CELLULITIS

DR.AMITHBABU.C.B MScD-ENDO

‡ ‡ ‡ ‡ ‡ ‡ ‡

INTRODUCTION CAUSES CLINICAL FEATURES COMPLICATIONS INVESTIGATION MANAGEMENT CASE REPORT

INTRODUCTION
‡ 1Cellulitis may be defined as a non suppurative inflammation of the of the subcutaneous tissues extending along the connective tissue plane and across the intercellular planes. ‡ It is also called as phlegmon. ‡ It is a potential complication of dental infection

1Text

book of oral pathology ,Anil Ghom, first edition-2009, page no: 449

‡ 2Today we know that serious odontogenic infections, beyond the tooth socket, are much more common as a result of endodontic infections than as a result of periodontal disease. ‡ The seriousness of an infection beyond the apex of a tooth depends on the number and virulence of the organisms, host resistance, and anatomic structures associated with the infection. ‡ Once the infection has spread beyond the tooth socket, it may localize or continue to spread through the bone and soft tissue as a diffuse abscess or cellulitis.
2Endodontics

, john ingle5 edition ,page no:69

‡ 3The terms abscess and cellulitis are often used interchangeably in common clinical use. ‡ An abscess is a cavity containing pus (purulent exudate) consisting of bacteria, bacterial byproducts, inflammatory cells, numerous lysed cells, and the contents of those cells. ‡ Cellulitis is a diffuse, erythematous, mucosal, or cutaneous infection that may rapidly spread into deep facial spaces and become life threatening.
3Endodontics

, john ingle 5 edition ,page no:69

‡ 4As a diffuse Cellulitis matures, it may contain foci of pus consistent with an abscess. ‡ The relationship of specific species of bacteria or aggregates of bacteria with the pathogenesis of endodontic abscesses/cellulitis has not been established. ‡ Endodontic infections occur when opportunistic pathogens gain access to the normally sterile dental pulp and produce disease. ‡ Infections of the root canal system may spread to the contiguous periradicular tissues.
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Endodontics , john ingle5 edition ,page no:69

‡ 5If bacteria from the infected pulp tissue gain entry into the periradicular tissue and the immune system is unable to suppress the invasion ,an other wise healthy patient eventually shows signs and symptoms of an acute periradicular abscess, cellulitis or both ‡ Depending on the relationship of the apices of the involved tooth to the muscular attachments ,the swelling may be localized to the vestibule or may extend into the fascial space.
5Pathways

of the pulp stephen cohen 9 edition , page no:591

CAUSES
‡ 6Streptococci are particularly potent producers of hyalurouidase and are therefore a common causative organism in cases of cellulitis. The less common hyaluronidase producing staphylococci are also pathogenic and frequently give rise to cellulitis.

6Shafer

s text book of oral pathology, 5 edition ,page no:697

of the face and neck most commonly results from dental infection, either as sequel of an apical abscess or osteomyelitis, or following periodontal infection. ‡ The pericoronal infection occurring around erupting or partially impacted third molars and resulting in cellulitis and trismus is an especially common clinical condition. ‡ Sometimes cellulitis of the face or neck will occur as a result of infection following a tooth extraction, injection, either with an infected needle or through an infected area, or following jaw fracture. ‡
7Shafer

7Cellulitis

s text book of oral pathology, 5 edition ,page no:697

CLINICAL FEATURES
‡ 8The patient with cellulitis of the face or neck originating from a dental infection is usually moderately ill and has elevated temperature and leukocytosis. ‡ One feels painful swelling of the soft tissues. ‡ Much of the swelling is due to inflammatory edema.
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Shafer s text book of oral pathology, 5 edition ,page no:697

‡ 9There is wide spread swelling ,redness and pain with out definite localization. ‡ Tenderness on palpation. ‡ Tissues are grossly edematous. ‡ Marked induration ‡ Tissues are firm to hard on palpation. ‡ Tissues are often discolored. ‡ Malaise ‡ lethargy
9Text

book of oral pathology ,Anil Ghom, first edition-2009, page no: 449

of the lymph nodes Large diffused border of the swelling making it difficult to determine where the swelling begins and ends. ‡ Palpation early cellulitis soft and tough Severe cellulitis firm ‡ As the typical facial cellulitis persists, the infection frequently tends to become localized and a facial abscess may form. When this happens the suppurative material present seeks to 'point' a out discharge upon a free surface . ‡
10

10Swelling

Shafer s text book of oral pathology, 5 edition ,page no:697

‡ 11Swelling develops rapidly ‡ The skin of swelling pits on pressure ‡ Swelling becomes red as the inflammation becomes localized . ‡ Pain may be sharp and acute , later deep, throbbing in character, it may increase while pus is formed and subside when the abscess ruptures or is incised.

