SPREAD OF INFECTION…

INTRODUCTION…Occurrence of infectious disease is

determine by the interaction of host, the organism & the environment…

Odontogenic infection can originate in the

dental pulp

root canal of tooth

periapical tissue..

Periodontal tissue

spongy bone

outer cortical plates

tissue spaces

mucous membrane

skin surface

Routes of infection…..

• The lymphatic system

• Blood stream

• Directly through the tissues

CELLULITIS…• Cellulites is a diffuse inflammation of

soft tissue which is not circumscribed or confined to one area, but which in contrary to the abscess tends to spread through tissue spaces & along facial planes…

• Microorganisms…..• Streptococci• Streptokinase• Hyaluronidase

• fibrinolysin

• Streptococci is the potent producer

of Hyaluronidase.• They consume local oxygen &

metabolize nutrients to produce acidic environment.

• Anaerobes such as prevotella & porphyromonas spp. destroy collagen.

• Cellulitis of face & neck is very common.

• It occurs due to infection following tooth extraction, injection either with an infected needle or through an infected area.

CLINICAL FEATURES….!• Elevated temperature• Leukocytosis• Painful swelling• Inflammatory edema• Orange peel like appearance of skin• Maxilla involve swelling of the upper

½ of the face & spread towards eye because of cavernous sinus thrombosis through the vein of inner canthus of eye..

• If the infection tends to spread in the mandible it perforates the outer cortical plate below the buccinator.

• Leads to diffuse swelling in the lower ½ of the face, which leads to cervical spread & may cause respiratory discomfort.

HISTOLOGICAL FEATURES..!

• Microscopic section through an area shows only a diffuse exudation of PMN leucocytes & occasional lymphocytes, with serous fluid & fibrin.

• It causes separation of connective tissue & muscle fibers.

TREATMENT…!• Cellulitis can be treated with

administration of antibiotics & removal of cause of infection….!!!

TISSUE SPACES…!!• Tissue spaces or facial spaces, are

potential spaces situated between planes of fascia that form natural pathway along which infection may spread ..

• These potential spaces are compartment that contain structure such as salivary glands ,fat or lymph nodes

SPREAD OF INFECTION FROM MAXILLARY TEETH

• Maxillary incisors------ labial, palatal abscess, vestibular abscess.

• Canine ------ labial or vestibular abscess, canine space.

• Premolar------ buccal or palatal side,

Canine spaceMolars-----buccal or palatal space,

buccal space abscess..

SPREAD OF INFECTION FROM MANDIBUBULLAR TEETH

• Mandibular incisor---- labial abscess, sub mental spaces abscess

• Canine root ------ labial or vestibular abscess.

• Premolar ----- vestibular abscess.• Molars---- vestibular abscess,

sublingual spaces, pterygomandibular abscess.

CANINE SPACES

• The CANINE SPACES is the region between the anterior surface of maxilla & the overlying levator muscle of the upper lip.

• Infection of space manifest as swelling with obliteration of the nasolabial fold.

BUCCAL SPACES

• Medially ------ buccinators, buccopharyngeal fascia.

• Laterally ----- skin &subcutaneous tissues.

• Anteriorly ---- the posterior border of zygomaticus major, anguli oris.

• Posteriorly ----- anterior edge of masseter muscle.

• Superiorly ---- zygomatic arch.• Inferiorly ---- lower border of

mandible.

INFRATEMPORAL SPACES

• Anteriorly ----- maxillary tuberosity.• Posteriorly ---- lateral pterygoid

muscle, condyle, & temporal muscle.

• Laterally --- tendon of temporal muscle & coronoid process.

• Medially ---- lateral pterygoid plate & inferior belly of the lateral pterygoid muscle.

PTERYGOMANDIBULAR SPACES

• The inferior portion of the infra temporal space is called the pterygomandibular space & it lies between the internal pterygoid muscle & ramus of mandible.

• The post zygomatic space extending antero medially from the infra temporal space.

LATERAL PHARYNGEAL SPACE BOUNDARIES

• The lateral pharyngeal space is bounded anteriorly by the buccopharyngeal aponeurosis, the parotid gland & pterygoid muscles.

• Posteriorly ---- prevertebral fascia• Laterally ---- carotid sheath • Medially ---- lateral wall of the

pharynx

RETROPHARYNGEAL SPACE

• The retropharyngeal space is bounded anteriorly -----the wall of the pharynx.

