ODONTOGENIC INFECTION

Babak Saedi

Tehran university of medical science

Background Among most frequently encountered

infections in human body Plagued our species for as long as we have

existed Pre-Columbian Indians, unearthed in the

American Midwest Early Egypt revealed bony crypts of dental

abscesses, sinus tracts, and the ravages of osteomyelitis of the mandible

Treatment of localized dental infection was probably the first primitive surgical procedure performed, using a sharp stone or pointed stick to establish drainage

MICROBIOLOGY OF ODONTOGENIC INFECTIONS Usually caused by endogenous bacteria Aerobic bacteria alone rarely causative agents Streptococcus species are usually the etiologic

organisms if aerobic bacteria present Half odontogenic infections: anaerobes Most odontogenic infections due to mixed flora Mixed infections may have 5-10 organisms

present

Continued…. Bacterial composition

1. 5%-aerobic bacteria 2. 60%-anaerobic bacteria3. 35% mixed aerobic and anaerobic bacteria

Commonly cultured organisms: alpha-hemolytic Streptococcus, Peptostreptococcus, Peptococcus, Eubacterium, Bacteroides (Prevotella) melaninogenicus, and Fusobacterium.

Quantitative estimations of the number of microorganisms in saliva and plaque range as high as 1011/ml.

Presentation

History-previous toothaches, onset, duration, presence of fever, and previous treatments (antibiotics ) important

Patients may complain of trismus, dysphagia and have shortness of breath should be investigated.

Findings vary from mild swelling and pain to life-threatening airway compromise and CNS impairment

Continued….

Possibly fatal infections may present with respiratory impairment, dysphagia, impaired vision, ophthalmoplegia, hoarseness, lethargy and decreased level of consciousness

Exam findings: Toxic, CNS impairment (decreased level of consciousness, meningeal irritation, severe headache, and vomiting), eyelid edema; and ophthalmoplegia.

Continued…. Rubor- (redness) cutaneous surface involved due

to vasodilatation effect of inflammation Tumor-(swelling) occurs due to the accumulation

of pus or fluid exudate Calor-(heat) is the result of increased blood flow to

the area due to the vasodilatation. Dolor-(or pain) results from pressure on sensory

nerve endings from tisssue distention caused by edema or infection

Functiolaesa-(loss of function) problems with mastication, trismus, dysphagia, and respiratory impairment

Continued…. Inspection, palpation, and percussion are

integral parts of the exam Begin extraorally and then move inraorally Skin of the face, head, and neck for

swelling, fluctuation, erythema, sinus or fistula formation, and subcutaneous crepitus

Assess for cervical lymphadenopathy and fascial space involvement

Assess for the presence and magnitude of trismus

Continued…. Inspect teeth for presence of caries and

large restorations, localized swellings, fistulas, and mobility

FOM inspected to assess for fascial space involvement

Visualize Wharton’s and Stenson’s ducts for quality of fluid (pus or saliva)

Ophthalmologic examination: extraocular muscle function, proptosis, presence of preseptal or postseptal edema

Potential pathways of extension of deep fascial space infections of the head and neck

Alveolar bone

Soft tissue

Fascial space

Alveolar bone

Soft tissue

Fascial space

Trait of anatomyTrait of anatomy

Tooth

Caries

Pulpitis

Apical infection

Caries

Pulpitis

Apical infection

Continued….

Fascial Spaces Fascial planes offer anatomic highways for

infection to spread superficial to deep planes Antibiotic availability in fascial spaces is

limited due to poor vascularity Treatment of fascial space infections

depends on I and D Fascial spaces are contiguous and infection

readily spreads from one space to another (open primary and secondary spaces)

Despite I and D the etiologic agent (tooth) must be removed

Primary Mandibular Spaces Submental space

1. Infection can result directly due to infected mandibular incisor or indirectly from the submandibular space

2. Space located between the anterior bellies of the digastric muscle laterally, deeply by the mylohyoid muscle, and superiorly by the deep cervical fascia, the platysma muscle, the superficial cervical fascia, and the skin

3. Dependent drainage of this space is performed by placing a horizontal incision in the most dependent area of the swelling extraorally with a cosmetic scar being the result

Continued…. Submandibular Space

1. Boundaries:1. Superior-mylohyoid muscle and inferior border of

the mandible

2. Anteriorly-anterior belly of the digastric muscle

3. Posteriorly-posterior belly of the digastric muscle

4. Inferiorly-hyoid bone

5. Superficially-platysma muscle and superficial layer of the deep cervical fascia

2. Infected mandibular 2nd and 3rd molars cause submandibular space involvement since root apices lay below mylohyoid muscle

Submandibular Space Abscess

Sublingual Space Infection

Continued….