11Oral

and dental diagnosis , Thoma kurt, 2 revised edition., page no:406

CLINICAL PICTURE

Buccal cellulitis

SPREAD OF INFECTION
‡
12Infections

arising in the maxilla perforate the outer conical layer of bone above the buccinator attachment and cause swelling, initially of the upper half of the face. The diffuse spread, however, soon involves the entire facial area.

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Shafer s text book of oral pathology, 5 edition ,page no:700

SPREAD OF INFECTION IN MAXILLAE
TOOTH AREA

CENTRAL AND LATERAL INCISOR

Labial ,palatal abscess or vestibular abscess. Sometimes may form within the lip. Enlarged upper lip protrudes Labial or vestibular. canine space abscess. Abscess along buccal or palatal side Swelling of cheek, edema of eye, pulling of corner of eye, obliteration of nasiolabial sulcus. Buccal or palatal surface

CANINE PREMOLARS MOLARS

Shafer s text book of oral pathology, 5 edition ,page no:700

Maxillary buccal vestibule

Para pharyngeal space

13Pathways

of pulp , Stephen cohen,9 edition, page no;593

SPREAD OF INFECTION IN MANDIBLE
‡ infection in the mandible perforates the outer cortical plate below the buccinator attachment, there is a diffuse swelling of the lower half of the face, which then sees a superior as well as cervical spread. Spread to the cervical tissue cause respiratory discomfort.
14When

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Shafer s text book of oral pathology, 5 edition ,page no:700

SPREAD OF INFECTION IN MANDIBLE
TOOTH CENTRAL AND LATERAL INCISORS CANINE PREMOLARS AREA Labial surface and into the chin. Labial or vestibular abscess vestibular abscesses, and lingual perforation may form sublingual abscesses More commonly on buccal surface ,to lower border of mandible,and into floor of the mouth. More commonly on buccal surface ,to lower border of mandible into submaxillary space. Buccal surface,angle of mandible,and into submaxillary space.

1 MOLAR

2 MOLAR

3 molar

Mandibular buccal vestibule ‡ 15Source of infection from mandibular anterior or posterior tooth breaks through the buccal cortical plate and or apices of involved tooth.

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of pulp , Stephen cohen,9 edition, page no;593

Mental space

Submental space

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of pulp , Stephen cohen,9 edition, page no;594

Sublingual space
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Submandibular

of pulp , Stephen cohen,9 edition, page no;594

Submasseteric space

Buccal vestibule

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of pulp , Stephen cohen,9 edition, page no;594

COMPLICATIONS
from the mid face can be dangerous because they can result in cavernous sinus thrombosis . ‡ If the submental,sublingual and submandibular spaces are involved at the same time, a diagnosis of ludwigs angina is made. ‡
19Infections

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of pulp , Stephen cohen9 edition , page no; 593 and 596

‡

cellulitis is a rare but serious sequel of infection from a dental origin. Without prompt treatment, further spread of infection is likely to occur, resulting in loss of vision and possibly death.

20Orbital

report: dental infection leading to orbital cellulitis, Department of Oral and Maxillofacial Surgery, King's College Hospital, London, UK. 1. Dent Update. 2006 May;33(4):217-8, 220

20Case

LUDWIG'S ANGINA
s angina is a severe form of cellulitis, beginning usually in the submaxillary space and secondarily involving the sublingual and submental spaces as well. ‡ The chief source of infection is involvement of a mandibular molar, either periapical or periodontal, and it may also result from a penetrating injury of the floor of the mouth such Stab wound, or from osteomyelitis in a compound jaw fracture. ‡
21Shafer

21Ludwig

s text book of oral pathology, 5 edition ,page no:697

cellulitis in some cases may damage the hypoglossal, vagal, glossopharyngeal and recurrent nerves of both sides. ‡ 23Orbital cellulitis is also caused as a result of odontogenic infection. ‡
acute cellulitis with severe neurological sequelae. A clinical case. Mallagray R, Betoret J, Navarro Cuellar C, Minerva Stomatol. 1999 Apr;48(4):161-4.
22Diffuse

22Acute

cellulitis as a sole symptom of odontogenic infection. Ngeow WC. Singapore Med J. 1999 Feb;40(2):101-3.

