TREATMENT OF FACIAL SOFT TISSUE INFECTIONS WITHIN FAST HEALTH REHABILITATION UDC: (Original scientific paper)

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1 Research in Physical Education, Sport and Health 2015, Vol. 4, No. 1, pp.7-13 ISSN(Print): ; ISSN(Online): TREATMENT OF FACIAL SOFT TISSUE INFECTIONS WITHIN FAST HEALTH REHABILITATION UDC: (Original scientific paper) Benedetti Alberto 1, Popovski Vladimir 1, Popovik-Monevska Danica 1, Kirkov Antonio 1, Pancevski Goran 1, Dvojakovska Suzana 1, Iliev Aleksandar 1, Gjorgievska Elizabeta 2, Stamatoski Aleksandar 3 1 University Ss Cyril and Methodius, Faculty of Dental Medicine, University Clinic for Maxillofacial Surgery, Skopje, Republic of Macedonia 2 University Ss Cyril and Methodius, Faculty of Dental Medicine, Department of Paediatric and Preventive Dentistry, Skopje, Republic of Macedonia 3 University Ss Cyril and Methodius, Doctor of Dental Medicine, postgraduate study, Republic of Macedonia Abstract Odontogenic infections are rapidly spreading health conditions, caused by bacterial inflammation that may produce serious health problems. The aim of study was to evaluate some clinical experience of the treated patients with face soft-tissue infections with speed health rehabilitations and their characteristics and treatment modalities using incision, drainage, sometimes tooth extraction with other medical treatments. This retrospective study has been done with face soft-tissue patients infections from January 2014 to January We found male preponderance, and mean age was Sources of infections were of odontogenic origin in 93% of cases. The mandibular 3 rd molar (20%) was found to be the most commonly offending tooth, followed by the mandibular 1 nd molar (16%). Deciduous teeth contained 6.4% of the involved teeth. Most patients had aggressive surgical treatment with extraction, surgical drainage, high dose intravenous antibiotics, corticosteroids, and rehydration. Most of the patients (40%) were hospitalized for 4-6 days. Speed health rehabilitation after facial soft-tissue infections is important to verify the patient s health and life. Antibiotic and surgical treatment results in good condition with normalization of the leukocytes, C-reactive protein counts and good health recovery. Key Words: facial soft-tissue infection, odontogenic infection, mandible, maxilla. Introduction Odontogenic infections are rapidly spreading health conditions, caused by spreading bacterial inflammation that may produce upper airway obstruction and serious health problems. They contribute a significant proportion of maxillofacial space infections in the world statistic (Kulkarni et al. 2008; Mathew et al. 2012). The most dangerous spreading bacterial infections of the face tissues are Ludwig s angina, cellulites and dental abscessus. In the early stages they can be managed with observation and antibiotics. When they become life-threatening with tendency to cause swelling, dysphagia, trizmus, with a body temperature more than 37C (98.6F) they may arise obstruction of the airway. Beside that, patients may have pain, neck swelling, malaise, fever, excess tiredness. The most common cause is an odontogenic infection, from one or more carious and grossly decayed teeth, infected root canals and after tooth extraction. Additional possible etiological factors include maxilla-mandible fractures, sialadenitis of the major glands, osteomyelitis and tongue piercing (Uluibau et al. 2005; Fereydoun et al. 2013; Wolfe et al. 2011; Bahl et al. 2014). The risk factors are recent dental treatment, systemic illness like a diabetes mellitus, alcoholism, compromised immune system (Bahl et al. 2014). The diagnosis is usually based on clinical observation, but visual examinations and other test which may be used are dental panoramic radiographs, computerized tomography, complete blood count tests and microbiological cultures of tissue from the affected area. Aggressive management of odontogenic infections, with respect to airway, including antibiotics, early surgical intervention, can result in significant drop in the mortality rate of life compromising infections. 7

