the management of odontogenic infection in a pregnant ... · tooth mobility is a sign of...

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Taiwan J Oral Maxillofac Surg 台灣口外誌

Introduction

Odontogenic infection is a prevalent dental

disease worldwide. About 90%–95% of all orofacial

infections originate from the teeth or their

supporting structures. The mandibular 3rd molar

was found to be the most commonly offending

tooth, followed by the mandibular 2nd molar.

The Management of Odontogenic Infection in a Pregnant Patient—A Case Report

Wang-Ting Huang*, Yu-Wei Chiu*, †, Pei-Yin Chen*, Ming-Yi Lu*, †,

Chih-Yu Peng*, †, Yi-Tzu Chen*, †

* Department of Oral and Maxillofacial Surgery, Chung Shan Medical University Hospital,

Taichung, Taiwan, R.O.C. † School of Dentistry, College of Oral Medicine, Chung Shan Medical University,

Taichung, Taiwan, R.O.C.

Abstract

In general, the dental management of pregnant patients requires special considerations as pregnancy is a dynamic state thatleads to several physiological changes. Surgical procedures for conditions unrelated to pregnancy, such as severe odontogenic infection, are occasionally necessary. In this article, we present a case of odontogenic infection of a pregnancy woman. A 30-year-old female who was in hersecond trimester (28 weeks) complained facial swelling over the lower right area lasting 3 days. The body temperature was 36.9 degrees Celsius, andmouth opening was only 10 mm. The clinical examination revealed 48 partial eruptionwith gingival swelling and 46 residual roots. We arranged admission immediately and administered empirical antibiotic therapy. Given the progression of swelling, magnetic resonance imagingwas conducted, and the department of anesthesiology and obstetrics was consulted. Under general anesthesia, we performed an incision, drainage, and removed teeth 46 and 48. The patient withstood the entire procedure well. Appropriate image examination, risks of medications to both mother and fetus, scheduling of dental surgical procedures, and process of general anesthesia during pregnancy need to be considered to maximize benefits to the mother and minimize risks to the developing fetus.

Key words: Odontogenic infection, Pregnancy, General anesthesia.

Taiwan J Oral Maxillofac Surg29: 182-193, September 2018 台灣口外誌

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台灣口外誌 The Management of Odontogenic Infection in a Pregnant Patient

The submandibular space is the most frequently

involved fascial space both in single and multiple

fascial space infections1. Patients usually present

with trismus, facial swelling, and dysphagia. Most

patients are treated with incision and drainage

under local or general anesthesia depending

upon the fitness of the patient, extraction of

the offending tooth, and intravenous antibiotic

coverage.

Infections are common in pregnancy due

to hormonal changes and altered immunological

activity; aggravating response to plaque

accumulation and caries can result in a serious

life-threatening condition2. Treatment of pregnant

patients involves dealing with the lives of two

individuals (the mother and unborn fetus).Certain

principles have been developed and must be

considered by an oral and maxillofacial surgeon

while handling such patients. We presented a case

of a pregnant woman with severe odontogenic

infection, and related articles were discussed.

Case Presentation

A 30-year-old female compla ined of

facial swelling over the lower right area lasting

3 days (Fig. 1). According to the patient’s

statement, she had right cheek swelling off and

on several times. This time, she had visited a

local dental clinic and took medication, but the

signsandsymptoms failed to improve. She was

referred to our hospital for further treatment

because of her 28-week pregnancy.

The body temperature was 36.9 degrees

Celsius. Blood pressure was 126/68 mmHg.

No tachycardia, shortness of breath, and

dysphagia were found. Oxygen saturation was

100% under room air. The swollen area involved

the submandibular and buccal spaces with

tenderness and local heat. Mouth opening was

only 10 mm. The clinical examination revealed

48 partialeruption with gingival swelling and 46

residual roots. No obvious vestibular swelling was

noted over this area. The lab data revealed WBC

count 11,800/µl and CRP reached 6.382 mg/dl.

Under the impression of cellulitis over the right

buccal and submandibular spaces with 48 origins,

the patientadmitted immediately and empirical

antibiotic therapy with Augmentin 1.2 g/vial

Q12H IVD was administrated.

