CHAPTER 17: COMPLEX ODONTOGENIC INFECTIONS

ppt

complex odontogenic infections

are severe dental infections that spread beyond local areas, involve deep fascial spaces, and may lead to potential systemic or life-threatening complications.

fascia

thin casing of connective tissue beneath the skin

• surrounds and holds in place:

  • organs, bones

  • blood vessels

  • nerve fibers, muscles

• deep spaces of the head and neck

  • fascia-lined spaces containing loose areolar connective tissue

  • these are “potential” spaces

    • only become actual spaces when invaded by bacteria

primary spaces

vestibular

canine / infraorbital

buccal

infratemporal

submandibular

submental

sublingual

secondary spaces

submasseteric / masseteric

pterygomandibular

superficial / deep temporal

parapharyngeal

retropharyngeal

danger

prevertebral

periorbital

vestibular space

• location:

  • lies between cortical bone and mucoperiosteum

• most common site

  • for spread of dental infections that break out of alveolar bone

• path of least resistance is determined by

  • thickness of bone in relation to the root apex

  • relationship of bone perforation to muscle attachments

• Infections from maxillary and mandibular teeth almost always begin in this space

• its infection may spread to:

  • canine / infraorbital space → maxilla

  • space of the body of the mandible → mandible

canine / infraorbital space

• Infections from:

  • Buccal roots of teeth, or

  • Teeth with root apices positioned more buccally

• Usual pathway:

  • Vestibular space → canine/infraorbital space

• location:

  • lies between levator anguli oris and levator labii superioris muscles

  • boundaries:

    • quadratus labii superioris muscle

    • levator anguli oris muscle

    • nasal cartilages

    • oral mucosa

• manifestation of infection:

  • swelling of vestibule, upper lip, lower eye lid

  • obliteration of the the nasolabial fold

clinical significance of canine / infraorbital space

• Most commonly affected by infections from the long root of the maxillary canine.

• Canine space infection occurs when infection from the maxillary canine apex perforates the alveolar bone:

  • Superior to the attachment of the levator anguli oris

  • Inferior to the origin of the levator labii superioris

• May also develop by extension from an adjacent buccal space infection.

• Infraorbital space infections may similarly spread directly into the buccal space.

• Infraorbital space abscesses often drain near the:

  • Medial canthus

  • Lateral canthus

dental source of canine / infraorbital space / periorbital

mx canines or incisors

periorbital space

• location:

  • lies between orbicularis oris and orbital septum

    
    

• manifestation of infection:

  • redness and swelling of eyelid → obstruct vision

buccal space

• location:

  • lies between buccinator and skin

  • location of the buccal pad

  • boundaries:

    • superficial: overlying skin and subcutaneous tissues

    • deep: buccinator muscle

• manifestation of the infection:

  • marked cheek swelling

  • skin irregularities over the zygomatic arch

  • its infections commonly drain spontaneously through the skin at the inferior border of the mandible.

  • this produces an orocutaneous fistula / sinus tract.

• If untreated, these relatively simple infections may spread to the deep fascial spaces of the neck, resulting in significant patient morbidity.

clinical findings of buccal space

• there may be skin irregularities over the zygomatic arch because:

  • fascial layers superficial to the arch are tightly bound to the bone.

  • these layers become superficially edematous.

• if there is no extension into adjacent spaces:

  • zygomatic arch usually remains palpable.

  • inferior border of the mandible usually remains palpable.

dental source of buccal space

mx-mn premolars or molars

infratemporal space

a potential fascial space that may be involved in the spread of maxillary odontogenic infections

• location:

  • posterior to the maxilla

  • continuous laterally and superiorly with the deep temporal space.

  • boundaries:

    • medial: lateral pterygoid plate of the sphenoid bone

    • superior: base of the skull

  • important structures

    • branches of the internal maxillary artery

    • pterygoid venous plexus

clinical significance of infratemporal space

the pterygoid plexus provides emissary veins that pass through foramina in the skull base and connect with intracranial dural sinuses.

because veins of the head and neck lack valves, bacteria can propagate retrogradely.

infection reaching the pterygoid plexus may travel directly to the cavernous sinus.

• due to its deep location, infratemporal space infections are difficult to adequately examine clinically.

  • temporal fullness may be visible.

dental source of infratemporal space

mx 3rd molars

mx sinusitis of odontogenic origin

• periapical infections from maxillary teeth may:

  • erode superiorly

  • penetrate the floor of the maxillary sinus

  • cause maxillary sinusitis

  • potentially spread to neighboring sinuses

• causes:

  • iatrogenic, traumatic

  • implant-related

  • periapical osteitis

  • endodontic foreign bodies

  • restorative materials

  • bone grafting materials

  • retained tooth or bone fragments

schneiderian membrane

any violation of this membrane may precipitate maxillary sinusitis.

