Diagnosis and Diagnosis and Management of Management of

Odontogenic Odontogenic InfectionsInfectionsNino Zaya, MDNino Zaya, MD

November 2, 2006November 2, 2006

ObjectivesObjectives

Understand the microbiology of Understand the microbiology of odontogenic infectionsodontogenic infections

Understand the signs symptoms and Understand the signs symptoms and findings in patients with odontogenic findings in patients with odontogenic infectionsinfections

Review the various pathways of spread Review the various pathways of spread with odontogenic infectionswith odontogenic infections

Understand the medical and surgical Understand the medical and surgical management of odontogenic infectionsmanagement of odontogenic infections

Case Case

43 y.o. male comes to the emergency 43 y.o. male comes to the emergency room with drooling, and shortness of room with drooling, and shortness of breath that is exacerbated when laying breath that is exacerbated when laying down. He has had right lower tooth down. He has had right lower tooth pain with mastication during the past pain with mastication during the past month with worsening during the past month with worsening during the past week. He states that during the last week. He states that during the last day he has had neck pain and day he has had neck pain and developed shortness of breath.developed shortness of breath.

Continued….Continued…. Physical Exam:Physical Exam:

Elevation FOM withElevation FOM withinduration in the submental,induration in the submental,bilateral submandibular,bilateral submandibular,and bilateral sublingual spaces,and bilateral sublingual spaces,as well as droolingas well as drooling Inability to lay supineInability to lay supine Extensive dental caries:Extensive dental caries:percussion tendernesspercussion tendernesstooth #31tooth #31 TachypneaTachypnea

BackgroundBackground Among most frequently encountered Among most frequently encountered

infections in human bodyinfections in human body Plagued our species for as long as we have Plagued our species for as long as we have

existedexisted Pre-Columbian Indians, unearthed in the Pre-Columbian Indians, unearthed in the

American MidwestAmerican Midwest Early Egypt revealed bony crypts of dental Early Egypt revealed bony crypts of dental

abscesses, sinus tracts, and the ravages of abscesses, sinus tracts, and the ravages of osteomyelitis of the mandibleosteomyelitis of the mandible

Treatment of localized dental infection was Treatment of localized dental infection was probably the first primitive surgical probably the first primitive surgical procedure performed, using a sharp stone procedure performed, using a sharp stone or pointed stick to establish drainageor pointed stick to establish drainage

AnatomyAnatomy

MICROBIOLOGY OF MICROBIOLOGY OF ODONTOGENIC ODONTOGENIC INFECTIONS INFECTIONS

Usually caused by endogenous bacteriaUsually caused by endogenous bacteria Aerobic bacteria alone rarely causative agentsAerobic bacteria alone rarely causative agents StreptococcusStreptococcus species are usually the species are usually the

etiologic organisms if aerobic bacteria presentetiologic organisms if aerobic bacteria present Half odontogenic infections: anaerobesHalf odontogenic infections: anaerobes Most odontogenic infections due to mixed Most odontogenic infections due to mixed

floraflora Mixed infections may have 5-10 organisms Mixed infections may have 5-10 organisms

presentpresent

Continued….Continued…. Bacterial compositionBacterial composition

1.1. 5%-aerobic bacteria 5%-aerobic bacteria 2.2. 60%-anaerobic bacteria60%-anaerobic bacteria3.3. 35% mixed aerobic and anaerobic bacteria35% mixed aerobic and anaerobic bacteria

Commonly cultured organisms: alpha-Commonly cultured organisms: alpha-hemolytic hemolytic Streptococcus, Streptococcus, Peptostreptococcus, Peptococcus, Peptostreptococcus, Peptococcus, Eubacterium, Bacteroides (Prevotella) Eubacterium, Bacteroides (Prevotella) melaninogenicus,melaninogenicus, and and Fusobacterium. Fusobacterium.

Quantitative estimations of the number of Quantitative estimations of the number of microorganisms in saliva and plaque range microorganisms in saliva and plaque range as high as 10as high as 101111/ml. /ml.

Presentation Presentation

History-previous toothaches, onset, History-previous toothaches, onset, duration, presence of fever, and previous duration, presence of fever, and previous treatments (antibiotics ) importanttreatments (antibiotics ) important

Patients may complain of trismus, Patients may complain of trismus, dysphagia and have shortness of breath dysphagia and have shortness of breath should be investigated. should be investigated.

