Call Girls Colaba Mumbai ❤️ 9920874524 👈 Cash on Delivery
Odontogenic Infection
1.
2. OdontogenicOdontogenic
Infection 1Infection 1
Dr. Adel I. AbdelhadyDr. Adel I. Abdelhady
BDS, MSc ( Tanta, Eg.), PhD (Egypt,USABDS, MSc ( Tanta, Eg.), PhD (Egypt,USA((
Ass. Prof. Oral and Maxillofacial surgeryAss. Prof. Oral and Maxillofacial surgery,,
Collage of DentistryCollage of Dentistry
King Faisal UniversityKing Faisal University
"Do not let sun sets on prisoned pus"
4. Oral flora is the main source ofOral flora is the main source of
odontogenic infectionodontogenic infection
bacteriabacteria PercentagePercentage % of Aerobic & Anaerobic% of Aerobic & Anaerobic
AerobicAerobic 7 %7 % Aerobic 25 %Aerobic 25 %
Anaerobic 75 %Anaerobic 75 %
Of the causative organismsOf the causative organisms
(number of patients was 404(.(number of patients was 404(.
AnaerobicAnaerobic 33 %33 %
MixedMixed 60 %60 %
7. Infection Arising and SpreadingInfection Arising and Spreading
Effectiveness of patientEffectiveness of patient
immune mechanismimmune mechanism
Microbe---virulenceMicrobe---virulence
QuantityQuantity
Failure to drainFailure to drain
accumulation pusaccumulation pus
Balance ImbalanceBalance Imbalance
ScaleScale
8. The Anatomical Factors InfluencingThe Anatomical Factors Influencing
the direction of spread within thethe direction of spread within the
tissuestissues
The site of the source of infection , upperThe site of the source of infection , upper
or lower jawor lower jaw
The point at which the pus escapes fromThe point at which the pus escapes from
the bone to the soft tissues labiobucally orthe bone to the soft tissues labiobucally or
linguopalatallylinguopalatally
The natural barriers to the spread of pus inThe natural barriers to the spread of pus in
the tissues as layer of fascia , muscle orthe tissues as layer of fascia , muscle or
jaw bonejaw bone
9. Sequence of odontogenicSequence of odontogenic
infectionsinfections
fascial spaces
Soft tissue &
cortical bone
Erosion of cancellous bone
Periapical through pulp necrosis
Periodontal through deep periodontal pocket
15. Changing directionsChanging directions
Localization andLocalization and
recoveryrecovery
Acute chronicAcute chronic
Diffusion or spreadDiffusion or spread
Blood system---Septicemia
lymphoid system---
Lymphadenopathy
From submandibular
space infection
spread to chest region
16. Inflammation as a Sign of Odontogenic InfectionInflammation as a Sign of Odontogenic Infection
Inflammation is an important pathologic process oftenInflammation is an important pathologic process often
encountered by dentists . As an indicator of disease, it hasencountered by dentists . As an indicator of disease, it has
been recognized for centuries. Almost 2,000 years ago,been recognized for centuries. Almost 2,000 years ago,
the Roman physicianthe Roman physician CelsusCelsus recognized the warmth,recognized the warmth,
redness, swelling, and pain associated with now is knownredness, swelling, and pain associated with now is known
asas "inflammation“."inflammation“.
These events caused by a series of cellular and tissueThese events caused by a series of cellular and tissue
responses to some injurious agent. These responses areresponses to some injurious agent. These responses are
directed atdirected at
destroying the incitingdestroying the inciting المحرضالمحرض agent or, rendering itagent or, rendering it
harmless, isolates the agent and prevents its spread toharmless, isolates the agent and prevents its spread to
other locations.other locations.
All this activity may cause damage or destruction toAll this activity may cause damage or destruction to
normal tissue in the immediate area; the inflammatorynormal tissue in the immediate area; the inflammatory
process cleans up resulting debris and starts restoringprocess cleans up resulting debris and starts restoring
damaged tissuesdamaged tissues
17. Types of InflammationTypes of Inflammation
There are two fundamentalThere are two fundamental
types of inflammation:types of inflammation:
acute and chronic.acute and chronic.
A rapid onset, shortA rapid onset, short
duration, and profoundduration, and profound
signs and symptomssigns and symptoms
characterizecharacterize acuteacute
inflammation.inflammation.
On the other hand, a slowOn the other hand, a slow
onset, long duration, andonset, long duration, and
less obvious signs andless obvious signs and
symptoms characterizesymptoms characterize
chronic inflammation.chronic inflammation.
In addition to the two basicIn addition to the two basic
forms (acute and chronic),forms (acute and chronic),
there are two others thatthere are two others that
appear less commonly:appear less commonly:
subacute and granulomatoussubacute and granulomatous
chronic inflammation.chronic inflammation.
Subacute inflammationSubacute inflammation is anis an
ill-defined form that hasill-defined form that has
some clinical features ofsome clinical features of
acute and some of chronicacute and some of chronic
inflammation or predisposeinflammation or predispose
to chronic infection.to chronic infection.
Granulomatous,Granulomatous, is ais a
special form of chronicspecial form of chronic
inflammation e.g.inflammation e.g.
tuberculosis.tuberculosis.
22. Acute InflammationAcute Inflammation
A series of responses of small bloodA series of responses of small blood
vessels and some blood and tissue cellsvessels and some blood and tissue cells
to "injurious" agents resulting into "injurious" agents resulting in
weakening, destruction, or isolation ofweakening, destruction, or isolation of
the agent.the agent.
In the first minutes, small blood vesselsIn the first minutes, small blood vessels
(capillaries and venules) increase their(capillaries and venules) increase their
diameter (dilate) allowing more blood todiameter (dilate) allowing more blood to
flow into the area.flow into the area.
This increased blood flow is fed byThis increased blood flow is fed by
dilation of supplying arterioles, a processdilation of supplying arterioles, a process
known as "active hyperemia" (hyper- =known as "active hyperemia" (hyper- =
increased; -emia = blood). Withincreased; -emia = blood). With
increased blood flow, increased numbersincreased blood flow, increased numbers
of blood cells enter the area too Fever,of blood cells enter the area too Fever,
leukocytosisleukocytosis, abscesses, and cellulitis, abscesses, and cellulitis
may be presentmay be present ..
23.
24. MicrobiologyMicrobiology
Odontogenic infections are multi-Odontogenic infections are multi-
microbial:microbial:
Gram (+) cocci, aerobic and anaerobic:Gram (+) cocci, aerobic and anaerobic:
Streptococci and their anaerobicStreptococci and their anaerobic
counterpart, peptostreptococcicounterpart, peptostreptococci
Staphylococci, and their anaerobicStaphylococci, and their anaerobic
counterpart, peptococcicounterpart, peptococci
Gram (+) rods:Gram (+) rods:
Lactobacillus, diphtheroids, actinomycesLactobacillus, diphtheroids, actinomyces
Gram (-) rods:Gram (-) rods:
Fusobacterium, Bacteroids,Fusobacterium, Bacteroids,
25. Host FactorsHost Factors
Immunity against intraoral infection isImmunity against intraoral infection is
composed of three sets of mechanisms:composed of three sets of mechanisms:
Humeral factorsHumeral factors
Cellular factorsCellular factors
Local factorsLocal factors
Decrease one of these mechanisms followedDecrease one of these mechanisms followed
by increases the potential for infection andby increases the potential for infection and
spread of infection may be supervene.spread of infection may be supervene.
26. Humoral FactorsHumoral Factors
Circulating immunoglobulins, along withCirculating immunoglobulins, along with
complement, combine with microbes tocomplement, combine with microbes to
form opsonins that promote phagocytosisform opsonins that promote phagocytosis
by macrophages.by macrophages.
IgA prevents colonization of microbes onIgA prevents colonization of microbes on
oral mucosal surfaces.oral mucosal surfaces.
In the presence of infection, histamine,In the presence of infection, histamine,
serotonin, prostaglandins supportserotonin, prostaglandins support
inflammationinflammation →→ vasodilation and increasedvasodilation and increased
vascular permeability.vascular permeability.
27. Cellular factorsCellular factors
Phagocytes engulf and kill microbes,Phagocytes engulf and kill microbes,
removing them, preventing replication.removing them, preventing replication.
Lymphocytes produce lymphokines andLymphocytes produce lymphokines and
immunoglobulines (aids humoral).immunoglobulines (aids humoral).
Lymphokines stimulate reproduction ofLymphokines stimulate reproduction of
other lymphocytes, and kills antigens.other lymphocytes, and kills antigens.
28. Local FactorsLocal Factors
Specific factors leading to resistance:Specific factors leading to resistance:
Abundant vascular supply allowingAbundant vascular supply allowing
humoral and cellular response.humoral and cellular response.
Mechanical cleansing by salivary flow.Mechanical cleansing by salivary flow.
Secretory IgA contained within saliva.Secretory IgA contained within saliva.
32. Clinical FeaturesClinical Features
Inflammation is tissue responseInflammation is tissue response
to injury or invasion byto injury or invasion by
microorganisms that involvesmicroorganisms that involves
vasodilation, capillaryvasodilation, capillary
permeability, mobilization ofpermeability, mobilization of
leukocytes, and phagocytosis.leukocytes, and phagocytosis.
Cardinal signs of inflammationCardinal signs of inflammation::
Red, hot, swelling, pain, with loss ofRed, hot, swelling, pain, with loss of
functionfunction
Other findings:Other findings: regionalregional
lymphadenopathylymphadenopathy,, fever, elevated whitefever, elevated white
blood cell count, tachycardia,blood cell count, tachycardia,
tachypnea, dehydration, malaise.tachypnea, dehydration, malaise.
33. Oral tissue examinationOral tissue examination
Examine quality and consistency:Examine quality and consistency:
Soft to fluctuant (fluid filled) to hardSoft to fluctuant (fluid filled) to hard
(indurated)(indurated)
Color and temperature determineColor and temperature determine
the presence and extent ofthe presence and extent of
infectioninfection
Normal v abnormal tissueNormal v abnormal tissue
architecture:architecture:
Distortion of mucobuccal foldDistortion of mucobuccal fold
Soft palate symmetric with uvula inSoft palate symmetric with uvula in
midlinemidline (deviation → involvement of(deviation → involvement of
lateral pharyngeal space(lateral pharyngeal space(
Nasolabial fold, circumorbital areasNasolabial fold, circumorbital areas
34. Examination, con’tExamination, con’t..
Identify causative factors:Identify causative factors:
Tooth, root tip, foreign body, etc.Tooth, root tip, foreign body, etc.
