Dental abscess: an underestimated trigger for severe diabetic ketoacidosis

For a diabetic patient, an odontogenic infection is never a minor incident. While the bidirectional link between periodontal health and glycemic homeostasis is firmly established, the progression of a localized infectious focus toward a life-threatening emergency remains a critical scenario too often overlooked. This clinical case documents an extreme pathological cascade occurring in a 57-year-old patient with poorly controlled type 2 diabetes (HbA1c 10.2%), where a simple dental abscess escalated into septic shock.

The objective of this presentation is to illustrate how a periapical infection of tooth 48 can become the primary focus of severe diabetic ketoacidosis (DKA), complicated by sepsis-induced cardiomyopathy (SICM). The study analyses the mechanisms by which an oral inflammatory state can precipitate multi-organ failure, marked here by an arterial pH of 7.04 and a sudden drop in the left ventricular ejection fraction to 36%.

The authors support the hypothesis that rapid control of the infectious source, combined with aggressive metabolic management, is imperative to reverse organ damage. This report highlights the crucial importance of oral cavity examination in the systematic assessment of any diabetic patient admitted in shock or metabolic decompensation.

Diagnostic approach and therapeutic protocol

This case report documents the clinical and multidisciplinary management of a 57-year-old female patient with poorly controlled type 2 diabetes (HbA1c of 10.2%), admitted for severe diabetic ketoacidosis (DKA) and septic shock of odontogenic origin.

• Study Design: Single clinical case report with a one-month longitudinal follow-up.
• Biological evaluation and scores: The diagnosis was based on arterial blood gases (pH 7.04, bicarbonates 1.9 mmol/L), β-hydroxybutyrate measurement (7.19 mmol/L) and blood glucose levels (14.4 mmol/L). The infectious profile was evaluated via procalcitonin (2.34 ng/mL), leukopenia (3.4×10⁹/L) and severity scores SOFA (4) and APACHE II (21).
• Cardiac imaging and monitoring: A cervical CT scan was performed to identify the infectious focus. Cardiac function was monitored by transthoracic echocardiography (initial LVEF of 36%).
• Intervention protocol (first hour): Simultaneous implementation of the "sepsis bundle" and the ACD protocol including:
  • Empirical broad-spectrum IV antibiotic therapy (amoxicillin-clavulanate and tinidazole).
  • Aggressive fluid resuscitation with crystalloids.
  • Continuous intravenous insulin therapy (0.1 U/kg/h).
  • Electrolytic correction (potassium nadir at 2.85 mmol/L).
• Focus control: Microbiological analysis by culture of oral secretions (tooth 48) and specialized consultation in maxillofacial surgery for the management of the periapical abscess.

Results: A reversible metabolic and cardiac collapse

Admission to the emergency department revealed severe metabolic and septic shock. Initial biological analyses confirmed profound diabetic ketoacidosis (DKA) and marked systemic inflammation.

L'imagerie par scanner cervical a identifié un abcès sous-mandibulaire gauche comme foyer infectieux primaire. L'examen clinique bucco-dentaire a mis en évidence une hygiène précaire et des caries dentaires profondes sur la dent 48, associées à un écoulement purulent. Malgré un score APACHE II de 21 et un score SOFA de 4 à l'entrée, la prise en charge multidisciplinaire a permis une stabilisation rapide.

From a cardiac perspective, echocardiography revealed sepsis-induced cardiomyopathy (SICM) with an LVEF collapsed to 36%, while cardiac biomarkers (troponin T < 0.02 ng/mL) and ECG were normal. This myocardial dysfunction proved to be fully reversible within 14 days following the control of the infectious focus and the metabolic crisis. Empirical antibiotic therapy with amoxicillin-clavulanic acid and tinidazole was maintained following culture results, allowing for resolution of the infection without therapeutic escalation to carbapenems.

The practitioner's analysis

This case highlights the danger of the interaction between diabetes and odontogenic infection. Hyperglycemia impairs innate immune functions, while the cytokine storm of sepsis exacerbates insulin resistance, creating a metabolic vicious cycle. The complete reversibility of SICM observed here — with LVEF rising to 72% by day 14 — confirms that cardiac function can fully normalize once the septic insult and metabolic imbalance are resolved.

Although this report is limited to a single case, it is consistent with literature describing a six-fold increase in the risk of sepsis in diabetic patients. The main limitation remains the absence of direct surgical drainage, as the abscess responded favorably to intensive medical treatment, which is not the rule for all deep space abscesses. These results demonstrate that early control of the infectious focus, even without systematic invasive intervention, is the pillar of survival.

For the dental surgeon, this case serves as a reminder that dental caries and periodontitis are not merely local issues. Deep caries on the 48 in a patient immunocompromised by uncontrolled diabetes can become the starting point for a lethal metabolic decompensation.

Dental abscess, a fulminant systemic trigger

This clinical case illustrates the severity of a metabolic decompensation initiated by an odontogenic infection in a 57-year-old patient with poorly controlled diabetes (HbA1c at 10.2%). The periapical abscess of tooth 48 caused severe diabetic ketoacidosis (pH 7.04, β-hydroxybutyrate 7.19 mmol/L) and septic shock complicated by sepsis-induced cardiomyopathy (LVEF collapsed to 36%). Thanks to immediate multidisciplinary management combining IV insulin therapy and antibiotic therapy (amoxicillin-clavulanate and tinidazole), all organic functions, including cardiac function (recovered to 72%), were fully restored within 14 days.

Specifically for the practitioner:

• Examination reflex: When faced with a diabetic patient presenting a metabolic emergency or unexplained fatigue, inspection of the oral cavity is imperative; a dental infection can be the hidden starting point of multi-organ failure.
• Management of the patient's condition: A high HbA1c level (> 10%) increases the risk of severe sepsis sixfold. In the event of dental pain reported by these patients, antibiotic therapy and control of the infectious focus must be aggressive and early.
• Reversibility of damage: Keep in mind that organ complications (such as transient heart failure) related to odontogenic sepsis are reversible if the infectious focus and glycemic imbalance are treated jointly without delay.

Technical lexicon of the study

Diabetic Ketoacidosis (DKA): Acute metabolic complication of diabetes characterized by hyperglycemia, ketonemia (β-hydroxybutyrate level of 7.19 mmol/L in this case) and severe metabolic acidosis (initial pH of 7.04).

Sepsis-induced cardiomyopathy (SICM): A reversible form of myocardial dysfunction occurring during sepsis, identified here by a left ventricular ejection fraction (LVEF) dropping to 36% in the absence of primary myocardial ischemia.

Kussmaul breathing: A compensatory, deep, and rapid breathing pattern (frequency of 44/min in the patient), aimed at eliminating carbon dioxide to compensate for metabolic acidosis.

β-hydroxybutyrate: Predominant ketone body whose serum measurement allows for confirming the diagnosis of ketoacidosis and evaluating the metabolic response to intravenous insulin treatment.

SOFA Score (Sequential Organ Failure Assessment): Scoring system used to quantify organ dysfunction during sepsis; the patient presented a score of 4 during initial management.

Procalcitonin (PCT): Biomarker of systemic inflammation of bacterial origin (2.34 ng/mL at admission), essential for monitoring infection severity and the efficacy of antibiotic therapy.

Periapical abscess: Purulent infection localized at the apex of a dental root (involving tooth 48 in this case), which served as an infectious portal of entry to the submandibular space and the circulatory system.

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