Odontogenic infections (OIs) are the main reason for consultations in dental practice. They affect people of all ages, and most of them respond well to current medical and surgical treatment. However, some of them can spread to vital and deep structures, overcome the host’s immune system, especially in patients with diabetes, immunocompromised, and even prove fatal. Phlegmon of the bottom of the oral cavity in the ICD - 10 is listed under the code K12.2. It is worthwhile to learn more about this disease. After all, it carries many dangers, and in some cases, can lead to death.
Ludwig's sore throat
Ludwig's sore throat is a severe form of diffuse cellulite, which can have an acute onset and spread very quickly, affecting the areas of the head and neck on a bilateral basis, and can also be life threatening. A case of serious dental infection has been presented, in which the emphasis is on the importance of airway maintenance, and then surgical decompression with adequate antibiotic coverage.
What kind of infection is this?
Odontogenic infections (OIs) are quite common and can usually be resolved by local medical and surgical agents, although in some cases they can be complicated and lead to death. Odontogenic phlegmon of the bottom of the oral cavity is usually secondary to cellulose necrosis, periodontal disease, pericoronitis, apical lesions or complications of certain dental procedures.
When does infection develop?
The spread of infection depends on the balance between the patient's condition and microbial factors. The virulence of microbes, along with the local and systemic conditions of the patient, determines the stability of the host. Systemic changes that contribute to the spread of infection can be observed in situations such as HIV / AIDS, decompensated diabetes mellitus, immune depression, alcoholism, or debilitated conditions.
Mortality risk
Ludwig's sore throat is an infection of the head and neck, characterized by rapid progression, swelling and necrosis of the soft tissues of the neck and floor of the mouth and is associated with high mortality. The disease includes progressive friction of soft tissues and a simultaneous change in sublingual, submandibular and submental spaces with elevation and subsequent displacement of the tongue, which can ultimately obstruct and destroy the airways. Before taking antibiotics, mortality in patients with Ludwig's tonsillitis was more than 50%. With the introduction of antibiotics and improved imaging and surgical methods, mortality has dropped to about 8%.
However, in the last 10-15 years, difficulties in the treatment of such cases have recurred, probably as a result of resistance to antibiotics caused by indiscriminate use and progressive aging of the population associated with chronic diseases such as diabetes.
Severity of infection
The location of the infectious process in the anatomical spaces of the climatic facies region determines the risk of compromised airways and exposure to vital structures and organs. There is a long simplified classification of the severity of OI, the assignment of a quantitative indicator from 1 to 4 (moderate, moderate, severe, extremely severe) to the anatomical spaces, depending on the degree of deterioration of the respiratory tract and / or vital structures, such as the mediastinum of the heart or the contents of the cranial cavity .
The increased severity of infection and the appearance of complications prolong the hospital stay, complicate surgical treatment and place increased demand on special care units. In this regard, the identification of risk factors associated with an increased severity and complications of phlegmon of the bottom of the oral cavity may be important for establishing early diagnosis and treatment.
We describe a case of severe odontogenic infection and establish correlations between the disease and systemic risk factors, such as diabetes mellitus, and possible resistance to empirical treatment with antibiotics.
Dental phlegmon history
Many patients with this diagnosis are consulted because of a sudden, progressive and painful hemorrhage in the left submandibular region over the past 48 hours.
A case history of phlegmon of the bottom of the oral cavity indicates that many patients have type 2 diabetes treated with glibenclamide (50 mg / day) and arterial hypertension. Over the past 12 months, both ailments have not been under the supervision of doctors.
What is prescribed to patients?
Initially, the patient needs to be diagnosed and treated by a dentist with symptoms of pericoronitis affecting tooth 3.8, with the appointment of oral antibiotics (Amoxicillin 500 mg + clavulanic acid 125 mg 3 times a day) and oral non-steroidal anti-inflammatory drugs (Ibuprofen 400 mg 3 times a day ) After a limited response to initial treatment of phlegmon of the bottom of the oral cavity, patients decide to consult the Department of Oral and Maxillofacial Surgery.
In consultation, patients are often diagnosed with asthenia, dehydration, fever (38.5 ° C), dysphagia, severe trismus and submandibular adenopathy. Tachycardia and tachypnea (23 rpm) associated with the inspiratory stridor and 93% SatO2 also develop. Patients have pronounced facial asymmetry with a painful seal.
