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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
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.
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
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 .
2.Suprahyoid
sublingual
submandibular sub maxillary
sub mental
lateral pharyngeal (pharyngo maxillary )
peritonsillar
3. Infrahyoid anterovisceral (pretracheal)
infratemporal
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
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-
CLINICAL FEATURES:
FIRM CIRCUMSCRIBED SWELLING BENEATH THE TOUNGE
DISCOMFORT & DIFFICULTY IN SWALLOWING
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
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::
ETIOLOGY:
1. PERIAPICAL,PERICORONAL OR PERIODONTAL INFECTION
5. Removal of cause -
The offending tooth is removed
COMPLICATIONS –
Masticatory space –
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
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
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
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
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.
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