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ODONTOGENIC INFECTIONS OF ORO FACIAL & NECK REGION

ETIOLOGY1
General classification:
Odontogenic:
Pulp disease. Periodontal disease. Secondarily infected cysts or odontomes. Remaining root fragment. Residual infection. Pericoronal infection.

Traumatic:
Penetrating soft & hard tissue wounds.

Implant & reconstructive surgery Others:


Infected antrum. Salivary gland afflictions. Secondary to oral malignancies.

Odontogenic infections1
Acute. Chronic. In the acute stage infection may remain intra bony or spread into soft tissues in following clinical forms: 1. Abscess.
1.Circumscribed collection of pus in a pathological tissue space. 2.It is a thick walled cavity containing pus. 3.Suppurative infections characteristic of staphylococci & anaerobes--- large accumulation of pus--- pointing & drainage.

Abscess

Odontogenic infections2
2.Cellulitis.
1.This is spreading infection of loose CT. 2.It is a diffuse, erythematous, mucosal or cutaneous infection. 3.It is result of streptococci & does not result in large accumulation of pus. 4.Streptococci produce streptokinase (fibrinolysin), hyaluronidase & streptodornase. 5.These break down fibrin & CT ground substance and lyse cellular debris, thus spread of exudation along the tissue planes.

Cellulitis

Odontogenic infections3
3.Fulminating infections.
1.Spread of infection in various primary spaces in the orofacial region. 2.Here secondary spaces along the pathway of least resistance are involved. 3.Spread of deep cervical spaces and beyond.

Acute Peri Apical Abscess1


An abscess arises and remains in the confines of space between the root apex & the alveolar bone. This is due to vascular dilatation, an exudate of neutrophil leucocytes & oedema in the peri apical region. it is due to persistent irritation from chronic pulp or acute virulent infection, or less host resistance.

Acute Peri Apical Abscess2


ETIOLOGY:
Main cause is infective necrosis of pulp which is due to;
Caries. Traumatic exposure of pulp. Sterile necrosis apical vessels are torn by blow on teeth. Chemical or thermal damage to pulp.

Entry of micro-organism in peri apical tissues

Acute Peri Apical Abscess3


is usually through; Apical foramina.
Bacteria or bacterial by products or toxins from necrotic pulp. Endodontic perforation. Chemical Irritation.

Accessory canals. Root fracture.

Clinical features:
History of previous pulpitis. Carious or heavily filled tooth.

Acute Peri Apical Abscess4


Tooth is tender and felt extruded in the tooth socket. When pus has formed there is severe throbbing pain in the affected tooth. Tooth is sensitive to percussion. Over lying gum may or may not be swollen Mobility may or may not be present.

Radiographic presentation: Little informative in initial stages.

Acute Peri Apical Abscess5


Treatment :
Antibiotics ,Analgesics & Drainage through pulp chamber. Extraction or endodontic treatment.

Acute Dento Alveolar Abscess1


This is continuation of peri apical abscess.
When pus does not remain confined to intra bony or in the peri apical region. It perforates the cortex and comes to lie under periosteum--- SUB PERIOSTEAL ABSCESS. The perforating the abscess come into the soft tissues then called as Acute Dento Alveolar Abscess.

Acute Dento Alveolar Abscess2


Clinical features: Pain depend on the stage of disease. Sub mucosal swelling in the sulcus, usually on outer aspect of alveolar process. Fluctuation may come after few days. If untreated may point or burst producing a discharging sinus.

Acute Dento Alveolar Abscess3


Radiographic features: Little informative in acute phase except little widening of periodontal ligament. But previous pathology if present will be seen. Treatment: Same i.e. endo or ext. Plus intra or extra oral drainage.

Acute Periodontal Abscess


Arise in periodontal membrane from adjacent periodontal pocket. Dull pain, rarely severe. Pus discharge via gingival pocket. May produce a sinus on alveolar process. Historically it was called PAROLIS.

CHRONIC PERI APICAL PERIODONTITIS


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When the irritation in the peri apical tissues persists either due incomplete resolution or treatment of acute periodontitis or pulpitis leading to necrotic pulp or a forgotten blow or massive fillings or unsuccessful R.C.T lead to chronic periodontitis. This goes on painlessly and chronic

CHRONIC PERI APICAL PERIODONTITIS


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periodontitis converts in to granulation tissue, which grows and causes the resorption of surrounding bone by the initiation of osteoclastosis and become separated from the surrounding bone by a layer of collagen. This lesion is called the DENTAL GRANULOMA.