However, the pat ient fe lt pain upon

swallowing and swelling was progressinglarger

over her right cheek the following morning. Given

the suspicious disease progression and upper

airway compression, we explained the current

condition and suggested magnetic resonance

imaging (MRI) without contrast. The T2-weighted

imagesshowed the diffused soft tissue swelling of

the right masticatory space, right submandibular

space, right cheek, and bilateral submental

region; abscess formation was strongly suspected

(Fig. 2). We also consulted the department

of anesthesiology and obstetrics for surgery

evaluation. Maternal and fetal general anesthesia

risks were explained to the patient and family by

the anesthesiologist. The obstetrician suggested

daily fetal monitoring and prescribed tocolytics

if preterm uterine contraction or preterm labor

occurred. We also informed the patient that

emergency cesarean section may be required if

fetal distress is noted.

Incision and drainage wereconductedin the

next morning under general anesthesia. A 1.5 cm

incision line was made over the R’t submandibular

area below the mandible inferior border about

one finger width. Drainage was performed with

blunt dissection into the R’t submandibular and

sublingual spaces. A considerable amount of pus

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was drained (Fig. 3). After copious normal saline

irrigation, we placed one Penrose and removed

teeth 48 and 46. The fetal heart rate (FHR) was

checked after the surgery and showed regular

heart beats (Fig. 4).

The pus culture contained Streptococcus cons t e l l a tu s , Geme l lamorb i l l o rum , and

Peptostreptococcus micros, which were sensitive

to Augmentin. After the operation, the patient

recovered well gradually. The lab data onthe

postoperative 4th day revealed WBC count

of 7,340/µl, and CRP declined to 0.784 mg/

dl. Other values were normal as well. Maximal

mouth opening improved to 35 mm, and no more

swelling was noted over the right cheek on the

5th day (Fig. 5). After Penrose removal on the

postoperative 6th day, the patientdischarged.

The child was born 3 months later without any

complications.

Discussion

Although the incidence of odontogenic

infections has improved in recent years as a

result of the amelioration in oral health care,

such infectionsare still the most common reason

for consultation and intervention by dentists.

The most frequent odontogenic infections are

those resulting from dental caries, dentoalveolar

infections (infection of the pulp and periapical

abscess), gingivitis, periodontitis (including peri-

implantitis), aponeurotic space infections, osteitis,

and osteomyelitis3-6. In general, treatment of

odontogenic infections is based on two main

elements: surgical treatment and antibiotic

therapy. Surgical innervation is indicated when

swelling in the neck occurs with the risk of

airway obstruction7. However, pregnancy and its

physiological changes make management of such

patients challenging. The clinician must consider

the treatment effects on the fetal and maternal

health while following well-established clinical

guidelines5.

Physiologic Changes during Pregnancy

Pregnancy is a state of physiological

condition that brings about various changes

throughout the female body. Cardiac output

increases by 20% at 8 weeks and continues to

rise until 30-32 weeks of gestation, at which time

it plateaus at approximately 50% above baseline

by decreasing afterload from declining vascular

resistance and increasing maternal heart rate to

about 15-20 beats/min6. Both systemic resistance

and blood pressure decrease in early pregnancy.

Blood pressure is normalized by the end of the

second trimester. In late pregnancy,the fetus may

compress the inferior vena cava; the symptoms

of supine hypotension syndrome may occur,

with bradycardia, hypotension, and syncope on

standing8-10.

The resp i ratory changes that occur

during pregnancy accommodate the increasing

requirement of maternal-fetal oxygen. The

enlarged fetus pushes the diaphragm up by

3-4 cm, causing an increase in intrathoracic

pressure. This phenomenon leads to an increase

in chest circumference that results in flaring of

the ribs. The anterior⁄posterior diameter of the

chest increases due to the superior shift of the

diaphragm. These changes increase tidal volume,

respiratory ventilation, and minute ventilation.

However, the diaphragmatic displacement leads

to a 15%-20% reduction in functional residual

capacity as the fetus grows. Hyperventilation

begins in the first trimester and may increase

up to 42% in late pregnancy8-10. Nasal breathing

becomes more difficult, and pregnant women tend

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Fig. 1. Right cheek was swollen, which involved the submandibular and buccal space, with tenderness

and local heat. Mouth opening was limited. Pain was also noted when swallowing.

Fig. 2. MRI without contrast. The T2-weighted images showed the diffused soft tissue swelling of the

right masticator space, right submandibular space, right cheek, and bilateral submental region.

Abscess formation was strongly suspected (arrow).

