International Journal of Infectious Diseases 16 (2012) e296–e302

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International Journal of Infectious Diseases

journal homepage: www.elsevier.com/locate/ijid

Odontogenic maxillofacial space infections at a tertiary care center in North India:

a five-year retrospective study
George C. Mathew b, Laxman Kumar Ranganathan b, Sumir Gandhi b, Mini Elizabeth Jacob a,*,
Inderjot Singh b, Manisha Solanki b, Saurab Bither b
a
Department of Community Medicine, Christian Medical College, Brown’s Road, Ludhiana 141008, Punjab, India
b
Department of Oral and Maxillofacial Surgery, Christian Dental College, Ludhiana, Punjab, India

A R T I C L E I N F O S U M M A R Y

Article history: Objective: Odontogenic infections contribute to a significant proportion of maxillofacial space infections
Received 5 August 2011 (MSI) across the world. MSI can cause several life-threatening complications despite skillful
Accepted 5 December 2011 management. The objective of this study was to review the clinical characteristics, management, and
Corresponding Editor: William Cameron, outcome of odontogenic MSI treated at a tertiary care center, and to identify the factors predisposing to
Ottawa, Canada life-threatening complications.
Methods: A retrospective chart review of all patients treated for MSI from January 2006 to December
Keywords: 2010 at the Christian Medical College Hospital in Ludhiana, North India, was conducted.
Odontogenic Results: Out of 137 patients identified, 66.4% were men. Mean patient age was 40 years, and 24.1% of the
Maxillofacial patients were diabetic. The most common origin was pulpal (70.8%), the most common space involved
Infection was the submandibular space, and the most common teeth responsible were the lower third molars.
Abscess
Twenty patients (14.6%) developed complications. Diabetes, multiple space involvement, and a total
Antibiotic
leukocyte count of 15  109/l were associated with complications.
Complication
Conclusions: Patients with MSI who present with multiple space involvement, a high leukocyte count,
and those with diabetes are at higher risk of developing life-threatening complications and need to be
closely monitored.
ß 2012 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

1. Introduction 2. Methods

Anatomical and microbial factors and impairment in host 2.1. Study design and sample
resistance, compounded by a delay in receiving adequate
treatment in the early stages, can result in the progression of a We carried out a retrospective study of all patients with a
localized odontogenic infection into a maxillofacial space infection diagnosis of odontogenic MSI treated in the Department of Oral
(MSI).1 Severe space infections present a challenging problem to and Maxillofacial Surgery at the Christian Medical College Hospital
the maxillofacial surgeon because of the complex anatomy and in Ludhiana, Punjab, from January 2006 to December 2010. All
serious medical complications that can occur despite skillful odontogenic infections that had spread beyond the confines of the
management. Septicemia,2 airway obstruction,3 cavernous sinus jaw were included. Localized dental abscesses without space
thrombosis,4,5 necrotizing fasciitis,6 and mediastinitis,7 which can involvement and non-odontogenic space infections were not
develop subsequent to MSI, are potentially fatal. The objective of included in the study.
this study was to review the clinical characteristics, management, Patients with MSI were diagnosed and managed using a
and outcome of odontogenic MSI managed at a tertiary care center, standard protocol. These patients were either admitted or
and to identify the factors predisposing to life-threatening managed as outpatients. Criteria for hospital admission included
complications. space infections with impending threat to the airway or vital
structures, fever greater than 38 8C, need for general anesthesia,
and the need for inpatient control of a concomitant systemic
disease.
* Corresponding author. Department of Epidemiology, Graduate School of Public
Health [University of Pittsburgh] 130 DeSoto Street, Pittsburgh, PA 15261 USA.
All patients who were admitted underwent pre-operative
Tel.: +412 223 2283. investigations, including hematological and biochemical tests.
E-mail address: mini.e.jacob@gmail.com (M.E. Jacob). Intravenous access was obtained and the patients were rehydrated.

