Odontogenic Infection Dr. Rahaf Al-Habbab BDS. MsD. DABOMS Diplomat of the American Boards of Oral...

Odontogenic Infection

Dr. Rahaf Al-Habbab BDS. MsD. DABOMSDiplomat of the American Boards of Oral and

Maxillofacial Surgery

Odontogenic Infection

• Infection that arises from the teeth, and spread beyond the teeth to the alveolar process and the deeper tissue of the face, oral cavity, head and neck, and have a characteristic flora

Origin:• Caries• Periodontal Disease• pulpitis Different Origins of Odontogenic Infection

Odontogenic Infection Types

Low-grade • Well localized infection that require only minimal treatment• Most common

Severe Infection:• Life threatening • Deep facial space infections

Microbiology of OI

• Most commonly part of the indigenous bacteria that normally live on or in the host (normal flora)

• Are the bacteria that causes dental caries, gingivitis, and periodontitis.

• Gaining access to deeper underlying tissues, causes Odontogenic Infection

Microbiology of OI

• Aerobic gram positive cocci• Anaerobic gram-positive cocci• Anaerobic gram-negative rods

As the infection progresses more deeply, different members of the infecting flora can begin to outnumber the previously

dominant species

Important Factors

• Almost all OI are caused by multiple bacteria (polymicrobial)

• Oxygen tolerance of the bacteria causing OI, because the oral flora is a combination of aerobic and anaerobic bacteria (aerobic 6%, anaerobic 44%, mixed 50%)

The predominant Aerobic bacteria found in 65% of OI are thestreptococcus milleri group, which consist of three members of the S.viridans group of bacteria:

• S. anginosus, S. intermedius, S. constellatus, which can grow in the presence and the absence of Oxygen

The Anaerobic bacteria found in OI include an even greatervariety of species, two groups predominate;

Gram positive cocci (65% of cases)• Streptococcus• Peptostreptococcus

Gram-negative anaerobic rods • Prevotella, and Porphyromonas (found in about 75%)• Fusobacterium (present in more than 50%)

Of the Anaerobic bacterai, gram +ve cocci and

gram –ve rods, play a more important pathogenic role

Where the Anaerobic gram –ve cocci and

gram +ve rods have little or no role in causing OI

Pathophysiology

• Initial inoculation of aerobic and anaerobic bacteria into the deeper tissue → S. milleri group organisms synthesize Hyaluronidase → allow infection to spread through connective tissue → Cellulitis type of Infection

• Metabolic by-products from the streptococci → create a favorable growth environment for the Anaerobe (release of essential nutrients, lower pH, local O2 supply consumption)

• As the local oxidation-reduction potential is lowered further → Anaerobic bacteria predominate → further liquification necrosis (by their synthesis of collagenases)

• As collagen is broken down and invading WBC necrosis and lyse → micro-abscesses form → Coalesce into a clinical Abscess

Clinical Progression

OI passes through four stages:

Inoculation Stage:• First 3 days• Soft, mildly tender, doughy swelling• Invading streptococci are just beginning to colonize the host

Cellulites Stage:• 3-5 days• Swelling become hard, red, and acutely tender• Infecting mixed flora stimulates the intense inflammatory response

Clinical Progression

Abscess Stage:• 5-7 days after the swelling onset• Anaerobic begin to predominate• Liquification of the abscess in the center of the swollen area

Resolution Stage:• Abscess drain spontaneously through skin or mucosa or it is surgically

drained• Immune system destroys the infecting bacteria• Process of healing and repair

Abscess Cellulitis Edema (Inoculation) characteristic

4-10 days 1-5 days 0-3 days Duration

Localized Diffuse Mild, diffuse Pain, borders

Smaller Large Variable Size

Shiny center Red Normal Color

Soft center Boardlike Jellylike Consistency

Decreasing Increasing Increasing Progression

Present Absent Absent Pus

Anaerobic Mixed Aerobic Bacteria

Less Greater low seriousness

Progression of Odontogenic Infection

Two major origins:

