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Odontogenic Infections

Dr. Rehab ElsharkawyLecturer of Oral and Maxillofacial Surgery

CAIRO UNIVERSITY

Infection: It is invasion of the bodyby pathogenic microorganisms.

Inflammation: is the response of thebody tissues to harmful stimuli, it ischaracterized by pain, swelling, heatand redness. It is a protective attemptby the body to remove the injuriousstimuli and to initiate the healingprocess for the tissue.

InflammationIt is characterized by five cardinal signs:Redness, Hotness, swelling, Pain, and loss offunction.Redness and heat: are due to increasedblood flow at body core temperature to theinflamed site.Swelling is caused by accumulation of fluid.Pain is due to release of chemicals thatstimulate nerve endings.Loss of function has multiple causes.

Pain from odontogenic infections is themost common problem seen by thedentists.Odontogenic infections arise from theteeth and have a characteristic flora.Range from low-grade, well localized tosevere, life-threatening.When addressed early, management iseasy and complications are rare.When allowed to progress can lead toserious morbidity or death in a short time.

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ODONTOGENIC PeriapicalPeridontal

NON- ODONTOGENIC Post Injecion(dentally related) Post Surgical

Post Trauma

NON- ODONTOGENIC SalivarySinusViral/Fungal

Head and Neck infection Odontogenic Infections Outline

1. Typical Microbiology of odontogenic infections.2. Natural history of progression of odontogenic

infections.3. Principles of therapy of odontogenic infections.4. Indications for referral to OMS.5. Principles of prevention of infection.

Wound infection.Metastatic infection.

1. Typical Microbiology of odontogenic infections.

Bacteria that cause odontogenic infections are part of thenormal flora (in plaque, on mucosal surfaces, in gingivalsulcus).These bacteria are primarily

Aerobic gram +ve cocci,Anaerobic gram +ve cocci,Anaerobic gram –ve rods.

These bacteria usually cause caries, gingivitis andperiodontitis.When they gain access to deeper tissues (Perio. pocket ornecrotic pulp) they cause OI.

Microbiology of odontogenicinfections

Almost all OIs are caused bymultiple bacteria, 5-8 differentspecies can be identified.

1. Predominant aerobic bac in OIs are the Streptococcusmilleri group.

2. Predominant anaerobic:a)Gram +ve cocci Anaerobic streptococci and

peptostreptococcus.b)Gram –ve rods Prevotella and Fusobacterium.

Infections caused by Aerobic bac. alone

6%

Infections caused by Anaerobic bac alone

44%

Infections caused by MIXED bac.

50%

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Pathobiology of Odontogenic Infections

1.Aerobic S. milleri group enters the deeper tissues(inoculation).

2.They synthesize hyaluronidase to allow spreadingthrough the CT (cellulitis).

3. Hypoxia and lowered pH creat favorableenvironment for the anaerobes.

4.Anaerobes follow, grow, predominate andsynthesize collagenase leading to liqufactionnecrosis (tissue destruction then pus Formation)(Abscess).

Pathobiology of Odontogenic Infections

Odontogenic infections pass through 4stages:

1. Inoculation Edema.2.Cellulitis stage (Aerobic bacteria).3.Abscess stage (Anaerobic bacteria).4.Resolution stage (After drianage).

Characteristic Edema Cellulitis Abscess

Duration 0-3days 1-5 days 4-10 daysPain mild Severe and

generalized Less severe and Localized

borderds diffuse diffuse circumscribed

Size variable Large Smallercolor Normal Erythematous Shiny centerconsistancy Soft doughy Hard indurated Fluctuant

Progression Increasing Increasing DecreasingPresence of pus

Absent absent Present

Bacteria Aerobic Mixed AnaerobicSeriousness Mild Sever Moderate

Factors that influence the spread of Odontogenic infections

1. Number of organisms.2. Virulence of the organisms.3. Status of patient’s immune system.

Severity of infection= Number X Virulence/ Host resistance.

4. Thickness of the cortical bone.5. Relationship of the tooth in the alveolus6. Position of muscle attachment in relation to

root tip.

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2. Natural history of progression of odontogenic infections.

