Management of Infections Flashcards
What are 3 initiating infections that can spread beyond the teeth to the alveolar process and the deeper tissues of the face, oral cavity, head, and neck?
- Caries
- Periodontal disease
- Pulpitis
Bacteria that cause infection are most commonly part of what?
Indigenous bacteria that normally live on or in the host
What are the primary oral bacteria type that can lead to infection?
Aerobic G+ cocci
Anaerobic G + cocci
Anaerobic G- rods
Almost all odontogenic infections have what bacterial source?
Polymicrobial
What are the predominant aerobic bacteria in odontogenic infections?
Streptococcus milleri group
What are the 2 main groups of anaerobic bacgteria found in odontogenic infections?
Anaerobic G+cocci: Streptococcus and Peptostreptococcus
What bacteria type initiates the odontogenic infection?
Aerobic streptococcus, release hyaluronidase to spread into connective tissue starting a cellulitis type infection, which is favorable to anaerobic growth
What occurs in the mixed aerobic/anaerobic infection allowing the anaerobes to eventually dominate after the aerobes have initiated the infection?
The oxidation-reduction potential lowers, aerobs dies out, and anaerobes cause liquefaction necrosis via collagenases
Early infections appearing initially as a cellulitis may be characterized as what type of infection?
Aerobic streptococcal infections
Late, chronic abscesses may be characterized as what type of infections?
Anaerobic infections
Clinically, the progression of the infecting flora from aerobic to anaerobic correlates with what?
The type of swelling
What is stage 1 of the 4 odontogenic infection stages characterized as the first 3 days of symptoms with a soft, mildly tender, doughy swelling . Invading aerobic streptococci are just beginning to colonize the host?
Inoculation stage
What is stage 2 of the 4 odontogenic infection stages characterized after 3-5 days, swelling is hard, red, and acutely tender. Infecting mixed flora stimulates intense inflammatory response?
Cellulitis stage
What is stage 3 of the 4 odontogenic infection stages characterized as 5-7 days after onset of swelling, liquefied abscess in center of swollen area. Caused by predominant anaerobes in infection?
Abscess Stage
What is stage 4 of the 4 odontogenic infection stages characterized when the abscess drains spontaneously through the skin or the mucosa, or it is surgically drained. Begins as the immune system destroys the infecting bacteria and the precesses of healing and repair ensue
Resolution stage
What are 2 major origins of odontogenic infections?
- Periapical
2. Deep periodontal pocket
Which cause of odontogenic infection is a result of pulpal necrosis and subsequent bacterial invasion in the periapical tissue?
Periapical
Which cause of odontogenic infection is a result of a deep periodontal pocket that allows inoculation of bacterial into the underlying soft tissues?
Periodontal
What is the most common cause of odontogenic infections?
Periapical
What is expected if you treat periapical pathosis with only antibiotics?
The pathosis will recur because you haven’t gotten rid of bacterial source, e.g. deep caries to pulp causing necrotic pulp
What is the primary treatment for pulpal infections?
Endo or extract, not antibiotics
What are 2 determinants of the location of an infection arising from a specific tooth?
- Thickness of bone overlying apex of tooth
2. Relationship of the site of perforation of bone to muscle attachments of maxilla and mandible
Once infection has eroded through the bone, the precise location of the soft tissue infection is determined by?
Relative position of perforation relative to muscle attachments
Infections from most maxillary teeth erode through bone in which direction?
Facial cortical plate, normally below the attachment of the muscles to the maxilla
Most maxillary dental abscesses appear initially as what?
Vestibular abscess
Maxillary [lingual] abscesses occur from what 2 teeth?
- Inclined lateral incisor
2. Palatal root maxillary first molar or premolar
How do maxillary molars commonly erode and what space infection do they cause?
They erode bone superior to the buccinator muscle insertion and cause buccal space infection
What is the maxillary tooth that can cause an infraorbital infection by eroding through bone superior to the insertion of the levator anguli oris muscle?
Max canine root, also called a canine space infection
Mandibular incisors, canines and premolar infections normally erode through what plate and cause what abscess type?
Facial cortical plate superior to attachment of lower lip muscles. Causes vestibular abscess.
Which mandibular teeth erode through the lingual cortical plate more often: anteriors or molars?
Mandibular molars
Mandibular first molar abscesses can drain which direction?
Buccal or Lingual
Mandibular second molar abscesses can drain which direction?
Buccal or Lingual, mostly Lingual
Mandibular third molar abscesses almost always erode in which direction?
Lingual
What muscle determines whether infections that drain lingually go superior into the sublingual space or inferior into the submandibular space?
Mylohyoid muscle
What is the most common odontogenic deep fascial space infection?
