Odontogenic Infection
Dr. Rahaf Al-Habbab BDS. MsD. DABOMS
Diplomat of the American Boards of Oral and
Maxillofacial Surgery
Odontogenic Infection
• Infection that arises from the teeth, and spread beyond the
teeth to the alveolar process and the deeper tissue of the
face, oral cavity, head and neck, and have a characteristic flora
Origin:
• Caries
• Periodontal Disease
• pulpitis
Different Origins of Odontogenic Infection
Odontogenic Infection Types
Low-grade
• Well localized infection that
require only minimal treatment
• Most common
Severe Infection:
• Life threatening
• Deep facial space infections
Microbiology of OI
• Most commonly part of the indigenous bacteria that normally
live on or in the host (normal flora)
• Are the bacteria that causes dental caries, gingivitis, and
periodontitis.
• Gaining access to deeper underlying tissues, causes
Odontogenic Infection
Microbiology of OI
• Aerobic gram positive cocci
• Anaerobic gram-positive cocci
• Anaerobic gram-negative rods
As the infection progresses more deeply, different members of
the infecting flora can begin to outnumber the previously
dominant species
Important Factors
• Almost all OI are caused by multiple bacteria (polymicrobial)
• Oxygen tolerance of the bacteria causing OI, because the oral
flora is a combination of aerobic and anaerobic bacteria
(aerobic 6%, anaerobic 44%, mixed 50%)
The predominant Aerobic bacteria found in 65% of OI are the
streptococcus milleri group, which consist of three members of the S.
viridans group of bacteria:
• S. anginosus, S. intermedius, S. constellatus, which can grow in the
presence and the absence of Oxygen
The Anaerobic bacteria found in OI include an even greater
variety of species, two groups predominate;
Gram positive cocci (65% of cases)
• Streptococcus
• Peptostreptococcus
Gram-negative anaerobic rods
• Prevotella, and Porphyromonas (found in about 75%)
• Fusobacterium (present in more than 50%)
Of the Anaerobic bacterai,
gram +ve cocci and
gram –ve rods, play a
more important
pathogenic role
Where the Anaerobic
gram –ve cocci and
gram +ve rods have little
or no role in causing OI
Pathophysiology
• Initial inoculation of aerobic and anaerobic bacteria into the deeper tissue
→ S. milleri group organisms synthesize Hyaluronidase → allow infection
to spread through connective tissue → Cellulitis type of Infection
• Metabolic by-products from the streptococci → create a favorable growth
environment for the Anaerobe (release of essential nutrients, lower pH,
local O2 supply consumption)
• As the local oxidation-reduction potential is lowered further → Anaerobic
bacteria predominate → further liquification necrosis (by their synthesis of
collagenases)
• As collagen is broken down and invading WBC necrosis and lyse → microabscesses form → Coalesce into a clinical Abscess
Clinical Progression
OI passes through four stages:
Inoculation Stage:
• First 3 days
• Soft, mildly tender, doughy swelling
• Invading streptococci are just beginning to colonize the host
Cellulites Stage:
• 3-5 days
• Swelling become hard, red, and acutely tender
• Infecting mixed flora stimulates the intense inflammatory response
Clinical Progression
Abscess Stage:
• 5-7 days after the swelling onset
• Anaerobic begin to predominate
• Liquification of the abscess in the center of the swollen area
Resolution Stage:
• Abscess drain spontaneously through skin or mucosa or it is surgically
drained
• Immune system destroys the infecting bacteria
• Process of healing and repair
characteristic
Edema (Inoculation)
Cellulitis
Abscess
0-3 days
1-5 days
4-10 days
Mild, diffuse
Diffuse
Localized
Size
Variable
Large
Smaller
Color
Normal
Red
Shiny center
Consistency
Jellylike
Boardlike
Soft center
Progression
Increasing
Increasing
Decreasing
Pus
Absent
Absent
Present
Bacteria
Aerobic
Mixed
Anaerobic
low
Greater
Less
Duration
Pain, borders
seriousness
Progression of Odontogenic Infection
Two major origins:
• Periapical (as a result of pulpal necrosis)
• Periodontal (as a result of deep periodontal pocket)
The periapical origin is the most common in odontogenic
infections
Progression of Odontogenic Infection
• Deep caries, resulting in dental pulp
necrosis, allows a pathway for
bacteria to enter the periapical tissue
• Bacterial invasion will result in active
infection
• Infection then spread equally in all
directions, but preferentially along
the line of least resistance
• If the cortical bone is
• Infection spreads through the
cancellous bone until it encounters
the cortical plate
thin, the infection erode
through the bone and
invade the soft tissue
Progression of Odontogenic Infection
• Treatment of the necrotic
pulp by standard endodontic
therapy or extraction of the
involved tooth should resolve
the problem
• Antibiotics alone may arrest,
BUT do not cure the infection
Spreading of the Infection
Determined by two major factors
The thickness of the bone
overlying the tooth apex
The relationship of the bone
perforation site to muscle
attachment of the maxilla and the
mandible
Maxillary Infection
• Most maxillary teeth erode through the facial cortical plate.