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Fig. 3. Pus discharged after blunt dissection to the right submandibular space. Pus culture was

conducted immediately and showed Streptococcus constellatus, Gemellamorbillorum, and

Peptostreptococcus micros infection.

Fig. 4. Fetal heart beat checked after the operation was in the normal range of 120–150 beats/min.

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to breathe with their mouths open, especially at

night. Ventilation patterns and patient position

must be adjusted for the pregnant patient to

avoid hypoxemia. Gastroesophageal reflux occurs

in 30%-50% of pregnancies due to increased

pressure by the fetus on the stomach with

relaxation of the lower esophageal sphincter tone

and decreased gastric motility5, 6. Vomiting and

constipation are elevated.

The plasma volume increases by 50% at

32 weeks of gestation; total red blood cell

mass increases only by 20%-30%, resulting in

hemodilution. The relatively greater increase

in plasma volume leads to physiologic anemia.

The changes also include increased number

of erythrocytes and leukocytes, erythrocyte

sedimentation rate, and most clotting factors,

causing a hypercoagulable state. The per-day

risk of deep vein thrombosis is highest in the first

4–6 weeks postpartum11.

Oral Changes during Pregnancy

Oral changes include gingivitis, gingival

hyperplasia, pyogenic granuloma, and salivary

changes. Pregnancy does not induce periodontal

disease but worsens an existing condition.

Gingivitis and periodontitis are some of the

changes commonly witnessed among 30% of

pregnant women due to the role of high levels

of circulating estrogen3, 4. The elevated levels

of inflammatory markers (i.e., interleukin 6,

interleukin 8, and PGE2) may increase the

risk of premature labor and low birth weight.

Tooth mobility is a sign of periodontal disease

caused by mineral changes in the lamina dura

and disturbances in the periodontal ligament

attachments.

Pregnancy epulis (or pregnancy granuloma or

pregnancy tumor) is also a common event during

pregnancy12-14. It usually presents at interdental

Fig. 5. Maximal mouth opening improved to 35 mm at the 5th day.

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buccal gingiva of anterior teeth and arises during

second trimester with rapid growth. It is seldom

larger than 2 cm with bleeding tendency but

always regresses soon after delivery. Surgical or

laser excision is performed if needed as dictated

by observable symptoms.

Recurrent vomiting is acommon event in

pregnancy that enhances the acidic environment,

leading to progress of carious pathogens and

increased demineralization. Thus, teeth become

prone to caries. The resolutions are limitation

of a sugary diet, regular brushing, and use of

fluoride-releasing restorative materials.

Dental Treatment

Summarized physiologic and other changes

associated with pregnancy, coronal scaling,

polishing, and root planning may be performed

at any time as required to maintain oral health.

Regular routine dental visits should be planned

for pregnant patients during early stages of

pregnancy to identify the problem as early as

possible and prevent serious complications. The

most, appropriate time for dental treatment is

the second trimester, which is considered the

safe period3, 4. Emergency treatment for pulpal,

periodontal, pericoronal, or early infection

should not be avoided. Given the increased

abdominopelvic mass in pregnancy, the inferior

vena cava is compressed when the patient is

placed in supine position, resulting in supine

hypotension syndrome. To prevent or alleviate

supine hypotension, the pregnant patient should

be rolled to the left side by 5-15 degrees (a

position in which the right hip is elevated 10-12

cm), which can be accomplished by inserting a

wedge or pillow under the right hip5, 11. However,

extensive and prolonged dental procedures

should be postponed until after delivery. Any

treatment should be directed toward controlling

disease, maintaining a healthy oral environment,

and preventing potential problems that may occur

later in the pregnancy or during the postpartum

period.

Image Examination

Imaging studies are important adjuncts in

the diagnostic evaluation of acute and chronic

conditions. However, no consensus has been

reached about the safety of these modalities for

pregnant women, thereby resulting in unnecessary

avoidance of useful diagnostic tests. According

to the recommendation of The American College

of Obstetricians and Gynecologists’ Committee,

ultrasonography and MRI are not associated

with any risk for the pregnant patient, but it

should only be used to answer a relevant clinical

question or provide medical benefit to the patient.

Ultrasonography involves the use of sound waves

and is not a form of ionizing radiation. No reports

have been made for documented adverse fetal

effects of diagnostic ultrasonography procedures,

including duplex Doppler imaging15.

