Pattern Of The Oro-Facial Infections In Patients Presenting To Ayub Medical Institute, Abbottabad

BACKGROUND

Orofacial space infections are commonly odontogenic in origin and the anatomical locations along with mode of spread to critical areas (e.g., orbit, brain, mediastinum) can result in morbidly and mortality if not diagnosed and treated well in time. This study was aimed to analyzing the incidence and pattern of oro-facial infections.

METHODS

This Descriptive case series was carried out at Oral Surgery unit (Ayub Medical College) Abbottabad from January 2016 - May 2017. The sample was collected using purposive, consecutive non-probability sampling. The demographic data, infection site and clinical features were recorded. The data was analyzed by using SPSS version 21. All the descriptive variables were analyzed for percentages & frequencies.

RESULTS

Thirty-six patients were included in the study. The male (23) to female (13) ratio was (1.7:1). Right Submandibular space was most common site. In one case each, there was involvement of retropharyngeal and retromandibular space. Majority of the patients presented with swelling (88.89%). Diabetes mellitus was the most commonly found systemic disorder in the patients affecting aggressiveness of infection.

CONCLUSION

The most common source of odontogenic facial space infections is mandibular molars resulting spread to submandibular space. Diabetes Mellitus was the most common systemic disorder affecting host immunity. The proximity of oro-facial spaces with the critical areas makes it crucial for clinicians to identify the condition promptly and provide pertinent treatment in order to avoid the fatal complications as the rate of spread of facial space infection is very rapid.

A systematic review of orbital apex syndrome of odontogenic origin: Proposed algorithm for treatment

Orbital apex syndrome (OAS) can be a rare, but severe complication of an odontogenic infection and has high morbidity and mortality. Antibacterial drugs are typically an appropriate treatment choice, but the most severe cases are fungal in nature and pose a tough challenge to the clinician. The aim of this study was to determine the predisposing factors, specific aspects in its management and the appropriate treatment strategy in order to improve patient outcome. A systematic review was conducted using PubMed, PubMed Central, Web of Science, and Scopus up to February 2020, based on the associations between dental extraction or infections and OAS. Of 721 papers found, 18 articles were considered eligible and presented in total 21 cases (13 fungal and eight bacterial infections). The information was organized into a diagnostic and treatment algorithm which included data extracted both from the included cases and updated literature of treatment efficacy studies. Immunosuppression (uncontrolled diabetes mellitus and chemotherapy) was found as an important predisposing factor particularly for fungal infections. In these cases, we suggest that early simultaneous approaches, including aggressive surgical procedures and systemic administration of amphotericin B, result in a better outcome. In conclusion, medical intervention success depends on aggressive treatment and multidisciplinary teamwork.

[Analysis of related factors affecting treatment results in 126 patients with oral and maxillofacial space infection]

PURPOSE

This study was aimed to retrospectively investigate the related factors of oral and maxillofacial space infection in 126 patients.

METHODS

The clinical data of 126 patients with oral and maxillofacial space infection were collected from the Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of Xinjiang Medical University during the period of 2015 to 2017. The clinical features (e.g. body mass index, the number of days from onset to hospital admission, and the number of inflammatory spaces, and etc.) as well as laboratory examination variables (e.g. leucocytic count, the number of neutrophilic granulocyte, interleukin-6, C reactive protein, calcitonin, blood glucose, blood lipids, albumin, and etc.). Pearson correlation method were used to analyze the correlated factors and multiple linear regression analysis was used to analyze the related factors with SPSS20.0 software package.

RESULTS

Correlation analysis showed that there was a significant correlation in the hospitalization days with the ages, white blood cells, neutrophilic granulocyte, neutrophil ratio, C reactive protein, body mass index, triglyceride, high density lipoprotein, the number of inflammatory spaces. The results of multiple linear regression analysis showed that there were 4 independent variables (P<0.05), which were the number of inflammatory spaces, the number of days from onset to hospital admission, triglyceride and neutrophilic granulocyte.

CONCLUSIONS

There was a positive correlation between the hospitalization days with the number of inflammatory spaces, triglyceride, inflammatory cells and cytokines in patients with oral and maxillofacial space infection. In addition, the related factors affecting the treatment results of oral and maxillofacial space infection include the number of inflammatory spaces, the number of days from onset to hospital admission, triglycerides and neutrophils.

