Orofacial infection part 1

orofacial infection

1. OROFACIAL INFECTION CHAPTER 1 INTRODUCTION DR. HAYDAR MUNIR SALIH ALNAMER BDS, PHD (BOARD CERTIFIED)

2. Infections of orofacial and neck region, particularly those of odontogenic origin, have been one of the most common diseases in human beings These infections range from periapical abscess to superficial and deep neck infections. The infections generally spread by following the path of least resistance through connective tissue and along fascial planes Early recognition of orofacial infection and prompt, appropriate therapy is absolutely essential

3. Etiology 1. Odontogenic: 2 . Traumatic: 3 . Implant surgery 4. Reconstructive surgery 5. Infections arising from contaminated needle punctures. 6. Others: This group includes instances of orofacial infections arising from other factors such as infected antrum, salivary gland afflictions, etc. 7. Secondary to oral malignancies .

4. PATHWAYS OF ODONTOGENIC INFECTION Invasion of the dental pulp by bacteria after decay of a tooth ↓ Inflammation, edema and lack of collateral blood supply ↓ Venous congestion or avascular necrosis (pulpal tissue death) ↓ Reservoir for bacterial growth (anaerobic) ↓ Periodic egress of bacteria into surrounding alveolar bone

5. Odontogenic infection: Acute stage Cellulitis : It is spreading infection of loose connective tissues. It is a diffuse, erythematous, mucosal or cutaneous infection. It is characteristically the result of streptococci infection; and does not normally result in large accumulation of pus. Antibiotics may arrest the spread of infection; and may bring about complete resolution of the condition.

6. Odontogenic infection: cellulitis

7. Odontogenic infections : acute stage 2 . Abscess: It is a circumscribed collection of pus in a pathological tissue space. A true abscess is a thick- walled cavity containing pus. The suppurative infections are characteristic of staphylococci, often with anaerobes , such as bacteroides , and are usually associated with large accumulation of pus, which require immediate drainage.

8. Odontogenic infection: abscess

9. characteristic Cellulitis Abscess Duration 3-7 days Over 5 days Localization Diffuse Localized Skin quality Reddened Peripherally reddened Tissue fluid Serum, flack of pus Pus Predominant bacteria Mixed Anaerobic

10. 1. Odontogenic infection/ Acute Stage: Acute periapical abscess The main cause is infective necrosis of pulp Severe throbbing pain in the affected tooth Mobility may or may not be present. It also shows periapical radiolucency, areas of resorption; and the different types of radiolucencies involving the root fractures. The treatment modalities comprise of the following: (1) Antibiotics, (2) Analgesics, (3) Drainage through the pulp chamber, (4) Extraction of the offending tooth, or (5) Endodontic treatment.

11. Acute periapical abscess

12. 1. Odontogenic infection/ Acute Stage : Acute dentoalveolar abscess This disease entity is a continuation of periapical abscess. 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 Treatment: The same treatment modalities hold true for dentoalveolar abscess. In addition, intra or extraoral incision and drainage may be required.

13. Acute dentoalveolar abscess

14. 1. Odontogenic infection/ Acute Stage : Pericoronitis / Acute pericoronal abscess. The meaning of the word “ peri ” means, surrounding, “ coronos ” means pertaining to crown, and “itis” means inflammation Trauma to the overlying gingivae from the cusps of an opposing tooth is the most Acute: Facial swelling, limitation of oral opening, severe throbbing pain, interfering sleep, discomfort on swallowing.

15. Pericoronitis / Acute pericoronal abscess

16. 2. Odontogenic infection Chronic Stage: In the chronic stage, the odontogenic infection can present itself in the following forms: 1. Chronic fistulous tract or sinus formation: Abscesses neglected for a long time discharge intraorally or extraorally . When the abscess discharges through the skin; the sinus may appear in a location unfavorable for drainage; and the resulting scar is always thickened, puckered, and depressed and more obvious esthetically prominent. 2. Chronic osteomyelitis 3. Cervicofacial actinomycosis .

