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‘Dental focal infections are back with a bang’. This was studies have demonstrated the association between
the title of an editorial in the Journal of American chronic oral infections (particularly marginal peri-
Dental Association in January 1998 (21). Actually, den- odontitis) and systemic diseases, such as cardiovascu-
tal focal infections have never been absent, but our lar diseases, stroke, diabetes, low birthweight of babies
attention is now being refocused on these infections. born prematurely, respiratory infections and rheuma-
Egyptian physicians knew, already in 1500 BC, that toid arthritis (15, 33, 35). These issues are the realm of
tooth infections had to be treated carefully to prevent periodontal medicine and will not be dealt with in the
life-threatening complications. In 1891, Miller (44) current review which is focused on acute dental focal
published his theory on focal infection suggesting infections. Thus, the association of dental infections
that oral microorganisms and their products are able with systemic health is broad and is not covered to its
to affect parts of the body adjacent to or distant from full extent in this article.
the mouth. Hunter (25) reprimanded dentists who The oral cavity contains a wide variety of organisms,
allowed development of chronic abscesses in the oral including viruses, fungi and protozoa, but bacteria are
cavity, and he believed that necrotic teeth could rep- the most abundant. This article will focus only on bac-
resent foci of infection causing arthritis, heart disease teria. However, bacteria may occasionally cause sys-
and other unexplained diseases. Billings (9) also spec- temic disease in concert with viruses and yeasts,
ulated that infected teeth and tonsils could be particularly in the compromised host. These organ-
responsible for a number of focal infections such as isms may also cause focal infection on their own.
arthritis, rheumatism, nephritis, endocarditis and Oral infections are among the most prevalent infec-
other diseases. The bacteria and their products were tious diseases of mankind. Being mostly chronic in
assumed to reach these sites through bone cavities, nature, they relatively rarely lead to acute or dramatic
blood or lymph vessels, and even along nerves. Tho- consequences for the patient. However, medically
den van Velzen et al. (61) suggested three different compromised subjects may be at risk even for chronic
ways by which oral bacteria can cause nonoral dis- oral conditions particularly if their immune system is
ease: (i) metastatic inflammation as a result of weak. In fact, translocation of oral bacteria to nonoral
immune injury; (ii) metastatic injury from microbial sites may lead to an infectious process, even in
toxins; and (iii) metastatic infection as a result of the immunocompetent subjects.
translocation of bacteria.
The focal infection theory was prevalent in the 19th
century and at the start of the 20th century, particu- Acute oral infections
larly in the USA. It resulted in an orgy of tooth extrac-
tions, even in patients with the simplest forms of Acute oral infections are diseases that have a rapid
gingivitis. The practitioners performing this ‘treatment’ onset, severe symptoms and a short course as
were called ‘hundred percenters’ because they tended opposed to chronic oral infections.
to extract all teeth without considering the extent of
the disease (55). The theory fell into mistrust and was
Pulpitis
gradually dismissed. Currently it is back, allegedly with
a bang, although in a new perspective (23). The main The pathogenesis of oral focal diseases has been
reason for this is that a number of epidemiological classically attributed to dental-pulp pathologies and
178
Dental focal infections
peri-apical infections (10). The main causes for titis. However, in sinusitis several teeth will be sensi-
inflammation of the dental pulp (pulpitis) are bacte- tive to percussion and the pain is aggravated when
ria and their metabolites, which reach the connective the patient bends forward.
tissue of the pulp via small canals in the dentine. The
bacteria are located in caries lesions, in cracks along
Pericoronitis
tooth restorations or in tooth crowns. Pulp inflamma-
tion can also develop as a result of trauma, such as A frequent acute condition in the mouth is pericoro-
following crown or bridge preparation. Toxic effects nitis. Pericoronitis occurs around a partially erupted
from filling materials can also cause pulp inflamma- third molar and frequently occurs in the mandible
tion. Acute pulpitis may induce almost intolerable of young individuals. As a result of the lack of local
pain. At the onset, the pain is induced by external dental hygiene, a biofilm containing predominantly
influences such as sweets and acid food or cold. Later, gram-negative anaerobic rods, spirochetes and cocci
the pain can be provoked by heat. Acute intervention develops in the pericoronary space. The acute condi-
involves excavation of carious lesions and removal of tion is characterized by severe pain, rubor, swelling,
the coronal part of the inflamed pulp tissue. Subse- suppuration and problems with swallowing. Trismus
quently, extirpation of the remaining pulp and widen- may also occur.
