This document provides information on orofacial and neck infections, including their etiology, types, pathways of spread, microbiology, clinical features, treatment, and classifications of fascial spaces. It discusses various types of infections such as acute periapical abscesses, acute dentoalveolar abscesses, acute periodontal abscesses, and infections of specific spaces like the canine space, buccal space, and infratemporal space. Treatment involves both medical approaches like antibiotics and surgical drainage of affected areas.

1. Orofacial &
neck
infections
INSTRUCTOR – DR.JESUS GEORGE
1

2. ETIOLOGY
 1-Odontogenic
 Pulp disease
 Periodontal disease
 Secondarily infected cyst & odontomes
 Remaining root fragment
 Pericoronal infection
 2-Trauma
 3-Implant Surgery
 4-Reconstructive Surgery
2

3. Cont.
 Contaminated Needle Puncture
 Infections Of Maxillary Antrum
 Infections of salivary glands
 Secondary to oral malignancies
3

4. Pathways of odontogenic
infections
Invasion of dental pulp by bacteria after
decay of a tooth

Inflammation, edema & lack of
collateral
blood supply

Venous congestion or avascular
necrosis
(pulpal tissue death) 4

5. Cont.
Reservoir of bacterial growth(anaerobic)

Periodic egress of bacteria into
surrounding
alveolar bone
5

6. MICROBIOLOGY
 Aerobic gram positive cocci bacteria-
streptococci milleri, strep. Sanguis,
strep. Salivarius, strep. Mutans.
 Anaerobic Cocci-peptostreptococcus.
 Bacteriodes-porphyromonas,
prevotella
6

7. TYPES
 A/c
 C/c
 Acute stage - 3 forms
 1.Abscess
 2.cellulitis
 3.fulminating infection
7

8. Abscess
 It is a circumscribed collection of pus
in a pathologic tissue space.
 Infections are characterised by
sphylococci.
8

9. CELLULITIS
 It is spreading infection of loose
connective tissues.
 It is a diffuse, erythematous, mucosal
or cutaneous infection.
 It is the result of streptococcal
infection.
 It does not result in accumulation of
large amount of pus.
9

10. Cont.
 Streptococcus produces
streptokinase, hyaluronidase &
streptodornase which break down
fibrin, connective tissue ground
substance & lyse cellular debris, which
facilitate rapid spread of bacteria.
10

11. FULMINATING INFECTIONS
 Here the infection involves secondary
spaces involving vital structures.
11

12. Chronic stage
 C/c fistulous tract or sinus
formation
 Abscesses neglected for a long time
may discharge intraorally or extra
orally
12

13. Treatment
 Medical treatment
 Soft or liquid diet
 Adequate hydration
 Diet rich in protein
 Analgesics
 Antiseptic mouthwash
 Antibiotics
13

14. Cont.
 In a non compromised patient, with
well localized abscess, surgical
drainage with dental therapy will
resolve the infection.
 In poorly localized, extensive abscess
& cellulitis antibiotic therapy is
needed.
 In compromised patients & patients
with trismus, airway obstruction &
fever antibiotic therapy is must.
14

15. Cont.
 Penicillin is the drug of choice.
 Penicillin+metronidazole Can Also Be
Used.
 Clindamycin
 Amoxycillin+clavulanic Acid
 First & Second Generation
Cephalosporins
15

16. Cont.
 Surgical treatment
 It involves blunt exploration of the
anatomic space or abscess.
 Abscess cavity is then irrigated with
betadine & saline.
 A drain is inserted into the space.
 Hilton`s method of incision & drainage
◦ No blood vessel or nerve is damaged.
◦ Topical anaesthesia is obtained.
16

17. Cont.
◦ Stab incision is made over the point of
maximum fluctuation in the most
dependent area along the skin creases,
through skin & subcutaneous tissue.
◦ If pus is not encountered deepening of
surgical site is done with artery forceps.
◦ Closed forceps are pushed through deep
fascia & advanced towards the pus
collection.
◦ Abscess cavity is entered & forceps is
opened parallel to vital structures.
17

18. Cont.
◦ Pus flows along the beaks of the forceps.
◦ A rubber drain is inserted into the depth of
cavity & secured to the wound margin with
the help of sutures.
◦ Drain is left for 24 hrs.
◦ Dressing is given without pressure.
◦ Drain allows discharge of tissue fluids &
pus from the wound.
◦ Drain is removed when the drainage is
completely ceased
18

