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Infection: It is invasion of the body

Odontogenic Infections by pathogenic microorganisms.

Inflammation: is the response of the


body tissues to harmful stimuli, it is
Dr. Rehab Elsharkawy characterized by pain, swelling, heat
Lecturer of Oral and Maxillofacial Surgery and redness. It is a protective attempt
CAIRO UNIVERSITY by the body to remove the injurious
stimuli and to initiate the healing
process for the tissue.

Inflammation ¾ Pain from odontogenic infections is the


most common problem seen by the
It is characterized by five cardinal signs: dentists.
Redness, Hotness, swelling, Pain, and loss of
¾ Odontogenic infections arise from the
function.
teeth and have a characteristic flora.
Redness and heat: are due to increased
¾ Range from low-grade, well localized to
blood flow at body core temperature to the
severe, life-threatening.
inflamed site.
¾ When addressed early, management is
Swelling is caused by accumulation of fluid.
easy and complications are rare.
Pain is due to release of chemicals that
¾ When allowed to progress can lead to
stimulate nerve endings.
serious morbidity or death in a short time.
Loss of function has multiple causes.

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Head and Neck infection Odontogenic Infections Outline

ODONTOGENIC Periapical 1. Typical Microbiology of odontogenic infections.


Peridontal 2. Natural history of progression of odontogenic
infections.
NON- ODONTOGENIC Post Injecion 3. Principles of therapy of odontogenic infections.
(dentally related) Post Surgical
4. Indications for referral to OMS.
Post Trauma
5. Principles of prevention of infection.
NON- ODONTOGENIC Salivary ¾Wound infection.
Sinus ¾Metastatic infection.
Viral/Fungal

1. Typical Microbiology of odontogenic infections. Microbiology of odontogenic


Infections caused by 6%
infections Aerobic bac. alone
„ Bacteria that cause odontogenic infections are part of the „ Almost all OIs are caused by Infections caused by
normal flora (in plaque, on mucosal surfaces, in gingival 44%
multiple bacteria, 5-8 different Anaerobic bac alone
sulcus).
species can be identified. Infections caused by 50%
„ These bacteria are primarily MIXED bac.
¾ Aerobic gram +ve cocci,
¾ Anaerobic gram +ve cocci,
1. Predominant aerobic bac in OIs are the Streptococcus
¾ Anaerobic gram –ve rods.
milleri group.
„ These bacteria usually cause caries, gingivitis and
2. Predominant anaerobic:
periodontitis.
a) Gram +ve cocci Anaerobic streptococci and
„ When they gain access to deeper tissues (Perio. pocket or
peptostreptococcus.
necrotic pulp) they cause OI.
b) Gram –ve rods Prevotella and Fusobacterium.

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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).

Characteristic Edema Cellulitis Abscess


Duration 0-3days 1-5 days 4-10 days
Factors that influence the spread
Pain mild Severe and Less severe of Odontogenic infections
generalized and Localized
borderds diffuse diffuse circumscribed 1. Number of organisms.
2. Virulence of the organisms.
Size variable Large Smaller
3. Status of patient’s immune system.
color Normal Erythematous Shiny center
consistancy Soft doughy Hard indurated Fluctuant Severity of infection= Number X Virulence
/ Host resistance.
Progression Increasing Increasing Decreasing
4. Thickness of the cortical bone.
Presence of Absent absent Present
pus 5. Relationship of the tooth in the alveolus
Bacteria Aerobic Mixed Anaerobic 6. Position of muscle attachment in relation to
Seriousness Mild Sever Moderate
root tip.

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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.

Acute Dento-Alveolar Abscess Spread of infection


Radiographic picture:
1. In the very early stage it may have negative It may spread by:
radiographic picture. 1.Continuity through tissue spaces and
2. Later there will be widening of the planes.
periodontal membrane space and 2. Lymphatic system.
interruption of the lamina dura. 3. Hematogenous spread.
3. Then localized ill-defined
area of radiolucency may
be seen in the periapical region.

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Natural history of progression of Thickness of the bone overlying the
odontogenic infections. apex of the tooth.

Major factors determining the the location of „ According to the


spread of infection from a specific tooth: thickness of the bone
1. Thickness of the cortical bone. overlying the apex the
2. Relationship of the tooth in the alveolus. infection may spread
into the buccal sulcular
(Bone overlying the apex of the tooth).
space or palatal space.
3. The relationship of the site of perforation of
bone to position of muscle attachments to the
jaws.

Maxillary vestibular space Maxillary vestibular space


¾ Between the oral mucosa and the muscle which lie ¾ Signs & Symptoms:
above the apices to the teeth. Pain, Swelling of the upper lip, Swelling and
¾ Anteriorly: Levator Anguli Oris, Nasalis, & obliteration of labial sulcus or buccal vestibule.
Depressor septi confine infection into the vestibule ¾ Spread:
or direct it into the soft tissues of the upper lip. Anterior it may spread Into the upper lip.
¾ Posteriorly: confined into vestibule by the Superiorly into the infraorbital space.
buccinator muscle.
Posterior Superior into infratemporal
¾ Infection originates anteriorly from maxillary
space.
incisors and posteriorly from Maxillary posterior
¾ Incision line as seen in figure.
teeth.

