Acute Infect

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Diagnosis and Management ofDiagnosis and Management of

Acute InfectionsAcute Infections

Oral and Paraoral TissuesOral and Paraoral Tissues

Material used by permission from B.C. DeckerMaterial used by permission from B.C. DeckerPublishing Co.Publishing Co.


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eneral Considerationseneral Considerations

Common types of infection!Common types of infection!

Periapical" peridontal" postsurgical" pericoronalPeriapical" peridontal" postsurgical" pericoronalMay begin as #ell$delineated" self$limitingMay begin as #ell$delineated" self$limiting

condition #ith potential to spread andcondition #ith potential to spread andresult in a ma%or fascial space infection.result in a ma%or fascial space infection.

&ife$threatening se'uelae can ensue!&ife$threatening se'uelae can ensue! (epticemia" ca)ernous sinus thrombosis" air#ay(epticemia" ca)ernous sinus thrombosis" air#ay

obstruction" mediastinitisobstruction" mediastinitis


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MicrobiologyMicrobiology

Odontogenic infections areOdontogenic infections aremultimicrobial!multimicrobial!

ram *+, cocci" aerobic and anaerobic!ram *+, cocci" aerobic and anaerobic! (treptococci and their anaerobic(treptococci and their anaerobic

counterpart" peptostreptococcicounterpart" peptostreptococci (taphylococci" and their anaerobic(taphylococci" and their anaerobic

counterpart" peptococcicounterpart" peptococci

ram *+, rods!ram *+, rods! &actobacillus" diphtheroids" Actinomyces&actobacillus" diphtheroids" Actinomyces

ram *$, rods!ram *$, rods! -usobacterium" Bacteroids" ikenella"-usobacterium" Bacteroids" ikenella"

Psuedomonas *occasional,Psuedomonas *occasional,


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/ost -actors/ost -actors

Immunity against intraoral infection isImmunity against intraoral infection is

composed of three sets of mechanisms!composed of three sets of mechanisms! /umoral factors/umoral factors

Cellular factorsCellular factors

&ocal factors&ocal factorsDecrease one of these mechanisms and itDecrease one of these mechanisms and it

increases the potential for infection.increases the potential for infection.


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/umoral -actors/umoral -actors

Circulating immunoglobulins" along #ithCirculating immunoglobulins" along #ithcomplement" combine #ith microbes tocomplement" combine #ith microbes toform opsonins that promoteform opsonins that promote

phagocytosis by macrophages.phagocytosis by macrophages. IgA pre)ents coloni0ation of microbesIgA pre)ents coloni0ation of microbes

on oral mucosal surfaces.on oral mucosal surfaces.

In presence of infection" histamine"In presence of infection" histamine"serotonin" prostaglandins supportserotonin" prostaglandins supportin1ammationin1ammation )asodilation and)asodilation andincreased )ascular permeability.increased )ascular permeability.


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Cellular factorsCellular factors

Phagocytes engulf and kill microbes"Phagocytes engulf and kill microbes"

remo)ing them" pre)enting replication.remo)ing them" pre)enting replication.

&ymphocytes produce lymphokines and&ymphocytes produce lymphokines andimmunoglobulines *aids humoral,.immunoglobulines *aids humoral,.

&ymphokines stimulate reproduction of&ymphokines stimulate reproduction of

other lymphocytes" and kills antigens.other lymphocytes" and kills antigens.


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&ocal -actors&ocal -actors

(peci2c factors leading to resistance!(peci2c factors leading to resistance! Abundant )ascular supply allo#ingAbundant )ascular supply allo#ing

humoral and cellular response.humoral and cellular response.

Mechanical cleansing by sali)ary 1o#.Mechanical cleansing by sali)ary 1o#. (ecretory IgA contained #ithin sali)a.(ecretory IgA contained #ithin sali)a.

/igh epithelial turno)er and sloughing"/igh epithelial turno)er and sloughing"

taking #ith it adherent bacteria.taking #ith it adherent bacteria.

A )ariety of micro1ora normallyA )ariety of micro1ora normallypre)enting selection for a singlepre)enting selection for a single

organism by competing for nutrients ororganism by competing for nutrients or

release of by$products.release of by$products.


