The role of immediate versus secondary removal of the odontogenic focus in treatment of deep head and neck space infections. A retrospective analysis of 248 patients. Clin Oral Investig. 2019;23:2921-2927. [PMID: 30623306 DOI: 10.1007/s00784-018-02796-7]

Odontogenic infections in the antibiotic era: approach to diagnosis, management, and prevention

PURPOSE

The prevalence of odontogenic infections remains one of the highest in the world. If untreated, odontogenic infections can break through the limitation, disseminate to other organs or spaces, and cause high mortality rates. However, it is still difficult to rapidly target limited or disseminated infections in clinical practice. The type of disseminated odontogenic infections and the responsible bacteria have not been described in detail.

METHODS

Search databases (e.g., PubMed, MEDLINE, Web of Science, Embase) for reports published from 2018.1 to 2022.9. Use search strategies: ("odontogenic infections" OR "pulpitis" OR "periapical lesions" OR "periodontal diseases") AND ("disseminated infections" OR "complication").

RESULTS

Fourteen different types of disseminated odontogenic infections, most of which are polymicrobial infections, can spread through the body either direct or through hematogenous diffusion. Multiple microbial infections can be more invasive in the transmission of infection. Secondary infections are commonly associated with bacteria like Fusobacterium spp., Streptococcus spp., Peptostreptococcus spp., Prevotella spp., and Staphylococcus spp. Antibiotics with broad-spectrum activity are fundamental as first-line antimicrobial agents based on the microorganisms isolated from disseminated infections.

CONCLUSION

This review elaborates on the epidemiology, microorganisms, risk factors, and dissemination routes, and provides evidence-based opinions on the diagnosis, multidisciplinary management, and prevention of odontogenic infections for dentists and clinicians.

Airway Management of Orofacial Infections Originating in the Mandible

The primary aim of this study was to assess the incidence of a difficult airway and emergency tracheostomy in patients with orofacial infections originating in the mandible, and a secondary aim was to determine the potential predictors of difficult intubation. This retrospective single-center study included all patients who were referred between 2015 and 2022 with an orofacial infection originating in the mandible and who were surgically drained under intubation anesthesia. The incidence of a difficult airway regarding ventilation, laryngoscopy, and intubation was analyzed descriptively. Associations between potential influencing factors and difficult intubation were examined via multivariable analysis. A total of 361 patients (mean age: 47.7 years) were included in the analysis. A difficult airway was present in 121/361 (33.5%) patients. Difficult intubation was most common in patients with infections of the massetericomandibular space (42.6%), followed by infections of the mouth floor (40%) and pterygomandibular space (23.5%). Dyspnea and stridor were not associated with the localization of infection (p = 0.6486/p = 0.4418). Multivariable analysis revealed increased age, restricted mouth opening, higher Mallampati scores, and higher Cormack-Lehane classification grades as significant predictors of difficult intubation. Higher BMI, dysphagia, dyspnea, stridor and a non-palpable mandibular rim did not influence the airway management. Patients with a difficult airway were more likely to be admitted to the ICU after surgery than patients with regular airway were (p = 0.0001). To conclude, the incidence of a difficult airway was high in patients with orofacial infections originating in the mandible. Older age, limited mouth opening, a higher Mallampati score, and a higher Cormack-Lehane grade were reliable predictors of difficult intubation.

