8/12/2019 Surgery 10

1/15

Oral Surgery

Odontogenic Infections

Done by : Muad Salahuddin Al-Zoubi

Dedicated to : Rmz Al-Rabadi

8/12/2019 Surgery 10

2/15

This lecture is about infections, what infections are in general and how to deal with infections

we should know about.

The subject will be divided into the oral infectionsand more importantly the maxillofacial

infectionsthat occur when the infection proceeds from any oral or primary space (to be

mentioned below) to the secondary spaces. When, where and how they will be treated, these

will be encountered in this and the coming lectures.

Microbiology of infections

The oral cavity is considered to be dirtier than the other sites of the human being, this means

that the bacteria in the oral cavity are very numerous and very diverse and the bacteria which

are responsible for most of the infections in the oral cavity are oral flora (i.e. present in the

mouths of every normal individual). In general, the most common bacteria in the oral cavity

are the streptococci and S.viridansin particular, the types of bacteria present in the oral cavity

are either aerobic gram positive cocci(e.g. S.viridans), anaerobic gram positive coccior

anaerobic gram negative rods, so the oral cavity is polymicrobial. In general, the oral

infections are mixed infections, which means that if a sample is taken from an oral infection

and tried to be studied microbiologically, not only one type of bacteria will be found but

several types will be found (i.e. aerobic and anaerobic bacteria, cocci and rods, gram positive

and negative).

The aerobic infections (alone) constitute about 5% of oral infections (e.g. S.viridansand other

sorts of gram positive aerobic bacteria). The anaerobic infections (purely anaerobic) constitute

about 35% of oral infections (e.g. abscesses are mostly if not totally anaerobic infections). The

remaining 60% infections (the majority) are mixed infections.

* The sites involved in infections are the teeth and periodontium, either the apex, root canals

(and lateral canals) or the periodontium itself.

In general, infections tend to go through the easiest route (with the least resistance), e.g. thebacteria that caused the infection will try to spread (against the patients immune system),

they will spread through the routes that are easy to pass through, say, there are two routes,

one with thick bone and the other with thin less dense bone, the bacteria will spread through

the least resistant route (thin bone in this case).

8/12/2019 Surgery 10

3/15

What determines the location or spread of infection ?

Example: patient with abscess in the vestibule, or in the floor of the mouth that raised the

tongue !

so, what determines the location of the abscess formation ?

1-Thickness of bone.

2- Muscle attachment (mentalis, zygomaticus major and minor, buccinators, muscles of the

lips .etc.).

Suppose that a patient had irreversible pulpitis, the source of bacteria will be the root canals,

the bacteria start to increase in number, then the bacteria go out from the root apex, if the

apex is located below the buccinator muscle attachment (upper tooth) or above mentalisfor

example, the infection will spread to the inside of the oral cavity, in this case the abscess will

be in the oral vestibule (vestibular abscess) if we considered the thin bone to be the buccal

bone. If the root is long (e.g. upper canine) and the apex is located above the buccinator

muscle attachment, the infection will spread above the muscle attachment, the infection

might reach the eye and the patient is seen having a closed eye because of swelling, so the

muscle attachment determines the location of the abscess and also the bone thickness (palata

bone is thicker in this case)

Examples :- If the palatal root of the upper first molar is the nonvital root, the palatal root is closer to the

palatal bone, in this case the abscess will appear palatal (the patient will complain of palatal

swelling).

- Infections in certain stages may develop swelling in the submandibular area and the skin

might become very thin, when the pus accumulates in the abscess the abscess will try to

expand taking over the normal tissues, if the patient is neglecting, the abscess might reach a

level that it drains extra-orally (very unlikely to be seen) but it might be seen especially in thedeprived areas where (poor countries with poor no medical care).

- In general, if maxillary teeth developed abscesses, most likely they will be vestibular,

exceptions include the palatal root of upper first molar will develop palatal abscess (very close

to palate), and the lateral incisor (palatal abscess) because the root is inclined palatally, canine

has long root it may form abscess higher in level the levator anguli oris muscle, it will appear in

the canine space (not intraorally). Mandibular teeth in most of the cases form vestibular

8/12/2019 Surgery 10

4/15

8/12/2019 Surgery 10

5/15

3- If the patient toxic (dehydrated hasnt eaten or drunk anything, very tired, this is a sign of a

bad infection)

4- Ask if the patient had any treatment for this infection, if he underwent drainage, took

antibiotics, underwent RCT, etc.

5- Vital signs, high grade temperature is an indication of severe infection, heart rate of more

than 100 beat/minute is also an indication of severe infection (normal HR is 60-100), also

respiratory rate of more than 16/minute is an indication of severe infection.

