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

2. 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

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

4. 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

5. 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

6. 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%)

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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.

17. 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.

18. 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

19. 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

20. 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

21. 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

22. 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, breaths per minute, can increase up to 18 in mild to moderate infections

23. 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

24. 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?

25. 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

26. 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

27. 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

28. 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

29. 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

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

31. 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)

32. 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

33. 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

34. 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

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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

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

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

46. 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

47. 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.

48. 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.

49. 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)

50. 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

51. 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.

52. 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

53. 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

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

55. 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
Avoid elective treatment; referral to primary care physician or ER at nearby hospital
Avoid elective treatment; send to ER at nearby hospital
Greater than 400

56. 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

57. 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

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

59. 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

60. 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

61. 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.

62. 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

63. What about Metastatic Infections?

64. 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

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

66. 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

67. 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

68. 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

69. 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

70. 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.

71. 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

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

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

74. Consultation with the patient’s cardiologist should still be considered

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

76. 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

77. 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

78. 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

79. 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

80. 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

81. Communications Between all Parties is Required

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