",isbn:"978-1-83969-452-3",printIsbn:"978-1-83969-451-6",pdfIsbn:"978-1-83969-453-0",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,hash:"a6e1a11c05ff8853c529750ddfac6c11",bookSignature:"Dr. René Mauricio Barría",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10734.jpg",keywords:"Neonatal Intensive Unit, Neonatal Diagnostic Techniques, Neonatal Nurses, Neonatologists, Newborn Diseases, Premature Diseases, Breast Feeding, Kangaroo-Mother Care Method, Neonatal Survival, Limit of Viability, Minimal Handling, Neonatal Stress",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 5th 2021",dateEndSecondStepPublish:"March 5th 2021",dateEndThirdStepPublish:"May 4th 2021",dateEndFourthStepPublish:"July 23rd 2021",dateEndFifthStepPublish:"September 21st 2021",remainingDaysToSecondStep:"2 days",secondStepPassed:!1,currentStepOfPublishingProcess:2,editedByType:null,kuFlag:!1,biosketch:"The principal investigator and academic expert in epidemiological methods and evidence-based health with an emphasis on children's health. 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His research interests lie in the areas of Maternal-Child Health, Neonatal Care and Environmental Health. He is skilled in epidemiological studies designs with special interest in cohort studies and clinical trials. Since 2010 until 2017 he was Director of the Evidence-Based Health Office and currently serves as Director of the Nursing Institute at the Universidad Austral de Chile. 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\n
1. Introduction
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\n
1.1. Patient examination and assessment: review
\n
A comprehensive and thorough clinical examination is a critical component of treatment of odontogenic infections. A good clinician will need to accurately evaluate and examine the patient, to formulate a prompt diagnosis and plan for surgical management accordingly. Every examination should begin with an accurate history and physical examination with focus on the evaluation of airway. Airway evaluation perhaps is the most important step in evaluating odontogenic infections and will guide the clinician and dictate the next appropriate course of treatment. Information on the timing of initiation of symptoms will give the clinician an understanding on how quickly the infection is progressing. It is absolutely crucial that the clinician promptly recognize any signs of impending airway and take necessary steps to take control over the airway as soon as possible. Once the airway is deemed stable, the clinician can proceed to accessing patient’s oral examination focusing on dentition, floor of the mouth, oral pharyngeal, pharyngeal space, and palatopharyngeal fold. This is then followed by a diagnosis and development of a treatment plan for patient care. Failure to complete a comprehensive history and examination of the patient can lead to improper treatment and/or delayed treatment of infections. This potentially leads to serious complications, including but not limited to airway compromise, mediastinitis, sepsis, and death [1].
\n
A patient history includes attaining information regarding the symptoms, onset, and duration of the present illness. This information helps form an understanding of the severity of the patient’s infection. Common signs and symptoms that should alert a provider of a developing or established infection include trismus, fever, difficulty swallowing, pain, difficulty breathing, dysphonia, and pain on swallowing [1–3]. The patient’s medical history and current medications are key in assessing the patient’s ability to fight infection as well as providing an insight to potential drug interactions.
\n
The physical examination can start by the recording of vital signs; any fever chills or malaise should be the warning sign for a well-established infection. Oftentimes, clinicians can quickly assess the patient and severity of their situation over the initial few minutes they meet with the patient. Clinicians can quickly assess for airway compromise by observing patient’s posture for sniffing position, any difficulty breathing, tolerating secretions, tongue position, and changes in voice, along with any obvious facial swelling. Clinicians should keep in mind that airway assessment is the most critical component of this examination and will help the clinician quickly determine should the patient require urgent surgical intervention. Clinicians should first establish whether the patient has a stable airway. Failure to recognize this crucial information will lead to more complications. Palpation, percussion, and thorough visual examination of the extra- and intraoral cavity provide necessary information for identifying the source and location of the infection. Providers should pay close attention to size swelling, tongue position, floor of the mouth swelling or elevation, visual disturbances, voice changes, vestibule, and uvula position. This should be followed by radiographic examination. If the clinician suspects that infection is diffused and involves multiple fascial spaces, then a maxillofacial or neck computed tomography (CT) with contrast should be obtained. The use of contrast should be avoided should the patient have any renal problems or any allergies to intravenous dye. A complete laboratory workup consisting of complete blood cell count and basic metabolic panel must be done. C-reactive protein levels must also be measured as markers to assess the severity of infection and response to treatment. It is important to note that the use of blood cultures is not indicated in dentoalveolar infections as they yield negative results. After gathering all clinical and radiographic findings, clinician should quickly establish a plan of care that can vary from establishing a secure and stable airway, emergent or urgent surgical management with intravenous or oral antibiotic therapy. These treatments could vary based on the clinical and radiographic findings. Clinicians should keep in mind that clinical-radiographic examination is the most crucial step in helping clinicians establish whether the patient will require to be managed in a hospital setting or in an outpatient setting. It is important to note that if the clinician suspects any possibility of airway embarrassment or quick progression to a toxic patient, prompt establishment of a secure airway should be the first and most important priority.
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2. Stages of abscess development
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Odontogenic infections are commonly caused by bacteria native to the oral cavity. They arise from either periapical or periodontal sources. Periapical infections are the most common cause of odontogenic infections. In periodontal infections, attachment loss of the gingival fibers and destruction of supportive structures expose the teeth and tissues to bacterial introduction. Periapical infections begin with a carious lesion causing pulpal necrosis that introduces the pulp to microorganisms. The infection can quickly spread to periapical tissues and may spread to other fascial spaces. Upon accessing the periapical tissues, the process can remain localized to the bony structures as a cystic lesion, granuloma, or focal osteomyelitis. Periapical infection can also spread through cortical bone causing cellulitis, localized and or deep-space abscess formation.
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After inoculation of bacteria into deeper tissues, abscess development progresses from cellulitis to abscess formation without early intervention. Cellulitis is an acute disorder associated with warm, diffuse, painful, indurated swelling of soft tissues that also may present with erythema. Indurated swelling begins to soften as an abscess develops represented by localized area of fluctuation (Table 1). An abscess is a collection of purulent material containing necrotic tissue, bacteria, and dead white blood cells. Patients may present at varying stages of the process. Bacteria responsible for odontogenic infections have the ability to spread hematogenously due to the high vascularity of head and neck structures allowing infections to present in distant sites including the orbit, brain, and spine [2, 4].
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2.1. Anatomic considerations
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Odontogenic infections spread from the bony structures through the cortical bone along the path of least resistance with the affected fascial spaces determined by the structures in proximity to the tooth roots [5]. This necessitates an understanding of fascial spaces and anatomy to effectively diagnose and develop a surgical plan for the management of infections. The spaces that are primarily affected by odontogenic infections are located adjacent to the origin. Those spaces are categorized as primary fascial spaces. They include buccal, canine, sublingual, submandibular, submental, and vestibular spaces.
\n
\n\n
\n
Characteristics
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Cellulitis
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Abscess
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\n\n\n
\n
Duration
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1-5 days
\n
4-10 days
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\n
\n
Pain
\n
Generalized
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Localized
\n
\n
\n
Size
\n
Large
\n
Small
\n
\n
\n
Location
\n
Diffuse
\n
Well circumscribed
\n
\n
\n
Palpation
\n
Doughy-indurated
\n
Fluctuant
\n
\n
\n
Presence of pus
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No
\n
Yes
\n
\n
\n
Degree of concern
\n
High
\n
Moderate
\n
\n
\n
Bacteria
\n
Mixed
\n
Anaerobic
\n
\n
\n
Color
\n
Red
\n
Shiny center
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\n\n
Table 1.
Cellulitis versus abscess.
Adapted from Flynn TR: Principles of Management and Prevention of Odontogenic Infections. In Peterson LJ, Ellis E, Hupp J, editors: Contemporary Oral and Maxillofacial Surgery, ed 6, St Louis, 2014, Mosby, pp 296–318.
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After infection spreads to primary spaces, they can progress to include secondary spaces. Secondary spaces include pterygomandibular, infratemporal, masseteric, lateral pharyngeal, superficial and deep temporal, masticator, and retropharyngeal.
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A basic understanding of the spread of infections into the primary spaces is established by understanding the origin and insertions of the buccinator and mylohyoid muscles in relation to the maxilla and the mandible. The buccinator inserts superiorly into the alveolus of the maxilla and inferiorly in the alveolus of the mandible. An infection that spreads within the constraints of those insertions results in a vestibular abscess, and the spread of infection above or below these insertions forms a buccal space infection. The mylohyoid muscle’s origin is from the mylohyoid line of the mandible. Teeth with root apices below this origin are the mandibular second and third molars. Infectious spread from these teeth through the lingual plate forms submandibular space infections. The roots of the mandibular premolars and first molars lie above the mylohyoid and therefore infectious spread lingually associated with these teeth creates sublingual space infections. The teeth most frequently identified as the source of an infection are the mandibular molars, followed by the mandibular premolars [1, 3, 5].
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A special note should be made of an indurated cellulitis involving bilateral submandibular, sublingual, and submental spaces with drooling, tongue displacement, dysphagia, and patient head positioned in the “sniffing” position. This is the classic description of Ludwig’s angina. This is a medical emergency in need of definitive airway management and timely surgical management and should be referred immediately to the nearest hospital for treatment. Patients with infections associated with maxillary molars may also present with maxillary sinusitis due to the close proximity of root apices with the floor of the maxillary sinus. Conversely, patients with maxillary sinusitis may also present with symptoms of an infection, so it is prudent to perform an examination to develop the appropriate diagnosis (Figures 1–5).
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Figure 1.
Fascial spaces of face and suprahyoid areas: (A) canine space infection; (B) masseteric space infection; (C) lateral pharyngeal and submandibular space infection; (D) submental space infection; (E) submental space infection surgical approach. Adapted from Cillo JE: Fascial Spaces of the Head and Neck. In Kademani D and Tiwana PS, editors: Atlas of Oral and Maxillofacial Surgery, St. Louis, 2016, Saunders.
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Figure 2.
(A) Right masticator space infection (60-day duration); (B) right temporal space CT of abscess (same patient); 60 ml of pus aspirated. (A from Flynn TR: The swollen face. Emerg Med Clin North Am 15:481, 2000. B from Flynn TR: Anatomy of oral and maxillofacial infections. In Topazian RG, Goldberg MH, Hupp JR, editors: Oral and maxillofacial infections, ed 4. Philadelphia, 2002, Saunders.).
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Figure 3.
(A) Pterygomandibular space infection. Infected fracture of the mandible involving a partially erupted and carious right lower third molar, which was the source. Significant deviation of the uvula to the opposite side and the swelling of the right anterior tonsillar pillar. (B) CT of a pterygomandibular space abscess. Fluid collection seen between the ascending ramus of the mandible and the medially displaced medial pterygoid muscle. (A from Flynn TR, Topazian RG: Infections of the oral cavity. In Waite D, editor: Textbook of practical oral and maxillofacial surgery. Philadelphia, 1987, Lea & Febiger. B from Flynn TR: The swollen face. Severe odontogenic infections. Emerg Med Clin North Am 15:481, 2000.).
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Figure 4.
(A) Submasseteric space infection. Significant swelling over the right mandibular ascending ramus seen and severe trismus reported. (B) CT of a submasseteric space abscess. Collection of pus between the ascending ramus of the mandible and the overlying edematous masseter muscle. (A from Goldberg MH: Odontogenic infections. In Topazian RG, Goldberg MH, Hupp JR, editors: Oral and maxillofacial infections, ed 4. Philadelphia, 2002, Saunders. B from Flynn TR: Anatomy of oral and maxillofacial infections. In Topazian RG, Goldberg MH, Hupp JR, editors: Oral and maxillofacial infections, ed 4. Philadelphia, 2002, Saunders.).
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Figure 5.
(A and B) Coronal and sagittal CTs with contrast of Ludwig’s angina. (C) Inability to protrude the tongue is a sign of an infectious process involving the floor of the mouth. Adapted from Farnish SE: Ludwig’s angina. In Bagheri SC, editor: Current Therapy in Oral and Maxillofacial Surgery, St. Louis, 2012, Saunders.
