2. Objectives
Deferential diagnosis of pulpal and
periapical infection.
Stages of periapical infection.
Different types of fascial space infection.
Management.
Complications.
3. An infection involves the invasion and
proliferation of microbes or physical and chemical
factors, heat, and irradiation.
Inflammationis the localized reaction of
vascular and connective tissue of the body to an
irritant, resulting in the development of an
exudates rich in proteins and cells.
4. So the inflammation is consider a
protective and aims to limiting or
eliminating the irritant with various
procedures while the mechanism of tissue
repair is triggered.
5. Type of irritant
1. Microbes,
2. physical
3. chemical factors,
4. heat,
5. irradiation.
6. Signs & symptom of inflammation
1. Redness.
2. Heat.
3. Swelling or edema.
4. Pain.
5. loss of function.
8. Bacteriology of oral cavity
The oral cavity provide an optimum
environment for microorganisms.
1- Moisture
2-Warmth
3-Protected crypts
9. Progression of odontogenic infections
Early infection is often initiated by high-virulence aerobic
organisms (commonly streptococci), which cause
cellulitis, followed by mixed aerobic and anaerobic
infections.
As the infections become more chronic (abscess stage),
the anaerobic bacteria predominate, and eventually the
infection becomes exclusively anaerobic.
So TTT------------
12. Streptococci favor spreading
of infection
This due to:
1. it produce fibrinolysin enzyme
2. Low chemotactic effect on
leukocytes
3. It grow in chains
13. Staphylococcus favor localization
of infection
This due to:
1. it produce coagulase enzyme
2. High chemotactic effect on
leukocytes
3. It grow in colonies
14. Most odontogenic infections are the
result of bacteria, which normally
colonize the bacterial plaque, tongue,
saliva, and gingival sulcus.
15. When caries is present,
Streptococcus mutans is the
predominant microorganism.
16. When gingivitis is present, Gram-
negative anaerobic rods prevail,
(Bacteroides intermedius) being the
most common pathogen.
17. When periodontitis is present,
Anaerobic Gram-negative microorganisms
prevail Bacteroides gingivalis) as the
most common pathogen.
18. In suppurative odontogenic infections (e.g.,
periapical abscesses) or in infections of the deep
fascial spaces, there is usually polymicrobial flora,
with melaninogen Bacteroides, Fusobacterium
nucleatum, as well as the species
Peptostreptococcus, Actinomyces, and
Streptococcus as the most common microbes.
22. Etiology of odontogenic infections
1. Non-vital teeth
2. Pericoronitis (due to a semi-impacted
mandibular tooth)
3. Tooth extractions
4. Infected cysts.
5. Postoperative trauma
6. Infection as a result of local anesthesia.
26. Acute dentoalveolar abscess of early
stage
Clinical pictures:
1- Extrusion of the tooth out of its
socket.
2- Tenderness: on percussion of the
involved tooth
3- sharp , shooting and throbbing pain
4-lymphadinitis & General features
28. Treatment of Acute dento-alveolar
abscess of early stage
Prophylactic antibiotics
Surgical treatment: pulp
extirpation-extraction
Anti-infalmmatory-
Analgesics
Rest on the bed & high
protein diet
29. Indication of extraction of the tooth
in ADAA
1. Healthy patients
2. Deciduous tooth
3. More than grade II
mobility
4. Accessible tooth for
extraction
5. pain control
30. Fate of ADAA infection
1.Resolve of abscess
2.Develop to ADAA in
late stage
3.Chronic status
32. Spread of infection
Though the lymph tissue
Through the veins
Through the tissue continuity
33. Factors governing the spread of
infection from early stage to late stage
1- Virulence and numbers of the invading
microorganisms
2- Host defense
3- Position of tooth in the alveolus
4- Relation of the root apices to the muscle
attachments
5- Organization of the cervical fascia
34. 1- Virulence of the invading
microorganisms
Virulence means all characteristics of the
microbe that are injurious to the host
which include:
1. Degree of invasiveness
2. Bacterial toxins and enzymes
35. 2- Host defense
1. Age of the patients
2. Medical status
3. Nutrition
4. Immuno-suppression diseases or
medication
37. 4- Relation of the root apices to the
muscle attachments
38. 4- Relation of the root apices to
the muscle attachments
39. six possible 1ry spaces
locations:
1. vestibular abscess
2. buccal space
3. palatal abscess
4. sublingual space
5. submandibular space
6. maxillary sinus
According to roots position and muscles
attachment
40. 5- Organization of the cervical fascia “facial spaces
“
The fascia are continuous layers of connective tissue consisting of
The superficial cervical fascia The
deep cervical fasciae
41. The superficial cervical
fascia (tela subcutanae).
