Transcript
OROFACIAL INFECTIONS
Group 2
Acute dental alveolar abscessPericoronitisAcute alveolar osteitisCellulitis Ludwig’s Angina Cavernous Sinus Thrombosis Osteomyelitis
Odontogenic Infections
GENERAL CLASSIFICATION-AETIOLOGYOdontogenic
Traumatic
Implant surgery
Reconstructive surgery
Infections from contaminated needles
Others:antrum associated,salivary gland afflictions
Secondary to malignancies
CAUSATIVE MICROORGANISMS Bacterial-odontogenic/non-odontogenic
Fungal
viral
POSSIBLE SPREAD OF INFXN
INFECTIONS
Acute:abscess,cellulitis,fulminating infections
Chronic:
Acute Dento-alveolar Abscess
Def:a circumscribed suppurative type of inflammation involving primarily the tooth and the investing alveolar bone.
This disease entity is a continuation of periapical abscess.
Clinical features
1.Pain:severe throbbing pain
2. Submucosal swelling in the sulcus
Usually on the outer aspect of alveolar process. Fluctuation may be elicited after few days. If left untreated, the swelling bursts and produces sinus tract discharging pus.
3.Tooth is sensitive to touch
4.Fever
5.lymphadenitis:nodes are enlarged, soft and tender
PATHOGENESIS
Bacterial irritation of pulp tissuesPulp hyperemiaPulpitisPulp necrosisAcute periapical periodontitisAlveolitis
PROGNOSIS &TREATMENT
Prognosis depends on virulence and number of microorganisms and patients resistance.It may resolve or progress to chronic dental alveolar abscess then to a periapical granuloma.Treatment:Antibiotics,analgesics,RCT,Extraction.In addition, intra-or extra oral incision and drainage may be required.
Surgical Therapy:
Surgical Technique for Incision and Drainage of an Abscess
Incision and drainage helps :
i. To get rid of toxic purulent material.
ii. To decompress the edematous tissues.
iii. To allow better perfusion of blood, containing antibiotic and defensive elements.
iv. To increase oxygenation of the infected area.
Technique:
1) Topical/Local anesthesia
2) Make a stab incision
3) Closed forceps pushed thru tough deep fascia to pus collection
4) Abscess cavity entered
5) Pus flows along the beaks
6) Placement of a drain; corrugated rubber drain placed and secured
7) Drain left for at least 24 hrs
8) Dressing applied over site of incision
EDEMA,CELLULITIS,ABSCESS
MICROBIOLOGYThe aerobic bacteria found in odontogenic infection are primarily gram positive cocci, most are viridans streptococci species, includeStrep. milleri, Strep. sanguis, Strep. salivarius, strep. mutans.These oral streptococci are also known as α-hemolytic streptococci, which account for about 80 percent of aerobic bacteria found in odontogenic infection.There are two main groups of bacteriodes. First is Oropharyngeal group, which is found in the mouth and contributes to odontogenic infections.The other group found in the gut—the enteric Bacteroides, they include B. Fragilis, B. Vidgatis, B. Distasonis, B. thetaiotaomicron, B. Ovatis. They are rarely seen in oral cavity and mostly do not cause odontogenic infections.Oropharyngeal bacteroides divided into: (a) Porphyromonas, and (b) Prevotella.a. Porphyromonas:It includes P. asacchrolyticus, P.Gingivalis, andP. endodontalis. b. Prevotella:It includes P. melaninogenicus, P. buccae, P. intermedius, P. oralis, P. loescheii, P. ruminocola, andP. denticola. Prevotella intermedius, Porphyromonas gingivalis, andPorphyromonas endodontalis appears to be most pathogenic among them.
These gram negative anaerobic rods, are usually susceptible to most antibiotic, but they are 25 percent resistant to penicillin V and nearly 50 percent resistant to cephalexin, and other first generation cephalosporin.The other group of anaerobic gram negative rod is the genus Fusobacterium. Fusobacterium, like bacteroides are pathogenic and have the ability to destroy tissues through production of proteolytic enzymes and endotoxins. Fusobacterium is usually sensitive to penicillin and penicillin like drugs, but are frequently resistant to erythromycin.
Fusobacterium species appears to be the most virulent and when in combination with Strep. milleri, commonly seen in aggressive odontogenic infections
that have descended into the lateral pharyngeal and retropharyngeal spaces and also into the mediastinum.
