key: cord-302379-jh6jxwyn authors: Jevon, Phil; Abdelrahman, Ahmed; Pigadas, Nick title: Management of odontogenic infections and sepsis: an update date: 2020-09-25 journal: Br Dent J DOI: 10.1038/s41415-020-2114-5 sha: doc_id: 302379 cord_uid: jh6jxwyn The management of odontogenic infections has improved over recent decades, but further improvements are still required. The ongoing education of GDPs and their dental teams on this issue continues to be important, especially during the current COVID-19 pandemic, where remote triage poses additional difficulties and challenges. Odontogenic infections can lead to sepsis, a potentially life-threatening condition caused by the body's immune system responding in an abnormal way. This can lead to tissue damage, organ failure and death. A patient with non-odontogenic-related infection could also present with sepsis at a dental practice. Early recognition and prompt management of sepsis improves outcomes. GDPs and their dental teams should be trained in the recognition and management of sepsis. Age-specific sepsis decision support tools have been developed by the UK Sepsis Trust to help dental staff recognise and manage patients with suspected sepsis. The aim of this article is to provide an update on the management of odontogenic infections and sepsis. Although the management of odontogenic infections has improved over recent decades, further improvements are needed and the ongoing education of GDPs and their dental teams on this issue is essential. In addition, the COVID-19 pandemic has imposed new difficulties and challenges; for example, telephone triage and prescription of antibiotics, and it is important to be up-to-date with current guidelines. 1, 2 Odontogenic infections can lead to sepsis, 3,4 a potentially life-threatening condition caused by the body's immune system responding abnormally. This can lead to tissue damage, organ failure and death. 5 A patient with nonodontogenic-related infection could also present with sepsis at a dental practice. Early recognition and prompt effective treatment of sepsis improves outcomes. 5 The dental team should be trained in the principles of the management of sepsis. 6 Agespecific sepsis decision support tools have been developed by the UK Sepsis Trust 7 to assist the dental team to recognise and manage patients with suspected sepsis. The aim of this article is to provide an update on the management of odontogenic infections and sepsis in the dental practice. The morbidity and mortality rate of odontogenic infections has dropped significantly over the past 70 years. 8, 9, 10 This dramatic drop is undoubtedly linked to the discovery of antibiotics, the improvement of the general population health standards, and a better understanding of appropriate medical and surgical management of these cases. Further improvements are needed and ongoing education of the dental team on this issue is very important. Odontogenic infections pass through three key stages: 11 • Stage 1: 1-3 days; soft and mildly tender swelling • Stage 2: 2-5 days; hard, red and severely sore swelling • Stage 3: 5-7 days; abscess formation. There is a strong belief that once the abscess has formed, surgical drainage is mandatory to achieve resolution. 12 Medical management has a role in selected cases. 13 Seven principles have been proposed to achieve the best outcome in managing odontogenic infections: 11 1. Establish the severity of the infection 2. Assess host defences 3. Elect the setting of care 4. Surgical intervention 5. Medical support 6. Antibiotic therapy 7. Frequently evaluate the patient. A careful history and thorough clinical examinations are essential to determine the severity of any infection. History-taking will highlight factors like immune system competence and the level of systemic reserves to fight infections. A physical examination can identify clinical observations outside normal limits. Several clinical and haematological parameters have been used as prognostic indicators for the severity of the infection. C-reactive protein (CRP), fever and anatomical locations have been investigated for the assessment of the extent of odontogenic infections and presumed duration of hospital stay. 14 Additional factors must be considered to establish the infection severity: • Anatomical location • Airway compromise. There are a number of potential spaces between the musculoskeletal head and neck structures and the regional fasciae and organs better known as fascial spaces. A summary of these spaces and their level of risk 11, 12 is found in Table 1 . In healthy and systemically well patients without trismus, infections of low-risk spaces can be initially treated in a primary care dental practice, while infections spreading to higher risk spaces should be managed more aggressively and may need to be treated in a secondary care centre. Ludwig's angina was described by Karl Friedrich Wilhelm von Ludwig in 1836 as a rapidly and frequently fatal progressive gangrenous cellulitis and ooedema of the soft tissues of the neck and floor of the mouth. 15 Thankfully, mortality rates have reduced significantly with the introduction of antibiotics, improved oral and dental hygiene, and timely surgical intervention. 15 The majority of Ludwig's angina infections are odontogenic; 16 peritonsillar or parapharyngeal abscesses, mandibular fractures, oral lacerations/piercing and submandibular sialoadenitis are other recognised causes. 