Author: Arif Razzak, Ali Al sharifi / Editor: Alex Goodson, Madhav Kittur / Reviewer: Tadgh Moriarty / Code: HAP9, MaC1, MaC3, MaP1, MaP2, MaP3, SLO1 / Published: 29/09/2020
Dental trauma refers to damage to the teeth or periodontia following injury. It can be classified as:
|Concussion||An injury to the tooth-supporting structures with no increase in tooth mobility, and no displacement of the tooth. The tooth however is tender to touch.|
|Subluxation||An injury to the tooth-supporting structures with an increase in tooth mobility. However tooth position remains correct|
|Intrusion||An injury resulting in apical displacement of the tooth (ie, the tooth has become displaced into the tooth socket)|
|Extrusion||Coronal displacement of the tooth (the tooth has moved out of the socket but has not come out completely)|
|Lateral luxation||Movement of a tooth in any direction that isnt axial. For example, the tooth may be displaced buccally or palatally|
|Avulsion||The tooth has been completed displaced out of the socket|
|Enamel fracture||Damage to the enamel of a tooth resulting in the loss of tissue, isolated to enamel only|
|Enamel and dentine fracture||Fracture of a tooth extending through both enamel and dentine, resulting in the loss of both tissues, not extending into the dental pulp|
|Complicated crown fracture||Fracture through the tooth extending into the dental pulp of a tooth. Also known as an enamel-dentine-pulp fracture|
|Root fracture||Fracture of the apical portion of the tooth which involved dentine, pulp and cementum|
|Alveolar bone fracture||Fracture of the alveolar process of the maxilla or mandible, which may or may not involve the socket itself. Note this is not the same as a fracture to the mandible or maxilla itself, and treatment between these two conditions is different.|
|Periodontia||Structures that are the supporting structures present around the teeth, including gingiva, bone, cementum and periodontal ligament|
Before we begin this session we must consider some basic dental anatomy. Teeth come in 4 main types: incisors, canines, premolar and molars, and are often coded for convenience.
The image below shows the notation. Each tooth type is given a number starting from the front and moving backwards. So the central incisor (very front tooth) is given a number one, the lateral incisor (the next tooth along) a number 2 and so forth. The number 3 is for canines, 4,5 for premolars, and 6-8 for molar teeth. The quadrant or corner the mouth is marked by the two perpendicular lines, with the horizontal and vertical line showing the tooths relationship to the midline of the mouth. Sometimes teeth may be marked as being UL2 or LR3. This is a shorthand method of denoting the Upper Left 2 (UL2) or Lower right 3 (LR3).
Decidious (baby) teeth are annotated differently, using letters instead of numbers.
Dental trauma is more common in patients who have a class 2 div 1 incisor relationship. Patients with this relationship have an increased overjet, which is when the top teeth are more anterior to the bottom teeth (see below, the blue arrow shows an average overjet, the red showing an increased overjet.)
Taken from www.pocketdentistry.com
The direction and amount of force will result in differences in the number of teeth affected and the type of injury sustained. Furthermore, younger patients will generally have softer bone, and in these age groups, avulsion of associated teeth is more likely. In older patient age groups, the bone tends to be more rigid, and therefore tooth fracture and alveolar bone fracture tends to be more likely.
Reference: Shulman-JD .And PetersonJ. : The association between incisor trauma and occlusal characteristics in individual’s 8-50years of age .Dent. Traumato. 2004. 20(2):67-72
On presentation of tooth avulsion, a thorough history should be taken, with particular reference to:
- Medical history, including tetanus status
- Mechanism of injury
- Loss of consciousness, nausea, vomiting or other signs of head injury
- Location of missing teeth
- Time of injury
- Any loose teeth/any teeth that are not in the correct place
- Any new sharp edges to teeth
If the patient has got the missing tooth with them, further questions to ask are:
- What medium was the tooth kept in (ideal medium is saliva or milk)?
- Is the patient aware if this is an adult or a baby tooth?