Findings vary from mild swelling and Findings vary from mild swelling and pain to life-threatening airway pain to life-threatening airway compromise and CNS impairment compromise and CNS impairment

Continued….Continued….

Possibly fatal infections may present Possibly fatal infections may present with respiratory impairment, dysphagia, with respiratory impairment, dysphagia, impaired vision, ophthalmoplegia, impaired vision, ophthalmoplegia, hoarseness, lethargy and decreased level hoarseness, lethargy and decreased level of consciousnessof consciousness

Exam findings: Toxic, CNS impairment Exam findings: Toxic, CNS impairment (decreased level of consciousness, (decreased level of consciousness, meningeal irritation, severe headache, meningeal irritation, severe headache, and vomiting), eyelid edema; and and vomiting), eyelid edema; and ophthalmoplegia. ophthalmoplegia.

Continued….Continued…. Rubor- (redness) cutaneous surface involved due Rubor- (redness) cutaneous surface involved due

to vasodilatation effect of inflammationto vasodilatation effect of inflammation Tumor-(swelling) occurs due to the accumulation Tumor-(swelling) occurs due to the accumulation

of pus or fluid exudateof pus or fluid exudate Calor-(heat) is the result of increased blood flow Calor-(heat) is the result of increased blood flow

to the area due to the vasodilatation. to the area due to the vasodilatation. Dolor-(or pain) results from pressure on sensory Dolor-(or pain) results from pressure on sensory

nerve endings from tisssue distention caused by nerve endings from tisssue distention caused by edema or infection edema or infection

Functiolaesa-(loss of function) problems with Functiolaesa-(loss of function) problems with mastication, trismus, dysphagia, and respiratory mastication, trismus, dysphagia, and respiratory impairment impairment

Continued….Continued….

Inspection, palpation, and percussion are Inspection, palpation, and percussion are integral parts of the examintegral parts of the exam

Begin extraorally and then move inraorallyBegin extraorally and then move inraorally Skin of the face, head, and neck for Skin of the face, head, and neck for

swelling, fluctuation, erythema, sinus or swelling, fluctuation, erythema, sinus or fistula formation, and subcutaneous crepitusfistula formation, and subcutaneous crepitus

Assess for cervical lymphadenopathy and Assess for cervical lymphadenopathy and fascial space involvementfascial space involvement

Assess for the presence and magnitude of Assess for the presence and magnitude of trismustrismus

Continued….Continued….

Inspect teeth for presence of caries and Inspect teeth for presence of caries and large restorations, localized swellings, large restorations, localized swellings, fistulas, and mobilityfistulas, and mobility

FOM inspected to assess for fascial space FOM inspected to assess for fascial space involvementinvolvement

Visualize Wharton’s and Stenson’s ducts Visualize Wharton’s and Stenson’s ducts for quality of fluid (pus or saliva)for quality of fluid (pus or saliva)

Ophthalmologic examination: extraocular Ophthalmologic examination: extraocular muscle function, proptosis, presence of muscle function, proptosis, presence of preseptal or postseptal edemapreseptal or postseptal edema

Continued….Continued…. Imaging studies can further Imaging studies can further

substantiate diagnosissubstantiate diagnosis Computerized tomograms should be Computerized tomograms should be

obtained when infection has spread obtained when infection has spread into fascial spaces in the orbit or neckinto fascial spaces in the orbit or neck

Infections, well-localized to oral cavity Infections, well-localized to oral cavity do not require special imaging studies do not require special imaging studies with a panorex being sufficient for with a panorex being sufficient for diagnosis and treatmentdiagnosis and treatment

Pathways of Odontogenic Pathways of Odontogenic InfectionInfection

Usual cause of odontogenic infection: necrosis of Usual cause of odontogenic infection: necrosis of tooth pulp and bacterial invasion through the pulp tooth pulp and bacterial invasion through the pulp chamber into deeper tissueschamber into deeper tissues

Pulp necrosis results from deep decay in tooth, Pulp necrosis results from deep decay in tooth, (inflammatory reaction)(inflammatory reaction)

The pulpal foramen does not allow drainage of the The pulpal foramen does not allow drainage of the infected pulp infected pulp

Further progression leads to medullary space Further progression leads to medullary space infection and osteomyelitisinfection and osteomyelitis

More commonly, get fistulous tracts through More commonly, get fistulous tracts through alveolar bonealveolar bone

Fistulous tract may penetrate oral mucosa or Fistulous tract may penetrate oral mucosa or facial skin facial skin

Continued….Continued….

