Ata Nevzat Yalcin

Paschalis Vergidis

Matthew E. Falagas

DESCRIPTION

• Odontogenic infections originate within the mouth and are associated with the teeth and surrounding structures. These infections can range from small apical abscesses to large soft-tissue infections extending to the neck and beyond.
• Odontogenic orofacial infections include dental caries, pulpitis, periapical abscess, gingivitis, periodontal disease, peri-implantitis, and infections in the deep fascia.

EPIDEMIOLOGY

Prevalence

• Odontogenic infections are prevalent worldwide and are the principal reason for seeking dental care.
• Periapical abscess, pericoronitis, and periodontal abscess are the most common emergency odontogenic infections.

RISK FACTORS

• Old age
• Pregnancy
• Diabetes
• Immunodeficiency
• Malnutrition
• Eruption of deciduous dentition
• Poor oral hygiene
• Smoking
• Disorders of salivation
• Hospitalization

GENERAL PREVENTION

• Good oral hygiene to prevent plaque build-up.
• Fluoride promotes remineralization of the teeth and can prevent caries.
• Chlorhexidine can reduce the amount of plaque formation and prevent disease

PATHOPHYSIOLOGY

• The dental biofilm is the etiological agent of odontogenic infections. It is defined as a proliferative bacterial, enzyme-active ecosystem.
• Perturbation of the colonizing microflora can lead to the development of disease within the mouth.
• Patients with poor oral hygiene have higher colony counts of mouth flora.
• Hospitalized patients have higher numbers of Gram-negative facultative rods (e.g. Escherichia coli, Klebsiella spp.).
• Disorders of salivation are associated with greater numbers of organisms.
• Disorders of cell-mediated immunity, deficiency of IgA, and reduction in neutrophils are all risk factors for the development of oral infections.

ETIOLOGY

• Odontogenic infection is polymicrobial and mixed.
• Most frequent pathogens isolated from odontogenic infections are
  • Streptococcus spp. (S. mutans group, S. anguis, S. mitis, S. salivarius)
  • Lactobacillus
  • Peptostreptococcus spp.
  • Actinomyces spp.
  • Fusobacterium spp.
  • Veillonella
• S. mutans is the only microorganism consistently isolated from all decayed dental fissures and caries cases.
• Periodontal infections are generally polymicrobial: Gram-positive aerobes, primarily streptococci, predominate in gingivitis, and the Gram-negative anaerobic rods predominate in bone-destroying periodontitis.

COMMONLY ASSOCIATED CONDITIONS

Necrotizing ulcerative periodontitis involves severe loss of periodontal attachment and alveolar bone. This entity may be associated with HIV infection.

[Outline]

• Information
• Description
• Epidemiology
  • Prevalence
• Risk Factors
• General Prevention
• Pathophysiology
• Etiology
• Commonly Associated Conditions

HISTORY

• Diagnosing the origin of odontogenic infection is important in order to manage the disease appropriately.
• Clinical manifestations may be useful when they are referred to a specific tooth.
• Periapical abscess and pulpitis
  • Patients complain initially of hot and cold sensitivity of the tooth; this may develop into a throbbing sensation that is worsened with eating.
  • Eventually, the tooth generates continuous pain.
• Gingivitis
  • Inflammation of the gums may lead to halitosis and bleeding after brushing.
• Periodontitis
  • Periodontal disease is often associated with localized pain along with hot and cold sensitivity.

PHYSICAL EXAM

• Pulpitis
  • Mild inflammation in early disease. Occlusion of blood vessels and necrosis of the pulp tissue in advanced disease.
• Gingivitis
  • The gums are hyperemic.
  • In acute necrotizing ulcerative gingivitis (Vincent's angina or trench mouth) the gingival surface becomes necrotic. Fever may be present.
• Periodontitis
  • Gingivitis may be present. Loss of the supporting structure may lead to motion of the tooth, and pressure on the tooth leads to formation of pus around the tooth.

DIAGNOSTIC TESTS & INTERPRETATION

Lab

• Microbiological testing can help to identify the cause, although all odontogenic infections are the result of biofilm evolution with marked similarities in the bacterial composition.
• Odontological microbiological studies are complex because of potential contamination.
• Bacterial culture is the traditional method of identification and also allows susceptibility testing.
• Immunofluorescent techniques and DNA hybridization are also useful.

Imaging

• X-rays provide essential information, but certain limitations should be considered.
• Radiographs can detect bone loss, areas of abscess formation, and loss of dentin and enamel.
• With deep extension of infection, CT or MRI scanning is most helpful.

[Outline]

• History
• Physical Exam
• Diagnostic Tests & Interpretation
  • Lab
  • Imaging

• The objective of treatment is to control the infective bacterial load by combining mechanical debridement, surgery, and/or systemic antibiotic treatment, where appropriate.
• Indications for antibiotic therapy
  • Acute-onset fascial or oral swelling
  • Swelling inferior to the mandible
  • Trismus
  • Dysphagia
  • Lymphadenopathy
  • Fever (>38.3°C)
  • Pericoronitis
  • Osteomyelitis

MEDICATION

First Line

• Outpatient treatment: Penicillin G, clindamycin, azithromycin
• Inpatient treatment: Clindamycin, ampicillin plus metronidazole, ampicillin/sulbactam, amoxicillin/clavulanate
• Early-onset aggressive or localized juvenile periodontitis: Doxycycline, metronidazole

Second Line

• Out-patient treatment (penicillin allergy): Clindamycin, azithromycin
• In-patient treatment (penicillin allergy): Clindamycin, third-generation cephalosporins

SURGERY/OTHER PROCEDURES

• All abscesses need to be drained. There are many intraoral routes for drainage.
• At times, the crown of the tooth needs to be removed or the tooth extracted.

[Outline]

• Information
• Medication
  • First Line
  • Second Line
• Surgery/Other Procedures

FOLLOW-UP RECOMMENDATIONS

• Frequent periodontal scaling can avert plaque formation and periodontitis.
• Frequent follow-up with a dentist, at least every 6 months, is mandatory.

COMPLICATIONS

• Fascial space infections (e.g., osteomyelitis of the jaw)
• Necrotizing fasciitis
• Odontogenic sinusitis
• Buccal and periorbital cellulitis
• Ludwig's angina: Bilateral infection that causes elevation of the tongue and floor of the mouth
• Lateral pharyngeal space infections are rarely caused by an odontogenic source
• Suppurative jugular thrombophlebitis (Lemierre's syndrome)
• Orbital and intracranial complications:
  • Orbital and intracranial abscess
  • Septic cavernous sinus thrombosis
  • Brain abscess and subdural empyema

[Outline]

• Follow Up Recommendations
• Complications

• Levi ME, Eusterman VD. Oral infections and antibiotic therapy. Otolaryngol Clin North Am 2011;44(1):57–78.
• Lopez-Piriz R, Aguilar L, Gimenez MJ. Management of odontogenic infections. Med Oral Patol Oral Cir Bucal 2007;12:E154–E159.

ICD9

• 521.00 Dental caries, unspecified
• 522.0 Pulpitis
• 522.4 Acute apical periodontitis of pulpal origin