23Orbital

COMMON FEATURES CELLULITIS AND PERICORONITIS
‡ ‡ ‡ ‡ ‡ ‡ ‡ Severe pain Extra oral swelling Fever Malaise Dehydration Difficulty in opening the mouth(depends) Lymphadenopathy
Shafer s text book of oral pathology, 5 edition ,page no:697.698 Carranza 's clinical periodontology,10th edition,, pg no 400,401

CELLULITIS
Most commonly associated with carious tooth. Clinical features Non Radiating pain Less frequently with restricted mouth opening

PERICORONITIS
Most commonly associated with unerupted third molar. Clinical features Radiating pain Foul order Most frequently associated with restricted mouth opening

Shafer s text book of oral pathology, 5 edition ,page no:697.698 carranza 's clinical periodontology,10th edition,, pg no 400,401

CELLULITIS AND PERICORONITIS

INVESTIGATION
facial involvement usually requires a panoramic Xray plus lateral cephalogram to exclude subjacent osteomyelitis, dental pathologies. ‡ 25The reaction to the infection may occur very quickly , the involved tooth may or may not show radiographic evidence of a widened periodontal ligament space. ‡ Sometimes periapical radiograph are required to find out the involved tooth. ‡ 26ultrasound can be used as first line diagnostic tool in the management of fascial space infections. ‡
25Pathways
26Ultrasound

24In

of the pulp 9 edition , stephen cohen, page no:591

as First Line Diagnostic Tool in the Management of Acute Odontogenic Infection of Fascial Spaces Suprakash .Ba, Srinivas Chakravarthia

most cases the tooth elicits a positive response to percussion and the periradicular area is tender to palpation. ‡ 28Ultrasonography is used now a days to differentiate between abscess and cellulitis. ‡ Biopsy is seldom performed because of the painful and difficult surgery, which would not grossly change the management of the condition ‡ Complete blood count with differential usually demonstrates a slight leukocytosis with neutrophilia. ‡
27Pathways

27In

of the pulp 9 edition , stephen cohen, page no:591

evaluation of inflammatory swellings of buccal space, Srinivas K, Sumanth KN, Chopra SS. Indian J Dent Res. 2009 Oct-Dec;20(4):458-62.

28Ultrasonographic

DIAGNOSIS
‡ Diagnosis can be made from the History Clinical examination X ray Blood culture

MANAGEMENT
most important elements of effective patient management are correct diagnosis and removal of the cause of endodontic infection . ‡ In an otherwise healthy patient , chemomechanical debridement of the infected root canal and incision for drainage of periradicular swelling usually prompt rapid improvement in clinical signs and symptoms. ‡
29The

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of the pulp 9 edition , stephen cohen, page no:596

‡

recommended , in conjunction with appropriate endodontic treatment , for progressive or persistent infections with systemic signs and symptoms such as fever(1000F[37.80C]), malaise, cellulitis, unexplained, and progressive or persistent swelling or both. ‡ 30Antibiotics are given to control infection, and analgesics may be needed to control pain.

30Antibiotics are

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of the pulp 9 edition , stephen cohen, page no:596

FIRST LINE CLASS 1 Flucloxacillin 500mg qds po

SECOND LINE Pencillin allergy: Clarithromycin 500mg bd po Pencillin allergy: Clarithromycin 500mg bd IV or Clindamycin 600mg tds IV Pencillin allergy: Clarithromycin 500mg bd IV or Clindamycin 900mg tds IV

Class 11

Flucloxacillin 2g qds IV OR Ceftriaxone 1g qds IV (OPAT) Flucloxacillin 2g qds IV

Class 111

Benzylpencillin 2.4 g 2-4 hourly IV+ Ciprofloxacin 400mg bd IV+ Clindamycin 900mg tds IV((If allergic to penicillin use Ciprofloxacin and Clindamycin only) Odontogenic Neck Infections, Mir Hasan Shaheel Mahmood TAJ June 2005; Volume 18 Number 1,
Cellulitis, Morton N. Swartz, M.D. n england journal med 350;9www.nejm.org february26, 2004,

Class 1V

SURGICAL INCISION AND DRAINAGE
is performed when the presence of pus is diagnosed.Its done in case of large cellulitis , a superficial erythematous spot develops, which is pathognomic of pus near the superficial surface. ‡ These superficial fluctuant areas can be incised and drained . ‡ Surgical knife is introduced in the most inferior portion of fluctuant area. ‡
31It

31Text

book of oral pathology ,Anil Ghom, first edition-2009, page no: 450

small sinus forceps is introduced in the wound, opened in several directions and drained. ‡ A rubber drain is placed in the deepest portion of the wound, so that just 12 cm lie above the source of the skin, where it is sutured. ‡ When no superficial spot is present,fluctuance is more difficult to determine ,particularly if deep pus is suspected.usually ,extraction of the offending tooth and specific antibiotic cover bring about resolution of the process. ‡

