J Oral Maxfllofac 50:33-35.
SW9
1992
The Third as a Deep Space A. THOMAS
of
INDRESANO, DMD,* RICHARD H. HAUG, DDS,t AND MICHAEL J. HOFFMAN, DDS*
An 81-month review of patients with deep space infections attributed to third molars requiring hospital admission is presented. Thirty-one patients were identified, with males predominating 2:l and mandibular third molars as an etiology predominating 151. All patients were aged 23 years or older. Most patients identified (24) had one or more medical problems or other risk factors, the most frequent of which was smoking (18). All patients developing postoperative infections (9) had complete or partial bone impactions and a preoperative diagnosis of pericoronitis.
or more of the following: a temperature elevated above 38.O”C, a white blood cell count elevated above 10.8 X 103/mL3, or impending airway obstruction. Each patient was categorized by age, sex, anatomic space, tooth of etiology, type of impaction, dental diagnosis, medical compromise, admission temperature, admission white blood cell count, pathogens isolated, and days hospitalized. The anatomic space was identified according to the system described by Spilka.4 The classification of impaction was according to the system described by Peterson.’ The data were collated and evaluated in an attempt to identify particular etiologic trends.
It is estimated that 80% of the population has at least one third molar.’ Pain, swelling, caries, and malposition are common problems associated with these teeth. A less frequent, but more serious, concern is the development of a deep space abscess caused by a third molar, requiring surgical drainage and hospital management. 2*3The purpose of this article is to review the population characteristics of patients with deep space infections attributed to third molars that require hospital admission to identify particular etiologic trends that might be helpful to the practitioner in the diagnosis and treatment of these patients. Materials and Methods
Results
This investigation was performed at the MetroHealth Medical Center, which serves approximately 3.4 million people in northeast Ohio. Hospital charts and radiographs of 31 patients with deep space infections caused by third molars admitted to the oral and maxillofacial surgery service from March 1983 through November 1989 were reviewed by two investigators. Criteria for admission were swelling of at least one fascial space, indicative of cellulitis or abscess, and one
Of the 3 1 patients identified, 20 were men and 11 were women, with an average age of 3 1.8 years (range, 23.2 to 83.3 years). The mandibular left third molar was the most frequent offender (16), followed by the mandibular right third molar ( 13). The maxillary right and left third molars were each involved once. The most frequent tooth position was the partial bony impaction (12), followed by fully erupted (9), soft-tissue impacted (6), and complete bony impacted (4). Twenty-one patients suffered from pericoronitis, while five patients each had periodontitis or carious pulp exposures as an etiology. Nine patients had postoperative infections, of which six had partial bony impactions and three had full bony impactions. All had suffered preoperatively from pericoronitis. Twenty-four patients had some form of medical problem or other risk factor. Most common were smoking (at least one pack of cigarettes per day), ethanol abuse, intravenous drug abuse, hepatitis, asthma, hypertension, and diabetes (Table
Received from MetroHealth Medical Center and the Case Western University, Cleveland. * Director, Division of Oral and Maxillofacial Surgery. t Assistant Professor of Surgery. $ Resident, Division of Oral and Maxillofacial Surgery. Address correspondence and reprint requests to Dr Haug: Division of Oral and Maxillofacial Surgery, MetroHealth Medical Center, 3395 Scranton Rd, Cleveland, OH 44 109. 0 1992 American Association of Oral and Maxillofacial Surgeons 027%2391/92/5001-0007$3.00/0
33
34
THIRD MOLAR DEEP SPACE INFECTIONS
1). Eighteen patients were smokers, and nine had one or more medical problems. Fifteen patients had single-space infections, and 16 had multispace infections. The submandibular space was most frequently affected (20), followed by the buccal space ( 15) and lateral pharyngeal space (8). Cultures from three patients grew no organisms, whereas in 11 only a single organism was isolated. cu-Hemolytic streptococci was most frequently isolated ( 14), followed by Bacteroides melaninogenicus (1 I), and ,&hemolytic streptococci (6). No correlation could be identified between pericoronitis, periodontitis, carious pulp exposures, and the organisms isolated (Table 2). The average admission white blood cell count was 13.4 X 103/mL3 (range, 6.1 to 25.7 X 103/mL3). The average admission temperature was 37.8”C (range, 36.9 to 39.2”C). The average length of hospitalization was 6.2 days (range, 3 to 13 days).
