1 Volume 23 2024 e243442 Original Article Braz J Oral Sci. 2024;23:e243442http://dx.doi.org/10.20396/bjos.v23i00.8673442 1 School of Dentistry, University of Passo Fundo, Passo Fundo, RS, Brazil. 2 School of Computer Science, University of Passo Fundo, Passo Fundo, RS, Brazil. Corresponding author: Matheus Albino Souza. University of Passo Fundo. BR 285/ São José, Building A7, suite 2. Zip code: 99052-900. Passo Fundo-RS-Brazil. Telephone: +55 54 3316-8402 E-mail: matheus292@yahoo.com.br Editor: Dr. Altair A. Del Bel Cury Received: May 13, 2023 Accepted: August 18, 2023 Maxillofacial infections of dental origin: risk factors for hospital admission Vinicios Fornari1 , Matheus Albino Souza1* , Felipe Gomes Dallepiane1 , Adriano Pasqualotti2 , Ferdinando De Conto1 Aim: to evaluate the occurrence of maxillofacial infection cases, which were treated at local hospital, identifying the main risk factors that determine the need for hospitalization of patients and the factors associated with staying length. Methods: A retrospective review of 191 records of patients with maxillofacial infection of odontogenic origin was performed, statistically evaluated by frequency and percentage of involvement, p values (based on the chi-square test) and odds ratio with a 95% confidence interval. A p-value <0.05 was considered statistically significant. Results: Among all the 191 patients, 31 had some harmful habits, such as smokers (13%) and alcoholics (1%). In addition, 39 patients reported some general health problem, such as systemic arterial hypertension (8.3%), depression (6.8%), diabetes (3.6%) and some immunosuppression (1.57%). Involvement of infection in deep facial spaces was present, with 119 patients presenting a deeper infection (62.3%) and 72 patients a superficial infection (37.7%). The most prevalent clinical signs and symptoms in the initial evaluation were pain (91.1%) and edema (90.1%), followed by erythema/hyperemia (44.5%), trismus (37.7%), abscess (30.9%), cellulitis (27.7%), fistula (16.8%), fever (16.8%), dysphagia (11%), dehydration (9.9%), odynophagia (7.9% ) and dyspnea (3.7%). Pulp necrosis was considered a risk factor for treatment in a hospital environment (0.032) and root canal treatment decreases the risk of hospitalization (p=0.002). Considering the evaluated patients, 146 (76.4%) were admitted and 45 (37.7%) were not admitted for hospitalization after initial clinical evaluation. Conclusion: there is a high occurrence of maxillofacial infection cases of dental origin, considering that involvement of infection in deeper facial spaces, as well as presence of pain, edema, erythema/hyperemia, trismus, abscess, cellulitis and pulp necrosis, represent the main risk factors for hospitalization and staying length. Keywords: Focal infection, dental. Hospitals. Risk factors. Time-to-treatment. https://orcid.org/0000-0002-9029-9290 https://orcid.org/0000-0002-9412-3807 https://orcid.org/0000-0001-9677-9984 https://orcid.org/0000-0001-7544-9425 https://orcid.org/0000-0002-8077-3550 2 Fornari et al. Braz J Oral Sci. 2024;23:e243442 Introduction Maxillofacial infections usually have odontogenic origin and they can reach deep tis- sues of the head and neck, compromising vital structures1,2. Although the incidence of these infections has decreased considerably due to the use of antibiotics and better oral hygiene conditions3, these infections continue to be a source of severe morbidity with associated mortality rates4,5. In general, decisions must be made in a short period of time by the oral and maxillofacial surgeon1. The most of infections is originated from the teeth, dental sockets and their sup- porting structures, affecting the jaws, face and deep tissues of the head and neck1,2. The involvement of the infectious process can vary from a well-localized form, which requires a simple approach, to a highly complex infection, requiring a multidisciplinary intervention in a hospital environment. The definition of objective criteria for the admission of odontogenic infection cases is important to improve patient manage- ment and limit the risk of deep infections6. Therefore, professionals who receive patients in the emergency unit of a hospi- tal must be aware of the clinical characteristics of maxillofacial infections, distin- guishing their etiologies and carefully evaluating their clinical signs and symptoms. In addition, the qualified understanding of the general medical history of and the course of the infection, so that the best conduct and treatment regimen are carried out, in order to decrease the rates of associated complications. The literature pres- ents