If the patient is not aware where the missing tooth (or tooth fragment) is, the following considerations should be thought of:
- If there are deep lacerations to the lips or cheeks, it is important to consider that the fragment may have become lodged in these areas. A soft tissue x-ray can help identify if there are any foreign bodies in the lips
- If there is a risk of the teeth and/or teeth fragments being aspirated, it is worth considering taking a chest x-ray to exclude this. As enamel is the most calcified structure in the human body, it often appears quite easily on an x-ray.
Clinically it is important to assess the patient, looking at both the appearance of the tooth and the appearance in the patients mouth. On avulsion, tooth sockets will generally be bleeding and open. If the sockets have closed, then this indicates that the injury is a delayed presentation. There have also been reported cases where trauma patients will comment that they lost teeth in the injury when in reality the teeth were lost some time ago, and either due to a head injury, or litigation purposes patients misreport the injury. In these cases it is important to clearly document that the tooth sockets have healed. It is not possible to implant a tooth back into a healed tooth socket.
Fresh tooth socket following trauma (taken from http://lifeinthefastlane.com/minor-injuries-004/
The image above shows a healed tooth socket following either tooth extraction or trauma some time ago, note the soft tissue now present in the socket, and the socket has now closed (taken from http://www.steinerbio.com/multiple-extractions-and-immediate-implant-grafting-with-socket-graft-putty/)
Examination of the teeth should highlight any fractures or chips to the teeth. Realistically in the Emergency Department, definitive management of these fractures and chips cannot be provided, and it is important to inform the patient that they should seek treatment quickly with their dentist and document this.
Image above shows large chip to upper right central incisor. This will need management by a dentist. Treatment can range from simple fillings, to root canal therapy and crown work. It is beyond the scope of Emergency Medicine to discuss assessments and treatments for dental trauma to that level, however it is important that patients are informed that they should present to a general dentist swiftly, as the chipped teeth are likely to be painful, and leaving deep cracks and chips in teeth can negatively affect their prognosis. Image Taken from http://moorefamilydentist.com/dealing-chipped-cracked-tooth
The position of the teeth should also be noted. In a simplistic view, a tooth can be pushed too far in, pushed too far out, or pushed inside or outside. A tooth pushed back into the gum is described as being intruded. A tooth pushed out from the gum is extruded. And a tooth pushed into a different position is described as being luxated. For example, a tooth pushed in towards the hard palate. A tooth can also be luxated buccally if it is positioned more towards the lips or cheek.
The image above shows extrusion and palatal luxation of the upper left first incisor (coded UL1, green arrow) and extrusion of the upper left second incisor (coded UL2 blue arrow). It shows how luxation injuries are often not isolated. Also note the tear in the gingivae between the UL1 and UL2. After repositioning of the teeth, this is likely to require suturing. The authors of this recommend that in these instances the maxillofacial team on-call should be contacted as suturing the gingivae can be technically challenging.
The mobility of the teeth should be checked, done by holding teeth between the thumb and index finger, and gently moving the teeth backwards and forwards. By doing this, we would aim to see if any teeth have had subluxation. This will also help determine any alveolar bone fractures. This can be seen when manipulating one tooth results in multiple blocks of teeth moving Another sign of an alveolar bone fracture is the presence of tears in the gingivae. Alveolar bone fractures are also identifiable on OPT (otherwise known as an OPG or a DPT radiograph) or periapical radiographs (most ED departments do not have access to periapical radiographs).
The images above show a fracture of the alveolar bone associated with the UR12, affected the maxilla. A gingival tear is visible, and on manipulation, both teeth move together as a block. Image sourced from http://dentaltraumaguide.org/Permanent_Alveolar_fracture_Description.aspx
It is important to differentiate between adult and deciduous (baby) teeth. This is important in trauma cases, as it has an effect on the management of the trauma.
