Screening of dental and sinus infections in rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis (RA) is associated with increased risk of infections. Screening for oral (dental and/or sinus) infection could be proposed before biologic disease-modifying antirheumatic drugs (bDMARDs) initiation but is not systematically recommended. The aim of our study was to assess the prevalence of oral infection in RA patients requiring bDMARDs. MATERIALS AND METHODS: This was a monocentric retrospective study. We included patients with RA and active disease requiring bDMARDs. Dental infection and sinusitis were assessed by a stomatologist and otorhinolaryngologist after clinical, panoramic dental X-ray and sinus CT evaluation. Factors associated with oral infections were analysed in uni- and multivariate models, estimating odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: We included 223 RA patients (79.4% women, mean disease duration 8.9 ± 8.6 years). The mean age was 54.4 ± 10.9 years and mean Disease Activity Score in 28 joints 5.5 ± 2.6. Systematic dental screening revealed infection requiring treatment before bDMARDs initiation in 46 (20.9%) patients. Sinusitis was diagnosed by the otorhinolaryngologist in 33 (14.8%) patients. Among the 223 patients, 69 (30.9%) had dental and/or sinus infection. On univariate analysis, active smoking was associated with increased probability of oral infection (OR = 2.16 [95% CI 1.02-4.57], P = .038) and methotrexate with reduced probability (OR = 0.43 [95% CI 0.23-0.81], P = .006). On multivariate analysis, no RA variables were associated with oral infection. CONCLUSION: In our study, asymptomatic oral infection was confirmed in one third of RA patients.

Ultrasonography on the Early Postoperative Control of Severe Odontogenic Infections.

The management of odontogenic infections remains an important segment of the oral-maxillofacial surgical practice. The implementation of ultrasonography (US) imaging for the diagnosis of head and neck infections increases the possibility of visualizing the abscess collections in the deep neck spaces of lateral pharyngeal, masticator, and submandibular areas. The US imaging can detect the presence of fluid collections and edema, which may indicate local inflammation. Signs of deeper infections, such as subcutaneous emphysema and perifascial fluid, may also be apparent via US imaging. We present a new technique that uses US imaging to evaluate the deep neck infections after drainage from the early postoperative time to determine the locations of the drains inside the collection area and the edema of adjacent tissues. This technique is less costly than computed tomography or magnetic resonance imaging and allows for early assessment of adjacent tissues, leading to an earlier extubation and reduced hospitalization time and costs.

Increasing Use of Intensive Care Unit for Odontogenic Infection Over One Decade: Incidence and Predictors.

PURPOSE: To determine whether intensive care unit (ICU) admissions for odontogenic infections have increased during the past decade and whether certain clinical features are associated with a greater rate of ICU admission. MATERIALS AND METHODS: The data from patients undergoing surgery for odontogenic infections at the Royal Brisbane and Women's Hospital in the 24 month from January 2003 to December 2004 were compared with those from patients treated from January 2013 to December 2014. A χ2 analysis was used to compare the demographic, admission, and clinical patient data in each cohort. A multiple logistic regression model was used to determine which clinical features were associated with greater rates of ICU admission. RESULTS: The rate of ICU admission increased significantly from 7 to 24% during the decade (χ2 = 12.74; P = .000), although the clinical presentation of patients admitted to the ICU was similar in both cohorts. The mean number of days spent in the ICU increased significantly from 1.7 ± 0.5 to 3.24 ± 2.5 days (t = -3.63; P = .001), and the overall length of stay increased from 1.7 ± 0.5 to 3.5 ± 4.1 days (t = 2.99; P = .004). The use of preoperative computed tomography (CT) increased significantly from 42.9 to 93.3% (χ2 = 13.25; P = .000). The most significant predictors of ICU admission were lower third molar involvement (P = .026), dysphagia (P = .020), and C-reactive protein (CRP) levels exceeding 150 mg/L (P = .039). CONCLUSIONS: The use of the ICU in the management of odontogenic infection has increased significantly at the Royal Brisbane and Women's Hospital over 1 decade. The demographic data and clinical presentation of the patients admitted to the ICU did not change significantly. However, the length of ICU stay and the total length of stay have both increased. A significant increase in CT usage for odontogenic infections also occurred. Third molar infections, dysphagia, and elevated CRP might be relevant clinical predictors of a more complicated course of care requiring ICU admission. More judicious use of CT scanning, combined with prompt surgical consultation and intervention, might reduce the rate of ICU admissions for odontogenic infections.

