Hospitalisations Due to Dental Infection: A Retrospective Clinical Audit from an Australian Public Hospital

The aim of this clinical audit is to evaluate the characteristics of dental infections requiring hospitalisations, which may help improve preventative and management policies. This study retrospectively evaluated the records of patients admitted to the Nepean hospital, Kingswood, New South Wales, Australia, due to dental infections between 2018 and 2019. A total of 102 patients, mostly in their thirties with equal gender distribution, were admitted with dental infections, presenting with pain (100%), swelling (99%), trismus (40.2%), dysphagia (27.4%), fever (21%) [>37 °C], tachycardia (24.8%) and tachypnoea (9.3%). Most patients (68%) presented on weekends, outside regular working hours, and public holidays. A total of 52.5% of patients had taken prior antibiotics. Dental caries, smoking, mental health issues, and illicit drug use were featured strongly. The majority of patients (56.4%) underwent treatment under local anaesthesia. The total length of hospital stay was 271 days (mean 2.7, SD 1.6). Augmentin was the most prescribed antibiotic. Complications were reported in 8.8% of the patients, primarily due to airway compromise. Dental infections leading to hospitalisations continue to be a burden on the healthcare system. A notable finding was that the presentations were primarily on weekends, outside regular working hours, and public holidays, and the majority required dental interventions under local anaesthesia. The provision of on-call emergency dental services may reduce potentially preventable hospitalisations and the length of hospital stay.


Introduction
Dental infection, often referred to as odontogenic infection, is an infection of the alveolus, jaws, or face originating from the bacterial invasion of endodontic or periodontal tissues [1].The etiological factors include dental caries, periodontal infections, pericoronitis, failed endodontic treatments, dental trauma, severe dental attrition, and infected dental cysts.[2].The preventable and treatable nature of these underlying causes emphasises the importance of timely dental interventions [3].Without appropriate dental treatment, these conditions may lead to periapical and periodontal abscesses [4].Advancements in dental science have facilitated the successful treatment of localised dental infections within outpatient settings in dental clinics [5].However, if left untreated, dental infections can result in severe and potentially life-threatening infections, necessitating hospitalisation [6].In a hospital setting, the management of dental infections often involves surgical intervention under general anaesthesia.This involves removing the infection source, performing surgical incisions with intraoral and/or extraoral drainage, and the administration of intravenous antibiotics and supportive care [7,8].
Dent.J. 2024, 12, 173 2 of 14 Dental infections resulting in hospitalisation pose a substantial risk to oral healthrelated morbidity and mortality and are a significant burden on public health in the form of potentially preventable hospitalisations [9].Complications arising from dental infections encompass a wide spectrum, ranging from maxillary sinusitis and osteomyelitis to more severe conditions like Ludwig's angina leading to airway compromise, including systemic complications such as septicaemia and septic shock [10].Dental infections have been reported to be the most common cause of oral health-related preventable hospitalisations [11].Studies have highlighted the considerable financial impact, with reported average hospital costs ranging from AUD 12,228 (Australia) to USD 47,835 (United States) per patient [12,13].
A study from the United States reported 61,439 hospitalisations attributed to dental infections with 2.96 days mean length of hospital stay and 66 deaths [14].The cost of dental infection to humans in the form of serious morbidities and mortalities and potentially preventable hospitalisation is evident across the globe [8,9,11,[15][16][17].
Recognising that dental caries and periodontal diseases are preventable and treatable conditions emphasises the importance of early dental interventions.Proactive oral healthrelated management strategies can mitigate complications and reduce the incidence of preventable hospitalisations [18].A recent systematic review underscored the need for comprehensive data collection to guide evidence-based policies for the prevention and management of dental infections [11].In line with this imperative, the current clinical audit is a preliminary study to evaluate the characteristics of patients presenting with dental infections requiring hospitalisations to the emergency department of a major public hospital in Australia to identify patterns that may help improve preventative and management policies.

Patient Selection
This study retrospectively evaluated the records of patients admitted to the Nepean hospital, Kingswood, New South Wales 2747, Australia, for the management of dental infections for 12 months (July 2018-June 2019) in the pre-COVID period.Nepean hospital is a major public teaching hospital providing health services for the Nepean Blue Mountains Local Health District (NBMLHD).The study population included all the patients who presented to the emergency department of Nepean hospital with dental infections requiring hospitalisations during the study period.The study population predominantly represents patients from the NBMLHD.Key inclusion criteria included inpatients, without age restriction, presenting with dental infections or post-operative dental infections to the emergency department of Nepean hospital requiring hospitalisations during the study period.Key exclusion criteria included outpatients presenting with dental infections not requiring hospitalisations, inpatients and outpatients presenting with oral health-related emergencies other than dental infections, and non-oral health-related emergency patients presenting to the emergency department of Nepean hospital.
Patients were identified retrospectively from the Excel data provided by the emergency department of the Nepean hospital.Using the Excel option 'sort and filter', the data were screened for oral health-related presentations using various keywords.The keywords used for screening patients with dental infections requiring hospitalisations included teeth, tooth, dental, mouth, jaw, facial, neck, maxilla, and mandible combined with pain, odontalgia, infection, abscess and swelling, and hospital admission.Patient's specific data were accessed on the electronic medical record software 'Cerner Millenium Powerchart 2011' using the patient's specific medical record number (MRN).According to the International Classification of Disease, revision 11 (ICD-11), code DA09.6, dental infections leading to dental abscesses were identified from patient records which required hospitalisations.

