the changing face of odonto genic

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J Oral Maxillofac Surg59:739-748, 2001

The Changing Face of Odontogenic

InfectionsWilliam Storoe, DDS,* Richard H. Haug, DDS,

and Thomas T. Lillich, PhD

Purpose: The purpose of this investigation was to compare characteristics of patients hospitalizedwith odontogenic infections during the 1980s to those of the 1990s.

Patients and Methods: This study was a retrospective record review that compared 2 cohorts ofpatients admitted to the same institution during two 81-month periods, one decade apart. Admission

criteria were face or neck swelling suggesting abscess or cellulitis and one or more of the following:temperature above 38C, white blood cell (WBC) count greater than 10.8 103/L, or concern about

airway compromise. Characteristics reviewed were age, gender, race, admission temperature, admissionWBC count, fascial space(s) involved, tooth of etiology, duration of hospitalization, and bacteria isolated.

Data were compared for statistical significance (P .05).

Results: No significant differences were found between the 2 cohorts for age, gender, race, admissiontemperature, admission WBC count, space involvement, or length of stay (P .05). One tooth(mandibular left first molar) of 52 was involved more frequently in the 1990 group (P .03).Gram-positive cocci were isolated significantly more frequently from the 1990s patients than from the

1980s patients (P .03). There were also significant differences (P .02) between cohorts in theisolation frequency of individual genera, such as alpha-hemolytic Streptococci, coagulase negative

staphylococci, Staphylococcus epidermidis, Bacteroides melanogenicus, beta-lactamase positive Bacte-roides, Eikenella corrodens, and Neisseria species. Eighty-one percent of the bacteria cultured from the

1990s patients were resistant to one or more common antibiotics; 47% of these organisms wereStaphylococcus aureus.

Conclusion: No clinically significant differences existed in the characteristics of patients hospitalizedwith odontogenic infections between the 1980s and the 1990s. Although there were differences in thetype and prevalence of bacteria isolated, this was probably a result of changes in nomenclature,

identification protocols, and isolation techniques. 2001 American Association of Oral and Maxillofacial Surgeons

The availability of penicillin and other wonder

drugs in the years immediately after World War II

ushered in an era of complacency in infectious dis-

ease treatment. Many traditional infectious disease

management approaches, such as isolation, quaran-

tine, and scrupulous application of aseptic technique

in the office and operatory, were de-emphasized or

discarded as no longer necessary because the new

drugs were so effective in treating common infec-tions. Antibiotics were prescribed when symptoms

first appeared without first determining either thecause of the disease or the chemotherapeutic suscep-tibility of the microbe. Many scientists and public

health professionals were ready to declare final vic-tory over infectious diseases, being firmly convinced

that antibiotics and vaccines would solve existing and

future disease threats. Events of the last 20 yearssuggest that such enthusiasm was premature.Although there have been recent dramatic improve-

ments in the morbidity and mortality associated with

infectious diseases, microorganisms have proved tobe quite adaptable, displaying an unsettling ability to

re-emerge in continuing cycles of disease.1 Neu2 ob-served that bacteria are more clever than men. They

have adapted to every environmental niche on theplanet and are now adjusting to a world laced withantibiotics. This ability has been shown over the past

decade in the number and variety of so-called emerg-

*Chief Resident, Division of Oral and Maxillofacial SurgeryMetroHealth Medical Center, Cleveland, OH.

Division Director and Professor of Oral and Maxillofacial Sur-

gery, College of Dentistry, University of Kentucky, Lexington, KY.

Professor and Associate Dean, College of Dentistry, University

of Kentucky, Lexington, KY.

Address correspondence and reprint requests to Dr Haug: Uni-

versity of Kentucky, 800 Rose St, D-508 College of Dentistry,

Lexington, KY 40536-0084.

2001 American Association of Oral and Maxillofacial Surgeons

0278-2391/01/5907-0005$35.00/0

doi:10.1053/joms.2001.24285

739


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ing infections not previously recognized in humans

and also in the re-emergence of diseases, sometimesin slightly different form, caused by well-known mi-croorganisms such as Staphylococci, Streptococci,