Trends and Outcome of Aggressive Fascial Space Infections

Background: Odontogenic infections are common and self-limiting in most cases; however, they can lead to severe consequences, considerable morbidity and can even be fatal despite modern medical therapy. Patients and Methods: This retrospective study included patients with severe deep fascial space infections treated in the Maxillofacial Surgery Unit, General Surgery Department, Faculty of Medicine, Sohag University, Sohag Governorate, Egypt, and the Department of Oral and Maxillofacial Surgery, King Fahd Specialist Hospital (tertiary referral center), Burayda City, Qassim Province, Saudi Arabia, from June 2017 to June 2022. Results: This study included 296 patients, 161 (54.4%) males, 135 (45.6%) females. The fifth decade of life was the most common vulnerable age group. Forty-three percent of patients had diabetes mellitus, 26.6% were hypertensive, and 13.3% were on long-term steroid therapy. In 83% of patients, the offending tooth was identified but in 17% of patients no dental cause was identified. The lower third molar tooth was most commonly involved. Sixty-nine (23.3%) patients had submandibular space infections. Fifty-three (17.9%) patients had canine space infections. Thirty (10.1%) patients had submasseteric space infection. Twenty-eight (9.5%) patients had submental space infections. Twenty-three (7.8%) patients had combined infection of the submasseteric, submandibular, and pterygomandibular spaces, whereas 19 (6.4%) patients presented with Ludwig's angina. Conclusions: Odontogenic infections are common. The submandibular space is the most commonly affected single space. These infections could lead to lethal complications in immunocompromised patients, especially patients with diabetes mellitus. These infections require urgent surgical intervention to decrease hospital stays and avoid potentially lethal complications.

Streptococcus anginosus: a stealthy villain in deep odontogenic abscesses

Odontogenic infections (OIs) occasionally spread to deep facial and neck tissues. Our study aimed to explore the role of Streptococcus anginous group (SAG) in these severe OIs. A retrospective study of patients aged ≥ 18 years who required hospital care for acute OI was conducted. We analysed data of OI microbial samples and recorded findings of SAG and other pathogens. These findings were compared with data regarding patients' prehospital status and variables of infection severity. In total, 290 patients were included in the analyses. The most common (49%) bacterial finding was SAG. Other common findings were Streptococcus viridans and Prevotella species, Parvimonas micra, and Fusobacterium nucleatum. Infection severity variables were strongly associated with SAG occurrence. Treatment in an intensive care unit was significantly more common in patients with SAG than in patients without SAG (p < 0.001). In addition, SAG patients expressed higher levels of C-reactive protein (p = 0.001) and white blood cell counts (p < 0.001), and their hospital stays were longer than those of non-SAG patients (p = 0.001). SAG is a typical finding in severe OIs. Clinical features of SAG-related OIs are more challenging than in other OIs. Early detection of SAG, followed by comprehensive infection care with prompt and careful surgical treatment, is necessary due to the aggressive behaviour of this dangerous pathogen.

The inception of a hospital-based dental emergency department in a precarious region decreases the incidence of severe cellulitis of odontogenic origin

INTRODUCTION

Although most localized odontogenic infections can be managed successfully without complications, some can cause extensive morbidity through the onset of cervicofacial cellulitis. The management of these more severe infections generally requires emergency treatment, including surgical treatment under general anesthesia, and prolonged length of hospital stay.

MATERIAL & METHODS

In this work, we assessed the impact of the provision of a hospital-based dental emergency department on the regional incidence of severe odontogenic cellulitis in a socioeconomically precarious region. Monthly case rates of odontogenic cellulitis treated between January 2010 and December 2019 at the hospital-based dental emergency department of Lille Medical University Hospital were collected.

RESULTS

The mean number of monthly severe odontogenic cellulitis cases treated under general anesthesia was significantly higher before than after the inception of the hospital-based dental emergency service [14.07 (5.83) vs 8.79 (4.42); p<0.0001]. Conversely, the monthly mean number of collected odontogenic cellulitis cases treated under local anesthesia was significantly lower before the emergency service was set up [22.42 (12.73) vs 43.32 (23.41); p<0.0001].

CONCLUSION

The provision of a hospital-based dental emergency department resulted in a decrease in severe dental infections in a region with high indices of socioeconomic precarity, morbidity and mortality. Greater accessibility to dental care allows for the rationalization of care through more precocious and fewer burdensome procedures.

Computed tomography analysis of fascial space involvement demonstrates correlations with laboratory tests, length of hospital stays and admission to the intensive care unit in odontogenic infections

OBJECTIVES

Odontogenic infections are frequent and can spread, leading to complications such as sepsis and the need for admission to an Intensive Care Unit (ICU). The purpose of this study was to perform a computed tomography analysis of the fascial space involvement and correlate with personal data, laboratory tests, length of hospital stays and admission to the ICU in patients with odontogenic infections who required hospitalization.

