Dento-Alveolar infectionsPart 1&2

8/2/2019 Dento-Alveolar infectionsPart 1&2

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DentoDento--Alveolar Alveolar

infectionsinfectionsDr Ashraf Abu KarakyDr Ashraf Abu KarakyBDS MSc MfDSRCSEd FFDRCSIBDS MSc MfDSRCSEd FFDRCSI

Oral & Maxillofacial SurgeonOral & Maxillofacial Surgeon

The University of JordanThe University of Jordan



Microbiology of OdontogenicMicrobiology of Odontogenic

InfectionsInfections Bacteria causing infections are partBacteria causing infections are part

of normal floraof normal flora

Gingivitis, periodontitis, dentalGingivitis, periodontitis, dentalcaries.caries.

Access to deeper underlying tissuesAccess to deeper underlying tissues



Almost all odontogenic inf. areAlmost all odontogenic inf. arecaused by multiple bacteriacaused by multiple bacteria

AnaerobicAnaerobic--aerobic characteristic of aerobic characteristic of the bacteriathe bacteria

6060% Mixed% Mixed

55% Aerobic% Aerobic

3333% Anaerobic (Aderhold% Anaerobic (Aderholdet al et al

Oral SurgOral Surg 19811981))



Aerobic bacteria Aerobic bacteria 2525%%

Gram positive cocciGram positive cocci 8585%%

Most common StreptococciMost common Streptococci 9090%%

StaphylococciStaphylococci 55%% Rarely found bacteria: Neisseria spp,Rarely found bacteria: Neisseria spp,

Corynebacterium spp andCorynebacterium spp and

Haemophillus spp.Haemophillus spp.



Anaerobic Bacteria Anaerobic Bacteria 7575%%

Anaerobic gram positive cocciAnaerobic gram positive cocci 3030%%StreptococcusStreptococcusPeptostreptococcusPeptostreptococcus

Gram negative rodsGram negative rods 5050%%Provotella and Porphyromonas spp. (previouslyProvotella and Porphyromonas spp. (previously

Bacteroides)Bacteroides) 7575%%FusobacteriumFusobacterium 2525%%

Gram negative cocci; Veillonella spp.Gram negative cocci; Veillonella spp. Gram positive rods; Eubacteruim and LactobacillusGram positive rods; Eubacteruim and Lactobacillus



Anaerobic bacteria Anaerobic bacteria

Gram + cocci Streptococcus andGram + cocci Streptococcus andPeptostreptococcusPeptostreptococcus

GramGram ± ± rods Provotella and Fusobacteriumrods Provotella and Fusobacterium

PLAY A MORE IMPORTANTPLAY A MORE IMPORTANTPATHOGONIC ROLEPATHOGONIC ROLE

the other Gramthe other Gram ± ± cocci and Gram +cocci and Gram +rods appear to be opportunisticrods appear to be opportunisticorganismsorganisms



Microorganism Vs HostMicroorganism Vs Host

Microorganism:Microorganism: 11-- VirulenceVirulence

22-- numbernumber

33-- structurestructure

Host: immunity & resistanceHost: immunity & resistance



Causes of dentoCauses of dento--alveolar Infectionsalveolar Infections

Mainly odontogenicMainly odontogenic

PeriapicalPeriapical

PeriodontalPeriodontal PericoronalPericoronal

Others like;Others like;

Cystic originCystic origin Neoplastic originNeoplastic origin



Predisposing FactorsPredisposing Factors

TraumaticTraumatic

ChemicalsChemicals

NutritionalNutritional EndocrineEndocrine

HematologicalHematological

ImmunologicalImmunological



Method of infection:Method of infection:

Inoculation into deeper tissuesInoculation into deeper tissues

------ Invasive org. (strep.) start infection process,Invasive org. (strep.) start infection process,Cellulitis.Cellulitis.