2 TREATMENT OF FACIAL SOFT TISSUE INFECTIONS WITHIN Material & Methods The medical records of 120 patients diagnosed with facial space infections and treated at the University clinic for maxillofacial surgery Skopje from January 2014 to January 2015 were reviewed. All patients were with odontogenic infections which had spread beyond the confines of the jaws and severely ill to warrant admission to the University clinic for surgical or without surgical management. Preoperative X-ray image exams were obtained providing radiographic diagnosis for the infection cause, and the main X-ray image was panoramic radiograph. Also, the usage of antibiotics was reviewed, singly or in combination as well as the various treatment modalities. Patients with a history of systemic diseases like diabetes mellitus, kidney failure, osteonecrosis of the jaw, drug allergy were also included. Outpatients with spreading facial odontogenic infections who did not require hospitalization were excluded. Routine investigations of blood were carried out in treated patients. Other analyzes were done with anamnesis date, frequency of offending teeth, clinical, laboratory, microbiological, X-ray finding, types of treatment, length of stay in the clinic and possible complications. Results A total of 120 patients with facial space infection were included over the period of study from January 2014 to January The ratio of males (58%) to females (40%) was 1.45:1 (Fig.1). Figure 1. Males to females distribution in the study population Systemic diseases were presented in 12.5% with most common incidence of diabetes mellitus (8%), kidney failure (2%), osteonecrosis of the jaw (2%), Parkinson s disease (1%) and 87.5% of the patients had no systemic disease (Tab.1). Table 1. Distribution of Systemic Diseases, n=11% Pre-existing medical problems Number Percentage Mental illness Intellectual disability (mental retardation) 1 1% Parkinson's disease 1 1% Kidney failure 2 2% Diabetes mellitus 9 8% Osteonecrosis of the jaw 2 2% Drug allergy *penicillin 1 1% The patients were between 2 and 83 years old (average age 36,86) with predominant age group between years (18%) followed by the years old (16%) (Fig.2). Sources of infections were of odontogenic origin in 93% of cases (Tab.2) (Fig. 3-10). The other sources of infections were of non-odontogenic origin 3%. Most of the patients had a toothache or pain (29%), swelling (29%) and limited mouth opening (18%). Mandibular teeth (84%) were more affected than maxillary (16%). The most involved permanent teeth were mandibular third molars (20%), mandibular first molars (16%) and mandibular second molars (15%) (Fig.11). Deciduous teeth contained 6.4% and among them mandibular molars (31%) were the most associated with infection. 8

3 B. Alberto, et al. Figure 2. Age group distribution of patients with facial space infections. Table 2. Clinical characteristics of facial space infections according to the aetiology and spectrum of clinical signs and symptoms in the same proportion of patients Variables frequency (n) percentage Aetiology Odontogenic infection % Non-odontogenic infection 4 3% Toothache or Pain Yes 77 29% Limited mouth opening Yes 48 18% Swelling Yes 77 29% Fever (high temperature) Yes 37 14% Fatigue Yes 20 8% Not available information 5 4% Figure 11. Affected Teeth. 9

4 TREATMENT OF FACIAL SOFT TISSUE INFECTIONS WITHIN Antibiotic treatment was performed and effective in five different groups. The most antibiotic regimens used were ceftriaxone (Lendacin 43%) and metronidazole (Efloran 14%). Corticosteroid, analgesic, antipyretic and antispasmodic therapy were used for speed healing and good recovery. (Tab.3). Table 3. Antibiotic, corticosteroid, analgesic, antipyretic and antispasmodic therapy used by the University Clinic for Maxillofacial Surgery Skopje Antibiotics Number of patients % Ceftriaxone (Lendacin) % Metronidazole (Efloran) 32 14% Garamycin (Gentamicin) 1 0% Lincomycin (Neloren) 4 2% Clindamycinum (Klimicin) 6 3% Corticosterioid medication Dexamethasone 68 30% Urbason (Methylprednisolone) 3 1% Analgesic, antipyretic and antispasmodic drug Ketoprofen (Ketonal) 6 3% Ketoprofen (Niflam) 4 2% The management modalities in our study were: incision and drainage (8%), tooth extraction (43%), and incision with tooth extraction (35%) (Fig. 12). Figure 12. Performed treatment with a severe odontogenic and non-odontogenic infections Overall, the mean duration of stay in the University clinic for maxillofacial surgery Skopje was 5.15 (range 2-14) days. Most of the patients (40%) were hospitalized for 4 6 days. The total length of hospital stay was less than 1 week in majority of cases (72%), followed by those who stayed in a period of 1-3 days (32%) (Tab.4). Table 4. Length of hospital stay Duration (days) Frequency (n) Percentage % % % % % not available information 1 1% 10

