1
Q
What bacteria makes up most oral infections?
A
MIXED in origin (aeroic and anaerobic gram + and -)
Anaerobes predominate (75%)
2
Q
What bacteria makes up acute infections (edema)?
A
Gram + aerobes
3
Q
What bacteria make up mixed infections (cellulitis)?
A
G+ aerobes decrease and anaerobes increase
4
Q
What bacteria make up chronic infection (abscess)?
A
Anaerobes predominate
5
Q
What are classic signs of inflammation?
A
Dolor - pain
Tumor - swelling
Calor - warmth
Rubor - redness
Loss of function
- Trismus (difficulty opening mouth)
- Difficulty breathing, swallowing, and chewing (emergencies)
6
Q
What is cellulitis?
A
diffuse, reddened, brawny (hard) swelling, tender to palpation
- Inflammatory response has not yet formed a true abscess
- Microorganisms have just begun overcoming host defense and spread beyond tissue planes
Tx: I&D and Ab
7
Q
What is an abscess?
A
Localized collection of pus that occurs as inflammatory response matures
- Can develop intraoral or extraoral drainage (body forms drain for you)
- Fluctuant Swelling (soft center)
8
Q
What is the most definitive tx for dental infection?
A
REMOVE THE CAUSE OF INFECTION
- Pulpectomy, extraction, remove foreign body, debride non-viable bone
9
Q
What are other tx options fo rdental infection?
A
- Establish drainage Via I&D
- Prescribe appropriate Abs
- Supportive care - rest and nutrition
- Re-eval frequently
10
Q
What is the main objective of performing I&D?
A
Allow for adequate drainage of pus
- Reduce tissue tension
- Increase blood flow
- Increase delivery of host defence
- Obtain specimen for culture and sensitivity (C&S) to see what bacteria is present and what Ab will work best
11
Q
When you do an I&D, you have seen puss ( alfredo sauce) what do you do with it beside suction it out?
A
Need to send to lab for C&S to determine what bacteria is present and what Ab will work best
- Gram staining for early dx and guiding Ab therapy
12
Q
What types of I&D’s are ALWAYS sent to the lab?
A
Always done when extra-oral I&D is used and/or I&D in hospital setting
- Not always done for early stage intra-oral I&D
13
Q
Indications for antibiotic treatment of odontogenic infection are?
A
Rapidly progressive swelling
Diffuse swelling (cellulitis)
Fascial space involvement
Compromised host defenses
Severe pericoronitis
Osteomyelitis
Trauma
14
Q
Steps of abx for pus?
A
- Use gram stain of pus
- Use general abx as lab is processing CNS –
- If you cannot wait for culture results, you begin empiric therapy—choosing an antibiotic based on the most likely pathogens and standard guidelines. Once sensitivity results are available, you switch to a more specific agent if needed.
- Even during empiric treatment, choose the antibiotic with the least broad coverage that will still treat the likely organisms. This minimizes unnecessary resistance and limits side effects.
- based on the causative organism and sensitivity can determine if gram + or gram - - After results, can move to a more specific abx
15
Q
Is it better to use a narrow spectrum or broad spectrum abx?
A
Narrow spectrum
16
Q
How do narrow spectrum abx work?
A
A narrow-spectrum antibiotic targets a limited group of bacteria. This is ideal because it preserves the normal microbial flora, reduces the risk of resistance, and focuses treatment on the actual organism causing the infection.
17
Q
Is bactericida or bacteriostatic preferred?
A
Bactericidal antibiotics kill bacteria outright rather than just inhibiting growth. These are preferred especially in serious infections, immunocompromised patients, or when rapid bacterial elimination is desired
18
Q
How does odontogenic infection spread?
A
Equally in ALL direction
- Can spread from original site to areas of head and neck and become life threatening
19
Q
What tissue do odontogenic infections involve?