Table 2. Frequency of Organisms Isolated and Source of Infection
Organism a-Hemolytic streptococci
Pericoronitis (n = 21)
Periodontitis (n = 5)
Caries (n = 5) Total
10
2
2
14
Bacteroides melaninogenicus
8
2
1
II
fl-Hemolytic streptococci
4
2
Staphylococcus aureus Staphylococcus epidermidis Hemophilus influenza Nisseria spp Bacteroides corrodens Eikenelfa corroders
2 2 2
y-Hemolytic streptococci
1
4
1
5
I
4 3 3 2 2
I
I
.4ctinom)jces Candida spp Eschericia coli
Discussion
6
2 I
2
1
I
Bacteroides, fiagilis
Deep space abscesses that require hospital admission, medical management, and surgical drainage, are a serious health problem. Because of the proximity of the upper airway, life-threatening complications may ensue, especially when there is a need for general anesthesia to accomplish the drainage necessary to control the infection. Advocacy for the removal of impacted third molars has waned in recent years. The idea that these teeth are in some way valuable has surfaced in the dental community. Third-party carriers are refusing to cover the costs of removal based on an unperceived need for treatment. This report documents 3 1 cases of very serious infection seen at one institution over a 6-year period. If this represents five cases per year at each major hospital in the United States ( 100 or more beds),
Table 1. Medical Problems or Other Risk Factors in Patients Developing Deep Space Abscesses Attributed to Third Molars (n = 24) Medical Compromise Smoking Ethanol abuse Intravenous drug abuse Hepatitis B Asthma Hypertension Diabetes Stroke Peripheral vascular disease Deep venous thrombosis Urinary tract infection
No. of Patients 18 5 4 3 3 3 2
1 1 1 1
No growth in three patients, one for each diagnosis.
it may indicate the occurrence of as many as 15,000 cases of serious or life-threatening infection per year.6 The average hospital stay for this problem at our institution was 6.2 days. A typical cost per day for this admission, including hospital bed, operating room, laboratory fees, and medications, excluding surgical and consultant fees and lost work time, is $1000. This represents $93,000,000 annually in hospital fees alone, and highly outweighs the cost of the removal of these teeth in an asymptomatic state. The 3 1 serious infections identified could have been avoided by the removal of the third molars during the teenage years, a common practice advocated by many. Several of these infections occurred after the removal of a third molar with the preoperative diagnosis of pericoronitis. None occurred postoperatively after the removal of a tooth that had not been infected in some way. This suggests that waiting for the tooth to become infected before removal may be risking a more serious infection and may not be the proper treatment. The findings in this study strongly suggest that patients who have diabetes, asthma, or hypertension, or who smoke or abuse drugs or alcohol, are a population at risk for developing a deep space abscess from an infected third molar. This medically compromised population should have their impacted mandibular third molars removed before signs of infection occur to obviate the more serious and potentially life-threatening risk of a deep space abscess.
35
INDRESANO, HAUG. AND HOFFMAN
References
bidity associated with mandibular third molar surgery. J Am Dent Assoc 101:240, 1980
1. Bishara SE, Andreason JO: Third molars: A review. Am J Orthod 83:131, 1983 2. Goldberg MH, Nemarich AN, Marco WP: Complications after third molar surgery: A statistical analysis of 500 consecutive procedures in private practice. J Am Dent Assoc 111:277, 1985 3. Bruce RA, Frederickson GC, Small GS: Age of patients and mor-
J Oral Maxillofac 50:35-36.
