Agus Nurwiadh, drg., Sp.

BM
 Invasion of microorganisms
into the body, penetrate and
INFECTION destroy host slowly and
spread out through out the
body
(Peterson, 2004)

2
 Mikro-
organis
me

enviro
ment

Host

( Topazian. Oral and maxillofacial

infections 4th editions, 2002)

3
 Host Factors

1. Humoral factors
2. Cellular factors
3. Local factors

Decrease one of these mechanisms and it

increases the potential for infection.

4
 Circulating
In presence of
immunoglobulins, IgA infection,
along with prevents histamine,
complement, colonizatio serotonin,
prostaglandins
combine with n of support
microbes to form microbes inflammation
opsonins that on oral  vasodilation
promote mucosal and increased
vascular
phagocytosis by surfaces. permeability.
macrophages.

5
Phagocytes engulf and kill microbes, removing them,
preventing replication.

Lymphocytes produce lymphokines and

immunoglobulines (aids humoral).

Lymphokines stimulate reproduction of other

lymphocytes, and kills antigens.

6
 Abundant vascular supply
allowing humoral and cellular
response.

Mechanical cleansing by salivary

flow.
Specific factors
leading to
resistance: Secretory IgA contained within
saliva.

High epithelial turnover and

sloughing, taking with it adherent
bacteria.
A variety of microflora normally preventing
selection for a single organism by competing
for nutrients or release of by-products.
7
Aerobic (25%)
 Gram-positive cocci

 Streptococcus spp.
 Streptococcus Group D. spp.
 Staphylococcus spp.
 Eikenella spp.
 Gram-negative cocci (Neisseria spp.)

 Gram-positive rods (Corynebacterium spp.)

 Gram-negative rods (Haemophilus spp.)

 Miscellaneous and undifferentiated

James R. Hupp, Edward Ellis, Myron R. Tucker Contemporary Oral and Maxillofacial Surgery
4th Ed. Mosby Elsevier (2008) 8
Anaerobic (75%)
 Gram-positive cocci
 Streptococcus spp.
 Peptostreptoccus spp.
 Gram-negative cocci (Viellonella spp.)
 Gram-positive rods
 Eubacterium spp.
 Lactobacillus spp.
 Actinomyces spp.
 Clostridia spp.
 Gram-negative rods
 Bacteroides spp.
 Fusobacterium spp.
 Miscellaneous
9
 Spaces Involved in Odontogen Infections

 Primary Maxillary Spaces

1. Canine
2. Buccal
3. Infratemporal
 Primary Mandibular Spaces
1. Submental
2. Buccal
3. Submandibular
4. Sublingual
 Secondary Fascial Spaces
1. Masseteric
2. Pterigomandibular
3. Superficial and deep temporal
4. Lateral pharyngeal
5. Retropharingeal
6. Prevertebral
James R. Hupp, Edward Ellis, Myron R. Tucker, Contemporary Oral and Maxillofacial
Surgery. 4th Ed. Mosby Elsevier (2008)
10
 Spreading of
Odontogen Infection

11
 Definition:
Refer to infection of cavities, pulpitis, periapical abscess,
gingivitis, periodontitis, pericoronitis, osteitis & infection of
the subaponeurotic spaces during tooth formation

Oral infection (origin):

i) Deep decay infecting the nerve
(root canal)
ii) Infection spread beyond tooth
root into periapical tissue
iii) Periodontal gum infection that
disperse through spongy bone
iv) Submerged/impacted teeth
v) Retained/broken roots at/ below
gum level
Spreading of Odontogenic Infection

From the site of the initial lesion, inflammation may

spread in three ways:
1. By continuity through tissue spaces and planes.
2. Byway of the lymphatic system.
3. By way of blood circulation.

Fragiskos D. Fragiskos, Oral Surgery, Springer, 2007

13
Spreading of Odontogenic Infection

1. Lack of vascularisation
2. Connective loose tissue
Space 3. Poor defence mechanism on
infection

14
 This illustration notes six
possible locations of fascial
spaces abscess:
1. Vestibular space
2. Buccal space
3. Palatal space
4. Sublingual space
5. Submandibular space
6. Maxillary sinus

James R. Hupp, Edward Ellis, Myron R. Tucker Contemporary Oral and Maxillofacial
Surgery. 4th Ed. Mosby Elsevier (2008) 15
 Incidence According to Location

Proportions of fascial
space involvement in
Mandibular (A) and
maxillary (B)
odontogenic infection.

