Reliability of Panoramic Radiography in Reliability of Panoramic Radiography in Evaluating the Topographic Relationship Evaluating the Topographic Relationship Between the Mandibular Canal and Between the Mandibular Canal and Impacted Third Molars Impacted Third Molars JADA The Journal of the American Dental Association March 2004, vol. 135, no. 3, pp. 312-318(7) pp. 312-318(7) Monaco G.[1]; Montevecchi M.[2]; Monaco G.[1]; Montevecchi M.[2]; Alessandri Bonetti G.[1]; Gatto M.R.A. Alessandri Bonetti G.[1]; Gatto M.R.A. [1]; Checchi L.[3] [1]; Checchi L.[3] Conclusion: Conclusion: Increased radiolucency, Increased radiolucency, narrowing and interruption of the narrowing and interruption of the radiopaque border, as well as the radiopaque border, as well as the concomitant presence of two or more concomitant presence of two or more radiographic markers, on the PR were radiographic markers, on the PR were
Transcript
Reliability of Panoramic Radiography in Reliability of Panoramic Radiography in Evaluating the Topographic Relationship Evaluating the Topographic Relationship Between the Mandibular Canal and Between the Mandibular Canal and Impacted Third MolarsImpacted Third Molars
JADA The Journal of the American Dental Association March 2004 vol 135 no 3 pp 312-318(7) pp 312-318(7)
Monaco G[1] Montevecchi M[2] Alessandri Monaco G[1] Montevecchi M[2] Alessandri Bonetti G[1] Gatto MRA[1] Checchi L[3]Bonetti G[1] Gatto MRA[1] Checchi L[3]ConclusionConclusion Increased radiolucency Increased radiolucency narrowing and interruption of the radiopaque narrowing and interruption of the radiopaque border as well as the concomitant presence of border as well as the concomitant presence of two or more radiographic markers on the PR two or more radiographic markers on the PR were highly predictive of contact between the were highly predictive of contact between the third molar and the mandibular canal An axial third molar and the mandibular canal An axial CT scan probably is indicated in such casesCT scan probably is indicated in such cases
According to various surveys the rate According to various surveys the rate of neurological complications has of neurological complications has varied from 05 to 1 percent for cases varied from 05 to 1 percent for cases involving permanent damage and 5 to involving permanent damage and 5 to 7 percent for cases involving 7 percent for cases involving temporary damagetemporary damage The risk increases The risk increases dramatically when there is contact between dramatically when there is contact between an impacted molar and the mandibular an impacted molar and the mandibular canal (defined as the absence of cortical canal (defined as the absence of cortical bone around the alveolar nerve the point at bone around the alveolar nerve the point at which the root touches the nerve) In these which the root touches the nerve) In these cases the incidence of temporary damage cases the incidence of temporary damage to the inferior alveolar nerve rises to about to the inferior alveolar nerve rises to about 30 percent of extractions30 percent of extractions
According to various surveys the rate According to various surveys the rate of neurological complications has of neurological complications has varied from 05 to 1 percent for cases varied from 05 to 1 percent for cases involving permanent damage and 5 to involving permanent damage and 5 to 7 percent for cases involving 7 percent for cases involving temporary damagetemporary damage The risk increases The risk increases dramatically when there is contact between dramatically when there is contact between an impacted molar and the mandibular an impacted molar and the mandibular canal (defined as the absence of cortical canal (defined as the absence of cortical bone around the alveolar nerve the point at bone around the alveolar nerve the point at which the root touches the nerve) In these which the root touches the nerve) In these cases the incidence of temporary damage cases the incidence of temporary damage to the inferior alveolar nerve rises to about to the inferior alveolar nerve rises to about 30 percent of extractions30 percent of extractions
ldquoHorizontal inclination is the most dangerous in terms of contact between tooth and
canalrdquo
ldquoHorizontal inclination is the most dangerous in terms of contact between tooth and
canalrdquo
MicroneurosurgeryMicroneurosurgery
bullNerves damaged from trauma or from an iatrogenic injury may be helped by microsurgery
bullIdeally performed 6-12 months following the trauma
bullEarly (~3 months) referral to specialist indicated if nerve shows no signs of improving
bullNerves damaged from trauma or from an iatrogenic injury may be helped by microsurgery
bullIdeally performed 6-12 months following the trauma
bullEarly (~3 months) referral to specialist indicated if nerve shows no signs of improving
FDA obtained evidence that Canfield manufactured and distributed adulterated (ie not manufactured according to good manufacturing practice) and unapproved drugs including DS Dressing (20 Eugenol) DS Mini-Dressing (20 Eugenol) DS Syringe (20 Eugenol) and DS Ointment (20 Eugenol) Canfield promoted these products for the treatment of dry socket a condition in which the socket does not heal properly following the extraction of a tooth The products were available nationwide through dental practices for use by dentists and consumers
FDA obtained evidence that Canfield manufactured and distributed adulterated (ie not manufactured according to good manufacturing practice) and unapproved drugs including DS Dressing (20 Eugenol) DS Mini-Dressing (20 Eugenol) DS Syringe (20 Eugenol) and DS Ointment (20 Eugenol) Canfield promoted these products for the treatment of dry socket a condition in which the socket does not heal properly following the extraction of a tooth The products were available nationwide through dental practices for use by dentists and consumers
FOR IMMEDIATE RELEASEOctober 6 2006FOR IMMEDIATE RELEASEOctober 6 2006
Permanent Injunction of Dental Products Manufacturer Furthers FDA Efforts Against Marketed Unapproved Drugs
Permanent Injunction of Dental Products Manufacturer Furthers FDA Efforts Against Marketed Unapproved Drugs
AlvogylregAlvogylregDry Socket Alveolar DressingDry Socket Alveolar DressingAlvogyl is a one-step self-eliminating Alvogyl is a one-step self-eliminating treatment which rapidly alleviates pain and treatment which rapidly alleviates pain and provides a soothing effect throughout the provides a soothing effect throughout the healing process Its fibrous consistency allows healing process Its fibrous consistency allows for easy filling of the socket and good for easy filling of the socket and good adherence during the entire healing process adherence during the entire healing process The active ingredients of Alvogyl include The active ingredients of Alvogyl include eugenol for analgesic action eugenol for analgesic action butambenbutamben for for anesthetic action and iodoform for anti-anesthetic action and iodoform for anti-microbial actionmicrobial action
AlvogylregAlvogylregDry Socket Alveolar DressingDry Socket Alveolar DressingAlvogyl is a one-step self-eliminating Alvogyl is a one-step self-eliminating treatment which rapidly alleviates pain and treatment which rapidly alleviates pain and provides a soothing effect throughout the provides a soothing effect throughout the healing process Its fibrous consistency allows healing process Its fibrous consistency allows for easy filling of the socket and good for easy filling of the socket and good adherence during the entire healing process adherence during the entire healing process The active ingredients of Alvogyl include The active ingredients of Alvogyl include eugenol for analgesic action eugenol for analgesic action butambenbutamben for for anesthetic action and iodoform for anti-anesthetic action and iodoform for anti-microbial actionmicrobial actionButamben a lipophilic
local anesthetic of the ester classester class produces a differential nerve block of long duration
Odontogenic Infections Odontogenic Infections Dr J Bruce Bavitz Dr J Bruce Bavitz
From From Diagnosis and Diagnosis and Treatment of Treatment of Odontogenic Odontogenic Infections Infections Hooley JR Hooley JR Whitacre RJ Whitacre RJ editors Stoma editors Stoma Press 1983Press 1983
Odontogenic Infxts-Odontogenic Infxts-PreventionPrevention((My heart artificial joint or jaw My heart artificial joint or jaw
are are notnot infected now and I donrsquot infected now and I donrsquot want them infected after the want them infected after the
Infect Control Hosp Epidemiol 2007 May28(5)577-82 Infect Control Hosp Epidemiol 2007 May28(5)577-82
Effect of a chlorhexidine mouthwash on the risk of Effect of a chlorhexidine mouthwash on the risk of postextraction bacteremiapostextraction bacteremiaTomaacutes I Alvarez M Limeres J Tomaacutes MTomaacutes M Medina JMedina J Otero JLOtero JL Diz Diz PPThe chlorhexidine group had 02 chlorhexidine mouthwash The chlorhexidine group had 02 chlorhexidine mouthwash administered for 30 seconds before any dental manipulation administered for 30 seconds before any dental manipulation Blood samples were collected at baseline 30 seconds 15 Blood samples were collected at baseline 30 seconds 15 minutes and 1 hour after the dental extractions Subculture and minutes and 1 hour after the dental extractions Subculture and further identification of the isolated bacteria were performed by further identification of the isolated bacteria were performed by conventional microbiological techniques RESULTS The conventional microbiological techniques RESULTS The prevalence of bacteremia after dental extraction in the control prevalence of bacteremia after dental extraction in the control and chlorhexidine groups were 96 and 79 respectively at 30 and chlorhexidine groups were 96 and 79 respectively at 30 seconds (P=008) 64 and 30 at 15 minutes (Plt001) and seconds (P=008) 64 and 30 at 15 minutes (Plt001) and 20 and 2 at 1 hour (P=005) The most frequently identified 20 and 2 at 1 hour (P=005) The most frequently identified bacteria were Streptococcus species in both the control and bacteria were Streptococcus species in both the control and chlorhexidine groups (64 and 68 respectively) particularly chlorhexidine groups (64 and 68 respectively) particularly viridans group streptococci CONCLUSION We recommend the viridans group streptococci CONCLUSION We recommend the routine use of a 02 chlorhexidine mouthwash before dental routine use of a 02 chlorhexidine mouthwash before dental extractions to reduce the risk of postextraction bacteremiaextractions to reduce the risk of postextraction bacteremia
bull ImmunocompromisedImmunocompromised Type one Type one diabetes high dose steroids diabetes high dose steroids immunosuppressive agents prior immunosuppressive agents prior infection history poor protoplasminfection history poor protoplasm
bull Metastaticdistant site infection risk Metastaticdistant site infection risk (heart valves orthopedic implants (heart valves orthopedic implants shunts)shunts)
Evidence Base for Evidence Base for Duration of Antimicrobial Duration of Antimicrobial
ProphylaxisProphylaxisbull ldquoldquoThe goal of antimicrobial prophylaxis is to The goal of antimicrobial prophylaxis is to
achieve serum and tissue levels of the antibiotic achieve serum and tissue levels of the antibiotic at the time of incision and for the duration of the at the time of incision and for the duration of the operation that are in excess of the minimum operation that are in excess of the minimum inhibitory concentration needed for the inhibitory concentration needed for the organisms that may be encountered during the organisms that may be encountered during the operation The National Surgical Infection operation The National Surgical Infection Prevention Project recommends the antibiotics Prevention Project recommends the antibiotics not be extended beyond 24 hours of the not be extended beyond 24 hours of the end of the operationrdquoend of the operationrdquo
Updated August 2003Updated August 2003
Proof Nailed Down that Proof Nailed Down that Antibiotics Use Leads to Antibiotics Use Leads to
ResistanceResistance ANTWERP Belgium Feb 9 2007 -- For the first ANTWERP Belgium Feb 9 2007 -- For the first time the unassailable proof that physicians can do time the unassailable proof that physicians can do harm by indiscriminate use of antibiotics has harm by indiscriminate use of antibiotics has emerged from a randomized controlled trialemerged from a randomized controlled trial
Physicians should take into account the striking Physicians should take into account the striking ecological side-effects of antibiotics when ecological side-effects of antibiotics when prescribing such drugs to their patients the prescribing such drugs to their patients the researchers concludedresearchers concluded
Malhotra-Kumar S et al Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers a randomized double-blind placebo-controlled study Lancet 2007 369 482-490
2007 AHA2007 AHA
The AHArsquos latest guidelines were published in its The AHArsquos latest guidelines were published in its scientific journal scientific journal CirculationCirculation in April 2007 and in April 2007 and
there is good news there is good news the AHA recommends that the AHA recommends that most of these patients no longer need most of these patients no longer need short-term antibiotics as a preventive short-term antibiotics as a preventive
measure before their dental treatmentmeasure before their dental treatment
Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE
2007 AHA2007 AHAPreventive antibiotics prior to a dental procedure Preventive antibiotics prior to a dental procedure
are advised for patients withare advised for patients with1 artificial heart valves 1 artificial heart valves 2 a history of infective endocarditis 2 a history of infective endocarditis 3 certain specific serious congenital (present from birth) 3 certain specific serious congenital (present from birth)
heart conditions including unrepaired or incompletely heart conditions including unrepaired or incompletely repaired cyanotic congenital heart disease including repaired cyanotic congenital heart disease including those with palliative shunts and conduits those with palliative shunts and conduits
4 a completely repaired congenital heart defect with 4 a completely repaired congenital heart defect with prosthetic material or device whether placed by prosthetic material or device whether placed by surgery or by catheter intervention during the first six surgery or by catheter intervention during the first six months after the procedure months after the procedure
5 any repaired congenital heart defect with residual 5 any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device patch or a prosthetic device
6 a cardiac transplant that develops a problem in a heart 6 a cardiac transplant that develops a problem in a heart valvevalve
According to the 2007 AHA guidelines According to the 2007 AHA guidelines which patient should receive antibiotics which patient should receive antibiotics before an extractionbefore an extraction
A Mitral valve prolapse with A Mitral valve prolapse with echocardiogram confirmed murmurechocardiogram confirmed murmur
B Recent (less than 6 months) bypass B Recent (less than 6 months) bypass surgerysurgery
C History of rheumatic heart diseaseC History of rheumatic heart disease
D Surgical repair of a heart valveD Surgical repair of a heart valve
E Heart transplant recipientsE Heart transplant recipients
J Am Dent Assoc 2003 Jul134(7)895-9J Am Dent Assoc 2003 Jul134(7)895-9
Antibiotic prophylaxis for dental Antibiotic prophylaxis for dental patients with total joint patients with total joint
replacementsreplacements
American Dental Association American Academy of Orthopedic SurgeonsAmerican Dental Association American Academy of Orthopedic Surgeons
The statement concludes that antibiotic The statement concludes that antibiotic prophylaxis is not indicated for dental patients prophylaxis is not indicated for dental patients with pins plates or screws nor is it routinely with pins plates or screws nor is it routinely
indicated for most dental patients with total joint indicated for most dental patients with total joint replacements However it is advisable to replacements However it is advisable to
consider premedication in a small number of consider premedication in a small number of patients who may be at potential increased risk of patients who may be at potential increased risk of experiencing hematogenous total joint infectionexperiencing hematogenous total joint infection
HEMATOGENOUS TOTAL JOINT INFECTION
PATIENT TYPE CONDITION PLACING PATIENT AT RISK
All patients during first two years following joint replacement
NAdagger
Immunocompromisedimmunosuppressed patients
Inflammatory arthropathies such as rheumatoid arthritis systemic lupus erythematosus
Drug- or radiation-induced immunosuppression
Patients with comorbiditiesDagger Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
Any perceived potential benefit of antibiotic Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known prophylaxis must be weighed against the known
risks of antibiotic toxicity allergy and risks of antibiotic toxicity allergy and development selection and transmission of development selection and transmission of
microbial resistancemicrobial resistance
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
According to various surveys the rate According to various surveys the rate of neurological complications has of neurological complications has varied from 05 to 1 percent for cases varied from 05 to 1 percent for cases involving permanent damage and 5 to involving permanent damage and 5 to 7 percent for cases involving 7 percent for cases involving temporary damagetemporary damage The risk increases The risk increases dramatically when there is contact between dramatically when there is contact between an impacted molar and the mandibular an impacted molar and the mandibular canal (defined as the absence of cortical canal (defined as the absence of cortical bone around the alveolar nerve the point at bone around the alveolar nerve the point at which the root touches the nerve) In these which the root touches the nerve) In these cases the incidence of temporary damage cases the incidence of temporary damage to the inferior alveolar nerve rises to about to the inferior alveolar nerve rises to about 30 percent of extractions30 percent of extractions
According to various surveys the rate According to various surveys the rate of neurological complications has of neurological complications has varied from 05 to 1 percent for cases varied from 05 to 1 percent for cases involving permanent damage and 5 to involving permanent damage and 5 to 7 percent for cases involving 7 percent for cases involving temporary damagetemporary damage The risk increases The risk increases dramatically when there is contact between dramatically when there is contact between an impacted molar and the mandibular an impacted molar and the mandibular canal (defined as the absence of cortical canal (defined as the absence of cortical bone around the alveolar nerve the point at bone around the alveolar nerve the point at which the root touches the nerve) In these which the root touches the nerve) In these cases the incidence of temporary damage cases the incidence of temporary damage to the inferior alveolar nerve rises to about to the inferior alveolar nerve rises to about 30 percent of extractions30 percent of extractions
ldquoHorizontal inclination is the most dangerous in terms of contact between tooth and
canalrdquo
ldquoHorizontal inclination is the most dangerous in terms of contact between tooth and
canalrdquo
MicroneurosurgeryMicroneurosurgery
bullNerves damaged from trauma or from an iatrogenic injury may be helped by microsurgery
bullIdeally performed 6-12 months following the trauma
bullEarly (~3 months) referral to specialist indicated if nerve shows no signs of improving
bullNerves damaged from trauma or from an iatrogenic injury may be helped by microsurgery
bullIdeally performed 6-12 months following the trauma
bullEarly (~3 months) referral to specialist indicated if nerve shows no signs of improving
FDA obtained evidence that Canfield manufactured and distributed adulterated (ie not manufactured according to good manufacturing practice) and unapproved drugs including DS Dressing (20 Eugenol) DS Mini-Dressing (20 Eugenol) DS Syringe (20 Eugenol) and DS Ointment (20 Eugenol) Canfield promoted these products for the treatment of dry socket a condition in which the socket does not heal properly following the extraction of a tooth The products were available nationwide through dental practices for use by dentists and consumers
