considerations for management and prevention of odontogenic infections

1. Principles of management and
prevention of Odontogenic
Infections
Chapter 16 of Contemporary Oral and Maxillofacial Surgery-2014
Seyed vahid malek hosseini
shahid sadoughi university of medical sciences

3. Microbiology of Odontogenic infections
• Bacteria that cause odontogenic infections are part of normal flora
• Aerobic gram positive coocci
• Anaerobic gram positive coocci
• An aerobic gram negative rods
• The cause dental caries ,gingivitis and periodentitis
• Almost all of of Odontogenic infections are caused by multiple
bacteria

4. Streptococcus milleri group
• Predominant aerobic bacteria in OI
• 3 members
• S.anginious
• S.intermedious
• S.constellatus
• They can initiate process of spreading in deep tissue because they can
live in absence of O2

7. How an-aerobic bacteria cause OIs
• 1-intial inoculation in deeper tissues
• 2-synthesis of hyaluronidase by s.milleri group
• 3-allowing other organisms to initiate cellulitis stage (aerobic strep inf)
Streptococci create a favorable environment for anaerobs by
• 1-release essential nutrients
• 2-lowered PH
• 3-consumption of O2
• Than anaerobic bacteria become predominant and cause liqueinfaction
necrosis by collagenase

8. liqueinfaction necrosis become
• Microabcess
• Than clinically recognizable abcess
• and In the abcess
• -anaerobics become predominate

9. 4 stage of odentogenic infections
• 1-inoculation stage-first 3 days-soft mildly tender doughy sweelling
(invading streps)
• 2cellulitis stage-after 3 to 5 days-swelling become hard, red ,acutely
tender(mixed flora)
• 3-abcess stage- at 5to7 days-liquefied abscess in the center of
swelling (anaerobic begin to predominate)
• 4-resolution stage-spontaneously or surgicaly drainage of abcess-
destruction of bacteria by immune system-healing

11. Natural history of progression of odontogenic
infections

12. odontogenic infections origins
• 1-periapical (palpal necrosis) –most common
• 2periodental(deep pocket)

13. 1-periapical
• Treatment =
• -endodontic or extraction
• Antibiotic alone therapy just may arrest OI

14. Predictable anatomic locations of spreading
• 1-thickness of bone overlying the apex
• 2-relationship of perforation site to muscle attachments

17. In maxilla
• 1-Most of the infections erode through the bone below the
attachment of muscles (vestibular abscess)
• 2-palatal abscess arises from severely inclined lateral incisor or palatal
root of first molar or premolar
• 3-buccal space infection from maxillary molar infections that erode
through bone superior to insertion of buccinators muscle
• 4-infraorbital (canine) space infection –long canine root-superior to
insertion of levator anguli oris muscle

18. mandible
• 1-vestibular abscess-incisors ,canine ,premolars –erode through facial
cortical plate , superior to attachment of the muscles of lower lip
• 2-first molar – may drain Buccally or lingual
• 3-second molar-may drain buccally or lingual - usually lingually
• 4-third molar –almost always lingually
• Mylohyoid muscle determine whether infections drain lingually go
superior to sunlingual space or below to submandibular space

19. Chronic sinus tract
• The abscess May establishes If the patient
• do not seek treatment
• In oral cavity or skin
• No pain as long as its open
• Treatment =endodontic or extraction
• Antibiotic = just arrest

20. Principles of therapy of Odontogenic
Infections

21. Principle 1 : determine severity of infection
• Complete history of current infection
• and physical examination

22. Complete history
• Chief compliant (patient own words)
• History of chief compliant of OI
• 1-how long OI been present
• 2-time of onset
• 3-how long from first symptoms(pain-swelling-drainage)
• 4-change of severity in time

23. Clinical sign of infections
• Infections are actually a severe inflammation
• So
• Redness-pain-swelling-warmth-loss of function

24. pain
• Most common compliant
• Where it started
• How it spread since first noted

