Specific infections of the oral cavity and facial region

Periapical infections

Acute periapical periodontitisSymptomatology;Patient complain of severe pain,Patient can indicate precisely the tooth that is

aching,Feeling of a tooth is too high, therefore it is the

first one to come in contact with the antagonist,Pain on eating,Pain increases when drinks hot liquids

Periapical infections cont…

Pain decreases when drinks cold drinksTooth is tender on vertical percussion

Periapical abscess

This is either an acute or chronic suppurative of the periapical tissues of the periodontium following pulp infection, traumatic injury of the teeth, or irritation of the apical tissues by mechanical or chemical manipulation.

It is also known s dentoalveolar abscess, Clinical presentations depends whether it is

acute or chronic,

Periapical abscess cont…

Acute; Extremely painful tooth, Slightly extruded from the socket, Lymphadenitis Fever,

Chronic There may be draining sinus tract in the alveolar mucosa, Otherwise it is asymptomatic

Periapical abscess cont…

Treatment;Root canal or extraction It is important to take x-ray with guttapercha in

through the sinus when there is sinus tract to establish the offending tooth,

X ray will show periapical radioluscence incase of chronic periapical abscess.

Complications of periapical abscess

Osteomyelitis,Fistula formation,Fascial spaces infection,Bacteremia,Periapical granuloma or cyst,

Lateral periodontal abscess

It is related to the pre-existing periodontal pocket, Clinically presents

Pocket depth of 5-8 mm Pain, Swelling destroying the cortical plate of bone ballooning

the overlying tissues, Tooth tender to percussion

Treatment- careful insertion of the probe to produce drainage,

Extraction of the tooth after acute symptoms have subsided.

Subperiosteal abscess

It is the result of pus from the apical or dentoalveolar abscess perforating through the lingual or buccal cortical plate of bone without perforating through the overlying periosteum,

Can also arise after mucoperiosteal flap has been raised from the bone as during the surgical extraction of teeth,

Usually this occurs when small piece of necrotic bone or foreign material has been left behind underneath the flap acts as a nidus of infection

Clinically presents as a rounded swelling overlying the cortical plate of maxilla or mandible,

Quite firm on palpation due to because of the pressure of the underlying fluid,

Extremely painfully,

Subperiosteal abscess cont…

Treatment I&D In the postsurgical abscess –re elevate the

mucoperisteal flap, Remove any visible debris, Irrigate copiously the cortical bone and

undersurface of the mucoperiosteal flap.

Pericoronitis

It is an inflammation of soft tissues surrounding the crown of a partially erupted or unerupted tooth,

Common site is usually the soft tissue of the crown of wisdom teeth of lower jaw,

Patient is usually an adolescent undergoing stress,

Causes includes; Impaction of food under the gum flap, as well as plaque

provide medium for bacteria multiplication

Pericoronitis cont…

Biting on the gum flap by opposing tooth-laceration-infection-swelling,

Ulceromembranous gingivitis-pericoronal pocket acts as focus from infection can originate

Clinical features; General features includes high temperature, severe malaise, e.t.c Local features include severe sharp pain of throbbing type,

discomfort in swallowing, mastication, trismus, Swollen and tender gum flap (operculum) Pus discharge beneath the flap Foetor oris Tender and enlarged sub-mandibular lymph nodes In chronic situation there is dull pain, slight trismus

Pericoronitis cont…

Treatment; Irrigation under LA beneath the operculum with

antiseptics, untill infection has subsided, Emperical antibiotic therapy, In mild infection- take x ray and see if tooth is in position

to erupt fully considering the age of the patient, Definitive treatment is after the control of infection Patient referred to maxillofacial surgeon for definitive

therapy

Cellulitis

This is a diffuse inflammation of the soft tissue/ loose connective tissue which tends to be self limiting and eventually may become an abscess,

It is a very serious infection and it can life threatening,

It is a potential complication of all acute dental infection

If the infection involves the submandibular, sublingual and submental spaces it is called Ludwig’s angina,

Cellulitis cont…

It is characterized by absence of pus initially, Infection may remain localized if the defense factors

are capable of walling off the infection and preventing it from spreading,

Occasionally it can be the Bacterial infection is over whelming and extremely virulent, Bacteria are resistant to antibiotics Body resistance is low and the invasion is unimpeded as it

progresses through the surrounding tissues.

