Orofacial Bacterial Infectious Diseases: An Update

The relationship between the uptake of alveolar bone inflammation and of cervical lymph nodes on fluoro-2-deoxy-D-glucose positron emission tomography

OBJECTIVES

To elucidate the relationships between the maximum standardized uptake value (SUVmax) of alveolar bone and those of lymph nodes (LNs) around the neck on 18F-fluoro-2-deoxy-D-glucose (18F-FDG) positron emission tomography (PET).

METHODS

The SUVmax values of alveolar bone and of level IA, level IB, and level IIA LNs of 174 patients, including those with and without active odontogenic inflammation, on PET/CT performed for a health check were retrospectively evaluated. The upper and lower jaws were divided into four blocks (right maxilla, left maxilla, right mandible, and left mandible). The SUVmax values of each block and of the LNs were calculated. The differences in the SUVmax of each LN level between patients with and without odontogenic inflammation, and the relationship between the SUVmax values of alveolar bone and of the LNs were analysed statistically.

RESULTS

Significant differences in SUVmax values of bilateral level IB and IIA LNs were found between patients with and without odontogenic inflammation (Mann-Whitney U test: right level IB, P = .008; left level IB, P = .006; right level IIA, P < .001; left level IIA, P = .002), but not in bilateral level IA LNs (Mann-Whitney U test: right level IA, P = .432; left level IA, P = .549). The inflammatory site with the highest SUVmax in level IB LNs was the ipsilateral mandible (multivariate analysis: right, beta = 0.398, P < .001; left, beta = 0.472, P < .001), and the highest SUVmax in level IIA LNs was the ipsilateral maxilla (multivariate analysis: right, beta = 0.223, P = .002; left, beta = 0.391, P < .001).

CONCLUSIONS

The SUVmax values of level IB and IIA LNs were associated with a tendency towards a higher SUVmax value of alveolar bone on 18F-FDG-PET.

The role of periodontitis in cancer development, with a focus on oral cancers

Periodontitis is a severe gum infection that begins as gingivitis and can lead to gum recession, bone loss, and tooth loss if left untreated. It is primarily caused by bacterial infection, which triggers inflammation and the formation of periodontal pockets. Notably, periodontitis is associated with systemic health issues and has been linked to heart disease, diabetes, respiratory diseases, adverse pregnancy outcomes, and cancers. Accordingly, the presence of chronic inflammation and immune system dysregulation in individuals with periodontitis significantly contributes to the initiation and progression of various cancers, particularly oral cancers. These processes promote genetic mutations, impair DNA repair mechanisms, and create a tumor-supportive environment. Moreover, the bacteria associated with periodontitis produce harmful byproducts and toxins that directly damage the DNA within oral cells, exacerbating cancer development. In addition, chronic inflammation not only stimulates cell proliferation but also inhibits apoptosis, causes DNA damage, and triggers the release of pro-inflammatory cytokines. Collectively, these factors play a crucial role in the progression of cancer in individuals affected by periodontitis. Further, specific viral and bacterial agents, such as hepatitis B and C viruses, human papillomavirus (HPV), Helicobacter pylori (H. pylori), and Porphyromonas gingivalis, contribute to cancer development through distinct mechanisms. Bacterial infections have systemic implications for cancer development, while viral infections provoke immune and inflammatory responses that can lead to genetic mutations. This review will elucidate the link between periodontitis and cancers, particularly oral cancers, exploring their underlying mechanisms to provide insights for future research and treatment advancements.

Oral Commensals in Healthy Individuals: A Clinicocytological Study

Background Each human being has a specific group of microorganisms that are necessary for both sustaining health and causing illness. Normally, these microorganisms maintain bio-communalism, do not harm the host, and lead to a state known as symbiosis or eubiosis. The commensal nature of these bacteria is always maintained in symbiosis and attains pathogenic potential when there is an imbalance between host immunity and microorganisms. Our study focuses on the identification and differentiation of the various commensals present in the oral cavity of healthy individuals over a given period of time. Aims and objectives This study aims to: (i) identify various commensal bacterial species present in the oral cavity; (ii) differentiate each commensal bacterial species present in the oral cavity of healthy individuals using cytological and culturing methods; (iii) identify the presence of different types of commensal bacterial species in the same individuals with the specific time intervals; (iv) compare and correlate the presence or absence of bacterial species present as a commensal in both male and female; (v) identify and characterize the commensal bacterial species present in the oral cavity of healthy individuals; (vi) investigate the consistency of commensal bacterial species presence over time and between genders.  Methodology We included sixty healthy individuals between the ages of 20 and 24 from both genders, took buccal smears once every two days for ten days, stained them with Gram stain, and grew them in blood agar and Mac Conkey agar. Results The most common commensals include Gram-positive cocci, and among them, Coagulase-negative staphylococcus species (85%) are predominant, followed by Staphylococcus aureus (13.33%), and Streptococcus species (1.67%). The presence of colonies remains the same in all three samples obtained from the same healthy individuals. Conclusion Loss of balance between commensals and pathogens can lead to dysbiosis, which results in disease.

