Diagnosis and Management of Odontogenic Infections

Nino Zaya, MD November 2, 2006

Objectives    

Understand the microbiology of odontogenic infections Understand the signs symptoms and findings in patients with odontogenic infections Review the various pathways of spread with odontogenic infections Understand the medical and surgical management of odontogenic infections

Case 

43 y.o. male comes to the emergency room with drooling, and shortness of breath that is exacerbated when laying down. He has had right lower tooth pain with mastication during the past month with worsening during the past week. He states that during the last day he has had neck pain and developed shortness of breath.

Continued«. 

Physical Exam:
Elevation FOM with induration in the submental, bilateral submandibular, and bilateral sublingual spaces, as well as drooling  Inability to lay supine  Extensive dental caries: percussion tenderness tooth #31  Tachypnea 

Background 
   

Among most frequently encountered infections in human body Plagued our species for as long as we have existed PrePre-Columbian Indians, unearthed in the American Midwest Early Egypt revealed bony crypts of dental abscesses, sinus tracts, and the ravages of osteomyelitis of the mandible Treatment of localized dental infection was probably the first primitive surgical procedure performed, using a sharp stone or pointed stick to establish drainage

Anatomy .

MICROBIOLOGY OF ODONTOGENIC INFECTIONS       Usually caused by endogenous bacteria Aerobic bacteria alone rarely causative agents Streptococcus species are usually the etiologic organisms if aerobic bacteria present Half odontogenic infections: anaerobes Most odontogenic infections due to mixed flora Mixed infections may have 5-10 organisms 5present .

2.Continued«. Quantitative estimations of the number of microorganisms in saliva and plaque range as high as 1011/ml. and Fusobacterium.  1. Eubacterium. Bacteroides (Prevotella) melaninogenicus. 3. Peptostreptococcus. . Bacterial composition 5%5%-aerobic bacteria 60%60%-anaerobic bacteria 35% mixed aerobic and anaerobic bacteria   Commonly cultured organisms: alpha-hemolytic alphaStreptococcus. Peptococcus.

dysphagia and have shortness of breath should be investigated. presence of fever. and previous treatments (antibiotics ) important Patients may complain of trismus. onset. duration. Findings vary from mild swelling and pain to lifelife-threatening airway compromise and CNS impairment .Presentation    HistoryHistory-previous toothaches.

. impaired vision. eyelid edema. lethargy and decreased level of consciousness Exam findings: Toxic. dysphagia. CNS impairment (decreased level of consciousness.Continued«. and vomiting). meningeal irritation.   Possibly fatal infections may present with respiratory impairment. hoarseness. severe headache. ophthalmoplegia. and ophthalmoplegia.

trismus. DolorDolor-(or pain) results from pressure on sensory nerve endings from tisssue distention caused by edema or infection FunctiolaesaFunctiolaesa-(loss of function) problems with mastication. and respiratory impairment . dysphagia.Continued«.(redness) cutaneous surface involved due to vasodilatation effect of inflammation TumorTumor-(swelling) occurs due to the accumulation of pus or fluid exudate CalorCalor-(heat) is the result of increased blood flow to the area due to the vasodilatation.      RuborRubor.

and subcutaneous crepitus Assess for cervical lymphadenopathy and fascial space involvement Assess for the presence and magnitude of trismus .Continued«. palpation. and neck for swelling. fluctuation. sinus or fistula formation. head. erythema.      Inspection. and percussion are integral parts of the exam Begin extraorally and then move inraorally Skin of the face.

    Inspect teeth for presence of caries and large restorations. presence of preseptal or postseptal edema .Continued«. and mobility FOM inspected to assess for fascial space involvement Visualize Wharton·s and Stenson·s ducts for quality of fluid (pus or saliva) Ophthalmologic examination: extraocular muscle function. localized swellings. proptosis. fistulas.

   Imaging studies can further substantiate diagnosis Computerized tomograms should be obtained when infection has spread into fascial spaces in the orbit or neck Infections.Continued«. well-localized to oral cavity do not wellrequire special imaging studies with a panorex being sufficient for diagnosis and treatment .

Pathways of Odontogenic Infection       Usual cause of odontogenic infection: necrosis of tooth pulp and bacterial invasion through the pulp chamber into deeper tissues Pulp necrosis results from deep decay in tooth. get fistulous tracts through alveolar bone Fistulous tract may penetrate oral mucosa or facial skin . (inflammatory reaction) The pulpal foramen does not allow drainage of the infected pulp Further progression leads to medullary space infection and osteomyelitis More commonly.

.Continued«.

Fascial Spaces      Fascial planes offer anatomic highways for infection to spread superficial to deep planes Antibiotic availability in fascial spaces is limited due to poor vascularity Treatment of fascial space infections depends on I and D Fascial spaces are contiguous and infection readily spreads from one space to another (open primary and secondary spaces) Despite I and D the etiologic agent (tooth) must be removed .

and the skin Dependent drainage of this space is performed by placing a horizontal incision in the most dependent area of the swelling extraorally with a cosmetic scar being the result 2. 3. the platysma muscle. and superiorly by the deep cervical fascia. .Primary Mandibular Spaces  1. deeply by the mylohyoid muscle. Submental space Infection can result directly due to infected mandibular incisor or indirectly from the submandibular space Space located between the anterior bellies of the digastric muscle laterally. the superficial cervical fascia.