25. Swelling and …
• Ask about area of swelling
• warmth
• Whether the area has felt warm to the touch
• Redness
• Ask about Any change of the color especially redness
• function
• Dentist should ask about trismus .dyspnea, dysphagia
• Finally
• Ask how patient feel in general
• Fatigue ,weak , sick, feverish

27. Previous Treatment
• Ask about
• Professional treatment
• Self treatment –leftover antibiotics-hot soaks –herbal remedies
• Completing the last treatment

28. Physical examination
• Vital signs( temperature -bp-pulse rate-respiratory rate)
• Severe infections = greater temperature than 38 c)
• Infection = pulse rate up to 100
• Severe infection = greater than 100= aggressive treatment
• Pain and anxiety = elevation on systolic bp
• septic shock result in Hypotension
• Extention of Infection in fascial spaces of neck = partial or complete upper
airway obstruction
• Normal respiratory rate=14-16 in a min
• Mild of moderate infection = respiratory rate greater than 18 per min

29. Mild infection
• Normal vital sign
• Only a mild temperature elevation
• Can be rapidly treated

30. Serious infection
• Abnormal vital signs
• Elevation in temperature ,blood pressure ,respiratory rate,
• Require more intensive therapy and evaluation by maxillofacial
surgeon

31. Physical examination
• Inspection of patients general appearance(toxic appearance ,malaise
,fatigue ,feverishness)
• Sign of infection
• Opening mouth
• Swallowing
• breathing

32. palpation
• In the area of swelling
• Tenderness
• Local warmth
• Consistency of swelling(soft-doughy-indurated-fluctuance)
• Fluctuance =a fluid filled balloon in the center of indurated tissue

33. Intra oral examination
• To find specific cause of infection
• Like severely carious teeth, periodontal abscess, periodontal disease ,
• Infected fracture of a tooth or entire of the jaw
• Should look for
• Area of gingivitis , swelling , draining sinus tracts

34. Radiographic examination
• Usually PA radiographs
• If there was any trismus and limited mouth opening or tenderness
=panoramic view may be necessary

35. Sense the stage of the infection and than ..
• Soft tissue infection in inoculation stage may be cured by removal of
odontogenic cause with or without supportive antibiotics
Cellulitis or abscess stages require removal of dental cause ,incision and
drainage and antibiotics

36. Distinctions between inoculation cellulitis and
abscess

37. Distinctions between inoculation cellulitis and
abscess
• Cellulitis is usually acute –more painful-larger-indurated or boardlike-
aggressive-dangerous-diffuse border-
• Abscess is assign of increasing host resistance-feels flucuant because
of the pus -chronic-les aggressive
• Inoculation =edema is its hallmark –minimal tenderness-diffuse and
jelly-like-easily treated-

38. Principle 2 evaluate state of patients host
defense mechanisms
• With patients medical history
• medical conditions that
• compromise host defense :
• Allow more bacteria
• to enter tissue or to
• be more active

39. Diabetes I and II
• Most common immunocompromising disease
• Lower control of hyperglycemia =lower resistance to all types of
infections

40. Leukemia and lymphomas and cansers
• Second major immunocompromosing diseases
• Result in decrease WBC function and antibody function and
production

41. HIV
• Because Odontogenic infections are caused by bacteria
• And hiv attacks t lymphocytes
• Hiv + patient are able to combat odontogenic infections fairly
• Until the AIDS stage when b cells are also impaired
• It will be more intensive than normal patients

42. Pharmaceuticals that compromise host
defense
• Cancer chemotherapeutic agents=decrease circulating WBC counts
usually less than 1000 cell/ml =effect of some agents can last for a
year after end of therapy
• Immunosuppressive therapy in organ transplantation and
autoimmune disease
• Most common drugs are cyclosporine ,tacrolimus ,azathioporine
• They can decrease b Cells and t cells function and decrease of
antibody production

43. Principle 2 evaluate state of patients host
defense mechanisms
• Patient with history of condition or anything that compromise host
defense must be treated more vigorously because infection may be
spread more
• So referral to MXF surgeon and initiate parenteral antibiotic therapy
must be considered

