PEDIATRICDENTISTRY/Copyright @1984by The American Academyof Pediatric Dentistry Volume 6 Number 4

The effects of odontogenic on the complete blood count in children and adolescents

Randy T. Travis, DMDClifford J. Steinle, DDS

Abstract whomsepsis is suspected. The latter study also dem- Hospital charts of children 2-18 years were reviewed onstrated that an elevation of the neutrophil count retrospectively and categorized by one of the following without a concurrent increase in the band neutrophil diagnoses:(1) dental (:aries, (2) dental caries count may occur in patients in whomthere is no evi- periradicularpathoses, (3) facial cellulitis of dental origin, dence of infection. 5 Weitzman, in a review of the or (4) periorbital cellulitis (nondental etiology). The medical literature concerning the diagnostic utility of values for each patient were tabulated in an attempt to the WBCcount and differential count, cites many establish a characteristic blood responsepattern for the generally known and accepted conclusions dealing various stages of dental infection. Results showedthat a with the effects of infectious and noninfectious enti- measurable blood response is uncommonuntil the ties6 on the WBCcount and the differential count. infection progressesto the stage of acute cellulitis. The WBCcount and differential count are not the However,at that stage, a characteristic pattern of blood response is seen for such . only components of the CBCto be affected by infec- tious processes. Anemiais a commonfeature of chronic infections and occasionally may complicate acute in- In the past, the CBChas been chiefly a tool of the fection; this usually indicates a hemolytic infection. physician. Standard normal values for the various CBC Clostridial bacteremia may produce massive intra- components have been available for nearly 40 years, vascular destruction of erythrocytes by producing a and in the last two decades clinicians have become lecithinase and hemolysins which act on the mem- branes of red cells and cause their destruction. Ane- adept at utilizing CBCresults for making diagnostic, prognostic, and therapeutic recommendations.17 Thus mia is common in cases of subacute bacterial far, use of the CBCby dentists has been limited; most endocarditis, , brucellosis, and chronic CBCexaminations are ordered as part of a battery of pulmonary infections such as lung abcesses and em- routine laboratory examinations upon admission to pyema. The of chronic infections usually is the hospital for operative dentistry and oral surgery. normocytic and normochromic but may be normo- However, some CBCexaminations are requested for cytic and hypochromic. The platelet count is a valu- treatment of patients with facial cellulitis of dental able test in that isolated thrombocytopenia may develop during the course of some acute gram-pos- origin to monitor the course of the infection and the 7 efficacy of therapy. The various indices of the CBC itive and gram-negative bacterial infections. long have been known as sensitive indicators of the As of this writing, no scientific studies examining physiologic3 and pathologic state of the individual. the hematologic effects of odontogenic infection as manifested in the routine CBCcould be found in the White blood cell count and the differential white blood medical or dental literature. It is the purpose of this cell counts have been used for the past 75 years to help evaluate infectious and noninfectious diseases. study to examine the effects of odontogenic infection Manroe et al. demonstrated that a carefully done upon various CBCparameters, and to define a char- differential white blood cell count maybe of signifi- acteristic hematologic pattern for such infections. cant help in distinguishing early-onset streptococcal Methods and Materials disease from other causes of respiratory distress in neonates. 4 Zipursky et al. concluded that an elevation Hospital charts of patients 2-18 years were re- of the band neutrophil count above the normal range viewed and selected in the following manner. A ret- is a valuable prognostic sign in premature infants in rospective search was conducted screening for one of

214 EFFECT OF ODONTOGFNIC INFFCTION ON CBC: Travis and Steinle TABLE1. Cumulative Summaryof Meanand Standard Deviation Values for CBCand Body Temperature Data Control Range Groupla Grouplb Group2 Group3

