Articles

Risk factors for the development of odontogenic infections: a literature systematic review

0000-0001-5026-3528Mónica Sofía Pallo-Sarabia¹  , 0000-0002-1479-1486Liset Camaño-Carballo¹  , 0009-0007-6909-9319Luis Francisco Villaroel-Miranda¹ 

¹Universidad Regional Autónoma de Los Andes. Ambato, Ecuador.

ABSTRACT

ABSTRACT Introduction: odontogenic infection is that which has its origin in the structures that form the tooth and the periodontium, and which by extension will affect the maxillary or mandibular bone in its periapical region. This type of infection is usually superficial, localized and limited, but on some occasions a secondary dissemination of the odontogenic infection to other anatomical regions can be observed. Objective: to determine the risk factors for the instauration of odontogenic infections. Methods: a systematic literature review was carried out at the Universidad Regional Autónoma de los Andes between December 2022 and April 2023 on the risk factors for the dissemination of odontogenic infections. Articles in English, Spanish and Portuguese published in PubMed, SciELO and LILACS databases were studied. Development: Of the 512 articles recovered, eight were identified after the screening process, which studied the risk factors for the spread of odontogenic infections. Most belonged to the Journal of Applied Oral Science and 100 % were descriptive studies. Conclusions: Obesity, immunosuppression and diabetes mellitus have a direct influence on the aggravation of odontogenic infections. On the other hand, factors such as oral hygiene, diet, tobacco and drug use are associated with the spread of odontogenic infections.

Key words: DENTISTRY; INFECTIONS; RISK FACTORS; HYGIENE.

INTRODUCTION

In recent years there has been an increase in preventive measures in the area of stomatology; however, infections of odontogenic origin continue to represent one of the conditions with a high incidence.^1,2

It is estimated that the treatment of odontogenic infections accounts for up to 10% of all antibiotic prescriptions. However, lack of knowledge may result in ineffective or delayed treatment.³⁾

Thus, odontogenic infections and their complications can produce systemic manifestations and compromise the patient's life, as they are sometimes no longer limited and can spread to other tissues, organs and systems.⁴⁾

Odontogenic infection is defined as an infection that has its origin in the structures that form the tooth and the periodontium, and which by extension will affect the maxillary or mandibular bone in the periapical region. On the other hand, when we speak of establishment we refer to the migration or propagation of this infection towards other anatomical regions, compromising structures through the facial and cervico-facial spaces.^5,6

The human being maintains a balance between the body's own flora, which tends to vary between regions. An alteration of this ecosystem can trigger the appearance of diseases and infections whose evolution will be conditioned by the general state of health of the patient, the cause of the infection, its location and severity, as well as the treatment employed.^7,8

The factors that influence the establishment of the infection are those that intervene in the balance of the triad formed by the resistance of the host, the capacity of the microbial agent to invade it and the action of the treatment. If this balance is disturbed, it can lead to the establishment of infection.⁹

Risk and predisposing factors can be many. Some have been suggested in the literature, such as underlying diseases,¹ health status, resistance, immune status (immunoglobulins and complement system) and immunosuppression,^8,10) mucosal epithelium status, capacity of the infectious agent, presence of oncologic diseases,^11,12) and antimicrobial resistance. ⁹⁾ Similarly, others related to habits and lifestyles, such as poor oral hygiene,¹³⁾ alcohol consumption,¹¹ and smoking,^14,15) have been reported.

Given the repercussions for the quality of life of the patients in the subject of the study, and the need for early identification of complications, as well as risk stratification, the present study was developed with the aim of determining the risk factors for the development of odontogenic infections.

METHODS

A systemic literature review was conducted at the Universidad Regional Autónoma de los Andes between December 2022 and April 2023 on the risk factors for the development of odontogenic infections. Articles in English, Spanish and Portuguese published in the databases PubMed, SciELO and LILACS were studied.

For the development of the study a search for information was carried out in the Pubmed, Lilacs and SciELO databases. For this, a search strategy was determined, using the terms odontogenic infections, associated factors, risk factors and predisposing factors.

For the selection of the literature to be used, it was limited by year of publication from 2017 onwards and English, Spanish or Portuguese were determined as languages. The bibliographic references of the selected articles were also analyzed in order to rescue other studies that could potentially be included in the review. Said

The research was conducted adhering to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology. This guides the correct documentation of the selection of the search, evaluation and selection of literature to be used (Table 1).

Table 1 Application of the PRISMA Methodology for the development of the study. 