44. Principle 3 determine whether patient should be
treated by general dentist or oral-maxillofacial
surgeon
• Most of OI can be managed by dentist with expectation of rapid
healing
• Some are life threatening and require aggressive treatment by
surgeon
• For some hospitalization is required

46. main criteria for Referring
• The main criteria for hospitalization is an impending threat to the
airway
• 1-rapidly progressive infection that may cause swelling in deep fascial
space of neck ,which can compress and deviate airway
• 2-dyspnea –swelling of upper airway-refuse to lie down-distorted
speech-distressed by breathing difficulty –should be referred directly
to emergency room
• 3-dysphagia-drooling-should be referred directly to emergency room

47. Other criteria
• 1-extraoral Swelling –buccal space-submandibular space –because
may require incision and drainage
• 2-High temperature
• 3-trismus-opening between 20 and 30 =mild -10 and 20 =moderate-
less than10 = severe
• Moderate of severe =infection in masticator spaces or worse both the
lateral pharyngeal space and retropharyngeal space
• 4- systematic involvement(toxic appearance)
• 5- compromised host defense

48. Toxic appearance
• Glazed eye
• Open mouth
• Dehydrated
• Sick appearance
• Fatigued
• Has a substantial amount of Pain
• elevated temperature

49. Principle 4: treat infection surgically
• The primary principle of management of OI is to perform surgical
drainage and remove the cause of infection (necrotic pulp mostly or
deep pocket)
• Endodontic access-wide incision of tissue in the neck-
• remove the cause of infection is the primary goal
• Secondary goal is to provide drainage

50. I & D
• 1-decrease the load of bacteria and necrotic debries
• 2-Reduce the hydrostatic pressure in the region .which improve blood
supply and delivery of host defense and antibiotic
• 3-stop cellulitis to spread deeper

51. Technique for I&D

52. Technique for I&D intra oraly
• 1-preffered site is the site with maximum swelling
• 2-avoid incising across a frenum or path of mental nerve

53. Technique for I&D extraoraly
• 1-method of pain control =regional nerve block by injecting in an area
away from site on infection
• 2-do not reuse the needle if it been used in an infection area
• 3-culture sensitivity test most be considered before I&D and it most
be carried out in the first portion of surgery
• 4-disinfect the area by betadine and dry it by gauze

55. incision
• 1-most be short .no more than 1cm length
• 2-wite a scalpel blade
• 3- open the cavity with a closed curved hemostat and then it will be
opened in several directions
• 4 –suction of pus and tissue fluids
• 5-insert a small drain to maintain opening to reach depth of abscess
(quarterinch sterile Penrose drain or rubber dam or surgical glove
material )-be aware of latex sensitivity
• 6-suture the drain to edge os incision with a non- resorbable suture-2
to 5 days

56. •Whenever an abscess or cellulitis is
diagnosed the surgeon must drain it.
• even if tooth cant be opened or extracted immedietly
• Antibiotic should be used if complete dranage cannot be
achieved

58. Principle 5 support patient medically
• Medically compromised patient
• 1-should be treated by specialists
• 2-hospitalization and consolation are required
• 3-antibiotics

59. Medications
• Coumadin (warfarin)-require reversal of anticoagulation before
surgery

60. Dehydration
• Fever increase fluid requirement
• Inadequate fluid intake –because of the swelling –pain and…
• They should be encouraged to drink water and to take high –
nutritional supplements
• -should be taking analgesics for pain

61. Principle 6 : choose and prescribe appropriate
antibiotic
• 1- seriousness of infection
• 2-whether adequate surgical treatment can be achieved
• 3- patients host defense

62. Indication for AB
• 1-Most common indication Presence of an acute-onset infection with
diffuse swelling and moderate to severe pain
• 2-immunologically compromised patient
• 3-involvement of the deep fascial space
• 4-severe pericoronitis with fever
• 5-osteomyelitis

