INFECTION

EVALUATE THE STATE OF THE PATIENT’S HOST

DEFENSE MECHANISMS

A. Review of host defense mechanism

B. Medical condition that compromise host defense

A. HOST DEFENSE MECHANISMS

• LOCAL DEFENSES– Intact anatomic barrier– Indigenous bacteria

• HUMORAL DEFENSES– Immunoglobulins– Complement

• CELLULAR DEFENSES– Phagocytes

• Granulocytes• Monocytes

– Lymphocytes

B. COMPROMISED HOST DEFENSES

• UNCONTROLLED METABOLIC DISEASESUremiaAlcoholismMalnutritionSevere diabetes

• SUPPRESSING DISEASESLeukemiaLymphoma

• SUPPRESSING DRUGSCancer chemotherapeutic agentsImmunosuppressive

Intact skinIntact mucosa

INTACT ANATOMIC BARRIER

BREACHES ANATOMIC BARRIER

• Surgical incisions

• Deep periodontal pockets

• Necrotic Dental pulps

INDIGENOUS BACTERIA

• Usually live in harmony

• Usually do not cause disease

• When normal bacteria are lost or altered will cause disease

DIFFERENCES BETWEEN CELLULITIS & ABSCESS

CELLULITIS ABSCESS

Acute Chronic

Severe & Generalized Localized

Large Small

Diffuse border Wellcircumscribed

Doughy to indurated Fluctuant

NO YES

Greater Less

Aerobic Anaerobic

continued……..

CHARACTERISTIC• Duration

• Pain

• Size

• Localization (peripheral definition)

• Palpation (texture)

• Presence of pus

• Degree of seriousness (potential danger)

• Bacteria

DIFFERENCES BETWEEN CELLULITIS & ABSCESS

CRITERIA FOR REFERRAL TO A SPECIALIST

Difficulty in breathing Rapidly progressive infection Difficulty in swallowing Fascial space involvement

Continued….

CRITERIA FOR REFERRAL TO A SPECIALIST

Elevated temperature (greater than 38°C)

Severe jaw trismus (less than 10 mm)

Toxic appearance Compromised host

defenses

INDICATIONS FOR USE OF ANTIBIOTICS

Acute-onset infection Diffuse swelling Compromised host defenses Involvement of fascial spaces Severe pericoronitis OSTEOMYELITIS

SITUATIONS IN WHICH USE OF ANTIBIOTICS IS NOT NECESSARY

• Chronic well-localized abscess

• Minor vestibular abscess

Continued………

SITUATIONS IN WHICH USE OF ANTIBIOTICS IS NOT NECESSARY

• Dry socket

• Root canal sterilization

• Mild pericoronitis

EFFECTIVE ORALLY ADMINISTERED ANTIBIOTICS USEFUL FOR

ODONTOGENIC INFECTIONS

o Penicillin

o Erythromycin

o Clindamycin

Continued….

EFFECTIVE ORALLY ADMINISTERED ANTIBIOTICS USEFUL FOR

ODONTOGENIC INFECTIONS

o Cephalexin

o Cefaclor

o Metronidazole

o Tetracycline

INDICATIONS FOR CULTURE AND ANTIBIOTIC SENSITIVITY

TESTING

Rapidly spreading infection

Post operative infection

Non responsive infection

Recurrent infection

Continued….

INDICATIONS FOR CULTURE AND ANTIBIOTIC SENSITIVITY

TESTING

Compromised host defenses

Osteomyelitis

Suspected actinomycosis

REASONS FOR TREATMENT FAILURE

• Inadequate surgery

• Depressed host defenses

• Foreign body

Continued….

