Odontogenic & Maxillofacial Infections

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CELLULITIS AND ALL DEEP SPACE INFECTIONS

CLINICAL DESCRIPTION

In this category the most important is Ludwig's angina. This is an inflammation of floor of the mouth and other related structures − This is a life−threatening condition, starts as a unilateral swelling of soft tissues around lower mandible usually arising from the lower second or third molars. The infection spreads to other tissues crossing the midline and becomes bilateral swelling. 

CLINICAL FEATURESSIGNS AND SYMPTOMS

  • Patients presents with rapid progressive swelling, difficulty in breathing, elevated tongue, drooling, difficulty in swallowing (dysphagia), bilateral facial space involvement, elevated temperature, severe jaw trismus (<10 mm), toxic appearance, compromised host defense, patient is dehydrated, weak and febrile.

INVESTIGATIONS

  • FBC
  • Culture and sensitivity
  • Skull views

TREATMENTNON-PHARMACOLOGICAL

  • Admit patient
  • Assess the patient for vital signs
  • Ensure airway patency
  • Removal of the cause
  • Extraction of the offending tooth or
  • Treat the tooth endodontically with root canal therapy
  • Sequestrectomy (removal of necrotic bone)
  • Keep patient hydrated (2-3L Fluids/24 hours for maintenance)
  • Encourage high-calorie food intake

PHARMACOLOGICAL 

  • Give analgesics for pain relief
  • Prescribe appropriate antibiotics for rapidly progressive swelling as follows:
    • Give Amoxycillin 250 mg - 500 mg 8 hourly for 7 days or Benzylpenicillin 0.5 - 2.0 MU IM or IV 6 hourly for 7 days plus
    • Give Metronidazole 200 mg - 400 mg 8 hourly or 7 days or Metronidazole 250 mg-500 mg IV 8 hourly for 7 days
  • If patient is allergic to penicillin
    • Give Erythromycin 250 mg - 500 mg 8 hourly (after food) for 7 days or
    • Give Clindamycin 150 mg - 300 mg (plus Metronidazole as above)
  • If severe difficulty in breathing perform tracheostomy
    • If the condition persists after a long time of first line antibiotic, give Ceftriaxone 2g od for 5 days 

Note: Antibiotics are indicated for diffuse swelling, compromised host defenses, involvement of fascial spaces, severe pericoronitis, osteomyelitis                  

At Health Centre level refer the patient to a district hospital

 

SALIVARY GLAND DISEASE

RETENTION CYSTS, THYROGLOSSAL DUCT CYSTS, BRACHIAL CLEFT CYSTS, ENLARGEMENTS, RANULAS ETC

CLINICAL DESCRIPTION

A cyst is an enclosed sac formed by the cluster of cells which group together. 

CLINICAL FEATURESSIGNS AND SYMPTOMS

  • Tooth sensitivity, swelling, tooth displacement, unexplained tooth mobility, numbness, or tenderness

INVESTIGATIONS

  • Skull views (PA, LO, TL, OPG)
  • Occlusal views
  • Ultrasound scan
  • CT scan or MRI

TREATMENT

  • Surgical procedure (if indicated)
  • Give Ciprofloxacin 250 - 500 mg 12 hourly for at least 5 days plus
  • Give Metronidazole 200 - 400 mg 8 hourly for at least 5 days if there is infection

 

MUMPS (EPIDEMIC PAROTITIS)

CLINICAL DESCRIPTION

Mumps is a contagious disease caused by a filterable virus. The parotid glands are the salivary glands most involved with mumps, but the sublingual and submandibular glands may also be affected. In 75-80% of cases both glands are involved. 

CLINICAL FEATURES

SIGNS AND SYMPTOMS

  • Swelling of the involved gland, Redness and slight swelling of the duct opening, Displacement of the auricle, the secretions are not purulent. Sometimes there is fever

INVESTIGATIONS

  • FBC
  • Diagnosis is clinical

TREATMENTOBJECTIVES

  • Relieve symptoms

NON-PHARMACOLOGICAL

  • Massage the gland

PHARMACOLOGICAL

  • Paracetamol
    • Children 30 - 40 mg/kg/24 hr. divided into 4 – 6 doses
    • Adults 1g PO 8 hourly or PRN

ALTERNATIVES

  • Tramadol 100 mg PO 8 hourly. PRN for adults.
  • ADRs: dependence, abdominal pain, anorexia, central nervous, stimulation, vertigo, skin rashes, sweating and vomiting. C/Is: Respiratory depression, in the presence of acute alcoholism, head injury, during pregnancy and lactation

Note. Not recommended for children below 12 years of age  

 

ACUTE AND NON-CHRONIC NON-OBSTRUCTIVE SUPPURATIVE SIALADENITIS

CLINICAL DESCRIPTION

Acute bacterial infection of the salivary glands usually involves the paratoid glands. This condition is usually seen in debilitating patients. The usual causative organism is Staphylococcus aureus.

CLINICAL FEATURESSIGNS AND SYMPTOMS

Pain and swelling of the involved gland

  • Purulent secretions can be expressed from the orifice of the duct
  • Fever

INVESTIGATIONS 

  • Sialography shows a tree in leaf appearance
  • FBC
  • Tissue should be taken for histology in doubtful cases

TREATMENTNON-PHARMACOLOGICAL 

  • Bed rest
  • Restricted jaw movement

PHARMACOLOGICAL

  • Clindamycin 150 to 300 mg PO 6 hourly or 300 mg IM or IV 6 hourly  
  • In severe infections 20 mg/kg/24hr. IM or IV into 4 doses

ALTERNATIVELY

  • Cloxacillin 500 mg PO 12 hourly for 7 – 10 days

OR 

  • Cephalexin: Adults 50 mg to 1 gm 6 hourly PO for 7-10 days 
  • Children 6 to 12 mg/kg PO 6 hourly. Maximum 25 mg/kg 6 hourly

 

TRIGEMINAL AND GLOSSOPHARYNGEAL NEURALGIA

CLINICAL DESCRIPTION

Trigeminal neuralgia (TN), also called tic douloureux, is a chronic pain condition that affects the trigeminal or 5th cranial nerve, one of the most widely distributed nerves in the head. The intensity of pain can be physically and mentally incapacitating.

Clinical FeaturesSIGNS AND SYMPTOMS

  • Unilateral pain with a trigger zone

INVESTIGATIONS

  • CT Scan or MRI

TreatmentPHARMACOLOGICAL 

  • Give Carbamazepine 100 mg 12 hourly for a month then review
  • Give Phenytoin 300 mg -500 mg 12 hourly per day, can be administered by IV
  • for severe TN pain
  • Give Gabapentin 300 mg 8 hourly Give Baclofen 5 mg 12 hourly or 8 hourly   a day which can be increased
    • Usual effective dose is 50-60 mg per day
    • Can be used alone or in combination with Carbamazepine

Note: If trigeminal neuralgia persists after 2 months refer to neurosurgery