A microbiological and clinical review of the acute dentoalveolar abscess

Odontogenic Cervicofacial Necrotizing Fasciitis: Microbiological Characterization and Management of Four Clinical Cases

Necrotizing fasciitis of the head and neck is a rare, very severe disease, which, in most cases, originates from odontogenic infections and frequently ends with the death of the patient. Rapid surgical intervention in combination with a preferably pathogen-specific antibiotic therapy can ensure patients’ survival. The question arises concerning which pathogens are causative for the necrotizing course of odontogenic inflammations. Experimental 16S-rRNA gene analysis with next-generation sequencing and bioinformatics was used to identify the microbiome of patients treated with an odontogenic necrotizing infection and compared to the result of the routine culture. Three of four patients survived the severe infection, and one patient died due to septic multiorgan failure. Microbiome determination revealed findings comparable to typical odontogenic abscesses. A specific pathogen which could be causative for the necrotizing course could not be identified. Early diagnosis and rapid surgical intervention and a preferably pathogen-specific antibiotic therapy, also covering the anaerobic spectrum of odontogenic infections, are the treatments of choice. The 16S-rRNA gene analysis detected significantly more bacteria than conventional methods; therefore, molecular methods should become a part of routine diagnostics in medical microbiology.

Treatment of odontogenic abscesses: comparison of primary and secondary removal of the odontogenic focus and antibiotic therapy

PURPOSE

To examine the time of removal of the odontogenic focus, antibiotic therapy and risk factors in odontogenic abscesses.

PATIENTS

From January 2012 to December 2015, inpatients undergoing incision due to odontogenic abscesses were identified in a retrospective study. All the patients were evaluated for time of removal of the odontogenic focus, antibiotic therapy, germ spectrum, complications and risk factors.

RESULTS

Two hundred ten patients completed the study. In 89 cases (42.4%), the odontogenic focus was removed as part of the abscess treatment (group A). In 121 cases (57.6%), the focus was secondarily removed (group B). On average, 2 ± 4 teeth were removed in group A, and 6 ± 5 teeth in group B (p < 0.0001). An average of 1.2 ± 0.4 surgical interventions were performed in group A, and 2 ± 0.2 operations in group B (p < 0.0001). Microbiological examination was positive in one-third of the cases (70 cases). Most commonly, streptococci (27%) were isolated. A resistance screening was possible in 57 of the detected germs (68.7%). In 89% of these patients, the combination of ampicillin-sulbactam was effective. The hospital stay was 4.8 ± 2 days for group A and 7.6 ± 3 days for group B (p < 0.0001). The clinical evaluation revealed 12 intermediate (5.7%) and three long-term (1.4%) complications. The long-term complications included a recurrence in two cases (1%) and an osteomyelitis in one case (0.5%). A logistic regression analysis identified no significant risk factor in relation to these complications.

CONCLUSION

The study shows that a primary removal of the odontogenic focus may have advantages over a secondary removal: (1) fewer operations, (2) shorter hospital stay and (3) shorter antibiotic therapy. Broad-spectrum penicillins in combination with beta-lactamase inhibitors are a possible, sufficient antibiotic regimen. Long-term complications are rare. No risk factors are identified in relation to these complications.

Oral antibiotic prescribing by NHS dentists in England 2010-2017

Introduction Dentists prescribe a significant proportion of all antibiotics, while antimicrobial stewardship aims to minimise antibiotic-prescribing to reduce the risk of developing antibiotic-resistance and adverse drug reactions.Aims To evaluate NHS antibiotic-prescribing practices of dentists in England between 2010-2017.Methods NHS Digital 2010-2017 data for England were analysed to quantify dental and general primary-care oral antibiotic prescribing.Results Dental prescribing accounted for 10.8% of all oral antibiotic prescribing, 18.4% of amoxicillin and 57.0% of metronidazole prescribing in primary care. Amoxicillin accounted for 64.8% of all oral antibiotic prescribing by dentists, followed by metronidazole (28.0%), erythromycin (4.4%), phenoxymethylpenicillin (0.9%), clindamycin (0.6%), co-amoxiclav (0.5%), cephalosporins (0.4%) and tetracyclines (0.3%). Prescriptions by dentists declined during the study period for all antibiotics except for co-amoxiclav. This increase is of concern given the need to restrict co-amoxiclav use to infections where there is no alternative. Dental prescribing of clindamycin, which accounted for 43.9% of primary care prescribing in 2010, accounted for only 14.6% in 2017. Overall oral antibiotic prescribing by dentists fell 24.4% as compared to 14.8% in all of primary care.Conclusions These data suggest dentists have reduced antibiotic prescribing, possibly more than in other areas of primary-care. Nonetheless, opportunities remain for further reduction.

Antibiotic sensitivity and resistance of bacteria from odontogenic maxillofacial abscesses

Objectives

This study investigated the types and antibiotic sensitivity of bacteria in odontogenic abscesses.

Materials and Methods

Pus specimens from 1,772 patients were collected from affected areas during incision and drainage, and bacterial cultures and antibiotic sensitivity tests were performed. The number of antibiotic-resistant bacteria was analyzed relative to the total number of bacteria that were tested for antibiotic susceptibility.

Results

Bacterial cultures from 1,772 patients showed a total of 2,489 bacterial species, 2,101 gram-positive and 388 gram-negative. For penicillin G susceptibility tests, 2 out of 31 Staphylococcus aureus strains tested showed sensitivity and 29 showed resistance. For ampicillin susceptibility tests, all 11 S. aureus strains tested showed resistance. In ampicillin susceptibility tests, 46 out of 50 Klebsiella pneumoniae subsp. pneumoniae strains tested showed resistance.

Conclusion

When treating odontogenic maxillofacial abscesses, it is appropriate to use antibiotics other than penicillin G and ampicillin as the first-line treatment.

