Severe Deep Fascial Spaces Infections with Pregnancy: A Retrospective Study

Introduction

Pregnancy is associated with great physiological changes in otherwise healthy women. These changes include immune system modulation to prevent loss of the developing fetus due to antigen-antibody reactions. ¹ Such immune changes include decreased neutrophils chemotaxis, cell-mediated immunity, and natural killer cell activity.^2–4 Intraoral changes include increased incidence of gingivitis and subsequent appearance of the so called pregnancy tumor, calcular deposition, cariogenic bacteria, and periodontal diseases.^5–7 Also there is a decrease in salivary PH ⁸ This can lead to relative ease of spread of dental and periodontal infections into deep fascial spaces if not treated promptly and adequately which can lead to considerable morbidity and even catastrophic outcomes.^9,10

Deep fascial spaces of the neck are potential ones located within the fascial layers of the neck. Normally, they contain loose connective tissues. Severe deep fascial space infections lead to destruction of such connective tissue with subsequent spread to the next space. ¹¹

Odontogenic infections are common, they occur mainly due to dental caries or periodontitis, which represent the major etiology for deep fascial spaces infections,^12,13 they are usually self-limiting, but pus may extend into fascial spaces. This propagation may occur with direct spread, by lymphatics, or through hematogenous dissemination. The severity of such infections depend on patient’s local or systemic factors, and on the pathogen virulence. ¹⁴

Treatment aims to remove of the causative agent, incision and drainage, administration of proper antibiotic therapy. ¹⁵ The earlier infection control achievement, the less mortality and morbidity. ¹⁶

The current work aimed to evaluate the demographics, causes, risk factors, patterns, modalities of treatment, outcomes, and complications of odontogenic fascial space infections to evaluate etiology, pattern, outcomes of treatment rendered, and complications of fascial space infections occurring in pregnancy. Also, the study aimed at comparing these trends to other reports.

Materials and Methods

Results

Records of 39 cases matched the set criteria for the current study. One case was omitted because of incomplete data which left 38 cases to be included.

The age of our patients ranged from 22 years to 45 years with a mean age of 30.8 ± 6.21 years and a median of 29 years while their age of pregnancy ranged from 16–31 weeks with a mean of 24.5 ± 4.3 weeks and a median of 26 weeks

(Table 1) summarizes the demographic data, medical history, spaces involved, management rendered, and complications observed.

The commonest affected single space in our series was the submandibular space which occurred in six cases (15.8%), while the canine space was the second single commonly involved one which occurred in five patients (13.2%). Each of the submasseteric and buccal spaces occurred in four cases for each of them (10.5%).

Affection of more than one space occurred as follow: Affection of submandibular and submasseteric together occurred in 3 cases (7.9%), while affection of both aforementioned spaces combined with pterygomandibular space occurred in two patients (5.3%). Lastly, affection of both spaces combined with buccal space occurred in patient (2.6%).

Twenty-nine cases were otherwise healthy (76.32%). Diabetes mellitus was identified alone in seven cases (18.42%) and combined with hypertension in one case (2.63%) and with valvular heart disease in another one.

Treatment rendered was one of the following methods:

The first treatment method was extraction of the offending tooth with incision and drainage under general anesthesia, which was done in 31 patient (81.6%) of the cases. The second option was to preform previous the procedure under local anesthesia which occurred in three cases (7.9%). The last option was the administration of medical treatment with spontaneous treatment which was utilized in four cases (10.5%).

Ten pregnant patients were admitted to the ICU which represent about 26.3% of total patients with mean of 5.5 ± 2.37 days with range 3–11 days. Among the nine who were medically compromised, seven were admitted to the ICU. There was statistically significant relationship between the compromised medical condition and ICU admission. (Table 2) No statistical difference was found between the length of ICU stay and the medical history. (Table 3).

We failed to get a correlation between the age of pregnancy and ICU stay. (Table 4).

Complications occurred in 11 patients (28.9%) of our patients. The most single common one was unesthetic scar which occurred in three patients (7.9%). Trismus was observed in two patients (5.3%). Recurrent abscess was found in one case, while scarring was combined with trismus in one case. Complications affecting the developing fetus and considered serious occurred in four patients: two cases of preterm labor and two cases of abortion, each two represented (5.3%) (Table 5).

Discussion

In pregnancy, the oral hygiene may be compromised due to variety of factors when combined with the drastic physiologic hormonal and immunologic changes, this may lead to a rapid change from simple infection into severe one with catastrophic outcomes on the mother and the fetus.

