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Severe Odontogenic Infections, Part 1:

Prospective Report
Article in Journal of Oral and Maxillofacial Surgery August 2006
DOI: 10.1016/j.joms.2006.03.015 Source: PubMed

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J Oral Maxillofac Surg

64:1093-1103, 2006

Severe Odontogenic Infections, Part 1:

Prospective Report
Thomas R. Flynn, DMD,* Rabie M. Shanti,
Michael H. Levi, ScD, Arthur K. Adamo, DDS,
Richard A. Kraut, DDS, and Norman Trieger, DMD, MD
Purpose: The purpose of this study was to prospectively evaluate a series of patients with severe

odontogenic infections (OI).

Patients and Methods: In this study, 37 consecutive hospitalized patients with odontogenic infection
were treated with intravenous penicillin (PCN) (unless allergic), and prompt incision and drainage.
Standardized data collection included demographic, preadmission, time-related, preoperative, anatomic,
treatment, microbiologic, and complications information. Appropriate descriptive statistics were computed.
Results: The sample consisted of 37 subjects (38% female) with a mean age of 34.9 years. Three
subjects (8%) had immunocompromising diseases. Caries was the most frequent dental disease (65%) and
the lower third molar was the most frequently involved tooth (68%). Trismus and dysphagia were present
on admission in over 70% of cases. The masticator, perimandibular (submandibular, submental, and/or
sublingual), and peripharyngeal (lateral pharyngeal, retropharyngeal, and/or pretracheal) spaces were
infected in 78%, 60%, and 43% of cases, respectively. Abscess was found in 76% of cases. PCN-resistant
organisms were identified in 19% of all strains isolated and in 54% of patients with sensitivity data. PCN
therapeutic failure occurred in 21% of cases and reoperation was required in 8%. Length of hospital stay
was 5.1 3.0 days. No deaths occurred.
Conclusions: This study indicated that PCN resistance, resulting in PCN therapeutic failure, was
unacceptably high in this sample. Alternative antibiotics, such as clindamycin, should be considered in
hospitalized patients with OI. Masticator space infection occurred much more frequently than previously
reported. Trismus and dysphagia should be appreciated as significant indicators of severe OI.
2006 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 64:1093-1103, 2006
Most published case series of severe odontogenic
infections are retrospective.1-9 As such, they are subject to errors due to missing data, misclassification or
misinterpretation of clinical records, and inconsistent
treatment methods. Therefore, we designed a prospective descriptive study of 37 consecutive cases of
severe odontogenic infections (OI), defined as those
warranting hospital admission. Standardized data
*Assistant Professor, Oral and Maxillofacial Surgery, Harvard
School of Dental Medicine; and Associate Visiting Surgeon, Massachusetts General Hospital, Boston, MA.
Howard Hughes Medical Institute-National Institutes of Health Research Scholar, National Institutes of Health, Bethesda, MD; and Predoctoral Candidate, Harvard School of Dental Medicine, Boston, MA.
Co-Director, Microbiology, Montefiore Medical Center; and Associate Professor of Pathology (Clinical), Albert Einstein College of
Medicine, Bronx, NY.
Director, Oral and Maxillofacial Surgery, North Bronx Healthcare Network; and Associate Clinical Professor of Oral and Maxillofacial Surgery, Albert Einstein College of Medicine, Bronx, NY.

were collected from each case, and uniform treatment methods were used.
The specific aims of this study were: 1) to accumulate prospective descriptive data to characterize severe OI, and 2) to determine the success rate of
intravenous penicillin (PCN) for treatment of severe
OI. Our hypothesis was that intravenous PCN, combined with prompt surgical incision and drainage
Professor and Chairman, Department of Oral and Maxillofacial
Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY.
Chairman Emeritus and Professor, Oral and Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, Montefiore
Medical Center/Albert Einstein College of Medicine, Bronx, NY.
Address correspondence and reprint requests to Dr Flynn: Harvard School of Dental Medicine, 188 Longwood Avenue, Boston,
MA 02115; e-mail: thomas_flynn@hsdm.harvard.edu
2006 American Association of Oral and Maxillofacial Surgeons

0278-2391/06/6407-0015$32.00/0
doi:10.1016/j.joms.2006.03.015

1093

1094
(I&D) of all affected anatomic spaces, would result in
improvement in swelling, fever, and white blood cell
count (WBC) by 48 hours after surgery.

