From Dental Decay to Systemic Failure: The Overlooked Consequences of Poor Oral Health

Abstract

Patient: Male, 65-year-old

Final Diagnosis: Fatal odontogenic infection complicated by retropharyngeal and epidural abscesses, leading to MSSA septicemia and death

Symptoms: Malaise • neck stiffness

Clinical Procedure: —

Specialty: Otolaryngology

Objective: Unusual clinical course

Background

Oral diseases, though largely preventable, continue to affect billions of people worldwide and impose a significant economic burden. Global estimates from 2015 are over $350 billion in direct costs and nearly $190 billion in indirect costs to dental diseases, which disproportionately impact low-income and marginalized populations. Despite effective preventive measures such as fluoride application and minimally invasive dentistry, untreated dental caries remains the most common oral pathology. Left unmanaged, these conditions can lead to severe complications, including infective endocarditis and deep neck infections (DNIs), with systemic implications ranging from sepsis to cardiovascular events.

Case Report

A 65-year-old man was admitted with malaise and neck stiffness. Laboratory analyses revealed leukocytosis, elevated procalcitonin, and D-dimer levels, although pulmonary embolism was excluded. The differential diagnosis included meningitis, severe osteoarthritis, and acute cervical spine inflammation. Empiric treatment with vancomycin and levofloxacin was initiated, while further evaluation with CT and contrast-enhanced MRI revealed extensive inflammation: a retropharyngeal abscess extending into the epidural space and compressing the spinal cord at the craniospinal junction. Initially, urosepsis was suspected due to catheterization challenges; however, urinary cultures were negative. A preoperative airway assessment led to a dental consultation, revealing extensive caries and poor oral hygiene. Multiple extractions confirmed an odontogenic source, but the patient ultimately developed sepsis from the abscess, leading to heart failure and death.

Conclusions

This case underscores the critical impact of neglected oral health and the necessity for timely dental intervention. It reinforces that early recognition and integrated oral-systemic healthcare are essential in preventing the progression of odontogenic infections into life-threatening complications.

Introduction

Oral diseases, although largely preventable, continue to affect billions of individuals worldwide and impose a substantial economic burden [1]. In 2015, global estimates indicated that dental diseases accounted for approximately $356.80 billion in direct costs and $187.61 billion in indirect costs [2]. These conditions disproportionately impact low-income and marginalized populations, reflecting their strong association with socioeconomic status and broader social and commercial determinants of health [3].

When left untreated, oral diseases can lead to complications such as infection, sepsis, tooth loss, and impaired mastication, and can negatively affect facial aesthetics and overall quality of life [3]. Furthermore, they have been linked to systemic conditions, including cardiovascular disease [4].

Among all oral diseases, untreated dental caries remains the most widespread condition globally. Despite the availability of effective preventive strategies for both pediatric and geriatric populations, dental caries can still lead to serious complications, including infective endocarditis and deep neck infections (DNIs) [3].

Case Report

A 65-year-old male patient was admitted to the hospital presenting with malaise and neck stiffness. Initial laboratory investigations revealed leukocytosis, elevated procalcitonin, and elevated D-dimer levels, without evidence of pulmonary embolism. The differential diagnosis included meningitis, severe osteoarthritis, and acute cervical spine inflammation. Empiric antibiotic therapy was initiated with vancomycin and levofloxacin.

To further assess the cause, urgent imaging studies – including CT and contrast-enhanced MRI of the head and neck – were performed. Robust inflammation with massive edema and multiple communicating collections was observed, involving the retropharyngeal space and extending into the epidural space as an abscess, causing compression of the spinal cord at the craniospinal junction and suboccipital region (Figures 1–3).

Figure 1.

Sagittal T2 weighted contrast-enhanced magnetic resonance imaging (MRI) of the neck. Blue arrow: Retropharyngeal abscess at the level of vertebrae C2–C7, measuring 81×45×22 mm (CC×LR×AP). Green arrow: Epidural abscess in the anterior region of the spinal canal with a maximum thickness of 11 mm at the level of vertebra C2, causing pressure on the spinal cord.

Figure 2.

Sagittal DWI (A) and sagittal ADC (B) MRI of the neck. Blue arrow: retropharyngeal abscess. Green arrow: epidural abscess. Visible strong diffusion restriction characteristic of retropharyngeal and epidural abscesses.

Figure 3.

(A, B) Axial T2 and axial T2-weighted contrast-enhanced MRI of the neck. Blue arrow: retropharyngeal abscess. Visible strong peripheral contrast enhancement of the abscess and surrounding soft tissues, indicative of an extensive inflammatory process.

The challenge the doctors encountered was to find the primary inflammatory site that was the source of the infection. Urosepsis was initially suspected due to observed catheterization difficulties, attributed to anatomical changes, including multiple post-inflammatory lesions and significant narrowing of the external urethral orifice. Following recalibration and successful Foley catheter placement, the bladder drained clear urine, and urine cultures later showed no signs of bacterial infection.

Due to the high risk of craniospinal destabilization, neurosurgical intervention was deferred. Instead, the ENT surgical team performed drainage of the retropharyngeal abscess, which was expected to decompress the epidural abscess due to anatomical continuity between the spaces. The airway was secured by performing a tracheostomy.

Despite these interventions, the patient’s condition deteriorated and progressed to sepsis. Blood cultures revealed methicillin-sensitive Staphylococcus aureus (MSSA), and treatment was adjusted accordingly with meropenem and cloxacillin. However, the primary source of infection remained unclear until the preoperative airway evaluation. During the pre-tracheostomy assessment, the anesthesiology team raised suspicion of dental involvement.

