Title: Diagnosis and Management of Odontogenic Infections
1 Diagnosis and Management of Odontogenic Infections
Nino Zaya MD
November 2 2006
Understand the microbiology of odontogenic infections
Understand the signs symptoms and findings in patients with odontogenic infections
Review the various pathways of spread with odontogenic infections
Understand the medical and surgical management of odontogenic infections
43 y.o. male comes to the emergency room with drooling and shortness of breath that is exacerbated when laying down. He has had right lower tooth pain with mastication during the past month with worsening during the past week. He states that during the last day he has had neck pain and developed shortness of breath.
Elevation FOM with
induration in the submental
and bilateral sublingual spaces
as well as drooling
Inability to lay supine
Extensive dental caries
Among most frequently encountered infections in human body
Plagued our species for as long as we have existed
Pre-Columbian Indians unearthed in the American Midwest
Early Egypt revealed bony crypts of dental abscesses sinus tracts and the ravages of osteomyelitis of the mandible
Treatment of localized dental infection was probably the first primitive surgical procedure performed using a sharp stone or pointed stick to establish drainage
6 Anatomy 7 MICROBIOLOGY OF ODONTOGENIC INFECTIONS
Usually caused by endogenous bacteria
Aerobic bacteria alone rarely causative agents
Streptococcus species are usually the etiologic organisms if aerobic bacteria present
Quantitative estimations of the number of microorganisms in saliva and plaque range as high as 1011/ml.
History-previous toothaches onset duration presence of fever and previous treatments (antibiotics ) important
Patients may complain of trismus dysphagia and have shortness of breath should be investigated.
Findings vary from mild swelling and pain to life-threatening airway compromise and CNS impairment
Possibly fatal infections may present with respiratory impairment dysphagia impaired vision ophthalmoplegia hoarseness lethargy and decreased level of consciousness
Exam findings Toxic CNS impairment (decreased level of consciousness meningeal irritation severe headache and vomiting) eyelid edema and ophthalmoplegia.
Rubor- (redness) cutaneous surface involved due to vasodilatation effect of inflammation
Tumor-(swelling) occurs due to the accumulation of pus or fluid exudate
Calor-(heat) is the result of increased blood flow to the area due to the vasodilatation.
Dolor-(or pain) results from pressure on sensory nerve endings from tisssue distention caused by edema or infection
Functiolaesa-(loss of function) problems with mastication trismus dysphagia and respiratory impairment
Inspection palpation and percussion are integral parts of the exam
Begin extraorally and then move inraorally
Skin of the face head and neck for swelling fluctuation erythema sinus or fistula formation and subcutaneous crepitus
Assess for cervical lymphadenopathy and fascial space involvement
Assess for the presence and magnitude of trismus
Inspect teeth for presence of caries and large restorations localized swellings fistulas and mobility
FOM inspected to assess for fascial space involvement
Visualize Whartons and Stensons ducts for quality of fluid (pus or saliva)
Ophthalmologic examination extraocular muscle function proptosis presence of preseptal or postseptal edema
Imaging studies can further substantiate diagnosis
Computerized tomograms should be obtained when infection has spread into fascial spaces in the orbit or neck
Infections well-localized to oral cavity do not require special imaging studies with a panorex being sufficient for diagnosis and treatment
15 Pathways of Odontogenic Infection
Usual cause of odontogenic infection necrosis of tooth pulp and bacterial invasion through the pulp chamber into deeper tissues
Pulp necrosis results from deep decay in tooth (inflammatory reaction)
The pulpal foramen does not allow drainage of the infected pulp
Further progression leads to medullary space infection and osteomyelitis
More commonly get fistulous tracts through alveolar bone
Fistulous tract may penetrate oral mucosa or facial skin
16 Continued. 17 Fascial Spaces
Fascial planes offer anatomic highways for infection to spread superficial to deep planes
Antibiotic availability in fascial spaces is limited due to poor vascularity
Treatment of fascial space infections depends on I and D
Fascial spaces are contiguous and infection readily spreads from one space to another (open primary and secondary spaces)
Despite I and D the etiologic agent (tooth) must be removed
18 Primary Mandibular Spaces
Infection can result directly due to infected mandibular incisor or indirectly from the submandibular space
Space located between the anterior bellies of the digastric muscle laterally deeply by the mylohyoid muscle and superiorly by the deep cervical fascia the platysma muscle the superficial cervical fascia and the skin
Dependent drainage of this space is performed by placing a horizontal incision in the most dependent area of the swelling extraorally with a cosmetic scar being the result
Superior-mylohyoid muscle and inferior border of the mandible
Anteriorly-anterior belly of the digastric muscle
Posteriorly-posterior belly of the digastric muscle
Superficially-platysma muscle and superficial layer of the deep cervical fascia
Infected mandibular 2nd and 3rd molars cause submandibular space involvement since root apices lay below mylohyoid muscle
