Reno - Dental Infection

7/28/2019 Reno - Dental Infection

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Dental Infection

Reno Rudiman


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Background

Infections of the teeth have plagued humansconstantly, despite a quest for better oralhygiene.

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

The infection may remain localized or quicklyspread through various fascial planes.


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Pathophysiology

Odontogenic infection may be primary orsecondary to periodontal, pericoronal, traumatic,or postsurgical infections.

A typical odontogenic infection originates fromcaries, which decalcify the protective enamel.

A balance of demineralization andremineralization of the tooth structure occurs inthe development of carious lesions.


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Once enamel is dissolved, the infectiouscaries can travel through the microporousdentin to the pulp. In the pulp, the

infection may develop a track through theroot apex and burrow through themedullar cavity of the mandible or maxilla.The infection then may perforate the

cortical plates and drain into thesuperficial tissues of the oral cavity ortrack into deeper fascial planes.


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Serotypes ofStreptococcus mutans(cricetus, rattus, ferus, sobrinus) areprimarily responsible for causing oral

disease.

Although lactobacilli are not primarycauses, they are progressive agents of

caries because of their great acid-producing capacity.


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Frequency

Dental caries is the most common chronicdisease in the world. The late 1970s signaled adecline in caries in certain segments of the worlddue to the addition of fluoride to public drinkingwater. In the US, a 36% decrease in cariesoccurred from 1972-1980.

In the United Kingdom, a 39% decline in cariesoccurred from 1970-1980.

In Denmark, a 39% decline occurred from 1972-1982.


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Morbidity/Mortality

Dental caries is not a life-threateningdisease; however, if an odontogenicinfection 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 maycomplain of localized pain, edema, andsensitivity to temperature and air.

Patients with deep infections or abscessesthat spread along the fascial planes maycomplain of fever and difficulty

swallowing, breathing, and opening themouth.


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Physical: Local Infection

Typically, the tooth is grossly decayed,though it may be normal with cavitatedlesions that may have a surrounding

chalky demineralized area and swollenerythematous gingiva.

Affected teeth generally are tender to

percussion 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 an eruptingor a partially impacted tooth when tissuecovering the tooth's crown becomes

inflamed and infected.

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

The tooth itself usually is not involved.


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Physical: Mandibular Infection

Submental space infection is characterizedby a firm midline swelling beneath thechin and is due to infection from the

mandibular incisors.

Sublingual space infection is indicated byswelling of the mouth's floor with possible

tongue elevation, pain, and dysphagia dueto 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 identifiedby swelling of the submandibular triangleof the neck around the angle of the jaw.

Tenderness to palpation and mild trismus istypical.

Infection is caused by mandibular molar

infections.


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Submandibular space infection


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Retropharyngeal space infection is identified bystiff neck, sore throat, dysphagia, hot potatovoice, 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 retropharyngeal lymph

nodes. High potential for spread to the mediastinum


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Ludwig angina

Characterized by brawny boardlikeswelling from a rapidly spreading cellulitis

of the sublingual, submental, andsubmandibular spaces with elevation andedema of the tongue, drooling, and airwayobstruction.

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


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Ludwig angina

If infection spreads through thebuccopharyngeal gap (space created bystyloglossus muscle between the middle

and superior constrictor muscle of thepharynx), potential exists for adjacentretropharyngeal and mediastinal infection.


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Middle and lateral facial edema

Buccal space infection is typically indicated bycheek edema and is due to infection of posteriorteeth, usually premolar or molar.

Masticator space infection always presents withtrismus manifestation and is due to infection ofthe third molar of the mandible.

Large abscesses may track toward the posterior

parapharyngeal spaces.

Patients may require fiberoptic nasoendotrachealintubation while awake.


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Middle and lateral facial edema

Canine space infection is evidenced byanterior cheek swelling with loss of thenasolabial fold and possible extension to

the infraorbital region. This is due toinfection of the maxillary canine andpotentially may spread to the cavernous

sinus.


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Gingivitis

Acute necrotizing ulcerative gingivitis (Vincentangina, trench mouth) is a condition in whichpatients present with edematous erythematous

gingiva with ulcerated, interdental papillaecovered with a gray pseudomembrane.

Patients may have fever and lymphadenopathyand may complain of metallic taste. The

condition is caused by invasive fusiform bacteriaand spirochetes but is not contagious.


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Causes:

Serotypes ofS mutansare thought to causeinitial caries infection. Infections through thefascial planes usually are polymicrobial (average

4-6 organisms). Dominant isolates are anaerobicbacteria.

Anaerobes (75%) - Peptostreptococci,Bacteroidesorganisms, and Fusobacterium

nucleatum

Aerobes (25%) - Alpha-hemolytic streptococci


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Lab Studies

Complete blood count (CBC) withdifferential is not mandatory, but a largeoutpouring of immature granulocytes may

indicate the severity of the infection.

Blood cultures in patients who are toxicmay help guide management if the course

is prolonged.


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Imaging Studies

Panorex and periapical dental films are used toidentify involvement of tooth and surroundingbone in the infectious process.

A soft-tissue x-ray of the neck can be used toidentify gas-producing infections and determinesany mass effect that may potentiallycompromise the airway.

CT scan may be used for severe fascial planeinfections to determine the extent, size, andlocation of the infectious process.


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CT Scan: Ludwig Angina


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Treatment

The infectious odontogenic source mustultimately be removed or controlled.

Pain medication and antibiotics may begiven if the patient is not systemically illand appears to have a simple localizedodontogenic infection or abscess.


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Treatment: Localized infections

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

After anesthesia of the tooth, locally or with adental block, make an incision in the mucosalarge enough to accommodate a quarter-inchPenrose drain.

Bluntly dissect the abscess cavity with the tips ofa hemostat. Suture in the Penrose drain with asilk suture and leave until suppurative drainageis no longer present (about 2-3 days).


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Treatment: Deep fascial infection

Infections of the neck's deeper fascial layers andmasseteric layers have a higher chance ofcausing impingement upon the airway directly orindirectly through extreme trismus.

Tracheostomy was the prior method of choicefor establishing the airway; as of recently,management through fiberopticnasoendotracheal intubation while patient isawake 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 withabnormal vital signs and/or is unable totake oral medication, consider admission

with further diagnostic studies and IVantibiotics.

Infections in the various fascial spaces

require 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 emergentcricothyroidotomy is located at thebedside until a secure airway can beestablished.


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Cricothyroidotomy


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