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Dental Alveolar Surgery

Principles of Management and Prevention of


Odontogenic Infections Part I

Presented By:
Gerald Volire DDS, B.Sc.D, DHSA, CDT, RDH, B.Sc.
geraldvoliere@yahoo.ca

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Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University
Principles of Management and Prevention of
Odontogenic Infections Part I
Introduction

One of the most difficult Caries, periodontal


problems to manage in disease, and pulpitis
dentistry is an Are the initiating infections that
odontogenic infection can spread beyond the teeth
to the alveolar process
Odontogenic infections And the deeper tissues of
arise from the teeth and the face, oral cavity,
have a characteristic head, and neck
flora
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Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University
Principles of Management and Prevention of
Odontogenic Infections Part I
Introduction

These infections may The majority of odontogenic


range from low-grade, infections are readily managed by
minor surgical procedures
well-localized infections
And supportive medical therapy
That require only minimal that includes antibiotic
administration
treatment
The practitioner must constantly
To severe, life-threatening bear in mind that these infections
deep fascial space occasionally become severe and
infections life-threatening in a short time

Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University 11/10/2017 3
Principles of Management and Prevention of
Odontogenic Infections Part I
Introduction

This topic is divided into three 2. The natural history of


main sections odontogenic infections
1. The typical microbiologic When infections occur, they may
erode through bone and into the
organisms involved in overlying soft tissue
odontogenic infections Knowledge of the usual pathway of
Appropriate therapy of infection from the teeth and
odontogenic infections depends surrounding tissues through the
on a clear understanding of the bone
causative bacteria And into the overlying soft tissue
planes is essential when planning
appropriate therapy
Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University 11/10/2017 4
Principles of Management and Prevention of
Odontogenic Infections Part I
Introduction

3. The principles of management of odontogenic


infections
The microbiology and typical pathway of infection
Prophylaxis against infection
The prophylaxis of wound infection and of metastatic
infection

Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University 11/10/2017 5
Principles of Management and Prevention of
Odontogenic Infections Part I
Outline

MICROBIOLOGY OF ODONTOGENIC INFECTIONS


NATURAL HISTORY OF PROGRESSION OF
ODONTOGENIC INFECTIONS

Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University 11/10/2017 6
Principles of Management and Prevention of
Odontogenic Infections Part I
Outline

Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University 11/10/2017 7
Principles of Management and Prevention of Odontogenic Infections Part I
Outline
PRINCIPLES OF THERAPY OF ODONTOGENIC INFECTIONS

Principle 1 : Determine Severity of Principle 5: Support Patient


Infection Medically
Principle 2: Evaluate State of Patient's
Host Defense Principle 6: Choose and Prescribe
Appropriate Antibiotic
Principle 3: Determine Whether Patient
Should Be Treated by General Dentist or Principle 7: Administer Antibiotic
Oral and Maxillofacial Surgeon Properly
Principle 4: Treat Infection Surgically
Principle 8: Evaluate Patient
Frequently

Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University 11/10/2017 8
Principles of Management and Prevention of Odontogenic Infections Part I
Outline
PRINCIPLES OF THERAPY OF ODONTOGENIC INFECTIONS

Principle 1 : Determine Severity Principle 2: Evaluate State of


of Infection Patient's Host Defense
Complete History Mechanisms
Physical Examination Medical Conditions That
Compromise Host Defenses
Pharmaceuticals That
Compromise Host Defenses

Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University 11/10/2017 9
Principles of Management and Prevention of Odontogenic Infections Part I
Outline
PRINCIPLES OF THERAPY OF ODONTOGENIC INFECTIONS

Principle 6: Choose and Use the Antibiotic with the


Prescribe Appropriate Lowest Incidence of Toxicity
Antibiotic and Side Effects
Determine the Need for Use a Bactericidal Antibiotic,
Antibiotic Administration If Possible
Use Empirical Therapy Be Aware of the Cost of
Routinely Antibiotics
Use the Narrowest-Spectrum Summary
Antibiotic
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Principles of Management and Prevention of Odontogenic Infections
Outline
PRINCIPLES OF PROPHYLAXIS OF WOUND INFECTION

Principle 1 : Procedure Should Have Significant Risk of Infection


Principle 2: Choose Correct Antibiotic
Principle 3: Antibiotic Plasma Level Must Be High
Principle 4: Time Antibiotic Administration Correctly
Principle 5: Use Shortest Antibiotic Exposure That Is Effective
Summary

Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University 11/10/2017 11
Principles of Management and Prevention of Odontogenic Infections Part I
Outline
PRINCIPLES OF PROPHYLAXIS AGAINST METASTATIC INFECTION

Prophylaxis Against Infectious Endocarditis


Prophylaxis in Patients with Other Cardiovascular
Conditions
Prophylaxis Against Total Joint Replacement Infection

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Ubi Pus, Ibi Evacua

A Latin aphorism or adage, often cited in medicine, meaning


Where there is pus, there evacuate it
It refers to what clinicians should do when there is a collection of
pus in the body
That is, to create an opening for it to evacuate
A contemporary expression of the same sentiment is also used
If there's pus about, let it out"

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History

Hippocrates was an ancient


Greek physician in the time of
Classical Athens, and is often
referred to as the father of
Western medicine

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Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University
Incision of an abscess above a front tooth and insertion of a surgical drain
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MICROBIOLOGY OF ODONTOGENIC INFECTIONS

The bacteria that cause infection are most These bacteria are primarily
commonly part of the indigenous bacteria aerobic gram-positive cocci,
that normally live on or in the host
anaerobic gram-positive cocci, and
Odontogenic infections are no exception anaerobic gram-negative rods
because the bacteria that cause
odontogenic infections are part of the These bacteria cause a variety of
normal oral flora: common diseases, such as
Those that comprise the bacteria of plaque Dental caries
Those found on the mucosal surfaces
Gingivitis
Those found in the gingival sulcus
Periodontitis
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MICROBIOLOGY OF ODONTOGENIC INFECTIONS

When these bacteria gain access to deeper underlying tissues


As through a necrotic dental pulp
Or through a deep periodontal pocket
They cause odontogenic infections
As the infection progresses more deeply
Different members of the infecting flora can find better growth conditions
And begin to outnumber the previously dominant species
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MICROBIOLOGY OF ODONTOGENIC INFECTIONS

Many carefully 1. Almost all odontogenic infections are caused by


multiple bacteria
performed microbiologic
The polymicrobial nature of these infections
studies of odontogenic makes it important that the clinician
infections have understands the variety of bacteria that are
demonstrated the likely to cause the infection
microbiologic In most odontogenic infections, the laboratory
composition of these can identify an average of five species of
bacteria
infections
For as many as eight different species to be
Several important factors identified in a given infection is not unusual
must be noted On rare occasions a single species may be
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MICROBIOLOGY OF ODONTOGENIC INFECTIONS

New molecular methods, 2. The oxygen tolerance of the


which identify the infecting bacteria causing odontogenic
species by their genetic
makeup
infections
Have allowed scientists to Because the mouth flora is a
identify greater numbers combination of aerobic and
and a whole new range of anaerobic bacteria
species not previously
associated with these It is not surprising to find that most
infections odontogenic infections have
Including unculturable anaerobic and aerobic bacteria
pathogens
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MICROBIOLOGY OF ODONTOGENIC INFECTIONS

Infections caused by aerobic The predominant aerobic bacteria in


bacteria alone account for 6% of all odontogenic infections (found in about
65% of cases) are the Streptococcus milleri
odontogenic infections group
Anaerobic bacteria alone are found Which consists of three members of the S.
in 44% of odontogenic infections viridans group of bacteria: S. sanginosus,
S. intermedius, and S. constellatus
Infections caused by mixed These facultative organisms, which can
anaerobic and aerobic bacteria grow in the presence and the absence of
compose 50% of all odontogenic oxygen
infections May initiate the process of spreading into
the deeper tissues
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MICROBIOLOGY OF ODONTOGENIC INFECTIONS

Miscellaneous bacteria contribute 5% or less of the aerobic


species found in these infections
Rarely found bacteria include
Staphylococci
Group D Streptococcus organisms
Other streptococci, Neisseria spp . , Corynebacterium spp . , and
Haemophilus spp.

