OdontogenicOdontogenic
Infection 1Infection 1
Dr. Adel I. AbdelhadyDr. Adel I. Abdelhady
BDS, MSc ( Tanta, Eg.), PhD (Egyp...
Odontogenic InfectionOdontogenic Infection
Infection due to
dental cause.
Oral flora is the
main source of OI:
Aerobic and...
Oral flora is the main source ofOral flora is the main source of
odontogenic infectionodontogenic infection
bacteriabacter...
Routes ofRoutes of
odontogenicodontogenic
infectionsinfections
▼▼
PulpalPulpal
oror
PeridontiumPeridontium
oror
SystemicSy...
Infection Arising and SpreadingInfection Arising and Spreading
 Effectiveness of patientEffectiveness of patient
immune m...
The Anatomical Factors InfluencingThe Anatomical Factors Influencing
the direction of spread within thethe direction of sp...
Sequence of odontogenicSequence of odontogenic
infectionsinfections
fascial spaces
Soft tissue &
cortical bone
Erosion of ...
Alveolar
bone
Soft tissue
Fascial space
Alveolar
bone
Soft tissue
Fascial space
Trait of anatomyTrait of anatomy
Tooth and...
Odontogenic infectionOdontogenic infection
• Periapical infection
•Periodontal
• Pericoronitis
• Periapical infection
•Per...
PericoronitisPericoronitis
Lower third molarLower third molar
Periapical infectionPeriapical infection
Acute-chronic
Periapical
infection
Acute-chronic
Periapical
infection
Fistular
Ce...
Pathways of Periapical infectionPathways of Periapical infection
Changing directionsChanging directions
 Localization andLocalization and
recoveryrecovery
 Acute chronicAcute chronic
 ...
Inflammation as a Sign of Odontogenic InfectionInflammation as a Sign of Odontogenic Infection
 Inflammation is an import...
Types of InflammationTypes of Inflammation
 There are two fundamentalThere are two fundamental
types of inflammation:type...

Life Threatening Infection
Intraoral infection with a skin fistula
Acute InflammationAcute Inflammation
 A series of responses of small bloodA series of responses of small blood
vessels an...
MicrobiologyMicrobiology
 Odontogenic infections are multi-Odontogenic infections are multi-
microbial:microbial:
 Gram ...
Host FactorsHost Factors
Immunity against intraoral infection isImmunity against intraoral infection is
composed of three ...
Humoral FactorsHumoral Factors
 Circulating immunoglobulins, along withCirculating immunoglobulins, along with
complement...
Cellular factorsCellular factors
 Phagocytes engulf and kill microbes,Phagocytes engulf and kill microbes,
removing them,...
Local FactorsLocal Factors
 Specific factors leading to resistance:Specific factors leading to resistance:
 Abundant vas...
Host defence mechanismsHost defence mechanisms
LocalLocal
defencesdefences
HumoralHumoral
defencesdefences
CellularCellula...
Compromised host defencesCompromised host defences
UncontrolledUncontrolled
metabolic diseasesmetabolic diseases
Suppressi...
Clinical FeaturesClinical Features
 Inflammation is tissue responseInflammation is tissue response
to injury or invasion ...
Oral tissue examinationOral tissue examination
 Examine quality and consistency:Examine quality and consistency:
 Soft t...
Examination, con’tExamination, con’t..
 Identify causative factors:Identify causative factors:
 Tooth, root tip, foreign...
How to diagnoseHow to diagnose??
 Local Signs and SymptomsLocal Signs and Symptoms
 Systemical Signs and SymptomsSystemi...
Local Signs and SymptomsLocal Signs and Symptoms
 PainPain
 SwellingSwelling
 Surface erythemaSurface erythema
 Pus fo...
Systemical Signs and SymptomsSystemical Signs and Symptoms
 FeverFever
 LymphadenopathyLymphadenopathy
 MalaiseMalaise
...
Management of odontogenicManagement of odontogenic
infectioninfection
 Prevention of the odontogenic infection is thePrev...
To avoid the following complicationsTo avoid the following complications::
 Scaring and sinus & fistulaScaring and sinus ...
The routes by which theThe routes by which the
infection can spreadinfection can spread
 1-By direct continuity through t...
Site at Which Pus AccumulatesSite at Which Pus Accumulates
 Pus tends to accumulate in specific regions whichPus tends to...
AnatomyAnatomy
Fascial space loose connective tissue
Among skin, maxillary and muscle
•Purulent--- spreading way
•Do not e...
Thank you & have a nice
day
Thank you & have a nice
day
Odontogenic Infection 2Odontogenic Infection 2
Dr. Adel I. AbdelhadyDr. Adel I. Abdelhady
BDS, MSc ( Tanta, Eg.(, PhD (Egy...
Sequence of odontogenicSequence of odontogenic
infectionsinfections
fascial spaces
Soft tissue &
cortical bone
Erosion of ...
Alveolar
bone
Soft tissue
Fascial space
Alveolar
bone
Soft tissue
Fascial space
Trait of anatomyTrait of anatomy
Tooth and...
CellulitisCellulitis
initial stage of infectioninitial stage of infection
 Diffuse, warm, erythematousDiffuse, warm, eryt...
True abscess formationTrue abscess formation
 As inflammatory responseAs inflammatory response
matures, may develop a foc...
Cellulitis Vs AbscessCellulitis Vs Abscess
Diffuse swelling
Localized swelling
Differences between cellulitis and abscessDifferences between cellulitis and abscess
CharacteristicsCharacteristics Cellul...
Types of odontogenic infectionTypes of odontogenic infection
 Simple, localised and controllableSimple, localised and con...
Simple odontogenic infectionSimple odontogenic infection
Infection of fascial spacesInfection of fascial spaces
Potential fascial spacesPotential fascial spaces
Primary MandibularPrimary Mandibular
spacesspaces
Primary MaxillaryPrimar...

Potentially Infected Fascial Spaces
Fascial SpacesFascial Spaces
 Bound by the fascial layers investingBound by the fascial layers investing
muscles of the b...
Fascial LayersFascial Layers
 Two main fascial layers in head andTwo main fascial layers in head and
neck are superficial...
Superficial Cervical FasciaSuperficial Cervical Fascia
 Continuation of deltopectoral fascia of ant.Continuation of delto...
Deep Cervical FasciaDeep Cervical Fascia
 Contains muscles, viscera, andContains muscles, viscera, and
neurovascular bund...
Carotid SheathCarotid Sheath
 Contains, carotid artery, internal jugularContains, carotid artery, internal jugular
vein, ...
Thank you & have a nice
day
Thank you & have a nice
day
Cervical Fascia CFCervical Fascia CF
 Superficial LayerSuperficial Layer
 Deep LayerDeep Layer
 Subdivisions notSubdivi...
Superficial fasciaSuperficial fascia
 Superior attachment –Superior attachment –
zygomatic processzygomatic process
 Inf...
Superficial Layer of the DeepSuperficial Layer of the Deep
Cervical FasciaCervical Fascia
 Completely surrounds theComple...
Deep Neck SpacesDeep Neck Spaces
 Described in relation to the hyoid.Described in relation to the hyoid.
 Entire length ...
Superficial SpaceSuperficial Space
 Entire length of neckEntire length of neck
 Surrounds platysmaSurrounds platysma
 C...
Retropharyngeal SpaceRetropharyngeal Space
 Entire length of neck.Entire length of neck.
 Anterior border - pharynx andA...
Parotid SpaceParotid Space
 Superficial layer of deepSuperficial layer of deep
fasciafascia
 Dense septa fromDense septa...
Odontogenic Infection 3Odontogenic Infection 3
Dr. Adel I. AbdelhadyDr. Adel I. Abdelhady
BDS, MSc ( Tanta, Eg.), PhD (Egy...
Fascial Layers of the Neck
 Two main fascial divisions exist, the superficial cervical
fascia and the deep cervical fasci...
Deep cervical fascia
 encloses the deep neck spaces
 3 layers, the superficial, middle, and deep
layers of the deep cerv...
The superficial layer of the deep cervical fascia
 investing fascia that surrounds the neckencompasses the
sternocleidoma...
The middle layer of the deep cervical
fascia
 2 divisions, muscular and visceral
 muscular division surrounds the strap ...
The deep layer of the deep cervical
fascia
 2 divisions, prevertebral and alar
 prevertebral division adheres to the ant...
Sublingual spaceSublingual space 11
 Borders:Borders:
 Anterior – mandibleAnterior – mandible
 Posterior – submandibula...
Sublingual spaceSublingual space 22
Submandibular spaceSubmandibular space 11
 Borders:Borders:
 Anterior – anterior belly of digastricAnterior – anterior b...
Pathways of spread of submandibularPathways of spread of submandibular
space infection from mandibular molarspace infectio...
Submandibular SpaceSubmandibular Space
 Likely cause
 Lower molars
 Neighboring space
 Sublingual
 Lateral pharyngeal...
Submandibular SpaceSubmandibular Space
Submental spaceSubmental space
 Borders:Borders:
 Sup.Sup. MylohyoidMylohyoid
 Inf.Inf. Platysma, Skin,Platysma, Skin,
...
Ludwig’s anginaLudwig’s angina
 Hippocrates in 1836, a postmortem findings,Hippocrates in 1836, a postmortem findings,
Ka...
Ludwig’s anginaLudwig’s angina
 Infection of 5 spaces;Infection of 5 spaces;
submental, and bilateralsubmental, and bilat...
Ludwig’s anginaLudwig’s angina
Signs and symptomsSigns and symptoms::
 Brauny oedema of theBrauny oedema of the
spaces.sp...
Ludwig’s angina with bilateralLudwig’s angina with bilateral
involvement of sublingual andinvolvement of sublingual and
su...
Ludwig’s anginaLudwig’s angina
Infection in multi-spaceInfection in multi-space
Ludwig’s anginaLudwig’s angina
Surgical interventionSurgical intervention
 DecompressionDecompression
sublingual andsublingual and
submandibular spaces....
Masticator and Temporal SpacesMasticator and Temporal Spaces
 SuprahyoidSuprahyoid
 Formed by superficial layer ofFormed...
Submasseteric spaceSubmasseteric space
 BordersBorders
 Anterior – buccal spaceAnterior – buccal space
 Posterior – par...
Submasseteric spaceSubmasseteric space
 Likely causes
 Lower third molar
 Angle fracture
 Contents
 Masseteric artery...
Pathway of spread fromPathway of spread from
masseteric space infectionmasseteric space infection
Infection in masseteric spaceInfection in masseteric space
Superficial and Deep temporalSuperficial and Deep temporal
 Superficial Temporal spacSuperficial Temporal spac
 Anterior...
Deep temporal
 Anterior – temporalis
muscle/infratemporal
space
 Posterior – temporalis
 Superior – temporalis
muscle a...
 Likely cause
 Upper molars
 Extension from
submasseteric/pterygomandibular
/infratemporal spaces
 Neighboring spaces
...
Infratemporal spaceInfratemporal space
 The infratemporal fossa spaceThe infratemporal fossa space
forms the upper extrem...
Infratemporal spaceInfratemporal space
 Contains maxillary artery, and pterygoidContains maxillary artery, and pterygoid
...
Infratemporal space
 Likely cause
 Upper molars
 Extension from
neighboring sites
 Neighboring spaces
 Deep temporal
...
Buccal spaceBuccal space
 Borders:Borders:
 Sup.Sup. ZygomaZygoma
 Inf. deep fascia Inferior border of mandibleInf. dee...
Pathway of spread for buccalPathway of spread for buccal
space infectionspace infection
Buccal space infectionBuccal space infection
Canine spaceCanine space
 If the canine root is short pus from periapical abscessIf the canine root is short pus from per...
Areas of spread in infraorbitalAreas of spread in infraorbital
space infectionsspace infections
Pterygomandibular SpacePterygomandibular Space
Borders:Borders:
Anterior – pterygomandibularAnterior – pterygomandibular
r...
Pterygomandibular SpacePterygomandibular Space
 Likely causes
 Lower third molar
 Angle fracture
 Contents
 V3
 Infe...
Lateral (Para) pharyngeal spaceLateral (Para) pharyngeal space
 Anterior – pterygomandibular
raphe, sublingual and
subman...
Lateral (para) pharyngeal spaceLateral (para) pharyngeal space
 Likely causes
 Lower third molars
 Tonsillar abscess
 ...
S/S Of Parpharyngeal space
anterior compartment
 bulging of lateral pharyngeal wall
 deviation of uvula
 trismus
 swel...
I&D Parpharyngeal space
Site of I&D
 Intraoral – anterior compartment
 Extraoral – posterior compartment
(submandibular...
Pharyngomaxillary Space orPharyngomaxillary Space or
ParapharyngealParapharyngeal
 Communicates
with several deep
neck sp...
Lateral (para) pharyngeal spaceLateral (para) pharyngeal space
 Infection manifests as:Infection manifests as:
 Trismus,...
Retropharyngeal space
 Borders
 Anterior – superior and middle constrictor
muscles
 Posterior – alar fascia
 Superior ...
 Likely causes
 Extension from
lateral pharyngeal
 Neighboring space
 Lateral pharyngeal
 Prevertebral
 Mediastinum
...
 Patient who have infection of the lateralPatient who have infection of the lateral
pharyngeal space have serious potenti...
Retropharyngeal space infectionsRetropharyngeal space infections
 The retropharyngeal space lies behind the softThe retro...
 The final danger of retropharyngealThe final danger of retropharyngeal
space infection is progressivespace infection is ...
 When the retropharyngeal or prevertebralWhen the retropharyngeal or prevertebral
spaces or both are involved as a result...
Potential Pathways of Spread ofPotential Pathways of Spread of
Odontogenic InfectionsOdontogenic Infections
Cavernous sinus thrombosisCavernous sinus thrombosis
 Cavernous sinus contains; CN III, IV, VCavernous sinus contains; CN...
Cavernous sinus thrombosisCavernous sinus thrombosis
 Earliest sign is vascularEarliest sign is vascular
congestion in pe...
Cavernous sinus thrombosisCavernous sinus thrombosis
 What are the pathways of odontogenicWhat are the pathways of odonto...
Principles of Management of
Odontogenic Infections
 Determine Severity of Infection
 Three major factors
 Anatomic loca...
2-Rate of Progression
 Onset of swelling
 Pain
 Trismus
 Airway compromise
Stages of odontogenic infections
 Days 1-3 - onset
 Soft
 Doughy
 Mildly tender
 Small, minimal
edema
 Aerobic bacte...
 Day >5
 Cellulitis softens and abscess becomes apparent
 Compressible and shiny
 Fluctuant
 Tender
 Pus filled
 Mo...
Airway Compromise
 Most frequent cause of death is airway
compromise
 Complete obstruction requires
 Intubation
 Trach...
