater bone turnover which can
be inhibited by the initiation of bisphosphonate therapy (Pogrel and Ruggiero 2017).
Patients on oral bisphosphonates tend to be at a much lower risk of implant loss or
osteonecrosis than patients given IV bisphosphonates (Bell and Bell 2008). One
study of 468 implants in 115 patients who had history of oral bisphosphonate use
found no evidence of bisphosphonate-associated osteonecrosis. In the same study,
466 of the 468 are fully osseointegrated (Grant et al. 2008). Regardless of whether
the patient is taking oral or IV bisphosphonate therapy, the practitioner should take
special consideration to evaluate the risk of implant failure and osteonecrosis. Current
American Association of Oral and Maxillofacial Surgeons (AAOMS)
21 Dental Implants 455

recommendations are that if dental implants are placed in patients on oral bisphos-
phonate therapy, informed consent must be obtained related to the possible long-term
implant failure and the low risk of developing osteonecrosis of the jaw (Ruggiero
et al. 2014). The patients should be placed on regular recall schedule.

21.2.13 Antibiotics and Rinses

As touched in the previous chapter on medical assessment, antibiotic prophylaxis in

implant surgery is still a controversial topic, and evidence is limited. Certain studies
show antibiotic prophylaxis and also show no apparent difference in postoperative
infection for patients who receive dental implants (Keenan and Veitz-Keenan 2015).
Other studies have shown that implant failure rates are significantly reduced when
antibiotic prophylaxis is given and a single dose of preoperative antibiotics is
usually sufficient (Sharaf and Dodson 2011; Deeb et al. 2015; Mazzocchi et al.
2007; Dent et al. 1997). Having patients use 15 ml of 0.12% chlorhexidine gluconate
rinse can be prescribed for two times a day for 2 weeks to aid in soft tissue
maintenance after implant placement.

21.2.14 Postoperative

It is important to take postoperative radiographs to assess implant placement and

angulation. Most providers will prescribe postoperative antibiotics in addition to
preoperative prophylactic antibiotics. However, it is questionable that the use of
postoperative prophylactic antibiotics is supported by the current literature. In a
review in the Cochrane Library from 2013 on the effectiveness of antibiotics to
prevent complications in implant surgery (Esposito et al. 2013b), the authors
concluded that there was good evidence to support the use of a single dose of
antibiotics (specifically 2 g of amoxicillin) was effective in reducing implant failures
but that it was unclear whether postoperative antibiotics were beneficial. There does
appear that there is a trend to reduced antibiotic use by providers placing dental
implants, thus adopting a more evidence-based approach (Khalil et al. 2015). Mild
analgesics such as NSAIDs can be prescribed for postoperative pain management.
Narcotic pain medications are rarely indicated unless significant adjunctive bony
surgery is done such as harvesting and placing cortical bone grafts from the
mandible. A 1–2-week follow-up should be scheduled to evaluate soft tissue healing.

21.3 Conclusion

Implants can be a valuable tool for the general dentist and a great option for many
patients. It is vital that the general dentists are aware of his/her abilities and
limitations. Always act in the patient’s best interest, and refer when appropriate.
Many cases are straightforward and conventional and will be well suited with the
general dentist. It is important to do a proper workup that includes a medical
456 M. A. Freilich et al.

assessment, a treatment plan that explains the risk and benefits of implants, and
alternatives. Implants are not for all patients in all circumstances but can be quite
useful for many patients. Being mindful of the relative contraindications can help
foresee obstacles and minimize complications.

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Forensic Odontology
22
Kevin Rand Torske

“We balance probabilities and chose the most likely. It is the

scientific use of the Imagination.”
Sherlock Holmes in—The Hound of the Baskervilles

Abstract
The skills and knowledge of dental professionals may assist the justice system in
the investigation of legal issues, especially in the identification of human remains.
The detailed analysis of antemortem and postmortem dental evidence is a primary
method of identification and, depending upon the condition of the recovered
remains, may represent the sole means of scientifically assured assessment. As
the requirements to perform this service often arrive with little warning or time
to prepare, prior knowledge and understanding of the principles involved greatly
assists in successful completion of this important task.

22.1 Introduction

Forensics may be defined as the collection of scientific evidence pertaining to the

investigation of criminal activity. A forensic scientist utilizes specific skills in the
gathering of evidence and assists law enforcement personnel, lawyers, judges, and
juries in understanding the relevance of pertinent information.
The investigation of civil or criminal legal matters involves a wide range of dis-
ciplines and expertise. Forensic scientists may have specialty skills in many

K. R. Torske (*)
Oral Pathology and Forensic Dentistry, Naval Medical Center, Portsmouth, VA, USA
e-mail: [email protected]

© Springer International Publishing Switzerland (outside the USA) 2019 461

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_22
462 K. R. Torske

branches, to include psychiatry and behavioral science, pathology/biology, anthro-

pology, criminalistics/crime scene investigation, entomology, accounting, toxicol-
ogy, digital and multimedia sciences, jurisprudence, questioned documents, or
odontology/dentistry.
Forensic Dentistry (Forensic Odontology) pertains to the collection and analysis
of dental evidence that may apply to a potential criminal event. The primary use of
forensic odontology skills is in the identification of human remains. Other possible
uses may include investigation of fraud, malpractice, or negligence, assault to
include bite mark or pattern injury analysis, determination of dental age, and
presenting testimony as an expert witness.

22.2 Forensics in the Dental Office

Whether realized or not, the practice of forensic dentistry is regularly performed in

the routine care of patients. The results of dental examinations and treatment as
documented in the patient’s dental record serve as the basis of forensic dental
evidence.

22.2.1 The Dental Record

The dental record is the single most important document in forensic dentistry.
Examination forms, dental radiographs, lab requests, and treatment/progress notes
all provide significant information as to the restorative dental profile of the patient.
Entries. Accurate and thorough documentation is required within the antemor-
tem dental record. It should ideally contain results of an initial examination, to
include charting of the patient’s presenting dental restorative profile. All existing
and missing teeth are annotated, as are all restored teeth, to include the type of res-
torations and surfaces involved. This serves as a basis for forensic assessment, with
any successive treatment modifying the initial dental restorative pattern.
Subsequent treatment should be detailed, to include tooth number, tooth sur-
faces, and type of restorations involved. Listing of the exact brand of restoration
may also be of forensic use, due to the unique chemical composition of different
dental restorative materials.
Legal Issues. The dental record is a legal document owned by the dental profes-
sional or practice. As the record is evidentiary material, accuracy and legibility are
important. To maintain a provable association to a specific individual, every docu-
ment, radiograph mount, or CD containing digital images must be labeled with at
least two forms of personal identifiable information. This should include the
patient’s full name, date of birth, and/or identification number (Social Security
number, military identification number, etc.). As many individuals have similar
names, the use of two forms of identifiable information is required so as to help
assure patient identification accuracy. Finally, all entries should be signed or initialed
by the provider.
22 Forensic Odontology 463

The dental record may be subpoenaed if required for forensic use. In addi-
tion, the Health Insurance Portability and Accountability Act (HIPAA) of 1996
allows for submission of dental records to coroners and medical examiners for
forensic purposes via 45 Code of Federal Regulations §164.512(g)(1). By means
of this statute, submission of the record for forensic purposes may be completed
without the need for specific permission from the patient, guardian, or next of
kin (GPO 2017).

22.3 Identification of the Deceased Patient

In dentistry, the most common application of forensic science is in the identification

of deceased human remains. The establishment of proven identification is vitally
important and affects issues such as life insurance, probation of a will, and possible
legal matters if the manner of death is in question.
Official identification is determined by the presiding jurisdictional agency—typ-
ically the coroner or medical examiner—and documented via the death certificate.
Evidence as to identity may be gathered by multiple forensic specialists serving in
a consultative role, to include experts in fingerprinting, DNA, and odontology.
The incident may involve only a single unknown individual or encompass mass
casualties due to natural disasters, criminal actions, or accidents. Regardless of the
size or cause of the event, the identification of deceased individuals follows routine
methods and nomenclature.

22.3.1 General Concepts

Types of Identification. The identification of human remains may be performed

in many manners with varying degrees of scientific certainty. These methods may
be categorized as either circumstantial or scientific. Circumstantial Identification
is one based upon inference and non-fact-based opinion. Scientific Identification
is based on facts and data gathered via proven principles and investigative
methods.
Categories of Identification. Regardless of method, conclusions are reported
based upon the level of certainty of the identification. This may include positive,
presumptive, or exclusion from identification.