4. Spilka CJ: Pathways of dental infection. J Oral Surg 24: I 11, 1966 5. Peterson LJ: Principles of management of impacted teeth, in Peterson LJ (ed): Contemporary Oral and Maxillofaciai Surgery. St Louis, MO, Mosby, 1988, p 243 (chap 9) 6. AHA Guide to Hospital Statistics, I990- 199 1, Table 5A. Chicago, IL, 1991, p 20
Surg
1992
Discussion The Third Molar as a Cause of Deep Space Infections Morton H. Goldberg, DMD, MD Universityof Connecticut.Farmington
The third molar as a cause of great concern to oral and tients, hospitals, third-party. health planners. This study the prevalence of third molar and raises thought-provoking
of deep space infections is indeed maxillofacial surgeons, their papayers, and medicoeconomic adds useful information about infections in compromised hosts questions about prophylactic
surgery. Data concerning the fate of asymptomatic third molars have been clouded by medical myths, long-established surgical habits, referral patterns, economic motivations, and the rites of passage of middle-class American culture.’ Because of these factors, long-term longitudinal studies of the natural history of impacted teeth have been difficult to establish or complete. Wowem and Nielsen,’ as well as Venta et al,3 concluded, however, that third molars continue to erupt after the age of 20 and recommended observation rather than extraction. However, conflicting data from the study by Garcia and Chauncy in men 25 years and older revealed few erupting and subsequently functioning third molars4 Subsequent functioning is the key to any discussion of whether or not third molars should be removed prophylactically to prevent pain or infection. Eruption late in life may be just as unacceptable to the patient as is surgery; witness the many anecdotal tales of frail, osteoporetic octogenarians facing the Hobson’s choice of eruption or extraction. The authors describe 24 of 3 1 patients admitted for deep space infections secondary to third molars as having “some form of medical problem or risk factor.” However, unlike diabetes, cancer, chemotherapy, or acquired immunodeficiency syndrome, I am unaware of any hard data that links asthma, hypertension, urinary tract infection, or smoking to increased incidence of odontogenic infection, as assumed by these authors. Furthermore, the singularly most important issue of antibiotic usage is not addressed in this article, even though 68% of these patients had a history of pericomitis and 29% had documented postextraction infection. Both the resuits and conclusions of this article (ie, perhaps fewer admissions) would have been altered if data concerning antibiotic success or failure had been analyzed. Antibiotic prophylaxis and therapy in the compromised host is a wellestablished and accepted principle of surgery. The failure to consider the influence of antibiotics on the infection rate and
hospital admission rate of patients is the most serious flaw in this article. The authors have also failed to compare admissions for infections of third molar origin in the compromised host with those of non-third molar odontogenic infection. While the authors’ extrapolation of costs to the $93 million level is certainly impressive, it pales in comparison to the estimated $300 million that is already spent annually on third molar extractions. Even if prophylactic extraction were limited to the “at risk population” studied here, the cost to the health care system to remove all impacted third molars from every diabetic, asthmatic, hypertensive, alcoholic, smoking, or drug-using patient would be staggering and would certainly deflect huge sums away from basic research on the cause and treatment of these problems. With a 5% postoperative infection rate in healthy patients, doubled in diabetics, and almost tripled in patients with leukemia or high-dose corticosteriod therapy, might not universal removal of impacted third molars cause more mischief and misery than careful observation and selective surgery? The incidence of third molar impaction has generally increased in our society, in the healthy as well as those who subsequently suffer ill health. Preventive dentistry, professional care, and the preservation of first and second molars by fluoride have resulted in an impaction rate probably never before experienced by the human race. A changing diet, with less abrasion, has also contributed to the increase of impacted teeth, a problem also recently described in wild mammals that have been domesticated.5 In both healthy and high-risk patients, certain judgmental criteria for asymptomatic third molars should be used in the surgical decision-making process: 1. a history of past infection; 2. nonprogressive, partial eruption with pericoronal flap and food entrapment; 3. periodontal pocketing involving the impacted tooth; 4. no attached gingiva in the neighborhood of the erupting third molar; 5. if infection of a fracture site is likely; 6. radiographic imaging reveals true cyst or tumor formation, or erosion of an adjacent tooth; 7. the patient will be spending an extended period in a location where oral maxillofacial surgery is unavailable.