 Trismus
 Ominous sign
 MIO of less than 20mm should be considered a
masticator space abscess until proven otherwise
 ...
Evaluate Host Defenses
 Immune system compromise
 Diabetes (WBC defect in phagocytosis and
chemotaxis and impaired vascu...
 Systemic Reserve
 Fever
 increases insensible fluid
loss and caloric
requirement
 ominous sign in elderly
patients (n...
Possible need for hospitalizationPossible need for hospitalization
 Immunocompromised patient:Immunocompromised patient: ...
Possible need for hospitalizationPossible need for hospitalization
 Airway compromise or threat to airway
 Trismus
 Air...
Diagnostic workshop for infectionDiagnostic workshop for infection
1. Patient assessment1. Patient assessment
 Physical e...
11..Patient assessmentPatient assessment
History:History:
duration of infection, sequence of events, antibioticduration of...
22..ImagingImaging
• Plane filmsPlane films
 Dental structures.Dental structures.
 Bone changesBone changes are evident ...
33..Lab studiesLab studies
A. Serum chemistryA. Serum chemistry
 In Fever and dehydrationIn Fever and dehydration
 ↓↓Na+...
33..Lab studiesLab studies
B. HaematologyB. Haematology
 Leukocytosis >12, 000/ mm3Leukocytosis >12, 000/ mm3
 Normocyti...
33..Lab studiesLab studies
D. Sampling techniques:D. Sampling techniques:
 AspirationAspiration
 SwabbingSwabbing
 Tiss...
OdontogenicOdontogenic
Infection 4Infection 4
Dr. Adel I. AbdelhadyDr. Adel I. Abdelhady
BDS, MSc ( Tanta, Eg.), PhD (Egyp...
POTENTIAL SPREAD
OF INFECTION
FROM LOWER
THIRD
MOLAR
SUPERIORLY
INFRATEMPORAL AND MASTICATOR SPACE
POSTERO INFERIORLY
PTER...
NOTE : DANGER SPACE IS THE SPACE BETWEEN
PREVERTIBRAL AND ALAR FASCIA
PTERYGOMANDIBULAR SPACE
PTERYGOID SPLEXUS
EMISSERY V...
33..Lab studiesLab studies
D. Sampling techniques:D. Sampling techniques:
 AspirationAspiration
 SwabbingSwabbing
 Tiss...
33..Lab studiesLab studies
F. Culture and antibiotic sensitivity testingF. Culture and antibiotic sensitivity testing::
Ev...
Principles of infection managementPrinciples of infection management
 Once diagnosis of infection is established, theOnce...
Support medicallySupport medically
 HydrationHydration
 NutritionNutrition
 Control feverControl fever
 Fever below 39...
 Fever in older patient usually indicatesFever in older patient usually indicates
significant infectionsignificant infect...
22..Medical therapyMedical therapy
Nutritional supportNutritional support
Daily requirements:Daily requirements:
 Adult m...
Medical therapyMedical therapy
Antibiotic therapyAntibiotic therapy
 Therapeutic Indications:Therapeutic Indications:
 E...
Indications for antibiotic useIndications for antibiotic use
33..Removal of the source ofRemoval of the source of
infectioninfection
 Ultimate goal of treatment is directed at removi...
Removal of the causeRemoval of the cause
44..Surgical treatmentSurgical treatment
 Sterile preparation and draping.Sterile preparation and draping.
 Aspiration o...
Surgical drainage and incisionSurgical drainage and incision
 How to judge the pus formation?How to judge the pus formati...
How to judge the pus formationHow to judge the pus formation??
Three stagesThree stages
InoculationInoculation
CellulitisC...
Fluctuant examinationFluctuant examination
44..Surgical treatmentSurgical treatment
 Sterile preparation and draping.Sterile preparation and draping.
 Aspiration o...
11--Incision & drainageIncision & drainage
Site of incision and drainageSite of incision and drainage
for FSfor FS
 Submandibular:Submandibular: Below inf mandible,...
Principles of surgical drainage &Principles of surgical drainage &
incisionincision
 Place the incision in an estheticall...
Principles of surgical drainage &Principles of surgical drainage &
incisionincision
Fascial spaces incision andFascial spaces incision and
drainagedrainage
Although no purulence is expressed, I&DAlthough no purulence is expressed, I&D
will alter the microenvironment whichwill a...
Principles of infectionPrinciples of infection
managementmanagement
Establishment of DrainageEstablishment of Drainage
Drainage, con’tDrainage, con’t
Penrose drain in place to providePenrose drain in place to provide
drainage for vestibular abscessdrainage for vestibular ...
 How the patientHow the patient
feels- Malaisefeels- Malaise
 PreviousPrevious
treatmenttreatment
 Self treatmentSelf t...
 UncontrolledUncontrolled
metabolic diseasesmetabolic diseases
 AlcoholismAlcoholism
 MalnutritionMalnutrition
 Diabet...
 Incision and drainageIncision and drainage
 Dependent siteDependent site
 Incision in healthyIncision in healthy
tissu...
Surgical TreatmentSurgical Treatment
Purposes of surgical drainage &Purposes of surgical drainage &
incisionincision
 Get rid the body of toxic purulent mater...
AntibioticsAntibiotics
E. Antimicrobial susceptibility testingE. Antimicrobial susceptibility testing
 Based onBased on M...
22..Medical therapyMedical therapy::
Antibiotic therapyAntibiotic therapy a : Prophylactica : Prophylactic
 Principles of...
 Pharmacokinetics:Pharmacokinetics: What the bodyWhat the body
does to a drugdoes to a drug
 Pharmacodynamics:Pharmacody...
Principles of antibioticPrinciples of antibiotic
administrationadministration
 Proper doseProper dose
 Proper time inter...
 Synergism:Synergism: A drug interact with another toA drug interact with another to
produced increased activityproduced ...
ManagementManagement
Referral or notReferral or not??
33..Lab studiesLab studies
F. Antimicrobial susceptibility testingF. Antimicrobial susceptibility testing
 Based onBased ...
Principles of Antibiotic TherapyPrinciples of Antibiotic Therapy
 Use EmpiricUse Empiric
TherapyTherapy
 Use narrowestUs...
Antibiotic TherapyAntibiotic Therapy
 Initial therapyInitial therapy
 Cover Gram positive cocci andCover Gram positive c...
Indications for Culture andIndications for Culture and
Ab. Sensitivity TestingAb. Sensitivity Testing
 Rapidly spreadingR...
Antibiotic Associated ColitisAntibiotic Associated Colitis
 DiagnosisDiagnosis
 Profuse wateryProfuse watery
diarrhea >1...
Reasons for Treatment FailureReasons for Treatment Failure
 Inadequate SurgeryInadequate Surgery
 Depressed hostDepresse...
Antibiotic TherapyAntibiotic Therapy
 Removal of the cause, drainage,Removal of the cause, drainage,
and supportive care ...
Antibiotic therapy, con’tAntibiotic therapy, con’t..
 Oral infections are typically polymicrobial.Oral infections are typ...
Antibiotic therapy, con’tAntibiotic therapy, con’t..
 PenicillinPenicillin (bacteriocidal) drug of choice for(bacteriocid...
Antibiotic therapy, con’tAntibiotic therapy, con’t..
 ErythromycinErythromycin (bacteriostatic) good 2(bacteriostatic) go...
22..Medical therapyMedical therapy
Antibiotic therapyAntibiotic therapy
 Combination therapy may be indicated in:Combinat...
22..Medical therapyMedical therapy
 Adjusting antibiotic therapyAdjusting antibiotic therapy::
 Nonresponsive or super-i...
22..Medical therapyMedical therapy
Adjunct to antibiotic administrationAdjunct to antibiotic administration
 Nystatin for...
Antibiotic resistanceAntibiotic resistance mechanismsmechanisms
1. alteration in permeability of bacterial cell wall1. alt...
Antibiotic resistanceAntibiotic resistance
1. Natural1. Natural 2. Acquired2. Acquired
11. Natural. Natural
 Due to:Due t...
Antibiotic resistanceAntibiotic resistance
2. Acquired2. Acquired
 Bacteria can adapt and become resistant as anBacteria ...
Choosing a suitable antibioticChoosing a suitable antibiotic
 Patient FactorsPatient Factors
 allergyallergy
 renal/hep...
Factors that determine degree of placentalFactors that determine degree of placental
transfer:transfer:
 Lipid solubility...
Approx. sameApprox. same
as maternalas maternal
20% to 50 of20% to 50 of
maternalmaternal
10% to 15 of10% to 15 of
materna...
Breast milk concentrationsBreast milk concentrations
Approx. sameApprox. same
as maternalas maternal
50% to 70 of50% to 70...
 Symptom subside?Symptom subside?
vital signs, trismus, swelling, p’t feelingvital signs, trismus, swelling, p’t feeling
...
Summary of infection managementSummary of infection management
InsureInsure
VitalVital
signssigns
2. Obtain2. Obtain
drain...
 Inadequate surgeryInadequate surgery
 Depressed host defencesDepressed host defences
 Foreign bodyForeign body
 Antib...
Case report 1Case report 1
Pt ; 38/FPt ; 38/F
 CC ; swellingCC ; swelling
 PI ; mouth opening limitation, dysphagia, Rt ...
Masseteric space and
parapharyngeal
infection preoperative
Masseteric space and
Parapharyngeal
infection postoperative
Case report 2Case report 2
 Pt ; 30/MPt ; 30/M
 CC ;transfer from ENT d/t deep neck infectionCC ;transfer from ENT d/t d...
Preoperative photo
Intraoperative I & D
Postoperative photo
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Odontogenic Infection
Odontogenic Infection
Odontogenic Infection
Odontogenic Infection
Odontogenic Infection
Odontogenic Infection
Odontogenic Infection
Odontogenic Infection
Odontogenic Infection
Odontogenic Infection
Odontogenic Infection
Odontogenic Infection
Odontogenic Infection
Odontogenic Infection
Odontogenic Infection
Odontogenic Infection
Odontogenic Infection
Odontogenic Infection
Odontogenic Infection
Odontogenic Infection
Odontogenic Infection
Odontogenic Infection
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Odontogenic Infection

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Oral & Maxillofacial Surgery
Forth Year

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Transcript of "Odontogenic Infection"

  1. 1. OdontogenicOdontogenic Infection 1Infection 1 Dr. Adel I. AbdelhadyDr. Adel I. Abdelhady BDS, MSc ( Tanta, Eg.), PhD (Egypt,USABDS, MSc ( Tanta, Eg.), PhD (Egypt,USA(( Ass. Prof. Oral and Maxillofacial surgeryAss. Prof. Oral and Maxillofacial surgery,, Collage of DentistryCollage of Dentistry King Faisal UniversityKing Faisal University "Do not let sun sets on prisoned pus"
  2. 2. Odontogenic InfectionOdontogenic Infection Infection due to dental cause. Oral flora is the main source of OI: Aerobic and Anaerobic Gr-ve and Gr. +ve cocci and rods.
  3. 3. Oral flora is the main source ofOral flora is the main source of odontogenic infectionodontogenic infection bacteriabacteria PercentagePercentage % of Aerobic & Anaerobic% of Aerobic & Anaerobic AerobicAerobic 7 %7 % Aerobic 25 %Aerobic 25 % Anaerobic 75 %Anaerobic 75 % Of the causative organismsOf the causative organisms (number of patients was 404(.(number of patients was 404(. AnaerobicAnaerobic 33 %33 % MixedMixed 60 %60 %
  4. 4. Routes ofRoutes of odontogenicodontogenic infectionsinfections ▼▼ PulpalPulpal oror PeridontiumPeridontium oror SystemicSystemic
  5. 5. Infection Arising and SpreadingInfection Arising and Spreading  Effectiveness of patientEffectiveness of patient immune mechanismimmune mechanism  Microbe---virulenceMicrobe---virulence  QuantityQuantity  Failure to drainFailure to drain accumulation pusaccumulation pus Balance ImbalanceBalance Imbalance ScaleScale
  6. 6. The Anatomical Factors InfluencingThe Anatomical Factors Influencing the direction of spread within thethe direction of spread within the tissuestissues  The site of the source of infection , upperThe site of the source of infection , upper or lower jawor lower jaw  The point at which the pus escapes fromThe point at which the pus escapes from the bone to the soft tissues labiobucally orthe bone to the soft tissues labiobucally or linguopalatallylinguopalatally  The natural barriers to the spread of pus inThe natural barriers to the spread of pus in the tissues as layer of fascia , muscle orthe tissues as layer of fascia , muscle or jaw bonejaw bone
  7. 7. Sequence of odontogenicSequence of odontogenic infectionsinfections fascial spaces Soft tissue & cortical bone Erosion of cancellous bone Periapical through pulp necrosis Periodontal through deep periodontal pocket
  8. 8. Alveolar bone Soft tissue Fascial space Alveolar bone Soft tissue Fascial space Trait of anatomyTrait of anatomy Tooth andTooth and PeriodontiumPeriodontium Caries Pulpitis Apical infection Caries Pulpitis Apical infection
  9. 9. Odontogenic infectionOdontogenic infection • Periapical infection •Periodontal • Pericoronitis • Periapical infection •Periodontal • Pericoronitis
  10. 10. PericoronitisPericoronitis Lower third molarLower third molar
  11. 11. Periapical infectionPeriapical infection Acute-chronic Periapical infection Acute-chronic Periapical infection Fistular Cellulitis Intraoral soft tissue abscess Osteomyelitis Septicemia Deep fascial space infection Ascending facial- cerebral infection
  12. 12. Pathways of Periapical infectionPathways of Periapical infection
  13. 13. Changing directionsChanging directions  Localization andLocalization and recoveryrecovery  Acute chronicAcute chronic  Diffusion or spreadDiffusion or spread Blood system---Septicemia lymphoid system--- Lymphadenopathy From submandibular space infection spread to chest region
  14. 14. Inflammation as a Sign of Odontogenic InfectionInflammation as a Sign of Odontogenic Infection  Inflammation is an important pathologic process oftenInflammation is an important pathologic process often encountered by dentists . As an indicator of disease, it hasencountered by dentists . As an indicator of disease, it has been recognized for centuries. Almost 2,000 years ago,been recognized for centuries. Almost 2,000 years ago, the Roman physicianthe Roman physician CelsusCelsus recognized the warmth,recognized the warmth, redness, swelling, and pain associated with now is knownredness, swelling, and pain associated with now is known asas "inflammation“."inflammation“.  These events caused by a series of cellular and tissueThese events caused by a series of cellular and tissue responses to some injurious agent. These responses areresponses to some injurious agent. These responses are directed atdirected at  destroying the incitingdestroying the inciting ‫المحرض‬‫المحرض‬ agent or, rendering itagent or, rendering it harmless, isolates the agent and prevents its spread toharmless, isolates the agent and prevents its spread to other locations.other locations.  All this activity may cause damage or destruction toAll this activity may cause damage or destruction to normal tissue in the immediate area; the inflammatorynormal tissue in the immediate area; the inflammatory process cleans up resulting debris and starts restoringprocess cleans up resulting debris and starts restoring damaged tissuesdamaged tissues
  15. 15. Types of InflammationTypes of Inflammation  There are two fundamentalThere are two fundamental types of inflammation:types of inflammation: acute and chronic.acute and chronic.  A rapid onset, shortA rapid onset, short duration, and profoundduration, and profound signs and symptomssigns and symptoms characterizecharacterize acuteacute inflammation.inflammation.  On the other hand, a slowOn the other hand, a slow onset, long duration, andonset, long duration, and less obvious signs andless obvious signs and symptoms characterizesymptoms characterize chronic inflammation.chronic inflammation.  In addition to the two basicIn addition to the two basic forms (acute and chronic),forms (acute and chronic), there are two others thatthere are two others that appear less commonly:appear less commonly: subacute and granulomatoussubacute and granulomatous chronic inflammation.chronic inflammation. Subacute inflammationSubacute inflammation is anis an ill-defined form that hasill-defined form that has some clinical features ofsome clinical features of acute and some of chronicacute and some of chronic inflammation or predisposeinflammation or predispose to chronic infection.to chronic infection.  Granulomatous,Granulomatous, is ais a special form of chronicspecial form of chronic inflammation e.g.inflammation e.g. tuberculosis.tuberculosis.