\n\n
Computed tomography with intravenous contrast dye is the ideal modality for the identification of and delineation of the anatomic spread of severe deep fascial space infections. When the infection involves only the more superficial spaces, CT may not be necessary. Infections involving the deeper structures can be significantly more difficult to delineate using clinical methods alone. Contrast-enhanced CT (CECT) is useful in these cases. In head and neck infections, CECT may demonstrate ring enhancement, which is the hypervascular capsule surrounding a well-established abscess cavity. The combination of CECT and experienced clinical examination was able to identify clinically significant loculations of pus in the head and neck in 85% of cases [6].
\n
\n
2.2. Deep-space neck infection
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If deep-space neck infection is suspected, it is imperative that the clinician makes an early diagnosis with a thorough clinical examination. These patients often present with nonspecific systemic signs, symptoms such as fever, chills, generalized malaise, and loss of appetite, but it is imperative that the clinician recognize more localized and specific symptoms such as dysphagia, trismus, odynophagia, odontalgia, or dysphonia. According to a study by Mayor and colleagues, most commonly shared signs and symptoms shared by patients with deep-space neck infection were odynophagia, followed by dysphagia, fever, neck pain, and neck swelling [7]. In addition, these patients may show signs of neck swelling, floor of the mouth elevation, drooling, and inability to tolerate their secretions, diaphoresis, and bulging of pharyngeal wall. According to Osborn et al. [7], classic description of pharyngeal wall bulging is the presence of a midline bulge for prevertebral infections and a unilateral bulge for retropharyngeal space infections. It is important to note that submandibular space infections are the most common site of deep-neck space infections. Infection of lateral pharyngeal space can also be caused by nonodontogenic source such as tonsillar infections from peritonsillar space. Infection can spread from lateral pharyngeal or prevertebral space into the retropharyngeal space or danger zone (Figure 6) [7].
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Figure 6.
Deep spaces of neck infections. Adapted with permission from Osborn et al. [7]. PubMed PMID: 18603196.
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\n
2.3. Surgical intervention
\n
Resolution of an odontogenic infection occurs after pharmacotherapy, but it is often studied in combination with surgical treatment [2, 3, 8]. Surgical intervention is believed by many to be the most important aspect of the management of odontogenic infection.
\n
Odontogenic infection with abscess collection, detected clinically or radiographically, warrants incision and drainage by transcutaneous or transoral approach, in addition to dental extraction. The following eight steps are used to guide treatment of severe odontogenic infections (Figure 7).
\n
Location and rate of progression determine the severity of the infection. In the various deep fascial spaces, infection can be classified as low, moderate, and high severity. Diligently taking the patient’s medical history leads to proper evaluation of host defenses. Indications for hospitalization of a patient with odontogenic infections are as follows:
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Figure 7.
Steps in the management of severe head and neck infections. Adapted from Flynn TR: Principles and Surgical Management of Head and Neck Infections. In Bagheri SC, editor: Current Therapy in Oral and Maxillofacial Surgery, St. Louis, 2012, Saunders.
\n
Impending airway compromise or threat to vital structures
Infection of deep-neck spaces or masticator space
Temperature of >101°F
Need for general anesthesia
Need for inpatient control of systemic disease.
\n
The surgical goals in head and neck infections are (1) to secure the airway, (2) to establish dependent drainage, and (3) to remove the cause of infection. Incision and drainage decreases the bacterial load the immune system must face by physically removing pus. Intraoral incisions are generally made in the oral vestibule at the point of maximum swelling. After surgical treatment, the patient must receive adequate medical support including nutrition, rehydration, and control of systemic disease. Steps six and seven will be discussed in detail later in this chapter. For outpatients, appropriate follow-up is 1–4 days. With hospitalized patients, daily follow-up is standard.
\n
\n
3. Treatment techniques
\n
The initial step in the treatment of odontogenic infections is to assure that a stable airway is established. A topical cleansing agent should then be applied and aspiration of abscess should be completed using a syringe connected to a needle in a sterile fashion. Aspirate should be sent for microbiologic culture examination. Prior to incision, local anesthetic infiltration can be administered. Depending on the involved fascial space, various skin incisions have been described (Figure 8).
\n
Figure 8.
Typical incision sites for extraoral incision and drainage. From Lui DW and Abubaker AO: Odontogenic Infection. In Kademani D and Tiwana PS, editors: Atlas of Oral and Maxillofacial Surgery, St. Louis, 2016, Saunders.
\n
On treating a submandibular abscess, the neck incision is approximately 2–4 cm below the angle of the mandible following a natural neck crease, inferior to the most inferior extent of inflammation. A mosquito hemostat is introduced through the skin, subcutaneous tissue, platysma muscle, and superficial layer of the deep cervical fascia until the inferior border of the mandible is encountered [9]. Subperiosteal instrumentation of the lateral and medial aspect of the mandibular ramus is then performed if masticator space is also involved. Normal saline solution should be used to irrigate all drainage sites. One-fourth inch penrose drains are then placed via incision sites and subsequently secured with 5/0 Prolene sutures. Dental extraction (removal of the source of infection) should be followed up next. The decision on extubation should be made with the anesthesiologist.
\n
For lateral pharyngeal abscess treatment, the submandibular approach allows exploration of the lateral pharyngeal space by blunt finger dissection. This occurs in the superomedial direction between the posterior belly of digastric and the sternocleidomastoid (SCM) muscles (Figure 9).
\n
Finger dissection of the lateral pharyngeal space is complete when the surgeon can palpate the endotracheal tube medially, the ipsilateral transverse processes of the vertebrae posteromedially, and the carotid sheath posterolaterally [9].
\n
On treatment of the retropharyngeal abscess, the submandibular approach allows for exploration of the suprahyoid component. If the infrahyoid portion was also involved, the anterior SCM approach should be used. Finger dissection of the retropharyngeal space is a continuation of the complete dissection of the lateral pharyngeal space. Palpation of the contralateral transverse processes of the vertebrae, the endotracheal tube from its posterior aspect, and, if necessary, the contralateral carotid sheath ensure completion of dissection [9]. If necessary, the danger space is entered by finger dissection through the alar fascia. It can be safely explored inferiorly as far as the T4 level.
\n
Figure 9.
(A) Lateral pharyngeal space abscess incision and drainage. (B) Retropharyngeal abscess surgical access for incision and drainage. Adapted from Lui DW and Abubaker AO: Odontogenic Infection. In Kademani D and Tiwana P, editors: Atlas of Oral and Maxillofacial Surgery, St. Louis, 2016, Saunders.
\n
Oral and maxillofacial surgeons should keep in mind that on treating descending mediastinal infection, thoracic surgical consultation is necessary. In a series of 10 patients, Freeman and colleagues reported no mortality when using the following treatment regimen: immediate thoracotomy incision and open-direct exploration, debridement, irrigation, and drainage of the mediastinum. Cervical incisions were used to explore and debride infection in the neck when necessary. Postoperative CT scans were obtained every 48–72 h, or more frequently if the clinical condition deteriorated [10]. These were used to guide additional surgeries to aggressively drain any new loculations of pus. In 30% of cases, extension of the infection into the abdomen through the diaphragm was found. The subjects underwent a mean of six operations and six CT scans. The length of hospital stay was 14–113 days, with a mean of 46 days [10]. In these series cases, early, aggressive, and additional surgeries combined with frequent postoperative CTs reduced the mortality of mediastinitis from 20 to 0% (Figure 10).
\n
Figure 10.
Treatment algorithm for patients with descending necrotizing mediastinitis (DNM). From Freeman RK, Vallieres E, Verrier ED, et al: Descending necrotizing mediastinitis: an analysis of the effects of serial surgical debridement on patient mortality, J Thorac Cardiovasc Surg 119:260, 2000.
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\n
3.1. Microbiology of an odontogenic infection
\n
It has been stated that odontogenic infections arise from bacterial introduction in the deeper tissues of the head and neck. There is vast array of bacterial species all residing contemporaneously in the oral cavity and contribute to the normal oral flora. Odontogenic infections are characterized as a combination of aerobic and anaerobic bacteria. This is why they are considered mixed infections. Streptococcal species are often responsible for orofacial cellulitis and abscess. Aerobic bacteria including Streptococcus viridans, S. milleri group species, beta-hemolytic streptococcus, and coagulase negative staphylococci have been cultured from odontogenic infections. Within the S. milleri group, the members S. anginosus, S. intermedius, and S constellatus are most often associated with cellulitis. Anaerobic bacteria are often isolated from sites with chronic abscess formation. These pathogens include Peptostreptococcus, Prevotella, Prophyromonas, Fusobacterium, Bacteroides, and EIkenella [2, 3, 9, 12, 13, 16]. The most common microorganisms isolated from odontogenic infections have been consistent over the years [3, 8]. However, what has changed is the prevalence, the ability to isolate, and the ability to classify them due to changes in nomenclature [2, 5, 14].
\n
Over the years, studies have shown that there has been a change in the antibiotic susceptibility of isolated organisms. While many streptococci are still penicillin-sensitive, especially those that are prevalent during the first 3 days of clinical symptoms, the gram-negative obligate anaerobes, present abundantly after 3 days, are producing penicillin-resistant strains [12, 17]. Recently, an increase in aerobes and anaerobes that are resistant to clindamycin regimens has been documented [2, 18]. This complicates recommendations for therapeutics for orofacial infections; however, traditionally used empirical antibiotics are excellent options if culture and sensitivity testing are not performed at or prior to the time of surgery. Nonetheless, providers must not forget the potential resistant organisms to empirical antibiotics. As a result of new resistant strains, antibiotic management of odontogenic infections has become increasingly more complex to cover a broader spectrum of offending microorganisms.
\n
\n
3.2. Antibiotics of choice
\n
Antibiotics are antimicrobials used for the treatment and prevention of infections. They are classified as either bactericidal or bacteriostatic. Bactericidal antibiotics kill bacteria by inhibiting cell wall synthesis and bacteriostatic antibiotics inhibit bacterial growth and reproductions. Table 2 lists common antibiotics and their classification. The choice of antimicrobial therapy for patients with odontogenic infections can be complex due to numerous variables that must be considered. Factors involved in antibiotic selection include host-specific factors and pharmacologic factors.\n
\n
Host factors include the microbiology of odontogenic infections, history of allergic responses or intolerance, previous antibiotic therapy, age, pregnancy status, and immune system status [12]. Traditional pathogens found to be in association with orofacial infections are mixed in origin and consist of facultative and obligate anaerobic bacteria. The duration of the infectious process aids in deciphering which organisms predominate. Allergy to antibiotics is noted during acquisition of the medical history as well as information regarding antibiotic intolerance. Previous antibiotic therapy, especially on a consistent basis, yields a propensity for resistant organisms to an antibiotic. Certain antibiotics should be avoided in children as well as pregnant patients. The immunocompetence of a patient may direct antibiotic therapy toward bactericidal, rather than bacteriostatic types.
\n
\n\n
\n
Empiric antibiotics of choice for odontogenic infections in outpatient setting
\n
\n\n\n
\n
No penicillin allergy
\n
Penicillin allergy
\n
\n
\n
PO
\n
PO
\n
\n
\n
-Pen VK 500 mg Q6h 7 days or Amoxicillin 500 mg Q8h, 7 days
\n
\n
\n
\n
-Clindamycin 300 mg Q6h, 7 days
\n
-Clindamycin 300 mg Q6h, 7 days
\n
\n
\n
-Cephalexin (or first generation cephalosporin) 500 mg Q 12h 7-10 days
\n
-Cephalexin (or first generation cephalosporin) 500 mg Q 12h 7-10 days
\n
\n
\n
-Azithromycin 500 mg Q24, 5 days
\n
-Azithromycin 500 mg Q24, 5 days
\n
\n
\n
\n
-Metronidazole 500 mg TID, 7 days
\n
\n
\n
\n
-Moxifloxacin 400 mg Q24 5 days
\n
\n
\n
Empiric antibiotics of choice for odontogenic infections in inpatient setting
\n
\n
\n
No penicillin allergy
\n
Penicillin allergy
\n
\n
\n
IV
\n
IV
\n
\n
\n
Clindamycin IV, 600 mg Q8h
\n
Clindamycin IV, 600 mg Q8
\n
\n
\n
Ampicillin + metronidazole, 0.5-2 g Q6h/500 mg Q8h
\n
Moxifloxacin 400 mg Q24
\n
\n
\n
Ampicillin + sulbactam, 1.5-3 g Q6h
\n
Cefotaxime, 1-2g Q12
\n
\n\n
Table 2.