It is a layer of loose C. T.
located directly beneath the
skin.
Is a continuous sheet extend
from the head & neck into
the regions of the thorax,
shoulders & axillae.
48. The danger space
Also called space 4 of
Grodinsky , it is the
potential space
between alar and
prevertebral fascia.
Its superior limit is
the skull base, and it
extends inferiorly
into the posterior
mediastinum.
56. Following factors should be taken into
consideration for management of odontogenic
infections
I
1. Determine the severity of infection.
2. Evaluate host defenses.
3. Indications for hospitalization.
II
4. Treat surgically.
5. Support medically.
6. Choose and prescribe antibiotic therapy.
7. Administer the antibiotic properly.
III
8. Evaluate the patient frequently.
57. Following factors should be taken into
consideration for management of odontogenic
infections
I
1. Determine the severity of infection.
2. Evaluate host defenses.
3. Indications for hospitalization.
58. Following factors should be taken into
consideration for management of odontogenic
infections
II
4. Treat surgically.
5. Support medically.
6. principle for antibiotic therapy.
7. Administer the antibiotic properly.
59. Following factors should be taken into
consideration for management of odontogenic
infections
III
8. Evaluate the patient frequently.
60. A- Determining the severity of
infection
1. Anatomic location.
2. Rate of progression.
3. Airway compromise.
61. B- Evaluate host defenses.
1. Age
2. Disease related
3. Defective immune system related
4. Drug related
62. C- indications for hospitalization
1. Temperature > 101°F (38.3°C)
2. Threat to the airway or vital structures
3. Infection in high severity anatomic spaces
4. Need for general anesthesia
5. Need for inpatient control of systemic disease
63. Objective of surgical drainage
1. Drain pus from tissue spaces
2. Relives tissue pressure.
73. principle for antibiotic therapy
1. Identification of causative organism
2. Determination of antibiotic sensitivity
3. Use of narrow spectrum antibiotic
4. Use of least toxic antibiotic
5. Patient drug history
6. Use of bactericidal rather than bacteriostatic antibiotic
7. Cost of antibiotic
75. determination of antibiotic
culture sensitivity indications:
1. If patient has received treatment for 3 days
without improvement
2. Post operative wound infection
3. Recurrent infection
4. Chronic specific and none specific
infection
76. USE OF NARROW SPECTRUM
ANTIBIOTICS
When a broad spectrum antibiotic is used, many
different bacteria, present in body are exposed to
antibiotic.
However if narrow spectrum antibiotic is used fewer
organisms have opportunity to become resistant
as they are not even partially sensitive
77. USE OF LEAST TOXIC ANTIBIOTIC
Antibiotics are used to kill bacteria but some antibiotics may injure
human cells. At times these drugs may be used but in most of
situations, less toxic drugs that are equally effective may be
used. Treatment with less toxic drug may be prolonged. Hence,
clinician should continuously monitor for signs of toxicity &
instruct patient to look for & report them as well
78. Use of bactericidal rather than
bacteriostatic antibiotic
Advantages of bactericidal antibiotics are:
1. Less reliance on host resistance
2. Killing of bacteria by antibiotic itself
3. Greater flexibility with dosage
intervals
4. Faster results than bacteriostatic
80. COST OF DRUG
It is difficult to place price tag on health, but
surgeon should consider the cost of antibiotic
prescribed.
In some situations more expensive drug may be
drug of choice.
But in some situations there is substantial
difference in the antibiotics of equal efficacy.
82. PROPER DOSAGE
- The goal of any drug therapy should be to prescribe /
administer sufficient amounts to achieve the desired
therapeutic effect but not enough to cause injury to the
host.
- For therapeutic purposes the peak concentration of the
antibiotic at the site of infection should be 3-4 times the
MIC.
83. PROPER DOSAGE
Sufficient antibiotic must be given to reach
therapeutic levels, because sub- therapeutic levels
may mask the infection and suppress the clinical
manifestations without actually killing the
bacteria.