FDA obtained evidence that Canfield manufactured and distributed adulterated (ie not manufactured according to good manufacturing practice) and unapproved drugs including DS Dressing (20 Eugenol) DS Mini-Dressing (20 Eugenol) DS Syringe (20 Eugenol) and DS Ointment (20 Eugenol) Canfield promoted these products for the treatment of dry socket a condition in which the socket does not heal properly following the extraction of a tooth The products were available nationwide through dental practices for use by dentists and consumers
FOR IMMEDIATE RELEASEOctober 6 2006FOR IMMEDIATE RELEASEOctober 6 2006
Permanent Injunction of Dental Products Manufacturer Furthers FDA Efforts Against Marketed Unapproved Drugs
Permanent Injunction of Dental Products Manufacturer Furthers FDA Efforts Against Marketed Unapproved Drugs
AlvogylregAlvogylregDry Socket Alveolar DressingDry Socket Alveolar DressingAlvogyl is a one-step self-eliminating Alvogyl is a one-step self-eliminating treatment which rapidly alleviates pain and treatment which rapidly alleviates pain and provides a soothing effect throughout the provides a soothing effect throughout the healing process Its fibrous consistency allows healing process Its fibrous consistency allows for easy filling of the socket and good for easy filling of the socket and good adherence during the entire healing process adherence during the entire healing process The active ingredients of Alvogyl include The active ingredients of Alvogyl include eugenol for analgesic action eugenol for analgesic action butambenbutamben for for anesthetic action and iodoform for anti-anesthetic action and iodoform for anti-microbial actionmicrobial action
AlvogylregAlvogylregDry Socket Alveolar DressingDry Socket Alveolar DressingAlvogyl is a one-step self-eliminating Alvogyl is a one-step self-eliminating treatment which rapidly alleviates pain and treatment which rapidly alleviates pain and provides a soothing effect throughout the provides a soothing effect throughout the healing process Its fibrous consistency allows healing process Its fibrous consistency allows for easy filling of the socket and good for easy filling of the socket and good adherence during the entire healing process adherence during the entire healing process The active ingredients of Alvogyl include The active ingredients of Alvogyl include eugenol for analgesic action eugenol for analgesic action butambenbutamben for for anesthetic action and iodoform for anti-anesthetic action and iodoform for anti-microbial actionmicrobial actionButamben a lipophilic
local anesthetic of the ester classester class produces a differential nerve block of long duration
Odontogenic Infections Odontogenic Infections Dr J Bruce Bavitz Dr J Bruce Bavitz
From From Diagnosis and Diagnosis and Treatment of Treatment of Odontogenic Odontogenic Infections Infections Hooley JR Hooley JR Whitacre RJ Whitacre RJ editors Stoma editors Stoma Press 1983Press 1983
Odontogenic Infxts-Odontogenic Infxts-PreventionPrevention((My heart artificial joint or jaw My heart artificial joint or jaw
are are notnot infected now and I donrsquot infected now and I donrsquot want them infected after the want them infected after the
Infect Control Hosp Epidemiol 2007 May28(5)577-82 Infect Control Hosp Epidemiol 2007 May28(5)577-82
Effect of a chlorhexidine mouthwash on the risk of Effect of a chlorhexidine mouthwash on the risk of postextraction bacteremiapostextraction bacteremiaTomaacutes I Alvarez M Limeres J Tomaacutes MTomaacutes M Medina JMedina J Otero JLOtero JL Diz Diz PPThe chlorhexidine group had 02 chlorhexidine mouthwash The chlorhexidine group had 02 chlorhexidine mouthwash administered for 30 seconds before any dental manipulation administered for 30 seconds before any dental manipulation Blood samples were collected at baseline 30 seconds 15 Blood samples were collected at baseline 30 seconds 15 minutes and 1 hour after the dental extractions Subculture and minutes and 1 hour after the dental extractions Subculture and further identification of the isolated bacteria were performed by further identification of the isolated bacteria were performed by conventional microbiological techniques RESULTS The conventional microbiological techniques RESULTS The prevalence of bacteremia after dental extraction in the control prevalence of bacteremia after dental extraction in the control and chlorhexidine groups were 96 and 79 respectively at 30 and chlorhexidine groups were 96 and 79 respectively at 30 seconds (P=008) 64 and 30 at 15 minutes (Plt001) and seconds (P=008) 64 and 30 at 15 minutes (Plt001) and 20 and 2 at 1 hour (P=005) The most frequently identified 20 and 2 at 1 hour (P=005) The most frequently identified bacteria were Streptococcus species in both the control and bacteria were Streptococcus species in both the control and chlorhexidine groups (64 and 68 respectively) particularly chlorhexidine groups (64 and 68 respectively) particularly viridans group streptococci CONCLUSION We recommend the viridans group streptococci CONCLUSION We recommend the routine use of a 02 chlorhexidine mouthwash before dental routine use of a 02 chlorhexidine mouthwash before dental extractions to reduce the risk of postextraction bacteremiaextractions to reduce the risk of postextraction bacteremia
bull ImmunocompromisedImmunocompromised Type one Type one diabetes high dose steroids diabetes high dose steroids immunosuppressive agents prior immunosuppressive agents prior infection history poor protoplasminfection history poor protoplasm
bull Metastaticdistant site infection risk Metastaticdistant site infection risk (heart valves orthopedic implants (heart valves orthopedic implants shunts)shunts)
Evidence Base for Evidence Base for Duration of Antimicrobial Duration of Antimicrobial
ProphylaxisProphylaxisbull ldquoldquoThe goal of antimicrobial prophylaxis is to The goal of antimicrobial prophylaxis is to
achieve serum and tissue levels of the antibiotic achieve serum and tissue levels of the antibiotic at the time of incision and for the duration of the at the time of incision and for the duration of the operation that are in excess of the minimum operation that are in excess of the minimum inhibitory concentration needed for the inhibitory concentration needed for the organisms that may be encountered during the organisms that may be encountered during the operation The National Surgical Infection operation The National Surgical Infection Prevention Project recommends the antibiotics Prevention Project recommends the antibiotics not be extended beyond 24 hours of the not be extended beyond 24 hours of the end of the operationrdquoend of the operationrdquo
Updated August 2003Updated August 2003
Proof Nailed Down that Proof Nailed Down that Antibiotics Use Leads to Antibiotics Use Leads to
ResistanceResistance ANTWERP Belgium Feb 9 2007 -- For the first ANTWERP Belgium Feb 9 2007 -- For the first time the unassailable proof that physicians can do time the unassailable proof that physicians can do harm by indiscriminate use of antibiotics has harm by indiscriminate use of antibiotics has emerged from a randomized controlled trialemerged from a randomized controlled trial
Physicians should take into account the striking Physicians should take into account the striking ecological side-effects of antibiotics when ecological side-effects of antibiotics when prescribing such drugs to their patients the prescribing such drugs to their patients the researchers concludedresearchers concluded
Malhotra-Kumar S et al Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers a randomized double-blind placebo-controlled study Lancet 2007 369 482-490
2007 AHA2007 AHA
The AHArsquos latest guidelines were published in its The AHArsquos latest guidelines were published in its scientific journal scientific journal CirculationCirculation in April 2007 and in April 2007 and
there is good news there is good news the AHA recommends that the AHA recommends that most of these patients no longer need most of these patients no longer need short-term antibiotics as a preventive short-term antibiotics as a preventive
measure before their dental treatmentmeasure before their dental treatment
Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE
2007 AHA2007 AHAPreventive antibiotics prior to a dental procedure Preventive antibiotics prior to a dental procedure
are advised for patients withare advised for patients with1 artificial heart valves 1 artificial heart valves 2 a history of infective endocarditis 2 a history of infective endocarditis 3 certain specific serious congenital (present from birth) 3 certain specific serious congenital (present from birth)
heart conditions including unrepaired or incompletely heart conditions including unrepaired or incompletely repaired cyanotic congenital heart disease including repaired cyanotic congenital heart disease including those with palliative shunts and conduits those with palliative shunts and conduits
4 a completely repaired congenital heart defect with 4 a completely repaired congenital heart defect with prosthetic material or device whether placed by prosthetic material or device whether placed by surgery or by catheter intervention during the first six surgery or by catheter intervention during the first six months after the procedure months after the procedure
5 any repaired congenital heart defect with residual 5 any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device patch or a prosthetic device
6 a cardiac transplant that develops a problem in a heart 6 a cardiac transplant that develops a problem in a heart valvevalve
According to the 2007 AHA guidelines According to the 2007 AHA guidelines which patient should receive antibiotics which patient should receive antibiotics before an extractionbefore an extraction
A Mitral valve prolapse with A Mitral valve prolapse with echocardiogram confirmed murmurechocardiogram confirmed murmur
B Recent (less than 6 months) bypass B Recent (less than 6 months) bypass surgerysurgery
C History of rheumatic heart diseaseC History of rheumatic heart disease
D Surgical repair of a heart valveD Surgical repair of a heart valve
E Heart transplant recipientsE Heart transplant recipients
J Am Dent Assoc 2003 Jul134(7)895-9J Am Dent Assoc 2003 Jul134(7)895-9
Antibiotic prophylaxis for dental Antibiotic prophylaxis for dental patients with total joint patients with total joint
replacementsreplacements
American Dental Association American Academy of Orthopedic SurgeonsAmerican Dental Association American Academy of Orthopedic Surgeons
The statement concludes that antibiotic The statement concludes that antibiotic prophylaxis is not indicated for dental patients prophylaxis is not indicated for dental patients with pins plates or screws nor is it routinely with pins plates or screws nor is it routinely
indicated for most dental patients with total joint indicated for most dental patients with total joint replacements However it is advisable to replacements However it is advisable to
consider premedication in a small number of consider premedication in a small number of patients who may be at potential increased risk of patients who may be at potential increased risk of experiencing hematogenous total joint infectionexperiencing hematogenous total joint infection
HEMATOGENOUS TOTAL JOINT INFECTION
PATIENT TYPE CONDITION PLACING PATIENT AT RISK
All patients during first two years following joint replacement
NAdagger
Immunocompromisedimmunosuppressed patients
Inflammatory arthropathies such as rheumatoid arthritis systemic lupus erythematosus
Drug- or radiation-induced immunosuppression
Patients with comorbiditiesDagger Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
Any perceived potential benefit of antibiotic Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known prophylaxis must be weighed against the known
risks of antibiotic toxicity allergy and risks of antibiotic toxicity allergy and development selection and transmission of development selection and transmission of
microbial resistancemicrobial resistance
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
ldquoHorizontal inclination is the most dangerous in terms of contact between tooth and
canalrdquo
ldquoHorizontal inclination is the most dangerous in terms of contact between tooth and
canalrdquo
MicroneurosurgeryMicroneurosurgery
bullNerves damaged from trauma or from an iatrogenic injury may be helped by microsurgery
bullIdeally performed 6-12 months following the trauma
bullEarly (~3 months) referral to specialist indicated if nerve shows no signs of improving
bullNerves damaged from trauma or from an iatrogenic injury may be helped by microsurgery
bullIdeally performed 6-12 months following the trauma
bullEarly (~3 months) referral to specialist indicated if nerve shows no signs of improving
FDA obtained evidence that Canfield manufactured and distributed adulterated (ie not manufactured according to good manufacturing practice) and unapproved drugs including DS Dressing (20 Eugenol) DS Mini-Dressing (20 Eugenol) DS Syringe (20 Eugenol) and DS Ointment (20 Eugenol) Canfield promoted these products for the treatment of dry socket a condition in which the socket does not heal properly following the extraction of a tooth The products were available nationwide through dental practices for use by dentists and consumers
FDA obtained evidence that Canfield manufactured and distributed adulterated (ie not manufactured according to good manufacturing practice) and unapproved drugs including DS Dressing (20 Eugenol) DS Mini-Dressing (20 Eugenol) DS Syringe (20 Eugenol) and DS Ointment (20 Eugenol) Canfield promoted these products for the treatment of dry socket a condition in which the socket does not heal properly following the extraction of a tooth The products were available nationwide through dental practices for use by dentists and consumers
FOR IMMEDIATE RELEASEOctober 6 2006FOR IMMEDIATE RELEASEOctober 6 2006
Permanent Injunction of Dental Products Manufacturer Furthers FDA Efforts Against Marketed Unapproved Drugs
Permanent Injunction of Dental Products Manufacturer Furthers FDA Efforts Against Marketed Unapproved Drugs
AlvogylregAlvogylregDry Socket Alveolar DressingDry Socket Alveolar DressingAlvogyl is a one-step self-eliminating Alvogyl is a one-step self-eliminating treatment which rapidly alleviates pain and treatment which rapidly alleviates pain and provides a soothing effect throughout the provides a soothing effect throughout the healing process Its fibrous consistency allows healing process Its fibrous consistency allows for easy filling of the socket and good for easy filling of the socket and good adherence during the entire healing process adherence during the entire healing process The active ingredients of Alvogyl include The active ingredients of Alvogyl include eugenol for analgesic action eugenol for analgesic action butambenbutamben for for anesthetic action and iodoform for anti-anesthetic action and iodoform for anti-microbial actionmicrobial action
AlvogylregAlvogylregDry Socket Alveolar DressingDry Socket Alveolar DressingAlvogyl is a one-step self-eliminating Alvogyl is a one-step self-eliminating treatment which rapidly alleviates pain and treatment which rapidly alleviates pain and provides a soothing effect throughout the provides a soothing effect throughout the healing process Its fibrous consistency allows healing process Its fibrous consistency allows for easy filling of the socket and good for easy filling of the socket and good adherence during the entire healing process adherence during the entire healing process The active ingredients of Alvogyl include The active ingredients of Alvogyl include eugenol for analgesic action eugenol for analgesic action butambenbutamben for for anesthetic action and iodoform for anti-anesthetic action and iodoform for anti-microbial actionmicrobial actionButamben a lipophilic
local anesthetic of the ester classester class produces a differential nerve block of long duration
Odontogenic Infections Odontogenic Infections Dr J Bruce Bavitz Dr J Bruce Bavitz
From From Diagnosis and Diagnosis and Treatment of Treatment of Odontogenic Odontogenic Infections Infections Hooley JR Hooley JR Whitacre RJ Whitacre RJ editors Stoma editors Stoma Press 1983Press 1983
Odontogenic Infxts-Odontogenic Infxts-PreventionPrevention((My heart artificial joint or jaw My heart artificial joint or jaw
are are notnot infected now and I donrsquot infected now and I donrsquot want them infected after the want them infected after the
Infect Control Hosp Epidemiol 2007 May28(5)577-82 Infect Control Hosp Epidemiol 2007 May28(5)577-82
Effect of a chlorhexidine mouthwash on the risk of Effect of a chlorhexidine mouthwash on the risk of postextraction bacteremiapostextraction bacteremiaTomaacutes I Alvarez M Limeres J Tomaacutes MTomaacutes M Medina JMedina J Otero JLOtero JL Diz Diz PPThe chlorhexidine group had 02 chlorhexidine mouthwash The chlorhexidine group had 02 chlorhexidine mouthwash administered for 30 seconds before any dental manipulation administered for 30 seconds before any dental manipulation Blood samples were collected at baseline 30 seconds 15 Blood samples were collected at baseline 30 seconds 15 minutes and 1 hour after the dental extractions Subculture and minutes and 1 hour after the dental extractions Subculture and further identification of the isolated bacteria were performed by further identification of the isolated bacteria were performed by conventional microbiological techniques RESULTS The conventional microbiological techniques RESULTS The prevalence of bacteremia after dental extraction in the control prevalence of bacteremia after dental extraction in the control and chlorhexidine groups were 96 and 79 respectively at 30 and chlorhexidine groups were 96 and 79 respectively at 30 seconds (P=008) 64 and 30 at 15 minutes (Plt001) and seconds (P=008) 64 and 30 at 15 minutes (Plt001) and 20 and 2 at 1 hour (P=005) The most frequently identified 20 and 2 at 1 hour (P=005) The most frequently identified bacteria were Streptococcus species in both the control and bacteria were Streptococcus species in both the control and chlorhexidine groups (64 and 68 respectively) particularly chlorhexidine groups (64 and 68 respectively) particularly viridans group streptococci CONCLUSION We recommend the viridans group streptococci CONCLUSION We recommend the routine use of a 02 chlorhexidine mouthwash before dental routine use of a 02 chlorhexidine mouthwash before dental extractions to reduce the risk of postextraction bacteremiaextractions to reduce the risk of postextraction bacteremia
bull ImmunocompromisedImmunocompromised Type one Type one diabetes high dose steroids diabetes high dose steroids immunosuppressive agents prior immunosuppressive agents prior infection history poor protoplasminfection history poor protoplasm
bull Metastaticdistant site infection risk Metastaticdistant site infection risk (heart valves orthopedic implants (heart valves orthopedic implants shunts)shunts)
Evidence Base for Evidence Base for Duration of Antimicrobial Duration of Antimicrobial
ProphylaxisProphylaxisbull ldquoldquoThe goal of antimicrobial prophylaxis is to The goal of antimicrobial prophylaxis is to
achieve serum and tissue levels of the antibiotic achieve serum and tissue levels of the antibiotic at the time of incision and for the duration of the at the time of incision and for the duration of the operation that are in excess of the minimum operation that are in excess of the minimum inhibitory concentration needed for the inhibitory concentration needed for the organisms that may be encountered during the organisms that may be encountered during the operation The National Surgical Infection operation The National Surgical Infection Prevention Project recommends the antibiotics Prevention Project recommends the antibiotics not be extended beyond 24 hours of the not be extended beyond 24 hours of the end of the operationrdquoend of the operationrdquo
Updated August 2003Updated August 2003
Proof Nailed Down that Proof Nailed Down that Antibiotics Use Leads to Antibiotics Use Leads to
ResistanceResistance ANTWERP Belgium Feb 9 2007 -- For the first ANTWERP Belgium Feb 9 2007 -- For the first time the unassailable proof that physicians can do time the unassailable proof that physicians can do harm by indiscriminate use of antibiotics has harm by indiscriminate use of antibiotics has emerged from a randomized controlled trialemerged from a randomized controlled trial
Physicians should take into account the striking Physicians should take into account the striking ecological side-effects of antibiotics when ecological side-effects of antibiotics when prescribing such drugs to their patients the prescribing such drugs to their patients the researchers concludedresearchers concluded
Malhotra-Kumar S et al Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers a randomized double-blind placebo-controlled study Lancet 2007 369 482-490
2007 AHA2007 AHA
The AHArsquos latest guidelines were published in its The AHArsquos latest guidelines were published in its scientific journal scientific journal CirculationCirculation in April 2007 and in April 2007 and
