European Archives of Paediatric Dentistry (2020) 21:145–154

https://doi.org/10.1007/s40368-019-00466-0

ORIGINAL SCIENTIFIC ARTICLE

Management of odontogenic infection in paediatric patients:

a retrospective clinical study
Sarah Wan‑Lin Lim1 · Wei Shiu Lee1 · Shani Ann Mani2   · Kathreena Kadir3

Received: 19 April 2018 / Accepted: 15 July 2019 / Published online: 22 July 2019
© European Academy of Paediatric Dentistry 2019

Abstract
Purpose  To investigate the outpatient and inpatient management of odontogenic infections among paediatric patients attend-
ing a university hospital.
Methods  A retrospective study (2013–2015) was carried out which involved retrieving relevant data from past records
(manual/electronic) of paediatric patients (under 18-years-old) who presented with odontogenic infections to the Paediatric
Dentistry and Oral and Maxillofacial clinic. Data collected was organised using descriptive statistics with SPSS version
12.0.1.
Results  A total of 153 patients were identified, of which 83.7% were managed as outpatients. Odontogenic infections were
more common in females (52.9%) and preschool children (58.2%). The most cases were seen in 2014 and maximum number
of cases per month was 12. Common presentations were pain (62.1%), intraoral swelling (37.9%) and spontaneous pus dis-
charge from the tooth and/or surrounding tissues (67.3%) with higher involvement of primary right molars. Dental panoramic
tomograph was the most common radiographic investigation done. Outpatients were commonly managed chairside with
pulpal opening (46.1%) at the paediatric dental clinic and 7% underwent extraction under general anaesthesia in day-care
setting. Inpatients were admitted for 3 days on average and most commonly definitive care was extraction under local/general
anaesthesia (68%). There were 22.7% outpatients and 72.0% inpatients who were prescribed antibiotics.
Conclusions  Overall, treatment and medications prescribed adhered to current guidelines. There was a tendency to solely
prescribe antibiotics in 8.6% of outpatients which is contrary to recommendations.

Keywords  Antibiotics · Odontogenic infection · Paediatric · Management

Introduction

Odontogenic infections among paediatric patients are

* Shani Ann Mani often caused by caries, periodontal problems or a history
shani@um.edu.my
of trauma and may involve multiple teeth (AAPD Clinical
Sarah Wan‑Lin Lim Affairs Committee 2015). They can range from localised
wanlinsarah@yahoo.com
abscesses to deep space head and neck infection (Holmes
Wei Shiu Lee and Pellecchia 2016). A study found that among paediatric
weishiulee@gmail.com
hospital patients, odontogenic facial infections comprised
Kathreena Kadir almost 50% of the total facial cellulitis cases (Unkel et al.
kathreena@um.edu.my
1997).
1
Faculty of Dentistry, University of Malaya, Management of odontogenic infections in children is
50603 Kuala Lumpur, Malaysia similar to that of adults (Rush et al. 2007). Guidelines
2
Department of Paediatric Dentistry and Orthodontics, Faculty seem to be in consensus that in localised dentoalveolar
of Dentistry, University of Malaya, 50603 Kuala Lumpur, infection/abscess, it is most important to remove the
Malaysia source of infection either by incision and drainage (I&D),
3
Department of Oral and Maxillofacial Clinical extraction or pulpal opening of the teeth (AAPD Clini-
Sciences, Faculty of Dentistry, University of Malaya, cal Affairs Committee 2015; Flynn 2011; Robertson et al.
50603 Kuala Lumpur, Malaysia