Escherichia coli, and Mycobacterium tuberculosis.Re-emergence is partly a result of acquisition of anti-

biotic resistance mechanisms either through mutationor by transfer of genetic information from other bac-

teria.2,3 Consequently, there has been a significant risein the antibiotic resistance of important pathogenic

genera. Today, infectious diseases remain the leadingcause of death worldwide and are third in the UnitedStates, where they also account for more than 25% of

physician office visits.1

Shifting infectious disease patterns and their mani-

festations have become a topic of discussion in the laypress, often creating public alarm through hyperbole

and, occasionally, misinterpretation of events.4,5 Ac-cording to Time magazine, for example, antibiotics

are so overused that the human body has becomesaturated. This has depressed the immune system andprovided an environment for the creation of bacte-

rial monsters.4 The media has also reported flesh-eating Streptococcus strains and killer bacteria that

are resistant to most common antibiotics.4,5 Thesereports raise public concerns that the normal bacte-rial flora is mutating uncontrollably and that infec-

tions are much more severe than they used to be.Although reports like these are dramatic, they are

based on assumption and empiricism rather than oncontrolled investigations that identify demography,

epidemiology, and other characteristics of an infectedpopulation. The question then arises: Is the face ofinfection in the general population changing? More

specifically: Are the characteristics of patients with

odontogenic infections during this era different from

those in the past? The purpose of this investigationwas to review the characteristics of patients hospital-ized with odontogenic infections within a specific

time frame (the 1980s) and then to compare themwith a similar population during an identical time

frame one decade later.

Patients and Methods

This investigation was conducted at the ClevelandMetroHealth Medical Center, a large county teachinghospital serving an urban population of 1.9 million

and a rural population of 2.0 million in northeasternOhio. Hospital charts and radiographs were reviewed

from 2 patient cohorts admitted to that institution;the first during the 81 months between March 1983

and November 1989 (1980s patients)6 and the otherduring the 81 months between July 1992 and March

1999 (1990s patients). There were eighty-six 1980spatients; 79 of whom had complete records (91.9%)(Table 1). There were seventy-three 1990s patients;

71 of whom (97.3%) had complete records (Table 1).Admission criteria were swelling of the face or neck

suggesting abscess or cellulitis and 1 or more of thefollowing: temperature above 38.0C, white bloodcell (WBC) count greater than 10.8 103/L or

concern about airway compromise. Patient character-istics reviewed were gender, age, race, admission

temperature, admission WBC count, duration of hos-pitalization, fascial space(s) involved, tooth of etiol-

ogy, and bacteria identified. Gender and race werecompared using a Pearson chi-square analysis. Age,length of stay, admission temperature, and admission

WBC counts were compared with a 2-tailed t test.

Table 1. PATIENT CHARACTERISTICS

No. of 1980sPatients

No. of 1990sPatients Statistic* P

Total patients identified 86 73 0.063 .8Total patients with complete records 79 71 0.006 .9Gender

Male 45 40 0.006 .9

Female 34 31Race

White 44 44African American 30 20 0.006 .6Hispanic 4 6

Asian 1 1Mean SD

Age (yr) 31.40 17.97 32.58 10.90 0.989 .6Admission temperature (C) 37.76 0.76 37.62 0.92 0.960 .4Admission WBC count (WBC 103/l) 14.40 5.36 13.93 4.837 1.040 .3Length of stay (d) 6.66 6.20 8.27 11.59 0.567 .6

*2 for total patients, gender, and race; t test for age, admission temperature, admission WBC, and length of stay.Abbreviations: WBC, white blood cell.

740 CHANGING FACE


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Tooth of etiology was compared using a chi- square

analysis. Fifty-two individual chi-square tests were re-quired because 52 different teeth were identified asbeing involved. For tests where 50% of the data cells

had expected counts less than 5, a Yates correctedchi-square (continuity correction) was reported. Oth-

erwise, a Pearson chi-square analysis was used todetermine the differences in tooth involvement be-

tween cohorts. No computations were performed forfrequency tables with zero tooth involvement. The

different anatomic spaces were compared with aMann-WhitneyUtest. Differences between cohorts infrequency of bacteria identified by standard labora-

tory procedures were compared using a Pearson chi-square analysis. Thirty-five individual Pearson chi-

square analyses were performed. A continuityadjustment was made when more than 25% of the

cells had expected counts less than 6. Differencesbetween cohorts were considered significant for any

of the criteria if P .05.

Results

The 2 decades had equal proportions of patients

identified and patients with complete charts. Therewas no significant difference between groups for gen-der, age, or ethnic distribution (Table 1). There was

also no difference for mean admission temperature,mean admission WBC count, or mean length of stay

(Table 1).There were 40 multispace infections (50.6%) in the

1980s patients and 37 (52.1%) in the 1990s patients(Table 2). The submandibular space was most fre-quently involved in the patients with multispace in-

fections in both groups; occurring 42 times (32.6%) inthe 1980s patients and 47 times (35.6%) in the 1990s

patients. It was also the most frequently involvedspace in patients with single space infections; occur-

ing 16 times in the 1980s patients (20.3%) and 17times in the 1990s patients (23.9%). There was nosignificant difference between groups with respect

to anatomic spaces involved (Mann-Whitney U 2505.5; (2-tailed) P .221).