5 B. Alberto, et al. Blood test count performed in patients shows that Leukocytes (normal range 4-9 x 10 9 /L) and C- reactive protein (normal range 0-5 mg/l) levels increased at the time of admission of the patients. Odontogenic facial infections indicate that blood test results of Leukocytes (min: 9.4 to max: /L) and C-reactive protein (min: 27 to max: 393.2) in our patients detects a wide diapason (Tab. 5). Table 5. Blood tests results of Leukocytes and C-reactive protein of the treated patients with facial space odontogenic infections Interpretation of included analyses minimum result maximum result Leukocytes C-reactive protein Discussion The review of completed charts revealed that odontogenic infections can constitute a large portion of facial odontogenic infections in all group patients (93%). They are mainly caused by bacterial infections resulting from poor oral hygiene, dental infections, types of periapical process or pulpitis, pericoronitis or spread infection of periodontal disease (Otasowie et al. 2012; Patankar et al. 2014; Kityamuwesi et al. 2015; Bridgeman et al. 1995). Although 50% of odontogenic infections are polymicrobial (Osunde et al. 2014; Gholahan et al. 2012). Early antibiotic treatment should be broad spectrum to cover Gram-positive and Gram-negative bacteria as well as anaerobes (Pourdanesh et al. 2013). The results of the present study indicated that the facial odontogenic infections became more prevalent with an increase in age to 30 years, and the highest prevalence was seen in 21 to 30- year-old patients, followed by years-old-patients. Manisha Gupta and Virendra Singh (2010) observed that maximum number of patient were less than 30 years old. The results of this study are compatible with those previously found in the literature in which the age of patients was between years old (Otasowie et al. 2012; Pourdanesh et al. 2013; Osunde et al. 2014; Bahl et al. 2014). The gender distribution in this study showed a preponderance of male patients as compared with female patients. Among 120 patients included in our study, 70 patients were male and 48 patients were female. Gender distribution in patients of odontogenic infections concurs with Bahl et al. (2014), Gupta and Singh (2010), Osunde et al. (2012), Pourdanesh et al. (2013), Rega et al., (2006). All patients had pain and swelling on presentation, which corroborates previous studies. Of the conclusive data, lower facial odontogenic infections outnumbered upper facial infections by more than 4.24:1 in our investigation. Gbolahan et al. (2012), Flynn et al. (2006), Flynn et al. (2006) said that odontogenic infection around the lower 2 nd and 3 rd molars are the common sources of Ludwig s angina. The systemic illness such as diabetes mellitus, malnutrition, acquired immunodeficiency syndrome are predisposing and risk factors. The commonest cause in our odontogenic cases is an infected lower wisdom with affecting 20% in our practice from Jaunary 2014 to January Mandibular 3 th molars are usually semi erupted and the surrounding soft tissues are suitable for bacterial growth. This is a similar result compatible with the study of Matew et al., (2012). Deciduous first molars (19%) were the most involved deciduous teeth in this study. Osunde et al. (2012) in their study reported that submandibular space was the most frequently involved single space and accounted for 43.9% of the cases. Rega et al. (2006) also reported that the submandibular space was the most frequent location for a single space abscess (30%), followed by the buccal space (27.5%) and the lateral pharyngeal space (12.5%). The high incidence of odontogenic infections arising from the mandibular 3 rd molar followed by the mandibular 2 nd molar has also been reported by Bahl et al., (2014). According to the collected data of Pourdanesh et al.,( 2013), the most involved teeth were mandibular third molars (34.5%), mandibular first molars (29.5%), and mandibular second molars (24.3%). The hospitalization period was in average of 5.15 days (time between the admission and the discharge) a period quite similar to the found by Uluibau et al. (2005) which was 3.3 days and Flynn et al.(2006) which was 6.2 days; and not similar to the results described by Pourdanesh et al. (2013) who presented an average of 9.2 days of hospitalization and Otasowie et al. (2012) who reported an average of 10.7 days with a standard deviation of ± 8.6. Fakir et al. (2008) reported an average of 14.1 days. In spite of these, antibiotic therapy and surgical intervention (extraoral or intraoral incision and 11

