Copy of sequlae of odontogenic infections / dental implant courses

INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

Definition:
“ They are potential spaces
between the different layers of fascia filled
with loose connective tissue and various
anatomical structures which breaks down
when invaded by infection…”
Space is a misnomer. There are no voids in tissues in
actual reality

 In 1811 Burns- first
described the fascia
of the head and neck
 In 19th & 20th century
confusion about
fascial spaces of the
head and neck
 In 1939 Malgaine-
”the cervical fascia
appeared in a new
form under the pen
of each author”

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Indian Dental academy
• www.indiandentalacademy.com
• Leader continuing dental education
• Offer both online and offline dental
courses

 ODONTOGENIC-arising from the teeth
 ABSCESS-localized area of inflammation
containing pus.
 CELLULITIS-diffused inflammation which
spreads through soft tissue spaces
and along fascial planes, usually as
a result of a focus of
infection(abscess)

 Pulp disease
 Periodontal disease
 Secondarily infected cysts/odontomes
 Remaining root fragment
 Residual infection
 Pericoronal infection
 Microbial invasion-bacteria, fungi, virus

General factors-
 Health status of the patient
 Competency of the immune system
 Extremes of age-newborn or frail elderly are
highly susceptible

 Local blood supply-
the greater the
vascularity ,the better and
more effective the host defense system.
 Local anatomy- infection tends to spread
along the path of least
resistance
E.g.: facial planes and
tissue spaces.

 Virulence
 Quantity – of organisms
 Portal entry-pulp, periodontal tissues,
surgical wounds
 Toxic factors produced by the microbes.
E.g.: endotoxins, hyaluronidase…

 Aerobic-anaerobic composition
*Aerobic gram +ve cocci
(streptococci, staphlylococci)

*Anaerobic gram +ve
cocci rods
eubacterium
peptostreptococci lactobacterium
peptococci
*Anaerobic gram –ve rods
porphromonas
prevotella
fusobacterterium

PULPITIS
Acute chronic
APICAL PERIODONTITIS
Acute chronic
PERIAPICAL ABSCESS PERIAPICAL GRANULOMA
Acute chronic
PERIODONTAL CYST
OSTEOMYELITIS
Acute chronic
focal diffuse
PERIOSTITIS
CELLUTITIS ABSCESS

Interstial hydrostatic pressure
Transudation of ECF +inflammatory
cells+compromised blood flow
IFP is relieved by swelling
In teeth the pressure cannot be relieved
Pulpal ischemia
Releases tissue breakdown products

Recruits macrophages and
histiocytes
(by chemotaxis)
Macrophages differenciate into
osteoclasts-and resorb bone
Bone necrosis & resorption
expands in spherical pattern
until the bony cortex is
reached
(densly mineralized tissue will
slow down the bone
resorption)
If bony cortical layer is breached
then infection enters the soft
tissue

Invading bacteria triggers
inflammatory process
Streptococci-is found in
early days of
infection(invades by
production of
streptokinase and
hyaluronidase)
There is an exponential
increase in streptococci-
they create an
enviornment for the
anaerobic flora(as they
consume local O2 &
nutrients)
Anaerobes (prevoltella and
porphyromonas)produce
collagenase
After it perforates the bony
cortical plate
It spreads to the most
vulnerable tissue(areolar
tissues)-since its not well
vascularized,loose and
dissected by low
hydrostatic pressure
Infection spreads along the
path of least resistance
deflected by dense and
vascularised structures

 buccinator-
below attachment-
facial swelling
above attachment-
intraoral swelling
 Masseter-
in between-
submasseteric space
laterally-temporal
space.

 Medial pterygoid
laterally-
pterygomandibular
space
medially-lateral
pharyngeal space
posteriorly-
retropharyngeal
space.

