Management of Severe Odontogenic

Infections

Dr Venezia Sharma

QVH East Grinstead

Overview

• Definition

• Complications

• Progression of Infection

• Fascial Spaces

• Assessment

• Management/Treatment

Definition

• An odontogenic infection is an acute or chronic infection originating from tooth related pathology

• 3 categories• Localised• Diffuse Widespread • Life threatening

Complications

Localised (periodontal, periapical, post surgical, pericoronal). They may begin as well-delineated, self limiting infections with a dangerous potential to spread

They could potentially track down into deep neck spaces and further still, become life threatening emergency referral

Presentation • Slowly enlarging swelling, dull ache or recurrent

draining abscess that swells and drains spontaneously not likely to require immediate treatment – patients immune response is effectively containing spread of infection

• Rapidly enlarging swelling causing dyspnoea, dysphagia and severe trismus requires aggressive and prompt attention – patients immune system unable to contain infection

Progression

If left untreated, odontogenic infections can spread and

contribute to polymicrobial infections at other sites:

• Sinuses Brain (Intracranial spread)• via Bloodstream (sepsis, cavernous sinus thrombosis)

• Deep Neck Spaces (Ludwig’s Angina)• Lungs, Pericardium (Mediastinitis)• Necrotizing fasciitis

Fascial Spaces

– Buccal space– Infraorbital space– Infratemporal space– Submental/Sublingual spaces– Submandibular space– Submasseteric space– Lateral and Retro pharyngeal spaces– Pterygomandibular space

Pathway of Spread:Infratemporal Space

• Usual Source – maxillary 3rd molars

• Boundaries – skull base, lat. pterygoid plate, continuous with temporal spaces

Pathway of SpreadInfraorbital Space Infection

Pathway of SpreadBuccal Space Infection

Pathway of SpreadMasseteric Space Infection

Pathway of SpreadSubmandibular Space Infection

(from lower molar)

Pathway of Spread Bilateral Submandibular and Sublingual

Space Infection(Ludwig’s Angina)

Assessment

• ABC (airway, stridor, anaesthetist support, HDU/ITU)

• Clinical assessment (source, location, nature)

• Full detailed History– Vital signs (systemically well? fever, tachycardia, malaise)

– Onset, duration, rapidity– Previous treatment ?– Radiographs ( locate source)

– Medically compromised (immunosuppressed, diabetic, alcoholism, neutropaenic)

Main Principles of Management

• Stabilise patient (airway, Sats/02)• IVI’s (antibiotics, fluids)• Investigations (Bloods, Xrays, US, CT)• Surgical Intervention

– Remove the cause– Establish drainage

• Regular review until signs of improvement• Care, nutrition, rest

Pathway of Spread Bilateral Submandibular and Sublingual

Space Infection(Ludwig’s Angina)

Ludwig’s Angina

• Rapidly spreading, indurated, bilateratal cellulitis that begins in the FOM and involves both the submandibular and sublingual spaces.

• Spreads along fascial planes. Not through lymphatics.• Commonly arises from odontogenic infections. (70-80%)

• 2nd and 3rd molars usually involved, as roots extend beyond mylohyoid muscle, thus crossing both submandibular and sublingual spaces

• Polymicrobial (commonly streptococcus, Staph and Bacteroides)

Ludwig’s AnginaClinical Manifestations:

Pain in FOM and anterior neck region, dysphagia, odynophagia, respiratory distress are common findings.

Fever, tachypnea, tachycardia, Stridor, hoarsness, cyanosis, resp. distress may suggest upper airway compromise.

Severe trismus, firm raised FOM, non pitting induration of submental and submaxillary spaces

Ludwig’s AnginaDiagnosis:Along with CT scans, plain radiographs of the neck are useful to show soft tissue swelling, presence of gas,extent of airway narrowing.Management:Airway management: Due to risk of rapid airway compromise, anaesthetic support and admission to ITUare important.IV antibiotic therapy, IV Dex.Surgical incision and drainage, removal of source.Close monitoring in ITU improvement.

Ludwig’s Angina

Ludwig’s Angina usually resolves without

complications, but in some unfortunate

situations, the condition can be FATAL!

