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The Sepsis Syndrome in Odontogenic Infection

Article in Journal of the Intensive Care Society · February 2009

DOI: 10.1177/175114370901000107

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© The Intensive Care Society 2009 Original articles

The sepsis syndrome in odontogenic

infection
T Handley, M Devlin, D Koppel, J McCaul

Odontogenic infection is a common cause of sepsis in the head and neck. Infection frequently spreads in a predictable
pattern within the fascial spaces of the neck and can result in airway compromise. Often the condition results in significant
morbidity and a prolonged hospital stay. In this study, we assessed the incidence of sepsis syndrome in patients presenting
to a regional maxillofacial unit with odontogenic infection. Six months of prospective data were collected, with sixty-seven
patients included. The focus of infection was mandibular in 70.1% and maxillary in 29.9%. The mean length of stay was
four days and 61.2% of patients were diagnosed with sepsis syndrome on admission. This group remained in hospital
significantly longer than non-sepsis syndrome patients (sepsis=4.7 days, non-sepsis=2.9 days. p=0.0145.) The site of
infection was not a significant factor in the development of the systemic inflammatory response syndrome (SIRS).

Keywords: sepsis; odontogenic infection; systemic inflammatory response syndrome (SIRS); dental infection

Introduction Parameter Definition

The sepsis syndrome and related disorders have been described Bacteraemia The presence of viable bacteria in
and the definitions used in clinical practice since 1992. These the blood
are summarised in Table 1. The systemic inflammatory response
Infection Microbial phenomenon characterised by
syndrome (SIRS) is a progressive, pathophysiological process an inflammatory response to the
which may be caused by a variety of clinical precursor events presence of microorganisms or the
including local or generalised infection, or non-infective invasion of normally sterile host tissue
inflammatory processes such as trauma, burns or pancreatitis. by those organisms
The sepsis syndrome is defined as SIRS with an identifiable
Systemic inflammatory The response to a variety of severe
source of infection, and is caused by the interplay of response syndrome clinical insults manifested by two or
microorganism virulence factors with the host inflammatory more of the SIRS criteria (see Table 2)
response. SIRS is the first stage of the systemic host response to
Sepsis SIRS + suspected/documented infection
infection or injury, and is defined as occurring in any patient
with any two or more of the four clinical criteria shown in Severe sepsis Sepsis + sepsis-induced organ
Table 2. These parameters were initially agreed and published dysfunction
jointly by the American College of Chest Physicians and the Septic shock Sepsis-induced hypotension despite
Society of Critical Care Medicine in 1992.1 They were adequate fluid resuscitation and
reaffirmed in 2001 by these societies and also by the European perfusion abnormalities such as lactic
Society of Intensive Care Medicine, the American Thoracic acidosis, oliguria, altered mental status
Society and the Surgical Infection Society.2 While there has Sepsis-induced A systolic blood pressure <90 mm Hg or
been some controversy regarding the inclusion of further hypotension a reduction of 40 mm Hg from baseline
criteria for the definition of sepsis, the original concepts remain in the absence of other causes of
robust and have been shown to be useful definitions both for hypotension
clinical research and for patient management.2 These criteria Table 1 Definition of sepsis and related disorders.
are the accepted international standard, but awareness of the
specific parameters has been demonstrated to be low among
both intensivists and other physicians and surgeons.3 In the or suspected infectious agents with two or more of the SIRS
Poeze et al study, only 20% of participants correctly gave criteria.2 The syndrome affects 500,000 patients per year in the
respiratory rate >20/min as a parameter for SIRS. A similar USA and is associated with 35-45% mortality.4 In patients who
level of SIRS awareness and recording was found previously in succumb, the condition progresses to severe sepsis when organ
our own institution (Handley, Devlin, McCaul et al, 2003, dysfunction occurs, and then to septic shock with hypotension
unpublished data). (see Figure 1). Mortality from sepsis-induced organ failure has
The sepsis syndrome is defined as the presence of confirmed been shown to be improving in some patient subgroups, even

