Professional Documents
Culture Documents
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Head and Neck infection Odontogenic Infections Outline
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Pathobiology of Odontogenic Infections Pathobiology of Odontogenic Infections
1. Aerobic S. milleri group enters the deeper tissues
(inoculation). Odontogenic infections pass through 4
2. They synthesize hyaluronidase to allow spreading stages:
through the CT (cellulitis). 1. Inoculation Edema.
3. Hypoxia and lowered pH creat favorable
2. Cellulitis stage (Aerobic bacteria).
environment for the anaerobes.
3. Abscess stage (Anaerobic bacteria).
4. Anaerobes follow, grow, predominate and
synthesize collagenase leading to liqufaction 4. Resolution stage (After drianage).
necrosis (tissue destruction then pus Formation)
(Abscess).
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2. Natural history of progression of Factors that influence the spread
odontogenic infections. of Odontogenic infections
Major origins to odontogenic infections:
1. Number of organisms.
1. Periapical due to pulp necrosis.
2. Virulence of the organisms.
2. Periodontal due to deep pocket.
3. Status of patient’s immune system.
Once tissues become inoculated with bacteria, active Severity of infection= Number X Virulence
infection starts and it spreads equally in all directions
/ Host resistance.
but along the lines of least resisance.
4. Thickness of the cortical bone.
Extraction or endo treatment. (removal of the cause). 5. Relationship of the tooth in the alveolus
Antibiotic alone is not enough. 6. Position of muscle attachment in relation to
root tip.
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Natural history of progression of Thickness of the bone overlying the
odontogenic infections. apex of the tooth.
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Palatal space Spaces of the Body of the Mandible
¾ It is the Potential space between the mandible and
¾ It is not a true fascial space, infection from maxillary
teeth erode through palatal bone and get entrapped
its periosteum.
beneath thick palatal periosteum. ¾ It extends around the entire mandible confined
¾ It is caused most commonly from the upper lateral bilaterally by the anterior border of masseter and
incisor or palatal root of post tooth. pterygoid muscles
¾ Clinically it causes pain, Fluculation and Swelling ¾ Infection of this space may arise from any tooth in
opposite to the affected tooth.
which the apical infection perforates bone and then
¾ Incision line as seen in figure. elevates the periosteum rather than perforates it.
¾ It causes firm painful swelling adjacent to the
mandible
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ANATOMIC SPACE INVOLVEMENT 1. Infraorbital space infection
¾ The Infraorbital space is a thin potential space
The primary spaces: are immediately adjacent to the
between the levator anguli oris and the levator labii
tooth-bearing portions of the maxilla and mandible.
superioris muscles.
Primary maxillary spaces ¾ The canine space becomes involved primarily as the
1. Canine result of infections from the maxillary canine tooth.
2. Buccal ¾ It is s evidenced by anterior cheek swelling with
Primary mandibular spaces oblitration of the nasolabial fold.
Buccal ¾ Spontaneous drainage commonly occurs inferior to
3. Submental the medial canthus of the eye.
4. Submandibular ¾ Potentially it may spread to the orbital, periorbital,
5. Sublingual buccal spaces, and cavernous sinus. (infraorbital
vein then ophthalmic vein through SOF into the CS).
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Summary
¾Infection from most maxillary teeth erode through the
Maxillary sinus involvement.
facial cortical plate. Infection from the maxillary posterior teeth may
¾They may erode below the attachment of muscles to erode through the floor of the maxillary sinus.
the maxilla leading to maxillary vestibular abscess. 20 % of maxillary sinusitis are odontogenic.
¾The maxillary molars infection may erode the bone It may spread superiorly
superior to the insertion of the buccinator muscle through the ethmoid sinus
leading to buccal space infection.
or the orbital floor to cause
¾The long maxillary canine root infection may erode the
orbital or periorbital infection
bone superior to the insertion of the levator anguli oris
muscle leading to infraorbital (canine) space infection. (redness and swelling of
¾Occasionally, a palatal abscess occurs from severely the eyelids).
inclined lateral incisor or palatal root of premolar or It is very serious infection.
molar.