 Mand.3rd molar:
sublingual
submandibular
buccal
masticator
lateral pharyngeal
retropharyngeal
 Maxillary 3rd molar
lateral pharyngeal
retropharyngeal
masticator
buccal
 maxillary canine
buccal
 Maxillary lateral
palatal

Grodinsky & Holyoke
classification:
Space 1 - platysma and
investing fascia
Space 2 - investing and
infrahyoid fascia
Space 2a - among
infrahyoid muscles
Space 3 - pretracheal and
retrovisceral
Space 4 - danger space
Space 4a - prevertebral
and investing fascia
Space 5 - within
prevertebral fascia

MANDIBULAR
 Submental
 Sublingual
 Submandibular
 Masticator-submasseteric
pterygomandibular
sup.temporal
deep temporal
 buccal
 Parotid
 Lateral pharyngeal
 Retropharyngeal
 Pretracheal
 Visceral
 Danger space
 Carotid sheath
 Mediastinum
MAXILLARY
 Palatal
 Buccal
 Infraorbital
 Periorbital
 Orbital
 Cavernous sinus
thrombosis

Ant:inferiob border of mand.
Post:hyoid bone
Superior:mylohyoid bone
Inferiof:investing fascia
Superficial:investing fascia
Lateral:ant.belly of
digastric muscle

Ant:lingual surface of
mandible
Post:submandibular space
Superior:oral mucosa
Inferior:mylohyoid muscle
Medial:muscles of tongue
Lateral:lingual surface of
mandible

Ant:anterior belly of digastric
muscle
Post:post.belly of digastric,
stylohyoid
muscle,stylopharngeus muscle
Superior:inf.and medial
surfaces of mandible
Inferior:digastric tendon
Superficial:platysma
m,investing fascia
Deep:mylohyoid,hypogloss
us,sup.constrictor muscle

Bilateral swelling of
sublingual,submandibula
r and submental spaces
Swelling is brawny,non
fluctuant,and painful.
Floor of the mouth & tongue are
elevated
Difficulty in respiration
Deglutition and speech are difficult

Ant:corner of mouth
post:masseter
muscle,pterygomandibular
space
Superior:maxilla,infraorbital
space
Inferior:mandible
Superficial:subcutaneous
tissue and skin
Deep:buccinator muscle

 Consists of the
masticatory muscles
 Superiorly is the
periosteum of the
zygoma and
temporalis fascia.
 Posteriorly- parotid
space
 Inferiorly-
submandibular and
sublingual spaces

 Space between the lateral border of ramus of
mandible and masseter

 Lateral-ramus of
mandible
 Medially-medial
pterygoid muscle
 Post- deep lobe of
parotid gland
 Anterior-
pterygomandibular
raphae
 Superiorly-
lat.pterygoid muscle
 Contents-lingual N,
inf.alv artery,
mylohyoid nerve and
vessels, loose areolar
tissues

Superficial temporal
space:between the
temoral fascia and
temporalis muscle
Deep temporal
space:between
temporalis and skull

 Extent:zygomatic arch
above to the lower
border of mandible.
Posteriorly:retrom-
andibular region.
 c/c:severe pain
reffered to the ear
 Pain increased on
eating(less fluid
consumption-
dehydrated)
 Its different from
submasseteric due to
absence of
trismus,eversion of ear
lobuled,pus when
paroid duct is milked

Ant:superior & middle
pharyngeal constrictor muscles
Post:caroid sheath & scalene
fascia
Superior:skull base
Inferior:hyoid bone
Superficial:pharyngeal
constrictors,retropharyngeal
space
Lateral:medial pterygoid muscle

 Ant:superior and
middle
pharyngeal
constrictor
muscles
 Post:alar fascia
 Superior:skull
base
 Inferior:fusion of
alar &
prevertebral
fasciae at C6-T4
 Lateral:carotid
sheath,lat.pharyn
geal space

 Ant:sternothyroid-
thyrohyoid fascia
 Posterior:retropharyn
geal space
 Superior:thyroid
cartilage
 Inferior:sup.mediasti
num
 Superficial;sternothro
id-thyrohyoid fascia
 Deep:visceral fascia
over trachea &
thyroid gland

 Etiology:- lat. Incisor
- palatal root of
post. teeth
 c/c: extremely painful
due to rich innervation
- localized due to adherent periosteum.

 It’s a swelling
present lateral to
the nose which
obliterates the
nasolabial fold.
 Spreads over the
levator anguli oris.

