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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00912-X
10.1016/j.ijscr.2024.110131
110131
Case Report
Maternal and Foetal care in odontogenic infections: A well curated management
Jain Rashi rashisjain99@gmail.com
⁎
Bhate Kalyani kalyani.bhate@dpu.edu.in

Manoj Kumar U.
Londhe Uday uday.londhe@dpu.edu.in

Bawane Shilpa shilpa.bawane@dpu.edu.in

Chincholkar Anuja
Dept. of Oral and Maxillofacial Surgery, Dr D Y Patil Dental College, Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune 411018, India
⁎ Corresponding author. rashisjain99@gmail.com
14 8 2024
10 2024
14 8 2024
123 11013127 6 2024
1 8 2024
7 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

Odontogenic and orofacial infections resulting from dental issues are uncommon but cause significant complications. Early intervention is crucial to prevent severe consequences, including deep neck space infections and potentially life-threatening complications. Pregnancy leads to hormonal changes, causing physiological and oral cavity alterations. These changes affect in gingival vascular system, immune response, chemical composition, pH levels, and sub-gingival flora. Managing severe neck infections during pregnancy is challenging due to potential risks for both the mother and fetus. Prompt treatment is essential to avoid complications such as airway obstruction and the associated need for emergency tracheostomy. Pregnancy can also lead to complications like preterm delivery, low birth weight, and maternal or fetal mortality.

Case presentation

A 28 year old pregnant female reported to university teaching hospital to outpatient department of oral and maxillofacial surgery, with complaint of swelling over lower right side of face and reduced mouth opening. On clinical examination it was diagnosed as sub mandibular and pterygoid space infection, primary cause being 47. Looking at the severity patient was advised for incision and drainage under general anesthesia after getting a fitness.

Clinical discussion

Untreated dental decay in pregnant women can progress to facial space infections with life-threatening consequences. In emergencies, incision and drainage may be necessary under general anesthesia to prevent severe complications.

Conclusion

This comprehensive approach not only addressed the odontogenic infection effectively but also ensured the well-being of both the mother and the developing foetus, exemplifying the importance of tailored care in managing pregnant individuals with dental concerns.

Highlights

• Urgency of managing orofacial infection in pregnancy

• Multidisciplinary approach

• The critical role of sonography in evaluating fetal well-being and reassuring patients during dental care in pregnancy

• Timely dental interventions in urgent scenarios can significantly enhance maternal-fetal health outcomes.

Keywords

Odontogenic infection
Foetal anomalies
Pregnancy care
Orofacial space infection
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pmc1 Introduction

Oral infections, predominantly of odontogenic origin, can initially remain confined to local areas but may spread to deeper tissues or distant organs through direct continuity or hematogenous/lymphatic routes, resulting in more severe processes [1]. Inadequate oral hygiene, antibiotic use, trauma, and dry mouth can foster oral infections, causing harm to the oral cavity and possibly allowing the infection to extend into adjacent tissues, leading to systemic infections. Chronic oral infections have been linked to cardiac diseases, and pregnancy has been associated with compromised oral health. Wong et al., in their paper, reported 1.44 % pregnant women with odontogenic infections getting complicated [2]. The incidence of fetal and maternal death associated with oro-fascial infection is high, 13 % and 5.8 %, respectively [3]. The insufficient understanding of the repercussions of severe odontogenic infections during pregnancy has resulted in hesitancy among health practitioners to pursue aggressive treatment for orofacial infections, attributed to concerns regarding potential risks associated with imaging modalities and medications, including antibiotics [4]. Severe odontogenic infections during pregnancy can be life-threatening for both the mother and the fetus, and healthcare providers must be able to manage them appropriately in a multidisciplinary team, considering the potential risks and benefits of dental or surgical treatment. Pregnancy is considered a risk factor for the development, severity, and complications of odontogenic infections. Orofacial infections during pregnancy pose a unique challenge, necessitating a comprehensive understanding of predisposing factors, diagnostic methodologies, and therapeutic interventions [5].

This case report aims to highlight the special care needed in managing orofacial infections in pregnant individuals, shedding light on the importance of a proactive and aggressive treatment approach. Furthermore, this report emphasizes the significance of a multidisciplinary approach, emphasizing the need for seamless coordination between dental practitioners, gynecologists, and anesthetists. This collaboration becomes particularly crucial in emergency scenarios, where swift decision-making and synchronized efforts can significantly impact the maternal and fetal outcomes. By exploring the intricacies of orofacial infection management during pregnancy, advocating general anesthesia with at most care and guidance, this case report aims to contribute to enhanced patient care and optimal treatment outcomes.

