Cervical necrotizing fasciitis caused by oral cavity infection: a case report considering therapeutic approach and its morphofunctional implications / Fascitis necrosante cervical causada por infección de la cavidad oral. Reporte de un caso considerando el abordaje terapéutico y sus implicaciones morfofuncionales

SUMMARY: Cervical necrotizing fasciitis (NF) is a rare complication of oral cavity infection with high morbi-mortality. Given its low prevalence, adequately reporting cases of NF, its therapeutic management, and associated morphofunctional modifications to the clinical and scientific community is pivotal. To that end, we herein describe a case of cervical NF in a 60-year-old patient with comorbidities and patient presented large, painful cervical swelling associated with a necrotic ulcer lesion in the anterior neck region. Intraoral examination indicated a periodontal abscess in the right mandibular area, while computed tomography indicated the lesion's extension from the right mandibular to the submandibular region. Following empirical intravenous antibiotic treatment, a broad surgical debridement was performed, and the foci of oral infection were removed. Debridement revealed communication between deep and superficial anatomical regions in the submandibular area, where we subsequently placed a Penrose drain. Biopsies showing acute inflammatory infiltrate associated with necrotic and hemorrhagic regions confirmed the diagnosis of NF. When an antibiogram revealed resistance to the empirical treatment, the antibiotic scheme was replaced with an adequate alternative. After a second debridement, we closed the defect with fascio-mucocutaneous advancement flaps with a lateral base while maintaining suction drainage. Having reacted positively, the patient was discharged 10 days after the operation. Despite an extensive morphofunctional change generated in the treated area, the patient showed no difficulties with breathing, phonation, swallowing, or mobilizing the area during control sessions. Altogether, this report contributes to the highly limited literature describing morphological aspects that can facilitate or delay the spread of infection or the morphofunctional disorders associated with the size and depth of surgical interventions for cervical NF, information that is relevant for the comprehensive, long-term prognosis of the treatment of NF.

La fascitis necrosante (FN) cervical es una rara complicación de una infección proveniente de la cavidad bucal asociada a una alta morbimortalidad. Por lo anterior, es fundamental informar a la comunidad clínica y científica los casos de FN, su manejo terapéutico y las modificaciones morfofuncionales asociadas. Se describe un caso de FN cervical en una paciente de 60 años quien presentó una gran tumefacción dolorosa asociada a una lesión ulcerosa necrótica en la región anterior del cuello. El examen intraoral mostró un absceso periodontal en el área mandibular derecha y la tomografía computarizada mostró la extensión de la lesión hacia la región submandibular. Tras el tratamiento antibiótico empírico, se realizó un desbridamiento quirúrgico extenso y se extirparon los focos de infección oral. El desbridamiento reveló comunicación entre las regiones anatómicas profundas y superficiales del área submandibular, donde se colocó un drenaje Penrose. Las biopsias mostraron un infiltrado inflamatorio agudo asociado con regiones necróticas y hemorrágicas, confirmando el diagnóstico de FN. El antibiograma reveló resistencia al tratamiento empírico, por lo que el esquema antibiótico se sustituyó. Tras un segundo desbridamiento, se cerró el defecto con colgajos de avance fascio-mucocutáneos de base lateral manteniendo drenaje aspirativo. El positivo progreso del paciente permitió su alta 10 días después. Aun cuando se generó una gran modificación morfofuncional en el área tratada, la paciente no presentó dificultades para respirar, hablar, deglutir o movilizar el área cervical intervenida durante las sesiones de control. Este informe contribuye a la limitada literatura que describe los aspectos morfológicos que pueden facilitar o retrasar la propagación de la FN y las consecuencias asociadas a los trastornos morfofuncionales provocadas por el tamaño y profundidad de las intervenciones quirúrgicas requeridas por la FN, información relevante para el pronóstico integral a largo plazo del tratamiento de la FN.