Buccal Space1. Boundaries:

1. Lateral-Skin of the face

2. Medial-Buccinator muscle

2. Both a primary mandibular and maxillary space

3. Most infections caused by posterior maxillary teeth

Buccal Space Abscess

Secondary Mandibular Spaces

Referred to as secondary spaces since they are infected after involvement of primary mandibular spaces

Failure to treat a primary space infection or a compromised host results in secondary space involvement

Connective tissue fascia has poor blood supply hence treatment usually surgical to drain purulent exudates

The secondary mandibular spaces include the masseteric, pterygomandibular, and temporal spaces

Continued….

Masseteric Space1. Located between lateral aspect of the

mandible and the masseter muscle

2. Involvement of this space generally occurs from buccal space primary involvement

3. Signs of involvement of the masseteric space include trismus and posterior-inferior face swelling

Continued….

Pterygomandibular Space1. Location: between medial aspect of the

mandible and the medial pterygoid muscle (communicates with infratemporal spaces)

2. 2ndary infection results from spread from the sublingual and submandibular spaces

3. Symptoms: 1. Trismus

2. Minimal swelling on exam

Continued…. Temporal Space

1. Location: posterior and superior to the masseteric and pterygomandibular spaces

2. Bounded laterally by the temporalis fascia and medially by the temporal bone

3. Two components:1. Superficial temporal space: located

between temporal fascia and temporalis muscle

2. Deep temporal space: located between the temporalis muscle and the temporal bone1. Continuous with the infratemporal space

Continued…. Masseteric, pterygomandibular, and

temporal spaces referred to as masticator space due to delineation by the muscles of mastication

1. Communicate freely with one another and are simultaneously involved

Secondary Mandibular Spaces

Primary Maxillary Spaces Canine Space

1. Location: between the levator anguli oris and the levator labii superioris muscles

2. Involvement primarily due to maxillary canine tooth infection

3. Long root allows erosion through the alveolar bone of the maxilla

4. Signs: 1. Obliteration of the nasolabial fold 2. Superior extension can involve lower eyelid

Buccal Space1. Posterior maxillary teeth are source of most buccal space

infections2. Results when infection erodes through bone superior to

attachment of buccinator muscle

Continued…. Infratemporal Space

1. Location: posterior to the maxilla 2. Boundaries:

1. Medial: lateral plate of the pterygoid process of the sphenoid bone

2. Superior: skull base 3. Lateral: infratemporal space is continuous

with the deep temporal space 3. Rare involvement with odontogenic

infections, but when occurs related to 3rd maxillary molar infections

Continued…. Primary maxillary space (canine, buccal,

and infratemporal space) involvement can ascend to cause orbital cellulitis (preseptal or postseptal) or cavernous sinus thrombosis

1. Ocular findings include erythema and swelling of the eyelids, and ophthalmoplegia

2. Cavernous sinus thrombosis 1. Can result from hematogenous spread of odontogenic

infections 2. Bacterial routes of spread:

1. Posterior: via pterygoid plexus or emissary veins 2. Anterior: via angular vein and inferior or superior

ophthalmic veins to the cavernous sinus3. Veins of the face and orbit valve less so retrograde flow

can occur

Orbital Abscess

Deep Neck Spaces Extension of odontogenic infections beyond the

primary spaces of maxilla and mandible is uncommon When occurs upper airway compromise and

descending mediastinitis are possible adverse sequelae

Posterior spread of ptyerygomandibular space infection is to lateral pharyngeal space

Lateral Pharyngeal space 1. Shape of an inverted cone with its base at the skull base and

its apex at the hyoid bone2. Location: medial to the medial pterygoid muscle and lateral

to the superior pharyngeal constrictor muscle 3. Anterior: pterygomandibular raphe4. Posterior: prevertebral fascia.

Continued…. Lateral pharyngeal space communicates with

retropharyngeal space. The styloid process separates posterior

compartment of the lateral pharyngeal space that contains the great vessels from the anterior space

Clinical presentation1. Severe trismus2. Lateral swelling of the neck3. Bulging of the lateral pharyngeal wall4. Rapid progression of infection in this space is common 5. Posterior compartment involvement can result in

thrombosis of the internal jugular vein, erosion of the carotid artery or its branches, and interference with cranial nerves IX to XII

Lateral Pharyngeal Space Abscess

Ludwig’s Angina

Early Ludwig's angina

Management of Odontogenic Infections Goals of management of odontogenic

infection:1. Airway protection

2. Surgical drainage

3. Medical support of the patient

4. Identification of etiologic bacteria

5. Selection of appropriate antibiotic therapy

Infection in masseteric spaceInfection in masseteric space

Infection in multi-spaceInfection in multi-space

Ludwig’s angina

Ludwig’s angina

Thank

you

Thank

you