- Email: [email protected]
Effect of time of extraction on resolution of odontogenic cellulitis
Effect of time of extraction on resolution of odontogenic cellulitis
H. David Hall, DMD, Nashville, Tenn Joseph W. Gunter, ir., DMD, Birmingham Homer C. Jamison, DDS, DPH, Birmingham Charles A. McCallum, Jr., DMD, MD, Birmingham
Acutely infected teeth were extracted when a patient was initially seen or after about thè third day of treatment. Results show that immediate extraction will not cause the infection to spread and that patients whose teeth were extracted immediately had fewer problems.
there is little evidence to suggest that extraction will cause an acute cellulitis to spread. On the contrary, the best evidence suggests that extraction does not spread acute cellulitis. Krogh’s1 study of about 3,000 patients with acutely infected teeth shows that the teeth can be extracted safely since complications occurred in only a few patients and none was serious. Krogh also suggested that early extraction probably caused faster resolution of the infection, but his data did not provide information with regard to this point. The present study was undertaken to compare the effects of immediate extraction and delayed extraction on the r_. olution of acute odontogenic cellulitis.
Methods A n infected tooth that causes a bacterial cellulitis must be extracted or the root canal must be filled. Usually the infected tooth is extracted, but the proper time to extract it has never been clearly established. The opinion that a tooth should not be extracted when an acute infection is present was almost universal before antibiotic therapy became available. Even now, many dentists think that it is dangerous to extract a tooth before the cellulitis has become localized or walled off. This view is based on the supposition that extraction causes the infection to spread unless there is a barrier between the infected and noninfected tissue; however, 626
Three hundred and fifty patients, who were treated for odontogenic cellulitis by the staff of the de partm ent of oral surgery at the University of Alabama during a three-and-a-half-year interval were selected for this study. The principal criteri on used to differentiate odontogenic cellulitis from other types of infectious cellulitis was the presence of an infected tooth in the involved region. A pa tient with this condition is shown in Figure 1, top and bottom. The 350 patients were randomly assigned to two treatment groups. The patients in treatment
group 1 were to have immediate extraction of the infected teeth; the patients in treatm ent group 2 were to have delayed extraction of the infected teeth. Immediate extractions were perform ed on the first day of treatment (average = day 1), and delayed extractions were performed on the third or fourth day of treatment (average = day 3.8). Rarely, it was difficult to determine which of two adjacent teeth was causing the infection; in these instances both teeth were extracted. A local anesthetic was usually used when the teeth were extracted. Oc casionally (6% of the patients), however, adequate block or infiltration anesthesia could not be per formed, and in these instances the teeth were ex tracted with the patient under general anesthesia. The need for incision and drainage (I and D) as well as supportive therapy (antibiotics, heat, rest in bed, and so on) was determined by the clinician, and the same criteria were applied for all patients. Patients were given appointments for daily examinations, and appropriate treatments were in stituted. Specific criteria (degree of pain elicited on palpation, size of swelling, oral temperature, presence of lymphadenopathy, location of swelling, and so on) for evaluation of the clinical condition were established. These criteria were then used in the assessment of each patient’s condition. The in formation was transferred to data processing cards, and the data were subsequently analyzed by a com puter. For about 10% of the patients, data were missing because of errors in handling of the records. If the missing data were not critical, the patients were included in the study; this occurred in about 3% of the patients. When the missing data were critical, the patients (29) were not included in the study. Thus, of the 350 patients initially selected, the data from 321 were used for this report. Of these patients, 172 were treated by immediate extraction and 149 patients by delayed extraction of the infected teeth. F ig l ■ Moderate size sw e llin g of s o fttis s u e s o v e rle fts id e o f m andible (top) caused by in fe cted lower le ft second m olar (bottom ). Note flu c tu a n t sw e llin g lateral to infected tooth.
Results O f the specific criteria used to evaluate the clinical status of the patient, the degree of pain elicited on palpation of the swollen tissue, the size of soft tissue swelling, and the oral tem perature revealed the most useful information. When all patients were considered, those in group 1 (immediate ex traction) showed a greater decrease in the degree of pain evoked on palpation between day 1 and 2 than did those in group 2 (delayed extraction) (Fig 2, top). Thereafter, the average am ount of
pain for each group decreased at similar rates until day 4. Between days 4 and 5, however, the pa tients in group 2 had a greater reduction in pain. By day 5, pain was nearly absent regardless of the time of extraction. Although the data shown in Figure 2, top, provide a general summary of the amount of pain experienced by the patients in these two treatment groups, a more accurate method
Hall—others: EXTRACTION TIME AND ODONTOGENIC CELLULITIS ■ 627
Immediate Extraction Delayed Extraction
M o d e ra te
m ined each day was p rin cip a lly due to fa ilu re of patients to keep appointm ents. Data werealso occasionally m issing even though the p a tie nt was examined.
