Principles of Management and Prevention of Odontogenic Infections

1. Principles of Management and Prevention of Odontogenic Infections

2. Introduction • Range from low grade to life threatening facial space infections Common types of infection: • Periapical, peridontal, postsurgical, periodontal May begin as well-delineated, self-limiting condition with potential to spread and result in a major fascial space infection. Life-threatening sequelae can ensue: • Septicemia, cavernous sinus thrombosis, airway obstruction, mediastinitis

3. Introduction (contd.) • Microbiology • History and evaluation • Management of Odontogenic Infection • Prophylaxis against infection

4. Infection-Interplay of 3 major factors

5. Microbiology Odontogenic infections are multimicrobial: • Gram (+) cocci, aerobic and anaerobic: • Streptococci and their anaerobic counterpart, peptostreptococci • Staphylococci, and their anaerobic counterpart, peptococci • Gram (+) rods: • Lactobacillus, diphtheroids, Actinomyces • Gram (-) rods: • Fusobacterium, Bacteroids, Eikenella, Psuedomonas (occasional)

6. Microbiology-Odontogenic Infections • Bacteria causing Odontogenic infections are a part of normal flora • Primarily • Aerobic gram positive cocci • Anaerobic gram positive cocci • Anaerobic gram negative rods

7. Role of Anaerobic Bacteria in Odontogenic Infections • Polymicrobial in nature • Anaerobic Only- 50% • Mixed anaerobic and aerobic- 44% • Aerobic Only- 6 %

8. Nature of the oral micro biota • Gram Positive cocci predominate • Streptococci, Peptostreptococci • Facultative streptococci form the most numerous group • Predominant aerobic Bacteria • Strep.milleri {Strep viridans (old name)} group which consists of • 3 members of the group namely • S.anginosus • S.intermedius • S.constellatus

9. Nature of the oral micro biota • Typical ANAEROBES: • Peptostreptococci • Prevotella(Bacteroides ) • Porphyroamonas • Fusobacteria • Actinomyces • Eubacterium • Clostridium • Veillonella

10. MOST COMMON PATHOGENS IN OROFACIAL INFECTIONS • MICROORGANISM CASES% Streptococcus milleri 65 Peptostreptococcus 65 Other Strep (anaer) 9 Prevotella 74 Porphyromonas 17 Fusobacterium 52 From:Emer. Med Cl of N. Am. August 2000

11. Nature of the oral micro biota • Facultative Organism initiate process of spreading to deeper tissues. • Pyogenic variety are scarce • Rarely found bacteria • Staphylococci • Streptococci group D • Neisseria • Hemophylus

12. Gram Positive rods and filaments • Large quantities • Actinomyces • A.israelii • A.naseslundii • A.odontolyticus

13. FUSOBACTERIUM

14. Pathobiology of OI Infections Environment is dominated by Anaerobes Micro-abscess formation Periapical infection Periodontal Infection Favorable Environment for Anaerobes Inoculation Into deep Tissues Liquefation necrosis Of tissues (collagenases) Metabolic by products (by streptococci) Abscess formation Synthesis of Hyaluronidase (Helps Infecting organisms to Spread) Breakdown of collagen Lysis of WBC Cellulitis

15. Clinical Progression and stages

16. STAGES OF INFECTION • 1ST: Inoculation • 2nd: Cellulitis • 3rd: Abscess • 4th: Resolution

17. Edema, Cellulitis, and abscess

18. Natural History of Progression of Odontogenic Infections

19. Pathway of Periapical Infections • Dental Pulp Necrosis---(Inoculation of bacteria)----Establishment of active infection---Spread of infection equally in all directions • Bone • cancellous bone---cortical bone---soft tissue

20. Pathway of Periapical Infections • Step 1- Etiology • Step 2- Path of least resistance • Cancellous to cortical Bone to soft tissue • Step 3- Location • Thickness of bone overlying the apex • Relationship of the site of perforation of bone to muscle • Precise location on soft tissue depends on muscle attachment

