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Introduction
Odontogenic infections arise from teeth & is generally caused by bacteria that have tendency to cause abscess formation.
These infecting bacteria enter the deep tissues of periodontium and periapical regions via roots of teeth.
o These infections range from low grade localized infections to sever life threating deep fascial space infections.
Treatment of these infections ranges from endodontic therapy & gingival curettage to extraction, incision and drainage.
Aerobic gram positive cocci Anaerobic gram positive cocci Anaerobic gram negative rods
Odontogenic infection results when these bacteria gain access to deeper underlying tissues of oral cavity through necrotic
dental pulp or deep periodontal pocket.
All odontogenic infections are poly microbial in nature (caused by multiple/mixed bacteria).
Percentage
Mixed 50%
Aerobic Only 6%
Tooth apex below the muscle attachment – vestibular abscess will occur.
Tooth apex above the muscle attachment – facial space will be infected.
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Mostly Maxillary Teeth erode facial cortical plates
Mostly maxillary molars cause buccal space infection (perforation above buccinators muscle)
Maxillary canine cause infra – orbital space infection (canine space) – perforation above levator anguli oris muscle.
Mostly mandibular anterior teeth erode facial cortical plates & cause vestibular abscess.
o Mandibular molars erode mostly lingual cortical plate.
o Mylohyoid muscle determines whether infections that are perforating lingual cortical plate;
Go superior to muscle into sub – lingual space. OR
Go below the mylohyoid muscle into sub – mandibular space.
Most common odontogenic infection is vestibular space infection
If these infections are untreated; The abscess will rupture spontaneously and drain and in result;
o The infection resolves OR
o Become chronic infection which drain into oral cavity or skin (figure; 16 – 5 in Tucker)
As long as sinus tract continuous to drain, patient does not have pain.
Antibiotic will stop the draining temporary and so definitive treatment will be extraction or endodontic therapy.
Complete History
Chief complaint recorded in patient’s own words.
Determine how long the infection has been present;
o Time of onset/beginning of infection by asking the patient, first appearance of symptoms;
Pain, swelling, or drainage
o Progression of infection; symptoms of infection has been
Constant,
waxed and waned (undergo alternate increased or decreased)
grown worse
o Rapidity of progress of infection; has the infection progress over a few hours or over days to a week?
Information about patient’s symptoms; (Signs of inflammation)
o Most common complaint is pain. – ask location & spread of pain (Dolar)
o Ask the patient for swelling – sometimes hidden & sometime visible (tumor)
o Ask whether the area of infection or swelling is warm to touch. (calor)
o Ask patient, if there is any change in color (redness) over the area of infection or redness. (rubor)
o Functio laesa – trismus (maximum inter – incisal opening less than 20 mm), difficulty chewing, difficulty swallowing (dysphagia),
difficulty in breathing.
Determine the general health of patient
o Malaise; fatigued, feverish, weak & sick patients.
Ask about previous dental treatments (professional or self – treatment)
Physical Examination
Examine patient’s vital signs.
o Pulse rate increases with increase in temperature of patient.
Pulse rate of greater than 100 beats/minute indicate sever infection.
o Blood pressure is not altered by infection. But it is the pain & anxiety in a patient which increases the blood pressure. – B.P decreases in
septic shock.
o Normal respiratory rate is 14 – 16 breaths/minute
Mild to moderate infection – respiratory rate greater than 18 breaths/minutes.
Studynama’s BDS Community is one of India’s Largest Community of Dental Students. About
19,232 Indian Dental Course students are members of this community and share FREE study
material, cases, projects, exam papers etc. to enable each other to do well in their semester exams.
01) Anesthesia
a. Regional nerve block is preferred. Alternatively, Infiltration into & around the area to be drained.
02) Stab Incision;
a. Directly over the site of maximum swelling or fluctuation and inflammation.
b. Avoid incising across Frenum or the path of mental nerve in lower premolar region.
c. It should be short, no more than 1 cm in length.
03) Insertion of Hemostat or Sinus Forceps
a. If pus is not encountered, further deepening of surgical site is achieved with sinus forceps (to avoid damage to vital structures)
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b. Closed forceps are pushed through the tough deep fascia and advanced towards the pus collection.
c. Abscess cavity is entered and forceps opened in a direction parallel to vital structures.
d. Pus flows along sides of the beaks.
e. Explore the entire cavity for additional loculi.
04) Placement of Drain
a. A soft rubber drain is inserted into the depth of the abscess cavity; and external part is secured to the wound margin with the help of
sutures.
b. Drain is left for at least 2 – 5 days.
c. Purpose of Drains;
i. Allow the discharge of tissue fluids and pus from the wound by keeping it patent.
ii. Maintain the opening
iii. Allow debridement of abscess cavity by irrigation.
d. The most commonly used drain for intra oral abscess is a quarter inch sterile Penrose drain.
i. Alternatively, thin strip of rubber dam can be used as a substitute (allergy if absent)
05) Dressing
a. Used when incisions are given extra orally.