M ild
Elicited
by
P a lp a tio n
F ig2 ■ Progressive decrease in to ta l num ber of patients exa
None
Pain
Num ber
321 I 0
of
256
1
205 I 3
2
Day
of
P atients
102
165
T
"T“
4
T re a tm e n t
- • — Immediate Extraction -o— Delayed Extraction
S m all
Size
of
Swelling
M o d e ra te
None N um ber
315 I 0
of
Patients
252 208
1
2
3
Day
of
—
165
102
4
5
Treatm ent
Immediate Extraction
—O— Delayed Extraction
100.1 r
(°F)
99.8
Oral
Tem perature
99.6
99.3
99.1
98.8 321
253
215
164
I
I
I
I
I
3
4
5
1
2 D ay
of
T re a tm e n t
103
of comparing the groups involves measurements of the magnitude of improvement and the number of patients showing improvement on each day. For this analysis, only patients who were examined on both days of each observation period and for whom abnormal values still existed were included. Tables 1 and 2 show that there was greater initial relief from pain in patients in whom the infected tooth was extracted on day 1 than in patients in whom extractions were delayed until day 3 or 4. Statis tically significant improvement, measured both as the magnitude of improvement and the number of patients showing improvement, was noted for the first two days only. The extent of improvement was relatively small. D ata in Figure 2, center, show the average size of soft tissue swelling for all patients examined in each treatment group. The patients in g r o u p 1 showed a greater initial decrease in swelling, whereas the patients in group 2 showed a greater reduction between days 4 and 5. Swelling was nearly absent in patients in both groups by day 5. The statistical analysis comparing these two me thods of therapy is shown in Tables 1 and 2. Pa tients who had immediate extraction of the in fected teeth showed a greater degree of improve m ent than did patients who had delayed extrac tions (Table 1). This difference was significant only for the first and third days after extraction and was small in magnitude. The proportion of patients showing improvement, however, was not affected by the time of extraction (Table 2). The average oral tem perature of all patients in each treatment group is shown in the data in Fig ure 2, bottom. The tem perature of the patients in group 2 is nearly 0.4 F higher on day 1 than that for the patients in group 1. The tem perature of the patients in both groups steadily decreased and by day 4 was nearly normal. The statistical evalua tion of the data in Tables 1 and 2 indicates the degree of improvement shown by the patients in the two groups. The patients in group 2 showed a significantly greater degree of improvement for the days 1 and 2 period of observation. This period coincided with the time of extraction for the pa tients in group 1. However, more patients in group 1 showed significant improvement in oral tempera ture during the days 3 and 4 period of observation.
Im m e d ia te
C lin ic a l m a n ife s ta tio n
P e r io d of o b s e rv a tio n D a ys
e x t r a c tio n *
D e g ree N o . of of p a tie n ts im p r o v e m e n t^ o b s e rv e d §
D e la y e d
e x t r a c tio n t
D e g re e of im p r o v e m e n t
No. of p a tie n ts o b s e rv e d
P v a lu e
1-2 2 -3 3 -4 4 -5
0 .6 2 ± 0 .7 3 II 0 . 6 4 ± 0 .6 9 0 .3 8 ± 0 . 5 7 0 .4 6 ± 0 .7 8
108 59 26 13
0 .2 3 ± 0 .3 2 ± 0 .4 6 ± 0 .2 9 ±
0 .5 2 0 .5 8 0 .5 9 0 .6 0
124 90 66 28
< 0 .0 0 5 < 0 .0 0 5 > 0 .0 5 > 0 .0 5
S w e llin g
1-2 2 -3 3 -4 4 -5
0 .3 4 ± 0 .3 8 ± 0 .4 9 ± 0 .3 0 ±
0 .5 4 0 .5 4 0 .5 9 0 .4 7
119 82 47 20
0 .2 3 ± 0 . 5 4 0 . 4 0 ± 0 .5 6 0 . 2 9 ± 0 .4 6 0 .3 0 ± 0 . 4 7
132 111 85 46
< 0 .0 1 > 0 .0 5 < 0 .0 0 5 > 0 .0 5
T e m p e r a tu r e
1-2 2 -3 3 -4 4 -5
0 .7 6 ± 0 .9 4 0 .5 3 ± 0 . 5 3 0 . 5 0 ± 0 .4 7 0 . 4 0 ± 0 .3 9
91 38 19 10
0 .9 7 ± 1 .0 0 0 .5 1 ± 0 . 6 2 0 .4 4 ± 0 .5 8 0 . 5 0 ± 0 .4 5
108 57 33 18
< 0 .0 0 5 > 0 .0 5 > 0 .0 5 > 0 .0 5
P a in e v o k e d on p a lp a tio n
Table 1 ■ Effect of tim e of extraction on course of odontogenic cellulitis; magnitude of im provem ent in patients.
‘ E x tr a c tio n o c c u r r e d o n d a y 1, th e d a y o f in itia l o b s e r v a tio n o f th e p a tie n t. t E x tr a c tio n o c c u r r e d o n d a y 3 o r 4. ^ S w e llin g a n d p a in e s tim a te d o n 0 (n o n e )to 3 ( c o n s id e r a b le ) s c a le . § P a tie n ts w ith n o d is c e r n ib le a b n o r m a lity a n d p a tie n ts w h o w e r e n o t o b s e r v e d b o th a t th e b e g in n in g a n d th e e n d o f e a c h o b s e r v a tio n p e r io d a r e e x c lu d e d . IIM e a n ± S D .
