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Brain abscess of odontogenic origin: report of case
CLINICAL
lary antrum suggested a more aggressive lesion. M icroscopic exam ination con firmed the working diagnosis and the additional presence of an aneurated bone cyst with its fresh blood-filled cavities separated by fibrous septae and lined by histiocytic and multinucleated giant cells. R ecognition of an aneurysmal bone cyst-precursor com plex lesion at the time of surgery is important not only in terms of diagnostic accuracy but also for the dif ficulties encountered during com plete removal of the incipient lesion and there fore, the possible chance for recurrence of the primary lesion. Aneurysmal bone cysts are known to result from an arteriove nous anomaly engrafted on an underly ing, preexistent, slow-growing lesion.5,11,12 During this process, the initial arterio venous anomaly form ing w ithin the in cipient lesion introduces more blood under hemodynamic pressure to the af fected site. This occurrence in the stromal soft tissue w ould seem to promote rapid expansion o'f the jaws. The sequence of events for a dentigerous cyst can follow a similar pathogenic pattern. In the dentigerous cyst, in con trast to the odontogenic keratocyst, the lin in g epithelium has low m etabolic activity, shows low m itotic figures, and generally is not actively disposed in the growth of the cyst.13,14 Rather, venous obstruction induced by the impacted tooth and follicular compression causes a tran
sudation across the vessel wall. Subsequent m odification of the p o olin g transudate and a further increase of its hydrostatic pressure facilitates further growth.15 The triggering potential in such an event can also provide, sim ultaneously, for an arteriovenus sh u n tin g and an engrafted aneurysmal bone cyst anomaly as seen in this patient. Conclusion T h is report of case has given further evi dence to support the concept that the aneurysmal bone cyst occurs as the out com e of secondary changes in an incip ien t, prim ary, slo w -g ro w in g lesion . Predisposition of aneurysmal bone cyst formation secondary to a dentigerous cyst can result from a com m on phenom enon of disturbed hem odynam ic alteration associated with the growth of the dentig erous cyst.
-------------------- J»A\DA\ -------------------Dr. N ad im i is a ssistant professor, d epartm ent of o ral path o lo g y , L oyola U niversity School of D entist ry. Dr. B ronny is chair, d ep artm en t of dentistry; Dr. Sbigoli is a form er general practice resident; Dr. G atti is associate professor, d ep artm en t of otolaryngologyhead an d n eck surgery; a n d Dr. H asiakos is attending dentist, d ep artm en t of dentistry, Foster G. McGaw H o sp ital, L oyola U niversity M edical Center. Address requests for re p rin ts to Dr. B ronny a t the Loyola U niversity M edical Center, 2160 First Ave, M aywood, IL 60153.
REPORTS
1. Jaffe, H .L . A neurysm al b o n e cyst. B ull H o sp J o in t Dis 11(1):S-13, 1950. 2. B atsakis, J.G . T u m o rs of the head an d neck: clin ic al a n d p a th o lo g ic al considerations, ed 2. B alti m ore, W illiam s 8e W ilkins Co, 1979, p p 393-395. 3. T illm a n , B .P., a n d others. A neurysm al bone cyst: an analysis of ninety-five cases, M ayo C linic Proc 43(7):478-495, 1968. 4. R uiter, D .J., a n d others. A neurysm al bone cyst: a clinico p ath o lo g ical study of 105 cases. C ancer 39(5): 22S1-2239, 1977. 5. Y arington, C .T ., Jr., an d others. A neurysm al bone cyst of the m a x illa : association w ith g ia n t cell reparative g ra n u lo m a . A rch O to lary n g o l 80:313-317, 1964. 6. Biesecker, J.L ., a n d others. A neurysm al bone cyst: a c lin ic o p ath o lo g ic study of 66 cases. Cancer 26(3):615-625, 1970. 7. Levy, W .M ., a n d others. A neurysm al bone cyst secondary to o th e r osseous lesions: re p o rt of 57 cases. Am J C lin P ath o l 6S(l):l-8, 1975. 8. N ad im i, H ., a n d others. C oexistent aneurysm al bone cyst w ith am eloblastom as: a h istologic survey. J O ral M ed 41(3):242-243, 1986. 9. H o p p e, W. A neurysm al bone cyst of the m a n d i ble: report of a case. O ral Surg 25(l):l-5, 1986. 10. S pjut, H .J., an d others. A tlas of tu m o r p a th o l ogy. T u m o rs of bone a n d cartilage, fascicle 5. W ash in g to n , DC, A rm ed Forces In stitu te of P athology, 1971, p p 357-367. 11. M ira, J. Bone tum ors. P h ila d e lp h ia , L ip p in c o tt Co, 1980, p p 478-491. 12. Buraczew ski, J., an d Dabska, M. Pathogenesis of aneurysm al bone cyst: re la tio n sh ip betw een the aneurysm al b o n e cyst a n d fibrous dysplasia of bone. C ancer 28(3):597-604, 1971. 13. M ain, D.M. T h e e n la rg e m en t of e p ith e lia l jaw cysts. O d o n tologisk Revy 21(1 ):29-49, 1970. 14. M ain, D.M. E p ith elial jaw cysts: a c linico p a th o lo g ic al reap p raisal. B r J O ral S urg 8(1):114-125, 1970. 15. Browne, R.M . T h e pathogenesis of odontogenic cysts: a review. J O ral P a th o l 4 (l):3 1 -4 6 ,1975.