ing of the root canal are performed, resulting in filling
of the root canal and a coronal restoration. The root
Phlegmon and abscess formation
canal is sealed off to prevent invasion of oral bacteria
and release of their products into the surrounding tis- Phlegmon (a spreading diffuse infectious process in
sues. the connective tissue with formation of suppurative/
purulent exudate or pus) and abscess formation usu-
ally result from apical periodontitis but can also be
Apical periodontitis
initiated by severe chronic periodontitis and pericor-
Untreated pulpitis will sooner or later lead to pulp onitis. The symptoms can vary from local swelling
necrosis. The necrotic tissues of the crown and root and rubor to more pronounced swelling with risk of
pulp serve as a locus minoris resistentiae and allow infection spreading to neighboring regions. Most of
oral obligate anaerobic and facultative anaerobic bac- these infections are drained through fistulas into the
teria to cause infection. Pulp necrosis will result in oral cavity. However, infection may spread to neigh-
inflammation of the tissue around the root apex. boring regions such as the maxillary sinus, the sublin-
Inflammatory mediators, produced by macrophages gual, submandibular and infraorbital regions, orbit
and lymphocytes, will recruit and activate osteoclasts, and brain, and to the parapharyngeal space, ending
resulting in peri-apical bone loss. This process may up in mediastinitis. In rare cases, so-called cervical
develop over years without overt clinical symptoms. necrotizing fasciitis can develop.
Histologically, the tissue around the apex can be
characterized as granuloma, abscess or cyst. The bal-
Necrotizing ulcerative gingivitis and
ance between organisms and the immune defense
periodontitis
can be altered by overgrowth of more virulent bacte-
ria, resulting in aggravation and acute pain. The pain Necrotizing ulcerative gingivitis is a form of necrotiz-
can, similarly to pulpitis, become severe, particularly ing periodontal disease that affects the gingiva with-
if pus from the apical focus accumulates below the out involving other tissues of the periodontium (4).
periostium. The succeeding sequence can be abscess The infection is also known as ‘trench mouth’ and
formation, perforation to the maxillary sinus and, in Vincent’s angina or Vincent’s stomatitis (named after
serious cases, the infection can spread as a gravity the French physician, Henri Vincent). Another, older,
abscess or phlegmon with infiltration of neighboring synonym is fusospirochetal gingivitis, referring to the
regions. In some cases a fistula will develop, which high numbers of fusiform bacteria and spirochetes
may allow accumulated pus to drain and therefore a seen in the dental plaque using dark-field micros-
decrease in symptoms will occur. Acute pain can also copy. Invasion of these organisms into the gingival
develop during root-canal treatment if infected and tissue explains the acute, necrotizing and ulcerative
necrotic pulp/root-canal material is forced into the nature of the infection. When other periodontal tis-
peri-apical area. Maxillary sinusitis can cause otitis sues are involved in the infection and alveolar bone
and temporomandibular joint symptoms that may loss occurs, the condition is called necrotizing ulcera-
resemble the pain from pulpitis and apical periodon- tive periodontitis. A major risk factor for acute
179
Olsen & van Winkelhoff
180
Dental focal infections
181
Olsen & van Winkelhoff
Submental space
During bacteremia, with, for example, Streptococ-
cus sanguinis, the concentration of bacterial heat Lateral pharyngeal space
182
Dental focal infections
183
Olsen & van Winkelhoff
Gas gangrene and necrotizing fasciitis Fig. 7. Abscess from previously traumatized tooth incised
in the labial fold. Courtesy of Geir Støre.
Dental infection is a common cause of gas gangrene
and necrotizing fasciitis. These infections may spread
downwards to the mediastinum, leading to mediasti-
nitis (8, 14), pericarditis, lung infection and sepsis.
They may also spread upwards to the skull base and
to the meninges, or through blood vessels to give sup-
purative thrombophlebitis, sepsis or disseminated
intravascular coagulation (30). Immunosuppressive
conditions and alcohol abuse may predispose but
these types of infections can also occur in healthy
individuals. Factors affecting mortality are diabetes,
alcohol abuse, delay of surgery and complicating
mediastinitis (62).