Patients and Methods

STUDY DESIGN/SAMPLE

In this study we used a prospective case series

design, in which all consecutive patients with OI
severe enough to justify hospitalization were treated
with intravenous PCN (unless allergic) and incision
and drainage of all affected anatomic deep fascial
spaces as soon as possible during the hospital stay.
The subjects enrolled in this study presented for
care between March 1996 and June 1999 at 1 of 4
large urban hospitals served by the Montefiore Medical Center Department of Dentistry, including Montefiore Medical Center, Jack Weiler Hospital at the Albert Einstein College of Medicine, North Central
Bronx Hospital, and Jacobi Medical Center.
A total of 37 subjects were enrolled in this study
based on the following criteria: severe OI (as determined by an attending oral and maxillofacial surgeon)
and hospital admission. Informed consent was obtained
using forms and procedures developed for this institutional review boardapproved study. The criteria for
hospital admission were: OI causing swelling in one or
more of the deep fascial spaces of the head and neck,
impending threat to the airway or vital structures, fever
greater than 101F, need for general anesthesia, or the
need for inpatient control of a concomitant systemic
disease. Potential subjects were excluded from this
study according to the following criteria: pregnancy,
nonodontogenic cause (eg, trauma-related or upper respiratory infection), and refusal of consent. Previously
published nomenclature and descriptions of the deep
fascial spaces were used for the purposes of this
study.10,11
TREATMENT METHODS

All patients were subjected to the same treatment

protocol. The patient was prepared for surgery as
soon as possible after hospital admission. Appropriate
preoperative medical workup was performed, including history and physical examination, complete blood
cell count, urinalysis, appropriate imaging studies,
and medical consultation when necessary. Preoperative imaging methods included periapical and panoramic dental x-rays, as well as preoperative computed tomography (CT) scanning in selected cases.
After establishment of a secure airway, the skin and
mucosa were prepared with antiseptic solution. I&D
was performed for all anatomic fascial spaces that
were involved by either cellulitis or abscess. Specimens for culture and sensitivity testing were har-

SEVERE ODONTOGENIC INFECTIONS

vested by either aspiration or by swab sampling of

open surgical wounds. All spaces that were opened
were copiously irrigated and maintained using latex
Penrose or Jackson-Pratt type drains. Postoperative
CT scanning was performed when indicated based on
the patients progress and response to treatment.
All patients received PCN intravenously at a dose of
2 million units every 4 hours, unless they gave a
history of PCN allergy or presented with signs and
symptoms of necrotizing fasciitis. Clindamycin 900
mg every 8 hours was administered intravenously to
PCN-allergic subjects. PCN therapeutic failure (PTF)
was defined as: 1) development of an allergic or toxic
reaction to the antibiotic; 2) development of necrotizing fasciitis, in which case broad-spectrum antibiotic therapy was indicated; or 3) no improvement of
temperature, WBC, and swelling after 48 hours of
continuous intravenous therapy with the same antibiotic, plus a postoperative CT scan demonstrating adequate surgical drainage of all anatomic deep fascial
spaces affected by cellulitis or abscess. If inadequate
surgical drainage was shown on postoperative CT
scan, then the operation was repeated, with appropriate drainage of all spaces affected by cellulitis or
abscess (Fig 1).
DATA COLLECTION

The demographic variables recorded were age, gender, and race. Preadmission variables were: smoking,
drug allergies, preadmission antibiotic therapy, and
the presence of immunocompromising diseases (such
as diabetes, human immunodeficiency virus [HIV] seropositivity, use of immunosuppressive medications,
severe kidney disease, and cancer chemotherapy
within the previous year). The time-related variables
included the number of preoperative days of pain,
preoperative days of swelling, length of stay (LOS),
operating room time, time between admission and
surgery, and season of the year. Preoperative clinical
variables included causative teeth, number of teeth
involved, dental diagnosis (such as caries, periodontal
disease, or pericoronitis), dyspnea, dysphagia, trismus
(maximum interincisal opening 20 mm), WBC, and
admission core temperature. For purposes of statistical analysis, certain variables were grouped together.
For example, upper teeth were grouped into categories of upper anterior, upper non-third-molar posterior, and upper third molars. Anamnestic data were
obtained from the subjects in a standardized fashion,
limited to the current episode of infection, and verified by the attending surgeon.
The anatomic variables included deep fascial
spaces involved by cellulitis or abscess, number of
spaces affected, and severity score (SS). A severity
score (low 1, moderate 2, or severe 3) was
developed for this study by categorizing the deep

1095

FLYNN ET AL

fascial spaces according to their proximity to the

airway, likelihood of preventing access to the airway,
or proximity to vital structures, such as the contents
of the mediastinum or the cranial cavity (Table 1).
The admission SS was the sum of the severity ratings
for each of the anatomic spaces that were affected by

Table 1. SEVERITY SCORES FOR SEVERE

ODONTOGENIC INFECTIONS

Severity Score

Anatomic Space

Severity score 1
(Low risk to
airway or vital
structures)