Cellulitis cont…

Sources; The mainly responsible organism is the β-hemolytic

streptococcus, which has great invasive ability (produce hyaluronidase-spreading factor, and fibrinosins)

Commonest cause of cellulitis of neck is infection arising from the region of the lower molars,

Many fascial spaces infection can be easily seen because of ; The apices of the second and more especially 3rd molars are often

close to the lingual surface of the mandible, The mylohyoid muscle inclines upwards as it runs backwards, the

apices of the 3rd molar are usually and of the 2nd molar are often below this line,

Cellulitis cont…

Posterior border of the mylohyoid muscle is close to the sockets of the 3rd molars. At this point the floor of the mouth consist of only mucous membrane covering part of the mandibular salivary gland.

For these reasons a virulent periapical infection of lower 3rd molar may penetrate the lingual plate of the jaw and can progress further to several fascial spaces.

Cellulitis cont…

Clinical features: Gross edema of the tissues, induration or boardlike (hardness) on palpation Pain or tender on palpation, It has diffuse /ill defined borders, It is reddish in colour, The presence of pus indicates that the body has walled

off the infection and that the local host resistance mechanism are bringing the infection under control.

Cellulitis cont…

Treatment; If an abscess is not formed within first few

days of the cellulitis, then antibiotics therapy may subdue the infection,

I&D when there is fluctuation,

N.B sometimes Incision without presence of pus relieves the pressure in the tissues giving relief and fast healing in cellulitis.

Ludwig’s angina

This is a serious generalized septic cellulitis of the submandibular region,

It is an extension of infection from mandibular molar teeth into the floor of the mouth.

Causes usually involves the molars of the lower jaw-generally 2nd and 3rd, because the apices of these teeth are lingual in localization and lie below the level of the mylohyoid line,

Infection spreads first to submandibular, and later submental and sublingual and later to the submandibular space on the other side.

Ludwig’s angina cont…

Causes; Mostly by β-hemolytic streptococcus, Anaerobic infection also accompanies it for the presence of

gas in the tissues Clinical features;

Respiratory distress, Brawny induration, Tissue are boardlike and do not pit, Dysphagia, difficult in eating and breathing No fluatuance Tissue may becomes gangrenous and have peculiar lifeless

appearance on cutting

Ludwig’s angina cont…

A noticeable margins exists between involved tissues and the surrounding normal tissues,

Three fascial spaces are involved bilaterally-submandibular, sublingual, and submental,

Patient has typical open mouth appearance, Floor of mouth is elevated, and tongue protruded

making breathing difficult. Fever, salivation, stiffness in tongue movements, Trismus (inability to open the mouth), Tissue of the neck becomes boardlike and Patient becomes toxic, breathing is difficult, and larynx

is edematous.

Ludwig’s angina cont…

Treatment; Intensive antibiotic therapy (high dose antibiotic

therapy), Incision and drainage to release tissue tension, provide

drainage, Incisions are made parallel to the inferior border of the

mandible (2cm madial) extended to the base of the tongue in the submandibular area.

In submental area incision is made through the mylohyoid muscle to mucous membrane in the mouth,

Ludwig’s angina cont…

In extreme respiratory distress do intubation or tracheotomy

The tooth from which the infection started should be extracted as soon as the patient’s condition allows.

Actinomycosis

Actinomycosis is a relatively uncommon infection of the soft tissue of the jaws,

It is usually caused by Actinomyces israeli but may also be caused by A. naeslundii or A. viscosus, which cause subacute or chronic infection most frequently located around the jaws,

This infection is often preceded by dental infections after tooth extraction,

Actinomycetes are gram positive micro organisms which show true branching,

It is an endogenous bacteria of the oral cavity, therefore can be isolated from the normal oral microflora.

Actinomycosis cont…

When this microorganism invades the tissues it excites an intense reaction of the PMNs,

The infection spreads centrifugally with strong tendency to erode through the skin and form multiple fistulas.

In contrast to Tb and syphilis the regional lymphnodes are never enlarged in connection with an actinomycotic focus.