there is good news there is good news the AHA recommends that the AHA recommends that most of these patients no longer need most of these patients no longer need short-term antibiotics as a preventive short-term antibiotics as a preventive
measure before their dental treatmentmeasure before their dental treatment
Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE
2007 AHA2007 AHAPreventive antibiotics prior to a dental procedure Preventive antibiotics prior to a dental procedure
are advised for patients withare advised for patients with1 artificial heart valves 1 artificial heart valves 2 a history of infective endocarditis 2 a history of infective endocarditis 3 certain specific serious congenital (present from birth) 3 certain specific serious congenital (present from birth)
heart conditions including unrepaired or incompletely heart conditions including unrepaired or incompletely repaired cyanotic congenital heart disease including repaired cyanotic congenital heart disease including those with palliative shunts and conduits those with palliative shunts and conduits
4 a completely repaired congenital heart defect with 4 a completely repaired congenital heart defect with prosthetic material or device whether placed by prosthetic material or device whether placed by surgery or by catheter intervention during the first six surgery or by catheter intervention during the first six months after the procedure months after the procedure
5 any repaired congenital heart defect with residual 5 any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device patch or a prosthetic device
6 a cardiac transplant that develops a problem in a heart 6 a cardiac transplant that develops a problem in a heart valvevalve
According to the 2007 AHA guidelines According to the 2007 AHA guidelines which patient should receive antibiotics which patient should receive antibiotics before an extractionbefore an extraction
A Mitral valve prolapse with A Mitral valve prolapse with echocardiogram confirmed murmurechocardiogram confirmed murmur
B Recent (less than 6 months) bypass B Recent (less than 6 months) bypass surgerysurgery
C History of rheumatic heart diseaseC History of rheumatic heart disease
D Surgical repair of a heart valveD Surgical repair of a heart valve
E Heart transplant recipientsE Heart transplant recipients
J Am Dent Assoc 2003 Jul134(7)895-9J Am Dent Assoc 2003 Jul134(7)895-9
Antibiotic prophylaxis for dental Antibiotic prophylaxis for dental patients with total joint patients with total joint
replacementsreplacements
American Dental Association American Academy of Orthopedic SurgeonsAmerican Dental Association American Academy of Orthopedic Surgeons
The statement concludes that antibiotic The statement concludes that antibiotic prophylaxis is not indicated for dental patients prophylaxis is not indicated for dental patients with pins plates or screws nor is it routinely with pins plates or screws nor is it routinely
indicated for most dental patients with total joint indicated for most dental patients with total joint replacements However it is advisable to replacements However it is advisable to
consider premedication in a small number of consider premedication in a small number of patients who may be at potential increased risk of patients who may be at potential increased risk of experiencing hematogenous total joint infectionexperiencing hematogenous total joint infection
HEMATOGENOUS TOTAL JOINT INFECTION
PATIENT TYPE CONDITION PLACING PATIENT AT RISK
All patients during first two years following joint replacement
NAdagger
Immunocompromisedimmunosuppressed patients
Inflammatory arthropathies such as rheumatoid arthritis systemic lupus erythematosus
Drug- or radiation-induced immunosuppression
Patients with comorbiditiesDagger Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
Any perceived potential benefit of antibiotic Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known prophylaxis must be weighed against the known
risks of antibiotic toxicity allergy and risks of antibiotic toxicity allergy and development selection and transmission of development selection and transmission of
microbial resistancemicrobial resistance
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
MicroneurosurgeryMicroneurosurgery
bullNerves damaged from trauma or from an iatrogenic injury may be helped by microsurgery
bullIdeally performed 6-12 months following the trauma
bullEarly (~3 months) referral to specialist indicated if nerve shows no signs of improving
bullNerves damaged from trauma or from an iatrogenic injury may be helped by microsurgery
bullIdeally performed 6-12 months following the trauma
bullEarly (~3 months) referral to specialist indicated if nerve shows no signs of improving
FDA obtained evidence that Canfield manufactured and distributed adulterated (ie not manufactured according to good manufacturing practice) and unapproved drugs including DS Dressing (20 Eugenol) DS Mini-Dressing (20 Eugenol) DS Syringe (20 Eugenol) and DS Ointment (20 Eugenol) Canfield promoted these products for the treatment of dry socket a condition in which the socket does not heal properly following the extraction of a tooth The products were available nationwide through dental practices for use by dentists and consumers
FDA obtained evidence that Canfield manufactured and distributed adulterated (ie not manufactured according to good manufacturing practice) and unapproved drugs including DS Dressing (20 Eugenol) DS Mini-Dressing (20 Eugenol) DS Syringe (20 Eugenol) and DS Ointment (20 Eugenol) Canfield promoted these products for the treatment of dry socket a condition in which the socket does not heal properly following the extraction of a tooth The products were available nationwide through dental practices for use by dentists and consumers
FOR IMMEDIATE RELEASEOctober 6 2006FOR IMMEDIATE RELEASEOctober 6 2006
Permanent Injunction of Dental Products Manufacturer Furthers FDA Efforts Against Marketed Unapproved Drugs
Permanent Injunction of Dental Products Manufacturer Furthers FDA Efforts Against Marketed Unapproved Drugs
AlvogylregAlvogylregDry Socket Alveolar DressingDry Socket Alveolar DressingAlvogyl is a one-step self-eliminating Alvogyl is a one-step self-eliminating treatment which rapidly alleviates pain and treatment which rapidly alleviates pain and provides a soothing effect throughout the provides a soothing effect throughout the healing process Its fibrous consistency allows healing process Its fibrous consistency allows for easy filling of the socket and good for easy filling of the socket and good adherence during the entire healing process adherence during the entire healing process The active ingredients of Alvogyl include The active ingredients of Alvogyl include eugenol for analgesic action eugenol for analgesic action butambenbutamben for for anesthetic action and iodoform for anti-anesthetic action and iodoform for anti-microbial actionmicrobial action
AlvogylregAlvogylregDry Socket Alveolar DressingDry Socket Alveolar DressingAlvogyl is a one-step self-eliminating Alvogyl is a one-step self-eliminating treatment which rapidly alleviates pain and treatment which rapidly alleviates pain and provides a soothing effect throughout the provides a soothing effect throughout the healing process Its fibrous consistency allows healing process Its fibrous consistency allows for easy filling of the socket and good for easy filling of the socket and good adherence during the entire healing process adherence during the entire healing process The active ingredients of Alvogyl include The active ingredients of Alvogyl include eugenol for analgesic action eugenol for analgesic action butambenbutamben for for anesthetic action and iodoform for anti-anesthetic action and iodoform for anti-microbial actionmicrobial actionButamben a lipophilic
local anesthetic of the ester classester class produces a differential nerve block of long duration
Odontogenic Infections Odontogenic Infections Dr J Bruce Bavitz Dr J Bruce Bavitz
From From Diagnosis and Diagnosis and Treatment of Treatment of Odontogenic Odontogenic Infections Infections Hooley JR Hooley JR Whitacre RJ Whitacre RJ editors Stoma editors Stoma Press 1983Press 1983
Odontogenic Infxts-Odontogenic Infxts-PreventionPrevention((My heart artificial joint or jaw My heart artificial joint or jaw
are are notnot infected now and I donrsquot infected now and I donrsquot want them infected after the want them infected after the
Infect Control Hosp Epidemiol 2007 May28(5)577-82 Infect Control Hosp Epidemiol 2007 May28(5)577-82
Effect of a chlorhexidine mouthwash on the risk of Effect of a chlorhexidine mouthwash on the risk of postextraction bacteremiapostextraction bacteremiaTomaacutes I Alvarez M Limeres J Tomaacutes MTomaacutes M Medina JMedina J Otero JLOtero JL Diz Diz PPThe chlorhexidine group had 02 chlorhexidine mouthwash The chlorhexidine group had 02 chlorhexidine mouthwash administered for 30 seconds before any dental manipulation administered for 30 seconds before any dental manipulation Blood samples were collected at baseline 30 seconds 15 Blood samples were collected at baseline 30 seconds 15 minutes and 1 hour after the dental extractions Subculture and minutes and 1 hour after the dental extractions Subculture and further identification of the isolated bacteria were performed by further identification of the isolated bacteria were performed by conventional microbiological techniques RESULTS The conventional microbiological techniques RESULTS The prevalence of bacteremia after dental extraction in the control prevalence of bacteremia after dental extraction in the control and chlorhexidine groups were 96 and 79 respectively at 30 and chlorhexidine groups were 96 and 79 respectively at 30 seconds (P=008) 64 and 30 at 15 minutes (Plt001) and seconds (P=008) 64 and 30 at 15 minutes (Plt001) and 20 and 2 at 1 hour (P=005) The most frequently identified 20 and 2 at 1 hour (P=005) The most frequently identified bacteria were Streptococcus species in both the control and bacteria were Streptococcus species in both the control and chlorhexidine groups (64 and 68 respectively) particularly chlorhexidine groups (64 and 68 respectively) particularly viridans group streptococci CONCLUSION We recommend the viridans group streptococci CONCLUSION We recommend the routine use of a 02 chlorhexidine mouthwash before dental routine use of a 02 chlorhexidine mouthwash before dental extractions to reduce the risk of postextraction bacteremiaextractions to reduce the risk of postextraction bacteremia
bull ImmunocompromisedImmunocompromised Type one Type one diabetes high dose steroids diabetes high dose steroids immunosuppressive agents prior immunosuppressive agents prior infection history poor protoplasminfection history poor protoplasm
bull Metastaticdistant site infection risk Metastaticdistant site infection risk (heart valves orthopedic implants (heart valves orthopedic implants shunts)shunts)
Evidence Base for Evidence Base for Duration of Antimicrobial Duration of Antimicrobial
ProphylaxisProphylaxisbull ldquoldquoThe goal of antimicrobial prophylaxis is to The goal of antimicrobial prophylaxis is to
achieve serum and tissue levels of the antibiotic achieve serum and tissue levels of the antibiotic at the time of incision and for the duration of the at the time of incision and for the duration of the operation that are in excess of the minimum operation that are in excess of the minimum inhibitory concentration needed for the inhibitory concentration needed for the organisms that may be encountered during the organisms that may be encountered during the operation The National Surgical Infection operation The National Surgical Infection Prevention Project recommends the antibiotics Prevention Project recommends the antibiotics not be extended beyond 24 hours of the not be extended beyond 24 hours of the end of the operationrdquoend of the operationrdquo
Updated August 2003Updated August 2003
Proof Nailed Down that Proof Nailed Down that Antibiotics Use Leads to Antibiotics Use Leads to
ResistanceResistance ANTWERP Belgium Feb 9 2007 -- For the first ANTWERP Belgium Feb 9 2007 -- For the first time the unassailable proof that physicians can do time the unassailable proof that physicians can do harm by indiscriminate use of antibiotics has harm by indiscriminate use of antibiotics has emerged from a randomized controlled trialemerged from a randomized controlled trial
Physicians should take into account the striking Physicians should take into account the striking ecological side-effects of antibiotics when ecological side-effects of antibiotics when prescribing such drugs to their patients the prescribing such drugs to their patients the researchers concludedresearchers concluded
Malhotra-Kumar S et al Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers a randomized double-blind placebo-controlled study Lancet 2007 369 482-490
2007 AHA2007 AHA
The AHArsquos latest guidelines were published in its The AHArsquos latest guidelines were published in its scientific journal scientific journal CirculationCirculation in April 2007 and in April 2007 and
there is good news there is good news the AHA recommends that the AHA recommends that most of these patients no longer need most of these patients no longer need short-term antibiotics as a preventive short-term antibiotics as a preventive
measure before their dental treatmentmeasure before their dental treatment
Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE
2007 AHA2007 AHAPreventive antibiotics prior to a dental procedure Preventive antibiotics prior to a dental procedure
are advised for patients withare advised for patients with1 artificial heart valves 1 artificial heart valves 2 a history of infective endocarditis 2 a history of infective endocarditis 3 certain specific serious congenital (present from birth) 3 certain specific serious congenital (present from birth)
heart conditions including unrepaired or incompletely heart conditions including unrepaired or incompletely repaired cyanotic congenital heart disease including repaired cyanotic congenital heart disease including those with palliative shunts and conduits those with palliative shunts and conduits
4 a completely repaired congenital heart defect with 4 a completely repaired congenital heart defect with prosthetic material or device whether placed by prosthetic material or device whether placed by surgery or by catheter intervention during the first six surgery or by catheter intervention during the first six months after the procedure months after the procedure
5 any repaired congenital heart defect with residual 5 any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device patch or a prosthetic device
6 a cardiac transplant that develops a problem in a heart 6 a cardiac transplant that develops a problem in a heart valvevalve
According to the 2007 AHA guidelines According to the 2007 AHA guidelines which patient should receive antibiotics which patient should receive antibiotics before an extractionbefore an extraction
A Mitral valve prolapse with A Mitral valve prolapse with echocardiogram confirmed murmurechocardiogram confirmed murmur
B Recent (less than 6 months) bypass B Recent (less than 6 months) bypass surgerysurgery
C History of rheumatic heart diseaseC History of rheumatic heart disease
D Surgical repair of a heart valveD Surgical repair of a heart valve
E Heart transplant recipientsE Heart transplant recipients
J Am Dent Assoc 2003 Jul134(7)895-9J Am Dent Assoc 2003 Jul134(7)895-9
Antibiotic prophylaxis for dental Antibiotic prophylaxis for dental patients with total joint patients with total joint
replacementsreplacements
American Dental Association American Academy of Orthopedic SurgeonsAmerican Dental Association American Academy of Orthopedic Surgeons
The statement concludes that antibiotic The statement concludes that antibiotic prophylaxis is not indicated for dental patients prophylaxis is not indicated for dental patients with pins plates or screws nor is it routinely with pins plates or screws nor is it routinely
indicated for most dental patients with total joint indicated for most dental patients with total joint replacements However it is advisable to replacements However it is advisable to
consider premedication in a small number of consider premedication in a small number of patients who may be at potential increased risk of patients who may be at potential increased risk of experiencing hematogenous total joint infectionexperiencing hematogenous total joint infection
HEMATOGENOUS TOTAL JOINT INFECTION
PATIENT TYPE CONDITION PLACING PATIENT AT RISK
All patients during first two years following joint replacement
NAdagger
Immunocompromisedimmunosuppressed patients
Inflammatory arthropathies such as rheumatoid arthritis systemic lupus erythematosus
Drug- or radiation-induced immunosuppression
Patients with comorbiditiesDagger Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
Any perceived potential benefit of antibiotic Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known prophylaxis must be weighed against the known
risks of antibiotic toxicity allergy and risks of antibiotic toxicity allergy and development selection and transmission of development selection and transmission of
microbial resistancemicrobial resistance
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
FDA obtained evidence that Canfield manufactured and distributed adulterated (ie not manufactured according to good manufacturing practice) and unapproved drugs including DS Dressing (20 Eugenol) DS Mini-Dressing (20 Eugenol) DS Syringe (20 Eugenol) and DS Ointment (20 Eugenol) Canfield promoted these products for the treatment of dry socket a condition in which the socket does not heal properly following the extraction of a tooth The products were available nationwide through dental practices for use by dentists and consumers
FDA obtained evidence that Canfield manufactured and distributed adulterated (ie not manufactured according to good manufacturing practice) and unapproved drugs including DS Dressing (20 Eugenol) DS Mini-Dressing (20 Eugenol) DS Syringe (20 Eugenol) and DS Ointment (20 Eugenol) Canfield promoted these products for the treatment of dry socket a condition in which the socket does not heal properly following the extraction of a tooth The products were available nationwide through dental practices for use by dentists and consumers
FOR IMMEDIATE RELEASEOctober 6 2006FOR IMMEDIATE RELEASEOctober 6 2006
Permanent Injunction of Dental Products Manufacturer Furthers FDA Efforts Against Marketed Unapproved Drugs
Permanent Injunction of Dental Products Manufacturer Furthers FDA Efforts Against Marketed Unapproved Drugs
AlvogylregAlvogylregDry Socket Alveolar DressingDry Socket Alveolar DressingAlvogyl is a one-step self-eliminating Alvogyl is a one-step self-eliminating treatment which rapidly alleviates pain and treatment which rapidly alleviates pain and provides a soothing effect throughout the provides a soothing effect throughout the healing process Its fibrous consistency allows healing process Its fibrous consistency allows for easy filling of the socket and good for easy filling of the socket and good adherence during the entire healing process adherence during the entire healing process The active ingredients of Alvogyl include The active ingredients of Alvogyl include eugenol for analgesic action eugenol for analgesic action butambenbutamben for for anesthetic action and iodoform for anti-anesthetic action and iodoform for anti-microbial actionmicrobial action
AlvogylregAlvogylregDry Socket Alveolar DressingDry Socket Alveolar DressingAlvogyl is a one-step self-eliminating Alvogyl is a one-step self-eliminating treatment which rapidly alleviates pain and treatment which rapidly alleviates pain and provides a soothing effect throughout the provides a soothing effect throughout the healing process Its fibrous consistency allows healing process Its fibrous consistency allows for easy filling of the socket and good for easy filling of the socket and good adherence during the entire healing process adherence during the entire healing process The active ingredients of Alvogyl include The active ingredients of Alvogyl include eugenol for analgesic action eugenol for analgesic action butambenbutamben for for anesthetic action and iodoform for anti-anesthetic action and iodoform for anti-microbial actionmicrobial actionButamben a lipophilic
local anesthetic of the ester classester class produces a differential nerve block of long duration
Odontogenic Infections Odontogenic Infections Dr J Bruce Bavitz Dr J Bruce Bavitz
From From Diagnosis and Diagnosis and Treatment of Treatment of Odontogenic Odontogenic Infections Infections Hooley JR Hooley JR Whitacre RJ Whitacre RJ editors Stoma editors Stoma Press 1983Press 1983
Odontogenic Infxts-Odontogenic Infxts-PreventionPrevention((My heart artificial joint or jaw My heart artificial joint or jaw