32A

32Text

book of oral pathology ,Anil Ghom, first edition-2009, page no: 450

‡ is important to provide a pathway of drainage to prevent further spread of the abscess and/or cellulitis. ‡ An incision for drainage for allows decompression of the increased tissue pressure associated with edema and provides significant pain relief. ‡ The incision provides a pathway not only for bacteria and bacterial byproducts but also for the inflammatory mediators associated with the spread of cellulitis.
33It

33Pathways

of the pulp 9 edition , stephen cohen, page no:596

inhibitory concentration of antibiotic may not reach the source of infection because of the decreased blood flow and because the antibiotic must diffuse through the edematous fluid and pus. ‡ Drainage of edematous fluid and purulent exudate improves circulation to the tissues associated with an abscess and cellulitis , providing better delivery of the antibiotic to the area . ‡

34An

34Pathways

of the pulp 9 edition , stephen cohen, page no:596

‡

Submaxillary abscess- center round the submaxillary lymph nodes ,which may be involved and break down. A rubber dam drain should be inserted into this area,and fastened with a suture to the end of the skin. ‡ Sublingual abscess- forming the infection of the posterior teeth are either drained by intra oral incision , or from an incision at the lower border of mandible.some times two drains are needed to drain all the involved areas.

35

35Oral

and dental diagnosis ,Thoma kurt, 2 revised edition, page no:418, 419

36Incision of

sub mental,and sub maxillary with parapharyngeal abscess
36Oral

Evacuation of pus from sub maxillary abscess

and dental diagnosis ,Thoma kurt, 2 revised edition, page no:205, 418

ENDODONTIC MANAGEMENT
‡ should be completed as soon as possible after the incision for drainage. The drain usually can be removed 1-2 days after improvement is noted in clinical signs and symptoms. If no significant improvement occurs, the diagnosis and treatment must be reviewed carefully. ‡ Consultation with specialist and referral may be indicated for sever infection or persistent infection
37Pathways

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of the pulp 9 edition , stephen cohen, page no:596

CASE REPORT-1

ORBITAL CELLULITIS AS A SOLE SYMPTOM OF ODONTOGENIC INFECTION

W C Ngeow
Singapore Med J 1999; Vol 40(02):
http://www.sma.org.sg/smj/4002/articles/4002cr1.html

INTRODUCTION
‡ Orbital and periorbital cellulitis are uncommon conditions which develop as a complication of infection of the paranasal sinuses, trauma to the eyelids or infection of the external ocular region. ‡ Infection of the paranasal sinuses usually happen at the ethmoidal and frontal sinuses, and occasionally the maxillary sinus. ‡ Maxillary sinusitis could result from dental infection and the percentage varies considerably between 4.6% and 47.0%(2)

‡ The dental origin may be periapical infection of the maxillary tooth/teeth or as a complication of dental extraction. ‡ The manifestation of the spread of dental infection to the maxillary sinus has been termed the endoantral syndrome.

‡ Toothache may be the patient s only complaint. ‡ In orbital cellulitis originating from the infection of the extraction socket, the time interval between dental extraction and development of orbital symptoms ranged from two hours to thirteen days. ‡ Patient may present with fever, elevated leukocyte counts and radiographic evidence of acute ipsilateral paranasal sinus infection. ‡ On rare occasions, the patient may also present with signs and symptoms of meningitis. ‡ This paper presents a case where orbital cellulitis was the only symptom of odontogenic infection.

CASE REPORT

‡ A 51-year-old English lady was referred to the Department of Oral and Maxillofacial Surgery at the Queen Victoria Hospital for the management of a unilateral orbital swelling that had persisted for the past two days. ‡ The swelling was not tender though slightly reddish in colour (Fig 1). She had not experienced any trauma to the orbital region and she claimed that her vision was fine. She did not feel any discomfort at the right orbital or infra-orbital region

‡ Clinical examination revealed a soft swelling on her right orbital region, most obvious at the lower eye lid. ‡ It was oedematous and slightly reddish in colour. It was not tender to palpation. Her visual acuity and eye movement were normal.

‡ Intraoral examination revealed retained roots of the maxillary right first premolar and first molar. ‡ Gutta percha ends could be seen at the remaining coronal region of both teeth, indicating both teeth had undergone root canal treatment. ‡ Both teeth were slightly tender to percussion but no swelling could be palpated at the buccal sulcus or palatal region. ‡ An orthopantomogram (OPG) and a Walter s (occipitomental) radiographic view were taken. Both radiographs showed opacity of the right maxillary sinus.

