Principles of management and prevention of

Odontogenic Infections Chapter 16 of Contemporary Oral and Maxillofacial Surgery-2014

Seyed vahid malek hosseinishahid sadoughi university of medical sciences

Microbiology of Odontogenic infections• Bacteria that cause odontogenic infections are part of normal flora• Aerobic gram positive coocci • Anaerobic gram positive coocci • An aerobic gram negative rods • The cause dental caries ,gingivitis and periodentitis • Almost all of of Odontogenic infections are caused by multiple

bacteria

Streptococcus milleri group • Predominant aerobic bacteria in OI• 3 members• S.anginious • S.intermedious • S.constellatus• They can initiate process of spreading in deep tissue because they can

live in absence of O2

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 (aerobic strep inf) Streptococci create a favorable environment for anaerobs by • 1-release essential nutrients• 2-lowered PH• 3-consumption of O2• Than anaerobic bacteria become predominant and cause liqueinfaction

necrosis by collagenase

liqueinfaction necrosis become• Microabcess • Than clinically recognizable abcess• and In the abcess• -anaerobics become predominate

4 stage of odentogenic infections• 1-inoculation stage-first 3 days-soft mildly tender doughy sweelling

(invading streps)• 2cellulitis stage-after 3 to 5 days-swelling become hard, red ,acutely

tender(mixed flora)• 3-abcess stage- at 5to7 days-liquefied abscess in the center of

swelling (anaerobic begin to predominate)• 4-resolution stage-spontaneously or surgicaly drainage of abcess-

destruction of bacteria by immune system-healing

Natural history of progression of odontogenic infections

odontogenic infections origins

• 1-periapical (palpal necrosis) –most common

• 2periodental(deep pocket)

1-periapical • Treatment =• -endodontic or extraction

• Antibiotic alone therapy just may arrest OI

Predictable anatomic locations of spreading • 1-thickness of bone overlying the apex• 2-relationship of perforation site to muscle attachments

In maxilla • 1-Most of the infections erode through the bone below the

attachment of muscles (vestibular abscess)• 2-palatal abscess arises from severely inclined lateral incisor or palatal

root of first molar or premolar• 3-buccal space infection from maxillary molar infections that erode

through bone superior to insertion of buccinators muscle• 4-infraorbital (canine) space infection –long canine root-superior to

insertion of levator anguli oris muscle

mandible• 1-vestibular abscess-incisors ,canine ,premolars –erode through facial

cortical plate , superior to attachment of the muscles of lower lip• 2-first molar – may drain Buccally or lingual• 3-second molar-may drain buccally or lingual - usually lingually• 4-third molar –almost always lingually • Mylohyoid muscle determine whether infections drain lingually go

superior to sunlingual space or below to submandibular space

Chronic sinus tract• The abscess May establishes If the patient• do not seek treatment• In oral cavity or skin• No pain as long as its open• Treatment =endodontic or extraction • Antibiotic = just arrest

Principles of therapy of Odontogenic Infections

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• So • Redness-pain-swelling-warmth-loss of function

pain• Most common compliant • Where it started • How it spread since first noted

Swelling and …• Ask about area of swelling• warmth• Whether the area has felt warm to the touch • Redness• Ask about Any change of the color especially redness• function• Dentist should ask about trismus .dyspnea, dysphagia• Finally • Ask how patient feel in general• Fatigue ,weak , sick, feverish

Previous Treatment • Ask about• Professional treatment • Self treatment –leftover antibiotics-hot soaks –herbal remedies• Completing the last treatment

Physical examination

• Vital signs( temperature -bp-pulse rate-respiratory rate)• Severe infections = greater temperature than 38 c)• Infection = pulse rate up to 100• Severe infection = greater than 100= aggressive treatment• Pain and anxiety = elevation on systolic bp• septic shock result in Hypotension • Extention of Infection in fascial spaces of neck = partial or complete upper

airway obstruction • Normal respiratory rate=14-16 in a min• Mild of moderate infection = respiratory rate greater than 18 per min

Mild infection• Normal vital sign • Only a mild temperature elevation• Can be rapidly treated

