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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 105-108

Microflora in odontogenic infections


1 Public Health Dentist, Private Practitioner, Ranchi, Jharkhand, India
2 Department of Conservative and Endodontiocs, PHC Sampatchak, Patna, Bihar, India
3 Department of Paediatric Dentistry, Ministry of Health, King Khaled Hospital, Riyadh, Saudi, Arabia
4 Department of Oral and Maxillofacial Surgery, SGT University, Gurugram, Haryana, India
5 Department of Public Health Dentistry, Kothiwal Dental College and Research Center, Moradabad, Uttar Pradesh, India

Date of Submission18-May-2020
Date of Decision12-Jun-2020
Date of Acceptance20-Jun-2020
Date of Web Publication08-Oct-2020

Correspondence Address:
Priyaranjan
Public Health Dentist, Private Practitioner, Ranchi, Jharkhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrr.jdrr_41_20

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  Abstract 


Purpose: This study was intended to evaluate the various causative microorganisms responsible for fascial space infections. Materials and Methods: A total of 88 patients who reported with an orofacial space infection of odontogenic origin were included in the study. Following a thorough evaluation, using a disposable syringe, pus sample was obtained and sent for culture and sensitivity test. Offending teeth were extracted under antibiotic coverage, and incision and drainage was done as and when indicated. The results of the culture and sensitivity along with the effective antibiotic were tabulated. Results: The results of this study show that submandibular space (38.8%) is the frequently involved fascial space. Majority of the patients are in the second and third decades of life (53.9%). Staphylococcus species (41.1%) is the most commonly isolated microorganism. Penicillin remains to be the drug of choice. Extraction of the offending tooth under antibiotic coverage and incision and drainage remains to be a treatment option. Conclusion: Based on the results of this study, it can be concluded that the causative microorganisms for odontogenic infections involved mixed aerobic–anaerobic bacteria. Anaerobic as well as aerobic cultures were necessary to isolate all pathogens.

Keywords: Odontogenic infection, penicillin, Staphylococcus


How to cite this article:
Priyaranjan, Shekhar V, Mohammed Abdul MS, Gulia SK, Ahmad FN. Microflora in odontogenic infections. J Dent Res Rev 2020;7:105-8

How to cite this URL:
Priyaranjan, Shekhar V, Mohammed Abdul MS, Gulia SK, Ahmad FN. Microflora in odontogenic infections. J Dent Res Rev [serial online] 2020 [cited 2020 Oct 28];7:105-8. Available from: https://www.jdrr.org/text.asp?2020/7/3/105/297526




  Introduction Top


Among the wide spectrum of work that encompasses the field of oral and maxillofacial surgery, odontogenic infections are considered to be one of the most commonly encountered conditions, particularly in the rural sector. It is a well-known fact that these infections can range from a low-grade localized periapical abscess that requires minimal intervention to severe, life-threatening fascial space infections.[1],[2] Majority of the odontogenic infections are bacterial infections involving either a disturbance of the normal flora or a displacement of the normal flora to the site, where they are habitually not seen.[3] Due to the polymicrobial nature of these infections, it is essential for clinicians to understand precisely the microorganisms that are likely to cause the infection.[2],[4] In spite of the drastic reduction in the complications from the spread of these infections with the advent of modern antibiotics, the management of pus in odontogenic infection still remains a challenge to the clinician.[5] Hence, this study is designed to prospectively assess the causative microorganisms responsible for odontogenic infections.


  Materials and Methods Top


The present study was conducted in a rural setup during the period of July 2017–December 2019. A total of 88 patients who had been diagnosed clinically and radiographically with orofacial space infection of odontogenic origin were included in the study. The institutional ethical clearance is obtained.

Patients diagnosed clinically and radiographically with odontogenic infection involving one or more of the deep fascial spaces in the head-and-neck region are included in the study. Pregnant patients, patients who require general anesthesia for the management of odontogenic infections, medically compromised patients, and patients who gave a history of prior antibiotic medication were excluded from this study.

The following parameters were evaluated in this study:

  1. Patient factors such as age and sex
  2. Involved fascial space and the predisposing factors
  3. Causative microorganism and the choice of antibiotic.


With the aid of a thorough clinical and systemic evaluation, the patient was taken up for treatment. After taking patient consent, a 10-ml disposable syringe with a disposable needle of 18G was used to aspirate the pus from the abscess. The aspirate was immediately transported to the department of microbiology of our institution for pus and culture sensitivity test under sterile conditions before the commencement of antibiotic therapy. Patients who were still in the state of cellulitis and in whom pus samples could not be drawn were kept on medical treatment after extraction of the offending tooth/teeth, and follow-up was done.

