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INTRODUCTION

Oral and maxillofacial infections are


commonly caused by teeth they are
referred as odontogenic infections.
The etiological agents may be bacteria
viruses or fungi.
The infection may spread directly from the
tooth or secondary infections of cyst or
tumours or infection of surgical wound or
by contaminated needles.
There are three stages in progression of acute
odontogenic infections
Stage 1
Most infections are odontogenic in
origin.They may be periapical periodontal or
pricoronal infection of tooth.
Patient may be asymptomatic.
Stage 2
When the infection is still confined with in the
alveolar bone it is termed as periapical
osteitis.Tooth is tender to percussion and
frequently extruded from the socket.
Patient complains of sever pain.
Stage 3
Once the infection exits through the bone and the periosteum
into the surrounding soft tissue ,an inflammatory oedema occu
A diffuse swelling develops extraorally which is soft and duffy in
consistency called Cellulitis. At this stage no pus formation occu

Stage 4
When suppuration does occur and the infection localises,the
condition is termed as, Absess .
With increased pressure it may even perforate the soft tissues
and pus discharge may be seen as sinus opening or fistulous tr

ROOTS OF SPREADS OF INFECTION


1.Spreads by direct continuity
2.Spreads by lymphatics to regional lymph nodes
3.spreads by blood stream
The infection causes formation of pus locally and pus
accumulation in :-
1. Tissue spaces
2. Between periosteam and bone
3. Spaces present between muscle layers

PATHOPHYSIOLOGY OF INFECTION
Hyperaemia due to vasodilatation of arterioles and
capillaries and increased Permeability of venules with
slowing of venous blood flow
Exudate rich of plasma protein antibodies and lymphocytes
Streptococci produce hyaluronidase an enzyme which
dissolves intercellular cement Substance and fibrinolysin
which breaks down fibrin the presence of these substance in
the infected tissues facilitates the spread of inflammatory
process
On the other hand staphylococci produce a substance
called coagulase which produces Fibrin from plasma which
tends to localise the inflammatory lesion
The vast majority of oral infections are caused by
streptococci or staphylococci whilst Such gram negative
Abscess
Characteristic Cellulitis Over 5 days
Duration 3-7days Moderate and localised
Pain severe and generalised Small
Circumscribed
Size large Fluctuant and tender
Localization diffuse Peripherally reddened
Centrally undermined
Palpation hard exquisitely tender Moderately heated
Appearance reddened Moderately severe
Skin quality thickened Pus
Moderate
Surface temp. Hot Anaerobic
Loss of function severe
Tissue fluid serosanguineous
0 of seriousness severe
Bacteria mixed
DIRECTION OF SPREAD OF INFECTION

Infection from any tooth will spread along the path of least
resistance.
It can perforate either the buccal cortical plate or lingual / palatal
cortical plate depending upon which is thinner.

1.Lower central and lateral incisor teeth


If the root of these teeth are extended above the attachment of
mentalis
muscle, pus accumulates in the vestibule
If the roots extended below the attachment of mentalis muscle
pus accumulates within the connective tissue of the muscle and
seen
as a extra oral swelling

2. Lower canine
Because the muscle attachment ( depressor labii inferioris ,
depressor
anguli oris,platysma ) located well below the root apex the
periapical infection from this tooth will localise in the oral vestibule
4. Mandibular first molar
If the root apices are above the oblique line of buccinator
attachment
then it will cause localised infection within the oral vestibule
If the root apices are below the buccinator attachment it can give
rise to
buccal space abscess on lingual aspect mylohyoid muscle is roughly
parallel
to the buccinator muscle . The apices of premolars and first molars
is
always above this muscle which give rise to sublingual space
infection
since there is loose connective tissue interspersed between the
muscle
forming the boundary the infection may spread across the midline in
the opposite side called LUDWIG’S ANGINA
6. Mandibular third molar
Placed medial to the vertical plane of ramus .therefore its apex is
more closer to lingual than the buccal cortical plate
In mesio angularly or horizontaly positioned tooth the infection will
tend to spread beyond the posterior extend of the mylohyoid muscle
localizing in the pterygomandibular space
Pericoronitis can give rise to submassetric space infection

INFECTION FROM UPPER TEETH


1. The infection from C .I , L.I may be confined in the buccal vestibule
by orbicularis oris and dense subcutaneous tissue of base of the nose
anine
he infection from this tooth will exit from the bone on the labial
spect the levator anguli oris muscle than determines whether
he infection will be localised within the vestibule or infection
ill spread in the canine space

Maxillary premolars
uscle attachment of zygomaticus major,zygomaticus minor &
evator labii superioris will tend to localised the infection within
he oral vestibule or may give canine space infection.

