Associated Factors Involved in Presentation and Care of Severe Odontogenic Infections

Severe dental infections requiring hospital admission and emergent surgical treatment are a costly burden on the medical system.  Several studies have looked at average length of stay in these patients as well as overall expenditures for their care.^(1,2)  Dental care prior to treatment and/or antibiotic use has also been examined.⁽³⁾  We seek to identify variables and hospital trends in an urban hospital’s patient population that may be helpful in identifying or treating these patients. 

A retrospective chart review was conducted in patients admitted for odontogenic infections that were taken to the operating room at Belleuve Hospital from 07/15/2012 to 7/15/2013.  We identified variables such as age, immunocompromised status, temperature and white count at admission, presence of trismus and history of recent related dental or medical treatment.  These factors were viewed in reference to postop treatment factors such as length of hospital stay and the time patients remained intubated postoperatively.

15 patients were identified who were emergently admitted from the emergency room and taken to the operating room for incision and drainage (as well as extraction of teeth when deemed necessary).  The mean age of patients was 43.6 years with a range of 11 to 69 years.  60% of patients were male.  12/15 (80%) of patients had sought medical or dental care prior to presentation to the emergency room. Of those that had sought care, 11/12 (92%) had been prescribed an antibiotic.  At presentation to the emergency room 11/15 (73%) of patients were noted to have significant trismus.  The average white blood cell (wbc) count at time of presentation was 13.72, (80% had counts over 10.8).  Only 4 of 17 patients were noted to have fevers over 100.5 prior to the surgical procedure.  Only 2 patients had a reported history of diabetes.  Average length of stay was 3.86 days (range 2 to 8) and 10 patients remained intubated postoperatively for airway protection. 

Severe odontogenic infections pose a significant problem for both patients and hospitals.  It is interesting to note that most patients presenting with severe odontogenic infections had been previously treated by either outside dentists or doctors and had been prescribed antibiotics.  Few of our patients had significant medical problems, such as diabetes, that would create immunocompromised states, therefore it is important to study these patients to determine if any other aspect of their presentation could be linked to an increased likelihood of hospital admission.  Although we found most of our patients presented with elevated white counts, very few of them actually had fevers prior to admission.  Most of our patients (70%) did present with trismus, which is likely the major factor that led to their admission.  At our institution if there is any concern for airway deviation or edema, patients are often kept intubated for airway protection and then extubated when it is safe to do so (as agreed by both the anesthesia and surgical teams) following ventilator weaning protocols and a cuff leak test.   At other institutions this practice may be different.    We recommend further study into these patients with the goal of reducing hospital admissions and better reducing cost of treatment.

References:

Seppanen L, Lemberg K, Lindqvist C, Rautemaa R.  Is dental treatment of an infected tooth a risk factor for locally invasive spread of infection.  J Oral Maxillofac Surg 69:986-993, 2011. 

Jundt JS, Gutta R.  Characteristics and cost impact of severe odontogenic infections.  Oral Surg Oral Med Oral Pathol Oral Radiol 114:558-566, 2012. 

Christensen B, Han M, Dillion JK.  The cause of cost in the managemet of odontogenic infection 1: a demographic survey and multivariate analysis.  J Oral Maxillofac Surg 71:2058-2067, 2013.