Microbiological Approach in Management of Recurrent Dento - Buccal Space Infection - Report of Three Uncommon Cases

Case Report

J Pathol & Microbiol. 2021; 3(1): 1018.

Microbiological Approach in Management of Recurrent Dento - Buccal Space Infection - Report of Three Uncommon Cases

Pavithra D¹*, Satish Kumar CSC², Keerthinarayanan¹ and Archana B³

¹Department of Oral Pathology and Microbiology, Thai Moogambigai Dental College, Chennai, India

²Department of Oral and Maxillofacial Surgery, Thai Moogambigai Dental College, Chennai, India

³Department of Periodontology, Thai Moogambigai Dental College, Chennai, India

*Corresponding author: Pavithra D, Department of Oral Pathology and Microbiology, Thai Moogambigai Dental College, No. 21 Kanni Street Jafferkhanpet, Chennai 600083, Tamil Nadu, India

Received: April 20, 2021; Accepted: May 11, 2021; Published: May 18, 2021

Abstract

The route of facial infection usually depends on the jaw-tooth relationship factors followed by virulence and type of microorganisms. Staphylococci are frequently associated with abscess formation. However, at times head and neck infection with an odontogenic origin are caused by gram-negative species like Klebsiella pneumonia without any predisposing opportunistic infectious etiology. In this report, we presented 3 rare cases of buccal space infection associated with Klebsiella pneumonia without any predisposing systemic disease. Appropriate diagnosis followed by antibiotics oral cephazolin (500mg BID) and intra-muscular gentamicin (150mg BID) at adequate strength and duration has brought a significant decrease in the progression of the disease that yielded complete recovery after 10days. Thus with odontogenic infections it is appropriate to always begin with the empiric antibiotic regimen with correlation to clinical presentation thinking of the most likely suspected microorganisms, which are usually the normal flora of the region, without forgetting the importance of early surgical intervention to reduce morbidity and complications.

Keywords: Buccal space infection; Gram-Negative microbes; Klebsiella pneumonia; Normal flora; Space infection

Introduction

The deep neck spaces are regions of loose connective tissue occupying the areas between the three layers of deep cervical fascia (superficial, middle, and deep layer) [1]. The facial layers may limit the spread of infection. However, the spaces of the neck communicate with one another forming paths that can allow the spread of the infection from the teeth and the associated oral tissues because the pathogens can travel within the facial planes, by the spread of the related inflammatory exudates. When involved in infections, the space can undergo cellulitis, which can cause a change in the normal proportions of the face [2]. Several reports have indicated that the origins of most space infections are odontogenic infections. Odontogenic infection such as acute periapical periodontitis, alveolar abscess, and pericoronitis especially from the 3rd mandibular and maxillary molars or as an extension of peritonsillar cellulitis, may involve several spaces in the head and neck region including, Buccal space, Buccinator space, Parapharyngeal space, Submandibular, Sublingual, lateral pharyngeal and Pterygoid space [3].

The route of facial infection usually depends on the jaw-tooth relationship factors such as configuration of roots, position of roots in the bone, thicknesses of bony plates followed by virulence and type of microorganisms involved through root apex or periodontal pockets [4]. Fascial space infections are associated with life threatening complications such as obstruction of the airway, intracranial spread, hematogenous dissemination and pleural extension. Staphylococci are frequently associated with abscess formation. These microorganisms produce coagulase, an enzyme that is deposited which can cause fibrin deposition in citrated or oxalated blood. Streptococci are associated more often with cellulites, which produce enzymes such as streptokinase (fibrinolysin), hylouronidaze, and streptodornase. These enzymes break down fibrin and connective tissue ground substance, and lyse cellular debris, thus facilitating rapid spread of bacterial invaders [5]. Studies have shown that gramnegative Klebsiella pneumonia (K. pneumoniae) is usually related to opportunistic infections in the respiratory or hepatobiliary systems. However, at times head and neck infection with an odontogenic origin are caused by these species without any predisposing opportunistic infectious etiology [6]. In this case, series, we report 3 rare cases of buccal space infection associated with Klebsiella pneumonia without any systemic disease.

Case Presentation

Case 1

An 18-year old boy reported to the outpatient department with a chief complaint of severe pain and swelling in his lower left facial region with inability to fully open his mouth since 3days. No associated symptoms like fever, cough and dysphagia. Upon physical examinations, vital signs were normal with no other specific systemic diseases as described by the patient. On extra oral examination, a diffuse swelling of about 4 x 4 cm approximately extending superiorinferiorly from the line joining the zygomatic process of maxilla to the commissure of the lower lip and anterio-posteriorly from alar region to the anterior border of the masseteric muscle, soft in consistency and tender on palpation with no associated sinus or fistula or any local rise in temperature. On intra oral examination, lower left first molar (36) was tender on percussion presenting with deep dental caries (Grossly decayed tooth) with diffused collection of pus in the surrounding tissue showing vestibular tenderness extending into the buccal mucosa. Intraoral periapical radiograph revealed diffuse periapical radiolucency into the surrounding tissue with no obvious bony changes. Orthopantamograph also revealed diffuse radiolucency in the buccal space region. A provisional diagnosis of buccal space infection secondary to deep dental caries in associated with 36 was given (Figure 1).