Fascial SpacesFascial Spaces Fascial planes offer anatomic highways for Fascial planes offer anatomic highways for

infection to spread superficial to deep infection to spread superficial to deep planesplanes

Antibiotic availability in fascial spaces is Antibiotic availability in fascial spaces is limited due to poor vascularitylimited due to poor vascularity

Treatment of fascial space infections Treatment of fascial space infections depends on I and Ddepends on I and D

Fascial spaces are contiguous and infection Fascial spaces are contiguous and infection readily spreads from one space to another readily spreads from one space to another (open primary and secondary spaces) (open primary and secondary spaces)

Despite I and D the etiologic agent (tooth) Despite I and D the etiologic agent (tooth) must be removed must be removed

Primary Mandibular Primary Mandibular SpacesSpaces

Submental spaceSubmental space1.1. Infection can result directly due to infected Infection can result directly due to infected

mandibular incisor or indirectly from the mandibular incisor or indirectly from the submandibular spacesubmandibular space

2.2. Space located between the anterior bellies of the Space located between the anterior bellies of the digastric muscle laterally, deeply by the mylohyoid digastric muscle laterally, deeply by the mylohyoid muscle, and superiorly by the deep cervical fascia, muscle, and superiorly by the deep cervical fascia, the platysma muscle, the superficial cervical the platysma muscle, the superficial cervical fascia, and the skinfascia, and the skin

3.3. Dependent drainage of this space is performed by Dependent drainage of this space is performed by placing a horizontal incision in the most placing a horizontal incision in the most dependent area of the swelling extraorally with a dependent area of the swelling extraorally with a cosmetic scar being the resultcosmetic scar being the result

Continued….Continued….

Submandibular SpaceSubmandibular Space1.1. Boundaries:Boundaries:

1.1. Superior-mylohyoid muscle and inferior border of Superior-mylohyoid muscle and inferior border of the mandiblethe mandible

2.2. Anteriorly-anterior belly of the digastric muscle Anteriorly-anterior belly of the digastric muscle

3.3. Posteriorly-posterior belly of the digastric musclePosteriorly-posterior belly of the digastric muscle

4.4. Inferiorly-hyoid boneInferiorly-hyoid bone

5.5. Superficially-platysma muscle and superficial layer Superficially-platysma muscle and superficial layer of the deep cervical fasciaof the deep cervical fascia

2.2. Infected mandibular 2Infected mandibular 2ndnd and 3 and 3rdrd molars cause molars cause submandibular space involvement since root submandibular space involvement since root apices lay below mylohyoid muscle apices lay below mylohyoid muscle

Submandibular Space Submandibular Space AbscessAbscess

Continued….Continued….

Sublingual SpaceSublingual Space1.1. Submandibular and sublingual spaces Submandibular and sublingual spaces

surgically distinct, but should be considered surgically distinct, but should be considered as surgical unit due to proximity and frequent as surgical unit due to proximity and frequent dual involvement in odontogenic infections. dual involvement in odontogenic infections.

2.2. Boundaries:Boundaries:1.1. Superior-oral mucosaSuperior-oral mucosa

2.2. Inferior-mylohyoid muscleInferior-mylohyoid muscle

3.3. Infected premolar and 1Infected premolar and 1st st molar teeth molar teeth frequently drain into this space due to their frequently drain into this space due to their root apices existing superior to the mylohyoid root apices existing superior to the mylohyoid muscle muscle

Sublingual Space Sublingual Space InfectionInfection

Continued….Continued….

