P.139 Odontogenic infections requiring hospital care

Abstract

The initial use of penicillin in the therapy of odontogenic infections in the 1940s led to a dramatic decline in the mortality rates for these infections. In 1940, Williams published a case series of Ludwig's angina, in which 24 of 44 (54%) of patients died.23 Only 3 years later, Williams and Guralnick published a case series of 20 patients with Ludwig's angina, in which 2 of 20 (10%) patients died.24 The dramatic decline in mortality rates from this once-dreaded head and neck infection was primarily due to the introduction of penicillin. In the intervening decades, further refinements in diagnosis, airway management, and surgical therapy have rendered serious morbidity and mortality from odontogenic infections so uncommon that death from odontogenic infection is virtually inconceivable to the lay public. The reduced frequency of these infections makes their diagnosis more difficult for the average practitioner, and therefore careful study of severe odontogenic infections is necessary, or preventable deaths can occur.The most common cause of abscesses involving the deep fascial planes of the head and neck is odontogenic infection.1 Infections arising on the respiratory and mucosal surfaces of the head and neck tend to drain into the anatomic cavities found there, such as the sinuses and the pharynx. The otherwise closed cavities of the head and neck all have natural drainage pathways, such as the ostia of the sinuses and the Eustachian tube. Conversely, the teeth carry abscess-producing bacteria deeply into the jaw bones along the external surfaces and internal canals of the roots. Once the infection has spread beyond the apex of the involved tooth into the alveolar process of the maxilla or mandible, the bacteria can propagate and spread through the medullary spaces until the cortical plate of the jaw is reached and eventually perforated. The typical pathways for the spread of infection arising from the teeth are illustrated in Figure 1. When a particularly virulent dental infection passes beyond the jaw bone, the point of perforation determines which deep anatomic fascial space becomes infected next. For example, infection spreading beyond the roots of the mandibular molar teeth tends to rupture the thin medial cortical plate of the mandible below the attachment of the mylohyoid muscle. This then directs the infection into the submandibular space, from where the infectious process can spread to the sublingual, submental, or lateral pharyngeal spaces. Thus, dental infections tend to penetrate deeply into the face and neck and usually require surgical drainage, because natural anatomic pathways for drainage do not exist.For these reasons, the emergency medicine practitioner must maintain a high index of suspicion for odontogenic infection when a patient presents with a painful swelling of the face or neck. Deep fascial space infections of the head and neck can rapidly progress to threaten vital structures and to obstruct the airway. Therefore, timely consultation with a dentist or dental specialist, such as an oral and maxillofacial surgeon, can be lifesaving.The primary consideration in the management of these infections is establishing and maintaining the security of the airway, followed by the rapid establishment of dependent drainage and removal of the cause of the infection. Antibiotics are adjunctive therapy for odontogenic infections, because odontogenic infections treated by antibiotics alone can be temporarily suppressed, only to return in a more severe manifestation at a subsequent time. Delay in diagnosis and effective treatment can therefore allow the infection to spread into deeper anatomic spaces, which can precipitate more severe complications.