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MICROBIOLOGY OF ODONTOGENIC INFECTIONS

The anaerobic bacteria found in The Prevotella and Porphyromonas spp. are found
odontogenic infections include an even in about 75% of these
greater variety of species And Fusobacterium organisms are present in more
than 50%
Two main groups predominate
Of the anaerobic bacteria, several gram-positive
1. The anaerobic gram-positive cocci are cocci (i.e., anaerobic Streptococcus and
found in about 65% of cases Peptostreptococcus spp . ) and gramnegative rods
(i.e., Prevotella and Fusobacterium spp. )
These cocci are anaerobic Streptococcus Play a more important pathogenic role
and Peptostreptococcus The anaerobic gram-negative cocci and the
anaerobic gram-positive rods appear to have little
2. Oral gram-negative anaerobic rods are or no role in the cause of odontogenic infections
cultured in about three quarters of the Instead, they appear to be opportunistic organisms
infections
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MICROBIOLOGY OF ODONTOGENIC INFECTIONS

The method by which mixed aerobic and Metabolic by-products from the streptococci
anaerobic bacteria cause infections is then create a favorable environment for the
known with some certainty growth of anaerobes
The release of essential nutrients
After initial inoculation into the deeper
tissues Lowered pH in the tissues
Consumption of local oxygen supplies
The facultative S. milleri group organisms
can synthesize hyaluronidase The anaerobic bacteria are then able to grow,
and as the local oxidation-reduction potential is
Which allows the infecting organisms to lowered further
spread through connective tissues
The anaerobic bacteria predominate and cause
Initiating a cellulitis type of infection liquefaction necrosis of tissues by their
synthesis of collagenases

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MICROBIOLOGY OF ODONTOGENIC INFECTIONS

As collagen is broken down and invading white blood cells necrose and lyse
Micro abscesses form and may coalesce into a clinically recognizable abscess
In the abscess stage, the anaerobic bacteria predominate
And may eventually become the only organisms found in culture
Early infections appearing initially as a cellulitis may be characterized as
aerobic streptococcal infections
And late, chronic abscesses may be characterized as anaerobic infections

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MICROBIOLOGY OF ODONTOGENIC INFECTIONS

Clinically, this progression of the infecting flora from 3. At 5 to 7 days after the onset of swelling, the
aerobic to anaerobic
anaerobes begin to predominate
Seems to correlate with the type of swelling that can be
found in the infected region Causing a liquefied abscess in the center of the
Thus, odontogenic infections seem to pass through four swollen area
stages This is the abscess stage
1. In the first 3 days of symptoms, a soft, mildly tender,
doughy swelling represents the inoculation stage 4. When the abscess drains spontaneously
In which the invading streptococci are just beginning to
through skin or mucosa or it is surgically
colonize the host drained, the resolution stage begins
2. After 3 to 5 days, the swelling becomes hard, red, and As the immune system destroys the infecting
acutely tender bacteria
As the infecting mixed flora stimulates the intense
inflammatory response of the cellulitis stage And the processes of healing and repair ensue

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MICROBIOLOGY OF ODONTOGENIC
INFECTIONS

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NATURAL HISORY OF PROGRESSION OF
ODONTOGENIC INFECTIONS

Odontogenic infections have two major origins:


1. Periapical, as a result of pulpal necrosis and subsequent bacterial
invasion into the periapical tissue
2. Periodontal, as a result of a deep periodontal pocket that allows
inoculation of bacteria into the underlying soft tissues
Of these two, the periapical origin is the most common in
odontogenic infections
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NATURAL HISORY OF PROGRESSION OF
ODONTOGENIC INFECTIONS

Necrosis of the dental pulp as a The infection spreads equally in all


result of deep caries allows a directions but preferentially along
pathway for bacteria to enter the the lines of least resistance
periapical tissues The infection spreads through the
Once this tissue has become cancellous bone until it encounters
inoculated with bacteria and an a cortical plate
active infection is established If this cortical plate is thin, the
infection erodes through the bone
and enters the surrounding soft
tissues
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NATURAL HISORY OF PROGRESSION OF
ODONTOGENIC INFECTIONS

Treatment of the necrotic pulp by standard endodontic therapy or


extraction of the tooth should resolve the infection
Antibiotics alone may arrest, but do not cure, the infection
Because the infection is likely to recur when antibiotic therapy has ended
without treatment of the underlying dental cause
Thus the primary treatment of pulpal infections is endodontic
therapy or tooth extraction, as opposed to antibiotics

