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Dentoalveolar Infections
Dentoalveolar Infections
Infections
Michael Lypka, MD, DMDa,b,*,
Jeffrey Hammoudeh, MD, DDSc
KEYWORDS
Dentoalveolar infection Maxillofacial infection
Odontogenic infection
Dentoalveolar infections represent a spectrum of should be apparent immediately, without the need
conditions ranging from localized periodontal for additional laboratory or radiologic data. The
abscesses, to deep neck space infections, to the history should include the onset, duration, and
most severe case of necrotizing fasciitis. The oral type of symptoms, as well as previous therapies.
and maxillofacial surgeon is faced with managing It is important to ascertain if the patient is having
all these conditions, from the most mundane to the any odynophagia, dysphagia, or respiratory diffi-
life threatening. A topic addressed by several inves- culties. The patient’s medical history, including
tigators over the years, and perhaps an uninspiring a history of diabetes, renal disorders, and immuno-
one to some with little new information, it has never deficiencies, can assist the clinician in assessing
been more important to be adept in diagnosing and the host’s ability to fight the infection. In some
managing dentoalveolar infections. A recent report cases, the oral and maxillofacial surgeon may be
by Sepannen and colleagues1 has shown a disturb- the first to diagnose diabetes because the stress
ing trend toward an increased severity of maxillo- of a dentoalveolar infection unmasks glucose intol-
facial infections in the last 10 years in 1 hospital erance. Current medications, including chemo-
district, with a trend toward more medically compli- therapy and steroid therapy, and a history of
cated patients. The subject of dentoalveolar infec- alcohol and drug abuse are also important histor-
tions allows oral and maxillofacial surgeons to ical information.
integrate their knowledge of anatomy, medicine, The physical examination begins with an assess-
microbiology, anesthesiology, pharmacology, and ment of the vital signs, followed by a thorough
surgery into a diagnostic and therapeutic plan that examination of the patient. Tachycardia suggests
can be not only intellectually stimulating but also dehydration or pain, or it may be the result of
potentially life saving. increased temperature. Hypotension would be the
most concerning, suggesting a dehydrated, septic
PATIENT ASSESSMENT patient. The patient with a severe dentoalveolar
infection has a typical toxic appearance. The
As in all patient encounters, evaluation of a patient head posture of the patient should be assessed,
with a dentoalveolar infection should begin with with the sniffing position and accessory respiratory
a good history and physical examination, and muscle use suggesting upper airway obstruction
a clinical impression of the severity of the infection from airway swelling. The quality of the patient’s
a
Division of Pediatric Plastic and Craniofacial Surgery, Department of Pediatric Surgery, University of Texas
Medical School at Houston, 6431 Fannin Street, MSB 5.281, Houston, TX 77030, USA
b
Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Medical School at
Houston, 6431 Fannin Street, MSB 5.281, Houston, TX 77030, USA
c
Division of Plastic and Maxillofacial Surgery, Department of Surgery, Children’s Hospital Los Angeles, Keck
School of Medicine, University of Southern California, 4650 Sunset Boulevard MS 96, Los Angeles, CA 90027,
USA
* Corresponding author. Division of Pediatric Plastic and Craniofacial Surgery, Department of Pediatric
Surgery, University of Texas Medical School at Houston, 6431 Fannin Street, MSB 5.281, Houston, TX 77030.
E-mail address: michael.a.lypka@uth.tmc.edu
voice, as in a “hot potato” voice, would indicate a thorough assessment, airway management
glottal swelling. The patient’s maximal incisal must be the primary consideration in managing
opening is an important physical finding, with a patient with dentoalveolar infection. Depending
a limited opening less than 30 mm indicating on the severity of airway compromise, close
involvement of the masticatory muscles, as in clinical observation, intubation, or tracheotomy
a masticator, or lateral pharyngeal space infection. are all considerations for airway management.
Limited mouth opening should alert the practitioner When intubation is deemed necessary for airway
to a more severe infection with a greater probability protection, awake fiberoptic techniques are pref-
of having a difficult intubation, if necessary.2 Floor erable. In other cases, tracheotomy may be the
of mouth elevation and uvular deviation indicating best alternative. Tracheotomy may result in earlier
sublingual and lateral pharyngeal space infection, transfer out of the intensive care unit and a reduced
respectively, should be noted on intraoral examina- hospital stay when compared with intubation in
tion. The condition of the dentition should be as- patients with deep neck space infections.9
sessed, and the source of the infection sought.
