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Odontogenic Infections
The modern emergency department sees a significant number of patients every day with problems related to the face and oral cavity. Emergency Medicine Clinics of North America Aug 2000
Odontogenic Infections
35 year old male, 3 day history of progressive painful facial swelling, difficulty opening mouth, difficulty swallowing, alteration in voice. 8 year old female, 5 days s/p dental extraction, persistent increasingly painful swelling left face, taking augmentin since extraction.
OUTLINE
Odontogenic Infections
Understand important aspects of history and clinical examination of patient. Understand treatment of odontogenic infections and when to refer treatment.
MICROBIOLOGY
Causative organisms
Aerobes only Anaerobes only Mixed 7% 33 % 60 %
MICROBIOLOGY Aerobic
Gram-positive cocci
Streptococcus spp. Streptococcus (group D) spp. Staphylococcus spp. Eikenella spp.
25%
85%
90% 2% 6% 2%
Gram-negative cocci (Neisseria spp.) Gram-positive rods (Corynebacterium spp.) Gram-negative rods (Haemophilus spp.) Miscellaneous and undifferentiated
2% 3% 6% 4%
MICROBIOLOGY Anaerobic
Gram-positive cocci
Streptococcus spp. Peptostreptococcus spp. Staphylococcus spp.
75%
30%
33% 65% 65%
4% 14%
Gram-negative rods
Bacteroides spp. Fusobacterium spp.
50%
75% 25%
Miscellaneous
6%
NATURAL HISTORY
Inoculation Cellulitis Abscess formation Resolution
NATURAL HISTORY
Predictable spread from one anatomic space to the next. Edema at leading edge of infection. Previously innoculated areas progressing through stages of cellulitis and abscess formation
ANATOMIC SPACE INVOLVEMENT Primary maxillary spaces Canine Buccal Infratemporal Primary mandibular spaces Submental Buccal Submandibular Sublingual
ANATOMIC SPACE INVOLVEMENT Secondary fascial spaces Masseteric Pterygomandibular Superficial and deep temporal Lateral pharyngeal Retropharyngeal Prevertebral
ASSESSMENT
Identify cause Determine severity Evaluate host defenses General practitioner / specialist
ASSESSMENT
Identify cause Caries Periodontitis Pericoronitis Tooth tenderness Tooth mobility Vestibular swelling
ASSESSMENT
Chief complaint Time of onset Change in symptoms Elicit symptoms Clinical signs
Dolor, tumor, calor, rubor, and functiolaesa
Extent and rate of progression Involved spaces Trismus Airway Vital structures
ASSESSMENT
Characteristic Cellulitis Abscess Duration Acute Chronic Pain Severe and 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
ASSESSMENT
Systemic involvement
Malaise Pyrexia Other signs
ASSESSMENT
Compromised Host Defenses
Suppressing diseases
Leukemia Lymphoma Malignant tumors
Suppressing drugs
Chemotherapeutic agents Immunosuppressives
ASSESSMENT
Criteria for Referral to a Specialist
Rapidly progressing infection Difficulty breathing Difficulty swallowing Fascial space involvement Elevated temperature (greater than 101F) Severe trismus (less than 10 mm) Toxic appearance Compromised host defenses
MANAGEMENT
Obtain drainage Maintain drainage Remove the cause Provide supportive care
MANAGEMENT
Obtain drainage
Pus must be drained Adequate access Blunt dissection All loculations entered Intra - oral and / or extra - oral
Obtain drainage
MANAGEMENT
Maintain drainage All involved spaces Dependent drainage Insertion of drain Maintenance of patency Slow advancement
MANAGEMENT
Remove the cause Pulp extirpation Tooth extraction Scaling Necrotic tissue / debris
MANAGEMENT
Provide supportive care General
Fluids Rest Nutrition Warmth
Antibiotic therapy
MANAGEMENT
Principles of antibiotic use Necessity Empirical therapy Narrow spectrum Low toxicity Bacteriocidal Administer properly Cost
MANAGEMENT
Antibiotics Good choices
Penicillin or amoxicillin ( + / - metronidazole ) Cephalexin, clindamycin, co-trimoxazole, tetracycline, erythromycin
Poor choices
Metronidazole alone Amoxicillin / clavulanic acid
PREVENTION
Local processes
Immunocompromised patient General preventive care Timely intervention Good surgical technique Infective endocarditis Arteriovenous fistulae Prosthetic valves and joints
Distant sites