Additional diseases
Despite the difficulties in conducting an oral examination due to trismus, painful retro-molar tumefaction can be identified with respect to the third molar 3.8, extending to the ipsilateral floor of the mouth.
A panoramic X-ray study showed the aforementioned third molar half-period in a distant position. Phlegmon was diagnosed on the floor of the mouth (Ludwig's angina), secondary to acute purulent pericorinitis of the tooth. In this case, an incision is made with phlegmon of the bottom of the oral cavity. But only if the patient's condition rapidly worsens.
Deterioration
Due to the severity of the symptoms, patients are hospitalized and informed consent is given for registration and surgical treatment for signature. Empirical intravenous antibacterial therapy (Clindamycin 600 mg every 8 hours and Ceftriaxone 2 g every 24 hours). After administration, a patient with putrid necrotic phlegmon of the bottom of the oral cavity, as a rule, has the following indicators: leukocytosis (20,000 cells / mm3), concentration of C-reactive protein 300 mg / l, blood glucose 325 mg / l and glycosylated hemoglobin (HbA1c) 17, 6% In this case, insulin treatment is prescribed.
Well-being of the patient
Within a few hours, the clinical condition worsens due to large edema developing in the oral cavity and shortness of breath. A study conducted using direct laryngoscopy, and performed emergency tracheotomy due to the impossibility of intubation and ventilation, can stabilize the patient's condition.
After these measures, the patient is placed under protective mechanical ventilation and transferred to the intensive care unit (ICU) to continue medical management and stabilization. It is necessary to do computed tomography of the head and neck, and also make sure that the patient did not develop acute renal failure with a plasma creatinine concentration of 5.7 mg / dl.
After stabilization, the causal tooth should be extracted and drained, followed by an extended cervicotomy. Cultures may be positive for Acinetobacter baumannii (AB) and methicillin-resistant Staphylococcus aureus (MRSA), so the doctor may prescribe Tigecycline treatment (50 mg every 12 hours for 14 days).
After such measures, the patient has every chance of a favorable outcome with a decrease in inflammatory parameters and restoration of renal function. Extubation is performed after two weeks if there is good respiratory and hemodynamic function, with a Glasgow coma score of 15.
Inflammatory indicators improve with the onset of fever. Spontaneous ventilation is quickly restored without the need for additional oxygen. On the 22nd day of hospitalization, the patient should already be in good general condition, hemodynamically stable, with a surgical wound without signs of infection and normalized inflammatory parameters. As a rule, after discharge, the patient is prescribed outpatient examinations after 7, 14 and 30 days.
The most common cause of death in patients with OI is airway obstruction. Therefore, the physician should evaluate this aspect during the initial evaluation of the patient. It is very important to identify certain signs and symptoms when anatomical spaces are compromised.
Hole reduction
It is believed that a buccal opening, which has decreased by 20 mm or more in a short period of time with severe pain, indicates infection in the anatomical spaces of the peri-mandible until the opposite is proved (2,8,10). However, regardless of the tris, the attending physician should assess the presence of dysphagia and visualize the oropharynx in search of a possible infectious process.
In the event of partial obstruction of the airways, abnormal sounds such as stiffness and wheezing due to turbulent passage of air through the airways will be heard. In these cases, the patient usually tilts his head forward or moves his neck to the opposite shoulder to straighten the respiratory tract and, thus, improve ventilation.
Oxygen saturation below 94% in a previously healthy patient is a sign of insufficient tissue oxygenation. In combination with the clinical signs of partial or complete obstruction, surgical intervention and urgent endotracheal intubation are necessary to provide airways through tracheotomy or cryocytomy.
It is important to consider that in studies conducted at the initial level, the number of leukocytes is an important indicator for urgent hospitalization of the patient with this disease. Leukocytosis above 12,000 cells / mm3 causes a systemic inflammatory response syndrome (SIRS), which is an important factor in determining hospitalization due to OI (13).
If, for example, a patient has white blood cells capable of receiving 20,000 cells / mm3 with fever (38.5 ° C), this will lead to an increase in metabolic and cardiovascular demand outside the reserve capacity, where fluid loss will increase significantly and cause severe dehydration .