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4. The submandibular space 4. The submandibular space
¾ It is bounded laterally by the medial surface ¾ The posterior boundary of the
of the mandible. It lies between the anterior submandibular space communicates with
and posterior bellies of the digastric muscle the secondary spaces of the jaw posteriorly.
and between the mylohyoid muscle and the ¾ Infection of the submandibular space causes
overlying skin. swelling that begins at the inferior border of
¾ It is involved primarily by lingual perforation the mandible and extends medially to the
of infection from the mandibular molars. digastric muscle and posteriorly to the hyoid
¾ If the infection erodes through the medial bone.
aspect of the mandible inferior to the ¾ The mandibular second and third molars are
mylohyoid line, the sub-mandibular space will the most commonly involved with the sub-
be involved. mandibular space primarily.
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Summary
¾ In the mandible, infections of the incisors, canines,
and premolars usually erode through the facial bone
superior to the attachment of the muscles of the lower
lip, resulting in vestibular abscesses.
¾ First molar infection may drain buccally (vestibular
abscess or buccal space) or lingually (sublingual or
submandibular space).
¾ Second molar infection may drain buccally but more
commonly lingually.
¾ Third molar infections almost always drain lingually
(submandibular space).
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2. The pterygomandibular 3. The temporal space
space ¾ It is posterior and superior to the masseteric and
¾ It lies between the mandible and the medial pterygomandibular spaces.
pterygoid muscle.
¾ It is divided into two portions by the temporalis
¾ This is the space into which local anesthetic solution muscle:
is injected in IANB. So infection of this space may 1)Superficial portion that extends to the temporal fascia
be caused by needle tract infection from a
2)Deep portion that is continuous with the infratemporal space.
mandibular block.
¾ They are rarely involved and usually only in severe
¾ Infections of this space spread primarily from the infections.
sublingual and submandibular spaces.
¾ When these spaces are involved, the swelling that
¾ It causes little or no facial swelling; but it causes occurs is evident in the temporal area, superior to
significant trismus. Therefore trismus without the zygomatic arch and posterior to the lateral
swelling is a valuable diagnostic clue for ptery- orbital rim.
gomandibular space infection.
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The lateral pharyngeal space The retropharyngeal space
¾ It lies behind the posterior aspect of the pharynx and
¾ When the lateral pharyngeal space is involved, the bounded posteriorly by the alar layer of prevertebral fascia.
odontogenic infection is severe and may be ¾ It begins at the base of the skull and extends inferiorly to
progressing at a rapid rate. the level of vertebra C7 or Tl.
¾ Direct effect of the infection on the contents of the ¾ It must be evaluated with lateral radiographs of the neck to
determine if the space is enlarged and thereby
space, thrombosis of the internal jugular vein, compromising the airway.
erosion of the carotid artery or its branches, and
¾ It has few contents, and therefore infection in this space
interference with cranial nerves IX through XII. does not carry some of the grave problems that involvement
¾ A third serious complication arises if the infection of the lateral pharyngeal space does.
progresses from the lateral pharyngeal space to ¾ How-ever, when the retropharyngeal space becomes
the retropharyngeal space. involved, the major concern is that the infection can extend
inferiorly to the mediastinum leading to serious
complications.
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Severity of the Infection Severity of the the Infection
A. Complete History: B. Physical Examination
Know Your Enemy
1. Chief Complaint: 1. Vital Signs:
2.Duration of the infection: ¾Temperature > 38 C Fever
¾ Onset of infection ¾Pulse rate > 90 beat/min (tachycardia)
¾ Course of infection ¾Blood Pressure: increased due to pain and anexiety.
Decreased due to septic shock.
¾ Rapidty of progression.
¾Increased Respiratory Rate> 20 breaths/min. (tachypnea)
3. Symptoms: 2.Cardinal signs of infection. (Loss of function)
¾Local: pain, swelling, hotness, redness, loss of function 3. Patients general appearance (toxic)
(trismus, dysphagia, dyspnea). 4.Palpation of areas of swelling.