are are notnot infected now and I donrsquot infected now and I donrsquot want them infected after the want them infected after the
Infect Control Hosp Epidemiol 2007 May28(5)577-82 Infect Control Hosp Epidemiol 2007 May28(5)577-82
Effect of a chlorhexidine mouthwash on the risk of Effect of a chlorhexidine mouthwash on the risk of postextraction bacteremiapostextraction bacteremiaTomaacutes I Alvarez M Limeres J Tomaacutes MTomaacutes M Medina JMedina J Otero JLOtero JL Diz Diz PPThe chlorhexidine group had 02 chlorhexidine mouthwash The chlorhexidine group had 02 chlorhexidine mouthwash administered for 30 seconds before any dental manipulation administered for 30 seconds before any dental manipulation Blood samples were collected at baseline 30 seconds 15 Blood samples were collected at baseline 30 seconds 15 minutes and 1 hour after the dental extractions Subculture and minutes and 1 hour after the dental extractions Subculture and further identification of the isolated bacteria were performed by further identification of the isolated bacteria were performed by conventional microbiological techniques RESULTS The conventional microbiological techniques RESULTS The prevalence of bacteremia after dental extraction in the control prevalence of bacteremia after dental extraction in the control and chlorhexidine groups were 96 and 79 respectively at 30 and chlorhexidine groups were 96 and 79 respectively at 30 seconds (P=008) 64 and 30 at 15 minutes (Plt001) and seconds (P=008) 64 and 30 at 15 minutes (Plt001) and 20 and 2 at 1 hour (P=005) The most frequently identified 20 and 2 at 1 hour (P=005) The most frequently identified bacteria were Streptococcus species in both the control and bacteria were Streptococcus species in both the control and chlorhexidine groups (64 and 68 respectively) particularly chlorhexidine groups (64 and 68 respectively) particularly viridans group streptococci CONCLUSION We recommend the viridans group streptococci CONCLUSION We recommend the routine use of a 02 chlorhexidine mouthwash before dental routine use of a 02 chlorhexidine mouthwash before dental extractions to reduce the risk of postextraction bacteremiaextractions to reduce the risk of postextraction bacteremia
bull ImmunocompromisedImmunocompromised Type one Type one diabetes high dose steroids diabetes high dose steroids immunosuppressive agents prior immunosuppressive agents prior infection history poor protoplasminfection history poor protoplasm
bull Metastaticdistant site infection risk Metastaticdistant site infection risk (heart valves orthopedic implants (heart valves orthopedic implants shunts)shunts)
Evidence Base for Evidence Base for Duration of Antimicrobial Duration of Antimicrobial
ProphylaxisProphylaxisbull ldquoldquoThe goal of antimicrobial prophylaxis is to The goal of antimicrobial prophylaxis is to
achieve serum and tissue levels of the antibiotic achieve serum and tissue levels of the antibiotic at the time of incision and for the duration of the at the time of incision and for the duration of the operation that are in excess of the minimum operation that are in excess of the minimum inhibitory concentration needed for the inhibitory concentration needed for the organisms that may be encountered during the organisms that may be encountered during the operation The National Surgical Infection operation The National Surgical Infection Prevention Project recommends the antibiotics Prevention Project recommends the antibiotics not be extended beyond 24 hours of the not be extended beyond 24 hours of the end of the operationrdquoend of the operationrdquo
Updated August 2003Updated August 2003
Proof Nailed Down that Proof Nailed Down that Antibiotics Use Leads to Antibiotics Use Leads to
ResistanceResistance ANTWERP Belgium Feb 9 2007 -- For the first ANTWERP Belgium Feb 9 2007 -- For the first time the unassailable proof that physicians can do time the unassailable proof that physicians can do harm by indiscriminate use of antibiotics has harm by indiscriminate use of antibiotics has emerged from a randomized controlled trialemerged from a randomized controlled trial
Physicians should take into account the striking Physicians should take into account the striking ecological side-effects of antibiotics when ecological side-effects of antibiotics when prescribing such drugs to their patients the prescribing such drugs to their patients the researchers concludedresearchers concluded
Malhotra-Kumar S et al Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers a randomized double-blind placebo-controlled study Lancet 2007 369 482-490
2007 AHA2007 AHA
The AHArsquos latest guidelines were published in its The AHArsquos latest guidelines were published in its scientific journal scientific journal CirculationCirculation in April 2007 and in April 2007 and
there is good news there is good news the AHA recommends that the AHA recommends that most of these patients no longer need most of these patients no longer need short-term antibiotics as a preventive short-term antibiotics as a preventive
measure before their dental treatmentmeasure before their dental treatment
Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE
2007 AHA2007 AHAPreventive antibiotics prior to a dental procedure Preventive antibiotics prior to a dental procedure
are advised for patients withare advised for patients with1 artificial heart valves 1 artificial heart valves 2 a history of infective endocarditis 2 a history of infective endocarditis 3 certain specific serious congenital (present from birth) 3 certain specific serious congenital (present from birth)
heart conditions including unrepaired or incompletely heart conditions including unrepaired or incompletely repaired cyanotic congenital heart disease including repaired cyanotic congenital heart disease including those with palliative shunts and conduits those with palliative shunts and conduits
4 a completely repaired congenital heart defect with 4 a completely repaired congenital heart defect with prosthetic material or device whether placed by prosthetic material or device whether placed by surgery or by catheter intervention during the first six surgery or by catheter intervention during the first six months after the procedure months after the procedure
5 any repaired congenital heart defect with residual 5 any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device patch or a prosthetic device
6 a cardiac transplant that develops a problem in a heart 6 a cardiac transplant that develops a problem in a heart valvevalve
According to the 2007 AHA guidelines According to the 2007 AHA guidelines which patient should receive antibiotics which patient should receive antibiotics before an extractionbefore an extraction
A Mitral valve prolapse with A Mitral valve prolapse with echocardiogram confirmed murmurechocardiogram confirmed murmur
B Recent (less than 6 months) bypass B Recent (less than 6 months) bypass surgerysurgery
C History of rheumatic heart diseaseC History of rheumatic heart disease
D Surgical repair of a heart valveD Surgical repair of a heart valve
E Heart transplant recipientsE Heart transplant recipients
J Am Dent Assoc 2003 Jul134(7)895-9J Am Dent Assoc 2003 Jul134(7)895-9
Antibiotic prophylaxis for dental Antibiotic prophylaxis for dental patients with total joint patients with total joint
replacementsreplacements
American Dental Association American Academy of Orthopedic SurgeonsAmerican Dental Association American Academy of Orthopedic Surgeons
The statement concludes that antibiotic The statement concludes that antibiotic prophylaxis is not indicated for dental patients prophylaxis is not indicated for dental patients with pins plates or screws nor is it routinely with pins plates or screws nor is it routinely
indicated for most dental patients with total joint indicated for most dental patients with total joint replacements However it is advisable to replacements However it is advisable to
consider premedication in a small number of consider premedication in a small number of patients who may be at potential increased risk of patients who may be at potential increased risk of experiencing hematogenous total joint infectionexperiencing hematogenous total joint infection
HEMATOGENOUS TOTAL JOINT INFECTION
PATIENT TYPE CONDITION PLACING PATIENT AT RISK
All patients during first two years following joint replacement
NAdagger
Immunocompromisedimmunosuppressed patients
Inflammatory arthropathies such as rheumatoid arthritis systemic lupus erythematosus
Drug- or radiation-induced immunosuppression
Patients with comorbiditiesDagger Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
Any perceived potential benefit of antibiotic Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known prophylaxis must be weighed against the known
risks of antibiotic toxicity allergy and risks of antibiotic toxicity allergy and development selection and transmission of development selection and transmission of
microbial resistancemicrobial resistance
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
AlvogylregAlvogylregDry Socket Alveolar DressingDry Socket Alveolar DressingAlvogyl is a one-step self-eliminating Alvogyl is a one-step self-eliminating treatment which rapidly alleviates pain and treatment which rapidly alleviates pain and provides a soothing effect throughout the provides a soothing effect throughout the healing process Its fibrous consistency allows healing process Its fibrous consistency allows for easy filling of the socket and good for easy filling of the socket and good adherence during the entire healing process adherence during the entire healing process The active ingredients of Alvogyl include The active ingredients of Alvogyl include eugenol for analgesic action eugenol for analgesic action butambenbutamben for for anesthetic action and iodoform for anti-anesthetic action and iodoform for anti-microbial actionmicrobial action
AlvogylregAlvogylregDry Socket Alveolar DressingDry Socket Alveolar DressingAlvogyl is a one-step self-eliminating Alvogyl is a one-step self-eliminating treatment which rapidly alleviates pain and treatment which rapidly alleviates pain and provides a soothing effect throughout the provides a soothing effect throughout the healing process Its fibrous consistency allows healing process Its fibrous consistency allows for easy filling of the socket and good for easy filling of the socket and good adherence during the entire healing process adherence during the entire healing process The active ingredients of Alvogyl include The active ingredients of Alvogyl include eugenol for analgesic action eugenol for analgesic action butambenbutamben for for anesthetic action and iodoform for anti-anesthetic action and iodoform for anti-microbial actionmicrobial actionButamben a lipophilic
local anesthetic of the ester classester class produces a differential nerve block of long duration
Odontogenic Infections Odontogenic Infections Dr J Bruce Bavitz Dr J Bruce Bavitz
From From Diagnosis and Diagnosis and Treatment of Treatment of Odontogenic Odontogenic Infections Infections Hooley JR Hooley JR Whitacre RJ Whitacre RJ editors Stoma editors Stoma Press 1983Press 1983
Odontogenic Infxts-Odontogenic Infxts-PreventionPrevention((My heart artificial joint or jaw My heart artificial joint or jaw
are are notnot infected now and I donrsquot infected now and I donrsquot want them infected after the want them infected after the
Infect Control Hosp Epidemiol 2007 May28(5)577-82 Infect Control Hosp Epidemiol 2007 May28(5)577-82
Effect of a chlorhexidine mouthwash on the risk of Effect of a chlorhexidine mouthwash on the risk of postextraction bacteremiapostextraction bacteremiaTomaacutes I Alvarez M Limeres J Tomaacutes MTomaacutes M Medina JMedina J Otero JLOtero JL Diz Diz PPThe chlorhexidine group had 02 chlorhexidine mouthwash The chlorhexidine group had 02 chlorhexidine mouthwash administered for 30 seconds before any dental manipulation administered for 30 seconds before any dental manipulation Blood samples were collected at baseline 30 seconds 15 Blood samples were collected at baseline 30 seconds 15 minutes and 1 hour after the dental extractions Subculture and minutes and 1 hour after the dental extractions Subculture and further identification of the isolated bacteria were performed by further identification of the isolated bacteria were performed by conventional microbiological techniques RESULTS The conventional microbiological techniques RESULTS The prevalence of bacteremia after dental extraction in the control prevalence of bacteremia after dental extraction in the control and chlorhexidine groups were 96 and 79 respectively at 30 and chlorhexidine groups were 96 and 79 respectively at 30 seconds (P=008) 64 and 30 at 15 minutes (Plt001) and seconds (P=008) 64 and 30 at 15 minutes (Plt001) and 20 and 2 at 1 hour (P=005) The most frequently identified 20 and 2 at 1 hour (P=005) The most frequently identified bacteria were Streptococcus species in both the control and bacteria were Streptococcus species in both the control and chlorhexidine groups (64 and 68 respectively) particularly chlorhexidine groups (64 and 68 respectively) particularly viridans group streptococci CONCLUSION We recommend the viridans group streptococci CONCLUSION We recommend the routine use of a 02 chlorhexidine mouthwash before dental routine use of a 02 chlorhexidine mouthwash before dental extractions to reduce the risk of postextraction bacteremiaextractions to reduce the risk of postextraction bacteremia
bull ImmunocompromisedImmunocompromised Type one Type one diabetes high dose steroids diabetes high dose steroids immunosuppressive agents prior immunosuppressive agents prior infection history poor protoplasminfection history poor protoplasm
bull Metastaticdistant site infection risk Metastaticdistant site infection risk (heart valves orthopedic implants (heart valves orthopedic implants shunts)shunts)
Evidence Base for Evidence Base for Duration of Antimicrobial Duration of Antimicrobial
ProphylaxisProphylaxisbull ldquoldquoThe goal of antimicrobial prophylaxis is to The goal of antimicrobial prophylaxis is to
achieve serum and tissue levels of the antibiotic achieve serum and tissue levels of the antibiotic at the time of incision and for the duration of the at the time of incision and for the duration of the operation that are in excess of the minimum operation that are in excess of the minimum inhibitory concentration needed for the inhibitory concentration needed for the organisms that may be encountered during the organisms that may be encountered during the operation The National Surgical Infection operation The National Surgical Infection Prevention Project recommends the antibiotics Prevention Project recommends the antibiotics not be extended beyond 24 hours of the not be extended beyond 24 hours of the end of the operationrdquoend of the operationrdquo
Updated August 2003Updated August 2003
Proof Nailed Down that Proof Nailed Down that Antibiotics Use Leads to Antibiotics Use Leads to
ResistanceResistance ANTWERP Belgium Feb 9 2007 -- For the first ANTWERP Belgium Feb 9 2007 -- For the first time the unassailable proof that physicians can do time the unassailable proof that physicians can do harm by indiscriminate use of antibiotics has harm by indiscriminate use of antibiotics has emerged from a randomized controlled trialemerged from a randomized controlled trial
Physicians should take into account the striking Physicians should take into account the striking ecological side-effects of antibiotics when ecological side-effects of antibiotics when prescribing such drugs to their patients the prescribing such drugs to their patients the researchers concludedresearchers concluded
Malhotra-Kumar S et al Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers a randomized double-blind placebo-controlled study Lancet 2007 369 482-490
2007 AHA2007 AHA
The AHArsquos latest guidelines were published in its The AHArsquos latest guidelines were published in its scientific journal scientific journal CirculationCirculation in April 2007 and in April 2007 and
there is good news there is good news the AHA recommends that the AHA recommends that most of these patients no longer need most of these patients no longer need short-term antibiotics as a preventive short-term antibiotics as a preventive
measure before their dental treatmentmeasure before their dental treatment
Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE
2007 AHA2007 AHAPreventive antibiotics prior to a dental procedure Preventive antibiotics prior to a dental procedure
are advised for patients withare advised for patients with1 artificial heart valves 1 artificial heart valves 2 a history of infective endocarditis 2 a history of infective endocarditis 3 certain specific serious congenital (present from birth) 3 certain specific serious congenital (present from birth)
heart conditions including unrepaired or incompletely heart conditions including unrepaired or incompletely repaired cyanotic congenital heart disease including repaired cyanotic congenital heart disease including those with palliative shunts and conduits those with palliative shunts and conduits
4 a completely repaired congenital heart defect with 4 a completely repaired congenital heart defect with prosthetic material or device whether placed by prosthetic material or device whether placed by surgery or by catheter intervention during the first six surgery or by catheter intervention during the first six months after the procedure months after the procedure
5 any repaired congenital heart defect with residual 5 any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device patch or a prosthetic device
6 a cardiac transplant that develops a problem in a heart 6 a cardiac transplant that develops a problem in a heart valvevalve
According to the 2007 AHA guidelines According to the 2007 AHA guidelines which patient should receive antibiotics which patient should receive antibiotics before an extractionbefore an extraction
A Mitral valve prolapse with A Mitral valve prolapse with echocardiogram confirmed murmurechocardiogram confirmed murmur
B Recent (less than 6 months) bypass B Recent (less than 6 months) bypass surgerysurgery
C History of rheumatic heart diseaseC History of rheumatic heart disease
D Surgical repair of a heart valveD Surgical repair of a heart valve
E Heart transplant recipientsE Heart transplant recipients
J Am Dent Assoc 2003 Jul134(7)895-9J Am Dent Assoc 2003 Jul134(7)895-9
Antibiotic prophylaxis for dental Antibiotic prophylaxis for dental patients with total joint patients with total joint
replacementsreplacements
American Dental Association American Academy of Orthopedic SurgeonsAmerican Dental Association American Academy of Orthopedic Surgeons
The statement concludes that antibiotic The statement concludes that antibiotic prophylaxis is not indicated for dental patients prophylaxis is not indicated for dental patients with pins plates or screws nor is it routinely with pins plates or screws nor is it routinely
indicated for most dental patients with total joint indicated for most dental patients with total joint replacements However it is advisable to replacements However it is advisable to
consider premedication in a small number of consider premedication in a small number of patients who may be at potential increased risk of patients who may be at potential increased risk of experiencing hematogenous total joint infectionexperiencing hematogenous total joint infection
HEMATOGENOUS TOTAL JOINT INFECTION
PATIENT TYPE CONDITION PLACING PATIENT AT RISK
All patients during first two years following joint replacement
NAdagger
Immunocompromisedimmunosuppressed patients
Inflammatory arthropathies such as rheumatoid arthritis systemic lupus erythematosus
Drug- or radiation-induced immunosuppression
Patients with comorbiditiesDagger Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
Any perceived potential benefit of antibiotic Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known prophylaxis must be weighed against the known
risks of antibiotic toxicity allergy and risks of antibiotic toxicity allergy and development selection and transmission of development selection and transmission of
microbial resistancemicrobial resistance
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
Odontogenic Infections Odontogenic Infections Dr J Bruce Bavitz Dr J Bruce Bavitz
From From Diagnosis and Diagnosis and Treatment of Treatment of Odontogenic Odontogenic Infections Infections Hooley JR Hooley JR Whitacre RJ Whitacre RJ editors Stoma editors Stoma Press 1983Press 1983
Odontogenic Infxts-Odontogenic Infxts-PreventionPrevention((My heart artificial joint or jaw My heart artificial joint or jaw
are are notnot infected now and I donrsquot infected now and I donrsquot want them infected after the want them infected after the
Infect Control Hosp Epidemiol 2007 May28(5)577-82 Infect Control Hosp Epidemiol 2007 May28(5)577-82