6 TREATMENT OF FACIAL SOFT TISSUE INFECTIONS WITHIN drainage) it is a basic necessary treatment for life-threatening odontogenic infections. The choice of antibiotic for the management of odontogenic infections depends on the laboratory results of culture and antibiotic sensitivity testing (Bahl et al. 2014). In the present study, the most prescribed antibiotics were cephalosporin (43%) and metronidazole (14%). Other authors state that the most antibiotic regimens used for odontogenic infections were penicillin G and metronidazole (55.4%) or cephazolin and metronidazole (35.7%) (Pourdanesh et al. 2013); benzylpenicillin and metronidazole (70%) or cephazolin and metronidazole (17%) (Uluibau et al. 2005). Patients with Ludwig s angina affecting and including bilateral submandibular, submental, and sublingual spaces with clinical presentation of displaced tongue, trismus, airway obstruction, dysphagea and/or dyspnea must undergo with extensive use of antibiotics and surgical emergency. Wolfe et al., (2011) show that nineteen (65.5%) of patients with Ludwig s angina had evidence of airway compromise. Otasowie et al. (2012) reported in their review of 10 cases with Ludwig s angina, 60% of patients had airway problem. Fakir et al. (2008) concluded that airway protection, aggressive antibiotic therapy and surgical decompression can significantly alter the mortality rate of Ludwig's angina. Early recognition and correct treatment with antibiotics is mandatory to avoid the patient s threatening complications because if some patient left untreated, the rapid dissemination of the odontogenic infection can be fatal. Conclusions The results of this study indicate that odontogenic infections were most prevalent predisposing factor for facial soft-tissue infections. Successful management of these infections depends on removal of the etiologic factor, choosing the proper antibiotic and surgical treatment. The combination of cephalosporins and metronidazole is accepted empirical regimen for odontogenic infections. Complete blood count test performed in odontogenic and non-odontogenic group of treated patients indicates an elevated leukocytes and c-reactive protein levels. Spreading odontogenic infections should be preventable by routine dental treatment to prevent a serious risk to the patient s health and life, because early treatment may decrease the length of management in facial soft-tissue infections of odontogenic origin. Acknowledgements The presented study has been carried with interdisciplinary assistance of all authors. References AH Kulkarni, Swarupa D Pai, Basant Bhattarai, Sumesh T Rao, and M Ambareesha (2008).Ludwig's angina andairway considerations: a case report. Cases J. 2008; 1: 19. doi: / Bridgeman A, Wiesenfeld D, Hellyar A, Sheldon W. (1995). Major maxillofacial infections. An evaluation of 107 cases. 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7 B. Alberto, et al Pourdanesh F, Dehghani N, Azarsina M, Malekhosein Z. (2013). Pattern of odontogenic infections at a tertiary hospital in tehran, iran: a 10-year retrospective study of 310 patients. J Dent (Tehran). 10(4): Epub 2013 May 31. Rashi Bahl, Sumeet Sandhu, Kanwardeep Singh, Nilanchal Sahai, and Mohita Gupta. (2014). Odontogenic infections: Microbiology and management. Contemp Clin Dent. 5(3): doi: / X Richard Kityamuwesi, Louis Muwaz, Arabat Kasangaki, Henry Kajumbula, and Charles Mugisha Rwenyonyi. (2015). Characteristics of pyogenic odontogenic infection in patients attending Mulago Hospital, Uganda: a cross-sectional study. BMC Microbiol. 2015; 15: 46. doi: /s z. Rega AJ, Aziz SR, Ziccardi VB. (2006) Microbiology and antibiotic sensitivities of head and neck space infections of odontogenic origin. J Oral Maxillofac Surg. 64(9): Wolfe MM, Davis JW, Parks SN. (2011). Is surgical airway necessary for airway management in deep neck infections and Ludwig angina? J Crit Care. 26(1):11-4. doi: /j.jcrc

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