Oral Surgery

Odontogenic Infections

Done by : Muad Salahuddin Al-Zoubi

Dedicated to : Rmz Al-Rabadi

This lecture is about infections, what infections are in general and how to deal with infections we should know about. The subject will be divided into the oral infections and more importantly the maxillofacial infections that occur when the infection proceeds from any oral or primary space (to be mentioned below) to the secondary spaces. When, where and how they will be treated, these will be encountered in this and the coming lectures.

Microbiology of infections
The oral cavity is considered to be dirtier than the other sites of the human being, this means that the bacteria in the oral cavity are very numerous and very diverse and the bacteria which are responsible for most of the infections in the oral cavity are oral flora (i.e. present in the mouths of every normal individual). In general, the most common bacteria in the oral cavity are the streptococci and S.viridans in particular, the types of bacteria present in the oral cavity are either aerobic gram positive cocci (e.g. S.viridans), anaerobic gram positive cocci or anaerobic gram negative rods, so the oral cavity is polymicrobial. In general, the oral infections are mixed infections, which means that if a sample is taken from an oral infection and tried to be studied microbiologically, not only one type of bacteria will be found but several types will be found (i.e. aerobic and anaerobic bacteria, cocci and rods, gram positive and negative). The aerobic infections (alone) constitute about 5% of oral infections (e.g. S.viridans and other sorts of gram positive aerobic bacteria). The anaerobic infections (purely anaerobic) constitute about 35% of oral infections (e.g. abscesses are mostly if not totally anaerobic infections). The remaining 60% infections (the majority) are mixed infections. * The sites involved in infections are the teeth and periodontium, either the apex, root canals (and lateral canals) or the periodontium itself. In general, infections tend to go through the easiest route (with the least resistance), e.g. the bacteria that caused the infection will try to spread (against the patients immune system), they will spread through the routes that are easy to pass through, say, there are two routes, one with thick bone and the other with thin less dense bone, the bacteria will spread through the least resistant route (thin bone in this case).

What determines the location or spread of infection ?

Example: patient with abscess in the vestibule, or in the floor of the mouth that raised the tongue ! so, what determines the location of the abscess formation ? 1-Thickness of bone. 2- Muscle attachment (mentalis, zygomaticus major and minor, buccinators, muscles of the lips .etc.). Suppose that a patient had irreversible pulpitis, the source of bacteria will be the root canals, the bacteria start to increase in number, then the bacteria go out from the root apex, if the apex is located below the buccinator muscle attachment (upper tooth) or above mentalisfor example, the infection will spread to the inside of the oral cavity, in this case the abscess will be in the oral vestibule (vestibular abscess) if we considered the thin bone to be the buccal bone. If the root is long (e.g. upper canine) and the apex is located above the buccinator muscle attachment, the infection will spread above the muscle attachment, the infection might reach the eye and the patient is seen having a closed eye because of swelling, so the muscle attachment determines the location of the abscess and also the bone thickness (palatal bone is thicker in this case) Examples : - If the palatal root of the upper first molar is the nonvital root, the palatal root is closer to the palatal bone, in this case the abscess will appear palatal (the patient will complain of palatal swelling). - Infections in certain stages may develop swelling in the submandibular area and the skin might become very thin, when the pus accumulates in the abscess the abscess will try to expand taking over the normal tissues, if the patient is neglecting, the abscess might reach a level that it drains extra-orally (very unlikely to be seen) but it might be seen especially in the deprived areas where (poor countries with poor no medical care). - In general, if maxillary teeth developed abscesses, most likely they will be vestibular, exceptions include the palatal root of upper first molar will develop palatal abscess (very close to palate), and the lateral incisor (palatal abscess) because the root is inclined palatally, canine has long root it may form abscess higher in level the levator anguli oris muscle, it will appear in the canine space (not intraorally). Mandibular teeth in most of the cases form vestibular

abscess, abscesses associated with molars depend on the mylohyoid attachment and the bone thickness, on the inner aspect of the mandible the attachement of the mylohyoid starts more inferior and ascends more superior (from anterior to posterior), anteriorly the sublingual gland is above it, posteriorly the submandiblar gland is below it, so the tips of the teeth (mandibular molars) will be below the muscle attachment, in this case the abscess will form in the submandibular space, if the tip of the tooth is above the mylohyoid attachment it will be a vestibular abscess.

- Bone thickness, (if the root is closer to the buccal bone buccal abscess, and vice versa), Example : lower third molar, the abscess tends to appear lingually (bone is thinner) in the submandibular space (the tip is below the mylohyoid attachment) this will form the so-called submandibular space infection. Sinus tract : a pathological communication between open space and closed space. Fistula : a pathological communication between two open spaces. Sinus tract is an indication of chronic infection, e.g. a patient had an infection then developed an abscess which was left to the degree that it has enlarged and found a way to drain its contents from an opening, in this case the patient has no swelling, no pain because anything that will form (pus) will find its way to the outside, this in never a thing that we would leave and this patient should have something done to him Sometimes, the abscess becomes huge (e.g. palatal abscess) to the degree you would say its impossible to be an abscess, but when you examine the patient and see the signs and ask about symptoms, you see carious teeth, the patient has pain, fever and on radiographs you see a non-vital tooth surrounded by radiolucency, so this appears to be an infection (abscess) .

