Complications of Severe Odontogenic Infections: A Review

Intracranial Infections Arising From an Odontogenic Infection: A Report of 2 Cases

Introduction

Intracranial empyema is a rare but serious and life-threatening infection. It is an accumulation of purulent material in the subdural or extradural space leading to development of subdural empyema or intracranial epidural abscess, respectively. The incidence of morbidity and mortality is high because the diagnosis is often unsuspected. Infections of dental origin could be responsible for such condition.

Case reports

A 22-year-old female and 30-year-old male patients, both with no significant medical history, presented with subdural empyema and intracranial epidural abscess, respectively, both complicating pan-sinusitis of dental origin. Successful outcomes were achieved with surgical drainage of the lesions, antibiotic therapy, and extraction of affected teeth. Female patient underwent further management for neurological sequelae, while male patient was discharged without neurological complications.

Discussion

Intracranial suppuration of odontogenic origin is an uncommon but extremely serious complication. The most common dental origins are caries with periapical involvement and periodontitis. Wisdom tooth extraction is the most common preceding dental procedure for this infection. A multidisciplinary approach is essential for the identification and treatment of suspected oral sources. Antibiotic therapy with surgical approach is the gold standard treatment.

Conclusion

This sequel to odontogenic infection is quite rare, but it can be prevented by a good oral hygiene and removal of abscessed teeth.

Hospitalisations Due to Dental Infection: A Retrospective Clinical Audit from an Australian Public Hospital

The aim of this clinical audit is to evaluate the characteristics of dental infections requiring hospitalisations, which may help improve preventative and management policies. This study retrospectively evaluated the records of patients admitted to the Nepean hospital, Kingswood, New South Wales, Australia, due to dental infections between 2018 and 2019. A total of 102 patients, mostly in their thirties with equal gender distribution, were admitted with dental infections, presenting with pain (100%), swelling (99%), trismus (40.2%), dysphagia (27.4%), fever (21%) [>37 °C], tachycardia (24.8%) and tachypnoea (9.3%). Most patients (68%) presented on weekends, outside regular working hours, and public holidays. A total of 52.5% of patients had taken prior antibiotics. Dental caries, smoking, mental health issues, and illicit drug use were featured strongly. The majority of patients (56.4%) underwent treatment under local anaesthesia. The total length of hospital stay was 271 days (mean 2.7, SD 1.6). Augmentin was the most prescribed antibiotic. Complications were reported in 8.8% of the patients, primarily due to airway compromise. Dental infections leading to hospitalisations continue to be a burden on the healthcare system. A notable finding was that the presentations were primarily on weekends, outside regular working hours, and public holidays, and the majority required dental interventions under local anaesthesia. The provision of on-call emergency dental services may reduce potentially preventable hospitalisations and the length of hospital stay.

Pediatric Odontogenic Infections

Odontogenic infections are a broad group of head and neck conditions that arise from the teeth and surrounding periodontium. These largely preventable infections disproportionately affect members of ethnic and racial minorities and low-income/uninsured groups, and result in significant costs to our health care system. Left untreated, odontogenic infections can spread to deep spaces of the head and neck and can result in life-threatening complications. The mainstay of treatment includes timely treatment of the affected teeth. These infections are a global public health concern that could be diminished with improved access to routine dental care.

The predictive value of laboratory tests in oro-maxillofacial infection of different severity

OBJECTIVE

We aimed to investigate the value of individual laboratory tests and combinations of tests for predicting disease severity.

METHODS

We retrospectively reviewed 62 patients with space infections in the oral and maxillofacial head and neck regions. Patients were divided into three groups according to severity. Laboratory tests associated with disease severity were identified.