2.Continued«. Submandibular Space Boundaries: 1. SuperiorSuperior-mylohyoid muscle and inferior border of the mandible AnteriorlyAnteriorly-anterior belly of the digastric muscle PosteriorlyPosteriorly-posterior belly of the digastric muscle InferiorlyInferiorly-hyoid bone SuperficiallySuperficially-platysma muscle and superficial layer of the deep cervical fascia 2. 3. Infected mandibular 2nd and 3rd molars cause submandibular space involvement since root apices lay below mylohyoid muscle . 4.  1. 5.

Submandibular Space Abscess .

Boundaries: 1. SuperiorSuperior-oral mucosa InferiorInferior-mylohyoid muscle 3. but should be considered as surgical unit due to proximity and frequent dual involvement in odontogenic infections. 2.Continued«. 2.  1. Sublingual Space Submandibular and sublingual spaces surgically distinct. Infected premolar and 1st molar teeth frequently drain into this space due to their root apices existing superior to the mylohyoid muscle .

Sublingual Space Infection .

2. Boundaries: 1. 3. LateralLateral-Skin of the face MedialMedial-Buccinator muscle 2.Continued«.  Buccal Space 1. Both a primary mandibular and maxillary space Most infections caused by posterior maxillary teeth .

Buccal Space Abscess .

pterygomandibular. and temporal spaces .Secondary Mandibular Spaces     Referred to as secondary spaces since they are infected after involvement of primary mandibular spaces Failure to treat a primary space infection or a compromised host results in secondary space involvement Connective tissue fascia has poor blood supply hence treatment usually surgical to drain purulent exudates The secondary mandibular spaces include the masseteric.

Continued«.  Masseteric Space 1. Located between lateral aspect of the mandible and the masseter muscle Involvement of this space generally occurs from buccal space primary involvement Signs of involvement of the masseteric space include trismus and posterior-inferior face swelling posterior- . 3. 2.

Trismus Minimal swelling on exam .Continued«. 3. Location: between medial aspect of the mandible and the medial pterygoid muscle (communicates with infratemporal spaces) 2ndary infection results from spread from the sublingual and submandibular spaces Symptoms: 1. 2. 2.  Pterygomandibular Space 1.

Location: posterior and superior to the masseteric and pterygomandibular spaces Bounded laterally by the temporalis fascia and medially by the temporal bone Two components: 1. 3. Continuous with the infratemporal space . Superficial temporal space: located between temporal fascia and temporalis muscle Deep temporal space: located between the temporalis muscle and the temporal bone 1.Continued«.  Temporal Space 1. 2. 2.

 Masseteric. pterygomandibular. and temporal spaces referred to as masticator space due to delineation by the muscles of mastication 1.Continued«. Communicate freely with one another and are simultaneously involved .

Secondary Mandibular Spaces .

2.Primary Maxillary Spaces  Canine Space 1. 2. Obliteration of the nasolabial fold Superior extension can involve lower eyelid  Buccal Space 1. Posterior maxillary teeth are source of most buccal space infections Results when infection erodes through bone superior to attachment of buccinator muscle . Location: between the levator anguli oris and the levator labii superioris muscles Involvement primarily due to maxillary canine tooth infection Long root allows erosion through the alveolar bone of the maxilla Signs: 1. 4. 2. 3.

3. Rare involvement with odontogenic infections. 2.  Infratemporal Space 1. 2. Location: posterior to the maxilla Boundaries: 1. Medial: lateral plate of the pterygoid process of the sphenoid bone Superior: skull base Lateral: infratemporal space is continuous with the deep temporal space 3. but when occurs related to 3rd maxillary molar infections .Continued«.

Can result from hematogenous spread of odontogenic infections Bacterial routes of spread: 1. and infratemporal space) involvement can ascend to cause orbital cellulitis (preseptal or postseptal) or cavernous sinus thrombosis 1. buccal. 2. Ocular findings include erythema and swelling of the eyelids. and ophthalmoplegia Cavernous sinus thrombosis 1.Continued«. 2. 2. Posterior: via pterygoid plexus or emissary veins Anterior: via angular vein and inferior or superior ophthalmic veins to the cavernous sinus Veins of the face and orbit valve less so retrograde flow can occur . 3.  Primary maxillary space (canine.

Orbital Abscess .

. Shape of an inverted cone with its base at the skull base and its apex at the hyoid bone Location: medial to the medial pterygoid muscle and lateral to the superior pharyngeal constrictor muscle Anterior: pterygomandibular raphe Posterior: prevertebral fascia. 4. 3.Deep Neck Spaces     1. Extension of odontogenic infections beyond the primary spaces of maxilla and mandible is uncommon When occurs upper airway compromise and descending mediastinitis are possible adverse sequelae Posterior spread of ptyerygomandibular space infection is to lateral pharyngeal space Lateral Pharyngeal space 2.

erosion of the carotid artery or its branches. Severe trismus Lateral swelling of the neck Bulging of the lateral pharyngeal wall Rapid progression of infection in this space is common Posterior compartment involvement can result in thrombosis of the internal jugular vein. 5.    Lateral pharyngeal space communicates with retropharyngeal space. 2. and interference with cranial nerves IX to XII .Continued«. 3. 4. The styloid process separates posterior compartment of the lateral pharyngeal space that contains the great vessels from the anterior space Clinical presentation 1.