METHODS

Patients with odontogenic infections admitted between June 2017 and May 2018 were prospectively evaluated. The fascial spaces involved were studied using computed tomography with contrast. The possible correlations of tomographic findings with comorbidities, nutritional status, the causative tooth, laboratory tests, length of hospital stays and admission to the ICU were analyzed.

RESULTS

We identified 66 cases of odontogenic infections which were admitted in the period analyzed. The involvement of primary spaces (86.7%) predominated, followed by secondary ones (8.7%), and cervical (4.6%). The most frequently involved fascial spaces were submandibular (27.1%), buccal (20.8%), sublingual (18.3%), submental (16.7%), and others (17.1%). There were significant differences between laboratory tests (p < 0.001), mean hospital stays (p < 0.001), and admissions to the ICU (p < 0.001) depending on the number of fascial spaces involved. There was no influence of comorbidities, nutritional status, or causative tooth on fascial space involvement.

CONCLUSION

There was a relationship between greater involvement of fascial spaces assessed by computed tomography and higher values of laboratory tests, more extended hospitalization stays and admission to the ICU.

LEVEL OF EVIDENCE

Level 2b.

Multivariate Analysis on Orofacial Odontogenic Infection in Northern Peninsular Malaysia

PURPOSE

This regional 2-center study was designed 1) to analyze the clinical features of all patients with odontogenic orofacial infection as per type of visit, 2) to analyze the clinical features of diabetic patients compared with nondiabetic patients, and 3) to identify potential variables that may associate with long length of stay (LOS) of patients admitted for orofacial odontogenic infection in Northern Peninsular Malaysia.

PATIENTS AND METHODS

All adult patients with orofacial odontogenic infections who attended the Oral and Maxillofacial Department of Hospital Raja Permaisuri Bainun and Hospital Sultan Abdul Halim from March 2015 to February 2019 were included. Data on patients' demography, medical history, smoking status, clinical presentation, and LOS were collected. Multivariate logistic regression analysis was performed using the dichotomous dependent variable, namely, short LOS (LOS <5 days) and long LOS (LOS ≥5 days).

RESULTS

A total of 355 patients were reported with the mean age of 39.93 ± 15.95 years old. Multivariate analysis revealed that diabetes (adjusted odds ratio = 4.387, 95% confidence interval = 1.453 to 13.241, P value = .009) and multiple space involvement (adjusted odds ratio = 4.859, 95% confidence interval = 1.280, 18.454, P value = .020) were responsible for long LOS.

CONCLUSIONS

Judicious treatment is recommended when treating patients of such infection that involves multiple spaces with underlying diabetes mellitus.

Surgical multidisciplinary approach in the management of odontogenic or non-odontogenic neck infections

In recent years, in our university hospital, the number of odontogenic and non-odontogenic abscesses has been rapidly increasing. We included 70 patients from January 4^th 2018 to February 19^th 2020 affected by the odontogenic ones. Deep neck infection can spread to the chest and is associated with high morbidity and mortality. The purpose of this mini-review is to demonstrate that, in case of complications, a multidisciplinary approach is needed to treat these infections, so that all practitioners should work together to achieve the patient’s rapid recovery.

Health status in patients hospitalised for severe odontogenic infections

OBJECTIVE

Previous findings refer to certain predisposing medical conditions that compound the risk of developing severe and potentially lethal acute odontogenic infections (OI). The objective of this study was to clarify this rationale and infection severity in general.

MATERIAL AND METHODS

Records of patients aged ≥18 years requiring hospital care for deep OI were retrospectively investigated. The main outcome variable was need for intensive care unit (ICU) treatment. Additional outcome variable was occurrence of infection complications and/or distant infections. Several parameters describing patients' prior health and recent dental treatment were set as independent variables.

