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When A Toothache Turns Deadly by Dr. Dominique Chagniot

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Categories: Oral Pathology, Pharmacology, and Cariology;
When A Toothache Turns Deadly 

Necrotizing fasciitis in the head and neck

by Dr. Dominique Chagniot

We’ve all heard about it in the news: “Flesh-Eating Bacterial Infection on the Rise,” or “Patient in Hospital Loses Limb to Flesh-Eating Disease.” Those headlines certainly grab attention and can come across as clickbait, and it might be natural to lose interest and think these articles hold no relevance to the field of dentistry. Well, think again!

Necrotizing fasciitis (from the Greek word nekros, meaning “corpse” or “dead,” and fasciitis, referring to inflammation of the fascia) is a rapidly progressive infection involving the skin, subcutaneous tissue and fascia; once identified, it’s considered a surgical emergency. Known colloquially as “the flesh-eating disease,” it is rightfully deserving of such an ominous name, with a mortality rate that ranges from 11%–22%. While news articles for the public usually mention a causative bacteria, there are actually four classifications of necrotizing fasciitis, based on the causative microorganism (Table 1).
When A Toothache Turns Deadly
Table 1: Necrotizing fasciitis classifications.

Most patients will have a polymicrobial, bacterial necrotizing fasciitis, and risk factors include uncontrolled diabetes, alcoholism and a compromised immune system. The most commonly documented site for this infection is in the limbs, where patients often present with pain out of proportion, swelling, erythema, tenderness and heat. Over time, the skin color changes—from red to purple to blue, and eventually to black once all blood supply to the skin has been compromised.


Early recognition is key
While the clinical appearance can be alarming (Fig. 1), what’s worse is that the dead tissue planes spread even further underneath the skin surface, so the full extent is not appreciated externally. Early recognition is key, because immediate intervention with surgery, intravenous antibiotics (often a combination of piperacillintazobactam, clindamycin and ciprofloxacin), and aggressive fluid and electrolyte repletion means a decreased mortality rate for patients. Surgical intervention, which involves repeated surgical debridements, often means the loss of fingers, toes or a greater portion of the involved limb.
When A Toothache Turns Deadly
Fig. 1: Polymicrobial necrotizing fasciitis of the left foot (in a case unrelated to what follows).

Necrotizing fasciitis of the head and neck can be more difficult to diagnose, because it is more rare (representing only about 2.6% of all necrotizing fasciitis cases) and often does not present with these classic signs. Ondontogenic infections are the No. 1 cause of necrotizing fasciitis of the head and neck. This is most common at the second-and third-molar sites because the roots of these teeth extend below the level of the mylohyoid and thus offer a direct path for an abscess to reach the sublingual and submandibular spaces. For most, the infection will stop here; the patient will be sent to the emergency department and treated with IV antibiotics, surgical drainage or a combination of both.

However, as we all learned in our periodontology curriculum, disease progression is twofold: pathogenic bacteria, in a susceptible host. Patients with uncontrolled diabetes, alcoholism, poor socioeconomic status (dehydration, malnutrition) and general immune compromise are at risk of an otherwise common odontogenic infection traveling through cervical fascial planes over the platysma muscle and extending to the anterior chest wall. At this point, the patient’s airway may be threatened, and it’s only a matter of time before systemic sepsis, toxic shock and multiorgan failure set in.

Case study
Our busy hospital has averaged about one case of head and neck necrotizing fasciitis per month. One such patient was a 37-year-old with diabetes (HbA1c of 11.3% at admission), chronic alcohol abuse and moderate obesity. He had pain with obvious caries to Teeth #1 and #32, and had previously seen a dentist about a year before but never followed up to get the teeth extracted.

When the patient was admitted, his right facial swelling was profound and his CT scans showed an advanced soft-tissue infection with subcutaneous air and abscess tracking from his neck, up his face and around his right orbit (Figs. 2 and 3). Luckily, he was maintaining his airway, but he did show obvious erythema traveling down his chest wall, signaling a rapidly spreading infection.
When A Toothache Turns Deadly
Fig. 2: Initial presentation demonstrating obvious right facial swelling to the middle and lower third, with overlying erythema, crepitus and pain on palpation. Mild blurry vision in the right eye. (Chest wall erythema, not visible in photo, also was present.)
When A Toothache Turns Deadly
Fig. 3a:  Axial cuts of CT scan. At the level of Tooth #1, gas and abscess in the right masticator space.
When A Toothache Turns Deadly
Fig. 3b: Axial cuts of CT scan. At the level of the orbit, gas tracking superiorly.


