Spread of oral infection /endodontic courses

SPREAD OF ORAL
INFECTION
INDIAN DENTAL ACADEMY
Leader in continuing Dental
Education
www.indiandentalacademy.com

LEARNING OBJECTIVES
At the end of the lecture student should be able to
understand & describe
•Routes of spread of infection.
•Etiology, clinical features, histopathological
features of Cellulitis.
•Etiology, clinical features, histopathological
features of Ludwig’s Angina.

Infection in dental pulp
Established
Spread through root canals
Periapical region

PULPITIS
Acute Chronic
APICAL PERIODONTITIS
Acute Chronic
PERIAPICAL ABSCESS PERIAPICAL GRANULOMA
Acute chronic PERIODONTAL CYST
OSTEOMYELITIS
Acute Chronic
Focal Diffuse
PERIOSTITIS
CELLULITIS ABSCESS

Oral infection
Originates in dental pulp Originates in periodontal
tissue
Through root canals Disperse through spongy
bone
Extend into periapical tissues May perforate cortical
plate
Spread in various tissue spaces OR Discharge on free
mucous membrane /skin

Drainage pathway of acute
periapical infection

Parulis-Surface of gingiva
Maxillary Sinus
Palate-
Palatal Abscess
Cellulitis-Soft tissue spaces superior to buccinator muscle
Cellulitis-Soft tissue spaces
inferior to buccinator muscle
Parulis-Surface of gingiva
Ludwig’s Angina-
Floor of the mouth

Osteomylitis-An inflammatory process
within medullary bone that involves
the marrow spaces
Parulis-A sessile nodule on the gingiva
at the site where a draining sinus
tract reaches the surface
Fistula-a drainage pathway or
abnormal communication between two
epithelium –lined surfaces because of
destruction of the intervening tissue

Cellulitis-A painful swelling of the
soft tissue of the mouth & face
resulting from a diffuse spreading of
purulent exudate along the fascial
planes that separate the muscle
bundles.
Ludwig’s Angina- Cellulitis involving
fascial spaces between muscles &
other structures of the posterior floor
of the mouth that can compromise
the airway

PARULIS
Palatal Abscess

ROUTES OF SPREAD OF
INFECTION
Lymphatic system
Bloodstream
Directly through tissues

1. The type & virulence of the
organism
2. General health of the patient
3. Anatomical site of initial infection
Anatomic features determine the
direction that the infection may take
FACTORS AFFECTING THE ABILITY
OF INFECTION TO SPREAD DEPEND
ON

CELLULITIS
(PHLEGMON)
Definition:
 A diffuse inflammation of soft tissues
which is not circumscribed or confined to
one area, but which, in contrary to the
abscess, tends to spread through tissue
spaces and along fascial planes.

CELLULITIS
 If an abscess is not able to establish
drainage through the surface of the skin
or into the oral cavity, it may spread
diffusely through fascial planes of the soft
tissue

ETIOLOGY & PATHOGENESIS
Streptococcal & anaerobic Prevotella&
Porphyromonas sapp.
Production of enzymes -hyluronidase,
streptokinase & Fibrinolysins
Dissolution of hyluronic acid & fibrin
Distruction of collagen

Cellulitis of face & neck- most
commonly
1.Dental infection as a sequel of an
apical abscess or osteomyelitis
2.Periodontal infections
3.Pericoronitis
4.Tooth extraction, injection either with
an infected needle or through an
infected area,
5.Jaw fracture

CLINICAL FEATURES
 Moderately ill with elevated
temperature.
 Painful swelling of involved
soft tissue that are firm and
brawny.
 If superficial, skin is inflammed
 Regional lymphadenopathy

 Maxilla: Perforation of outer cortical plate
above buccinator- Swelling initially of the
upper half of face.
 Diffuse spread involves entire facial area
 Extension towards eye- Cavernous sinus
thrombosis

 Mandible: Perforation below buccinator-
swelling of lower half of face.
 Later superior & cervical spread
 Spread to cervical tissue- Respiratory
discomfort
 Infection frequently tends to become
localized- facial abscess
 Discharge upon a free surface

