OS Sheet #4 By Lana Obeidat

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OS Sheet #4 By Lana Obeidat

Post by Sura on 9/3/2012, 2:22 am


عدد المساهمات : 484
النشاط : 2
تاريخ التسجيل : 2010-09-29

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Re: OS Sheet #4 By Lana Obeidat

Post by Shadi Jarrar on 9/4/2012, 11:09 pm

management of dental infections

it’s an important topic for the dentist not just the oral surgeon , you’ll be seeing it a lot in the dental practice
- the cause of dental infection can be odontogenic and non odontogenic
- examples of non-odontogenic causes: periodontal infections , respiratory tract infection , salivary glands infections , viral infections , autoimmune diseases , sinus infection ( upper part of the maxilla and the nose , trauma , ulcers ( can get infected and spread into the surrounding area)
- the head and neck anatomy can control the spread of infection, meaning: if the infection is related to one tooth it doesn’t necessarily mean it’s going to be localized there, it can spread to the path of least resistance , so if it finds a way it will spread to other areas, and this is the concept of spread of infection to the fascial spaces.
- the head and neck area is made of compartments separated by connective fascia and they are potential spaces ( potential means they are not existing but they can exist or swell up if there is an abscess or pus that is caused by odontogenic or non-odontogenic infection)

- the development of the management of odontogenic infections or fascia infections has spread up in the last century only (in literature: in 1930’s and 1940’s when patients were diagnosed with ludwigs angina : which is a bilateral infection of the sub mental , submandibular space involving the floor of the mouth and the surrounding areas , the complication of this out of 40 patients 30-35 patient would die . in the late 1940’s the mortality rate went down to 30-40% and the reason behind that wasn’t the antibiotics, it was the principle of the management of those infections, the realization of the anatomical basis , there were steps to manage the case, how to avoid the airway, where to make an incision and drainage including the involved site , and therefore the success in management has become much better along with the revolution of antibiotics which helps a lot in the management but even though as soon as the causative agent of infection is removed patients can improve without medication ).

- always remove the cause before doing anything , that way you can insure that there’s a chance to improve.

- vestibular abscess : when a fistula forms due to an infection ( let’s say on the upper 6 or 5) in the vestibule , this abscess can be treated either by simple treatments RCT or extraction, or it can spread to other areas and what determines that is :
1. anatomical factor Smug muscle attachment))and boundaries : in the mandible the lower molars and premolars their root apices are located at the level of the mylohyoid muscle , the root might be at a lower level than the mylohyoid , so if there is infection there will be a perforation of the bone, it wouldn’t go to the floor of the mouth, it actually goes to a deeper level reaching the submandibular space for example and therefore causing swelling and infections in that area.
case: a pregnant patient with swelling on her left side of the face, has a non-vital upper molar , the non vitality of the molar can cause vestibular abscess that can spread superiorly to the level of insertion of the buccinators ( so the root tip is higher than the buccinator ) and the infection will spread into the buccal space ( which is a space between the buccinator and skin) a collection of pus happened and spread partially to the submandibular area .
- being a pregnant lady has importance in means of host defence factors, being pregnant has exposed her to infections and hormonal changes and aggravated what is supposed to be a minor infection.

2. microbiology: a minimum of the micro inhibitory concentration (MIC) should be found for the infection to occur
3. virulence : pathogenic bacteria is already found in the oral cavity ( no need to get it from out side the oral cavity)
4. environmental factors : iatrogenic , bad oral hygiene ( they can lead to infection)
5. host defence ( pregnancy, diabetes , autoimmune disease, steroids, HIV, graft patients, chemotherapy, )
• regarding immunity in diabetes : the patient has a problem in the hemotaxis ( the migration potential of the PMNC is weak, and in the vascularity : poor circulation, means no proper response from the body : meaning when an infection occurs , hyperemia will happen : increased in vascularity to allow cells to come and defend the body against infection, this in diabetes is defective

arthritis: caused by immune response complex, but not due to autoimmune disease
SLE: he might take steroids that might lower the immune response
chemotherapy : it affects the cell lines, meaning all PMNC, lymphocytes will be reduced, means they should be isolated during the active period of taking chemotherapeutics
age: it doesn’t have a role in infections , the problem is what comes with age : illness and dehydration , chronic diseases, and so on.

