Original Article 121

Tongue Blade Bite Test Predicts Mandible Fractures

John Neiner, MD1 Rachael Free, MD1 Gloria Caldito, PhD1 Tara Moore-Medlin, BS1
Cherie-Ann Nathan, MD1

1 Department of Otolaryngology, LSU Health Shreveport, Address for correspondence John Neiner, MD, Department of
Shreveport, Louisiana Otolaryngology, LSU Health Shreveport, 1501 Kings Highway,
Shreveport, Louisiana 71130 (e-mail: [email protected]).
Craniomaxillofac Trauma Reconstruction 2016;9:121–124

Abstract The aim of the study is to evaluate the utility of a simple tongue blade bite test in

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predicting mandible fractures and use this test as an alternative screening tool for
further workup. This is a retrospective chart review. An institutional review board
approved the retrospective review of patients evaluated by the Department of
Otolaryngology at a single institution for facial trauma performed from November 1,
2011, to February 27, 2014. Patients who had a bite test documented were included in
the study. CT was performed in all cases and was used as the gold standard to diagnose
mandible fractures. Variables analyzed included age, sex, fracture type/location on CT,
bite test positivity, and operative intervention. A total of 86 patients met the inclusion
criteria and of those 12 were pediatric patients. Majority of the patients were male
(80.2%) and adult (86.0%; average age: 34.3 years). Fifty-seven patients had a negative
bite test and on CT scans had no mandible fracture. Twenty-three patients had a positive
bite test and a CT scan confirmed fracture. The bite test revealed a sensitivity of 88.5%
(95% CI: 69.8–97.6%), specificity of 95.0% (95% CI:86.1–99%), positive predictive value
[PPV] of 88.5% (95% CI: 69.8–97.6%), and negative predictive value [NPV] of 95.0% (95%
CI: 86.1–99.0%). Among pediatric patients, the sensitivity was 100% (95% CI: 29.9–
100%), specificity was 88.9% (95% CI: 68.4–100%), PPV was 75.0% (95% CI: 19.4–99.4%),
Keywords and NPV was 100% (95% CI: 63.1–100%). The tongue blade bite test is a quick
► mandible inexpensive diagnostic tool for the otolaryngologist with high sensitivity and specificity
► trauma for predicting mandible fractures. In the pediatric population, where avoidance of
► tongue blade unnecessary CT scans is of highest priority, a wider range of data collection should be
► pediatrics undertaken to better assess its utility.

Mandible fractures account for 40 to 60% of all facial bone It has also been noted that fewer young children and more
fractures, most commonly in males aged 16 to 30 years. It is adolescents and adults are being treated for mandibular
among the most common maxillofacial fractures, three times fractures than ever before, possibly due to stringent use of
more common than zygomatic fractures and six times more seatbelts and child-restraint devices than in previous years.2,6
common than maxillary fractures.1,2 Concomitant injuries The gold standard for diagnosis is a noncontrasted computed
are common, with lacerations and neurologic injuries tomographic (CT) scan. However, this is a time-consuming
encountered most frequently. In the past, the most common test and the cost and radiation exposure associated with this
mechanism for these fractures was motor vehicle crashes. diagnostic modality raise the question of which patients
There has been a shift in recent years toward violent mech- should receive a CT scan and in which patient a mandibular
anisms and sporting injuries accounting for most fractures.2–5 fracture can be reliably ruled out by history and clinical

received Copyright © 2016 by Thieme Medical DOI http://dx.doi.org/

April 19, 2015 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0035-1567812.
accepted after revision New York, NY 10001, USA. ISSN 1943-3875.
July 18, 2015 Tel: +1(212) 584-4662.
published online
November 9, 2015
122 Tongue Blade Bite Test Predicts Mandible Fractures Neiner et al.

examination alone. In the pediatric population, where avoid- Table 1 Test results for fractures by CT and bite tests (N ¼ 86)
ance of excess radiation is a concern, others have questioned
the utility of CT scans where decisions are often made by Bite/CT test CT—fractures CT—no Total
clinical exam alone.7,8 By screening patients in whom a fractures
fracture is suspected, unnecessary imaging can potentially Bite—fractures 23 3 26
be avoided resulting in less cost and harm to the patient as (SE ¼ 88.5%)
(PPV ¼ 88.5%)
well as less time spent in the emergency room and higher
patient turnover. Bite—no 3 57 60
The tongue blade bite test (TBBT) will be evaluated in this fractures (SP ¼ 95.0%)
(NPV ¼ 95.0%)
study and consists of inserting a wooden tongue depressor
into both sides of the patient’s mouth and having the patient Total 26 60 86
bite down while the physician attempts to pull the tongue Abbreviations: CT, computed tomography; NPV, negative predictive
blade out. If the physician cannot pull the tongue blade out, value; PPV, positive predictive value; SE, standard error.
the test is considered negative. In this study, the sensitivity

