Management of oral and maxillofacial infections
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The entire field of dentistry initially started out with treatment of infections. We weren't placing beautiful veneers, straightening teeth or restoring teeth with implants, but simply helping people get through pain and suffering. That is no less important today, with alarming rates of diabetes and immunocompromised patients being vulnerable to dental disease, and with full access to care still being a difficult thing to achieve. So hopefully this lecture, attached, can help dentists and physicians as a refresher on how to treat infections.
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Management of oral and maxillofacial infections
- 1. George P. Hatzigiannis DMD, MD Management of Oral and Maxillofacial Infections George P. Hatzigiannis DMD, MD Diplomate, American Board of Oral & Maxillofacial Surgery Dr. George P.C.
- 2. George P. Hatzigiannis DMD, MD Outline Determine severity of infection Review anatomy Evaluate host defenses Determine setting of treatment Support patient medically Treat infection with surgery Choose and Rx antibiotic(s) Review bugs
- 3. George P. Hatzigiannis DMD, MD Determine Severity of Infection
- 4. George P. Hatzigiannis DMD, MD History and Exam History Onset Duration Rapidity Loss of function Physical Exam Vital signs Examination of swelling Analysis of spacial involvement Systemic involvement Evaluate airway! This should take no more than 10 minutes!
- 5. George P. Hatzigiannis DMD, MD
- 6. George P. Hatzigiannis DMD, MD Diagnosis Local Signs Pain Swelling Erythema Purulence Warmth Loss of function Dolor Tumor Rubor Pus Calor Laesio Functio
- 7. George P. Hatzigiannis DMD, MD Local vs Systemic
- 8. George P. Hatzigiannis DMD, MD Systemic Signs Leukocytosis Malaise Lymphadenopathy Fever
- 9. George P. Hatzigiannis DMD, MD Evaluate the Airway! Patient leaning forward Drooling Open mouth breathing Use of accessory muscles of respiration Dilatation of nares Tachypnea Stridor Hypoxia Cyanosis
- 10. George P. Hatzigiannis DMD, MD Pathobiology of Odontogenic Infections Initiated by aerobic bacteria Gain entrance to tissue Aerobic bacteria cause cellulitis Cause hypoxia and acidosis Create favorable environment for anaerobes Anaerobes follow Tissue destruction leads to pus Enzymes destroy antibiotics Symbiosis between two causes serious infections
- 11. George P. Hatzigiannis DMD, MD Natural Course of Cellulitis Range from early & easy to life-threatening Caused by aerobic bacteria Abscess Pus-filled cavity Caused by anaerobic bacteria Sinus Tract Continual drainage Must eliminate cause to cure
- 12. George P. Hatzigiannis DMD, MD Review of Anatomy
- 13. George P. Hatzigiannis DMD, MD Fascial Space Anatomy Space of the body of the mandible Vestibular Buccal Submental Sublingual Submandibular Masticator Pterygomandibular Masseteric Superficial and deep temporal Canine
- 14. George P. Hatzigiannis DMD, MD Effect of Mylohyoid
- 15. George P. Hatzigiannis DMD, MD
- 16. George P. Hatzigiannis DMD, MD You’re in Trouble NOW! Lateral pharyngeal Retropharyngeal Prevertebral Mediastinitis
- 17. George P. Hatzigiannis DMD, MD
- 18. George P. Hatzigiannis DMD, MD Ludwig’s Angina Bilateral cellulitis of sublingual, submandibular and submental spaces Brawny induration of FOM extending to epiglottis, rare fluctuance Elevates and immobilizes muscles of the tongue, leading to airway loss Affects mostly young adults Historical 40% mortality now 5-10%
- 19. George P. Hatzigiannis DMD, MD
- 20. George P. Hatzigiannis DMD, MD Airway Management Non-Surgical Oral airway Nasal airway LMA Endotracheal tube Fiberoptic assistance Surgical
- 21. George P. Hatzigiannis DMD, MD Airway Management Factors to consider Anesthetist & surgeon experience Severity of infection Emergent vs expectant Location of pus loculation by CT CONSIDER Pre-marking tracheotomy or cricothyrotomy site Aspiration of fragile pus loculation
- 22. George P. Hatzigiannis DMD, MD Evaluation of Host Defenses
- 23. George P. Hatzigiannis DMD, MD The state of the host is ultimately the most important factor in the final outcome of a bacterial insult
- 24. George P. Hatzigiannis DMD, MD Causes of Depressed Physiologic / metabolic Disease related Defective immune system Drug suppression
- 25. George P. Hatzigiannis DMD, MD Layers of Immune System Native (Innate) Specific (Acquired) Intact skin, mucosa Humoral (Immunoglobulins) Saliva Cellular Indigenous flora Phagocytes (PMNs/Mono) Complement system Lymphocytes (B/T cells)
- 26. George P. Hatzigiannis DMD, MD
- 27. George P. Hatzigiannis DMD, MD Compromised Host Severe diabetes Malnutrition IV drug abuse Renal disease and uremia Alcohol abuse with liver disease HIV Splenectomy Collagen vascular disease Chronic corticosteroids Neoplasms Chemotherapy
- 28. George P. Hatzigiannis DMD, MD Determine Setting of Treatment
- 29. George P. Hatzigiannis DMD, MD Options Treat it Yourself Outpatient Refer to Specialist Inpatient
- 30. George P. Hatzigiannis DMD, MD Is the patient “sick?”