184
Dental focal infections
Peritonsillar abscess
Extension of infection around the third molar may
result in peritonsillar abscess. It is usually seen unilat-
erally, with extreme soreness of the throat, odynopha-
Fig. 9. Irradiated mandible with osteoradionecrosis and gia, persistent pain in the peritonsillar area and
superinfection. Courtesy of Geir Støre. trismus (30). The uvula may be forced to the opposite
site. Fever, malaise and headache can follow. Of 311
and soft tissue. Such tissue is susceptible to infection abscesses of dental origin, the parapharyngeal and
with oral bacteria. Until recently, a common view was peritonsillar abscesses were the rarest and the peri-
that the infection of the bone was superficial and mandibular abscess the most common (58).
secondary (40). Several studies, using scanning and
transmission electron microscopy (59), DNA–DNA
Suppurative arthritis of the
hybridization (60) and 16S ribosomal DNA sequenc-
temporomandibular joint
ing (1), have shown independently that the medullary
parts of bone in osteoradionecrosis are heavily Direct extension of an adjacent infection, such as
infected with a wide variety of facultative anaerobic osteomyelitis of the jaw, traumatic and surgical
and strict anaerobic bacteria, some of which are not wound infection of the temporomandibular joint or
yet cultivable. hematogenous spread of bacteria from a distal site
secondary to a systemic process may cause suppura-
tive arthritis of the temporomandibular joint (32).
Acute maxillary sinusitis
Moses et al. (46) reported a case of septic arthritis of
Maxillary sinusitis usually appears unilaterally and the temporomandibular joint after removal of third
constitutes approximately 10–12% of all cases of max- molars.
illary sinusitis (12). The etiology includes most often
peri-apical dental abscesses, severe periodontitis,
Orbital cellulitis/abscess
peri-implantitis and postextraction infection. A num-
ber of other dentally related etiologies can occur (30). Dental infections, maxillary osteomyelitis and dental
Maxillary sinusitis may become chronic following the extractions may cause orbital cellulitis (30). Compli-
acute phase or can manifest itself as a chronic inflam- cations can be loss of sight and fatal cerebral com-
mation without acute episodes. Acute maxillary plications. Orbital cellulitis starts with a painful and
sinusitis is caused by bacteria invading the sinus from erythematous swelling of the eyelid. The patients
a focus of dental infection. Infection from maxillary may have severe orbital pain, fever, propoptosis,
premolars and molars, peri-apical abscesses, severe conjunctivitis, chemosis, impaired movements of
peri-implantitis, postextraction infection and cysts the eye and optic nerve damage. Mun ~ oz-Guerra
are the most common causes (7). Signs and symp- et al. (47) reported a subperiosteal abscess of the
toms include dull or intense pressure, erythema, orbit that was an unusual complication of an
swelling of cheek and anterior maxilla and the drain- uneventful extraction of the left third maxillary
age of foul-smelling material. Acute maxillary sinusitis molar. It was probably caused by extension of the
can cause orbital abscess/cellulitis (41, 42), cavernous infection to the pterygopalatine and temporal
sinus thrombosis, meningitis and intracranial regions progressing to the inferior orbital fissure.
abscess. In cases where the origin is a peri-apical Also, Sakkas et al. (57) and Kim et al. (28) reported
abscess, there is toothache and swelling of the gingiva an orbital abscess after extraction of a maxillary wis-
and buccal vestibule. Bomeli et al. (11) examined the dom tooth. Direct spread of a dentoalveolar abscess
frequency of a dental cause for acute maxillary sinusi- of the maxillary first molar via the maxillary sinus
185
Olsen & van Winkelhoff
caused eye loss in a 42-year-old HIV-seropositive tially diagnosed as cerebral metastases of a suggested
woman (41). Allan et al. (3) reported a patient with lung carcinoma. Both species were also isolated from
orbital cellulitis and a postseptal abscess secondary multiple relapsing purulent skin lesions. The patient
to infection from a maxillary molar tooth. In this had a poor dentition (29). This combination of oral
patient the infection spread to the maxillary sinus pathogens has been found more often in brain
and then to the orbit via a defect in the orbital abscesses (69), and both species may represent a syn-
floor. ergistic pathogenic combination (65). It has been sug-
gested that a patent foramen ovale in patients with
severe periodontitis may be a risk factor for intracra-
Brain and liver abscess
nial infection caused by oral pathogens (27). Brain
Brain abscesses are rare but can be life-threatening. abscesses have been confused with metastatic lesions
They are sometimes caused by oral infection and of a tumor of unknown origin. Rahamat-Langendoen
dental treatment (34). Oral infection with recurrent et al. (54) described a patient with a very poor denti-
bacteremia should always be considered in the path- tion, stomatitis and alcohol abuse; stereotactic biopsy
ogenesis of the so-called ‘cryptic’ intracerebral and detected the presence of brain abscess, and pus was
intraspinal infections (20). Ewald et al. (20) reported collected from one of three lesions. Aggregatibacter
six patients with intracerebral (n = 4) and intraspinal actinomycetemcomitans was detected in this patient
(n = 2) infections. All patients had dental pathologies. (Fig. 8).