• Positive Identification—Distinct and unique biological commonalities are pres-

ent between antemortem and postmortem biologic evidence, without presence of
any unexplainable discrepancies. Identification is assured beyond reasonable
doubt.
• Presumptive (“Consistent-with”) Identification—Commonalities are present
between antemortem and postmortem biologic evidence, without presence of
any unexplainable discrepancies; however, an insufficient amount of unique or
distinct characteristics are shared for certainty in identification.
464 K. R. Torske

• Exclusion of Identification—Unexplainable discrepancies exist in the

comparison of antemortem and postmortem biologic evidence so as to defini-
tively exclude the establishment of identification beyond reasonable doubt.

If an inadequate amount of antemortem and/or postmortem biologic evi-

dence is available for conclusive review, the term Insufficient Evidence may be
used.
Discrepancies are often noted in the comparison of antemortem and postmor-
tem evidence and may be either explainable or unexplainable. Explainable dis-
crepancies provide for a rational and logical explanation of differences in
comparison. In dental analysis, this typically involves progression of dental
treatment over time. For example, in an older antemortem dental record, a molar
tooth is depicted with a mesial-occlusal amalgam; however, the postmortem
remains demonstrate a mesial-­occlusal-­distal resin restoration in the same tooth.
This discrepancy is explainable as simple further treatment for which the cor-
responding antemortem dental record depicting such continued care is unavail-
able for review.
Explainable discrepancies may also involve the presence or absence of teeth
where mesial drift may be associated. If a permanent mandibular first molar is lost
at an early age, the second and third molars may move mesially to fill the gap. The
loss of the first molar may be annotated in the antemortem dental records, but in
postmortem examination, its absence may not be obvious due to mesial drift. This
may lead to a difference in teeth listed as present or missing in comparison of the
dental evidence.
Unexplainable discrepancies may also exist, where logical rationale cannot
be proffered to clarify differences between antemortem and postmortem evi-
dence. As the human dentition cannot heal from previous antemortem trauma or
treatment procedures, unexplainable discrepancies are usually associated with
the absence of documented restored tooth surfaces in the recovered remains, or
the postmortem presence of teeth that were listed as extracted in the antemortem
dental records.
The level of certainty depends upon the amount and uniqueness of shared
characteristics between the antemortem and postmortem evidence; however, it
may be influenced by whether the postmortem scenario includes an open or
closed population. A closed population is one that has a defined number of casu-
alties and presumptive identifications, such as from an aircraft accident with a
verified manifest of passengers and crew. An open population is one for which
the potential casualties are undefined, such as the recovery of a single unknown
individual without any material evidence so as to provide an initial presumptive
identification. If the population is closed, the required amount of unique com-
mon characteristics may be lessened, especially if all other possible casualties
may be excluded. On the other hand, if the population is open, the importance
of uniqueness is amplified so as to confidently arrive at a scientifically reason-
able positive identification.
22 Forensic Odontology 465

22.3.2 Circumstantial Identification

Circumstantial identification may rely upon multiple approaches, the most common
being visual identification or material evidence. Although occasionally used as a
solitary means of analysis, the best use of circumstantial methods may be in arriving
at an initial presumptive identification. This may serve as a starting point to request
antemortem dental records, fingerprints, or DNA reference samples so that a formal
scientific identification may follow.
Visual Identification. Visual identification is based upon the recognition of a
person via outward physical appearance. Although potentially useful immediately
after death, soft tissue decomposition rapidly alters physical appearance, rendering
visual identification increasingly unreliable with the passage of time. Unique
features such as tattoos or scars may increase the validity of visual identification,
especially if such items are documented via antemortem photographs or within a
medical record.
Material Evidence. Items found on or associated with a decedent may assist in
identification. This may include identification media such as a driver’s license,
military identification card, passport or “dog tags,” or distinctive clothing items or
jewelry. Material evidence may be swapped between casualties, whether accidently
or intentionally, which may lead to erroneous assumptions upon review.
Forensic Anthropology. Identification based upon forensic anthropology lies on
the border between circumstantial and scientific, depending primarily upon the
scenario where utilized. The forensic anthropologist’s evaluation of the skeletal
remains typically provides information regarding the patient’s height, age, sex and
race. These four items represent the decedent’s biological profile and are procured
via well-established scientific protocols. Unfortunately, exact determinations of
height and age cannot typically be established, and a range of possibilities is usually
proffered. Should the decedent’s biological profile match that found within the
antemortem evidence, this may serve as support to identification. However, a
biological profile is typically not unique to an individual, so additional forms of
identification may be required to arrive at a positive conclusion to identity
(Christensen et al. 2014).

22.3.3 Scientific Identification

Three forms of scientific identification are commonly utilized, to include analysis

and comparison of fingerprints, nuclear DNA, and dental restorative patterns. Each
method has advantages and disadvantages depending upon the situation and quality
of the recovered postmortem remains.
Fingerprint Identification. Human fingerprints consist of a pattern of whorls,
arches, or loops which may be used as a marker for human identity (Champod 2015;
Yager and Amin 2004). Fingerprints are stable throughout life, are difficult to alter,
and are relatively unique to a specific individual.
466 K. R. Torske

Standardized methods are employed for the collection and analysis of finger-
prints, making this technique highly reliable and reproducible. The Federal Bureau
of Investigation holds a fingerprint identification database termed the Integrated
Automated Fingerprint Identification System (IAFIS) which contains the finger-
print profile of over 70 million subjects. This program may be used to analyze and
compare recovered postmortem fingerprints for identification purposes.
Advantages of fingerprint identification include the stability of the fingerprint
pattern throughout life, a centralized database of antemortem records, a well-­
established and standardized protocol for retrieval and comparison, an ability to be
performed by an automated system, and the rapidity of comparison and conclusions
with high accuracy and relative low cost. Disadvantages mainly involve the
postmortem loss of soft tissue due to trauma or decomposition, leading to
complications in the recovery of quality postmortem fingerprints.
DNA Identification. The use of deoxyribonucleic acid (DNA) for forensic iden-
tification has been performed since the 1980s (Amorim and Budowle 2016; Butler
2015). Two main forms of DNA are commonly analyzed, nuclear and mitochon-
drial. Nuclear DNA is a 50/50 combination contributed by one’s biological mother
and father, whereas mitochondrial DNA is solely inherited via the maternal line.
Two copies of nuclear DNA (nDNA) are found in all nucleated cells of the body,
thereby potentially retrieved from all cells excluding red blood cells. Although
easily retrieved from healthy soft tissue, changes due to significant decomposition
or fire may limit or preclude the recovery of viable nDNA sequences.
Although a significant amount of one’s nuclear DNA sequence is shared with
other individuals, focal highly variable sequences may be found—termed
minisatellites—that are unique to an individual. The analysis and comparison of
these minisatellites forms the basis of nuclear DNA identification.
An antemortem nDNA reference sample is required for comparison. Hair or
blood samples from the presumptive individual are typically utilized, although
tissue archived from previous biopsies is occasionally available. The FBI also
houses the National DNA Index System (NDIS) and Combined DNA Index System
(CODIS) which contain DNA profiles of individuals processed through the justice
system.
The nDNA retrieved from the postmortem remains is then compared to antemor-
tem reference samples for potential identification. This process requires specific
scientific equipment and time for analysis and comparison.
Advantages of nuclear DNA identification include high accuracy, reliability, and
international standardization. Limitations may include difficulty in obtaining
antemortem reference samples, longer time required for processing and analysis
compared to other forms of identification, and relative high cost. In addition, the
retrieval of viable postmortem nDNA may not be possible from skeletonized
remains or those suffering from significant soft tissue decomposition or degradation.
Mitochondrial DNA (mtDNA) may be found in all cells, and as opposed to only
two copies of nDNA per cell, mtDNA is relatively abundant due to hundreds of
mitochondria found within the cytoplasm. In addition to greater abundance, mtDNA
22 Forensic Odontology 467

is relatively more resistant to degradation from decomposition and may be har-

vested from osseous hard tissues such as skeletonized remains.
Mitochondrial DNA is inherited solely from one’s biological mother and does
not significantly change though generations. An individual, therefore, has the same
mtDNA sequence profile as their mother and all relatives born via the same maternal
lineage. Antemortem mtDNA reference samples may therefore be obtained from
any maternal relative.
Advantages for mtDNA identification are greater ability to retrieve viable post-
mortem DNA and relative ease in locating antemortem DNA reference samples.
The greatest disadvantage for mtDNA is lack of specificity for a single individual,
as positive sequence matches only prove relationship to a maternal family line.