Clinical characteristics and course of primary brain abscess

BACKGROUND

Due to improved diagnostic methods, the incidence of brain abscess is still rising. Therefore, clear and evidence-based therapy for the patients who suffer from brain abscesses is necessary. Brain abscesses are potentially life-threatening conditions that possibly lead to permanent injuries even after sufficient healing has taken place. The aims of this study were to analyze the clinical aspects of patients with brain abscesses and thereby to reveal the relevant aspects for the future treatment of the brain lesions.

METHODS

We retrospectively identified 47 patients (24 male, 23 female) who had received surgery or undergone the frameless stereotactic drainage of brain abscesses in our center from March 2009 to May 2017. We analyzed the clinical characteristics of the patients, as well as comorbidities and outcomes.

RESULTS

The mean age was 58 (range 7 to 86). Focus identification was successful in 28 patients (60%), with the most frequent causes of brain abscesses including the following: sinusitis (25%), dental infections (25%), and mastoiditis (21%). The mean Charlson Comorbidity Index was 1.57. Among the patients, 34% showed immunosuppressive conditions. We performed 1.5 surgeries per patient (53% via craniotomy, 28% biopsies or stereotactic drainage, 19% both procedures), followed by antibiotic treatment for 6.5 weeks (mean). In 30% of patients, no bacteria could be isolated. During the follow-up period (a median of 12 months), 23.4% of the patients died. The mortality rate during the initial hospital stay was 4.3%.

CONCLUSION

One third of the patients with brain abscesses showed immunosuppressive conditions, whereas brain abscesses also often occur in patients with good medical conditions. The isolation of the focus of infection is often possible. Surgical procedures showed very good outcomes. Patients over 60 years showed significantly worse clinical outcomes.

[Clinical characteristics of oral and maxillofacial space infection in patients with different ages]

PURPOSE

To analyze the general information,clinical symptoms, etiology of infection, and complications of oral and maxillofacial space infection in patients with different ages, in order to provide references for prevention of complications.

METHODS

Three hundred and forty-eight patients with oral and maxillofacial space infection treated in the Oncology Department of Oral and Maxillofacial Surgery of the First Affiliated Hospital of Xinjiang Medical University were retrospectively analyzed from March 2007 to Feburary 2017. Statistical analysis was performed with SPSS 20.0 software package.

RESULTS

All patients were divided into 2 groups. 152(43.68%) patients were senior and 196(56.32% ) patients were younger. In the two groups, male patients accounted for 59.69% in the younger group, 59.87% in the senior group. There was no significant difference. We also have found that label test and interval times of symptoms appeared to visit. There was no significant difference. 51.53% of the younger patients had negative bacterial culture results, which was significantly more than those of the senior groups.

CONCLUSIONS

In patients with oral and maxillofacial space infection, senior patients had many similar clinical characteristics to younger patients, but senior patients suffered from more and severe complications.

Treatment options for odontogenic maxillary sinusitis: a review

OBJECTIVE

The aim of this article is to review the main treatment options for odontogenic sinusitis that are used today.

MATERIAL AND METHODS

Search on PubMed, Cochrane Library, PMC, Science Direct data bases. For a literature review search keywords were used: odontogenic sinusitis, odontogenic maxillary sinusitis treatment OR diagnosis, maxillary sinusitis of dental source OR dental origin OR etiology.

RESULTS

2886 articles were found in the databases using keywords. After duplicate citations screened, inclusion/exclusion criteria applied, excluded articles after titles, summaries and full-text reading 25 articles were included in the literature review.

CONCLUSION

Although clinical symptomatology is not conspicuous among other types of sinusitis, the odontogenic maxillary sinusitis treatment regimen is different. It consists of eliminating dental infection and management of sinusitis. The usage of Caldwell-Luc approach is limited these days and recommended only when a better access to sinus is needed, for example, removing large foreign bodies. Endoscopic sinus surgery is widely used these days to remove the inflamed sinus mucosa, foreign bodies, displaced teeth, while preserving physiological function of the sinus. Sometimes dental infection removal alone is sufficient to resolve the odontogenic maxillary sinusitis, but sometimes concomitant endoscopic sinus surgery or Caldwell-Luc approach is necessary for full resolution.

