Dentoalveolar infections

1. Dentoalveolar infections Pamela Dickson

2. Dentoalveolar infections Definition: pus producing (or pyogenic) infections associated with the teeth and surrounding supporting structures such as the periodontium and the alveolar bone. The clinical presentation of dentoalveolar infections depends on the virulence of the causative microorganisms, the local and systemic defence mechanisms of the host, and the anatomical features of the region. The resulting infection may present as: • an abscess localised to the tooth that initiated the infection • a diffuse cellulitis that spreads along fascial planes • a mixture of both.

3. Odontogenic infection • Develops by the extension of the initial carious lesion into dentine and spread of bacteria to the pulp • The pulp responds to the infection with acute inflammation which causes necrosis. • Once pus formation occurs, it may remain localised at the root apex and develop into either an acute or a chronic abscess, develop into a focal osteomyelitis or, as hydrostatic pressure increases, it can track along the path of least resistance to the tissue spaces. • Potential for local and distant spread.

4. Local measures • Abscesses can compress other structures and reduce blood supply. • Abscesses have poor blood supply and therefore antimicrobials wont reach them. • Correct treatment is DRAINAGE and REMOVAL OF CAUSE • Drainage can be though the tooth or via Hiltons method

5. Hiltons method of drainage • For when pus in soft tissues • When XLA and RCT no use • Find most dependent point of abscess and incise through mucosa and periosteum • Blunt dissection to break down lobules of pus

6. General measures • Analgesics – paracetamol, ibuprofen, cocodamol • Supportive – fluids, rest, diet • Antibiotics IF systemic involvement, cellulitis, compromised host defences involvement of fascial spaces.

7. Spread to fascial spaces • One of the most serious and potentially life-threatening complications • Whatever the cause, spread of infection through the potential spaces in the neck poses a risk to the airway. • It may also result in systemic compromise and cardiovascular collapse. Furthermore, infection can spread inferiorly into the mediastinal or pleural cavities; or superiorly to the peri-orbital or orbital tissues, and via the facial vein to the cavernous sinus.

9. Symptoms • In addition to pain around the causative tooth or teeth, patients with neck space infection will feel generally unwell. • They may complain of fever and rigors. • Particularly worrying symptoms are trismus, dysphagia, dyspnoea, and change in voice. An example of the latter is the ‘hot potato’ voice resulting from elevation of the floor of mouth and tongue in the oral cavity. • These all indicate actual or impending airway compromise and patients presenting in this way should be referred for urgent assessment in hospital.

12. Initial assessment Initial assessment of the patient should include the following: • Taking a comprehensive medical and dental history • Checking for presence of fever, malaise, fatigue, dizziness or other debility • Measuring the pulse and temperature (normal axillary temperature is 36.3-37) • Defining nature location and extent of the swelling • Identifying the cause of the infection Patients admitted to hospital with neck space infection will undergo blood tests, possible further imaging including ultrasound and/or CT scan, and eventual microbiological investigation. Where possible, a sample of pus is obtained for microbiological culture and antibiotic sensitivity testing. Most often, pus is obtained at the time of operation. The acute odontogenic abscess is usually polymicrobial in nature, comprising facultative anaerobes (for example, viridans streptococci and the Streptococcus anginosusgroup), and strict anaerobes like Prevotellaand Fusobacterium species.9,10

13. Vital signs • Septic patients may be tachycardic (pulse rate >90 beats per minute) and pyrexial. If there is an abscess, a swinging pyrexia may be seen. • The respiratory rate is a sensitive sign that may increase before an abnormality is seen in other vital signs. A rate of >20 breaths per minute is abnormal in an adult. • The combination of a high respiratory rate, tachycardia, very high or very low temperature, with a very high or very low white blood cell count is the systemic inflammatory response syndrome (SIRS). • Sepsis is defined as the presence of SIRS in addition to a confirmed infective process. • Septic shock occurs when a septic patient remains hypotensive despite aggressive attempts at restoring the blood pressure. • Importantly, it is well recognized that the prognosis of septic patients is improved when appropriate treatment is delivered promptly.