Swelling in the vicinity of the body of the mandible NATURAL HISTORY OF PROGRESSION
should be carefully assessed. A palpable inferior
border suggests a buccal space infection, Dentoalveolar infections arise from either periapi-
amenable to intraoral drainage, whereas swelling cal or periodontal sources. In the case of periapi-
extending inferior to it would suggest submandib- cal infection, pulpal necrosis resulting from
ular space infection, requiring extraoral drainage. dental caries allows invasion of bacteria into the
Radiographic imaging is a useful aid in diagnosing periapical tissue. In the case of periodontal infec-
and guiding surgical therapy for dentoalveolar infec- tion, deep periodontal pockets allow inoculation
tions. The gold standard for imaging of maxillofacial of bacteria into the underlying soft tissues. Periap-
infections, especially deep anatomic space infec- ical infection is by far the most common cause of
tions, is computed tomography (CT) with intrave- odontogenic infections. Once bacteria gain ac-
nous contrast.3 The contrast enhances the ability cess to the periapical bone, 2 possibilities may
to visualize abscess cavities, assess lymphadenop- arise. Either a chronic process ensues, such as
athy, and visualize vascular structures, such as periapical cyst or granuloma formation, osteomye-
jugular venous thrombosis. Although magnetic reso- litis, or fistula formation, or an acute phenomenon
nance imaging is useful for localization of soft tissue takes place. An acute process may take the form
abscess,4 the length of the study makes it a less- of cellulitis, dentoalveolar abscess, fascial space
desirable option, especially in a patient with possible infection, or, in the worst case, necrotizing fascii-
impending airway compromise. Ultrasonography tis. Bacteria from the periodontal or periapical
may be used to differentiate cellulitis from abscess soft tissues may rarely spread hematogenously,
in superficial neck infections, but its role in deep as evidenced by infection at distant anatomic sites
neck space infections is limited.5,6 Lateral plain films such as the spine,10 liver, or brain.11
to assess retropharyngeal involvement are largely of
historical interest, given the availability and speed of LOCAL ANATOMIC CONSIDERATIONS
the current CT scanners. Certainly, an orthopanto-
mogram is a useful radiograph to assess the denti- Periapical infections that perforate the cortical
tion and determine the source of the infection. bone, usually at the thinnest site, localize based
Laboratory workup should consist of a complete on the relationship of the roots of the teeth to the
blood cell count with differential and basic meta- origins and insertions of facial muscles to the
bolic panels. C-reactive protein may be used as maxillary and mandibular alveoli (Fig. 1). An under-
a marker to assess the severity of infection7 and standing of these relationships is essential in diag-
response to treatment. Typically, blood cultures nosing and predicting the spread of dentoalveolar
yield negative results in patients with dentoalveo- infections. The buccinator muscle inserts onto the
lar infections and are not indicated. Culture and most superior and inferior portions of the alveolar
sensitivity testing should be a routine practice processes of the maxilla and mandible, respec-
during surgical drainage to guide antibiotic tively. Bony destruction with spread of infection
therapy, especially given nonresponse rates above the superior attachment or below the infe-
of 21% with empirical penicillin therapy in the rior attachment results in a buccal space infection.
