Complex Odontogenic Infections: Diagnosis & Management

1. COMPLEX ODONTOGENIC
INFECTIONS
Dr. Razan Ahmed

3. CONTENTS
• Introduction
• Surgical Anatomy
• Deep fascial space infections
• Arising from any tooth
• Arising from maxillary teeth
• Arising from mandibular teeth
• Deep cervical facial space infection
• Management of fascial space infection
• Other infectuons in head and neck region

4. INTRODUCTION
• Common cause of presentation due to caries with subsequent
periapical pathology
• Infection extending beyond alveolar process and basal bone
• Extending into vestibule
• Extending distal to vestibule or other fascial spaces
• Complicated by airway compromise and systemic involvement
• Best managed by Oral and maxillofacial surgeon

6. SURGICAL ANATOMY
• Importance?
• Assessing the extent of the infection(clinical and radiographic findings
correlation)
• Adequate surgical access and drainage, without causing iatrogenic injury to
vital structures resulting in morbidity
• Determining path of spread of infection

7. DEFINING THE DEEP FASCIAL SPACE
• Potential spaces
• Invaded by bacteria
• Culminates in typical stages of infection

9. CERVICAL FASCIA DIVIDED INTO
• Superficial cervical facial
• Envelops platysma muscle and muscles of facial expression
• Deep cervical fascia
• Divided into Superficial, middle and deep layers

14. Deep Fascial Space Infections
Infections arising from any tooth
• Vestibular space(most common): vestibular space abscess
• Buccal space
• Subcutaneous space

15. INFECTIONS ARISING FROM MAXILLARY
TEETH
• Primary space:
• Buccal space
• Vestibular space
• Palatal space(maxillary palatal roots)
• Secondary space:
• Infraorbital/canine space
• Orbital space

18. INFRAORBITAL/CANINE SPACE
• Superior to attachment of levator anguli oris and inferior to origin of
quadratus labii superioris
• Extension from buccal space to canine space and vice versa
• Caudal to attachment of levator anguli oris is vestibular space
• Drainage point: medial and lateral canthi- path of least resistance
• Clinical finding: obliteratrion/flattening of nasolabial fold

21. BUCCAL SPACE
• Overlying skin and subcutaneous tissue
• Underneath- buccinator muscle
• Affected teeth- buccal roots of maxillary molars- alveolar bone perforates
superior to buccinator muscle attachment
• Clinical findings: swelling between zygomatic arch and inferior border of
mandible(both palpable)

23. INFRATEMPORAL SPACE
• Connected to deep temporal space laterally and superiorly
• Infection in either space involves the other space
• Bounded medially by lateral pterygoid and superiorly by base of skull
• Contents: internal maxillary artery and pterygoid venous plexus
• Pterygoid venous tributaries-emissary veins. Connects to dural sinuses
• Posterior route of spread of infection into cavernous sinus
• Affected teeth- maxillary third molars

24. MAXILLARY SINUS SPACE
• Periapical infection spreads superiorly to erode sinus wall, resulting as
maxillary sinusitis
• Clinical features consistent with maxillary sinusitis. Hence
odontogenic infection must be ruled out
• May progress to involve other sinuses
• Can propagate into periorbital space
• Treatment include management of odontogenic infection and
functional endoscopic assisted sinus surgery (FESS)

26. ORBITAL SPACE
• Periorbital and infraorbital space
• Preseptal cellulitis- anterior to orbital septum leads to orbital cellulitis
• Infraorbital space may communicate with cavernous sinus infection-
anterior route, via superior orbital fissure

28. INFECTIONS ARISING FROM MANDIBULAR
TEETH
• Primary spaces
• Vestibular space- most common
• Body of mandible
• Secondary spaces
• Perimandibular space(sublingual space, submandibular space, submental
space)
• Masticator space( masseteric space, pterygomandibular space, superficial
temporal space, deep temporal space)

30. BODY OF MANDIBLE
• Potential space between bone cortex and periosteum of mandible
• Diffuse space throughout the mandible
• May secondarily infect perimandibular spaces or buccal space

32. PERI-MANDIBULAR SPACE
• Mylohyoid muscle attachment
demarcates boundary between
submandibular space and
sublingual space
• Perforation of lingual cortex
• Infections arising from anterior
teeth- submandibular space
• Posterior teeth infection-
sublingual space

33. SUBLINGUAL SPACE
• Bounded by oral mucosa and
mylohyoid muscle
• Freely communicates posteriorly
with submandibular space
• Usually presents together with
submandibular space infection
• Clinical findings include intraoral
elevation of floor of mouth and
tongue, difficulty in speech and
swallowing

