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Flashcards in Dr. Pompura -- Dental Infections Deck (45)

Describe the pathogenesis of a dento-alveolar abscess

  1. Inoculation from the nerve of the tooth to the apex of the tooth
  2. Stick in jaw bone
  3. Spread most commonly through lateral extension (least resistance)


5 ways odontogenic infection can spread

  1. Direct extension
  2. Lymphatic spread
  3. Hematologous spread
  4. Ingestion (rare -- HCl acidity in stomach)
  5. Aspiration

NOTE: 2, 3, 4, 5, esp. in severely immunocompromised patient


3 factors affecting the outcome of an odontogenic infection

  • Organism virulence
  • Host resistance
  • Anatomical pathways of the spread of infection via direct extension (basically, luck)


3 destinations of dentoalveolar abscess spread

Infection perforates into the cortical plates and periostium and:

  1. Drains into the superficial tissues into the oral cavity
  2. Drains onto the skin
  3. Tracts into deeper fascial planes and spaces


Reason for facial inflammation and eye swelling to the point that it is closed in event of odontogenic infection

  1. Upper cuspid tooth (upper eye tooth) origin
  2. Infection stuck between 3 muscles of the area
  3. Filling of infraorbital space
  4. Eye closes


If infection reaches the infraorbital space, to where can it spread and how?

Cavernous sinus via veins of the face


Clinical picture of infraorbital space infection (2)

  1. Swelling toward eye
  2. No trismus


Medial boundary of the buccal space

Buccinator muscle


Lateral boundary of buccal space

Subcutaneous tissue and skin


Clinical picture of buccal space infection (2)

  1. Cheek swelling
  2. No trismus


Location of sublingual space

Floor of the mouth between the mucosa and the mylohyoid muscle


Clinical picture of sublingual space infection

Elevation of the tongue and floor of mouth (causes "hot potato" voice)


Most common  source of sublingual space infection

Wisdom tooth removal


Space with which the sublingual space communicates posteriorly

Submandibular space


Location of the submandibular space

Below the mylohyoid muscle


Clinical picture of submandibular space infection (3)

  • Firm, ill-defined swelling below the anterior border of the mandible
  • Tender
  • Mild trismus


Define Ludwig's Angina and the spaces involved

Aggressive rapidly spreading cellulitis (NOT abscess) involving:

  • Bilateral submandibular spaces
  • Bilateral sublingual spaces
  • Submental space

Emergent situation -- LOSS OF AIRWAY IMMINENT


3 divisions of the parapharyngeal spaces

  • Pterygomandibular space
  • Lateral pharyngeal space
  • Retropharyngeal space


Clinical picture of parapharyngeal space infection (4)

  • Terribly sore throat
  • Inability to swallow
  • Trismus
  • 1 side of tonsils edematous and uvula deviated


2 spaces that, if infected, may cause madiastinitis or brain abscess

  • Retropharyngeal space
  • Prevertebral ("danger") space


7 steps of the acute inflammatory reaction involved in the evolution of odontogenic infection without treatment

  1. Acute pulpitis
  2. Inflammation
  3. Cellulitis in the pulp
  4. Abscess in the pulp
  5. Cellulitis or abscess at the peri-apical area
  6. Cellulitis of the surrounding soft tissue spaces
  7. Abscess of the surrounding soft tissue spaces


Usefulness of understanding the steps of the acute inflammatory reaction of odontogenic infections in terms of treatment

Helps to determine the timing and therefore the microorganisms involved so that the right antibiotics can be chosen


2 possible outcomes of chronic odontogenic infection

  • Infectio ncan remain dormant and relatively asymptomatic, but can turn into acute phase when patient's resistance is lowered
  • Constant bacteremia via the seating or pumping action of chewing on infected tooth. May affect distal organs (i.e. infective endocarditis)


5 clinical findings of acute odontogenic infection

Cardinal signs of inflammation

  1. Pain
  2. Swelling
  3. Warmth over the affected area
  4. Loss of function (i.e. trismus, dysphagia, dysphonia, dyspnea)
  5. Redness


4 stages of odontogenic infection and its general timeline

  1. Inoculation
  2. Cellulitis (1 - 2 days)
  3. Absces (2 - 3 days)
  4. Resolution


Type of bacteria causing cellulitis secondary to odontogenic infection



Type of bacteria causing abscess secondary to odontogenic infection



Define typical cellulitis

Necrotic tissue with fluid (i.e. diffuse inflammation)


How does abscess formation in the course of odontogenic infection?

Occurs once the bacteria, necrotic tissue and WBCs coalesce within the surrounding soft tissue (pus)


4 ways to remove the cause of odontogenic infection

  • Curretage
  • Extraction
  • Endodontic treatment
  • Debridement


5 steps of patient care in setting of odontogenic infection

  1. Airway management***
  2. Medical problems
  3. Rest and nutrition
  4. Localization
  5. Fever


6 signs and symptoms of airways embarrassment

  1. Difficulty managing own secretions (drooling)
  2. Use of accessory muscles of respiration (patient does not want to be reclined)
  3. Respiratory rate, rhythm, depth
  4. Dysphagia
  5. Dysphonia
  6. Dyspnea


3 methods of maintaining airway

  • Intubation
  • Surgical decompression
  • Tracheotomy (to bypass area of obstruction)


Define specific therapy in setting of odontogenic infection

Cornerstone of all infection management = elimination of the cause. Unfortunately, offending tooth is not always obvious.


Define supportive therapy

Treatment of symptoms to help patient cope with disease, but still must eliminate disease eventually


2 specific therapies for odontogenic infection

  1. Root canal or
  2. Extraction


Treatment if soft tissue is involved in infection (i.e. presence of facial swelling)

Incision and drainage (I+D) of soft tissue space involving:

  1. Placing incisions through soft tissue in an area of localized abscess, allowing the pus to drain
  2. Place a conduit to encourage drainage (keep incision open)


5 functions of I+D

  1. Relieve pressure and pain symptoms
  2. Remove pus (increase antibiotic efficiency)
  3. Facilitate microbial elimination, reducing tissue bacterial load
  4. Decompresses the swollen area (confern = comfort and airway)
  5. Changes the micro-environment, alters the O2 tension


How does pus removal make antibiotics more efficient?

Antibiotics cannot penetrate pus, so less pus = easier for blood flow to reach infection


Average number of species laying a causative role in odontogenic infection

4 - 6

NOTE: anaerobes : aerobes ratio is 2 or 3 : 1


4 possible antibiotic choices for odontogenic infections, starting with the most commonly chosen

  1. Penicillin
  2. Amoxicillin
  3. Clindamycin
  4. Metronidazole (Flagyl)


Advantage of using amoxicillin over penicillin in terms of patient compliance

Penicillin = taken 4 x per day

Amoxicillin = 3 x per day


When to use clindamycin to treat odontogenic infection

If penicillin allergic or too much penicillin use


Spectrum of metronidazole

Anti-anaerobe only


2 cautions when using metronidazole

  • Never use as single agent (not activity against aerobes)
  • Alcohol + flagyl = vomiting (inhibition of oxidation of acetaldehyde), so do not give to alcoholic