Effect of a chlorhexidine mouthwash on the risk of Effect of a chlorhexidine mouthwash on the risk of postextraction bacteremiapostextraction bacteremiaTomaacutes I Alvarez M Limeres J Tomaacutes MTomaacutes M Medina JMedina J Otero JLOtero JL Diz Diz PPThe chlorhexidine group had 02 chlorhexidine mouthwash The chlorhexidine group had 02 chlorhexidine mouthwash administered for 30 seconds before any dental manipulation administered for 30 seconds before any dental manipulation Blood samples were collected at baseline 30 seconds 15 Blood samples were collected at baseline 30 seconds 15 minutes and 1 hour after the dental extractions Subculture and minutes and 1 hour after the dental extractions Subculture and further identification of the isolated bacteria were performed by further identification of the isolated bacteria were performed by conventional microbiological techniques RESULTS The conventional microbiological techniques RESULTS The prevalence of bacteremia after dental extraction in the control prevalence of bacteremia after dental extraction in the control and chlorhexidine groups were 96 and 79 respectively at 30 and chlorhexidine groups were 96 and 79 respectively at 30 seconds (P=008) 64 and 30 at 15 minutes (Plt001) and seconds (P=008) 64 and 30 at 15 minutes (Plt001) and 20 and 2 at 1 hour (P=005) The most frequently identified 20 and 2 at 1 hour (P=005) The most frequently identified bacteria were Streptococcus species in both the control and bacteria were Streptococcus species in both the control and chlorhexidine groups (64 and 68 respectively) particularly chlorhexidine groups (64 and 68 respectively) particularly viridans group streptococci CONCLUSION We recommend the viridans group streptococci CONCLUSION We recommend the routine use of a 02 chlorhexidine mouthwash before dental routine use of a 02 chlorhexidine mouthwash before dental extractions to reduce the risk of postextraction bacteremiaextractions to reduce the risk of postextraction bacteremia
bull ImmunocompromisedImmunocompromised Type one Type one diabetes high dose steroids diabetes high dose steroids immunosuppressive agents prior immunosuppressive agents prior infection history poor protoplasminfection history poor protoplasm
bull Metastaticdistant site infection risk Metastaticdistant site infection risk (heart valves orthopedic implants (heart valves orthopedic implants shunts)shunts)
Evidence Base for Evidence Base for Duration of Antimicrobial Duration of Antimicrobial
ProphylaxisProphylaxisbull ldquoldquoThe goal of antimicrobial prophylaxis is to The goal of antimicrobial prophylaxis is to
achieve serum and tissue levels of the antibiotic achieve serum and tissue levels of the antibiotic at the time of incision and for the duration of the at the time of incision and for the duration of the operation that are in excess of the minimum operation that are in excess of the minimum inhibitory concentration needed for the inhibitory concentration needed for the organisms that may be encountered during the organisms that may be encountered during the operation The National Surgical Infection operation The National Surgical Infection Prevention Project recommends the antibiotics Prevention Project recommends the antibiotics not be extended beyond 24 hours of the not be extended beyond 24 hours of the end of the operationrdquoend of the operationrdquo
Updated August 2003Updated August 2003
Proof Nailed Down that Proof Nailed Down that Antibiotics Use Leads to Antibiotics Use Leads to
ResistanceResistance ANTWERP Belgium Feb 9 2007 -- For the first ANTWERP Belgium Feb 9 2007 -- For the first time the unassailable proof that physicians can do time the unassailable proof that physicians can do harm by indiscriminate use of antibiotics has harm by indiscriminate use of antibiotics has emerged from a randomized controlled trialemerged from a randomized controlled trial
Physicians should take into account the striking Physicians should take into account the striking ecological side-effects of antibiotics when ecological side-effects of antibiotics when prescribing such drugs to their patients the prescribing such drugs to their patients the researchers concludedresearchers concluded
Malhotra-Kumar S et al Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers a randomized double-blind placebo-controlled study Lancet 2007 369 482-490
2007 AHA2007 AHA
The AHArsquos latest guidelines were published in its The AHArsquos latest guidelines were published in its scientific journal scientific journal CirculationCirculation in April 2007 and in April 2007 and
there is good news there is good news the AHA recommends that the AHA recommends that most of these patients no longer need most of these patients no longer need short-term antibiotics as a preventive short-term antibiotics as a preventive
measure before their dental treatmentmeasure before their dental treatment
Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE
2007 AHA2007 AHAPreventive antibiotics prior to a dental procedure Preventive antibiotics prior to a dental procedure
are advised for patients withare advised for patients with1 artificial heart valves 1 artificial heart valves 2 a history of infective endocarditis 2 a history of infective endocarditis 3 certain specific serious congenital (present from birth) 3 certain specific serious congenital (present from birth)
heart conditions including unrepaired or incompletely heart conditions including unrepaired or incompletely repaired cyanotic congenital heart disease including repaired cyanotic congenital heart disease including those with palliative shunts and conduits those with palliative shunts and conduits
4 a completely repaired congenital heart defect with 4 a completely repaired congenital heart defect with prosthetic material or device whether placed by prosthetic material or device whether placed by surgery or by catheter intervention during the first six surgery or by catheter intervention during the first six months after the procedure months after the procedure
5 any repaired congenital heart defect with residual 5 any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device patch or a prosthetic device
6 a cardiac transplant that develops a problem in a heart 6 a cardiac transplant that develops a problem in a heart valvevalve
According to the 2007 AHA guidelines According to the 2007 AHA guidelines which patient should receive antibiotics which patient should receive antibiotics before an extractionbefore an extraction
A Mitral valve prolapse with A Mitral valve prolapse with echocardiogram confirmed murmurechocardiogram confirmed murmur
B Recent (less than 6 months) bypass B Recent (less than 6 months) bypass surgerysurgery
C History of rheumatic heart diseaseC History of rheumatic heart disease
D Surgical repair of a heart valveD Surgical repair of a heart valve
E Heart transplant recipientsE Heart transplant recipients
J Am Dent Assoc 2003 Jul134(7)895-9J Am Dent Assoc 2003 Jul134(7)895-9
Antibiotic prophylaxis for dental Antibiotic prophylaxis for dental patients with total joint patients with total joint
replacementsreplacements
American Dental Association American Academy of Orthopedic SurgeonsAmerican Dental Association American Academy of Orthopedic Surgeons
The statement concludes that antibiotic The statement concludes that antibiotic prophylaxis is not indicated for dental patients prophylaxis is not indicated for dental patients with pins plates or screws nor is it routinely with pins plates or screws nor is it routinely
indicated for most dental patients with total joint indicated for most dental patients with total joint replacements However it is advisable to replacements However it is advisable to
consider premedication in a small number of consider premedication in a small number of patients who may be at potential increased risk of patients who may be at potential increased risk of experiencing hematogenous total joint infectionexperiencing hematogenous total joint infection
HEMATOGENOUS TOTAL JOINT INFECTION
PATIENT TYPE CONDITION PLACING PATIENT AT RISK
All patients during first two years following joint replacement
NAdagger
Immunocompromisedimmunosuppressed patients
Inflammatory arthropathies such as rheumatoid arthritis systemic lupus erythematosus
Drug- or radiation-induced immunosuppression
Patients with comorbiditiesDagger Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
Any perceived potential benefit of antibiotic Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known prophylaxis must be weighed against the known
risks of antibiotic toxicity allergy and risks of antibiotic toxicity allergy and development selection and transmission of development selection and transmission of
microbial resistancemicrobial resistance
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
Odontogenic Infxts-Odontogenic Infxts-PreventionPrevention((My heart artificial joint or jaw My heart artificial joint or jaw
are are notnot infected now and I donrsquot infected now and I donrsquot want them infected after the want them infected after the
Infect Control Hosp Epidemiol 2007 May28(5)577-82 Infect Control Hosp Epidemiol 2007 May28(5)577-82
Effect of a chlorhexidine mouthwash on the risk of Effect of a chlorhexidine mouthwash on the risk of postextraction bacteremiapostextraction bacteremiaTomaacutes I Alvarez M Limeres J Tomaacutes MTomaacutes M Medina JMedina J Otero JLOtero JL Diz Diz PPThe chlorhexidine group had 02 chlorhexidine mouthwash The chlorhexidine group had 02 chlorhexidine mouthwash administered for 30 seconds before any dental manipulation administered for 30 seconds before any dental manipulation Blood samples were collected at baseline 30 seconds 15 Blood samples were collected at baseline 30 seconds 15 minutes and 1 hour after the dental extractions Subculture and minutes and 1 hour after the dental extractions Subculture and further identification of the isolated bacteria were performed by further identification of the isolated bacteria were performed by conventional microbiological techniques RESULTS The conventional microbiological techniques RESULTS The prevalence of bacteremia after dental extraction in the control prevalence of bacteremia after dental extraction in the control and chlorhexidine groups were 96 and 79 respectively at 30 and chlorhexidine groups were 96 and 79 respectively at 30 seconds (P=008) 64 and 30 at 15 minutes (Plt001) and seconds (P=008) 64 and 30 at 15 minutes (Plt001) and 20 and 2 at 1 hour (P=005) The most frequently identified 20 and 2 at 1 hour (P=005) The most frequently identified bacteria were Streptococcus species in both the control and bacteria were Streptococcus species in both the control and chlorhexidine groups (64 and 68 respectively) particularly chlorhexidine groups (64 and 68 respectively) particularly viridans group streptococci CONCLUSION We recommend the viridans group streptococci CONCLUSION We recommend the routine use of a 02 chlorhexidine mouthwash before dental routine use of a 02 chlorhexidine mouthwash before dental extractions to reduce the risk of postextraction bacteremiaextractions to reduce the risk of postextraction bacteremia
bull ImmunocompromisedImmunocompromised Type one Type one diabetes high dose steroids diabetes high dose steroids immunosuppressive agents prior immunosuppressive agents prior infection history poor protoplasminfection history poor protoplasm
bull Metastaticdistant site infection risk Metastaticdistant site infection risk (heart valves orthopedic implants (heart valves orthopedic implants shunts)shunts)
Evidence Base for Evidence Base for Duration of Antimicrobial Duration of Antimicrobial
ProphylaxisProphylaxisbull ldquoldquoThe goal of antimicrobial prophylaxis is to The goal of antimicrobial prophylaxis is to
achieve serum and tissue levels of the antibiotic achieve serum and tissue levels of the antibiotic at the time of incision and for the duration of the at the time of incision and for the duration of the operation that are in excess of the minimum operation that are in excess of the minimum inhibitory concentration needed for the inhibitory concentration needed for the organisms that may be encountered during the organisms that may be encountered during the operation The National Surgical Infection operation The National Surgical Infection Prevention Project recommends the antibiotics Prevention Project recommends the antibiotics not be extended beyond 24 hours of the not be extended beyond 24 hours of the end of the operationrdquoend of the operationrdquo
Updated August 2003Updated August 2003
Proof Nailed Down that Proof Nailed Down that Antibiotics Use Leads to Antibiotics Use Leads to
ResistanceResistance ANTWERP Belgium Feb 9 2007 -- For the first ANTWERP Belgium Feb 9 2007 -- For the first time the unassailable proof that physicians can do time the unassailable proof that physicians can do harm by indiscriminate use of antibiotics has harm by indiscriminate use of antibiotics has emerged from a randomized controlled trialemerged from a randomized controlled trial
Physicians should take into account the striking Physicians should take into account the striking ecological side-effects of antibiotics when ecological side-effects of antibiotics when prescribing such drugs to their patients the prescribing such drugs to their patients the researchers concludedresearchers concluded
Malhotra-Kumar S et al Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers a randomized double-blind placebo-controlled study Lancet 2007 369 482-490
2007 AHA2007 AHA
The AHArsquos latest guidelines were published in its The AHArsquos latest guidelines were published in its scientific journal scientific journal CirculationCirculation in April 2007 and in April 2007 and
there is good news there is good news the AHA recommends that the AHA recommends that most of these patients no longer need most of these patients no longer need short-term antibiotics as a preventive short-term antibiotics as a preventive
measure before their dental treatmentmeasure before their dental treatment
Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE
2007 AHA2007 AHAPreventive antibiotics prior to a dental procedure Preventive antibiotics prior to a dental procedure
are advised for patients withare advised for patients with1 artificial heart valves 1 artificial heart valves 2 a history of infective endocarditis 2 a history of infective endocarditis 3 certain specific serious congenital (present from birth) 3 certain specific serious congenital (present from birth)
heart conditions including unrepaired or incompletely heart conditions including unrepaired or incompletely repaired cyanotic congenital heart disease including repaired cyanotic congenital heart disease including those with palliative shunts and conduits those with palliative shunts and conduits
4 a completely repaired congenital heart defect with 4 a completely repaired congenital heart defect with prosthetic material or device whether placed by prosthetic material or device whether placed by surgery or by catheter intervention during the first six surgery or by catheter intervention during the first six months after the procedure months after the procedure
5 any repaired congenital heart defect with residual 5 any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device patch or a prosthetic device
6 a cardiac transplant that develops a problem in a heart 6 a cardiac transplant that develops a problem in a heart valvevalve
According to the 2007 AHA guidelines According to the 2007 AHA guidelines which patient should receive antibiotics which patient should receive antibiotics before an extractionbefore an extraction
A Mitral valve prolapse with A Mitral valve prolapse with echocardiogram confirmed murmurechocardiogram confirmed murmur
B Recent (less than 6 months) bypass B Recent (less than 6 months) bypass surgerysurgery
C History of rheumatic heart diseaseC History of rheumatic heart disease
D Surgical repair of a heart valveD Surgical repair of a heart valve
E Heart transplant recipientsE Heart transplant recipients
J Am Dent Assoc 2003 Jul134(7)895-9J Am Dent Assoc 2003 Jul134(7)895-9
Antibiotic prophylaxis for dental Antibiotic prophylaxis for dental patients with total joint patients with total joint
replacementsreplacements
American Dental Association American Academy of Orthopedic SurgeonsAmerican Dental Association American Academy of Orthopedic Surgeons
The statement concludes that antibiotic The statement concludes that antibiotic prophylaxis is not indicated for dental patients prophylaxis is not indicated for dental patients with pins plates or screws nor is it routinely with pins plates or screws nor is it routinely
indicated for most dental patients with total joint indicated for most dental patients with total joint replacements However it is advisable to replacements However it is advisable to
consider premedication in a small number of consider premedication in a small number of patients who may be at potential increased risk of patients who may be at potential increased risk of experiencing hematogenous total joint infectionexperiencing hematogenous total joint infection
HEMATOGENOUS TOTAL JOINT INFECTION
PATIENT TYPE CONDITION PLACING PATIENT AT RISK
All patients during first two years following joint replacement
NAdagger
Immunocompromisedimmunosuppressed patients
Inflammatory arthropathies such as rheumatoid arthritis systemic lupus erythematosus
Drug- or radiation-induced immunosuppression
Patients with comorbiditiesDagger Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
Any perceived potential benefit of antibiotic Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known prophylaxis must be weighed against the known
risks of antibiotic toxicity allergy and risks of antibiotic toxicity allergy and development selection and transmission of development selection and transmission of
microbial resistancemicrobial resistance
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Infect Control Hosp Epidemiol 2007 May28(5)577-82 Infect Control Hosp Epidemiol 2007 May28(5)577-82
Effect of a chlorhexidine mouthwash on the risk of Effect of a chlorhexidine mouthwash on the risk of postextraction bacteremiapostextraction bacteremiaTomaacutes I Alvarez M Limeres J Tomaacutes MTomaacutes M Medina JMedina J Otero JLOtero JL Diz Diz PPThe chlorhexidine group had 02 chlorhexidine mouthwash The chlorhexidine group had 02 chlorhexidine mouthwash administered for 30 seconds before any dental manipulation administered for 30 seconds before any dental manipulation Blood samples were collected at baseline 30 seconds 15 Blood samples were collected at baseline 30 seconds 15 minutes and 1 hour after the dental extractions Subculture and minutes and 1 hour after the dental extractions Subculture and further identification of the isolated bacteria were performed by further identification of the isolated bacteria were performed by conventional microbiological techniques RESULTS The conventional microbiological techniques RESULTS The prevalence of bacteremia after dental extraction in the control prevalence of bacteremia after dental extraction in the control and chlorhexidine groups were 96 and 79 respectively at 30 and chlorhexidine groups were 96 and 79 respectively at 30 seconds (P=008) 64 and 30 at 15 minutes (Plt001) and seconds (P=008) 64 and 30 at 15 minutes (Plt001) and 20 and 2 at 1 hour (P=005) The most frequently identified 20 and 2 at 1 hour (P=005) The most frequently identified bacteria were Streptococcus species in both the control and bacteria were Streptococcus species in both the control and chlorhexidine groups (64 and 68 respectively) particularly chlorhexidine groups (64 and 68 respectively) particularly viridans group streptococci CONCLUSION We recommend the viridans group streptococci CONCLUSION We recommend the routine use of a 02 chlorhexidine mouthwash before dental routine use of a 02 chlorhexidine mouthwash before dental extractions to reduce the risk of postextraction bacteremiaextractions to reduce the risk of postextraction bacteremia
bull ImmunocompromisedImmunocompromised Type one Type one diabetes high dose steroids diabetes high dose steroids immunosuppressive agents prior immunosuppressive agents prior infection history poor protoplasminfection history poor protoplasm
bull Metastaticdistant site infection risk Metastaticdistant site infection risk (heart valves orthopedic implants (heart valves orthopedic implants shunts)shunts)
Evidence Base for Evidence Base for Duration of Antimicrobial Duration of Antimicrobial
ProphylaxisProphylaxisbull ldquoldquoThe goal of antimicrobial prophylaxis is to The goal of antimicrobial prophylaxis is to
achieve serum and tissue levels of the antibiotic achieve serum and tissue levels of the antibiotic at the time of incision and for the duration of the at the time of incision and for the duration of the operation that are in excess of the minimum operation that are in excess of the minimum inhibitory concentration needed for the inhibitory concentration needed for the organisms that may be encountered during the organisms that may be encountered during the operation The National Surgical Infection operation The National Surgical Infection Prevention Project recommends the antibiotics Prevention Project recommends the antibiotics not be extended beyond 24 hours of the not be extended beyond 24 hours of the end of the operationrdquoend of the operationrdquo
