Odontogenic infections: predicting evolution to optimize management

Dental or periodontal infections represent a major clinical challenge when inflammation progresses to deep facial spaces. Beyond the immediate life-threatening risk associated with complications such as sepsis or mediastinitis, these pathologies generate high healthcare costs, primarily due to surgical interventions and the length of hospitalisation. For the practitioner, predicting treatment outcomes and managing the progression of the infection remains complex, particularly in extensive cases.

This retrospective study, conducted with 61 patients hospitalized at the Bonn University Hospital between January and August 2020, evaluates the clinical value of procalcitonin (PCT) as a prognostic marker. While PCT is already a standard for risk stratification in severe respiratory infections, its utility for the assessment of odontogenic abscesses lacked solid evidence until now. The objective is to determine whether PCT can serve as a decision-making tool to identify risk groups early and optimize treatment planning in order to reduce the economic impact and improve patient outcomes.

Study design and population

The authors conducted a retrospective study including 61 patients treated at the Bonn University Hospital between January and August 2020. Recruitment specifically targeted cases of odontogenic abscesses showing a tendency for local or regional spread, justifying full hospitalisation.

Clinical and therapeutic protocol

The care protocol was standardized for the entire cohort:

• Antibiotic therapy: systematic intravenous administration in a hospital setting.
• Surgical procedure: systematic drainage of the lesion, performed via intra-oral or extra-oral route depending on the clinical extension.
• Biological sampling: preoperative evaluation of C-reactive protein (CRP), white blood cell count, and procalcitonin (PCT).

Analysis and statistics settings

PCT was stratified into three categories: normal (<0.1 µg/l), moderate (0.1–0.5 µg/l), and high (>0.5 µg/l). One outlier (>60 µg/l), deemed clinically implausible, was excluded from the analysis. To evaluate length of stay (LOS) and the presence of pus, researchers used Wilcoxon-Mann-Whitney tests, Fisher's exact test, as well as discrete-time risk models (time-to-event) supplemented by a decision tree regression approach.

Cohort analysis and PCT stratification

The study involved 61 patients hospitalised for odontogenic abscesses requiring intravenous antibiotic therapy and surgical drainage. A primary clinical finding emerged from the biological data: almost all patients presented procalcitonin (PCT) levels below 2 µg/l.

An atypical case, however, marked the records with a PCT value greater than 60 µg/l. In the absence of clinical complications, systemic infection, or septic pathology in this patient, the authors excluded this data from the statistical analysis to avoid any interpretation bias of the predictive models.

To evaluate the relevance of PCT as a risk marker, researchers segmented the population into three concentration categories:

The analysis compared these PCT levels, as well as CRP and leukocyte rates, to the actual presence of pus during incision. In a hospital setting, clinicians used computed tomography (CT) imaging in a targeted manner, reserving it for cases of diagnostic uncertainty or suspicion of extensive infection spread.

The central objective remains the correlation between these biomarkers and the length of stay (LOS). Statistical models integrated not only preoperative values, but also the evolution of CRP, leukocytes, and PCT between preoperative and postoperative samples to identify groups of patients at risk of prolonged stay.

The challenge of early stratification in private practice and hospital settings

When faced with an odontogenic infection, the practitioner is confronted with a major clinical uncertainty: the progression towards life-threatening complications such as necrotizing fasciitis or mediastinitis. This retrospective study, conducted on 61 patients at the Bonn University Hospital, addresses a gap in evidence regarding the utility of procalcitonin (PCT) in the management of odontogenic abscesses. While PCT is already a standard for sepsis or respiratory infections, its application in oral surgery remains poorly documented. The objective here is clear: to determine if PCT can predict the length of hospital stay (LOS) and identify risk groups upon admission.

Methodological analysis and identified limits

The methodology is based on the analysis of inflammatory markers (CRP, leukocytes, PCT) correlated with the presence of pus during incision and the need for reintervention. The use of discrete hazard models to analyze the length of stay highlights a commitment to statistical finesse uncommon in retrospective studies in the field. However, the practitioner must consider the limitations of this work: a modest sample size (n=61), a monocentric design, and the exclusion of extreme data (a PCT value > 60 µg/l discarded), which may smooth the clinical reality of the most severe infections.

Implications for clinical practice

The interest of this research lies in the potential economic and therapeutic gain. If PCT proves to be a reliable predictive marker, it would allow for accelerated referral to intensive care or, conversely, early discharge to reduce costs. For the clinician, this means a transition from empirical management based on abscess volume to precise biological stratification. The study seeks to transform a laboratory parameter into a concrete surgical decision-making tool to optimize the care pathway.

Study summary

This retrospective study, including 61 patients hospitalized for odontogenic abscesses, evaluates the use of procalcitonin (PCT) as a predictive marker for clinical outcome. The authors specifically analyze the correlation between PCT levels, the presence of pus during surgical drainage, and the total length of stay (LOS) to improve risk stratification.

In concrete terms, for the practitioner:

• Optimize follow-up: Integrate procalcitonin (PCT) measurement into the initial assessment to early identify infections presenting a risk of systemic spread or prolonged stay.
• Anticipate logistics: Use this biomarker as a prognostic indicator to better estimate the required length of hospital stay and adapt resource management in the practice or hospital department.
• Refine triage: In cases of diffuse infections, PCT allows for more precise stratification than clinical parameters alone, facilitating referral to intensive care or revision surgery.

Technical Lexicon

Procalcitonin (PCT): Biological marker of inflammation used in this study for infection risk stratification and as a prognostic indicator for the duration of hospitalisation.

Apical periodontitis: Inflammatory reaction of endodontic origin identified as the initial stage of infection before its spread to subperiosteal bone areas and soft tissues.

Length of Stay (LOS): Hospitalization duration expressed in days, used as a key parameter to evaluate the therapeutic outcome and the economic impact of surgical interventions.

Necrotizing fasciitis: A serious systemic infectious complication, mentioned as a potential life-threatening threat resulting from the uncontrolled spread of an odontogenic infection.

Mediastinitis: Severe inflammation of the mediastinal space, cited as a major complication related to the downward progression of cervicofacial abscesses.

Intravenous antibiotic: Imperative parenteral therapeutic modality for the hospital management of odontogenic abscesses with a tendency to spread.

Surgical drainage: Intra-oral or extra-oral purulent evacuation procedure, constituting a mandatory inclusion criterion for the treatment of patients in this cohort.

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