• Periapical (as a result of pulpal necrosis)• Periodontal (as a result of deep periodontal pocket)

The periapical origin is the most common in odontogenic infections


• Deep caries, resulting in dental pulp necrosis, allows a pathway for bacteria to enter the periapical tissue

• Bacterial invasion will result in active infection

• Infection then spread equally in all directions, but preferentially along the line of least resistance

• Infection spreads through the cancellous bone until it encounters the cortical plate

• If the cortical bone is thin, the infection erode through the bone and invade the soft tissue


• Treatment of the necrotic pulp by standard endodontic therapy or extraction of the involved tooth should resolve the problem

• Antibiotics alone may arrest, BUT do not cure the infection

Spreading of the Infection Determined by two major factors

The thickness of the bone overlying the tooth apex

The relationship of the bone perforation site to muscle attachment of the maxilla and the mandible

Maxillary Infection

• Most maxillary teeth erode through the facial cortical plate.• Erode through the bone below the attachment of the

muscles attaching to the maxilla

Means that:• Most maxillary dental abscesses appear initially as vestibular

abscess

• Occasionally, a palatal abscess arises from the apex of a severely inclined lateral incisor or a palatal root of a maxillary first molar.

Maxillary Infection

• More commonly; The maxillary molars cause infections that erode through the bone superior to the insertion of the buccinator muscle

Resulting in: • Buccal space infection

• Occasionally, long maxillary canine root allows infection to erode through the bone superior to levator anguli oris insertion, causing Infraorbital (canine) space infection.

Mandibular Infection

Incisors, canine, and premolars:

• Usually erode through the facial cortical plate superior to the attachment of the lower lip muscles

Resulting in:• Vestibular abscess

Mandibular Infection

Mandibular molars: • Infections erode through the lingual cortex more frequentlyFirst molar • Infections may drain buccally or lingually Second molars• Can perforate buccally or lingually (usually lingually)Third molars:• Almost always erode through the lingual cortical plate

The mylohyoid muscle determines wither infections that drain lingually go superior to the muscle into the sublingual space or below it into the

submandibular space

Principles of OI Management

Principle 1: Determine Infection SeverityPrinciple 2: Evaluate State of patient’s host defense mechanismPrinciple 3: Determine whether patient should be treated by general dentist or Oral and Maxillofacial SurgeonPrinciple 4: Treat infection surgicallyPrinciple 5: Support patient medicallyPrinciple 6: Choose and prescribe Appropriate antibioticPrinciple 7: Administer antibiotic properlyPrinciple 8: Evaluate patient frequently

Principle 1: Determine Infection Severity

Complete history:• Chief complaint: In patients own words• Duration and onset: How long, progression • Signs and symptoms: Pain, swelling, warmth, erythema and redness, and

loss of function (mouth opening, dysphagia, dyspnea) • General condition: fatigued, feverish, weak, and sick are said to have

malaise Malaise: generalized reaction to a moderate to severe infection

• Ask about Treatment: professional and self-treatment• Complete medical history


Physical Examination:Vital signs: Temperature, blood pressure, pulse rate, and respiratory rate• Temperature: Patient with severe infection have temperature of 101° F

or higher (greater than 38.3° C)• Pulse Rate: pulse rate of up to 100 beats/min are not uncommon in an

infection patient, id PR is greater than 100 bpm may indicate severe infection

• Blood Pressure: significant pain and anxiety can result in the elevation of systolic blood pressure, However, severe septic shock result in Hypotension

• Respiratory rate: clear upper airway and no difficulty in breathing RR, 14-16 breaths per minute, can increase up to 18 in mild to moderate

infections


Physical Examination:• Inspection of general appearance• Careful head and neck examination• Palpation of swelling : tenderness, heat, consistency ( doughy, indurated,

fluctuant) Fluctuance: feeling of fluid filled balloon, almost always indicate pus in the

center of the indurated area.Intraoral Examination: cause of infection, and assess airway and tongue

positionRadiographic Examination: PA, Panoramic radiograph

Determine the diagnosis

Summery

• Edema represents the earliest ,inoculation stage of infection that is most easily treated

• Cellulitis, is an acute, painful infection with more swelling and diffuse borders

• Has a hard consistency on palpation and contains NO PUS

• Acute Abscess, more mature infection with more localized pain, less swelling, well circumscribed borders

Which is more serious?

