Diagnosis and Management of Odontogenic Infections

1
Diagnosis and Management of Odontogenic Infections

• Nino Zaya, MD
• November 2, 2006

2
Objectives

• Understand the microbiology of odontogenic
  infections
• Understand the signs symptoms and findings in
  patients with odontogenic infections
• Review the various pathways of spread with
  odontogenic infections
• Understand the medical and surgical management of
  odontogenic infections

3
Case

• 43 y.o. male comes to the emergency room with
  drooling, and shortness of breath that is
  exacerbated when laying down. He has had right
  lower tooth pain with mastication during the past
  month with worsening during the past week. He
  states that during the last day he has had neck
  pain and developed shortness of breath.

4
Continued.

• Physical Exam
• Elevation FOM with
• induration in the submental,
• bilateral submandibular,
• and bilateral sublingual spaces,
• as well as drooling
• Inability to lay supine
• Extensive dental caries
• percussion tenderness
• tooth 31
• Tachypnea

5
Background

• Among most frequently encountered infections in
  human body
• Plagued our species for as long as we have
  existed
• Pre-Columbian Indians, unearthed in the American
  Midwest
• Early Egypt revealed bony crypts of dental
  abscesses, sinus tracts, and the ravages of
  osteomyelitis of the mandible
• Treatment of localized dental infection was
  probably the first primitive surgical procedure
  performed, using a sharp stone or pointed stick
  to establish drainage

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Anatomy
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MICROBIOLOGY OF ODONTOGENIC INFECTIONS

• Usually caused by endogenous bacteria
• Aerobic bacteria alone rarely causative agents
• Streptococcus species are usually the etiologic
  organisms if aerobic bacteria present
• Half odontogenic infections anaerobes
• Most odontogenic infections due to mixed flora
• Mixed infections may have 5-10 organisms present

8
Continued.

• Bacterial composition
• 5-aerobic bacteria
• 60-anaerobic bacteria
• 35 mixed aerobic and anaerobic bacteria
• Commonly cultured organisms alpha-hemolytic
  Streptococcus, Peptostreptococcus, Peptococcus,
  Eubacterium, Bacteroides (Prevotella)
  melaninogenicus, and Fusobacterium.
• Quantitative estimations of the number of
  microorganisms in saliva and plaque range as high
  as 1011/ml.

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Presentation

• History-previous toothaches, onset, duration,
  presence of fever, and previous treatments
  (antibiotics ) important
• Patients may complain of trismus, dysphagia and
  have shortness of breath should be investigated.
  
• Findings vary from mild swelling and pain to
  life-threatening airway compromise and CNS
  impairment

10
Continued.

• Possibly fatal infections may present with
  respiratory impairment, dysphagia, impaired
  vision, ophthalmoplegia, hoarseness, lethargy and
  decreased level of consciousness
• Exam findings Toxic, CNS impairment (decreased
  level of consciousness, meningeal irritation,
  severe headache, and vomiting), eyelid edema and
  ophthalmoplegia.

11
Continued.

• Rubor- (redness) cutaneous surface involved due
  to vasodilatation effect of inflammation
• Tumor-(swelling) occurs due to the accumulation
  of pus or fluid exudate
• Calor-(heat) is the result of increased blood
  flow to the area due to the vasodilatation.
• Dolor-(or pain) results from pressure on sensory
  nerve endings from tisssue distention caused by
  edema or infection
• Functiolaesa-(loss of function) problems with
  mastication, trismus, dysphagia, and respiratory
  impairment

12
Continued.

• Inspection, palpation, and percussion are
  integral parts of the exam
• Begin extraorally and then move inraorally
• Skin of the face, head, and neck for swelling,
  fluctuation, erythema, sinus or fistula
  formation, and subcutaneous crepitus
• Assess for cervical lymphadenopathy and fascial
  space involvement
• Assess for the presence and magnitude of trismus

13
Continued.

• Inspect teeth for presence of caries and large
  restorations, localized swellings, fistulas, and
  mobility
• FOM inspected to assess for fascial space
  involvement
• Visualize Whartons and Stensons ducts for
  quality of fluid (pus or saliva)
• Ophthalmologic examination extraocular muscle
  function, proptosis, presence of preseptal or
  postseptal edema

