Download Odontogenic infection

Babak Saedi
Tehran university of medical science
Background
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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
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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….
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Bacterial composition
1.
2.
3.
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5%-aerobic bacteria
60%-anaerobic bacteria
35% mixed aerobic and anaerobic bacteria
Commonly cultured organisms: alphahemolytic 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
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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.
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Continued….
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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….
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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
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Potential pathways of extension of deep fascial space infections of the head and neck
Trait of anatomy
Tooth
Caries
Alveolar
bone
Pulpitis
Soft tissue
Apical
infection
Fascial space
Continued….
Fascial Spaces
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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
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Submental space
1.
2.
3.
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
Continued….
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Submandibular Space
1.
Boundaries:
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2.
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
Submandibular Space Abscess
Sublingual Space Infection
Continued….
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Buccal Space
1. 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
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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….
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Masseteric Space
1. 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 posteriorinferior face swelling
Continued….
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Pterygomandibular Space
1. 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….
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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 bone
1. Continuous with the infratemporal space
Continued….
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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
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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
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Buccal Space
1. Posterior maxillary teeth are source of most buccal space
infections
2. Results when infection erodes through bone superior to
attachment of buccinator muscle
Continued….
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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….
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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
2. Cavernous sinus thrombosis
1.
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2.
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
3. Veins of the face and orbit valve less so retrograde
flow can occur
1.
2.
Orbital Abscess
Deep Neck Spaces
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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
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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.
Continued….
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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
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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
Lateral Pharyngeal Space
Abscess
Ludwig’s Angina
Early Ludwig's angina
Management of Odontogenic
Infections
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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 space
Infection in multi-space
Ludwig’s
angina
Thank
you