2 Case report

Patient information- A 28-year-old female, four months pregnant at 18 weeks gestation, sought medical attention at the university teaching hospital's outpatient department of oral and maxillofacial surgery. She presented with a distressing complaint of swelling in the lower right back region of her jaw. The patient reported the onset of a small extra-oral swelling eight days prior, which had progressively intensified over time. Notably, in the last two days, she experienced a substantial reduction in her ability to open her mouth. Patient was on tablet Augmentin 625 mg for 5 days which was prescribed by her general dentist (Fig. 1).Fig. 1 Clinical photo showing the extent of swelling.

Fig. 1

2.1 Clinical findings

Upon meticulous inspection, a swelling was identified over the right mandibular angle region, extending precisely 1 cm below the lower border of mandible to the ala-tragus line and from angle to corner of the mouth. Further investigation through palpation revealed distinctive characteristics of the swelling: it exhibited hardness, suggesting a substantial degree of tissue involvement, and the overlying skin displayed induration, indicative of inflammation and potential infection. Moreover, the warmth detected upon touch underscored the acute nature of the condition, emphasizing the presence of an active inflammatory process. These palpable findings, in conjunction with the observed limitations in mouth opening measured at a mere 0.4 cm, collectively painted a compelling clinical picture. The amalgamation of signs, including the specific location, consistency, and associated skin changes, led to a clinical diagnosis that strongly suggested a comprehensive infection involving the right submandibular, sub masseteric, and pterygomandibular spaces.

2.2 Diagnostic assessment

Following a series of routine blood investigations, the patient's total leucocyte count was observed to be 13,000 μL. Patient had reduced mouth opening and thus IOPA could not be taken. Subsequently, an ultra-sonography was conducted to meticulously assess the foetus for any anomalies before the planned surgical procedure. The findings within the USG report affirming the overall health and normal development of the foetus were reassuring.

2.3 Therapeutic intervention

Present study was carried out in line with SCARE guidelines. The Department of Oral and Maxillofacial Surgery conducted a formal consultation with the Departments of Obstetrics and Gynecology and Anesthesiology regarding patient's condition. Following a comprehensive assessment, the decision was made to admit the patient under the Department of Oral and Maxillofacial Surgery for incision and drainage procedure under general anesthesia. All necessary consents were taken from the patient and relative prior to the surgery. The urgency of the situation prompted immediate intervention, and the patient was administered IV Augmentin 1.2 g twice a day after consultation with the gynecologist. In alignment with the gynecologist's recommendation, a pre-surgery ultrasound (USG) was performed to rule out fetal anomalies and confirm the fetal status. An hour before the surgery, the patient received IV Augmentin 1.2 g and 500 ml of Ringer's Lactate, followed by the subcutaneous administration of Injection Proluton Depot 500 mg 30 min before the surgery. The patient was intubated using a retrograde technique, and during general anesthesia administration, a slight left lateral decubitus position was employed to reduce uterine aortocaval compression pressure.

Hilton's Method was used to carry out incision and drainage. First, we carried out extra-oral drainage i.e. Submandibular, sub masseteric and buccal space (Fig. 2). Fascial Spaces were explored using Sinus Forceps. Pus samples were collected for culture sensitivity tests. Once thorough drainage and irrigation was done extra orally, we went ahead with the extraction of carious 47. Intra orally, pterygomandibular and lateral pharyngeal space was drained. Notably, pus discharge was observed from the lateral pharyngeal space. Finally irrigation was carried out and followed by the placement of corrugated drains placed intra- and extra-orally along different spaces. Post-surgery, an immediate USG was conducted to monitor the fetal heart rate, revealing a reassuring rate of 118 bpm. Patient was discharged on post-op day 5, after removal of the drain and completion of her antibiotics course. There was no change in antibiotics post culture report (Fig. 3). Follow up was kept for 2 weeks post-surgery. The successful surgical intervention, adherence to medical protocols, and careful monitoring collectively contribute to the comprehensive and effective management of the patient's condition.Fig. 2 Intra-operative Incision and drainage.

Fig. 2

Fig. 3 Post-surgery culture report.

Fig. 3

3 Discussion

Dental infections represent a significant yet frequently underestimated health concern, often overlooked by both patients and healthcare providers. The subtlety of these infections, particularly in non-pregnant females, can mask their potential severity. However, during pregnancy, these latent infections have the propensity to become activated, posing a considerable threat to the overall well-being of the expectant mother. Pregnancy induces notable physiological changes in female patients, potentially leading to significant alterations in oral microbial flora and fostering the colonization of diverse pathogens [6].

