sign in sign up
<<
Home , Buccal space, Canine space, Deep temporal space, Drooling, Infratemporal space, Orbicularis oris muscle

ODONTOGENTIC INFECTIONS

The Host

The Organism The Environment

In a state of homeostasis, there is  Peter A. Vellis, D.D.S. a balance between the three.

PROGRESSION OF ODONTOGENIC Infection Spread Determinants INFECTIONS • Location, location , location 1. Source 2. density 3. Muscle attachment 4. Fascial planes

 “The Path of Least Resistance”

Odontogentic Infections Progression of Odontogenic Infections

• Common occurrences • Periapical due primarily to caries • Periodontal and periodontal • Soft tissue involvement disease. – Determined by perforation of the cortical bone in relation to the muscle attachments • Odontogentic infections • ‐ acute, painful, diffuse borders can extend to potential • fascial spaces. ‐ chronic, localized pain, fluctuant, well circumscribed. INFECTIONS Severity of the Infection Classic signs and symptoms: • Dolor- Pain Complete Tumor- Swelling History Calor- Warmth – Chief Complaint Rubor- Redness – Onset Loss of function – Duration – Symptoms Difficulty in breathing, swallowing, chewing

Severity of the Infection Physical Examination

• Vital Signs • How the patient – Temperature‐ feels‐ Malaise systemic involvement >101 F • Previous treatment – Blood Pressure‐ mild • Self treatment elevation • Past Medical – Pulse‐ >100 History – Increased Respiratory • Review of Systems Rate‐ normal 14‐16 –

Fascial Planes/Spaces Fascial Planes/Spaces

• Potential spaces for • Primary spaces infectious spread – Canine between loose – Buccal connective tissue – Submandibular – Submental • Planes compartmentalize – Sublingual structures (muscle, – Vestibular , vessels) Fascial Planes/Spaces Base of the Upper

• Secondary spaces become involved via spread from primary space infections – Masseteric – Pterygomandibular – Infratemporal – Superficial/Deep Temporal – Lateral/Retropharyngeal – Prevertebral – Periorbital Source – Maxillary incisors

Palatal Swelling

Upper lip swollen Anatomic Location: Alar base and nasal tip elevated Between the palatal cortical bone and Labial vestibule obliterated mucoperiosteum

Canine Space

Clinical Presentation:

Anatomic Location: Obliterated Superiorly by the levator muscles of upper lip and lower eye lid Anteriorly by the orbicularis oris muscle Swelling of the vestibule Posteriorly by the and zygomaticus muscle. Periorbital Space Periorbital (Preseptal) Lies between the orbicularis oculi Space and the orbital septum Clinical Presentation: Redness and swelling of the , may obstruct vision

INFECTIOUS SWELLINGS OF THE DENTODENTO-- MANDIBULAR FACIAL VESTIBULE ALVEOLAR RIDGES (VESTIBULAR ABSCESS)

 Anatomic location

 Signs and symptoms  Anatomic location

 Signs and symptoms  Odontogenic origin

 Odontogenic origin  Pattern of spread  Pattern of spread  Risk  Risk

LOW LOW

SPACE OF THE BODY OF THE (SUBPERIOSTEAL ABSCESS)

 Anatomic location

 Signs and symptoms

 Odontogenic origin

 Pattern of spread

 Risk

LOW Submental space

 Anatomic location Odontogenic origin: Mandibular incisors, chin,  Signs and symptoms lower lip or tip of .

 Odontogenic origin

 Pattern of spread

 Risk

MOD

Submental space

• Located between the mylohyoid and platysma superio‐inferiorly • Between the diverging anterior bellies of the digastric muscles laterally. • Communicates with posteriorly.

Submental Space Infection Submental space Sign and symptoms: • Swollen area under the chin, in the middle third of the mandible. They may have difficulty swallowing and elevation of the tongue is usually not seen. Patterns of spread: • May spread to submandibular spaces unilaterally or bilaterally and then to the parapharyngeal spaces. • Move inferiorly to involve fascial planes of the neck. • Move superiorly and involve the . Submental Space Infection Sublingual space

 Superior to the and inferior to the mucosa of the floor of the .  Lingual surfaces of the mandible are this space’s lateral and anterior borders.  , geniohyoid and muscles can divide this space into two sections

Sublingual space Sublingual space Signs and symptoms: usually there is no external swelling, patients may experience Odontogenic origin: Usually caused by infection discomfort during swallowing and may have involving any mandibular tooth( incisors, canines, elevation of the tongue. premolars and mesial roots of the first molars) that has its apex above the mylohyoid muscle.

