Case series | Volume 36, Article 258, 10 Aug 2020 | 10.11604/pamj.2020.36.258.24864

Odontogenic cervico-facial cellulitis during pregnancy: about 3 cases

Zakaria Aziz, Salma Aboulouidad, Mohammed El Bouihi, Saad Fawzi, Mohammed Lakouichmi, Nadia Mansouri Hattab

Corresponding author: Zakaria Aziz, Maxillo Facial Surgery Department University Hospital Center Mohammed VI, Marrakech, Morocco

Received: 07 Jul 2020 - Accepted: 26 Jul 2020 - Published: 10 Aug 2020

Domain: Maxillofacial surgery

Keywords: Facial cellulitis, odontogenic, pregnancy, extraction

©Zakaria Aziz et al. Pan African Medical Journal (ISSN: 1937-8688). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cite this article: Zakaria Aziz et al. Odontogenic cervico-facial cellulitis during pregnancy: about 3 cases. Pan African Medical Journal. 2020;36:258. [doi: 10.11604/pamj.2020.36.258.24864]

Available online at: https://www.panafrican-med-journal.com/content/article/36/258/full

Home | Volume 36 | Article number 258

Case series

Odontogenic cervico-facial cellulitis during pregnancy: about 3 cases

Odontogenic cervico-facial cellulitis during pregnancy: about 3 cases

Zakaria Aziz1,&, Salma Aboulouidad1, Mohammed El Bouihi1, Saad Fawzi1, Mohammed Lakouichmi2, Nadia Mansouri Hattab1

 

1Maxillo Facial Surgery Department University Hospital Center Mohammed VI, Marrakech, Morocco, 2Maxillo Facial Surgery Department, Avicenne Military Hospital, Cadi Ayyad University, Marrakech,Morocco

 

 

&Corresponding author
Zakaria Aziz, Maxillo Facial Surgery Department University Hospital Center Mohammed VI, Marrakech, Morocco

 

 

Abstract

Pregnancy is considered as a risk factor for development, severity, and complications of odontogenic infections. Without adequate treatment, the infection can spread and threaten both the mother’s and the foetus lives. We aim to analyze the predisposing factors, diagnostic and therapeutic aspects of cervico-facial cellulitis during pregnancy, through a descriptive retrospective study conducted at oral and maxillofacial surgery department of Mohamed VI university hospital center at Marrakesh, between June 2017 and June 2019. A total of three patients; all patients were at their last trimester were recruited. Every patient was immediately given intravenous antibiotics, drainage was carried out under local anesthesia, and the causing tooth was removed. During hospitalization, one patient was referred to the gynaecology department for preterm labor, while the remaining two patients were discharged after the pus drainage has stopped. The possible compromise of oral health during pregnancy is well known, however severe odontogenic infections are rarely considered in the literature. It is essential to aggressively treat the gravid patient to minimize the risk of infection spreading to the facial spaces. Moreover, poor oral health in pregnancy has been implicated in adverse birth outcomes, specifically prematurity. We recommend upgrading communication between obstetrician and dentists so that regular routine dental visits are planned for pregnant patients during early stages of pregnancy in order to identify and manage the problem as early as possible.

 

 

Introduction    Down

Odontogenic infection is the most prevalent disease worldwide and it´s known to be the main cause of facial space infections [1]. Without adequate treatment, the infection can spread along fascial planes caudally to the cranial base, and in a rostral direction to the mediastinum [2]. On the other hand, pregnancy is an altered physiological state with decreased immune functions that affects almost every system of the body [3], the implication of wich is rapidly spreading cellulitis that can be life threatening for both the mother and the foetus. In fact, pregnancy is considered as a risk factor for development, severity, and complications of odontogenic infections [4, 5]. An early diagnosis based on clinical features is crucial for an effective therapy. Management plan should be such that it should maximize benefit to the mother and minimizing the risk to the developing fetus [6]. Consequently, treatment decision should be taken by a multidisciplinary team including the obstetrician, the oral and maxillofacial surgeon and the anesthesiologist [2]. The aim of this paper was to analyze the predisposing factors, diagnostic and therapeutic aspects of cervico-facial cellulitis during pregnancy.

