Lessons From Two Cases of Odontogenic Septicemia
Patient characteristics are summarized in Table 2. Medical treatment for hematologic malignancy was transplant in 14 cases and chemotherapy alone in 23. The source of stem cell was bone marrow in seven cases, peripheral blood in five, and cord blood in two. Autologous transplant was performed in four cases, whereas the remaining ten patients received allogeneic transplant. Grade B chemotherapies (moderate myelosuppression) were performed in 34 patients (91.9%), grade C (severe myelosuppression) in 18 (48.6%), and grade D (severe myelosuppression and persistent immunodeficiency) in 15 (40.5%). Some patients were graded several times. Total courses of grade B chemotherapy were 64, grade C 22, and grade D 15.
The extraction of 45 non-salvageable teeth from 10 patients was performed following administration of prophylactic antibiotics. On the day of operation, the median white blood cell (WBC) count was 4100/μl (range: 1300–11300) and the platelet count was 22.8 × 10/μl (range: 2.4-43.1) (Table 3). Platelet transfusion was required in one patient.
Although all patients received the scheduled chemotherapy with no alteration, interruption or delay caused by the dental treatment, in two of the 37 patients (5.4%), severe odontogenic infections occurred. These cases are discussed in detail below.
A 57-year-old female with B-cell lymphoma received CHOP therapy (myelosuppression grade B) on the day of hospitalization. The primary dental examination was performed 10 days after the start of chemotherapy. When bone marrow recovered on the 19th day, non-salvageable teeth with marginal periodontitis were extracted in preparation for subsequent autologous peripheral blood stem cell transplantation.
During the night after the procedure, body temperature became elevated (Figure 1). Based on clinical findings and laboratory data, the patient was diagnosed as having sepsis with disseminated intravascular coagulation resulting from infection after dental extraction. She received intravenous antibiotics (meropenem, clindamycin and teicoplanin). The patient duly recovered, and the remaining non-salvageable teeth were extracted 10 days after the onset of septicemia.
(Enlarge Image)
Figure 1.
Summary of case 1. G-CSF, granulocyte colony stimulating factor; BT, body temperature; EXT, tooth extraction; WBC, white blood cells.
A 67-year-old male with myelodysplastic syndrome-derived overt leukemia received remission induction therapy (IDA, Ara-C) on the day of hospitalization. He underwent primary dental examination 5 days after the start of grade C myelosuppression chemotherapy. Whereas some asymptomatic teeth with advanced marginal periodontitis were observed, invasive treatments (i.e. tooth extraction) could not be provided because of thrombocytopenia caused by hematologic tumor and chemotherapy (platelet count was 2.1 × 10/μl). Dental treatment was restricted to conservative therapy such as oral hygiene instruction.
When the WBC count dropped to 400/μl during the 20 days after initiation of chemotherapy, body temperature rose to 39°C (Figure 2). Pulse rate was over 100 beats per minute and respiratory rate was over 20 breaths per minute. The clinical examination revealed severe gum pain and broad swelling around a tooth with advanced marginal periodontitis. Although the results of bacterial detection (2 trials of blood culture) were negative, clinical findings indicated the sepsis syndrome resulting from odontogenic infection. The infection was resolved by administration of antibiotic drugs (cefepime, hydrochloride and clindamycin).
(Enlarge Image)
Figure 2.
Summary of case 2. G-CSF, granulocyte colony stimulating factor; BT, body temperature; EXT, tooth extraction; WBC, white blood cells.
Results
Patient characteristics are summarized in Table 2. Medical treatment for hematologic malignancy was transplant in 14 cases and chemotherapy alone in 23. The source of stem cell was bone marrow in seven cases, peripheral blood in five, and cord blood in two. Autologous transplant was performed in four cases, whereas the remaining ten patients received allogeneic transplant. Grade B chemotherapies (moderate myelosuppression) were performed in 34 patients (91.9%), grade C (severe myelosuppression) in 18 (48.6%), and grade D (severe myelosuppression and persistent immunodeficiency) in 15 (40.5%). Some patients were graded several times. Total courses of grade B chemotherapy were 64, grade C 22, and grade D 15.
The extraction of 45 non-salvageable teeth from 10 patients was performed following administration of prophylactic antibiotics. On the day of operation, the median white blood cell (WBC) count was 4100/μl (range: 1300–11300) and the platelet count was 22.8 × 10/μl (range: 2.4-43.1) (Table 3). Platelet transfusion was required in one patient.
Although all patients received the scheduled chemotherapy with no alteration, interruption or delay caused by the dental treatment, in two of the 37 patients (5.4%), severe odontogenic infections occurred. These cases are discussed in detail below.
Case 1
A 57-year-old female with B-cell lymphoma received CHOP therapy (myelosuppression grade B) on the day of hospitalization. The primary dental examination was performed 10 days after the start of chemotherapy. When bone marrow recovered on the 19th day, non-salvageable teeth with marginal periodontitis were extracted in preparation for subsequent autologous peripheral blood stem cell transplantation.
During the night after the procedure, body temperature became elevated (Figure 1). Based on clinical findings and laboratory data, the patient was diagnosed as having sepsis with disseminated intravascular coagulation resulting from infection after dental extraction. She received intravenous antibiotics (meropenem, clindamycin and teicoplanin). The patient duly recovered, and the remaining non-salvageable teeth were extracted 10 days after the onset of septicemia.
(Enlarge Image)
Figure 1.
Summary of case 1. G-CSF, granulocyte colony stimulating factor; BT, body temperature; EXT, tooth extraction; WBC, white blood cells.
Case 2
A 67-year-old male with myelodysplastic syndrome-derived overt leukemia received remission induction therapy (IDA, Ara-C) on the day of hospitalization. He underwent primary dental examination 5 days after the start of grade C myelosuppression chemotherapy. Whereas some asymptomatic teeth with advanced marginal periodontitis were observed, invasive treatments (i.e. tooth extraction) could not be provided because of thrombocytopenia caused by hematologic tumor and chemotherapy (platelet count was 2.1 × 10/μl). Dental treatment was restricted to conservative therapy such as oral hygiene instruction.
When the WBC count dropped to 400/μl during the 20 days after initiation of chemotherapy, body temperature rose to 39°C (Figure 2). Pulse rate was over 100 beats per minute and respiratory rate was over 20 breaths per minute. The clinical examination revealed severe gum pain and broad swelling around a tooth with advanced marginal periodontitis. Although the results of bacterial detection (2 trials of blood culture) were negative, clinical findings indicated the sepsis syndrome resulting from odontogenic infection. The infection was resolved by administration of antibiotic drugs (cefepime, hydrochloride and clindamycin).
(Enlarge Image)
Figure 2.
Summary of case 2. G-CSF, granulocyte colony stimulating factor; BT, body temperature; EXT, tooth extraction; WBC, white blood cells.