The picture below shows a classical mixed dentition. It shows how to identify the adult vs the deciduous teeth. Patients and their parents can often help identify whether the tooth lost was an adult tooth or a deciduous tooth, however this cannot be relied upon.
As a general rule, a patients teeth will be symmetrical (most teeth will erupt within 3 months of the contralateral side erupting). So in the above picture, the missing tooth is likely to be a deciduous tooth, as the contralateral tooth is a deciduous tooth. Also note the shallow socket, suggesting that the tooth missing had no root. The baby tooth root is resorbed during the eruption processes of the underlying adult tooth.
Investigations that should be considered are outlined in the table below:
|Chest X-ray||Used to exclude aspiration risk when patient is unaware of where a missing tooth or tooth fragment is.|
|Soft tissue view||Useful to exclude fragments of teeth becoming lodged within deep lacerations to the lips, cheeks and face|
|Orthopantomogram (OPT or OPG)||Assessment of dental structures. Can be useful if doubt exists over whether tooth is a deciduous (baby) or adult tooth, and useful to assess degree of damage to dental and periodontal structures. This type of x-ray can also be beneficial to assess if a tooth has fractured at crown level, or have been intruded, as in both scenarios only a very small tip of a tooth can be seen.|
Management depends on the type of injury sustained. Readers of this guide are advised to see www.dentaltraumaguide.org where animated sequences and instructions can be found for the management of all the different types of trauma, as well as indications for future prognosis of teeth.
In the immediate management of an avulsed tooth, it is important to hold the tooth at the crown only (the part that is normally visible in the mouth) and to avoid touching the root surface. The tooth should be held in a physiologically acceptable medium (saliva or milk) and not placed in any strong antibacterial/antimicrobial solutions (e.g. bleach) before re-implantation. The aim of this is to maintain as much viable tissue on the root surface as possible. The patient should seek treatment as soon as possible.
For primary teeth, treatment generally revolves around reassurance, warning patients of damage to underlying successive adult teeth (which may result in miscoloured, misshaped teeth). If the primary tooth has been avulsed then IT SHOULD NOT BE REIMPLANTED. Doing this is likely to result in further damage to the underlying adult tooth. If the primary teeth are very loose and present a potential airway risk, then they should be removed (which can generally be done with some local anaesthetic and a piece of gauze or a needle holder). An intruded primary tooth should also be considered for extraction due to the risk of damage to the underlying developing tooth germ, although this might be better performed by a general dental practitioner.
With adult teeth, management is different. Luxated, intruded and extruded teeth should be replaced into the correct position, and a splint should be used to stabilise them. Different types of splint exist, the most common used are composite (a type of white dental filling material) or composite and wire splints, but black silk suture splints and suckdown splints are also used to a lesser extent. However these type of splints would not be easy to use in an ED setting. The splints should remain for 2-4 weeks (this requires follow up with a dentist, who may remove the splint at 2 weeks and resplint the area). However it is generally recommended that splinting is carried out by an individual who is dentally qualified, or has experiencing in splinting the teeth.
Avulsed teeth should be picked up from the crown only, and saline used to briefly clean debris from the root of the tooth. Saline should also be used to irrigate the socket to remove any blood clots that may be present here. Removing this blood clot will allow for revascularisation of the tooth to occur. The tooth should be gently placed back into the socket, and splinting carried out, ensuring that the tooth is orientated correctly in the correct socket. Antibiotics should be given and a tetanus booster considered. Note that in patients with immunodeficiency, it may be appropriate to avoid reimplanting the tooth due to the increased risk of infection. It is worth noting that teeth that are outside of the mouth for more than 60 minutes are more likely to fail and undergo root resorption (breakdown) or anklyosis (fusion of root to the bone) and ultimately fail. Antibiotics are recommended in most situations, especially if the patient has significant comorbidities or concomitant injuries present. Tetracyclines or penicillin (penicillin V/amoxicillin) are recommended first line. A tetanus booster should be considered, and patients advised to rinse with chlorhexidine 0.1% mouthwash for 1-2 weeks.7
Cracked teeth are more complicated to treat, and require assessment by a qualified dentist. Attempts should be made to locate missing fragments, and the patient warned about risk of future pain and requirement for future dental work. Sensitive toothpaste, paracetamol and NSAIDs can be recommended for these patient groups to help with pain that is likely to occur on contact with hot/cold food, drinks or other substances.