Thirty different teeth were the source of infection

in the 1980s patients and 22 in the 1990s patients(Table 3). Because this was a retrospective review ofrecords, it was not possible to identify the presenceor absence of any one tooth in all patients. Because

there were equal proportions between decades forpatients identified, patients with complete records,

and all other patient population characteristics suchas age, gender and race, it was assumed that there

would be equal proportions of individual teethpresent in individual patients from each decade. Be-cause of these equal proportions, for our statistical

comparison, we assumed that all teeth were present

in all patients. The only tooth with a statistically

significant difference between decades was the man-dibular left first molar (X2(1) 4.495, P .034),

being reported in the records with a frequency of8.9% (7/79) for the 1980s and 20.1% (15/73) for the1990s. Although a trend was observed that maxillary

molars were the etiology more frequently for the1980s patients than for the 1990s patients (13 vs 8),

the mandibular molars as a group were the morefrequent etiology in the 1990s than the 1980s (91 vs

64). It must be noted that both single and multiplemandibular molars were the etiology in individualpatients.

The manner in which we reported the bacteriaisolated was limited by our ability to retrieve data in a

retrospective review of records and by changes in

nomenclature and culture techniques from the 1980sto the 1990s. Patients in both groups were culturedaccording to prevailing clinical laboratory techniquesand protocols. All isolates from any one individual,

whether from a sterile abscess, multiple sites, ormultiple cultures, were recorded. At least one bacte-

rium was isolated from 96% (76/79) of patients in the1980s group and 90% (64/71) in the 1990s group.

Most patients from both groups (1980s: 65/79 and1990s: 60/71) had multiple organisms isolated. Therewere 180 bacteria isolated from seventy-nine 1980s

patients compared with 115 from seventy-one 1990s

Table 2. FREQUENCY OF FASCIAL SPACE(S)INVOLVED

1980sPatients

1990sPatients

Multiple space involvement

Total spaces 129 132Multispace 40(50.6%) 37(52.1%)Submandibular space 42(32.6%) 47(35.6%)Lateral pharyngeal space 12(59.3%) 23(17.4%)Buccal space 37(28.7%) 15(11.4%)Submental space 10(7.6%) 12(9.1%)Sublingual space 5(3.9%) 5(3.8%)Retropharyngeal space 1(.8%) 4(3.0%)Canine space 13(10.1%) 3(2.3%)Mediastinal space 2(1.5%)Peritonsillar space 1(.8%)Pretracheal space 1(.8%)Medial pterygoid space 1(.8%)Masseteric space 5(3.9%) Temporal space 4(3.1%)

Single space involvementTotal spaces 39 34Submandibular space 16(20.3%) 17(23.9%)Buccal space 13(16.5%) 6(8.54%)Canine space 7(8.9%) 3(4.2%)Submental space 2(2.5%) 2(2.8%)Temporal space 1(1.3%) 2(2.8%)Lateral pharyngeal space 3(4.2%)Masseteric space 1(1.4%)

STOROE, HAUG, AND LILLICH 741


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patients. For the initial analysis, isolates were grouped

into 4 categories: gram-positive cocci, other gram-

positive bacteria, gram-negative anaerobes and other

gram-negative bacteria (Table 4). Gram-positive cocci

(X2(1) 5.357, P .021) and gram-negative anaer-

obes (X2(1) 4.223, P .038) were isolated signif-

icantly less frequently from the 1990s patients than

from the 1980s patients.

Table 5 compares the frequency with which bacte-

ria were isolated from the 2 groups. For instance,

alpha-hemolytic Streptococciwere isolated from 47 of

79 patients during the 1980s and from 24 of 71 pa-

Table 3. FREQUENCY OF TOOTH INVOLVEMENT

Tooth Number/Letter 1980s Patients 1990s Patients

Maxillary left third molar 1 1Maxillary left second molar 2 0Maxillary left first molar 2 1

Maxillary left second premolar 0 0Maxillary left first premolar 0 0Maxillary left canine 1 0Maxillary left lateral incisor 1 1Maxillary left central incisor 0 2Maxillary right central incisor 0 1Maxillary right lateral incisor 2 0Maxillary right canine 1 1Maxillary right first premolar 0 0Maxillary right second premolar 2 0Maxillary right fist molar 4 0Maxillary right second molar 1 2Maxillary right third molar 1 4Mandibular right third molar 15 21Mandibular right second molar 13 13