Vestibular
Subperiosteal
Space of the body of the mandible
Infraorbital
Buccal
Submandibular
Submental
Sublingual
Pterygomandibular
Submasseteric
Superficial temporal
Deep temporal (or infratemporal)
Lateral pharyngeal
Retropharyngeal
Pretracheal
Danger space (space 4)
Mediastinum
Intracranial infection

Severity score 2
(Moderate risk
to airway or
vital structures)

Severity score 3
(High risk to
airway or vital
structures)

NOTE. The severity score for a given subject is the sum of the
severity scores for all of the spaces involved by cellulitis or abscess,
based on clinical and radiographic examination.
Flynn et al. Severe Odontogenic Infections. J Oral Maxillofac Surg
2006.

cellulitis or abscess, as determined by clinical and

radiographic examination. For example, a subject
whose infection involved the right buccal, right submandibular, and right lateral pharyngeal spaces was
given an SS of 6, which is the total of 1 for the buccal
space, 2 for the pterygomandibular space, and 3 for
the lateral pharyngeal space. For purposes of statistical analysis, masticator space infection was defined as
infection involving any or all of the following spaces:
pterygomandibular, submasseteric, superficial temporal, or deep temporal (including the infratemporal
portion of the deep temporal space).

FIGURE 1. A, Contrast-enhanced CT of Case #20, 5 days after

intraoral and extraoral I&D with drains placed in the right pterygomandibular (solid arrow), anterior compartment of the right lateral pharyngeal (open arrow), and posterior compartment of the right lateral
pharyngeal (arrowhead) spaces. Note that the swollen oropharyngeal
tissues are in circumferential contact with the endotracheal tube. This
CT shows adequate surgical drainage of all infected spaces. In this
case, the criteria for PTF were met and penicillin was replaced with
clindamycin. Rapid improvement ensued. B, Contrast-enhanced CT of
Case #18, 5 days after intraoral I&D of the left pterygomandibular
space. Note the penrose drain in that space (open arrow). The
infection has extended into the left and right lateral pharyngeal spaces
(white arrows) and the retropharyngeal space (arrowhead). This patient needed reoperation, with tracheotomy under local anesthesia and
repeat I&D of all affected spaces. Reprinted from Flynn TR: Surgical
management of orofacial infections. Atlas Oral Maxillofac Surgery
Clin North Am 8:99, 2000, with permission from Elsevier.
Flynn et al. Severe Odontogenic Infections. J Oral Maxillofac Surg
2006.

1096

SEVERE ODONTOGENIC INFECTIONS

Table 2. DEMOGRAPHIC VARIABLES

Age (years)
Gender
Male
Female
Ethnicity
African-American/black
White
Hispanic
Asian

Mean SD

Range

34.9 15.8

1476

n (Cases)

% of Cases

23
14

62
38

20
8
8
1

54
22
22
3

Flynn et al. Severe Odontogenic Infections. J Oral Maxillofac Surg 2006.

The recorded treatment variables included the anatomic spaces drained and the presence or absence of
pus at the time of drainage. If pus was present, the
stage of infection was recorded as abscess; if not, the
stage was recorded as cellulitis. The product at I&D
was categorized as pus if it could be described as a
creamy yellow to grey fluid, or flecks or curds of pus
suspended in a bloody fluid drained from any of the
spaces that were explored at surgery. Cellulitis was
recorded when the product at I&D consisted only of
serosanguineous fluid. Treatment variables also included the number of spaces drained, type and number of drains used, number of teeth extracted, and
antibiotic(s) used. The anesthesia treatment variables
were: type of anesthesia (general or local), difficulty
of intubation, type of anesthesia for intubation (general, intravenous sedation, or topical anesthesia), and
type of intubation (endotracheal or tracheotomy).
The microbiologic variables were: genus and species identification, oxygen requirements (anaerobic
or aerobic, including facultative), PCN and clindamycin sensitivity, and number of species isolated per
case. For purposes of statistical analysis, certain
groups of species were evaluated together, such as
Prevotella and Porphyromonas, Streptococcus milleri group species, and PCN-resistant strains. Although multiple cultures were taken in some cases,
only the results of the initial culture taken at the onset
of treatment were used in the statistical analyses.
The complications recorded were: PTF, facial nerve
deficit, need for reoperation, emergency airway management, spread of infection into the chest or the
brain, trigeminal nerve deficit, and death.
DATA MANAGEMENT AND ANALYSES

Data were recorded prospectively on standardized

collection forms. A database was constructed using
Microsoft Excel (Microsoft, Redmond, WA) and imported into SPSS 12.0 (SPSS, Inc, Chicago, IL) for
statistical analysis. Descriptive statistics were computed for all of the study variables.

