Orofacial & Orofacial & neck neck infections infections INSTRUCTOR – DR.JESUS GEORGE INSTRUCTOR – DR.JESUS GEORGE

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ETIOLOGYETIOLOGY1-OdontogenicPulp diseasePeriodontal diseaseSecondarily infected cyst &

odontomesRemaining root fragmentPericoronal infection2-Trauma3-Implant Surgery4-Reconstructive Surgery

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Cont.Cont.Contaminated Needle Puncture

Infections Of Maxillary Antrum

Infections of salivary glandsSecondary to oral malignancies

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Pathways of odontogenic Pathways of odontogenic infectionsinfections Invasion of dental pulp by bacteria after decay of a tooth Inflammation, edema & lack of collateral

blood supply Venous congestion or avascular necrosis (pulpal tissue death)

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Cont.Cont.

Reservoir of bacterial growth(anaerobic)

Periodic egress of bacteria into

surrounding alveolar bone

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MICROBIOLOGYMICROBIOLOGYAerobic gram positive cocci

bacteria-streptococci milleri, strep. Sanguis, strep. Salivarius, strep. Mutans.

Anaerobic Cocci-peptostreptococcus.

Bacteriodes-porphyromonas, prevotella

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TYPESTYPES A/cC/cAcute stage - 3 forms1.Abscess2.cellulitis 3.fulminating infection

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Abscess Abscess It is a circumscribed collection of

pus in a pathologic tissue space. Infections are characterised by

sphylococci.

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CELLULITISCELLULITISIt is spreading infection of loose

connective tissues.It is a diffuse, erythematous,

mucosal or cutaneous infection.It is the result of streptococcal

infection.It does not result in accumulation

of large amount of pus.

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Cont.Cont.Streptococcus produces

streptokinase, hyaluronidase & streptodornase which break down fibrin, connective tissue ground substance & lyse cellular debris, which facilitate rapid spread of bacteria.

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FULMINATING INFECTIONSFULMINATING INFECTIONSHere the infection involves

secondary spaces involving vital structures.

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Chronic stageChronic stageC/c fistulous tract or sinus formation

Abscesses neglected for a long time may discharge intraorally or extra orally

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TreatmentTreatmentMedical treatmentSoft or liquid dietAdequate hydrationDiet rich in proteinAnalgesicsAntiseptic mouthwashAntibiotics

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Cont.Cont.In a non compromised patient, with

well localized abscess, surgical drainage with dental therapy will resolve the infection.

In poorly localized, extensive abscess & cellulitis antibiotic therapy is needed.

In compromised patients & patients with trismus, airway obstruction & fever antibiotic therapy is must.

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Cont.Cont.Penicillin is the drug of choice. Penicillin+metronidazole Can

Also Be Used.ClindamycinAmoxycillin+clavulanic AcidFirst & Second Generation

Cephalosporins

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Cont.Cont.Surgical treatmentIt involves blunt exploration of the

anatomic space or abscess.Abscess cavity is then irrigated with

betadine & saline.A drain is inserted into the space.Hilton`s method of incision &

drainage◦No blood vessel or nerve is damaged.◦Topical anaesthesia is obtained.

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Cont.Cont.◦Stab incision is made over the point of

maximum fluctuation in the most dependent area along the skin creases, through skin & subcutaneous tissue.

◦If pus is not encountered deepening of surgical site is done with artery forceps.

◦Closed forceps are pushed through deep fascia & advanced towards the pus collection.

◦Abscess cavity is entered & forceps is opened parallel to vital structures.

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Cont.Cont.◦Pus flows along the beaks of the

forceps.◦A rubber drain is inserted into the depth

of cavity & secured to the wound margin with the help of sutures.

◦Drain is left for 24 hrs.◦Dressing is given without pressure.◦Drain allows discharge of tissue fluids &

pus from the wound.◦Drain is removed when the drainage is

completely ceased

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ACUTE PERIAPICAL ACUTE PERIAPICAL ABSCESSABSCESSEtiology

◦Caries◦Contamination of traumatic exposure of

pulp.◦Chemical or thermal damage to pulp.

