Are Deep Odontogenic Infections Associated With an Increased Risk for Sepsis?

BACKGROUND: Quick Sequential Organ Failure Assessment (qSOFA) is recommended to identify sepsis. Odontogenic infection (OI) can progress to sepsis, causing systematic inflammatory complications or organ failure. PURPOSE: The purpose of the study was to measure the association between OI location and risk for sepsis at admission. STUDY DESIGN, SETTING, AND SAMPLE: This retrospective cohort study included subjects treated for OI at Baylor University Medical Center in Dallas, TX, from January 9, 2019 to July 30, 2022. Subjects > 18 years old who were treated under general anesthesia were included. OI limited to periapical, vestibular, buccal, and/or canine spaces were excluded from the sample. PREDICTOR VARIABLE: The primary predictor variable was OI anatomic location (superficial or deep). Superficial OI infection includes submental, submandibular, sublingual, submasseteric, and/or superficial temporal spaces. Deep OI includes pterygomandibular, deep temporal, lateral pharyngeal, retropharyngeal, pretracheal, and/or prevertebral. MAIN OUTCOME VARIABLES: The primary outcome variable was risk for sepsis measured using a qSOFA score (0 to 3). A higher score (>0) indicates the patient has a high risk for sepsis. COVARIATES: Covariates were demographics, clinical, laboratory, and radiological findings, antibiotic route, postoperative endotracheal intubation, tracheostomy, intensive care unit, admission, and length of stay. ANALYSES: Descriptive and bivariate analyses were performed. A χ2 test was used for categorical variables. The Mann-Whitney U test was used for continuous variables. Statistical significance was P < .05. RESULTS: The sample was composed of 168 subjects with a mean age of 42.8 ± 21.5 and 69 (48.6%) subjects were male. There were 11 (6.5%) subjects with a qSOFA score > 0. The relative risk of a qSOFA > 0 for a deep OI is 5.4 times greater than for a superficial OI (136 (95.8) versus 21 (80.8%): RR (95% confidence interval): 5.4 (1.51 to 19.27), P = .004). After adjusting for age, sex, American Society of Anesthesiologists score, and involved anatomical spaces, there was a significant correlation between laterality and the number of involved anatomical spaces and qSOFA score (odd ratio = 9.13, 95% confidence interval: 2.48 to 33.55, adjusted P = <.001). CONCLUSION AND RELEVANCE: The study findings suggest that the OI location is associated with the qSOFA score >0.

When is surgical intervention needed in oral and maxillofacial space infection patients? A retrospective case control study in 46 patients.

OBJECTIVE: Patients with mild oral and maxillofacial space infection (OMSI) usually need only antimicrobial therapy. However, surgical intervention is eventually needed after using antibiotics for a period. The objective of this study was to explore the risk factors for drug therapy failure in OMSI. SUBJECTS AND METHODS: A retrospective case‒control study was designed. From August 2020 to September 2022, patients at Shanghai Jiao Tong University Affiliated Ninth People's Hospital who were diagnosed with OMSI were retrospectively reviewed. The outcome variable was surgical intervention after the use of antibiotics. We collected common biological factors, including demographic characteristics, routine blood test results, C-reactive protein (CRP) levels and composite indicators, such as neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR). The χ2 test and binary logistic regression were used to examine the association between biological factors and the outcome variable. RESULTS: Forty-six patients were included in this study. Further surgical intervention was needed in 20 patients (43.5%). The NLR showed a significant association with further surgical drainage (p = 0.01). A binary logistic regression equation was found by using stepwise regression based on the Akaike information criterion (R2 = 0.443), which was associated with sex (odds ratio [OR], 0.216; p = 0.092), NLR (OR, 1.258; p = 0.045), red blood cell (RBC) count (OR, 4.372; p = 0.103) and monocyte (MONO) count (OR, 9.528, p = 0.023). Receiver operating characteristic analysis produced an area under the curve for NLR of 0.725 (p = 0.01) and for the binary logistic regression model of 0.8365 (p < 0.001). CONCLUSION: Surgical interventions are needed in some mild OMSI patients when antimicrobial therapy fails to stop the formation of abscesses. The binary logistic regression model shows that NLR can be used as an ideal prognostic factor to predict the outcome of antimicrobial therapy and the possibility of requiring surgical intervention. STATEMENT OF CLINICAL RELEVANCE: Using simple, inexpensive, and easily achieved biological parameters (such as routine blood test results) and composite indicators calculated by them (such as NLR) to predict whether surgical intervention is needed in the future provides a reference for clinical doctors and enables more cost-effective and efficient diagnosis and treatment.