Maxillary molars
eriapical infection from the upper molars usually perforate the
uccal cortex . The attachment of buccinator will determines that
he infection weather localised intraorally or spreads extra orally
Secondary sites of spread of odontogenic
infection

Facial spaces:
These areas are either clefts ( potential spaces between
facial layers ) or compartment containing connective tissue &
various anatomic tooth structures they are not voids in the
tissues .

They are not voids in the tissues


These are not present in healthy people but become filled
during infections
When filled with loose areolar tisses , it is called clefts
CLASSIFICATION ACCORDING TO
TOPAZIAN:
1.Face buccal
canine
masticatory massetric
pterygoid
zygomatico temporal
parotid

2.Suprahyoid
sublingual
submandibular sub maxillary
sub mental
lateral pharyngeal (pharyngo maxillary )
peritonsillar
3. Infrahyoid anterovisceral (pretracheal)

4. Spaces of total neck retropharyngeal


danger space
spaces of carotid sheath
CLASSIFICATION BY PETERSON

PRIMARY MAXILLARY SPACES canine


buccal

infratemporal

PRIMARY MANDIBULAR SPACES submental


buccal

submandibular

sublingual
SECONDARY FACIAL SPACES massetric

pterygomandibular
superficial
SPACES ASSOCIATED WITH THE UPPER JAW
1. CANINE SPACE -- potential space present on the anterior
surface of the maxilla between bone and canine fossa
musculature

BOUNDARIES –
Superiorly - limited by levator anguli oris and levator labii
superioris Inferiorly - limited by orbicularis oris
Anteriorly - lateral wall of nose
Posteriorly - communicates with buccal space

INFECTION - spreads from long canine root or upper first


premolar root

CONTENTS - Infraorbital nerve

CLINICAL FEATURES –
Swelling of the affected side upper lip , cheek upto the medial
canthus
of eye
Obliteration of naso labial fold
Drooping of angle of the mouth
2.SUBPERIOSTEAL ABSCESS OF PALATE –
Palate is covered by tightly adherent
mucoperiosteum
Pus tends to accumulate between the
periosteum and bone

CLINICAL FEATURES –
Circumscribed , fluctuant swelling confined to
one side of the palate
May not discharge spontaneously
Doesn’t cross the midline

INFECTION –
From upper lateral incisors
Palatal pocket in premolars and molars
Infection of palatal root of upper molar
3. BUCCAL SPACE –
BOUNDARIES –
Medially - buccinator muscle and buccopharyngeal
fascia
Laterally - skin of cheek and subcutanous tissue
Anteriorly - posterior border of zygomaticus major
above and depressor anguli oris below
Posteriorly - anterior edge of masseter muscle
Superiorly - zygomatic arch
Inferiorly - lower border of mandible

CONTENTS –
buccal fat pad
parotid duct
facial artery

SPREAD OF INFECTION –
through maxillary and mandibular molars
4.INFRA TEMPORAL SPACE
upper extremities of pterygomandibular space

BOUNDARIES-
Laterally- ramus of the mandible
temporalis muscle
temporal fascia
Medially- lateral pterygoid plate,inferior portion of lateral
ptrygoid muscle & lateral pharyngeal wall
Superiorlly-infra temporal surface of greater wing of
sphenoid
bone
Inferiorlly- lower head of lateral pterygoid muscle
Anteriorlly-infra temporal surface of maxilla,posterior
surface of
zygomatic bone

CONTENTS-

ORIGIN OF PTERYGOID MUSCLE


PTERYGOID VENOUS PLEXUS
INFECTION-
FROM UPPER MOLARS
CONTAMINATED NEEDLE DURING PSA BLOCK
CLINICAL FEATURES-
SEVERE TRISMUS
BULDGING OF TEMPORALIS MUSCLE
THIS SITUATION IS DANGEROUS DUE TO THE COMMUNICATION
PTERYGOID VENOUS PLEXUS WITH CAVERNOUS SINOUS THRO
EMMISSORY VEINS.

