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# 20. Tooth # 17 was extracted as well. The The purpose of this article is to not only shed documented that there is no significant dif-
patient was left intubated until the next day light on the application of basic principles, ference in resolution of infection rates in
due to airway edema. After significant reso- but also to call attention to the principles patients who received shorter (3 to 4 days)
lution of the swelling, infection, edema, and that were missed in managing this patient versus longer (7 days) course of antibiotic
positive cuff leak test, he was successfully that led to his second hospital admission. therapy, as long as they underwent surgical
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extubated. His WBC returned to normal. He treatment. In the absence of surgical treat-
remained off intravenous antibiotics. Drains Discussion: ment, administration of antibiotics does not
were advanced and removed. The patient The patient’s first admission to the hospital necessarily prevent the deterioration of the
was discharged from the hospital in stable resulted from the progressively worsening infection. 1,2,4 The penetration of antibiot-
condition. He followed up every week for swelling of his neck and tongue, dysphagia, ics into the infected region is low until the
four weeks as an outpatient and had com- limited mouth opening, and shortness of abscess is surgically drained. Furthermore,
pletely healed. breath. He had a low-grade fever, and his surgically draining the infection aids in re-
WBC was elevated. CT scan revealed a left ducing the bacterial load and alters the envi-
Principles of Management of Odontogen- posterior retropharyngeal abscess extending ronment from anaerobic to aerobic, thereby
ic Infection: from an abscess in the left floor of mouth allowing resolution. 5
Odontogenic infections are one of the most along the mandible, with narrowing of the
common pathologies of the maxillofacial upper airway. Fluid collection with rim en- The purpose of this case report is to increase
region. They arise from the teeth due to hancing effect in the left anterior floor of awareness pertaining to the management
caries, pulp and periodontal disease. If left mouth measuring 3.0 x 1.2 cm, communi- of odontogenic infections and educate oral
untreated the infectious process will erode cating with the posterior floor of mouth, col- healthcare providers of the importance of es-
and extend beyond the alveolar bone into lection measuring 1.7 x 1.0 cm. The patient tablishing surgical drainage of an infection
the fascial spaces. The severity of infec- was admitted to the ICU for airway mon- to prevent life-threatening complications.
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tions may range from low grade requiring itoring. Given his immunocompromised References
minimal intervention to high grade that can state due to the history of MCD, use of 1. Ogle OE. Odontogenic Infections. Dent Clin
be life-threatening warranting aggressive cyclophosphamide and prednisone, he was North Am. 2017 Apr;61(2):235-252.
management. As oral healthcare provid- started on intravenous antibiotics vancomy- 2. Flynn TR: Principles of management and pre-
2
ers, it is certainly important to understand cin and Zosyn. Fiberoptic scope exam noted vention of odontogenic infections. In: Hupp JR,
the basic principles of management of an moderate swelling of the left floor of mouth Ellis E (eds), Tucker MR. Contemporary oral
and no drainable abscess. The next day, ul-
odontogenic infection. The eight steps in the trasonographic examination of the neck was and maxillofacial Surgery, 6th ed. St. Louis, MO:
treatment of odontogenic infection include: 2 completed. However, it resulted into inabil- Mosby Elsevier, 296-318, 2014.
1) Determination of the severity of infec- ity to visualize the known retropharyngeal 3. Flynn TR. What are the antibiotics of choice
tion: involves determining anatomic lo- abscess. The patient remained in the ICU. for odontogenic infections, and how long should
cation of the abscess, rate of progression, Antibiotics were switched to Unasyn. On the treatment course last? Oral Maxillofac Surg
Clin North Am. 2011 Nov;23(4):519-36.
and potential for airway compromise. day five, he was discharged due to improve- 4. Katoumas K, Anterriotis D, Fyrgiola M, Li-
2) Evaluation of the patient’s host defens- ment in his clinical exam and normal WBC. anou V, Triantafylou D, Dimopoulos I. Epide-
es: includes knowing thorough medical The patient did not receive surgical drain- miological analysis of management of severe
history and medications, taking into age of the abscess during his admission. odontogenic infections before referral to the
account the patient’s immune system to emergency department. J Craniomaxillofac Surg.
estimate the patient’s ability to mount Six days later, the patient returned to the 2019 Aug;47(8):1292-1299.
an immune response against infection. emergency room of a different hospital with 5. Japanese Association for Infectious Disease/
3) Decision on the setting of care: wheth- worsening neck swelling and was admitted Japanese Society of Chemotherapy; JAID/JSC
er the patient should be managed by a for the second time. His clinical exam was Committee for Developing Treatment Guide and
general dentist or an oral and maxillo- concerning for a multi-space neck infec- Guidelines for Clinical Management of Infec-
tious Disease; Odontogenic Infection Working
facial surgeon, outpatient vs. inpatient tion secondary to an odontogenic source. Group. The 2016 JAID/JSC guidelines for clin-
admission. His CT findings were consistent with the ical management of infectious disease-Odon-
4) Surgical management: can range from clinical exam. The patient was emergently togenic infections. J Infect Chemother. 2018
endodontic access opening to extraction taken to the operating room for incision and May;24(5):320-324.
with or without incision and drainage, drainage of multiple neck space abscess and
to aggressive surgical debridement. extraction of necrotic tooth. Post operative- Dr. Pooja Gangwani is
5) Medical management: comprises of ly, he remained in the hospital for medical a Board Certified Oral
control and optimization of systemic management, intravenous antibiotics, and & Maxillofacial Surgeon
medical conditions, and managing sys- close monitoring. Significant improvement and an Assistant Professor
temic manifestations. resulted in his discharge on day five. The at the University of
6) Prescribing appropriate antibiotics: most important aspect of his care during the Rochester Medical Center.
empirical therapy, if needed, guided by second hospital admission was performing She is a full-time faculty
culture and sensitivity. the surgical drainage. member in a residency
7) Administering antibiotics via the ap- program.
propriate route at therapeutic doses: Antibiotic therapy is an adjunct to surgical
the peak plasma level of the antibiot- treatment in management of odontogenic
ics should be at least four or five times infections. She cares for patients with maxillofacial
the minimal inhibitory concentration trauma and jaw deformities. In addition,
(MIC) for the bacteria. Studies have shown that in patients receiv- Dr. Gangwani has contributed several
8) Frequent evaluation of the patient: lack ing incision and drainage and/or extraction journal articles and book chapters
of improvement or patient deterioration or endodontic therapy on an offending to the professional literature. She is
indicates failure of treatment. tooth, the choice of antibiotics does not af- named co-editor for the special series
fect the cure rates. Similarly, studies have titled “Virtual Surgical Planning in
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Maxillofacial Surgery.”
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