Overview

Odontogenic Infections
Noah A. Sandler, DMD, MD
Assistant Professor Division of Oral and Maxillofacial Surgery University of Minnesota

Microbiology Progression of infection Assessment Fascial spaces Treatment/antibiotics

Microbiology
Polymicrobial Mixed aerobic/ anaerobic Aerobic-cellulitis Anaerobic-abscess

Causative Organisms
Number of Patients Percentage

Aerobic only Anaerobic only Mixed

28 133 243

7 33 60

Microorganisms Causing Odontogenic Infections

Aerobic
Organism Percentage 25% 85 90 2 6 2 2 3 6 4 Gram-positive cocci Streptococcus spp. Streptococcus (Group D) spp. Staphylococcus spp. Eikenella spp. Gram-negative cocci (Neisseria spp.) Gram-positive rods (Corynebacterium spp.) Gram-negative rods (Haemophilus spp.) Miscellaneous and undifferentiated

Anaerobic

Microorganisms Causing Odontogenic Infections

75% 30 33 65 4 14

Gram-positive cocci Streptococcus spp. Peptostreptoccus spp. Gram-negative cocci (Viellonella spp .) Gram-positive rods Eubacterium spp. Lactobacillus spp. Actinomyces spp. Clostridia spp. Gram-negative rods Bacteroides spp. Fusobacterium spp. Miscellaneous

50 75 25 6

Excerpted from Contemporary Oral and Maxillofacial Surgery, Third Edition, 1998

Excerpted from Contemporary Oral and Maxillofacial Surgery, Third Edition, 1998

Progression
Periapical/periodontal Spread through least resistance Role of muscle attachments

Differences Between Cellulitis and Abscess

Characteristic Duration Pain Size Localization Palpation Presence of pus
Degree of seriousness

Bacteria

Cellulitis Acute Severe/generalized Large Diffuse borders Doughy to indurated No Greater Aerobic

Abscess Chronic Localized Small

Well circumscribed

Fluctuant Yes Less Anaerobic

Excerpted from Contemporary Oral and Maxillofacial Surgery, Third Edition, 1998

Assessment
History Onset, duration, rapidity Previous treatment Medically compromised

Assessment
Physical exam Vital signs
malaise temp tachycardia

Fascial Spaces
Potential spaces Bounded by muscle attachments; bone Spread to secondary neck spaces

Abcess vs. cellulitis Radiographs

Buccal space

Buccal space

Maxillary Spaces: Canine Spaces

Usual source: canine Boundaries: lev anguli oris; lev labi superioris Loss of nasolabial fold

Vestibule

Vestibule

Maxillary Spaces: Buccal Space

Usual source: maxillary molar, premolar Boundaries: skin, buccinator muscle

Maxillary Spaces: Infratemporal Space

Buccal space

Usual source: maxillary third molar Boundaries: skull base, lateral pterygoid plate, continuous with temporal space

Mandibular Spaces: Buccal Space

Usual source: mandibular molar, premolar Boundaries: skin, buccinator muscle

Mandibular Spaces: Submental Space

Usual source: mandibular incisors Boundaries: skin, mylohold muscle, ant belly of digastrics

Mandibular Spaces: Submandibular Space

Usual source: mandibular molar, premolar Boundaries: medial mandible, below mylohyoid-muscle, skin/ superficial fascia

Mandibular Spaces: Submandibular Space

Lose inferior border on palpation Communicates with secondary spaces in neck

Mandibular Spaces: Sublingual Space

Usual source: mandibular molar, premolar Boundaries: medial mandible, above mylohyoid-muscle, mucosa

Mandibular Spaces: Sublingual Space

Floor of mouth swelling Nothing visible/ palpable extraoral Communicates posterior with submandibular space

Mandibular Spaces: Ludwigs Angina

Bilateral submandibular, sublingual, submental spaces Treat aggressively, potential airway compromise

Mandibular Spaces: Pterygomandibular Spaces

Usual source: mandibular molar, premolar Boundaries: medial mandible, medial pterygoid Trismus

Mandibular Spaces: Masseteric Space

Usual source: mandibular third molar Boundaries: masseter, lateral border of mandible Swelling at angle, possible trismus

Mandibular Spaces: Temporal Space

Usual source: other spaces (infratemporal, masseterm pterygomand) Boundaries
superficial: between fascia and muscle deep: below muscle

Mandibular Spaces: Masticator Space

Masseteric, Pterygomandibular, Temporal spaces Communicate Non-specific

Cervical Fascial Spaces

Lateral pharyngeal
deviated uvula

Retropharyngeal
airway obstruction; mediastinum

Prevertebral
thorax, mediastinum

Treatment
Medical support Antibiotics Removal of source Incision and drainage Re-evaluation

Medical Support
Airway maintenance Rehydration Analgesia Nutrition

Antibiotics
Usually bactericidal Therapeutic dose Intravenous vs oral Compliance/ complete course

Indication for Use of Antibiotics

Rapidly progressive swelling Diffuse swelling Compromised host defenses Involvement of fascial spaces Severe periocoronitis Osteomyelitis

Situations in Which Use of Antibiotics is not Necessary

Chronic well-localized abscess Minor vestibular abscess Dry socket Mild periocoronitis

Effective Orally Administered Antibiotics Useful for Odontogenic Infections

Penicillin Erythromycin Clindamycin Cefadroxil Metronidazole Tetracycline

Prophylactic Antibiotics
Routine procedures, healthy patient: NO antibiotics Extent/time Immunocompromised Foreign body

Compromised Host Defenses

Uncontrolled metabolic diseases
Uremia Alcoholism Malnutrition Severe diabetes

Indications for Culture and Antibiotics Sensitivity Training

Rapidly spreading infection Postoperative infection Nonresponsive infection Recurrent infection Compromised host defenses Osteomyelitis Suspected actinomycosis

Suppressing diseases
Leukemia Lymphoma Malignant tumors

Suppressing drugs
Cancer chemotherapeutic drugs Immunosuppressives

Incision and Drainage

Intraoral vs. extraoral Wide incision Blunt dissection to periosteum Subperiosteal

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Criteria for Referral to a Specialist

Rapidly progressive infection Difficulty in breathing Difficulty in swallowing Fascial space involvement Elevated temperative (greater than 101 degrees Farenheit) Severe jaw trismus (less than 10 mm) Toxic appearance Compromised host defenses

Thank You

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