Diagnosis and

Management of
Odontogenic Infections
Nino Zaya, MD
November 2, 2006
 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
 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.
 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
 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
Anatomy
 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
 Continued….
 Bacterial composition
1. 5%-aerobic bacteria
2. 60%-anaerobic bacteria
3. 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.
 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
 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.
 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
 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
 Continued….
 Inspect teeth for presence of caries and large
restorations, localized swellings, fistulas, and mobility
 FOM inspected to assess for fascial space involvement
 Visualize Wharton’s and Stenson’s ducts for quality of
fluid (pus or saliva)
 Ophthalmologic examination: extraocular muscle
function, proptosis, presence of preseptal or postseptal
edema
 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
 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
Continued….
 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
 Primary Mandibular Spaces
 Submental space
1. Infection can result directly due to infected mandibular
incisor or indirectly from the submandibular space
2. 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
3. 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
 Continued….
 Submandibular Space
1. Boundaries:
1. Superior-mylohyoid muscle and inferior border of the mandible
2. Anteriorly-anterior belly of the digastric muscle
3. Posteriorly-posterior belly of the digastric muscle
4. Inferiorly-hyoid bone
5. Superficially-platysma muscle and superficial layer of the deep
cervical fascia
2. Infected mandibular 2nd and 3rd molars cause
submandibular space involvement since root apices lay
below mylohyoid muscle
Submandibular Space Abscess
 Continued….
 Sublingual Space
1. Submandibular and sublingual spaces surgically distinct,
but should be considered as surgical unit due to
proximity and frequent dual involvement in odontogenic
infections.
2. Boundaries:
1. Superior-oral mucosa
2. Inferior-mylohyoid muscle
3. Infected premolar and 1st molar teeth frequently drain into
this space due to their root apices existing superior to the
mylohyoid muscle
Sublingual Space Infection
 Continued….
 Buccal Space
1. Boundaries:
1. Lateral-Skin of the face
2. Medial-Buccinator muscle
2. Both a primary mandibular and maxillary space
3. Most infections caused by posterior maxillary
teeth
Buccal Space Abscess
 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
 Continued….
 Masseteric Space
1. Located between lateral aspect of the mandible
and the masseter muscle
2. Involvement of this space generally occurs from
buccal space primary involvement
3. Signs of involvement of the masseteric space
include trismus and posterior-inferior face
swelling
 Continued….
 Pterygomandibular Space
1. Location: between medial aspect of the mandible
and the medial pterygoid muscle (communicates
with infratemporal spaces)
2. 2ndary infection results from spread from the
sublingual and submandibular spaces
3. Symptoms:
1. Trismus
2. Minimal swelling on exam
 Continued….
 Temporal Space
1. Location: posterior and superior to the masseteric
and pterygomandibular spaces
2. Bounded laterally by the temporalis fascia and
medially by the temporal bone
3. Two components:
1. Superficial temporal space: located between temporal
fascia and temporalis muscle
2. Deep temporal space: located between the temporalis
muscle and the temporal bone
1. Continuous with the infratemporal space
 Continued….
 Masseteric, pterygomandibular, and temporal
spaces referred to as masticator space due to
delineation by the muscles of mastication
1. Communicate freely with one another and are
simultaneously involved
Secondary Mandibular Spaces
 Primary Maxillary Spaces
 Canine Space
1. Location: between the levator anguli oris and the levator labii
superioris muscles
2. Involvement primarily due to maxillary canine tooth infection
3. Long root allows erosion through the alveolar bone of the maxilla
4. Signs:
1. Obliteration of the nasolabial fold
2. Superior extension can involve lower eyelid
 Buccal Space
1. Posterior maxillary teeth are source of most buccal space infections
2. Results when infection erodes through bone superior to attachment of
buccinator muscle
 Continued….
 Infratemporal Space
1. Location: posterior to the maxilla
2. Boundaries:
1. Medial: lateral plate of the pterygoid process of the
sphenoid bone
2. Superior: skull base
3. Lateral: infratemporal space is continuous with the deep
temporal space
3. Rare involvement with odontogenic infections, but
when occurs related to 3rd maxillary molar
infections
 Continued….