inpatient setting in 1 report.8 Cultures should Infectious escape within these insertions results in
preferably be aspirates and transported to the a vestibular space infection. The mylohyoid
laboratory within 2 hours. muscle arises from the mylohyoid line of the
With completion of a history and physical mandible, and its relationship to the root apices
examination, and perhaps before completion of of the lower molar and premolar teeth defines
Dentoalveolar Infections 417
vein in adjacent fascial space infections. A good lingual cortex of the mandible. The submental
example of this phenomenon is Lemierre space, which can be affected by lower incisor
syndrome,12 in which oropharyngeal infection teeth infections, is bounded by the anterior digas-
spreads to the internal jugular vein, thrombosing it. tric muscles on each side and freely communi-
Between the deep layers of fascia exist potential cates with the submandibular space. Rarely,
spaces for routes of spread of infection (Fig. 2). The when bilateral submandibular, sublingual, and
retropharyngeal space lies between the bucco- submental spaces are involved with cellulitis, it is
pharyngeal fascia and alar fascia, whereas danger known as Ludwig angina. Ludwig angina results
space No. 4,13 often incorrectly named the prever- in extensive induration of the submental and
tebral space, takes up the space between the alar submandibular regions, with elevation of the
and prevertebral fascia. A potential space between tongue intraorally, resulting in impending airway
the vertebral bodies and the prevertebral fascia obstruction if no intervention is taken. Although
makes up the prevertebral space. The significance classically a cellulitis, abscess is often present.
of the anatomy here illustrates how a dentoalveolar The patient’s airway is the primary concern, some-
infection of the lateral pharyngeal space can travel times necessitating tracheotomy.17 Surgical
to the thorax by spreading to the retropharyngeal drainage is the preferred treatment.
space tracking caudad, and piercing the weak The masticator space is defined by the superfi-
alar fascia into danger space No. 4, gaining access cial layer of the deep cervical fascia because it
to the mediastinum. envelops the mandible and masticatory muscles.
It is made up of the submasseteric space,
SPECIFIC HEAD AND NECK SPACE INFECTIONS bounded by the masseter muscle laterally, the
pterygomandibular space, bounded by the medial
The authors briefly describe common head and pterygoid muscle medially, and the deep and
neck space infections, keeping in mind the fascial superficial temporal spaces, surrounding the tem-
relationships discussed earlier. In the maxilla, the poralis muscle superiorly extending up from the
canine space is involved, usually from a canine coronoid process of the mandible. Spread of
tooth, when infection erodes through the alveolar infection to the deep temporal space from an
bone superior to the origin of the levator anguli abscessed molar can therefore explain temporal
oris muscle (Fig. 3). Swelling of the midface on bone osteomyelitis, as reported by Adams and
the affected side occurs, often with extension Bryant.18 The lateral pharyngeal space is an in-
superiorly, resulting in a preseptal cellulitis. The verted cone extending from the base of the skull
buccal space is superficial to the buccinator to the hyoid bone inferiorly. It is bounded laterally
muscle and is lined externally by the skin and by the medial pterygoid muscle and medially by
superficial fascia of the face (Fig. 4). This space the superior pharyngeal constrictor or buccophar-
may be affected by maxillary or, less commonly, yngeal fascia. It is split into anterior and posterior
mandibular teeth when infection erodes outside compartments by styloid musculature, the poste-
the insertion of the muscle. The infratemporal rior of which contains the carotid sheath and
space lies posterior to the maxilla and can be cranial nerves IX through XII. Spread of infection
involved when a maxillary third molar becomes in- posteriorly into any of these spaces causes
fected. It is significant in that hematogenous significant trismus, and in the case of extension
spread of infection through the adjacent valveless into the posterior compartment of the lateral
pterygoid plexus to the cavernous sinus can result pharyngeal space, cranial nerve involvement,
in cavernous sinus thrombosis,14 a life-threatening Horner syndrome, or jugular venous thrombosis.
infection. A similar pathway of spread to the orbit Spread of infection to the lateral pharyngeal
can result in orbital infection.15,16 space, as discussed in the Fascial Anatomy of
The spaces of the mandible adjacent the teeth Space Infections section, can allow extension
include the submandibular, submental, and sublin- into the retropharyngeal space, subsequently
gual spaces (Fig. 5). The sublingual space lies gaining entry to the mediastinum.