  16. 16.  Life Threatening Infection
  17. 17. Intraoral infection with a skin fistula
  18. 18. Acute InflammationAcute Inflammation  A series of responses of small bloodA series of responses of small blood vessels and some blood and tissue cellsvessels and some blood and tissue cells to "injurious" agents resulting into "injurious" agents resulting in weakening, destruction, or isolation ofweakening, destruction, or isolation of the agent.the agent.  In the first minutes, small blood vesselsIn the first minutes, small blood vessels (capillaries and venules) increase their(capillaries and venules) increase their diameter (dilate) allowing more blood todiameter (dilate) allowing more blood to flow into the area.flow into the area.  This increased blood flow is fed byThis increased blood flow is fed by dilation of supplying arterioles, a processdilation of supplying arterioles, a process known as "active hyperemia" (hyper- =known as "active hyperemia" (hyper- = increased; -emia = blood). Withincreased; -emia = blood). With increased blood flow, increased numbersincreased blood flow, increased numbers of blood cells enter the area too Fever,of blood cells enter the area too Fever, leukocytosisleukocytosis, abscesses, and cellulitis, abscesses, and cellulitis may be presentmay be present ..
  19. 19. MicrobiologyMicrobiology  Odontogenic infections are multi-Odontogenic infections are multi- microbial:microbial:  Gram (+) cocci, aerobic and anaerobic:Gram (+) cocci, aerobic and anaerobic:  Streptococci and their anaerobicStreptococci and their anaerobic counterpart, peptostreptococcicounterpart, peptostreptococci  Staphylococci, and their anaerobicStaphylococci, and their anaerobic counterpart, peptococcicounterpart, peptococci  Gram (+) rods:Gram (+) rods:  Lactobacillus, diphtheroids, actinomycesLactobacillus, diphtheroids, actinomyces  Gram (-) rods:Gram (-) rods:  Fusobacterium, Bacteroids,Fusobacterium, Bacteroids,
  20. 20. Host FactorsHost Factors Immunity against intraoral infection isImmunity against intraoral infection is composed of three sets of mechanisms:composed of three sets of mechanisms:  Humeral factorsHumeral factors  Cellular factorsCellular factors  Local factorsLocal factors Decrease one of these mechanisms followedDecrease one of these mechanisms followed by increases the potential for infection andby increases the potential for infection and spread of infection may be supervene.spread of infection may be supervene.
  21. 21. Humoral FactorsHumoral Factors  Circulating immunoglobulins, along withCirculating immunoglobulins, along with complement, combine with microbes tocomplement, combine with microbes to form opsonins that promote phagocytosisform opsonins that promote phagocytosis by macrophages.by macrophages.  IgA prevents colonization of microbes onIgA prevents colonization of microbes on oral mucosal surfaces.oral mucosal surfaces.  In the presence of infection, histamine,In the presence of infection, histamine, serotonin, prostaglandins supportserotonin, prostaglandins support inflammationinflammation →→ vasodilation and increasedvasodilation and increased vascular permeability.vascular permeability.
  22. 22. Cellular factorsCellular factors  Phagocytes engulf and kill microbes,Phagocytes engulf and kill microbes, removing them, preventing replication.removing them, preventing replication.  Lymphocytes produce lymphokines andLymphocytes produce lymphokines and immunoglobulines (aids humoral).immunoglobulines (aids humoral).  Lymphokines stimulate reproduction ofLymphokines stimulate reproduction of other lymphocytes, and kills antigens.other lymphocytes, and kills antigens.
  23. 23. Local FactorsLocal Factors  Specific factors leading to resistance:Specific factors leading to resistance:  Abundant vascular supply allowingAbundant vascular supply allowing humoral and cellular response.humoral and cellular response.  Mechanical cleansing by salivary flow.Mechanical cleansing by salivary flow.  Secretory IgA contained within saliva.Secretory IgA contained within saliva.
  24. 24. Host defence mechanismsHost defence mechanisms LocalLocal defencesdefences HumoralHumoral defencesdefences CellularCellular defencesdefences • Intact anatomicIntact anatomic barrierbarrier • IndigenousIndigenous bacteriabacteria • ImmunoglobulinsImmunoglobulins • ComplementComplement • phagocytesphagocytes • GranulocytesGranulocytes • MonocytesMonocytes • LymphocytesLymphocytes
  25. 25. Compromised host defencesCompromised host defences UncontrolledUncontrolled metabolic diseasesmetabolic diseases SuppressingSuppressing diseasesdiseases Suppressing drugsSuppressing drugs  UremiaUremia  AlcoholismAlcoholism  MalnutritionMalnutrition  Severe diabetesSevere diabetes  LeukaemiaLeukaemia  LymphomaLymphoma  MalignantMalignant tumourstumours  chemotherapeuticschemotherapeutics  ImmunosuppressivesImmunosuppressives
  26. 26. Clinical FeaturesClinical Features  Inflammation is tissue responseInflammation is tissue response to injury or invasion byto injury or invasion by microorganisms that involvesmicroorganisms that involves vasodilation, capillaryvasodilation, capillary permeability, mobilization ofpermeability, mobilization of leukocytes, and phagocytosis.leukocytes, and phagocytosis.  Cardinal signs of inflammationCardinal signs of inflammation::  Red, hot, swelling, pain, with loss ofRed, hot, swelling, pain, with loss of functionfunction  Other findings:Other findings: regionalregional lymphadenopathylymphadenopathy,, fever, elevated whitefever, elevated white blood cell count, tachycardia,blood cell count, tachycardia, tachypnea, dehydration, malaise.tachypnea, dehydration, malaise. 
  27. 27. Oral tissue examinationOral tissue examination  Examine quality and consistency:Examine quality and consistency:  Soft to fluctuant (fluid filled) to hardSoft to fluctuant (fluid filled) to hard (indurated)(indurated)  Color and temperature determineColor and temperature determine the presence and extent ofthe presence and extent of infectioninfection  Normal v abnormal tissueNormal v abnormal tissue architecture:architecture:  Distortion of mucobuccal foldDistortion of mucobuccal fold  Soft palate symmetric with uvula inSoft palate symmetric with uvula in midlinemidline (deviation → involvement of(deviation → involvement of lateral pharyngeal space(lateral pharyngeal space(  Nasolabial fold, circumorbital areasNasolabial fold, circumorbital areas
  28. 28. Examination, con’tExamination, con’t..  Identify causative factors:Identify causative factors:  Tooth, root tip, foreign body, etc.Tooth, root tip, foreign body, etc.  Vital signs should be taken:Vital signs should be taken:  TemperaturesTemperatures >> 101 to 102°F accompanied101 to 102°F accompanied by an elevated heart rate indicate systemicby an elevated heart rate indicate systemic involvement of the infection and increasedinvolvement of the infection and increased urgency of treatment.urgency of treatment.
  29. 29. How to diagnoseHow to diagnose??  Local Signs and SymptomsLocal Signs and Symptoms  Systemical Signs and SymptomsSystemical Signs and Symptoms Signs and Symptoms
  30. 30. Local Signs and SymptomsLocal Signs and Symptoms  PainPain  SwellingSwelling  Surface erythemaSurface erythema  Pus formationPus formation  Limitation of motionLimitation of motion LocallyLocally
  31. 31. Systemical Signs and SymptomsSystemical Signs and Symptoms  FeverFever  LymphadenopathyLymphadenopathy  MalaiseMalaise  Toxic appearanceToxic appearance  LeukocytosisLeukocytosis
  32. 32. Management of odontogenicManagement of odontogenic infectioninfection  Prevention of the odontogenic infection is thePrevention of the odontogenic infection is the golden standardgolden standard  Mild odontogenic infection can be easilyMild odontogenic infection can be easily treated with simple antibiotictreated with simple antibiotic  Complex odontogenic infection may requireComplex odontogenic infection may require an incision and drainagean incision and drainage  Complicated odontogenic infection mayComplicated odontogenic infection may require patient admission and hospitalizationrequire patient admission and hospitalization  Any odontogenic infection should be treatedAny odontogenic infection should be treated promptly and not be underestimated!promptly and not be underestimated! Why?Why?
  33. 33. To avoid the following complicationsTo avoid the following complications::  Scaring and sinus & fistulaScaring and sinus & fistula formation.formation.  Loss of bone and teethLoss of bone and teeth  Spread to potential fascialSpread to potential fascial spaces and airwayspaces and airway  Orbital and intracranialOrbital and intracranial spread via facial andspread via facial and angular veinsangular veins  Spread into the neck, withSpread into the neck, with large vessel complicationslarge vessel complications  Septic shock from gram –veSeptic shock from gram –ve
  34. 34. The routes by which theThe routes by which the infection can spreadinfection can spread  1-By direct continuity through the tissues1-By direct continuity through the tissues  2-By the lymphatics to the regional nodes and2-By the lymphatics to the regional nodes and eventually into the bloodstream, secondaryeventually into the bloodstream, secondary abscess may develop.abscess may develop.  3-By bloodstream ,local thrombophlebitis may3-By bloodstream ,local thrombophlebitis may propagate along the veins, entering cranialpropagate along the veins, entering cranial cavity via emissary vein to produce cavernouscavity via emissary vein to produce cavernous sinus thrombophlebitis , organism or infectedsinus thrombophlebitis , organism or infected emboli may be swept into blood stream leadingemboli may be swept into blood stream leading to bacteraemia , septicemia or pyaemiato bacteraemia , septicemia or pyaemia
  35. 35. Site at Which Pus AccumulatesSite at Which Pus Accumulates  Pus tends to accumulate in specific regions whichPus tends to accumulate in specific regions which are referred to as tissue spaces, none of which areare referred to as tissue spaces, none of which are actually spaces until pus has been formed.actually spaces until pus has been formed.  Some of these potential spaces are compartmentsSome of these potential spaces are compartments which contain structure such as SG,LN, BPF thesewhich contain structure such as SG,LN, BPF these structures surrounded by loose connective tissue .structures surrounded by loose connective tissue .  Pus destroys the loose connective tissue andPus destroys the loose connective tissue and separate the anatomical boundaries of theseparate the anatomical boundaries of the compartmentcompartment as it increase in volume, soas it increase in volume, so creating an abscess cavity bounded bycreating an abscess cavity bounded by fascia , muscle and bonefascia , muscle and bone
  36. 36. AnatomyAnatomy Fascial space loose connective tissue Among skin, maxillary and muscle •Purulent--- spreading way •Do not exist in healthy state •Become filling during infection
  37. 37. Thank you & have a nice day Thank you & have a nice day
  38. 38. Odontogenic Infection 2Odontogenic Infection 2 Dr. Adel I. AbdelhadyDr. Adel I. Abdelhady BDS, MSc ( Tanta, Eg.(, PhD (Egypt,USABDS, MSc ( Tanta, Eg.(, PhD (Egypt,USA(( Ass. Prof. Oral and Maxillofacial surgeryAss. Prof. Oral and Maxillofacial surgery,, Tanta UniversityTanta University King Faisal UniversityKing Faisal University "Do not let sun sets on prisoned pus"
  39. 39. Sequence of odontogenicSequence of odontogenic infectionsinfections fascial spaces Soft tissue & cortical bone Erosion of cancellous bone Periapical through pulp necrosis Periodontal through deep periodontal pocket
  40. 40. Alveolar bone Soft tissue Fascial space Alveolar bone Soft tissue Fascial space Trait of anatomyTrait of anatomy Tooth andTooth and PeriodontiumPeriodontium Caries Pulpitis Apical infection Caries Pulpitis Apical infection
  41. 41. CellulitisCellulitis initial stage of infectioninitial stage of infection  Diffuse, warm, erythematousDiffuse, warm, erythematous indurated, hard painfulindurated, hard painful swelling that is tender toswelling that is tender to palpation.palpation.  Inflammatory response notInflammatory response not yet forming a true abscess.yet forming a true abscess.  Microorganisms have justMicroorganisms have just begun to overcome hostbegun to overcome host defenses and spread beyonddefenses and spread beyond tissue planes.tissue planes.
  42. 42. True abscess formationTrue abscess formation  As inflammatory responseAs inflammatory response matures, may develop a focalmatures, may develop a focal accumulation of pus.accumulation of pus.  May have spontaneousMay have spontaneous drainage intraorally ordrainage intraorally or extraorally.extraorally.  Abscess is a pocket of tissueAbscess is a pocket of tissue containing necrotic tissue,containing necrotic tissue, bacterial colonies,and deadbacterial colonies,and dead white cells, the area may orwhite cells, the area may or may not be fluctuant, the pat.may not be fluctuant, the pat. Is often is a febrile, oftenIs often is a febrile, often cused by anaerobic bacteria.cused by anaerobic bacteria.