~ 4.83 ~ 4.60 ~ 4.72 ~ 4.58 RBC/mm3 4.32 - 5.12 ~ 0.51 ~ 0.40 ~ 0.55 ~ 0.37 ~ 38.4 ~ 38.0 ~ 37.6 ~ 36.77 Hct % 34.5 - 40.9 ~ 3.5 g 3.2 ~ 5.3 ~ 3.0 ~ 12.9 ~ 12.84 ~ 12.9 ~ 12.4 Hgb mg/100 cc 11.7 - 14.1 ~ 1.2 ~ 7.1 ~ 1.3 ~ 1.1 ~ 81.1 ~ 82.5 ~ 80.9 ~ 80.7 MCV3 u 76 - 84 ~ 13.4 ~ 15.0 ~ 4.9 ~ 4.6 ~ 29.3 ~ 28.9 ~ 27.39 ~ 27.6 MCH pg 24.4 - 28.5 ~ 5.4 ~ 8.5 ~ 2.0 ~ 4.2 ~ 33.6 ~ 33.8 ~ 33.7 ~ 33.8 MCHCgm/100 ml 32.1 - 36.1 ~ 0.9 g 0.8 g 1.47 ~ 0.9 ~ 337,500 ~ 394,250 Platelets/mm3 135,000- 466,480 no data no data ~ 62,077 ~ 59,225 ~ 7,200 ~ 7,100 ~ 12,400 ~ 15,000 Total3 WBC/mm 4,500 - 11,000 ~ 2,200 ~ 2,100 ~ 3,600 ~ 6,200 56.0 P 34.0 L 73.8 P 18.8 L 70.6 P 19.1 L Differential WBC 4.0 M2.7 E no data no data 5.8 M.9 E 5.4 M1.1 E .5B 3.0 Bands .1 B .8 Bands .1 B 3.3 Bands Body temp. (°F) 98° ~ 98.5 ~ 98.6 ~ 100.2 ~ 100.2 (acceptable range ~ 0.8 ~ 0.7 ~ 1.40 ~ 1.7 97° _o) 99 Age ~ 6.9 yrs ~ 6.4 yrs ~ 6.1 yrs ~ 8.4 yrs ~ 5.9 yrs Sample size control population N = 35 N = 36 N = 40 N = 42

three final diagnoses: (1) dental caries, (2) facial was: Group la, N=33; Group lb, N=36; Group 2, lulitis secondary to dental origin, and (3) periorbital N = 40; and Group 3, N = 42. cellulitis (dental etiology having been ruled out). Group Leukocyte count (WBCcount), erythrocyte count 1 was divided into two subgroups. Group la was (RBC count), hematocrit, hemoglobin concentration, designated "multiple caries without, periradicular pa- mean corpuscular volume, mean corpuscular hemo- thosis." Group lb was designated "multiple caries globin, and mean corpuscular hemoglobin concentra- with periradicular pathoses." The subclassification was tion were analyzed by automated instrumentation in based upon a thorough review of each patient’s den- the hospital hematology laboratory. The WBCdiffer- tal chart. Multiple caries were confirmed through ex- ential count and the platelet count were completed amination of full mouth radiographs and/or clinical manually by conventional smear techniques and read charting. Periradicular pathosis likewise was con- by certified technicians. firmed through examination of dental radiographs andY The CBCutilized for each patient was that obtained or specific mention of single or multiple fistulas or upon admission to the hospital. Values for body tem- parulis of dental etiology. In Groups 2 and 3, the use perature also were obtained upon admission. All val- of the term "cellulitis" to describe each patient’s con- ues for body temperature were adjusted to an dition upon admission to the hospital was consistent equivalent oral temperature if taken rectally or in the 8 with the definition given by Schuster and Burnett. axillary areas. 1° Control values for each of the com- The search was terminated when the number of pro- ponent analyses comprising the CBCwere standard spective cases in each of the four groups was 60 (N normal values for the population served by the Cin- = 6O). cinnati Childrens’s Hospital Medical Center (CHMC). In each group, the patient’s medical history was These values were obtained previously and apart from reviewed. Any case with a suspected or positive his- this study by the (CHMC)hematology laboratory for tory of or abnormality was ex- purposes of establishing normal CBCvalues. Veni- cluded from the study. Also excluded were patients puncture and capillary bed blood samples were drawn receiving therapy and those patients re- from 100 patients 2-10 years (6.3 years mean age) ceiving any pharmacologic agent with known he- undergoing outpatient surgery who presented in good matologic effects. 9 Final population size for each group health with no apparent illness or infection as certi-

PEDIATRICDENTISTRY: December 1984Nol, 6 No, 4 215 TAi~LE2. Absolute C.ounts for Individual LeukocyteSpecies Range %Greater % Less Than Cells/mm3 ~ cells/mm 3 g cells/mm 3 Than MaximumLimit MinimumLimit n