Subtherapeutic doses may cause the recurrence of
infection once the drug is discontinued.
84. DRUG T1/2(hr) USUALADULT
DODAGE
PEDIATRIC
DOSAGE
Penicillin G 0.5 600,000-1,200,000
U 4hrly
100,000U/Kg/day
in 3 doses
Penicillin V 1.0 500mg qid 50mg/Kg/d in 3-4
D
Amoxycillin 1.0 250-500mg tds 25mg/Kg/d in 3 D
Ampicillin 0.7 250-500mg qid 100mg/kg/d in 4 D
Oxacillin 0.5 500-1000mg 6hrly 50-100mg/Kg/d 4
D
Dicloxacillin 0.5 250-500mg qid 12.5-50mg/Kg/d 4
D
Cefotaxim 0.7 1-2g 8-12hrly
Cephalexin 0.7 500-1000mg qid 25-50mg/Kg/d 4D
Metronidazole 8 400mg tds 30-40mg/Kg/d
Clindamycin 4 150-450mg 6hrly 10-20mg/Kg/d 3-
4D
85. PROPER TIME INTERVAL
Each antibiotic has established plasma
half life (t1/2), during which half of the
absorbed dose is excreted.
86. As most of the antibiotics are eliminated
by kidneys, in patients with pre
existing renal diseases longer interval
between doses is maintained.
87. indications of combination therapy
1. When it is necessary to increase the antibacterial spectrum
in the patient with life threatening sepsis of unknown
cause.
2. When increased bactericidal effect against a specific
organism is desired
3. In prevention of rapid emergence of resistant bacteria.
4. Empiric treatment of certain odontogenic infections
88. Penicillin
it is considered an antibiotic of choice for the treatment of
odontogenic infections.
Penicillin inhibits synthesis of the cell wall.
The semisynthetic derivatives(amoxicillin-ampicillen) is
effective against aerobic Gram-positive rods and
anaerobic Gram-positive and -negative cocci. as well as
anaerobic G –ve rods and relatively effective against
aerobic Gram-negative rods.
89. The recommended dose administration is 500–1000
mg every 6–8 h for ampicillin, and 500 mg every 8
h for amoxicillin.
90. combinations of semisynthetic penicillins with various -
lactamase inhibitors
1. Ampicillin with sulbactam
2. Amoxicillin with clavulanic acid,
They may be administered orally, and the recommended
doses are 375–750 mg every 12 h for ampicillin/sulbactam,
and 625 mg every 8 h for amoxicillin/ clavulanic acid.
91. It is worth noting that penicillins are not
contraindicated during pregnancy, and are
classed as relatively safe drugs (category B
according to the FDA categorization1)
The most common and most serious adverse
reactions to penicillins are hypersensitivity
reactions 3–5% of the population).
92. Cephalosporins
The mechanism of action of cephalosporins, regardless of generation, is
the same as that of penicillin. As far as antimicrobial effectiveness is
concerned, orally administered first-generation cephalosporins
(cefalexin and cefadroxil) are not advantageous compared to
penicillin or ampicillin, while orally administered second-generation
cephalosporins (cefaclor, cefatrizine, loracarbef, cefprozil and
cefuroxime) are characterized by resistance to -lactamases, which
neutralize ampicillin, and may be used as alternative drugs if there is
no response to penicillin.
93. Cephalosporins are considered relatively safe
drugs during pregnancy (category B
according to FDA categorization) and their
dose needs to be decreased only in case of
advanced renal failure.
94. Macrolides
Their antimicrobial spectrum includes Gram-positive aerobic and
anaerobic cocci of the mouth, while Gram-negative aerobes and
anaerobes are resistant.
As such, they are a good alternative solution for treatment of odontogenic
infections without complications of mild and intermediate severity in
patients allergic to lactams.
Erythromycin and azithromycin are considered relatively safe drugs for
pregnant patients (category B according to FDA categorization
95. Clindamycin
effectiveness against the most frequent pathogens in
odontogenic infections, such as Gram-positive
aerobic and anaerobic cocci and Gram negative
anaerobic rods.
Clindamycin is not effective against Gram-negative
aerobic rods.
The recommended dose for oral administration is 300
mg every 8 h, which does not need to be adjusted
even in end-stage renal failure.
