Odontogenic Infection Dr. Rahaf Al-Habbab BDS. MsD. DABOMS Diplomat of the American Boards of Oral and Maxillofacial Surgery

Odontogenic Infection Infection that arises from the teeth, and spread beyond the teeth to the alveolar process and the deeper tissue of the face, oral cavity, head and neck, and have a characteristic flora Origin: Caries Periodontal Disease pulpitis Different Origins of Odontogenic Infection

Odontogenic Infection Types Low-grade Well localized infection that require only minimal treatment Most common Severe Infection: Life threatening Deep facial space infections

Microbiology of OI Most commonly part of the indigenous bacteria that normally live on or in the host (normal flora) Are the bacteria that causes dental caries, gingivitis, and periodontitis. Gaining access to deeper underlying tissues, causes Odontogenic Infection

Microbiology of OI Aerobic gram positive cocci Anaerobic gram-positive cocci Anaerobic gram-negative rods As the infection progresses more deeply, different members of the infecting flora can begin to outnumber the previously dominant species

Important Factors Almost all OI are caused by multiple bacteria (polymicrobial) Oxygen tolerance of the bacteria causing OI, because the oral flora is a combination of aerobic and anaerobic bacteria (aerobic 6%, anaerobic 44%, mixed 50%)

The predominant Aerobic bacteria found in 65% of OI are the streptococcus milleri group, which consist of three members of the S. viridans group of bacteria: S. anginosus, S. intermedius, S. constellatus, which can grow in the presence and the absence of Oxygen The Anaerobic bacteria found in OI include an even greater variety of species, two groups predominate; Gram positive cocci (65% of cases) Streptococcus Peptostreptococcus Gram-negative anaerobic rods Prevotella, and Porphyromonas (found in about 75%) Fusobacterium (present in more than 50%) Of the Anaerobic bacterai, gram +ve cocci and gram –ve rods, play a more important pathogenic role Where the Anaerobic gram –ve cocci and gram +ve rods have little or no role in causing OI

Pathophysiology Initial inoculation of aerobic and anaerobic bacteria into the deeper tissue → S. milleri group organisms synthesize Hyaluronidase → allow infection to spread through connective tissue → Cellulitis type of Infection Metabolic by-products from the streptococci → create a favorable growth environment for the Anaerobe (release of essential nutrients, lower pH, local O2 supply consumption) As the local oxidation-reduction potential is lowered further → Anaerobic bacteria predominate → further liquification necrosis (by their synthesis of collagenases) As collagen is broken down and invading WBC necrosis and lyse → micro-abscesses form → Coalesce into a clinical Abscess

Clinical Progression OI passes through four stages: Inoculation Stage: First 3 days Soft, mildly tender, doughy swelling Invading streptococci are just beginning to colonize the host Cellulites Stage: 3-5 days Swelling become hard, red, and acutely tender Infecting mixed flora stimulates the intense inflammatory response

Clinical Progression Abscess Stage: Resolution Stage: 5-7 days after the swelling onset Anaerobic begin to predominate Liquification of the abscess in the center of the swollen area Resolution Stage: Abscess drain spontaneously through skin or mucosa or it is surgically drained Immune system destroys the infecting bacteria Process of healing and repair

Abscess Cellulitis Edema (Inoculation) characteristic 4-10 days 1-5 days 0-3 days Duration Localized Diffuse Mild, diffuse Pain, borders Smaller Large Variable Size Shiny center Red Normal Color Soft center Boardlike Jellylike Consistency Decreasing Increasing Progression Present Absent Pus Anaerobic Mixed Aerobic Bacteria Less Greater low seriousness

Progression of Odontogenic Infection Two major origins: Periapical (as a result of pulpal necrosis) Periodontal (as a result of deep periodontal pocket) The periapical origin is the most common in odontogenic infections

Progression of Odontogenic Infection Deep caries, resulting in dental pulp necrosis, allows a pathway for bacteria to enter the periapical tissue Bacterial invasion will result in active infection Infection then spread equally in all directions, but preferentially along the line of least resistance Infection spreads through the cancellous bone until it encounters the cortical plate If the cortical bone is thin, the infection erode through the bone and invade the soft tissue

Progression of Odontogenic Infection Treatment of the necrotic pulp by standard endodontic therapy or extraction of the involved tooth should resolve the problem Antibiotics alone may arrest, BUT do not cure the infection

Spreading of the Infection Determined by two major factors The relationship of the bone perforation site to muscle attachment of the maxilla and the mandible The thickness of the bone overlying the tooth apex

Maxillary Infection Most maxillary teeth erode through the facial cortical plate. Erode through the bone below the attachment of the muscles attaching to the maxilla Means that: Most maxillary dental abscesses appear initially as vestibular abscess Occasionally, a palatal abscess arises from the apex of a severely inclined lateral incisor or a palatal root of a maxillary first molar.