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146
2015; Segura-Egea et al. 2018). Systemic antibiotic ther-
apy is only required when patient is immunocompromised
or there are signs of a systemic spread (AAPD Clinical
Affairs Committee 2015; Flynn 2011; Robertson et al.
2015; Segura-Egea et  al. 2018). In cases of spreading
infection such as odontogenic facial cellulitis or where
signs of systemic involvement are present, prompt atten-
tion should be given because severe complications can
occur rapidly especially in children (AAPD Clinical
Affairs Committee 2016). Hospital admission and intra-
venous (IV) antibiotic therapy is necessarily followed by
immediate surgical intervention as this contributes to a
more rapid cure (Robertson et al. 2015; Thikkurissy et al.
2010). In-patient management often requires a multidisci-
plinary approach whereby there is a confluence of dental
and medical management.
There is a paucity of data regarding medical and surgi-
cal management of odontogenic infections among paedi-
atric patients (Rush et al. 2007), with almost no clear-cut
guidelines and little literature on how localized infections
should be managed. Although immediate intervention of
some sort is recommended, the statement is not clear on
the prescription of antibiotics, the need for an intraca-
nal medicament and whether infections drained through
the pulp should be left open for drainage or not (AAPD
Clinical Affairs Committee 2016). Numerous studies have
reported the inadvertent use of antibiotics to contain odon-
togenic infections in children with no immediate interven-
tion, leaving the tooth to be treated days later (Al-Malik
and Al-Sarheed 2017; Cherry et al. 2012; Dailey and Mar-
tin 2001; Peedikayil 2011). Older protocols which are still
followed suggest removal of the source supplemented with
an antibiotic course (Fouad et al. 1996; Hills-Smith and
Schuman 1983). Defensive prescription to stay away from
lawsuits (Wilson 2002) and behavioural problems in chil-
dren that impede active intervention encourage the above
practice. More recently, emphasis on responsible use of
antibiotics due to the global rise in drug resistant bacte-
rial strains has been highlighted (Gibson and Levin 2018).
Comparatively, there are clearer guidelines for spreading
odontogenic infections and more studies reported (Kara
et al. 2014; Kuo et al. 2013; Rush et al. 2007; Thikkurissy
et al. 2010). No study has been done in this region regard-
ing the management of odontogenic infections, both
spreading and localised, in paediatric patients. We hope
that by comparing current practices against latest stand-
ards, it would lead to clinicians who are more effective in
their management of odontogenic infections, ultimately
resulting in better patient care and outcomes. Serving
as a preliminary step to a clinical audit, the purpose of
this study was to investigate the inpatient and outpatient
management of odontogenic infections among paediatric
patients attending a university hospital in Malaysia.
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European Archives of Paediatric Dentistry (2020) 21:145–154
Methods
Ethical clearance was obtained from the Human Research
and Ethics Committee of the institution.
A retrospective study spanning 3 years (2013–2015)
was designed. All records of paediatric patients (children
under the age of 18) attending a university hospital in
Malaysia for management of odontogenic infections were
included in the study. To avoid data loss, no exclusion
criteria was imposed.
Patients with odontogenic infections initially presented
during working hours at the primary care clinic at the
dental faculty. From the primary care clinic, all patients
requiring outpatient care were referred and treated by
paediatric dentistry residents, while spreading infections
were routinely referred and managed by the oral and max-
illofacial surgery residents with in-patient care. Patients’
presenting after office hours at the hospital’s paediatric
emergency department were attended by the oral and max-
illofacial surgery residents, who treated localized odonto-
genic infections on-site and followed-up at oral and max-
illofacial surgery outpatient clinic. Those with systemic
involvement at initial visit were admitted to the hospital
paediatric department’s ward for further in-patient care
and management. Once the infection had resolved they
were referred to the paediatric dental department for con-
tinuation of their dental care.
Taking into account the various possible routes that a
paediatric patient with odontogenic infection could present
at the faculty, relevant data for the study was retrieved and
collected from two main sources, the paediatric dentistry
clinic and oral and maxillofacial surgery clinic. Sources of
data included oral and maxillofacial surgery post-graduate
on-call logbooks, paediatric post-graduate logbooks, oral
and maxillofacial surgery in-patient logbooks (ward Book
and OT Book) and patient attendance records from the
faculty’s informatics database. Patient records were either
in physical paper form or electronic form retrievable from
the Dental Information System (DEISY).
A data collection form was created using Microsoft
Word to facilitate systematic collection of relevant data.
Within the form, pertinent information needed for the
study such as patients’ registration number (RN), gender,
age, race and the date on which patients were seen were
recorded. The signs and symptoms that were commonly
experienced by patients with odontogenic infections such
as pain and swelling (whether extra-oral or intraoral)
and the duration, tooth/site involved, past medical his-
tory (PMH) and any special investigations done were also
tabulated.
Data collection regarding management was divided into
outpatient and inpatient management, respectively. Under
European Archives of Paediatric Dentistry (2020) 21:145–154 147

outpatient management, information such as whether tooth

was extracted, any incision and drainage (I&D) done, any
pulpal opening done and the type of dressing used, pre-
scription of analgesics and/or antibiotics as well as any
follow up done and when, were collected. Similarly, for
in-patient management, the days of admission, antibiotics
and/or analgesic prescribed, definitive management as well
as any follow up done and when, were recorded. Data col-
lection was conducted between the months of June–August
2016.
The data collected was organised using descriptive statis-
tics with SPSS version 12.0.1. Fig. 1  Age distribution of the children presenting with odontogenic
infection