1201-9712/$36.00 – see front matter ß 2012 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijid.2011.12.014
 G.C. Mathew et al. / International Journal of Infectious Diseases 16 (2012) e296–e302 e297

Empirical treatment with intravenous antibiotics was started Table 1

Patient characteristics
preoperatively. All patients subsequently underwent incision and
drainage under local or general anesthesia. Irrespective of whether Variable Frequency Percentage
pus had formed or not, spaces were explored and drains placed. The Gender
causative diseased teeth were extracted. If pus or a serosanguinous Male 91 66.4
discharge was drained, it was sent for culture. Intravenous Female 46 33.6
antibiotics were continued for a minimum of 1 week, and the Age group, years
65 11 8.0
patient was followed up until complete resolution of infection.
<65 126 92.0
Diabetes
2.2. Data collection Present 33 24.1
Absent 104 75.9
Other illnesses
A retrospective medical chart review was performed of patients
Present 10 7.3
with a diagnosis of odontogenic MSI who were treated in the Absent 127 92.7
department. Clinical charts and investigation reports were Site
reviewed. The following variables were recorded systematically: Maxilla 28 20.6
demographic data (age, sex), etiopathogenesis (etiology, number Mandible 108 79.4
Fever
and location of teeth involved, spaces involved, associated
Present 49 35.8
systemic diseases, previous antibiotic treatment), clinical presen- Absent 88 64.2
tation (presenting symptoms, time from onset of symptoms until Admission
presentation, temperature at presentation), results of investiga- Inpatient 91 66.4
Outpatient 46 33.6
tions (white blood cell (WBC) count, blood sugars, pus culture),
WBC count,  109/l
medical treatment (antibiotics used), surgical treatment (type of 15 79 77.5
anesthesia, intubation, incision, usage of drains), and outcome <15 23 22.5
(complications, duration of stay). Bacterial growth on culture
Positive 20 16.4
Negative 102 83.6
2.3. Data management and analysis
Type of anesthesia
General 71 51.8
Data were recorded on standardized collection forms. A Local 66 48.2
database was constructed using Microsoft Excel (Microsoft, Intra-operative drainage of pus
Present 94 68.6
Redmond, WA, USA) and imported into Epi Info version 3.5.3 for
Absent 43 31.4
statistical analysis. Descriptive statistics were computed for all Complications
variables. Univariate analysis was done for identifying associations Present 20 14.6
of different variables with life-threatening complications. Odds Absent 117 85.4
ratios and p-values (based on the Chi-square test or Fisher’s exact Duration of stay, days
>6 26 28.6
test) were calculated. A p-value of <0.05 was considered to be
6 65 71.4
statistically significant. Significant risk factors were further Number of spaces involved
analyzed using multivariate logistic regression analysis. Multiple 88 64.2
Single 49 35.8
3. Results WBC, white blood cell.

3.1. Patient characteristics

The mean age of the study subjects was 39.96 years, with a
One hundred and thirty-seven patients with complete records standard deviation (SD) of 15.9 years. The age distribution of the
were included in the study. Eleven patients with incomplete study subjects is shown in Figure 1. The most common sign/
records were excluded. The demographic and clinical character- symptom was swelling (100%), followed by pain (97.1%), trismus
istics of the patients in our study are summarized in Table 1. (50.4%), fever (42.3%), dysphagia (40.1%), pus discharge at

Figure 1. Distribution of patients according to age.