RESULTS

As the severity of infection increased, leukocytes, neutrophils, C-reactive protein (CRP), procalcitonin (PCT), soluble interleukin receptor (sILR) 2, IL6, and creatinine (CR) increased. In the ROC analysis of group 1 (moderate infection) versus group 2 (severe infection), the area under the curve (AUC) values for leukocytes (AUC = 0.724), neutrophils (AUC = 0.714), PCT (AUC = 0.762) and a combination of the 3 tests (AUC = 0.768) suggested a strong predictive value. Furthermore, in the ROC analysis of group 2 (severe infection) versus group 3 (extremely severe infection), the AUC values for CRP (AUC = 0.84), PCT (AUC = 0.799), sIL2R (AUC = 0.937), IL6 (AUC = 0.863) and a combination of the four tests (AUC = 0.943) suggested a strong predictive value.

CONCLUSIONS

Leukocytes, neutrophils, and PCT were associated with multispace infection and high severity. CRP, PCT, sIL2R, and/or IL6 were associated with extremely severe infections occurring in the oral and maxillofacial head and neck regions.

Effectiveness of Oral Cephalexin-Clavulanic Acid, Cefuroxime, and Amoxicillin-Clavulanic Acid in the Management of Dental Infections: A Real-World, Retrospective, Electronic Medical Record-Based Study in India

BACKGROUND

Despite multiple antibiotics being available to manage dental infections (DI), there is lack of data comparing commonly prescribed antibiotics in India.

OBJECTIVES

The aim of this study was to evaluate the real-world effectiveness and tolerability of cephalexin-clavulanic acid fixed-dose combination (cephalexin CV FDC) in contrast with amoxicillin-clavulanic acid (co-amoxiclav FDC) and cefuroxime among patients with dental infections (odontogenic) in India.

METHODS

This retrospective, multi-centric, observational, real-world electronic medical record (EMR)-based study was conducted between January 2022 and December 2022. The EMRs of 355 adults with DI receiving oral cephalexin CV, co-amoxiclav, or cefuroxime were categorized into two distinct groups: Group I (Test Group) with patients prescribed cephalexin extended release 375/750 mg along with clavulanic acid 125 mg; and Group II (Comparator Group) with patients prescribed co-amoxiclav 625 mg (500 mg amoxicillin + 125 mg clavulanic acid) or cefuroxime (250 mg/500 mg).

RESULTS

Toothache was the most common complaint, reported by 95.5% of patients, followed by swelling (46.8%), tooth sensitivity (35.5%), pus discharge (33.0%), redness and halitosis (30.4% each). Dental caries was observed in 81.1% of patients. Clinical improvement, defined as improvement/partial resolution of infection-related clinical signs and symptoms (composite measure of pain, swelling, fever, requirement of additional antimicrobial therapy) as per dentists' judgment, was recorded in 98.3% of patients with cephalexin CV, 96.8% of patients with co-amoxiclav, and 98.9% of patients treated with cefuroxime within 10 days. Time (days) to clinical improvement was numerically lesser among patients receiving cephalexin CV (4.6 ± 2.0) compared with cefuroxime (4.9 ± 2.1) and co-amoxiclav (5.0 ± 2.6). All treatments were well tolerated.

CONCLUSION

Cephalexin CV was as effective as co-amoxiclav and cefuroxime, with faster clinical improvement and better resolution of certain symptoms.

Orofacial fascial space abscess disguised as temporomandibular disorder: a report of 3 cases and literature review