- 31. George P. Hatzigiannis DMD, MD
- 32. George P. Hatzigiannis DMD, MD You or the Specialist Ability to evaluate airway Ability to perform surgical drainage Ability to manage systemic disease
- 33. George P. Hatzigiannis DMD, MD Inpatient Setting Compromised defenses Rapid, progressive infection Secondary fascial space involvement Temperature > 101°F Severe trismus (< 10 mm) Toxic appearance Dehydration, inability to hydrate Difficulty swallowing or speaking Difficulty breathing Concern about compliance
- 34. George P. Hatzigiannis DMD, MD Support Patient Medically
- 35. George P. Hatzigiannis DMD, MD Support Patient Medically Fluids Nutritional support Analgesics Glucose control Airway support Monitoring
- 36. George P. Hatzigiannis DMD, MD Fluid/Nutrition IVF Nutritional analysis Consider labs Ensure vs. TPN
- 37. George P. Hatzigiannis DMD, MD Patient Monitoring Response to treatment Temperature White blood cell count Malaise (how do you feel today?) Swelling? Consider new imaging studies
- 38. George P. Hatzigiannis DMD, MD
- 39. George P. Hatzigiannis DMD, MD Imaging Contrast-Enhanced CT Advantages Quick, easy Widely available Familiarity Superior anatomic detail Differentiate abscess and cellulitis Disadvantages Ionizing radiation Allergenic contrast agent Soft tisue detail
- 40. George P. Hatzigiannis DMD, MD Principles of Surgery
- 41. George P. Hatzigiannis DMD, MD Basic Principles of Surgery Anesthesia Asepsis Hemostasis Restoration of Function
- 42. George P. Hatzigiannis DMD, MD Surgical Goals Provide drainage Must be adequate Ideally dependent Remove the cause of infection Pulpectomy Extraction Foreign body Non-viable bone Culture when possible?
- 43. George P. Hatzigiannis DMD, MD Incision & Drainage The cornerstone of all infection care “Do it when you think of it and earlier, rather than later”
- 44. George P. Hatzigiannis DMD, MD Incision & Drainage Dependent site Incision in healthy tissue Adequate drainage Explore involved space(s) completely Irrigation Role in cellulitis
- 45. George P. Hatzigiannis DMD, MD
- 46. George P. Hatzigiannis DMD, MD
- 47. George P. Hatzigiannis DMD, MD
- 48. George P. Hatzigiannis DMD, MD
- 49. George P. Hatzigiannis DMD, MD
- 50. George P. Hatzigiannis DMD, MD
- 51. George P. Hatzigiannis DMD, MD Bugs
- 52. George P. Hatzigiannis DMD, MD Useful Definitions Bacteremia: bacteria in bloodstream Sepsis: bacteria causing systemic immune response Septic shock: sepsis with drop in blood pressure and organ failure (vasodilation, renal failure, ARDS, DIC, etc)
- 53. George P. Hatzigiannis DMD, MD Bacterial Virulence Gain access to tissue Protection from host defenses Capsule, slime layer Produce tissue damage Endotoxins Exotoxins Enzymes (coagulase, streptolysins)
- 54. George P. Hatzigiannis DMD, MD Infectivity Virulence x Numbers Host Resistance
- 55. George P. Hatzigiannis DMD, MD Microbiology Gram stain Gram + and - Cocci and rods Only rational guide until C&S Culture and sensitivity Takes 24-48 hours Delayed results if anaerobes or rare breeds
- 56. George P. Hatzigiannis DMD, MD
- 57. George P. Hatzigiannis DMD, MD
- 58. George P. Hatzigiannis DMD, MD Microbiology of Odontogenic Infections Mixed aerobic/anaerobic infections Aerobes only - 7% Mixed infections - 60% Anaerobes only - 33% Average isolates per specimen - 4 Gram + aerobic & facultative streptococci Common pathogen and most numerous
- 59. George P. Hatzigiannis DMD, MD Microbiology Changes in Last 20 Years Patient characteristics, signs, symptoms, LOS all very similar Type and prevalence bacteria different with increased beta-lactamase activity Most differences due to better isolation and nomenclature changes
- 60. George P. Hatzigiannis DMD, MD Trends Increase in beta-lactamase producing bacteria Increase in E. corrodens Increase in S. aureus (MRSA) ? Decrease in bacteroides
- 61. George P. Hatzigiannis DMD, MD Clues to Anaerobic Infection Foul-smelling discharge Gas production Tissue necrosis Often involve multiple organisms, and gram stain showing multiple morphotypes indicative Failure to recover pathogen with normal aerobic cultures
- 62. George P. Hatzigiannis DMD, MD Antibiotics
- 63. George P. Hatzigiannis DMD, MD Principles of Antibiotic Therapy Determine if an infection is present Evaluate the patient’s host defenses Make a decision! (ABx, surgery, or both) If an antibiotic is needed: Which organisms are most likely present? What is empiric choice? Culture & sensitivities?
