A retrospective analysis of orofacial infections requiring

hospitalization in Al Madinah, Saudi Arabia

Mushtaq I. Parker, MDS
Sameer M. Khateery‡, BDS, FAAHD, MS, OMS Cert (USA)
Dental Center, King Fahad Hospital, Al Madinah, Al Munawwarah, KSA

An oral and maxillofacial surgeon is usually faced with the management of orofacial infections. In most of the cases, the infection is odontogenic in origin1 and is usually attributed to the endogenous flora of the mouth. Non-odontogenic infections on the other hand depend on the type and site of infection.2  An important feature of suppurative odontogenic infections is that they are typically polymicrobial in nature, with mixed aerobic and anaerobic bacteria present.3-5 However, the anaerobes generally outnumber aerobes by a factor of two to four folds.6-15      

Early recognition and management of orofacial infections is mandatory. The majority of orofacial infections spread along the contiguous fascial planes, leading to more severe infections.1 Due to the proximity of the central nervous system and respiratory passages, timely efforts are required to establish a patent airway, mechanical debridement, drainage and appropriate antimicrobial therapy.13        

The purpose of this article was to do an epidemiological study of odontogenic and non-odontogenic orofacial infections seen in a major hospital in Al-Madinah Al Munawarah region. The results were compared to those from similar studies in other places. To the best of our knowledge, there is no published data on such surveys of orofacial infections in the Kingdom of Saudi Arabia or the neighboring countries.

A retrospective analysis of the hospital records of 373 patients with orofacial infections who were hospitalized and treated in the Department of Oral & Maxillofacial Surgery unit of King Fahad Hospital, Al-Madinah Al-Munawwarah, over a period of six years(1413-1418) corresponding to 1993-1998, was carried out. Both odontogenic and non-odontogenic infections were included.           

The records were reviewed and analyzed for the following data: age, gender, route of admission (emergency room (ER) or outpatient department (OPD)), offending tooth, trismus, associated medical conditions, causative microorganisms, length of stay (LOS) in the hospital and complications if any.      

The age distribution of patients over the 6-year review period in respect of various age groups is shown in Fig. 1.  One hundered and ninety-seven patients (52.8%) were males and 176 (47.2%) wre females giving a ratio of 1.1 to 1.0.  Odontogenic infections accounted for 310 (83.1%) cases.  The rest 63 (16.9%) were non-odontogenic infections.  Table 1 shows the details of the teeth involved in odontogenic infections while in Table 2, the type of non-odontogenic infections are listed.  Isolated causative organisms are shown in Table 3.  Treatment modalities are shown in Fig. 2.  The various antibiotics used singly or in combination are detailed in Fig. 3.

These hospitalized cases of orofacial infections were about 25% of the total admissions for oral and maxillofacial surgical management (Fig. 4).  There were only 2 cases (0.5%) with complications.

Epidemiological surveys are conditioned by geography, population density, socioeconomic profiles, type of government, era and the facilities available for conducting such surveys. Comparison of surveys therefore requires consideration of these factors.16 The present survey was on the epidemiology of orofacial infections.

Our study included a wide age range of patients with the largest number, 102 cases (27.3%) in the 6 to 12 years age group, most probably because of early dental neglect. This is in contrast with other studies, where majority of the cases were in the 25-35, 20-29, and 23-70 years age groups, respectively.4,9,17 The relationship between the gender of the patients and orofacial infections in our study (M:F: 1.12.1) correlated well with other studies.4,18,19       

A lot of information is available in the literature on odontogenic infections which account for most infections in the oral cavity. They may originate from dental caries, deep restorations that approximate the pulp chamber, pulpitis, periapical abscess, periodontitis, periodontal abscess, and pericoronitis.2 In the present study of 373 patients, the mandibular first permanent molar was the most offending tooth at 33.2% followed by mandibular third molars (10%), mandibular permanent second molars (9.1%), mandibular second deciduous molars (7.2%), maxillary first permanent molars (5%) mandibular first deciduous molars (13 cases: 3.5%), maxillary deciduous first molar (2.4%) and maxillary second molar (2.4%). Haug et  al17 in their study reported that the highest incidence involved lower second and third molars.1  The difference in the results could be due to the fact that the subjects in the two studies were from culturally different  groups.           

