PRINCIPLES OF THERAPY OF ODONTOGENIC INFECTIONS

DETERMINE INFECTION SEVERITY

• assessing the severity of the infection is accomplished through the following:

  • Complete history of the infectious condition (involves a written questionnaire with follow-up verbal interview)

  • Physical examination

Complete history of the infectious condition (involves a written questionnaire with follow-up verbal interview)

• after a complete medical history, focusing on the infectious condition includes gathering the following relevant information:

  • Chief complaint

  • Duration and onset of symptoms

  • Description of the symptoms

  • Course of the infection

  • Rapid progression of the infection

  • Patient’s general overall well-being

  • Treatment

Chief complaint

Recorded in the patient’s own words

Duration and onset of symptoms

May indicate the start of the infection

Description of the symptoms

based on the five cardinal signs of inflammation or infection

Pain

• the most common complaint

• Initial occurrence & spread or radiating pain must be noted

Swelling

Minor cases that is not visible to the operator may sometimes be more obvious to the patient

Heat

Pertains to any area that feels warm to the touch

Redness

Any color changes to the affected area

Loss of function

Trismus, dysphasia, dyspnea, and difficulty in chewing should be evaluated

Course of the infection

Constant, intermittent, subsiding, or worsening symptoms

Rapid progression of the infection

Progression occurs over a few hours, days, or weeks

Patient’s general overall well-being

Presence of fatigue, fever, and weakness can suggest malaise which indicates a generalized reaction to a moderate-to-severe infection

Treatment

Includes any previous professional dental treatments and self-treatments or home remedies

Physical examination

• involves the following steps:

  • Obtain the patient’s vital signs

  • Patient’s general appearance is evaluated

  • Patient’s head & neck are examined

  • Radiographic examination

Obtain the patient’s vital signs

body temperature, pulse rate/PR, blood pressure/BP, & respiratory rate/RR

Temperature

Patient with a severe infection has a temp. >38.3 degree Celsius or 101 degree Fahrenheit

PR

> 100 beats per minute may indicate the presence of a severe infection (PR INCREASES AS TEMPERATURE INCREASES)

RR

greater than or equal to 18 breaths per minute is suggestive of mild-to-moderate infections (presence of partial or complete upper airway obstruction must be considered due to the potential of the infection to extend into the deep fascial spaces of the neck)

BP

significant pain & anxiety can result in > systolic BP, but severe septic shock results in hypotension

BP

Is the vital sign that varies the least with an infection

Once all vital signs have been taken, interpretation of the results are as follows:

• normal vital signs with mild temperature elevation

• Abnormal vital signs with elevated temperature, PR, RR

Normal vital signs with mild temperature elevation

Mild infection that can be readily treated

Abnormal vital signs with elevated temperature, PR, RR

Serious infection that requires intensive therapy and evaluation by an oral & maxillofacial surgeon

Patients general appearance is evaluated

Presence of severe malaise is also referred to as a “toxic appearance”

Patient’s head & neck are examined

Based on the 5 cardinal signs of inflammation or infection

Patient’s head & neck are examined

• Similar to those mentioned under complete history of the infectious conditions

• Includes extraoral & intraoral examination

• Swollen areas are examined by palpation

• Consistency of a swelling

includes extraoral & intraoral examination

assess airway & tongue position

Swollen areas are examined by palpation

Done to check the presence of tenderness, amount of local heat/warmth, & to determine the consistency of the swelling

Consistency of a swelling

May vary depending on the stage of clinical progression such as soft & doughy (edema), hard (indurated or similar to that of a tightened muscle), or fluctuant

Radiographic examination

Periapical and/or panoramic radiographs

EVALUATE THE STATE OF THE PATIENT’S HOST DEFENSE MECHANISMS

medical conditions may compromise host defenses & have the following effects: allow more bacteria to enter the tissues, permit bacteria to be more active, or prevent the humoral & cellular defenses from exerting their full effect

EVALUATE THE STATE OF THE PATIENT’S HOST DEFENSE MECHANISMS

• involves the adequate assessment of several diseases / conditions such as:

  • Uncontrollable metabolic diseases

  • Immune system-suppressing diseases

  • Immunosuppressive therapies

Uncontrollable metabolic diseases

result in decreased function of leukocytes, with decreased chemotaxis, phagocytosis, and bacterial destruction

Uncontrollable metabolic diseases

examples: poorly controlled diabetes including type 1 & type 2 (most common immunosuppressive diseases), severe alcoholism with malnutrition, and end-stage renal disease with uremia (excessive amounts of urea in the blood)

Immune system-suppressing diseases

result in decreased function of white blood cells (WBC), with decreased antibody synthesis, and production

