Flynn 2006
Flynn 2006
Flynn 2006
64:1104-1113, 2006
Purpose: The purpose of this study was to identify significant predictors of 4 outcomes in patients with
severe odontogenic infections: abscess formation, penicillin therapeutic failure (PTF), length of hospital
stay (LOS), and need for reoperation.
Patients and Methods: We used a prospective case series study design and enrolled 37 consecutive
patients admitted for severe odontogenic infection between March 1996 and June 1999. Treatment
consisted of intravenous penicillin (PCN) or clindamycin in PCN-allergic patients, surgical incision and
drainage, and extraction(s) as soon as possible. Study variables were categorized as demographic,
preadmission, time-related, preoperative, anatomic, treatment, microbiologic, and complications. The
primary outcome variables were abscess formation, PTF, LOS, and reoperation. Multivariate linear and
logistic regression techniques were used to measure associations between study variables and the
outcome variables.
Results: The sample consisted of 37 subjects (23 male, 14 female) with a mean age of 34.9 ⫾ 15.8 years.
Multivariate analyses, controlling for confounding variables, indicated that culture of Peptostreptococci
was a negative predictor of abscess formation. LOS was predicted by the number of infected spaces and
duration of operation. There was no significant predictor of PTF or reoperation on multivariate analysis,
although PCN-resistant organisms were isolated in all cases of PTF.
Conclusion: Increased LOS in severe odontogenic infections is predicted by the anatomic extent and
severity of the infection and the occurrence of complications such as PTF and the need for reoperation.
PTF is significantly associated with later identification of PCN-resistant organisms. The role of Peptostrep-
tococci in abscess formation warrants further investigation.
© 2006 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 64:1104-1113, 2006
Dodson et al,1 Biederman and Dodson,2 Peters et al,3 The predictor variables identified in these studies
and Huang et al4 identified predictor variables associ- included admission temperature, admission white
ated with increased hospital stay and other unfavor- blood cell count (WBC), systemic diseases, and in
able outcomes, such as the need for surgical drainage. pediatric patients over the age of 5, lower face infec-
tions and odontogenic etiology.
The specific aim of this study was to identify pre-
*Assistant Professor of Oral and Maxillofacial Surgery, Harvard dictors of unfavorable outcomes in patients with se-
School of Dental Medicine, Boston, MA; and Associate Visiting vere odontogenic infections (OI): 1) abscess forma-
Surgeon, Massachusetts General Hospital, Boston, MA. tion; 2) penicillin therapeutic failure (PTF); 3) length
†Howard Hughes Medical Institute-National Institutes of Health Re- of hospital stay (LOS); and 4) complications. We hy-
search Scholar, National Institutes of Health, Bethesda, MD; and Pre- pothesize that we will be able to identify 1 or more
doctoral Candidate, Harvard School of Dental Medicine, Boston, MA. variables associated with these unfavorable out-
‡Associate Professor of Oral Health Policy and Epidemiology, comes.
Harvard School of Dental Medicine, Boston, MA.
Supported in part by the Montefiore Medical Center Department
of Dentistry and the Massachusetts General Hospital Department of
Patients and Methods
Oral and Maxillofacial Surgery Education and Research Fund.
Address correspondence and reprint requests to Dr Flynn: Har- STUDY DESIGN/SAMPLE
vard School of Dental Medicine, 188 Longwood Ave, Boston, MA In this study we used a prospective case series
02115; e-mail: [email protected] design in which consecutive patients with OIs severe
© 2006 American Association of Oral and Maxillofacial Surgeons enough to justify hospitalization were treated with
0278-2391/06/6407-0016$32.00/0 intravenous (IV) penicillin (PCN) or clindamycin (in
doi:10.1016/j.joms.2006.03.031 PCN-allergic patients) and surgical incision and drain-
1104
FLYNN, SHANTI, AND HAYES 1105
age (I&D) of all anatomic deep fascial spaces affected Table 1. SEVERITY SCORES FOR SEVERE
by cellulitis or abscess as soon as possible during their ODONTOGENIC INFECTIONS
hospital stay.