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Figure 2. Patient signs and symptoms.

presentation (34.3%), and dyspnea (17.5%). The pattern of signs and

symptoms is shown in Figure 2.
Of the 137 patients, 24.1% were diabetic, while 7.3% had other
illnesses like hypertension and renal disease. Ninety-two (67.2%)
of the patients were already on antibiotics, either self-prescribed,
or prescribed by a physician or a general dental practitioner.
Eighty-five percent of these patients were on amoxicillin or a third-
generation cephalosporin.
The origin of the infection is profiled in Figure 3. Odontogenic
MSI in our study originated from a pulpal focus in 97 (70.8%)
patients. Out of the 136 infections originating in the teeth or
sockets (needle tract infection excluded), 108 (79.4%) had
origins in the mandible and 28 (20.6%) had origins in the
maxilla. Out of the 127 infections starting in a tooth, the most
frequently involved tooth was 38 followed by 48, 37, 46, 47, and
Figure 4. Teeth involved in maxillofacial space infection.
36 (Figure 4).
The mean number of infected spaces was 2.6 with a SD of 1.8.
The most common space involved was the submandibular space 17 (12.4%) had six spaces affected. There was one patient with
(69.3%). The frequency of involvement of different spaces is given seven spaces, one with eight spaces, and one with nine spaces
in Figure 5. Twenty patients (14.6%) presented with Ludwig’s involved. All the patients who had six or more spaces involved
angina involving the submandibular, sublingual, and submental were those who were diagnosed with Ludwig’s angina.
spaces bilaterally.
Forty-nine (35.8%) patients in the study had only one space
involvement. Thirty-seven patients (27.0%) had two spaces
affected, 25 (18.2%) had three spaces affected, four (2.9%) had
four spaces affected, two (1.5%) had five spaces affected, and

Figure 3. Origin of infection. Figure 5. Maxillofacial spaces involved.

 G.C. Mathew et al. / International Journal of Infectious Diseases 16 (2012) e296–e302 e299

Table 2
Profiles of patients with complications

Case Age Sex Spaces Origin of infection Comorbidities Complications Treatment Outcome

1 32 M Submandibular, submental, Pulpal Nil Airway obstruction Tracheotomy, drainage Good

sublingual
2 25 M Ludwig’s angina Extraction site Nil Necrotizing fasciitis Drainage, skin graft Good
3 36 M Ludwig’s angina Pulpal Diabetes, Airway obstruction Intubation, drainage Good
drug addiction
4 60 M Submandibular, buccal Periodontal Diabetes, Airway obstruction Tracheotomy, drainage Good
hypertension
5 65 F Ludwig’s angina Pulpal Diabetes, Renal failure Tracheotomy, Death
renal failure drainage, dialysis
6 40 F Ludwig’s angina Periodontal Diabetes Airway obstruction Intubation, drainage Good
7 23 F Submandibular, buccal, Pulpal Nil Necrotizing fasciitis Drainage, skin graft Good
submental
8 30 M Submandibular, buccal, Pulpal Nil Airway obstruction, Tracheotomy, drainage Good
submental, pterygomandibular re-exploration
9 22 M Ludwig’s angina Pulpal Nil Airway obstruction Intubation, drainage Good
10 60 M Ludwig’s angina Pulpal Diabetes Airway obstruction Intubation, drainage Good
11 30 M Submandibular, submental, Pulpal Diabetes Airway obstruction Tracheotomy, drainage Good
sublingual
12 75 M Ludwig’s angina Periodontal Diabetes, Renal failure, Drainage, dialysis Death
renal failure cardiac failure
13 17 M Ludwig’s angina Pulpal Nil Airway obstruction Tracheotomy, drainage Good
14 45 F Ludwig’s angina, Buccal Pulpal Diabetes Trismus Tracheotomy, drainage, Good
mouth opening exercises
15 45 M Ludwig’s angina Periodontal Nil Airway obstruction Intubation, drainage Good
16 30 M Ludwig’s angina Pulpal Nil Airway obstruction Tracheotomy, drainage Good
17 42 F Ludwig’s angina Pulpal Nil Airway obstruction Tracheotomy, drainage Good
18 70 M Submandibular, buccal Periodontal Nil Re-exploration Drainage Good
19 56 M Submandibular Pulpal Diabetes Necrotizing fasciitis Drainage, skin graft Good
20 35 M Ludwig’s angina, submasseteric, Pulpal Nil Airway obstruction Tracheotomy, drainage Good
temporal, pterygomandibular
M, male; F, female.