Section	Item
Eligibility Criteria	Inclusion and Exclusion Criteria
Sources of information	Scielo, PubMed y LILACS
Search strategy	Based on the combination of terms, according to the taxonomy of the databases, using as connectors the Boolean operators AND and OR, and the fields Title, abstract and keywords.
Selection process	Discarding of duplicate documents. Reading of abstracts. The selection of articles was made by reading each one completely.
Data collection process	Use of Scimago to collect important information from the journals containing the selected papers
Data list	Odontogenic infections, predisposing factors, risk factors,
Synthesis methods	Presentation in tables of results and traceability of the papers obtained from the systematic review.

RESULTS

The literature search identified 512 articles by means of the search strategies performed in the databases. Eight articles were selected after screening the articles, a process shown in Figure 1.

Fig. 1 Information screening diagram 

Table 2 summarizes the main characteristics of the articles, while Table 3 summarizes the main findings.

Table 2 Characteristics of the selected articles and the journals where they are published. 

Nº	Autor	Año	Revista	País	Buscador
1	Chaparro-González NT, Fox- Delgado MA, Chaparro RTP, Perozo-Ferrer BI, Díaz-Amell AR, Quintero VCT, et al.	2018	Journal of Applied Oral Science	Uruguay	ScIELO
2	Sánchez Huamán B, Alonso Claudio C.	2017	Journal of dentistry	Perú	ScIELO
3	Ruiz de la Cuesta F, Cortes Castell E, Garcia Ruiz ME, Severa Ferrandiz G	2019	Journal of Pediatrics	España	PubMed
4	Sena WG de, Maia GF de A, Carneiro SC de AS, Fragoso RE de L, Ribeiro WHV.	2022	Journal of Applied Oral Science	Brasil	LILACS
5	Blázquez M.	2017	Journal of Applied Oral Science	España	Pubmed
6	Pavan EP, Rocha-Junior WGP, Gitt HA, Luz JGC, Pavan EP, Rocha-Junior W	2020	International Journal of Odontostomatology	Brasil	ScIELO
7	Keswani ES, Venkateshwar G	2019	Journal of Oral Maxillofacial Surgery	Estados Unidos	PubMed
8	Zawiślak E, Nowak R. Odontogenic	2021	Journal of Applied Oral Science	Estados Unidos	PubMed

