Management of complex multi-space odontogenic infections.

The successful management of multi-space orofacial odontogenic infections involves identification of the source of the infection, the anatomical spaces encountered, the predominant microorganisms that are found during the various stages of odontogenic fascial space infection, the impact of the infectious process on defense systems, the ability to use and interpret laboratory data and imaging studies, and a thorough understanding of contemporary antibiotic and supportive care. The therapeutic goals, when managing multi-space odontogenic infections, are to restore form and/or function while limiting patient disability and preventing recurrence. Odontogenic infections are commonly the result of pericoronitis, carious teeth with pulpal exposure, periodontitis, or complications of dental procedures. The second and third molars are frequently the etiology of these multi-space odontogenic infections. Of the two teeth, the third molar is the more frequent source of infection. Diagnostic imaging modalities are selected based on the patient's history, clinical presentation, physical findings and laboratory results. Periapical and panoramic x-rays are reliable initial screening instruments used in determining etiology. Magnetic resonance imaging and computed tomography are ideal imaging studies that permit assessment of the soft tissue involvement to include determining fluid collections, distinguishing abscess from cellulitis, and offering insight as to airway patency. Antibiotics are administered to assist the host immune system's effort to control and eliminate invading microorganisms. Early infections, first three (3) days of symptoms, are primarily caused by aerobic streptococci which are sensitive to penicillin. Amoxicillin is classified as an extended spectrum penicillin. The addition of clavulanic acid to amoxicillin (Augmentin) increases the spectrum to staphylococcus and other anaerobes by conferring beta-lactamase resistance. In late infections, more than three (3) days of symptoms, the predominant microorganisms are anaerobes, predominantly Peptostreptococcus, Fusobacterium, or Bacteroides, that are resistant to penicillin. Clindamycin is an attractive alternative drug for first line therapy in the treatment of these infections. The addition of metronidazole to penicillin is also an excellent treatment choice. Alternatively, Unasyn (Ampicillin/Sublactam), should be considered. The mainstay of management of these infections remains appropriate culture for bacterial identification, timely and aggressive incision and drainage, and removal of the etiology. It is usually preferable to drain multi-space infections involving the submandibular, submental, masseteric, pterygomandibular, temporal, and/or lateral pharyngeal masticator spaces, as early as possible from an extraoral approach. Trismus and airway management are important considerations and may preclude the selection of other surgical approaches. The patients with multi-space infections should be hospitalized and patient care provided by experienced clinicians capable of management of airway problems, in administration of parenteral antibiotics and fluids, utilization of interpretation of laboratory and diagnostic imaging studies, and control of possible surgical complications.