15 A compromised airway is synonymous with Ludwig's angina and the initial assessment of a patient with Ludwig's angina should follow the familiar 'Airway, Breathing, Circulation, Disability, Exposure' (ABCDE) approach. Signs of a compromised airway in these patients could include noisy (gurgling) breathing with drooling saliva, stridor, dyspnoea, tachypnoea, tachycardia, dysphagia and trismus. The initial immediate management usually includes positioning the patient in an upright position and administering oxygen 15 litres/minute, 15 while colleagues call 999 for an ambulance. A healthy immune system is essential to the maintenance of host defence against infection. Multiple medical conditions can affect it. 17 Box 1 summarises the common factors that can cause immune system compromise. The concept of 'physiologic reserve' represents a significant driver of outcome in patients fighting infection. This can be defined as the capability of an organ to carry out its activity under stress. 18 Age is an essential factor that is inversely related to the physiologic reserve; that is, decreased respiratory, cardiovascular and metabolic reserve. 19 Elect the setting of care An uncomplicated localised dental abscess in a healthy young person, who does not show signs and symptoms of a worsening immune response, can be safely treated in a dental practice. Early and adequate intervention is essential in order to prevent avoidable deterioration with invasion of adjusted anatomical spaces and symptoms of sepsis ( Fig. 1) . Similarly, severe neck infection in an immunocompromised elderly person warrants treatment in a secondary care setting. The clinical decision to choose the setting of care is not always straightforward though, prompting the need for clear secondary care referral criteria. Although there are no agreed national guidelines on when to admit to a secondary care setting, criteria for hospital admission have been proposed 2,20 (Box 2). A careful history, thorough clinical examinations and a high index of suspicion will enable the GDP to diagnose and appropriately manage patients presenting with odontogenic sepsis. Early surgical intervention has been advocated to improve the clinical outcome of odontogenic infection. The dramatic improvement in the outcome of sever odontogenic infection is directly linked to the immediate establishment of a safe airway, followed by early surgical intervention. Once the airway has been deemed patent and not at risk of being compromised, in either a hospital setting or dental practice, the principles of management are very similar. Thorough knowledge of head and neck anatomy will enable the surgeon to access the abscess cavities using incisions in safe places without damaging any vital structures like blood vessels or nerves. Most of the odontogenic infections can be drained through intraoral access. Five principles must be followed: 11 21 Although abscess formation takes place between the fifth and seventh days, early elimination of the infection source and surgical intervention will decompress the involved anatomical spaces. 14 Relying on antibiotics only in relieving dental infection is likely to be less effective and can cause antimicrobial resistance. 22 Two of the challenges to performing adequate drainage of any odontogenic infection in dental practice are: 23 1. Achieving adequate local anaesthesia 2. Risk of spreading the infection to other anatomical spaces. The ability to deliver safe, adequate local anaesthesia is essential for any dental procedure. The mechanism of action of the local anaesthetic solution depends on the tissue pH. In the presence of infection, tissue pH becomes more acidic, which slows down the degree of ionisation, resulting in less optimal or failed anaesthesia. 23 To overcome this problem, the injection of the anaesthetic solution at a distance from the inflammatory site is required (nerve blocks). It will also avoid infection spread to different tissue spaces. Although surgical drainage is the classic approach to most of the odontogenic infection, medical support has a critical role in controlling the disease. 24 Adequate hydration, nutrition and control of fever are essential to optimise the medical care for patients presenting with odontogenic infections. Stabilisation of any underlying systemic disease (for example, uncontrolled diabetes) is extremely important. 24 Box 2 Criteria for referral to secondary care 2, 20 • Difficulty in swallowing and dehydration First-line antibiotics for dental abscess in dental practices (adults and children more than 12 years) Odontogenic infections are multi-microbial with a combination of facultative and anaerobes species. Facultative Streptococcus viridans group are commensal Gram-positive bacteria and include S. anginosus, S. intermedius and S. constellatus. These organisms are abundant in the mouth and most frequently associated with orofacial cellulitis and abscess. After a few days, the anaerobes (Prevotella and Porphyromonas) predominate. The majority of the facultative streptococci that cause odontogenic infections are sensitive to penicillin. 25 Approximately a quarter of strains of Prevotella and Porphyromonas are penicillin-resistant. 26 The Scottish Dental Clinical Effectiveness Programme (SDCEP) has published evidencebased guidance on antibiotic prescription in dental practice. Penicillin-based antibiotics remain the first line for the treatment of odontogenic infections. Metronidazole is effective against anaerobic bacteria. 