Life-Threatening paediatric odontogenic cellulitis secondary to a partially erupted primary molar

Case report

This unusual presentation was of a 15-month-old male who was admitted to Great Ormond Street Hospital for Children (GOSH). He presented with a right unilateral facial and neck swelling of rapid onset over three hours, resulting in airway occlusion and septic shock. Medically, the child was fit and well with no pre-existing medical conditions, having been born at 39 weeks gestation without complications. Vaccinations were reportedly up to date. The patient's father reported that the patient initially displayed changes in behaviour indicative of toothache on the lower right quadrant. After two days, the father noticed a rapidly increasing facial swelling and called for an ambulance which took the patient to a local district general hospital. After admission, the patient's condition deteriorated, his airway was compromised and the patient was intubated before being transferred to GOSH due to the severity of his condition. The swelling was reported initially as in the right parotid region spreading to the submandibular region and then crossing the midline at the time of intubation (Figure 1). At the time of onset of the swelling, the patient's father noticed a green discharge from an apparent ‘hole in the gum’ of the lower right quadrant.

The patient remained intubated in the Paediatric Intensive Care Unit (PICU) for 13 days. During this time several medical specialties carried out various investigations to identify an underlying cause. Ultrasound examination of the neck and face found no discrete collection but noted extensive soft tissue oedema. Initial antibiotic therapy was commenced with co-amoxiclav as a first line therapy, however, this was changed to piperacillin-tazobactam and gentamicin after further deterioration. A cultured swab isolated Staphylococcus aureus (S aureus) and Streptococcus millerai.

On the seventh day of the patient's stay in PICU the dental team were contacted to assess for a possible dental cause. Extra-oral examination found a non-fluctuant, diffuse soft tissue swelling of the right face and neck. Intra-oral examination found the following teeth to be present: URB, URA, ULA, ULB, LLB, LLA, LRA, LRD. The LRD was partially erupted (Figure 2) with swelling of the overlying gingival tissues. Lateral oblique radiographs showed normal dental development and presence of the partially erupted LRD, which was intact and non-carious (Figure 3). The diagnosis reached was paediatric facial cellulitis of odontogenic origin secondary to the partially erupted LRD. The decision was made that extraction of LRD was not clinically indicated as it should spontaneously erupt fully in due course and high dose antibiotics were being administered. The patient's father was advised to keep the area clean with regular oral hygiene, corsodyl gel swabs and cessation of dummy use to prevent re-infection.

After 13 days in total, and continued antibiotic therapy, the swelling had reduced and the patient was extubated and discharged home with an uneventful recovery (Figure 4) and reviewed locally in primary care.

Discussion

Facial cellulitis is a bacterial infection of the dermis and subcutaneous tissue with the following classic clinical signs:

It is recorded in accordance with the Eron classification (Table 1).^{1, 2}

The diagnosis is usually based on clinical examination, and treatment should be based on the severity and underlying cause, which may involve incision and drainage supplemented with antibiotic therapy.^{2, 3} Any cellulitis resulting in a risk to the airway or the patient's acute systemic health should be treated as a medical emergency and managed by an appropriate team, which may include referral to emergency medical teams. Urgent admission to hospital should be sought for the following; anyone who has Class III or Classs IV cellulitis; severely deteriorating cellulitis; the very elderly or young; those with significant facial cellulitis; and those who are immunocompromised. Oral antibiotics may be administered in cases of less severe cellulitis.⁴

During the assessment of a patient with cellulitis, care should also be taken to assess for any underlying risk factors and co-morbidities so that these can be managed to aid recovery. Published guidance in relation to emergency dental care from SDCEP is a useful resource for general dental practitioners and classes ‘oro-facial swelling that is significant and worsening’ as an ‘emergency care’ condition which should be seen by a clinician within 60 minutes.⁵

Rapid resolution of such an infection can be helped by early diagnosis and appropriate antibiotic use.⁶ It is usual to begin empirical antibiotic therapy before a culture can be tested for sensitivity and then a definitive antibiotic therapy can be instigated. The value of early diagnosis and management highlights the importance of prompt dental input in cases of facial cellulitis in a hospital setting, as well as appropriate antimicrobial culture and sensitivity tests.

The most common organisms implicated are Haemolytic streptococci and Staphylococcus aureus (S aureus) and so empirical antibiotic therapy is targeted to these micro-organisms.⁷Staphylococcus aureus is a gram-positive bacterium which commonly colonizes the skin without problem, however, it can cause infection when entering the body, such as through a break in the skin or mucosa. Although local departments have individual antimicrobial policies, some evidence suggests flucloxacillin as a suitable empirical therapy, with clarithromycin as an alternative for those with penicillin allergy.⁸ If there is doubt in appropriate management, a microbiologist should be consulted.

Paediatric facial cellulitis is usually associated with carious teeth (of which posterior teeth are mostly affected) and can be preceded by toothache or less frequently trismus or pyrexia.⁶ This case was unusually associated with a non-carious but partially erupted deciduous tooth, which may have been precipitated by the tooth erupting causing a break in the oral mucosa and bacterial communication within the follicular space.

Conclusion

Overall, facial cellulitis in children of odontogenic origin is commonly associated with carious teeth and the association with an intact but partially erupted primary tooth is unusual. A large swelling in a child such as this requires immediate medical attention due to the risk of airway compromise. Dentists in both primary and secondary care should fully assess swellings for signs of cellulitis to avoid rapid spread and instigate appropriate management, or referral to suitable services.