This period generally coincided with the time of extraction for the patients in group 2. Since ex traction causes bacteremia and a slight rise in temperature, the differences in tem perature be tween the patients in the two groups might be re lated to this event. The variables that affect tem perature (use of antipyretic therapy and time of day during which measurements are made) are com parable for both groups. There were no serious complications in the patients in group 1 or group 2. Specifically, the extraction of teeth, even maxillary anterior teeth or teeth (usually mandibular molars) that require the removal of bone and sectioning, did not cause the infection to spread. The data in Figure 3 show that extraction of specific teeth occurred with about equal frequency in each treatment group. Although the same criteria for treatm ent were
C lin ic a l m a n ife s ta tio n
P e r io d o f o b s e rv a tio n da ys
used for all patients, with the exception of time of extraction, two differences in treatment were apparent. The first of these differences is the ne cessity for I and D. This procedure was performed in about 28 % of the patients in group 2, whereas it was performed in about 14% of patients in group 1 (Table 3). Furtherm ore, when I and D was re quired, it was necessary to make an extraoral (ra ther than intraoral) incision in 42 % of the patients in group 2 in contrast to only 27 % of the patients in group 1. Finally, drains were used in the site of in cision for an average of 3.5 days in patients in group 2 but for only 2.8 days in patients in group 1. The second difference was related to the adminis tration of antibiotics. Only 70 % of patients in group 1 were also treated with an antibiotic, whereas an antibiotic was administered to about 97 % of patients in group 2. There was also a small difference in
Im m e d ia te
e x tra c tio n *
D e la y e d
e x t r a c tio n t
N o . of p a tie n ts o b s e rv e d }
N o. of p a tie n ts im p ro v e d No. %
No. of p a tie n ts o b s e rv e d
N o. of p a tie n ts im p ro v e d No. %
P v a lu e !
P a in e v o k e d on p a lp a tio n
1 -2 2 -3 3 -4 4 -5
108 59 26 13
57 33 11 6
53 56 42 46
124 90 66 28
31 28 32 8
25 31 48 29
< 0 .0 0 5 < 0 .0 2 > 0 .0 5 > 0 .0 5
S w e llin g
1 -2 2 -3 3 -4 4 -5
119 82 47 20
44 31 21 6
37 38 45 30
1 32 111 85 46
34 42 25 14
26 38 29 30
> 0 .0 5 > 0 .0 5 > 0 .0 5 > 0 .0 5
T e m p e r a tu r e
1-2 2 -3 3 -4 4 -5
91 38 19 10
67 27 14 6
73 71 74 60
1 08 57 33 18
81 41 19 12
75 72 58 67
> 0 .0 5 > 0 .0 5 < 0 .0 1 > 0 .0 5
Table 2 ■ Effect of tim e of extraction on course of odontogenic cellulitis; num ber of patients showing im prove ment.
'E x tr a c tio n o c c u r r e d o n d a y 1, th e d a y o f in itia l o b s e r v a tio n o f th e p a tie n t . tE x tr a c tio n o c c u r r e d o n d a y 3 o r 4. (E x c lu d e s p a tie n ts w ith n o d is c e r n ib le a b n o r m a lity a n d p a tie n ts w h o w e r e no t o b s e rv e d b o th a t th e b e g in n in g a n d th e e n d o f e a c h o b s e r v a tio n p e r io d . ^ C o m p u te d fr o m c u m u la tiv e b in o m ia l p r o b a b ilit ie s .
Hall—others: EXTRACTION TIME AND ODONTOGENIC CELLULITIS ■ 629
TOOTH NUMBER
1 2
5
-
3
4
5
6
7
8
9
10 11 12 13 14
15
16
n j i 1J I *iiirp "ip in IT 1
10 Fig 3 ■ Numbers on this frequency dis tribution of infected teeth represent num ber of teeth extracted.
-1 0
15-
-15 »
2520-
-
Immediate
-
Delayed
10 -
-10
ri il
-5
i n n TOOTH
the length of time patients received an antibiotic. The patients in group 1 received an antibiotic for an average of 2.9 days, whereas the average for the patients in group 2 was 4.2 days. The two groups were nearly identical, however, with respect to the antibiotic chosen. Penicillin was the drug selected more than 95 % of the time in both groups of patients. Despite occasional accidental deviations from experimental design, the two groups of patients were comparable. The average age, sex, race, and general health (by history) were similar for both groups. However, the mean oral temperature, the size of swelling, and the degree of pain elicited on palpation were slightly greater in the patients in group 2.