19. ACUTE PERIAPICAL
ABSCESS
 Etiology
◦ Caries
◦ Contamination of traumatic exposure of
pulp.
◦ Chemical or thermal damage to pulp.
 The entry to periapical tissues is by
◦ Apical foramina,
◦ Accessary canals,
◦ Endodontic perforation,
◦ Opening in the floor of pulp chamber,
19

20. Cont.
 Clinical features
◦ Severe throbbing pain in the affected
tooth
◦ The offending tooth may be sensitive to
percussion.
◦ Mobility may or may not be present.
 Radiographic features
◦ Tooth has caries with periapical pathology,
root # or erosion.
◦ There may be periapical radiolucency.
20

21. Cont.
 Treatment
◦ Antibiotics
◦ Analgesics
◦ Drainage through pulp chamber
◦ Extraction of tooth
◦ Endodontic treatment
21

22. Acute dentoalveolar
abscess
 Etiology
 Continuation of periapical abscess.
 Clinical features
 Pain
 Submucosal swelling in the sulcus on
the outer aspect of alveolar process.
 If left untreated, swelling bursts &
produces a sinus.
22

23. Cont.
 Radiologic features
 More marked radiolucency than
periapical abscess.
 Treatment
 Same as periapical abscess.
 Extraoral incision & drainage may be
required.
23

24. Acute periodontal abscess
 Etiology
 Periodontitis with periodontal pockets.
 Clinical features
 Dull pain
 Pus discharge via gingival pocket
 Sinus either on the outer or inner
aspect of alveolar process.
24

25. Spread of oral infection
 Routes of spread
 Direct continuity through tissues
 By lymphatics to the lymph
nodes.From lymph nodes to tissues
results in secondary areas of cellulitis
or tissue space abscess.
 By blood stream-local
thrombophlebitis may spread via the
veins entering the cranial cavity
producing cavernous sinus 25

26. Cont.
 Factors influencing spread
◦ General factors
 Host resistance
 Virulance of micro organism
 Combination of both
◦ Local factors
 Anatomic barriers-
 Alveolar bone
 Periosteum
 Adjacent muscles & fascia
26

27. General clinical features in
patient with orofacial infection
 Redness due to vasodialtation
 Swelling due to accumulation of
exudate or pus
 Temperature over the infected area
due to increased blood flow &
increased metabolism
 Pain due to pressure in nerve endings
& release of mediators of pain.
 Fever
27

28. Cont.
 Head ache
 Lymphadenopathy
◦ Acute infection-soft, tender, enlarged,
surrounding tissues are edematous&
overlying skin is erythematous
◦ Chronic infection-firm, nontender enlarged
lymph nodes.
 Presence of draining sinus & fistula
 Difficulty in opening mouth
28

29. Cont.
 Increased salivation
 Change in phonation
 Difficulty in breathing
 Bad breath
29

30. Radiologic examination
 IOPA
 Lateral oblique view of mandible
 PA & lateral view of neck
 CT
 MRI
30

31. General principles of
management of a/c orofacial
infections
 Immediate hospitalization
 Medical treatment
 Surgical management
31

32. Medical management
 Antibiotics
 Hydration of the patient through iv
route
 Analgesics
 Bed rest
 Mouth rinses
 Opening of tooth for drainage
32

33. Surgical management
 Needle decompression
 Done in case of pterigomandibular,
peritonsillar,lateral pharyngeal space
infection that is likely to rupture during
passage of endotracheal tube.
 Extraction of tooth
 Early extraction leads to early
resolution of infection by eliminating
the source of infection & provides a
portal of drainage 33

34. Cont.
 Surgical drainage-
 Incision is placed on the most
dependent areas.
 Incision should be parallel to skin
creases
 Incision should lie in aesthetically
acceptable site as far as possible.
 Incision should be supported by
healthy underlying dermis &
subcutaneous tissue. 34

35. Cont.
 Intraoral incision should not be placed
over frenal attachments, should be
placed parallel to nerve fibers in the
region of mental nerve.
 Removal cause such as infected
tooth, segment of necrotic bone,
foreign body, if not already done, then
is done at the time of drainage
procedure
35