- steps of the management of odontogenic infections : a surgeon called Peterson proposed 8 steps for management
- the outcome of the patient due to management is getting better
1. determine the severity of the infection ( the most important point) : a decision should be made to know the severity of the infection
most patient with infections have a rapidly progressing disease (the patient of infection shouldn’t be left more than 2 days without being examined because infections can spread very quickly and cause life threatening situations

to determine the severity :
1) anatomical location : a classification of the risk according to the site : tendomandibular space is close to the oropharynix and it’s a risky space to be involved ,because it might cause swelling to the area and then obstruction of the airway (strider sounds) here you either go for tracheotomy or tracheostomy
( buccal space, submental space : not very risky)
2) rate of progression : ask the patient and think about hospitalization, antibiotics and surgery before it gets worse
3) airway compromise
2. taking proper history to check about host defence problems
3. decide the setting of the care : decide whether the patient is an out patient or admitted to the hospital : severity, vital signs : high fever, weak puls , site, airway.
vestibular abscess: antibiotics , if sever IV antibiotics should be considered and drainage
4. surgical treatment and the patient must be (5) supported medically : fever means high metabolism means loss of fluids means high load on the heart Smug so they should be supported medically : IV fluids , anti-pyritic : acetaminophens , non steroidal ( voltarine) , IM injections are very appropriate and easy to give , in the glutial region , even the IV line can be used.
5. supported medically
6. Choose and prescribe antibiotic therapy
- empirical ( culture and sensitivity of antibiotics) : mainly in dentistry the reason behind infection is anaerobes, streptococcus, gram +ve, -ve , if there was a strange history ( rapidly spreading ) , like necrotizing fasciitis, and not responding to the antibiotic you can go to the sensitivity to determine the causative micro organism , but we usually don’t do that in common practice unless the patient is severely ill and we want to know what’s the response to the antibiotic type
7. administer antibiotic properly ( IV or oral )
8. re-evaluate the patient frequently

because the fascial spaces are important we like to discuss them in detail , they are not very common , because antibiotics here are OCT drugs, meaning the infections are well controlled here

- fascial spaces anatomy :
1) primary : maxilla, canine , buccal, infra-temporal , mandible : submandibular , sublingual, submental
2) secondary : Masseteric, pterygomandibular, superficial and deep temporal, Lateral pharyngeal, Retropharyngeal, prevertebral

- 1. canine space anatomy :
when an infection is related to the upper canine it can be simple and easy ( makes a vestibular abscess) or it can be more difficult : and that is by if the level of the apex of the canine is higher than the muscle attachment of that area (lip muscles ) so if it goes higher than the lip muscles it goes to the canine space area and swelling happens and this infection might spread into dangerous areas
because in the face we have emissary veins ( valve less veins) so the blood can go bi-directionally, so it can reach the cavernous sinus from the mid-face , through angular vein or pterygoidail venous plexus and that’s extremely dangerous

superiorly : levator muscles
inferiorly : orbicularis oris
anteriorly: skin and sub-coetaneous tissue
posteriorly : maxilla
medially : levator muscles (Med Levator labii alaquae nasii)
laterally : muscles of the zygoma (Zygomaticus major)

it’s a contained space between the muscles and the maxilla.
might cause obliteration into the labial fold ( drainage could occur , but sometime it doesn’t happen and it can spread into other areas

- cavernous sinusitis :
is a serious complication of the mid fascial infections , since it’s related to too many important cranial nerves
- on the lateral wall of the cavernous sinus we have 3rd,4th,5th and branches of the 6th and therefore the function of those nerves can be affected , that’s why when a patient has sever cavernous sinus he might suffer from abducent cavernous palsy/ lat gaze palsy ( can’t move his eye laterally because the 6th cranial nerve is affected)
- the infection of the cavernous sinus can spread posteriorly into the brain stem , or rarely to the respiratory centre and that can cause death
- it’s very rare , but it should be known so that the patients can be treated aggressively with no delay
a presentation of the middle face infection : a purulent infection causing damage and necrosis of the whole orbit and spread posteriorly , swollen skin and shiny, pus discharge – this is a risky area and can spread into the cranium

2. buccal space :
Superiorly: Zygoma
Inferiorly: Inferior border of mandible
Anteriorly: Modiolus (where the facial muscles held together by fibrous tissue )
Posteriorly: Masseter
Medially: Buccinator
Laterally: Skin, sub-coetaneous
infections can easily spread, the buccal space infection can go posteriorly to reach the sub-massetric space ,, can go mesially to reach the medial ptyrgoidal space or peri- tonsillar space ( this is how they communicate )
• Infection from maxillary or mandibular teeth (mainly maxillary) due to anatomical reasons
• in buccal space it contains facial artery, vein, and facial nerve( the buccal branch , zygomatic, and mandibular ) , Stenson’s duct ( the parotid duct as it opens opposite to the 2nd molar ), buccal fat pad.
• The buccal fat pad obstructs the infection spreading from buccal to lateral pharyngeal space.