Even with rigid adherence to these criteria, many asymptomatic third molars will require surgery. It is not wise or necessary, however. to advocate universal prophylactic removal
SW9
1992
The Third as a Deep Space A. THOMAS
of
INDRESANO, DMD,* RICHARD H. HAUG, DDS,t AND MICHAEL J. HOFFMAN, DDS*
An 81-month review of patients with deep space infections attributed to third molars requiring hospital admission is presented. Thirty-one patients were identified, with males predominating 2:l and mandibular third molars as an etiology predominating 151. All patients were aged 23 years or older. Most patients identified (24) had one or more medical problems or other risk factors, the most frequent of which was smoking (18). All patients developing postoperative infections (9) had complete or partial bone impactions and a preoperative diagnosis of pericoronitis.
or more of the following: a temperature elevated above 38.O”C, a white blood cell count elevated above 10.8 X 103/mL3, or impending airway obstruction. Each patient was categorized by age, sex, anatomic space, tooth of etiology, type of impaction, dental diagnosis, medical compromise, admission temperature, admission white blood cell count, pathogens isolated, and days hospitalized. The anatomic space was identified according to the system described by Spilka.4 The classification of impaction was according to the system described by Peterson.’ The data were collated and evaluated in an attempt to identify particular etiologic trends.
It is estimated that 80% of the population has at least one third molar.’ Pain, swelling, caries, and malposition are common problems associated with these teeth. A less frequent, but more serious, concern is the development of a deep space abscess caused by a third molar, requiring surgical drainage and hospital management. 2*3The purpose of this article is to review the population characteristics of patients with deep space infections attributed to third molars that require hospital admission to identify particular etiologic trends that might be helpful to the practitioner in the diagnosis and treatment of these patients. Materials and Methods
Results
This investigation was performed at the MetroHealth Medical Center, which serves approximately 3.4 million people in northeast Ohio. Hospital charts and radiographs of 31 patients with deep space infections caused by third molars admitted to the oral and maxillofacial surgery service from March 1983 through November 1989 were reviewed by two investigators. Criteria for admission were swelling of at least one fascial space, indicative of cellulitis or abscess, and one
Of the 3 1 patients identified, 20 were men and 11 were women, with an average age of 3 1.8 years (range, 23.2 to 83.3 years). The mandibular left third molar was the most frequent offender (16), followed by the mandibular right third molar ( 13). The maxillary right and left third molars were each involved once. The most frequent tooth position was the partial bony impaction (12), followed by fully erupted (9), soft-tissue impacted (6), and complete bony impacted (4). Twenty-one patients suffered from pericoronitis, while five patients each had periodontitis or carious pulp exposures as an etiology. Nine patients had postoperative infections, of which six had partial bony impactions and three had full bony impactions. All had suffered preoperatively from pericoronitis. Twenty-four patients had some form of medical problem or other risk factor. Most common were smoking (at least one pack of cigarettes per day), ethanol abuse, intravenous drug abuse, hepatitis, asthma, hypertension, and diabetes (Table
Received from MetroHealth Medical Center and the Case Western University, Cleveland. * Director, Division of Oral and Maxillofacial Surgery. t Assistant Professor of Surgery. $ Resident, Division of Oral and Maxillofacial Surgery. Address correspondence and reprint requests to Dr Haug: Division of Oral and Maxillofacial Surgery, MetroHealth Medical Center, 3395 Scranton Rd, Cleveland, OH 44 109. 0 1992 American Association of Oral and Maxillofacial Surgeons 027%2391/92/5001-0007$3.00/0
33
34
THIRD MOLAR DEEP SPACE INFECTIONS
1). Eighteen patients were smokers, and nine had one or more medical problems. Fifteen patients had single-space infections, and 16 had multispace infections. The submandibular space was most frequently affected (20), followed by the buccal space ( 15) and lateral pharyngeal space (8). Cultures from three patients grew no organisms, whereas in 11 only a single organism was isolated. cu-Hemolytic streptococci was most frequently isolated ( 14), followed by Bacteroides melaninogenicus (1 I), and ,&hemolytic streptococci (6). No correlation could be identified between pericoronitis, periodontitis, carious pulp exposures, and the organisms isolated (Table 2). The average admission white blood cell count was 13.4 X 103/mL3 (range, 6.1 to 25.7 X 103/mL3). The average admission temperature was 37.8”C (range, 36.9 to 39.2”C). The average length of hospitalization was 6.2 days (range, 3 to 13 days).