34. SUBMANDIBULAR SPACE
• Triangular space- bounded
between bellies of digastric
muscles and inferior border of
mandible
• Posteriorly communicates freely
with pterygomandibular space and
lateral pharyngeal space
• Manifests as extraoral swelling
• Drained extraorally

35. SUBMENTAL SPACE
• Arise from mandibular incisor
teeth
• Progression of infection from
submandibular space through
anterior belly of digastric muscle
• Lets infection spread to
contralateral perimandibular
spaces

36. LUDWIG’S ANGINA
• Involvement of all 5
perimandibular spaces( bilateral
submandibular spaces, bilateral
sublingual spaces and submental
space)
• State of emergent treatment
• Airway maintenance is prime
concern(intubation/tracheostomy)

37. CLINICAL FINDINGS:
• Firm induration of skin below mandible(submandibular-submental spaces)
• Elevation of floor of mouth and tongue(sublingual space)
• Abscess cavities below mandible
• Dysphagia, dysphonia, dyspnea-upper airway obstruction, trismus,
• Inability to visualize posterior oropharynx, cervical immobility, globus
sensation, inability to handle oral secetions, head held forward

38. Perimandibular
space
Pterygomandibula
r space via
buccopharyngeal
gap
Lateral pharyngeal
space
Retropharyngeal
space

39. PTERYGOMANDIBULAR SPACE
• 78% of cases of masticator space infection
• Most common culprit tooth- mandibular third molar-pericoronitis(direct
route)
• Bounded by buccal space, parotid gland, pterygoid muscle, inferior border of
mandible, medial pterygoid muscle and ascending ramus

41. • Masseteric/submasseteric space bounded by masseter muscle and
ascending ramus of mandible
• Superficial temporal space bounded by temporalis muscle and
temporalis fascia
• Deep temporal space is bounded by temporalis muscle and calvarium
• Zygomatic arch divides masseteric space and superficial temporal
space
• Lateral pterygoid muscle separates deep temporal space and
pterygomandibular space

44. • Infratemporal space- Inferior aspect of deep temporal space
• Bounded by lateral pterygoid muscle and infratemporal crest of sphenoid
bone
• Mandibular molars infection(periapical/pericoronitis) affects
submasseteric space and pterygomandibular space
• Mandible angle fracture infection affects submasseteric space

45. • Clinical findings of submasseteric space infection includes trismus;
CT/MRI shows diffuse enlarged masseter muscle
• Clinical findings of pterygomandibular space infection shows trismus,
intraoral findings include edema of anterior tonsillar region and
deviation of uvula to unaffected side.
• Abscess cavity in CT with contrast reveals as ring enhancement

47. • Spread of infection is directed by gravity, hence temporal space
involvement is not common
• Involvement of both submasseteric space and temporal spaces gives
clinically as an hour glass appearance

49. Deep cervical space infections
• Lateral pharyngeal space
• Retropharyngeal space

50. Lateral pharyngeal space
• Inverted triangle shape
• Extends superiorly from base of skull
down to hyoid bone
• Lateral border: medial pterygoid muscle
• Medial border: superior pharyngeal
constrictor muscle
• Anterior border: pterygomandibular raphe
• Posterior border: retropharyngeal space
• Divided in two by styloid process:
• Anterior compartment- loose areolar tissue
• Posterior compartment- carotid sheath, CN
IX and CN XII

52. • Clinical findings:
• Swelling of lateral neck- inability to visualize angle of mandible
• Trismus
• Deviation of lateral wall of oropharynx to midline
• Dysphagia
• Dysphonia
• Drooling of saliva
• High grade fever
• Malaise
• Compromised airway

53. • Sequelea:
• Rapid progress into retropharyngeal space
• Airway obstruction
• Thrombosis of internal jugular vein
• Erosion of carotid artery
• Impingement on cranial nerves- IX, X and XII

54. Retropharyngeal space
• Anterior border: superior middle
and inferior pharyngeal constrictor
muscles and retropharyngeal
fascia
• Posterior border: alar fascia
• Superior border: base of skull
• Inferior border: C6-T4
• At caudal end, alar fascia fuses
with buccopharyngeal fascia

55. • Contains loose areolar connective tissue
• Infection extends from lateral pharyngeal space and can progress in to
danger space behind alar fascia
• Danger space extends from base of skull to diaphragm
• bounded anteriorly and posteriorly by alar fascia and prevertebral
fascia respectively

57. Mediastenitis
• Progression of infection into mediastinum
• Mediastinum contains heart, phrenic nerve, vagus nerve, trachea,
main stem bronchi, esophagus, and great vessels (aorta, superior and
inferior vena cava)
• Critically ill appearance due to compression of heart and lungs and
neurogenic compressions with resultant cardiopulmonary failure
• Poor prognosis