Clinically: swelling below zygomatic arch and above inferior border of mandible which can spread to other spaces
- Infratemporal Space : inferior to the temporal bone
- posterior to the maxilla , behind the maxilla there’s temporal muscles and bones
- it’s medial to the mandible , because the mandible is posterior to the maxilla
- lies posterior to the maxilla bilaterally
- rarely infected, cause is usually from the maxillary third molar
- Superiorly Infratemporal crest of sphenoid bone
- Inferiorly Lateral pterygoid
- Anteriorly Maxillary tuberosity
- Posteriorly: Mandibular condyle
- Mediallly Lateral pterygoid plate
Laterllay Coronoid process

if there’s an infection in this space it will make compression on the neighbouring structures and it might obstruct the air way , since it’s inferior to it’s site
Mandibular spaces:
1) Submental Space:

- Superiorly Mylohyoid
- Inferiorly Skin, sub-coetaneous
- Anteriorly Lingual mandible
- Posteriorly Hyoid
- Medially Common space, no medial wall
- Lat Medial Mandible
- Primarily infected by mandibular incisors ( since they have long roots ) so the infection will spread and be able to reach the area just underneath the mylohyoid and can spread to the submental and submandibular space ., this is actually very common to see in patients who had trauma to their lower teeth, the teeth got non-vital and he’ll come complaining from the submental area because the infection reached there

2) Submandibular Space : commonly infected , due to lower molars, submandibular and submental glands and other causes
Superiorly: Inferior Mandible, Mylohyoid
Inferiorly: Hyoid
Anteriorly : Ant. Digastric
Posteriorly: Post. Digastric
Medially: Mylohyoid, hyoglossus
Laterally : Inf. mandible, skin, sub-coetaneous

Contains submandibular gland, facial and lingual arteries, and lymphatics, mandibular branch of the facial nerve ( when we remove the gland there’s a possible weakness of the angle of the mouth , since that in this area the mandibular branch passes through it ) , the lingual nerve gives innervations to the submandibular ganglion , ( parasympathetic supply to the submandibualr ganglion ( auriculo temporal, lingual nerve , to the submandibular ganglion )

• most common infected space
• infection then perforation of the lingual plate that gets contained in the submandibular space, can cause huge swelling of the area and can spread to other spaces ( sublingual and submental) causing Ludwig angina that might cause obstruction to the airway

• Infection results in dysphagia, pain, swelling

3) Sublingual Space
Superiorly: Sublingual mucosa
Inferiorly: Mylohyoid
Anteriorly: Lingual border mandible
Posteriorly: Hyoid
Medially: Genioglossus
Laterally: Medial mandible

- Contains sublingual gland, lingual nerve, Wharton's duct ( submandibular gland opening) , hypoglossal nerve.
Lingual perforation of mandibular first molar the and premolars mainly. ( because it’s more anerioly since the mylohyiod is present with a slope, so when it goes anteriorly the roots are higher than the mylohyiod and this means it can be contained in the sublingual space ,, the and premolars mainly.
communication can happen because the myelohyoid is not fully extended on all of the mandible so if a sublingual infection happens it can communicat through the posterior border of the mylohyiod and reach the submandibular space

Ludwig’s Angina
• Infection of 5 spaces; submental, and bilateral submandibular and sublingual spaces.
• brauny edema of the spaces. : there’s no pus , there’s a huge edema and cillulitis in the area, so multiple drains will be put in the interstial cells to try to lower the pressure of edema in that area and get a better performance of the airway
• the patients should be hospitalized with severe care and with antibiotics and airway maintainance ( oro-pharyngeal tube or tracheastomy tube)
• it’s a very severe complication that is seen in patients with severe immunecompromised status

The End
done by: Lana Obeidat
Shadi Jarrar
مشرف عام

عدد المساهمات : 997
النشاط : 12
تاريخ التسجيل : 2009-08-28
العمر : 27
الموقع : Amman-Jordan


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