Oxidative Stress and Natural Products in Orthodontic Treatment: A Systematic Review

In recent years, orthodontics, a specialized branch of dentistry, has evolved considerably in terms of both techniques and materials used. Aimed at correcting dental malocclusions and craniofacial anomalies, it improves the functionality and aesthetics of the face and oral cavity. However, orthodontic treatment, in its developmental stages, may induce oxidative stress (O.S.) phenomena, with an increase in the production of reactive oxygen species (ROS), damaging the dental and periodontal tissues involved, affecting the short-, medium- and long-term results. Studies on the antioxidant effects of natural products (e.g., resveratrol, green tea, turmeric, etc.) in the medical field have aroused considerable interest in recent years. A systematic literature review was conducted on the PubMed, Scopus, and Web of Science databases using natural products (N.P.s), O.S., and orthodontic as keywords. The study aims to consider the determinants of the increase in ROS occurring during orthodontic treatment and the possibility of natural products being able to control and neutralize biochemical phenomena by restoring the physiological process in which the balance between the production of ROS and the ability of the body's antioxidant system to neutralize them is in favor of the latter.

Risk Factors for Maxillofacial Space Infection Complications: A Retrospective Analysis of 457 Patients

This study was performed to determine the risk factors associated with systemic complications of maxillofacial space infection (MSI), and to propose an objective evaluation index - severity score of MSI. 457 MSI patients from Jan 2010 to Dec 2020 were reviewed retrospectively. The predictor variables included demographic, origin of infection, underlying systemic disease, pre-hospital medication history, laboratory examinations and severity scores of space infection. The severity score of space infection was proposed to evaluate the airway compromise of anatomic spaces. The primary outcome variable was the complication. The impact factors of complications were analyzed using univariate analysis and multivariate logistic regression. 457 patients were included (average age 46.3 y, male to female ratio 1.43:1). Among them, 39 patients developed postoperative complications. In the complication group, there were 18 patients (46.2%) with pulmonary infection, and two patients died. We found that the history of diabetes mellitus (OR=4.74, 95% confidence interval (CI)=2.22, 10.12), high temperature (≥39°C) (OR=4.16, 95% CI=1.43, 12.06), advanced age (≥65 y) (OR=2.88, 95% CI=1.37, 6.01), and severity score of space infection (OR=1.14, 95% CI=1.04, 1.25) were independent risk factors for complications of MSI. All the risk factors needed to be closely monitored. Severity score of MSI was an objective evaluation index to predict complications.

Development and Evaluation of Essential Oil-Based Nanoemulgel Formulation for the Treatment of Oral Bacterial Infections

Prevalence of oral infections in diabetic patients is a health challenge due to persistent hyperglycemia. However, despite great concerns, limited treatment options are available. We therefore aimed to develop nanoemulsion gel (NEG) for oral bacterial infections based on essential oils. Clove and cinnamon essential oils based nanoemulgel were prepared and characterized. Various physicochemical parameters of optimized formulation including viscosity (65311 mPa·S), spreadability (36 g·cm/s), and mucoadhesive strength 42.87 N/cm²) were within prescribed limits. The drug contents of the NEG were 94.38 ± 1.12% (cinnamaldehyde) and 92.96 ± 2.08% (clove oil). A significant concentration of clove (73.9%) and cinnamon essential oil (71.2 %) was released from a polymer matrix of the NEG till 24 h. The ex vivo goat buccal mucosa permeation profile revealed a significant (52.7-54.2%) permeation of major constituents which occurred after 24 h. When subjected to antimicrobial testing, significant inhibition was observed for several clinical strains, namely Staphylococcus aureus (19 mm), Staphylococcus epidermidis (19 mm), and Pseudomonas aeruginosa (4 mm), as well as against Bacillus chungangensis (2 mm), whereas no inhibition was detected for Bacillus paramycoides and Paenibacillus dendritiformis when NEG was utilized. Likewise promising antifungal (Candida albicans) and antiquorum sensing activities were observed. It was therefore concluded that cinnamon and clove oil-based NEG formulation presented significant antibacterial-, antifungal, and antiquorum sensing activities.