HISTOLOGICAL FEATURES
 Diffuse nonspecific acute
inflammation
 Characterized by diffuse
exudation of
Polymorphonuclear
leukocytes, occasionally
lymphocytes.
 Separating muscle
bundles
Muscle fibre bundles

TWO SEVERE FORM OF CELLULITIS
Ludwig’s Angina
Cavernous Sinus Thrombosis

A-Submandibular space
B-Sublingual space
C-Mylohyoid muscle

LUDWIG’S ANGINA
 German physician Ludwig(1836)
 Angina- Latin ‘angere’= to
strangle
 Severe cellulitis
 Beginning in the submandibular
space
 Secondary involvement of
sublingual and submental spaces
 Bilateral involvement of all three
spaces

SOURCE OF INFECTION
Mandibular 2nd
and 3rd
molar
Penetrating injury of floor of the
mouth
Osteomyelitis due to compound jaw
fracture

CLINICAL FEATURES
 Rapidly increasing board like swelling of the
floor of the mouth
 Elevation & protrusion of tongue(woody
tongue)
 Swelling is firm, painful,
diffuse with no localization

CLINICAL FEATURES
 Swelling & tenderness involving neck above the
level of hyoid bone (bull neck)
 Oedema of glottis with risk of death .

 Difficulty in swallowing, eating, breathing
 Increased temperature, rapid pulse, fast
respiration
 Spread to parapharyngeal spaces, carotid
sheath or pterygopalatine fossa

LABORATORY FINDINGS
 Leukocytosis
 ESR
 Mixed infection, No specific organism
But streptococci- invariably present.

TREATMENT
 Maintenance of the airway
 Incision & drainage
 Antibiotic therapy
 Elimination of original focus of infection

CAVERNOUS SINUS
THROMBOSIS OR
THROMBOPHLEBITIS
 It is serious condition consisting of formation of a
thrombus in the cavernous sinus or its
communicating branches
 Infections of head, face & intraoral structures above
maxilla are particularly prone to produce this
disease.

C AVERNOUS SINUS
THROMBOSIS OR
THROMBOPHLEBITIS
C linical features
 Patient extremely ill
 Exopthalmous with edema of eyelids
 Paralysis of external ocular muscles
 Impairment of vision
 Photophobia and lacrimation
 Headache, nausea, vomiting, fever, chills

MAXILLARY SINUSITIS
•An acute or chronic inflammation
of maxillary sinus
•It is usually caused by infection
(bacterial or viral), but can also be
caused by allergic reactions or
other responses to environmental
agents.

SINUSITIS
 It is caused by infection (such as a cold or an
upper respiratory tract infection) spreading to
the sinuses from the nose
 Direct extension of dental infection, which is
dependent on relation and proximity of teeth to
sinus
 From local spread of infection from frontal or
paranasal sinuses

 Allergies to dust, pollen, indoor air
pollutants, such as cigarette smoke, rug
shampoo and formaldehyde (used in the
manufacture of carpeting, particleboard
and plywood); and outdoor air pollutants
all can induce inflammation.

 Excessive dryness in homes and offices
from dry-air heating and air-conditioning
systems can also inflame the sinuses.
 Immunologic, as well as structural
problems, such as narrow drainage
passages, nasal obstruction (tumors,
polyps or a deviated septum)

SYMPTOMS OF ACUTE MAXILLARY
SINUSITIS
1. Fever
2. Nasal obstruction
3. Hoarsy voice
4. Pus-like (purulent) nasal discharge
5. Loss of sense of smell
6. Facial pain or headache that is sometimes
aggravated by bending over
7. Pain may be referred to teeth, ear, and other areas

SYMPTOMS OF C HRONI C
MAXILLARY SINUSITIS
1. A dull ache or pressure across the
midface, especially between or deep into
the eyes
2. A headache that occurs daily for weeks
at a time, and is often notably worse in
the morning and with head movement
3. Nasal congestion
4. Postnasal drip
5. Fetid breath

 Clouding of the sinus due to hyperplastic
tissue or fluid pressure
 CT scan may reveal thickening of the
mucosa
RADIOGRAPHIC FEATURES

TREATMENT OF MAXILLARY
SINUSITIS
 Removal of the cause
 If a bacterial infection is present, antibiotics, such
as amoxicillin, erythromycin or sulfa drugs
 Decongestants

FO C AL INFE C TION &
FOCUS OF INFECTION
 A focal infection is a localized or general
infection caused by the dissemination of
microorganisms or toxic products from a focus
of infection.
 Focus of infection is a circumscribed area of the
tissue, which is infected with exogenous
pathogenic microorganisms located near a
mucous or cutaneous surface

ME C HANISM OF FO C AL
INFECTION
 Toxins or toxic products may be carried through
blood stream or lymphatic channels from an
infected focus to a distant site where they may
incite a hypersensitive reaction in tissues.