Is there need for technical investigations in order to predict potential length of hospital stay of oral infections?

OBJECTIVE: Oral and maxillofacial infections are generally treated by primary dental or medical caregivers. Nevertheless, because these infections are known to have life-threatening complications, there is a need of clear indicators for emergency services medical staff, particularly in determining when morbidity can be expected and when in-hospital treatment is required. This retrospective study aimed to identify variables that were observable at admission, which could indicate high complication rates, long hospital stays, and/or a need for tracheostomy. MATERIALS AND METHODS: We examined data from all cases of severe oral and maxillofacial infections that were treated at the University Hospital of Leuven, between January 2013 and June 2017. 64 cases were identified after applying exclusion criteria. Uni- and multivariate analyses were performed. RESULTS: A univariate analysis showed that body temperature, C-reactive protein (CRP) levels, white blood cell counts, and positive bacterial cultures were significantly associated with longer hospital stays, which indicated potential future morbidity. A multivariate analysis showed that dyspnoea, age, and CRP comprised the most significant combination for predicting the length of hospital stay. CONCLUSION: Based on the statistical analysis of this population, the research group concludes that a thorough anamnesis and clinical examination should be accompanied by a blood analysis of CRP and white blood cell counts. Only then can a well-founded decision be reached on the severity of the case and the need for hospital admission. In an acute setting, radiological imaging is not required for assessing future morbidity, but it should be performed when accessible.

Clinical characteristics and course of primary brain abscess.

BACKGROUND: Due to improved diagnostic methods, the incidence of brain abscess is still rising. Therefore, clear and evidence-based therapy for the patients who suffer from brain abscesses is necessary. Brain abscesses are potentially life-threatening conditions that possibly lead to permanent injuries even after sufficient healing has taken place. The aims of this study were to analyze the clinical aspects of patients with brain abscesses and thereby to reveal the relevant aspects for the future treatment of the brain lesions. METHODS: We retrospectively identified 47 patients (24 male, 23 female) who had received surgery or undergone the frameless stereotactic drainage of brain abscesses in our center from March 2009 to May 2017. We analyzed the clinical characteristics of the patients, as well as comorbidities and outcomes. RESULTS: The mean age was 58 (range 7 to 86). Focus identification was successful in 28 patients (60%), with the most frequent causes of brain abscesses including the following: sinusitis (25%), dental infections (25%), and mastoiditis (21%). The mean Charlson Comorbidity Index was 1.57. Among the patients, 34% showed immunosuppressive conditions. We performed 1.5 surgeries per patient (53% via craniotomy, 28% biopsies or stereotactic drainage, 19% both procedures), followed by antibiotic treatment for 6.5 weeks (mean). In 30% of patients, no bacteria could be isolated. During the follow-up period (a median of 12 months), 23.4% of the patients died. The mortality rate during the initial hospital stay was 4.3%. CONCLUSION: One third of the patients with brain abscesses showed immunosuppressive conditions, whereas brain abscesses also often occur in patients with good medical conditions. The isolation of the focus of infection is often possible. Surgical procedures showed very good outcomes. Patients over 60 years showed significantly worse clinical outcomes.

Necrotizing Orbital Cellulitis Secondary to Odontogenic Streptococcus constellatus.

A 69-year-old woman with orbital cellulitis secondary to odontogenic Streptococcus constellatus was transferred to the authors' institution for surgical management of infection refractory to intravenous antibiotics. She underwent debridement with preservation of the globe, recovering full motility. Visual recovery was limited by optic nerve ischemia. This case supports the importance of urgent surgical drainage in necrotizing orbital infections secondary to odontogenic Streptococcus constellatus.

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.

The importance of early intervention in the treatment of dental infection.

UNLABELLED: With recent reports of increasing hospital admissions relating to dental infection, the authors believe it is time to re-visit the importance of its effective early treatment. A series of three cases is used to illustrate the potentially life-threatening progression of what, in the early stages, is an easily treatable condition. CLINICAL RELEVANCE: The principles of effective management of dental infection are highlighted in the first instance and then indications for specialist maxillofacial referral are discussed.

Vacuum-assisted closure of a tissue deficit of the submental area in a patient with a necrotizing soft tissue odontogenic infection.