Clinical improvement was achieved in all patients
after decompression, evacuation of pus and targeted
Management of acute oral focal
antibiotics. Wagner et al. (66) described a patient
infections
with brain and liver abscesses caused by oral infec-
tion with S. intermedius. A patient with generalized Some acute soft-tissue infections are potentially
periodontal disease, dental caries and peri-apical lethal. Therefore, prompt diagnosis and treatment are
pathology developed a cerebral abscess with right important. In patients where the infection has spread
hemiparesis and epileptic fits (48). The patient made to neighboring regions, surgical treatment under gen-
an uneventful recovery 29 months postoperatively eral anesthesia and treatment with intravenous anti-
after immediate administration of intravenous antibi- biotics may be necessary. Usually, abscesses are
otics, craniotomy, resection of the abscess cavity and drained by incision and antibiotics are given if the
removal of periodontally decayed and peri-apically general health condition is affected or if the host is
involved teeth. Another patient, with deep facial immunocompromised. C-reactive protein levels have
space infection, developed a brain abscess (56). been shown to correlate well with the severity and the
Although a number of reports have suggested a dental resolution of acute dental infections and can thus be
etiology for brain abscesses, few efforts have been used as a reliable parameter for monitoring the effec-
made to compare brain-abscess isolates with isolates tiveness of therapy (17).
from the oral cavity using highly discriminative meth-
ods. Marques da Silva et al. (39) compared brain-
abscess isolates and oral isolates using phenotypic
and three genetic (restriction fragment length poly-
morphism, ribotyping and random amplification of
polymorphic DNA) fingerprinting techniques. The
phenotypic method and restriction fragment length
polymorphism showed identical profiles between
brain and periodontal isolates, while ribotyping and
random amplification of polymorphic DNA showed
very close similarity. It was suggested that gene trans-
fer by genetic recombination in the periodontal
pocket might have been responsible for the emer-
gence of a strain variant (of S. constellatus) that had
caused an abscess at a distant site.
Aggregatibacter actinomycetemcomitans in combi-
nation with Actinomyces meyeri were isolated from Fig. 10. Intra-orally incised dental abscess. Courtesy of
the pus of multiple intracerebral lesions that were ini- Hans Reidar Haanaes.
186
Dental focal infections
Acknowledgments
Tooth extraction
Mild infections do not usually require tooth extrac- Professor Geir Støre (Section for Maxillo-Facial Sur-
tion. In the case of a hopeless tooth, extraction will gery, ENT Department, Rikshospitalet University
remove the infectious source and provide drainage of Hospital, Oslo) and Professor Hans Reidar Haanaes
pus. If the tooth cannot be spared, early extraction is (Section of Oral Surgery and Oral Medicine, Institute
preferable, even if this may aggravate the swelling. of Clinical Dentistry, Faculty of Dentistry, University
of Oslo, Oslo) are acknowledged for generously sup-
Antibiotics plying clinical photographs.
187
Olsen & van Winkelhoff
4. Armitage GC. Development of a classification system for 25. Hunter W. Role of sepsis and antisepsis in medicine. Lancet
periodontal diseases and conditions. Ann Periodontol 1999: 1910: 1: 79–86.
4: 1–6. 26. Kachlany SC. Aggregatibacter actinomycetemcomitans leu-
5. Bahrani-Mougeot FK, Paster BJ, Coleman S, Ashar J, Barb- kotoxin: from threat to therapy. J Dent Res 2010: 89: 561–
uto S, Lockhart PB. Diverse and novel oral bacterial species 570.
in blood following dental procedures. J Clin Microbiol 2008: 27. Kawamata T, Takeshita M, Ishizuka N, Hori T. Patent fora-
46: 2129–2132. men ovale as a possible risk factor for cryptogenic brain
6. Baqain ZH, Newman L, Hyde N. How serious are oral infec- abscess: report of two cases. Neurosurgery 2001: 49: 204–
tions? J Laryngol Otol 2004: 118: 561–565. 206; discussion 206–207.
