Odontogenic. Overview. Microorganisms Causing Odontogenic Infections. Microbiology. Microorganisms Causing Odontogenic Infections Anaerobic 75%

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1 Odontogenic Infections Overview Microbiology Progression of infection Assessment Fascial spaces Treatment/antibiotics Microbiology Polymicrobial Mixed aerobic/ anaerobic Aerobic-cellulitiscellulitis Anaerobic-abscess Microorganisms Causing Odontogenic Infections Aerobic Organism Percentage 25% Gram-positive cocci 85 Streptococcus spp. 90 Streptococcus t (Group D) spp. 2 Staphylococcus spp. 6 Eikenella spp. 2 Gram-negative cocci (Neisseria spp.) 2 Gram-positive rods (Corynebacterium spp.) 3 Gram-negative rods (Haemophilus spp.) 6 Miscellaneous and undifferentiated 4 Excerpted from Contemporary Oral and Maxillofacial Surgery, Third Edition, 1998 Microorganisms Causing Odontogenic Infections Anaerobic 75% Gram-positive cocci 30 Streptococcus spp. 33 Peptostreptoccus spp. 65 Gram-negative cocci (Viellonella spp.) 4 Gram-positive rods 14 Eubacterium spp. Lactobacillus spp. Actinomyces spp. Clostridia spp. Gram-negative rods 50 Bacteroides spp. 75 Fusobacterium spp. 25 Miscellaneous 6 Excerpted from Contemporary Oral and Maxillofacial Surgery, Third Edition, 1998 Progression Periapical/periodontal Spread through least resistance Role of muscle attachments 1

2 Differences Between Cellulitis and Abscess Characteristic Cellulitis Abscess Duration Acute Chronic Pain Severe/generalized Localized Size Large Small Localization Diffuse borders Well circumscribed Palpation Doughy to indurated Fluctuant Presence of pus No Yes Degree of seriousness Greater Less Bacteria Aerobic Anaerobic Excerpted from Contemporary Oral and Maxillofacial Surgery, Third Edition, 1998 Assessment History Onset, duration, rapidity Previous treatment Medically compromised Assessment Physical exam Vital signs malaise temp tachycardia Abcess vs. cellulitis Radiographs Fascial Spaces Potential spaces Bounded by muscle attachments; bone Spread to secondary neck spaces 2

3 Buccal space Buccal space Vestibule Vestibule Maxillary Spaces: Canine Spaces Usual source: canine Boundaries: lev anguli oris; lev labi superioris Loss of nasolabial fold Maxillary Spaces: Buccal Space Usual source: maxillary molar, premolar Boundaries: skin, buccinator muscle Buccal space 3

4 Maxillary Spaces: Infratemporal Space Usual source: maxillary third molar Boundaries: skull base, lateral pterygoid plate, continuous with temporal space Buccal Space Usual source: mandibular molar, premolar Boundaries: skin, buccinator muscle Submental Space Usual source: mandibular incisors Boundaries: skin, mylohold muscle, ant belly of digastrics 4

5 Submandibular Space Usual source: mandibular molar, premolar Boundaries: medial mandible, below mylohyoid-muscle, skin/ superficial fascia Submandibular Space Lose inferior border on palpation Communicates with secondary spaces in neck Sublingual Space Usual source: mandibular molar, premolar Boundaries: medial mandible, above mylohyoid-muscle, mucosa Sublingual Space Floor of mouth swelling Nothing visible/ palpable extraoral Communicates posterior with submandibular space Ludwig s Angina Bilateral submandibular, sublingual, submental spaces Treat aggressively, potential airway compromise 5

6 Pterygomandibular Spaces Usual source: mandibular molar, premolar Boundaries: medial mandible, medial pterygoid Trismus Masseteric Space Usual source: mandibular third molar Boundaries: masseter, lateral border of mandible Swelling at angle, possible trismus Temporal Space Usual source: other spaces (infratemporal, masseterm pterygomand) Boundaries superficial: between fascia and muscle deep: below muscle Masticator Space Masseteric, Pterygomandibular, Temporal spaces Communicate Communicate Non-specific 6

7 Cervical Fascial Spaces Lateral pharyngeal deviated uvula Retropharyngeal airway obstruction; mediastinum Prevertebral thorax, mediastinum Treatment Medical support Antibiotics Removal of source Incision and drainage Re-evaluation Medical Support Airway maintenance Rehydration Analgesia Analgesia Nutrition 7

8 Antibiotics Usually bactericidal Therapeutic dose Intravenous vs oral Compliance/ complete course Indication for Use of Antibiotics Rapidly progressive swelling Diffuse swelling Compromised host defenses Involvement of fascial spaces Severe periocoronitis Osteomyelitis Compromised Host Defenses Uncontrolled metabolic diseases Uremia Alcoholism Malnutrition Poorly controlled diabetes Suppressing diseases Leukemia Lymphoma Malignant tumors Suppressing drugs Cancer chemotherapeutic drugs Immunosuppressives Situations in Which Use of Antibiotics is not Necessary (in healthy patients) Chronic well-localized abscess Minor vestibular abscess Dry socket Mild periocoronitis Effective Orally Administered Antibiotics Useful for Odontogenic Infections penicillin- drug of choice if patient is not allergic clindamycin Cephalosporins amoxicillin/clavulonic acid metronidazole Indications for Culture and Antibiotics Sensitivity Rapidly spreading infection Nonresponsive infection p Recurrent infection Compromised host defenses Osteomyelitis Suspected actinomycosis 8

9 Incision and Drainage Intraoral vs. extraoral Wide incision Blunt dissection to periosteum Blunt dissection to periosteum Subperiosteal 9

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11 Criteria for Referral to a Specialist Rapidly progressive infection Difficulty in breathing Difficulty in swallowing Deep fascial space involvement Elevated temperative (greater than 101 degrees Farenheit) Severe trismus Toxic appearance Compromised host defenses Thank You 11

Deep Neck Spaces and Infections

Deep Neck Spaces and Infections Elizabeth J. Rosen, MD Faculty Advisor: Byron J. Bailey, MD The University of Texas Medical Branch Department of Otolaryngology Grand Rounds Presentation April 17, 2002