Management of Odontogenic Infections
David B. Ettinger MD,DMD
Stages of Infection
I. Cellulitis II. Abscess III. Sinus Tract/Fistula
CELLULITIS
A painful swelling of the soft tissue of the mouth and face resulting from a diffuse spreading of purulent exudate along the fascial planes that separate the muscle bundles.
Abscess
Well defined borders Pus accumulation in tissues Fluctuant to palpation
Cellulitis spreading infection Abscess localized infection
FISTULA
A drainage pathway or abnormal communication between two epithelium-lined surfaces due to destruction of the intervening tissue.
Sinus Tract
Abscess ruptures to produce a draining sinus tract
Management of Infection
Determine the severity of the infection Evaluate the host defense Decide on setting of care Treat surgically Support medically Choose and prescribe antibiotics appropriately Evaluate patient frequently
Severity of Infection
Rate of progression Potential for airway compromise or affecting vital organs Anatomic location of infection
HISTORY
Duration of infectious process. Sequence of events and changes in symptoms or signs. Antibiotics prescribed, dosages and responses. Review of systems with emphasis on neuro-ophthalmologic and cardiopulmonary and immune systems. Social history exposure, travel, (fungal or parasitic infections), chemical dependency.
SIGNS OF SEVERITY
Fever Dehydration Rapid progression of swelling Trismus Marked pain Quality and/or location of swelling Elevation of tongue Difficulty with speech and swallowing
Anatomic Location
Graded in severity by level to which the airway and vital structures are threatened
Low
Buccal, Vestibular, Subperiosteal Masticator space
Moderate
Severe
Lateral pharyngeal Retropharyngeal Danger Space
What are the primary fascial spaces?
The spaces directly adjacent to the origin of the odontogenic infections. Infections spread from the origin into these spaces, which are: Vestibular Canine Buccal Submental Sublingual Submandibular
Vestibular
Buccal
Likely from
Upper
Premolar Upper molar Lower molars
CANINE SPACE
Superior to levator muscle attachment in canine fossa Can lead to:
- orbital cellulitis - carvernous sinus thrombosis
A unique aspect of the veins in the head and neck is their valveless nature
Maxillofacial Infections Selected Readings OMFS Vol 2 No 1
CAVERNOUS SINUS THROMBOSIS
Cranial nerves III, IV, V, (opthalmic), VI Internal carotid artery
SUBMENTAL SPACE
Anterior mandibular teeth Deep to mentalis muscle
Submental Space
Most likely caused by lower anterior teeth or mandibular sympysis fracture
SUBLINGUAL SPACE
Presents in floor of mouth Superior to mylohyoid Drained intraorally parallel to Whartons duct
Submandibular Space
Likely cause:
Lower
molars
SUBMANDIBULAR SPACE
Extra-oral presentation Deep to mylohyoid I & D through skin with blunt incision
LUDWIGS ANGINA
Bilateral submandibular, sublingual, and sub-mental involvement Rarely fluctuant Often fatal Requires early, aggressive intervention
Submandibular
Submandibular
Submental
Department of Oral and Maxillofacial Surgery
What are the secondary fascial spaces?
Fascial spaces that become involved following spread of infection from the primary spaces.
The secondary spaces are:
Pterygomandibular Masseteric Superficial and deep temporal Infratemporal Lateral pharyngeal Retropharyngeal Prevertebral
The hallmark of masticator space infection is: TRISMUS
PHARYNGEAL SPACE INFECTIONS
Lateral pharyngeal Retro-pharyngeal
(both can lead directly to mediastinum)
What factors influence the spread of odontogenic infection?
Thickness of bone adjacent to the offending tooth Position of muscle attachment in relation to root tip Virulence of the organism Status of patients immune system
INCISION AND DRAINAGE
The production of laudable pus by: - mucosal incision - extraction - endodontic access - periodontal curetage
INCISION AND DRAINAGE
Incise in healthy skin Incise in gravity-dependent, esthetic area if possible Explore entire abscess cavity Non-absorbable drains
PRINCIPLES IN THE USE OF DRAINS (II)
Drained wounds should be cleansed frequently. Bacteria can migrate into a wound along the drain surface. Latex Penrose drains are best used unmodified.
INDICATIONS FOR CULTURE
Nonresolving infection in spite of appropriate care Atypical flora expected
= long term antibiotic treatment = age extremes (<2 or >65) = patients with malignancies
Infections with systemic involvement Immunocompromised or myelosuppressed patients
the most important therapeutic action in the management of orofacial infections is the drainage of pus, and antibiotics are merely an adjunct
Pogrel, A; OMFS Clinics of North America Feb 1993
EMPIRIC THERAPY OF ODONTOGENIC INFECTIONS
Penicillin Penicillin + metronidazole PCN allergy clindamycin
MANAGEMENT OF ODONTOGENIC INFECTIONS
1. Determine severity Assess history of onset and progression perform physical examination of area: (1) Determine character and size of swelling (2) Establish presence of trismus
2. Evaluate host defenses Evaluate: (1) Diseases that compromise the host (2) Medications that may compromise the host 3. Perform surgery Remove the cause of infection Drain pus Relieve pressure
MANAGEMENT OF ODONTOGENIC INFECTIONS
4. Select antibiotic Determine:
(1) Most likely causative organisms based on history (2) Host defense status (3) Allergy history (4) Previous drug history Prescribe drug property (route,dose and dosage interval, and duration) Confirm treatment response Evaluate for side effects and secondary infections
5. Follow up
Follow-up
Patient should be monitored frequently
out-patient
should return for f/u in 2-
3 days Patient should have decreased swelling, discharge, airway edema, malaise in 2-3 days
Follow up
If no improvement consider:
Re-culture Re-image Repeat
I and D
Questions