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NATURAL HISORY OF PROGRESSION OF
ODONTOGENIC INFECTIONS

When the infection erodes through the cortical plate of the alveolar process,
it spreads into predictable anatomic locations
The location of the infection arising from a specific tooth is determined by the
following two major factors
The thickness of the bone overlying the apex of the tooth
The relationship of the site of perforation of bone to muscle attachments of
the maxilla and mandible

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Figure I 5-1 demonstrates how infections perforate through bone into the overlying soft
tissue
In Figure I 5-1, A, the labial bone overlying the apex of the tooth is thin compared with the
bone on the palatal aspect of the tooth
Therefore, as the infectious process spreads, it goes into the labial soft tissues

In Figure 1 5- 1, B, the tooth is


severely proclined, which
results in thicker labial bone and
a relatively thinner palatal bone
In this situation, as the infection
spreads through the bone into
the soft tissue, the infection is
seen as a palatal abscess

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NATURAL HISORY OF PROGRESSION OF
ODONTOGENIC INFECTIONS

Once the infection has eroded through the bone


The precise location of the soft tissue infection is
determined by the position of the perforation
relative to the muscle attachments

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In Figure 15-2, A, the infection has eroded through to the facial aspect of the tooth
And inferior to the attachment of the buccinator muscle
Which results in an infection that appears as a vestibular abscess

In Figure 1 5-2, B, the


infection has eroded
through the bone
superior to the
attachment of the
buccinator muscle
And is expressed as an
infection of the buccal space
Because the buccinator
muscle separates the buccal
and vestibular spaces

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NATURAL HISORY OF PROGRESSION OF
ODONTOGENIC INFECTIONS

Infections from most maxillary teeth erode through the


facial cortical plate
These infections also erode through the bone below the
attachment of the muscles that attach to the maxilla
Which means that most maxillary dental abscesses appear
initially as vestibular abscesses

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Likewise, on occasion a long maxillary canine root allows infection to erode through the
bone superior to the insertion of the levator anguli oris muscle
And causes an infraorbital (canine) space infection

Occasionally, a palatal abscess arises from


the apex of a severely inclined lateral
incisor or the palatal root of a maxillary
first molar or premolar (Fig. 1 5-3)
More commonly, the maxillary molars
cause infections that erode through the
bone superior to the insertion of the
buccinator muscle
Which results in a buccal space infection

Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University

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NATURAL HISORY OF PROGRESSION OF
ODONTOGENIC INFECTIONS

Mandibular molar teeth infections In the mandible, infections


erode through the lingual cortical of the incisors, canines, and
bone more frequently than with the
anterior teeth premolars
First molar infections may drain Usually erode through the
buccally or lingually
facial cortical plate superior
Infections of the second molar can
perforate buccally or lingually (but to the attachment of the
usually lingually) muscles of the lower lip
Third molar infections almost always Resulting in vestibular
erode through the lingual cortical
plate abscesses

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NATURAL HISORY OF PROGRESSION OF
ODONTOGENIC INFECTIONS

The mylohyoid muscle determines whether


infections that drain lingually go superior to that
muscle into the sublingual space or below it into
the submandibular space

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NATURAL HISORY OF PROGRESSION OF
ODONTOGENIC INFECTIONS

The most common odontogenic deep fascial


space infection is a vestibular space abscess
(Fig. 1 5-4)
Occasionally, patients do not seek treatment
for these infections
And the process ruptures spontaneously and drains
Resulting in resolution or chronicity of the infection
The infection recurs if the site of spontaneous
drainage closes

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NATURAL HISORY OF PROGRESSION OF
ODONTOGENIC INFECTIONS

Sometimes the abscess


establishes a chronic sinus
tract that drains to the oral
cavity or to the skin (Fig. 15-5)

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NATURAL HISORY OF PROGRESSION OF
ODONTOGENIC INFECTIONS

As long as the sinus tract continues to drain, the patient experiences no pain
Antibiotic administration usually stops the drainage of infected material
temporarily
But when the antibiotic course is over, the drainage recurs
Definitive treatment of a chronic sinus tract requires treatment of the original
causative problem
Which is usually a necrotic pulp
In such a case the necessary surgery is endodontic therapy or extraction of
the infected tooth
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PRINCIPLES OF THERAPY OF ODONTOGENIC
INFECTIONS

