Severe odontogenic infections: a 5-year review of a major referral hospital in Ghana

Severe odontogenic infections: a 5-year review of a major referral hospital in Ghana

Paa-Kwesi Blankson^1,&, Grace Parkins^1,2, Matthew Owusu Boamah^1,2, Alhassan Emil Abdulai^1,2, Abdul-Majeed Ahmed¹, Sarah Bondorin^1,2, Isaac Nuamah¹

¹Department of Oral & Maxillofacial Surgery, Korle-Bu Teaching Hospital, Accra, Ghana, ²School of Medicine & Dentistry, College of Health Sciences, University of Ghana, Accra, Ghana

^&Corresponding author
Paa-Kwesi Blankson, Department of Oral & Maxillofacial Surgery, Korle-Bu Teaching Hospital, Accra, Ghana

Introduction    

Odontogenic infections, in their severe forms have generally been considered to be decreasing in occurrence [1, 2], with many attributed reasons such as availability of antimicrobials [1], advancements in healthcare delivery and general improvement in oral hygiene, with subsequent reduction in mortality [3]. Infections of dental origin in themselves are fairly common, with some authors suggesting it to account for a proportionate amount of antibiotic prescription [4]. However, when not controlled, these could spread into anatomically associated spaces of the maxillofacial and cervical region, thus risking myriad possible complications including respiratory obstruction, Ludwig's angina, facial cellulitis, deep neck abscesses, NCF, aspiration pneumonia, septicaemia, descending mediastinitis, brain abscess, thoracic empyema, endocarditis, pericarditis, pleuropulmonary suppuration, pneumothorax, abscess of the carotid sheath and jugular thrombophlebitis, hematogenous dissemination to distant organs, and coagulation abnormalities ranging from thrombocytopenia to a fulminant state of disseminated intravascular coagulation (DIC), which could all eventually result in mortality [2, 3, 5, 6]. Suggested guidelines used by the Maxillofacial unit, recommends hospital admission of patients with severe odontogenic infections, characterized by one or more of the following signs/symptoms; rapidly progressing infection, involvement of multiple fascial spaces or high-risk spaces such as the pterigo-mandibular space, unrelenting fever or signs of volume depletion, CNS signs (e.g., decreased level of consciousness, headache, or abnormal eye signs such as proptosis, pupillary dilation, diplopia, papilloedema), outpatient treatment failure, presence of comorbid conditions that require supportive medical care and extremes of age [7]. Korle Bu Teaching Hospital is presently the third largest Hospital in Africa. Being the premier national referral centre in Ghana with a 2,000-bed capacity, the hospital attends to patients from its nearby communities as well as all over the country, especially the southern zone of the country. The objective of this retrospective study was to determine the incidence of such severe odontogenic infections over the past 5 years at the Korle-Bu Teaching Hospital. The details of which will guide strategies in management. This review forms part of preliminary studies by the Department of Oral & Maxillofacial surgery unit of the hospital and the University of Ghana School of Medicine & Dentistry on the epidemiology, management, economic cost and microbiology of odontogenic infections.

Methods     

A retrospective descriptive review was done, involving the consecutive inclusion of all patients with severe odontogenic infection requiring admission to the Maxillofacial unit in the period between 1^st August 2012 and 31^stJuly 2017. For all patients with near-fatal odontogenic infections admitted, independent variables including age, sex, diagnosis, duration of hospital stay, National Health Insurance (NHIS) status, and outcome of management were obtained from patient records, entered into a computerized questionnaire, processed and analyzed using Stata statistical software (version 14). The incidence proportion, which is a fraction of the total number of severe cases seen per the total number of tooth-related infections were obtained for the respective years. The Department's annual reports for the past 5 years were also reviewed to determine the total hospital attendance to the Department.