JICS Volume 10, Number 1, January 2009 21

Original articles

Criterion Positive result

Maxillofacial Sepsis: Admission Sheet
Temperature <36°C or >38°C
Insert Label
Pulse rate >90 beats per minute
Patient Details:
Respiratory rate >20 breaths per minute

White cell count (WCC) <4 or >12 x 109/L

Table 2 Systemic inflammatory response syndrome criteria.
Date of Admission: …../…../….. Ward: 62/HDU/ITU

Temperature: <36° or >38°

Infection Pulse Rate: >90

Respiratory Rate: >20

+ Sepsis Severe sepsis Septic shock
White Cell Count: <4 or >12
SIRS
Tick as appropriate

Septic Focus: Mandibular Dentition

Figure 1 Pathogenesis of the sepsis syndrome.
without specific sepsis therapies.5 These survival enhancements
have been speculated to be due to changes in definition, but
importantly also due to early recognition and initiation of
supportive and appropriate surgical and antimicrobial
intervention.4
Infection in the head and neck is a common presentation in
maxillofacial surgery, the majority being odontogenic in origin.6
This particular source of infection can rapidly spread through
the anatomical spaces of the head and neck through the path of
least resistance in a predictable pattern (see Figure 2). In severe
cases, this can compromise the airway, necessitating surgical
airway management. Significant morbidity has also been
reported by spread to other anatomical regions or tissues.7,8
Maxillary sinus
Buccinator
muscle
Deep lobe of
submandibular
gland
Dentition
Salivary Gland
Lymph Node
Treatment: IV Antibiotics
Surgery
Figure 3
A recent retrospective review has identified parameters at
presentation which may contribute to increased susceptibility
to odontogenic infection and increased hospital stay. In a study
of 22 patients, serum prealbumin was shown to be low in
odontogenic infection and also to correlate with time in
hospital.9 To date no study has addressed the incidence of
systemic clinical features of odontogenic infection at time of
presentation as identified by the presence of sepsis syndrome.
The incidence of sepsis in this patient group therefore remains
unknown. Furthermore, no study has addressed any impact on
management or length of stay in hospital for such patients.
Observing and recording the clinical criteria for SIRS at the
time of admission allows rapid diagnosis. Recognition of the
severity of this condition enables appropriate treatment to be
provided immediately and effectively, aiming to reduce
morbidity and length of stay in hospital.10 This study
investigates the prevalence of sepsis in patients presenting to
the Southern General regional maxillofacial unit with infection
in the head and neck region.

Mylohyoid muscle Patients and methods

Following a data-gathering exercise assessing levels of
recording of SIRS criteria in case-notes, significant shortfalls in
Superficial lobe of
submandibular gland data collection had been found. A training event was held,
emphasising the significance of these parameters and
Figure 2 Potential initial pathways of spread of odontogenic familiarising staff with the data collection form used in this
infection within the facial tissues.
study (Figure 3). Data were collected from the regional

