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Selectedreadings in Oral and Maxillofacial Surgery SELECTED READINGS IN ORAL AND MAXILLOFACIAL SURGERY MAXILLOFACIAL INFECTIONS Andrew Read-Fuller, DDS, MD Andrew Mueller, DMD, MD Richard A. Finn, DDS Volume 23, Number 3 November, 2015 Maxillofacial Infections A. Read-Fuller, DDS, MD, et al. MAXILLOFACIAL INFECTIONS Andrew Read-Fuller, DDS, MD, MS, Andrew Mueller, DMD, MD, Richard Finn, DDS INTRODUCTION Oral and maxillofacial infections are among the most common surgical problems faced by oral and maxillofacial surgeons in the United States. Although severe maxillofacial infections re- quiring inpatient hospitalization are rare,(1) the mortality rate of patients admitted with maxillofa- cial infections is estimated to be one in 150.(2) Proper management of odontogenic study included traumatic cases (10.7%), im- infections has important economic implica- munosuppression (1.6%), and pathology tions as well. One study demonstrated that (1.6%), while other causes were responsible the average hospital bill for a patient admit- for the remaining 8% of cases.(5) Byers, et ted with an odontogenic infection was over al’s multicenter study found a dental origin in $17,000, with length of stay, time spent in 86% of maxillofacial infections presenting to intensive care, and repeated trips to the op- Scottish hospitals.(6) erating room accounting for 90% of variation in the hospital bill.(3) By definition, odontogenic infections of the head and neck begin in the teeth through In all phases of treating a maxillofacial a variety of disease processes. Caries is the infection, from diagnosis to perioperative most common of these dental diseases, fol- medical evaluation and surgical interven- lowed by periodontal disease and pericoroni- tion, experience and timely intervention is tis.(7) Lower teeth are much more commonly critical to achieving a favorable outcome. An the source of severe odontogenic infections, adequate understanding of the etiology, di- with the mandibular third molar as the origin agnosis, microbiology, and management of in a majority of cases. This is followed by these conditions is, therefore, critical for the other mandibular posterior teeth, while max- oral and maxillofacial surgeon. illary posterior teeth contribute much less fre- quently to these infections.(7) ETIOLOGY AND PATHOGENESIS Maxillofacial infections have significant- ly different distribution among children. They Maxillofacial infections are most com- are more likely to occur in the upper face monly caused by odontogenic sources.(4) than the lower face, and these upper face A retrospective review of hospital admis- infections are caused by odontogenic, trau- sions for maxillofacial infections by one oral matic, and other unknown sources at very and maxillofacial surgery graduate program similar rates. In contrast, lower face infec- showed that 79% were for infections of odon- tions, which occur with less frequency, are togenic origin. Other sources identified in the much more commonly due to odontogenic sources.(8) SROMS 2 VOLUME 23.3 Maxillofacial Infections A. Read-Fuller, DDS, MD, et al. PATIENT DEMOGRAPHICS The findings in the Australian study(15) were consistent with other reviews showing that the uninsured and underinsured, as well Infections of the maxillofacial region are as other patients of limited means, compose more likely to occur in certain patient popu- a very high proportion of patients seeking lations. Males, both adult and children, are emergency treatment for maxillofacial in- more likely to present emergently with odon- fections.(17) In one review of patients hos- togenic and other maxillofacial infections, pitalized with odontogenic infections, nearly although there is significant variation in the 62% were unfunded.(3) Of Scottish patients degree of male predominance.(5,8-12) The presenting to hospitals with maxillofacial in- mean age of patients presenting with acute fections, 54% were from the lowest two so- maxillofacial infections ranges from 25-38 cioeconomic quintiles, 36% from the lowest years in various studies.(6,9-12) quintile alone.(6) Patients with systemic diseases are Routine dental care may be instrumen- more likely to present emergently with sig- tal in preventing severe odontogenic infec- nificant head and neck infections. Huang, et tion. British oral and maxillofacial surgeons al. found that 34.1% of such patients suffer noted a significant increase in emergency from significant medical comorbidities, with room visits, admissions, and surgeries for 88.9% of those patients having diabetes mel- maxillofacial infections after the National litus.(13) Although the association between Health Service changed their reimbursement maxillofacial and systemic disease is undis- system, eliminating fees per tooth extracted, puted, there is a lack of data demonstrating and implemented a single fee for the more a causal relationship.