Fascial space abscess is a condition in which infections spread into fascial spaces. It is a severe and life-threatening disease unless treated at an early stage. Due to the similarity of clinical symptoms, fascial space abscesses in the orofacial area are often disguised as other diseases, such as temporomandibular disorder (TMD). In this case series, we report three cases of fascial space abscesses disguised as TMD. In all cases, patients complained of severely limited mouth opening and pain in the temporomandibular joint (TMJ) and masseter muscles, which led clinicians to diagnose them with TMD. After two patients showed facial swelling and the third complained of dyspnea, clinicians realized the possibility of an orofacial fascial space abscess. On further evaluation, all patients showed increased C-reactive protein in blood tests, and the location of the fascial space abscess was confirmed by enhanced computed tomography images. Moreover, all patients had suspicious sources of odontogenic infections in panoramic images, periapical abscess on maxillary molars and periodontal disease on maxillary and mandibular molars, which were not appropriately evaluated at the first visit. This case series emphasizes the need for clinicians to realize the possibility of orofacial fascial space abscesses based on: clinical symptoms of severely limited mouth opening (< 15 mm) with pain in the facial area, including TMJ or masseter muscle, and possible sources of infection such as odontogenic infection, other infectious lesions, trauma, or invasive treatments. These clinical insights will enable the early detection of fascial space abscesses.

Dental Infection Causing Methicillin-Resistant Staphylococcus aureus Bacteremia and Spinal Infection: A Case Report

Poor dentition as a source of infection causing bacteremia and spinal infections (such as paraspinal abscess, and discitis) should be considered even in the absence of recent dental surgery. The case presents a patient found to have an infection in the cervical and thoracic spine, methicillin-resistant Staphylococcus aureus bacteremia, and poor dentition. Although the patient had a history of drug use, he denied a history of intravenous drug use. He had Crohn's disease that resulted in periodontal and endodontal tooth disease. The patient was found to have poor dentition with erythematous gums. He had not been to the dentist in over 24 years and had active dental caries. Since he presented with bacteremia and a spinal infection, it is likely the patient had an infection in the oral cavity that spread hematogenously to the blood, and then the spine. This report highlights the importance of considering tooth infections as the source of bacteremia and spinal infections.

The COVID-19 pandemic and its possible impact on the treatment of odontogenic and intraoral abscesses

Most odontogenic and intraoral abscesses can be treated on an outpatient basis with local anesthesia. However, severe disease progression may require an incision under general anesthesia (GA) with postoperative inpatient treatment. This study aimed to evaluate the first "COVID-19 year" in Germany and compare the first "COVID-19 year" with the two previous years. All consecutive cases with odontogenic or intraoral abscesses treated in an outpatient or inpatient setting between 2018 and 2021 were included in this study. Data were collected, including the type of anesthesia, length of hospital stay, and healthcare costs. Despite the lower total number of abscess treatments in the first year of COVID-19 (n = 298 patients) than that in the two previous years (n = 663 patients), the number of advanced abscesses requiring intervention under GA was significantly higher (p < 0.001). This increased burden of care was also reflected in increased healthcare costs. The measures taken against the COVID-19 pandemic had an impact on the course of other diseases, for example, odontogenic and intraoral abscesses. The results showed an emerging conflict in patient care during the pandemic crisis that should be considered in possible future pandemics.

Polymicrobial Bacterial Meningitis in a Patient with Chronic Suppurative Otitis Media: Case Report and Literature Review

Polymicrobial meningitis is a rare entity in the adult population, especially in the antibiotic era. However, disorders such as chronic suppurative otitis media (CSOM) or even poor oral hygiene are considered risk factors for the development of such cerebral infection. We report a case of polymicrobial meningitis associated with oto-mastoiditis in a 64-year-old female patient known to have CSOM. The patient presented atypical symptoms for community-acquired meningitis, showing subacute evolution of headache, without fever or neck stiffness. The aerobe microorganisms Streptococcus anginosus and Corynebacterium spp., sensitive to beta-lactamines, and the anaerobe Prevotella spp., resistant to penicillin and metronidazole, were isolated from CSF specimens, while Proteus mirabilis and Enterococcus faecalis were identified from the ear drainage. The diversity of pathogens identified in our case led us to the hypothesis of two different sources of meningitis: otogenic and/or odontogenic. Favorable evolution was obtained after a multi-disciplinary approach, combining surgery and broad-spectrum antibiotics. In addition, we performed a literature review that highlights the low incidence of polymicrobial mixed aerobe-anaerobe meningitis.