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Overview
Odontogenic Microbiology
Progression of infection
Infections Assessment
Fascial spaces
Treatment/antibiotics

Microorganisms Causing
Microbiology Odontogenic Infections
Organism Percentage
Polymicrobial Aerobic 25%
Gram-positive cocci 85
Mixed aerobic/ anaerobic Streptococcus spp. 90
Aerobic cellulitis
Aerobic-cellulitis St
Streptococcus
t (G
(Group D) spp. 2
Anaerobic-abscess Staphylococcus spp. 6
Eikenella spp. 2
Gram-negative cocci (Neisseria spp.) 2
Gram-positive rods (Corynebacterium spp.) 3
Gram-negative rods (Haemophilus spp.) 6
Miscellaneous and undifferentiated 4
Excerpted from Contemporary Oral and Maxillofacial Surgery, Third Edition, 1998

Microorganisms Causing
Odontogenic Infections Progression
Anaerobic 75%
Gram-positive cocci 30
Streptococcus spp. 33 Periapical/periodontal
Peptostreptoccus spp. 65
Gram-negative cocci (Viellonella spp.) 4
Spread through least resistance
Gram positive rods
Gram-positive 14 Role of muscle attachments
Eubacterium spp.
Lactobacillus spp.
Actinomyces spp.
Clostridia spp.
Gram-negative rods 50
Bacteroides spp. 75
Fusobacterium spp. 25
Miscellaneous 6
Excerpted from Contemporary Oral and Maxillofacial Surgery, Third Edition, 1998

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Differences Between
Cellulitis and Abscess
Characteristic Cellulitis Abscess
Duration Acute Chronic
Pain Severe/generalized Localized
Size Large Small
Localization Diffuse borders Well circumscribed
Palpation Doughy to indurated Fluctuant
Presence of pus No Yes
Degree of seriousness Greater Less
Bacteria Aerobic Anaerobic

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

Assessment Assessment
History Physical exam
Onset, duration, rapidity Vital signs
Previous treatment malaise
Medically compromised 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,
skin buccinator Buccal
muscle space

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Maxillary Spaces:
Infratemporal Space
Usual source: maxillary third molar
Boundaries: skull base, lateral
pterygoid plate, continuous with
temporal space

Mandibular Spaces:
Buccal Space
Usual source: mandibular molar,
premolar
Boundaries: skin,
skin buccinator
muscle

Mandibular Spaces:
Submental Space
Usual source: mandibular incisors
Boundaries: skin, mylohold
muscle ant belly of digastrics
muscle,

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Mandibular Spaces: Mandibular Spaces:


Submandibular Space Submandibular Space
Usual source: mandibular molar,
premolar Lose inferior border on palpation
Boundaries: medial mandible,
mandible Communicates with secondary
below mylohyoid-muscle, skin/ spaces in neck
superficial fascia

Mandibular Spaces: Mandibular Spaces:


Sublingual Space Sublingual Space
Usual source: mandibular molar,
premolar Floor of mouth swelling
Boundaries: medial mandible,
mandible Nothing visible/ palpable extraoral
above mylohyoid-muscle, mucosa Communicates posterior with
submandibular space

Mandibular Spaces:
Ludwigs Angina
Bilateral submandibular,
sublingual, submental spaces
Treat aggressively,
aggressively potential
airway compromise

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Mandibular Spaces:
Pterygomandibular Spaces
Usual source: mandibular molar,
premolar
Boundaries: medial mandible,
mandible
medial pterygoid
Trismus

Mandibular Spaces: Mandibular Spaces:


Masseteric Space Temporal Space
Usual source: mandibular third Usual source: other spaces
molar (infratemporal, masseterm
Boundaries: masseter,
masseter lateral p yg
pterygomand) )
border of mandible Boundaries
Swelling at angle, possible trismus 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


Medical support Airway maintenance
Antibiotics Rehydration
Removal of source Analgesia
Incision and drainage Nutrition
Re-evaluation

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Indication for Use of


Antibiotics
Antibiotics
Usually bactericidal Rapidly progressive swelling
Therapeutic dose Diffuse swelling
Intravenous vs oral Compromised host defenses
Compliance/ complete course Involvement of fascial spaces
Severe periocoronitis
Osteomyelitis

Compromised Host Situations in Which Use of


Defenses Antibiotics is not Necessary
(in healthy patients)
Uncontrolled metabolic diseases
Uremia
Alcoholism Chronic well-localized abscess
Malnutrition
Poorly controlled diabetes Minor vestibular abscess
Suppressing diseases Dry socket
Leukemia
Lymphoma
Malignant tumors
Mild periocoronitis
Suppressing drugs
Cancer chemotherapeutic drugs
Immunosuppressives

Effective Orally Administered


Indications for Culture and
Antibiotics Useful for
Odontogenic Infections
Antibiotics Sensitivity
penicillin- drug of choice if patient is not Rapidly spreading infection
allergic
Nonresponsive
p infection
clindamycin
Recurrent infection
Cephalosporins
Compromised host defenses
amoxicillin/clavulonic acid
Osteomyelitis
metronidazole
Suspected actinomycosis

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Incision and Drainage


Intraoral vs. extraoral
Wide incision
Blunt dissection to periosteum
Subperiosteal

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Criteria for Referral to a


Specialist
Rapidly progressive infection
Difficulty in breathing
Difficulty in swallowing
Deep p fascial space
p involvement
Elevated temperative (greater than 101
degrees Farenheit)
Severe trismus
Toxic appearance
Compromised host defenses

Thank You

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