The PRINCIPLES in management of

ODONTOGEN infection
 DEFINITION

Invasion of microorganisms
into the body, penetrate and
INFECTION destroy host slowly and
spread out through out the
body
(Peterson, 2004)

2
 INFECTION

Mikro-
organis
me

enviro
ment

Host

( Topazian. Oral and maxillofacial

infections 4th editions, 2002)

3
 Host Factors

1. Humoral factors
2. Cellular factors
3. Local factors

Decrease one of these mechanisms and

it increases the potential for infection.
4
 1.Humoral Factors

Circulating In presence of
infection,
immunoglobulins, IgA prevents histamine,
along with colonization serotonin,
complement, combine of microbes prostaglandins
support
with microbes to form on oral inflammation 
opsonins that mucosal vasodilation and
promote phagocytosis surfaces. increased
vascular
by macrophages. permeability.

5
 2. Cellular factors

Phagocytes engulf and kill microbes, removing them,

preventing replication.

Lymphocytes produce lymphokines and immunoglobulines

(aids humoral).

Lymphokines stimulate reproduction of other lymphocytes,

and kills antigens.
6
 3. Local Factors

Abundant vascular supply allowing

humoral and cellular response.

Mechanical cleansing by salivary flow.

Specific factors
leading to
resistance:
Secretory IgA contained within saliva.

High epithelial turnover and

sloughing, taking with it adherent
bacteria.
A variety of microflora normally preventing
selection for a single organism by competing for
nutrients or release of by-products.
7
Microorganisms Causing Odontogen Infections

Aerobic (25%)
• Gram-positive cocci
– Streptococcus spp.
– Streptococcus Group D. spp.
– Staphylococcus spp.
– Eikenella spp.
• Gram-negative cocci (Neisseria spp.)
• Gram-positive rods (Corynebacterium spp.)
• Gram-negative rods (Haemophilus spp.)
• Miscellaneous and undifferentiated
James R. Hupp, Edward Ellis, Myron R. Tucker Contemporary Oral and Maxillofacial Surgery
4th Ed. Mosby Elsevier (2008) 8
Microorganisms Causing Odontogen Infections –
cont.
Anaerobic (75%)
• Gram-positive cocci
– Streptococcus spp.
– Peptostreptoccus spp.
• Gram-negative cocci (Viellonella spp.)
• Gram-positive rods
– Eubacterium spp.
– Lactobacillus spp.
– Actinomyces spp.
– Clostridia spp.
• Gram-negative rods
– Bacteroides spp.
– Fusobacterium spp.
• Miscellaneous 9
 Spaces Involved in Odontogen Infections
• Primary Maxillary Spaces
1. Canine
2. Buccal
3. Infratemporal
• Primary Mandibular Spaces
1. Submental
2. Buccal
3. Submandibular
4. Sublingual
• Secondary Fascial Spaces
1. Masseteric
2. Pterigomandibular
3. Superficial and deep temporal
4. Lateral pharyngeal
5. Retropharingeal
6. Prevertebral

James R. Hupp, Edward Ellis, Myron R. Tucker, Contemporary Oral and Maxillofacial
Surgery. 4th Ed. Mosby Elsevier (2008) 10
 Spreading of
Odontogen Infection

11
• Definition:
Refer to infection of cavities, pulpitis, periapical abscess, gingivitis,
periodontitis, pericoronitis, osteitis & infection of the
subaponeurotic spaces during tooth formation

Oral infection (origin):

i) Deep decay infecting the nerve
(root canal)
ii) Infection spread beyond tooth
root into periapical tissue
iii) Periodontal gum infection that
disperse through spongy bone
iv) Submerged/impacted teeth
v) Retained/broken roots at/ below
gum level
Spreading of Odontogenic Infection

From the site of the initial lesion, inflammation may

spread in three ways:
1. By continuity through tissue spaces and planes.
2. Byway of the lymphatic system.
3. By way of blood circulation.

Fragiskos D. Fragiskos, Oral Surgery, Springer, 2007

13
Spreading of Odontogenic Infection

1. Lack of vascularisation
2. Connective loose tissue
Space 3. Poor defence mechanism on
infection

14
 This illustration notes six
possible locations of fascial
spaces abscess:
1. Vestibular space
2. Buccal space
3. Palatal space
4. Sublingual space
5. Submandibular space
6. Maxillary sinus

James R. Hupp, Edward Ellis, Myron R. Tucker Contemporary Oral and Maxillofacial
Surgery. 4th Ed. Mosby Elsevier (2008) 15
 Incidence According to Location

Proportions of fascial
space involvement in
Mandibular (A) and
maxillary (B)
odontogenic infection.