Discussion The belief that extraction of a tooth associated with acute cellulitis will spread infection seems unfounded. Some reports describe distant infec tions such as those of the central nervous system and cavernous sinus thrombosis after extraction. Table 3 ■ Effect of tim e of extraction on incision and drainage. Im m e d ia te e x t r a c tio n *
D e la y e d e x tra c tio n t
P a tie n ts tr e a t e d by m e a n s of 1and D
14%
28%
P a tie n ts tr e a t e d by m e a n s o f 1 a n d D w ith a n e x t r a o r a l in c is io n
27%
42%
2.8 da ys
3 .5 d a y s
630 ■ JADA, Vol. 77, September 1968
-2 0 -15
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 1*
*1 7 2 p a tie n ts . Î1 4 9 p a tie n ts .
r 25
15-
5-
A v e r a g e le n g th o f tim e th a t d ra in w a s u s e d a fte r th e 1and D
-5
0
NUMBER
These distant infections would seem to result from extraction-induced bacteremia. However, the extraction of noninfected as well as infected teeth produce bacteremias, and thus, distant infections would appear to be unrelated to the cellulitis. Jh is conclusion is further supported by a report2 of 27 cases in which an infection of the central nervous system which occurred after extractions was lethal. O f these patients, 70% had a clean mouth at the time of the extraction, and apparent ly none had an odontogenic cellulitis. However, the spread of a local cellulitis by extraction could more reasonably be associated with this surgery. Two facts, however, indicate that extraction may also be unrelated to the subsequent spread of a local infection. The first is the relative scarcity of reports suggesting such as association; the second is the observation that a local cellulitis occasional ly develops after the extraction of a tooth in a re gion previously free of detectable cellulitis. Thus, there appears to be little evidence to suggest that the extraction of teeth, with an associated acute cellulitis, will probably spread the infection. However, there is much better evidence to sug gest that a tooth may be safely extracted when an acute cellulitis is present. After the extraction of more than 3,000 teeth with an associated acute in fection, Krogh1 reported that an extraction did not appear to spread the infection, even though most of these patients were not treated with an antibiotic. There were only a few complications, and these were of a minor nature. This paper also indicates that the early extrac tion of infected teeth is a safe procedure. In 172 patients with acute cellulitis, immediate extraction of the infected tooth did not cause the spread of the infection in any instance. Furtherm ore, nearly
30% of these patients did not receive an antibiotic after the extraction, even though a cellulitis was present. These data indicate that teeth may be safe ly extracted when an acute local cellulitis is present and often even without antibiotic therapy for the patient. In addition, the present study indicated that pa tients for whom extraction of infected teeth is im mediate have a more favorable course than those patients for whom extraction is delayed four days. This suggests that the extraction has a salutary ef fect on the cellulitis. The cardinal principle of therapy for infections has been to do that which will aid the inflammatory response to the infection. A n extraction seems to do this since it removes the necrotic pulpal tissue that provides nutrim ent for bacteria, and it removes the root structure that serves as a barrier between the bacteria within the canal and the surrounding inflammatory reaction. The remaining bacteria are thus exposed to the host’s defenses and are almost always killed, often without the aid of an antibiotic. Immediate extraction of the infected tooth clear ly aided the resolution of the cellulitis. The extent of the aid, however, was relatively small and there fore does not indicate that early extraction of in fected teeth is advisable. However, when the inci dence of I and D was considered, this complication occurred far more often and m ore frequently re quired external drainage when patients were treated by delayed extraction of the infected tooth. This evidence clearly indicates that when extrac tion is planned for treatment of a patient with acute odontogenic cellulitis, the extraction should be performed at the earliest possible time.
Summary Three hundred and fifty patients with odontogenic cellulitis were assigned to two treatm ent groups.
In the patients of one group, the infected teeth were extracted on the first day of treatment, and in the patients of the other group, the infected teeth were extracted on about the fourth day of treatment. In neither group did the extraction of the infected teeth spread the cellulitis. The patients in whom extraction was performed on the first day of treat ment recovered somewhat more rapidly than those in whom extraction was delayed until about the fourth day of treatment. More important, early extraction considerably reduced the necessity for I and D. Thus, when extraction is indicated for treatment of patients with odontogenic cellulitis, the preferred treatm ent includes extraction of the infected tooth at the earliest possible time.
The authors wish to thank fo rm e r interns and residents R. Q. Borland, H. C. Doku, T. F. Dudley, R. J. Finn, D. E. Hallum, J. D. Lance, G. W. M atthews, Jr., F. E. M ille r, R. M. P hillips, A. W. Talley, L. W. Stark, B. S. Stephens, J. E. Stewart, J. M. Studdard, and R. C. W illiam s.
This study was supported in pa rt by USPHS grants no. DE-00066, D-1524, and 5-K3-DE 21941. D octor Hall was associate professor and chairm an, depart m ent of oral surgery, Doctor G unter is a resident, depart m ent of oral surgery, Doctor Jamison is professor and Doctor McCallum is professor and dean, U niversity of Ala bama School of D entistry, Birm ingham 35233. Doctor Hall a t present is professor and head, division of oral surgery, departm ent of surgery, Vanderbilt U niversity School of M edicine, N ashville, Tenn 37203.
1. Krogh, H.W. Extraction of teeth in the presence of acute in fections. J Oral Surg 9:136 A p ril 1951. 2. Haymaker, W. Fatal in fe ctio ns of the central nervous system and meninges a fte r tooth extraction, w ith an analysis of 28 cases. Am er J O rtho Oral Surg 31:117 March 1945.