14. When to refer Following this assessment the clinician should decide whether treatment can be provided in primary care or whether a referral is necessary for example if there is/ are: • Signs of septicaemia such as grossly elevated temperature ( above 39.5), lethargy, tachycardia • Spreading cellulitis (rapidly progessing infection) • Breathing or swallowing compromised • Severe trismus • Compromised host defences • Swellings that may compromise the airway or cause difficulty in swallowing or closure of the eye • Dehydration • Significant trismus associated with a dental infection • Failure to respond to previous treatment • An uncooperative patient

15. Principles of the surgical management of deep neck space infection • The patient presenting with suspected neck space infection should be assessed immediately for Airway, Breathing, and Circulation (ABC). • This gauges the urgency of the need for referral to hospital. • A stable patient with localised swelling and minimal soft tissue involvement is likely to be suitable for early, local treatment including pulp extirpation or extraction of the tooth, with or without systemic antibiotics. • For those patients referred to hospital, the principles of establishing surgical drainage, removal of the source of infection, and systemic antibiotics also apply. • Septic patients will be treated aggressively with fluid resuscitation and early, empirical administration of antibiotics. • Drainage of neck space infections will usually take place inthe operating theatre under general anaesthetic. • Severe airway compromise may necessitate placement of a tracheostomy tube and post-operative admission to intensive care. • In Ludwig’s angina, there is often no collection of pus, but surgical exploration of the affected spaces is performed to ‘decompress’ the neck. Surgical drains are placed until resolution of the infection. Corticosteroids (eg dexamethasone) may be given to help reduce the oedema associated with these infections.

16. Early recognition and management of dento-alveolar infections is critical because patients (particularly children and immunocompromised patients) can become systemically ill within a short time. If untreated, local infections can spread, giving rise to serious life threatening sequelae.

17. Ludwig’s angina • Ludwig’s angina is a specific diagnosis and is defined as a bilateral cellulitis of the submandibular and sublingual spaces, most often arising from a lower molar tooth. The floor of the mouth contains the sublingual, submandibular and submental spaces with ready communication across the midline. Infection can, therefore, spread to involve all spaces in the floor of the mouth. • Clinically, there is a firm swelling of the floor of the mouth and resultant elevation of the tongue. The submandibular and sublingual spaces become tense and tender. There may be accompanying trismus, dysphagia, and respiratory embarrassment. • The cellulitis may spread to involve the lateral pharyngeal space. • These patients require immediate referral to hospital for urgent antibiotic therapy and surgical drainage, with or without additional airway support. • 90% of cases of ludwigs angina are precipitated by dental or post extraction infection

18. It is important to remember that the vast majority of odontogenic infections can be managed using local measures such as extraction of the tooth, extirpation of the pulp, or intra-oral incision and drainage of a buccal space abscess. Antibiotic therapy is indicated where there are signs of systemic infection, but they are not a substitute for removing the source of infection. • Benefits of prescribing is limited by a number of problems associated with their use eg side effects, allergic reactions, toxicity, development of resistant strains of microbes • Antimicrobial resistance is a world wide problem • Dentist working in the NHS primary care prescribe nearly 1-% of all the oral antimicrobials in primary care in England. • Inappropriate use of AB may contribute to problem of antimicrobial resistance.

19. Indications for Prescribing Antimicrobial is only indicated • As an adjunct to the management of acute of chronic infection • For the definitive management of active infective disease eg NUG • Where definitive treatment has to be delayed due to referral to specialist services. Eg inability to establish drainage in an uncooperative patient who required sedation or GA for treatment or a patient who needs to be treated in a hospital environment due to comorbidities. • When there is an elevated temperature, evidence of systemic spread and local lymph gland involvement Follow up the patient 2-3 days after the drainage and removal of the cause. If there is resolution of the infection and the temperature is normal, stop antimicrobials

20. First choice antimicrobial A penicillin

21. Second choice antimicrobial • As first line treatment for patients allergic to penicillin or • As first lined treatment for patients who have had a recent course of penicillin • As an adjuct to amoxicillin in severe spreading infections or • If a predominantly anaerobic infection is suspected or microbially proven

22. Third choice antimicrobial • Macrolide • Can be used as an alternative to penicllin. • Azithromycin and clarithromycin are better tolerated than erythromycin which causes nausea vomiting and diarrhoea in some cases and any organisms are resistant to it. • The prescribing of clindamycin , cephalosporins, co-amoiclav offers no advantage over a penicillin, metronidazole or a macrolide and is not recommended for the routine management of dentoalveolar infections. Inappropriate use of clindamycin cephalosporins or co-amoxiclav can lead to development of resistance and can lead to the development of clostridium difficile infection.

24. Chronic dento-alveolar infections Chronic dentoalveolar infections can occur in association with decayed or restored teeth. They commonly present as a minor , well localised abscess , sometimes with a discharging sinus and rarely require antimicrobial therapy unless: • There is an acute flare up and there is evidence of gross local spread or • There is systemic involment shown by an elevated temperature or malaise The principals of treatment are • Removal of the cause drainage of the infection • Long standing chronic infections which do not respond to simple treatment eg osteomyelitis should be referred to a consultant specialist

27. FGDP guideline "Antimicrobial Prescribing for GDPs"- chapter 4: Acute Dento-alveolar Infections • Dental Update 2016; 43: 745–752