• Erode through the bone below the attachment of the
muscles attaching to the maxilla
Means that:
• Most maxillary dental abscesses appear initially as vestibular
abscess
• Occasionally, a palatal abscess arises from the apex of a
severely inclined lateral incisor or a palatal root of a maxillary
first molar.
Maxillary Infection
• More commonly; The maxillary molars cause infections that
erode through the bone superior to the insertion of the
buccinator muscle
Resulting in:
• Buccal space infection
• Occasionally, long maxillary canine root allows infection to
erode through the bone superior to levator anguli oris
insertion, causing Infraorbital (canine) space infection.
Mandibular Infection
Incisors, canine, and premolars:
• Usually erode through the facial cortical plate superior to the
attachment of the lower lip muscles
Resulting in:
• Vestibular abscess
Mandibular Infection
Mandibular molars:
• Infections erode through the lingual cortex more frequently
First molar
• Infections may drain buccally or lingually
Second molars
• Can perforate buccally or lingually (usually lingually)
Third molars:
• Almost always erode through the lingual cortical plate
The mylohyoid muscle determines wither infections that drain lingually go
superior to the muscle into the sublingual space or below it into the
submandibular space
Principles of OI Management
Principle 1: Determine Infection Severity
Principle 2: Evaluate State of patient’s host defense mechanism
Principle 3: Determine whether patient should be treated by
general dentist or Oral and Maxillofacial Surgeon
Principle 4: Treat infection surgically
Principle 5: Support patient medically
Principle 6: Choose and prescribe Appropriate antibiotic
Principle 7: Administer antibiotic properly
Principle 8: Evaluate patient frequently
Principle 1: Determine Infection
Severity
Complete history:
• Chief complaint: In patients own words
• Duration and onset: How long, progression
• Signs and symptoms: Pain, swelling, warmth, erythema and redness, and
loss of function (mouth opening, dysphagia, dyspnea)
• General condition: fatigued, feverish, weak, and sick are said to have
malaise
Malaise: generalized reaction to a moderate to severe infection
• Ask about Treatment: professional and self-treatment
• Complete medical history
Principle 1: Determine Infection
Severity
Physical Examination:
Vital signs: Temperature, blood pressure, pulse rate, and respiratory rate
• Temperature: Patient with severe infection have temperature of 101° F or
higher (greater than 38.3° C)
• Pulse Rate: pulse rate of up to 100 beats/min are not uncommon in an
infection patient, id PR is greater than 100 bpm may indicate severe
infection
• Blood Pressure: significant pain and anxiety can result in the elevation of
systolic blood pressure, However, severe septic shock result in
Hypotension
• Respiratory rate: clear upper airway and no difficulty in breathing
RR, 14-16 breaths per minute, can increase up to 18 in mild to moderate
infections
Principle 1: Determine Infection
Severity
Physical Examination:
• Inspection of general appearance
• Careful head and neck examination
• Palpation of swelling : tenderness, heat, consistency ( doughy, indurated,
fluctuant)
Fluctuance: feeling of fluid filled balloon, almost always indicate pus in the
center of the indurated area.
Intraoral Examination: cause of infection, and assess airway and tongue
position
Radiographic Examination: PA, Panoramic radiograph
Determine the diagnosis
Summery
• Edema represents the earliest ,inoculation stage of infection
that is most easily treated
• Cellulitis, is an acute, painful infection with more swelling and
diffuse borders
• Has a hard consistency on palpation and contains NO PUS
• Acute Abscess, more mature infection with more localized
pain, less swelling, well circumscribed borders
Which is more serious?