Table 2. Frequency of Organisms Isolated and Source of Infection
Organism a-Hemolytic streptococci
Pericoronitis (n = 21)
Periodontitis (n = 5)
Caries (n = 5) Total
10
2
2
14
Bacteroides melaninogenicus
8
2
1
II
fl-Hemolytic streptococci
4
2
Staphylococcus aureus Staphylococcus epidermidis Hemophilus influenza Nisseria spp Bacteroides corrodens Eikenelfa corroders
2 2 2
y-Hemolytic streptococci
1
4
1
5
I
4 3 3 2 2
I
I
.4ctinom)jces Candida spp Eschericia coli
Discussion
6
2 I
2
1
I
Bacteroides, fiagilis
Deep space abscesses that require hospital admission, medical management, and surgical drainage, are a serious health problem. Because of the proximity of the upper airway, life-threatening complications may ensue, especially when there is a need for general anesthesia to accomplish the drainage necessary to control the infection. Advocacy for the removal of impacted third molars has waned in recent years. The idea that these teeth are in some way valuable has surfaced in the dental community. Third-party carriers are refusing to cover the costs of removal based on an unperceived need for treatment. This report documents 3 1 cases of very serious infection seen at one institution over a 6-year period. If this represents five cases per year at each major hospital in the United States ( 100 or more beds),
Table 1. Medical Problems or Other Risk Factors in Patients Developing Deep Space Abscesses Attributed to Third Molars (n = 24) Medical Compromise Smoking Ethanol abuse Intravenous drug abuse Hepatitis B Asthma Hypertension Diabetes Stroke Peripheral vascular disease Deep venous thrombosis Urinary tract infection
No. of Patients 18 5 4 3 3 3 2
1 1 1 1
No growth in three patients, one for each diagnosis.
it may indicate the occurrence of as many as 15,000 cases of serious or life-threatening infection per year.6 The average hospital stay for this problem at our institution was 6.2 days. A typical cost per day for this admission, including hospital bed, operating room, laboratory fees, and medications, excluding surgical and consultant fees and lost work time, is $1000. This represents $93,000,000 annually in hospital fees alone, and highly outweighs the cost of the removal of these teeth in an asymptomatic state. The 3 1 serious infections identified could have been avoided by the removal of the third molars during the teenage years, a common practice advocated by many. Several of these infections occurred after the removal of a third molar with the preoperative diagnosis of pericoronitis. None occurred postoperatively after the removal of a tooth that had not been infected in some way. This suggests that waiting for the tooth to become infected before removal may be risking a more serious infection and may not be the proper treatment. The findings in this study strongly suggest that patients who have diabetes, asthma, or hypertension, or who smoke or abuse drugs or alcohol, are a population at risk for developing a deep space abscess from an infected third molar. This medically compromised population should have their impacted mandibular third molars removed before signs of infection occur to obviate the more serious and potentially life-threatening risk of a deep space abscess.
35
INDRESANO, HAUG. AND HOFFMAN
References
bidity associated with mandibular third molar surgery. J Am Dent Assoc 101:240, 1980
1. Bishara SE, Andreason JO: Third molars: A review. Am J Orthod 83:131, 1983 2. Goldberg MH, Nemarich AN, Marco WP: Complications after third molar surgery: A statistical analysis of 500 consecutive procedures in private practice. J Am Dent Assoc 111:277, 1985 3. Bruce RA, Frederickson GC, Small GS: Age of patients and mor-
J Oral Maxillofac 50:35-36.