Inoculation stage do not require I&D, just remove the necrotic pulp & do RCT or tooth & prescribe antibiotics.
Antibiotics that have narrow spectrum are as much effective as wide spectrum bacteria but without upsetting normal host
bacteria & development of resistance.
Studynama’s BDS Community is one of India’s Largest Community of Dental Students. About
19,232 Indian Dental Course students are members of this community and share FREE study
material, cases, projects, exam papers etc. to enable each other to do well in their semester exams.
Use the Antibiotic with Lowest Incidence of Toxicity & Side Effects
o Penicillin
Allergy is major side effect (hives, itching or wheezing)
o Clindamycin
They have low incidence of toxicity & Side effects.
On rare occasion, this drug can cause severe watery diarrhea, called pseudomembranous colitis in severely ill &
debilitated patients.
Other drugs which cause this pseudomembranous colitis are;
o Ampicillin (amoxicillin)
o Oral cephalosporin
These drugs cause elimination of anaerobic gut flora which allows overgrowth of antibiotic resistant
bacteria “clostridium defficle”. This bacterium produce toxin which injure the gut wall & result in colitis
o Macrolide
In this group erythromycin is no longer used because it causes drug reaction & involver microsomal enzyme system.
In this group, azithromycin is best and should be used because it has low toxicity and less drug interaction.
o Moxifloxacin
It is a new member of fluoroquinolone group and has;
Much better effectiveness against oral pathogens as compared to older members of this class
However, it is used by specialists because of its toxicity;
Muscle weakness, mental clouding, drug interactions with commonly used drugs,
Contraindicated in Children under 18 years & Pregnancy.
o Oral Cephalosporin; cephalexin & cefadroxil
Although they have only mild toxicity they are not used for treating odontogenic infection.
They cause allergy similar to penicillin, that’s why if the patient is allergic to penicillin, don’t give
cephalosporin also.
o Tetracycline
They are also no longer used for treating odontogenic infection & are used
Topically in very high local concentrations, such as when they are inserted into periodontal
pockets.
They have minor toxicity & when taking systemically, patient may experience photosensitivity.
Tetracycline, in pregnant women produce tooth discoloration in their infants, if given before age
of 12 years.
Tooth discoloration results due to chelation of the tetracycline to calcium, which result in incorporation
of tetracycline into developing teeth.
o Metronidazole
Mild toxicity = GI disturbances
Produce Disulfiram Effects
Patient taking metronidazole who also consumes ethanol may experience sudden, violent
abdominal cramping & vomiting.
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Use Bactericidal Antibiotic, if possible
o Bactericidal antibiotics interfere with cell wall production in newly forming, growing bacteria.
The defective cell wall is not able to withstand the osmotic pressure and bacterial cell die without attack from host defense cells.
o Bacteriostatic antibiotics interfere with bacterial reproduction and growth.
They slow the bacterial reproduction and allows host defense cells to phagocytize the bacteria
o That’s why bacteriostatic antibiotics should be avoided in immunocompromised patients. & in these
immunocompromised patient bactericidal antibiotics are drug of choice.
Use cost effective antibiotics
SUMMARY
Antibiotics should be used in patients with complex infections, prevention of endocarditis or infections of prosthetic – implanted device.
Antibiotics plays an adjunctive role in odontogenic infection & surgical treatment of infection is primary method.
Use empiric antibiotic therapy with narrow spectrum antibiotic
The antibiotic of choice for odontogenic infection is penicillin.
o Other alternatives = amoxicillin.
Broad spectrum antibiotics such as Augmentin should not be used with simple routine odontogenic infections but should be
reserved for complex infections.
Antibiotics for prevention are amoxicillin
o If patient is allergic to penicillin group, alternative antibiotic = clindamycin, azithromycin
Metronidazole should be given only when anaerobic bacteria are suspected.
Moxifloxacin should be used specialists in the treatment of severe infections.
Principles of Prophylaxis
Against Metastatic Infections
Metastatic infection is defined as infection that
occurs at a location physically separate from the
portal of entry of the bacteria.
The incidence of metastatic infection can be
reduced if antibiotic administration is used to
eliminate the bacteria before they can establish an
infection at the remote site.
For metastatic infection to occur, following factors
must be present;
o Susceptible location in which an infection can be
established.
o Bacterial seeding of that susceptible area via blood
– attachment & growth of bacteria
o Impairment of local defense system
These bacteria are protected from
WBC by thin coating of fibrin & an
extracellular matrix produced by them
resulting a biofilm.
These bacteria are also protected from
antibiotics because in the biofilm they
are in metabolically inactive state.
All dental procedures that involve manipulation of gingival tissues or the periapical region of
teeth or perforation of the oral mucosa will require prophylaxis for IE.
THE END