22.3.4 Dental Identification

22.3.4.1 General Information

A third form of scientific identification utilizes the comparison of antemortem and
postmortem dental evidence to determine potential similarities. An individual’s
dentition may display extremely distinctive characteristics due to restorations,
anatomy, or pathology, and this uniqueness may be utilized to form a scientifically
valid opinion as to identity.
Dental remains are the strongest tissue in the human body and the most resistant
to decomposition and damage from fire. This presents an advantage over fingerprints
and DNA as identification may be performed on skeletonized or severely burned
remains. Dental analysis is also relatively quick and inexpensive.
Dental identification drawbacks often revolve around access to antemortem den-
tal records. As opposed to large, centralized databases of antemortem fingerprints or
DNA reference samples, antemortem dental records are often held individually by a
dental provider or practice. Identity of the provider may be difficult to determine
and unknown to friends or relatives. The quality and accuracy of the antemortem
record may also influence identification.
Fingerprints and DNA remain stable throughout life; therefore, even older ante-
mortem reference samples may be utilized for comparison. The fluctuating nature of
a dental profile, however, may negatively impact analysis. Evolution from decidu-
ous to adult dentition and continuing changes via caries, periodontal disease, and
resultant dental care constantly alter the antemortem dentition over time. The accu-
racy and usefulness of older antemortem dental evidence may consequently be less-
ened, hampering dental identification.

22.3.4.2 Antemortem Evaluation

Antemortem dental evidence analysis primarily involves the review of obtained
dental records, with the goal of creating a snapshot of the most likely dental
restorative profile of the patient immediately before death.
The antemortem charts should be obtained and distributed by the law enforce-
ment group with jurisdiction over the identification event, typically being the local
468 K. R. Torske

medical examiner or coroner. Care must be taken to verify receipt of the correct
record and all pages reviewed to confirm belonging to the same individual.
The initial dental examination results, progress/treatment notes, and dental
radiographs are reviewed. Laboratory forms may also provide useful information.
The most up-to-date information should be reviewed first as this ought to provide
the most accurate portrayal of the dentition at the time of death.

ANTEMORTEM DENTAL RECORD

Last Name: First Name: Middle Initial:

Social Security Number (ID number): Date of Birth / Age:

Sex: Race: Grade/Rank:

Date of Analysis: Analyst(s): Signature(s):

DESCRIPTION
Tooth Number
1
2
3
4
5
6
R L
I E 7
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
G F 8
H 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 T
T 9
10
11
12
13
14
15
16
SYMBOLS 17
Primary Codes Secondary Codes 18
M Mesial S Silver amalgam 19

O Occlusal E Resin (composite) 20

D Distal R Root canal 21
F Facial C Crown 22
I Incisal H Porcelain 23
L Lingual P Pontic 24
U Unerupted/Impacted N Non-precious 25
V Virgin (unrestored) G Gold 26
X Extracted T Denture tooth 27
J Missing crown Z Temporary 28
I No data B Primary tooth (deciduous) 29
/ Not recovered ~~~ Fracture line 30
31
32

Comments: Radiographs Used: Date:

Radiographs Used: Date:

Radiographs Used: Date:

Radiographs Used: Date:

Radiographs Used: Date:

Fig. 22.1 Antemortem dental record form

22 Forensic Odontology 469

All information regarding the patient should be recorded on a single antemortem

dental record, to include the patient’s full name, date of birth, identification number
(Social Security number, military identification number, etc.), sex, and race
(Fig. 22.1). Dental information should likewise be documented, to include teeth
present, extracted, and restored. Restoration type and surfaces involved should be
detailed, both within the narrative description section and within the odontogram.
An annotation should be made for every tooth, even ones that are present and
unrestored.
Any unusual or unique features may be described in the Comments section.
Dental or surgical treatment such as permanent retainers, dental implants, or fracture
repair should be annotated. Distinctive anatomic features such as root dilacerations,
diastemas, sinus morphology, atypical tooth anatomy, or tooth location should also
be charted, as should any evident pathology.
Challenges: Tooth Numbering. The acquired antemortem dental records may
utilize different tooth numbering systems, confounding accurate analysis
(Table 22.1). Knowledge of these systems is important, especially if mass casualty
identifications include decedents from multiple countries.
In the United States, the Universal system is most common. The adult Universal
system begins with the maxillary right posterior third molar as tooth #1 and proceeds
to the maxillary left third molar as tooth #16. The numbering progresses in a
clockwise circle to the mandibular left third molar as tooth #17 and onto the
mandibular right third molar as tooth #32. The deciduous dentition numbering
follows a similar progression but utilizes letters A thru T instead of numbers and
begins with the maxillary right second deciduous molar.

Table 22.1 Common tooth numbering systems

Right Left
Universal—adult
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
Federation Dentaire Internationale—adult
1-8 1-7 1-6 1-5 1-4 1-3 1-2 1-1 2-1 2-2 2-3 2-4 2-5 2-6 2-7 2-8
4-8 4-7 4-6 4-5 4-4 4-3 4-2 4-1 3-1 3-2 3-3 3-4 3-5 3-6 3-7 3-8
Zsigmondy/Palmer—adult
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Universal—deciduous
A B C D E F G H I J
T S R Q P O N M L K
Federation Dentaire Internationale—deciduous
5-5 5-4 5-3 5-2 5-1 6-1 6-2 6-3 6-4 6-5
8-5 8-4 8-3 8-2 8-1 7-1 7-2 7-3 7-4 7-5
Zsigmondy/Palmer—deciduous
E D C B A A B C D E
E D C B A A B C D E
Maxillary teeth, top row; mandibular teeth, bottom row
470 K. R. Torske

The Federation Dentaire Internationale (FDI) system is utilized by the World

Health Organization and many countries outside the United States. The system is
quadrant based, beginning with the central incisor as tooth #1 and progressing to the
third molar as tooth #8. The quadrants are labeled 1 thru 4 in a clockwise direction,
beginning with the maxillary right. When in use, this gives all teeth a two-digit
designation, with the first digit being the quadrant and the second being the specific
tooth. For example, the maxillary right central incisor is tooth 1-1 and the mandibular
left second premolar is 3-5. The deciduous FDI system is likewise similar, with the
teeth numbered 1 thru 5, but the quadrants designated as 5 thru 8.
Although a dash is ideally present between the first and second digits in the FDI
system, this is often omitted in practice. This may create confusion as tooth “13” in
the FDI system would be the maxillary right canine whereas tooth “13” in the
Universal system is the maxillary left second premolar. Care must therefore be
taken when analyzing international records so as to correctly identify the tooth in
question.
The adult Zsigmondy/Palmer system is also quadrant based, with tooth number-
ing similar to the FDI system. The quadrants, however, are designated by symbols
instead of numbers:

• ┘ = maxillary right
• └ = maxillary left
• ┌ = mandibular left
• ┐ = mandibular right

The teeth are then designated with both the symbol and tooth number. For exam-
ple, the maxillary right second premolar would be 5┘. The deciduous dentition
follows a similar pattern, but the five primary teeth are designated as A thru E.
Challenges: Dental Radiograph Assessment. Film orientation in dental radio-
graph review strongly influences evaluation of right vs. left and therefore tooth
numbers. Correct assessment of orientation is critical if accurate review of the teeth
is to be accomplished.
Plain films for periapical or bitewing radiographs have a raised dot in one cor-
ner, and its location helps determine orientation of the film. In forensic events,
these radiographs are oftentimes digitally scanned for submission. The scanned
image, however, loses the elevation of the dot, and orientation may come into
question.
If the radiograph film is placed in a horizontal position, the raised dot will be in
the upper left or lower right corners. This orientation will present the image as if
looking at the teeth from the outside of the patient. If the dot is in the opposite
corners—upper right or lower left—then the film is reversed, and the image presents
the teeth as if looking from inside the patient’s mouth. Noting the location of the dot
may therefore assist in establishing accurate orientation of the film.
22 Forensic Odontology 471

22.3.4.3 Postmortem Evaluation

The postmortem phase of dental identification includes the thorough evaluation of
recovered dental remains. Dental radiographs and charting should be performed,
with the goal of accurate representation of the decedent’s dental restorative profile.
Access into the oral cavity is the first step in postmortem evaluation. This may be
complicated by rigor mortis, with resultant contraction of the muscles of mastication.
Opening of the oral cavity may be assisted by manual or surgical means.
Manual opening of the mouth may be done by hand or accomplished by multiple
methods:

• Tongue depressors: Place two tongue depressors into the oral cavity along the
right or left molar occlusal plane. Then place a third in between the first two,
tapping it in with a bone mallet. Repeat with the addition of more tongue
depressors until the mouth is opened and rigor mortis broken.
• Rib spreader: The blades of a rib spreader may be inserted along the molar occlu-
sal plane, taking care not to leverage on incisor or canine teeth. The rib spreader
may then be compressed to open the oral cavity. Although more expedient, the
use of a metallic rib spreader risks fracture of cusp tips, so care must be taken
with use.