Control (A) PMNs 2,520 - 6,160 (B) Lymphocytes 1,530 - 3,740 Control (C) 180 - 440 population for CHMC (D) Eosinophils 122 - 297 (E) 22 - 55 (F)Band forms 135 - 330 Group 2 (A) PMNs 4,386 - 17,548 9,574 3,422 85.O% 0.0% 40 (B) Lymphocytes 596 - 6,096 2,433 1,164 10.0% 20.0% (C) Monocytes 176 - 1,782 746 397 80.0% 2.5% (D) Eosinophils 0 - 700 110 147 7.1% 65.0% (E) Basophils 0 - 162 17 42 12.5% 87.5% (F) BandNeutrophils 0 - 712 99 195 15.8% 82.5% Group 3 (A) PMNs 2,400 - 23,331 10,595 5,065 83.3% 2.4% (B) Lymphocytes 708 - 7,261 2,859 1,420 19.0% 7.1% (C) Monocytes 0 - 4,480 860 822 74.8% 9.5% (D) Eosinophils 0 - 1,370 169 288 16.7% 59.5% (E) Basophils 0 - 360 15 44 11.9% 88.1% (F) Band Neutrophils 0 - 4,256 501 1,052 28.6% 66.7%

fled by preoperative history and physical by an ex- hospital and must be completed manually by certified amining physician. technicians.) This policy and the fact that the data in Blood samples in Groups 2 and 3 were obtained by this study was gathered in retrospect accounts for the venipuncture. Blood samples in Groups la and lb fact that WBCdifferential counts and platelet counts were obtained by capillary bed sticks. Differences in were not obtainable for patients in Groups la and lb. CBCvalues for venipuncture specimens and capillary The data were compiled and analyzed in the fol- bed specimens are negligible with the exception of lowing manner: maxima, minima, mean, and stan- the hemoglobin w~lue which is approximately 1 mg/ dard deviation were calculated for each CBCparameter 100cc lower in venous blood than in capillary blood. for each patient in each of the four test groups. In The hemoglobin values collected in this study were Groups 2 and 3, absolute counts were obtained for not adjusted for this difference due to the fact that each type of leukocyte. The absolute count for a par- control values utilized in the study reflect hemoglo- ticular leukocyte was calculated in the manner pre- bin values both for venous and capillary bed speci- scribedu in a standard reference text. mens collected from a large population. Platelet counts and WBCdifferential counts were not performed for Absolutevalue for Value for that par- Total blood samples obtained from capillary bed specimens particular leukocyte = ticular cell (from x WBCx 1/100 1 in Groups la and lb unless total WBCcount exceeded in question(cells/ differential count) count mm3) 11,000 WBC/mm3. It is the policy of the hematology laboratory of CHIvICto omit WBCdifferential counts These calculations were conducted because the dif- on blood samples submitted unless total WBCcount 3 ferential count alone rarely has any significant mean- exceeds 11,000 cells/mm or unless specifically re- ing without being interpreted in relation to the total quested in doctor’s orders. Platelet counts likewise WBC11 count. are omitted unless specifically requested or unless Tests of significance utilized in this study were the accompanied by an elevated WBCcount (greater than t-test of the differences between two means and the 11,000). (This is because the WBCdifferential count chi-square (x2). Statistical significance was defined and the platelet count are not yet automated at this p~.05.12

