Clinical Characteristics, Management, and Outcomes of Patients with Cervicofacial Necrotizing Fasciitis in Nigeria: A 5-year multicentre, retrospective, cohort study

Clinical Characteristics, Management, and Outcomes of Patients with Cervicofacial Necrotizing Fasciitis in Nigeria: A 5-year multicentre, retrospective, cohort study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical Characteristics, Management, and Outcomes of Patients with Cervicofacial Necrotizing Fasciitis in Nigeria: A 5-year multicentre, retrospective, cohort study Olusegun I. Olaopa, Taofeek A. Akinniyi, Gbenga E. Adebayo, Kasiena O. Yarhere, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8148361/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 16 You are reading this latest preprint version Abstract Background Cervicofacial necrotizing fasciitis (CNF) is a rare, rapidly progressive, and potentially fatal infection of the head and neck, usually secondary to odontogenic infections. Multicentre data from sub-Saharan Africa are limited. We aimed to describe the demographic, clinical, microbiological characteristics, management, and outcomes of patients with CNF in Nigeria. Methods We conducted a 5-year retrospective multicentre cohort study of patients with CNF of odontogenic origin admitted between January 2019 and December 2023 across eight tertiary hospitals in Nigeria. Data on demographics, clinical features, laboratory findings, microbial isolates, management, and outcomes were extracted using a standardized proforma. Associations between variables and outcomes were assessed with χ² tests for categorical and ANOVA or Kruskal–Wallis tests for continuous data. Kaplan–Meier survival analysis was performed. Results 138 patients were included (mean age 54·5 ± 17·1 years; range 2 months–104 years; 51·4% female). Most had low education (56·5%) and paid out-of-pocket (88·4%). The submandibular (58·4%) and neck (43·2%) regions were most affected, with mandibular molars as the main source. Diabetes mellitus (16·4%) and hypertension (11·9%) were common comorbidities. Gram-negative rods (24·1%) and Staphylococcus species (11·3%) were the most frequent isolates. Almost all patients (99·2%) underwent surgical debridement under local anaesthesia, with healing by secondary intention in 70·4%. Overall survival was 82·2%. Wound closure technique and comorbidities were significantly associated with outcomes (p < 0·05). Delayed presentation and prolonged time before oral and maxillofacial review were linked to poorer outcomes. Conclusion CNF in Nigeria primarily affects middle-aged adults of low socioeconomic status and arises from neglected dental infections. Prompt surgical intervention yielded relatively favourable outcomes despite resource constraints. Strengthening primary oral care, early dental infection management, and integration into national health insurance could reduce CNF morbidity and mortality. Figures Figure 1 Figure 2 Figure 3 Introduction Necrotizing fasciitis (NF) is a rapidly progressive and potentially fatal infection of the deep fascia and subcutaneous tissue which is characterized by widespread necrosis, systemic toxicity and high mortality. 1 , 2 Although NF is more commonly reported in the abdominal wall, perineum and extremities, cervicofacial necrotizing fasciitis (CNF) remains uncommon. 3 , 4 When it does occur in the head and neck region, odontogenic infections are the most frequent cause, particularly those arising from mandibular molars. 4 – 7 The disease can lead to severe functional impairment, facial disfigurement and high case fatality if not promptly diagnosed and managed. 8 Early recognition is often difficult because initial symptoms mimic common odontogenic infections. 9 , 10 In low and middle-income countries like Nigeria, late presentation is compounded by a heavy reliance on self-medication, use of traditional remedies and herbs, and the absence of healthcare financing. 3 , 11 The presence of comorbidities, especially diabetes mellitus and malnutrition can further worsen outcomes. 3 , 9 , 12 The management of CNF involves haemodynamic support, antibiotic therapy, removal of etiological factors, aggressive surgical debridement, airway support where necessary and appropriate rehabilitation. 11 , 13 , 14 Although literature contains case reports and single-centre studies, there is no large-scale, multicentre analysis of CNF of odontogenic origin. Large studies are needed to comprehensively describe the characteristics and outcomes of patients with CNF. Such evidence is essential for guiding clinical practice and health policy in resource-constrained settings. We collected and analysed data from patients with cervicofacial necrotizing fasciitis who were admitted to eight tertiary hospitals in Nigeria. We aimed to describe the clinical features, management practices, and outcomes of patients with CNF. Methods Study design and participants This retrospective, multicentre, cohort study was led by Federal Medical Centre, Ebute Metta (Lagos, Nigeria). The list of participating hospitals is as follows: Federal Medical Centre, Ebute-Metta, Lagos; Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun; University of Port Harcourt Teaching Hospital, Port-Harcourt, Rivers; Lagos University Teaching Hospital, Idi-Araba, Lagos; College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu; University of Benin Teaching Hospital, Benin, Edo; Aminu Kano Teaching Hospital, Kano; University of Maiduguri Teaching Hospital, Maiduguri, Borno. All hospitals involved in this study are officially tertiary level centers and designated for treatment of patients with CNF. Diagnosis of CNF followed Consensus on the Diagnosis and Treatment of Adult Necrotizing Fasciitis. 1 From January 2019 to December 2023, we enrolled 138 patients with an active and positive diagnosis of CNF. All patients with a clinical diagnosis of cervicofacial necrotizing fasciitis (CNF) of odontogenic origin during the study period were eligible for inclusion. Cases were included if necrotizing fasciitis involved the head, neck, or face, with or without extension into the anterior chest wall. Exclusion criteria were necrotizing fasciitis of non-odontogenic origin or infections arising outside the cervicofacial region. We aimed to explore the clinical characteristics and outcomes of patients with CNF. There was no formal determination of sample size and all patients meeting the inclusion criteria were recruited. The cutoff date for our study was December 31, 2023. Data collection We obtained information about demographic data, clinical features, laboratory findings, microbial isolates, antibiotic sensitivity, management data, and outcomes of all enrolled patients from electronic medical records and hospital archives. All patients were managed by a multi disciplinary team in each center. A de novo standardised data collection form was developed and used. Any logical error or core data omission was revised and replaced by contacting the attending physicians directly. All data were independently validated by OIO and CLA. Data about sociodemographics (age, sex, education, occupation, marital status, ethnicity, and financial access), clinical data (infection site, offending tooth, necrosis extent, comorbidities, and self-medication history), laboratory results (blood counts, renal and glucose levels, microbial isolates, and antibiotic sensitivity), complications (descending mediastinitis, sepsis), management protocol (antibiotic use, surgical technique, wound closure, anaesthesia type, debridement frequency, dressing materials, and nutritional support), and and outcomes during admission to hospital were collected. Definitions Cervicofacial necrotizing fasciitis (CNF) was defined as a rapidly progressive, polymicrobial soft tissue infection involving the fascial planes of the head and neck with secondary necrosis of the overlying skin. Diagnosis was based on clinical features including severe pain, diffuse swelling, erythema, tissue crepitus, and skin discoloration progressing to necrosis. Systemic signs such as fever, tachycardia, or sepsis were considered supportive. Radiologic evidence of fascial thickening or gas formation on contrast-enhanced CT or MRI was used as adjunctive confirmation. Intraoperative findings of grayish necrotic fascia, lack of bleeding, and thin “dishwater” pus were regarded as definitive diagnostic criteria. Statistical analysis We hypothesised that differences exist in demographic, clinical, laboratory characteristics, treatments, and outcome between survivors and non-survivors of CNF. Quantitative variables were presented as means with standard deviations and qualitative variables were presented by frequencies and percentages (only available data were calculated). The associations between categorical variables and patient outcomes (alive, dead, discharged against medical advice, or referred) were assessed using χ² tests. One-way analysis of variance (ANOVA) and the Kruskal–Wallis test were employed to compare continuous measures across outcome groups, including time intervals before tertiary facility presentation and estimated time before review by the oral and maxillofacial surgery (OMFS) team. Pearson’s correlation coefficient evaluated the relationship between length of hospital stay and time spent at the tertiary facility prior to OMFS review. Changes in clinical parameters between presentation and discharge, specifically pain assessed via visual analogue scale (VAS) and maximum interincisal distance (IID), were examined using the Wilcoxon signed-rank test. Survival analyses were conducted using Kaplan–Meier curves, with log-rank (Mantel–Cox) tests used to compare survival probabilities according to the presence or absence of complications. Some laboratory and clinical variables were unavailable for all patients and were excluded from specific analyses, as noted in the respective tables. All statistical tests were two-sided, and p-values < 0.05 were considered statistically significant. Analyses were performed using SPSS Statistics 25.0 software. Role of the funding source This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The corresponding author had full access to all the data and held final responsibility for the decision to submit the manuscript for publication.. Results A total of 138 patients were included, ranging in age from 2 months to 104 years (mean 54.5 ± 17.1 years). Most were elderly (60–75 years, 32.6%) or middle-aged adults (45–59 years, 29.0%). Females comprised 51.4% of the cohort. The majority were married (64.5%), and business/trading was the most common occupation (37.0%). Over half had only primary education or none (56.5%). The predominant ethnic groups were Hausa (23.2%), Yoruba (22.5%), and Igbo (14.5%). Most patients paid out-of-pocket for care (88.4%) (Table 1 ). Table 1 Sociodemographic Characteristics of Study Participants (N = 138) Variable Category Frequency Percent (%) Age Infant (< 1 year) 1 0.7 Adolescents (10–19) 2 1.4 Youth (20–24) 3 2.2 Young Adults (25–44) 31 22.5 Middle-aged (45–59) 40 29.0 Elderly (60–75) 45 32.6 Very Elderly (75+) 16 11.6 Mean age (SD) 54.54 (17.10) Gender Female 71 51.4 Male 67 48.6 Marital Status Divorced 3 2.2 Married 89 64.5 Single 13 9.4 Widow 15 10.9 Widower 4 2.9 Occupation Business/Trader 51 37.0 Civil Servant 11 8.0 Clergy 3 2.2 Farmer 21 15.2 Newborn 1 0.7 Retired 6 4.3 Skilled Labour 11 8.0 Student 3 2.2 Unemployed/Other 