Adult-onset Still's disease initially thought to be an odontogenic infection: A case report.

OBJECTIVE: To present a case of Adult-onset Still's disease (AOSD) initially suspected to be odontogenic inflammation. BACKGROUND: Adult-onset Still's disease is a rare, complex autoinflammatory disease and a known cause of fever of unknown origin. MATERIALS AND METHODS: The patient had both a fever and dental pain. Following meticulous examination, the patient was diagnosed with AOSD. CONCLUSION: Clinicians should keep in mind that a patient such as AOSD may visit their clinics.

Management of a Severe Cervicofacial Odontogenic Infection.

INTRODUCTION: Odontogenic infections originate from a tooth or from its supporting structures, generally secondary to a pulp necrosis, periodontal disease, pericoronitis, apical lesions, or complications of dental procedures, which can be restricted to the alveolus or can reach the jaws and face through maxillofacial spaces. These are the most common conditions which affect the head and neck regions. AIM: The aim of this study is to report a severe case of a cervicofacial odontogenic infection while discussing the most relevant aspects. CASE REPORT: A 47-year-old female patient with a background of diabetes mellitus (DM) had a cervicofacial infection presenting edema and erythema in the left hemiface extending from the frontoparietal to cervical region and was submitted to extensive surgical treatment combined with antibiotic therapy. CONCLUSION: Although the prevalence and complication rates of odontogenic infections had decreased with the advancement of diagnostic techniques, availability of effective antibiotics, and improvement in oral hygiene, still there are conditions that require attention and accurate treatment to prevent the progression of the pathology to deeper fascial spaces. CLINICAL SIGNIFICANCE: Odontogenic infections can be treated with fewer complications if approached earlier when diagnosed while their premature clinical manifestations. However, if the treatment is postponed and the infection spreads into deeper fascial spaces, it can damage vital structures, and, consequently, threaten the patient's life. In these cases, extensive and aggressive therapy should be performed.

Ultrasound-guided simultaneous irrigation and drainage of facial abscess.

The establishment of drainage and the elimination of the origin of infection are essential procedures for successful management of odontogenic infections. Irrigation and aspiration are considered as the 2 main procedures for the treatment of facial space infections; we invented a new method named simultaneous irrigation and aspiration. The simultaneous irrigation and aspiration method is significantly less painful and less invasive compared with the standard surgical incision and drainage. This method was thought to be useful for managing facial infections if proper patient selection is performed.

Descending necrotizing mediastinitis of odontogenic origin--personal experience and literature review.

UNLABELLED: Descending necrotizing mediastinitis is the most severe form of mediastinal infection. The aim of the study was to present the optimal diagnostic and treatment approach to this severe, life-threatening condition. PATIENTS AND METHODS: Three patients (men, aged 75, 73, and 63) with descending necrotizing mediastinitis hospitalised between April 2007 and February 2009 have been included in the study. The diagnosis of the condition was made based on cervico-thoracic computed tomography and surgical findings. The surgical treatment in each of the cases included bilateral longitudinal cervicotomy, transversal suprasternal cervicotomy and posterior-lateral thoracotomy. RESULTS: The period between the initiation of ambulatory treatment of the dental infection and diagnosing the mediastinitis was 9, 8 and 11 days, respectively. Engagement of all cervical spaces and mediastinal sections with polybacterial (three or more agents) dental infection, originating from third and fourth lower molars was present in each of the patients. Chronic alcoholism and diabetes are factors influencing the course of mediastinitis. The outcome in all the three patients was lethal (within 72 hours). CONCLUSION: Success in the treatment of descending necrotic mediastinitis of odontogenic origin may be expected only in case of early diagnose and aggressive cervical and mediastinal drainage, performed by bilateral longitudinal cervicotomy and posterior-lateral thoracotomy.

Odontogenic sinusitis: developments in diagnosis, microbiology, and treatment.