Hall—others: EXTRACTION TIME AND ODONTOGENIC CELLULITIS ■ 631
H. David Hall, DMD, Nashville, Tenn Joseph W. Gunter, ir., DMD, Birmingham Homer C. Jamison, DDS, DPH, Birmingham Charles A. McCallum, Jr., DMD, MD, Birmingham
Acutely infected teeth were extracted when a patient was initially seen or after about thè third day of treatment. Results show that immediate extraction will not cause the infection to spread and that patients whose teeth were extracted immediately had fewer problems.
there is little evidence to suggest that extraction will cause an acute cellulitis to spread. On the contrary, the best evidence suggests that extraction does not spread acute cellulitis. Krogh’s1 study of about 3,000 patients with acutely infected teeth shows that the teeth can be extracted safely since complications occurred in only a few patients and none was serious. Krogh also suggested that early extraction probably caused faster resolution of the infection, but his data did not provide information with regard to this point. The present study was undertaken to compare the effects of immediate extraction and delayed extraction on the r_. olution of acute odontogenic cellulitis.
Methods A n infected tooth that causes a bacterial cellulitis must be extracted or the root canal must be filled. Usually the infected tooth is extracted, but the proper time to extract it has never been clearly established. The opinion that a tooth should not be extracted when an acute infection is present was almost universal before antibiotic therapy became available. Even now, many dentists think that it is dangerous to extract a tooth before the cellulitis has become localized or walled off. This view is based on the supposition that extraction causes the infection to spread unless there is a barrier between the infected and noninfected tissue; however, 626
Three hundred and fifty patients, who were treated for odontogenic cellulitis by the staff of the de partm ent of oral surgery at the University of Alabama during a three-and-a-half-year interval were selected for this study. The principal criteri on used to differentiate odontogenic cellulitis from other types of infectious cellulitis was the presence of an infected tooth in the involved region. A pa tient with this condition is shown in Figure 1, top and bottom. The 350 patients were randomly assigned to two treatment groups. The patients in treatment
group 1 were to have immediate extraction of the infected teeth; the patients in treatm ent group 2 were to have delayed extraction of the infected teeth. Immediate extractions were perform ed on the first day of treatment (average = day 1), and delayed extractions were performed on the third or fourth day of treatment (average = day 3.8). Rarely, it was difficult to determine which of two adjacent teeth was causing the infection; in these instances both teeth were extracted. A local anesthetic was usually used when the teeth were extracted. Oc casionally (6% of the patients), however, adequate block or infiltration anesthesia could not be per formed, and in these instances the teeth were ex tracted with the patient under general anesthesia. The need for incision and drainage (I and D) as well as supportive therapy (antibiotics, heat, rest in bed, and so on) was determined by the clinician, and the same criteria were applied for all patients. Patients were given appointments for daily examinations, and appropriate treatments were in stituted. Specific criteria (degree of pain elicited on palpation, size of swelling, oral temperature, presence of lymphadenopathy, location of swelling, and so on) for evaluation of the clinical condition were established. These criteria were then used in the assessment of each patient’s condition. The in formation was transferred to data processing cards, and the data were subsequently analyzed by a com puter. For about 10% of the patients, data were missing because of errors in handling of the records. If the missing data were not critical, the patients were included in the study; this occurred in about 3% of the patients. When the missing data were critical, the patients (29) were not included in the study. Thus, of the 350 patients initially selected, the data from 321 were used for this report. Of these patients, 172 were treated by immediate extraction and 149 patients by delayed extraction of the infected teeth. F ig l ■ Moderate size sw e llin g of s o fttis s u e s o v e rle fts id e o f m andible (top) caused by in fe cted lower le ft second m olar (bottom ). Note flu c tu a n t sw e llin g lateral to infected tooth.
Results O f the specific criteria used to evaluate the clinical status of the patient, the degree of pain elicited on palpation of the swollen tissue, the size of soft tissue swelling, and the oral tem perature revealed the most useful information. When all patients were considered, those in group 1 (immediate ex traction) showed a greater decrease in the degree of pain evoked on palpation between day 1 and 2 than did those in group 2 (delayed extraction) (Fig 2, top). Thereafter, the average am ount of
pain for each group decreased at similar rates until day 4. Between days 4 and 5, however, the pa tients in group 2 had a greater reduction in pain. By day 5, pain was nearly absent regardless of the time of extraction. Although the data shown in Figure 2, top, provide a general summary of the amount of pain experienced by the patients in these two treatment groups, a more accurate method
Hall—others: EXTRACTION TIME AND ODONTOGENIC CELLULITIS ■ 627
Immediate Extraction Delayed Extraction
M o d e ra te
m ined each day was p rin cip a lly due to fa ilu re of patients to keep appointm ents. Data werealso occasionally m issing even though the p a tie nt was examined.