Mandibular right first molar 7 15Mandibular right second premolar 1 6Mandibular right first premolar 1 4Mandibular right canine 2 0Mandibular right lateral incisor 2 1Mandibular right central incisor 1 1Mandibular left central incisor 2 1Mandibular left lateral incisor 0 1Mandibular left canine 1 1Mandibular left first premolar 3 0Mandibular left second premolar 5 4Mandibular left first molar 6 10Mandibular left second molar 9 14Mandibular left third molar 14 18Maxillary deciduous left second molar 0 0Maxillary deciduous left first molar 1 0Maxillary deciduous left canine 1 0Maxillary deciduous left lateral incisor 1 0Maxillary deciduous left central incisor 0 0Maxillary deciduous right central incisor 0 0Maxillary deciduous right lateral incisor 0 0Maxillary deciduous right canine 2 0Maxillary deciduous right first molar 2 0Maxillary deciduous right second molar 0 0Mandibular deciduous right second molar 1 1Mandibular deciduous right first molar 1 1Mandibular deciduous right canine 0 1Mandibular deciduous right lateral incisor 1 0Mandibular deciduous right central incisor 1 0Mandibular deciduous left central incisor 1 0Mandibular deciduous left lateral incisor 1 0

Mandibular deciduous left canine 0 0Mandibular deciduous left first molar 1 0Mandibular deciduous left second molar 0 0

742 CHANGING FACE


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tients during the 1990s. Bacteria isolated from the1980s patients belonged to 19 unique genera or spe-

cies and those from the 1990s group to 24 uniquegenera or species. Comparisons between the 2 pa-

tient groups revealed significant differences for alpha-hemolytic Streptococci, coagulase negative Staphy-lococci, Staphylococcus epidermidis, Bacteroides

melaninogenicus , beta-lactamase positive Bacte-roides, Eikenella corrodens, and Neisseria species

(Table 5).Culture and antibiotic sensitivity data were avail-

able from ten 1990s patients (14%) (Table 6). Datafrom the 1980s patients were unavailable. Of the 32bacterial isolates, 81% (26/32) were resistant to one

Table 4. BACTERIA ISOLATED

No. Isolated From1980s Patients (% of total)

No. Isolated From1990s Patients (% of total) 2 P

Gram-positive cocci 101(56) 80(70) 5.357 .021Other gram-positive bacteria 9(5) 5(4) 0.066 .8

Gram-negative anaerobes 41(23) 15(13) 4.323 .038Other gram-negative bacteria 29(16) 15(13) 0.520 .5Total isolates 180(100) 115(100)

Table 5. COMPARISON OF BACTERIA IDENTIFIED FROM BOTH PATIENT GROUPS

BacteriaNo. of

1980s PatientsNo. of

1990s Patients 2 P

Gram-positive cocciAlpha-Hemolytic Streptococci 47 24 9.900 0.002Beta-Hemolytic Streptococci 22 21 0.055 0.815Staphylococcus aureus 12 8 0.498 0.480Coagulase-negative Staphylococci 18 22.759 0.001Staphylococcus epidermidis 15 14.979 0.001Gamma-Hemolytic Streptococci 2 5 0.846* 0.358Peptostreptococcus sp 3 3 0.000* 1.000Enterococcus sp 1 0.003* 0.957

Other gram-positive bacteriaDiphtheroids 6 4 0.023 0.878Actinomyces sp 2 0.406* 0.524Lactobacillus sp 1 0.000* 1.000Corynebacterium sp 1 0.003* 0.957

Gram-negative anaerobesBacteroides melaninogenicus 27 29.59 0.001Bacteroides (-lactamase ) 6 4.928 0.03Bacteroides (-lactamase ) 4 2.660* 0.103Bacteroides (not fragilis) 2 0.622* 0.430Fusobacterium necrophorum 2 0.622* 0.430Bacteroides fragilis 1 1 0.000* 1.000

Other gram-negative bacteriaEikenella corrodens 13 3 5.870 0.02Haemophilus influenzae 8 2 2.144* 0.143Neisseria sp 9 6.704* 0.01

Klebsiella sp 4 3 0.000* 1.000Enterobacter sp 3 1 0.159* 0.690Escherichia coli 3 1.155* 0.283Citrobactersp 1 0.000* 1.000Hemophilus hemolyticus 1 0.000* 1.000Proteus mirabilis 1 0.003 0.957Actinobacter calcoaceticus (Iwoffi) 1 0.003* 0.957Serratia marcescens 1 0.003* 0.957Pseudomonas aeruginosa 1 0.003* 0.957Pseudomonas sp 1 0.003* 0.957Stenotrophomonas maltophilia 1 0.003* 0.957

Total Isolates 180 115

* Yates corrected chi-square is reported because more than 50% of the cells have expected counts less than 5.



