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Cerebralabscessofodontogenicorigin CaseReport ARTICLEINPRESS


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doi:10.1016/j.jcms.2006.10.004, available online athttp://www.sciencedirect.com

Case Report

Cerebral abscess of odontogenic origin


Anastassios I. MYLONAS1, Fotios H. TZERBOS1, Maria MIHALAKI1, Dimitrios ROLOGIS2, Iossif BOUTSIKAKIS3

1Department of Oral and Maxillofacial Surgery (Head: Dr. F. H. Tzerbos, DMD, PhD);2Department of Neurosurgery (Head: Assoc. Prof. Dr. Dimitrios Rologis, MD);3Department of Internal Medicine and Infections Control Unit (Head: Dr. Iossif Boutsikakis, MD), ‘Metropolitan’ Hospital, N. Faliro, Piraeus, Greece

SUMMARY. Introduction: Cerebral abscess is a rare but serious and life-threatening infection. Dental infections have occasionally been reported as the source of bacteria for such an abcess. Patient and methods: A 54-year-old man was admitted with a right hemiparesis and epileptic fits. After clinical, laboratory and imaging examination, the diagnosis of a cerebral abscess of the left parietal lobe was made. The intraoral clinical examination as well as a panoramic radiograph confirmed the presence of generalized periodontal disease, multiple dental caries, and periapical pathology. The treatment included: (i) Immediate administration of high-dose intravenous antibiotics and (ii) surgical procedures consisting of craniotomy and resection of the abscess cavity first, and secondly removal of the periodontal, decayed and periapically involved teeth of the patient, in an effort to eradicate all the possible septic foci, presuming the cerebral abscess to be of odontogenic infection. Results: The patient made an uneventful recovery, and 29 months postoperatively he had completely recovered from the hemiparesis. r 2006 European Association for Cranio-Maxillofacial Surgery

Keywords: cerebral abscess; odontogenic origin


Cerebral abscess is a rare but serious and life- threatening infection, and constitutes a localized area of suppuration within the brain. It usually occurs after cranial trauma or surgery, or secondary to a

‘septic’ focus elsewhere, spread either by direct extension or haematologically (Corson et al., 2001).

Initially, it was resistant to antimicrobial chemother- apy, having been one of the rare bacterial infections where morbidity and mortality rates remained almost unaffected by the improvements in antimicrobial therapy until the late 1960s (Hollin et al., 1967).

Recently, the advances in neuro-scanning techniques such as CT and MRI, as well as the introduction of more effective antibiotics, have reduced the mortality rate to 0–24% (Matheison and Johnson, 1997).

Dental infections have occasionally been reported as the source of bacteria which can give rise to such a cerebral abscess (Schuman and Turner, 1994). The most common causal organisms identified in both oral and cranial sites, have been the microaerophilic streptococci (viridans streptococci) and anaerobic bacteria (Bacteroides sp., Actinobacillus actinomyce- tem comitans;Gortvai et al., 1987;Marks et al., 1988;

Renton et al., 1996). Also considering that cerebral abscesses are frequently polymicrobial, some other additional microorganisms such as Staphylococcus aureus and facultative anaerobic Gram-negative bacteria (i.e. the Enterobacteriaceae) have been reported as the causal microflora depending on the underlying source of infection (Corson et al., 2001).

Reviewing the relevant literature, only seven refer- ences related cerebral abscesses and dental foci (Table 1). The purpose of this paper is to present an interesting case report with a cerebral abscess possibly of odontogenic origin.


A 54-year-old man was admitted to this hospital with a right hemiparesis and epileptic fits. After the clinical, laboratory and imaging examination a diagnosis of cerebral abscess of the left parietal lobe was made (Figs. 1 and 2). In the search for the source of this infection, after examining the whole body for possible ‘septic’ foci with the corresponding clinical, imaging and laboratory investigations, the head and neck area was found more suspicious, thus opinions were requested. ENT colleagues could find no cause for the infection. Intraoral clinical and radiological examination, including a panoramic radiograph and a Dentascan, confirmed the presence of generalized

1Based on a paper presented at the 5th European Congress of Oto-Rhino-Laryngology Head and Neck Surgery, 11–16 Septem- ber 2004, Rodos-Kos, Hellas.



periodontal disease, multiple dental caries and periapical pathology (Fig. 3). In particular, periapical lesions were found in the molar, bicuspid, canine and maxillary incisor regions bilaterally, along with severe periodontal disease in the anterior maxillary teeth. In the mandible, periapical pathology along with periodontal destruction involved the molar region bilaterally; the anterior teeth of the mandible were severely affected by rapidly progressive periodontitis, showing increased mobility. The patient declined periodontal and endodontic treatment where needed, and considering the general reluctance of both the patient and his family to follow a dental treatment

plan and a regular programme of oral hygiene, the staff of the Department of Oral and Maxillofacial Surgery advocated the removal of almost all the patient’s teeth. This effort to eradicate all possible

‘septic’ foci, together with construction of immediate upper and lower complete dentures, presumed the cerebral abscess originated as an odontogenic infection.

