Dentoalveolar infections - PowerPoint Presentation

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Dentoalveolar infections

Pamela Dickson

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Dentoalveolar infections

Definition: pus producing (or pyogenic) infections associated with the teeth and surrounding supporting structures such as the periodontium and the alveolar bone.

The clinical presentation of

dentoalveolar

infections depends on the 

virulence

 of the causative microorganisms, the 

local

 and 

systemic defence

 mechanisms of the host, and the 

anatomical features

 of the region.

The resulting infection may present as:

• an abscess localised to the tooth that initiated the infection

• a diffuse cellulitis that spreads along fascial planes

• a mixture of both.

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Odontogenic infection

Develops by the extension of the initial carious lesion into dentine and spread of bacteria to the pulp

The pulp responds to the infection with acute inflammation which causes necrosis.

Once pus formation occurs, it may remain

localised

at the root apex and develop into either an acute or a chronic abscess, develop into a focal osteomyelitis or, as hydrostatic pressure increases, it can track along the path of least resistance to the tissue spaces.

Potential for local and distant spread.

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Local measures

Abscesses can compress other structures and reduce blood supply.

Abscesses have poor blood supply and therefore antimicrobials wont reach them.

Correct treatment is DRAINAGE and REMOVAL OF CAUSE

Drainage can be though the tooth or via Hiltons method

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Hiltons method of drainage

For when pus in soft tissues

When XLA and RCT no use

Find most dependent point of abscess and incise through mucosa and periosteum

Blunt dissection to break down lobules of pus

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General measures

Analgesics – paracetamol, ibuprofen,

cocodamol

Supportive – fluids, rest, diet

Antibiotics IF systemic involvement, cellulitis, compromised host

defences

involvement of fascial spaces.

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Spread to fascial spaces

One of the most serious and potentially life-threatening complications

Whatever the cause, spread of infection through the potential spaces in the neck poses a risk to the airway.

It may also result in systemic compromise and cardiovascular collapse. Furthermore, infection can spread inferiorly into the mediastinal or pleural cavities; or superiorly to the peri-orbital or orbital tissues, and

via

the facial vein to the cavernous sinus.

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Symptoms

In addition to pain around the causative tooth or teeth, patients with neck space infection will feel generally unwell.

They may complain of fever and rigors.

Particularly worrying symptoms are trismus, dysphagia, dyspnoea, and change in voice. An example of the latter is the ‘hot potato’ voice resulting from elevation of the floor of mouth and tongue in the oral cavity.

These all indicate actual or impending airway compromise and patients presenting in this way should be referred for urgent assessment in hospital.

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Initial assessment

Initial assessment of the patient should include the following:

Taking a comprehensive medical and dental history

Checking for presence of fever, malaise, fatigue, dizziness or other debility

Measuring the pulse and temperature (normal axillary temperature is 36.3-37)

Defining nature location and extent of the swelling

Identifying the cause of the infection

Patients admitted to hospital with neck space infection will undergo blood tests, possible further imaging including ultrasound and/or CT scan, and eventual microbiological investigation. Where possible, a sample of pus is obtained for microbiological culture and antibiotic sensitivity testing. Most often, pus is obtained at the time of operation. The acute odontogenic abscess is usually

polymicrobial

in nature, comprising facultative anaerobes (for example,

viridans

streptococci and the

Streptococcus

anginosus

group), and strict anaerobes like

Prevotella

and

Fusobacterium

species.9,10

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Vital signs

Septic patients may be

tachycardic

(pulse rate >90 beats per minute) and

pyrexial

. If there is an abscess, a swinging pyrexia may be seen.

The respiratory rate is a sensitive sign that may increase before an abnormality is seen in other vital signs. A rate of >20 breaths per minute is abnormal in an adult.

The combination of a high respiratory rate, tachycardia, very high or very low temperature, with a very high or very low white blood cell count is the

systemic inflammatory response syndrome

(SIRS).

Sepsis is defined as the presence of SIRS in addition to a confirmed infective process.

Septic shock occurs when a septic patient remains hypotensive despite aggressive attempts at restoring the blood pressure.

Importantly, it is well recognized that the prognosis of septic patients is improved when appropriate treatment is delivered promptly.

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When to refer

Following this assessment the clinician should decide whether treatment can be provided in primary care or whether a referral is necessary for example if there is/ are:

Signs of septicaemia such as grossly elevated temperature ( above 39.5), lethargy, tachycardia

Spreading cellulitis (rapidly

progessing

infection)

Breathing or swallowing compromised

Severe trismus

Compromised host defences

Swellings that may compromise the airway or cause difficulty in swallowing or closure of the eye

Dehydration

Significant trismus associated with a dental infection

Failure to respond to previous treatment

An uncooperative patient

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Principles of the surgical management of deep neck space infection

The patient presenting with suspected neck space infection should be assessed immediately for Airway, Breathing, and Circulation (ABC).

