Paula Piekoszewska-Ziętek1, Anna Turska-Szybka2, *Dorota Olczak-Kowalczyk2
Odontogenic infections – review of the literature
Infekcje zębopochodne – przegląd piśmiennictwa
1Doctoral Student, Department of Pediatric Dentistry, Medical University of Warsaw
Head of Department: Professor Dorota Olczak-Kowalczyk, MD, PhD
2Department of Pediatric Dentistry, Medical University of Warsaw
Head of Department: Professor Dorota Olczak-Kowalczyk, MD, PhD
Zmiany infekcyjne zębopochodne mogą wpływać na ogólny stan zdrowia człowieka. Szerząc się przez ciągłość, powodują zajęcie sąsiadujących przestrzeni anatomicznych. Wyróżniono kilka mechanizmów łączących infekcje zębopochodne ze schorzeniami ogólnoustrojowymi. Wysiew drobnoustrojów do krwi może być przyczyną infekcji ogólnoustrojowych i zmian zapalnych w narządach odległych od jamy ustnej. Coraz częściej infekcje jamy ustnej są wiązane z rozwojem chorób o etiologii wieloczynnikowej. Celem pracy było przedstawienie aktualnej wiedzy na temat infekcji zębopochodnych i ich wpływu na zdrowie człowieka. W bazach Pubmed/Medline oraz Embase poszukiwano prac oryginalnych opublikowanych od 2000 roku w języku polskim i angielskim, posługując się słowami kluczowymi dotyczącymi tematu pracy.
Wykorzystano 42 prace oryginalne. Omówiono postacie kliniczne zakażeń, ich rozpoznawania i leczenia. Przedstawiono drogi rozprzestrzeniania się infekcji i ich powikłania, a także aktualne poglądy dotyczące zależności między infekcjami w jamie ustnej a wybranymi chorobami ogólnymi.
Odontogenic infectious lesions may affect a human’s overall condition in a variety of ways. As they spread continuously, they involve many adjacent anatomical spaces. Several mechanisms linking odontogenic infections with systemic diseases have been specified. The bacteria penetrate the bloodstream, potentially causing systemic infections or inflammations in organs distant from the oral cavity. It is increasingly common for oral cavity infections to be associated with diseases of multifactor aetiology. The aim of the study was to present the current state of knowledge concerning odontogenic infections and their influence on human health. Pubmed/Medline and Embase databases were searched for original papers published since 2000, written in Polish or in English.
42 original papers were used. The following issues have been discussed: clinical presentations of infections, principles of diagnostics, and treatment. Pathways of infection spread and the complications have been described. Current views considering the relations between oral infections and chosen systemic diseases have also been presented.
Conditions posing a risk of systemic complications are understood as inflammatory responses that can transmit due to the spread of pathogens from the original site of involvement (1). Such inflammations may vary in location, yet most commonly they originate with tonsillar or odontogenic involvement (2). According to Kinzer et al. (3), tonsillitis remains the underlying cause of 70% of severe deep neck infections. In adults, however, it is a lack of adequate hygiene of the oral cavity and its consequences that play a significant role. The relationship between the general level of wellbeing and the quality of a person’s teeth was observed as early as in the ancient times, with the topic discussed by Assyrian, Egyptian and Greek physicians of the times alike.
Naturally, odontogenic pain and infections are a common reason for consulting a dentist (4). Their underlying reasons may vary, including e.g. dental caries, pulpitis and pulp necrosis, failed endodontic treatment, gingivitis or periodontitis, impacted teeth or impeded teeth eruption, conditions following apicoectomy, infected cysts, inflammation in the bony structures, retained dental roots. When untreated, odontogenic infections tend to spread rapidly and involve further anatomical structures in the cervical and craniofacial region (5-7). They may pose serious health or even life risk due to their direct proximity to the respiratory tract and the brain (8, 9). Pathogens may also penetrate the bloodstream, e.g. during dental procedures where surrounding tissue continuity is damaged. Even transient bacteraemia may lead to pathological changes in organs distant from the oral cavity. Among the diseases associated with odontogenic infections the following are listed: infective endocarditis, pneumonia, coronary artery disease, mediastinitis, myocarditis, brain stroke, aggravation of chronic obstructive pulmonary disease, anaemia, osteoporosis, rheumatoid arthritis, gout, cerebral abscess, iritis, keratitis, optic neuritis, Ludwig’s angina (lat. angina Ludovici), and sepsis (10, 11). The relationships between the incidence of these conditions and odontogenic infections have not so far been clearly explained and confirmed by research. The existence of odontogenic bacteraemia, however, does not raise any doubts (12, 13). According to Jundt and Gutt (14), the noxiousness and the potential deadliness of odontogenic infections remain underestimated, both by patients with lax oral hygiene standards, and physicians overestimating the value of antibiotic therapy as the sole solution. Greater stress put on dental prophylaxis, as well as early diagnosis and treatment of diseases of the oral cavity may have significant beneficial impact on the patient’s health, significantly reducing the risk of multiple systemic diseases (14).
