Update On Antimicrobial Therapy in Management of Acute Odontogenic Infection in Oral and Maxillofacial Surgery

U p d a t e o n A n t i m i c ro b i a l
T h e r a p y i n Ma n a g e m e n t of
A c u t e Od o n t o g e n i c In f e c t i o n i n
Oral and Maxillofacial S urgery
Sam R. Caruso, DMDa,*, Elena Yamaguchi, MDb,
Jason E. Portnof, DMD, MD, FACD, FICDc,d
KEYWORDS
Odontogenic infections Antibiotics Caries Head & neck infections Antimicrobial therapy
Oral flora Incision and drainage
KEY POINTS
Odontogenic infections have many presentations and contribute primarily to health disorders seen
in both inpatient and outpatient settings across the United States and worldwide.
There are varying antimicrobial therapies that can be used for patients with odontogenic infections.
Each case should be assessed in full before concluding the antibiotic of choice for the patient’s
therapy; this is a continually evolving scenario that requires close follow-up with the possibility
for change.
Pharmacotherapy is an adjuvant therapy, not the definitive treatment for odontogenic infections.
INTRODUCTION anatomic spaces adjacent to the oral cavity and

spread along the contiguous facial planes, leading
This article focuses on the antimicrobial therapy of to more serious infections.1 Holmes and Pellecchia1
head and neck infections from odontogenic origin. divide facial infections by primary and secondary
It will not discuss the antimicrobial treatment of un- spaces. Primary spaces include buccal, canine,
complicated dental caries and periodontal disease. sublingual, submandibular, submental, and vestib-
This discussion is limited to adult immunocompe- ular spaces. After a direct primary infection, second-
tent patients; pediatrics, pregnant patients, patients ary infection can take place. These spaces include
with renal, hepatic, and cardiac problems are pterygomandibular, infratemporal, masseteric,
excluded, and management of these patients lateral pharyngeal, superficial, and deep temporal,
should be addressed on a case-by-case basis by masticator, and retropharyngeal.
the provider. Infections in the head and neck have an array of
Odontogenic infections are among the most com- presentations. However, they most often demon-
mon infections of the oral cavity. They are sourced strate classic signs and symptoms of infection in
primarily from dental caries and periodontal disease the early stages, including inflammation, edema,
(gingivitis and periodontitis). Many odontogenic in- redness, and pain (calor [heat], rubor [redness],
fections are self-limiting and may drain spontane- dolor [pain], tumor [swelling]). As the infection per-
ously. However, these infections may drain into the sists, systemic symptoms may result, including
oralmaxsurgery.theclinics.com
a
Department of Oral & Maxillofacial Surgery, Broward Health Medical Center, Nova Southeastern University
College of Dental Medicine, 1600 S. Andrews Avenue, Fort Lauderdale, FL 33301, USA; b Private Practice, In-
fectious Diseases, 13550 South Jog Rd, Suite 202A, Delray, FL 33446, USA; c Department of Oral & Maxillofacial
Surgery, Nova Southeastern University College of Dental Medicine, 3200 S. University Dr., Davie, FL 33314, USA;
d
Private Practice, Oral & Maxillofacial Surgery, Surgical Arts of Boca Raton, 9980 North Central Park Bvld, Suite
#113, Boca Raton, FL 33428, USA
* Corresponding author.
