Management of Odontogenic Infections for The

6/6/16 Surgical Management of Odontogenic Infections – the Role of the Dentist Isaac Liau Why Dentists SHOULD See Facial Swellings! § It’s an emergency… § Early intervention prevents hospital admission § Relief of pain is a practice builder § Dentists have knowledge, equipment and skill that ED doctors/GP’s do not § Draining pus is really satisfying! 1 6/6/16 Differential Diagnosis of Facial Swellings § Use a system that works for you (surgical sieve, by tissue type, common + critical) § Skin infections § Salivary gland pathology § Viral infections § Lymphadenitis § Trauma § Neoplasm § Odontogenic infection Principles in the Management of Odontogenic Infections 1. Determine severity of infection 2. Evaluate host defences 3. Decide on the setting of care 4. Treat surgically 5. Support medically 6. Choose and prescribe antibiotic therapy 7. Administer the antibiotic properly 8. Evaluate the patient frequently Flynn TR, 2004 2 6/6/16 Case study 1 § Robert, 19 y.o . male § FIFO worker from Olympic Dam § Not had a chance to see a dentist since leaving SDS due to time and lack of private health insurance § Presents with a moderate L facial swelling § Preceded by intermittent toothache from 23 for past 2 months § MHx – mild asthma Case Study 2 § Terrence, 54 y.o . male § Lives in supported residential care on disability support pension due to refractory schizophrenia § Presents with sudden L “lower jaw” swelling starting this morning, worsening rapidly since § Starting to feel unwell and had difficulty eating breakfast § MHx – schizophrenia, type 2 diabetes, hypertension, current 40 pack year smoker, +++ EtOH § Medications – olanzapine, perindopril, atorvastatin § Non compliant with medications 3 6/6/16 1.) Determine Severity of Infection §Anatomical location §Superficial/Low risk § Vestibular § Canine § Buccal § Infraorbital §Moderate Risk (chance of losing airway) § Submandibular § Submental § Sublingual § Pterygomandibular § Submasseteric § Superficial temporal § Deep temporal 4 6/6/16 § High Risk (airway under direct threat) § Lateral Pharyngeal § Retropharyngeal § Pretracheal § Extreme Risk (immediate threat to life) § Danger space (Grodinsky and Holyoke space 4) § Mediastinum § Intracranial 5 6/6/16 6 6/6/16 §Simply put… §Outwards and up à proceed with management §Inwards and down à call for help 1.) Determine Severity of Infection §Rate of progression § Obtain history from patient § Assess all symptoms § Rapid progression is a poor sign § Stages of progression § Inoculation § Cellulitis § Abscess 7 6/6/16 1.) Determine Severity of Infection §Airway compromise § Exclude red flags à all warrant automatic referral § Trismus § 3+ fingers – normal; 2 – reduced; 1 – emergency! § Consider pain restriction § Odynophagia (pain swallowing) § Dysphagia (can’t swallow) § Dysphonia (hot potato voice) § Protruding tongue 2.) Evaluate host defences § Immune system compromise § Diabetes § Smoking § Alcohol abuse/IVDU § Other (eg, medical immunosuppression, organ transplant, active malignancy, HIV, chronic renal failure, etc) § Systemic physiological reserve § Hydration status § Age § Vital signs § Blood markers (white cell count, CRP, ESR) 8 6/6/16 3.) Determine setting of care § Outpatient (General dental practice) § Superficial space involvement § Airway secure § Systemically stable (no fever or dehydration) § Minimal medical comorbidities § Patient can tolerate under LA § Inpatient (for OMS review) § Everything else! Case Studies – Who should go where? § 1.) Robert – Canine Space § Superficial swelling § No airway threat and systemically well § Compliant in chair § Suitable for LA management by dentist § 2.) Terrence – Submandibular Space § Deep space involvement § Unable to assess high risk spaces due to trismus § Red flag signs for airway threat § Poor co-operation under LA § Systemic signs of sepsis § Medical risk factors for rapid infection spread § Needs hospital admission and GA, contact OMS ASAP, send in ambulance 9 6/6/16 4.) Treat Surgically §SECURE