Surgical opening of the oral cavity involves reflecting the buccal skin and soft
tissues, exposure of the mandibular ramus, and sectioning of the ramus with a
Stryker saw or a similar battery-powered saw. This serves to fully loosen the
mandible for access and provides unobstructed view of the facial surfaces of all
teeth. Surgical opening, however, should only be attempted after approval from the
coroner or medical examiner, as the facial remains may contain evidence for autopsy
or be viewable during funeral ceremonies.
After access is obtained, thorough cleaning of the dentition is accomplished with
2 × 2 or 4 × 4 surgical gauze. Use of a tooth brush is not recommended, as this may
abrade decomposing gingival soft tissues leading to additional levels of debris on
the tooth surfaces.
A full set of periapical and bitewing dental radiographs should be taken, with the
goal to recapitulate what may have been taken during normal dental examinations
and treatment. Stabilization of the sensor or film may require additional assistance
or may be attached to the lingual surfaces of the relevant teeth via rope wax.
A full dental examination is performed, to include charting of teeth present,
missing, and restored, with all information listed on a single postmortem dental
record form (Fig. 22.2). A detailed listing of the types of restorations and surfaces
involved should be annotated in both the narrative description and odontogram.
Unique anatomic or pathologic features may be described in the Comments section.
The case number, analyst names, and biologic information of sex, race, and
estimated age should also be noted.
472 K. R. Torske

POSTMORTEM DENTAL RECORD

Case Number: Analyst(s): Signature(s):

Date of Analysis: Place of Examination:

Sex: Racial Traits: Estimated Dental Age::

Associated Information:

DESCRIPTION
Tooth Number
1
2
3
4
5
6 R L
7 I E
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
G F
8 H 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 T
9 T
10
11
12
13
14
15
16
17 SYMBOLS

18 Primary Codes Secondary Codes

19 M Mesial S Silver amalgam
20 O Occlusal E Resin (composite)
21 D Distal R Root canal

22 F Facial C Crown

23 I Incisal H Porcelain
24 L Lingual P Pontic
25 U Unerupted/Impacted N Non-precious
26 V Virgin (unrestored) G Gold
27 X Extracted T Denture tooth
28 J Missing crown Z Temporary
29 I No data B Primary tooth (deciduous)
30 / Not recovered ~~~ Fracture line
31
32

Radiographs Used: Date: Comments:

Radiographs Used: Date:

Radiographs Used: Date:

Radiographs Used: Date:

Radiographs Used: Date:

Fig. 22.2 Postmortem dental record form

22.3.4.4 Comparison Assessment

The antemortem and postmortem dental record forms are mirror images of one
another, providing for simplified side-by-side comparison. Upon review, unique and
distinct commonalities should be sought, especially in the size, shape, location, and
type of dental restorations. Shared anatomic or pathologic features should also be
reviewed, such as missing teeth, root dilacerations, diastemas, and maxillary sinus
22 Forensic Odontology 473

DENTAL IDENTIFICATION SUMMARY REPORT

Case Number: Number of Deceased:

Rank: DOB: Sex: Race: Social Security Number:
Analyst(s): Place of Examination:

Date analysis started: Date analysis ended:

Comparison of Antemortem and Postmortem Dental Records and Radiographs Reveal Compatibility on Teeth Number (Describe Feature)

1/ 9/ 17/ 25/
2/ 10/ 18/ 26/
3/ 11/ 19/ 27/
4/ 12/ 20/ 28/
5/ 13/ 21/ 29/
6/ 14/ 22/ 30/
7/ 15/ 23/ 31/
8/ 16/ 24/ 32/
Key: V = unrestored tooth; X = tooth missing; M = mesial surface; O = occlusal surface; D = distal surface; F = facial surface; L = lingual surface; I = incisal surface;
U = unerupted tooth; R= root canal filling; S = silver amalgam; E = resin (composite); C = Crown; G = gold; H = porcelain; P = pontic; B = primary (deciduous) tooth

Remarks:

Opinion (circle one): Positive Identification Probable (’Consistent With”) Identification Insufficient Evidence Excluded

Signature of Analyst: Date:

Signature of Reviewer: Date:

Fig. 22.3 Dental identification summary report form

morphology. Radiographic comparison typically provides the most substantial and

convincing visual evidence and may be used to verify an association.
If a match is obtained between the antemortem and postmortem evidence, this is
detailed in a Dental Identification Summary Report form (Fig. 22.3). The postmortem
case number and name of the deceased are noted, along with other relevant
information. A detailed description of all comparative dental commonalities is
provided, along with any remarks pertaining to the assessment. An identification
category is finally chosen depending upon level of certainty. This document is then
presented to the coroner or medical examiner as the consultant odontologist’s
opinion of identity.
Challenges: Lack of Evidence. The largest obstacle in forensic dental identifi-
cation is a lack of evidence from which to form an opinion. This may be due to mini-
mal availability of antemortem dental charts or radiographs, a lack of recovered
postmortem dental remains, or insufficient uniqueness via comparison. The cate-
gory of Insufficient Evidence is included on the Dental Identification Summary
Report should this situation exist.
474 K. R. Torske

Table 22.2 Dental identification go-kit items

Access Tongue depressors (box)
Bone mallet
Rib spreader
Bite block
Surgical scalpel and blades
Surgical scissors
Autopsy (Stryker) saw and blades
Periosteal elevators
Radiographs Laptop computer with associated software
Sensors
Sensor holders and rope wax
Portable X-ray machine
Multi-outlet and extension cord
Cleaning 4 × 4 gauze
Surgical basin (bowl)
Isopropyl alcohol
Examination Lighting (head lamp, flashlights, etc.)
Dental mirrors
Dental explorers
Cheek retractors
Personal protective equipment Gloves
Masks
Eye protection
Surgical gowns
Shoe protectors
Head covers
Lead vest and gloves (radiographic hygiene)
Documentation Antemortem, postmortem, and comparison documents
Clipboard
Writing instruments

22.3.5 Role in a Mass Disaster

Mass disasters may be due to multiple reasons, to include criminal actions, natural
catastrophes, or accidents, all of which resulting in multiple casualties in a short
period of time. Depending upon location and size of the event, the responsibilities
associated with victim identification fall to different agencies, to include city,
county, state, or federal. The forensic dentist may act as a consultant to any of the
agencies and assist in the identification effort.
Preparations for Forensic Dental Identification. The requirement to perform a
forensic dental examination often appears suddenly, with little warning or time to
prepare. The forensic dentist may need to travel to relatively austere sites without a
proper operatory for equipment and lighting. To alleviate stress and assure
preparedness, the prior creation of a forensic “Go-Kit” is recommended (Table 22.2).
This kit should contain all items required for the identification, to include postmortem
examination, antemortem chart assessment, and final comparisons. Having a pre-­
made kit to “grab and go” greatly assists in the identification effort so that required
items are not forgotten.
22 Forensic Odontology 475

22.4 Bite Mark (Pattern Injury) Analysis

The evaluation of pattern injuries due to bite trauma is occasionally undertaken by

forensic odontologists. A bite on exposed skin may leave an imprint with a specific
configuration, which may potentially correlate with the arch shape and tooth
location of a suspect. In theory, a positive correlation may connect the suspect with
a crime, while unexplainable discrepancies may support innocence. In practice,
however, the use of bite mark evidence has proven relatively unreliable and has led
to false convictions in court (Reardon 2014).
The human skin is a relatively poor impression material due to elasticity, and a
bite mark pattern may change over time due to healing. The human dentition may
display unique characteristics via restoration morphology, type, and location, yet
arch shape and tooth position may be relatively nonspecific to an individual. These
factors lead to ambiguity in assessment and possible erroneous conclusions. Even if
all factors are perfect and analysis and conclusions are properly performed, the
American Board of Forensic Odontology (ABFO) does not sanction a “without
doubt” identification of a perpetrator based upon bite mark assessment (ABFO
2017).
Although utilizing bite mark analysis to ascertain guilt may be scientifically
questionable, its use may assist in supporting innocence, especially if the suspects
arch shape and tooth location are radically different than the pattern injury. The
specific procedures for bite mark analysis are highly detailed and may be performed
via physical or computer-aided assessment. The basic steps include:

• Pattern recognition as a true bite mark

• Photographic documentation of the trauma
• Evidence collection and preservation
–– DNA and physical evidence of bite mark
–– Impressions and casts of suspect
• Analysis and comparison of collected evidence
• Communication of conclusions

Detailed instructions for bite mark analysis are beyond the scope of this text yet
may be found within the ABFO website or numerous textbooks on the subject
(ABFO 2017).

