infection Flashcards
1
Q
acute dentoalveolar abscess
A
localised suppurative inflammation involving teeth and supporting structures
2
Q
what the the pathogens mostly in an acute dentoalveolar abscess?
A
anaerobes
3
Q
acute dentoalveolar abscess - how do pathogens gain entry to PA tissue?
A
through necrotic pulp or PDL
4
Q
acute dentoalveolar abscess S+S
A
pain on biting (pressure on apical pathology)
pyrexia
lymphadenopathy
5
Q
what can lack of appropriate tx of an acute dentoalveolar abscess lead to/
A
chronic dentoalveolar abscess
- persistent low-grade chronic infection
granuloma can be asymptomatic until acute stage of infection
6
Q
cardinal signs of inflammation
A
tenderness
pain
redness
swelling
7
Q
feature of chronic infection
A
sinus formation (IO or EO) may stimulate epithelial cells and initiate development of cyst
8
Q
common odontogenic sources of infection
A
PA infection
- PA abscess
- apical periodontitis
- cellulitis - spreading of infection into surrounding
tissues
pericoronitis
- impaction of food and bacteria
- swelling and inflammation
9
Q
path of spread - PA infection
A
caries pulpitis PA infection alveolar bone localised STs fascial space
10
Q
PA infection U tooth directions of spread
A
nasal passage MS oral cavity buccal sulcus buccal space lateral to buccinator
11
Q
PA infection L tooth directions of spread
A
FOM: above/below mylohyoid
oral cavity
buccal space
12
Q
path of spread - pericoronitis
A
operculum food trapping/bacterial ingress pericoronitis localised STs fascial space
13
Q
pericoronitis L8 directions of spread
A
buccal space masticatory space lat pharyngeal space sublingual space submandibular space
14
Q
fascial space involvement
A
if infection continues to spread, it can travel into the fascial spaces, some of which can lead to EO swelling
15
Q
primary fascial spaces
A
palatal vestibular canines buccal submental submandibular sublingual
16
Q
where does a palatal fascial space infection often originate from?
A
U laterals
17
Q
canine fascial space
A
eats through maxillary bone nasolabial fold obliteration orbital region involvement can cause CST cranial spread through external angular vein levator anguli oris and oculi
18
Q
buccal fascial space
A
U and L premolars/molars can spread into: - temporal space superiorly - submandibular space inferiorly - masseteric space posteriorly
19
Q
submental fascial space
A
L incisors and canines
has perforated through lingual cortex
also if have infected mandibular fracture to symphysis
taut skin, can be a bit red
20
Q
submandibular fascial space
A
commonly teeth where roots below mylohyoid, usually 7+8 (rarely 6/premolars)
can’t palpate border of mandible
often present w trismus
pain and redness over swelling
21
Q
sublingual fascial space
A
L incisors, canines, premolars, mesial root 6
roots lie above mylohyoid attachment
diff swallowing/breathing
tongue displaced posteriorly and medially
raised FOM
voice can sound different “hot potato”
22
Q
Ludwig’s angina
A
bilateral submental, submandibular and sublingual swelling
medical emergency - refer to hospital
hard swelling, often diffuse cellulitis
FOM raised, trismus, difficulty breathing, tongue swollen
23
Q
secondary fascial spaces
A
if infection continues to spread
temporal, masseteric, pterygomandibular, lateral pharyngeal, retropharyngeal, prevertebral spaces
parotid, superficial, deep temporal
24
Q
consequence of infection spreading to secondary fascial spaces
A
can lead to infection becoming life-threatening - trismus, difficulty breathing, speaking and swallowing
need hospital for IV ABs, +/- EO I+D - after EO drainage drains are inserted into the fascial spaces up to 48hrs post-op
if infection not txed - can lead to sepsis
25
SIRS
body's response to a stimulus, such as infection or trauma
diagnosis: 2 or more of
- temp <36 or >38 degrees
- hr >90bpm
- resp rate >20bpm
- WBC count <4000/mm3 or >12000/mm3 or >10% immature (band) forms
26
sepsis
life-threatening condition caused by an overreaction of the body's immune response to infection
diagnosis: SIRS + infection present
27
septic shock
sepsis with persistent hypotension despite adequate fluid replacement
28
worst outcome of sepsis
organ failure and death
