The document discusses several challenging and complex odontogenic infections: 1) Deep neck space infections which can spread along fascial planes from the skull base to the mediastinum and cause serious complications. Primary spaces affected by odontogenic infections include the buccal, submandibular, and sublingual spaces. 2) Ludwig's angina which presents as bilateral cervical swelling and can cause dysphagia, drooling, neck tenderness, and potential airway obstruction. The infection spreads along fascial planes from the mandible. 3) Acute necrotizing ulcerative gingivitis (ANUG) which presents as "punched-out" gingival lesions and

1. Challenging and
Complex
Odontogenic
Infections

2. Overview
 Challenging and complex odontogenic infections
 Deep neck space infection
 Ludwig’s angina
 Acute Necrotising Ulcerative Gingivitis (ANUG)
 Interesting case reports on odontogenic infections

3. Challenging and complex
odontogenic infections

4. Deep Neck Space infection

5. Deep Neck Space Infection
Reference: Pellecchia R. A Textbook of Advanced Oral and Maxillofacial Surgery Volume 3. Chapter 1. Antimicrobial Therapy and
Surgical Management of Odontogenic Infections.. http://dx.doi.org/10.5772/63317
DNI: Deep neck infection
Deep neck
space
infections
(DNIs)
DNIs: Group of severe bacterial infections in potential
spaces and fascial planes of the neck
Abscesses, cellulitis and phlegmons can spread along
these fascial planes from the skull base to the
mediastinum → Serious and potentially life-threatening
complications
Spaces primarily affected by odontogenic infections:
Located adjacent to the origin of dental infection

6.  Spaces are categorized as:
Reference: https://pocketdentistry.com/fascial-spaces-of-the-head-and-neck/
Deep Neck Space Infection: Spaces
Primary
fascial
spaces
Buccal, canine,
sublingual,
submandibular,
submental, and vestibular
spaces
Secondary
spaces
Pterygomandibular,
infratemporal,
masseteric, lateral
pharyngeal, superficial
and deep temporal,
masticator, and
retropharyngeal

7. Potential pathways of spread into deep fascial space
infections
Reference: https://www.mdnxs.com/topics-2/infectious-disease/deep-neck-infection/

8. Fascial spaces of face and suprahyoid areas
Reference: Pellecchia R. A Textbook of Advanced Oral and Maxillofacial Surgery Volume 3. Chapter 1. Antimicrobial Therapy and
Surgical Management of Odontogenic Infections.. http://dx.doi.org/10.5772/63317
Potential infection sites of deep fascial space
infections
Canine
space
infection
Lateral
pharyngeal and
submandibular
space infection
Masseteric
space
infection
Submental
space
infection

9. Treatment algorithm- Deep space neck infection
Treatment algorithm for patients with descending necrotizing mediastinitis (DNM).
Reference: Pellecchia R. A Textbook of Advanced Oral and Maxillofacial Surgery Volume 3. Chapter 1. Antimicrobial Therapy and
Surgical Management of Odontogenic Infections.. http://dx.doi.org/10.5772/63317

10. Steps in management of severe head and neck
infections
Reference: Pellecchia R. A Textbook of Advanced Oral and Maxillofacial Surgery Volume 3. Chapter 1. Antimicrobial Therapy and
Surgical Management of Odontogenic Infections.. http://dx.doi.org/10.5772/63317
Surgical
goals
Secure
airway
Remove
cause of
infection
Establish
dependent
drainage
 Incision and drainage ↓ bacterial load
 Intraoral incisions are generally made in the oral vestibule at the point of maximum
swelling
 After surgical treatment, patient must receive adequate medical support including
nutrition, rehydration, and control of systemic disease

11. Ludwig’s Angina

12. Ludwig’s Angina
Reference: Dowdy RAE et al, Ludwig’s Angina: Anesthetic Management. Anesth Prog. 2019;66:103–110.
Image source:Heavey J, Gupta N. Images in clinical medicine. Ludwig's angina. N Engl J Med. 2008 Oct 2;359(14):1501.
Ludwig’s Angina
Gangrenous cellulitis of
the neck that spreads via
continuity of fascial
planes
Commonest cause:
Odontogenic; can be due
to both aerobic and
anaerobic bacteria
Bilateral
cervical
swelling
Dysphagia Drooling
Neck
tenderness
Elevation and
posterior
distension
tongue
Restricted neck
movement
Trismus
Dyspnea, and
stridor (difficult
airway
management)
Signs
&
Symptoms

