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NPM 160112162015
UNIVERSITAS PADJADJARAN
BANDUNG
2017
Management of severe odontogenic infections in pregnancy
D Wong,* A Cheng, R Kunchur, S Lam, PJ Sambrook, AN Goss
*Private Practice, Morphett Vale, South Australia.
Oral and Maxillofacial Surgery Unit, Royal Adelaide Hospital, South Australia.
Flinders Medical Centre, Bedford Park, South Australia.
Oral and Maxillofacial Surgery Unit, The University of Adelaide and Royal Adelaide Hospital, South Australia.
Abstract
Background: The objective of this study was to review the management of patients presenting
with severe odontogenic infections and who are also pregnant.
Methods: A retrospective clinical audit was conducted of all female patients admitted to the Royal
Adelaide Hospital by the Oral and Maxillofacial Surgery Unit from 1999 to 2009 with severe
odontogenic infections. Pregnant patients were identied and their age, medical history,
previous obstetric and gynaecological history, stage of current pregnancy, presenting
infection, diagnosis and management were recorded, as well as the outcome of the pregnancy.
Results: A total of 346 female patients were admitted to the Royal Adelaide Hospital under
the care of the Oral and Maxillofacial Surgery Unit with an admission diagnosis of severe
odontogenic infection and ve were pregnant. Besides surgical and anaesthetic assessment,
mother and foetus were assessed by the Obstetric and Gynaecology Unit. In all, ve with severe
infection were successfully resolved and four proceeded to a normal delivery with a healthy child.
The remaining patient had an already planned therapeutic abortion.
Conclusions: Pregnant patients with severe odontogenic infections require urgent referral to a
tertiary hospital with full surgical, anaesthetic and obstetric services. This allows appropriate
management of the complex requirements of mother and foetus
Introduction
Ideally routine dental treatment is best avoided in pregnancy, and preferentially dental
tness should be instituted prior to pregnancy. Minor routine dental treatment can be
completed in the second trimester with the rst and third trimesters best being avoided.
Emergency treatment for pulpal, periodontal, pericoronal or early infection should not be
avoided. Delay or avoidance by either the patient or clinician may result in severe spreading
odontogenic infection. It is essential that dentists have an understanding of pregnancy and how
pregnant females are physiologically and psychologically different to non-pregnant females.
It is estimated that up to 50% of all fertilized eggs are spontaneously aborted before the
woman knows she is pregnant, and of those women who know they are pregnant, it is
estimated that 1520% have a spontaneous abortion.1 In 2002, there were 250 988
volume.4,5 Cardiac output increases mainly due to an increased stroke volume or later in
pregnancy, due to an increased heart rate.4,5 Early in pregnancy there is a decrease in systemic
resistance and blood pressure. Blood pressure returns to normal by the end of the second
trimester. In late pregnancy the foetus may compress the inferior vena cava and consequently
signs and symptoms of supine hypotension syndrome, with bradycardia, hypotension and syncope
on standing may occur.6 There are corresponding respiratory alterations including an increase in
the anterior posterior diameter of the chest due to the superior shift of the diaphragm. There is an
increase in the respiratory drive with an increase in tidal volume, respiratory and minute
ventilation. This leads to a mild respiratory alkalosis and dyspnoea is quite common.
Simultaneously there is an increase in oxygen consumption and a decrease in oxygen reserves.
With the alimentary system there is a predisposition towards gastric reux and heartburn. This
is due to increased pressure by the foetus on the stomach with relaxation of the lower
oesophageal sphincter tone and decreased gastric motility. Vomiting and constipation are
increased.7 Hepatic function changes with the decrease in total protein and albumen levels with
an increase in serum alkaline phosphatase, bilirubin, cholesterol, triglyceride and aminotransfer-
ase. The decreased albumin levels may lead to periph-eral oedema.4 There is an increased risk of
urinary tract infections and alteration in kidney output. Haematologically, there is an
increase in erythrocyte and leukocyte counts. However, the relatively greater increase in
concurrent gestational diabetes.9 However, avoiding dental treatment, either in the lead up to
pregnancy or during pregnancy, may sometimes result in spreading odontogenic infections.
Management of spreading odontogenic infections is at best complicated, particularly when
swelling in the neck occurs with the risk of airway obstruction. The detailed issues relating to
management of severe odontogenic infections in non-pregnant patients have been previously
published.10
In this paper we review the management of severe odontogenic infections in pregnancy,
illustrate it with a consecutive cohort of cases and make recommendations on how to minimize the
risk for the mother and foetus.
Methods
A retrospective audit was conducted for all female patients admitted to the Royal
Adelaide Hospital by the Oral and Maxillofacial Unit (OMS) from 1999 to 2009 with spreading
odontogenic infection to determine those concurrently pregnant. For this group their age,
medical history, previous obstetric and gynaecological history, stage of current pregnancy,
presenting infec-tion, diagnosis and management were recorded.
The management of these patients with severe odontogenic infections followed the
standard unit guidelines by the OMS and Anaesthetic (A) Units.10 The Obstetric and
Gynaecological Service (O & G) reviewed the state of the pregnancy and determined foetal
health with foetal monitoring and ultrasound being performed as required.
