VERIFIABLE CPD PAPER Medical emergencies CLINICAL Management of odontogenic infections and sepsis: an update Phil Jevon,*1 Ahmed Abdelrahman2 and Nick Pigadas3 Key points Provides overview of management of Discusses recognition and management of sepsis in Considers sepsis in light of the COVID-19 odontogenic infection. the dental practice. pandemic. Abstract The management of odontogenic infections has improved over recent decades, but further improvements are still required. The ongoing education of GDPs and their dental teams on this issue continues to be important, especially during the current COVID-19 pandemic, where remote triage poses additional difculties and challenges. Odontogenic infections can lead to sepsis, a potentially life-threatening condition caused by the body’s immune system responding in an abnormal way. This can lead to tissue damage, organ failure and death. A patient with non-odontogenic-related infection could also present with sepsis at a dental practice. Early recognition and prompt management of sepsis improves outcomes. GDPs and their dental teams should be trained in the recognition and management of sepsis. Age-specifc sepsis decision support tools have been developed by the UK Sepsis Trust to help dental staf recognise and manage patients with suspected sepsis. The aim of this article is to provide an update on the management of odontogenic infections and sepsis. Introduction Early recognition and prompt effective • Stage 1: 1–3 days; sof and mildly tender treatment of sepsis improves outcomes.5 swelling Although the management of odontogenic The dental team should be trained in the • Stage 2: 2–5 days; hard, red and severely infections has improved over recent decades, principles of the management of sepsis.6 Age- sore swelling further improvements are needed and the specifc sepsis decision support tools have been • Stage 3: 5–7 days; abscess formation. ongoing education of GDPs and their dental developed by the UK Sepsis Trust7 to assist the teams on this issue is essential. In addition, dental team to recognise and manage patients Tere is a strong belief that once the abscess the COVID-19 pandemic has imposed new with suspected sepsis. has formed, surgical drainage is mandatory to difficulties and challenges; for example, Te aim of this article is to provide an update achieve resolution.12 Medical management has telephone triage and prescription of antibiotics, on the management of odontogenic infections a role in selected cases.13 and it is important to be up-to-date with and sepsis in the dental practice. current guidelines.1,2 Principles of efective management Odontogenic infections can lead to sepsis,3,4 Management of odontogenic of odontogenic infections a potentially life-threatening condition caused infections by the body’s immune system responding Seven principles have been proposed to achieve abnormally. Tis can lead to tissue damage, The morbidity and mortality rate of the best outcome in managing odontogenic organ failure and death.5 A patient with non- odontogenic infections has dropped infections:11 odontogenic-related infection could also signifcantly over the past 70 years.8,9,10 Tis 1. Establish the severity of the infection present with sepsis at a dental practice. dramatic drop is undoubtedly linked to the 2. Assess host defences discovery of antibiotics, the improvement of 3. Elect the setting of care 1Academy Tutor, Medical Education, Manor Hospital the general population health standards, and 4. Surgical intervention Walsall, UK; 2OMFS Speciality Trainee, Manor Hospital a better understanding of appropriate medical 5. Medical support Walsall, UK; 3Consultant Maxillofacial/Head and Neck Surgeon, Manor Hospital Walsall, UK. and surgical management of these cases. 6. Antibiotic therapy *Correspondence to: Phil Jevon Further improvements are needed and 7. Frequently evaluate the patient. Email address: [email protected] ongoing education of the dental team on this Refereed Paper. issue is very important. Establish the severity of infection Accepted 27 May 2020 Odontogenic infections pass through three A careful history and thorough clinical https://doi.org/10.1038/s41415-020-2114-5 key stages:11 examinations are essential to determine the BRITISH DENTAL JOURNAL | VOLUME 229 NO. 6 | SEpTEMbEr 25 2020 363 © The Author(s), under exclusive licence to british Dental Association 2020 CLINICAL Medical emergencies severity of any infection. History-taking Table 1 Risks associated with anatomical location will highlight factors like immune system competence and the level of systemic Risk Low Moderate High Extreme reserves to fight infections. A physical Vestibular Submandibular Lateral pharyngeal Mediastinum examination can identify clinical observations outside