Remote manifestation of oral and dental infectious foci.
Plan
Introduction.
Problematic.
Goals.
Definitions.
Concept of land.
Responsible oral health homes.
Pathogenic mechanisms.
Remote clinical manifestations.
Diagnostic approach and course of action.
Conclusion.
- Introduction :
Focal infection represents the set of manifestations that appear in the body at a distance from a suspected oral-dental focus, assumed to be responsible.
In addition to these cases of infection, there are aseptic accidents (inflammatory of neurovegetative, allergic and reflex origin). This is why the term “focal infection” has been replaced by “distant manifestations of infections or irritations of oral-dental origin”.
The management of certain pathologies requires inter-departmental collaboration (doctor and odontostomatologist). Sometimes, we are led to receive patients referred by other specialties, with a view to searching for a possible oral-dental etiology, in the context of a secondary pathology (infectious endocarditis, nephropathy, alopecia areata, etc.).
Problematic
Is there really a link between remote pathologies?
and oral health centers?
The dentist may receive patients from colleagues for local etiological research of general clinical manifestations.
How can we confirm an infection remotely?
What is its dental origin?
Goals
- Know its manifestations from a distance.
- Highlight the causal link between its clinical manifestations and the oral-dental entry point ( cause and effect link).
- Definitions:
- Focal infection of dental origin:
Focal infection of oral origin means that an oral infectious focus can be the origin of distant lesions. This concept remains controversial since it is difficult to prove with absolute certainty the oral origin of the germs responsible for an extraoral infection.
- Bacteremia:
It is a physiological state characterized by the transient passage of germs into the circulating blood and devoid of clinical manifestations.
- Sepsis:
It is a serious general infection of the body resulting in significant discharges of pathogenic germs into the blood, and clinically characterized by a deterioration in the general condition, high fever, chills and a positive blood culture. Most often of bacterial origin, it can also be caused by viruses, fungi or parasites.
- Septic accidents:
A local pathological lesion called a primary focus is likely to cause a secondary focus at a distance by the same microorganism , which evokes the notion of microbial metastasis.
- Aseptic accidents:
A primary oral-dental lesion can trigger remote manifestations, the expression of which causes inflammatory or purely reflex disorders.
3. Concept of the field:
The quality of the terrain, genetic or acquired, is essential, because some patients are more vulnerable to infections, the defense barriers becoming weakened (alcoholism, drug addiction, malnutrition, diabetes, radiotherapy, anticancer chemotherapy, long-term corticosteroid therapy, orthopedic prostheses, etc.).
4. Responsible oral-dental foci:
4.1. Mucous foci : we can cite:
- Pericoronitis which accompanies the eruption of the lower DDS;
- Gingivitis and gingivostomatitis;
- Ulcerations, canker sores, fistulas;
- Mucosal wounds following trauma;
- Incisions and tears during oral surgery procedures.
Remote manifestation of oral and dental infectious foci.
Oral infectious foci
4.2. Dental and peridental homes:
- Acute foci: pulpitis, pulp polyp, pulp gangrene, desmodontitis.
- Filled teeth, even if properly treated, it is illusory to consider them as sterile teeth.
- Periodontal diseases with chronic progression, with rich microbial flora, very polymorphic, therefore very septic,
- Irritating spines: overflowing fillings, septum syndrome, unsuitable prosthesis, occlusion disorders, etc.
5. Pathogenic mechanisms:
5.1 Infectious theory : Several pathways are possible :
- Bloodstream or bacteremia:
Physiological, spontaneous bacteremia (during chewing, brushing and swallowing). In the normal state, no pathological manifestation. But this passage of germs is followed by their fixation on certain organs. Bacteremia can occur after even minimal oral-dental acts, this is induced bacteremia.
- Release of toxins or toxemia:
The bacteria present in the infectious foci release toxins which will cause problems at a distance.
- Pyophagia:
Swallowing the pus will cause the germs to pass into the general circulation and the infection to settle on certain target organs.
- Inhalation:
Inhalation of pus can occur during sleep or during general anesthesia, and therefore cause pulmonary foci.