Buccal SpaceBuccal Space1.1. Boundaries: Boundaries:

1.1. Lateral-Skin of the face Lateral-Skin of the face

2.2. Medial-Buccinator muscle Medial-Buccinator muscle

2.2. Both a primary mandibular and Both a primary mandibular and maxillary spacemaxillary space

3.3. Most infections caused by posterior Most infections caused by posterior maxillary teethmaxillary teeth

Buccal Space AbscessBuccal Space Abscess

Secondary Mandibular Secondary Mandibular SpacesSpaces

Referred to as Referred to as secondarysecondary spaces since they are spaces since they are infected after involvement of primary mandibular infected after involvement of primary mandibular spacesspaces

Failure to treat a primary space infection or a Failure to treat a primary space infection or a compromised host results in secondary space compromised host results in secondary space involvementinvolvement

Connective tissue fascia has poor blood supply Connective tissue fascia has poor blood supply hence treatment usually surgical to drain purulent hence treatment usually surgical to drain purulent exudates exudates

The secondary mandibular spaces include the The secondary mandibular spaces include the masseteric, pterygomandibular, and temporal masseteric, pterygomandibular, and temporal spacesspaces

Continued….Continued….

Masseteric SpaceMasseteric Space1.1. Located between lateral aspect of the Located between lateral aspect of the

mandible and the masseter muscle mandible and the masseter muscle

2.2. Involvement of this space generally Involvement of this space generally occurs from buccal space primary occurs from buccal space primary involvement involvement

3.3. Signs of involvement of the masseteric Signs of involvement of the masseteric space include trismus and posterior-space include trismus and posterior-inferior face swellinginferior face swelling

Continued….Continued….

Pterygomandibular SpacePterygomandibular Space1.1. Location: between medial aspect of the Location: between medial aspect of the

mandible and the medial pterygoid mandible and the medial pterygoid muscle (communicates with muscle (communicates with infratemporal spaces)infratemporal spaces)

2.2. 2ndary infection results from spread from 2ndary infection results from spread from the sublingual and submandibular spacesthe sublingual and submandibular spaces

3.3. Symptoms: Symptoms: 1.1. TrismusTrismus

2.2. Minimal swelling on examMinimal swelling on exam

Continued….Continued….

Temporal SpaceTemporal Space1.1. Location: posterior and superior to the Location: posterior and superior to the

masseteric and pterygomandibular masseteric and pterygomandibular spaces spaces

2.2. Bounded laterally by the temporalis Bounded laterally by the temporalis fascia and medially by the temporal bonefascia and medially by the temporal bone

3.3. Two components:Two components:1.1. Superficial temporal space: located between Superficial temporal space: located between

temporal fascia and temporalis muscletemporal fascia and temporalis muscle2.2. Deep temporal space: located between the Deep temporal space: located between the

temporalis muscle and the temporal bonetemporalis muscle and the temporal bone1.1. Continuous with the infratemporal space Continuous with the infratemporal space

Continued….Continued….

Masseteric, pterygomandibular, and Masseteric, pterygomandibular, and temporal spaces referred to as temporal spaces referred to as masticator spacemasticator space due to delineation by due to delineation by the muscles of masticationthe muscles of mastication

1.1. Communicate freely with one another and Communicate freely with one another and are simultaneously involvedare simultaneously involved

Secondary Mandibular Secondary Mandibular SpacesSpaces

Primary Maxillary SpacesPrimary Maxillary Spaces Canine SpaceCanine Space

1.1. Location: between the levator anguli oris and the levator Location: between the levator anguli oris and the levator labii superioris muscles labii superioris muscles

2.2. Involvement primarily due to maxillary canine tooth Involvement primarily due to maxillary canine tooth infection infection

3.3. Long root allows erosion through the alveolar bone of the Long root allows erosion through the alveolar bone of the maxillamaxilla

4.4. Signs: Signs: 1.1. Obliteration of the nasolabial fold Obliteration of the nasolabial fold 2.2. Superior extension can involve lower eyelidSuperior extension can involve lower eyelid

Buccal SpaceBuccal Space1.1. Posterior maxillary teeth are source of most buccal space Posterior maxillary teeth are source of most buccal space

infectionsinfections2.2. Results when infection erodes through bone superior to Results when infection erodes through bone superior to

attachment of buccinator muscleattachment of buccinator muscle

Continued….Continued….