The subjects enrolled in this study presented for Severity Score Anatomic Space
care between March 1996 and June 1999 at 1 of 4 Severity score ⫽ 1 Vestibular
large urban hospitals served by the Montefiore Medi- (low risk to Subperiosteal
cal Center Department of Dentistry, including Monte- airway or vital Space of the body of the mandible
fiore Medical Center, Jack Weiler Hospital at the Al- structures) Infraorbital
Buccal
bert Einstein College of Medicine, North Central Severity score ⫽ 2 Submandibular
Bronx Hospital, and Jacobi Medical Center in New (moderate risk Submental
York, NY. To be eligible for enrollment, subjects had to airway or Sublingual
to be admitted to the hospital for evaluation and vital structures) Pterygomandibular
management of a severe maxillofacial infection of Submasseteric
Superficial temporal
odontogenic origin, determined by the attending oral Deep temporal (or infratemporal)
and maxillofacial surgeon. The patient had to consent Severity score ⫽ 3 Lateral pharyngeal
to enrollment using forms and procedures developed (high risk to Retropharyngeal
for this institutional review board-approved study. airway or vital Pretracheal
The criteria for hospital admission were: OI causing structures) Danger space (space 4)
Mediastinum
swelling in 1 or more of the deep fascial spaces of the Intracranial infection
head and neck, impending threat to the airway or vital
structures, fever greater than 101°F, need for general NOTE. The severity score for a given subject is the sum of the
severity scores for all of the spaces involved by cellulitis or abscess,
anesthesia, or the need for inpatient control of a based on clinical and radiographic examination.
concomitant systemic disease. Potential subjects were Flynn, Shanti, and Hayes. Severe Odontogenic Infections. J Oral
excluded from this study according to the following Maxillofac Surg 2006.
criteria: pregnancy, nonodontogenic cause (eg, trau-
ma-related or upper respiratory infection), and refusal
of consent. Previously published nomenclature and The demographic variables recorded were age, gen-
descriptions of the deep fascial spaces were used for der, and race. Preadmission variables were: smoking,
the purposes of this study.5,6 drug allergies, preadmission antibiotic therapy, and
the presence of immunocompromising diseases. The
TREATMENT METHODS time-related variables were: the number of preopera-
All patients were subjected to the treatment proto- tive days of pain, preoperative days of swelling, LOS,
col described in our previous report.7 IV PCN 2 mil- operating room time, time between admission and
lion units was administered every 4 hours. PCN-aller- surgery, and season of the year. To maximize the
gic patients received IV clindamycin 900 mg every 8 accuracy of anamnestic data, such as the number of
hours. Broad-spectrum antibiotic therapy with genta- days of preoperative swelling, questions were care-
micin, metronidazole, and clindamycin was used in fully scripted on the data recording form, limited to
patients with necrotizing fasciitis. All patients were the current episode of infection, and verified by the
taken to the operating room for I&D of all anatomic attending surgeon.
spaces affected by cellulitis or abscess as soon as Preoperative clinical variables included causative
possible after admission. Culture and sensitivity test- teeth, number of teeth involved, dental diagnosis
ing was performed at surgery for all patients. (such as caries, periodontal disease, or pericoronitis),
PTF was defined as the need to discontinue PCN dyspnea, dysphagia, trismus (maximum interincisal
because of: 1) toxic or allergic reactions; 2) develop- opening ⱕ20 mm), WBC, and admission core temper-
ment of necrotizing fasciitis; or 3) failure of clinical ature.
improvement 48 hours or more after I&D plus post- The anatomic variables were: deep fascial spaces
operative computed tomography imaging demon- involved by cellulitis or abscess, number of spaces
strating adequate drainage of all affected anatomic affected, and severity score (SS). A severity rating of 1,
spaces. 2, or 3 was given to each anatomic space according to
its low, moderate, or high severity, respectively, as
STUDY VARIABLES detailed in Table 1.
Study data were collected for each patient using a The recorded treatment variables were the ana-
standardized data form. The variables were catego- tomic spaces that were drained and the presence or
rized as demographic, preadmission, time-related, absence of pus at surgical drainage. If pus was
preoperative, anatomic, treatment, microbiologic, present, the stage of infection was recorded as ab-
and complications. scess; if not, then the stage of infection was recorded
1106 SEVERE ODONTOGENIC INFECTIONS
No. of % of No. of % of
Cases Cases Cases Cases
Gender Infratemporal 1 3
Male 23 62 Maxillary sinus 1 3
Female 14 38 Parotid 1 3
Ethnicity Groups of spaces affected
African-American/black 20 54 Masticator 29 78
White 8 22 Perimandibular (submandibular,
Hispanic 8 22 sublingual, and submental) 22 60
Asian 1 3 Space 3 (lateral pharyngeal,
Penicillin allergy 3 8 retropharyngeal, and pretracheal) 16 43
Immune system compromise Stage of infection
Diabetes 2 5 Cellulitis (no pus at I&D) 9 24
HIV seropositivity 1 3 Abscess (pus at I&D) 28 76
Smoking Antibiotics used
Not recorded 4 11 Penicillin 33 89
Yes 15 41 Clindamycin 3 8
No 18 49 Gentamicin ⫹ metronidazole ⫹
Preadmission antibiotics clindamycin 1 3
No antibiotic 17 46 Airway management techniques
Penicillin 10 27 Fiberoptic intubation 18 49
Clindamycin 5 14 Direct laryngoscopic intubation 16 43
Penicillin ⫹ cephalexin 2 5 No intubation 3 8
Erythromycin 1 3 Tracheotomy (at reoperation) 1 3
Penicillin ⫹ clindamycin 1 3 Penicillin therapeutic failure (N ⫽ 33)* 7 21
Penicillin ⫹ metronidazole 1 3 Facial nerve deficit 3 8
Dental etiology Need for reoperation 3 8
Caries 24 65 Death 0 0
Periodontitis 8 22
Pericoronitis 8 22 *Thirty-three of 37 subjects received penicillin. Three subjects
received clindamycin because of penicillin allergy and 1 received
Needle track infection (after dental clindamycin, gentamicin, and metronidazole because of necrotizing
procedures) 2 5 fasciitis.