Microbial profiling of peri-implantitis compared to the periodontal microbiota in health and disease using 16S rRNA sequencing

PURPOSE

The objective of this study was to analyze the microbial profile of individuals with peri-implantitis (PI) compared to those of periodontally healthy (PH) subjects and periodontitis (PT) subjects using Illumina sequencing.

METHODS

Buccal, supragingival, and subgingival plaque samples were collected from 109 subjects (PH: 30, PT: 49, and PI: 30). The V3-V4 region of 16S rRNA was sequenced and analyzed to profile the plaque microbiota.

RESULTS

Microbial community diversity in the PI group was higher than in the other groups, and the 3 groups showed significantly separated clusters in the buccal samples. The PI group showed different patterns of relative abundance from those in the PH and PT groups depending on the sampling site at both genus and phylum levels. In all samples, some bacterial species presented considerably higher relative abundances in the PI group than in the PH and PT groups, including Anaerotignum lactatifermentans, Bacteroides vulgatus, Faecalibacterium prausnitzii, Olsenella uli, Parasutterella excrementihominis, Prevotella buccae, Pseudoramibacter alactolyticus, Treponema parvum, and Slackia exigua. Network analysis identified that several well-known periodontal pathogens and newly recognized bacteria were closely correlated with each other.

CONCLUSIONS

The composition of the microbiota was considerably different in PI subjects compared to PH and PT subjects, and these results could shed light on the mechanisms involved in the development of PI.

Prevalence of Methicillin and β−Lactamase Resistant Pathogens Associated with Oral and Periodontal Disease of Children in Mymensingh, Bangladesh

Oral and periodontal diseases (OPD) is considered one of the main problems of dentistry worldwide. This study aimed to estimate the prevalence of oral and periodontal pathogenic bacteria along with their antimicrobial resistance pattern in 131 children patients aged between 4–10 years who attended in Mymensingh Medical College Hospital during October 2019 to March 2020. OPD pathogens were identified through isolation, cultural and biochemical properties, and nucleic acid detection. The isolates were subjected to antimicrobial susceptibility to 12 antibiotics commonly used in dentistry. In addition, the isolates were analyzed molecularly for the presence of six virulence and three antibacterial resistance genes. Five pathogens were identified, of which Staphylococcus aureus (S. aureus) (49%) and S. salivarius (46%) were noticed frequently; other bacteria included S. mutans (16.8%), S. sobrinus (0.8%) and L. fermentum (13.7%). The virulence genes—clumping factor A (clfA) was detected in 62.5% isolates of S. aureus, and gelatinase enzyme E (gelE) gene was detected in 5% isolates of S. salivarius, while other virulence genes were not detected. All the tested isolates were multidrug-resistant. The overall prevalence of MDR S. aureus, Streptococcus spp. and L. fermentum was 92.2%, 95.1% and 100%, respectively. It was observed that a high proportion of isolates were found resistant to 5–8 antibiotics. A majority of S. aureus, Streptococcus spp., and L. fermentum isolates tested positive for the β−lactamase resistance genes blaTEM and cfxA, as well as the methicillin resistance gene mecA. Phylogenetically, the resistance genes showed variable genetic character among Bangladeshi bacterial pathogens. In conclusion, S. aureus and S. salivarius were major OPD pathogens in patients attended in Mymensingh Medical College Hospital of Bangladesh, and most were Beta-lactam and methicillin resistant.

Preliminary Novel Analysis on Antimicrobial Properties of Concentrated Growth Factor against Bacteria-Induced Oral Diseases

OBJECTIVE

 Concentrated growth factor (CGF) is particularly gaining acceptance and popularity in regenerative dentistry. Nonetheless, there are no available studies showing its effect against microorganisms of oral cavity particularly in chronic oral disease-induced biofilms. This in vitro research was conducted to determine the antimicrobial effects of CGF against Staphylococcus aureus sp. (S. aureus) and Streptococcus mutans sp. (S. mutans).