Empiric antibiotics of choice for odontogenic infections in outpatient and inpatient setting.
Adapted from Flynn.
\n
Pharmacologic factors of interest include spectrum of antibiotics, pharmacokinetics, tissue distribution of antimicrobials, cost of antibiotics, adverse reactions, and potential drug interactions [12]. The antibiotic spectrum is of important consideration, because it is best for the patient to receive therapy with antibiotics that are effective against the involved microorganisms. Pharmacokinetically, the effectiveness of such antibiotics is dependent upon serum concentration needed to kill bacteria or the time necessary to maintain adequate serum levels. Beta-lactams and vancomycin are time dependent, whereas fluoroquinolones are concentration dependent. The ability of an antibiotic to reach the site of an infection should be considered, because abscess cavities are avascular. Thus, antibiotic effectiveness is based on the ability to penetrate an abscess. Adverse reactions and potential drug interactions will be discussed later in the chapter.
\n
Pathogen-specific antibiotic therapy is driven by results of culture and sensitivity testing. Site cultures are not obtained until surgical intervention is done; patients with orofacial infections warrant timely therapeutic management. Empirical antibiotic therapy for odontogenic infections is based on an understanding of common pathogens cultured from the infection site. Empiric antibiotics may be difficult to ascertain due to the complex microbiology of such infections; the timing of antibiotic administration and antibiotic resistance are important. Table 2 shows empiric antibiotics of choice for odontogenic infections in the outpatient setting. Penicillin still remains the antibiotic of choice in the outpatient setting for the management of odontogenic infections when there is no history of allergy [1–3], especially in infections of less than 3-day duration [3, 12]. Clindamycin is the antibiotic of choice for patients with an allergy to penicillin [1–3, 8]. This may also be considered for infections of longer than 3 days of duration due to the increase in penicillin-resistant organisms present at this stage [12, 17]. Of the macrolides, azithromycin has fewer drug interactions and is used to treat infections; however, resistance to macrolides has been reported [17]. Cephalosporins have been found to be effective in the treatment of orofacial infections, but there are pathogens that produce cephalosporinases. There also must be consideration for cross-allergy in penicillin-allergic patients. Metronidazole is excellent for obligate anaerobes and studies have shown its effectiveness in the outpatient setting; however, it is often used in the inpatient setting in combination with other antibiotics [2, 8, 12]. Moxifloxicin, a fourth-generation fluoroquinolone, has a spectrum of coverage including oral aerobes and anaerobes, including E. corrodens, which is clindamycin resistant. Moxifloxicin is an excellent antibiotic choice when initial antibiotics and surgery have remained ineffective (Table 3).
\n
\n\n
\n
Bactericidal
\n
Bacteriostatic
\n
\n\n\n
\n
Beta-lactams
\n
Macrolides
\n
\n
\n
Penicillins
\n
Erythromycin
\n
\n
\n
Cephalosporins
\n
Clarithromycin
\n
\n
\n
Carbapenems
\n
Azithromycin
\n
\n
\n
Monobactams
\n
\n
\n
\n
Aminoglycosides
\n
Clindamycin
\n
\n
\n
Vancomycin
\n
Tetracyclines
\n
\n
\n
Metronidazole
\n
Sulfa antibiotics
\n
\n
\n
Fluoroquinolones
\n
\n
\n\n
Table 3.
Bactericidal and bacteriostatic antibiotics.
Adapted from Flynn.
\n
\n
3.3. Duration of antibiotics
\n
A common antibiotic course for orofacial infections is 7–10 days. Flynn et al. hypothesized that antibiotic therapy for 4 days or less combined with appropriate surgical treatment results in equal or better clinical outcomes, as measured by time to resolution, morbidity, selections for antibiotic-resistant strains, and expense. In this systematic review, it was found that no clinically significant difference was found at day 7 with antibiotic courses of 7 days or less with appropriately administered surgical treatment. Chardin and colleagues [19] found no significant difference in clinical cure rate of antibiotic therapy after surgical intervention with amoxicillin 1 g for 3 days versus the same therapy for 7 days. Lewis and colleagues [16] found similar results when comparing surgical intervention followed by 3-g amoxicillin for two doses 8 h apart from penicillin V of 250 mg by mouth four times per day for 5 days. These studies support the emphasis on prompt and efficient surgical intervention in combination with antibiotic therapy.
\n
\n\n
\n
Antibiotic
\n
Usual dose (mg)
\n
Usual interval (h)
\n
Wholesale cost 2010 ($)
\n
1-week retail cost 2010($)
\n
Amoxicillin cost ratio
\n
\n\n\n
\n
Penicillins
\n
\n
\n
Amoxicillin
\n
500
\n
8
\n
0.37
\n
11.99
\n
1.00
\n
\n
\n
Penicillin V
\n
500
\n
6
\n
074
\n
12.29
\n
1.03
\n
\n
\n
Augmentin
\n
875
\n
12
\n
5.05
\n
51.99
\n
4.34
\n
\n
\n
Augmentin XR
\n
20,000
\n
12
\n
7.38
\n
108.99
\n
9.09
\n
\n
\n
Cephalosporins
\n
\n
\n
Cephalexin
\n
500
\n
6
\n
1.23
\n
15.19
\n
1.27
\n
\n
\n
Erythomycins
\n
\n
\n
Erythromycin
\n
500
\n
6
\n
0.30
\n
17.99
\n
1.50
\n
\n
\n
Clarithromycin
\n
500
\n
24
\n
5.01
\n
34.69
\n
2.89
\n
\n
\n
Azithromycin
\n
250
\n
12
\n
7.78
\n
120.99
\n
10.09
\n
\n
\n
Anaerobic
\n
\n
\n
Clindamycin (generic)
\n
150
\n
6
\n
1.19
\n
31.79
\n
2.65
\n
\n
\n
Clindamycin (2T)
\n
300
\n
6
\n
2.38
\n
59.99
\n
5.00
\n
\n
\n
Clindamycin (generic)
\n
300
\n
6
\n
3.76
\n
87.59
\n
7.31
\n
\n
\n
Metronidazole
\n
500
\n
6
\n
0.73
\n
34.49
\n
2.88
\n
\n
\n
Other
\n
\n
\n
Vancomycin
\n
125
\n
6
\n
29.10
\n
849.99
\n
70.89
\n
\n
\n
Ciprofloxacin
\n
500
\n
12
\n
5.13
\n
13.49
\n
1.13
\n
\n
\n
Moxifloxacin (Alyelox)
\n
400
\n
24
\n
16.35
\n
138.99
\n
11.59
\n
\n\n
Table 4.
Cost of oral antibiotics used in odontogenic infections.
\n
\n
\n
3.4. Cost of antibiotics
\n
The cost of antibiotics whether a factor that is often not considered during the treatment of odontogenic infections should be considered. The central focus is the resolution of infectious process with surgical treatment while providing effective and appropriate antibiotic therapy that will reduce the morbidity associated with the infection. Antibiotic cost can be compared based on the cost for a standard prescription for antibiotics of preference in oral formulations. Amoxicillin is one of the least expensive oral formulations of antibiotics. Flynn considered the retail cost for a 1-week prescription that an uninsured patient would pay for antibiotic therapy. He obtained the cost of commonly prescribed antibiotics from a pharmacy chain in the Boston area. Then, he formulated a numeric cost comparison ratio by dividing the cost of the commonly prescribed medications by the cost of an amoxicillin prescription. This comparison found that the cost of a 150-mg Cleocin prescription is significantly less than the 300-mg prescription with a two 150-mg capsule regimen four times a day being 63% the cost of a 300-mg capsule four times a day therapy [8, 12] (Table 4).\n
\n
\n
3.5. Antibiotic resistance
\n
A problem that has emerged regarding the effectiveness of selected antibiotic therapy for the management of odontogenic infections is antibiotic resistance. Antibiotic resistance occurs by four mechanisms namely alteration of a drug’s target site, inability of a drug to reach its target, inactivation of an antimicrobial agent, or active elimination of an antibiotic from the cell [8, 17]. Alteration of the target site for an antibiotic occurs by genes allowing bacteria to synthesize peptides that prevent binding diminishing the affinity of the antibiotic. Some bacteria have bypass pathways that use alternate metabolic pathways when specific antibiotics are present. Antibiotics may be inactivated by bacterial enzymes; these enzymes can result in neutralization. Penicillinase and beta-lactamases are examples of this mechanism. Genes present in some bacteria produce proteins that prevent antibiotic uptake or signal for the removal of the antibiotic from the cell leading to antibiotic resistance as well. The genes necessary to drive antibiotic resistance are acquired through four mechanisms namely spontaneous mutation, gene transfer, bacteriophages, and mosaic genes [4, 8, 17]. Spontaneous mutation is considered the dominate source antibiotic resistance. Gene transfer occurs with transmissible DNA segments that transfer and insert genetic material after bacterial conjugation. Bacteriophages are viruses that infect bacteria and replicate to insert genetic material, subsequently highjacking the control of the bacteria’s genetic and bacterial metabolism. Mosaic genomes are formed by bacteria incorporating fragmented DNA directly from dead members of related species. Collectively, these mechanisms allow the spread of genetic material from one bacterial species to another and can result in the resistant strain becoming the predominate strain of the species [8, 17].
\n
Strides have been made to reduce the prevalence and manage antibiotic resistance. Non-antibiotic attempts relate to the hospital setting. This includes reduction of colonization sites, patient isolation, decreased length of hospital stay, and aseptic technique during intervention. Antibiotic-associated attempts include limiting antibiotic therapy to as narrow of a spectrum as possible to effectively manage the offending bacteria and utilizing broader spectrum antibiotics only when indicated. Culture and sensitivity testing of purulent exudate aid in identifying the susceptibility of bacteria to specific antibiotics. Kuriyama et al. examined a relationship between past administration of beta-lactam antibiotics and those patients producing increased amounts of resistant bacteria with odontogenic infections. It is beneficial to the clinician and patient to be diligent in obtaining history of previous odontogenic infections to guide treatment and consideration of possible antibiotic resistance.
\n
\n
\n
4. Complications of antibiotic therapy and drug interactions
\n
Antibiotic drugs have the potential to alter the effectiveness of other drugs and interfere with the metabolism of other drugs. The cytochrome p450 system is a complex set of drug-metabolizing enzymes in the liver and gastrointestinal (GI) system that breaks down many different drugs. When antibiotics that utilize this metabolic pathway inhibit cytochromes that are needed for metabolism of other drugs altering the bioavailability of one of the involved drugs, some of these interactions can lead to some severe adverse effects.
\n
Providers should be mindful of some of the potential adverse reactions associated with antibiotic therapy and other medications. Erythromycin and other macrolides have been found to have drug interactions with numerous drugs including statins, theophylline, warfarin, carbamazepine, triazolam/midazolam, and antiarrhythmic. Side effects of these interactions range from bleeding issues, increased sedation, confusion, and seizures to cardiac dysrhythmias and death. Metronidazole has the potential for increased bleeding with the coadministration of warfarin due a decrease in the metabolism anticoagulants. Clindamycin may destroy gut flora and prevent absorption of vitamin K, which can cause an increase in anticoagulation. Metronidazole can also affect renal clearance of lithium and also has a disulfiram effect in combination with alcohol. Fluoroquinolones have been found to interfere with theophylline metabolism and cause seizures. These drugs have also been found to cause spontaneous tendon rupture. Fluoroquinolones should be avoided in children due to chondrotoxicity in growing cartilage.
