Dentoalveolar

Infections
Prof Manal Baddour
O A dentoalveolar abscess is an acute lesion
characterized by localization of pus in the
structures that surround the teeth
 dentoalveolar abscess
The term comprises 3 distinct processes, as follows:
O A periapical abscess
O A periodontal abscess
O Pericoronitis
 Periodontal abscess
O A periodontal abscess involves the
supporting structures of the teeth
(periodontal ligaments, alveolar
bone).
O This is the most common dental
abscess in adults
O May occur in children with impaction
of a foreign body in the gingiva.
 Periapical abscess
O Originates in the dental pulp
O Is usually secondary to dental caries
O Is the most common dental abscess in children
O Dental caries erode the protective layers of the tooth (ie,
enamel, dentin) and allow bacteria to invade the pulp,
producing a pulpitis.
O Pulpitis can progress to necrosis, with bacterial invasion
of the alveolar bone, causing an abscess.
 Pericoronitis
O Pericoronitis describes the infection
of the gum flap (operculum) that
overlies a partially erupted or
impacted third molar.
 Microbiology
O Odontogenic infections are polymicrobial, with an
average of 4-6 different causative bacteria.
O The dominant isolates are strictly anaerobic:
O gram-negative rods
O gram-positive cocci
O facultative and microaerophilic streptococci
O Anaerobic bacteria outnumber aerobes 2-3:1.
O In general, strictly anaerobic gram-negative rods are
more pathogenic than facultative or strictly anaerobic
gram-positive cocci.
 Microaerophilic Streptococci

O Streptococcus constellatus
O Streptococcus intermedius
O The mixed aerobic-anaerobic composition of
the bacteria involved in suppurative
odontogenic infections is thought to be
important in the pathogenesis of infection.
aerobic-anaerobic interaction
O The respiration of aerobic bacteria depletes
the local environment of oxygen, creating an
oxygen-poor, nutrient-rich habitat suitable
for anaerobic growth.
O Once anaerobiosis is achieved, anaerobes
proliferate, secreting toxins and enzymes
that result in tissue destruction and abscess
formation.
O Generally, a nonpathogenic resident bacterium gains
entry when the host's defenses are breached.
O The predominant species associated with dental abscess
include:
O Bacteroides,
O Fusobacterium,
O Actinomyces,
O Peptostreptococcus
O Porphyromonas
O Prevotella oralis, Prevotella melaninogenica, and viridans
Streptococci.
O Beta-lactamase producing organisms occur in
approximately one third of dental abscesses
 Prevotella
O Prevotella oralis are nonpigmented
O Prevotella melaninogenica are pigmented
O part of the normal oral and vaginal florae
O anaerobic Gram negative bacilli isolated from
respiratory tract infections and their
complications, including aspiration pneumonia,
lung abscess, chronic otitis media, chronic
sinusitis, abscesses around the oral cavity,
human bites, paronychia, brain abscesses, and
osteomyelitis.
 Age
O Dental abscess is rare in infants because
abscesses do not form until teeth erupt.
O In children, periapical abscess is the most common
type of dental abscess.
O This is because of the combination of:
O poor hygiene,
O thinner enamel,
O primary dentition having more abundant blood
supply, which allows for an increased inflammatory
response.
O In adults, periodontal abscess is more common
than periapical abscess.
 Teeth
O The tooth that is most frequently involved is
the:
O lower third molar,
O followed by other lower posterior teeth;
O upper posterior teeth are involved much less
frequently,
O and anterior teeth are rarely involved.
 Antimicrobial Therapy
O Antimicrobials are not always warranted.
O For example, a draining abscess or a fistula
containing a chronic infection usually only
requires the extraction of the offending tooth.
O Other disease processes, including acute
periapical abscesses, periodontal abscesses,
pericoronitis, and deep fascial space
infections may require antimicrobial therapy.
Antimicrobial Therapy
O Antimicrobials must never be used as a
replacement for appropriate surgical
drainage and/or debridement, and should
only be used as adjunctive therapy.
O Antimicrobial therapy initiated soon after
diagnosis and before surgery can shorten
the period of infection and minimize
associated risks such as bacteremia
 Penicillins
O Penicillins have been used as first-line
agents in the treatment of odontogenic
infections.
O The increasing prevalence of -lactamase
production in dental pathogens and the
coincident reports of clinical failures have
decreased the usefulness of these agents.
O Amoxicillin, is still the drug of choice for
prophylaxis against endocarditis.
 Clindamycin
O Clindamycin recently is the drug of choice in
treating odontogenic infections
O Clindamycin has excellent activity against
aerobic gram positive cocci, such as
Staphylococcus aureus, Streptococcus spp,
and most anaerobes, including penicillin
resistant strains of Bacteroides, Prevotella,
and Porphyromonas spp (-lactamase
producing strains).
 Metronidazole
O Metronidazole is a bactericidal agent that is
highly active against most anaerobes.
O Rapid absorption occurs after oral
administration.
OTHANK YOU