ODONTOGENIC

INFECTIONS
 SPREAD OF INFECTIONS
(HOST DEFENCE MECHANISM)

• General Factors
• Local factors
 GENERAL FACTORS
 RESISTANCE OF BODY
• Humoral Mechanism
 B Lymphocytes - Immunoglobulin
 Complement - serum proteins
• Cellular Factors
 Cell mediated - Phagocytosis
 Polys ; monocytes
 BATCERIAL CONCENTRATION
• ↑Bactrial →Toxins → ↑Host over come
 BACTERIAL VIRULENCE
• Potent Exo/Endno Toxins.
• Produces Lytic enzymes.
 LOCAL FACTORS
 INTACT ANATOMICAL BARRIERS
• Bone
• Periostium
• Adjacent muscles / soft tissues
 INDIGENOUS BACTERIA
 MICROBIOLOGY OF
ODONTOGENIC INFECTION
 NORMAL FLORA (causative orgms)
• Aerobic gm + cocci
• Anerobic gm + cocci
• Anerobic gm + rods
 PATHOGENIC ORGMS
• STREPTOCOCCUS
 Alpha hemolyticus

 Beta hemolyticus

 Peptococcus

 Peptostreptococcus

• BACTEROIDES
• FUSOBACTERIUM
 MICROBIOLOGY OF
ODONTOGENIC INFECTION
 MIXED INFECTION
• Aerobic 5%
• Anaerobic 35%
• Aerobic & Anaerobic 60%
 COURSE OF INFECTION
• Initiation – Aerobic streptococci
(more invasive & virulent)
• Progression – Aerobic & mostly Anaerobic
(predominates as O2 falls)
• Chronic stage - Anaerobic
 ETIOLOGY
 PERIAPICAL INFECTION (PULP
NECROSIS)
 PERIODONTAL INFECTION
 PERICORONITIS
 EXTACTED WOUND INFECTION
 LOCAL TRAUMATIC INJURY
 HAEMATOGENOUS INFECTION
 STAGES OF
ODONTOGENIC INFECTION
 PERIAPICAL OSTEITIS
• Infection confined within bone
• Toot extruded from socket
• Tender on percussion
 CELLULITIS
• Infection perforates bone & enters into soft
tissues
• Swelling/doughy
• Not sharply demarcated
• No fluctuation
 ABSCESS
• Swelling- firm consistency
• Well demarcated
• Fluctuation present
 DIAGNOSIS OF ODONTOGENIC
INFECTION
 HISTORY
• Tooth ache
• Duration-acute/chronic
• Medical history
 EXAMINATION (GENERAL)
• Signs of toxemia
 Pain

 Fever-101°F

 Malaise

• Vital signs
 Temp - 101°F

 BP -normal

 Pulse rate -100 /min

 Resp 20/min
 DIAGNOSIS
 LOCAL EXAMINATION
• Tooth
 carious

 Tender

 Elevated

 Adjacent swelling/sinus

• Trismus
• Inflammed Pericoronal flap
• Painful deglutation
• Swelling
 Warm

 Tender

 Soft/doughy/firm/fluctuant

 RADIOGRAPHS
 SPACES INVOLVED IN
ODONTOGENIC INFECTIONS
 PRIMARY SPACES
• Maxillary
 Canine
 Buccal
 Infra temporal
• Mandibular spaces
 Sub mental
 Buccal
 Submandibular
 Sublingual
 SPACES INVOLVED IN
ODONTOGENIC INFECTIONS
 SECONDARY FACIAL SPACES
• Masseteric
• Superficial and deep temporal
• Parotid
• Pterygo mandibular
• Lateral pharyngeal
• Retro pharyngeal
• Pre vertebral
 LOCALIZATION OF ACUTE
ODONTOGENIC INFECTIONS
 INFLUENCING FACTORS
• Location OF Teeth apices
• Muscle attachment
• Thickness of labial/lingual cortical plates
 ADVANTAGES
• Tooth Involved
• Incision & Drainage
 PRIMARY SITE
OF LOCALIZATION FROM MAXILLARY
TEETH
 Central incisor apices
• Below Orbicularis Oris – Buccal vestibular swelling
 Lateral incisor
• Below Orbicularis Oris – Buccal vestibular swelling
• Root close to palate - palatal swelling
 Canine apex
• Below lev Ang oris - Buccal vestibular swelling
• Above lev Ang oris -canine space involvement
 Pre molars apices
• Below buccinator attachment - Buccal vestibular
swelling
• Above buccinator attachment -Buccal space inf
 Molars apices
• Below buccinator attachment - Buccal vest swelling
• Above buccinator attachment -Buccal space inf
• Palatal Root close to palate - palatal swelling
 Primary Site OF LOCALIZATION
FROM MANDIBULAR TEETH
 Incisors apices
• Above Orbicularis Oris/ mentalis – Buccal vestibular swelling
Below Orbicularis Oris/ mentalis - submental space inf
 Canine Apex
• Above dep ang oris - Buccal vestibular swelling
 Premolars
• Same as max premolars
 Molars apices
• Buccally
 Above buccinator attachment - Buccal vest swelling
 Below buccinator attachment - Buccal space inf
• Lingually
 1st molar & mesial root of 2nd molar

