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    By Dr. Mahdi Faour
  • 2. Contents
    • Infection in general
    • 3. Types of infection
    • 4. Etiology of orofacial infections
    • 5. Predisposing factors for acute oral infections
    • 6. Microbiology
    • 7. Routes of spread of infection
    • 8. Anatomical factors influencing the direction of spread
  • Infection
    Definition: Infection is the pathological state resulting from the invasion of the body by pathogenic microorganisms.
    The reaction of the tissues to the presence of these microorganisms and the toxins generated by them is INFLAMMATION.
  • 9. Types of Infection
    Bacterial Infection: not only one particular specie, but due to a mixture of species which make up the oral flora.
    Fungal Infection: Actinomycosis
    Viral Infection: Not recognized because they are complicated early by secondary bacterial infection.
    Parasitic infection: Very rare( ex. Lyshmoniasis)
  • 10. Etiology of Infection
    • The majority of oral, facial, and neck infections are odontogenic in origin.
    • 11. Although they may be caused by infections from
    Antrum (maxillary sinus)
    Major salivary glands
    Specific Infections of jaws (osteoradionecrosis, osteomyelitis)
  • 12. Odontogenic Causes of Infections
    1. Decay (caries) reaching the dental pulp= pulpitis, this in turn spreads to supporting bone resulting in periapical abscess which in turn may spread subperiosteally.
    2. Periapical abscess may occur in seemingly intact but devitalized teeth (trauma, cracks or decay under fillings).
    3. Periodontal diseases
    4. Erupting teeth (especially partially impacted lower third molars) can result in inflammation and infection of the gum flap preventing eruption (operculum) with swelling pus etc. around the crown (pericoronitis).
    5. Retained roots supragingival or subgingival.
  • 13. Predisposing factors for acute oral Infections
    Endocrine disturbances
    Nutritional deficiency (decreases resistance)
    Chemical compounds used in dentistry (arsenic)
    Blood disorders (leukemia, anemia)
    General diseases (syphilis, TB)
    Immunological diseases (AIDS)
    Fractures of jaw
    Pressure type of anesthesia
    Improper use of surgical burs without cooling
  • 14.
  • 15. Microbiology
    Odontogenic infections are multimicrobial:
    Gram (+) cocci, aerobic and anaerobic:
    Streptococci and their anaerobic counterpart, peptostreptococci
    Staphylococci, and their anaerobic counterpart, peptococci
    Gram (+) rods:
    Lactobacillus, diphtheroids, Actinomyces
    Gram (-) rods:
    Fusobacterium, Bacteroids, Eikenella, Psuedomonas (occasional)
  • 16. Aerobic 25%
    Gram-positive cocci 85%
    Streptococcus spp. (90%)
    Streptococcus (group D) spp. (2%)
    Staphylococcus spp. (6%)
    Eikenella spp. (2%)
    Gram-negative cocci (Neisseria spp.) 2%
    Gram-positive rods (Corynebacterium spp.) 3%
    Gram-negative rods (Haemophilus spp.) 6%
    Miscellaneous and undifferentiated 4%
  • 17. Anaerobic 75%
    Gram-positive cocci 30%
    Streptococcus spp. 33%
    Peptostreptococcus spp. 65%
    Staphylococcus spp. 65%
    Gram-negative cocci (Veillonella spp.) 4%
    Gram-positive rods 14%
    Lactobacillus spp.
    Actinomyces spp.
    Clostridia spp.
    Gram-negative rods 50%
    Bacteroides spp. 75%
    Fusobacterium spp. 25%
    Miscellaneous 6%
  • 18. Rate of spread of infection
    Rate depends on:
    Virulence of the invading microbes
    Dosage or number of these microbes
    Host resistance
    Severity of infection=
    (Virulence x Dose)/Resistance
  • 19.
    • Clinically odontogenic infections can be distinguished in three periods:
    Period of periapical of dento-alveolar abscess (in which the initial lesion develops)
    Period of extension to the adjacent bone and facial spaces
    Period of serious complications (embolism, septicemia, pyemia)
  • 20. Routes of spread of infection
    By direct continuity through the tissues
    Apical infection
    Alveolar bone
    Soft tissue
    Fascial space
  • 21. By the lymphatics, to the regional lymph nodes and eventually to the blood stream. If infection becomes established in lymph nodes, then secondary abscess may develop.
  • 22. By the bloodstream. Local thrombophlebitis may rarely propagate along the veins, entering the cranial cavity via emissary veins to produce cavernous sinus thrombophlebitis. Septicemia, pyaemia, and bacteraemia can be caused by bloodstream spread. (N.B. Facial veins are valveless)
    Hematogenous spread of infection from jaw to cavernous sinus may occur anteriorly via inferior or superior ophthalmic vein or posteriorly via emissary veins from pterygoid plexus.
