1. Admission clerking & consideration for patient with maxillofacial Mohd Azizul Mohd Atan Sakinah Mohd Saleh Nur Fatin Rusli

2. Principles of therapy of odontogenic infections Principle 1: Determine Severity Of Infection Principle 2: Evaluate State Of Patient’s Host Defense Mechanism Principle 3: Determine Whether Patient Should Be Treated By General Dentist Or Oral And Maxillofacial Surgeon Principle 4: Treat Infection Surgically Principle 5: Support Patient Medically Principle 6: Choose And Prescribe Appropriate Antibiotic Principle 7: Administer Antibiotic Properly Principle 8: Evaluate Patient

4. Principle 1: Determine Severity Of Infection Complete history – Follows the same general guidelines as any other history taking. – Patient’s chief complaint, onset of infection, duration of infection, signs and symptoms, characteristic of pain, etc. – Patient feels? –malaise (feel fatigue, feverish, weak, sick)  indicates a generalized reaction to a moderate to severe infection. – Treatment? –previous professional tx and self-tx. – Patient’s complete medical history.

5. Physical examination 1.Vital signs: Temperature  Severe infections  temperatures elevated greater than 38.3 ͦC Blood pressure  Vital sign that varies the least with infection.  Severe septic shock results in hypotension. Pulse rate  Pulse rates of up to 100 beats/min are not uncommon in patients with infections.  If greater than 100 beats/min, severe infection. Respiratory rate  Consider the potential for partial or complete upper airway obstruction.  Normal: 14-16 breaths per minute.  Patients with mild to moderate infections may have elevated respiratory rates greater than 18 breaths/min.

6. 2. Physical examination of the patient – Inspection general appearance – Examination of head and neck  check for cardinal signs of infection – Palpation - area of swelling – Intraoral examination – Radiographic examination

7. Principle 2: Evaluate State Of Patient’s Host Defense Mechanism Compromised Host Defenses Uncontrolled metabolic diseases Poorly controlled diabetes Alcoholism Malnutrition End-stage renal disease Immune system-supressing diseases Human immunodeficiency virus/acquired immunodefiency syndrome Lymphomas and leukemias Other malignancies Congenital and acquired immunologic diseases Immunosuppressive therapies Cancer chemotherapy Corticosteroids Organ transplantation

8. Principle 3: Determine Whether Patient Should Be Treated by General Dentist or Oral and Maxillofacial Surgeon Criteria for Referral to an Oral and Maxillofacial Surgeon:  Difficulty breathing  Difficulty swallowing  Dehydration  Moderate to severe trismus (interincisal opening less than 20mm)  Swelling extending beyond the alveolar process  Elevated temperature (greater than 101 ͦF)  Severe malaise and toxic appearance  Compromised host defenses  Need for general anesthesia  Failed prior treatment

9. Principle 4: Treat Infection Surgically The primary principle of management of odontogenic infections is to perform surgical drainage. Primary goal in surgical management of infection  to remove the cause of infection. Secondary goal  to provide drainage of accumulated pus and necrotic debris.

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

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

17. Principle 7: Administer Antibiotic Properly Prescribed antibiotic  proper dose  proper interval Clinician must make it clear for patient to finish the entire prescription.

18. 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

20. PRINCIPLES OF PROPHYLAXIS OF INFECTION 1)Procedure should have significant risk of infection 2)Choose correct antibiotic 3)Antibiotic plasma level must be high 4)Time antibiotic administration correctly 5)Use shortest antibiotic exposure that is effective

21. 1)Procedure have significant risk of infection The procedure must have a high enough incidence of bacteria to be reduced with antibiotic therapy Factors related to Post-op infection i.Size of bacterial inoculum ii.Duration of surgery ( >4 hrs) iii.Presence of FB, implant or dead space iv.State of host resistance (depressed host defense)

22. 2.)Choose correct antibiotic Antibiotic criteria: – The antibiotic should be effective against the organisms most likely to cause infection – Narrow spectrum antibiotic – Least toxic to patient – Bacteriacidal antibiotic more preferable Antibiotic prophylaxis of choice before oral surgery= Amoxicilin @ Penicilin Allergic to penicilin, use clindamycin

23. 3)Antibiotic plasma level must be high Antibiotic level in plasma must be higher than when antibiotic used therapeutically Peak Plasma Level should be high-ensure diffusion of antibiotic into all fluid and tissue Usual recommended: – Dosage for prophylaxis at least 2x of therapeutic antibiotic

24. 4)Time antibiotic administration Must be given 2 hours or less before surgery Antibiotic administration after surgery is greatly decreased its efficacy or has no effect on preventing infection There is evidence administration after 2 hours or more may increase risk of wound infection If surgery prolonged, additional dose is required, intraoperative dose interval should be shorter

25. 5)Use shortest effective antibiotic exposure Must be in the target tissue before surgery Adequate plasma level is maintained The prophlactic antibiotic is necessary for the time of surgery

26. PRINCIPLES OF PROPHYLAXIS AGAINST METASTATIC INFECTION A.Prophylaxis against IE B.Prophylaxis in patient with Cardiovascular conditions C.Prophylaxis against Total Joint Replacement Infection

27. A)Prophylaxis against IE Mortality, morbidity of IE are high IE reaction must be treated in hospital with high dosage of iv antibiotic, damaged heart valve is replaced surgically with prosthetic valve Dental procedures cause bacteremia -S. viridans which might cause IE Antibiotic prophylaxis for "All dental procedures that involve manipulation of gingival tissue/periapical region/perforation of oral mucosa” 2g of Amoxicilin orally ½ to 1 hours before procedure

28. Patient with antibiotic prophylaxis that required dental tx needs a period of >10 days between the appoinment Patient at risk of IE should have comprehensive prophylaxis program such as excellent OH and periodic professional care If surgery is required, the mouth can be rinsed with antibacterial agent preoperatively Even with appropriate measures are taken, it still can happen. Patient should be informed by dentist about signs & symptom of IE post-operatively

29. B)Prophylaxis in patient with Cardiovascular conditions Patient with CABG, transvenous pacemaker, atherosclerotic vascular disease, alloplastic graft – No need antibiotic prophlaxis Patient who receiving renal dialysis or have hydrocephaly – need to consult physician AHA does not recommend antibiotic prophlaxis for nonvalvular device

30. C)Prophylaxis against Total Joint Replacement Infection Patient with TJRI- risk of bacteremia & infection Infection might come from dental procedure eg extraction (recent literature opposed it) Instead it appears the infection come from others through hematogenous spread which result to septicemia But odontogenic infection might cause TJRI ADA & AAOS recognize that patient with prosthetic joint not at a risk of joint infection after dental procedure ADA recommend antibiotic prophylaxis for susceptible pt only

31. Summary:

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