Maxillary Infection Resulting in: More commonly; The maxillary molars cause infections that erode through the bone superior to the insertion of the buccinator muscle Resulting in: Buccal space infection Occasionally, long maxillary canine root allows infection to erode through the bone superior to levator anguli oris insertion, causing Infraorbital (canine) space infection.

Mandibular Infection Incisors, canine, and premolars: Usually erode through the facial cortical plate superior to the attachment of the lower lip muscles Resulting in: Vestibular abscess

Mandibular Infection Mandibular molars: Infections erode through the lingual cortex more frequently First molar Infections may drain buccally or lingually Second molars Can perforate buccally or lingually (usually lingually) Third molars: Almost always erode through the lingual cortical plate The mylohyoid muscle determines wither infections that drain lingually go superior to the muscle into the sublingual space or below it into the submandibular space

Principles of OI Management Principle 1: Determine Infection Severity Principle 2: Evaluate State of patient’s host defense mechanism Principle 3: Determine whether patient should be treated by general dentist or Oral and Maxillofacial Surgeon Principle 4: Treat infection surgically Principle 5: Support patient medically Principle 6: Choose and prescribe Appropriate antibiotic Principle 7: Administer antibiotic properly Principle 8: Evaluate patient frequently

Principle 1: Determine Infection Severity Complete history: Chief complaint: In patients own words Duration and onset: How long, progression Signs and symptoms: Pain, swelling, warmth, erythema and redness, and loss of function (mouth opening, dysphagia, dyspnea) General condition: fatigued, feverish, weak, and sick are said to have malaise Malaise: generalized reaction to a moderate to severe infection Ask about Treatment: professional and self-treatment Complete medical history

Principle 1: Determine Infection Severity Physical Examination: Vital signs: Temperature, blood pressure, pulse rate, and respiratory rate Temperature: Patient with severe infection have temperature of 101° F or higher (greater than 38.3° C) Pulse Rate: pulse rate of up to 100 beats/min are not uncommon in an infection patient, id PR is greater than 100 bpm may indicate severe infection Blood Pressure: significant pain and anxiety can result in the elevation of systolic blood pressure, However, severe septic shock result in Hypotension Respiratory rate: clear upper airway and no difficulty in breathing RR, 14-16 breaths per minute, can increase up to 18 in mild to moderate infections

Principle 1: Determine Infection Severity Physical Examination: Inspection of general appearance Careful head and neck examination Palpation of swelling : tenderness, heat, consistency ( doughy, indurated, fluctuant) Fluctuance: feeling of fluid filled balloon, almost always indicate pus in the center of the indurated area. Intraoral Examination: cause of infection, and assess airway and tongue position Radiographic Examination: PA, Panoramic radiograph Determine the diagnosis

Summery Edema represents the earliest ,inoculation stage of infection that is most easily treated Cellulitis, is an acute, painful infection with more swelling and diffuse borders Has a hard consistency on palpation and contains NO PUS Acute Abscess, more mature infection with more localized pain, less swelling, well circumscribed borders Which is more serious?

Principle 2: Evaluate State of Patient’s Host Defense Mechanism Medical conditions that compromise host defenses 1- Uncontrolled Metabolic Diseases: Poorly controlled Diabetes: Type I and Type II, are the most common immunosuppressive diseases Renal disease with Uremia Severe alcoholism with malnutrition Resulting in decrease function of leukocytes, including decrease chemotaxis, phagocytosis, and bacterial killing

Principle 2: Evaluate State of Patient’s Host Defense Mechanism 2- Immunocompromising Diseases: Leukemia Lymphoma Different types of cancer Decrease white blood cells function and antibodies synthesis and production

Principle 2: Evaluate State of Patient’s Host Defense Mechanism Immunocompromising Diseases: Human Immunodeficiency Virus Infection (HIV) HIV attacks T lymphocytes, affecting resistance to viruses and intracellular pathogens, Fortunately, Odontogenic infections are caused largely by extracellular pathogens (Bacteria) , therefore HIV-seropositive individuals are able to combat OI fairly well until they aquire immunodeficiency syndrome has progressed into advanced stage, when the B lymphocytes are also severely impaired