Principle 2: Evaluate State of Patient’s Host Defense Mechanism

Medical conditions that compromise host defenses

1- Uncontrolled Metabolic Diseases: • Poorly controlled Diabetes: Type I and Type II, are the most

common immunosuppressive diseases• Renal disease with Uremia• Severe alcoholism with malnutrition

Resulting in decrease function of leukocytes, including decrease chemotaxis, phagocytosis, and bacterial killing


2- Immunocompromising Diseases:• Leukemia• Lymphoma• Different types of cancer

Decrease white blood cells function and antibodies synthesis and production


Immunocompromising Diseases:• Human Immunodeficiency Virus Infection (HIV)

HIV attacks T lymphocytes, affecting resistance to viruses and intracellular pathogens, Fortunately,

Odontogenic infections are caused largely by extracellular pathogens(Bacteria) , therefore

HIV-seropositive individuals are able to combat OI fairly well until they aquireimmunodeficiency syndrome has progressed into advanced stage, when theB lymphocytes are also severely impaired


3- Immunosuppressive Therapies:• Cancer chemotherapy• Corticosteroids• Organ transplantation

Decrease white blood cells count, T and B lymphocyte function, and immunoglobulin production, more likely to develop infection

Patient taking any of these medications should be treated vigorously , prophylactic antibiotics should be given for routine oral surgery

procedure to prevent INFECTION and Endocarditis

Principle 3: Determine whether patient should be treated by General Dentist or Oral and Maxillofacial

Surgeon

Minor infection vs. life-threatening infection

Criteria indicating immediate referral to a Hospital emergency room tosecure the airway:• Rapidly progressing infection• Difficulty in breathing (dyspnea)• Difficulty in swallowing (dysphagia)• Dehydration• Moderate to severe trismus (interincisal distance less than 20mm)• Swelling extending beyond the alveolar process• Elevated temperature (˃101° F)• Severe malaise and toxic appearance• Compromised host defenses• Need for general anesthesia• Failure of prior treatment

Principle 4: Treat infection surgically

• Remove the cause of the infection• Drain the accumulate pus and necrotic debris

I&D Technique

• Adequate pain control (block or infiltration)

• Disinfect the surface mucosa with a solution such as povidone-iodine (Betadine)

• Obtain a specimen for C&S testing using an 18 gauge needle (1-2ml)

I&D Technique

Incision is made Over the site of maximum swelling and inflammation using a scalpel blade just through the mucosa and submucosa (not more than 1cm long)

Avoid incising across the frenum or the

mental nerve region

I&D Technique

Small curved hemostat is inserted through the incision to the abscess cavity

Hemostat is open in different directions to break up any small pus loculations or cavities

I&D Technique

Small drain is then inserted and secure in place using a non-resorbable suture (1/4 inch sterile penrose drain)

Drain is removed 2-5 days following drainage, when all drainage have stopped

Principle 5: Support Patient Medically

• Treat and control the underlying medical condition

• Proper hydration

• High-calorie nutritional supplement

• Adequate analgesia for proper rest

Principle 6: Choose and Prescribe Appropriate Antibiotic

1- Determine the need of AB administration:

Indications:

• Swelling extending beyond the alveolar process• Cellulitis• Trismus• Lyphadenopathy• Temperature higher than 101° F• Severe pericoronitis• Osteomyelitis


1- Determine the need of AB administration:

Not Indicated:

• Patient demand• Toothache• Periapical abscess• Dry socket (self limiting)• Multiple dental extractions in a non compromised patient• Mild pericoronitis (inflammation of the operculum only)• Drained alveolar abscess


2- Use Empirical Therapy Routinely:

Odontogenic infections are caused by a highly predictable group of bacteria, with a very well known antibiotic sensitivity.