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or more antibiotic. Sixty-two percent of the resistantbacteria were gram positive (16/26) and 38% were

gram negative (10/26); Staphylococcus aureus andcoagulase negative staphylococci were the most com-

mon gram-positive antibiotic resistant bacteria iso-lated. Klebsiella pneumoniae was the most commongram-negative antibiotic resistant isolate.

Discussion

There are several surveys in the surgical literature

concerning the epidemiology of odontogenic infec-tions that are relevant to this investigation. Theirstudy designs will be summarized and then compari-

sons made with the present study in the context ofthe patient populations investigated.

Kannangara et al7 studied the bacteriology andtreatment of dental infections in 61 patients treated

between 1976 and 1979. They reported limited pop-ulation data, but did identify bacteria. Between Janu-ary 1973 and January 1976, Hunt et al8 collected

epidemiologic and microbiologic data from patientswith odontogenic infections. However, data from this

study may be less relevant because the information

was from only 74 patients from among several hun-dred reviewed. Dodson et al9 retrospectively re-viewed the demographics of 113 pediatric patientswith odontogenic infections admitted from January

1982 through December 1986. Heimdahl et al10 re-ported management and microbiologic data for 58

patients with odontogenic infections, but providedonly limited demographic data.

Sethi and Stanley11 reported gender, age, admissiontemperature, and bacteria involved in their retrospec-tive review of 61 patients with deep neck space

abscesses. However, not all their infections were

odontogenic. Bartlett and OKeefe12 reported demo-graphic data for 20 patients; however, they concen-

trated on perimandibular space infections, not all ofwhich were odontogenic. Between 1978 and 1980,

Labriola et al13 treated 50 consecutive patients withorofacial infections in whom they investigated ana-tomic space involvement and microbial etiology;

however, again the infections were not purely odon-togenic. Between 1981 and 1990 Har-el et al14 con-

ducted a retrospective survey of 110 patients withdeep neck abscesses in which microbe involvement,

space involvement, and selected patient characteris-tics were reported. This study also has limited appli-cability because not all infections were odontogenic.

Sakaguchi et al15 investigated 91 patients with deepneck infections between 1985 and 1994. Although

they reported space involvement and some patientcharacteristics, not all study participants had infec-

tions of odontogenic origin.In their 1978 review, Chow et al16 concluded that

the clinical manifestations of odontogenic orofacial

infections were a result of both the microbial floracausing the infection and the anatomic route(s) by

which it spread through the fascial planes. They also

discussed how different aspects of the human denti-tion are more apt to infect predetermined fascialplanes, and they identified the tooth of etiology cor-responding to these infections. Moenning et al17 re-

ported that the understanding of the complex micro-bial environment of odontogenic infections and the

perceived changes in etiology over time might be aresult of changes in the methods of collecting and

analyzing samples. It may reflect greater recognitionof bacterial species that have always been involved ormay merely reflect poor cutaneous skin preparation

and scrub techniques.

Table 6. ANTIBIOTIC RESISTANCE IN THE 1990s PATIENTS ISOLATES

No. Resistant No. Sensitive Total

IsolateGamma Streptococci(not Enterococcus) 0 1 1Beta Streptococci (non A/B) 0 1 1

Coagulase-negative Staphylococci 6 0 6Enterococcus 1 0 1Staphylococcus aureus 9 1 10

Total gram positive 16 3 19Actinobacter calcoaceticus (lwoffi) 1 0 1Bacteroides sp 0 1 1Eikenella sp 1 0 1Enterobacter cloacae 1 0 1Klebsiella pneumoniae 3 0 3Pseudomonas aeruginosa 1 2 3Pseudomonas-like 2 0 2Stenothrophomonas maltophilia 1 0 1

Total gram negative 10 3 13Totals 26 6 32

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Haug et al6 previously observed that epidemiologic

survey groups vary with geographic region, popula-tion density, socioeconomic status, regional govern-ment, era in time, and facility in which the study was

conducted. The current study reduced or eliminatedmost of the variables by comparing 2 matched patient

populations over 2 periods of 81 months each, 10years apart, who were all treated at the same institu-

tion.

GENDER

There have been few reports describing the rela-tionship between patient gender and the incidence of

odontogenic infection. Kannangara et al7 reported amale predominance in his study, finding 40 (66%)

males and 21 females (34%). Dodson et al9 review of113 pediatric patients with odontogenic infections

also identified a male predominance, with 67 males(59%) and 46 females (41%). Hunt et als9 survey

noted a female predominance with 30 males (41%)and 43 females (59%). Sethi and Stanley11 identified aslight predilection for males, but did not list exact

numbers for each gender. Although the present inves-tigation identified no significant gender differences

between the groups, both did have a slight predilec-tion toward males.