Guía clínica para el tratamiento de lesiones endoperiodontales sin compromiso radicular en pacientes periodontales / Clinical practice guide for the treatment of endoperiodontal lesions without root compromise in periodontal patients

La comunicación patológica entre la pulpa y el pe-riodonto se denomina lesión endoperiodontal. Puede presentarse de forma aguda o crónica, y su mani-festación más común es la presencia de un absceso acompañado de dolor. Es importante realizar una detenida evaluación clínica y radiográfica para esta-blecer un correcto diagnóstico y plan de tratamiento. Por este motivo, el objetivo de esta guía es presentar un protocolo consensuado entre las Cátedras de Pe-riodoncia y Endodoncia de la Facultad de Odontología de la Universidad de Buenos Aires (FOUBA), para su tratamiento (AU)

The pathological communication between the pulp and the periodontium is called Endoperiodontal Lesion. It can be presented in an acutely or chronically form and its most common manifestation is the presence of an abscess accompanied by pain. It is important to carry out a careful clinical and radiographic evaluation to establish a correct diagnosis, prognosis, and treatment plan. For this reason, the objective of this guide is to present a consensus protocol between Periodontics and Endodontics Departments of the Faculty of Dentistry of the University of Buenos Aires (FOUBA) for their treatment (AU)

Non-surgical management of an extraoral cutaneous sinus tract of odontogenic origin.

Chronic apical periodontitis associated with dental pulp necrosis is the main cause of odontogenic extraoral cutaneous sinus openings. These tracts are often initially misdiagnosed unless the treating clinician considers a dental aetiology. This case report of a 19-year-old woman describes the diagnosis and treatment of an extraoral cutaneous sinus tract of odontogenic origin. Non-surgical conservative endodontic therapy was opted as the involved teeth were restorable. One month after the completion of obturation, there was closure of the sinus tract. One year follow-up showed complete resolution of the sinus tract with minimal scar formation.

Case report: vertebral osteomyelitis secondary to a dental abscess.

BACKGROUND: Vertebral osteomyelitis can be attributed to many factors including immunosuppression, diabetes, malignancy, collagen disease, periodontal disease, open fractures, and endoscopic procedures. Anaerobic bacteria, such as Veillonella species, are found in the oral cavity and are rarely implicated in the infection. This report describes vertebral osteomyelitis secondary to a dental abscess with positive Veillonella cultures. CASE DESCRIPTION: A 76-year-old man presented to the hospital due to back pain with a four-day history of fever and chills. CT scans revealed several abscesses in the lumbar region as well as indications of vertebral osteomyelitis. After a psoas drain, the patient began antibiotics with a combination of ampicillin-sulbactam, metronidazole, and levofloxacin, but due to the patient's penicillin allergy, he was initially desensitized to this antibiotic for a significant period of time. Laminectomies, foraminotomies, and facetectomies were performed, but the infection spread to vertebral levels. The patient was then switched to a combination of vancomycin, metronidazole, and levofloxacin which eliminated the infection. Final laminectomy was performed with posterior segmental instrumentation and arthrodesis. Post-operatively, there were no signs of infection. The patient recovered well and regained mobility. Deeper examination of the patient's medical history revealed a severe tooth abscess immediately before the onset of bacteremia. CONCLUSION: We believe that a delay in the onset of antibiotic treatment is what led to the initial bacteremia that ultimately took root in the lower lumbar vertebrae. To the best of our ability, we could identify only one other case that linked vertebral osteomyelitis to the oral cavity.

Necrotizing fasciitis as a complication of odontogenic infection: a review of management and case series.

BACKGROUND: The aims of the present study were to establish the incidence of head and neck necrotizing fasciitis (NF) in the Adelaide Oral and Maxillofacial Surgery Unit; review the current literature regarding the management of head and neck NF; and determine the evidence for the role of hyperbaric oxygen therapy in the management of NF. METHODS: A retrospective audit of all patients admitted to the Royal Adelaide Hospital Oral and Maxillofacial Surgery Unit 2006-2015 with severe odontogenic infections was carried out. Patient demographics were recorded and treatment details were collected and analysed. RESULTS: A total of 672 patients were admitted for management of severe odontogenic infections. Of these, three were identified as NF. One case was treated using hyperbaric oxygen as an adjunct to conventional surgical and medical management. Two cases were managed using aggressive surgical management alone. Two patients survived. The incidence of head and neck NF in South Australia is 48/100 000 infections per year. CONCLUSIONS: The first-line treatment of severe odontogenic infections remains conventional surgical and medical management; however, hyperbaric oxygen therapy may have an additional role in the management of NF and other rare severe infections in medically complex patients.