13. Ludwig Angina: Clinical presentation
Superficial localized infection
Localized pain, may present with
cellulitis, and sensitivity to tooth
percussion and temperature.
Ogle OE. Odontogenic Infections. Dent Clin N Am. 2017: 61;235–252
Deep infections or abscesses
May be present with swelling, fever, and
sometimes difficulty swallowing, opening the
mouth, or breathing (especially those that
spread along fascial planes)
This image is for representation purpose only

14. Pathways for spread of odontogenic infections Mallampati classification
Reference: Dowdy RAE et al. Ludwig’s Angina: Anesthetic Management. Anesth Prog. 2019;66:103–110
Ludwig Angina: Spread of infection
Coronal section at first molars,
Maxillary antrum
Nasal cavity, Palatal plate
Sublingual space (above
mylohyoid muscle), submandibular
space
Infection spreads through the
buccal plates inside the
attachment of the buccinator
muscle
Infection spreads through the
buccal plates outside the
attachment of the buccinator
(A) Class I: Soft palate, uvula, fauces,
and tonsillar pillars are visible
(B) Class II: Soft palate, uvula, and
fauces are visible
(C) Class III: Soft palate and base of
uvula are visible
(D) Class IV: Hard palate is visible

15. Ludwig Angina: Causative bacteria and treatment
Reference: Dowdy RAE et al, Ludwig’s Angina: Anesthetic Management. Anesth Prog. 2019;66:103–110
Treatment
Causative bacteria:
Streptococcus viridans, Staphylococcus aureus, B-haemolytic streptococcus species,
Staphylococcus epidermidid, Bacteroid genus, Fusobacterium nucleatum,
Peptostreptococcus, and Enterobacter aerogenes.
>50% of diabetic patients with Ludwig Angina present with Klebsiella pneumoniae
Intravenous
antibiotics,
Incision and
drainage
Regimen of
choice
IV Penicillin G +
metronidazole
(or similar
effective against
b-lactamase–
producing
anaerobic flora)
Failure to
recognize and
properly treat it
may cause
compromised
airway and lead
to mortality
Additional
treatment may
include
intravenous
dexamethasone
(10 mg every 8
hrs) for 48 hrs to
reduce edema
helping to
preserve airway
integrity

16. Ludwig Angina: Preoperative assessment
Preoperative assessment
Reference: Dowdy RAE et al, Ludwig’s Angina: Anesthetic Management. Anesth Prog. 2019;66:103–110
Identifying
features that
may cause
difficulties with
mask
ventilation
Direct
laryngoscopy Intubation
 Alternative methods of ventilation must be considered and immediately
accessible
 This includes a plan on how and when they would be used in the event
that a patient cannot be mask ventilated or intubated
 Marking external anatomical airway landmarks prior to manipulating the
airway can save vital time if an emergent airway becomes necessary

17. Ludwig Angina- Difficult Airway Algorithm
Reference: Dowdy RAE et al. Ludwig’s Angina: Anesthetic Management. Anesth Prog. 2019;66:103–110

18. Acute Necrotising Ulcerative
Gingivitis/ANUG

19. Acute necrotizing ulcerative gingivitis/ Vincent
angina/trench mouth
Aaron SL et al. Acute Necrotizing Ulcerative Gingivitis. StatPearls Publishing. Jan 2020.
Image source: Malek R, Gharibi A, Khlil N, Kissa J. Necrotizing ulcerative gingivitis. Contemporary clinical dentistry. 2017 Jul;8(3):496.
Rapidly destructive, non-communicable microbial disease of gingiva in
the context of an impaired host immune response
ANUG
ANUG: Acute necrotizing ulcerative gingivitis
“Punched-out"
crater-like
lesions of the
papillary gingiva
Sudden onset
of inflammation
Pain
This image is for representation purpose only

20. Acute necrotizing ulcerative gingivitis/ Vincent
angina/trench mouth
Aaron SL et al. Acute Necrotizing Ulcerative Gingivitis. StatPearls Publishing. Jan 2020.
ANUG: Acute necrotizing ulcerative gingivitis, NUP: Necrotizing ulcerative periodontitis
Caused by
opportunistic
bacterial
infection
and is
predominantly
associated with
fusiform and
spirochete
bacteria
Presents as an
acute, painful,
and
destructive
ulceration and
inflammation
of interdental
gum tissue
Rare infectious
disease of the
gum tissue,
affecting <1%
of the
population
Represents
the most
severe of
conditions
associated
with the
dental biofilm
Can lead to
very rapid
tissue
destruction,
NUP, and
even fatal
cancrum oris
(noma), if left
untreated