\n
Antibiotic allergy should be obtained while obtaining a patient’s medical history. It is important to inquire about the nature of an allergy to access whether a true anaphylactoid allergy exists. Penicillin is a common antibiotic for which patients report an allergy. One to 10% of patients develop an allergic response to penicillin during an initial course and a less than 1% chance of development of an allergic reaction exists with additional courses [8, 21]. There is a possibility for cross-allergy to cephalosporins. This occurs in 10–15% of patients with an allergy to penicillin and often involves patients with a history of anaphylaxis.
\n
Antibiotic-associated colitis (AAC) is another possible adverse effect of antimicrobial therapy. Clostridium difficile is an enteric anaerobe that produces an exotoxin found in a stool assay of affected patients. Diagnosis of C. difficile occurs after symptoms of fever, abdominal cramping, five or more episodes of diarrhea per day, or positive results in a stool sample. AAC has been found to occur with clindamycin, beta-lactam/beta-lactamase inhibitor combinations, cephalosporins, and other antibiotic therapy, and is treated with the removal of the offending antibiotic and oral metronidazole or vancomycin. If no resolution occurs, these patients should be referred as soon as possible to rule out the potential need for surgical intervention.
\n
A patient who is on oral contraceptive pills should be informed of the necessity to utilize other forms of birth control. Antibiotic therapy my kill enough gut flora that inhibits recirculation of estrogen which reduces the serum levels of estrogen and may allow for the patient to become pregnant. This has been found to only involve oral contraceptives, not implantable or injectable forms [8].
\n
\n
\n
5. Management of medication-related osteonecrosis of the jaw
\n
The American Association of Oral and Maxillofacial Surgeons (AAOMS) in 2014 as described in their position paper changed the nomenclature from bisphosphonate-related osteonecrosis of the jaw (BRONJ) to medication-related osteonecrosis of the jaw (MRONJ). The change in designation signals the increasing number of osteonecrosis cases secondary to the use of alternative antiresorptive and antiangiogenic therapies [23]. The oral and maxillofacial surgeon often encounters patients treated with antiresorptive medications via either oral or parenteral route. Most of those patients who require treatment with antiresorptive medications are afflicted with metastatic bone tumors with primary sites from the breast, prostate, and lung. Lytic bone lesions are more often associated with multiple myeloma. Included in the antiresorptive medication regimen are receptor activator of nuclear factor (RANK) ligand inhibitors and in particular, Denosumab. The RANK ligand inhibitors work by the inhibition of osteoclast formation thus reducing the risk of fracture of vertebral, non-vertebral, and hip in the osteoporotic patient [23]. Controversy persists as to the mechanism and pathophysiology of MRONJ. Theories include altered bone remodeling or oversuppression of bone resorption, angiogenesis inhibition, constant microtrauma, suppression of innate or acquired immunity, vitamin D deficiency, soft-tissue BP toxicity, and inflammation or infection [23]. In the context of managing MRONJ, as a bacterial infection one must be cognizant of postsurgical risks following extraction of teeth especially those with existing periodontal disease and or periapical pathology [23]. Dentoalveolar surgery is still considered a major risk in developing MRONJ. Approximately 52–61% of those patients following dentoalveolar surgery are at risk to develop MRONJ [23]. Actinomyces species was one of the first bacteria identified in osteonecrosis of the jaw. Biopsied specimens of bone have recently identified a combination of bacteria and fungi associated with the biofilm on exposed bone [23]. As a result, a regimen of complex therapies is often required to treat the osteonecrosis-related biofilm of bone.
\n
\n
5.1. Staging of MRONJ
\n
Stage 1:
\n
Exposed and necrotic bone asymptomatic with no evidence of infection localized to the alveolus.
\n
Stage 2:
\n
Exposed and necrotic bone with evidence of infection and symptoms.
\n
Stage 3:
\n
Exposed and necrotic bone with evidence of infection and one of the following:\n
Exposed and necrotic bone beyond the alveolus with extension to the inferior border of the mandible and or maxillary sinus and zygoma.
Pathologic fracture.
Extraoral fistula.
OA or oronasal fistula.
Osetolysis beyond the inferior border of the mandible or sinus floor.
\n\n
Those patients afflicted in Stages 1–3 can be treated empirically with long-term use of Chlorhexidine rinses [23]. Presurgical management with Chlorhexidine and a regimen of broad-spectrum antibiotics have been used as a modality of care with the initial management of symptomatic MRONJ. It appears that a specific antibiotic regimen is not universally accepted and is often the preference of the surgeon as to what is found to be most effective. Clearly, the approach to the use of antibiotics for those afflicted with MRONJ identifies this condition with a bacterial component. Developing a strategy as to what antibiotics would be effective is found on the understanding and identification of the bacterial flora. Coverage for Actinomyces is essential, as it is one of the most predictable bacterial organisms isolated in patients with MRONJ. Actinomyces is a gram-positive organism that thrives best in an anaerobic environment. This is an opportunistic organism that is best treated with Amoxicillin for 6 months to a year.
\n
\n
\n
\n
6. Summary
\n
Odontogenic infections are emergencies that may present in the outpatient setting. Management of such emergencies can occur in the dental office; however, there are circumstances that warrant referral for definitive treatment. Clinicians treating orofacial infections should be able to effectively examine and assess patients, have an understanding of common microorganisms associated with an abscess, head and neck anatomy, and vectors of development and spread of an abscess. Providers choosing to engage in management should promptly provide treatment of odontogenic infections with a combination approach, involving surgical intervention and antimicrobial therapy. It is important to confirm that the patient does not have any medical condition that necessitates antibiotic prophylaxis prior to surgical intervention. If so, the provider should refer to the current American Heart Association guidelines for antibiotic prophylaxis regimen (Table 5).\n
\n
Antimicrobial therapy is complicated by the mixed flora of an abscess and varied responses of microorganisms to penicillin. Antibiotic therapy selection should be chosen according to safety, cost, consideration for a patient’s medical history, effectiveness of antibiotic, and stage in abscess development. The use of clindamycin has increased in dentistry; however, multiple clinical studies comparing clindamycin to penicillin or ampicillin have found clinical success rates of 97% or higher with penicillin [3]. Penicillin continues to be the drug of choice in odontogenic infections, while clindamycin is an excellent alternative in patient with penicillin allergy. A 7-day antibiotic therapy has traditionally been effective; however, studies have shown that a 3- to 4-day regimen should suffice in healthy patients [6]. Regardless of the empirical antibiotic choice, surgical intervention that removes the source of the infection is considered the primary treatment modality.
\n
\n\n
\n
Situation
\n
Agent
\n
Regimen: single dose 30-60 min before procedure
\n
\n
\n
\n
\n
Adults
\n
Children
\n
\n\n\n
\n
Oral
\n
Amoxicillin
\n
2 g
\n
50 mg/kg
\n
\n
\n
Unable to take oral medication
\n
Ampicillin OR
\n
2 g IM or IV
\n
50 mg/kg IM or IV
\n
\n
\n
\n
Cefazolin or cefriaxone
\n
1 g IM or IV
\n
50 mg/kg IM or IV
\n
\n
\n
Allergic to penicillins or ampicillin oral
\n
Cephalexin OR
\n
2 g
\n
50 mg/kg
\n
\n
\n
\n
Clindamycin OR
\n
600 mg
\n
20 mg/kg
\n
\n
\n
\n
Azhithromycin or clarithromycin
\n
500 mg
\n
15 mg/kg
\n
\n
\n
Allergic to penicillins or ampicillin and unable to take oral medication
\n
Cefazolin or ceftriaxone OR
\n
1 g IM or IV
\n
50 mg/kg IM or IV
\n
\n
\n
\n
Clindamycin
\n
600 mg IM or IV
\n
20 mg/kg IM or IV
\n
\n\n
Table 5.
Antibiotic prophylaxis regimen.
IM, intramuscular; IV, intravenous.
\n
\n\n',keywords:"odontogenic infection, cellulitis, abscess, multifascial space abscess, management of odontogenic infections, ludwigs angina",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/51850.pdf",chapterXML:"https://mts.intechopen.com/source/xml/51850.xml",downloadPdfUrl:"/chapter/pdf-download/51850",previewPdfUrl:"/chapter/pdf-preview/51850",totalDownloads:3120,totalViews:1534,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,dateSubmitted:"August 11th 2015",dateReviewed:"March 24th 2016",datePrePublished:null,datePublished:"August 31st 2016",dateFinished:null,readingETA:"0",abstract:"Dentoalveolar infections include a wide range of conditions from localized abscesses to deep-neck space infections or more severe cases of necrotizing fasciitis. Odontogenic infections and emergencies are a significant part of an oral and maxillofacial surgeon’s daily practice. On a daily basis, an oral surgeon needs to be prepared to deal with any infection-related emergencies ranging from a toothache, localized vestibular abscess to deep head and neck abscesses. Management of these odontogenic infections could propose a challenge due to complex microbiology of the odontogenic infection and the potential for advancement to a life-threatening emergency. It is crucial that the oral and maxillofacial surgeon has knowledge of anatomic boundaries and fascial spaces to be able to make an accurate diagnosis and perform prompt surgical management. For the patient, odontogenic infections may carry high incidence of morbidity and mortality if not treated promptly. Management of patient with an odontogenic infection is a multifaceted approach involving (1) an examination and assessment of the patient, (2) identifying the source of the infection, (3) anatomic considerations, (4) surgical intervention, (5) administration of the appropriate antimicrobial therapy, and (6) referral to an appropriate provider if indicated. This chapter provides the clinician with a better understanding of diagnosis and pharmacological management as well as surgical treatment of patients with odontogenic infections.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/51850",risUrl:"/chapter/ris/51850",book:{slug:"a-textbook-of-advanced-oral-and-maxillofacial-surgery-volume-3"},signatures:"Robert Pellecchia, Curtis Holmes, Golaleh Barzani and Francesco R.\nSebastiani",authors:[{id:"177670",title:"Dr.",name:"Robert",middleName:null,surname:"Pellecchia",fullName:"Robert Pellecchia",slug:"robert-pellecchia",email:"rpelloms@gmail.com",position:null,institution:{name:"Geisinger Medical Center",institutionURL:null,country:{name:"United States of America"}}},{id:"185973",title:"Dr.",name:"Golaleh",middleName:null,surname:"Barzani",fullName:"Golaleh Barzani",slug:"golaleh-barzani",email:"gbarzani@gmail.com",position:null,institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_1_2",title:"1.1. Patient examination and assessment: review",level:"2"},{id:"sec_3",title:"2. Stages of abscess development",level:"1"},{id:"sec_3_2",title:"2.1. Anatomic considerations",level:"2"},{id:"sec_4_2",title:"2.2. Deep-space neck infection",level:"2"},{id:"sec_5_2",title:"2.3. Surgical intervention",level:"2"},{id:"sec_7",title:"3. Treatment techniques",level:"1"},{id:"sec_7_2",title:"3.1. Microbiology of an odontogenic infection",level:"2"},{id:"sec_8_2",title:"3.2. Antibiotics of choice",level:"2"},{id:"sec_9_2",title:"3.3. Duration of antibiotics",level:"2"},{id:"sec_10_2",title:"3.4. Cost of antibiotics",level:"2"},{id:"sec_11_2",title:"3.5. Antibiotic resistance",level:"2"},{id:"sec_13",title:"4. Complications of antibiotic therapy and drug interactions",level:"1"},{id:"sec_14",title:"5. Management of medication-related osteonecrosis of the jaw",level:"1"},{id:"sec_14_2",title:"5.1. Staging of MRONJ",level:"2"},{id:"sec_16",title:"6. Summary",level:"1"}],chapterReferences:[{id:"B1",body:'\nSato FR, Hajala FA, Freire Filho FW, Moreira RW, de Moraes M. Eight-year retrospective study of odontogenic origin infections in a postgraduation program on oral and maxillofacial surgery. J Oral Maxillofac Surg 2009;67:1.