• Posteriorly --- prevertebral fascia • Laterally ---- lateral pharyngeal

space & carotid sheath…

PAROTID SPACE

• The parotid space contain the parotid gland & all associated structures, including the facial nerve, the auriculotemporal nerve, the posterior facial vein, & the external carotid, internal maxillary, & superficial temporal arteries.

SPACE OF BODY OF MANDIBLE

• The space of the body of the mandible is enclosed by a layer of fascia derived from the outer layer of the deep cervical fascia, which attaches to the inferior border of the mandible and then splits to enclose the body of the mandible. Superiorly, it becomes continuous with the alveolar mucoperiosteum and muscles of facial expression, which have their attachment on the mandible.

SPACE OF BODY OF MANDIBLE

• The space contains, the mandible anterior to the ramus as well as the covering periosteum, fascia, muscle attachments, blood vessels, nerves, teeth, and periodontal structures. Shapiro pointed out that infections in this space may be dental. Periodontal or vascular in origin, or may arise from fractures or by direct extension from infection in the masticator or lateral pharyngeal spaces.

Submasseteric Space

• Boundaries. The submasseteric space is situated between the masseter muscle and the lateral surface of the mandibular ramus. The masseter attaches to the ramus at three sites: the deep part on the lateral surface of the eoronoid process, the middle part in a linear pattem on the lateral surface of the ramus extending upward and backward, and the superticial part close to the angle of the mandible.

Submasseteric Space

• The submasseteric space is a narrow space that parallels the middle attachment by extending upward and backward between tl1e middle and deep attachments. The posterior boundary of this space is the parotid gland, and anteriorly it adjoins the retromolar fossa

Clinical Features

• Infection of this space usually occurs from a mandibular third molar, the infection passing through the retromolar fossa and into the submasseteric space. The patient may suffer from severe trismus and pain, and there may be facial swelling . The patient is often seriously ill.

SUBMANDIBULAR OR INFRAMANDIBULAR SPACES

• Ther are three chief spaces in the submandibular region:

• 1. the submanibular space• 2. the sublingual space• 3. the submental space

SUBMANDIBULAR SPACE

• BOUNDARIES:• THE SUBMANDIBULAR SPACE IS

LOCATED medial to the mandible and below te posterior portion of the mylohyoid muscle.

• It is bordered medially by hyoglossus and diagastric muscle and laterally by superficial fascia and skin.

• This place encoses the submandibular salivary gland and lymph nodes.

CLINICAL FEATURES• Infection of the submandibular space usually

originates from the mandibular molars and produces a swelling near the angle of the jaw.

• The space abscess is triangular, begins at lower border of the mandible, and extends to the level of the hyoid bone.

• It is one of the most commonly involved facial and cervical tissue spaces.

• The infection spreads locally to involve the other submandibular spaces like the lateral pharyngeal space, the carotid space etc.

SUBLINGUAL SPACE

• BOUNDARIES:• The sublingual space is bound by the

mucosa of the floor superiorly• The inferior border is mylohyoid muscle,

anteriorly and laterally by the body of mandible.

• Medially by the median raphae of the tongue.

• Posteriorly by the submandibular space.

CLINICAL FEATURES

• Infection in the sublingual space produces an obvious swellin in the floor of the outh and may cause both dyspnea and dysphagia.

• Extension of the infection takes the same path as infection of submandibular space.

Submental space

• BOUNDARIES:• The submental space extends from the

anterior border of the submandibular space to the midline and is limited in depth by the mylohyoid muscle.

CLINICAL FEATURES

• Infection in this area presents an anterior swelling in the submental area. This may cause dyspnea and dysphagia.

• The spread of infection is similar to that in the submandibular and sublingual spaces.

Ludwig’s Angina

• Ludwig’s angina is an acute, toxic cellulitis, beginning usually in the submandibular space and secondarily involving the sublingual and submental spaces as well. The disease is not usually considered to be true Iudwig’s angina unless all submandibular spaces are involved. It is most commonly a disease of dental origin..

Ludwig’s Angina• The chief source of infection is

involvement of a mandibular molar, either periapical or periodontal.

• It may also result from submandibular glandsialadenitis, oral soft tissue lacerations, a penetrating injury of the floor of the mouth, such as a gunshot or stab wound, or from osteomyelitis in a compound jaw fracture.