Updated August 2003Updated August 2003
Proof Nailed Down that Proof Nailed Down that Antibiotics Use Leads to Antibiotics Use Leads to
ResistanceResistance ANTWERP Belgium Feb 9 2007 -- For the first ANTWERP Belgium Feb 9 2007 -- For the first time the unassailable proof that physicians can do time the unassailable proof that physicians can do harm by indiscriminate use of antibiotics has harm by indiscriminate use of antibiotics has emerged from a randomized controlled trialemerged from a randomized controlled trial
Physicians should take into account the striking Physicians should take into account the striking ecological side-effects of antibiotics when ecological side-effects of antibiotics when prescribing such drugs to their patients the prescribing such drugs to their patients the researchers concludedresearchers concluded
Malhotra-Kumar S et al Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers a randomized double-blind placebo-controlled study Lancet 2007 369 482-490
2007 AHA2007 AHA
The AHArsquos latest guidelines were published in its The AHArsquos latest guidelines were published in its scientific journal scientific journal CirculationCirculation in April 2007 and in April 2007 and
there is good news there is good news the AHA recommends that the AHA recommends that most of these patients no longer need most of these patients no longer need short-term antibiotics as a preventive short-term antibiotics as a preventive
measure before their dental treatmentmeasure before their dental treatment
Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE
2007 AHA2007 AHAPreventive antibiotics prior to a dental procedure Preventive antibiotics prior to a dental procedure
are advised for patients withare advised for patients with1 artificial heart valves 1 artificial heart valves 2 a history of infective endocarditis 2 a history of infective endocarditis 3 certain specific serious congenital (present from birth) 3 certain specific serious congenital (present from birth)
heart conditions including unrepaired or incompletely heart conditions including unrepaired or incompletely repaired cyanotic congenital heart disease including repaired cyanotic congenital heart disease including those with palliative shunts and conduits those with palliative shunts and conduits
4 a completely repaired congenital heart defect with 4 a completely repaired congenital heart defect with prosthetic material or device whether placed by prosthetic material or device whether placed by surgery or by catheter intervention during the first six surgery or by catheter intervention during the first six months after the procedure months after the procedure
5 any repaired congenital heart defect with residual 5 any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device patch or a prosthetic device
6 a cardiac transplant that develops a problem in a heart 6 a cardiac transplant that develops a problem in a heart valvevalve
According to the 2007 AHA guidelines According to the 2007 AHA guidelines which patient should receive antibiotics which patient should receive antibiotics before an extractionbefore an extraction
A Mitral valve prolapse with A Mitral valve prolapse with echocardiogram confirmed murmurechocardiogram confirmed murmur
B Recent (less than 6 months) bypass B Recent (less than 6 months) bypass surgerysurgery
C History of rheumatic heart diseaseC History of rheumatic heart disease
D Surgical repair of a heart valveD Surgical repair of a heart valve
E Heart transplant recipientsE Heart transplant recipients
J Am Dent Assoc 2003 Jul134(7)895-9J Am Dent Assoc 2003 Jul134(7)895-9
Antibiotic prophylaxis for dental Antibiotic prophylaxis for dental patients with total joint patients with total joint
replacementsreplacements
American Dental Association American Academy of Orthopedic SurgeonsAmerican Dental Association American Academy of Orthopedic Surgeons
The statement concludes that antibiotic The statement concludes that antibiotic prophylaxis is not indicated for dental patients prophylaxis is not indicated for dental patients with pins plates or screws nor is it routinely with pins plates or screws nor is it routinely
indicated for most dental patients with total joint indicated for most dental patients with total joint replacements However it is advisable to replacements However it is advisable to
consider premedication in a small number of consider premedication in a small number of patients who may be at potential increased risk of patients who may be at potential increased risk of experiencing hematogenous total joint infectionexperiencing hematogenous total joint infection
HEMATOGENOUS TOTAL JOINT INFECTION
PATIENT TYPE CONDITION PLACING PATIENT AT RISK
All patients during first two years following joint replacement
NAdagger
Immunocompromisedimmunosuppressed patients
Inflammatory arthropathies such as rheumatoid arthritis systemic lupus erythematosus
Drug- or radiation-induced immunosuppression
Patients with comorbiditiesDagger Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
Any perceived potential benefit of antibiotic Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known prophylaxis must be weighed against the known
risks of antibiotic toxicity allergy and risks of antibiotic toxicity allergy and development selection and transmission of development selection and transmission of
microbial resistancemicrobial resistance
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
Infect Control Hosp Epidemiol 2007 May28(5)577-82 Infect Control Hosp Epidemiol 2007 May28(5)577-82
Effect of a chlorhexidine mouthwash on the risk of Effect of a chlorhexidine mouthwash on the risk of postextraction bacteremiapostextraction bacteremiaTomaacutes I Alvarez M Limeres J Tomaacutes MTomaacutes M Medina JMedina J Otero JLOtero JL Diz Diz PPThe chlorhexidine group had 02 chlorhexidine mouthwash The chlorhexidine group had 02 chlorhexidine mouthwash administered for 30 seconds before any dental manipulation administered for 30 seconds before any dental manipulation Blood samples were collected at baseline 30 seconds 15 Blood samples were collected at baseline 30 seconds 15 minutes and 1 hour after the dental extractions Subculture and minutes and 1 hour after the dental extractions Subculture and further identification of the isolated bacteria were performed by further identification of the isolated bacteria were performed by conventional microbiological techniques RESULTS The conventional microbiological techniques RESULTS The prevalence of bacteremia after dental extraction in the control prevalence of bacteremia after dental extraction in the control and chlorhexidine groups were 96 and 79 respectively at 30 and chlorhexidine groups were 96 and 79 respectively at 30 seconds (P=008) 64 and 30 at 15 minutes (Plt001) and seconds (P=008) 64 and 30 at 15 minutes (Plt001) and 20 and 2 at 1 hour (P=005) The most frequently identified 20 and 2 at 1 hour (P=005) The most frequently identified bacteria were Streptococcus species in both the control and bacteria were Streptococcus species in both the control and chlorhexidine groups (64 and 68 respectively) particularly chlorhexidine groups (64 and 68 respectively) particularly viridans group streptococci CONCLUSION We recommend the viridans group streptococci CONCLUSION We recommend the routine use of a 02 chlorhexidine mouthwash before dental routine use of a 02 chlorhexidine mouthwash before dental extractions to reduce the risk of postextraction bacteremiaextractions to reduce the risk of postextraction bacteremia
bull ImmunocompromisedImmunocompromised Type one Type one diabetes high dose steroids diabetes high dose steroids immunosuppressive agents prior immunosuppressive agents prior infection history poor protoplasminfection history poor protoplasm
bull Metastaticdistant site infection risk Metastaticdistant site infection risk (heart valves orthopedic implants (heart valves orthopedic implants shunts)shunts)
Evidence Base for Evidence Base for Duration of Antimicrobial Duration of Antimicrobial
ProphylaxisProphylaxisbull ldquoldquoThe goal of antimicrobial prophylaxis is to The goal of antimicrobial prophylaxis is to
achieve serum and tissue levels of the antibiotic achieve serum and tissue levels of the antibiotic at the time of incision and for the duration of the at the time of incision and for the duration of the operation that are in excess of the minimum operation that are in excess of the minimum inhibitory concentration needed for the inhibitory concentration needed for the organisms that may be encountered during the organisms that may be encountered during the operation The National Surgical Infection operation The National Surgical Infection Prevention Project recommends the antibiotics Prevention Project recommends the antibiotics not be extended beyond 24 hours of the not be extended beyond 24 hours of the end of the operationrdquoend of the operationrdquo
Updated August 2003Updated August 2003
Proof Nailed Down that Proof Nailed Down that Antibiotics Use Leads to Antibiotics Use Leads to
ResistanceResistance ANTWERP Belgium Feb 9 2007 -- For the first ANTWERP Belgium Feb 9 2007 -- For the first time the unassailable proof that physicians can do time the unassailable proof that physicians can do harm by indiscriminate use of antibiotics has harm by indiscriminate use of antibiotics has emerged from a randomized controlled trialemerged from a randomized controlled trial
Physicians should take into account the striking Physicians should take into account the striking ecological side-effects of antibiotics when ecological side-effects of antibiotics when prescribing such drugs to their patients the prescribing such drugs to their patients the researchers concludedresearchers concluded
Malhotra-Kumar S et al Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers a randomized double-blind placebo-controlled study Lancet 2007 369 482-490
2007 AHA2007 AHA
The AHArsquos latest guidelines were published in its The AHArsquos latest guidelines were published in its scientific journal scientific journal CirculationCirculation in April 2007 and in April 2007 and
there is good news there is good news the AHA recommends that the AHA recommends that most of these patients no longer need most of these patients no longer need short-term antibiotics as a preventive short-term antibiotics as a preventive
measure before their dental treatmentmeasure before their dental treatment
Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE
2007 AHA2007 AHAPreventive antibiotics prior to a dental procedure Preventive antibiotics prior to a dental procedure
are advised for patients withare advised for patients with1 artificial heart valves 1 artificial heart valves 2 a history of infective endocarditis 2 a history of infective endocarditis 3 certain specific serious congenital (present from birth) 3 certain specific serious congenital (present from birth)
heart conditions including unrepaired or incompletely heart conditions including unrepaired or incompletely repaired cyanotic congenital heart disease including repaired cyanotic congenital heart disease including those with palliative shunts and conduits those with palliative shunts and conduits
4 a completely repaired congenital heart defect with 4 a completely repaired congenital heart defect with prosthetic material or device whether placed by prosthetic material or device whether placed by surgery or by catheter intervention during the first six surgery or by catheter intervention during the first six months after the procedure months after the procedure
5 any repaired congenital heart defect with residual 5 any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device patch or a prosthetic device
6 a cardiac transplant that develops a problem in a heart 6 a cardiac transplant that develops a problem in a heart valvevalve
According to the 2007 AHA guidelines According to the 2007 AHA guidelines which patient should receive antibiotics which patient should receive antibiotics before an extractionbefore an extraction
A Mitral valve prolapse with A Mitral valve prolapse with echocardiogram confirmed murmurechocardiogram confirmed murmur
B Recent (less than 6 months) bypass B Recent (less than 6 months) bypass surgerysurgery
C History of rheumatic heart diseaseC History of rheumatic heart disease
D Surgical repair of a heart valveD Surgical repair of a heart valve
E Heart transplant recipientsE Heart transplant recipients
J Am Dent Assoc 2003 Jul134(7)895-9J Am Dent Assoc 2003 Jul134(7)895-9
Antibiotic prophylaxis for dental Antibiotic prophylaxis for dental patients with total joint patients with total joint
replacementsreplacements
American Dental Association American Academy of Orthopedic SurgeonsAmerican Dental Association American Academy of Orthopedic Surgeons
The statement concludes that antibiotic The statement concludes that antibiotic prophylaxis is not indicated for dental patients prophylaxis is not indicated for dental patients with pins plates or screws nor is it routinely with pins plates or screws nor is it routinely
indicated for most dental patients with total joint indicated for most dental patients with total joint replacements However it is advisable to replacements However it is advisable to
consider premedication in a small number of consider premedication in a small number of patients who may be at potential increased risk of patients who may be at potential increased risk of experiencing hematogenous total joint infectionexperiencing hematogenous total joint infection
HEMATOGENOUS TOTAL JOINT INFECTION
PATIENT TYPE CONDITION PLACING PATIENT AT RISK
All patients during first two years following joint replacement
NAdagger
Immunocompromisedimmunosuppressed patients
Inflammatory arthropathies such as rheumatoid arthritis systemic lupus erythematosus
Drug- or radiation-induced immunosuppression
Patients with comorbiditiesDagger Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
Any perceived potential benefit of antibiotic Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known prophylaxis must be weighed against the known
risks of antibiotic toxicity allergy and risks of antibiotic toxicity allergy and development selection and transmission of development selection and transmission of
microbial resistancemicrobial resistance
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
bull ImmunocompromisedImmunocompromised Type one Type one diabetes high dose steroids diabetes high dose steroids immunosuppressive agents prior immunosuppressive agents prior infection history poor protoplasminfection history poor protoplasm
bull Metastaticdistant site infection risk Metastaticdistant site infection risk (heart valves orthopedic implants (heart valves orthopedic implants shunts)shunts)
Evidence Base for Evidence Base for Duration of Antimicrobial Duration of Antimicrobial
ProphylaxisProphylaxisbull ldquoldquoThe goal of antimicrobial prophylaxis is to The goal of antimicrobial prophylaxis is to
achieve serum and tissue levels of the antibiotic achieve serum and tissue levels of the antibiotic at the time of incision and for the duration of the at the time of incision and for the duration of the operation that are in excess of the minimum operation that are in excess of the minimum inhibitory concentration needed for the inhibitory concentration needed for the organisms that may be encountered during the organisms that may be encountered during the operation The National Surgical Infection operation The National Surgical Infection Prevention Project recommends the antibiotics Prevention Project recommends the antibiotics not be extended beyond 24 hours of the not be extended beyond 24 hours of the end of the operationrdquoend of the operationrdquo
Updated August 2003Updated August 2003
Proof Nailed Down that Proof Nailed Down that Antibiotics Use Leads to Antibiotics Use Leads to
ResistanceResistance ANTWERP Belgium Feb 9 2007 -- For the first ANTWERP Belgium Feb 9 2007 -- For the first time the unassailable proof that physicians can do time the unassailable proof that physicians can do harm by indiscriminate use of antibiotics has harm by indiscriminate use of antibiotics has emerged from a randomized controlled trialemerged from a randomized controlled trial
Physicians should take into account the striking Physicians should take into account the striking ecological side-effects of antibiotics when ecological side-effects of antibiotics when prescribing such drugs to their patients the prescribing such drugs to their patients the researchers concludedresearchers concluded
Malhotra-Kumar S et al Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers a randomized double-blind placebo-controlled study Lancet 2007 369 482-490
2007 AHA2007 AHA
The AHArsquos latest guidelines were published in its The AHArsquos latest guidelines were published in its scientific journal scientific journal CirculationCirculation in April 2007 and in April 2007 and
there is good news there is good news the AHA recommends that the AHA recommends that most of these patients no longer need most of these patients no longer need short-term antibiotics as a preventive short-term antibiotics as a preventive
measure before their dental treatmentmeasure before their dental treatment
Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE
2007 AHA2007 AHAPreventive antibiotics prior to a dental procedure Preventive antibiotics prior to a dental procedure
are advised for patients withare advised for patients with1 artificial heart valves 1 artificial heart valves 2 a history of infective endocarditis 2 a history of infective endocarditis 3 certain specific serious congenital (present from birth) 3 certain specific serious congenital (present from birth)
heart conditions including unrepaired or incompletely heart conditions including unrepaired or incompletely repaired cyanotic congenital heart disease including repaired cyanotic congenital heart disease including those with palliative shunts and conduits those with palliative shunts and conduits
4 a completely repaired congenital heart defect with 4 a completely repaired congenital heart defect with prosthetic material or device whether placed by prosthetic material or device whether placed by surgery or by catheter intervention during the first six surgery or by catheter intervention during the first six months after the procedure months after the procedure
5 any repaired congenital heart defect with residual 5 any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device patch or a prosthetic device
6 a cardiac transplant that develops a problem in a heart 6 a cardiac transplant that develops a problem in a heart valvevalve
According to the 2007 AHA guidelines According to the 2007 AHA guidelines which patient should receive antibiotics which patient should receive antibiotics before an extractionbefore an extraction
A Mitral valve prolapse with A Mitral valve prolapse with echocardiogram confirmed murmurechocardiogram confirmed murmur
B Recent (less than 6 months) bypass B Recent (less than 6 months) bypass surgerysurgery
C History of rheumatic heart diseaseC History of rheumatic heart disease
D Surgical repair of a heart valveD Surgical repair of a heart valve
E Heart transplant recipientsE Heart transplant recipients
J Am Dent Assoc 2003 Jul134(7)895-9J Am Dent Assoc 2003 Jul134(7)895-9
Antibiotic prophylaxis for dental Antibiotic prophylaxis for dental patients with total joint patients with total joint
replacementsreplacements
American Dental Association American Academy of Orthopedic SurgeonsAmerican Dental Association American Academy of Orthopedic Surgeons
The statement concludes that antibiotic The statement concludes that antibiotic prophylaxis is not indicated for dental patients prophylaxis is not indicated for dental patients with pins plates or screws nor is it routinely with pins plates or screws nor is it routinely
indicated for most dental patients with total joint indicated for most dental patients with total joint replacements However it is advisable to replacements However it is advisable to
consider premedication in a small number of consider premedication in a small number of patients who may be at potential increased risk of patients who may be at potential increased risk of experiencing hematogenous total joint infectionexperiencing hematogenous total joint infection
HEMATOGENOUS TOTAL JOINT INFECTION
PATIENT TYPE CONDITION PLACING PATIENT AT RISK
All patients during first two years following joint replacement
NAdagger
Immunocompromisedimmunosuppressed patients
Inflammatory arthropathies such as rheumatoid arthritis systemic lupus erythematosus
Drug- or radiation-induced immunosuppression