Sinusitis of odontogenic origin

Odontogenic sinusitis is a well-recognized condition and accounts for approximately 10% to 12% of cases of maxillary sinusitis. An odontogenic source should be considered in individuals with symptoms of maxillary sinusitis with a history of odontogenic infection, dentoalveolar surgery, periodontal surgery, or in those resistant to conventional sinusitis therapy. Diagnosis usually requires a thorough dental and clinical evaluation including appropriate radiographs. The most common causes of odontogenic sinusitis include dental abscesses and periodontal disease that had perforated the Schneidarian membrane, irritation and secondary infection caused by intra-antral foreign bodies, and sinus perforations during tooth extraction. An odontogenic infection is a polymicrobial aerobic-anaerobic infection, with anaerobes outnumbering the aerobes. The most common isolates include anaerobic streptococci and gram-negative bacilli, and Enterobacteriaceae. Surgical and dental treatment of the odontogenic pathological conditions combined with medical therapy is indicated. When present, an odontogenic foreign body should be surgical removed. Surgical management of oroantral communication is indicated to reduce the likelihood of causing chronic sinus disease. The management of odontogenic sinusitis includes a 3- to 4-week course of antimicrobials effective against the oral flora pathogens.

Criteria for admission of odontogenic infections at high risk of deep neck space infection

OBJECTIVES

Many patients with odontogenic infections are hospitalised because of the risk of deep neck space infection. The objective of this study was to identify risk factors allowing more reliable selection of patients requiring hospitalisation for both specialists and emergency physicians.

MATERIAL AND METHODS

This retrospective study was based on a cohort of 97 patients hospitalised for odontogenic infection in the Department of Otorhinolaryngology and Head and Neck Surgery of Centre hospitalier Sud Francilien, Île-de-France, from January 2008 to June 2012.

RESULTS

The majority of patients presented with dental abscess (66 patients; 68%). Nineteen patients (20%) presented with deep neck space infection. The frequency of deep neck space infection was significantly higher in patients with mandibular odontogenic infection (16/55 patients (29%) than in those with maxillary odontogenic infection (3/42 (7%); P ≤ 0.009). The incidence of deep neck space infection was significantly higher in patients with dental abscess (17/66, (26%) than in those without dental abscess (2/31 (6%); P ≤ 0.03).

CONCLUSION

In addition to the well-known classical criteria (fever, neck swelling, dyspnoea, dysphagia, trismus, leukocytosis, elevated C reactive protein (CRP)), the criteria for admission for odontogenic infection should include mandibular odontogenic infection and/or the presence of dental abscess.

The importance of early intervention in the treatment of dental infection

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.

CLINICAL RELEVANCE

The principles of effective management of dental infection are highlighted in the first instance and then indications for specialist maxillofacial referral are discussed.

Length of hospital stay and management of facial cellulitis of odontogenic origin in children

PURPOSE

This study's purpose was to assess characteristics of pediatric patients with odontogenic-based facial cellulitis, treatment strategies, and their relationship to length of stay (LOS).

METHODS

This retrospective study was performed on individuals younger than 18 years old who were hospitalized for facial cellulitis of odontogenic origin (FCOO). Medical records were reviewed for all patients with a discharge diagnosis of FCOO or buccal cellulitis. Patients' clinical characteristics were evaluated and assessed for their relationship to LOS.

RESULTS

A total of 106 children were diagnosed with FCOO. LOS was significantly shorter in patients who had a tooth extracted within 48 hours versus patients who had a tooth extracted at 48 hours or longer (P=.007). LOS was significantly shorter in patients with upper face and left face infections than lower face infections (P=.01) and right face infections (P=.01), respectively. Patients with a primary first molar infection had the shortest LOS; patients with a white blood cell count less than 10,000 cells/mm3 had shorter LOS.

CONCLUSIONS

Early tooth extraction may decrease the length of stay in management of pediatric facial cellulitis of odontogenic origin. The type of tooth involved and white blood cell count at admission have a significant impact on length of stay.