Principle 2: Evaluate State of Patient’s Host Defense Mechanism 3- Immunosuppressive Therapies: Cancer chemotherapy Corticosteroids Organ transplantation Decrease white blood cells count, T and B lymphocyte function, and immunoglobulin production, more likely to develop infection Patient taking any of these medications should be treated vigorously , prophylactic antibiotics should be given for routine oral surgery procedure to prevent INFECTION and Endocarditis

Minor infection vs. life-threatening infection Principle 3: Determine whether patient should be treated by General Dentist or Oral and Maxillofacial Surgeon Minor infection vs. life-threatening infection Criteria indicating immediate referral to a Hospital emergency room to secure the airway: Rapidly progressing infection Difficulty in breathing (dyspnea) Difficulty in swallowing (dysphagia) Dehydration Moderate to severe trismus (interincisal distance less than 20mm) Swelling extending beyond the alveolar process Elevated temperature (˃101° F) Severe malaise and toxic appearance Compromised host defenses Need for general anesthesia Failure of prior treatment

Principle 4: Treat infection surgically Remove the cause of the infection Drain the accumulate pus and necrotic debris

I&D Technique Adequate pain control (block or infiltration) Disinfect the surface mucosa with a solution such as povidone-iodine (Betadine) Obtain a specimen for C&S testing using an 18 gauge needle (1-2ml)

Avoid incising across the frenum or the mental nerve region I&D Technique Incision is made Over the site of maximum swelling and inflammation using a scalpel blade just through the mucosa and submucosa (not more than 1cm long) Avoid incising across the frenum or the mental nerve region

I&D Technique Small curved hemostat is inserted through the incision to the abscess cavity Hemostat is open in different directions to break up any small pus loculations or cavities

I&D Technique Small drain is then inserted and secure in place using a non-resorbable suture (1/4 inch sterile penrose drain) Drain is removed 2-5 days following drainage, when all drainage have stopped

Principle 5: Support Patient Medically Treat and control the underlying medical condition Proper hydration High-calorie nutritional supplement Adequate analgesia for proper rest

Principle 6: Choose and Prescribe Appropriate Antibiotic 1- Determine the need of AB administration: Indications: Swelling extending beyond the alveolar process Cellulitis Trismus Lyphadenopathy Temperature higher than 101° F Severe pericoronitis Osteomyelitis

Principle 6: Choose and Prescribe Appropriate Antibiotic 1- Determine the need of AB administration: Not Indicated: Patient demand Toothache Periapical abscess Dry socket (self limiting) Multiple dental extractions in a non compromised patient Mild pericoronitis (inflammation of the operculum only) Drained alveolar abscess

Principle 6: Choose and Prescribe Appropriate Antibiotic 2- Use Empirical Therapy Routinely: Odontogenic infections are caused by a highly predictable group of bacteria, with a very well known antibiotic sensitivity. Effective Orally Administered Antibiotics for OI: Penicillin Amoxicillin Clindamycin Azithromycin Metronidazole Moxifloxacin

Principle 6: Choose and Prescribe Appropriate Antibiotic 2- Use the Narrowest-Spectrum Antibiotics: Will affect streptococci and oral anaerobic bacteria, but will have little or no effect on the staphylococci of the skin or GI tract, so does not result in the development of bacterial resistance Narrow and Broad-spectrum Antibiotics: Narrow-Spectrum Wide-Spectrum (simple OI) (complex OI) Amoxicillin Amoxicillin with clavulanic acid Penicillin Azithromycin Clindamycin Tetracycline Metronidazole Moxifloxacin

Simple vs. Complex Odontogenic Infection Simple odontogenic Infections: Swelling limited to the alveolar process and vestibular space First attempt at treatment Non-immunocompromised patients Complex Odontogenic Infections: Swelling extending beyond the vestibular space Failed prior treatment Immunocompromised patient

Principle 6: Choose and Prescribe Appropriate Antibiotic 3- Use the antibiotic with the lowest incidence of toxicity and side effects 4- Use a bactericidal antibiotic, if possible 5- Be aware of the coast of antibiotics

Principle 7: Administer Antibiotic Properly Proper dose should be given The peak plasma level should be 4 or 5 times the minimal inhibitory concentration for the bacteria involved in the infection

Principle 8: Evaluate Patient Frequently Patient should be followed carefully to monitor response to treatment and complications Additional antibiotics may be necessary in infection that have not resolved rapidly Reasons for treatment failure: Inadequate surgery Foreign body Antibiotic problems: Patient noncompliance Drug not reaching site Drug dose too low Wrong bacterial diagnosis Wrong antibiotic

Thank You Reference: Contemporary Oral and Maxillofacial Surgery James R. Hupp, Edward Ellis III, Myron R. Tucker, 5th Edition Chapter 15

Odontogenic Infection Part II Dr. Rahaf Al-Habbab BDS. MsD. DABOMS Diplomat of the American Boards of Oral and Maxillofacial Surgery 2013

Principles of Prevention of Infection The use of antibiotics to treat an already established infection is a well accepted and well-defined technique But The use of antibiotics for prevention is less widely accepted

Principles of Prophylaxis of Wound Infection There is little scientific evidence that demonstrates the effectiveness of prophylactic antibiotics in dentistry and Oral and maxillofacial surgery.