  43. 43. Cellulitis Vs AbscessCellulitis Vs Abscess Diffuse swelling Localized swelling
  44. 44. Differences between cellulitis and abscessDifferences between cellulitis and abscess CharacteristicsCharacteristics CellulitisCellulitis AbscessAbscess DurationDuration AcuteAcute 3-5 days3-5 days Chronic 5 daysChronic 5 days PainPain Sever andSever and generalizedgeneralized LocalizedLocalized SizeSize LargeLarge SmallSmall LocalizationLocalization Diffuse bordersDiffuse borders WellWell circumscribedcircumscribed PalpationPalpation Doughy to induratedDoughy to indurated Fluctuant, tenderFluctuant, tender Presence of pusPresence of pus NoNo YesYes Degree ofDegree of seriousnessseriousness GreaterGreater lessless BacteriaBacteria AerobicAerobic AnaerobicAnaerobic
  45. 45. Types of odontogenic infectionTypes of odontogenic infection  Simple, localised and controllableSimple, localised and controllable  PeriapicalPeriapical  PeriodontalPeriodontal  VestibularVestibular  PalatalPalatal  Complex, invasive and may be dangerousComplex, invasive and may be dangerous  Fascial spacesFascial spaces  LungLung  BrainBrain  MediastinumMediastinum  Metastatic infection to the heart subacuteMetastatic infection to the heart subacute bacterial endocarditisbacterial endocarditis
  46. 46. Simple odontogenic infectionSimple odontogenic infection
  47. 47. Infection of fascial spacesInfection of fascial spaces
  48. 48. Potential fascial spacesPotential fascial spaces Primary MandibularPrimary Mandibular spacesspaces Primary MaxillaryPrimary Maxillary spacesspaces Secondary fascialSecondary fascial spacesspaces SublingualSublingual  BuccalBuccal SubmandibularSubmandibular SubmentalSubmental CanineCanine BuccalBuccal InfratemporalInfratemporal MassetericMasseteric PterygomandibularPterygomandibular Superficial and deepSuperficial and deep temporaltemporal Lateral pharyngealLateral pharyngeal RetropharyngealRetropharyngeal PrevertebralPrevertebral
  49. 49.
  50. 50. Potentially Infected Fascial Spaces
  51. 51. Fascial SpacesFascial Spaces  Bound by the fascial layers investingBound by the fascial layers investing muscles of the body, they contain variousmuscles of the body, they contain various structures.structures.  Delineate different regions in the body.Delineate different regions in the body.  These areThese are potential spaces.potential spaces.  They are not true spaces, or voids, butThey are not true spaces, or voids, but infections and body’s biochemicalinfections and body’s biochemical response can "dissect" along these fascialresponse can "dissect" along these fascial layers as a means of spreadinglayers as a means of spreading
  52. 52. Fascial LayersFascial Layers  Two main fascial layers in head andTwo main fascial layers in head and neck are superficial (lying closest toneck are superficial (lying closest to the surface) and deep cervical fasciathe surface) and deep cervical fascia (cloaking anterior and posterior(cloaking anterior and posterior regions of the neck).regions of the neck).
  53. 53. Superficial Cervical FasciaSuperficial Cervical Fascia  Continuation of deltopectoral fascia of ant.Continuation of deltopectoral fascia of ant. chest wall, Camper’s fascia of abdomen.chest wall, Camper’s fascia of abdomen.  Contains the intrinsic muscles of the faceContains the intrinsic muscles of the face and neck innervated by CN VII.and neck innervated by CN VII.  Most associated infections result fromMost associated infections result from cellulitis, folliculitis, carbuncle, furuncle, orcellulitis, folliculitis, carbuncle, furuncle, or trauma to overlying skin.trauma to overlying skin.  Although there is potential for spread toAlthough there is potential for spread to deeper layers, treatment is usually directdeeper layers, treatment is usually direct incision over the fluctuance.incision over the fluctuance.
  54. 54. Deep Cervical FasciaDeep Cervical Fascia  Contains muscles, viscera, andContains muscles, viscera, and neurovascular bundles in fascial sheets.neurovascular bundles in fascial sheets.  Acts as the lubricating system ofActs as the lubricating system of musculoskeletal system.musculoskeletal system.  The continuation and bony attachmentsThe continuation and bony attachments form the planes and compartmentsform the planes and compartments containing deeper structures.containing deeper structures.
  55. 55. Carotid SheathCarotid Sheath  Contains, carotid artery, internal jugularContains, carotid artery, internal jugular vein, and vagus nerve.vein, and vagus nerve.  Ansa cervicalis, sympathetic trunk, andAnsa cervicalis, sympathetic trunk, and lymphatics are adjacent, but not within.lymphatics are adjacent, but not within.  Intrathoracic propagation may lead toIntrathoracic propagation may lead to mediastinitis, empyema, and pericarditis.mediastinitis, empyema, and pericarditis.
  56. 56. Thank you & have a nice day Thank you & have a nice day
  57. 57. Cervical Fascia CFCervical Fascia CF  Superficial LayerSuperficial Layer  Deep LayerDeep Layer  Subdivisions notSubdivisions not histologically separatehistologically separate  SuperficialSuperficial  Enveloping layerEnveloping layer  Investing layerInvesting layer  MiddleMiddle  Visceral fasciaVisceral fascia  Prethyroid fasciaPrethyroid fascia  Pretracheal fasciaPretracheal fascia  Deep layer of DCFDeep layer of DCF
  58. 58. Superficial fasciaSuperficial fascia  Superior attachment –Superior attachment – zygomatic processzygomatic process  Inferior attachment –Inferior attachment – thorax, axilla.thorax, axilla.  Similar toSimilar to subcutaneous tissuesubcutaneous tissue  Ensheathes platysmaEnsheathes platysma and muscles of facialand muscles of facial expressionexpression
  59. 59. Superficial Layer of the DeepSuperficial Layer of the Deep Cervical FasciaCervical Fascia  Completely surrounds theCompletely surrounds the neck.neck.  Arises from spinousArises from spinous processes.processes.  Superior border – nuchalSuperior border – nuchal line, skull base, zygoma,line, skull base, zygoma, mandible.mandible.  Inferior border – chest andInferior border – chest and axillaaxilla  Splits at mandible andSplits at mandible and covers the massetercovers the masseter laterally and the mediallaterally and the medial surface of the medialsurface of the medial pterygoid.pterygoid.  EnvelopesEnvelopes  SCMSCM  TrapeziusTrapezius  SubmandibularSubmandibular  ParotidParotid  Forms floor ofForms floor of submandibular spacesubmandibular space
  60. 60. Deep Neck SpacesDeep Neck Spaces  Described in relation to the hyoid.Described in relation to the hyoid.  Entire length of neckEntire length of neck  Superficial spaceSuperficial space  RetropharyngealRetropharyngeal  DangerDanger  PrevertebralPrevertebral  Vascular visceralVascular visceral  SuprahyoidSuprahyoid  SubmandibularSubmandibular  PharyngomaxillaryPharyngomaxillary (Parapharyngeal)(Parapharyngeal)  ParotidParotid  PeritonsillarPeritonsillar  TemporalTemporal  MasticatorMasticator  InfrahyoidInfrahyoid  Anterior visceralAnterior visceral
  61. 61. Superficial SpaceSuperficial Space  Entire length of neckEntire length of neck  Surrounds platysmaSurrounds platysma  Contains areolar tissue,Contains areolar tissue, nodes, nerves and vesselsnodes, nerves and vessels  Subplatysmal FlapsSubplatysmal Flaps  Involved with cellulitis andInvolved with cellulitis and superficial abscessessuperficial abscesses  Treat with incision alongTreat with incision along Langer’s lines, drainageLanger’s lines, drainage and antibioticsand antibiotics
  62. 62. Retropharyngeal SpaceRetropharyngeal Space  Entire length of neck.Entire length of neck.  Anterior border - pharynx andAnterior border - pharynx and esophagus (buccopharyngealesophagus (buccopharyngeal fascia)fascia)  Posterior border - alar layer ofPosterior border - alar layer of deep fasciadeep fascia  Superior border - skull baseSuperior border - skull base  Inferior border – superiorInferior border – superior mediastinummediastinum  Combines withCombines with buccopharyngeal fascia atbuccopharyngeal fascia at level of T1-T2level of T1-T2  Midline raphe connectsMidline raphe connects superior constrictor to the deepsuperior constrictor to the deep layer of deep cervical fascia.layer of deep cervical fascia.  Contains retropharyngealContains retropharyngeal nodes.nodes.
  63. 63. Parotid SpaceParotid Space  Superficial layer of deepSuperficial layer of deep fasciafascia  Dense septa fromDense septa from capsule into glandcapsule into gland  Direct communication toDirect communication to parapharyngeal spaceparapharyngeal space  ContainsContains  External carotid arteryExternal carotid artery  Posterior facial veinPosterior facial vein  Facial nerveFacial nerve  Lymph nodesLymph nodes
  64. 64. Odontogenic Infection 3Odontogenic Infection 3 Dr. Adel I. AbdelhadyDr. Adel I. Abdelhady BDS, MSc ( Tanta, Eg.), PhD (Egypt,USABDS, MSc ( Tanta, Eg.), PhD (Egypt,USA)) Ass. Prof. Oral and Maxillofacial surgeryAss. Prof. Oral and Maxillofacial surgery,, Tanta UniversityTanta University King Faisal UniversityKing Faisal University "Do not let sun sets on prisoned pus"
  65. 65. Fascial Layers of the Neck  Two main fascial divisions exist, the superficial cervical fascia and the deep cervical fascia.  Superficial cervical fascia  just deep to the dermis  surrounds the muscles of fscial expression  includes the superficial musculoaponeurotic system (SMAS)  extends from the epicranium to the axillae and chest  space deep to this layer contains fat, neurovascular bundles, and lymphatics
  66. 66. Deep cervical fascia  encloses the deep neck spaces  3 layers, the superficial, middle, and deep layers of the deep cervical fascia.
  67. 67. The superficial layer of the deep cervical fascia  investing fascia that surrounds the neckencompasses the sternocleidomastoid muscle, trapezius, muscles of mastication, and submandibular and parotid glands, limited superiorly by the nuchal ridge, mandible, zygoma, mastoid, and hyoid bones  Inferiorly, it is bounded by the clavicles, sternum, scapula, hyoid, and acromion, contributes to the fascia covering the digastric muscle and to the lateral aspect of the carotid sheathIn its course from the hyoid bone to the medial table of the ramus of the mandible, it envelops the anterior belly of the digastric muscle and forms the floor of the submandibular space  Laterally, this fascia helps to define the parotid and masticator spaces
  68. 68. The middle layer of the deep cervical fascia  2 divisions, muscular and visceral  muscular division surrounds the strap muscles (ie, sternohyoid, sternothyroid, thyrohyoid, omohyoid) and the adventitia of the great vessels  visceral division surrounds the constrictor muscles of the pharynx and esophagus to create the buccopharyngeal fascia and the anterior wall of the retropharyngeal space  Both the muscular and visceral divisions contribute to the formation of the carotid sheath  also envelops the larynx, trachea, and thyroid gland  attaches to the base of the skull superiorly and extends inferiorly as low as the pericardium via the carotid sheath
  69. 69. The deep layer of the deep cervical fascia  2 divisions, prevertebral and alar  prevertebral division adheres to the anterior aspect of the vertebral body and extends laterally to the transverse processes of the vertebrae.  alar division lies between the prevertebral division and the visceral division of the middle layer and defines the posterior border of the retropharyngeal space  surrounds the deep neck muscles and contributes to the carotid sheath  Posteriorly, the muscular division of the middle layer of the deep cervical fascia fuses with the alar division of the deep layer of the deep cervical fascia at the level of thoracic vertebrae 1-2 (T1-T2).
  70. 70. Sublingual spaceSublingual space 11  Borders:Borders:  Anterior – mandibleAnterior – mandible  Posterior – submandibular spacePosterior – submandibular space  Superior – oral mucosaSuperior – oral mucosa  Inferior – mylohyoidInferior – mylohyoid  Medial – tongue musclesMedial – tongue muscles  Lateral – mandibleLateral – mandible  Contains sublingual gland, lingual nerve, sublingual a &Contains sublingual gland, lingual nerve, sublingual a & v Wharton's duct, hypoglossal nerve.v Wharton's duct, hypoglossal nerve.  Infection would lead to dysphagia, pain, elevation ofInfection would lead to dysphagia, pain, elevation of the floor of mouth and sup. displacement of tonguethe floor of mouth and sup. displacement of tongue..
  71. 71. Sublingual spaceSublingual space 22
  72. 72. Submandibular spaceSubmandibular space 11  Borders:Borders:  Anterior – anterior belly of digastricAnterior – anterior belly of digastric  Posterior – posterior belly ofPosterior – posterior belly of digastric/stylohyoid/digastric/stylohyoid/ stylopharyngeusstylopharyngeus  Superior – mylohyoid/mandibleSuperior – mylohyoid/mandible  Inferior – digastric tendon andInferior – digastric tendon and hyoidhyoid  Deep –Deep – mylohyoid/mylohyoid/hyoglossus/styloglhyoglossus/stylogl  Superficial –Superficial – platysma / faciaplatysma / facia
  73. 73. Pathways of spread of submandibularPathways of spread of submandibular space infection from mandibular molarspace infection from mandibular molar
  74. 74. Submandibular SpaceSubmandibular Space  Likely cause  Lower molars  Neighboring space  Sublingual  Lateral pharyngeal  Submental  Buccal  Contents  Submandibular gland  Lymph nodes  Hypoglossal nerve  Nerve to mylohyoid  Facial artery and vein  S/S  Extraoral below inferior border  May obliterate inferior border  Site for I&D  Extraoral - Submandibular incision
  75. 75. Submandibular SpaceSubmandibular Space
  76. 76. Submental spaceSubmental space  Borders:Borders:  Sup.Sup. MylohyoidMylohyoid  Inf.Inf. Platysma, Skin,Platysma, Skin,  Ant.Ant. Lingual mandibleLingual mandible  Post.Post. HyoidHyoid  Med.Med. Common space, no medial wallCommon space, no medial wall  Lat.Lat. Medial MandibleMedial Mandible  Causes: from mand. incisor teeth or continuationCauses: from mand. incisor teeth or continuation form submandibular space infection andform submandibular space infection and SymphysisSymphysis fracturefracture
  77. 77. Ludwig’s anginaLudwig’s angina  Hippocrates in 1836, a postmortem findings,Hippocrates in 1836, a postmortem findings, Karl Friedrich WilhelmKarl Friedrich Wilhelm von Ludwigvon Ludwig  A rapidly progressive gangrenous cellulitisA rapidly progressive gangrenous cellulitis originating in submandibular gland.originating in submandibular gland.  Inflammatory distention of the fascial planesInflammatory distention of the fascial planes of the neck can lead to respiratory tractof the neck can lead to respiratory tract obstruction and death.obstruction and death.  It extends by continuity rather than lymphaticIt extends by continuity rather than lymphatic spread.spread.  Mortality rate exceeds 50% during the pre-Mortality rate exceeds 50% during the pre- antibiotic era, attributed to overwhelmingantibiotic era, attributed to overwhelming sepsis.sepsis.