7. Bertrand B, Rombaux P, Eloy P, Reychler H. Sinusitis of 28. Kim IK, Kim JR, Jang KS, Moon YS, Park SW. Orbital abscess
dental origin. Acta Otorhinolaryngol Belg 1997: 51: 315–322. from odontogenic infection. Oral Surg Oral Med Oral
8. Biasotto M, Chiandussi S, Costantinides F, Di Lenarda R. Pathol Oral Radiol Endod 2007: 103: e1–e6.
Descending necrotizing mediastinitis of odontogenic ori- 29. Kuijper EJ, Wiggerts HO, Jonker GJ, Schaal KP, de Gans J.
gin. Recent Pat Antiinfect Drug Discov 2009: 4: 143–150. Disseminated actinomycosis due to Actinomyces meyeri
9. Billings F. Focal infection: its broader application in the eti- and Actinobacillus actinomycetemcomitans. Scand J Infect
ology of disease. J Am Med Assoc 1914: 4: 899–903. Dis 1992: 24: 667–672.
10. Bindslev PH, Schou S. Akutte tilstande i mundhulen [Article 30. Kuriyama T, Lewis MAO, Williams DW. Infections of the
in Danish; English summary]. Ugeskr Laeger 2010: 172: oral and maxillofacial region. In: Andersson L, Kahnberg K-
3018–3022. E, Pogrel MA, editors. Oral and maxillofacial surgery, Chap-
11. Bomeli SR, Bransletter BF 4th, Ferguson BJ. Frequency of a ter 29. Chichester, UK: Wiley-Blackwell, 2010: 467–582.
dental source for acute maxillary sinusitis. Laryngoscope 31. Legert KG, Zimmerman M, Stierna P. Sinusitis of odonto-
2009: 119: 580–584. genic origin: pathophysiological implications of early treat-
12. Brook I. Sinusitis of odontogenic origin. Otolaryngol Head ment. Acta Otolaryngol 2004: 124: 655–663.
Neck Surg 2006: 135: 349–355. 32. Leighty SM, Spach DH, Myall RW, Burns JL. Septic arthritis
13. Camp S, Lei Y, Costalonga M, Zhang Y, Zaia A, Vajna R, Ross of the temporomandibular joint: review of the literature
KF, Herzberg MC. Systemic disease and the oral microbiota. and report of two cases in children. Int J Oral Maxillofac
In: Lamont RJ, Burne RA, Lantz MS, LeBlanc DJ, editors. Surg 1993: 22: 292–297.
Oral microbiology and immunology, Chapter 16. Washing- 33. Leishman SJ, Do HL, Ford PJ. Cardiovascular disease and
ton, D.C.: ASM Press, 2006: 361–375. the role of oral bacteria. J Oral Microbiol 2010: 2: 5781.
14. Cirino LM, Elias FM, Almeida JL. Descending mediastinitis: 34. Li X, Tronstad L, Olsen I. Brain abscess caused by oral infec-
a review. Sao Paulo Med J 2006: 124: 285–290. tion. Endod Dent Traumatol 1999: 15: 95–101.
15. Debelian GJ, Olsen I, Tronstad L. Systemic diseases caused 35. Li X, Kolltveit KM, Tronstad L, Olsen I. Systemic diseases
by oral microorganisms. Endod Dent Traumatol 1994: 10: caused by oral infection. Clin Microbiol Rev 2000: 13: 547–
57–65. 558.
16. Debelian GJ, Olsen I, Tronstad L. Anaerobic bacteremia and 36. Lockhart PB, Brennan MT, Sasser HC, Fox PC, Paster BJ,
fungemia in patients undergoing endodontic therapy: an Bahrani-Mougeot FK. Bacteremia associated with tooth-
overview. Ann Periodontol 1998: 3: 281–287. brushing and dental extraction. Circulation 2008: 117:
17. Drazi
c R, Jurisic M, Markovic A, Colic S, Gacic B, Stojcev- 3118–3125.
