Management of Oro-Facial Infections PDF

MANAGEMENT OF ORO-FACIAL INFECTIONS Infection Involves the proliferation of microbes resulting in triggering of the defense mechanism, a process manifesting as inflammation. Incidence 90–95% of infections that manifest in the orofacial region are odontogenic The majority of infec...

MANAGEMENT OF ORO-FACIAL INFECTIONS Infection Involves the proliferation of microbes resulting in triggering of the defense mechanism, a process manifesting as inflammation. Incidence 90–95% of infections that manifest in the orofacial region are odontogenic The majority of infections in orofacial and neck regions belong to this group. approximately 70% present as periapical inflammation, principally the acute dentoalveolar abscess, with the periodontal abscess following ETIOLOGY: Odontogenic Non-vital teeth Pericoronitis Tooth extraction Periapical granulomas and infected cysts. Others Postoperative trauma, defects due to fracture, salivary gland disease, and infection as a result of local anesthesia (Rare causes) Signs of infection -Redness : due to vasodilatation. - Hotness : due to inflow of warm blood. - Pain : due to pressure on the nerve ending by edema. - Loss of function :due to reflex inhibition of muscle movement associated with pain 1 PATHWAYS OF ODONTOGENIC INFECTION when inadequately managed, an infection will progress and spread through the path of least resistance The periapical infection progress can vary according to the: Host resistance. The number and virulence of the organism. Anatomy of the involved area Host Defense Mechanisms Innate immunity Intact Anatomic Barrier Neutrophils. Macrophages. Dendritic cells. Natural killer cells. Lymphoid cells. Complement system Acquired immunity HUMORAL DEFENSES CELLULAR DEFENSES Immunoglobulins Phagocytes Complement Granulocytes Monoytes Lymphocytes 2 MICROBIOLOGY OF ODONTOGENIC INFECTIONS The most commonly isolated aerobic bacteria from odontogenic infections are the viridans-type Streptococci. The most isolated anaerobic bacteria from odontogenic infections include Bacteroides spp Approximately 50% to 60% of all odontogenic infections involve a combination of both aerobic and anaerobic bacteria Anatomy of involved area (local factors) The thickness of bone The type of muscle attachment The faciolingual location of the source of the infection 3 Phases and fates of oral infection: Resolution Acuteness Chronicity Phases and fates of oral infection: 1. Acuteness Once the periodontal or periapical tissues get inoculated with bacteria, the infection may spread equally in all directions within bone. At this stage, if an intervention such as an endodontic or periodontal procedure or dental extraction is done, the further spread may be arrested or even abolished with judicious antibiotics When left untreated, the infection continues to spread follows the path of least resistance depending principally on the thickness of bone,the faciolingual location of the source of the infection and the type of muscle attachment When infections reach the soft tissues, it generally manifests in three stages The inoculation (edema) stage refers to the stage in which the invading bacteria begin to colonize and typically occurs in the first 3 days of onset of symptoms. This stage is characterized by diffuse, soft, doughy red swelling that is mildly tender 4 The cellulitis stage occurs between days 3 and 5 and represents the intense inflammatory response elicited by streptococci infection. This stage is characterized by poorly defined diffuse firm red swelling that is exquisitely painful to palpation. Indurated (consistency of a taught muscle/wooden like/ brawny hard). Streptococci produce enzymes such as streptokinase (fibrinolysin), hyaluronidase, and streptodornase. These enzymes break down fibrin and connective tissue ground substance and lyse cellular debris, thus facilitate rapid spread of bacteria along the tissue planes indurated (consistency of a taught muscle/wooden like/ brawny hard) The abscess stage as the infection evolves and anaerobes begin to predominate, liquefaction of tissues occurs with the formation of purulence. As purulence is formed, the swelling and redness become better defined and localized, and the consistency changes from firm to fluctuant. The suppurative infections are characteristic of staphylococci, often with anaerobes, such as bacteroides, and are usually associated with large accumulation of pus, which require immediate drainage. These microorganisms produce coagulase, an enzyme, that may cause fibrin deposition. In addition, the pressure from the expanding abscess, preventing compromising blood flow leading to ischemia, and thereby further increasing the zone of necrosis within the abscess cavity. 