T Handley, M Devlin, D Koppel, J McCaul, JICS Volume 10, Number 1, January 2009 18
 The Principles in
Management of
Odontogen Infections

19
Complete history
• Chief complaint
• Determine how long the infection has been present
- onset of the infection
- duration of the infection
• Elicit the patient's symptoms
- dolor ( pain )
- tumor ( swelling )
- calor ( warmth )
- rubor ( redness )
- functio laesa ( loss of function )
• Previous professional treatment and self - treatment
Physical examination
• Collect patient's vital signs (T,BP,P,R)
• Inspect patient's general appearance
- fatique/malaise
- ask patient to open mouth widely ,swallow
and take deep breath ( to check for
dysfunction )
- Palpation of the area of swelling
• Intraoral examination
• Radiograph exam
Petersons Principles of oral and maxillofacial Surgery, 2004

22
COMPROMISED HOST DEFENSES
 Uncontrolled metabolic disease:
1. Uremia
2. Alcoholism
3. Malnutrition
4. Severe diabetes
 Suppressing disease:
1. Leukemia
2. Lymphoma
3. Maligant tumors
 Suppresing drugs:
Cancer chemotherapeutics agents
Immunosupressive agents
23
 Rapid progressive infection
 Difficulty in breathing
 Difficulty in swallowing
 Fascial space involvement
 Elevated temperature ( > 38,1O C)
 Severe jaw trismus (less than 10 mm)
 Toxic appearance
 Compromised host defenses

24
Goals to remove the cause of the
infection and provide drainage of
accumulated pus and necrotic debris
3 types : - Endodontic Treatment
- Extraction
- Incision and Drainage

25
  Drainage of pus provides for a reduction in tissue tension,
which improves the local blood supply and increase the
delivery of host defense to the localized area

 Technique for I & D :

1. Selection of site for the incision
2. Administer anesthesia at the site of incision
3. Obtain a specimen of pus for culture and sensitivity
4. Make an incision with no 11 blade
5. Insert a curved hemostat through the incision into the abscess
cavity

26
Petersons Principles of oral and maxillofacial Surgery, 2004 27
 Intra Oral

Petersons Principles of oral and maxillofacial Surgery, 2004 28

29
Incision And Drainage Of Abscess

30
 Prescribe analgesics
 Give post operative instructions
 Encourage patient to have adequate fluid
intake, nutritional intake and rest

31
 Indication for use of antibiotics

1. Rapidly progressive swelling

2. Diffuse swelling
3. Compromised host defenses
4. Involvement of fascial spaces
5. Severe pericoronitis
6. Osteomyelitis
32
Petersons Principles of oral and maxillofacial Surgery, 2004
33
1. Rapidly spreading infection
2. Postoperative infection
3. Nonresponsive infection
4. Recurrent infection
5. Compromised host defenses

34
Effective orally administered antibiotics
useful for odontogen infection
 - penicillin
 - erythromycin
 - clindamycin
 - cefadroxil
 - metronidazole
 - tetracycline
35
Severe odontogenic infections: Epidemiological, microbiological and
therapeutic factors. R. Sánchez, E. Mirada 1, J. Arias, J.R. Paño , M.
Burgueño . Med Oral Patol Oral Cir Bucal, 2008
36
 Follow up patient carefully
 Reason for treatment failure
- Inadequate surgery
- Depressed host defense
- Foreign body
- Antibiotic problem
- Patient non compaliance
- Drug not reaching site
- Wrong bacterial diagnosis
- Wrong antibiotics
37
38
39
CONCLUSION

40
 Incidence Mortality

Sepsis
400,000 7-17%

Severe Sepsis 20-53%

300,000

Approximately 200,000 Septic

53-63%
patients including 70,000 Shock
Medicare patients have
septic shock annually

Balk, R.A. Crit Care Clin 2000;337:52

41
TERIMA KASIH

42