normal limits. Several clinical and Infraorbital Submental Retropharyngeal Intracranial infection haematological parameters have been used Buccal Sublingual Pretracheal as prognostic indicators for the severity of Spaces Pterygomandibular the infection. C-reactive protein (CRP), fever and anatomical locations have been Submasseteric investigated for the assessment of the extent of Temporal odontogenic infections and presumed duration of hospital stay.14 Additional factors must be considered to Box 1 Factors that can compromise the immune system establish the infection severity: • Diabetes steroid therapy • Anatomical location • Organ transplants • Airway compromise. • Malignancy • Chemotherapy There are a number of potential spaces • Chronic renal disease malnutrition between the musculoskeletal head and neck • Alcoholism. structures and the regional fasciae and organs better known as fascial spaces. A summary of these spaces and their level of risk11,12 is found management usually includes positioning the need for clear secondary care referral in Table 1. the patient in an upright position and criteria. Although there are no agreed national In healthy and systemically well patients administering oxygen 15 litres/minute,15 guidelines on when to admit to a secondary without trismus, infections of low-risk spaces while colleagues call 999 for an ambulance. care setting, criteria for hospital admission can be initially treated in a primary care have been proposed2,20 (Box 2). dental practice, while infections spreading to Assess host defences A careful history, thorough clinical higher risk spaces should be managed more A healthy immune system is essential to the examinations and a high index of suspicion aggressively and may need to be treated in a maintenance of host defence against infection. will enable the GDP to diagnose and secondary care centre. Multiple medical conditions can afect it.17 Box appropriately manage patients presenting with 1 summarises the common factors that can odontogenic sepsis. Ludwig’s angina cause immune system compromise. Ludwig’s angina was described by Karl Friedrich The concept of ‘physiologic reserve’ Surgical intervention Wilhelm von Ludwig in 1836 as a rapidly represents a signifcant driver of outcome in Early surgical intervention has been advocated and frequently fatal progressive gangrenous patients fghting infection. Tis can be defned to improve the clinical outcome of odontogenic cellulitis and ooedema of the sof tissues of as the capability of an organ to carry out its infection. Te dramatic improvement in the the neck and foor of the mouth.15 Tankfully, activity under stress.18 Age is an essential factor outcome of sever odontogenic infection is mortality rates have reduced significantly that is inversely related to the physiologic directly linked to the immediate establishment with the introduction of antibiotics, improved reserve; that is, decreased respiratory, of a safe airway, followed by early surgical oral and dental hygiene, and timely surgical cardiovascular and metabolic reserve.19 intervention. intervention.15 Te majority of Ludwig’s angina Once the airway has been deemed patent infections are odontogenic;16 peritonsillar Elect the setting of care and not at risk of being compromised, in or parapharyngeal abscesses, mandibular An uncomplicated localised dental abscess in either a hospital setting or dental practice, the fractures, oral lacerations/piercing and a healthy young person, who does not show principles of management are very similar. submandibular sialoadenitis are other signs and symptoms of a worsening immune Thorough knowledge of head and neck recognised causes.15 response, can be safely treated in a dental anatomy will enable the surgeon to access A compromised airway is synonymous with practice. Early and adequate intervention the abscess cavities using incisions in safe Ludwig’s angina and the initial assessment is essential in order to prevent avoidable places without damaging any vital structures of a patient with Ludwig’s angina should deterioration with invasion of adjusted like blood vessels or nerves. Most of the follow the familiar ‘Airway, Breathing, anatomical spaces and symptoms of sepsis odontogenic infections can be drained through Circulation, Disability, Exposure’ (ABCDE) (Fig. 1). intraoral access. approach. Signs of a compromised airway Similarly, severe neck infection in an Five principles must be followed:11,12 in these patients could include noisy immunocompromised elderly person warrants • Elimination of the source of the infection. (gurgling) breathing with drooling saliva, treatment in a secondary care setting. Te Tis can be achieved by either removing stridor, dyspnoea, tachypnoea, tachycardia, clinical decision