Management Of Severe Odontogenic Infections

In Pregnancy

D Wong,* A Cheng,R Kunchur, S Lam, PJ Sambrook, AN Goss

*Private Practice, Morphett Vale, South Australia.

Oral and Maxillofacial Surgery Unit, Royal Adelaide Hospital, South Australia.

Flinders Medical Centre, Bedford Park, South Australia.

Oral and Maxillofacial Surgery Unit, The University of Adelaide and Royal
Adelaide Hospital, South Australia.

ABSTRACT

Background: The objective of this study was to review the management of

patients presenting with severe odontogenic infections and who are also pregnant.

Methods: A retrospective clinical audit was conducted of all female

patients admitted to the Royal Adelaide Hospital by the Oral and Maxillofacial
Surgery Unit from 1999 to 2009 with severe odontogenic infections. Pregnant
patients were identified and their age, medical history, previous obstetric and
gynaecological history, stage of current pregnancy, presenting infection, diagnosis
and management were recorded, as well as the outcome of the pregnancy.

Results: A total of 346 female patients were admitted to the Royal

Adelaide Hospital under the care of the Oral and Maxillofacial Surgery Unit with
an admission diagnosis of severe odontogenic infection and five were pregnant.
Besides surgical and anaesthetic assessment, mother and foetus were assessed by
the Obstetric and Gynaecology Unit. In all, five with severe infection were
successfully resolved and four proceeded to a normal delivery with a healthy
child. The remaining patient had an already planned therapeutic abortion.

Conclusions: Pregnant patients with severe odontogenic infections require

urgent referral to a tertiary hospital with full surgical, anaesthetic and obstetric
services. This allows appropriate management of the complex requirements of
mother and foetus.
 Keywords: Pregnancy, odontogenic infection, anaesthesia, obstetrics,
surgical management.

Abbreviations and acronyms: A = anaesthetic; DVT = deep venous

thrombosis; O&G = obstetric and gynaecological service; OMS = oral and
maxillofacial unit.

INTRODUCTION

Ideally routine dental treatment is best avoided in pregnancy, and

preferentially dental fitness should be instituted prior to pregnancy. Minor routine
dental treatment can be completed in the second trimester with the first and third
trimesters best being avoided. Emergency treatment for pulpal, periodontal,
pericoronal or early infection should not be avoided. Delay or avoidance by either
the patient or clinician may result in severe spreading odontogenic infection. It is
essential that dentists have an understanding of pregnancy and how pregnant
females are physiologically and psychologically different to non-pregnant
females.

It is estimated that up to 50% of all fertilized eggs are spontaneously

aborted before the woman knows she is pregnant, and of those women who know
they are pregnant, it is estimated that 1520% have a spontaneous abortion.1 In
2002, there were 250 988 registered births in Australia2 and 52 000 therapeutic
abortions.3 Pregnancy results in profound physiologic changes in otherwise
medically fit females. Cardiovascular changes include an increase in blood
volume and cardiac output, and a decrease in blood pressure. Blood volume can
increase by up to 50% by the 32 week of gestation, mainly due to an increase in
plasma volume. 4,5 Cardiac output increases mainly due to an increased stroke
volume or later in pregnancy, due to an increased heart rate.4,5 Early in
pregnancy there is a decrease in systemic resistance and blood pressure. Blood
pressure returns to normal by the end of the second trimester. In late pregnancy
the foetus may compress the inferior vena cava and consequently signs and
symptoms of supine hypotension syndrome, with bradycardia, hypotension and
syncope on standing may occur.6 There are corresponding respiratory alterations
including an increase in the anterior posterior diameter of the chest due to the
superior shift of the diaphragm. There is an increase in the respiratory drive with
an increase in tidal volume, respiratory and minute ventilation. This leads to a
mild respiratory alkalosis and dyspnoea is quite common. Simultaneously there is
an increase in oxygen consumption and a decrease in oxygen reserves. With the
alimentary system there is a predisposition towards gastric reflux and heartburn.
This is due to increased pressure by the foetus on the stomach with relaxation of
the lower oesophageal sphincter tone and decreased gastric motility. Vomiting
and constipation are increased.7 Hepatic function changes with the decrease in
total protein and albumen levels with an increase in serum alkaline phosphatase,
bilirubin, cholesterol, triglyceride and aminotransferase. The decreased albumin
levels may lead to peripheral oedema.4 There is an increased risk of urinary tract
infections and alteration in kidney output. Haematologically, there is an increase
in erythrocyte and leukocyte counts. However, the relatively greater increase in
plasma volume leads to a physiologic anaemia.7 Pregnancy also leads to
hypocoagulable states due to an increase in the various coagulant factors and a
drop in anticoagulant factors.8 Gestational diabetes is common. All of these
physiologic changes need to be understood for pregnant patients requiring
unavoidable medications, anaesthesia or surgery (Table 1).