\n'},{id:"B2",body:'\nLypka M, Hammoudeh J. Dentoalveolar infections. Oral Maxillofac Surg Clin N Am 2011;23(3):415–424.\n'},{id:"B3",body:'\nFlynn TR, Shanti RM, Levi MH, et al. Severe odontogenic infections, part 1: prospective report. J Oral Maxillofac Surg 2006;64:1093.\n'},{id:"B4",body:'\nLevi M. The Microbiology of orofacial abscesses and issues in antimicrobial therapy. In: Piecuch JF, editor. Oral and maxillofacial surgery knowledge update 2001. Rosemont, IL: American Association of Oral and Maxillofacial Surgeons; 2001. pp. 5–22.\n'},{id:"B5",body:'\nStoroe W, Haug RH, Lillich TT. The changing face of odontogenic infections. J Oral Maxillofac Surg 2001;59:739.\n'},{id:"B6",body:'\nFlynn TR. Principles and surgical management of head and neck infections. In: Bagheri SC, editor. Current therapy in oral and maxillofacial surgery. St. Louis: Saunders; 2012. pp. 1080–1091.\n'},{id:"B7",body:'\nTimothy M Osborn, et al. Deep space neck infection: principles of surgical management. Oral Maxillofac Surg Clin N Am 2008;20:353–365.\n'},{id:"B8",body:'\nFlynn T. What are the antibiotics of choice for odontogenic infections, and how long should the treatment course last? Oral Maxillofac Surg Clin N Am 2011;23(4):519–536.\n'},{id:"B9",body:'\nKuriyama T, Nakagawa K, Karasawa T, et al. Past administration of b-lactam antibiotics and increase in the emergence of b-lactamase-producing bacteria in patients with orofacial odontogenic infections. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:186–192.\n'},{id:"B10",body:'\nLui DW, Abubaker AO. Odontogenic infection. In: Kademani D, Tiwana P, editors. Atlas of oral and maxillofacial surgery. St. Louis: Saunders; 2016. pp. 145–152.\n'},{id:"B11",body:'\nFreeman RK, Vallieres E, Verrier ED, et al: Descending necrotizing mediastinitis: an analysis of the effects of serial surgical debridement on patient mortality. J Thorac Cardiovasc Surg 2000;119:260.\n'},{id:"B12",body:'\nFlynn TR, Halpern LR: Antibiotic selection in head and neck infections. Oral Maxillofac Surg Clin N Am 2003;15:17.\n'},{id:"B13",body:'\nBrook I. Microbiology and management of periotonsillar, retropharyngeal, and parapharyngeal abscesses. J Oral Maxillofac Surg 2004;62:1545–1550.\n'},{id:"B14",body:'\nHaug R. The changing microbiology of maxillofacial infections. Oral Maxillofac Surg Clin N Am 2003;15:1–15.\n'},{id:"B15",body:'\nKuriyama T, Karasawa T, Nakagawa K, et al. Bacteriologic features and antimicrobial susceptibility in isolates from orofacial odontogenic infections. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:600–608.\n'},{id:"B16",body:'\nRega AJ, Aziz SR, Ziccardi VB. Microbiology and antibiotic sensitivities of head and neck space infections of odontogenic origin. J Oral Maxillofac Surg 2006;64:1377–1380.\n'},{id:"B17",body:'\nFlynn TR. Update on the antibiotic therapy of oral and maxillofacial infections. In: Piecuch JF, editor. Oral and maxillofacial surgery knowledge update 2001. Rosemont, IL: American Association of Oral and Maxillofacial Surgeons; 2001: pp. 23–50.\n'},{id:"B18",body:'\nPoeschl PW, Spusta L, Russmeuller G, et al. Antibiotic susceptibility and resistance of the odontogenic microbiological spectrum and its clinical impact on severe deep space head and neck infections. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;11:151–156.\n'},{id:"B19",body:'\nChardin H, Yasukawa K, Nouacer N, et al. Reduced susceptibility to amoxicillin of oral streptococci following amoxicillin exposure. J Med Microbiol 2009;58(Pt 8):1092–1097.\n'},{id:"B20",body:'\nLewis MA, McGowan DA, MacFarlane TW. Short course high-dosage amoxycillin in the treatment of acute dento-alveolar abscess. Br Dent J 1986;161(8):299–302.\n'},{id:"B21",body:'\nCraig TJ, Mende C. Common allergic and allergic-like reactions to mediations: when the cure becomes the curse. Postgrad Med 1999;105:173–1781.\n'},{id:"B22",body:'\nHersh EV. Adverse drug interactions in dental practice: interactions involving antibiotics. Part II. J Am Dent Assoc 1999;130:236–251.\n'},{id:"B23",body:'\nRuggiero SL, Dodson TB, et al. Medication related osteonecrosis of the jaws—2014 update. American Association of Oral and Maxillofacial Surgeons; J Oral Maxillofac Surg. 2014;72(10): 2–19.\n'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Robert Pellecchia",address:"rpelloms@gmail.com",affiliation:'
Department of Dentistry and Oral Maxillofacial Surgery, Geisinger Medical Center, Danville, PA, USA
Department of Dentistry and Oral Maxillofacial Surgery, The Brooklyn Hospital Center, Brooklyn, NY, USA
'},{corresp:null,contributorFullName:"Francesco R. Sebastiani",address:null,affiliation:'
Department of Dentistry and Oral Maxillofacial Surgery, The Brooklyn Hospital Center, Brooklyn, NY, USA
'}],corrections:null},book:{id:"5112",title:"A Textbook of Advanced Oral and Maxillofacial Surgery",subtitle:"Volume 3",fullTitle:"A Textbook of Advanced Oral and Maxillofacial Surgery Volume 3",slug:"a-textbook-of-advanced-oral-and-maxillofacial-surgery-volume-3",publishedDate:"August 31st 2016",bookSignature:"Mohammad Hosein Kalantar Motamedi",coverURL:"https://cdn.intechopen.com/books/images_new/5112.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"90148",title:"Dr.",name:"Mohammad Hosein",middleName:"Kalantar",surname:"Motamedi",slug:"mohammad-hosein-motamedi",fullName:"Mohammad Hosein Motamedi"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},chapters:[{id:"51850",title:"Antimicrobial Therapy and Surgical Management of Odontogenic Infections",slug:"antimicrobial-therapy-and-surgical-management-of-odontogenic-infections",totalDownloads:3120,totalCrossrefCites:1,signatures:"Robert Pellecchia, Curtis Holmes, Golaleh Barzani and Francesco R.\nSebastiani",authors:[{id:"177670",title:"Dr.",name:"Robert",middleName:null,surname:"Pellecchia",fullName:"Robert Pellecchia",slug:"robert-pellecchia"},{id:"185973",title:"Dr.",name:"Golaleh",middleName:null,surname:"Barzani",fullName:"Golaleh Barzani",slug:"golaleh-barzani"}]},{id:"50951",title:"Complications of Antibiotic Therapy and Introduction of Nanoantibiotics",slug:"complications-of-antibiotic-therapy-and-introduction-of-nanoantibiotics",totalDownloads:1795,totalCrossrefCites:0,signatures:"Esshagh Lasemi, Fina Navi, Reza Lasemi and Niusha Lasemi",authors:[{id:"166999",title:"Dr.",name:"Fina",middleName:null,surname:"Navi",fullName:"Fina Navi",slug:"fina-navi"},{id:"184969",title:"Dr.",name:"Niusha",middleName:null,surname:"Lasemi",fullName:"Niusha Lasemi",slug:"niusha-lasemi"}]},{id:"50504",title:"Shared Medical and Virtual Surgical Appointments in Oral Surgery",slug:"shared-medical-and-virtual-surgical-appointments-in-oral-surgery",totalDownloads:1254,totalCrossrefCites:0,signatures:"Alexandra Radu and Michael P. 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Arcuri, M. Giarda, L. Stellin, A. Gatti, M. Nicolotti, M. Brucoli, A.\nBenech and P. Boffano",authors:[{id:"155785",title:"Dr.",name:"Francesco",middleName:null,surname:"Arcuri",fullName:"Francesco Arcuri",slug:"francesco-arcuri"},{id:"165255",title:"Dr.",name:"Livia",middleName:null,surname:"Stellin",fullName:"Livia Stellin",slug:"livia-stellin"},{id:"165256",title:"Dr.",name:"Alessandro",middleName:null,surname:"Gatti",fullName:"Alessandro Gatti",slug:"alessandro-gatti"},{id:"165258",title:"Dr.",name:"Matteo",middleName:null,surname:"Brucoli",fullName:"Matteo Brucoli",slug:"matteo-brucoli"},{id:"165259",title:"Dr.",name:"Mariangela",middleName:null,surname:"Giarda",fullName:"Mariangela Giarda",slug:"mariangela-giarda"},{id:"165260",title:"Prof.",name:"Arnaldo",middleName:null,surname:"Benech",fullName:"Arnaldo Benech",slug:"arnaldo-benech"},{id:"165261",title:"Dr.",name:"Matteo",middleName:null,surname:"Nicolotti",fullName:"Matteo Nicolotti",slug:"matteo-nicolotti"}]},{id:"45357",title:"Rigid Fixation of Intraoral Vertico-Sagittal Ramus Osteotomy for Mandibular Prognathism",slug:"rigid-fixation-of-intraoral-vertico-sagittal-ramus-osteotomy-for-mandibular-prognathism",signatures:"Kazuma Fujimura and Kazuhisa Bessho",authors:[{id:"162569",title:"Associate Prof.",name:"Kazuma",middleName:null,surname:"Fujimura",fullName:"Kazuma Fujimura",slug:"kazuma-fujimura"}]},{id:"38528",title:"Soft-Tissue Response in Orthognathic Surgery Patients Treated by Bimaxillary Osteotomy. Cephalometry Compared with 2-D Photogrammetry",slug:"soft-tissue-response-in-orthognathic-surgery-patients-treated-by-bimaxillary-osteotomy-cephalometry-",signatures:"Jan Rustemeyer",authors:[{id:"159569",title:"Prof.",name:"Jan",middleName:null,surname:"Rustemeyer",fullName:"Jan Rustemeyer",slug:"jan-rustemeyer"}]},{id:"44955",title:"Corticotomy and Miniplate Anchorage for Treating Severe Anterior Open-Bite: Current Clinical Applications",slug:"corticotomy-and-miniplate-anchorage-for-treating-severe-anterior-open-bite-current-clinical-applicat",signatures:"Mehmet Cemal Akay",authors:[{id:"48935",title:"Prof.",name:"Mehmet Cemal",middleName:null,surname:"Akay",fullName:"Mehmet Cemal Akay",slug:"mehmet-cemal-akay"}]},{id:"45007",title:"Office – Based Facial Cosmetic Procedures",slug:"office-based-facial-cosmetic-procedures",signatures:"Farzin Sarkarat, Behnam Bohluli and Roozbeh Kahali",authors:[{id:"73778",title:"Dr.",name:"Behanm",middleName:null,surname:"Bohluli",fullName:"Behanm Bohluli",slug:"behanm-bohluli"},{id:"163344",title:"Dr.",name:"Farzin",middleName:null,surname:"Sarkarat",fullName:"Farzin Sarkarat",slug:"farzin-sarkarat"},{id:"163346",title:"Dr.",name:"Roozbeh",middleName:null,surname:"Kahali",fullName:"Roozbeh Kahali",slug:"roozbeh-kahali"}]},{id:"44956",title:"Facial Sculpturing by Fat Grafting",slug:"facial-sculpturing-by-fat-grafting",signatures:"Behnam Bohluli, Mehran Aghagoli, Farzin Sarkarat, Mansour\nMalekzadeh and Nima Moharamnejad",authors:[{id:"73778",title:"Dr.",name:"Behanm",middleName:null,surname:"Bohluli",fullName:"Behanm Bohluli",slug:"behanm-bohluli"},{id:"163344",title:"Dr.",name:"Farzin",middleName:null,surname:"Sarkarat",fullName:"Farzin Sarkarat",slug:"farzin-sarkarat"}]},{id:"44958",title:"Diagnosis and Management of Temporomandibular Disorders",slug:"diagnosis-and-management-of-temporomandibular-disorders",signatures:"Fina Navi, Mohammad Hosein Kalantar Motamedi, Koroush Taheri\nTalesh, Esshagh Lasemi and Zahra Nematollahi",authors:[{id:"166999",title:"Dr.",name:"Fina",middleName:null,surname:"Navi",fullName:"Fina Navi",slug:"fina-navi"}]}]}]},onlineFirst:{chapter:{type:"chapter",id:"64630",title:"Process of Risk Management",doi:"10.5772/intechopen.80804",slug:"process-of-risk-management",body:'
1. Definition of risk
Risk is defined in terms of uncertain events which may have positive or negative effect on the project objectives. Risks include circumstances or situations, the existence or occurrence of which, in all reasonable foresight, results in an adverse impact on any aspect of the implementation of the project. Various definitions of risks are presented in Table 1.
