May4 M2-Dental Infections

Question 1

2 important things about odontogenic infections and toothaches

Answer 1

• toothache can cause severe infection and fatality very fast bc of airway obstruction
• during rotations, give Abx but also refer to dentist otherwise becomes chronic and end up needing surgery

Question 2

symptoms of ondotogenic infection and important thing to check

Answer 2

• toothache
• face swelling
• pt hiding face with their hands
• distorted face
• tongue hanging and can’t close their mouth = SIGN OF AIRWAY OBSTRUCTION. have to look at the tongue

Question 3

first step of odontogenic infection

Answer 3

tooth inoculated and infected with bacteria, like a cavity, inside the pulp chamber (root canal chamber) which contains blood supply and nerves
= cellulitic inflammatory response, abscess formation

Question 4

2nd step of odontogenic infection: what the abscess does

Answer 4

either:

• moves up root canal
• goes down to apex where blood and nerves are. abscess breaks down the bone, get cellulitic inflammation sprading

Question 5

3rd step of odontogenic infection: where the abscess spreads

Answer 5

to mandibulary bone, through ostium and drain in tissues outside the bone

Question 6

4 ways odontogenic infections can spread and main one

Answer 6

• direct extension: basic lateral spread through mandibulary bone
• lymphatic spread
• hematogenous spread
• ingestion (rare bc of HCl in stomach)
• aspiration

Question 7

what is the ultimate thing that cures the odotongenic infection and what influences that

Answer 7

• patient immune system* influenced by
• Abx given and microbial resistance
• surgical decompression
• drainage

Question 8

3 routes of direct extension spreading of a dentoalveolar abscess and most common

Answer 8

• towards deeper facial planes of face, head and neck, tooth apex
• fistula up in the mouth interior
• fistula outside the mouth, towards exterior, through the face (cheek, neck, mandible)

Question 9

one complication of odontogenic infection related to the eyes

Answer 9

• infraorbital space infection bc this area is squared off by many muscles. area under orbit and around maxilla is infected
• swollen eyelids

Question 10

clinical picture of infraorbital space infection

Answer 10

• swelling pointing towards the eye

- no trismus (inability to fully open the mouth)

Question 11

tooth that most commonly causes infraorbital space infection (following odontogenic infection at this tooth)

Answer 11

canines, cuspid tooth (3rd tooth after central incisor and lateral incisor). the vampire tooth.

Question 12

symptom of buccal space infection (abscess)

Answer 12

• patient look like they’re holding their breath
• pain
• swelling
• no trismus

Question 13

important concept about facial spaces where odontogenic infection can spread

Answer 13

can reach any space. all spaces are connected

Question 14

why infection to the sublingual space and submandibular space is said to be more important

Answer 14

• infections draining towards medial airways, anatomical airways of pt
• incoming blockage

Question 15

sublingual and submandibular spaces (one on each side) infection: where the infection is located

Answer 15

at floor of the mouth and as you go downards, you have in this order

1. mucosa
2. sublingual space
3. mylohyoid muscle
4. submandibular space
   * these two spaces communicate in the back*

Question 16

other landmark to identify where sublingual space infection locates

Answer 16

travelled above mylohyoid line, and is between mouth mucosa and mylohyoid muscle

Question 17

symptoms of sublingual space infection (odotongenic)

Answer 17

• elevation of the tongue
• elevation of the floor of the mouth
• hot potato voice (can’t speak properly) but tongue hurts

Question 18

symptoms of submandibular space infection (odontogenic)

Answer 18

• can’t palpate inferior border of the mandible (under the head) bc neck is swollen (bc infection encroaches in areas of the neck)
• firm, ill-defined anterior border of mandible
• tender to palpation
• mild trismus

Question 19

sign indication a patient has an airway obstruction or respiratory disease bc of an odontogenic infection

Answer 19

they want to sit up, easier to breathe

Question 20

Ludwig’s angina definition (rare thing)

Answer 20

aggressive rapidly spreading cellulitis to

• bilateral submandibular and sublingual spaces
• submental space

Question 21

parapharyngeal spaces infection (odontogenic): 2 spots the infection eventually goes to

Answer 21

• mediastinitis (mediastinum)
• intracranial abscess (brain)
• leads to death*

Question 22

main problem with odontogenic infections

Answer 22

airway occlusion

Question 23

how to evaluate if problems of airway occlusion are present in odontogenic infection

Answer 23

• get to back of the tongue
• pull it down
• edematous pharynx on the infected side + uvula displaced on other side
• trismus
• always have cricothyrotomy

