Kuliah 3 - Dental Infection

7/28/2019 Kuliah 3 - Dental Infection

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Reno Rudiman


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Background

Infections of the teeth have plaguedhumans constantly, despite a quest forbetter oral hygiene.

Infections usually arise from pulpitis andassociated necrotic dental pulp that initiallybegins on the tooth's surface as dentalcaries.

The infection may remain localized orquickly spread through various fascialplanes.


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Pathophysiology

Odontogenic infection may be primary or

secondary to periodontal, pericoronal,

traumatic, or postsurgical infections.


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Once enamel is dissolved, the infectious

caries can travel through the microporousdentin to the pulp

In the pulp, the infection may develop a track

through the root apex and burrow throughthe medullar cavity of the mandible ormaxilla.

The infection then may perforate the corticalplates and drain into the superficial tissues ofthe oral cavity or track into deeper fascialplanes.


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Serotypes ofStreptococcus mutans

(cricetus, rattus, ferus, sobrinus) are

primarily responsible for causing oral

disease.

Although lactobacilli are not primary

causes, they are progressive agents ofcaries because of their great acid-

producing capacity.


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Frequency

Dental caries is the most common chronicdisease in the world. The late 1970ssignaled a decline in caries in certainsegments of the world due to the additionof fluoride to public drinking water. In theUS, a 36% decrease in caries occurredfrom 1972-1980.

In the United Kingdom, a 39% decline incaries occurred from 1970-1980.

In Denmark, a 39% decline occurred from1972-1982.


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Morbidity/Mortality

Dental caries is not a life-threatening

disease; however, if an odontogenic

infection spreads through fascial planes,

patients are at risk for sepsis and airwaycompromise (eg, Ludwig angina,

retropharyngeal abscess).

Odontogenic infections carry significantmorbidity of pain and cosmetic defect.


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History

Patients with superficial infections may

complain of localized pain, edema, and

sensitivity to temperature and air.

Patients with deep infections or

abscesses that spread along the fascial

planes may complain of fever anddifficulty swallowing, breathing, and

opening the mouth.


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Physical: Local Infection

Typically, the tooth is grossly decayed,

though it may be normal with cavitated

lesions that may have a surrounding

chalky demineralized area and swollenerythematous gingiva.

Affected teeth generally are tender topercussion and temperature.


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Dentoalveolar ridge edema is evidencedby a periodontal, periapical, andsubperiosteal abscess.

Infection from the tooth spreads to theapex to form a periapical or periodontalabscess.

With further invasion, the infection mayelevate the periosteum and penetrateadjacent tissues.


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Pericoronal infection occurs in anerupting or a partially impacted toothwhen tissue covering the tooth's crown

becomes inflamed and infected.

An abscess may form and requireincision and drainage (I&D).

The tooth itself usually is not involved.


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Physical: Mandibular Infection

Submental space infection is

characterized by a firm midline swelling

beneath the chin and is due to infection

from the mandibular incisors. Sublingual space infection is indicated

by swelling of the mouth's floor with

possible tongue elevation, pain, anddysphagia due to anterior mandibular

tooth infection.


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Sublingual space


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Spread of infection


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Submandibular space infection is

identified by swelling of the

submandibular triangle of the neck

around the angle of the jaw. Tenderness to palpation and mild trismus is

typical.

Infection is caused by mandibular molar

infections.


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Submandibular space infection


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Retropharyngeal space infection is

identified by stiff neck, sore throat,

dysphagia, hot potato voice, and stridor

with possible spread to the mediastinum. These infections are due to infections of the

molars.

More common in children younger than 4 years.

Etiology: URTI with spread to retropharyngeallymph nodes.

High potential for spread to the mediastinum


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Ludwig angina

Characterized by brawny boardlike swellingfrom a rapidly spreading cellulitis of thesublingual, submental, and submandibularspaces with elevation and edema of thetongue, drooling, and airway obstruction.