Results     

Annual records of diagnosed tooth-related infections totaled 4018, 3374, 3049, 2839 and 2384 patients for the respective years of review. The maxillofacial unit, for the past 5 years therefore recorded 15,664 cases of odontogenic infections, out of a total of 39,194 patients seen at the department in general. Of these, a total of 243 patients with near-fatal severe odontogenic infection, requiring admission were included in the survey for the period of the study, this representing 1.6% of all dento-alveolar infections This consisted of 121 males and 122 females, representing a ratio of 1:1. With an average of 42.9 years (SD=16.6), the age ranged from 18 months to 91 years. The distribution of occurrence of severe odontogenic infection as shown in Figure 1 indicates a steady rise in admission of such cases. The incidence proportions of near-fatal odontogenic infection for the five-year study period were 8.2, 8.9, 17.7, 17.9 and 27.7 people per 1000 cases of tooth-related infections for the respective years (Figure 2). The incidence, however of odontogenic infections among patients attending the outpatient dental clinic of the hospital was 40.3%, while that of dentoalveolar abscess was 5.7%. The incidence of severe, near-fatal odontogenic infections among patients attending dental clinic of the hospital was 0.62%. Most (52%) of the patients presented with bilateral cellulitis of the submandibular, sublingual and submental spaces, characteristic of Ludwig's angina, while a proportional 3%, as shown in Figure 3, included other manifestations of odontogenic infections such as deep cervical and pharyngeal abscess, sepsis, intracranial abscess and infra orbital abscess. The mean hospital stay for the patients with severe odontogenic infection was 9.1 days (SD=5.9). Furthermore, the recorded deaths from the admitted cases were 14, representing a fatality rate of 5.8%. Of the admitted cases of severe odontogenic infections, 31.3% were not beneficiaries of the National Health Insurance scheme.

Discussion     

Odontogenic infections have for over the past century, been recognized as an important cause of morbidity and mortality [8], though the knowledge of the potential for tooth abscess to spread has been known since antiquity, mentioned in the London Bills of Mortality in the early 1600´s, as a leading cause of death [9]. Severe odontogenic infection and its complications are a sequelae to the breach of the pulp chamber by implicated bacteria. The pathophysiology of the condition has been very well described in literature [4, 5, 6, 10]. Though cases of odontogenic infections, in general, seem to have reduced over the years, findings of the incidence of severe odontogenic infections from this study do not favour the suggestion that its incidence is reducing in Ghana. The rise in new cases of severe odontogenic infections could be accounted for by either the increasing risk factors among the populace or by the relative attrition of Oral & Maxillofacial Surgeons in peripheral hospitals. In either case, the condition seems to persist as a pertinent clinical problem in Ghana that needs to be addressed. Though the intensity and criteria for admissions may vary across institutions and communities, the situation may not be peculiar to this part of the world alone. Scotland recorded 3,500 hospital admissions between 2000 and 2005 for acute dental infections while hospitals in England saw a doubling of admissions for surgical treatment of dental abscesses over a similar period [6]. Similarly, admissions in the United States relating to acute dental infections are estimated to occur at a rate of 1 per 2,600 of the population per year [11]. Though this study found a 0.62% incidence of severe dentoalveolar abscess requiring admissions among patients attending the hospital's dental clinic, studies in Nigeria found 6.4% of dental clinic attendance being because of dentoalveolar abscess [12]. In Australia, 9% of emergency dental presentations resulted in admissions [13]. The incidence and varying presentations of severe odontogenic infections should also reinforce the need for Clinicians, to exclude odontogenic causes of conditions such as facial cellulitis, deep neck abscesses and descending mediastinitis. It has also been reported that the incidence of deep neck space infection is significantly higher in patients with odontogenic abscess, compared with those without odontogenic abscess [1]. Typical of patient in Figure 4, most (52%) of the patients were admitted with the diagnosis of Ludwig's angina. Also, 10% of the patients had cervico-facial necrotizing fasciitits (Figure 5), with a significant proportion (3%) presenting with other complications including sepsis, intra-cranial abscess, periorbital abscess (Figure 6), anterior descending mediastinitis (Figure 7), and infratemporal abscess. This, together with the fatality rate of 5.8%, suggest that the patients presented late to the facility.

Conclusion     

This study highlights the importance of persisting severe, near-fatal odontogenic infections in Ghana. Its clinical complications may require a multidisciplinary approach in treatment. However, not only is there a need to assess the public, professional and institutional strategies to management, but for more evidence-based studies in our local setting to aid in management.

Competing interests     

The authors declare no competing interests.

Authors’ contributions     

All authors have equally contributed to this article and have read and agreed to the final manuscript.

Figures     

Figure 1: annual admissions of near-fatal odontogenic infections

Figure 2: incident proportions of severe odontogenic infection

Figure 3: distribution of admitting diagnoses

Figure 4: severe odontogenic infection manifesting as Ludwig’s angina

Figure 5: necrotizing cervical fasciitis from a dentoalveolar infection

Figure 6: orbital cellulitis resulting from a dentoalveolar infection

Figure 7: descending necrotizing fasciitis resulting in bilateral breast abscess and anterior mediastinitis, secondary to a dentoalveolar infection

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