  • 23. Anatomical factors influencing the direction of spread within tissue
    1.The site of the source of infection (maxilla or mandible and even the particular segment of the jaw).
    2.The point at which pus escapes from the bone and discharges into the soft tissues (linguopalatally or labiobuccally).
    3.The natural barriers to the spread of pus in the tissues, such as by layers of fascia or muscle or the jaw bones themselves.
  • 24. Facial Spaces
    Fascial spaces are fascia-lined areas that can be eroded or distended by purulent exudate.
    These areas are potential spaces that do not exist in healthy people but become filled during infections.
  • 25. As infection erodes through bone, it can express itself in a variety of places, depending on thickness of overlying bone and relationship of muscle attachments to site of perforation. This illustration notes six possible locations: 1-vestibular abscess, 2-buccal space, 3-palatal abscess, 4-sublingual space, 5-submandibular space, and 6-maxillary sinus.
  • 26.
  • 27. Principles of Treatment of orofacial Infections
  • 28. Principles of Treatment of orofacial Infections
    1.Remove the cause.
    2.Establish drainage.
    3.Institute antibiotic therapy.
    4.Supportive care, including proper rest and nutrition.
  • 29. Basic Principles of Local Treatment
    Opening the abcess
    Surgical treatment of abscess and phlegmon is based on the pus drainage, and therefore in all cases the following steps should be followed.
    1. Incision
    2. Opening the abscess
  • 30. Drainage of abscess
    Drainage of abscess
    3.Taking of smear to determine the bacteria
    4.Drainage of abscess
  • 31.
  • 32.
  • 33. Abscess of Orofacial Spaces
  • 34.
  • 35. Canine Fossa(infra-orbital)
    Superior: inferior margin of the orbit
    Inferior: alveolar process of maxilla
    Mesial: margin of periform aperture
    Lateral: zygomatic-maxillary suture
  • 36. Canine Fossa Infection
    • Odontogenic origin:maxillary canines and premolars
    • 37. Nonodontogenic:
    Skin infections
    Infection can be superficial (due to dermatologic infections) or can be deep (between muscles and bone-odontogenic infection), and the infections quickly spreads from superficial to deep and vice versa.
  • 38. Clinical Presentation (canine Fossa)
    Edema, localized in the infraorbital region, which spreads towards the lower eyelid and side of the nose as far as the corner of the mouth.
    There is also obliteration of the nasolabial fold, and somewhat of the mucolabial fold.
    The edema at the infraorbital region is painful and there is fluctuation during palpation, and later on the skin becomes taut and shiny due to suppuration, while its color is reddish(fig)
  • 39. Extraoral swelling at the infraorbital region and nasolabial fold with red shiny skin
    Glassy oedematous swelling of eye region of canine fossa abscess
  • 40. Canine space infection
    in patient's right side
    resulted from infected
    canine tooth. The
    swelling of nasolabial
    and infraorbital areas is
  • 41. Treatment of Canine Fossa Abscess
    1.The incisionfor drainage is performed intraorally at the mucobuccal fold (parallel to the alveolar bone), in the canine region.
  • 42. 2. A hemostatis then inserted, which is placed at the depth of the purulent accumulation until it comes into contact with bone, while the index finger of the nondominant hand palpates the infraorbital margin.
  • 43. 3. Finally, a rubber drain is placed, which is stabilized with a suture on the mucosa.
  • 44. Buccal Space
    Superior: inferior margin of zygomatic arch
    Inferior: Inferior margin of mandible
    Anterior: Corner of the mouth
    Posterior: anterior margin of Masseter muscle
    Interior: Buccinator muscle
    Superficial fascia
    Buccinator muscle
    Buccal Pad of fats
    Submucous layer
    Mucous membrane
  • 45. Buccal Space Infection
    • Odontogenic: (most frequently)maxillary and mandibular posterior teeth.
    • 46. Nonodontogenic: adenophlegmon of facial lymph nodes.
    • 47. Secondary spread of infection:
    Superiorly: pterygopalatine space
    Inferiorly: pterygomandibular space
  • 48. Buccal space lies between
    buccinator muscle and
    overlying skin and
    superficial fascia. This
    potential space may
    become involved via
    maxillary or mandibular
  • 49. Clinical Presentation of Buccal Abscess
    Swelling of the cheek, which extends from the zygomatic arch as far as the inferior border of the mandible, and from the anterior border of the ramus to the corner of the mouth.