AGE

A broad age range was found in both study groups.

The ages ranged from 3.0 years in both groups to 56.0years in the 1980s patients and 83.3 years in the 1990s

patients. The mean age was 31.40 17.97 for the1980s patients and was 32.58 10.90 for the 1990spatients.

There was no significant difference in age betweenthe 2 groups. These findings correlate well with pre-

vious reports. Kannangara et als7 study was similar,with a range of 6 to 79 years, and most patients being

between 20 and 29 years old. Sethi and Stanley11

reported a similar range of 3 to 87 years, with a meanof 45.5. Sakaguchi et als15 study corresponds most

closely to this investigation, with a mean of 36 yearsand a range of 1 to 81 years. However, as already

noted, not all of the deep neck space infections in

that investigation were odontogenic. Bartlett andOKeefe12 reported an age range of 23 to 70 years,with a mean of 43 years; however, their study onlyinvolved 20 patients. Dodson et als9 study of 113

pediatric patients reported a mean age of 4.55 years.

RACE

This investigation was conducted in a region with

the following racial distribution: White (72%), AfricanAmerican (24%), Hispanic (2%), Asian (1%), and other(1%). The only previous study to consider the rela-

tionship between race and infection was by Haug et

al6 which showed a disproportionately high number

of infections in the racial minorities in the region. Thepresent study also found a disproportionately highpercentage of African Americans and Hispanics with

infection as compared with the general population ofthe region (Table 1); although no significant differ-

ences were found between the 1989 and 1999 co-horts.6

ADMISSION TEMPERATURE

A temperature greater than 37.0C is considered tobe a fever, or pyrexia.18,19 It is a result of the hypo-thalamic-thermoregulation centers response to regu-

latory chemicals induced by bacterial cell compo-nents such as endotoxins or cell wall fragments.18-20

Temperature is both a good predictor of acute infec-tion and a way to monitor a patients response to

treatment.20 Sethi and Stanley11 reported a mean ad-mission temperature of 38.4C (range, 37.0C to

39.5C), but not all the infections were odontogenic.Dodson et al9 reported a mean admission temperatureof 38.17C, but no range was reported. The mean oral

admission temperature for the 1980s patients in thisstudy was 37.76C (range, 36.0C to 39.2C). This

was similar to the mean for the 1990s patients oraladmission temperature of 37.62C (range, 36.0C to39.8C). Both Sethi and Stanleys and Dodson et als

mean admission temperatures correlated well withthese findings.

ADMISSION WHITE BLOOD CELL COUNT

Acute bacterial infections trigger a neutrophil re-lease from the bone marrow, and thus an increase inthese cells in peripheral blood is a useful indicator of

infection.18,19 Dodson et al9 reported an average ad-mission WBC count of 13.29 103/L for a pediatric

population; however, no range was cited. Heimdahlet al10 concluded that the WBC count is of minor

importance when judging the severity of an orofacialinfection. Perhaps the WBC count is most useful inassessing improvement or regression of a patients re-

sponse to therapy, rather than as a predictor of actualpatient status. There was no significant difference in

admission WBC counts between our 2 study groups.

LENGTH OF STAY

Patients generally remain hospitalized until the in-fection resolves or is controlled, until there is no

further airway compromise, and until the patient isreturning to a preinfection state of health. Har-el et

al14 reported an average hospital stay of 8.9 days for110 patients with deep neck abscesses. Sakaguchi et

al8 reported an average stay of 8.2 days (range, 1 to 31days) for patients with deep neck infections. Dodsonet al9 reported an average length of hospitalization of

3.5 days for a pediatric population. The present study



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found an average stay of 6.66 days (range, 1 to 41

days) for the 1980s patients, and the 1990s patientshad an average stay of 8.27 days (range, 2 to 69 days).The length of stay for both groups was similar to

those reported for other studies except Dodson etals9 pediatric population. This indicates that the

length of hospitalization is similar in different regionsof the world when similar adult infections are com-

pared. However, there is a difference between lengthof hospitalization for adults and children. Also, al-

though there has been a trend over the last decadetoward outpatient management of patients in the gen-eral medical community, this investigation identified

no such change in the treatment of patients withodontogenic infections. Changes in health care reim-

bursement have shifted management of healthy pa-tients or elective surgeries into the outpatient arena,

but acute emergencies and life-threatening problemshave remained as situations warranting admission and

inpatient management. Certainly airway compromiseand the potential for sepsis continue to warrant thevigilance afforded by the inpatient setting. Moreover,

although not statistically significant, the mean lengthof stay was longer in the 1990s, indicating that either

the patients were sicker or took longer to improve. Acontributing factor may be the increasing incidenceof antibiotic resistant bacteria.21,22