29
management of infection
```
history
exam
resuscitative (ABC) and supportive tx
special investigations
take pt observations (baseline in case infection progresses)
remove source of infection - RCT/ext
remove any pus accumulated - I+D of swelling (if no drainage through RCs/socket - establish drainage
(ABs)
```
30
can't remove source of infection immediately
e.g. unable to numb pt
| still important to I+D as much pus as possible to reduce swelling
31
special investigations
xray
sensitivity testing
referral CT/MRI/US
32
HPC
```
when
had previously
spread
systemic symptoms
pain
mouth opening
changed colour/consistency
getting bigger/smaller
```
33
MH
drug allergies
diabetes
immunocompromised
34
DH
recent tx
| had before
35
SH
any responsibilities e.g. kids
| when last ate and drank - don't let them if even small chance of GA
36
sepsis 6
```
give O2 (high-flow)
give IV antibiotics
give IV fluids
take blood cultures
measure urine output
measure lactate
```
37
EO examination
facial profile - asymmetry, LNs, colour change
TMJ
MofM
SOB
38
IO exam
perio, carious teeth
sinus tract
deviation of uvula (parapharyngeal spread) - risk of aspiration
39
determining severity
onset, progression, history, trismus, systemic symptoms
pt factors e.g. diabetic/on steroids
warning signs
40
warning signs to refer
```
fever
dehydration
crossing midline
rapid progression of swelling
increasing trismus
quality/location of swelling
elevation of tongue/firmness of FOM
difficulty speaking and swallowing
eye involvement
```
41
pt observations
hr 60-100bpm
bp 90/60 - 120/80 mmHg
temp 36-38 degrees
O2 sats 95-100%
42
aspiration of pus
may take from a swelling to do culture and sensitivity of bacteria
allows for more targeted AB tx
in taking an aspiration you also decrease the size of the swelling
in case it doesn't respond to AB therapy so you can see what it will be sensitive to
43
indications for prescribing ABs
local measures have failed (e.g. tooth ext but swelling and infection remains)
pt systemically unwell
cellulitis
infection spreading
44
SDCEP refer to A and E or urgent OMFS
significant trismus
FOM swelling
eye involvement
difficulty breathing
45
complications
```
SIRS and sepsis
multiorgan failure
death
scars
orbital infections
CST
- bulging eye, loss of vision
- headache
- CNs paralysed
mediastinitis
pericarditis
```
46
in practice guidelines
```
establish diagnosis
document - pulse, temp, resp rate
remove cause
I+D
emergency referral: phone ahead (OMFS)
- send referral letter w pt to A and E
(ABs)
```
47
swab
rub it over area
problems
- easily contaminated by oral bacteria
- anaerobes exposed to air
48
amoxicillin
500mg
send 15
x3 daily
5 dys
49
metronidazole
200/400mg
send 15
x3 daily
5 days
not if heavy drinker/warfarin
if penicillin allergy
adjunct if spreading infection/pyrexia
50
phenoxymethylpenicillin
250mg
send 40
2 x4 daily
5 days
51
when should you use second line antibiotics?
if don't respond to 1st line or severe infection with spreading cellulitis
52
consequence of 2nd line ABs
c dificile infection
53
co-amoxiclav
250/125
send 15
x3 daily
5 days
54
clindamycin
150mg
send 20
x4 daily
5 days
55
which AB has the side effect of AB associated colitis?
clindamycin
56
clarithromycin
250mg
send 14
x2 daily
7 days
57
primary fascial spaces
```
palatal
vestibular
canines
buccal
submental
submandibular
sublingual
```
58
secondary posterior potential spaces
masticatory
lateral pharyngeal
retropharyngeal
prevertebral
59
masticatory spaces
```
superficial temporal
deep temporal
infratemporal
pterygomandibular
masseteric
```
60
describe the stages between caries/(trauma) and an infected apical radicular cyst
```
pulp hyperaemia (increased blood flow)
acute pulpitis - chronic pulpitis
acute apical periodontitis
- out into PDL - no longer just pulpal
acute apical abscess
(chronic sinus)
chronic apical infection (granuloma)
- collection of granulation tissue
radicular cyst
- not everyone gets this, genetic? doesn't tend to cause
pain
infected apical radicular cyst
- causes pain
```
61
can you diagnose an abscess radiographically?
no can only see a radiolucency
| so unlikely to see if an acute abscess
62
what does pain result from in an abscess?