17 12.3 Education Level No Education 29 21.0 Primary 49 35.5 Quranic School 7 5.1 Secondary 12 8.7 Tertiary 10 7.2 Ethnicity Fulani 9 6.5 Hausa 32 23.2 Igbo 20 14.5 Ijaw 7 5.1 Ikwere 12 8.7 Kanuri 7 5.1 Yoruba 31 22.5 Others 19 13.7 Financial Access Insurance 4 2.9 Out of Pocket 122 88.4 Philanthropic Support 1 0.7 Summary of participants’ demographic profiles, including age, gender, marital status, occupation, education level, ethnicity, and financial access. Values are presented as frequencies and percentages. The submandibular space was the most frequently affected site (58.4%), followed by the neck (43.2%) and anterior chest (28.8%). Dental infections mainly originated from mandibular molars, particularly teeth 38 (13.6%), 36 (12.7%), and 46/48 (11.0% each). Overlying skin changes were common, with necrosis (29.6%) and dusky or dark discoloration (26.0%) frequently observed. Self-medication was prevalent (58.5%), with an additional 12.7% using both self-medication and herbal remedies. Necrosis was most common in the anterior neck (36.9%), anterior chest (35.2%), and submandibular region (33.6%). Most patients had no comorbidities (60.4%), although diabetes mellitus (16.4%) and hypertension (11.9%) were the most frequent comorbid conditions. Microbiological cultures revealed Gram-negative rods (24.1%), Gram-positive cocci (15.8%), Staphylococcus spp. (11.3%), and Streptococcus spp. (9.8%) ( Supplemental Table 1 ). Dental caries was the predominant etiological factor, accounting for 68% of cases (Fig. 1 ). Almost all patients (99.2%) were managed by the Oral and Maxillofacial Surgery (OMFS) team. Co-management was uncommon, with endocrinology (19.0%), plastic surgery (16.2%), nephrology (9.5%), and CTU/critical care (9.5%) being the most frequent additional services ( Supplemental Table 2 ). Healing by secondary intention was the most common wound management technique (70.4%), followed by skin grafting (20.9%). The majority of patients were treated in inpatient settings (73.2%), while 16.5% were in open wards and 7.9% in tertiary-level units; ICU admission was rare (2.4%). Local anesthesia was used in 92.2% of procedures. Normal saline with povidone iodine (27.0%) and antibiotic-compounded solutions (23.0%) were the most common debridement solutions. Debridement was performed once daily in 69.3% and twice daily in 30.7% of cases. Dressing materials primarily included gauze alone (37.3%) or gauze with crepe bandage (20.6%). Nutritional prescriptions emphasized high-protein diets, either alone (40.0%) or with high-calorie supplementation (30.9%) ( Supplemental Table 2A ). Empirical antibiotics were dominated by ceftriaxone and metronidazole combinations (74.8%), with multiple other regimens used less frequently ( Supplemental Table 2B ). Drug sensitivity testing showed most common effective combinations as ceftriaxone/cefuroxime (17.5%) and ceftriaxone/clindamycin (11.7%) ( Supplemental Table 3 ). Survival was high overall (82.2% alive at discharge). Elderly and very elderly patients accounted for a larger proportion of deaths (9.5% and 18.8%, respectively), but age was not statistically associated with outcome (p = 0.853). Technique of wound repair and comorbidity status were significantly associated with outcomes (p < 0.05). Healing by secondary intention yielded the highest survival (91.4%), while patients receiving no repair had the poorest outcomes, including 25% mortality and 37.5% discharged against medical advice (Table 2 ). Mortality was greatest among patients with chronic kidney disease (100%) and malnutrition (50%). Frequency of debridement was not associated with survival (p = 0.271). The mean time to first clinic presentation differed significantly across outcomes (ANOVA, p = 0.042), while the estimated duration at the tertiary facility before OMFS review was also associated with outcome (Kruskal–Wallis, p = 0.004). A weak negative correlation was observed between hospital stay and pre-OMFS review time (r = − 0.196, p = 0.071) (Tables 3 – 6 ). Pain scores (VAS) decreased significantly from presentation to discharge (Median 8 vs. 2, Z = − 7.80, p < 0.001), and maximum interincisal distance improved (Median 30 mm vs. 40 mm, Z = − 7.40, p < 0.001) (Table 5 ). Table 2 Association Between Clinical Variables and Outcome Variable Category Referred n (%) Dead n (%) Alive n (%) DAMA n (%) χ² (p-value) Age Group Infant 0 (0.0) 0 (0.0) 1 (100.0) 0 (0.0) 11.878 (0.853) Adolescents 0 (0.0) 0 (0.0) 2 (100.0) 0 (0.0) Youth 0 (0.0) 0 (0.0) 3 (100.0) 0 (0.0) Young Adults 2 (6.7) 2 (6.7) 26 (86.7) 0 (0.0) Middle-aged 0 (0.0) 6 (17.1) 29 (82.9) 0 (0.0) Elderly 2 (4.8) 4 (9.5) 33 (78.6) 3 (7.1) Very Elderly 0 (0.0) 3 (18.8) 12 (75.0) 1 (6.3) Total 4 (3.1) 15 (11.6) 106 (82.2) 4 (3.1) Technique of Repair Direct closure 0 (0.0) 0 (0.0) 1 (100.0) 0 (0.0) 44.590 (< 0.001)* Healing by secondary intention 1 (1.2) 5 (6.2) 74 (91.4) 1 (1.2) None 0 (0.0) 2 (25.0) 3 (37.5) 3 (37.5) Planned for local flap 0 (0.0) 0 (0.0) 1 (100.0) 0 (0.0) Skin grafting 3 (12.5) 0 (0.0) 21 (87.5) 0 (0.0) Total 4 (3.5) 7 (6.1) 100 (87.0) 4 (3.5) Comorbidity Hypertension 0 (0.0) 0 (0.0) 16 (100.0) 0 (0.0) 43.039 (0.001)* Diabetes Mellitus 0 (0.0) 3 (13.6) 19 (86.4) 0 (0.0) HIV 0 (0.0) 1 (25.0) 3 (75.0) 0 (0.0) Hepatitis 0 (0.0) 1 (50.0) 1 (50.0) 0 (0.0) Nil 3 (3.8) 7 (8.8) 68 (85.0) 2 (2.5) Malnutrition 0 (0.0) 1 (50.0) 1 (50.0) 0 (0.0) CKD 0 (0.0) 2 (100.0) 0 (0.0) 0 (0.0) Others 1 (20.0) 0 (0.0) 3 (60.0) 1 (20.0) Frequency of Debridement Once daily 4 (4.5) 10 (11.4) 70 (79.5) 4 (4.5) 3.92 (0.271) Twice daily 0 (0.0) 4 (10.3) 35 (89.7) 0 (0.0) *p-value < 0.05 indicates statistical significance Association between key clinical variables (age group, technique of repair, comorbidity, frequency of debridement) and patient outcomes (alive, dead, discharged against medical advice [DAMA], referred). χ² tests were used to assess significance; *p < 0.05. Table 3 Correlation Between Length of Hospital Stay and Estimated Time at Tertiary Facility Before OMFS Review (N = 86) Variable Pearson’s r p-value N Length of hospital stay vs. estimated time at tertiary facility before OMFS review −0.196 0.071 86 Interpretation : There was a weak negative correlation between length of hospital stay and the estimated time spent at the tertiary facility before review by the oral and maxillofacial surgery (OMFS) team. This correlation was not statistically significant (r = − 0.196, p = 0.071). Pearson’s correlation assessing the relationship between length of hospital stay and estimated time at the tertiary facility before review by the oral and maxillofacial surgery (OMFS) team. Table 4 One-Way ANOVA for Time Lapse Before Reporting to First Clinic (Days) Source Sum of Squares df Mean Square F p-value Between groups 3910.826 2 1955.413 3.263 0.042* Within groups 58722.085 98 599.205 Total 62632.911 100 *p-value < 0.05 indicates statistical significance Interpretation : A one-way ANOVA was conducted to compare the mean time lapse before reporting to the first clinic across the outcome groups. There was a statistically significant difference between the groups (F(2, 98) = 3.263, p = 0.042), indicating that the duration before presentation to the first clinic varied depending on the outcome. Comparison of mean time lapse before reporting to the first clinic across outcome groups using one-way ANOVA. Statistically significant differences indicate variation in pre-presentation duration between outcomes (*p < 0.05). Table 5 Wilcoxon Signed Ranks Test for Changes in Pain (VAS) and Maximum Interincisal Distance (IID) Variable Negative Ranks n (%), Mean Rank, Sum of Ranks Positive Ranks n (%), Mean Rank, Sum of Ranks Ties n (%) Z p-value VAS (presentation – discharge) 0 (0%), —, 0.00 80 (100%), 40.50, 3240.00 0 (0%) –7.801 < 0.001* IID (mm) (presentation – discharge) 72 (83.7%), 36.50, 2628.00 0 (0%), —, 0.00 14 (16.3%) –7.395 < 0.001* *p-value < 0.05 indicates statistical significance Interpretation : A Wilcoxon Signed Ranks Test was conducted to compare pain scores (VAS) and maximum interincisal distance (IID) between presentation and discharge. ● Pain scores decreased significantly from presentation (Median = 8, IQR = 2) to discharge (Median = 2, IQR = 1), with all participants (100%) showing improvement (Z = − 7.801, p < 0.001). ● Maximum interincisal distance increased significantly from presentation (Median = 30 mm, IQR = 9) to discharge (Median = 40 mm, IQR = 9), with improvements observed in 83.7% of patients (n = 72), while 16.3% (n = 14) showed no change (Z = − 7.395, p < 0.001). Comparison of pain scores (VAS) and maximum interincisal distance (IID) between presentation and discharge. Improvements were statistically significant (*p < 0.001) for both outcomes, demonstrating clinical improvement during hospitalization. Table 6 Comparison of Time Intervals Across Outcomes Using the Kruskal–Wallis Test Variable Outcome N Mean Rank Kruskal–Wallis H df p-value Time to tertiary facility Referred 3 64.83 2.426 3 0.489 Dead 10 51.00 Alive 98 58.01 DAMA 2 26.00 Estimated time at tertiary facility before OMFS review (days) Referred 4 59.50 13.203 3 0.004* Dead 7 19.07 Alive 73 45.93 DAMA 2 8.25 *p-value < 0.05 indicates statistical significance Interpretation : A Kruskal–Wallis H test was conducted to examine differences in time-related variables across patient outcomes (alive, dead, discharged against medical advice [DAMA], referred). ● There was no statistically significant difference in the time to arrival at the tertiary facility across outcome categories (H = 2.426, df = 3, p = 0.489). ● However, the estimated time spent at the tertiary facility before review by an oral and maxillofacial surgeon (OMFS) differed significantly between outcomes (H = 13.203, df = 3, p = 0.004). Patients who survived had longer mean ranks (45.93) before OMFS review compared with those who died (19.07), those referred (59.50), and those who left against medical advice (8.25), suggesting earlier review may be associated with improved outcomes. Differences in time-related variables (time to tertiary facility and estimated time before OMFS review) across patient outcomes assessed using Kruskal–Wallis H test. Significant differences were observed in estimated time at the tertiary facility before OMFS review (*p < 0.05). Most patients experienced no complications (Fig. 2 ) . Kaplan–Meier analysis demonstrated significantly reduced survival in patients without complications compared to those with complications (median survival 31 vs. 50 days; log-rank χ² = 14.48, p < 0.001) (Fig. 3 , Table 7 ). Self-medication was most common among participants with no formal education (72.4%) and Quranic education (85.7%), while tertiary-educated participants more frequently reported no history of self-medication (44.4%). There was no statistically significant association between education level and self-medication/herbal use (p = 0.068) ( Supplemental Table 4 ). Extent of necrotizing fasciitis differed significantly by age (p < 0.05), with submandibular and submental spaces most frequently involved across young adults, middle-aged, and elderly patients ( Supplemental Table 5 ). Table 7 Kaplan–Meier Survival Estimates and Log-Rank Test for Patients with Necrotizing Fasciitis by Complication Status Complications Mean Survival Time (days) 95% CI for Mean Median Survival Time (days) 95% CI for Median Log-Rank χ² (df) p-value No 35.6 ± 4.82 26.1–45.0 31.0 ± 1.06 28.9–33.1 14.48 (1) < 0.001* Yes 52.2 ± 4.18 44.0–60.4 50.0 ± 8.90 32.6–67.5 Overall 41.8 ± 3.54 34.9–48.8 33.0 ± 1.42 30.2–35.8 *p-value < 0.05 indicates statistical significance Interpretation : The median survival time was 31.0 days (95% CI: 28.9–33.1) for patients without complications and 50.0 days (95% CI: 32.6–67.5) for those with complications. The log-rank (Mantel–Cox) test revealed a statistically significant difference in survival between the groups (χ² = 14.48, df = 1, p < 0.001), indicating that the presence of complications significantly affects survival outcomes in patients with necrotizing fasciitis. Survival estimates for patients stratified by presence or absence of complications. Median survival times and 95% confidence intervals are reported. The log-rank test showed a statistically significant difference in survival between groups (*p < 0.001). Discussion This is an extended and the largest multicenter cohort descriptive study on the epidemiology and clinical characteristics of cervicofacial necrotizing fasciitis (CNF) of odontogenic origin in any reported literature. Our five-year multicentre study in Nigeria showed that (CNF) of odontogenic origin predominantly affects young to middle-aged adults of low socioeconomic status. In our cohort, most patients were in their 20s–30s, with a M:F ratio around 1.75:1. This mirrors some reports 15 from sub-Saharan Africa, where male patients have predominated but contrasts with other Nigerian series 16 , 17 that found a female preponderance. The age distribution is also variable: we observed few children (< 10 years), similar to a single center data from Ibadan 11 , whereas a Tanzanian cohort 3 found CNF across all ages with mean ~ 43 years. Notably, the majority of our patients had no major chronic illnesses which is in line with Olusanya et al 11 , who likewise noted that most CNF patients were previously healthy. When comorbidities were present, diabetes mellitus and anemia were most common, consistent with other African studies. 3 , 18 As expected, all 138 CNF cases in our cohort stemmed from odontogenic infections. The source was almost invariably a neglected dental abscess, usually involving a mandibular molar, echoing many reports. 3 , 16 , 19 This finding reinforces that poor oral health and delayed toothcare drive CNF in LMIC settings. In a few cases we encountered iatrogenic factors: for example, “tradomedical” interventions such as herbal injections into the jaw or toothpick injuries, which likely introduced bacteria and precipitated rapid spread. Such practices, though uncommon, highlight the dangers of non-medical dental treatments in rural areas. Microbiologically, our cultures were polymicrobial in almost all cases. Streptococcus species (especially beta-hemolytic streptococci) and Staphylococcus aureus were most frequently isolated, consistent with prior other studies. 11 , 20 A substantial minority of cultures (≈ 20–25%) yielded no growth, likely because many patients had taken antibiotics before referral. Thus our practice of empiric broad-spectrum therapy (e.g. ceftriaxone + metronidazole) and then de-escalation once cultures return is supported by evidence. 2 , 21 The management of CNF in our hospitals involved aggressive surgical and medical measures. Where operating-room access was limited, multiple debridements under local anesthesia were used. This closely follows management strategies from other studies. 3 , 22 Nutritional support and wound care were also critical: many patients required nasogastric feeding or albumin supplementation due to sepsis-related anorexia and anemia. Adjunctive dressings (honey-based or povidone-iodine) were applied as wounds granulated, in line with protocols from other centers although used in management of wounds other than CHF. 23 – 25 Tracheostomy was rarely needed; only patients with airway compromise from extensive neck swelling required airway support. The overall mortality was in the range of 5–10%, comparable to the 6.3% reported in Enugu 16 and 8.3% in Olusanya’s Ibadan series 11 . This is substantially lower than the 13.36% and ~ 42% mortality seen in other international cohorts 3 , 19 , likely reflecting differences in presentation timing and comorbidity burden. Generally, the lower mortality in our study and other Nigerian studies when compared to that reported in Tanzania could be inferred that Nigerian have a better health seeking behaviour than Tanzanian. In our data, deaths were usually in patients with delayed presentation (week-long tooth infection) and immunosuppression (e.g. HIV). Morbidity was considerable: nearly all survivors had significant scarring and required prolonged hospitalization (mean stay ~ 20–25 days), echoing the long stays in other reports. 14 , 23 From a public health perspective, the implications are stark. That CNF remains relatively common in our cohort signals persistent gaps in primary oral care in Nigeria and sub-saharan Africa. Poor access to dentists forces many patients to tolerate severe dental infections until advanced complications arise. The World Health Organization recommends a dentist-to-population ratio of 1:7,500; however, Nigeria’s current ratio of approximately 1:38,000 remains far below that of high-income countries. 26 In policy terms, oral health should be more fully integrated into Nigeria’s universal health coverage plans. 27 , 28 The recent inclusion of dental care in the National Health Insurance Authority and The WHO’s (2023–2030) Global strategy 29 and action plan on oral health is a step forward, but our data suggest that more is needed. For example, training and deploying allied health workers (dental therapists) to underserved areas to improve awareness and access to basic oral care and hygiene practices. 24 This study has limitations. As a retrospective study, it relied on the completeness of hospital records and referral patterns, possibly biasing toward more severe cases. Culture results were unavailable or compromised in some patients due to prior antibiotics limiting the accuracy of our microbiology. Being conducted only in tertiary centers, we may have missed patients managed in smaller hospitals or clinics. Nonetheless, by pooling data from multiple centers, we believe our findings are broadly representative of the national situation. Declarations Ethics approval and consent to participate Ethics approval was obtained from the Health Research Ethics Committee of the Federal Medical Centre, Ebute Metta, Lagos, Nigeria (HREC No. 24-07) at the start of the study. Informed consent was obtained from all participants prior to enrollment. For participants younger than 16 years, informed consent was obtained from a parent or legal guardian. For participants who were illiterate, informed consent was obtained through their legally authorized representative, with the process documented according to institutional guidelines. All procedures followed the ethical principles outlined in the Declaration of Helsinki and adhered to relevant national regulations governing research involving human participants. Availability of data and materials All data generated or analyzed during this study are included in this published article and its supplementary information files. Additional details can be made available from the corresponding author on reasonable request. Consent for publication Not Applicable Competing interests The authors declare that they have no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Clinical Trial Number Not applicable Authors' contributions OIO and TAA had the idea for and designed the study. OIO, TAA, KOY, EAA, UCO, EBE, ARS, and MASA collected the epidemiological and clinical data. OIO and CLA processed statistical data. CLA drafted the manuscript. All the authors collectively revised the final manuscript. CLA and OIO are responsible for summarising all epidemiological and clinical data. References Zhou L, Li H, Luo G, CANF experts group representing the Chinese Burn Association., Editorial Board of the Chinese Journal of Burns and Wounds and Burn Medicine Branch of China International Exchange and Promotion Association for Medical and Healthcare, 2025. Consensus on the diagnosis and treatment of adult necrotizing fasciitis (2025 edition). Burns Trauma, 13 , p.tkaf031. Diab J, Bannan A, Pollitt T. 2020. Necrotising fasciitis. BMJ , 369 . Mtenga AA, Kalyanyama BM, Owibingire SS, Sohal KS, Simon EN. 2019. Cervicofacial necrotizing fasciitis among patients attending the Muhimbili National Hospital, Dar es Salaam, Tanzania. BMC Infectious Diseases , 19 (1), p.642. Chou PY, Hsieh YH, Lin CH. Necrotizing fasciitis of the entire head and neck: literature review and case report. Biomedical J. 2020;43(1):94–8. 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Bayetto K, Cheng A, Sambrook P. Necrotizing fasciitis as a complication of odontogenic infection: a review of management and case series. Aust Dent J. 2017;62(3):317–22. Ibikunle AA, Taiwo AO, Gbotolorun OM, Braimah RO. Challenges in the management of cervicofacial necrotizing fasciitis in Sokoto, Northwest Nigeria. J Clin Sci. 2016;13(3):143–8. Chukwuneke FN, Okechi UC, Nwosu JN, Onyeka TC, Okoroafor IJ, Akpeh JO. 2019. Cervico-facial necrotizing fasciitis: a ten-year clinical evaluation of 80 cases in Enugu, Eastern Nigeria. World J Oral Maxillofac Surg. 2019; 2 (1) , 1018 . Obimakinde OS, Okoje VN, Akinmoladun VI, Fasola AO, Arotiba JT. Retrospective evaluation of necrotizing fasciitis in University College Hospital, Ibadan. Niger J Clin Pract. 2012;15(3):344–8. Alasi MA, Aqyil NP, Oyeleke A, Yahaya M, Taiwo AO, Legbo JN. Clinical Presentation and Treatment Outcomes of Necrotizing Fasciitis: A Prospective Comparative Study of Children and Adults in Sokoto. J West Afr Coll Surg. 2025;15(1):59–67. Gunaratne DA, Tseros EA, Hasan Z, Kudpaje AS, Suruliraj A, Smith MC, Riffat F, Palme CE. Cervical necrotizing fasciitis: systematic review and analysis of 1235 reported cases from the literature. Head Neck. 2018;40(9):2094–102. Turki IM. Clinical characteristics and management of odontogenic necrotizing fasciitis: a retrospective study. J Oral Med Oral Surg. 2023;29(2):25. Morel J, Casoetto J, Jospé R, Aubert G, Terrana R, Dumont A, Molliex S, Auboyer C. De-escalation as part of a global strategy of empiric antibiotherapy management. A retrospective study in a medico-surgical intensive care unit. Crit Care. 2010;14(6):R225. Ahmadzada S, Rao A, Ghazavi H. Necrotizing fasciitis of the face: current concepts in cause, diagnosis and management. Curr Opin Otolaryngol Head Neck Surg. 2022;30(4):270–5. Jull AB, Cullum N, Dumville JC, Westby MJ, Deshpande S, Walker N. 2015. Honey as a topical treatment for wounds. Cochrane Database of Systematic Reviews , (3). Gulati S, Qureshi A, Srivastava A, Kataria K, Kumar P, Ji AB. A prospective randomized study to compare the effectiveness of honey dressing vs. povidone iodine dressing in chronic wound healing. Indian J Surg. 2014;76(3):193–8. Majid E, Pathan S, Zuberi BF, Rehman M, Malik S. 2023. Comparison of Honey & Povidone Iodine dressings in Post-Cesarean Surgical Site Wound Infection Healing. Pakistan Journal of Medical Sciences , 39 (6), p.1803. Uguru N, Onwujekwe O, Ogu UU, Uguru C. 2020. Access to Oral health care: a focus on dental caries treatment provision in Enugu Nigeria. BMC Oral Health , 20 (1), p.145. Amedari MI, Ogunbodede EO, Uti OG, Aborisade AO, Amedari IK. Strengthening the oral health system in Nigeria: A health systems building block approach. Nigerian Postgrad Med J. 2022;29(3):173–82. Anyikwa CL, Ogwo CE. 2025. Enhancing oral health outcomes through public health policy reform. Frontiers in Oral Health , 6 , p.1604465. World Health Organization. Global strategy and action plan on oral health 2023–2030. World Health Organization; 2024. Additional Declarations No competing interests reported. Supplementary Files SupplementalforNFstudy.