  78. 78. Ludwig’s anginaLudwig’s angina  Infection of 5 spaces;Infection of 5 spaces; submental, and bilateralsubmental, and bilateral submandibular andsubmandibular and sublingual spaces.sublingual spaces.  Foul serosanguinous fluid,Foul serosanguinous fluid, no frank purulence. Fascia,no frank purulence. Fascia, muscle, connective tissuemuscle, connective tissue involvement, sparinginvolvement, sparing glandsglands
  79. 79. Ludwig’s anginaLudwig’s angina Signs and symptomsSigns and symptoms::  Brauny oedema of theBrauny oedema of the spaces.spaces.  Paucity of pusPaucity of pus (therefore not an(therefore not an abscess).abscess).  No lymphadenopathy.No lymphadenopathy.  Minimal inflammation ofMinimal inflammation of pharynx.pharynx.
  80. 80. Ludwig’s angina with bilateralLudwig’s angina with bilateral involvement of sublingual andinvolvement of sublingual and submandibular spacessubmandibular spaces
  81. 81. Ludwig’s anginaLudwig’s angina
  82. 82. Infection in multi-spaceInfection in multi-space Ludwig’s anginaLudwig’s angina
  83. 83. Surgical interventionSurgical intervention  DecompressionDecompression sublingual andsublingual and submandibular spaces.submandibular spaces. Incision andIncision and drainagedrainage  DebridementDebridement
  84. 84. Masticator and Temporal SpacesMasticator and Temporal Spaces  SuprahyoidSuprahyoid  Formed by superficial layer ofFormed by superficial layer of deep cervical fasciadeep cervical fascia  Masticator spaceMasticator space  Antero-lateral toAntero-lateral to pharyngomaxillary space.pharyngomaxillary space.  ContainsContains  MasseterMasseter  PterygoidsPterygoids  Body and ramus of theBody and ramus of the mandiblemandible  Inferior alveolar nervesInferior alveolar nerves and vesselsand vessels  Tendon of the temporalisTendon of the temporalis musclemuscle
  85. 85. Submasseteric spaceSubmasseteric space  BordersBorders  Anterior – buccal spaceAnterior – buccal space  Posterior – parotid glandPosterior – parotid gland  Superior – zygomatic archSuperior – zygomatic arch  Inferior – inferior border of mandibleInferior – inferior border of mandible  Superficial – masseterSuperficial – masseter  Deep – ramusDeep – ramus  Infection causes trismus.Infection causes trismus.  Communicates with temporalCommunicates with temporal fossafossa
  86. 86. Submasseteric spaceSubmasseteric space  Likely causes  Lower third molar  Angle fracture  Contents  Masseteric artery and vein  Neighboring space  Buccal  Pterygomandibular  Superficial temporal  Parotid  Swelling  Extraoral over the masseter/ascending ramus  Site of I&D  Intraoral  Extraoral – submandibular approach
  87. 87. Pathway of spread fromPathway of spread from masseteric space infectionmasseteric space infection
  88. 88. Infection in masseteric spaceInfection in masseteric space
  89. 89. Superficial and Deep temporalSuperficial and Deep temporal  Superficial Temporal spacSuperficial Temporal spac  Anterior – superificalAnterior – superifical temporalis fasciatemporalis fascia  Posterior – superficialPosterior – superficial temporalis fasciatemporalis fascia  Superior – pericraniumSuperior – pericranium  Inferior – masseteric spaceInferior – masseteric space  Medial – temporalis muscleMedial – temporalis muscle  Lateral – superficialLateral – superficial temporalis fasciatemporalis fascia
  90. 90. Deep temporal  Anterior – temporalis muscle/infratemporal space  Posterior – temporalis  Superior – temporalis muscle attachment  Lateral - temporalis  Inferior – infratemporal space  Medial - squamous temporal bone
  91. 91.  Likely cause  Upper molars  Extension from submasseteric/pterygomandibular /infratemporal spaces  Neighboring spaces  Pterygomandibular  Submasseteric  Infratemporal  Contents  Temporal arteries and veins  Swelling  Above zygomatic arch and behind lateral orbital rim  Almost always associated with trismus  Site of I&D  Intraoral – incision at superior aspect of ascending ramus and dissect posteriorly and superiorly on temporalis into superficial temporal space then medially through temporalis into deep temporal space  Extraoral – incision parallel to zygomatic branch of VII, slightly superior to zygomatic arch
  92. 92. Infratemporal spaceInfratemporal space  The infratemporal fossa spaceThe infratemporal fossa space forms the upper extremity offorms the upper extremity of pterygomandibular spacepterygomandibular space  Borders:Borders:  Anterior – maxillary tuberosityAnterior – maxillary tuberosity  Posterior – mandibular condylePosterior – mandibular condyle  Superior – infratemporal crest ofSuperior – infratemporal crest of sphenoid/deep temporal spacesphenoid/deep temporal space  Inferior – lateral pterygoidInferior – lateral pterygoid /pterygomandibular spac/pterygomandibular spac  Medial – lateral pterygoidMedial – lateral pterygoid plate/pterygopalatine foramenplate/pterygopalatine foramen  Lateral – coronoidLateral – coronoid process/temporalis tendonprocess/temporalis tendon
  93. 93. Infratemporal spaceInfratemporal space  Contains maxillary artery, and pterygoidContains maxillary artery, and pterygoid plexus of veins.plexus of veins.  Communicates with submassetric andCommunicates with submassetric and pterygo-mandibular spaces.pterygo-mandibular spaces.  One of the potential spaces forOne of the potential spaces for displacement of maxillary third molars.displacement of maxillary third molars.
  94. 94. Infratemporal space  Likely cause  Upper molars  Extension from neighboring sites  Neighboring spaces  Deep temporal  Pterygomandibular  Contents  Internal maxillary artery  Pterygoid plexus of veins  V3  Swelling  Not clinically seen – behind tuberosity  Trismus due to involvement of muscles of mastication  Site of I&D  Intraoral – from pterygomandibular space  Extraoral – submandibular approach
  95. 95. Buccal spaceBuccal space  Borders:Borders:  Sup.Sup. ZygomaZygoma  Inf. deep fascia Inferior border of mandibleInf. deep fascia Inferior border of mandible  AntromediallyAntromedially Buccinator ms.Buccinator ms.  Posteromedially Masseter ms.Posteromedially Masseter ms.  Lat.forward extension of deep fascia fromLat.forward extension of deep fascia from the capsule ofthe capsule of parotid gland and platysma ms.parotid gland and platysma ms.  Contains facial artery, vein, and nerve; Stenson’s duct,Contains facial artery, vein, and nerve; Stenson’s duct, buccal fat pad.buccal fat pad.  The buccal fat pad acts as an impediment for spread ofThe buccal fat pad acts as an impediment for spread of infection from buccal to lateral pharyngeal space.infection from buccal to lateral pharyngeal space.
  96. 96. Pathway of spread for buccalPathway of spread for buccal space infectionspace infection
  97. 97. Buccal space infectionBuccal space infection
  98. 98. Canine spaceCanine space  If the canine root is short pus from periapical abscessIf the canine root is short pus from periapical abscess will emerge below the origin of levator anguli oris inwill emerge below the origin of levator anguli oris in buccal vestibule but if long pus will emerges betweenbuccal vestibule but if long pus will emerges between levator labii superiors and levator labii superiors alaquelevator labii superiors and levator labii superiors alaque nasinasi  Borders:Borders:  Sup.Sup. Origin of levator musclesOrigin of levator muscles  Inf .Inf . Orbicularis orisOrbicularis oris  Ant.Ant. Skin, subQSkin, subQ  Post.Post. MaxillaMaxilla  Med.Med. Levator labii alaquae nasiiLevator labii alaquae nasii  Lat.Lat. Zygomaticus majorZygomaticus major  Contains angular artery and vein, infraorbital foramen.Contains angular artery and vein, infraorbital foramen.  These provide a path of communication to cavernousThese provide a path of communication to cavernous sinus via ophthalmic vein, leading to cavernous sinusitissinus via ophthalmic vein, leading to cavernous sinusitis and brain abscess.and brain abscess.
  99. 99. Areas of spread in infraorbitalAreas of spread in infraorbital space infectionsspace infections
  100. 100. Pterygomandibular SpacePterygomandibular Space Borders:Borders: Anterior – pterygomandibularAnterior – pterygomandibular raphe/buccal spaceraphe/buccal space Posterior – parotidPosterior – parotid Superior – lateral pteygoidSuperior – lateral pteygoid Inferior – inferior border ofInferior – inferior border of mandiblemandible Lateral – ramusLateral – ramus Medial – medial pterygoidMedial – medial pterygoid Infection would causes trismus.Infection would causes trismus.  Commonly would lead to para-Commonly would lead to para- pharyngeal space involvement.pharyngeal space involvement.
  101. 101. Pterygomandibular SpacePterygomandibular Space  Likely causes  Lower third molar  Angle fracture  Contents  V3  Inferior alveolar vein and artery  Neighboring spaces  Buccal  Deep temporal  submasseteric  Lateral pharyngeal  Parotid  Peritonsillar  Swelling  Intraoral over medial aspect of ramus  Not usually any extraoral  Trismus due to involvement of medial pterygoid  Site of I&D  Intraoral  Extraoral - submandibular
  102. 102. Lateral (Para) pharyngeal spaceLateral (Para) pharyngeal space  Anterior – pterygomandibular raphe, sublingual and submandibular spaces  Posterior – retropharyngeal/carotid sheath  Superior – skull base  Inferior – hyoid bone  Medial – superior and middle constrictors and its coveringand its covering buccopharyngeal fasciabuccopharyngeal fascia  Lateral – medial pterygoid/parotid capsule  Note: Divided into anterior (muscular) and posterior (vascular) compartments, by the stylohyoid process/ligaments and muscles Cone shapeCone shape
  103. 103. Lateral (para) pharyngeal spaceLateral (para) pharyngeal space  Likely causes  Lower third molars  Tonsillar abscess  Neighboring spaces  Submandibular  Sublingual  Retropharyngeal  Pterygomandibular  Peritonsillar  Contents  Anterior compartment  Loose CT  Lymph nodes  Ascending pharyngeal artery  Posterior compartment  carotid sheath (ie, carotid artery, internal jugular vein, vagus nerve)  glossopharyngeal  hypoglossal nerves  superior sympathetic chain lymphatics  accessory nerve
  104. 104. S/S Of Parpharyngeal space anterior compartment  bulging of lateral pharyngeal wall  deviation of uvula  trismus  swelling at angle indicates extension to inferior extent of anterior compartmen  Posterior compartment  Posterolateral wall and posterior tonsillar pillar edema  Minimal trismus  Cranial nerve involvement (IX-XII)  Horner’ syndrome (ptosis, miosis, anhidrosis) from involvement of superior sympathetic chain
  105. 105. I&D Parpharyngeal space Site of I&D  Intraoral – anterior compartment  Extraoral – posterior compartment (submandibular approach – with finger dissection to identify hyoid, digastric and styloid process)  Carotid space – same as posterior compartment lateral pharyngeal
  106. 106. Pharyngomaxillary Space orPharyngomaxillary Space or ParapharyngealParapharyngeal  Communicates with several deep neck spaces.  Parotid  Masticator  Peritonsillar  Submandibular  Retropharyngeal
  107. 107. Lateral (para) pharyngeal spaceLateral (para) pharyngeal space  Infection manifests as:Infection manifests as:  Trismus, DysphagiaTrismus, Dysphagia  FeverFever  Pharyngeal bulgePharyngeal bulge  Induration at mandibular angleInduration at mandibular angle  If the posterior compartment is involved:If the posterior compartment is involved:  sepsissepsis  dyspneadyspnea  minimal trismusminimal trismus  ? hearing loss due to blockade of Eustachian tube? hearing loss due to blockade of Eustachian tube
  108. 108. Retropharyngeal space  Borders  Anterior – superior and middle constrictor muscles  Posterior – alar fascia  Superior – cranial base  Inferior – fusion of alar and prevertebral fascia (upper mediastinum - C6-T4)  Medial – midline  Lateral – lateral pharyngeal space/carotid sheath
  109. 109.  Likely causes  Extension from lateral pharyngeal  Neighboring space  Lateral pharyngeal  Prevertebral  Mediastinum  Contents  Branches of cranial nerves IX,X  Pharyngeal vessels  S/S  Bulge in posterior wall of pharynx  Odynophagia/dysphagia  Fever/leukocytosis/chills  Sialorrhea/respiratory distress  Site of I&D  Extraoral  incision along anterior border of SCM below hyoid  muscle and carotid sheath are retracted laterally  finger inserted posterior to inferior constrictor for blunt dissection  transoral  for localized infections
  110. 110.  Patient who have infection of the lateralPatient who have infection of the lateral pharyngeal space have serious potentialpharyngeal space have serious potential problems. When the it is involved, theproblems. When the it is involved, the Odontogenic infection is severe and may beOdontogenic infection is severe and may be progressing at a rapid rate.progressing at a rapid rate.  Another possible problem is the contents of theAnother possible problem is the contents of the space, especially those of the posteriorspace, especially those of the posterior compartment, as thrombosis of the internalcompartment, as thrombosis of the internal jugular vein, erosion of the carotid artery or itsjugular vein, erosion of the carotid artery or its branches and interference of cranial nerve IXbranches and interference of cranial nerve IX through XII. The other serious complication arisethrough XII. The other serious complication arise if the infection progress from the lateralif the infection progress from the lateral pharyngeal to retropharyngeal space.pharyngeal to retropharyngeal space.