SPACES ASSOCIATED WITH LOWER JAW –


SUBMENTAL SPACE
- POTENTIAL SPACE PRESENT JUST BELOW THE
CHIN
REGION ON THE MEDIAL SURFACE OF THE MANDIBLE
BOUNDARIES
SUPERIORLY :– MYLOHYOID MUSCLE
INFERIORLY – INVESTING LAYER OF DEEP CERVICA FASCIA,
PLETYSMA,SUPERFACIAL FACIA,SKIN
LATERALLY – LOWER BORDER OF THE MANDIBLE
ANTERIORLY BELLY OF DIAGESTRIC MUSCLE
CONTENTS:
-- SUBMENTAL LYMPH NODES
-- ADIPOSE TISSUE
INFECTION :
-- FROM LOWER ANTERIOR TEETH,LOWER LIP,SKIN OF THE CH
TIP OF THE TONGUE,ANTERIOR PART OF THE FLOOR OF THE MOUTH
SUBLINGUAL TISSUE

CLINICAL FEATURES:
FIRM CIRCUMSCRIBED SWELLING BENEATH THE TOUNGE
DISCOMFORT & DIFFICULTY IN SWALLOWING

SUB MANDIBULAR SPACE INFECTION


POTETIAL SPACE PRESENT ON THE MEDIAL SURFACE OF THE
POSTERIOR ASPECT OF THE MANDIBLE.

BOUNDRIES:
LATERALLY--- SKIN
--- SUPERFECIAL FASCIA
-- PLYTISMA
-- DEEP FASCIA
MEDIALLY :
-- MYLOHYOID MUSCLE
-- HYOGLOSSUS MUSCLE
-- STYLOGLOSSUS MUSCLE

INFERIORLY:
--ANTERIOR & POSTERIOR BELLY OF DIAGASTRIC

SUPERIORLY:
--MEDIAL ASPECT OF MYLOHYIOD
ANTERIORLY:
--MYLOHYIOD SPACE
POSTERIORLY:
--HYIOD BONE

CONTENTS:
--SUBMANDIBULAR SALIVARY GLAND & LYMPH NODE
--FACIAL ARTERY
--PROXIMAL PART OF WHARTON’S DUCT
--LINGUAL & HYPOGLOSSAL NERVE
INFECTION:
-- INFECTED LOWER MOLAR APICES PRESENT BELOW THE
MYLOHYOID INSERTION
-- THE LOWER TEETH ,MAXILLARY SINUS,UPPER
MOLARS,C MIDDLE THIRD OF TONGUE & FLOOR OF
THE
MOUTH DRAIN INTO SUBMANDIBULAR LYMPH NODE

CLINICAL FEATURES:
--SWELLING WHICH IS SOFT& BRAWNY EXTRA ORALLY
--ASSOCIATED WITH LOWER MOLAR INFECTION
SUBLINGUAL SPACE ::
--POTENTIAL SPACE PRESENT IN THE ANTERIOR PART OF THE
OF THE MOUTH

BOUNDARIES:
ANTERIORLY & LATERALLY-- MEDIAL SURFACE OF THE MIDLI
MANDIBLE & BODY OF THE MANDI
SUPERIORLY—SUBLINSGUAL MUCOSA,MYLOHYIOD
INFERIORLY– MYLOHYIOD MUSCLE
POSTERIORLY– HYIOD BONE
MEDIALLY– GENIOGLOSSUS,GENIOHYIOD,STYLOGLOSSUS MUS
ONLY LOOSE CONNECTIVE TISSUE SEPERATES RIGHT & LEFT
SUBLINGUAL SPACE

INFECTION MAY COME FROM LOWER ANTERIORS


LOWER PREMOLARS
LOWER FRIST MOLARS

CLINICAL FEATURES:
-- TONGUE IS RAISED
-- FIRM PAINFUL SWELLING IN THE ANTERIOR PART OF THE FLOOR OF
THE
MOUTH
-- SWELLING HAS SHINY GELETINOUS APPEARANCE
-- PAIN & DISCOMFORT ON SWELLING
-- ENLARGED SUBMENTAL & SUBMANDIBULAR LYMPH NODES
LUDWIG’S ANGINA::

DEFINITION– IT IS A FIRM, ACUTE,TOXIC CELLULITIS OF THE


SUBMANDIBULAR,SUBLINGUAL SPACES BILATERLLY
& OF THE SUBMENTALIS SPACE.