Brain abscess of odontogenic origin: report of case Jay A. Aldous, DDS, MS G. Lynn Powell, DDS Suzanne S. Stensaas, PhD A d va n ced d e n ta l in fectio n rarely causes brain abscess resu ltin g in d ea th . G o o d d e n ta l h yg ien e a n d rem o v in g abscessed teeth are a d v ise d fo r p re v e n tio n o f a n y such occurrence. A n in terc ra n ia l infec tio n is described in a 29-year-old m a le w h o also h a d a d e n ta l p h o b ia .
he spread of d en tal abscesses or oral infection to distant areas of the head and neck is uncom m on but has been documented.1-3 Result ing intracranial infections or abscesses are c o m p lic a te d .4,5 T h e fa cia l, a n gu lar,
T
ophthalmic, and other veins can be path ways for in fectio n to travel from the m outh, through the cavernous sinus and into the cranium .1,3,6 Brain abscesses of dental origin are difficult to manage and frequently result in death. ‘’2'4,5 Preventing abscesses by ro u tin e d en tal and oral hygiene care or early removal of nontrea ta b le teeth is p ru d e n t. T h is is esp ecially advisable for patients w ith chronic dental phobia. Report of case A 29-year-old white male died of a brain abscess o f dental origin , according to autopsy reports. H e had sought dental
care for painful gingiva in the anterior mandibular area. Results of an exam in a tio n by a V eterans A d m in istra tio n h o sp ita l show ed that the p atien t had heavy calculus, and poor oral hygiene. T he soft tissues appeared to be normal except for acute gingivitis, bordering on Vincent’s infection. Caries was noted on the maxillary right first and second m olars, left first and second premolars, and second molar, and m andibular left first m olar. A lthou gh dental care to treat these conditions was authorized by the Veterans Administra tion, the patient did not seek the needed treatment at that time. During the next 10 years, he had several
A ldous-Powell-Stensaas : BRAIN ABSCESS OF O D O N TO G EN IC O RIG IN ■ 861
CLINICAL
REPORTS
h o sp ital adm issions and clinic visits for psychiatric problem s, alcohol and drug abuse, and dental pain. D uring the fourth year, h o sp ital records reported th at he had dental caries an d reddened gingiva. In the fifth year, the p atien t had em er gency treatm ent because of p ain in the m a n d ib u la r rig h t second m olar. E ndo d o n tic th e r a p y w as s ta rte d , b u t the p a t ie n t fa ile d to k ee p a s u b s e q u e n t ap p o in tm e n t. L ater in the fifth year, the p a tie n t h a d h is three re m a in in g th ird m olars rem oved u nder general anesthesia because of infection and im paction. T he
blood cells, an d an ECG show ed an intrav e n tr ic u la r c o n d u c tio n defect. S in u s r a d io g r a p h s sh o w ed p a n s in u s itis n o t involving the sphenoid. D rainage of the left frontal abscess was advised. T h e p atien t was stable u n til the 23rd day w hen his tem perature rose to 104 F and his blood pressure dropped. H e was stabilized again w ith intravenous fluids. B ecause o f th e p a t ie n t’s h is to ry an d presum ed sepsis, intravenous gentam icin an d m etronidazole were started, in ad ditio n to chloram phenicol. H e was stable u n til g rand m al seizures developed again,
B ra in abscesses of dental origin are difficult to control or resolve with antibiotics alone.