The principal advantage of MRI over

ultrasonography and computed tomography is

its ability to image deep soft tissue structures

in a manner that is not operator dependent

and does not use ionizing radiation. MRI also

adequately images most soft tissue structures

without the use of contrast to define the tissue

structure and tissue edema. However, the use of

gadolinium contrast with MRI should be limited;

it may be used as a contrast agent in a pregnant

woman only if it significantly improves diagnostic

performance and is expected to improve fetal

or maternal outcome. In our case, the MRI

image greatly helped to check whether airway

compression is noted or not and detect pus

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accumulation and tissue edema.

With few exceptions, radiation exposure

through radiography and computed tomography

(CT) is at a dose much lower than exposure

associated with fetal harm15, 16. If these techniques

are necessary in addition to ultrasonography

or MRI or are more readily available for the

diagnosis in question, they should not be withheld

from a pregnant patient. A radiation physicist

should be consulted to calculate the total dose

received by the fetus.

CT is a specific use of ionizing radiation

that plays an important diagnostic role. Radiation

exposure from CT procedures varies depending

on the number and spacing of adjacent image

sections. The doses of head or neck CT may be

at the range of 0.001-0.01 mGy of radiation.

A single CT scan has less than the normal safe

level of irradiation but is still greater than dental

radiographs. Thus, CT scanning is best avoided

in pregnant patients and only used if strongly

clinically indicated15, 16.

Most dentists do not recommend routine

radiographs during pregnancy. However, minimal

radiographs may be necessary in such cases16,

17. Adequate radiation protection measures such

as high-speed films, lead aprons, and thyroid

collars should be provided for the patient. Doses

<5-10 rads (cGy) are not teratogenic. A full-

mouth series of dental radiographs results in only

8 × 10-4 cGy; this amount is much less than the

daily dose acquired from cosmic radiation17, 18.

Nevertheless, the dentist should always practice

the aslowasreasonably achievable principle, and

only radiographs necessary for diagnosis should

be obtained.

Surgery under General Anesthesia

Urgent ly needed surgery shou ld be

performed regardless of the trimester, whereas

completely elective surgery should be postponed

until after delivery. Non-urgent surgery that

cannot wait until delivery is generally performed

during the second trimester. However, severe

odontogenic infection can be di f f icult to

manage, and the risk of death from either airway

obstruction or overwhelming systemic infection

remains. Therefore, surgery for the management

of odontogenic infection should not be postponed.

Given the physiologic changes of women during

pregnancy, anesthetic and surgical management

of such patientsshould differ from those of non-

pregnant patients.

From the anestheticperspective, the altered

cardiovascular state of mother and fetus needs to

be monitored. Furthermore, the anesthesiologist

must consider the effects of the disease process

itself, inhibit uterine contractions, and avoid

preterm labor and delivery. Postural hypotension

can be prevented by the left lateral position to

minimize compression of the inferior vena cava

by the placenta. The altered respiratory pattern

may increase the risk of both the mother and

fetus to hypoxia, particularly in the induction

stage of the anesthetic19, 20. Pre-oxygenation

with 100% oxygen for 5 min and rapid-sequence

intravenous induction and intubation would

reduce the opportunity of hypoxia. In case of

failed intubation, then a laryngeal mask airway

is used to ventilate successfully and safely.

The upper airway mucosa, particularly of the

nose, is highly friable, and increased bleeding

may occur during intubation and require careful

management. The increased risk of gastric reflux

needs to be extensively evaluated to minimize the

postoperative risk of aspiration pneumonia.

Anesthetic agents have no known teratogenic

effects, and multiple large retrospective studies

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have not shown an increase in congenital defects

in infants born to mothers who underwent surgery

and anesthesia during pregnancy21. However, the

lowest effective concentrations should be used for

the shortest time period, especially because these

drugs cause significant maternal hypotension.

Benzodiazepine use is usually avoided during the

first trimester. However, it may be appropriate to

address pre-operative anxiety and avoid increases

in circulating catecholamine levels, which impair

uteroplacental perfusion. Most other anesthetic

medications, including barbiturates, propofol,

opioids, muscle relaxants, and local anesthetics,

have been widely used during pregnancy with a

good safety record8, 9.

FHR Monitoring

The FHR should be documented pre- and

postoperatively, regardless of gestational age. It

may help detect an early compromise, allowing

optimization of maternal hemodynamics and

oxygenation intra- and postoperatively9, 22. We

checked the pre- and postoperative FHR and

also followed the data daily, which showed no

obvious abnormal heart rate. The American

College of Obstetricians and Gynecologists

stated that the decision to use intermittent or

continuous intraoperative fetal monitoring should

be individualized and based on factors such as

gestational age, type of surgery, and available

resources15. However, even though we performed

continuous monitoring when possible, continuous

FHR monitoring has not been shown conclusively

to improve fetal outcome in women under general

anesthesia.