5 Abscess: The odontogenic abscesses present in the following forms: a) Acute periapical abscess: An abscess arises and remains in the confines of alveolar bone i.e. the pus is contained in a thick-walled cavity. b) Acute dentoalveolar abscess: Once the infection has crossed the confines of alveolar bone and comes to lie in the neighbouring soft tissues, and it gets localized. c) Acute periodontal abscess. d) Acute pericoronal abscess. 2.The chronicity With long standing infection of non-virulent organisms, the infection becomes chronic with production in localized area of necrosis These infections may occasionally rupture and drain spontaneously, which results in temporary resolution, preventing spread to deeper potential spaces. Spontaneously draining infections may continue to drain and form a fistula to the oral cavity or a sinus tract to skin, or reclose and result in the reforming of an abscess 3.The resolution When an infection is drained, either spontaneously or via surgery, the host defense mechanism destroys the involved bacteria and healing begins to occur; this is the hallmark of the resolution stage. 6 Pathway of Odontogenic infection Acute Dentoalveolar Abscess Definition An acute purulent inflammation of the periapical tissues, presenting at nonvital teeth, when microbes exit the infected root canals into periapical tissue. Stages 1. Early stage: ADAA without soft tissue involvement. 2. Late stage: ADAA with soft tissue involvement Signs & Symptoms Early stage: ADAA without soft tissue involvement (Central Bone Abscess) 1. A feeling of elongation of the tooth. 2. severe throbbing pain 3. Systemic Symptoms (fever, chills, malaise with pain in muscles and joints and lymphadenitis) 7 Signs & Symptoms Late stage: ADAA with soft tissue involvement (Subperiosteal Abscess) 1. As pus break through the cortical plates and escape into the soft tissues immediate relief of the severe throbbing pain occurs. 2. Edema appears intraorally or extraorally 3. Trismus and dysphagia are common. 4. Systemic Symptoms( fever, chills, malaise with pain in muscles and joints and lymphadenitis). Radiographic appearance 1. Early stage of ADAA has a negative radiographic picture as no changes can be noticed apart from a slight widening of the periodontal space in the periapical region. 2. Late stage of ADAA there is widening of the periodontal space with interruption of the lamina dura and a localized ill-defined area of radiolucency may be seen in the periapical region. Treatment Early stage of ADAA 1. Evacuate the imprisoned pus at the periapical area (access opening). 2. Removal of the cause of the infection. 3. Raising the body resistance and helping it to overcome the invading organisms (e.g. antibiotics) Treatment Late stage of ADAA 1. General supportive measures (Bed rest , Adequate fluid intake, Adequate nourishment). 2. Antibiotics to help body to overcome the invading microorganisms. 3. Analgesics to help in alleviating the pain. 4. Heat application to increase the circulation and enhance body defense. 8 5. Incision and drainage when indicated. 6. Elimination of the cause through RCT or extraction Complications of ADAA 1. Fascial space infection. 2. Ludwig’s angina. 3. Osteomyelitis. 4. Septicemia. 5. Fatal complications: meningitis, brain abscess or cavernous sinus thrombosis Periodontal Abscess Definition An acute or chronic purulent inflammation, which develops in an existing periodontal pocket. Clinically Characterized by edema located at the middle of the tooth, dull pain, and redness of the gingiva. Symptoms are not as severe as those observed in the acute dentoalveolar abscess. 9 Treatment Simple and entails incision, through the gingival sulcus with a probe or scalpel, of the periodontal pocket that has become obstructed. Incision may also be performed at the gingiva; more specifically, at the most bulging point of the swelling or where fluctuation is greatest. Periodontal abscess VS Acute dentoalveolar abscess Chronic Dentoalveolar Abscess Definition Acute odontogenic infections, if not treated in time, develop into chronic infections, resulting in spontaneous drainage intraorally or on the skin. Asymptomatic , mild intermittent pain or mild edema and redness of the tissues of the periapical region. The tooth is sensitive to percussion and the pulp of the offending tooth tests nonvital 10 Radiographic picture irregular radiolucent area surrounding the apex of the root is observed in cases of chronic dentoalveolar abscesses, which is due to bone destruction Treatment Eliminating the infection from the responsible tooth with endodontic therapy or in conjunction with surgical treatment (apicoectomy) Fistulectomy ( Extraoral fistula) Periapical Granuloma A small mass of well-defined granulation tissue developing in the periodontal tissues around the apex of the tooth. Radiographically, a small well-defined radiolucent area surrounded by radiopaque line around the root apex. Treatment a. RCT with apicoectomy and apical curettage. b. Extraction of the offending tooth, usually the granuloma comes out attached to the root apex. If not, the socket has to be curetted. 