Treatment included (i) Immediate administration of high dose intravenous antibiotics, (ii) craniotomy and resection of the abscess cavity (Fig. 4), and (iii) removal of the periodontally diseased and decayed teeth, alveoloplasty, and construction of immediate upper and lower complete dentures.

The intravenous antibiotic regimen administered for 23 consecutive days, included: (a) Ceftriaxone [pd.sol.inf ROCEPHINs/Roche 2000 mg/vial (iv.inf)]  2 per day, (b) Metronidazole [inj.sol.inf FLAGYLs/Aventis 500 mg/100 ml-vial]  4 per day, and (c) Vancomycin [ly.pd.iv.infVONCONs/ Lilly 500 mg/vial  2]  3 per day. The patient recovered uneventfully. The intravenous antibiotic regimen, was continued by administering Ofloxacin [inj.sol.inf TABRINs/Hoechst Marion Roussel 200 mg/100 ml-vial  2]  3, and Teicoplanin [ly.pd.inj TARGOCIDs/Vianex 400 mg/vial]  2, for a further 5 weeks (34 days) after the neurosurgical procedure. It should be noticed that Ceftriaxone [ROCEPHINs] and Teicoplanin [TARGOCIDs] presented the following side effects/adverse reactions:

fever, diffuse pruritic maculopapular rash, and cholestatic jaundice, leading to their discontinuation.

Muscular power on the right side slowly improved over the following weeks, and on the day of discharge the patient presented with a slight improvement of mobility and no more epileptic fits. Twenty-nine months postoperatively, the patient had almost recovered from the hemiparesis, although he com- plains of slightly sub-optimal speech.

Fig. 1 – 54 y.o. male, CT scan (axial view): cerebral abscess of the left parietal lobe.

Table 1 – Previously reported cerebral abscesses of odontogenic origin

Authors Title of publication Journal

Hollin SA and Gross SW (1964) Subdural empyema of odontogenic origin J Mt Sinai Hosp NY 1964 November – December; 31: 540–544

Hollin SA et al. (1967) Intracranial abscesses of odontogenic origin Oral Surg Oral Med Oral Pathol 1967 March 23 (3): 277–293

Baddour HM et al. (1979) Frontal lobe abscess of dental origin. Report of a case Oral Surg Oral Med Oral Pathol 1979 April;

47(4): 303–306

Schotland C et al. (1979) [Brain abscess after odontogenic infection] German SSO Schweiz Monatsschr Zahnheilkd 1979 April; 89(4): 325–329

Aldous JA et al. (1987) Brain abscess of odontogenic origin: report of case J Am Dent Assoc 1987 December; 115 (6):

861–863 Carver DD and Peterson SS


Brain abscess of odontogenic origin: report of a case J Houston Dist Dent Soc 1988 May:24 Corson MA et al. (2001) Are dental infections a cause of brain abscess? Case

report and review of the literature

Oral Dis 2001 January; 7(1): 61–65

pd.sol.inf. – powder for solution for infusion. inj.sol.inf. – injection of solution in infusion. ly.pd.iv.inf. – lyophilized powder for intravenous infusion.



Cerebral abscesses, although rarely, can result from dental or maxillofacial infections constituting direct threats to the patient’s life (Corson et al., 2001). The most common sites of cerebral abscesses are the temporal lobes (42%) and the cerebellum (30%;

Yang, 1981). They may occur following cranial trauma, or cranio-maxillofacial surgery, or secondary to a ‘septic’ focus elsewhere and spread either by direct extension or haematological route (Corson et al., 2001). The oral cavity is considered as being home to a rich and abundant microflora. To be more specific, dental plaque contains one of the most concentrated accumulations of microorganisms in the human body. In particular, approximately 350 different bacterial strains can be isolated in marginal

periodontitis, and 150 in endodontic infections (Corson et al., 2001). The oral/dental procedures purported to have caused a cerebral abscess include dentoalveolar surgery, operative dentistry, perio- dontal therapy, dental local anaesthetic injection and dental prophylaxis (Schuman and Turner, 1994).

Cerebral abscesses are frequently polymicrobial.

The most common aetiological organisms reported in clinical series are microaerophilic streptococci (Strepto- cocci viridans), anaerobic bacteria (Bacteroides sp., Actinobacillus actinomycetem comitans), Staphylo- coccus aureus, and facultative anaerobic Gram neg.

bacteria (Enterobacteriaceae; Gortvai et al., 1987;

Marks et al., 1988; Renton et al., 1996; Corson et al., 2001). Oral pathogens from an odontogenic infec- tion could enter the brain via either an haematological route (facial, angular, ophthalmic artery, spread

Fig. 2 – Same, MRI scan (sagittal view): cerebral abscess of the left parietal lobe.