¾General: Fever, Malaise. (Tender, hot, Fleshy,indurated, fluctuant)
4. Any previous treatment (proffesional or self). 5. LN involvement.
5. Past Medical History
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Severity of the the Infection Periapical radiograph
C. Radiographic Examination:
Why? Acute inflammation around the apex of a tooth:
1. To establish the presence of infection in deeper A. Where there is little or no previous chronic
inflammation: loss of the lamina dura
spaces.
B. Where the periapical periodontal ligament was
2. To find the cause of the infection. previously widened or a granuloma was present:
Which? poorly defined radiolucency denoting localised bone
1. Periapical radiograph. destruction.
2. Panorex C. Chronic cases: widening of the periodontal ligament
space with preservation of the radio-opaque lamina
3. CT scans
dura
4. MRI
5. Plain Films
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Evaluate host defense capabilities
Evaluate host defense capabilities
a. Medical conditions that compromise host defense:
1. Uncontrolled metabolic diseases
b. Pharmaceuticals that compromise host defense:
¾Alcoholism
¾Malnutrition (Decrease chemotaxis,
¾ Chemotherapeutic agents
¾Uncontroled Diabetes phagocytosis and bacterial killing) ¾ Immuno suppressive therapy:
¾Renal disease with uremia. • for organ transplant or autoimmune disease,
• decrease T and B lymphoctes
2. Immune system suppressing diseases • and decrease IG production.
¾Leukemias (Decrease white cell function • eg. Cyclosporin, Azathioprine and
¾Lymphomas and Antibodies synthesis) Corticosteroids.
¾Malignant Tumors
¾AIDS (T lymphocytes then B lymphocytes in late stage)
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Why surgical drainage of accumulated pus?
1. Removes Bacteria & Pus When Culture and Sensitivity Testing?
¾ Decrease # of bacteria – decreases load on host resistance
¾ Decreased pus (prevent inactivation of antibiotics).
1. Rapidly spreading infection.
¾ Hastens resolution (removal of pus, usually takes the body a long time)
2. Decompresses the cavity so decreases the hydrostatic 2. Post-op infection.
pressure, which in turn will: 3. Non-responsive infection after more than 48 hours.
¾ Aborts spread into deeper spaces 4. Recurrent infection.
¾ Decrease pain
5. Compromised host defenses.
¾ Improve local blood supply
¾ Improves the delivery of host defenses to the area. 6. Osteomyelitis.
3. Alters the tissue oxygen tension from anaerobic to aerobic 7. Suspected actinomycosis.
¾ Destroys the environment necessary for the growth of anaerobic
organisms.
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I and D technique Vestibular abscess
1. Select the proper site I directly over the site of maximum swelling
2. Disinfect the surface Avoid area of frenum and mental nerve
3. Obtain the proper anesthesia
4. Incise and penetrate
5. Placement of the drain
¾ Use small incisions and blunt dissection without direct
exposure and visualization of the entire infected anatomic
space.
¾ To avoid crushing of a vital structure within the beaks of a
hemostat during blunt dissection, it is crucial to insert the
instrument closed, then open it at the depth of penetration,
and then withdraw the instrument in the open position.
¾ Dissect a pathway for the drain that includes the locations
where pus is most likely to be found.
A vertical incision
over the
pterygomandibular
raphe can be used
to drain the
pterygomandibular
space as well as the
lateral pharyngeal
space and deep
temporal space.
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Support the patient Medically.
1. Fluids for hydrational support.
2. Nutritional support (high caloric diet).
3. Control the fever. 5. PRESCRIBE THE
4. Relief pain. APPROPRIATE ANTIBIOTIC.
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.
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Indications for antibiotic therapy Situations in which the use of
Antibiotic is not necessary
1. Swelling extending beyond the Toothache.
alveolar process.
Periapical abscess.