11  Management of odontogenic infections (1)controlling (3) mobilizing (2) establishing the source of the host drainage the infection defense system Management of Infection 1. Determine the cause and the severity of the infection 2. Evaluate the host defense 3. Decide on setting of care 4. Treat surgically (Incision and Drainage) 5. Support medically 6. Choose and prescribe antibiotics appropriately 7. Evaluate patient frequently 1. Determine the cause and the Severity of Infection Odontogenic infections can range from routine and localized to severe and life-threatening. Determination of severity begins with a complete history, followed by physical examination, and any necessary testing (e.g., radiographic imaging studies, laboratory studies) Complete History The patient’s chief complaint. A thorough history of the chief complaint (history of present illness). This provides the clinician with valuable clues that could help determine the origin and etiology of the infection. Changes in the character and location of pain History of extraction or any other trauma to the site Duration of the symptoms Previous treatment history Past medical and social history Physical Examination The clinician should avoid examining the oral cavity first, which makes it easy to miss obvious yet extremely important findings that have a direct impact upon management. It is recommended that the clinician begin from “big to small,” or “outside then inside.” a.General examination (The patients may present with fatigue, fever, and malaise or so-called toxic appearance) Vital signs (temperature, blood pressure, heart rate, and respiratory rate) Head and neck examination Palpation of swellings should be done to know the tenderness Generalized lymph node examination 12 b.Extraoral examination Skin changes—swelling, redness, ulcers, etc. Bony enlargements Lymph node swellings Presence of any sinus openings, fistula, etc C.Intra-oral examination Mandibular mouth opening Oral cavity examination Swelling (consistency, fixity), discharge, dental caries, deviation of tissues (tongue, uvula) Imaging Studies periapical (IOPA) or orthopantomogram (OPG) depending on the symptomatology and clinical examination. CT scan may be required in severe cases to assess the pathway Laboratory Studies The most used laboratory study is the complete blood count, with focus on the white blood cell (WBC) count, and more specifically, the WBC differential count. 2. Evaluate State of Patient’s Host Defense Mechanisms two main categories of medical comorbidities that adversely affect the host defense system are inadequately controlled metabolic diseases and conditions that directly affect the immune system 3.Decide on setting of care When infection detected early, the vast majority of odontogenic infections may be safely managed by the general dentist. Based upon location, severity, surgical access, and status of host defenses. The decision to refer to oral & maxillofacial surgeon for hospital admission a) Anatomic location Graded in severity by level to which the airway and vital structures are threatened Low Buccal, Vestibular, Subperiosteal Moderate Masticator space Severe Lateral pharyngeal Retropharyngeal Danger Space of infection 13 b) Severity of infection c) Surgical Access The need for GA or not d) Status of Host Defenses Many patients with or without underlying conditions are often dehydrated and have elevated blood glucose, which could further compromise the host defense system. 4. Treat Infections Surgically (Definitive treatment) “the most important therapeutic action in the management of orofacial infections is the drainage of pus, and antibiotics are merely an adjunct…” (Pogrel, A; OMFS Clinics of North America.Feb 1993) incision and drainage three factors involved in the management of odontogenic infections—eliminating the source of the infection, establishing surgical drainage, and mobilizing the host defense system—it is easy to understand the central role of surgical management because the first two factors can only be achieved surgically 14 Drainage of pus, is achieved (1) By way of the root canal. (2) Scaling and root planing with debridement (3) With an intraoral incision. (4) With an extraoral incision. (5) Through the extraction socket ▪ Incision and drainage of the abscess should be performed at the appropriate time. This is when the pus has accumulated in the soft tissues and fluctuates during palpation, that is when pressed between the thumb and middle finger, there is a wave-like movement of the fluid inside the abscess. Heat