96. The most serious and common side-effect of clindamycin is
antibiotic-associated diarrhea (0.3–21%) and an even more
severe diarrheal state, pseudomembranous colitis (1.9–10%).
Clindamycin belongs to category B according to the FDA
categorization for pregnancy and has been extensively used
during pregnancy. Even so, there are no controlled studies
concerning its safety in humans.
97. metronidazole
Mainly metronidazole and ornidazole belong to the group of
nitroimidazole drugs, whose mechanism of action has not
been fully clarified even today.
They are drugs with rapid bactericidal action principally
against Gram-negative anaerobes, a slightly more
restricted bactericidal action against Gram-positive
anaerobes (microaerophilic
The usual dose for oral administration is 500 mg every 8 h for
metronidazole, and 500 mg every 12 h for ornidazole.
98. Pregnancy is not a contraindication for
administration (category B of FDA
categorization), but nitroimidazoles must be
avoided during the first trimester, while the
dose must be decreased to half the normal
dose only in cases of severe renal failure.
101. Antibiotic Therapy
Removal of the cause, drainage, and
supportive care more important than
antibiotic therapy.
Infections are cured by the patient’s
defenses, not antibiotics.
102. Antibiotic therapy
Oral infections are typically polymicrobial.
Antibiotic effectiveness dependent upon adequate
tissue (not serum) concentration for an
appropriate amount of time.
Antibiotics should be prescribed for at least one
week
103. Antibiotic therapy
Penicillin (bacteriocidal) drug of choice for treatment of
odontogenic infections (5% incident of allergy).
Clindamycin (batericiodal) 1st line after penicillin; effective
against anaerobes; stop taking at first sign of diarrhea.
Cephalosporin (slightly broader spectrum and bacteriocidal);
cautious use in penicillin-allergic patients → cross-sensitivity; if
history of anaphylaxis to penicillin, do not use.
104. Antibiotic therapy
Erythromycin (bacteriostatic) good 2nd line drug
after penicillin; use enteric-coated to reduce GI upset.
Metronidazole (bacteriocidal) excellent against
anaerobes only.
Augmentin (amoxicillin + clavulanic acid) kills
penicillinase-producing bacteria that interferes with
amoxicillin; expensive.
105. H- EVALUATE THE PATIENT
FREQUENTLY
1. Subjective sense of feeling better
2. Objective signs of improvement
3. Review culture & sensitivity reports
4. Reevaluate host responses if
necessary
107. Abscess of Base of
Upper Lip
Etiology. It is usually caused by
infected root canals of maxillary
anterior teeth.
Clinical Presentation.
swelling and protrusion of the
upper lip,
diffuse spreading and obliteration
of the depth of the mucolabial fold
108.
109. Treatment
• incision for drainage:
• is made at the mucolabial fold parallel to
the alveolar process.
•A hemostat is then inserted inside the
cavity, which reaches bone, aiming for the
apex of the responsible tooth, facilitating
the evacuation of pus.
•A rubber drain is placed until the clinical
symptoms of the infection subside .
111. •Canine Space infection
•Clinical Presentation.
This is characterized :
edema localized in the infraorbital region,
• obliteration of the nasolabial fold and
somewhat of the mucolabial fold.
•the skin becomes taut and shiny due to
suppuration, while its color is reddish
118. Sublingual Abscess
There are two sublingual spaces
above the mylohyoid muscle, to
the right and left of the midline.
These spaces are divided by
dense fascia. Abscesses formed in
these spaces are known as
sublingual abscesses.
.
119. Etiology.
the mandibular anterior teeth, premolars and the first
molar, whose apices are found above the attachment of
the mylohyoid muscle.
Also, infection may spread to this space from other
bordering spaces with which it communicates
(submandibular, submental, lateral pharyngeal).
120. Treatment. I&D
intraoral incision, laterally, and
along Wharton’s duct and the
lingual nerve.
In order to locate the pus, a
hemostat is used to explore the
space inferiorly, in an
anteroposterior direction and
beneath the gland.
After drainage is complete, a
rubber drain is placed.
121. Etiology. Infection of this space may
originate from
the mandibular second and third
molars, if their apices are found
beneath the attachment of the
mylohyoid muscle. It may also be
the result of spread of infection
from the sublingual or submental
spaces.
Sub-mandibular Abscess
122. Clinical Presentation. The infection
presents asmoderate
swelling at the submandibular area,
which spreads, creating greater edema
that is indurated and redness of the
overlying skin.