A
Soft tissue/ fascial spaces - more common
Osseous structures (osteomyelitis) - less common
Vital structures
20
Q
What are odontogenic facial infections most present as?
A
Vestibular space abscess
21
Q
What path do odontogenic facial infections favor?
A
Path of LEAST resistance
22
Q
What is the path of least resistance determined by?
A
- Anatomical location of teeth
- Muscle attachments
- Thickness of bone at apex
Lingual plate is normally thinner than buccal
23
Q
What are fascial spaces?
A
potential spaces between fascia and underlying organs/tissues
24
Q
Where do fascial spaces NOT exist?
A
Healthy spaces
- exist when extended by fluid or infections
25
What do fascial spaces allow for?
Infection to spread from one area to the adjoining ones
26
What are the boundaries to the fascial spaces?
Fascial layers/planes, muscles, bone, skin, mucous membrane
27
What is the primary facial space?
the fascial space in the head and neck that is the first to be affected by an infection
28
What are the primary maxillary spaces?
Canine/infraorbital
Buccal
Infratemporal
29
What are the primary mandibular spaces?
Sublingual
Submandibular
Submental
Buccal
30
Where are canine/infraorbital spaces?
Usually from canine root apices
31
What are side effects of canine/infraorbital spaces?
Will not be able to open eye wall
32
Where can canine/infraorbital infections spread to?
Brain via cavernous sinus thrombosis
33
I&Ds are ______ and ________ dependent
Intra-oral; gravity
- Placed at depth of maxillary labial vestibule adjacent to tooth causing infection
34
Where are buccal infections located?
- Between buccinator muscle and overlying skin and superficial fascia
- Can be from UPPER and LOWER molars
35
What occurs if you have low muscle attachment and a buccal infection?
Spreads more laterally into this space
36
What are tx for buccal infections?
Intraoral I&D through depth of buccal sulcus adjacent to tooth causing infection
37
Where are infratemporal infections?
Posterior maxillary teeth
38
What are tx for infratemporal infections?
Refer to OS
Needs Extra-oral I&D
39
Where are sublingual infections?
In lingual aspect from ABOVE mylohyoid muscle
- Usually mand PMs or M1
40
What is tx for sublingual infections?
Need intra-oral I&D (goes against gravity)
41
Where do submandibular infections occur?
Infection from BELOW mylohyoid muscle
- More likely to be Mand M2 and M3 based on mylohyoid muscle attachment
42
What is tx for submandibular infections?
Extra-oral I&D and its gravity dependent
43
Where do submental infections occur?
anterior mandible
below mylohyoid muscle
44
What is tx for submandibular infection?
Need extra-oral I&D and its gravity dependent
45
Where do buccal infections occur?
Max and mand teeth
46
What is a secondary infection?
The "new" space that becomes infected after spread from primary
47
What are secondary fascial spaces?
Masticator (Sub-masseteric)
Pterygomandibular
Superficial and deep temporal
Lateral pharyngeal
Retropharyngeal
Prevertebral
48
What is the progression of bactera/puss traveling?
1. Masticator space → lateral pharyngeal space → retropharyngeal space → danger space → Mediastinitis
Mediastinitis is infection of the mediastinum, the area in the chest containing the heart, great vessels, and trachea
2. Submandibular space → Submental space → contralateral submental space → sublingual Ludwig's angina → airway obstruction
3. Canine space → infraorbital space → angular vein → cavernous sinus thrombosis
49
What are radiographic/imaging for complex odontogenic infection?
Periapical
Pano
Plain films
CT with contrast
- Helps delineate position and size of infection as well as relation to adjacent structures
- Also helpful to evaluate changes to upper airway
- Rim enhancement around infected area
50
What’s the purpose of complete blood count with differential?
When there is a large outpouring of immature granulocytes (high WBC), this indicates a severe infection
51
What is ludwigs angina?
fulminating, BILATERAL sublingual, submandibular, submental, and cervical infection or cellulitis displacing the tongue with potential airway obstruction
LIFE THREATENING
52
What are ludwigs angina from?
