OS1- 6.1

INFECTION

• proliferation of microbes that triggers the body’s defense mechanism, a process manifesting as inflammation

INFLAMMATION

• localized reaction of the vascular and connective tissue of the body to an irritant resulting in the development of an exudate that is rich in proteins and cells

TYPES OF INFLAMMATION DEPENDING ON THE DEGREE AND SEVERITY

• acute inflammation

• subacute inflammation

• chronic inflammation

ACUTE INFLAMMATION

• is associated with typical signs and symptoms

• characterized by rapid progression

• if it does not regress completely, it may lead to subacute or chronic inflammation

SUBACUTE INFLAMMATION

• transition phase between acute to chronic inflammation

CHRONIC INFLAMMATION

• presents a prolonged time frame with slight clinical symptoms

• characterized mainly by the development of connective tissue

PHASES OF NATURAL PROGRESSION OF INFLAMMATION

• serous phase

• cellular phase

• reparative phase

SEROUS PHASE

• lasts approximately for 36 hours

• characterized by local edema, erythema with elevated temperature, and pain

• a serous exudate is present which usually contains proteins

CELLULAR PHASE

• progression of the serous phase

• wherein exudates contains massive accumulation of polymorphonuclear leukocytes, leading to the formation of pus

→ abscess- if pus forms in a newly formed cavity

→ empyema- if pus forms in a cavity that already exists

DIFFERENCE OF ABSCESS AND EMPYEMA

• ABSCESS- if pus forms in a newly formed cavity

• EMPYEMA- if pus forms in a cavity that already exist

REPARATIVE PHASE

• begins immediately after inoculation

• wherein products of the acute inflammatory reaction are eliminated and followed by the reparation of the destroyed tissue

• is achieved by the formation of a granulation tissue which is then covered by a fibrous connective tissue that ensures the return of the affected area to normal function

INOCULATION

• entry of pathologic microbes into the body even in the absence of a disease

5 CARDINAL SIGNS OF INFLAMMATION

1. rubor

2. tumor

3. calor

4. dolor

5. functio laesa

RUBOR

• redness or erythema

• the first sign of inflammation caused by the vasodilation effect of the inflammation

TUMOR

• swelling or edema

• the 2nd sign of inflammation caused by pus accumulation or leakage of plasma into the interstitial fluid at the affected site resulting in edema

CALOR

• heat or warmth

• 3rd sign of inflammation brought about by accelerated local metabolism

DOLOR

• pain

• the 4th sign of inflammation that results from the pressure on the sensory nerve which is caused by edema or infection

FUNCTIO LAESA

• loss of function

• the 5th sign that is attributed to problems with mastication, moderate to severe trismus, dysphagia, and respiratory impairement

TRISMUS

• refers to the jaw’s limited or restricted range of motion characterized by a progressive reduction in mouth opening

→ mild trismus- maximum interincisal opening is 20-30 mm

→ moderate trismus- maximum interincisal opening is 10-20mm

→ severe trismus- maximum interincisal opening is <10mm

SEVERITY OF TRISMUS

• mild trismus

• moderate trismus

• severe trismus

MILD TRISMUS

• maximum interincisial opening is 20-30cm

MODERATE TRISMUS

• maximum interincisal opening is 10-20 cm

SEVERE TRISMUS

• maximum interincisal opening is <10 cm

ODONTOGENIC INFECTIONS

• refers to an infection that has a characteristic flora that usually begins in the teeth, spreads over the alveolar process, and then to the deeper tissues and spaces of the head, neck, oral cavity, face

• its’ degree of severity may rage from:

a. low grade infection- well localized infection that requires minimal treatment

b. high grade infection- life threatening infection that affects the deep fascial spaces of the head and neck

• caused mainly by aerobic and anaerobic bacteria (25-45% anaerobic bacteria and 5% aerobic bacteria)

DEGREE OF SEVERITY OF ODONTOGENIC INFECTION

• low grade infection

• high grade infection

LOW GRADE ODONTOGENIC INFECTION

• refers to well localized infection that requires minimal treatment

HIGH GRADE ODONTOGENIC INFECTION

• refers to life threatening infection that affects the deep fascial spaces of the head and neck