The pathogenic microbial flora and its antibiotic susceptibility pattern in odontogenic infections

Suppurative head and neck infections of odontogenic origin are the most frequent type of head and neck infections. According to the literature, 7-10% of all antibiotics are currently prescribed for their treatment. Since penicillin was invented, the overall antibiotic sensitivity and resistance pattern of the isolated pathogenic microflora has continuously changed. The response of microorganisms to antibiotics and the development of resistance to their action is a purely evolutive process characterized by genetic mutations, acquisition of genetic material or alteration of gene expression and metabolic adaptations. All this makes challenging and difficult the correct choice of empirical antibiotic treatment for head and neck space infections even today. The aim of this paper was to evaluate the literature and to evidence the most frequent locations of odontogenic head and neck infections, the dominant pathogenic microbial flora, the genetic mutations and metabolic changes necessary for bacteria in order to aquire antibiotic resistance and as well its susceptibility and resistance to common antibiotics. We also aimed to highlight the possible changes in bacterial resistance to antibiotics over time, and to assess whether or not there is a need for fundamental changes in the empirical antibiotic treatment of these infections and show which these would be.

Institutional microbial analysis of odontogenic infections and their empirical antibiotic sensitivity

Most purulent orofacial infections are of odontogenic origin. It is well established that odontogenic infections are polymicrobial in nature. Empiric antibiotics were administered before the culture and sensitivity test results were obtained and specific antibiotics were administered based on the culture and sensitivity test results. But resistance was a challenging problem all throughout along with development of more virulent strains of microorganisms which were more infectious and resistant to many known antibiotics.

Objective

To identify the causative aerobic and anaerobic micro-organisms responsible for orofacial infections and to evaluate the resistance against empirical antibiotics used in the treatment of space infections.

Method

142 patients with head and neck fascial space infections of odontogenic origin were randomly taken, the pus samples and aspirates were collected aseptically from patients for aerobic and anaerobic microbiological study.

Results

In this study the most common aerobic organism isolated was streptococcus viridians (34.49%), most common anaerobe was peptostreptococci, (61.11%) and the most common mixed organism was streptococcus with peptostreptococci (30%). Amoxicillin was the most commonly used empirical drug in all cases and showed highest resistance (96.55%) for all the organisms. But linezolid (100%) was sensitive to all the aerobic, anaerobic and mixed group of organisms. Metronidazole (100%) turned out to be sensitive to the entire anaerobic group. Clindamycin (100%) appeared sensitive to the entire aerobic group.

Conclusion

Knowledge about the pathologic flora involved in head and neck infection in a locality and their sensitivity and resistance to commonly used antibiotics will help the clinician in administering appropriate antibiotics.

Odontogenic orbital abscess with intracranial and pulmonary involvement

A 58-year-old woman presented to the emergency department with left ptosis and complete ophthalmoplegia. Imaging demonstrated a left orbital abscess. Her past medical history included cavitatory lung disease and "aseptic" meningitis 2 months previously. An anaerobic organism and commensal of the oral flora, Peptostreptococcus sp., was cultured from the orbital abscess. The patient was found to have a carious upper molar with chronic buccal abscess, which was extracted. This case presents an uncommon pathogen arising from an odontogenic infection as the etiology for orbital abscess, cavitatory lung disease, and meningitis in one patient.

The Assessment of Oral Microflora Exposed to 3% Ethanolic Extract of Brazilian Green Propolis Preparation Used for Hygiene Maintenance following Minor Oral Surgeries

The aim of this study was to investigate the influence of a topically administered hygienic preparation containing a 3% ethanolic extract of Brazilian green propolis (EEP-B) on oral microflora spectrum changes in a group of patients who underwent common oral surgery procedures. Two gel samples were compared: the tested gel containing an active ingredient, that is, a 3% EEP-B (gel GA), and a placebo as the negative control (gel GC). The collection of microbiological material included 14 patients requiring surgical extraction of wisdom molars and short endosseous implant installation. Clinical examinations were carried out as follow-up, that is, baseline and after 5-6 weeks' time. During the first and subsequent assessment, swabs were taken from the mucosal surface. The number of microorganism species was found to have increased following the application of GC gel over the period of 5-6 weeks. This mainly affected Gram-positive rods and bacilli as well as Gram-negative rods. Application of the GA gel enriched with 3% EEP-B caused a profound reduction in the amount of Neisseria spp. and Bifidobacterium spp. strains. Elimination of seven species of microorganisms was observed: Streptococcus acidominimus, Streptococcus oralis, Staphylococcus epidermidis, Veillonella parvula, Bifidobacterium breve, Bifidobacterium longum, and Lactobacillus acidophilus.

The clinical relevance of microbiology specimens in head and neck space infections of odontogenic origin

It is common surgical practice to take a specimen for microbial culture and sensitivity when incising and draining infections of odontogenic origin in the head and neck. We aimed to find out if routine testing has any therapeutic value. We retrospectively studied 90 patients (57 male and 33 female) admitted to Northampton General Hospital for treatment of odontogenic infections, and reviewed admission details, antimicrobial treatment, microbiological findings and their sensitivity or resistance, and complications. Specimens were sent from 72 (80%) patients of which 61 (85%) were infected. The most commonly isolated organism was Streptococcus viridans. Interim reports were published after a mean of 3 days (range 1-4), and 94% of patients were discharged within a mean of 2 days (range 0-9) postoperatively. Almost 95% of patients were discharged before results were available, and there were no reported complications. We therefore suggest that microbial culture has little therapeutic value in the management of these patients. With culture and sensitivity tests costing £25 - £30, omission of this practice in the case of uncomplicated (single tissue space) odontogenic infections could save resources in the National Health Service without affecting the care of patients.

Antibiotic prophylaxis during dental procedures in patients with in situ lower limb prosthetic joints

The average age of patients presenting for total joint arthroplasty is decreasing. The number of primary and revision arthroplasty procedures performed in the UK, Europe and USA is increasing annually. As number of procedures performed increases, the life expectancy of our patients and therefore the in vivo duration of prosthetic joints increase, and the potential for complications such as infection increases. One potential source for this is bacterial dissemination during dental surgery. Many attempts have been made to address this issue in the form of national guidelines, but there is no clear consensus on antibiotic prophylaxis before these procedures in order to decrease the risk of prosthetic joint infection. This continues to be an area of indecision and uncertainty resulting in patients having delays in their treatment while decisions are made by oral and orthopaedic surgeons about prophylactic antibiotic use. This article reviews the existing national guidelines, highlighting the current views and issues surrounding this subject, and a critical appraisal of current evidence for the use of prophylactic antibiotics in this patient population is presented. We will also review the response in literature to the 2009 American Academy of Orthopaedic Surgeons information statement release on antibiotic prophylaxis in joint arthroplasty patients undergoing dental procedures.