(14) expensive treatment.(18,19) By decreasing access to needed dental extractions, more Socioeconomic status, patient attitudes, severe manifestations of odontogenic infec- and other psychosocial factors correlate with tions are likely to occur. the patients presenting with maxillofacial infections. A survey of Australian patients CLINICAL PRESENTATION showed that only 16% regularly visited the dentist, and the majority had unfavorable AND HISTORY impressions of oral healthcare, reporting not only difficulty paying for dental treatment, Patients presenting with a significant but also phobias and fears of going to the maxillofacial infection report certain common dentist.(15) Additionally, this study found that complaints, particularly when their infection 34% struggled with either mental illness or has an odontogenic source. Rapidly-wors- substance abuse, which was thought to ex- ening swelling, dysphagia, pain, and trismus plain, in part, the poor oral health of those are the most common presenting symptoms. presenting with odontogenic infections. (15) (7,17) In fact, Uluibau, et al. found that 44 % Specifically, an association between drug of patients had trismus when they presented and alcohol abuse and the development of to the emergency room with an odontogenic severe deep space odontogenic infections infection.(15) has been demonstrated.(16) SROMS 3 VOLUME 23.3 Maxillofacial Infections A. Read-Fuller, DDS, MD, et al. Sato, et al. reviewed records from all of the likelihood that the patient will require maxillofacial infections and found trismus substantial surgical interventions, more in- (43%), fever (28%), and dysphagia (25%) tensive care, or a greater length of hospital were the most common presenting symp- stay. toms.(5) Fetid breath and active drainage may also be found, although less often, and Laboratory Values and Vital Signs 26% of patients present with a draining si- nus tract.(6) Among patients in the Byers, et al. audit of Scottish medical centers 16% Obtaining a patient’s history of symp- met the criteria for systematic inflammatory toms is the first important step in gauging response syndrome (SIRS) on admission.(6) the probability of severe infection. Patients Byers, et al. also found that 34% of patients with symptoms for a greater length of time reported dental treatment within the previous prior to admission are more likely to have a two weeks, while 6% reported recent trauma. greater number of involved spaces and, sub- (6) Therefore, taking a proper history may sequently, an increased length of hospital help reveal the origin of the infection. stay (LOS).(20) ANATOMICAL SPACES Certain admission laboratory values have been shown to be important in assess- ing a patient with a maxillofacial infection. Flynn, et al. examined the frequency C-reactive protein (CRP) is perhaps most and distribution of spaces involved in severe predictive of the severity of a clinical course odontogenic infections.(7) They found the (21) and LOS. In fact, every increase in CRP pterygomandibular space most frequently of 100 roughly translates to an additional 24 involved (59% of the time), followed by the hours of admission.(22) submandibular space (54%) and then the lat- eral pharyngeal space (43%), buccal space WBC count correlates with a difficult (41%), and space of the body of the man- clinical course for children(23) and can be dible (35%). The average number of spaces predictive of an increased length of hospital involved was 3.3 and ranged from 1-8.(7) stay(10) but may not have the same prognos- Other studies have had similar results al- tic value in adults.(24) CRP may be a more though the submandibular space(9) and the accurate predictor of post-operative compli- buccal mandibular space(5,6) were the most cations and infection severity than WBC.(25) commonly involved. Prealbumin, a marker frequently used PREDICTING DISEASE SEVERITY in nutritional assessment of the inpatient, is AND PROGRESSION frequently low in the patient admitted for an odontogenic infection, and when assessed in conjunction with BUN, accurately predicts One of the most important tasks for length of stay 77% of the time.(26) Tempera- the oral and maxillofacial surgeon called to ture may have a bearing on length of stay evaluate a patient presenting with a maxillo- in adults according to some studies(22,24) facial infection is to rapidly assess him or her while others have found no correlation.(27) and determine the severity of the infection. This assessment must include an evaluation SROMS 4 VOLUME 23.3 Maxillofacial Infections A. Read-Fuller, DDS, MD, et al. Children are also more likely to prog- Diabetes mellitus is a common medi- ress favorably if they are younger,
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