Vital signs should be taken:Vital signs should be taken:
TemperaturesTemperatures >> 101 to 102°F accompanied101 to 102°F accompanied
by an elevated heart rate indicate systemicby an elevated heart rate indicate systemic
involvement of the infection and increasedinvolvement of the infection and increased
urgency of treatment.urgency of treatment.
35.
36.
37.
38.
39.
40.
41.
42.
43. How to diagnoseHow to diagnose??
Local Signs and SymptomsLocal Signs and Symptoms
Systemical Signs and SymptomsSystemical Signs and Symptoms
Signs and Symptoms
44. Local Signs and SymptomsLocal Signs and Symptoms
PainPain
SwellingSwelling
Surface erythemaSurface erythema
Pus formationPus formation
Limitation of motionLimitation of motion
LocallyLocally
45. Systemical Signs and SymptomsSystemical Signs and Symptoms
FeverFever
LymphadenopathyLymphadenopathy
MalaiseMalaise
Toxic appearanceToxic appearance
LeukocytosisLeukocytosis
46. Management of odontogenicManagement of odontogenic
infectioninfection
Prevention of the odontogenic infection is thePrevention of the odontogenic infection is the
golden standardgolden standard
Mild odontogenic infection can be easilyMild odontogenic infection can be easily
treated with simple antibiotictreated with simple antibiotic
Complex odontogenic infection may requireComplex odontogenic infection may require
an incision and drainagean incision and drainage
Complicated odontogenic infection mayComplicated odontogenic infection may
require patient admission and hospitalizationrequire patient admission and hospitalization
Any odontogenic infection should be treatedAny odontogenic infection should be treated
promptly and not be underestimated!promptly and not be underestimated!
Why?Why?
47. To avoid the following complicationsTo avoid the following complications::
Scaring and sinus & fistulaScaring and sinus & fistula
formation.formation.
Loss of bone and teethLoss of bone and teeth
Spread to potential fascialSpread to potential fascial
spaces and airwayspaces and airway
Orbital and intracranialOrbital and intracranial
spread via facial andspread via facial and
angular veinsangular veins
Spread into the neck, withSpread into the neck, with
large vessel complicationslarge vessel complications
Septic shock from gram –veSeptic shock from gram –ve
48. The routes by which theThe routes by which the
infection can spreadinfection can spread
1-By direct continuity through the tissues1-By direct continuity through the tissues
2-By the lymphatics to the regional nodes and2-By the lymphatics to the regional nodes and
eventually into the bloodstream, secondaryeventually into the bloodstream, secondary
abscess may develop.abscess may develop.
3-By bloodstream ,local thrombophlebitis may3-By bloodstream ,local thrombophlebitis may
propagate along the veins, entering cranialpropagate along the veins, entering cranial
cavity via emissary vein to produce cavernouscavity via emissary vein to produce cavernous
sinus thrombophlebitis , organism or infectedsinus thrombophlebitis , organism or infected
emboli may be swept into blood stream leadingemboli may be swept into blood stream leading
to bacteraemia , septicemia or pyaemiato bacteraemia , septicemia or pyaemia
49. Site at Which Pus AccumulatesSite at Which Pus Accumulates
Pus tends to accumulate in specific regions whichPus tends to accumulate in specific regions which
are referred to as tissue spaces, none of which areare referred to as tissue spaces, none of which are
actually spaces until pus has been formed.actually spaces until pus has been formed.
Some of these potential spaces are compartmentsSome of these potential spaces are compartments
which contain structure such as SG,LN, BPF thesewhich contain structure such as SG,LN, BPF these
structures surrounded by loose connective tissue .structures surrounded by loose connective tissue .
Pus destroys the loose connective tissue andPus destroys the loose connective tissue and
separate the anatomical boundaries of theseparate the anatomical boundaries of the
compartmentcompartment as it increase in volume, soas it increase in volume, so
creating an abscess cavity bounded bycreating an abscess cavity bounded by
fascia , muscle and bonefascia , muscle and bone
50. AnatomyAnatomy
Fascial space loose connective tissue
Among skin, maxillary and muscle
•Purulent--- spreading way
•Do not exist in healthy state
•Become filling during infection
51. Thank you & have a nice
day
Thank you & have a nice
day
52. Odontogenic Infection 2Odontogenic Infection 2
Dr. Adel I. AbdelhadyDr. Adel I. Abdelhady
BDS, MSc ( Tanta, Eg.(, PhD (Egypt,USABDS, MSc ( Tanta, Eg.(, PhD (Egypt,USA((
Ass. Prof. Oral and Maxillofacial surgeryAss. Prof. Oral and Maxillofacial surgery,,
Tanta UniversityTanta University
King Faisal UniversityKing Faisal University
"Do not let sun sets on prisoned pus"
53. Sequence of odontogenicSequence of odontogenic
infectionsinfections
fascial spaces
Soft tissue &
cortical bone
Erosion of cancellous bone
Periapical through pulp necrosis
Periodontal through deep periodontal pocket
55. CellulitisCellulitis
initial stage of infectioninitial stage of infection
Diffuse, warm, erythematousDiffuse, warm, erythematous
indurated, hard painfulindurated, hard painful
swelling that is tender toswelling that is tender to
palpation.palpation.
Inflammatory response notInflammatory response not
yet forming a true abscess.yet forming a true abscess.
Microorganisms have justMicroorganisms have just
begun to overcome hostbegun to overcome host
defenses and spread beyonddefenses and spread beyond
tissue planes.tissue planes.
56. True abscess formationTrue abscess formation
As inflammatory responseAs inflammatory response
matures, may develop a focalmatures, may develop a focal
accumulation of pus.accumulation of pus.
May have spontaneousMay have spontaneous
drainage intraorally ordrainage intraorally or
extraorally.extraorally.
Abscess is a pocket of tissueAbscess is a pocket of tissue
containing necrotic tissue,containing necrotic tissue,
bacterial colonies,and deadbacterial colonies,and dead
white cells, the area may orwhite cells, the area may or
may not be fluctuant, the pat.may not be fluctuant, the pat.
Is often is a febrile, oftenIs often is a febrile, often
cused by anaerobic bacteria.cused by anaerobic bacteria.
58. Differences between cellulitis and abscessDifferences between cellulitis and abscess
CharacteristicsCharacteristics CellulitisCellulitis AbscessAbscess
DurationDuration AcuteAcute 3-5 days3-5 days Chronic 5 daysChronic 5 days
PainPain Sever andSever and
generalizedgeneralized
LocalizedLocalized
SizeSize LargeLarge SmallSmall
LocalizationLocalization Diffuse bordersDiffuse borders WellWell
circumscribedcircumscribed
PalpationPalpation Doughy to induratedDoughy to indurated Fluctuant, tenderFluctuant, tender
Presence of pusPresence of pus NoNo YesYes
Degree ofDegree of
seriousnessseriousness
GreaterGreater lessless
BacteriaBacteria AerobicAerobic AnaerobicAnaerobic
59.
60.
61. Types of odontogenic infectionTypes of odontogenic infection
Simple, localised and controllableSimple, localised and controllable
PeriapicalPeriapical
PeriodontalPeriodontal
VestibularVestibular
PalatalPalatal
Complex, invasive and may be dangerousComplex, invasive and may be dangerous
Fascial spacesFascial spaces
LungLung
BrainBrain
MediastinumMediastinum
Metastatic infection to the heart subacuteMetastatic infection to the heart subacute
bacterial endocarditisbacterial endocarditis
69. Fascial SpacesFascial Spaces
Bound by the fascial layers investingBound by the fascial layers investing
muscles of the body, they contain variousmuscles of the body, they contain various
structures.structures.
Delineate different regions in the body.Delineate different regions in the body.
These areThese are potential spaces.potential spaces.
They are not true spaces, or voids, butThey are not true spaces, or voids, but
infections and body’s biochemicalinfections and body’s biochemical
response can "dissect" along these fascialresponse can "dissect" along these fascial
layers as a means of spreadinglayers as a means of spreading
70. Fascial LayersFascial Layers
Two main fascial layers in head andTwo main fascial layers in head and
neck are superficial (lying closest toneck are superficial (lying closest to
the surface) and deep cervical fasciathe surface) and deep cervical fascia
(cloaking anterior and posterior(cloaking anterior and posterior
regions of the neck).regions of the neck).
71.
72.
73. Superficial Cervical FasciaSuperficial Cervical Fascia
Continuation of deltopectoral fascia of ant.Continuation of deltopectoral fascia of ant.
chest wall, Camper’s fascia of abdomen.chest wall, Camper’s fascia of abdomen.
Contains the intrinsic muscles of the faceContains the intrinsic muscles of the face
and neck innervated by CN VII.and neck innervated by CN VII.
Most associated infections result fromMost associated infections result from
cellulitis, folliculitis, carbuncle, furuncle, orcellulitis, folliculitis, carbuncle, furuncle, or
trauma to overlying skin.trauma to overlying skin.
Although there is potential for spread toAlthough there is potential for spread to
deeper layers, treatment is usually directdeeper layers, treatment is usually direct
incision over the fluctuance.incision over the fluctuance.
74. Deep Cervical FasciaDeep Cervical Fascia
Contains muscles, viscera, andContains muscles, viscera, and
neurovascular bundles in fascial sheets.neurovascular bundles in fascial sheets.
Acts as the lubricating system ofActs as the lubricating system of
musculoskeletal system.musculoskeletal system.
The continuation and bony attachmentsThe continuation and bony attachments
form the planes and compartmentsform the planes and compartments
containing deeper structures.containing deeper structures.
75. Carotid SheathCarotid Sheath
Contains, carotid artery, internal jugularContains, carotid artery, internal jugular
vein, and vagus nerve.vein, and vagus nerve.
Ansa cervicalis, sympathetic trunk, andAnsa cervicalis, sympathetic trunk, and
lymphatics are adjacent, but not within.lymphatics are adjacent, but not within.
Intrathoracic propagation may lead toIntrathoracic propagation may lead to
mediastinitis, empyema, and pericarditis.mediastinitis, empyema, and pericarditis.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
96.
97.
98.
99.
100. Thank you & have a nice
day
Thank you & have a nice
day
101. Cervical Fascia CFCervical Fascia CF
Superficial LayerSuperficial Layer
Deep LayerDeep Layer
Subdivisions notSubdivisions not
histologically separatehistologically separate
SuperficialSuperficial
Enveloping layerEnveloping layer
Investing layerInvesting layer
MiddleMiddle
Visceral fasciaVisceral fascia
Prethyroid fasciaPrethyroid fascia
Pretracheal fasciaPretracheal fascia
Deep layer of DCFDeep layer of DCF
102.