14
Continued.

• Imaging studies can further substantiate
  diagnosis
• Computerized tomograms should be obtained when
  infection has spread into fascial spaces in the
  orbit or neck
• Infections, well-localized to oral cavity do not
  require special imaging studies with a panorex
  being sufficient for diagnosis and treatment

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Pathways of Odontogenic Infection

• Usual cause of odontogenic infection necrosis of
  tooth pulp and bacterial invasion through the
  pulp chamber into deeper tissues
• Pulp necrosis results from deep decay in tooth,
  (inflammatory reaction)
• The pulpal foramen does not allow drainage of the
  infected pulp
• Further progression leads to medullary space
  infection and osteomyelitis
• More commonly, get fistulous tracts through
  alveolar bone
• Fistulous tract may penetrate oral mucosa or
  facial skin

16
Continued.
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Fascial Spaces

• Fascial planes offer anatomic highways for
  infection to spread superficial to deep planes
• Antibiotic availability in fascial spaces is
  limited due to poor vascularity
• Treatment of fascial space infections depends on
  I and D
• Fascial spaces are contiguous and infection
  readily spreads from one space to another (open
  primary and secondary spaces)
• Despite I and D the etiologic agent (tooth) must
  be removed

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Primary Mandibular Spaces

• Submental space
• Infection can result directly due to infected
  mandibular incisor or indirectly from the
  submandibular space
• Space located between the anterior bellies of the
  digastric muscle laterally, deeply by the
  mylohyoid muscle, and superiorly by the deep
  cervical fascia, the platysma muscle, the
  superficial cervical fascia, and the skin
• Dependent drainage of this space is performed by
  placing a horizontal incision in the most
  dependent area of the swelling extraorally with a
  cosmetic scar being the result

19
Continued.

• Submandibular Space
• Boundaries
• Superior-mylohyoid muscle and inferior border of
  the mandible
• Anteriorly-anterior belly of the digastric muscle
  
• Posteriorly-posterior belly of the digastric
  muscle
• Inferiorly-hyoid bone
• Superficially-platysma muscle and superficial
  layer of the deep cervical fascia
• Infected mandibular 2nd and 3rd molars cause
  submandibular space involvement since root apices
  lay below mylohyoid muscle

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Submandibular Space Abscess
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Continued.

• Sublingual Space
• Submandibular and sublingual spaces surgically
  distinct, but should be considered as surgical
  unit due to proximity and frequent dual
  involvement in odontogenic infections.
• Boundaries
• Superior-oral mucosa
• Inferior-mylohyoid muscle
• Infected premolar and 1st molar teeth frequently
  drain into this space due to their root apices
  existing superior to the mylohyoid muscle

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Sublingual Space Infection
23
Continued.

• Buccal Space
• Boundaries
• Lateral-Skin of the face
• Medial-Buccinator muscle
• Both a primary mandibular and maxillary space
• Most infections caused by posterior maxillary
  teeth

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Buccal Space Abscess
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Secondary Mandibular Spaces

• Referred to as secondary spaces since they are
  infected after involvement of primary mandibular
  spaces
• Failure to treat a primary space infection or a
  compromised host results in secondary space
  involvement
• Connective tissue fascia has poor blood supply
  hence treatment usually surgical to drain
  purulent exudates
• The secondary mandibular spaces include the
  masseteric, pterygomandibular, and temporal spaces

26
Continued.

• Masseteric Space
• Located between lateral aspect of the mandible
  and the masseter muscle
• Involvement of this space generally occurs from
  buccal space primary involvement
• Signs of involvement of the masseteric space
  include trismus and posterior-inferior face
  swelling

27
Continued.

• Pterygomandibular Space
• Location between medial aspect of the mandible
  and the medial pterygoid muscle (communicates
  with infratemporal spaces)
• 2ndary infection results from spread from the
  sublingual and submandibular spaces
• Symptoms
• Trismus
• Minimal swelling on exam

