Text Book Reading

ODONTOGENIC
INFECTIONS

Bailey 5th edition

Chapter 53

 Odontogenic infections are common

infections are usually associated with dental
caries or periodontal disease and are seen
more often in underserved populations
where regular dental care is lacking.
Those individuals with poor dental hygiene
and those who are immunosuppressed are
most susceptible.

 In most cases, odontogenic infections are

successfully treated in the early stages by the
dental professional with a minor dental
procedure and oral antibiotics.
In some cases, the infection will spread from
the dental alveolar structures into the adjacent
soft tissue spaces. This can lead to serious
infections of the fascial spaces of the face and
neck.
When these infections are not promptly
managed, serious, even life-threatening
complications can arise.

Demographics
Although any tooth can produce an
odontogenic infection, most infections
involve the mandibular first, second, and
third molars
In the pediatric population, odontogenic
infections are less common overall, but are
more likely to occur in maxillary teeth

Microbiology
Normal flora in the oral cavity
contains over 1,000,000 organisms
per cubic centimeter of which 10%
are aerobic cocci and 90% anaerobic
bacteria:
Streptococci are the most common aerobic
bacteria found in the oral cavity
Staph are more prevalent in the setting of
a mixed flora infection.
Anaerobes increase in number in the
setting of chronic infections like
periodontitis all cases

Spread Of Localized Infections

Most odontogenic infections begin with necrosis
in the dental pulp from deep caries then
followed by the spread of bacteria through the
pulp chamber into the adjacent bone and soft
tissues
It may take several months and even years for
an infection from dental decay to reach the
dental pulp and produce pulp necrosis and
periapical abscess.
If the infection involves the adjacent soft tissue,
it can cause a diffuse inflammatory response
with cellulitis or form an abscess.

Spread Of Localized Infections

An odontogenic infection produces pain
when the necrotic pupal contents are under
pressure and when the soft tissues and
periosteum over the cortical bone are
distended.
The pain can decrease significantly as the
tissue pressure drops when infection
spreads through the bone and periosteum
into the soft tissues.
The treatment of a dental infection at this
stage drainage of the infected soft
tissues combined with extraction of the

Spread Of Localized Infections

Dental infections of the anterior maxilla will

spread superiorly into potential space
bounded by the mimetic muscles.
Maxillary tooth infections occasionally can
also spread via the dental roots into the
maxillary sinus.

Canine Space Infections

Infection from a maxillary cuspid tooth
perforates the lateral cortex, superior to the
attachment of those upper lip elevator
produces a firm swelling of the medial cheek
and lateral surface of the nose that blunts
the nasal labial crease rarely involve the
orbit.
Treated by drainage with an intraoral incision
placed high in the maxillary vestibule

Buccal Space Infections

Infection perforating the bone above the
attachment of the buccinator muscle on the
maxilla or below the attachments of the
buccinator muscle on the mandible leads to
a buccal space infection or abscess
Usually a buccal infection will be superficial
to the orbital septum and not involve the
orbital contents.
The buccal space has an ability to expand
to a surprisingly large volume with purulent
secretions. Despite the impressive swelling,
a patient may not have much trismus.

Masticator Space Infections

The masticator spaces include the

masseteric space, the pterygoid space, and
the temporal spaces.
The source is usually the mandibular molar
but can also be a maxillary molar.
Infections of the temporal space can usually
be drained either intraorally or externally
but are probably best drained with an
external incision

Mandibular Space Infections

The mylohyoid is the critical structure in

understanding sublingual and
submandibular space infections. The
mylohyoid forms the floor of the oral cavity
and separates the sublingual space above
from the submandibular space below.

Sublingual Space
Infections of the sublingual space typically
start out as tender brawny swellings of the
lateral floor of the mouth near the
mandible. As the infection progresses, it
spreads towards midline and often to the
opposite sublingual space.

Submandibular space
The submandibular space is separated from
the overlying sublingual space by the
mylohyoid muscle.
The lateral extent of the submandibular
space is the skin, superficial fascial and
platysma muscle.