103. Superficial fasciaSuperficial fascia
Superior attachment –Superior attachment –
zygomatic processzygomatic process
Inferior attachment –Inferior attachment –
thorax, axilla.thorax, axilla.
Similar toSimilar to
subcutaneous tissuesubcutaneous tissue
Ensheathes platysmaEnsheathes platysma
and muscles of facialand muscles of facial
expressionexpression
104. Superficial Layer of the DeepSuperficial Layer of the Deep
Cervical FasciaCervical Fascia
Completely surrounds theCompletely surrounds the
neck.neck.
Arises from spinousArises from spinous
processes.processes.
Superior border – nuchalSuperior border – nuchal
line, skull base, zygoma,line, skull base, zygoma,
mandible.mandible.
Inferior border – chest andInferior border – chest and
axillaaxilla
Splits at mandible andSplits at mandible and
covers the massetercovers the masseter
laterally and the mediallaterally and the medial
surface of the medialsurface of the medial
pterygoid.pterygoid.
EnvelopesEnvelopes
SCMSCM
TrapeziusTrapezius
SubmandibularSubmandibular
ParotidParotid
Forms floor ofForms floor of
submandibular spacesubmandibular space
105.
106. Deep Neck SpacesDeep Neck Spaces
Described in relation to the hyoid.Described in relation to the hyoid.
Entire length of neckEntire length of neck
Superficial spaceSuperficial space
RetropharyngealRetropharyngeal
DangerDanger
PrevertebralPrevertebral
Vascular visceralVascular visceral
SuprahyoidSuprahyoid
SubmandibularSubmandibular
PharyngomaxillaryPharyngomaxillary
(Parapharyngeal)(Parapharyngeal)
ParotidParotid
PeritonsillarPeritonsillar
TemporalTemporal
MasticatorMasticator
InfrahyoidInfrahyoid
Anterior visceralAnterior visceral
107. Superficial SpaceSuperficial Space
Entire length of neckEntire length of neck
Surrounds platysmaSurrounds platysma
Contains areolar tissue,Contains areolar tissue,
nodes, nerves and vesselsnodes, nerves and vessels
Subplatysmal FlapsSubplatysmal Flaps
Involved with cellulitis andInvolved with cellulitis and
superficial abscessessuperficial abscesses
Treat with incision alongTreat with incision along
Langer’s lines, drainageLanger’s lines, drainage
and antibioticsand antibiotics
108. Retropharyngeal SpaceRetropharyngeal Space
Entire length of neck.Entire length of neck.
Anterior border - pharynx andAnterior border - pharynx and
esophagus (buccopharyngealesophagus (buccopharyngeal
fascia)fascia)
Posterior border - alar layer ofPosterior border - alar layer of
deep fasciadeep fascia
Superior border - skull baseSuperior border - skull base
Inferior border – superiorInferior border – superior
mediastinummediastinum
Combines withCombines with
buccopharyngeal fascia atbuccopharyngeal fascia at
level of T1-T2level of T1-T2
Midline raphe connectsMidline raphe connects
superior constrictor to the deepsuperior constrictor to the deep
layer of deep cervical fascia.layer of deep cervical fascia.
Contains retropharyngealContains retropharyngeal
nodes.nodes.
109. Parotid SpaceParotid Space
Superficial layer of deepSuperficial layer of deep
fasciafascia
Dense septa fromDense septa from
capsule into glandcapsule into gland
Direct communication toDirect communication to
parapharyngeal spaceparapharyngeal space
ContainsContains
External carotid arteryExternal carotid artery
Posterior facial veinPosterior facial vein
Facial nerveFacial nerve
Lymph nodesLymph nodes
110. Odontogenic Infection 3Odontogenic Infection 3
Dr. Adel I. AbdelhadyDr. Adel I. Abdelhady
BDS, MSc ( Tanta, Eg.), PhD (Egypt,USABDS, MSc ( Tanta, Eg.), PhD (Egypt,USA))
Ass. Prof. Oral and Maxillofacial surgeryAss. Prof. Oral and Maxillofacial surgery,,
Tanta UniversityTanta University
King Faisal UniversityKing Faisal University
"Do not let sun sets on prisoned pus"
111. Fascial Layers of the Neck
Two main fascial divisions exist, the superficial cervical
fascia and the deep cervical fascia.
Superficial cervical fascia
just deep to the dermis
surrounds the muscles of fscial expression
includes the superficial musculoaponeurotic system (SMAS)
extends from the epicranium to the axillae and chest
space deep to this layer contains fat, neurovascular bundles,
and lymphatics
112. Deep cervical fascia
encloses the deep neck spaces
3 layers, the superficial, middle, and deep
layers of the deep cervical fascia.
113. The superficial layer of the deep cervical fascia
investing fascia that surrounds the neckencompasses the
sternocleidomastoid muscle, trapezius, muscles of
mastication, and submandibular and parotid glands,
limited superiorly by the nuchal ridge, mandible, zygoma,
mastoid, and hyoid bones
Inferiorly, it is bounded by the clavicles, sternum,
scapula, hyoid, and acromion, contributes to the fascia
covering the digastric muscle and to the lateral aspect of
the carotid sheathIn its course from the hyoid bone to the
medial table of the ramus of the mandible, it envelops the
anterior belly of the digastric muscle and forms the floor
of the submandibular space
Laterally, this fascia helps to define the parotid and
masticator spaces
114. The middle layer of the deep cervical
fascia
2 divisions, muscular and visceral
muscular division surrounds the strap muscles (ie,
sternohyoid, sternothyroid, thyrohyoid, omohyoid) and
the adventitia of the great vessels
visceral division surrounds the constrictor muscles of the
pharynx and esophagus to create the buccopharyngeal
fascia and the anterior wall of the retropharyngeal space
Both the muscular and visceral divisions contribute to the
formation of the carotid sheath
also envelops the larynx, trachea, and thyroid gland
attaches to the base of the skull superiorly and extends
inferiorly as low as the pericardium via the carotid sheath
115. The deep layer of the deep cervical
fascia
2 divisions, prevertebral and alar
prevertebral division adheres to the anterior aspect of the vertebral
body and extends laterally to the transverse processes of the
vertebrae.
alar division lies between the prevertebral division and the visceral
division of the middle layer and defines the posterior border of the
retropharyngeal space
surrounds the deep neck muscles and contributes to the carotid
sheath
Posteriorly, the muscular division of the middle layer of the deep
cervical fascia fuses with the alar division of the deep layer of the
deep cervical fascia at the level of thoracic vertebrae 1-2 (T1-T2).
116. Sublingual spaceSublingual space 11
Borders:Borders:
Anterior – mandibleAnterior – mandible
Posterior – submandibular spacePosterior – submandibular space
Superior – oral mucosaSuperior – oral mucosa
Inferior – mylohyoidInferior – mylohyoid
Medial – tongue musclesMedial – tongue muscles
Lateral – mandibleLateral – mandible
Contains sublingual gland, lingual nerve, sublingual a &Contains sublingual gland, lingual nerve, sublingual a &
v Wharton's duct, hypoglossal nerve.v Wharton's duct, hypoglossal nerve.
Infection would lead to dysphagia, pain, elevation ofInfection would lead to dysphagia, pain, elevation of
the floor of mouth and sup. displacement of tonguethe floor of mouth and sup. displacement of tongue..
122. Submental spaceSubmental space
Borders:Borders:
Sup.Sup. MylohyoidMylohyoid
Inf.Inf. Platysma, Skin,Platysma, Skin,
Ant.Ant. Lingual mandibleLingual mandible
Post.Post. HyoidHyoid
Med.Med. Common space, no medial wallCommon space, no medial wall
Lat.Lat. Medial MandibleMedial Mandible
Causes: from mand. incisor teeth or continuationCauses: from mand. incisor teeth or continuation
form submandibular space infection andform submandibular space infection and
SymphysisSymphysis fracturefracture
123. Ludwig’s anginaLudwig’s angina
Hippocrates in 1836, a postmortem findings,Hippocrates in 1836, a postmortem findings,
Karl Friedrich WilhelmKarl Friedrich Wilhelm von Ludwigvon Ludwig
A rapidly progressive gangrenous cellulitisA rapidly progressive gangrenous cellulitis
originating in submandibular gland.originating in submandibular gland.
Inflammatory distention of the fascial planesInflammatory distention of the fascial planes
of the neck can lead to respiratory tractof the neck can lead to respiratory tract
obstruction and death.obstruction and death.
It extends by continuity rather than lymphaticIt extends by continuity rather than lymphatic
spread.spread.
Mortality rate exceeds 50% during the pre-Mortality rate exceeds 50% during the pre-
antibiotic era, attributed to overwhelmingantibiotic era, attributed to overwhelming
sepsis.sepsis.
124. Ludwig’s anginaLudwig’s angina
Infection of 5 spaces;Infection of 5 spaces;
submental, and bilateralsubmental, and bilateral
submandibular andsubmandibular and
sublingual spaces.sublingual spaces.
Foul serosanguinous fluid,Foul serosanguinous fluid,
no frank purulence. Fascia,no frank purulence. Fascia,
muscle, connective tissuemuscle, connective tissue
involvement, sparinginvolvement, sparing
glandsglands
125.
126.
127. Ludwig’s anginaLudwig’s angina
Signs and symptomsSigns and symptoms::
Brauny oedema of theBrauny oedema of the
spaces.spaces.
Paucity of pusPaucity of pus
(therefore not an(therefore not an
abscess).abscess).
No lymphadenopathy.No lymphadenopathy.
Minimal inflammation ofMinimal inflammation of
pharynx.pharynx.
128. Ludwig’s angina with bilateralLudwig’s angina with bilateral
involvement of sublingual andinvolvement of sublingual and
submandibular spacessubmandibular spaces
132. Surgical interventionSurgical intervention
DecompressionDecompression
sublingual andsublingual and
submandibular spaces.submandibular spaces.
Incision andIncision and
drainagedrainage
DebridementDebridement
133. Masticator and Temporal SpacesMasticator and Temporal Spaces
SuprahyoidSuprahyoid
Formed by superficial layer ofFormed by superficial layer of
deep cervical fasciadeep cervical fascia
Masticator spaceMasticator space
Antero-lateral toAntero-lateral to
pharyngomaxillary space.pharyngomaxillary space.