E-mail address: scaruso@browardhealth.org
Oral Maxillofacial Surg Clin N Am 34 (2022) 169–177

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170 Caruso et al
more significant generalized or pronounced mixed aerobic and anaerobic bacteria present.13–15
edema, trismus, tachycardia, dysphagia fever, fa- However, the anaerobes generally outnumber the
tigue, and malaise.2 aerobic bacteria by a factor of 3- to 4fold.16,17
These infections pose many threats, including Knowledge of the usual microbial flora of the
patient mortality. Primary concern of the disease mouth and dental surfaces will help in the selection
is that of airway security. In the past, the major of empiric antimicrobial therapy while awaiting
cause of mortality was due to airway obstruction. final culture results. In general, it is recommended
Modern treatment guidelines for early airway se- to use antibiotics that cover these organisms,
curity and surgical intervention have reduced this including anaerobic bacteria, as these may not
airway-related mortality. A 2015 study by Bali necessarily grow with the usual available tech-
and colleagues3 demonstrated that embarrass- niques or because of delays in getting samples
ment of the airway was a tertiary cause of mortality to the microbiology laboratory. When “normal
accounting for only 5% of 18 deaths among 2790 oropharyngeal flora” results are obtained from cul-
patients. The 2 most common causes of mortal- ture, practitioners should choose broad-spectrum
ities in these patients were sepsis and preexisting antibiotics and not consider these results true
organ failure. In addition, there are morbidities negative cultures.
related to the course of spread to critical struc- Actinomycosis is a rare subacute to chronic
tures, which can include the orbit, brain, and bacterial infection caused by Actinomyces spp, a
spine.1 Risks of odontogenic infection also include bacterium that normally colonizes the human
progression to sepsis, bacteremia, endocarditis, mouth. One of the common presentations includes
and acute respiratory distress syndrome.4–7 cervicofacial actinomycosis.18 It is characterized
For the modern oral and maxillofacial surgeon or by contiguous spread, suppurative and granulo-
surgical trainee, these infections are commonly matous inflammation, and formation of multiple
seen in an emergent setting, whether in office or abscesses and sinus tracts that may discharge
in the local emergency department. In 2007, the sulfur granules.18 It is important to consider Acti-
Nationwide Emergency Department Sample data- nomycosis in the differential diagnosis of orofacial
base included 302,507 Emergency Department and head and neck infections, as treatment with
visits for facial cellulitis in the United States.8 antimicrobial therapy is quite different from the
These patient encounters led to a significant finan- treatment of other odontogenic infections. The
cial expense. Kim and colleagues9 showed many preferred treatment for Actinomycosis is penicillin
factors associated with increased length of stay G 18 to 24 million units IV daily in divided doses for
in odontogenic infections with a mean cost of 2 to 6 weeks and then amoxicillin 500 to 750 mg
$24,290 per patient. orally 3 to 4 times a day for 6 to 12 months.18
Abramowicz and colleagues10 explored the
nationwide inpatient sample from 2012 and 2013
DIAGNOSTICS OF ODONTOGENIC
showing that facial cellulitis accounted for 74,480
INFECTIONS
hospitalizations. Demographic results from the
Imaging
study show a greater number of women than
men and mean age of 47.5 years.10 In the retro- A careful history and physical examination are
spective analysis of the nationwide inpatient sam- important in the diagnosis of odontogenic infec-
ple, 86.1% of the patients were routinely tions. Clinical symptoms, vital signs, microbiolog-
discharged and 0.2% of the patients died inthe ical evaluation, and diagnostic imaging are all
hospital.10 Of note, this study did not distinguish crucial in identifying the cause of infection and to
between odontogenic and other causes of facial help guide the course of treatment.
cellulitis. It is inferred that many of these infections Modern imaging techniques provide the sur-
are odontogenic in nature. Other sources for head geon excellent topography of the spreading infec-
and neck infections could include peritonsillar, tion, but not all active infections warrant computed
intravenous (IV) drug abuse, and foreign bodies.11 tomography (CT) imaging for definitive treat-
ment.19,20 There are “red-flag” clinical symptoms
MICROBIOLOGY OF ODONTOGENIC to consider CT imaging and likely inpatient stay.