Odontogenic cervico-fascial infections: a continuing threat

STATEMENT OF THE PROBLEM

Dental abscesses are common and occasionally can progress to life-threatening cervico-fascial infections. Despite medical advances, odontogenic cervico-fascial infections (OCFIs) continue to be a threat. The potential seriousness of odontogenic infections (Ols), or dental abscesses, is frequently underestimated. General dental practitioners (GDPs) in primary care face the challenging decision of whether to refer patients to secondary care or to manage them in the community.

PURPOSE OF THE REVIEW

This paper reviews the relevant aspects of Ols that might be helpful to primary care dental practitioners in providing a better understanding of the anatomy and pathology and aims to assist in clinical decision.

METHOD

An up-to-date review of literature on OCFIs, highlighting their potential risks with clinical examples.

RESULTS AND CONCLUSION

Dental abscesses are common and continue to be a major cause for emergency hospital admission to oral and maxillofacial surgery departments. They occasionally spread to fascial spaces of the neck, potentially posing significant morbidity and mortality. GDPs are usually the first point of contact and face the challenge of recognising those at risk of developing OCFIs, which are potentially life threatening and require urgent referral for hospital treatment. We propose a patient care pathway to be used in primary care.

Periodontal disease: Mechanisms of infection and inflammation and possible impact on miscellaneous systemic diseases and conditions

Periodontitis is a chronic inflammatory disease, resulting from a predominantly gram-negative microbial infection within the sub-gingival dental plaque biofilm. The resulting inflammatory response in the periodontal tissues may facilitate intravascular dissemination of micro-organisms and their products, throughout the body. The total surface area of this inflammatory field is estimated to be the size of the palm of the hand. A skin lesion of this size would prompt immediate medical intervention. However, the intra-oral (and similar-sized) infection is frequently ignored by health professionals, despite the fact that it may be associated with a range of systemic diseases/conditions.

Cervicofacial necrotizing fasciitis following periodontal abscess

Soft tissue infections are characterized by acute inflammation, diffuse edema, and suppuration, and are often associated with symptoms such as malaise, fever, tachycardia, and chills. Necrotizing fasciitis is a destructive bacterial infection affecting subcutaneous tissue and superficial fascia and is associated with high rates of mortality. It usually involves the abdomen and extremities, but it also can occur in the head and neck. Early diagnosis is critical and the most commonly accepted treatment includes radical surgical intervention and administration of broad-spectrum antibiotics. This article reports and discusses the case of a patient with odontogenic cervicofacial necrotizing fasciitis, and emphasizes the importance of early and effective treatment.

Brain abscess secondary to a dental infection in an 11-year-old child: case report

A primary molar dental abscess was implicated as the cause of a brain abscess in an 11-year-old boy. This case report describes the neurological signs and symptoms, and acute management of a brain abscess in a child. A brain abscess is provisionally diagnosed from the patient's medical history, as well as the presence of signs and symptoms such as fever, headache, nausea, vomiting, focal neurological deficit, altered mentation, speech alterations, papillary edema, and neck stiffness or seizures. A definitive diagnosis of brain abscess is confirmed through imaging. The dental source of infection is identified by the exclusion of more probable foci such as the ears, heart, lungs, eyes or sinuses.

[Fundoscopic vessel examination in patients with severe maxillofacial phlegmons]

Using the fundoscopic vessels examination in patients with odontogenic phlegmon it was found out that in severe infectious disease of maxillofacial area the vascular figure is significantly changed. These changes confirm the growing brain swelling with intracranial hypertension as a result of heavy CNS intoxication.

Infection from an exfoliating primary tooth in a child with severe neutropenia: a case report

In patients with deficient immune defenses, a localized oral infection can progress to a systemic infection. The purpose of this paper was to describe the case of a child with acute lymphoblastic leukemia who presented with fever, trismus, and submandibular swelling in the absence of the typical dental causes of infection such as deep dental caries or clinically significant periodontal disease. Treatment included an aggressive intravenous antibiotic regimen and extraction of the offending tooth after the recovery from bone marrow suppression.

