Combined Hospital Meeting

Diagnosis and Management of Odontogenic Infections

Jeff Lee Dept. of Oral and Maxillofacial Surgery 1/15/02

Odontogenic Infections
The modern emergency department sees a significant number of patients every day with problems related to the face and oral cavity. Emergency Medicine Clinics of North America Aug 2000

Odontogenic Infections
35 year old male, 3 day history of progressive painful facial swelling, difficulty opening mouth, difficulty swallowing, alteration in voice. 8 year old female, 5 days s/p dental extraction, persistent increasingly painful swelling left face, taking augmentin since extraction.

OUTLINE

Microbiology Natural history Assessment Management Prevention

Odontogenic Infections
Understand important aspects of history and clinical examination of patient. Understand treatment of odontogenic infections and when to refer treatment.

MICROBIOLOGY

Causative organisms
Aerobes only Anaerobes only Mixed 7% 33 % 60 %

MICROBIOLOGY Aerobic
Gram-positive cocci
Streptococcus spp. Streptococcus (group D) spp. Staphylococcus spp. Eikenella spp.

25%
85%
90% 2% 6% 2%

Gram-negative cocci (Neisseria spp.) Gram-positive rods (Corynebacterium spp.) Gram-negative rods (Haemophilus spp.) Miscellaneous and undifferentiated

2% 3% 6% 4%

MICROBIOLOGY Anaerobic
Gram-positive cocci
Streptococcus spp. Peptostreptococcus spp. Staphylococcus spp.

75%
30%
33% 65% 65%

Gram-negative cocci (Veillonella spp.) Gram-positive rods

Eubacteriumspp. Lactobacillus spp. Actinomyces spp. Clostridia spp.

4% 14%

Gram-negative rods
Bacteroides spp. Fusobacterium spp.

50%
75% 25%

Miscellaneous

6%

NATURAL HISTORY
Inoculation Cellulitis Abscess formation Resolution

NATURAL HISTORY
Predictable spread from one anatomic space to the next. Edema at leading edge of infection. Previously innoculated areas progressing through stages of cellulitis and abscess formation

ANATOMIC SPACE INVOLVEMENT Primary maxillary spaces Canine Buccal Infratemporal Primary mandibular spaces Submental Buccal Submandibular Sublingual

ANATOMIC SPACE INVOLVEMENT

ANATOMIC SPACE INVOLVEMENT

ANATOMIC SPACE INVOLVEMENT Secondary fascial spaces Masseteric Pterygomandibular Superficial and deep temporal Lateral pharyngeal Retropharyngeal Prevertebral

ASSESSMENT

Identify cause Determine severity Evaluate host defenses General practitioner / specialist

ASSESSMENT

Identify cause Caries Periodontitis Pericoronitis Tooth tenderness Tooth mobility Vestibular swelling

ASSESSMENT

Diagnostic radiographs -Panorex -CAT Scan with contrast

ASSESSMENT Determine severity Complete history

Chief complaint Time of onset Change in symptoms Elicit symptoms Clinical signs
Dolor, tumor, calor, rubor, and functiolaesa

ASSESSMENT Determine severity Vital signs Local involvement

Extent and rate of progression Involved spaces Trismus Airway Vital structures

ASSESSMENT

Characteristic Cellulitis Abscess Duration Acute Chronic Pain Severe and generalized Localized Size Large Small Localization Diffuse borders Well circumscribed Palpation Doughy to indurated Fluctuant Presence of pus No Yes Degree of seriousness Greater Less Bacteria Aerobic Anaerobic

ASSESSMENT

Systemic involvement
Malaise Pyrexia Other signs

ASSESSMENT
Compromised Host Defenses

Uncontrolled metabolic diseases

Uremia Alcoholism Malnutrition Severe diabetes

Suppressing diseases
Leukemia Lymphoma Malignant tumors

Suppressing drugs
Chemotherapeutic agents Immunosuppressives

ASSESSMENT
Criteria for Referral to a Specialist

Rapidly progressing infection Difficulty breathing Difficulty swallowing Fascial space involvement Elevated temperature (greater than 101F) Severe trismus (less than 10 mm) Toxic appearance Compromised host defenses

MANAGEMENT
Obtain drainage Maintain drainage Remove the cause Provide supportive care

MANAGEMENT
Obtain drainage

Pus must be drained Adequate access Blunt dissection All loculations entered Intra - oral and / or extra - oral

Obtain drainage

MANAGEMENT
Maintain drainage All involved spaces Dependent drainage Insertion of drain Maintenance of patency Slow advancement

MANAGEMENT
Remove the cause Pulp extirpation Tooth extraction Scaling Necrotic tissue / debris

MANAGEMENT
Provide supportive care General
Fluids Rest Nutrition Warmth

Antibiotic therapy

MANAGEMENT
Principles of antibiotic use Necessity Empirical therapy Narrow spectrum Low toxicity Bacteriocidal Administer properly Cost

MANAGEMENT
Antibiotics Good choices
Penicillin or amoxicillin ( + / - metronidazole ) Cephalexin, clindamycin, co-trimoxazole, tetracycline, erythromycin

Poor choices
Metronidazole alone Amoxicillin / clavulanic acid

PREVENTION
Local processes

Immunocompromised patient General preventive care Timely intervention Good surgical technique Infective endocarditis Arteriovenous fistulae Prosthetic valves and joints

Distant sites