216 EFFECTOF ODONTOGENICINFECTION ON CBC: Travis and Steinle Results terpreted relative to its use in calculating the absolute The results are presented in detail in tabular form value of the various types of leukocytes encountered in Table 1. The mean age for each group was as fol- (Table 2). (neutrophils, eosinophils, lows: 6.3 years for the control group referenced; 6.4 sophils, and band neutrophils) will be discussed first years for Group la; 6.1 years for Group lb; 8.4 years followed by agranulocytes (monocytes and lympho- for Group 2; and 5.9 years for Group 3. For purposes cytes). of clarity, the results are grouped according to the various CBCtests. A. Granulocytes Red Blood Cell Count and Indices 1. Neutrophilic leukocytes (PMNs): 85.0% of the pa- Mean values for the hematocrit, hemoglobin, mean tients in Group 2 had an absolute neutrophil count corpuscular volume, mean corpuscular hemoglobin, in excess of normal as compared to 83.3% for Gr.oup and mean corpuscular hemoglobin concentration were 3. One of 42 patients in Group 3 (2.4%) had an ab- well within the normal ranges for each group. solute neutrophil count below normal. There were no patients (0 of 40) in Group 2 who had absolute neu- Platelet Count trophil counts below normal limits. The mean abso- Groups 2 and 3 were well within control ranges lute3 neutrophil count for Group 2 was 9,574 cells/mm with mean platelet count values of 337,500 platelets/ vs. 10,595 cells/ram 3 for Group 3. These values were mm3 and 394,250 platelets/mm 3, respectively. This not statistically significant at the .05 level (p~.10). difference, however, was significant (p~<.001). 2. Eosinophilic leukocytes: 7.1% of the patients in Leukocyte Count Group 2 had an absolute eosinophil count higher than Two of 35 patients in Group la (5.7%) had total normal. In Group 3 16.7% of the patients had higher WBCcounts in excess of the maximumnormal limit. than normal eosinophil counts; 65.0% of the patients One of the 34 patients in Group lb (2.9%) had a total in Group 2 had lower than normal eosinophil counts WBCcount in excess of normal. Twenty-four of 40 as compared to 59.5% of the patients in Group 3. The patients in Group 2 (60.0%) had total WBCcounts mean absolute eosinophil count for Group 2 was 147 3 3 excess of normal. Thirty-one of 42 patients in Group cells/mm vs. 288 cells/mm for Group 3. The differ- 3 (73.8%) had total WBCcounts greater than the max- ence in the mean absolute count for both groups was imum normal limits. Values lower than the minimum significant at the .05 level (p~.02). normal limit for the total WBCcount were encoun- 3. Basophilic leukocytes: 12.5%of the patients in Group tered in 2 of 35 patients in Group la (5.7%) and 2 2 had absolute counts in excess of normal; 34 patients in Group lb (5.7%). was not 11.9% of the patients in Group 3 had absolute baso- observed in Groups 2 and 3. phil counts in excess of normal. Of the patients in The mean total leukocyte count was within.normal Group 3, 11.9% had absolute basophil counts in ex- range for the dental caries group (Group la) and also cess of normal; 87.5% and 88.1% of the patients in for the dental caries with periradicular pathoses group Groups 2 and 3, respectively, had absolute basophil (Group lb). The dental caries group yielded a slightly counts below normal. The mean absolute basophil higher mean WBCcount than the caries with peri- count for Groups 2 and 3 was 17 cells/mm 3 and 15 radicular pathoses group (x for group la = 7,200 cells/ cells/mm3, respectively. This difference was not sig- mm3;x for group lb = 7,100 cells/mm3. This differ- nificant at the .05 level. ence was not statistically significant. The mean total 4. Nonsegmented(band) neutrophils: 27.5% of the pa- leukocyte count exceeded the maximumnormal limit tients in Group 2 exhibited band neutrophils in the in the facial cellulitis of dental etiology group (Group WBCdifferential count as compared to 35.7% for the 2) and in the periorbital cellulifis group (Group 3). patients in Group 3. The mean value for the absolute The mean total WBCcount was 12,400 cells/ram 3 for band neutrophil count for all patients in Groups 2 Group 2 and 15,000 cells/ram 3 for Group 3. The mean and 3 was 99 cells/mm 3 and 501 cells/mm 3, respec- total WBCcount difference between Group 2 and tively. Calculating the mean value for only those pa- Group 3 was significant (p~<.050). When mean WBC tients in each group who exhibited band neutrophils counts were compared in Group la and Group 2, in the WBCdifferential count revealed a mean count statistical significance was found at the .001 level of 357 band neutrophils/mm 3 in Group 2 and 1,403 (p~<.001). The difference in the mean WBCcounts for band neutrophils in Group 3 (Table 3). Calculated Group lb and Group 2 also was found to be statis- test values utilizing the mean values from all patients tically significant at the .001 level (p~<.001). in botl~ groups revealed a significant difference at the .05 level (p~.0001). The same level of confidence was WBCDifferential Count obtained utilizing the mean absolute band neutrophil The results of the WBCdifferential count were in- value for only those patients in Groups 2 and 3 who

PEDIATRICDENTISTRY: December 1984/Vol. 6 No. 4 217 TABLE3. Prevalance of Band in Patients With Acute Cellulitis of Dental and Nondental Etiology Numberexhibiting bands in NumberExhibiting Bands Differential C AbsoluteBand In Differential Count(%) Count 500 Cells/mm~ (%)

Dentalcellulitis 40 11 (27.5%) 3 of 11 (27.2%) Periorbital cellulitis 42 15 (35.7%) 12 of 15 (80.0%)

actually exhibited band neutrophils in their individ- icant difference only between the noncellulitis groups ual WBCdifferential counts. Because of the difference (Groups la and lb) and the cellulitls groups (Groups between the two groups, the following hypothesis 2 and 3). The difference was significant at the .05 level was advanced: (p~<.001).