Postoperative infection (third molar
exodontia) 1 3 Flynn, Shanti, and Hayes. Severe Odontogenic Infections. J Oral
Maxillofac Surg 2006.
Teeth involved
Lower third molars 25 68
Other lower posteriors 18 49
Upper third molars 3 8 required reoperation had a mean LOS of 10.0 ⫾ 4.0
Other upper posteriors 3 8 days, while patients who did not require reoperation
Upper anteriors 0 0 had a mean LOS of 4.62 ⫾ 2.5 days (t test, P ⫽ .001).
Lower anteriors 0 0 There was no statistically significant association be-
Dyspnea 5 14
Dysphagia 29 78
Trismus (MIO ⱕ 20mm) 27 73
Season of occurrence Table 3. CONTINUOUS STUDY VARIABLES
Summer 15 41
Spring 8 22 Mean Years
Autumn 7 19 ⫾ SD Range
Winter 7 19 Age 34.9 ⫾ 15.8 14–76
Spaces affected White blood cell count on
Pterygomandibular 22 60 admission (⫻103) 14.9 ⫾ 4.2 5.9–26.0
Submandibular 20 54 Admission core temperature (°F) 101.3 ⫾ 1.3 98.0–104.4
Lateral pharyngeal 16 43 Number of teeth involved 1.5 ⫾ 0.9 1–5
Buccal 15 41 Days of preoperative swelling 8.2 ⫾ 14.6 1–71
Space of body of mandible 13 35 Time between admission and
Submasseteric 9 24 OR (hours) 5.1 ⫾ 7.5 0.2–23.3
Deep temporal (including infratemporal) 6 16 Duration of surgery (hours) 2.1 ⫾ 0.7 0.9–3.8
Sublingual 6 16 Number of spaces affected 3.3 ⫾ 1.5 1–8
Submental 4 11 Severity score 6.0 ⫾ 3.1 1–16
Superficial temporal 3 8 Number of spaces drained 3.1 ⫾ 1.8 1–8
Infraorbital 2 5 Length of hospital stay (days) 5.1 ⫾ 3.0 1–14
Retropharyngeal 2 5
Flynn, Shanti, and Hayes. Severe Odontogenic Infections. J Oral
Maxillofac Surg 2006.