• may occur through:

  • spread of a periapical infection

  • penetration by a dental implant

  • iatrogenic injury from sinus membrane elevation for bone graft placement

• common clinical findings

  • facial pain

  • postnasal discharge

  • congestion

common bacteria associated with odontogenic mx sinusitis

• anaerobic gram-negative

  • Streptococcus

  • Peptostreptococcus

  • Fusobacterium

• aerobic gram-negative

  • Streptococcus

  • Staphylococcus

• less common but more difficult to treat:

  • Aspergillus species

spread of odontogenic mx sinusitis

• Acute odontogenic sinusitis may:

  • Propagate through the ethmoid sinus

  • Spread to the periorbital space

• Preseptal cellulitis:

  • Infection of the eyelid structures anterior to the orbital septum.

  • May occasionally progress to orbital cellulitis.

• Spread to cavernous sinus

  • Infection can spread freely because the veins of the head and neck have no valves.

  • Possible routes include:

    • Infraorbital vein → infraorbital space

    • Inferior ophthalmic vein

    • Via the sinuses → common ophthalmic vein → superior orbital fissure → cavernous sinus

  • Spread to the cavernous sinus can cause cavernous sinus thrombosis.

    • Can be fatal even with optimal medical and surgical management.

• surgical management:

  • open sinus surgery

  • functional endoscopic-assisted sinus surgery

perimandibular space

submental

ssublingual

submandibular spaces

described by Grodinsky and Holyoke

submental space

swelling at below the chin between anterior bellies of digastric

becomes involved as an extension of the submandibular space infections due to no true barrier

• spread

  • The only anterior barrier of the submandibular space is the anterior belly of the digastric muscle

  
  

dental source of submental space

mn incisor

sublingual space

commonly the first deep fascial space involved in mandibular odontogenic infections

• boundaries:

  • floor of the mouth, submucosa, mylohyoid muscle

• clinical findings:

  • elevation of the tongue

  • elevation of the floor of the mouth

  • difficulty with speech

  • difficulty swallowing

  • there should be no noticeable extraoral swelling because the infection is limited to an area cephalad to the mylohyoid muscle.

• important feature:

  • isolated sublingual space infection without simultaneous submandibular involvement is unusual.

  • reason:

    • sublingual space has no posterior boundary

    • it freely communicates with the submandibular space

  
  

dental source of sublingual space

mn incisor, canine, premolar or 1st molar (roots above mylohyoid muscle)

submandibular space

• location:

  • below the mylohyoid muscle and superficial layer of deep cervical fascia

  • occurs caudal to the mylohyoid muscle.

  • therefore, the only barriers between the abscess cavity and skin are:

    • superficial layer of deep fascia (SLDF), platysma muscle

    • boundaries:

      • inferior border of the mandible

      • anterior belly of digastric

      • posterior belly of digastric

• clinical findings:

  • almost always presents with visible extraoral swelling (submandibular triangle)

  • 
    

dental source of submandibular space

occurs caudal to the mylohyoid muscle.

mn 2nd or 3rd molar (roots below mylohyoid muscle)

unlike the sublingual space, it almost always presents with visible extraoral swelling.

determining the space of spread

• infection perforating the lingual cortex cephalad/superior to the mylohyoid attachment:

  • → sublingual space

• infection perforating the lingual cortex inferior/caudal to the mylohyoid attachment:

  • → submandibular space

ludwig's angina

a life-threatening cellulitis involving ALL perimandibular spaces

• clinical findings:

  • elevates floor of mouth

  • displaces the tongue upwards and backwards

  • blocks oropharynx compromises the airway

• other clinical findings:

  • firm swelling, trismus

  • dysphagia, dysphonia

  • globus sensation

  • “hot potato” voice

• when all 3 regions are involved, there are actually five spaces:

  • 2 submandibular spaces

  • 2 sublingual spaces

  • 1 submental space

• tx:

  • hospitalization (surgical intervention with I&D)

  • aggressive antibiotic therapy (ampicillin-sulbactam)

  • airway management (ex: tracheal intubation, tracheostomy)

masticator space

deep temporal

pterygomandibular

superficial temporal spaces

masseteric or submasseteric

mnemonic: TIME (temporalis, internal/medial pterygoid, masseter, external/lateral pterygoid)

submasseteric / masseteric space

lies between masseter and ascending ramus

dental source: impacted mn third molars

major pathway of spread in ludwig’s angina

submandibular space →

buccopharyngeal gap →

pterygomandibular space →

lateral pharyngeal space →

retropharyngeal space

an infected mandibular angle fracture

another common cause of infections in submasseteric and masseteric space

superficial & deep temporal spaces

• superficial temporal space

  • presents with lateral “hourglass” facial swelling

  • formed by the temporalis fascia and temporalis muscle

• deep temporal space

  • formed by the temporalis muscle and calvarium

dental source of superficial & deep temporal spaces

mx second or third molar

pterygomandibular space

• location:

  • lies between the medial pterygoid muscle and mandibular ramus

  • boundaries:

    • buccal space, parotid gland

    • pterygoid muscle

    • inferior border of mandible

    • medial pterygoid muscle

    • ascending ramus of mandible

    • 
      

• contains:

  • inferior alveolar nerve

  • inferior alveolar vessels

• critical clinical feature:

  • trismus → due to involvement of the medial pterygoid muscle

• high risk!