Odontogenic cervical necrotizing fasciitis, etiological aspects.

INTRODUCTION: Cervical necrotizing fasciitis is a rare but very severe infection that affects the soft-tissues of the cephalic extremity. Cervical necrotizing fasciitis most frequently occurs secondarily to inflammatory odontogenic disorders and represents the most severe infection of maxillofacial spaces, with a high lethal potential. MATERIALS AND METHODS: In this study, we selected 55 patients with confirmed cervical necrotizing fasciitis of odontogenic origin, treated in the Clinic of Oral and Maxillofacial Surgery in Cluj-Napoca during January 1996-December 2012. RESULTS: In the majority of cases, the disease evolved without the presence of associated systemic disorders (60% [45.49-72.69]), the rest of the patients having 1-4 types of systemic disorders; type 2 diabetes mellitus was the most frequent type of underlying systemic disorder. From the appearance of the first symptoms until the presentation for treatment, a time interval of 2-30 days elapsed. During this time period, 78.18% (95% confidence interval [CI] [65.49-89.06]) of the patients received antibiotic treatment, but without results. Mandibular molars were the most frequent starting point of the disease, and the submandibular space was the first affected by the disease, 47.27% (95% CI [32.76-61.79]). Bacteriological exams showed that facultatively aerobic/anaerobic G + bacteria were the most frequently identified (72.22% [58.21-83.60]). CONCLUSION: The odontogenic lesions of the lower molars, complicated by submandibular space infections, are the most frequent starting point of odontogenic cervicofacial necrotizing fasciitis. Delayed surgical treatment and strict antibiotic therapy play an important role in favoring the development of odontogenic necrotizing fasciitis.

[Surgical treatment of acute descending necrotising mediastinitis]. / Az acut descendáló necrotizáló mediastinitis sebészi kezelése.

INTRODUCTION: Acute descending necrotizing mediastinitis (DNM) is a severe septic inflammation of the mediastinum with necrosis, which progrediates rapidly and leads to death without adequate surgical treatment in 80% of cases. PATIENTS AND METHOD: 17 patients were treated with acute DNM between 1999 and 2012 at the Thoracic Surgical Department of Koranyi National Institute and Semmelweis University of Hungary. The infection source was primarily in the head-neck region with dental infections in eight cases, retro/parapharyngeal abscess in four patients, primary collar phlegmone and abscess in one case and two retrotonsillar abscesses. Further, in one case there was a previous operation (mediastinoscopy) in the history and in another case there was "difficult intubation process" (not recognized trachea-laesion) mentioned during abdominal operation. Primary exploration was performed from the neck in nine cases, thoracotomies plus collar incisions were carried out in four cases, athoracotomy only was done in one and orofacial exploration in further three patients. Disease progression could be evaluated by computer tomography which had to be followed by immediate surgery. RESULTS: Four patients needed two operations, five patients underwent exploration three times, while three patients needed 4 interventions four times. More than one anatomical region was explored in 70% of the cases. Based on our experience prognosis is affected by the time elapsed between detection and surgical intervention, age of the patient and comorbidites such as diabetes mellitus. We lost nine patients (53%), eight patients recovered and symptom free (47%). CONCLUSIONS: Successful treatment is based on early diagnosis, urgent elimination of the primary source, adequate exploration of the cervico-facial region, debridement, collar and upper mediastinal drainage. If the inflammation spreads below the azygos vein or the aortic arch, a right thoracotomy should be performed with wide mediastinal exploration, debridement, and thoracic suction-lavage drainage. Treatment should be completed with broad spectrum and targeted antibiotics as well as organ support. Mortality and morbidity can be reduced with prompt and aggressive therapy.

Protocol for immediate implant replacement of infected teeth.

Extraction and immediate implant placement has become routine procedure due to reduced treatment time and the preservation of anatomical structures. However, in many cases, this technique involves teeth with different degrees of tissue compromise due to underlying infections. Until now, the degree of implant compromise has not been described, nor has a clinical management protocol been established for these cases. The aim of this article is to report the clinical results of a protocol used for immediate implant placement and provisionalization in infected extraction sockets. A classification of the implant surface compromise (in contact with previously infected tissue) is also described to facilitate the comparative analysis. It is possible to maintain the benefits of immediate implant placement and provisionalization in infected sites by applying a clinical protocol that considers antibiotic therapy, a thorough curettage of the infected tissue, antisepsis, and sufficient primary implant stability.