some studies that identify the risk factors associated with sign and symptoms of maxillofacial infections. However, there is no relation with the possible reasons for hospital admission and staying length in their findings, with few information regarding this topic. This study aimed to describe the occurrence of cases of maxillofacial infection attended by the Residency Service of Oral and Maxillofacial Surgery and Traumatol- ogy of the Clinic Hospital in the city of Passo Fundo (Passo Fundo, RS, Brazil), iden- tifying the main risk factors that determine the need for hospitalization of patients, as well as factors associated with staying length. The hypotheses were that (i) sys- temic conditions, (ii) location of infectious process, (iii) depth of infectious process, (iv) presence of clinical signs and symptons, (v) pulp vitality and (vi) use of medication represent risk factors for hospital admission of patients with maxillofacial infection of dental origin. Material and Methods Study design The present study was submitted and approved by the Research Ethics Committee of the University of Passo Fundo (Passo Fundo, RS, Brazil), under protocol number 4.023.577. The documentary, retrospective and descriptive study was carried out through the electronic medical records contained in the PEP SOUL MV System of Clinic Hospital, reviewing the attendances. 3 Fornari et al. Braz J Oral Sci. 2024;23:e243442 In the data collection, 191 records of patients with maxillofacial infection associated to odontogenic origin were included in the present study. The evaluation and data collection were performed by the Oral and Maxillofacial Surgery and Traumatology team at the emergency unit of the Clinical Hospital of Passo Fundo (Passo Fundo, RS, Brazil) through clinical examination, in the period of time between December 2014 and September 2020. Data on the patient’s initial condition were collected at the hospital’s emergency unit and the evolution was daily evaluated in the hospitalized patients. In those who were not hospitalized, returns for reassessment took place at an outpatient clinic, every 48 hours. Inclusion and exclusion criteria For the inclusion criteria of patients, all data in the medical records should be duly completed. For the exclusion criteria of patients, forms with incomplete records and cases of maxillofacial infection with no odontogenic origin were excluded, totaling 22 cases that were not included in the present study, due to one of these reasons. The collected data were arranged in a custom spreadsheet created in the Microsoft Excel program (Seattle, WA, United States). Study variables After the data recording, information about sex, age, past medical history, presence or absence of harmful habits, infection location, etiology, clinical signs and symptoms, and use of medication prior to the initial assessment were considered. The variables were correlated with the outcome of hospitalization and time of hospitalization. Statistical analysis The results were statistically evaluated by frequency and percentage of involvement, p values provided by the chi-square test, and odds ratio (O.R.) with a 95% confidence interval. In addition, the T-Student test was used to assess whether the location of the infection, medical comorbidities, etiologies or conducts interfered with the patients’ length of stay. A p-value <0.05 was considered statistically significant. Data were ana- lyzed by using the SPSS sofwtare (Chicago, IL, United States). Results After data collection, the results of present study revealed a male:female ratio of 92:99 from a total of 191 patients, being 48% men and 52% women. The average age of all patients treated was 29.8 years, ranging from 11 and 48 years. Considering the eval- uated patients, 146 (76.4%) were admitted and 45 (37.7%) were not admitted after initial clinical evaluation. It was observed that hospitalized patients had a mean age of 28.5 years and non-hospitalized patients had a mean age of 30.9 years. Among all the evaluated patients, 31 had some harmful habit, being 28 (13%) smok- ers and 3 (1%) alcoholics. In addition, 39 patients reported general health prob- lem, in which 16 (8.3%) had a diagnosis of systemic arterial hypertension (SAH), 13 (6.8%) depression, 7 (3.6%) diabetes and 3 (1.57%) presented some form of immu- 4 Fornari et al. Braz J Oral Sci. 2024;23:e243442 nosuppression (HIV positive, cancer patient and/or chronic imusuppressant user). The total of 75 patients reported use of previous medication, self-medication or pro- fessional prescription, with 52 (27.2%) using antibiotics and 23 (12%) non-steroidal