Odontogenic infections can rarely progress to necrotizing soft tissue infections. Cervical necrotizing fasciitis (CNF) is a rare but fulminant infection that spreads along the fascial planes, including connective tissue, muscle, and subcutaneous fat, and is typified by necrosis of the skin and other adjacent tissues. This article aims to present the treatment of a patient with submental skin and soft tissue necrosis due to an odontogenic infection and the subsequent management of the tissue deficit with a vacuum-assisted closure (VAC) system. The patient presented with extensive skin necrosis in the submental area and was immediately hospitalized, and management of the odontogenic infection was performed. When the patients' infection had been sufficiently controlled, a wound VAC device was placed in the deficit. The VAC device was removed after 12 days, and the patient was discharged. In conclusion, VAC can be used to manage tissue deficits with good aesthetic results.

Periodontal disease and systemic illness: will the evidence ever be enough?

The concept of focal infection or systemic disease arising from infection of the teeth was generally accepted until the mid-20th century when it was dismissed because of lack of evidence. Subsequently, a largely silo approach was taken by the dental and medical professions. Over the past 20 years, however, a plethora of epidemiological, mechanistic and treatment studies have highlighted that this silo approach to oral and systemic diseases can no longer be sustained. While a number of systemic diseases have been linked to oral diseases, the weight of evidence from numerous studies conducted over this period, together with several systematic reviews and meta-analyses, supports an association between periodontitis and cardiovascular disease, and between periodontitis and diabetes. The association has also been supported by a number of biologically plausible mechanisms, including direct infection, systemic inflammation and molecular mimicry. Treatment studies have shown that periodontal treatment may have a small, but significant, systemic effect both on endothelial function and on glycemic control. Despite this, however, there is no direct evidence that periodontal treatment affects either cardiovascular or diabetic events. Nevertheless, over the past 20 years we have learnt that the mouth is an integral part of the body and that the medical and dental professions need to work more closely together in the provision of overall health care for all patients.

Increased infection risk postliver transplant without pretransplant dental treatment.

OBJECTIVE: Infections cause considerable morbidity after liver transplantation (LT). Acute liver failure is a rapidly progressing life-threatening condition where pretransplant dental evaluation is not always possible. We investigated how missing pretransplant dental treatment in acute or subacute liver failure correlates with post-transplant infectious complications. SUBJECTS AND METHODS: Medical and dental data came from hospital records and infection data from the Finnish LT registry. The follow-up was until February 2011. Of 51 patients (LT during 2000-2006), 16 had and 35 did not have dental treatment pretransplant. RESULTS: Univariate Cox regression analysis demonstrated a 2.46-fold (95% CI 1.06-5.69) infection risk among the patients omitted from dental treatment. After adjustment for either pretransplant factors alone or both pre- and post-transplant factors, the corresponding infection risk increased, respectively, to 8.17-fold (95% CI 2.19-30.6) and 8.54-fold (95% CI 1.82-40.1). This increased risk involved a variety of bacterial, viral, and fungal infections of various sources both < 6 and > 6 months after transplantation. CONCLUSION: High risk of infections was noticed in acute liver failure patients without pretransplant dental treatment, but a more severe medical condition might have influenced the results. We encourage eradication of dental infection foci whenever clinical condition allows.

The role of unfinished root canal treatment in odontogenic maxillofacial infections requiring hospital care.

OBJECTIVES: The aim of this study was to evaluate clinical and radiological findings and the role of periapical infection and antecedent dental treatment of infected focus teeth in odontogenic maxillofacial abscesses requiring hospital care. MATERIALS AND METHODS: In this retrospective cohort study, we evaluated medical records and panoramic radiographs during the hospital stay of patients (n = 60) admitted due to odontogenic maxillofacial infection originating from periapical periodontitis. RESULTS: Twenty-three (38 %) patients had received endodontic treatment and ten (17 %) other acute dental treatment. Twenty-seven (45 %) had not visited the dentist in the near past. Median age of the patients was 45 (range 20-88) years and 60 % were males. Unfinished root canal treatment (RCT) was the major risk factor for hospitalisation in 16 (27 %) of the 60 cases (p = .0065). Completed RCT was the source only in 7 (12 %) of the 60 cases. Two of these RCTs were adequate and five inadequate. CONCLUSIONS: The initiation of inadequate or incomplete primary RCT of acute periapical periodontitis appears to open a risk window for locally invasive spread of infection with local abscess formation and systemic symptoms. Thereafter, the quality of the completed RCT appears to have minor impact. However, a considerable proportion of the patients had not received any dental treatment confirming the importance of good dental health. Thus, thorough canal debridement during the first session is essential for minimising the risk for spread of infection in addition to incision and drainage of the abscess. If this cannot be achieved, tooth extraction should be considered. CLINICAL RELEVANCE: Incomplete or inadequate canal debridement and drainage of the abscess may increase the risk for spread of endodontic infection.