Vestibular space infection
If the vestibular abscess ruptures and remains open to a chronic sinus tract that drains orally or to the skin, will the patient experience pain?
No
Definitive treatment of chronic sinus tract requires what and what is the common cause?
Treat the original causative problem (usually necrotic pulp)
What are 8 Principles of Therapy of Odontogenic Infections?
- Determine severity
- Evaluate Patient’s Host Defense Mechanism
- Determine who treats, Gen Dentist or OMFS
- Treat infection surgically
- Support pt medically
- Choose and Prescribe appropriate antibiotic
- Admin antibiotic properly
- Eval pt frequently
What information must you get to determine the severity of an infection?
- Chief complaint
- Length of infection (onset, course, rapidity)
- Elicit patientt’s symptoms
- Patient’s general feeling
- Treatment (patient’s own pain management or previous professional treatment)
- Normal Medical history
- Physical Exam
What are the cardinal signs of inflammation?
Dolor (Pain) [re: Dang that hurts] Tumor (Swelling) Calor (Warmth) Rubor (Erythema, redness) [re: Ruby red] Functio Laesa (loss of function)
What is the most common complaint of odontogenic infection?
Pain
What term indicates a generalized reaction to a moderate to severe infection?
Malaise (feel fatigued, feverish, weak, and sick)
What are 3 things to do during the physical exam to aide in determining the severity of the infection?
- Take Vitals
- Extraoral exam
- Intraoral exam
- Radiographs
What is the character of temperature in patients with severe infections?
Temperature elevated to 101°F (>38.3°C)
What vital also increases as the patient’s temperature increases?
Pulse rate
What is the vital sign that varies the least with infection?
Blood pressure
What is one of the major considerations in odontogenic infections?
Potential for partial or complete upper airway obstruction as a result of extent of infection into deep fascial spaces of neck
What is the respiratory rate of a patient with mild to moderate infection?
18 breaths/min (normal =14-16 breaths/min) (after walking up stairs in from locker room to Lyons 443 = 87.5 breaths/min with atrial fibrillation and tunnel vision)
What are 3 general consistencies of swelling when palpated?
- Doughy
- Indurated (hard)
- Fluctuant (puss-filled)
If swelling is soft , mildly tender and edematous it indicates what stage of infection: Inoculation, Cellulitis, or abscess?
Inoculation stage
Indurated (firm) swelling indicates what stge of infection: Inoculation, Cellulitis, or abscess?
Cellulitis
Central fluctuant swelling indicates what stage of infection: Inoculation, Cellulitis, or abscess?
Abscess
How may soft tissue infections in the inoculation stage be cured?
Remove odontogenic cause with or without antibiotic support
Infections in the cellulitis or abscess stage require what treatment?
Removal of dental cause plus incision and drainage, and antibiotics
Is the duration of cellulitis acute or chronic?
Acute
What is the most severe presentation of the infection?
Cellulitis
What is a sign of increasing host resistance?
Abscess
Which is more painful: cellulitis or abscess?
Cellulitis
What is the the hallmark of the inoculation stage?
Edema. Typically diffuse, jellylike with minimal tenderness to palpation.
What is the character of the border of cellulitis?
Indistinct and diffuse
What is the feeling of severe cellulitis?
Indurated/boardlike
How is severity related to firmness of cellulitis?
More sever cellulitis is firmer
Is a localized abscess dangerous and why?
Less dangerous, more chronic and less aggressive
The presence of pus indicates what?
The body has locally walled off the infection and local host resistance mechanism are bringing infection under control
What represents the earliest inoculation stage of infection that is most easily treated?
Edema
What is an acute, painful infection with more swelling and diffuse borders, a which has a hard consistency?
Cellulitis
Does cellulitis contain pus?
No
What is a more mature infection with more localized pain, less swelling, and well-circumscribed borders?
Acute Abscess
What type of infection is slow growing, is less serious that cellulitis, especially when it has drained spontaneously?
Chronic Abscess
What are 3 general conditions that can cause a compromised host defense that can lead to susceptibility to increased infection?
- Uncontrolled metabolic disease
- Immune system-suppressing diseases
- Immunosuppressive therapies
What are 4 examples of uncontrolled metabolic diseases that can compromise host defenses?
- Poorly controlled diabetes
- Alcoholism
- Malnutrition
- End-stage renal disease
What are 4 examples of immune system-suppressing diseases?
- Human immunodeficiency virus/acquired immunodeficiency syndrome
- Lymphomas and leukemias
- Other malignancies
- Congenital and acquired immunologic diseases
What are 3 examples of immunosuppressive therapies?