22.5 Conclusion

The skill sets of forensic odontology are performed daily in routine care of patients
yet may also be called upon in the event of a mass disaster. The detailed comparison
of antemortem and postmortem dental evidence provides for the accurate, reliable,
and expedient identification of human remains. As the need to perform this important
task often arrives suddenly and unannounced, thorough knowledge of the required
476 K. R. Torske

steps and subsequent preparation minimizes stress and increases efficiency of the
dental team.

References
ABFO. Bitemark methodology standards and guidelines. American Board of Forensic Odontology.
2017. https://abfo.org/resources/id-bitemark-guidelines. Accessed 25 Nov 2017.
Amorim A, Budowle B. Handbook of forensic genetics: biodiversity and heredity in civil and
criminal investigation. 1st ed. London: World Scientific; 2016.
Butler J. The future of forensic DNA analysis. Philos Trans R Soc Lond B Biol Sci.
2015;370(1674):pii: 20140252. https://doi.org/10.1098/rstb.2014.0252.
Champod C. Fingerprint identification: advances since the 2009 National Research Council report.
Philos Trans R Soc Lond B Biol Sci. 2015;370(1674):pii: 20140259. https://doi.org/10.1098/
rstb.2014.0259.
Christensen A, Passalacqua N, Bartelink E. Forensic anthropology: current methods and practice.
1st ed. Oxford: Academic Press; 2014.
GPO. 45 Code of Federal Regulations §164.512, p. 880. 2017. https://www.gpo.gov/fdsys/pkg/
CFR-2011-title45-vol1/pdf/CFR-2011-title45-vol1-sec164-512.pdf. Accessed 25 Nov 2017.
Reardon S. Faulty forensic science under fire: US panels aim to set standards for crime labs.
Nature. 2014;505(7486):13–4.
Yager N, Amin A. Pattern Fingerprint classification: a review. Pattern Anal Appl. 2004;7:77–93.
 Part V
Illustrative Case Reports
Case 1: Diagnostic Dilemma - White
and Red lesion 23
Easwar Natarajan

23.1 Case 1: Parts I and II

Case 1: Part I

E. Natarajan (*)
Section of Oral and Maxillofacial Pathology, University of Connecticut School of Dental
Medicine, Farmington, CT, USA
e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2019 479

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_23
480 E. Natarajan

This 55-year-old woman is a patient who recently transferred care to your practice
seeking comprehensive dental rehabilitation, including the replacement of several,
poorly contoured amalgam restorations. You delivered a full-coverage crown for
tooth # 2 3 months ago and are planning other full-coverage restorations in the
coming months. Today, she is here for a routine hygiene visit.
During this appointment, the patient brings the area (photograph Case 1) on the
right buccal mucosa to the hygienist’s attention. She reports being aware of
sensitivity and a stinging sensation in this area for the past month. Sometimes, the
cheek feels burnt, especially when she eats foods that are salty, abrasive, minty, or
acidic (e.g., citrus, vinegar in salad dressing). She tried using a commercial
mouthwash to try to address what she assumed was an infection—she was unable to
tolerate the rinse as it “burned” this area of her mouth.
The patient reports being otherwise healthy and active. She is regular with annual
physical evaluations. Her medical history is significant for a long history of
hypertension and type II diabetes, both of which are controlled with diet and
exercise. She also has a past history of exercise-induced asthma and rheumatoid
arthritis, neither of which require any medication at this time. She takes no
medications on a regular basis and takes a daily multivitamin. She has never smoked
cigarettes. She drinks a glass of wine with dinner but has found that red wine tends
to irritate her right cheek.

Case Work-Up Questions

Question 1. What additional questions (if any) would you ask this patient?
Question 2. In order to evaluate this finding, what other information will you seek during
the oral exam?
Question 3. Based on the brief history and findings as seen above, what is your clinical
differential diagnosis?
What is the respective pathological process for each diagnosis? Justify.
Question 4. In view of the differential diagnosis considered, what is your next step?
Question 5. If a biopsy of this lesion was obtained and the diagnosis reported was
“lichenoid stomatitis, perivascular inflammation,” how would you manage this
patient?
23 Case 1: Diagnostic Dilemma - White and Red lesion 481

Case 1: Part II

Approach to clinical diagnostic work-up and management summary

1. Additional questions—data gathering
specific to this patient Patient responses
(a) Temporal relationship. Did the sensitivity (a) Reports that sensitivity may have started a
start shortly after you received the few weeks after full-coverage crown # 2
full-coverage crown on # 2? was delivered
(b) Have the symptoms remained constant, (b) No history of pain. Symptoms of
or are they intermittent in nature? Do discomfort/burning are intermittent, not
you have pain? constant
(c) Do you have similar areas on any other (c) The only area affected is the right side.
oral surfaces? On the left cheek, Right buccal mucosa and attached gingiva
gingivae, tongue surfaces, labial of # 2 and 3. No other oral sites involved
mucosae, palate? (d) Mild discomfort in the area of # 2 and 3.
(d) Do you have discomfort when you brush No pain. No gingival sloughing reported
your teeth? Do they peel away? (e) There is no history of cutaneous pruritus,
(e) Do you have any scaly, itchy, rashes, or scaly plaques, and papules. No nail, scalp
spots on your skin? Especially around involvement
the wrists, ankles, nails, scalp? Hair (f) There is no history of eye irritation, except
loss? for occasional eye dryness—Uses artificial
(f) H
 ave you noticed redness, stinging/ tears
irritation or gritty sensations involving (g) No history of genital discomfort
the eyelids? (h) No nasal bleeding/discomfort
(g) Any genital mucosal discomfort? (i) No recent disease activity reported
(h) Any nasal discomfort/bleeding?
(i) Any recent joint-related issues re:
rheumatoid arthritis

2. Oral examination—things to look for

in this patient Examination findings
(a) Source of potential chronic irritation? (a) No evidence of sharp margins on # 2 crown.
Evaluate # 2 and 3 restorations No obvious inciting agent detected
(b) Distribution—is this the only such (b) Erythematous, erosive, and lichenoid change
finding in the oral cavity? Is this a is localized to the right posterior buccal
generalized finding? Is it bilateral? mucosa in the region of # 2. This is unilateral
(c) Appearance of gingival tissues in the (c) Focal lichenoid erosion # 2 region. Rest of the
area and beyond gingivae are within normal limits
(d) Size (in cm), borders, and extent of (d) 1.5 × 3 cm erosive lichenoid lesion extending
lesion to the buccal vestibule adjacent to # 1,2,3
(e) Areas of sloughing/blistering on (e) No evidence of tissue sloughing/blistering
pressure (Nikolsky sign) (f) The white changes are non-wipeable
(f) Are the white changes wipeable or (g) Non-ulcerated
non-wipeable? (h) Tender on palpation. No induration,
(g) Ulcerated/non-ulcerated nodularity
(h) Palpation—is this finding supple,
indurated, nodular, or tender?
482 E. Natarajan

3. Differential diagnoses
(pathological process) Discussion
I. Lichen planus Pros (findings that support diagnosis)
Pathological process— Red and white, lacy lesion on the buccal mucosa and gingiva.
systemic immune-mediated Discomfort and sensitivity to acidic/abrasive food. Middle-aged
woman. Chronic duration >3 weeks. Erosion. Intermittent
Cons (findings that do not support diagnosis)
Unilateral and too focal. Not widespread within the mouth. No
cutaneous or other mucosal involvement
II. Lichenoid stomatitis Pros (findings that support diagnosis)
Pathological process— Red and white, lacy lesion on the buccal mucosa and gingiva.
Iimmune-­mediated Discomfort, sensitivity to acidic food. Chronic duration. Potential
condition (local/systemic) temporal relationship with crown # 2 suggesting a localized
contact-type hypersensitivity reaction manifesting as a lichenoid
lesion
Cons (findings that do not support diagnosis)
The focal findings militate against lichenoid stomatitis resulting
from systemic sensitization (i.e., medication-­related lichenoid
stomatitis)
III. Discoid lupus Pros (findings that support diagnosis)
erythematosus Red and white, lacy lesion on the buccal mucosa and gingiva.
Pathological process— FOCAL oral lichenoid finding is suggestive. Discomfort and
systemic immune-mediated sensitivity to acidic food. Chronic duration
condition Cons (findings that do not support diagnosis)
No cutaneous lesions. Scaly plaques, hypopigmentation not
reported. No history of alopecia. Systemic lupus is ruled out as the
patient is generally healthy and active
IV. Traumatic irritation/ Pros (findings that support diagnosis)
erosion Red and white lesion on the buccal mucosa. Foci of erosion,
Pathological process— atrophy, and associated discomfort. Sensitivity to abrasive foods.
localized reactive/ Recently placed crown # 2 (potential ill-fitting margins), rough
inflammatory process surfaces. Temporal relationship—symptoms correlate with
approximate time the crown was placed
Cons (findings that do not support diagnosis)
Examination revealed no evidence of obvious surface or margin
irregularity. The area is above the line of intercuspation and hence
not prone to occlusive friction