Infratemporal SpaceInfratemporal Space1.1. Location: posterior to the maxilla Location: posterior to the maxilla 2.2. Boundaries: Boundaries:

1.1. Medial: lateral plate of the pterygoid Medial: lateral plate of the pterygoid process of the sphenoid bone process of the sphenoid bone

2.2. Superior: skull base Superior: skull base 3.3. Lateral: infratemporal space is continuous Lateral: infratemporal space is continuous

with the deep temporal space with the deep temporal space

3.3. Rare involvement with odontogenic Rare involvement with odontogenic infections, but when occurs related to infections, but when occurs related to 33rdrd maxillary molar infections maxillary molar infections

Continued….Continued…. Primary maxillary space (canine, buccal, Primary maxillary space (canine, buccal,

and infratemporal space) involvement can and infratemporal space) involvement can ascend to cause orbital cellulitis (preseptal ascend to cause orbital cellulitis (preseptal or postseptal) or cavernous sinus or postseptal) or cavernous sinus thrombosis thrombosis

1.1. Ocular findings include erythema and swelling of Ocular findings include erythema and swelling of the eyelids, and ophthalmoplegia the eyelids, and ophthalmoplegia

2.2. Cavernous sinus thrombosis Cavernous sinus thrombosis 1.1. Can result from hematogenous spread of odontogenic Can result from hematogenous spread of odontogenic

infections infections 2.2. Bacterial routes of spread:Bacterial routes of spread:

1.1. Posterior: via pterygoid plexus or emissary veins Posterior: via pterygoid plexus or emissary veins 2.2. Anterior: via angular vein and inferior or superior Anterior: via angular vein and inferior or superior

ophthalmic veins to the cavernous sinusophthalmic veins to the cavernous sinus3.3. Veins of the face and orbit valve less so retrograde flow Veins of the face and orbit valve less so retrograde flow

can occur can occur

Orbital AbscessOrbital Abscess

Deep Neck SpacesDeep Neck Spaces Extension of odontogenic infections beyond the Extension of odontogenic infections beyond the

primary spaces of maxilla and mandible is uncommonprimary spaces of maxilla and mandible is uncommon When occurs upper airway compromise and When occurs upper airway compromise and

descending mediastinitis are possible adverse descending mediastinitis are possible adverse sequelae sequelae

Posterior spread of ptyerygomandibular space Posterior spread of ptyerygomandibular space infection is to lateral pharyngeal space infection is to lateral pharyngeal space

Lateral Pharyngeal space Lateral Pharyngeal space 1.1. Shape of an inverted cone with its base at the skull base and Shape of an inverted cone with its base at the skull base and

its apex at the hyoid boneits apex at the hyoid bone2.2. Location: medial to the medial pterygoid muscle and lateral Location: medial to the medial pterygoid muscle and lateral

to the superior pharyngeal constrictor muscle to the superior pharyngeal constrictor muscle 3.3. Anterior: pterygomandibular rapheAnterior: pterygomandibular raphe4.4. Posterior: prevertebral fascia. Posterior: prevertebral fascia.

Continued….Continued…. Lateral pharyngeal space communicates with Lateral pharyngeal space communicates with

retropharyngeal space. retropharyngeal space. The styloid process separates posterior The styloid process separates posterior

compartment of the lateral pharyngeal space that compartment of the lateral pharyngeal space that contains the great vessels from the anterior space contains the great vessels from the anterior space

Clinical presentationClinical presentation1.1. Severe trismusSevere trismus2.2. Lateral swelling of the neckLateral swelling of the neck3.3. Bulging of the lateral pharyngeal wallBulging of the lateral pharyngeal wall4.4. Rapid progression of infection in this space is common Rapid progression of infection in this space is common 5.5. Posterior compartment involvement can result in Posterior compartment involvement can result in

thrombosis of the internal jugular vein, erosion of the thrombosis of the internal jugular vein, erosion of the carotid artery or its branches, and interference with carotid artery or its branches, and interference with cranial nerves IX to XIIcranial nerves IX to XII

Lateral Pharyngeal Space Lateral Pharyngeal Space AbscessAbscess

Continued….Continued…. Retropharyngeal SpaceRetropharyngeal Space

1.1. Posteromedial to lateral pharyngeal space and Posteromedial to lateral pharyngeal space and anterior to the prevertebral space anterior to the prevertebral space