Evaluation of bacterial spectrum of orofacial infections and their antibiotic susceptibility

Introduction:

The inappropriate use of antibiotics has contributed to a worldwide problem of antimicrobial resistance. The objective of present study is to assess the most common microorganisms causing orofacial infections and their antimicrobial susceptibility to routinely used antibiotics in this part of India.

Materials and Methods:

Sixty eight patients with orofacial infection were selected on the basis of a series of predefined inclusion and exclusion criteria. Samples were collected under aseptic conditions and subjected to culture and antibiotic susceptibility testing. Descriptive statistics were provided.

Results:

A total of 64 aerobic and 87 anaerobic strains were isolated. The predominant bacteria were Streptococci viridans (64%), Prevotella (43%), Peptostreptococcus (26%), Porphyromonas (7%), and Fusobacterium (14%). The isolated strains seemed to be highly sensitive to the routinely used antibiotics such as amoxicillin – clavulanate and amoxicillin alone, clindamycin, and levofloxacin. In contrast, more resistance to erythromycin was observed.

Conclusion:

Amoxicillin still possesses powerful antimicrobial activity against major pathogens in orofacial odontogenic infections. Amoxicillin/clavulanate and clindamycin would also be advocated as being useful alternatives for the management of severe orofacial infections. However, the findings of this study indicate that erythromycin is of questionable benefit in the treatment of severe orofacial odontogenic infections.

Should patients with hip joint prosthesis receive antibiotic prophylaxis before dental treatment?

The safety committee of the American Academy of Orthopedic Surgeons (AAOS) recommended in 2009 that clinicians should consider antibiotic prophylaxis for all patients with total joint replacement before any invasive procedure that may cause bacteremia. This has aroused confusion and anger among dentists asking for the evidence. The present review deals with different aspects of the rationale for this recommendation giving attention to views both in favor of and against it.

The role of phenoxymethylpenicillin, amoxicillin, metronidazole and clindamycin in the management of acute dentoalveolar abscesses--a review

Antibiotics are the most widely prescribed category of drugs issued on prescription by general dental practitioners. Despite this there remains little evidence-based literature on what should be prescribed for any given clinical situation, at what dosage and for how long. Given the current climate of evidence-based research, the need to keep antibiotic prescribing to an acceptable minimum, increasing levels of resistance of micro-organisms and widespread hospital infections with 'superbugs', there is a distinct need for appropriate prescribing guidelines. Considering best practice, an extensive review of the literature and a thorough understanding of current empirical treatment regimes, an attempt has been made to recommend suitable antibiotic prescribing for the adult patient suffering from acute dentoalveolar infections based on evidence.

Eight-year retrospective study of odontogenic origin infections in a postgraduation program on oral and maxillofacial surgery

PURPOSE

Infections are one of the most commonly found conditions in oral and maxillofacial surgery practice. They always represent a risk to patients regardless of whether they are of odontogenic origin or not, and if not treated at an early stage they may rapidly evolve and spread to adjacent anatomical structures, leading to serious complications and, occasionally, to death. For this reason, the objective of this study was to retrospectively analyze data from patients with infections attended by the Department of Oral and Maxillofacial Surgery of the Piracicaba Dental School at the State University of Campinas-Unicamp.

PATIENTS AND METHODS

In accordance with date and inclusion criteria, sampling comprised 210 patient reports from January 1999 to March 2007. Patients' demographic data reviewed were gender, age, signs and symptoms, facial spaces affected, and therapy adopted.

RESULTS

The mean age of patients was 30 years old (SD = 16.6), and the main origin of infections was odontogenic (79.31%); principal signs and symptoms were trismus (43.33%), fever (28.10%), and dysphagia (25.24%). The main facial spaces affected were the buccal mandibular space (50.00%), submandibular space (31.90%), and buccal maxillary space (19.05%). Surgical drainage was carried out in 46.67% of cases, and 10.95% of these interventions were performed under general anesthetic. Only 3 of all patients developed complications.

CONCLUSIONS

Infection patients were basically young adults; no predisposition concerning gender or race was detected. The therapeutic protocol adopted presented very positive results, with a small number of complications.

The microbiology of the acute dental abscess

The acute dental abscess is frequently underestimated in terms of its morbidity and mortality. The risk of potential serious consequences arising from the spread of a dental abscess is still relevant today with many hospital admissions for dental sepsis. The acute dental abscess is usually polymicrobial comprising facultative anaerobes, such as viridans group streptococci and the Streptococcus anginosus group, with predominantly strict anaerobes, such as anaerobic cocci, Prevotella and Fusobacterium species. The use of non-culture techniques has expanded our insight into the microbial diversity of the causative agents, identifying such organisms as Treponema species and anaerobic Gram-positive rods such as Bulleidia extructa, Cryptobacterium curtum and Mogibacterium timidum. Despite some reports of increasing antimicrobial resistance in isolates from acute dental infection, the vast majority of localized dental abscesses respond to surgical treatment, with antimicrobials limited to spreading and severe infections. The microbiology and treatment of the acute localized abscess and severe spreading odontogenic infections are reviewed.

Deep space neck infection: principles of surgical management

Knowledge of the management of infections of the deep spaces of the neck is essential to the daily practice of oral and maxillofacial surgery. Timely decisions must be made through the acute course of the disease. Interventions must be performed with the appropriate surgical skill. The surgeon must decide on medical and surgical management, including antibiotic selection, how to employ supportive resuscitative care, when to operate, what procedures to perform, and how to secure the airway. To make these decisions the surgeon must understand the anatomy of the region and the etiology of infection, appropriate diagnostic workup, and medical and surgical management. This article provides a review of these pertinent topics.