21. Aaron SL et al. Acute Necrotizing Ulcerative Gingivitis. StatPearls Publishing. Jan 2020.
Factors involved in development of ANUG
ANUG: Acute necrotizing ulcerative gingivitis
Psychological
stress
Insufficient
sleep HIV infection
Pre-existing
gingivitis
Poor diet alcohol and
tobacco consumption Poor oral hygiene

22. Sequence of ANUG
Aaron SL et al. Acute Necrotizing Ulcerative Gingivitis. StatPearls Publishing. Jan 2020.
Psychological stress Reduces gingival microcirculation and salivary flow
Alters immune response Alters patient's behavior and mood
Insufficient oral hygiene, malnutrition, and ↑ tobacco consumption
ANUG:Acute necrotizing ulcerative gingivitis
Acute necrotizing ulcerative gingivitis

23. Aaron SL et al. Acute Necrotizing Ulcerative Gingivitis. StatPearls Publishing. Jan 2020.
Treatment and Management of ANUG
ANUG treatment has multifactorial approach in successive stages and includes-
Treatment of
the acute
phase:
Superficial
debridement,
oral hygiene
instructions,
utilization of
antimicrobial
mouthwash
and oral
antibiotics
Treatment of
any
preexisting
condition
Treatment of
disease
sequelae
Transition to
supportive
or
maintenance
phase
Initiation of a
compre-
hensive
prophylaxis
plan involving
root planning
and
predisposing
factor
management

24. Interesting case reports on
odontogenic infections

25. Clinical examination
 Temperature-100°F
 Pulse rate- 80 beats per minute
 BP- 100/70 mmHg
 Respiratory rate- 22 breaths per minute
 Mouth opening was limited to 1.5 cm (interincisal distance)
 Extra-oral swelling was indurated and non-fluctuant with bilateral involvement of the
submandibular and sublingual region
 An infected third molar had been extracted
3 days earlier
Case report 1
Balasubramanian S et al. SRM J Res Dent Sci. 2014;5:211-4.
Case presentation: A 65-year-old patient presented with chief complaints of
inability to open the mouth, pain and difficulty in swallowing with a swelling in
relation to the lower jaw and neck for the past 4 days.

26. Balasubramanian S et al. SRM J Res Dent Sci. 2014;5:211-4.
Case report 1 (continued)
Blood
report
• Normal except for rise in ESR, WBC count, and
neutrophils
Diagnosis
• Ludwig’s angina
Treatment
• The patient was posted for surgical decompression
under local anesthesia with monitoring of oxygen
saturation and vital signs by anesthesiologist

27. On examination
Case report: 2
Gawande MJ et al. Bilateral canine space infection secondary to odontogenic origin. A rare case report.
Int J Med Surg Sci. 2019; 6(4): 129-132.
A 54-year-old man came to the clinic with complaints of pain and swelling on the
upper front-side of his face. bilateral canine space infection secondary to
odontogenic origin.
Temperature-
100°F
Pulse rate- 84
beats per
minute
BP- 120/70
mmHg
Respiratory
rate- 19
breaths per
minute

28. Gawande MJ et al. Bilateral canine space infection secondary to odontogenic origin. A rare case report.
Int J Med Surg Sci. 2019; 6(4): 129-132.
Case report 2 (continued)
Local examination
The face showed enlargement
and swelling in the upper front
region of the jaw
Investigation
Panoramic radiograph images
showed a radiolucent
appearance of the canine region

29. Diagnosis:
Based on results of the clinical and radiographic
examinations, diagnosis of bilateral canine space infection
was made.
Treatment:
 FNAC was performed from canine region followed by
intraoral drainage incision at the most prominent part of
swelling (Modified Hiltons method).
 Approximately 5 ml of pus was removed and
postoperative dressing was applied.
 Further endodontic treatment was performed and
followed by continued antibiotic therapy.
FNAC: Fine needle aspiration cytology
Case report 2 (continued)

30. Case report 3
Gawande MJ et al. Bilateral canine space infection secondary to odontogenic origin. A rare case report.
Int J Med Surg Sci. 2019; 6(4): 129-132.
Case presentation: A 21-year-old male patient, with painful gingival inflammation
evolving since 4 days, consulted urgently to dental clinic.
He reported that he had taken some medicines such as antiviral
treatment (acyclovir) and anti-inflammatory drugs (diclofenac)
He had a poor plaque control without any parafunction and was a
chronic nonsmoker. No other significant medical history or known
allergies
He had a stressful job; he worked as a model and was
under a severe diet
The patient reported subjective malaise, chills, and difficulty in
eating due to intensive pain