63. Other indications

64. Containdication for AB
• 1-minor –chronic well-localized abscess
• 2-well localized dentoalveolar abscess
• 3-localized alveolar osteitis (dry socket)
• 4-mild pericoronitis with minor gingival edema and pain

67. AB used in OI
• Usually penicillin
• For penicillin –allergic=clindamycin and azithromycin
• For anaerobic bacteria=metronidazole and should be used in
combination to others
• Fewest times daily to improve compliance
• C&S test should be considered

68. When C&S test should be considered
• 1- rapid onset of sever infection and rapid spreading
• 2-post operative infection
• 3- infection that does not resolve as expected
• 4-resistant bacteria infection after 2 days to 2 weeks infection- free
period
• 5-patient with compromised host defense

69. Use narrowest –spectrum antibiotic
• Penicillin will kill streptococci and oral anaerobic bacteria and a litle
effect on staphylococci of skin and no effect on gastrointestinal tract
bacteria = does no facilitate developing resistance
• Co –amoxicillin is broad and result in alternation in flora and
resistance
AB with narrow-spectrum activity are as effective as others but with
less upsetting flora and less developing resistance
• Resistance can be passed on by dental patient to their families ,
coworkers and entire communities

72. Use the AB with lowest incidence of toxicity
and side effect
• The older generation antibiotics usually used for OI have a surprising
low incidence of toxicity related problems.
• Allergy to penicillin in 2% of all population
• Clindamycin = pseudomembranous (diarrhea) colitis by clostridium
difficile
• In macrolide family azithromycin has the best combination of
effectiveness , low toxicity an infrequent drug interaction
• Erytromycin is no longer considered because of the drug interactions
involving the liver microsomal enzyme and low effectiveness

73. • Moxifloxacin= beter effect on oral pathogens but significant toxicity
,mental clouding and muscle weakness, fatal drug interactions with
many commonly used drugs ,contraindicated in children under18,and
pregnant women,
• Oral cephalosporins have lost much of their effectiveness and may
cause allergic reactions like penicillin
• Tetracycline are no longer considered for the same reason.except
topically like in pockets-photosensitivity in systemic use-
contraindication in pregnancy and children.(discoloration)

74. • Metronidazile .mild toxicity-reaction to alcohol and disulfiram effect
Sudden violent abdominal cramping and vomiting

75. Use a bactericidal AB if possible
• Host defense play a less important role
• Specially in medically compromised patient
Penicillin

76. Drug of choice
• Penicillin –narrow spectrum- low toxicity
• Amoxicillin is preferable to penicillin V because of less frequent
dosage
Co-amoxicillin (broad) for complex infections
Azithromycin –in allergy
Clindamycin-allergy anaerobic bacteria
Metronidazole- anaerobic bacteria –combination with aerobic AB
Moxifloxacin-only by specialist

77. Principle 7 : administer antibiotic properly
• For odontogenic infection a 3or 4 day course of penicillin with
appropriate surgery is effective as a 7 day course
• entire prescription must be taken

78. Principle 8: evaluate frequently
• 2 to 3 days after completion of the original therapy
• Check the site of I&D to remove the drain
•Failure=main reason inadequate surgery -so extraction or I&D
into the area that was not detected in the first time, must be
considered
• Second reason of failure : depressed host defense.

79. • Third reason : presence of foreign body(infected radiopaque body) a
shelter from immune system
• Dental implants should be debrided or removed
• Forth :antibiotic may be problematic :poor penetration to abscess
(inadequate surgery or drainage blood supply , low dose ),
• Incorrect chose of AB for the bacteria
• Resistance of bacteria
• Establishment of a secondary infection like candida

81. Recurrence of infection
• Early removal of the drain
• Patient may stooped taking the drug too early
• Surgical intervention and antibiotic therapy should be considered

82. Principles of prevention
of infection
•Prophylaxis of wound infection

83. Principles of Prophylaxis of wound infection
• Prophylactic AB are effective against post operative infections and
blood borne infections