Table 3 Main results of selected studies 

N°	Author	Research design	Description	Results
1	Blázquez et al.^12	Retrospective study	A review of the clinical history of the patients was carried out, extracting all the necessary data and detailing the existence of certain systemic alterations or bad habits that required special attention in order to establish a relationship between the appearance of complications and the presence of predisposing factors. The study population and sample were 104 patients, 88 had some predisposing factor for developing an odontogenic infection	Predominance of infections in the female sex, but with a very insignificant difference to establish that this type of infection has a predilection according to sex. The most affected age group was between 51 and 80 years of age, with 47 patients. Regarding the etiology that causes the most frequent odontogenic infection, pulp caries was the most frequent cause, with 37 %, that is, 39 patients. The teeth most involved in this study were the lower molars. The most frequent predisposing factor was poor oral hygiene followed by its association with some type of drug. Immunosuppression and diabetes also occupy an important place.
2	Chaparro et al.^14	Descriptive observational study	An observational, descriptive, field-designed research was carried out on a population of 32 patients in a rehabilitation center for drug addicts, located in the state of Zulia, Venezuela. The non-probabilistic, intentional sampling technique was applied to form the sample, according to the following inclusion and exclusion criteria.	Once the data on oral and maxillofacial infections in patients addicted to drugs confined in the study center were collected, it was found that the highest proportion of patients was found in the age groups of 25 to 35 years, most of the patients were male (81.3 %), 3 %), clinical alterations in soft and/or hard tissues, major salivary glands, cervical ganglion chains, facial and neck skin alterations, facial malformations and asymmetries, and sequelae of conditions in the maxillofacial area were recorded. The presence of dental caries and clinical signs of periodontal disease was recorded, as well as the presence of harmful oral habits.
3	Sánchez et al.^16	Observational, cross-sectional, retrospective study	The study population and sample consisted of 90 clinical histories of patients under 15 years of age who were hospitalized for odontogenic facial infections. The variables to be studied were presentation and management of odontogenic facial infections with their dimensions of sex, age, causal dental group, anatomic location, length of hospital stay, antibiotic therapy and dental treatment.	The presentation was greater in the male sex (60 %) and in the ages between 1 and 4 years (52.22 %). Posterior teeth were the causal teeth with the highest percentage of presentation (76.67 %). Infections were located more on the upper face (63.33 %).
4	Ruiz et al.^17	Observational and retrospective study	A study was carried out on childhood deep cervical abscesses in the children's ENT unit for 15 years. Patients diagnosed with such disease during the period 2002-2016, analyzing the clinical, diagnostic and therapeutic characteristics.	The most affected area has been the peritonsillar spaces 30% and the least affected submandibular abscesses 12.3%. The predominant sex in the affected patients was male, the most frequent clinical symptom was fever with 70 %, the most frequently used complementary examinations were CT scan 50 % followed by ultrasound in 28 %.
5	Sena et al.^18	Observational study	Detailed descriptions were made of all the medical records collected with the diagnosis of odontogenic infection from July to November 2021. The inclusion criteria were available reports of patients with a clinical history of odontogenic infection and seen in the emergency department of the Hospital da Restauração during the proposed period. The exclusion criterion was the absence of reports and examinations.	Predominance of the male sex affected by odontogenic infections, corresponding to more than half of the women. The most affected age groups were children aged 1 to 10 years (27 %) and adults aged 18 to 40 years (45 %). The most commonly used treatment procedure was extraoral drainage, followed by intraoral drainage.
6	Pavan et al.^19	Diagnostic study / Observational study	Patients diagnosed with odontogenic infections requiring hospitalization and admitted to the Oral and Maxillofacial Surgery Clinic between October 2016 and April 2018 were prospectively evaluated. For each patient, data on age, sex, risk factors (such as diabetes mellitus, smoking and drug use), signs and symptoms, fascial spaces affected, tooth causing infection, vital signs on admission, laboratory tests, behavior during hospitalization and length. of hospital stay.	The mean age was 30 years. There was a predominance of the male sex in both groups. The risk factors detected were: diabetes mellitus, two cases (4.0 %); smoking, seven cases (14.0 %); and drug abuse, two cases (4.0 %). Mandibular teeth were the main cause of infection, in a 4:1 ratio with respect to maxillary teeth. Specifically, lower molars affected 37 patients (74.0 %) in the study. When the infection came from the upper teeth, molars were also the main cause in six patients (12.0 %). cause in six patients (12.0 %).
7	Keswani et al.^20	Retrospective study	A retrospective analysis of 315 patients treated at Dr. DY Patil Dental College and Hospital in Nerul, Navi Mumbai, from January 2007 to December 2011 was performed. Multiple variables were analyzed. Localized infections such as dentoalveolar infections without space involvement and infections of non odontogenic cause were excluded from the study.	Most patients were from lower socioeconomic backgrounds. The mean age for men was 38, and for women, the mean age was 37. There was a predominance of the male sex with no significant difference between groups. The main etiology was pulp (219 patients), pericoronitis (84 patients) and periodontal (12 patients). In most cases, the teeth affected were mandibular and maxillary first, second and third molars (95.9 %) and also maxillary canines, maxillary premolars and mandibular central incisor (4.1 %). The most affected teeth were the mandibular third mandibular molars
8	Zawislak et al.(21)	Retrospective study	The study involved 85 patients hospitalized for odontogenic head and neck infections between January 2018 and June 2019. Characteristics analyzed included age, sex, location of infection, size of fascial spaces occupied, laboratory markers of inflammation (leukocyte count and CRP levels), type of anesthesia used, causative dental group, duration of hospitalization, seasonality, and type of culture. microorganisms	A detailed analysis of the patients' ages showed that 12.2 % were less than 20 years old, 61.2 % were between 31 and 40 years old, 17.6 % were between 41 and 60 years old and 8.2 % were over 60 years old. The most common source of odontogenic infection was mandibular molars (74.1 %), and no infections derived from mandibular incisors and canines were observed.

Source: Own elaboration

DISCUSSION

Several studies conclude that there is a relationship between factors such as age, gender, causal tooth, some type of comorbidity, initial location of the infectious process, which as a variable may influence this relationship.

Similarly, several authors,^{22,23,24,25,26} include in their research the study of these factors, and by interrelating each variable they affirm the relationship between the risk factors and the appearance and possible establishment of odontogenic infections to deeper levels; in their studies they determine that the average age is approximately 30 years, sex predominantly male with an approximate ratio of 2:1, with the most predominant causal dental organs being the lower molars, directly influencing the appearance of odontogenic infections at the maxillofacial level, concluding that the oral cavity alone should not be treated in isolation since the stomatognathic system works together with the rest of the organism, and in the case of a harmful habit such as poor hygiene, consumption of tobacco and other substances this is reflected in a harmful way, leading us to have a greater predisposition to the appearance of odontogenic infections.

Chaparro et al.,¹⁴ conducted a study on oral and maxillofacial infections in patients addicted to drugs, in which clinical alterations in soft and/or hard tissues, major salivary glands, cervical ganglion chains, facial and neck skin alterations, facial malformations and asymmetries, as well as sequelae of conditions in the maxillofacial area, including the presence of dental caries and clinical signs of periodontal disease; as well as the presence of harmful oral habits were recorded.