Within about six hours of his arrival to the hospital, we took the patient to the operating room for incision and drainage of his right submandibular, submental, pterygomandibular, canine, submasseteric, infratemporal and deep temporal spaces. Teeth #1, #31 and #32 were extracted and we debrided necrotic tissue of his right face and neck, including necrotic masseter and temporalis muscle.

He was brought back to the operating room for a total of eight times over an 11-day span, which is the typical standard of care for patients with this disease process. Frequent, repeated surgical debridement is indicated because even within a 24-hour period, additional tissue that didn’t appear compromised in the operating room at first will begin to show signs of tissue death and must be eliminated to halt disease progression. A large incision around the face or neck is necessary to allow direct visualization of tissue beds, but can often leave patients with soft-tissue defects, paralysis, numbness and unsightly scars.

This patient required a modified Blair incision (parotidectomy incision) with temporal extension for complete access, including a right mandibulotomy to access necrotic tissue in the sublingual space and the floor of the mouth (Fig. 4). This was coupled with correction of his electrolytes and hyperglycemia, and antimicrobials as recommended by our colleagues in the infectious disease department, which included antibiotics and a short course of amphotericin B in an abundance of caution to cover for the possibility of an aggressive fungal coinfection (which he did not end up having). The patient remained intubated in the intensive care unit for 10 days, and had a total hospital stay of 16 days. Although his experience was devastating and traumatic, he was very lucky to have survived this deadly disease.
When A Toothache Turns Deadly
Fig. 4: Wound bed after the sixth surgical debridement. Mandibular hardware is shown after mandibulotomy for surgical access.


Postsurgical follow-up
We had the opportunity to see the patient seven months after his last surgical debridement. Fortunately, his diabetes is now well-controlled and he is without pain. He does display obvious postsurgical changes with associated facial deformity (Fig. 5), and his deficits include right-sided facial nerve weakness and sensory disturbances, which have had some improvement, albeit sluggish. His mouth opening is 20 mm and is limited by a firm scar band to the right pterygomandibular raphe. His reconstruction bar can be appreciated in Fig. 6, maintaining the mandibulotomy segments while bone continues to heal across the gap.
When A Toothache Turns Deadly
When A Toothache Turns Deadly
When A Toothache Turns Deadly
Figs. 5a-c: Postoperative clinical exam reveals tissue deficiency in the right face with facial nerve weakness.
When A Toothache Turns Deadly
Fig. 6: Postoperative panoramic radiograph shows reconstruction bar to right mandible.


Interestingly, the patient’s mandible is deviated significantly to the left when resting, but pulls back to midline upon opening, presumably from unopposed muscle pull from left masseter, temporalis, and medial and lateral pterygoids inserting to the left mandible (Fig. 7). We discussed additional surgeries the patient could benefit from for function, including scar band release. (Orthognathic surgery would not help the patient’s occlusion.) Surgeries available for cosmesis include fat grafting to the right face, a pectoralis rotational muscle flap for tissue bulk and facial reanimation surgery with a plastic surgeon. For now, the patient’s main concern is his limited mouth opening, and he will undergo surgery for scar contracture release with our team in the near future.
When A Toothache Turns Deadly
Fig. 7: Deviation of mandible to left from unopposed muscle pull.

Necrotizing fasciitis of the head and neck is rare and limited to those with uncontrolled comorbidities. Early diagnosis with aggressive fluid resuscitation, repeated surgical debridement and intravenous antibiotics is key in decreasing the rate of mortality. Now, will this information change how you practice dentistry? Not necessarily. But remember that given the odontogenic etiology of head and neck necrotizing fasciitis, you are the most likely person to first encounter these patients, and therefore you could save the patient’s life by understanding just how ominous an oral infection can become in patients with comorbidities. With necrotizing fasciitis, time is always of the essence, and your heightened awareness can help patients seek medical attention right away.
Author Bio
Dr. Dominique Chagniot Dr. Dominique Chagniot is a chief resident in oral and maxillofacial surgery at UCSF Fresno. Chagniot’s training takes place at Community Regional Medical Center in Fresno, the second-largest hospital in California by bed size. She is often the lead resident surgeon in cases ranging from benign pathology, temporomandibular joint disorders and obstructive sleep apnea to congenital deformities, trauma, and head and neck infections. Chagniot will complete residency in June and hopes to practice in Northern California.
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When A Toothache Turns Deadly
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by Dr. Dominique Chagniot
December 2023
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