MICROBIOLOGY OF ODONTOGENIC INFECTION

• it is mainly caused by anaerobic and aerobic bacteria

PREDOMINANT AEROBIC BACTERIA

• it includes the streptococcus milleri group (strep anginosus, strep intermedius, strep constallatus) that can grow in the presence or absence of oxygen

STREPTOCOCCUS MILLERI GROUP

• streptococcus anginosus

• streptococcus intermedius

• streptococcus constallatus

PREDOMINANT ANAEROBIC BACTERIA

• consists of 2 groups of bacteria:

a. gram + cocci such as streptococcus and peptostreptococcus

b. gram - rods such as prevotella, fusobacterium, and porphyromonas

TWO MAJOR ORIGINS OF ODONTOGENIC INFECTION

→ periapical origin

→ periodontal origin

PERIAPICAL ORIGIN

• most common

• a result of pulpal necrosis caused by deep caries formation

PERIODONTAL ORIGIN

• result of deep periodontal pocket formation

STAGES OF CLINICAL PRGRESSION OF ODONTOGENIC INFECTION

→ inoculation stage

→ cellulitis stage

→ abscess stage

→ resolution stage

INOCULATION STAGE

• occurs during the 1st to 3rd day when the invading bacteria are just beginning to colonize the host resulting to edema which is the hallmark of the inoculation stage

• treatment:

  • may be performed by the removal of the odontogenic cause with or without supportive antibiotic therapy

CELLULITIS STAGE

• occurs during the 1st to 5th day when the infecting mixed flora stimulates a severe inflammatory response which makes it the most severe presentation of an infection

• treatment:

  • requires the removal of the dental cause of the problem, including incision and drainage with supportive antibiotic therapy

CELLULITIS

• an erythematous, hot, swollen skin with irregular or indistinct margins that fades into the surrounding skin that affects deeper dermis and subcutaneous tissues

ABSCESS STAGE

• occurs during the 4th to 10th day after the onset of swelling when anaerobic bacteria begin to predominate and serves as a sign of increasing host resistance to infection

• treatment:

  • requires the removal of the dental cause of the problem, including incision and drainage with supportive antibiotic therapy

FLUCTUANCE

• a wavelike motion of fluid collected in a cavity that indicates pus accumulation in the center of the indurated area

RESOLUTION STAGE

• refers the process of healing and repair when the abscess drains spontaneously through the skin, mucosa, or by surgical intervetion

FACTORS THAT DETERMINES THE SPREAD OF AN ODONTOGENIC INFECTION

→ thickness of the bone overlying the tooth apex

→ relationship of point of bone perforation site to the muscle attachment of the maxilla and the mandible

THICKNESS OF THE BONE OVERLYING THE TOOTH APEX

• infection can spread equally in all directions or along the path of least resistance

• it spreads through cancellous bone until it reaches the cortical plate

  • maxillary teeth: most infections erode through the facial (labial and buccal) cortical plate

  • mandibular teeth: most infections erode through the lingual cortical plate

RELATIONSHIP OF POINT OF BONE PERFORATION SITE TO MUSCLE ATTACHMENT OF THE MAXILLA AND TE MANDIBLE

• it determines the fascial involvement

  • if the tooth apex is lower than the muscle attachment- results in an infection of the vestibular space

  • if the tooth apex is higher than the muscle attachment- results in an infection of the adjacent fascial space

PATHWAY OF AN ODONTOGENIC INFECTION (6)

→ invasion of dental pulp by bacteria following tooth decay

→ inflammation, edema, and lack of collateral blood supply

→ venous congestion or avascular necrosis of the pulp

→ reservoir for bacterial growth

→ periodic egress of bacteria to the surrounding alveolar process

→ periapical infection progressing to other areas or spaces

ROUTES OF SPREAD OF AN ODONTOGENIC INFECTION

→ spreading per continuitatem

→ spreading through the lymphatic system

→ spreading through the vascular system

SPREADING PER CONTINUITATEM

• spreads from cell to cells by means of secretion, through the tissues, or by the path of least resistance trough the spaces of the head and neck