- 64. George P. Hatzigiannis DMD, MD Choose & Rx Antibiotic Is antibiotic necessary? Use empiric therapy routinely Use narrowest spectrum drug Use antibiotic with lowest toxicity Use bactericidal if possible Be aware of cost! New is not necessarily best!
- 65. George P. Hatzigiannis DMD, MD Antibiotics Unnecessary Chronic localized abscess Minor vestibular abscess Dry socket Root canal sterilization Chronic pericoronitis
- 66. George P. Hatzigiannis DMD, MD Indications for Antibiotics Acute onset infection Diffuse swelling Compromised defenses Fascial space involvement Severe pericoronitis Osteomyelitis
- 67. George P. Hatzigiannis DMD, MD Reasons for Failure Inadequate surgery Depressed defenses Foreign body Antibiotic problems Noncompliance Drug not reaching site Drug dosage too low Wrong bacterial diagnosis Wrong antibiotic
- 68. George P. Hatzigiannis DMD, MD Antibiotic Modes of Action Mechanism Example Cell wall action PCN, Cephs, Vanco Protein synthesis interfere Erythro, Clinda, Tetra Detergent effect Polymyxin, Nystatin, Ampho Nucleic Acid Metabolism Cipro, Metro Intermediary Metabolism Bactrim
- 69. George P. Hatzigiannis DMD, MD Antibiotic Modes of Action
- 70. George P. Hatzigiannis DMD, MD ABx for Odontogenic Infections “The Old List” Penicillin Erythromycin Clindamycin Cephalexin Cefaclor Metronidazole ? Tetracycline
- 71. George P. Hatzigiannis DMD, MD Penicillin Spectrum Most streptococci Oral anaerobes Fusobacterium Actinomyces Dosage: 2 gms load, 500 mg QID Up to 24 mill units IV / 24 hours
- 72. George P. Hatzigiannis DMD, MD Amoxicillin Inhibits biosynthesis of cell wall mucopeptide Broad spectrum of activity against Gram + and - organisms Stable in gastric acid Does NOT penetrate CSF well TID dosing
- 73. George P. Hatzigiannis DMD, MD 60% of patients with + history in fact are NOT allergic to penicillins or other B lactams
- 74. George P. Hatzigiannis DMD, MD Cephalosporins Gram + aerobes Gram - aerobes Gram + anaerobes Gram - anaerobes 1st generation keflex ++ + + - 2nd generation cefuroxime + ++ + ++ 3rd generation cefotaxime + ++ + ++
- 75. George P. Hatzigiannis DMD, MD Clindamycin Inhibitor of protein synthesis Static in low concentration, cidal in high Metabolized in liver, excreted in urine and feces Superior action against anaerobes, especially bacteroides species Consider for serious anaerobic infections in pcn allergic Excellent abscess penetration but poor CSF penetration Dose: 150 - 450 PO TID
- 76. George P. Hatzigiannis DMD, MD Erythromycin Macrolide family Inhibits protein synthesis High incidence GI irritation High incidence of bacterial resistance Dose: 200-500 mg PO QID
- 77. George P. Hatzigiannis DMD, MD Azithromycin Broader spectrum Includes H. infuenzae QD dosing Less GI upset 500 mg PO QD
- 78. George P. Hatzigiannis DMD, MD Metronidazole Bactericidal due to intracellular action Excellent in anaerobic infections including all species bacteroides Little activity against other flora Excellent CSF penetration Excellent in combination with PCN Dose: 500 mg PO TID (QID if severe)
- 79. George P. Hatzigiannis DMD, MD Metronidazole Interactions Ethanol Inhibits alcohol dehydrogenase activity, causing disulfiram-like reaction Oral anticoagulants Prolongs INR Barbiturates and phenytoin Decreases anti-microbial effectiveness by increasing metabolism Adverse reactions: Seizures Metallic taste Peripheral neuropathy
- 80. George P. Hatzigiannis DMD, MD Bactericidal Bacteristatic Penicillins Tetracycline Cephalosporins Erythromycin Carbapenems Sulfonamides Fluoroquinolones Metronidazole Either: Macrolides, Clindamycin
- 81. George P. Hatzigiannis DMD, MD Penicillins (in combination) Clindamycin Metronidazole (in combination) Levaquin First generation cephalosporins Amoxicillin/ clavulanate Imipenem ABx for Odontogenic Infections “The New List”
- 82. George P. Hatzigiannis DMD, MD Antibiotic-Associated Colitis 1/3 clindamycin 1/3 ampicillin 1/3 cephalosporin Many others sporadically Associations Advanced age Female Inflammatory bowel disease
- 83. George P. Hatzigiannis DMD, MD New PDR?
- 84. George P. Hatzigiannis DMD, MD
- 85. George P. Hatzigiannis DMD, MD
- 86. George P. Hatzigiannis DMD, MD Thank You