Periapical abscess on lower molars
53
What is cavernous sinus thrombosis?
serious condition recognized by marked edema and congestion of eyelids and conjunctiva as a result of impaired venous drainage
- Not as common as Ludwigs
54
What does cavernous sinus thrombosis start at?
Unilateral and becomes bilateral
55
What is the pathophysiology of cavernous sinus thrombosis?
Hematogenous (blood) spread of infection from jaw to cavernous sinus occurs anteriorly via inferior or superior ophthalmic vein or posteriorly via emissary veins from pterygoid plexus
56
What are signs and symptoms of cavernous sinus thrombosis?
(almost all have to do with eyes)
- Ocular pain
- High fluctuating fever, chills, sweat
- Periorbital and conjunctival edema (swelling around the eyes), starts unilateral and progresses to bilateral as a result of thrombophlebitis (blood clot)
- Pulsating exophthalmos (buldging of eyes) and retinal haemorrhage (bleeding/ broken blood vessels)
- Ophthalmoplegia (weakness of eye muscle), paralysis, dilated pupils, and loss of corneal reflex (inability for both eyes to blink)
- Other cranial nerve involvement e.g. trigeminal nerve
57
What is osteomyelitis?
Inflammation and infection of bone MARROW
58
How does osteomyelitis occur?
- Starts in medullary bone and continues to adjacent cortical plates and periosteum
- Follows indolent (little pain), yet progressive and persistent course
- If untreated progresses from inflammation to destruction of bone, to necrosis (sequestra)
59
Where does osteomyelitis more commonly occur in the mouth? Why?
Mandible due to dense, poorly vascularized cortical plates
- Mostly supplied by IA neurovascular bundle
- Thick overlying cortical playes
- Maxilla is less dense with excellent blood supply -- Blood supply from several arteries
60
What patients does osteomyelitis occur in?
Immunocompromised
Patients that have conditions affecting jaw vascularity
Pathogenesis
Increased change with increased age due to decreased endosteal blood supply
61
What immunocompromised patients does osteomyelitis occur in?
DM
Malignancy
AIDS
Chronic steroids and chemotheraputic agents
Immunosuppresents
TB
62
What are examples of patients that have conditions affecting jaw vascularity?
H/O irradiation tx to jaw
Advanced osteoporosis
Osteopetrosis
Late stage cemento-osseous dysplasia
Osteitis deformans (Paget's disease)
63
What are examples of patients that have pathogenesis?
Result of infection or trauma, allowing inoculation of bacteria in jaws
Usually self limiting in healthy patient but if progresses, considered pathologic
Will spread until stopped by surgery and medical tx
64
How is facial bone osteomyelitis different from long bone osteomyelitis?
Mixed infection when involving jaws
65
What bacteria causes facial bone osteomyelitis? Long bone osteomyelitis?
Facial: Alpha Hemolytic Streptococci and anaerobic bacteria (Peptostreptococcus, Fusobacterium, and Prevotella) are primary pathogens
Long bone: staphylococcus
66
In the Acute phase of Osteomyelitis, what laboratory should be ordered?
CBC for acute phase (< 1 month)
67
What do you expect to see in the acute phase of osteomyelitis CBC?
Common to see leukocytosis (increased WBC) which is uncommon in chronic phase
Elevated ESR and CRP = indicators for inflammation
68
What are a good way to evaluate osteomyelitis?
Xrays (including pano) are used but lag behind the disease process BECAUSE Bone must lose 30-60% of mineral content before changes become visible on xray and early osteomyelitis is bone marrow and soft tissue inflammation so not enough bone destruction yet (xrays detect hard tissue density)
69
What does ACUTE osteomyelitis appear on xray?
Typically normal in early stages.
Reason: Not enough bone loss yet to be detectable.