anti-inflammatory drugs (NSAIDs) (Table 1). Table 1. Analysis of variables: location of infection, harmful habits, medical comorbidities, etiology and use of previous medication for risk factors for hospital admission through chi-square test and odds ratio (N=191). Category Variable Admission P value Odds ratio CI 95% Yes No Total Location Maxilar 41 16 54 0.338 0.708 0.348 – 1.438 Mandible 105 24 134 Smoking Yes 23 5 28 0.441 1.496 0.534 – 4.194 No 123 40 163 Alcoholism Yes 1 2 3 0.076 0.478 0.163 – 1.397 No 145 43 188 Hipertension Yes 10 6 16 0.170 0.478 0.163 – 1.397 No 136 39 175 Depression Yes 13 0 13 0.038 1.338 1.229 – 1.458 No 133 45 178 Diabetes Yes 6 1 7 0.556 1.886 0.221 – 16.091 No 140 44 184 Imunossupression Yes 2 1 3 0.688 0.611 0.054 – 6.901 No 144 44 188 Pulp necrosis Yes 111 24 135 0.032 2.096 1.056 – 4.159 No 43 21 64 Tooth extraction Yes 19 5 24 0.736 1.197 0.420 – 3.411 No 127 40 167 Endodontics Yes 15 13 28 *0.002 2.365 1.428 – 3.918 No 131 32 163 Pericoronitis Yes 3 2 5 0.380 0.451 0.073 – 2.788 No 143 43 186 Antibiotics Yes 43 9 52 0.213 1.670 0.741 – 3.763 No 103 36 139 NSAIDs Yes 16 7 23 0.407 0.668 0.256 – 1.743 No 130 38 168 Regarding the location of the infectious process, two macrosites were considered: max- illa and mandible. The most common site of involvement was the mandible with 134 (70.2%) cases, followed by the maxilla in 57 (29.8%) cases. The physical examination and imaging evaluation allowed to evaluate whether the infection was superficial in the 5 Fornari et al. Braz J Oral Sci. 2024;23:e243442 vestibular space or in a deeper space, where 119 (62.3%) patients had a deeper infec- tion and 72 (37.7%) had a superficial infection. Most hospitalized patients 105 (71.9%) underwent tomography, but the primary evaluation was through physical examination. The most prevalent clinical signs and symptoms in the initial evaluation were: pain in 174 patients (91.1%) and edema in 172 patients (90.1%), followed by erythema/hyperemia in 85 patients (44.5%), trismus (after measurement, maximum opening up to 25mm) in 72 patients (37.7%), abscess in 59 patients (30.9%), cellulitis in 53 patients (27.7%), fis- tula (spontaneous drainage) in 32 patients (16.8%), fever (axillary temperature > 37.6°C) in 32 patients (16.8%), dysphagia in 21 patients (11%), dehydration in 19 patients (9.9%), odynophagia in 15 patients (7.9% ) and dyspnea in 7 patients (3.7%) (Table 2). Table 2. Analysis of clinical signs and symptoms and use of medication prior to the initial assessment for risk factors for hospital admission using the chi-square test and odds ratio (N=191). Category Variable Admission PValue Odds ratio CI 95% Yes No Total Pain Yes 131 43 174 0.230 0.406 0.089 – 1.848 No 15 2 17 Edema Yes 140 32 172 0.001 9.479 3.348 – 26.840 No 6 13 19 Deep facial Space Yes 111 8 119 0.001 14.668 6.248 – 34.436 No 35 37 72 Erythema/ Hyperemia Yes 73 12 85 0.006 2.750 1.317 – 5.741 No 73 33 106 Trismus Yes 71 1 72 <0.001 41.653 5.589 – 310.407 No 75 44 119 Abscess Yes 43 16 59 0.438 0.757 0.373 – 1.534 No 103 29 132 Celulitis Yes 48 5 53 0.004 3.918 1.453 – 10.564 No 98 40 138 Fistula Yes 22 10 32 0.261 0.621 0.269 – 1.433 No 124 35 159 Fever Yes 31 1 32 0.003 11.861 1.571 – 89.537 No 115 44 159 Disphagia Yes 21 0 21 0.007 1.360 1.243 – 1.488 No 125 45 170 Dehydration Yes 19 0 19 0.011 1.354 1.239 – 1.480 No 127 45 172 Odynophagia Yes 15 0 15 0.025 1.344 1.232 – 1.465 No 131 45 176 Dyspnea Yes 7 0 7 0.135 1.324 1.219 – 1.437 No 139 45 184 6 Fornari et al. Braz J Oral Sci. 2024;23:e243442 The patients who were diagnosed with pulp necrosis as an etiology of the infectious process was shown to be associated with a higher risk for treatment in a hospital environment (0.032), confirming the fifth hypothesis of present study. Furthermore, it is noteworthy that root canal treatment reduces the risk of hospitalization, as the variable endodontics was considered a protective factor for hospitalization (p=0.002). In the analysis of the use of antibiotic and anti-inflammatory medication prior to the evaluation in the emergency unit, it was found that indiscriminate use, or even pre- scribed at the primary or secondary care level, was not significant as a risk or protec- tion factor for hospitalization of patients (p=0.213, p=0.407) (Table 1), rejecting the sixth hypothesis of present study. Regarding the subjective and objective clinical analysis, it was found that the involve- ment of infection in deeper spaces (O.R. 14.668), and the signs and symptoms of edema (O.R. 9.479), cellulitis (stiffened consistency of edema), trismus (O.R. 41.653), dysphagia (difficulty swallowing), fever (O.R. 11.861), odynophagia (painful swallow- ing), erythema/hyperemia (redness and local heat) and dehydration (prostration, toxic appearance and/or dry mouth) were statistically significant as risk factors for the hospital admission of the studied patients (Table 2), confirming the third and fourth hypothesis of present study. Finally, no significant difference was observed in the association between hospital admission and age, harmful habits and location of the infectious process, rejecting the first and second hypothesis of present study. For the 146 patients who were hos- pitalized, the characteristics and the average length of staying were analyzed accord- ing to age, location of infection, presence of medical comorbidities, etiology, infection in deeper spaces and practices. It was observed that age is not correlated with a prolonged hospital staying of the analyzed patients (p = 0.937). The T-Student statistical analysis confirmed that the highest average length of stay- ing occurred in diabetic patients (6.67 days) (Table 3). In addition, among the con- ducts during hospitalization, 105 (71.9%) patients underwent computed tomography, 144 (98.6%) patients received empirical intravenous antibiotic therapy, 111 (76.0%) patients underwent drainage surgery and 76 ( 52.0%) patients focused on the infec- tious process during hospitalization. Only patients who underwent tomography were associated with a longer hospital staying (p= 0.010), and this finding may be asso- ciated with more severe infections. The other conducts were not significant for the length of hospital staying of the patients (Table 4). The mean length of staying for all patients was 5.01 days. Table 3. Analysis of the mean length of staying according to the location of the infection, medical comorbidities, etiology and infection in deep facial spaces (N=146). Category Variable Staying days P Value N Mean SD Location Maxilar 41 5.1 3.321 0.751 Mandible 105 4.96 3.082 Continue 7 Fornari et al. Braz J Oral Sci. 2024;23:e243442 Continuation Diabetes Sim 6 6.67 3.724 0.189 Não 140 4.94 3.109 Hipertension Sim 10 5.40 2.836 0.688 Não 136 4.99 3.169 Depression Sim 13 5.38 3.280 0.657 Não 133 4.98 3.137 Imunossupression Sim 2 5.00 1.414 0.995 Não 144 5.01 3.160 Pulp necrosis Sim 111 5.08 2.986 0.705 Não 43 4.86 3.516 Tooth extraction Sim 19 5.53 4.659 0.447 Não 127 4.94 2.864 Endodontics Sim 15 3.87 1.885 0.136 Não 131 5.15 3.232 Pericoronoritis Sim 3 3.67 2.082 0.455 Não 143 5.04 3.158 Deep facial space Sim 111 5.21 3.390 0.186 Não 35 4.40 2.089 Table 4. Analysis of the average length of staying according to the practiced conduct (N=146). Conduct Variable Staying days P Value N Mean SD Tomography Yes 105 5.43 3.334 0.010 No 41 3.45 2.291 Antibiotic Yes 144 5.06 3.134 0.111 No 2 1.50 0.707 Drainage Yes 111 5.26 3.351 0.090 No 35 4.23 2.211 Infection focus removal Yes 76 5.14 3.365 0.601 No 70 4.87 2.894 Discussion The vast majority of studies showed a male prevalence in maxillofacial infections of odontogenic origin7-9. However, in the present study, a slight prevalence of females was observed in 52% of the sample. The average age of patients in these studies was 29.8 years, which is considered a low average age when compared to other studies in the literature6,9. However, these findings are similiar to those data already reported in another study10. Regarding the hospitalization outcome, the average age of admitted 8 Fornari et al. Braz J Oral Sci. 2024;23:e243442 patients was 28.5 years (SD 16.9) and 30.9 years (SD 18.0) for those not hospital- ized. Therefore, the mean age was not statistically significant for hospital admission, as well as the gender of the patients. In the present study, the location of the infection was divided into two macrosites: maxilla and mandible. The predominance of the mandible was higher with 134 (70.1%) cases, followed by the maxilla in 57 (29.8%) cases. This finding corroborated with previous studies6,8. Despite the mandible being the site with greater predomi- nance, the location was not statistically significant for hospital admission of patients, as described by Alotaibi et al.6, in their previous study. The general health problems, such as diabetes, immunosuppression, alcoholism and using of chronic medication are being associated with more severe cases of odontogenic infection that requires hospital care11. Kamiński et al.11, concluded that it is essential to pay attention to the high-risk group (old age, diabetes mellitus, underlying systemic disease), because they can often progress to life-threatening conditions. Furthermore, the high prevalence of diabetes