Advantages Reduce the incidence of postoperative infection and thereby reduces postoperative morbidity Appropriate and effective antibiotics prophylaxis may reduce the coast of health care Requires shorter –term administration than therapeutic use.

Disadvantages Can alter host flora, allowing the overgrowth of antibiotic-resistant and pathogenic bacteria that may then cause infection Allow antibiotic-resistant organisms to spread to the patient’s family and community May provide no benefit (infection risk is so low)

Disadvantages (cont.) May encourage lax surgical and aseptic technique on the dentist part Coast of antibiotic must be considered Toxicity of the drug to the patient must be kept in mind

Principles of Prophylactic Antibiotic Use Risk of infection must be significant Correct narrow-spectrum antibiotic must be chosen Antibiotic level must be high Antibiotic must be in the target tissue before surgery Use the shortest effective antibiotic exposure.

Principle 1: Procedure Should have Significant Risk of Infection Clean surgery with strict adherence to basic surgical principles, has an infection rate of about 3%. 10% infection rate or higher (infection-prone procedure) is considered unacceptable, and AB must be strongly considered However, several factors might influence the use of AB prophylaxis

Factors Related to Postoperative Infection Size of bacterial inoculum Duration of surgery ( more than 4 hours in hospital surgeries) Presence of foreign body, implant, or dead space. State of host resistance (immunosuppressive, cancer) The most common immunocompromising disease is Diabetes mellitus

Diabetes Mellitus Measuring the level of DM control over the previous 3-4 Months The Glycosylated Hemoglobin test Hemoglobin A1c (8% or less)

Finger Stick Blood Glucose (mg/dl %) Dental Treatment for Diabetics Based on Fingerstick Blood Glucose Testing Dental Treatment Finger Stick Blood Glucose (mg/dl %) Administer glucose; postpone elective treatment Less than 85 Stress reduction; consider AB prophylaxis for extraction 85-200 Stress reduction; AB prophylaxis; referral to primary care physician 200-300 Avoid elective treatment; referral to primary care physician or ER at nearby hospital 300-400 Avoid elective treatment; send to ER at nearby hospital Greater than 400

Principle 2: Choose Correct Antibiotics The choice of AB for prophylaxis after surgery should be based on the following criteria: First, AB should be effective against the organisms most likely causing the infection Second, Chosen AB should be narrow-spectrum Third, Should be the least toxic AB available Fourth, should be bactericidal AB

AB of Choice Taking these four criteria into account, the antibiotic of Choice for prophylaxis is: Penicillin and Amoxicillin Effective against streptococcus Narrow spectrum Low toxicity Bactericidal

Allergic to Penicillin Clindamycin Fairly effective against oral streptococcus Narrow spectrum Bacteriostatic Azithromycin Reasonably effective against the usual organisms

Principle 3: Antibiotic Plasma Level must be High Prophylactic antibiotic plasma level must be higher than therapeutic level Plasma level should be high at the time of surgery to ensure diffusion of the AB into all tissue and spaces at surgery site The usual prophylaxis recommendation is two times the usual therapeutic dose (use the AHA recommendation for Infective Endocarditis): Penicillin and Amoxicillin, 2g Clindamycin, 600mg Azithromycin, 500mg

Principle 4: Time AB Administration Correctly Should be administered 2 hours or less before the surgery Varies according to the rout of administration For oral administration is usually 1 hour IV rout, much shorter duration is required

Principle 4: Time AB Administration Correctly Giving prophylactic AB postoperatively was found to increase the risk of postoperative infection Intraoperative AB administration in prolonged procedure should be given at half the usual interval time; Penicillin and Clindamycin should be given every 3 hours, to avoid periods of inadequate AB level in tissue fluids.

Principle 5: Use Shortest Antibiotic Exposure That is Effective AB must be given before the surgery Adequate plasma level must be maintained during surgery Continuation of the AB administration after surgery produce little to no benefit

What about Metastatic Infections?