- Cancer chemotherapy
- Corticosteroids
- Organ transplantation
What are 3 drugs that decrease T and B lymphocyte function and immunoglobulin production?
- Cyclosporin
- Corticosteroids
- Azathioprine (Imuran)
What is the treatment protocol when a patient has a compromised host defense?
Treated more vigorously and refer to OMFS
What are the criteria for referral to OMFS?
- Difficulty breathing (dyspnea)
- Difficulty swallowing (dysphagia)
- Dehydration
- Moderate to severe trismus (interincisal open <20mm)
- Swelling extending beyond the alveolar process
- Elevated temperature (greater than 101°F)
- Severe malaise and toxic appearance
- Compromised host defense
- Need for general anesthesia
- Failed prior treatment
What are the 3 main criteria indicating immediate referral to the ER?
- Rapidly progressing (significantly worse in 1-2 days)
- Difficulty breathing (dyspnea)
- Difficulty swallowing (dysphagia)
What are the criteria to classify trismus as mild, moderate or severe?
- Mild: max interincisal opening 20-30mm
- Moderate: max interincisal opening 10-20mm
- Severe: max interincisal opening <10mm
What are 2 primary principles of management of odontogenic infections?
- Perform drainage
2. Remove cause of infection
What is the primary goal of surgical management of infection?
Remove cause of infection
What is the secondary goal of surgical management of infection?
Provide drainage of accumulation of pus and necrotic debris
If endodontic opening of a tooth does not provide adequate drainage of abscess, what must be performed?
Incision and drainage
What is the preferred site for Intraoral incision for incision and drainage?
Directly over site of maximum swelling and inflammation, but not across a frenum or path of mental nerve in lower premolar region
What is the depth and length of incision for incision and drainage?
Through mucosa and submucosa, no more than 1cm in length
What is done once an incision is made?
Insert curved hemostats and open in multiple directions to break up loculations or pus pockets
Once all areas of an abscess cavity have been opened and all pus removed what can be inserted to maintain the opening?
Small drain: 1⁄4 sterile penrose drain, sterile rubber dam material, or sterile surgical glove material. All are sutured with non-resorbable tissue to one side of viable tissue of the incision
How long is the drain?
Must reach bottom of the abscess
How long does the drain remain in place?
2-5 days
Do inoculation stage infections (edema) normally require incision and drainage?
No
What is the primary method for treating odontogenic infection?
Perform surgery to remove source of infection and drain anatomic spaces
What must be done everytime cellulitis or abscess is diagnosed?
Drainage
What must be used when complete abscess drainage cannot be achieved by extraction alone?
Antibiotic
What is a major instruction to give patient for post surgery support?
Drink sufficient water and juice, increase caloric intake
What are 3 factors to consider before prescribing antibiotics?
- Seriousness of infection
- Can adequate surgical treatment be achieved
- State of patient’s host defenses
What are 7 definite indications for antibiotic use?
- Swelling extending beyond the alveolar process
- Cellulitis
- Trismus
- Lymphadenopathy
- Temperature higher than 101°F
- Severe pericornitis
- Osteomyelitis
What are 7 situations where antibiotics are not indicated?
- Patient demand
- Toothache
- Periapical abscess
- Dry socket
- Multiple dental extractions in noncompromised patient
- Mild pericornitis (inflammation of operculum only)
- Drained alveolar abscess
What is the overall indicator for the use or non-use of antibiotics?
Use only when clear evidence exists of bacterial invasion into deeper tissue spaces that is greater than host defenses can overcome
What are 6 antibiotics effective against odontogenic infection causing bacteria?
- Penicillin
- Amoxicillin
- Clindamycin
- Azithromycin
- Metronidazole
- Moxifloxacin
What is an antibiotic that is effective only against obligate anaerobic bacteria?
Metronidazole
What is the drug of choice for odontogenic infections?
Penicillin
Alternative treatment for odontogenic infection in penicillin allergic patients
Clindamycin or azithromycin
What is the best way to prescribe an antibiotic to ensure patient compliance?
Prescribe to take the fewest amount of times/day
What is good about amoxicillin and clindamycin prescriptions over penicillin?
Give 3/day versus penicillin 4/day
What spectrum antibiotic is best?
Narrow spectrum
What is a major side effect of penicillin?
Allergy
What is a major side effect of azithromycin, clindamycin?
Severe diarrhea
What is the peak plasma level of antibiotic to kill bacteria involved in infection?
4-5 times the minimal inhibitory concentration
How long after initial therapy should patient be asked to return for evaluation?
2 days
What is the most common cause of treatment failure?
Inadequate surgery
What is the most common secondary infection encountered by dentists?
Oral or vaginal candidiasis
What is the definition of “fascial spaces”?