Emphasize the profound urgency in managing orofacial infection in pregnant women due to the inherent risks to both the expectant mother and the developing fetus. Given the potential complications associated with untreated odontogenic infections, particularly those extending into the fascial spaces, a comprehensive and multidisciplinary approach is imperative. The optimal management of severe infections involves performing incision and drainage in the operating room under general anesthesia, accompanied by intravenous antibiotic administration [4]. Consulting a gynecologist is of paramount importance as the treatment is being rendered to 2 patients: mother and foetus. All treatment should be done only after consultation with the patient's gynaecologic specialist [8]. Simultaneously, involving an anesthesiologist is crucial to ensure the safe administration of anesthesia, if required, and to manage potential complexities associated with the pregnancy.

Special care management of odontogenic infections in pregnant females with fascial space involvement, it is essential to consider the safety of anesthetic agents. Existing literature consistently supports the cautious use of commonly prescribed medications, indicating that judicious administration at therapeutic doses does not pose a significant risk to fetal outcomes [9]. While emphasizing the importance of careful consideration and weighing of risks and benefits, this case report highlights those dental procedures, especially when urgent or emergent, can contribute significantly to improving maternal-fetal health.

Non-elective surgeries are preferably scheduled during the second trimester of pregnancy, as this period is associated with the lowest risk of preterm delivery. Enhanced surgical exposure is facilitated by the lower position of the uterus in the abdomen, and by the eighth week, major embryonic development is typically complete [4].

There does not seem to be a correlation between surgery or anesthesia and congenital abnormalities. However, there is a significant relationship between surgery and/or anesthesia and foetal death [8]. Reports indicate that anesthesia administered during pregnancy can potentially cause neuronal injury, resulting in impairments of learning and memory across various animal species, regardless of the type of anesthetic used and the timing of administration during pregnancy [10].

3.1 Special care management

The utilization of ultrasonography (USG) for assessing fetal heart rate and potential anomalies prior to surgery plays a pivotal role in positively impacting maternal reassurance. Conducting a preoperative USG not only provides valuable insights into the fetal well-being but also serves as a proactive measure to address any potential concerns. Furthermore, an immediate postoperative USG for fetal heart rate and anomaly confirmation offers real-time assurance to the mother regarding the safety and normalcy of the unborn child. This integrated approach, incorporating pre- and postoperative USG assessments, not only enhances the overall safety of the procedure but also fosters a sense of confidence and well-being for the expectant mother throughout the surgical intervention (Fig. 4) (Table 1).Fig. 4 Post-surgery USG report.

Fig. 4

Table 1 Protocol for special care management in pregnant females.

Table 1

4 Patient perspective

The patient was not only concerned about her own health but also well-being of the fetus. The patient desired to undergo treatment but feared its effect on the fetus. Pre and post operative investigations helped to ensure patient compliance.

5 Conclusion

The preoperative and postoperative, sonography to assess foetal well-being not only served as a vital diagnostic tool but also played a pivotal role in alleviating the patient's concerns and optimizing her overall care. This case highlights the importance of individualized care, multidisciplinary collaboration, and thoughtful consideration of both physiological and psychological aspects in the successful management of odontogenic infections in pregnant individuals, contributing valuable insights to the evolving landscape of dental care during pregnancy.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

As it is a case report, ethics approval is not applicable.

Funding

None.

Guarantor

Dr. Rashi Jain.

CRediT authorship contribution statement

Dr. Kalyani Bhate – Operating surgeon, study concept, provision of study materials or patients, collection and assembly of data, data analysis and interpretation, manuscript writing, final approval of manuscript.

Dr. Rashi Jain - Conception and design, data analysis and interpretation, manuscript writing, final approval of manuscript.

Dr. Manoj Kumar U - Data analysis and interpretation, manuscript writing, final approval of manuscript.

Dr. Uday Londhe - Data analysis and interpretation, manuscript writing.

Dr. Shilpa Bawane - Data analysis and interpretation, manuscript writing.

Dr. Anuja Chincholkar - Data analysis and interpretation, manuscript writing.

Declaration of competing interest

All authors declare no conflict of interest.

Acknowledgement

We the authors, would like to acknowledge the help and support of all the faculty of department of gynecology, Department of anaesthesiology and department of oral and maxillofacial surgery.
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