2.2. Anterior: superior pharyngeal constrictor muscle Anterior: superior pharyngeal constrictor muscle 3.3. Posterior: alar layer of prevertebral fascia Posterior: alar layer of prevertebral fascia 4.4. Extends from skull base superiorly to C7 to T1 Extends from skull base superiorly to C7 to T1

inferiorlyinferiorly5.5. Retropharyngeal space infections can spread to Retropharyngeal space infections can spread to

mediastinummediastinum6.6. Other complications of retropharyngeal space Other complications of retropharyngeal space

involvement:involvement:1.1. Airway obstruction Airway obstruction 2.2. Aspiration of pus in the event of spontaneous rupture Aspiration of pus in the event of spontaneous rupture 3.3. Rupture can occur during endotracheal intubationRupture can occur during endotracheal intubation

Retropharyngeal AbscessRetropharyngeal Abscess

Continued….Continued….

Prevertebral SpacePrevertebral Space1.1. Potential space between two layers of Potential space between two layers of

prevertebral fascia (alar and prevertebral fascia (alar and prevertebral layers) prevertebral layers)

2.2. Extends from skull base superiorly to Extends from skull base superiorly to the diaphragm inferiorly the diaphragm inferiorly

3.3. Mediastinitis is concern with Mediastinitis is concern with prevertebral space infections similarly prevertebral space infections similarly to retropharyngeal space infectionsto retropharyngeal space infections

Anatomic PlanesAnatomic Planes

Management of Management of Odontogenic InfectionsOdontogenic Infections

Goals of management of Goals of management of odontogenic infection:odontogenic infection:

1.1. Airway protectionAirway protection

2.2. Surgical drainageSurgical drainage

3.3. Medical support of the patient Medical support of the patient

4.4. Identification of etiologic bacteriaIdentification of etiologic bacteria

5.5. Selection of appropriate antibiotic Selection of appropriate antibiotic therapytherapy

Continued….Continued…. Airway protectionAirway protection

1.1. Floor of mouth and tongue elevation or narrowing can Floor of mouth and tongue elevation or narrowing can cause respiratory distress cause respiratory distress

2.2. Expedient assessment and diagnosis of airway Expedient assessment and diagnosis of airway compromise is the most important initial step in compromise is the most important initial step in managing odontogenic infectionsmanaging odontogenic infections

3.3. Airway loss is primary cause of death in these patientsAirway loss is primary cause of death in these patients4.4. Initially intact airway must be continuously reevaluated Initially intact airway must be continuously reevaluated

during treatmentduring treatment5.5. Signs and findings of airway compromise: inability to Signs and findings of airway compromise: inability to

assume a supine position, drooling, dysphonia, stridor, assume a supine position, drooling, dysphonia, stridor, and restlessness etc.and restlessness etc.

6.6. Surgeon must decide the need, timing and method to Surgeon must decide the need, timing and method to establish an emergency airwayestablish an emergency airway

Continued….Continued….

Surgical drainageSurgical drainage1.1. Administration of intravenous antibiotics without Administration of intravenous antibiotics without

drainage of pus may not allow for resolution of an drainage of pus may not allow for resolution of an abscessabscess

2.2. Starting antibiotic therapy without Gram's stain Starting antibiotic therapy without Gram's stain and cultures may result in failure to identify and cultures may result in failure to identify pathogens pathogens

3.3. Important to drain all primary spaces as well as Important to drain all primary spaces as well as explore and drain potentially involved secondary explore and drain potentially involved secondary spacesspaces

4.4. CT scans may help identifying spaces involvedCT scans may help identifying spaces involved

5.5. Panorex can help identify putative teeth involvedPanorex can help identify putative teeth involved

Continued….Continued…. Canine, sublingual and vestibular abscesses Canine, sublingual and vestibular abscesses

are drained intraorallyare drained intraorally Masseteric, pterygomandibular, and lateral Masseteric, pterygomandibular, and lateral

pharyngeal space abscesses can be drained pharyngeal space abscesses can be drained with combination intraoral and extraoral with combination intraoral and extraoral drainagedrainage

Temporal, submandibular, submental, Temporal, submandibular, submental, retropharyngeal, and buccal space abscesses retropharyngeal, and buccal space abscesses may mandate extraoral incision and drainage may mandate extraoral incision and drainage

Technique:Technique:1.1. Small incision are made in a dependent area Small incision are made in a dependent area 2.2. Placement of a hemostat in the abscess cavity with Placement of a hemostat in the abscess cavity with

entry into all loculations of the abscessentry into all loculations of the abscess3.3. Penrose drains inserted into cavity to allow for Penrose drains inserted into cavity to allow for

postoperative drainage of the abscess postoperative drainage of the abscess

Continued….Continued….

