(2) adated from quizlet ryanef123: OMFS 2 - Management of Odontogenic Infections (Dr. Stephens)

T/F: Odontogenic infections are caused by normal oral bacteria flora

True

Infections are almost always ___________

Polymicrobial

• Single primary organism usually not identifiable via routine testing

• 50–60% involve both aerobic and anaerobic bacteria

Odontogenic infections involve what type of bacteria?

• Aerobic and anaerobic gram positive cocci

• Anaerobic gram negative rods

Aerobic bacteria are most commonly ________

Viridans type streptococci (streptococcus viridans)

What are facultative organisms?

Survive with or without oxygen

Aerobic bacteria initiate progression of ______ to _______ infections

Superficial to deeper

Anaerobic bacteria are most commonly ________

Bacteroides spp

followed by prevotella spp or peptostreptococcus spp

What is the progression of invasion?

• Initial invasion

• Anaerobic shift and tissue breakdown

• Expanding abscess increases hydrostatic pressure

Initial invasion: Bacterial penetrate deeper soft tissues and _________

Fascial (potential) spaces

Initial invasion: Spread is facilitated by _____, which breaks down hyaluronic acid

Hyaluronidase

Initial invasion: enables movement through ________ tissue

Subcutaneous

Anaerobic shift and tissue breakdown: bacterial metabolism _____ pH, creating acidic environment

Lowers

This is why we use carbocaine for infected areas - does not contain epinephrine or other vasoconstrictors, and its chemical properties (lower pH) match infected tissue

Anaerobic shift and tissue breakdown: Favors ______, leading to liquefaction necrosis

Anaerobes

Anaerobic shift and tissue breakdown: Breakdown of _____ and formation of ______

WBCs, microabscesses

Anaerobic shift and tissue breakdown: Microabscesses may _______ into a clinical abscess

Coalesce

Expanding abscess increases hydrostatic pressure: _______ blood vessels, causing ischemia

Compresses

(Makes it harder for abx to reach abscess)

Expanding abscess increases hydrostatic pressure: Leads to expansion of ______ within abscess cavity

Necrotic tissue

What are the main sources of odontogenic infection?

• Endodontic (necrotic pulp)

• Periodontal (deep pockets, pericoronitis)

what is the subperiosteal plane?

anatomical space between the gum tissue and the jawbone where dental infections can accumulate to form a subperiosteal abscess, a localized collection of pus that requires surgical drainage and antibiotics to prevent the spread of infection to surrounding tissues

Infection erodes through what cortical bone in subperiosteal plane?

Facial or lingual

Infection erodes through facial or lingual cortical bone into which plane?

Subperiosteal

What does infection spread depend on?

• Tooth location

• Bone thickness

• Muscle attachments

(Infection takes the path of least resistance)

Infection from maxillary molars erodes through what?

Facial cortex (thinner facial bone)

Infection from mandibular molars erodes through what?

Buccal or lingual cortex (thinner, apices lingual)

What are potential spaces most often created by?

Infection or surgery

What does spread of infection depend on?

Relation to muscle attachments

What does an infection that spreads buccally depend on?

Buccinator muscle attachment

What does an infection that spreads lingually depend on?

Mylohyoid muscle attachment

If infection of a maxillary molar is below the buccinator attachment, where will it go? (path of least resistance)

Vestibular space

If infection of a maxillary molar is above the buccinator attachment, where will it go? (path of least resistance)

Buccal space

If infection of a mandibular molar is below the buccinator attachment, where will it go? (path of least resistance)

Buccal space

If infection of a mandibular molar is above the buccinator attachment, where will it go? (path of least resistance)

Vestibular space

(lingual) If infection of a mandibular molar is below the mylohyoid attachment, where will it go? (path of least resistance)

Submandibular space

(lingual) If infection of a mandibular molar is above the mylohyoid attachment, where will it go? (path of least resistance)

Sublingual space

Where does lingual infection of a maxillary molar go?

Palatal space

Where do endodontic infections originate?

The pulp

Where do bacteria and byproducts travel through to lead to bone erosion and abscess formation? (for endo origin)

The apex

Where do periodontal infections originate?

The periodontium

Typically involve perio tissues leading to purulence adjacent to teeth and PDL

Which infection origin (endo or perio) is more likely to cause bone erosion?

Endo

T/F: Periodontal origin infections spread directly into potential spaces

True (but less common)

What are the 4 stages of infection?

• Inoculation (edema)

• Cellulitis

• Abscess

• Resolution

What stage of infection?

• Day 0-3

• Soft red swelling

• Mildly tender

Inoculation (edema)

What stage of infection?

• Day 3-5

• Firm (indurated)

• Diffuse

• Painful swelling

must be treated

Cellulitis

What stage of infection?

• Anaerobes dominate, purulence forms → localized swelling (fluctuance)

Abscess

What stage of infection?

• Drainage occurs

• Healing begins

Resolution

What is the most common clinical presentation of odontogenic infection?