2. Cellulitis.
3. Lymphadenopathy Dry socket (premature fibrinolysis with loss of
4. Temperature higher than 38 C. blood clot) (self limiting).
5. Trismus Multiple dental extractions (In a non
6. Compromised host defenses compromised patient).
7. Severe pericoronitis. Mild pericoronitis (Irrigation).
8. Osteomyelitis.
Drained alveolar abscess.
2. USE EMPIRICAL THERAPY Almostall OIs are caused by multiple bacteria, 5-8 different
ROUTINELY. species can be identified.
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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-Spectrum Broad-Spectrum
Penicillin. Amoxicillin.
Clindamycin. Augmentin
Metronidazole. Azithromycin
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Antibiotic drugs either kill bacteria (bactericidal) or
interfere with their reproduction, allowing the body’s
5. USE BACTERICIDAL immune system to deal with the infection
ANTIBIOTIC IF POSSIBLE. (bacteriostatic).
Bactericidal: Bacteriostatic
PCN
Erythromycin
Cephalosporins
Tetracyclines
Vancomycin
Chloramphenicol
Aminoglycosides
sulfonamides
Metronidazole
Either:
Clindamycin
Penicillin Penicillin
It is a group of antibiotics derived from
Advantages:
Penicillum fungi.
1. Bactericidal.
It works by inhibiting the formation of the
2. Excellent distribution.
bacterial cell wall.
3. Low toxicity.
Pen G, Pen V, Procaine pen G
4. Low cost.
Aminopenicillins: Ampicillin, Amoxicillin.
Penicillinase resistant: Cloxacillin, Side effects:
dicloxicillin, Oxacillin Allergy: Maculopapular rash and bronchospasm
B Lactamase Inhibators: ----------- Stevens-Johnson syndrome----------
angioedema and anaphylaxis
¾ Clavulanic acid: Amoxicillin/clavulanic acid
(Augmentin,Hibiotic)
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Macrolides Metronidazole (Flagyl)
¾ Mechanism of action: Inhibition of bacterial protein
biosynthesis.
Disrupting the DNA structure, thus inhibiting Nucleic acid
¾ Active against aerobic and anaerobic gram-positive cocci. synthesis.
¾ Examples: Bactericidal.
¾ - Erythromycin: GI disturbances Rapidly and completely absorped when given orally.
¾ -Azithromycin: Broader spectrum, improved tissue Well distributed into bone, saliva, mucosa, brain abscess.
penetration, prolonged tissue levels(1x2), less drug Excellent anaerobic spectrum including Bacteroides
interaction, less GI upset. (Zithromax) Little activity with other oral flora.
¾ Bacteriostatic. Excellent combination with PCN
¾ Used in mild infections or penicillin allergy. Drug interaction:
¾ Drug interaction (inhibits hepatic metabolism): Alcohol: (nausea, vomiting, Cramps, headache,
tachycardia, shortness of breath) (Anti-abuse type reaction,
¾ Theophyllin (nausea and vomiting), warfarin ( increases Disulfiram- like effect).
INR), Carbamazepine (drowziness), Cyclosporine (elevated
serum levels)
Clindamycin
Administer the antibiotic properly
Inhibits Protein Synthesis
1.Proper route of administration.
Bacteriostatic in low dose, Cidal at high
2.Proper dose.
dose
3.Proper time interval.
Covers most oral flora.
4.Adequate period of administration.
Superior action against Anaerobes esp.
Bacteroides species (proevotella and 5.Consider combination therapy
porphyromonas)
Used in Pencillin allergy patients.
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Evaluate the patient frequently Reasons for Treatment Failure
1. Re-evaluate the patient frequently
1. Inadequate Surgery.
2. Response to treatment
¾ Temperature 2. Depressed host defenses (immunocompromising
¾ Swelling disease or dimished physiologic reserves).
¾ Pain 3. Foreign body (implants).
¾ Trismus 4. Antibiotic problems
¾ General condition.