Also, the angle of the mandible is
obliterated, while pain during palpation
and moderate trismus due to
involvement of the medial pterygoid
muscle are observed as well.
123.
124. A hemostat is inserted into the cavity of the
abscess to explore the space and an
attempt is made to communicate with
the infected spaces.
Blunt dissection must be performed along
the medial surface of the mandibular
bone also, because pus is often located in
this area as well. After drainage, a
rubber drain is placed.
125. - Masticator space infection
a- Submasseteric Abscess
Etiology. Infection of this space
originates in the mandibular
third molars (pericoronitis)
127. Clinical Presentation. It is
characterized by a firm
edema that is painful to pressure in the
region of the masseter muscle.
Severe trismus and an inability to
palpate the angle of the mandible are
observed.
Intraorally, there is edema present at
the retromolar area and at the anterior
border of the ramus.
This abscess rarely fluctuates, while it
may present generalized symptoms.
128. Treatment.
Treatment of this abscess is basically intraorally.
with an incision that begins at the coronoid process and runs
along the anterior border of the ramus towards the
mucobuccal fold, approximately as far as the second molar.
Extraorally on the skin, beneath the angle of the mandible . In
both cases, a hemostat is inserted, which proceeds as far as
the center of suppuration and until it comes into contact with
bone.
Because access is distant from the purulent accumulation, often
it is difficult to drain the area well, resulting in frequent
129. Masticator space infection
b- Temporal Abscess
Anatomic Location.
A-The superficial temporal space is
bounded laterally by the temporal
fascia and medially by the
temporalis muscle
B- the deep temporal space is found
between the medial surface of the
temporalis muscle and the temporal
bone
130. Temporal Space infection
Clinical Presentation. It is
characterized by painful edema of
the temporal fascia, trismus (the
temporalis and medial pterygoid
muscles are involved), and pain
during palpation of the edema.
131. Etiology. Infection of the temporal space is
caused by the spread of infection from the
infratemporal space, with which it
communicates.
132. Treatment. The incision for drainage is
performed horizontally, at the margin of
the scalp hair and approximately 3 cm
above the zygomatic arch. It then
continues carefully between the two
layers of the temporal fascia as far as the
temporalis muscle. A curved hemostat is
used to drain the abscess.
133. Masticator space infection
C- Pterygomandibular Space
An abscess of this space is caused mainly by infection of
mandibular third molars or the result of an inferior
alveolar nerve block, if the penetration site of the needle
is infected (pericoronitis).
Clinical Presentation.
Severe trismus and slight extraoral edema beneath the
angle of the mandible are observed.
Intraorally, edema of the soft palate of the affected side
is present, as is displacement of the uvula and lateral
pharyngeal wall, while there is difficulty in swallowing.
134. Right pterygomandibular
space abscess. Note the
swelling of the anterior
tonsillar pillar and the
deviation of the
edematous uvula to the
opposite side.
135. Treatment.
The abscess is drained, permitting
the evacuation of pus along the
shaft of the instrument.
138. Left lateral pharyngeal space
abscess. Note the swelling just
anterior to the sternocleidomastoid
muscle above the level of the hyoid
bone and the deviation of the head
toward the right shoulder, in an
attempt to place the upper airway
directly over the deviated trachea
139.
140. Incision for temporal &
submassetric space
Submandibular, submasseteric,
pterygomandibular
Submental,
Sublingual
Incision for retropharyngeal,
lateral pharyngeal spaces
Incision for retropharyngeal,
lateral pharyngeal
141. Upper Canine
Canine space Buccal space
Pterygomandibular space
Submandibular space
Lateral pharyngeal space
Retropharyngeal space
Superior mediastinum
142. Upper Molars
Buccal space infratmporal
space
Temporal space
Ptergomandibular space
Submandibular space Lateral
pharyngeal space
147. 1- Ludwig's angina
Ludwig's angina is
bilateral, brawny,
induration of the
submandibular,
sublingual, and
submental spaces.
148. Ludwig’s angina with bilateral involvement
of sublingual and submandibular spaces
149. The principles of treatment of
Ludwig's angina are early diagnosis,
surgical intervention, and definitive
airway management.
After securing an airway, surgical
drainage of each individual space
should begin even before fluctuance
becomes palpable externally.