  111. 111. Retropharyngeal space infectionsRetropharyngeal space infections  The retropharyngeal space lies behind the softThe retropharyngeal space lies behind the soft tissue of the posterior aspect of the pharynx it istissue of the posterior aspect of the pharynx it is bounded anteriorly by superior pharyngealbounded anteriorly by superior pharyngeal constrictor muscle and posteriorly by the alarconstrictor muscle and posteriorly by the alar layer of the prevertebral fascialayer of the prevertebral fascia  The space begun at the base of skull andThe space begun at the base of skull and extends inferiorly to the level of vertebra C7 orextends inferiorly to the level of vertebra C7 or T1, where the alar fascia fuses anteriorly withT1, where the alar fascia fuses anteriorly with the buccopharyngeal fascia.the buccopharyngeal fascia.  Its danger when it is become infected theIts danger when it is become infected the infection can extend inferiorly to posteriosuperiorinfection can extend inferiorly to posteriosuperior mediastinummediastinum
  112. 112.  The final danger of retropharyngealThe final danger of retropharyngeal space infection is progressivespace infection is progressive involvement of the prevertebral space.involvement of the prevertebral space. which is separated from retropharyngealwhich is separated from retropharyngeal space by alar layer of prevertebral fasciaspace by alar layer of prevertebral fascia if this fascia is perforated and the spaceif this fascia is perforated and the space is involved .is involved .  The prevertebral space extends from theThe prevertebral space extends from the base of the skull to the diaphragmbase of the skull to the diaphragm infection of this space can extends to theinfection of this space can extends to the thorax and mediastinumthorax and mediastinum
  113. 113.  When the retropharyngeal or prevertebralWhen the retropharyngeal or prevertebral spaces or both are involved as a result ofspaces or both are involved as a result of odontogenic infection the patient is alwaysodontogenic infection the patient is always seriously ill .The following potentialseriously ill .The following potential complications:complications:  1-Upper airway obstruction1-Upper airway obstruction  2-Rupture of the retropharyngeal space2-Rupture of the retropharyngeal space abscess and aspiration of pus to the lungabscess and aspiration of pus to the lung and asphyxiationand asphyxiation  3-Spread of infection into the mediastinum3-Spread of infection into the mediastinum which results of severe infection in thewhich results of severe infection in the thoraxthorax
  114. 114. Potential Pathways of Spread ofPotential Pathways of Spread of Odontogenic InfectionsOdontogenic Infections
  115. 115. Cavernous sinus thrombosisCavernous sinus thrombosis  Cavernous sinus contains; CN III, IV, VCavernous sinus contains; CN III, IV, V (ophthalmic division) and VI, and internal carotid(ophthalmic division) and VI, and internal carotid artery.artery.  Valveless veins of head and neck result in aValveless veins of head and neck result in a "venous lake" throughout the midface and skull"venous lake" throughout the midface and skull base.base.  This will result in retrograde flow dependent onThis will result in retrograde flow dependent on pressure gradient;pressure gradient;  Thus infection may spread from midface toThus infection may spread from midface to cavernous sinus and other parts of brain viacavernous sinus and other parts of brain via sup. and inf. ophthalmic veinssup. and inf. ophthalmic veins,, or emissaryor emissary veins connecting pterygoidveins connecting pterygoid plexusplexus throughthrough ovale and lacerum foramina to the cranial vault.ovale and lacerum foramina to the cranial vault.
  116. 116. Cavernous sinus thrombosisCavernous sinus thrombosis  Earliest sign is vascularEarliest sign is vascular congestion in periorbital,congestion in periorbital, scleral and retinal veinsscleral and retinal veins  Other signs include;Other signs include; periorbital edemaperiorbital edema proptosis ,dilated pupilsproptosis ,dilated pupils abscent of corneal reflexabscent of corneal reflex nausea, vomiting,nausea, vomiting, diplopia, visualdiplopia, visual impairment,impairment, ophthalmoplegia,ophthalmoplegia, photophobia,photophobia, papilledema.papilledema.
  117. 117. Cavernous sinus thrombosisCavernous sinus thrombosis  What are the pathways of odontogenicWhat are the pathways of odontogenic infection to the cavernous sinus…..twoinfection to the cavernous sinus…..two routes:routes:  Anterior routeAnterior route: via angular and inferior: via angular and inferior ophthalmic veinophthalmic vein  Posterior route:Posterior route: via the transverse facialvia the transverse facial vein and the pterygoid venous plexusvein and the pterygoid venous plexus
  118. 118. Principles of Management of Odontogenic Infections  Determine Severity of Infection  Three major factors  Anatomic location  Rate of progression  Airway compromise
  119. 119. 2-Rate of Progression  Onset of swelling  Pain  Trismus  Airway compromise
  120. 120. Stages of odontogenic infections  Days 1-3 - onset  Soft  Doughy  Mildly tender  Small, minimal edema  Aerobic bacteria  Least severe  Days 2-5 - cellulitis  Hard  Red  hot  ++ tender  Diffuse and spreading borders  Mixed aerobic and anaerobic  Serosanguinous fluid
  121. 121.  Day >5  Cellulitis softens and abscess becomes apparent  Compressible and shiny  Fluctuant  Tender  Pus filled  Moderate to severe  Anaerobic  Resolution  After spontaneous or surgical drainage  Swelling decreases  May remain firm for weeks due to inflammation and wound healing
  122. 122. Airway Compromise  Most frequent cause of death is airway compromise  Complete obstruction requires  Intubation  Tracheostomy  Cricothirotomy – emergency situations  Partial airway obstruction  Stridor  Coarse breath sounds  Drooling  Accessory muscle use
  123. 123.  Trismus  Ominous sign  MIO of less than 20mm should be considered a masticator space abscess until proven otherwise  Need to observe the oropharynx and position of the uvula to assess for swelling  Pulse oximeter  Below 94% is ominous sign  Indicated insufficient oxygenation  Radiographs  Soft tissue radiographs of cervical airway  CT scan (with contrast) – also identifies pus
  124. 124. Evaluate Host Defenses  Immune system compromise  Diabetes (WBC defect in phagocytosis and chemotaxis and impaired vascular flow through small vessels)  Steroid therapy  Organ transplant  Malignancy  Chemotherapy  Chronic renal disease  Malnutrition  Alcoholism  End stage AIDS (controversial – more defect of T cells)
  125. 125.  Systemic Reserve  Fever  increases insensible fluid loss and caloric requirement  ominous sign in elderly patients (normally not able to mount fever as younger people)  physiologic stress may disrupt control of systemic disease  difficult glucose control in diabetics  Indications for hospital admission  Temperature > 38.3  Increases fluid loss  Dehydration  Physical signs  Dry skin  Loss of turgor  Chapped lips  Dry mucous membranes  Elevated BUN  Elevated urine specific gravity
  126. 126. Possible need for hospitalizationPossible need for hospitalization  Immunocompromised patient:Immunocompromised patient: diabetic,diabetic, alcoholic, malnourishmentalcoholic, malnourishment  Systemic involvement:Systemic involvement: fever >39 C, malaise,fever >39 C, malaise, dehydrationdehydration  Patient compliance:Patient compliance: patient is incapable of selfpatient is incapable of self carecare  Rapid spread:Rapid spread: Trismus, paresthesiaTrismus, paresthesia  Need for parenteral antibioticsNeed for parenteral antibiotics  Special features:Special features: resistant organisms,resistant organisms, osteomyelitis, actinomycosisosteomyelitis, actinomycosis
  127. 127. Possible need for hospitalizationPossible need for hospitalization  Airway compromise or threat to airway  Trismus  Airway swelling  Masticator space infection  Perimandibular space infections  Rapidly spreading cellulites  IV antibiotics  Need for GA for I&D  Need for control of systemic disease  Decreased systemic reserve (elderly)  Elevated WBC – more a predictor of length of stay
  128. 128. Diagnostic workshop for infectionDiagnostic workshop for infection 1. Patient assessment1. Patient assessment  Physical examination:Physical examination:  Head and neckHead and neck  OphthalmologicOphthalmologic  NeurologicalNeurological 2. Imaging2. Imaging 3. Lab studies:3. Lab studies: Serum chemistrySerum chemistry  HaematologyHaematology UrinalysisUrinalysis Culture and antibioticCulture and antibiotic sensitivity testingsensitivity testing Sampling techniquesSampling techniques
  129. 129. 11..Patient assessmentPatient assessment History:History: duration of infection, sequence of events, antibioticduration of infection, sequence of events, antibiotic prescribed, habits,prescribed, habits,  Physical examination:Physical examination:  Head and neck:Head and neck: Swelling, asymmetry, abscessSwelling, asymmetry, abscess versus cellulitis, lymphadenopathy, trismus, sinusversus cellulitis, lymphadenopathy, trismus, sinus discharge, draining fistulae, pharyngeal fullness, rashesdischarge, draining fistulae, pharyngeal fullness, rashes  Neurological:Neurological: altered mental status, neck rididity,altered mental status, neck rididity, fetor and sensory deficits, nausea, seizuresfetor and sensory deficits, nausea, seizures  OphthalmologicOphthalmologic:: Proptosis, ophthalmoplegia andProptosis, ophthalmoplegia and photophobiaphotophobia  Mediastinal:Mediastinal: dyspnea, chest pain, distended neckdyspnea, chest pain, distended neck veins, widened mediastinum.veins, widened mediastinum.
  130. 130. 22..ImagingImaging • Plane filmsPlane films  Dental structures.Dental structures.  Bone changesBone changes are evident after 5 - 14 days ofare evident after 5 - 14 days of infection (33% - 50% demineralization).infection (33% - 50% demineralization).  CT, MRI & UltrasonographyCT, MRI & Ultrasonography Determine extent of space and cavities infectionDetermine extent of space and cavities infection  Nuclear bone scansNuclear bone scans (Tc 99m & Ga 67)(Tc 99m & Ga 67) Localizes active foci, diagnosis of biologic activityLocalizes active foci, diagnosis of biologic activity e.g. osteolytic and osteoblastic and healinge.g. osteolytic and osteoblastic and healing responses in osteomyelitisresponses in osteomyelitis..
  131. 131. 33..Lab studiesLab studies A. Serum chemistryA. Serum chemistry  In Fever and dehydrationIn Fever and dehydration  ↓↓Na++ and Cl- if ↑ sweatingNa++ and Cl- if ↑ sweating  ↑↑ Na++ and Cl- if volume depletedNa++ and Cl- if volume depleted  K and HCO3 remain unchangedK and HCO3 remain unchanged  Bl. U/N may be ↑Bl. U/N may be ↑  In septic shock → exaggeration of the above findingsIn septic shock → exaggeration of the above findings  Evidence of acute renal failure:Evidence of acute renal failure:  K, Cl and volume retentionK, Cl and volume retention  Renal (metabolic) acidosisRenal (metabolic) acidosis  ↓↓ HCO3-HCO3-  Albumen may ↓ in osteomyelitis and necrotizing infection.Albumen may ↓ in osteomyelitis and necrotizing infection.
  132. 132. 33..Lab studiesLab studies B. HaematologyB. Haematology  Leukocytosis >12, 000/ mm3Leukocytosis >12, 000/ mm3  Normocytic, normochromic anaemiaNormocytic, normochromic anaemia  Thrombocytosis (> 500,000/mm3Thrombocytosis (> 500,000/mm3  ↑↑ ESR with most of the bacterial and fungalESR with most of the bacterial and fungal infection but no ↑ in viral infection.infection but no ↑ in viral infection. C. UrinalysisC. Urinalysis  Proteinuria with extensive infectionProteinuria with extensive infection  Oliguria and anaemia in septic shock.Oliguria and anaemia in septic shock.
  133. 133. 33..Lab studiesLab studies D. Sampling techniques:D. Sampling techniques:  AspirationAspiration  SwabbingSwabbing  Tissue sample The specimen has to beTissue sample The specimen has to be transferred directly to lab.transferred directly to lab.  AspirateAspirate  Dark, malodorous pusDark, malodorous pus,, is indicative of anaerobic infections.is indicative of anaerobic infections.  White-yellow pusWhite-yellow pus,, implicates aerobic gram-positive cocciimplicates aerobic gram-positive cocci  Dark-stained fluidDark-stained fluid,, is often produced by gram-negative entericis often produced by gram-negative enteric bacteriabacteria  Sulphur granules,Sulphur granules, in yellowish exudatesin yellowish exudates implicates actinomycesimplicates actinomyces  Gas,Gas, with or without puswith or without pus, suggests clostridial or anaerobic, suggests clostridial or anaerobic infections.infections.
  134. 134. OdontogenicOdontogenic Infection 4Infection 4 Dr. Adel I. AbdelhadyDr. Adel I. Abdelhady BDS, MSc ( Tanta, Eg.), PhD (Egypt,USABDS, MSc ( Tanta, Eg.), PhD (Egypt,USA)) Ass. Prof. Oral and Maxillofacial surgeryAss. Prof. Oral and Maxillofacial surgery,, Collage of DentistryCollage of Dentistry King Faisal UniversityKing Faisal University "Do not let sun sets on prisoned pus"
  135. 135. POTENTIAL SPREAD OF INFECTION FROM LOWER THIRD MOLAR SUPERIORLY INFRATEMPORAL AND MASTICATOR SPACE POSTERO INFERIORLY PTERYGOMANDIBULAR SPACE INFERIORLY SUBMANDIBULAR SPACE LUDWIG’S ANGINA ANTERIORLY,BUCCALY BUCCAL SPACE BUCCALY MESSETRIC SPACE
  136. 136. NOTE : DANGER SPACE IS THE SPACE BETWEEN PREVERTIBRAL AND ALAR FASCIA PTERYGOMANDIBULAR SPACE PTERYGOID SPLEXUS EMISSERY VEINS CAVERNOUS SINUS THROMBOSIS LATERAL PHARYNGEAL SPACE RETROPHARYNGEAL SPACE MEDIASTINUM CAROTID SHEATH DANGER SPACE
  137. 137. 33..Lab studiesLab studies D. Sampling techniques:D. Sampling techniques:  AspirationAspiration  SwabbingSwabbing  Tissue sample The specimen has to beTissue sample The specimen has to be transferred directly to lab.transferred directly to lab.  AspirateAspirate  Dark, malodorous pusDark, malodorous pus,, is indicative of anaerobic infections.is indicative of anaerobic infections.  White-yellow pusWhite-yellow pus,, implicates aerobic gram-positive cocciimplicates aerobic gram-positive cocci  Dark-stained fluidDark-stained fluid,, is often produced by gram-negative entericis often produced by gram-negative enteric bacteriabacteria  Sulphur granules,Sulphur granules, in yellowish exudatesin yellowish exudates implicates actinomycesimplicates actinomyces  Gas,Gas, with or without puswith or without pus, suggests clostridial or anaerobic, suggests clostridial or anaerobic infections.infections.