In all cases of dental trauma, follow up with a dentist should be advised, as the blood supply to the teeth may be affected, resulting in devitalisation of the tooth pulp. This needs to be monitored and treated by a dentist accordingly. It is also useful to advise patients on the use of 0.2% chlorhexidine mouthrinse as brushing is likely to be very painful.
|Dental pulp||Collection of blood vessels and nerves that are present within all vital teeth. This normally provides feedback during chewing processes|
|Apical foramen||The opening at the bottom of the tooth root which acts as an entrance for blood vessels from the periodontal tissues to the tooth pulp|
|Root canal therapy||A treatment modality which aims to fully chemically decontaminate and clean the area previously occupied by the dental pulp, and to seal the area from the oral environment.|
|Caries||A disease process whereby oral pathogens produce acid from metabolising sugars in the diet resulting in acid production, which subsequently breaks down tooth structures|
|Periodontitis||A chronic condition whereby bacteria present on gingival margins produce and release toxins resulting in an immune response which ultimately results in breakdown of alveolar bone and other supportive tooth structures, ultimately leading to tooth mobility and tooth loss.|
|Dentinal tubules||Small microscopic tubes present within dentine, which are normally filled with a mixture of fluid and air. Movement of fluid in these tubules may result in the sensation of pain|
The two most common conditions that effect teeth are caries and periodontitis. Caries results in what patients may describe as rotten teeth and results from acid producing bacteria causing breakdown of tooth substances. This alone can result in dentine hypersentivity, as this can expose dentinal tubules present within the tooth. When exposed, changes in temperature and osmolarity can cause movement of fluids within these tubules, ultimately resulting in a normally short lasting pain to stimulus.
The image above shows the Image taken from enchantedlearning.com
If the carious process continues, it can result in a pulpal exposure, whereby the blood vessels and nerves present within the tooth become exposed to the bacterial pathogens causing the dental decay. The bacteria eventually cause pulpal necrosis, and begin to infect the pulpal system. Eventually the toxins released by the bacteria will begin to seep out through the apical foramen, and result in a periapical abscess.
The image above demonstrates how when caries breaching the pulp chamber; the pulp undergoes necrosis, and the subsequent release of toxins and bacteria from the apical foramen results in abscess formation.
Abscesses in the oral cavity can spread via tissue spaces. This occurs because as the abscess grows, the abscess will follow the path of least resistance. In the maxilla, abscesses generally drain either buccally or palatally. In the mandible, abscesses often may penetrate though the alveolar bone buccally, to form a buccal abscess, or lingually to form a sublingual abscess. If the abscess expands below the mylohyoid, a submandibular abscess may develop. Abscesses can also tract posteriorly under the masseter forming a submasseteric abscess. Finally abscesses may spread via the pterygomandibular and parapharyngeal spaces.
Sub-masseteric abscesses can result in trismus, and this requires admission to hospital. Sublingual and submandibular abscesses can result in a raised floor of mouth, which is an airway risk. If the patient goes on to develop sublingual swelling bilaterally, then this is termed Ludwigs angina, and is a life threatening condition that requires urgent management.
Periodontitis, otherwise known as gum disease and historically termed pyorrhea, results from oral pathogens releasing toxins, ultimately damaging the tooth supporting structures via a chronic disease process. This results in the gums receding, exposing the tooth root surface which can cause sensitivity. Furthermore the damage caused to the tooth supporting structures results in tooth mobility, which can also cause pain.
Sourced from http://www.brightonimplantclinic.co.uk
The image above shows advanced periodontitis, resulting in exposure root surface. The teeth will be less stable and may move. Furthermore, the exposed root surface may feel sensitive. This condition is not an emergency, and patient should be advised to seek treatment with a general dental practitioner.
