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 space Molars-----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 submassetericspace is situated between the masseter muscle and the lateral surface of the mandibularramus. 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 retromolarfossa
Clinical Features • Infection of this space usually occurs from a mandibular third molar, the infection passing through the retromolarfossa 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 submandibularglandsialadenitis, 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 Tschiassnyinitial 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 pterygopalatinefossa. • 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 . • Fusiformbacilli and spiral forms, various staphylococci, diphtheroids and many other microorganisms have been cultured on different occasions.
Laboratory Findings • Prevotellamelaninogenicus,Prevotellaoralis, 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. Haymalterreviewed 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
Complications of Dental Infection • 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.
Cavernous Sinus Thrombosis ofThrombophlebitis • 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 ofThrombophlebitis • 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.