mellitus (30.3%) indicates that it may be a precipitating factor in deep neck infections. In the present study, the vast majority of patients were young adults (mean age 29 years), in which only 20.4% had a systemic health problem, where 3.6% were diabetic and 1% had the harmful habit of alcoholism. Thus, diabetes, alcoholism and systemic arterial hyper- tension were not considered a significant risk factor for hospital admission, whereas only patients diagnosed with depression were associated with hospital admission. This data is in accordance with the results of previous studies that shows a positive association between depression and oral diseases, where all psychiatric diagnoses were associated with increased dental caries and oral pathology, being a predispos- ing factor for odontogenic infection, in addition to tooth loss12,13. The poor oral health can be observed in patients who were diagnosed with psychiatric ilness, due their lifestyle, poor oral hygiene and difficulties in access to dental care12. In addition, it also can be explained by the side effects of psychotropic medications like antipsychotics, antidepressants, and mood stabilizers, which are used by these patients. All of these medications induce xerostomia, reducing salivary flow14. Among these psychatric ilness, depression, anxiety, panic disorders, phobias, dementia and schizophrenia can be identified as potential conditions for the occurence of dental infections. As a consequence, dental erosion, dental decay and tooth loss can be developed12. Despite not evaluating the association of several psychiatric diseases with the development of maxillofacial infections, the present study revealed that there may be an association between depression and the onset of maxillofacial infections, which is in agreement with the previously described findings. The etiology of odontogenic infection is predominantly related to periapical pathol- ogy associated to pulp necrosis of the dental element. In addition, there is a range of patients destinated to hospital emergency room after undergoing dental surgical pro- cedures or due to pericoronitis15,16. In the present study, pulp necrosis was the most prevalent etiology, with the highest risk for hospital patients admission. According to previous studies of the literature, the systemic response to the infection is more exacerbated and the course of the infection is more severe in the absence of previous dental treatment (endodontic treatment or other dental treatment related to acute 9 Fornari et al. Braz J Oral Sci. 2024;23:e243442 symptoms). Further findings lead to state that incomplete debridement of the root canal during the first session increases the risk of spreading the infection with sys- temic symptoms. Therefore, complete debridement of the root canal during the first session is essential to minimize the risk of infection spreading, in addition to incision and surgical treatment of the abscess. If it is not possible to be performed, the tooth extraction should be considered9,17. The found results of the present study demon- strate that endodontic procedures represent a protective factor for hospitalization of patients with odontogenic infections. The clinical evaluation of the signs and symptoms of a maxillofacial infection must be performed in a qualified manner, in order to determine the diagnosis and prognosis of each case, helping to define the best treatment regimen. In this sense, the patient’s evaluation should involve the analysis of swelling and hardening of the face, possible blockage of the airway and the signs and symptoms reported by the patient, such as diffuse pain, facial swelling, halitosis and general malaise18. The present study con- firmed that the presence of hardened edema and signs of dehydration (prostration and/or general malaise) represent risk factors for hospital admission in maxillofacial infections. In accordance, the requirement for hospitalization is determined by the severity, location and extention of the infectious process8. Gholami et al.19, found that patients with diagnosis of dysphagia, odynophagia, trismus and fever represented clinical risk factors for hospitalization, as described in the present study, with the exception of the infection location. Many authors related the involvement of multiple facial spaces with a higher rate of severity of the infectious process15,20-23. In the present study, the presence or absence of infection in deeper facial spaces was correlated with the need for hospital admis- sion. In this scenario, the presence of infection in deeper spaces represents statis- tically significant