1, 27, 28 The antibiotic doses recommended in the SDCEP's guidance are based on the doses recommended by the British National Formulary (BNF) 13 (Table 2 ). In secondary care settings, the antibiotics are prescribed in accordance with the local hospital antimicrobial therapy. Consultation with the on-call microbiologist is a common practice for severe cases and cases which are not responding to first-line treatment. The last principle, but as vital as the previous ones, is the periodic re-evaluation of these patients. In outpatient settings, the recommended follow-up is after two days. 29 Forty-eight hours will allow the drainage to cease and the immune system to overcome the initial insult from the infection. If no improvement or deterioration of symptoms is noted, further escalation in care must be provided. The review interval, however, depends on the clinical course of the infection. A patient with a rapidly developing swelling and mild temperature may need review within 24 hours, but a patient with a chronic abscess and no systemic symptoms will need to be reviewed at the end of the antibiotic treatment. Causes of treatment failure include: • Failure to remove the source of infection • Underlying systemic disease; for example, uncontrolled diabetes • Antibiotic-related factors -patient non-compliance, drug not reaching site secondary to inadequate drainage, wrong antibiotic choice or incorrect dose. In hospital settings, more frequent evaluations are essential as the disease is expected to be more aggressive. The COVID-19 pandemic has dramatically changed dental practice since March 2020. Guidance on the management of acute dental problems is available. 2, 30 This is likely to change as the situation evolves. Advice, analgesia and antimicrobials (when indicated) should form the basis of primary care dental triage when using remote consultation (telephone call or video call). 1 While assessing the patient, COVID-19 status should be established and documented, as this will determine how the patient's care will be managed should referral to an urgent dental care centre or secondary care be required. Patients should be advised that dental treatment options are currently severely restricted and that they should call back in 48-72 hours if their symptoms have not resolved. 2 The SDCEP's flowchart (Fig. 2) helps the remote management of patients by guiding the GDP to categorise the patient into one of three management groups. 2 The SDCEP has also recently updated their Drugs for the management of dental problems Worryingly, there has been a rise in anecdotal reports of antibiotics apparently being overprescribed for dental pain since the outbreak of COVID-19. 31 This pandemic has demonstrated the havoc a pathogen can unleash when we have no protection against it. Inappropriate use of antibiotics increases the likelihood that resistant bacteria will evolve 31 and it is essential that GDPs remain guardians against antimicrobial resistance. 1,32 Antibiotics should only be prescribed if it is likely that the patient has a bacterial infection, and the principles of prescribing and follow-up (as detailed earlier) should be followed. It is estimated that 234,000 patients develop sepsis in the UK every year, 5 with 70% of sepsis cases originating in the primary care setting. Annually, there are approximately 44,000 deaths from sepsis in the UK 5 and six million deaths worldwide. 33 Although deaths from sepsis due to odontogenic infection are very rare, they have been reported. 34 The incidence of sepsis is on the increase, possibly due to: 35 • A growing elderly population • An increased use of invasive surgery • An increased incidence of bacterial resistance • An increased number of immunocompromised patients. A localised infection which progresses into an uncontrolled systemic response is usually the cause of sepsis. Progression to acute physiological deterioration with the risk of multiple organ failure and death can be swift. • pneumonia: 50% • Urinary tract: 20% • Abdomen: 15% • Skin, soft tissue, bone and joint: 10% • Endocarditis: 1% • Device-related infection: 1% • Meningitis: 1% • Others: 2%. In normal circumstances, the body's immune system will prevent or fight infection (bacteria, viruses, fungi). However, the immune system can sometimes go into overdrive, resulting in vital organs and other tissues being targeted. This can result from any injury or infection in the body. Although a wide variety of different microorganisms (for example, Streptococcus, E. coli, MRSA or Clostridium difficile) can cause sepsis, it is usually caused by common bacteria that don't normally make patients ill. 36 Any infection can lead to sepsis (Box 3), though pneumonia (commonly referred to as chest sepsis) is the cause in half of the cases. 5 The National Institute for Health and Care Excellence (NICE) 6 The UK Sepsis Trust has developed age-specific sepsis decision support tools to assist the dental team to assess both adult and paediatric patients who may have sepsis. 7 Utilisation of these sepsis decision tools will help determine if Red Flag sepsis (see below) is present, prompting appropriate timely action. The prompt transfer of patients presenting with orofacial infections suspected of sepsis to an acute hospital setting for early treatment should ultimately improve sepsis survival rates. 37 The Care Quality Commission (CQC) 38 endorses these sepsis decision tools and, ideally, all three should be readily available in the dental practice. The 'GDP sepsis decision support tool for primary dental care' (Fig. 3) should be applied to all adults and young people aged 12 years and over with fever (or recent fever), symptoms presenting with a source of orofacial/dental infection (including post-operative infection) or have clinical observations outside normal limits. 