[Septic metastases of suppuration of odontogenic origin]

The infections of odontogenic origin, set in the soft tissues region of the viscerocranium are among the most frequent conditions specific to this anatomical level. A distinct category among these, represented by the conditions with diffuse character, may have serious forms, developing systemic septic metastases. The current paper displays a study approaching seven cases of odontogenic diffuse infections with metastases at distance. The ways in which the septic metastases appeared, as well as the topic and general prescribed treatment have been analyzed. The expanding at distance of the suppuration occurred at those patients who were suffering from cervical necroziting fasciitis associated to some immunodepressing conditions. Out of the 7 patients involved in the study, 4 were suffering from uncompensated diabetes and obesity. All those 7 patients had septic conditions localized in mediastinal region, and in 3 cases hepatic septic affections were observed. The best treatment possible for these conditions proved to be the surgical one associated with that concerned with the sustenance of the general state of health, the rebalancing of the homeostatic constants and the antibacterial one. The post-surgical evolution in case of 5 patients was a good one, in case of 2 patients being unfavourable because of the appearance of the multiorganic insufficiency and of death.

Facial cellulitis secondary to dens invaginatus: a case report

We describe a case of dens invaginatus in an unerupted permanent maxillary lateral incisor, which led to facial cellulitis in a 10-year-old girl. We review the importance of recognizing dens invaginatus and present strategies for preventing loss of vitality in the affected tooth.

[Diagnostic and prognostic value of determination of the endogenic intoxication and functional activity of neutrophils indices in odontogenic phlegmon]

There were studied up the peripheral blood indices in 109 patients, suffering odontogenic phlegmon (OPH), coexistant with severe and of medium severity systemic inflammatory response syndrome (SIRS). In the patients with OPH and severe SIRS (with the complicated course), the blood neutrophils indices, concerning endogenic intoxication and functional activity, differ essentially from those parameters, present in patients, suffering noncomplicated course of the disease.

Bilateral septic cavernous sinus thrombosis following the masticator and parapharyngeal space infection from the odontogenic origin: a case report

Neglect of odontogenic infections can have serious consequences. If they spread through fascial planes and intracranially they can cause an abscess, orbital cellulitis, and eventually cavernous sinus thrombosis. The authors report a case of rapid progressive bilateral orbital cellulitis and cavernous sinus thrombosis that originated from dental caries. Septic cavernous sinus thrombosis is a medical emergency. Early recognition and prompt treatments direct to the underlying sources of infection are crucial. Broad-spectrum intravenous antibiotics are the mainstay of treatment to reduce morbidity and mortality from this lethal condition. Management should be based on early diagnosis and prompt management with intravenous broad-spectrum antibiotics and surgical intervention.

Facial cellulitis secondary to dens invaginatus: a case report

We describe a case of dens invaginatus in an unerupted permanent maxillary lateral incisor, which led to facial cellulitis in a 10-year-old girl. We review the importance of recognizing dens invaginatus and present strategies for preventing loss of vitality in the affected tooth.

[Descending necrotizing mediastinitis of odontogenic origin]

BACKGROUND

Descending necrotizing mediastinitis (DNM) following an oropharyngeal infection is a rare disease with a rapid course and a mortality rate of up to 40%. The aim of this study, is to outline the diagnosis and the appropriate treatment of DNM.

METHODS

A retrospective study (1986-2007) of patients with DNM was made. Only patients with cervical cellulitis associated with DNM were included.

RESULTS

Eight men and two women with an average age of 43 years were treated. Five had diabetes. The average for diagnosis and treatment was eight days. In eight cases, we found a dental origin and in two cases a pharyngeal origin. The diagnosis of DNM was made thanks to cervico thoracic CT scan in six cases. In the others patients, they had at presentation clinical and radiological evidence of mediastinal diffusion. All patients were treated by broad spectrum antibiotherapy. All had cervical drainage. Mediastinal drainage was made by cervical approach in 2 two cases and via a right thoracotomy in eight cases. Eight patients died.

CONCLUSION

Odontogenic DNM is a rare disease with rapid course. Clinical diagnosis is difficult and early recognition with a low thresold for CT scanning is essential. CT is also useful for the treatment and in the post operative assessment. All affected tissue plane must be debrided. Surgical management and mediastinal drainage remain controversial about the indication of thoracotomy.