‡ The Walter s view also showed radiopacity at the right lower orbital rim indicating a soft tissue swelling over the region (Fig 2).

‡ The OPG showed an obvious periapical lesion on the maxillary right first premolar. The periodontal ligament of the maxillary right first molar was widened. The root canal treatment of tooth showed inadequate working length (Fig 3).

‡ A diagnosis of periapical infection originating from the inadequately treated root canals resulting in unilateral sinusitis and eventual orbital cellulitis was made. ‡ The patient was prescribed 250 mg amoxycillin with 125 mg clavulanic acid mg for five days. She was reviewed the following week and the orbital cellulitis was no longer present. ‡ The roots of the maxillary right first premolar and first molar were no longer tender to percussion. As she was having dental treatment with a dental student, she was advised to have her root canal treatment to remove the source of infection.

DISCUSSION
‡ Accurate diagnosis is important as it allows for prompt treatment to prevent further complications of orbital cellulitis. Complications of maxillary dental infection include maxillary sinusitisand pansinusitis. ‡ On rare occasions, this may eventually lead to orbital cellulitis. Complication of orbital cellulitis includes neurological or ophthalmological problems. Its sequelae includes severe loss of vision, blindness with ptosis and extropia, cavernous sinus thrombosis, empyema and death.

‡ Antibiotic therapy alone was found to be effective in over 80% of patients with orbital and periorbital cellulitis in general. ‡ However, no study has been done to show the effectiveness of antibiotic therapy alone in treating orbital and periorbital cellulitis due to dental infection. ‡ The source of infection is the incomplete root canal treatment done on the tooth . As shown in this case, the orbital cellulitis was controlled with oral antibiotic. ‡ The patient however, was refered for the retreatment to remove the source of infection on the maxillary right first premolar.

‡ Radiograph is an important tool to confirm the diagnosis. ‡ As shown in this case, there was only slight tenderness of the retained roots when percussed. Radiographically, however, there was a radiopacity of the right maxillary sinus with a well defined periapical lesion of the first maxillary premolar. ‡ The periodontal ligament of the first maxillary molar was also widened. The root canals of both the teeth were also inadequately sealed. ‡ These findings confirmed the cause of the unilateral maxillary sinusitis and orbital cellulitis as of dental origin.

CONCLUSION
‡ Odontogenic infection may present as an orbital cellulitis. Medical practitioners should be thoroughly familiar with the manifestations of dental infection into the maxillary sinus and orbital area even though uncommon. ‡ Orbital cellulitis can lead to serious complications. One must suspect the maxillary tooth as a possible source of infection and prompt treatment with antibiotics is mandatory. Endodontic treatment should be performed where indicated to remove the source of infection.

CASE REPORT-2

LIFE-THREATENING ORO-FACIAL INFECTIONS
*E.K. AMPONSAH and 2P. DONKOR *1st Medical University named after Academic Pavlov, Saint Petersburg 197061. Russia Federation and formerly of Tarkwa Government Hospital, Tarkwa, Ghana 2Department of Surgery, School of Medical Sciences, Komfo Anokye Teaching Hospital, P.O. Box 1934, Kumasi, Ghana

March 2007 Volume 41, Number 1 GHANA MEDICAL JOURNAL

Case report-1
‡ A nineteen-year-old girl (Figure 1) was rushed to the Dental Department of Tarkwa Government Hospital after collapsing with rigors at home. A pharmacist or chemical seller had previously pre-scribed amoxycillin for her toothache and a swelling of the lower jaw. She had no significant medical history

‡ On arrival she was in respiratory distress, had a pulse of 180 beats per minute and a blood pressure of 110/40mmHg. Her axillary temperature was 40.5 degrees Celsius and her Glasgow Coma Score (GCS) was 10/15. ‡ There was an obvious right submandibular and submental swelling, with minor trismus. The tongue was elevated and was in contact with the palate making breathing, swallowing and feeding difficulty. ‡ A presumptive diagnosis of septic shock secondary to dental infection facial cellulitis was made.

TREATMENT
‡ She was admitted and treated with high flow oxygen, intravenous fluids, ceftriazone and metroni-dazole. ‡ Extraction of the involved tooth, together with an incision of submental region to drain the abscess under general anesthesia was undertaken three days after admission. Intraoperatively 20mls of pus was obtained. ‡ Staphylococcus aureus was subsequently isolated from the pus and blood culture. The patient was discharged from hospital seven days after surgery in satisfactory condition

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