The entry to periapical tissues is by ◦Apical foramina, ◦Accessary canals, ◦Endodontic perforation, ◦Opening in the floor of pulp chamber, ◦Root fracture or resorption.

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Cont.Cont.Clinical features

◦Severe throbbing pain in the affected tooth

◦The offending tooth may be sensitive to percussion.

◦ Mobility may or may not be present.Radiographic features

◦Tooth has caries with periapical pathology, root # or erosion.

◦There may be periapical radiolucency.

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Cont.Cont.Treatment

◦Antibiotics◦Analgesics◦Drainage through pulp chamber◦Extraction of tooth◦Endodontic treatment

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Acute dentoalveolar Acute dentoalveolar abscessabscessEtiologyContinuation of periapical abscess.Clinical featuresPainSubmucosal swelling in the sulcus

on the outer aspect of alveolar process.

If left untreated, swelling bursts & produces a sinus.

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Cont.Cont.Radiologic featuresMore marked radiolucency than

periapical abscess.TreatmentSame as periapical abscess.Extraoral incision & drainage

may be required.

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Acute periodontal Acute periodontal abscessabscessEtiologyPeriodontitis with periodontal

pockets.Clinical featuresDull painPus discharge via gingival pocketSinus either on the outer or inner

aspect of alveolar process.

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Spread of oral infectionSpread of oral infectionRoutes of spreadDirect continuity through tissuesBy lymphatics to the lymph nodes.From

lymph nodes to tissues results in secondary areas of cellulitis or tissue space abscess.

By blood stream-local thrombophlebitis may spread via the veins entering the cranial cavity producing cavernous sinus thrombosis. It may cause septicemia

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Cont.Cont.Factors influencing spread

◦General factors Host resistance Virulance of micro organism Combination of both

◦Local factors Anatomic barriers- Alveolar bone Periosteum Adjacent muscles & fascia

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General clinical features in General clinical features in patient with orofacial patient with orofacial infection infection Redness due to vasodialtationSwelling due to accumulation of

exudate or pusTemperature over the infected area

due to increased blood flow & increased metabolism

Pain due to pressure in nerve endings & release of mediators of pain.

Fever27

Cont.Cont.Head acheLymphadenopathy

◦Acute infection-soft, tender, enlarged, surrounding tissues are edematous& overlying skin is erythematous

◦Chronic infection-firm, nontender enlarged lymph nodes.

Presence of draining sinus & fistulaDifficulty in opening mouth

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Cont.Cont.Increased salivationChange in phonationDifficulty in breathingBad breath

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Radiologic examinationRadiologic examinationIOPALateral oblique view of mandiblePA & lateral view of neckCTMRI

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General principles of General principles of management of a/c management of a/c orofacial infectionsorofacial infections

Immediate hospitalizationMedical treatmentSurgical management

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Medical managementMedical managementAntibioticsHydration of the patient through

iv routeAnalgesicsBed restMouth rinsesOpening of tooth for drainage

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Surgical managementSurgical managementNeedle decompressionDone in case of pterigomandibular,

peritonsillar,lateral pharyngeal space infection that is likely to rupture during passage of endotracheal tube.

Extraction of toothEarly extraction leads to early

resolution of infection by eliminating the source of infection & provides a portal of drainage

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Cont.Cont.Surgical drainage-Incision is placed on the most

dependent areas.Incision should be parallel to skin

creasesIncision should lie in aesthetically

acceptable site as far as possible.Incision should be supported by

healthy underlying dermis & subcutaneous tissue.

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Cont.Cont.Intraoral incision should not be

placed over frenal attachments, should be placed parallel to nerve fibers in the region of mental nerve.