Management of the infection followed the standard OMS and A protocols, namely,
removal of the cause which is the tooth, incision and drainage of the abscess, supportive treatment
to both the mother and foetus and high dose intravenous antibiotics.10
The patients were contacted by phone in 2011 by their admitting consultant to
determine if there were any subsequent complications to the pregnancy and the health of the
child.
Results
Three hundred and forty-six female patients were admitted to the Royal Adelaide
Hospital under the care of the OMS Unit with an admission diagnosis of severe odontogenic
infection. Of these, ve were pregnant. The details of these patients are presented in Table 2.
Discussion
This paper shows that the pregnant patients with severe odontogenic infections were
successfully managed and four of the pregnancies proceeded to successful delivery of a live baby
without congenital defects and in one case the patient had already booked for termination of
pregnancy.
Anaesthetic and surgical management requires mod-ication to that of non-pregnant
patients.10 The principles of surgical and anaesthetic management need to be well understood by
the initial dentist managing the case, otherwise there is a risk that the patient will be
undermanaged. This occurred with two patients in our series who preferentially should have
been referred earlier. From the anaesthetic point of view, the altered cardiovascular state of
mother and foetus needs to be monitored. Postural hypotension is a risk and the patient is
best nursed in the left lateral position to minimize compression of the inferior vena cava by the
placenta. The altered respiratory drive predisposes both the mother and the foetus to hypoxia,
particularly in the induction stage of the anaesthetic. The upper airway mucosa, particularly of the
nose, is more friable and thus increased bleeding may occur during intubation. The increased
risk of gastric reux needs to be carefully evaluated to minimize the risk of aspiration and
Supine hypotension Due to compression of inferior vena Position patient in left lateral position
syndrome cava leads to bradycardia,
hypotension and syncope
Can disrupt uteroplacental blood ow
Respiratory changes Increase in tidal volume, respiratory and
minute ventilation
Mild respiratory alkalosis and dyspnea Can affect induction and maintenance of
intravenous sedation and general anaesthesia
Increased renal clearance of creatinine, urea, Consider when prescribing renally cleared
uric acid and renally cleared medications medications
Increased risk of urinary tract infections Use urinary catheter with caution
Analgesics Aspirin delivery complications and Contraindicated in 3rd trimester,
post-partum haemorrhage use with caution in 1st and 2nd
trimester
NSAIDS can inhibit induction of labour and Contraindicated in 3rd trimester,
also cause constriction of the ductus use with caution in 1st and 2nd
arteriosus leading to pulmonary hypertension trimester
in the infant
Anaesthesia 3rd trimester increased risk of regurgitation Avoid intravenous sedation and general
and aspiration anaesthesia where possible in pregnancy
patients
Radiography Total radiation exposure less than 610 centi- Full mouth series of intraoral radiographs and
Grays (cGy) has no association with increased panoramic radiograph are within safe dose
congenital defects or growth retardation CT scan has radiation exposure of 37 cGy
only indicated for spreading odontogenic
infections
Metronidazole may be teratogenic in the rst trimester although recent studies have
shown no denitive teratogenic effect. Gentamicin should be avoided as it is associated with
potential toxicity in the developing foetus. Tetracyclines are best avoided as they are
ineffective for odontogenic infections and they may stain the developing teeth.
Most sedatives such as the benzodiazepines cross the placental barrier and thus are
best avoided. Local anaesthesia generally is safe although there is uncer-tainty through lack
of data on the use of bupivicaine and mepivicaine. Although it is commonly stated that
prilocaine and octopressin should be avoided in preg-nancy the tiny amounts involved have
defects or intra-uterine growth retardation.14 Thus generally for a patient with a spreading
odontogenic infection, a single OPG will provide sufcient information at an acceptable
radiation exposure.14 With advanced spreading odontogenic infections into the neck,
generally this is best demonstrated by a CT scan. A single CT scan has less than the normal safe
level of irradiation (e.g. 510 cGy) but is greater than for an OPG.15 Thus, CT scanning is
best avoided in pregnant patients and only used if strongly clinically indicated, such as to
dene a pus collection in patients not responding to surgical management.13 Ultrasound has
a place in dening moderate to large pus collections in the neck and it should be considered
over and above a CT scan.
Surgically, the standard means of management of spreading odontogenic infections
need to be followed. In advanced pregnancy, the risk of hypercoagulation needs to be
considered and the use of thrombolic stockings to minimize deep venous thrombosis (DVT)
formation. The patient should also be mobilized early. All patients in this study had
management which followed the recommended guidelines (Table 3). However, there were
some important variations. Three patients had initially presented to peripheral hospitals
without OMS staff. One was in the country, some hours drive from Adelaide, and two were in
the outer urban areas. All three were initially medically stabilized and transferred to the
central tertiary hospital where the full range of services were available.
Table 3. Protocol for management of pregnant patients with severe odontogenic infections
Infection assessment
Airway monitoring
Severe spreading odontogenic infection can be difcult to manage and there is a small
but real risk of death from either airway obstruction or overwhelming systemic
infection. Pregnancy and its physiological changes make management of such
patients challenging. The treating clinician must consider the anaesthetic and surgical
effects on the foetal and maternal health while following well established clinical
guidelines in managing odontogenic infection. This retrospective study demonstrated
that successful clinical outcomes can be achieved by emergency referral to a tertiary
centre with full surgical, anaesthetic and obstetric services available.
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