Results Thirty-seven patients had taken medications prior to their

visit to the institution. A total of 32 out of 37 patients who
A total of 153 patients reported with odontogenic infections had taken some form of medication, had taken antibiotics
in children aged 18 and below, of which 83.7% were man- before their visit. There were 11 non-immunocompromised
aged as outpatients. Based on Table 1, the female: male ratio patients (26.8%) who were prescribed antibiotics prior to
was 1.1:1. Figure 1 illustrates that the number of cases was their visit. History of fever was seen in 12.4% of patients.
highest among preschool children, peaking at 6-years-old Only four patients had immunocompromised conditions
and showed a decreasing trend from the start of the mixed namely Down’s syndrome, Type II diabetes mellitus and
dentition stage with minimal cases occurring from 11 years myelodysplastic syndrome with acute myeloid leukaemia
onwards. Figure 2 shows that over the 3 years, the number (AML) transformation. Pain was reported in 62.1% of the
of cases were greatest in 2014 (70 patients). The maximum cases (Table 3). Intraoral swelling (37.9%) was more com-
number of patients seen per month was 12. In 2015, there monly seen compared to extraoral swelling (19.0%) whilst
were consistently between 4 and 6 patients who presented 13.1% of patients presented with both. Cases involving pus
every month. discharge amounted to 67.3% whilst the remaining presented
The university hospital was the first place where most as facial cellulitis. Generally, primary molars were the most
patients in this study came to seek treatment (Table  2). commonly involved teeth (Fig. 3). There was no significant
association between odontogenic infections involving the
upper/lower teeth and right/left facial regions. However,
Table 1  Demographic profile of the children presenting with odonto- there was higher involvement of upper and lower teeth on
genic infection the right side. Figure 3 also shows that the highest number
Demographics n (%) arose from primary mandibular second molar as the source
of infection. Primary mandibular anteriors were almost
Total patients 153 (100)
always not affected. Multiple quadrants were involved in
 Outpatients 128 (83.7)
3.9% of the cases. There were seven cases where permanent
 Inpatients 25 (16.3)
teeth were involved and maxillary central incisors or first
Gender
permanent molars would be most commonly affected.
 Male 72 (47.1)
Overall, the number of patients managed as outpa-
 Female 81 (52.9)
tients (83.7%) greatly outweighed those managed as
Age
inpatients (16.3%). Based on Table 5, majority of those
 Mean ± SD 6.36 ± 2.4
who received outpatient management did not have cel-
 ≤ 6 years old (preschool) 89 (58.2)
lulitis and most of the inpatients had cellulitis, but were
 7–12 years old (primary school) 58 (37.9)
not immunocompromised. Only one outpatient had an
 13–18 years old (secondary school) 5 (3.3)
immunocompromised condition (type II diabetes mel-
 Missing 1 (0.7)
litus). The dental panoramic tomograph (DPT) was the
Race
most common radiographic investigation carried out for
 Malay 100 (65.4)
outpatients and inpatients (Table  4). Management of
 Chinese 24 (15.7)
patients is shown in Table 5. Most outpatient manage-
 Indian 20 (13.1)
ment was carried out at the paediatric dentistry clinic.
 Others 9 (5.9)
Outpatients in our study with chairside treatment had

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148 European Archives of Paediatric Dentistry (2020) 21:145–154

Fig. 2  Timeline showing number of patients per month with odontogenic infection from 2013 to 2015

Table 2  Presenting history Outpatient (n = 128) Inpatient (n = 25) Total (n = 153)

of children with odontogenic
infections n (%) n (%) n (%)

