From Volume 41, Issue 1, January 2014 | Pages 68-72
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.
Recent reports have highlighted a worrying rise in the number of patients admitted to hospital for incision and drainage of dental abscesses under general anaesthetic.1,2
An article reviewing such hospital admissions in England as a whole found that the number almost doubled between 1998 and 2006.1 A group of authors in Hull Royal Infirmary have reported a less dramatic, but still substantive, increase of 47% in their unit between 1999 and 2004.2
Fortunately, death from dental sepsis is rare in the UK.3,4 However, there is still the potential for significant associated morbidity. A series of three cases is presented which have been referred recently to maxillofacial departments across Scotland. We believe these serve to highlight the ease with which a simple dento-alveolar infection can become potentially life-threatening.
A common theme among these cases is airway compromise due to aggressive infection spreading through the soft tissue spaces in the oropharynx and neck. Figures 1 and 2 demonstrate several of the potential soft tissue spaces, normally filled with loose areolar connective tissue, which can allow rapid spread of infection.
Dental abscess can lead to airway embarrassment and the following cases highlight the dangers of suboptimal initial management of dental infection. A compromised airway often happens via swelling of the submandibular and sublingual spaces, resulting in elevation of the tongue. There is also the possibility of pus entering the lateral pharyngeal and retropharyngeal spaces where swelling can lead to tracheal deviation and also reduce the diameter of the upper airway. Pus may then track inferiorly through the deep cervical fascia of the neck towards the mediastinum.
A 30-year-old fit and healthy male was originally admitted under the care of ENT (ear, nose and throat) for the management of dysphagia and odynophagia. These symptoms had been present for three days and were increasing in severity. He received medical management for tonsillitis and was discharged from hospital.
He was re-admitted the following day, again under the care of our ENT colleagues, for an enlarging swelling in his left neck with associated trismus. The neck swelling was described as being 3 cm in diameter, firm and non-fluctuant. He was only able to consume liquids due to ongoing odynophagia. At this point, he remained afebrile with stable observations. Further examination of the head and neck revealed multiple carious teeth in the upper and lower left quadrants of his mouth. Routine bloods revealed a raised CRP (C-reactive protein) and white cell count, both indicative of acute infection. The oral and maxillofacial team were then asked for an opinion (Figure 3).
Clinical and radiographic examination demonstrated caries and periapical pathology in teeth UR6, UL7 and LL8, with collections in the left submasseteric, submandibular and parapharyngeal fascial spaces. There was also deviation and restriction of the airway as demonstrated by Figure 4. Theatre was expedited for urgent tracheostomy to secure his airway. He underwent incision and drainage of the collections and extraction of UR6, UR5, UL7, LL8 and LR8. Post-operatively, he spent one night in HDU (high dependency unit) before being transferred to the general ward.
The tracheostomy was removed after five days and the patient discharged after a nine-day stay in hospital. He was finally discharged from oral and maxillofacial surgery as an outpatient five weeks after his initial admission. Upon discharge, he had lost two stones in weight, his trismus had still not fully resolved, and he was undergoing jaw physiotherapy.
This case highlights that a delay in treatment due to referral to the incorrect specialty may result in a compromised airway and significant morbidity.
A 32-year-old male was transferred to the maxillofacial department after an initial referral to ENT. He had a five-day history of sore throat and worsening left submandibular swelling, which was tender and firm. He was unable to swallow his own saliva.
Recent dental history included an incomplete root canal treatment on a lower left molar. Medically, he was fit and well and his observations on admission included a temperature of 38.0 ºC, blood pressure 127/71 mmHg, heart rate 92, and oxygen saturation 99% on air. His CRP was raised at 153.
Nasoendoscopy revealed a compromised upper airway and the patient was therefore intubated. A CT (computed tomography) scan revealed collections of pus in the left sublingual space, crossing the midline, and in the left submandibular space. All collections were seen to be anterior to the hyoid bone. Extensive subcutaneous oedema was noted over the anterior neck but there was no prevertebral or upper mediastinal collection (Figure 5).