1108 SEVERE ODONTOGENIC INFECTIONS
1 B F/22 12.6 7 4 2 99 Y N 3 N
2 W M/22 11.6 4 2 1 145 N N 4 N
3 B M/23 13.0 3 2 1 82 Y N 3 N
4 A F/45 13.7 4 2 1 94 Y N 3 N
5 W M/26 13.8 3 2 2 116 Y N 3 N
6 H F/43 15.6 3 3 3 102 Y N 6 Y
7 B M/21 15.4 7 4 1 70 Y N 3 N
8 B M/33 14.2 5 3 2 75 Y N 4 N
9 W M/76 15.3 5 4 1 55 Y C 4 N
10 B M/54 13.0 3 3 2 60 Y N 4 N
11 B F/27 17.0 13 6 1 200 Y Y 9 N
12 H M/46 11.7 2 2 3 113 Y N 4 N
13 B F/21 26.0 8 4 2 154 Y N 7 N
14 B F/45 6.7 5 2 1 110 Y Y Y 5 N
15 W F/60 14.7 6 3 3 90 Y Y Y 6 N
16 B M/14 12.1 2 1 1 115 Y C Y 3 N
17 B M/41 15.1 8 4 2 175 Y N N 6 N
18 B F/23 21.6 4 5 1 100 N Y Y 14 Y
19 W F/22 13.6 6 3 3 120 N Y Y 7 N
20 B M/42 16.1 9 4 1 225 N Y Y 9 N
21 W M/31 12.4 7 2 1 115 Y C N 2 N
22 H M/45 16.9 16 8 5 182 Y NF Y 14 N
23 H F/29 10.4 6 6 1 180 N N N 7 N
24 B F/19 16.2 5 2 1 135 Y N N 4 N
25 H M/25 18.2 12 6 1 190 Y N N 6 N
26 B M/24 22.1 5 4 1 110 Y N N 3 N
27 B M/39 24.9 9 5 1 157 Y N N 10 Y
28 W M/28 13.8 5 2 1 185 Y N Y 4 N
29 B F/31 16.8 6 4 2 130 Y N Y 3 N
30 B M/23 12.7 8 4 1 110 N N N 3 N
31 B F/75 5.9 1 1 1 80 Y N N 3 N
32 H M/36 11.3 5 3 1 160 N N N 3 N
33 B M/29 14.8 5 2 1 90 N N N 4 N
34 B F/21 15.3 6 3 1 120 N N Y 4 N
35 H M/28 19.8 9 3 1 175 Y N N 4 N
36 W M/71 12.6 3 2 1 106 Y Y Y 5 N
37 H M/30 13.0 5 2 1 112 Y N Y 1 N
Abbreviations: A, Asian; B, African-American/black; H, Hispanic; W, white; WBC, white blood cell count on admission; OR, operating room;
I&D, incision and drainage; PTF, penicillin therapeutic failure; PCN, penicillin; LOS, length of hospital stay; C, subject received clindamycin;
NF, subject received multiple antibiotics for necrotizing fasciitis.
Flynn, Shanti, and Hayes. Severe Odontogenic Infections. J Oral Maxillofac Surg 2006.
Peptostreptococci in culture had only 86% of the risk allergy or necrotizing fasciitis were excluded from the
of abscess formation seen in subjects that are culture- model because they had no possibility of developing
negative for Peptostreptococci. When all 37 cases (in- PTF. Using logistic regression analysis, no significant
cluding those without complete culture and sensitiv- predictor of PTF was found when all potentially con-
ity data) were included in this model, the results were founding variables were controlled for.
similar (OR ⫽ 0.10; CI, 0.01 to 1.005; P ⫽ .05). To create a multivariate model for LOS, we selected
To create a multivariate model for PTF, we selected a set of variables that were biologically important
a set of variables that were biologically important (age, gender, and race) or were nearly or actually
(age, gender, and race) or were nearly or actually statistically significantly associated with LOS (P ⱕ
statistically significantly associated with PTF (P ⱕ .15). The potentially significant predictor variables
.15). The potentially significant predictor variables were: WBC, immune system compromise, SS, number
were: age, gender, white ethnicity, presence of PCN- of infected spaces, time in the operating room, space
resistant organisms, LOS, and dyspnea on admission. 3 infection, number of involved teeth, infection of
The 4 subjects that did not receive PCN because of upper third molars, infection of non-third molar lower
1110 SEVERE ODONTOGENIC INFECTIONS
another study, by using contrast-enhanced computed ported no increased incidence of severe OI in HIV-
tomography combined with physical examination, seropositive subjects, but did find an increased inten-
Miller et al13 detected abscess formation with 95% sity of care required in these cases. In a retrospective
sensitivity, 80% specificity, and 89% accuracy. series of 185 cases, Huang et al4 found a statistically
There were no preadmission, timing, anatomic, or significant correlation of medically compromising dis-
preoperative clinical variables that predicted PTF by eases, including diabetes, renal insufficiency, hepatic
multivariate analysis. It is also interesting to note that cirrhosis, myeloproliferative disorders, and chemo-
none of the species or groups of related species iden- therapy, with advancing age, LOS, complications, the
tified in our cultures was significantly associated with need for tracheotomy, and death. Chen et al,20 in a
PTF, in spite of recent reports of increasing PCN retrospective analysis of 214 cases, found significant
resistance among oral pathogens.14-16 However, all associations of immunocompromising diseases, such
patients who experienced PTF were later found to as diabetes, renal failure, and malignancy, with com-
harbor PCN-resistant organisms (Fisher’s exact, P ⫽ plications of infection such as death, shock, medias-
.001). tinitis, and necrotizing fasciitis. The lack of statisti-
The identification of PCN-resistant pathogens is of- cally significant association between LOS and immune
ten delayed for as much as 2 weeks when conven- system compromise found in the current study may
tional culture and sensitivity methods are used for be because of the small sample size, because the
slow-growing oral bacteria. Therapeutic decisions relationship was nearly significant (t test, P ⫽ .11).