¾ Patient noncompliance
3. Check site of I and D. ¾ Drug not reaching the site
4.Need for additional imaging? ¾ Drug dose too low
5. Toxicity reactions. ¾ Wrong antibiotic
6. Superinfections (candidiasis).
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Maxillary sinus infection Buccal space infection
May spread to: infraorbital, periorbital superficial
Infection of maxillary teeth may pread to the temporal, and infratemporal, spaces .
maxillary sinus through erosion of the floor.
Infratemporal space: contains pterygoid venous
Then it may spread superiorly through the plexus
ethmoid sinus to cause periorbital infection.
Infection may reach the inferior ophthalmic Emissary veins from the plexus connect with the
V. intracranial dural sinuses.
They follow the common ophthalmic vein Veins of the face and orbit are valveless, so blood
through superior orbital fissure directly into borne infections may pass superiorly along their
CS. course.
Common ophthalmic V. is the origin of Infratemporal space is the origin of posterior route by
anterior route by which infection can spread
to the CS. which infection can spread to the CS.
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Cavernous sinus thrombosis (CST)
It is the formation of a blood clot within the CS.
Perimandibular spaces
It can spread to contralateral cavernous sinus within 24–48
hr. Infection can spread easily from
submandibular space to the submental
It is life-threatening and requires immediate treatment.
space to the contralateral submandibular
Clinical picture: space. It can also spread from behind the
1. Headache, fever, tachycardia, Orbital pain and visual free posterior margin of the mylohyoid
disturbances. muscle to involve the sublingual space
2. Unilateral periorbital and conjunctival edema, and also.
proptosis ( ophthalmic veins). This rapidly spreading cellulitis :
3. Opthalmoplegia (Paralysis of the cranial nerves III, IV, VI) 1. can obstruct the airway.
4. Ptosis (cranial nerve III and sympathetic ). 2. can spread to the deep fascial spaces
5. Sensory deficits of areas supplied by V1 and V2. of the neck.
6. Confusion, drowsiness, and coma
Ludwig’s Angina
Clinical Presentation:
1. Severe and painful indurated bilateral board-like hardness
Def: Ludwig’s angina is an of the submandibular region above the hyoid bone, without
acute cellular infection and is apparent fluctuation, because the pus is localized deep in
characterized by bilateral the tissues.
involvement of the submandibular 2. Painful indurated edema of the floor of the mouth.
and sublingual spaces, as well as
3. The tongue is elevated towards the palate and displaces
the submental space.
the epiglottis posteriorly, resulting in obstruction of the
airway.
Etiology: The most frequent 4. Difficulty in swallowing, speaking and breathing,
cause of the disease is periapical 5. Drooling of saliva.
or periodontal infection of
6. Trismus.
mandibular teeth, especially of
those whose apices are found 7. Elevated temperature.
beneath the mylohyoid muscle. 8. Anxiety.
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Treatment Deep fascial spaces of the neck.
1.Immediate establishment of airway security by
early intubation or tracheotomy. Submandibular , sublingual, or pterygomandibular
2. Surgically with drainage of all the abscessed infections can spread to lateral pharyngeal space.
spaces. (bet medial pterygoid and superior constrictor muscles
and then bet the pterygomandibular raphe and the
3.Concurrent administration of antibiotics. posterior pharyngeal space, it contains the carotid
sheath).
The incisions:
1. Infection of the lateral pharyngeal space can
Extraoral : bilateral, parallel, and medial to the inferior compress, deviates, or completely obstruct the
border of the mandible, at the premolar and molar region airway.
Intraoral: parallel to the ducts of the submandibular glands. 2. It may invade vital structures such as major vessles
(thrombosis of the IJV, erosion of the CA).
Exploration and communication of the spaces of infection.
3. It may allow extension into retropharyngeal space or
Rubber drains are placed in order to the mediastinum.
keep the drainage sites open for at least 3 days.
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Airway management
Patient airway should be monitores and THANK YOU
secured whenever indicated.
Tracheotomy .
Cricothyroidotomy
Blind nasal endotracheal intubation under
general anaesthesia.
Awake fibreoptic intubation.
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