Principles of Management and Prevention of Odontogenic Infections PDF

PRINCIPLES OF MANAGEMENT AND PREVENTION OF ODONTOGENIC INFECTIONS Oral Surgery 2 | Dr. Kenny Dean Ardaña | Midterm ○ This results in microabscesses, which may coalesce and...

PRINCIPLES OF MANAGEMENT AND PREVENTION OF ODONTOGENIC INFECTIONS Oral Surgery 2 | Dr. Kenny Dean Ardaña | Midterm ○ This results in microabscesses, which may coalesce and clinically manifest as an abscess. Topic Outline: ○ In addition, the pressure from the expanding abscess Microbiology of Odontogenic Infections Pathophysiology of Odontogenic Infections increases the hydrostatic pressure on the surrounding blood Principles of Management vessels, preventing compromising blood flow leading to ○ Principle 1: Determine Severity of Infection ischemia, and thereby further increasing the zone of b within ○ Principle 2: Evaluate State of Patient’s Host the abscess cavity. Defense Mechanisms ○ Principle 3: Determine Whether Patient Should Be Treated by General Dentist or Oral and Maxillofacial Surgeon ○ Principle 4: Treat Infections Surgically ○ Principle 5: Support Patient Medically ○ Principle 6: Choose and Prescribe Appropriate Antibiotic ○ Principle 7: Administer Antibiotic Properly ○ Principle 8: Evaluate Patient Frequently ○ General Dentist’s Role in the Management of Odontogenic Infections, Principles of Prevention of Infection Principles of Prophylaxis of Wound Infection Principles of Prophylaxis Against Metastatic Infection MICROBIOLOGY OF ODONTOGENIC INFECTIONS Odontogenic infections are primarily caused by normal oral bacterial flora, which include: ○ aerobic gram-positive cocci ○ anaerobic gram-positive cocci PATHOPHYSIOLOGY OF ODONTOGENIC INFECTIONS ○ anaerobic gram-negative rods Odontogenic infections, as the term implies, arise from tooth- Odontogenic infections are almost invariably polymicrobial, related endodontic or periodontal sources. involving multiple bacteria, and the identification of a single These etiologies may include: primary organism is usually not possible via routine culture ○ a necrotic pulp from a carious or fractured tooth and sensitivity testing. ○ pericoronitis from a partially impacted tooth Viridans-type streptococci- most commonly isolated aerobic ○ or deep periodontal pockets bacteria from odontogenic infections. Regardless of the source, when inadequately managed, an Facultative organisms- possess the ability to survive with/ infection will progress and spread through the path of least without oxygen. resistance. ○ These bacteria are believed to initiate the progression of a For an odontogenic infection of endodontic origin, the infection in superficial infection into the deeper tissues. the periradicular region will gradually erode through the facial or Bacteroides spp. - The most commonly isolated anaerobic lingual cortex of the bone of the maxilla or mandible. bacteria from odontogenic infection. followed by: The location of this erosion through bone largely depends upon ○ Prevotella and Peptostreptococcus spp. the faciolingual location of the source of the infection, as well Once bacteria infiltrate the deeper soft tissues, they penetrate as the thickness of the cortical bone. throughout the fascial spaces, or potential spaces, and spread by producing hyaluronidase, an enzyme that cleaves hyaluronic acid and allows the spread of the infection through the subcutaneous tissue. ○ As the infection spreads into the deeper tissues, byproducts of bacterial metabolism create an acidic environment, facilitating the growth of anaerobes. Anaerobes predominate, there is further tissue breakdown and liquefaction necrosis as well as the breakdown of white blood cells (WBCs). ngp | 1. 4 STAGES OF INFECTION: 1. 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 PRINCIPLES OF MANAGEMENT swelling that is mildly tender Management of odontogenic infections involves three factors: 2. Cellulitis stage 1. Controlling the source of the infection occurs between days 3 and 5 and represents the 2. Establishing drainage intense inflammatory response elicited by the infecting 3. Mobilizing the host defense system mixed microbial flora. odontogenic infections, regardless of the severity of the This stage is characterized by poorly defined diffuse firm infection. red swelling that is exquisitely painful to palpation 3. Abscess stage PRINCIPLE 1: DETERMINE SEVERITY OF INFECTION As the infection evolves and anaerobes begin to 1. Complete History predominate, liquefaction of tissues occurs with the 2. Physical Examination formation of purulence, which is the hallmark of the 3. Ancilliary Testing abscess stage. ➔ Determination of severity begins with a: As purulence is formed, the swelling and redness 1. Complete history become better defined and localized, and the consistency - The goal here is to gather as much information as possible in changes from firm to fluctuant order for use to have an accurate diagnosis. 