Penicillin compared with other advanced broad spectrum antibiotics regarding antibacterial activity against oral pathogens isolated from odontogenic abscesses

OBJECTIVES

We examined the spectrum of oral pathogens found in odontogenic abscesses and their susceptibility to penicillin as well as to amoxicillin with clavulanic acid, doxycycline, clindamycin and moxifloxacin. The in vitro results were compared with clinical observations.

PATIENTS AND METHODS

One hundred and eighty eight swabs were obtained from 94 patients with odontogenic abscesses. Bacterial strains were isolated for susceptibility tests. The same patients were investigated for their clinical outcome after standard therapy.

RESULTS

A total of 517 bacterial strains were isolated from 94 patients. Ninety eight per cent of abscesses were polymicrobial. The most prevalent bacteria were Viridans streptococci representing 54% of the aerobic/facultative anaerobic bacteria. Prevotella spp. comprised 53% of the anaerobes. No multiresistant strains were detected. Susceptibility testing revealed a sensitivity of over 99% of aerobes/facultative aerobes and 96% of anaerobes sensitivity for moxifloxacin. The corresponding values for penicillin were lowest at 61% and 79%, respectively. In the clinical collective, patients with minor abscesses and no risk of further progression received surgical treatment without antibiotics (36%). Penicillin was administered additionally in 30%. Amoxicillin with clavulanic acid was given in 18% and clindamycin in 15%. Ninety two of the 94 patients showed significant recovery with the described treatment. Only in two cases was a change to the latest broader spectrum antibiotics necessary.

CONCLUSION

In contrast to the moderate in vitro results, penicillin successfully treated the pathogens derived from odontogenic abscess sufficiently when adequate surgical treatment was provided. One third of the patients was treated successfully with incision and drainage only. We suggest that one good reason for its clinical efficacy is the susceptibility of the dominant aerobe/facultative aerobe and anaerobe strains to penicillin.

In vitro susceptibility of the Streptococcus milleri group to antimicrobial peptides

AIM

To determine the susceptibility of strains of the Streptococcus milleri group (SMG) to commercially available antimicrobial peptides.

METHODOLOGY

Thirty strains of SMG from a range of sources were assessed for their susceptibility to 10 antimicrobial peptides of either human, animal or insect origin, using a double layer diffusion assay.

RESULTS

The majority of the test strains were sensitive to the amidated peptides, mastoparan (100%; n = 30), magainin 2 amide (95%; n = 21) and indolicin (91%; n = 23). Some strains were susceptible to cecropin B (30%; n = 30) and histatin (10%; n = 30), whilst no activity was observed for the defensins HNP-1 and HNP-2, histatin 8, cecropin P1 and magainin 2.

CONCLUSIONS

The majority of strains were resistant to the human derived peptides. The ability to resist such peptides may be a factor in the colonisation of the oral cavity and the survival and initiation of infection in the pulp and root canal environment. Interestingly, the present study indicated that amidated and alpha helical peptides exhibit antimicrobial activity against SMG. Structural modification of these peptides may allow a targeted approach for the development of these substances as preventative or therapeutic agents.

Referred otalgia: a structured approach to diagnosis and treatment

Many patients who present with otalgia have a normal otological examination, and a distant source of pain must be considered. The ear receives an extensive sensory innervation arising from six nerve roots. Many other structures in the head, neck and thorax share a common neuronal pathway with the ear, and these tissues represent the possible sites of disease in the cases of referred otalgia. Consequently, the differential diagnosis is extensive and varied. Making an accurate diagnosis relies on an understanding of the complex distribution of nerve fibres and a structured approach to patient assessment. This article aims to classify the aetiology of referred otalgia and to outline current treatments for these conditions. The origins of referred otalgia may be as remote as the cranial cavity and thorax; however, dental disease, tonsillitis, temporomandibular joint disorders and cervical spine pathology represent the most frequent causes. Ear pain may also be the first sign of a head and neck malignancy. Patients complaining of otalgia, with risk factors for an aerodigestive neoplasm, and a normal ENT examination require an urgent otolaryngological opinion.

Osseous Coagulum Collected in Bone Traps: Potential for Bacterial Contamination and Methods for Decontamination

Because of its excellent osteogenic potential, autogenous bone is the preferred grafting material for dental procedures; however, bone collected in osseous coagulum traps is subject to contamination by oral bacteria. This study assessed bacterial contamination of osseous coagulum and tested treatments for reducing contamination. Fifty bone samples from patients undergoing implant osteotomy procedures were collected in osseous coagulum traps, divided into groups of 10, and rinsed with normal saline, 0.12% chlorhexidine, or 50 mg/mL tetracycline. Twenty control samples received no treatment. The bone samples were plated in triplicate on selective and differential media to assay aerobic and anaerobic bacteria and potential bacterial pathogens, including staphylococci, streptococci, enterics, and black-pigmented bacteria (BPB). Inoculations were performed with an Autoplate 4000, and plates were incubated at 37 degrees C either aerobically or in a Coy anaerobic chamber. Bacteria were isolated from all samples. In control samples, the mean colony-forming units (cfu) per milliliter of suspended osseous coagulum was 6.5 x 10(4) +/- 9.6 x 10(4) in aerobic cultures and 4.8 x 10(4) +/- 6.9 x 10(4) in anaerobic cultures. Viridans streptococci were isolated from 46 samples, with a mean of 2.9 x 10(4) +/- 4.1 x 10(4) cfu/mL. Enterics were in 16 samples with cfu ranging from 200 cfu/mL to 3.4 x 10(4) cfu/mL. Mannitol nonfermenting staphylococci were found in one sample at 106 cfu/mL. BPB were not isolated. A Mann-Whitney U test with significance set at P = .05 determined that the only statistically significant reductions in bacterial numbers occurred in tetracycline-treated samples of anaerobic bacteria (5-fold decrease, P = .02) and aerobic bacteria (6-fold decrease, P = .01). Tetracycline treatments effected a 7-fold decrease in streptococci, but the difference was not significant (P = .07). These data indicate significant bacterial contamination of bone collected in osseous coagulum traps and justify further research into methods for eliminating that contamination.