Cemental tear: clinical characteristics and its predisposing factors.

INTRODUCTION: Cemental tears often show characteristics mimicking a periapical or periodontal lesion. This leads to difficulty in the early diagnosis of cemental tears. METHODS: In this multicenter study, 71 teeth with cemental tears being confirmed by direct inspection or histological examination were included. For each case, demographic data, dental history, clinical and radiographic findings, and the results of exploratory surgery were recorded and analyzed. RESULTS: Maxillary or mandibular incisors (76.1%) were most frequently affected by cemental tears. Univariate analysis of predisposing factors found that teeth with cemental tears occurred more commonly in men (77.5%) and patients older than 60 years of age (73.2%). Analysis of clinical characteristics showed that teeth with cemental tears were prone to have abscess formation (66.2%), a deep pocket >6 mm (73.2%), positive vitality test (65.3%), healthy antagonist teeth (84.3%), and moderate to severe attrition (77.9%). About 56.3% of cemental tears could be detected on preoperative radiographs. Further analysis of radiographic findings showed that teeth with cemental tears were more likely to have periodontal bone destruction (85.9%) or periapical bone destruction (64.8%). CONCLUSIONS: Endodontists and dentists may avoid misdiagnosis and unnecessary treatment of teeth with cemental tears if they can properly evaluate the radiographs and pulp vitality of teeth as well as know the predisposing factors and clinical characteristics of teeth with cemental tears in advance.

Enamel pearls as a predisposing factor to localized periodontitis.

Enamel pearls are enamel anomalies on primary and permanent teeth roots that usually appear at furcation areas, especially in maxillary second and third molars. Enamel pearls usually occur singularly, but as many as four have been observed on the same tooth. This report describes an unusual case of multiple enamel pearls associated with periodontal pockets localized on all maxillary first and second molars. Because the patient had an advanced stage of periodontitis, the maxillary right first and left second molars were extracted. The remaining two maxillary molars were included in a strict follow-up protocol. Enamel pearls were confirmed as the cause of localized periodontitis; therefore, it is very important to recognize their radiologic aspect to ensure proper treatment of the involved teeth.

[Clinical and therapeutical considerations regarding odontogenic acute mediastinitis]. / Consideratii clinico-terapeutice în mediastinitele acute de cauza dentara.

Odontogenic acute mediastinitis is an polymicrobial infections caused in most cases by gram negative and anaerobic germs. The odontogenic origin of the cases in this study was based on anamnestic inquiry of the patients, which reveales a dental treatment 7-15 days before the diagnosis of acute mediastinitis was established. Clinical features are often nonspecific at the debut of this affection; septic shock could appear suddenly associated with multiple systems and organs failure. This is the explication why, some of these patients presented septic shock when are diagnosed. In this situations, when acute mediastinitis is suspected, based on clinical and imaging findings, it must be confirmed by surgical exploration and perioperative bacteriological evaluations. Positive diagnosis is based on clinical features associated with labs and imaging studies. Surgery plays an important role in therapy of acute mediastinitis: debridement and drainage of mediastinum with subsequently lavage of it, using antiseptic solutions. Broad spectrum antibiotherapy should be administrated immediately, before antibiogram is ready.

"Abscess" as a perioperative risk factor for paresthesia after third molar extraction under general anesthesia.

OBJECTIVE: To evaluate postextractive neurological complications after third molar extraction under general anesthesia and to identify correlations between the surgical procedure, the third molar-related pathology, and neurological involvement. STUDY DESIGN: The clinical records of 183 patients were analyzed for a total of 408 third molars extracted at the Dental Clinic of Trieste (Italy). Individual effects of clinical data on the presence of paresthesia were evaluated by a logistic regression model. RESULTS: Neurological involvement was observed in 13 patients (6.1%). No permanent inferior alveolar nerve damage was found (0%) and only 1 patient presented a permanent lesion of the ipsilateral lingual nerve (0.3%). Pell and Gregory classification and surgical difficulty were not associated with the incidence or gravity of neurological lesions (P = NS). Among the pathologies associated with third molars, only the variable "abscess" presented a significant correlation with paresthesia (OR 6.86; 95% CI 1.21-38.8; P = .029). CONCLUSION: The percentage of nerve injuries agrees with the literature data, inclusion class, and surgical technique seem not to influence paresthesia risk. Further studies are necessary to evaluate the role of infectious pathologies as a cofactor in the development of neurological lesions after oral surgery.