Delay of proper surgical intervention either in the form of endodontic treatment or extraction, by some dental practitioners due to either lack of knowledge or the fear of facing social or even legal problems ¹⁷ Also, some cultural practices and social believes in some of the third World may contribute to further delay in seeking medical professional treatment.^18,19

In the current study, the mean age for our patients was 30.8 years with the youngest being 22 and the oldest 45 years. This was slightly younger than those in the study of Fomete et al. ¹⁹ which was 33.8 years with range of 20 to 55 years. In contrast to that one for Wazir et al. ²⁰ who obtained younger age group with a mean of 24.78 years and an age range of 17–30 years. This difference at age group may be due to difference of marriage age. In some Nigerian reports there is a mention for seeking a traditional medication by patients before attending professional medical practitioner which may contribute to a delay of presentation and an increased morbidity and mortality.^18,21

The mean age of pregnancy at time of presentation was 24.5 weeks with range of 16 to weeks which is close to the 24.9 weeks Fomete et al. ¹⁹ In contrast, Ali et al (18) demonstrated that 60% of their cases occurred in the third trimester. Similarly, Wazir et al. ²⁰ showed that 50% of their cases were in the third trimester. This may be due to the delay in seeking treatment.

In the current study, the commonest single deep fascial space affected was the submandibular abscess which affected six patients, while the second commonly affected one was the canine space that occurred in five patients. The third commonly affected space was shared by buccal and submasseteric spaces, with each affected four cases. The submandibular space is being the most commonly affected space in different studies done either on pregnant patients or even the general population.^13,18–20, this may be due to that lower molars are more affected and their roots apices are located beneath the mylohyoid line, leading to direct affection of the submandibular space.

Twenty-nine patients (76.32%) of this study were otherwise healthy subjects, while nine patients had a positive medical condition. Diabetes mellitus was the single common condition occurring alone in seven patients (18.42%) and combined with hypertension in one patient (2.63%) and with valvular heart disease in another patient. Omission of those cases with medical conditions from the study as in the studies of Ali et al. ¹⁸ and Wazir ²⁰ et al. may not demonstrate the effects of various medical problems on the final outcomes.

Management of our cases was one of three methods:

The commonest was removal of the cause as well as incision and drainage under GA, done in 31 cases representing 81.6% of our cases, while performing the procedure under local anesthesia was done in just only three cases representing 7.9% of our patients. Operating the patients under GA is much more convenient and safer from surgical point of view, but it is much more demanding from the anesthetic point and postoperative care. We think that the studies whose patients were operated under local anesthesia^18,19,21 may be due to lack of proper equipment and/or the lack of other non-maxillofacial personnel who can perform anesthesia and postoperative care for pregnant patients. We believe that operating pregnant patients with deep fascial space infections under local anesthesia can be done in selected cases in which the space is accessible from an intraoral approach, and there is adequate mouth opening with patent airway. This explains the limited number of our cases managed under local anesthesia.

Ten patients from this series were admitted into ICU representing 26.3% of our cases, with mean of stay 5.5 days ranging from 3–11 days. Seven out of the ten patients were medically compromised. We obtained statistically significant relationship between compromised medical condition and ICU admission. This may demonstrate the severity of the condition when compared with to otherwise healthy patients suffering from deep fascial space infection. ICU admission is mandatory in severe cases either pregnant or not.^9,13

We had 11 cases presented with complications. The commonest one was unaesthetic scar which occurred alone in three patients (7.9% of all cases) and combined with trismus in one case. Such cases were offered later, plastic surgical procedures to improve the final outcomes. Two cases of trismus occurred postoperatively, representing 5.3% of our patients while one case of recurrent abscess and another case of trismus combined with ugly neck scar worse documented in our patients each representing 2.6% of our patients.

In our series we obtained four cases of serious complications: two cases had preterm labor representing 5.3% of total patients and another two cases suffered from abortion. Abortion may occur in severe cases which can result from severe maternal sepsis. ⁹ We hadn’t any death case for our patients in spite of the severity, this can be attributed to adequate treatment rendered and the extensive utilization of ICU.

Conclusions

Odontogenic infections are not uncommon. Such conditions may have severe disastrous outcomes affecting the mother and developing fetus. These infections require prompt aggressive urgent multidisciplinary surgical and medical intervention to decrease and avoid possible complications. Proper early dental treatment via regular dental visits in pregnancy is recommended to eliminate the possible sources for development of such serious conditions.