last h o sp ital dental entry before the final adm ission was in the n in th year: teeth— p o o r condition. In th e te n th year, th e p a tie n t was a d m itte d to the h o s p ita l w ith fro n ta l headache, chills an d fever, follow ed by s w e llin g of th e le ft eye a n d a w h ite p u ru le n t nasal discharge. T h e diagnosis w as p an sin u sitis, an d cep h ap irin sodium was started. T hree days later, the patient u n d e r w e n t tr e p h e n a tio n of the r ig h t f r o n t a l s in u s ; c u l tu r e s w e re ta k e n . C u l tu r e r e s u lts r e p o r te d a n a e ro b e s , m o stly bacterio d es. N ext, in tra v e n o u s ch lo ram phenicol therapy was begun. O n th e 2 0 th d ay of h o s p ita liz a tio n , the p a tie n t h ad a g rand m al seizure. A C T scan at th a t tim e showed a collection of flu id in the left frontal lobe consistent w ith an abscess. S im ilar dense m aterial w as v isib le in th e su b d u ra l an d su b ara ch n o id spaces; this was interpreted as em p y em a a n d m e n in g itis ; the n e u ro surgery departm ent was consulted. T h e p atient, w ho w eighed 250 lb, had a te m p e ra tu re of 101 F; b lo o d pressure, 130/70 m m H g; respiration rate, 20; pulse rate, 88. H e was alert b u t n o t oriented; had fixed an d d ilated p u p ils; erythem atous fundi; intact cranial nerves III, IV, an d VI, a n d responded only to sim ple co m m an d s. P o ssib le g en eralized r ig h t side w eakness a n d p o sitiv e B a b in sk i’s r e f le x o n th e r i g h t sid e i n d ic a t in g p y ra m id a l tra c t in v o lv e m e n t w as o b served. L a b o ra to ry values were: w h ite b lood cell co u n t (WBC), 6,500; hem ato c rit, 46.7; SM AC (20) w ith in n o rm a l lim its. U rinalysis show ed 12 to 15 w hite 862 ■ JADA, Vol. 115, December 1987
th e n e x t e v e n in g . T h e seizu res w ere controlled w ith phénobarbital. Early on day 25, his tem perature rose to 104 F an d h is b lo o d p re ssu re d ro p p e d . H e w as tre a te d w ith in tr a v e n o u s flu id s a n d dopam ine. L ater in the m o rn in g of the 25th day, he appeared weak, w ith p u p ils dilated an d fixed, no m ovem ent of the eyes as positio n was changed, and no co rn e al reflex. H o u rs la te r th e h y p o ten sio n becam e m ore severe, re q u irin g d opam ine to m ain tain blood pressure and he h ad no spontaneous respirations. At a b o u t 11:30 p m , th e p a t i e n t ’s b lo o d p r e s s u r e d r o p p e d to zero , h is h e a r t stopped, an d he was pronounced dead.
m a n d ib u lar rig h t second prem olar and first m o la r. T h e re was extensive p e ri o d o n tal disease, particularly severe in the left m axilla. F lu id from the intracranial cavity was s u b m itte d fo r a e ro b ic a n d a n a e ro b ic cultures; Escherichia coli an d enterococci w ere f o u n d . T h e p o s tm o rte m e x a m in a tio n also disclosed p u ru len t m aterial in the sub arach n o id and subdural space, frontal pole abscess w ith extension in to ventricles, an d cerebral edema, ultim ately re s u ltin g in te m p o ral lobe in fa rc tio n , u ncal h ern iatio n , an d death. T h e final m edical sum m ary said that: “T h e p atien t d ied as a re su lt of a diffuse p u r u le n t m e n i n g i t i s th a t in v o lv e d th e s u b a r a c h n o id a n d s u b d u r a l sp aces. A ll external surfaces of the brain, spinal cord, a n d th e v entricles were involved. T h e m eningitis probably developed after the form ation of a left frontal lobe abscess th a t re su lte d from the h e m a to g e n o u s seeding of the b rain by organism s from the chronic dental abscess. Discussion Brain abscesses of dental origin are dif fic u lt to c o n tro l o r resolve w ith a n ti b io tic s a lo n e .4,5 T h e e x tre m e ly h ig h m ortality rate (m ore th an 90%) of in tra cran ial abscesses of odontogenic o rig in as com pared w ith those from other foci is d ifficult to ex p lain .4 T h e prim ary defense a g a in s t in fe c tio n is the im m u n o lo g ic system. T h e stim ulation of this system to m anufacture w hite blood cells is p art of the im m u n o lo g ic response. T h e p atien t in this case showed a m in im al response to
Postmortem evidence suggested that dental abscesses may have provided the infective organism.
T h e first 14 days of fin a l h o s p ita l ization stay the WBC averaged 6,500 w ith a h ig h of 8,500 an d a low of 5,200. O n the 15th day, the co u n t started to rise. A h ig h of 16,200 was recorded on the 18th day of hospitalizatio n and dropped to 8,800 on the day the p atien t died. T h e differential re a d in g sho w ed b an d s in th e n o rm a l ra n g e a n d a n increased p erc en ta g e of segm ented neutrophils. P ostm ortem exam ination disclosed sev eral periapical dental abscesses in clu d in g abscesses in v o lv in g the m a x illa ry left second prem o lar and first m olar, an d the
the infection u n til the 18th day of h o sp i talization w hen there was a shift in the d if f e r e n tia l w h ite b lo o d c e ll c o u n t. Factors th a t may influence the im m u n o lo g ic resp o n se m ay be n u tritio n , liver disease, some d ru g therapy, an d substance abuse. T h is p atien t’s response probably was influenced by several of these factors. T h e d e a th re p o rte d in th is case is consistent w ith other recorded m ortalities th a t o cc u rre d in sp ite of a p p lie d a g gressive an tib io tic and surgical therapy. T h e postm ortem evidence suggested the d e n ta l abscesses o f th e te e th in th e
CLINICAL
m a x illa ry le ft a n d m a n d ib u la r r ig h t q u ad ra n ts, an d the p e rio d o n ta l disease present may have provided the infective o rg a n is m . T h e se w ere lo n g - s ta n d in g d e n ta l c o n d itio n s as in d ic a te d in th e d en tal records. At the tim e of the left c ra n io to m y , the p o ste rio r w all of the frontal sinus was exam ined, b u t n o defect was found. O ther routes for an infection to travel from the m o u th to the brain have been discussed,1'3,6 such as venous drainage. Infection can also involve the p o rtio n of the brain opposite the side of th e in fected to o th o r teeth. A lth o u g h cultures of the dental abscess were not do n e, th e c u ltu re s of the in tr a c r a n ia l cavity and sinus fluids were consistent w ith bacteria th a t are found in the m outh an d have been reported to have caused b rain abscess in the past.3,5
Conclusions
T h is p a tie n t w as described as h av in g d en tal p h o b ia , an d yet allo w ed d ental specialists to p ro v id e treatm en t. M any p h y sic a l e x a m in a tio n s a n d ad m issio n notes refer to his dental status and need for treatm ent, b u t he did n o t choose to o b ta in tr e a tm e n t. A lth o u g h d e n tis ts id e a lly w a n t to sav e n a t u r a l te e th , patients w ith dental p h o b ia or those who do not choose to seek treatm ent follow -up present problem s. T im ely extractions and antibiotic therapy should be considered for these patients. -----------------------JA D )A ----------------------Dr. A ldous is a ssistant professor, d e p artm e n t of surgery; Dr. Pow ell is associate professor; an d Dr.