Odontogenic in 90% of cases and arisesfrom the second and third mandibular molarsin 75% of cases.


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Ludwig angina

If infection spreads through the

buccopharyngeal gap (space created by

styloglossus muscle between the middle

and superior constrictor muscle of thepharynx), potential exists for adjacent

retropharyngeal and mediastinal

infection.


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Middle and lateral facial edema

Buccal space infection is typically indicated

by cheek edema and is due to infection of

posterior teeth, usually premolar or molar.

Masticator space infection always presentswith trismus manifestation and is due to

infection of the third molar of the mandible.

Large abscesses may track toward the posterior

parapharyngeal spaces.

Patients may require fiberoptic

nasoendotracheal intubation while awake.


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Middle and lateral facial edema

Canine space infection is evidenced by

anterior cheek swelling with loss of the

nasolabial fold and possible extension to

the infraorbital region. This is due toinfection of the maxillary canine and

potentially may spread to the cavernous

sinus.


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Gingivitis

Acute necrotizing ulcerative gingivitis(Vincent angina, trench mouth) is acondition in which patients present withedematous erythematous gingiva withulcerated, interdental papillae covered witha gray pseudomembrane.

Patients may have fever andlymphadenopathy and may complain ofmetallic taste. The condition is caused byinvasive fusiform bacteria and spirochetesbut is not contagious.


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Causes:

Serotypes ofS mutans are thought tocause initial caries infection. Infectionsthrough the fascial planes usually arepolymicrobial (average 4-6 organisms).Dominant isolates are anaerobic bacteria.

Anaerobes (75%) - Peptostreptococci,Bacteroides organisms, andFusobacterium nucleatum

Aerobes (25%) - Alpha-hemolyticstreptococci


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Lab Studies

Complete blood count (CBC) with

differential is not mandatory, but a large

outpouring of immature granulocytes

may indicate the severity of theinfection.

Blood cultures in patients who are toxic

may help guide management if thecourse is prolonged.


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Imaging Studies

Panorex and periapical dental films areused to identify involvement of tooth andsurrounding bone in the infectious process.

A soft-tissue x-ray of the neck can be usedto identify gas-producing infections anddetermines any mass effect that maypotentially compromise the airway.

CT scan may be used for severe fascialplane infections to determine the extent,size, and location of the infectious process.


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CT Scan: Ludwig Angina


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Treatment

The infectious odontogenic source must

ultimately be removed or controlled.

Pain medication and antibiotics may be

given if the patient is not systemically ill

and appears to have a simple localized

odontogenic infection or abscess.


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Treatment: Localized infections

I&D may be performed if a periapical orperiodontal abscess is identified,depending on physician comfort level.

After anesthesia of the tooth, locally or with

a dental block, make an incision in themucosa large enough to accommodate aquarter-inch Penrose drain.

Bluntly dissect the abscess cavity with the

tips of a hemostat. Suture in the Penrosedrain with a silk suture and leave untilsuppurative drainage is no longer present(about 2-3 days).


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Treatment: Deep fascial

infection Infections of the neck's deeper fascial

layers and masseteric layers have a higherchance of causing impingement upon theairway directly or indirectly through

extreme trismus. Tracheostomy was the prior method of

choice for establishing the airway; as ofrecently, management through fiberopticnasoendotracheal intubation while patientis awake is preferred.

Various drains and incisions are used fordrainage of the affected fascial space.


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Treatment: Emergency Care

If the patient appears systemically ill

with abnormal vital signs and/or is

unable to take oral medication, consider

admission with further diagnostic studiesand IV antibiotics.

Infections in the various fascial spacesrequire I&D by the consulting physician.


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Treatment: Emergency Care

If airway issues are of concern (eg,Ludwig angina, retropharyngealabscesses), call anesthesiology and

surgeon as soon as possible to establishan airway.

Ensure that equipment for an emergent

cricothyroidotomy is located at thebedside until a secure airway can beestablished.


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Cricothyroidotomy


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Kuliah 3 - Dental Infection

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