PURPOSE OF REVIEW: Odontogenic causes of sinusitis are frequently missed; clinicians often overlook odontogenic disease whenever examining individuals with symptomatic rhinosinusitis. Conventional treatments for chronic rhinosinusitis (CRS) will often fail in odontogenic sinusitis. There have been several recent developments in the understanding of mechanisms, diagnosis, and treatment of odontogenic sinusitis, and clinicians should be aware of these advances to best treat this patient population. RECENT FINDINGS: The majority of odontogenic disease is caused by periodontitis and iatrogenesis. Notably, dental pain or dental hypersensitivity is very commonly absent in odontogenic sinusitis, and symptoms are very similar to those seen in CRS overall. Unilaterality of nasal obstruction and foul nasal drainage are most suggestive of odontogenic sinusitis, but computed tomography is the gold standard for diagnosis. Conventional panoramic radiographs are very poorly suited to rule out odontogenic sinusitis, and cannot be relied on to identify disease. There does not appear to be an optimal sequence of treatment for odontogenic sinusitis; the dental source should be addressed and ESS is frequently also necessary to alleviate symptoms. SUMMARY: Odontogenic sinusitis has distinct pathophysiology, diagnostic considerations, microbiology, and treatment strategies whenever compared with chronic rhinosinusitis. Clinicians who can accurately identify odontogenic sources can increase efficacy of medical and surgical treatments and improve patient outcomes.

Imaging of Odontogenic Infections.

Odontogenic infections represent a common clinical problem in patients of all ages. The presence of teeth enables the direct spread of inflammatory products from dental caries, trauma, and/or periodontal disease into the maxilla and mandible. The radiographic changes seen depend on the type and duration of the inflammatory process and host body response. Imaging plays a central role in identifying the source of infection and the extent of the disease spread and in detecting any complications. Many different imaging modalities can be used. The radiographic features associated with acute and chronic inflammatory processes are discussed.

Controversies in the Management of Oral and Maxillofacial Infections.

The management and treatment of odontogenic infection, and its frequent extension into the head and neck, remains an important section of oral and maxillofacial surgical practice. This area of maxillofacial expertise is widely recognized by the medical community and an essential component to the hospital referral system. Although the general principles of infection management have not changed, there have been modifications in the timing of treatment sequences and treatment techniques. These modifications are influenced by the development of diagnostic methods and advances in bacterial genetics and antibiotic usage. This article reviews treatment considerations and controversies surrounding this subject.

Mediastinitis necrotizante descendente de origen odontogénico / Descending necrotizing mediastinitis of odontogenic origin

Resumen Introducción: El tratamiento inoportuno e ineficaz de las infecciones odontogénicas puede causar complicaciones potencialmente mortales como la mediastinitis necrotizante descendente (MND). La MDN es una infección grave que afecta al cuello-tórax, con una alta tasa de mortalidad por sepsis e insuficiencia orgánica si no se trata de manera rápida y efectiva. Objetivo: Describir un caso de MND de origen odontogénico y su manejo médico-quirúrgico. Caso clínico: Presentamos un paciente de sexo masculino de 34 años que ingresa con un cuadro infeccioso agudo de origen odontogénico, que compromete espacios de la cabeza, cuello y tórax (mediastino superior), el cual se trata exitosamente. Discusión: Las infecciones odontogénicas son generalmente localizadas y que se pueden tratar mediante terapias convencionales. A pesar de esto, si estas infecciones no pueden controlarse, ya sea por no realización de tratamientos oportunos o por estados inmunosuprimidos del paciente, se pueden desarrollar diferentes complicaciones como la MND. Conclusión: Un diagnóstico rápido, el tratamiento quirúrgico agresivo, la terapia antibiótica adecuada y la atención de apoyo son los pilares fundamentales para el manejo de la MND.

Introduction: Inappropriate and ineffective treatment of odontogenic infections can cause life-threatening complications such as Descending Necrotizing Mediastinitis (MND). MDN is a serious infection that affects the neck-thorax, with a high mortality rate from sepsis and organ failure if it is not treated quickly and effectively. Aim: To describe a case of MND of odontogenic origin and its medical-surgical management. Case report: We present a 34-year-old male patient who is admitted with an acute infectious condition of odontogenic origin, which compromises spaces of the head, neck and thorax (upper mediastinum), which is treated successfully. Discussion: Odontogenic infections are generally localized and can be treated by conventional therapies. In spite of this, if these infections cannot be controlled, either by not carrying out appropriate treatments or by immunosuppressed states of the patient, different complications such as MND can develop. Conclusion: A rapid diagnosis, aggressive surgical treatment, adequate antibiotic therapy and supportive care are the fundamental pillars for the management of MND.