There are marked oral changes with 70% of pregnant females having
pregnancy gingivitis and an increase in periodontal disease including gingival
bleeding, hyperplasia and pregnancy epulis.9 There is a threefold increase in
periodontal disease if there is concurrent gestational diabetes.9 However, avoiding
dental treatment, either in the lead up to pregnancy or during pregnancy, may
sometimes result in spreading odontogenic infections. Management of spreading
odontogenic infections is at best complicated, particularly when swelling in the
neck occurs with the risk of airway obstruction. The detailed issues relating to
management of severe odontogenic infections in non-pregnant patients have been
previously published.10

In this paper we review the management of severe odontogenic infections

in pregnancy, illustrate it with a consecutive cohort of cases and make
recommendations on how to minimize the risk for the mother and foetus.

METHODS

A retrospective audit was conducted for all female patients admitted to the
Royal Adelaide Hospital by the Oral and Maxillofacial Unit (OMS) from 1999 to
2009 with spreading odontogenic infection to determine those concurrently
pregnant. For this group their age, medical history, previous obstetric and
gynaecological history, stage of current pregnancy, presenting infection, diagnosis
and management were recorded.

The management of these patients with severe odontogenic infections

followed the standard unit guidelines by the OMS and Anaesthetic (A) Units.10
The Obstetric and Gynaecological Service (O & G) Reviewed the state of the
pregnancy and determined foetal health with foetal monitoring and ultrasound
being performed as required.
 Management of the infection followed the standard OMS and A protocols,
namely, removal of the cause which is the tooth, incision and drainage of the
abscess, supportive treatment to both the mother and foetus and high dose
intravenous antibiotics.10

The patients were contacted by phone in 2011 by their admitting

consultant to determine if there were any subsequent complications to the
pregnancy and the health of the child.

RESULTS

Three hundred and forty-six female patients were admitted to the Royal
Adelaide Hospital under the care of the OMS Unit with an admission diagnosis of
severe odontogenic infection. Of these, five were pregnant. The details of these
patients are presented in Table 2.

DISCUSSION

This paper shows that the pregnant patients with severe odontogenic
infections were successfully managed and four of the pregnancies proceeded to
successful delivery of a live baby without congenital defects and in one case the
patient had already booked for termination of pregnancy.

Anaesthetic and surgical management requires modification to that of non-

pregnant patients.10 The principles of surgical and anaesthetic management need
to be well understood by the initial dentist managing the case, otherwise there is a
risk that the patient will be undermanaged. This occurred with two patients in our
series who preferentially should have been referred earlier. From the anaesthetic
point of view, the altered cardiovascular state of mother and foetus needs to be
monitored. Postural hypotension is a risk and the patient is best nursed in the left
lateral position to minimize compression of the inferior vena cava by the placenta.
The altered respiratory drive predisposes both the mother and the foetus to
hypoxia, particularly in the induction stage of the anaesthetic. The upper airway
mucosa, particularly of the nose, is more friable and thus increased bleeding may
occur during intubation. The increased risk of gastric reflux needs to be carefully
evaluated to minimize the risk of aspiration and aspiration pneumonia
postoperatively.4,5
 Pharmacologically, altered hepatic and renal excretion capabilities need to
be carefully considered. In the first trimester of pregnancy older drugs with a
known low teratogenic rate need to be used. Non-steroidal anti-inflammatory
drugs are best avoided in general but particularly so in the third trimester due to
the effect on the foetus ductus arteriosus. Narcotic analgesics similarly are best
avoided as they cross the placental barrier and may result in neonatal respiratory
depression. Hence, the analgesic drugs of choice in pregnancy are paracetamol
and short courses of morphine. Similarly, antibiotic use needs to be carefully
considered although in a spreading odontogenic infection this is an important
adjunct to surgical management. Metronidazole may be teratogenic in the first
trimester although recent studies have shown no definitive teratogenic effect.
Gentamicin should be avoided as it is associated with potential toxicity in the
developing foetus. Tetracyclines are best avoided as they are ineffective for
odontogenic infections and they may stain the developing teeth.