The combination of a probability of an event and its consequences
3
Association of Project Management Body of Knowledge [1]
Project Risk is an uncertain event or condition, that, if it occurs, has a positive/negative effect on project objectives. A risk has a cause and if it occurs, a consequence.
4
British Standard BS IEC 62198:2001
Combination of probability of an event occurring and its consequences on project objectives
5
www.business.dictionary.com/definition/risk.html
A probability or threat of damage, injury, liability, loss, or any other negative occurrence that is caused by external or internal vulnerabilities and that may be avoided through preemptive action.
“A chance or possibility of danger, loss, injury or other adverse consequences” and the definition of risk is “exposed to danger.” However, taking risk can also result in positive outcome. A third possibility is risk related to uncertainty of outcome.
Risk has been interpreted as Risk = hazard × exposure where Hazard is defined as the way in which a thing or situation can cause harm and exposure as the extent to which the likely recipient of the harm can be influenced by the hazard
Table 1.
Definitions of risk.
2. Classification of risks
Classification and definition of risks is furnished in Table 2.
Risk
Definitions
Pure risk
A risk which has chance of loss or no loss. Example. A building may get affected by fire or not. These are best covered by insurance
Speculative risk
Involves chance of gain/loss. Example. A builder may take a risk by promoting a new venture depending upon the prevailing conditions in the vicinity of proposed project, but it may bring him gain/loss.
Fundamental risk
These are external to a project and which, if they materialise, would be on a large scale and cannot be prevented. These risks are associated with major natural, economic, political or social changes and generate large scale losses. Examples are: Floods, earthquakes, fluctuation of exchange rates, etc. This risk may or may not be insurable.
Particular risk
These are project specific risks and are identified within the parameters of a project and can be controlled during the implementation of a project, e.g. quality risks, safety risks, legal risks, etc.
Table 2.
Classification of risks and their definitions.
Source: Project Risk Management, D Van Well-Stam et al., Kogan Page Publications, 2003.
3. Introduction to risk management
Risk management is a planned and a structured process aimed at helping the project team make the right decision at the right time to identify, classify, quantify the risks and then to manage and control them. The aim is to ensure the best value for the project in terms of cost, time and quality by balancing the input to manage the risks with the benefits from such act. It is just a cost benefit analysis.
Risk management is a continuous process which is to be implemented in any project from inception to completion. However, in order to realise its full potential, risk management should be implemented at the earliest stage of a project, i.e. feasibility design and construction. Risk is an uncertain event or condition that, if occurs, has a positive or negative effect on a project’s objectives. Components of risk are the probability of the occurrence of an event and the impact of the occurrence of that event. There are many sources of uncertainty in construction projects, which include the performance of construction parties, resources availability, contractual relations, etc. because of which, construction projects face problems that cause delay in the project completion time. Success of a project is measured by its ability to get completed within the budgeted cost and time. These goals are interrelated where each parameter has an impact when other parameters get affected. An accurate cost estimating and scheduling should be performed in order to meet the overall budget and time deadline of a project. As such, risk management becomes an integral part of construction management which intends to identify and manage potential and unforeseen risks during the period of implementation of the project; hence, the necessity of risk management [5].
4. Definitions of risk management
Definitions of risk management are presented in Table 3.
Sl. no
Definition of risk management
1
https://en.wikipedia.org/wiki/Risk_management Risk Management is the identification, evaluation, and prioritization of risks followed by coordinated and an economical application of resources to minimise, monitor, and control the probability or impact of unfortunate events [6] or to maximize the realization of opportunities.
2
Nadeem Ehsan et al., 2012 Risk Management in a project involves the identification of influencing factors which could have negative impact on the the cost, schedule and quality objectives of the project and quantification of impact of potential risk and implementation of mitigation measures to minimise the potential impact of risk
3
Bahamid et al., 2017 Risk Management is defined as organized and comprehensive method tailored towards “ organizing”, “identifying” and “responding” to risk factors in order to achieve project goals.
4
www.stakeholdermap.com/risk/risk-management-construction Risk Management in construction consists of planning, monitoring and implemeting the measures needed to prevent exposure to risk. To do this, it is necessary to identify the hazards, assess the extent of risks, provision of measures to control the risks and to manage residual risk
5
www.vp-projects.kau.edu.sa Risk management is a systematic method of identifying, analysing, treating and monitoring the risks that are all involved in any activity/ process and is a systematic method that minimises the risks which may be an impediment to attainment of objectives
6
Cleden [4] Risk is exposure to the consequences of uncertainty. In a project context, it is the chance of something happening that will have an impact upon objectives. It includes the possibility of loss or gain, or variation from a desired or planned outcome, as a consequence of the uncertainty associated with following a particular course of action. Risk thus has two elements: the likelihood or probability of something happening, and the consequences or impacts if it does.
7
Project Risk Management, D Vanwell-Stam, Kogan Page India publications, 2004 The entire set of activities and measures that are aimed at dealing with risks in order to maintain control over a project
8
www.gpmfirst.com/risk.management-construction Risk Management is a means of dealing with uncertainty – identifying sources of uncertainty and the risks associated with them, and then managing those risks such that negative outcomes are minimized (or avoided altogether), and any positive outcomes are capitalised upon.
9
Risk Management in Construction Projects by NICMAR [2] Risk Management is the planned and structured process of bringing the project team make the right decisions at the right time by identifying, classifying and quantifying the risks and then for managing and controlling them,
10
Dr Patrick et al., 2006 retrieved from feaweb.aub.edu.lb Risk Management is “a systematic way of looking at areas of risk and consciously determining how each should be treated. It is a management tool that aims at identifying sources of risk and uncertainty, determining their impact, and developing appropriate management responses”
11
http://economictimes.indiatimes.com/definition/risk-management Risk Management refers to the practice of identifying potential risks in advance, analysing them and taking precautionary steps to reduce/curb the risk.
Table 3.
Definitions of risk management.
5. Importance of risk management in construction projects
Construction projects are extremely complex and fraught with uncertainty. Risk and uncertainty can potentially have damaging consequences for the construction projects. Hence, risk analysis and risk management has come to be a major feature of the project management in construction projects. Construction projects are unique, inherently complex, dynamic and risks emanate from multiple sources. The interests of individuals and organisations who are actively involved in a construction project may be positively or negatively affected depending upon the course which a project takes from concept to completion. Multiple stakeholders with varied experience and skills have different expectations and interests in the project which creates problems for smooth execution of the project. Risk management is a concept which many construction companies have never thought of, despite the fact that, the risks can be better controlled if they are identified in the first instance and a well-structured mitigation mechanism is in place. Risk management helps the key project participants namely the client, contractor/developer, consultant and supplier to meet their commitments and to minimise negative impacts on construction project performance in relation to cost, time and quality objectives. Success of a construction project is associated with three aspects of time, cost and quality outcomes.
Successful commissioning of any project, necessarily calls for sound planning on various fronts and getting the project executed in a competent manner. An organisation executing a project would have to reckon with the various risks to which the project may be exposed to and these have to be managed effectively. The construction industry, being vulnerable is potentially more prone to risks and uncertainties than any other industry. The process of taking a project from the conceptual stage to its final completion and putting into operation is quite complex and entails painstaking process at every stage. Construction industry is highly fragmented in that each of its participants—designers, constructors, planners, suppliers, etc. can be highly skilled in their own area and yet there is no clear perspective as to how all the players can come on the same platform for achieving the objectives.
Construction industry is also dependent on quality of its people rather than technology. The increasing technological complexity and more complex interdependencies and perpetual shortage of resources namely materials, equipment, technical/supervisory staff, finance, etc. calls for a comprehensive risk management framework which will insulate the risks of the participants to a great extent.
Given the nature of the construction sector, risk management is an extremely important process. It is most widely used in such of those projects where susceptibility to risks is very high and is characterised by planning, monitoring and controlling the risks in a more structured and formal manner. The most efficient method of identifying the risks is to study a project of similar size which was executed in the recent past which gives an insight into the failure/success of the project. In order to be sure that the project objectives are met, the portfolio of risks associated with all stakeholders should be considered across the project life cycle (PLC). In later stages, risk management when applied systemically helps to control those critical elements which can negatively impact project performance. Keeping track of identified threats will result in early warnings to the project manager if any of the objectives, time, cost or quality, are not being met. There are a plethora of risks which are to be identified in the construction industry and which can be faced in each construction project at any point of time regardless of its size and scope. Frequent change in scope is one of the major risks in any construction project. If revised scope or design is implemented, it can have effect in the form of additional resources of time and cost. Early project completion may be as troublesome as delays in a schedule. Completing too early which may be a result of insufficient planning or design problems can lead to a low quality of final product and increased overall cost. Thus it is important to keep a balance in the concept of time–cost-quality trade-off, which more widely is becoming an important issue for the construction sector. Risks may vary depending on the project scope, types and are to be treated accordingly.
Risk identification, the first step in the risk management process is usually informal and is performed in various ways, depending on the organisation and the project team. Identification of risks relies mostly on past experience and study of similar executed projects. This being a preliminary stage, a combination of tools and techniques may be used to identify the risks in any project. Here are many methods that fit specific types of challenges and projects especially at identification stage. Risks and threats may be difficult to eliminate, but when they have been identified, it becomes easy to take actions and have control over them. Risk management will be more effective if the source of the risks have been identified and allocated before any problems occur. The main purpose of risk management is that the stakeholders should prepare for potential problems that can occur unexpectedly during the course of a project. Risk management will not only facilitate anticipating problems in advance, but also preparing oneself for the potential problems that may occur unexpectedly. Handling potential threats is not only a way to minimise the losses within a project, but also a way to transform risks into opportunities which can lead to economic and financial profitability. The purpose of identifying risks is to obtain a list of risks which has got the potential to have a cascading effect on the progress of project and different techniques are applied for managing/mitigating the same. In order to find all potential risks which might impact a specific project, different techniques are applied. The project team should use a method they are familiar with so that the exercise will be effective. Effective identification of risks is the first step to a successful risk management.
Parameter
Methodology
Documentation reviews
A structured review of project documentation, study of history of execution of similar projects and quality of plans as well as the consistency between those plans and project requirements/ assumptions would be an indicator of risks in the project
Information gathering techniques
Brainstorming
Delhi technique
Checklist analysis
Cause and effect diagram
Questionnaires
SWOT analysis
Expert judgement
Table 4.
Identification of risks: tools and techniques.
6.1.1 Risk identification techniques
Tools and techniques for risk identification are presented in Table 4.
Various risks that confront a construction industry are not limited to and include financial, economical, political, legal environmental, technical, contractual, planning/scheduling, design, quality operational labour, stakeholder safety and security, logistics and construction.
6.2 Risk assessment
Risk assessment is the second stage in the risk management process where collated data is analysed for potential risks. Risk assessment is described as short listing of risks starting from low impact highest impact on the project, out of all threats mentioned in the identification phase. Risk assessment consists of qualitative risk assessment and qualitative risk assessment.
6.2.1 Qualitative risk assessment
This involves registration of identified risks in a formal manner. A risk register is used for formalising this process which is not limited to the following
Classification and reference
Description of the risk
Relationship of the risk to other risks
Potential impact
Likelihood of occurrence
Risk response/mitigation strategy
Allocation of risks to stakeholders.
