Orofacial Infections - Part 1 PDF

Oral and Dental Surgery - II Orofacial Infections - Part-I Asst. Prof. Ezgi YÜCEER ÇETİNER School of Dental Medicine Department of Oral and Maxillofacial Surgery [email protected] Course Content 1. Microbiology of Orofacial Infections 2. Pathophysiology of Oral Infections 3. Ma...

Oral and Dental Surgery - II Orofacial Infections - Part-I Asst. Prof. Ezgi YÜCEER ÇETİNER School of Dental Medicine Department of Oral and Maxillofacial Surgery [email protected] Course Content 1. Microbiology of Orofacial Infections 2. Pathophysiology of Oral Infections 3. Management of Odontogenic Maxillofacial Infections Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Learning Outcomes At the end of this course you will; Know the pathophysiology of odontogenic infections. Define microbiology of odontogenic infections. Explain how to manage orofacial infections. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Resource • Hupp, J. R., Tucker, M. R., & Ellis, E. (2019). Contemporary Oral and maxillofacial surgery. 7th Ed., Elsevier. Chapter 16 Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Origin of Maxillofacial Infections • 1- Odontogenic Infections • 2-Non-odontogenic Infection • Salivary Gland Infections • Otitis media and tonsillitis • Jaw fractures • Dental caries • Periodontal Disease • Pericoronotis • Cutaneous infections Infected Odontogenic Cysts • Chemical irritations of mucosal and cutaneous layers • Non-sterile infiltration of local anesthetics • Specific bacterial infections • Paranasal sinusitis • • Remnant roots • Pulpal necrosis in devitalized teeth Management of Odontogenic Maxillofacial Infections 1.Determine the severity of infection. 2. Evaluate host defenses. 3. Decide on the setting of care. 4. Treat surgically. 5. Support medically. 6. Choose and prescribe antibiotic therapy. 7. Administer the antibiotic properly. 8. Evaluate the patient frequently. Microbiology of Odontogenic Infections  Odontogenic infections are primarily caused by normal oral bacterial flora, which include aerobic and anaerobic gram-positive cocci and anaerobic gram-negative rods.  Odontogenic infections are almost invariably polymicrobial, involving multiple bacteria.  Approximately 50% to 60% of all odontogenic infections involve a combination of both aerobic and anaerobic bacteria. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Pathophysiology of Odontogenic Infections  The location of this erosion through bone largely depends upon the faciolingual location of the source of the infection, as well as the thickness of the cortical bone Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Pathophysiology of Odontogenic Infections  When infections reach the soft tissues, it generally manifests in four stages: inoculation (edema), cellulitis, abscess, and resolution.  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.  The cellulitis stage occurs between days 3 and 5 and represents the intense inflammatory response elicited by the infecting mixed microbial flora. This stage is characterized by poorly defined diffuse firm red swelling that is exquisitely painful to palpation. As the infection evolves and anaerobes begin to predominate, liquefaction of tissues occurs with the formation of purulence, which is the hallmark of the abscess stage. As purulence is formed, the swelling and redness become better defined and localized, and the consistency changes from firm to fluctuant.  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. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Pathophysiology of Odontogenic Infections Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Pathophysiology of Odontogenic Infections  In clinical practice, the most commonly encountered odontogenic infection is a vestibular space abscess of endodontic origin.  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. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 1: Determine Severity of Infection • Determination of severity begins with a complete history, followed by physical examination, and any necessary ancillary testing (e.g., radiographic imaging studies, laboratory studies). Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 1: Determine Severity of Infection • Physical examination must be performed in a comprehensive and organized fashion • It is recommended that the clinician begin from “big to small,” or “outside then inside.” • This begins with obtaining vital signs (temperature, blood pressure, heart rate, and respiratory rate). Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 1: Determine Severity of Infection • Patient with left canine space infection with periorbital space extension, with malaise and characteristic “toxic appearance” indicating compromised host defenses. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 2: Evaluate State of Patient’s Host Defense Mechanisms  When the host defense mechanism is compromised, it must be compensated for by aggressively managing the infection with surgical treatment and, in most cases, adjunctive antibiotic therapy.  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.  Poorly controlled diabetes mellitus  Severe alcoholism,  Hematologic cancers such as leukemia and lymphoma  HIV infections,  Chemotherapeutic agents for malignant conditions  Immunosuppressants and corticosteroids used for various indications (such as autoimmune diseases and organ transplantation) Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 3: Determine Whether Patient Should Be Treated by General Dentist or Oral and Maxillofacial Surgeon  The decision should be based upon location, severity, surgical access, and status of host defenses Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 4: Treat Infections Surgically One of the most common misconceptions about odontogenic infections is the role of antibiotics as the main treatment modality. It cannot be stressed enough that odontogenic infections are a surgically managed disease process and that antibiotics only serve an adjunctive role, if they are indicated at all. Robust evidence clearly shows that surgical management is significantly superior to antibiotic-only therapy in improving various clinical parameters, including body temperature, laboratory values, and hospital stay. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 4: Treat Infections Surgically Management of Odontogenic Infections eliminating the source of the infection: extraction, pulp extipation (with subsequent definitive root canal theraphy, and periodontal therapy establishing surgical drainage: incision and drainage mobilizing the host defense system Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 4: Treat Infections Surgically Elimination of the Source:  The method of source control depends on the specific etiology (endodontic or periodontal), as well as the severity.  