EIGHTEEN

Orofacial Infection and Its Spread

Key Words Periapical (Dental Abscess) Periodontal Abscess Pericoronitis Routes of Spread of Orofacial Infection Fascial Spaces Facial Cellulites Necrotizing Fasciitis Cavernous Sinus Thrombosis Infection of Nonodontogenic Origin

KEY WORDS Abscess A collection of pus in a cavity formed by disintegration of tissue as result of infection. Infection The communication of disease by the invasion of body tissue by specific pathogenic microorganisms. Inflammation The inflammation is the series of changes which occurred in the living tissue to response to the irritant, provided the irritant is not such of to kill the tissue out right. Discharging Sinus An unhealthy granulation tissue tract opening in one side of the single compartment (example extraoral discharging sinus). Fistulae An unhealthy granulation tissue tract opening in both side of two different compartment (example oroantral fistulae). Infections of odontogenic in origin have a mixed bacteriological etiology, which includes streptococci, which may be aerobic and anaerobic, and Bacteroides, which are anaerobic. The majority of localized dental infections are as follows: Periapical (Dental) Abscess Commonest type of abscess arises from an infected pulp chamber.

Pathophysiology of odontogenic infection can be explained as: invasion of the dental pulp by bacterial infection following dental caries of a tooth inflammation, edema and lack of collateral blood supply venous congestion or a vascular necrosis consequently death of the pulp reservoir for bacterial growth the bacteria penetrate and spreading into the surrounding bone. Treatment 1. Suitable antibiotics to control infection. 2. Analgesic, anti-inflammatory to relieve pain and inflammation.
Table 18.1: The differentiation of abscesses which are periapical and periodontal in origin Periapical (dental) abscess Pain History of toothache swelling Over tooth apex, likely to Periodontal abscess Acute onset Usually localized. Extraoral swelling may or may not be present Always present, more likely in presence of periodontal disease Frequently on attached gingiva Tooth/teeth tender on percussion (TTP), worse laterally More likely tooth is caries-free or unrestored Tooth usually vital Little evidence in early stages there may be bone loss

Pocket Sinus Percussion

May or may not be present Tracks to periapically

Tooth/teeth tender on percussion (TTP) specially on axial direction Restora- More likely in heavily tion restored fractured crown status Vitality Tooth nonvital X-ray Loss of lamina dura in periapical region after 10 to 14 days

Orofacial Infection and its Spread

127

3. Periapical curettage apisectomy, R.C.T. and crown preparation if possible. 4. Otherwise remove the offending tooth and curettage of the socket and sutures. Periodontal Abscess An acute infection and collection of pus within a gingival or periodontal pocket. Treatment 1. Suitable antibiotics preferably combination with metronidazole to control infection; 2. Analgesic to relieve pain; 3. Maintenance of oral hygiene by chlorhexidine mouth wash; 4. Followed by supra and subgingival curettage to remove the calculus as foreign bodies. Pericoronitis Define as infection under the operculum or inflammation of a surrounding soft tissue of a partially erupted tooth. Clinical Features Pain, swelling, difficulty in opening the mouth (trismus), difficulty in swallowing (dysphagia), regional lymph adenopathy. Treatment 1. Primary treatment of irrigation under the operculum with hydrogen per oxide or povidone iodine solution. 2. Antibiotic, analgesic and anti-inflammatory to control spread of infection, trismus and lymph adenopathy. 3. The secondary treatment includes chemocautarization by 30 to 40 percent trichlor acetic acid to cautarize the opercurculum or operculectomy by electrocautary loop. 4. In case of repeated episodic attack, surgical removal of the offending tooth is a choice of treatment. Routes of Spread of Orofacial Infection a. By direct continuity via the tissue. b. Via the lymphatics into the regional lymph nodes and subsequently into the blood stream.

c. Via the blood stream very rare example local thrombothlebitis may propagate along the veins, entering the cranial cavity via emissary veins to produce cavournous thrombothlebitis. The Factors Influencing Spread The general factors includes: a. Host resistance. b. Virulence activity of microbes. c. Compromise proposed defenses. d. Combination of both. Local Factors a. Via alveolar bone. b. Via periosteum. c. Adjacent fascia and muscles. Spread of Infection The majority of infection remains localized and infection may spread in the form of pus from an infected tooth with spread along the path of least resistance. This may produce an extra-oral and intraoral discharging sinus. This may spread along the tissues and fascial planes to produce severe life threatening systemic infection. The pattern of spread associated with specific teeth having a distinct correlation can be shown as in Table 18.2. Fascial Spaces The fascial spaces are potential areas between layers of fascia. These areas are normally filled with loose connective tissue, which readily breaks down when invaded by infection, as per Shapiro.

Fig. 18.1: Lymphatic drainage of tongue

128

Synopsis of Oral and Maxillofacial Surgery

Buccal Mandibular Preauricular Skin of anterior face, mucous membrane of lips and cheeks Skin over mandible, mucous membrane of lips and cheeks Skin inferior to temple, external auditory meatus, lateral part of forehead, lateral part of eyelids, posterior part of cheeks, portion of outer ear, parotid gland External ear, scalp above and behind the ear Pre and postauricular nodes Scalp posterior to ear, occipital region Pinna and adjoining skin, pre and post auricular nodes Submandibular, submental, inferior auricular, tonsillar and tongue nodes.