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and specificity of the test compared with CT scans will be
analyzed. We also wanted to determine these parameters for Results
the pediatric population where avoidance of unnecessary CT
scans is of highest priority. Both the TBBT and CT were performed on 86 patients to
Review of the literature reveals periodic reference to the diagnose mandibular fractures. Fifty-seven patients had a
TBBT1,9; however, there is no prior mention in the literature negative bite test and on CT scans had no mandible fracture.
of the accuracy of this “pull” test as compared with the Twenty-three patients had a positive bite test and a CT
sensitivity and specificity of the gold standard CT scan. In confirmed fracture. Six patients had bite tests that conflicted
this study, we aim to show the accuracy of the pull TBBT in with CT findings. CT is the gold standard and properties of the
predicting mandible fractures in the setting of facial trauma. bite test (sensitivity, specificity, PPV, and NPV) were deter-
With this information, we aim to decrease the unnecessary mined by comparing its results with those of CT. The bite test
cost and radiation exposure associated with over-imaging revealed a sensitivity of 88.5% (95% CI: 69.8–97.6%),
patients at low risk of having a mandibular fracture. specificity of 95.0% (95% CI: 86.1–99%), PPV of 88.5% (95%
CI: 69.8–97.6%), and NPV of 95.0% (95% CI: 86.1–99.0%).
Among pediatric patients, the sensitivity was 100% (95% CI:
Materials and Methods
29.9–100%), specificity was 88.9% (95% CI: 68.4–100%), PPV
An institutional review board approved (Louisiana State was 75.0% (95% CI: 19.4–99.4%), and NPV was 100% (95% CI:
University Shreveport STUDY000000079) retrospective chart 63.1–100%). The results for both tests are shown in ►Table 1.
review of patients evaluated by the Department of Otolaryn- Summary statistics for patient characteristics and outcomes
gology at a single institution for facial trauma was performed are shown in ►Table 2. The majority of the patients were male
from November 1, 2011, to February 27, 2014. Patients were (80.2%) and adult (86%). CT scan identified 26 mandible
identified using the search function of an electronic medical fractures of various subsites (►Table 3). Fracture rate by CT
record for various CPT diagnostic codes corresponding to is 30.2% and by bite test is 30.2%. Average age at diagnosis was
facial trauma. Patients who had a bite test documented on 34.3 years and ranged from 3 to 101.
first evaluation by the otolaryngologist were included in the The chi-square test was used to determine the association
study. Evaluation was performed either acutely in the between sex and age on fracture rates by CT. The association
inpatient setting or subacutely as outpatient. Patients were between sex and fracture by CT revealed that the proportion
excluded if they were intubated, unable to tolerate or coop- of males (n ¼ 69) with fractures was 31.9% and female
erate for a bite test, or had an obvious open bite deformity or (n ¼ 17) fracture rates of 23.5%, p-value ¼ 0.50 (>0.05);
open fracture. CT had been performed in all cases and was hence, surprisingly there was no significant difference
used as the gold standard to diagnose mandible fractures.
Variables analyzed included age, sex, fracture type/location
on CT, bite test positivity, and operative intervention. Eight-
Table 2 Summary statistics for patient characteristics and
six patients met inclusion criteria and of those 12 were
outcomes (N ¼ 86)
pediatric patients. The majority of the patients were male
(80.2%) and adult (86.0% with average age 34.3 years). CT is
Characteristic/Outcome Number (%) or mean  SD,
the gold standard and properties of the bite test (sensitivity, median, range
specificity, positive predictive value [PPV], and negative
Male sex 69 (80.2)
predictive value [NPV]) were determined by comparing its
results with those of CT. The results for both tests are shown Adult 74 (86.0)
in ►Table 1. Exact 95% confidence intervals (CI) for the Age at diagnosis (y) 34.3  16.4, 31.0, 3–101
proportions were obtained using the binomial distribution. Had fractures (by CT test) 26 (30.2)
The chi-square test was used to determine the association
Had fractures (by bite test) 26 (30.2)
between sex and age on fracture rates (by CT).

Craniomaxillofacial Trauma and Reconstruction Vol. 9 No. 2/2016

 Tongue Blade Bite Test Predicts Mandible Fractures Neiner et al. 123

Table 3 Fracture locations

Age Sex Fracture location Fracture classification Bite test

16 M Angle Displaced Pos
34 M Ramus/Subcondylar/Parasymphyseal Displaced Pos
22 M Symphysis/Parasymphysis/Coronoid Displaced Pos
43 M Angle/Parasymphyseal Displaced Pos
22 M Body Displaced Pos
17 M Condyle/Parasymphyseal Displaced Pos
26 F Condyle/Parasymphyseal Displaced Pos
30 M Angle/Parasymphyseal Displaced Pos
43 M Angle/Parasymphyseal Displaced Pos