  • due to its close proximity to the lateral pharyngeal space

dental source of pterygomandibular & parapharyngeal space

mn 3rd molars due to pericoronitis

deep cervical fascial spaces of the neck

danger

parapharyngeal

retropharyngeal

prevertebral spaces

parapharyngeal

aka: lateral pharyngeal space

an inverted triangle-shaped space

• location:

  • between masticator space anteriorly & retropharyngeal space posteriorly

• possible routes of infection:

  • any extension posteriorly from the:

    • pterygomandibular space

    • sublingual space

    • submandibular space

• very high risk!

  • due to its close proximity to the retropharyngeal space

dental source of retropharyngeal & danger

mn molars

manifestation of parapharyngeal space

• intraoral:

  • edema on the superior constrictor muscle resulting in bulging of the oropharynx

• extraoral:

  • swelling of the lateral neck (inability to visualize and palpate the angle of the mandible)

retropharyngeal space

located behind the posterior pharyngeal wall

extends from the base of the skull to the mediastinum

• very high risk!

  • acts as a “highway” for infection spread

• contents:

  • loose areolar connective tissue

  • lymph node

• complications:

  • erosion of the carotid artery wall

  • thrombosis of the internal jugular vein (IJV)

  • impingement on cranial nerves IX, X, and XII

    • IX – glossopharyngeal nerve

    • X – vagus nerve

    • XII – hypoglossal nerve

danger space

• location:

  • between alar fascia anteriorly & prevertebral fascia posteriorly

• extends from the base of the skull to the posterior mediastinum and diaphragm

• extremely high risk!

  • acts as a “highway” for infection spread from the retropharyngeal space

prevertebral space

rarely involved in odontogenic infections.

• reason:

  • prevertebral fascia is tightly adherent to the vertebrae.

• a rare prevertebral space infection may occur with vertebral osteomyelitis

complications of prevertebral space

mediastinitis

neural compression

compression of the heart and lungs

rupture of esophagus, lungs, lower airway

interrupted cardiovascular and respiratory systems

primary goals of management of fascial space infections

medical optimization

airway protection (general endotracheal intubation or surgical airway, cricothyrotomy or tracheotomy)

removal of the source of infection

surgical incision and drainage

adjunctive antibiotic therapy

frequent assessment of response to therapy

specific infections

candidiasis

actinomycosis

cavernous sinus thrombosis

cervical necrotizing fasciitis

osteomyelitis (acute-chronic suppurative, chronic sclerosing, garre’s)

cavernous sinus thrombosis

one of the most severe complications of a maxillary odontogenic infection

a rare, life-threatening condition where a blood clot (thrombus) forms in the cavernous sinus

• usually a late complication of:

  • infection of the central face

  • paranasal sinus infections

• other causes:

  • extraction of mx anterior teeth in the presence of an acute infection

• tx:

  • mainstay is aggressive antibiotic administration

cavernous sinuses

are intracranial compartments that serve as bilateral venous drainage channels for the middle cranial fossa

contents of the cavernous sinus

internal carotid artery

cranial nerves II, III, IV, VI

2nd division of cranial nerve V

cervical necrotizing fasciitis

aka: “flesh-eating” bacterial infection

a soft tissue infection characterized by widespread tissue death involving several fascial spaces

• unique characteristic:

  • does NOT follow the normal fascial planes of the head and neck

• affects the investing layer of the deep cervical fascia, deep to the platysma muscle

• tx:

  • removal of the offending source

  • aggressive surgical debridement

  • empiric antibiotics

  • medical optimization

osteomyelitis

more common in the mandible

Defined as inflammation of bone

predominant bacteria → staphylococcus

an infection or inflammation of the bone marrow (origin: medullary spaces)

• classifications:

  • suppurative (acute, chronic, infantile)

  • non-suppurative (chronic sclerosing [focal-diffuse], garre’s)

  
  

acute suppurative osteomyelitis

infection of the medullary bone with purulence

• causes:

  • bacteremia

  • extension of periapical abscess

  • osteoradionecrosis (ORN) or medication-related osteonecrosis of the jaw (MRONJ)

  • physical injury:

