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.
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