• Above mylohyoid attachment - Sublingual space

inf
 Distal root of 2nd molar & 3rd molar

• Below mylohyoid attachment - Submand space

inf / pterygomand space
 PRINCIPLES OF THERAPY
OR
TREATMENT OF ODONTOGENIC INF
 Treatment
1 DETERMINE THE SEVERITY OF INF
2 EVALUATE HOST DEFENCE MECHANISM
3 RX BY DENTIST/ SPECIALIST
4 SUPPORTIVE CARE
5 SURGICAL THERAPY
6 ANTIBIOTICS
7 EVALUATE PATIENT FREQUENTLY
 1- SEVERITY
 Determine the severity of INF
• Signs of toxemia
 Pain

 Fever-101°F

 Malaise

• Acute/chronic
• Cellulitis/abscess
 I&D
 2 -COMPROMIESD HOST
DEFENCE
 Metabolic
• Diabetes
• Malnutrition
• Alcoholism
• Uremia
 Suppressing Diseases
• Leukaemias
• Lymphomas
 Cytotoxic Drugs
• Immunosuoppressive
• Cytotoxic
• Steroids
 4 - SUPPORTIVE CARE
 Bed rest
 Hydration of patient
• Oral fluids , juices
• I/V
 Heat application
• mouth rinses
 Analgesics
 5- SURGICAL THERAPY
DRAINAGE
 Trephination - Periapical osteitis
• Necrotic pulp removed/RCT
 Extraction of offending tooth
 Incision and drainage
• Drainage of PUS
• Reduces tissue tension
• Improves local blood supply
• Increases delivery of local defence
 INCISION AND DRAINAGE
EXTRA ORAL
 GA
 Antiseptic
 Incision
 Most dependent area
 Two finger below lower border mandible
 Parallel to skin fold
 Drain
 Corrugated rubber drain
 Rodivick drain
 Stitch
 Secure
 Keeps opening patent
 INCISION AND DRAINAGE
(VESTIBULAR ABSCESS)
INTRA ORAL
 Anesthesia
• Away from site of incision
• Surface anesthesia
• Block
• Infiltration ant/post
 Pus for c/s
• 18 gauge needle
• 1-2ml pus aspirated
• Laboratory
• Adequate for both aerobic/anaerobic cultures
 Incision
• No 11 blade
• Most dependent area
• Through mucosa & sub mucosa
• I cm in length
 INCISION DRAINAGE
INTR ORAL
 Drainage
• Curved closed hemostat is inserted into the abscess
cavity----then opened to break locs
•
• Hilton’s method
 Break loculations

 Drain placement
• Rubber drain / pen rose / rubber dam
• Upto depth of abscess cavity
• Drain is Sutured to one side with nonresorbable
sutures
 Duration
• Uptill active drainage
• 2 to 5 days
 6 - Medical support to patients
ANTIBIOTICS
 Is antibiotic necessary
 Use empiric therapy routinely
 Use the narrowest spectrum
antibiotics
 Use antibiotic with lowest side effects
 Use bacteriocidal antibiotic if possible
 Consider cost of antibiotics
 Administer Antibiotic Properly
 ANTIBIOTICS - INDICATIONS
 Acute onset of INF
 Diffuse Swelling
 When early surgical Rx not possible
 Compromised host defences
 Involvement of facial spaces
 Severe Pericoronitis- 100 f
 Signs of Osteomylitis
ANTIBIOTICS NOT NECESSARY
 Chronic, well localized abscess
 Minor vestibular abscess
 Dry socket
 Mild pericoronitis
 Root canal sterilization
 PRINCIPLES OF USE OF
ANTIBIOTICS
 USE EMPIRIC THERAPY
• Prescribed with assumption that
appropriate drug is selected
• Against highly predictable organisms
• C & S not necessary for routine Odon
INF
• Both against aerobes & anaerobes
• Pen, ERY, CLIND, CEPH,MET
 CULTURE & ANTIBIOTIC
SESITIVITY
INDICATIONS
 Rapidly spreading infection