    • fracture, surgery

• clinical findings:

  • pain → primary feature

  • lower lip paresthesia

  • lymphadenopathy

• radiographic findings:

  • moth-eaten appearance

  • not visible unless approximately 60% of the bone is demineralized

• tx:

  • debridement of necrotic bone

  • aggressive antibiotic therapy

  • drainage of pus

sequestrum

a dead bone surrounded by granulation tissues

involucrum

reactive new bone formation

cloaca

the draining sinus

chronic suppurative osteomyelitis

treated in a manner similar to the acute form with removal of the source of the infection

• causes:

  • a sequela of acute osteomyelitis

  • may represent a long-term, low-grade inflammatory reaction

• clinical findings:

  • pain → primary feature

  • lower lip paresthesia

  • lymphadenopathy

• radiographic findings:

  • moth-eaten appearance

  • not visible unless approximately 60% of the bone is demineralized

• tx:

  • culture and sensitivity testing of bone biopsy

  • aggressive debridement of necrotic bone

    • may involve large segments of the jaws

  • high-dose IV antibiotics (6 weeks of outpatient IV antibiotics)

  • chronic, unresponsive cases may require 6 months or more of IV antibiotics.

diffuse chronic sclerosing osteomyelitis (non-suppurative)

a low-grade inflammatory reaction in the maxilla and mandible

causes: bacteria, chronic periodontal disease

focal chronic sclerosing osteomyelitis (non-suppurative)

aka: focal sclerosing osteitis, bony scar, condensing osteitis

common to young adults

a common phenomenon, usually seen at the apex of a tooth with long-standing, low-grade pulpitis

• radiographic appearance:

  • increased radiopacity

• tx:

  • no treatment (physiologic bone reaction)

osteomyelitis with proliferative periostitis (non-suppurative)

aka: garre’s osteomyelitis

• a chronic disease that usually affects children

  • due to their increased vascularity and regenerative capabilities

• radiographic findings:

  • onion-skin appearance

  • due to paracortical bone formation from repetitive irritation of the periosteum

  • usually associated with a mild, long-standing periapical tooth infection

• tx:

  • removal of the offending infectious source

  • short course of antibiotic therapy (penicillin, tetracycline, clindamycin)

  • long-term antibiotic therapy is not indicated.

actinomycosis

a chronic but relatively uncommon infectious process affecting the maxillofacial skeleton

• clinical findings:

  • induration with nodular fibrosis

  • intermittent spontaneous drainage tracts

  • forms a fistula to the cutaneous skin surface

  • presence of sulfur granules

    • small yellow bodies found in the pus of actinomycotic infections

• tx:

  • surgical removal of the infection

  • long-term oral penicillin therapy

  • if allergic to penicillin:

    • doxycycline

    • clindamycin

actinomyces israelii (anaerobic bacteria)

causative agent of actinomycosis

this organism usually causes no pathologic signs, it must seed itself in an area of susceptibility in order to flourish such as:

• injured site

• area of fracture

• tooth extraction site

• other traumatic area

candidiasis

most common fungal disease evaluated by dentists

candida albicans → an endogenous organism normally present in the mouth

occurs in the presence of an altered host defense system (ex: immunocompromised patients)

• diagnosis:

  • Traditionally:

    • Skin/mucosal scraping

    • Smear with 20% potassium hydroxide (KOH)

    • Microscopy may reveal:

      • Hyphae

      • Pseudohyphae

  • Limitation:

    • Unreliable because it typically does not demonstrate tissue invasion.

  • More reliable:

    • Tissue biopsy + periodic acid–Schiff (PAS) staining

    • Demonstrates tissue invasion.

• tx:

  • elimination of contributing local or systemic factors

  • topical therapies such as:

    • nystatin oral suspension

    • clotrimazole troches

3 most common forms of candidiasis

pseudomembranous candidiasis

erythematous candidiasis

angular cheilitis

pseudomembranous candidiasis

distinct white patches that can be wiped off easily exposing an underlying erythematous surface

erythematous candidiasis

appears to be a raw surface, such as that seen with the loss of filiform papillae of the tongue

angular cheilitis

appears as white ulcerated patches in the corners of the mouth

• associated with;

  • px with occlusal vertical dimension problems

  • edentulous px without appropriate prosthodontic support

  • px with dentures having inadequate:

    • vertical dimension, “freeway” space

• Chronic moisture at the corners of the mouth provides an optimal environment for Candida overgrowth.

• clinical findings:

  • erythema

  • white patches at the commissures often bilateral

  • often accompanied by Staphylococcus aureus infection.

• nutritional deficiencies:

  • folic acid deficiency

  • iron deficiency

  • riboflavin deficiency

  • thiamine deficiency

  • vitamin B12 deficiency

• tx:

  • nystatin oral suspension