Principle 2: Evaluate State of Patient’s
Host Defense Mechanism
Medical conditions that compromise host defenses
1- Uncontrolled Metabolic Diseases:
• Poorly controlled Diabetes: Type I and Type II, are the most
common immunosuppressive diseases
• Renal disease with Uremia
• Severe alcoholism with malnutrition
Resulting in decrease function of leukocytes, including decrease
chemotaxis, phagocytosis, and bacterial killing
Principle 2: Evaluate State of Patient’s Host Defense
Mechanism
2- Immunocompromising Diseases:
• Leukemia
• Lymphoma
• Different types of cancer
Decrease white blood cells function and antibodies
synthesis and production
Principle 2: Evaluate State of Patient’s Host Defense
Mechanism
Immunocompromising Diseases:
• Human Immunodeficiency Virus Infection (HIV)
HIV attacks T lymphocytes, affecting resistance to viruses and intracellular
pathogens, Fortunately,
Odontogenic infections are caused largely by extracellular pathogens
(Bacteria) , therefore
HIV-seropositive individuals are able to combat OI fairly well until they aquire
immunodeficiency syndrome has progressed into advanced stage, when the
B lymphocytes are also severely impaired
Principle 2: Evaluate State of Patient’s Host Defense
Mechanism
3- Immunosuppressive Therapies:
• Cancer chemotherapy
• Corticosteroids
• Organ transplantation
Decrease white blood cells count, T and B lymphocyte function, and
immunoglobulin production, more likely to develop infection
Patient taking any of these medications should be treated vigorously ,
prophylactic antibiotics should be given for routine oral surgery procedure
to prevent INFECTION and Endocarditis
Principle 3: Determine whether patient should be
treated by General Dentist or Oral and Maxillofacial
Surgeon
Minor infection vs. life-threatening infection
Criteria indicating immediate referral to a Hospital emergency room to
secure the airway:
• Rapidly progressing infection
• Difficulty in breathing (dyspnea)
• Difficulty in swallowing (dysphagia)
• Dehydration
• Moderate to severe trismus (interincisal distance less than 20mm)
• Swelling extending beyond the alveolar process
• Elevated temperature (˃101° F)
• Severe malaise and toxic appearance
• Compromised host defenses
• Need for general anesthesia
• Failure of prior treatment
Principle 4: Treat infection surgically
• Remove the cause of the infection
• Drain the accumulate pus and necrotic debris
I&D Technique
• Adequate pain control (block or infiltration)
• Disinfect the surface mucosa with a solution such as
povidone-iodine (Betadine)
• Obtain a specimen for C&S testing using an 18 gauge needle
(1-2ml)
I&D Technique
Incision is made Over
the site of maximum
swelling and
inflammation using a
scalpel blade just
through the mucosa
and submucosa (not
more than 1cm long)
Avoid incising across
the frenum or the
mental nerve region
I&D Technique
Small curved
hemostat is inserted
through the incision to
the abscess cavity
Hemostat is open in
different directions to
break up any small pus
loculations or cavities
I&D Technique
Small drain is then
inserted and secure in
place using a nonresorbable suture
(1/4 inch sterile
penrose drain)
Drain is removed 2-5
days following
drainage, when all
drainage have stopped
Principle 5: Support Patient Medically
• Treat and control the underlying medical condition
• Proper hydration
• High-calorie nutritional supplement
• Adequate analgesia for proper rest
Principle 6: Choose and Prescribe Appropriate
Antibiotic
1- Determine the need of AB administration:
Indications:
•
•
•
•
•
•
•
Swelling extending beyond the alveolar process
Cellulitis
Trismus
Lyphadenopathy
Temperature higher than 101° F
Severe pericoronitis
Osteomyelitis
Principle 6: Choose and Prescribe Appropriate
Antibiotic
1- Determine the need of AB administration:
Not Indicated:
•
•
•
•
•
•
•
Patient demand
Toothache
Periapical abscess
Dry socket (self limiting)
Multiple dental extractions in a non compromised patient
Mild pericoronitis (inflammation of the operculum only)
Drained alveolar abscess
Principle 6: Choose and Prescribe Appropriate
Antibiotic
2- Use Empirical Therapy Routinely:
Odontogenic infections are caused by a highly predictable group of
bacteria, with a very well known antibiotic sensitivity.