Staj
ci
c L. C-reactive protein as an inflammatory marker in 37. Lo pez JP, Camacho AF. Facial cellulitis resulting from a
monitoring therapy effectiveness of acute odontogenic painless dental abscess. Pediatr Dermatol 2007: 24: 588–589.
infections. Srp Arh Celok Lek 2011: 139: 446–451 [Article in 38. Marcus BJ, Kaplan J, Collins KA. A case of Ludwig angina: a
Serbian; Summary in English]. case report and review of the literature. Am J Forensic Med
18. Enwonwu CO, Falkler WA, Idigbe EO. Oro-facial gangrene Pathol 2008: 29: 255–259.
(nomad/cancrum oris): pathogenetic mechanisms. Crit Rev 39. Marques da Silva R, Caugant DA, Josefsen R, Tronstad L,
Oral Biol Med 2000: 11: 159–171. Olsen I. Characterization of Streptococcus constellatus
19. Esquivel BD, Huerta AS, Molina MJL. Report of 16 cases of strains recovered from a brain abscess and periodontal
Ludwig’s angina: 5-year review [Article in Spanish; English pockets in an immunocompromised patient. J Periodontol
summary]. Pract Odontol 1991: 12: 23–24, 28. 2004: 75: 1720–1723.
20. Ewald C, Kuhn S, Kalff R. Pyogenic infections of the central 40. Marx RE. Osteoradionecrosis: a new concept of its patho-
nervous system secondary to dental affections – report of physiology. J Oral Maxillofac Surg 1983: 48: 283–289.
six cases. Neurosurg Rev 2006: 29: 163–166. 41. Masipa JN, Bouckaert M, Masureik C, Lemmer J, Meyerov
21. Focal infection: back with a bang! Editorial. J Am Dent Assoc R, Feller L. Orbital abscess as a complication of odonto-
1998: 129: 8–9. genic infection. A case report and review of the literature.
22. Fujiyoshi T, Okasaka T, Yoshida M, Makishima K. Clinical and SADJ 2007: 62: 318–319.
bacteriological significance of the Streptococcus milleri group 42. Mehra P, Caiazzo A, Bestgen S. Odontogenic sinusitis
in deep neck abscesses [Article in Japanese; English sum- causing orbital cellulitis. J Am Dent Assoc 1999: 130:
mary]. Nihon Jibiinkoka Gakkai Kaiho 2001: 104: 147–156. 1086–1092.
23. Goymerac B, Woollard G. Focal infection: a new perspective 43. Meurman JH, Ha €ma€la
€inen P. Oral health and morbidity –
on an old theory. Gen Dent 2004: 52: 357–361. implications of oral infections on the elderly. Gerodontology
24. Herrera D, Alonso B, de Arriba L, Santa-Cruz I, Serrano C, 2006: 23: 3–16.
Sanz M. Acute gingival and periodontal lesions. Periodontol 44. Miller W. The human mouth as a focus of infection. Dental
2000 2014: 65: 149–177. Cosmos 1891: 33: 689–713.
188
Dental focal infections
45. Minassian C, D’Aiuto F, Hingorani AD, Smeeth L. Invasive 58. Schmieg E, Schmelzle R. Treatment of odontogenic
dental treatment and risk for vascular events. A self-con- abscesses [Article in German]. Dtsch Zahnarztl Z 1975: 30:
trolled case series. Ann Intern Med 2010: 153: 499–506. 54–57.
46. Moses JJ, Lange CR, Arredondo A. Septic arthritis of the 59. Støre G, Olsen I. Scanning and transmission electron
temporomandibular joint after the removal of third molars. microscopy demonstrates bacteria in osteoradionecrosis.
J Oral Maxillofac Surg 1998: 56: 510–512. Int J Oral Maxillofac Surg 2005: 34: 777–781.
47. Mun oz-Guerra MF, Gonza lez-Garcia R, Capote AL, Escorial 60. Støre G, Eribe ERK, Olsen I. DNA-DNA hybridization dem-
LN. Subperiostal abscess of the orbit: an unusual
V, Gõas onstrates multiple bacteria in osteoradionecrosis. Int J Oral
complication of the third molar surgery. Oral Surg Oral Maxillofac Surg 2005: 34: 193–196.
