Odontogenic-Like Pain in Partial Edentulism: An Unusual Presentation of Diffuse Large B-Cell Lymphoma of the Mandible

Primary bone lymphoma is a rare entity and it usually occurs in long bones. Primary mandibular involvement is very rare, and it usually shows unspecific features, mimicking odontogenic inflammatory lesions. We present the unusual case of a diffuse large B-cell lymphoma (DLBCL) of the right mandibular body in a 91-year-old woman, who presented with acute pain in the mandibular region initially suspicious for odontogenic abscess. No significant findings were seen on orthopantomography (OPG) and her almost complete edentulism made the diagnosis of abscess unlikely. Computed tomography and magnetic resonance images showed an expansive mass around the right mandibular body with erosion of cortical bone and involving the right mandibular canal and nerve. Final diagnosis of DLBCL was pathologically proven. The presence of odontogenic-like pain in nearly complete edentulism should be suspicious for malignancy, and it needs further diagnostic workup despite the absence of signs on OPG.

Clinical Relevance of the Microbiome in Odontogenic Abscesses

Odontogenic abscesses are usually caused by bacteria of the oral microbiome. However, the diagnostic culture of these bacteria is often prone to errors and sometimes fails completely due to the fastidiousness of the relevant bacterial species. The question arises whether additional pathogen diagnostics using molecular methods provide additional benefits for diagnostics and therapy. Experimental 16S rRNA gene analysis with next-generation sequencing (NGS) and bioinformatics was used to identify the microbiome of the pus in patients with severe odontogenic infections and was compared to the result of standard diagnostic culture. The pus microbiome was determined in 48 hospitalized patients with a severe odontogenic abscess in addition to standard cultural pathogen detection. Cultural detection was possible in 41 (85.42%) of 48 patients, while a pus-microbiome could be determined in all cases. The microbiomes showed polymicrobial infections in 46 (95.83%) cases, while the picture of a mono-infection occurred only twice (4.17%). In most cases, a predominantly anaerobic spectrum with an abundance of bacteria was found in the pus-microbiome, while culture detected mainly Streptococcus, Staphylococcus, and Prevotella spp. The determination of the microbiome of odontogenic abscesses clearly shows a higher number of bacteria and a significantly higher proportion of anaerobes than classical cultural methods. The 16S rRNA gene analysis detects considerably more bacteria than conventional cultural methods, even in culture-negative samples. Molecular methods should be implemented as standards in medical microbiology diagnostics, particularly for the detection of polymicrobial infections with a predominance of anaerobic bacteria.

Microbiome of Odontogenic Abscesses

Severe odontogenic abscesses are regularly caused by bacteria of the physiological oral microbiome. However, the culture of these bacteria is often prone to errors and sometimes does not result in any bacterial growth. Furthermore, various authors found completely different bacterial spectra in odontogenic abscesses. Experimental 16S rRNA gene next-generation sequencing analysis was used to identify the microbiome of the saliva and the pus in patients with a severe odontogenic infection. The microbiome of the saliva and the pus was determined for 50 patients with a severe odontogenic abscess. Perimandibular and submandibular abscesses were the most commonly observed diseases at 15 (30%) patients each. Polymicrobial infections were observed in 48 (96%) cases, while the picture of a mono-infection only occurred twice (4%). On average, 31.44 (±12.09) bacterial genera were detected in the pus and 41.32 (±9.00) in the saliva. In most cases, a predominantly anaerobic bacterial spectrum was found in the pus, while saliva showed a similar oral microbiome to healthy individuals. In the majority of cases, odontogenic infections are polymicrobial. Our results indicate that these are mainly caused by anaerobic bacterial strains and that aerobic and facultative anaerobe bacteria seem to play a more minor role than previously described by other authors. The 16S rRNA gene analysis detects significantly more bacteria than conventional methods and molecular methods should therefore become a part of routine diagnostics in medical microbiology.