28
Continued.

• Temporal Space
• Location posterior and superior to the
  masseteric and pterygomandibular spaces
• Bounded laterally by the temporalis fascia and
  medially by the temporal bone
• Two components
• Superficial temporal space located between
  temporal fascia and temporalis muscle
• Deep temporal space located between the
  temporalis muscle and the temporal bone
• Continuous with the infratemporal space

29
Continued.

• Masseteric, pterygomandibular, and temporal
  spaces referred to as masticator space due to
  delineation by the muscles of mastication
• Communicate freely with one another and are
  simultaneously involved

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Secondary Mandibular Spaces
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Primary Maxillary Spaces

• Canine Space
• Location between the levator anguli oris and the
  levator labii superioris muscles
• Involvement primarily due to maxillary canine
  tooth infection
• Long root allows erosion through the alveolar
  bone of the maxilla
• Signs
• Obliteration of the nasolabial fold
• Superior extension can involve lower eyelid
• Buccal Space
• Posterior maxillary teeth are source of most
  buccal space infections
• Results when infection erodes through bone
  superior to attachment of buccinator muscle

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Continued.

• Infratemporal Space
• Location posterior to the maxilla
• Boundaries
• Medial lateral plate of the pterygoid process of
  the sphenoid bone
• Superior skull base
• Lateral infratemporal space is continuous with
  the deep temporal space
• Rare involvement with odontogenic infections, but
  when occurs related to 3rd maxillary molar
  infections

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Continued.

• Primary maxillary space (canine, buccal, and
  infratemporal space) involvement can ascend to
  cause orbital cellulitis (preseptal or
  postseptal) or cavernous sinus thrombosis
• Ocular findings include erythema and swelling of
  the eyelids, and ophthalmoplegia
• Cavernous sinus thrombosis
• Can result from hematogenous spread of
  odontogenic infections
• Bacterial routes of spread
• Posterior via pterygoid plexus or emissary veins
  
• Anterior via angular vein and inferior or
  superior ophthalmic veins to the cavernous sinus
• Veins of the face and orbit valve less so
  retrograde flow can occur

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Orbital Abscess
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Deep Neck Spaces

• Extension of odontogenic infections beyond the
  primary spaces of maxilla and mandible is
  uncommon
• When occurs upper airway compromise and
  descending mediastinitis are possible adverse
  sequelae
• Posterior spread of ptyerygomandibular space
  infection is to lateral pharyngeal space
• Lateral Pharyngeal space
• Shape of an inverted cone with its base at the
  skull base and its apex at the hyoid bone
• Location medial to the medial pterygoid muscle
  and lateral to the superior pharyngeal
  constrictor muscle
• Anterior pterygomandibular raphe
• Posterior prevertebral fascia.

36
Continued.

• Lateral pharyngeal space communicates with
  retropharyngeal space.
• The styloid process separates posterior
  compartment of the lateral pharyngeal space that
  contains the great vessels from the anterior
  space
• Clinical presentation
• Severe trismus
• Lateral swelling of the neck
• Bulging of the lateral pharyngeal wall
• Rapid progression of infection in this space is
  common
• Posterior compartment involvement can result in
  thrombosis of the internal jugular vein, erosion
  of the carotid artery or its branches, and
  interference with cranial nerves IX to XII

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Lateral Pharyngeal Space Abscess
38
Continued.

• Retropharyngeal Space
• Posteromedial to lateral pharyngeal space and
  anterior to the prevertebral space
• Anterior superior pharyngeal constrictor muscle
• Posterior alar layer of prevertebral fascia
• Extends from skull base superiorly to C7 to T1
  inferiorly
• Retropharyngeal space infections can spread to
  mediastinum
• Other complications of retropharyngeal space
  involvement
• Airway obstruction
• Aspiration of pus in the event of spontaneous
  rupture
• Rupture can occur during endotracheal intubation

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Retropharyngeal Abscess
40
Continued.