This section discusses the management of the odontogenic


infection
A series of principles are discussed that are useful in treating
patients who come to the dentist with infections related to
the teeth and gingiva

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PRINCIPLES OF THERAPY OF ODONTOGENIC
INFECTIONS

The clinician must keep in mind the


information in the preceding two sections to The first three principles are perhaps the
understand these principles most important in determining the
By following these principles in stepwise outcome
fashion Yet they can be accomplished by the
The clinician may not always achieve the experienced practitioner
expected result
Within the first few minutes of the
But he or she will certainly have met the initial patient encounter
standard of care

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Principle 1: Determine Severity of Infection

Most odontogenic infections are mild and require only


minor surgical therapy
When the patient comes for treatment, the initial goal is
to assess the severity of the infection
This determination is based on a complete history of the
current infectious illness and a physical examination
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Principle 1: Determine Severity of Infection
Complete History

The history of the patient's infection follows the same general


guidelines as any history
The initial purpose is to find out the patient's chief complaint
Typical chief complaints of patients with infections are
"I have a toothache,"
"My jaw is swollen,"
Or "I have a gum boil in my mouth"
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Principle 1: Determine Severity of Infection
Complete History

The complaint should be recorded in the patient's own words


The next step in taking of the history is determining how long the
infection has been present
First, the dentist should inquire as to time of onset of the infection
How long ago did the patient first have symptoms of pain,
swelling, or drainage which indicated the beginning of the
infection?
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Principle 1: Determine Severity of Infection
Complete History

The course of the infection is then discussed


Have the symptoms of the infection been constant?
Have they waxed and waned?
Or has the patient steadily grown worse since the
symptoms were first noted?

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Principle 1: Determine Severity of Infection
Complete History

The practitioner should determine the rapidity of


progress of the infection
Has the infection process progressed rapidly over a few
hours, or has it gradually increased in severity over several
days to a week?

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Principle 1: Determine Severity of Infection
Complete History

The next step is eliciting the These signs and symptoms are the
patient's symptoms Latin terms
Dolor (pain)
Infections are actually a
severe inflammatory response Tumor (swelling)
Calor (warmth)
And the cardinal signs of
inflammation are clinically Rubor (erythema, redness)
easy to discern Functio laesa (loss of function)

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Principle 1: Determine Severity of Infection
Complete History

The most common complaint is pain


The patient should be asked where the pain
actually started and how the pain has spread since
it was first noted

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Principle 1: Determine Severity of Infection
Complete History

The second sign is tumor (swelling)


Swelling is a physical finding that is sometimes
subtle and not obvious to the practitioner
Although it is obvious to the patient
It is important that the dentist ask the patient to
describe any area of swelling
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Principle 1: Determine Severity of Infection
Complete History

The third characteristic of infection is calor


(warmth)
The patient should be asked whether the area has
felt warm to the touch

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Principle 1: Determine Severity of Infection
Complete History

Redness of the overlying area is the next


characteristic to be evaluated
The patient should be asked if there has been or
currently is any change in color, especially redness,
over the area of the infection

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Principle 1: Determine Severity of Infection
Complete History

Functio laesa should then be checked


When inquiring about this characteristic
The dentist should ask about trismus (difficulty in opening
the mouth widely)
And difficulty in chewing, swallowing (dysphagia), or
breathing (dyspnea)
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Principle 1: Determine Severity of Infection
Complete History

The dentist should then ask


how the patient feels in
general
Patients who feel fatigued,
feverish, weak, and sick are
said to have malaise
Malaise usually indicates a
generalized reaction to a
moderate to severe
infection

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Principle 1: Determine Severity of Infection
Complete History

In the next step the dentist inquires about treatment


The dentist should ask about previous professional
treatment and self-treatment
Many patients doctor themselves with leftover
antibiotics, hot soaks, and a variety of other home or
herbal remedies
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Principle 1: Determine Severity of Infection
Complete History

Occasionally, a dentist sees a patient who received treatment in an


emergency room 2 or 3 days earlier and was referred to a dentist
by the emergency room physician
The patient may have neglected to follow that advice until the
infection became severe
Sometimes, the patient did not take the prescribed antibiotic
because he or she could not afford to purchase it

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Principle 1: Determine Severity of Infection
Complete History