INFECTIONS These “red-flag” clinical symptoms include but
are not limited to trismus, fever, dysphagia, odyno-
Odontogenic infections are usually attributed to the phagia, pain, and dyspnea.1,19,20
endogenous flora of the mouth and not the intro- Weyh and colleagues19 suggested “red-flag”
duction of nonresident bacteria.12 It is important clinical signs that warrant the use of CT imaging
to emphasize that suppurative odontogenic infec- and include fever, pain, voice change, elevated
tions are typically polymicrobial in nature, with floor of mouth, signs of inflammation of deep
Management of Acute Odontogenic Infection 171
fascial spaces, periorbital edema, nonpalpable implants may compromise accurate delineation of
inferior border of the mandible, dyspnea, neck disease.21
dysphagia or odynophagia, and trismus. The study Although in-office panoramic imaging may be
found 56.6% of CT imaging was unnecessary. readily available, it is only beneficial in identifying
Christensen and colleagues20 performed a study a possible odontogenic source of the infection,
that determined emergency medicine physicians as the soft tissue is not adequately visualized.
conducted CT imaging on 61.7% of patients who Panoramic imaging can be reserved for an outpa-
did not require CT imaging by study standards. tient setting or should medical CT be
Recommendations were made to increase educa- unavailable.19
tion to providers to avoid unnecessary imaging.20 In patients with persistent odontogenic infec-
There is a wide array of clinical imaging that can tions that are not clearly diagnosed by CT imaging
be used to assess head and neck infections in the with IV contrast and/or MRI, nuclear medicine
emergency setting, but the most common is CT studies, such as triple-phase bone scan or
imaging with IV contrast in a hospital setting and indium-labeled scans, can be used especially in
cone beam CT or panoramic film if the patient is cases of osteomyelitis of the jaw, but they are
being evaluated in an outpatient clinic. CT is not typically used because they can be difficult
particularly sensitive for soft tissue with IV contrast to interpret.24
and remains the imaging modality of choice for
assessment of most odontogenic infections Microbiology
(Fig. 1).21
Obtaining appropriate material for culture and pro-
CT 3-dimensional imaging will show ring
cessing is important in the diagnosis of odonto-
enhancing loculations of well-formed abscesses,
genic infections. One of the difficulties in defining
gas formation or entrapment, and finally, the soft
etiologic agents for odontogenic infections is the
tissue edema associated with these infections.
presence of normal resident flora. For closed
Using IV contrast-enhanced CT for emergency
space infections, it is very important that the
diagnosis of head and neck infections is currently
normal oral flora be excluded during the specimen
routine because it is fast, readily available, and
collection. Needle aspiration of loculated pus by
relatively inexpensive.22,23 However, limited soft
an extraoral approach is desirable, and specimens
tissue contrast and artifacts from bone and dental
should be transported immediately to the labora-
tory under anaerobic conditions. Figs. 2 and 3
show a clinical specimen of an odontogenic
abscess.
Contamination by the resident oral flora is inev-
itable for intraoral infections. In this setting, direct
microscopic examination of stained smears,
Fig. 1. Gross airway deviation, infection, and gas for-

mation in the deep spaces. (A) The gross deviation of
the airway of the patient (arrow). (B) The gas forma-
tion from infection in the pterygomandibular and Fig. 2. A submandibular space abscess of odontogenic
inferior temporal deep spaces (arrows). origin.
172 Caruso et al
OUTPATIENT MANAGEMENT OF
ODONTOGENIC INFECTIONS
Most outpatient odontogenic infections are
treated with b-lactam antibiotics. The b-lactam
ring is crucial to the bactericidal activity of the
medication because of their inhibition of bacterial
cell wall biosynthesis. b-Lactam antibiotics include
penicillin derivatives, cephalosporins, cephamy-
cins, monobactams, carbapenems and
cabacephems.
The first-generation penicillins include penicillin
V, which is orally administered, and penicillin G,
which is administered parenterally. The usual adult
dose for penicillin is 250 to 500 mg orally 4 times a
day.