This study is aimed at summarizing and presenting the current state of knowledge concerning odontogenic infections and their overall impact on human health, based on the available literature of the subject.
Material and methods
Pubmed/Medline and Embase databases were searched to find papers related to odontogenic infections, applying the following keywords: “odontogenic infection dentistry”, “odontogenic infection children”, “dental focal infection”, “dental focal infection children”, “focal infection theory”, “diabetes oral infection”, “diabetes oral bacteria”, “oral bacteria lung infection”, “odontogenic bacteraemia”, “endocarditis oral bacteria”, “odontogenic cardiovascular disease”, “odontogenic infection treatment”, “transplantation and odontogenic infection”, “transplantation and oral infection”, “chemotherapy and odontogenic infection”, “chemotherapy and oral infection”. The study has covered original papers published after 2000 in English or in Polish, related to children, adolescents or adults. The applied criteria resulted in 42 papers being selected for the purpose of this review.
Terminology and clinical presentation of inflammations
Inflammatory infiltration is a tissue response precipitated by the penetration of blood plasma and blood cells outside blood vessels. “Cellulitis”, or inflammation of connective tissue denotes the spread of inflammatory process resulting in a response manifesting as swelling and redness, as well as immune response of the body (5, 10). Untreated, this leads to a progression of the pathological process, i.e. the accumulation of the purulent content and formation of an abscess. An abscess is an encapsulated reservoir of pus, formed through the effect of cellular enzymes such as lysozyme, protease, lipase, and oxidase on necrotic tissues and leukocytes. In the craniofacial and cervical region it may be located either intraorally (abscesses of the vestibule, palate, canine fossa, the floor of the oral cavity, the tongue, and the cheek), or extraorally (submental, submandibular, submasseteric, peritonsillar, and buccal abscesses, abscesses of pterygomandibular space, pterygopalatine space, parapharyngeal space, temporal space, subtemporal space) (15). Acute purulent inflammation may originate from an infection of tissues surrounding the tooth (periodontal abscess) or pulpal disease (periapexal abscess). Depending on its stage, it manifests as a subperiosteal or submucosal abscess (16). Chronic purulent inflammation develops when a long-existing pathological lesion is limited by the immune system or is able to drain spontaneously by forming a fistula which is a canal connecting the focus of infection with the oral (mucosal fistula) or external environment (cutaneous fistula) (17).
Phlegmon is a diffuse, acute inflammatory condition of loose connective tissue, encompassing several anatomic spaces at the same time (5), with Ludwig’s angina, or phlegmon of the oral cavity, being it peculiar form. The disease process involves bilaterally the floor of the oral cavity, the sublingual space, submandibular and parapharyngeal space, pushing the tongue upwards, thus obstructing the airflow through the upper respiratory tract and causing dyspnoea. The patient’s condition is severe, with high temperature, chills and trismus, requiring immediate surgical intervention and hospital-based treatment (3, 8).