    The skin appears taut and red, with or without fluctuation of the abscess.
    There can be intraoral bulging.
  • 50. This buccal space infection
    was result of maxillary molar.
    Typical swelling of the cheek
    is demonstrated, which does
    not extend beyond inferior
    border of mandible.
  • 51. Buccal-space infection with periorbital extension developing from a nonvital maxillary molar tooth
  • 52. Obvious swelling of the right cheek.
    Side view. Fluctuant mass extending toward the buccal side of the gum end to the gingival-buccal reflection
    ---Gingiva with swelling and erythema.
  • 53. Treatment of Buccal Space Abscess
    Access to the buccal space is usually intraoral for three main reasons:
    1. Because the abscess fluctuates intraorally in the majority of cases.
    2. To avoid injuring the facial nerve.
    3. For esthetic reasons.
    • The intraoral incision is made at the posterior region of the mouth, in an anteroposterior direction and very carefully in order to avoid injury of the parotid duct. A hemostat is then used to explore the space thoroughly.
    • 54. An extraoral incision is made when intraoral access would not ensure adequate drainage, or when the pus is deep inside the space. The incision is made approximately 2 cm below and parallel to the inferior border of the mandible.
    of Intraoral Incision of buccal Abscess
  • 55. Submental Space
    Lateral: anterior bellies of the right and left Digastric muscles
    Anterior: internal border of corpus of mandible
    Posterior: Hyoid bone
    Roof: Mylohoid muscle
    Lower margin: Skin and Platysma muscle
  • 56. Submental Space Infection
    • Odontogenic: from frontal teeth of the mandible
    • 57. Nonodontogenic: adenophlegmon or trauma
    • 58. Secondary spread: from submandibular or sublingual spaces
  • Clinical Presentation of submental Abscess
    Edema in submental region which can spread to submandibular space.
    Palpation is painful and fluctuation is present
    Hyperemia of skin
    Functional disturbances in protrusion of the jaw
    Dysphagia or discomfort while swallowing can be present.
  • 59. Clinical photograph showing severe extraoral swelling at the submental region
  • 60. Submental
  • 61. Submental space infection appears as discrete swelling in central area of sub-mandibular region.
  • 62. Submental space abscess, secondary to dental disease
  • 63. Treatment of submental Abscess
    1. Local anesthesia is performed around the abscess
    Peripheral infiltration anesthesia of healthy
    tissues surrounding inflammation
    Mature submental abscess ready for incision and drainage.
  • 64. 2. An incision on the skin is made beneath the chin, in a horizontal direction and parallel to the anterior border of the chin.
    Diagrammatic illustration (a) and clinical photograph (b) showing the incision for drainage of the abscess.
  • 65. The pus is then drained in the same way as in the other
    cases .
    Withdrawal of the hemostat from the cavity with open beaks, facilitating the evacuation of pus
    Insertion of a hemostat and exploration of the abscessed area
  • 66. Rubber drain placed at the drainage site of the abscess
  • 67. Submandibular Space
    Superior: Mylohoid muscle
    Inferior: Skin
    External: inferior border of the body of mandible
    Anterior: Anterior belly of Digastric muscle
    Posterior: Posterior belly of Digastric muscle
    Consists of:
    Submandibular salivary glands
    Submandibular lymph nodes
    Facial artery
    Anterior facial vein
  • 68. Submandibular Space Infection
    • Odontogenic: mandibular molars and premolars
    • 69. Nonodontogenic:
    Adenophlegmon of submandibular lymph nodes
    Purulent process of submandibular salivary glands
    • Secondary spread: submental (most frequently) or sublingual.
  • Clinical Presentation
    The infection presents as moderate swelling at the submandibular area, which spreads, creating greater edema that is indurated and redness of the overlying skin.
    Angle of the mandible is obliterated
    Pain during palpation
    Moderate trismus due to involvement of the medial pterygoid muscle
  • 70. Clinical photograph showing severe swelling at the left posterior area of the mandible
  • 71. This submandibular space infection produced large, indurated swelling of submandibular space.
  • 72. Abscesses of the submandibular neck space are common in children. The treatment is incision and drainage. Cultures are obtained and the appropriate antibiotic is administered.
  • 73. Treatment of Submandibular Abscess
    1.The incision for drainage is performed on the skin, approximately 1 cm beneath and parallel to the inferior border of the mandible. During the incision, the course of the facial artery and vein (the incision should be made posterior to these) and the respective branch of the facial nerve should be taken into consideration.