Major origins to odontogenic infections:1. Periapical due to pulp necrosis.2. Periodontal due to deep pocket.

Once tissues become inoculated with bacteria, activeinfection starts and it spreads equally in all directionsbut along the lines of least resisance.

Extraction or endo treatment. (removal of the cause).Antibiotic alone is not enough.

Factors that influence the spread of Odontogenic infections

1. Number of organisms.2. Virulence of the organisms.3. Status of patient’s immune system.

Severity of infection= Number X Virulence/ Host resistance.

4. Thickness of the cortical bone.5. Relationship of the tooth in the alveolus6. Position of muscle attachment in relation to

root tip.

Acute Dento-Alveolar AbscessRadiographic picture:1. In the very early stage it may have negative

radiographic picture.2. Later there will be widening of the

periodontal membrane space andinterruption of the lamina dura.

3. Then localized ill-definedarea of radiolucency maybe seen in the periapical region.

Spread of infection

It may spread by:1.Continuity through tissue spaces and

planes.2. Lymphatic system.3. Hematogenous spread.

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Natural history of progression of odontogenic infections.

Major factors determining the the location ofspread of infection from a specific tooth:1. Thickness of the cortical bone.2. Relationship of the tooth in the alveolus.

(Bone overlying the apex of the tooth).3. The relationship of the site of perforation of

bone to position of muscle attachments to thejaws.

Thickness of the bone overlying the apex of the tooth.

According to thethickness of the boneoverlying the apex theinfection may spreadinto the buccal sulcularspace or palatal space.

Maxillary vestibular spaceBetween the oral mucosa and the muscle which lieabove the apices to the teeth.Anteriorly: Levator Anguli Oris, Nasalis, &Depressor septi confine infection into the vestibuleor direct it into the soft tissues of the upper lip.Posteriorly: confined into vestibule by thebuccinator muscle.Infection originates anteriorly from maxillaryincisors and posteriorly from Maxillary posteriorteeth.

Maxillary vestibular spaceSigns & Symptoms:

Pain, Swelling of the upper lip, Swelling andobliteration of labial sulcus or buccal vestibule.

Spread: Anterior it may spread Into the upper lip.Superiorly into the infraorbital space.Posterior Superior into infratemporalspace.

Incision line as seen in figure.

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Palatal space

It is not a true fascial space, infection from maxillaryteeth erode through palatal bone and get entrappedbeneath thick palatal periosteum.It is caused most commonly from the upper lateralincisor or palatal root of post tooth.Clinically it causes pain, Fluculation and Swellingopposite to the affected tooth.Incision line as seen in figure.

Spaces of the Body of the MandibleIt is the Potential space between the mandible andits periosteum.It extends around the entire mandible confinedbilaterally by the anterior border of masseter andpterygoid musclesInfection of this space may arise from any tooth inwhich the apical infection perforates bone and thenelevates the periosteum rather than perforates it.It causes firm painful swelling adjacent to themandible

Mandibular Vestibular Space

It is the space present between the oralmucosa & the buccinator muscle laterally &the mentalis anterorily.Infection of this space may originate fromany lower tooth, most often Incisors,Premolars and 1st molar.It caused swelling and Obliteration of thebuccal vestibuleIt may spread posteriorly to the buccalspace or anteriorly to mentalis space

The relationship of the site of perforation ofbone to muscle attachments to the jaws.

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ANATOMIC SPACE INVOLVEMENT

The primary spaces: are immediately adjacent to thetooth-bearing portions of the maxilla and mandible.Primary maxillary spaces

1. Canine2. BuccalPrimary mandibular spaces

Buccal3. Submental4. Submandibular5. Sublingual

1. Infraorbital space infectionThe Infraorbital space is a thin potential spacebetween the levator anguli oris and the levator labiisuperioris muscles.The canine space becomes involved primarily as theresult of infections from the maxillary canine tooth.It is s evidenced by anterior cheek swelling withoblitration of the nasolabial fold.Spontaneous drainage commonly occurs inferior tothe medial canthus of the eye.Potentially it may spread to the orbital, periorbital,buccal spaces, and cavernous sinus. (infraorbitalvein then ophthalmic vein through SOF into the CS).