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/istorical -eatures/istorical -eatures

(lo#ly enlarging s#elling #ith a dull ache(lo#ly enlarging s#elling #ith a dull ache

or recurrent draining abscess that s#ellsor recurrent draining abscess that s#ells

and drains spontaneously is not likely toand drains spontaneously is not likely to

re'uire aggressi)e treatment #ithin there'uire aggressi)e treatment #ithin the

hour 3 the patient4s immune response ishour 3 the patient4s immune response is

e5ecti)ely containing the spread ofe5ecti)ely containing the spread of

infection.infection.

/o#e)er" 67$hour painful s#elling causing/o#e)er" 67$hour painful s#elling causing

pain during s#allo#ing or se)ere trismuspain during s#allo#ing or se)ere trismus

needs aggressi)e and prompt treatment.needs aggressi)e and prompt treatment.


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/istorical -eatures" con4t./istorical -eatures" con4t.

Immediate treatment or referral is criticalImmediate treatment or referral is critical#hen patient4s immune system has not#hen patient4s immune system has not

been containing the infection.been containing the infection. (peci2c #arning signs include!(peci2c #arning signs include!

Dyspnea *di8culty breathing,Dyspnea *di8culty breathing, Dysphagia *di8culty9pain #ith s#allo#ing,Dysphagia *di8culty9pain #ith s#allo#ing, (e)ere trismus(e)ere trismus :apidly progressi)e s#elling:apidly progressi)e s#elling


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Clinical -eaturesClinical -eatures

In1ammation is tissue response toIn1ammation is tissue response toin%ury or in)asion by microorganismsin%ury or in)asion by microorganisms

that in)ol)es )asodilation" capillarythat in)ol)es )asodilation" capillary

permeability" mobili0ation of leukocytes"permeability" mobili0ation of leukocytes"

and phagocytosis.and phagocytosis.

Cardinal signs of in1ammation!Cardinal signs of in1ammation! :ed" hot" s#elling" pain" #ith loss of:ed" hot" s#elling" pain" #ith loss of

functionfunction Other 2ndings!Other 2ndings! regional lymphadenopathyregional lymphadenopathy""

fe)er" ele)ated #hite blood cell count"fe)er" ele)ated #hite blood cell count"

tachycardia" tachypnea" dehydration" malaise.tachycardia" tachypnea" dehydration" malaise.


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Cellulitis! initial stage ofCellulitis! initial stage of

infectioninfection Di5use" reddened" soft orDi5use" reddened" soft or

hard s#elling that ishard s#elling that is

tender to palpation.tender to palpation. In1ammatory response notIn1ammatory response not

yet forming a true abscess.yet forming a true abscess.

Microorganisms ha)e %ustMicroorganisms ha)e %ust

begun to o)ercome hostbegun to o)ercome hostdefenses and spreaddefenses and spread

beyond tissue planes.beyond tissue planes.


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True abscess formationTrue abscess formation

As in1ammatoryAs in1ammatory

response matures"response matures"

may de)elop a focalmay de)elop a focalaccumulation of pus.accumulation of pus.

May ha)eMay ha)e

spontaneous drainagespontaneous drainage

intraorally orintraorally ore;traorally.e;traorally.


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Oral tissue e;aminationOral tissue e;amination

;amine 'uality and consistency!;amine 'uality and consistency! (oft to 1uctuant *1uid 2lled, to hard(oft to 1uctuant *1uid 2lled, to hard

*indurated,*indurated,

Color and temperature determine theColor and temperature determine thepresence and e;tent of infectionpresence and e;tent of infection


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;amination" con4t.;amination" con4t.

Identify causati)e factors!Identify causati)e factors!

Tooth" root tip" foreign body" etc.Tooth" root tip" foreign body" etc. >ital signs should be taken!>ital signs should be taken!

TemperaturesTemperatures >>?@? to ?@6?@? to ?@6--

accompanied by an ele)ated heart rateaccompanied by an ele)ated heart rate

indicate systemic in)ol)ement of theindicate systemic in)ol)ement of the

infection and increased urgency ofinfection and increased urgency of

treatment.treatment.


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Principles in Treatment of OralPrinciples in Treatment of Oral

and Paraoral Infectionsand Paraoral Infections

?.?. :emo)e the cause.:emo)e the cause.

6.6. stablish drainage.stablish drainage.

.. Institute antibiotic therapy.Institute antibiotic therapy.

7.7. (upporti)e care" including proper(upporti)e care" including properrest and nutrition.rest and nutrition.