Submandibular space
The medial limits of the space are the
mylohyoid. hypoglossus, and styloglossus
muscles, while the inferior border is the
anterior and posterior digastric muscles.
The anterior portion of the submandibular
space communicates freely with the
submental space, while the posterior
portion communicates with the sublingual
space and deeper neck spaces

Submental Space
The submental space represents a midline
space beneath the anterior aspect of the
lower jaw.
Its boundaries both anterior digastric muscles,
while the roof consists of the mylohyoid
muscle and the floor of the mouth mucosa.
The anterior and lateral borders are formed by
the anterior mandible arch, while the hyoid is
the posterior border.

Angina Ludwig
Ludwig angina is a distinct pattern of
infection that usually originates in the
submandibular or sublingual space and then
disseminates to all the floor of the mouth
spaces by way of the posterior border of the
mylohyoid to involve the submandibular
and sublingual spaces bilaterally as well as
the submental space.

Angina Ludwig
The infection begins as a cellulitis,
advances to a fasciitis, and then becomes a
true suppurative infection.
Over 90% of cases of Ludwig angina are
odontogenic, usually arising from infected
second and third mandibular molars

Angina Ludwig
Ludwig infections tend to spread quickly from one
space to another, resulting in progressive brawny
edema of the anterior and lateral neck skin with
the floor of the mouth swelling and elevation of
the tongue odynophagia, dysphagia, drooling.
Effective treatment of Ludwig angina involves
three critical elements. These are (a) securing a
safe airway, (b) administering appropriate
antibiotics, and (c) surgical drainage of the
infected spaces.

Angina Ludwig
When the diagnosis of Ludwig angina is made
and the disease puts the airway at risk, all
authors agree that establishing a secure
airway is critical tracheostomy prior to
surgical drainage of the infection if necessary
Surgical drainage is clearly indicated for
patients with an abscess, patients with
impending complications, and those showing
no improvement after 24 to 48 hours of
appropriate parenteral antibiotics.

Angina Ludwig
Traditional surgical management of Ludwig
angina called for a horizontal incision
placed superior to the hyoid and extending
laterally to a few centimeters below each
angle of the mandible.
Recent studies reported early surgical
drainage using multiple small incisions as
equally effective in treating the infection.

General Treatment
Guidance
The appropriate management of an
odontogenic infection can involve medical,
surgical, or dental treatment or some
combination of all of these.
The use of drains in treating infections has
not been studied specifically. Some
surgeons prefer suction drains, while others
favor passive dependent drainage.

Imaging

The use of diagnostic imaging has become

routine in the management of an odontogenic
infection. Dental films often will reveal a
radiolucency, and orthopantograms may
show some thinning of the cortical bone.
Computerized tomography (CT) with contrast
is the most commonly ordered study. The CT
scan can show the presence or absence of a
fluid collection as well as involvement of the
various anatomic spaces.

Treatment With Antibiotics

Complications Of Odontogenic
Infections
Deep Neck Space Infections
The deep neck space infections associated
with odontogenic sources include infections
involving the retropharyngeal space and the
parapharyngeal space require treatment
with incision and drainage and administration
of systemic antibiotics.

Complications Of Odontogenic
Infections
Cervical Necrotizing Fasciitis
Necrotizing fasciitis is a rare but severe
bacterial infection of the soft tissues of the
neck and its fascia
When the diagnosis is missed or when
treatment is delayed, the infection can spread
rapidly to involve the subcutaneous fat, deep
fascia, and muscles

Complications Of Odontogenic
Infections
Mediastinitis
Infections that reach the deep neck spaces as
well as those that extend in the soft tissues of
the lower neck can extend to involve the
mediastinum.
These infections are potentially lethal and must
be treated aggressively.
Surgical drainage of both the neck and
mediastinum, eradication of the odontogenic
source and broad-spectrum intravenous
antibiotic therapy are all required.

Thank You