RESULTS

Of the 303 acute OI patients included, 71 patients (23%) required treatment in the ICU, with no significant difference between previously healthy and patients with disease history. OIs originating from teeth in the mandible compared with maxilla had 7.8-fold risk (p = .007) for ICU treatment in binary logistic regression analyses. Elevated levels of infection parameters at hospital admission predicted further ICU stay. Infection complications and/or distant infections occurred in 7.6% of patients, of which septicaemia and pneumonia were the most common. The mortality rate was 0.3%. Infection complications and/or distant infections occurred significantly more often in smokers (p = .001) and in patients with excessive consumption of alcohol or drugs (p = .025), however smoking showed 3.5-folded independent risk for infection complications and/or distant infections (p = .008) in logistic regression.

CONCLUSIONS

Severe OIs often occur in previously healthy patients. Smokers in particular are prone to the most serious OIs.

Odontogenic Head and Neck Region Infections Requiring Hospitalization: An 18-Month Retrospective Analysis

The aim of this study was to comprehensively review our experience with odontogenic infections in the head and neck region requiring treatment at a national referral center. We retrospectively reviewed 85 patients treated at the Chair and Clinic of Maxillofacial Surgery of the University Hospital in Wrocław between January 2018 and June 2019. We excluded patients with nonondontogenic infections or other than purulent clinical forms of dentivitis in the head and neck region. Several demographic, clinicopathological, and treatment variables were assessed. The majority of patients were men who were referred for inpatient treatment by a dentist or family doctor, presented to the Hospital Emergency Ward (SOR) by themselves, or transported to the SOR by paramedics SOR from their home or another hospital. All patients were treated in accordance with the current guidelines for head and neck region odontogenic infections. An incision was made and the abscess was drained. The odontogenic cause was removed followed by the collection of tissue for microbiological examination. The course of infection was monitored by means of laboratory parameters such as leukocyte counts and c-reactive protein levels. Odontogenic infections in the head and neck region are a persistent and common problem. Rapid, accurate diagnosis and treatment minimizes the risk of life-threatening complications, shortens the hospitalization period, and lowers treatment costs.

Maxillofacial space infection experience and risk factors: a retrospective study of 222 cases

BACKGROUND

Maxillofacial space infection (MSI) experience review is beneficial for its management.

AIM

To identify potential risk factors predisposing to the exacerbation of MSI and a prolonged length of stay (LOS).

METHODS

We performed a comprehensive retrospective review of medical records of 222 MSI patients admitted in Center of Stomatology during 1993-2019.

RESULTS

About 63.5% of 222 patients had an odontogenic infection, and submandibular space was the most involved space. Streptococcus spp. was the most common organism isolated (72.4%). Multiple-space cases had more systemic diseases, respiratory difficulty, and life-threatening complications and exhibited worse clinical characteristics (higher white-blood-cell-count, higher body temperature, and restricted mouth opening) than single-space cases (P < 0.05). No significant difference in LOS was found between multiple-space cases and single-space cases. Diabetes and hypertension both accounted for 35.1% in life-threatening cases. Multiple-space infection (60.4%), respiratory difficulty (11.7%), and systemic conditions (43.2%) were identified as critical risk factors associated with life-threatening complications in MSI patients (P < 0.001). A significantly prolonged LOS was found in cases aged ≥ 60 years or with systemic diseases. Community outpatient treatment shortened 1.9 days of LOS compared with self-medication before admission during 2010-2019 (P < 0.05).

CONCLUSION

Comprehensive managements are advisable for MSI patients with multiple-space infection, respiratory difficulty, systemic diseases to avoid disseminated exacerbation, and occurrence of life-threatening complications. Community outpatient treatment was beneficial to a reduced LOS. Timely access to dental outpatient management and simultaneously steady control of diabetes and hypertension was advocated. Improved coverage of insured dental outpatient treatment should be stressed.

