Odontogenic Infections 1

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Diagnosis and Management of

Odontogenic Infections

Jeff Lee

Dept. of Oral and Maxillofacial Surgery1/15/02

Combined Hospital Meeting


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Odontogenic Infections The modern emergency department sees a

significant number of patients every day

with problems related to the face and oral

cavity. Emergency Medicine Clinics of North America Aug 2000


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35 year old male, 3 day history of

progressive painful facial swelling,

difficulty opening mouth, difficulty

swallowing, alteration in voice. 8 year old female, 5 days s/p dental

extraction, persistent increasingly painful

swelling left face, taking augmentin since

extraction.



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OUTLINEOUTLINE

MicrobiologyNatural history

AssessmentManagement

Prevention


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Understand important aspects of history and

clinical examination of patient.

Understand treatment of odontogenic

infections and when to refer treatment.



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MICROBIOLOGYMICROBIOLOGY

Causative organismsAerobes only 7 %

Anaerobes only 33 %

Mixed 60 %


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Aerobic 25%

Gram-positive cocci 85%Streptococcus spp. 90%

Streptococcus (group D) spp. 2%

Staphylococcus spp. 6%

Eikenella spp. 2%Gram-negative cocci (Neisseria spp.) 2%

Gram-positive rods (Corynebacterium spp.) 3%

Gram-negative rods (Haemophilus spp.) 6%

Miscellaneous and undifferentiated 4%


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Anaerobic 75%

Gram-positive cocci 30%Streptococcus spp. 33%

Peptostreptococcus spp. 65%

Staphylococcus spp. 65%

Gram-negative cocci (Veillonella spp.) 4%

Gram-positive rods 14%

Eubacteriumspp.Lactobacillus spp.

Actinomyces spp.

Clostridia spp.

Gram-negative rods 50%Bacteroides spp. 75%

Fusobacterium spp. 25%

Miscellaneous 6%


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Inoculation

Cellulitis

Abscess formation

Resolution

NATURAL HISTORY NATURAL HISTORY


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Predictable spread

from one anatomic

space to the next.

Edema at leading edgeof infection.

Previously innoculated

areas progressingthrough stages of

cellulitis and abscess

formation

NATURAL HISTORY NATURAL HISTORY


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ANATOMIC SPACE INVOLVEMENTANATOMIC SPACE INVOLVEMENT

Primary maxillary spaces

CanineBuccal

Infratemporal

Primary mandibular spacesSubmental

Buccal

Submandibular

Sublingual


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Secondary fascial spaces

MassetericPterygomandibular

Superficial and deep temporal

Lateral pharyngealRetropharyngeal

Prevertebral


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ASSESSMENTASSESSMENT

Identify cause

Determine severity

Evaluate host defenses

General practitioner / specialist


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Identify cause

Caries

Periodontitis

Pericoronitis

Tooth tendernessTooth mobility

Vestibular swelling


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Diagnostic radiographs-Panorex

-CAT Scan with contrast


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Determine severity

Complete history

Chief complaint

Time of onset

Change in symptoms

Elicit symptoms

Clinical signsDolor, tumor, calor, rubor, and functiolaesa


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Determine severity

Vital signsLocal involvement

Extent and rate of

progressionInvolved spaces

Trismus

AirwayVital structures


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Characteristic Cellulitis Abscess

Duration Acute Chronic

Pain Severe and generalized Localized

Size Large Small

Localization Diffuse borders Well circumscribed

Palpation Doughy to indurated FluctuantPresence of pus No Yes

Degree of seriousness Greater Less

Bacteria Aerobic Anaerobic


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Systemic involvementMalaise

Pyrexia

Other signs


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Compromised Host Defenses

Uncontrolled metabolic diseases

Uremia

Alcoholism

Malnutrition

Severe diabetes Suppressing diseases

Leukemia

Lymphoma

Malignant tumors

Suppressing drugs

Chemotherapeutic agents

Immunosuppressives


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Criteria for Referral to a Specialist Rapidly progressing infection

Difficulty breathing

Difficulty swallowing Fascial space involvement

Elevated temperature (greater than 101F)

Severe trismus (less than 10 mm) Toxic appearance

Compromised host defenses


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MANAGEMENTMANAGEMENT

Obtain drainage

Maintain drainage

Remove the cause Provide supportive

care


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Obtain drainage Pus must be drained

Adequate access Blunt dissection

All loculations entered

Intra - oral and / or

extra - oral


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Obtain drainage


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Maintain drainageAll involved spaces

Dependent drainage

Insertion of drain

Maintenance of

patency

Slow advancement


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Remove the cause

Pulp extirpation

Tooth extractionScaling

Necrotic tissue / debris


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Provide supportive care

General

Fluids

Rest

Nutrition

Warmth

Antibiotic therapy


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Principles of antibiotic use

Necessity

Empirical therapy

Narrow spectrum Low toxicity

Bacteriocidal Administer properly

Cost


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Antibiotics Good choices

Penicillin or amoxicillin ( + / - metronidazole )

Cephalexin, clindamycin, co-trimoxazole,

tetracycline, erythromycin

Poor choicesMetronidazole alone

Amoxicillin / clavulanic acid


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PREVENTIONPREVENTION

Local processes

Immunocompromised patient General preventive care

Timely intervention Good surgical technique

Distant sites

Infective endocarditis

Arteriovenous fistulae

Prosthetic valves and joints

Odontogenic Infections 1

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