 

 

Methods Up    Down

We conducted a descriptive retrospective study at oral and maxillofacial surgery department, Mohamed VI university hospital of Marrakesh, between June 2017 and June 2019 including all pregnant women presenting with odontogenic facial cellulitis. The following variables were studied: patient age, gestational age, time from onset of symptoms, previous medication, extra and intraoral examination, involved tooth and radiographic assessments, duration of hospital stay. All the patients were hospitalized and gynaecological opinion was taken for both maternal and fetal health status. They underwent blood tests including complete blood count and CRP as inflammatory parameter. Drainage was carried out under local anesthesia using a N°15 blade then a rubber drain was placed in the cavity and maintained till stoppage of the pus drainage. Once microbiological sample was taken, the patient was immediately given intravenous antibiotics (Amoxicillin+ clavulanic acid 1g/8 hours) and a bolus corticotherapy (120 mg methyprednisolone). The causing tooth was removed as soon as mouth opening has improved.

 

 

Results Up    Down

A total of three patients were recruited in this work (Table 1). The mean age was 27,5 years and all patients were at their last trimester (mean gestational age at 31 weeks). Investigations revealed taking non-steroidal anti-inflammatory drugs to relief a toothache. The duration of symptoms ranged from 5 to 9 days. Clinically, they all presented with limited mouth opening and facial swelling (Figure 1). Tenderness and warmth were observed on palpation extraorally and the offending teeth were tender to percussion. Laboratory investigations revealed increased CRP and leukocyte count. Staphylococcus aureus was found in one microbiological screening while the others showed sterile culture. The mean hospital stay duration was 12,6 days and switch to oral antibiotics was done once local and systemic infection signs disappeared. Total duration of antibiotherapy was 21 days. During hospitalization, one patient was referred to the gynaecology department for preterm labor at 35 weeks giving birth to a healthy male newborn. The remaining two patients were discharged after the pus drainage has stopped.

 

 

Discussion Up    Down

Cervico-facial cellulitis are bacterial infections affecting the cellular adipose spaces of the head and the neck. They are a local-regional complication that is most of the time of dental origin [7]. Odontogenic infections can lead to serious complications if not treated early, including upper airway obstruction, descending mediastinitis, septic shock, acute renal failure, disseminated intravascular coagulation, jugular vein thrombosis, carotid artery pseudoaneurysm, and pericardial effusion [8]. The possible compromise of oral health during pregnancy is well known, however severe odontogenic infections are rarely considered in the literature [1]. Moreover, poor oral health in pregnancy has been implicated in adverse birth outcomes, specifically prematurity, development of preeclampsia, and infants born at small-for-gestational-age [9]. Pregnancy is associated with many physiological and hormonal changes, providing the oral and maxillofacial surgeon with many challenges [10]. This change place the mother at a higher risk of infection or of doing worse, once infected. The immune response is greatly diminished during pregnancy, resulting in potential faster progression of an infection. In addition, there is decreased neutrophil chemotaxis, cell-mediated immunity, and natural killer cell activity [11, 12]. From an oral perspective, pregnancy-associated hormonal changes also affect the gingival tissues. They become much more sensitive and susceptible to irritation from soft plaque. Plaque accumulates, becomes hard calculus deposits on the teeth, and harbors bacteria in large numbers resulting in a constant, low-grade intraoral infection. An exaggerated local inflammatory response can then begin and may result in erythematous and edematous swelling of the gingiva between the teeth, also known as pregnancy gingivitis [13]. Approximately 70% pregnant women have this condition, even with routine oral care [10]. Furthermore, during pregnancy, women tend to have frequent meals and snacks in addition to increased acid reflux and vomiting, which cause further accumulation of plaque, as well as an increase in decay or rapid progression of previously present decay [ 13, 14].