Clinical signs (pain, swelling, fever) appear before radiographic signs.
70
What does CHRONIC osteomyelitis appear on xray?
Once enough bone has been destroyed, X-rays can show classic changes:
“Moth-eaten” appearance → areas of irregular bone destruction.
Possible sequestra (dead bone pieces), sclerosis (reactive bone), and periosteal thickening.
X-rays and panos are good for initial evaluation, but limited for early detection.
71
What is the standard of imaging for osteomyelitis? Why?
CT is the standard imaging for assessing bone because it:
Provides 3-D views of the area.
Shows cortical bone involvement much better than MRI or X-ray.
Helps identify sequestra, osteolytic areas, and extent of necrosis.
72
What are the downfalls of CT scan?
CT still requires ~30–50% demineralization before bone destruction is visible, so it is not the best for very early osteomyelitis
73
What is the best modality for EARLY osteomyelitis detection?
MRI
It shows bone marrow edema, which appears BEFORE bone is destroyed.
Excellent for evaluating soft tissue involvement, abscesses, and spread of infection.
You can see infection prior to cortical changes.
MRI does not require mineral loss—its strength is detecting fluid and inflammation, not density.
74
How does nuckear medicie detect?
Radionuclides such as technetium-99m which highlights areas of increased bone turnover
75
What is tx for osteomyelitis?
Need BOTH medical and surgical tx
- Medical alone with only delay approp tx
- Need to send tissue from affected site for microbial exam, C&S, and histopath to get best Ab and ensure it is not malignant
76
What is medical tx for osteomyelitis?
1. Begin empiric Ab based on Gram stain results
2. Then get on BEST Ab following C&S results (takes several days)
3. IV Ab therapy for 6 weeks
- Includes carbapenems, cephalosporins, fluoroquinolones, Clindamycin, Metronidazole, or combination therapy
77
What is tx for chronic refractory osteomyelitis?
Hyperbaric oxygen chamber
- 100% oxygen chamber at increased atmospheric pressure for 90 min x 50 days/week for 20-60 tx
78
How do you know you have chronic refractory osteomyelitis?
Persistent or recurrent bone infection lasting longer than 6 months despite surgical and medical tx
79
What is surgical tx of osteomyelitis?
Sequestrectomy
Saucerizaiton
Decortication
Segmental resection
80
What is sequestrectomy?
removal of infected and avascular pieces of bone
- Ab will not be able to penetrate into this since it is avascular
81
What is saucerization?
removal of adjacent bony cortices and open packing to permit healing by secondary intention after infected bone is removed
- Leaves a saucer shaped defect instead of deep hollow cavity
- Saucer cannot accumulate a large clot
82
What is decortication?
removal of dense, chronically infected, and poorly vascularized bony cortex and placement of vascular periosteum adjacent to medullary bone to increase blood flow and healing in affected area
KEY: cuts back to healthy, bleeding bone
83
What is segmental resection?
Remove complete section of mandible
84
How do you treat dead bone (sequestrum)?
Sequestrectomy --> removal of infected and avascular pieces of bone
- Need to remove all necrotic bone until establish bleeding, healthy bone
85
What is excisional biopsy?
total excision for microscopic study
86
What is incisional biopsy?
Removal of part of lesions
87
What is excisional biopsy used for?
- For slow growing lesions that appear benign and are small
- Involves a small perimeter (2-3 mm) of normal tissue to ensure total removal
- Removal of entire lesion (acts as definitive tx)
- Able to send off and confirm dx
88
What are incisional biopsy used for?
- For too large of lesions and for established diagnosis when suspicious of malignancy -prior to definitive tx
- Need a representative area of lesion in wedge fashion
- Shows complete tissue change and extends into normal tissue at base or margin
- Avoid necrotic tissue
- Taken from edge of lesion
- Deep, narrow biopsy
89
Aspirational biopsy? How does it work and what “instrument” do you use?