150. Clinical Presentation. The middle
third of the tongue is elevated
towards the palate, while the
anterior portion projects out
of the mouth.The posterior
portion displaces the
edematous epiglottis
posteriorly, resulting in
obstruction of the airway.
151. The incisions must be bilateral,
extraoral, parallel, and medial to the
inferior border of the mandible, at
the premolar and molar region , and
intraoral, parallel to the ducts of the
submandibular glands.
152. 2- Cavernous sinus thrombosis
It is an uncommon but potentially lethal
extension of odontogenic infection.
An orofacial infection can reach the
cavernous sinus through two routes: an
anterior route via the angular and inferior
ophthalmic veins, and a posterior route via
the transverse facial vein and the pterygoid
153.
154. . Cavernous sinus thrombosis
The first clinical signs of cavernous sinus
thrombosis include vascular congestion in
periorbital, scleral, and retinal veins.
Other clinical signs include periorbital edema,
proptosis, thrombosis of the retinal vein, ptosis,
dilated pupils, absent corneal reflex, and
supraorbital sensory deficits.
155. 3- Cervicofacial necrotizing
fasciitis?
Cervicofacial necrotizing fasciitis is a very aggressive
infection of the skin and superficial fascia of the head and
neck and is commonly seen in diabetic and
immunocompromised patients.
It carries a mortality rate of 30%-50% from sepsis of the
dead tissue in the affected area.
In suppurative odontogenic infections (e.g., periapical abscesses) or in infections of the deep fascial spaces, there is usually polymicrobial flora, with melaninogen Bacteroides, Fusobacterium nucleatum, as well as the species Peptostreptococcus, Actinomyces, and Streptococcus as the most common microbes.
Diffuse, reddened, soft or hard swelling that is tender to palpation.
Inflammatory response not yet forming a true abscess.
As inflammatory response matures, may develop a focal accumulation of pus.
May have spontaneous drainage intraorally or extraorally.
in the acute phase, no signs are observedat the bone (which may be observed 8–10 days later), unless there is recurrence of a chronic abscess, where upon osteolysis is observed. Radiographic verification of a deeply carious tooth or restoration very close to the pulp, as well as thickening of the periodontal ligament, are data that indicate the causative tooth.
Whether the pus spreads buccally, palatally or lingually depends mainly on the position of the tooth in the dental arch, the thickness of the bone, and the distance it must travel.
Whether the pus spreads buccally, palatally or lingually depends mainly on the position of the tooth in the dental arch, the thickness of the bone, and the distance it must travel.
For example:
The palatal roots of the posterior teeth and the maxillary lateral incisor are considered responsible for the palatal spread of pus, while the mandibular third molar and sometimes the mandibular second molar are considered responsible for the lingual spread of infection.
Inflammation may even spread into the maxillary sinus when the apices of posterior teeth are found inside or close to the floor of the antrum.
Relation of the root apices to the muscle attachments
In the maxilla, the attachment of the buccinator muscle is significant.
When the apices of the maxillary premolars and molars are found beneath the attachment of the buccinator muscle, the pus spreads intraorally; however, if the apices are found above its attachment, infection spreads upwards and extraorally.
Exactly the same phenomenon is observed in the mandible as in the maxilla if the apices are found above or below the attachment of the buccinator muscle
Spread of pus depending on the length of root and attachment of buccinator muscle.
a Apex above attachment: accumulation of pus in the buccal space.
b Apex beneath the buccinator muscle: intraoral pathway towards the mucobuccal fold
In its deeper portion it contains the platysma muscle while more superficially it contains the muscles of facial expressions. Nerves vessels, lymphatic and fat deposits are found throughout.
Three major factors must be considered in
determining the severity of an infection of the
head and neck:
Anatomic location,
Rate of progression,
Airway compromise.
Malnutrition syndrome, often as a result of Chronic alcoholism
- Poorly controlled diabetes
- Patient’s with malignancy & leukemia’s are more likely to be infected.
- A.I.D.S.
- Multiple myeloma
- Whole body radiation
Congenital defects such as agammaglobulinemia
Patients with these conditions may be unable to fight successfully against invading bacteria.