Cefazolin versus ampicillin/sulbactam as an empiric antibiosis in severe odontogenic neck infection descending from the lower jaw-retrospective analysis of 350 cases

OBJECTIVES

Odontogenic infections descending from the lower jaw may lead to severe health conditions. Commonly, a biphasic treatment of surgical drainage and antibiotic therapy is conducted. The choice of the administered empiric antibiotic agent remains debatable.

MATERIAL AND METHODS

Retrospectively, we analyzed 350 medical records of patients who were consecutively treated with odontogenic infections descending from the lower jaw. All patients received surgical drainage and either cefazolin or ampicillin/sulbactam as empiric antibiosis. In particular, the number of secondary operations, infectious parameters, and length of in-hospital stay were investigated.

RESULTS

The most frequently infected space was the perimandibular/buccal space for both groups followed by the submandibular space. Number of revision procedures, early recurrence, and length of stay presented no significant difference between both groups (p > 0.05). Inflammatory parameters (c-reactive protein, leukocytes) similarly decreased in both groups.

CONCLUSION

Cefazolin targets the majority of the pathogens detected in severe odontogenic neck infections descending from the lower jaw and reveals comparable results to AMP/S in regard to the inflammatory parameters and in-hospital stay.

CLINICAL RELEVANCE

Cefazolin is a feasible empiric antibiosis for odontogenic neck infections descending from the lower jaw if surgical drainage is performed.

Risk Factors for Reoperation in Patients Hospitalized for Odontogenic Infections

PURPOSE

One of the most common adverse events after treatment of severe odontogenic infections is the need for a second procedure. The identification of risk factors for reoperation could help surgeons predict the need for reoperation or even tailor treatment to avoid this complication altogether. The purpose of this study was to identify risk factors associated with reoperation in patients hospitalized with odontogenic infections.

PATIENTS AND METHODS

We designed a retrospective cohort study from an eligible population of all patients treated at our institution for an odontogenic infection with incision and drainage under general anesthesia from August 1, 2015, to June 30, 2019. The primary outcome variable was a return to the operating room because of treatment failure. The potential predictor variables included demographic characteristics, history or physical examination findings from admission, admission laboratory values, initial computed tomography results, and medications provided during treatment. Statistical analysis was performed using the χ² test and logistic regression, and from these results, a multiple logistic regression model was created.

RESULTS

A total of 223 patients were included in the study. Men comprised 50.7% of the study population, and the average age was 38.9 ± 13.3 years. The mean number of involved spaces was 2.6 ± 1.7 spaces. Reoperation was performed in 25 patients (11.2%). In the adjusted model, an increased number of involved spaces (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.3 to 2.7) and increased age (OR, 1.05; 95% CI, 1.004 to 1.09) were associated with increased odds of reoperation, and antibiotic therapy with a penicillin-type antibiotic (OR, 0.1; 95% CI, 0.04 to 0.5) and dexamethasone use (OR, 0.9; 95% CI, 0.8 to 0.98) were negatively associated with reoperation.

CONCLUSIONS

Further studies could be directed at determining whether certain timing or dosing regimens of dexamethasone could be helpful in reducing adverse outcomes in patients with odontogenic infections or determining feasible strategies when penicillin allergies are reported.

Mapping the microbiological diversity of odontogenic abscess: are we using the right drugs?

OBJECTIVES

The aim of this study was categorizing the microbial flora and susceptibility to antibiotics and to clarify to which degree the empiric administered antibiotics are suitable for therapy.

MATERIALS AND METHODS

A 3.5-year retrospective study evaluated hospital records of 206 patients who suffered from head and neck infections of odontogenic origin. All patients underwent surgical incision and drainage and received intravenous antibiotics and inpatient treatment. The specimens were obtained by performing a swab.

RESULTS

Two hundred six patients were included with 251 strains isolated (1.22 per patient). One hundred eight strains showed antibiotic resistance. Eighty-seven patients showed at least one bacterial strain that showed antibiotic resistance (42.2%). The most frequent isolated bacteria were Streptococcus spp. (n = 116), with a high rate of antibiotic resistance (50.8%). We investigated 205 cases of antibiotic resistance in 87 subjects. Nine bacterial strains showed no susceptibility to unacid (4.3%) and 36 strains to clindamycin (17.5%).

