● Stages of abscesses:

○ Inoculation {Edema}

◆ 1 - 3 days

◆ Streptococci colonize

◆ Soft, mild tender, dough swelling

◆ Aerobic

○ Cellulitis {Most severe}

◆ 3 - 5 days

◆ Hard, red, acute tender, indurated swelling

◆ Aerobic & anaerobic

◆ Considered the “intense inflammatory stage”

○ Abscess

◆ 5 - 7 days

◆ Liquified abscess, central fluctuance

◆ Anaerobic

◆ Pus present

○ Resolution

◆ 7 - xx days

◆ Spontaneous fistula

◆ Healing & repair

● Infection spreads along areas of LEAST resistance.

○ Location of infection arising from specific tooth det by:

◆ Thickness of bone overlying apex

◆ Site of perforation of bone to muscle attachments

◆ If tooth apex lower than muscle attachment =

vestibular abscess results

◆ Apex higher than muscle attachment = adjacent

fascial space involved

● Primary Tx of pulpal infections is Endo or Extract

 ○ NOT antibiotics—only arrest, do not cure infection

● Mandibular infections:
○ Incisors, canines, premolars:

◆ Erode facially

◆ Vestibular swelling

○ Molars:

◆ Erode lingually

◆ If apices below mylohyoid ridge = pus enters

submandibular space = airway risk!

● Maxillary Infections:
○ Most erode through thin labial plate

● Principles of Odontogenic Infections:

○ 1—det. Severity of infection

◆ Complete med Hx

◆ Time of onset of infection

◆ Course of infection

◆ Rapidity of progress

◆ Patients symptoms

◆ Tx inquiry

◆ Physical examination

◆ Vitals—temp, BP, Pulse, RR

◆ EIE

◆ Radiograph exam

○ 2—evaluate state of patients host defense

mechanisms
◆ Medical conditions—uncontrolled metabolic

diseases, immune compromised diseases /

therapies
◆ Drugs currently prescribed

○ 3—det. Whether patient should be treated by

 ○

general dentist or OMFS

◆ 3 criteria for immediate referral:

◆ Rapidly progressing

◆ Dyspnea—difficult breathing

◆ Dysphagia

○ 4—treat infection surgically

◆ Primary goal—remove cause of infection

◆ Secondary goal—provide drainage

○ 5—support patient medically

○ 6—choose & prescribe appropriate antibiotic
◆ 3 factors:

◆ Seriousness of infection

◆ Whether adequate surgical tx can be achieved

◆ State of pt host defenses

○ 7—administer antibiotic properly

◆ Proper dose—Take UNTIL GONE

◆ proper time interval

◆ Proper route—PO

○ 8—evaluate patient frequently

◆ Follow up 2 - 3 days after

○ 9—prophylaxis of wound infection

● NEVER give steroids for infections!!!

● Drugs that compromise host defenses:

○ Cyclosporine

○ Corticosteroids**

◆ Do NOT give for infections!!

○ Tacrolimus

○ Azathioprine

● Contraindications for treating with antibiotics:

○ Extraction
 ○ Localized alveolar osteitis—i.e. dry sockets
○ Localized dento-alveolar abscess
○ Mild pericoronitis with minor edema and minor pain
○ Patient demands them
○ Toothache
○ PA abscess

● The Primary principle of management of odontogenic

infections is:
○ To perform surgical drainage

○ To remove the cause of the infection

● All infections do NOT require antibiotics.

● Use Narrowest-spectrum antibiotic!

○ Use bactericidal antibiotics if possible.

◆ Especially in immunocompromised patients

○ Be aware of cost—use generic

● Narrow spectrum Antibiotics given PO effective for

SIMPLE odontogenic infections:
○ Penicillin—narrow

○ Amoxicillin—narrow

○ Clindamycin—narrow

○ Metronidazole—narrow **Major contraindication for pts who are

alcoholics, as well as hypertensive & A-fib.**

● Broad spectrum Antibiotics given PO effective for

Complex odontogenic infections:
○ Amoxicillin w/ Clavulanic acid—for sinus infections

○ Azithromycin

○ Moxifoxacin

○ Tetracycline
● Simple Vs. Complex Odontogenic Infections:
○ Simple:

◆ Swelling limited to alveolar process & vestibular

space
◆ 1st attempt at Tx

◆ Pt NOT immunocompromised

○ Complex:

◆ Swelling extending beyond vestibular space

◆ Failed prior Tx

◆ Pt is immunocompromised

● Post-Op evaluation:
○ 2 - 3 days after

○ Reasons for tx failure:

◆ #1—cause of not improving = improper surgical

intervention!
◆ Wrong tooth

◆ Inadequate I&D

◆ #2—depressed host defense

◆ i.e. immunocompromised

◆ #3—foreign body

◆ i.e. implant

◆ #4—antibiotic related

● Principles of prophylaxis of wound infection:

○ 1—procedure should have significant risk of

infection
◆ 4 factors for determining:

◆ Size of bacterial inoculum

◆ Length of surgical procedure

◆ Presence of foreign body—i.e. implant

◆ Depressed host defenses

◆ Pt receiving chemo therapy

 ◆ Dialysis pt
◆ Diabetes mellitus

○ 2—choose correct antibiotic

◆ Narrow spectrum

◆ Effective against bacteria present

◆ Least toxic

◆ Bactericidal

○ 3—antibiotic plasma level must be high

◆ Dose should be 2x that of normal

○ 4—time antibiotic administration correctly

◆ Must be given 2 hours or less before surgery begins

◆ PO—1 hour

◆ IV—shorter is possible

○ 5—use shortest antibiotic exposure that is

effective