AIRWAY!! §Remove cause. §Remove pus. Removal of Cause § OPG x-ray § Endodontic extirpation and dressing § Debride peri-coronal space § EXTRACT TOOTH 10 6/6/16 Drainage of Pus (under LA) § Establish LA – preferably with regional block § Infiltrations less effective § Avoid intraligamentary injections § Avoid needle passage through infected tissues (go around) § Scalpel incision at point of maximum fluctuance § Avoid important structures § Incise in layers until abscess cavity 11 6/6/16 Drainage of Pus (under LA) § Blunt dissection § Microbial swab (opt.) § Copious irrigation with sterile saline § Insertion of drain (opt.) § Corrugated or Penrose type § Remove in 24 - 48 hours § Regular warm salt water / half-strength chlorhexidine rinse Inpatient Surgical Intervention § RAH Protocol for Severe Odontogenic Infection (2006) § Secure airway in OT (within 4 hours) § Examination under anaesthesia § Early and aggressive surgical exploration of all involved spaces § Extract causative teeth § Postoperative medical support § At least 24hrs intubated in ICU § IV antibiotics and fluids 12 6/6/16 5.) Support Medically § Fluid rehydration § Encourage oral intake § IV fluids if insufficient § Control fever (paracetamol) § Optimise management of medical comorbidities § Pain control as required 6.) Choose and prescribe antibiotics § Antibiotics should only ever be used as an adjunct to surgery § Superficial infections § Penicillin V 500mg 6 hourly, 5 days – OR – § Amoxycillin 500mg 8 hourly, 5 days § Clindamycin 300mg 8 hourly, 5 days (penicillin allergic) § Deep or unresponsive infections § Add - metronidazole 400mg 12 hourly, 5 days § OR - Amoxycillin/clavulanic acid 875mg/125mg (Augmentin duo forte) 12 hourly, 5 days 13 6/6/16 6.) Antibiotics (continued) § IV antibiotic regimens (depends on hospital and surgeon preference) § Penicillin G 1.2g 6 hourly § Amoxycillin 2g 8 hourly § PLUS – Metronidazole 500mg 12 hourly § If unresponsive/resistant bacterial strains identified – § Piperacillin/tazobactam(Tazocin) § Or as per culture results/specialist Infectious Diseases advice 7.) Administer antibiotics properly § Correct antibiotic (no erythromycin or flucloxacillin) § Correct dose § Correct duration § Correct route § Usually switch IV to oral Abx when 24hrs post resolution of fever 14 6/6/16 Caution – Antibiotic Resistance! § Retrospective review of all infections admitted under OMS at RAH, 2006-2014 § 672 patients in total § Penicillin resistance § Rate 10.8% § Resulted in 2.3x longer hospital stay (10.7 vs. 4.6 days) § 43.5% non-responsive to first surgery (required 2nd operation) § Average cost of admission $35000 vs. $10000 § Most cases received multiple prior courses of oral ABx to treat toothache! Fact or Fiction - Antibiotics? § Antibiotics alone will eradicate an odontogenic infection § Antibiotics will definitively treat a toothache § You have “unlimited ammo” with repeat antibiotic courses § Antibiotics don’t have side effects § You have to “settle the swelling” on antibiotics before you extract the tooth § Antibiotics help “localize” the swelling prior to drainage 15 6/6/16 Some Pearly Points to Finish… § Never let the sun set on pus! § Have an emergency action plan § It’s OK to refer on if you don’t feel comfortable managing the situation – but do it properly § Call the on-call OMS registrar in advance § RAH ED dentist has less equipment than you do § Most doctors know very little about managing odontogenic infections § Try to assist / do an I+D during your Oral Surgery rotation Useful References § Flynn TR, 2004. Chapter 15 – Principles of management of odontogenic infections. In: Peterson’s principles of oral and maxillofacial surgery, 2nd ed. BC Decker Inc, London. § Therapeutic Guidelines, Oral and Dental (ver. 2, 2012) § Uluibau IC, Jaunay T, Goss AN. Severe odontogenic infections. Aust Dent J. 2005; 50(4 Suppl 2):S74-81 § Wong D, Cheng A, Kunchur R et al. Severe odontogenic infections in pregnancy. AustDent J. 2012;57(4):498-503 16.

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