MATERIALS AND METHODS

 Blood samples were obtained from a healthy volunteer. CGF was then prepared using specialized centrifugation equipment (Medifuge, Silfradent, Santa Sofia FC, Italy) and protocol. Antimicrobial activity of the CGF was observed and recorded on standard strains of S. aureus and S. mutans using a well diffusion method to determine the inhibition zone, broth microdilution to determine minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC), and crystal violet assay for biofilm assessment, with chlorhexidine (CHX) 0.12% used as a positive control. Statistical analysis was then performed using one-way analysis of variance followed by Tukey Test post hoc analysis.

RESULTS

 It was observed that there was a presence of clear zones of inhibition around the CGF after 24 hours of incubation. The mean diameter of the inhibition zone was 1.26 ± 0.12 nm and 1.20 ± 0.06 nm for S. aureus and S. mutans, respectively, with significance difference (p < 0.05) against the control group CHX 0.12%. The MIC values of the CGF against S. aureus and S. mutans were 47.9% and 34.17%, respectively, and the MBC values of the CGF against S. aureus and S. mutans were 100%. The viability and the ability in inhibiting the biofilm formation of S. mutans and S. aureus following treatment with CGF showed a reduction in the concentration-dependent manner as compared with the control group.

CONCLUSION

 CGF possesses antimicrobial and antibiofilm activity against S. aureus and S. mutans.

Cervicofacial necrotizing fasciitis after topical application of herbal medicine

Cervical necrotizing fasciitis represents an aggressive form of deep neck space infection with a high mortality rate. The origin is generally odontogenic, in most cases, resulting from a dental abscess. A series of three cases developed after local application of herbal medicine in patients with no co-morbidities and with a history of a toothache in the lower quadrants for >2 weeks is presented. All patients were managed with antibiotics, extraction of offending tooth and serial wound debridement. Two patients recovered with a resultant skin defect on the neck and one died due to multiple organ failure. This case series demonstrated that early diagnosis, prompt surgical intervention and appropriate medical treatment are very important to increase patient survival. Late report to hospital because of financial constraints and over-reliance on herbal preparation could lead to the development of serious complication in patients with dental infections and could even lead to death of the patient.

Development and Optimization of Cinnamon Oil Nanoemulgel for Enhancement of Solubility and Evaluation of Antibacterial, Antifungal and Analgesic Effects against Oral Microbiota

Oral health is a key contributor to a person’s overall health and well-being. Oral microbiota can pose a serious threat to oral health. Thus, the present study aimed to develop a cinnamon oil (CO)-loaded nanoemulsion gel (NEG1) to enhance the solubilization of oil within the oral cavity, which will enhance its antibacterial, antifungal, and analgesic actions against oral microbiota. For this purpose, the CO-loaded nanoemulsion (CO-NE) was optimized using I-optimal response surface design. A mixture of Pluracare L44 and PlurolOleique CC 497 was used as the surfactant and Capryol was used as the co-surfactant. The optimized CO-NE had a globule size of 92 ± 3 nm, stability index of 95% ± 2%, and a zone of inhibition of 23 ± 1.5 mm. This optimized CO-NE formulation was converted into NEG1 using 2.5% hydroxypropyl cellulose as the gelling agent. The rheological characterizations revealed that the NEG1 formulation exhibited pseudoplastic behavior. The in vitro release of eugenol (the marker molecule for CO) from NEG1 showed an enhanced release compared with that of pure CO. The ex vivo mucosal permeation was found to be highest for NEG1 compared to the aqueous dispersion of CO-NE and pure cinnamon oil. The latency reaction time during the hot-plate test in rats was highest (45 min) for the NEG1 sample at all-time points compared with those of the other tested formulations. The results showed that the CO-NEG formulation could be beneficial in enhancing the actions of CO against oral microbiota, as well as relieving pain and improving overall oral health.