 Post operative INF

 Non responsive INF

 Recurrent INF

 Compromised host defence

 Osteomylitis/ actinomycosis
 BACTERIOCIDAL / STATIC
ANTIBIOTICS
 Use bactericidal antibiotics
• Bactericidal
 defective cell wall synthesis
 cell death
• Bacteriostatic
 Stops bacterial reproduction
 Host defence plays role
 No role in immuno compromised
 BACTERIOCIDAL / STATIC
ANTIBIOTICS
 Bacteriocidal
• Penicillin's
• Cephalosprins
• vancomycin
• Amino glycosides
 Gentamycin
 Streptomycin
 Bacteriostatic
• Erythromycin,
• Lincomycin
• Tetracycline's
• Clindamycin
 SIDE EFFECTS
 NEPHROTOXIC
• Amino glycosides
• Amphotericin
 HEPATOTOXIC
• Erythromycin
• Tetracycline
• Lincomycin
 Anaphylaxis – pencilline
 Bone marrow Depression – chloramphenicol
 Discoloration teeth – tetracycline
 Oral Candidiasis – Antibiotics
 DRUG INTER ACTION
 Heparine /warfarin +Aspirin -Anticog
effect
 Warfarin +antibotic------Anticog
 Halothane (GA)+ Adrenaline----
Arrhythmias
 Oral contraceptives + Ampicillin /
Tetracycline--- Contraceptive failure
 Digoxin +Erytromycin--- Digoxin Tox
 ANTIBIOTIC ADMINISTRATION
 Proper Dosage
- Adequate Plasma Level
- 4 or5 times the Minimum Inhibitory
Concentration for Specific Org.
 Proper Interval
- 4 Times the plasma half life of drug
- e.g. Earyth half life is 1.5 hrs
- Important in Bacteriostatic drug
 Proper Duration
- 2 to 3 days after infection
resolved
 TREATMENT FAILURE
REASONS
 DPRESSED HOST DEFENCE
 INADEQUATE SURGERY
 ANTIBIOTIC RELATED
• PATIENT NON COMPLIANCE
• DRUG NOT REACHING SITE
• DOSE TOO LOW
• WRONG BACTERIAL
DIAGNOSIS/WRONG ANTIBIOTICS
 PROPHYLAXIS OF INFECTION
(USE OF ANTIBIOTICS)
 ADVANTAGES:
1. They may reduce the incidence of post op
infection and thus reduce post op morbidity
2. May reduce cost of health care
3. May shorten administration of therapeutic
dosage thus decreasing the total amount of AB
used.
4. To Prevent Metastatic Infection
 PROPHYLAXIS OF INFECTION
(USE OF ANTIBIOTICS)
 DIS-ADVANTAGES:
1. The may alter host flora

2. Studies show that administration of AB in one patient allows

AB-resistant organisms to spread to patient family and relatives

3. May provide no benefit in certain situations when risk of infec is

very low.

4. May encourage lax surgical and aseptic technniques.

 PROPHYLAXIS OF WOUND
INFECTION (PRINCIPLES)
 1- Procedure should have significant
risk (3% or 10%)
• Extent of surgery
I. Clean surgery with strict adherence to basic surg princ
(3%)
II.Infection rates of >/10%- use P-AB

• Duration of surgery (operations lasting longer than 4

hours)
• Size of bacterial inoculum
• Presense of foreign body (e.g a dental implant)
• State of host defense
 2 -Antibiotic selection

 CRITERIA:

1. Should be effective against orgs most likely to

cause infec
2. Empiric therapy
3. Narrow spectrum
4. Bacteriocidal
5. Least side effects
6. Examples:= pencillin, amoxicillin, clindamycin (if
pencillin allergy), azithromycin
 3- Antibiotic plasma level must
be high
• To ensure diffusion into all tissues
before surgery
• Dose 2 times the usual therapeutic dose
egs
 Penicillin - 1gm
 Cephalosporin's -1gm
 Clindamycin – 300mg
 Erythromycin – 1gm
 4- Administer antibiotic timely
• 2 hours or less Before surgery- for maximum effects
• TIMING OF DOSING: varies with the route used:
 Oral:1hr
 IV: much shorter pre op dose interval possible