Cytotoxic drugs : patients may have increased susceptibility to infections for upto 1 yr after the course of cancericidal drugs
Immunosuppressive drugs :
- glucocorticoids
- azathioprine
- cyclosporine
- steroids
The objective of surgical drainage is to drain pus from tissue spaces & to insert drain so that more pus do not accumulate in these spaces. This procedure removes infected pus relives tissue pressure. In many odontogenic infections drainage can be accomplished by extracting offending tooth.
Surgical drainage also plays important role In
patients with cellulitis without pus formation.
The purpose is to release pressure & thereby
increase vascular flow. In most patients with
moderate to severe cellulitis incision &
exploration almost reveal some areas of abscess
formation. Hence surgical intervention is must in
both with chronic abscess with pus formation &
acute indurated cellulitis.
Surgical treatment may range from something as simple as the opening of a tooth and extirpation of the necrotic tooth pulp to treatment as complex as the wide incision of soft tissue in the sub-mandibular and neck regions for a severe infection.
Fever below 103°F (39.4°C) is probably beneficial.
Above 103°F, however, fever can become destructive
by increasing metabolic and cardiovascular demands
beyond physiologic reserve capacity.
Daily sensible fluid loss, consisting primarily of sweat,
is increased by 250 mL per degree of fever.
Insensible fluid loss, consisting mainly of evaporation
from lungs and skin, is increased by 50 to 75 mL per
degree of fever per day.
Fever also increases metabolic demand by 5 to
8% per degree of fever per day. Therefore, it
may be necessary to supplement the infected
patient’s oral intake
ODONTOGENIC INFECTIONS
Caused by MIXED flora =approx 70%
- Fusobacterium + S. milleri
Caused by AEROBIC flora = approx 5% - Streptococcus milleri, S. sanguais - S. salivarius, S. mutans
Caused by ANAEROBIC flora = approx 25%
- Prevotella melaninogenica, P.intermedia
- P.oralis, P.denticola, fusobacterium
According to studies bacteria found in well
circumscribed non-advancing abscess are
almost anaerobic bacteria only.
Microbiology of cellulitis type infections, that
do not have abscess formation, show almost
exclusively aerobic bacteria.
So, it seems that early infections that
present as a cellulitis without abscess
formation are most likely caused by aerobic
bacteria. As infection becomes more severe,
microbiology becomes of mixed type. If
infection process is controlled by host’s
defenses, aerobic bacteria no longer survive
& only anaerobic bacteria are found.
Usual dosage interval for therapeutic use is four times the t1/2
The high cost of newer macrolides compared to erythromycin must be noted, without a substantial difference in effectiveness against oral pathogens. Gastrointestinal disturbances (nausea, vomiting, abdominal cramping, diarrhea) are the most common side-effects of erythromycin. Newer macrolides are advantageous compared to erythromycin in that they are better tolerated and may be administered, due to their longer half-life, every 12 or 24 h instead of every 6 h.
which spreads towards the medial canthus of the eye, lower eyelid, and side of the nose as far as the corner of the mouth.
The edema at the infraorbital region is painful during palpation,
and later on
Submental Abscess
Treatment.
After local anesthesia is performed around the abscess an incision on the skin is made beneath the chin, in a horizontal direction and parallel to the anterior border of the chin. The pus is then drained in the same way as in the other cases.
Sublingual Abscess
There are two sublingual spaces above the mylohyoid muscle, to the right and left of the midline. These spaces are divided by dense fascia. Abscesses formed in these spaces are known as sublingual abscesses.
.
Etiology.
The teeth that are most commonly responsible for infection of the sublingual space are the mandibular anterior teeth, premolars and the first molar, whose apices are found above the attachment of the mylohyoid muscle. Also, infection may spread to this space from other bordering spaces with which it communicates (submandibular, submental, lateral pharyngeal).
Treatment. I&D
The incision for drainage is performed intraorally, laterally, and along Wharton’s duct and the lingual nerve. In order to locate the pus, a hemostat is used to explore the space inferiorly, in an anteroposterior direction and beneath the gland. After drainage is complete, a rubber drain is placed.
Clinical Presentation. It is characterized by a firm
edema that is painful to pressure in the region of the masseter muscle, which extends from the posterior border of the ramus of the mandible as far as the anterior border of the masseter muscle. Also, severe trismus and an inability to palpate the angle of the mandible are observed. Intraorally, there is edema present at the retromolar area and at the anterior border of the ramus. This abscess rarely fluctuates, while it may present generalized symptoms.