Presenting history
History of complaint
 Had prior dental visit 30 (23.4) 1 (4.0) 31 (20.3)
 First visit at UM for the complaint 98 (76.6) 24 (96.0) 122 (79.7)
Taken medication before visit 36 (28.1) 1 (4.0) 37 (24.2)
 Both antibiotics and analgesics 17 (47.2) 0 (0.0) 17 (45.9)
 Only antibiotics 14 (38.9) 1 (100.0) 15 (40.5)
 Only analgesics 5 (13.9) 0 (0.0) 5 (13.5)
No medication taken 92 (71.8) 24 (96.0) 116 (75.8)
History of fever 18 (14.1) 1 (4.0) 19 (12.4)
Medical history
No medical history 36 (28.1) 6 (24.0) 42 (27.5)
 Taken antibiotics 11 (30.6) 0 (0.0) 11 (26.2)
Medical history not stated in records 55 (43.0) 11 (44.0) 66 (43.1)
 Taken antibiotics 8 (14.5) 0 (0.0) 8 (12.1)
Had medical history 37 (28.9) 8 (32.0) 45 (29.4)
 Immunocompromised children 1 (2.7) 3 (25.0) 4 (8.9)
  Taken antibiotics 1 (100.0) 3 (100.0) 4 (100)
 Non immunocompromised children 36 (97.2) 5 (62.5) 41 (91.1)
  Taken antibiotics 11 (30.6) 0 (0.0) 11 (26.8)

the source of infection removed either through extrac-
tion (16.4%), incision and drainage (10.2%) or pulpal
opening (46.1%) of the teeth which is in accordance
with current recommendations. Examples of intracanal
medicaments used were odontopaste and calcium hydrox-
ide whilst the tooth was dressed with either a zinc oxide
eugenol (ZOE) based cement (IRM or kalzinol) or a glass
ionomer cement (GIC). Most inpatient management was
carried out by the department of oral and maxillofacial
clinical sciences. Nine out of the ten outpatients who
underwent procedures under general anaesthesia (GA) in
day-care setting had extractions done. Extraction under
GA for pus drainage was the most common definitive
management for inpatients (48%). Length of stay was
usually 7 days or less, except one patient who was hos-
pitalized for almost 2 weeks. Some inpatients had addi-
tional investigations such as renal profile (16%) and full
blood count (16%) taken as part of investigations prior to
GA. Examples of other medical investigations done were
random blood sugar (RBS) (n = 1), fasting blood sugar
(FBS) (n = 1) and culture and sensitivity (C&S) (n = 1).
Sixty-three outpatients (49.3%) received follow up while
in 80% of inpatients, records documenting follow up were
not traceable.
Based on Table 6, 29 outpatients (22.7%) were pre-
scribed antibiotics. The number of patients that received
either single or multiple antibiotics were 13 (10.2%)
and 14 (10.9%), respectively. Syrup amoxicillin was the

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Table 3  Signs and symptoms Presenting features of odontogenic infections Outpatient (n = 128) Inpatient (n = 25) Total (n = 153)
of children presenting with
odontogenic infection n (%) n (%) n (%)

Signs and symptoms

 Pain
  Yes 86 (67.2) 9 (36.0) 95 (62.1)
  No 8 (6.3) 2 (8.0) 10 (6.5)
  Not stated 34 (26.6) 14 (56.0) 48 (31.4)
Swelling
 Extraoral only 19 (14.8) 10 (40.0) 29 (19.0)
 Intraoral only 57 (44.5) 1 (4.0) 58 (37.9)
 Both extra and intraoral 18 (14.1) 2 (8.0) 20 (13.1)
 Facial cellulitis 27 (21.1) 23 (92.0) 50 (32.7)
 Pus discharge 98 (76.6) 5 (20.0) 103 (67.3)
Number of teeth involved
Single 110 (85.9) 19 (76.0) 129 (84.3)
Multiple 18 (14.1) 6 (24.0) 24 (15.7)
Quadrant (FDI) of tooth involvement
Upper quadrant only 57 (44.5) 9 (36.0) 66 (43.1)
Lower quadrant only 56 (43.8) 6 (24.0) 62 (40.5)
Upper and lower quadrants 1 (0.8) 0 (0.0) 1 (0.7)
Not stated 14 (10.9) 10 (40.0) 24 (15.7)

Fig. 3  Number of teeth involved with odontogenic infection in each quadrant

antibiotic of choice when a single antibiotic was pre- choice in managing outpatients. Table 6 shows that 80%
scribed whilst those who were given multiple antibiotics of inpatients received multiple antibiotics, most com-
usually received a combination of syrup amoxicillin and monly in the form of IV augmentin and flagyl (33.3%).
metronidazole. Paracetamol (PCM) was the analgesic of PCM was also the analgesic of choice among inpatients.