Date Collection
Deidentified data related to outcome measurement was transferred to Microsoft Excel software (© 2024 Microsoft Corporation, Redmond, WA, USA) for further analysis.Data were collected for each individual patient for the following variables: date and time of presentation, age, gender, aboriginal and torres strait islander status, smoking, comorbidities, body mass index, clinical features, vital signs, facial space involvement, aetiology, jaw and teeth involvement, investigation, treatment, previous treatment, hospital stay, culture and sensitivity/microbiology, and outcome.
Demographic information was recorded upon presentation.Body mass index and clinical data at presentation included respiratory rate, oxygen saturation, pulse rate, blood pressure, mean arterial pressure, temperature, and random blood sugar.Medical, dental, and social histories and clinical examinations, including previous treatments, aetiology, pain, facial swelling, trismus, dysphagia, and facial space involvement, were recorded from the clinical notes.Orthopantomogram (OPG) was taken to investigate the aetiology and odontogenic origin of dental infection.Identification of cellulitis, frank abscess collections, and facial space involvement was confirmed by the radiologist's report on contrast-enhanced computed tomography (CT) scans in selected cases.Blood tests, including white blood cell count, C-reactive protein, OPG, and contrast-enhanced CT, were recorded from the investigations.
Surgical treatments, type of antibiotics, length of hospital and intensive care unit stay, and complications were recorded from clinical and discharge notes.Procedures under general anaesthesia were performed at Nepean hospital theatre by consultants and registrars of the oral and maxillofacial, Plastics, and Ear Nose and Throat (ENT) departments.The Plastics and ENT clinicians performed incision and drainage only and referred patients to private dentists or the Nepean Centre for Oral Health (public dental clinic) for dental management.Patients treated under local anaesthesia had antibiotics commenced at Nepean hospital and were then transferred to Nepean Centre for Oral Health for surgical procedures.Patients were transferred back to the respective wards following procedures by general dentists or oral surgery registrars and discharged from the hospital.Some measurements were not recorded, and the total number reported in this study is presented as "n" in the data table.

Data Analysis
The data were rearranged in Microsoft Excel (© 2024 Microsoft) for each measurement, and subsequent analysis was performed utilising various functions.Following the analysis, the data were transferred into a table format in Microsoft Word.Additionally, graphs and figures were generated using Microsoft Excel.

Time of Presentation
Most of the patients, 70 in total (68%), requiring hospitalisations presented on weekends, out of regular working hours, and public holidays (Figure 1).

Time of Presentation
Most of the patients, 70 in total (68%), requiring hospitalisations presented on weekends, out of regular working hours, and public holidays (Figure 1).

Demographics
There were no gender differences.The mean age of the study group was 40.1 years, while the highest presentations were reported in the thirties in both genders (Figure 3).

Demographics
There were no gender differences.The mean age of the study group was 40.1 years, while the highest presentations were reported in the thirties in both genders (Figure 3).

White Blood Cell Counts and C-Reactive Protein
Elevated values of white blood cell count was reported in 51.6% of cases (more than 11 × 10 9 /L) and C-reactive protein in 78% of cases (more than 10 mg/L) (Table 5).

Management
Surgical management was performed in 78 (76.5%) cases, including 63 (61.8%) extractions mainly under local anaesthesia and 44 (56.4%) in the dental clinic, while incision and drainage were mainly intraoral and required in 38 (37.2%) patients.Augmentin was administered as the main antibiotic for both intravenous in 71 (69.6%) patients in the hospital and discharge prescriptions were given to 77 (79.4%) patients (Table 6).

