Principles of managementof Odontogenic Infections
Dr Milad Parvin
Oral and Maxillofacial Surgeon
Assistant professor
Boushehr University of Medical Sciences
Microbiology of Odontogenic infections
• Bacteria that cause odontogenic infections are part of normal flora
• Aerobic gram positive cocci
• Anaerobic gram positive cocci
• Anaerobic gram negative rods
• They cause dental caries, gingivitis and periodentitis
• Almost all of of Odontogenic infections are caused by multiple bacteria
How an Aerobic bacteria cause OIs
• 1-intial inoculation in deeper tissues
• 2-synthesis of hyaluronidase by s.milleri group
• 3-allowing other organisms to initiate cellulitis stage
How an Aerobic bacteria cause OIs
•Streptococci create a favorable environment for anaerobs by:
1-release essential nutrients
2-lowering PH
3-consumption of O2
• Than anaerobic bacteria become predominant and cause liquefaction necrosis by collagenase
liquefaction necrosis become:
Microabcess
Than clinically recognizable abscess
anaerobes become predominate
odontogenic infections origins
1-periapical (palpal necrosis): most common
2- periodental(deep pocket)
Predictable anatomic locations of spreading
• 1-thickness of bone overlying the apex
• 2-relationship of perforation site to muscle attachments
Principle 1:
determine severity of infection
• Complete history of current infection
• and physical examination
Complete history
• Chief compliant (patient own words)
• History of chief compliant of OI
1-how long OI been present
2-time of onset
3-how long from first symptoms (pain-swelling-drainage)
4-change of severity in time
Clinical sign of infections
• Infections are actually a severe inflammation
Redness
Pain
Swelling
Warmth
loss of function
Previous Treatment
• Professional treatment
• Self treatment
• leftover antibiotics
• herbal remedies
• Completing the last treatment
Physical examination
• Vital signs
• Temperature
• Blood pressure
• pulse rate
• respiratory rate: 14-16 in a min
• Pain and anxiety
• septic shock results in Hypotension
• Extention of Infection in fascial spaces of neck = partial or complete upper airway obstruction
Physical examination
• Inspection of patients general appearancetoxic appearancemalaisefatiguefeverishness
• Sign of infection
• Opening mouth
• Swallowing
• breathing
palpation
• In the area of swelling
• Tenderness
• Local warmth
• Consistency of swelling(soft-doughy-indurated-fluctuance)
• Fluctuance =a fluid filled balloon in the center of indurated tissue
Intra oral examination
• To find specific cause of infection
• Like severely carious teeth, periodontal abscess, periodontal disease ,
• Infected fracture of a tooth or entire of the jaw
• Should look for
• Area of gingivitis , swelling , draining sinus tracts
Radiographic examination
• Usually PA radiographs
• If there was any trismus and limited mouth opening or tenderness=panoramic view may be necessary
Serious infection
• Abnormal vital signs
• Elevation in temperature ,blood pressure ,respiratory rate,
• Require more intensive therapy and evaluation by maxillofacial surgeon
Sense the stage of the infection and then ..
inoculation stage:
may be cured by removal of odontogenic cause
with or without supportive antibiotics
Cellulitis or abscess stages:
removal of dental cause
incision and drainage
antibiotics
Principle 2 evaluate state of patients host
defense mechanisms
compromise host defense:
• infection may be spread more• treated more vigorously
• referral to MXF surgeon
• parenteral antibiotic therapy
Principle 3 determine whether patient should be treated by general dentist or oral-maxillofacial surgeon
Mostly: managed by DENTIST
Main criteria for Referring
1- rapidly progressive infection
2- dyspnea
3- dysphagia
4- drooling
threat to the airway
Other criteria
• 1-extraoral Swelling
• 2-High temperature
• 3-trismus
• MIO between:
• 20 and 30 =mild
• 10 and 20 =moderate
• less than 10 = severe
Other criteria
• Moderate or severe:
• infection in masticator spaces or worse both the lateral pharyngeal space and retropharyngeal space
• 4- systematic involvement (toxic appearance)
• 5- compromised host defense
Principle 4: treat infection surgically
odontogenic infections are a
surgicallymanaged disease process
antibiotics
Principle 4: treat infection surgically
elimination of the cause
source control
endodontic or periodontal
primary principle
Incision & Drainage
1-decrease the load of bacteria and necrotic debries
2-Reduce the hydrostatic pressure in the region. which improve blood supply and delivery of host defense and antibiotic
3-stop cellulitis to spread deeper
•Whenever an abscess or cellulitis is diagnosed the surgeon must drain it.
• even if tooth cant be opened or extracted immedietly
• Antibiotic should be used if complete dranage cannot be achieved
Dehydration
• Fever increase fluid requirement
• Inadequate fluid intake –because of the swelling –pain and…
• They should be encouraged to drink water and to take high –nutritional supplements
• -should be taking analgesics for pain
Principle 6 : choose and prescribe
appropriate antibiotic
• 1- seriousness of infection
• 2-whether adequate surgical treatment can be achieved
• 3- patients host defense
AB used in OI
For anaerobic bacteria = metronidazole and should be used in combination to others
Fewest times daily to improve compliance
C&S test should be considered
Use a bactericidal AB if possible
• Host defense play a less important role
• Specially in medically compromised patient
Penicillin
Principle 7 : administer antibiotic properly
• For odontogenic infection a 3or 4 day course of penicillin with appropriate surgery is effective as a 7 day course
• entire prescription must be taken
Principle 8: evaluate frequently
2 to 3 days after therapy
Check the site of I&D to remove the drain