Effective Orally Administered Antibiotics for OI:
•
•
•
•
•
•
Penicillin
Amoxicillin
Clindamycin
Azithromycin
Metronidazole
Moxifloxacin
Principle 6: Choose and Prescribe Appropriate
Antibiotic
2- Use the Narrowest-Spectrum Antibiotics:
Will affect streptococci and oral anaerobic bacteria, but will have little or no
effect on the staphylococci of the skin or GI tract, so does not result in
the development of bacterial resistance
Narrow and Broad-spectrum Antibiotics:
Narrow-Spectrum
(simple OI)
Amoxicillin
Penicillin
Clindamycin
Metronidazole
Wide-Spectrum
(complex OI)
Amoxicillin with clavulanic acid
Azithromycin
Tetracycline
Moxifloxacin
Simple vs. Complex Odontogenic Infection
Simple odontogenic Infections:
• Swelling limited to the alveolar process and vestibular space
• First attempt at treatment
• Non-immunocompromised patients
Complex Odontogenic Infections:
• Swelling extending beyond the vestibular space
• Failed prior treatment
• Immunocompromised patient
Principle 6: Choose and Prescribe Appropriate
Antibiotic
3- Use the antibiotic with the lowest incidence of toxicity and side
effects
4- Use a bactericidal antibiotic, if possible
5- Be aware of the coast of antibiotics
Principle 7: Administer Antibiotic Properly
• Proper dose should be given
• The peak plasma level should be 4 or 5 times the minimal
inhibitory concentration for the bacteria involved in the
infection
Principle 8: Evaluate Patient Frequently
• Patient should be followed carefully to monitor response to
treatment and complications
• Additional antibiotics may be necessary in infection that have not
resolved rapidly
Reasons for treatment failure:
•
•
•
•
•
•
•
•
Inadequate surgery
Foreign body
Antibiotic problems:
Patient noncompliance
Drug not reaching site
Drug dose too low
Wrong bacterial diagnosis
Wrong antibiotic
Thank You
Reference: Contemporary Oral and Maxillofacial Surgery
James R. Hupp, Edward Ellis III, Myron R. Tucker, 5th Edition
Chapter 15
Odontogenic Infection
Part II
Dr. Rahaf Al-Habbab BDS. MsD. DABOMS
Diplomat of the American Boards of Oral and
Maxillofacial Surgery
2013
Principles of Prevention of Infection
The use of antibiotics to treat an already established infection is
a well accepted and well-defined technique
But
The use of antibiotics for prevention is less widely accepted
Principles of Prophylaxis of Wound Infection
There is little scientific evidence that demonstrates the
effectiveness of prophylactic antibiotics in dentistry and Oral
and maxillofacial surgery.
Advantages
• Reduce the incidence of postoperative infection and
thereby reduces postoperative morbidity
• Appropriate and effective antibiotics prophylaxis may
reduce the coast of health care
• Requires shorter –term administration than
therapeutic use.
Disadvantages
• Can alter host flora, allowing the overgrowth of antibioticresistant and pathogenic bacteria that may then cause
infection
• Allow antibiotic-resistant organisms to spread to the patient’s
family and community
• May provide no benefit (infection risk is so low)
Disadvantages (cont.)
• May encourage lax surgical and aseptic technique on the
dentist part
• Coast of antibiotic must be considered
• Toxicity of the drug to the patient must be kept in mind
Principles of Prophylactic Antibiotic Use
• Risk of infection must be significant
• Correct narrow-spectrum antibiotic must be chosen
• Antibiotic level must be high
• Antibiotic must be in the target tissue before surgery
• Use the shortest effective antibiotic exposure.
Principle 1: Procedure Should have Significant
Risk of Infection
• Clean surgery with strict adherence to basic surgical
principles, has an infection rate of about 3%.
• 10% infection rate or higher (infection-prone procedure) is
considered unacceptable, and AB must be strongly
considered
However, several factors might influence the use of AB
prophylaxis
Factors Related to Postoperative Infection
• Size of bacterial inoculum
• Duration of surgery ( more than 4 hours in hospital surgeries)
• Presence of foreign body, implant, or dead space.
