Kim and Lee Maxillofacial Plastic and Reconstructive Surgery (2021) 43:3 Maxillofacial Plastic and https://doi.org/10.1186/s40902-020-00288-x Reconstructive Surgery RESEARCH Open Access Clinical utility of procalcitonin in severe odontogenic maxillofacial infection Ji-Kwan Kim and Jae-Hoon Lee* Abstract Background: Most of the maxillofacial infections are bacterial infections, and there is a possibility that systemic infections occur by maxillofacial infections. The aim of this study was to investigate the diagnostic value of procalcitonin in patients with odontogenic bacterial infections of the maxillofacial region. Methods: We enrolled sixty patients, who were admitted with odontogenic maxillofacial infection from September 2018 to March 2020. White blood cell counts, C-reactive protein, and procalcitonin concentrations were evaluated. Sixty patients were classified into two groups, sepsis and non-sepsis groups, based on systemic inflammatory response syndrome. A Student t test was performed to statistically analyze the difference in inflammatory markers between sepsis and non-sepsis groups. Results: The mean procalcitonin values on admission were 7.24 ng/mL (range, 0.09–37.15 ng/mL) and 0.40 ng/mL (range, 0.02–4.94 ng/mL) in the sepsis group and non-sepsis group, respectively. The procalcitonin values between the two groups showed a significant difference (P < 0.05). The area under the curve of procalcitonin was 0.927 (P < 0.001), and the cutoff value of procalcitonin that maximizes the area under the curve was calculated to be 0.87 ng/ mL. Conclusions: According to our study, routine laboratory tests have insufficient accuracy in diagnosing sepsis syndrome. Therefore, it is strongly recommended to perform the procalcitonin test in patients with maxillofacial infection in addition to the conventional laboratory tests to diagnose the systemic inflammatory condition of the patients. Keywords: Abscess, Head and neck infection, Dental infections, Procalcitonin, Sepsis, SIRS Backgrounds by a microorganism that has invaded the human body Maxillofacial infections are life-threatening diseases and is caused by the interaction between the inflamma- commonly caused by odontogenic origin. Fascial space tory factor of the microorganism and the inflammatory infections of odontogenic origin have latent spaces that response of the host. SIRS is the initial step in the sys- are anatomically connected to each other, thus allowing temic host response to infection or injury, defined to the infections to spread, causing airway compromise, occur in patients with any two or more of the four clin- and invading sensitive anatomical structures such as the ical criteria listed in Table 1 [1]. Sepsis syndrome is de- mediastinum and spinal cord. It can spread to the area, fined as SIRS that can identify the source of infection be life threatening, and progress to sepsis due to bacter- and is caused by the interaction of microbial inflamma- ial infection in the blood. tory factors with host inflammatory responses. Sepsis syndrome is a systemic inflammatory response Procalcitonin (PCT) is a precursor of calcitonin and is syndrome (SIRS) that is triggered when blood is infected synthesized by thyroid C cells. Additionally, PCT is pro- duced by the reaction to endotoxins and the mediation * Correspondence: [email protected] produced in response to bacterial infections [2]. PCT Department of Oral and Maxillofacial Surgery, College of Dentistry, Dankook University, 119 Dandae-ro, Dongnam-gu, Cheonan, Chungnam, South Korea has the highest sensitivity and specificity for predicting © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Kim and Lee Maxillofacial Plastic and Reconstructive Surgery (2021) 43:3 Page 2 of 7 Table 1 Systemic inflammatory response syndrome criteria Laboratory examination Criterion Positive result Antecubital venous blood was drawn before admission Temperature < 36 °C or > 38 °C for the measurement of white blood cell (WBC) counts, Pulse rate > 90 beats per minute C-reactive protein (CRP), and PCT concentrations. Add- itionally, bloodstream infection was confirmed through Respiratory rate > 20 breaths per minute blood culture tests in all patients. Simultaneously with 9 White blood cell count < 4 or > 12 × 10 /L the operation, pus culture was performed. systemic bacterial inflammation [3–5]. PCT levels are as- Systemic inflammatory response syndrome analysis sociated with the severity of bacterial infections and may The vital signs of patients and WBC were measured at the also be helpful in determining the initiation and duration time of admission. Patients with any two or more of the fol- of antibiotic treatment via PCT measurements [6–8]. lowing clinical criteria