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62 M Ramus Displaced Pos
17 F Ramus/Condyle/angle Displaced Pos
35 M Ramus/Parasymphyseal Displaced Pos
19 M Body Displaced Pos
33 F Subcondylar Displaced Pos
23 M Subcondylar/Parasymphyseal Displaced Pos
18 M Angle Displaced (minimally) Pos
53 M Coronoid Displaced (minimally) Neg
23 M Ramus/Angle Displaced (minimally) Pos
23 M Ramus/Angle Displaced (minimally) Pos
25 M Angle Nondisplaced Pos
23 M Angle Nondisplaced Pos
24 M Bilateral angles Nondisplaced Neg
49 M Coronoid Nondisplaced Pos
54 F Ramus Nondisplaced Neg
39 M Body Nondisplaced Pos
49 M Subcondylar Nondisplaced Pos

Abbreviations: F, female; M, male; Neg, negative; Pos, positive.

between males and females on fracture rate. Adult fracture unlikely. In this medicolegal climate, physicians often feel
rate was 31.1% compared with children with a fracture rate of pressured to order all tests possible in fear of missing a
25.0%, p-value ¼ 0.67 (>0.05); hence, there was no diagnosis. While CT imaging has become commonplace and
significant difference between adults and children. remains the standard of care at most trauma facilities for any
moderate-to-high impact facial trauma, there are clinical
situations where facial trauma is of low impact and clinical
Discussion
judgment and bedside tests such as the TBBT can help
Mandibular fractures account for a high number of maxillo- determine if a CT may not be warranted.
facial fractures encountered by the facial trauma Our results were comparable with the previously men-
physician. The current gold standard for diagnosis is the CT tioned studies in the literature with various permutations of
scan. However, owing to the time consumption, high cost, and the bite test. In the study conducted by Alonso and Purcell, the
radiation exposure of this modality, we propose that the TBBT sensitivity and specificity of the TBBT to detect mandibular
is a suitable screening tool to augment clinical judgment fractures were 95.7 and 63.5%, respectively.1 In the prospec-
which would allow for avoidance of further imaging in tive study of Schwab et al, the sensitivity and specificity of the
patients with low risk of mandibular fracture. This is espe- TBBT were 95 and 67%, respectively.6 In our study, the
cially important in the pediatric population where the risks of sensitivity and specificity of the TBBT were 89.5 and 93.3%,
radiation exposure are highest. The results of our study respectively. In the pediatric population, the sensitivity and
showed that the TBBT is a reliable screening tool to add to specificity were 100 and 87.7%, respectively. From these
the diagnostic armamentarium in identify those at high risk results, we conclude that the TBBT is a quick, inexpensive
of a mandibular fracture from those in which a fracture is diagnostic tool for the facial trauma physician with high

Craniomaxillofacial Trauma and Reconstruction Vol. 9 No. 2/2016

124 Tongue Blade Bite Test Predicts Mandible Fractures Neiner et al.

sensitivity and specificity for predicting mandible fractures Because of the ubiquity of CT scanning in the emergency
especially in the pediatric population, where avoidance of department, in the large majority of patients, a CT scan had
unnecessary CT scans is of highest priority. However, we already been performed at the time of initial evaluation by
advocate that a wider range of data collection should be the facial trauma physician and the presence of a mandible
undertaken to better assess the utility of this test in the fracture may have already been known prior to the exam.
pediatric population to achieve tighter confidence intervals. It There can also be significant interclinician variability of the
is important to note that the test is limited only to pediatric force of the pull test and it is unknown what effect this would
patients that would comply with the test. have on the result of the screening test. We suggest a light-to-
In previous studies, this test had been compared with the moderate pull, as instances, where the bite test is positive, are
sensitivities and specificities of X-ray and panorex.1,6 Alonso often apparent at the onset of the pull with very little force
and Purcell conducted a prospective cohort study to deter- exerted.
mine the sensitivity and specificity of the TBBT using X-ray
studies as the gold standard.1 Schwab et al also conducted a
Conclusion
prospective study and determined the sensitivity and speci-

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
ficity of the TBBT as compared with the gold standard of In review of craniomaxillofacial trauma literature, this is the
panoramic tomography.6 Therefore, this study will be the first first study analyzing the utility of the TBBT. The test is a quick
of its kind in the literature to study the accuracy of the TBBT inexpensive diagnostic tool for the facial trauma physician
with the pull method as opposed to the break method with high sensitivity and specificity for predicting mandible
mentioned previously, which we hypothesize as safer owing fractures. When used in addition to a thorough head and neck
to less force and the lack of a broken wooden tongue blade trauma exam and when taken in context with the history and
that may contain sharp edges. nature of the trauma, we believe that this test can provide
For a few patients, TBBT results did not correlate with CT additional indications for avoiding or pursuing further
findings. On review of the false positives, while the patient workup such as a CT scan. In the pediatric population, where
lacked mandible fractures, all three patients sustained peri- avoidance of unnecessary CT scans is of highest priority, a
orbital fractures. This is an interesting finding and can be wider range of data collection should be undertaken to better
further evaluated with future studies. In evaluating screening assess the utility.
tools, false negatives are always of utmost concern. In our
study population, there were three false negatives, and
patients who had a negative TBBT and CT were positive for
a mandible fracture. On review, one of these patients had a
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