Odontogenic Infections 1
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Transcript of Odontogenic Infections 1
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Diagnosis and Management of
Odontogenic Infections
Jeff Lee
Dept. of Oral and Maxillofacial Surgery1/15/02
Combined Hospital Meeting
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Odontogenic Infections The modern emergency department sees a
significant number of patients every day
with problems related to the face and oral
cavity. Emergency Medicine Clinics of North America Aug 2000
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35 year old male, 3 day history of
progressive painful facial swelling,
difficulty opening mouth, difficulty
swallowing, alteration in voice. 8 year old female, 5 days s/p dental
extraction, persistent increasingly painful
swelling left face, taking augmentin since
extraction.
Odontogenic Infections
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OUTLINEOUTLINE
MicrobiologyNatural history
AssessmentManagement
Prevention
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Understand important aspects of history and
clinical examination of patient.
Understand treatment of odontogenic
infections and when to refer treatment.
Odontogenic Infections
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MICROBIOLOGYMICROBIOLOGY
Causative organismsAerobes only 7 %
Anaerobes only 33 %
Mixed 60 %
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MICROBIOLOGYMICROBIOLOGY
Aerobic 25%
Gram-positive cocci 85%Streptococcus spp. 90%
Streptococcus (group D) spp. 2%
Staphylococcus spp. 6%
Eikenella spp. 2%Gram-negative cocci (Neisseria spp.) 2%
Gram-positive rods (Corynebacterium spp.) 3%
Gram-negative rods (Haemophilus spp.) 6%
Miscellaneous and undifferentiated 4%
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MICROBIOLOGYMICROBIOLOGY
Anaerobic 75%
Gram-positive cocci 30%Streptococcus spp. 33%
Peptostreptococcus spp. 65%
Staphylococcus spp. 65%
Gram-negative cocci (Veillonella spp.) 4%
Gram-positive rods 14%
Eubacteriumspp.Lactobacillus spp.
Actinomyces spp.
Clostridia spp.
Gram-negative rods 50%Bacteroides spp. 75%
Fusobacterium spp. 25%
Miscellaneous 6%
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Inoculation
Cellulitis
Abscess formation
Resolution
NATURAL HISTORY NATURAL HISTORY
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Predictable spread
from one anatomic
space to the next.
Edema at leading edgeof infection.
Previously innoculated
areas progressingthrough stages of
cellulitis and abscess
formation
NATURAL HISTORY NATURAL HISTORY
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ANATOMIC SPACE INVOLVEMENTANATOMIC SPACE INVOLVEMENT
Primary maxillary spaces
CanineBuccal
Infratemporal
Primary mandibular spacesSubmental
Buccal
Submandibular
Sublingual
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ANATOMIC SPACE INVOLVEMENTANATOMIC SPACE INVOLVEMENT
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ANATOMIC SPACE INVOLVEMENTANATOMIC SPACE INVOLVEMENT
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ANATOMIC SPACE INVOLVEMENTANATOMIC SPACE INVOLVEMENT
Secondary fascial spaces
MassetericPterygomandibular
Superficial and deep temporal
Lateral pharyngealRetropharyngeal
Prevertebral
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ASSESSMENTASSESSMENT
Identify cause
Determine severity
Evaluate host defenses
General practitioner / specialist
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ASSESSMENTASSESSMENT
Identify cause
Caries
Periodontitis
Pericoronitis
Tooth tendernessTooth mobility
Vestibular swelling
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ASSESSMENTASSESSMENT
Diagnostic radiographs-Panorex
-CAT Scan with contrast
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ASSESSMENTASSESSMENT
Determine severity
Complete history
Chief complaint
Time of onset
Change in symptoms
Elicit symptoms
Clinical signsDolor, tumor, calor, rubor, and functiolaesa
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ASSESSMENTASSESSMENT
Determine severity
Vital signsLocal involvement
Extent and rate of
progressionInvolved spaces
Trismus
AirwayVital structures
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ASSESSMENTASSESSMENT
Characteristic Cellulitis Abscess
Duration Acute Chronic
Pain Severe and generalized Localized
Size Large Small
Localization Diffuse borders Well circumscribed
Palpation Doughy to indurated FluctuantPresence of pus No Yes
Degree of seriousness Greater Less
Bacteria Aerobic Anaerobic
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ASSESSMENTASSESSMENT
Systemic involvementMalaise
Pyrexia
Other signs
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ASSESSMENTASSESSMENT
Compromised Host Defenses
Uncontrolled metabolic diseases
Uremia
Alcoholism
Malnutrition
Severe diabetes Suppressing diseases
Leukemia
Lymphoma
Malignant tumors
Suppressing drugs
Chemotherapeutic agents
Immunosuppressives
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ASSESSMENTASSESSMENT
Criteria for Referral to a Specialist Rapidly progressing infection
Difficulty breathing
Difficulty swallowing Fascial space involvement
Elevated temperature (greater than 101F)
Severe trismus (less than 10 mm) Toxic appearance
Compromised host defenses
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MANAGEMENTMANAGEMENT
Obtain drainage
Maintain drainage
Remove the cause Provide supportive
care
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MANAGEMENTMANAGEMENT
Obtain drainage Pus must be drained
Adequate access Blunt dissection
All loculations entered
Intra - oral and / or
extra - oral
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Obtain drainage
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MANAGEMENTMANAGEMENT
Maintain drainageAll involved spaces
Dependent drainage
Insertion of drain
Maintenance of
patency
Slow advancement
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MANAGEMENTMANAGEMENT
Remove the cause
Pulp extirpation
Tooth extractionScaling
Necrotic tissue / debris
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MANAGEMENTMANAGEMENT
Provide supportive care
General
Fluids
Rest
Nutrition
Warmth
Antibiotic therapy
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MANAGEMENTMANAGEMENT
Principles of antibiotic use
Necessity
Empirical therapy
Narrow spectrum Low toxicity
Bacteriocidal Administer properly
Cost
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MANAGEMENTMANAGEMENT
Antibiotics Good choices
Penicillin or amoxicillin ( + / - metronidazole )
Cephalexin, clindamycin, co-trimoxazole,
tetracycline, erythromycin
Poor choicesMetronidazole alone
Amoxicillin / clavulanic acid
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PREVENTIONPREVENTION
Local processes
Immunocompromised patient General preventive care
Timely intervention Good surgical technique
Distant sites
Infective endocarditis
Arteriovenous fistulae
Prosthetic valves and joints