  • 74. 2. A hemostat is inserted into the cavity of the abscess to explore the space and an attempt is made to communicate with the infected spaces .
  • 75. 3.After drainage, a rubber drain is placed.
    Stabilization of a rubber
    drain at the site of incision
    Postoperative clinical  photograph 10 days later
  • 76. The submandibular abscess was incised and drained. It contained thick, greenish pus. A drain was left in the wound.
  • 77. Submandibular abscess in an adult with diabetes mellitus.
  • 78. VIDEO of Incision
    of Submandibular Abscess
  • 79. Sublingual Space
    Superior: mucous membrane of floor of mouth
    Inferior: Mylohoid muscle
    Posterior: muscles of the tongue and hyoid bone
    Lateral and anterior: inner surface of body of mandible
    Medially: Lingual septum
  • 80. Sublingual Space
    Consists of:
    Submandibular duct(Wharton’s duct)
    Sublingual gland
    Sublingual and lingual nerve
    Terminal branches of lingual artery
    Part of submandibular gland
    Can be divided into:
    Proper sublingual space
    Mandibular-lingual sulcus
    (right & left)
  • 81. Sublingual Space Infection
    • Odontogenic: mandibular anterior teeth, premolars, and 1st molars whose apices are found above the attachment of the Mylohoid muscle.
    • 82. Nonodontogenic: Sublingual glands infection
    • 83. Secondary spread from:
    Submental by ascending way through
    fibers of Mylohoid muscle
    Lateral pharyngeal
  • 84.
  • 85. Clinical Presentation
    Firm, painful swelling of mucosa of floor of the mouth, resulting in elevation of the tongue towards the palate and backwards
    Pain and difficulty swallowing (Dysphagia)
    Movement of the tongue is painful
    Mandibular-lingual sulcus is obliterated and mucosa presents a bluish tinge
    Moderate or no external swelling
    The patient speaks with difficulty, because of the edema, and movements of the tongue are painful.
  • 86. B- This isolated sublingual space infection produced unilateral swelling of floor of mouth.
    A-Sublingual space between oral mucosa and Mylohoid muscle.
  • 87. Swelling of the mucosa of the mouth floor and characteristic elevation of the tongue towards
    the opposite side
    Abscess in the sublingual space 
    due to infection of Wharton's duct infection
  • 88. Extension of sublingual abscess to the submandibular space.
  • 89. Treatment of Sublingual Abscess
    1.The incision for drainage is performed intraorally, laterally, and along Wharton’s duct and the lingual nerve
  • 90. 2.In order to locate the pus, a hemostat is used to explore the space inferiorly, in an anteroposterior direction and beneath the gland.
  • 91. 3.After drainage is complete, a rubber drain is placed.
  • 92. Pterygomandibular Space
    External : anterior margin of ramus of mandible
    Internal: external surface of lateral pterygoid muscle
    Superior: medial pterygoid muscle
    Posterior: partially by parotid gland and styloglossus muscle
    Anterior: Buccinator muscle
    Consists of:
    mandibular neurovascular bundle
    Lingual nerve
    part of the buccal fat pad
  • 93. Pterygomandibular Space Infection
    • Odontogenic:
    3rd molar pericoronitis
    Apical infection of molars
    • Nonodontogenic:
    Septic mandibular Nerve block----
    Fracture of the jaw
    • Secondary Spread:
    lateral pharyngeal spaces.
  • 94. Clinical Presentation of Pterygomandibular Abscess
    Severe trismus and slight extraoral edema beneath the angle of the mandible are observed
    Tenderness and pain on deep palpation over medial aspect of ramus
    edema of the soft palate of the affected side is present
    displacement of the uvula and lateral pharyngeal wall
    There is difficulty in swallowing.
  • 95. Treatment of Pterygomandibular Abscess
    1.The incision for drainage is performed on the mucosa of the oral cavity and, more specifically, along the mesial temporal crest. The incision must be 1.5 cm long and 3–4 mm deep.
  • 96. 2.A curved hemostat is then inserted, which proceeds posteriorly and laterally until it comes into contact with the medial surface of the ramus.
    3.The abscess is drained, permitting the evacuation of pus along the shaft of the instrument.
  • 97. To Be Continued……
  • 98.
  • 99. Cellulitis: initial stage of infection
    Diffuse, reddened, soft or hard swelling that is tender to palpation.
    Inflammatory response not yet forming a true abscess.
    Microorganisms have just begun to overcome host defenses and spread beyond tissue planes.
  • 100. True abscess formation
    As inflammatory response matures, may develop a focal accumulation of pus.
    May have spontaneous drainage intraorally or extraorally.