58. Management of fascial space infections
Primary goals:
• Medical optimization
• Airway protection(intubation/tracheostomy)
• Removal of source of infection
• Surgical incision and drainage
• Adjunctive antibiotic therapy
• Frequent assessment of response to therapy

60. Specific infections
Cavernous sinus thrombosis
• Venous drainage channels for middle cranial fossa
• Bordered by superior orbital fissure which contains ophthalmic veins-
route for spread of infection
• Contents: CN III, IV, Va, VB, VI and internal carotid artery
• Any of the above structures might be affected
• Most commonly palsy of CN VI is seen, inability to abduct affected eye
• Congestion of retinal veins of eye

62. Necrotizing fasciitis
• Flesh eating bacterial infection
• Doesnot follow fascial spaces
• Polymicrobial
• Destructive- high mortality rate despite adequate treatment
• Affects superficial layer of dep cervical fascia deep to platysma-
resulting in thrombosis of underlying muscle and necrosis of overlying
platysma muscle and skin

64. • Management: aggressive debridement and removal of all affected
tissues, broad spectrum IV antibiotics
• Serial debridements are usually needed to completely eradicate
infection

69. Osteomyelitis
• Inflammation/infection of bone
• Classified as:
• Suppurative
• Chronic sclerosing
• Osteomyelitis with proliferative periostitis(Garre osteomyelitis)
• originates from medullary space, followed by edema of marrow
• Increased hydrostatic pressure because of compact cortical bone affects
nutrient supply, culminating in necrosis and pain

76. • Failure of circulation of cancellous bone is crucial in progression
• Bone healing is reduced
• Blood borne immunity is inhibited, promoting growth of microbes
• More common in mandible than maxilla
• Rich innervation in maxilla
• Periosteal supply penetrates maxilla cortex- thinner than mandible
• Rare in immunocompetent individuals
• More common with diabetes, HIV, chronic drug abusers and immunosuppresants
• Predominant bacteria- Staphylococcus species
• Others include streptococci, bacteroides, peptostretococcus, ekinella, candida,
actinomyces, klebsiella, fusobacterium, lactobacillus, and hemophilus

77. • Ideally antibiotic therapy is driven by culture and sensitivity testing

78. Acute suppurative osteomyelitis
• Infection of medullary bone with associated purulence
• Often seen in osteoradionecrosis(ORN) or medication-related
osteonecrosis of jaw(MRONJ)
• Organisms colonize surface of bone before entering medullary space
with resultant necrotic areas
• Clinical findings: edema, restricted movement, erythema and pain
• Late radiographic appearance- moth eaten appearance of bone, can
be mistaken with malignancy

79. • Radiopaque areas surrounded by radiolucent areas
Radiopaque- sequestra, unresorbed bone
Radiolucent- involucrum(new bone)
• Treatment includes debridement of bone, sequestrectomy,
corticotomy/saucerization and adjunctive antibiotics
• Etiology must be addressed- carious tooth, failed root canal treatment
or dental implant, or in case of ORN/MRONJ-necrotic bone
• Can progress to pathological fracture of mandible

80. Chronic suppurative osteomyelitis
• Long standing
• Similar treatment as acute form
• Larger debridement is necessary along with long duration I/V
antibiotics(6 months or more)
• Culture/sensitivity highly recommended

81. Chronic sclerosing osteomyelitis
• Etiology species: Actinomyces and Eikenella species
• Sclerosis and fibrosis of medullary space
• Intense pain-pathognomonic
• Increased trabeculation on radiographs
• Resection is often the treatment

82. Osteomyelitis with proliferative periostitis (Garre Osteomyelitis)
• Chronic disease that usually affects children
• Due to high vascularity
• Onion skinning appearance on radiographs. Extracorticular bone
perpendicular to cortex
• Usually associated with infected mandibular tooth
• Inflammation causes deposition of bone lifting the periostium off the
cortex
• Treatment: removal of infection+ antibiotics(short term)

86. Actinomycosis
• Actinomyces israelii or Actinomyces naeslundiI
• Anaerobic environment required to thrive
• Presents as induration and nodular fibrosis with spontaneous discharge tracts to skin
• Seeds into area of susceptibility, injured site, fractures or tooth extraction site to flourish
• Does not follow planes of head and neck
• Lumpy pseudo tumor formation with cutaneous tracts with sulfur granules
• Treatment of choice: I/V penicillin followed by oral dose
• Surgical placement of drains facilitate aerobic environment
•

91. Candidiasis
• Most common fungal disease of oral cavity
• Candida albicans- involved species(normal oral flora)
• Requires altered host immune system(opportunistic infection)
• Forms:
• Pseudo membranous
• erythromatous
• Angular cheilitis
• Treatment includes removal of source, antifungals(oral or systemic)