These changes are aggravated during second and last trimester of pregnancy [10]. As in the present study where all patients were at their last trimester. On the other hand, oral health procedures in pregnancy are often avoided and misunderstood by physicians, dentists, and patients. There was some degree of confusion over the safety of accessing dental care during pregnancy [15]. In fact, none of our patients sought for dental care before or during pregnancy, as in Elneel Ahmed Mohamed Ali study [15] where 50% of patients had experienced toothaches many months before but didn´t seek any treatment because of misconceptions among women regarding dental treatment during pregnancy and 40% patients were delayed because of instructions from their doctors. Authors recommended that dental care shoud be provided during the second trimester so as to reduce any risk to the early development of the fetus and for the woman´s comfort [5, 12, 15]. The diagnosis of facial cellulitis is usually obvious based on clinical grounds: facial and cervical painful swelling sometimes associated to pus discharge [16]. If not, a radiograph and a CT scan is performed [1]. The prevalence of odontogenic infection involving fascial spaces in descending order is submandibular, submental, buccal and sublingual [15, 17, 18], this findings are consistent with our results. 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 [10]. In general, a single orthopantomogram will provide sufficient information at an acceptable radiation exposure. 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. 5-10 cGy) but is greater than for an Orthopantomogram. 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.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 [19].

In our study, all patients had orthopantomograms that helped defining the causing tooth and the most commonly involved tooth was mandibular last molar. Management of mild infections should be managed via incision/ drainage under local anesthetic with subsequent antibiotic coverage. It is essential to aggressively treat the gravid patient to minimize the risk of infection spreading to the facial spaces. Facial space infection should be handled in a standard fashion: airway assessment (if any doubt, intubate), imaging (computed tomography scan), and to the operating room for adequate incision and drainage. Postoperatively, if the patient is unable to maintain oral intake, parenteral nutritional support must be instituted. More severe infections should be managed in the operating room under general anesthesia with intravenous antibiotics and incision and drainage [1]. Antibiotics that are acceptable during pregnancy include penicillin, amoxicillin, and clindamycin. Tetracycline should be avoided since it tends to cause permanent discoloration of primary and temporary dentition of the unborn child [12]. Local anesthesia is preferred than general anesthesia can induce premature delivery, inhalation and pneumonia risk [10, 16]. This paper showed that the pregnant patients with severe odontogenic infections were successfully managed with one case of preterm birth. A metanalysis indicates a likely association between preterm birth and paradontal status [20]. Our work serves as a reminder for all health practitioners to not neglect even minimal complaints of dental pain and diagnosis odontogenic infections in pregnancy at an early stage, and then refer these patients for timely and appropriate management by a multi-disciplinary team.

 

 

Conclusion Up    Down

Odontogenic cellulitis during pregnancy is relatively frequent in our context. This is due to poor oral health, inaccessibility to dental care and lack of sanitary programs including dental consultation. We recommend upgrading communication between obstetrician and dentists so that regular routine dental visits are planned for pregnant patients during early stages of pregnancy in order to identify and manage the problem as early as possible.

What is known about this topic

  • Pregnancy is considered as a risk factor for development of odontogenic infections;
  • Cervico-facial cellulitis can be life-threatening for both the mother and the fetus.

What this study adds

  • Cervico facial cellulitis during pregnancy leads to obstetrical complications such as preterm birth;
  • Early diagnosis and management strategy of cervico facial cellulitis in pregnant women;
  • The importance of dental care in pregnant women.

 

 

Competing interests Up    Down

The author declare no competing interests.

 

 

Authors' contributions Up    Down

All authors read and approved the final version of the manuscript.

 

 

Tables and figures Up    Down

Table 1: summary of patient´s data

Figure 1: A) picture showing extensive submandibular space infection resulting in facial swelling and limited mouth opening; B) orthopantomogram of the same patient showing a carious third molar (N°38)

 

 

References Up    Down

  1. Akhter T, Jabeen U, Khaliq M, Anwar M. Pregnancy complicated by odontogenic facial space infection; a study. JMSCR. 2016;4(11):13584-13588. Google Scholar

  2. Tocaciu S, Robinson BW, Sambrook PJ. Severe odontogenic infection in pregnancy: a timely reminder. Australian Dental Journal.2017;62(1): 98-101. PubMed | Google Scholar

  3. Finn R, St Hill CA, Govan AJ, Ralfs IG, Gurney FJ, Denye V. Immunological responses in pregnancy and survival of fetal homograft. Br Med J. 1972;3(5819):150-152. PubMed | Google Scholar

  4. Abramowicz S, Abramowicz JS, Dolwick MD. Severe Life-Threatening Maxillofacial Infection in pregnancy presented as Ludwig´s Angina. Infectious Diseases in Obstetrics and Gynecology. 2006; 2006(51931):1-4. PubMed | Google Scholar