ContainsContains
MasseterMasseter
PterygoidsPterygoids
Body and ramus of theBody and ramus of the
mandiblemandible
Inferior alveolar nervesInferior alveolar nerves
and vesselsand vessels
Tendon of the temporalisTendon of the temporalis
musclemuscle
134. Submasseteric spaceSubmasseteric space
BordersBorders
Anterior – buccal spaceAnterior – buccal space
Posterior – parotid glandPosterior – parotid gland
Superior – zygomatic archSuperior – zygomatic arch
Inferior – inferior border of mandibleInferior – inferior border of mandible
Superficial – masseterSuperficial – masseter
Deep – ramusDeep – ramus
Infection causes trismus.Infection causes trismus.
Communicates with temporalCommunicates with temporal
fossafossa
135. Submasseteric spaceSubmasseteric space
Likely causes
Lower third molar
Angle fracture
Contents
Masseteric artery
and vein
Neighboring space
Buccal
Pterygomandibular
Superficial temporal
Parotid
Swelling
Extraoral over the
masseter/ascending
ramus
Site of I&D
Intraoral
Extraoral –
submandibular
approach
136. Pathway of spread fromPathway of spread from
masseteric space infectionmasseteric space infection
138. Superficial and Deep temporalSuperficial and Deep temporal
Superficial Temporal spacSuperficial Temporal spac
Anterior – superificalAnterior – superifical
temporalis fasciatemporalis fascia
Posterior – superficialPosterior – superficial
temporalis fasciatemporalis fascia
Superior – pericraniumSuperior – pericranium
Inferior – masseteric spaceInferior – masseteric space
Medial – temporalis muscleMedial – temporalis muscle
Lateral – superficialLateral – superficial
temporalis fasciatemporalis fascia
139. Deep temporal
Anterior – temporalis
muscle/infratemporal
space
Posterior – temporalis
Superior – temporalis
muscle attachment
Lateral - temporalis
Inferior –
infratemporal space
Medial - squamous
temporal bone
140. Likely cause
Upper molars
Extension from
submasseteric/pterygomandibular
/infratemporal spaces
Neighboring spaces
Pterygomandibular
Submasseteric
Infratemporal
Contents
Temporal arteries and veins
Swelling
Above zygomatic arch and
behind lateral orbital rim
Almost always associated
with trismus
Site of I&D
Intraoral – incision at
superior aspect of ascending
ramus and dissect
posteriorly and superiorly on
temporalis into superficial
temporal space then
medially through temporalis
into deep temporal space
Extraoral – incision parallel
to zygomatic branch of VII,
slightly superior to zygomatic
arch
141. Infratemporal spaceInfratemporal space
The infratemporal fossa spaceThe infratemporal fossa space
forms the upper extremity offorms the upper extremity of
pterygomandibular spacepterygomandibular space
Borders:Borders:
Anterior – maxillary tuberosityAnterior – maxillary tuberosity
Posterior – mandibular condylePosterior – mandibular condyle
Superior – infratemporal crest ofSuperior – infratemporal crest of
sphenoid/deep temporal spacesphenoid/deep temporal space
Inferior – lateral pterygoidInferior – lateral pterygoid
/pterygomandibular spac/pterygomandibular spac
Medial – lateral pterygoidMedial – lateral pterygoid
plate/pterygopalatine foramenplate/pterygopalatine foramen
Lateral – coronoidLateral – coronoid
process/temporalis tendonprocess/temporalis tendon
142. Infratemporal spaceInfratemporal space
Contains maxillary artery, and pterygoidContains maxillary artery, and pterygoid
plexus of veins.plexus of veins.
Communicates with submassetric andCommunicates with submassetric and
pterygo-mandibular spaces.pterygo-mandibular spaces.
One of the potential spaces forOne of the potential spaces for
displacement of maxillary third molars.displacement of maxillary third molars.
143. Infratemporal space
Likely cause
Upper molars
Extension from
neighboring sites
Neighboring spaces
Deep temporal
Pterygomandibular
Contents
Internal maxillary artery
Pterygoid plexus of
veins
V3
Swelling
Not clinically seen –
behind tuberosity
Trismus due to
involvement of
muscles of
mastication
Site of I&D
Intraoral – from
pterygomandibular
space
Extraoral –
submandibular
approach
144. Buccal spaceBuccal space
Borders:Borders:
Sup.Sup. ZygomaZygoma
Inf. deep fascia Inferior border of mandibleInf. deep fascia Inferior border of mandible
AntromediallyAntromedially Buccinator ms.Buccinator ms.
Posteromedially Masseter ms.Posteromedially Masseter ms.
Lat.forward extension of deep fascia fromLat.forward extension of deep fascia from the capsule ofthe capsule of
parotid gland and platysma ms.parotid gland and platysma ms.
Contains facial artery, vein, and nerve; Stenson’s duct,Contains facial artery, vein, and nerve; Stenson’s duct,
buccal fat pad.buccal fat pad.
The buccal fat pad acts as an impediment for spread ofThe buccal fat pad acts as an impediment for spread of
infection from buccal to lateral pharyngeal space.infection from buccal to lateral pharyngeal space.
145. Pathway of spread for buccalPathway of spread for buccal
space infectionspace infection
147. Canine spaceCanine space
If the canine root is short pus from periapical abscessIf the canine root is short pus from periapical abscess
will emerge below the origin of levator anguli oris inwill emerge below the origin of levator anguli oris in
buccal vestibule but if long pus will emerges betweenbuccal vestibule but if long pus will emerges between
levator labii superiors and levator labii superiors alaquelevator labii superiors and levator labii superiors alaque
nasinasi
Borders:Borders:
Sup.Sup. Origin of levator musclesOrigin of levator muscles
Inf .Inf . Orbicularis orisOrbicularis oris
Ant.Ant. Skin, subQSkin, subQ
Post.Post. MaxillaMaxilla
Med.Med. Levator labii alaquae nasiiLevator labii alaquae nasii
Lat.Lat. Zygomaticus majorZygomaticus major
Contains angular artery and vein, infraorbital foramen.Contains angular artery and vein, infraorbital foramen.
These provide a path of communication to cavernousThese provide a path of communication to cavernous
sinus via ophthalmic vein, leading to cavernous sinusitissinus via ophthalmic vein, leading to cavernous sinusitis
and brain abscess.and brain abscess.
148. Areas of spread in infraorbitalAreas of spread in infraorbital
space infectionsspace infections
149.
150. Pterygomandibular SpacePterygomandibular Space
Borders:Borders:
Anterior – pterygomandibularAnterior – pterygomandibular
raphe/buccal spaceraphe/buccal space
Posterior – parotidPosterior – parotid
Superior – lateral pteygoidSuperior – lateral pteygoid
Inferior – inferior border ofInferior – inferior border of
mandiblemandible
Lateral – ramusLateral – ramus
Medial – medial pterygoidMedial – medial pterygoid
Infection would causes trismus.Infection would causes trismus.
Commonly would lead to para-Commonly would lead to para-
pharyngeal space involvement.pharyngeal space involvement.
151. Pterygomandibular SpacePterygomandibular Space
Likely causes
Lower third molar
Angle fracture
Contents
V3
Inferior alveolar vein and artery
Neighboring spaces
Buccal
Deep temporal
submasseteric
Lateral pharyngeal
Parotid
Peritonsillar
Swelling
Intraoral over medial
aspect of ramus
Not usually any
extraoral
Trismus due to
involvement of medial
pterygoid
Site of I&D
Intraoral
Extraoral -
submandibular
152. Lateral (Para) pharyngeal spaceLateral (Para) pharyngeal space
Anterior – pterygomandibular
raphe, sublingual and
submandibular spaces
Posterior –
retropharyngeal/carotid sheath
Superior – skull base
Inferior – hyoid bone
Medial – superior and middle
constrictors and its coveringand its covering
buccopharyngeal fasciabuccopharyngeal fascia
Lateral – medial
pterygoid/parotid capsule
Note: Divided into anterior
(muscular) and posterior
(vascular) compartments, by the
stylohyoid process/ligaments
and muscles
Cone shapeCone shape
154. S/S Of Parpharyngeal space
anterior compartment
bulging of lateral pharyngeal wall
deviation of uvula
trismus
swelling at angle indicates extension to inferior extent of
anterior compartmen
Posterior compartment
Posterolateral wall and posterior tonsillar pillar edema
Minimal trismus
Cranial nerve involvement (IX-XII)
Horner’ syndrome (ptosis, miosis, anhidrosis) from
involvement of superior sympathetic chain
155. I&D Parpharyngeal space
Site of I&D
Intraoral – anterior compartment
Extraoral – posterior compartment
(submandibular approach – with finger
dissection to identify hyoid, digastric and
styloid process)
Carotid space – same as posterior compartment
lateral pharyngeal
156. Pharyngomaxillary Space orPharyngomaxillary Space or
ParapharyngealParapharyngeal
Communicates
with several deep
neck spaces.
Parotid
Masticator
Peritonsillar
Submandibular
Retropharyngeal
157. Lateral (para) pharyngeal spaceLateral (para) pharyngeal space
Infection manifests as:Infection manifests as:
Trismus, DysphagiaTrismus, Dysphagia
FeverFever
Pharyngeal bulgePharyngeal bulge
Induration at mandibular angleInduration at mandibular angle
If the posterior compartment is involved:If the posterior compartment is involved:
sepsissepsis
dyspneadyspnea
minimal trismusminimal trismus
? hearing loss due to blockade of Eustachian tube? hearing loss due to blockade of Eustachian tube
158. Retropharyngeal space
Borders
Anterior – superior and middle constrictor
muscles
Posterior – alar fascia
Superior – cranial base
Inferior – fusion of alar and prevertebral
fascia (upper mediastinum - C6-T4)
Medial – midline
Lateral – lateral pharyngeal space/carotid
sheath
159. Likely causes
Extension from
lateral pharyngeal
Neighboring space
Lateral pharyngeal
Prevertebral
Mediastinum
Contents
Branches of cranial
nerves IX,X
Pharyngeal vessels
S/S
Bulge in posterior wall of
pharynx
Odynophagia/dysphagia
Fever/leukocytosis/chills
Sialorrhea/respiratory
distress
Site of I&D
Extraoral
incision along anterior
border of SCM below hyoid
muscle and carotid sheath
are retracted laterally
finger inserted posterior to
inferior constrictor for blunt
dissection
transoral
for localized infections
160.
161.
162. Patient who have infection of the lateralPatient who have infection of the lateral
pharyngeal space have serious potentialpharyngeal space have serious potential
problems. When the it is involved, theproblems. When the it is involved, the
Odontogenic infection is severe and may beOdontogenic infection is severe and may be
progressing at a rapid rate.progressing at a rapid rate.