The patient's complete The first step in the physical


medical history should be examination is to obtain the
patient's vital signs, including
obtained in the usual temperature, blood pressure,
manner by interview pulse rate, and respiratory
rate
Or by self-administered
The need for evaluation of
questionnaire with verbal temperature is obvious
follow-up of any positive Patients who have systemic
findings involvement of infection have
elevated temperatures
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Principle 1: Determine Severity of Infection
Physical Examination

Patients with severe infections have


temperatures elevated to 101F or higher The vital sign that varies the least
(greater than 38.3C) with infection is the patient's blood
The patient's pulse rate increases as the pressure
patient's temperature increases
Only if the patient has significant
Pulse rates of up to 100 beats/min are not
uncommon in patients with infections pain and anxiety will there be an
If pulse rates increase to greater than 100 elevation in systolic blood pressure
beats/min, the patient may have a severe
infection
Severe septic shock results in
hypotension
And should be treated more aggressively

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Principle 1: Determine Severity of Infection
Physical Examination

The patient's respiratory rate should be closely observed


One of the major considerations in odontogenic infections is the
potential for partial or complete upper airway obstruction
As a result of extension of the infection into the deep fascial
spaces of the neck
As respirations are monitored, the dentist should carefully check
to ensure that the upper airway is clear and that breathing is
without difficulty
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Principle 1: Determine Severity of Infection
Physical Examination

Patients who have normal vital signs with


only a mild temperature elevation usually
The normal respiratory rate is have a mild infection that can be readily
14 to 16 breaths per minute treated
Patients who have abnormal vital signs
Patients with mild to with elevation of temperature, pulse rate,
moderate infections may have and respiratory rate
elevated respiratory rates Are more likely to have serious infection
and require more intensive therapy and
greater than 18 breaths/min evaluation by an oral and maxillofacial
surgeon

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Principle 1: Determine Severity of Infection
Physical Examination

Once vital signs have been taken, attention should be turned to


physical examination of the patient
The initial portion of the physical examination should be
inspection of the patient's general appearance
Patients who have more than a minor, localized infection have an
appearance of fatigue, feverishness, and malaise

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Principle 1: Determine Severity of Infection
Physical Examination

This is a "toxic appearance (Fig.1 5-6)


The patient's head and neck should be
carefully examined for the cardinal signs of
infection
And the patient should be inspected for any
evidence of swelling and overlying
erythema
The patient should be asked to open the
mouth widely, swallow, and take deep
breaths so that the dentist can check for
trismus, dysphagia, or dyspnea

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Principle 1: Determine Severity of Infection
Physical Examination

These are ominous signs of a severe infection, and the


patient should be referred immediately to an oral and
maxillofacial surgeon or emergency room
A recent study of severe odontogenic infections requiring
hospitalization found trismus (maximum interincisal
opening less than 20 mm) in 73% of cases, dysphagia in
78%, and dyspnea in 14%
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Principle 1: Determine Severity of Infection
Physical Examination

Areas of swelling must be examined by palpation


The dentist should gently touch the area of Another characteristic consistency
swelling to check for tenderness, amount of local
warmth or heat, and the consistency of the is fluctuant
swelling
The consistency of the swelling may vary from Fluctuance is the feeling of a fluid-
very soft and almost normal
filled balloon
Through a firmer, fleshy swelling (described as
having a doughy feeling) Fluctuant swelling almost always
To an even firmer or hard swelling (described as
feeling indurated) indicates an accumulation of pus in
An indurated swelling has similar firmness to a the center of an indurated area
tightened muscle

Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University 11/10/2017 64
Principle 1: Determine Severity of Infection
Physical Examination

The dentist then performs an intraoral The dentist should look


examination to try to find the specific and feel for areas of
cause of the infection
There may be severely carious teeth, an
gingival swelling and
obvious periodontal abscess, severe fluctuance
periodontal disease, combinations of
caries and periodontal disease And for localized
Or an infected fracture of a tooth or the vestibular swellings or
entire jaw draining sinus tracts
Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University 11/10/2017 65
The next step is to perform a radiographic examination
Principle 1: Determine Severity of Infection
This usually consists of the indicated periapical radiographs Physical Examination

Occasionally, however, extraoral radiographs, such as a panoramic radiograph, may be necessary