M ild
Elicited
by
P a lp a tio n
F ig2 ■ Progressive decrease in to ta l num ber of patients exa
None
Pain
Num ber
321 I 0
of
256
1
205 I 3
2
Day
of
P atients
102
165
T
"T“
4
T re a tm e n t
- • — Immediate Extraction -o— Delayed Extraction
S m all
Size
of
Swelling
M o d e ra te
None N um ber
315 I 0
of
Patients
252 208
1
2
3
Day
of
—
165
102
4
5
Treatm ent
Immediate Extraction
—O— Delayed Extraction
100.1 r
(°F)
99.8
Oral
Tem perature
99.6
99.3
99.1
98.8 321
253
215
164
I
I
I
I
I
3
4
5
1
2 D ay
of
T re a tm e n t
103
of comparing the groups involves measurements of the magnitude of improvement and the number of patients showing improvement on each day. For this analysis, only patients who were examined on both days of each observation period and for whom abnormal values still existed were included. Tables 1 and 2 show that there was greater initial relief from pain in patients in whom the infected tooth was extracted on day 1 than in patients in whom extractions were delayed until day 3 or 4. Statis tically significant improvement, measured both as the magnitude of improvement and the number of patients showing improvement, was noted for the first two days only. The extent of improvement was relatively small. D ata in Figure 2, center, show the average size of soft tissue swelling for all patients examined in each treatment group. The patients in g r o u p 1 showed a greater initial decrease in swelling, whereas the patients in group 2 showed a greater reduction between days 4 and 5. Swelling was nearly absent in patients in both groups by day 5. The statistical analysis comparing these two me thods of therapy is shown in Tables 1 and 2. Pa tients who had immediate extraction of the in fected teeth showed a greater degree of improve m ent than did patients who had delayed extrac tions (Table 1). This difference was significant only for the first and third days after extraction and was small in magnitude. The proportion of patients showing improvement, however, was not affected by the time of extraction (Table 2). The average oral tem perature of all patients in each treatment group is shown in the data in Fig ure 2, bottom. The tem perature of the patients in group 2 is nearly 0.4 F higher on day 1 than that for the patients in group 1. The tem perature of the patients in both groups steadily decreased and by day 4 was nearly normal. The statistical evalua tion of the data in Tables 1 and 2 indicates the degree of improvement shown by the patients in the two groups. The patients in group 2 showed a significantly greater degree of improvement for the days 1 and 2 period of observation. This period coincided with the time of extraction for the pa tients in group 1. However, more patients in group 1 showed significant improvement in oral tempera ture during the days 3 and 4 period of observation.
Im m e d ia te
C lin ic a l m a n ife s ta tio n
P e r io d of o b s e rv a tio n D a ys
e x t r a c tio n *
D e g ree N o . of of p a tie n ts im p r o v e m e n t^ o b s e rv e d §
D e la y e d
e x t r a c tio n t
D e g re e of im p r o v e m e n t
No. of p a tie n ts o b s e rv e d
P v a lu e
1-2 2 -3 3 -4 4 -5
0 .6 2 ± 0 .7 3 II 0 . 6 4 ± 0 .6 9 0 .3 8 ± 0 . 5 7 0 .4 6 ± 0 .7 8
108 59 26 13
0 .2 3 ± 0 .3 2 ± 0 .4 6 ± 0 .2 9 ±
0 .5 2 0 .5 8 0 .5 9 0 .6 0
124 90 66 28
< 0 .0 0 5 < 0 .0 0 5 > 0 .0 5 > 0 .0 5
S w e llin g
1-2 2 -3 3 -4 4 -5
0 .3 4 ± 0 .3 8 ± 0 .4 9 ± 0 .3 0 ±
0 .5 4 0 .5 4 0 .5 9 0 .4 7
119 82 47 20
0 .2 3 ± 0 . 5 4 0 . 4 0 ± 0 .5 6 0 . 2 9 ± 0 .4 6 0 .3 0 ± 0 . 4 7
132 111 85 46
< 0 .0 1 > 0 .0 5 < 0 .0 0 5 > 0 .0 5
T e m p e r a tu r e
1-2 2 -3 3 -4 4 -5
0 .7 6 ± 0 .9 4 0 .5 3 ± 0 . 5 3 0 . 5 0 ± 0 .4 7 0 . 4 0 ± 0 .3 9
91 38 19 10
0 .9 7 ± 1 .0 0 0 .5 1 ± 0 . 6 2 0 .4 4 ± 0 .5 8 0 . 5 0 ± 0 .4 5
108 57 33 18
< 0 .0 0 5 > 0 .0 5 > 0 .0 5 > 0 .0 5
P a in e v o k e d on p a lp a tio n
Table 1 ■ Effect of tim e of extraction on course of odontogenic cellulitis; magnitude of im provem ent in patients.
‘ E x tr a c tio n o c c u r r e d o n d a y 1, th e d a y o f in itia l o b s e r v a tio n o f th e p a tie n t. t E x tr a c tio n o c c u r r e d o n d a y 3 o r 4. ^ S w e llin g a n d p a in e s tim a te d o n 0 (n o n e )to 3 ( c o n s id e r a b le ) s c a le . § P a tie n ts w ith n o d is c e r n ib le a b n o r m a lity a n d p a tie n ts w h o w e r e n o t o b s e r v e d b o th a t th e b e g in n in g a n d th e e n d o f e a c h o b s e r v a tio n p e r io d a r e e x c lu d e d . IIM e a n ± S D .