Another possible problem is the contents of theAnother possible problem is the contents of the
space, especially those of the posteriorspace, especially those of the posterior
compartment, as thrombosis of the internalcompartment, as thrombosis of the internal
jugular vein, erosion of the carotid artery or itsjugular vein, erosion of the carotid artery or its
branches and interference of cranial nerve IXbranches and interference of cranial nerve IX
through XII. The other serious complication arisethrough XII. The other serious complication arise
if the infection progress from the lateralif the infection progress from the lateral
pharyngeal to retropharyngeal space.pharyngeal to retropharyngeal space.
163. Retropharyngeal space infectionsRetropharyngeal space infections
The retropharyngeal space lies behind the softThe retropharyngeal space lies behind the soft
tissue of the posterior aspect of the pharynx it istissue of the posterior aspect of the pharynx it is
bounded anteriorly by superior pharyngealbounded anteriorly by superior pharyngeal
constrictor muscle and posteriorly by the alarconstrictor muscle and posteriorly by the alar
layer of the prevertebral fascialayer of the prevertebral fascia
The space begun at the base of skull andThe space begun at the base of skull and
extends inferiorly to the level of vertebra C7 orextends inferiorly to the level of vertebra C7 or
T1, where the alar fascia fuses anteriorly withT1, where the alar fascia fuses anteriorly with
the buccopharyngeal fascia.the buccopharyngeal fascia.
Its danger when it is become infected theIts danger when it is become infected the
infection can extend inferiorly to posteriosuperiorinfection can extend inferiorly to posteriosuperior
mediastinummediastinum
164. The final danger of retropharyngealThe final danger of retropharyngeal
space infection is progressivespace infection is progressive
involvement of the prevertebral space.involvement of the prevertebral space.
which is separated from retropharyngealwhich is separated from retropharyngeal
space by alar layer of prevertebral fasciaspace by alar layer of prevertebral fascia
if this fascia is perforated and the spaceif this fascia is perforated and the space
is involved .is involved .
The prevertebral space extends from theThe prevertebral space extends from the
base of the skull to the diaphragmbase of the skull to the diaphragm
infection of this space can extends to theinfection of this space can extends to the
thorax and mediastinumthorax and mediastinum
165. When the retropharyngeal or prevertebralWhen the retropharyngeal or prevertebral
spaces or both are involved as a result ofspaces or both are involved as a result of
odontogenic infection the patient is alwaysodontogenic infection the patient is always
seriously ill .The following potentialseriously ill .The following potential
complications:complications:
1-Upper airway obstruction1-Upper airway obstruction
2-Rupture of the retropharyngeal space2-Rupture of the retropharyngeal space
abscess and aspiration of pus to the lungabscess and aspiration of pus to the lung
and asphyxiationand asphyxiation
3-Spread of infection into the mediastinum3-Spread of infection into the mediastinum
which results of severe infection in thewhich results of severe infection in the
thoraxthorax
166.
167. Potential Pathways of Spread ofPotential Pathways of Spread of
Odontogenic InfectionsOdontogenic Infections
168. Cavernous sinus thrombosisCavernous sinus thrombosis
Cavernous sinus contains; CN III, IV, VCavernous sinus contains; CN III, IV, V
(ophthalmic division) and VI, and internal carotid(ophthalmic division) and VI, and internal carotid
artery.artery.
Valveless veins of head and neck result in aValveless veins of head and neck result in a
"venous lake" throughout the midface and skull"venous lake" throughout the midface and skull
base.base.
This will result in retrograde flow dependent onThis will result in retrograde flow dependent on
pressure gradient;pressure gradient;
Thus infection may spread from midface toThus infection may spread from midface to
cavernous sinus and other parts of brain viacavernous sinus and other parts of brain via
sup. and inf. ophthalmic veinssup. and inf. ophthalmic veins,, or emissaryor emissary
veins connecting pterygoidveins connecting pterygoid plexusplexus throughthrough
ovale and lacerum foramina to the cranial vault.ovale and lacerum foramina to the cranial vault.
169. Cavernous sinus thrombosisCavernous sinus thrombosis
Earliest sign is vascularEarliest sign is vascular
congestion in periorbital,congestion in periorbital,
scleral and retinal veinsscleral and retinal veins
Other signs include;Other signs include;
periorbital edemaperiorbital edema
proptosis ,dilated pupilsproptosis ,dilated pupils
abscent of corneal reflexabscent of corneal reflex
nausea, vomiting,nausea, vomiting,
diplopia, visualdiplopia, visual
impairment,impairment,
ophthalmoplegia,ophthalmoplegia,
photophobia,photophobia,
papilledema.papilledema.
170. Cavernous sinus thrombosisCavernous sinus thrombosis
What are the pathways of odontogenicWhat are the pathways of odontogenic
infection to the cavernous sinus…..twoinfection to the cavernous sinus…..two
routes:routes:
Anterior routeAnterior route: via angular and inferior: via angular and inferior
ophthalmic veinophthalmic vein
Posterior route:Posterior route: via the transverse facialvia the transverse facial
vein and the pterygoid venous plexusvein and the pterygoid venous plexus
171. Principles of Management of
Odontogenic Infections
Determine Severity of Infection
Three major factors
Anatomic location
Rate of progression
Airway compromise
173. Stages of odontogenic infections
Days 1-3 - onset
Soft
Doughy
Mildly tender
Small, minimal
edema
Aerobic bacteria
Least severe
Days 2-5 - cellulitis
Hard
Red
hot
++ tender
Diffuse and
spreading borders
Mixed aerobic and
anaerobic
Serosanguinous
fluid
174. Day >5
Cellulitis softens and abscess becomes apparent
Compressible and shiny
Fluctuant
Tender
Pus filled
Moderate to severe
Anaerobic
Resolution
After spontaneous or surgical drainage
Swelling decreases
May remain firm for weeks due to
inflammation and wound healing
175. Airway Compromise
Most frequent cause of death is airway
compromise
Complete obstruction requires
Intubation
Tracheostomy
Cricothirotomy – emergency situations
Partial airway obstruction
Stridor
Coarse breath sounds
Drooling
Accessory muscle use
176. Trismus
Ominous sign
MIO of less than 20mm should be considered a
masticator space abscess until proven otherwise
Need to observe the oropharynx and position of the
uvula to assess for swelling
Pulse oximeter
Below 94% is ominous sign
Indicated insufficient oxygenation
Radiographs
Soft tissue radiographs of cervical airway
CT scan (with contrast) – also identifies pus
177. Evaluate Host Defenses
Immune system compromise
Diabetes (WBC defect in phagocytosis and
chemotaxis and impaired vascular flow through small
vessels)
Steroid therapy
Organ transplant
Malignancy
Chemotherapy
Chronic renal disease
Malnutrition
Alcoholism
End stage AIDS (controversial – more defect of T
cells)
178. Systemic Reserve
Fever
increases insensible fluid
loss and caloric
requirement
ominous sign in elderly
patients (normally not
able to mount fever as
younger people)
physiologic stress may
disrupt control of
systemic disease
difficult glucose control
in diabetics
Indications for hospital
admission
Temperature > 38.3
Increases fluid loss
Dehydration
Physical signs
Dry skin
Loss of turgor
Chapped lips
Dry mucous
membranes
Elevated BUN
Elevated urine
specific gravity
179. Possible need for hospitalizationPossible need for hospitalization
Immunocompromised patient:Immunocompromised patient: diabetic,diabetic,
alcoholic, malnourishmentalcoholic, malnourishment
Systemic involvement:Systemic involvement: fever >39 C, malaise,fever >39 C, malaise,
dehydrationdehydration
Patient compliance:Patient compliance: patient is incapable of selfpatient is incapable of self
carecare
Rapid spread:Rapid spread: Trismus, paresthesiaTrismus, paresthesia
Need for parenteral antibioticsNeed for parenteral antibiotics
Special features:Special features: resistant organisms,resistant organisms,
osteomyelitis, actinomycosisosteomyelitis, actinomycosis
180. Possible need for hospitalizationPossible need for hospitalization
Airway compromise or threat to airway
Trismus
Airway swelling
Masticator space infection
Perimandibular space infections
Rapidly spreading cellulites
IV antibiotics
Need for GA for I&D
Need for control of systemic disease
Decreased systemic reserve (elderly)
Elevated WBC – more a predictor of length of stay
181. Diagnostic workshop for infectionDiagnostic workshop for infection
1. Patient assessment1. Patient assessment
Physical examination:Physical examination:
Head and neckHead and neck
OphthalmologicOphthalmologic
NeurologicalNeurological
2. Imaging2. Imaging
3. Lab studies:3. Lab studies:
Serum chemistrySerum chemistry
HaematologyHaematology
UrinalysisUrinalysis
Culture and antibioticCulture and antibiotic
sensitivity testingsensitivity testing
Sampling techniquesSampling techniques
182. 11..Patient assessmentPatient assessment
History:History:
duration of infection, sequence of events, antibioticduration of infection, sequence of events, antibiotic
prescribed, habits,prescribed, habits,
Physical examination:Physical examination:
Head and neck:Head and neck: Swelling, asymmetry, abscessSwelling, asymmetry, abscess
versus cellulitis, lymphadenopathy, trismus, sinusversus cellulitis, lymphadenopathy, trismus, sinus
discharge, draining fistulae, pharyngeal fullness, rashesdischarge, draining fistulae, pharyngeal fullness, rashes
Neurological:Neurological: altered mental status, neck rididity,altered mental status, neck rididity,
fetor and sensory deficits, nausea, seizuresfetor and sensory deficits, nausea, seizures
OphthalmologicOphthalmologic:: Proptosis, ophthalmoplegia andProptosis, ophthalmoplegia and
photophobiaphotophobia
Mediastinal:Mediastinal: dyspnea, chest pain, distended neckdyspnea, chest pain, distended neck
veins, widened mediastinum.veins, widened mediastinum.
183. 22..ImagingImaging
• Plane filmsPlane films
Dental structures.Dental structures.
Bone changesBone changes are evident after 5 - 14 days ofare evident after 5 - 14 days of
infection (33% - 50% demineralization).infection (33% - 50% demineralization).