Results
A total of 37 subjects (23 male, 14 female) from 14
to 76 years of age (mean 34.9 15.8) were enrolled
in this study. There were 20 (54%) African-American/
black, 8 (22%) Hispanic, 8 (22%) Caucasian, and 1
(3%) Asian patient (Table 2).
Three subjects (8%) were PCN-allergic, 3 (8%) had
immunocompromising diseases (2 insulin-dependent
diabetics and 1 HIV-seropositive individual with a
CD4 count of 400 cells/L). There were 15 (41%)
smokers, although this variable was not recorded for
4 subjects (11%). At the time of entry into this study,
20 (54%) subjects were taking various oral antibiotics,
predominantly penicillins or other beta-lactam antibiotics, as detailed in Table 3.
The most frequent dental disease leading to severe
odontogenic infection was caries (65%), followed by
pericoronitis (22%) and periodontal disease (22%)
(Table 4). These percentages total more than 100%
because multiple dental diseases were present in

Table 3. PREADMISSION VARIABLES

Penicillin allergy
Immune system compromise
Diabetes
HIV seropositivity
Smoking
Not recorded
Yes
No
Preadmission antibiotics
No antibiotic
Penicillin
Clindamycin
Penicillin cephalexin
Erythromycin
Penicillin clindamycin
Penicillin metronidazole

n (Cases)

% of Cases

2
1

5
3

4
15
18

11
41
49

17
10
5
2
1
1
1

46
27
14
5
3
3
3

Flynn et al. Severe Odontogenic Infections. J Oral Maxillofac Surg

2006.

1097

FLYNN ET AL

Table 4. PREOPERATIVE CLINICAL VARIABLES

n (Cases)

% of Cases

24
8
8
2
1

65
22
22
5
3

25
18
3
3
0
0
5
29
27

68
49
8
8
0
0
14
78
73

Dental etiology
Caries
Pericoronitis
Periodontitis
Needle track infection (after dental procedures)
Postoperative infection (third molar exodontia)
Teeth involved
Lower third molars
Other lower posteriors
Upper third molars
Other upper posteriors
Upper anteriors
Lower anteriors
Dyspnea
Dysphagia
Trismus (MIO 20 mm)
White blood cell count on admission ( 103)
Admission core temperature (F)
Number of teeth involved

Mean SD

Range

14.9 4.2
101.3 1.3
1.5 0.9

5.926.0
98.0104.4
15

Flynn et al. Severe Odontogenic Infections. J Oral Maxillofac Surg 2006.

some patients. The most frequently involved tooth

was the lower third molar (68%), followed by other
lower posterior teeth (bicuspids and first and second
molars). Anterior teeth gave rise to no infection severe enough to warrant hospitalization in this study.
Table 4 lists the distribution of causative teeth, dental
etiologies, and other preoperative clinical variables.
On admission, 5 subjects (14%) reported dyspnea,
29 (78%) complained of dysphagia, and 27 (73%) had
trismus (MIO 20 mm). Maximum interincisal opening (MIO) was not recorded in 3 subjects. The initial
core temperature ranged from 98.0F to 104.4F, with
a mean SD of 101.3 1.3. The initial mean SD
WBC was 14.9 4.2, with a range of 5.9 to 26.0
103/uL (Table 4).
Subjects presented with a history of 8.2 14.6 days
of preoperative swelling (range, 1 to 71). After admission to the hospital, which was defined as leaving the
emergency room or clinic for the hospital floor or
operating room, surgery was performed 5.1 7.5

hours later, with a range of 0.2 to 23.3 hours. The

duration of surgery, defined as the time between
entry into and leaving the operating suite, was 2.1
0.7 hours, with a range of 0.9 to 3.8 (Table 5). The
largest number of cases, 15, occurred during the summer (Table 5).
A variable number and combination of fascial
spaces were infected (Table 6). The mean SD number of infected spaces per case was 3.3 1.5 (range,
1 to 8). The admission SS was 5.9 3.1 (range, 1 to
16). The most commonly infected space was the
pterygomandibular (22 cases, 60%), followed closely
by the submandibular (20 cases, 54%) and lateral
pharyngeal (16 cases, 43%).
At surgery, 3.1 1.8 spaces were drained (range, 1
to 8). Twenty-eight cases (76%) yielded pus at I&D,
and pus was not encountered in 9 cases (24%). LOS
was 5.1 3.0 days, with a range of 1 to 14 days.
Airway management was by endotracheal intubation in all but 3 cases, 18 (49%) by fiberoptic laryn-

Table 5. TIME-RELATED VARIABLES

Days of preoperative swelling

Time between admission and OR (h)
Duration of surgery (h)
Season of occurrence
Summer
Spring
Autumn
Winter