  138. 138. 33..Lab studiesLab studies F. Culture and antibiotic sensitivity testingF. Culture and antibiotic sensitivity testing:: Even if there is no pus aspiratedEven if there is no pus aspirated forfor C&SC&S  IndicationsIndications  Rapidly spreading or extensive infectionRapidly spreading or extensive infection  Infection in compromised patientInfection in compromised patient  Infection not responding to antibioticsInfection not responding to antibiotics  Recurrent infectionRecurrent infection  OsteomyelitisOsteomyelitis  Postoperative infectionPostoperative infection  Infections with unusual features:Infections with unusual features:  Tissue necrosisTissue necrosis  Gas productionGas production  Chronic or multiple fistulae or sinus tractsChronic or multiple fistulae or sinus tracts  Hospital-acquired infections (NOSOCOMIAL)Hospital-acquired infections (NOSOCOMIAL)
  139. 139. Principles of infection managementPrinciples of infection management  Once diagnosis of infection is established, theOnce diagnosis of infection is established, the principles of treatment are common.principles of treatment are common.  ABC’s first,ABC’s first,  Secure and maintain a patent, functional airway, andSecure and maintain a patent, functional airway, and IV access for fluids and medications.IV access for fluids and medications.  In case of respiratory distress or embarrassment,In case of respiratory distress or embarrassment, intubation should be strongly considered.intubation should be strongly considered.  Fiberoptic intubation or surgical airway, "cric" orFiberoptic intubation or surgical airway, "cric" or "trach" may be necessary if oedema has distorted"trach" may be necessary if oedema has distorted the anatomy.the anatomy. 1. Vital signs:
  140. 140. Support medicallySupport medically  HydrationHydration  NutritionNutrition  Control feverControl fever  Fever below 39.4 isFever below 39.4 is beneficialbeneficial  Promotes phagocytosisPromotes phagocytosis  Increases blood flow toIncreases blood flow to areaarea  Increases metabolicIncreases metabolic raterate  Enhances antibodyEnhances antibody functionfunction
  141. 141.  Fever in older patient usually indicatesFever in older patient usually indicates significant infectionsignificant infection  Should control fever in elderly at a lowerShould control fever in elderly at a lower temperature because of increased CV andtemperature because of increased CV and metabolic demandsmetabolic demands  Other methods for fever controlOther methods for fever control  Cool water or alcohol sponge bathCool water or alcohol sponge bath  Chilled drinksChilled drinks  Immersion in bath of tepid waterImmersion in bath of tepid water  Correct electrolyte imbalancesCorrect electrolyte imbalances  Control systemic diseaseControl systemic disease
  142. 142. 22..Medical therapyMedical therapy Nutritional supportNutritional support Daily requirements:Daily requirements:  Adult male, 20-30 k Cal/kg body wt/d. (younger ↑Adult male, 20-30 k Cal/kg body wt/d. (younger ↑ require and elder ↓)require and elder ↓)  Sepsis → ↑ caloric require. (13%/1 C° )Sepsis → ↑ caloric require. (13%/1 C° )  Protein requirement for young adult is 0.45g/kg/d.Protein requirement for young adult is 0.45g/kg/d.  Iron, Magnesium, and other trace elements must beIron, Magnesium, and other trace elements must be monitored.monitored.  Blood cultures: Indicated for all serous head and neckBlood cultures: Indicated for all serous head and neck infections (2 culture bottle 5 cc bl. Each for aerobicinfections (2 culture bottle 5 cc bl. Each for aerobic and anaerobic).and anaerobic).
  143. 143. Medical therapyMedical therapy Antibiotic therapyAntibiotic therapy  Therapeutic Indications:Therapeutic Indications:  Extensive or unusual infectionsExtensive or unusual infections  Systemic spread or sepsisSystemic spread or sepsis  Chronic and /or non responsive infectionsChronic and /or non responsive infections  Debilitated patientDebilitated patient  Infections in an operative site or in the hospitalisedInfections in an operative site or in the hospitalised patientpatient ● Oral rout: on empty stomach, 2gs Penicillin reachesOral rout: on empty stomach, 2gs Penicillin reaches high peak after 1 hour.high peak after 1 hour. ● Parenteral root is indicated in sever infectionParenteral root is indicated in sever infection
  144. 144. Indications for antibiotic useIndications for antibiotic use
  145. 145. 33..Removal of the source ofRemoval of the source of infectioninfection  Ultimate goal of treatment is directed at removing theUltimate goal of treatment is directed at removing the source of infection.source of infection.  For odontogenic infections, this means endodonticFor odontogenic infections, this means endodontic treatment, or extraction of the offending dentition.treatment, or extraction of the offending dentition.  Should be done concurrently with establishment ofShould be done concurrently with establishment of drainage of the involved space (s).drainage of the involved space (s).  Antimicrobial aids in eliminating infections from the body.Antimicrobial aids in eliminating infections from the body. But are not curative so long as the source of infection isBut are not curative so long as the source of infection is present.present.  In OMFS, treatment is incision and drainage (I&D) of theIn OMFS, treatment is incision and drainage (I&D) of the involved space and removal of the causative agent.involved space and removal of the causative agent.
  146. 146. Removal of the causeRemoval of the cause
  147. 147. 44..Surgical treatmentSurgical treatment  Sterile preparation and draping.Sterile preparation and draping.  Aspiration of the swelling for investigation &Aspiration of the swelling for investigation & samplingsampling  Place 1-2 cm incision in a healthy skin orPlace 1-2 cm incision in a healthy skin or mucosa not over most fluctuant areamucosa not over most fluctuant area  Place skin incision in aesthetically acceptablePlace skin incision in aesthetically acceptable area.area.  blunt dissection with instrument and/or finger.blunt dissection with instrument and/or finger.  Use shortest and most direct route to theUse shortest and most direct route to the space.space.  Secure drains, penrose or red rubberSecure drains, penrose or red rubber catheters, avoid gauze drainscatheters, avoid gauze drains
  148. 148. Surgical drainage and incisionSurgical drainage and incision  How to judge the pus formation?How to judge the pus formation?  Purposes of surgical drainage and incisionPurposes of surgical drainage and incision  Principles of surgical drainage and incisionPrinciples of surgical drainage and incision
  149. 149. How to judge the pus formationHow to judge the pus formation?? Three stagesThree stages InoculationInoculation CellulitisCellulitis AbscessAbscess  Duration--- >5 daysDuration--- >5 days  Palpation---Palpation--- FluctuantFluctuant  Appearance---Appearance--- ReddenedReddened  Needle aspirationNeedle aspiration  B-ultrasoundB-ultrasound  CTCT CharacteristicCharacteristic
  150. 150. Fluctuant examinationFluctuant examination
  151. 151. 44..Surgical treatmentSurgical treatment  Sterile preparation and draping.Sterile preparation and draping.  Aspiration of the swelling for investigation &Aspiration of the swelling for investigation & samplingsampling  Place 1-2 cm incision in a healthy skin orPlace 1-2 cm incision in a healthy skin or mucosa not over most fluctuant areamucosa not over most fluctuant area  Place skin incision in aestheticallyPlace skin incision in aesthetically acceptable area.acceptable area.  blunt dissection with instrument and/orblunt dissection with instrument and/or finger.finger.  Use shortest and most direct route to theUse shortest and most direct route to the space.space.  Secure drains, penrose or red rubberSecure drains, penrose or red rubber catheters, avoid gauze drainscatheters, avoid gauze drains
  152. 152. 11--Incision & drainageIncision & drainage
  153. 153. Site of incision and drainageSite of incision and drainage for FSfor FS  Submandibular:Submandibular: Below inf mandible, inBelow inf mandible, in submandibular trianglesubmandibular triangle  Masticator:Masticator: E/O at Inferior border ofE/O at Inferior border of mandible, I/O at pterygomandibular raphaemandible, I/O at pterygomandibular raphae  Temporal:Temporal: Above zygomatic arch, I/O atAbove zygomatic arch, I/O at raphaeraphae  Infratemporal:Infratemporal: Above and lateral toAbove and lateral to maxillary tuberositymaxillary tuberosity  Buccal:Buccal: Inf. mandible, I/O buccal mucosaInf. mandible, I/O buccal mucosa inf to Stenson’s duct.inf to Stenson’s duct.  Lat Pharyngeal:Lat Pharyngeal: Angle of mandible, I/O atAngle of mandible, I/O at raphae.raphae.
  154. 154. Principles of surgical drainage &Principles of surgical drainage & incisionincision  Place the incision in an estheticallyPlace the incision in an esthetically acceptableacceptable  Place the incision in a dependent positionPlace the incision in a dependent position to encourage drainage by gravityto encourage drainage by gravity  Dissect bluntly through deeper tissuesDissect bluntly through deeper tissues and explore all pockets and portions ofand explore all pockets and portions of the abscessthe abscess  Place a drain and stabilize it with suturesPlace a drain and stabilize it with sutures
  155. 155. Principles of surgical drainage &Principles of surgical drainage & incisionincision
  156. 156. Fascial spaces incision andFascial spaces incision and drainagedrainage
  157. 157. Although no purulence is expressed, I&DAlthough no purulence is expressed, I&D will alter the microenvironment whichwill alter the microenvironment which promoted the infection.promoted the infection.  This disruption of the balance amongstThis disruption of the balance amongst different organism, together with adifferent organism, together with a competent immune system and aid ofcompetent immune system and aid of antimicrobials will lead to resolution of theantimicrobials will lead to resolution of the infection.infection.  If the infective source is removedIf the infective source is removed simultaneously, the above manoeuvre issimultaneously, the above manoeuvre is curative.curative. Incision & drainage
  158. 158. Principles of infectionPrinciples of infection managementmanagement
  159. 159. Establishment of DrainageEstablishment of Drainage
  160. 160. Drainage, con’tDrainage, con’t
  161. 161. Penrose drain in place to providePenrose drain in place to provide drainage for vestibular abscessdrainage for vestibular abscess
  162. 162.  How the patientHow the patient feels- Malaisefeels- Malaise  PreviousPrevious treatmenttreatment  Self treatmentSelf treatment  Past MedicalPast Medical HistoryHistory Severity of the InfectionSeverity of the Infection
  163. 163.  UncontrolledUncontrolled metabolic diseasesmetabolic diseases  AlcoholismAlcoholism  MalnutritionMalnutrition  DiabetesDiabetes  Suppressing diseasesSuppressing diseases  LeukemiaLeukemia  LymphomaLymphoma  Malignant TumorsMalignant Tumors
  164. 164.  Incision and drainageIncision and drainage  Dependent siteDependent site  Incision in healthyIncision in healthy tissuetissue  Adequate drainageAdequate drainage  Exploration of allExploration of all involved spacesinvolved spaces  IrrigationIrrigation Surgical TreatmentSurgical Treatment Intraoral Aspiration
  165. 165. Surgical TreatmentSurgical Treatment
  166. 166. Purposes of surgical drainage &Purposes of surgical drainage & incisionincision  Get rid the body of toxic purulent materialGet rid the body of toxic purulent material  Decompress the tissuesDecompress the tissues  Allowing better perfusion of blood containingAllowing better perfusion of blood containing antibiotics and defensive elementsantibiotics and defensive elements  Increased oxygenation of the infected areaIncreased oxygenation of the infected area
  167. 167. AntibioticsAntibiotics E. Antimicrobial susceptibility testingE. Antimicrobial susceptibility testing  Based onBased on MICMIC ((Minimum InhibitoryMinimum Inhibitory ConcentrationConcentration)) Therapeutic antibiotic dose is 3-4 times theTherapeutic antibiotic dose is 3-4 times the MIC; and 8 times in compromised hosts.MIC; and 8 times in compromised hosts.  Minimal Bactericidal Concentration (MBC):Minimal Bactericidal Concentration (MBC): is the antimicrobial concentration that killsis the antimicrobial concentration that kills 99,9 % of bacteria.99,9 % of bacteria.  Organisms are considered antibioticOrganisms are considered antibiotic resistant if MBC> MIC by 32-fold.resistant if MBC> MIC by 32-fold.
  168. 168. 22..Medical therapyMedical therapy:: Antibiotic therapyAntibiotic therapy a : Prophylactica : Prophylactic  Principles of prophylactic antibiotic usePrinciples of prophylactic antibiotic use CriteriaCriteria AdvantagesAdvantages DisadvantagesDisadvantages  Significant risk ofSignificant risk of infectioninfection  Choose correctChoose correct antibioticantibiotic  High levelHigh level  Timing (when)Timing (when)  Shortest effectiveShortest effective antibioticantibiotic  ReducesReduces incidence ofincidence of infectioninfection  Reduces healthReduces health  care costscare costs  Reduces totalReduces total antibiotic useantibiotic use  Allows fewerAllows fewer resistant bacteriaresistant bacteria  Alter hostAlter host  flora?flora?  Benefit?Benefit?  Cost?Cost?  Toxicity?Toxicity?
  169. 169.  Pharmacokinetics:Pharmacokinetics: What the bodyWhat the body does to a drugdoes to a drug  Pharmacodynamics:Pharmacodynamics: What the drugWhat the drug does to a bodydoes to a body  It can’t hurt and it might help shouldIt can’t hurt and it might help should not be the reason you are prescribingnot be the reason you are prescribing antibioticsantibiotics
  170. 170. Principles of antibioticPrinciples of antibiotic administrationadministration  Proper doseProper dose  Proper time intervalProper time interval  Proper route of administration (oral,Proper route of administration (oral, parenteral)parenteral)  Combination antibiotic therapy to obtainCombination antibiotic therapy to obtain potentiation, to delay development of drugpotentiation, to delay development of drug resistance, to broaden the spectrum of anti-resistance, to broaden the spectrum of anti- infective druginfective drug
  171. 171.  Synergism:Synergism: A drug interact with another toA drug interact with another to produced increased activityproduced increased activity  Antagonism:Antagonism: Is a drug with opposite actionIs a drug with opposite action to other drug, it inhibit its actionto other drug, it inhibit its action  Mode of action of Antibiotics:Mode of action of Antibiotics:  1-Interference with the cell wall1-Interference with the cell wall  2-Interference with biochemical activity2-Interference with biochemical activity  3-Inhibition of protein synthesis3-Inhibition of protein synthesis  4.Interference with cell metabolism4.Interference with cell metabolism
  172. 172. ManagementManagement
  173. 173. Referral or notReferral or not??
  174. 174. 33..Lab studiesLab studies F. Antimicrobial susceptibility testingF. Antimicrobial susceptibility testing  Based onBased on MICMIC ((Minimum InhibitoryMinimum Inhibitory ConcentrationConcentration)) Therapeutic antibiotic dose is 3-4 times theTherapeutic antibiotic dose is 3-4 times the MIC; and 8 times in compromised hosts.MIC; and 8 times in compromised hosts.  Minimal Bactericidal Concentration (MBC):Minimal Bactericidal Concentration (MBC): is the antimicrobial concentration that killsis the antimicrobial concentration that kills 99,9 % of bacteria.99,9 % of bacteria.  Organisms are considered antibioticOrganisms are considered antibiotic resistant if MBC> MIC by 32-fold.resistant if MBC> MIC by 32-fold.