CT, MRI & UltrasonographyCT, MRI & Ultrasonography
Determine extent of space and cavities infectionDetermine extent of space and cavities infection
Nuclear bone scansNuclear bone scans (Tc 99m & Ga 67)(Tc 99m & Ga 67)
Localizes active foci, diagnosis of biologic activityLocalizes active foci, diagnosis of biologic activity
e.g. osteolytic and osteoblastic and healinge.g. osteolytic and osteoblastic and healing
responses in osteomyelitisresponses in osteomyelitis..
184. 33..Lab studiesLab studies
A. Serum chemistryA. Serum chemistry
In Fever and dehydrationIn Fever and dehydration
↓↓Na++ and Cl- if ↑ sweatingNa++ and Cl- if ↑ sweating
↑↑ Na++ and Cl- if volume depletedNa++ and Cl- if volume depleted
K and HCO3 remain unchangedK and HCO3 remain unchanged
Bl. U/N may be ↑Bl. U/N may be ↑
In septic shock → exaggeration of the above findingsIn septic shock → exaggeration of the above findings
Evidence of acute renal failure:Evidence of acute renal failure:
K, Cl and volume retentionK, Cl and volume retention
Renal (metabolic) acidosisRenal (metabolic) acidosis
↓↓ HCO3-HCO3-
Albumen may ↓ in osteomyelitis and necrotizing infection.Albumen may ↓ in osteomyelitis and necrotizing infection.
185. 33..Lab studiesLab studies
B. HaematologyB. Haematology
Leukocytosis >12, 000/ mm3Leukocytosis >12, 000/ mm3
Normocytic, normochromic anaemiaNormocytic, normochromic anaemia
Thrombocytosis (> 500,000/mm3Thrombocytosis (> 500,000/mm3
↑↑ ESR with most of the bacterial and fungalESR with most of the bacterial and fungal
infection but no ↑ in viral infection.infection but no ↑ in viral infection.
C. UrinalysisC. Urinalysis
Proteinuria with extensive infectionProteinuria with extensive infection
Oliguria and anaemia in septic shock.Oliguria and anaemia in septic shock.
186. 33..Lab studiesLab studies
D. Sampling techniques:D. Sampling techniques:
AspirationAspiration
SwabbingSwabbing
Tissue sample The specimen has to beTissue sample The specimen has to be
transferred directly to lab.transferred directly to lab.
AspirateAspirate
Dark, malodorous pusDark, malodorous pus,, is indicative of anaerobic infections.is indicative of anaerobic infections.
White-yellow pusWhite-yellow pus,, implicates aerobic gram-positive cocciimplicates aerobic gram-positive cocci
Dark-stained fluidDark-stained fluid,, is often produced by gram-negative entericis often produced by gram-negative enteric
bacteriabacteria
Sulphur granules,Sulphur granules, in yellowish exudatesin yellowish exudates implicates actinomycesimplicates actinomyces
Gas,Gas, with or without puswith or without pus, suggests clostridial or anaerobic, suggests clostridial or anaerobic
infections.infections.
187. OdontogenicOdontogenic
Infection 4Infection 4
Dr. Adel I. AbdelhadyDr. Adel I. Abdelhady
BDS, MSc ( Tanta, Eg.), PhD (Egypt,USABDS, MSc ( Tanta, Eg.), PhD (Egypt,USA))
Ass. Prof. Oral and Maxillofacial surgeryAss. Prof. Oral and Maxillofacial surgery,,
Collage of DentistryCollage of Dentistry
King Faisal UniversityKing Faisal University
"Do not let sun sets on prisoned pus"
188. POTENTIAL SPREAD
OF INFECTION
FROM LOWER
THIRD
MOLAR
SUPERIORLY
INFRATEMPORAL AND MASTICATOR SPACE
POSTERO INFERIORLY
PTERYGOMANDIBULAR
SPACE
INFERIORLY
SUBMANDIBULAR SPACE
LUDWIG’S ANGINA
ANTERIORLY,BUCCALY
BUCCAL SPACE
BUCCALY
MESSETRIC
SPACE
189. NOTE : DANGER SPACE IS THE SPACE BETWEEN
PREVERTIBRAL AND ALAR FASCIA
PTERYGOMANDIBULAR SPACE
PTERYGOID SPLEXUS
EMISSERY VEINS
CAVERNOUS SINUS
THROMBOSIS
LATERAL PHARYNGEAL SPACE
RETROPHARYNGEAL SPACE
MEDIASTINUM
CAROTID SHEATH
DANGER SPACE
190. 33..Lab studiesLab studies
D. Sampling techniques:D. Sampling techniques:
AspirationAspiration
SwabbingSwabbing
Tissue sample The specimen has to beTissue sample The specimen has to be
transferred directly to lab.transferred directly to lab.
AspirateAspirate
Dark, malodorous pusDark, malodorous pus,, is indicative of anaerobic infections.is indicative of anaerobic infections.
White-yellow pusWhite-yellow pus,, implicates aerobic gram-positive cocciimplicates aerobic gram-positive cocci
Dark-stained fluidDark-stained fluid,, is often produced by gram-negative entericis often produced by gram-negative enteric
bacteriabacteria
Sulphur granules,Sulphur granules, in yellowish exudatesin yellowish exudates implicates actinomycesimplicates actinomyces
Gas,Gas, with or without puswith or without pus, suggests clostridial or anaerobic, suggests clostridial or anaerobic
infections.infections.
191. 33..Lab studiesLab studies
F. Culture and antibiotic sensitivity testingF. Culture and antibiotic sensitivity testing::
Even if there is no pus aspiratedEven if there is no pus aspirated forfor C&SC&S
IndicationsIndications
Rapidly spreading or extensive infectionRapidly spreading or extensive infection
Infection in compromised patientInfection in compromised patient
Infection not responding to antibioticsInfection not responding to antibiotics
Recurrent infectionRecurrent infection
OsteomyelitisOsteomyelitis
Postoperative infectionPostoperative infection
Infections with unusual features:Infections with unusual features:
Tissue necrosisTissue necrosis
Gas productionGas production
Chronic or multiple fistulae or sinus tractsChronic or multiple fistulae or sinus tracts
Hospital-acquired infections (NOSOCOMIAL)Hospital-acquired infections (NOSOCOMIAL)
192.
193. Principles of infection managementPrinciples of infection management
Once diagnosis of infection is established, theOnce diagnosis of infection is established, the
principles of treatment are common.principles of treatment are common.
ABC’s first,ABC’s first,
Secure and maintain a patent, functional airway, andSecure and maintain a patent, functional airway, and
IV access for fluids and medications.IV access for fluids and medications.
In case of respiratory distress or embarrassment,In case of respiratory distress or embarrassment,
intubation should be strongly considered.intubation should be strongly considered.
Fiberoptic intubation or surgical airway, "cric" orFiberoptic intubation or surgical airway, "cric" or
"trach" may be necessary if oedema has distorted"trach" may be necessary if oedema has distorted
the anatomy.the anatomy.
1. Vital signs:
195. Fever in older patient usually indicatesFever in older patient usually indicates
significant infectionsignificant infection
Should control fever in elderly at a lowerShould control fever in elderly at a lower
temperature because of increased CV andtemperature because of increased CV and
metabolic demandsmetabolic demands
Other methods for fever controlOther methods for fever control
Cool water or alcohol sponge bathCool water or alcohol sponge bath
Chilled drinksChilled drinks
Immersion in bath of tepid waterImmersion in bath of tepid water
Correct electrolyte imbalancesCorrect electrolyte imbalances
Control systemic diseaseControl systemic disease
196. 22..Medical therapyMedical therapy
Nutritional supportNutritional support
Daily requirements:Daily requirements:
Adult male, 20-30 k Cal/kg body wt/d. (younger ↑Adult male, 20-30 k Cal/kg body wt/d. (younger ↑
require and elder ↓)require and elder ↓)
Sepsis → ↑ caloric require. (13%/1 C° )Sepsis → ↑ caloric require. (13%/1 C° )
Protein requirement for young adult is 0.45g/kg/d.Protein requirement for young adult is 0.45g/kg/d.
Iron, Magnesium, and other trace elements must beIron, Magnesium, and other trace elements must be
monitored.monitored.
Blood cultures: Indicated for all serous head and neckBlood cultures: Indicated for all serous head and neck
infections (2 culture bottle 5 cc bl. Each for aerobicinfections (2 culture bottle 5 cc bl. Each for aerobic
and anaerobic).and anaerobic).
197. Medical therapyMedical therapy
Antibiotic therapyAntibiotic therapy
Therapeutic Indications:Therapeutic Indications:
Extensive or unusual infectionsExtensive or unusual infections
Systemic spread or sepsisSystemic spread or sepsis
Chronic and /or non responsive infectionsChronic and /or non responsive infections
Debilitated patientDebilitated patient
Infections in an operative site or in the hospitalisedInfections in an operative site or in the hospitalised
patientpatient
● Oral rout: on empty stomach, 2gs Penicillin reachesOral rout: on empty stomach, 2gs Penicillin reaches
high peak after 1 hour.high peak after 1 hour.
● Parenteral root is indicated in sever infectionParenteral root is indicated in sever infection
199. 33..Removal of the source ofRemoval of the source of
infectioninfection
Ultimate goal of treatment is directed at removing theUltimate goal of treatment is directed at removing the
source of infection.source of infection.
For odontogenic infections, this means endodonticFor odontogenic infections, this means endodontic
treatment, or extraction of the offending dentition.treatment, or extraction of the offending dentition.
Should be done concurrently with establishment ofShould be done concurrently with establishment of
drainage of the involved space (s).drainage of the involved space (s).
Antimicrobial aids in eliminating infections from the body.Antimicrobial aids in eliminating infections from the body.
But are not curative so long as the source of infection isBut are not curative so long as the source of infection is
present.present.
In OMFS, treatment is incision and drainage (I&D) of theIn OMFS, treatment is incision and drainage (I&D) of the
involved space and removal of the causative agent.involved space and removal of the causative agent.
201. 44..Surgical treatmentSurgical treatment
Sterile preparation and draping.Sterile preparation and draping.
Aspiration of the swelling for investigation &Aspiration of the swelling for investigation &
samplingsampling
Place 1-2 cm incision in a healthy skin orPlace 1-2 cm incision in a healthy skin or
mucosa not over most fluctuant areamucosa not over most fluctuant area
Place skin incision in aesthetically acceptablePlace skin incision in aesthetically acceptable
area.area.
blunt dissection with instrument and/or finger.blunt dissection with instrument and/or finger.
Use shortest and most direct route to theUse shortest and most direct route to the
space.space.
Secure drains, penrose or red rubberSecure drains, penrose or red rubber
catheters, avoid gauze drainscatheters, avoid gauze drains
202. Surgical drainage and incisionSurgical drainage and incision
How to judge the pus formation?How to judge the pus formation?