Clindamycin versus Unasyn in the treatment of facial cellulitis of odontogenic origin in children

The study was undertaken to characterize the microbiology of dental abscesses in children and to compare clindamycin and ampicillin/sulbactam in the treatment of facial cellulitis of odontogenic origin. Sixty children with acute facial cellulitis of dental origin underwent surgery (extraction or root canal procedure) within 24 hours of presentation. Pus samples were cultured aerobically and anaerobically. Patients were randomized (1:1) to receive intravenous ampicillin/sulbactam or clindamycin for 48 hours followed by oral amoxicillin/clavulanate or clindamycin for 7 days. A total of 211 bacterial isolates were recovered from 54 samples. The most common aerobic and facultative organisms were viridans streptococci, Neisseria, and Eikenella species. Among anaerobes, Prevotella and Peptostreptococcus species were the most frequent. No treatment failure occurred in either group. Dental abscesses in children are polymicrobial aerobic/anaerobic infections. Treatment of complicated dental infections with ampicillin plus a beta-lactamase inhibitor or clindamycin in combination with surgical drainage is very effective.

Microbiology and antibiotic sensitivities of head and neck space infections of odontogenic origin

PURPOSE

The purpose of this study is to assess the anatomical spaces and causative micro-organisms responsible for deep fascial space head and neck infections and evaluate the resistance of antibiotics used in the treatment of these infections.

PATIENTS AND METHODS

A 6-year retrospective study evaluated hospital records of 103 patients. All patients in this study underwent surgical incision and drainage, received IV antibiotics, and had culture and sensitivity performed. Patient demographics reviewed were gender, age, involved fascial space(s), micro-organisms identified and antibiotic resistance from culture and sensitivity testing.

RESULTS

There were 56 male (54%) and 47 (46%) female patients. The submandibular space was the most frequent location for a single space abscess (30%), followed by the buccal space (27.5%) and the lateral pharyngeal space (12.5%). Sixty-three patients presented with multiple space involvement, totaling 142 spaces involved. A total of 269 bacterial strains were isolated from 103 patients. The bacteria were found to be 63.5% gram-positive. Gram-positive cocci were isolated 57.7% of specimens and gram-negative rods were isolated in 33% of cultures. There were 178 aerobes (65.7%) and 91 anaerobes (34.3%) isolated. The most common bacteria isolated were Viridans streptococci, Provetella, Staphylococci, and Peptostreptococcus. Culture and sensitivities were reviewed on 101 patients.

CONCLUSION

Patients who underwent surgical incision and drainage in the operating room had a tendency for involvement of multiple space abscesses with the submandibular space, submental, and lateral pharyngeal spaces effected most frequently. Cultures and sensitivities commonly showed greater growth in aerobes (65.7%) than in anaerobes. Gram positive cocci and gram negative rods had the greatest growth percentage in cultures.

Severe odontogenic infections, part 1: prospective report

PURPOSE

The purpose of this study was to prospectively evaluate a series of patients with severe odontogenic infections (OI).

PATIENTS AND METHODS

In this study, 37 consecutive hospitalized patients with odontogenic infection were treated with intravenous penicillin (PCN) (unless allergic), and prompt incision and drainage. Standardized data collection included demographic, preadmission, time-related, preoperative, anatomic, treatment, microbiologic, and complications information. Appropriate descriptive statistics were computed.

RESULTS

The sample consisted of 37 subjects (38% female) with a mean age of 34.9 years. Three subjects (8%) had immunocompromising diseases. Caries was the most frequent dental disease (65%) and the lower third molar was the most frequently involved tooth (68%). Trismus and dysphagia were present on admission in over 70% of cases. The masticator, perimandibular (submandibular, submental, and/or sublingual), and peripharyngeal (lateral pharyngeal, retropharyngeal, and/or pretracheal) spaces were infected in 78%, 60%, and 43% of cases, respectively. Abscess was found in 76% of cases. PCN-resistant organisms were identified in 19% of all strains isolated and in 54% of patients with sensitivity data. PCN therapeutic failure occurred in 21% of cases and reoperation was required in 8%. Length of hospital stay was 5.1 +/- 3.0 days. No deaths occurred.

CONCLUSIONS

This study indicated that PCN resistance, resulting in PCN therapeutic failure, was unacceptably high in this sample. Alternative antibiotics, such as clindamycin, should be considered in hospitalized patients with OI. Masticator space infection occurred much more frequently than previously reported. Trismus and dysphagia should be appreciated as significant indicators of severe OI.

Autoaggregation and Coaggregation of Bacteria Associated with Acute Endodontic Infections

Biofilms and microbial aggregates are a common mechanism for the survival of bacteria in nature. Microbial aggregates have been associated with intraradicular and extraradicular endodontic disease. One objective of this study was to assess bacteria isolated from acute endodontic infections for autoaggregation and coaggregation. Another objective was to use both a conventional visual assay and a novel fluorescent dye-staining technique to study bacterial aggregation. Sixty-two strains of bacteria were isolated from 10 clinical samples of endodontic abscesses or cellulitis. Autoaggregation was detected in 35/62 (56.45%) of the bacteria using the visual assay. Coaggregation of bacteria from each of the samples was demonstrated for 29/183 (15.85%) bacterial pairs using the visual assay and 148/183 (80.87%) using the dye-staining assay. Coaggregation was observed for each of the 15 genera assayed, especially Prevotella, Streptococcus, and Fusobacterium. The dye-staining assay using a confocal microscope was a highly sensitive method to detect aggregation of bacteria.

Pharmaceutical prescribing for children. Part 3. Antibiotic prescribing for children with odontogenic infections

This paper is the third in a series on the prescribing of medicines for children by dentists working in primary care. It deals with antibiotics, which may be prescribed for infections arising from teeth, and reviews current best practice.

Clindamycin in dentistry: More than just effective prophylaxis for endocarditis?

Clindamycin is a broad-spectrum antibiotic with activity against aerobic, anaerobic, and beta-lactamase-producing pathogens. This antibiotic has been used for many years as prophylactic treatment during dental procedures to prevent endocarditis. However, the spectrum and susceptibility of the bacteria species involved in dental infections indicate that clindamycin would also be an effective treatment option for these conditions. In addition to its antiinfective properties, clindamycin has high oral absorption, significant tissue penetration, including penetration into bone, and stimulatory effects on the host immune system. This review discusses the microbiologic and clinical evidence supporting the efficacy and safety of clindamycin for the successful management of dental infections.