• After surgery – minimum/ no effect

P.AB given 2 hors or more AFTER surgery may INCREASE the risk
of wound infec

Prolonged surgery
 Additional intra operative dose to keep plasma level high
 ½ the normal therapeutic dosage interval e.g.
• Penicillin - every 2 hrs
• Cephalo -2hrs
• Clinda – 3hrs
• Ery – 2hrs
 PROPHYLAXIS OF WOUND
INFECTION (PRINCIPLES)
 5- use shortest antibiotic
exposure
• A preoperative dose
• Maintain intraop plasma levels
• Final dose given after surgical operation
1. Short procedures – a single pre op dose
2. 1 to 2 hr surgery – pre op dose & single
post op dose
3. No benefit after surgical operation
4. (minimum bacterial migration in wound)
METASTATIC INFECTION
 METASTATIC INFECTION
 It is defined as infection that occurs
at a location distant from the portal
of entry of the bacteria eg Bacterial
endocarditis
 Prophylactic antibiotics are used to
avoid metastatic infection.
 METASTATIC INFECTION
(FACTORS NECESSARY)
 Distant susceptible site
• Deformed heart valve with altered endothelial
surface
 Hematogenous bacterial seeding
• Oral surgery -- bacteremia (Quantity,duration)
15min to 1hr )
 Impaired local defenses
Damaged endothelial surface/prosthetic valve --
Bacteremia ---Cardiac vegetation --- fibrin
coating & __Difficult WBC phagocytosis -----
infective endocarditis
 INFECTIOUS ENDOCARDITIS
 It is defined as multiplication & fixation of an
offending microbial agent on the damaged
endocardium resulting in fever and heart
damage
 Pathophysiology
Rh fever--- turbulent flow ----- loss of
surface Endothelium----exposure of
underlying collagen --Fibrin/ platelets
attached---sterile vegetation___oral
Surgery____ Bacteremia___Vegetation
Become infected----infected Endocarditis
(PREDISPOSING FACTORS) pcp
dram
 Prosthetic heart valves
 Congenital heart malformations
 Rheumatic valve disease
 Degenerative valve disease
 Aortic stenosis/ regurgitation
 Mitral valve prolapse/insufficiency
 Previous episode of bacterial
endocarditic
 MICROBIOLOGY
 Streptococcus viridians
• Mitis
• Mutans
• Sanguis
• Salivarius
 CLINICAL SIGNS
 Low grade fever (<39°c )
 Feeling of weakness
 Anorexia & weight loss
 Exhaustion
 Diagnosis- history/ repeated blood
cultures
 DENTAL PROCEDURES
REQUIRING
ENDOCARDITIS PROPHYLAXIS
 Tooth extraction
 Periodontal surgery
 Sub gingival dental prophylaxis
 Endodontic surgery
 Incision & drainage
 ANTIBIOTIC PROPHYLAXIS

 GOALS
• Reduce the intensity of bacteremia
• Assist reticuloendothelial system in
phagocytosis
• Decrease bacterial adherence to damaged
heart surfaces
 REGIMEN
• Prescribed before surery (1 to 2hrs )
 Adequate blood concentration
 Decreased microbial resistance
 ANTIBIOTIC REGIMEN
 Amoxicillin PRE OP POST OP
3gm- 1hrs 1.5gm/6hr
50mg/kg 25mg/kg

