Basic and patient-oriented research
Severe Odontogenic Infections, Part 1: Prospective Report

https://doi.org/10.1016/j.joms.2006.03.015Get rights and content

Purpose

The purpose of this study was to prospectively evaluate a series of patients with severe odontogenic infections (OI).

Patients and Methods

In this study, 37 consecutive hospitalized patients with odontogenic infection were treated with intravenous penicillin (PCN) (unless allergic), and prompt incision and drainage. Standardized data collection included demographic, preadmission, time-related, preoperative, anatomic, treatment, microbiologic, and complications information. Appropriate descriptive statistics were computed.

Results

The sample consisted of 37 subjects (38% female) with a mean age of 34.9 years. Three subjects (8%) had immunocompromising diseases. Caries was the most frequent dental disease (65%) and the lower third molar was the most frequently involved tooth (68%). Trismus and dysphagia were present on admission in over 70% of cases. The masticator, perimandibular (submandibular, submental, and/or sublingual), and peripharyngeal (lateral pharyngeal, retropharyngeal, and/or pretracheal) spaces were infected in 78%, 60%, and 43% of cases, respectively. Abscess was found in 76% of cases. PCN-resistant organisms were identified in 19% of all strains isolated and in 54% of patients with sensitivity data. PCN therapeutic failure occurred in 21% of cases and reoperation was required in 8%. Length of hospital stay was 5.1 ± 3.0 days. No deaths occurred.

Conclusions

This study indicated that PCN resistance, resulting in PCN therapeutic failure, was unacceptably high in this sample. Alternative antibiotics, such as clindamycin, should be considered in hospitalized patients with OI. Masticator space infection occurred much more frequently than previously reported. Trismus and dysphagia should be appreciated as significant indicators of severe OI.

Section snippets

Study design/sample

In this study we used a prospective case series design, in which all consecutive patients with OI severe enough to justify hospitalization were treated with intravenous PCN (unless allergic) and incision and drainage of all affected anatomic deep fascial spaces as soon as possible during the hospital stay.

The subjects enrolled in this study presented for care between March 1996 and June 1999 at 1 of 4 large urban hospitals served by the Montefiore Medical Center Department of Dentistry,

Results

A total of 37 subjects (23 male, 14 female) from 14 to 76 years of age (mean 34.9 ± 15.8) were enrolled in this study. There were 20 (54%) African-American/black, 8 (22%) Hispanic, 8 (22%) Caucasian, and 1 (3%) Asian patient (Table 2).

Three subjects (8%) were PCN-allergic, 3 (8%) had immunocompromising diseases (2 insulin-dependent diabetics and 1 HIV-seropositive individual with a CD4 count of 400 cells/μL). There were 15 (41%) smokers, although this variable was not recorded for 4 subjects

Discussion

In this study we prospectively evaluated 37 consecutive patients with severe OI and managed them with a standardized protocol of high-dose intravenous PCN (unless the patient was PCN allergic) and early incision and drainage. We encountered a PTF rate of 21% in severe OI requiring hospitalization. Such a failure rate is clinically unacceptable. The isolation of 1 or more PCN-resistant strains in OI has risen steadily in 4 recent studies, from 33% of cases in 1991 to 55% in 1995, and 54% of

Acknowledgments

The authors wish to acknowledge Mauricio Wiltz, DDS, and all of the Oral and Maxillofacial Surgery residents at the Montefiore Medical Center for their assistance in the care of patients and gathering of data. This study was supported in part by the Montefiore Medical Center Department of Dentistry and the Massachusetts General Hospital Department of Oral and Maxillofacial Surgery Education and Research Fund.

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