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.

Multidisciplinary approach to the rehabilitation of a crown fracture with glass-fibre-reinforced composite: a case report.

Traumatic tooth injuries are common in children. When permanent teeth are involved, it can be a challenge to save these teeth. This clinical case study describes the multidisciplinary treatment of a complex crown fracture and luxation of a right maxillary incisor along with esthetic management. After periodontal surgery including guided bone regeneration and endodontic treatment, we used a glass-fibre-reinforced composite post to increase retention and distribute stress along the root. The restoration was completed using composite in an incremental technique. During follow-up appointments, clinical and radiographic examinations revealed no root canal or periodontal problems, suggesting the efficacy of the treatment in retaining the fractured tooth. Periodontal surgery with endodontic treatment is an alternative treatment for severe trauma in permanent teeth.

Experimental evidence supports the abscess theory of development of radicular cysts.

OBJECTIVE: The objective of this study was to experimentally induce inflammatory cysts in an animal model so as to test the hypothesis that radicular cysts develop via the "abscess pathway." METHODOLOGY: Twenty-eight perforated custom-made Teflon cages were surgically implanted into defined locations in the back of 7 Sprague Dawley rats. A week after the implantation of the cages, a known quantity of freshly grown, close allogeneic oral keratinocytes in phosphate buffer solution (PBS) was injected into each cage. One cage per animal was treated as the control that received only epithelial cells. The remaining 3 cages of each animal were trials. Seven days post epithelial cell inoculation; a suspension of 0.2 mL of Fusobacterium nucleatum (10(8) bacteria per mL) was injected into each of the 3 trial cages. Two, 12, and 24 weeks after the inoculation of the bacteria, the cages were taken out, and the tissue contents were fixed and processed by correlative light and transmission electron microscopy. Sixteen of the 21 trial cages could be processed and yielded results. RESULTS: Inoculations of epithelial cells followed 1 week later by F. nucleatum into tissue cages resulted in the development inflammatory cysts in 2 of the 16 cages. The 2 cages contained a total of 4 cystic sites. None of the control cages showed the presence of any cyst-like pathology. CONCLUSIONS: Inflammatory cysts were induced by initiating acute inflammatory foci (abscess/necrotic area) by bacterial injection that got enclosed by a proliferating epithelium. This finding provides strong experimental evidence in support of the "abscess theory" of development of radicular cysts.

Mandibular fracture caused by periodontal abscess: Radiological, US, CT and MRI findings.

Mandibular fracture is a rare but possible outcome of a periodontal abscess. A case of complete fracture of the mandible with abscess infiltrating the surrounding soft tissues is described. The patient reported nor trauma, nor locoregional surgery. Ultrasonography and orthopantomography revealed the fracture of the mandible and the abscess at the masseter muscle. Further preoperative diagnostic examinations included CT and MRI. CT revealed the complete fracture line more clearly; MR the extension of the abscess.

Case report: brain and liver abscesses caused by oral infection with Streptococcus intermedius.

Organ abscesses are a rare and life-threatening complication mostly of hematogenously disseminated infections. We report a case of brain and liver abscesses. Identification of the lesions was made by contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI), respectively. An oral examination comprised an oral focus of infection. Streptococcus intermedius was isolated from oral smear, liver and ventricular drainage, and blood sample. After the commencement of antibiotic therapy, drainage of abscesses and oral rehabilitation, complete recovery was noted.

Septicemia due to Solobacterium moorei in a patient with multiple myeloma.

We report a case of bacteremia caused by Solobacterium moorei, an anaerobic, non-sporulated Gram-positive bacillus in a patient with a multiple myeloma. The source of infection was presumably related to multiple dento-alveolar abscesses. This is the first recovery of S. moorei from blood cultures.