Principles of managementof Odontogenic Infections

Dr Milad Parvin

Oral and Maxillofacial Surgeon

Assistant professor

Boushehr University of Medical Sciences

Microbiology of Odontogenic infections

• Bacteria that cause odontogenic infections are part of normal flora

• Aerobic gram positive cocci

• Anaerobic gram positive cocci

• Anaerobic gram negative rods

• They cause dental caries, gingivitis and periodentitis

• Almost all of of Odontogenic infections are caused by multiple bacteria

How an Aerobic bacteria cause OIs

• 1-intial inoculation in deeper tissues

• 2-synthesis of hyaluronidase by s.milleri group

• 3-allowing other organisms to initiate cellulitis stage

How an Aerobic bacteria cause OIs

•Streptococci create a favorable environment for anaerobs by:

1-release essential nutrients

2-lowering PH

3-consumption of O2

• Than anaerobic bacteria become predominant and cause liquefaction necrosis by collagenase

liquefaction necrosis become:

Microabcess

Than clinically recognizable abscess

anaerobes become predominate

4 stage of

odentogenic

infections

odontogenic infections origins

1-periapical (palpal necrosis): most common

2- periodental(deep pocket)

Predictable anatomic locations of spreading

• 1-thickness of bone overlying the apex

• 2-relationship of perforation site to muscle attachments

Principles of therapy of OdontogenicInfections

Principle 1:

determine severity of infection

• Complete history of current infection

• and physical examination

Complete history

• Chief compliant (patient own words)

• History of chief compliant of OI

1-how long OI been present

2-time of onset

3-how long from first symptoms (pain-swelling-drainage)

4-change of severity in time

Clinical sign of infections

• Infections are actually a severe inflammation

Redness

Pain

Swelling

Warmth

loss of function

pain

• Most common compliant

• Where it started

• How it spread since first noted

• Trismus• Dyspnea• dysphagia

Finally:

Ask how patient feel in general:Fatigue ,weak , sick, feverish

Previous Treatment

• Professional treatment

• Self treatment

• leftover antibiotics

• herbal remedies

• Completing the last treatment

Physical examination

• Vital signs

• Temperature

• Blood pressure

• pulse rate

• respiratory rate: 14-16 in a min

• Pain and anxiety

• septic shock results in Hypotension

• Extention of Infection in fascial spaces of neck = partial or complete upper airway obstruction

Physical examination

• Inspection of patients general appearancetoxic appearancemalaisefatiguefeverishness

• Sign of infection

• Opening mouth

• Swallowing

• breathing

palpation

• In the area of swelling

• Tenderness

• Local warmth

• Consistency of swelling(soft-doughy-indurated-fluctuance)

• Fluctuance =a fluid filled balloon in the center of indurated tissue

Intra oral examination

• To find specific cause of infection

• Like severely carious teeth, periodontal abscess, periodontal disease ,

• Infected fracture of a tooth or entire of the jaw

• Should look for

• Area of gingivitis , swelling , draining sinus tracts

Radiographic examination

• Usually PA radiographs

• If there was any trismus and limited mouth opening or tenderness=panoramic view may be necessary

Mild infection

• Normal vital sign

• Only a mild temperature elevation

• Can be rapidly treated

Serious infection

• Abnormal vital signs

• Elevation in temperature ,blood pressure ,respiratory rate,

• Require more intensive therapy and evaluation by maxillofacial surgeon

Sense the stage of the infection and then ..

inoculation stage:

may be cured by removal of odontogenic cause

with or without supportive antibiotics

Cellulitis or abscess stages:

removal of dental cause

incision and drainage

antibiotics

Principle 2 evaluate state of patients host

defense mechanisms

Principle 2 evaluate state of patients host

defense mechanisms

compromise host defense:

• infection may be spread more• treated more vigorously

• referral to MXF surgeon

• parenteral antibiotic therapy

Principle 3 determine whether patient should be treated by general dentist or oral-maxillofacial surgeon

Mostly: managed by DENTIST

Main criteria for Referring

1- rapidly progressive infection

2- dyspnea

3- dysphagia

4- drooling

threat to the airway

Other criteria

• 1-extraoral Swelling

• 2-High temperature

• 3-trismus

• MIO between:

• 20 and 30 =mild

• 10 and 20 =moderate

• less than 10 = severe

Other criteria

• Moderate or severe:

• infection in masticator spaces or worse both the lateral pharyngeal space and retropharyngeal space

• 4- systematic involvement (toxic appearance)

• 5- compromised host defense

Principle 4: treat infection surgically

odontogenic infections are a

surgicallymanaged disease process

antibiotics

Principle 4: treat infection surgically

elimination of the cause

source control

endodontic or periodontal

primary principle

Principle 4: treat infection surgically

Secondary goal is to provide drainage

Incision & Drainage

1-decrease the load of bacteria and necrotic debries

2-Reduce the hydrostatic pressure in the region. which improve blood supply and delivery of host defense and antibiotic

3-stop cellulitis to spread deeper

•Whenever an abscess or cellulitis is diagnosed the surgeon must drain it.

• even if tooth cant be opened or extracted immedietly

• Antibiotic should be used if complete dranage cannot be achieved

Principle 5 support patient medically

Medications

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

Dehydration

• Fever increase fluid requirement

• Inadequate fluid intake –because of the swelling –pain and…

• They should be encouraged to drink water and to take high –nutritional supplements

• -should be taking analgesics for pain

Principle 6 : choose and prescribe

appropriate antibiotic

• 1- seriousness of infection

• 2-whether adequate surgical treatment can be achieved

• 3- patients host defense

AB used in OI

For anaerobic bacteria = metronidazole and should be used in combination to others

Fewest times daily to improve compliance

C&S test should be considered

Use a bactericidal AB if possible

• Host defense play a less important role

• Specially in medically compromised patient

Penicillin

Principle 7 : administer antibiotic properly

• For odontogenic infection a 3or 4 day course of penicillin with appropriate surgery is effective as a 7 day course

• entire prescription must be taken

Principle 8: evaluate frequently

2 to 3 days after therapy

Check the site of I&D to remove the drain

Recurrence of infection

• Early removal of the drain

• Patient may stoped taking the drug too early

• Surgical intervention and antibiotic therapy should be considered