MAJOR PATHOGENS IN ODONTOGENIC INFXNS.
MEDICAL THERAPY
Supportive care:hydration,soft or liquid diet rich in protein,analgesics,use antiseptic mouthwashes to maintain oral hygiene.
Antibiotic therapy:
PERICORONITIS
Def:inflammation of soft tissues surrounding crown of partially erupted tooth/unerupted tooth EtiologyBacterial growth under flapTraumatic irritation
Common site: impacted/malposedthird molars
TYPES
a)Acuteb)Subacutec)chronic
SIGNS AND SYMPTOMS OF ACUTE PERICORONITIS
Severe painDysphagiaTrismusHalitosisLymphadenitisExtra oral swellingConstitutional symptoms:fever,chills,increased resp. rate, general malaise
SUBACUTE/CHRONIC SIGNS AND SYMPTOMS
Dull painStiffnessPus under flapBad tastelymphadenitis
Spread: The pericoronal infection, if left untreated can spread to the following regions:
i. It can extend submucosally and form a vestibular abscess against mandibular second or third molars; and may discharge as intraoral sinus.
ii. It can extend on the outer surface of buccinator causing buccal space abscess.
iii. It can extend into the submandibular, pterygomandibular and submasseteric spaces.
iv. Rarely, it can extend down to lower border of
mandible behind the depressor anguli oris muscle;
and burst through the skin (if not incise
TREATMENT
Operculectomy
Indicated if
i. Tooth is in good position
ii. 1/3 rd of crown is covered by flap
STEPS
a) LA
b) Irrigation under flap
c) Scalpel/electro scalpel used to remove flap
d) Surgical pack
e) Antibiotics and analgesics
CONSERVATIVE TREATMENT
Selective grinding of opposite toothIrrigation under flapWarm saline and hydrogen peroxide mouthwash antibiotics
ACUTE ALVEOLAR OSTEITIS/DRY SOCKET Def:a complication of XLA in which blood clot disintegrates and patient experiences severe pain.
Causative factors;
Infection:Poor oral hygiene
Trauma:difficult extraction
Immuno-compromised states:HIV,DM
Predisposing factors
Vasoconstrictors in LA
Reduced vascularity- common in the mandible
Smoking
Overinsing mouth
PATHOGENESIS
Inflammation causes release of tissue activator that converts plasminogen to plasmin that causes lysis of fibrinogen causing clot dissolution hence bare bone is left.
Kinogen is also transformed to kinins causing severe pain.
SIGNS AND SYMPTOMS
1. Occur 3rd -4th day after extraction
2. Very severe pain
3. No clot in socket i.e bare bone
4. Bad taste and smell
5. No frank sequestration
6. Rarely pyrexia
7. Lymph node enlargement
TREATMENT
1. Irrigation- with warm saline to remove any debris or foreign material
2. Dressing –zinc-oxide eugenol with some cotton fibers. Dressing is changed every 24-48hrs.
3. Curettage –avoid on the bony walls
4. Antibiotics – not to be used except for guarding against superimposed infection.
It is an acute infection of the skin extending deep into subcutaneous tissues underlying the dermis if abscess is NOT able to establish drainage through the surface of skin or into oral cavity. may spread diffusely through facial planes of soft
tissue. There is edematous spread of acute inflammatory process .