• State of host resistance (immunosuppressive, cancer)
• The most common immunocompromising disease is Diabetes
mellitus
Diabetes Mellitus
Measuring the level of DM control over the previous 3-4
Months
• The Glycosylated Hemoglobin test
• Hemoglobin A1c (8% or less)
Dental Treatment for Diabetics Based on Fingerstick Blood
Glucose Testing
Finger Stick Blood
Glucose (mg/dl
%)
Dental Treatment
Less than 85
Administer glucose; postpone elective treatment
85-200
Stress reduction; consider AB prophylaxis for extraction
200-300
Stress reduction; AB prophylaxis; referral to primary care
physician
300-400
Avoid elective treatment; referral to primary care physician or
ER at nearby hospital
Greater than 400
Avoid elective treatment; send to ER at nearby hospital
Principle 2: Choose Correct Antibiotics
The choice of AB for prophylaxis after surgery should be based
on the following criteria:
• First, AB should be effective against the organisms most likely
causing the infection
• Second, Chosen AB should be narrow-spectrum
• Third, Should be the least toxic AB available
• Fourth, should be bactericidal AB
AB of Choice
Taking these four criteria into account, the antibiotic
of Choice for prophylaxis is:
Penicillin and Amoxicillin
•
•
•
•
Effective against streptococcus
Narrow spectrum
Low toxicity
Bactericidal
Allergic to Penicillin
Clindamycin
• Fairly effective against oral streptococcus
• Narrow spectrum
• Bacteriostatic
Azithromycin
• Reasonably effective against the usual organisms
• Narrow spectrum
• Bacteriostatic
Principle 3: Antibiotic Plasma Level
must be High
• Prophylactic antibiotic plasma level must be higher than
therapeutic level
• Plasma level should be high at the time of surgery to ensure
diffusion of the AB into all tissue and spaces at surgery site
• The usual prophylaxis recommendation is two times the
usual therapeutic dose (use the AHA recommendation for
Infective Endocarditis):
• Penicillin and Amoxicillin, 2g
• Clindamycin, 600mg
• Azithromycin, 500mg
Principle 4: Time AB Administration Correctly
• Should be administered 2 hours or less before the surgery
• Varies according to the rout of administration
• For oral administration is usually 1 hour
• IV rout, much shorter duration is required
Principle 4: Time AB Administration Correctly
Giving prophylactic AB postoperatively was found to increase
the risk of postoperative infection
Intraoperative AB administration in prolonged procedure should
be given at half the usual interval time;
• Penicillin and Clindamycin should be given every 3 hours, to
avoid periods of inadequate AB level in tissue fluids.
Principle 5: Use Shortest Antibiotic Exposure
That is Effective
• AB must be given before the surgery
• Adequate plasma level must be maintained during surgery
• Continuation of the AB administration after surgery produce
little to no benefit
What about Metastatic Infections?
Principles of Prophylaxis Against Metastatic
Infection
• Defined as: Infection that occurs at a location physically
distant from the port of bacterial entry
• Bacterial Endocarditis is best example
• Incident of infection can be reduced if AB administration is
used preoperatively
Factors Necessary for Metastatic Infection
• Distant susceptible site (Deformed heart valve, Non-Bacterial
Thrombotic Endocarditis, NBTE)
• Hematogenous bacterial seeding (Bacteremia)
• Impaired local defenses
Prophylaxis Against Infectious Endocarditis
• Bacteremia has been shown to cause IE (streptococcus
viridans) which is part of the normal oral flora
• Prophylactic AB has shown to prevent IE resulting from dental
procedures
• IE can result in high morbidity and mortality
• All dental procedures can result in Bacteremia
• Depending on the procedure the need of antibiotics is
decided in high risk patients
Cardiac Conditions Associated with the Highest Risk of Adverse
outcome from Endocarditic for which Prophylaxis with dental
procedure is Recommended
 Prosthetic Cardiac Valve
 Previous Infective Endocarditis
 Congenital Heart Disease (CHD)
• Unrepaired cyanotic CHD, including palliative shunts and coduits
• Completely repaired congenital heart defect with prosthetic material or
device, whether placed by surgery or by catheter intervention, during the
first 6 months after the procedure
• Repaired CHD with residual defects at the site or adjacent to the site of a
prosthetic patch or prosthetic device (which inhibit endothelialization)
 Cardiac transplantation recipients who have cardiac valculopathy
Dental Procedures for which Endocarditis
Prophylaxis is Recommended for patients
All dental procedures that involve manipulation of gingival
tissue or the periapical region of teeth or perforation of the
oral mucosa
Dental Procedures for which Prophylaxis is NOT
Recommended
•
•
•
•
•
•
•
•
•
•
Restorative dentistry
Routine local anesthetic injection
Intracanal endodontic therapy and placement of rubber dams
Suture removal
Placement of removable appliances
Making of impressions
Taking oral radiographs
Fluoride treatment
Orthodontic appliance adjustment
Shedding of primary teeth
If unexpected bleeding occurs during the procedure or
the patient failed to inform you about his condition
• Prophylaxis AB should be given during the first 2 hours after
the procedure
• Prophylaxis given longer than 4 hours after the bacteremia
has limited prophylactic benefits.