Underlying causes, location and spreading of the inflammatory process
Many authors have established the molar teeth (over 70% of cases), less frequently premolars, and canines (5, 10, 18, 19) to be the most common sources of infection, with pulpal pathologies (depending on the study, as much as 50-100% of cases) and periodontitis (20-30%) as the most frequent causes (3, 9, 20, 21). The inflammatory process can spread along the fascial spaces of the cranio-facial and cervical region, following the destruction of the osseous lamina. The infections diffuse by the continuity of tissues, involving further anatomical spaces. The transmission of the inflammatory process depends on the infection’s starting point (the maxilla or the mandible), its relation to the muscle attachments and the fascia. Fascial spaces are sites of reduced resistance, encompassing loose tissues. When infected, they swell and fill with serous or purulent exudate. Bacteria may penetrate blood vessels and travel to more distant sites in the body (22). A pathological process in the maxilla often spreads towards the cheek and the canine fossa, owing to the slight thickness of the buccal wall, or to the palate. In the posterior-lateral section, it may involve the subtemporal space, or damage the floor of the maxillary sinus. For the mandible, infections spread owing to the thin lingual lamina, in its anterior portion to the submental space, whereas in its lateral portion – to submandibular space, the floor of the oral cavity, or the sublingual space, depending on the location of dental roots in relation to the mylohyoid muscle (8, 10). According to Kinzer et al. (3) and Zhang et al. (23), it is most common for the submandibular space to be involved, less frequently – the cheek or parapaharyngeal space. The continuity of the spaces and the lack of anatomical barriers that would limit the infection contribute to the substantial danger of their spread to more remote anatomical sites. Spreading of the infectious process from the buccal space or the canine fossa towards the orbit may result in serious intracranial complications, due to the presence of the so called “triangle of death” in this particular region, namely the combination of the facial vein, angular vein and ophthalmic upper and lower veins, that all communicate with the cavernous sinus. The progression of the infectious process into the paraharyngeal or retropharyngeal space may lead to the involvement of the mediastinum. Such conditions are life-threatening (8, 24).
Among the symptoms of odontogenic diseases there is pain. The tooth becomes tender upon percussion or even upon regular contact when biting. The pain is acute, throbbing, possibly unremitting (4). When untreated, it is typical for a localized subperiosteal abscess to form, then a less painful submucosal abscess follows. The pain and the focal swelling are the first alarming symptoms, prompting the patient to seek the dentist’s intervention. According to studies conducted by Moghimi et al. (10), painful swelling prompted 100% of patients with a pathology situated within the maxilla and 86% of patients with one located in the mandible to see a dentist. Trismus tends to be another significant symptom, with prevalence of 50-65% (10, 14, 25). Infections associated with swelling of the neck may cause difficulties in swallowing, painful swallowing, the sensation of lacking air, or problems emitting voice (14, 18). According to Wang et al. (2), sore throat is also very common (72% of cases), particularly when the peritonsillar space is involved. The infections may be accompanied by fever and purulent exudate (14, 25, 26). Laboratory findings show an elevated WBW count and CRP level (3, 27). It is important to differentiate odontogenic pain from pain of different aetiology, such as the inflammation of the salivary glands, vasculitis, disorders of the temporomandibular joint, cluster headaches, or neuralgias, including trigeminal neuralgia (8).
The majority of odontogenic infections are linked to multiple bacteria, including aerobic, moderate anaerobic, and strict anaerobic bacteria. Streptoccocus viridans prove the most common ones, along with Klebsiella pneumoniae (22, 28). Depending on how advanced the studies are, various microorganisms are detected, with the most recent ones reporting the growing contribution of the anaerobic flora to the infections of the head and the neck. In their study that covered 96 patients, Lee and Kanagalingam (29) showed the pathogen most commonly isolated in the parapharyngeal space to be K. pneumoniae, whereas in the submandibular and parotid space – Streptococcus milleri and Staphylococcus aureus respectively. Bahl et al. (30) in their research into antibiotic susceptibility confirmed the most common aerobic bacteria in odontogenic foci to be of Streptococcus genus, whereas the anaerobic ones – the organisms of Bacteroides and Prevotella genera. It was emphasised that the bacteria were resistant to pure ampicillin, owing to the production of beta-lactamase by the organisms, that may lead to failed treatment with penicillin. Jundt and Gutt (14) conducted bacteriological tests of purulent exudate collected from odontogenic foci, isolating Streptoccous viridians, Peptostreptococcus, Staphylococcus, as well as bacteria of Prevotella, Bacteroides and Actionomyces genera.
