Odontogenic infections (OIs) are the main reason for consultations in dental practice. They affect people of all ages and most respond well to current medical and surgical treatments. However, some of them can spread to vital and deep structures, override the host's immune system, especially in diabetic, immunocompromised patients, and even be fatal. Phlegmon of the floor of the mouth in the ICD - 10 is listed under the code K12.2. It is worth learning more about this disease. After all, it carries many dangers, and in some cases, it can be fatal.
Angina Ludwig
Ludwig's angina is a severe form of diffuse cellulitis that can have an acute onset and spread very quickly, bilaterally affecting the head and neck, and can also be life-threatening. A case of serious dental infection is presented emphasizing the importance of airway maintenance followed by surgical decompression with adequate coverage.antibiotics.
What is this infection?
Odontogenic infections (OIs) are quite common and can usually be resolved by local medical-surgical means, although in some cases they can be complicated and lead to death. Odontogenic phlegmons of the floor of the mouth are usually secondary to pulp 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. Microbial virulence, along with the local and systemic conditions of the patient, determines host resistance. Systemic changes that promote the spread of infection can be observed in situations such as HIV/AIDS, decompensated diabetes mellitus, immune depression, alcoholism, or debilitated conditions.
Mortal risk
Ludwig's angina is a head and neck infection 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 involves progressive soft tissue friction and simultaneous alteration of the sublingual, submandibular, and submental spaces, with elevation and subsequent displacement of the tongue, which may eventually obstruct and destroy the airway. Before taking antibioticsmortality in patients with Ludwig's angina was more than 50%. With the introduction of antibiotics and improvements in imaging and surgical treatment, mortality has dropped to about 8%.
However, in the past 10-15 years, there has been a resurgence of difficulties in treating such cases, likely as a result of antibiotic resistance 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 climatofacial region determines the risk of compromising the respiratory tract and affecting vital structures and organs. There is a long-simplified classification of OI severity, assigning a score of 1 to 4 (moderate, moderate-moderate, severe, extremely severe) to anatomical spaces depending on the degree of deterioration of the airways and/or vital structures such as the mediastinum of the heart or the contents of the cranial cavity..
Increased severity of infection and complications are prolonging hospital stays, complicating surgical treatment and placing increased demand on dedicated care units. In this regard, the identification of risk factors associated with increased severity and complications of phlegmon of the floor of the mouth, may be important to establish early diagnosis and treatment.
We describe a case of severe odontogenic infection and establish correlationsbetween the disease and systemic risk factors such as diabetes mellitus and possible resistance to empiric antibiotic treatment.
Case history of phlegmon of the floor of the mouth
Many patients with this diagnosis consult because of a sudden, progressive and painful hemorrhage in the left submandibular region within the last 48 hours.
A history of floor phlegmon indicates that quite a few patients have type 2 diabetes treated with glibenclamide (50 mg/day) and hypertension. For the past 12 months, both ailments have not been under the supervision of doctors.
What is prescribed for patients?
Initially, the patient should be diagnosed and treated by a dentist for symptoms of pericoronitis affecting tooth 3.8, with 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 for floor phlegmon, patients decide to consult with the Department of Maxillofacial Surgery.
At 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 inspiratory stridor and SatO2 93% also develop. Patients have severe facial asymmetry with painful induration.
Additional diseases
Despite the difficulties in performing intraoralexamination due to trismus, painful retromolar thumefaction can be identified in relation to the third molar 3, 8 extending to the ipsilateral floor of the mouth.
Panoramic X-ray study showed said third molar half-life at the remote position. A phlegmon on the floor of the mouth (Ludwig's angina) secondary to acute purulent pericorinitis of the tooth was diagnosed. In this case, an incision is made with phlegmon of the bottom of the mouth. But only if the patient's condition deteriorates rapidly.
Deterioration
Due to the severity of symptoms, patients are hospitalized and signed informed consent for registration and surgical treatment. Empiric intravenous antibiotic therapy (Clindamycin 600 mg every 8 hours and Ceftriaxone 2 g every 24 hours). After admission, a patient with putrefactive necrotic phlegmon of the floor of the mouth, as a rule, has indicators: leukocytosis (20,000 cells / mm3), C-reactive protein concentration 300 mg / l, blood glucose 325 mg / l and glycosylated hemoglobin (HbA1c) 17, 6%. In this case, insulin treatment is prescribed.
He alth of the patient
Within a few hours, the clinical condition worsens due to a large swelling developing in the oral cavity and difficulty in breathing. An examination conducted using direct laryngoscopy and an emergency tracheotomy performed due to the impossibility of intubation and ventilation can stabilize the patient's condition.
After these measures, the patientplaced under protective mechanical ventilation and transferred to the Intensive Care Unit (ICU) for continued medical management and stabilization. It is necessary to do a CT scan of the head and neck, and also to make sure that the patient has not developed acute renal failure with a plasma creatinine concentration of 5.7 mg / dL.
After stabilization of the condition, the causal tooth should be extracted and fused, followed by an extended cervicotomy. Cultures may be positive for Acinetobacter baumannii (AB) and methicillin-resistant Staphylococcus aureus (MRSA), so the doctor may prescribe treatment with Tigecycline (50mg 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.
Inflammation scores improve as the fever subsides. Spontaneous ventilation is quickly restored without the need for supplemental 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 scheduled for outpatient examinations after 7, 14 and 30 days.
The most common cause of death in OI patients is airway obstruction. Therefore, the physician should evaluate this aspectduring the initial evaluation of the patient. It is very important to identify certain signs and symptoms when anatomical spaces are compromised.
Reduce Hole
A buccal opening that has decreased by 20 mm or more in a short period of time with severe pain is considered to indicate an infection in the anatomical spaces of the perimandible until proven otherwise (2, 8, 10). However, regardless of triis, the attending physician should assess for dysphagia and visualize the oropharynx for possible infection.
In case of partial airway obstruction, abnormal sounds such as hardness and wheezing will be heard due to turbulent passage of air through the airways. In these cases, the patient usually tilts the head forward or moves the neck to the opposite shoulder to straighten the airway and thus improve ventilation.
Oxygen saturation below 94% in a previously he althy patient is a sign of inadequate tissue oxygenation. Combined with clinical signs of partial or complete obstruction, surgery and urgent endotracheal intubation should be performed to secure the airway via tracheotomy or cryocytotomy.
It is important to note that in studies conducted at the initial level, the number of leukocytes is an important indicator for urgent hospitalizationsick with this disease. Leukocytosis above 12,000 cells/mm3 causes systemic inflammatory response syndrome (SIRS), which is an important factor in determining hospitalization due to OI (13).
If, for example, a patient's leukocytes are designed to receive 20,000 cells/mm3 with fever (38.5°C), then this will increase metabolic and cardiovascular demand beyond the reserve capacity, where fluid loss is significant will increase and cause severe dehydration.