The offending teeth showed obvious relationships to the adjoining anatomical fascial spaces. In our study, the most frequently involved space was the submandibular space (63.8%), followed by the submasseteric space (12.1%) and the buccal space (9.4%). This finding correlates with those of Labriola et al11 and Haug et al.17        

The literature is replete with reports on non-odontogenic infections in the oro-facial regions. The cases of non-odontogenic infections in the present study are shown in Table 3. The management protocol of these cases, however, remains the same as that of odontogenic infections.

Firstly, the successful treatment of orofacial infections depends primarily on an initial debridement and/or incision and drainage. Doing this alters the ability of the environment to sustain anaerobic growth by removing hypoxic tissue. Without the anaerobes, the aerobic component of infection may be rendered non-pathogenic.  Secondly, when choosing an antibiotic, one must remember that a pathogenic complex of bacteria rather than a single microorganism is being treated.12 Early and definitive antibiotic therapy must therefore be instituted. A culture and antibiotic sensitivity test of the pathogens may facilitate the resolution of an infection. However, an empirical therapy may be initiated since the preponderant organisms in oral cavity are streptococci, staphylococci, and bacteroides, in that order.20 Many authors reported different types of treatment of odontogenic infections. Sandor et al2 advocated clindamycin or penicillin V and metronidazole as first line of treatment, and clindamycin or augmentin with metronidazole as second line of treatment. In the present study, either a combination of ampicillin (Bristol, Italy) and metronidazole (P.S.I. Ltd, K.S.A) or keflex (Hikma, Jordan) and metronidazole was used.

The microbiological environment of an odontogenic infection is complex. It is now well established that typical odontogenic infection is a mixed aerobic and anaerobic infection with anaerobes outnumbering aerobes by two to four-folds.6-15 Recent reports indicate that there may be as many as 264 morphologically and biochemically distinct bacterial groups or species that colonize oral and dental sites.21 The most commonly isolated aerobic species were a-hemolytic strepto-cocci. Staph. aureus was not a common isolate. The most commonly isolated anaerobes were bacteroides species such as B. Melaninogenicus.12 Heimdahl et al1 reported that in their study Bacteroides, Prevotella and Fusobacterium were frequently isolated. In the present study, the commonly found species were different strains of Streptococci and Staph. aureus, whereas no anaerobic species was isolated. The factors responsible for obtaining good culture results include proper preparation of the site, appropriate methods of collection and transport of culture specimens to the laboratory. In our present study,  the protocol for aerobic species was followed mainly. Although bacteria play a major role in odontogenic infections, antimicrobials are not always warranted.2 A draining abscess or a fistula containing a chronic infection usually requires extraction of offending tooth.2 However, other disease processes including acute periapical abscess, periodontal abscess, pericoronitis and deep fascial space infections may require antimicrobial therapy. Antimicrobials must never be used as a replacement for appropriate surgical drainage and/or debridement, and should only be used as an adjunctive therapy.2 Antimicrobial therapy has an essential role in the management of these infections. If it is initiated soon after diagnosis and before surgery, it can shorten the period of infection and minimize associated risks.2       

The average LOS in our series was four days and this is in agreement with the report by Peters et al22 as the LOS is dependent basically upon underlying general medical conditions and presence or absence of deep-seated infection. On the basis of our observation, late referrals and non-compliance on the part of patients were contributing factors to the increased LOS for patients who stayed for more than 10 days in the hospital.      

There are many complications subsequent to odontogenic infections as reported in the literature. Notable sequelae are septicemia with disseminated intravascular coagulation,23 mediastinitis, thoracic emphysema, cardiac tamponade,24,25 and death.23-25 In our cases, we encountered complications in only 2 cases (0.54%). In the first case, the patient developed respiratory distress which was managed by naso-endotracheal intubation and oxygen therapy and which resulted in full recovery. In the second case,  the patient had Ludwig's Angina, which disseminated to parapharyngeal and mediastinal spaces. An ENT surgeon successfully managed the patient by exploring the retrophaynageal space and performing drainage. The patient recovered in a few days. We noticed that there are no oro-facial infections surveys reported in KSA, and we recommend that more studies be conducted on this subject.

Address reprint requests to:

Dr. Sameer M. Khateery
Dept. of Oral & Maxillofacial Surgery
King Fahad Hospital
PO Box 6920, Al Madinah, Al Munawwarah, KSA