Management of Odontogenic Infection Flashcards
Pathiobiology of Odontogenic Infection
Initiated by aerobic bacteria and perpetuated by anaerobic bacteria
Aerobic Phase
- Cellulitis
- Abscess
- Fistula
Doesn’t always progress to the next stage but may become severe stage
Cellulitis
Primarily streptococcus
Early - Mild, soft/red, easily treated
Advanced - diffuse, hard, life threatening, hard to treat
Abscess
Primarily filled with anaerobes
Pus filled cavity
Propagation of Odontogenic Infection - Determination of spread
Determination of spread = muscle attachments, bone thickness, root angulation
Primary Space Infection
Immediately adjacent to where tooth is
Vestibular Canine Buccal Sublingual Submental Submandibular
Spread of Maxillary Infection
Usually goes through facial bone rather than palatal.
Roots of anterior teeth usually below muscles = vestibular infection
Roots of posterior teeth above muscles = buccal space infection
Spread of Mandibular Infection
Thin labial bone anterior
Thin lingual bone posterior
Mylohyoid muscles - roots of 2nd and 3rd molars are below (submandibular) and the rest are above (sublingual)
Submental Space Infection
Not odontogenic source typically
Ludwig’s angina
Bilateral submandibular, sublingual and submental space cellulitis
Life threatening
Secondary spaces
Masticator space (masseteric, superficial/deep temporal, infratemporal, pterygomandibular) of infections = trismus
Pterygomandibular Space Infection (secondary space)
Trismus is hallmark
Direct spread from submandibular or sublingual infection or needle track infection
Lateral Pharyngeal Space
Vascular necrosis and hemorrhage
Direct airway impingement
Spreads to superior mediastinum or to inferior mediastinum = danger space
Rapid/Severe Fascial Space Involvement risk factors
High speed hand piece for extractions
Non-sterile water/air
Vented into wound
Rapid/Severe Fascial Space Involvement Presentation
Rapidly involves multiple spaces including distant
May have crepitance on palpation or air on radiograph
Principles of therapy of odontogenic infections
Determine Severity! Evaluate host defenses Refer Treat surgically Support medically Antiobiotics Re-evaluate frequently
Factors to Consider
Rate of progression! Quality and Quantity of swelling Location of swelling Trismus Systemic Involvement Airway
Location of swelling
Primary Space
Secondary Space - admission advised
Neck space - admission advised
Use CT scan
Trismus
Indicates secondary space involvement
Important when evaluating referral or admission
Trismus measurements
<15 mm = refer/consider admission
<10 mm = admission advised
35 mm normal
Systemic Issues w/ odontogenic Infections
Temperature >101 degrees
General malaise
Lab Tests
WBC count not good measure of severity of odontogenic infection (Elevated early and remains high)
Temperature is most correlative
Airway
Any compromise is serious
Dysphagia, odynophagia, dyspnea, drooling, posturing
Surgical Goals
Remove source of infection!
Drain pus
Release tension to improve circulation (cellulitis)
Medical Management
Fluids, analgesics, nutrition, antibiotics
Antiobiotic Therapy
Empiric Therapy Narrow spectrum Least toxic Bactericidal Cost?
Mild Infection Antiobiotic
PCN VK
or
Amoxicillin!!
Moderate Infection
Amoxicillin plus metronidazole
PCN Allergy
Clindamycin
3rd line - Clarithromycin
Reasons for Failure
Bad surgery = source remains or all spaces not explored or inadequate drainage
Unrecognized immune suppression
Foreign body
Antibiotic Problem