Mean SD

Range

8.2 14.6
5.1 7.5
2.1 0.7

171
0.223.3
0.93.8

Flynn et al. Severe Odontogenic Infections. J Oral Maxillofac Surg 2006.

n (Cases)

% of Cases

15
8
7
7

41
22
19
19

1098

SEVERE ODONTOGENIC INFECTIONS

Table 6. ANATOMIC VARIABLES

Number of spaces affected

Severity score
Spaces affected
Pterygomandibular
Submandibular
Lateral pharyngeal
Buccal
Space of body of mandible
Submasseteric
Deep temporal (including
infratemporal)
Sublingual
Submental
Superficial temporal
Infraorbital
Retropharyngeal
Infratemporal
Maxillary sinus
Parotid
Groups of spaces affected
Masticator
Perimandibular (submandibular,
sublingual, and submental)
Space 3 (lateral pharyngeal,
retropharyngeal, and pretracheal)

Mean SD

Range

3.3 1.5
6.0 3.1

18
116

n (Cases)

% of Cases

22
20
16
15
13
9

59
54
43
41
35
24

6
6
4
3
2
2
1
1
1

16
16
11
8
5
5
3
3
3

29

78

22

60

16

43

Flynn et al. Severe Odontogenic Infections. J Oral Maxillofac Surg 2006.

goscopy, and 16 (43%) by direct laryngoscopy. One

case required urgent tracheotomy under local anesthesia at reoperation for extension of infection with
dyspnea (Table 7). Topical anesthetics and mild sedation were most commonly used for analgesia during
fiberoptic intubation, and general anesthesia was
most commonly used for direct laryngoscopy.
Intravenous PCN was used initially in 33 cases.
Because of PCN allergy, intravenous clindamycin (900

mg every 8 hours) was used initially in 3 cases. One

patient was admitted with necrotizing fasciitis, and
intravenous gentamicin, clindamycin, and metronidazole were used for broad-spectrum antibiotic coverage, as shown in Table 7.
Bacterial species identification and PCN and clindamycin sensitivity were performed in the last 24
consecutive cases enrolled in this study. Cultures
yielded no growth in 2 of those cases (8%). The

Table 7. TREATMENT VARIABLES

Stage of infection
Cellulitis (no pus at I&D)
Abscess (pus at I&D)
Antibiotics used
Penicillin
Clindamycin
Gentamicin Metronidazole Clinda
Airway management techniques
Fiberoptic intubation
Direct laryngoscopic intubation
No intubation
Tracheotomy (at reoperation)
Number of spaces drained
Length of hospital stay (days)

n (Cases)

% of Cases

9
28

24
76

33
3
1

89
8
3

18
16
3
1

49
43
8
3

Abbreviations: I&D, incision and drainage; Clinda, clindamycin.

Flynn et al. Severe Odontogenic Infections. J Oral Maxillofac Surg 2006.

Mean SD

Range

3.1 1.8
5.1 3.0

18
114

FLYNN ET AL

various species isolated, the number of strains and

percent of cases in which they were identified, and
the PCN resistance rate for each species are listed
in Table 8. A total of 90 strains were isolated, with
a mean SD of 3.8 2.0 species per case (range,
0 to 8).
Two cases (8%) yielded aerobic bacteria only, 4
cases (17%) yielded anaerobes only, and 16 cases
(67%) yielded a mixed flora (Table 9). Thus, anaerobes were present in 20 of 24 (83%) of cases with
culture data.
Seventeen (19%) of the 90 isolated strains were
PCN-resistant; 1 or more PCN-resistant organisms
were found in 13 (54%) of the 24 cases with antibiotic sensitivity data. Four clindamycin-resistant
strains were identified, one each of Streptococcus
milleri, Eikenella corrodens, and Streptococcus
mitis, and one strain of Klebsiella pneumoniae
that was also resistant to PCN. Clindamycin-resistant strains were identified in 4 (17%) cases with
sensitivity data.
Complications, including penicillin therapeutic failure (PTF), facial nerve deficit, reoperation, and death
are listed in Table 10. The criteria for PTF were met in
7 (21%) of the 33 cases that received PCN. Only 6
complications other than PTF occurred in this study:
3 facial nerve deficits that were improving at last
follow-up and 3 reoperations. Extension of infection
into the mediastinum or cranial cavity did not occur.
No deaths occurred.
A second operation was required in 3 cases (8%):
minor intraoral I&D (n 2) and tracheotomy and drainage of right and left lateral pharyngeal and retropharyngeal spaces (n 1). In the latter case, the subject
developed dysphagia, dyspnea, and increasing swelling
5 days after initial drainage of the right pterygomandibular space. Repeat CT scan showed extension of the
infection into both lateral pharyngeal spaces and the
retropharyngeal space (Fig 1). After tracheotomy under
local anesthesia, all of the infected spaces were drained
and the antibiotic was changed from PCN to clindamycin. Rapid improvement ensued. PCN-resistant organisms were later identified in this case.
Table 11 lists each of the 37 cases and clinically
important data for each case.