Immune system-suppressing diseases

• examples: human immunodeficiency virus (HIV) / acquired immune deficiency syndrome (AIDS), congenital & acquired immunologic diseases, lymphomas, leukemia, and many types of cancer

Immunosuppressive therapies

result in decreased function of white blood cells (WBC), T & B lymphocytes, and immunoglobulin production

Immunosuppressive therapies

examples: cancer chemotherapy, corticosteroid therapy, and organ transplantation

DETERMINE WHETHER THE PATIENT SHOULD BE TREATED BY A GENERAL DENTIST OR AN ORAL & MAXILLOFACIAL SURGEON

• mild / uncomplicated odontogenic infections

• Severe odontogenic infection

Mild/uncomplicated odontogenic infections

May be treated by a general dentist with rapid resolution through minor surgical procedures & antibiotic therapy (if indicated)

Severe odontogenic infections

My be potentially life-threatening and should be referred to an oral & maxillofacial surgeon who can manage the patient in hospital setting or as outpatients

Criteria for referral to an oral & maxillofacial surgeon:

• dyspnea (difficulty in breathing)

• dysphagia (difficulty in swallowing)

• dehydration

• moderate to severe trismus (maximum interincisal opening is < 20 mm)

• swelling and/or spread of infection extending beyond the alveolar process

• elevated body temperature that is > 38.3° C or 101° F

• severe malaise & toxic facial appearance (sickly, dehydrated appearance with glazed eyes & open mouth)

• compromised host defenses

• signs of systemic involvement

• need for general anesthesia

• failed prior treatment

Criteria for referral to a hospital emergency room (due to impending threat to the airway:

• history of rapidly progressing infection

• dyspnea (difficulty in breathing)

• dysphagia (difficulty in swallowing)

history of rapidly progressing infection

• infection began 1-2 days before the initial examination

history of rapidly progressing infection

• presence of rapid growth with associated signs & symptoms including pain and swelling that may affect the deep fascial spaces of the neck which can compress & deviate the airway

Dyspnea (difficulty in breathing)

seen in patients with severe swelling of the soft tissues of the upper airway

Dyspnea (difficulty in breathing)

• signs & symptoms: patient is distressed (due to breathing difficulties), with muffled or distorted speech, and patient may refuse to lie down

dysphagia (difficulty in swallowing)

• occurs in patients with acutely progressive deep fascial space infection

dysphagia (difficulty in swallowing)

• presence of dooling is due to the inability to swallow one's saliva which indicates

dysphagia (difficulty in swallowing)

narrowing of the oropharynx with potential for acute airway obstruction

dysphagia (difficulty in swallowing)

• definitive treatment can follow once airway is secure

TREAT THE INFECTION SURGICALLY

• goals in the surgical management of odontogenic infection

• Culture & sensibility (C&S) testing before incision & drainage (I&D)

goals in the surgical management of odontogenic infection

• remove the cause of the odontogenic infection

  • Via tooth extraction or endodontic treatment

• Provide drainage of accumulated pus and necrotic debris

Culture & sensitivity (C&S) testing before incision and drainage (I&D)

C&S is performed using a large gauge needle (18 gauge) in a small syringe (3 mL), which is inserted into the abscess or cellulitis where 1-2mL of pus or tissue fluid is aspirated

indications for C&S testing:

1. infection spreads beyond the alveolar process

2. rapid onset & progression of infection

3. postoperative infection

4. previous or multiple antibiotic therapy

5. non-responsive infection that does not resolve as expected (i.e., after > 48 hours

6. recurrent infection

7. compromised host defenses

postoperative infection

absence of infection on the original day of the surgery, but infection is present after 3 to 4 days

recurrent infection

initial infection has resolved with an infection-free period of 2 days to 2 weeks followed by a 2nd infection indicates that bacteria is resistant to the previously used antibiotic

compromised host defenses

these patients are prone to harbor unusual pathogens that can be identified by the test

SUPPORT THE PATIENT MEDICALLY

• a patient's systemic resistance to infections is a determinant of a good outcome

• host systemic resistance must be considered in three areas

• children and elderly patients may have reduced or altered physiologic reserves even without medically compromising diseases

• patients with pain and/or dysphagia usually lack adequate fluid & nutritional intake

host systemic resistance must be considered in three areas:

• Immune system compromise (many systemic diseases can reduce the patient's ability to resist infection and undergo surgery)

• Control of systemic disease (systemic conditions such as cardiovascular, respiratory hematologic and metabolic systems require medical support from a tear of specialists)

• Physiologic reserves

Immune system compromise

many systemic diseases can reduce the patient's ability to resist infection and undergo surgery