Importância do exame radiográfico na avaliação odontológica prévia à cirurgia cardíaca / Importance of radiographic examination in dental evaluation prior to cardiac surgery

INTRODUÇÃO: A intervenção imediata em casos de focos infecciosos orais é extremamente necessária para prevenção da ocorrência de Endocardite Infecciosa (EI) nos pacientes com comprometimento valvar. Para tanto, o acompanhamento odontológico e a realização de exame radiográfico se faz indispensável na programação da cirurgia cardíaca. A radiografia panorâmica é um dos exames complementares mais requisitados em ambiente hospitalar, pois fornece qualidade de informações a respeito das condições dentárias e das estruturas de suporte associadas, sendo uma boa opção como exame de triagem e complementação diagnóstica. RELATO DE CASO: Paciente do gênero feminino, 74 anos, com diagnóstico médico de Insuficiência Cardíaca Congestiva perfil B, Estenose Aórtica sintomática, Insuficiência Tricúspide e Mitral importantes, internada em planejamento de intervenção cirúrgica cardíaca; solicitada avaliação odontológica pré-operatória, como protocolo da Instituição. Ao exame físico intra oral, paciente desdentada total superior e inferior com leve abaulamento em região ântero-posterior do rebordo maxilar. Foi requisitada radiografia panorâmica, sendo possível verificar a imagem sugestiva de raízes residuais intra ósseas na região dos dentes canino superior direito e primeiro molar superior direito. Realizada cirurgia exploratória com abertura de retalho em envelope para extração das raízes residuais, seguida de curetagem dos alvéolos, que continham grande quantidade de tecido de granulação apresentando secreção purulenta. Foi prescrita profilaxia antibiótica com 2G de amoxicilina uma hora antes do procedimento para prevenção de EI. Paciente foi, então, liberada para realização da intervenção cardíaca após remoção dos focos infecciosos orais. CONCLUSÃO: Nesse contexto, nota-se a importância do exame complementar radiográfico na avaliação odontológica para o correto diagnóstico e planejamento terapêutico do paciente, especialmente para aqueles em programação de cirurgia cardíaca.

Odontogenic facial swelling of unknown origin.

BACKGROUND: Current radiography techniques have limitations in detecting subtle odontogenic anomalies or defects that can lead to dentoalveolar and facial infections. This report examines the application of micro-CT imaging on two extracted teeth to enable detailed visualization of subtle odontogenic defects that had given rise to facial swelling. METHODS: Two extracted non-carious mandibular left primary canine teeth (73) associated with odontogenic infections were selected from two patients, and an intact contralateral tooth (83) from one of the patients was used as a control. All three teeth were subjected to three-dimensional micro-CT imaging at a resolution of 20 µm. RESULTS: Tooth 73 from the first case displayed dentine pores (channels) that established communication between the pulp chamber and the exposed dentine surface. In comparison, tooth 73 from the second case had a major vertical crack extending from the external enamel surface into the pulp chamber. The control tooth did not display any anomalies or major cracks. CONCLUSIONS: The scope of micro-CT imaging can be extended from current in vitro applications to establish post-extraction diagnosis of subtle odontogenic defects, in a manner similar to deriving histopathological diagnoses in extracted teeth. Ongoing technological advancements hold the promise for more widespread translatory applications.

[Cutaneous sinus tract due to an asymptomatic dental infection]. / Fisteldannelse i huden som følge af enubehandlet asymptomatisk tandinfektion.

Pyogenic cutaneous lesions of the cervicofacial region may have a variety of causes but one possibility that should be considered is a cutaneous sinus tract (CST) of dental origin. Correct diagnosis is based on a high index of suspicion and radiologic evidence of a dental pathology. Patients with odontogenic CST should be referred to a dentist and the treatment consists of either endodontic therapy or extraction of the involved tooth. We present a case report with misdiagnosis of CST of dental origin.

An unusual case of a brain abscess arising from an odontogenic infection.

A brain abscess that originates from an odontogenic infection, although rare, can at times be difficult to diagnose, especially in the context of pain and trismus. We report a rare case of odontogenic infection as a result of an infected maxillary third molar, causing an infratemporal and temporalis collection, resulting in a brain abscess with concurrent cerebritis. This is a clinical case review documenting an uncommon but potentially fatal complication.

Dental infections and coronary atherosclerosis.