Farmakologi, diubah hati dan kemampuan ekskresi ginjal perlu

dipertimbangkan dengan cermat. Pada trimester pertama kehamilan obat yang
lebih tua dengan tingkat teratogenik rendah dikenal perlu digunakan. Non-steroid
anti-inflammatory sebaiknya dihindari pada umumnya tapi terutama di trimester
ketiga karena efek pada janin ductus arteriosus. analgetik narkotik sama sebaiknya
dihindari saat mereka menyeberangi penghalang plasenta dan dapat menyebabkan
depresi pernafasan neonatal. Oleh karena itu, obat analgesik pilihan pada
kehamilan adalah parasetamol dan kursus singkat morfin. Demikian pula,
penggunaan antibiotik perlu dipertimbangkan dengan cermat meskipun dalam
infeksi odontogenik menyebarkan ini merupakan tambahan penting untuk
manajemen bedah. Metronidazol mungkin teratogenik pada trimester pertama
meskipun studi terbaru menunjukkan tidak ada efek teratogenik definitif.
Gentamisin harus dihindari karena dikaitkan dengan potensi toksisitas pada janin
berkembang. Tetrasiklin sebaiknya dihindari karena mereka tidak efektif untuk
infeksi odontogenik dan mereka dapat menodai gigi berkembang.

Most sedatives such as the benzodiazepines cross the placental barrier and
thus are best avoided. Local anaesthesia generally is safe although there is
uncertainty through lack of data on the use of bupivicaine and mepivicaine.
Although it is commonly stated that prilocaine and octopressin should be avoided
in pregnancy the tiny amounts involved have no effect on inducing labour.11

Kebanyakan obat penenang seperti benzodiazepin melintasi penghalang

plasenta dan dengan demikian dihindari terbaik. anestesi lokal umumnya aman
meskipun ada ketidakpastian karena kurangnya data tentang penggunaan
bupivicaine dan mepivicaine. Meskipun umumnya menyatakan bahwa prilocaine
dan octopressin harus dihindari pada kehamilan jumlah kecil yang terlibat tidak
berpengaruh pada menginduksi labour.11

sedasi intravena memiliki efek fisiologis kurang dari anestesi umum pada
pasien hamil dan janin yang sedang berkembang, dan dapat digunakan untuk
jangka pendek, prosedur sederhana seperti ekstraksi. Perawatan harus diambil
untuk melindungi saluran napas terhadap regurgitasi. Dengan infeksi menyebar
parah di leher, maka itu adalah wajib bahwa pasien diintubasi. Jika mereka
memiliki trismus, ini berarti intubasi serat optik. Meskipun secara teoritis ada
risiko teratogenesis dan aborsi spontan, penelitian besar yang telah
membandingkan hasil kehamilan di mana pasien memiliki anestesi umum
terhadap mana mereka tidak, tidak menunjukkan perubahan risk.12,13

Intravenous sedation has less physiological effect than general anaesthesia

on the pregnant patient and the developing foetus, and can be used for short,
simpler procedures such as extraction. Care needs to be taken to protect the
airway against regurgitation. With severe spreading infections in the neck, then it
is mandatory that the patient is intubated. If they have trismus, this means a fibre
optic intubation. Although theoretically there is a risk of teratogenesis and
spontaneous abortion, large studies which have compared the outcome of
pregnancy where the patient did have a general anaesthetic versus where they
didnt, shows no change in risk.12,13