7 It details what to look out for if the patient has presumed infection and, in particular, what constitutes Red Flag sepsis. Red Flag sepsis is a definition from the UK Sepsis Trust which lists a set of easyto-assess clinical parameters, the presence of one of which in the context of infection identifies sepsis with a high risk of death and a requirement for urgent treatment (Fig. 3) . 7 If Red Flag sepsis is present: There are two paediatric sepsis decision tools, one for children aged 5-11 years (Fig. 4) and one for children <5 years (Fig. 5) . These should be used in children who have a suspected source of orofacial/dental infection (including post-operative infection) or have clinical observations outside the normal range. 7 The paediatric sepsis decision tools take into account paediatric considerations, including differences in paediatric physiology. COVID-19 infection can cause sepsis on its own. 5 Unfortunately, the sepsis signs and symptoms for a number of initial conditions can be very similar. This stresses the importance for dental teams to be familiar with sepsis and the decision tools described here for safe management of such patients. In addition, evidence suggests that, for a period of time following sepsis, patients may be vulnerable and develop further infections including COVID-19; therefore, they have an increased risk of readmission with infective complications (including sepsis). 5 The NICE advises that patients with suspected sepsis are assessed following a structured set of observations to stratify the risk of acute illness or death. 6 The Royal College of Physicians' National Early Warning Score (NEWS) 2 is widely used by the ambulance service and in hospitals, and reliably detects deterioration in adults, triggering review, treatment and escalation of care, particularly sepsis. 41 Although NEWS2 hasn't yet been validated for use in primary care, NHS England is encouraging its widespread use in this sector. 42 The CQC has created a webpage titled 'Dental mythbuster 25: sepsis' on its website, 38 providing helpful information relating to the management of sepsis in the dental practice, including online links to professional guidelines (NICE and UK Sepsis Trust) as well as what to expect from the CQC, relating to sepsis, when they review dental practices to determine whether they are safe and well-led. When reviewing dental practices, the CQC will ask dental staff what systems and processes are in place to manage a patient with a bacterial infection, including procedures for follow-up and referral for specialist care when necessary. This will include treating patients who: • Are not responding to conventional oral antibiotic treatment • Cannot have their infection drained at an initial appointment. The CQC will also ask what advice is given to patients, including when they should seek emergency advice or treatment, if symptoms worsen or when the dental surgery is closed. Odontogenic infections can lead to sepsis, which can result in tissue damage, organ failure and death. This article has outlined the management of odontogenic infections, including the latest COVID-19 guidelines. Drugs for the Management of Dental Problems During COVID-19 Pandemic Management of Acute Dental Problems During COVID-19 Pandemic Severe odontogenic infections with septic progress -a constant and increasing challenge: a retrospective analysis Medical emergencies: Sepsis in primary dental care Professional resources Sepsis: recognition, diagnosis and early management NICE guideline UK Sepsis Trust. Clinical Tools. 2020. Available online at Changing trends in deep neck abscess. A retrospective study of 110 patients Deep neck abscesseschanging trends Life-threatening oro-facial infections Peterson's principles of oral and maxillofacial surgery Deep space neck infection: principles of surgical management Prescribing in Dental Practice Increasing frequency and severity of odontogenic infection requiring hospital admission and surgical management Ludwig's angina Ludwig's angina Management of head and neck infections in the immunocompromised patient Organ reserve, excess metabolic capacity, and aging Influence of Aging and Environment on Presentation of Infection in Older Adults Criteria for admission of odontogenic infections at high risk of deep neck space infection Irrigating drains for severe odontogenic infections do not improve outcome Antibiotic selection in head and neck infections Pharmacology of Local Anaesthetics Used in Oral Surgery Is conservative treatment of deep neck space infections appropriate? Evaluation of bacterial spectrum of orofacial infections and their antibiotic susceptibility Severe odontogenic infections. Part 2. Prospective outcomes study Management of Acute Dental Problems: Guidance for healthcare professionals SDCEP. Drug prescribing for dentistry: dental clinical guidance Deep Neck Infection COVID-19 guidance and standard operating procedure When to prescribe antibiotics Royal College of Surgeons, Faculty of General Dental Practice (UK) & BDA. Open letter on prescribing antibiotics during COVID-19 Assessment of Global Incidence and Mortality of Hospital-treated Sepsis. Current Estimates and Limitations Death from overwhelming odontogenic sepsis: a case report Sepsis guidance implementation advice for adults Sepsis Decision Support Tool for Primary Dental Care Dental mythbuster 25: Sepsis Resuscitation Council UK. The ABCDE Approach Basic Guide to Medical Emergencies in the Dental Practice: Second Edition NEWS) 2: Standardising the assessment of acute-illness severity in the NHS National Early Warning Score (NEWS) The recognition and management of sepsis in the dental practice has also been discussed, including the age-specific sepsis decision support tools developed by the UK Sepsis Trust.