Principles of therapy of odontogenic infections

Principle 5: Support Patient Medically Systemic resistance to infection is the most important determinant of a good outcome Host systemic resistance Immune system compromise Control of systemic disease Physiologic reserves

Odontogenic infection Immune system compromise Treated by Specialist +Hospitalization +Medical consultation = EXAMPLE: Diabetic patient Cardiovascular pt Anticoagulant therapy (warfarin) Control of blood sugar directly related to resistance to infection Reduce ability to respond to stress of infxn and surgery May need reversal of the medication before surgery Significant infection  blood sugar  insulin requirement  control of HTn cardiac arrythmias, atherosclerotic Ds

Infection Without immune compromise Reduced physiologic reserves = Children  dehydration, high fever Elderly  reduced ability to mount a fever, susceptible to dehydration Highly elevated fever  active hydration + nutritional support Consideration (immediate post-treatment period) -Drink sufficient water -take high calorie diet -prescribed with adequate analgesic -post-op instruction should be given to the patient

Principles 6: Choose and prescribe antibiotic A.TO PRESCRIBE OR NOT TO PRESCRIBE? Three factors must be considered : The seriousness of the infection when first come to the dentist Whether adequate surgical treatment can be achieved The state of the patient’s host defense Indications for antibioticAntibiotic not necessary Acute onset, rapid, diffuseMinor, chronic, well-localized abscess Medically compromised patientWell-localized dentoalveolar abscess mild/no facial swelling Infection involve deep fascial spacesLocalized alveolar osteitis Severe pericoronitisMild pericoronitis, ging edema and mild pain Osteomyelitispatient demand

Patient compliance decreases with increasing number of pills Routine C&S testing is not cost-effective. Indication to send specimen for C&S testing: -rapid onset; rapid spread -postop infection -infection not resolving -compromise immunr system Effective orally administered antibiotic for odontogenic infection Penicillin Amoxicillin Clindamycin Azithromycin Metronidazole (useful only against anaerobe) moxifloxacin B. USE EMPIRICAL THERAPY ROUTINELY Give antibiotic with the assumption that an appropriate drug is being given

C. USE NARROW SPECTRUM ANTIBIOTIC D. USE ANTIBIOTIC WITH LOWEST INCIDENCE OF TOXICITY Narrow spec for simple infxnBroad-spec for complex infxn PenicillinAmoxicillin ClindamycinAugmentin MetronidazoleAzithromycin tetracycline moxifloxacilin DRUGEFFECTS PenicillinKnown allergy Azithromycin and Clindamycin Low toxicity & side effect Severe diarrhea (rare) MoxifloxacilinNew; better effectiveness; significant toxicity CephalosporinsAllergy; No longer used in odontogenic infxn TetracyclineDiscolouration; photosensitivity MetronidazoleMild toxicity; typical GIT disturbance; disulfram effect

E. USE A BACTERICIDAL ANTIBIOTIC Bacteriostatic require reasonably intact host defense F. BE AWARE OF THE COST

Principle 7: administer antibiotic properly Prescribed antibiotic  proper dose  proper interval Clinician must make it clear for patient to finish the entire prescription.

Principle 8: Evaluate patient frequently Usually follow up in 2 days after therapy If successful? Swelling and pain  dramatically If unsuccessful? Why? Examine specific toxicity rxn Aware of 2ndary/superinfxns  oral/ vaginal candidiasis Follow up after infxn resolve Reasons for failure Inadequate surgery Depressed host defenses Foreign body Antibiotic problem: Patient noncompliance Drug not reaching site Drug dose too low Wrong bacterial diagnosis Wrong antibiotic