This gauges the urgency of the need for referral to hospital.

A stable patient with localised swelling and minimal soft tissue involvement is likely to be suitable for early, local treatment including pulp extirpation or extraction of the tooth, with or without systemic antibiotics.

For those patients referred to hospital, the principles of establishing surgical drainage, removal of the source of infection, and systemic antibiotics also apply.

Septic patients will be treated aggressively with fluid resuscitation and early, empirical administration of antibiotics.

Drainage of neck space infections will usually take place in

the operating theatre under general anaesthetic.

Severe airway compromise may necessitate placement of a tracheostomy tube and post-operative admission to intensive care.

In Ludwig’s angina, there is often no collection of pus, but surgical exploration of the affected spaces is performed to ‘decompress’ the neck. Surgical drains are placed until resolution of the infection. Corticosteroids (

eg

dexamethasone) may be given to help reduce the oedema associated with these infections.

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Early recognition and management of dento-alveolar infections is critical because patients (particularly children and immunocompromised patients) can become systemically ill within a short time. If untreated, local infections can spread, giving rise to serious life threatening sequelae.

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Ludwig’s angina

Ludwig’s angina is a specific diagnosis and is defined as a bilateral cellulitis of the submandibular and sublingual spaces, most often arising from a lower molar tooth. The floor of the mouth contains the sublingual, submandibular and submental spaces with ready communication across the midline. Infection can, therefore, spread to involve all spaces in the floor of the mouth.

Clinically, there is a firm swelling of the floor of the mouth and resultant elevation of the tongue. The submandibular and sublingual spaces become tense and tender. There may be accompanying trismus, dysphagia, and respiratory embarrassment.

The cellulitis may spread to involve the lateral pharyngeal space.

These patients require immediate referral to hospital for urgent antibiotic therapy and surgical drainage, with or without additional airway support.

90% of cases of

ludwigs

angina are precipitated by dental or post extraction infection

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It is important to remember that the vast majority of odontogenic infections can be managed using local measures such as extraction of the tooth, extirpation of the pulp, or intra-oral incision and drainage of a buccal space abscess. Antibiotic therapy is indicated where there are signs of systemic infection, but they are not a substitute for removing the source of infection.

Benefits of prescribing is limited by a number of problems associated with their use

eg

side effects, allergic reactions, toxicity, development of resistant strains of microbes

Antimicrobial resistance is a world wide problem

Dentist working in the NHS primary care prescribe nearly 1-% of all the oral antimicrobials in primary care in England.

Inappropriate use of AB may contribute to problem of antimicrobial resistance.

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Indications for Prescribing

Antimicrobial is only indicated

As an adjunct to the management of acute of chronic infection

For the definitive management of active infective disease

eg

NUG

Where definitive treatment has to be delayed due to referral to specialist services.

Eg

inability to establish drainage in an uncooperative patient who required sedation or GA for treatment or a patient who needs to be treated in a hospital environment due to comorbidities.

When there is an elevated temperature, evidence of systemic spread and local lymph gland involvement

Follow up the patient 2-3 days after the drainage and removal of the cause. If there is resolution of the infection and the temperature is normal, stop antimicrobials

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First choice antimicrobial

A penicillin

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Second choice antimicrobial

As first line treatment for patients allergic to penicillin or

As first lined treatment for patients who have had a recent course of penicillin

As an

adjuct

to amoxicillin in severe spreading infections or

If a predominantly anaerobic infection is suspected or

microbially

proven

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Third choice antimicrobial

Macrolide

Can be used as an alternative to

penicllin

.

Azithromycin and clarithromycin are better tolerated than erythromycin which causes nausea vomiting and diarrhoea in some cases and any organisms are resistant to it.

The prescribing of clindamycin ,

cephalosporins

, co-

amoiclav

offers no advantage over a penicillin, metronidazole or a macrolide and is not recommended for the routine management of

dentoalveolar

infections. Inappropriate use of clindamycin

cephalosporins

or co-

amoxiclav

can lead to development of resistance and can lead to the development of clostridium difficile infection.

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Chronic dento-alveolar infections

Chronic

dentoalveolar

infections can occur in association with decayed or restored teeth. They commonly present as a minor , well localised abscess , sometimes with a discharging sinus and rarely require antimicrobial therapy unless:

There is an acute flare up and there is evidence of gross local spread or

There is systemic

involment

shown by an elevated temperature or malaise

The principals of treatment are

Removal of the cause drainage of the infection

Long standing chronic infections which do not respond to simple treatment

eg

osteomyelitis should be referred to a consultant specialist

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FGDP guideline "Antimicrobial Prescribing for GDPs"- chapter 4: Acute Dento-alveolar Infections

Dental Update 2016; 43: 745–752