Serious infection • Abnormal vital signs • Elevation in temperature ,blood pressure ,respiratory rate,• Require more intensive therapy and evaluation by maxillofacial

surgeon

Physical examination• Inspection of patients general appearance(toxic

appearance ,malaise ,fatigue ,feverishness)• 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

Sense the stage of the infection and than ..• Soft tissue infection in inoculation stage may be cured by removal of

odontogenic cause with or without supportive antibiotics

Cellulitis or abscess stages require removal of dental cause ,incision and drainage and antibiotics

Distinctions between inoculation cellulitis and abscess

Distinctions between inoculation cellulitis and abscess • Cellulitis is usually acute –more painful-larger-indurated or boardlike-

aggressive-dangerous-diffuse border-• Abscess is assign of increasing host resistance-feels flucuant because

of the pus -chronic-les aggressive• Inoculation =edema is its hallmark –minimal tenderness-diffuse and

jelly-like-easily treated-

Principle 2 evaluate state of patients host defense mechanisms• With patients medical history • medical conditions that• compromise host defense :• Allow more bacteria• to enter tissue or to• be more active

Diabetes I and II• Most common immunocompromising disease • Lower control of hyperglycemia =lower resistance to all types of

infections

Leukemia and lymphomas and cansers• Second major immunocompromosing diseases• Result in decrease WBC function and antibody function and

production

HIV• Because Odontogenic infections are caused by bacteria • And hiv attacks t lymphocytes • Hiv + patient are able to combat odontogenic infections fairly• Until the AIDS stage when b cells are also impaired • It will be more intensive than normal patients

Pharmaceuticals that compromise host defense• Cancer chemotherapeutic agents=decrease circulating WBC counts

usually less than 1000 cell/ml =effect of some agents can last for a year after end of therapy• Immunosuppressive therapy in organ transplantation and

autoimmune disease • Most common drugs are cyclosporine ,tacrolimus ,azathioporine• They can decrease b Cells and t cells function and decrease of

antibody production

Principle 2 evaluate state of patients host defense mechanisms• Patient with history of condition or anything that compromise host

defense must be treated more vigorously because infection may be spread more • So referral to MXF surgeon and initiate parenteral antibiotic therapy

must be considered

Principle 3 determine whether patient should be treated by general dentist or oral-maxillofacial surgeon• Most of OI can be managed by dentist with expectation of rapid

healing• Some are life threatening and require aggressive treatment by

surgeon• For some hospitalization is required

main criteria for Referring• The main criteria for hospitalization is an impending threat to the

airway• 1-rapidly progressive infection that may cause swelling in deep fascial

space of neck ,which can compress and deviate airway• 2-dyspnea –swelling of upper airway-refuse to lie down-distorted

speech-distressed by breathing difficulty –should be referred directly to emergency room• 3-dysphagia-drooling-should be referred directly to emergency room

Other criteria • 1-extraoral Swelling –buccal space-submandibular space –because

may require incision and drainage • 2-High temperature • 3-trismus-opening between 20 and 30 =mild -10 and 20 =moderate-

less than10 = severe• Moderate of severe =infection in masticator spaces or worse both the

lateral pharyngeal space and retropharyngeal space• 4- systematic involvement(toxic appearance)• 5- compromised host defense

Toxic appearance • Glazed eye• Open mouth • Dehydrated • Sick appearance • Fatigued • Has a substantial amount of Pain • elevated temperature

Principle 4: treat infection surgically• The primary principle of management of OI is to perform surgical

drainage and remove the cause of infection (necrotic pulp mostly or deep pocket)• Endodontic access-wide incision of tissue in the neck-• remove the cause of infection is the primary goal• Secondary goal is to provide drainage

I & D• 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

Technique for I&D

Technique for I&D intra oraly• 1-preffered site is the site with maximum swelling• 2-avoid incising across a frenum or path of mental nerve

