May4 M2-Dental Infections Flashcards
2 important things about odontogenic infections and toothaches
- toothache can cause severe infection and fatality very fast bc of airway obstruction
- during rotations, give Abx but also refer to dentist otherwise becomes chronic and end up needing surgery
symptoms of ondotogenic infection and important thing to check
- toothache
- face swelling
- pt hiding face with their hands
- distorted face
- tongue hanging and can’t close their mouth = SIGN OF AIRWAY OBSTRUCTION. have to look at the tongue
first step of odontogenic infection
tooth inoculated and infected with bacteria, like a cavity, inside the pulp chamber (root canal chamber) which contains blood supply and nerves
= cellulitic inflammatory response, abscess formation
2nd step of odontogenic infection: what the abscess does
either:
- moves up root canal
- goes down to apex where blood and nerves are. abscess breaks down the bone, get cellulitic inflammation sprading
3rd step of odontogenic infection: where the abscess spreads
to mandibulary bone, through ostium and drain in tissues outside the bone
4 ways odontogenic infections can spread and main one
- direct extension: basic lateral spread through mandibulary bone
- lymphatic spread
- hematogenous spread
- ingestion (rare bc of HCl in stomach)
- aspiration
what is the ultimate thing that cures the odotongenic infection and what influences that
- patient immune system* influenced by
- Abx given and microbial resistance
- surgical decompression
- drainage
3 routes of direct extension spreading of a dentoalveolar abscess and most common
- towards deeper facial planes of face, head and neck, tooth apex
- fistula up in the mouth interior
- fistula outside the mouth, towards exterior, through the face (cheek, neck, mandible)
one complication of odontogenic infection related to the eyes
- infraorbital space infection bc this area is squared off by many muscles. area under orbit and around maxilla is infected
- swollen eyelids
clinical picture of infraorbital space infection
- swelling pointing towards the eye
- no trismus (inability to fully open the mouth)
tooth that most commonly causes infraorbital space infection (following odontogenic infection at this tooth)
canines, cuspid tooth (3rd tooth after central incisor and lateral incisor). the vampire tooth.
symptom of buccal space infection (abscess)
- patient look like they’re holding their breath
- pain
- swelling
- no trismus
important concept about facial spaces where odontogenic infection can spread
can reach any space. all spaces are connected
why infection to the sublingual space and submandibular space is said to be more important
- infections draining towards medial airways, anatomical airways of pt
- incoming blockage
sublingual and submandibular spaces (one on each side) infection: where the infection is located
at floor of the mouth and as you go downards, you have in this order
- mucosa
- sublingual space
- mylohyoid muscle
- submandibular space
* these two spaces communicate in the back*
other landmark to identify where sublingual space infection locates
travelled above mylohyoid line, and is between mouth mucosa and mylohyoid muscle
symptoms of sublingual space infection (odotongenic)
- elevation of the tongue
- elevation of the floor of the mouth
- hot potato voice (can’t speak properly) but tongue hurts
symptoms of submandibular space infection (odontogenic)
- can’t palpate inferior border of the mandible (under the head) bc neck is swollen (bc infection encroaches in areas of the neck)
- firm, ill-defined anterior border of mandible
- tender to palpation
- mild trismus
sign indication a patient has an airway obstruction or respiratory disease bc of an odontogenic infection
they want to sit up, easier to breathe
Ludwig’s angina definition (rare thing)
aggressive rapidly spreading cellulitis to
- bilateral submandibular and sublingual spaces
- submental space
parapharyngeal spaces infection (odontogenic): 2 spots the infection eventually goes to
- mediastinitis (mediastinum)
- intracranial abscess (brain)
- leads to death*
main problem with odontogenic infections
airway occlusion
how to evaluate if problems of airway occlusion are present in odontogenic infection
- get to back of the tongue
- pull it down
- edematous pharynx on the infected side + uvula displaced on other side
- trismus
- always have cricothyrotomy
gold standard to diagnose airway occlusion due to odontogenic infection
CT scan
evolution of an odontogenic infection
- acute pulpitis
- inflammation
- cellulitis in pulp
- abscess in pulp
- cellulitis or abscess in peri-apical area
- cellulitis of surrounding soft tissue spaces
- abscess of surrounding soft tissue spaces
cellulitis definition
diffuse inflam reaction by body in response to bacteria. Indulated, hard, not specific
abscess definition
presence of pus. Coalescence of WBCs, necrotic tissue. abscess can be wiggled, is spongy
type of bacteria in the inoculation and cellulitis stage
aerobic bacteria
type of bacteria in abscess and pus stage
anaerobic bacteria
clinical findings of acute odontogenic infection
- pain
- swelling
- heat
- redness
- loss of function (trismus, dysphagia, dysphonia, dyspnea)
- findings of inflammation*
4 stages (time frame) of odontogenic infection (applies to immunocompetent)
- inoculation
- cellulitis (1-2 days)
- abscess (2-3 days)
- resolution
steps until cellulitis appears
-bacterial colonization in potential space = colonization = inflam rx
-soft and spongy, tender (painful when touch) to palpation
-when full inflam response mounted, call that cellulitis
(poorly localized, reddened, endurated, tender area)
when abscess formation occurs
when bacteria, necrotic tissue and WBCs coalesce with surrounding soft tissue (this makes pus)
how to dx an abscess (odontogenic) clinically, what are the criteria
-history of swelling for 48-72 hours
-severe pain
-pulsating throbbing pain to the offending tooth (fluctuance)
-
steps of odontogenic infection management
- patient care
- incision and drainage (I and D)
- Abx therapy
- remove the cause (curettage, extraction, endodontic treatment, debridement)
patient care meaning
- *manage airways**
- fever
- medical problems
- rest and nutrition
- hydration
- localization
what are signs and symptoms of airway embarrassment
- hard to manage own secretions
- use accessory muscles of respiration
- RR, rhythm, depth
- dysphagia
- dysphonia
- dyspnea
- can lead to airway obstruction rapidly*
management of patient with airway embarrassment
intubation asap. otherwise surgical airway (tracheostomy)
steps of incision and drainage
- place incisions through soft tissue in area of localized abscess, allowing pus to drain
- place counduit to encourage drainage
main goal while doing I and D
- decrease the bacterial load
- decompress on airways
- remove pus impenetrable to Abx
- get O2 in there to remove the anaerobes
bacteria causing first stage (cellulitis)
aerobes
bacteria causing 2nd stage (abscess)
anaerobes
initial Abx used in odontogenic infection (Abx is 3rd step, after I and D)
treat empirically first
perform culture and sensitivity test to narrow later
bacteria of the aerobic stage of infection (Cellulitis)
- strep spp
- lactobacillus
bacteria of the anaerobic stage of odontogenic infection (abscess)
- gram+ cocci (like strep, pepto..)
- bacteroides
- lactobacillus
- veillonella
- etc. (many gram+ and gram-)
problem of using Abx only
- Abx assist the patient in eliminating the infection and that’s it
- need to address the cause otherwise will recur
- immune system does it all
most important factor in how much Abx will help a patient
patient compliance
-usually 7-10 days regimen
(important) primary Abx given in odontogenic infections
- penicillin#1
- amoxicillin
(note: penicillin doesn’t work if already used it many times)
Abx for anaerobes used in odontogenic infections
metronidazole (Flagyl)
a broad spectrum Abx used in odontogenic infection
clindamycin
when to hydrate patients with odontogenic infection
- can’t tolerate po fluids
- fever and trismus + no po intake for few days