The clinical significance of anaerobic bacteria in acute orofacial odontogenic infections

A review of the literature on orofacial odontogenic infections indicates that the underlying microflora is typically polymicrobial, predominantly involving strictly anaerobic gram-positive cocci and gram-negative rods, along with facultative and microaerophilic streptococci. Although no single species has been consistently implicated in all of these infections, the pathogenic potential of some of these organisms has been documented by many studies. This potential can be explained by a number of virulence factors demonstrated in anaerobic bacteria, as well as by synergistic interrelationships with other members of the infectious flora. Awareness of the anaerobic component of orofacial odontogenic infections dictates to a large extent the selection of antimicrobial therapy, mainly because of the frequency of beta-lactamase production by anaerobic gram-negative rods.

Identification of the anginosus group within the genus Streptococcus using polymerase chain reaction

The aim of this study was to establish an identification method for the anginosus group within the genus Streptococcus by polymerase chain reaction (PCR). Using a primer pair based on the group-specific sequences of penicillin-binding protein 2B (pbp2b) gene, a 275-bp fragment was amplified from each species in the group but no size-matched products were obtained in other streptococci. Further identification in the species or subspecies level was possible by a multiplex PCR with primers for the 16S ribosomal RNA gene of Streptococcus anginosus, the hyaluronate lyase genes both of Streptococcus intermedius and Streptococcus constellatus subsp. constellatus, and the intermedilysin (ily) gene of S. intermedius. In the case ofStreptococcus constellatus subsp. pharyngis, the amplified fragment from the S. intermedius-type hyaluronate lyase gene was obtained, while that from the ily gene was not. These results also indicate that two different hyaluronate lyase genes are distributed among the anginosus group.

Balance of tumor necrosis factor alpha and interleukin-10 in a buccal infection in a streptozotocin-induced diabetic rat model

This study evaluates the local levels of proinflammatory cytokine, tumor necrosis factor alpha (TNF-alpha), and anti-inflammatory cytokine, interleukin-10 (IL-10), in an experimental buccal abscess of a diabetic rat model. We prepared a buccal cavity induced by injection of carrageenin in a diabetic rat (blood glucose, 460.6 +/- 54.7 mg/dl, mean +/- SE) induced by streptozotocin (STZ). The buccal abscess was formed by the direct inoculation of Streptococcus pyogenes S-8 (2 x 10(7) cfu) into the buccal cavity at day 5 after carrageenin injection. Cytokine levels in the exudate of the buccal abscess were measured by enzyme-linked immunosorbent assay for 48 h after infection. Bacterial counts, weighing of exudate, and histological analysis were also performed. The mean TNF-alpha levels in the buccal abscess exudate of the diabetic group, which were generally higher than those of the control group, tended to increase over time until 48 h after infection, while the TNF-alpha levels in the control group peaked at 24 h after infection and then decreased. The IL-10 levels in the diabetic group remained almost unchanged until 48 h after infection, while the IL-10 levels in the control group were significantly higher than in the diabetic group at 12-24 h after infection. The mean ratio of TNF-alpha to IL-10 levels was 1.17-1.67 in the diabetic group, which was higher than the 0.26-0.69 of the control group. The bacterial counts in the buccal abscess and the weight of exudate were significantly higher in the diabetic group compared to the control group at 36-48 h. Histological findings showed that inflammatory cell infiltration was remarkable in the diabetic group compared to that of the control group. These results suggest that the elevated proinflammatory TNF-alpha levels and decreased anti-inflammatory IL-10 levels, which are produced at local infection sites, may at least in part be related to the severity of inflammation in this rat model with diabetes induced by STZ.

Apical periodontitis development and bacterial response to endodontic treatment. Experimental root canal infections in monkeys with selected bacterial strains

In six monkeys, 160 root canals were inoculated with a combination of four bacterial strains belonging to species Streptococcus milleri, Peptostreptococcus anaerobius, Prevotella oralis, and Fusobacterium nucleatum. In two other monkeys, 24 root canals were inoculated with a five-strain combination consisting of these strains and a strain of Enterococcus faecalis. All strains were previously isolated from an infected monkey root canal. After 8-12 months, survival of the strains was recorded bacteriologically, and the reaction in the periapical region was radiographed. From 180 of 184 root canals, one or more of the bacterial strains were reisolated. The two facultative strains were more frequently reisolated than the anaerobic strains. Apical periodontitis was registered in the periapical region of more than 96% of root canals with reisolated bacteria but in none of those without reisolated bacteria. Endodontic treatment was carried out in two sessions with an interval of 14 d without interappointment dressings, and the effect was evaluated bacteriologically before and after each treatment. The chemo-mechanical treatment reduced significantly the number of strains and bacterial cells. The facultative bacteria were more resistant to the treatment than the anaerobic bacteria. The five-strain combination had a higher survival rate than the four-strain combination.

The microbial synergy of Peptostreptococcus micros and Prevotella intermedia in a murine abscess model

This study characterized the microbial interaction of Peptostreptococcus micros and Prevotella intermedia, the major pathogens of dentoalveolar infection, using a murine model. Subcutaneous injection of P. micros cells in the dorsum of the mouse together with living cells of P. intermedia resulted in a significantly larger abscess when compared with single injection of the organisms (P < 0.02). The abscess size was also significantly increased (P < 0.05) when the plate-cultured cell suspension of P. micros was injected into mouse with the culture filtrate of P. intermedia. The heat-treated culture filtrate of P. intermedia also enhanced the virulence of P. micros. P. micros culture filtrate did not affect the virulence of P. intermedia. Interestingly, the virulence of P. micros appeared to be enhanced even when the culture filtrate of P. intermedia was injected at separate sites in the mouse. These results suggest that a heat-stable product or products of P. intermedia increase the virulence of P. micros indirectly by altering the host condition, whereas living cells of P. micros can directly enhance virulence of P. intermedia.

Identification of bacteria in acute endodontic infections and their antimicrobial susceptibility

OBJECTIVE

The purpose of the study was to identify the bacterial composition of the microbiota from acute endodontic abscesses/cellulitis and their antimicrobial susceptibilities.