2. Buccal space infectionIt is bounded by the overlying skin of the face onthe lateral aspect and the buccinator muscle on themedial aspect .May become infected from either the posteriormaxillary or mandibular teeth.The buccal space becomes involved from the teethwhen infection erodes through the bone superior tothe attachment of the buccinator muscle.Involvement of the buccal space usually results inswelling below the zygomatic arch and above theinferior border of the mandible.

Infection from this space may spread to Submasseteric,Pterygomandibular, Lateral pharyngeal, Superficial & Deep Temporal spaces.

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SummaryInfection from most maxillary teeth erode through thefacial cortical plate.They may erode below the attachment of muscles tothe maxilla leading to maxillary vestibular abscess.The maxillary molars infection may erode the bonesuperior to the insertion of the buccinator muscleleading to buccal space infection.The long maxillary canine root infection may erode thebone superior to the insertion of the levator anguli orismuscle leading to infraorbital (canine) space infection.Occasionally, a palatal abscess occurs from severelyinclined lateral incisor or palatal root of premolar ormolar.

Maxillary sinus involvement.Infection from the maxillary posterior teeth mayerode through the floor of the maxillary sinus.20 % of maxillary sinusitis are odontogenic.It may spread superiorly

through the ethmoid sinusor the orbital floor to causeorbital or periorbital infection(redness and swelling ofthe eyelids).It is very serious infection.

Infratemporal space infectionIt lies posterior to the maxilla. It is bounded mediallyby the lateral plate of the pterygoid process of thesphenoid bone and superiorly by the base of the skull.This space contains branches of the internal maxillaryartery and the pterygoid venous plexus.The infratemporal space is rarely infected, but when itis, the cause is usually an infection of the maxillarythird molar.Infratemporal space is the origin of posterior route bywhich infection can spread to the CS.

3. The submental spaceIt lies between the anterior bellies of thedigastric muscle and between the mylohyoidmuscle and the overlying skin.It is primarily infected by mandibular incisors,which are sufficiently long to allow theinfection to erode through the labial boneapical to the attachment of the mentalismuscle.The infection is thus allowed to proceedunder the inferior border of the mandible andinvolve the submental space.

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4. The submandibular spaceIt is bounded laterally by the medial surfaceof the mandible. It lies between the anteriorand posterior bellies of the digastric muscleand between the mylohyoid muscle and theoverlying skin.It is involved primarily by lingual perforationof infection from the mandibular molars.If the infection erodes through the medialaspect of the mandible inferior to themylohyoid line, the sub-mandibular space willbe involved.

4. The submandibular spaceThe posterior boundary of thesubmandibular space communicates withthe secondary spaces of the jaw posteriorly.Infection of the submandibular space causesswelling that begins at the inferior border ofthe mandible and extends medially to thedigastric muscle and posteriorly to the hyoidbone.The mandibular second and third molars arethe most commonly involved with the sub-mandibular space primarily.

5. The sublingual space

It’s lateral boundery is the medial surface of themandible, it lies between the oral mucosa of thefloor of the mouth and the mylohyoid muscle.It is involved primarily by lingual perforation ofinfection from the mandibular molars, andpremolars.If the infection erodes through the medial aspect ofthe mandible above attachment of the mylohyoidmuscle, the infection will be in the sublingualspace and is most com-monly seen with premolarsand the first molar.

5. The sublingual spaceClinically little or no extraoral swelling isproduced by an infection of the sublingualspace.Much intraoral swelling is seen in thefloor of the mouth on the infected sidethen bilaterally, and the tongue becomeselevated.Its posterior border is open, and thereforeit freely communicates with thesubmandibular space.

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SummaryIn the mandible, infections of the incisors, canines,and premolars usually erode through the facial bonesuperior to the attachment of the muscles of the lowerlip, resulting in vestibular abscesses.First molar infection may drain buccally (vestibularabscess or buccal space) or lingually (sublingual orsubmandibular space).Second molar infection may drain buccally but morecommonly lingually.Third molar infections almost always drain lingually(submandibular space).