36. Classification of fascial
spaces
Primary maxillary spaces
 Canine
 Buccal
 Infratemporal
Primary mandibular spaces
 Submental
 Buccal
 Submandibular
 Sublingual
36

37. Cont.
Secondary fascial spaces
 Masseteric
 Pterigomandibular
 Superficial & deep temporal
 Lateral pharyngeal
 Retropharyngeal
 Prevertebral
 Parotid space
37

38. Canine space infection
Etiology
 Infection of maxillary canine, premolar
& mesiobuccal root of 1st molar.
Boundaries
 Inferiorly-caninus muscle
 Anteriorly-orbicularis oris muscle
 Posteriorly-buccinator muscle
 Medially-anterolateral surface of
maxilla
38

39. Cont.
 Clinical features
 Swelling of cheek & upper lip
 Obliteration of nasolabial fold
 Drooping of angle of mouth
 Edema of lower eyelids
 Marked Periorbital Edema
 Redness & Marked Tenderness Of
Facial Tissues
39

40. Cont.
 In c/c stage-fistula near the medial
canthus eye.
 Offended tooth is mobile & tender to
percussion
 Treatment
 Incision & drainage-
 Through the mucosa of buccal
vestibule in the region of lateral incisor
& canine.
40

41. Cont.
 A curved mosquito artery forceps is
inserted, pus is evacuated & a drain is
inserted & is secured with suture
41

42. Buccal space infection
Etiology
 Infection of maxillary & mandibular
premolars & molars
 Pericoronitis of lower 3rd molar.
Boundaries
 Anteromedially-buccinator muscle
 Posteromedially-masseter muscle
 Laterally-deep fascia from parotid
capsule & platysma muscle
42

43. Cont.
 Inferiorly-deep fascia & depressor
anguli oris
 Superiorly-zygomatic process of
maxilla & zygomaticus major & minor
muscles
Contents
 Buccal pad of fat
 Stenson`s duct
 Facial artery
43

44. Cont.
 Clinical features
 Gum boil in vestibule
 Swelling extending from lower border
of mandible to infraorbital margin, from
anterior border of masseter to angle of
mouth
 Edema of lower eyelid
44

45. Cont.
 Spread
 To pterigomandibular space
 Infratemporal space
 Submasseteric space
 Treatment
 Incision & drainage through mucosa of
cheek in premolar molar region.
45

46. Infratemporal space infection
 Also called retrozygomatic space
because it is situated behind the
zygomatic bone.
 Etiology
 Infection of buccal roots of maxillary
2nd &3rd molars
 LA injection with contaminated
needles in the area of tuberosity
 Spread from other spaces
46

47. Cont.
 Boundaries
 Laterally - by ramus of mandible,
temporalis muscle & its tendon .
 Medially - medial pterygoid plate ,
lateral pterygoid muscle , medial
pterygoid muscle ,lower part of
temporal fossa of the skull & lateral
wall of pharynx .
 Superiorly - greater wing of sphenoid
& by zygomatic arch . 47

48. Cont.
 Inferiorly - lateral pterigoid muscle
 Anteriorly - infra temporal surface of
maxilla
 Posteriorly- parotid gland
 Contents
 Medial & lateral pterigoid muscle
 Pterigoid venous plexus
 Maxillary artery
 Mandibular nerve
48

49. Cont.
 Middle meningeal artery
 Clinical features
 Limitation of mouth opening
 Swelling in front of ear on the affected
side
 Proptosis of eye
 Swelling in the area of tuberosity
 Elevation of temperature
49

50. Cont.
 Incision & drainage
 Incision is given in buccal vestibule
opposite the 2nd & 3rd molars
 In severe infection incision is made at
the upper posterior edge of temporalis
muscle.
 Sinus forceps is directed upwards &
medially.
50

51. Cont.
 In case of failure to improve mouth
opening temporalis myotomy or
excision of coronoid process is done.
Spread
 To temporal space
 Pterigomandibular space
 Cavernous sinus
51

52. Abscess of upper lip
Etiology
 Infection of upper incisors & canine
Clinical features
 Swelling in the base of the upper lip
 Swelling in vestibule
Treatment
 Antibiotics
 Incision & drainage
 Extraction of offending tooth or RCT
52

