Odontogenic Odontogenic InfectionsInfections

DR MOHAMMAD AKHEEL DR MOHAMMAD AKHEEL

OMFS PG OMFS PG

Odontogenic InfectionsOdontogenic Infections

One of the most One of the most difficult problemsdifficult problems

Range from low-Range from low-grade to severe, life-grade to severe, life-threateningthreatening

Most are easily Most are easily managed with minor managed with minor surgery and surgery and antibioticsantibiotics

Odontogenic InfectionsOdontogenic InfectionsOdontogenic InfectionsOdontogenic Infections

Systematic Systematic approach to approach to Infection PatientInfection Patient– Typical MicrobiologyTypical Microbiology– Natural history of Natural history of

odontogenic odontogenic infectionsinfections

– Principles of Principles of infection infection managementmanagement

– Indications for Indications for referral to OMSreferral to OMS

Microbiology Microbiology Microbiology Microbiology

Indigenous bacteriaIndigenous bacteria– Normal oral floraNormal oral flora

Polymicrobial Polymicrobial Aerobic-anaerobic compositionAerobic-anaerobic composition

– Aerobic gram + cocci (Streptococci)Aerobic gram + cocci (Streptococci)– Anaerobic gram + cocci (Strep, Peptostrep, Anaerobic gram + cocci (Strep, Peptostrep,

Pepto), gram + rods (Eubac, Lacto), and Pepto), gram + rods (Eubac, Lacto), and gram - rods (Porphromonas or Prevotella, gram - rods (Porphromonas or Prevotella, Fusobacterium)Fusobacterium)

Progression of Odontogenic Progression of Odontogenic InfectionsInfections

Progression of Odontogenic Progression of Odontogenic InfectionsInfections

PeriapicalPeriapical PeriodontalPeriodontal Soft tissue involvementSoft tissue involvement

– Determined by perforation of the cortical Determined by perforation of the cortical bone in relation to the muscle attachmentsbone in relation to the muscle attachments

Cellulitis- acute, painful, diffuse bordersCellulitis- acute, painful, diffuse borders Abscess- chronic, localized pain, fluctuant, Abscess- chronic, localized pain, fluctuant,

well circumscribed.well circumscribed.

Progression of Odontogenic Progression of Odontogenic InfectionsInfections

Progression of Odontogenic Progression of Odontogenic InfectionsInfections

Progression of Odontogenic Progression of Odontogenic InfectionsInfections

Principles of TreatmentPrinciples of TreatmentPrinciples of TreatmentPrinciples of Treatment

Determine the Determine the severity of the severity of the infectioninfection

Complete historyComplete history Physical Physical

examinationexamination State of the patients State of the patients

host defense host defense Treat the infection Treat the infection

surgicallysurgically

Principles of TreatmentPrinciples of TreatmentPrinciples of TreatmentPrinciples of Treatment

Support the patient Support the patient medicallymedically

Choose and Rx the Choose and Rx the appropriate ABappropriate AB

Re-evaluate the Re-evaluate the patient frequentlypatient frequently

Referral to OMS?Referral to OMS?

Severity of the InfectionSeverity of the InfectionSeverity of the InfectionSeverity of the Infection

Complete Complete HistoryHistory– Chief ComplaintChief Complaint– OnsetOnset– Duration Duration – SymptomsSymptoms

Severity of the InfectionSeverity of the InfectionSeverity of the InfectionSeverity of the Infection

How the patient How the patient feels- Malaisefeels- Malaise

Previous Previous treatmenttreatment

Self treatmentSelf treatment Past Medical Past Medical

HistoryHistory

Physical ExaminationPhysical ExaminationPhysical ExaminationPhysical Examination

Vital SignsVital Signs– Temperature- Temperature-

systemic systemic involvement >101 Finvolvement >101 F

– Blood Pressure- Blood Pressure- mild elevationmild elevation

– Pulse- >100Pulse- >100– Increased Increased

Respiratory Rate- Respiratory Rate- normal 14-16normal 14-16

Physical ExaminationPhysical ExaminationPhysical ExaminationPhysical Examination

General appearanceGeneral appearance Palpate the area of Palpate the area of

swellingswelling– Indurated- firm, hardIndurated- firm, hard– Fluctuant- fluid filledFluctuant- fluid filled– Doughy- normalDoughy- normal

Intra-oral examIntra-oral exam

Intraoral ExamIntraoral Exam

Radiographic ExaminationRadiographic Examination

PanorexPanorex Plain FilmsPlain Films CTCT MRIMRI

Radiographic Examination-Plain Radiographic Examination-Plain FilmsFilms

Radiographic Examination- Radiographic Examination- CTCT

Host Defense MechanismsHost Defense MechanismsHost Defense MechanismsHost Defense Mechanisms