6- If the infection has lead to any obstruction in the airways this is absolutely dangerous, an

example is an infection that reached the sublingual space resulting in an elevation of the

tongue that lead to airway obstruction its very dangerous not because it can spread to

somewhere, but simply because it can kill the patient, its very vital in such a case to think of it

as an emergency.

7- Physical examination, is the area of the infection indurated or fluctuant, if the infection is

still in the area of developing it will feel indurated, if the infection is well established and an

abscess was formed it will feel fluctuant, if its less indurated this means that the abscess is

developing but its not wellestablished, and we need to take radiographs to locate the tooth

that resulted in this.

Another determinants of the severity of infection and the spread of the infection that shouldbe taken into consideration is the patient immune defense, if the patient is already

immunocompromised or medically compromised, the infection will spread rapidly, especially

those with uncontrolled diseases such as DM (if DM patients is well controlled, we deal with

them as normal people), patients with uncontrolled DM have very deranged immune system

to the degree that any sort of simple infection has the ability to spread. Uremia in cases of

chronic renal disease, instead of discharging the waste in the urine, they will stay in the body.

Alcoholism, those who drinks alcohol in large amounts that exceeds particular limits, for

females if they consume more than 14 units a week, for males more than 21 units a week,

those people has deranged immune system, they can easily develop infections since they

dont have a proper competent immune system.Patient who underwent chemotherapy, they

definitely are immunocompromised, some cells (including stem cells) are killed,

immunosupressed patients taking steroids (steroids are anti-inflammatory and

immunosuppressants) can also easily get infections.

8/12/2019 Surgery 10

6/15

Always check the glucose level (DM is very common in our country), if you see a patient who

developed an abscess, has a carious tooth but the progression was very quick, you should

think about having a problem in the immune system, the first thing you should think about

that the patient does not know that he has DM so we check the glucose, so, oral infection

might be the cause of discovering a chronic disease (e.g. glucose level of 400 mg/dl)

For patients who are immunocompromised that we think they will develop an infection, wegive antibiotic before we treat (prophylactic antibiotic).

Treat or Refer?!

If I am a GP and a patient came to my clinic, shall I treat or shall I refer this patient, what are

the things that are beyond my expertise so that I refer the patient to the hospital or to

specialist?

1- Rapid progression, if a patient told you that two days ago he felt toothache then he came to

you with swelling, his eye is closed (swelling), the floor of the mouth is raised this is a case of

rapid progression, but if you see a small abscess its not rapidly progressive.

2- Difficulty in breathing, (infection of sublingual area, an emergency), here you dont refer the

patient to a specialist, but you call the specialist by yourself, and tell him that the patient has

an infection, his tongue is raised and has a difficulty in breathing and we need to send him to

the hospital because he might need intubation to ensure normal breathing.

3- Space involvement, there are primary and secondary spaces, primary spaces are those to

which the infection is firstly spread e.g. vestibular space/vestibular abscess, submandibular

area directly from the root apex, canine space, and the secondary spaces are those that are

not firstly affected e.g pharyngeal space.

Abscessprimary spacesecondary space (more serious secondary infection)

So if the infection involved several spaces or involved a secondary space we think that this is

serious, this patient needs referral.

4- High grade temperature (above 38.1C), the patient is thought to have a serious infection

and might need referral, you call the specialist, this patient might need to be given fluids,

antibiotics or hospital admission.

8/12/2019 Surgery 10

7/15

5- Trismus, especially in the case of posterior teeth involved in infection, this might affect the

muscles of mastication, and it might be very severe, imagine that a patient has an infection

and developed severe trismus, this patient wouldnt be able to eat, the infection will spread

and might affect breathing and swallowing, those need something to be done and shouldnt

be left alone, any limitation of mouth opening means that theres trismusbut the severity

varies if the patient cannot open more than 1 cm (sometimes less than that), this is severe

trismus, the patient is very toxic

6- Medically compromised patients, a patient has an abscess and while taking the history its

found that he had undergone a kidney transplant, he might have rapid progression, space

involvement or trismus, so those patients should be dealt with very rapidly, we call a specialist

and admit the patient to the hospital, we should attack the infection aggressively.

7- Toxic appearance, a patient with small dental abscess, but the patient is very toxic, tired,hasnt eaten, hasnt slept, pale, this patient deserves to be referred to a proper specialist

Treatment

- When do we treat surgically?

- The answer is ALWAYS.

Its not right to give him antibiotics beforesurgical treatment, to resolve the infection then

treat the tooth endodontically.

The surgical treatment includes one of following options :

- Incision and drainage.

- Extraction of the tooth.