Removal cause such as infected tooth, segment of necrotic bone, foreign body, if not already done, then is done at the time of drainage procedure

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Classification of fascial Classification of fascial spacesspacesPrimary maxillary spacesCanineBuccalInfratemporalPrimary mandibular spacesSubmentalBuccalSubmandibularSublingual

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Cont.Cont.

Secondary fascial spacesMassetericPterigomandibularSuperficial & deep temporalLateral pharyngealRetropharyngealPrevertebral Parotid space

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Canine space infectionCanine space infection

EtiologyInfection of maxillary canine, premolar & mesiobuccal root of 1st molar.BoundariesInferiorly-caninus muscleAnteriorly-orbicularis oris musclePosteriorly-buccinator muscleMedially-anterolateral surface of maxilla

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Cont.Cont.Clinical featuresSwelling of cheek & upper lipObliteration of nasolabial foldDrooping of angle of mouthEdema of lower eyelidsMarked Periorbital EdemaRedness & Marked Tenderness Of

Facial Tissues

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Cont.Cont.In c/c stage-fistula near the

medial canthus eye.Offended tooth is mobile &

tender to percussionTreatmentIncision & drainage-Through the mucosa of buccal

vestibule in the region of lateral incisor & canine.

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Cont.Cont.A curved mosquito artery forceps

is inserted, pus is evacuated & a drain is inserted & is secured with suture

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Buccal space infectionBuccal space infection

EtiologyInfection of maxillary & mandibular premolars & molarsPericoronitis of lower 3rd molar.BoundariesAnteromedially-buccinator musclePosteromedially-masseter muscleLaterally-deep fascia from parotid capsule & platysma muscle

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Cont.Cont.Inferiorly-deep fascia & depressor

anguli orisSuperiorly-zygomatic process of

maxilla & zygomaticus major & minor muscles

ContentsBuccal pad of fatStenson`s ductFacial artery

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Cont.Cont.Clinical featuresGum boil in vestibuleSwelling extending from lower

border of mandible to infraorbital margin, from anterior border of masseter to angle of mouth

Edema of lower eyelid

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Cont.Cont.SpreadTo pterigomandibular spaceInfratemporal spaceSubmasseteric spaceTreatmentIncision & drainage through

mucosa of cheek in premolar molar region.

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Infratemporal space Infratemporal space infectioninfectionAlso called retrozygomatic space

because it is situated behind the zygomatic bone.

EtiologyInfection of buccal roots of

maxillary 2nd &3rd molarsLA injection with contaminated

needles in the area of tuberositySpread from other spaces

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Cont.Cont.Boundaries Laterally - by ramus of mandible,

temporalis muscle & its tendon . Medially - medial pterygoid plate ,

lateral pterygoid muscle , medial pterygoid muscle ,lower part of temporal fossa of the skull & lateral wall of pharynx .

Superiorly - greater wing of sphenoid & by zygomatic arch .

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Cont.Cont.Inferiorly - lateral pterigoid muscleAnteriorly - infra temporal surface of

maxillaPosteriorly- parotid gland Contents Medial & lateral pterigoid muscle

Pterigoid venous plexusMaxillary arteryMandibular nerve

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Cont.Cont.Middle meningeal arteryClinical featuresLimitation of mouth openingSwelling in front of ear on the

affected sideProptosis of eyeSwelling in the area of tuberosityElevation of temperature

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Cont.Cont.Incision & drainageIncision is given in buccal

vestibule opposite the 2nd & 3rd molars

In severe infection incision is made at the upper posterior edge of temporalis muscle.

Sinus forceps is directed upwards & medially.

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Cont.Cont.In case of failure to improve

mouth opening temporalis myotomy or excision of coronoid process is done.