risk factor for admission. Previously, a clinical criteria score was developed in a research study for hospital admission due to odontogenic infections, in which trismus, dysphagia, dehydration and infection in the deeper facial spaces were considered significant risk factors for hospital admission24. It is also in accor- dance with the findings of the present study. Regarding the previous use of antibiotics and non-steroidal anti-inflammatory drugs (NSAIDs), self-medication and inappropriate use of antibiotics, in addition to other fac- tors, it seems to be associated with the spread of odontogenic infections25. Further- more, the use of antibiotics in head and neck infections requires updated protocols, based not only on existing scientific evidence, but also on the epidemiological reality of each center15. According to these findings, there is an increasingly urgent need for adequate control of the indiscriminate use of these medications. Performing an uni- variate analysis, the use of antibiotics prior to hospital admission of patients did not statistically corroborate as a risk factor, neither as a protective factor for the hospital- ization of patients with maxillofacial infection of odontogenic origin. For non-steroidal anti-inflammatory drugs, Delbet-Dupas et al.26, analyzed whether the use of anti-in- flammatory drugs would modify the prognosis of severe odontogenic infection, and concluded that dysphonia, odynophagia and fever are more frequent in this group of patients, consdering the fact that patients using anti-inflammatory drugs may present more severe dental infection upon admission. In the present study, 23 patients (12%) 10 Fornari et al. Braz J Oral Sci. 2024;23:e243442 arrived at the hospital using NSAIDs, and this data was not significant as a risk or protecting factor. Therefore, it is understood that the indiscriminate use of this medi- cation should be discouraged. Considering the staying lenght of hospitalization, the highest average number of days is found in patients with diabetes mellitus (3.6% of the 146 hospitalized patients). This result is important, as it is known that compromised immune systems can lead to the opportunistic progression of apparently minor infections, increasing the chances of superficial oral abscesses into the deep neck infections27,28. It is in accordance with the found data of our study. In addition, hipertension and depression are also included in the statistics of longer hospitalization, although they were not statistically signifi- cant, which may represent that patients with pre-existing comorbidities need longer hospital care, which has already been reported in specific studies29,30. The computed tomography has gained widespread use as the imaging modal- ity of choice for deep infections of the neck space in the emergency setting, as it overcomes the field of view limitations of ultrasound evaluation, consuming less time and being more accessible than magnetic resonance imaging31. However, Christensen et al.32, analyzed the unnecessary use of computed tomography in patients, establishing two important criteria, which must be identifiable through physical examination, when applying this imaging modality: loss of palpable limits of the mandible body and trismus. Thus, it is essential to associate these studies with the results of our research, since computed tomography performed in patients is associated with a longer hospital staying. This fact that has already been reported in the literature, especially in more severe cases33. The main limitation of the present study is related to its retrospective design. Due to the retrospective nature, it is necessary to have medical records to evaluate and measure the variables that were used in the present study. In addition, the group of patients and the severity of clinical signs/symptoms in the hospital emergency set- ting are different from those found in the outpatient setting34. Therefore, it is nec- essary to consider and evaluate the clinical differences between these situations in future studies. Considering the limitations of present study, it is possible to conclude that there is a high occurrence of maxillofacial infection cases of dental origin, considering that involvement of infection in deeper facial spaces, as well as presence of pain, edema, erythema/hyperemia, trismus, abscess, cellulitis and pulp necrosis, represent the main risk factors for hospitalization and staying length. Disclosure statement The authors deny any conflicts of interest. The authors declare no financial affiliation (e.g., employment, direct payment, stock holdings, retainers, consultantships, patent licensing arrangements or honoraria), or involvement with any commercial organi- sation with direct financial interest in the subject or materials discussed in this man- uscript, nor have any such arrangements existed in the past three years. Any other potential conflict of interest is disclosed. 