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150 European Archives of Paediatric Dentistry (2020) 21:145–154

Table 4  Special Investigations carried out prior to management

Imaging Others
Dental panoramic Intraoral peri- Bitewing (BW) Full blood count Renal profile Other medical
tomograph (DPT) apical (IOPA) investigations

Outpatients, n (%) (n = 128) 62 (48.4) 20 (15.6 7 (5.5) 1 (0.8) 0 (0) 1 (0.8)

Inpatients, n (%) (n = 25) 11 (44.0) 0 (0) 0 (0) 4 (16.0) 4 (16.0) 2 (8.0)

Table 5  Presentation and Presentation and management Outpatient (n = 128) Inpatient (n = 25)

management of outpatients and
inpatients with odontogenic n (%) n (%)
infection
Diagnosis
 Cellulitis 27 (21.1) 23 (92.0)
 Localised dentoalveolar infection 101 (78.9) 2 (8.0)
 Immunocompromised 1 (0.8) 3 (12.0)
 Non immunocompromised/not stated 127 (99.2) 22 (88.0)
 Taken medication before visit
 Antibiotic only 14 (10.9) 1 (4.0)
 Analgesic only 5 (3.9) 0 (0)
 Both antibiotic and analgesic 17 (13.3) 0 (0)
 Had history of fever 18 (14.1) 1 (4.0)
Admission (days)
 Mean ± SD – 3.11 ± 2.86
 Less or equal to a week – 18 (72.0)
 More than a week – 1 (4.0)
 Incomplete data – 6 (24.0)
Managementa
 Incision and drainage under LA 13 (10.2) 0 (0.0)
 Extraction of tooth under LA 21 (16.4) 5 (20.0)
 Pulpal opening 59 (46.1) 0 (0.0)
 Extraction under GA (with/without comprehensive care 9 (7.0) 12 (48.0)
 Incision and drainage under GA 1 (0.8) 1 (4.0)
 Antibiotics given 29 (22.7) 18 (72.0)
  Antibiotics given without any active intervention 11 (8.6) 0 (0.0)
 Analgesic given 15 (10.9) 8 (32.0)
  Analgesic given without any active intervention 6 (4.7) 0 (0.0)
 Discharged at own risk – 2 (8.0)
 Incomplete data 27 (21.1) 5 (20.0)
Follow-up
 Within 2 weeks 29 (22.7) 3 (12.0)
 > 2 weeks, within 1 month 12 (9.4)
 More than 1 month 22 (17.2)
 No follow up/not stated/untraceable 65 (50.8) 20 (80.0)
 Discharged at own risk, hence no follow up 2 (8.0)
a
 Total number of procedures done may exceed total number of patients

Discussion ‘superbugs’, practitioners are advised to prescribe antibi-

otics judiciously (Al-Haroni 2008). Nevertheless, recent
Older studies regarded frequent antibiotic prescriptions for studies showed antibiotic usage is widespread and dental
odontogenic infections as the norm (Hills-Smith and Schu- practice guidelines are not adhered to (Al-Malik and Al-
man 1983). With the advent of antibiotic resistance and Sarheed 2017; Cherry et al. 2012). The management of

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Table 6  Medications Medication Outpatient (n = 128) Inpatient (n = 25)

prescribed and completeness
of prescription records among n (%) n (%)
outpatients and inpatients with
Prescribed antibiotics 29 (22.7) 18 (72.0)
odontogenic infection
Type of antibiotics stated 27 (21.1) 15 (60.0)
Single antibiotics 13 (10.2) 3 (20.0)
 Syrup amoxicillin 7 (5.5) –
 Cap amoxicillin 1 (0.8) –
 Augmentin 1 (0.8) –
 Syrup augmentin 4 (3.1) 1 (6.7)
 IV augmentin – 2 (13.3)
Multiple antibiotics 14 (10.9) 12 (80.0)
 Metronidazole, augmentin 1 (0.8) –
 IV flagyl IV augmentin – 5 (33.3)
 Metronidazole, amoxicillin 3 (2.3) –
 Syrup metronidazole, syrup amoxicillin 8 (6.3) –
 IV flagyl IV amoxicillin – 1 (6.7)
 Metronidazole, fortum 1 (0.8) –
 IV flagyl IV cloxacillin – 1 (6.7)
 IV flagyl, IV tazocin, IV vancomycin – 1 (6.7)
 IV metronidazole IV ampicillin – 1 (6.7)
 IV metronidazole IV viacin – 1 (6.7)
 Syrup metronidazole, Syrup augmentin 1 (0.8) 2 (13.3)
Type of antibiotics not stated (e.g., IV AB, under antibiotics) 2 (1.6) 3 (12.0)
Not prescribed antibiotics 95 (74.2) 7 (28.0)
Prescribed analgesic 15 (11.7) 8 (32.0)
Type of analgesics stated 14 (10.9) 8 (32.0)
 Syrup PCM 14 (10.9) 5 (20.0)
 Tab PCM – 2 (8.0)
 Supp. PCM – 1 (4.0)
Type of analgesic not stated (e.g., analgesic given) 1 (0.7)
Not prescribed analgesics/analgesic prescription not documented 109 (85.2) 17 (68.0)
Non-specific data (e.g., medication given) 4 (3.1)
Complete record of prescriptions of all patients
Antibiotic prescriptions
 Yes 12 (9.4) 5 (20.0)
 No 15 (11.7) 10 (40.0)
 Not stated 2 (1.6) 3 (12.0)
Analgesic prescriptions
 Yes 7 (5.5) 2 (8.0)
 No 7 (5.5) 6 (24.0)
 Not stated 1 (0.7) 0 (0.0)