- Contiguity:
It is the extension from near to near through the natural anatomical pathways . Exp: CB – orbital region; odontogenic infection – mediastenitis (sometimes lethal).
4.2. Immuno-allergic theory:
This is the theory that has the most supporters. The importance of allergic mechanisms in distant manifestations of BD origin now seems preponderant.
4.3. Neurovegetative reflex theory:
This is the most contested theory because it is the most difficult to prove.
6. Remote clinical manifestations:
6.1. Sepsis: This refers to a potentially fatal condition that corresponds to the infection of the blood most often by a bacterium, sometimes a virus or more rarely a fungus. The latter is dependent on:
- Microbial virulence of oral-dental foci;
- The resistance of the individual.
Among bacteria, approximately 40% of septicemias are Gram-negative bacilli and 5% of septicemias with Gram-positive bacilli develop severe septic shock.
- Acute septicemia : They are rare in odontostomatological practice:
- Chronic septicemia: Seen when microbial virulence is attenuated and in the case of chronic infectious foci that evolve quietly (apical granulomas).
6.2. Craniofacial thrombophlebitis:
It is the formation of a clot (thrombus) in the deep venous network (venous thrombosis) following an infectious process. It can affect:
- Facial vein thrombophlebitis;
- Thrombophlebitis of the ophthalmic vein.
- Thrombophlebitis of the cavernous sinus.
- Thrombophlebitis of the superior longitudinal sinus:
6.3. Cardiovascular manifestations:
- OSLER’s infective endocarditis:
Infective endocarditis is the most common heart disease caused by bacterial metastasis of oral origin. In 90% of cases, endocarditis affects the left heart valves (mitral and aortic).
In 25 to 40% of identified cases, the entry point is oral (according to the French Union of Oral Health). Streptococci alone represent more than 50% of cases.
EI can be individualized into:
- Acute endocarditis.
- Subacute endocarditis.
Some people are more at risk of developing infective endocarditis:
- People over 60 years old;
- people who have a history of heart problems such as valve surgery (prosthetic heart valve),
- men (with a risk twice that of women);
- people whose immune system is weakened by illness or immunosuppressive treatment;
- people with diabetes;
- people who suffer from chronic alcoholism or drug addiction.
- People who suffer from autoimmune diseases (e.g. lupus).
The practitioner must be vigilant regarding prevention in this area and during care and extractions in patients at risk (see the latest recommendations).
The 2015 European and American recommendations limited antibiotic prophylaxis to dental care of patients at high risk of IE. Following the latest recommendations of 2016, antibiotic prophylaxis should not be prescribed systematically.
- Atherosclerosis:
There is considerable evidence of a potential association between atherosclerosis and periodontitis; hence the need to treat periodontal disease.
6.4 . Respiratory manifestations:
Infection occurs either through the blood (bacteremia) or by inhalation.
In 1/3 of cases of lung abscesses are caused by microorganisms of oral origin (periodontal infection, chronic abscess, pericoronitis).
Several studies have shown that daily HBD reduces the rate of pneumonia by approximately 50%.
6.5. Gastrointestinal manifestations:
- Helicobacter pylori (HP), the etiological agent of chronic gastritis, enteritis, colitis, can be isolated from saliva samples and dental plaque.
- Ferguson et al demonstrated that HP from a gastric biopsy was identical to that from saliva. It was therefore suggested that the oral cavity could represent a possible source of gastrointestinal infection.
6.6. Osteoarticular manifestations:
Subacute inflammatory rheumatism in adults following an ENT infection may also be due to a dental infection.
The role of dental infection is more discussed in progressive polyarthritis and spondylarthritis. The fact that it is difficult to affirm the dental etiology of rheumatism should not obscure the irradiation of dental infectious foci under antibiotic cover in unexplained inflammatory rheumatism.
6.7. Renal manifestations:
Even if it is difficult to affirm the dental origin of a glomerulopathy, while those of anginal origin are frequent, the aggravating role of dental foci is certain.
6.8. Grafting and transplantation:
It poses a problem of prevention, the restoration of the oral cavity before any graft or organ transplant operation and antibiotic prophylaxis in transplant or grafted patients.