22 Volume 10, Number 1, January 2009 JICS


maxillofacial unit in Glasgow prospectively over a six month
period. The specially designed SIRS data sheet was completed
by junior medical staff on the patient’s admission to hospital.
All patients admitted to the Southern General Hospital with a
confirmed focus of odontogenic infection by clinical and
radiographic criteria, were included in this study. Data
collection included the recording of SIRS parameters, the
patient’s age, sex, site of infection, length of stay in hospital,
referral source, time from admission to operation and any ICU
admissions.
Diagnosis of the odontogenic focus of infection was made
using a combination of clinical, operative and radiographic
findings. These admission sheets were then reviewed for the
definable SIRS criteria as shown in Table 2, in order to
establish whether a diagnosis of sepsis could be made at initial
presentation. We also assessed the difference in length of stay
between those presenting with SIRS and those not.
Results
Sixty-seven patients were included in the study, with a total
average age of 38.7 years (range 4-91). The ratio of males to
females was 1:1. The mean age of the male patients was 37.2
years (range 4-71) and the mean age of the female patients was
40.3 years (range 13-91). The referral source is shown in
Figure 4. The majority of these patients were from accident
and emergency departments and the local dental hospital
(GDH). The mean length of stay in hospital of patients was 4.0
days (range 1-17).
31.34% A&E
GDH
41.79% Dentist
16.42% GP
Other
7.46%
2.99%
Figure 4 Pie chart illustrating the various referral sources.
The clinical focus of infection was the maxillary dentition in
29.9% (n=20) of cases and the mandibular dentition in 70.1%
(n=47) of cases. Sixty-four patients (95.5%) required incision
and drainage as part of the management of their head and neck
infection. Fifty-six (83.5%) of these patients had their
operation on the same day as admission to hospital with the
remaining eight (11.9%) being operated on the day following
admission. Only three patients did not require an operation
and were treated with intravenous antibiotics and supportive
measures.
Forty-one patients (61.2%) had sepsis diagnosed on their
admission to hospital. The average length of stay for patients
diagnosed with sepsis was 4.7 days (range 2-17), compared
JICS Volume 10, Number 1, January 2009
Original articles
with patients without systemic sepsis whose average length of
stay was 2.9 days (range 1-6). This achieved statistical
significance, (p=0.0145 Mann-Whitney U test). Patients with
SIRS and a mandibular focus of infection had a longer hospital
stay, 5.3 days, than those patients presenting with SIRS and a
maxillary focus of infection of 3.0 days. This was also
statistically significant (p=0.0146 Mann-Whitney U test). The
site of the infection was not a statistically significant factor in
the likelihood of having SIRS in this series (see Figures 5a and
5b). Mandibular dental sepsis was associated with a 63.8%
SIRS rate while maxillary dental sepsis was associated with a
rate of 55% (p=0.46, Chi-square test), indicating no statistical
difference in the likelihood of developing SIRS dependent upon
the site of the infective odontogenic focus. However, the
average length of stay associated with mandibular infection was
4.6 days as compared to 2.6 days in association with maxillary
infection. This was statistically significant (p=0.00089, Mann-
Whitney U test). Twenty-two (53.7%) of the 41 patients with a
diagnosis of SIRS also had positive bacterial cultures.
2.13% 6.38%
6.38%
2.13%
Submandibular
4.26%
Submasseteric
Subligual
Submental
78.72% Parapharyngeal
Buccal
5%
Buccal
30%
Canine
65% Palatal
Figure 5a and 5b Proportions of fascial space involvement in
mandibular and maxillary odontogenic infection.
Six of the sixty-seven patients in this study were admitted
postoperatively to the ICU for the management of septic
complications. All admissions involved airway patency
considerations; of these, two cases had septic shock and
another two developed single or multiple organ failure. All
six of these patients presented with sepsis on admission with