ORAL FO C I OF INFECTION
 Periapical infection like periapical
granuloma, cyst and abscess
 Teeth with infected root canals
 Periodontal diseases with special reference
to tooth extraction or manipulation

INFE C TION OF SPE C
IFI C TISSUE SPA C ES
 Tissue spaces- Potential spaces situated
between planes of fascia that form natural
pathways along which infection may spread,
producing cellulitis, or within which
infection may become localized with actual
abscess formation.

 Shapiro- The facial spaces are potential
tissue spaces which are compartments
that contain structures such as salivary
gland, fat or lymph node.
 Many of these spaces run into each other,
allowing infection to spread from one
space to another.


IMPORTANT SPACES IN
MAXILLOFACIAL REGION
Lower jaw
 Submental space
 Submandibular space
 Buccal space
 Submasseteric space
 Parotid space
 Pterygomandibular space
 Pharyngeal space
 Peritonsillar space

Upper jaw
 Within the lip
 Within canine fossa
 Palatal subperiosteal interval
 Buccal space
 Maxillary antrum
 Infratemporal space
 Subtemporalis muscle interval

INFECTION SPREAD FROM
MAXILLARY TEETH
1. Maxillary sinus, the canine fossa, palatal
space, infratemporal fossa, buccal space
and vestibular space.
2. Infection can spread to the cavernous
sinus from the infratemporal fossa and
from the canine fossa. Infection in the
cavernous sinus can lead to cavernous
sinus thrombosis, which is potentially
fatal.

INFECTION SPREAD FROM
MANDIBULAR TEETH
1.Infections from mandibular teeth can spread
to the vestibular and buccal space in the
same way as from the maxillary teeth.
2.Infection can also spread to the
pterygomandibular space, sublingual space,
submandibular space and submental space.
3.The sublingual, submental and
submandibular spaces can be referred
collectively as the submandibular spaces.

INFRATEMPORAL SPACE
Boundaries-
Anteriorly- Infratemporal surface of
maxilla and posterior surface of
zygomatic bone
Posteriorly- Lateral pterygoid muscle,
Condyle, Temporal bone


Laterally- Tendon of temporal muscle,
Coronoid process
Medially- Lateral pterygoid plate,
Inferior belly of lateral pterygoid muscle

Contents
 The pterygoid plexus
 Internal maxillary artery
 Mandibular, mylohoid, lingual, buccinator
and chorda tympani nerves
 External pterygoid muscle

 Swelling E/O over sigmoid notch
 I/O in tuberosity region
 Trismus
 Swelling of eyelids
 Dysphagia
 Pain or pressure sensation
in area of infection
CLINICAL FEATURES

PTERYGOMANDIBULAR
SPACE
The space between the medial area of the
mandible and the medial pterygoid
muscle, a target area for administering
local anesthesia to the inferior alveolar
nerve.

Boundries
1. Medially – medial pterygoid muscle
2. Laterally – medial surface of ramus of
mandible
3. Superiorly – lateral pterygoid
4. Posteriorly – deep lobe of parotid gland
5. Inferiorly – attachment of medial
pterygoid to the mandible
6. Anteriorly – pterygomandibular raphe

CLINICAL FEATURES
 Arise through Pericoronitis of mandibular third
molar
 Or Injection of LA in this space
 Severe trismus
 Extreme radiating pain
 No facial swelling
 Swelling of lateral posterior portion of soft
palate

LATERAL PHARYNGEAL
SPACE
Boundaries
 Anteriorly-Buccoopharyngeal aponeurosis,
Parotid gland, Pterygoid muscle
 Posteriorly- Prevertebral fascia
 Laterally- Carotid sheath
 Medially-Lateral wall of pharynx