application a. Increase the blood supply to the area. b. Stimulate phagocytosis. c. Has some analgesic effect. d. Help liquefaction and pus formation Indications a. Space infections (primary) that has localized pus collection with a clinically evident point of fluctuance. Example: buccal space infection with point of fluctuance on face. b. Space infections (secondary) that has pus collection with no clinical sign of fluctuance but requires immediate drainage to prevent progression. Example: masseteric space infection—only clinical sign is trismus. c. Non-suppurative space infection such as Ludwig’s angina, where I&D serves as a method of decompression of the tissue planes, but could be lifesaving. The goal of surgical drainage Incision and drainage facilitates healing by two main mechanisms. The first and most important mechanism is decreasing the bacterial load. Lowering the bacterial load with elimination of the source and drainage of the infection allows the host defense system (third component of management) to remove any residual infection. The second mechanism of surgical drainage is decreasing the pressure of the infected tissues. When the hydrostatic pressure of the infected tissues is decompressed with surgical drainage, the local blood supply is improved, and this allows the host defense system, and adjunctive antibiotics, to better reach the infected. Incision and drainage is not solely reserved for abscesses, but can facilitate healing of cellulitis without waiting for the localization of the infection (abcess formation), via the same mechanism 1. It reduces pressure of edematous tissues on the airway reducing respiratory embarrassment. 15 2. Adequate culture specimen can be obtained, so an empirical antibiotic therapy may be continued or changed a. Blunt dissection into the tissue spaces breaks the pus locules and fibrous barrier, thus facilitating reach of the antibiotics into the infective site. 3. It allows placement of drains, which may be valuable to drain pus collection as time progresses, and irrigation of the tissues at regular intervals. 4. Serves to abort the spread of the infection into deeper anatomic spaces. Type of anaethesia ✓ Regional nerve block anesthesia is always preferred over infiltration techniques for two reasons: (1) penetration of the local anesthetic is difficult when the agent is injected directly into an infected area because the acidic (low pH) local environment (2) infiltration anesthesia carries the risk of seeding infection to neighboring uninfected sites or tissue spaces ✓ Oro/ nasal tracheal intubation ✓ Fiber-optic intubation or tracheostomy may be considered in; patients with limited mouth opening (trismus) or in patients having intra-oral and pharyngeal infections (sub-lingual, lateral/retropharyngeal spaces) where the chances of aspiration is high in the event of oro/naso-tracheal intubations 16 Guidelines for placement of incisions in infected cases: 1. Incisions should be placed in the most dependent areas. 2. Incisions should be parallel to the skin creases. 3. Incisions should lie in an esthetically acceptable site as far as possible. 4. Incisions should be supported by healthy underlying dermis and subcutaneous tissue. Placing the incision through the thin, often shiny skin directly overlying the abscess, which normally gets undermined by an abscess burrowing its way to the surface; results in a puckered contracted scar which gets collapsed into abscess cavity. 5. Incisions placed intraorally, should not crossfrenal attachments, and should be placed parallel to nerve fibers in the region of mental nerve. 6. The removal of the cause; such as an infected tooth, a segment of necrotic bone, a foreign body, if not already done, then should be done at the time of incision and drainage procedure. Hilton’s Method of Abscess Drainage Antisepsis of the area with an antiseptic solution before the incision. Anesthesia of the area where incision and drainage of the abscess are to be performed, with the block technique together, in order to avoid the risk of existing microbes spreading into deep tissues. Stab incision with the help of 11 number blade is made at the most dependent area along the skin crease through skin and subcutaneous tissue. The length of the incision must be sufficient—at least 10 to 15 mm Closed forceps are pushed through the tough deep fascia and advanced towards the pus collection. Abscess cavity is entered, and forceps opened in a direction parallel to vital structures. Pus flows along sides of the beaks. Explore the entire cavity for additional loculi Pus collected and sent for culture and sensitivity test. Abscess cavity is irrigated with antiseptic solution. 