3.2. Treatment third-generation cephalosporins along with metronidazole.

Amikacin or clindamycin was added in 14 patients.
Eighty-nine patients (65.0%) were admitted for management, Surgical drainage was done under local anesthesia for
while 48 patients (35.0%) were managed as outpatients. Eleven of 66 patients (48.2%). General anesthesia was utilized for the
the 24 patients who complained of dyspnea developed respiratory remaining 71 (51.8%). Among the patients who underwent
distress and eight of these needed an emergency tracheostomy. general anesthesia, the airway was managed by oral endotracheal
The remaining three were managed by endotracheal intubation intubation in 45 (63.4%) cases and nasal intubation in 16 (22.5%)
and ventilation. Two patients who did not complain of dyspnea on cases and through tracheostomy in 10 cases (14.1%). A fiberoptic
presentation developed respiratory distress after admission. They intubation was performed if there was trismus or a possibility of
also underwent emergency tracheotomy. Emergency tracheotomy pus in the airway.
was thus needed in 10 (7.3%) patients. Empirical antibiotic therapy Sixty-two patients in the study had extra-oral incisions made
was instituted and incision and drainage of involved spaces was for the drainage of pus. Thirty-seven patients had only intra-oral
done for all patients. incisions and drainage made, while 38 patients had both intra- and
One hundred and ten patients were empirically started with extra-oral incisions. Pus was drained during surgery in 94 (68.6%)
amoxicillin and clavulanic acid combination, along with metroni- of the patients and a serosanguinous discharge in 43 (31.4%).
dazole for anaerobic cover. Other patients received second- and Drains were placed in 111 (81.0%) patients.

Table 3
Patient characteristics and complications—univariate analysis

Variable Categories With complication Without complication p-Value OR (95% CI)

Age, years 65 3 8 0.20 2.40 (0.58–9.97)

<65 17 109
Gender Male 15 76 0.34 1.68 (0.57–4.95)
Female 5 41
Diabetes Present 9 24 0.02 3.17 (1.18–8.52)
Absent 11 93
Site Mandible 18 90 0.17 2.60 (0.57–11.9)
Maxilla 2 26
Fever Present 11 38 0.05 2.54 (0.97–6.65)
Absent 9 79
WBC count,  109/l 15 14 65 0.01 3.84 (1.34–11.03)
<15 6 17
Bacterial growth on culture Present 6 14 0.08 2.70 (0.89–8.18)
Absent 14 88
Number of spaces involved Multiple 19 69 0.00 13.22 (1.7–102.1)
Single 1 48

OR, odds ratio; CI, confidence interval; WBC, white blood cell.
e300 G.C. Mathew et al. / International Journal of Infectious Diseases 16 (2012) e296–e302