20 Submandibular Space Abscess 21 Continued.
Submandibular and sublingual spaces surgically distinct but should be considered as surgical unit due to proximity and frequent dual involvement in odontogenic infections.
Infected premolar and 1st molar teeth frequently drain into this space due to their root apices existing superior to the mylohyoid muscle
22 Sublingual Space Infection 23 Continued.
Lateral-Skin of the face
Both a primary mandibular and maxillary space
Most infections caused by posterior maxillary teeth
24 Buccal Space Abscess 25 Secondary Mandibular Spaces
Referred to as secondary spaces since they are infected after involvement of primary mandibular spaces
Failure to treat a primary space infection or a compromised host results in secondary space involvement
Connective tissue fascia has poor blood supply hence treatment usually surgical to drain purulent exudates
The secondary mandibular spaces include the masseteric pterygomandibular and temporal spaces
Located between lateral aspect of the mandible and the masseter muscle
Involvement of this space generally occurs from buccal space primary involvement
Signs of involvement of the masseteric space include trismus and posterior-inferior face swelling
Location between medial aspect of the mandible and the medial pterygoid muscle (communicates with infratemporal spaces)
2ndary infection results from spread from the sublingual and submandibular spaces
Minimal swelling on exam
Location posterior and superior to the masseteric and pterygomandibular spaces
Bounded laterally by the temporalis fascia and medially by the temporal bone
Superficial temporal space located between temporal fascia and temporalis muscle
Deep temporal space located between the temporalis muscle and the temporal bone
Continuous with the infratemporal space
Masseteric pterygomandibular and temporal spaces referred to as masticator space due to delineation by the muscles of mastication
Communicate freely with one another and are simultaneously involved
Cummings Otolaryngology Head and Neck Surgery. Chapter 67. Odontogenic Infections.
Images LA. http//www.aafp.org/afp/990700ap/109.ht ml
PowerShow.com is a leading presentation/slideshow sharing website. Whether your application is business, how-to, education, medicine, school, church, sales, marketing, online training or just for fun, PowerShow.com is a great resource. And, best of all, most of its cool features are free and easy to use.
You can use PowerShow.com to find and download example online PowerPoint ppt presentations on just about any topic you can imagine so you can learn how to improve your own slides and presentations for free. Or use it to find and download high-quality how-to PowerPoint ppt presentations with illustrated or animated slides that will teach you how to do something new, also for free. Or use it to upload your own PowerPoint slides so you can share them with your teachers, class, students, bosses, employees, customers, potential investors or the world. Or use it to create really cool photo slideshows - with 2D and 3D transitions, animation, and your choice of music - that you can share with your Facebook friends or Google+ circles. That's all free as well!
For a small fee you can get the industry's best online privacy or publicly promote your presentations and slide shows with top rankings. But aside from that it's free. We'll even convert your presentations and slide shows into the universal Flash format with all their original multimedia glory, including animation, 2D and 3D transition effects, embedded music or other audio, or even video embedded in slides. All for free. Most of the presentations and slideshows on PowerShow.com are free to view, many are even free to download. (You can choose whether to allow people to download your original PowerPoint presentations and photo slideshows for a fee or free or not at all.) Check out PowerShow.com today - for FREE. There is truly something for everyone!