4. Resolution stage  Chief Complaint When an infection is drained, either spontaneously or o Fever- increase in the body's 'set-point' via surgery, the host defense mechanism destroys the temperature is often due to a physiological involved bacteria and healing begins to occur; this is the process brought about by infectious causes hallmark of the resolution stage. or non-infectious causes such as inflammation, malignancy, or autoimmune processes. o Fever and malaise: increase in the body's 'set-point' temperature is often due to a physiological process brought about by infectious causes or non-infectious causes such as inflammation, malignancy, or autoimmune processes. 2  o Malaise: indicates a physical or  Oral Cavity physiological response against moderate to ➔ common imaging studies used for odontogenic severe infection infections include: o Trismus: it can show severity of infection - periapical radiographs through swelling and inflammation which can - panoramic radiographs restrict the jaw movement. = so, the more - cone-beam computed tomography the patient can't open his/her jaw, the more ➔ Bitewing radiographs have no significant role in the severe the infection can be. assessment of odontogenic infections because they do not  History of the present illness capture the periapical region, which is the most common and o It helps determine the origin and etiology of important area from which odontogenic infections originate infection which is presented in chronological ➔ Panoramic radiographs- allow a general overall view of order, it also tackles the anatomic spaces na the jaws, nasal cavity, maxillary sinuses, and dentition, and involved and the aggressiveness of infection. have the benefit of simple acquisition with minimal discomfort  Past medical and Social history for the patient (especially if trismus is present).  Review of Systems ➔ Periapical views- allow a more detailed assessment of the o Pertinent positive are disease-specific and teeth and their periapical regions and have the benefit of less can be learned by rote, are used to “rule in” radiation dosage. a particular diagnosis. o Pertinent negatives- require more analytical ➔ A cone-beam computed tomography- scan allows a and creative thinking, are gleaned from the three-dimensional view of the maxillofacial skeleton and teeth differential diagnosis and function to “rule and is useful if the source of the infection is unclear based out” other diagnostic possibilities. upon the history and clinical examination 2. Physical Examination ➔ (ALARA rule: as low as reasonably achievable).  Vital Signs ➔ the most commonly used laboratory study is the Patients with odontogenic infections often have an complete blood count, with focus on the white elevated HRB: blood cell (WBC) count, and more specifically, o Heart rate of more than 100 beats/min the WBC differential count. (tachycardia) The rationale for this test is that an elevated WBC represents a o Respiratory rate of more than 20 breaths/min strong immune response to the infection in the form of (tachypnea) increased WBC production and mobilization into the o Blood pressure increased(hypertension) bloodstream.  General Appearance o Occur as early as the patient enters the PRINCIPLE 2: EVALUATE STATE OF PATIENT’S HOST examination room DEFENSE MECHANISMS o fatigued or lethargic 1. Medical comorbidities o stridor - an abnormal, high-pitched 1. poorly controlled diabetes- strongly associated with respiratory sound produced by irregular impaired healing. airflow in a narrowed airway. This is primarily 2. Severe alcoholism, which is frequently accompanied by caused by infection. malnutrition- also severely impairs the body’s ability to  Head and Neck examination defend against infections 3. Hematologic cancers such as leukemia and lymphoma- adversely affect the function of leukocytes and therefore the ability to defend against infections. 4. Chemotherapeutic agents for malignant conditions- for malignant conditions, thereby weakening the immune system. 3  PRINCIPLE 3: DETERMINE WHETHER PATIENT SHOULD BE 6. Incision and Drainage TREATED BY GENERAL DENTIST OR ORAL AND o The length of the incision must be MAXILLOFACIAL SURGEON sufficient—at least 10 to 15 mm—and the depth must be at a depth of at least through the mucosal and submucosal tissue layers. 