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Romanian Neurosurgery (2018) XXXII 2: 283 - 289 | 283 

 

 
 
 
 
 
 

DOI: 10.2478/romneu-2018-0034   

Brain Abscess and Dental Infections: a review 

Johana Maraby-Salgado1, Samer S. Hoz2, Alexis Narvaez-Rojas4, 
Guru Dutta Satyarthee5, Loraine Quintana-Pajaro1, Alfonso 
Pacheco-Hernandez, Luis Rafael Moscote-Salazar3 
1Cartagena University, Cartagena de Indias, COLOMBIA 
2Department of Neurosurgery, Neurosurgery teaching Hospital-Baghdad, IRAQ 
3Department of Neurology, Division of Neurosurgery, Cartagena University, Cartagena de 
Indias, COLOMBIA 
4Universidad Nacional Autonoma de Nicaragua, MANAGUA 
5All India Institute of Medical Science, New Delhi, INDIA 

 
Abstract: Odontogenic infections may cause brain abscesses. Although infrequent, 
infections can lead to development of aggressive brain lesions that may be life-
threatening for patients. With the advent of new antibiotic treatments, dental abscesses 
appear to be under control but all patients with high risk of brain abscess should be 
assessed and treated properly. Hereby, we present an overview of the information 
available in the literature of the relationship between brain and dental abscesses. 
Key words: brain abscess; dental infection; neurosurgery 

 
Introduction 

Dental abscess and facial cellulitis put 
dentists on alert for potentially life-
threatening conditions such as sepsis or 
airway obstruction, but the risk of a brain 
abscess is a complication of odontogenic 
infection that dentists rarely consider. [1] 
Untreated odontogenic infections can 
advance to osteomyelitis, cellulitis, myofascial 
space abscess, lymphadenitis, bacteremia, or 
sepsis, all of which can be extremely 
dangerous. Brain abscesses, which are rare, 
are also a potential type of infection that 
could arise. These are suppurative infections 

of the brain parenchyma that are surrounded 
by a vascularized capsule. In the United 
States, there are only 1,500 to 2,500 brain 
abscess cases each year [2,3]. Central nervous 
system (CNS) infections and their sequelae 
still constitute a major source of morbidity. 
[4,5] In the recent past, the introduction of 
newer broad spectrum antibiotics, improved 
imaging technology, and intensive care 
facilities have significantly altered the natural 
history of CNS infections. [6] Brain abscess 
(BA) is a universal health problem with a high 
morbidity and mortality rate; thus, the disease 
today presents a leading public health 



 
 
 
 
 
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problem and a major burden on health care 
facilities all around the world. [6,7] BA is a 
dynamic focal form of intracranial 
suppuration and a serious life‑threatening 
emergency. [7] They begin as a localized area 
of cerebritis and develop into an encapsulated 
collection of pustular materials presenting as 
a mass‑like lesion, similar to the abscess in 
other sites. Bacterial brain abscesses have 
three main etiologies. The most common 
cause is contiguous spread of infection from 
the oropharynx, middle ear, and paranasal 
sinuses. Brain abscesses can also arise from 
hematogenous dissemination of bacteria. 
Previous cranial trauma and neurosurgical 
procedures can also cause brain abscesses. [8-
10] However, in up to 15%–30% of cases, the 
cause of brain abscesses is unknown. The 
majority of brain abscesses arise from the 
direct spread of infection through the facial 
planes, and often originate in the paranasal 
sinuses, middle ear and mastoid área [1]. 

History 
Over the years, there have been a number 

of case reports of brain abscess, in which the 
microorganisms were thought to have arisen 
from a dental source. There are few reports of 
brain abscesses of odontogenic origin [11,12]. 
Corson et al. [13] reviewed 17 reports from 
the 1940s to the 1990s, in which the mortality 
rate was 30 % (6/20). Antunes et al. [12] 
described the location of brain abscesses and 
their treatment in 11 cases from the 1960s to 
the 1980s, and in five cases from 2001 
through 2007. A systematic review by 
Moazzam et al. [11] included 60 individual 
cases, 40 of which were published since 2000. 