4. Management—next steps based on differential diagnoses specific to this patient

Based on the clinical history and examination findings, we favor a benign immune-­
mediated process. This is a chronic, red-white lichenoid lesion on the buccal mucosa with
intermittent symptoms
 • Topical immunomodulation with a steroidal rinse or ointment is an option. However, any
management should be accompanied by follow-up visits
In this patient, a topical steroidal agent was used for a period of 1 month. At the follow-up
visit, the lesion appeared larger and unresolved. Patient symptoms persisted. There were
no other oral lesions. At this point, a biopsy was indicated
 • Incisional biopsy of the lichenoid red-white lesion on the right buccal mucosa is
recommended. A punch or scalpel biopsy approach may be employed
   Justification: There is no identifiable inciting agent/frictional source. This red-white
finding is a solitary finding and is unilateral. The findings are NOT compatible with lichen
planus which tends to be bilateral. The lesion has not responded well to topical
immunomodulation. This is a clinically indeterminate lesion and warrants investigation, i.e.,
tissue biopsy. Ensure that you discuss your thought process and approach to differential
diagnosis with the patient
23 Case 1: Diagnostic Dilemma - White and Red lesion 483

5. Biopsy diagnosis: “Lichenoid stomatitis; perivascular inflammation.”

Management
 • Interpretation
– The presence of a “lichenoid” inflammatory infiltrate implies that there is a
T-lymphocyte-mediated epithelial-stromal interface disorder
– Lichenoid inflammation with interface stomatitis and perivascular inflammatory
aggregates can be seen in a range of disorders:
Contact hypersensitivity—inciting agents include cinnamon/amalgam/restorative metals
Discoid lupus erythematosus—immune-complex-mediated disorder almost always
accompanied by cutaneous manifestations
Systemic lupus erythematosus—immune-complex-mediated systemic disorder almost
always accompanied by a range of multi-organ/systemic involvement
 • Patient education
– Emphasize that all findings are benign. Findings are likely secondary to the metal backing
in the crown. Potentially could be unrelated
– Discuss options of another attempt of topical immunomodulation. Alternately replace the
metal-backed crown with a full-coverage crown made of a different material
 • Management guidelines (specific to this patient)
– Another brief course of topical immunomodulation—rinse/ointment with follow-up to
track progress
– Alternate restorative material in fabrication of new full-coverage crown for # 2 and 3.
Evaluate compatibility prior to proceeding with extensive restorative plan
– Regular monitoring visits to evaluate this red-white lichenoid lesion
Patient progress:
The current patient was diagnosed with “lichenoid stomatitis; perivascular inflammation.” The
biopsy report contained a comment that stated, “The presence of perivascular inflammation
suggests the possibility of a localized contact hypersensitivity response (e.g. amalgam/
restorative material)”
The patient was provided with the option of 1 more month of topical immunomodulation to
evaluate response. Topical steroidal mouth rinses were prescribed to use t.i.d. × 1 month and
q.d. × 1 month. At a 3-month follow-up visit, the lesion appeared at less than 90% of its
original dimension. At a subsequent follow-up visit, the lesion was absent
The treatment plan was modified slightly to reflect a potential sensitivity to some component of
the original full-coverage crown on # 2; subsequent crown fabrication was planned with this
potential reaction in mind
Case 2: Diagnostic Dilemma - Crusty Lips
24
Easwar Natarajan

24.1 Case 2: Parts I and II

Case 2: Part I

E. Natarajan (*)
Section of Oral and Maxillofacial Pathology, University of Connecticut School
of Dental Medicine, Farmington, CT, USA
e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2019 485

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_24
486 E. Natarajan

This 22-year-old woman is referred to you by her physician for evaluation and man-
agement of the findings noted on her lips. The patient reports that around 4 months
ago, she developed a “cold sore” on the lower lip likely due to prolonged sun expo-
sure during a sailing trip. Her initial attempts to address this with over-the-­counter
docosanol cream were unsuccessful. She consulted with her physician who pre-
scribed penciclovir cream. The lesions were unresponsive after two courses of pen-
ciclovir and continued to progress in severity and extent (they involved the whole
lower lip and upper lip vermilion). She was prescribed valacyclovir PO and has
been on this medication for the past 3 months.
The patient is generally healthy with no significant medical history. In addition
to 500 mg valacyclovir taken once/day, she takes an oral contraceptive and a daily
multivitamin. She is reportedly allergic to penicillins. She works at a local bank and
is understandably frustrated and conscious about the appearance of the lips. She
does not smoke cigarettes, does not use recreational drugs, and does not drink
alcohol. She has a past history of cold sores.

Case Work-Up Questions

Question 1. What additional questions (if any) would you ask this patient?
Question 2. In order to properly evaluate this finding, what other elements of information
will you seek to establish during the course of your oral examination?
Question 3. Based on the brief history and findings as seen above, what is your clinical
differential diagnosis?
What is the respective pathological process for each diagnosis? Justify
24 Case 2: Diagnostic Dilemma - Crusty Lips 487

Case 2: Part II

Approach to clinical diagnostic work-up and management summary

1. Additional questions—data gathering
specific to this patient Patient responses
(a) Specific duration? Onset? Have the lesions (a) Lesions present continuously for
been present for all these months, or have 4 months. No periods of quiescence.
they fluctuated? Periods of quiescence Progressed in severity
(b) Any new medications around the time of (b) No new medications or other exposure
onset? reported
(c) Do you, or have you had, sores/similar areas (c) There are no lesions reported inside the
inside your mouth? mouth
(d) If you have oral lesions, are they all over (d) No intraoral lesions reported. All lesions
the place? On the gingiva, tongue surfaces, restricted to the vermilion and skin of
buccal mucosa, hard palate, soft palate? the lips
(e) Do the areas on the lips bleed, crust? (e) Yes. Occasional bleeding followed by
(f) D o you have pain? If yes, describe the yellow crust
nature and quality of pain. (f) N o pain. Substantial discomfort and
(g) Did you take any new medication shortly burning
before the lip lesions presented? Any (g) No new medications other than
change from generic to brand name or vice docosanol to address initial “cold sore”
versa? (h) No history of other skin lesion, rashes,
(h) Do you have similar areas, rashes, scaly or other findings
patches on other skin surfaces? (i) No extraoral mucosal involvement
(i) Do you have a history of irritation, burning, reported. No conjunctival burning, nasal,
pain involving other “wet surfaces”—nose, genital involvement
eyelids, throat, vulvovaginal areas?

