Abstract
Our aim was to investigate delay in the treatment of patients with acute odontogenic infections. A prospective clinical study and a questionnaire survey were designed and implemented in the emergency maxillofacial surgical patients of Helsinki University Hospital, Finland, over a one-year period. Altogether 88 adult patients with odontogenic infections confirmed by hospital examination were included in the analysis. The outcome variable was admission to hospital. Two-thirds of the patients had had previous visits for health care for their current infection. Treatment was started in nearly half the patients before hospital admission, and half of the treatment provided was exclusively antibiotics. The focus of infection was detected in half the patients before admission. Patients who were required further hospitalisation were younger than who were discharged (p = 0.021). Less well-educated patients were more likely to be hospitalised than patients in other education groups (p = 0.033). Leucocytosis was more prevalent in patients with a mandibular focus (p = 0.008), non-identified focus (p = 0.010), and infection as a result of elective tooth extraction (p = 0.026). The number of previous health care visits for the acute infection was notably high. Early treatment of infection may be overlooked, particularly in younger age groups and less well-educated patients. Challenges in making the correct diagnosis and prescribing effective treatment for such infections cause additional health care visits and unnecessary delay in care. More attention should be paid to the early detection and comprehensive primary treatment of odontogenic infections.
Introduction
Most deep neck infections are odontogenic and, without appropriate treatment, the infection spreads and causes a potentially life-threatening risk to the patient. Over the last decades the number of medically compromised patients has increased, and the course of such infections has become more severe and complex.
Patients’ history, including older age, diabetes mellitus, and immunosuppression, have been shown to predispose to deep odontogenic infections. Clinical features are more severe in patients with underlying disease, but severe infections may also occur in previously healthy patients. Earlier treatment of these infections with antibiotics alone, no surgical intervention, and severe infection suggest that hospital stay will be prolonged. Poor oral health and the absence of preceding dental treatment have also been shown to be associated with these infections.
Acute infections that originate from the mandibular teeth are known to be more severe than infections of maxillary origin, and those that spread to deeper tissue spaces most commonly arise from the molar region. Blunting of the mandibular inferior border at the body, induration of the floor of the mouth, trismus, and odynophagia are clear signs of severe infection. Severe immunodeficiency as a result of chronic illness or medication is a cause for admission to hospital in patients with acute infections. The signs and symptoms of a severe infection are local swelling and rash; difficulty in swallowing, breathing, or speaking; restricted mouth opening; fever; increased heart rate; malaise; light-headedness; tiredness; and changes in the cognitive state. Ideally, effective treatment should begin before these symptoms develop.
As an effective treatment, the dental focus should be treated at an early stage. However, in patients admitted to hospital with such an infection, the dental focus is often not removed even though the patients have been previously diagnosed with an infection.
Identifying the focus tooth can be challenging, as the symptoms and findings may not be clear, particularly in early infections. In addition, difficulties in accessing or seeking treatment may lead to delayed treatment. Restrictions in public health care dental benefits and difficulty in accessing care have been found to increase the prevalence and severity of these infections, and the cost of care.
To assess the importance of these preadmission issues, we evaluated patients’ backgrounds and treatment history before their hospital care assessment. The purpose of this study was to investigate the reasons for delay in treatment of patients with acute odontogenic infections. Our hypotheses were that there are delays in the early detection and treatment of these infections and that these delays may predispose patients to hospitalisation.
Patients and methods
Study design
To clarify treatment delay in patients with acute odontogenic infections we designed and implemented a prospective clinical study and a questionnaire survey. Patients recruited were examined for suspected acute infections between 1 January and 31 December 2018 in the Töölö Hospital Emergency Department, Helsinki University Hospital (HUH). The oral and maxillofacial emergency service is part of the Department of Oral and Maxillofacial Surgery, Helsinki University Hospital, Helsinki, Finland, with a catchment area of more than 1.6 million inhabitants.
The questionnaire survey recorded patients’ educational standard; history of smoking, alcohol, or drug abuse; previous visits to dental or general health care; previous antibiotic treatment and treatment given for the present infection; and the date on which the symptoms began. The delays from onset of symptoms and from when previous treatment was started before hospital admission were clarified with specific questions.
All patients’ records were reviewed for the duration of treatment of the present infection. Data recorded included age, sex, history, details of treatment of the infection, hospital care, inflammatory variables, and site of infection.
Patients were recruited and the questionnaire survey given at the time of admission to hospital. Data about patients’ visits to the polyclinic and hospital care during the period of treatment of the infection were collected.
