Odontogenic Infections

Ickman Setoaji W, drg., MM

• Most of the infections of the head and neck region are odontogenic
infections
• Many different strains of bacteria exist in the oral cavity. Oral bacteria in
certain infections may number from 350 to 500 different species
• The most common oral infections are those arising from pulpa necrosis and
the subsequent overflow into the surrounding tissue, or periodontal
infections that result from the invasion of bacteria into bone or soft tissue
• Infectious bacteria in the mouth are either aerobic or anaerobic
• About 60 percent of all oral infections are a mix of these two types of flora
General Factors spread of infection
• 1.Microorganism : quantity and virulence
• 2. Anatomic Consideration :Infection tends to spread through path of
least resistance. Barriers are - alveolar bone, periosteum,muscles and
fascia
• 3. Personal resistance to infection : such as in patients with AIDS,
diabetes, leukaemia etc have low resistance, increase susceptibility to
infections
Anatomic Consideration
• Spasia fasialis
Spasia fasialis adalah suatu area yang tersusun atas beberapa lapis
fasia di daerah kepala dan leher berupa jaringan ikat yang membungkus
otot-otot dan berpotensi untuk terserang infeksi serta dapat tembus
oleh eksudat purulent.
Anatomic Consideration
• Space of odontogenic infection
• 1. Primary Spaces
• A. MAXILLARY
• i. Canine space
• ii. Buccal space
• iii. Infratemporal space
• B. MANDIBULAR
• i. Submental space
• ii. Submandibular space
• iii. Sublingual space
• iv. Buccal space
Anatomic Consideration
• 2. Secondary Spaces
• a. Masseteric space
• b. Pterygomandibular space
• c. Superficial and deep temporal space
• d. Lateral pharyngeal space
• e. Retropharyngeal space
• f. Prevertebral spaces
• g. Parotid space
Canine space

• The canine space is the area at

the apex of the maxillary canine
root system (canine fossa),
bordered by the zygomaticus
minor, orbicularis oris, levator
labii superioris, levator labii
superioris alaeque nasi, and
levator anguli oris muscles
Bucal Space
• This space contains the buccal pad of
fat and is bounded:
• Medially: By the buccinator muscle
• Laterally: By the skin and
subcutaneous tissue.
• Anteriorly: By the posterior border of
the zygomaticus major muscle above
and the depressor anguli oris below.
• Posteriorly: By the anterior edge of
the masseter muscle.
• Superiorly: By the zygomatic arch.
• Inferiorly: By the lower border of the
mandible
Sublingual Space
• Medially: By the median raphe of the
mylohyoid and intrinsic tongue muscles.
• Laterally: By the body of mandible.
• Anteriorly: By the body of the mandible.
• Posteriorly: By the hyoid bone.
• Inferiorly: By the mylohyoid muscle.
• Superiorly: By the lingual mucosa.
• It contains: Sublingual salivary gland,
submandibular duct, lingual and
hypoglossal nerve, lingual vessel and
loose connective tissue between the
muscles of the tongue
Submental Space
• Laterally: By the anterior belly of
digastric muscle.
• Superiorly: By the mylohyoid
muscle.
• Inferiorly: By skin, superficial
fascia, platysma and deep
cervical fascia
Submandibula space
• Superiorly: By the medial aspect of
the mandible below the attachment
of the mylohyoid muscle.
• Medially: By the mylohyoid,
hyoglossus, styloglossus muscle.
• Laterally: By the skin, superficial
fascia, platysma muscle.
• Inferiorly: By the anterior and
posterior belly of the digastric
muscles
Pterygomandibular Space
• This space can get infected through
the lower third molar. It is the
space into which the
• needle is passed for inferior
alveolar nerve block.
• Its boundaries are:
• Laterally: By the medial surface of
ramus of mandible.
• Medially: By the lateral aspect of
the medial pterygoid muscle
• Posteriorly: This space
communicates with lateral
pharyngeal space.
Pathway of dental infection
• Infeksi yang terjadi ada kepala dan leher paling sering disebabkan dari
infeksi odontogenik baik berasal dari infeksi jaringan pulpa maupun
periodontal.
• Kelanjutan dari abses periapikal dapat menyebar ke segala arah
mencari jalan keluar (drainase).
• Drainase alami pada tubuh mengakibatkan terjadinya fistula.
 Pulpitis