Third-generation penicillins (aminopenicillins)
are effective against a wider spectrum of bacteria
Fig. 3. The surgical intervention, incision and than first-generation penicillins and are generally
drainage, of the submandibular abscess and culture used as a first-line agent against odontogenic in-
of purulent material. fections. Amoxicillin is a third-generation penicillin
that is commonly prescribed for adults as 500 mg
orally 3 times a day or 500 to 875 mg orally 2 times
such as Gram stain, often provides more useful in- a day. As b-lactamase production among oral an-
formation than culture results from surface swabs. aerobes, such as Prevotella and Fusobacterium
The gram-stain step is implemented to provide spp, is increasing, monotherapy treatment with
basic information about the culture sample and standard penicillin has been found to be less effec-
to provide some information to the clinician while tive. For this reason, it is not recommended.25
awaiting culture results. If the sample shows Also, the need to take the oral penicillin 3 to 4 times
excess epithelial cells, the laboratory can a day on an empty stomach, because gastric acid
conclude that the sample was poorly obtained inactivates the drug with the result that only 30%
and includes skin or oral mucous membrane flora. of the oral dose is absorbed, makes amoxicillin
If the presence of white blood cells is predominant, the drug of choice for initial empiric antibiotic treat-
it can be assumed that the clinician gathered a ment of mild odontogenic infections in patients
good collection of purulent material. without penicillin allergy.
Gram stains can also be helpful if they show a Monotherapy with penicillin is no longer recom-
mixture of gram-positive and gram-negative bac- mended because of bacterial resistance. Some
teria and the aerobic culture is negative. This experts have recommended the use of penicillin
should raise the suspicion of anaerobic involve- plus metronidazole as an alternative. A multiantibi-
ment. This information is useful especially if only otic regimen is less commonly adhered to,
aerobic cultures are sent. requiring patients to take 2 medications several
Cultures will be specifically plated for both aero- times a day. For this reason, more practitioners
bic and anaerobic growth. The plates are moni- are using amoxicillin monotherapy instead. The
tored based on hospital protocol, with a authors of this article have anecdotally found
minimum of daily evaluation. Aerobic growth more compliance with patients taking twice-daily
assessment begins at 24 hours, and anaerobic dosing and routinely prescribe 875 mg amoxicillin
growth assessment begins at 48 hours (Fig. 4). 2 times a day in patients for 7 days as the first-line
In addition to cultures from abscesses or outpatient treatment of dental and mild odonto-
drainage, tissue biopsies should be routinely genic infections. Al-Belasy and colleagues26
examined for histopathological evidence of acute showed that along with appropriate surgical man-
or chronic inflammation and infection. Tissue bi- agement, a 3-day course of amoxicillin has shown
opsies should also be sent for aerobic and anaer- similar clinical outcomes to a 7-day course.
obic cultures and if suspected for acid fast and There are many b-lactam-resistant bacteria in-
fungal cultures before they are sent to the pathol- side the oral cavity. These bacteria produce b-lac-
ogy laboratory. Specific microbial agents can tamase, thereby inactivating the b-lactam ring.
sometimes be detected by immunofluorescence Bacteria that produce b-lactamase enzymes will
or polymerase chain reaction. be resistant to b-lactam antibiotics. b-Lactamase
Fig. 4. In vitro microbiological evaluation of odontogenic abscesses and some regularly studied samples. (A)
Gram stain showing gram-positive cocci in chains throughout, a large epithelial cell in the center, and several
white blood cells throughout. (B) Blood agar plate from culture of oral flora. (C) Chocolate agar plate high-
lighting Haemophilus. (D) Columbia CNA plate highlighting alpha streptococcus and coagulase-negative Staph-
ylococcus. (E) MacConkey agar growing enteric gram-negative bacilli. These same colonies can also be pictured in
panels D and E. (F). Beta-hemolysis of blood agar.