REPORTS
S te n s a a s is a s s i s t a n t p r o f e s s o r , d e p a r tm e n t of p a thology, school of m edicine, U niversity of U tah, D e n tal E d u c a tio n , B u ild in g 518, S a lt L ake C ity, 84112. Address requests for re p rin ts to Dr. A ldous.
1. P elleg rin o , S.V. E xtension of d e ntal abscess to the orbit. JAD A 100(6):873-874, 1980. 2. In g h a m , H .R ., a n d o th e rs. A bscesses o f the fro n ta l lobe of the b ra in secondary to covert d e ntal sepsis. L ancet 2(8088):497-499, 1978. 3. G o te in e r, D .; S o n is , S .T .; a n d F a c ia n o , R. C a v e rn o u s s in u s th ro m b o s is a n d b r a in ab sc e ss in itia te d a n d m a in ta in e d by p e rio d o n ta lly involved teeth. J O ral M ed 37(3):80-83,1982. 4. H o llin , S .A ., a n d G ro ss, S.W . In tr a c r a n ia l abscesses of odon to g en ic orig in . O ral S urg O ral Med O ral P ath o l 23(3):277-291, 1967. 5. V a lachovic, R ., a n d H a rg reav es, J.A . D en tal im p lic a tio n s o f b r a in a bscess in c h ild r e n w ith c o n g en ital h e art disease. O ral S urg O ral M ed O ral P ath o l 48(6):495-500, 1979. 6. F ie ld in g , A .F ., a n d o th e rs. C a v e rn o u s s in u s throm bosis: re p o rt of case. JADA 106(3):342-345, 1983.
D entistry on Stam ps - A .m o n g the dentists hon o red for their activities as o u tstan d in g p atrio ts is G eneral E m ilio N unez Rodriguez. N unez was b o rn on Dec 27, 1855, in San Francisco Sugar M ill, Sagua la G rande, Province of Las Villas, Cuba. In 1875 he in te rru p te d h is studies in H avana to jo in the C uban Army as a soldier in the “T en Years W ar” (1868-1878), the first of three w ars fo u g h t for independence from Spain. D uring the war, he was prom oted several times and attained the ran k of m ajor. Because of his continued efforts to conspire against Spain, N unez was im prisoned and held in the M orro Cas tle Fortress. H e was released som e tim e later on the co n d itio n th a t he n ot leave H avana. W hen the second w ar for independence began in 1879 he joined the rebellion (O ct 17, 1879) and continued the fight after oth er lead ers were forced to surrender. W hen he, too, was forced to surrender, he left for exile in the U nited States, lan d in g at Pensacola, FL, on Dec 20, 1880. After sp ending som e tim e in P h ilad elp h ia, New York, an d M exico he returned to P h ilad e lp h ia to study dentistry. In 1886, N unez registered as a freshm an in the d epartm ent of dentistry of the U niversity of Pennsylvania, and on May 1, 1889, received his DDS degree. W hen the th ird w ar for independence began in C uba in 1895, he was requested by the C uban p atrio ts to stay in the U nited States to organize the C uban D epartm ent of E xpeditions. In this capacity, N unez organized directly or indirectly 47 w ar expeditions to C uba, sending m en, arms, am m u n itio n , an d m aterials to the C uban forces fig h tin g d u rin g the 41m onth war. N unez accom panied the com m ander-in-chief, G eneral M ax im o Gomez, w hen he entered H avana a t the end of the war. G eneral N unez’s civilian activities included acting as: governor of the Province of H avana; president of the N atio n al C ouncil of Veterans of W ar (1911); secretary of the ag ricu ltu re departm ent; secretary of the com merce an d labor departm ent (1915); an d vice-president of the R epublic of C uba 09171921). G eneral N unez died in H avana on May 5, 1921. C uba has issued four stam ps h o n o rin g Nunez; Scott 544, 549, C127, C128; Yvert 427, 433, A125, and A126. H annelore T. Loevy, CD, MS A letha Kowitz, MA
Aldous-Powell-Stensaas : BRAIN ABSCESS OF O D O N TO G EN IC ORIGIN ■ 863