Death due to eosinophilic necrotizing myocarditis despite steroid treatment.

We report a case of a 16-year-old boy who was treated for a suspected dental infection with a tooth extraction and amoxicillin therapy. The decedent developed a rash and presented to the emergency department with what was thought to be a possible allergic reaction to amoxicillin despite completion of the antibiotic course. The patient was given a course of prednisone. Several weeks later, while still completing the course of prednisone, the patient experienced shortness of breath and collapsed. Resuscitation efforts were unsuccessful. Postmortem examination revealed a necrotizing eosinophilic myocarditis. This case reveals that despite steroid therapy, a patient may still die of eosinophilic myocarditis.

Odontogenic infection causing orbital cellulitis in a pediatric patient.

Odontogenic abscess can become an orbital cellulitis, causing potentially serious intracranial and orbital complications. The full clinical complications from odontogenic orbital cellulitis in a pediatric patient are rarely seen daily in hospital emergency departments. Thus, odontogenic orbital cellulitis still remains a rarity, resulting in a medical challenge. With this in mind, this study aimed to describe a case of periorbital and orbital cellulitis resulting from odontogenic origin in a 6-year-old patient who was successfully treated by performing intravenous antibiotic administration combined with surgical drainage.

A case report of Lemierre's Syndrome associated with dental sepsis.

INTRODUCTION: Lemierre's syndrome is a potentially fatal condition characterised by spread of an oropharyngeal infection, resulting in thrombosis of the internal jugular vein. This leads to septicaemia and possible metastatic abscesses. CASE PRESENTATION: We discuss the case of a previously healthy 17-year-old male who developed Lemierre's syndrome following dental sepsis. He presented with bilateral submandibular and submental swelling extending into the neck and chest. His management included a tracheostomy; incision and drainage of the abscesses; drainage of a pleural effusion and prolonged anticoagulant therapy. CONCLUSION: The incidence of Lemierre's disease appears to be increasing and early diagnosis is essential. A high index of suspicion is needed in cases of oropharyngeal infection followed by fever, tender swelling of the neck and dysphagia - especially in young patients.

Periodontal disease: Mechanisms of infection and inflammation and possible impact on miscellaneous systemic diseases and conditions.

Periodontitis is a chronic inflammatory disease, resulting from a predominantly gram-negative microbial infection within the sub-gingival dental plaque biofilm. The resulting inflammatory response in the periodontal tissues may facilitate intravascular dissemination of micro-organisms and their products, throughout the body. The total surface area of this inflammatory field is estimated to be the size of the palm of the hand. A skin lesion of this size would prompt immediate medical intervention. However, the intra-oral (and similar-sized) infection is frequently ignored by health professionals, despite the fact that it may be associated with a range of systemic diseases/conditions.

Odontogenic cervico-fascial infections: a continuing threat.

STATEMENT OF THE PROBLEM: Dental abscesses are common and occasionally can progress to life-threatening cervico-fascial infections. Despite medical advances, odontogenic cervico-fascial infections (OCFIs) continue to be a threat. The potential seriousness of odontogenic infections (Ols), or dental abscesses, is frequently underestimated. General dental practitioners (GDPs) in primary care face the challenging decision of whether to refer patients to secondary care or to manage them in the community. PURPOSE OF THE REVIEW: This paper reviews the relevant aspects of Ols that might be helpful to primary care dental practitioners in providing a better understanding of the anatomy and pathology and aims to assist in clinical decision. METHOD: An up-to-date review of literature on OCFIs, highlighting their potential risks with clinical examples. RESULTS AND CONCLUSION: Dental abscesses are common and continue to be a major cause for emergency hospital admission to oral and maxillofacial surgery departments. They occasionally spread to fascial spaces of the neck, potentially posing significant morbidity and mortality. GDPs are usually the first point of contact and face the challenge of recognising those at risk of developing OCFIs, which are potentially life threatening and require urgent referral for hospital treatment. We propose a patient care pathway to be used in primary care.