ANATOMIC SPACE INVOLVEMENTThe secondary spaces: If proper treatment is not received forinfections of the primary spaces, the infections may extendposteriorly to involve these spaces. When they are involved,the infections frequently become more severe, cause greatercomplications and greater morbidity, and are more difficult totreat.A. The masticator space1. The masseteric space.2. The pterygomandibular space.3. The superficial temporal space.4. The deep temporal space.B. Cervical Fascial Spaces:1. Lateral pharyngeal space.2. Retropharyngeal space.

1. The masseteric spaceIt lies between the lateral aspect of the ramus ofthe mandible and the masseter muscle.It is involved as the result of spread of infectionfrom the buccal space or from soft tissue infectionaround the mandibular third molar.When the masseteric space is involved, the areaoverlying the angle of the jaw and ramus becomesswollen.Because of the involvement of the massetermuscle, the patient will also have trismus causedby inflammation of the masseter muscle.

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2. The pterygomandibularspace

It lies between the mandible and the medialpterygoid muscle.This is the space into which local anesthetic solutionis injected in IANB. So infection of this space maybe caused by needle tract infection from amandibular block.Infections of this space spread primarily from thesublingual and submandibular spaces.It causes little or no facial swelling; but it causessignificant trismus. Therefore trismus withoutswelling is a valuable diagnostic clue for ptery-gomandibular space infection.

3. The temporal spaceIt is posterior and superior to the masseteric andpterygomandibular spaces.It is divided into two portions by the temporalismuscle:

1)Superficial portion that extends to the temporal fascia2)Deep portion that is continuous with the infratemporal space.

They are rarely involved and usually only in severeinfections.When these spaces are involved, the swelling thatoccurs is evident in the temporal area, superior tothe zygomatic arch and posterior to the lateralorbital rim.

The lateral pharyngeal spaceIt extends from the base of the skull to the hyoid boneinferiorly. It is medial to the medial pterygoid muscle andlateral to the superior pharyngeal constrictor on the medialside.It is bounded anteriorly by the pterygomandibular raphe andextends posteromedially to the prevertebral fascia.The clinical findings are lateral swelling of the neck, andintraoraly swelling of the lateral pharyngeal wall, toward themidline.It causes difficulty in swallowing, high temperature andpatient becomes quite sick.

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The lateral pharyngeal space

When the lateral pharyngeal space is involved, theodontogenic infection is severe and may beprogressing at a rapid rate.Direct effect of the infection on the contents of thespace, thrombosis of the internal jugular vein,erosion of the carotid artery or its branches, andinterference with cranial nerves IX through XII.A third serious complication arises if the infectionprogresses from the lateral pharyngeal space tothe retropharyngeal space.

The retropharyngeal spaceIt lies behind the posterior aspect of the pharynx andbounded posteriorly by the alar layer of prevertebral fascia.It begins at the base of the skull and extends inferiorly tothe level of vertebra C7 or Tl.It must be evaluated with lateral radiographs of the neck todetermine if the space is enlarged and therebycompromising the airway.It has few contents, and therefore infection in this spacedoes not carry some of the grave problems that involvementof the lateral pharyngeal space does.How-ever, when the retropharyngeal space becomesinvolved, the major concern is that the infection can extendinferiorly to the mediastinum leading to seriouscomplications.

4. Principles of therapy1. Determine the severity of the infection.

a. Complete history.b. Physical examination.

2. Evaluate host defense capabilities.a. Medical condition that compromise host defence.b. Drugs that compromise host defence.

3. Treat the infection surgically.4. Support the patient Medically.5. Prescribe the appropriate Antibiotic.6. Evaluate the patient frequently.7. Referral to OMS?

Factors that govern disease severityHost resistance factors: (natural and acquired).Microbial Factors:

1. Pathogenicity: ability of an organism to cause disease.2. Virulence: degree of pathogenicity.a. Adherece: eg. Pilli that help adhesion to host cells to start the

disease.b. Invasiveness: Ability to invade tissue, multiply and spread

rapidly eg. Polysacharide capsule that protects bac fromphagocytosis.

c. Toxin production: Products that have direct harmful effect oncells (Exotoxins and endotoxins).

d. Extracellular enzymes. Substanced produced to help spread,invasion, establishment of MO into the tissues (Collagenase,hyaluronidase, Ig A protease, Fibrinolysin).