Discussion
Dental infections requiring hospitalisation not only present with significant morbidity and occasional mortality but also carry significant financial implications for both patients and healthcare systems.Our study sheds light on various aspects of these infections, including their temporal patterns, patient demographics, clinical characteristics, diagnostic approaches, management strategies, and clinical outcomes.
Temporal patterns of presentation reveal a concerning trend, with a majority of patients with dental infections (68%) presenting to public hospitals during weekends, out of regular working hours, and on public holidays.Similar patterns have been observed elsewhere, with likely causes attributed to factors such as the limited availability of dentists during these hours, patient education, anxiety, and cost concerns [20].This distribution can lead to increased strain on emergency healthcare services, potentially leading to longer wait times and preventable hospitalisations.Australia's national health insurance scheme, Medicare, excludes the adult population from dental care, leaving a gap in access to essential services [21].Consequently, adult patients with dental infections seek dental consultations from general practitioners or present to public hospitals for treatment.In this study, a large proportion of patients (52.9%) received empirical antibiotic prescriptions, mainly from general medical practitioners (74%), a finding that is consistent with previous studies (33-75%) [22,23].The prevalent prescription of antibiotics without active dental treatment by general practitioners is alarming [24].The inappropriate use of empirical antibiotic prescription without active dental interventions can lead to antimicrobial resistance, increased morbidity and mortality, potential adverse reactions, drug interactions, and increased healthcare expenditure [25,26].
This study observed an equal distribution of gender presentations, which contrasts with the findings from previous Australian studies reporting predominantly male populations with dental infections requiring hospitalisations.However, the highest presentations of dental infections occurring in the fourth decade of life, a demographic often actively involved in the workforce, aligns with both the Australian and global data [7,[27][28][29][30][31][32].The prevalence of comorbid conditions such as smoking, illicit drug use, and mental health issues is consistent with findings from other studies [11].Individuals with these conditions are at elevated risk of dental caries and periodontal disease and are less likely to seek preventative dental care [33].
The clinical presentations of dental infections characterised by severe pain and immediate facial swelling seem to be the main trigger for patients seeking emergency services, although trismus and dysphagia were reported in 40% and 27% of patients, respectively, which was mainly associated with those originating in mandibular teeth.Abnormal values of vital signs were observed in a relatively smaller proportion of patients presenting with dental infections (Table 1), indicating reduced systemic involvement and disease severity.The number of patients presenting with abnormal white blood cell counts (52.7%) and C-reactive protein (78.1%) reported in this study were comparable with other reports [34].
The majority of dental infections were of pulpal origin followed by periodontitis and pericoronitis, which is consistent with findings from other studies [11].Notably, while all teeth were involved; molar teeth (40.9%), including third molar teeth (9.8%), were predominantly presented.The anatomical position of lower molar teeth leading to trismus, dysphagia, and airway complications observed aligns with previous studies [1,35].The spread of the dental infection frequently involves multiple spaces, notably buccal space, canine space, and submandibular space, resulting in facial swelling and triggering emergency hospital presentation [1].In this study, contrast computed tomography was employed in 75 (73.5%)patients, revealing a frank collection of abscesses in 19 (25.3%) patients, who mostly required procedures under general anaesthesia in a hospital setup.A significant proportion of inpatients (56.4%) were referred to the nearby teaching dental hospital, 'Nepean Centre for Oral Health', for procedures under local anaesthesia, which provides dental services during regular working hours on weekdays to eligible patients.Although the antibiotic of choice was Augmentin, a change to definitive antibiotics was required in five patients due to resistant bacterial strains.
The mean length of hospital stay (M = 2.7, SD = 1.6, days) and total intensive care unit days (15 days) were both less than those reported in our previous study [11].Likewise, the absence of mortality and relatively fewer complications, primarily related to airway compromise resulting from dental infections, represents a favourable outcome compared to previous reports [11].Despite favourable clinical outcomes observed in our study, the financial impact of odontogenic infections remains a significant concern.
The limitations of the study include a small sample size, a single-centre study, and the sample representing only the population of the Nepean blue mountains local health district.There is some heterogenicity in data reporting as some data are missing or not reported for some patients in patients' electronic records.Due to these limitations, the current study may not represent the true picture of dental infections requiring hospitalisations in Australia.Nonetheless, to the best of our knowledge, this is the first study in New South Wales, the most populated state of Australia, investigating the presentations of dental infections in the human population of all age groups requiring hospitalisations.

Conclusions
In conclusion, this study provides important information about the characteristics, management, and trends of dental infections leading to potentially preventable hospitalisations, which continue to be a significant burden on the public healthcare system.A notable finding was the highest presentations of dental infections requiring hospitalisations to the emergency department of Nepean hospital on weekends, outside regular working hours, and public holidays, predominantly requiring dental interventions under local anaesthesia.The provision of emergency or on-call dental services on weekends, outside regular working hours, and on public holidays may help reduce the number of potentially preventable hospitalisations and the length of hospital stay.Although this study provides some insight into dental infections requiring hospitalisations in the limited Australian literature, more nationwide and multicentre studies with a larger population reporting on all variables and statistical co-relations between various characteristics and length of hospital stay are required to help guide preventative policies.

Figure 1 .Figure 1 .
Figure 1.Percentages of dental infections based on the time of presentations.

Figure 3 .
Figure 3. Patient distribution based on gender and age.

Figure 3 .
Figure 3. Patient distribution based on gender and age.

Table 1 .
Clinical features and vital signs associated with dental infections.

Table 1 .
Clinical features and vital signs associated with dental infections.

Table 2 .
Treatments prior to presentations.
* Some patients in this group received treatments from medical practitioners (antibiotics) as well as dental practitioners (extractions).** Some antibiotics' names were not reported in patients' clinical records.

Table 2 .
Treatments prior to presentations.
* Some patients in this group received treatments from medical practitioners (antibiotics) as well as dental practitioners (extractions).** Some antibiotics' names were not reported in patients' clinical records.

Table 3 .
Demographic information and associated comorbidities.

Table 3 .
Demographic information and associated comorbidities.

Table 6 .
In-patient management, length of hospital stay, and outcome.

Table 7 .
Microbiological culture results of dental infections.