Patients with comorbiditiesDagger Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
Any perceived potential benefit of antibiotic Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known prophylaxis must be weighed against the known
risks of antibiotic toxicity allergy and risks of antibiotic toxicity allergy and development selection and transmission of development selection and transmission of
microbial resistancemicrobial resistance
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
bull ImmunocompromisedImmunocompromised Type one Type one diabetes high dose steroids diabetes high dose steroids immunosuppressive agents prior immunosuppressive agents prior infection history poor protoplasminfection history poor protoplasm
bull Metastaticdistant site infection risk Metastaticdistant site infection risk (heart valves orthopedic implants (heart valves orthopedic implants shunts)shunts)
Evidence Base for Evidence Base for Duration of Antimicrobial Duration of Antimicrobial
ProphylaxisProphylaxisbull ldquoldquoThe goal of antimicrobial prophylaxis is to The goal of antimicrobial prophylaxis is to
achieve serum and tissue levels of the antibiotic achieve serum and tissue levels of the antibiotic at the time of incision and for the duration of the at the time of incision and for the duration of the operation that are in excess of the minimum operation that are in excess of the minimum inhibitory concentration needed for the inhibitory concentration needed for the organisms that may be encountered during the organisms that may be encountered during the operation The National Surgical Infection operation The National Surgical Infection Prevention Project recommends the antibiotics Prevention Project recommends the antibiotics not be extended beyond 24 hours of the not be extended beyond 24 hours of the end of the operationrdquoend of the operationrdquo
Updated August 2003Updated August 2003
Proof Nailed Down that Proof Nailed Down that Antibiotics Use Leads to Antibiotics Use Leads to
ResistanceResistance ANTWERP Belgium Feb 9 2007 -- For the first ANTWERP Belgium Feb 9 2007 -- For the first time the unassailable proof that physicians can do time the unassailable proof that physicians can do harm by indiscriminate use of antibiotics has harm by indiscriminate use of antibiotics has emerged from a randomized controlled trialemerged from a randomized controlled trial
Physicians should take into account the striking Physicians should take into account the striking ecological side-effects of antibiotics when ecological side-effects of antibiotics when prescribing such drugs to their patients the prescribing such drugs to their patients the researchers concludedresearchers concluded
Malhotra-Kumar S et al Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers a randomized double-blind placebo-controlled study Lancet 2007 369 482-490
2007 AHA2007 AHA
The AHArsquos latest guidelines were published in its The AHArsquos latest guidelines were published in its scientific journal scientific journal CirculationCirculation in April 2007 and in April 2007 and
there is good news there is good news the AHA recommends that the AHA recommends that most of these patients no longer need most of these patients no longer need short-term antibiotics as a preventive short-term antibiotics as a preventive
measure before their dental treatmentmeasure before their dental treatment
Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE
2007 AHA2007 AHAPreventive antibiotics prior to a dental procedure Preventive antibiotics prior to a dental procedure
are advised for patients withare advised for patients with1 artificial heart valves 1 artificial heart valves 2 a history of infective endocarditis 2 a history of infective endocarditis 3 certain specific serious congenital (present from birth) 3 certain specific serious congenital (present from birth)
heart conditions including unrepaired or incompletely heart conditions including unrepaired or incompletely repaired cyanotic congenital heart disease including repaired cyanotic congenital heart disease including those with palliative shunts and conduits those with palliative shunts and conduits
4 a completely repaired congenital heart defect with 4 a completely repaired congenital heart defect with prosthetic material or device whether placed by prosthetic material or device whether placed by surgery or by catheter intervention during the first six surgery or by catheter intervention during the first six months after the procedure months after the procedure
5 any repaired congenital heart defect with residual 5 any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device patch or a prosthetic device
6 a cardiac transplant that develops a problem in a heart 6 a cardiac transplant that develops a problem in a heart valvevalve
According to the 2007 AHA guidelines According to the 2007 AHA guidelines which patient should receive antibiotics which patient should receive antibiotics before an extractionbefore an extraction
A Mitral valve prolapse with A Mitral valve prolapse with echocardiogram confirmed murmurechocardiogram confirmed murmur
B Recent (less than 6 months) bypass B Recent (less than 6 months) bypass surgerysurgery
C History of rheumatic heart diseaseC History of rheumatic heart disease
D Surgical repair of a heart valveD Surgical repair of a heart valve
E Heart transplant recipientsE Heart transplant recipients
J Am Dent Assoc 2003 Jul134(7)895-9J Am Dent Assoc 2003 Jul134(7)895-9
Antibiotic prophylaxis for dental Antibiotic prophylaxis for dental patients with total joint patients with total joint
replacementsreplacements
American Dental Association American Academy of Orthopedic SurgeonsAmerican Dental Association American Academy of Orthopedic Surgeons
The statement concludes that antibiotic The statement concludes that antibiotic prophylaxis is not indicated for dental patients prophylaxis is not indicated for dental patients with pins plates or screws nor is it routinely with pins plates or screws nor is it routinely
indicated for most dental patients with total joint indicated for most dental patients with total joint replacements However it is advisable to replacements However it is advisable to
consider premedication in a small number of consider premedication in a small number of patients who may be at potential increased risk of patients who may be at potential increased risk of experiencing hematogenous total joint infectionexperiencing hematogenous total joint infection
HEMATOGENOUS TOTAL JOINT INFECTION
PATIENT TYPE CONDITION PLACING PATIENT AT RISK
All patients during first two years following joint replacement
NAdagger
Immunocompromisedimmunosuppressed patients
Inflammatory arthropathies such as rheumatoid arthritis systemic lupus erythematosus
Drug- or radiation-induced immunosuppression
Patients with comorbiditiesDagger Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
Any perceived potential benefit of antibiotic Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known prophylaxis must be weighed against the known
risks of antibiotic toxicity allergy and risks of antibiotic toxicity allergy and development selection and transmission of development selection and transmission of
microbial resistancemicrobial resistance
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
Evidence Base for Evidence Base for Duration of Antimicrobial Duration of Antimicrobial
ProphylaxisProphylaxisbull ldquoldquoThe goal of antimicrobial prophylaxis is to The goal of antimicrobial prophylaxis is to
achieve serum and tissue levels of the antibiotic achieve serum and tissue levels of the antibiotic at the time of incision and for the duration of the at the time of incision and for the duration of the operation that are in excess of the minimum operation that are in excess of the minimum inhibitory concentration needed for the inhibitory concentration needed for the organisms that may be encountered during the organisms that may be encountered during the operation The National Surgical Infection operation The National Surgical Infection Prevention Project recommends the antibiotics Prevention Project recommends the antibiotics not be extended beyond 24 hours of the not be extended beyond 24 hours of the end of the operationrdquoend of the operationrdquo
Updated August 2003Updated August 2003
Proof Nailed Down that Proof Nailed Down that Antibiotics Use Leads to Antibiotics Use Leads to
ResistanceResistance ANTWERP Belgium Feb 9 2007 -- For the first ANTWERP Belgium Feb 9 2007 -- For the first time the unassailable proof that physicians can do time the unassailable proof that physicians can do harm by indiscriminate use of antibiotics has harm by indiscriminate use of antibiotics has emerged from a randomized controlled trialemerged from a randomized controlled trial
Physicians should take into account the striking Physicians should take into account the striking ecological side-effects of antibiotics when ecological side-effects of antibiotics when prescribing such drugs to their patients the prescribing such drugs to their patients the researchers concludedresearchers concluded
Malhotra-Kumar S et al Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers a randomized double-blind placebo-controlled study Lancet 2007 369 482-490
2007 AHA2007 AHA
The AHArsquos latest guidelines were published in its The AHArsquos latest guidelines were published in its scientific journal scientific journal CirculationCirculation in April 2007 and in April 2007 and
there is good news there is good news the AHA recommends that the AHA recommends that most of these patients no longer need most of these patients no longer need short-term antibiotics as a preventive short-term antibiotics as a preventive
measure before their dental treatmentmeasure before their dental treatment
Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE
2007 AHA2007 AHAPreventive antibiotics prior to a dental procedure Preventive antibiotics prior to a dental procedure
are advised for patients withare advised for patients with1 artificial heart valves 1 artificial heart valves 2 a history of infective endocarditis 2 a history of infective endocarditis 3 certain specific serious congenital (present from birth) 3 certain specific serious congenital (present from birth)
heart conditions including unrepaired or incompletely heart conditions including unrepaired or incompletely repaired cyanotic congenital heart disease including repaired cyanotic congenital heart disease including those with palliative shunts and conduits those with palliative shunts and conduits
4 a completely repaired congenital heart defect with 4 a completely repaired congenital heart defect with prosthetic material or device whether placed by prosthetic material or device whether placed by surgery or by catheter intervention during the first six surgery or by catheter intervention during the first six months after the procedure months after the procedure
5 any repaired congenital heart defect with residual 5 any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device patch or a prosthetic device
6 a cardiac transplant that develops a problem in a heart 6 a cardiac transplant that develops a problem in a heart valvevalve
According to the 2007 AHA guidelines According to the 2007 AHA guidelines which patient should receive antibiotics which patient should receive antibiotics before an extractionbefore an extraction
A Mitral valve prolapse with A Mitral valve prolapse with echocardiogram confirmed murmurechocardiogram confirmed murmur
B Recent (less than 6 months) bypass B Recent (less than 6 months) bypass surgerysurgery
C History of rheumatic heart diseaseC History of rheumatic heart disease
D Surgical repair of a heart valveD Surgical repair of a heart valve
E Heart transplant recipientsE Heart transplant recipients
J Am Dent Assoc 2003 Jul134(7)895-9J Am Dent Assoc 2003 Jul134(7)895-9
Antibiotic prophylaxis for dental Antibiotic prophylaxis for dental patients with total joint patients with total joint
replacementsreplacements
American Dental Association American Academy of Orthopedic SurgeonsAmerican Dental Association American Academy of Orthopedic Surgeons
The statement concludes that antibiotic The statement concludes that antibiotic prophylaxis is not indicated for dental patients prophylaxis is not indicated for dental patients with pins plates or screws nor is it routinely with pins plates or screws nor is it routinely
indicated for most dental patients with total joint indicated for most dental patients with total joint replacements However it is advisable to replacements However it is advisable to
consider premedication in a small number of consider premedication in a small number of patients who may be at potential increased risk of patients who may be at potential increased risk of experiencing hematogenous total joint infectionexperiencing hematogenous total joint infection
HEMATOGENOUS TOTAL JOINT INFECTION
PATIENT TYPE CONDITION PLACING PATIENT AT RISK
All patients during first two years following joint replacement
NAdagger
Immunocompromisedimmunosuppressed patients
Inflammatory arthropathies such as rheumatoid arthritis systemic lupus erythematosus
Drug- or radiation-induced immunosuppression
Patients with comorbiditiesDagger Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
Any perceived potential benefit of antibiotic Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known prophylaxis must be weighed against the known
risks of antibiotic toxicity allergy and risks of antibiotic toxicity allergy and development selection and transmission of development selection and transmission of
microbial resistancemicrobial resistance
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
Proof Nailed Down that Proof Nailed Down that Antibiotics Use Leads to Antibiotics Use Leads to
ResistanceResistance ANTWERP Belgium Feb 9 2007 -- For the first ANTWERP Belgium Feb 9 2007 -- For the first time the unassailable proof that physicians can do time the unassailable proof that physicians can do harm by indiscriminate use of antibiotics has harm by indiscriminate use of antibiotics has emerged from a randomized controlled trialemerged from a randomized controlled trial
Physicians should take into account the striking Physicians should take into account the striking ecological side-effects of antibiotics when ecological side-effects of antibiotics when prescribing such drugs to their patients the prescribing such drugs to their patients the researchers concludedresearchers concluded
Malhotra-Kumar S et al Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers a randomized double-blind placebo-controlled study Lancet 2007 369 482-490
2007 AHA2007 AHA
The AHArsquos latest guidelines were published in its The AHArsquos latest guidelines were published in its scientific journal scientific journal CirculationCirculation in April 2007 and in April 2007 and
there is good news there is good news the AHA recommends that the AHA recommends that most of these patients no longer need most of these patients no longer need short-term antibiotics as a preventive short-term antibiotics as a preventive
measure before their dental treatmentmeasure before their dental treatment
Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE
2007 AHA2007 AHAPreventive antibiotics prior to a dental procedure Preventive antibiotics prior to a dental procedure
are advised for patients withare advised for patients with1 artificial heart valves 1 artificial heart valves 2 a history of infective endocarditis 2 a history of infective endocarditis 3 certain specific serious congenital (present from birth) 3 certain specific serious congenital (present from birth)
heart conditions including unrepaired or incompletely heart conditions including unrepaired or incompletely repaired cyanotic congenital heart disease including repaired cyanotic congenital heart disease including those with palliative shunts and conduits those with palliative shunts and conduits
4 a completely repaired congenital heart defect with 4 a completely repaired congenital heart defect with prosthetic material or device whether placed by prosthetic material or device whether placed by surgery or by catheter intervention during the first six surgery or by catheter intervention during the first six months after the procedure months after the procedure
5 any repaired congenital heart defect with residual 5 any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device patch or a prosthetic device
6 a cardiac transplant that develops a problem in a heart 6 a cardiac transplant that develops a problem in a heart valvevalve
According to the 2007 AHA guidelines According to the 2007 AHA guidelines which patient should receive antibiotics which patient should receive antibiotics before an extractionbefore an extraction
A Mitral valve prolapse with A Mitral valve prolapse with echocardiogram confirmed murmurechocardiogram confirmed murmur
B Recent (less than 6 months) bypass B Recent (less than 6 months) bypass surgerysurgery
C History of rheumatic heart diseaseC History of rheumatic heart disease
D Surgical repair of a heart valveD Surgical repair of a heart valve
E Heart transplant recipientsE Heart transplant recipients
J Am Dent Assoc 2003 Jul134(7)895-9J Am Dent Assoc 2003 Jul134(7)895-9
Antibiotic prophylaxis for dental Antibiotic prophylaxis for dental patients with total joint patients with total joint
replacementsreplacements
American Dental Association American Academy of Orthopedic SurgeonsAmerican Dental Association American Academy of Orthopedic Surgeons
The statement concludes that antibiotic The statement concludes that antibiotic prophylaxis is not indicated for dental patients prophylaxis is not indicated for dental patients with pins plates or screws nor is it routinely with pins plates or screws nor is it routinely
indicated for most dental patients with total joint indicated for most dental patients with total joint replacements However it is advisable to replacements However it is advisable to
consider premedication in a small number of consider premedication in a small number of patients who may be at potential increased risk of patients who may be at potential increased risk of experiencing hematogenous total joint infectionexperiencing hematogenous total joint infection
HEMATOGENOUS TOTAL JOINT INFECTION
PATIENT TYPE CONDITION PLACING PATIENT AT RISK
All patients during first two years following joint replacement
NAdagger
Immunocompromisedimmunosuppressed patients
Inflammatory arthropathies such as rheumatoid arthritis systemic lupus erythematosus
Drug- or radiation-induced immunosuppression
Patients with comorbiditiesDagger Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
Any perceived potential benefit of antibiotic Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known prophylaxis must be weighed against the known
risks of antibiotic toxicity allergy and risks of antibiotic toxicity allergy and development selection and transmission of development selection and transmission of
microbial resistancemicrobial resistance
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
2007 AHA2007 AHA
The AHArsquos latest guidelines were published in its The AHArsquos latest guidelines were published in its scientific journal scientific journal CirculationCirculation in April 2007 and in April 2007 and
there is good news there is good news the AHA recommends that the AHA recommends that most of these patients no longer need most of these patients no longer need short-term antibiotics as a preventive short-term antibiotics as a preventive
measure before their dental treatmentmeasure before their dental treatment
Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE
2007 AHA2007 AHAPreventive antibiotics prior to a dental procedure Preventive antibiotics prior to a dental procedure
are advised for patients withare advised for patients with1 artificial heart valves 1 artificial heart valves 2 a history of infective endocarditis 2 a history of infective endocarditis 3 certain specific serious congenital (present from birth) 3 certain specific serious congenital (present from birth)
heart conditions including unrepaired or incompletely heart conditions including unrepaired or incompletely repaired cyanotic congenital heart disease including repaired cyanotic congenital heart disease including those with palliative shunts and conduits those with palliative shunts and conduits
4 a completely repaired congenital heart defect with 4 a completely repaired congenital heart defect with prosthetic material or device whether placed by prosthetic material or device whether placed by surgery or by catheter intervention during the first six surgery or by catheter intervention during the first six months after the procedure months after the procedure
5 any repaired congenital heart defect with residual 5 any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device patch or a prosthetic device
6 a cardiac transplant that develops a problem in a heart 6 a cardiac transplant that develops a problem in a heart valvevalve