Local defensesLocal defenses– Intact anatomic barrierIntact anatomic barrier– Indigenous bacteriaIndigenous bacteria

Humoral defensesHumoral defenses– ImmunoglobulinsImmunoglobulins– ComplementComplement

Cellular defensesCellular defenses– PhagocytesPhagocytes– LymphocytesLymphocytes

Medically Compromised Medically Compromised PatientsPatients

Medically Compromised Medically Compromised PatientsPatients

Uncontrolled Uncontrolled metabolic diseasesmetabolic diseases– AlcoholismAlcoholism– MalnutritionMalnutrition– DiabetesDiabetes

Suppressing Suppressing diseasesdiseases– LeukemiaLeukemia– LymphomaLymphoma– Malignant TumorsMalignant Tumors

Medically Compromised Medically Compromised PatientsPatients

Medically Compromised Medically Compromised PatientsPatients

Suppressing drugsSuppressing drugs– Chemotherapeutic Chemotherapeutic

agentsagents– ImmunosuppressivesImmunosuppressives

Indications for Indications for Referral to OMSReferral to OMSIndications for Indications for

Referral to OMSReferral to OMS

Rapidly Rapidly progressing progressing infectioninfection

Difficulty in Difficulty in breathingbreathing

Difficulty Difficulty swallowingswallowing

Fascial space Fascial space involvementinvolvement

Indications for ReferralIndications for ReferralIndications for ReferralIndications for Referral

Elevated Elevated Temperature >101 FTemperature >101 F

Severe trismusSevere trismus Toxic appearanceToxic appearance Compromised host Compromised host

defensesdefenses

Signs of InflammationSigns of InflammationSigns of InflammationSigns of Inflammation

Dolor- PainDolor- Pain Tumor- SwellingTumor- Swelling Calor- WarmthCalor- Warmth Rubor- RednessRubor- Redness Loss of functionLoss of function

– TrismusTrismus– Difficulty in Difficulty in

breathing, breathing, swallowing, chewingswallowing, chewing

Surgical TreatmentSurgical TreatmentSurgical TreatmentSurgical Treatment

Provide drainageProvide drainage Remove the cause Remove the cause

of infectionof infection– PulpectomyPulpectomy– ExtractionExtraction– Remove foreign Remove foreign

bodybody– Debride non-viable Debride non-viable

bonebone Culture and Culture and

sensitivitysensitivity

Surgical TreatmentSurgical TreatmentSurgical TreatmentSurgical Treatment

Incision and Incision and drainagedrainage– Dependent siteDependent site– Incision in healthy Incision in healthy

tissuetissue– Adequate drainageAdequate drainage– Exploration of all Exploration of all

involved spacesinvolved spaces– IrrigationIrrigation

Surgical TreatmentSurgical Treatment

Indications for Culture and Indications for Culture and Sensitivity TestingSensitivity Testing

Indications for Culture and Indications for Culture and Sensitivity TestingSensitivity Testing

Rapidly spreading Rapidly spreading infectioninfection

Post-op infectionPost-op infection Non-responsive Non-responsive

infectioninfection Recurrent infectionRecurrent infection Compromised host Compromised host

defensesdefenses

Microbiologic ConsiderationsMicrobiologic Considerations

Identification of Identification of bacteriabacteria– Representative Representative

specimen collectedspecimen collected– Examine specimenExamine specimen– Submit for culture Submit for culture

and sensitivityand sensitivity– Gram StainGram Stain

Culture and SensitivityCulture and Sensitivity

Gram StainGram Stain

Choosing the Appropriate Choosing the Appropriate AntibioticAntibiotic

Choosing the Appropriate Choosing the Appropriate AntibioticAntibiotic

Is an antibiotic Is an antibiotic necessary?necessary?

Indications:Indications:– Acute onset infectionAcute onset infection– Diffuse swellingDiffuse swelling– Compromised host Compromised host

defensesdefenses– Involvement of Involvement of

fascial spacesfascial spaces– Severe pericoronitisSevere pericoronitis

Principles of Antibiotic Principles of Antibiotic TherapyTherapy

Principles of Antibiotic Principles of Antibiotic TherapyTherapy

Use Empiric Use Empiric TherapyTherapy

Use narrowest Use narrowest spectrum drugspectrum drug

Use antibiotic with Use antibiotic with the lowest toxicitythe lowest toxicity

Use bactericidal Use bactericidal antibioticantibiotic

Be aware of Cost $$Be aware of Cost $$$$

Principles of Antibiotic Principles of Antibiotic TherapyTherapy

Principles of Antibiotic Principles of Antibiotic TherapyTherapy

Administer the Administer the antibiotic properlyantibiotic properly

Proper route of Proper route of administrationadministration

Proper doseProper dose Proper time intervalProper time interval Adequate period of Adequate period of

administrationadministration

Antibiotic Cost ComparisonAntibiotic Cost ComparisonAntibiotic Cost ComparisonAntibiotic Cost Comparison