Control of systemic disease

systemic conditions such as cardiovascular, respiratory hematologic and metabolic systems require medical support from a tear of specialists

children

susceptible to high fever and dehydration

elderly patients

susceptible to dehydration

patients with pain and/or dysphagia usually lack adequate fluid & nutritional intake

prescribe good pain control medications for proper rest and encourage the patients to drink more fluids & take high-calorie nutritional supplements

CHOOSE AND PRESCRIBE THE APPROPRIATE ANTIBIOTIC

antibiotics should be used when there is clear evidence of bacterial invasion into deeper tissues that is greater than the host defenses can overcome

recommended guidelines in choosing a specific antibiotic:

• Determine the need for antibiotic administration

• Use empirical therapy routinely

• Use the antibiotic with the narrowest-spectrum

• Use antibiotics with the lowest incidence of toxicity and side effects

• Uses Bactericidal antibiotic (if possible)

• Be aware of the cost of antibiotics

Determine the need for antibiotic administration

three factors are considered to determine antibiotic administration:

• seriousness of the infection

• amenability to surgical management

• state of the patient's host defenses

seriousness of the infection

presence of swelling, rapid progression, or cellulitis supports the use of antibiotics with surgical intervention

amenability to surgical management

some cases may require the prompt extraction of the offending tooth in the presence of an infection in order to obtain rapid resolution of the infection

state of the patient's host defenses

young & healthy patients may be able to mobilize host defenses: antibiotic therapy may not be needed for minor infections

state of the patient’s host defense

patients with decreased host resistance (such as metabolic diseases, those receiving chemotherapy, etc.): vigorous antibiotic therapy may be required even for minor infections

indications for therapeutic use of antibiotics

• swelling extends beyond the alveolar process with involvement of the deep fascial spaces

• involvement of the deep fascial spaces

• cellulitis where there is an acute-onset infection with diffuse swelling and moderate-to-severe pain

• trismus

• lymphadenopathy (enlargement of the lymph nodes)

• severe percoronitis that occurs with elevated temperature that is > 38.3° C or > 101° F, trismus, and swelling of the lateral aspect of the face

• osteomyelitis (infection of the bone)

• immunocompromised patients

situations when antibiotic is not necessary

• patient demands or insists on the use of the drug

• severe pain

• routine toothache

• minor, chronic, well-localized abscess extraction of the offending tooth may result in complete evacuation of the periapical abscess, provided the patient's has intact host defenses & the absence of any immunocompromising conditions)

• well-localized dentoalveolar abscess with little or no facial swelling (endodontic treatment is performed or tooth extraction with incision & drainage)

• localized alveolar osteitis or dry socket (treatment is palliative since it is a self-limiting condition that is not treated as an infection, even though bacterial pathogens play a role in its etiology)

• multiple tooth extractions in an immunocompetent patient

• mild acute pericoronitis with minor gingival edema & mild pain (when only the operculum or pericoronal flap is inflamed; operculectomy or irrigation with extraction of the partially erupted tooth can obtain resolution of the infection)

• drained alveolar abscess

Use empirical therapy routinely

• effective oral antibiotics useful for odontogenic infections (all are effective against aerobes, facultative streptococci, & anaerobes except metronidazole):

• penicillin

• Amoxicillin

• Clindamycin

• Azithromycin

• Metronidazole

• Moxifloxacin

Penicillin

Common drug of choice; high clinical cure rate than newer antibiotics

Amoxicillin

High clinical cure rate than newer antibiotics

Clindamycin & Azithromycin

Alternative drug for penicillin-allergic patients

Metronidazole

Effective only against anaerobic bacteria

Moxifloxacin

Restricted to prescription by specialists for the treatment of severe infections

Drugs that need to be taken less frequently is generally preferable: patient compliance decreases with increasing number of pills per day

• penicillin, amoxicillin, & Clindamycin (taken thrice a day instead of 4x a day)

• Azithromycin (taken twice a day instead of 4x a day)

• Moxifloxacin (taken once a daily)

Use the antibiotic with the narrowest-spectrum

narrow-spectrum antibiotics are considered just as effective as broad-spectrum antibiotics

penicillin, clindamycin, amoxicillin, and metronidazole

These are narrow-spectrum antibiotics for simple odontogenic infections (destroys streptococci & anaerobes, without upsetting normal host microflora of the gastrointestinal tract which prevents antibiotic resistance of the bacteria)

simple odontogenic infection

involves only the alveolar process or the oral vestibule, is in its first course of treatment, & in an immunocompetent patient

amoxicillin with clavulanic acid (for sinus infections), azithromycin, tetracycline, moxifloxacin

these are broad-spectrum antibiotics for complex odontogenic infections

complex odontogenic infection

spreads beyond the alveolar process & oral vestibule, with prior treatment failures, & in an immunocompromised patient