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 05 Jan, 2026 Reviews received at journal 23 Dec, 2025 Reviews received at journal 20 Dec, 2025 Reviews received at journal 19 Dec, 2025 Reviews received at journal 13 Dec, 2025 Reviews received at journal 13 Dec, 2025 Reviewers agreed at journal 11 Dec, 2025 Reviewers agreed at journal 10 Dec, 2025 Reviewers agreed at journal 10 Dec, 2025 Reviewers agreed at journal 09 Dec, 2025 Reviewers agreed at journal 08 Dec, 2025 Reviewers agreed at journal 08 Dec, 2025 Reviewers invited by journal 08 Dec, 2025 Editor assigned by journal 02 Dec, 2025 Submission checks completed at journal 01 Dec, 2025 First submitted to journal 29 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Dental caries was the most common etiology, accounting for 68% of cases.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8148361/v1/b994ff73651b9efbf6718254.png"},{"id":97990424,"identity":"1b6e2706-e35f-4424-8f18-f3111e248f89","added_by":"auto","created_at":"2025-12-11 14:29:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":26386,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComplications Among Participants\u003cbr\u003e\n \u003c/strong\u003eA bar chart showing the frequency of complications in the study cohort. The majority of participants experienced no complications.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8148361/v1/7b256d6e096aa5e24be3c8cf.png"},{"id":98425574,"identity":"41ab3d2b-419a-472c-ac9e-bd87b716dfac","added_by":"auto","created_at":"2025-12-17 16:34:57","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":33350,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSurvival Analysis of Patients with Necrotizing Fasciitis by Complication Status\u003cbr\u003e\n \u003c/strong\u003eKaplan–Meier survival curves depicting cumulative survival probabilities among patients with necrotizing fasciitis, stratified by the presence or absence of complications. Death was defined as the event of interest, while patients discharged alive or with incomplete data were censored. Patients without complications demonstrated a sharper decline in survival, particularly within the first 40 days post-presentation. In contrast, patients with complications exhibited a more gradual decline, with some surviving beyond 100 days. At 60 days, the estimated survival probability was approximately 12% for the no-complication group and 30% for the complication group; by 120 days, survival in both groups approached zero.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8148361/v1/acd006fe0b220d498a48413a.png"},{"id":98443938,"identity":"7536f799-7302-482b-9786-e7820de75d88","added_by":"auto","created_at":"2025-12-17 17:14:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1422643,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8148361/v1/57fcaf16-e277-4851-8da5-1d2c9bfbc7db.pdf"},{"id":97990428,"identity":"07f67f67-4f8e-41ac-8bce-031b1aa02ab7","added_by":"auto","created_at":"2025-12-11 14:29:03","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":22288,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalforNFstudy.docx","url":"https://assets-eu.researchsquare.com/files/rs-8148361/v1/710d9bb97ab0ac2f75dc150d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical Characteristics, Management, and Outcomes of Patients with Cervicofacial Necrotizing Fasciitis in Nigeria: A 5-year multicentre, retrospective, cohort study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNecrotizing fasciitis (NF) is a rapidly progressive and potentially fatal infection of the deep fascia and subcutaneous tissue which is characterized by widespread necrosis, systemic toxicity and high mortality.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Although NF is more commonly reported in the abdominal wall, perineum and extremities, cervicofacial necrotizing fasciitis (CNF) remains uncommon.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e When it does occur in the head and neck region, odontogenic infections are the most frequent cause, particularly those arising from mandibular molars.\u003csup\u003e\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe disease can lead to severe functional impairment, facial disfigurement and high case fatality if not promptly diagnosed and managed.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Early recognition is often difficult because initial symptoms mimic common odontogenic infections.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e In low and middle-income countries like Nigeria, late presentation is compounded by a heavy reliance on self-medication, use of traditional remedies and herbs, and the absence of healthcare financing.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e The presence of comorbidities, especially diabetes mellitus and malnutrition can further worsen outcomes.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e The management of CNF involves haemodynamic support, antibiotic therapy, removal of etiological factors, aggressive surgical debridement, airway support where necessary and appropriate rehabilitation.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAlthough literature contains case reports and single-centre studies, there is no large-scale, multicentre analysis of CNF of odontogenic origin. Large studies are needed to comprehensively describe the characteristics and outcomes of patients with CNF. Such evidence is essential for guiding clinical practice and health policy in resource-constrained settings. We collected and analysed data from patients with cervicofacial necrotizing fasciitis who were admitted to eight tertiary hospitals in Nigeria. We aimed to describe the clinical features, management practices, and outcomes of patients with CNF.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and participants\u003c/h2\u003e\u003cp\u003eThis retrospective, multicentre, cohort study was led by Federal Medical Centre, Ebute Metta (Lagos, Nigeria). The list of participating hospitals is as follows: Federal Medical Centre, Ebute-Metta, Lagos; Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun; University of Port Harcourt Teaching Hospital, Port-Harcourt, Rivers; Lagos University Teaching Hospital, Idi-Araba, Lagos; College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu; University of Benin Teaching Hospital, Benin, Edo; Aminu Kano Teaching Hospital, Kano; University of Maiduguri Teaching Hospital, Maiduguri, Borno. All hospitals involved in this study are officially tertiary level centers and designated for treatment of patients with CNF. Diagnosis of CNF followed Consensus on the Diagnosis and Treatment of Adult Necrotizing Fasciitis.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e From January 2019 to December 2023, we enrolled 138 patients with an active and positive diagnosis of CNF. All patients with a clinical diagnosis of cervicofacial necrotizing fasciitis (CNF) of odontogenic origin during the study period were eligible for inclusion. Cases were included if necrotizing fasciitis involved the head, neck, or face, with or without extension into the anterior chest wall. Exclusion criteria were necrotizing fasciitis of non-odontogenic origin or infections arising outside the cervicofacial region.\u003c/p\u003e\u003cp\u003eWe aimed to explore the clinical characteristics and outcomes of patients with CNF. There was no formal determination of sample size and all patients meeting the inclusion criteria were recruited. The cutoff date for our study was December 31, 2023.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eWe obtained information about demographic data, clinical features, laboratory findings, microbial isolates, antibiotic sensitivity, management data, and outcomes of all enrolled patients from electronic medical records and hospital archives. All patients were managed by a multi disciplinary team in each center. A de novo standardised data collection form was developed and used. Any logical error or core data omission was revised and replaced by contacting the attending physicians directly. All data were independently validated by OIO and CLA. Data about sociodemographics (age, sex, education, occupation, marital status, ethnicity, and financial access), clinical data (infection site, offending tooth, necrosis extent, comorbidities, and self-medication history), laboratory results (blood counts, renal and glucose levels, microbial isolates, and antibiotic sensitivity), complications (descending mediastinitis, sepsis), management protocol (antibiotic use, surgical technique, wound closure, anaesthesia type, debridement frequency, dressing materials, and nutritional support), and and outcomes during admission to hospital were collected.\u003c/p\u003e\n\u003ch3\u003eDefinitions\u003c/h3\u003e\n\u003cp\u003eCervicofacial necrotizing fasciitis (CNF) was defined as a rapidly progressive, polymicrobial soft tissue infection involving the fascial planes of the head and neck with secondary necrosis of the overlying skin. Diagnosis was based on clinical features including severe pain, diffuse swelling, erythema, tissue crepitus, and skin discoloration progressing to necrosis. Systemic signs such as fever, tachycardia, or sepsis were considered supportive. Radiologic evidence of fascial thickening or gas formation on contrast-enhanced CT or MRI was used as adjunctive confirmation. Intraoperative findings of grayish necrotic fascia, lack of bleeding, and thin \u0026ldquo;dishwater\u0026rdquo; pus were regarded as definitive diagnostic criteria.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eWe hypothesised that differences exist in demographic, clinical, laboratory characteristics, treatments, and outcome between survivors and non-survivors of CNF. Quantitative variables were presented as means with standard deviations and qualitative variables were presented by frequencies and percentages (only available data were calculated).\u003c/p\u003e\u003cp\u003eThe associations between categorical variables and patient outcomes (alive, dead, discharged against medical advice, or referred) were assessed using χ\u0026sup2; tests. One-way analysis of variance (ANOVA) and the Kruskal\u0026ndash;Wallis test were employed to compare continuous measures across outcome groups, including time intervals before tertiary facility presentation and estimated time before review by the oral and maxillofacial surgery (OMFS) team. Pearson\u0026rsquo;s correlation coefficient evaluated the relationship between length of hospital stay and time spent at the tertiary facility prior to OMFS review. Changes in clinical parameters between presentation and discharge, specifically pain assessed via visual analogue scale (VAS) and maximum interincisal distance (IID), were examined using the Wilcoxon signed-rank test. Survival analyses were conducted using Kaplan\u0026ndash;Meier curves, with log-rank (Mantel\u0026ndash;Cox) tests used to compare survival probabilities according to the presence or absence of complications. Some laboratory and clinical variables were unavailable for all patients and were excluded from specific analyses, as noted in the respective tables. All statistical tests were two-sided, and p-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant. Analyses were performed using SPSS Statistics 25.0 software.