A diagnosis of Ludwig's angina was made, necessitating the placement of a tracheostomy and bilateral incision and drainage of the fascial spaces. Extractions of teeth LL6, LL7 (retained roots) and LL8 were undertaken. As seen in Figure 6, drains were placed in the left and right submasseteric and left submental spaces.
Additional treatment involved aggressive therapy with IV antibiotics (benzylpenicillin and metronidazole). Culture and sensitivity testing revealed oral flora only. The patient remained in HDU for two nights. The tracheostomy was removed after five days, and the patient had a total stay in hospital of eight days. He was finally discharged from maxillofacial care after review two weeks later.
Again, a case highlighting the significance of dental infection that demonstrates airway compromise and significant morbidity. A 46-year-old man was referred to the maxillofacial department by his general dental practitioner initially complaining of a five-day history of left-sided toothache. He had been prescribed oral antimicrobial therapy. Over this five-day period, his pain was increasing and he began to develop neck swelling. This left-sided facial and neck swelling was associated with decreased mouth opening. At presentation to the maxillofacial unit, the patient was grey in colour and cold to touch and was finding it difficult to swallow his saliva.
His temperature was 38.9 ºC, blood pressure 132/85mmHg, heart rate 101, and oxygen saturation on air 98%. He had an extensive medical history: including a stroke one year previously; two MIs (myocardial infarctions); a quadruple heart bypass and hypertension. Bloods on admission showed an elevated WCC (white cell count) of 13.2 and a raised CRP of 178. Intra-oral dental examination was difficult and the patient was unable to tolerate a panoramic radiograph. A postero-anterior mandible and a lateral oblique view were therefore taken and revealed multiple carious teeth in the lower left quadrant of his mouth.
By the time the patient was taken to theatre for incision and drainage of the left-sided submandibular dental abscess and extraction of teeth, he was in a rapidly deteriorating condition. He developed stridor and was unable to be intubated by a consultant anaesthetist. As such, an emergency tracheostomy had to be performed with the patient awake under local anaesthetic. Teeth LL5, LL6 and LL7 were extracted.
The high airway pressures at attempted intubation (and then, tracheostomy placement) resulted in a right-sided pneumothorax. A chest drain was inserted in ITU (intensive therapy unit). After an overnight stay in ITU, the patient returned to the maxillofacial ward. The intra-and extra-oral drains placed in theatre were removed two and three days post-operatively, respectively.
The patient remained as an inpatient for a further seven days on IV co-amoxiclav, then IV clindamycin as per advice from microbiology. He was decannulated four days post-operatively. He was eventually discharged after being under the care of the maxillofacial surgery team for eight days.
From the case reports above, it is immediately obvious how serious dental infection can be, even in young, fit and well individuals. It is also apparent that delays in treatment of the initial toothache are what make the difference between resolution, with simple dental treatment, and major surgery in a hospital setting.
Fortunately, none of these cases resulted in mortality. However, the airway was compromised in all three cases. Three relatively recent reports3,4,5 discuss cases where dental sepsis resulted in death. The causes varied from erosion of the subclavian vein, disseminated intravascular coagulation and descending necrotizing mediastinitis. This is all exceptionally worrying as the mean age for patients admitted to hospital requiring drainage of dental-related sepsis is 32 (in England).1
Many reasons may be suggested as to why patients fail to seek treatment of toothache promptly. One paper2 notes that more than 60% of patients presenting with dental sepsis on an emergency basis were not registered with a dentist. Another report of a fatal case states that the patient in question cited a ‘fear of doctors and dentists’ as the reason for not seeking help.4
All too often, the maxillofacial service sees cases of patients with dental abscesses managed with oral antibiotics only, the cause of the problem being allowed to persist.
Should a patient present with a facial swelling, there are several warning signs to assess as indicators that referral for maxillofacial management is required. These are listed in Table 1.
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The importance of early treatment of dental infection is self-evident and has previously been highlighted.1,3,4 It is therefore worth emphasizing the local measures which should be employed:6
There is clearly also a need to educate our medical colleagues to ensure the rapid onward referral of this patient group.