Periodontitis apikalis

Osteomielitis Abses periapikal Granuloma Periapikal

Abses Fasialis Kista

Ludwig Angina
Clinical Features (Signs and Symptoms)
• 1. Mild Infection
• • Inflammatory sign (+)
– Dolor
– Calor
– Rubor
– Tumor
– Loss of function
• • Lymphadenopathy
• • Pyrexia (fever)
Clinical Features (Signs and Symptoms)
• 2. Severe Infection
• • Inflammatory signs (+) and toxicity
• – Paleness
• – Rapid respiration
• – Rapid thrombing pulse
• – Shivering
• – Fever
• – Lethargy
• – Diaphoresis (severe sweating)
Clinical Features (Signs and Symptoms)
• 3. Extreme Infection
• • Inflammatory sign + sign of toxicity + CNS changes
• – Impaired eye movement/vision
• – Decreased level of consciousness
• • Meningeal irritation (severe headache, stiff neck, vomiting)
• • Edema of eyelids
• • Airway compromise
• • Difficulty in swallowing
Physical Examination
• Inspection
• Palpation
• Percussion
Physical Examination
• Palpation :
Confirm size
Note Tenderness
Local Temperature
Determine fluctuance
Crepitus
Maxillary Teeth
Incisive central Canine

Or

Incisive lateral

Or
Maxillary Teeth
Premolar Molar

Or
Mandibular teeth
• Incisor Canine
Mandibular teeth
• Premolar
Mandibular teeth
• Molar 1
Mandibular teeth
Molar 2 Molar 3
LUDWIG'S ANGINA (PHLEGMON)
• Ludwig's angina is a bilateral swelling of the sublingual,
submandibular, and submental spaces
• if the involvement is not of all the three spaces, that too bilaterally,
the infection will not be Ludwig's angina
Clinical Features
• It is brawny indurated, nonfluctuant, and painful to touch
• Because of its position the Ludwig's angina patient has a typical open
mouthed appearance
• The floor of the mouth is elevated, the tongue is protruded, making
respiration difficult
• Deglutition and speech are also difficult
• Saliva may drool from the mouth
• Fever and inability to open mouth
Pathophysiology
• It can start in the submandibular space and then spread upwards to
sublingual space and to all the other space
• Or the infection starts in the sublingual space, spreads on both the
sides, and then moves posteriorly over the edge of the mylohyoid
muscle to involve the submandibular space and finally to the
submental spaces
• The infection is caused by α-hemolytic streptococcus or by a mixture
of aerobic and anaerobic organisms
• Further more, the infection spreads to the pharyngeal spaces and
the mediastenum
COMPLICATIONS OF
ODONTOGENIC INFECTION
• 1. Cavernous Sinus Thrombosis
• 2. Meningitis
• 3. Mediastenitis
TREATMENT OF ODONTOGENIC
INFECTION
• Extraction of the infected tooth
this will remove the source of
infection
• Antibiotics: Must be given.
Incision and drainage (Hilton's method)
• Knowledge of local anatomy of the area
to be incised
• Incision placed in esthetically accepted
area.
• Confirm presence of the abscess via
needle aspiration
• Incision and drainage may be performed
only if pus can be aspirated
• An incision is made at the most fluctuant
part of the abscess, it should preferably
also be the most dependent area.
• The surgical incision is made parallel and
medial to the lower border of the
mandible
Incision and drainage
• A sinus forcep should be
inserted into the abscess space
• The pus is pressed out from all
sides to drain the pus
• The cavity is then irrigated with
antiseptic
• A drain is then passed into the
cavity and secured
• The offending tooth is extracted.
A gauze dressing is given and
changed every day
• Antibiotics are continued till the
abscess dries
• Assess the airway upon respiratory distress,
• oropharyngeal tissue swelling or inability to secure the airway via
endotracheal intubation or tracheostomy
Osteomyelitis
• Definition
• It is a diffuse inflammation of
the soft tissue and bone
involving the cancellous bone
marrow and the periosteal
component
Classification
Acute Osteomyelitis
• Etiology
• It is generally caused by odontogenic infection and the S. aureus
• From infections other than teeth, e.g. middle ear, boil on chin
• Clinical features
• Severe deep seated pain
• Indurated swelling
• Loss of sensation in lower lip
• Number of teeth become tender to percussion
• The lymph nodes are enlarged and tender
• High intermittent fever
• Among the jaws, osteomyelitis is mostly seen
• in the mandible as--
• Maxilla is more porous and richly supplied by blood vessels.
• Maxilla has thin cortical plates and paucity of medullary tissues due
to which any maxillary infection remains confined within the bone and
the edema and pus dissipates into the soft tissues and sinuses.
Chronic Osteomyelitis
• Primary chronic osteomyelitis is characterized by:
a. Insidious onset with slight pain.
b. Slow increase in jaw size
c. Gradual development of sequestra, often without fistula