6.9. Neurological manifestations:
- Pain: this is the most common and frequent sign of pulp excitation; localized to the tooth in the case of dentinitis or radiating in the case of pulpitis (synalgia phenomenon): dento-dental, dento-cutaneous or dento-mucosal. Irradiation can affect the eye, ear and TMJ.
- Nervous hyperesthesia:
Pain when pressing on the trigeminal nerve at the terminal branches.
They correspond to the Vallex points which are:
- Mental foramina: terminal branch of the inferior dental nerve;
- The suborbital hole: terminal branch of the upper jaw.
6.10. Ocular manifestations:
Due to the anatomical proximity between the eye and the tooth, a dental lesion can, through simple contiguity and diffusion, cause damage to the eye:
Remote manifestation of oral and dental infectious foci.
- Infectious disease:
- Lower eyelid edema and abscesses;
- Acute osteoperiostitis at the orbital rim;
- At the level of the lacrimal ducts: dacryocystitis – pericystitis.
- inflammatory disease:
Uveitis, conjunctivitis, vascularity, optic neuritis…
- Reflex attack or reflex manifestations:
Ophthalmic neuralgia: It can be infraorbital, retroorbital or involve the anterior segment of the eyeball.
6.11. Skin and hair life manifestations:
- Skin disorders :
“Any excitation of the trigeminal nerve of dental origin has its constant repercussions on the scalp and the face.” Rousseau-Decelle and Raison
- Violent excitement results in sensory, thermal, vasomotor and secretory phenomena.
- Low excitement produces acne, eczema, alopecia.
- Erythrosis: This is the most common dental dermatosis. In children, it is the classic “tooth burn” that accompanies the eruption of baby teeth. In adults, erythrosis is seen during pulpitis.
- Hair life disorders:
- Slowing down of hair life.
- Diffuse hair removal.
- Alopecia.
Remote manifestation of oral and dental infectious foci.
6.12. Premature low birth weight:
At the current state of publication, the association between oral infection and premature birth of hypotrophic newborns is not established, but studies are underway to confirm the results.
It is therefore advisable to carefully monitor the dental and periodontal condition of pregnant women and to intervene if necessary, preferably between the 3rd and 6th month .
7. Diagnostic approach and course of action:
In the presence of a remote manifestation likely to be of oral-dental origin, the specialist must, after having highlighted the infectious and irritating foci, establish the cause and effect relationships between the detected stomatological lesions and the secondary manifestations.
- Preventive treatment:
It is based on the fight against oral septicity which plays a major role in the development of caries and alveolysis, consequently: the prophylaxis of focal accidents cannot be conceived without rigorous oral hygiene.
- Curative treatment: it depends on:
- The nature of the condition that prompted the search for infectious foci: if the condition in question (e.g. Osler’s endocarditis) is life-threatening, it is essential to eliminate any suspect foci. If the supposed second condition does not compromise life-threatening prognosis, the therapeutic approach does not require radical treatment.
- The anatomical situation and the pathological damage to the tooth: curative treatment can be conservative or radical.
- Conservative treatment: consists of:
– Early treatment of dental caries at the dentinitis stage.
– Treatment of pulpopathies.
- Non-conservative treatment:
We believe that conservative treatments do not imply total safety, and due to the seriousness of some secondary pathologies, non-conservative treatment becomes essential. This involves the removal of oral-dental infectious foci under certain precautions.
Conclusion
The importance of oral-dental infectious foci in certain general conditions has been demonstrated.
We recommend a thorough dental-stomatological clinical examination for prevention and better treatment of certain secondary conditions, such as Osler’s infective endocarditis.
Even if the oral-dental focus is not decisive, it is in any case aggravating, hence the need for perfect oral-dental hygiene .
Remote manifestation of oral and dental infectious foci.
Wisdom teeth can cause infections if not removed.
Dental crowns restore the function and appearance of damaged teeth.
Swollen gums are often a sign of periodontal disease.
Orthodontic treatments can be performed at any age.
Composite fillings are discreet and durable.
Composite fillings are discreet and durable.
Interdental brushes effectively clean tight spaces.
Visiting the dentist every six months prevents dental problems.