When a patient attends with dental pain and/or dental abscess, it is important to do a full set of observations, and as well as a good history, the following questions should be asked:
- Any difficulty with breathing, or difficulty with drooling saliva?
- Medical history
- Has the patient got a current dentist?
- Any difficulty with mouth opening?
- Any swellings?
- Any voice changes?
- Any restriction on eye opening?
- Any bad taste (associated with the drainage of pus into the mouth)?
Patients may often confuse dental pain with a dental abscess, and may describe a swelling sensation (although there may in fact be no swelling). Also patients may report not being able to chew due to dental pain as not being able to swallow, and a good way to further enquire about this is whether the patient has been able to swallow fluids.
Warning signs to look out for are:
- Patients with a raised floor of mouth
- Patients drooling, with difficulty swallowing and/or talking
- Patients with hot potato voice, or alteration to voice
- Patients who are having difficulty opening the eye
- Patients who are showing signs of sepsis (febrile, tachycardia, tachypnoea, hypotensive). It should be noted it is exceedingly rare to get sepsis from a dental origin.
- Erythema associated with the dental abscess spreading down the neck and towards the mediastinum
It is important to examine the patient, feeling for raised lymph nodes, and palpating abscesses. The floor of mouth should be soft, and not firm/raised. Any draining sinuses should be noted, and pressure applied to suspicious teeth. Teeth causing abscesses will generally be tender to touch.
An orthopantomogram (OPT or OPG) is a useful investigation to assess the cause of the dental abscess, and to help exclude conditions which may clinically appear similar (a sebaceous cyst on the face can mimic the appearance of a dental abscess). The OPT will also help identify the causative tooth, and should emergency treatment be required, this x-ray can be vital to ensure the correct tooth is removed.
If patients are unable to tolerate OPT radiographs (patients may be unable to stand still due to neurological or motor diseases such as dementia etc), then a lateral oblique mandible of the area can be beneficial (if it is a mandibular abscess). However this should only be used as a second line view, as it does not include the full detail provided by an OPT.
The image below shows an example OPT, with arrows showing carious lesions, and the periapical (around the tip of the tooth root) radiolucency classic of dental abscess. It may be worthwhile discussing these images with your local maxillofacial unit if there are concerns, as sometimes the changes can be more subtle.
Reference: Wetherell et al. Management of acute dental pain: a practical approach for primary health care providers. Aust Prescr 2001;24:1448.
Patients with isolated dental pain should be referred to their general dental practitioner as most hospitals lack the appropriate equipment required to diagnose and treat these patients in the emergency department.
Patients with red flags suggestive of a spreading infection should undergo maxillo-facial review. Red flags include fever, signs of sepsis (tachycardia, tachypnoea, raised white cell count, fever), periorbital cellulitis, and lymphadenopathy. Patients with symptoms or signs of potential airway compromise should undergo urgent anaesthetic and maxillofacial review; trismus (difficulty mouth opening), drooling, difficulty swallowing, voice changes, raised tongue or floor of mouth.
Buccal space or palatal dental abscesses are relatively easy to incise and drain under local anaesthetic; however care should be taken for abscesses in the lower premolar region due to the close relationship to the mental nerve. Copious saline irrigation should be used, and the use of drain may be considered. An emperical prescription of co-amoxiclav or metronidazole will also be beneficial in these patients.
Sublingual space abscesses are more difficult to manage, as the anatomy in this area is more complex. Furthermore, it is often a more difficult space to access, and patients with lingual swellings will often have issues secondarily to a raised floor of mouth.