a mandibular primary focus. All underwent surgical
23
Original articles
intervention on the day of admission.
Of the parameters required for the diagnosis of SIRS, five
cases did not have the white cell count recorded and one did
not have the respiratory rate documented. This did not affect
the results, as none of the other parameters were positive for
SIRS in these patients.
Discussion
Odontogenic infection is extremely common and may result in
significant morbidity and mortality if not recognised and
treated appropriately. Abscess formation and the spread of
infection within the fascial neck spaces can lead to direct
pressure on the upper airway (Figure 6). This can result in
significant compromise to airway patency with immediate
threat to life. Odontogenic infection has also been reported to
spread into adjacent and non-adjacent structures causing
significant morbidity and also mortality, including necrotising
fasciitis.6-8,11-18
Figure 6 CT scan of cervicofacial abscess illustrating airway
deviation and compromise.
It was our aim to quantify the prevalence of SIRS in our
patients presenting with odontogenic infection to the regional
maxillofacial unit at the Southern General Hospital, Glasgow.
Development of SIRS is the common first step in the
traumatised host to many forms of insult. In the case of a
suspected infective cause, if an organism is isolated then the
patient has, by definition, developed sepsis syndrome. Even in
the absence of a cultured organism, a diagnosis of sepsis
syndrome can be made if a clinical focus of infection is
diagnosed. Only 53.7% of the patients with SIRS had positive
cultures. This low percentage is most likely to be due to the
immediate administration of intravenous antibiotic therapy on
admission, producing negative bacterial cultures. Many
patients also had commenced oral antimicrobial therapy prior
to presentation.
24
The sepsis syndrome is a clinical state where the host
systemic response remains compensated in the face of infective
insult. This clinical phase precedes sepsis-induced organ
dysfunction and thus merits careful but aggressive resuscitative
management. A large proportion of our patients with
cervicofacial odontogenic infection need urgent intervention to
avert sepsis progression. The patients referred to the unit may
represent the more severe end of the odontogenic infection
spectrum, but until this study we were unsure as to the
severity of systemic upset in this group. It is clear that most of
these patients are significantly systemically unwell.
In managing the septic patient the first consideration is to
attempt to identify and eliminate the source of infection. When
indicated, surgical drainage and debridement should be
performed promptly.9 Empirical antibiotics should be
commenced as early as possible, be broad enough in spectrum
to cover the likely infecting organisms, and be able to penetrate
to the site of infection.10,19-21 Research has shown that the
commencement of intravenous antibiotic therapy within the
first hour after the recognition of sepsis is vital to reduce the
likelihood of complications.22 Thus early awareness and
institution of appropriate management measures should
optimise clinical outcomes; this is planned to be the subject of
ongoing study.
We have produced a stamp detailing the SIRS criteria,
which can be used for future admissions in order to accurately
record the diagnosis of SIRS (Figure 7). This step aims to
introduce the concepts of SIRS and sepsis to routine practice
and so facilitate prompt and appropriate intervention for this
patient group.
Figure 7 Stamp produced in order to help record SIRS criteria
accurately within case record clinical entries.
Conclusions
The sepsis syndrome was present in at least 61.2.% of patients
presenting over the study period with odontogenic infection to
a regional maxillofacial unit. Clinical recording of SIRS
parameters was incomplete in the case series reported.
Adoption of assessment of SIRS parameters in the initial
assessment of odontogenic infection patients presenting to the
maxillofacial unit should become routine and may help
guide intervention.
Volume 10, Number 1, January 2009 JICS
 Original articles