enzymes are generally secreted by gram-negative More than 90% of clindamycin is absorbed
bacteria. The b-lactamase inhibitor, clavulanic following oral administration. Absorption is
acid (clavulanate), is a b-lactam, structurally delayed but not decreased with the ingestion of
similar to the penicillins, and is often coformulated food. Clindamycin’s broad-spectrum coverage
with the b-lactam antibiotics amoxicillin or ticarcil- and excellent clinical efficacy, coupled with the in-
lin. The combination of amoxicillin with clavulanate crease in both penicillin resistance and the reports
potassium is generally prescribed as 875 mg orally of treatment failures with penicillin, has prompted
2 times a day. The authors recommend switching some experts to recommend clindamycin to be
to amoxicillin-clavulanic acid when there is not the drug of choice in treating odontogenic
an adequate response to amoxicillin in 48 hours infections.28
or use amoxicillin-clavulanic acid from the begin- The principal side effect associated with clin-
ning when the infection is moderate or if there is damycin is diarrhea, with a reported incidence
involvement of the maxillary sinuses. ranging from 0.1% to 17%.12 Clindamycin has
Clindamycin has excellent activity against gram- also been associated with pseudomembranous
positive organisms, such as Staphylococcus colitis. This concern may be exaggerated, howev-
aureus, Streptococcus spp, and most anaerobes er, and the risk is probably no greater than with
above the diaphragm and b-lactamase-producing other broad-spectrum antimicrobials, including
strains, and is used primarily in patients with odon- broad-spectrum penicillins and
togenic infections that are allergic to penicillin. cephalosporins.29
Clindamycin binds to the 50S ribosomal subunit The usual dose of clindamycin for odontogenic
of susceptible bacteria and interferes with protein infections is 300 to 450 mg orally every 6 hours.27
synthesis.27 Knowledge of the local susceptibilities pattern is
174 Caruso et al
important, as in some areas Streptococcus angi- erythromycin as effective adjunctive treatments

nosus, a prominent pathogen in odontogenic in- in the treatment of relatively mild odontogenic oro-
fections, is becoming increasingly resistant to facial infections but should be used in combination
clindamycin.27 with antibiotics that provide anaerobic coverage.
Cephalosporin antibiotics are a class of b-lac- Although metronidazole is highly active against
tam family antibiotics, originally derived from the anaerobic gram-negative bacilli and spirochetes,
fungus, Acremonium. Cephalosporins act by it is only moderately active against anaerobic
inhibiting enzymes in the cell walls of gram- cocci and is not active against aerobes, including
positive and gram-negative bacteria in the same Streptococcus spp. As a result, it cannot be
fashion as penicillins but are less susceptible to used alone in the treatment of odontogenic infec-
b-lactamases. tions. It should be used in combination with peni-
Cephalosporins have been reported to have cillins, cephalosporins, macrolides, or quinolones
cross-sensitivity with penicillins. However, cross- in the appropriate clinical setting.
reactivity with penicillins and other classes of b-
lactams, including other cephalosporins, is less INPATIENT MANAGEMENT OF COMPLICATED
common than previously thought, especially ODONTOGENIC INFECTIONS
among patients who have had mild (nonanaphy-
lactic) reactions to penicillins. For patients in which signs and symptoms of
In patients allergic to penicillins, but tolerant to odontogenic infection do not improve within 48
cephalosporins, and unable to take clindamycin, to 72 hours after surgical drainage and appro-
the authors recommend oral cefuroxime 500 mg priate oral antibiotics, referral to an oral and
twice daily for the treatment of mild odontogenic maxillofacial surgeon and an infectious disease
infections. Cefuroxime is the only oral cephalo- specialist is recommended. Severe infections
sporin that has coverage for anaerobic bacteria. must be identified promptly, as they can rapidly
Cefuroxime covers aerobic gram-positive organ- progress and be life threatening. Patients with
isms, such as S aureus, Streptococcus spp, persistent fever (temperature 38 C or 100.4 F),
anaerobic gram-positive cocci such as Peptos- stridor, odynophagia, rapid progression and the
treptococcus spp, and Viridans streptococci. For involvement of multiple spaces, and secondary
more serious cases, metronidazole 500 mg orally anatomic spaces should be treated in an inpatient
every 8 hours is recommended in addition to cefur- hospital setting.