-------- Local oxidation potential loweredLocal oxidation potential lowered

---------- Anaerobic bacteria growAnaerobic bacteria grow

------------ Chronic infection & AbscessChronic infection & Abscess

-------------- More AnaerobesMore Anaerobes

Early, Acute, Cellulitis: aerobic streptococcalEarly, Acute, Cellulitis: aerobic streptococcal

Late, Chronic, Abscess: anaerobicLate, Chronic, Abscess: anaerobic



Natural History of Progression of Natural History of Progression of

Odontogenic InfectionsOdontogenic Infections Periapical invasionPeriapical invasion

Periodontal invasionPeriodontal invasion



-- Necrosis of dental pulpNecrosis of dental pulp

---- bacteria enter periapical tissuebacteria enter periapical tissue

------ Active infectionActive infection-------- spread of infection Leastspread of infection Least

resistance Pathwayresistance Pathway

------------ Cancellous bone towards CorticalCancellous bone towards CorticalBoneBone

-------------- Perforation towards soft tissuePerforation towards soft tissue



The location of infection from specificThe location of infection from specifictooth is determined by:tooth is determined by:

11-- the thickness of the bone overlyingthe thickness of the bone overlyingthe apex of the tooththe apex of the tooth

22-- The relationship of the site of The relationship of the site of perforation of bone to muscleperforation of bone to muscleattachments of the maxilla andattachments of the maxilla andmandiblemandible



MaxillaMaxilla

-- Most infections erode through the labioMost infections erode through the labio--bucco cortical platebucco cortical plate

-- Most bellow attachment of the musclesMost bellow attachment of the muscles------

Vestibular AbscessVestibular Abscess-- Palatal abscessPalatal abscess«« Lateral Incisor andLateral Incisor and

palatal root of upper molarspalatal root of upper molars

-- Canine.. Superior to insertion of levatorCanine.. Superior to insertion of levator

anguli orisanguli oris ---------- Canine Space InfectionCanine Space Infection-- Molars.. Superior to insertion of buccinatorMolars.. Superior to insertion of buccinator

musclemuscle ± ±-------- Buccal Space InfectionBuccal Space Infection



MandibleMandible

-- Incisors, canines and premolars usually erodeIncisors, canines and premolars usually erode

labio bucco cortical plate and above associatedlabio bucco cortical plate and above associated

musclesmuscles ---------------------------- Vestibular AbscessVestibular Abscess

-- First Molar either buccally or linguallyFirst Molar either buccally or lingually-- Second Molar usually linguallySecond Molar usually lingually

-- Third molar almost always linguallyThird molar almost always lingually

--Mylohyoid muscle :Mylohyoid muscle : SublingualSublingual ororSubmandibular Space AbscessSubmandibular Space Abscess



Management of Dentoalveolar Management of Dentoalveolar

InfectionsInfectionsAims of treatment:Aims of treatment:

Elimination of causative factorElimination of causative factor

decrease virulence, and number of decrease virulence, and number of microorganismsmicroorganisms

Increase host resistanceIncrease host resistance



Principles of therapy of Principles of therapy of

odontogenic infectionsodontogenic infections PrinciplePrinciple 11:Determine severity of infection:Determine severity of infection

-- Complete historyComplete historyCC, HCC (onset, duration, rapidity), S&S (dolor, tumor, calor, ruborCC, HCC (onset, duration, rapidity), S&S (dolor, tumor, calor, rubor

and functio laesa), General feeling (fatigue and malaise), Previousand functio laesa), General feeling (fatigue and malaise), Previous

ttt,ttt,PMH, SH.PMH, SH.

-- Physical examination.Physical examination.General appearance ,Vital signs, swelling, erythema, mouth opening,General appearance ,Vital signs, swelling, erythema, mouth opening,

swallowing.swallowing.

Swelling: tender, warm, soft, hard, indurated, fluctuant (fluid filled,Swelling: tender, warm, soft, hard, indurated, fluctuant (fluid filled,pus)pus)

IOE (cause), RG examinationIOE (cause), RG examination

-- Cellulitis or abscess?Cellulitis or abscess?



