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

most common site for spread of dental infections that break out of alveolar bone

• location:

  • lies between cortical bone and mucoperiosteum

• path of least resistance is determined by

  • thickness of bone in relation to the root apex

  • relationship of bone perforation to muscle attachments

• 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

• boundaries:

  • between levator anguli oris and levator labii superioris muscles

• clinical findings:

  • 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

• occurs when infection from the mx canine apex perforates the alveolar bone:

  • superior to the attachment of the levator anguli oris

  • inferior to the origin of the levator labii superioris

• abscesses often drain near the:

  • medial canthus

  • lateral canthus

• may also develop by extension from an adjacent buccal space infection → may similarly spread directly into the buccal space

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 bc:

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

  • these layers become superficially edematous.

• if infection has not spread to adjacent spaces:

  • zygomatic arch, inferior border of the mandible usually remains palpable.

dental source of buccal space

mx-mn premolars or mx molars

infratemporal space

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

• location:

  • posterior to the maxilla continuous with deep temporal space (so infections involving one may also involve the other)

  • 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 finding:

  • temporal fullness may be visible

  • difficult to examine because of its deep location.

clinical significance of infratemporal space

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

• pterygoid plexus

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

  • the is the vein that pass through foramina in the skull base and connect with intracranial dural sinuses

• 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 → maxillary sinusitis → potentially spread to neighboring sinuses

• causes:

  • periapical osteitis

  • restorative materials

  • bone grafting materials

  • endodontic foreign bodies

  • retained tooth or bone fragments

  • iatrogenic, traumatic, implant-related

schneiderian membrane

any violation of this membrane may cause mx 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, congestion

  • postnasal discharge

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 → 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.

• tx:

  • open sinus surgery

  • functional endoscopic-assisted sinus surgery

perimandibular space

submental

ssublingual

submandibular spaces

described by Grodinsky and Holyoke

submental space

commonly affected by infections from mandibular incisor

• it develops as an extension of a submandibular space infection, why?

  • the anterior belly of the digastric muscle is the main anterior boundary of the submandibular space.

  • it is not a true barrier between the:

    • submandibular space-submental space

• spread across the midline:

  • infection from one submandibular space can pass through the submental space and reach the opposite submandibular space

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, floor of the mouth

  • difficulty with speech, swallowing

  • there should be no noticeable extraoral swelling bc the infection is limited to an area cephalad/superior to the mylohyoid muscle

• note:

  • has no posterior boundary → freely communicates with the submandibular space

  • therefore, isolated sublingual infection without submandibular involvement is uncommon!

  
  

dental source of sublingual space

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

submandibular space

• location:

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

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

    • platysma muscle

    • superficial layer of deep fascia (SLDF)

    • boundaries:

      • inferior border of the mandible

      • anterior & posterior belly of digastric

    • shape:

      • triangular space

• clinical findings:

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

• note:

  • has no posterior boundary.

  • freely communicates with deeper neck spaces, including:

    • pterygomandibular space

    • lateral pharyngeal space

  • therefore, infection can cause significant morbidity.

dental source of submandibular space

occurs caudal/below 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

• technically involves 5 spaces:

  • 2 sublingual, 2 submandibular, 1 submental

• intraoral clinical findings:

  • elevation of tongue, floor of mouth

  • bilateral fluctuant swelling (inf. border of mn → hyoid bone)

  • blocks oropharynx compromises the airway

• other clinical findings:

  • trismus, dysphagia, dysphonia

  • globus sensation, “hot potato” voice

  • inability to handle oral secretions

  • head held in forward “sniffing” position

• tx:

  • hospitalization (surgical intervention with I&D)

  • aggressive antibiotic therapy (ampicillin-sulbactam)

  • airway management (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

• boundaries:

  • masseter muscle

  • ascending ramus of the mandible

• dental source:

  • impacted mn third molars

• another common cause:

  • infected mandibular angle fracture

major pathway of spread in ludwig’s angina

submandibular space →

buccopharyngeal gap →

pterygomandibular space →

lateral pharyngeal space →

retropharyngeal space →

danger space →

mediastinum → mediastinitis

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

• boundaries:

  • 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

parapharyngeal

retropharyngeal

danger

prevertebral spaces

in order!

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 pushes the superior constrictor medially → causes bulging of the lateral oropharyngeal wall toward the midline which is called pharyngeal draping

• extraoral:

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

[is dangerous bc it is close to the airway, carotid sheath, cranial nerves]

retropharyngeal space

• location:

  • located behind the posterior pharyngeal wall

  • extends from the base of the skull to the mediastinum

  • boundaries:

    • anterior:

      • superior, middle, and inferior pharyngeal constrictor muscles

      • retropharyngeal fascia

    • posterior: alar fascia

    • superior: base of skull

    • inferior: usually between C6 and T4

• contents:

  • loose areolar connective tissue, lymph node

• very high risk!

  • acts as a “highway” for infection spread to danger space

• 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

  • boundaries:

    • anterior: alar fascia

    • posterior: prevertebral fascia

    • superior: skull base

    • inferior: diaphragm

• 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

  • infection in this space can spread far down toward the mediastinum

• remember: lateral pharyngeal → retropharyngeal → danger → mediastinum

prevertebral space

• rarely involved in odontogenic infections, why?

  • its fascia is tightly adherent to the vertebrae

• a rare 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

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

• possible route:

  • inferior ophthalmic vein → superior orbital fissure → cavernous sinus

• 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, V2, VI

cervical necrotizing fasciitis

aka: “flesh-eating” bacterial infection

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

• a soft tissue infection characterized by widespread tissue death involving:

  • necrosis of the platysma, skin, underlying soft tissues

• note:

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

  • polymicrobial, extremely destructive, potentially fatal

• tx:

  • removal of all affected/nonviable tissues, source of infection

  • aggressive surgical debridement

  • empiric broad bacteriacidal IV antibiotics

  • medical optimization: surgical airway, ICU monitoring

osteomyelitis

inflammation of bone, predominant bacteria → staphylococcus

• more common in the mandible, why?