Linking chronic periodontitis and oral cancer: A review

The aim of this article is to survey the accessible writing on the pathogenetic systems engaged with the relationship between oral malignancy and periodontitis. Gingival tissue contains multiple microbiota, which can induce inflammatory reactions. This reaction plays a crucial role in assessing the susceptibility of patients to periodontal diseases. The link between chronic periodontitis and the risk of malignancy through this inflammation of the affected epithelium have been studied thoroughly. Many studies have reported that, chronic periodontitis has systemic influence which has high risk of developing different types of cancers. Also, various confounding factors such as consumption of alcohol, smoking, diet, age and gender have been found to be associated with both chronic periodontitis and oral cancer. An online quest for a wide range of articles distributed was started utilizing MEDLINE/PubMed, with the keywords, for example, 'oral squamous cell carcinoma (OSCC)', 'oral microbiota,' 'microorganisms and malignancy and Porphyromonas gingivalis. This review aimed to study the current literature linking chronic periodontitis and oral cancer.

Impact of Epigenetic Alterations in the Development of Oral Diseases

BACKGROUND

Epigenetic mechanisms alter gene expression and regulate vital cellular processes that contribute to the onset and progression of major dental diseases. Their reversible character may prove beneficial for therapeutic targeting. This review aims to provide an update on the main epigenetic changes that contribute to the pathogenesis of Oral Squamous Cell Carcinoma (OSCC), pulpitis and periodontitis as well as dental caries and congenital orofacial malformations, in an effort to identify potential therapeutic targets.

METHODS

We undertook a structured search of bibliographic databases (PubMed and MEDLINE) for peer-reviewed epigenetic research studies focused on oral diseases in the last ten years. A qualitative content analysis was performed in screened papers and a critical discussion of main findings is provided.

RESULTS

Several epigenetic modifications have been associated with OSCC pathogenesis, including promoter methylation of genes involved in DNA repair, cell cycle regulation and proliferation leading to malignant transformation. Additionally, epigenetic inactivation of tumor suppressor genes, overexpression of histone chaperones and several microRNAs are implicated in OSCC aggressiveness. Changes in the methylation patterns of IFN-γ and trimethylation of histone Η3Κ27 have been detected in pulpitis, along with an aberrant expression of several microRNAs, mainly affecting cytokine production. Chronic periodontal disease has been associated with modifications in the methylation patterns of Toll-Like Receptor 2, Prostaglandin synthase 2, E-cadherin and some inflammatory cytokines, along with the overexpression of miR-146a and miR155. Furthermore, DNA methylation was found to regulate amelogenesis and has been implicated in the pathogenesis of dental caries as well as in several congenital orofacial malformations.

CONCLUSION

Strong evidence indicates that epigenetic changes participate in the pathogenesis of oral diseases and epigenetic targeting may be considered as a complementary therapeutic scheme to the current management of oral health.

New Insights into Oral Cancer-Risk Factors and Prevention: A Review of Literature

The oral cancer constitutes 48% of head and neck cancer cases. Ninety percent of oral cancer cases are histologically diagnosed as oral squamous cell carcinomas (OSCCs). Despite new management strategies, the 5-year survival rate of oral cancer is still below 50% in most countries. Head and neck cancers are heterogeneous tumors, and this characteristic of them provides a challenge to treatment plan. Due to the poor outcomes in oral cancer, prevention is a necessity. In this review, a relevant English Literature search in PubMed, ScienceDirect, and Google Scholar from 2000 to mid-2018 was performed. All published articles related to oral cancer and its prevention were included. The risk factors of oral cancer and strategies of oral cancer prevention will be discussed.

Untreated Dental Caries May be Associated with Subsequent Mortality among Working-Age Adults: Evidence from NHANES III

OBJECTIVES

Poor oral health has been shown to be associated with selected adverse health outcomes. This study assessed the association between untreated dental caries and mortality and examined whether having dental insurance mitigates the risk of mortality among working-age US adults with dental caries.

METHODS

Analysis used the publicly available linked mortality file for NHANES III, an observational study conducted in 1988-1994, with follow-up through December 2015. Propensity score matching was conducted to create similar populations of insured and uninsured adults, resulting in a sample of 4420 matched observations. The Cox proportional hazard model was used to investigate the effect of untreated dental caries and that of dental insurance on risk of all-cause mortality. The descriptive and final outcome statistical analyses were adjusted for complex sampling technique using weights, strata and cluster variables.

RESULTS

Adults with untreated dental caries had a higher risk of mortality (HR: 1.33; 95% CI: 1.06-1.68) than those with no dental caries. Having dental insurance was associated with a lower risk of mortality (HR: 0.73; 95% CI: 0.59-0.92). An interaction between caries treatment status and dental insurance was not statistically significant.

