orofacial infection

1. OROFACIAL INFECTION
CHAPTER 1
INTRODUCTION
DR. HAYDAR MUNIR SALIH ALNAMER
BDS, PHD (BOARD CERTIFIED)

2. • Infections of orofacial and neck region, particularly those
of odontogenic origin, have been one of the most
common diseases in human beings
• These infections range from periapical abscess to
superficial and deep neck infections. The infections
generally spread by following the path of least resistance
through connective tissue and along fascial planes
• Early recognition of orofacial infection and prompt,
appropriate therapy is absolutely essential

3. ETIOLOGY
1. Odontogenic:
2. Traumatic:
3. Implant surgery
4. Reconstructive surgery
5. Infections arising from contaminated needle punctures.
6. Others: This group includes instances of orofacial
infections arising from other factors such as infected
antrum, salivary gland afflictions, etc.
7. Secondary to oral malignancies.

4. PATHWAYS OF ODONTOGENIC INFECTION
Invasion of the dental pulp by
bacteria after decay of a tooth
↓
Inflammation, edema and lack of
collateral blood supply
↓
Venous congestion or avascular
necrosis (pulpal tissue death)
↓
Reservoir for bacterial growth
(anaerobic) ↓
Periodic egress of bacteria into
surrounding alveolar bone

5. ODONTOGENIC INFECTION: ACUTE STAGE
1. Cellulitis: It is spreading infection of loose connective
tissues. It is a diffuse, erythematous, mucosal or cutaneous
infection. It is characteristically the result of streptococci
infection; and does not normally result in large
accumulation of pus.
• Antibiotics may arrest the spread of infection; and may bring
about complete resolution of the condition.

6. ODONTOGENIC
INFECTION:
CELLULITIS

7. ODONTOGENIC INFECTIONS : ACUTE STAGE
2. Abscess: It is a circumscribed collection of pus in a
pathological tissue space. A true abscess is a thick- walled
cavity containing pus. The suppurative infections are
characteristic of staphylococci, often with anaerobes, such
as bacteroides, and are usually associated with large
accumulation of pus, which require immediate drainage.

8. ODONTOGENIC INFECTION: ABSCESS

9. characteristic Cellulitis Abscess
Duration 3-7 days Over 5 days
Localization Diffuse Localized
Skin quality Reddened Peripherally reddened
Tissue fluid Serum, flack of pus Pus
Predominant bacteria Mixed Anaerobic

10. 1. ODONTOGENIC INFECTION/ ACUTE STAGE:
ACUTE PERIAPICAL ABSCESS
The main cause is infective necrosis of pulp
Severe throbbing pain in the affected tooth
Mobility may or may not be present.
It also shows periapical radiolucency, areas of resorption;
and the different types of radiolucencies involving the root
fractures.
The treatment modalities comprise of the following: (1)
Antibiotics, (2) Analgesics, (3) Drainage through the pulp
chamber, (4) Extraction of the offending tooth, or (5)
Endodontic treatment.

11. ACUTE PERIAPICAL ABSCESS

12. 1. ODONTOGENIC INFECTION/ ACUTE STAGE:
ACUTE DENTOALVEOLAR ABSCESS
• This disease entity is a continuation of periapical abscess.
• Submucosal swelling in the sulcus, usually on the outer
aspect of alveolar process. Fluctuation may be elicited after
few days. If left untreated, the swelling bursts and produces
sinus tract discharging pus
• Treatment: The same treatment modalities hold true for
dentoalveolar abscess. In addition, intra or extraoral incision
and drainage may be required.

13. ACUTE DENTOALVEOLAR ABSCESS

14. 1. ODONTOGENIC INFECTION/ ACUTE STAGE:
PERICORONITIS / ACUTE PERICORONAL ABSCESS.
• The meaning of the word “peri” means, surrounding,
“coronos” means pertaining to crown, and “itis” means
inflammation
• Trauma to the overlying gingivae from the cusps of an
opposing tooth is the most
• Acute: Facial swelling, limitation of oral opening, severe
throbbing pain, interfering sleep, discomfort on
swallowing.

15. PERICORONITIS / ACUTE PERICORONAL
ABSCESS

16. 2. ODONTOGENIC INFECTION CHRONIC
STAGE:
In the chronic stage, the odontogenic infection can present
itself in the following forms:
1. Chronic fistulous tract or sinus formation: Abscesses
neglected for a long time discharge intraorally or extraorally.
When the abscess discharges through the skin; the sinus may
appear in a location unfavorable for drainage; and the resulting
scar is always thickened, puckered, and depressed and more
obvious esthetically prominent.
2. Chronic osteomyelitis
3. Cervicofacial actinomycosis.