In patients with facial cellulitis whoexhibit band Discussion neutrophils in the WBCdifferential count, an ab- solute count of greater than 500 band neutro- Clinically, the findings of greatest practical signif- phi]s/mn"l 3 implies a nondental etiology; whereas, icance deal with the white cell portion of the blood. an absolute count below 500 band neutrophils/ Dental infection, from the stage of incipient caries to mm3 implies a dental etiology (Table 3). fulminant cellulitis, had no effect upon the RBCpor- tion of the CBC. Consequently, the majority of this The calculated chi-square was 5.66. This value proved discussion will center on findings associated with the to be statistically significant (p~.025). total WBCcount, the WBCdifferential count, and the interrelationship between them. Body temperature and B. Agranulocytes its relationship to dental infection will be discussed 1. Lymphocyticleukocytes: 10.0% of patients in Group as an incidental finding. 2 and 19.0% of patients in Group 3 had an absolute Of primary importance in this study is the finding lymphocyte count greater than normal. Twenty per that no abnormal CBCvalues are encountered with cent of patients in Group 2 and 7.1% of patients in dental infections until they reach the stage of acute Group 3 had an absolute lymphocyte count lower facial cellulitis. Bacterial invasion and colonization of than normal. The differences in these percentages for the teeth (caries) fails to elicit a systemic blood re- the two groups were not statistically significant. sponse as measured by the CBC. Perhaps more sur- However, the difference in the mean absolute lym- prising is the fact that invasion of the periradicular phocyte count for Groups 2 and 3 was statistically area by the advancing infection likewise fails to elicit significant (2 = 2,433 cells/mm 3 for Group 2, x = a systemic blood response. A response is seen, how- 2,859 cells/mm 3 for Group 3). The mean values for ever, when dental infection reaches the stage of acute each group were still well within range of normal and facial cellulitis. The characteristic responses seen in therefore not clinically .significant. this study were: (1) neutrophilia, (2) , 2. Monocyticleukocytes: 80.0%of the patients in Group , and (4) basopenia. These findings were 2 had an absolute count in excess of normal also true for those patients with cellulitis of nondental as compared to 74.8% of the patients in Group 3. Of origin and were consistent with the WBCpicture of the patients of Group 2 2.5% had an absolute mono- bacterial infections in general as reported by Weitz- cyte count below normal as compared to 9.5% of the man.6 There was a difference, however, with regard patients in Group 3. The mean absolute monocyte to the appearance of band neutrophils in the two count for patients in Group 2 was 746 cells/mm 3 as groups of patients presenting with cellulitis. Band compared to 960 cells/mm 3 in Group 3. Mean values neutrophils appeared in the WBCdifferential counts for both groups exceeded the control values for nor- of the two groups with similar frequency (27.5% for mal. This difference was not significant at the .05 patients of Group 2 vs. 35.7% for patients of Group level. 3) with a slight edge going to those patients with cellulitis of nondental origin. However, comparing Body Temperature only those patients who actually exhibited band neu- The mean body temperature for Group la was trophils in the WBCdifferential, the number of band 98.5°F; Group lb, 98.6°F; Group 2, 100.2°F; and Group neutrophils appearing per patient was radically dif- 3, 100.2°F. The difference in mean body temperature ferent for the two groups (x = 357 .cells mm/3 for amongthe four groups showed a statistically signif- Group 2 vs. x = 1,403 cells/mm a for Group 3). It