- Use of 18 gauge needle and syringe (5 or 10 mL) to penetrate lesion and aspirate content
- Carried out on ALL lesions containing fluid or any intra-osseous lesion before surgical exploration
- Aspirated to determine contents of fluctuant mass in soft tissue
90
What are aspirational biopsys used for?
rule out vascular lesion that could cause life-threatening hemorrhage
91
What is a punch biopsy?
Surgical instrument used to punch out a representative portion of tissue
- Circular blade attached to plastic handle
- 2-10 mm of diameter
- Removes a core of tissue at the base which can be simply and atraumatically released using curved scissors
- May not require sutures if small diameter punch
92
What is the liquid in the biopsy jar?
10% Formalin fixation (Neutral, Phosphate buffered) solution
- Specimen should be totally immersed
- Fixation solution stops tissue autolysis prior to sample reaching pathology lab
93
What is an odontogenic cyst?
Benign pathological cavity within bone or soft tissue
94
What is the histology of odontogenic cyst?
Lumen: contains fluids, keratin, or cellular debris
Lined by epithelium for cysts in oral region
Formed by CT wall
95
What is an odontogenic cyst lined with?
lining of lumen is derived from epithelium produced during tooth development
- derived from tissues of developing teeth
96
What are types of odontogenic cysts?
Includes Periapical cyst, dentigerous cyst, residual cyst, and OKC
97
What are the ways to classify odontogenic cysts?
1. Histiogenic classification
2. Inflammatory vs developmental
98
What are odontogenic cysts derived from rest cell of Mallassez?
Periapical cyst
99
What are odontogenic cysts derived from reduced enamel epithelium?
Dentigerous cyst
100
What are odontogenic cysts derived from dental lamina (rest of serrae)?
Odontogenic Keratocyst
101
What are unclassified odontogenic cysts?
Paradental cyst
102
What are inflammatory vs developmental cysts?
Inflammatory: paradental cyst
Developmental: dentigerous cyst and odontogenic keratocyst
103
What is common tx for odontogenic cyst?
Currettage
Marsupilization
Marsupilization followed by cystectomy
Enucleation
Enucleation followed by Carnoy's Solution
Enucleation followed by Peripheral ostectomy
Surgical resection
104
What is curettage of odontogenic cyst?
Surgical scraping of cyst from bony walls with a curette instrument
Ex) after TE, we do this for PA lesions
If not taking tooth out, create a bony window to expose cyst and then curettage
105
What is marsupilization?
Marsupialization involves creating a surgical window in the cyst wall, evacuating its contents, and maintaining an opening to allow continuous drainage. This reduces intracystic pressure, allows the cyst to shrink, and promotes endosteal bone formation to fill the defect.
106
How does marsupilization work?
A window is opened in the cyst wall.
Cyst fluid drains → reduces pressure.
Cyst lining collapses + shrinks over time.
Bone gradually fills the space.
The opening is maintained using iodoform-soaked gauze or an acrylic plug to prevent oral contamination.
107
What are indications of marsupilization?
- Anatomically close to vital structures
- If access to cyst is difficult
- Young patient with dentigerous cyst to allow eruption of unerupted tooth
- For unhealthy or debilitated patients since simple and less stressful
- For very large cysts where fracture is a risk during enucleation
108
What are contraindications for marsupilization?
Recurrent OKC
Recurring cyst
Smaller cyst < 2x2 cm
109
What are adv and disadv of marsupilization?
Advantages
- Shorter operating time.
- Lower risk of jaw fracture in large lesions.
- Minimal blood loss.
- Shrinks cystic lining and reduces defect size.
- Promotes endosteal bone formation.
- Better preservation of the alveolar ridge, useful for future prosthetics or tooth eruption.
Disadvantages
- Pathologic tissue remains in the body (not completely removed).
- Cannot obtain histology of the entire cyst lining.
- Requires frequent postoperative care.