Inclusion and exclusion criteria
Patients recruited were 18 years of age or older and were examined for suspected odontogenic infection. Those who agreed to participate and had confirmed infection at the hospital examination were included. Patients whose infective aetiology was other than odontogenic were excluded. Written consent was obtained from all patients.
Study variables
To examine severity of infection, the outcome variable was need for further treatment in hospital wards.
The primary predictive variables were delay in treatment (days) categorised as ≤5 or >5; preceding visits to health services before referral to hospital (yes/no); focus of infection identified before referral (yes/no); site of infective focus (mandible/maxilla); postoperative infection as a result of elective tooth extraction (yes/no); and previous treatment of the infection (yes/no). Delay in treatment was defined as days passed from the onset of symptoms to arrival at hospital. Additionally, previous treatment was categorised into the following groups: root canal treatment, extraction, drainage of an abscess, and exclusive use of antibiotics.
Explanatory variables were age, sex, current smoking (yes/no), heavy alcohol use (yes/no), disease history (yes/no), and basic education. Age was categorised using mean values. Education was categorised as basic education (compulsory comprehensive schools), upper secondary education (matriculation examination or vocational qualification), and higher education (university or university of applied sciences). Heavy alcohol use was calculated according to the Finnish Current Care Guidelines consumption limits for heavy alcohol use: ≥12–16 units (144–192 g of pure alcohol) per week for female patients and ≥23–24 units (276–288 g of pure alcohol) /week for male patients.
Associations between predictive variables and patients’ infection variables including body temperature, C-reactive protein (CRP) concentration, and white blood cell (WBC) count at hospital admission were analysed. Body temperature of 38.0 °C or higher was used to signify patients with fever. In addition, associations between admission to hospitalisation and infective variables were analysed.
Statistical analysis
We analysed the data with the aid of IBM SPSS Statistics for Macintosh (version 25.0, IBM Corp). To evaluate differences between groups in categorical variables, we used the chi-squared and Fisher’s exact tests, as appropriate. We used the t test and the Mann-Whitney U test to assess the significance of differences between continuous variables. Probabilities of less than 0.05 were considered significant.
Results
A total of 102 patients were recruited. Two patients refused to participate and 12 patients were excluded for diagnoses other than odontogenic infection, so 88 patients with infections of odontogenic origin were included in the analyses.
Of these 88 patients, 29 were required inpatient care and the remaining 59 were discharged after receiving emergency care. Half the patients had a history of chronic disease, the most common of which were cardiovascular diseases (CVD, other than hypertension only) in 18 of 88 patients, and diabetes in 10 of 88 patients. Five patients had mental disorders. The remaining chronic diseases recorded were autoimmune-diseases, malignancies, severe pulmonary diseases, pancreatitis, hepatitis, and alcoholic cirrhosis. Eight patients had more than one chronic disease. Descriptive statistics of the 88 patients are presented in Table 1 .
| Variable | No. |
|---|---|
| Sex: | |
| Male | 53 |
| Female | 35 |
| Mean (range) age (years): | 45 (19–84) |
| Current smoker: | |
| Yes | 39 |
| No | 49 |
| Heavy use of alcohol: | |
| Yes | 7 |
| No | 81 |
| History of chronic disease: | |
| Yes | 44 |
| No | 44 |
| Education: | |
| Basic | 15 |
| Upper secondary | 45 |
| Higher | 24 |
| Not documented | 4 |
Mean (SD) age was lower among patients kept in hospital than in those who were discharged (48 (16) years compared with 40 (15) years, p = 0.021). Lower education level was associated with further hospital care (p = 0.033), but sex, smoking, and drinking habits had no such correlation (further details are shown in Table 2 ).
| Variable | Need for hospitalisation | No need for hospitalisation | p Value |
|---|---|---|---|
| Sex: | 0.831 * | ||
| Male | 20 | 33 | |
| Female | 14 | 21 | |
| Mean (range) age (years): | 40 (21–79) | 48 (19–84) | 0.021 ** |
| Current smoker: | 0.083 * | ||
| Yes | 19 | 20 | |
| No | 15 | 34 | |
| Heavy use of alcohol: | 0.811 * | ||
| Yes | 3 | 4 | |
| No | 31 | 50 | |
| History of chronic disease: | 0.381 * | ||
| Yes | 15 | 29 | |
| No | 19 | 25 | |
| Education (n = 84): | 0.033 ** | ||
| Basic | 10 | 5 | |
| Upper secondary | 17 | 28 | |
| Higher | 6 | 18 |
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