Patient-induced progressive facial subcutaneous emphysema masquerading as odontogenic abscess

Facial subcutaneous emphysema (SE) is an uncommon sequelae of dental procedures and often attributed to the use of high-speed air-driven handpieces during surgical extractions, forcing air through fascial spaces. Rarely have there been documented cases of patient-induced SE. In this case report, we present an 18-year-old woman who was referred to the emergency department with a 5-day history of progressive swelling and pain to her right cheek, following a prolonged, but simple extraction of tooth 18. While the dentist and emergency physicians were concerned about an infectious aetiology, history taking, clinical review and imaging corroborated the diagnosis of patient-induced SE secondary to habitual straw use. This report highlights the need for routine postextraction counselling of sinus precautions irrespective of extraction complexity. Additionally, emergency physicians should be aware of SE masquerading as other pathology, including odontogenic abscesses, allergic reactions, angioedema and gas-forming bacterial infections, such as necrotising fasciitis, to ensure appropriate treatment is provided to patients.

Orofacial Infections in Kenya: A Retrospective Study

Background: Orofacial infections are either odontogenic or non-odontogenic in nature. The clinical spectrum of these infections is diverse. This study aimed to describe the presentation and management of patients presenting with orofacial infections at Kenyatta National Hospital (KNH). Materials and Methods: This was a retrospective study based on clinical records of patients treated for orofacial bacterial infections at KNH fromJanuary 2016 to December 2018. Data on the following study variables were obtained and analyzed: demographic data, clinical presentation, diagnosis, management, and treatment outcome. Results: 214 clinical records were studied. Male to female ratio was 1.4:1 with age range of 3 months to 78 years (mean=27.0 years). Swelling (96.30%, n=206) was the most common symptom, next was pain (58.90%, n=123). The most common source of infection was odontogenic (60.30%,n=129) in nature. Permanent teeth (57.00%, n=122) were more commonly involved than deciduous teeth (2.80%, n=6). In both dentitions, the mandibular posterior teeth were the most commonly involved, Ludwig’s angina (30.84%, n=66) and submandibular abscess (25.23%, n=54) were the most common clinical diagnoses of orofacial bacterial infection. The commonly used treatment modality was a triad of extraction of the associated tooth, incision and drainage, and antibiotic therapy. These management modalities resulted in favorable treatment outcomes (92.50%, n=198) in most cases. Conclusion: Orofacial infections can occur among all sociodemographic groups. These infections are potentially life-threatening if not diagnosed early and managed promptly. Multidisciplinary teams are required to manage the severe morbidity and mortality of advanced orofacial infections. Keywords: Orofacial infections, Odontogenic, Abscess, Ludwig’s angina

Descending Necrotizing Mediastinitis in Covid- 19 Time

Introduction: Descending Necrotizing Mediastinitis (DNM) is the fatal form of mediastinitis and mostly develops as a complication of peritonsillar abscesses or dental- odontogenic infections. The aim of this study is to evaluate clinical and surgical feature of the patients with DNM who were managed in our Department during the period of general lockdown in Greece, between March 2020 and June 2020, because of the Covid19. Patients and Methods: During the period of general lockdown in Greece, 4 patients, mean age 46, 25 years (range 39-59), with DNM treated to our Department of General Thoracic Surgery. Primary odontogenic abscess occurred to 2 patients and peritonsillar abscess to other 2 of them. Diagnosis was confirmed by computed tomography (CT) of the neck and chest. All patients underwent surgical drainage of abscesses of the involved cervical region and mediastinum by lateral cervicotomy and left thoracotomy in three of them and cervicotomy, and bilateral thoracotomy in one patient. Results: The delay between the occurrence of thoracic symptoms and mediastinal drainage varied from 1 to 3 days. The side of the thoracotomy depended on the involved mediastinal compartments and side of pleural effusion. The duration of mediastinal drainage varied from 12 to 20 days (mean: 17 days). One patient died of multiorgan failure related to post-op septic shock. Conclusion: Between January 2000 and January 2020, 21 patients with DNM were treated at our Department, whilst during the four - month of lockdown, four patients were treated. We concluded that the patients delay for dentistry recourse because of covid-19, result in the increased number of patients with DNM in the above period. Delayed diagnosis and inadequate drainage are the main causes of the high mortality rate of DNM. If one realistically hopes to avoid the high mortality rate, aggressive surgical drainage and debridement of the neck and drainage of the mediastinum via a posterolateral thoracotomy by a multidisciplinary team of surgeons is a must.