Effective Orally Administered Antibiotics for OI:• Penicillin• Amoxicillin• Clindamycin• Azithromycin• Metronidazole• Moxifloxacin


2- Use the Narrowest-Spectrum Antibiotics:

Will affect streptococci and oral anaerobic bacteria, but will have little or no effect on the staphylococci of the skin or GI tract, so does not result in

the development of bacterial resistance

Narrow and Broad-spectrum Antibiotics: Narrow-Spectrum Wide-Spectrum (simple OI) (complex OI) Amoxicillin Amoxicillin with clavulanic acid Penicillin Azithromycin Clindamycin Tetracycline Metronidazole Moxifloxacin

Simple vs. Complex Odontogenic Infection

Simple odontogenic Infections:• Swelling limited to the alveolar process and vestibular space• First attempt at treatment• Non-immunocompromised patients

Complex Odontogenic Infections:• Swelling extending beyond the vestibular space • Failed prior treatment• Immunocompromised patient


3- Use the antibiotic with the lowest incidence of toxicity and side effects

4- Use a bactericidal antibiotic, if possible

5- Be aware of the coast of antibiotics

Principle 7: Administer Antibiotic Properly

• Proper dose should be given

• The peak plasma level should be 4 or 5 times the minimal inhibitory concentration for the bacteria involved in the infection

Principle 8: Evaluate Patient Frequently

• Patient should be followed carefully to monitor response to treatment and complications

• Additional antibiotics may be necessary in infection that have not resolved rapidly

Reasons for treatment failure:• Inadequate surgery• Foreign body• Antibiotic problems:• Patient noncompliance• Drug not reaching site• Drug dose too low• Wrong bacterial diagnosis• Wrong antibiotic

Thank You

Reference: Contemporary Oral and Maxillofacial Surgery James R. Hupp, Edward Ellis III, Myron R. Tucker, 5th Edition

Chapter 15

Odontogenic InfectionPart II

Dr. Rahaf Al-Habbab BDS. MsD. DABOMSDiplomat of the American Boards of Oral and

Maxillofacial Surgery2013

Principles of Prevention of Infection

The use of antibiotics to treat an already established infection is a well accepted and well-defined technique

But

The use of antibiotics for prevention is less widely accepted

Principles of Prophylaxis of Wound Infection

There is little scientific evidence that demonstrates the effectiveness of prophylactic antibiotics in dentistry and Oral

and maxillofacial surgery.

Advantages

• Reduce the incidence of postoperative infection and thereby reduces postoperative morbidity

• Appropriate and effective antibiotics prophylaxis may reduce the coast of health care

• Requires shorter –term administration than therapeutic use.

Disadvantages

• Can alter host flora, allowing the overgrowth of antibiotic-resistant and pathogenic bacteria that may then cause infection

• Allow antibiotic-resistant organisms to spread to the patient’s family and community

• May provide no benefit (infection risk is so low)

Disadvantages (cont.)

• May encourage lax surgical and aseptic technique on the dentist part

• Coast of antibiotic must be considered

• Toxicity of the drug to the patient must be kept in mind

Principles of Prophylactic Antibiotic Use

• Risk of infection must be significant

• Correct narrow-spectrum antibiotic must be chosen

• Antibiotic level must be high

• Antibiotic must be in the target tissue before surgery

• Use the shortest effective antibiotic exposure.

Principle 1: Procedure Should have Significant Risk of Infection

• Clean surgery with strict adherence to basic surgical principles, has an infection rate of about 3%.

• 10% infection rate or higher (infection-prone procedure) is considered unacceptable, and AB must be strongly considered

However, several factors might influence the use of AB prophylaxis

Factors Related to Postoperative Infection

• Size of bacterial inoculum

• Duration of surgery ( more than 4 hours in hospital surgeries)

• Presence of foreign body, implant, or dead space.