This prompted a dental consultation, during which the dental surgeon noted extensive dental caries and poor oral hygiene. Multiple teeth were extracted. Based on the severity of the findings and the clinical course, an odontogenic source was identified as the most probable origin of the infection. The patient died due to heart failure caused by septicemia that developed from the retropharyngeal abscess.

Discussion

This case highlights the dangerous systemic consequences of untreated dental infections, which in rare instances lead to deep neck infections and even central nervous system involvement. The diagnostic process in this case was complicated by non-specific symptoms and an initial suspicion of urosepsis, delaying identification of the odontogenic source and contributing to a poor outcome. Preventive strategies in oral health aim to stop disease onset or halt progression and restore lost function. Strong scientific evidence supports the use of fluoride-containing agents (eg, fluoride varnishes and toothpastes) in reducing the incidence of dental caries across all age groups [5]. Furthermore, minimally invasive dentistry is a validated tertiary prevention strategy, particularly relevant for older adults who may have limited access to regular dental care [6].

Nonetheless, inequitable access to dental services, delays in treatment, and low oral health literacy continue to contribute to the progression of dental diseases, especially among socioeconomically disadvantaged populations [3]. Poor oral health and the absence of timely dental intervention are associated with a heightened risk of serious infections, including deep neck infections (DNIs) [7]. In our patient, long-standing dental neglect, revealed only after airway evaluation, was identified as the most likely origin of the infection.

Evidence indicates that many patients with odontogenic emergencies had previously sought medical care for infection-related symptoms [8]. However, only a minority had received adequate dental treatment prior to hospitalization for DNI [6]. This underscores the critical role of both daily oral hygiene and timely dental care in preventing the development of odontogenic infections and their complications. It highlights the need for timely dental evaluations in systemic infections of unclear etiology, particularly when initial symptoms are vague or misleading.

The most common DNIs include parapharyngeal and retropharyngeal abscesses [9]. Retropharyngeal abscesses are infections localized between the pharynx and the cervical vertebrae, which decrease in frequency following the initiation of antibiotic therapy [9–11]. These lesions are complications of pharyngitis or dental pathologies [9,12–15]. Common causative pathogens include Staphylococcus aureus, Streptococcus viridans, Klebsiella pneumoniae, Bacteroides, and Peptostreptococcus [16,17].

These abscesses may present with vague symptoms – odynophagia, fever, neck swelling, or general malaise – that can delay diagnosis and increase risk [18]. Management typically includes intravenous antibiotic therapy and, in select cases, surgical drainage [19]. The choice of surgical approach in the management of deep neck infections depends on several factors, including the size and anatomical location of the abscess, the patient’s clinical status, and the response to initial empiric antimicrobial therapy. Abscesses exceeding 2.5 cm in diameter or those that fail to improve after 48 hours of appropriate antibiotic treatment generally require surgical drainage [16,20]. External drainage is typically preferred for large, deep-seated, or complicated collections – particularly when adjacent vital structures are displaced medially, as confirmed by radiologic imaging. In selected cases, such as superficial or localized abscesses, the intraoral approach can be a viable alternative. This method is associated with shorter hospitalization, lower morbidity, reduced treatment costs, and a decreased risk of injury to neurovascular structures [21].

Empiric antimicrobial therapy should be initiated promptly to prevent disease progression and systemic complications. Initial antibiotic regimens should provide broad-spectrum coverage, including aerobic and anaerobic bacteria, with common agents being penicillins combined with beta-lactamase inhibitors (eg, ampicillin-sulbactam or amoxicillin-clavulanate), or carbapenems (eg, meropenem or imipenem). Antibiotic selection should subsequently be adjusted based on microbiological culture results and the patient’s clinical response, with intravenous administration continued until significant clinical improvement is achieved [17,22,23].

Failure to initiate timely treatment can result in severe complications, including mediastinitis, jugular vein thrombosis, sepsis, or airway obstruction, all of which carry high mortality rates [14,24,25]. Given the rapid progression and lack of pathognomonic symptoms, DNIs require heightened clinical vigilance and multidisciplinary collaboration for early identification and management. In the present case, a 65-year-old man with long-standing dental neglect developed a retropharyngeal abscess that extended to the epidural space, resulting in spinal cord compression and death. Despite early antimicrobial therapy and surgical drainage of the neck abscess, neurosurgical intervention was not pursued due to the patient’s poor condition, underscoring the clinical challenge when critical structures are involved and treatment options are limited.

Although pharyngeal abscess is a rare condition, there are several case reports in the literature regarding this lesion. In the cases described, there is no data on the cause of the pharyngeal abscess. Each case was treated with targeted antibiotic therapy depending on the bacterial strains cultured and surgical drainage of the abscess applied [24,26,27]. Redere reported a case of a pharyngeal abscess measuring 5.4×1.0×3.3 cm treated empirically with vancomycin and piperacillin-sulbactam. The treatment was so effective that a follow-up CT scan performed after the treatment to assess the evolution of the abscess and clinical status showed a decrease in the abscess and resolution of symptoms, and it did not require surgical drainage [28].

In contrast to these reports, our case exhibited a more aggressive progression, attributed to delayed diagnosis and missed dental etiology. While other cases benefited from early identification and effective antibiotic therapy alone or with drainage, the delayed recognition of dental involvement in our patient allowed the infection to progress unchecked, eventually leading to sepsis and death.

This case contributes to the literature by illustrating how failure to identify and treat dental sources of infection can result in catastrophic consequences, particularly when deep neck infections spread to the central nervous system. It also reinforces the value of dental consultations in unexplained deep neck or epidural infections and supports more integrated models of oral-systemic healthcare.

Conclusions

This case highlights the severe consequences of neglected oral health and the importance of timely dental care. Clinicians should consider odontogenic sources in deep neck infections, particularly when no other focus is identified. Improving access to preventive dental services remains essential to reducing such life-threatening complications.