Patterns of spread:

. PosterioPosterio--inferiorlyinferiorly into the submandibular space.

. PosterioPosterio--laterallylaterally into the or .

Sublingual Space Infection Sublingual Space Infection Submandibular Space Infection Submandibular space

• Lies inferior to the mylohyoid muscle. • Located medial to the body of mandible. • Medial boundaries are mylohyoid and hypoglossus muscles • Lateral borders are body of mandible and platysma. • Anterior and posterior bellies of and the lower border of the mandible form the .

Submandibular space Submandibular space

Signs and symptoms Patterns of spread:

Swellingwelling of the submandibular region  Sublingual space by extending around the posterior border of the mylohyoid or by perforating the mylohyoid.  Feels hard due to localization of the deep to  Submandibular space on the opposite side. the platysma.  Fascial planes of the neck by extending inferiorly. There is a limited range of opening due to  Parapharyngeal or pterygomandibular spaces by extending interference with muscle activities. Patients may posteriorly. have a higher potential for developing a systemic spread of this infection.  by extending superiosuperio--posteriorly.posteriorly.

Submandibular space Ludwig’s angina

Odontogenic origin: Anatomic location: It is a massive bilateral cellulites involving mandibular fascial spaces including the sublingual, submandibular Most frequent causes of this space infection are the and submental spaces. Usually the pharyngeal spaces become dental , pericornitis of mandibular molars involved and post surgical infections.  which penetrate the lingual cortical plate below the attachment of the mylohyoid muscle drain into this space. Soft tissue infections in the retromolar area may spread directly into this space. Ludwig’s angina Ludwig’s angina Sign and symptoms: Odontogenic origin:  Swelling may displace the tongue upwards and backward. . Infection from mandibular teeth can spread to the  The external clinical appearance is an indurated massive bilateral submental, sublingual and submandibular spaces. submandibular swelling, which extends down the anterior part of the .The spread from any of the above spaces to all of them neck to the clavicles. constitutes clinical syndrome termed Ludwig’s angina.  Patients frequently have up to 104°F. Swallowing is difficult, breathing becomes progressively more labored and is evident. Pattern of spread:  Spread to the via fascial planes in the neck.  Cause glottic edema and lead to respiratory obstruction

Ludwigs angina

Ludwig’s angina is an acute medical emergency requiring immediate hospitalization.

SWELLINGS OF THE LATERAL FACE AND

SWELLINGS OF THE LATERAL FACE • Maxillary Buccal Vestibule AND CHEEK • • Masseteric space • Deep temporal space • Superficial temporal space Parotid space MAXILLARY BUCCAL VESTIBULE BUCCAL SPACE

BUCCAL SPACE Buccal Space

• Boundaries: Buccinator muscle and/or medially. Skin laterally. posteriorly.zygomatic arch superiorly. Lower border of the mandible inferiorly. Zygomatic muscle and depressors anteriorly.

MASSETERIC SPACE Masseteric Space

• Anatomic Location: • Source of Infection: – Lateral surface of the usually impacted 3rd in ramus which discharge is – Medial surface of the through the lingual masseter cortical plate. Apices may very close or within space MASSETERIC SPACE Temporal Space Infection

Parotid Space Pharyngeal Spaces

• These infections can become increasingly more severe, with greater complications and morbidity. • Difficult to treat due the poor blood supply, which diminishes the effectiveness of . • Often require immediate surgical intervention to Parotid Space Pain, trismus drain Medial bulge of posterior lateral pharyngeal wall Cause—, , Sjogren’s syndrome

Pharyngeal Spaces Pterygomandibular Space

• If your patient does not show signs of external swelling, and yet the signs and symptoms of infection are present (such as trismus, fever, toxicity, etc.), then examination of the pharyngeal area may reveal anterior pillar or pharyngeal area swelling.

• Pharyngeal swelling may ultimately develop from infections of most other fascial spaces.

• Pharyngeal swelling may be due to odontogenic infections or it may be the result of tonsillar or infections of the . Pterygomandibular Space

• Anatomic Location: located between the medial surface of the ramus of the mandible and the lateral surface of the . • Limited superiorly by the lateral pterygoid which separates this space from the . • Principal contents are the inferior alveolar neurovascular bundle, the lingual nerve, and the chorda tympani.