53. Palatal abscess
Etiology
 Periodontal abscess from palatal
pockets
 Apical abscess from palatal roots of
posterior teeth usually from the lateral
incisor
Boundaries
 Inferiorly-hard palate
 Superiorly-periosteum & mucosa
 Laterally-alveolar process of maxilla &53

54. Cont.
Clinical features
 Fluctuant swelling in palate near the
offending tooth
 Offending tooth is tender to
percussion
Incision & drainage
 Anterioposterior incision is made
through the mucosa down to bone
54

55. Submental space infection
Etiology
 Infection from 6 mandibular anterior
teeth
 Infection of submental lymph nodes
Boundaries
 Laterally-lower border of mandible,
anterior belly of digastric muscle
 Superiorly-mylohoid muscle
55

56. Cont.
 Inferiorly-deep cervical fascia,
platysma, superficial fascia, skin
Contents
 Submental lymph nodes
 Anterior jugular vein
Clinical features
 Distinct ,firm swelling in midline
,beneath the chin
56

57. Cont.
 Skin overlying the swelling is board
like & taut
 Fluctuation of swelling
 Nonvital, fractured or carious anterior
teeth
 Offending tooth is tender on
percussion& sometimes mobile
57

58. Cont.
Incision & drainage
 Transverse incision in skin below
symphysis of mandible.
Spread
 Submandibular space
58

59. Submandibular space
infection
Etiology
 Infection From Mandibular Molars
 Infection Of Submandibular Salivary
Gland
 Infection From Submental Space
 Infection From Submental Lyph Nodes
 Infection From Sublingual Space
 Infection from middle 1/3 of tongue,
posterior part of floor of mouth,
maxillary teeth, cheek, maxillary sinus59

60. Cont.
Boundaries
 Anteromedially-mylohyoid Muscle
 Posteromedially-hyoglossusmuscle
 Superolaterally-medial Surface Of
Mandible
 Anteroposteriorly-anterior belly of
digastric
 Posterosuperiorly-posterior belly of
digastric,stylohyoid ,stylopharyngeus
musle 60

61. Cont.
 Laterally-platysma & skin
 Contents
 Submandibular salivary gland
 Submandibular lymphnodes
 Facial artery & vein
 Clinical features
 Firm swelling in submandibular region
 Constitutional symptoms
61

62. Cont.
 Tenderness of swelling
 Redness of overlying skin
 Teeth Are Sensitive To Percussion &
Mobile
 Dysphagia
 Moderate Trismus
62

63. Cont.
 Incision & drainage
 Incision of 1.5 to 2cm length is made
2cm below the lower border of
mandible in the skin creases.
 Skin & subcutaneous tissues are
incised.
 Spread
 Submental space
 Submandibular space of opposite side
 Sublingual space 63

64. Sublingual space infection
Etiology
 Infection from mandibular incisors,
canines, premolars & molars
Boundaries
 Inferiorly-mylohyoid muscle
 Laterally-medial side of mandible
 Medially-hyoglossus, genioglossus,
geniohyoid muscles
 Posteriorly-hyoid bone
64

65. Cont.
 Contents
 Geniohyoid, genioglossus, mylohyoid
muscle
 Deep part of submandibular salivary
gland
 Sublingual salivary gland
 Lingual nerve
 Hypoglossal nerve
65

66. Cont.
 Clinical features
 Enlarged tender lymph nodes.
 Pain & discomfort on deglutition
 Speech is affected
 Painful swelling in floor of mouth
 Tongue may be pushed superiorly
 Incision & drainage
 Incision made close to lingual cortical
plate.
66

67. Cont.
 Spread
 Sublingual space of opposite side
 Submandibular space
 Pterigomandibular space
 Parapharyngeal space
 Submental & submandibular
lyphnodes
67

68. Temporal space
 Etiology
 Secondary to the involvement of
infratemporal space
 Boundaries
 Superficial temporal space-b/w
temporal fascia & temporalis muscle.
 Deep temporal space-b/w temporalis
muscle & skull
68

69. Cont.
 Clinical features
 Pain
 Trismus
 Swelling over temporal region
 Incision & drainage
 Incision in temporal region in hairline
45 to zygomatic arch
69

