Management of severe odontogenic infections in pregnancy

Oral and maxillofacial Surgery Journal Reading

LAW SUI YNG

NPM 160112162015

UNIVERSITAS PADJADJARAN

FAKULTAS KEDOKTERAN GIGI

BANDUNG

2017
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 identied 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 ve were pregnant. Besides surgical and anaesthetic assessment,
mother and foetus were assessed by the Obstetric and Gynaecology Unit. In all, ve 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
 Introduction

Ideally routine dental treatment is best avoided in pregnancy, and preferentially dental
tness should be instituted prior to pregnancy. Minor routine dental treatment can be
completed in the second trimester with the rst 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 t females. Cardiovas-cular 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 reux 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 aminotransfer-

ase. The decreased albumin levels may lead to periph-eral 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.7Pregnancy also leads to hypocoagulable

states due to an increase in the various coagulant factors and a drop in anticoagulant

factors.8 Gesta-tional 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, hyper-

plasia and pregnancyepulis.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 infec-tion, 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, ve 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 mod-ication 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 reux needs to be carefully evaluated to minimize the risk of aspiration and

aspiration pneumonia postoperatively.4,5

Table 1. Summary of the changes seen in pregnant females and the actions required
Systems Potential changes Actions
Cardiovascular changes Decrease in blood pressure (1st Monitor
trimester)

Increase in blood volume, heart

rate and cardiac output Monitor

Hypercoagulable state due to DVT precautions

increase in clotting factors

Supine hypotension Due to compression of inferior vena Position patient in left lateral position
syndrome cava leads to bradycardia,
hypotension and syncope
Can disrupt uteroplacental blood ow
Respiratory changes Increase in tidal volume, respiratory and
minute ventilation
Mild respiratory alkalosis and dyspnea Can affect induction and maintenance of
intravenous sedation and general anaesthesia

Predisposition to rhinitis, epistaxis and Avoid nasal intubation

upper respiratory tract infections due to
changes to upper airway mucosa

Gastro-intestinal Predisposition to gastric reux due to Risk of aspiration with anaesthesia

changes relaxation of lower oesophageal sphincter
tone and increased gastric pressure

Nausea, vomiting and constipation common Consider when prescribing medication

Renal changes Increase renal blood ow and glomerular

ltration rate

Increased renal clearance of creatinine, urea, Consider when prescribing renally cleared
uric acid and renally cleared medications medications

Increased risk of urinary tract infections
Analgesics Aspirin delivery complications and
post-partum haemorrhage
NSAIDS can inhibit induction of labour and
also cause constriction of the ductus
arteriosus leading to pulmonary hypertension
in the infant
Use urinary catheter with caution
Contraindicated in 3rd trimester,
use with caution in 1st and 2nd
trimester
Contraindicated in 3rd trimester,
use with caution in 1st and 2nd
trimester

Contraindicated in 3rd trimester (e.g.

codeine, propoxyphene)
Narcotics can lead to neonatal respiratory Morphine appears to be safe when
depression, associated with congenital defects administered for short periods of time

Antibiotics Metronidazole potentially teratogenic Contraindicated during pregnancy

Tetracyclines cause tooth discolouration Contraindicated during pregnancy

and can inhibit bone development

Gentamicin potential ototoxicity Contraindicated during pregnancy

Sedatives anxiolytics Cross-placental barrier and inhibit neuronal

function and associated with oral cleft
development

Local Anaesthetic Bupivacaine hydrochloride and mepivacaine Contraindicated during pregnancy

FDA category C due to lack of data available
in studies

Anaesthesia 3rd trimester increased risk of regurgitation Avoid intravenous sedation and general
 and aspiration anaesthesia where possible in pregnancy
patients

Radiography Total radiation exposure less than 610 centi-
Grays (cGy) has no association with increased
congenital defects or growth retardation
Full mouth series of intraoral radiographs and
panoramic radiograph are within safe dose
CT scan has radiation exposure of 37 cGy
only indicated for spreading odontogenic
infections

Pharmacologically, altered hepatic and renal excretion capabilities need to be carefully

considered. In the rst trimester of pregnancy older drugs with a known low teratogenic rate
need to be used. Non-steroidal anti-inammatory 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.

Table 2. Summary of the management of consecutive pregnant cases treated

Metronidazole may be teratogenic in the rst trimester although recent studies have
shown no denitive 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.
 Most sedatives such as the benzodiazepines cross the placental barrier and thus are
best avoided. Local anaesthesia generally is safe although there is uncer-tainty through lack
of data on the use of bupivicaine and mepivicaine. Although it is commonly stated that
prilocaine and octopressin should be avoided in preg-nancy the tiny amounts involved have

no effect on inducing labour.11

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 bre optic intubation. Although theoretically there is a
risk of teratogenesis and spontaneous abortion, large studies which have com-pared the
outcome of pregnancy where the patient did have a general anaesthetic versus where they

didnt, shows no change in risk.12,13

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 sufcient 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

dene a pus collection in patients not responding to surgical management.13 Ultrasound has
a place in dening moderate to large pus collections in the neck and it should be considered
over and above a CT scan.
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.

Table 3. Protocol for management of pregnant patients with severe odontogenic infections

Emergency referral by LDO or LMO to hospital

Medical assessment including maternal airway

and foetal health

On referral to a tertiary hospital with full

specialist teams - Oral and Maxillofacial Surgery
(OMS) - Obstetrics and Gynaecology (O & G) -
Anaesthesia and intensive care (A)

Admit under the care of the OMS team

Control airway (A)

Full maternal and foetal monitoring (O & G)

Infection assessment

Airway monitoring

Commence intravenous antibiotics

Full specialist assessment by teams

Develop plan and informed consent - Surgical

management - Extraction - Incision and drainage

Admit to ICU if airway issues (A)

Ongoing maternal and foetal monitoring (O&G)

General ward until stable

Discharge on oral antibiotics

Outpatient review by obstetrician and OMS

 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 post-procedure. Of the ve patients, two were considered high risk of
miscarriage by the O & G Service. One patient had had ve 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 recom-mended that she have a further anaesthetic for incision and drainage, but
following informed consent discus-sions 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.
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 bre 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
nal patient was surgically treated uneventfully.
 Conclusion

Severe spreading odontogenic infection can be difcult 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.
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