Odontogenic infection in maxillofacial region กลุ่มงานทันตกรรม รพ.วานรนิวาส

Infection in oral and maxillofacial region Odontogenic infection Necrotizing facciitis, frequently odontogenic source Osteomyelitis Osteoradionecrosis Bisphosphonate-relaed osteonecrosis Salivary grand infection Fungal & viral infection

Odontogenic infection

Dental infection => space infection

Dental infection => space infection

Host Anatomical factor Microbial

Severity score= 1 Subperiosteal abscess

Low severity Severity score= 1 Vestibular abscess

Low severity Severity score= 1 Canine space abscess ระวังPeriorbital!!!

Low severity Severity score= 1 Buccal space abscess

Limited mouth opening ( 1cm) Severity score= 2 Submasseteric space Pterygomandibular space Temporal space Limited mouth opening ( 1cm)

Severity score= 2 Submental space infection Submandibular space abscess

Ludwig’s angina Rapidly obstruct upper airway Involvement submandibular spaces bilaterally ,submental space,sublingual Rapid spread to lateral pharyngeal / retropharyngeal space Rapidly obstruct upper airway

Severity score= 3

Severity score= 4 Danger space, Mediasternum

The most frequent cause of death in reported cases of odontogenic infection is Airway Obstraction Clinical apparent partial air way obstruction with lowO2sat => secure airway

Management of odontogenic infection Step 1.Determine the severity of infection ---Anatomical location ---Rate of progression : Inoculation,Cellulitis,Abscess ---Air way compromise

Chronic renal failure* Malnutrition Alcoholism End-stage AIDS Step 2. Evaluated host defend DM* Steroid therapy Organ transplants Malignancy Chemotherapy Chronic renal failure* Malnutrition Alcoholism End-stage AIDS

Step 3.Decide on setting care -Refer > Severe score 2 IPD : score 1, mild score 2 fever, dehydration, control host disease OPD : mild score 1-2 follow up in *few days (7 days may be too long)

Step 4.Treat surgically Mild root canal treatment or Tooth extraction ? Surgical drain (intraoral or extraoral) --If drain inserted, drains should be discontinued when drainage cease <72hrs --Irrigate with NSS daily

Stage of Infection

Early incision and drainage aborts the spread of infection into deeper and more critical anatomic space, even when it is in the cellulitis stage Williams and Guralnick N Engl J med 1943 Flyn TR, AAOMS 1999 แต่ถ้าแก่มากๆหรือในเด็กถ้าไม่ได้บวมมากก็สามารถชะลอไปก่อนได้

Step 5. support medically Control fever& adequate hydration

Step 6. Choose antibiotic therapy Usual Odontogenic infection : 70%= gram(+)cocci :Streptococus sp. 30% = anaerobic : gram (-) rod , Bacteroid sp, prevotella, prophyromonas, fusobacterium, Klebsiella Step 7.Administer the antibiotics

Usual Odontogenic infection

In thailand เก็บclindamycin ไว้กรณี severe infection รพ.ศูนย์ต่างๆพบว่าการรักษาคนไข้ในประเทศไทย IV FOR ODONTOGENIC INFECTION 1st line drug : PGS + Metronidazole or 1st gen cephalosporin+Metronidazole กรณีมีStaphlylococus(skin) เก็บclindamycin ไว้กรณี severe infection

Culture& sensitivity testing Expensive&time consumimg!! Can be dalayed for as mush as 2 weeks When dealing with Unusual Infection **subjected to multiple course of antibiotics DM : Klebsiella pneumoniae HIV/AIDS :Mycobacteria IV Drug abusers : Staphylococus aureus Gram stain?cheap screen!!

Step 8.Evaluated the patient frequenly No fever 1-2 days, การบวมลดลง, การปวดลดลง,รับประทานข้าวได้ เปลี่ยนเป็นยากินและ D/S ได้ นัด F/U

Step 1.Determine the severity of infection Step 2. Evaluated host defend Step 3.Decide on setting care Step 4.Treat surgically Step 5. support medically Step 6. Choose antibiotic therapy Step 7.Administer the antibiotics Step 8.Evaluated the patient frequenly