SpreadTo temporal spacePterigomandibular spaceCavernous sinus

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Abscess of upper lipAbscess of upper lip

EtiologyInfection of upper incisors & canineClinical featuresSwelling in the base of the upper lipSwelling in vestibuleTreatmentAntibioticsIncision & drainageExtraction of offending tooth or RCT

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Palatal abscessPalatal abscessEtiologyPeriodontal abscess from palatal pocketsApical abscess from palatal roots of posterior teeth usually from the lateral incisorBoundariesInferiorly-hard palateSuperiorly-periosteum & mucosaLaterally-alveolar process of maxilla & teeth

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Cont.Cont.

Clinical featuresFluctuant swelling in palate near the offending toothOffending tooth is tender to percussionIncision & drainageAnterioposterior incision is made through the mucosa down to bone

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Submental space Submental space infectioninfectionEtiologyInfection from 6 mandibular anterior teethInfection of submental lymph nodesBoundariesLaterally-lower border of mandible, anterior belly of digastric muscleSuperiorly-mylohoid muscle

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Cont.Cont.Inferiorly-deep cervical fascia,

platysma, superficial fascia, skinContentsSubmental lymph nodesAnterior jugular veinClinical featuresDistinct ,firm swelling in

midline ,beneath the chin

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Cont.Cont.Skin overlying the swelling is

board like & tautFluctuation of swellingNonvital, fractured or carious

anterior teethOffending tooth is tender on

percussion& sometimes mobile

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Cont.Cont.

Incision & drainageTransverse incision in skin below symphysis of mandible.SpreadSubmandibular space

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Submandibular space Submandibular space infectioninfectionEtiologyInfection From Mandibular MolarsInfection Of Submandibular Salivary GlandInfection From Submental SpaceInfection From Submental Lyph NodesInfection From Sublingual SpaceInfection from middle 1/3 of tongue, posterior part of floor of mouth, maxillary teeth, cheek, maxillary sinus & palate

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Cont.Cont.BoundariesAnteromedially-mylohyoid MusclePosteromedially-hyoglossusmuscleSuperolaterally-medial Surface Of MandibleAnteroposteriorly-anterior belly of digastricPosterosuperiorly-posterior belly of digastric,stylohyoid ,stylopharyngeus musle

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Cont.Cont.Laterally-platysma & skinContentsSubmandibular salivary glandSubmandibular lymphnodesFacial artery & veinClinical featuresFirm swelling in submandibular

regionConstitutional symptoms

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Cont.Cont.Tenderness of swellingRedness of overlying skinTeeth Are Sensitive To

Percussion & MobileDysphagiaModerate Trismus

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Cont.Cont.Incision & drainageIncision of 1.5 to 2cm length is made

2cm below the lower border of mandible in the skin creases.

Skin & subcutaneous tissues are incised.SpreadSubmental spaceSubmandibular space of opposite sideSublingual spaceParapharyngeal space

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Sublingual space Sublingual space infectioninfectionEtiologyInfection from mandibular incisors, canines, premolars & molarsBoundariesInferiorly-mylohyoid muscleLaterally-medial side of mandibleMedially-hyoglossus, genioglossus, geniohyoid musclesPosteriorly-hyoid bone

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Cont.Cont.ContentsGeniohyoid, genioglossus,

mylohyoid muscleDeep part of submandibular

salivary glandSublingual salivary glandLingual nerveHypoglossal nerve

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Cont.Cont.Clinical featuresEnlarged tender lymph nodes.Pain & discomfort on deglutitionSpeech is affected Painful swelling in floor of mouth Tongue may be pushed superiorlyIncision & drainageIncision made close to lingual

cortical plate.

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Cont.Cont.SpreadSublingual space of opposite sideSubmandibular spacePterigomandibular spaceParapharyngeal spaceSubmental & submandibular

lyphnodes

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Temporal spaceTemporal spaceEtiologySecondary to the involvement of

infratemporal spaceBoundariesSuperficial temporal space-b/w

temporal fascia & temporalis muscle.