Thorough extraoral examination is required, including palpation in the area of the sternocleidomastoid muscle and the lower edges of the mandible to identify any swollen structures or enlarged lymph nodes. The intraoral exam should be aimed at detecting any potential sources of infection, such as deep carious lesions, necrotic pulp, discoloured teeth, loose teeth, teeth tender to percussion, active fissures, or elevated mucosa (3, 17). It is necessary to evaluate the respiratory function and look for trismus (31). There are also indications for monitoring inflammatory markers such as CRP (8). Radiological imaging is necessary to confirm the diagnosis and the location of the inflammation focus. Most commonly, a panoramic radiograph is taken, whereas dental or bitewing radiographs are less frequently used (4). CT and MRI are the most sensitive modalities for imaging deep infections, particularly where there are reservoirs of purulent content, and they are most accurate in determining the location and the full extent of the infection. CT with a contrastive agent is used to evaluate the patency of the airways and the extent of deep-seated reservoirs of puss within the soft tissues (8, 32, 33). Noninvasive US examination may be applied to assess superficial infections, especially to rule out that exudate is accumulating (3, 32).
The primary principles of treating odontogenic infections have long been known, as they had been established well before antibiotics were discovered. These originally included draining the purulent exudate, removing the source of the inflammation (which boils down to the removal of the affected tooth, or currently also endodontic treatment) (6). With the rise of antibiotics, this scheme of action has been extended by the pharmacological treatment, i.e. antibiotic therapy, intravenous fluid therapy for better hydration, and adequate anaelgesic therapy (6, 9). The doctor who sees the affected patient first plays the crucial role in the treatment of odontogenic infections. The correct course of treatment consists in administering endodontic treatment or a surgical procedure (such as decompression of a submucosal abscess, or tooth extraction), or referring the patient to a specialist if necessary. Antibiotic therapy is crucial, yet treatment limited to its application is an incorrect way of proceeding, and may result in a decline in the patient’s condition or a relapse of the infection in an aggravated form at a later time (9, 18). Antibiotic therapy tends to be applied based on empirical grounds. The drugs should feature a broad spectrum of action, with commonly used ones including cephalosporins, penicillins, clindamycin, or metronidazole. If the patient’s condition fails to improve upon receiving the therapy, they should be tested for bacterial susceptibility, with an antibiogram obtained to determine effective treatment (3, 29, 34). Such tests have become increasingly important, as we are faced with a growing number of reports concerning the resistance of bacterial species causing odontogenic infections to antibiotics, mainly ones from the penicillin group (the incidence of penicillin-resistant microorganisms in the samples isolated from odontogenic foci ranges from 5 to 20%) or macrolides. There has been a study finding a susceptibility to penicillin in 87% of the bacteria from S. viridians genus, yet in as little as 27% of staphylococcus bacteria (22). In such cases, clindamycin, vancomycin or gentamicin are indicated (14, 22). The aim of the clinical examination is to facilitate a decision whether it is necessary to hospitalize the patient or ambulatory treatment is still feasible. Trismus limits the possibility to perform surgical treatment, oftentimes necessary to extract the affected tooth, in an ambulatory setting. The patient may require intensive care and postsurgical intubation. The duration of hospital-based treatment varies, ranging from several to over ten days (14, 18, 27). In their study, Kara et al. (35) demonstrated the duration of hospital stay to have been significantly statistically shorter for the infections of the upper portion of the face as compared to those with lower-face involvement. Prompt extraction of the affected tooth meant shorter hospitalization time.
Odontogenic infections have drawn the attention of a plethora of researchers. It is a problem that still fails to have been sufficiently explained, thus remaining a controversial issue, with theories related to the topic shifting and changing. The oral cavity may be a source of microorganisms able to spread to remote locations within the body. This puts patients affected with primary or secondary immune deficiency (36) at a particular risk. Dental procedures as well as daily activities such as chewing food or hygienic practices, when there is a coexisting periodontal disease or an orthodontic brace is worn, may pave the way for the bacteria to enter the bloodstream. Bacteraemia lasts approximately 30 minutes, with its peak taking place within the several initial minutes. Then, the level of bacteria in the blood gradually decreases due to the work of the immune system (37). Three mechanism have been specified that link the odontogenic infections to remote organs within the body. The first is a metastatic infection that occurs due to bacteraemia when the spreading bacteria are not inhibited by the mononuclear phagocyte system, and find environment promoting their growth. Another is a metastatic damage where bacteria produce exotoxins and proteins, including cytolytic enzymes, which secreted out of the bacterial organisms damage the host’s cells. Also, bacterial endotoxins are produced (e.g. lipopolysaccharide – LPS) that are released from cellular membranes upon a bacterium’s death, causing a sequence of pathological reactions in the body. The last one is a metastatic inflammation where bacterial antigens, upon penetrating the bloodstream, react with circulating antibodies, forming immune complexes causing acute and chronic inflammatory states in the locations where they are accumulated (13, 36). The spreading bacteria may cause systemic complications such as septic shock or multiple organ dysfunction. Their prevalence may amount to over 20% of cases, out of which 40-50% are mortal (10, 22, 23). Sepsis is diagnosed based on the presence of minimum two of the following symptoms: tachycardia > 90 heart beats per minute, body temperature below 36°C or above 38.5°C, respiratory rate > 20 per minute, elevated WBC count, or over 10% of immature forms. When treatment is inadequate, symptoms of dysfunction of subsequent body organs and systems follow, leading to consequences that are oftentimes irrevocable. In the gravest scenario the patient dies (23, 28).