have been defined as SIRS: the body PCT analysis can be performed within 1 h, so that the temperature less than 36 °C or more than 38 °C, the pulse patient’s systemic infection status can be quickly identi- rate over 90 times per minute, the respiratory rate over 20 fied, initiating treatment. times per minute, and the number of white blood cells less There have been several studies assessing the utility of than 4 × 109/L or more than 12 × 109/L (Table 1). Patients PCT analysis for systemic bacterial infections; however, with SIRS were classified in the sepsis group, and patients only a few studies have reported on the utility of PCT in without SIRS were classified in the non-sepsis group. patients with odontogenic maxillofacial infections. Add- itionally, it is generally known that sepsis syndrome may Diagnosis of maxillofacial fascial infection and severity occur due to severe odontogenic maxillofacial infection, scoring although there have been no studies of patients with The site of infection was confirmed via enhanced com- sepsis syndrome caused by odontogenic infection. This puted tomography taken at the time of admission, and study aimed to investigate the diagnostic value of PCT the severity of infection was also recorded. The severity in patients with odontogenic bacterial infections of the of infection was measured by the sum of each severity maxillofacial region. score of anatomic spaces affected by abscess or cellulitis based on the study by Flynn et al. [9]. Abscess with low risk to airway or vital structures such as vestibular, sub- Materials and methods periosteal, infraorbital, and buccal space abscess was cal- Patients culated as severity score of 1 point. Submandibular, We studied patients who were admitted to the Depart- submental, sublingual, pterygomandibular, submasse- ment of Oral and Maxillofacial Surgery at Dankook Uni- teric, superficial temporal, and deep temporal space ab- versity Hospital (Cheonan, Korea) from September 2018 scess was calculated as severity score of 2 points which to March 2020 for the treatment of odontogenic max- were considered moderate risk to airway or vital struc- illofacial infections. Ethical approval was sought and tures. At last, abscess with high risk to airway or vital given by the Dankook University Dental Hospital Insti- structures such as lateral pharyngeal, retropharyngeal, tutional Review Board (IRB number: DKUH IRB 2020- pretracheal, and mediastinal space abscess was calcu- 05-006) for carrying out this study. lated as severity score of 3 points. We collected details on age, sex, vital signs, underlying diseases, and site of infection. Adult patients (ages older Data analysis than 19 years) were only included in the investigation, After confirming SIRS, patients were classified based on and patients with non-maxillofacial infections such as the presence or absence of sepsis syndrome, and Stu- pneumonia and endocarditis were excluded. dent’s t test was performed to statistically analyze the The criteria for admission were swelling of the face or difference in inflammatory markers between the two neck that suggested an abscess or cellulitis and manifest- groups (the sepsis and non-sepsis groups). Second, to ation of one or more of the following symptoms: a com- confirm that the degree of local site infection may affect promised airway, restricted mouth opening, dysphagia, sepsis syndrome, the severity score and the number of or body temperature greater than 38 °C. affected spaces were compared using Student’s t test. Antimicrobial drugs were administered from the day Finally, to measure the sensitivity, specificity, and pre- of admission to the day before discharge, and the abscess dictive cutoff value of PCT in diagnosing sepsis syn- was drained. When deep space infection was observed drome in patients with odontogenic maxillofacial or intraoral incision was difficult to perform due to se- infection, the receiver operating characteristic (ROC) vere restriction of mouth opening, drainage was per- curve was used to measure the area under the curve formed under general anesthesia. (AUC). Kim and Lee Maxillofacial Plastic and Reconstructive Surgery (2021) 43:3 Page 3 of 7 Statistical analysis was performed using the Statistical WBC values did not show any significant difference be- Package for the Social Sciences statistics software ver- tween the two groups (Table 2). sion 26 (IBM, Chicago, IL, USA). Data are expressed as According to the blood culture test results, only one the mean ± standard deviation (SD). P value less than patient was found to have bacterial infection, and blood 0.05 was considered as statistically significant. culture test results from all other patients were negative.