lary antrum suggested a more aggressive lesion. M icroscopic exam ination con firmed the working diagnosis and the additional presence of an aneurated bone cyst with its fresh blood-filled cavities separated by fibrous septae and lined by histiocytic and multinucleated giant cells. R ecognition of an aneurysmal bone cyst-precursor com plex lesion at the time of surgery is important not only in terms of diagnostic accuracy but also for the dif ficulties encountered during com plete removal of the incipient lesion and there fore, the possible chance for recurrence of the primary lesion. Aneurysmal bone cysts are known to result from an arteriove nous anomaly engrafted on an underly ing, preexistent, slow-growing lesion.5,11,12 During this process, the initial arterio venous anomaly form ing w ithin the in cipient lesion introduces more blood under hemodynamic pressure to the af fected site. This occurrence in the stromal soft tissue w ould seem to promote rapid expansion o'f the jaws. The sequence of events for a dentigerous cyst can follow a similar pathogenic pattern. In the dentigerous cyst, in con trast to the odontogenic keratocyst, the lin in g epithelium has low m etabolic activity, shows low m itotic figures, and generally is not actively disposed in the growth of the cyst.13,14 Rather, venous obstruction induced by the impacted tooth and follicular compression causes a tran
sudation across the vessel wall. Subsequent m odification of the p o olin g transudate and a further increase of its hydrostatic pressure facilitates further growth.15 The triggering potential in such an event can also provide, sim ultaneously, for an arteriovenus sh u n tin g and an engrafted aneurysmal bone cyst anomaly as seen in this patient. Conclusion T h is report of case has given further evi dence to support the concept that the aneurysmal bone cyst occurs as the out com e of secondary changes in an incip ien t, prim ary, slo w -g ro w in g lesion . Predisposition of aneurysmal bone cyst formation secondary to a dentigerous cyst can result from a com m on phenom enon of disturbed hem odynam ic alteration associated with the growth of the dentig erous cyst.
-------------------- J»A\DA\ -------------------Dr. N ad im i is a ssistant professor, d epartm ent of o ral path o lo g y , L oyola U niversity School of D entist ry. Dr. B ronny is chair, d ep artm en t of dentistry; Dr. Sbigoli is a form er general practice resident; Dr. G atti is associate professor, d ep artm en t of otolaryngologyhead an d n eck surgery; a n d Dr. H asiakos is attending dentist, d ep artm en t of dentistry, Foster G. McGaw H o sp ital, L oyola U niversity M edical Center. Address requests for re p rin ts to Dr. B ronny a t the Loyola U niversity M edical Center, 2160 First Ave, M aywood, IL 60153.
REPORTS
1. Jaffe, H .L . A neurysm al b o n e cyst. B ull H o sp J o in t Dis 11(1):S-13, 1950. 2. B atsakis, J.G . T u m o rs of the head an d neck: clin ic al a n d p a th o lo g ic al considerations, ed 2. B alti m ore, W illiam s 8e W ilkins Co, 1979, p p 393-395. 3. T illm a n , B .P., a n d others. A neurysm al bone cyst: an analysis of ninety-five cases, M ayo C linic Proc 43(7):478-495, 1968. 4. R uiter, D .J., a n d others. A neurysm al bone cyst: a clinico p ath o lo g ical study of 105 cases. C ancer 39(5): 22S1-2239, 1977. 5. Y arington, C .T ., Jr., an d others. A neurysm al bone cyst of the m a x illa : association w ith g ia n t cell reparative g ra n u lo m a . A rch O to lary n g o l 80:313-317, 1964. 6. Biesecker, J.L ., a n d others. A neurysm al bone cyst: a c lin ic o p ath o lo g ic study of 66 cases. Cancer 26(3):615-625, 1970. 7. Levy, W .M ., a n d others. A neurysm al bone cyst secondary to o th e r osseous lesions: re p o rt of 57 cases. Am J C lin P ath o l 6S(l):l-8, 1975. 8. N ad im i, H ., a n d others. C oexistent aneurysm al bone cyst w ith am eloblastom as: a h istologic survey. J O ral M ed 41(3):242-243, 1986. 9. H o p p e, W. A neurysm al bone cyst of the m a n d i ble: report of a case. O ral Surg 25(l):l-5, 1986. 10. S pjut, H .J., an d others. A tlas of tu m o r p a th o l ogy. T u m o rs of bone a n d cartilage, fascicle 5. W ash in g to n , DC, A rm ed Forces In stitu te of P athology, 1971, p p 357-367. 11. M ira, J. Bone tum ors. P h ila d e lp h ia , L ip p in c o tt Co, 1980, p p 478-491. 12. Buraczew ski, J., an d Dabska, M. Pathogenesis of aneurysm al bone cyst: re la tio n sh ip betw een the aneurysm al b o n e cyst a n d fibrous dysplasia of bone. C ancer 28(3):597-604, 1971. 13. M ain, D.M. T h e e n la rg e m en t of e p ith e lia l jaw cysts. O d o n tologisk Revy 21(1 ):29-49, 1970. 14. M ain, D.M. E p ith elial jaw cysts: a c linico p a th o lo g ic al reap p raisal. B r J O ral S urg 8(1):114-125, 1970. 15. Browne, R.M . T h e pathogenesis of odontogenic cysts: a review. J O ral P a th o l 4 (l):3 1 -4 6 ,1975.