Because of limited mouth opening or other extenuating circumstances

After the physical examination, the


practitioner should begin to have a sense
of the stage of the presenting infection
Very soft, mildly tender, edematous
swellings indicate the inoculation stage
Whereas an indurated swelling indicates the
cellulitis stage (Fig. 15-7)

And central fluctuance indicates an


abscess (Fig. 15-8)

Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University 11/10/2017 66
Principle 1: Determine Severity of Infection
Physical Examination

Soft tissue infections in the inoculation stage may be


cured by removal of the odontogenic cause with or
without supportive antibiotics
Infections in the cellulitis or abscess stages require
removal of the dental cause of infection plus incision and
drainage and antibiotics

Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University 11/10/2017 67
Principle 1: Determine Severity of Infection
Physical Examination

Distinctions between
the inoculation,
cellulitis, and abscess
stages are typically in
duration, pain, size,
peripheral definition,
and consistency on
palpation, presence of
purulence, infecting
bacteria, and potential
danger (Table 15-3)
11/10/2017 68
Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University
Principle 1: Determine Severity of Infection
Physical Examination

The duration of cellulitis is usually thought


to be acute and is the most severe Edema, the hallmark of the
presentation of the infection inoculation stage, is typically diffuse
An abscess, however, is a sign of increasing and jellylike, with minimal
host resistance to the infection tenderness to palpation
Cellulitis is usually described as more The size of a cellulitis is typically
painful than an abscess, which may be the larger and more widespread than
result of its acute onset and distention of
that of an abscess or edema
tissues

Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University 11/10/2017 69
Principle 1: Determine Severity of Infection
Physical Examination

The periphery of a cellulitis is usually


indistinct
When palpated, edema can be very
soft or doughy
With a diffuse border that makes it
difficult to determine where the swelling A severe cellulitis is almost always
begins or ends described as indurated or even as
The abscess usually has distinct and well- being "boardlike"
defined borders
The severity of the cellulitis
Consistency to palpation is one of the increases as its firmness to
primary distinctions among the stages of
infection
palpation increases

Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University 11/10/2017 70
Principle 1: Determine Severity of Infection
Physical Examination

The presence of pus usually indicates that the


On palpation, an abscess feels fluctuant body has locally walled off the infection and
because it is a pus-filled cavity in the tissue that the local host resistance mechanisms are
bringing the infection under control
Thus an infection may appear innocuous in
its early stages and extremely dangerous In many clinical situations, the distinction
in its more advanced, indurated, rapidly between severe cellulitis and abscess may be
spreading stages difficult to make
Especially if an abscess lies deeply within the
A localized abscess is typically less
soft tissue
dangerous, because it is more chronic and
less aggressive In some patients an indurated cellulitis may
have areas of abscess formation within it

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Principle 1: Determine Severity of Infection
Physical Examination

Severe infections occupying multiple deep fascial spaces may be in an early


stage in one anatomic space, and in a more severe, rapidly progressive stage
in another fascial space
A severe, deeply invading infection may pass through ever deeper anatomic
spaces in a predictable fashion like a fire in a house
Where there may be smoke in one room, intense heat in another room, and
open flames near the source of the fire
The goal of therapy in such infections is to abort the spread of the infection in
all involved anatomic spaces
Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University 11/10/2017 72
Principle 1: Determine Severity of Infection
Physical Examination

In summary, edema represents the An acute abscess is a more mature


earliest, inoculation stage of infection that infection with more localized pain, less
is most easily treated swelling, and well-circumscribed borders
A cellulitis is an acute, painful infection The abscess is fluctuant on palpation
with more swelling and diffuse borders because it is a pus-filled tissue cavity
Cellulitis has a hard consistency on A chronic abscess is usually slow growing
palpation and contains no pus and less serious than a cellulitis
Cellulitis may be a rapidly spreading Especially if it has drained spontaneously
process in serious infections to the external environment

Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University 11/10/2017 73
Bibliography

Peterson L. J. Ellis III. E. Hupp J. R. Tucker M. R. et al. (2003).


Contemporary Oral And Maxillofacial Surgery. Fourth Edition.
Mosby Elsevier. 776 pages.
Fragiskos F.D. (2007). Oral Surgery. Springer-Verlag. 367 pages
Malamed S.F. (1997). Handbook of Local Anesthesia. Mosby. 329
pages.

Dr. Gerald Volire School & Hospital of Stomatology Wenzhou Medical University 11/10/2017 74