Table 18.2: Pattern of spread of odontogenic abscesses according to position of the tooth and the potential path of spread Tooth Maxillary teeth Molars and premolars Swelling or sinus in buccal sulcus may spread to buccal space (lateral to buccinator) Canine fossa - facial nasolabial fold area May track to palate due to distal inclination of root, - but usually labial Labially - can give a swollen lip Both have the potential to spread in various direction, submandibular space via lingual plate, pterygo mandibnular space, lateral pharyngeal space and on down the neck Spread laterally infection from the third molar may gives severe trismus with an extension into the submasseteric space Buccally, if lingual may be submental or submandibular depending on level of drainage and mylohyoid attachment Buccally Labially Potential path of spread

Postauricular Infra-auricular Occipital Superficial cervical Deep cervical

Canine Lateral incisor

Cental incisor Mandibulor teeth Pericoronitis may tack buccally along the inner aspect of buccinator to present in second pre-molar and first molar region. Migratory abscess of buccal sulcus Second molar

Facial Cellulites It is a diffuse inflammation involving subcutaneous and deeper tissues on examination overlying skin is firm without fluctuation. The condition having the rapid onset without any formation of pus. Treatment 1. Surgical eradication of infected focus. 2. Suitable systemic antibiotics. 3. In case of abscess formation, incision and surgical drainage by Hiltons method is necessary. Hilton Method In this technique, a pair of fine sinus forceps are inserted closed into the wound and opened slowly but firmly to separate the soft tissue planes. The forceps are then withdrawn open to avoid damaging nerves or vessels by closing them blind. This procedure is repeated till the abscess is reached and pus discharges. In dental infections, an area of rough cortical bone can be felt on the mandible or maxilla where the periosteum has been raised cited from Prof JR Moore. Solnitzky discuss an excellent article describe the relations of dental infection and facial spaces of the head and neck region . The most common dental sources of infection are infections of the lower molar teeth. Such infections tend to spread particularly to one of the following compartments or space: the masticator space, the submandibular space, the

First molar

Premolar and canine Incisors

The location of the lymphatic nodes and the lymphatic drainage areas of the face and neck:
Lymphatic nodes Submental The areas of drainage The tip of tongue, part of the floor of the mouth in the midline, mandibular incisors, related gingiva, middle alveolar process and basal bone of the mandible, midportion of lower lip and chin All maxillary teeth, mandibular teeth except incisors, inferior nasal cavity, palate, body of tongue, upper lip, lateral portion of lower lip, angle of mouth, medial angle of eye, and submittal lymph nodes Skin of the medial angle of eye, skin of anterior face, superficial part of nose

Submandibular

Accessory facial infraorbital

Orofacial Infection and its Spread

129

sublingual space and temporal space. Infections of the maxillary teeth are less frequent and tend to spread to the pterygopaltine and infratemporal fossae. In either case, the spreading suppurative process may involve secondarily the parotid space the lateral pharyngeal space. In fulminating cases, the infection may spread through the visceral space into the mediastinum. Submasseteric space infection is characterized by mandibular sub periosteal abscess cellulites of the mandibular area involving medial pterygoid and obviously masseter. Clinically, the feature of trismus, pain and swelling. Submandibular and sublingual space infection The most serious infection involving the sublingual and submandibular space is Ludwigs angina. This acute overwhelming, generalized condition involving the above spaces. This is a cellulites involving floor of the mouth and quickly extend into the neck. Tongue and floor of the mouth are elevated. As it tracks down to the pharynx, a hot potato speech is a very important significance feature. The danger signs are dysphasia and phonation problems includes asphyxia known as edema glottis and need immediate airways establishment by tracheostomy. Recent advancement of antibiotics the cases of Ludwigs angina not commonly seen. Treatment 1. Reverse U shape incision along the deep part of the chin recommended by Love and Baily for drainage. 2. High doses of suitable systemic antibiotics along with the intravenous or oral fluids and therapeutic oxygen. 3. If necessary tracheostomy for airway establishment. Necrotizing Fasciitis This is a rare infection in the head and neck characterized by a rapidly progressive necrosis of fascia and subcutaneous fat, which undermines and eventually causes necrosis of overlying subcutaneous tissue and skin. Cavernous Sinus Thrombosis The facial veins do not have any valve. The veins in the facial regions directly communicate with the
Fig. 18.3: Cross-section of mandibular ramus region: 1. Superficial temporal space 2. Infratemporal space 3. Masseteric space 4. Pterygomandibular space 5. Lateral pharyngeal space 6. Lateral pterygoid muscle 7. Medial pterygoid muscle 8. Temporalis muscle

Fig. 18.2: Cross-section of premolar area in mandibular region: 1. Sublingual space 2. Submandibular space 3. Submandibular salivary gland 4. Hyoid bone 5. Mandible 6. Mylohyoid muscle 7. Platysma muscle 8. Deep cervical fascia