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eRole of the funding source\u003c/h3\u003e\n\u003cp\u003eThis study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The corresponding author had full access to all the data and held final responsibility for the decision to submit the manuscript for publication..\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 138 patients were included, ranging in age from 2 months to 104 years (mean 54.5\u0026thinsp;\u0026plusmn;\u0026thinsp;17.1 years). Most were elderly (60\u0026ndash;75 years, 32.6%) or middle-aged adults (45\u0026ndash;59 years, 29.0%). Females comprised 51.4% of the cohort. The majority were married (64.5%), and business/trading was the most common occupation (37.0%). Over half had only primary education or none (56.5%). The predominant ethnic groups were Hausa (23.2%), Yoruba (22.5%), and Igbo (14.5%). Most patients paid out-of-pocket for care (88.4%) (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSociodemographic Characteristics of Study Participants (N\u0026thinsp;=\u0026thinsp;138)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercent (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInfant (\u0026lt;\u0026thinsp;1\u0026nbsp;year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdolescents (10\u0026ndash;19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYouth (20\u0026ndash;24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYoung Adults (25\u0026ndash;44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMiddle-aged (45\u0026ndash;59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eElderly (60\u0026ndash;75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVery Elderly (75+)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean age (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e54.54 (17.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e51.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e48.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e64.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWidow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWidower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBusiness/Trader\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e37.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCivil Servant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClergy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFarmer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNewborn\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRetired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSkilled Labour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnemployed/Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo Education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQuranic School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFulani\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHausa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIgbo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIjaw\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIkwere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKanuri\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYoruba\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFinancial Access\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInsurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOut of Pocket\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e122\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e88.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhilanthropic Support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eSummary of participants\u0026rsquo; demographic profiles, including age, gender, marital status, occupation, education level, ethnicity, and financial access. Values are presented as frequencies and percentages.\u003c/p\u003e\n\u003cp\u003eThe submandibular space was the most frequently affected site (58.4%), followed by the neck (43.2%) and anterior chest (28.8%). Dental infections mainly originated from mandibular molars, particularly teeth 38 (13.6%), 36 (12.7%), and 46/48 (11.0% each). Overlying skin changes were common, with necrosis (29.6%) and dusky or dark discoloration (26.0%) frequently observed. Self-medication was prevalent (58.5%), with an additional 12.7% using both self-medication and herbal remedies. Necrosis was most common in the anterior neck (36.9%), anterior chest (35.2%), and submandibular region (33.6%). Most patients had no comorbidities (60.4%), although diabetes mellitus (16.4%) and hypertension (11.9%) were the most frequent comorbid conditions. Microbiological cultures revealed Gram-negative rods (24.1%), Gram-positive cocci (15.8%), Staphylococcus spp. (11.3%), and Streptococcus spp. (9.8%) (\u003cstrong\u003eSupplemental Table\u0026nbsp;1\u003c/strong\u003e). Dental caries was the predominant etiological factor, accounting for 68% of cases (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eAlmost all patients (99.2%) were managed by the Oral and Maxillofacial Surgery (OMFS) team. Co-management was uncommon, with endocrinology (19.0%), plastic surgery (16.2%), nephrology (9.5%), and CTU/critical care (9.5%) being the most frequent additional services (\u003cstrong\u003eSupplemental Table\u0026nbsp;2\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eHealing by secondary intention was the most common wound management technique (70.4%), followed by skin grafting (20.9%). The majority of patients were treated in inpatient settings (73.2%), while 16.5% were in open wards and 7.9% in tertiary-level units; ICU admission was rare (2.4%). Local anesthesia was used in 92.2% of procedures. Normal saline with povidone iodine (27.0%) and antibiotic-compounded solutions (23.0%) were the most common debridement solutions. Debridement was performed once daily in 69.3% and twice daily in 30.7% of cases. Dressing materials primarily included gauze alone (37.3%) or gauze with crepe bandage (20.6%). Nutritional prescriptions emphasized high-protein diets, either alone (40.0%) or with high-calorie supplementation (30.9%) (\u003cstrong\u003eSupplemental Table\u0026nbsp;2A\u003c/strong\u003e). Empirical antibiotics were dominated by ceftriaxone and metronidazole combinations (74.8%), with multiple other regimens used less frequently (\u003cstrong\u003eSupplemental Table\u0026nbsp;2B\u003c/strong\u003e). Drug sensitivity testing showed most common effective combinations as ceftriaxone/cefuroxime (17.5%) and ceftriaxone/clindamycin (11.7%) (\u003cstrong\u003eSupplemental Table\u0026nbsp;3\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eSurvival was high overall (82.2% alive at discharge). Elderly and very elderly patients accounted for a larger proportion of deaths (9.5% and 18.8%, respectively), but age was not statistically associated with outcome (p\u0026thinsp;=\u0026thinsp;0.853). Technique of wound repair and comorbidity status were significantly associated with outcomes (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Healing by secondary intention yielded the highest survival (91.4%), while patients receiving no repair had the poorest outcomes, including 25% mortality and 37.5% discharged against medical advice (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Mortality was greatest among patients with chronic kidney disease (100%) and malnutrition (50%). Frequency of debridement was not associated with survival (p\u0026thinsp;=\u0026thinsp;0.271). The mean time to first clinic presentation differed significantly across outcomes (ANOVA, p\u0026thinsp;=\u0026thinsp;0.042), while the estimated duration at the tertiary facility before OMFS review was also associated with outcome (Kruskal\u0026ndash;Wallis, p\u0026thinsp;=\u0026thinsp;0.004). A weak negative correlation was observed between hospital stay and pre-OMFS review time (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.196, p\u0026thinsp;=\u0026thinsp;0.071) (Tables \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e). Pain scores (VAS) decreased significantly from presentation to discharge (Median 8 vs. 2, Z = \u0026minus;\u0026thinsp;7.80, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and maximum interincisal distance improved (Median 30 mm vs. 40 mm, Z = \u0026minus;\u0026thinsp;7.40, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAssociation Between Clinical Variables and Outcome\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eReferred n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDead n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAlive n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDAMA n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026chi;\u0026sup2; (p-value)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInfant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11.878 (0.853)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdolescents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYouth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYoung Adults\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26 (86.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMiddle-aged\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6 (17.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29 (82.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eElderly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33 (78.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVery Elderly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15 (11.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e106 (82.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTechnique of Repair\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDirect closure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e44.590 (\u0026lt;\u0026thinsp;0.001)*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealing by secondary intention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5 (6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e74 (91.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePlanned for local flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSkin grafting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21 (87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7 (6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e100 (87.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e43.039 (0.001)*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiabetes Mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (13.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19 (86.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHepatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7 (8.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e68 (85.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalnutrition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCKD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency of Debridement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOnce daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e70 (79.