Odontogenic infections

Copyright 2003, Elsevier Science (USA). All rights reserved.
Principles of
Management of
Odontogenic Infections
Fouad Al-Belasy

Disclaimer
 This presentation is based on chapter 16 authored by
Thomas R. Flynn in Hupp JR, et al. (ed. 6). Contemporary
Oral and Maxillofacial Surgery. St Louis, Mosby, 2014.
 Some pictures used in this presentation and their content
have been obtained from a number of other sources. Their
use is purely for academic and teaching purposes.
 This presentation does not have any intended commercial
use. In case the owner of any of the pictures has any
objection and seeks their removal please contact at
albelasy@netscape.net. These pictures will be removed
immediately.

Objectives
 Etiology
 Microbiology
 Natural history of
progression
 Eight principles of
therapy
 Antibiotic guidelines
 Conclusion

Introduction
 You will be treating
infections every day of
your practice
 Learning this material
will:
Enhance the comfort of
your practice, and
Aid in the confidence
with which you treat
patients

Introduction
Dental Infections:
Most frequent reason for
dental consultation
Affects entire population –
children to elderly
Considerable cost to
community
Can be fatal

Spectrum of Severity
May range from:
Low-grade, localized and
easily treated , to
Severe, rapidly spreading,
life-threatening fascial
space infections
The end result of
untreated dental infections
may be death!

Etiology
Odontogenic sources
•Pulpal disease
•Periodontal disease
•Long standing pericoronal
infection
•Infection of an odontogenic cyst
or tumor
•Infection of an extraction wound
or fracture site
Non-odontogenic sources
•Oral mucosa/skin
•Salivary glands
•Sinuses

Microbiology
Most infections result from indigenous
bacteria
Primarily aerobic & anaerobic Gram +
cocci, and anaerobic Gram – rods
Most of these bacteria cause common
caries and periodontal disease - become
pathogenic when gaining access to deeper
tissues

Microbiology
 Odontogenic infections are polymicrobial in
nature: multiple bacterial species isolated
• Average 5 species isolated
• Not unusual to identify as many as 8 species
• Rarely a single species isolated
• Both aerobic and anaerobic species isolated
Aerobic 6%
Anaerobic 44%
Mixed aerobic and anaerobic 50%
 Culture techniques must be accurate to identify
all species

Aerobic Bacteria
Most common
Strep. milleri group:
65% of aerobic infections
Miscellaneous:
staph. 5% of aerobic infections
Minor contributors
Gram – cocci (Neisseria)
Gram + rods (Corynebacterium)
Gram – rods (Haemophilus)

Streptococcus Milleri
 Predominant aerobic Gram + Cocci.
which consists of three member of
Strep. viridans group:
o S. anginosus
o S. intermedius
o S. constellatus

Anaerobic Bacteria
Most common
Gram + cocci:
Streptococcus and Peptostreptococcus
-75%
Gram – rods:
Prevotella and Porphyromonas spp. 75%
Fusobacteria - 50% of anaerobic
infections
Opportunists with little role
Gram – cocci (Viellonella)
Gram + rods (Actinomyces, Lactobacilli)

Major Pathogens of Dental
Infections
Early Lesions
Streptococcus milleri group
Mature Lesions
Other members of strep. viridans group
Peptostreptococcus
Prevotella
Porphyromonas
Fusobacteria
Hence, aerobic and anaerobic Gram+cocci
and anaerobic Gram-rods play the major
role.

Stages of Infection
1. Inoculation (edema) stage (0-3 days):
Aerobes inoculate the host resulting in a
soft, doughy, and mildly tender swelling
2. Cellulitis stage (3-5 days): Mixed species
- Intense inflammatory response, hard,
red, exquisitely tender swelling
3. Abscess stage (5-7 days): anaerobes
predominate, liquefied abscess in the
center of a swelling
4. Resolution stage: Spontaneous drainage,
or surgical drainage

Stages of Infection

Natural History of Progression

Principles of Management

1. Determine Severity of
Infection
 Most odontogenic infections are mild
and require only minor surgical therapy
 Determination of severity is based on:
• Complete history of the current
infection
• Physical examination