[Local ocular immunity parameters in chronic rhino- or odontogenic infection]

Thirty-four patients with foci of chronic rhino- or odontogenic infection were examined. All the patients underwent physical examination, biochemical blood analysis, immunological test for immunoglobulins A, G, and M, circulating immune complexes, leukocyte migration inhibition test with phytohemagglutinin, Con A, with antigens of the retina, vitreous body, iris, and lens, scrapes from the dentogingival pocket, conjunctival and nasal cavities for Chlamydia, followed by direct immunofluorescence, polymerase chain reaction, and culture. Chronic rhino- or odontogenic infection foci impair local ocular immunity in ophthalmologically healthy patients. The foci of chronic rhinogenic infection cause more pronounced changes in systemic and local ocular immunity than those of chronic odontogenic infection. In half the patients with chronic rhino- or odontogenic infection foci, Chlamydia are detectable in the oral, nasal, and ocular mucosae, which suggests that there is generalized infection and there is a need for complex sanitation of the body. Isolated local treatment for Chlamydia infection is not promising.

[Cervicofacial actinomycosis: two case reports]

Infectious diseases transmitted by actinomycosis species cause severe destructive lesions. This rare and specific infection is mainly found in the orofacial regions. Causes of any hard tissue swelling in the jaw have, thus, to be assessed carefully. When actinomycosis is identified, a surgical intervention with curettement, draining and long-term antibiosis is required. The aim of the current article is to describe two clinical cases and to show the necessity of both, microbiological and histological laboratory diagnostics, to hedge the clinic diagnosis.

Septic pulmonary embolism secondary to dental focus

A 24-year-old female was admitted to an infectious diseases unit with complaints of dyspnea and fever. She had suffered from multiple episodes of fever for 1 year. The diagnostic workup revealed multiple pulmonary nodules on the chest CT scan, suggesting septic pulmonary embolism, and a periapical abscess around the maxillary right central incisor. Because no other infectious source was found and resolution of the fever and the pulmonary lesions occurred only after extraction of the affected tooth and antibiotic therapy, the condition was diagnosed as a periapical abscess complicated by septic pulmonary embolism.

[Multiple brain abscesses of odontogenic origin caused by Fusobacterium nucleatum]

Infection caused by the anaerobic gram-negative rod Fusobacterium nucleatum belongs to endogenous infections. A 41-year-old man developed multiple brain abscesses of odontogenic origin. The main causes were poor oral hygiene and no dental check-ups. Pus aspired from a site in the brain contained DNA of the bacterium Fusobacterium nucleatum. Several teeth with periapical abscesses were extracted. Initially, the patient was treated empirically with a combination of cefotaxime and metronidazole (18 days). Subsequently, co-trimoxazole and rifampicin were administered (8 months). Four and eight months after the onset of the disease, MRI scans revealed only persistent residual changes in the brain parenchyma; the patient was asymptomatic, with no neurological signs and back at work.

[Correlations between dental-oral infections and cardiovascular disease]

The potential role of periodontal disease, gingivitis and other dental infections as a possible chronic source of infection and inflammation represents a continuous challenge to the host organism. The high number of oral pathogens, lipopolysaccharides and soluble mediators are related to the pathogenesis of local inflammation and the initiation of systemic inflammation process, which may impair systemic health. In the last decades, studies suggested that there could be a connection between the local oral infections and several systemic conditions such as diabetes, cardiovascular disease, low birth weight and chronic obstructive pulmonary disease. Cardiovascular disease is the number one cause of death in the last century. The primary contributing factor in the majority of cardiovascular diseases is atherosclerosis. The role of infection is believed to provide a critical inflammatory stimulus that contributes to atherogenesis. The present review is a short summary of studies of the last years about the possible pathogenic role of local oral infections as a contributing factor in the initiation and progression of cardiovascular disease.