- Iodoform packing causes unpleasant taste/smell.
- Need for repeated pack changes or acrylic plug adjustments.
- Healing is slow and may require secondary surgery (e.g., later enucleation).
110
What are the stages of marsupilization followed by cystectomy?
Stage 1: Perform Marsupialization to decrease size of cystic cavity and reduce risk of intrabony defects
Stage 2: Then go in and remove the remaining cyst (cystectomy)
For large lesion on mandible
111
What is enucleation?
shelling out the entire cystic lesion without rupture
112
What is enucleation used for?
cysts that are not very large and have minimal risk of injuring vital structures
113
What are indications for enucleation?
Tx of common types of cyst
Recurrence of cyst
Any cyst in jaw that will not affect adjacent structures
114
What is the clinical appearance of an OKC?
painless, slow-growing swelling or expansion of jaw
115
What is the xray appearance of OKC?
most common in posterior mandible
- Well-defined unilocular or multi-locular radiolucent lesion with smooth, scalloped borders
- Can displace teeth
116
What is treatment for OKC?
Need to tx aggressively to prevent recurrence
117
What are tx options for OKC?
Enucleation followed by use of Carnoy’s solution: promotes a chemical necrosis and is composed of 60% ethanol, 30% chloroform, and 10% acetic acid
- Known to reduce rate of OKC recurrence
- FDA banned chloroform so now use modified Carnoy’s solution for OKCs
118
What is follow up for OKC?
2x a year for first year with pano
Annual basis for next 5 years
Then once every two years
119
How do odontogenic tumors derived?
From tissues of developing teeth
120
What are the classifications of odontogenic tumors based on origin?
- Odontogenic Epithelium
- Mixed
- Odontogenic Ectomesenchyme
121
What are the classifications of odontogenic tumors based onbiologic classification?
- benign, NO recurrence
- benign, some recurrence
- benign, aggressive
- malignant
122
What is surgical tx for odontogenic tumor?
Surgical management includes removal of tumor followed by appropriate method for reconstruction of defect
- Type of surgical approach employed is dependent on type (biologic behavior) and size of tumor
- Type of reconstruction is based on size and extend of defect
123
What are types of surgical removal for odontogenic tumors?
1. Enucleation
2. resection
124
How is enucleation of odontogenic tumor done?
Def: local removal of tumor by appropriate instrumentation in DIRECT contact with lesion
For simplest, benign tumors that are not super aggressive
125
How is resection of odontogenic tumor done?
Def: removal of tumor by incising through uninvolved tissues around tumor, delivering tumor withOUT direct contact
Aka en bloc resection
126
What are the types of resection for odontogenic tumors?
- Marginal (Segmental) resection: resection withOUT disruption of continuity of bone
- Partial resection: resection removing full-thickness portion of jaw so the jaw continuity is disrupted
Varies from small continuity defect to hemimandibulectomy
- Total resection: removal of involved bone
Hemimaxillectomy and hemi-mandibulectomy
- Composite resection: resection of tumor with bone, adjacent soft tissue, and contiguous lymph node channels
Used for malignant tumors
127
What are the demographics of ameloblastoma?
Middle aged people
128
What is tx for unicystic ameloblastoma?
enucleation and peripheral osteotomy if extension through cyst wall
129
What is tx for Classic infiltrative (aggressive) - Solid ameloblastoma in maxilla and mandible?
Mandible: adequate normal bone around resection
Maxilla: more aggressive with 1.5 cm margin
130
What is tx fir ameloblastic carcinoma?
radical surgical resection or neck dissection
131
What is demographic for adenomatoid odontogenic tumor (AOT)?
Teenagers
More common in females
132
What is tx for AOT?
Simple surgical enucleation due to rare recurrence
133
What is demographic for odontoma?
In teens or early 20s
134
What is tx for odontoma?
ELECTIVE surgery
Oral Surgery
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