General differences betweenGeneral differences between

C

ellulitis and AbscessC

ellulitis and AbscessCharacteristic Cellulitis AbscessCharacteristic Cellulitis Abscess

Duration Acute ChronicDuration Acute Chronic

Pain severe & generalized LocalizedPain severe & generalized LocalizedSize Large SmallSize Large Small

Localization diffuse borders well circumscribedLocalization diffuse borders well circumscribed

Palpation indurated FluctuantPalpation indurated Fluctuant

Degree of Seriousness Greater LessDegree of Seriousness Greater Less

Bacteria Aerobic AnaerobicBacteria Aerobic Anaerobic Deep abscess is difficult to distinct from cellulitisDeep abscess is difficult to distinct from cellulitis

Indurated cellulitis may have areas of abscess formation in itIndurated cellulitis may have areas of abscess formation in it



PrinciplePrinciple 22: Evaluate state of : Evaluate state of patient`s host defense mechanismspatient`s host defense mechanisms

-- Uncontrolled metabolic diseasesUncontrolled metabolic diseasesUremiaUremia

AlcoholismAlcoholismMalnutritionMalnutritionSevere diabetesSevere diabetes

-- Suppressing diseasesSuppressing diseasesLeukemiaLeukemiaLymphomaLymphoma

Malignant tumorsMalignant tumors-- Suppressing drugsSuppressing drugsCancer chemotherapeutic agentsCancer chemotherapeutic agentsImmunosuppressive agentsImmunosuppressive agents



PrinciplePrinciple 33: Determine whether: Determine whetherpatient should be treated by generalpatient should be treated by generaldentist or specialistdentist or specialist

-- Rapid progressive infectionRapid progressive infection

-- Difficulty in breathingDifficulty in breathing-- Difficulty in swallowingDifficulty in swallowing-- Facial space involvementFacial space involvement-- Elevated temperatureElevated temperature

-- Severe jaw trismusSevere jaw trismus-- Toxic appearanceToxic appearance

-- Compromised host defenceCompromised host defence



PrinciplePrinciple 44: treat infection: treat infectionsurgicallysurgically

Abscess or CellulitisAbscess or Cellulitis



CellulitisCellulitis

Mild SevereMild Severe

remove causeremove cause remove causeremove cause(I&D)(I&D)

antistrep. Antibiotic antistrep. Antibioticantistrep. Antibiotic antistrep. Antibiotic

Resolve? Resolve?Resolve? Resolve?

If not: I&D If not: Additional SurgeryIf not: I&D If not: Additional Surgery



AbscessAbscess

remove causeremove cause

I & DI & DAntistrept. AntibiotcsAntistrept. Antibiotcs

antianaerobicantianaerobic

Resolve?Resolve?

If not: additional surgeryIf not: additional surgery



Incision & DrainageIncision & Drainage

Evacuation of pusEvacuation of pus

Prevent spread of infectionPrevent spread of infection

Decrease number of bacteriaDecrease number of bacteria Decrease pressure and painDecrease pressure and pain

Reduction in tissue tension whichReduction in tissue tension which

improve local blood supply andimprove local blood supply andincrease the delivery of hostincrease the delivery of hostdefenses to the localized area.defenses to the localized area.