17. Fascial space infection Fasciae covering muscle bundles are normally in close apposition. If these fasciae are forced apart, avascular spaces are created. If localization of an infection by virulent bacteria fails, inflammatory exudate opens up the fascial spaces carrying bacteria with It into the tissue planes Before the advent of antibiotics the mortality was high and the disease is still life-threatening if treatment is delayed.

18. SPREAD OF OROFACIAL INFECTION By direct continuity through the tissues . b. By lymphatics to the regional lymph nodes and eventually into the blood stream. When the infection gets established in the lymph nodes, secondary c . By the blood stream : Rarely, local thrombophlebitis may propagate along the veins, entering the cranial cavity via emissary veins to produce cavernous sinus thrombophlebitis

19. The site of the source of infection such as upper or lower jaw, and the particular segment of the jaw involved . 2. The point at which the pus escapes from the bone and discharges into the soft tissues either labiolingually or buccopalatally . 3. The natural barriers to the spread to pus in the tissues such as layers of fascia or muscle or the jaw bones Anatomical Factors Influencing the Direction of Spread

20. Anatomical Factors Influencing the Direction of Spread

21. General Principles of Therapy for the Management of Acute Extensive Orofacial Infection Immediate hospitalization 2. Aggressive medical treatment (Supportive treatment along with antibiotic therapy ) 3. Aggressive surgical intervention (including intubation and tracheostomy) should be done.

22. The following criteria justify hospital admission of patient with orofacial infection (1) Fever over 101oF, (2) Dehydration, (3) Impending airway compromise, (4) threat to vital structures, (5) Infection of deep cervical space or masticator space, (6) Need for general anesthesia, (7) Need for inpatient control of systemic disease

23. Airway comprise due to massive orofacial infection

24. Indications for use of Antibiotics I) Acute onset of infection, ( ii) Diffuse infections, ( iii) Compromised host defenses, ( iv) Involvement of fascial spaces, ( v) Severe Pericoronitis, and ( vi) Osteomyelitis.

25. Selection of antibiotics a. In case, there is no exudates available for culture and antibiotic sensitivity of organism(s) involved before initial therapy, then the initial selection is made on empiric basis. b. In general, bactericidal antibiotics should be preferred to bacteriostatic antibiotics c. It is preferable to use antibiotic with the narrowest spectrum

26. Principles for the use of antibiotic therapy Antibiotics do not replace surgical drainage of infection Whenever possible, the organism and sensitivity should be determined Prescribe on basis of culture results and 'most likely organism' while waiting for results Certain antibiotics are reserved for serious infections Synergistic combinations may be required in some infections, e.g. aminoglycoside, cephalosporin and metronidazole for faecal peritonitis In serious infections seek advice from clinical bacteriologist

27. Criteria for Changing Antibiotics: (Antibiotic rotation) Allergy Toxic reaction Repeated surgery unsuccessful (no improvement in SIRS) At least 48 hr. of IV antibiotic At least 72 hr. of oral antibiotics Culture and sensitivity report result in antibiotic resistance

28. Supportive therapy

29. Supportive therapy ( i ) Administration of antibiotics, ( ii) Hydration of patient through IV route, maintain adequate nutritional status—high protein intake through Ryle‘s tube feeding ( iii) Analgesic, ( iv) Bed rest, ( v) Application of heat in the form of moist pack and/or mouth rinses.

30. SURGICAL MANAGEMNT

31. Surgical Management: It consists of: Extraction of the offending tooth or teeth, Incision and drainage ( iii) Combination of both

32. The first line treatment of an accesses is ……… .

33. Principles of Surgical Management: I. Determination of severity of infection Evaluation of the airway in the form of difficulty in breathing, swallowing, speaking, or handling secretions A change in quality of voice indicates a swelling in or near glottis, such as in parapharyngeal spaces Ability to protrude the tongue past the vermilion border of the upper lip is a fairly reliable sign that the sublingual space is not severely involved

34. Parapharngeal space infection

35. Needle decompression

36. Principles of Surgical Management : II. Determination of the anatomical location of infection It is necessary to determine the precise location and involvement of different oral, fascial and cervical swelling associated with each of the superficial and deep fascial spaces involved.