Principles of therapy
1- Severity of the infection (duration), upon history taking, if it started long time (say 10 days ago), severe infection is expected to be found, if it started the day before for example, less severe infection is expected. 2-Cardinal signs of inflammation (hotness, redness, swelling, pain and loss of function).

3- If the patient toxic ( dehydrated hasnt eaten or drunk anything, very tired, this is a sign of a bad infection) 4- Ask if the patient had any treatment for this infection, if he underwent drainage, took antibiotics, underwent RCT, etc. 5- Vital signs, high grade temperature is an indication of severe infection, heart rate of more than 100 beat/minute is also an indication of severe infection (normal HR is 60-100), also respiratory rate of more than 16/minute is an indication of severe infection. 6- If the infection has lead to any obstruction in the airways this is absolutely dangerous, an example is an infection that reached the sublingual space resulting in an elevation of the tongue that lead to airway obstruction its very dangerous not because it can spread to somewhere, but simply because it can kill the patient, its very vital in such a case to think of it as an emergency. 7- Physical examination, is the area of the infection indurated or fluctuant, if the infection is still in the area of developing it will feel indurated, if the infection is well established and an abscess was formed it will feel fluctuant, if its less indurated this means that the abscess is developing but its not well established, and we need to take radiographs to locate the tooth that resulted in this. Another determinants of the severity of infection and the spread of the infection that should be taken into consideration is the patient immune defense, if the patient is already immunocompromised or medically compromised, the infection will spread rapidly, especially those with uncontrolled diseases such as DM (if DM patients is well controlled, we deal with them as normal people), patients with uncontrolled DM have very deranged immune system to the degree that any sort of simple infection has the ability to spread. Uremia in cases of chronic renal disease, instead of discharging the waste in the urine, they will stay in the body. Alcoholism, those who drinks alcohol in large amounts that exceeds particular limits, for females if they consume more than 14 units a week, for males more than 21 units a week, those people has deranged immune system, they can easily develop infections since they dont have a proper competent immune system. Patient who underwent chemotherapy, they definitely are immunocompromised, some cells (including stem cells) are killed, immunosupressed patients taking steroids (steroids are anti-inflammatory and immunosuppressants) can also easily get infections.

Always check the glucose level (DM is very common in our country), if you see a patient who developed an abscess, has a carious tooth but the progression was very quick, you should think about having a problem in the immune system, the first thing you should think about that the patient does not know that he has DM so we check the glucose, so, oral infection might be the cause of discovering a chronic disease (e.g. glucose level of 400 mg/dl) For patients who are immunocompromised that we think they will develop an infection, we give antibiotic before we treat (prophylactic antibiotic).

Treat or Refer?!
If I am a GP and a patient came to my clinic, shall I treat or shall I refer this patient, what are the things that are beyond my expertise so that I refer the patient to the hospital or to specialist? 1- Rapid progression, if a patient told you that two days ago he felt toothache then he came to you with swelling, his eye is closed (swelling), the floor of the mouth is raised this is a case of rapid progression, but if you see a small abscess its not rapidly progressive. 2- Difficulty in breathing, (infection of sublingual area, an emergency), here you dont refer the patient to a specialist, but you call the specialist by yourself, and tell him that the patient has an infection, his tongue is raised and has a difficulty in breathing and we need to send him to the hospital because he might need intubation to ensure normal breathing. 3- Space involvement, there are primary and secondary spaces, primary spaces are those to which the infection is firstly spread e.g. vestibular space/vestibular abscess, submandibular area directly from the root apex, canine space, and the secondary spaces are those that are not firstly affected e.g pharyngeal space. Abscess primary space secondary space (more serious secondary infection) So if the infection involved several spaces or involved a secondary space we think that this is serious, this patient needs referral. 4- High grade temperature (above 38.1C), the patient is thought to have a serious infection and might need referral, you call the specialist, this patient might need to be given fluids, antibiotics or hospital admission.