ANATOMIC SPACE

Odontogenic soft tissue infections usually spreadfrom the structures supporting the affected tooth

along the planes of least resistance to the fascialspaces in the vicinity.16 Labriola et al13 found that themost frequent single space infection was submandib-

ular (26%), followed by buccal (21%), masticator(15%), and canine (13%). They did not offer informa-

tion about multispace infections. Our study identifieda similar order of frequency in both groups for both

single and multispace infections.

TOOTH INVOLVEMENT

Chow et al16 discussed potential pathways forspread of infection and how odontogenic infections

most commonly involve the mandibular molar teeth.

Other authors have also reported the mandibular mo-lars as the most frequently involved teeth in odonto-genic infections.6,11,16 This report confirms these pre-vious studies. The mandibular third molar was the

most frequently involved tooth in both groups; onlythe mandibular left first molar was significantly differ-

ent between the 2 groups. We have no explanationfor this observation.

BACTERIAL INVOLVEMENT

Until the mid-1970s, it was believed that odonto-

genic infections were caused by a single species of

aerobic or facultative bacteria.18 Subsequently, it has

been well established that odontogenic infections arepolymicrobial.6,10,11,16-20,23-26 It has also been observedthat the bacteria identified from odontogenic infec-

tions have changed over the decades.17,18 Moenninget al17 reported that the bacterial flora of odontogenic

infections is no longer predominately facultative ormicroaerophilic, withStaphylococcus and Streptococ-

cus as the primary genera, but rather is more often amixed flora with anaerobes outnumbering aerobes

2:1. Alpha-hemolytic streptococci are the most fre-quently isolated bacteria8,12,13; although Bacteroidesmelaninogenicus has been reported as the most com-

mon in some studies.14,16 In this study, there were 19bacterial genera or species isolated in the 1980s pa-

tients, with alpha-hemolytic Streptococcipredominat-ing almost 2:1 over B melaninogenicus and beta-

hemolytic Streptococci 3:1 over S epidermidis, andalmost 4:1 over S aureus and E corrodens (Table 5).

There were 24 genera or species isolated in the 1990spatients, with coagulase-negative Staphylococci, al-pha-hemolytic Streptococci, and beta-hemolytic Strep-

tococci having nearly a 1:1:1 ratio and predominatingequally over all other bacteria by more than a 2:1

ratio (Table 5). No isolates of B melaninogenicus

were reported in the 1990s patients; however 13other Bacteroides isolates were identified. Signi-

ficant differences between the groups were foundfor alpha-hemolytic Streptococci, coagulase-negative

staphylococci, S epidermidis, B melaninogenicus,beta-lactamase positive Bacteroides, E corrodens, andNeisseria species suggesting that there has been ashift in the microbiologic flora involved in odonto-genic infections. Alpha-hemolytic Streptococci were

the most common isolates in both groups, thus con-firming previous reports of the frequency with which

these bacteria are isolated from odontogenic infec-tions.8,12,13 It is clear that these common Gram-posi-

tive cocci remain a threat to patients with odonto-genic infections. The significance of the differencesfor the other isolates is less clear because of changes

in bacterial nomenclature and laboratory protocols inthe past 10 years. For example, there was a statisti-

cally significant difference between groups for B

melaninogenicus mainly because there were no iso-lates identified from the 1990s patients. This is be-cause B melaninogenicus was reclassified in 1990;bacteria identified as B melaninogenicus in the 1980s

patients should have been reported as either Pre-votella or Porphyromonas in the 1990s patients.25

Consequently, the difference between the 2 groupsfor this obligate anaerobe is a statistical anomaly.

The statistically significant difference betweengroups for S epidermidis and coagulase-negativestaphylococci can be explained by changes in labora-

tory protocol. S epidermidis is a coagulase-negative

746 CHANGING FACE


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staphylococcus. During the 1980s, it was common to

speciate isolates, although this provided little clini-cally useful information. Consequently, protocolchanges were made that resulted in all coagulase-

negative staphylococci being reported as such with-out further identification. A more accurate picture

of the statistically significant differences betweengroups emerges by analyzing S epidermidis and coag-

ulase-negative staphylococci together. When this isdone, there is no significant difference between the

groups (X2(1) 0.883, 0.347). The significant de-creases in Neisseria species and E corrodens from the1980s patients to the 1990s patients are most proba-

