Odontogenic Infection Ettinger
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Transcript of Odontogenic Infection Ettinger
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Management of OdontogenicInfections
David B. Ettinger MD,DMD
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Stages of Infection
I. Cellulitis
II. Abscess
III. Sinus Tract/Fistula
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CELLULITIS
A painful swelling of the soft tissue
of the mouth and face resulting
from a diffuse spreading of
purulent exudate along the fascial
planes that separate the musclebundles.
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Abscess
Well defined borders
Pus accumulation in tissues
Fluctuant to palpation
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Cellulitis spreading infection
Abscess localized infection
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FISTULA
A drainage pathway or abnormalcommunication between twoepithelium-lined surfaces due to
destruction of the intervening tissue.
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Sinus Tract
Abscess ruptures to produce adraining sinus tract
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Management of Infection
Determine the severity of the infection
Evaluate the host defense
Decide on setting of care Treat surgically
Support medically
Choose and prescribe antibioticsappropriately
Evaluate patient frequently
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Severity of Infection
Rate of progression
Potential for airway compromise or
affecting vital organs
Anatomic location of infection
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HISTORY
Duration of infectious process. Sequence of events and changes in
symptoms or signs.
Antibiotics prescribed, dosages and
responses. Review of systems with emphasis on
neuro-ophthalmologic andcardiopulmonary and immune
systems. Social history exposure, travel,
(fungal or parasitic infections),chemical dependency.
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SIGNS OF SEVERITY
Fever
Dehydration
Rapid progression of swelling
Trismus
Marked pain
Quality and/or location of swelling
Elevation of tongue
Difficulty with speech andswallowing
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Anatomic Location
Graded in severity by level to which theairway and vital structures arethreatened Low
Buccal, Vestibular, Subperiosteal
Moderate Masticator space
Severe Lateral pharyngeal
Retropharyngeal
Danger Space
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What are theprimary fascial
spaces?The spaces directly adjacent to the origin of theodontogenic infections. Infections spread from
the origin into these spaces, which are:
Vestibular SubmentalCanine Sublingual
Buccal Submandibular
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Vestibular
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Buccal
Likely from
Upper Premolar
Upper molar Lower molars
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CANINE SPACE
Superior tolevator muscleattachment in
canine fossa Can lead to:
- orbital cellulitis
- carvernous sinusthrombosis
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A unique aspect of the veins inthe head and neck is theirvalveless nature
Maxillofacial Infections
Selected Readings
OMFS Vol 2 No 1
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CAVERNOUS SINUSTHROMBOSIS
Cranial nerves III, IV, V, (opthalmic), VI
Internal carotid artery
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SUBMENTAL SPACE
Anterior mandibular teeth
Deep to mentalis muscle
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Submental Space
Most likelycaused by lower
anterior teeth ormandibularsympysis fracture
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SUBLINGUAL SPACE
Presents infloor of mouth
Superior tomylohyoid
Drainedintraorally
parallel toWhartons duct
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Submandibular Space
Likely cause: Lower molars
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SUBMANDIBULAR SPACE
Extra-oral presentation
Deep to mylohyoid I & D through skin with blunt
incision
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LUDWIGS ANGINA
Bilateral sub-mandibular,sublingual, andsub-mentalinvolvement
Rarely
fluctuant Often fatal
Requires early,aggressive
intervention
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Department of Oral and Maxillofacial Surgery
SubmentalSubmandibular
Submandibular
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What are the secondaryfascial
spaces?Fascial spaces that become involved
following spread of infection from theprimary spaces.
The secondary spaces are:
Pterygomandibular Infratemporal
Masseteric Lateral pharyngealSuperficial and deep temporal Retropharyngeal
Prevertebral
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The hallmark of masticator
space infection is: TRISMUS
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PHARYNGEAL SPACE
INFECTIONS
Lateral pharyngeal
Retro-pharyngeal
(both can lead directly to
mediastinum)
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What factors influence the spread ofodontogenic infection?
Thickness of bone adjacentto the offending tooth
Position of muscleattachment in relation toroot tip
Virulence of the organism Status of patients immune
system
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INCISION AND DRAINAGE
The production of laudable pusby:
- mucosal incision
- extraction
- endodontic access- periodontal curetage
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INCISION AND DRAINAGE
Incise in healthy skin
Incise in gravity-dependent,esthetic area if possible
Explore entireabscess cavity
Non-absorbable drains
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PRINCIPLES IN
THE USE OF DRAINS (II)
Drained wounds should be
cleansed frequently. Bacteria can migrate into a
wound along the drain surface.
Latex Penrose drains are bestused unmodified.
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INDICATIONS FOR
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INDICATIONS FORCULTURE
Nonresolving infection in spite ofappropriate care
Atypical flora expected
=long term antibiotic treatment
= age extremes (65)
= patients with malignancies
Infections with systemicinvolvement
Immunocompromised ormyelosuppressed patients
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the most important therapeutic
action in the management oforofacial infections is thedrainage of pus, and antibiotics
are merely an adjunctPogrel, A;
OMFS Clinics of
North AmericaFeb 1993
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EMPIRIC THERAPY OF
ODONTOGENIC INFECTIONS
Penicillin
Penicillin + metronidazole
PCN allergy clindamycin
MANAGEMENT OF ODONTOGENIC
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MANAGEMENT OF ODONTOGENICINFECTIONS
1. Determine severity Assess history of onset andprogression perform physicalexamination of area:
(1) Determine character and size
of swelling
(2) Establish presence of trismus
2. Evaluate host defenses Evaluate:
(1) Diseases that compromise
the host
(2) Medications that maycompromise the host
3. Perform surgery Remove the cause of infection
Drain pus
Relieve pressure
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MANAGEMENT OFODONTOGENIC INFECTIONS
4. Select antibiotic
5. Follow up
Determine:
(1) Most likely causativeorganisms based on history
(2) Host defense status
(3) Allergy history
(4) Previous drug history
Prescribe drug property
(route,dose and dosage
interval, and duration)
Confirm treatment response
Evaluate for side effects and
secondary infections
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Follow-up
Patient should be monitoredfrequently
out-patient should return for f/u in 2-3 days
Patient should have decreasedswelling, discharge, airway edema,malaise in 2-3 days
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Follow up
If no improvement consider:
Re-culture
Re-imageRepeat I and D
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Questions