6.2.1.1 Classification and reference
Classification is an aid to identifying the source of risk. Examples are furnished below (Table 5).
Risk
Classification
Environmental
Site conditions, health and safety issues at site
Contractual
Client, contractor, sub-contractor, etc.
Design
Planning permission, preliminary and detailed design, etc.
Table 5.
Classification of risk and its reference.
Referencing refers to unique reference number given for each of the identified risks.
6.2.1.2 Description of the risk
This involves giving a brief description of the risk. The description must be unique in order to avoid confusion with similar risks in the risk management process.
6.2.1.3 Relationship to other risks
In any project, it is extremely rare that any activity is independent of activities which occurs concurrently or consequentially and this will always be the case for risks also for successful implementation of risk management,
6.2.1.4 Potential impact (I)
Impact of risk on a project is measured in terms of cost and quality. Since this assessment is done at an early stage of the project, information may not be available to accurately predict the impact of risk on the project. At this stage, the risk is classified suitably and accordingly high impact risks are to be given more fundamental consideration than that of medium/low/negligible risks by ranking the impact of risks on a scale of 1 (low) to 10 (high).
6.2.1.5 Likelihood of occurrence (P) and calculation of risk factor (RF)
Based on intuition and experience, the likelihood of occurrence (P) of risks and its impact (I) is to be given on a suitable scale ex. 1–10 (1 refers to low probability and 10 refers to high probability). The risk factor for each of the identified risks is calculated by the formula RF = P + I – (P*I) (where the values of P and I are brought on a scale of 0–1 by dividing the values with 10).
6.2.1.6 Risk response/mitigation strategy
This action is taken to reduce, eradicate or to avoid the identified risks. The most common among the risk mitigation methods are risk avoidance, risk transfer, risk reduction and risk sharing. Based on the competency in handling the risks, the identified risks are allocated to respective stakeholders who will be responsible for addressing those risks.
6.3 Quantitative risk assessment
This risk assessment is normally taken for such of those risks which are classified are high/critical/unmanageable as per the qualitative risk assessment. The purpose of this assessment is to find the amount of contingency to be inserted in the estimate for the risks undergoing this assessment so that in case the risks occur, there would be sufficient budgeted amount to overcome the extra expenditure.
Quantitative methods need a lot of analysis to be performed. This analysis should be weighed against the effort and outcomes from the chosen method. Complex and larger projects require more in depth analysis as compared to projects which are small in size. The purpose of carrying out quantitative analysis is to estimate the impact of a risk in a project in terms of scope, time, cost and quality. The suitability of this analysis is more for medium and large projects as these projects have more complex risks as compared to smaller projects.
The detailed quantitative assessment of risk is the one which is identified as risk analysis. In undertaking quantitative assessment, the potential impact of risks in terms of time, cost and quality is quantified. While preparing the estimate, it is generally split into two distinct elements, namely (1) base estimate of those items which are known and a degree of certainty exists and (2) contingency allowance for all uncertain elements of a project. Historically, contingencies have been calculated on a rule of thumb basis varying from 5 to 10% on risk-free base estimate. By adopting risk management approach, contingencies are set up to reflect realistically the risks that are inherent in the project. When used correctly, contingency allowances ensure that expenditure against risks is controlled. The methods for quantitative risk assessment are described below.
6.3.1 Scenario technique: Monte Carlo simulation
The Monte Carlo method is based on statistics which are used in a simulation to assess the risks. This is a statistical technique whereby randomly generated data is used within predetermined parameters and produce realistic project outcomes. The overall project outcome is predicted by randomly simulating a combination of values for each risk and repeating the calculation a number of times and all outcomes are recorded. After completing the simulations required, the average is drawn from all of the outcomes, which will constitute the forecast for the risk. It is important to realise that parameters and appropriate distribution within which the random data is simulated is itself a series of subjective inputs. Accurate and realistic project outcomes will not be generated if inaccurate parameters are set. Different scenarios are generated by simulation are used for forecasting, estimations and risk analysis. Data from already executed projects is normally collected for simulation purpose. The data for variables is presented in terms of pessimistic, most likely and optimistic scenarios depending upon the risks encountered, i.e. pessimistic value means lot of risks and optimistic value means least risks. The result from this method is a probability of a risk to occur is often expressed as percentage. The most common way of performing the Monte Carlo simulation is to use the program Risk Simulator Palisade Software, where more efficient simulations can be performed.
6.3.2 Modelling technique: sensitivity analysis
This is a method used to demonstrate the variable impact on the whole caused by a change in one or more element or risk. It is used to test the robustness of choices made where rankings have been established, particularly when those rankings are considered to be marginal. It can identify the point where variation in one parameter will affect decision making. A typical method for carrying out sensitivity analysis is by use of a spider diagram which shows the areas in the project which are the most critical and sensitive The higher the level of uncertainty a specific risk has, the more sensitive it is concerning the objectives. In other words, the risk events which are the most critical to the project are the most sensitive and appropriate action needs to be taken (Heldman, 2005). Disadvantage with this analysis is that the variables are considered separately, which means that there is no connection between them (Perry, 1986 and Smith et al.. 2006). The method requires a project model in order to be analysed with computer software. According to Smith et al. (2006), the project stands to be benefited if the analysis is carried out in the initial phases of a project in order to focus on critical areas during the execution of the project.
6.3.3 Decision tree
Decision tree analysis is commonly used when there is sequence of interrelated possible courses of action and future outcomes in terms of time and cost. This method of analysis is commonly used when certain risks have an exceptionally high impact on the two main project objectives, i.e. time and cost. Where probabilities and values of potential outcomes are known or can be estimated, they are used for quantification to provide a more informed basis for decision making. Each decision process expected value (EV) which forms the basis for decision making process. A sample problem on decision tree is given in Table 6.
Method
Design time (months)
Construction period in months and probabilities
Total time (construction period + design time) (months)
This can be depicted in the form of decision trees and the expected value (EV) in terms of time for each of the three scenarios is furnished. The least of this i.e. construction management will be preferred since it consumes less time.
6.3.4 Multiple estimating using risk analysis
Multiple estimating using risk analysis (MERA) attempts to provide a range of estimates. These are presented as risk free base estimate, average risk estimate (ARE) and maximum likely risk estimate (MLRE). ARE is the sum of risk free base estimate and average risk allowance and MLRE is the sum of ARE and maximum risk allowance.
MERA attempts to finds a level i.e. the estimate that has a 50% chance of being successful. This is known as average risk estimate (ARE) which is found out by multiplying the average allowance with average probability of occurrence. Maximum risk allowance is found out by multiplying the maximum allowance with maximum probability of occurrence of that risk. This is added to ARE to get MLRE which is the estimate that has 90% chance of not being exceeded.
6.3.5 Quantitative risk assessment: outputs
The output of quantitative risk assessment is presented in Table 7.
Parameter
Outputs
Probabilistic Analysis of project
Estimates are made of potential project schedule and cost outcomes listing the possible completion dates and costs with their confidence levels. This output is described as cumulative distribution and also risk tolerances for permitting quantification of cost and time contingency reserves. Contingency reserves bring the risk of overshooting stated project objectives to acceptable levels to the organisation
Prioritised list of quantified risks
This list includes risks that pose the greatest threat or present the greatest opportunity in a project. These risks also have the greatest impact on cost contingency
Trends in quantitative risk analysis results
As the risk analysis is repeated, a trend becomes apparent that leads to conclusions affecting risk responses, Historical information on project’s schedule, cost, quality and performance reflects new insights gained through quantitative process. This takes the form of quantitative risk analysis report.
Table 7.
Quantitative risk assessment: outputs.
6.4 Risk response planning
The risk response will be in the form of mitigation by adopting necessary strategies in respect of positive and negative risks which is furnished below (Tables 8–10).
Risk mitigation strategy
Description
Risk avoidance
Risk avoidance involves changing the project management plan to eliminate the threat entirely. The project manager may isolate the project objectives that are in jeopardy. Examples: (a) Extending the schedule of an activity; (b) Changing the strategy or reducing the scope of work; (c) Changes in clauses of contract regarding abnormal price rise of any material or dealing with extra quantum of work.
Risk transfer
Risk transfer requires shifting some or all of the negative impact of a threat along with ownership of the response to a third party. Examples are
Risk transferred to Consultant
Design Risk, technical Risk and Foundations for all major structures
Risk transferred to Insurance Company
Security of materials at site, Fire Hazards, Boiler operations, safety of electrical rooms, loss in Turbines and Generators, Unforeseen Risks, etc.
Risk reduction
Risk reduction implies reduction in the probability and consequence of an adverse risk event to be within acceptable threshold limits. Conducting detailed tests or choosing a more stable supplier are some examples. Risk reduction is adopted where the resultant increase in costs is less than the potential loss that could be caused by the risk being mitigated. Examples are:
Preparedness to tackle any natural disaster
Detailed site investigation where adverse ground conditions are known to exist but the full extent is not known. A detailed ground investigation was performed upon which an estimate was prepared.
Contingency planning
Removal of engineering/structural barriers
Strengthening the quality assurance procedures
Paying higher amount than recommended by Govt for land acquisition
Design as per standards
Risk acceptance
This strategy is adopted when it is not possible to eliminate all risks from a project. This strategy indicated that the project team had decided not to change the project management plan or is unable to identify any other suitable response strategy. This requires no action except to document the strategy leaving the project team to deal with risks as they occur
Table 8.
Strategies for mitigating negative risks.
Risk mitigation strategy
Description
Exploit
This strategy is selected for risks with positive impacts where the organisation wishes to ensure that the opportunity is realised. This strategy seeks to eliminate the uncertainty associated with a particular risk by ensuring that the opportunity is exploited. Examples are assigning the most talented resources of the organisation to the project to reduce the time for completion or providing at a lower cost than originally planned
Share
Sharing a positive risk involves allocating some or all of the ownership of the opportunity to a third party capable of capturing the opportunity for the benefit of the project. Risk sharing, joint ventures, etc. are examples of this strategy
Enhance
This strategy is used to enhance the positive impact of an opportunity. Identifying and maximising key drivers of risks may increase their probability of occurrence. Examples are adding more resources to an activity for completing it before scheduled time
Accept
Accepting an opportunity means willing to take advantage if it comes along, but not pursuing it actively.
Contingent response strategies
Some responses are designed for implementation only if certain events occur. It is appropriate for the project team to prepare a contingency response plan that will be executed under certain predefined conditions if there will be sufficient warning to implement the plan
Expert judgement
Expert judgement is from knowledgeable individuals pertaining to the actions to be taken on a specific and a defined risk.
Table 9.
Risk mitigation strategies for positive risks/opportunities.
Source: Project Risk Management, Van Well Stam et al. 2008.
Sl. No
Contents
1
Identified risk. Their descriptions, areas of project affected, their causes and how they affect project objectives
2
Risk owners and assigned responsibilities
3
Prioritised list of project risks based on the outputs from quantitative analysis reports
4
Agreed upon response strategies and specific actions taken to implement the strategy
5
Triggers, symptoms and warning signs of risks occurrence
6
Fallback plans as a reaction to a risk that has occurred and primary response proved to be inadequate
7
Contingency reserves to be calculated based on quantitative risk analysis of the project and the threshold risk of the organisation.
Table 10.
Contents of risk response: outputs.
6.5 Monitoring and controlling risks: inputs
Inputs to monitoring and controlling of risks are presented in Table 11.
6.5.1 Monitoring and controlling risks: tools and techniques
Tools and Techniques for monitoring and controlling risks are furnished in Table 12.
Parameter
Inputs
Risk register
The key inputs to risk register includes identified risks and owners of risk, agreed upon risk responses, specific actions to be implemented, symptoms/warning signs of any risk, residual/secondary risks, list of low priority risks and contingency measures in terms of time/cost
Risk management plan
The risk management plan should contain risk tolerances, assignment of manpower including bearer of risk, time and other resources to project risk management
Work performance information
Work performance information related to various performance results is to be quantified in terms of deliverable status, schedule progress and costs incurred.