-- FRIST DISCRIBED BY WILHELM FREDREICH VON LUIDWIG IN


36

ETIOLOGY:
1. PERIAPICAL,PERICORONAL OR PERIODONTAL INFECTION

A LOWER THIRD MOLAR


2. TRAUMATIC INJURIES & INFECTED LESIONS
3. INFECTIVE CONDITIONS SUCH AS OSTEOMYELITIS MAY
MENIFEST AS LUDWIG’S ANGINA
4. CYSTS OR TUMORS IN THIRD MOLAR REGION
PETHOLOGY:
1. INFECTION FROM LOWER THIRD MOLAR REACHES
THE SUBMANDIBULAR SPACES
2. FROM HERE INFECTION SPREADS ALONG THE
SUMANDIBULAR SALIVARY GLANDS ABOVE THE
LOHYIOD
FROM ONE SIDE OF THE SUBLINGUAL SPCE IT MOVES ACROSS THE
GENIOGLOSSUS MUSCLE AND REACHES THE SUBLINGUAL SPACES ON
OTHER
SIDE IT THEN CROSS ONCE THE MYLOHYIOD MUSCLE & REACH THE
OPPOSITE SIDE SUBMANDIBULAR SPACE.

SUBMENTAL SPACE GET INVOLVED VIA LYMPHATICS


SINCE IT IS CELLULITIS IT SPREADS RAPIDLY ALONG THE FACIAL AND
TISSUE PLANES

IT SPREADS IN THE TONGUE POSTERIORLY ALONG THE COURSE OF


SUBLINGUAL ARTERY IN THE CLEFT BETWEEN THE GENIOGLOSSUS
AND GENIOHYOID MUSCLE PRODUCING OEDEMA OF LARYNGEAL
INLET

FROM SUBMANDIBULAR SPACE IT CAN PASS ALONG THE INVESTING


LAYER OF DEEP CERVICAL FASCIA ALONG THE ANTERIOR ASPECT OF
THE NECK TO THE CLAVICLE AND THE MEDIASTINUM
CLINICAL FEATURES -
SYSTEMIC FEATURES- PYREXIA , DEHYDRATION , DYSPHAGIA ,
DYSPNOEA , HOARSENESS OF VOICE AND STRIDOR

EXTRA ORAL FEATURES – HARD TO FIRM BROWNY INDURATED


SWELLING
SKIN OVER THE SWELLING APPEARS ERYTHMATOUS
AND STRETCHED
SWELLING IS TENDER WITH LOCAL RISE IN
TEMPERATURE

Difficulty in closing the mouth and drooling of saliva


Respiratory distress

INTRA ORAL FEATURES –


Trismus , floor of the mouth is raised , tongue raised upwards ,
increased salivation
MANAGEMENT -
1.Airway maintainence- Intubation is contraindicated
perforation may lead to aspiration of pus
Tracheostomy and Cricothyroidectomy is advisable

2. Parentral antibiotics - Penicillin antibiotic of choice


Amoxycillin + Cloxacillin
Metronidazole in anaerobic infection

3.Surgical decompression – performed under L.A


Decompression improves vascularity and potentiates
the
action of antibiotics
Bilateral submandibular incision with a midline
submental
A drain is inserted and loose dressing is placed
incision pus should be drained
4.Hydration of the patient –
It is necessary to put the pt on i.v. fluids

5. Removal of cause -
The offending tooth is removed
COMPLICATIONS –

Death due to airway compromise


septicemia
aspiration of pus
mediastinitis
carotid blow out

Masticatory space –

Potential space present around the muscle of mastication


a) SUBMASSETRIC SPACE
Present between the three layers of masseter muscles
BOUNDARIES –

Superiorly - zygomatic arch


Lateraly - masseter muscle
Medially - lateral aspect of the mandibular ramus
Inferiorly - attachment of masseter onto the lower border of
the
mandible