Brain abscess of odontogenic origin: report of case Jay A. Aldous, DDS, MS G. Lynn Powell, DDS Suzanne S. Stensaas, PhD A d va n ced d e n ta l in fectio n rarely causes brain abscess resu ltin g in d ea th . G o o d d e n ta l h yg ien e a n d rem o v in g abscessed teeth are a d v ise d fo r p re v e n tio n o f a n y such occurrence. A n in terc ra n ia l infec tio n is described in a 29-year-old m a le w h o also h a d a d e n ta l p h o b ia .
he spread of d en tal abscesses or oral infection to distant areas of the head and neck is uncom m on but has been documented.1-3 Result ing intracranial infections or abscesses are c o m p lic a te d .4,5 T h e fa cia l, a n gu lar,
T
ophthalmic, and other veins can be path ways for in fectio n to travel from the m outh, through the cavernous sinus and into the cranium .1,3,6 Brain abscesses of dental origin are difficult to manage and frequently result in death. ‘’2'4,5 Preventing abscesses by ro u tin e d en tal and oral hygiene care or early removal of nontrea ta b le teeth is p ru d e n t. T h is is esp ecially advisable for patients w ith chronic dental phobia. Report of case A 29-year-old white male died of a brain abscess o f dental origin , according to autopsy reports. H e had sought dental
care for painful gingiva in the anterior mandibular area. Results of an exam in a tio n by a V eterans A d m in istra tio n h o sp ita l show ed that the p atien t had heavy calculus, and poor oral hygiene. T he soft tissues appeared to be normal except for acute gingivitis, bordering on Vincent’s infection. Caries was noted on the maxillary right first and second m olars, left first and second premolars, and second molar, and m andibular left first m olar. A lthou gh dental care to treat these conditions was authorized by the Veterans Administra tion, the patient did not seek the needed treatment at that time. During the next 10 years, he had several
A ldous-Powell-Stensaas : BRAIN ABSCESS OF O D O N TO G EN IC O RIG IN ■ 861
CLINICAL
REPORTS
h o sp ital adm issions and clinic visits for psychiatric problem s, alcohol and drug abuse, and dental pain. D uring the fourth year, h o sp ital records reported th at he had dental caries an d reddened gingiva. In the fifth year, the p atien t had em er gency treatm ent because of p ain in the m a n d ib u la r rig h t second m olar. E ndo d o n tic th e r a p y w as s ta rte d , b u t the p a t ie n t fa ile d to k ee p a s u b s e q u e n t ap p o in tm e n t. L ater in the fifth year, the p a tie n t h a d h is three re m a in in g th ird m olars rem oved u nder general anesthesia because of infection and im paction. T he
blood cells, an d an ECG show ed an intrav e n tr ic u la r c o n d u c tio n defect. S in u s r a d io g r a p h s sh o w ed p a n s in u s itis n o t involving the sphenoid. D rainage of the left frontal abscess was advised. T h e p atien t was stable u n til the 23rd day w hen his tem perature rose to 104 F and his blood pressure dropped. H e was stabilized again w ith intravenous fluids. B ecause o f th e p a t ie n t’s h is to ry an d presum ed sepsis, intravenous gentam icin an d m etronidazole were started, in ad ditio n to chloram phenicol. H e was stable u n til g rand m al seizures developed again,
B ra in abscesses of dental origin are difficult to control or resolve with antibiotics alone.