bly a result of laboratory protocol changes andchanges in therapy, respectively. The complete ab-

sence of Neisseria identified in the 1990s patientssuggests a decision by the clinical laboratory not to

seek this species in clinical specimens from odonto-genic infections. The decrease in E corrodens isolated

from the 1990s patients may be a result of improvedanaerobic infection treatment with antibiotics thathave been developed in the past 10 years. Unfortu-

nately, no data about preadmission treatment wereavailable. The only other bacteria with a significant

difference between groups were beta-lactamase posi-tive bacteroides, which were not reported at all in the1980s patients. Although the reason for this change is

unclear, rather than reflecting some important shift inodontogenic infection etiology, it is probably caused

by a nomenclature or protocol change. For example,it is curious that there are no Prevotella or Porphy-romonas species reported in the 1990s patients, de-spite their importance in periodontal and other odon-togenic infections. It has been reported that more

than 50% of Prevotella species are beta- lactamaseproducers.28 It is possible, therefore, that the signifi-

cant difference seen between groups is another con-sequence of the nomenclature change in B melani-nogenicus previously discussed. It can be concludedthat there has been little change in the kinds of bac-teria isolated from odontogenic infections in the 2

groups of patients 10 years apart; alpha- hemolyticstreptococci remain the most frequently isolated bac-

teria.

From the limited antibiotic sensitivity data availableit was not possible to determine if there has beenchanges between groups in the kind, number, andfrequency of resistant isolates. There were no data

available for the 1980s patients, and only 10% of the1990s patients had a culture and antibiotic sensitivity

test done at least once during their hospitalization(Table 6). Despite their limitations, the data confirm

some disturbing trends. Eighty-one percent (26/32) ofthe isolates were resistant to one or more antibiotics.Despite the relatively low overall occurrence (Table

5), S aureus was the most frequently identified anti-

biotic resistant isolate (9/32). In addition to its innate

virulence, S aureus is of increasing concern becauseit, along with other Gram-positive cocci, is becomingresistant to most common antibiotics. For example,

methicillin-resistant S aureus that also exhibits inter-mediate resistance (minimum inhibitory concentra-

tion 8 g/mL) to vancomycin, the antimicrobialregarded as the antibiotic of last resort for these

bacteria, has recently been reported in Japan and theUnited States.21 Another trend is the number of anti-

biotic-resistant coagulase-negative staphylococci iso-lated. These bacteria have long been regarded as ap-athogenic members of the normal flora; however,

they are increasingly becoming recognized as impor-tant causes of infections, especially those acquired in

hospitals.22 Because most of the infections they causeare nosocomial, it should not be surprising to see in-

creasing multiple antibiotic resistance. Against a back-ground of the empiricism with which many clinicians

continue to treat these patients (eg, only 10% of thepatients in the 1990s had a culture and antibioticsensitivity test performed), it is predictable that there

will be more initial treatment failures and a conse-quent increase in patient morbidity and total cost of

care.Moenning et al17 suggested that wounds or cavities

can become contaminated with normal skin micro-

flora, including Staphylococcus species, through ex-ternal drainage. Although it is possible that such con-

tamination occurred during the harvest of culturematerial in the cases included in this investigation, it

is unlikely because proper surgical technique andrigorous preoperative antimicrobial skin preparationwere used. One would expect surgical technique and

skin preparation to improve with time, thereby reduc-ing the incidence of sample contamination from cu-

taneous sources. However, this does not seem to bethe case in this comparison of odontogenic infections

from the 1980s and the 1990s, which showed nochange in the frequency of Staphylococcus speciesisolated. Assuming that proper technique was followed

and that the sites were prepared properly, it is improb-able that there has been a shift in the kinds of bacteria

causing odontogenic infections in the last 10 years.

Summary

This investigation of odontogenic infections and

the review of the literature indicate that patient char-acteristics and the clinical signs and symptoms pa-

tients exhibit have remained constant over the past 2decades. There is a good deal of similarity between

the findings of this study and other investigationsperformed at different institutions, under differentconditions, and at different times. What has changed

is the type and prevalence of bacteria isolated from



10/10

odontogenic infections; however, this is thought to

be due to changes in nomenclature, identificationprotocols, and isolation techniques. Perhaps improve-ment in laboratory procedures to process, grow, and

identify bacteria from odontogenic infections has ledto this difference. A definitive explanation of this

change awaits prospective studies that use more rig-orous microbial identification procedures than are

normally used in hospital settings. An especially im-portant aspect of subsequent studies will be a deter-

mination of the antibiotic sensitivity patterns of thebacteria isolated from odontogenic infections.

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