Principles of Prophylaxis Against Metastatic Infection Defined as: Infection that occurs at a location physically distant from the port of bacterial entry Bacterial Endocarditis is best example Incident of infection can be reduced if AB administration is used preoperatively

Factors Necessary for Metastatic Infection Distant susceptible site (Deformed heart valve, Non-Bacterial Thrombotic Endocarditis, NBTE) Hematogenous bacterial seeding (Bacteremia) Impaired local defenses

Prophylaxis Against Infectious Endocarditis Bacteremia has been shown to cause IE (streptococcus viridans) which is part of the normal oral flora Prophylactic AB has shown to prevent IE resulting from dental procedures IE can result in high morbidity and mortality All dental procedures can result in Bacteremia Depending on the procedure the need of antibiotics is decided in high risk patients

Cardiac Conditions Associated with the Highest Risk of Adverse outcome from Endocarditic for which Prophylaxis with dental procedure is Recommended Prosthetic Cardiac Valve Previous Infective Endocarditis Congenital Heart Disease (CHD) Unrepaired cyanotic CHD, including palliative shunts and coduits Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization) Cardiac transplantation recipients who have cardiac valculopathy

Dental Procedures for which Endocarditis Prophylaxis is Recommended for patients All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa

Dental Procedures for which Prophylaxis is NOT Recommended Restorative dentistry Routine local anesthetic injection Intracanal endodontic therapy and placement of rubber dams Suture removal Placement of removable appliances Making of impressions Taking oral radiographs Fluoride treatment Orthodontic appliance adjustment Shedding of primary teeth

If unexpected bleeding occurs during the procedure or the patient failed to inform you about his condition Prophylaxis AB should be given during the first 2 hours after the procedure Prophylaxis given longer than 4 hours after the bacteremia has limited prophylactic benefits.

Antibiotics Regiments for prophylaxis of Bacterial Endocarditis 30-60 Min Before Procedure Children Regiment Adult Agent Situation 50 mg/kg 2g Amoxicillin Oral 50 mg/kg IM or IV 2 g IM or IV 1 g IM or IV Ampicillin Cafazolin/ceftriaxone parenteral 20 mg/kg 15 mg/kg 2 g 600 mg 500 mg Cephalexin Clindamycin Azithromycin/clarithromycin PCN allergy, Oral 600 mg IM or IV Cefazolin/ceftriaxone PCN, allergy, parenteral

Prophylaxis in Patients with other Conditions Do not require PAB Coronary Artery Bypass Grafting (CABG)

Prophylaxis in Patients with other Conditions Transvenous Pacemaker (Battery Pack Implanted in their Chest) Do Not Require PAB

Consultation with the patient’s cardiologist should still be considered

Prophylaxis in Patients with other Conditions Renal Dialysis Patients for Renal Failure (Arteriovenous Fistula) Patient Nephrologists should decide the proper PAB

Prophylaxis against Total Joint Replacement Infection American Dental Association (ADA) and the American Academy of Orthopedic Surgeons (AAOS) RECOMMENDATION: Most patients with prosthetic joints are not at risk for joint infection after a dental surgical procedure

Conditions placing patients at risk for prosthetic joint infection Prosthetic joint placed within 2 years Rheumatoid arthritis Systemic lupus erythematosus Insulin-dependent diabetes Previous prosthetic joint infection Congenital or acquired immunosuppressive diseases Malnourishment hemophilia

Procedures that indicate prophylaxis for prosthetic joint replacement Dental extraction Periodontal procedures, including scaling and root planning Dental implant placement and reimplantation of avulsed teeth Periapical endodontic procedures Initial placement of orthodontic bands but not brackets Intraligamentary local anesthetic injections Dental prophylaxis when bleeding is expected Subgingival placement of antibiotic fibers or strips

Antibiotic Regimens for Prophylaxis of Total Joint Replacement Infection Dose Drug Regimen 2g orally 1 hour before procedure Amoxicillin, cephalexin, or cephradine Standard oral prophylaxis 600 mg orally 1 hour before procedure Clindamycin Penicillin-allergic oral prophylaxis 1g IV 1 hour before procedure 2g IV 1 hour before procedure Cephazolin Or Ampicillin Parenteral prophylaxis 600 mg IV 1 hour before procedure Penicillin-allergic parenteral prophylaxis

Indication for Parenteral Regimen Patient having general anesthetic and allowed nothing by mouth Unable to take oral medications High-risk patients, such as those with history of previous bacterial endocarditis

Communications Between all Parties is Required

Thank You Reference: Contemporary Oral and Maxillofacial Surgery James R. Hupp, Edward Ellis III, Myron R. Tucker, 5th Edition Chapter 15