J Oral Marillofac Surg

49:97S-990. 1991

An Epidemiologic and Anatomic Survey of Odon togenic Infections

RICHARD H. HAUG, DDS,* MICHAEL J. HOFFMAN, DDS,t AND A. THOMAS INDRESANO, DMDS

An 81-month review of patients with infections of odontogenic origin ad- mitted to the oral and maxillofacial surgery service at a county hospital and teaching facility in northeast Ohio is presented. Age, sex, race, etiology, pathogens isolated, admission temperature, and admission white blood cell count were identified and related to the anatomic space(s) encoun- tered. Multispace and single-space infections occurred with equal distri- bution. In both the multispace and single-space infections, the subman- dibular and buccal spaces were most frequently involved. Males were af- fected with single-space infections twice as often as females. An equal distribution among sexes was found in multispace infections. The most common age range for all infections was 25 to 30 years. a-Hemolytic strep- tococci, Bacteroides melaninogenicus, and P-hemolytic streptococci were the most frequently isolated pathogens. Third molars were the prevalent cause in both multispace and single-space infections that required hospi- tal admission.

The purpose of this study was to review the pop- ulation characteristics of patients with odontogenic infections admitted to the oral and maxillofacial sur- gery service in an urban county hospital over an 81-month period, and to correlate these findings with the anatomic spaces involved. Age, sex, and race of the patients, etiology of the infection, patho- gens isolated, and admission temperature and white blood cell count were all identified and related to the space(s) involved. The findings were then com- pared with those from other studies involving dif- ferent patient populations to see if any trends could be found that might be helpful in understanding the development of such infections.

Received from Metrohealth Medical Center, Cleveland. * Assistant Professor of Surgery, the Case Western Reserve

University. t Resident, Division of Oral and Maxillofacial Surgery. $ Director, Division of Oral and Maxillofacial Surgery; Asso-

ciate Professor of Surgery, the Case Western Reserve Univer- sity.

Address correspondence and reprint requests to Dr Haug: Di- vision of Oral and Maxillofacial Surgery, Metrohealth Medical Center, 3395 Scranton Road, Cleveland, OH 44109.

0 1991 American Association of Oral and Maxillofacial Sur- geons

0278-2391/91/4909-0009$3.00/O

Materials and Methods

This investigation was performed at the Metro- Health Medical Center, which services approxi- mately 3.4 million people in northeast Ohio. Hospi- tal charts and radiographs of 86 consecutive pa- tients with odontogenic infections admitted to the Oral and Maxillofacial Surgery Service from March 1983 through November 1989 were reviewed by two investigators. This represented 100% of the admis- sions for that diagnosis during the period studied. Complete records and radiographs were recovered for 79 patients (91.9%). Each odontogenic infection was categorized by fascial space(s) involved ac- cording to the system described by Spilka.’ Factors reviewed were age, race, sex, tooth of etiology, pathogens isolated, admission temperature, and ad- mission white blood cell count. The data were then collated and evaluated in relation to the anatomic space(s) involved.

Results

The admission temperatures and white blood cell counts showed no correlation with any type of an- atomic space involvement. The mandibular third

976

HAUGETAL 977

molars were the most frequent source of the infec- tion. Two thirds of these were due to pericoronitis and occurred in patients between 23 and 35 years of age. The remaining one-third were due to periodon- titis or carious teeth with pulp exposures. When deciduous teeth were the cause, all were carious and occurred in patients under 10 years of age. The mandibular premolars and first and second molars implicated in infections were almost exclusively carious. Periodontitis as a source of infection in- creased in frequency with increasing age above 45 years.

SUBMANDIBULAR SPACE

The submandibular space was the most fre- quently encountered location for both single-space (41%) and multispace (64%) infections (Table 1). Single-space submandibular infections were en- countered mostly in males (81%) (Table 2). The age distribution ranged from 5.4 to 35.4 years, with a mean of 28.7 years. Whites were most affected with infections involving the submandibular space, fol- lowed by blacks and Hispanics (Table 3). The man- dibular third molars were the most frequent teeth involved, followed by the mandibular right second molar (Table 4). The submandibular space had the broadest range of pathogens isolated (Table 5). c;u-Hemolytic streptococci were isolated most often, followed by Staphylococcus epidermidis and p-hemolytic streptococci.