Med Oral Pathol Oral Radiol Endod 2006: 102: e9–e13. 61. Thoden van Velzen SK, Abraham-Inpijn L, Moorer WR. Pla-
48. Mylonas AI, Tzerbos FH, Mihalaki M, Rologis D, Boutsikakis que and systemic disease: a reappraisal of the focal infec-
I. Cerebral abscess of odontogenic origin. J Craniomaxillo- tion concept. J Clin Periodontol 1984: 11: 209–220.
fac Surg 2007: 35: 63–67. 62. Umeda M, Minamikawa T, Komatsubara H, Shibuya Y, Yo-
49. Neagu I, Tabarcea IC, Vataman R. Associated risk factors in koo S, Komori T. Necrotizing fasciitis caused by dental
developing oral manifestations in patients with blood dys- infection: a retrospective analysis of 9 cases and review of
crasia [Article in Romanian; English summary]. Rev Med the literature. Oral Surg Oral Med Oral Pathol Oral Radiol
Chir Soc Med Nat Iasi 2010: 114: 555–561. Endod 2003: 95: 283–290.
50. Olsen I. Update on bacteraemia related to dental proce- 63. van Winkelhoff AJ, Abbas F, Pavicic MJ, de Graaff J. Chronic
dures. Transfus Apher Sci 2008: 39: 173–178. conjunctivitis caused by oral anaerobes and effectively trea-
51. Olsen I, Solberg CO, Finegold SM. A primer on anaerobic ted with systemic metronidazole and amoxicillin. J Clin
bacteria and anaerobic infections for the uninitiated. Infec- Microbiol 1991: 29: 723–725.
tion 1999: 27: 159–165. 64. van Winkelhoff AJ, Slots J. Actinobacillus actinomycetem-
52. Pallasch TJ, Slots J. Antibiotic prophylaxis and the medically comitans and Porphyromonas gingivalis in nonoral infec-
compromised patient. Periodontol 2000 1996: 10: 107–138. tions. Periodontol 2000 1999: 20: 122–135.
53. Patel M, Chettiar TP, Wadee AA. Isolation of Staphylococus 65. van Winkelhoff AJ, Overbeek BP, Pavicic MJ, van den
aureus and black-pigmented bacteroides indicate a high Bergh JP, Ernst JP, de Graaff J. Long- standing bactere-
risk for the development of Ludwig’s angina. Oral Surg Oral mia caused by oral Actinobacillus actinomycetemcomitans
Med Oral Pathol Oral Radiol Endod 2009: 108: 667–672. in a patient with a pacemaker. Clin Infect Dis 1993: 16:
54. Rahamat-Langendoen JC, van Vonderen MG, Engstro € m LJ, 216–218.
Manson WL, van Winkelhoff AJ, Mooi-Kokenberg EA. Brain 66. Wagner KW, Scho €n R, Schumacher M, Schumeizeisen R,
abscess associated with Aggregatibacter actinomycetemcom- Schultze D. Case report: brain and liver abscesses caused
itans: case report and review of literature. J Clin Periodontol by oral infection with Streptococcus intermedius. Oral Surg
2011: 38: 702–706. Oral Med Oral Pathol Oral Radiol Endod 2006: 102: e21–
55. Rosan B, Rossman L. Endodontic microbiology. In: Lamont e23.
RJ, Burne RA, Lantz MS, LeBlanc DJ, editors. Oral microbi- 67. Weine FS, Buchanan LS. Controversies in clinical endodon-
ology and immunology, Chapter 15. Washington, D.C.: ASM tics: part 3. Filling from the open position. Compend Contin
Press, 2006: 349–360. Educ Dent 1997;18:906–910, 912, 914, 916–918.
56. Sakamoto H, Karakida K, Otsuru M, Arai M, Shimoda M. A 68. Zaleckas L, Rasteniene R, Rimkuviene J, Seselgyte R. Retro-
case of brain abscess extended from deep fascial space spective analysis of cellulitis of the floor of the mouth.
infection. Oral Surg Oral Med Oral Pathol Oral Radiol En- Stomatologija 2010: 12: 23–27.
dod 2009: 108: e21–e25. 69. Zijlstra EE, Swart GR, Godfroy FJ, Degener JE. Pericarditis,
57. Sakkas N, Schoen R, Schmeizeisen R. Orbital abscess after pneumonia and brain abscess due to a combined Actino-
extraction of a maxillary wisdom tooth. Br J Oral Maxillofac myces–Actinobacillus actinomycetemcomitans infection.
Surg 2007: 45: 245–246. J Infect 1992: 25: 83–87.
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