Patients with difficulty opening, drooling, difficulty swallowing, a firm floor of mouth or voice changes should be admitted for incision and drainage under general anaesthesia with removal of any offending teeth. These patients should be started on IV antibiotics, and SHOULD RECEIVE AN URGENT MAXILLOFACIAL AND URGENT ANAESTHETIC REVIEW. These patients can undergo further airway compromise and should be classed as an acute emergency.8
It is important to note that patients with an associated erythema on the skin spreading down to the mediastinum are at risk of a rare condition known as acute purulent mediastinitis. This is where an infection spreads from its odontogenic or oropharyngeal origin through the fascial planes into the mediastinum. This is a life-threatening clinical scenario that requires early diagnosis (consider early CT) aggressive broad spectrum IV antibiotics, and multi-disciplinary team input. While initial mortality rates were as high as 40%, with earlier diagnosis and treatment, this figure has reduced to 4.3%.9,10
Most teeth extractions will involve bleeding to some degree, however generally, the application of pressure via a damp gauze will suffice to ensure haemostasis is achieved. However in general dental practice, the most common local anaesthetic used in the UK is lidocaine 2% with 1:80,000 adrenaline, which acts as a vasoconstrictor. This helps with haemostatic during and shortly after the procedure, but after patients leave the practice, the adrenaline can wear off, resulting in post-operative bleeding.
The majority of the time, the application of simple measures such as damp gauze and pressure will suffice. Patients who are on anticoagulation or antiplatelet therapy, and patients with clotting deficiencies (e.g. haemophilia, blood dyscrasia, von willibrand disease etc) are more at risk of bleeding (and are often more difficult to achieve good haemostasis).
The aetiology for dry socket is unclear, however there are thought to be 3 main pathogenic causes of a dry socket. The first theory is that the blood clot that was initially present post-tooth extraction is dislodged and lost (possibly due to the mechanical forces placed on it), and the exposed bone is then infected by microorganisms. The second theory is that the blood clot undergoes fibrinogenesis as a result of the healing and remodelling process. The third theory implicates bacterial enzymatic processes in the breakdown of the blood clot. There is some debate about risk factors for dry socket. A systematic review concluded age, difficult extraction and history of previous infection were risk factors, however consensus was lacking on whether smoking, alcohol and oral contraceptive pill contributed. (Tarakji B, Saleh LA , Umair A, Azzeghaiby SN, Hanouneh S. Systemic Review of Dry Socket: Aetiology, Treatment, and Prevention. J Clin Diagn Res. 2015 Apr; 9(4): ZE10ZE13. Bowe D, Rogers S, Stassen L, The management of dry socket/alveolar osteitis, Irish Dental Association, 2011; 57 (6): 305-310).
Bleeding sockets need to be differentiated between a true bleeding socket compared with just some blood stained saliva. A fresh bleeding socket will be seen oozing, and not just spitting of blood. It is important to investigate potential causes of the bleeding (is the patient clotting normally? is the patient on any anticoagulants? etc).
Dry sockets usually present with a bad taste, and sometimes also have a bad odour. A diagnosis is often made based on the history, but a tender region, with denuded bone and lots of food debris in the region of a recent extraction are tell-tale signs of a dry socket.
The image below shows a dry socket.
Note how there is denuded bone present in the site of a recent extraction. Food debris is also visible in the area as well.
For bleeding sockets, useful investigations may include:
- INR if appropriate
Dry sockets usually do not require any special tests, but an x-ray can be useful to rule out tooth fragments being left behind in the socket area. OPT long cone periapical radiographs are common views used to do this.
Bleeding sockets are often managed with combination local measures, including:
- Application of damp gauze
- Application of gauze soaked in tranexamic acid or adrenaline (or adrenaline containing local anaesthetic)
- Use of heamostatic agents such as hemocollagen or surgicel
- Use of resorbable sutures (these are best placed by experienced operators and is beyond the scope of this module to teach how to suture intra-orally). Readers should note that suturing intra-orally can be challenging due to the limited space available for manoeuvring of instruments
- Local infiltration of adrenaline (often with a local anaesthetic)
- Review of anticoagulation regimes if appropriate. Note that the bleeding risk must be weighed up with the risk of thrombo-embolic event. Reversal of these agents can be considered, but there is a poor evidence base for reveral of factor Xa and factor 2 inhibitors (e.g. rivaroxaban, dabigatran)
- Use of devices such as bipolar machines (although this is often not required)
- Consider the use of a 5% tranexamic mouthrinse to be used 4x daily as a prophylactic measure afterwards.