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Severity of the InfectionA. Complete History:1. Chief Complaint:2.Duration of the infection:

Onset of infectionCourse of infectionRapidty of progression.

3. Symptoms:Local: pain, swelling, hotness, redness, loss of function

(trismus, dysphagia, dyspnea). General: Fever, Malaise.

4. Any previous treatment (proffesional or self).5. Past Medical History

Know Your Enemy

Severity of the the InfectionB. Physical Examination1. Vital Signs:

Temperature > 38 C FeverPulse rate > 90 beat/min (tachycardia)Blood Pressure: increased due to pain and anexiety.

Decreased due to septic shock.Increased Respiratory Rate> 20 breaths/min. (tachypnea)

2.Cardinal signs of infection. (Loss of function)3. Patients general appearance (toxic)4.Palpation of areas of swelling.

(Tender, hot, Fleshy,indurated, fluctuant)5. LN involvement.

B. Physical Examination

6. Intraoral examination:Severley Carious teethPeriodontal abscessPericoronitisTooth tendernessTooth mobilityVestibular swellingDraining sinus tract.

Clinical features of odontogenic infectionsIntraoral

1. Pain on percussion.2. Pain exacerbated by hot or

cold.3. Tooth feels extruded from

the socket.4. Intraoral swelling.5. Erythematous gingiva.6. Carious tooth.7. Intraoral seepage of

purulent material.

Extra oral

Local: 1. Hotness, 2. redness, 3. pain, 4. swelling, 5. loss of function. (Trismus,Dysphagia,Respiratory difficulty)

Systemic:1. Fever,2. Malaise3. lymphadenopathy

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Severity of the the InfectionC. Radiographic Examination:Why?1. To establish the presence of infection in deeper

spaces.2. To find the cause of the infection.Which?1. Periapical radiograph.2. Panorex3. CT scans4. MRI5. Plain Films

Periapical radiograph

Acute inflammation around the apex of a tooth:A. Where there is little or no previous chronic

inflammation: loss of the lamina duraB. Where the periapical periodontal ligament was

previously widened or a granuloma was present:poorly defined radiolucency denoting localised bonedestruction.

C. Chronic cases: widening of the periodontal ligament space with preservation of the radio-opaque lamina dura

Severity of the the InfectionD.Blood investigations eg, CBC,

differential WBC count, sedimentationrate, and blood cultures, may beordered if clinically indicated.

EVALUATE HOST DEFENSE CAPABILITIES.

Know your army

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Evaluate host defense capabilities

a. Medical conditions that compromise host defense:1. Uncontrolled metabolic diseases

Alcoholism Malnutrition (Decrease chemotaxis, Uncontroled Diabetes phagocytosis and bacterial killing) Renal disease with uremia.

2. Immune system suppressing diseasesLeukemias (Decrease white cell functionLymphomas and Antibodies synthesis)Malignant TumorsAIDS (T lymphocytes then B lymphocytes in late stage)

Evaluate host defense capabilities

b. Pharmaceuticals that compromise host defense:Chemotherapeutic agentsImmuno suppressive therapy:

• for organ transplant or autoimmune disease,• decrease T and B lymphoctes• and decrease IG production.• eg. Cyclosporin, Azathioprine and

Corticosteroids.

TREAT INFECTION SURGICALLY

Goals of Surgical Treatment

1. Remove the cause of infection:RCTExtraction

2.Provide surgical drainage ofaccumulated pus and bacteria.

3. Culture and sensitivity test.

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Why surgical drainage of accumulated pus?

1. Removes Bacteria & PusDecrease # of bacteria – decreases load on host resistanceDecreased pus (prevent inactivation of antibiotics).Hastens resolution (removal of pus, usually takes the body a long time)

2. Decompresses the cavity so decreases the hydrostaticpressure, which in turn will:Aborts spread into deeper spacesDecrease painImprove local blood supplyImproves the delivery of host defenses to the area.

3. Alters the tissue oxygen tension from anaerobic to aerobicDestroys the environment necessary for the growth of anaerobicorganisms.

When Culture and Sensitivity Testing?

1. Rapidly spreading infection.2. Post-op infection.3. Non-responsive infection after more than 48 hours.4. Recurrent infection.5. Compromised host defenses.6. Osteomyelitis.7. Suspected actinomycosis.