between the floor of the mouth and mylohyoid
muscle, and is typically affected by infections of OTHER DENTOALVEOLAR INFECTIONS
premolar teeth or spread from the adjacent
submandibular space. The submandibular space In the most severe form, dentoalveolar infections
lies between the mylohyoid muscle and the over- can progress to necrotizing fasciitis, an aggres-
lying skin and superficial fascia. Its medial border sive, typically polymicrobial, infection resulting in
is formed by the anterior and posterior digastric liquefaction of underlying fat and fascia. With
muscles (Fig. 6). It is involved when the lower a mortality of up to 60%,19 early recognition and
second and third molar abscesses perforate the aggressive operative intervention are necessary.20
Dentoalveolar Infections 419
Fig. 2. Fascial spaces of the neck (red line) investing fascia (superficial layer of the deep cervical fascia), (blue line)
pretracheal fascia (visceral division of the middle layer of the deep cervical fascia), (green line) buccopharyngeal
fascia (visceral division of the middle layer of the deep cervical fascia), (orange line) alar fascia (deep layer of the
deep cervical fascia), (brown line) carotid sheath, (yellow line) prevertebral fascia (deep layer of the deep cervical
fascia), (purple line) muscular division of the middle layer of the deep cervical fascia. (From Netter illustration
Elsevier Inc. All rights reserved. Available at www.netterimages.com; with permission.)
420 Lypka & Hammoudeh
Retropharyngeal space
Medial pterygoid muscle
Lateral pharyngeal space
Mandible
Masseteric space
Masseter muscle
Pterygomandibular space
Airway
Superior pharyngeal
Tongue constrictor muscle
Fig. 5. Anatomy of maxillofacial space infections. (From Girn J, Jo C. Ludwig’s angina. In: Bagheri S, Jo C, editors.
Clinical review of oral and maxillofacial surgery. St Louis: Mosby; 2008. p. 71; with permission.)
whereas clindamycin is a reasonable choice in the as the incision and drainage. Abscess, without
penicillin allergic patient. For more severe infections question, requires incision and drainage, whereas
managed in the hospital, ampicillin/clavulanic acid, the surgical management of cellulitis is more
with excellent activity against anaerobic bacterial controversial. It is the opinion of these authors,
b-lactamases, or moxifloxacin,29 a fluorquinolone and others,30 that there is benefit to aggressive
with efficacious broad-spectrum coverage, are surgical management of all fascial spaces affected
good options. Regardless of the empirical choice, by cellulitis because it alters the bacterial milieu
surgical therapy is the primary treatment modality and hastens the resolution of infection.
for dentoalveolar infections and antibiotic therapy A few guiding principles of surgical drainage
must be guided by the culture and sensitivity testing. include placing the incision in healthy mucosa or
skin and in an aesthetic area, if possible; obtaining
SURGICAL THERAPY gravity-dependent drainage; and performing blunt
dissection during drainage to avoid damage to
The primary goal of surgical therapy for dentoal- adjacent vital structures.31 The specific sites of
veolar infections is to drain the infection and re- drainage for each particular space infection are
move the source of infection, usually by not discussed in detail in this article but are shown
extracting the offending tooth at the same time in Figs. 7 and 8. Many infections may require
422 Lypka & Hammoudeh
26. Kuriyama T, Karasawa T, Nakagawa K, et al. Bacte- 29. Warnke PH, Becker ST, Springer IN, et al. Peni-
riologic features and antimicrobial susceptibility in cillin compared with other advanced broad spec-
isolates from orofacial odontogenic infections. Oral trum antibiotics regarding antibacterial activity
Surg Oral Med Oral Pathol Oral Radiol Endod against oral pathogens isolated from odontogenic
2000;90:600–8. abscesses. J Craniomaxillofac Surg 2008;36:
27. Lewis MA, Parkhurst CL, Douglas CW, et al. Prevalence 462–7.
of penicillin resistant bacteria in acute suppurative oral 30. Flynn TR. Surgical management of orofacial infec-
infection. J Antimicrob Chemother 1995;35:785–91. tions. Atlas Oral Maxillofac Surg Clin North Am
28. Poeschl PW, Spusta L, Russmeuller G, et al. Antibi- 2000;8:77–100.
otic susceptibility and resistance of the odontogenic 31. Topazian RG, Goldberg MH. Odontogenic infections
microbiological spectrum and its clinical impact on and deep fascial space infections of dental origin.
severe deep space head and neck infections. Oral In: Topazian RG, editor. Oral and maxillofacial infec-
Surg Oral Med Oral Pathol Oral Radiol Endod tions. 4th edition. Philadelphia: WB Saunders
2010;11:151–6. Company; 2002.