Purposes of surgical drainage and incisionPurposes of surgical drainage and incision
Principles of surgical drainage and incisionPrinciples of surgical drainage and incision
203. How to judge the pus formationHow to judge the pus formation??
Three stagesThree stages
InoculationInoculation
CellulitisCellulitis
AbscessAbscess
Duration--- >5 daysDuration--- >5 days
Palpation---Palpation---
FluctuantFluctuant
Appearance---Appearance---
ReddenedReddened
Needle aspirationNeedle aspiration
B-ultrasoundB-ultrasound
CTCT
CharacteristicCharacteristic
205. 44..Surgical treatmentSurgical treatment
Sterile preparation and draping.Sterile preparation and draping.
Aspiration of the swelling for investigation &Aspiration of the swelling for investigation &
samplingsampling
Place 1-2 cm incision in a healthy skin orPlace 1-2 cm incision in a healthy skin or
mucosa not over most fluctuant areamucosa not over most fluctuant area
Place skin incision in aestheticallyPlace skin incision in aesthetically
acceptable area.acceptable area.
blunt dissection with instrument and/orblunt dissection with instrument and/or
finger.finger.
Use shortest and most direct route to theUse shortest and most direct route to the
space.space.
Secure drains, penrose or red rubberSecure drains, penrose or red rubber
catheters, avoid gauze drainscatheters, avoid gauze drains
208. Site of incision and drainageSite of incision and drainage
for FSfor FS
Submandibular:Submandibular: Below inf mandible, inBelow inf mandible, in
submandibular trianglesubmandibular triangle
Masticator:Masticator: E/O at Inferior border ofE/O at Inferior border of
mandible, I/O at pterygomandibular raphaemandible, I/O at pterygomandibular raphae
Temporal:Temporal: Above zygomatic arch, I/O atAbove zygomatic arch, I/O at
raphaeraphae
Infratemporal:Infratemporal: Above and lateral toAbove and lateral to
maxillary tuberositymaxillary tuberosity
Buccal:Buccal: Inf. mandible, I/O buccal mucosaInf. mandible, I/O buccal mucosa
inf to Stenson’s duct.inf to Stenson’s duct.
Lat Pharyngeal:Lat Pharyngeal: Angle of mandible, I/O atAngle of mandible, I/O at
raphae.raphae.
209. Principles of surgical drainage &Principles of surgical drainage &
incisionincision
Place the incision in an estheticallyPlace the incision in an esthetically
acceptableacceptable
Place the incision in a dependent positionPlace the incision in a dependent position
to encourage drainage by gravityto encourage drainage by gravity
Dissect bluntly through deeper tissuesDissect bluntly through deeper tissues
and explore all pockets and portions ofand explore all pockets and portions of
the abscessthe abscess
Place a drain and stabilize it with suturesPlace a drain and stabilize it with sutures
212. Although no purulence is expressed, I&DAlthough no purulence is expressed, I&D
will alter the microenvironment whichwill alter the microenvironment which
promoted the infection.promoted the infection.
This disruption of the balance amongstThis disruption of the balance amongst
different organism, together with adifferent organism, together with a
competent immune system and aid ofcompetent immune system and aid of
antimicrobials will lead to resolution of theantimicrobials will lead to resolution of the
infection.infection.
If the infective source is removedIf the infective source is removed
simultaneously, the above manoeuvre issimultaneously, the above manoeuvre is
curative.curative.
Incision & drainage
218. Penrose drain in place to providePenrose drain in place to provide
drainage for vestibular abscessdrainage for vestibular abscess
219. How the patientHow the patient
feels- Malaisefeels- Malaise
PreviousPrevious
treatmenttreatment
Self treatmentSelf treatment
Past MedicalPast Medical
HistoryHistory
Severity of the InfectionSeverity of the Infection
221. Incision and drainageIncision and drainage
Dependent siteDependent site
Incision in healthyIncision in healthy
tissuetissue
Adequate drainageAdequate drainage
Exploration of allExploration of all
involved spacesinvolved spaces
IrrigationIrrigation
Surgical TreatmentSurgical Treatment
Intraoral Aspiration
224. Purposes of surgical drainage &Purposes of surgical drainage &
incisionincision
Get rid the body of toxic purulent materialGet rid the body of toxic purulent material
Decompress the tissuesDecompress the tissues
Allowing better perfusion of blood containingAllowing better perfusion of blood containing
antibiotics and defensive elementsantibiotics and defensive elements
Increased oxygenation of the infected areaIncreased oxygenation of the infected area
225. AntibioticsAntibiotics
E. Antimicrobial susceptibility testingE. Antimicrobial susceptibility testing
Based onBased on MICMIC ((Minimum InhibitoryMinimum Inhibitory
ConcentrationConcentration))
Therapeutic antibiotic dose is 3-4 times theTherapeutic antibiotic dose is 3-4 times the
MIC; and 8 times in compromised hosts.MIC; and 8 times in compromised hosts.
Minimal Bactericidal Concentration (MBC):Minimal Bactericidal Concentration (MBC):
is the antimicrobial concentration that killsis the antimicrobial concentration that kills
99,9 % of bacteria.99,9 % of bacteria.
Organisms are considered antibioticOrganisms are considered antibiotic
resistant if MBC> MIC by 32-fold.resistant if MBC> MIC by 32-fold.
226. 22..Medical therapyMedical therapy::
Antibiotic therapyAntibiotic therapy a : Prophylactica : Prophylactic
Principles of prophylactic antibiotic usePrinciples of prophylactic antibiotic use
CriteriaCriteria AdvantagesAdvantages DisadvantagesDisadvantages
Significant risk ofSignificant risk of
infectioninfection
Choose correctChoose correct
antibioticantibiotic
High levelHigh level
Timing (when)Timing (when)
Shortest effectiveShortest effective
antibioticantibiotic
ReducesReduces
incidence ofincidence of
infectioninfection
Reduces healthReduces health
care costscare costs
Reduces totalReduces total
antibiotic useantibiotic use
Allows fewerAllows fewer
resistant bacteriaresistant bacteria
Alter hostAlter host
flora?flora?
Benefit?Benefit?
Cost?Cost?
Toxicity?Toxicity?
227. Pharmacokinetics:Pharmacokinetics: What the bodyWhat the body
does to a drugdoes to a drug
Pharmacodynamics:Pharmacodynamics: What the drugWhat the drug
does to a bodydoes to a body
It can’t hurt and it might help shouldIt can’t hurt and it might help should
not be the reason you are prescribingnot be the reason you are prescribing
antibioticsantibiotics
228. Principles of antibioticPrinciples of antibiotic
administrationadministration
Proper doseProper dose
Proper time intervalProper time interval
Proper route of administration (oral,Proper route of administration (oral,
parenteral)parenteral)
Combination antibiotic therapy to obtainCombination antibiotic therapy to obtain
potentiation, to delay development of drugpotentiation, to delay development of drug
resistance, to broaden the spectrum of anti-resistance, to broaden the spectrum of anti-
infective druginfective drug
229. Synergism:Synergism: A drug interact with another toA drug interact with another to
produced increased activityproduced increased activity
Antagonism:Antagonism: Is a drug with opposite actionIs a drug with opposite action
to other drug, it inhibit its actionto other drug, it inhibit its action
Mode of action of Antibiotics:Mode of action of Antibiotics:
1-Interference with the cell wall1-Interference with the cell wall
2-Interference with biochemical activity2-Interference with biochemical activity
3-Inhibition of protein synthesis3-Inhibition of protein synthesis
4.Interference with cell metabolism4.Interference with cell metabolism
234. 33..Lab studiesLab studies
F. Antimicrobial susceptibility testingF. Antimicrobial susceptibility testing
Based onBased on MICMIC ((Minimum InhibitoryMinimum Inhibitory
ConcentrationConcentration))
Therapeutic antibiotic dose is 3-4 times theTherapeutic antibiotic dose is 3-4 times the
MIC; and 8 times in compromised hosts.MIC; and 8 times in compromised hosts.
Minimal Bactericidal Concentration (MBC):Minimal Bactericidal Concentration (MBC):
is the antimicrobial concentration that killsis the antimicrobial concentration that kills
99,9 % of bacteria.99,9 % of bacteria.
Organisms are considered antibioticOrganisms are considered antibiotic
resistant if MBC> MIC by 32-fold.resistant if MBC> MIC by 32-fold.
235. Principles of Antibiotic TherapyPrinciples of Antibiotic Therapy
Use EmpiricUse Empiric
TherapyTherapy
Use narrowestUse narrowest
spectrum drugspectrum drug
Use antibiotic withUse antibiotic with
the lowest toxicitythe lowest toxicity
Use bactericidalUse bactericidal
antibioticantibiotic
Be aware of Cost $$Be aware of Cost $$
$$
236. Antibiotic TherapyAntibiotic Therapy
Initial therapyInitial therapy
Cover Gram positive cocci andCover Gram positive cocci and
anaerobesanaerobes
If pt is diabetic, should considerIf pt is diabetic, should consider
covering gram negatives empirically.covering gram negatives empirically.
Unasyn, Clindamycin, 2Unasyn, Clindamycin, 2ndnd
generationgeneration
cephalosporin.cephalosporin.
PCN, gentamicin and flagyl -PCN, gentamicin and flagyl -
developing nationsdeveloping nations..
IV abx alone (based on retro andIV abx alone (based on retro and
parapharyngeal infections)parapharyngeal infections)
Patient stability and nature of lesion.Patient stability and nature of lesion.
Cellulitis/phlegmon by CT.Cellulitis/phlegmon by CT.
Abscesses in clinically stable patient.Abscesses in clinically stable patient.
If no clinical improvement in 24 - 48If no clinical improvement in 24 - 48
hours proceed to surgicalhours proceed to surgical
interventionintervention..