T Handley, M Devlin, D Koppel, J McCaul, JICS Volume 10, Number 1, January 2009 18
 The Principles in
Management of
Odontogen Infections

19
 Principal I : Determine Severity of
Infection.
Complete history
• Chief complaint
• Determine how long the infection has been present
- onset of the infection
- duration of the infection
• Elicit the patient's symptoms
- dolor ( pain )
- tumor ( swelling )
- calor ( warmth )
- rubor ( redness )
- functio laesa ( loss of function )
• Previous professional treatment and self - treatment
cont-

Physical examination
• Collect patient's vital signs (T,BP,P,R)
• Inspect patient's general appearance
- fatique/malaise
- ask patient to open mouth widely ,swallow
and take deep breath ( to check for
dysfunction )
- Palpation of the area of swelling
• Intraoral examination
• Radiograph exam
Cont- Stages of Infection

Petersons Principles of oral and maxillofacial Surgery, 2004

22
 Principle-2
Evaluate state of Patient’s Host defense
Mechanisms

COMPROMISED HOST DEFENSES

• Uncontrolled metabolic disease:
1. Uremia
2. Alcoholism
3. Malnutrition
4. Severe diabetes
• Suppressing disease:
1. Leukemia
2. Lymphoma
3. Maligant tumors
• Suppresing drugs:
Cancer chemotherapeutics agents
Immunosupressive agents 23
 Principle - 3
Determine Whether Patient Should Be Treated by
General Dentist or Specialist

• Rapid progressive infection

• Difficulty in breathing
• Difficulty in swallowing
• Fascial space involvement
• Elevated temperature ( > 38,1O C)
• Severe jaw trismus (less than 10 mm)
• Toxic appearance
• Compromised host defenses
24
 Principle-4
Treat Infection Surgically

Goals to remove the cause of the

infection and provide drainage of
accumulated pus and necrotic debris
3 types : - Endodontic Treatment
- Extraction
- Incision and Drainage

25
Cont-

• Drainage of pus provides for a reduction in tissue tension,

which improves the local blood supply and increase the
delivery of host defense to the localized area

• Technique for I & D :

1. Selection of site for the incision
2. Administer anesthesia at the site of incision
3. Obtain a specimen of pus for culture and sensitivity
4. Make an incision with no 11 blade
5. Insert a curved hemostat through the incision into the abscess
cavity

26
Location extra oral incision

Petersons Principles of oral and maxillofacial Surgery, 2004 27

 Intra Oral

Petersons Principles of oral and maxillofacial Surgery, 2004 28

Intra Oral Incision

29
Incision And Drainage Of Abscess

30
 Principle -5
Support Medically
• Prescribe analgesics
• Give post operative instructions
• Encourage patient to have adequate fluid
intake, nutritional intake and rest

31
 Principle -6
Choose and Prescribe Appropriate
Antibiotic

• Indication for use of antibiotics

1. Rapidly progressive swelling

2. Diffuse swelling
3. Compromised host defenses
4. Involvement of fascial spaces
5. Severe pericoronitis
6. Osteomyelitis

32
Petersons Principles of oral and maxillofacial Surgery, 2004
33
 Indications for Culture and
antibiotic Sensitivity Testing

1. Rapidly spreading infection

2. Postoperative infection
3. Nonresponsive infection
4. Recurrent infection
5. Compromised host defenses

34
 Principle-7
Administer Antibiotic Properly

Effective orally administered antibiotics

useful for odontogen infection
• - penicillin
• - erythromycin
• - clindamycin
• - cefadroxil
• - metronidazole
• - tetracycline

35
Severe odontogenic infections: Epidemiological, microbiological and
therapeutic factors. R. Sánchez, E. Mirada 1, J. Arias, J.R. Paño , M.
Burgueño . Med Oral Patol Oral Cir Bucal, 2008
36
 Principle-8
Evaluate Patient Frequently
• Follow up patient carefully
• Reason for treatment failure
- Inadequate surgery
- Depressed host defense
- Foreign body
- Antibiotic problem
- Patient non compaliance
- Drug not reaching site
- Wrong bacterial diagnosis
- Wrong antibiotics

37
SUMMARY

38
CONCLUSION

39
 Mortality Increases in Septic Shock Patients
Incidence Mortality

Sepsis
400,000 7-17%

Severe Sepsis 20-53%

300,000

Approximately 200,000 Septic

53-63%
patients including 70,000 Shock
Medicare patients have
septic shock annually

Balk, R.A. Crit Care Clin 2000;337:52 40