References 15.Ogiso A, Tamura M, Minemura T et al. Mediastinitis caused by

odontogenic infection associated with adult respiratory distress syndrome.
1. Bone RC, Balk RA, Cerra FB et al. Definitions for sepsis and organ
Oral Surg Oral Med Oral Pathol 1992;74:15-18.
failure and guidelines for the use of innovative therapies in sepsis. The
16.Reed JM, Anand VK. Odontogenic cervical necrotizing fasciitis with
ACCP/SCCM Consensus Conference Committee. American College of
intrathoracic extension. Otolaryngol Head Neck Surg 1992;107:596-600.
Chest Physicians/Society of Critical Care Medicine. Chest 1992;101:1644-
17.Rubin MM, Cozzi GM. Fatal necrotizing mediastinitis as a complication
55.
of an odontogenic infection. J Oral Maxillofac Surg 1987;45:529-33.
2. Levy MM, Fink MP, Marshall JC et al. 2001 SCCM/ESICM/ACCP/
18.Zeitoun IM, Dhanarajani PJ. Cervical cellulitis and mediastinitis caused
ATS/SIS International Sepsis Definitions Conference. Intensive Care Med
by odontogenic infections: report of two cases and review of literature.
2003; 29:530-38.
J Oral Maxillofac Surg 1995;53:203-08.
3. Poeze M, Ramsay G, Gerlach H et al. An international sepsis survey: a
19.Jimenez MF, Marshall JC. Source control in the management of sepsis.
study of doctors’ knowledge and perception about sepsis. Crit Care
Intensive Care Med 2001;27 Suppl 1:S49-S62.
2004;8:409-13.
20.Ibrahim EH, Sherman G, Ward S et al. The influence of inadequate
4. Wheeler AP, Bernard GR. Treating patients with severe sepsis. New Engl J
antimicrobial treatment of bloodstream infections on patient outcomes in
Med 1999;340:207-14.
the ICU setting. Chest 2000;118:146-55.
5. Rangel-Frausto MS, Pittet D, Costigan M et al. The natural history of the
21.Leibovici L, Shraga I, Drucker M et al. The benefit of appropriate
systemic inflammatory response syndrome (SIRS). A prospective study.
empirical antibiotic treatment in patients with bloodstream infection.
JAMA 1995;273:117-23.
J Intern Med 1998;244:379-86.
6. Green AW, Flower EA, New NE. Mortality associated with odontogenic
22.Weinstein MP, Murphy JR, Reller LB et al. The clinical significance
infection! Br Dent J 2001;190:529-30.
of positive blood cultures: a comprehensive analysis of 500 episodes
7. Sakamoto H, Aoki T, Kise Y et al. Descending necrotizing mediastinitis
of bacteremia and fungemia in adults. II. Clinical observations, with
due to odontogenic infections. Oral Surg Oral Med Oral Pathol Oral Radiol
special reference to factors influencing prognosis. Rev Infect Dis
Endod 2000;89:412-19.
1983;5:54-70.
8. Sugata T, Fujita Y, Myoken Y et al. Cervical cellulitis with
mediastinitis from an odontogenic infection complicated by diabetes
mellitus: report of a case. J Oral Maxillofac Surg 1997;55:864-69.
9. Cunningham LL Jr, Madsen MJ, Van Sickels JE. Using prealbumin as an
inflammatory marker for patients with deep space infections of
Thomas PB Handley Trainee Doctor, Regional Maxillofacial
odontogenic origin. J Oral Maxillofac Surg 2006;64:375-78. Unit, Southern General Hospital, Glasgow
10.Dellinger RP, Carlet JM, Masur H et al. Surviving Sepsis Campaign
Mark F Devlin Consultant, Maxillofacial/Cleft Surgeon,
guidelines for management of severe sepsis and septic shock. Crit Care
Regional Maxillofacial Unit, Southern General Hospital, Glasgow
Med 2004;32:858-73.
11.Bounds GA. Subphrenic and mediastinal abscess formation: a comp- David A Koppel Consultant, Maxillofacial/Craniofacial
lication of Ludwig’s angina. Br J Oral Maxillofac Surg 1985;23:313-21.
Surgeon, Regional Maxillofacial Unit, Southern General Hospital,
12.Garatea-Crelgo J, Gay-Escoda C. Mediastinitis from odontogenic
Glasgow
infection. Report of three cases and review of the literature. Int J Oral
Maxillofac Surg 1991;20:65-68. James A McCaul Consultant, Maxillofacial/Head and Neck
13.Haraden BM, Zwemer FL, Jr. Descending necrotizing mediastinitis: Surgeon, Bradford Teaching Hospitals NHS Foundation Trust
complication of a simple dental infection. Ann Emerg Med 1997;29:
jim.mccaul@btinternet.com
683-86.
14.Moncada R, Warpeha R, Pickleman J et al. Mediastinitis from This work was carried out at the Regional Maxillofacial Unit of the
odontogenic and deep cervical infection. Anatomic pathways of Southern General Hospital, Glasgow.
propagation. Chest 1978; 73:497-500.

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