11 Fornari et al. Braz J Oral Sci. 2024;23:e243442 Acknowledgements The authors would like to thank Hospital Vicente de Paulo for their availability in carrying out this study. Author contribution Vinícios Fornari – Data collection and article writing / Matheus Albino Souza – Data collection and article writing / Felipe Gomes Dallepiane – Data collection / Adriano Pasqualotti – statistical analysis / Ferdinando De Conto – Data collection. All authors contributed significantly from manuscript findings, revision and final approval of the manuscript. References 1. Krishnan V, Johnson JV, Helfrick JF. Management of maxillofacial infections: a review of 50 cases. J Oral Maxillofac Surg. 1993 Aug;51(8):868-74. doi: 10.1016/s0278- 2391(10)80105-3. 2. Ogle OE. Odontogenic Infections. Dent Clin North Am. 2017 Apr;61(2):235-52. doi: 10.1016/j.cden.2016.11.004. 3. Hwang T, Antoun JS, Lee KH. Features of odontogenic infections in hospitalised and non-hospitalised settings. Emerg Med J. 2011 Aug;28(9):766-9. doi: 10.1136/emj.2010.095562. 4. Har-El G, Aroesty JH, Shaha A, Lucente, FE. Changing trends in deep neck abscess. A retrospective study of 110 patients. Oral Surg Oral Med Oral Pathol Oral Radiol. 1994 May;77(5):446-50. doi: 10.1016/0030-4220(94)90221-6. 5. Parhiscar A, Har-El G. Deep neck abscess: a retrospective review of 210 cases. Ann Otol Rhinol Laryngol. 2001 Nov;110(11):1051-4. doi: 10.1177/000348940111001111. 6. Alotaibi N, Cloutier L, Khaldoun E, Bois E, Chirat M, Salvan D. Criteria for admission of odontogenic infections at high risk of deep neck space infection. Eur Ann Otorhinolaryngol Head Neck Dis. 2015 Nov;132(5):261-4. doi: 10.1016/j.anorl.2015.08.007. 7. Shah N, Patel S, Rupawala T, Makwana S, Mansuri S, Bhimani K. Evaluation of efficacy of ultrasonography as an additional diagnostic tool for deciding management protocol of odontogenic superficial fascial space infections: a prospective clinical study. J Maxillofac Oral Surg. 2022 Dec;21(4):1148-54. doi: 10.1007/s12663-021-01560-x. 8. Park J, Lee JY, Hwang DS, Kim YD, Shin SH, Kim UK, et al. A retrospective analysis of risk factors of oromaxillofacial infection in patients presenting to a hospital emergency ward. Maxillofac Plast Reconstr Surg. 2019 Nov;41(1):49. doi: 10.1186/s40902-019-0238-9. 9. Grönholm L, Lemberg KK, Tjäderhane L, Lauhio A, Lindqvist C, Rautemaa-Richardson, R. The role of unfinished root canal treatment in odontogenic maxillofacial infections requiring hospital care. Clin Oral Investig. 2013 Mar;17(1):113-21. doi: 10.1007/s00784-012-0710-8. 10. Sato FRL, Hajala FAC, Freire Filho FWV, Moreira RWF, de Moraes M. Eight-year retrospective study of odontogenic origin infections in a postgraduation program on oral and maxillofacial surgery. J Oral Maxillofac Surg. 2009 May;67(5):1092-7. doi: 10.1016/j.joms.2008.09.008. 11. Kamiński B, Błochowiak K, Kołomański K, Sikora M, Karwan S, Chlubek D. Oral and maxillofacial infections-a bacterial and clinical cross-section. J Clin Med. 2022 May;11(10):2731. doi: 10.3390/jcm11102731. https://doi.org/10.1016/j.cden.2016.11.004 https://doi.org/10.1136/emj.2010.095562 https://doi.org/10.1016/0030-4220(94)90221-6 https://doi.org/10.1016/0030-4220(94)90221-6 https://doi.org/10.1177/000348940111001111 https://doi.org/10.1016/j.anorl.2015.08.007 12 Fornari et al. Braz J Oral Sci. 2024;23:e243442 12. Kisely S, Sawyer E, Siskind D, Lalloo R. The oral health of people with anxiety and depressive disorders - a systematic review and meta-analysis. J Affect Disords. 2016 Aug;200:119-32. doi: 10.1016/j.jad.2016.04.040. 13. Cirkel LL, Jacob L, Smith L, López-Sánchez GF, Konrad M, Kostev K. Relationship between chronic gingivitis and subsequent depression in 13,088 patients followed in general practices. J Psychiatr Res. 2021 Jun;138:103-6. doi: 10.1016/j.jpsychires.2021.03.059. 14. Friedlander, A.H., Marder, S.R. The psychopathology, medical management and dental implications of schizophrenia. J. Am. Dent. Assoc. 2002 May;133(5):603-10; quiz 624-5. doi: 10.14219/jada.archive.2002.0236. 15. Ohshima A, Ariji Y, Goto M, Izumi M, Naitoh M, Kurita K, et al. Anatomical considerations for the spread of odontogenic infection originating from the pericoronitis of impacted mandibular third molar: computed tomographic analyses. Oral Surg Oral Med Oral Pathol Oral Radiol. 