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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

Mandibular Vestibular Space


The relationship of the site of perforation of
¾ It is the space present between the oral bone to muscle attachments to the jaws.
mucosa & the buccinator muscle laterally &
the mentalis anterorily.
¾ Infection of this space may originate from
any lower tooth, most often Incisors,
Premolars and 1st molar.
¾ It caused swelling and Obliteration of the
buccal vestibule
¾ It may spread posteriorly to the buccal
space or anteriorly to mentalis space

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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).

2. Buccal space infection


¾ It is bounded by the overlying skin of the face on
the lateral aspect and the buccinator muscle on the Infection from this space
medial aspect . may spread to
¾ May become infected from either the posterior Submasseteric,Pterygo
maxillary or mandibular teeth. mandibular, Lateral
¾ The buccal space becomes involved from the teeth pharyngeal, Superficial
when infection erodes through the bone superior to & Deep Temporal
the attachment of the buccinator muscle. spaces.
¾ Involvement of the buccal space usually results in
swelling below the zygomatic arch and above the
inferior border of the mandible.

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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.

Infratemporal space infection 3. The submental space


¾ It lies between the anterior bellies of the
¾ It lies posterior to the maxilla. It is bounded medially
digastric muscle and between the mylohyoid
by the lateral plate of the pterygoid process of the
sphenoid bone and superiorly by the base of the skull.
muscle and the overlying skin.
¾ This space contains branches of the internal maxillary ¾ It is primarily infected by mandibular incisors,
artery and the pterygoid venous plexus. which are sufficiently long to allow the
¾ The infratemporal space is rarely infected, but when it infection to erode through the labial bone
is, the cause is usually an infection of the maxillary apical to the attachment of the mentalis
third molar. muscle.
¾ Infratemporal space is the origin of posterior route by ¾ The infection is thus allowed to proceed
which infection can spread to the CS.
under the inferior border of the mandible and
involve the submental space.

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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.

5. The sublingual space 5. The sublingual space


¾ It’s lateral boundery is the medial surface of the ¾ Clinically little or no extraoral swelling is
mandible, it lies between the oral mucosa of the produced by an infection of the sublingual
floor of the mouth and the mylohyoid muscle.
space.
¾ It is involved primarily by lingual perforation of
¾ Much intraoral swelling is seen in the
infection from the mandibular molars, and
premolars. floor of the mouth on the infected side
¾ If the infection erodes through the medial aspect of then bilaterally, and the tongue becomes
the mandible above attachment of the mylohyoid elevated.
muscle, the infection will be in the sublingual ¾ Its posterior border is open, and therefore
space and is most com-monly seen with premolars it freely communicates with the
and the first molar.
submandibular space.

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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).

ANATOMIC SPACE INVOLVEMENT


The secondary spaces: If proper treatment is not received for
1. The masseteric space
infections of the primary spaces, the infections may extend ¾ It lies between the lateral aspect of the ramus of
posteriorly to involve these spaces. When they are involved, the mandible and the masseter muscle.
the infections frequently become more severe, cause greater
complications and greater morbidity, and are more difficult to ¾ It is involved as the result of spread of infection
treat. from the buccal space or from soft tissue infection
A. The masticator space around the mandibular third molar.
1. The masseteric space. ¾ When the masseteric space is involved, the area
2. The pterygomandibular space. overlying the angle of the jaw and ramus becomes
3. The superficial temporal space. swollen.
4. The deep temporal space. ¾ Because of the involvement of the masseter
B. Cervical Fascial Spaces: muscle, the patient will also have trismus caused
1. Lateral pharyngeal space. by inflammation of the masseter muscle.
2. Retropharyngeal 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.

The lateral pharyngeal space


¾ It extends from the base of the skull to the hyoid bone
inferiorly. It is medial to the medial pterygoid muscle and
lateral to the superior pharyngeal constrictor on the medial
side.
¾ It is bounded anteriorly by the pterygomandibular raphe and
extends posteromedially to the prevertebral fascia.
¾ The clinical findings are lateral swelling of the neck, and
intraoraly swelling of the lateral pharyngeal wall, toward the
midline.
¾ It causes difficulty in swallowing, high temperature and
patient becomes quite sick.

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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.

4. Principles of therapy Factors that govern disease severity


1. Determine the severity of the infection. „ Host resistance factors: (natural and acquired).
a. Complete history. „ Microbial Factors:
b. Physical examination. 1. Pathogenicity: ability of an organism to cause disease.
2. Evaluate host defense capabilities. 2. Virulence: degree of pathogenicity.
a. Medical condition that compromise host defence. a. Adherece: eg. Pilli that help adhesion to host cells to start the
b. Drugs that compromise host defence. disease.
b. Invasiveness: Ability to invade tissue, multiply and spread
3. Treat the infection surgically. rapidly eg. Polysacharide capsule that protects bac from
4. Support the patient Medically. phagocytosis.
5. Prescribe the appropriate Antibiotic. c. Toxin production: Products that have direct harmful effect on
cells (Exotoxins and endotoxins).
6. Evaluate the patient frequently.
d. Extracellular enzymes. Substanced produced to help spread,
7. Referral to OMS? invasion, establishment of MO into the tissues (Collagenase,
hyaluronidase, Ig A protease, Fibrinolysin).