• Prevertebral Space
• Potential space between two layers of
  prevertebral fascia (alar and prevertebral
  layers)
• Extends from skull base superiorly to the
  diaphragm inferiorly
• Mediastinitis is concern with prevertebral space
  infections similarly to retropharyngeal space
  infections

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Anatomic Planes
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Management of Odontogenic Infections

• Goals of management of odontogenic infection
• Airway protection
• Surgical drainage
• Medical support of the patient
• Identification of etiologic bacteria
• Selection of appropriate antibiotic therapy

43
Continued.

• Airway protection
• Floor of mouth and tongue elevation or narrowing
  can cause respiratory distress
• Expedient assessment and diagnosis of airway
  compromise is the most important initial step in
  managing odontogenic infections
• Airway loss is primary cause of death in these
  patients
• Initially intact airway must be continuously
  reevaluated during treatment
• Signs and findings of airway compromise
  inability to assume a supine position, drooling,
  dysphonia, stridor, and restlessness etc.
• Surgeon must decide the need, timing and method
  to establish an emergency airway

44
Continued.

• Surgical drainage
• Administration of intravenous antibiotics without
  drainage of pus may not allow for resolution of
  an abscess
• Starting antibiotic therapy without Gram's stain
  and cultures may result in failure to identify
  pathogens
• Important to drain all primary spaces as well as
  explore and drain potentially involved secondary
  spaces
• CT scans may help identifying spaces involved
• Panorex can help identify putative teeth involved

45
Continued.

• Canine, sublingual and vestibular abscesses are
  drained intraorally
• Masseteric, pterygomandibular, and lateral
  pharyngeal space abscesses can be drained with
  combination intraoral and extraoral drainage
• Temporal, submandibular, submental,
  retropharyngeal, and buccal space abscesses may
  mandate extraoral incision and drainage
• Technique
• Small incision are made in a dependent area
• Placement of a hemostat in the abscess cavity
  with entry into all loculations of the abscess
• Penrose drains inserted into cavity to allow for
  postoperative drainage of the abscess

46
Continued.

• Medical support of the patient
• Rehydrate patient as dehydration may be present
• Treat conditions that predispose patient to
  infection (DM)
• Correct electrolyte disturbances
• Oral pain, trismus, and swelling can be addressed
  by appropriate analgesia and treatment of
  underlying infection

47
Continued.

• Identification of etiologic bacteria
• Expected causes are alpha hemolytic streptococci
  and oral anaerobes
• Cultures should be performed on all patients
  undergoing incision and drainage and
  sensitivities ordered if patient is not
  progressing well (possible antibiotic resistance)
• An aspirate of the abscess can be performed and
  sent for culture and sensitivities if incision
  and drainage delayed

48
Continued.

• Selection of antibiotic therapy
• Parenteral penicillin
• Metronidazole in combination with penicillin can
  be used in severe infections
• Clindamycin for penicillin-allergic patients
• Cephalosporins (first-generation cephalosporins)
• Antibiotics do not substitute for incision and
  drainage in cases of significant odontogenic
  infections
• Causes for clinical failure include inadequate
  drainage or antibiotic resistance
• Mediastinal involvement should prompt CT scan of
  the chest and cardiothoracic surgery consultation

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Case continued.

• Patient taking to OR for a
• flexible fiberoptic intubation
• with standby tracheostomy
• equipment available.
• External I and D and Cx,
• extraction tooth 31
• Parenteral antibiotics
• Eventually, extubated after
• resolution FOM edema
• D/c on oral antibiotics with
• follow-up with oral surgery address
• remaining teeth

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Ludwigs Angina
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Conclusions

• Most odontogenic infections are caused by
  anaerobes
• Identify possible complications of odontogenic
  infections
• Antibiotics may not sufficient and incision and
  drainage of these abscesses may be necessary for
  resolution
• Extracting the causative tooth facilitates the
  resolution of the infection

52
Bibliography

• Anatomyhttp//www.sadanet.co.za/dhw/owners_manual
  /anatomy1.html
• Cummings Otolaryngology Head and Neck Surgery.
  Chapter 67. Odontogenic Infections.
• Images LA. http//www.aafp.org/afp/990700ap/109.ht
  ml