According to the 2007 AHA guidelines According to the 2007 AHA guidelines which patient should receive antibiotics which patient should receive antibiotics before an extractionbefore an extraction
A Mitral valve prolapse with A Mitral valve prolapse with echocardiogram confirmed murmurechocardiogram confirmed murmur
B Recent (less than 6 months) bypass B Recent (less than 6 months) bypass surgerysurgery
C History of rheumatic heart diseaseC History of rheumatic heart disease
D Surgical repair of a heart valveD Surgical repair of a heart valve
E Heart transplant recipientsE Heart transplant recipients
J Am Dent Assoc 2003 Jul134(7)895-9J Am Dent Assoc 2003 Jul134(7)895-9
Antibiotic prophylaxis for dental Antibiotic prophylaxis for dental patients with total joint patients with total joint
replacementsreplacements
American Dental Association American Academy of Orthopedic SurgeonsAmerican Dental Association American Academy of Orthopedic Surgeons
The statement concludes that antibiotic The statement concludes that antibiotic prophylaxis is not indicated for dental patients prophylaxis is not indicated for dental patients with pins plates or screws nor is it routinely with pins plates or screws nor is it routinely
indicated for most dental patients with total joint indicated for most dental patients with total joint replacements However it is advisable to replacements However it is advisable to
consider premedication in a small number of consider premedication in a small number of patients who may be at potential increased risk of patients who may be at potential increased risk of experiencing hematogenous total joint infectionexperiencing hematogenous total joint infection
HEMATOGENOUS TOTAL JOINT INFECTION
PATIENT TYPE CONDITION PLACING PATIENT AT RISK
All patients during first two years following joint replacement
NAdagger
Immunocompromisedimmunosuppressed patients
Inflammatory arthropathies such as rheumatoid arthritis systemic lupus erythematosus
Drug- or radiation-induced immunosuppression
Patients with comorbiditiesDagger Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
Any perceived potential benefit of antibiotic Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known prophylaxis must be weighed against the known
risks of antibiotic toxicity allergy and risks of antibiotic toxicity allergy and development selection and transmission of development selection and transmission of
microbial resistancemicrobial resistance
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
2007 AHA2007 AHAPreventive antibiotics prior to a dental procedure Preventive antibiotics prior to a dental procedure
are advised for patients withare advised for patients with1 artificial heart valves 1 artificial heart valves 2 a history of infective endocarditis 2 a history of infective endocarditis 3 certain specific serious congenital (present from birth) 3 certain specific serious congenital (present from birth)
heart conditions including unrepaired or incompletely heart conditions including unrepaired or incompletely repaired cyanotic congenital heart disease including repaired cyanotic congenital heart disease including those with palliative shunts and conduits those with palliative shunts and conduits
4 a completely repaired congenital heart defect with 4 a completely repaired congenital heart defect with prosthetic material or device whether placed by prosthetic material or device whether placed by surgery or by catheter intervention during the first six surgery or by catheter intervention during the first six months after the procedure months after the procedure
5 any repaired congenital heart defect with residual 5 any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device patch or a prosthetic device
6 a cardiac transplant that develops a problem in a heart 6 a cardiac transplant that develops a problem in a heart valvevalve
According to the 2007 AHA guidelines According to the 2007 AHA guidelines which patient should receive antibiotics which patient should receive antibiotics before an extractionbefore an extraction
A Mitral valve prolapse with A Mitral valve prolapse with echocardiogram confirmed murmurechocardiogram confirmed murmur
B Recent (less than 6 months) bypass B Recent (less than 6 months) bypass surgerysurgery
C History of rheumatic heart diseaseC History of rheumatic heart disease
D Surgical repair of a heart valveD Surgical repair of a heart valve
E Heart transplant recipientsE Heart transplant recipients
J Am Dent Assoc 2003 Jul134(7)895-9J Am Dent Assoc 2003 Jul134(7)895-9
Antibiotic prophylaxis for dental Antibiotic prophylaxis for dental patients with total joint patients with total joint
replacementsreplacements
American Dental Association American Academy of Orthopedic SurgeonsAmerican Dental Association American Academy of Orthopedic Surgeons
The statement concludes that antibiotic The statement concludes that antibiotic prophylaxis is not indicated for dental patients prophylaxis is not indicated for dental patients with pins plates or screws nor is it routinely with pins plates or screws nor is it routinely
indicated for most dental patients with total joint indicated for most dental patients with total joint replacements However it is advisable to replacements However it is advisable to
consider premedication in a small number of consider premedication in a small number of patients who may be at potential increased risk of patients who may be at potential increased risk of experiencing hematogenous total joint infectionexperiencing hematogenous total joint infection
HEMATOGENOUS TOTAL JOINT INFECTION
PATIENT TYPE CONDITION PLACING PATIENT AT RISK
All patients during first two years following joint replacement
NAdagger
Immunocompromisedimmunosuppressed patients
Inflammatory arthropathies such as rheumatoid arthritis systemic lupus erythematosus
Drug- or radiation-induced immunosuppression
Patients with comorbiditiesDagger Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
Any perceived potential benefit of antibiotic Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known prophylaxis must be weighed against the known
risks of antibiotic toxicity allergy and risks of antibiotic toxicity allergy and development selection and transmission of development selection and transmission of
microbial resistancemicrobial resistance
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
According to the 2007 AHA guidelines According to the 2007 AHA guidelines which patient should receive antibiotics which patient should receive antibiotics before an extractionbefore an extraction
A Mitral valve prolapse with A Mitral valve prolapse with echocardiogram confirmed murmurechocardiogram confirmed murmur
B Recent (less than 6 months) bypass B Recent (less than 6 months) bypass surgerysurgery
C History of rheumatic heart diseaseC History of rheumatic heart disease
D Surgical repair of a heart valveD Surgical repair of a heart valve
E Heart transplant recipientsE Heart transplant recipients
J Am Dent Assoc 2003 Jul134(7)895-9J Am Dent Assoc 2003 Jul134(7)895-9
Antibiotic prophylaxis for dental Antibiotic prophylaxis for dental patients with total joint patients with total joint
replacementsreplacements
American Dental Association American Academy of Orthopedic SurgeonsAmerican Dental Association American Academy of Orthopedic Surgeons
The statement concludes that antibiotic The statement concludes that antibiotic prophylaxis is not indicated for dental patients prophylaxis is not indicated for dental patients with pins plates or screws nor is it routinely with pins plates or screws nor is it routinely
indicated for most dental patients with total joint indicated for most dental patients with total joint replacements However it is advisable to replacements However it is advisable to
consider premedication in a small number of consider premedication in a small number of patients who may be at potential increased risk of patients who may be at potential increased risk of experiencing hematogenous total joint infectionexperiencing hematogenous total joint infection
HEMATOGENOUS TOTAL JOINT INFECTION
PATIENT TYPE CONDITION PLACING PATIENT AT RISK
All patients during first two years following joint replacement
NAdagger
Immunocompromisedimmunosuppressed patients
Inflammatory arthropathies such as rheumatoid arthritis systemic lupus erythematosus
Drug- or radiation-induced immunosuppression
Patients with comorbiditiesDagger Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
Any perceived potential benefit of antibiotic Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known prophylaxis must be weighed against the known
risks of antibiotic toxicity allergy and risks of antibiotic toxicity allergy and development selection and transmission of development selection and transmission of
microbial resistancemicrobial resistance
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
According to the 2007 AHA guidelines According to the 2007 AHA guidelines which patient should receive antibiotics which patient should receive antibiotics before an extractionbefore an extraction
A Mitral valve prolapse with A Mitral valve prolapse with echocardiogram confirmed murmurechocardiogram confirmed murmur
B Recent (less than 6 months) bypass B Recent (less than 6 months) bypass surgerysurgery
C History of rheumatic heart diseaseC History of rheumatic heart disease
D Surgical repair of a heart valveD Surgical repair of a heart valve
E Heart transplant recipientsE Heart transplant recipients
J Am Dent Assoc 2003 Jul134(7)895-9J Am Dent Assoc 2003 Jul134(7)895-9
Antibiotic prophylaxis for dental Antibiotic prophylaxis for dental patients with total joint patients with total joint
replacementsreplacements
American Dental Association American Academy of Orthopedic SurgeonsAmerican Dental Association American Academy of Orthopedic Surgeons
The statement concludes that antibiotic The statement concludes that antibiotic prophylaxis is not indicated for dental patients prophylaxis is not indicated for dental patients with pins plates or screws nor is it routinely with pins plates or screws nor is it routinely
indicated for most dental patients with total joint indicated for most dental patients with total joint replacements However it is advisable to replacements However it is advisable to
consider premedication in a small number of consider premedication in a small number of patients who may be at potential increased risk of patients who may be at potential increased risk of experiencing hematogenous total joint infectionexperiencing hematogenous total joint infection
HEMATOGENOUS TOTAL JOINT INFECTION
PATIENT TYPE CONDITION PLACING PATIENT AT RISK
All patients during first two years following joint replacement
NAdagger
Immunocompromisedimmunosuppressed patients
Inflammatory arthropathies such as rheumatoid arthritis systemic lupus erythematosus
Drug- or radiation-induced immunosuppression
Patients with comorbiditiesDagger Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
Any perceived potential benefit of antibiotic Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known prophylaxis must be weighed against the known
risks of antibiotic toxicity allergy and risks of antibiotic toxicity allergy and development selection and transmission of development selection and transmission of
microbial resistancemicrobial resistance
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
J Am Dent Assoc 2003 Jul134(7)895-9J Am Dent Assoc 2003 Jul134(7)895-9
Antibiotic prophylaxis for dental Antibiotic prophylaxis for dental patients with total joint patients with total joint
replacementsreplacements
American Dental Association American Academy of Orthopedic SurgeonsAmerican Dental Association American Academy of Orthopedic Surgeons
The statement concludes that antibiotic The statement concludes that antibiotic prophylaxis is not indicated for dental patients prophylaxis is not indicated for dental patients with pins plates or screws nor is it routinely with pins plates or screws nor is it routinely
indicated for most dental patients with total joint indicated for most dental patients with total joint replacements However it is advisable to replacements However it is advisable to
consider premedication in a small number of consider premedication in a small number of patients who may be at potential increased risk of patients who may be at potential increased risk of experiencing hematogenous total joint infectionexperiencing hematogenous total joint infection
HEMATOGENOUS TOTAL JOINT INFECTION
PATIENT TYPE CONDITION PLACING PATIENT AT RISK
All patients during first two years following joint replacement
NAdagger
Immunocompromisedimmunosuppressed patients
Inflammatory arthropathies such as rheumatoid arthritis systemic lupus erythematosus
Drug- or radiation-induced immunosuppression
Patients with comorbiditiesDagger Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
Any perceived potential benefit of antibiotic Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known prophylaxis must be weighed against the known
risks of antibiotic toxicity allergy and risks of antibiotic toxicity allergy and development selection and transmission of development selection and transmission of
microbial resistancemicrobial resistance
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
HEMATOGENOUS TOTAL JOINT INFECTION
PATIENT TYPE CONDITION PLACING PATIENT AT RISK
All patients during first two years following joint replacement
NAdagger
Immunocompromisedimmunosuppressed patients
Inflammatory arthropathies such as rheumatoid arthritis systemic lupus erythematosus
Drug- or radiation-induced immunosuppression
Patients with comorbiditiesDagger Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
Any perceived potential benefit of antibiotic Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known prophylaxis must be weighed against the known
risks of antibiotic toxicity allergy and risks of antibiotic toxicity allergy and development selection and transmission of development selection and transmission of
microbial resistancemicrobial resistance
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
Prevention-Good Surgical Prevention-Good Surgical Care Care
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
TreatmentTreatment((My teeth gums jaw are My teeth gums jaw are
infectedhelliphelliphellipcure me Doctor)infectedhelliphelliphellipcure me Doctor)
11 Determine etiologyDetermine etiology
22 Determine how sick patient isDetermine how sick patient is
33 Determine if you want to treatDetermine if you want to treat
44 Give antibiotics (Give antibiotics (therapeutictherapeutic not not prophylactic)prophylactic)
55 Remove etiologyRemove etiology
66 Consider I+D with C+SConsider I+D with C+S
77 Close follow upClose follow up
Determine EtiologyDetermine Etiology
bull Usually non-vital toothUsually non-vital tooth
bull Rare perio-abscess or pericoronitisRare perio-abscess or pericoronitis
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
Determine EtiologyDetermine Etiology
bull Usually non-vital toothUsually non-vital tooth
bull Rare perio-abscess or pericoronitisRare perio-abscess or pericoronitis
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
bull More expensive not usually better for More expensive not usually better for odontogenic infectionsodontogenic infections
bull Not effective for intrapulpal Not effective for intrapulpal pathology or for walled off pathology or for walled off abscesseshellipneed surgeryabscesseshellipneed surgery
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
AntibioticsAntibiotics
bull Give ASAP-- in office before surgeryGive ASAP-- in office before surgery
bull Big Dog Infection Then IV antibioticsBig Dog Infection Then IV antibiotics
bull Bugs are usually overgrowth of normal Bugs are usually overgrowth of normal flora -- both aerobes and anaerobesflora -- both aerobes and anaerobes
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
Remove Etiology (More Remove Etiology (More important than important than
bull Never faulted for performing I+DNever faulted for performing I+D
bull Never faulted for obtaining C+S but Never faulted for obtaining C+S but expensive (about $35000)expensive (about $35000)
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
Incision and Drainage Incision and Drainage 101101bull Intraoral more esthetic but not always Intraoral more esthetic but not always
indicated as most dependent area bestindicated as most dependent area best
bull Must contact bone Must contact bone
bull Obtain cultures without contaminationObtain cultures without contamination
bull Suture in drain after copious irrigationSuture in drain after copious irrigation
bull Anesthesia usually challengingAnesthesia usually challenging
bull Recall fascial space anatomyRecall fascial space anatomy
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
I+D with C+SI+D with C+S
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
Anaerobic Culture TubeAnaerobic Culture Tube
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
Cellulitis vs AbscessCellulitis vs Abscess
bull CellulitisCellulitisbull DiffuseDiffuse
bull InduratedIndurated
bull AcuteAcute
bull ldquoldquoBody losingrdquoBody losingrdquo
bull AbscessAbscessbull LocalizedLocalized
bull FluctuantFluctuant
bull ChronicChronic
bull ldquoldquoLaudable PusrdquoLaudable Pusrdquo
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
Ludwigrsquos AnginaLudwigrsquos Angina
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
Which is true concerning odontogenic Which is true concerning odontogenic infectionsinfections
11 Identify and remove the etiology as Identify and remove the etiology as soon as possiblesoon as possible
22 Cephalosporins in general are superior Cephalosporins in general are superior to penicillinsto penicillins
33 Most serious infections are from Most serious infections are from periodontal abscessesperiodontal abscesses
44 Can produce death from airway Can produce death from airway obstructionobstruction
AA 1313
BB 2424
CC 1414
DD 124124
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
Follow UpFollow Up
bull Usually better 3-4 days post Usually better 3-4 days post SurgAbsSurgAbs
bull Be ready to refer if not (document)Be ready to refer if not (document)
bull If the patient is not improving the If the patient is not improving the problem is usually surgical problem is usually surgical notnot antibiotic resistancehelliphellipThe antibiotic resistancehelliphellipThe etiology remains pus has not been etiology remains pus has not been drained or dead bone still presentdrained or dead bone still present
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
Your patient has developed an infection for Your patient has developed an infection for which you have prescribed an antibiotic which you have prescribed an antibiotic Three days later the infection has not Three days later the infection has not responded to your treatment What may responded to your treatment What may account for thisaccount for this
11 The patient if noncompliantThe patient if noncompliant
22 The etiology has not yet been removedThe etiology has not yet been removed
33 Your empiric therapy is incorrectYour empiric therapy is incorrect
44 There are depressed host defensesThere are depressed host defenses
AA 1313
BB 2424
CC 123123
DD 12341234
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
Morbidity and mortality from Morbidity and mortality from odontogenic infections is caused odontogenic infections is caused most often bymost often by
AA Cavernous sinus thrombosisCavernous sinus thrombosis
BB MediastinitisMediastinitis
CC Airway compromiseAirway compromise
DD Endotoxin shockEndotoxin shock
EE Non-working interferencesNon-working interferences
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
Determine Etiology
How Sick Is Patient
Treat
Antibiotics
Slide 28
Remove Etiology (More important than antibiotics)
Incision and Drainage 101
I+D with C+S
Anaerobic Culture Tube
Cellulitis vs Abscess
Ludwigrsquos Angina
Follow Up
Slide 37
Questions jbavitzunmcedu
QuestionsQuestionsjbavitzunmcedujbavitzunmcedu
Slide 3
Slide 4
Microneurosurgery
Slide 6
Slide 7
Odontogenic Infections Dr J Bruce Bavitz
Odontogenic Infxts-Prevention (My heart artificial joint or jaw are not infected now and I donrsquot want them infected after the procedure)
Prevention-Antiseptic Rinse
Slide 11
Prevention-Prophylactic Antibiotics
Prophylactic Antibiotics-When
Evidence Base for Duration of Antimicrobial Prophylaxis
Proof Nailed Down that Antibiotics Use Leads to Resistance
2007 AHA
Slide 17
Slide 18
Slide 19
Slide 20
Prevention-Good Surgical Care
Treatment (My teeth gums jaw are infectedhelliphelliphellipcure me Doctor)
![Accuracy of Panoramic Radiography for Detection of Periapical Endodontic … · 2020. 4. 20. · International Endodontic Journal, 40(6), 433-440 [9] Jimenez-Pinzon A, Segura-Egea](https://static.documents.pub/doc/80x56/5fe9e4b773d7b255640d3dca/accuracy-of-panoramic-radiography-for-detection-of-periapical-endodontic-2020-4.jpg)