• Secondary chronic osteomyelitis is characterized by:

a. Minimal pain
b. Presence of fistula.
c. Induration of soft tissue
d. A thickened or 'wooden' character to the affected area with pain and
tenderness on palpation
Treatment
• Evaluation and correction of host defense deficiencies
• Removal of loose teeth
• Incision and drainage
• A broad-spectrum bacteriocidal antibiotic started
• Sequestrectomy
Sequestrectomy
• Sequestrectomy is the removal
of the sequestra to prevent the
spread of infection and minimize
tooth mobility
• Sequestra are cortical or cortico
– cancellous bone generally
formed 2 weeks after the onset
of infection and are avascular
bony fragments which are poorly
penetrable by antibiotics and are
highly susceptible to pathologic
fracture
Antibiotic for Odontogenic Infections
• PENICILLIN
• Penicillin V or amoxicillin remain the antibiotics of choice in the
treatment of dentoalveolar infections in a noncompromised patient
• Amoxicillin combined with clavulanate is almost 100 percent
effective, but the cost of amoxicillin clavulanate is a factor
• It is also safe to give large doses because the therapeutic index is high
Antibiotic for Odontogenic Infections
• CEPHALOSPORINS
• They have a less-effective spectrum than penicillin, and there is a risk
of allergic reaction if used on a penicillin-allergic patient
• The second and third-generation cephalosporins are broader
spectrum than first-generation
Antibiotic for Odontogenic Infections
• CLINDAMYCIN
• Clindamycin is active against most anaerobes, including bacteroides,
prevotella, clostridium, peptococcus, peptostreptococcus, and
fusobacterium organisms.
• It is frequently used to treat moderately severe infection in which
anaerobes are significant pathogens
• Common side effects are diarrhea, nausea, and skin rashes
Antibiotic for Odontogenic Infections
• METRONIDAZOLE
• Metronidazole is an antiprotozoal drug that also has striking
antibacterial effects against most anaerobic gram-negative bacilli
(bacteroides, prevotella, and fusobacterium and clostridium species)
• A dosage of 500 mg orally three times daily is recommended
Antibiotic for Odontogenic Infections
• In noncompromised patients, penicillin still remains the empirical
antibiotic of choice for mouth infections.
• the addition of metronidazole can be added to penicillin to increase
effectiveness.
• The use of penicillin first, then with the addition of metronidazol after
two or three days (if there is no effect from the penicillin), is a good
medication combination for infection in the mouth.