  5. Skouteris CA. Dental management of the pregnant patient. Hoboken, NJ, USA. John Wiley & Sons, Inc. 2018. Google Scholar

  6. Flynn RT, Susarla SM, Thomas Flynn R, Srinivas Susarla M. Oral and maxillofacial surgery for pregnant patients. Oral and Maxillofacial Surgery Clinics of North America. 2007;19(2): 207-221. PubMed | Google Scholar

  7. La Rosa J, Bouvier S, Langeron O. Prise en charge des cellulites maxillo-faciales. Le praticien en anesthésie réanimation. 2008;12(5):309-315. PubMed | Google Scholar

  8. Lee JK, Kim HD, Lim SC. Predisposing factors of complicated deep neck infection: an analysis of 158 cases. Younsei Medical Journal. 2007; 48(1): 55-62. PubMed | Google Scholar

  9. Kim Boggess A, Burton Edelstein L. Oral health in women during preconception and pregnancy: implications for birth outcomes and infant oral health. Maternal and Child Health Journal.2006 Sep;10(5 Suppl):S169-74. PubMed | Google Scholar

  10. Turner M, Aziz Sr. Management of the pregnant oral and maxillofacial surgery patient. J Oral Maxillofac Surg. 2002;60(12):1479-1488. PubMed | Google Scholar

  11. Silver RM, Peltier MR, Branch DW. The immunology of pregnancy (Maternal-Fetal Medicine) principles and practice. Philadelphia, PA: WB Saunders. Creasy RK, Resnik R, editors. 2004.

  12. Lawrenz DR, Whitley BD, Helfrick JF. Considerations in the management of maxillofacial infections in the pregnant patient. Journal of Oral and Maxillofacial Surgery. 1996;54(4):474-485. PubMed | Google Scholar

  13. Soma Mukherjee, Surbhi Sharma, Laxmi Maru. Poor dental hygiene in pregnancy leading to submandibular cellulitis and intrauterine fetal demise: case report and littérature review.Int J Prev Med. 2013;4(5): 603-606. PubMed | Google Scholar

  14. Lukacs JR, Largaespada LL. Explaining sex differences in dental caries prevalence: saliva hormones, and “live-history” etiologies. American Journal of Human Biology. 2006;18(4): 540-55. PubMed | Google Scholar

  15. Elneel Ahmed Mohamed Ali, Amel Salah Eltayeb, Musadak Ali Karrar Osman. Delay in the referral of pregnant patients with fascial spaces infection: a cross-sectional observational study from Khartoum Teaching Dental Hospital, Sudan. Journal of Maxillofacial and Oral Surgery. 2019;19(2):298-301. PubMed | Google Scholar

  16. K Doumbia-Singare,Timbo SK, Keita M,Mohamed Ag A, Guindo B,Soumaoro S. Cellulite cervico-faciale au cours de la grossesse: à propos d´une série de 10 cas au Mali. Bulletin de la Société de pathologie exotique. 2014;107(5): 312-316. PubMed | Google Scholar

  17. Anthony Rega J, Shahid Aziz R, Vincent Ziccardi B. Microbiology and antibiotic sensitivities of head and neck space infections of odontogenic origin. J Oral Maxillofac Surg. 2006;64(9):1377-1380. PubMed | Google Scholar

  18. Wazir Sana, Khan Muslim, Mansoor Nadia, Wazir Ashfaq. Odontogenic fascial space infections in pregnancy: a study. Pakistan Oral & Dental Journal. 2013;33(1):17-22. Google Scholar

  19. Wong D, Cheng A, Kunchur R, Lam S, Sambrook PJ, Goss AN. Management of severe odontogenic infections in pregnancy. Australian Dental Journal. 2012;57(4):498-503. PubMed | Google Scholar

  20. Jean-Noël Vergnes, Michel Sixou. Preterm low birth weight and maternal periodontal status: a meta-analysis. Am J Obstet Gynecol. 2007;196(2): 135(e1-e7). PubMed | Google Scholar

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case series

Odontogenic cervico-facial cellulitis during pregnancy: about 3 cases

Case series

Odontogenic cervico-facial cellulitis during pregnancy: about 3 cases

Case series

Odontogenic cervico-facial cellulitis during pregnancy: about 3 cases