• However, this has become rare since the advent of antibiotics

Ludwig’s Angina• The second and third molars are the

teeth most commonly cited as the source of infection. The study of Tschiassny showed that of 30 teeth involved in 24 cases of ludwig’s angina, 20% were first molars, 40% were second molars, and 40% were third molars.

• The explanation for this phenomenon lies in the fact that when an infection perforates bone to establish drainage, it seeks the path of least resistance

• Since the outer cortical plate of the mandible is thick in the molar region, the lingual plate is the one most frequently perforated. According to the studies of Tschiassny initial infection of the submandibular space, particularly in cases of the second and third molars, is due to the fact that the apices of these teeth are situated below the mylohyoid ridge in 65% of cases.

Ludwig’s Angina

• He also noted that because the apices ofthe roots of the first molar are above this ridge in about 60% of the cases, infection of the sublingual space is most common in cases of infection of this tooth.

Clinical Features• The patient with Ludwig’s angina

manifests a rapidly developing boardlike swelling of the floor of the mouth and consequent elevation of the tongue. The swelling is firm, painful and diffuse, showing no evidence of localization and paucity of pus. There is difficulty in eating and swallowing as well as in breathing.

• Patients usually have a high fever, rapid pulse and fast respiration. A moderate leukocytesis is also found.

Clinical Features

• As the disease continues, the swelling involves the neck, and edema of the glottis may occur. This carries the serious risk of death by suffocation. Next, the infection may spread to the parapharyngeal spaces, to the carotid sheath or to the pterygopalatine fossa.

• Cavernous sinus thrombosis with subsequent meningitis may be sequela to this type of spread of the infection.

Laboratory Findings

• Most cases of Ludwig’s angina are mixed infection, but streptococci are almost invariably present .

• Fusiform bacilli and spiral forms, various staphylococci, diphtheroids and many other microorganisms have been cultured on different occasions.

Laboratory Findings

• Prevotella melaninogenicus,Prevotella oralis, have also been isolated from patients with Ludwig's angina.

• There are no apparent specific organisms associated with the etiology of this disease. It appears to be a nonspecific mixed infection.

Treatment and Prognosis.

• Management consists of early recognition of incipient cases, maintenance of airway; intense and prolonged antibiotic therapy; extraction of the affected tooth, and surgical drainage.

• Before the advent of antibiotics, the disease carried an exceedingly high mortality rate, primarily due to asphyxiation and severe sepsis.

Treatment and Prognosis.

• Most studies reported a death rate of 40-50%. Antibiotics have greatly reduced the occurrence of cases of Ludwig’s angina, and the seriousness of the cases that do arise is attenuated by the antibiotic therapy.

• The edema of the glottis, which may develop rapidly, often necessitates emergency tracheotomy to prevent suffocation.

Complications of Dental Infection

• A variety of intracranial complications may occur as a direct result of dental infection or dental extraction. Haymalter reviewed a series of28 fatal infections occurring after tooth extraction noting that the infection process proceeded along fascial planes to the base of the skull and then traversing the skull by one or more routes, spreading to the intracranial cavity despite combative measures.

Complications of Dental Infection

The specific complications included:• Subdural empyema: 1• Suppurative encephalitis and

epyndimitis: 1• Transverse myelitis: 1• Subdural empyema and brain abscess 2• Leptomeningitis: 2• Leptomeningitis and brain abscess: 2• Brain abscess: 8• Sinus thrombosis: 11

• The majority of these cases occurred after extraction of maxillary teeth. Interestingly only 8 of the 28 cases occurred in patients whose mouths were classified as being in poor hygienic condition. Furthermore, in 19 of the 28 cases the dental extraction involved only a single tooth.

Complications of Dental Infection

Cavernous Sinus Thrombosis of

Thrombophlebitis• Cavernous sinuses are bilateral

venous channels for the content of middle cranial fossa, particularly the parotid gland. Areas drained by cavernous sinus include the orbit, paranasal sinuses, anterior mouth, and middle portion of the face.

Cavernous Sinus Thrombosis of

Thrombophlebitis• Cavernous sinus thrombophlebitis is a serious

condition consisting in the formation of a thrombus in the cavernous sinus or its communicating branches. Infections of the head, face and intraoral structures above the maxilla are particularly prone to produce this disease.