last h o sp ital dental entry before the final adm ission was in the n in th year: teeth— p o o r condition. In th e te n th year, th e p a tie n t was a d m itte d to the h o s p ita l w ith fro n ta l headache, chills an d fever, follow ed by s w e llin g of th e le ft eye a n d a w h ite p u ru le n t nasal discharge. T h e diagnosis w as p an sin u sitis, an d cep h ap irin sodium was started. T hree days later, the patient u n d e r w e n t tr e p h e n a tio n of the r ig h t f r o n t a l s in u s ; c u l tu r e s w e re ta k e n . C u l tu r e r e s u lts r e p o r te d a n a e ro b e s , m o stly bacterio d es. N ext, in tra v e n o u s ch lo ram phenicol therapy was begun. O n th e 2 0 th d ay of h o s p ita liz a tio n , the p a tie n t h ad a g rand m al seizure. A C T scan at th a t tim e showed a collection of flu id in the left frontal lobe consistent w ith an abscess. S im ilar dense m aterial w as v isib le in th e su b d u ra l an d su b ara ch n o id spaces; this was interpreted as em p y em a a n d m e n in g itis ; the n e u ro surgery departm ent was consulted. T h e p atient, w ho w eighed 250 lb, had a te m p e ra tu re of 101 F; b lo o d pressure, 130/70 m m H g; respiration rate, 20; pulse rate, 88. H e was alert b u t n o t oriented; had fixed an d d ilated p u p ils; erythem atous fundi; intact cranial nerves III, IV, an d VI, a n d responded only to sim ple co m m an d s. P o ssib le g en eralized r ig h t side w eakness a n d p o sitiv e B a b in sk i’s r e f le x o n th e r i g h t sid e i n d ic a t in g p y ra m id a l tra c t in v o lv e m e n t w as o b served. L a b o ra to ry values were: w h ite b lood cell co u n t (WBC), 6,500; hem ato c rit, 46.7; SM AC (20) w ith in n o rm a l lim its. U rinalysis show ed 12 to 15 w hite 862 ■ JADA, Vol. 115, December 1987
th e n e x t e v e n in g . T h e seizu res w ere controlled w ith phénobarbital. Early on day 25, his tem perature rose to 104 F an d h is b lo o d p re ssu re d ro p p e d . H e w as tre a te d w ith in tr a v e n o u s flu id s a n d dopam ine. L ater in the m o rn in g of the 25th day, he appeared weak, w ith p u p ils dilated an d fixed, no m ovem ent of the eyes as positio n was changed, and no co rn e al reflex. H o u rs la te r th e h y p o ten sio n becam e m ore severe, re q u irin g d opam ine to m ain tain blood pressure and he h ad no spontaneous respirations. At a b o u t 11:30 p m , th e p a t i e n t ’s b lo o d p r e s s u r e d r o p p e d to zero , h is h e a r t stopped, an d he was pronounced dead.
m a n d ib u lar rig h t second prem olar and first m o la r. T h e re was extensive p e ri o d o n tal disease, particularly severe in the left m axilla. F lu id from the intracranial cavity was s u b m itte d fo r a e ro b ic a n d a n a e ro b ic cultures; Escherichia coli an d enterococci w ere f o u n d . T h e p o s tm o rte m e x a m in a tio n also disclosed p u ru len t m aterial in the sub arach n o id and subdural space, frontal pole abscess w ith extension in to ventricles, an d cerebral edema, ultim ately re s u ltin g in te m p o ral lobe in fa rc tio n , u ncal h ern iatio n , an d death. T h e final m edical sum m ary said that: “T h e p atien t d ied as a re su lt of a diffuse p u r u le n t m e n i n g i t i s th a t in v o lv e d th e s u b a r a c h n o id a n d s u b d u r a l sp aces. A ll external surfaces of the brain, spinal cord, a n d th e v entricles were involved. T h e m eningitis probably developed after the form ation of a left frontal lobe abscess th a t re su lte d from the h e m a to g e n o u s seeding of the b rain by organism s from the chronic dental abscess. Discussion Brain abscesses of dental origin are dif fic u lt to c o n tro l o r resolve w ith a n ti b io tic s a lo n e .4,5 T h e e x tre m e ly h ig h m ortality rate (m ore th an 90%) of in tra cran ial abscesses of odontogenic o rig in as com pared w ith those from other foci is d ifficult to ex p lain .4 T h e prim ary defense a g a in s t in fe c tio n is the im m u n o lo g ic system. T h e stim ulation of this system to m anufacture w hite blood cells is p art of the im m u n o lo g ic response. T h e p atien t in this case showed a m in im al response to
Postmortem evidence suggested that dental abscesses may have provided the infective organism.
T h e first 14 days of fin a l h o s p ita l ization stay the WBC averaged 6,500 w ith a h ig h of 8,500 an d a low of 5,200. O n the 15th day, the co u n t started to rise. A h ig h of 16,200 was recorded on the 18th day of hospitalizatio n and dropped to 8,800 on the day the p atien t died. T h e differential re a d in g sho w ed b an d s in th e n o rm a l ra n g e a n d a n increased p erc en ta g e of segm ented neutrophils. P ostm ortem exam ination disclosed sev eral periapical dental abscesses in clu d in g abscesses in v o lv in g the m a x illa ry left second prem o lar and first m olar, an d the
the infection u n til the 18th day of h o sp i talization w hen there was a shift in the d if f e r e n tia l w h ite b lo o d c e ll c o u n t. Factors th a t may influence the im m u n o lo g ic resp o n se m ay be n u tritio n , liver disease, some d ru g therapy, an d substance abuse. T h is p atien t’s response probably was influenced by several of these factors. T h e d e a th re p o rte d in th is case is consistent w ith other recorded m ortalities th a t o cc u rre d in sp ite of a p p lie d a g gressive an tib io tic and surgical therapy. T h e postm ortem evidence suggested the d e n ta l abscesses o f th e te e th in th e
CLINICAL
m a x illa ry le ft a n d m a n d ib u la r r ig h t q u ad ra n ts, an d the p e rio d o n ta l disease present may have provided the infective o rg a n is m . T h e se w ere lo n g - s ta n d in g d e n ta l c o n d itio n s as in d ic a te d in th e d en tal records. At the tim e of the left c ra n io to m y , the p o ste rio r w all of the frontal sinus was exam ined, b u t n o defect was found. O ther routes for an infection to travel from the m o u th to the brain have been discussed,1'3,6 such as venous drainage. Infection can also involve the p o rtio n of the brain opposite the side of th e in fected to o th o r teeth. A lth o u g h cultures of the dental abscess were not do n e, th e c u ltu re s of the in tr a c r a n ia l cavity and sinus fluids were consistent w ith bacteria th a t are found in the m outh an d have been reported to have caused b rain abscess in the past.3,5
Conclusions
T h is p a tie n t w as described as h av in g d en tal p h o b ia , an d yet allo w ed d ental specialists to p ro v id e treatm en t. M any p h y sic a l e x a m in a tio n s a n d ad m issio n notes refer to his dental status and need for treatm ent, b u t he did n o t choose to o b ta in tr e a tm e n t. A lth o u g h d e n tis ts id e a lly w a n t to sav e n a t u r a l te e th , patients w ith dental p h o b ia or those who do not choose to seek treatm ent follow -up present problem s. T im ely extractions and antibiotic therapy should be considered for these patients. -----------------------JA D )A ----------------------Dr. A ldous is a ssistant professor, d e p artm e n t of surgery; Dr. Pow ell is associate professor; an d Dr.