Fascia-lined tissue compartments filled with loose areolar connective tissue. Potential spaces in health.
Infections that pass beyond the alveolar process toward the oral cavity (deep side) of the muscle invade which space?
Vestibular
infections that pass beyond the alveolar process toward the soft tissues on the superficial (skin side) of the muscle enter what space?
Buccal or subcutaneous space
Which infection is not likely to threaten the airway or vital structures?
Low severity infection
Which infection that hindes access to the airway by causing trismus or elevation of the tongue, can make endotracheal intubation difficult?
Moderate severity infection
Which infection can directly compress or deviate the airway or damage vital organs, such as the brain, heart, or lungs?
High severity infection
Buccal space is actually part of what space that extends from head to toe?
Subcutaneous space
Spontaneous drainage of maxillary canine infections can cause what?
Obliterate nasiolabial fold and drain to either medial or lateral canthus of eye
Which teeth most commonly cause buccal space infections?
Maxillary molars
Where are buccal space infections usually located?
Below zygomatic arch and above inferior border mandible
Which space, posterior to the maxilla, is bounded medially by the lateral pterygoid plate of sphenoid and superiorly by the base of the skull, and laterally and superiorly is continuous with the deep temporal space?
Infratemporal space
20% of cases of maxillary sinusitis have what cause?
Odontogenic
What are 2 pathways to infect the cavernous sinus?
- infratemporal space (posterior route)
2. Infraorbital space (anterior route)
The space of the body of the mandible and the palatal space are both what type of spaces?
Subperiosteal spaces
What are 3 components of the perimandibular spaces?
- Submandibular
- Sublingual
- Submental
What is the lateral border of the sublingual and the submandiblar spaces?
The medial border of mandible
Sublingual and Submandibular spaces are involved in what infections?
Lingual perforations of infections from mandibular molars and premolars
What is the factor that determines whether the infection is submandibular or sublingual?
Attachment of mylohyoid muscles on mylohyoid ridge of medial aspect mandible
If an infection erodes through the lingual portion of the mandible above the mylohyoid line, the infection will be in what space?
Sublingual
Which teeth most commonly cause sublingual space infections?
First Molar and Premolars
Which tooth is most commonly involved in submandibular space infections?
Mandibular 3rd molar
What determines if the mandibular 2nd molar will involve the sublingual or the submandibular space?
Length of roots
Which part of the sublingual space is open and freely communicates with the submandibular space?
Posterior
Does the sublingual space have a lot of intraoral or extraoral swelling?
Little extraoral, lot of intraoral
Which space infection often becomes bilateral?
Sublingual, and tongue gets elevated
The posterior spaces of the submandibular space communicate with what?
Deep spaces of neck
How are submental space infections most commonly caused?
Submandibular space infection that goes around anterior belly of digatric muscle
What is a bilateral infection of the submandibular, sublingual, and submental spaces, characterized as a rapidly spreading cellulitis that can obstruct the airway and commonly spreads posteriorly to the deep fascial spaces of the neck?
Ludwig’s angina
What are 4 compartments of the masseteric space?
- Submasseteric space
- Pterygomandibular space
- Superficial temporal space
- Deep temporal space
What is the masseteric space where local anesthetic is given for an IAN block?
Pteyrgomandibular space
What is a valuable diagnosis for pterygomandibular space infections?
Trismus without swelling
What is contained in the lateral pharyngeal space (considered a deep cervical fascial space)?
Carotid sheath, CN IX (glossopharyngeal), CN X (Vagus), CN XII (hypoglossal)
Where is the danger space located?
Between alar fascia anteriorly and prevertebral fascia from base of skull to diaphragm
What are 5 general goals of management of fascial space infections?
- Medical support of patient to protect airway and correct host defense compromises if they exist
- Surgical removal of source of infection as early as possible
- Surgical drainage of infection w/ drains placed 4. Administration of correct antibiotics and dose
- Frequent reevaluation of pt progress
What is the best drainage to get if possible?
Pendant drainage (gravity fed)
Where should you perform incision and drainage if the infection is going extraoral?
NOT over the greatest fluctuance, but instead you should incise in a natural skin crease
What prescription should your write after you remove the source of infection then incision and drainage (if possible)?
500mg, 7 days, penicillin
How will buccinators space infection look intraorally?
Normal intraorally, swelling is extraoral, with drainage extraorally
What is the only space infection that does not have a bilateral counterpart?
Submental space
What is concern when performing incision and drainage on a sublingual space infection?
Lingual nerve and submandibualr duct. Must angle the incision in.
What are 2 reasons for doing extraoral draining?
Access and pendant drainage
If the patient has trismus, consider it what space infection until proven otherwise?
Masseter space infection