Aetiology:Streptococcus pyogenes
Cellulitis
two dangerous forms:
Ludwig’s Angina
Cavernous Sinus Thrombosis
Cellulitis
named after German physician who described the seriousness of disorder in 1836
Angina comes from Latin word angere
strangle
Ludwig’s Angina
AETIOLOGY
1.Odontogenic infections:abcesses2.Iatrogenic: Use of contaminated
needles3.Traumatic injuries to oro- facial
region: mandibular fractures,deep penetrating wounds
4.Osteomyelitis5.Submandibular/sublingual
sialadenitis6.Secondary infections of oral
malignancies
70% of cases, develop from spread of an acute infection from lower molar teeth
prevalence in patients who are immunocompromised secondary to disorders such as:
diabetes mellitus organ transplantation acquired immunodeficiency syndrome (AIDS) aplastic anemia
Ludwig’s Angina
Clinical Features
massive swelling on neck
often extends close to clavicle
involvement of sublingual space results in
• elevation Woody Tongue• posterior enlargement can compromise• protrusion of tongue airway
Ludwig’s Angina
Ludwig’s Angina
Clinical Features
involvement of submandibular space results in
• enlargement• tenderness of neck above
level of hyoid bone Bull Neck• pain in neck + floor of mouth• restricted neck movement
Ludwig’s Angina
Clinical Features
involvement of submandibular space results in
• dysphagia• dysphonia• dysarthria• drooling• sore throat
Ludwig’s Angina
Clinical Features
involvement of lateral pharyngeal space
• respiratory obstruction secondary to laryngeal edema
• tachypnea• dyspnea• tachycardia• patient needs to maintain erect position
Ludwig’s Angina
Treatment & Prognosis
centers around 4 activities
• maintenance of airway• incision + drainage• antibiotic therapy• elimination of original focus
of inflammation
Ludwig’s Angina
Treatment & Prognosis
initial observation many clinicians administer
• systemic corticosteroid medications such as intravenous (IV) dexamethasone
attempt to reduce cellulitis
Ludwig’s Angina
Treatment & Prognosis
if signs or symptoms of impending airway obstruction:
• fiber-optic nasotracheal intubation
• tracheostomy
• cricothyroidotomy
Ludwig’s Angina
Treatment & Prognosis
if signs or symptoms of impending airway obstruction:
• cricothyroidotomy
sometimes performed instead of tracheostomy
perceived lower risk of spreading infection to mediastinum
Ludwig’s Angina
Treatment & Prognosis
• cricothyroidotomy
Ludwig’s Angina
Treatment & Prognosis high dose of penicillin(penicillin G, 2 to 4 million
units, IV 4 to 6 hourly; or 500 mg six hourly orally). Amoxycillin; 500 mg 6 and 8 hourly, IV and orally Cloxacillin; 500 mg orally, 8 hourly. In case of allergy to penicillin; Erythromycin 600 mg
6 to 8 hourly. Gentamicin has activity against some resistant
staphylococci and pseudomonas. 80 mg I.M, B.D. Clindamycin IV 300 to 600 mg 8 hourly, orally and
intravenously. Its spectrum of activity includes gram positive cocci including penicillinase resistant staphylococci, and Bacteroides.
Ludwig’s Angina
TREATMENT CTD
Metronidazole: It is a useful antibiotic against anaerobic flora found in oral infections. It is administered in the form of 400 mg 8 hourly orally or intravenously.
Cephalosporins: These are closely related to penicillin and have similar spectrum of their activity. These are usually reserved for resistant infections.
Usually, a combination of antibiotic therapy is indicated for aggressive management of Ludwig’s angina, a penicillin or it’s derivative alongwith metronidazole or gentamicin.
Note: Antibiotics should be changed subsequent to the result of bacterial culture and sensitivity testing
Treatment & Prognosis
if infection remains:
diffuse surgical intervention indurated is at discretion of clinician brawny + often governed by patient’s
response to noninvasive therapy
Ludwig’s Angina
Treatment & Prognosis
complications:
• Pericarditis• Pneumonia• Mediastinitis• Sepsis• Empyema• Respiratory Obstruction
Ludwig’s Angina
edematous periorbital enlargement
with involvement of eyelids + conjunctiva. Aetiology:StaphylococciStreptococci and some gram –vebacteria
Cavernous Sinus Thrombosis
in cases, involving canine space
swelling along lateral border of nose
may extend up to medial aspect of eye + periorbital area
protrusion + fixation of eyeball
Cavernous Sinus Thrombosis
in cases, involving canine space
induration + swelling of adjacent forehead + nose
pupil dilation lacrimation may also photophobia occur loss of vision
Cavernous Sinus Thrombosis
in cases, involving canine space
pain over eye + along distribution of:
• opthalmic Trigeminal • maxillary branches Nerve
Cavernous Sinus Thrombosis
Treatment & Prognosis
surgical drainage + high-dose antibiotic medication similar to those administered for patient’s with Ludwig’s Angina
Cavernous Sinus Thrombosis
OML may be defined as an inflammatory condition of bone, that begins as an infection of medullary cavity and haversian systems of the cortex and extends to involve the periosteum of the affected area.
an acute or chronic inflammatory process in extends
medullary spaces OR away from cortical surfaces of bone initial site of
involvement
Osteomyelitis
caused by bacterial infections
result in expanding lytic destruction of involved bone
with suppuration sequestra formation
Osteomyelitis
PREDISPOSING FACTORS 1. Conditions that alter host defenses would include chronic debilitating systemic diseases—such as diabetes mellitus, agranulocytosis, leukemia, severe anemia, malnutrition, drug abuse, chronic alcoholism, sickle cell disease, and febrile illnesses such as typhoid.