7. Irrigate o with sterile normal saline using a syringe with a thin tip or a syringe with an angiocatheter attached can be used to thoroughly irrigate the abscess cavity with sterile saline solution after incision and drainage 8. Suture Location and severity ➔ These infections usually present with concerning signs and symptoms such as fever, difficulty breathing and/or swallowing, trismus, and drooling. ➔ Difficulty breathing, difficulty swallowing, and difficulty with handling of oral secretions are indicators of airway compromise, and patients demonstrating such signs and symptoms should be transported to a local hospital emergency room immediately (ideally with a consultation by an oral and maxillofacial surgeon). Surgical access ➔ Patients with odontogenic infections often present with trismus, which limits intraoral access (and often represents severe infections). ➔ These patients usually require surgical care under general anesthesia, with subsequent monitoring and medical management in a hospital setting ➔ Such patients should be promptly referred to an oral and maxillofacial surgeon for appropriate surgical and medical care without delay. Status of host defenses ➔ Patients with underlying medical comorbidities that affect host defenses require expeditious and aggressive management by an oral and maxillofacial surgeon. PRINCIPLE 4: TREAT INFECTIONS SURGICALLY Odontogenic infections are a surgically managed disease process. ➔Primary goal:  Elimination of the cause PRINCIPLE 5: SUPPORT PATIENT MEDICALLY o Endodontic Supportive measures: o Periodontal  Pain Control ➔Secondary goal:  Fever Management  Provide drainage of accumulated pus and necrotic debris.  Hydration SURGICAL TECHNIQUE  Nutrition 1. Determine the most appropriate route for surgical  Antibiotic Therapy access for incision and drainage  Blood Glucose control 2. Determine the need for microbiologic analysis  Referral and culture and sensitivity testing. PRINCIPLE 6: CHOOSE AND PRESCRIBE APPROPRIATE 3. Antisepsis ANTIBIOTIC o Mouth rinse with 0.12% chlorhexidine Guidelines recommended for consideration when choosing an solution antibiotic: 4. Choose the method of analgesia and pain control 1. Determine the need for antibiotic administration o Regional nerve block anesthesia Three factors to be considered: 5. Culture specimen is obtained (if indicated) Seriousness of the infection 4 - Swelling, progressed rapidly, and diffuse cellulitis indicates use of antibiotics plus surgical therapy. Adequate surgical treatment can be achieved. - Prompt removal of offending tooth in the presence of infection is encouraged; prior period of antibioyoc therapy is not necessary. State of patient’s host defenses - Patients who have any type of decreased host resistance, may require vigorous antibiotic therapy even for minor infection Indications for the use of Antibiotics: Swelling extending beyond the alveolar process Cellulitis Trismus Lymphadenopathy Temperature higher than 101F (38.3 degree C) 4. Use the antibiotic with the lowest incidence of toxicity and Severe pericoronitis side effects Osteomyelitis Immunocompromised patient (with appropriate → penicillin and azithromycin- tend to have lower incidences of surgical management of infection adverse effects. Use of antibiotics is not necessary: →. The most common side effects of penicillin are: Patient demand  Hives Severe pain (not attributable to infection)  Rash Toothache  Gl upset (diarrhea) Periapical periodontitis or abscess  Anaphylaxis is also included as severe adverse reaction Alveolar osteitis (dry socket) but it is rare. Postoperative administration in an immunocompetent patient after multiple dental → azithromycin- best effectiveness-to-toxicity ratio among extractions macrolide antibiotics for odontogenic infections. Mild pericoronitis Drained abscess limited to the alveolar abscess → pseudomembranous colitis- long-term use of clindamycin which 2. Use Empirical Antibiotic Therapy Routinely is caused by alteration of the GI flora and subsequent ➔ Effective against aerobic and facultative overgrowth of Clostridium difficile (resistant) streptococci and oral anaerobes: - Penicillin → Moxifloxacin- is a fluoroquinolone antibiotic with a broad - Amoxicillin spectrum and is much more effective against oral bacteria than - Clindamycin its older counterparts - Azithromycin - significant adverse effects such as: ➔ antibiotic that targets obligate anaerobes:  spontaneous tendon rupture - Metronidazole - a nitroimidazole antibiotic that targets obligate  hepatitis anaerobes, is seldom used in routine infections and is  dysrhythmia occasionally used only in conjunction with standard antibiotics  peripheral neuropathy in severe infections with a positive culture for a significant level  psychiatric effects of anaerobic bacteria. ➔ Clindamycin is dosed orally four times daily → erythromycin- macrolide; no longer considered effective ➔ Amoxicillin-clavulanate (Augmentin) is dosed orally twice daily, 5. Use the antibiotic with the lowest incidence of toxicity and with a higher compliance rate and therefore a more effective side effects form of antibiotic treatment Bactericidal antibiotics are preferred over bacteriostatic antibiotics 3. Use Empirical Antibiotic Therapy Routinely Bacteriostatic antibiotics such as: ➔ Broad-spectrum antibiotics can dramatically alter the normal  azithromycin bacterial flora of various organ systems such as the skin and  clindamycin (at low doses; at high doses clindamycin is the gastrointestinal (GI) tract bactericidal) - which could lead to untoward effects, such as the development of - slow down bacterial reproduction and allow the host superinfections or opportunistic infections (e.g., fungal) that are defense to eliminate the bacteria. usually controlled by the existing bacteria. 