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Noah A. Sandler, DMD, MDAssistant Professor

Division of Oral and Maxillofacial SurgeryUniversity of Minnesota

OdontogenicInfections

Overview

• Microbiology• Progression of infection• Assessment• Fascial spaces• Treatment/antibiotics

Microbiology

• Polymicrobial• Mixed aerobic/ anaerobic• Aerobic-cellulitis• Anaerobic-abscess

Causative Organisms

Aerobic only 28 7Anaerobic only 133 33Mixed 243 60

Number of Patients Percentage

Microorganisms CausingOdontogenic Infections

Aerobic 25%

Gram-positive cocci 85Streptococcus spp. 90Streptococcus (Group D) spp. 2Staphylococcus spp. 6Eikenella spp. 2

Gram-negative cocci (Neisseria spp.) 2Gram-positive rods (Corynebacterium spp.) 3Gram-negative rods (Haemophilus spp.) 6Miscellaneous and undifferentiated 4

Organism Percentage

Excerpted from Contemporary Oral and Maxillofacial Surgery, Third Edition, 1998

Microorganisms CausingOdontogenic Infections

Anaerobic 75%

Gram-positive cocci 30Streptococcus spp. 33

Peptostreptoccus spp. 65Gram-negative cocci (Viellonella spp.) 4Gram-positive rods 14

Eubacterium spp.Lactobacillus spp.Actinomyces spp.

Clostridia spp.Gram-negative rods 50

Bacteroides spp. 75

Fusobacterium spp. 25Miscellaneous 6

Excerpted from Contemporary Oral and Maxillofacial Surgery, Third Edition, 1998

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Progression

• Periapical/periodontal• Spread through least resistance• Role of muscle attachments

Differences BetweenCellulitis and Abscess

Duration Acute ChronicPain Severe/generalized LocalizedSize Large SmallLocalization Diffuse borders Well circumscribed

Palpation Doughy to indurated FluctuantPresence of pus No YesDegree of seriousness Greater LessBacteria Aerobic Anaerobic

Excerpted from Contemporary Oral and Maxillofacial Surgery, Third Edition, 1998

Characteristic Cellulitis Abscess

Assessment

• History• Onset, duration, rapidity• Previous treatment• Medically compromised

Assessment

• Physical exam• Vital signs

–malaise– temp–tachycardia

• Abcess vs. cellulitis• Radiographs

Fascial Spaces

• Potential spaces• Bounded by muscle attachments;

bone• Spread to secondary neck spaces

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Buccal space Buccal space

Vestibule Vestibule

Maxillary Spaces:Canine Spaces

• Usual source: canine• Boundaries: lev anguli oris; lev

labi superioris• Loss of nasolabial fold

Maxillary Spaces: Buccal Space

• Usual source: maxillary molar,premolar

• Boundaries: skin, buccinatormuscle

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Buccal space

Maxillary Spaces:Infratemporal Space

• Usual source: maxillary third molar• Boundaries: skull base, lateral

pterygoid plate, continuous withtemporal space

Mandibular Spaces:Buccal Space

• Usual source: mandibular molar,premolar

• Boundaries: skin, buccinatormuscle

Mandibular Spaces:Submental Space

• Usual source: mandibular incisors• Boundaries: skin, mylohold

muscle, ant belly of digastrics

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Mandibular Spaces:Submandibular Space

• Usual source: mandibular molar,premolar

• Boundaries: medial mandible,below mylohyoid-muscle, skin/superficial fascia

Mandibular Spaces:Submandibular Space

• Lose inferior border on palpation• Communicates with secondary

spaces in neck

Mandibular Spaces:Sublingual Space

• Usual source: mandibular molar,premolar

• Boundaries: medial mandible,above mylohyoid-muscle, mucosa

Mandibular Spaces:Sublingual Space

• Floor of mouth swelling• Nothing visible/ palpable extraoral• Communicates posterior with

submandibular space

Mandibular Spaces:Ludwig’s Angina

• Bilateral submandibular,sublingual, submental spaces

• Treat aggressively, potentialairway compromise

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Mandibular Spaces:Pterygomandibular Spaces• Usual source: mandibular molar,

premolar• Boundaries: medial mandible,

medial pterygoid• Trismus

Mandibular Spaces:Masseteric Space

• Usual source: mandibular thirdmolar

• Boundaries: masseter, lateralborder of mandible

• Swelling at angle, possible trismus

Mandibular Spaces:Temporal Space

• Usual source: other spaces(infratemporal, massetermpterygomand)

• Boundaries–superficial: between fascia and

muscle–deep: below muscle

Mandibular Spaces:Masticator Space

• Masseteric, Pterygomandibular,Temporal spaces

• Communicate• Non-specific

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Cervical Fascial Spaces

• Lateral pharyngeal–deviated uvula

• Retropharyngeal–airway obstruction; mediastinum

• Prevertebral–thorax, mediastinum

Treatment

• Medical support• Antibiotics• Removal of source• Incision and drainage• Re-evaluation

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Medical Support

• Airway maintenance• Rehydration• Analgesia• Nutrition

Antibiotics

• Usually bactericidal• Therapeutic dose• Intravenous vs oral• Compliance/ complete course

Indication for Use ofAntibiotics

• Rapidly progressive swelling• Diffuse swelling• Compromised host defenses• Involvement of fascial spaces• Severe periocoronitis• Osteomyelitis

Situations in Which Use ofAntibiotics is not Necessary• Chronic well-localized abscess• Minor vestibular abscess• Dry socket• Mild periocoronitis

Effective Orally AdministeredAntibiotics Useful for

Odontogenic Infections

• Penicillin• Erythromycin• Clindamycin• Cefadroxil• Metronidazole• Tetracycline

Prophylactic Antibiotics

• Routine procedures, healthypatient: NO antibiotics

• Extent/time• Immunocompromised• Foreign body

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Compromised HostDefenses

• Uncontrolled metabolic diseases– Uremia

– Alcoholism– Malnutrition– Severe diabetes

• Suppressing diseases– Leukemia

– Lymphoma– Malignant tumors

• Suppressing drugs– Cancer chemotherapeutic drugs

– Immunosuppressives

Indications for Culture andAntibiotics Sensitivity

Training• Rapidly spreading infection• Postoperative infection• Nonresponsive infection• Recurrent infection• Compromised host defenses• Osteomyelitis• Suspected actinomycosis

Incision and Drainage

• Intraoral vs. extraoral• Wide incision• Blunt dissection to periosteum• Subperiosteal

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Criteria for Referral to aSpecialist

• Rapidly progressive infection• Difficulty in breathing• Difficulty in swallowing• Fascial space involvement• Elevated temperative (greater than

101 degrees Farenheit)• Severe jaw trismus (less than 10 mm)• Toxic appearance• Compromised host defenses

Thank You