Table 4 MSI occur as an outcome of a prolonged disease process. Most

Patient characteristics and complications—multivariate analysis
patients have had recurring symptoms much before the onset of
Variable Regression p-Value OR (95% CI) space infection. In our study the most common presenting
coefficient complaint of patients with MSI was that of swelling associated
Diabetes 0.64 0.26 1.9 (0.62–5.80) with pain. Swelling was a ubiquitous complaint, as the cases
Total leukocyte count 15  109/l 1.15 0.04 3.16 (1.03–9.72) included in our study were space infections that had advanced
Multiple space involvement 2.17 0.04 8.71 (1.07–70.82) beyond the confines of the jaw. Bridgeman et al.16 observed that
OR, odds ratio; CI, confidence interval. despite the presence of intermittent pain in the past, 98% of the
patients presented for care only when there was a sudden onset of
swelling. They had not sought treatment or had received
Pus or serosanguinous discharge drained from 122 patients was inadequate treatment for the symptom of odontogenic pain. In
sent for culture for aerobic bacteria. Anaerobic culture was not our study, 50.4% of the patients had reached the stage of trismus,
routinely performed. One hundred and two (83.6%) of these did not indicating that the infection had involved the masticatory spaces
have any bacterial growth on culture. The most common organism and could disturb the upper airway abruptly. Among these patients
grown was viridans Streptococcus. 26% also had dyspnea suggesting that airway obstruction had
already set in. Dentists and patients often underestimate the
3.3. Incidence and predictors of complications significance of trismus and attribute it to other causes. Trismus in
patients with an odontogenic infection is a danger sign and
Twenty patients developed complications during the course warrants close examination of the patient for symptoms and signs
of treatment, details of which are given in Table 2. The results of upper airway compromise, like tongue elevation, stridor,
of univariate analysis are shown in Table 3. Factors associated difficulty in swallowing saliva, and breathlessness.
with a statistically significant increased risk of developing Twenty-four percent of our patients were diabetic, clearly
life-threatening complications included diabetes (p-value 0.02), indicating a higher risk for MSI among diabetics, as the prevalence
multiple space involvement (p value 0.00), and a total leukocyte of diabetes among the urban population in India has been found to
count 15  109/l (p-value 0.01). be 12.1%.17 The percentage of diabetics is, however, lower than that
The results of multivariate logistic regression (shown in reported by Huang et al. (88.9%)8 and Parhiscar and Har-El (50%).11
Table 4) confirmed that multiple space involvement (odds ratio Immunological research has demonstrated several defects in the
(OR) 8.71, 95% confidence interval (95% CI) 1.07–70.82) and a total host immune mechanisms of diabetic subjects. Polymorphonucle-
leukocyte count of 15  109/l (OR 3.16, 95% CI 1.03–9.72) were ar leukocytes exhibit impaired migration, phagocytosis, intracel-
independent predictors of life-threatening complications. lular killing, and chemotaxis.18 Besides generalized impairments in
immunity, certain non-immunologic factors contribute to an
4. Discussion increased infection risk. Vascular abnormalities like microangio-
pathy and macroangiopathy favor infection by compromising local
Odontogenic infections are the most common type of head and circulation, leading to a delayed response to infection.19
neck infections among adults.1 Odontogenic infections contrib- The most common origin of the MSI in our study was from a
ute to MSI in the range of 50–89% in reports from different parts of pulpal focus. After the intact pulp chamber is breached, the root
the world. Huang et al.8 reported 50% odontogenic infections in canals are colonized by a diverse mix of anaerobic bacteria. Abscess
185 cases of deep neck infections in Taiwan; Zhang et al.9 formation occurs when these bacteria and their toxic products
reported 56.1% among 212 cases of MSI in China, and Bross- enter the peri-apical tissue via the apical foramen and induce acute
Soriano et al.10 reported 89% in their 121 cases of Ludwig’s angina inflammation and pus formation.20 This pus spreads to the
in Mexico. An increasing proportion of odontogenic cause among maxillofacial spaces in proximity with the roots of these teeth.
deep neck abscesses over the years has been reported by This can be affirmed from our finding of the submandibular space
Parhiscar and Har-El from the USA.11 These data indicate that being the most commonly involved space and 38 and 48 (lower
the prevention and treatment of odontogenic infections has not wisdom teeth) being the teeth most commonly involved. Adults
been on a par with the control of other causes of MSI like tend to have more mandibular infections, while children tend to
tonsillopharyngitis and lymphadenitis. Unlike these conditions, have maxillary infections.12 Among the mandibular spaces, the
odontogenic infections cannot be managed by antibiotic treat- submandibular space has been reported to be the most commonly
ment alone; antibiotics are an adjunct to definitive treatment. involved in MSI.1,9,21,22 The mandibular buccal,13 the lateral
Self-medication by the patient and non-provision of definitive pharyngeal,8 and the pterygomandibular spaces,14 have been
management by the primary practitioner, dental or medical, puts reported to be the most common in some studies. Pericoronitis
the patient at serious risk for progression of infection. Our study leading to severe infection had a low prevalence in our study (5%),
of 137 severe odontogenic infections in a span of 5 years draws probably because pericoronitis occurs in younger individuals and
attention to the need for improving awareness regarding is often treated immediately due to its severe symptoms. The
odontogenic infections among primary practitioners. A call for latency in presentation to the treatment facility is the probable
public health measures to control odontogenic infections is reason behind the higher proportion of multiple space infections
warranted. compared to single space infections in our study. Other studies
Most of the patients in our study were adults in the age group of have also reported a preponderance of multiple space infections
31–50 years. This confirms the reports of previous studies that compared to single space infections in patients with head and neck
although children may acquire maxillofacial infections, the infections of odontogenic origin.21,23
majority occur in adults in this age group.1,8,9,12–14 The probable We had a high proportion of patients presenting with Ludwig’s
reason for adults being at higher risk is the neglect of oral health angina (14.6%) compared to other studies. Sato et al.13 reported
and the higher prevalence of systemic diseases that compromise 2.85% cases with Ludwig’s angina in 210 cases of maxillofacial
immunity. A high male to female ratio in our study corresponds infections in Brazil; Uluibau et al.1 reported 6.25% in 48 cases of
with most of the previous studies.1,8,9,12,14 There is some evidence severe odontogenic infection in Australia, and Huang et al.8
that women tend to have better oral health and seek oral health reported 12.4% in a sample of 185 cases of deep neck infection in
care more frequently.15 Taiwan. A 4-year prospective study at a tertiary care center in
 G.C. Mathew et al. / International Journal of Infectious Diseases 16 (2012) e296–e302 e301