Coronary artery disease (CAD)/ischaemic heart disease (IHD) results from narrowed coronary arteries, typically due to atherosclerosis. Its development is associated with certain risk factors that also include bacterial infections originating in the oral cavity. Periodontitis is believed to predispose for the development of atherosclerosis of coronary blood vessels, myocardial infarction, or brain stroke (11, 37). The relation between the bacteria of the oral cavity and the development of infectious endocarditis has also been known (12, 37). Several studies have been conducted aimed at explaining the relationship between odontogenic diseases and cardio-vascular conditions (11). Various mechanisms have been suggested as possible links between these disease entities. According to a hypothesis by Wick (38), heat-shock proteins of bacterial (GRoEL) and human (hHSP60) origin may mimic each other, thus causing a cross immune response against hHSP60 bacteria exposed on damaged endothelial cells. This finding has also been confirmed by Ford et al. (39) who established the presence of over-sensitive T lymphocytes in the peripheral blood of patients suffering from atherosclerosis. The antibodies produced against GroEL cross-reacted with hHSP60. There have also been studies evidencing that treated periodontitis significantly reduces the level of cardio-vascular markers, such as interleukins 6 and CRP, and affects endothelial function (40). The European Society of Cardiology (ESC) recommends preventive antibiotic treatment to be introduced in patients from the group at highest risk for infectious endocarditis, i.e. those with an artificial heart valve or artificial material used in a repair surgery of a heart valve, those with a history of infectious endocarditis, with a congenital heart defect, particularly tetralogy of Fallot (ToF), as well as in patients with palliative shunts, conduits, and other kinds of prostheses that remain as a result of a heart surgery, when they undergo procedures at highest risk for infectious endocarditis (dental procedures involving the gums, and the periapical teeth area, or involving the perforation of the oral mucosa, including plaque removal, teeth extraction and endodontic treatment) (41). Preventive treatment consists in the administration of amoxicillin or ampicillin orally or intravenously in the dosage of 2 g for adult patients, and 50 mg/kg of body weight for paediatric patients. Where there is an allergy to penicillins, clindamycin is indicated, administered orally or intravenously in the dosage of 600 mg for adult patients or 20 mg/kg of body weight for paediatric patients. The antibiotic is administered 30-60 minutes prior to the procedure, depending on the route of administration (41).
Diabetes is a metabolic disease characterized by hyperglycaemia related to a factual (type 1) or relative lack of insulin (insulin resistance – type 2). Severe periodontitis and diabetes are frequent comorbidities. In the light of current research, this seems a bilateral relationship, with both disease entities mutually affecting each other. Uncontrolled periodontitis contributes to the aggravation of diabetes, and impedes its metabolic control. Uncontrolled diabetes, in turn, exacerbates periodontitis. Diabetic patients have been proved to develop periodontitis more often, with its severity depending on the advancement of their primary condition. Owing to their compromised immunity, they are more prone to inflammatory processes of various kinds, including odontogenic ones, and thus to the diffusion of bacteria to remote sites in the body upon bacterial penetration of the bloodstream (27, 36). Studies conducted both in vitro and on a living organism have proved monocytes in diabetic patients to reveal an over-reactivity causing increased production of proinflammatory mediators (such as interleukin 1ß, prostaglandin E2, or TNF-α). Patients suffering from diabetes and periodontitis displayed a significantly higher level of inflammatory mediators as compared to patients without systemic comorbidities (42). Infections of the oral cavity may trigger an aggravation of a systemic disease. Diabetes and periodontitis cause physiological changes that are enhanced when these two entities overlap. Diabetes results in an excessive accumulation of glycation end products, which in the occurrence of a focus of infection causes an excessive response in the host. The increased resistance to insulin, reduced uptake of glucoses by the skeletal muscles, constitutes an element of the adaptation to the catabolic conditions accompanying the inflammation. Inflammatory mediators reduce the sensitivity to insulin, which is a feature linking inflammation to diabetes. Both, diabetes and infections alike, result in a metabolic disruption in the body, hence allowing the suspicion that each may adversely impact the other (42). Zheng et al. (43) in their study assessed the impact of diabetes on the course of severe cranio-facial and cervical infections. The compared factors included the aetiology, clinical parameters (duration, the involved spaces), and laboratory findings. Diabetics revealed a more severe course of the disease, a larger number of involved anatomical spaces, and a higher prevalence of complications, including a higher mortality rate, with the level of diabetes control (the glucose level on the admission day) being an important factor. The American Academy of Pediatric Dentistry (AAPD) includes diabetes in the group of systemic diseases associated with delayed wound healing and high incidence of infections. Hence, introduction of preventive antibiotic therapy in patients with type 1 diabetes and uncontrolled diabetes prior to performing dental procedures causing transient bacteraemia is indicated (34, 44).