Table 1. Frequency of Fascial Spaces Involved

Single space (n = 40) Submandibular Buccal Canine Submental Temporal

Multispace combinations tn = 39) Submandibular/buccal Submandibular/submental Buccahcanine Submandibular/lateral pharyngeal Buccahlateral pharyngeal Submandibular/buccal/sublingual BuccaUlateral pharyngeal/temporal BuccaVmasseteric Submandibular/sublingual BuccaUtemporal Submandibular/buccal/lateral pharyngeal Submandibular/buccal/submental Submandibular/submandibular/submental Submandibular/submental/masseteric Submandibular/lateral pharyngeaVmasseteric Submandibular/lateral pharyngeaUretropharyngea1 Canine/masseteric

16 13 7 2 I

6 5 5 3 3 3 2 2 2 I 1 I I 1 1 I 1

Table 2. Male/Female Distribution

Submandibular Buccal Canine Submental Lateral pharyngeal Temporal Masseteric Sublingual Retropharyngeal Multispace

Male Female

13 3 9 4 3 4 2 0 0 I 0 1 0 0 0 0 0 0

18 21

BUCCAL SPACE

The buccal space was the second most frequently encountered location for both single-space (33%) and multispace (62%) infections (Table 1). There were more than twice as many males as females with single-space infections (Table 2). Patients with buccal space infections had the most variable age range, 3.3 to 82.0 years, with a mean of 31 years. Blacks were affected more than twice as often as whites (Table 3). The tooth of origin most fre- quently encountered was the mandibular left third molar, followed by the mandibular left second mo- lar (Table 5). a-Hemolytic streptococci were the most commonly isolated pathogens. followed by Bacteroides melaninogenicus and P-hemolytic streptococci (Table 5).

CANINE SPACE

The canine space was the third most frequently encountered location for a single-space infection (18%) (Table 1). It was found with approximately equal distribution among males and females (Table 2). The ages affected ranged from 3.1 to 59.3 years, with a mean of 25.3 years. Whites were affected more than twice as often as blacks (Table 3). The

Table 3. Anatomic Distribution Related to Race

White Black Hispanic Asian tn = 44) tn = 30) tn = 4) tn = I)

Submandibular II 4 I 0 Buccal 4 9 0 0 Canine 5 2 0 0 Submental I I 0 0 Lateral

pharyngeal 0 I 0 0 Temporal 0 I 0 0 Masseteric 0 0 0 0 Sublingual 0 0 0 0 Retropharyngeal 0 0 0 0 Multispace 23 I2 3 1

978 SURVEY OF ODONTOGENIC INFECTIONS

Table 4. Tooth of Etiology and Space(s) Affected

Submandibular

Canine

Submental

Lateral pharyngeal Masseteric

Sublingual Temporal Retropharyngeal Multispace

K. L, 18, 27, 28 (n = I) 29. 30 (n = 2) 31 (n = 3) 17 (n = 4)

32 (n = 6)

I, S, 1, 2, 3, 13. 14, 19, 28, 29, 30, 32 (n = 1)

18 (n = 2) 17 (n = 3)

C, I, 6, 7, 10, 11 (n = 1) H (n = 2)

23, 25 (n = 1) 15 (n = 1) (n = 01

(n = 0) 13 (n = 1)

(n = 0)

B. D, N, 0, P. Q. 2. 3, 10, 16, 20, 21. 23. 24. 25, 28 (n = 1)

22. 29 (n = 2)

14, 30 (n = 31 19, 31 (n = 6) 32 (n = 7)

17 (n = 8) 18 (n = IO)

primary dentition was found to be the source as often as the adult dentition (Table 4). a-Hemolytic streptococci were the most frequently encountered organisms, followed by Bacteroides melaninogeni- cus, P-hemolytic streptococci, and Staphylococcus epidermidis (Table 5).

SUBMENTAL SPACE

The submental space was involved in only two single-space infections (5%), but in eight multi- space infections (21%) (Table 1). Both of the single- space infections were found in males, ages 10.8 and 59.0 years (Table 2). One patient was black and the other white (Table 3). The mandibular left lateral and right central incisor were the cause (Table 4). cx-Hemolytic streptococci and Bacteroides melani- nogenicus were isolated (Table 5).

LATERAL PHARYNGEAL SPACE

The lateral pharyngeal space was involved only once (3%) as a single-space infection, but 11 times (28%) as a multispace infection (Table 1). The sin- gle-space infection was in a 35.3-year-old black woman. The upper left second molar was the cause; a-hemolytic streptococci and Bacteroides melani- nogenicus were isolated (Tables 4 and 5).