 Erythromycin – 1gm/2hr 500mg/6hr

20mg /kg 10mg kg/6hr

 Clindamycin – 300mg/1hr 150mg/6hr

10mg/kg 5mg/kg
 PROPHYLAXIS OF INFECTIVE
ENDOCARDITIS
 Local disinfective measures
• chlorhexidine
 Reduce size of bacteremia
 Antibiotic prophylaxis
 Anticoagulant in prosthetic heart
valve
 Use of rubber dam
ACUTE ALVEOLAR
ABSCESS
(ACUTE PERI APICAL
ABSCESS)
 ETIOLOGY
 Necrotic pulp/carious tooth
 Traumatic pulp exposure
• Trauma
• Endodontic procedures
 Periodontal lesions
 Pre existing chronic periapical infection
 Alveolar/Mandibular fractures
 Chemical/ Thermal injury
 Infected cyst
 MICROBIOLOGY
 Streptococcus
• viridans
 Bacteroides
 Fusobacterium
 CLINICAL FEATURES
 Swelling
• Firm, tender
• Redness of over lying skin
 Pain
• Throbbing
 Tooth
• Carious/ non vital / discoloured
• Mobile
• Extruded from socket
• Tender on percussion /Biting
 Discharging sinus
• Oral
• Extra Oral
 Radiographic factures
 TREATMENT
 Incision & drainage
 Antibiotics
 Extraction / RCT
 LUDWIG’S ANGINA
 It is defined as a massive, firm
cellulitis affecting simultaneously
submental, sublingual and sub
mandibular spaces bilaterally
 Etiology
• Odontogenic Infections
 MODE OF SPREAD
 Odontogenic infection
 Submandibular space -Mylohyoid
Muscle Sublingual space ipsilateral
 Sublingual space -Tongue (Cleft
hyoglossus& genioglossus Muscles)
--Sublingual Space of contralateral
 Submental space via lymphatics
 SIGNS & SYMPTOMS
 Facial Swelling – (Bilateral)
• Massive, Firm,Brawny
• May extend upto clavicles
 Intra oral swelling
• Sublingual tissues
• Distension - floor of mouth
• Tongue displacement/ protrusion
• Difficult speech/ deglutition
 Signs of Toxemia
• High grade fever
• Progressive dyspnoea / Cynosis
 Blood gases assessment

• Oedema glottis- Respiratory obstruction

• Fatal within 12 to 24hrs
 TREATMENT
 Admission in hospital
 Incision and drainage
 Antibiotics
• Penicillin 500mg I/v – 8HRLY
• Metronidazle 500mg I/v -8HRLY
 INCISION & DRAINAGE
 Anesthesia
• Awaked endotracheal intubation with fiberoptic
laryngoscope
• I/v analgesia + local analgesia
• Naso pharyngeal airway/ tracheostomy set –
ready
 I&D
• Classical u shaped incision – obsolete
• Separate drainage of all three spaces
• Sublingual space drained through intra oral
approach at base of alveolar process in lingual
sulcus.
 PERICORONITIS
 It is infection of soft tissues around
the crown of a partially impacted
tooth
 MICROBIOLOGY
• same
 PREDISPOSING FACTORS
 Transient decrease in host defence
• Fatigue, emotional stress
• Pregnancy, upper resp INF,flu
 Trauma
• Impinging cusp of max molar
 Entrapment of food under operculum
 SIGNS AND SYMPTOMS
 Pain
 Trismus
 Facial swelling
 Foetor oris
 Painful / difficult swallowing
 Fever, lymphadenopathy
 Operculum;
• Swollen, tender, pus discharge on pressure
• Indentation, sloughing, ulceration
 CLASSIFICATION
 Acute
 Sub acute
 Chronic
 DIAGNOSIS
 Clinical examination
• Space for eruption
 Age of patient – 25years
 History of previous attacks
 Radiographs (PA,OPG)
 TREATMENT
 Supportive
• Hydration ,Diet, Rest ,Ant inflammatory drugs
 Local measures
• Saline mouth washes /2Hrs
• Irrigation of pericoronal space
 1% gentian violet
 Saline
 Povidone iodine
 Chlorhexidine
 Hydrogen per oxide- liberates oxygen- Reduces An B
• Extraction/grinding of cusp of upper molar
 TREATMENT
 Therapy
• Penicillin
• Mentronidazole
• Analgesic/ anti inflammatory
 Surgical
• Incision & drainage
• Removal of impacted tooth
 NEUROLOGICAL
COMPLICATIONS OF
ODONTOGENIC INFECTIONS
 Meningitis
• Most common complication
• Signs/ symptoms
 Headache, fever vomiting
 Neck rigidity, confusion
 Positive kernig's & Brudzinski’s signs
 Lumbar puncture & CSF exam
 Cavernous sinus thrombosis
• Direct extension via venous system or by
infected emboli
• Signs / symptoms
 Fever, Pain /tenderness eyes
 Oedema of eyelids, lacrimation, proptosis
 Opthalmoplegia, ptosis, papillary dilatation, absent
corneal reflex
 Brain abscess
• By bacteremia
• single or multiple abscesses
• Signs/symptoms
 Depends on site of involvement
 Headache, nausea, vomiting
 Majority patients are afebrile
 Hemiplegia, papilledema, aphasia
 Convulsions