However, certain situations preclude adequate source control. An example is significant trismus that does not allow the clinician to properly access the offending tooth or teeth due to limited access to the oral cavity. In such instances, depending on the severity and location of the infection, the clinician may begin empirical antibiotic therapy or perform incision and drainage first to improve mandibular opening prior to eliminating the infection source. When an infection is deemed serious and aggressive, the patient must be treated under general anesthesia in a controlled operating room setting for immediate surgical management. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 4: Treat Infections Surgically Incision and Drainage:  Following source control, surgical drainage of the infection is the second component of surgical treatment.  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 area. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 4: Treat Infections Surgically  When the access is deemed insufficient, analgesia and anxiolysis may be used, because limited mandibular mouth opening with a vestibular space infection is almost invariably due to guarding from pain.  The next step in surgical treatment is to determine the need for microbiologic analysis and culture and sensitivity testing. Although not necessary on a routine basis, some situations warrant serious consideration for laboratory evaluation Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 4: Treat Infections Surgically Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 5: Support Patient Medically  Supportive measures include hydration, improved nutrition, pain control, adjunctive antibiotic therapy, and blood glucose control.  Most patients presenting with odontogenic infections are dehydrated and poorly nourished due to poor oral intake from pain and discomfort. Thorough surgical care (i.e., source control and incision and drainage) should always be supplemented with adequate pain control and encouragement of oral (or intravenous) hydration and improved nutritional intake.  For the acutely dehydrated patient, the clinician may elect to administer fluids intravenously to replenish lost intravascular volume.  The patient may present with other systemic illnesses that require special attention such as diabetes, hypertension, dysrhythmias, congestive heart failure, and autoimmune diseases with immunosuppressive therapy. Especially when multiple such comorbidities exist, expert consultation is frequently necessary from different specialists such as internal medicine and infectious diseases. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 6: Choose and Prescribe Appropriate Antibiotic • Although odontogenic infections must be managed with surgery, certain situations benefit from adjunctive antibiotic therapy. • The clinician should never assume antibiotics are required for appropriately managing odontogenic infections. • Inappropriate reliance on antibiotics not only poses the risk of increased antibiotic resistance and increased risk of antibiotic adverse effects (including opportunistic infections and more serious risks such as anaphylaxis), but it also may lead to inadequate surgical management. • It must be clearly understood that antibiotics should always be regarded as an adjunct to, not a substitution for, surgical management. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 6: Choose and Prescribe Appropriate Antibiotic Determine the Need for Antibiotic Administration: Three main factors should be considered when determining the appropriateness of adjunctive antibiotic use: (1) severity of the infection, (2) ability to render surgical treatment, and (3) patient host defense system. Use Empirical Antibiotic Therapy Routinely: 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 Use an Antibiotic With the Narrowest Spectrum: Broad-spectrum antibiotics can dramatically alter the normal bacterial flora of various organ systems such as the skin and the gastrointestinal (GI) tract, which could lead to untoward effects, such as the development of superinfections or opportunistic infections (e.g., fungal) that are usually controlled by the existing bacteria. Broad-spectrum antibiotics can also lead to the development of bacterial antibiotic resistance. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 6: Choose and Prescribe Appropriate Antibiotic Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 6: Choose and Prescribe Appropriate Antibiotic Use the Antibiotic With the Lowest Incidence of Toxicity and Side Effects: As with any drug, antibiotics have adverse effects, which may vary from mild to severe. It is the clinician’s responsibility to be thoroughly aware of the adverse effects of commonly used antibiotics in order to weigh the risks and benefits of antibiotic usage. Use a Bactericidal Antibiotic Whenever Possible: Bactericidal antibiotics are preferred over bacteriostatic antibiotics because they lyse and kill bacteria and lessen the burden on the host defense system. Be Aware of the Cost of Antibiotics: Unnecessarily expensive drugs place a financial burden not only on the patient, but also on the health care system, and they should be used only when the clinical circumstances warrant it. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 7: Administer Antibiotic Properly • The proper dose, timing, 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. • The clinician should refer to the manufacturer’s dosage recommendations based upon the indications. • 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. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 8: Evaluate Patient Frequently • In most cases of uncomplicated odontogenic infections in immunocompetent patients, uneventful healing occurs within 1 week. • The typical follow-up period is 2 to 3 days after surgical treatment. At this time, an appropriately responding patient will have significant improvement of pain, intraoral swelling, and overall wellness. • If swelling and induration have decreased and there is no persistent drainage, any surgically placed drains should be removed, and the wound should be allowed to heal by secondary intention. • If the patient has persistent swelling, pain, drainage, and even constitutional symptoms, the clinician should carefully assess the cause of the inadequate clinical response. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 8: Evaluate Patient Frequently  As a general rule, inadequate surgical treatment (source control, drainage, or both) should be presumed the primary reason until proven otherwise. It is especially important to ascertain complete removal of the source of the infection.  Another reason for inadequate response is compromised host defenses. If a compromise is identified, it must be controlled (e.g., hydration, nutrition, glycemic control) and surgical measures aggressively performed. Adjunctive antibiotics are usually indicated when host defense is compromised, often for longer periods.  Another reason for failure is problems with antibiotic administration. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner THANK YOU.. Orofacial Infections Part-1 27.10.2023 Dental Anesthesia and Pain Control © Asst. Prof. Ezgi Yüceer Çetiner