Pembedahan, pasien perlu diperiksa dan bekerja dengan hati-hati. Tidak

ada kontraindikasi untuk penggunaan hemat radiologi. Telah terbukti bahwa dosis
kurang dari 5 sampai 10 centigrays (cGy) tidak memiliki hubungan dengan
peningkatan pengembangan cacat bawaan atau intra-uterine pertumbuhan
retardation.14 demikian umumnya untuk pasien dengan infeksi odontogenik
menyebar, sebuah OPG tunggal akan memberikan cukup informasi pada
exposure.14 radiasi diterima dengan canggih menyebarkan infeksi odontogenik ke
leher, umumnya ini yang terbaik ditunjukkan oleh CT scan. Sebuah single CT
scan memiliki kurang dari tingkat yang aman normal iradiasi (misalnya 5-10 cGy)
tapi lebih besar dari untuk OPG.15 demikian, CT scan sebaiknya dihindari pada
pasien hamil dan hanya digunakan jika sangat indikasi klinis, seperti untuk
mendefinisikan koleksi nanah pada pasien yang tidak menanggapi
management.13 bedah USG memiliki tempat dalam mendefinisikan moderat
untuk koleksi nanah besar di leher dan harus dipertimbangkan atas dan di atas CT
scan.

Surgically, the patient needs to be carefully examined and worked up.

There is no contraindication to the sparing use of radiology. It has been shown
that doses of less than 5 to 10 centigrays (cGy) have no association with increased
development of congenital defects or intra-uterine growth retardation.14 Thus
generally for a patient with a spreading odontogenic infection, a single OPG will
provide sufficient information at an acceptable radiation exposure.14 With
advanced spreading odontogenic infections into the neck, generally this is best
demonstrated by a CT scan. A single CT scan has less than the normal safe level
of irradiation (e.g. 510 cGy) but is greater than for an OPG.15 Thus, CT
scanning is best avoided in pregnant patients and only used if strongly clinically
indicated, such as to define a pus collection in patients not responding to surgical
management.13 Ultrasound has a place in defining moderate to large pus
collections in the neck and it should be considered over and above a CT scan.

Pembedahan, cara standar pengelolaan penyebaran infeksi odontogenik

perlu diikuti. Pada kehamilan lanjut, risiko hiperkoagulasi perlu dipertimbangkan
dan penggunaan stoking thrombolic untuk meminimalkan pembentukan
mendalam trombosis vena (DVT). Pasien juga harus dimobilisasi awal. Semua
pasien dalam penelitian ini memiliki manajemen yang mengikuti pedoman yang
direkomendasikan (Tabel 3). Namun, ada beberapa variasi penting. Tiga pasien
awalnya disampaikan kepada rumah sakit perifer tanpa staf OMS. Salah satunya
di negeri ini, beberapa jam berkendara dari Adelaide, dan dua berada di daerah
perkotaan luar. Ketiga awalnya medis stabil dan dipindahkan ke rumah sakit
tersier pusat di mana berbagai layanan yang tersedia.

Surgically, the standard means of management of spreading odontogenic

infections need to be followed. In advanced pregnancy, the risk of
hypercoagulation needs to be considered and the use of thrombolic stockings to
minimize deep venous thrombosis (DVT) formation. The patient should also be
mobilized early. All patients in this study had management which followed the
recommended guidelines (Table 3). However, there were some important
variations. Three patients had initially presented to peripheral hospitals without
OMS staff. One was in the country, some hours drive from Adelaide, and two
were in the outer urban areas. All three were initially medically stabilized and
transferred to the central tertiary hospital where the full range of services were
available.

O & G Layanan meninjau semua pasien sebelum terhitung pengobatan.

Secara khusus, mereka meninjau riwayat obstetri pasien sebelumnya dan dinilai
kesehatan janin dengan USG dan pemantauan janin. Semua pasien memiliki
penilaian ini diulang pascaprosedur. Dari lima pasien, dua dianggap berisiko
tinggi keguguran oleh O & G Service. Satu pasien telah memiliki lima keguguran
sebelumnya dan pada 33 minggu ini adalah yang terpanjang bahwa dia telah
mengadakan anak menuju jangka. Namun, ia memiliki infeksi berat dengan
trismus dan membuka rahang terbatas. Oleh karena itu, dia punya ekstraksi dan
drainase dilakukan dengan anestesi lokal dan sedasi IV. Dia dipertahankan di ICU
untuk observasi selama satu hari dan kemudian memiliki empat hari lebih lanjut
dalam bangsal. Dia melahirkan secara jangka normal dengan kelahiran hidup.
Pasien kedua adalah pada 35 minggu dan pengiriman sebelumnya telah melalui
operasi caesar. Dia adalah karena memiliki operasi caesar dekat dengan waktu
ketika ia mengembangkan infeksi berat dengan trismus. Dia memiliki pencabutan
gigi tiga sampai empat hari sebelumnya, sebelum masuk. Dianjurkan bahwa ia
memiliki anestesi lebih lanjut untuk insisi dan drainase, tapi setelah diskusi
informed consent dengan dokter kandungannya, anestesi dan dokter bedah, dia
menolak. Dengan demikian, dia dipertahankan pada antibiotik tingkat tinggi dan
melanjutkan untuk operasi caesar lebih lanjut dengan kelahiran hidup normal.
Infeksi diselesaikan dengan drainase spontan melalui soket ekstraksi sebelumnya.