TechniqueTechnique

Stab incision, bladeStab incision, bladenumbernumber 1111

Most prominentMost prominent

area or lowestarea or lowest

HemostatHemostat

IrrigationIrrigation

DrainDrain



Type of drainsType of drains

Rubber dam stripsRubber dam strips

Rubber tubesRubber tubes(Penrose drain)(Penrose drain)

Corrugated drainsCorrugated drains

Vacuum drainsVacuum drains



Avoid Vital Structures Avoid Vital Structures



PrinciplePrinciple 55: support patient medically: support patient medically

-- fluid intakefluid intake

-- nutritional supplementsnutritional supplements

-- restrest

-- analgesicsanalgesics

-- Assess the need for HOSPITALIZATIONAssess the need for HOSPITALIZATION



PrinciplePrinciple 66: choose and prescribe: choose and prescribeappropriate antibioticappropriate antibiotic

-- Determine need for antibioticDetermine need for antibiotic

Rapidly progressive swellingRapidly progressive swellingDiffuse swellingDiffuse swelling

Compromised host defensesCompromised host defenses

Involvement of facial spacesInvolvement of facial spaces

Severe pericoronitisSevere pericoronitisOsteomyelitisOsteomyelitis



Use of antibiotic is not necessaryUse of antibiotic is not necessary

-- Chronic wellChronic well--localized abscesslocalized abscess

-- Minor vestibular abscessMinor vestibular abscess-- Mild pericoronitisMild pericoronitis



-- Use narrowest spectrum antibioticUse narrowest spectrum antibiotic

-- Use antibiotic with lowest incidenceUse antibiotic with lowest incidence

of toxicity and side effectsof toxicity and side effects-- Use bactericidal antibiotic, if possible.Use bactericidal antibiotic, if possible.

-- Be aware of the cost of antibioticsBe aware of the cost of antibiotics

-- Administer antibiotic properlyAdminister antibiotic properly



PrinciplePrinciple 77: evaluate patient: evaluate patientfrequentlyfrequently

Reasons for treatment failure:Reasons for treatment failure:

-- Causative factor not eliminatedCausative factor not eliminated-- Inadequate surgeryInadequate surgery

-- Foreign bodyForeign body

-- Antibiotic problems;Antibiotic problems;Patient nonPatient non--compliancecompliance

Drug not reached siteDrug not reached site

Wrong bacterial diagnosisWrong bacterial diagnosis

Wrong antibioticWrong antibiotic



Principles of prophylaxis of woundPrinciples of prophylaxis of wound

infectioninfection

Reduce incidence of infection andReduce incidence of infection andthereby postoperative morbiditythereby postoperative morbidity

Reduces cost of health careReduces cost of health care Fewer opportunities exist forFewer opportunities exist for

resistant bacteria to arise whenresistant bacteria to arise wheneffective prophylactic antibiotics areeffective prophylactic antibiotics areusedused



Disadvantages of prophylacticDisadvantages of prophylactic

antibioticsantibiotics

Alter host bacteriaAlter host bacteria

More resistant bacteriaMore resistant bacteria

More pathogenic bacteriaMore pathogenic bacteria May encourage lax surgical techniqueMay encourage lax surgical technique

CostCost

Drugs toxicityDrugs toxicity



Principles of prophylactic antibioticPrinciples of prophylactic antibiotic

11--Risk of infection must be significantRisk of infection must be significant

-- size of bacterial inoculumsize of bacterial inoculum

-- extent and time of surgeryextent and time of surgery

-- presence of foreign bodypresence of foreign body

-- state of host resistancestate of host resistance



22--Choose correct antibioticChoose correct antibiotic

-- effective against the organismeffective against the organism

-- narrow spectrumnarrow spectrum-- least toxicleast toxic

-- bactericidalbactericidal

Drug of choice: PENICILLINDrug of choice: PENICILLIN

Allergy: Cefadroxil (broad spectrum)Allergy: Cefadroxil (broad spectrum)

ClindamycinClindamycin(less effective against strep.)(less effective against strep.)