Deep temporal space-b/w temporalis muscle & skull

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Cont.Cont.Clinical featuresPainTrismusSwelling over temporal regionIncision & drainageIncision in temporal region in

hairline 45 to zygomatic arch

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Parotid spaceParotid spaceEtiologyInfection through stenson`s ductBlood borne infectionInfection from

submasseteric,pterigomandibular & lateral pharyngeal space

BoundariesInferiorly-stylomandibular ligamentAnteriorly-masseteric space

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Cont.Cont.Space formed by splitting deep

cervical fascia around the parotid gland

ContentsParotid glandParotid lymph nodesFacial nerveRetromandibular veinExternal carotid artery

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Cont.Cont.Clinical featuresSevere pain referring to ear

accentuated by eatingSwelling extending from

zygomatic arch to lower border of mandible.

Ear lobe may be lifted upPus escapes from stenson`s duct

when gland is milked

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Cont.Cont.Incision & drainageIncision is made on skin behind the

posterior border of mandible extending from inferior aspect of lobule of ear to just above mandible

SpreadSubmasseteric spacePterigomandibular spaceLateral pharyngeal space

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Submasseteric space Submasseteric space infectioninfectionEtiologyInfection Of Lower 3rd MolarBoundariesAnterior-anterior border of

masseter & buccinator musclePosterior-parotid gland,posterior

part of masseterInferior- attachment of masseter

to lower border of mandible74

Cont.Cont.Medial-lateral surface of ramus of

mandibleLateral-medial surface of

masseter muscleContentsMasseteric NerveSuperficial Temporal ArteryTransverse Facial Artery

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Cont.Cont.Clinical FeaturesModerate swelling extending from

lower border of mandible to zygomatic arch, anteriorly to anterior border of masseter, posteriorly to posterior border of mandible

Tenderness over angle of mandibleComplete Limitation Of Mouth

Opening Pyrexia & Malaise

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Cont.Cont.Incision & drainageIntraoral-incision is made

vertically over the lower part of anterior border of ramus of mandible, deep to bone

Extraoral-incision is placed in skin behind the angle of mandible

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Pterigo - mandibular Pterigo - mandibular space infectionspace infectionEtiologyPericoronitis related to the

mandibular third molar .Inferior alveolar nerve block

using contaminated needle .Infection form maxillary third

molar .Boundaries .Posterior - parotid gland .

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Cont.Cont.Medial - lateral surface of medial

pterygoid muscle .Lateral - medial surface of ramus of

mandible .Anterior -pterygomandibular raphae .Superior - lateral pterygoid muscle .Contents .Lingual nerve .Mandibular nerve .

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Cont.Cont.Inferior alveolar artery .Mylohyoid muscleClinical features .Limitation of mouth opening .Tenderness & swelling medial to

anterior border of ramus of the mandible .

Dysphagia .Difficulty in breathing

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Cont.Cont.Incision & drainage .Intraoral – a vertical incision;

approximately 1.5 cm in length , is made on the anterior & medial aspect of the ramus of mandible .

Extraoral - an incision is taken in the skin below the angle of the mandible .

Spread .Infra temporal space

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Cont.Cont.Lateral pharyngeal space .Retropharygeal space .Submandibular space . .

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LATERAL PHARYNGEAL LATERAL PHARYNGEAL SPACE SPACE ..EtiologyMandibular third molar area .Sublingual , submandibular &

ptergomandibular space infection .Boundaries .Inferiorly - hyoid bone .Anteriorly - pterygomandibular raphe Laterally - ascending ramus of

mandibular Medially - pharyngeal wall .

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Cont.Cont.Posteriorly - styloid muscle , upper part

of carotid sheath , prevertebral fascia .Contents Anterior compartment - lymph nodes ,

facial artery , loose areolar connective tissue .

Posterior compartment - carotid sheath , internal carotid artery , glossopharyngeal nerve , cervical sympathetic trunk .

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Cont.Cont.Clinical Features .Respiratory Embarrassment Due

To Edema Of The Larynx .Malaise .Pyrexia .Brawny Induration Of The Face .Trismus .Severe pain Dysphagia

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Cont.Cont.Incision & drainageExtraoral - an incision is made

along the anterior border of sternocleidomastoid muscle , extending from below the angle of the mandible , to the middle third of submandibular gland .