STUDY DESIGN

Purulence from 17 patients with acute endodontic abscesses/cellulitis was obtained by needle aspiration and processed under anaerobic conditions. Bacteria were isolated and identified by biochemical or molecular methods. The antimicrobial susceptibility of isolated bacteria was determined by using the Etest.

RESULTS

All 17 aspirates contained a mix of microorganisms. A total of 127 strains of bacteria were isolated. Of 127 strains, 80 strains were anaerobes and 47 strains were aerobes. The mean number of strains per sample was 7.5 (range, 3 to 13). The average number of viable bacteria was 6.37 x 10(7) (range, 10(4) to 10(8)) colony-forming units/mL. Strict anaerobes and microaerophiles were the dominant bacteria in 82% (14 of 17) of the cases. The genera of bacteria most frequently encountered were Prevotella and Streptococcus. Prevotella and Peptostreptococcus were frequently found to dominate the mixture. The combination of Prevotella and Streptococcus was found in 53% (9 of 17). The previously reported uncultured Prevotella clone PUS9.180 was frequently identified. The percentage of bacteria susceptible/intermediate for each antibiotic in this study was penicillin V, 81% (95 of 118); metronidazole, 88% (51 of 58); amoxicillin, 85% (100 of 118); amoxicillin + clavulanic acid, 100% (118 of 118); and clindamycin, 89% (105 of 118).

CONCLUSIONS

The present results confirm the existence of mixed infection with the predominance of anaerobic bacteria in acute endodontic abscesses/cellulitis. The frequency of uncultured Prevotella clone PUS9.180 suggests the possible key role of this Prevotella species in acute endodontic infections. Penicillin V still possesses antimicrobial activity against the majority of bacteria isolated from acute endodontic infections. However, if penicillin V therapy has failed to be effective, the combination of penicillin V with metronidazole or amoxicillin with clavulanic acid is recommended. Switching to clindamycin is another good alternative.

Endodontics in the adult patient: the role of antibiotics

OBJECTIVES

The aim of this study was to review the published work on the indications and efficacy for antibiotics in endodontic therapy.

DATA SOURCES

Published works in the medical and dental literature.

STUDY SELECTION

Evaluation of published clinical trials in endodontic and other pertinent literature.

CONCLUSIONS

Antibiotics are not routinely indicated in the practice of endodontics. Therapeutic antibiotics may be required as an adjunct to operative treatment when there is pyrexia and/or gross local swelling; they are only rarely indicated in the absence of operative intervention. Prophylactic antibiotics may be required for certain patients who are susceptible to serious infective sequaelae.

The virulence of mixed infection with Streptococcus constellatus and Fusobacterium nucleatum in a murine orofacial infection model

Orofacial infections are usually polymicrobial, and it is the microbial interactions of pathogenic species that cause tissue destruction. In this study, the microbial interaction between Streptococcus constellatus and Fusobacterium nucleatum was characterized using a murine orofacial infection model. A mixture of viable S. constellatus and F. nucleatum cells (both 2 x 10(8) CFU/mouse) was injected into the submandible; as a result, all of the test mice died. In contrast, none of the experimental animals monoinjected with either S. constellatus or F. nucleatum died (P<0.001), indicating that the synergism between the two resulted in the virulence. When a mixture of viable S. constellatus cells and a culture filtrate of F. nucleatum was tested, lethality and the bacterial cell count per lesion were significantly enhanced as compared with monoinjections (P<0.02). However, the virulence of F. nucleatum was not enhanced by infection of a culture filtrate of S. constellatus. The enhancement of virulence was observed even when viable S. constellatus cells and the culture filtrate of F. nucleatum were injected at separate sites. Heat treatment of the culture filtrate of F. nucleatum did not affect the enhancement. These results indicate that a heat-stable substance(s) produced by F. nucleatum contributes to the microbial synergy of S. constellatus and F. nucleatum in orofacial infections.

Antibiotic prescribing by general dental practitioners in the Greater Glasgow Health Board, Scotland

OBJECTIVE

To investigate antibiotic prescribing patterns by general dental practitioners (GDPs) in the Greater Glasgow Health Board Area, Scotland.

STUDY DESIGN

A 10% sample of prescriptions were selected at random from 35,545 prescriptions written by GDPs over a 6-month period.

MAIN OUTCOME MEASURES

Absolute and relative frequencies were used to describe the different classes of antibiotics used and the variations in prescribing practice.

RESULTS

GDPs prescribed a wide range of antibiotics. Seventeen different antibiotics were prescribed with amoxycillin, metronidazole and penicillin V accounting for almost 90% of the prescriptions. In general the antibiotics were prescribed at the British National Formulary (BNF) recommended doses. There were, however, wide variations in the frequencies and durations of the prescriptions for all antibiotics.

CONCLUSIONS

The present study provides evidence of sub-optimal prescribing of antibiotics by dentists in Scotland, with considerable variation from the recommended frequencies and doses.

A study of therapeutic antibiotic prescribing in National Health Service general dental practice in England

OBJECTIVE

To study the therapeutic prescribing of antibiotics by general dental practitioners.

DESIGN

A postal questionnaire of National Health Service general dental practitioners in ten English Health Authorities.

SUBJECTS

General dental practitioners (1,544) contracted to provide NHS treatment in the Health Authorities of Liverpool, Wirral, Oxfordshire, Buckinghamshire, Nottingham, North Nottinghamshire, Sheffield, Newcastle, Northumberland and North Tyneside.

MAIN OUTCOME MEASURES

The questionnaires were analysed and the responses to each question expressed as absolute frequencies.

RESULTS

Responses to the questionnaire were received from 929 (60.1%) practitioners. More than 95% of practitioners recognised the need for prescribing antibiotics where there was evidence of spreading infection. Some practitioners (12.5%) prescribed antibiotics for acute pulpitis and (3.3%) for chronic marginal gingivitis. Antibiotics were prescribed by practitioners before drainage of acute abscesses (69%) and by 23% after drainage. Practitioners were generally not influenced by patient's expectations of receiving antibiotics (92%), but would prescribe when under pressure of time (30.3%), if they were unable to make a definitive diagnosis (47.3%), or if treatment had to be delayed (72.5%). Amoxicillin was the most frequently prescribed antibiotic used for most clinical conditions apart from pericoronitis, acute ulcerative gingivitis and dry sockets where metronidazole was the drug of choice. There was a wide variety of dosage, frequency and duration for all the antibiotics used in the treatment of acute dental infections.

