Odontogenic infection

1. Babak Saedi Tehran university of medical science Odontogenic infection

2. 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

3. 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

4. Continued…. • Bacterial composition • 5%-aerobic bacteria • 60%-anaerobic bacteria • 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.

5. 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

6. 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.

7. 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

8. 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

9. 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

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

11. Trait of anatomy Tooth Caries Pulpitis Apical infection Alveolar bone Soft tissue Fascial space

12. Continued….

14. 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

15. Primary Mandibular Spaces • Submental space • Infection can result directly due to infected mandibular incisor or indirectly from the submandibular space • 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 • 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

16. Continued…. • Submandibular Space • Boundaries: • Superior-mylohyoid muscle and inferior border of the mandible • Anteriorly-anterior belly of the digastric muscle • Posteriorly-posterior belly of the digastric muscle • Inferiorly-hyoid bone • Superficially-platysma muscle and superficial layer of the deep cervical fascia • Infected mandibular 2nd and 3rd molars cause submandibular space involvement since root apices lay below mylohyoid muscle

17. Submandibular Space Abscess

18. Sublingual Space Infection

19. Continued…. • Buccal Space • Boundaries: • Lateral-Skin of the face • Medial-Buccinator muscle • Both a primary mandibular and maxillary space • Most infections caused by posterior maxillary teeth

20. Buccal Space Abscess

21. 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

22. Continued…. • Masseteric Space • Located between lateral aspect of the mandible and the masseter muscle • Involvement of this space generally occurs from buccal space primary involvement • Signs of involvement of the masseteric space include trismus and posterior-inferior face swelling

23. Continued…. • Pterygomandibular Space • Location: between medial aspect of the mandible and the medial pterygoid muscle (communicates with infratemporal spaces) • 2ndary infection results from spread from the sublingual and submandibular spaces • Symptoms: • Trismus • Minimal swelling on exam

24. Continued…. • Temporal Space • Location: posterior and superior to the masseteric and pterygomandibular spaces • Bounded laterally by the temporalis fascia and medially by the temporal bone • Two components: • Superficial temporal space: located between temporal fascia and temporalis muscle • Deep temporal space: located between the temporalis muscle and the temporal bone • Continuous with the infratemporal space

25. Continued…. • Masseteric, pterygomandibular, and temporal spaces referred to as masticator space due to delineation by the muscles of mastication • Communicate freely with one another and are simultaneously involved

26. Secondary Mandibular Spaces

27. Primary Maxillary Spaces • Canine Space • Location: between the levator anguli oris and the levator labii superioris muscles • Involvement primarily due to maxillary canine tooth infection • Long root allows erosion through the alveolar bone of the maxilla • Signs: • Obliteration of the nasolabial fold • Superior extension can involve lower eyelid • Buccal Space • Posterior maxillary teeth are source of most buccal space infections • Results when infection erodes through bone superior to attachment of buccinator muscle

28. Continued…. • Infratemporal Space • Location: posterior to the maxilla • Boundaries: • Medial: lateral plate of the pterygoid process of the sphenoid bone • Superior: skull base • Lateral: infratemporal space is continuous with the deep temporal space • Rare involvement with odontogenic infections, but when occurs related to 3rd maxillary molar infections

29. Continued…. • Primary maxillary space (canine, buccal, and infratemporal space) involvement can ascend to cause orbital cellulitis (preseptal or postseptal) or cavernous sinus thrombosis • Ocular findings include erythema and swelling of the eyelids, and ophthalmoplegia • Cavernous sinus thrombosis • Can result from hematogenous spread of odontogenic infections • Bacterial routes of spread: • Posterior: via pterygoid plexus or emissary veins • Anterior: via angular vein and inferior or superior ophthalmic veins to the cavernous sinus • Veins of the face and orbit valve less so retrograde flow can occur

30. Orbital Abscess

31. 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 • Shape of an inverted cone with its base at the skull base and its apex at the hyoid bone • Location: medial to the medial pterygoid muscle and lateral to the superior pharyngeal constrictor muscle • Anterior: pterygomandibular raphe • Posterior: prevertebral fascia.

32. 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 presentation • Severe trismus • Lateral swelling of the neck • Bulging of the lateral pharyngeal wall • Rapid progression of infection in this space is common • 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

33. Lateral Pharyngeal Space Abscess

34. Ludwig’s Angina

35. Early Ludwig's angina

36. Management of Odontogenic Infections • Goals of management of odontogenic infection: • Airway protection • Surgical drainage • Medical support of the patient • Identification of etiologic bacteria • Selection of appropriate antibiotic therapy

37. Infection in masseteric space

38. Infection in multi-space Ludwig’s angina

39. Thank you