Pterygomandibular Space Pterygomandibular Space • Signs and Symptoms: • Moderate to severe trismus. • Odontogenic Origin: associated • Moderate swelling of the tonsillar pillar medially. with partially erupted • Tenderness can be elicited over the medial aspect of mandibular third molars. the mandible; however, this symptom would be • Contaminated needle difficult to recognize in the presence of severe used or the injection site trismus. is not disinfected prior to the injection. • Mandibular second molar infections

Pterygomandibular Space Pterygomandibular Space

• Patterns of Spread: • Risk: HIGH. – superiorly to involve the temporal spaces • Regarded as EXTREMELY SERIOUS due to the close – antero‐medially, then posteriorly to involve parapharyngeal spaces proximity to the lateral pharyngeal, retropharyngeal – anteriorly and laterally to involve the buccal and spaces and fascial planes of the neck. submasseteric spaces • These infections REQUIRE CLOSE SUPERVISION BY – anteriorly to the infratemporal space SPECIALISTS and frequently involve hospitalization of – anteriorly and inferiorly to the submandibular space. the patient. Parapharyngeal Spaces

Signs and Symptoms: • High fever and significant malaise • Pain on swallowing is extreme and there is some limitation of opening • The tonsil and lateral pharyngeal wall are pushed towards the opposite side of the mouth, the uvula is also deflected medially, but the soft is not affected. • There may be slight external swelling

Parapharyngeal Spaces Parapharyngeal Spaces • Patterns of Spread: – inferiorly via and fascial planes of the neck • Odontogenic Origin: to the mediastinum and pericardium. – superiorly to the temporal spaces, , foramen Most result from ovale, and brain. infections of the mandibular third • Risk: HIGH. Infections of parapharyngeal spaces are molar area. EXTREMELY SERIOUS and require IMMEDIATE hospitalization. Their anatomical location and serious • Peritonsillar abscesses complications require immediate, aggressive, and may also spread to the expert care. lateral pharyngeal space.

Parapharyngeal Spaces Lateral Pharyngeal Space • Lateral pharyngeal • Anatomic location: A potential cone‐shaped space with the skull as the roof, while the apex is closely associated with • Retropharyngeal spaces the carotid sheath below. • Between the medial pterygoid muscle laterally and the superior constrictor muscle and extends inferiorly to the . • Below the hyoid bone this space is contiguous with the which leads to the mediastinum. Lateral Pharyngeal Space Lateral Pharyngeal Space Abscess

Cervical Spaces Cervical Spaces

• Odontogenic Origin: Dental infections involving • Signs and Symptoms: can vary in clinical most fascial spaces of the head can spread directly or appearance depending upon the specific fascia or layer involved. The following may indirectly to the fascial planes of the neck. be involved: • Risk: High. The seriousness of any infection – Brawny swelling of the neck – Difficulty in swallowing (regardless of source) involving any of the cervical – Difficulty in breathing fascia cannot be over‐emphasized and immediate – Obliteration of the sternal notch referral to a specialist or hospital is essential! – Signs of inflammation can vary depending upon the depth of the involved space from the skin

Peritonsillar Absces Presentation/Origin

• Peritonsillar Space – Fever, malaise – , – “Hot‐potato” voice, trismus, bulging of superior tonsil pole and , deviation of uvula – Cause—extension from Microbiology Aerobic

• Most infections are Polymicrobial, 5‐8 species • Streptococci 70% of • Staphylococci 6% Mixed aerobic/anaerobic: 60% • Misc 1% Anaerobic only: 35% • Rare: Neisseria, Corynebacterium, Aerobic only: 5% Haemophilus, Group D

Anaerobic Micro‐pathophysiology

• G+ cocci 33% (Strepto., Pepto., and • Initial infection by aerobic bacteria. Produces Peptostrepto‐coccus each 11%) cellulitis without pus‐this can spread rapidly‐ • G+ rods 15% (Eubacterium and Lactobacillus) local tissue becomes hypoxic and acidic ‐ • G‐ rods 50% (Prevotella(Bacteroides) 34%), anaerobic bacti., then grow, destroying tissue Fusobacterium 13%) and causing pus production and abscess formation

Imaging Imaging

• High‐resolution Ultrasound • Contrast enhanced CT – Advantages – Advantages • Avoids radiation • Quick, easy • Widely available • Portable • Familiarity – Disadvantages • Superior anatomic detail • Not widely accepted • Differentiate abscess and cellulitis • Operator dependent – Disadvantages • Inferior anatomic detail • Ionizing radiation – Uses • Allergenic contrast agent • Following infection during therapy • Soft tissue detail • Image guided aspiration • Artifact Imaging Infection Management