2004 Nov;98(5):589-97. doi: 10.1016/S1079210404005074. 16. Sánchez R, Mirada E, Arias J, Paño Pardo JR, Burgueño García M. Severe odontogenic infections: epidemiological, microbiological and therapeutic factors. Med Oral Patol Oral Cir Bucal. 2011;16(5):e670-6. doi: 10.4317/medoral.16995. 17. Peñarrocha-Diago M, Camps-Font O, Sánchez-Torres A, Figueiredo R, Sánchez-Garcés MA, Gay-Escoda C. Indications of the extraction of symptomatic impacted third molars. A systematic review. J Clin Exp Dent. 2021 Mar;13(3):e278-86. doi: 10.4317/jced.56887. 18. Beech N, Goh R, Lynham A. Management of dental infections by medical practitioners. Aust Fam Physician. 2014 May;43(5):289-91. 19. Gholami M, Mohammadi H, Amiri N, Khalife H. Key factors of odontogenic infections requiring hospitalization: a retrospective study of 102 cases. J Oral Maxillofac Surg Med Pathol. 2017 Sep;29(5):395-9. doi: 10.1016/j.ajoms.2017.03.016. 20. Lopes ABS, Ramos-Jorge ML, Machado GF, Vieira-Andrade RG, Ramos-Jorge J, Fernandes IB. Longitudinal evaluation of determinants of the clinical consequences of untreated dental caries in early childhood. Community Dent Oral Epidemiol. 2022 Apr;50(2):91-8. doi: 10.1111/cdoe.12635. 21. Qian Y, Ge Q, Zuo W, Cheng X, Xing D, Yang J, et al. Maxillofacial space infection experience and risk factors: a retrospective study of 222 cases. Ir J Med Sci. 2021 Aug;190(3):1045-53. doi: 10.1007/s11845-020-02431-z. 22. Brajkovic D, Zjalic S, Aleksandar K. Evaluation of clinical parameters affecting the prognosis in surgically treated patients with descending necrotizing mediastinitis - A retrospective study. J Stomatol Oral Maxillofac Surg. 2022 Nov;123(6):e731-7. doi: 10.1016/j.jormas.2022.05.017. 23. Weise H, Naros A, Weise C, Reinert S, Hoefert S. Severe odontogenic infections with septic progress - a constant and increasing challenge: a retrospective analysis. BMC Oral health. 2019 Aug;19(1):173. doi: 10.1186/s12903-019-0866-6. 24. Sainuddin S, Hague R, Howson K, Clark S. New admission scoring criteria for patients with odontogenic infections: a pilot study. Br J Oral Maxillofac Surg 2017 Jan;55(1):86-9 doi: 10.1016/j.bjoms.2016.05.003. 25. Mannan S, Tordik PA, Martinho FC, Chivian N, Hirschberg CS. Dental abscess to septic shock: a case report and literature review. J Endod. 2021 Apr;47(4):663-70. doi: 10.1016/j.joen.2020.12.016. 26. Delbet-Dupas C, Devoize L, Mulliez A, Barthélémy I, Dang NP. Does anti-inflammatory drugs modify the severe odontogenic infection prognosis? A 10-year’s experience. Med Oral Patol Oral Cir Bucal. 2020 Jan;26(1):e28-35. doi: 10.4317/medoral.23926. 27. Vilén ST, Ahde H, Puolakka T, Mäkitie A, Uittamo J, Snäll J. Differences in characteristics and infection severity between odontogenic and other bacterial oro-naso-pharyngeal infections. Head Face Med. 2023 Mar;19(1):10. doi: 10.1186/s13005-023-00354-5. https://doi.org/10.1016/S1079210404005074 https://doi.org/10.4317/medoral.16995 13 Fornari et al. Braz J Oral Sci. 2024;23:e243442 28. Kamat RD, Dhupar V, Akkara F, Shetye O. A comparative analysis of odontogenic maxillofacial infections in diabetic and nondiabetic patients: an institutional study. J Korean Assoc Oral Maxillofac Surg. 2015 41(4):176-80. doi: 10.5125/jkaoms.2015.41.4.176. 29. Rautemaa R, Lauhio A, Cullinan MP, Seymour G. Oral infections and systemic disease - an emerging problem in medicine. Clin Microbiol Infect. 2007 Nov;13(11):1041-7. doi: 10.1111/j.1469-0691.2007.01802.x. 30. Priyamvada S, Motwani GA. Study on Deep Neck Space Infections. Indian J Otolaryngol. 2019;71 (Suppl 1):912-7. doi: 10.1007/s12070-019-01583-4. 31. Caprioli S, Tagliafico A, Fiannacca M, Borda F, Picasso R, Conforti C, et al. Imaging assessment of deep neck spaces infections: an anatomical approach. Radiol Med. 2023 Jan;128(1):81-92. doi: 10.1007/s11547-022-01572-8. 32. Christensen BJ, Park EP, Suau S, Beran D, King BJ. Evidence-based clinical criteria for computed tomography imaging in odontogenic infections. J Oral Maxillofac Surg. 2019 Feb;77(2):299-306. doi: 10.1016/j.joms.2018.09.022. 33. Fu B, McGowan K, Sun H, Batstone M. Increasing use of intensive care unit for odontogenic infection over one decade: incidence and predictors. J Oral Maxillofac Surg. 2018 Nov;76(11):2340-7. doi: 10.1016/j.joms.2018.05.021. 34. Fu B, McGowan K, Sun JH, Batstone M. Increasing frequency and severity of odontogenic infection requiring hospital admission and surgical management. Br J Oral Maxillofac Surg. 2020 May;58(4):409-15. doi: 10.1016/j.bjoms.2020.01.011. https://doi.org/10.5125/jkaoms.2015.41.4.176 https://doi.org/10.1007/s12070-019-01583-4