Medical support of the patientMedical support of the patient1.1. Rehydrate patient as dehydration may Rehydrate patient as dehydration may

be present be present

2.2. Treat conditions that predispose Treat conditions that predispose patient to infection (DM) patient to infection (DM)

3.3. Correct electrolyte disturbances Correct electrolyte disturbances

4.4. Oral pain, trismus, and swelling can be Oral pain, trismus, and swelling can be addressed by appropriate analgesia addressed by appropriate analgesia and treatment of underlying infectionand treatment of underlying infection

Continued….Continued….

Identification of etiologic bacteriaIdentification of etiologic bacteria1.1. Expected causes are alpha hemolytic Expected causes are alpha hemolytic

streptococci and oral anaerobesstreptococci and oral anaerobes2.2. Cultures should be performed on all Cultures should be performed on all

patients undergoing incision and drainage patients undergoing incision and drainage and sensitivities ordered if patient is not and sensitivities ordered if patient is not progressing well (possible antibiotic progressing well (possible antibiotic resistance)resistance)

3.3. An aspirate of the abscess can be An aspirate of the abscess can be performed and sent for culture and performed and sent for culture and sensitivities if incision and drainage sensitivities if incision and drainage delayeddelayed

Continued….Continued…. Selection of antibiotic therapySelection of antibiotic therapy

1.1. Parenteral penicillin Parenteral penicillin 2.2. MetronidazoleMetronidazole in combination with penicillin can in combination with penicillin can

be used in severe infections be used in severe infections 3.3. Clindamycin for penicillin-allergic patientsClindamycin for penicillin-allergic patients4.4. Cephalosporins (first-generation cephalosporins) Cephalosporins (first-generation cephalosporins) 5.5. Antibiotics do not substitute for incision and Antibiotics do not substitute for incision and

drainage in cases of significant odontogenic drainage in cases of significant odontogenic infectionsinfections

6.6. Causes for clinical failure include inadequate Causes for clinical failure include inadequate drainage or antibiotic resistance drainage or antibiotic resistance

7.7. Mediastinal involvement should prompt CT scan Mediastinal involvement should prompt CT scan of the chest and cardiothoracic surgery of the chest and cardiothoracic surgery consultationconsultation

Case continued….Case continued…. Patient taking to OR for a Patient taking to OR for a flexible fiberoptic intubation flexible fiberoptic intubation with standby tracheostomy with standby tracheostomy equipment available.equipment available. External I and D and Cx, External I and D and Cx, extraction tooth #31 extraction tooth #31 Parenteral antibioticsParenteral antibiotics Eventually, extubated afterEventually, extubated afterresolution FOM edemaresolution FOM edema D/c on oral antibiotics withD/c on oral antibiotics withfollow-up with oral surgery address follow-up with oral surgery address remaining teethremaining teeth

Ludwig’s AnginaLudwig’s Angina

ConclusionsConclusions

Most odontogenic infections are caused Most odontogenic infections are caused by anaerobesby anaerobes

Identify possible complications of Identify possible complications of odontogenic infections odontogenic infections

Antibiotics may not sufficient and Antibiotics may not sufficient and incision and drainage of these incision and drainage of these abscesses may be necessary for abscesses may be necessary for resolutionresolution

Extracting the causative tooth Extracting the causative tooth facilitates the resolution of the infectionfacilitates the resolution of the infection

BibliographyBibliography

Anatomy:http://www.sadanet.co.za/Anatomy:http://www.sadanet.co.za/dhw/owners_manual/anatomy1.htmldhw/owners_manual/anatomy1.html

Cummings Otolaryngology: Head Cummings Otolaryngology: Head and Neck Surgery. Chapter 67. and Neck Surgery. Chapter 67. Odontogenic Infections.Odontogenic Infections.

Images LA. Images LA. http://www.aafp.org/afp/990700ap/1http://www.aafp.org/afp/990700ap/109.html09.html