I & D Surgical Drains

A surgical drain is a tube used to remove pus,blood or other fluids from a wound and it keepsthe incision line open for drainge.Types of drains:

A.Passive drains, depend on gravity to remove fluidfrom a wound area. Made of a soft, flat, flexiblelatex. eg. Penrose drain.

B.Active drains use a negative-pressure system,created by a compressible reservoir. It allowsreliable measurement and assessment of thecharacter of drainage. Eg. Jackson-Pratt Drain.

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I and D technique1. Select the proper site2. Disinfect the surface3. Obtain the proper anesthesia4. Incise and penetrate5. Placement of the drain

Use small incisions and blunt dissection without directexposure and visualization of the entire infected anatomicspace.To avoid crushing of a vital structure within the beaks of ahemostat during blunt dissection, it is crucial to insert theinstrument closed, then open it at the depth of penetration,and then withdraw the instrument in the open position.Dissect a pathway for the drain that includes the locationswhere pus is most likely to be found.

Vestibular abscessI directly over the site of maximum swelling

Avoid area of frenum and mental nerve

A vertical incisionover thepterygomandibularraphe can be usedto drain thepterygomandibularspace as well as thelateral pharyngealspace and deeptemporal space.

Extra-oral Incision and Drainage

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Support the patient Medically.1.Fluids for hydrational support.2.Nutritional support (high caloric diet).3.Control the fever.4.Relief pain.5.Adjust insulin dose with the increased

requirments.6.Optimizing control of hypertension , cardiac

dysrethmia, coronary heart diseases.7.Adjust INR in patients under anticoagulant

therapy.

5. PRESCRIBE THE APPROPRIATE ANTIBIOTIC.

Principles of Antibiotic Therapy1.Determine the need for antibiotic

therapy.2.Use empirical therapy routinely.3.Use narrowest spectrum drug.4.Use antibiotic with the lowest toxicity

and side effects.5.Use bactericidal antibiotic if possible.6.Be aware of the Cost. $$$

1. DETERMINE THE NEED FOR ANTIBIOTIC THERAPY

1.Seriousness of the infection.2.Whether adequate surgical treatment can be achieved.3.State of the patient’s defeses.

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Indications for antibiotic therapy

1. Swelling extending beyond thealveolar process.

2. Cellulitis.3. Lymphadenopathy4. Temperature higher than 38 C.5. Trismus6. Compromised host defenses7. Severe pericoronitis.8. Osteomyelitis.

Situations in which the use of Antibiotic is not necessary

Toothache.Periapical abscess.Dry socket (premature fibrinolysis with loss ofblood clot) (self limiting).Multiple dental extractions (In a noncompromised patient).Mild pericoronitis (Irrigation).Drained alveolar abscess.

2. USE EMPIRICAL THERAPY ROUTINELY.

Microbiology of odontogenic infections

Almost all OIs are caused by multiple bacteria, 5-8 differentspecies can be identified.

1. Predominant aerobic bac in OIs are the Streptococcusmilleri group.

2. Predominant anaerobic:a)Gram +ve cocci Anaerobic streptococci and

peptostreptococcus.b)Gram –ve rods Prevotella and Fusobacterium.

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3. Use narrowest spectrum drug.Why?

Because Broad-Spectrum drugs:1. Upset the normal host microflora populations.2. Increase the chance of bacterial resistance.

Narrow-SpectrumPenicillin.Clindamycin.Metronidazole.

Broad-SpectrumAmoxicillin.AugmentinAzithromycin

4. USE ANTIBIOTIC WITH THE LOWEST TOXICITY AND SIDE

EFFECTS.

Penicillin: Allergy (hives, itching, wheezing).Clindamycin, amoxicillin and ampicillin:Pseudomembranous colitis (due toovergrowth of clostridium difficile andproduction of toxins that injur the gut wall(watery diarrhea).Metronidazole: Disulfiram effect (Anti-abusetype reaction)Azithromycin: low toxicity or side effectsand no drug interactions.Tetracyclines: Photosensitivity, Toothdiscoloration due to chelation to Ca.

