Management of odontogenic Infection Flashcards
diagram about infection
- ven diagram encompesses - just keep in mind..
infection in middle with
- patient health
- anatomical factors
- microbial factor
etiology of odontogenic
pulpal
periodontal
peri-coronal
- subset of the periodontal like in3rd molars
abscess
localized collection of pus due to the breadown of infected tissue involved
cellulitits
diffuse inflammatory characterized by extensive hard swelling, induration and erythema
MORE DIFFUSE than than an abscess
pt. presents stressed and discomfort on lower left
now difficulty swallowing and a lot of swelling
trismus
convexity
pterygoid space infection secondary to the pericoronitis
10-11 year old boy with swelling around inferior of eye
firm swelling closer to maxilla and soft swelling near the infraorbital region
hit with hockey stick around maxillary incisors
canine space infection
NO INFECTION IN EYE – palpating lymphatic space - built up pressure from apical abscess / cellulitis
microbiology of odontogenic infection
higher % of ANAEROBIC involved than aerobes
many are POLYMICROBIAL
prominent aneerobes are
- bacteriocides, peptostreptococus , actinomyces, (the general microbial that we see in the mouth)
Aerobe = treptococcus
so management – not really doing the culture and specifying the treatment
- make assumption that we need polymicrobial
spread of infection usually through
- direct extension
- hematogenous – bacteremia
- lymphatic - lymphadenopathy
anatomical considerations for DIRECT extension for vestibular abscess
APEX of teeth are housed within the normal structure
most likely peri-apical infections break out to the buccal side into vestibule
peri-apoical infections usually break out
towards the buccal
- remember that posteiror mandibular molars are close to mylohyoid line and can break out into the submandibular space
palpate swelling for abscess
balloon - feel like the fluid
palpate cellulitis
no give – more like a baseball not as fluctuant
basal bone and alveolar bone in relation to the molars
alveolar bone is more lingual in this location of the molars
mylohyoid line and implication with apex of teeth (posterior lower molars) breakout of infection
break out into the SUBMANDIBULAR SPACE –
the first and second molar is very close to this mylohyoid line
the molars are situated more over the mylohyoid line above alveolar bone than the basal bone
most likely teeth to break out into the vestibule
the maxillary teeth
so typical alveolar abscess breaks out
toward buccal into the vestibule
mandibular molars will break out
submandibular space
posteiror molar that broke out buccally was from?
the furcation - not a peri-apical
mandibular anterior / incisor region - anatomic considerations for direct break out
mandibular incisors – spread into the MENTALIS SPACE
- since this muscle attaches relatively high – may break out into this space versus the oral cavity
direct FACIAL spaces to consider
- buccal
- pterygomandibular
- masseteric
- submandibular
- sublingual
- canine space
buccal facial space - genreal
superficial to the buccinator muscle
- roots of teeth insert above usually
more in children into buccal space infection
lower third molars can spread directly into what facial space
pterygomandibular space
pterygomandibular space infectin symptoms may present with
difficulty swallowing and opening
- muscle is inflammed
may not present with swelling – more convex
space lateral to the body of the mandible is
submasseteric space
submasseteric space potential symptoms
swelling externally
may be trismus
but not really airway problems
impacted 3rd molar that is placed more buccally could have more tendency to go towards ____ space as compared to _____ space even though this space is more common
may go towards the submasseteric space
vs the pterygomandibular space (more likely)
probably wont feel a fluctuant swelling
apical abscess on the mandibular molars likely spread to
submandibular space
probably wont feel fluctuance at first
sublingual space infectino - general
NOT common
lower anterior and pre molar peri-apical disease more likely to spread out towards the vestibular space - more simple vestibular abscesses
so think about other things if lingual floor swelling – like stone / trauma / of the salivary gland
canine space
in the infraorbital area or canine fossa
more likely in children – apex could be above the insertion of the muscles
masticatino and swallowing not involved in
canine space / infraorbital area
SECONDARY fascial spaces
- peritonsilar
- lateral pharyngeal
- retropharyngela
- temporal
- infratemporal
- parotid
massive swelling in tonsilar area - but no teeth involved
peritonsilar space infection
and rule out maxillary molars pathology
behind the pterygoid space?