2. Conditions that alter vascularity of bone, include—therapeutic irradiation, osteoporosis, Paget’s disease, fibrous dysplasia, bone malignancy, metallic bone necrosis (caused by mercury, bismuth, and arsenic). An intrinsic and extrinsic vascular component has a more profound influence, both in onset of occurrence as well as in resolution outcome.
3. Virulence of organisms: Certain organisms precipitate thrombi formation by virtue of their destructive lysoso`mal enzymes (Hudson 1993).
ETIOLOGY 1.odontogenic infections
2. Trauma: It is the second leading cause: (a) Especially, compound fracture, and (b) Surgery-iatrogenic
3. Infections of oro-facial regions derived from:
a. Periostitis following gingival ulceration,
b. Lymph nodes infected from furuncles, and
c. Lacerations
d. Peritonsillar abscess.
4. Infections derived by hematogenous route: Furuncle on face, wound on the skin, upper respiratory tract infection, middle ear infection, mastoiditis, systemic tuberculosis.
PATHOGENESIS The process leading to osteomyelitis is initiated by acute inflammation, hyperemia, increased capillary permeability and infiltration of granulocytes. Tissue necrosis occurs, as proteolytic enzymes are liberated and as destruction of bacteria and vascular thombosis continues, there is a pus formation. The pus is a combination of necrotic tissue and dead bacteria and WBC accumulate. When pus accumulates, the intramedullary pressure increases resulting in vascular collapse, venous stasis, and ischemia. Subsequently, pus travels through haversian and nutrient canals and accumulates beneath the periosteum, elevating it from the cortex; and thereby further reducing vascular supply. Compression of neurovascular bundle accelerates thrombosis, ischemia, and infarction, later resulting in paresthesia and sequestrum formation. As natural host defenses and therapy begin to be effective, the process may become chronic, inflammation regresses, granulation tissue is formed; new blood vessels cause lysis of bone, thus separating fragments of necrotic bone (sequestrum) from viable bone. Small sections of bone may be completely lyzed, whereas larger ones may be isolated by a bed of granulation tissue encased in a sheath of new bone (Involucrum). Sequestra, may be revascularized, remain quiescent, or continue to be chronically infected and require surgical removal. Occasionally, involucrum gets penetrated by channels, known as cloacae, through which pus escapes from sequestrum to an epithelial surface.
CLASSIFICATION
MICROBIOLOGY
Most of the cases are caused by aerobic streptococci (α-hemolytic streptococci, Streptococcus viridans), anaerobic streptococci; and other anaerobes, such as Peptost-reptococci, Fusobacteria, and Bacteroides (Peterson 1999). Sometimes, anaerobic or microaerophilic
cocci, Gram negative organisms such as Klebsiella,
Pseudomonasand Proteusare also found. Other organisms
such as M. tuberculosis, T. pallidum, and Actinomyces species
produce their respective specific forms of OML.