2. Oral examination—things to look for in

this patient Examination findings
(a) Presence of skin rashes—palms, soles, (a) No evidence of extraoral lesions. No
wrists (visible surfaces). Conjunctival and evidence of nasal or conjunctival
nasal mucosal exam (cursory exam) redness, erosions etc.
(b) Extent of involvement around the lips (b) Involvement restricted to vermilion and
(c) Is the skin at the base of the amber crusts skin of lips
intact? Do the crusts peel away? (c) The underlying skin is intact but notably
(d) Is there intraoral involvement? Any atrophic. Natural vermilion markings are
evidence of vesicles, ulcers? indiscernible
(d) No intraoral lesions noted. There are no
intraoral ulcers/vesicles noted
488 E. Natarajan

3. Differential diagnoses (pathological

process) Discussion
I. Herpes labialis Pros (findings that support diagnosis)
Pathological process—reactivated herpes Reportedly began as a “cold sore” after sun
simplex viral infection exposure. Discomfort. Amber-golden crusty
lesions on the vermilion and skin of lip. Previous
history of herpes labialis
Cons (findings that do not support diagnosis)
Duration >2 weeks is inconsistent. Too
widespread (upper, lower, right, and left) on the
vermilion. Nonresponsive to antiviral agents for
over 3 months
II. Impetigo Pros (findings that support diagnosis)
Pathological process—bacterial infection Amber-colored crusted, scaly lesions on the
of the skin (staphylococcal/streptococcal) vermilion and skin. Exfoliation of vermilion
surfaces. Discomfort and sensitivity. No intraoral
involvement. No other extraoral sites. Prolonged
sun-exposure caused potential lip exfoliation, lip
fissures, and potential portals of entry for bacterial
infection
Cons (findings that do not support
diagnosis—none
III. Erythema multiforme Pros (findings that support diagnosis)
Pathological process—systemic immune-­ Involvement of the vermilion and skin of the lip.
mediated mucocutaneous reaction Occasional bleeding. Crusty, scaly lesions
Cons (findings that do not support diagnosis)
Duration >2 weeks. Onset is not acute/explosive.
No report of severe pain. All lesions localized to
the vermilion and skin of lips. No extraoral
cutaneous lesions (rashes, targetoid lesions). No
oral ulcers. No history of sensitizing agent (e.g.,
new medication, drugs, alcohol)
24 Case 2: Diagnostic Dilemma - Crusty Lips 489

4. Management—next steps based on differential diagnoses specific to this patient

• The diagnosis in this patient’s case was made on clinical grounds. The historical information,
clinical presentation, and correlation were most consistent with impetigo—a cutaneous
bacterial infection (commonly staphylococcal/streptococcal). In the setting of exfoliative
cheilitis on the vermilion/lip skin, there could be an element of candidal infection
 • Patient education (specific to this patient)
– Explain that she does not have herpes infection. Stop antiviral mediation
– Explain that impetigo is a bacterial skin infection. In her case, this is has been a
prolonged course over 3–4 months. This will likely require antibiotic therapy (systemic
and topical)
– Emphasize keeping the vermilion and skin of the lips clean and well lubricated during
therapy. Avoid drying, soap-containing face washes. Frequent gentle face washes (wash
cloths) in between topical antibiotic applications
 • Management
– Prescribe systemic antibiotics—penicillins, cephalosporins, or clindamycin (in case of
penicillin allergies)
– Topical mupirocin ointment application—used q.i.d. × 1 week
– Maintain lip and skin surfaces clean and lubricated (recommend petroleum jelly product)
in between antibiotic ointment application
Patient progress:
The current patient was diagnosed with impetigo and was managed with clindamycin (P.O.)
and topical mupirocin ointment applications. She was diligent in following facial hygiene
measures during this time. At her 1-week follow-up visit, there was significant improvement in
her presentation (see photograph below)
She continues to be lesion and symptom free since this initial episode but does report
occasional sensitivity in areas of vermilion surface atrophy (secondary to chronic infection and
exfoliation). The natural surface markings of the lower vermilion are lost and appear atrophic

 atient Progress—1 Week s/p Antibiotic Therapy for Impetigo Presenting

P
with Significant Improvement
Case 3: Diagnostic Dilemma - White
Patch 25
Easwar Natarajan

25.1 Case 3: Parts I and II

Case 3: Part I

E. Natarajan (*)
Section of Oral and Maxillofacial Pathology, University of Connecticut
School of Dental Medicine, Farmington, CT, USA
e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2019 491

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_25
492 E. Natarajan

This 62-year-old woman who recently moved to your state is a new patient to your
practice. Her last dental visit was over 2 years ago. She has no particular complaints
but would like to see the hygienist and have a comprehensive dental evaluation.
During the course of the initial oral examination, your hygienist notes the asymp-
tomatic, incidental white plaque shown in the clinical photograph (Case 3). The
hygienist brings this plaque to your attention. On questioning, the patient says that
she is unaware of this finding.
The patient is otherwise healthy and active. She is regular with her annual physi-
cal evaluations and has identified a primary care physician in your area. Her medical
history is significant for well-controlled hypertension, hypercholesterolemia, and
hypothyroidism. Her medications include lisinopril, pravastatin, and levothyroxine.
She also has a long-standing history of cutaneous and vulvar lichen planus, diag-
nosed when she was in her early 30s, and uses topical steroidal ointments for occa-
sional cutaneous flares. She reports having smoked cigarettes (1 pack/day) for
around 4–5 years in her 20s and quit 36 years ago. She drinks an occasional glass of
wine.

Case Work-Up Questions

Question 1. What additional questions (if any) would you ask this patient?
Question 2. In order to properly evaluate this finding, what other elements of information
will you seek to establish during the course of your oral examination?
Question 3. Based on the brief history and findings as seen above, what is your clinical
differential diagnosis?
What is the respective pathological process for each diagnosis? Justify
Question 4. In view of the differential diagnosis considered, what is your next step?
Question 5. If a biopsy of this lesion was obtained and the diagnosis reported was “epithelial
dysplasia,” how would you manage this plaque?
25 Case 3: Diagnostic Dilemma - White Patch 493

Case 3: Part ­II

Approach to clinical diagnostic work-up and management summary
1. Additional questions—data gathering specific
to this patient Patient responses
(a) Do you recall biting, chewing your cheek? Other (a) No history of trauma or chewing
parafunctional habits? habits
(b) Do you place cinnamon or other substances in this (b) Denies placing cinnamon in this
area? area
(c) Given your history of cutaneous lichen planus, do (c) No history of oral lichen planus
you have, or have you ever been told that you have
oral lichen planus?

2. O
 ral examination—things to look for in this patient Examination findings
(a) Source of chronic friction/trauma—sharp teeth, (a) No evidence of sharp teeth/
malocclusion along occlusal plane, ill-contoured traumatic agent on exam
restorations/prostheses (b) 1.5 × 1.0 cm. Irregular
(b) Size (in cm), borders, and extent of lesion. Are the shapeWell-defined, demarcated
borders demarcated or diffuse? border
(c) Does this plaque extend beyond this area? (c) Plaque is confined to this area
(d) Distribution—is this the only finding in the oral (d) Only finding in the oral cavity
cavity? (e) Non-wipeable (not debris)
(e) Wipeable or non-wipeable (f) N
 on-ulcerated. No erosions
(f) Ulcerated/non-ulcerated (g) Supple, non-tender
(g) Palpation—is this plaque supple, indurated, nodular, (non-indurated)
or tender?

3. Differential diagnoses
(pathological process) Discussion
I. Benign frictional hyperkeratosis Pros (findings that support diagnosis)
Pathological process—reactive Solitary, asymptomatic, non-wipeable white plaque in a
hyperplasia trauma prone location on the buccal mucosa
Demarcated, non-ulcerated, supple, non-indurated
Cons (findings that do not support diagnosis)
No history of specific trauma/friction. No identifiable
traumatic source on examination
II. Epithelial dysplasia Pros (findings that support diagnosis)
Pathological process—potentially Solitary, asymptomatic, non-wipeable white plaque
malignant/premalignant No history of specific trauma/friction. No identifiable
traumatic source on examination
History of cigarette smoking. DO NOT DISMISS distant
history of tobacco use
Non-ulcerated, supple, non-indurated
Cons (findings that do not support diagnosis)
Not in a classic cancer prone location, i.e., lateral/ventral
tongue, floor of mouth
Not a diffuse white plaque with ill-defined borders
494 E. Natarajan

4. Management—next steps based on differential diagnoses specific to this patient

• I ncisional biopsy of the non-wipeable white plaque is recommended. A punch or scalpel
biopsy approach may be employed
Justification: There is no identifiable inciting agent/frictional source. The patient’s distant
tobacco history (however brief) is significant. By definition, this is a clinically indeterminate
lesion and warrants investigation, i.e., tissue biopsy. Ensure that you discuss your thought
process and approach to differential diagnosis with the patient