218 EFFECTOF ODONTOGENICINFECTION ON CBC: Travis and Steinle appears from these findings that the likelihood of a characteristic alteration of the CBCwhich involves shift to the left is greater in nonodontogenic cellulitis only the white cell portion of the blood. The spe- than in odontogenic cellulitis. These results also sug- cific findings are neutrophilia, monocytosis, eosi- gest that in patients with facial cellulitis, an absolute nopenia, basopenia, and generalized . band3 count of greater than 500 band neutrophils/mm 2. Neither caries nor periradicular involvement causes strongly implies a nondental etiology, or at least an alterations of the CBC. additional contributing agent other than odontogenic 3. Cellulitis of dental origin characteristically does not infection. Therefore, in patients presenting with fa- cause a shift to the left. If, however, immature cial cellulitis in whomthe clinical examination fails to neutrophils are encountered, an absolute band determine the causative agent, the absolute band count of greater than 500 cells/mm 3 implies non- neutrophil count (band neutrophil fragment in the dental etiology or at least an additional nondental WBCdifferential count x total WBCcount) may be of contributor to the infection. practical diagnostic importance. 4. In no case should laboratory values usurp clinical The effects of dental infection on body temperature findings; rather, they should be used as augmen- appear to duplicate the trend manifested by the he- tative evidence either supporting or refuting the matologic reaction. Normal values for body temper- tentative clinical diagnosis. ature were seen in patients with caries alone and also in patients with caries plus periradicular pathosis. Only in patients with facial cellulitis was there fever. This Dr. Travis is in private practice of pediatric dentistry in Madison- would be expected in view of current theories on the ville, KY.The research herein was completedwhile he was a res- ident in pediatric dentistry at the Children’sHospital Medical Center interrelationship between leukocytosis and fever pro- at Cincinnati, OH.Dr. Steinle is director, Dentistry for the Hand- 7 duction. There was no difference in the magnitude icapped (UACCDD),and associate director, pediatric dentistry, of fever in patients with nonodontogenic cellulitis as Children’s Hospital Medical Center, Cincinnatti, OH45229. Re- compared to patients with facial cellulitis of dental print requests shouldbe sent to Dr. Steinle. origin. It is beyond the scope of this study to elucidate the histologic and bacteriologic picture in the progression 1. Todd JK: Childhoodinfections. AmJ Dis Child 127:810-16, 1974. of dental caries from the incipient stage to its final 2. Bentley SA, Lewis SM: Automated differential leukocyte manifestation. However, one aspect of this process counting: the present state of the art. Br J Haem35:481-85, will be discussed. There has been perpetual difficulty 1977. in establishing which bacteria predominate once the 3. Arkin CF, Sherry MA,Gough AG, Copeland BE: An automatic infectious process of dental caries involves the peri- leukocyte analyzer. AmJ Clin Pathol 67:159-69, 1977. 4. Manroe BL, Rosenfeld CR, WeinbergAG, BrowneR: The dif- radicular area. The majority of studies designed to ferential leukocyte count in the assessment and outcomeof investigate this situation have been based upon bac- early-onset neonatal GroupB streptococcal disease. J Pediatr terial cultures taken after extraction Of offending teeth. 91:632-37,1977. Hence, the problem of culture contamination seems 5. Zipursky A, Palko J, Milner R, Akenzua Gh The hematology inescapable. Even studies utilizing preextraction cul- of bacterial infections in prematureinfants. Pediatrics 57:839- 53, 1976. tures taken through the root canal or through the 6. WeitzmanM: Diagnostic utility of white blood cell and differ- alveolar plate reveal microorganisms generally found ential cell counts. AmJ Dis Child 129:1183-89,1975. in the normal flora of the oral cavity. Because of this 7. Weinstein L, Swartz MN:Pathologic Physiology, 6th ed. Phil- dilemma, some investigators have suggested that the adelphia; WBSaunders Co, 1979, pp 545-61. dental13 granuloma is predominantly a sterile lesion. 8. Schuster GS, Burnett GW:Management of Infections of the Oral and Maxillofacial Regions, 1st ed. Philadelphia; WBSaun- If this is the case for periradicular involvement of ders Co, 1981, pp 75,176. dental infection generally, it would provide an expla- 9. GoodmanLS, Gilman A: The Pharmacological Basis of Ther- nation for one finding of this study -- namely, that apeutics, 5th ed. NewYork; MacMillanPublishing Co, Inc, the white blood cell response in patients with peri- 1975. radicular lesions is no different from those patients 10. BerkowR: MerckManual of Diagnosis, 13th ed. Rahway,NJ; who have carious lesions without periradicular in- Merckand Co, Inc, 1977 p 4. 11. Fischbach FT: A Manualof Laboratory Diagnostic Tests. Phil- volvement. adelphia; JE Lippincott Co, 1980 pp 1-68. Conclusions 12. Phillips JL: Statistical Thinking. San Francisco; WHFreeman and Co, 1973 pp 77-88. Findings from this study suggest four conclusions. 13. Shafer WG,Hine MK,Levy BM:A Textbook of Oral Pathol- 1. Facial cellulitis of odontogenic origin causes a ogy, 3rd ed. Philadelphia; WBSaunders Co, 1974, pp 433-77.

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