 Ant: nasal cartilages
 Post: buccal space
 Superior: quadratus labii superioris
 Inferior: oral mucosa
 Superficial: quadratus labii
superioris
 Deep: levator anguli oris
maxilla

 infections can
spread from the
orbit – thru the sup
and inf. Opthalmic
veins & and the
deep facial vein
through the
pterygoid plexus..
 Speads easily due
to the valveless
channels.

 Infection from the
neck spread thru
the carotid sheath
into the
mediastinum.

 Space infections that spead to the danger
space can spread down to the mediastinum.
 Can compress the major vessels,lower airway
& upper digestive
tract.

 Determine the severity
of the infection
 Complete history
 Physical examination
 State of the patients
host defense
 Treat the infection
surgically

Determine severity
Vital signs
Local involvement
Extent and rate of
progression
Involved spaces
Trismus
Airway
Vital structures

Compromised Host Defenses
– Uncontrolled metabolic
diseases
􀂄 Uremia
􀂄 Alcoholism
􀂄 Malnutrition
􀂄 Severe diabetes
– Suppressing diseases
􀂄 Leukemia
􀂄 Lymphoma
􀂄 Malignant tumors
– Suppressing drugs
􀂄 Chemotherapeutic agents
􀂄 Immunosuppressives

 Vital Signs
◦ Temperature-
systemic involvement
>101 F
◦ Blood Pressure- mild
elevation
◦ Pulse- >100
◦ Increased Respiratory
Rate- normal 14-16

 cellulitis abscess
Duration Acute Chronic
Pain Severe and generalized Localized
Size Large Small
Localization Diffuse borders Well circumscribed
Palpation Doughy to indurated Fluctuant
Presence of pus No Yes
Degree of seriousness Greater Less
Bacteria Aerobic Anaerobic

 Panorex
 Plain Films
 CT
 MRI

 General appearance
 Palpate the area of swelling
◦ Indurated- firm, hard
◦ Fluctuant- fluid filled
◦ Doughy- normal
 Intra-oral exam

 Incision and drainage

 Abscess opening externally

Provide supportive care
– General
􀂄Fluids
􀂄Rest
􀂄Nutrition
􀂄Warmth
– Antibiotic therapy

 Proper antibiotics
 Proper route of administration-IV
more faster acting
 Proper dose
 Proper time interval
 proper period of administration

• penicillin,
• clindamycin,
• metronidazole,
• cephlosporins,
 amoxicillin+clavunate.
 tetracyclins & quinalones are not effective
towards severe anaerobic infections.
• erythromycin –poorly absorbed and less
efffective in odontogenic infections.
• An article stated that the antibiotics given will make the patient
asymptomatic by the 3rd day but has to be given for 2 days more
for complete result

 Re evalation is nessary to determine the
recovery…

 Orbital infections-spreads from paranasal sinus
thru the infratemporal and pterygopalatine fossa
thru the valveless inf. Opthalmic vein, thru the
angular vein from the canine.
 Necrotizing fascitis-superficial bacterial infection
causes superficial thrombosis resulting in necrosis
and loss of a large area of skin
 Cavernous sinus thrombosis-”picket fence fever” and
opthalmic symptoms like
 diplopia,
 opthalmoplegia,
 ptosis
 Late symptoms- pulse rate, temperature curve
it is called cross of death .
 Treatment- immediate heparinization

 Brain abscess-
neurological symptoms, nausea, vomitting,nuchal
rigidity,mental status changes
Rx-aggressive antibiotic therapy
corticosteroids
aspiration and excision
 Mediastinitis-infection spreads from neck thru
carotid sheath into mediastinum
C/F-fever, tachycardia,leukocytosis,pain in
cheast,back or neck
Rx-debridement of necrotic tissue
surgical drainage
antimicrobial coverage

To study the phenomena of disease without books is
to sail an uncharted
Sea ,while to study books without patients is not to
go sea at all….
SIR WILLIAM OSLER

CASE REPORT

 Drain was placed, decayed tooth was extracted,
and the patient was put on antibioticswww.indiandentalacademy.com

HAVE A NICE &BEAUTIFUL DAY…..

Copy of sequlae of odontogenic infections / dental implant courses

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