  • mandible → thicker cortex

    • blood supply mainly from:

      • inferior alveolar artery, periosteum

  • maxilla → thinner cortex

    • periosteal vessels penetrate the cortex more easily.

    • maxilla has more porous bone.

• how it develops?

  • begins in the medullary spaces of the jaw

  • bacteria enter the marrow spaces → marrow edema.

  • bc the marrow is enclosed by cortical bone → pressure increases.

  • if pressure becomes greater than the pressure in the feeding arteries:

    • blood supply decreases, tissue necrosis occur → pain develops

  • failure of microcirculation prevents delivery of:

    • oxygen, nutrients, blood-borne immune defenses → allows bacteria to proliferate and spread.

    • risk factors:

      • immunocompromised conditions, poorly controlled diabetes mellitus

      • chronic corticosteroid use, chronic drug abuse, chronic malnutrition

• tx:

  • empiric antibiotic of choice: penicillin

  • others: fluoroquinolones, clindamycin

• general types:

  1. acute / chronic suppurative osteomyelitis

  2. chronic sclerosing osteomyelitis

  3. osteomyelitis with proliferative periostitis (Garre osteomyelitis)

  
  

acute suppurative osteomyelitis

infection of the medullary bone with purulence

• associated with:

  • bacteremia, fracture, surgery

  • extension of periapical abscess

  • osteo-radio-necrosis (ORN)

  • medication-related osteo-necrosis of the jaw (MRONJ)

• clinical findings:

  • pain → primary feature

  • usually no systemic manifestations

  • lymphadenopathy, edema, erythema, pain

  • lower lip paresthesia, restricted movement

• radiographic findings:

  • early stage:

    • no changes bc there is minimal bone loss

  • later stage:

    • moth-eaten appearance → radiolucent

    • sequestrum → radiopaque within radiolucency

    • involucrum → surrounding radiolucent

• tx:

  • debridement of necrotic bone

  • aggressive antibiotic therapy

  • drainage of pus

sequestrum

radiopaque within radiolucent

a dead bone surrounded by granulation tissues

involucrum

reactive new bone formation

surrounding radiolucent area

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

• 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.

• why in need of longer treatment?

  • bc antibiotic penetration into bone is difficult and eliminating bacterial colonization is more challenging.

diffuse chronic sclerosing osteomyelitis (non-suppurative)

causes: bacteria, chronic periodontal disease

a low-grade inflammatory reaction in the maxilla and mandible

chronic sclerosing osteomyelitis (non-suppurative)

aka: focal sclerosing osteitis, bony scar, condensing osteitis

rare form of osteomyelitis.common to young adults

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

• bacterias:

  • Actinomyces & Eikenella corrodens → can cause sclerosis & fibrosis

• clinical finding:

  • chronic dull pain, intense pain may fluctuate with:

    • acute exacerbations, mandibular expansion, soft tissue edema

  • no: pus, drainage

• symptoms can persist for up to 5 years before diagnosis

• radiographic finding:

  • increased trabecular bone density → increased radiopacity

• tx:

  • no treatment (physiologic bone reaction)

  • surgical resection of diseased bone is often required.

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

• causes:

  • periapical infection of a mandibular tooth

• clinical findings:

  • mandibular expansion, pain

  • no: purulence, drainage, erythema

• radiographic findings:

  • onion-skin appearance → due to paracortical bone formation from repetitive irritation of the periosteum

• note:

  • sometimes called periostitis ossificans, but this is considered inappropriate → bc the periosteum itself does not become ossified

• 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

usually affects soft tissue, but can also involve bone → Actinomyces osteomyelitis

• clinical findings:

  • forms a lumpy pseudotumor

  • induration with nodular fibrosis

  • intermittent spontaneous drainage tracts

  • forms a fistula to the cutaneous skin surface

  • infection does not respect normal anatomical planes.

  • presence of sulfur granules (small yellow pus)

    • because it drains spontaneously:

      • patient often does not experience severe pain.[

• bacteria:

  • Actinomyces israelii

  • A. naeslundii, A. odontolyticus

  • A. meyeri, A. viscosus

• tx:

  • surgical removal of the infection

  • long-term oral penicillin therapy (IV penicillin if acute)

  • 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

• diagnosis is done thru:

  • 20% potassium hydroxide (KOH) → unreliable, no tissue invasion

    • microscopy may reveal:

      • hyphae, pseudohyphae

  • tissue biopsy + periodic acid–schiff (PAS) staining → more reliable; there’s tissue invasion

• risk factors:

  • immunocompromised states:

    • AIDS,diabetes mellitus, chemotherapy, leukemia

• species:

  • candida albicans → an endogenous organism normally present in the mouth

    • others:

      • C. krusei, C. tropicalis, C. glabrata

      • C. parapsilosis, C. pseudotropicalis, C. guilliermondii

• tx:

  • elimination of contributing local or systemic factors

  • topical therapies such as:

    • nystatin oral suspension

    • clotrimazole troches → higher toxicity, contains sugar

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

aka: perleche

• associated with;

  • px with dentures with inadequate vertical dimension & “freeway” space

  • reduced vertical dimension → overclosure of lips → chronic moisture

• clinical findings:

  • erythema, white patches at the commissures often bilateral

  • often accompanied by Staphylococcus aureus infection.

• nutritional deficiencies:

  • folic acid, iron, riboflavin, thiamine, vit. B12

• tx:

  • eliminate contributing factors

  • nystatin oral suspension