INFECTION can spread from lower third molar

CLINICAL FEATURES –
external facial swelling confined to masseter muscle
complete trismus
acutely tender
b) Pterygomandibular space –
BOUNDARIES -
Medially – medial pterygoid muscle
Laterally - medial surface of the ramus of the mandible
Superiorly – lateral pterygoid
Posteriorly – deep lobe of the parotid gland
Inferiorly - attachment of the medial pterygoid to the
mandible
Anteriorly – pteygomandibular raphe

CONTENTS –
Inferior alveolar nerve and vessels
Lingual nerve
Loose areolar tissue

INFECTION FROM LOWER THIRD MOLAR

CLINICAL FEATURES –
Trismus
Intra oral swelling in the medial aspect of the ramus of the mand
c). Temporal Space
Divided into  Superficial temporal space
 Deep temporal space
Superficial temporal space is between superficial temporal fascia
& lateral aspect of temporalis muscle

Deep temporal space is present between the medial surface of


the temporalis muscle & the periosteum of the temporal bone

Contents:
- vessels supplying the temporalis muscle

Clinical features:
- swelling confined to the shape of the muscle extending from
the lateral orbital rim, above the zygomatic arch, covering of
the lateral aspect
d).Lateral pharyngeal space 

Synonyms  Parapharnygeal space


 Pharyngomaxillary space

Boundaries potential cone shaped space


 base is uppermost at the base of the skull
 apex is at the hyoid bone

Clinical features
- Pain on swallowing
- Trismus
- Tonsils & lateral pharyngeal wall are pushed to the midline
- No extra oral swelling
- It may lead to thrombophlebitis of internal jugular vein or
may cause carotid blowout
Peri tonsillar abscess:
Infection in connective tissue bed of the faucial tonsil
And can also be from the infection of the third molar
Clinical features
Acute pain in throat on the affected side which radiates to the ear
Dysphagia
Trismus
Awkward speech described as hot potato speech
Foul breath
Bulge in the soft palate on the affected site

SPACES IN THE NECK


Retropharyngeal Danger space and prevertebral spaces all lie between
deep cervical Fascia that surrounds the pharynx and oesophagus and
vertebral spine with its muscle attachments posteriorly
Principles of management of
odontogenic infections
Determine the severity of
infection
Evaluate host defense
Decide on the setting of care
Treat surgically
Support medically
Choose and prescribe antibiotic
therapy
Administer the antibiotic
properly
.Determine
Evaluate the severty
the patient of infection
frequently
A careful history and thorough physical examination to determ
the anatomic location, rate of progression and the potential fo
airway compromise of a given infection.
2.Evaluate host defenses
Immune system compromise:
diabetes,steroid therapy,organ transplant,malignancy
chemotherapy,chronic renal disease,malnutrition,
alcoholism,end –stage AIDS

Systemic reserve
The host response to severe infection can place a sever
physiologic load on the body.fever can increase fluid losses
and calori requirements.

A prolonged fever may cause dehydration , which can there


decrease cardiovascular resevers and deplete glycogen stor
shifting the body metabolism to a catabolic state.
3. Decide on the setting of care
Indications for hospital care
temp.>101 F
dehydration,infection in moderate to severe anatomic spac
threat to airway or vital structures
need for genral anesthesia
need for in patient controll of systemic disease

4.Treat surgically
Airway security
Surgical drainage:drainage of pus and removal of cause
An intra oral incision should be made through the mucous
membrane , parallel to the surface of alveolar bone
ilton s method of incision and drainage
Method of incision and drainage esp. in head and neck rigion.
Technique:
1.Anesthesia is achieved by regional blocking or by topical
anesthesia by ethylchloride spray.
2.Ethylchoride is sprayed on the most flectuant part until
frosting occurs.
3.The incision is made through skin , superficial fascia ,muscle,
deep fascia parallel to the main nerves & vessels in closed
proximity to that area.
4.A sinus forceps is inserted through the incision towards the
area of pus collection .the forceps is closed when it is entered
into the tissues. Once it is inside ,it is gently opened up in a
direction parallel to the important structures .
5.The pus collected in that area flows along the beaks of the
sinus forceps.
6. The drain is secured to the skin by sutures .a loose dressing
is placed on the wound

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