31. Physical examination
Thin, febrile, tired male, no
adenopathy was noted on cervical
ganglionic area examination.
Clinical examination
Revealed halitosis, erythematous,
and swelling gingiva localized at
the buccal side of upper central,
upper and lower lateral incisors
and canines
A pseudomembrane formation
along the gingival margins and
decapitated ulcerated papillae
were also noted
Case report 3 (continued)
Malek R, et al. Necrotizing Ulcerative Gingivitis. Contemp Clin Dent. 2017; 8(3):496-500.
This image is for representation purpose only

32. Investigations
 X-ray examination showed a generalized periodontal ligament
enlargement, a passive eruption of the right maxillary canine,
an idiopathic root resorption of the lower incisors, and a
marginal alveolar bone loss in the lower central incisors which
might be due to occlusal trauma
 HIV test was done, and the result was negative
Case report 3 (continued)
Malek R, et al. Necrotizing Ulcerative Gingivitis. Contemp Clin Dent. 2017; 8(3):496-500.
Diagnosis:
Necrotizing ulcerative gingivitis

33. Treatment
 10 volumes diluted hydrogen peroxide was
applied to the necrotic
pseudomembranous lesions using sterile
swabs in conjunction with suitable
ultrasonic supragingival debridement
 The patient was prescribed oral antibiotic
(250 mg metronidazole every 8 h for 7
days) and oral mouth rinse (0.12%
chlorhexidine twice daily for 10 days)
 The gingiva state was evaluated 2 days
and 7 days after
 Subgingival debridement was conducted
Case report 3 (continued)
Malek R, et al. Necrotizing Ulcerative Gingivitis. Contemp Clin Dent. 2017; 8(3):496-500.
This image is for representation purpose only
Necrotizing ulcerative gingivitis
Post treatment
This image is for representation purpose only

34. Follow-up
 Major improvement in symptoms with
almost complete resolution of ulcerated
pseudomembranous areas and reduction
of erythema and swelling
 In context of global periodontal approach,
gingivectomy was done in the right
maxillary canine 23, two months after
healing
 The patient was seen regularly, once a
month
 Favorable evolution was noted without any
tissue sequelae
 Symmetrical and homogeneous
architecture of the healing gingiva was
obtained
Case report 3 (continued)
Malek R, et al. Necrotizing Ulcerative Gingivitis. Contemp Clin Dent. 2017; 8(3):496-500.
This image is for representation purpose only

35. Safety Information of Augmentin
• Very common undesirable side (≥1/10); Diarrhea (adults)
• Common undesirable side (≥1/100 and <1/10); Mucocutaneous
candidiasis, diarrhea (children), nausea, vomiting
• Uncommon (≥ 1/1000 to < 1/100) - Dizziness, headache, Indigestion
• Very rare (< 1/10,000) - Antibiotic-associated colitis (including
pseudomembranous colitis and haemorrhagic colitis)
Version:
Based on :
AUGMENTIN 625/1g DUO tabs: Prescribing Information Version AUG-TAB/PI/IN/2019/01 dated 22 Mar 2019
•AUGMENTIN DDS: Prescribing Information Version AUG-DDS/PI/IN/2019/01 dated 4 April 2019
AUGMENTIN DUO: Prescribing Information Version AUG-SUS/PI/IN/2019/01 dated 4 April 2019

36. GlaxoSmithKline Pharmaceuticals Ltd.,
Dr. Annie Besant Road, Worli,
Mumbai- 400 030. (India)
Please report adverse events with any GSK product to the company
at india.pharmacovigilance@gsk.com
For the use only of Registered Medical Practitioners
Trademarks are owned by or property of GSK group of companies
Full prescribing information available on request from
Registered medical practitioners can refer company website
http://india-pharma.gsk.com/en-in/products/prescribing-information/ for
full Product Information.
http://india-pharma.gsk.com/media/700985/augmentin-dds.pdf;
http://india-pharma.gsk.com/media/700988/augmentin-duo-
suspension.pdf;
http://india-pharma.gsk.com/media/700991/augmentin-duo-tablets.pdf;
Prescribing information
36
PM-IN-ACA-PPT-210003
DATE OF PREPARATION: APRIL 2021

37. Thank you !!