1. Determine Severity of Infection
(cont’d)
Complete history:
Chief complaint
Time of onset
Course of infection since onset
Rate of progression
Eliciting information about
patient’s symptoms: pain,
swelling, heat, redness, and loss
of function
General appearance of patient
Previous treatment
Medical history

(cont’d)
Clinical examination:
Vital signs
Extraoral examination
Inspection of:
•general appearance
•cardinal signs of inflammation
•any loss of functions
Palpation of area of swelling
Intraoral examination:
•source of infection

(cont’d)
Radiographic examination
Periapical
OPG
CT scan
Assessment
Stage is edema, cellulitis, or abscess
Severity is low, moderate, or high

2. Evaluate Host Defenses
Compromised Host Defenses:

3. Determine the Setting of Care
Criteria for Referral to an OMF Surgeon:

(cont’d)
Indications for Hospital Admission:

(cont’d)
When to Go to the Operating
Room

4. Treat Infection Surgically
 Ranges from opening
a tooth and
extirpation of necrotic
pulp to neck incisions
Goals:
 Remove source of
infection
 Provide a path for
drainage

4. Treat Infection Surgically (cont’d)
Getting a specimen for C&S
test:
Disinfect mucosa or skin
Local anesthesia
Insert large gauge needle into
abscess cavity
Aspirate pus (1-2 ml)
Send for microscopy, culture &
sensitivity
It is OK to culture when patient is
already on oral antibiotics – yield is
good as penetration of abscess is
only 1/3 of serum level

4. Treat Infection Surgically
(cont’d)
Indications for C & S testing:

4. Treat Infection Surgically (cont’d)

5. Support Patient Medically
 Host systemic resistance must be
considered in 3 areas:
 Immune system compromise
 Control of systemic diseases:
o Hypertension, dysrhythmias, med.
warfarin
 Physiologic reserves
 Fever elevation by 1∘
F per day
Increases:
• Daily fluid requirements by 800ml/∘
F/day
• Caloric requirements by 3% - 5% /∘
F/day

5. Support Patient Medically
(cont’d)
 Fluids PO vs. IV
 High calorie nutrition
 Adequate analgesics
& antipyretics
 Appropriate
antibiotics
 Complete bed rest

6. Choose and Prescribe
Antibiotics
 not all infections require antibiotics
 Indications for therapeutic use of
antibiotics:

6. Choose & Prescribe Antibiotics
(cont’d)
 When use of antibiotics is not necessary?

6. Antibiotics: Empiric Choice
(cont’d)
Odontogenic infections generally
caused by predictable group of bacteria
An antibiotic is prescribed empirically
i.e. on the basis that an appropriate
antibiotic is being given
Routine culture & sensitivity testing is
not cost-effective

6. Antibiotics: Empiric Choice
(cont’d)

6. Antibiotics: Choice (cont’d)
Factors governing choice:
Narrow spectrum
Lowest incidence of toxicity and
side effects
Bactericidal vs. bacteriostatic
Cost

6. Antibiotics: Principles of Use

7. Administer Antibiotic
Properly
Proper dose
Peak plasma level of antibiotic should be
4-5 times the MIC for bacteria involved in
infection
Proper dose interval
Interval is 4 times the t ½ life of
antibiotic
Proper route !
Proper duration !

8. Evaluate Patient Frequently
 Close follow up to monitor response to
treatment and complications
• Pain
• Swelling
• Trismus
• Temperature
• General appearance
• Drainage site:
o drain removed at day 2-5
• Recurrent infection

8. Evaluate Patient Frequently (cont’d)
Reasons for treatment failure:

8. Evaluate Patient Frequently (cont’d)
Criteria for changing antibiotics:

Conclusion
 Careful evaluation
 Prompt treatment
 Refer as necessary
 Close follow up

Conclusion

References
Fragiskos FD: Oral surgery. Springer-Verlag
Berlin Heidelberg, pp. 205-241, 2007
Flynn TR: Principles of management of
odontogenic infections. In Peterson's principles
of oral and maxillofacial surgery. BC Decker Inc,
Hamilton , London, pp. 277-293, 2004

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