Vestibular space abscess of endodontic origin

T/F: An odontogenic infection will not rupture and drain spontaneously

False (It MAY drain spontaneously)

Odontogenic infections can form ______ to oral cavity or ______ to skin

Fistula, sinus tract

Why do we always put a drain into odontogenic infections?

They may reclose and reform abscess if not resolved (bc oral cavity heals really fast so incision closes quickly)

What are the 3 core infection management factors?

• Control the source of infection

• Establish drainage

• Mobilize the host defense system

What is an example of eliminating the source of infection?

Removing an infected tooth, endo tx, perio tx

What is key once an abscess forms?

Surgical intervention

What must you do to any purulent collection?

Drain it

Mobilize host defense system, but remember antibiotics are _______, not primary tx

Adjunctive

What are the principles of infection management?

• Determine severity

• Evaluate host defense

• Determine treatment setting

• Surgical treatment

• Medical treatment

• Antibiotic choice

• Antibiotic administration

• Reevaluation

What is in the physical exam?

• Swelling

• Pain

• Trismus

• Fever

• Airway compromise

Red flag symptom: How do we directly check for dyspnea?

Listen for if they have difficulty breathing

Red flag symptom: How do we directly check for dysphagia/odontophagia?

Ask if they have pain with swallowing

Red flag symptom: How do we directly check for dysphonia?

Listen for voice change

Interpreting history: chronic pain may mean ______

Necrotic pulp or periodontal disease

Interpreting history: pain migration may mean ______

Deeper space involvement

Interpreting history: >30 days may mean ______

It's a chronic, contained infection

Interpreting history: rapid onset may mean _______

Aggressive infection or immune compromise

Interpreting history: persistent infection post treatment may mean _______

Aggressive case

What is a concerning heart rate?

>100 bpm (tachycardia)

What is a concerning respiratory rate?

>20 breaths/min (tachypnea)

What is a concerning body temperature?

>101 degrees F (systemic involvement!!)

What is a concerning peripheral oxygen saturation level?

SpO₂ <95% (possible airway compromise!!)

How to check for general appearance and airway? (4 things)

1. Observe pt on entry

2. Fatigue, drooling, voice change

3. Listen for stridor

4. Assess swelling, asymmetry, and erythema

Fatigue, drooling, and voice change may mean _______

Severe infection

if you hear stridor it may mean _______

Airway obstruction risk

harsh, high-pitched, monophonic sound that occurs during breathing (usually in) due to narrowed or partially blocked upper airways. It is a symptom of an underlying airway disorder rather than a diagnosis itself (wheeze in lower airway, expiration)

Palpation and consistency of swelling: doughy (thickened and soft) may indicate ______

Early infection (edema), mild tenderness

Palpation and consistency of swelling: indurated (thickened, hard, inflexible) may indicate ______

Cellulitis, diffuse and tender

Palpation and consistency of swelling: fluctuant (moving in waves, thick balloon) may indicate ______

Abscess, localized and less tender

Is it possible for multiple consistencies in swelling to exist?

Yes

Always identify if swelling is ______ or ________

Vestibular or gingival

Is vestibular or gingival swelling worse?

Vestibular (bc it could've moved anywhere)

Swelling in the temple area means which space is involved?

• Superficial temporal

• Deep temporal

Swelling in the orbit means which space is involved?

Periorbital space

Swelling in the nasolabial area (loss of nasolabial fold) means which space is involved?

Canine space

Swelling in the cheek area means which space is involved?

Buccal space

Swelling in the angle of the mandible means which space is involved?

• Masseteric space

• Lateral pharyngeal space

Swelling of the inferior border of mandible and lateral neck means which space is involved?

Submandibular space

Swelling of the inferior border of mandible and midline neck means which space is involved?

Submental space

What is normal maximum incisal opening (MIO)?

>40mm

What might trismus indicate?

Deep space infection (but can also be from guarding)

T/F: Severity of swelling correlates with infection severity

True

A swelling may be absent with deep infections, what intervention would be required in this case to identify definitively (when you have other signs such as dysphagia, odynophagia, dysphonia, dyspnea)?

CT scan

What else can limited opening affect?

• Intraoral access

• Anesthesia

_____mm opening suggests severe infection

<15mm

What is one way to look for signs of airway compromise?

Deviation of uvula

Common modalities of imaging are PA, pan, cone beam CT. They can show tooth abnormality, but we need a _______ to show infection

CT scan

What imaging system has a broad view and has minimal discomfort?

Panoramic

What imaging system has a detailed tooth/root view and minimal radiation?

PA

What is a 3D imaging system that is useful for unclear sources?

Cone beam CT (***not diagnostic****)

What imaging system identifies deep space infections and requires this with IV contrast?

Medical grade CT

Surgical management and healing is dependent on ________ host defense system

Intact

Compromised host defense requires aggressive treatment and ______

Antibiotics

What medical comorbidities are metabolic?

• Diabetes

• Alcoholic liver disease

What medical comorbidities are immune system disorders?

• Leukemia/lymphoma

• HIV