This period generally coincided with the time of extraction for the patients in group 2. Since ex traction causes bacteremia and a slight rise in temperature, the differences in tem perature be tween the patients in the two groups might be re lated to this event. The variables that affect tem perature (use of antipyretic therapy and time of day during which measurements are made) are com parable for both groups. There were no serious complications in the patients in group 1 or group 2. Specifically, the extraction of teeth, even maxillary anterior teeth or teeth (usually mandibular molars) that require the removal of bone and sectioning, did not cause the infection to spread. The data in Figure 3 show that extraction of specific teeth occurred with about equal frequency in each treatment group. Although the same criteria for treatm ent were
C lin ic a l m a n ife s ta tio n
P e r io d o f o b s e rv a tio n da ys
used for all patients, with the exception of time of extraction, two differences in treatment were apparent. The first of these differences is the ne cessity for I and D. This procedure was performed in about 28 % of the patients in group 2, whereas it was performed in about 14% of patients in group 1 (Table 3). Furtherm ore, when I and D was re quired, it was necessary to make an extraoral (ra ther than intraoral) incision in 42 % of the patients in group 2 in contrast to only 27 % of the patients in group 1. Finally, drains were used in the site of in cision for an average of 3.5 days in patients in group 2 but for only 2.8 days in patients in group 1. The second difference was related to the adminis tration of antibiotics. Only 70 % of patients in group 1 were also treated with an antibiotic, whereas an antibiotic was administered to about 97 % of patients in group 2. There was also a small difference in
Im m e d ia te
e x tra c tio n *
D e la y e d
e x t r a c tio n t
N o . of p a tie n ts o b s e rv e d }
N o. of p a tie n ts im p ro v e d No. %
No. of p a tie n ts o b s e rv e d
N o. of p a tie n ts im p ro v e d No. %
P v a lu e !
P a in e v o k e d on p a lp a tio n
1 -2 2 -3 3 -4 4 -5
108 59 26 13
57 33 11 6
53 56 42 46
124 90 66 28
31 28 32 8
25 31 48 29
< 0 .0 0 5 < 0 .0 2 > 0 .0 5 > 0 .0 5
S w e llin g
1 -2 2 -3 3 -4 4 -5
119 82 47 20
44 31 21 6
37 38 45 30
1 32 111 85 46
34 42 25 14
26 38 29 30
> 0 .0 5 > 0 .0 5 > 0 .0 5 > 0 .0 5
T e m p e r a tu r e
1-2 2 -3 3 -4 4 -5
91 38 19 10
67 27 14 6
73 71 74 60
1 08 57 33 18
81 41 19 12
75 72 58 67
> 0 .0 5 > 0 .0 5 < 0 .0 1 > 0 .0 5
Table 2 ■ Effect of tim e of extraction on course of odontogenic cellulitis; num ber of patients showing im prove ment.
'E x tr a c tio n o c c u r r e d o n d a y 1, th e d a y o f in itia l o b s e r v a tio n o f th e p a tie n t . tE x tr a c tio n o c c u r r e d o n d a y 3 o r 4. (E x c lu d e s p a tie n ts w ith n o d is c e r n ib le a b n o r m a lity a n d p a tie n ts w h o w e r e no t o b s e rv e d b o th a t th e b e g in n in g a n d th e e n d o f e a c h o b s e r v a tio n p e r io d . ^ C o m p u te d fr o m c u m u la tiv e b in o m ia l p r o b a b ilit ie s .
Hall—others: EXTRACTION TIME AND ODONTOGENIC CELLULITIS ■ 629
TOOTH NUMBER
1 2
5
-
3
4
5
6
7
8
9
10 11 12 13 14
15
16
n j i 1J I *iiirp "ip in IT 1
10 Fig 3 ■ Numbers on this frequency dis tribution of infected teeth represent num ber of teeth extracted.
-1 0
15-
-15 »
2520-
-
Immediate
-
Delayed
10 -
-10
ri il
-5
i n n TOOTH
the length of time patients received an antibiotic. The patients in group 1 received an antibiotic for an average of 2.9 days, whereas the average for the patients in group 2 was 4.2 days. The two groups were nearly identical, however, with respect to the antibiotic chosen. Penicillin was the drug selected more than 95 % of the time in both groups of patients. Despite occasional accidental deviations from experimental design, the two groups of patients were comparable. The average age, sex, race, and general health (by history) were similar for both groups. However, the mean oral temperature, the size of swelling, and the degree of pain elicited on palpation were slightly greater in the patients in group 2.