Respiratory tract diseases
Bacteria inhabiting the oral cavity may have influence on the occurrence or aggravation of the diseases of the respiratory tract, such as bacterial pneumonia or chronic obstructive pulmonary disease. The underlying microorganisms include Staphylococcus aureus, Streptococci viridans, Streptococcus intermedius, Actinomyces odontolyticus, Haemofilus influenzae, Mycoplasama pneumoniae or Selenomonas spp. (36, 37). The bacteria may penetrate the lower respiratory tract as a result of aspiration of saliva, inhalation, by continuity of tissues, or via the vascular route. Aspiration pneumonitis may lead to the formation of an abscess or an empyema threatening with complications, possibly even including death. The predisposing factors include chronic pulmonary diseases, diabetes, age > 70 years, heart failure, smoking, alcohol dependency, immunosuppression, prolonged antibiotic therapy, impaired fagocytosis, artificial ventilation, or intubation (36, 45). Diseases of the respiratory system do not constitute an indication for antibiotic prophylaxis prior to dental procedures.
Rheumatoid arthritis (RA) is a chronic inflammatory rheumatoid disease of an autoimmune background. Both RA and periodontitis feature an increased level of pro-inflammatory cytokines, metalloproteinases, prostaglandin PG2, and inflammatory cells. Bacterial antigens cause an inflammatory response in the joints, facilitating colonization with bacteria. Nonetheless, dental procedures have not been assessed to constitute potential risk factors for the development of joint infections in the light of recently conducted studies (46, 47). In their study, Schram et al. (46) have even found RA patients to be less susceptible to the infections of joint replacements caused by oral bacteria than the control group. Antibiotic prophylaxis is not recommended for routine use prior to dental procedures in this group of patients, but ought to be individually considered (46).
Secondary immunodeficiency manifests as a compromised humoral or cellular immune response occurring in a healthy patient, following a disease or due to iatrogenic factors. They are related to the impairment of the body’s immune response by infections, metabolic disorders, malignancies, or toxins. Secondary immunodeficiency is more frequent than primary one, and it can affect all age groups. Their common causes include malnutrition, HIV/AIDS, malignant tumours, immunosuppressive treatment (48, 49). Over the recent years, an increase in the number of patients suffering from neoplastic disease and organ transplant patients has been noted, requiring regular dental check-ups and screening. Systemic complications following organ transplants may manifest in the oral cavity, predisposing for further development of the infection. Owing to the administration of immunosuppressive drugs, organ recipients may experience secondary immunodeficiency (50, 51). Bacterial, viral and fungal infections may have untypical presentations in such patients, dynamically spread to other organs, and be more resistant to treatment than in patients from the healthy population (52). Pathological processes in the oral cavity may, in turn, lead to an aggravation of the patient’s overall condition (51). Prior to conducting a dental procedure threatening with a transient bacteraemia, prophylactic antibiotic therapy should be administered to such patients (44). A collaboration between the dentist and the patient’s attending physician, able to prepare the patient adequately for the dental treatment (being equipped with relevant knowledge about the patient’s condition), should be a standard. A similar collaboration is necessary in the case of patients before, during, and after cancer treatment. The dentist’s role, according to AAPD, consists primarily in successfully treating all diseases of the oral cavity, as they may pose a potential infection risk, delay the treatment of the patient’s primary disease, or aggravate in the course of receiving therapy (53). Prior to receiving cancer treatment, the patient needs to be treated for all potential conditions threatening with systemic complications (54). Endodontic, surgical and periodontal treatment should be completed in a timeframe allowing the tissues to heal properly before the introduction of chemo- or radiotherapy (55). While cancer treatment is in progress, dental care should be focused on treating and alleviating the effects of its complications in the oral cavity. When necessary, dental treatment may be carried out, taking into consideration the patient’s current results, optimally in between chemotherapy cycles (55). The number of current publications describing the relationship between odontogenic infections and the complications in the course of chemotherapy remains scarce. Hong et al. (56) have stated infections of this type to occur in approx. 