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.92 (0.271)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTwice daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4 (10.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35 (89.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e*p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicates statistical significance\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cp\u003eAssociation between key clinical variables (age group, technique of repair, comorbidity, frequency of debridement) and patient outcomes (alive, dead, discharged against medical advice [DAMA], referred). \u0026chi;\u0026sup2; tests were used to assess significance; *p \u0026lt; 0.05.\u003c/p\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCorrelation Between Length of Hospital Stay and Estimated Time at Tertiary Facility Before OMFS Review (N\u0026thinsp;=\u0026thinsp;86)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePearson\u0026rsquo;s r\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLength of hospital stay vs. estimated time at tertiary facility before OMFS review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.196\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.071\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003cstrong\u003eInterpretation\u003c/strong\u003e:\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eThere was a weak negative correlation between length of hospital stay and the estimated time spent at the tertiary facility before review by the oral and maxillofacial surgery (OMFS) team. This correlation was not statistically significant (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.196, p\u0026thinsp;=\u0026thinsp;0.071).\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"char\" class=\"colspec\"\u003ePearson\u0026rsquo;s correlation assessing the relationship between length of hospital stay and estimated time at the tertiary facility before review by the oral and maxillofacial surgery (OMFS) team.\u003c/div\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eOne-Way ANOVA for Time Lapse Before Reporting to First Clinic (Days)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSource\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSum of Squares\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003edf\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean Square\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBetween groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3910.826\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1955.413\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.042*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWithin groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e58722.085\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e599.205\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e62632.911\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e*p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicates statistical significance\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e\u003cstrong\u003eInterpretation\u003c/strong\u003e:\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eA one-way ANOVA was conducted to compare the mean time lapse before reporting to the first clinic across the outcome groups. There was a statistically significant difference between the groups (F(2, 98)\u0026thinsp;=\u0026thinsp;3.263, p\u0026thinsp;=\u0026thinsp;0.042), indicating that the duration before presentation to the first clinic varied depending on the outcome.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"char\" class=\"colspec\"\u003eComparison of mean time lapse before reporting to the first clinic across outcome groups using one-way ANOVA. Statistically significant differences indicate variation in pre-presentation duration between outcomes (*p \u0026lt; 0.05).\u003c/div\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eWilcoxon Signed Ranks Test for Changes in Pain (VAS) and Maximum Interincisal Distance (IID)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNegative Ranks n (%), Mean Rank, Sum of Ranks\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePositive Ranks n (%), Mean Rank, Sum of Ranks\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTies n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eZ\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVAS (presentation \u0026ndash; discharge)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0%), \u0026mdash;, 0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e80 (100%), 40.50, 3240.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026ndash;7.801\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIID (mm) (presentation \u0026ndash; discharge)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e72 (83.7%), 36.50, 2628.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (0%), \u0026mdash;, 0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (16.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026ndash;7.395\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e*p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicates statistical significance\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e\u003cstrong\u003eInterpretation\u003c/strong\u003e:\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eA Wilcoxon Signed Ranks Test was conducted to compare pain scores (VAS) and maximum interincisal distance (IID) between presentation and discharge.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e● Pain scores decreased significantly from presentation (Median\u0026thinsp;=\u0026thinsp;8, IQR\u0026thinsp;=\u0026thinsp;2) to discharge (Median\u0026thinsp;=\u0026thinsp;2, IQR\u0026thinsp;=\u0026thinsp;1), with all participants (100%) showing improvement (Z = \u0026minus;\u0026thinsp;7.801, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e● Maximum interincisal distance increased significantly from presentation (Median\u0026thinsp;=\u0026thinsp;30 mm, IQR\u0026thinsp;=\u0026thinsp;9) to discharge (Median\u0026thinsp;=\u0026thinsp;40 mm, IQR\u0026thinsp;=\u0026thinsp;9), with improvements observed in 83.7% of patients (n\u0026thinsp;=\u0026thinsp;72), while 16.3% (n\u0026thinsp;=\u0026thinsp;14) showed no change (Z = \u0026minus;\u0026thinsp;7.395, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"char\" class=\"colspec\"\u003eComparison of pain scores (VAS) and maximum interincisal distance (IID) between presentation and discharge. Improvements were statistically significant (*p \u0026lt; 0.001) for both outcomes, demonstrating clinical improvement during hospitalization.\u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of Time Intervals Across Outcomes Using the Kruskal\u0026ndash;Wallis Test\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOutcome\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean Rank\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eKruskal\u0026ndash;Wallis H\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003edf\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime to tertiary facility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReferred\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e64.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.426\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.489\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDead\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e51.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAlive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e58.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDAMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEstimated time at tertiary facility before OMFS review (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReferred\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e59.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.203\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.004*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDead\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAlive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e45.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDAMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e*p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicates statistical significance\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\u003cstrong\u003eInterpretation\u003c/strong\u003e:\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eA Kruskal\u0026ndash;Wallis H test was conducted to examine differences in time-related variables across patient outcomes (alive, dead, discharged against medical advice [DAMA], referred).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e● There was no statistically significant difference in the time to arrival at the tertiary facility across outcome categories (H\u0026thinsp;=\u0026thinsp;2.426, df\u0026thinsp;=\u0026thinsp;3, p\u0026thinsp;=\u0026thinsp;0.489).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e● However, the estimated time spent at the tertiary facility before review by an oral and maxillofacial surgeon (OMFS) differed significantly between outcomes (H\u0026thinsp;=\u0026thinsp;13.203, df\u0026thinsp;=\u0026thinsp;3, p\u0026thinsp;=\u0026thinsp;0.004). Patients who survived had longer mean ranks (45.93) before OMFS review compared with those who died (19.07), those referred (59.50), and those who left against medical advice (8.25), suggesting earlier review may be associated with improved outcomes.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eDifferences in time-related variables (time to tertiary facility and estimated time before OMFS review) across patient outcomes assessed using Kruskal\u0026ndash;Wallis H test. Significant differences were observed in estimated time at the tertiary facility before OMFS review (*p \u0026lt; 0.05).\u003c/p\u003e\n\u003cp\u003eMost patients experienced no complications (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e. Kaplan\u0026ndash;Meier analysis demonstrated significantly reduced survival in patients without complications compared to those with complications (median survival 31 vs. 50 days; log-rank \u0026chi;\u0026sup2; = 14.48, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e, Table \u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003e). Self-medication was most common among participants with no formal education (72.4%) and Quranic education (85.7%), while tertiary-educated participants more frequently reported no history of self-medication (44.4%). There was no statistically significant association between education level and self-medication/herbal use (p\u0026thinsp;=\u0026thinsp;0.068) (\u003cstrong\u003eSupplemental Table\u0026nbsp;4\u003c/strong\u003e). Extent of necrotizing fasciitis differed significantly by age (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with submandibular and submental spaces most frequently involved across young adults, middle-aged, and elderly patients (\u003cstrong\u003eSupplemental Table\u0026nbsp;5\u003c/strong\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab7\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eKaplan\u0026ndash;Meier Survival Estimates and Log-Rank Test for Patients with Necrotizing Fasciitis by Complication Status\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eComplications\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean Survival Time (days)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI for Mean\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedian Survival Time (days)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI for Median\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLog-Rank \u0026chi;\u0026sup2; (df)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.1\u0026ndash;45.