70. Parotid space
 Etiology
 Infection through stenson`s duct
 Blood borne infection
 Infection from
submasseteric,pterigomandibular &
lateral pharyngeal space
 Boundaries
 Inferiorly-stylomandibular ligament
 Anteriorly-masseteric space
70

71. Cont.
 Space formed by splitting deep
cervical fascia around the parotid
gland
 Contents
 Parotid gland
 Parotid lymph nodes
 Facial nerve
 Retromandibular vein
 External carotid artery
71

72. Cont.
 Clinical features
 Severe pain referring to ear
accentuated by eating
 Swelling extending from zygomatic
arch to lower border of mandible.
 Ear lobe may be lifted up
 Pus escapes from stenson`s duct
when gland is milked
72

73. Cont.
 Incision & drainage
 Incision is made on skin behind the
posterior border of mandible extending
from inferior aspect of lobule of ear to
just above mandible
 Spread
 Submasseteric space
 Pterigomandibular space
 Lateral pharyngeal space
73

74. Submasseteric space infection
 Etiology
 Infection Of Lower 3rd Molar
 Boundaries
 Anterior-anterior border of masseter &
buccinator muscle
 Posterior-parotid gland,posterior part
of masseter
 Inferior- attachment of masseter to
lower border of mandible
74

75. Cont.
 Medial-lateral surface of ramus of
mandible
 Lateral-medial surface of masseter
muscle
 Contents
 Masseteric Nerve
 Superficial Temporal Artery
 Transverse Facial Artery
75

76. Cont.
 Clinical Features
 Moderate swelling extending from
lower border of mandible to
zygomatic arch, anteriorly to anterior
border of masseter, posteriorly to
posterior border of mandible
 Tenderness over angle of mandible
 Complete Limitation Of Mouth
Opening
 Pyrexia & Malaise 76

77. Cont.
 Incision & drainage
 Intraoral-incision is made vertically
over the lower part of anterior border
of ramus of mandible, deep to bone
 Extraoral-incision is placed in skin
behind the angle of mandible
77

78. Pterigo - mandibular space
infection
 Etiology
 Pericoronitis related to the mandibular
third molar .
 Inferior alveolar nerve block using
contaminated needle .
 Infection form maxillary third molar .
 Boundaries .
 Posterior - parotid gland .
78

79. Cont.
 Medial - lateral surface of medial
pterygoid muscle .
 Lateral - medial surface of ramus of
mandible .
 Anterior -pterygomandibular raphae .
 Superior - lateral pterygoid muscle .
 Contents .
 Lingual nerve .
 Mandibular nerve .
79

80. Cont.
 Inferior alveolar artery .
 Mylohyoid muscle
 Clinical features .
 Limitation of mouth opening .
 Tenderness & swelling medial to
anterior border of ramus of the
mandible .
 Dysphagia .
 Difficulty in breathing
80

81. Cont.
 Incision & drainage .
 Intraoral – a vertical incision;
approximately 1.5 cm in length , is
made on the anterior & medial aspect
of the ramus of mandible .
 Extraoral - an incision is taken in the
skin below the angle of the mandible .
 Spread .
 Infra temporal space
81

82. Cont.
 Lateral pharyngeal space .
 Retropharygeal space .
 Submandibular space . .
82

83. LATERAL PHARYNGEAL
SPACE .
 Etiology
 Mandibular third molar area .
 Sublingual , submandibular &
ptergomandibular space infection .
 Boundaries .
 Inferiorly - hyoid bone .
 Anteriorly - pterygomandibular raphe
 Laterally - ascending ramus of
mandibular
 Medially - pharyngeal wall . 83

84. Cont.
 Posteriorly - styloid muscle , upper
part of carotid sheath , prevertebral
fascia .
 Contents
 Anterior compartment - lymph nodes ,
facial artery , loose areolar connective
tissue .
 Posterior compartment - carotid
sheath , internal carotid artery ,
glossopharyngeal nerve , cervical 84

85. Cont.
 Clinical Features .
 Respiratory Embarrassment Due To
Edema Of The Larynx .
 Malaise .
 Pyrexia .
 Brawny Induration Of The Face .
 Trismus .
 Severe pain
 Dysphagia
85