5- Trismus, especially in the case of posterior teeth involved in infection, this might affect the muscles of mastication, and it might be very severe, imagine that a patient has an infection and developed severe trismus, this patient wouldnt be able to eat , the infection will spread and might affect breathing and swallowing, those need something to be done and shouldnt be left alone, any limitation of mouth opening means that theres trismus but the severity varies if the patient cannot open more than 1 cm (sometimes less than that), this is severe trismus, the patient is very toxic 6- Medically compromised patients, a patient has an abscess and while taking the history its found that he had undergone a kidney transplant, he might have rapid progression, space involvement or trismus, so those patients should be dealt with very rapidly, we call a specialist and admit the patient to the hospital, we should attack the infection aggressively. 7- Toxic appearance, a patient with small dental abscess, but the patient is very toxic, tired, hasnt eaten, hasnt slept, pale, this patient deserves to be referred to a proper specialist

Treatment
- When do we treat surgically? - The answer is ALWAYS. Its not right to give him antibiotics before surgical treatment, to resolve the infection then treat the tooth endodontically. The surgical treatment includes one of following options : - Incision and drainage. - Extraction of the tooth. - Pulp extirpation and drainage through the root canals

Abscess and Cellulitis

Duration Pain Localization Surface temperature Loss of function Bacterial involvement Tissue fluids Level of seriousness Cellulitis Shorter More Less localized (diffuse) Higher than abscess More Aerobic More edematous More Abscess Longer Less More localized Lower than cellulitis Less Anaerobic Pus Less

Cellulitis is more dangerous, the infection is in the subcutaneous tissue and spreads rapidly, in the case of an abscess, the body has succeeded to localize the infection in a certain area, in the case of cellulitis the body couldnt localize the infection and the infection is spreading rapidly (more severe). Support the patient medically Give antibiotics after surgery, they will act more rapidly since the surgery has lessened the load of bacteria. Incision and drainage has long been known and had saved the lives of many people, surgery on its merit is the most important, and it can heal the patient, but we need to support the patient after we treat the infection in the surgical maneuver, we need to make sure that the patient is well hydrated so we advice him to take fluids and we give him antibiotics to make sure that this patient will recover soon. When to give antibiotics? Diffuse swelling, immunocompromised patient, space involvement, severe pericoronitis, osteomylitis.

Empirical therapy It is a matter of expecting, if a patient has an abscess, we expect anerobic infection, so, we give amoxicillin and metronidazole. Or we take a sample and ??????????!!!!!!!!!!! BUT I expect that the doctor was going to talk about taking a sample and sending it to culture to know exactly the causative micro-organism and prescribe the antibiotic which is known to be most effective against this micro-organism(s).

THANK YOU! Continue below, there are appendices!

Appendix A
Since the lecture was not very clear, this appendix includes images from the related chapter of the book and boxes that summarizes the most important points in a trial to compensate for any lack of information or lack of understanding.

Appendix B
Sinus and Fistula
Sinus.A sinus is a track leading from a focus of suppuration to a cutaneous or mucous surface. It usually represents the path by which the discharge escapes from an abscess cavity that has been prevented from closing completely, either from mechanical causes or from the persistent formation of discharge which must find an exit. A sinus is lined by granulation tissue, and when it is of long standing the opening may be dragged below the level of the surrounding skin by contraction of the scar tissue around it. As a sinus will persist until the obstacle to closure of the original abscess is removed, it is necessary that this should be sought for. It may be a foreign body, such as a piece of dead bone, an infected ligature, or a bullet, acting mechanically or by keeping up discharge, and if the body is removed the sinus usually heals. The presence of a foreign body is often suggested by a mass of redundant granulations at the mouth of the sinus. If a sinus passes through a muscle, the repeated contractions tend to prevent healing until the muscle is kept at rest by a splint, or put out of action by division of its fibres. The sinuses associated with empyema are prevented from healing by the rigidity of the chest wall, and will only close after an operation which admits of the cavity being obliterated. In any case it is necessary to disinfect the track, and, it may be, to remove the unhealthy granulations lining it, by means of the sharp spoon, or to excise it bodily. To encourage healing from the bottom the cavity should be packed with bismuth or iodoform gauze. The healing of long and tortuous sinuses is often hastened by the injection of Beck's bismuth paste. If disfigurement is likely to follow from cicatricial contraction for example, in a sinus over the lower jaw associated with a carious tooth the sinus should be excised and the raw surfaces approximated with stitches. A fistula is an abnormal canal passing from a mucous surface to the skin or to another mucous surface. Fistul resulting from suppuration usually occur near the natural openings of mucous canals for example, on the cheek, as a salivary fistula; beside the inner angle of the eye, as a lacrymal fistula; near the ear, as a mastoid fistula; or close to the anus, as a fistula-in-ano. Intestinal fistul are sometimes met with in the abdominal wall after strangulated hernia, operations for appendicitis, tuberculous peritonitis, and other conditions. In the perineum, fistul frequently complicate stricture of the urethra. Fistul also occur between the bladder and vagina (vesico-vaginal fistula), or between the bladder and the rectum (recto-vesical fistula). The treatment of these various forms of fistula will be described in the sections dealing with the regions in which they occur. Congenital fistul, such as occur in the neck from imperfect closure of branchial clefts, or in the abdomen from unobliterated ftal ducts such as the urachus or Meckel's diverticulum, will be described in their proper places.

From (http://www.manual-of-surgery.com/content/0021-Sinus-and-Fistula.html)

DONE !