odontogenic infections among paediatric patients reported
from other countries were primarily hospital based (Kara
et al. 2014; Kuo et al. 2013; Lin and Lu 2006; Rush et al.
2007; Thikkurissy et al. 2010). Although most studies
focused specifically on odontogenic facial cellulitis (Kara
et al. 2014; Lin and Lu 2006; Thikkurissy et al. 2010), our
study encompassed the whole spectrum of odontogenic
infections ranging from localised dentoalveolar infec-
tion to cellulitis, since no similar studies were reported in
this region. In terms of gender distribution, in our study,
females slightly outnumbered the males. Other similar
studies found an equal distribution between males and
females (Lin and Lu 2006; Thikkurissy et al. 2010), with
the exception of one study whereby a male: female ratio
of 1.4:1 was reported (Kara et al. 2014). The mean age
of our study was 6.36 ± 2.4, comparable to other studies
which ranged from 5.72 to 8.3 (Kara et al. 2014; Lin and
Lu 2006; Thikkurissy et al. 2010). Considering that caries
is one of the major causes of odontogenic infections, the
above finding was consistent with the caries prevalence

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152
among 6-year-olds in Malaysia (71.3%) (AAPD Clinical
Affairs Committee 2015; Lin and Lu 2006; Oral Health
Division 2017). The fact that it peaks at 6-years-old sug-
gests that sufficient time has lapsed for caries progres-
sion to involve the pulp and periapical tissues. Further-
more, treatment needs of school going children are likely
to be met on a regular basis through the school dental
service implemented in primary and secondary schools.
The attendance pattern suggests that younger non-school
going children are more available to seek care whilst in
school going children the demands of school may override
a “minor toothache”.
For 79.7% of patients in this study, our institution was the
first place where they sought treatment for the complaint.
The remainder was mostly patients with a persisting problem
that did not resolve after previous treatment elsewhere or
referred cases requiring management by specialists. Obtain-
ing patient’s PMH including drug history is critical in man-
aging odontogenic infections (Holmes and Pellecchia 2016).
In our study, 37 patients had taken some form of medica-
tion prior to their visit of which 86% had taken antibiotics,
possibly because they were prescribed antibiotics by their
previous clinician or obtained over-the-counter drugs. This
significantly high percentage of antibiotic intake indicates
that detailed drug history is imperative, since patients’ clini-
cal presentations may have changed from the initial condi-
tion (Harte et al. 2005). Fever is one of the signs of systemic
involvement warranting emergency IV antibiotic therapy
(AAPD Clinical Affairs Committee 2016). History of fever,
onset and duration of presenting illness, gives the clinician
an idea of the severity of the infection (Holmes and Pellec-
chia 2016). All four immunocompromised patients had taken
antibiotics while 11 patients with positive medical history
records, but who were not immunocompromised had also
taken antibiotics. Current literature recommends that antibi-
otics should only be prescribed for those who are moderately
or severely immunocompromised (Robertson et al. 2015).
Pain and swelling have been established as known pres-
entations of odontogenic infection (AAPD Clinical Affairs
Committee 2015; Robertson et al. 2015). There were 62.1%
positive findings for pain recorded in our study. Current
literature shows that perception of pain varies from child
to child, with children also denying pain out of fear and
intent to avoid dental treatment (Mathews 2011). Extraoral
swellings were seen in 32% of patients, implying that these
patients presented after there was noticeable evidence of
infection. Patients’ mostly presented in later stages of infec-
tion as 67.3% of the children presented with pus discharge
on their first visit.
Primary molars were most commonly found as the source
of infection with mandibular molars more affected than
maxillary ones. The higher involvement of primary maxil-
lary anterior teeth could stem from Severe Early Childhood
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European Archives of Paediatric Dentistry (2020) 21:145–154
Caries (SECC) which commonly involves these teeth (Lin
and Lu 2006). Results from our study showed that odonto-
genic infections could also arise from multiple teeth and this
often occurs in SECC cases.
In this sample, DPT was the most taken radiograph in
both outpatients and inpatients whilst bitewing (BW) and
intraoral periapical (IOPA) radiographs were almost always
not taken for inpatients, as most often, patients presented