SPREADING THROUGH THE LYMPHATIC SYSTEM

• spreads from the skin or mucosa to the regional lymph nodes

SPREADING THROUGH THE VASCULAR SYSTEM

• infectious agents travel though the bloodsteam or via blood circulating through the body

CLINICAL CATEGORIES OF BLOODSTREAM INFECTIONS

→ bactermia

→ sepsis or septicemia

→ severe sepsis

→ septic shock

→ multiple organ failure

BACTEREMIA

• presence of bacteria in the blood and is the means by which local infection spreads to distant organs

  • s/s: fever, rigors, chills, diaphoresis

TYPES OF BACTEREMIA

→ asymptomatic bacteremia

→ symptomatic bacteremia

ASYMPTOMATIC BACTEREMIA

• occurs when the defense system of the body effectively eliminates small quantities of bacteria resulting in the absence of clinical signs and symptoms

SYMPTOMATIC BACTEREMIA

• occurs in normal healthy individual where infection may occur at distant areas after manipulative procedures such as vigorous chewing, tooth extraction, oral prophylaxis, drug infusion, catheter insertions, or surgery

SEPSIS/ SEPTICEMIA

• rapidly progressing life threatening infection that arise from systemic infection throughout the body leading to a severe inflammatory response syndrome

• characterized by the presence of SIRS criteria with evidence of infection

  • s/s: fever or hypothermia, leukocytosis, tachypnea, tachycardia, hypotension, confusion, reduced vascular tone, organ dysfunction

SEVERE INFLAMMATORY RESPONSE SYNDROME (SIRS)

• refers to a widespread inflammatory response to a variety of clinical insult

• its criteria is characterized by the presence of more 2 of the following: elevated temperature, rapid heart rate, increased respiratory rate, and leukocytosis

SEVERE SEPSIS

• a serious condition that can result to multiple organ dysfunction caused by abrupt drop in arterial blood pressure with a resultant decrease in effective blood flow to vital organs

• characterized by the presence of sepsis criteria with evidence of organ dysfunction

  • s/s: hypotension, hypoxemia, thrombocytopenia, metabolic acidosis, oliguria, confusion, and disseminated intravascular cascade

DISSEMINATED INTRAVASCULAR CASCADE

• pathologic, widespread activation of blood clotting factors

SEPTIC SHOCK

• a potentially fatal condition that results in multiple organ dysfunction caused by abrupt drop in arterial blood pressure with a resultant decrease in effective blood flow to vital organs despite adequate supply of fluids

• characterized by severe sepsis criteria with evidence of persistent organ dysfunction and hypotension

• s/s: myocardial depression, metabolic acidosis, imbalance in oxygen delivery and consumption

HEMODYNAMIC ALTERATIONS

→ hyperdynamic state (warm shock)- shows high cardiac output

→ hypodynamic state (cold state)- shows low cardiac output

MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS)

• progressive impairment of more than 2 organ systems from an uncontrolled inflammatory response to severe illness or injury

• characterized by altered function of multiple organ systems where intervention is needed in order to sustain life

  • s/s: combination of cardiovascular, pulmonary, renal, hepatic, neurological, integumentary, and hematologic system dysfunction

PRINCIPLES OF THERAPY OF ODONTOGENIC INFECTIONS (8)

→ determine infection severity

→ evaluate the state of the patient’s host defense mechanism

→ determine whether the patient must be treated by a general dentist or an OMS surgeon

→ treat the infection surgically

→ support the patient medically

→ choose and prescribe the appropriate antibiotic

→ administer the antibiotics properly

→ evaluate the patient frequently

DETERMINING THE INFECTION SEVERITY

1. complete history of the infectious condition (involves a written questionnaire with verbal follow ups)

2. physical examination

COMPLETE HISTORY OF INFECTIOUS CONDITION (7)