4. Spilka CJ: Pathways of dental infection. J Oral Surg 24: I 11, 1966 5. Peterson LJ: Principles of management of impacted teeth, in Peterson LJ (ed): Contemporary Oral and Maxillofaciai Surgery. St Louis, MO, Mosby, 1988, p 243 (chap 9) 6. AHA Guide to Hospital Statistics, I990- 199 1, Table 5A. Chicago, IL, 1991, p 20
Surg
1992
Discussion The Third Molar as a Cause of Deep Space Infections Morton H. Goldberg, DMD, MD Universityof Connecticut.Farmington
The third molar as a cause of great concern to oral and tients, hospitals, third-party. health planners. This study the prevalence of third molar and raises thought-provoking
of deep space infections is indeed maxillofacial surgeons, their papayers, and medicoeconomic adds useful information about infections in compromised hosts questions about prophylactic
surgery. Data concerning the fate of asymptomatic third molars have been clouded by medical myths, long-established surgical habits, referral patterns, economic motivations, and the rites of passage of middle-class American culture.’ Because of these factors, long-term longitudinal studies of the natural history of impacted teeth have been difficult to establish or complete. Wowem and Nielsen,’ as well as Venta et al,3 concluded, however, that third molars continue to erupt after the age of 20 and recommended observation rather than extraction. However, conflicting data from the study by Garcia and Chauncy in men 25 years and older revealed few erupting and subsequently functioning third molars4 Subsequent functioning is the key to any discussion of whether or not third molars should be removed prophylactically to prevent pain or infection. Eruption late in life may be just as unacceptable to the patient as is surgery; witness the many anecdotal tales of frail, osteoporetic octogenarians facing the Hobson’s choice of eruption or extraction. The authors describe 24 of 3 1 patients admitted for deep space infections secondary to third molars as having “some form of medical problem or risk factor.” However, unlike diabetes, cancer, chemotherapy, or acquired immunodeficiency syndrome, I am unaware of any hard data that links asthma, hypertension, urinary tract infection, or smoking to increased incidence of odontogenic infection, as assumed by these authors. Furthermore, the singularly most important issue of antibiotic usage is not addressed in this article, even though 68% of these patients had a history of pericomitis and 29% had documented postextraction infection. Both the resuits and conclusions of this article (ie, perhaps fewer admissions) would have been altered if data concerning antibiotic success or failure had been analyzed. Antibiotic prophylaxis and therapy in the compromised host is a wellestablished and accepted principle of surgery. The failure to consider the influence of antibiotics on the infection rate and
hospital admission rate of patients is the most serious flaw in this article. The authors have also failed to compare admissions for infections of third molar origin in the compromised host with those of non-third molar odontogenic infection. While the authors’ extrapolation of costs to the $93 million level is certainly impressive, it pales in comparison to the estimated $300 million that is already spent annually on third molar extractions. Even if prophylactic extraction were limited to the “at risk population” studied here, the cost to the health care system to remove all impacted third molars from every diabetic, asthmatic, hypertensive, alcoholic, smoking, or drug-using patient would be staggering and would certainly deflect huge sums away from basic research on the cause and treatment of these problems. With a 5% postoperative infection rate in healthy patients, doubled in diabetics, and almost tripled in patients with leukemia or high-dose corticosteriod therapy, might not universal removal of impacted third molars cause more mischief and misery than careful observation and selective surgery? The incidence of third molar impaction has generally increased in our society, in the healthy as well as those who subsequently suffer ill health. Preventive dentistry, professional care, and the preservation of first and second molars by fluoride have resulted in an impaction rate probably never before experienced by the human race. A changing diet, with less abrasion, has also contributed to the increase of impacted teeth, a problem also recently described in wild mammals that have been domesticated.5 In both healthy and high-risk patients, certain judgmental criteria for asymptomatic third molars should be used in the surgical decision-making process: 1. a history of past infection; 2. nonprogressive, partial eruption with pericoronal flap and food entrapment; 3. periodontal pocketing involving the impacted tooth; 4. no attached gingiva in the neighborhood of the erupting third molar; 5. if infection of a fracture site is likely; 6. radiographic imaging reveals true cyst or tumor formation, or erosion of an adjacent tooth; 7. the patient will be spending an extended period in a location where oral maxillofacial surgery is unavailable.
Even with rigid adherence to these criteria, many asymptomatic third molars will require surgery. It is not wise or necessary, however. to advocate universal prophylactic removal