Question 24

gold standard to diagnose airway occlusion due to odontogenic infection

Answer 24

CT scan

Question 25

evolution of an odontogenic infection

Answer 25

1. acute pulpitis 2. inflammation 3. cellulitis in pulp 4. abscess in pulp 5. cellulitis or abscess in peri-apical area 6. cellulitis of surrounding soft tissue spaces 7. abscess of surrounding soft tissue spaces

Question 26

cellulitis definition

Answer 26

diffuse inflam reaction by body in response to bacteria. Indulated, hard, not specific

Question 27

abscess definition

Answer 27

presence of pus. Coalescence of WBCs, necrotic tissue. abscess can be wiggled, is spongy

Question 28

type of bacteria in the inoculation and cellulitis stage

Answer 28

aerobic bacteria

Question 29

type of bacteria in abscess and pus stage

Answer 29

anaerobic bacteria

Question 30

clinical findings of acute odontogenic infection

Answer 30

- pain - swelling - heat - redness - loss of function (trismus, dysphagia, dysphonia, dyspnea) * findings of inflammation*

Question 31

4 stages (time frame) of odontogenic infection (applies to immunocompetent)

Answer 31

1. inoculation 2. cellulitis (1-2 days) 3. abscess (2-3 days) 4. resolution

Question 32

steps until cellulitis appears

Answer 32

-bacterial colonization in potential space = colonization = inflam rx -soft and spongy, tender (painful when touch) to palpation -when full inflam response mounted, call that cellulitis (poorly localized, reddened, endurated, tender area)

Question 33

when abscess formation occurs

Answer 33

when bacteria, necrotic tissue and WBCs coalesce with surrounding soft tissue (this makes pus)

Question 34

how to dx an abscess (odontogenic) clinically, what are the criteria

Answer 34

-history of swelling for 48-72 hours -severe pain -pulsating throbbing pain to the offending tooth (fluctuance) -

Question 35

steps of odontogenic infection management

Answer 35

1. patient care 2. incision and drainage (I and D) 3. Abx therapy 4. remove the cause (curettage, extraction, endodontic treatment, debridement)

Question 36

patient care meaning

Answer 36

* *manage airways** - fever - medical problems - rest and nutrition - hydration - localization

Question 37

what are signs and symptoms of airway embarrassment

Answer 37

- hard to manage own secretions - use accessory muscles of respiration - RR, rhythm, depth - dysphagia - dysphonia - dyspnea * can lead to airway obstruction rapidly*

Question 38

management of patient with airway embarrassment

Answer 38

intubation asap. otherwise surgical airway (tracheostomy)

Question 39

steps of incision and drainage

Answer 39

1. place incisions through soft tissue in area of localized abscess, allowing pus to drain 2. place counduit to encourage drainage

Question 40

main goal while doing I and D

Answer 40

- decrease the bacterial load - decompress on airways - remove pus impenetrable to Abx - get O2 in there to remove the anaerobes

Question 41

bacteria causing first stage (cellulitis)

Answer 41

aerobes

Question 42

bacteria causing 2nd stage (abscess)

Answer 42

anaerobes

Question 43

initial Abx used in odontogenic infection (Abx is 3rd step, after I and D)

Answer 43

treat empirically first | perform culture and sensitivity test to narrow later

Question 44

bacteria of the aerobic stage of infection (Cellulitis)

Answer 44

- strep spp | - lactobacillus

Question 45

bacteria of the anaerobic stage of odontogenic infection (abscess)

Answer 45

- gram+ cocci (like strep, pepto..) - bacteroides - lactobacillus - veillonella - etc. (many gram+ and gram-)

Question 46

problem of using Abx only

Answer 46

- Abx assist the patient in eliminating the infection and that's it - need to address the cause otherwise will recur - immune system does it all

Question 47

most important factor in how much Abx will help a patient

Answer 47

patient compliance | -usually 7-10 days regimen

Question 48

(important) primary Abx given in odontogenic infections

Answer 48

- penicillin#1 - amoxicillin (note: penicillin doesn't work if already used it many times)

Question 49

Abx for anaerobes used in odontogenic infections

Answer 49

metronidazole (Flagyl)

Question 50

a broad spectrum Abx used in odontogenic infection

Answer 50

clindamycin

Question 51

when to hydrate patients with odontogenic infection

Answer 51

- can't tolerate po fluids | - fever and trismus + no po intake for few days