Discussion The belief that extraction of a tooth associated with acute cellulitis will spread infection seems unfounded. Some reports describe distant infec tions such as those of the central nervous system and cavernous sinus thrombosis after extraction. Table 3 ■ Effect of tim e of extraction on incision and drainage. Im m e d ia te e x t r a c tio n *
D e la y e d e x tra c tio n t
P a tie n ts tr e a t e d by m e a n s of 1and D
14%
28%
P a tie n ts tr e a t e d by m e a n s o f 1 a n d D w ith a n e x t r a o r a l in c is io n
27%
42%
2.8 da ys
3 .5 d a y s
630 ■ JADA, Vol. 77, September 1968
-2 0 -15
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 1*
*1 7 2 p a tie n ts . Î1 4 9 p a tie n ts .
r 25
15-
5-
A v e r a g e le n g th o f tim e th a t d ra in w a s u s e d a fte r th e 1and D
-5
0
NUMBER
These distant infections would seem to result from extraction-induced bacteremia. However, the extraction of noninfected as well as infected teeth produce bacteremias, and thus, distant infections would appear to be unrelated to the cellulitis. Jh is conclusion is further supported by a report2 of 27 cases in which an infection of the central nervous system which occurred after extractions was lethal. O f these patients, 70% had a clean mouth at the time of the extraction, and apparent ly none had an odontogenic cellulitis. However, the spread of a local cellulitis by extraction could more reasonably be associated with this surgery. Two facts, however, indicate that extraction may also be unrelated to the subsequent spread of a local infection. The first is the relative scarcity of reports suggesting such as association; the second is the observation that a local cellulitis occasional ly develops after the extraction of a tooth in a re gion previously free of detectable cellulitis. Thus, there appears to be little evidence to suggest that the extraction of teeth, with an associated acute cellulitis, will probably spread the infection. However, there is much better evidence to sug gest that a tooth may be safely extracted when an acute cellulitis is present. After the extraction of more than 3,000 teeth with an associated acute in fection, Krogh1 reported that an extraction did not appear to spread the infection, even though most of these patients were not treated with an antibiotic. There were only a few complications, and these were of a minor nature. This paper also indicates that the early extrac tion of infected teeth is a safe procedure. In 172 patients with acute cellulitis, immediate extraction of the infected tooth did not cause the spread of the infection in any instance. Furtherm ore, nearly
30% of these patients did not receive an antibiotic after the extraction, even though a cellulitis was present. These data indicate that teeth may be safe ly extracted when an acute local cellulitis is present and often even without antibiotic therapy for the patient. In addition, the present study indicated that pa tients for whom extraction of infected teeth is im mediate have a more favorable course than those patients for whom extraction is delayed four days. This suggests that the extraction has a salutary ef fect on the cellulitis. The cardinal principle of therapy for infections has been to do that which will aid the inflammatory response to the infection. A n extraction seems to do this since it removes the necrotic pulpal tissue that provides nutrim ent for bacteria, and it removes the root structure that serves as a barrier between the bacteria within the canal and the surrounding inflammatory reaction. The remaining bacteria are thus exposed to the host’s defenses and are almost always killed, often without the aid of an antibiotic. Immediate extraction of the infected tooth clear ly aided the resolution of the cellulitis. The extent of the aid, however, was relatively small and there fore does not indicate that early extraction of in fected teeth is advisable. However, when the inci dence of I and D was considered, this complication occurred far more often and m ore frequently re quired external drainage when patients were treated by delayed extraction of the infected tooth. This evidence clearly indicates that when extrac tion is planned for treatment of a patient with acute odontogenic cellulitis, the extraction should be performed at the earliest possible time.
Summary Three hundred and fifty patients with odontogenic cellulitis were assigned to two treatm ent groups.
In the patients of one group, the infected teeth were extracted on the first day of treatment, and in the patients of the other group, the infected teeth were extracted on about the fourth day of treatment. In neither group did the extraction of the infected teeth spread the cellulitis. The patients in whom extraction was performed on the first day of treat ment recovered somewhat more rapidly than those in whom extraction was delayed until about the fourth day of treatment. More important, early extraction considerably reduced the necessity for I and D. Thus, when extraction is indicated for treatment of patients with odontogenic cellulitis, the preferred treatm ent includes extraction of the infected tooth at the earliest possible time.
The authors wish to thank fo rm e r interns and residents R. Q. Borland, H. C. Doku, T. F. Dudley, R. J. Finn, D. E. Hallum, J. D. Lance, G. W. M atthews, Jr., F. E. M ille r, R. M. P hillips, A. W. Talley, L. W. Stark, B. S. Stephens, J. E. Stewart, J. M. Studdard, and R. C. W illiam s.
This study was supported in pa rt by USPHS grants no. DE-00066, D-1524, and 5-K3-DE 21941. D octor Hall was associate professor and chairm an, depart m ent of oral surgery, Doctor G unter is a resident, depart m ent of oral surgery, Doctor Jamison is professor and Doctor McCallum is professor and dean, U niversity of Ala bama School of D entistry, Birm ingham 35233. Doctor Hall a t present is professor and head, division of oral surgery, departm ent of surgery, Vanderbilt U niversity School of M edicine, N ashville, Tenn 37203.
1. Krogh, H.W. Extraction of teeth in the presence of acute in fections. J Oral Surg 9:136 A p ril 1951. 2. Haymaker, W. Fatal in fe ctio ns of the central nervous system and meninges a fte r tooth extraction, w ith an analysis of 28 cases. Am er J O rtho Oral Surg 31:117 March 1945.
Hall—others: EXTRACTION TIME AND ODONTOGENIC CELLULITIS ■ 631