- Pulp extirpation and drainage through the root canals

8/12/2019 Surgery 10

8/15

Abscess and Cellulitis

Cellulitis Abscess

Duration Shorter Longer

Pain More Less

Localization Less localized (diffuse) More localizedSurface temperature Higher than abscess Lower than cellulitis

Loss of function More Less

Bacterial involvement Aerobic Anaerobic

Tissue fluids More edematous Pus

Level of seriousness More Less

Cellulitis is more dangerous, the infection is in the subcutaneous tissue and spreads rapidly,

in the case of an abscess, the body has succeeded to localize the infection in a certain area, in

the case of cellulitis the body couldnt localize the infection and the infection is spreading

rapidly (more severe).

Support the patient medically

Give antibiotics after surgery, they will act more rapidly since the surgery has lessened the

load of bacteria. Incision and drainage has long been known and had saved the lives of manypeople, surgery on its merit is the most important, and it can heal the patient, but we need to

support the patient after we treat the infection in the surgical maneuver, we need to make

sure that the patient is well hydrated so we advice him to take fluids and we give him

antibiotics to make sure that this patient will recover soon.

When to give antibiotics?

Diffuse swelling, immunocompromised patient, space involvement, severe pericoronitis,

osteomylitis.

8/12/2019 Surgery 10

9/15

Empirical therapy

It is a matter of expecting, if a patient has an abscess, we expect anerobic infection, so, we

give amoxicillin and metronidazole.

Or we take a sample and ??????????!!!!!!!!!!!

BUT I expect that the doctor was going to talk about taking a sample and sending it to culture

to know exactly the causative micro-organism and prescribe the antibiotic which is known to

be most effective against this micro-organism(s).

THANK YOU!

Continue below, there are appendices!

8/12/2019 Surgery 10

10/15

Appendix A

Since the lecture was not very clear, this appendix includes images from the related chapter

of the book and boxes that summarizes the most important points in a trial to compensate

for any lack of information or lack of understanding.

8/12/2019 Surgery 10

11/15

8/12/2019 Surgery 10

12/15

8/12/2019 Surgery 10

13/15

8/12/2019 Surgery 10

14/15

8/12/2019 Surgery 10

15/15

Appendix B

Sinus and Fistula

Sinus.A sinus is a track leading from a focus of suppuration to a cutaneous or mucous surface. It usually

represents the path by which the discharge escapes from an abscess cavity that has been prevented fromclosing completely, either from mechanical causes or from the persistent formation of discharge which must

find an exit. A sinus is lined by granulation tissue, and when it is of long standing the opening may be dragged

below the level of the surrounding skin by contraction of the scar tissue around it. As a sinus will persist until

the obstacle to closure of the original abscess is removed, it is necessary that this should be sought for. It may

be a foreign body, such as a piece of dead bone, an infected ligature, or a bullet, acting mechanically or by

keeping up discharge, and if the body is removed the sinus usually heals. The presence of a foreign body is

often suggested by a mass of redundant granulations at the mouth of the sinus. If a sinus passes through a

muscle, the repeated contractions tend to prevent healing until the muscle is kept at rest by a splint, or put

out of action by division of its fibres. The sinuses associated with empyema are prevented from healing by the

rigidity of the chest wall, and will only close after an operation which admits of the cavity being obliterated. Inany case it is necessary to disinfect the track, and, it may be, to remove the unhealthy granulations lining it, by

means of the sharp spoon, or to excise it bodily. To encourage healing from the bottom the cavity should be

packed with bismuth or iodoform gauze. The healing of long and tortuous sinuses is often hastened by the

injection of Beck's bismuth paste. If disfigurement is likely to follow from cicatricial contractionfor example,

in a sinus over the lower jaw associated with a carious tooththe sinus should be excised and the raw

surfaces approximated with stitches.

A fistulais an abnormal canal passing from a mucous surface to the skin or to another mucous surface. Fistul

resulting from suppuration usually occur near the natural openings of mucous canalsfor example, on the

cheek, as a salivary fistula; beside the inner angle of the eye, as a lacrymal fistula; near the ear, as a mastoid

fistula; or close to the anus, as a fistula-in-ano. Intestinal fistul are sometimes met with in the abdominal

wall after strangulated hernia, operations for appendicitis, tuberculous peritonitis, and other conditions. In the

perineum, fistul frequently complicate stricture of the urethra.

Fistul also occur between the bladder and vagina (vesico-vaginal fistula), or between the bladder and the

rectum (recto-vesical fistula).

The treatmentof these various forms of fistula will be described in the sections dealing with the regions in

which they occur.

Congenital fistul, such as occur in the neck from imperfect closure of branchial clefts, or in the abdomenfrom unobliterated ftal ducts such as the urachus or Meckel's diverticulum, will be described in their proper

places.

From (http://www.manual-of-surgery.com/content/0021-Sinus-and-Fistula.html)

DONE !