oxime. The other cephalosporins do not provide When evaluating antimicrobial options for inpa-
adequate anaerobic coverage, and they must be tient management of odontogenic infections,
used in combination with either clindamycin or ampicillin-sulbactam (Unasyn) remains the first
metronidazole. choice for empiric coverage of most inpatients
As bactericidal antibiotics, quinolones inhibit the without penicillin allergy. This is formally an “off-la-
bacterial enzyme DNA gyrase and topoisomerase bel” use for odontogenic infections. The recom-
IV. They are not used as first-line oral agents in mended dose is IV 3 g every 6 to 8 hours;
the treatment of odontogenic infections. Use duration is 7 to 14 days (including oral step-
should be limited to patients with positive cultures down therapy).30 Unasyn provides broad
with Gram negatives that are not covered by extended coverage, including those that produce
amoxicillin or amoxicillin-clavulanic acid. Quino- b-lactamases. Unasyn is the treatment of choice
lones should be used in combination with amoxi- in immunocompetent patients. Penicillin G in com-
cillin or amoxicillin-clavulanic acid, clindamycin bination with metronidazole can also be consid-
or metronidazole, as many quinolones do not ered. This combination would be delivered as
have excellent activity against gram-positive penicillin G, 2 to 4 million units IV every 4 to 6 hours
cocci, and they do not cover anaerobes. along with 500 mg of metronidazole IV or orally
The FDA recommends avoiding unnecessary every 8 hours. For penicillin-allergic patients, the
treatment of patients with quinolones unless the current standard of care is clindamycin 600 mg
patient lacks alternatives. Quinolones can cause IV every 8 hours plus levofloxacin 500 to 750 mg
disabling and potential irreversible reactions, IV or PO every 24 hours.
including tendonitis/tendon rupture, peripheral Some experts advise against isolated clindamy-
neuropathy, central nervous system effects, and cin for initial therapy because of resistant S angi-
worsening of myasthenia gravis symptoms, nosus (millergi group) in 20-30% of isolates.
including muscle weakness. Equally Prevotella can be resistant to clindamycin
Macrolide antibiotics include azithromycin, clar- in about 20-30% of isolates.27 This susceptibility is
ithromycin, and erythromycin. Al-Belasy and dependent on local patterns of resistance. Infor-
Hairam26 described azithromycin and mation for local resistance patterns should be
available within the local hospital microbiology due to the risk of worsening hyperglycemia.35–37 A
department. survey of maxillofacial specialists in the United
If the penicillin allergy is confirmed as nonsevere, Kingdom in 2017 showed that 15% of practitioners
one could prescribe ceftriaxone (a third-generation used steroids to combat odontogenic infections.38
cephalosporin 1 to 2 g IV every 24 hours) plus This number increased to 60% when the infection
metronidazole (500 mg IV every 8 hours) or ceftriax- threatened airway compromise.38 The use of corti-
one 1-2 g IV every 24 hours and Clindamycin 600- costeroids in treating odontogenic infections is
900 mg IV every 6 to 8 hours. If available, cefoxitin quite debated with evidence supporting both argu-
2 g every 6 hours or cefotetan 2 g IV every 12 hours ments for and against.39
is also an option. The above antibiotic combina-
tions are not exhaustive and are the antibiotic com- SUMMARY
binations preferred by the authors, but different
antibiotic regimens can be selected taking in Antibiotics are an important aspect of care of the
consideration the presence or absence of antibiotic patient with an acute odontogenic infection. Anti-
allergies, drug interactions and local susceptibility biotics are not a substitute for definitive surgical
patterns of antibiotic resistance. management. Incision and drainage and the elim-
ination of the infection source are the main factors
CHLORHEXIDINE GLUCONATE in a favorable outcome.26
Some minor odontogenic infections can be
Oral suspension of 0.12% chlorhexidine gluconate treated effectively with surgery alone, and without
mouth rinse is a regular part of the oral infection additional antimicrobial drugs.26 However, these
and postoperative regimen of many oral and maxil- patients should be monitored closely for progres-
lofacial surgeons and dentists. In light of the abun- sion or resolution of the infection. Medical man-
dance of use of the suspension, there appears to be agement, including antibiotic medications,
a relative lack of recent data on the use of chlorhex- combined with surgery for removal of the infective
idine gluconate suspension in the prevention and source will provide ultimate treatment for the
treatment of odontogenic infections. Much of its infection.