CONCLUSIONS

Adults with untreated dental caries have a higher risk of mortality, even in the presence of dental insurance. Untreated caries may be an indicator for multiple risk factors, including personal attitudes regarding health and healthcare-seeking behaviour.

Relationship between 18F-FDG Uptake in the Oral Cavity, Recent Dental Treatments, and Oral Inflammation or Infection: A Retrospective Study of Patients with Suspected Endocarditis

[18F]-fluorodeoxyglucose positron emission tomography ([18F]FDG PET/CT) has proven to be a useful diagnostic tool in patients with suspected infective endocarditis (IE), but is conflicting in relation to dental procedures.

QUESTIONS

Is there a correlation between [18F]FDG PET/CT findings, recent dental treatment, and an affected oral cavity? (2) Is there a correlation between infective endocarditis (IE), oral health status, and (extra)cardiac findings on [18F]FDG PET/CT?

METHODS

This retrospective study included 52 patients. All [18F]FDG PET/CT scans were examined visually by pattern recognition using a three-point scale and semi-quantified within the volume of interest (VOI) using SUVmax.

RESULTS

19 patients were diagnosed with IE (group 1), 14 with possible IE (group 2), and 19 without IE based on the modified Duke criteria (group 3). No correlation was found between visual PET and SUVmax and sites of oral inflammation and infection. The visual PET scores and SUVmax were not significantly different between all groups. A significant difference in the SUVmax of the valve between all groups was observed.

CONCLUSIONS

This study suggests that no correlation exists between the PET findings in the oral cavity and dental treatments or inflammation/infection. No correlation between IE, actual oral health status, and extra-cardiac findings was demonstrated. Additional research is needed to conclude whether [18F]FDG PET/CT imaging is a reliable diagnostic modality for oral inflammation and infection sites.

Periodontitis and oral cancer - current concepts of the etiopathogenesis

Gingival tissues are attacked by oral pathogens which can induce inflammatory reactions. The immune-inflammatory responses play essential roles in the patient susceptibility to periodontal diseases. There is a wealth of evidence indicating a link between chronic inflammation and risk of malignant transformation of the affected oral epithelium. Periodontitis is associated with an increased risk of developing chronic systemic conditions including autoimmune diseases and different types of cancers. Besides, some risk factors such as smoking, alcohol consumption and human papilloma virus have been found to be associated with both periodontitis and oral cancer. This review article aimed to study the current concepts in pathogenesis of chronic periodontitis and oral cancer by reviewing the related articles.

Odontogenic necrotizing fasciitis: a systematic review of the literature

Background

While odontogenic soft tissue infections of the head and neck are common, progression to necrotizing fasciitis is relatively rare. Necrotizing fasciitis is a potentially life-threatening and rapidly progressive soft tissue infection that can lead to significant skin and soft tissue loss, mediastinitis, vascular thrombosis or rupture, limb loss, organ failure, and death.

Methods

A PubMed literature search was conducted for case reports and case series on odontogenic necrotizing fasciitis. Individual patient data was analyzed and compiled and demographic, treatment, microbiology, and mortality data were extracted. Fisher’s exact test was used to examine the relationship between death from odontogenic necrotizing fasciitis and diabetes mellitus (DM) and human immunodeficiency virus (HIV) positivity.

Results

A total of 58 studies totaling 164 patients were identified. Thirty-three patients had DM and 3 were HIV +. All patients underwent aggressive surgical debridement and treatment with IV antibiotics. Twenty patients were also treated with hyperbaric oxygen. There were 16 deaths reported, for a mortality rate of 9.8%. The mortality rate among patients with DM was 30.3 and 0% among HIV positive patients. There was a statistically significant increase in the mortality rate in DM patients with odontogenic necrotizing fasciitis (p = 0.0001, odds ratio for death 9.1).

Conclusions

Necrotizing fasciitis arising from odontogenic infection is a rapidly progressive and life-threatening illness. Prompt recognition of the infection, aggressive and often serial surgical debridement, and aggressive broad-spectrum antibiotics are necessary to prevent serious morbidity and mortality. Patients with diabetes mellitus are at a significantly increased risk of death from odontogenic necrotizing fasciitis.