17  Corrugated rubber drain is inserted deep into the abscess cavity and secured to the edge of the incision and the drain is removed once there are no active exudates. Dressing placed over the incision Purpose of keeping the drain: The purpose of drain is to allow the discharge of tissue fluids and pus from the wound by keeping it patent. The drain allows for debridement of the abscess cavity by irrigation. Tissue fluids flow along the external surface of a latex drain. Hence, it is not always necessary to make perforations in the drain, which could weaken and perhaps cause fragmentation within the tissues Removal of drains: Drains should be removed when the drainage has nearly completely ceased. Thus, drains are usually left in infected wounds for 2–7 days 5.Supportive therapy It involves those modalities which aid the patient’s own body defenses. It consists of the following: 1. Adequate control of systemic diseases that may affect treatment ( blood glucose control) 2. Administration of antibiotics. 3. Hydration of patient as Patients with infection and fever present a considerable loss of body fluids—250 mL for every degree (centigrade) temperature rise. Ambulatory patients must drink 8–10 glasses of water or any other liquid. Intravenous fluids can be given to those patients who are hospitalized to improve hydration. 4. Maintain adequate nutritional status-high protein intake. The daily calorie requirement also increases by up to 13% for each degree (centigrade) above normal body temperature 5. Analgesic. 6. Bed rest. 7. Application of heat in the form of moist pack, advice mouth rinses. 8. Frequent wound irrigation and change of dressings, and removal of drain. 8. Dental management by extraction or root-canal treatment for drainage 18 6.Antibiotic administration Involves the empiric administration of the most appropriate antibiotic, which is based on knowledge of antimicrobial effectiveness, side-effects, adverse reactions, contraindications, and the cost Odontogenic infections are almost invariably caused by normal oral flora (predominantly facultative oral streptococci, anaerobic streptococci, and Prevotella and Fusobacterium species) and typically have a predictable bacterial composition. This predictability makes the routine use of culture and sensitivity testing unnecessary and impractical because the causative organisms are already known. The predictable nature of the causative organisms in odontogenic infections also favors the use of a limited number of antibiotics, when indicated. These include penicillin, amoxicillin, clindamycin, and azithromycin, which are effective against aerobic and facultative streptococci and oral anaerobes Antibiotic classification II.Bacteriostatic antibiotics Drug merely retards the growth of the bacteria by attaching to the ribosomes and DNA inside the cell. 19 Narrow spectrum versus Broad spectrum antibiotic Narrow-spectrum antibiotics are active against a select group of bacterial types. Broad-spectrum antibiotics are active against a wider number of bacterial types and, thus, may be used to treat a variety of infectious diseases. Indications for antibiotics Presence of cellulitis (with or without concomitant abscess) Swelling extending beyond the alveolar process Trismus Lymphadenopathy Fever (>101°F [38.3°C]) Severe pericoronitis Osteomyelitis Immunocompromised patient (with appropriate surgical management of infection 20 Indications for Culture and Antibiotic Sensitivity Testing ✓ Rapidly progressive infection ✓ Previous, multiple antibiotic therapy ✓ Nonresponsive infection (after >48 h) ✓ Recurrent infection ✓ Compromised host defenses Administer Antibiotic Properly ❖ The proper dose, timing, route and duration of administration of antibiotics are as important as proper antibiotic selection. The goal is to achieve a high-enough plasma level to kill or halt the bacteria that are sensitive to the antibiotic while minimizing adverse side effects ❖ Use of antimicrobial with least toxicity and side effects- prevents vital organ damage and Use of bactericidal rather than bacteriostatic drug prevents residual infection. ❖ Duration of administration can vary depending on the patient’s response to surgical treatment and antibiotic therapy, but the typical regimen consists of a 4- to 5-day course ❖ On the other hand, a prescribed course of antibiotics must be completed, regardless of symptoms, to minimize the risk of increasing antibiotic resistance 7. Evaluate Patient Frequently The swelling normally decreases by 48–72 hours postoperatively, allowing for a temporary rise in swelling because of surgical trauma. Trismus and WBC count, usually tend to reduce by 24– 48 hours after surgery. A review of the case does not show any improvement by 48–72 hours postoperatively, then a re-evaluation should be done for the following: Effectiveness of the wound drainage, Antibiotic therapy, and A search for a previously undetected source of infection 21