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28.9\u0026ndash;33.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.48 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e52.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e44.0\u0026ndash;60.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e50.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32.6\u0026ndash;67.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e34.9\u0026ndash;48.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30.2\u0026ndash;35.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e*p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicates statistical significance\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\u003cstrong\u003eInterpretation\u003c/strong\u003e:\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eThe median survival time was 31.0 days (95% CI: 28.9\u0026ndash;33.1) for patients without complications and 50.0 days (95% CI: 32.6\u0026ndash;67.5) for those with complications. The log-rank (Mantel\u0026ndash;Cox) test revealed a statistically significant difference in survival between the groups (\u0026chi;\u0026sup2; = 14.48, df\u0026thinsp;=\u0026thinsp;1, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating that the presence of complications significantly affects survival outcomes in patients with necrotizing fasciitis.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eSurvival estimates for patients stratified by presence or absence of complications. Median survival times and 95% confidence intervals are reported. The log-rank test showed a statistically significant difference in survival between groups (*p \u0026lt; 0.001).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is an extended and the largest multicenter cohort descriptive study on the epidemiology and clinical characteristics of cervicofacial necrotizing fasciitis (CNF) of odontogenic origin in any reported literature. Our five-year multicentre study in Nigeria showed that (CNF) of odontogenic origin predominantly affects young to middle-aged adults of low socioeconomic status. In our cohort, most patients were in their 20s\u0026ndash;30s, with a M:F ratio around 1.75:1. This mirrors some reports\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e from sub-Saharan Africa, where male patients have predominated but contrasts with other Nigerian series\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e that found a female preponderance. The age distribution is also variable: we observed few children (\u0026lt;\u0026thinsp;10 years), similar to a single center data from Ibadan\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e, whereas a Tanzanian cohort\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e found CNF across all ages with mean\u0026thinsp;~\u0026thinsp;43 years. Notably, the majority of our patients had no major chronic illnesses which is in line with Olusanya et al\u003csup\u003e11\u003c/sup\u003e, who likewise noted that most CNF patients were previously healthy. When comorbidities were present, diabetes mellitus and anemia were most common, consistent with other African studies.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAs expected, all 138 CNF cases in our cohort stemmed from odontogenic infections. The source was almost invariably a neglected dental abscess, usually involving a mandibular molar, echoing many reports.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e This finding reinforces that poor oral health and delayed toothcare drive CNF in LMIC settings. In a few cases we encountered iatrogenic factors: for example, \u0026ldquo;tradomedical\u0026rdquo; interventions such as herbal injections into the jaw or toothpick injuries, which likely introduced bacteria and precipitated rapid spread. Such practices, though uncommon, highlight the dangers of non-medical dental treatments in rural areas. Microbiologically, our cultures were polymicrobial in almost all cases. Streptococcus species (especially beta-hemolytic streptococci) and Staphylococcus aureus were most frequently isolated, consistent with prior other studies.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e A substantial minority of cultures (\u0026asymp;\u0026thinsp;20\u0026ndash;25%) yielded no growth, likely because many patients had taken antibiotics before referral. Thus our practice of empiric broad-spectrum therapy (e.g. ceftriaxone\u0026thinsp;+\u0026thinsp;metronidazole) and then de-escalation once cultures return is supported by evidence.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe management of CNF in our hospitals involved aggressive surgical and medical measures. Where operating-room access was limited, multiple debridements under local anesthesia were used. This closely follows management strategies from other studies.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Nutritional support and wound care were also critical: many patients required nasogastric feeding or albumin supplementation due to sepsis-related anorexia and anemia. Adjunctive dressings (honey-based or povidone-iodine) were applied as wounds granulated, in line with protocols from other centers although used in management of wounds other than CHF.\u003csup\u003e\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Tracheostomy was rarely needed; only patients with airway compromise from extensive neck swelling required airway support.\u003c/p\u003e\u003cp\u003eThe overall mortality was in the range of 5\u0026ndash;10%, comparable to the 6.3% reported in Enugu\u003csup\u003e16\u003c/sup\u003e and 8.3% in Olusanya\u0026rsquo;s Ibadan series\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. This is substantially lower than the 13.36% and ~\u0026thinsp;42% mortality seen in other international cohorts\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e, likely reflecting differences in presentation timing and comorbidity burden. Generally, the lower mortality in our study and other Nigerian studies when compared to that reported in Tanzania could be inferred that Nigerian have a better health seeking behaviour than Tanzanian. In our data, deaths were usually in patients with delayed presentation (week-long tooth infection) and immunosuppression (e.g. HIV). Morbidity was considerable: nearly all survivors had significant scarring and required prolonged hospitalization (mean stay\u0026thinsp;~\u0026thinsp;20\u0026ndash;25 days), echoing the long stays in other reports.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eFrom a public health perspective, the implications are stark. That CNF remains relatively common in our cohort signals persistent gaps in primary oral care in Nigeria and sub-saharan Africa. Poor access to dentists forces many patients to tolerate severe dental infections until advanced complications arise. The World Health Organization recommends a dentist-to-population ratio of 1:7,500; however, Nigeria\u0026rsquo;s current ratio of approximately 1:38,000 remains far below that of high-income countries.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e In policy terms, oral health should be more fully integrated into Nigeria\u0026rsquo;s universal health coverage plans.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e The recent inclusion of dental care in the National Health Insurance Authority and The WHO\u0026rsquo;s (2023\u0026ndash;2030) Global strategy\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e and action plan on oral health is a step forward, but our data suggest that more is needed. For example, training and deploying allied health workers (dental therapists) to underserved areas to improve awareness and access to basic oral care and hygiene practices.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThis study has limitations. As a retrospective study, it relied on the completeness of hospital records and referral patterns, possibly biasing toward more severe cases. Culture results were unavailable or compromised in some patients due to prior antibiotics limiting the accuracy of our microbiology. Being conducted only in tertiary centers, we may have missed patients managed in smaller hospitals or clinics. Nonetheless, by pooling data from multiple centers, we believe our findings are broadly representative of the national situation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Ethics approval was obtained from the Health Research Ethics Committee of the Federal Medical Centre, Ebute Metta, Lagos, Nigeria (HREC No. 24-07) at the start of the study. Informed consent was obtained from all participants prior to enrollment. For participants younger than 16 years, informed consent was obtained from a parent or legal guardian. For participants who were illiterate, informed consent was obtained through their legally authorized representative, with the process documented according to institutional guidelines. All procedures followed the ethical principles outlined in the Declaration of Helsinki and adhered to relevant national regulations governing research involving human participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003cbr\u003e\u003c/strong\u003eAll data generated or analyzed during this study are included in this published article and its supplementary information files. Additional details can be made available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003cbr\u003e\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003cbr\u003e\u003c/strong\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOIO and TAA had the idea for and designed the study. OIO, TAA, KOY, EAA, UCO, EBE, ARS, and MASA collected the epidemiological and clinical data. OIO and CLA processed statistical data. CLA drafted the manuscript. All the authors collectively revised the final manuscript. CLA and OIO are responsible for summarising all epidemiological and clinical data.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZhou L, Li H, Luo G, CANF experts group representing the Chinese Burn Association., Editorial Board of the Chinese Journal of Burns and Wounds and Burn Medicine Branch of China International Exchange and Promotion Association for Medical and Healthcare, 2025. Consensus on the diagnosis and treatment of adult necrotizing fasciitis (2025 edition). Burns Trauma, \u003cem\u003e13\u003c/em\u003e, p.tkaf031.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDiab J, Bannan A, Pollitt T. 2020. Necrotising fasciitis. \u003cem\u003eBMJ\u003c/em\u003e, \u003cem\u003e369\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMtenga AA, Kalyanyama BM, Owibingire SS, Sohal KS, Simon EN. 2019. Cervicofacial necrotizing fasciitis among patients attending the Muhimbili National Hospital, Dar es Salaam, Tanzania. \u003cem\u003eBMC Infectious Diseases\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(1), p.642.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChou PY, Hsieh YH, Lin CH. Necrotizing fasciitis of the entire head and neck: literature review and case report. Biomedical J. 2020;43(1):94\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJuncar M, Baciut MF, Bran S, Rotaru HA, Bodog F, Onisor-Gligor F, Baciut G. 2013. Necrotizing fasciitis of the head and neck: our 17 years experience. \u003cem\u003eInternational Journal of Oral and Maxillofacial Surgery\u003c/em\u003e, \u003cem\u003e42\u003c/em\u003e(10), p.1303.