5. Management following biopsy proven diagnosis of epithelial dysplasia

 • Patient education (specific to this patient)
– Explain that epithelial dysplasia is a premalignant epithelial process resulting from
genetic deregulation
– Tobacco use (however distant) may be a contributing risk factor
– The changes may be irreversible. There is a risk of transformation to squamous cell
carcinoma (oral cancer)
– Emphasize indefinite clinical monitoring/follow-up at regular intervals (3–6 months)
– Inform and educate patient about “things to look out for”—ulceration, redness,
discomfort, pain, and bleeding. If the patient notes any “evolutionary” changes, they
should contact you/oral surgeon, warranting further biopsies
 • Management guidelines (specific to this patient)
– The white plaque on the left posterior buccal mucosa was diagnosed as “epithelial
dysplasia.” The grade of epithelial dysplasia (mild, moderate, severe) is not a predictor of
malignant transformation potential
– The left buccal mucosal plaque was 1.5 × 1 cm (<2.0 sq. cm). Surgical excision of the
visible plaque is recommended
– Baseline photographic documentation of the white plaque prior to and post-excision
– Establish defined monitoring schedule (3–6 months recall)
– Evaluate for suspicious findings at recall visits—increase in size, change in color, change
in surface texture, and symptoms
– Biopsy suspicious findings (if any) at recall visits
Patient progress:
This patient was diagnosed with epithelial dysplasia following incisional biopsy of the left
buccal mucosal plaque. The plaque was surgically excised. During her monitoring visits
(3-month schedule), the lesion recurred appearing diffusely white with milky white borders.
At her 2.5-year follow-up visit, the plaque measured ~ 1.5 sq. cm and exhibited a small focus of
erythema with pebbly surface change (not noted in photographs obtained at her previous
3-month visit). The white plaque and the internal area of pebbly change were surgically excised
Histopathological exam revealed “epithelial dysplasia with a focus of superficial microinvasive
squamous cell carcinoma” (stage I)
Following surgical excision with wide margins, the patient required no further adjunctive
therapy (stage I disease)
She continues to be monitored on a regular basis with routine photographic documentation
Case Studies Evidence-Based Treatment
Planning 26
Michael T. Goupil

26.1 Introduction

In Chap. 1, the approach to evidence-based patient care was defined as looking at

the three areas—the patient, the dentist, and current knowledge. The major portion
of the chapter provided suggestions on how to access the most current literature, as
well as a systematic method to critically evaluate that literature using the Paul-Elder
Critical Thinking Model™. The following case studies will provide a framework to
ensure that the “patient” portion section is reasonably complete.
When collecting patient data, four major domains can be used to categorize the
data—dental issues, medical issues, socioeconomic issues, and legal/ethical issues.
The most applicable treatment plans for a patient need to be developed by looking
at all four of these domains. The first two domains, medical and dental, are fairly
straightforward. The ability to accomplish many dental procedures may be directly
affected by the patient’s medical condition. The relationship between diabetes and
periodontal disease is well known. But the other two domains, socioeconomic and
legal/ethical, may be equally important. For example, what does the patient truly
want and is it realistic, and what can they reasonably afford?

M. T. Goupil (*)
Division of Oral and Maxillofacial Surgery, University of Connecticut School of Dental
Medicine, Farmington, CT, USA
Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT, USA
e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2019 495

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_26
496 M. T. Goupil

26.2 Case Study #4

A 58-year-old male has just moved into your area and presents as a new patient
“seeking a new front tooth and a new plate”. He filled out your standardized medical
history form which revealed the following:

1. Hypertension controlled with lisinopril and atenolol

2. Prostate cancer which is treated with Lupron® injections every 4 months
3. Past history of heroin abuse and currently on methadone maintenance

The patient has copies of previous radiographs as he is seeking legal compensa-

tion for his previous dental care. He tells you that he had root canal treatment on the
upper left lateral incisor [#10] which fractured 1 month after placement of his cur-
rent “upper plate,” and it was then “pulled.” He also had to have another tooth
“pulled” [maxillary left second bicuspid, #13] which became loose after being an
“anchor for the plate.”

Patient presents with full mouth series of radiographs taken at time of insertion
of maxillary removable partial denture.
26 Case Studies Evidence-Based Treatment Planning 497

26.3 Domain Problem List

26.3.1 Medical Issues

Hypertension
Need to take blood pressure at every patient visit.
Are you concerned about the use of epinephrine? Some physicians are and if you
get a medical consultation you may be told not to use local anesthesia with
epinephrine; there is no science to substantiate this.
Patients on antihypertensive medication may have orthostatic hypotension and
become syncopal.
Some antihypertensive medications may cause gingival hyperplasia.
Prostate Cancer
Usually will not affect long-term survival.
May develop metastatic lesions to the jaw.
Hormone therapy affects bone density.
Patients are significantly prone to periodontal disease.
Past Heroin Use on Methadone
What is hepatitis status? Liver function?
Methadone in syrup form is high in sugar with increased caries risk.
Methadone also decreases salivary flow.
What will you prescribe if you need to give analgesics?

26.3.2 Dental Issues

Increased caries risk

Non-serviceable maxillary removable partial denture
Wants a permanent tooth in upper left anterior maxilla [#10]

26.3.3 Socioeconomic Issues

Past drug user

Limited funds
Single with no children—lack of family support system

26.3.4 Legal/Ethical Issues

Current dental situation is a result of unethical dental care.

Patient seeking legal recourse.
Will patient be super critical of future dental care?
Should you consider reduced fees to compensate for poor care provided by another
dental provider?
498 M. T. Goupil

There may be a number of other issues to be addressed, but a critical assessment

and integration of the above issues will help develop rational treatment options.
The patient was provided with the following treatment plans:

Option #1
New maxillary removable partial denture to replace all missing teeth even though
patient did not want a removable maxillary anterior tooth.
Option #2
Permanent anterior fixed partial denture to replace the missing lateral incisor.
This is reasonable as the abutment teeth are already heavily restored and full
crowns may be advantageous.
Option #3
Dental implants to replace missing maxillary teeth.

There are pros and cons to each of the above treatment plans. The dentist needs
to consider his/her own abilities. What is the patient or health-care system going to
be able to afford? What is the patient’s motivation as to ability to maintain the pro-
vided care?
This patient opted for treatment plan #2.

Mounted casts with maxillary fixed partial denture completed and ready for sur-
vey design for removable partial denture

26.4 Case Study #5

A 34-year-old make patient presents as a new patient to your practice. When the
patient called to make the appointment, he told the receptionist that he was in some
discomfort due to “broken teeth” and that he had not been to the dentist in at least
26 Case Studies Evidence-Based Treatment Planning 499

10 years. He was told to fill out the medical history form that would be mailed to
him and to bring it in for his evaluation appointment.
The medical history form revealed that he had no allergies, but he did have
depression and anxiety that were being treated with Effexor® and Wellbutrin®. When
the patient introduced himself at the consultation appointment, he stated that he
preferred to be called “Cassie” and that he was currently undergoing gender
reassignment.

Pretreatment panoramic radiograph

Pretreatment study casts

26.4.1 Medical Issues

Transgender Status
Individuals whose sense of gender identity does not correspond to their genetic/
anatomical sex.
Treatment options include psychological, hormonal replacement/blockers, real-­
life experience, and genital surgery and may affect cosmetic dentistry goals.
500 M. T. Goupil

Depression
May affect patient’s understanding/acceptance of treatment plans
Anxiety
May affect patient for certain aspects of care being provided and reliability to
keep scheduled appointments.
Patient may be more prone to syncopal episodes.
Need to consider anxiety reduction protocols.
Prescription Medications
Wellbutrin® [bupropion]
Adverse effects include tachycardia, headache, and significant xerostomia.
Effexor® [venlafaxin]
Adverse effects include headache, somnolence, and significant xerostomia.
May impair platelet aggregation.

26.4.2 Dental Issues

Dental Pain
High Carries Risk—medication induced xerostomia
Consider topical fluoride [PreviDent®] and chlorhexidine antiseptic rinses
Heavily Restored Dentition
Multiple Fractured Posterior Teeth

26.4.3 Socioeconomic Issues

Limited Funds

26.4.4 Legal/Ethical Issues

Transgender Status
The dental record must reflect the legal sex of the patient—this designator may
change. Patient may have their name legally changed; this needs to be reflected
in the chart.
The patient may be subjected to illegal discrimination or substandard care on the
part of the dentist and/or staff.
Most graduation dentists do not feel prepared to treat patients with a LGBT
background.

There may be a number of other issues to be addressed, but a critical assessment

and integration of the above issues will help develop rational treatment options.
The patient was provided the following treatment plan:
26 Case Studies Evidence-Based Treatment Planning 501

Oral Surgery—extraction of all four third molars [#s 1, 16, 17, and 32] and maxil-
lary right and left second molars [#s 2 and 15] and the mandibular right second
molar [#31].
Periodontics—gross debridement, prophylaxis, close monitoring of oral hygiene.
Endodontics—carious exposure maxillary left canine [#11].
Restorative—multiple Class II, III, IV, and V restorations.
Anxiety reduction protocol could include show/tell/do, oral antianxiety medication,
nitrous oxide sedation, and parenteral sedation.
Although not functionally necessary, the extracted second molars could be replaced
with dental implants at a later date.

Posttreatment Results
The patient will require close follow-up for oral hygiene maintenance and
encouragement.