• involves a written questionnaire with verbal follow ups and gathering of the following information:

  • chief complaint

  • duration and onset of symptoms

  • description of symptoms

  • course of infection (constant, worsening, intermittent, or subsiding symptoms)

  • rapid progression of infection (few hours, days, weeks, or months)

  • patient’s general well being

  • treatment

DURATION OF SYMPTOMS

• based on the 5 cardinal signs

  • pain- the most common complaint

  • redness- any color change to the affected area

  • heat- pertains to any area that feels warm to touch

  • swelling- minor case that is not visible to the operator but may be very obvious to the patient

  • loss of function- trismus, dyspagia, dyspnea, difficulty in chewing

PHYSICAL EXAMINATION

• involves the ff steps:

  • obtain patient’s vital signs

  • patient’s general appearance is evaluated

  • patient’s head and neck region are examined

  • radiographic examination

> 38.3ºC or 101ºF

temperature of a patient with severe infection

PR > 100 beats per minute

• indicates severe infection

RR OF ≥ 18 BREATHS PER MINUTE

• indicates mild to moderate infection

BLOOD PRESSURE

• varies the least with presence of infection

  • patient with pain and anxiety results to systolic BP

  • patient that had severe septic shock are hypotensive

INTEPRETATION OF THE RESULTS OF THE OBTAINED VITAL SIGNS

• normal vital signs with mild temperature elevation- indicates mild infection that can be readily treated

• abnormal vital signs with elevated temperature, PR, and RR- indicates serious infection that requires intensive therapy and evaluation by an oral and maxillofacial surgeon

NORMAL VITAL SIGNS WITH MILD TEMPERATURE ELEVATION

• indicates mild infection that can be readily treated

ABNORMAL VITAL SIGNS WITH ELEVATED TEMPERATURE

• indicates severe infection that requires intensive therapy and evaluation by an OMS surgeon

PALPATION

• it is done to check for presence of tenderness, amount of local heat/warmth, and in determining the consistency of the swelling

CONSISTENCY OF THE SWELLING

• may vary depending on the stage of progression such as:

  • soft and doughy (edema)

  • hard (indurated, similar to a tightened muscle)

  • fluctuant

EVALUATE THE STATE OF THE PATIENT’S HOST DEFENSE MECHANISMS

• involves the adequate assessment of the following conditions:

  • uncontrollable metabolic diseases

  • immune system suppressing diseases

  • immunosuppressive therapy

UNCONTROLLABLE METABOLIC DISEASE

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

  • ex: poorly controlled type 1 and 2 diabetes, end stage renal disease with uremia, and severe alcoholism with malnutrition

IMMUNE SYSTEM SUPPRESSING DISEASE

• results in decreased function of WBC, and decreased antibody synthesis and production

  • ex: AIDS, HIV, congenital and acquired immunologic disorders, lymphoma, leukemia, and other cancers

IMMUNOSUPPRESSIVE THERAPY

• results in decreased function of WBC, T and B lymphocytes, and immunoglobulin production

  • ex: cancer chemotherapy, corticosteroid therapy, organ trasplantation

EFFECTS OF MEDICAL CONDITIONS TO HOST DEFENSE MECHANISM (3)

→ allows more bacteria to enter the tissue

→ permits the bacteria to be more active

→ prevents the humoral and cellular defenses to exert its full effect

MILD/ UNCOMPLICATED ODONTOGENIC INFECTIONS

• may be treated by a general dentist with rapid resolution to minor surgical procedures and antibiotic therapy

SEVERE ODONTOGENIC INFECTIONS

• may be potentially life threatening and should be referred to an OMS surgeon who can manage the patient in a hospital setting or as an outpatient

CRITERIA FOR REFERRAL TO AN OMS SURGEON (11)

→ dyspnea

→ dysphagia

→ dehydration

→ moderate to severe trismus

→ swelling or spread of infection to surrounding alveolar process

→ elevated body temperature that is > 38.3ºC or 101ºF

→ severe malaise or toxic appearance

→ compromised host defense

→ signs of systemic involvement

→ needs general anesthesia

→ failure of prior therapy

CRITERIA FOR REFERRAL TO HOSPITAL EMERGENCY ROOM (3)