• State of host resistance (immunosuppressive, cancer)

• The most common immunocompromising disease is Diabetes mellitus

Diabetes Mellitus

Measuring the level of DM control over the previous 3-4Months

• The Glycosylated Hemoglobin test• Hemoglobin A1c (8% or less)

Dental Treatment for Diabetics Based on Fingerstick Blood Glucose Testing

Dental Treatment Finger Stick Blood Glucose (mg/dl

%)Administer glucose; postpone elective treatment Less than 85

Stress reduction; consider AB prophylaxis for extraction 85-200

Stress reduction; AB prophylaxis; referral to primary care physician

200-300

Avoid elective treatment; referral to primary care physician or ER at nearby hospital

300-400

Avoid elective treatment; send to ER at nearby hospital Greater than 400

Principle 2: Choose Correct Antibiotics

The choice of AB for prophylaxis after surgery should be basedon the following criteria:

• First, AB should be effective against the organisms most likely causing the infection

• Second, Chosen AB should be narrow-spectrum

• Third, Should be the least toxic AB available

• Fourth, should be bactericidal AB

AB of Choice

Taking these four criteria into account, the antibioticof Choice for prophylaxis is:

Penicillin and Amoxicillin• Effective against streptococcus• Narrow spectrum• Low toxicity• Bactericidal

Allergic to Penicillin

Clindamycin• Fairly effective against oral streptococcus• Narrow spectrum• Bacteriostatic

Azithromycin • Reasonably effective against the usual organisms• Narrow spectrum• Bacteriostatic

Principle 3: Antibiotic Plasma Level must be High

• Prophylactic antibiotic plasma level must be higher than therapeutic level

• Plasma level should be high at the time of surgery to ensure diffusion of the AB into all tissue and spaces at surgery site

• The usual prophylaxis recommendation is two times the usual therapeutic dose (use the AHA recommendation for Infective Endocarditis):

• Penicillin and Amoxicillin, 2g• Clindamycin, 600mg• Azithromycin, 500mg

Principle 4: Time AB Administration Correctly

• Should be administered 2 hours or less before the surgery

• Varies according to the rout of administration

• For oral administration is usually 1 hour

• IV rout, much shorter duration is required

Principle 4: Time AB Administration Correctly

Giving prophylactic AB postoperatively was found to increasethe risk of postoperative infection

Intraoperative AB administration in prolonged procedure shouldbe given at half the usual interval time;

• Penicillin and Clindamycin should be given every 3 hours, to avoid periods of inadequate AB level in tissue fluids.

Principle 5: Use Shortest Antibiotic Exposure That is Effective

• AB must be given before the surgery

• Adequate plasma level must be maintained during surgery

• Continuation of the AB administration after surgery produce little to no benefit

What about Metastatic Infections?

Principles of Prophylaxis Against Metastatic Infection

• Defined as: Infection that occurs at a location physically distant from the port of bacterial entry

• Bacterial Endocarditis is best example

• Incident of infection can be reduced if AB administration is used preoperatively

Factors Necessary for Metastatic Infection

• Distant susceptible site (Deformed heart valve, Non-Bacterial Thrombotic Endocarditis, NBTE)

• Hematogenous bacterial seeding (Bacteremia)

• Impaired local defenses

Prophylaxis Against Infectious Endocarditis

• Bacteremia has been shown to cause IE (streptococcus viridans) which is part of the normal oral flora

• Prophylactic AB has shown to prevent IE resulting from dental procedures

• IE can result in high morbidity and mortality

• All dental procedures can result in Bacteremia

• Depending on the procedure the need of antibiotics is decided in high risk patients

Cardiac Conditions Associated with the Highest Risk of Adverse outcome from Endocarditic for which Prophylaxis with dental

procedure is Recommended

Prosthetic Cardiac Valve

Previous Infective Endocarditis

Congenital Heart Disease (CHD)• Unrepaired cyanotic CHD, including palliative shunts and coduits• Completely repaired congenital heart defect with prosthetic material or

device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure

• Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)