84. 1-procedure should have significant risk of
infection
• Most office procedures Do not require prophylactic AB
• Like extraction, frenectomy, biopsy, minor alveoloplasty, torus
reduction, periapical infection, severe periodontitis, multiple
extractions

85. • Size : a present abscess or cellulitis
• Time: longer than 4 hours
• Presence of a Foreign body : commonly dental implant
• depressed patient host defense(most important )
• Organ transplantation –chemotherapy(until a year after end of
cession)
• Diabetes

86. diabetes
• The most common
• Immunosuppressive
• disease
• HBa1c most
• be under 7%

87. Principle 2 : choose correct antibiotic
• AB Should be
• 1-effective against organism
• 2-narrow –spectrum
• 3-the least toxic AB available
• 4-bactericidal
• So its penicillin or amoxicillin
• Allergy =>clindamycin
• 3rd choice is azithromycin

88. Principle 3: plasma level must be high
• Drug must be given in a dose at least two times the usual dose
• For penicillin and amoxicillin this is 2 gr
• Clindamycin 600 mg
• Azithromycin 500 mg

89. Principle 4: Time antibiotic administration
correctly
• AB must be given 2 hours or less before surgery begins
For the oral route its 1 hour
For prolonged operations intraoperative dose must be considered
Its intervals should be shorter (half)-penicillin and clindamycin should
be given every 3 hours during prolonged surgery

90. Principle 5: use shortest antibiotic exposure
that is effective
• For short operations a single dose before the surgery is enough
• Use of antibiotics is only necessary in the time of surgery
• not after that

91. Principles of prophylaxis against metastatic
infection
• Metastatic infection: infection that occurs at a location physically
separate from the portal entry of bacteria
• Bacterial endocarditis

92. Conditions for metastatic infection
• 1-suspectible location (hearth valve )
• 2-bacteremia
• 3-bacterial proteins –adheins in 3 streps(s.sanguis- s.mitis s.oralis )
• 4-impaired local host defense

93. Bacterial endocarditis treatment (hospital)
• High dose of intravenous antibiotic for prolonged periods
• Often damaged native valve must be surgically replaced by a
prosthetic valve
• Recurrence reduces survival rate in 5 years to 60%

94. Bacterial endocarditis
prophylaxis guideline
• 1-previos endocarditis
• 2-prosthetic heart valve
• 3-cyanotic congenital heart defects –not been repaired or have partial
defect after repair
• 4- heart transplant with valvopathy
• -----6 mounts after procedure (endothlialization time)

99. Other considerations
• Patient with daily taking of penicillin => streptococcus may be resistant to
penicillin so patient should use
• clindamycin or clarithromycin or azithromycin
• If possible a period of 10 days after AB completed to allow flora to become
normal
• 10 days between appointment for the same reason and to reduce resistant
colonies
• In the case of an unexpected bleeding or a patient who didn’t inform the
surgeon of the condition , AB prophylaxis should be administered as soon
as possible
• The limitation of AB prophylaxis is 4 hours

100. Before the surgery for the patients in the risk
of IE
• -comprehensive prophylaxis program including
• 1-excellent oral hygiene
• 2-excellent periodic care
• 3-treat of all dental and periodontal diseases
• 4-mount wash with chlorhexidine before surgery
• 5-patient should be inform about signs of IE (it may still occur)
• -prosthetic valve E is more fatal than native valve E

101. Prophylaxis in patients with other
cardiovascular conditions
• 1-in renal dialysis metastatic infection can occur in shunts
• 2-patient who have hydrocephaly in ventriculoatrial shunts
• 3- nonvalvular cardiovascular devices -just if there must be a I&D of
abscess in other sites

102. Prophylaxis against total joint replacement
infection
• Risk of hematogenous spread of bacteria
• May result in the lose of implant
• Aggressive treatment including extraction , I&D ,high dose
bactericidal AB and C&S test

103. Thank
you