[Endodontic biofilms and secondary infection of total hip arthroplasty]

Biofilms are well recognised in different settings. Endodontic biofilms containing bacteria responsible for bacteraemia and secondary infection of total hip arthroplasties (THA) represent a diagnostic challenge because they are often asymptomatic. Their treatment is difficult and inadequate management of such unrecognised sources of systemic infection can lead to the devastating situation of an infected arthroplasty necessitating implant removal, long term antibiotic treatment and secondary implantation of a new prosthesis. Since about ten percent of secondary infected THA can have a dental origin, this article is intended to give guidelines to all intervening care providers: general practitioner, orthopaedic surgeon and dentist.

Oral infection, hyperglycemia, and endothelial dysfunction

Metabolic syndrome and type 2 diabetes (T2DM) resulting from sustained hyperglycemia are considered as risk factors for cardiovascular disease (CVD) but the mechanism for their contribution to cardiopathogenesis is not well understood. Hyperglycemia induces nonenzymatic glycation of protein-yielding advanced glycation end products (AGE), which are postulated to stimulate interleukin-6 (IL-6) expression, triggering the liver to secrete tissue necrosis factor alpha (TNF-alpha) and C-reactive protein (CRP) that contribute to CVD pathogenesis. Although the high prevalence of periodontitis among individuals with diabetes is well known by dental researchers, it is relatively unrecognized in the medical community. The expression of the same proinflammatory mediators implicated in hyperglycemia (i.e., IL-6, TNF-alpha, and CRP) have been reported to be associated with periodontal disease and increased risk for CVD. We will review published evidence related to these 2 pathways and offer a consensus.

Ten Years of Descending Necrotizing Mediastinitis: Management of 23 Cases

PURPOSE

Through a 10-year retrospective study, we report our experience in the management of descending necrotizing mediastinitis (DNM), a rare and often lethal complication of odontogenic and oropharyngeal infections.

PATIENTS AND METHODS

We reassessed 23 patients between the ages of 16 and 69 years (mean, 49 years) seen between 1996 and 2005, with DNM secondary to odontogenic abscess or phlegmon in 9 cases or secondary to peritonsillar abscess in 14 cases. In this study, 48% of the patients had immune system disorders, mainly diabetes mellitus (6 patients). The diagnosis of DNM was confirmed by cervicothoracic computed tomography.

RESULTS

Eight patients underwent a bilateral collar cervicotomy, and 15 underwent a combined cervicothoracic approach. Five, 2, 1, and 1 patients underwent surgery 2, 3, 4, and 5 times, respectively. Seven patients died as a result of septic shock and multiorgan failure, for a mortality rate of 30.4%. Four of those who died had a compromised immune system.

CONCLUSION

The relatively high mortality rate seen in this study shows that, in addition to early diagnosis and aggressive treatment, it is important to give greater attention to and be more medically and surgically aggressive in the management of patients whose immune system is compromised in any way.

Periodontitis as a component of hyperinflammation: treating periodontitis in obese diabetic patients

Increasing evidence points to periodontal disease as a significant risk factor in the etiology of other diseases with inflammatory components, such as cardiovascular disease and type 2 diabetes mellitus. Thus, it may be possible to reduce the risk for other diseases with an inflammatory component by maintaining a healthy periodontium. In addition to plaque and calculus, other factors such as diet, body weight, lifestyle, and environmental stress complicate the maintenance of a healthy periodontium. It is becoming more important for the general dentist to address these additional risk factors in addition to providing conventional treatment for periodontal disease. This review addresses a multifactorial approach to the treatment of periodontal disease and suggests that the "focal theory" of infection may still be relevant for oral inflammation.

Orbital abscess as a complication of odontogenic infection. A case report and review of the literature

Orbital abscess is a rare complication of odontogenic infection. This report describes a case of an orbital abscess in a 42-year-old HIV-seropositive woman who developed this condition as a complication by direct spread via the maxillary sinus of a dento-alveolar abscess of the maxillary first premolar, resulting in the loss of her eye.

[Diagnosing and treatment of dental foci in Dutch medical centres]

Although not scientifically proven, dental foci are believed to result in severe local or systemic disease. Eradicating dental foci in order to prevent possible interference with a medical treatment may be important in specific patient groups. To gain insight in the number of dental focus examinations, the medical evidence, the number of potential foci determined, as well as the treatment eradicating the focus, all dental focus examinations in 16 Dutch hospitals were registered during 3 months. A total number of 470 examinations were performed. Scheduled heart(valve)surgery and radiotherapy of the head and neck were the main reasons for a dental focus examination. Dental foci were found and treated in more than 50% of the patients examined. There was a significant difference between dentate and edentulous patients in the percentage of patients diagnosed and treated for a dental focus. More than 80% of dentate and less than 20% of edentulous patients were treated.