 Primary maxillary space (canine, buccal, and
infratemporal space) involvement can ascend to
cause orbital cellulitis (preseptal or postseptal) or
cavernous sinus thrombosis
1. Ocular findings include erythema and swelling of the
eyelids, and ophthalmoplegia
2. Cavernous sinus thrombosis
1. Can result from hematogenous spread of odontogenic infections
2. Bacterial routes of spread:
1. Posterior: via pterygoid plexus or emissary veins
2. Anterior: via angular vein and inferior or superior ophthalmic veins
to the cavernous sinus
3. Veins of the face and orbit valve less so retrograde flow can occur
Orbital Abscess
 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
1. Shape of an inverted cone with its base at the skull base and its apex
at the hyoid bone
2. Location: medial to the medial pterygoid muscle and lateral to the
superior pharyngeal constrictor muscle
3. Anterior: pterygomandibular raphe
4. Posterior: prevertebral fascia.
 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
1. Severe trismus
2. Lateral swelling of the neck
3. Bulging of the lateral pharyngeal wall
4. Rapid progression of infection in this space is common
5. 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
Lateral Pharyngeal Space
Abscess
 Continued….
 Retropharyngeal Space
1. Posteromedial to lateral pharyngeal space and anterior to the
prevertebral space
2. Anterior: superior pharyngeal constrictor muscle
3. Posterior: alar layer of prevertebral fascia
4. Extends from skull base superiorly to C7 to T1 inferiorly
5. Retropharyngeal space infections can spread to mediastinum
6. Other complications of retropharyngeal space involvement:
1. Airway obstruction
2. Aspiration of pus in the event of spontaneous rupture
3. Rupture can occur during endotracheal intubation
Retropharyngeal Abscess
 Continued….
 Prevertebral Space
1. Potential space between two layers of
prevertebral fascia (alar and prevertebral layers)
2. Extends from skull base superiorly to the
diaphragm inferiorly
3. Mediastinitis is concern with prevertebral space
infections similarly to retropharyngeal space
infections
Anatomic Planes
 Management of Odontogenic
Infections
 Goals of management of odontogenic
infection:
1. Airway protection
2. Surgical drainage
3. Medical support of the patient
4. Identification of etiologic bacteria
5. Selection of appropriate antibiotic therapy
 Continued….
 Airway protection
1. Floor of mouth and tongue elevation or narrowing can cause
respiratory distress
2. Expedient assessment and diagnosis of airway compromise is the most
important initial step in managing odontogenic infections
3. Airway loss is primary cause of death in these patients
4. Initially intact airway must be continuously reevaluated during
treatment
5. Signs and findings of airway compromise: inability to assume a supine
position, drooling, dysphonia, stridor, and restlessness etc.
6. Surgeon must decide the need, timing and method to establish an
emergency airway
 Continued….
 Surgical drainage
1. Administration of intravenous antibiotics without drainage
of pus may not allow for resolution of an abscess
2. Starting antibiotic therapy without Gram's stain and
cultures may result in failure to identify pathogens
3. Important to drain all primary spaces as well as explore
and drain potentially involved secondary spaces
4. CT scans may help identifying spaces involved
5. Panorex can help identify putative teeth involved
 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:
1. Small incision are made in a dependent area
2. Placement of a hemostat in the abscess cavity with entry into all
loculations of the abscess
3. Penrose drains inserted into cavity to allow for postoperative
drainage of the abscess
 Continued….
 Medical support of the patient
1. Rehydrate patient as dehydration may be present
2. Treat conditions that predispose patient to
infection (DM)
3. Correct electrolyte disturbances
4. Oral pain, trismus, and swelling can be addressed
by appropriate analgesia and treatment of
underlying infection
 Continued….
 Identification of etiologic bacteria
1. Expected causes are alpha hemolytic streptococci
and oral anaerobes
2. Cultures should be performed on all patients
undergoing incision and drainage and
sensitivities ordered if patient is not progressing
well (possible antibiotic resistance)
3. An aspirate of the abscess can be performed and
sent for culture and sensitivities if incision and
drainage delayed
 Continued….
 Selection of antibiotic therapy
1. Parenteral penicillin
2. Metronidazole in combination with penicillin can be used
in severe infections
3. Clindamycin for penicillin-allergic patients
4. Cephalosporins (first-generation cephalosporins)
5. Antibiotics do not substitute for incision and drainage in
cases of significant odontogenic infections
6. Causes for clinical failure include inadequate drainage or
antibiotic resistance
7. Mediastinal involvement should prompt CT scan of the
chest and cardiothoracic surgery consultation
 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
Ludwig’s Angina
 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
 Bibliography
 Anatomy:http://www.sadanet.co.za/dhw/owne
rs_manual/anatomy1.html
 Cummings Otolaryngology: Head and Neck
Surgery. Chapter 67. Odontogenic Infections.
 Images LA.
http://www.aafp.org/afp/990700ap/109.html