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Potential Path#ays of (pread ofPotential Path#ays of (pread of

Odontogenic InfectionsOdontogenic Infections


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Path#ays of spread of periapicalPath#ays of spread of periapical

abscess into the )estibular softabscess into the )estibular soft

tissuetissue


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Path#ays of spread ofPath#ays of spread of

submandibular space infection fromsubmandibular space infection from

mandibular molarmandibular molar


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&ud#ig4s angina #ith bilateral&ud#ig4s angina #ith bilateral

in)ol)ement of sublingual andin)ol)ement of sublingual and

submandibular spacessubmandibular spaces


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Path#ay of spread for buccalPath#ay of spread for buccal

space infectionspace infection


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Path#ay of spread fromPath#ay of spread from

masseteric space infectionmasseteric space infection


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Areas of spread in infraorbitalAreas of spread in infraorbital

space infectionsspace infections


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Areas of spread of palatal abcessAreas of spread of palatal abcess


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stablishment of Drainagestablishment of Drainage


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Drainage" con4tDrainage" con4t


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Drainage" con4tDrainage" con4t

P d i i l


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Penrose drain in place toPenrose drain in place to

pro)ide drainage forpro)ide drainage for

)estibular abscess)estibular abscess


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Antibiotic TherapyAntibiotic Therapy

:emo)al of the cause" drainage" and:emo)al of the cause" drainage" and

supporti)e care more important thansupporti)e care more important than

antibiotic therapy.antibiotic therapy.

Infections are cured by the patient4sInfections are cured by the patient4sdefenses"defenses" notnotantibiotics.antibiotics.

:isks of allergy" to;icity" side e5ects":isks of allergy" to;icity" side e5ects"

resistance and superinfectionresistance and superinfectioncausing serious or potentially fatalcausing serious or potentially fatal

conse'uences must be considered.conse'uences must be considered.


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Antibiotic therapy" con4t.Antibiotic therapy" con4t.

Oral infections are typically polymicrobial.Oral infections are typically polymicrobial.

Antibiotic e5ecti)eness dependent uponAntibiotic e5ecti)eness dependent upon

ade'uate tissue *not serum, concentrationade'uate tissue *not serum, concentrationfor an appropriate amount of time.for an appropriate amount of time.

Antibiotics should be prescribed for atAntibiotics should be prescribed for at

least one #eek 3 ade'uate tissueleast one #eek 3 ade'uate tissue

concentration achie)ed in 67$7 hours"concentration achie)ed in 67$7 hours"

#ith bacteriocidal acti)ity occurring o)er#ith bacteriocidal acti)ity occurring o)er

the ne;t $ days.the ne;t $ days.


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PenicillinPenicillin*bacteriocidal, drug of choice*bacteriocidal, drug of choicefor treatment of odontogenic infectionsfor treatment of odontogenic infections

*E incident of allergy,.*E incident of allergy,.

ClindamycinClindamycin *batericiodal, ?*batericiodal, ?stst

line afterline after

penicillinF e5ecti)e against anaerobesF stoppenicillinF e5ecti)e against anaerobesF stop

taking at 2rst sign of diarrhea.taking at 2rst sign of diarrhea.

CephalosporinCephalosporin *slightly broader*slightly broader

spectrum and bacteriocidal,F cautious usespectrum and bacteriocidal,F cautious usein penicillin$allergic patientsin penicillin$allergic patients = cross$= cross$

sensiti)ityF if history of anaphyla;is tosensiti)ityF if history of anaphyla;is to

penicillin" do not use.penicillin" do not use.


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ErythromycinErythromycin*bacteriostatic, good 6*bacteriostatic, good 6ndndline drug after penicillinF use enteric$line drug after penicillinF use enteric$

coated to reduce I upset.coated to reduce I upset. MetronidazoleMetronidazole*bacteriocidal, e;cellent*bacteriocidal, e;cellent

against anaerobes only.against anaerobes only.

AugmentinAugmentin*amo;icillin + cla)ulanic*amo;icillin + cla)ulanicacid, kills penicillinase$producing bacteriaacid, kills penicillinase$producing bacteriathat interferes #ith amo;icillinF e;pensi)e.that interferes #ith amo;icillinF e;pensi)e.


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(upporti)e Care(upporti)e Care

To ensure the patient4s ma;imumTo ensure the patient4s ma;imumimmune response!immune response! Increase 1uid intake *?G ounces9hour,.Increase 1uid intake *?G ounces9hour,.

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