Performance reports
Performance reports will be analysed for variance analysis, earned value data and forecasting the likely date of completion of project
Monitoring and controlling of risks will result in identification of new risks, reassessment of current risks and closing of risks that are not a threat to project. Project risk assessment is to be performed regularly. The frequency and depth of assessment depends on how the project progresses relative to the objectives.
Risk audits
The purpose of risk audits is to examine and document the effectiveness of risk responses in dealing with identified risks and their root causes as well as effectiveness of the risk management process meetings. A separate risk audit meeting may be held or it may be included in routine project review meetings.
Earned value analysis
Variance analysis is done by comparing the planned results with actual. Trends in execution of a project are reviewed using performance information and based on earned value analysis, deviation from cost and schedule targets is determined which may indicate potential impact of threat/opportunities.
Technical performance measurement
This measures technical accomplishments during project execution and will help in forecasting degree of success in achieving the project scope and it may expose the degree of technical risk faced by the project
Reserve analysis
This compares the amount of contingency reserves available at any time to the amount of risk remaining in the project to determine whether the reserves are adequate
Status meetings
Project risk management should be an agenda item at all status review meetings. The amount of time for any item will depend on risks that have been identified, their priority and difficulty of response. Frequent discussions about risk make it more likely that concerned stakeholders will identify risks and opportunities.
Table 12.
Monitoring and controlling risks: tools and techniques.
To maximise the efficiency of risk management, the risk management process should be continuously developed during the entire project.
The benefits from risk management finally go to the stakeholders involved. A clear understanding and awareness of potential risks in the project contributes to better management of risks by suitable mitigation techniques. Another benefit of working with risk management is increased level of control over the whole project and more efficient problem solving processes which can be supported on a more genuine basis
Risk management when conducted effectively, reduce sudden surprises. The advantage with risk management is that the stakeholders are aware as to the risk that they have to bear among all the risks that have been identified in a project and can prepare themselves accordingly, should any eventuality occur. No doubt, this formal exercise may translate into extra cost for an activity, but if taken in holistic manner, the benefits will far outweigh the costs. This has another advantage in that there is no passing of buck as risks are either shared/retained or transferred depending upon the ability of the stakeholder to handle the risk. The three approaches to risk management are normally risk natural firm which does not invest much in risk management but is still aware of important risk, risk averse firm where no investments are made and the last one is risk seeker wherein the organisation is prepared to face all risks and is often called gambler. The outcome of the objectives of project naturally depends upon the path adopted by the firms in their approach to risk management.
8. Conclusions
The fact that there are manifold risks which can be identified in any construction project is explained by their size and complexity. Bigger the project is, the larger the number of potential risks that may be faced.
Occurrence of risk is stimulated by several factors. Most often the risks faced in any project are financial, environmental (surrounding location of project and overall regulations), time, design and quality. The technology used for construction and the internal environment also contributes to risk which can have substantial bearing on the outcome of a project.
Risks are directly proportional to complexity of a project. Bigger and more complex a project is, the more resources are required to complete it. In spite of identifying all potential risks, there might be more potential threats. Therefore, the project team should not solely focus on management of those identified risks but also be alert for any new potential risks which may arise during execution.
Risk management is a tool for managing risks in a project and a project manager should be prepared for managing uncertainties not included in a risk management plan.
Effective management of risky project demands rapid and realistic predictions of alternative courses of action and positive decision making and requires flexible attitudes and procedures.
Perception of severity and frequency of occurrence of risk is to be done in tandem between the stakeholders. This will eliminate lot of unnecessary correspondence as well as misunderstanding and friction between the stakeholders
Insurance is just one aspect of risk mitigation and it cannot absorb all the risks. Insurance is project specific and it should be taken as per the needs of client/contractor. Other ways of risk mitigation needs to be explored.
Adoption of good project management practices like proper planning and implementation, willingness of stake holders to share the risks in the project is essential for success of a project
Executing a complex project requires meticulous planning, i.e. planning to the smallest details, and this can be achieved through concerted dedication from the concerned stakeholders.
Risks are to be thoroughly studied and understood before bidding for the project.
Special care should be taken regarding the seasonal variation of labourers, so that the construction activities does not get delayed due to shortfall in manpower resources during execution, which can have adverse effects on cost and time
Proper risk allocation techniques should be framed between the stakeholders so that in the event of occurrence of a risk, this will eliminate doubts as to which stakeholder should address the risk
Given its complexity, risk management is a very important process in construction projects. It is most widely used in those projects which exhibits high level of uncertainty. Formal planning, assessment and monitoring/control process characterises risk management in such projects.
Risk management procedures should be initiated in the early stages of the project where planning and contracting of work, together with the preliminary capital budget are being chalked out. In later stages, Risk management applied systemically, helps to control those critical elements which can have negative impact on project performance.
Keeping track of identified threats, will result in early warnings to the project manager if any of the objectives, time, cost or quality, is being met or not.
Risks in complex construction projects can be mitigated by entering into various agreements like execution, operation/maintenance, etc.
Proper risk strategy formulation and research is necessary based on real life experiences so that identification of potential risks and providing solutions can produce effective and efficient risk strategies to overcome impacts of risk events.
Risk identification is the first step in the risk management process. It means that the identification of risks which is informal relies mostly on past experience of similar executed projects and that of advice from experts. There are a good number of methods for identifying the risks in a project and a combination of methods may be used for identification of risks in a project.
Handling potential threats is not only a way to minimise losses within the project, but also a way to transform risks into opportunities, which can lead to economical profitability and finally, .it is suggested that if risks are given due care at all stages of the project, stakeholders will be showered with manifold benefits subsequent to commissioning of project
\n',keywords:"risk management, risk assessment, risk mitigation",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/64630.pdf",chapterXML:"https://mts.intechopen.com/source/xml/64630.xml",downloadPdfUrl:"/chapter/pdf-download/64630",previewPdfUrl:"/chapter/pdf-preview/64630",totalDownloads:1155,totalViews:1768,totalCrossrefCites:0,dateSubmitted:"April 19th 2018",dateReviewed:"August 8th 2018",datePrePublished:"March 8th 2019",datePublished:"April 17th 2019",dateFinished:null,readingETA:"0",abstract:"Cost saving and timely performance are of utmost importance to all stakeholders who are involved in a construction project that is owner, contractor, consultant and subcontractor. The prime causes of risks in construction projects involve delay and failure to complete the work at specified cost and within the agreed time frame. Unexpected delays in construction projects are caused by internal and external environments embedding several risk factors which may occur concurrently. The cost overrun and schedule overrun not only influence the construction industry’s completion of a project but can also have profound effect on the economy of a country. Even though the failure of the construction projects to get completed within the budgeted cost and time has received attention by researchers, lot more need to be researched as to what can be done to have tight leash on construction projects so that they can be brought on track. In order to meet the stiff deadlines involving complexity of construction projects, the scheduling of projects should be flexible enough to accommodate changes without negatively affecting the overall project cost and duration. This chapter deals with Perspectives on Risk Assessment and Management Paradigms as applicable to any project in general and construction industry in particular.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/64630",risUrl:"/chapter/ris/64630",signatures:"K. Srinivas",book:{id:"7573",title:"Perspectives on Risk, Assessment and Management Paradigms",subtitle:null,fullTitle:"Perspectives on Risk, Assessment and Management Paradigms",slug:"perspectives-on-risk-assessment-and-management-paradigms",publishedDate:"April 17th 2019",bookSignature:"Ali G. Hessami",coverURL:"https://cdn.intechopen.com/books/images_new/7573.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"108303",title:"Prof.",name:"Ali G.",middleName:null,surname:"Hessami",slug:"ali-g.-hessami",fullName:"Ali G. Hessami"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"255339",title:"Prof.",name:"K",middleName:null,surname:"Srinivas",fullName:"K Srinivas",slug:"k-srinivas",email:"ksrinivasap@gmail.com",position:null,institution:null}],sections:[{id:"sec_1",title:"1. Definition of risk",level:"1"},{id:"sec_2",title:"2. Classification of risks",level:"1"},{id:"sec_3",title:"3. Introduction to risk management",level:"1"},{id:"sec_4",title:"4. Definitions of risk management",level:"1"},{id:"sec_5",title:"5. Importance of risk management in construction projects",level:"1"},{id:"sec_6",title:"6. Risk management process",level:"1"},{id:"sec_6_2",title:"6.1 Identification of risks",level:"2"},{id:"sec_6_3",title:"6.1.1 Risk identification techniques",level:"3"},{id:"sec_8_2",title:"6.2 Risk assessment",level:"2"},{id:"sec_8_3",title:"Table 5.",level:"3"},{id:"sec_8_4",title:"Table 5.",level:"4"},{id:"sec_9_4",title:"6.2.1.2 Description of the risk",level:"4"},{id:"sec_10_4",title:"6.2.1.3 Relationship to other risks",level:"4"},{id:"sec_11_4",title:"6.2.1.4 Potential impact (I)",level:"4"},{id:"sec_12_4",title:"6.2.1.5 Likelihood of occurrence (P) and calculation of risk factor (RF)",level:"4"},{id:"sec_13_4",title:"6.2.1.6 Risk response/mitigation strategy",level:"4"},{id:"sec_16_2",title:"6.3 Quantitative risk assessment",level:"2"},{id:"sec_16_3",title:"6.3.1 Scenario technique: Monte Carlo simulation",level:"3"},{id:"sec_17_3",title:"6.3.2 Modelling technique: sensitivity analysis",level:"3"},{id:"sec_18_3",title:"Table 6.",level:"3"},{id:"sec_19_3",title:"6.3.4 Multiple estimating using risk analysis",level:"3"},{id:"sec_20_3",title:"Table 7.",level:"3"},{id:"sec_22_2",title:"6.4 Risk response planning",level:"2"},{id:"sec_23_2",title:"6.5 Monitoring and controlling risks: inputs",level:"2"},{id:"sec_23_3",title:"Table 11.",level:"3"},{id:"sec_26",title:"7. Benefits with risk management",level:"1"},{id:"sec_27",title:"8. Conclusions",level:"1"}],chapterReferences:[{id:"B1",body:'Association of Project Management Body of Knowledge. Retrieved from: http://www.cs.bilkent.edu.tr/~cagatay/cs413/PMBOK.pdf'},{id:"B2",body:'Banaitiene N, Banaitis A. Risk Management in Construction Projects. Retrieved from: https://cdn.intechopen.com/pdfs/38973/IntechRisk_management_in_construction_projects_pdf'},{id:"B3",body:'Chicken JC, Posner T. The Philosophy of Risk, Vol. 21. London: Thomas Telford; 1998'},{id:"B4",body:'Cleden D. Managing Project Uncertainty, 1st ed. Great Britain: Gower Publishing Ltd; 2009'},{id:"B5",body:'Cooper D, Grey S, Raymond G, Walker P. Project Risk Management Guidelines—Managing Risk in Large Projects and Complex Procurements. Wiley Publishers; 2005. ISBN 9780470022825'},{id:"B6",body:'De Marco A, Thaheem MJ. Risk analysis is construction projects—A practical selection methodology. American Journal of Applied Sciences. 2014;11(1):74-84'},{id:"B7",body:'Institute of Risk Management. Retrieved from: https://www.theirm.org/media/886059/ARMS_2002_IRM.pdf'},{id:"B8",body:'Adams J. 1995. Retrieved from: http://www.john-adams.co.uk/wp-content/uploads/2017/01/RISK-BOOK.pdf'},{id:"B9",body:'Hopkin P. Fundamentals of Risk Management. 5th ed. Great Britain: Kogan Page Limited; 2013'},{id:"B10",body:'Project Management Institute. Guide to Project Management Body of Knowledge. 4th ed. USA: PMI; 2008. ISBN 978-1-933890-51-7'},{id:"B11",body:'Risk Management. India: School of Distance Education, National Institute of Construction Management and Research'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"K. Srinivas",address:"ksrinivasap@gmail.com",affiliation:'
National Institute of Construction Management and Research, Pune, Maharashtra, India
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