• There are many routes by which the infection may reach the cavernous sinus. The facial and angular veins carry infection from the face and lip, while dental infection is carried by way of the pterygoid plexus.

Cavernous Sinus Thrombosis of

Thrombophlebitis• Gram-positive

organisms(specifically S. aureus) are usually the pathogens in this setting.

• It has been emphasized by Mazzeo that infection spreading by the facial or external route is very rapid with a short fulminating course because of the large, open system of veins leading directly to the cavernous sinus.

Cavernous Sinus Thrombosis of

Thrombophlebitis• ln contrast, infection spreading

through the pterygoid or internal route reaches the cavernous sinus only through many small, twisting passages and has a much slower course, often with a lack of obvious symptoms early in the disease.

Clinical Features.

• The patient with cavernous sinus thrombophlebitis is extremely ill and manifests the characteristic features of exophthalmos with edema of the eyelids as well as chemosis. Paralysis of the exteral ocular muscles is reported, along with impairment of vision and sometimes photophobia and lacrimation. There are also headaches, nausea and vomiting, pain, chills and fever..

Clinical Features.

• Orbital cellulitis and cavernous sinus thrombosis can have similar signs and symptoms, and differentiation between them sometimes is impossible on clinical basis alone. Neuroimaging with C11 MRI or magnetic resonance angiography may help distinguish these entities

Treatment and Prognosis.

• A combination of intravenous antibiotics, anticoagulants. and surgery is the optimal treatment for cavernous sinus thrombosis.

• The primary site of infection may require early drainage, especially when acute sinusitis is the cause of infection.

Treatment and Prognosis.

• The disease was once almost invariably fatal, death occurs as a result of brain abscess or meningitis. The use of antibiotics has decreased this mortality but the condition is still serious, with a mortality rate of upto 30%.

Maxillary sinusitis

• An acute or chronic inflammation of the maxillary sinus, is often due to direct extension of dental infection, but originates also from infectious diseases due to bacteria, fungus, or virus such as the common cold, influenza and the exanthematous diseases; from local spread of infection in the adjoining frontal or paranasal sinuses; or from traumatic injury of the sinuses with a superimposed infection.

Maxillary sinusitis• The common organisms include

Streptococcus pneumoniae, Hemophilus influenzae, Moraxella catarrhalis in children, gram- negative bacilli, anaerobic organisms, rhinovirus and parainfluenza viruses. etc. The occurrence of maxillary sinusitis as a result of the extension of dental infection known as odontogenic sinusitis, is dependent, to a great extent, upon the relation and proximity of the second premolar, the first and second molar teeth to the sinus..

Maxillary sinusitis

• When sinusitis is secondary to dental infection, the microorganisms associated with the sinusitis are the same as those associated with the dental infection. Apart from periapical infection, foreign bodies, tumors, and granulomatous lesions of the nasomaxillary complex may also produce maxillary sinusitis

Acute Maxillary Sinusitis

• Acute sinusitis may result from an acute periapical abscess or acute exaerbation of a chronic inflammatory periapical lesion. which involves the sinus through direct extension. In some cases a latent chronic sinusitis may be awakened by extraction ofa maxillary bicuspid or molar and perforation of the sinus.

Acute Maxillary Sinusitis

• Usually the organisms involved in acute sinusitis are S. pneumoniae, H. influenzae, and Moraxella catarrhalis.

• Anerobic organisms are isolated during acute infections at times.

Clinical Features.

• Patients with acute maxillary sinusitis suffer from moderate to severe pain with swelling overlying the sinus or may have headache. Pressing over the maxilla increases the pain. Often, the Painful sensation is one of pressure.

• Pain may be referred to various areas, including the cheek, posterior teeth, and ear.

Clinical Features.• Sometimes patient may feel numbness

in maxillary molars and premolars. Sinus pain increases when the patient bends over or is supine. The patient may complain of a discharge of pus into the nose and often a foetid breath. Fever and malaise are usually present.

• The diagnosis of acute maxillary sinusitis from clinical manifestations alone is quite difficult.

Diagnosis.

• Clinical signs and symptoms, transillumination with strong flashlight in darkroom, sinus view radiograph, nasal and sinus endoscopy, and computed tomogaphy are some aids that can be used in diagnosis.