17. FASCIAL SPACE INFECTION
• Fasciae covering muscle bundles are normally in close
apposition. If these fasciae are forced apart, avascular
spaces are created. If localization of an infection by
virulent bacteria fails, inflammatory exudate opens up
the fascial spaces carrying bacteria with It into the tissue
planes
• Before the advent of antibiotics the mortality was high
and the disease is still life-threatening if treatment is
delayed.

18. SPREAD OF OROFACIAL INFECTION
a. By direct continuity through the tissues.
b. By lymphatics to the regional lymph nodes and eventually
into the blood stream. When the infection gets established in
the lymph nodes, secondary
c. By the blood stream: Rarely, local thrombophlebitis may
propagate along the veins, entering the cranial cavity via
emissary veins to produce cavernous sinus thrombophlebitis

19. 1. The site of the source of infection such as upper or lower
jaw, and the particular segment of the jaw involved.
2. The point at which the pus escapes from the bone and
discharges into the soft tissues either labiolingually or
buccopalatally.
3. The natural barriers to the spread to pus in the tissues such
as layers of fascia or muscle or the jaw bones
Anatomical Factors Influencing the Direction of Spread

20. ANATOMICAL FACTORS INFLUENCING THE
DIRECTION OF SPREAD

21. GENERAL PRINCIPLES OF THERAPY FOR THE
MANAGEMENT OF ACUTE EXTENSIVE OROFACIAL
INFECTION
1. Immediate hospitalization
2. Aggressive medical treatment (Supportive
treatment along with antibiotic therapy)
3. Aggressive surgical intervention (including
intubation and tracheostomy) should be done.

23. THE FOLLOWING CRITERIA JUSTIFY HOSPITAL
ADMISSION OF PATIENT WITH OROFACIAL
INFECTION
(1) Fever over 101oF,
(2) Dehydration,
(3) Impending airway compromise,
(4) threat to vital structures,
(5) Infection of deep cervical space or masticator space,
(6) Need for general anesthesia,
(7) Need for inpatient control of systemic disease

24. AIRWAY COMPRISE DUE TO MASSIVE OROFACIAL INFECTION

26. INDICATIONS FOR USE OF ANTIBIOTICS
I) Acute onset of infection,
(ii) Diffuse infections,
(iii) Compromised host defenses,
(iv) Involvement of fascial spaces,
(v) Severe Pericoronitis, and
(vi) Osteomyelitis.

27. SELECTION OF ANTIBIOTICS
a. In case, there is no exudates available for culture and
antibiotic sensitivity of organism(s) involved before initial
therapy, then the initial selection is made on empiric basis.
b. In general, bactericidal antibiotics should be preferred
to bacteriostatic antibiotics
c. It is preferable to use antibiotic with the narrowest
spectrum

28. PRINCIPLES FOR THE USE OF ANTIBIOTIC
THERAPY
• Antibiotics do not replace surgical drainage of infection
• Whenever possible, the organism and sensitivity should be
determined
• Prescribe on basis of culture results and 'most likely organism'
while waiting for results
• Certain antibiotics are reserved for serious infections
• Synergistic combinations may be required in some infections,
e.g. aminoglycoside, cephalosporin and metronidazole for
faecal peritonitis
• In serious infections seek advice from clinical bacteriologist

29. CRITERIA FOR CHANGING ANTIBIOTICS:
(ANTIBIOTIC ROTATION)
1. Allergy
2. Toxic reaction
3. Repeated surgery unsuccessful (no improvement in SIRS)
4. At least 48 hr. of IV antibiotic
5. At least 72 hr. of oral antibiotics
6. Culture and sensitivity report result in antibiotic resistance

30. SUPPORTIVE THERAPY

31. SUPPORTIVE THERAPY
(i) Administration of antibiotics,
(ii) Hydration of patient through IV route, maintain adequate
nutritional status—high protein intake through Ryle‘s tube
feeding
(iii) Analgesic,
(iv) Bed rest,
(v) Application of heat in the form of moist pack and/or
mouth rinses.

32. SURGICAL MANAGEMNT

33. SURGICAL MANAGEMENT:
It consists of:
(i) Extraction of the offending tooth or teeth,
(ii) Incision and drainage
(iii) Combination of both

34. THE FIRST LINE TREATMENT OF AN
ACCESSES IS……….

35. PRINCIPLES OF SURGICAL MANAGEMENT:
I.DETERMINATION OF SEVERITY OF INFECTION
• Evaluation of the airway in the form of difficulty in breathing,
swallowing, speaking, or handling secretions
• A change in quality of voice indicates a swelling in or near
glottis, such as in parapharyngeal spaces
• Ability to protrude the tongue past the vermilion border of
the upper lip is a fairly reliable sign that the sublingual space
is not severely involved

36. PARAPHARNGEAL SPACE INFECTION

37. NEEDLE DECOMPRESSION

38. PRINCIPLES OF SURGICAL MANAGEMENT:
II.DETERMINATION OF THE ANATOMICAL LOCATION OF INFECTION
It is necessary to determine the precise location and
involvement of different oral, fascial and cervical swelling
associated with each of the superficial and deep fascial
spaces involved.