6. Be Aware of the Cost of Antibiotics ➔ Broad-spectrum antibiotics can also lead to thedevelopment of - Unnecessarily expensive drugs place a financial burden not bacterial antibiotic resistance only on the patient, but also on the health care system, and they should be used only when the clinical circumstances warrant it. 5 - The choice of generic medications over brand-name versions - May encourage lax surgical and aseptic techniques on the part of helps decrease overall costs. the dentist. PRINCIPLE 7: ADMINISTER ANTIBIOTIC PROPERLY - Cost - Toxicity ➔ The proper dose, timing, and duration of administration of PRINCIPLES OF PROPHYLAXIS AGAINST METASTATIC antibiotics are as important as proper antibiotic selection. INFECTION ➔ The goal is to achieve a high-enough plasma level to kill or halt ➔Metastatic Infections occur in distant sites, not directly the bacteria that are sensitive to the antibiotic while minimizing connected to the site of origin of the infection. adverse side effects. ➔Sites that are considered most susceptible to the metastatic PRINCIPLE 8: EVALUATE PATIENT FREQUENTLY spread of infection include: - Patients should be carefully monitored for response to  heart valves treatment and complications.  prosthetic joint replacements ➔ Patients should be asked to return to the dentist 2-3 days after ➔Factors necessary for Metastatic Infection: completion of the original therapy. - Distant susceptible site ➔ Uncomplicated odontogenic infections in immunocompetent - Hematogenous bacterial seeding patients, uneventful healing occurs within 1 week - Occurs as a result of a bacteremia which bacteria ➔ If swelling and induration have decreased and there is no from the mouth are carried to the susceptible site. persistent drainage, any surgically placed drains should be - Impaired local defenses removed, and the wound should be allowed to heal by PRINCIPLES OF ORAL PROPHYLAXIS AGAINST METASTATIC secondary intention. INFECTIVE ENDOCARDITIS ➔ If the patient has persistent swelling, pain, drainage, and even - Maintaining optimal oral hygiene should be the main goal in constitutional symptoms, the clinician should carefully assess preventing infective endocarditis. the cause of the inadequate clinical response. - Prior to and during invasive dental procedures, surgical ➔ reasons for treatment failure: asepsis and careful surgical technique should be employed.  Inadequate surgery 1. Identification of High-Risk Patients  Depressed host defenses 2. Antibiotic Prophylaxis 3. Timing of Administration  Foreign body 4. Minimizing Invasive Procedures  Antibiotic-related problems Note: Patients who require a series of dental treatments that a. Patient noncompliance requires antibiotic prophylaxis, a period of 10 or more days b. Drug not reaching site between appointments is appropriate. c. Drug dose too low d. Wrong identification of bacteria PROPHYLAXIS AGAINST PROSTHETIC JOINT INFECTION e. Wrong antibiotic - It involves giving antibiotics before certain dental or surgical GENERAL DENTIST ROLE procedure to reduce the risk of bacteria from entering the blood The most important role of a dentist is to recognize, assess, and stream. triage the infection. - Clindamycin and Amoxicillin are prescribed before dental PRINCIPLES OF PROPHYLAXIS OF WOUND INFECTION procedure. 1. Procedure should have significant risk of infection. 2. Choose correct antibiotic 3. Antibiotic plasma level must be high PROPHYLAXIS IN PATIENTS WITH OTHER 4. Time antibiotic administration correctly CARDIOVASCULAR CONDITIONS 5. Use shortest antibiotic exposure that is effective - Patients who receive chronic renal dialysis warrant ➔ 3 distinct advantages: consideration for antibiotic prophylaxis prior to invasive dental - Prophylactic antibiotics may reduce the incidence of postoperative procedure. infection, and thereby, reduce the incidence of postoperative - Ventriculoatrial shunts in patients with hydrocephaly. morbidity - Strong consideration for antibiotic prophylaxis should be given - Appropriate and effective antibiotic prophylaxis may reduce the when there is an already established infection. cost of health care. - Appropriate use of prophylactic antibiotics requires a shorter term administration rather than therapeutic use. ➔ Disadvantages:: - May alter host flora - Several studies have shown, antibiotic administration in one patient allows antibiotic-resistant organisms to spread to the patient's family and to the community. - The risk on infection is so low, that the antibiotic does not significantly decrease the incidence of infection. 6