Fig. 3 – Same, panoramic radiograph: generalized periodontal and apical disease, and multiple dental caries.


through the cavernous sinus), or a lymphatic route, or by direct extension through the fascial planes. In view of their relative rarity, the diagnosis of such a life- threatening condition as a cerebral abscess is a significant challenge for every clinician, since it often occurs ‘spontaneously’, and the source of infection should then be identified. Although a previous stroke (Chen et al., 1995) or an underlying neoplasm (Shimomura et al., 1994) may serve as a nidus for abscess formation, in most cases there is no apparent predisposing cerebral pathology. On the other hand odontogenic sources of infections (especially period- ontal) are commonly found in adults (Corson et al., 2001).

The search for the aetiological organism in any infection must always be based on sound micro- biological methodology. The causal organism should therefore be identified in both the oral and cranial sites. In particular, modern sampling techniques such as molecular finger-printing based upon nucleotide sequencing, should be used to identify the isolates precisely, in order to positively confirm the role of an odontogenic infection in the pathogenesis of a cerebral abscess (Corson et al., 2001).

Regarding treatment for patients with cerebral abscesses of odontogenic origin, it should be stressed that the decision to treat dental disease radically or more conservatively depends on the overall medical status of the patient, the severity of dental disease, and the patient’s understanding of dental treatment, and good oral hygiene methods. In particular, when the patient’s medical status makes it practical and beneficial, dental treatment should be more conser- vative to preserve the dentition. Then the full range of therapeutic procedures should be offered i.e. perio- dontal surgery, root canal therapy and endodontic surgery and restorative dentistry. The patient’s will-

ingness to follow a regular oral hygiene programme along with follow-up, as well as the original severity of his dental disease, are factors in deciding the type of dental management for cases with a cerebral abscess of odontogenic origin. In the authors’

opinion, it seems unwise if not very risky to avoid multiple extractions in cases when the patient presents with a cerebral abscess and severe dental disease, and is unlikely to cooperate with meticulous dental treatment and oral hygiene, thus risking recurrence. Despite seeming radical, such interven- tion is considered to be the treatment of choice in cases such as this.


A cerebral abscess linked to a dental source is a rare occurrence since in most individuals the blood-brain barrier along with the immune response will exclude bacteria. In the literature so far, the role of odontogenic infections in the pathogenesis of a cerebral abscess has been implicated whenever periodontal disease preexisted and in combination with the absence of any predisposing intracranial pathology, as in the present case. However, the management of these life-threatening infections depends on the location and the dimensions of the lesion, as well as on the level of medical alertness.


Aldous JA, Powell GL, Stensaas SS: Brain abscess of odontogenic origin: report of case. J Am Dent Assoc 115: 861–863, 1987 Baddour HM, Durst NL, Tilson HB: Frontal lobe abscess of dental

origin. Report of a case. Oral Surg Oral Med Oral Pathol 47:

303–306, 1979

Fig. 4 – Same, resection of the abscess following craniotomy.


Carver DD, Peterson SS: Brain abscess of odontogenic origin:

report of a case. J Houston Dist Dent Soc 1988 May: 24 Chen S-T, Tang L-M, Ro L-S: Brain abscess as a complication of

stroke. Stroke 26: 696–698, 1995

Corson MA, Postlethwaite KP, Seymour RA: Are dental infections a cause of brain abscess? Case report and review of the literature. Oral Dis 7: 61–65, 2001

Gortvai P, De Louvois J, Hurley R: The bacteriology and chemotherapy of acute pyogenic brain abscess. Br J Neurosurg 1: 189–203, 1987

Hollin SA, Gross SW: Subdural empyema of odontogenic origin.

J Mt Sinai Hosp NY 31: 540–544, 1964

Hollin SA, Hayashi H, Gross SW: Intracranial abscesses of odontogenic origin. Oral Surg Oral Med Oral Pathol 23:

277–293, 1967

Marks PV, Patel KS, Mee EW: Multiple brain abscess secondary to dental caries and severe periodontal disease. Br J Oral Surg 117:

453–455, 1988

Matheison GE, Johnson JP: Brain abscess. Clin Infect Dis 25:

763–781, 1997

Renton TF, Danks J, Rosenfield JV: Cerebral abscess complicating dental treatment. Case report and review of the literature. Aust Dent J 41: 12–15, 1996

Schuman NJ, Turner JE: Brain abscess and dentistry: a review of the literature. Quintessence Int 25: 411–413, 1994

Schotland C, Stula D, Levy A, Spiessl B: Brain abscess after odontogenic infection. SSO Schweiz Monatsschr Zahnheilkd 89: 325–329, 1979 [in German]

Shimomura T, Hori S, Kasai N, Tsuruta K, Okada H:

Meningioma associated with intratumoral abscess formation:

case report. Neurol Med Chir (Tokyo) 34: 440–443, 1994 Yang SY: Brain abscess: a review of 400 cases. J Neurosurg 55:

794–799, 1981

Anastassios I. MYLONAS, D.M.D., Ph.D.

Oral and Maxillofacial Surgeon 1-3 Arahossias Street, Ilissia 15771 Zografou, Athens, Greece Tel./Fax: +30 210 771 1603 E-mail:draimylo@otenet.gr Paper received 22 November 2005 Accepted 16 October 2006



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