→ history of rapidly progressing infection

→ dyspnea

→ dysphagia

HISTORY OF RAPIDLY PROGRESSING INFECTION

• wherein the infection begain 2-3 days before the initial examination

• presence of rapid growth with associated signs and symptoms such as pain and swelling that may affect the deep fascial spaces of the neck

DYSPNEA

• common on patients with severe swelling of the soft tissues of the upper airway

  • s/s: patient is distressed, muffled or difficulty in speech, patient refuse to lie down

DYSPHAGIA

• difficulty in swallowing

• occurs in patients with acutely progressing deep fascial space infection

• has presence of drooling

DROOLING

• is due to the inability to swallow one’s saliva, indicating narrowing of the oropharynx

GOALS IN THE SURGICAL REMOVAL OF AN ODONTOGENIC INFECTION

→ removal of the cause of the odontogenic infection

→ provide drainage of accumulated pus or necrotic debris

CULTURE AND SENSITIVITY TEST

• done before the incision and drainage

• usually performed with a large gauge needle (18 gauge) and a small syringe (3ml) which is inserted into the abscess or cellulitis where 1-2mL of pus or tissue fluid is aspirated

INDICATIONS FOR CULTURE AND SENSITIVITY TEST (7)

• infection spreads beyond the alveolar process

• rapid onset and progression of infection

• post operative infection

• previous or multiple antibiotic therapy

• recurrent infection

• non responsive infection that does not respond as expected

• compromised host defense

PATIENT’S SYSTEMIC RESISTANCE TO INFECTION

• the determinant of a good ooutcome

AREAS TO BE CONSIDERED IN THE HOST SYSTEMIC RESISTANT (3)

→ immune system compromise

→ control of systemic disease

→ physiologic reserves

CHILDREN

• susceptible to high fever and dehydration

ELDERLY PATIENTS

• susceptible to dehydration

FACTORS TO CONSIDER IN DETERMINING ANTIBIOTIC ADMINISTRATION (3)

→ seriousness of the infection

→ amenability to surgical management

→ state of the patient’s host defense

INDICATIONS FOR THERAPEUTIC USE OF ANTIBIOTICS (8)

→ swelling extends beyond the alveolar process with invilvement of the deep fascial spaces

→ involvement of deep fascial spaces

→ trismus

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

→ severe pericoronitis with elevated temperature, trismus, and swelling of the lateral aspect of the face

→ lymphadenopathy

→ osteomyelitis

→ immunocompromised patients

SITUATIONS WHERE ANTIBIOTIC USE IS NOT NECESSARY (9)

→ patient demand or insist the use of antibiotic

→ severe pain

→ routine toothache

→ multiple tooth extraction of an immunocompetent patient

→ minor, chronic, well localized abscess

→ presence of well localized dentoalveolar abscess with little or no facial swelling

→ mild acute pericoronitis with mild gingival edema and mild pain

→ localized alveolar osteitis or dry socket

→ drained alveolar abscess

EFFECTIVE ORAL ANTIBIOTICS USEFUL FOR ODONTOGENIC INFECTIONS

• taken 3x a day

  • penicillin (most common drug of choice; high clinical cure rate than newer antibiotics)

  • amoxicillin (high clinical cure rate than newer antibiotics)

  • clindamycin (alternative drug for penicillin allergic pt)

• taken 2x a day

  • axithromycin (alternative drug for penicillin allergic pt)

  • metronidazole (effective only to anaerobic bacteria)

• taken 1x a day

  • mociflocxacin (for tx of severe infection only)

NARROW SPECTRUM ANTIBIOTICS FOR SIMPLE ODONTOGENIC INFECTION

• destroys streptococcus and anaerobes without upsetting normal host microflora of the GI tract which prevents antibiotic resistance of the bacteria

• includes penicillin, amoxicillin, clindamycin, and metronidazole