lateral pharyngeal
retropharyngeal space
lateral pharyngeal space
can coincide with the pterygoid space infection
just medial to the lateral pharyngeal space
retropharyngeal space –so could spread here too
spread of infection from pterygoid to ___ space
lateral pharyngeal space
spread of infection to the temporalis space likely from
submasseteric space
AND
pterygomandibular space
superficial to or deep to the ZYGOMATIC ARCH A
swelling at location of zygomatic arch
temporalis space infection likely from submasseteric space or pterygomandibular space
lymphatic spread
- general outline
consider chain posterior to sternocleidomastoid and anterior to it
submandibular
submental
into anterior cervical
most of the area of head and neck drain into
submandibular / submental
submnetal node drainage primary
mid lower lip
chin
tip of tongue
lower incisor and ginginva
submental node drainage
secondary
submandibular and superior deep cervical nodes
submandibular node drainage
just about everything else
upper and lower jaw (BESIDES INCISORS)
LIPS - EXCEPT MID LOWER
anterior nasal cavity
anterior palate
body of tongue
secondary drainage for submandibular node drainage
deep cervical nodes
lower incisor lymph drain?
to the SUBMENTAL
tip of tongue lymph drains
to the SUBMENTAL
SUBMANDIBULAR LYMPHADONPATHY from maxillary?
yes– drains all maxillary
primary drainage of the deep cervical node
base of tongue
posterior palate
sublingual region
secondary drainage of the deep cervical node
submental, submandibular and accessory nodes
drainage of tongue
tip = submental
body = submandibualr
base = deep cervical
drainage of the tongue
can cross over - so variable
T/F antibiotics are essential in the treatment of odontogenic infections
FALSE – are NOT
essentials in treatment of odontogenic infections
- eliminate the source of the infection
2. establishment of drainage
fistula drainage?
if fistula present – drainage has already been established –
manifest as pain swelling off and on
drainage off and on
re-establish drainage
treatment for fistula
endo tx
patient already has established drainage and may be off and on so treat the source of infection
pt has bump of granulation tissue
tx?
put gutta percha point and take x-ray to confirm which tooth it is associated with and perform endo tx
incision and drainage use noramally - general
modality of tx
WITH FLUCTUANT SWELLING
If rock hard – probably not
incision with
15 blade into abscess cavity
just at the surface!
then can follow up with a more blunt instrument to chase it - but NO sharp disection to establish drainage
if establish drainage then decompresses / heals then comes back?
consider leaving something in the space for drainage
- latex rubber drain and suture to keep drainage
remove drain after?
usually 48 hours
- if really deep could be left longer
now treat the tooth usually after drainage has been established
peri-coronal infection - most likely from
tends to be almost exclusively with impacted 3rd molars
gets better and worse
recurrent swelling
symptoms of pericorintis
rx too?
temporalis muscle could be involved
can see loss of bone radigrpahically as well
initial tx of peri-corinitis
antibiotics
rinses
perio-probe to lift tissue
not take tooth out – traumatic extraction
want to get rid of acute infection first
if peri-coronitis and hurts mostly when closes down? what to do
remember do not want to extract the acutely infected tooth
take upper third molar out – may be supra-erupted and traumitizing the lower
antibiotic dose for penicillin V
500 q4-6h
antibiotic dose for erythromycin
250 q6h
antibiotic dose for doxycycline
100 q12h x 2 then 50 q12
antibiotic dose for keflex
500 q 6hrs
- like penicillin V
antibiotic dose for metronidazole
250 q8h
antibiotic dose for clindamycin
150 q6 hr
antibiotic dose for amaxicillin
500 Q8HR
complications of odontogenic infectinos
- airway obstruciton
- mediastinitis
- osteomyletitis
- sinusitis
- cavernous sinus thrombosis
- endocarditis
- systemic sepsis
osteomyelitis usually seen with
pt. that is not as healthy
a bilateral sublingual and submandibualr space cellulitis
LUDWIG’S ANGINA
Ludwig’s angina is?
a bilateral submandibualr and sublingual space cellulitis
needs to have all 4 spaces involved
struggles to breathe and keep mouth closed
radiation patient?
antibiotic tx probably necesary
evident cloudiness in one of the sinuses?
potential sign of root fragment displacment in into the sinus
if cavernous sinus infection?
probably from midface odontogenic if occurs
but dont rule out lower face infection
dx of cavernous sinus infection
muscle and a lot of nerves and muscles there
ecchymosis of eyes
eagleston’s criteria for
cavernous sinus thrombosis
eagleston’s criteria for cavernous sinus thrombosis
- site of infection
- evidence of bloos stream invasion (liek presence of fever)
- venous obstruction of retina conjunctiva, eyelid
- paresisi of nerves 3, 4, 6
- abscess formation in adjacent soft tissue
- evidence of meningeal irritiation
pt with cavernous sinus thrombosis close their eye?
YES – facial (VII) nerve closes eye
droopy eyelid - b/c patient cant open