• Contrast enhanced CT • Treat surgically – Modality of choice • Remove the source – Miller, et al: CT vs. PE • Open the involved spaces ‐ drain • Accuracy of diagnosis: CT = 77%, PE = 63% • • Sensitivity: CT = 95%, PE = 55% Appropriate Abx coverage • Medical support and Re‐evaluation

Surgical Management Incision & Drainage

• Extraction vs Total Pulpectomy • Avoid areas of function • I & D • Incise thru healthy tissue • Drain placement • Incise in a dependant area • Incise over bone when possible • Use blunt dissection • Always suction and cultures in hand

Drains I & D and Drains

• Place in dependant site, to depth of • Increase blood flow to site dissection, secure to skin with • Change the bacterial population of site nonresorbable suture • Decrease the bacterial load at site • If possible place drain in each involved • Allow for irrigation of site space • Allow for C & S and Gram staining • If deep gradually back drain out Surgical Treatment Surgical Treatment

• Provide drainage • Incision and drainage • Remove the cause of – Dependent site infection – Incision in healthy – Pulpectomy tissue – Extraction – Adequate drainage – Remove foreign body – Exploration of all – Debride non‐viable involved spaces bone – Irrigation • Culture and sensitivity

Surgical Treatment Indications for Culture and Sensitivity Testing • Rapidly spreading infection • Post‐op infection • Non‐responsive infection • Recurrent infection • Compromised host defenses

Culture and Sensitivity Microbiologic Considerations

• Identification of bacteria – Representative specimen collected – Examine specimen – Submit for culture and sensitivity – Gram Stain Choosing the Appropriate Principles of Therapy Antibiotic • Use Empiric Therapy • Is an antibiotic • Use narrowest necessary? spectrum drug • Indications: • Use antibiotic with the lowest toxicity – Acute onset infection – Diffuse swelling • Use bactericidal – Compromised host antibiotic defenses • Be aware of Cost $$$ – Involvement of fascial spaces – Severe pericoronitis

Antibiotic Cost Comparison Principles of Antibiotic Therapy

• Administer the Drug Dose Cost for 10 days antibiotic properly • Pen VK QID $1.20 • Proper route of administration • E‐mycin QID $3.20 • Proper dose • Keflex QID $4.00 • Proper time interval • Duricef BID $37.80 • Adequate period of • Cipro BID $34.20 administration

Antibiotic Compliance Antibiotic Use Indications

• Dosage interval that encourages • Acute onset compliance • Diffuse swelling QD or BID 70% • Compromised host defenses QID 40% • Trismus • Non‐compliant after start feeling • Involved Fascial spaces better • 3‐5 days 50% Cardinal signs – >7 days 20% fever – tachycardia Antibiotic Administration Antibiotic Agents

• Proper Dosage and Interval • Penicillin G or V • Narrow Range *(ASAP) • Penicillinase Resistant Penicillin • Peak plasma level 4‐5 X Minimum Inhibitory • Concentration (MIC) • • Continue 2‐3d after resolution of infection • Erythromycin • Ciprofloxacin • Gentamycin

Ext Spectrum Pens with Clav. Clindamycin

• Augmentin and Timentin • Spectrum: Aerobes, Alpha hemolytic Strept, • Spectrum: All anaerobes, Streptococci, meth. S.aureus, G+ and G‐ anaerobes (Clostridium, Sensitive S.aureus, S.epidermidis, H. Actinomyces) Influenzae, Enterococcus • Good bone penetration • Pseudomonas aeuruginosa sensitive to ticarcillin

Clindamycin Clindamycin

• Mechanism: Bacteriostatic, inhibits protein • Dose: PO 150‐450mg q6h synthesis by binding to the 50s bacterial IV150‐900mg q6‐8h ribosomal subunit, Bactericidal at high blood levels • Adverse Effects: Pseudomembranous colitis (toxin produced by overgrowth of C.difficile) Metronidazole Metronidazole

• Spectrum: G‐ and obligate anaerobes • Adverse effects: Convulsive seizures, n/v, including Bacteroides fragilis peripheral neuropathy, diarrhea, reversible • Mechanism: Bactericidal (in bacti cell wall , rash, pruritis chemical reduction produces cytoxic product) • Dose: PO 500mg TID • Doesn’t cross blood brain barrier IV15mg/kg load 7.5mg/kg q6h

Development of an adverse reaction?

CASE #1 CASE #1 CASE #1 QUESTIONS ???