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5. USE BACTERICIDAL ANTIBIOTIC IF POSSIBLE.

Antibiotic drugs either kill bacteria (bactericidal) orinterfere with their reproduction, allowing the body’simmune system to deal with the infection(bacteriostatic).

Bactericidal:PCNCephalosporinsVancomycinAminoglycosidesMetronidazole

BacteriostaticErythromycinTetracyclinesChloramphenicolsulfonamides

Either:Clindamycin

PenicillinIt is a group of antibiotics derived fromPenicillum fungi.It works by inhibiting the formation of thebacterial cell wall.Pen G, Pen V, Procaine pen GAminopenicillins: Ampicillin, Amoxicillin.Penicillinase resistant: Cloxacillin,dicloxicillin, OxacillinB Lactamase Inhibators:Clavulanic acid: Amoxicillin/clavulanic acid(Augmentin,Hibiotic)

PenicillinAdvantages:1. Bactericidal.2. Excellent distribution.3. Low toxicity.4. Low cost.Side effects:Allergy: Maculopapular rash and bronchospasm

----------- Stevens-Johnson syndrome----------angioedema and anaphylaxis

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MacrolidesMechanism of action: Inhibition of bacterial proteinbiosynthesis.Active against aerobic and anaerobic gram-positive cocci.Examples:

- Erythromycin: GI disturbances-Azithromycin: Broader spectrum, improved tissue

penetration, prolonged tissue levels(1x2), less druginteraction, less GI upset. (Zithromax)Bacteriostatic.Used in mild infections or penicillin allergy.Drug interaction (inhibits hepatic metabolism):

Theophyllin (nausea and vomiting), warfarin ( increasesINR), Carbamazepine (drowziness), Cyclosporine (elevatedserum levels)

Metronidazole (Flagyl)Disrupting the DNA structure, thus inhibiting Nucleic acidsynthesis.Bactericidal.Rapidly and completely absorped when given orally.Well distributed into bone, saliva, mucosa, brain abscess.Excellent anaerobic spectrum including BacteroidesLittle activity with other oral flora.Excellent combination with PCNDrug interaction:Alcohol: (nausea, vomiting, Cramps, headache,tachycardia, shortness of breath) (Anti-abuse type reaction,Disulfiram- like effect).

Clindamycin

Inhibits Protein SynthesisBacteriostatic in low dose, Cidal at high doseCovers most oral flora.Superior action against Anaerobes esp. Bacteroides species (proevotella and porphyromonas)Used in Pencillin allergy patients.

Administer the antibiotic properly

1.Proper route of administration.2.Proper dose.3.Proper time interval.4.Adequate period of administration.5.Consider combination therapy

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Evaluate the patient frequently

1.Re-evaluate the patient frequently2.Response to treatment

TemperatureSwellingPainTrismusGeneral condition.

3. Check site of I and D.4.Need for additional imaging?5. Toxicity reactions.6. Superinfections (candidiasis).

Reasons for Treatment Failure

1. Inadequate Surgery.2. Depressed host defenses (immunocompromising

disease or dimished physiologic reserves).3. Foreign body (implants).4. Antibiotic problems

Patient noncomplianceDrug not reaching the siteDrug dose too lowWrong antibiotic

Indications for Referral to OMS1. Rapidly progressing infection2. Fascial space involvement3. Difficulty in breathing4. Difficulty in swallowing5. Toxic appearance6. Elevated Temperature >101 F7. Dehydration8. Severe trismus9. Failed prior treatment.10.Compromised host defenses11.Need for general anesthesia.

Complications of Odontogenicinfections

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Maxillary sinus infectionInfection of maxillary teeth may pread to themaxillary sinus through erosion of the floor.Then it may spread superiorly through theethmoid sinus to cause periorbital infection.Infection may reach the inferior ophthalmicV.They follow the common ophthalmic veinthrough superior orbital fissure directly intoCS.Common ophthalmic V. is the origin ofanterior route by which infection can spreadto the CS.

Buccal space infectionMay spread to: infraorbital, periorbital superficialtemporal, and infratemporal, spaces .Infratemporal space: contains pterygoid venousplexusEmissary veins from the plexus connect with theintracranial dural sinuses.