Lateral Pharyngeal Space Abscess .

4. 5. 2. Airway obstruction Aspiration of pus in the event of spontaneous rupture Rupture can occur during endotracheal intubation . 3.  Retropharyngeal Space 1. 3. 6. Posteromedial to lateral pharyngeal space and anterior to the prevertebral space Anterior: superior pharyngeal constrictor muscle Posterior: alar layer of prevertebral fascia Extends from skull base superiorly to C7 to T1 inferiorly Retropharyngeal space infections can spread to mediastinum Other complications of retropharyngeal space involvement: 1. 2.Continued«.

Retropharyngeal Abscess .

2.Continued«.  Prevertebral Space 1. 3. Potential space between two layers of prevertebral fascia (alar and prevertebral layers) Extends from skull base superiorly to the diaphragm inferiorly Mediastinitis is concern with prevertebral space infections similarly to retropharyngeal space infections .

Anatomic Planes .

3.Management of Odontogenic Infections  Goals of management of odontogenic infection: 1. 2. Airway protection Surgical drainage Medical support of the patient Identification of etiologic bacteria Selection of appropriate antibiotic therapy . 4. 5.

stridor. 3. 5. drooling.  Airway protection 1. dysphonia. and restlessness etc. Floor of mouth and tongue elevation or narrowing can cause respiratory distress Expedient assessment and diagnosis of airway compromise is the most important initial step in managing odontogenic infections Airway loss is primary cause of death in these patients Initially intact airway must be continuously reevaluated during treatment Signs and findings of airway compromise: inability to assume a supine position. 6. 2.Continued«. 4. Surgeon must decide the need. timing and method to establish an emergency airway .

Administration of intravenous antibiotics without drainage of pus may not allow for resolution of an abscess Starting antibiotic therapy without Gram's stain and cultures may result in failure to identify pathogens Important to drain all primary spaces as well as explore and drain potentially involved secondary spaces CT scans may help identifying spaces involved Panorex can help identify putative teeth involved . 4.  Surgical drainage 1.Continued«. 3. 5. 2.

retropharyngeal. sublingual and vestibular abscesses are drained intraorally Masseteric.Continued«. 3. and buccal space abscesses may mandate extraoral incision and drainage Technique: Small incision are made in a dependent area Placement of a hemostat in the abscess cavity with entry into all loculations of the abscess Penrose drains inserted into cavity to allow for postoperative drainage of the abscess .     1. 2. pterygomandibular. submandibular. submental. Canine. and lateral pharyngeal space abscesses can be drained with combination intraoral and extraoral drainage Temporal.

 Medical support of the patient 1. 3. 2.Continued«. trismus. and swelling can be addressed by appropriate analgesia and treatment of underlying infection . Rehydrate patient as dehydration may be present Treat conditions that predispose patient to infection (DM) Correct electrolyte disturbances Oral pain. 4.

3.Continued«. 2.  Identification of etiologic bacteria 1. Expected causes are alpha hemolytic streptococci and oral anaerobes Cultures should be performed on all patients undergoing incision and drainage and sensitivities ordered if patient is not progressing well (possible antibiotic resistance) An aspirate of the abscess can be performed and sent for culture and sensitivities if incision and drainage delayed .

Continued«. 2. 6. Parenteral penicillin Metronidazole in combination with penicillin can be used in severe infections Clindamycin for penicillin-allergic patients penicillinCephalosporins (first-generation cephalosporins) (firstAntibiotics do not substitute for incision and drainage in cases of significant odontogenic infections Causes for clinical failure include inadequate drainage or antibiotic resistance Mediastinal involvement should prompt CT scan of the chest and cardiothoracic surgery consultation . 4. 5. 7.  Selection of antibiotic therapy 1. 3.

extraction tooth #31  Parenteral antibiotics  Eventually. extubated after resolution FOM edema  D/c on oral antibiotics with followfollow-up with oral surgery address remaining teeth  .  External I and D and Cx.Case continued«. Patient taking to OR for a flexible fiberoptic intubation with standby tracheostomy equipment available.

Ludwig·s Angina .

Conclusions     Most odontogenic infections are caused by anaerobes Identify possible complications of odontogenic infections Antibiotics may not sufficient and incision and drainage of these abscesses may be necessary for resolution Extracting the causative tooth facilitates the resolution of the infection .

Bibliography    Anatomy:http://www. http://www. Odontogenic Infections.sadanet.za/dhw/owne rs_manual/anatomy1.html Cummings Otolaryngology: Head and Neck Surgery. Images LA.co.html .org/afp/990700ap/109. Chapter 67.aafp.

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