Discussion
In this study we prospectively evaluated 37 consecutive patients with severe OI and managed them
with a standardized protocol of high-dose intravenous PCN (unless the patient was PCN allergic) and
early incision and drainage. We encountered a PTF
rate of 21% in severe OI requiring hospitalization.
Such a failure rate is clinically unacceptable. The
isolation of 1 or more PCN-resistant strains in OI

1099
has risen steadily in 4 recent studies, from 33% of
cases in 1991 to 55% in 1995, and 54% of cases in
the current study.12-14 In the current study, there
were 10 cases receiving PCN with culture and sensitivity testing in which PCN-resistant organisms
were later identified. PCN failed in 6 (60%) and was
successful in 4 (40%) of those cases. If we can
predict an increasing rate of PCN resistance among
the pathogens of OI, then the rate of PTF in severe
OI can also be expected to increase.
It should be noted that in 2000, Kuriyama et al15
found an increased rate of resistance to beta-lactam
antibiotics in subjects with OI who had received such
antibiotics prior to sampling. They recommended beta-lactamase stable antibiotics in patients with unresolved infections that have previously received betalactam antibiotics. These data were not available
during the patient treatment period of this study,
which ended in 1999. This study provides clinical
evidence to support the laboratory findings of increased resistance among bacteria cultured from
OI.12-15
Although clindamycin has recently been recommended for widespread use in dentistry,16 multiple
clinical studies that have compared PCN and clindamycin found success rates with PCN17,18 or ampicillin19 at 97% of cases or higher. Only the study of
Kannangara et al in 198020 found a clinical PCN success rate of 80% versus clindamycin at 100%. All of the
PCN failures in Kannangaras study were in mandibular fractures that harbored Bacteroides fragilis, not in
OI.20
In this study of patients with OI severe enough to
warrant hospitalization, penicillins clinical success
rate was 79%. A comparison with clindamycin was
not part of the study design.
It is impossible to compare the complication rate in
this study with that of other published reports because of differences in study design, patient population, cause of infection, and the lack of a common
method of calibrating severity. Such calibration may
be possible in the future by using C-reactive protein,
WBC or SS, or a combination thereof.1,3,21
As in other reports,7 the most frequently identified
causative tooth was the lower third molar in 25 (68%)
cases, followed by other lower posterior teeth in 18
(49%) cases. Upper posterior teeth were involved
much less frequently, and no anterior teeth were
identified as causing severe OI in this study. Pericoronitis was not diagnosed as frequently in this study as
in others.7-9
In this study, the most frequently infected deep
fascial spaces were, in descending order, pterygomandibular (n 22 patients), submandibular (n 20),
lateral pharyngeal (n 16), and buccal (n 15). If
infections involving any portion of the masticator

1100

SEVERE ODONTOGENIC INFECTIONS

Table 8. DETAILED MICROBIOLOGIC DATA (N 24)

No growth (2 cases)
Aerobes (including facultative species)
All S. milleri group species (as detailed below)
S. constellatus
S. intermedius
S. anginosus
S. milleri
S. milleri I
S. milleri II
All other S. viridans species (excluding S. milleri)
S. mitis*
S. sanguis
Other streptococci (as detailed below)
-hemolytic streptococcus Group F
-hemolytic streptococcus Group C
-hemolytic streptococcus not Group ABCDFG
Other aerobic/facultative species (as detailed below)
Gemella morbillorum
S. acidominimus
Corynebacterium spp.
Lactobacillus acidophilus
Staphylococcus coagulase negative
Staphylococcus epidermidis
Klebsiella pneumoniae*
Enterococcus spp.
Anaerobes
All Prevotella and Porphyromonas species (as detailed below)
P. oralis
P. oris
P. buccae
P. intermedia
P. melaninogenica
P. denticola
P. gingivalis
P. loeschii
F. nucleatum
All Peptostreptococcus species (as detailed below)
P. micros
P. prevotii
Other anaerobic species (as detailed below)
Veillonella spp.
Wolinella spp.
Capnocytophaga spp.
Actinomyces odontolyticus
Actinomyces israelii
Bacillus gracilis
Bacillus spp.
Bacteroides fragilis
Bacteroides ureolyticus
Propionibacterium acnes
Hemophilus influenzae
Bifidobacterium spp.
Clostridium spp.
Eikenella corrodens*