CONCLUSIONS

The results obtained from this questionnaire support the conclusion that the therapeutic prescribing of antibiotics in general dental practice varies widely and is suboptimal. There is a clear need for the development of prescribing guidelines and educational initiatives to encourage the rational and appropriate use of the antibiotics in National Health Service general dental practice.

Periodontic-endodontic lesions

Lesions of the periodontal ligament and adjacent alveolar bone may originate from infections of the periodontium or tissues of the dental pulp. This review focuses on the relationship of lesions of endodontic origin with lesions of periodontal origin and their classification.

Abscess forming ability of streptococcus milleri group: synergistic effect with Fusobacterium nucleatum

The abscess forming abilities of "Streptococcus milleri" strains (Streptococcus constellatus, Streptococcus anginiosus, and Streptococcus intermedius) isolated from dentoalveolar abscesses and the synergistic effect of Fusobacterium nucleatum co-inoculated with the isolates were examined on a mouse subcutaneous abscess model. Five days after inoculation, all S. milleri strains formed abscesses, which showed less pathological spread to surrounding connective tissues than those formed by Staphylococcus aureus 209P strain and were similar to those by F. nucleatum ATCC25586. When each S. milleri strain and F. nucleatum were co-inoculated, abscess sizes and each bacterial number recovered from abscesses increased in comparison to those treated by bacterial mono-inoculation of each S. milleri strain or F. nucleatum alone. The strongest synergistic effect was observed in the combination of S. constellatus and F. nucleatum. In a time course experiment with this combination, the recovery of S. constellatus subsequently decreased after the decrement of F. nucleatum, and it appeared that the association with F. nucleatum maintained the bacterial number of S. constellatus in the abscess. The cell-free supernatant of F. nucleatum had a tendency to increase the abscess size caused by S. constellatus in this model. When S. constellatus was cultured with F. nucleatum culture supernatant in vitro, growth enhancement in the early phase was observed. Furthermore, the phagocytic killing of S. constellatus by human polymorphonuclear leukocytes (PMNs) was significantly suppressed and the PMN membranes appeared to be injured by addition of the F. nucleatum culture supernatant. These results suggest that the pathogenicity of S. milleri strains in odontogenic infections may be enhanced by the co-existence of F. nucleatum.

Hyaluronidase activity in human pus from which Streptococcus intermedius was isolated

Hyaluronidase (HAase) activity was detected in both a human pus sample and the culture supernatant of the only bacterial isolate from the pus, Streptococcus intermedius, using a zymographic technique. The optimum pH range for HAase activity was similar for both samples. Although the bands showing the strongest HAase activity of these samples differed from each other with respect to molecular size, both samples were equally inhibited by an antiserum raised against HAase of S. intermedius. These results suggest that S. intermedius may produce HAase in vivo as well as in vitro, and that this enzyme and/or its fragments may play an important role in host tissue degradation.

Tooth loss due to periodontal abscess: a retrospective study

This retrospective study focused on the frequency of tooth loss due to periodontal abscess among 42 patients who were treated by a single clinician over a 5- to 29-year period. A total of 114 patients were selected from the active periodontal recall schedule of a single periodontist at The University of Iowa College of Dentistry. The criteria for inclusion in the study included having a history of moderate to advanced periodontitis, being on 3 to 6 month recall periodontal maintenance care, and completion of active periodontal therapy prior to October 1987. Other parameters evaluated were age; gender; number of teeth present and missing at the initial, reevaluation, and last periodontal recall visit; initial periodontal prognosis; furcation involvement; non-surgical and surgical periodontal therapy; and reasons for tooth loss. Patients were grouped according to the number of teeth lost following active periodontal treatment into well-maintained (0 to 3), downhill (4 to 9), and extreme downhill (10 to 23) groups. Forty-two of the 114 patients were identified as having one or more periodontal abscesses. A total of 109 teeth were affected by periodontal abscess of which 49 (45%) teeth were lost and 60 (55%) were successfully maintained over an average of 12.5 years (5 to 29 years). More furcated teeth were lost than nonfurcated teeth and teeth given a hopeless prognosis were lost more consistently than those given a questionable prognosis in all groups. The frequency of periodontal abscess and tooth loss per patient was greater in the downhill and extreme downhill response groups than the well-maintained group. This suggests that teeth with a history of periodontal abscess can be treated and maintained for several years.

Study of β-Lactam antibiotic susceptibilites and characteristics of penicillin-binding proteins from Streptococcus anginosus, S. constellatus and S. intermedius

Twenty-two isolates from dentoalveolar abscesses from 11 patients belonging to the Streptococcus milleri group were classified into 3 species, S. anginosus, S. constellatus and S. intermedius, according to their patterns of glycosidase production. The minimum inhibitory concentration (MIC) values of 6 β-lactams, penicillin G (PCG), ampicillin (ABPC), cefaclor (CCL), cephalexin (CEX), flomoxef (FMOX) and imipenem (IPM), were all within a narrow range against the 3 species and were close to those of the corresponding type strains. All of the isolates were more susceptible to PCG, ABPC and IPM than to CCL and CEX. Highly β-lactam-resistant strains were not observed. Fluorogram patterns of penicillin-binding proteins (PBPs) were similar within the S. milleri group. Some isolates of S. anginosus and S. constellatus had extra bands which were not detected in the type strains, so that the PBP band patterns may not be able to accurately identify the species within the S. milleri group, especially between S. anginosus and S. constellatus. These results support the view that a genetically close relationship exists among the different species within this group. ABPC showed stronger affinities for almost all PBPs compared with CCL, reflected by lower ABPC MIC values. The PBPs with the highest affinity for ABPC were different from those for CCL. However, scanning electron microscopic observations showed that morphological changes of the bacterial cells were similar after treatment with these antibiotics at their MICs.