OMFS 2 - Management of Odontogenic Infections (Dr. Stephens)

True

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

Polymicrobial

(Single primary organism usually not identifiable via routine testing; 50–60% involve both aerobic and anaerobic bacteria)

Infections are almost always ___________

Aerobic and anaerobic

Most odontogenic infections involve both ______ and _______ bacteria

- Aerobic and anaerobic gram positive cocci

- Anaerobic gram negative rods

Odontogenic infections involve what type of bacteria?

Viridans type streptococci (streptococcus viridans)

Aerobic bacteria are most commonly ________

Survive with or without oxygen

What are facultative organisms?

Superficial to deeper

Aerobic bacteria initiate progression of ______ to _______ infections

Bacteroides spp

(followed by prevotella spp or peptostreptococcus spp)

Anaerobic bacteria are most commonly ________

- Initial invasion

- Anaerobic shift and tissue breakdown

- Expanding abscess increases hydrostatic pressure

What is the progression of invasion?

Fascial (potential) spaces

Initial invasion: Bacterial penetrate deeper soft tissues and _________

Hyaluronidase

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

Subcutaneous

Initial invasion: enables movement through ________ tissue

Lowers

(This is why we use carbocaine for infected areas)

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

Anaerobes

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

WBCs, microabscesses

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

Coalesce

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

Compresses

(Makes it harder for abx to reach abscess)

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

Necrotic tissue

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

- Endodontic (necrotic pulp)

- Periodontal (deep pockets, pericoronitis)

What are the main sources of odontogenic infection?

Facial or lingual

Infection erodes through what cortical bone in subperiosteal plane?

Subperiosteal

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

- Tooth location

- Bone thickness

- Muscle attachments

(Infection takes the path of least resistance)

What does infection spread depend on?

Facial cortex (thinner facial bone)

Infection from maxillary molars erodes through what?

Buccal or lingual cortex (thinner, apices lingual)

Infection from mandibular molars erodes through what?

Potential space

Define the following:

An area between two layers of tissue that are normally pressed together but may separate and contain fluid, air, pus, etc.

Infection or surgery

What are potential spaces most often created by?

Relation to muscle attachments

What does spread of infection depend on?

Buccinator muscle attachment

What does an infection that spreads buccally depend on?

Mylohyoid muscle attachment

What does an infection that spreads lingually depend on?

Vestibular space

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

Buccal 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)

Vestibular space

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

Submandibular space

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

Sublingual space

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

Palatal space

Where does lingual infection of a maxillary molar go?

The pulp

Where do endodontic infections originate?

The apex

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

The periodontium

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

Where do periodontal infections originate?

Endo

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

True (but less common)

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

- Inoculation (edema)

- Cellulitis

- Abscess

- Resolution

What are the 4 stages of infection?

Inoculation (edema)

What stage of infection?

- Day 0-3

- Soft red swelling

- Mildly tender

Cellulitis

What stage of infection?

- Day 3-5

- Firm (indurated)

- Diffuse

- Painful swelling

must be treated

Abscess

What stage of infection?

- Anaerobes dominate, purulence forms --> localized swelling (fluctuance)

Resolution

What stage of infection?

- Drainage occurs

- Healing begins

Vestibular space abscess of endodontic origin

What is the most common clinical presentation of odontogenic infection?

False (It MAY drain spontaneously)

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

Fistula, sinus tract

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

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

Why do we always put a drain into odontogenic infections?

- Control the source of infection

- Establish drainage

- Mobilize the host defense system

What are the 3 core infection management factors?

Removing an infected tooth, endo tx, perio tx

What is an example of eliminating the source of infection?

Surgical intervention

What is key once an abscess forms?

Drain it

What must you do to any purulent collection?

Adjunctive

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

- Determine severity

- Evaluate host defense

- Determine treatment setting

- Surgical treatment

- Medical treatment

- Antibiotic choice

- Antibiotic administration

- Reevaluation

What are the principles of infection management?

early assessment

What can prevent deeper spread of infections?

Ascertain onset, progression, and systemic involvement

What is the goal with obtaining a complete history, physical exam, and testing?

- Swelling

- Pain

- Trismus

- Fever

- Airway compromise

What is in the physical exam?

Red flag symptoms

Direct questioning is required to evaluate for what type of symptoms?

Take pts temp

Red flag symptom: How do we directly check for fever and malaise?

Listen for if they have difficulty breathing

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

Ask if they have pain with swallowing

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

Listen for voice change

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

Check for limited mouth opening

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

Emergency referral

Identification of red flag symptoms may require __________

Necrotic pulp or periodontal disease

Interpreting history: chronic pain may mean ______

Deeper space involvement

Interpreting history: pain migration may mean ______

It's a chronic, contained infection

Interpreting history: >30 days may mean ______

Aggressive infection or immune compromise

Interpreting history: rapid onset may mean _______

Aggressive case

Interpreting history: persistent infection post treatment may mean _______

>100 bpm (tachycardia)

What is a concerning heart rate?

>20 breaths/min (tachypnea)

What is a concerning respiratory rate?

>101 degrees F (systemic involvement!!)

What is a concerning body temperature?

SpO₂ <95% (possible airway compromise!!)

What is a concerning peripheral oxygen saturation level?

1. Observe pt on entry

2. Fatigue, drooling, voice change

3. Listen for stridor

4. Assess swelling, asymmetry, and erythema

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

Severe infection

Fatigue, drooling, and voice change may mean _______

Airway obstruction risk

if you hear stridor it may mean _______

Early infection (edema), mild tenderness

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

Cellulitis, diffuse and tender

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

Abscess, localized and less tender

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

Yes

Is it possible for multiple consistencies in swelling to exist?

Vestibular or gingival

Always identify if swelling is ______ or ________

Vestibular (bc it could've moved anywhere)

Is vestibular or gingival swelling worse?

- Superficial temporal

- Deep temporal

Swelling in the temple area means which space is involved?

Periorbital space

Swelling in the orbit means which space is involved?

Canine space

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

Buccal space

Swelling in the cheek area means which space is involved?

- Masseteric space

- Lateral pharyngeal space

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

Submandibular space

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

Submental space

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

>40mm

What is normal maximum incisal opening (MIO)?

Deep space infection (but can also be from guarding)

What might trismus indicate?

True

T/F: Severity of swelling correlates with infection severity

CT scan

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)?

- Intraoral access

- Anesthesia

What else can limited opening affect?

<15mm

_____mm opening suggests severe infection

Floor of the mouth

Intra-orally, examine the pharyngeal walls, uvula, and ______

Deviation of uvula

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

CT scan

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