Treatment of Odontogenic Infections

Odontogenic infections, primarily consisting of periodontal disease (periodontitis and gingivitis) and dental caries, are typical and have local (tooth loss) and in a few instances, systemic implications. In the United States, it’s estimated that twenty-five percent of adults over age 60 have lost all of their teeth (edentulism), around half from periodontal disease and half from dental caries.

Besides inflicting pain and discomfort, odontogenic infections may extend beyond natural barriers and cause probable life-threatening complications, like infections of the deep fascial regions of the head and neck.

Periodontal infection also can be related to numerous systemic disorders. They involve fever of an unknown origin, bacteremic seeding of prosthetic devices and heart valves, low birth weight/preterm birth babies, and a higher risk of cerebrovascular events and coronary heart disease.

Careful attention to oral hygiene is the most important plan for efficient control of subgingival and supragingival plaque which, in turn, is important for the prevention of caries and periodontal disease. For people with mental or physical limitations who can’t adequately undertake efficient oral hygiene procedures alone, it is important there is assistance with day-to-day oral hygiene by a care provider. More frequent visits to the dentist and the use of an electric toothbrush should be considered with such patients. Prompt restorative care and routine check-ups by a dental professional should be actively promoted.

With the realization of microbial specificity of such infections, systemic antibiotics and topical antiseptics play a vital role in the treatment and control of periodontal disease and dental caries.

The necessity for dental extractions was considerably reduced by the obtainability of improved restorative materials, like fluoride-releasing and bonding agents, and improved dental restorative care.

Dental caries– Management of dental caries along with restorative therapy (i.e. fillings) is the preferred treatment approach in multiple countries. But, restorative therapy has to be blended with preventive measures, as restorations possess brief durability and new dental caries might form in the margins of restorations if the causes of the disease persists.

Pulpitis – Inflammation of the dental pulp, or pulpitis, happens as progression of caries. The dental pulp becomes exposed, resulting in infection. The dominant and early symptom of acute pulpitis is a serious toothache which may be elicited by thermal changes, particularly cool drinks.

Irreversible pulpitis will be characterized by intense and acute pain, and is among the most common reasons for individuals requiring emergency care. Aside from tooth removal, the usual approach to relieving irreversible pulpitis pain is drilling inside the tooth, getting rid of the nerve (inflamed pulp), as well as root canal cleaning.

Acute gingivitis– This will rarely require systemic antimicrobial treatment. Chlorhexidine 0.12% oral rinse may be utilized in many instances. Exceptions involve individuals who have severe pain, rapidly advancing disease, or HIV infection where systemic treatment is indicated. Potential regimens involve metronidazole and penicillin, clindamycin, ampicillin-sulbactam, or amoxicillin-clavulanate.

Periodontitis– Because of microbial specificity within different types of periodontitis, specific kinds of serious periodontitis will be amenable to systemic antimicrobials, along with mechanical debridement (scaling & root planing). The approach has often obviated the necessity for extreme surgical periodontal tissue resection.

Efficacy of local antibiotic treatment alongside scaling and root planing in chronic periodontitis also has been assessed. Adjunctive local antibiotics were proven to substantially decrease the degree of periodontal detachment or pocket depth. Efficient agents involve 2% Arestub (minocycline spheres), 10% Atridox (doxycycline hyclate extend release liquid), as well as 25% Elyzol (metronidazole gel). The agents will release controlled portions of the antibiotic beneath the gum and are utilized alongside scaling and root planing to decrease the pocket depth in adult periodontitis.

With localized juvenile periodontitis, the systemic tetracycline treatment directed against a HACEK infection known as actinobacillus actinomycetemcomitans and blended with local periodontal therapy yielded outstanding results. Doxycycline or tetracycline administration to children 8 years of age or younger, unfortunately, may lead to staining of the permanent dentition and generally isn’t advised. Moreover, tetracycline resistance amongst periodontal pathogens was increasingly apparent.

Regular systemic antimicrobials used to avoid postoperative infections after periodontal and/or oral surgery in a healthy host does remain controversial.

Suppurative odontogenic infections– The most vital treatment modality for pyogenic odontogenic infections includes surgical removal and drainage of necrotic tissue. A needle aspiration by the extra oral route may be especially useful for evacuation of pus and microbiologic sampling alike. The necessity for extraction or definitive restoration of an infected tooth, the main infection source, is usually readily apparent. Endodontic therapy using root filling and deep periodontal scaling is needed in most cases.

Antibiotic therapy– It might stop local infection spread, as well as prevent hematogenous dissemination. The antimicrobial agents are generally indicated if regional lymphadenopathy and fever are present, or if the infection has perforated the bony cortex, and spread to the surrounding soft tissue. Seriously immunocompromised individuals are especially at risk of orofacial infections spreading; empiric broad spectrum antimicrobial treatment with these individuals is warranted.

The option of certain antibiotics for the treatment of odontogenic infections is based on knowledge of the indigenous organisms colonizing the mucous membranes, gums and teeth, as well as certain periodontopathic and cariogenic pathogens related to medical disease, instead of on the results of susceptibility and culture testing.

The production of beta-lactamase amongst oral anaerobes, especially pigmented Fusobacterium spp and Prevotella spp, is highly recognized, and therapy failure with penicillin by itself was well documented. Therefore, penicillin monotherapy is no longer advised.

Ampicillin-sulbactam (three grams IV every 6 hours) offers prolonged coverage against anaerobes, involving the ones which produce beta-lactamases, and is also the therapy of choice. One alternative is penicillin G (two to four million units IV each 4-6 hours) along with metronidazole (500 milligrams IV or orally each 8 hours).

Even though metronidazole is extremely active against anaerobic gram-negative spirochetes and bacilli, it’s only moderately active to anaerobic cocci and isn’t active against aerobes that include streptococci. Consequently, it shouldn’t be used solely in odontogenic infections except with advanced periodontitis and acute necrotizing gingivitis.

Patients who are allergic to penicillin should be treated using clindamycin (600 milligrams IV each 8 hours). Tetracycline and erythromycin aren’t advised due to increasing resistance amongst a few streptococci strains and their loss of optimal anaerobic activity.

Osteomyelitis– Treatment of osteomyelitis of the jaw will be complicated by the existence of teeth and consistent oral environment exposure. Antibiotic treatment must be extended, often from weeks to months.

If available, adjuvant treatment using hyperbaric oxygen might hasten the process of healing, especially if combined with surgery, yet information that supports this is inconclusive.

Surgical management that includes closed-wound suction irrigation, decortication, saucerization, and sequestrectomy is occasionally needed. On rare occasions, in advanced cases, the whole infected jaw segment must be resected.