Pus samples were processed as follows:

  1. Smear studies of gram staining
  2. Aerobic culture
  3. Anaerobic culture and aerobic culture.


For aerobic culture, the samples were inoculated on MacConkey's agar, blood agar, and nutrient broth. After overnight inoculation, the plates were observed for colony formation. The colonies were identified by gram staining and biochemical tests. For Gram-positive cocci catalase, bacitracin sensitivity, optochin sensitivity, coagulase test, and growth in 6.5% sodium chloride were used. For Gram-negative bacilli oxidase test, catalase test, indole test, urease test, citrate test, and triple sugar iron were used. If no growth was observed after the first culture, subcultures from nutrient broth were made on MacConkey's agar and blood agar and looked for growth after overnight incubation. Growth was identified using appropriate biochemical tests.

For anaerobic culture, sample was inoculated into plain blood agar, kanamycin and vancomycin blood agar, and bile esculin agar and incubated anaerobically in gas pack anaerobic system for 48–72 h. The plates were observed for colony formation. The colonies were identified by gram's stain, hemolysis, brick red fluorescence under ultraviolet light, and sensitivity to antibiotics such as penicillin, vancomycin, kanamycin, and sodium polyethanol sulfonate, and colonies were tested for aerotolerance. If no growth was observed after the first culture, subculture was done from Robertson's cooked meat broth on plain blood agar and bile esculin agar and identified as mentioned above. Antibiotic sensitivity was done by Kirby–Bauer disk diffusion method.

All patients were started with empirical antibiotics (amoxicillin with clavulanic acid and metronidazole) preoperatively and continued postoperatively. Causative teeth were extracted immediately. Incision and drainage was carried out under aseptic conditions. Corrugated rubber drain was placed if required and stabilized with sutures. The drain was kept in place for <48 h. Based on the culture and sensitivity report depending on the clinical course of the disease, appropriate antibiotics were given as and when required.


  Results Top


The results of this study show that submandibular space (38.8%) is the frequently involved fascial space. Majority of the patients are in the second and third decades of life (53.9%). Staphylococcus species (41.1%) is the most commonly isolated microorganism. Penicillin remains to be the drug of choice. Extraction of the offending tooth under antibiotic coverage and incision and drainage as indicated remains to be a treatment option. The results are depicted in [Figure 1], [Figure 2], [Figure 3].
Figure 1: Age distribution

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Figure 2: Fascial spaces involved

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Figure 3: Causative microorganisms

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  Discussion Top


The microbial isolates in odontogenic infection are complex of species predominantly of bacteria which may be aerobes and anaerobes to mixture of aerobes and anaerobes.[6] Previous studies reveal that major isolates obtained in odontogenic infection are streptococci and anaerobic bacteria, which are regarded as normal flora of the tooth and gingival crevice.[7]

The results of the present study revealed that microbiological flora ranged from aerobes, anaerobes and mixture of aerobes, and anaerobes with aerobic Staphylococcus aureus being the most commonly isolated microbe constituting 41.1%, followed by Enterococcus species (21.1%). This is in accordance with previous studies.[1],[6],[8],[9] Aerobic microorganisms and a mixture of aerobes and anaerobes microorganisms were isolated from the primary fascial spaces, whereas anaerobic microorganisms were isolated from secondary fascial spaces. Isolates obtained from patients who reported during the acute stages of their disease revealed aerobic microorganisms and a mixture of aerobes and anaerobes microorganisms, whereas isolates obtained from patients who reported during the chronic stages of their disease revealed anaerobes microorganisms. Few studies in the past have reported aerobic Streptococcus viridans and anaerobic Bacteroides and Prevotella as the most commonly isolated microbe.[5],[6],[7] Submandibular space was the most commonly involved fascial spaces accounting for 38.8% of the fascial spaces, followed by the buccal space (26.5%). This is in concurrence with previous studies.[8],[9]

Previous studies reported lesser isolates of Pseudomonas.[10],[11] However, the results of this study show higher isolates of Pseudomonas. This is in accordance with previous studies.[1] This could be attributed to the fact that when bacteria of the normal flora are suppressed, Pseudomonas becomes dominant.[12] The injudicious use of antibiotics in the recent past could be the cause for higher isolation of drug-resistant pathogen like Pseudomonas.[13] The incidence of Klebsiella in this study is similar to that of the previous studies.[13] Previous studies have stated that Gram-negative bacilli isolated in odontogenic infections would lead to synergism with other bacterial species.[14]

The aerobic microbial strains isolated in the present study were most sensitive to both co-amoxiclav and azithromycin. The efficacy of co-amoxiclav and azithromycin against the aerobic organisms of odontogenic infection has also been reiterated by Lewis et al.[15] All the anaerobic microbial strains isolated were found to be sensitive to both metronidazole and clindamycin. In the present study, all the patients were started empirically on broad-spectrum antibiotics and changed depending upon the culture and sensitivity report and the clinical course of the disease as and when required based on the reports by Balcerak et al.[16]