DrugDrug DoseDose Cost for 10 Cost for 10 daysdays

Pen VKPen VK QIDQID $1.20$1.20 E-mycinE-mycin QIDQID $3.20$3.20 KeflexKeflex QIDQID $4.00$4.00 DuricefDuricef BIDBID $37.80$37.80 CiproCipro BIDBID $34.20$34.20

Antibiotic ComplianceAntibiotic ComplianceAntibiotic ComplianceAntibiotic Compliance

Dosage interval that encourages Dosage interval that encourages compliancecompliance

QD or BIDQD or BID 70%70%QIDQID 40%40%

Non-compliant after start feeling Non-compliant after start feeling betterbetter

3-5 days3-5 days 50%50%>7 days>7 days 20%20%

Support Patient MedicallySupport Patient MedicallySupport Patient MedicallySupport Patient Medically

FluidsFluids NutritionNutrition AnalgesicsAnalgesics Consider need for Consider need for

insulininsulin

Patient MonitoringPatient MonitoringPatient MonitoringPatient Monitoring

Re-evaluate the Re-evaluate the patient frequentlypatient frequently

Response to Response to treatmenttreatment– TemperatureTemperature– SwellingSwelling– How do you feel?How do you feel?

Need for additional Need for additional imaging?imaging?

Patient MonitoringPatient Monitoring

Development of an Development of an adverse reaction?adverse reaction?

Antibiotic Associated ColitisAntibiotic Associated Colitis

DiagnosisDiagnosis– Profuse watery Profuse watery

diarrhea >10 per daydiarrhea >10 per day– CrampingCramping– FeverFever– C. difficle culture and C. difficle culture and

toxin assaytoxin assay– Tissue cultureTissue culture

TreatmentTreatment– D/C current ABD/C current AB– Fluid managementFluid management– AntibioticsAntibiotics

» MetronidazoleMetronidazole» Vancomycin POVancomycin PO

Reasons for Treatment FailureReasons for Treatment FailureReasons for Treatment FailureReasons for Treatment Failure

Inadequate SurgeryInadequate Surgery Depressed host Depressed host

responsesresponses Foreign bodyForeign body Antibiotic problemsAntibiotic problems

– Patient noncompliancePatient noncompliance– Drug not reaching the Drug not reaching the

sitesite– Drug dose too lowDrug dose too low– Wrong antibioticWrong antibiotic

Fascial Space InfectionsFascial Space Infections

Mandibular Odontogenic InfectionsMandibular Odontogenic Infections

Sublingual spaceSublingual space Submental spaceSubmental space Submandibular Submandibular

spacespace Masticator spaceMasticator space Lateral pharyngeal Lateral pharyngeal

spacespace Retropharyngeal Retropharyngeal

spacespace

Submental Space InfectionSubmental Space Infection

Submental Space InfectionSubmental Space Infection

Sublingual Space InfectionSublingual Space Infection

Sublingual Space InfectionSublingual Space Infection

Submandibular Space Submandibular Space InfectionInfection

Masticator Space InfectionMasticator Space Infection

Masticator Space InfectionMasticator Space Infection

Lateral Pharyngeal SpaceLateral Pharyngeal Space

Retropharyngeal SpaceRetropharyngeal Space

Ludwig’s AnginaLudwig’s Angina

Maxillary Odontogenic InfectionsMaxillary Odontogenic Infections

Canine spaceCanine space Infratemporal Infratemporal

spacespace Temporal spaceTemporal space Buccal spaceBuccal space

Canine Space InfectionCanine Space Infection

Buccal Space InfectionBuccal Space Infection

Temporal Space InfectionTemporal Space Infection

Temporal Space InfectionTemporal Space Infection

Head and Neck InfectionsHead and Neck Infections

Peritonsilar Peritonsilar abcessabcess

Acute orbital Acute orbital cellulitiscellulitis

Cavernous sinus Cavernous sinus thrombosisthrombosis

MeningitisMeningitis Necrotizing Necrotizing

fascitisfascitis

Acute Orbital CellulitisAcute Orbital Cellulitis

Treatment of Odontogenic Treatment of Odontogenic InfectionsInfections

Determine the Determine the severity of the severity of the infectioninfection

Complete historyComplete history Physical Physical

examinationexamination State of the patients State of the patients

host defense host defense Treat the infection Treat the infection

surgicallysurgically

Support the patient Support the patient medicallymedically

Choose and Rx the Choose and Rx the appropriate ABappropriate AB

Re-evaluate the Re-evaluate the patient frequentlypatient frequently

Referral to OMS?Referral to OMS?

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