REPORTS
S te n s a a s is a s s i s t a n t p r o f e s s o r , d e p a r tm e n t of p a thology, school of m edicine, U niversity of U tah, D e n tal E d u c a tio n , B u ild in g 518, S a lt L ake C ity, 84112. Address requests for re p rin ts to Dr. A ldous.
1. P elleg rin o , S.V. E xtension of d e ntal abscess to the orbit. JAD A 100(6):873-874, 1980. 2. In g h a m , H .R ., a n d o th e rs. A bscesses o f the fro n ta l lobe of the b ra in secondary to covert d e ntal sepsis. L ancet 2(8088):497-499, 1978. 3. G o te in e r, D .; S o n is , S .T .; a n d F a c ia n o , R. C a v e rn o u s s in u s th ro m b o s is a n d b r a in ab sc e ss in itia te d a n d m a in ta in e d by p e rio d o n ta lly involved teeth. J O ral M ed 37(3):80-83,1982. 4. H o llin , S .A ., a n d G ro ss, S.W . In tr a c r a n ia l abscesses of odon to g en ic orig in . O ral S urg O ral Med O ral P ath o l 23(3):277-291, 1967. 5. V a lachovic, R ., a n d H a rg reav es, J.A . D en tal im p lic a tio n s o f b r a in a bscess in c h ild r e n w ith c o n g en ital h e art disease. O ral S urg O ral M ed O ral P ath o l 48(6):495-500, 1979. 6. F ie ld in g , A .F ., a n d o th e rs. C a v e rn o u s s in u s throm bosis: re p o rt of case. JADA 106(3):342-345, 1983.
D entistry on Stam ps - A .m o n g the dentists hon o red for their activities as o u tstan d in g p atrio ts is G eneral E m ilio N unez Rodriguez. N unez was b o rn on Dec 27, 1855, in San Francisco Sugar M ill, Sagua la G rande, Province of Las Villas, Cuba. In 1875 he in te rru p te d h is studies in H avana to jo in the C uban Army as a soldier in the “T en Years W ar” (1868-1878), the first of three w ars fo u g h t for independence from Spain. D uring the war, he was prom oted several times and attained the ran k of m ajor. Because of his continued efforts to conspire against Spain, N unez was im prisoned and held in the M orro Cas tle Fortress. H e was released som e tim e later on the co n d itio n th a t he n ot leave H avana. W hen the second w ar for independence began in 1879 he joined the rebellion (O ct 17, 1879) and continued the fight after oth er lead ers were forced to surrender. W hen he, too, was forced to surrender, he left for exile in the U nited States, lan d in g at Pensacola, FL, on Dec 20, 1880. After sp ending som e tim e in P h ilad elp h ia, New York, an d M exico he returned to P h ilad e lp h ia to study dentistry. In 1886, N unez registered as a freshm an in the d epartm ent of dentistry of the U niversity of Pennsylvania, and on May 1, 1889, received his DDS degree. W hen the th ird w ar for independence began in C uba in 1895, he was requested by the C uban p atrio ts to stay in the U nited States to organize the C uban D epartm ent of E xpeditions. In this capacity, N unez organized directly or indirectly 47 w ar expeditions to C uba, sending m en, arms, am m u n itio n , an d m aterials to the C uban forces fig h tin g d u rin g the 41m onth war. N unez accom panied the com m ander-in-chief, G eneral M ax im o Gomez, w hen he entered H avana a t the end of the war. G eneral N unez’s civilian activities included acting as: governor of the Province of H avana; president of the N atio n al C ouncil of Veterans of W ar (1911); secretary of the ag ricu ltu re departm ent; secretary of the com merce an d labor departm ent (1915); an d vice-president of the R epublic of C uba 09171921). G eneral N unez died in H avana on May 5, 1921. C uba has issued four stam ps h o n o rin g Nunez; Scott 544, 549, C127, C128; Yvert 427, 433, A125, and A126. H annelore T. Loevy, CD, MS A letha Kowitz, MA
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