They may however be involved by direct spread of actinomycetes, Diagnosis is established by examination of the pus which contains

sulphur granules, These yellow granules are formed by the hyphae of the

actinomsetes and can be examined under the microscope or cultured.

Actinomycosis cont…

Treatment;Surgical incision and drainage,Excision of all sinus tracts,Antibiotic therapy. Antibiotic of choice is penicillin

or tetracycline, this should be prolonged for 8-12 weeks because actinomycosis is an indolent infection that tends to erode through tissues rather than follow typical fascial planes and spaces.

Osteomyelitis

this is an inflammatory disease of the jaw bone with the accumulation of pus in the bone marrow.

It affects the bone marrow, It usually begins in the medullary cavity, involving the

cancellous bone and then extends and spreads to the cortical bone and eventually periosteum.

Etiology ; Causative organism is commonly a Staphylococcus aureus,

however other organisms such as pneumococcus or salmonella may be involved in the infection.

Osteomyelitis cont…

Mode of entry; Blood stream-from a local infection e.g boil, infection may also follow

traumatic rupture of blood vessels e.g dental extraction thereby allowing the organisms to enter the blood stream,

Periapical infection- periodontal infection or periapical abscesses connected with carious teeth may lead to acute osteomyelitis. Also untreated or infected fracture of the jaw is common cause of osteomyelitis

Pathogenesis- initial stage typical acute inflammatory reaction occurs, due to the compactness of the bone increased tension produced by exudates causes compression of the blood vessels and subsequent ischemia, necrosis of the bone marrow and bone therefore follows, the pus that forms tracts under periosteum, thus limiting the blood supply to the living bone, the dead bone acts as a foreign body and separates from the living bone. The dead bone which is separated from the living bone is known as sequestrun.

Osteomyelitis cont…

The sequestrum acts as a foreign body and contributes to t he persistence of osteomyelitis in three ways It prevents the adequate drainage of pus, It provides a focus for bacterial growth, It provides ideal conditions for the

development of a chronic infection

Osteomyelitis cont…

Clinical features; In the initial stage there is no swelling, Patient has malaise, Elevation body temperature, Enlargement of regional lymph nodes Teeth in the affected area become painful and loose, Difficult in chewing, Swelling and pain, Pus ruptures through the periosteum into the muscular and

subcutaneous fascia, Eventually discharged through the skin surface through the

fistula,

Osteomyelitis cont…

In early stages –little or no radiographic changes,

After two weeks the bone become radioluscent in the affected areas,

Later sequestrum visible as a radioluscent area surrounded by radio-opaque areas representing the new bone or involucrum.

Osteomyelitis cont… Treatment: Treatment of osteomyelitis is both medical and surgical, Acute osteomyelitis of the jaws is primarily managed by the administration of

appropriate antibiotics, The precipitating cause /condition must also be carefully managed, Antibiotic of choice is penicillin Chronic osteomyelitis requires both aggressive antibiotic therapy and aggressive

surgical therapy, Incision made and all non vital bone removed, Bone removed with ronguer, or drill with large round bur (decortication and

saucerization), Bone removed until vital bone reached in all directions, Irrigation with antiseptic done, If bleeding achieved then primary closure by suture is performed. Antibiotic should be continued for a long time 6-8 week sometimes up to 6

months.

Deep seated O.I

Primary maxillary spaces:Canine space infectionBuccal space infection Infratemporal space infection

Primary mandibular spaces:Submental infectionBuccal SubmandibularSublingual

Deep seated O.I

Secondary fascial spacesSubmasseteric PterygomandibularSuperficial and deep temporal Lateral pharyngeal Retropharyngeal prevertebral

NB- Note cavernous sinus thrombosis.

Management of deep seated infections Medical support of the patient with special

attention to correcting host defense compromises where they exist,

Administration of proper antibiotics in appropriate dosages,

Surgical removal of the source of infection as early as possible,

Surgical drainage of the infection with placement of proper drains,

Constant re-evaluation of the resolution of the infection

More serious infections will require:

Fluid requirement and nutrition, High dosage bactericidal antibiotics and

intravenously, Monitoring of airway, Surgical management of fascial spaces and

aggressive exploration. NB. Immediate referral required for the above

immediate management by dentist s.or maxillofacial surgeon