CONCLUSION

Antibiotic resistance against clindamycin was rather high. The distribution of the afflicted spaces and isolated bacteria was alike recent findings. It is mandatory to understand that immediate surgical treatment in terms of incision and drainage is the basis in abscess treatment. Antibiotic treatment is adjunct therapy.

CLINICAL RELEVANCE

Streptococcus species were the most frequently identified bacteria presenting antibiotic resistance in more than 50%. Increased resistant rates for clindamycin require reconsiderations regarding an empiric antibiotic treatment.

Fatal complications in a patient with severe multi-space infections in the oral and maxillofacial head and neck regions: A case report

BACKGROUND

Odontogenic infection is one of the common infectious diseases in oral and maxillofacial head and neck regions. Clinically, if early odontogenic infections such as acute periapical periodontitis, alveolar abscess, and pericoronitis of wisdom teeth are not treated timely, effectively and correctly, the infected tissue may spread up to the skull and brain, down to the thoracic cavity, abdominal cavity and other areas through the natural potential fascial space in the oral and maxillofacial head and neck. Severe multi-space infections are formed and can eventually lead to life-threatening complications (LTCs), such as intracranial infection, pleural effusion, empyema, sepsis and even death.

CASE SUMMARY

We report a rare case of death in a 41-year-old man with severe odontogenic multi-space infections in the oral and maxillofacial head and neck regions. One week before admission, due to pain in the right lower posterior teeth, the patient placed a cigarette butt dipped in the pesticide "Miehailin" into the "dental cavity" to relieve the pain. Within a week, the infection gradually spread bilaterally to the floor of the mouth, submandibular space, neck, chest, waist, back, temporal and other areas. The patient had difficulty breathing, swallowing and eating, and was transferred to our hospital as an emergency admission. Following admission, oral and maxillofacial surgeons immediately organized consultations with doctors in otolaryngology, thoracic surgery, general surgery, hematology, anesthesia and the intensive care unit to assist with treatment. The patient was treated with the highest level of antibiotics (vancomycin) and extensive abscess incision and drainage in the oral, maxillofacial, head and neck, chest and back regions. Unfortunately, the patient died of septic shock and multiple organ failure on the third day after admission.

CONCLUSION

Odontogenic infection can cause serious multi-space infections in the oral and maxillofacial head and neck regions, which can result in multiple LTCs. The management and treatment of LTCs such as multi-space infections should be multidisciplinary led by oral and maxillofacial surgeons.

Deep neck space infections: an upward trend and changing characteristics

PURPOSE

This study reviews our experience with deep neck space infections (DNIs) requiring surgical intervention, including cervical necrotizing fasciitis. The aim of the study was to identify predisposing and aggravating factors of the disease and recognize the possible factors that can lead to life-threatening complications and slow down the healing process.

METHODS

We compare the results to previous data from 1985 to 2005 to find possible alterations and changing trends. The characteristics of four lethal cases are described. This retrospective analysis includes patient data from 2004 to 2015 in tertiary referral hospital and in total, 277 patients were found.

RESULTS

Surgical drainage through a neck opening ± intraoral incision was made in 215 (77.6%) patients, an intraoral incision was only made in 62 patients (22.4%). ICU care was needed in 66 (23.8%) cases. Odontogenic etiology (44.8%) was the most common origin. The most common comorbidity was a psychiatric disorder and/or dementia and occurred in 55 (19.9%) patients. Patients with underlying illnesses were more likely to be admitted to the ICU (p = 0.020), required a longer ICU stay (p = 0.004) and repeated surgery (p = 0.009). Gas formation seemed to be predictive of a more severe course of infection. Early extraction of the odontogenic foci was related to a lower length of stay (LOS) (p = 0.039).

CONCLUSION

The annual numbers have risen from 14 to 24 cases per year when compared to previous data. DNIs remain a cause of lethal complications; the mortality was 1.4% and overall complications occurred in 61 (22.0%) patients.