An association between dental and other bacterial infections and coronary heart disease has recently been observed in both cross-sectional and longitudinal studies. To elucidate this topic, the severity of dental infections and coronary atheromatosis was assessed, together with measurements of the conventional coronary risk factors, in 100 individuals (88 men, 12 women, mean age 48, range 28-68 years) referred for diagnostic coronary angiography. Pantomography X-rays and coronary angiograms of the participants were scored blindly by single observers, a dentist and a radiologist respectively. The median pantomography score was 3.0 in male individuals belonging to the highest tertile of coronary atheromatosis score, as compared with 0.0 among the rest of the male participants (P = 0.003). The association between dental infections and severe coronary atheromatosis in males remained significant after adjusting for the effect of age, blood lipids, body mass index, hypertension, smoking and social class. No association between dental infections and coronary atheromatosis was observed in the small number of females studied. This observation supports the proposal that bacterial infections play a role in the pathogenesis of coronary atherosclerosis.

Oral infections in home-living elderly patients admitted to an acute geriatric ward.

Little is known about the oral health of the frail and home-living elderly. The effects of dentogenic infections on the general condition of the elderly are also unknown. We therefore set out to investigate 191 elderly patients referred to an acute geriatric hospital due to sudden worsening of their general health. The patients' mean age was 81.2 +/- 6.4 years (range, 67 to 96 years), and they had lived at home before hospitalization. The patients were examined and their diagnoses set by a team of physicians. The dentist's examination was also made bedside. Panoramic x-rays were taken for those who were able to stand (n = 148). Particular attention was paid to the occurrence of dental infection foci and systemic infection parameters of blood. Only patients free from other than dental infections were included in the statistical analyses (n = 184). Panoramic x-rays revealed dentogenic infection foci in 71.1% of the dentate patients. Periodontal condition was poor in 96.2% of the patients (CPI score, 2 to 4). All infection parameters were high in patients with high periodontal treatment need, but the differences were not statistically significant. Neither were there statistically significant correlations between the number of dentogenic infection foci recorded from the radiographs and infection parameters of blood. More of the edentulous patients had positive salivary yeast counts than did the dentate patients (84.4% vs. 66.1%; P < 0.05). No correlation was found between the main systemic diagnoses and dental infections. Since the prevalence of dentogenic infection foci in our subjects was high, and they did not cause marked increase in the hematological infection parameters investigated, it seems clear that geriatricians should refer their patients for dental examinations. Although our patients represent the home-living elderly population in a Nordic country with a high standard of living and good medical care, dental care had been neglected regardless of the patients' systemic disease.

Deep facial infections of odontogenic origin: CT assessment of pathways of space involvement.

PURPOSE: We investigated the pathways of spread of odontogenic infection in the facial and neck spaces. METHODS: CT scans of 45 patients with extensive spread of odontogenic infection into the facial and neck spaces were analyzed to document pathways of spread. RESULTS: Odontogenic infections arising in the mandible first spread upward, into the masseter and/or medial pterygoid muscles in the masticator space, and downward, into the sublingual and/or submandibular spaces, and then spread into the spaces or muscles adjacent to one or more of these locations. Infections from the masseter muscle spread into the parotid space to involve the temporalis and lateral pterygoid muscles. Infections from the medial pterygoid muscle spread into the parapharyngeal space to involve the lateral pterygoid muscle. Infections in the maxilla did not spread downward; instead, they tended to spread upward and superficially into the temporal and/or masseter spaces and deeply involve the lateral and/or medial pterygoid muscles in the medial masticator space. CONCLUSION: CT may be useful to depict the extent of infection and to plan treatment of extensive odontogenic infection, which can be life threatening when therapy is ineffective.

The masticator space: the influence of CT scanning on therapy.

The masticator space is an important suprahyoid tissue compartment bounded by the superficial layer of the deep cervical fascia, enclosing the ramus of the mandible plus the masseteric and pterygoid muscles. Pathology of this space has been clinically difficult to diagnose and treat. Twenty-five patients with either tumor or infection involving the masticator space who underwent CT scanning were evaluated retrospectively. Ten patients had infection and 15 had tumor. CT was influential in directing appropriate biopsies or therapy in 24 of 25 patients. It misguided therapy once. The gross anatomic and CT appearance of the normal and the diseased masticator space is described along with pictures of representative cases. A discussion is given of the advantages, disadvantages, and pitfalls of computerized tomography of the masticator space.