Histologic Features

• The lining of the maxillary sinus may show a typical acute inflammatory infiltrate with edema of the connective tissue and often hemorrhage. A squamous metaplasia of the specialized ciliated columnar epithelium occurs sometimes.

Treatment and Prognosis

• The prime objective of treatment is the removal of the infecting locus. This is particularly efficacious if the infection is of dental origin. Because of the infection present, antibiotics should also be administered.

Chronic Maxillary Sinusitis

• Chronic sinusitis refers to sinusitis of more than 3 months duration and may develop as the acute lesion subsides or may represent a chronic lesion from the onset. Common predisposing factors are recent upper respiratory viral infections or allergic sinusitis.

Chronic Maxillary Sinusitis

• In cases of acute or chronic maxillary sinusitis, the possibility of phycomycosis infection (q.v.) must always be considered, especially in diabetic patients. In chronic sinusitis, the organisms are anaerobes and streptococcus. bacteroides, or veillonella are the most commonly involved.

Clinical Features.• Clinical symptoms of chronic sinusitis

may be generally lacking, and the condition may be discovered only during routine examination.

• Sometimes headache, fever, vague facial pain or upper toothache is present, or there is a stuffy sensation on the affected side of the face.

• There may be a mild discharge of pus into the nose and a fetid breath.

Clinical Features.

• Children may have persistent cough, fever, and purulent rhinorrhea. ln chronic sinusitis, rarely will there be dystrophic calcification termed antrolith, which may be detected radiographically

Radiographic Features.

• Sinusitis can be seen on the radiograph as a clouding of the sinus due to the hyperplastic tissue or fluid present. Films of both sinuses should be compared before a diagnosis is attempted. CT scan may reveal thickening of the mucosa.

Histologic Features.

• The mucosa lining the maxillary sinus may show remarkable thickening and the development of numerous sinus ‘polyps’. These polyps are simply hyperplastic granulation tissue with lymphocytic and sometimes plasma cell infiltration.

Histologic Features.

• This tissue which is usually covered by ciliated columnar epithelium. tends to till the sinus and obliterate it. In some instances there is no remarkable proliferation of granulation tissue; rather, there is only a mild lymphocytic infiltration of the lining tissue with squamous metaplasia of the epithelium.

Treatment and Prognosis

• The treatment for chronic maxillary sinusitis consists in removal of the cause of the disease. The prognosis is considered good if the disease is due to dental infection. since it can be eliminated. Infection from other sites may be difficult to eradicate.

FOCAL INFECTION

AARUSHI SHAH

Spread in various tissue spaces or discharge onto a free mucous membrane

It may perforate the outer cortical bone

Disperse trough the spongy bone

Extend trough the root canals and into the periapical tissues

Oral infection originates in the dental pulp or in superficial periodontal tissues

INTRODUCTION:

• It has been observed since long time that infections from the oral cavity can spread to distant parts of the body and produce fresh lesions over there.

• A focal infection is a localized or general infection caused by the dissemination of microorganisms or toxic products from a focus of infection

• Moreover, oral tissues are vulnerable to infections caused by various microorganisms (e.g. bacteria, virus and fungus), which produce a wide variety of lesions in the oral cavity.

• Infections from these primary lesions may spread to the distant organs to initiate secondary diseases.

FOCUS OF INFECTION:

• Circumscribed area of tissue, which is infected by exogenous pathogenic organisms and is usually located near the skin or mucosal surface, is called a “focus of infection”.

MECHANISM OF FOCAL OF INFECTION:

Two generally accepted mechanisms:1) Metastasis of microorganisms from an

infected focus by either hematogenous or lymphogenous spread.

2) Toxins may be carried through the blood stream or lymphatic channels from a focus to distant site, where they incite a hypersensitive reaction in the tissues.

• The spread of microorganisma through vascular or lymphatic channels is a recognized phenomenon

• Thus certain organisms have a predilection for isolating themselves in specific sites in the body

• The production of toxins by microorganisms and their dissemination by vascular chhanels are also important

• E.g.: SCARLET FEVER , cutaneous features of the disease being due to the erythrogenic toxin liberated by the infecting streptococci.

• RHEUMATIC FEVER: which probably develops as a result of an altered reactivity or hypersensitization of the tissue to hemolytic streptococci.

• A high concentratiion of antibodies to antigens of the group of hemolytic streptococci is found in many patients with rheumatic fever.