They reported the precipitating dental 
pathology or procedures, the pathogenic 
microorganisms, the locations of CNS 
infections, and clinical outcomes [11]. The 
mortality rate of patients with intracranial 
bacterial infections of oral origin in that study 
was improved to 8.3 % (5/60) [11]. Ewald et 
al. [14] reported six cases of pyogenic 
infection of the CNS secondary to dental 
infection. They indicated that there was no 
definable origin for intracerebral or 
intraspinal infection in up to 25 % of cases, 
and these are termed ‘‘cryptic abscesses’’ [14], 
[6]. They noted that a dental focus should 
always be considered in the evaluation and 
treatment of ‘‘cryptic’’ CNS infections, and 
recommended clinical evaluation by a dentist 
and oral pantomogram [6]. In the report 
described by Neidert et al. [15] regarding the 
suspected origin of infection, most cases 
could be linked to an oral/dental source 
(23%) followed by sinusitis (14%) or a cardiac 
source (14%), and no specific origin of 
infection could be determined in other cases 
(43 %). [16] 

Mechanism of Infection  
To determine the oral origin of 

intracranial infections, oral surgeons should 
know the underlying mechanism of oral 
bacterial spread into the CNS. Hematogenous 
spread via bacteremia is probably a more 
common route tan direct venous drainage. 
Therefore, there appears to be no predilection 
for the location of odontogenic foci. There 
may be no apparent past history or symptoms 
of acute inflammation caused by odontogenic 
foci or dental procedures prior to 



 
 
 
 
 

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development of brain abscess. Microbes can 
spread as a result of acuteinfection with a 
large number of involved pathogens or highly 
virulent microorganisms, as well as chronic 
infection with recurrent bacteremia [16].  

The oral cavity is well recognised as being 
home to a rich and abundant microflora. [13] 
In particular, dental plaque contains one of 
the most concentrated accumulations of 
microorganisms in the human body, with 
approximately 350 different bacterial strains 
isolated in marginal periodontitis and 150 in 
endodontic infections. Bacteria gaining access 
to the blood stream may then spread to 
distant sites and there has long been an 
association between oral bacteria, in 
particular a-haemolytic streptococci, and 
bacterial endocarditis. Dental procedures 
alleged to have caused a brain abscess are very 
wide ranging, and include extraction, 
operative dentistry, periodontal therapy, 
dental local anaesthetic injection and dental 
prophylaxis [17]. This would suggest that the 
mechanism esponsible for the production of 
the bacteraemia is not as critical as the host 
response. In this case report there was no 
apparent history of an acute dental infection 
or dental procedure prior to development of 
the brain abscess. However it would appear 
that from very mild manipulations of the 
mouth, bacteria can transfer into the blood 
stream. One study in children found a 
transient bacteraemia in 38.5% of episodes of 
tooth brushing, while procedures such as 
dental extraction, produce a massive shower 
of organisms into the blood stream [18]. 
Within 1 min of a dental procedure, 
microorganisms may have reached the heart, 

lungs and peripheral capillary system. In most 
individuals the reticuloendothelial system 
eliminates these microbes in a matter of 
minute [13]. This is not the case in 
immunocompromised populations, for 
example, organ transplant patients and those 
with AIDS where there has been a reported 
increased incidence of brain absces. [6] 
Although certain underlying brain 
pathologies such as a previous stroke [13] or 
underlying neoplasm [13] may serve as a 
nidus for abscess formation, in most cases 
there is no apparent predisposing brain 
lesion. 

Epidemiology 
Brain abcess (BA) is one of the most 

serious diseases of the CNS. This condition is 
more common among men twice to three 
times, and morbidity rate is highest in fourth 
decade of the life [3,25] Brain abcess is still 
associated with high morbidity, including 
seizures (up to 80%), persistent altered mental 
status, and focal motor deficits. [26] Brain 
abscess continues to be a significant problem 
in the developing world due to large scale 
poverty, illiteracy, and lack of higiene. 