Determinant of antibacterial failure in patients with head and neck infections with odontogenic source.

INTRODUCTION: Odontogenic infections are polymicrobial in origin and can be life-threatening. Antibacterial failure is an important issue in the treatment of odontogenic infections. This study aimed to determine the factors associated with antibacterial failure in patients with head and neck infections with odontogenic sources. MATERIAL AND METHOD: This retrospective epidemiological study was performed using data collected from 229 patients with head and neck infections with an odontogenic source who had been operated on in Shahid Rajaee hospital from March 2014 to December 2019. RESULTS: 123 (53.7%) patients were female and there were106 (46.3%) males. The mean age ± SD was 33.01±13.37 years (range 7 to 80). The most common offending teeth were lower molars (81.7%) and lower premolars (5.7%). The most common site of infection was the submandibular area (36.4%) followed by the buccal (20.4%) and pterygomandibular (17.1%) regions. The most common pathogen was Streptococcus haemolyticus. The length of hospitalization was higher (4.66 days) in patients with failure of treatment compared to those without it (6.00 days) (p=0.002). A combination of penicillin G and metronidazole was prescribed for all patients with failure of treatment compared with 57.6% in patients without failure of treatment (p=0.002). There was no statistically significant difference between the two groups regarding age, duration of illness before hospitalization, WBC, gender and history of chemotherapy, hypertension, smoking, pregnancy, alcohol usage, diabetes mellitus, the rate of fever, trismus, dysphagia, malaise, antibiotic before hospitalization, and surgical approach. CONCLUSION: Possible determinants in this study were not associated with antibacterial failure. Further studies should be conducted to investigate this relationship.

Is there association between severe multispace infections of the oral maxillofacial region and diabetes mellitus?

PURPOSE: This study aims to identify the impact of diabetes on the final outcome (length of hospital stay and development of complications) in patients with severe multispace infections in the head and neck. Furthermore, it intends to characterize significant clinical features of these patients compared with nondiabetics. MATERIALS AND METHODS: A retrospective study was conducted in 117 patients who received treatment for multispace infections of the head and neck region from 2007 through 2010 at the Department of Oral and Maxillofacial Surgery, Shanghai Ninth Hospital. The study identified diabetic patients and compared them with nondiabetic patients. Demographics, etiology of infection, clinical parameters (time from first onset of symptoms to hospital admission, number of spaces affected, and distribution of involved spaces), and laboratory values (bacteriology, admission blood glucose level, admission white blood cell count, and percentage of neutrophils on admission) were analyzed for clinical significance. Statistical analyses of the results between groups were performed using the Student t test, χ(2) test, variance analysis, logistic regression analysis, and linear regression analysis. RESULTS: Admission blood glucose level was the only factor influencing the complications in multispace infections in the oral-maxillofacial region. Compared with nondiabetic patients, diabetics had infections that involved more spaces, longer hospital stays, and more frequent complications. Some diabetic patients died. The disease status (with or without diabetes) was associated with clinical outcomes (length of hospital stay and complications) in the therapy procedures. CONCLUSIONS: This study identifies uncontrolled diabetes mellitus as an important indicator of clinical features and outcomes in treating multispace infections of the oral-maxillofacial region.

Ascending necrotizing fasciitis of the face following odontogenic infection.

Necrotizing fasciitis (NF) of the face is a rare but extremely dangerous complication of dental infection associated with a nearly 30% mortality rate. This infection spreads rapidly along the superficial fascial planes of the head and neck and can lead to severe disfigurement. Reports in the literature of cases of NF of the face caused by dental infection are few. We report such a case in a 36-year-old woman and review the current standards of diagnosis and management. The patient initially presented with pain and severe swelling in the left side of her face subsequent to a dental infection. The symptoms had progressed quickly and had not improved with administration of oral antibiotics in the outpatient setting. The patient had no palpable crepitus despite its classic association with NF. The infection also took a rare, ascending route of spread with involvement of the temporalis muscle. Cultures taken during debridement grew Streptococcus anginosus and Bacteroides. Biopsies of involved muscle showed histologic evidence of necrosis. Through early surgical intervention including aggressive debridement, and the adjunctive use of appropriate antibiotics, the patient recovered with minimal loss of facial mass and no skin loss. Although NF of the face is rare, the surgeon must maintain a high index of suspicion with any patient presenting after a dental infection with rapid progression of swelling and a disproportionate amount of pain that is unresponsive to antibiotics.