Case Presentation 1

Ludwig’s Angina Associated

With Molar Infection

Resident & Staff Physician 2006; Vol. 52; 8

Case Presentation 1• 47 yr female • Presented to A&E, toothache assoc to LR molar along

with 4/7 Hx of facial swelling and pain• Drooling• Dysphagia• Difficulty speaking• Severe trismus

PMH: Hypertension, Cocaine use, poor OH Vital Signs: Temp 38 C, BP 108/63, HR 120, Resps 30

Resident & Staff Physician 2006; Vol. 52; 8

Case Presentation 1• 47 yr female • Presented to A&E, toothache assoc to LR molar along

with 4/7 Hx of facial swelling and pain• Drooling• Dysphagia• Difficulty speaking• Severe trismus

PMH: Hypertension, Cocaine use, poor OH Vital Signs: Temp 38 C, BP 108/63, HR 120, Resps 30

Resident & Staff Physician 2006; Vol. 52; 8

Case Presentation 1

O/E:

Swelling RT mandible and LT face, with overlying erythema, hot and tender to touch, taut but with no crepitus.

Tongue was protruding.

LR7 was necrotic.

No stridor.

Resident & Staff Physician 2006; Vol. 52; 8

Case Presentation 1

Investigations:

WBC 27.8Blood cultures (-) veUrine (+) ve cocaine

CT – swelling with inflamm. changes and air within soft tissues along the entire mandible

Resident & Staff Physician 2006; Vol. 52; 8

Case Presentation 1Diagnosis: Ludwig’s Angina secondary to necrotic

LR7

Treatment:

Pt was nasally intubated and transferred to ITU

Broad spec. IV Abs and IV fluids

On days 5 and 11, pt underwent surgery

Extraction of LR carious molars. Intra and extra oral

drains placed.

Patients condition continued to deteriorate.

Died on day 14. Autopsy revealed an abscess in the FOM

and upper RT neck region. Resident & Staff Physician 2006; Vol. 52; 8

Case Presentation 2

Mortality Associated With

An Odontogenic Infection !

BDJ 190, 529-530, 2001

Case Presentation 2• 25 male • 3/7 Hx rapidly advancing bilat neck swelling

O/E: Severe trismus (1cm opening)Raised FOMSlight dysphagiaNo respiratory problems

PDH: irregular attender, 4/12 general intermittent dental painOPG gross caries both RT and LT lower

Quads

PMH: NRMH

BDJ 190, 529-530, 2001

Case Presentation 2

BDJ 190, 529-530, 2001

Preoperative OPG showing carious teeth with assoc. periapical pathology

Case Presentation 2

• Treatment– Taken to theatre within 3 hrs of presenting– Awake FOI and IV Abs commenced– R/O carious teeth and E/O incisions– No frank pus located– E/O drains placed

Over next 2 days condition significantly improved

Dx home, oral Abs

BDJ 190, 529-530, 2001

Case Presentation 22/7 later pt reattendedPyrexial, not been taking medsDifficulty swallowing. Pus draining from E/O incision

Blood cultures IV Benzyl Pen / MetronidazoleMonitored regularlyMarked improvement in swelling and swallowingDx home, oral Abs, r/v 1/52

BDJ 190, 529-530, 2001

Case Presentation 2 No further contact made by pt

On day of f/u appt, pt in A&E - emergency ambulance

At home suffered sudden haemorrhaging from oral cavity respiratory arrest

O/E Hb 5.8

bleeding from aerodigestive tract NOT orally

Despite resuscitation died 2 hrs later

BDJ 190, 529-530, 2001

Case Presentation 2

At post mortem abscess found at root of neck communicating with op site. It involved subclavian vein and partially destroyed it.

Subsequent haemorrhage tracked behind pleura through into pleural cavity massive haemothorax

BDJ 190, 529-530, 2001

Case Presentation 2

On admission, CXR showed a mass RT chest, which on post mortem was found to be blood trapped beneath the parietal pleura.

BDJ 190, 529-530, 2001

Case Presentation 2 Post mortem showed lateral pharyngeal space to be

reservoir of infection, tracking down around carotid sheath, to the root of the neck.Further clarification – ideally MRI or US

(clearly define spaces and differentiate between abscess/cellulitis)

However, as the patients clinical condition was improving, there was no indications for further imaging.

This case highlights the importance of taking all odontogenic infections seriously.

BDJ 190, 529-530, 2001

THANK YOU