patients of all ages can be affected
strong male predominance
most cases involves mandible
Osteomyelitis
Acute Supporative Osteomyelitis
Chronic Suppporative Osteomyelitis
Osteomyelitis
acute inflammatory process spreads through medullary spaces of bone
insufficient time has passed for body to react to presence of inflammatory infiltrate
Osteomyelitis (Acute Suppurative Osteomyelitis)
Clinical Features
symptoms of acute inflammatory process less than1 month in duration
fever
leukocytosis
Osteomyelitis (Acute Supporative Osteomyelitis)
Clinical Features
lymphadenopathy
soft tissue swelling of affected area
on occasion, paresthesia of lower lip
Osteomyelitis (Acute Supporative Osteomyelitis)
Histopathologic Features
biopsy material from patients
• liquid content• lack of soft tissue component• consist predominantly of
necrotic bone
Osteomyelitis (Acute Supporative Osteomyelitis)
Histopathologic Features
necrotic bone
• loss of osteocytes• peripheral resorption• bacterial colonization• acute inflammatory infiltrate
consists of polymorphonuclear leukocytes
Osteomyelitis (Acute Supporative Osteomyelitis)
Radiographic Features
ill- defined radioluscency
periosteal new bone formation may be seen
• response to subperiosteal spread of infection
• proliferations more common in young patients
Osteomyelitis (Acute Supporative Osteomyelitis)
Radiographic Features
periosteal new bone formation may be seen
• single-layered radioopaque line
• separated from normal cortex by an intervening radiolucent band
Osteomyelitis (Acute Supporative Osteomyelitis)
Radiographic Features
on occasion, exfoliation of fragments of necrotic bone
fragment of necrotic bone that has separated from adjacent vital bone is teremed sequestrum
Osteomyelitis (Acute Supporative Osteomyelitis)
Radiographic Features
on occasion, fragments of necrotic bone may become surrounded by new vital bone, known as involucrum
Osteomyelitis (Acute Supporative Osteomyelitis)
Treatment
if obvious abscess formation,
• antibiotics penicillin clindamycin cephalexin cefotaxime gentamicin
• drainage
Osteomyelitis (Acute Supporative Osteomyelitis)
defensive response leads to production of granulation tissue
subsequent forms dense scar tissue
• attempt to wall off infected area
Osteomyelitis (Chronic Supporative Osteomyelitis)
Osteomyelitis (Chronic Supporative Osteomyelitis)
subsequent forms dense scar tissue
• encircled dead space acts as reservoir for bacteria
• antibiotic medications have great difficulty reaching the site
Osteomyelitis (Chronic Supporative Osteomyelitis)
Clinical Features
if acute osteomyelitis is not resolved expeditiously
entrenchment of chronic osteomyelitis occurs
sometimes may arise without previous acute episode
Osteomyelitis (Chronic Supporative Osteomyelitis)
Clinical Features
swelling pain sinus formation purulent discharge sequestrum formation tooth loss pathologic fracture
Osteomyelitis (Chronic Supporative Osteomyelitis)
Clinical Features
may experience acute exacerbations or periods of decreased pain associated with chronic smoldering progression
Osteomyelitis (Chronic Supporative Osteomyelitis)
Histophathologic Features
biopsy material from patient• soft tissue component
• consists of chronically or subacutely inflammed connective tissue filling the intertrabecular areas of bone
• scattered sequestra + pockets of abscess formation
Osteomyelitis (Chronic Supporative Osteomyelitis)
Radiographic Features
patchy ragged ill-defined radiolucency
• often contains central radiopaque sequestra
Osteomyelitis (Chronic Supporative Osteomyelitis)
Radiographic Features
Osteomyelitis (Chronic Supporative Osteomyelitis)
Treatment
difficult to manage medically
• pockets of dead bone• organisms are protected
from antibiotic drugs
due to surrounding wall of fibrous connective tissue
Osteomyelitis (Chronic Supporative Osteomyelitis)
Treatment
surgical intervention is mandatory
antibiotic medications are similar to those used in acute form
• but must be given intravenously in high doses
Osteomyelitis (Chronic Supporative Osteomyelitis)
COMPLICATIONS
Complications:Several sequalae/complications can
occur as a result of OML of jaws.
1. Neoplastic transformation:With chronic OML,
neoplastic conversion of inflammatory metaplasia
to squamous cell carcinoma is noted. The incidence
reported is 0.2 to 1.5 percent.
2. Discontinuity defects:The defects can be (a) spontaneous or (b) surgically induced; necessitating
jaw reconstruction; once infection is resolved
(Figs 41.11A to D).
3. Progressive diffuse sclerosis:It involves the medullary
and cortical portions of maxillofacial skeleton;
especially mandible, over a period of time.
HBO THERAPY
SURGICAL THERAPY
The surgical treatment
modalities include: (1) Incision and drainage
(2) Extraction of loose or offending teeth (3) Debridement (4) Decortication (5) Continuous or
Intermittent indwelling closed catheter irrigation
(6) Sequestrectomy (7) Saucerization (8) Resection
of jaw (9) Trephination (10)
Immediate or delayed reconstruction with bone
graft.
Surgical intervention is done under antibiotic cover,
started at least, 1 to 2 days prior to the procedure.
ANTIBIOTIC PROPHYLAXIS
DISADVANTAGES OF AB PROPHYThey may alter host natural flora
Development of antibiotic resistant microorganisms
They may provide no benefit
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