odontogenic infection ettinger

8/13/2019 Odontogenic Infection Ettinger

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Management of OdontogenicInfections

David B. Ettinger MD,DMD


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Stages of Infection

I. Cellulitis

II. Abscess

III. Sinus Tract/Fistula


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CELLULITIS

A painful swelling of the soft tissue

of the mouth and face resulting

from a diffuse spreading of

purulent exudate along the fascial

planes that separate the musclebundles.


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Abscess

Well defined borders

Pus accumulation in tissues

Fluctuant to palpation


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Cellulitis spreading infection

Abscess localized infection


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FISTULA

A drainage pathway or abnormalcommunication between twoepithelium-lined surfaces due to

destruction of the intervening tissue.


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Sinus Tract

Abscess ruptures to produce adraining sinus tract


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Management of Infection

Determine the severity of the infection

Evaluate the host defense

Decide on setting of care Treat surgically

Support medically

Choose and prescribe antibioticsappropriately

Evaluate patient frequently


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Severity of Infection

Rate of progression

Potential for airway compromise or

affecting vital organs

Anatomic location of infection


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HISTORY

Duration of infectious process. Sequence of events and changes in

symptoms or signs.

Antibiotics prescribed, dosages and

responses. Review of systems with emphasis on

neuro-ophthalmologic andcardiopulmonary and immune

systems. Social history exposure, travel,

(fungal or parasitic infections),chemical dependency.


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SIGNS OF SEVERITY

Fever

Dehydration

Rapid progression of swelling

Trismus

Marked pain

Quality and/or location of swelling

Elevation of tongue

Difficulty with speech andswallowing


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Anatomic Location

Graded in severity by level to which theairway and vital structures arethreatened Low

Buccal, Vestibular, Subperiosteal

Moderate Masticator space

Severe Lateral pharyngeal

Retropharyngeal

Danger Space


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What are theprimary fascial

spaces?The spaces directly adjacent to the origin of theodontogenic infections. Infections spread from

the origin into these spaces, which are:

Vestibular SubmentalCanine Sublingual

Buccal Submandibular


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Vestibular


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Buccal

Likely from

Upper Premolar

Upper molar Lower molars


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CANINE SPACE

Superior tolevator muscleattachment in

canine fossa Can lead to:

- orbital cellulitis

- carvernous sinusthrombosis


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A unique aspect of the veins inthe head and neck is theirvalveless nature

Maxillofacial Infections

Selected Readings

OMFS Vol 2 No 1


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CAVERNOUS SINUSTHROMBOSIS

Cranial nerves III, IV, V, (opthalmic), VI

Internal carotid artery


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SUBMENTAL SPACE

Anterior mandibular teeth

Deep to mentalis muscle


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Submental Space

Most likelycaused by lower

anterior teeth ormandibularsympysis fracture


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SUBLINGUAL SPACE

Presents infloor of mouth

Superior tomylohyoid

Drainedintraorally

parallel toWhartons duct


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Submandibular Space

Likely cause: Lower molars


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SUBMANDIBULAR SPACE

Extra-oral presentation

Deep to mylohyoid I & D through skin with blunt

incision


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LUDWIGS ANGINA

Bilateral sub-mandibular,sublingual, andsub-mentalinvolvement

Rarely

fluctuant Often fatal

Requires early,aggressive

intervention


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Department of Oral and Maxillofacial Surgery

SubmentalSubmandibular

Submandibular


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What are the secondaryfascial

spaces?Fascial spaces that become involved

following spread of infection from theprimary spaces.

The secondary spaces are:

Pterygomandibular Infratemporal

Masseteric Lateral pharyngealSuperficial and deep temporal Retropharyngeal

Prevertebral


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The hallmark of masticator

space infection is: TRISMUS


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PHARYNGEAL SPACE

INFECTIONS

Lateral pharyngeal

Retro-pharyngeal

(both can lead directly to

mediastinum)


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What factors influence the spread ofodontogenic infection?

Thickness of bone adjacentto the offending tooth

Position of muscleattachment in relation toroot tip

Virulence of the organism Status of patients immune

system


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INCISION AND DRAINAGE

The production of laudable pusby:

- mucosal incision

- extraction

- endodontic access- periodontal curetage


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INCISION AND DRAINAGE

Incise in healthy skin

Incise in gravity-dependent,esthetic area if possible

Explore entireabscess cavity

Non-absorbable drains


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PRINCIPLES IN

THE USE OF DRAINS (II)

Drained wounds should be

cleansed frequently. Bacteria can migrate into a

wound along the drain surface.

Latex Penrose drains are bestused unmodified.


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INDICATIONS FOR


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INDICATIONS FORCULTURE

Nonresolving infection in spite ofappropriate care

Atypical flora expected

=long term antibiotic treatment

= age extremes (65)

= patients with malignancies

Infections with systemicinvolvement

Immunocompromised ormyelosuppressed patients


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the most important therapeutic

action in the management oforofacial infections is thedrainage of pus, and antibiotics

are merely an adjunctPogrel, A;

OMFS Clinics of

North AmericaFeb 1993


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EMPIRIC THERAPY OF

ODONTOGENIC INFECTIONS

Penicillin

Penicillin + metronidazole

PCN allergy clindamycin

MANAGEMENT OF ODONTOGENIC


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MANAGEMENT OF ODONTOGENICINFECTIONS

1. Determine severity Assess history of onset andprogression perform physicalexamination of area:

(1) Determine character and size

of swelling

(2) Establish presence of trismus

2. Evaluate host defenses Evaluate:

(1) Diseases that compromise

the host

(2) Medications that maycompromise the host

3. Perform surgery Remove the cause of infection

Drain pus

Relieve pressure


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MANAGEMENT OFODONTOGENIC INFECTIONS

4. Select antibiotic

5. Follow up

Determine:

(1) Most likely causativeorganisms based on history

(2) Host defense status

(3) Allergy history

(4) Previous drug history

Prescribe drug property

(route,dose and dosage

interval, and duration)

Confirm treatment response

Evaluate for side effects and

secondary infections


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Follow-up

Patient should be monitoredfrequently

out-patient should return for f/u in 2-3 days

Patient should have decreasedswelling, discharge, airway edema,malaise in 2-3 days


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Follow up

If no improvement consider:

Re-culture

Re-imageRepeat I and D


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Questions

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