South India24 has reported 20 cases (18%) of Ludwig’s angina to death, and the local rates of beta-lactam resistance are very high.
among 111 patients in a span of 4 years. In patients with airway The combination of these antibiotics provides an antibiotic
obstruction, we preferred tracheotomy to endotracheal intubation spectrum against the viridans streptococci and the strict anaerobes
for maintaining the airway. A study by Potter et al.25 has shown that are predominant in odontogenic infections.20
that patients with deep neck infections who undergo tracheotomy Few studies have looked at patient characteristics associated
for airway management spend less time in intensive care, have with complications in MSI. Diabetes9,22 and multiple space
lower rates of complications, and incur lower costs when involvement22 have already been noted to be significantly
compared to patients who undergo endotracheal intubation. associated with life-threatening complications. We have identified
Patients who underwent tracheotomy for airway management that patients with diabetes, multiple space involvement, or a total
in our study made an uneventful recovery. leukocyte count 15  109/l on admission tend to develop
We performed surgical drainage for all patients irrespective of complications during treatment. Multivariate analysis failed to
the presence of pus. It is often debated whether drainage should be show an independent association between diabetes and complica-
performed when the patient has only cellulitis. The issue of tions, which indicates that a well-managed diabetes need not result
cellulitis being managed differently is a carryover from a pre- in complications during treatment. It is the diabetic with a spreading
antibiotic era, during which time there was a risk that surgical uncontrolled infection (as indicated by multiple space involvement
intervention could make the condition worse.1,26 We attribute our and a high leukocyte count) who tends to develop life-threatening
higher treatment success rate to this active intervention in all complications. Other studies have also noted that well-managed
cases. The only two deaths that occurred in the study sample were diabetes can lead to a prognosis similar to that of a non-diabetic with
of patients with diabetes and chronic renal failure, where the similar severity of infection.24,29 Good control of blood sugars and
systemic condition led to death. Currently there is an evolving aggressive management of the diabetic patient with multiple space
consensus that the difference between cellulitis and abscess is no infection and a high leukocyte count can ensure a reduction in
longer clinically relevant and that both need to be drained.1 complications during the course of treatment.
In our study no bacterial growth was observed in 83.6% of the Conflict of interest: No competing interest declared.
samples that were cultured, and anaerobes were isolated in only a
few cases. Similar findings have been recorded elsewhere. In India
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