Antibiotics Regiments for prophylaxis of
Bacterial Endocarditis
Situation
Agent
Regiment
Adult
30-60 Min Before
Procedure
Children
Oral
Amoxicillin
2g
50 mg/kg
parenteral
Ampicillin
Cafazolin/ceftriaxone
2 g IM or IV
1 g IM or IV
50 mg/kg IM or IV
50 mg/kg IM or IV
PCN allergy,
Oral
Cephalexin
Clindamycin
Azithromycin/clarithromycin
2g
600 mg
500 mg
50 mg/kg
20 mg/kg
15 mg/kg
PCN, allergy,
parenteral
Cefazolin/ceftriaxone
Clindamycin
1 g IM or IV
50 mg/kg IM or IV
600 mg IM or IV 50 mg/kg IM or IV
Prophylaxis in Patients with other Conditions
Do not require PAB
Coronary Artery
Bypass Grafting
(CABG)
Prophylaxis in Patients with other Conditions
Transvenous
Pacemaker
(Battery Pack Implanted in
their Chest)
Do Not Require PAB
Consultation with the patient’s cardiologist
should still be considered
Prophylaxis in Patients with other Conditions
Renal Dialysis Patients for
Renal Failure
(Arteriovenous Fistula)
Patient Nephrologists should
decide the proper PAB
Prophylaxis against Total Joint Replacement
Infection
American Dental Association (ADA) and the American Academy
of Orthopedic Surgeons (AAOS) RECOMMENDATION:
Most patients with prosthetic joints are not at risk for joint
infection after a dental surgical procedure
Conditions placing patients at risk for
prosthetic joint infection
•
•
•
•
•
•
•
•
Prosthetic joint placed within 2 years
Rheumatoid arthritis
Systemic lupus erythematosus
Insulin-dependent diabetes
Previous prosthetic joint infection
Congenital or acquired immunosuppressive diseases
Malnourishment
hemophilia
Procedures that indicate prophylaxis for
prosthetic joint replacement
• Dental extraction
• Periodontal procedures, including scaling and root planning
• Dental implant placement and reimplantation of avulsed
teeth
• Periapical endodontic procedures
• Initial placement of orthodontic bands but not brackets
• Intraligamentary local anesthetic injections
• Dental prophylaxis when bleeding is expected
• Subgingival placement of antibiotic fibers or strips
Antibiotic Regimens for Prophylaxis of Total
Joint Replacement Infection
Regimen
Drug
Dose
Standard oral prophylaxis
Amoxicillin, cephalexin, or
cephradine
2g orally 1 hour before
procedure
Penicillin-allergic oral
prophylaxis
Clindamycin
600 mg orally 1 hour
before procedure
Parenteral prophylaxis
Cephazolin
Or
Ampicillin
1g IV 1 hour before
procedure
2g IV 1 hour before
procedure
Penicillin-allergic
parenteral prophylaxis
Clindamycin
600 mg IV 1 hour before
procedure
Indication for Parenteral Regimen
• Patient having general anesthetic and allowed nothing by
mouth
• Unable to take oral medications
• High-risk patients, such as those with history of previous
bacterial endocarditis
Communications Between all Parties is
Required
Thank You
Reference: Contemporary Oral and Maxillofacial Surgery
James R. Hupp, Edward Ellis III, Myron R. Tucker, 5th Edition
Chapter 15