C LINI C AL FEATURES
 Source of infection- third molar
 Difficulty in swallowing and breathing
 Tonsillar pillars & tonsils displaced
medially
 Trismus
 Must be differentiated from peritonsillar
abscess,-Trismus is less severe /absent &
the tonsil is enlarged & inflamed ,

RETROPHARYNGEAL
SPACE
Boundaries
 Anteriorly-Wall of pharynx
 Posteriorly- Prevertebral fascia
 Laterally- Lateral pharyngeal space and
carotid sheath

CLINICAL FEATURES
 Infection results from medial extension from
lateral pharyngeal space.
 Displacing the buccopharyngeal fascia forward
impinging on the pharynx.
 Pain, dysphagia, & dyspnoea.

PAROTID SPACE
Boundaries
 Posteriorly- Behind the ramus of mandible
 Medially- between the masseter and internal
pterygoid muscle .

CONTENTS
 Parotid gland
 Facial nerve
 Auriculotemporal nerve
 Posterior facial vein
 External carotid, Internal maxillary,
Superficial temporal arteries

CLINICAL FEATURES
 Infection from lateral pharyngeal
space or by retrograde extension along
the parotid duct.
 Elevation of ear lobe
 Escape of pus from duct when the
gland is milked.

Boundaries
 Enclosed by a layer of fascia derived from
the outer layer of deep cervical fascia.
 Superiorly- Continuous with alveolar
mucoperiosteum and muscles of facial
expression.
SPACE OF THE BODY OF
THE MANDIBLE

 Induration or fluctuation of labial sulcus if
outer cortical plate involved.
 Swelling restricted to floor of mouth if inner
cortical plate involved.
 Swelling in oral vestibule if molar teeth and
outer cortical plate are involved.
 Perforation below the external oblique line-
the infection may point on skin.
C LINI CAL FEATURES

 It is situated between the masseter muscles
and lateral surface of mandibular ramus
 Parallel to the middle attachment by
extending upwards and backwards between
the middle and deep attachment
SUBMASSETERIC SPACE

Boundaries
 Posteriorly- parotid fascia and
retromandibular portion of parotid gland.
 Anteriorly- facial extension of
parotideomasseteric fascia.

 Infection from third
molar
 Patient seriously ill
 Pain and swelling
 Severe trismus

Boundaries
 Located medial to mandible & below the
posterior portion of mylohyoid
 Medially by- hyoglossus & digastric muscles
 Laterally by superfacial fascia & skin
 Encloses- submandibular gland & LN
SUBMANDIBULAR SPACE

 Infection from mandibular molars
 Swelling near the angle of jaw
 Sialadinitis and lymphadenitis
 Involvement of other submandibular
spaces, lateral pharyngeal space,
cranial fossa or mediastinum

Boundaries
 Superiorly- Mucosa of the floor of mouth
 Inferiorly- Mylohyoid muscle
 Anteriorly and laterally- Body of mandible
 Medially- Median raphe of tongue
 Posteriorly- Hyoid bone
SUBLINGUAL SPACE

 Swelling in the floor of mouth
 Dyspnoea
 Dysphagia
C LINICAL FEATURES

Boundaries
 Extends from the anterior border of
submandibular space to the midline and is
limited in depth by mylohyoid muscle .
SUBMENTAL SPACE

C linical features
 Anterior swelling in the
Submental area
 Dyspnoea
 Dysphagia
SUBMENTAL SPACE

CANINE SPACE
 Location: between the levator anguli oris and
the levator labii superioris muscles
 Involvement primarily due to maxillary canine
tooth infection
 Clinical Signs:
1. Obliteration of the nasolabial fold
2. Superior extension can involve lower eyelid

BUCCAL SPACE

BUCCAL SPACE
1. Results when infection erodes through
bone superior to attachment of
buccinator muscle
2. Boundaries:
1. Lateral-Skin of the face
2. Medial-Buccinator muscle
3. Most infections caused by posterior
maxillary teeth

POTENTIAL PATHWAYS OF SPREAD OF
ORAL INFECTIONS

Spread of oral infection /endodontic courses

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