Veins of the face and orbit are valveless, so bloodborne infections may pass superiorly along theircourse.Infratemporal space is the origin of posterior route bywhich infection can spread to the CS.

The cavernous sinus

Is a large collection of veinscreating a cavity bordered by thetemporal and the sphenoidbones, lateral to the sella turcica.The internal carotid artery, andcranial nerve III, IV, V, and VI allpass through it.The cavernous sinuses receivevenous blood from the facialveins (via the superior andinferior ophthalmic veins)

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Cavernous sinus thrombosis (CST)It is the formation of a blood clot within the CS.It can spread to contralateral cavernous sinus within 24–48hr.It is life-threatening and requires immediate treatment.Clinical picture:

1. Headache, fever, tachycardia, Orbital pain and visualdisturbances.

2. Unilateral periorbital and conjunctival edema, andproptosis ( ophthalmic veins).

3. Opthalmoplegia (Paralysis of the cranial nerves III, IV, VI)4. Ptosis (cranial nerve III and sympathetic ).5. Sensory deficits of areas supplied by V1 and V2.6. Confusion, drowsiness, and coma

Perimandibular spacesInfection can spread easily fromsubmandibular space to the submentalspace to the contralateral submandibularspace. It can also spread from behind thefree posterior margin of the mylohyoidmuscle to involve the sublingual spacealso.This rapidly spreading cellulitis :

1. can obstruct the airway.2. can spread to the deep fascial spacesof the neck.

Ludwig’s Angina

Def: Ludwig’s angina is anacute cellular infection and ischaracterized by bilateralinvolvement of the submandibularand sublingual spaces, as well asthe submental space.

Etiology: The most frequentcause of the disease is periapicalor periodontal infection ofmandibular teeth, especially ofthose whose apices are foundbeneath the mylohyoid muscle.

Clinical Presentation:1. Severe and painful indurated bilateral board-like hardness

of the submandibular region above the hyoid bone, withoutapparent fluctuation, because the pus is localized deep inthe tissues.

2. Painful indurated edema of the floor of the mouth.3. The tongue is elevated towards the palate and displaces

the epiglottis posteriorly, resulting in obstruction of theairway.

4. Difficulty in swallowing, speaking and breathing,5. Drooling of saliva.6. Trismus.7. Elevated temperature.8. Anxiety.

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Treatment1.Immediate establishment of airway security byearly intubation or tracheotomy.

2. Surgically with drainage of all the abscessedspaces.

3.Concurrent administration of antibiotics.The incisions:

Extraoral : bilateral, parallel, and medial to the inferiorborder of the mandible, at the premolar and molar regionIntraoral: parallel to the ducts of the submandibular glands.Exploration and communication of the spaces of infection.Rubber drains are placed in order to

keep the drainage sites open for at least 3 days.

Deep fascial spaces of the neck.

Submandibular , sublingual, or pterygomandibularinfections can spread to lateral pharyngeal space.(bet medial pterygoid and superior constrictor musclesand then bet the pterygomandibular raphe and theposterior pharyngeal space, it contains the carotidsheath).

1. Infection of the lateral pharyngeal space cancompress, deviates, or completely obstruct theairway.

2. It may invade vital structures such as major vessles(thrombosis of the IJV, erosion of the CA).

3. It may allow extension into retropharyngeal space orthe mediastinum.

Deep fascial spaces of the neck. Retropharyngeal Space:contains only loose CT andLNs so infection can spreadeasily to the other lateralpharyngeal space and canrupture the alar fascia to enterthe danger space.DS between alar fascia andprevertebral fascia from baseof the skull to diaphragm and itis continuous with themidiastinum.

MidiastinitisThe mediastinum is the spacebetween the lungs and itcontains the heart, the vagusand phrenic nerves, thetrachea, esophagus, aorta, infand sup vena cava.Infection can compress theheart and the lung, interferswith neurologic control of theheart rate and respiration,rupture into lung, or esophagus,or spread to abdominal cavity.

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Airway management

Patient airway should be monitores and secured whenever indicated.

Tracheotomy .CricothyroidotomyBlind nasal endotracheal intubation under general anaesthesia.Awake fibreoptic intubation.

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