Medication

For most dentists, another concern is the

prescription and administration of drugs. During

pregnancy, a high volume of drug distribution,

decline in maximum plasma concentration, short

plasma half-life, rise in lipid solubility, and

elevated rate of clearance may cause easy access

of boundless drugs through the placenta and

cause teratogenic effects to the fetus. The United

States of America Food and Drug Administration

has categorized teratogenic drugs, which

cause birth defects, and provided the definitive

guidelines for prescribing drugs during pregnancy.

Class A is defined as safe, class B is defined as

probably safe, class C is classified as avoid unless

treatment profit, class D is suggested as avoid,

and class X is teratogenicity. Based on this

classification, Augmentin and acetaminophen are

in category of B. Nonsteroid anti-inflammatory

drugs (NSAIDs) should be avoided, especially

after 32 weeks of gestation, because they may

cause premature closure of the fetal ductus

arteriosus4-6, 11. NSAIDs can also inhibit uterine

contraction. Antibiotics that are acceptable

include penicillin, amoxicillin, metronidazole,

and clindamycin. Tetracycline should be avoided

because it tends to cause permanent discoloration

of primary and temporary dentition of the unborn

child.

Conclusion

Infections are common in pregnancy due

to hormonal changes and altered immunological

activity. Aggravating response to plaque

accumulation and caries can result in a serious

life-threatening condition, like Ludwig’s angina.

Every mother should be closely examined by a

dentist before and during pregnancy to prevent

dental problems leading to grave outcomes for

maternity and the fetus. Providing adequate

treatment including oral hygiene instructions is

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necessary. Prophylactic removal of the wisdom

teeth to avoid pericoronitis leading to severe

odontogenic fascial space infections should

be considered. Moreover, pregnant patients

reporting with dyspnea, dysphagia, limited mouth

opening (i.e., less than 20 mm), swelling extending

beyond alveolar process, and fever(above 38.3

degrees) should be referred at the earliest time

to an oral and maxillofacial surgeon to avoid life-

threatening complications in these patients. The

clinician must consider the effects of treatment

on the fetal and maternal health while following

well-established clinical guidelines in managing

odontogenic infection.

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Received: July 04, 2018Accepted: August 23, 2018Reprint requests to: Dr. Yi-Tzu Chen, Department of Oral and Maxillofacial Surgery, Chung Shan

Medical University Hospital, No. 110, Sec. 1, Jianguo South Dist., Taichung City 402, Taiwan, R.O.C.

齒源性感染在孕婦的治療與處理—病例報告

黃莞婷*,†　邱昱瑋*,†　陳珮吟*　呂明怡*,†　彭芷瑜*,†　陳怡孜*,†

*中山醫學大學附設醫院口腔顎面外科

†中山醫學大學口腔醫學院牙醫學系

摘　　要

針對懷孕婦女的牙科治療需要格外謹慎，因為懷孕過程不同時期會產生不

同生理變化，這時期仍可能需要進行非產科相關的手術。報告為三十歲女性

在懷孕二十八周時，因為右頰腫脹持續三天而就診，當時體溫為攝氏三十六

點九度，張口度僅十釐米合併吞嚥疼痛。臨床檢查發現口內右下第三大臼齒

為水平阻生齒且右下第一大臼齒為殘根。考慮疾病嚴重，安排病人住院給予

抗生素治療。由於右頰持續腫脹，安排核磁共振造影做進一步評估，並會診

婦產科及麻醉科做手術風險評估及說明，在病患與家屬同意下進行全身麻

醉，移除右下第一及第三大臼齒並進行口外切開引流。術後恢復良好，胎兒

亦沒有任何併發症產生。針對懷孕婦女進行牙科治療或非產科手術時，恰當

影像評估、母體及胎兒用藥安全、適時安排牙科治療及安全的全身麻醉過程

都必須要列入治療考量，才能提供母體跟胎兒最大的幫助，將傷害發生可能

性降到最低。

關鍵詞：齒源性感染，懷孕，全身麻醉。

the management of odontogenic infection in a pregnant ... · tooth mobility is a sign of...

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