Dry sockets are best managed by irrigating the area with saline, and then placing aveogyl, which is a dressing material containing eugenol, which helps relieve pain and aid healing. It should be noted that the use of chlorhexidine as a direct socket irrigant has results in 2 deaths in the UK due to previously unknown allergy, and therefore current guidance is not to use chlorhexidine for socket irrigation. There was a previous tendency to prescribe antibiotics either prophylactically or as a treatment of this condition. The most recent guidance states that antibiotics should only be considered in those with signs of spreading infection, systemic infections of for immunocompromised patients.
(References: Scottish Dental Clinical Effectiveness Programme. Management of Acute Dental Problems. March 2013.
Medicines and Healthcare products Regulatory Agency. Drug safety update: Chlorhexidine: reminder of potential for hypersensitivity; 2012)
Bleeding sockets can occasionally be difficult to manage when the local anaesthetic wears off after suturing, it is possible for the bleeding to re-occur. Patients therefore should be informed of this, and given instructions on where to report to if this should occur.
Patients with bleeding sockets SHOULD NOT BE ENCOURAGED TO RINSE WITH WATER OR SALINE. This is a common misconception. By doing this, it results in further dislodgement of the blood clot. Patients should restart rinsing again with salty water the next day, after a stable clot has formed, to prevent infection.
It is important to inform patients when using hemocollagen that one of its constituent parts is made of bovine collagen. For some religious groups, as well as vegetarian patients, this may be an issue, and an alternative such as surgicel (oxidised cellulose mesh) may be more appropriate if available.
- Shulman-JD .And PetersonJ. : The association between incisor trauma and occlusal characteristics in individual’s 8-50years of age .Dent. Traumato. 2004. 20(2):67-72
- H papa, DC Jones. Mediastinitis from odontogenic infection. A case report. BDJ 2005 198, 547-548.,
- Estrera AS, Landay MJ, Grisham JM, et al. Descending necrotising mediastinitis. Surg Gynecol Obstet 1983; 157: 542552.)
- Moghadam H G, Caminiti M F. Life-threatening hemorrhage after extraction of third molars: case report and management protocol. J Can Dent Assoc 2002; 68: 670674.
- Tarakji B, Saleh LA , Umair A, Azzeghaiby SN, Hanouneh S. Systemic Review of Dry Socket: Aetiology, Treatment, and Prevention. J Clin Diagn Res. 2015 Apr; 9(4): ZE10ZE13.
- Bowe D, Rogers S, Stassen L, The management of dry socket/alveolar osteitis, Irish Dental Association, 2011; 57 (6): 305-310)
- Dental Trauma Guidelines. International association of dental traumatology. Revised 2012
- Robertson D, Keys W, Rautemaa-Richardson R, Burns R, Smith A. Management of sever acute dental infections. BMJ 2015;350:h1300
- Deu Martin M, Saez-Barba M, Lopez-Sanz I, Alcaraz Penarrocha R, Romero Vielva L, Sole Montserrat J. Mortality risk factors in descending necrotizing mediastinitis. Arch Bronchoneumol. 2010 Apr;46(4): 182-7.
- Wakahara T, Tanaka Y, Maniwa Y, Nishio W, Yoshimura M. Successful management of descending necrotizing mediastinitis. Asian Cardiovasc Thorac Ann. 2011;19:228–231
- Taberner-Vallverdu M, Sanchez-Garces MA, Gay-Escoda C. Efficacy of different methods used for dry socket prevention and risk factor analysis: A systematic review. Med Oral Patol Oral Cir Bucal. 2017 Nov 1;22(6):e750-758