REASONS FOR TREATMENT FAILURE

• Antibiotic problems :

- patient non compliance

- drug not reaching site

- drug dosage too low

- wrong bacterial diagnosis

- wrong antibiotic

ADVANTAGES OF APPROPRIATE PROPHYLACTIC ANTIBIOTIC USE

Reduces incidence of infection Reduces health care costs Reduces total antibiotic usage Allows fewer resistant bacteria

DISADVANTAGES OF APPROPRIATE PROPHYLACTIC ANTIBIOTIC USE

• Alters host flora

• May be of no benefit

• May encourage lax surgery

PRINCIPLES OF PROPHYLACTIC ANTIBIOTIC

USE

• Risk of infection must be significant• Choose correct antibiotic• Antibiotic level must be high• Time the antibiotic correctly• Use shortest effective antibiotic

exposure

FACTORS RELATED TO POSTOPERATIVE INFECTION

• Size of bacterial inoculum

• Extend and time of surgery

• Presence of foreign body

• State of host resistance

FACTORS NECESSARY FOR METASTATIC INFECTION

• Distant susceptible site• Hematogenous bacterial seeding• Impaired local defenses

continued……..

FACTORS NECESSARY FOR METASTATIC INFECTION

• Hematogenous bacterial seeding

CARDIAC VALVULAR LESIONS THAT MAY PREDISPOSE TOWARD

ENDOCARDITIS

Prosthetic heart valve Most congenital heart malformations Rheumatic valve disease Degenerative valve disease

Continued….

CARDIAC VALVULAR LESIONS THAT MAY PREDISPOSE TOWARD

ENDOCARDITIS

Idiopathic hypertrophic subaorthic stenosis

Mitral valve prolapse with insufficiency

Previous episode of bacterial endocarditis

DENTAL PROSEDURES THAT REQUIRE ENDOCARDITIS

PROPHYLAXIS

Tooth extraction Periodontal surgery Subgingival dental prophylaxis Endodontic surgery Incision and drainage of infections

DENTAL PROSEDURES THAT DO NOT REQUIRE

ENDOCARDITIS PROPHYLAXIS

• Supragingival prophylaxis

• Restorative tooth preparation

• Placement of orthodontic appliances

• Conservative endodontic therapy

ANTIBIOTIC REGIMEN FOR PROPHYLAXIS OF TOTAL JOINT

REPLACEMENT INFECTIONSTANDARD RECOMMENDATION1. Cephalosporin (cefadroxil preferred) • Pre operatively : 500 mg orally 1 hr before surgery• Post operatively : 250 mg orally 6 hr after initial

doseOR

2. Clindamycin (penicillin-allergic patients)• Pre operatively : 300 mg orally 1 hr before

surgery• Post operatively : 150 mg orally 6 hr after initial

dose

SPACES INVOLVED IN ODONTOGENIC INFECTION

• Primary maxillary spaces Canine Buccal Infra temporal

• Primary mandibular spaces Submental Buccal Submandibular Sublingual

• Secondary fascial spaces Masseteric Pterygomandibular Superficial and deep

temporal Lateral pharyngeal Retropharyngeal Prevertebral

SPACES INVOLVED IN ODONTOGENIC INFECTIONS

• Primary Maxillary Spaces

– Caninus

– Buccal

– Infratemporal

SPACES INVOLVED IN ODONTOGENIC INFECTIONS

Primary Mandibular Spaces– Submental– Buccal– Submandibular– Sublingual

Continued….

Buccal Space

Sublingual Space

Sublingual Space

Submandibular Space

SPACES INVOLVEMENT IN ODONTOGENIC INFECTION

Secondary Mandibular Spaces Masseteric Pterygomandibular Superficial and deep temporal Lateral pharyngeal Retropharyngeal Prevertebral

Continued….

SPACES INVOLVEMENT IN ODONTOGENIC INFECTION

Continued….

Secondary Mandibular Spaces

SPACES INVOLVEMENT IN ODONTOGENIC INFECTION

• Secondary Mandibular Spaces Lateral

pharyngeal

Continued….

SPACES INVOLVEMENT IN ODONTOGENIC INFECTION

Secondary Mandibular Spaces

Retropharyngeal

Continued….

COMPLEX ODONTOGENIC INFECTION

I. Fascial space infection A.Maxillary spaces B.Mandibular spaces C.Secondary fascial spaces D.Cervical fascial spaces E.Management of fascial space infections II. OsteomyelitisIII. ActinomycosisIV. Candidosis Continued….

COMPLEX ODONTOGENIC INFECTION

II. Osteomyelitis

Continued….

COMPLEX ODONTOGENIC INFECTION

III. Actinomycosis

Continued….

COMPLEX ODONTOGENIC INFECTION

IV. Candidosis

The End