TEMPORAL SPACE

The temporal space was involved only once as a single-space infection (3%) and three times as a

multispace infection (8%) (Table 1). The one single- space infection was in a 57.5-year-old black woman. The maxillary left second premolar was the cause and no organisms were able to be isolated.

MASSETERIC, SUBLINGUAL,

RETROPHARYNGEAL SPACES

The masseteric, sublingual, and retropharyngeal spaces were not involved as single spaces in this series.

MULTISPACE INFECTIONS

Multispace infections were encountered as often as single-space infections (Table 1). The anatomic spaces most frequently affected were submandibu- lar (64%), buccal (62%), lateral pharyngeal (28%), submental (21%), and canine (15%) (Table 1). The multispace infections had about equal distribution between males and females (Table 2). They affected the broadest range of ages, 3.3 to 83.3 years, with a mean of 32.2 years. Whites were infected twice as frequently as blacks, eight times as frequently as Hispanics, and 24 times as frequently as Asians (Ta- ble 3). Virtually every tooth in the mouth caused an infection of at least one space, yet the mandibular second and third molars were the most frequent cause (Table 4). The broadest range of organisms were isolated with multispace infections, yet oz-hemolytic streptococci, Bacteroides melanino- genicus, and P-hemolytic streptococci predomi- nated (Table 5).

Discussion

Epidemiologic surveys will vary with geographi- cal region, population density, socioeconomic sta- tus, regional government, era in time, and facility in which the study was conducted. Comparison of sur- veys requires consideration of these factors.’ This study was performed in a large county teaching hos- pital serving an urban population of 1.4 million and a rural population of 2.0 million in northeast Ohio. The study was conducted over an 81-month period from March 1983 through November 1989. The ra- cial distribution in the region was white (75%), black (23%), Hispanic (2%), and Asian (1%).

Many surveys exist in the oral and maxillofacial surgical literature regarding the epidemiology of odontogenic infections, yet relatively few relate the anatomic location to the infection. Labriola and co- workers in 1983 reviewed 50 consecutive infections treated by the Oral and Maxillofacial Surgery Ser- vice in the primary teaching center of the state of Kentucky between May 1978 and March 1980.’

HAUG ET AL 979

Table 5. Frequency of Pathogens Isolated and Facial wee(s) Affected

No. of Lateral Patients Submandibular Buccal Canine Pharyngeal Submental Temporal Multispace

a-Hemolytic streptococci 47 9 8 5 1 I - 23 Bacteroides melaninogcnicus 27 4 5 3 I I - I3 P-Hemolytic streptococci 22 5 4 2 - - - II Staphylococcus epidermidis IS 6 3 I - - 5 Staphylococcus aurew I2 5 1 1 - - - 4 Neisseria species 9 2 2 1 - - - 4 Hemophilus injluenzae 8 2 I - - - - 5 Eikenellu corrodens 7 2 I I - - - 3 Diphtheroids 6 0 I 2 - - - 3 Candida species 4 1 I - - - 2 Klebsiella 4 0 - I - - - 3 Escherichiu coli 3 I - 1 - - - I Bacteroides ureolyticus 3 I - - - - 2 Enterobucter 3 1 - - - 2 Peptostreptococ,cus 3 - - - - - - 3 Bacteroides corrodens 2 - - - - - 2 Actinomyces 2 I I - - - - 0 y-Hemolytic streptococci 2 - - - - - 2 Hemophilus hemoiytic-us I - - - - - - I Citrobactc,r I - I - - - 0 Lactobacillus I I - - - 0 Bacteroides fra,qilis I - - - - 1

They noted that the most frequently encountered single-space infection was the submandibular (26%), followed by the buccal (21%), masticator (15%), and canine (13%). While our study identified a similar order of frequency, we found a much higher percentage of submandibular and buccal space infections.