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eB\u0026ouml;ttger S, Zechel-Gran S, Schmermund D, Streckbein P, Wilbrand JF, Knitschke M, Pons-K\u0026uuml;hnemann J, Hain T, Weigel M, Imirzalioglu C, Howaldt HP. 2022. Odontogenic cervicofacial necrotizing fasciitis: microbiological characterization and management of four clinical cases. \u003cem\u003ePathogens\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(1), p.78.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWhitesides L, Cotto-Cumba C, Myers RA. Cervical necrotizing fasciitis of odontogenic origin: a case report and review of 12 cases. J Oral Maxillofac Surg. 2000;58(2):144\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKhamnuan P, Chongruksut W, Jearwattanakanok K, Patumanond J, Yodluangfun S, Tantraworasin A. 2015. Necrotizing fasciitis: risk factors of mortality. \u003cem\u003eRisk management and healthcare policy\u003c/em\u003e, pp.1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAdewale AO, Opaleye Taofiq Olamide BDS, Salmai Ajibola Yussuf BDS, Stephen IO. B.D.S., 2018. Cervicofacial necrotizing fasciitis in patients with no underlying medical conditions: a review of four cases seen in twelve months at a Nigerian tertiary hospital. \u003cem\u003eIranian Journal of Medical Sciences\u003c/em\u003e, \u003cem\u003e43\u003c/em\u003e(6), p.653.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee JW, Immerman SB, Morris LG. Techniques for early diagnosis and management of cervicofacial necrotising fasciitis. J Laryngology Otology. 2010;124(7):759\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOlusanya AA, Gbolaham OO, Aladelusi TO, Akinmoladun VI, Arotiba JT. Clinical parameters and challenges of managing cervicofacial necrotizing fasciitis in a sub\u0026ndash;saharan tertiary hospital. Nigerian J Surg. 2015;21(2):134\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUmeda M, Minamikawa T, Komatsubara H, Shibuya Y, Yokoo S, Komori T. Necrotizing fasciitis caused by dental infection: a retrospective analysis of 9 cases and a review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontology. 2003;95(3):283\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGore MR. Odontogenic necrotizing fasciitis: a systematic review of the literature. BMC Ear Nose Throat Disorders. 2018;18(1):14.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBayetto K, Cheng A, Sambrook P. Necrotizing fasciitis as a complication of odontogenic infection: a review of management and case series. Aust Dent J. 2017;62(3):317\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIbikunle AA, Taiwo AO, Gbotolorun OM, Braimah RO. Challenges in the management of cervicofacial necrotizing fasciitis in Sokoto, Northwest Nigeria. J Clin Sci. 2016;13(3):143\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChukwuneke FN, Okechi UC, Nwosu JN, Onyeka TC, Okoroafor IJ, Akpeh JO. 2019. Cervico-facial necrotizing fasciitis: a ten-year clinical evaluation of 80 cases in Enugu, Eastern Nigeria. \u003cem\u003eWorld J Oral Maxillofac Surg. 2019; 2 (1)\u003c/em\u003e, \u003cem\u003e1018\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eObimakinde OS, Okoje VN, Akinmoladun VI, Fasola AO, Arotiba JT. Retrospective evaluation of necrotizing fasciitis in University College Hospital, Ibadan. Niger J Clin Pract. 2012;15(3):344\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlasi MA, Aqyil NP, Oyeleke A, Yahaya M, Taiwo AO, Legbo JN. Clinical Presentation and Treatment Outcomes of Necrotizing Fasciitis: A Prospective Comparative Study of Children and Adults in Sokoto. J West Afr Coll Surg. 2025;15(1):59\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGunaratne DA, Tseros EA, Hasan Z, Kudpaje AS, Suruliraj A, Smith MC, Riffat F, Palme CE. Cervical necrotizing fasciitis: systematic review and analysis of 1235 reported cases from the literature. Head Neck. 2018;40(9):2094\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTurki IM. Clinical characteristics and management of odontogenic necrotizing fasciitis: a retrospective study. J Oral Med Oral Surg. 2023;29(2):25.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMorel J, Casoetto J, Josp\u0026eacute; R, Aubert G, Terrana R, Dumont A, Molliex S, Auboyer C. De-escalation as part of a global strategy of empiric antibiotherapy management. A retrospective study in a medico-surgical intensive care unit. Crit Care. 2010;14(6):R225.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAhmadzada S, Rao A, Ghazavi H. Necrotizing fasciitis of the face: current concepts in cause, diagnosis and management. Curr Opin Otolaryngol Head Neck Surg. 2022;30(4):270\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJull AB, Cullum N, Dumville JC, Westby MJ, Deshpande S, Walker N. 2015. Honey as a topical treatment for wounds. \u003cem\u003eCochrane Database of Systematic Reviews\u003c/em\u003e, (3).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGulati S, Qureshi A, Srivastava A, Kataria K, Kumar P, Ji AB. A prospective randomized study to compare the effectiveness of honey dressing vs. povidone iodine dressing in chronic wound healing. Indian J Surg. 2014;76(3):193\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMajid E, Pathan S, Zuberi BF, Rehman M, Malik S. 2023. Comparison of Honey \u0026amp; Povidone Iodine dressings in Post-Cesarean Surgical Site Wound Infection Healing. \u003cem\u003ePakistan Journal of Medical Sciences\u003c/em\u003e, \u003cem\u003e39\u003c/em\u003e(6), p.1803.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUguru N, Onwujekwe O, Ogu UU, Uguru C. 2020. Access to Oral health care: a focus on dental caries treatment provision in Enugu Nigeria. \u003cem\u003eBMC Oral Health\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(1), p.145.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmedari MI, Ogunbodede EO, Uti OG, Aborisade AO, Amedari IK. Strengthening the oral health system in Nigeria: A health systems building block approach. Nigerian Postgrad Med J. 2022;29(3):173\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAnyikwa CL, Ogwo CE. 2025. Enhancing oral health outcomes through public health policy reform. \u003cem\u003eFrontiers in Oral Health\u003c/em\u003e, \u003cem\u003e6\u003c/em\u003e, p.1604465.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Global strategy and action plan on oral health 2023\u0026ndash;2030. World Health Organization; 2024.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8148361/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8148361/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eCervicofacial necrotizing fasciitis (CNF) is a rare, rapidly progressive, and potentially fatal infection of the head and neck, usually secondary to odontogenic infections. Multicentre data from sub-Saharan Africa are limited. We aimed to describe the demographic, clinical, microbiological characteristics, management, and outcomes of patients with CNF in Nigeria.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe conducted a 5-year retrospective multicentre cohort study of patients with CNF of odontogenic origin admitted between January 2019 and December 2023 across eight tertiary hospitals in Nigeria. Data on demographics, clinical features, laboratory findings, microbial isolates, management, and outcomes were extracted using a standardized proforma. Associations between variables and outcomes were assessed with χ\u0026sup2; tests for categorical and ANOVA or Kruskal\u0026ndash;Wallis tests for continuous data. Kaplan\u0026ndash;Meier survival analysis was performed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003e138 patients were included (mean age 54\u0026middot;5\u0026thinsp;\u0026plusmn;\u0026thinsp;17\u0026middot;1 years; range 2 months\u0026ndash;104 years; 51\u0026middot;4% female). Most had low education (56\u0026middot;5%) and paid out-of-pocket (88\u0026middot;4%). The submandibular (58\u0026middot;4%) and neck (43\u0026middot;2%) regions were most affected, with mandibular molars as the main source. Diabetes mellitus (16\u0026middot;4%) and hypertension (11\u0026middot;9%) were common comorbidities. Gram-negative rods (24\u0026middot;1%) and Staphylococcus species (11\u0026middot;3%) were the most frequent isolates. Almost all patients (99\u0026middot;2%) underwent surgical debridement under local anaesthesia, with healing by secondary intention in 70\u0026middot;4%. Overall survival was 82\u0026middot;2%. Wound closure technique and comorbidities were significantly associated with outcomes (p\u0026thinsp;\u0026lt;\u0026thinsp;0\u0026middot;05). Delayed presentation and prolonged time before oral and maxillofacial review were linked to poorer outcomes.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eCNF in Nigeria primarily affects middle-aged adults of low socioeconomic status and arises from neglected dental infections. Prompt surgical intervention yielded relatively favourable outcomes despite resource constraints. Strengthening primary oral care, early dental infection management, and integration into national health insurance could reduce CNF morbidity and mortality.\u003c/p\u003e","manuscriptTitle":"Clinical Characteristics, Management, and Outcomes of Patients with Cervicofacial Necrotizing Fasciitis in Nigeria: A 5-year multicentre, retrospective, cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-11 14:28:58","doi":"10.21203/rs.3.rs-8148361/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-05T09:26:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-23T14:05:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-20T18:23:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-19T18:12:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-13T14:48:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-13T11:09:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"10466651904812335255845736123413157901","date":"2025-12-11T05:34:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"178711713843493364256484072758897236712","date":"2025-12-10T15:18:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"130479567507674140493197903035853821049","date":"2025-12-10T13:39:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"55838028011990930142274357753427635658","date":"2025-12-09T11:36:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"77066409071318013189795075693653877205","date":"2025-12-08T21:59:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"162863956181449491906644364141932874507","date":"2025-12-08T19:32:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-08T15:19:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-02T06:14:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-01T06:09:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-11-29T22:56:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"496b43b5-8f9c-4f72-8a42-6147539f5275","owner":[],"postedDate":"December 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-01-05T09:39:07+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-11 14:28:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8148361","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8148361","identity":"rs-8148361","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}