# of Strains

% of Cases

None

12
3
2
0
4
1
2
2
1
1
3
1
1
1
12
1
1
2
1
4
1
1
1

50
13
8
0
17
4
8
8
4
4
13
4
4
4
50
4
4
8
4
17
4
4
4

23
2
1
10
6
1
1
1
1
5
12
11
1
21
1
1
2
1
1
4
2
1
1
3
1
1
1
1

63
8
4
42
25
4
4
4
4
21
50
46
4
88
4
4
8
4
4
17
9
4
4
13
4
13
4
4

% of Strains
PCN-Resistant

*Clindamycin-resistant strain.
Not all strains were tested for antibiotic sensitivity. Blank cells none of the strains were tested for antibiotic sensitivity.
Flynn et al. Severe Odontogenic Infections. J Oral Maxillofac Surg 2006.

0
0
0
0
0
0
0
0
0
33
0
100
0
58
0
100
100
100
100
35
0
100
30
67
0
0
0
0
25
0
0
0
0
0
0
0
0
0
0
0
0
0
0

1101

FLYNN ET AL

Table 9. SUMMARY MICROBIOLOGIC DATA

(N 24)

Culture and Sensitivity Results

# of Cases

% of Cases

No growth
Oxygen requirements
Aerobes only
Anaerobes only
Mixed aerobes and anaerobes
Antibiotic resistance
Penicillin
Clindamycin

2
4
16

8
17
67

13
4

54
17

Flynn et al. Severe Odontogenic Infections. J Oral Maxillofac Surg

2006.

space (submasseteric, pterygomandibular, superficial

or deep temporal) are considered, this space represented 78% of cases (n 29). Masticator space involvement was identified much more frequently in
this study than in other anatomic studies of severe OI,
where the submandibular space was the most frequently reported location.4-6,8,9
Dysphagia and trismus were presenting symptoms in
a high proportion of subjects, at 29 (78%) and 27 (73%)
cases, respectively. It appears from this study, therefore,
that the most common manifestation of severe OI may
be infection involving the masticator and/or submandibular spaces due to pericoronitis or caries of a mandibular
posterior tooth, most commonly the lower third molar.
Trismus and dysphagia were the most frequent presenting sign and symptom, and these should therefore be
considered highly suggestive of severe OI. The incidence of trismus and dysphagia were not reported in
previous studies of OI.1-9,22
The most frequently used airway management
technique in this study was fiberoptic intubation
under light sedation in 18 (49%) cases, followed by
direct laryngoscopic intubation under general anesthesia in 16 (43%) cases. Airway management technique was selected by the anesthesiologist in consultation with the oral and maxillofacial surgeon.
These data reflect the perceived increasing avail-

Table 10. COMPLICATIONS (N 37)

Penicillin therapeutic failure

(n 33)*
Facial nerve deficit
Need for reoperation
Death

# of Cases

% of Cases

7
3
3
0

21
8
8
0

*33 of 37 subjects received penicillin; 3 subjects received clindamycin because of penicillin allergy and 1 received clindamycin,
gentamicin, and metronidazole because of necrotizing fasciitis.
Flynn et al. Severe Odontogenic Infections. J Oral Maxillofac Surg
2006.

ability of and facility in fiberoptic intubation techniques among anesthesiologists, and they are consistent with recent results found in the
otolaryngology literature.23
The most frequent pathogens isolated in the 24
cases for which complete species identification was
performed were: Prevotellae, Viridans streptococci
(including the S. milleri group), and Peptostreptococci. These results are consistent with the studies of
Heimdahl et al,24 Lewis et al,25 Sakamoto et al,26 and
others.12,15,27,28
The design of this study did not include a prospective evaluation of the utility of computed tomography
(CT) in the pre- and postoperative evaluation of severe OI. This may have led to misclassification of the
anatomic location of infection in some cases, which is
a limitation of this study. The accuracy of abscess
detection in head and neck infections is improved by
the combination of clinical examination and contrastenhanced CT.29
During the course of the study, however, we observed several advantages of CT. A preoperative CT
scan can be useful in identifying airway displacement
or effacement and in visually demonstrating the airway problem to the anesthesiologist before the airway management plan is formulated. This has led to a
routine policy of passing the fiberoptic cable and
endotracheal tube through the naris on the side opposite the infection, toward which the airway has
been deviated. This maneuver has led to easier and
more rapid fiberoptic intubation.
In addition, postoperative CT was very useful in
identifying correct drain placement as well as undrained loculations of pus or extension of infection
during treatment. In descending necrotizing mediastinitis, Freeman et al30 reported a reduced mortality of
0 in 10 cases, using a protocol of open thoracotomy
for direct mediastinal drainage and postoperative CT
taken every 48 to 72 hours in patients with lack of
clear improvement after surgery. They reported using
ranges of 3 to 15 CT scans per case and 4 to 8
operations per case. Laparotomy for extension of infection into the abdominal cavity was necessary in
30% of cases, and CT was most useful in identifying
the need for laparotomy.30 Recently, CT has been
used to trace the anatomic pathways of the spread of
infection arising from maxillary and mandibular
teeth.31-33
The results of this study indicate that PCN resistance,
resulting in PCN therapeutic failure, was unacceptably
high in this group of patients. Alternative antibiotics,
such as clindamycin, should be considered in hospitalized patients with OI. Anatomic involvement of the
masticator space, resulting in trismus, was diagnosed
much more frequently in this study than has been previously reported. Trismus and dysphagia on presenta-