With regard to pediatric patients, odontogenic infection spreads swiftly due to the wide marrow spaces and less density of the bones when compared to adults.[17] In addition to this, identification of the offending tooth and microorganisms causing infection is very difficult due to the close proximity of the skin, teeth, salivary glands, sinuses, and eustachian tubes.[17]

The ideal means of managing a pyogenic orofacial infection is by surgical drainage and along with definitive restoration or extraction of the offending tooth.[3] Immediate extraction of teeth in the setting of an acute infection is beneficial since it results in faster resolution of the infection, decreased pain, and earlier return of function and oral intake.[8] This principle was employed in the present study. Failure to include patients in whom advanced infections involving the retropharyngeal or parapharyngeal fascial spaces in addition to not involving the duration of course of the disease are the limitations of this study.


  Conclusion Top


It can be concluded based on the results of this study that successful management of odontogenic infections depends greatly on the removal of etiologic factor in addition to employing the appropriate antibiotics. More studies are required over a period of time with the aid of larger sample size and the requirement for revision from time to time due to the advent of newer antibiotics and their changing sensitivities to different isolates.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Patankar A, Dugal A, Kshirsagar R, Hariram, Singh V, Mishra A. Evaluation of microbial flora in orofacial space infections of odontogenic origin. Natl J Maxillofac Surg 2014;5:161-5.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Peterson LJ, Ellis E III, Hupp JR, Tucker MR, editors. Contemporary Oral and Maxillofacial Surgery. 4th ed. Peterson St. Louis: Mosby; 2003.  Back to cited text no. 2
    
3.
Topazian RG, Goldberg MH, Hupp JR, editors. Oral and Maxillofacial Infections. 4th ed. Philadelphia: WB Saunders; 2002. p. 99-213.  Back to cited text no. 3
    
4.
Aderhold L, Knothe H, Frenkel G. The bacteriology of dentogenous pyogenic infections. Oral Surg Oral Med Oral Pathol 1981;52:583-7.  Back to cited text no. 4
    
5.
Bahl R, Sandhu S, Singh K, Sahai N, Gupta M. Odontogenic infections: Microbiology and management. Contemp Clin Dent 2014;5:307-11.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Sánchez R, Mirada E, Arias J, Paño JR, Burgueño M. Severe odontogenic infections: Epidemiological, microbiological and therapeutic factors. Med Oral Patol Oral Cir Bucal 2011;16:e670-6.  Back to cited text no. 6
    
7.
Hardie JM, Bowden GH. The normal microbial flora of the mouth. In: Skinner FA, Carr JG, editors. The Normal Microbial Flora of Man. New York: Academic Press; 1974. p. 47-83.  Back to cited text no. 7
    
8.
Uppada UK, Sinha R. Outcome of odontogenic infections in rural setup: Our experience in management. J Maxillofac Oral Surg 2020;19:113-8.  Back to cited text no. 8
    
9.
Zamiri B, Hashemi SB, Hashemi SH, Rafiee Z, Ehsani S. Prevalence of odontogenic deep head and neck spaces infection and its correlation with length of hospital stay. Shiraz Univ Dent J 2012;13:29-35.  Back to cited text no. 9
    
10.
Labriola JD, Mascaro J, Alpert B. The microbiologic flora of orofacial abscesses. J Oral Maxillofac Surg 1983;41:711-4.  Back to cited text no. 10
    
11.
Rega AJ, Aziz SR, Ziccardi VB. Microbiology and antibiotic sensitivities of head and neck space infections of odontogenic origin. J Oral Maxillofac Surg 2006;64:1377-80.  Back to cited text no. 11
    
12.
Bratton TA, Jackson DC, Nkungula-Howlett T, Williams CW, Bennett CR. Management of complex multi-space odontogenic infections. J Tenn Dent Assoc 2002;82:39-47.  Back to cited text no. 12
    
13.
Haug RH. The changing microbiology of maxillofacial infections. Oral Maxillofac Surg Clin North Am 2003;15:1-5.  Back to cited text no. 13
    
14.
Walton RE. Culturing exudates of odontogenic infection-a successful procedure? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:525.  Back to cited text no. 14
    
15.
Lewis MA, MacFarlane TW, McGowan DA. Reliability of sensitivity testing of primary culture of acute dentoalveolar abscess. Oral Microbiol Immunol 1988;3:177-80.  Back to cited text no. 15
    
16.
Balcerak RJ, Sisto JM, Bosack RC. Cervicofacial necrotizing fasciitis: Report of three cases and literature review. J Oral Maxillofac Surg 1988;46:450-9.  Back to cited text no. 16
    
17.
Nagaveni NB, Umashankara KV. Microflora of orofacial space infections of odontogenic origin in children – A bacteriological study. J Interdiscipl Med Dent Sci 2014;2:118.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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