usually from build up of pressure as pus builds up
63
c-fibres
innervate pulp
| really hard to localise pulpal pain
64
a-fibres
innervate PDL
good pain localisation
when infection spreads to periodontium pt will be able to localise pain well
65
pulp hyperaemia
```
pain
- lasts for seconds
- stimulated by hot/cold or sweet foods
- resolves after stimulus
caries approaching pulp - can still treat tooth without treating pulp
```
66
acute pulpitis clinical features
constant severe pain
reacts to thermal stimuli
poorly localised pain
referral of pain
no/min response to analgesics - hard for blood to get in
open symptoms less severe - less build up of pressure
67
acute periodontitis
```
easy to diagnose
TTP
tooth non-vital (unless traumatic)
slight increase in mobility
radiographs
- loss of clarity of LD
- radiolucent shadow - may indicate an 'old' lesion e.g. flare up of an apical granuloma
- delay in changes at the apex - widening of apical PD space
```
68
traumatic periodontitis
```
cause - parafct
diagnosis
- TTP
- normal vitality
- radiographs - widening of PDL space
examine occlusion
tx - therapy for parafct
```
69
dental abscesses
acute apical abscess - commonest pus producing infection
other possible causes
- PD abscess
- pericoronitis
- sialadenitis (infection of salivary glands)
70
abscesses MOs
polymicrobial
| anaerobes
71
acute apical abscess
clinical features - reflect stage of abscess
- initially almost identical to acute apical periodontitis (before eroding through bone and into ST)
symptoms
- severe unremitting pain
- acute tenderness in fct
- acute TTP
BUT no swelling, redness or heat yet - get when spreads into STs
72
5 cardinal signs of inflammation
```
heat
redness
swelling
pain
loss of fct
```
73
once abscess perforates through bone
pain often remits (unless in palate)
swelling, redness and heat in STs
as swelling increases pain returns
initial reduction in TTP as pus escapes into STs
74
reversible pulpitis
```
a level of inflammation in which returning to a normal state is possible if noxious stimuli removed
mild/mod pain when stimulated
no pain without stimulus
subsides <5secs
no mobility
no pain on percussion
```
75
irreversible pulpitis
a higher level of inflammation in which pulp has been damaged beyond recovery
sharp, throbbing, severe pain upon stimulus
- can be spontaneous/no stimulation
pain persists after stimulus removed >5secs
tx - RCT or ext
76
site of swelling depends on
position of tooth in arch
root length
muscle attachments
potential spaces in proximity to lesion
77
periapical granuloma (chronic apical periodontitis)
mass of chronically inflamed granulation tissue at apex of tooth
- plasma cells, lymphocytes, and few histocytes with fibroblasts and capillaries
not a true granuloma because not granulomatous inflammation
= has epithelial histocytes mixed with lymphocytes and GCs
78
aetiology of radicular cyst
```
caries/trauma/PDD
death of pulp
apical bone inflammation
dental granuloma
stimulation of epithelial rests of malassez
epithelial proliferation
periapical cyst formation
```
79
where does infection spread?
along path of least resistance
80
path of spread maxillary teeth
buccal space
buccal sulcus
maxillary sinus
81
maxillary palatal spread
less likely to spread palatally - dense bone
likely in U2s as root lies palatally
v painful - taut tissues
82
path of spread mandibular teeth
buccal space
buccal sulcus
sublingual (anteriors)
submandibular (posteriors)
83
posterior potential spaces
masticatory space
lateral pharyngeal space
retropharyngeal space
prevertebral space
84
masticatory spaces
```
superficial temporal
deep temporal
infratemporal
pterygomandibular
masseteric
```
85
what symptoms will pt have if infection spreads into masticatory space?
severe trismus
may/may not have swelling depending on where it spreads
- unlikely if lingual spread
- swelling if buccal spread
86
CST
brain spread possible
| infratemporal space - pterygoid venous plexus
87
route of spread into chest
retropharyngeal space
| prevertebral space
88
upper anteriors spread of infection
lips
nasolabial region
lower eyelid
2s - palate (less common)
89
upper posteriors spread of infection
cheek
infratemporal region
maxillary antrum (v rare)
palate (less common)
90
lower anteriors spread of infection
mental and submental space
91
lower posteriors spread of infection
```
buccal space
submasseteric space
sublingual space
submandibular space
lateral pharyngeal space
```
92
which part of a swelling should you incise?
the most fluctuant part
| but take into account proximity of nerves etc
93
Ludwig's angina
bilateral cellulitis of the sublingual and submandibular spaces
94
IO features of Ludwig's angina
raised tongue
diff breathing
diff swallowing
drooling
95
EO features of Ludwig's angina
diffuse redness and swelling bilaterally in SM region
96
systemic features of Ludwig's angina
raised hr, resp rate, temp, WCC
97
EO drain
to allow rest of pus to drain
| remove when it has stopped draining pus
98
OM predisposing factors
```
bisphosphonates
impaired vascularity of bone
foreign bodies
compound fractures
impaired host defences
```
99
mechanisms of AB resistance
altered target site
enzyme inactivation
reduced uptake
100
breakpoint
a chosen conc of an AB which defines whether a species of bacteria is susceptible or resistant to the AB
101
clinical resistance
when infection is highly unlikely to respond to even max doses of AB