Technique for I&D extraoraly• 1-method of pain control =regional nerve block by injecting in an area

away from site on infection• 2-do not reuse the needle if it been used in an infection area• 3-culture sensitivity test most be considered before I&D and it most

be carried out in the first portion of surgery• 4-disinfect the area by betadine and dry it by gauze

incision• 1-most be short .no more than 1cm length • 2-wite a scalpel blade • 3- open the cavity with a closed curved hemostat and then it will be

opened in several directions• 4 –suction of pus and tissue fluids• 5-insert a small drain to maintain opening to reach depth of abscess

(quarterinch sterile Penrose drain or rubber dam or surgical glove material )-be aware of latex sensitivity • 6-suture the drain to edge os incision with a non- resorbable suture-2 to 5

days

•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

Principle 5 support patient medically• Medically compromised patient • 1-should be treated by specialists• 2-hospitalization and consolation are required • 3-antibiotics

Medications • Coumadin (warfarin)-require reversal of anticoagulation before

surgery

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

Indication for AB• 1-Most common indication Presence of an acute-onset infection with

diffuse swelling and moderate to severe pain• 2-immunologically compromised patient • 3-involvement of the deep fascial space• 4-severe pericoronitis with fever• 5-osteomyelitis

Other indications

Containdication for AB• 1-minor –chronic well-localized abscess• 2-well localized dentoalveolar abscess• 3-localized alveolar osteitis (dry socket)• 4-mild pericoronitis with minor gingival edema and pain

AB used in OI• Usually penicillin• For penicillin –allergic=clindamycin and azithromycin• For anaerobic bacteria=metronidazole and should be used in

combination to others• Fewest times daily to improve compliance• C&S test should be considered

When C&S test should be considered • 1- rapid onset of sever infection and rapid spreading

• 2-post operative infection

• 3- infection that does not resolve as expected• 4-resistant bacteria infection after 2 days to 2 weeks infection- free

period• 5-patient with compromised host defense

Use narrowest –spectrum antibiotic• Penicillin will kill streptococci and oral anaerobic bacteria and a litle

effect on staphylococci of skin and no effect on gastrointestinal tract bacteria = does no facilitate developing resistance

• Co –amoxicillin is broad and result in alternation in flora and resistanceAB with narrow-spectrum activity are as effective as others but with less upsetting flora and less developing resistance • Resistance can be passed on by dental patient to their families ,

coworkers and entire communities

Use the AB with lowest incidence of toxicity and side effect• The older generation antibiotics usually used for OI have a surprising

low incidence of toxicity related problems.• Allergy to penicillin in 2% of all population • Clindamycin = pseudomembranous (diarrhea) colitis by clostridium

difficile• In macrolide family azithromycin has the best combination of

effectiveness , low toxicity an infrequent drug interaction• Erytromycin is no longer considered because of the drug interactions

involving the liver microsomal enzyme and low effectiveness

• Moxifloxacin= beter effect on oral pathogens but significant toxicity ,mental clouding and muscle weakness, fatal drug interactions with many commonly used drugs ,contraindicated in children under18,and pregnant women,

• Oral cephalosporins have lost much of their effectiveness and may cause allergic reactions like penicillin

• Tetracycline are no longer considered for the same reason.except topically like in pockets-photosensitivity in systemic use-contraindication in pregnancy and children.(discoloration)

• Metronidazile .mild toxicity-reaction to alcohol and disulfiram effect Sudden violent abdominal cramping and vomiting

Use a bactericidal AB if possible• Host defense play a less important role• Specially in medically compromised patient

Penicillin

Drug of choice

• Penicillin –narrow spectrum- low toxicity • Amoxicillin is preferable to penicillin V because of less frequent

dosageCo-amoxicillin (broad) for complex infectionsAzithromycin –in allergyClindamycin-allergy anaerobic bacteria Metronidazole- anaerobic bacteria –combination with aerobic ABMoxifloxacin-only by specialist

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 completion of the original therapy • Check the site of I&D to remove the drain

•Failure =main reason inadequate surgery -so extraction or I&D into the area that was not detected in the first time, must be considered• Second reason of failure : depressed host defense.