must often be made in an earlier time frame. This Grodinsky and Holyoke21 found that infection in-
points out the need for more rapid methods of bac- volving space 3, which includes any or all of the
terial identification and antibiotic sensitivity testing, lateral pharyngeal, retropharyngeal, and pretracheal
such as molecular techniques based on the polymer- spaces, nearly significantly predicted LOS on bivariate
ase chain reaction.17 analysis (t test, P ⫽ .053.) Because the SS assigns a
In other studies of orofacial infections, several clin- greater weight to space 3 infections, its value as a
ically useful predictors of the LOS have been identi- means of assessing and quantitating the severity of
fied, including admission WBC and temperature, cases is supported by this finding. SS was significantly
lower face infection, and medical or immune system associated with LOS on bivariate analysis (linear re-
compromise.1-4 In this study, only complications (PTF gression, P ⫽ .007), but this relationship was not
and re-operation) and variables related to the ana- significant when other potential confounding vari-
tomic extent or location of the infection (number of ables were controlled for on multivariate analysis.
infected spaces, time spent in the operating room, PTF was also correlated significantly with an in-
and infection of non-third molar lower posterior creased LOS. These findings are readily explained by
teeth) predicted LOS. Thus, these variables appear to this study’s protocol to allow at least 48 hours of IV
be valid measures of the severity of infection, which PCN therapy before changing antibiotics.
in turn appears to be directly related to LOS. Reoperation was significantly associated with an
Admission temperature did not predict LOS in this increased LOS. The additional time required for recu-
study, as in Peters et al.3 These results do not support peration from the second surgery necessarily pro-
the findings of Dodson et al,1 who reported that longed LOS. Interestingly, measures of the severity of
admission temperature and admission WBC can pre- infection, such as WBC, SS, space 3 infection, and
dict LOS; but our results are consistent with the asso- admission temperature did not predict reoperation.
ciation of deep infection and operating room use with Stage of infection (abscess or cellulitis) did not pre-
an increased LOS in those 2 studies. This inconsis- dict the need for reoperation, nor did preadmission
tency is almost certainly explained by the fact that antibiotics or any microbiologic variable, as might be
Dodson et al were studying children who commonly expected. Recently, Ylijoki et al22 found that a rising
develop high fevers, which complicates their manage- C-reactive protein on the second day after I&D was
ment and contributes to LOS. Wall et al18 found that predictive of the need for reoperation. C-reactive pro-
WBC ⬎ 15.4 ⫻ 109/L and serum sodium ⬍ 135 tein levels were not measured in the current study.
mmol/L were associated with necrotizing fasciitis in The use of oral antibiotics before admission pre-
general surgical infections. Although serum sodium dicted none of the significant outcomes in this study.
was not evaluated in this study, future research may Apparently, preadmission antibiotics did not hasten
fruitfully investigate its role in predicting LOS. abscess formation or shorten hospital stay. In contrast
Immune system compromise was not significantly to other studies, preadmission antibiotics were not
associated with LOS in the current study. Only 3 (8%) associated with culture identification of PCN-resistant
of the subjects in the present study were immuno- organisms.23-25 This may be because of the relatively
compromised (2 insulin-dependent diabetics and 1 small number of cases (24) for which culture and
HIV-seropositive individual). Carey and Dodson19 re- sensitivity data were available.
1112 SEVERE ODONTOGENIC INFECTIONS
Biederman and Dodson2 found lower face infection third molar lower posterior teeth also predicted the
to be a predictor of the need for use of the operating LOS. No clinically useful variables predicted the need
room. In their pediatric study, lower face infection for reoperation.
also correlated with odontogenic cause; upper face Directions for future research include development
infection correlated with sinus and other respiratory of biochemical and clinical predictors of outcomes in
tract infections. This may be explained by the deep severe OI, and molecular methods for bacterial iden-
portal of entry (bone) and the increased likelihood of tification and antibiotic sensitivity testing.26
abscess formation in OI. All cases in the current study
were odontogenic. Acknowledgment
Chen et al20 performed a retrospective multivariate The authors thank Drs Richard Kraut, Norman Trieger, Arthur
analysis of mortality in severe head and neck infec- Adamo, Mauricio Wiltz, and all of the Oral and Maxillofacial Surgery
residents at the Montefiore Medical Center for their assistance in
tions of various etiologies. They found that systemic the care of patients and gathering of data.
disease, neck swelling, and an increased time be-
tween the onset of symptoms and treatment were
significant predictors of complications, which in- References
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