Sanchez et al.,¹⁶ carried out a study on the management of odontogenic facial infections in hospitalized patients in the period 2011-2016. They carried out a descriptive, cross-sectional and retrospective study made up of a population of 90 patients, with the aim of describing the presentation and management of odontogenic facial infections. Regarding the results, they determined that male patients presented the disease in a higher percentage (60 %); the average length of hospital stay for the resolution of the disease was four days. Regarding treatment, clindamycin was the most commonly used antibiotic therapy (57,78 %) and the dental treatment was chamber opening plus drainage of the causal tooth (56,67 %). Posterior teeth were the causal teeth with the highest percentage of presentation (76,67 %). Infections were located more on the upper side (63,33 %).

Pavan et al.,¹⁹ reported that the patients participating in their study with odontogenic infection were between the last years of the third decade of life and the first years of the fourth decade, agreeing with other studies such as Sena et al.,¹⁸ Keswani et al.,²⁰ which mentions that adults in the age range of 31 to 50 years are more prone to neglect oral health.

In addition to addressing in their study the increase in heart rate, which is among the factors that are part of the systemic inflammatory response syndrome, which is one of the domains of another proposed index for this type of infections. Adding to the above, it is interesting to note that all cases of diabetes mellitus, drug abuse and smoking cases were in Group 2, which means that these comorbidities contributed as risk factors for the aggravation of these cases. In the analysis of this study it is detailed that patients with diabetes mellitus required prolonged hospitalizations and due to the alterations produced, among which is the reduction of neutrophil activity in the fight against infections.

Ruiz et al.,¹⁷ conducted a study on children's deep cervical abscesses in a children's ENT unit for 15 years. They performed an observational and retrospective study of patients diagnosed with such disease during the period 2002-2016, analyzing the clinical, diagnostic and therapeutic characteristics. It was noted that clinical indicators such as trismus, edema and dysphagia were the main symptoms of establishing odontogenic infections. The presence of trismus and dysphagia are considered strong indicators of severe odontogenic infection due to their effect on the masticatory space and upper airway, respectively.

Keswani et al^,(20 performed a retrospective analysis of 315 patients treated from January 2007 to December 2011. After analysis of the records they determined that most of the patients were from low-income socioeconomic backgrounds and were salaried workers who had consulted a general practitioner or general dentist or had self-medicated before presenting with acute symptoms.

Early recognition and immediate treatment with intravenous antibiotics with extraction of the involved tooth/teeth and incision and drainage helped to resolve the infections within 72 h. Medically compromised patients within this study had a longer hospital stay compared to patients without an underlying medical condition. Most spatial infections involved multiple spaces and local anesthesia with sedation was found to be the satisfactory mode of anesthesia. Complications were very few.

Zawislak et al.,²¹ performed a retrospective epidemiological analysis which was based on a review of the medical records of patients treated at the Department of Maxillofacial Surgery of the Medical University Hospital in Wroclaw. In his analysis the author involved 85 patients aged five to 72 years, hospitalized for odontogenic head and neck infections between January 2018 and June 2019. Characteristics analyzed included age, sex, location of infection, size of fascial spaces occupied, laboratory markers of inflammation (leukocyte count and CRP levels), type of anesthesia used, causative dental group, length of hospitalization, seasonality, and type of culture. Microorganisms.

Detailed analysis of patient ages showed that 12,2 % were less than 20 years old, 61,2 % were between 21 and 40 years old, 17.6 % were between 41 and 60 years old, and 8,2 % were over 60 years old. The study found that odontogenic inflammations remain a persistent problem, not only in adulthood, but are also problems experienced in childhood and adolescence. On the other hand, the present study also determined that the most common source of odontogenic infection was the mandibular molars (74,1 %), and no infections derived from the mandibular incisors and canines were observed.

CONCLUSIONS

Local anatomical barriers such as bone, muscle, fascia, nerves, arteries and blood vessels constitute pathways for the establishment of odontogenic infections. Immunosuppression, diabetes, poor oral hygiene and drug use are associated with an increased risk of complications in patients with odontogenic infection, as well as its establishment. Cardiac, immunological and endocrine-metabolic comorbidities contribute to the appearance of systemic inflammatory response syndrome, which is considered as a risk indicator in this type of infections. The teeth with the highest incidence of developing an odontogenic infection correspond to the lower molar group, especially the third molars.

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Funding

The authors did not receive funding for the development of this research

Received: July 18, 2023; Accepted: October 05, 2023

The authors declare that there is no conflict of interest.

All authors participated in the conceptualization, formal analysis, project management, writing - original draft, writing - revision, editing and approval of the final manuscript