6% of patients treated for cancer, yet they may pose a substantial risk for the patient’s overall condition. Akashi et al. (57) observed severe odontogenic infections to have occurred in 5.4% of patients participating in their study. AAPD has developed guidelines concerning the use of prophylactic antibiotic treatment for patients who are to undergo dental procedures related to tissue damage and a risk for transient hyperaemia while receiving their cancer treatment. Administering an antibiotic is not indicated when the absolute neutrophil count > 2000/mm3. When it falls in the range between 1000 and 2000/mm3, the decision whether to administer an antibiotic depends on the patient’s general condition and the type of the procedure planned, whereas an absolute neutrophil count < 1000/mm3 necessitates any dental procedure to be performed in a hospital setting only. The patient’s attending physician may individually order a preventive, one-time antibiotic dose, or an extended drug administration scheme (53).
In their daily practice, dentists and dental surgeons commonly encounter cases of odontogenic infections that tend to pose diagnostic challenges. The diagnosis should always be based on a thorough clinical and radiological examination. Wang et al. (2) analysed 196 cases treated at Kaohsiung Medical university due to deep infections of the neck, finding odontogenic infections to be the second most common ones. Zhang et al. (23), in turn, in their study indicated 56.1% of the analysed cases to be odontogenic infections.
The majority of odontogenic infections take their source in the structures of the mandible rather than the maxilla. This is associated with trapping of food remnants, disposition to caries and pulpal disease, thus odontogenic infections, and the direct proximity of other anatomical spaces of the neck and the chest (10, 19). The infections are most typically associated with side teeth, mandibular third molars in particular (18). Kinzer et al. (3) have pointed out the role of prostheses in the occurrence of odontogenic infections. Dental prostheses, placed in the oral environment, are colonized by the same bacteria, pathological and physiological flora alike. In three of the examined patients, an abscess of the retropharyngeal space or of the mediastinum was observed after they had aspirated a prosthesis.
While substantial attention has been paid to odontogenic infections in adult patients, there is a shortage of publications devoted to children. Michael and Hibbert (6) in their study described the aetiology, characteristics and methods of treatment of odontogenic face oedema in a paediatric population. They identified several treatment options for those cases, including immediate hospital admission, introduction of intravenous antibiotic therapy, and surgical treatment, immediate surgical treatment without pharmacological therapy, or an initial antibiotic therapy followed by causal treatment after acute infection symptoms resolve. Kara et al. (35) examined the effect of prompt surgical intervention (within 48 hrs) on the overall time of treatment of connective tissue inflammation in children, demonstrating prompt extraction to reduce hospitalization time. The source tooth and the TBC findings are of importance here as well. Odontogenic infections in children call for immediate intervention, as due to immune immaturity and the anatomical structure of the bones, they may spread very rapidly, resulting in serious topical and systemic complications. The collaboration between the treating doctor and the young patient may be difficult, owing to the child’s apprehension and anxiety, difficulty in accurately expressing how they feel, and their lack of cooperation during various tests and examinations, including the radiological one, ultimately delaying diagnosis and treatment (6).
It is important for the dentist to be able to diagnose and administer adequate medical care in the case of odontogenic infections. Untreated, or misdiagnosed, they lead to a number of serious, or even life-threatening complications. With such morbid clinical implications in mind, adequate prophylaxis is of utmost importance. Whenever caries, pulpal or periodontal disease occur, treatment should be instituted without any delay, to prevent the progress of the infection and the spread of the bacteria that potentially result in an aggravation of the patient’s overall condition.
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