237. Indications for Culture andIndications for Culture and
Ab. Sensitivity TestingAb. Sensitivity Testing
Rapidly spreadingRapidly spreading
infectioninfection
Post-op infectionPost-op infection
Non-responsiveNon-responsive
infectioninfection
Recurrent infectionRecurrent infection
Compromised hostCompromised host
defensesdefenses
238. Antibiotic Associated ColitisAntibiotic Associated Colitis
DiagnosisDiagnosis
Profuse wateryProfuse watery
diarrhea >10 per daydiarrhea >10 per day
CrampingCramping
FeverFever
toxin assaytoxin assay
Tissue cultureTissue culture
TreatmentTreatment
D/C current ABD/C current AB
Fluid managementFluid management
AntibioticsAntibiotics
MetronidazoleMetronidazole
Vancomycin POVancomycin PO
239. Reasons for Treatment FailureReasons for Treatment Failure
Inadequate SurgeryInadequate Surgery
Depressed hostDepressed host
responsesresponses
Foreign bodyForeign body
Antibiotic problemsAntibiotic problems
Patient noncompliancePatient noncompliance
Drug not reaching theDrug not reaching the
sitesite
Drug dose too lowDrug dose too low
Wrong antibioticWrong antibiotic
240. Antibiotic TherapyAntibiotic Therapy
Removal of the cause, drainage,Removal of the cause, drainage,
and supportive care more importantand supportive care more important
than antibiotic therapy.than antibiotic therapy.
Infections are cured by the patient’sInfections are cured by the patient’s
defenses,defenses, notnot antibiotics.antibiotics.
Risks of allergy, toxicity, sideRisks of allergy, toxicity, side
effects, resistance andeffects, resistance and
superinfection causing serious orsuperinfection causing serious or
potentially fatal consequences mustpotentially fatal consequences must
be considered.be considered.
241. Antibiotic therapy, con’tAntibiotic therapy, con’t..
Oral infections are typically polymicrobial.Oral infections are typically polymicrobial.
Antibiotic effectiveness dependent uponAntibiotic effectiveness dependent upon
adequate tissue (not serum) concentrationadequate tissue (not serum) concentration
for an appropriate amount of time.for an appropriate amount of time.
Antibiotics should be prescribed for at leastAntibiotics should be prescribed for at least
one week – adequate tissue concentrationone week – adequate tissue concentration
achieved in 24-48 hours, with bacteriocidalachieved in 24-48 hours, with bacteriocidal
activity occurring over the next 3-5 days.activity occurring over the next 3-5 days.
242. Antibiotic therapy, con’tAntibiotic therapy, con’t..
PenicillinPenicillin (bacteriocidal) drug of choice for(bacteriocidal) drug of choice for
treatment of odontogenic infections (5% incidenttreatment of odontogenic infections (5% incident
of allergy).of allergy).
ClindamycinClindamycin (batericiodal) 1(batericiodal) 1stst
line afterline after
penicillin; effective against anaerobes; stoppenicillin; effective against anaerobes; stop
taking at first sign of diarrhea.taking at first sign of diarrhea.
CephalosporinCephalosporin (slightly broader spectrum and(slightly broader spectrum and
bacteriocidal); cautious use in penicillin-allergicbacteriocidal); cautious use in penicillin-allergic
patients → cross-sensitivity; if history ofpatients → cross-sensitivity; if history of
anaphylaxis to penicillin, do not use.anaphylaxis to penicillin, do not use.
243. Antibiotic therapy, con’tAntibiotic therapy, con’t..
ErythromycinErythromycin (bacteriostatic) good 2(bacteriostatic) good 2ndnd
line drug afterline drug after
penicillin; use enteric-coated to reduce GI upset.penicillin; use enteric-coated to reduce GI upset.
Erythromycin is less effective than penicillinErythromycin is less effective than penicillin
MetronidazoleMetronidazole (bacteriocidal) excellent against(bacteriocidal) excellent against
anaerobes only.anaerobes only.
AugmentinAugmentin (amoxicillin + clavulanic acid) kills(amoxicillin + clavulanic acid) kills
penicillinase-producing bacteria that interferes withpenicillinase-producing bacteria that interferes with
amoxicillin; expensive.amoxicillin; expensive.
VancomycinVancomycin for methicillin-resistant staphylococcifor methicillin-resistant staphylococci
(MRS)(MRS)
QuinolonesQuinolones for chronic osteomyelitis.for chronic osteomyelitis.
244. 22..Medical therapyMedical therapy
Antibiotic therapyAntibiotic therapy
Combination therapy may be indicated in:Combination therapy may be indicated in:
Life-threatening infectionsLife-threatening infections
Necrotizing fasciitisNecrotizing fasciitis
Chronic osteomyelitis (Quinolones have goodChronic osteomyelitis (Quinolones have good
bone penetration)bone penetration)
Prevention of resistant organisms e.g.Prevention of resistant organisms e.g.
bacteroids and staphylococcibacteroids and staphylococci
Combination therapy involves a BSA (penicillin)Combination therapy involves a BSA (penicillin)
and drug active against gram-negative or one ofand drug active against gram-negative or one of
the beta lactamase inhibitor combinations.the beta lactamase inhibitor combinations.
245. 22..Medical therapyMedical therapy
Adjusting antibiotic therapyAdjusting antibiotic therapy::
Nonresponsive or super-infectionsNonresponsive or super-infections
Culture and antibiotic sensitivity testsCulture and antibiotic sensitivity tests
resultsresults
ToxicityToxicity::
Aminoglycosides (nephro-and ototoxicity)Aminoglycosides (nephro-and ototoxicity)
Clindamycin, cephalosporinsClindamycin, cephalosporins
(pseudomembranous colitis)(pseudomembranous colitis)
Erythromycin (hepatotoxicity in high doses)Erythromycin (hepatotoxicity in high doses)
Penicillins and cephalosporins (hypersensitivityPenicillins and cephalosporins (hypersensitivity
246. 22..Medical therapyMedical therapy
Adjunct to antibiotic administrationAdjunct to antibiotic administration
Nystatin for fungal superinfection (Candida)Nystatin for fungal superinfection (Candida)
Hyperbaric oxygen therapyHyperbaric oxygen therapy::
Increase vascularityIncrease vascularity
Aids in bone healingAids in bone healing
Increases antibiotic delivery to tissues.Increases antibiotic delivery to tissues.
247. Antibiotic resistanceAntibiotic resistance mechanismsmechanisms
1. alteration in permeability of bacterial cell wall1. alteration in permeability of bacterial cell wall
for the drugfor the drug
2. changes in the target sites for the drug in the2. changes in the target sites for the drug in the
bacterial cell wallbacterial cell wall
3. bypassing metabolic reactions blocked by the3. bypassing metabolic reactions blocked by the
drugdrug
4. drug inactivation4. drug inactivation
1-3 = tolerance 4 = antibiotic destructive1-3 = tolerance 4 = antibiotic destructive
cross resistance = bacteria resistant to onecross resistance = bacteria resistant to one
antibiotic: is the resistance to other forms ofantibiotic: is the resistance to other forms of
the antibiotic which are chemically closelythe antibiotic which are chemically closely
relatedrelated
248. Antibiotic resistanceAntibiotic resistance
1. Natural1. Natural 2. Acquired2. Acquired
11. Natural. Natural
Due to:Due to:
the production of enzymes by bacteriathe production of enzymes by bacteria
nullifying the antibiotic effect e.g:nullifying the antibiotic effect e.g:
Penicllinase production by Staph. Aureus orPenicllinase production by Staph. Aureus or
by the virtue of morphological/biologicalby the virtue of morphological/biological
factors which exclude the natural targetfactors which exclude the natural target
areas of the bacteria to the action of theareas of the bacteria to the action of the
antibioticantibiotic
249. Antibiotic resistanceAntibiotic resistance
2. Acquired2. Acquired
Bacteria can adapt and become resistant as anBacteria can adapt and become resistant as an
adaptive reaction to prolonged or continuousadaptive reaction to prolonged or continuous
use of an antibiotic mediated by mutationuse of an antibiotic mediated by mutation
Mutation- natural mutants (chromosomal) theMutation- natural mutants (chromosomal) the
removal of the dominant antibiotic sensitiveremoval of the dominant antibiotic sensitive
strains by the administration of antibiotics allowsstrains by the administration of antibiotics allows
these bacteria to proliferate freely withoutthese bacteria to proliferate freely without
competition e.g strept viridanscompetition e.g strept viridans
250. Choosing a suitable antibioticChoosing a suitable antibiotic
Patient FactorsPatient Factors
allergyallergy
renal/hepatic functionrenal/hepatic function
immuno-compromiseimmuno-compromise
oral toleranceoral tolerance
severity of illnessseverity of illness
age/weightage/weight
pregnancy/breastpregnancy/breast
feedingfeeding
oral contraceptive/otheroral contraceptive/other
medicationmedication
Microbial FactorsMicrobial Factors
culture and sensitivityculture and sensitivity
likely organisms’likely organisms’
sensitivitysensitivity
251. Factors that determine degree of placentalFactors that determine degree of placental
transfer:transfer:
Lipid solubilityLipid solubility
Ionization of compoundIonization of compound
Protein bindingProtein binding
Placental foetal blood flowPlacental foetal blood flow
Considerations in the pregnant or lactating
patient with infection:
252. Approx. sameApprox. same
as maternalas maternal
20% to 50 of20% to 50 of
maternalmaternal
10% to 15 of10% to 15 of
maternalmaternal
Penicillins,Penicillins,
amoxicillin,amoxicillin,
ampicillin,ampicillin,
methicillin,methicillin,
sulfonamides,sulfonamides,
chloramphenicol,chloramphenicol,
and tetracyclinsand tetracyclins
AminoglycosidesAminoglycosides
(not safe for(not safe for
pregnant, notpregnant, not
absorbed fromabsorbed from
bowel)bowel)
Cephalosporins,Cephalosporins,
clindamycin, andclindamycin, and
erythromycinerythromycin
Foetal serum concentrationsFoetal serum concentrations
253. Breast milk concentrationsBreast milk concentrations
Approx. sameApprox. same
as maternalas maternal
50% to 70 of50% to 70 of
maternalmaternal
Less than 25% ofLess than 25% of
maternalmaternal
Sulfonamides,Sulfonamides,
Metronidazole andMetronidazole and
isoniazidisoniazid
ChloramphenicolChloramphenicol
and erythromycinand erythromycin
Cephalosporins,Cephalosporins,
clindamycin, andclindamycin, and
erythromycinerythromycin
276. Case report 2Case report 2
Pt ; 30/MPt ; 30/M
CC ;transfer from ENT d/t deep neck infectionCC ;transfer from ENT d/t deep neck infection
from dental originfrom dental origin
PI ; both submn swelling & TdPI ; both submn swelling & Td
mouth opening limit, dysphagia, dyspnea,mouth opening limit, dysphagia, dyspnea,
neck Td & redness, #38 area pusneck Td & redness, #38 area pus
DX ; submn & mental space abscessDX ; submn & mental space abscess
pretracheal space abscesspretracheal space abscess
descending necrotizing mediastinitisdescending necrotizing mediastinitis