37. Superficial fascial space

38. Deep fascia spaces

39. Principles of Surgical Management: III. Evaluation of the host defenses a. Diabetes mellitus b. Steroid therapy within the past two years: i . Asthma ii. Autoimmune or inflammatory disease iii. Organ transplant therapy c. Cancer chemotherapy within the past year d. Renal dialysis e. HIV seropositivity f. Primary immunodeficiencies

40. Surgical drainage Some authors advocate that drainage of all spaces involved by cellulitis or abscess caused by odontogenic infection, should be done, as soon as possible after diagnosis NEVER LET SUNSHINE RISE ON ABSCESS !

41. Surgical drainage 1. It is impossible to diagnose deep space infections either by clinical or radiological examination with100 percent accuracy. 2. Drainage of cellulitis seems to abort the spread of infection into neighboring deep fascial spaces. 3. Adequate culture specimen can be obtained from cellulitis fluid. 4. Physical debridement and irrigation of infected space may hasten healing by decreasing the size of bacterial inoculum and the amount of necrotic tissue present. 5. Early drainage may prevent later colonization of the site by more highly antibiotic resistant microorganisms. 6. Length of stay in the hospital may be decreased.

42. Guidelines for placement of incisions in infected cases: 1. Incisions should be placed in the most dependent areas. 2. Incisions should be parallel to the skin creases. 3. Incisions should lie in an esthetically acceptable site as far as possible. 4. Incisions should be supported by healthy underlying dermis and subcutaneous tissue. 5 . Incisions placed intraorally, should not cross frenal attachments, and should be placed parallel to nerve fibers in the region of mental nerve. 6. The removal of the cause; such as an infected tooth, a segment of necrotic bone, a foreign body, if not already done, then should be done at the time of incision and drainage procedure.

43. Extra oral incisions lines

44. Intra oral incisions lines

45. Extraction of tooth in the presence of acute abscess: This is a controversial subject. One school of thought believes that there is potential spread of infection by manipulation of tooth during extraction. The other school of thought challenges this view and believes that early extraction leads to early resolution of infection by eliminating the source of infection and by providing a portal of drainage . It is worthwhile considering administration of antibiotics prior to carrying out extraction of offending tooth during acute stage of infection

46. Hilton’s Method of Incision and Drainage 1. Topical anesthesia : Topical anesthesia is achieved with the help of ethyl chloride spray. 2. Stab incision : Made over a point of maximum fluctuation in the most dependent area along the skin creases, through skin and subcutaneous tissue. 3. If pus is not encountered, further deepening of surgical site is achieved with sinus forceps (to avoid damage to vital structures). 4. Closed forceps are pushed through the tough deep fascia and advanced towards the pus collection.

47. Hilton’s Method of Incision and Drainage

48. Hilton’s Method of Incision and Drainage 5. Abscess cavity is entered and forceps opened in a direction parallel to vital structures. 6. Pus flows along sides of the beaks. 7. Explore the entire cavity for additional loculi . 8. Placement of drain: corrugated rubber drain is inserted into the depth of the abscess cavity; and external part is secured to the wound margin with the help of sutures. 9. Drain left for at least 24 hours. 10. Dressing: Dressing is applied over the site of incision taken extraorally without pressure.

49. Hilton’s Method of Incision and Drainage

50. Surgical Technique for Incision and Drainage of an Abscess .

51. Drain Purpose of keeping the drain: The purpose of drain is to allow the discharge of tissue fluids and pus from the wound by keeping it patent. The drain allows for debridement of the abscess cavity by irrigation. Removal of drains: Drains should be removed when the drainage has nearly completely ceased.

52. drain