• Third reason : presence of foreign body(infected radiopaque body) a shelter from immune system• Dental implants should be debrided or removed• Forth :antibiotic may be problematic :poor penetration to abscess

(inadequate surgery or drainage blood supply , low dose ),• Incorrect chose of AB for the bacteria • Resistance of bacteria• Establishment of a secondary infection like candida

Recurrence of infection

• Early removal of the drain• Patient may stooped taking the drug too early

• Surgical intervention and antibiotic therapy should be considered

Principles of prevention of infection•Prophylaxis of wound infection

Principles of Prophylaxis of wound infection• Prophylactic AB are effective against post operative infections and

blood borne infections

1-procedure should have significant risk of infection• Most office procedures Do not require prophylactic AB• Like extraction, frenectomy, biopsy, minor alveoloplasty, torus

reduction, periapical infection, severe periodontitis, multiple extractions

• Size : a present abscess or cellulitis • Time: longer than 4 hours • Presence of a Foreign body : commonly dental implant• depressed patient host defense(most important )• Organ transplantation –chemotherapy(until a year after end of

cession)• Diabetes

diabetes• The most common • Immunosuppressive• disease• HBa1c most • be under 7%

Principle 2 : choose correct antibiotic• AB Should be• 1-effective against organism • 2-narrow –spectrum• 3-the least toxic AB available• 4-bactericidal

• So its penicillin or amoxicillin • Allergy =>clindamycin • 3rd choice is azithromycin

Principle 3: plasma level must be high• Drug must be given in a dose at least two times the usual dose• For penicillin and amoxicillin this is 2 gr • Clindamycin 600 mg• Azithromycin 500 mg

Principle 4: Time antibiotic administration correctly• AB must be given 2 hours or less before surgery begins For the oral route its 1 hour

For prolonged operations intraoperative dose must be considered Its intervals should be shorter (half)-penicillin and clindamycin should be given every 3 hours during prolonged surgery

Principle 5: use shortest antibiotic exposure that is effective• For short operations a single dose before the surgery is enough

• Use of antibiotics is only necessary in the time of surgery• not after that

Principles of prophylaxis against metastatic infection• Metastatic infection: infection that occurs at a location physically

separate from the portal entry of bacteria• Bacterial endocarditis

Conditions for metastatic infection • 1-suspectible location (hearth valve )• 2-bacteremia • 3-bacterial proteins –adheins in 3 streps(s.sanguis- s.mitis s.oralis )• 4-impaired local host defense

Bacterial endocarditis treatment (hospital)• High dose of intravenous antibiotic for prolonged periods• Often damaged native valve must be surgically replaced by a

prosthetic valve• Recurrence reduces survival rate in 5 years to 60%

Bacterial endocarditis prophylaxis guideline• 1-previos endocarditis• 2-prosthetic heart valve• 3-cyanotic congenital heart defects –not been repaired or have partial

defect after repair • 4- heart transplant with valvopathy• -----6 mounts after procedure (endothlialization time)

Other considerations • Patient with daily taking of penicillin => streptococcus may be resistant to

penicillin so patient should use • clindamycin or clarithromycin or azithromycin • If possible a period of 10 days after AB completed to allow flora to become

normal• 10 days between appointment for the same reason and to reduce resistant

colonies• In the case of an unexpected bleeding or a patient who didn’t inform the

surgeon of the condition , AB prophylaxis should be administered as soon as possible• The limitation of AB prophylaxis is 4 hours

Before the surgery for the patients in the risk of IE• -comprehensive prophylaxis program including • 1-excellent oral hygiene• 2-excellent periodic care• 3-treat of all dental and periodontal diseases • 4-mount wash with chlorhexidine before surgery• 5-patient should be inform about signs of IE (it may still occur) • -prosthetic valve E is more fatal than native valve E

Prophylaxis in patients with other cardiovascular conditions• 1-in renal dialysis metastatic infection can occur in shunts• 2-patient who have hydrocephaly in ventriculoatrial shunts• 3- nonvalvular cardiovascular devices -just if there must be a I&D of

abscess in other sites

Prophylaxis against total joint replacement infection • Risk of hematogenous spread of bacteria• May result in the lose of implant • Aggressive treatment including extraction , I&D ,high dose

bactericidal AB and C&S test

Thank you