Maxfacts

This section is essentially an overview of the infections which present to maxillofacial clinicians. Some are extremely common and require very little in the way of specialist input and others are rare.

Specific surgical infections such as cervicofacial abscesses or osteomyelitis are dealt with in the relevant sections.

Bacterial infections

Acute bacterial infections

Pericoronitis may just require débridement (removal of damaged tissue) of the affected area in uncomplicated cases if the tooth is to be retained. Any abscess should be drained. If there is obvious trauma from an opposing tooth that is otherwise non-functional, then removal of this tooth may allow resolution of the symptoms. The affected tooth can be reviewed and arrangements made for its removal, if indicated. If an antibacterial agent is required, a specific anaerobicidal such as metronidazole minimizes the risk of an unwanted candida infection.

Treatment of alveolar osteitis (dry socket) consists of irrigation of the socket and placement of an obtundent dressing (blunting pain and inflammation). This may be supplemented with metronidazole (antibacterial agent) 200 to 400 mg three times a day for three days to eradicate any secondary infection with anaerobic bacteria that is present. Diagnosis of alveolar osteitis and its treatment are further described in the respective sections about bone lesions.

Treatment of acute periodontal disease (inflammation of soft and hard tissues supporting teeth) must take into account the treatment of any underlying condition. Apart from this, treatment consists of debriding the relevant area and drainage. The important issue is whether this is achieved by removal of the tooth, or by retention of the tooth and cleaning out associated periodontal pockets.

Necrotising ulcerative gingivitis acutely mandates adequate analgesia (pain control) to allow adequate fluid intake and débridement (removal) of the affected tissue. Good oral hygiene is essential. This is supplemented by antibacterial therapy, metronidazole 200 to 400 mg three times a day is the initial drug of choice.

Noma, which is the severe debilitating version of necrotising ulcerative gingivitis in malnourished people, especially children, presents a chronic problem created by extreme, often absolute, trismus resulting from destruction of facial tissue that requires surgical division and reconstruction with robust vascularised tissue (the submental flap works well). This is a condition seen in extremely poor countries with widespread malnutrition and lack of simple healthcare interventions.

The treatment of dental and dentoalveolar abscesses is described on our pages about abscesses:

The treatment of acute osteomyelitis, an inflammation of bone of infective origin, is described on our pages about bone lesions:

Any bite wounds are likely to be inoculated with significant numbers of bacteria. Irrigation and debridement of a bite wound are therefore mandatory. The choice of antibacterial medication(s) is based on the likely infecting organisms. For animal and human bites, amoxycillin-clavulinic acid is the drug of choice. A clarithromycin and metronidazole combination is an alternative if somebody is allergic to penicillin. The tetanus immunisation status needs to be reviewed.

The treatment of acute salivary gland infections is described on our pages about salivary gland problems:

Treatment of the superficial skin infections impetigo and erysipelas consists of anti-staphylococcal antibacterials such as flucloxacillin.

The treatment of furuncles and carbuncles may require the drainage of any abscess present. Antistaphylococcal medication should be prescribed and face hygiene optimised. A combination of chlorhexidine and neomycin ) or mupirocin cream (a topical antibacterial agent) applied to the nares (nostrils) helps reduce staphylococcal carriage. When quiescent, any affected cyst should be excised.

Cat scratch disease usually does not require any specific therapy.

Chronic bacterial infections

There are recurrent (especially in children) and chronic forms of bacterial infections of the salivary glands; these are described on our pages about salivary gland problems / diagnosis and salivary gland problems / treatment.

There is a wide and bewildering range of chronic bacterial (and non-bacterial) forms of osteomyelitis; these conditions are described on our pages about bone lesions / diagnosis and bone lesions / treatment.

Treatment of actinomycosis involves prolonged, high-dose antibacterial medication . Depending on response this treatment may even need to be continued for 12 months. Penicillin is the drug of choice; erythromycin or clindamycin are used when somebody is allergic to penicillin. If there is significant bone involvement, then resection and saucerization of the involved bone are required. Older texts and some microbiologists advocate prolonged (6 weeks) intravenous administration of amoxycillin . Although this regimen can be achieved in some communities with highly developed outreach services, a high-dose oral equivalent has regularly been effective.

The treatment of mycobacterial infections is entirely dependent on the infecting microorganism. Mycobacterium tuberculosis responds to complex chemotherapy but atypical mycobacteria rarely do. Chemotherapy for tuberculosis is prolonged and involves optimising host factors and long-term combination chemotherapy. Currently used drugs include isoniazid, rifampicin, pyrazinamide and ethambutol. Treatment should be carried out by/with infectious disease specialists because of the increasing problem with drug resistance, especially secondary to poor compliance with treatment.

The treatment of infections with atypical mycobacteria, by contrast, is by excision of the affected gland. Anti-tuberculous medications are not particularly helpful, but long-term treatment with clarithromycin may improve resolution of non-discharging cervical (neck) lymph nodes.  

Penicillin is the drug of choice for the treatment of syphilis. Contact tracing may be required. The possibility of other sexually transmitted diseases, including HIV infection, should be considered.

Viral infections

Acute viral infections

Mumps is usually self-limiting; only potential complications may require treatment (though not in maxillofacial clinic).

Epstein-Barr virus infection is typically self-limiting and there is no need for specific therapy, apart from supportive treatment such as analgesia and fluid support.

Cytomegalovirus infection is treated with antiviral agents, aciclovir or ganciclovir.

Primary varicella-zoster infection gives rise to chickenpox. The treatment is symptomatic, with attention paid to adequate fluid intake.

Treatment of herpes simplex infection typically involves systemic and/or topical antiviral agents, such as aciclovir or famciclovir. If given early (in the first 2 to 3 days), these may shorten the course of the infection. Labial (lips) secondary herpes (usually type 1) is commonly managed topically, whereas genital herpes (usually type 2) is more often managed with systemic aciclovir and is an increasing problem as a sexually transmitted disease. There is a crossover between the two types of virus and the sites. Supportive measures are important, and adequate fluid intake must be ensured in young an in debilitated patients.

Chronic viral infections

Treatment of herpes zoster infection is with systemic aciclovir, 500 mg five times a day for five days.

Other chronic viral infections (different types of hepatitis, HIV) may be of relevance with regard to some oral or maxillofacial surgical interventions, but a maxillofacial clinic is not the place for treatment of these conditions.

Fungal infections

Treatment of candidiasis (mostly caused by candida albicans) must include dealing with any underlying factors (for example, optimising control of diabetes, stopping smoking). When the candida infection is associated with steroid inhalers, consideration should be given to the use of a spacer. Dental hygiene must be maintained at a high level. Antifungal therapy may be topical or systemic. The decision to use systemic antifungal agents will be based on the severity and duration of symptoms, in addition to consideration of underlying systemic disease.

‘Azole antifungals’ are the mainstay of systemic therapy, with fluconazole the best tolerated (50 to 100 mg daily for ten days to three weeks). Miconazole is used in gel (mouth) and cream (angular cheilitis) form as the topical agent of choice. Combining the two agents in recalcitrant cases may help because fluconazole-resistant (and itraconazole-resistant) cases of candida infections have emerged (such as infections with the less common candida strains, for example candida dublensii). Voriconazole is an expensive reserve.