A BA may be developed from three 
sources and one of these is through from 
pericranial contiguous focus in 25-50% of 
cases (such as the sinuses, middle ear, or 
dental infection), interestingly dental 
infections, ethmoid or frontal sinusitis 
(usually spreads to the frontal lobe), and 
subacute or chronic otitis media or 
mastoiditis (preferentially spreads to the 
inferior temporal lobe and cerebellum). [4] 



 
 
 
 
 
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Etiology 
BA are frequently polymicrobial, From 

oral cavity, hemathogenous spread (intra‑
abdominal/ pelvic infections), and from 
otorhinolaringeal infections the commonest 
organisms isolated are anaerobic pathogens 
(Streptococci, Bacteroides spp., Prevotella 
melaninogenica, Propionibacterium, 
Fusobacterium, and Actinomyces and aerobic 
gram‑negative rods, like Morganella 
morganii) [4,19-21] 

There are reports that E. faecalis was also 
found in a case of brain abscess secondary to 
odontogenic procedures in a patient with 
teleangiectasia, although its occurrence is rare 
and infrequent, since it is usually a 
nosocomial pathogen [22] E. faecalis is an 
infrequent causative agent of brain abscess. 
This organism is usually a nosocomial 
pathogen, and its presence in the central 
nervous system (CNS), rarely if ever as a 
cause of meningitis, has been associated with 
anatomic defects, prior neurosurgery and 
trauma, or high-grade bacteremia and 
immunodeficiency [22,23]. Common portals 
of entry for enterococcal bacteremia are the 
urinary tract and sites of intra-abdominal and 
pelvic sepsis [22-24]. However, recently, 
literature provided evidence that due to its 
ability to produce biofilms, E. faecalis is often 
involved in endodontic infections [23], 
rendering sites of dental work a potential 
portal of enterococcal bacteremia. [22] A 
literature review revealed four cases of brain 
abscess involving pus from which E. faecalis 
was isolated [22, 25, 26] 

There have also been reports of 
Aggregatibacter actinomycetemcomitans, which 
is recognised as one of the major pathogens in 
destructive periodontal disease. A cerebral 
abscess linked to a dental source is a rare 
occurrence, since in most individuals the 
blood-brain barrier, along with the immune 
response, will exclude bacteria. [27] A. 
actinomycetemcomitans has been also 
described as a cause of meningitis, brain 
abscess, endophthalmitis (with and without 
concomitant endocarditis), soft tissue 
infections, septic arthritis, osteomyelitis, and 
endocarditis. It may be part of the 
endogenous flora of the mouth and can be 
recovered from about 20% of healthy 
teenagers and adults It is normally found in 
dental plaque, periodontal pockets and 
gingival sulcus, and is one of the major 
pathogens in adult and juvenile forms of 
periodontitis. It is present in more than 50% 
of adults with refractory periodontitis and 
90% of patients with localised aggressive 
periodontitis. [27, 28] 

Clinical presentation 
BA can be primarily present in four basic 

syndromes, viz. focal mass expansion, intra‑
cranial hypertension, diffuse destruction, and 
focal neurological deficit. [29] In most cases, 
predisposing risk factors, such as congenital 
heart disease, decreased immunity, or the 
presence of a septic focus, can be identified. 
[4] 

The clinical presentation of intracranial 
abscess is dependent on the origin of 
infection, site, size, number of lesions, specific 
brain structures involved, the neighborhood 



 
 
 
 
 

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anatomy disturbances involving cisterns, 
ventricles, and the dural venous sinuses, and 
any secondary cerebral injury. [30] 
Frequently patients present with symptoms of 
increased intracranial pressure (headache, 
nausea/vomiting, and altered mental status), 
focal neurologic deficits, and fever (although 
fever can be absent in 30-76% of cases). 
Nathoo et al. [7] reported that headaches, 
fever, and nuchal rigidity were the 
commonest clinical presentation. The 
duration of symptoms ranged from 1 day to 8 
weeks (average 11.4 ± 10 days; P = 0.7). [4]. 
This is generally present in patients with 
brain abscess, secondary to periodontal 
infections. 