The relationship between the sex of the patient and odontogenic infection is sparsely reported in the literature. Kannangara and coworkers, in a re- view of 61 patients treated between 1976 and 1979 at the Martin Luther King Jr General Hospital in Los Angeles, identified 40 males (66%) and 21 females (34%) with odontogenic infections.4 Hunt and oth- ers surveyed 74 patients treated between January 1973 and January 1976 at the Emory University School of Dentistry.’ In their study, 30 males (41%) and 43 females (59%) were identified. Dodson and coinvestigators performed a retrospective review of 113 pediatric odontogenic infections admitted to the San Francisco General Hospital between January 1982 and December 1986.6 In that review, 67 pa- tients (59%) were male and 46 (41%) were female. Our study showed approximately equal distribution between males and females having multispace in- fections, but a predominance of males (68%) having single-space infections. When single- and multi- space infections were grouped together, males pre- dominated (60%). Our study shows a correlation with the studies performed by Kannangara and co- workers and Dodson and others. Hunt’s study pro- vided less relevant epidemiologic data because only

74 patients were reported from several hundred re- viewed.

Our investigation reported a very broad age range of patients having infections, from 3.3 years to 83.3 years, with the majority in the 25-35-year age group. This compared well with other studies. Kannangara and coworkers study involved range of 6 to 79 years, with the majority between 20 and 29 years of age.4 Bartlett and O’Keefe reviewed 20 patients in 1979 in Tufts University,7 and their age range was 23 to 70 years, with a mean of 43 years.

The literature provides no data regarding the re- lationship between race and infection. Our study shows that the black, Hispanic, and Asian popula- tion’s rates of infection were disproportionately high in relation to the general population investi- gated.

Teeth of origin showed obvious relationships to the adjacent anatomic space infected. The molars were the most frequent cause of infection, the high- est incidence involving lower second and third mo- lars (Table 4).

Although various combinations of pathogens iso- lated from odontogenic infections have been re- ported, there are definite similarities in most stud- ies. cY-Hemolytic streptococci were most frequently encountered, with Bacteroides melaninogenicus second. Labriola and coworkers reported a total of 42 different species of organisms.3 In their study, a-hemolytic streptococci predominated two to one over all others. Bacteroides melaninogenicus was a distant second, followed by other Bacteroides spe-

980 SURVEY OF ODONTOGENIC INFECTIONS

ties, and then @hemolytic streptococci. Kannan- gara and coinvestigators isolated 42 species and found that Bacteroides species predominated over all others, followed by Peptococcus, Staphylococ- cus species, and a-hemolytic streptococci.4 Hunt and his group isolated 14 species; cw-hemolytic streptococci predominated two to one, with Staph- ylococcus species following as a distant second. Bartlett and O’Keefe isolated 31 species.’ a-Hemolytic streptococci predominated, followed closely by Bacteroides melaninogenicus. Aderhold and coworkers, in a review of 50 patients with odontogenic infection in Frankfort, West Germany isolated 29 species of organisms.’ a-Hemolytic streptococci predominated, followed by @hemolytic streptococci, Bacteroides melanino- genicus, and other Bacteroides species. Chow and coinvestigators reviewed 3 I patients with odonto- genie infections at Harbor General Hospital in Tor- rance, California between 1971 and 1976.9 In their study, 43 species were isolated, and Bacteroides melaninogenicus predominated, followed by Strep- tococcus species. Our study isolated 23 species or groups. a-Hemolytic streptococci were found to

predominate in single space as well as multispace infections, followed by Bacteroides melaninogeni- cus, @hemolytic streptococci, and Staphylococcus species.

References

I. Spilka CJ: Pathways of dental infection. J Oral Surg 24: 111, 1966

2. Haug RH, Prather J, Indresano AT: An epidemiologic sur- vey of facial fractures and concomitant injury. J Oral Maxillofac Surg 48:926, 1990

3. Labriola JD, Mascaro J, Alpert B: The microbiologic flora of orofacial abscesses. J Oral Maxillofac Surg 47:711, 1983

4. Kannangara DW, Thadepalli H, McQuirter JL: Bacteriology and treatment of dental infections. Oral Surg Oral Med Oral Pathol 50: 103, 1980

5. Hunt DE, King TJ, Fuller GE: Antibiotic susceptibility of bacteria isolated from oral infections. J Oral Surg 36:527, 1978

6. Dodson TB, Perrott DH, Kaban LB: Pediatric maxillofacial infections: A retrospective study of 113 patients. J Oral Maxillofac Surg 47:327, 1989

7. Bartlett JG, O’Keefe P: The bacteriology of perimandibular space infections. J Oral Surg 37:407, 1979

8. Aderhold L, Knothe H, Frenkel G: The bacteriology of den- tigerous pyogenic infections. Oral Surg Oral Med Oral Pathol 52:583, 1981

9. Chow AW. Roser SM, Brady FA: Orofacial odontogenic infections. Ann Intern Med 88:398, 1978