130

Synopsis of Oral and Maxillofacial Surgery

cranial cavity, and very rarely infection may backtrack from the face up into the skull to the cavernous sinus. According to Eagleton, the six important features of cavernous sinus thrombosis: 1. A known site of infection. 2. Evidence of blood stream infection (septicemia). 3. Early sign of venous obstruction of the retina, conjunctiva, or eye lid. 4. Paresis of the third, forth and sixth cranial nerves resulting from inflammatory edema. 5. Abscess formation of neighboring soft tissues; 6. Evidence of meningeal irritation. The condition is very dangerous and fatal to the patient. The recent advancement of antibiotics and the supportive surgical protocol the condition can be controlled before the development of the cavernous sinus thrombosis. Treatment 1. 2. 3. 4. 5. High doses of selective systemic antibiotics. Fluid transfusion, therapeutic oxygen. Treatment of toxemia. Constant monitor of the patient. In case of edema glottis emergency tracheotomy.

Treatment 1. Removal of infective focus; 2. Incision and drainage by Hilton methods; 3. Suitable appropriate antibiotics, for control of infection; 4. If necessary fluid transfusion; 5. Relief of pain by suitable analgesics. Some Analytical Observations 1. Submasseteric space infection is more common in Disto Angular impaction as because the insertion of the masserter of the intermediate part is floating or loosely attached below (Bransby and Zachary) Cited from Shafer. The infection and pus may tract the least resistance path under the masseter which is attached to the lateral surface of the ramus of the mandible. 2. Migratory abscess of buccal sulcus is a complication of subacute pericoronitis. Pus may track buccally along inner aspect of the buccinators and discharging extra oral sinus in relation to the first molar and second premolar cited from Howe. 3. Impacted lower third molar have the potential to spread in many directions; some mandibular space via lingual plate, pterygo mandibular space, lateral pharyngeal space and on down the neck. Spreading laterally infection from the third molar may give severe trismus with an extension into the submasseteric space. 4. The choice of antibiotics depends on certain aspects in orofacial infections. The oral surgeon should provide drainage of any collection of pus whether by incision, extirpation of pulp, or extraction. Ideally antibiotics, supplement of drainage, where drainage is possible. But certain clinical features like: Toxemia ( temperature and malaise) Associated regional lymphadenitis Trismus Dysphagia Inadequate drainage Supportive medical background Rapid spread towards soft tissue. Demands Intensive Immediate Antibiotic Therapy The empirical choice of antibiotics commonly and recent trend of using as follows: Penicillin derivatives Amoxycillin 500 mg 8 hourly alone and Cloxacillin 500 mg 8 hourly used combine, in case of normal infection.

Infection of Nonodontogenic Origin Any of the spreading infection above may derived from non-odontogenic sources as follows: 1. Salivary Gland: Suppurative parotatis. 2. Skin: Furncle (Suppurative follicutitis), infected sebaceous cyst. 3. Bone: Acute osteomyelitis and chronic osteomyelitis (See the Vol. I). 4. Nasal passages, paranasal sinuses infection (See the Vol. I). Assessment of Infection History of the patient includes speed of onset, features of toxemia and difficulty in breathing and swallowing. Medical factors may be due to drugs, diabetes. Examination includes TPR, heart rate, lymphadenopathy, spread towards floor of the mouth, tongue elevation, neck involvement and special examination of airway and voice. Delineate extend of swallowing as base line. Bacteriological culture includes aspiration of pus and culture. Other test includes radiography, vitality test and urinalysis (routine urine analysis, random blood sugar and PP Blood sugar).

Orofacial Infection and its Spread

131

In case of allergic to penicillin derivatives, Erythromycin 600 mg 6 to 8 hourly may be given. Gentamicin (Genticin actively against some resistance staphylococci and Seudomonas auriginosa . 80 mg twice daily by I/M route along with ampicillin 500 mg twice daily by I/M route. Clindamycin a improvised form of Lyncomycin very effective against anaerobic infection and achieve high concentration of bone. It is used in septicemia, severe dental infection and osteomyelitis. The doses are 300 to 600 mg 8 hourly by oral, IM and IV. Moderate of severe infection authors clinical experience Cefotexime (Omnatax, Taxim) 1 to 2 gm twice daily IM, IV as Ceftrioxone (Monocef 1 to 2 gm IM or IV twice daily is effective. In addition to that Metronidazole 400 mg 3 times daily in oral route also effective in anaerobic infection in orofacial origin.

Sometimes due to haphazard irregular use of antibiotics surgeon may face difficulty to control infection. In particular case, stoppage of antibiotics for at least 3 days and collection of infected pus or materials for culture and sensitivity may helps proper selection of antibiotics. Ciprofloxacin 500 mg with Tinidazole 300 mg this combination drugs twice daily commonly routine used in case of average normal orofacial infection for 5 to 7 days. Typical incision and drainage the various facial spaces recommended by Cunnings et al as A, superficial and deep temporal space, B, submandibular masseteric space and pterygomandibular space, C, submental space, D, lateral pharyngeal and retropharyngeal space.