39. SUPERFICIAL
FASCIAL SPACE

40. DEEP FASCIA SPACES

41. PRINCIPLES OF SURGICAL MANAGEMENT:
III.EVALUATION OF THE HOST DEFENSES
a. Diabetes mellitus
b. Steroid therapy within the past two years:
i. Asthma
ii. Autoimmune or inflammatory disease
iii. Organ transplant therapy
c. Cancer chemotherapy within the past year
d. Renal dialysis
e. HIV seropositivity
f. Primary immunodeficiencies

42. SURGICAL DRAINAGE
• Some authors advocate that drainage of all spaces
involved by cellulitis or abscess caused by odontogenic
infection, should be done, as soon as possible after
diagnosis
• NEVER LET SUNSHINE RISE ON ABSCESS !

43. SURGICAL DRAINAGE
1. It is impossible to diagnose deep space infections either by clinical or
radiological examination with100 percent accuracy.
2. Drainage of cellulitis seems to abort the spread of infection into
neighboring deep fascial spaces.
3. Adequate culture specimen can be obtained from cellulitis fluid.
4. Physical debridement and irrigation of infected space may hasten
healing by decreasing the size of bacterial inoculum and the amount of
necrotic tissue present.
5. Early drainage may prevent later colonization of the site by more
highly antibiotic resistant microorganisms.
6. Length of stay in the hospital may be decreased.

44. GUIDELINES FOR PLACEMENT OF INCISIONS IN
INFECTED CASES:
1. Incisions should be placed in the most dependent areas.
2. Incisions should be parallel to the skin creases.
3. Incisions should lie in an esthetically acceptable site as far as possible.
4. Incisions should be supported by healthy underlying dermis and
subcutaneous tissue.
5. Incisions placed intraorally, should not cross frenal attachments, and
should be placed parallel to nerve fibers in the region of mental nerve.
6. The removal of the cause; such as an infected tooth, a segment of
necrotic bone, a foreign body, if not already done, then should be done
at the time of incision and drainage procedure.

45. EXTRA ORAL INCISIONS LINES

46. INTRA ORAL INCISIONS LINES

47. EXTRACTION OF TOOTH IN THE PRESENCE OF
ACUTE ABSCESS:
• This is a controversial subject. One school of thought believes
that there is potential spread of infection by manipulation of
tooth during extraction. The other school of thought
challenges this view and believes that early extraction leads
to early resolution of infection by eliminating the source of
infection and by providing a portal of drainage.
• It is worthwhile considering administration of antibiotics prior
to carrying out extraction of offending tooth during acute
stage of infection

48. HILTON’S METHOD OF INCISION AND DRAINAGE
1. Topical anesthesia: Topical anesthesia is achieved with the
help of ethyl chloride spray.
2. Stab incision: Made over a point of maximum fluctuation
in the most dependent area along the skin creases, through
skin and subcutaneous tissue.
3. If pus is not encountered, further deepening of surgical
site is achieved with sinus forceps (to avoid damage to vital
structures).
4. Closed forceps are pushed through the tough deep fascia
and advanced towards the pus collection.

49. HILTON’S METHOD OF INCISION AND DRAINAGE

50. HILTON’S METHOD OF INCISION AND DRAINAGE
5. Abscess cavity is entered and forceps opened in a direction
parallel to vital structures.
6. Pus flows along sides of the beaks.
7. Explore the entire cavity for additional loculi.
8. Placement of drain: corrugated rubber drain is inserted into
the depth of the abscess cavity; and external part is secured
to the wound margin with the help of sutures.
9. Drain left for at least 24 hours.
10. Dressing: Dressing is applied over the site of incision taken
extraorally without pressure.

51. HILTON’S METHOD OF INCISION AND DRAINAGE

52. SURGICAL
TECHNIQU
E FOR
INCISION
AND
DRAINAGE
OF AN
ABSCESS.

53. DRAIN
• Purpose of keeping the drain: The purpose of drain is to
allow the discharge of tissue fluids and pus from the
wound by keeping it patent. The drain allows for
debridement of the abscess cavity by irrigation.
• Removal of drains: Drains should be removed when the
drainage has nearly completely ceased.

54. DRAIN