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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

Clinical features of odontogenic infections


B. Physical Examination
Intraoral Extra oral
¾ Local:
6. Intraoral examination: 1. Pain on percussion.
2. Pain exacerbated by hot or 1. Hotness,
¾ Severley Carious teeth cold. 2. redness,
¾ Periodontal abscess 3. Tooth feels extruded from 3. pain,
the socket. 4. swelling,
¾ Pericoronitis
4. Intraoral swelling.
5. loss of function.
¾ Tooth tenderness 5. Erythematous gingiva.
(Trismus,Dysphagia,
¾ Tooth mobility 6. Carious tooth.
Respiratory difficulty)
¾ Vestibular swelling 7. Intraoral seepage of
purulent material. ¾ Systemic:
¾ Draining sinus tract. 1. Fever,
2. Malaise
3. lymphadenopathy

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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

Severity of the the Infection


D.Blood investigations eg, CBC,
differential WBC count, sedimentation
EVALUATE HOST DEFENSE
rate, and blood cultures, may be CAPABILITIES.
ordered if clinically indicated.

Know your army

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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)

Goals of Surgical Treatment


1. Remove the cause of infection:
TREAT INFECTION
¾RCT
SURGICALLY
¾Extraction
2.Provide surgical drainage of
accumulated pus and bacteria.
3. Culture and sensitivity test.

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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.

I&D Surgical Drains


„ A surgical drain is a tube used to remove pus,
blood or other fluids from a wound and it keeps
the incision line open for drainge.
„ Types of drains:
A.Passive drains, depend on gravity to remove fluid
from a wound area. Made of a soft, flat, flexible
latex. eg. Penrose drain.
B.Active drains use a negative-pressure system,
created by a compressible reservoir. It allows
reliable measurement and assessment of the
character of drainage. Eg. Jackson-Pratt Drain.

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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.

Extra-oral Incision and Drainage

„ 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.

Principles of Antibiotic Therapy


1.Determine the need for antibiotic
1. DETERMINE THE NEED FOR
therapy. ANTIBIOTIC THERAPY
2.Use empirical therapy routinely.
3.Use narrowest spectrum drug. 1. Seriousness of the infection.
4.Use antibiotic with the lowest toxicity 2. Whether adequate surgical treatment can be achieved.
and side effects. 3. State of the patient’s defeses.
5.Use bactericidal antibiotic if possible.
6.Be aware of the Cost. $$$

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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.

Microbiology of odontogenic infections

2. USE EMPIRICAL THERAPY „ Almostall OIs are caused by multiple bacteria, 5-8 different
ROUTINELY. species can be identified.

1. Predominant aerobic bac in OIs are the Streptococcus


milleri 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-Spectrum Broad-Spectrum
„ Penicillin. „ Amoxicillin.

„ Clindamycin. „ Augmentin

„ Metronidazole. „ Azithromycin

„ Penicillin: Allergy (hives, itching, wheezing).


„ Clindamycin, amoxicillin and ampicillin:
Pseudomembranous colitis (due to
4. USE ANTIBIOTIC WITH THE overgrowth of clostridium difficile and
LOWEST TOXICITY AND SIDE production of toxins that injur the gut wall
(watery diarrhea).
EFFECTS.
„ Metronidazole: Disulfiram effect (Anti-abuse
type reaction)
„ Azithromycin: low toxicity or side effects
and no drug interactions.
„ Tetracyclines: Photosensitivity, Tooth
discoloration due to chelation to Ca.

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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).

Indications for Referral to OMS


1. Rapidly progressing infection Complications of Odontogenic
2. Fascial space involvement
3. Difficulty in breathing
infections
4. Difficulty in swallowing
5. Toxic appearance
6. Elevated Temperature >101 F
7. Dehydration
8. Severe trismus
9. Failed prior treatment.
10.Compromised host defenses
11.Need for general anesthesia.

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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.

The cavernous sinus


„ Is a large collection of veins
creating a cavity bordered by the
temporal and the sphenoid
bones, lateral to the sella turcica.
„ The internal carotid artery, and
cranial nerve III, IV, V, and VI all
pass through it.
„ The cavernous sinuses receive
venous blood from the facial
veins (via the superior and
inferior ophthalmic veins)

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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.

Deep fascial spaces of the neck. Midiastinitis


„ The mediastinum is the space
„ Retropharyngeal Space: between the lungs and it
contains only loose CT and contains the heart, the vagus
LNs so infection can spread and phrenic nerves, the
easily to the other lateral trachea, esophagus, aorta, inf
pharyngeal space and can
rupture the alar fascia to enter and sup vena cava.
the danger space. „ Infection can compress the
„ DS between alar fascia and heart and the lung, interfers
prevertebral fascia from base with neurologic control of the
of the skull to diaphragm and it heart rate and respiration,
is continuous with the rupture into lung, or esophagus,
midiastinum. or spread to abdominal cavity.

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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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