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Management of Odontogenic Infections, image - Coggle Diagram
Management of Odontogenic Infections
Examination
1) Determine the
SEVERITY
of the infection
Signs & Symptoms
WARNING SIGNS !!!
Dysphagia
Dyspnea
Moderate to severe trismus
Elevated temperature
Toxic appearance
Dehydration
Slowly enlarging swelling with dull ache and recurrent draining abcess does not require emergency tx
Complete history
Chief complaint: CARDINAL SIGNS OF INFLAMMATION
dolor (pain), tumor (Swelling), calor (Warmth), rubor (erythema/ redness), & function laesa (loss of function)
Time of onset
Change in symptoms
Rapidity of infection progression
Presence of malaise
Monitor Vital Signs
Blood pressure
Pain & anxiety can raise BP
Septic shock --> HYPOTENSION
Temperature (>38.3 degrees = severe infection)
Pulse rate (>100BPM may indicate severe infection)
Respiratory rate
To check for potential ariway obstruction
Ensure that airway is clear!
18 breaths/min = severe infection
Head & Neck Examination
Check for
trismus, dysphagia or dyspnea
Ask pt to open wide, swallow and take deep breaths
Palpate swelling
fluctuant usu indicates pus accumulation
Determine the involved spaces
Signs of inflammation @ lymph nodes
Loss of function: dysphagia, trismus, dyspnea
Eye examination
Intra-oral Examination
Gingival swelling
Uvula displacement
Salivary glands
Teeth (abcess, gross caries)
Radiographic Examination
PAs for teeth that may be the cause
DPT for limited mouth opening
2) Determine the patient's
HOST DEFENCE MECHANISMS
↓ host defences may cause infection to spread more rapidly and require more aggressive tx
Medical conditions that compromise host defence
Uncontrolled metabolic conditions
Uncontrolled diabetes
End stage renal failure
Severe alcoholism
Malnutrition
Immune System Suppressing Diseases
Leukemia, lymphoma, cancers
HIV
Immune suppressive therapies
Chemotherapy
Immunosuppresants
Corticosteroids
Organ Transplant
3) Determine the
SETTING
of treatment
Criteria for referral to OMS
Rapidly spreading infection over 1-2 days that's not improving
Difficulty breathing or swallowing
Dehydration
Moderate to severe trismus
Fever
Malaise & toxic appearance
Protect the Airway!
Especially crucial if pt has LUDWIGS ANGINA
Head tilt chin lift, ensure correct posture, intubation, tracheostomy
Surgical Management
Aims
Remove cause of infection
Provide drainage for accumulated pus and necrotic debris
Methods
Extraction
Pulpectomy/ RCT
Periodontal debridement
Exploration of socket/ wound
INCISION & DRAINAGE
Purpose
Abcess: decrease bacterial load and reduce hydrostatic pressure --> improve blood supply and delivery of host defences
Cellulitis: abort spread of infection into deeper anatomical spaces
When?
In cases of
ABCESS & CELLULITIS
You must do I&D prior to prescription of antibiotics as antibiotics are unable to penetrate the fibrous capsule surround the abscess/cellulitis
How
Incise at site of MAXIMUM SWELLING & INFLAMMATION
Insert
CLOSED HEMOSTAT
through incision and open hemostat in several directions to break up small loculations
Aspirate
pus with suction
Maintain
drainage
Insert drain if necessary (most common is quarter inch penrose drain)
Suture drain to incision with non-resorbable sutures
Drain remain in place for 2-5 days
Culture & Sensitivity Testing
Indications
Inf spreading beyond alevolar process
Rapidly progression inf
Previous/ multiple abx therapy
Non-responsive infection
Recurrent infection
Compromised host defences
NOTE: problems with anaesthesia
difficult to achieve anaesthesia due to
increased acidity of inflammed tissues
decreased lipid solubility
strategies to improve
buffer with sodium bicarbonate
inject to distant site
avoid giving excess LA (might force infection further into tissues)
Antibiotic Therapy
Need to be prescribe for at least
a week
in order to achieve adequate tissue concentration for an appropriate time
For simple cases,
empirical antibiotics
are sufficient
When C&S results are out, change or continue antibiotics
Consider the necessity of Abx
Seriousness of infection
Whether adequate surgical tx can be achieved
Pt's host defences
Indications
Acute onset of infection
Involvement of deep fascial spaces
Systemic involvement
Osteomyelitis
Severe pericoronitis
Mx compromised
Contraindications
Well localised abcess
Minor abccess
Dry socket
Non-immunocompromised pt
Common Antibiotics
PENICILLIN 600mg every 6 hours
CLINDAMYCIN 300-450mg every 6 hours
CEPHALOSPORIN 500mg every 6 hours
ERYTHROMYCIN 500mg every 6 hours
METRONIDAZOLE 500 TDS
Supportive Therapy
Home
↑ fluid intake
Nutritional intake
Analgesics for pain relief
Operator
May need to see pt daily until resolution
Medical physician
Control of systemic diseases