with a clear-cut diagnosis of the involved tooth from clini-
cal findings. On the contrary, a previous study primarily
obtained IOPA radiographs followed by DPT and com-
puted tomograph (Thikkurissy et al. 2010). However, like
our study, some patients had more than one radiograph taken
(Thikkurissy et al. 2010). Young children are less likely to
cooperate due to limited mouth opening and pain associ-
ated with odontogenic infection and this could explain the
high number of DPTs taken in our study. However, intraoral
radiographs are ideal should the patient be cooperative due
to lower radiation exposure and sharper image quality.
Surgical intervention to remove the source of infection is
crucial in managing odontogenic infections (AAPD Clinical
Affairs Committee 2015, 2016; Holmes and Pellecchia 2016;
Robertson et al. 2015; Rush et al. 2007). Our study found
that pulpal opening was the most common method to remove
the infectious source whilst in other studies it was by extrac-
tion of the abscessed tooth (Al-Malik and Al-Sarheed 2017;
Rush et al. 2007). Following pulpal opening, the tooth was
always dressed with an intracanal medicament and access
cavity closed (Siqueira 2003) in this study. This is a suit-
able alternative to control infection in young uncooperative
patients who are unwilling for extraction and for teeth indi-
cated for pulpectomy. Details of management with pulpal
opening are not mentioned in other studies and guidelines
(Al-Malik and Al-Sarheed 2017; AAPD Clinical Affairs
Committee 2015). Nine patients in our study had extraction
done under GA in day-care setting. The treatment choice is
influenced by the restorability of the tooth concerned, sever-
ity of the infection and the ability to achieve sufficient anaes-
thesia (LA or GA) (AAPD Clinical Affairs Committee 2016;
Robertson et al. 2015). Other factors determining treatment
options would include patients’ and their parents’ or guard-
ians’ wishes, patient’s age and ability to cooperate, medical
and social status of the child (AAPD Clinical Affairs Com-
mittee 2016; Robertson et al. 2015). Regardless, removing
the infectious source as soon as possible would ensure rapid
resolution of infection and reduce the usage of antibiotics
(Fouad et al. 1996; Rush et al. 2007). Supplemental antibi-
otics are not warranted in immunocompetent patients after
successful drainage has been achieved (Fouad et al. 1996;
Robertson et al. 2015). A finding of concern which does
not follow the current recommendations is that 8.6% of
outpatients were prescribed antibiotics without any active
intervention. However, this may have been compromised
European Archives of Paediatric Dentistry (2020) 21:145–154 153
treatment in very young children lacking cooperative ability.
Although current literature suggests that it is good practice
to review patient within 1 day (Robertson et al. 2015), only
50.8% of the outpatients in our study were followed-up at
varying time periods. However, informal ways of following
up for example; through phone call or text where images can
be exchanged to ascertain resolution of the condition may
not have been recorded.
Patient management varies with the severity of odonto-
genic infection. Febrile patients with acute signs of spread-
ing infection such as stridor and odynophagia normally war-
rant immediate referral to the oral maxillofacial surgeons
(Gregoire 2010; Robertson et al. 2015). The main objec-
tives for admission were to contain the infection from fur-
ther systemic spread and to monitor patients’ vital signs.
The average length of stay of children in our study was
3.11 ± 2.86 days which falls within the range of 2–6 days
found in other studies (Kara et al. 2014; Thikkurissy et al.
2010). Our study found that definitive management of inpa-
tients was extractions (done under LA or GA). It is likely
that complete removal of the infectious source by extrac-
tion was the primary aim in inpatients not only because it
allowed complete drainage but it also reduced the likeli-
hood of a recurrent episode in which more morbidities and
life-threatening complications could entail (Robertson et al.
2015).
Appropriate pharmacotherapy is another important
aspect in treating spreading odontogenic infections and
in immunocompromised patients. Odontogenic infec-
tions are usually mixed infections consisting of a polymi-
crobial aetiology (Ellison 2009; Holmes and Pellecchia
2016; Robertson and Smith 2009; Rush et al. 2007). Our
study found that 29 outpatients were prescribed antibiot-
ics, almost consistent with the number of outpatients who
had cellulitis (27 patients) (Table 3), indicating that these
outpatients were likely to be given antibiotics due to signs