Cardiac transplantation recipients who have cardiac valculopathy

Dental Procedures for which Endocarditis Prophylaxis is Recommended for patients

All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the

oral mucosa

Dental Procedures for which Prophylaxis is NOT Recommended

• Restorative dentistry• Routine local anesthetic injection• Intracanal endodontic therapy and placement of rubber dams• Suture removal• Placement of removable appliances• Making of impressions• Taking oral radiographs• Fluoride treatment• Orthodontic appliance adjustment• Shedding of primary teeth

If unexpected bleeding occurs during the procedure or the patient failed to inform you about his condition

• Prophylaxis AB should be given during the first 2 hours after the procedure

• Prophylaxis given longer than 4 hours after the bacteremia has limited prophylactic benefits.

Antibiotics Regiments for prophylaxis of Bacterial Endocarditis

30-60 Min Before ProcedureChildren

RegimentAdult

Agent Situation

50 mg/kg 2g Amoxicillin Oral

50 mg/kg IM or IV50 mg/kg IM or IV

2 g IM or IV1 g IM or IV

Ampicillin Cafazolin/ceftriaxone

parenteral

50 mg/kg20 mg/kg 15 mg/kg

2 g600 mg500 mg

CephalexinClindamycin Azithromycin/clarithromycin

PCN allergy, Oral

50 mg/kg IM or IV50 mg/kg IM or IV

1 g IM or IV600 mg IM or IV

Cefazolin/ceftriaxoneClindamycin

PCN, allergy, parenteral

Prophylaxis in Patients with other Conditions

Do not require PABCoronary Artery Bypass Grafting

(CABG)


Transvenous Pacemaker

(Battery Pack Implanted in their Chest)

Do Not Require PAB

Consultation with the patient’s cardiologist should still be considered


Renal Dialysis Patients for Renal Failure

(Arteriovenous Fistula)Patient Nephrologists should

decide the proper PAB

Prophylaxis against Total Joint Replacement Infection

American Dental Association (ADA) and the American Academyof Orthopedic Surgeons (AAOS) RECOMMENDATION:

Most patients with prosthetic joints are not at risk for joint infection after a dental surgical procedure

Conditions placing patients at risk for prosthetic joint infection

• Prosthetic joint placed within 2 years• Rheumatoid arthritis• Systemic lupus erythematosus• Insulin-dependent diabetes• Previous prosthetic joint infection• Congenital or acquired immunosuppressive diseases• Malnourishment• hemophilia

Procedures that indicate prophylaxis for prosthetic joint replacement

• Dental extraction• Periodontal procedures, including scaling and root planning• Dental implant placement and reimplantation of avulsed

teeth• Periapical endodontic procedures• Initial placement of orthodontic bands but not brackets• Intraligamentary local anesthetic injections• Dental prophylaxis when bleeding is expected• Subgingival placement of antibiotic fibers or strips

Antibiotic Regimens for Prophylaxis of Total Joint Replacement Infection

Dose Drug Regimen

2g orally 1 hour before procedure

Amoxicillin, cephalexin, or cephradine

Standard oral prophylaxis

600 mg orally 1 hour before procedure

Clindamycin Penicillin-allergic oral prophylaxis

1g IV 1 hour before procedure2g IV 1 hour before procedure

CephazolinOrAmpicillin

Parenteral prophylaxis

600 mg IV 1 hour before procedure

Clindamycin Penicillin-allergic parenteral prophylaxis

Indication for Parenteral Regimen

• Patient having general anesthetic and allowed nothing by mouth

• Unable to take oral medications

• High-risk patients, such as those with history of previous bacterial endocarditis

Communications Between all Parties is Required

Thank You

Reference: Contemporary Oral and Maxillofacial Surgery James R. Hupp, Edward Ellis III, Myron R. Tucker, 5th Edition

Chapter 15

Odontogenic Infection Dr. Rahaf Al-Habbab BDS. MsD. DABOMS Diplomat of the American Boards of Oral...

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