Intraoral - a vertical incision is placed over the pterygomandibular raphe .

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Retropharyngeal space Retropharyngeal space (prevertebral space )(prevertebral space )Etiology Infection from the iateral

pharyngeal space Boundaries .Laterally - carotid sheath Inferiorly-6th thoracic vertebraClinical features .Painful deglutition .Snoring .

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Cont.Cont.Choking .Stertorous breathing .Incision & drainage .Same as lateral pharyngeal

space

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PericoronitisPericoronitisDefinitionAn inflammatory process involving

the soft tissue covering the crown of partially erupted or unerupted teeth

EtiologyImpacted teeth .Trauma to the overlying gingivae

from the cusps of an opposing tooth .

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Cont.Cont.Clinical features Dull painSwollen ,red,tender gingival padPus discharge from the gingival padFoetor orisIndentations of cusps of upper teethDiscomfort on swallowingRestriction of oral opening

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Cont.Cont.Enlarged tender submandibular

lymph nodesPyrexia/feverMalaise AnorexiaSpreadBuccal space Submandibular spacePterigomandibular spaceSubmasseteric space

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Ludwig`s anginaLudwig`s anginaDefinitionA massive, firm, brawny, cellulitis

or induration & acute toxic stage involving simultaneously submandibular, sublingual & submental spaces bilaterally.

EtiologyOdontogenic-

◦A/c dentoalveolar abscess◦A/c periodontal abscess

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Cont.Cont.◦Pericoronal abscess◦Infected mandibular cyst

Iatrogenic◦La using contaminated needles

Trauma in orofacial regionOsteomyelitisSubmandibular & sublingual

sialadenitisSecondary infections of oral

malignancies93

Cont.Cont.TonsillitisForeign bodies like fish boneOral soft tissue lacerationsClinical featuresPyrexia .AnorexiaChills .Malaise .Dysphagia .

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Cont.Cont.Impaired speech .Hoarseness of voice .Firm or hard brawny swelling in

bilateral submandibular & submental regions extending to the clavicles .

Swelling is non pitting , non fluctuant ,tender with ill defined borders .

Restricted mouth opening .Air way obstruction .

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Cont.Cont.Mouth remains open due to

edema of sublingual tissues Reduced tongue movements .Increased respiratory rate .Cyanosis .Raised floor of mouth .Tongue is raised against palate .Increased salivation .Drooling of saliva .

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Cont.Cont.SpreadSubmasseteric space .Pterygomandibular space .Parapharyngeal space .Paratonsillar space .Mediastinum .Cavernous sinus thrombosis .

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Cont.Cont.Treatment Maintenance of air way .

◦ Nasotracheal intubationSurgical decompression.

◦Bilateral submandibular incision s & a midline submental incision 1cm below inferior border of mandible for drainage .

Extraction of offending tooth .

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Cont.Cont.Antibiotic therapy .

◦Aqueous penicillin G 2 - 4 million units , i v 4-6 hourly or 500mg 6 hourly orally

◦Ampicillin or amoxycillin 500mg 6 & 8 hourly i v & orally respectively .

◦Cloxacillin 500mg orally 8 hourly .◦Erythromycin 600mg 6- 8 hourly .◦Gentamycin 80mg i m bd .◦Clindamycin i v 300mg 600mg 8 hourly

. or orally 99

Cont.Cont.◦Metronidazole 400mg 8 hourly orally or

i v .Hydration of the pt .Hydro therapy

◦Cold application decreases inflammation , exudates , edema .

ComplicationsOsteomyelitis .Maxillary Sinusitis .Septicaemia .

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Cont.Cont.Mediastinitis .Pericarditis .Jugular vein thrombosis .Meningitis . Brain abscess .Cavernous sinus thrombosis

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