The O & G Service reviewed all of the patients prior to treatment

commencing. In particular, they reviewed the patients previous obstetric history
and assessed foetal health by ultrasound and foetal monitoring. All the patients
had this assessment repeated postprocedure. Of the five patients, two were
considered high risk of miscarriage by the O & G Service. One patient had had
five previous miscarriages and at 33 weeks this was the longest that she had held a
child toward term. However, she did have a severe infection with trismus and
limited jaw opening. Hence, she had the extraction and drainage performed under
local anaesthesia and IV sedation. She was maintained in ICU for observation for
one day and then had a further four days in the ward. She had a normal term
delivery with a live birth. The second patient was at 35 weeks and her previous
deliveries had been by caesarean section. She was due to have a caesarean section
close to the time when she developed the severe infection with trismus. She had a
tooth extraction three to four days previously, prior to admission. It was
recommended that she have a further anaesthetic for incision and drainage, but
following informed consent discussions with her obstetrician, anaesthetist and
surgeons, she declined. Accordingly, she was maintained on high level antibiotics
and proceeded to a further caesarean section with a normal live birth. The
infection resolved with spontaneous drainage via the previous extraction socket.

Tiga pasien yang tersisa stabil dari sudut pandang kebidanan. Satu sudah
memutuskan untuk memiliki terminasi. Itu mungkin untuk mengelola infeksi nya
dengan anestesi lokal dan dia diamati di rumah sakit selama satu hari. Setelah
infeksi telah dikendalikan ia melanjutkan dengan aborsi yang direncanakan.
Dengan pasien keempat dia mengalami infeksi parah dan alergi terhadap penisilin.
Dengan demikian, dia diberi klindamisin dan metronidazol. Dia membutuhkan
intubasi serat optik untuk insisi dan drainase. Dia dipertahankan dalam perawatan
intensif selama tiga hari dan kemudian enam hari, sampai infeksi telah teratasi.
Dia melahirkan secara normal dan kelahiran hidup. Pasien final pembedahan
diperlakukan uneventfully.

The remaining three patients were stable from the obstetric point of view.
One had already decided to have a termination. It was possible to manage her
infection with local anaesthesia and she was observed in hospital for one day.
After the infection was controlled she proceeded with the planned abortion. With
the fourth patient she had a severe infection and was allergic to penicillin.
Accordingly, she was given clindamycin and metronidazole. She required a fibre
optic intubation for incision and drainage. She was maintained in intensive care
for three days and then six days, until the infection had resolved. She had a
normal delivery and a live birth. The final patient was surgically treated
uneventfully.

CONCLUSIONS

Parah infeksi odontogenik menyebarkan bisa sulit untuk mengelola dan

ada risiko kecil tapi nyata kematian baik dari obstruksi jalan napas atau infeksi
sistemik yang hebat. Kehamilan dan perubahan fisiologis yang membuat
manajemen dari pasien tersebut menantang. Dokter mengobati harus
mempertimbangkan anestesi dan efek bedah pada kesehatan janin dan ibu saat
mengikuti pedoman klinis mapan dalam mengelola infeksi odontogenik.
penelitian retrospektif ini menunjukkan bahwa hasil klinis yang sukses dapat
dicapai dengan rujukan darurat ke pusat tersier dengan penuh bedah, anestesi dan
layanan kebidanan yang tersedia.

Severe spreading odontogenic infection can be difficult to manage and

there is a small but real risk of death from either airway obstruction or
overwhelming systemic infection. Pregnancy and its physiological changes make
management of such patients challenging. The treating clinician must consider the
anaesthetic and surgical effects on the foetal and maternal health while following
well established clinical guidelines in managing odontogenic infection. This
retrospective study demonstrated that successful clinical outcomes can be
achieved by emergency referral to a tertiary centre with full surgical, anaesthetic
and obstetric services available.