86. Cont.
 Incision & drainage
 Extraoral - an incision is made along
the anterior border of
sternocleidomastoid muscle ,
extending from below the angle of the
mandible , to the middle third of
submandibular gland .
 Intraoral - a vertical incision is placed
over the pterygomandibular raphe .
86

87. Retropharyngeal space
(prevertebral space )
 Etiology
 Infection from the iateral pharyngeal
space
 Boundaries .
 Laterally - carotid sheath
 Inferiorly-6th thoracic vertebra
 Clinical features .
 Painful deglutition .
 Snoring .
87

88. Cont.
 Choking .
 Stertorous breathing .
 Incision & drainage .
 Same as lateral pharyngeal space
88

89. Pericoronitis
 Definition
 An inflammatory process involving the
soft tissue covering the crown of
partially erupted or unerupted teeth
 Etiology
 Impacted teeth .
 Trauma to the overlying gingivae from
the cusps of an opposing tooth .
89

90. Cont.
 Clinical features
 Dull pain
 Swollen ,red,tender gingival pad
 Pus discharge from the gingival pad
 Foetor oris
 Indentations of cusps of upper teeth
 Discomfort on swallowing
 Restriction of oral opening
90

91. Cont.
 Enlarged tender submandibular lymph
nodes
 Pyrexia/fever
 Malaise
 Anorexia
 Spread
 Buccal space
 Submandibular space
 Pterigomandibular space
91

92. Ludwig`s angina
 Definition
 A massive, firm, brawny, cellulitis or
induration & acute toxic stage
involving simultaneously
submandibular, sublingual &
submental spaces bilaterally.
 Etiology
 Odontogenic-
◦ A/c dentoalveolar abscess
◦ A/c periodontal abscess 92

93. Cont.
◦ Pericoronal abscess
◦ Infected mandibular cyst
 Iatrogenic
◦ La using contaminated needles
 Trauma in orofacial region
 Osteomyelitis
 Submandibular & sublingual
sialadenitis
 Secondary infections of oral
malignancies 93

94. Cont.
 Tonsillitis
 Foreign bodies like fish bone
 Oral soft tissue lacerations
 Clinical features
 Pyrexia .
 Anorexia
 Chills .
 Malaise .
 Dysphagia .
94

95. Cont.
 Impaired speech .
 Hoarseness of voice .
 Firm or hard brawny swelling in
bilateral submandibular & submental
regions extending to the clavicles .
 Swelling is non pitting , non fluctuant
,tender with ill defined borders .
 Restricted mouth opening .
 Air way obstruction .
95

96. Cont.
 Mouth remains open due to edema of
sublingual tissues
 Reduced tongue movements .
 Increased respiratory rate .
 Cyanosis .
 Raised floor of mouth .
 Tongue is raised against palate .
 Increased salivation .
 Drooling of saliva .
96

97. Cont.
 Spread
 Submasseteric space .
 Pterygomandibular space .
 Parapharyngeal space .
 Paratonsillar space .
 Mediastinum .
 Cavernous sinus thrombosis .
97

98. Cont.
 Treatment
 Maintenance of air way .
◦ Nasotracheal intubation
 Surgical decompression.
◦ Bilateral submandibular incision s & a
midline submental incision 1cm below
inferior border of mandible for drainage
.
 Extraction of offending tooth .
98

99. Cont.
 Antibiotic therapy .
◦ Aqueous penicillin G 2 - 4 million units , i
v 4-6 hourly or 500mg 6 hourly orally
◦ Ampicillin or amoxycillin 500mg 6 & 8
hourly i v & orally respectively .
◦ Cloxacillin 500mg orally 8 hourly .
◦ Erythromycin 600mg 6- 8 hourly .
◦ Gentamycin 80mg i m bd .
◦ Clindamycin i v 300mg 600mg 8 hourly .
or orally
99

100. Cont.
◦ Metronidazole 400mg 8 hourly orally or i
v .
 Hydration of the pt .
 Hydro therapy
◦ Cold application decreases inflammation ,
exudates , edema .
 Complications
 Osteomyelitis .
 Maxillary Sinusitis .
 Septicaemia . 100

101. Cont.
 Mediastinitis .
 Pericarditis .
 Jugular vein thrombosis .
 Meningitis .
 Brain abscess .
 Cavernous sinus thrombosis
101