Diagnosis 
Neuroimaging, usually a computed 

tomography (CT) scan with contrast, is 
essential to diagnose a BA. The typical finding 
on CT scan or MRI is a hypodense lesion with 
a contrast‑enhancing ring. [26] CT facilitates 
early detection, exact localization, and 
accurate characterization, determination of 
number, size and staging of the abscess,  

Diagnosing the microbiological source of 
any infection must be based on sound 
microbiological methodology. Bacteria 
isolated from the distant abscess must 
represent that found within the oral cavity. 
An array of molecular fingerprinting 
techniques based upon nucleotide sequencing 
can now be applied to provide supportive 
evidence for the identification of isolates from 
different sources. Such techniques should be 
utilized to further our understanding as to 

whether oral sources of infection can give rise 
to brain abscess. [13] 

The differential diagnosis between BA and 
brain tumors is of extreme importance. 
Rahmat-Langendoen et al. explores 
difficult.their similarity and shows that the 
symptoms are similar that makes the 
diagnosis of BA of dental origin extremely. 
[28] 

Treatment 
Recently, Mouren et al, described in a case 

report a patient with brain abscess secondary 
to odontogenic injection using 
metronidazole, vancomycin, and cefotaxime 
[31]. Although BA is essentially a surgical 
pathology, Arlotti et al. [32] recommend that 
choice of patients for a medical approach 
must be made on an individual basis. These 
authors consider best candidates for medical 
treatment to be those with a small abscess 
(<2.5 cm), in good initial 

clinical condition, Glasgow Coma Scale 
(GCS) > 12, and for whom the etiology is well
‑known (microorganism isolated from 
material other than the abscess pus) 
recommendation grade C; or in the case of 
multiple abscesses, after surgery of abscesses 
>2.5 cm or surgery of abscesses that cause a 
mass effect, or in patients at serious risk of 
operation even if in these, the final decision 
must consider that the prognosis is often bad 
in any case recommendation grade D. [4] 

For Muzumdar et al. [29], there are no 
pragmatic rules for treatment of brain abscess 
and each case must be individualized and 
treated on its own merits. The main stay of 
the treatment includes prompt action and 



 
 
 
 
 
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institution of antibiotic therapy. Penicillin 
and chloramphenicol have long been used 
until we have opted for cefotaxime/ 
ceftriaxone/ceftazidime, vancomycin, and 
metronidazole, and this is in agreement with 
the treatment administered to the patient. 
Steroid administration should be generally 
avoided unless the patient demonstrates signs 
of meningitis or disproportionate cytotoxic 
edema posing a life threatening problem. 
Legg advocated anticonvulsant therapy for 5 
years to all patients with cerebral abscess. 
Discontinuation of antiepileptic drugs can be 
considered when patient is seizure-free for at 
least 2 years after surgery and 
electroencephalogram. [29] 

Bacteroides, Peptostreptococcus, and 
Fusobactrium are common anaerobes and are 
sensitive to metronidazole. Staphylococcus is 
common in post-traumatic and postoperative 
cases; in infants and neonates, post‑
meningitic abscess is caused by gram‑
negative organisms. [17] Sulpha drugs are 
most effective in Nocardia and vancomycin 
against Staphylococcus. [4] 

Conclusions 
A cerebral abscess linked to a dental 

source is a rare occurrence and its clinical 
features are often nonspecific. It is worth 
noting that this latter component calls upon 
dental clinicians to pay more attention in the 
identification and treatment of oral and 
odontogenic sources for brain abscesses. 
 
Correspondence 
Dr. Luis Rafael Moscote-Salazar 
e-mail: mineurocirujano@aol.com 

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