Читать книгу Management of Complications in Oral and Maxillofacial Surgery - Группа авторов - Страница 58

 Etiology: preoperative infection or inflammation, surgical debris, inadequate irrigation, patient risk factors

 Management: incision and drainage, irrigation, antibiotics

Surgical wound infection rates as a result of third molar extraction range from 0.8% to 4.2% and almost exclusively involve the mandibular third molars [1–6, 10, 11]. According to most general surgery and infectious disease literature, any surgical procedure within the oropharynx is considered a clean‐contaminated wound, a class II wound, and carries a <10% risk of surgical site infection (SSI). If inflammation without purulence is noted, such as that with pericoronitis, the wound is then classified as contaminated, class III, and carries an SSI rate of 20%. The presence of purulence or necrotic tissue at the time of surgery results in a 40% risk of SSI. Class I data are available to support the use of preoperative antibiotic prophylaxis for clean‐contaminated wounds; however, there are no data to support continued antibiotic administration beyond the first 24 hours after surgery [12–14]. In relation to third molar surgery, 50% of infections are localized subperiosteal abscess‐type infections occurring approximately two to four weeks after surgery [10]. This type of infection is attributed to debris left under the surgically created mucoperiosteal flap and would likely not be prevented with the use of antibiotic prophylaxis. The remainder of third molar SSIs are rarely severe enough to necessitate further surgery or antibiotics. SSI occurring within the first postoperative week occurs only 0.5–1% of the time [10, 11, 15].

The risk of developing an SSI associated with the removal of third molars increases with an increased degree of impaction, need for bone removal or sectioning of the tooth, the presence of gingivitis, periodontal disease, and/or pericoronitis, surgeon experience, increasing age, and antibiotic use. The benefit of systemic antibiotic administration on incidence of SSI in relation to third molar extractions is questionable and is not currently recommended as the incidence of adverse reactions from antibiotic administration is higher than the incidence of SSI, 11% and 0.8–4.2%, respectively [10, 11, 15]. It is also unlikely that perioperative systemic antibiotics are of any benefit in delayed, subperiosteal type, infections due to the nature of these infections as described previously [10].

Signs of SSI can vary from localized swelling and erythema to fluctuance and trismus or systemic manifestations with fevers, dehydration, etc. [10]. The treatment of SSI due to third molar surgery involves surgical incision and drainage in addition to the administration of systemic antibiotics. Penicillin is often used as the vast majority of infections are caused by a mixed flora of microorganisms, with anaerobic and Gram‐positive streptococci being the most common. Amoxicillin has a slightly wider spectrum of activity and metronidazole can be added to cover anaerobic organisms. For the penicillin allergic patients, clindamycin is a good choice of antibiotic and can also be used when aerobic and anaerobic coverage is desired. Most often, patients will present with a vestibular, body of the mandible, or localized subperiosteal abscess. A rare occurrence is the spread of infection along fascial tissue planes and involvement of multiple potential spaces. This situation requires surgical drainage, intravenous (IV) antibiotics, and close follow‐up as progression to parapharyngeal, submandibular, and retropharyngeal spaces can lead to airway embarrassment and even mediastinal abscess formation with potentially fatal result [10, 15] (Algorithm 2.2).