1102

SEVERE ODONTOGENIC INFECTIONS

Table 11. SELECTED DATA FOR ALL CASES

No. of
No. of
Pus
PCN
Case
Age
WBC Severity Infected Infected OR Time at
Resistant LOS
no. Race Gender (years) (103) Score
Spaces
Teeth (minutes) I&D PTF Strains (days) Reoperation
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37

B
W
B
A
W
H
B
B
W
B
B
H
B
B
W
B
B
B
W
B
W
H
H
B
H
B
B
W
B
B
B
H
B
B
H
W
H

F
M
M
F
M
F
M
M
M
M
F
M
F
F
F
M
M
F
F
M
M
M
F
F
M
M
M
M
F
M
F
M
M
F
M
M
M

22
22
23
45
26
43
21
33
76
54
27
46
21
45
60
14
41
23
22
42
31
45
29
19
25
24
39
28
31
23
75
36
29
21
28
71
30

12.6
11.6
13.0
13.7
13.8
15.6
15.4
14.2
15.3
13.0
17.0
11.7
26.0
6.7
14.7
12.1
15.1
21.6
13.6
16.1
12.4
16.9
10.4
16.2
18.2
22.1
24.9
13.8
16.8
12.7
5.9
11.3
14.8
15.3
19.8
12.6
13.0

7
4
3
4
3
3
7
5
5
3
13
2
8
5
6
2
8
4
6
9
7
16
6
5
12
5
9
5
6
8
1
5
5
6
9
3
5

4
2
2
2
2
3
4
3
4
3
6
2
4
2
3
1
4
5
3
4
2
8
6
2
6
4
5
2
4
4
1
3
2
3
3
2
2

2
1
1
1
2
3
1
2
1
2
1
3
2
1
3
1
2
1
3
1
1
5
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1

99
145
82
94
116
102
70
75
55
60
200
113
154
110
90
115
175
100
120
225
115
182
180
135
190
110
157
185
130
110
80
160
90
120
175
106
112

Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
Y
Y
N
Y
Y
Y
Y
Y
Y
N
Y
N
N
N
Y
Y
Y

N
N
N
N
N
N
N
N
C
N
Y
N
N
Y
Y
C
N
Y
Y
Y
C
NF
N
N
N
N
N
N
N
N
N
N
N
N
N
Y
N

Y
Y
Y
N
Y
Y
Y
N
Y
N
N
N
N
N
Y
Y
N
N
N
N
Y
N
Y
Y

3
4
3
3
3
6
3
4
4
4
9
4
7
5
6
3
6
14
7
9
2
14
7
4
6
3
10
4
3
3
3
3
4
4
4
5
1

N
N
N
N
N
Y
N
N
N
N
N
N
N
N
N
N
N
Y
N
N
N
N
N
N
N
N
Y
N
N
N
N
N
N
N
N
N
N

Abbreviations: A, Asian; B, African-American/black; H, Hispanic; W, white; F, female; M, male; WBC, white blood cell count on admission;
OR, operating room; I&D, incision and drainage; PTF, penicillin therapeutic failure; PCN, penicillin; LOS, length of hospital stay; Y, yes; N,
no; C, subject received clindamycin; NF, subject received multiple antibiotics for necrotizing fasciitis.
Flynn et al. Severe Odontogenic Infections. J Oral Maxillofac Surg 2006.

tion should be appreciated as significant indicators of

severe OI. Directions for future research include: biochemical and clinical predictors of outcomes in severe
OI, and molecular methods for bacterial identification
and antibiotic sensitivity testing.34
Acknowledgments
The authors wish to acknowledge Mauricio Wiltz, DDS, and all of
the Oral and Maxillofacial Surgery residents at the Montefiore
Medical Center for their assistance in the care of patients and
gathering of data. This study was supported in part by the Montefiore Medical Center Department of Dentistry and the Massachusetts General Hospital Department of Oral and Maxillofacial Surgery
Education and Research Fund.

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