21. Anatomic location

22. Anatomic location

24. Palatal Abscess

25. Mylohyoid muscle Sublingual Space

26. Mylohyoid muscle Submandibular space

27. Quick recap • Two major origins • Periapical • Periodontal • Infections follow the path of least resistance • Cancellous –cortical – Soft tissue

28. Infections are dynamic and progressive • Dependent on • Time • Host resistance vs. virulence • Anatomic location (muscle attachments) • Treatment

29. Periapical Infections • Primary treatment • Endodontics • Tooth extraction • NOT Antibiotics

30. Odontogenic Infections Simple or Serious

31. PRINCIPLE1: Determine Severity of Infection PRINCIPLE2 : Evaluate state of Patient’s Host Defence Mechanisms PRINCIPLE 3: Treatment to be rendered by Generalist or OMF Surgeon PRINCIPLE4 :Treat Infection Surgically PRINCIPLE 5 : Support patient Medically PRINCIPLE 6 :Choose and Prescribe appropriate Antibiotic PRINCIPLE 7 : Administer Antibiotics Properly PRINCIPLE 8 : Post Operative evaluation Odontogenic Infections-Principles of therapy

32. What is a simple, Non threatening Odontogenic infection? • Those occurring in healthy, immune competent patient • No systemic involvement • Low grade temperature <100 F • Localized abscess • Those with Fistula development

33. Assessment of Severity of Infection

34. Principle 1- Determine the Severity of Infection • HOW SICK IS YOUR PATIENT? • Complete History • CC, HOPI, Clinical Features,signs and symptoms • Onset • Duration • Rapidity • Loss of function • Physical Signs-Check vitals Take no more than a few minutes

35. Cardinal signs of inflammation:Red, hot, swelling, pain, with loss of function

36. Principle 1-(contd) • Physical examination • Vital signs • temperature • blood pressure • respiratory rate • Pulse rate

37. Who should be treated? • Normal vital signs with mild infections • Patients with • abnormal vital signs , • with elevated • temperatures, • pulse rate, • respiratory rate • (need more intensive therapy, consider referring to an Oral and Maxillofacial Surgeon)

38. Physical signs • Look for general appearance • Toxic appearance Patient who have more than a Localized minor infection-fatigue, feverishness and malaise, • Examine head and neck area. • Look for: • signs of infection, overlying erythema • Look for 4 D’s • Difficulty in opening the mouth (Trismus) • Dysphagia • Dyspnea • Dehydration • presence of any one OF THE 3 D’s is a sign of severe infection

39. Physical examination-Palpation • Tenderness, warmth • Consistency-soft to firm, indurated (similar to tightened muscle) to hard • Intra oral examination- Look for specific causes like periodontal abscess • Other features • gingival, vestibular swelling, • draining sinus tracts • Perform a radiographic examination

40. Staging based on physical examination • Inoculation stage- very soft, mildly tender, edematous • Cellulitis stage-indurated • Abscess- fluctuance

41. Evaluate the state of Patient’s Host Defense Mechanisms

42. Compromised Host defense • Can be divided in to 4 categories • Physiologic • Disease related • Defective immune system • Drug suppression related • When dealing with established infections in patients who fit in any one of these categories Antibiotics should be considered

43. Medical conditions that compromise host defenses • Uncontrolled metabolic diseases • Immunocompromising diseases • Pharmaceuticals that compromise host defences

44. Principle 3 • What should be • Treated at your office • REFERRED • To an Oral Maxillofacial Surgeon • Hospital

45. Criteria for referral • Difficulty in breathing (________) (Remember the 4Ds) • Difficulty in swallowing(________) • Loss of fluids from the body(________) • Difficulty in opening the mouth(_______) • Swelling extending beyond the alveolar process • Elevated temperature (>101 F) • Severe malaise and toxic appearance • Compromised host defenses • Need for GA • Failed prior treatment

47. Always examine intraorally

48. Principle 4 • Treat Infection Surgically

49. Remove the cause of Infection • Treatment options- • simple endodontic access • Extraction • wide incisions

50. Before Incision and drainage • Consider performing a Culture and sensitivity