33-- Antibiotic plasma level must beAntibiotic plasma level must behighhigh



Routs of spread of infectionRouts of spread of infection

-- Direct continuityDirect continuity

-- Blood streamBlood stream

-- Lymphatic systemLymphatic system



Phases & Fate of infectionPhases & Fate of infection

AcuteAcute

ChronicChronic

ResolutionResolution



Types of dentoTypes of dento--alveolar infectionsalveolar infections

Acute dentoalveolar abscessAcute dentoalveolar abscess

Early stageEarly stage

Late stageLate stage Chronic dentoalveolar abscessChronic dentoalveolar abscess

Periapical GranulomaPeriapical Granuloma



Acute dentoalveolar abscess/Early Acute dentoalveolar abscess/Early

stagestage

SuppurativeSuppurative

No soft tissueNo soft tissueinvolvementinvolvement

No cortexNo cortexpenetrationpenetration



Clinical PresentationClinical Presentation

Tender to percussion or masticationTender to percussion or mastication

Elongated teeth sensationElongated teeth sensation

NonNon--vital tooth or teethvital tooth or teeth Throbbing painThrobbing pain

Generalized symptoms of infectionGeneralized symptoms of infection



Acute dentoalveolar abscess/Late Acute dentoalveolar abscess/Late

stagestage

SuppurativeSuppurative

Cortical perforationCortical perforation

Soft tissueSoft tissue

involvementinvolvement



SwellingSwelling

NonNon-- vital tooth or teethvital tooth or teeth

Symptoms related to local spread;Symptoms related to local spread;trismus, dysphagiatrismus, dysphagia

Generalized symptomsGeneralized symptoms



Chronic dentoalveolar abscessChronic dentoalveolar abscess

Long standingLong standing

Low gradeLow grade

Sinus tractSinus tract



Clinical presentationClinical presentation

AsymptomaticAsymptomatic

NonNon--vital tooth or teethvital tooth or teeth

Acute exacerbationsAcute exacerbations

SuperinfectionsSuperinfections

Sinus tract & fistulaSinus tract & fistula

Chronic generalized symptoms;Chronic generalized symptoms;

lymphadenopathy, increased lymphocyteslymphadenopathy, increased lymphocytesincreased ESRincreased ESR



Periapical granulomaPeriapical granuloma

Well definedWell definedgraulation tissuegraulation tissuesurrounding the apexsurrounding the apexof the toothof the tooth

Etiology: odontogenicEtiology: odontogenicwith predisposingwith predisposingfactorsfactors

Bacteriology: mainlyBacteriology: mainlystreptococcus & streptococcus &

staph., anaerobesstaph., anaerobesothers lactobacilliothers lactobacilli



Clinical presentationClinical presentation

AsymptomaticAsymptomatic

Discovered by routine examinationDiscovered by routine examination

Discolored nonDiscolored non--vital teethvital teeth



RadiographyRadiography

Periapical xPeriapical x--raysrays

OPGOPG

Occlussal filmOcclussal filmCTCT

MRIMRI



Acute/Early stage Acute/Early stage

NegativeNegative

SometimesSometimeswidening of PDLwidening of PDL



Acute/Late stage Acute/Late stage

Widening of PDLWidening of PDL

Interruption of Interruption of lamina durralamina durra

With or withoutWith or withoutlocalized ill definedlocalized ill definedRLRL



Chronic dentoalveolar abscessChronic dentoalveolar abscess

Irregular periapicalIrregular periapicalRLRL

With or withoutWith or without

apex resorptionapex resorption



Periapical granulomaPeriapical granuloma

Small well definedSmall well definedRL at the apexRL at the apexsurrounded by ROsurrounded by RO

line (condensingline (condensingOstitis)Ostitis)



Primary carePrimary care

HospitalizationHospitalization

Air wayAir way

IV fluidIV fluid

FeverFever IV antibioticIV antibiotic

Vital structuresVital structures

Medical statusMedical status

Social statusSocial status

GAGA



Management of fistulasManagement of fistulas



ComplicationsComplications

ChronicityChronicity

CellulitesCellulites

OsteomylitisOsteomylitis Laryngeal oedemaLaryngeal oedema

Cavernous sinusCavernous sinus

Heamtogenous spreadHeamtogenous spread



PericorinitisPericorinitis



Thank youThank you

Dento-Alveolar infectionsPart 1&2

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