use in modern oral and maxillofacial surgery and
dentistry is based on anecdotal practices. CLINICS CARE POINTS
Halabi and colleagues31 showed that chlorhexi-
dine gluconate mouth rinse was a safe and effective
way to reduce alveolar osteitis postoperatively in
patients with tooth extraction. Chlorhexidine gluco-
nate has also been shown to significantly reduce Appropriate management of odontogenic in-
plaque and gingival bleeding sores over placebos fections has a major effect on total health
in periodontal studies.32 A review by Daly and col- care dollars and overall patient outcomes.
leagues33 suggested there were benefits to chlor-
Outpatient vs inpatient management of
hexidine gluconate (both 0.12% and 0.2%) rinse odontogenic infections varies dramatically
after tooth extraction in the prevention of alveolar in both surgical intervention and medication
osteitis, but also identified incidents of patient selection.
adverse reactions to the solution. Given the high
Working closely with a microbiology labora-
frequency that this medication is prescribed, the tory could improve outcomes by providing cli-
authors recommend further study of this topic, nicians more data about the source and
and evidence-based prescribing practices. delivering guidance for specific antibiotic
therapy.
STEROIDS Chlorhexidine gluconate is used regularly for
these infections, but further studies should be
The use of steroids in acute odontogenic infection conducted to support its use.
has been the source of some controversy. Syn-
The use of steroids in odontogenic infections
thetic glucocorticoids tend to be much more potent is a debated topic with strong literature both
than their natural corticosteroid counterparts. for and against. Steroids should be used on a
Methylprednisolone is about 5 times as potent, case-by-case basis.
and betamethasone and dexamethasone are 20
Surgical intervention is the gold-standard
to 30 times as potent as natural corticosteroids.34 treatment for odontogenic infections, but
There are contraindications for the use of steroids. pharmacotherapy is an important adjuvant
For example, a common contraindication includes in successful outcomes.
a medical history significant for diabetes mellitus
176 Caruso et al
DISCLOSURES 13. Greenberg RN, James RB, Marier RL, et al. Microbi-
ologic and antibiotic aspects of infections in the oral
All authors of this article have no conflicts of inter- and maxillofacial region. J Oral Surg 1979;37(12):
ests to disclose. 873–84.
14. Kannangara DW, Thadepalli H, McQuirter JL. Bacte-
ACKNOWLEDGMENTS riology and treatment of dental infections. Oral Surg
The authors would like to provide a special thanks Oral Med Oral Pathol 1980;50(2):103–9.
to Elizabeth George, Assistant Chief Medical 15. von Konow L, Nord CE, Nordenram A. Anaerobic
Technologist of Microbiology at Memorial Health- bacteria in dentoalveolar infections. Int J Oral Surg
care System, Hollywood, FL, and her team for their 1981;10(5):313–22.
assistance with this article. 16. Baker KA, Fotos PG. The management of odonto-
genic infections. A rationale for appropriate
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Update On Antimicrobial Therapy in Management of Acute Odontogenic Infection in Oral and Maxillofacial Surgery

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Update On Antimicrobial Therapy in Management of Acute Odontogenic Infection in Oral and Maxillofacial Surgery

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U p d a t e o n A n t i m i c ro b i a l

INTRODUCTION anatomic spaces adjacent to the oral cavity and

Oral Maxillofacial Surg Clin N Am 34 (2022) 169–177

Fig. 1. Gross airway deviation, infection, and gas for-

important, as in some areas Streptococcus angi- erythromycin as effective adjunctive treatments

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