Necrotising fasciitis of the submandibular region; a complication of odontogenic origin

Inadequate treatment or neglect of odontogenic infections can have serious consequences. The potential for spreading through fascial planes and intracranially can cause compromise of the airway and cavernous sinus thrombosis respectively. On rare occasions this can lead to a rapidly progressing necrotising fasciitis, with destruction of soft tissue, making reconstruction difficult. Antibiotic administration without removal of the cause is inadequate and can complicate subsequent management. We report the presentation and successful management of a 13-year-old boy, who developed necrotising fasciitis in the submandibular region as a result of inadequate initial treatment of a carious, lower molar resulting in significant skin and soft tissue loss.

Periodontal infections and cardiovascular disease: the heart of the matter

BACKGROUND

Oral infection models have emerged as useful tools to study the hypothesis that infection is a cardiovascular disease (CVD) risk factor. Periodontal infections are a leading culprit, with studies reporting associations between periodontal disease and CVD. The results, however, have varied, and it often is unclear what conclusions can be drawn from these data.

SUMMARY

An association exists between periodontal disease and CVD. It is unknown, however, whether this relationship is causal or coincidental. Early studies predominantly used nonspecific clinical and radiographic definitions of periodontal disease as surrogates for infectious exposure. While most studies demonstrated positive associations between periodontal disease and CVD, not all studies were positive, and substantial variations in results were evident. More recent studies have enhanced the specificity of infectious exposure definitions by measuring systemic antibodies to selected periodontal pathogens or by directly measuring and quantifying oral microbiota from subgingival dental plaque. Results from these studies have shown positive associations between periodontal disease and CVD.

CONCLUSIONS

Evidence continues to support an association among periodontal infections, atherosclerosis and vascular disease. Ongoing observational and focused pilot intervention studies may inform the design of large-scale clinical intervention studies. Recommending periodontal treatment for the prevention of atherosclerotic CVD is not warranted based on scientific evidence. Periodontal treatment must be recommended on the basis of the value of its benefits for the oral health of patients, recognizing that patients are not healthy without good oral health. However, the emergence of periodontal infections as a potential risk factor for CVD is leading to a convergence in oral and medical care that can only benefit the patients and public health.

Case report: teeth and tonsils: the use of culture and sensitivity testing for antibiotic prescribing in dental infection

This case report highlights the usefulness of bacterial culture and sensitivity testing in the prescribing of antibiotics for dental infections, demonstrated by the management of a 10-year-old child with a non-vital upper central incisor and, reportedly, associated recurrent tonsillitis.

Descending Necrotizing Anterior Mediastinitis: Analysis of Survival and Surgical Treatment Modalities

PURPOSE

Descending necrotizing anterior mediastinitis (DNAM) is a severe infectious disease with a very high mortality rate. The aim of this study was to define the impact of several clinical factors on survival.

PATIENTS AND METHODS

Between 1985 and 2002, 27 patients were managed for DNAM, 11 with combined transthoracic mediastinal and cervical drainage (group A) and 16 with a less aggressive surgical approach, such as cervical drainage and transcervical mediastinal drainage (group B). The records of all patients were statistically analyzed for the impact of several clinical factors on survival.

RESULTS

Although patients in group A were admitted to the hospital faster, treated with antibiotics as outpatients earlier, and operated on much sooner after hospital admission compared with the patients in group B, multivariate analysis revealed that early combined transthoracic mediastinal and cervical debridement and drainage was the only favorable factor for survival in patients DNAM patients (odds ratio = 9.99; 95% confidence interval = 1.02 to 97.49).

CONCLUSIONS

Less extensive surgical approaches (ie, thoracic drainage without cervical drainage or combined cervical and subxiphoid thoracic drainage) led to unsatisfactory results and high reoperation rates. In contrast, early, aggressive combined cervical and thoracic drainage proved to be an effective method for managing DNAM.