of a spreading infection which is in accordance with cur-
rent guidelines (AAPD Clinical Affairs Committee 2015,
2016; Robertson et al. 2015). In our study, amoxicillin was
the antibiotic of choice when used alone in outpatients,
and was supplemented with metronidazole when anaerobic
bacterial involvement was suspected, which is in accord-
ance with current literature (AAPD Clinical Affairs Com-
mittee 2016; Flynn 2011; Holmes and Pellecchia 2016).
Outpatients who were not prescribed antibiotics amounted
to 74.2%, suggesting awareness among clinician regard-
ing antibiotic resistance. This trend was unlike previous
studies (Al-Malik and Al-Sarheed 2017) and definitely
encouraging. Inpatients often received metronidazole in
combination with various other antibiotics also mainly
from the penicillin group. Other suggested antibiotics for
odontogenic infections are clindamycin, azithromycin and
moxifloxacin which are to be considered in the case of
penicillin allergy (Flynn 2011). One study also suggested
that amoxicillin in combination with clavulanic acid could
be used as an alternative when amoxicillin resistance was
evident (Laskarides 2016). This is coincident with the
findings of our study whereby a few patients were given
augmentin either solely or in combination with metro-
nidazole. One outpatient was given intravenous fortum
which is a broad spectrum third generation cephalosporin
in combination with metronidazole. In cases where swell-
ings still persist despite prescription of penicillin and the
child is to be managed under GA, a cephalosporin may be
a good alternative (Moursi et al. 2012). PCM was the only
analgesic prescribed. Although generally non-steroidal
anti-inflammatory drugs (NSAIDS) such as ibuprofen are
suitable for paediatric use, it is contraindicated in children
with asthma among others and thus is not broadly used.
Among all analgesics, PCM is the preferred first line agent
used in children because of its superior tolerability profile
(Laskarides 2016).
Incomplete records hindered optimal data collection.
In many cases, radiographs were untraceable. Clinician
entry of patient notes varied and this resulted in some loss
of data. Our data indicated no specific mention of PMH in
43.1% of the patients, whilst these patients were most likely
healthy. Additionally, 32 patients had incomplete data on
what procedure was done. Since meticulous record-keeping
is crucial for future audits, all students and clinicians should
be routinely trained for data entry on the digital (DEISY)
system for systematic data extraction. We recommend that
the subsequent studies include data collection of symptoms
like trismus and fever during visit to better grasp the general
presentation of inpatients. Further studies could also be car-
ried out to look into whether a particular ethnic group has a
higher propensity of developing odontogenic infections and
why. Besides that, further studies are needed to investigate
how soon after admission for IV antibiotics is definitive care
carried out for inpatients.
Conclusions
Based on this study’s limitations and results, the following
conclusions can be made:
1. Overall, definitive treatment in managing odontogenic
infections for both outpatients and inpatients complied
to current guidelines.
2. Antibiotic prescription was generally in adherence with
current recommendations. However, there was a ten-
dency to solely prescribe antibiotics in 8.6% of patients,
which is contrary to guidelines.
13

154
Acknowledgements  This work was supported by the University
Malaya Research Grant-Programme RP053A-17HTM.
Funding  This study was funded by University Malaya Research Grant-
Programme RP053A-17HTM.
Compliance with ethical standards  Treatment of oral infection and management of systemic disease.
Conflict of interest  The authors declare that they have no conflict of
interest.
Research involving human participants  All procedures performed were
in accordance with the ethical standards of the institutional committee
and with the 1964 Helsinki declaration and its later amendments or
comparable ethical standards. Ethical approval to conduct the study
was obtained from the Medical Ethics Committee, Faculty of dentistry,
University Malaya [(Reference number: DF CD1606/0029(U)]. Being a
retrospective study, data was collected from records of patients stored
in the Faculty of Dentistry, University Malaya. Data was anonymised
and de-identified prior to analysis. Written and verbal consent was
obtained from all patients and parents of participants under 18 years of
age included in the study as a routine procedure at the time of examina-
tion, diagnosis and treatment. This was approved by the ethics com-
mittee.
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