  175. 175. Principles of Antibiotic TherapyPrinciples of Antibiotic Therapy  Use EmpiricUse Empiric TherapyTherapy  Use narrowestUse narrowest spectrum drugspectrum drug  Use antibiotic withUse antibiotic with the lowest toxicitythe lowest toxicity  Use bactericidalUse bactericidal antibioticantibiotic  Be aware of Cost $$Be aware of Cost $$ $$
  176. 176. Antibiotic TherapyAntibiotic Therapy  Initial therapyInitial therapy  Cover Gram positive cocci andCover Gram positive cocci and anaerobesanaerobes  If pt is diabetic, should considerIf pt is diabetic, should consider covering gram negatives empirically.covering gram negatives empirically.  Unasyn, Clindamycin, 2Unasyn, Clindamycin, 2ndnd generationgeneration cephalosporin.cephalosporin.  PCN, gentamicin and flagyl -PCN, gentamicin and flagyl - developing nationsdeveloping nations..  IV abx alone (based on retro andIV abx alone (based on retro and parapharyngeal infections)parapharyngeal infections)  Patient stability and nature of lesion.Patient stability and nature of lesion.  Cellulitis/phlegmon by CT.Cellulitis/phlegmon by CT.  Abscesses in clinically stable patient.Abscesses in clinically stable patient.  If no clinical improvement in 24 - 48If no clinical improvement in 24 - 48 hours proceed to surgicalhours proceed to surgical interventionintervention..
  177. 177. Indications for Culture andIndications for Culture and Ab. Sensitivity TestingAb. Sensitivity Testing  Rapidly spreadingRapidly spreading infectioninfection  Post-op infectionPost-op infection  Non-responsiveNon-responsive infectioninfection  Recurrent infectionRecurrent infection  Compromised hostCompromised host defensesdefenses
  178. 178. Antibiotic Associated ColitisAntibiotic Associated Colitis  DiagnosisDiagnosis  Profuse wateryProfuse watery diarrhea >10 per daydiarrhea >10 per day  CrampingCramping  FeverFever  toxin assaytoxin assay  Tissue cultureTissue culture  TreatmentTreatment  D/C current ABD/C current AB  Fluid managementFluid management  AntibioticsAntibiotics  MetronidazoleMetronidazole  Vancomycin POVancomycin PO
  179. 179. Reasons for Treatment FailureReasons for Treatment Failure  Inadequate SurgeryInadequate Surgery  Depressed hostDepressed host responsesresponses  Foreign bodyForeign body  Antibiotic problemsAntibiotic problems  Patient noncompliancePatient noncompliance  Drug not reaching theDrug not reaching the sitesite  Drug dose too lowDrug dose too low  Wrong antibioticWrong antibiotic
  180. 180. Antibiotic TherapyAntibiotic Therapy  Removal of the cause, drainage,Removal of the cause, drainage, and supportive care more importantand supportive care more important than antibiotic therapy.than antibiotic therapy.  Infections are cured by the patient’sInfections are cured by the patient’s defenses,defenses, notnot antibiotics.antibiotics.  Risks of allergy, toxicity, sideRisks of allergy, toxicity, side effects, resistance andeffects, resistance and superinfection causing serious orsuperinfection causing serious or potentially fatal consequences mustpotentially fatal consequences must be considered.be considered.
  181. 181. Antibiotic therapy, con’tAntibiotic therapy, con’t..  Oral infections are typically polymicrobial.Oral infections are typically polymicrobial.  Antibiotic effectiveness dependent uponAntibiotic effectiveness dependent upon adequate tissue (not serum) concentrationadequate tissue (not serum) concentration for an appropriate amount of time.for an appropriate amount of time.  Antibiotics should be prescribed for at leastAntibiotics should be prescribed for at least one week – adequate tissue concentrationone week – adequate tissue concentration achieved in 24-48 hours, with bacteriocidalachieved in 24-48 hours, with bacteriocidal activity occurring over the next 3-5 days.activity occurring over the next 3-5 days.
  182. 182. Antibiotic therapy, con’tAntibiotic therapy, con’t..  PenicillinPenicillin (bacteriocidal) drug of choice for(bacteriocidal) drug of choice for treatment of odontogenic infections (5% incidenttreatment of odontogenic infections (5% incident of allergy).of allergy).  ClindamycinClindamycin (batericiodal) 1(batericiodal) 1stst line afterline after penicillin; effective against anaerobes; stoppenicillin; effective against anaerobes; stop taking at first sign of diarrhea.taking at first sign of diarrhea.  CephalosporinCephalosporin (slightly broader spectrum and(slightly broader spectrum and bacteriocidal); cautious use in penicillin-allergicbacteriocidal); cautious use in penicillin-allergic patients → cross-sensitivity; if history ofpatients → cross-sensitivity; if history of anaphylaxis to penicillin, do not use.anaphylaxis to penicillin, do not use.
  183. 183. Antibiotic therapy, con’tAntibiotic therapy, con’t..  ErythromycinErythromycin (bacteriostatic) good 2(bacteriostatic) good 2ndnd line drug afterline drug after penicillin; use enteric-coated to reduce GI upset.penicillin; use enteric-coated to reduce GI upset. Erythromycin is less effective than penicillinErythromycin is less effective than penicillin  MetronidazoleMetronidazole (bacteriocidal) excellent against(bacteriocidal) excellent against anaerobes only.anaerobes only.  AugmentinAugmentin (amoxicillin + clavulanic acid) kills(amoxicillin + clavulanic acid) kills penicillinase-producing bacteria that interferes withpenicillinase-producing bacteria that interferes with amoxicillin; expensive.amoxicillin; expensive.  VancomycinVancomycin for methicillin-resistant staphylococcifor methicillin-resistant staphylococci (MRS)(MRS)  QuinolonesQuinolones for chronic osteomyelitis.for chronic osteomyelitis.
  184. 184. 22..Medical therapyMedical therapy Antibiotic therapyAntibiotic therapy  Combination therapy may be indicated in:Combination therapy may be indicated in:  Life-threatening infectionsLife-threatening infections  Necrotizing fasciitisNecrotizing fasciitis  Chronic osteomyelitis (Quinolones have goodChronic osteomyelitis (Quinolones have good bone penetration)bone penetration)  Prevention of resistant organisms e.g.Prevention of resistant organisms e.g. bacteroids and staphylococcibacteroids and staphylococci  Combination therapy involves a BSA (penicillin)Combination therapy involves a BSA (penicillin) and drug active against gram-negative or one ofand drug active against gram-negative or one of the beta lactamase inhibitor combinations.the beta lactamase inhibitor combinations.
  185. 185. 22..Medical therapyMedical therapy  Adjusting antibiotic therapyAdjusting antibiotic therapy::  Nonresponsive or super-infectionsNonresponsive or super-infections  Culture and antibiotic sensitivity testsCulture and antibiotic sensitivity tests resultsresults  ToxicityToxicity::  Aminoglycosides (nephro-and ototoxicity)Aminoglycosides (nephro-and ototoxicity)  Clindamycin, cephalosporinsClindamycin, cephalosporins (pseudomembranous colitis)(pseudomembranous colitis)  Erythromycin (hepatotoxicity in high doses)Erythromycin (hepatotoxicity in high doses)  Penicillins and cephalosporins (hypersensitivityPenicillins and cephalosporins (hypersensitivity
  186. 186. 22..Medical therapyMedical therapy Adjunct to antibiotic administrationAdjunct to antibiotic administration  Nystatin for fungal superinfection (Candida)Nystatin for fungal superinfection (Candida)  Hyperbaric oxygen therapyHyperbaric oxygen therapy::  Increase vascularityIncrease vascularity  Aids in bone healingAids in bone healing  Increases antibiotic delivery to tissues.Increases antibiotic delivery to tissues.
  187. 187. Antibiotic resistanceAntibiotic resistance mechanismsmechanisms 1. alteration in permeability of bacterial cell wall1. alteration in permeability of bacterial cell wall for the drugfor the drug 2. changes in the target sites for the drug in the2. changes in the target sites for the drug in the bacterial cell wallbacterial cell wall 3. bypassing metabolic reactions blocked by the3. bypassing metabolic reactions blocked by the drugdrug 4. drug inactivation4. drug inactivation  1-3 = tolerance 4 = antibiotic destructive1-3 = tolerance 4 = antibiotic destructive cross resistance = bacteria resistant to onecross resistance = bacteria resistant to one antibiotic: is the resistance to other forms ofantibiotic: is the resistance to other forms of the antibiotic which are chemically closelythe antibiotic which are chemically closely relatedrelated
  188. 188. Antibiotic resistanceAntibiotic resistance 1. Natural1. Natural 2. Acquired2. Acquired 11. Natural. Natural  Due to:Due to:  the production of enzymes by bacteriathe production of enzymes by bacteria nullifying the antibiotic effect e.g:nullifying the antibiotic effect e.g: Penicllinase production by Staph. Aureus orPenicllinase production by Staph. Aureus or  by the virtue of morphological/biologicalby the virtue of morphological/biological factors which exclude the natural targetfactors which exclude the natural target areas of the bacteria to the action of theareas of the bacteria to the action of the antibioticantibiotic
  189. 189. Antibiotic resistanceAntibiotic resistance 2. Acquired2. Acquired  Bacteria can adapt and become resistant as anBacteria can adapt and become resistant as an adaptive reaction to prolonged or continuousadaptive reaction to prolonged or continuous use of an antibiotic mediated by mutationuse of an antibiotic mediated by mutation  Mutation- natural mutants (chromosomal) theMutation- natural mutants (chromosomal) the removal of the dominant antibiotic sensitiveremoval of the dominant antibiotic sensitive strains by the administration of antibiotics allowsstrains by the administration of antibiotics allows these bacteria to proliferate freely withoutthese bacteria to proliferate freely without competition e.g strept viridanscompetition e.g strept viridans
  190. 190. Choosing a suitable antibioticChoosing a suitable antibiotic  Patient FactorsPatient Factors  allergyallergy  renal/hepatic functionrenal/hepatic function  immuno-compromiseimmuno-compromise  oral toleranceoral tolerance  severity of illnessseverity of illness  age/weightage/weight  pregnancy/breastpregnancy/breast feedingfeeding  oral contraceptive/otheroral contraceptive/other medicationmedication  Microbial FactorsMicrobial Factors  culture and sensitivityculture and sensitivity  likely organisms’likely organisms’ sensitivitysensitivity
  191. 191. Factors that determine degree of placentalFactors that determine degree of placental transfer:transfer:  Lipid solubilityLipid solubility  Ionization of compoundIonization of compound  Protein bindingProtein binding  Placental foetal blood flowPlacental foetal blood flow Considerations in the pregnant or lactating patient with infection:
  192. 192. Approx. sameApprox. same as maternalas maternal 20% to 50 of20% to 50 of maternalmaternal 10% to 15 of10% to 15 of maternalmaternal Penicillins,Penicillins, amoxicillin,amoxicillin, ampicillin,ampicillin, methicillin,methicillin, sulfonamides,sulfonamides, chloramphenicol,chloramphenicol, and tetracyclinsand tetracyclins AminoglycosidesAminoglycosides (not safe for(not safe for pregnant, notpregnant, not absorbed fromabsorbed from bowel)bowel) Cephalosporins,Cephalosporins, clindamycin, andclindamycin, and erythromycinerythromycin Foetal serum concentrationsFoetal serum concentrations
  193. 193. Breast milk concentrationsBreast milk concentrations Approx. sameApprox. same as maternalas maternal 50% to 70 of50% to 70 of maternalmaternal Less than 25% ofLess than 25% of maternalmaternal Sulfonamides,Sulfonamides, Metronidazole andMetronidazole and isoniazidisoniazid ChloramphenicolChloramphenicol and erythromycinand erythromycin Cephalosporins,Cephalosporins, clindamycin, andclindamycin, and erythromycinerythromycin
  194. 194.  Symptom subside?Symptom subside? vital signs, trismus, swelling, p’t feelingvital signs, trismus, swelling, p’t feeling  Failure reason?Failure reason? etiology, surgery, host immune,etiology, surgery, host immune, foreign body, antibioticsforeign body, antibiotics  Adverse effectAdverse effect  Secondary infectionsSecondary infections
  195. 195. Summary of infection managementSummary of infection management InsureInsure VitalVital signssigns 2. Obtain2. Obtain drainagedrainage 3. Maintain3. Maintain drainagedrainage 4. Remove4. Remove the causethe cause 5. Provide5. Provide supportivesupportive carecare • AirAir wayway • PulsePulse • BPBP • AdequateAdequate accessaccess • BluntBlunt dissectiondissection • AllAll loculationsloculations enteredentered • All involvedAll involved spacesspaces • DependentDependent drainagedrainage • MaintenanceMaintenance of Patencyof Patency • PulpPulp extirpationextirpation • ToothTooth extractionextraction • NecroticNecrotic tissuetissue /debris./debris. • FluidsFluids • RestRest • NutritionNutrition • WarmthWarmth • AntibioticAntibiotic
  196. 196.  Inadequate surgeryInadequate surgery  Depressed host defencesDepressed host defences  Foreign bodyForeign body  Antibiotic problemsAntibiotic problems  Patient non-compliancePatient non-compliance  Drug not reaching siteDrug not reaching site  Drug dosage too lowDrug dosage too low  Wrong bacterial diagnosisWrong bacterial diagnosis  Wrong antibioticWrong antibiotic Reasons for treatment failureReasons for treatment failure
  197. 197. Case report 1Case report 1 Pt ; 38/FPt ; 38/F  CC ; swellingCC ; swelling  PI ; mouth opening limitation, dysphagia, Rt buccal &PI ; mouth opening limitation, dysphagia, Rt buccal & sub mn swelling and rednesssub mn swelling and redness  Dx ; masticatory spce, lat. Pharyngeal space abscessDx ; masticatory spce, lat. Pharyngeal space abscess  Tx ; I & D X 2Tx ; I & D X 2  (submn & submental, deep neck carotid sheath(submn & submental, deep neck carotid sheath area)area)  anti theraphy ( aug + micronomycin + flagyl)anti theraphy ( aug + micronomycin + flagyl)  fluid etc supplementary tx (O2 etc)fluid etc supplementary tx (O2 etc)  lab ; WBC 30260, segmental neutrophil 85.9%, CRPlab ; WBC 30260, segmental neutrophil 85.9%, CRP 36.536.5
  198. 198. Masseteric space and parapharyngeal infection preoperative Masseteric space and Parapharyngeal infection postoperative
  199. 199. Case report 2Case report 2  Pt ; 30/MPt ; 30/M  CC ;transfer from ENT d/t deep neck infectionCC ;transfer from ENT d/t deep neck infection from dental originfrom dental origin  PI ; both submn swelling & TdPI ; both submn swelling & Td mouth opening limit, dysphagia, dyspnea,mouth opening limit, dysphagia, dyspnea, neck Td & redness, #38 area pusneck Td & redness, #38 area pus  DX ; submn & mental space abscessDX ; submn & mental space abscess pretracheal space abscesspretracheal space abscess descending necrotizing mediastinitisdescending necrotizing mediastinitis
  200. 200. Preoperative photo
  201. 201. Intraoperative I & D
  202. 202. Postoperative photo

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