• Fact that microorganisms cannot be cultured from the blood or from any of the tissues involved in the disease indicates that this is not a direct bacterial infection.

Oral foci of infection• Infected periapical lesions: -periapical cyst -periapical granuloma -periapical abcess• Teeth with infected root canals• Periodontal diseases with special

refernces to tooth extraction or manipulaiton

Significance of oral foci of infection

• Oral foci of infection either cause or aggravate a great many systemic diseases.

• Most frequently mentioned are: - Arthritis - valvular heart disease ( subacute

bacterial endocarditis) - gastrointestinal diseases - ocular diseases

• Skin diseases• Renal diseases

Arthritis• Rheumatoid type of disease• Unknown etiology• Close resemblance to many

features of rheumatic fever.• Microorganisms cannot be cultured

from the joints, the patients frequently have high antibody titer to group A hemolytic streptococci.

• This suggests a tissue hypersensitivity reaction.

• Dental infection is implicated because of the occurrence of streptococci infection in the mouth.

• Theory of rheumatoid arthritis which favor streptococci

1. Streptococcal infection of tonsil. Throat, or nasal sinuses causes the initial or recurrent attacks.

2. Removal of septic foci show dramatic improvement.

3) The pathologic and anatomic features of lymphoid tissue in tonsillar infection, sinus infection, root abcesses suggest that toxic products can be absorbed into the circulation.

4) A temporary bacteremia may occur immediately after tonsillectomy or tooth extraction or after vigorous massage of the gums.

Points against this theory• Often no infection focus can be found.• No dramatic results are produced when a

focus has been extirpated(removed).• Sulfonamides, antibiotics and vaccines

fail to produce beneficial effects.• Many person who are I n good health or

are suffering from a disease other than rheumatoid arthritis may have septic foci.

Subacute bacterial endocarditis(infective endocarditis)

• Close similarity between the etiologic agent of the disease and the microorganisms in the oral cavity, in the pulp, in the periapical lesions.

• Symptoms of Subacute bacterial endocarditis have been observed in some cases shortly after extraction of teeth.

• Transient bacteremia follows tooth extraction.

• It is due to accretion (growth or incrase by accumulation) of bacterial vegetation on heart valves.

• Streptococci of the viridance type once caused the majority of the cases of Subacute bacterial endocarditis

• The advent of the antibiotics has resulted in the drug resistance microorganisms assuming a more important role.

• The majority cases of SBE as following tooth extraction have occurred within a few weeks to a few months after the dental procedure.

• Premedication with various antibiotics is usually prescribed to prevent the transient bacteremias

• This prophylactic measures is considered to be an absolute necessity in patients who have a past history of rheumatic fever or evidance of known vascular damage.

Gastrointestinal diseases• Periodically related• Include gastric and duodenal ulcers• Produced experimentally by the injection

of streptococci• According to some workers, constant

swallowing of microorganism might lead to a variety of GI disease.

• Low PH of the gastric secretion is an adequate defense against such infection.

Ocular disease• Woods evaluated the role of foci infection

in ocular disease and as pointed out by easlick

1) Many ocular disease occur in which no systemic cause other than the presence of remote foci of infection.

2) Dramatic healing of ocular disease are reported to have followed the removal of these foci

3) Some reports indicate the presence of blood stream infection in the early stages of ocular disease

• Iritis may be produced in animal experiments by the injection of microorganisms, especially streptococci.

:OBJECTION TO THESE POINTS:• Can be found to have focal infection, but

no ocular disease.• Spontaneous cures frequently occur if

nothing is done.

Skin Disease• To be related to foci of infection• Only some forms eczema and possibly

urticaria can be related to oral foci of infection

• A few other dermatoses have been ralted to focus of infection

• Includes - erythema mutiforme, - pustular dermatitis - lupus erythematosus - lichen planus -

• If such relationship does exist, the mechanism is probably sensitization rather than metastatic spread of microorganism

Renal disease• Microorganisms most commonly

involved in UTI(urinary tract infection) are:

- Escherichia coli - staphylococci and streptococci• Of the streptococci, streptococcus

hemolyticus seems to be most common.

• Oral foci of infection play a small role even when the possibility of superimposition on a damaged urinary tract exists.

• Occurrence of metastatic infections from the mouth to distant bodily sites is also not very common.

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