CHRONIC PERI APICAL PERIODONTITIS


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SIGNS AND SYMPTOMS Usually no symptoms and it is chance finding on routine X-rays. Involved tooth is discolored and non-vital. Some times there is mild discomfort or intermittent pain, tooth may be slightly tender to percussion and over lying gum tissues opposite tooth apex may also

CHRONIC PERI APICAL PERIODONTITIS


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tender to touch. If pus has formed in side the granuloma (Central Abscess) there will be local tissue swelling and pus may penetrate the tissues forming chronic discharging sinus. In long standing cases pus may track to the skin forming extra-oral skin sinus.

CHRONIC PERI APICAL PERIODONTITIS


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PATHOLOGY It is the typical chronic inflammatory reaction that is infiltration of Lymphocytes, Plasma cells and Macrophages.

CHRONIC PERI APICAL PERIODONTITIS


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RADIOGRAPHY There is well circumscribed radiolucent area around the apex and is due to the resorption of bone around the granuloma. This is usually with in the limits of 5mm. More than 5mm and if out line is sharply defined than cyst is forming but is always confirmed by histopathology.

CHRONIC PERI APICAL PERIODONTITIS

CHRONIC PERI APICAL PERIODONTITIS


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BACTERIOLOGY Some granulomas are sterile but bacteria can be cultured from many and mixed infection is the rule.

CHRONIC PERI APICAL PERIODONTITIS


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Dental granuloma grows symptomlessly causing resorption of bone or the root apex Central abscess formation chronic sinus or track to the skin to form the Skin sinus. Acute exacerbation

Skin Sinus Due Chronic infection from deciduous molar

Spreading type of infection


Into soft tissue intra oral or extra oral swelling or abscess depending on muscle attachments. Spread into adjacent surgical spaces along facial planes cellulitis. More dangerous distant spread

Maxillary teeth
Molars
PALATAL ABSCESS BUCCAL VESTIBULAR/ SULCULAR ABSCESS FACIAL SWELLING OR ABSESS which may lead to cellilitis.

Anterior & Premolars.


Palatal abscess. Labial abscess.

Cellulitis from maxillary teeth cause swelling of upper half of face direction towards eye may cause dangerous complication CAVERNOUS SINUS THROMBOSIS.

Mandibular premolars and molars.


Labial or buccal vestibular / sulcular abscess. Lingual palate perforation depending on mylohyoid muscle infection or pus or exudation may involve submandibular/ sublingual spaces LUDWIGS ANGINA.

Mandibular anterior teeth.


Incisors or canines.
If pus perforate above mentalis labial abscess. Below insertion of mentalis cause subcutaneous abscess. Most often between two mentalis muscles.

Usually odontogenic infection remained confined in the peri apical area or periodontal pockets. Peri apical infections may perforate cortex and form local abscess or spread intra medullary chronic infection or focal osteomyelitis.

But depending on;


The number and virulence of micro organisms, type and severity of mechanical or chemical irritant and defense of the host; Or initial PAI is not completely or adequately treated.
It may lead to spreading type of infection Cellulitis. Or may spread to adjacent facial and cervical or distant spaces

FACIAL SPACES
Fascialined areas-- potential spaces that do not exist in healthy persons. They become filled by pus or exudation during infection. Some contain neurovascular structure compartments. Others filled with loose areolar CT-- Clefts

Primary facial spaces


Primary spaces are adjacent to tooth bearing area & are directly involved by infection.
Primary maxillary spaces.
Canine Buccal Infratemporal.

Primary mandibular spaces.


Submental. Buccal. Submandibular. Sublingual.

Secondary Facial Spaces


Secondary spaces are away or lie more posteriorly tooth bearing area and are lined with a CT fascia which has poor blood supply. Involvement of these spaces produce more complicated infective conditions. They are;

Masseteric. Pterygomandibular. Superficial & deep temporal. This group is also known as the MASTICATOR SPACE because muscle & fascia of mastication bound them.

Cervical Facial Spaces


Uncommon occurrence. But spread to deep cervical spaces may have life threatening sequelae.
Lateral pharyngeal. Retropharyngeal. Prevertebral.

PRIMARY MAXILLARY SPACES

Primary mandibular spaces 1

When bilateral submandibular, sublingual & submental spaces become involved --- Ludwig's angina. It is a rapidly spreading cellulitis and commonly spread to secondary mandibular spaces. This usually produce life threatening condition.

Cervical Facial Spaces

Principles of management
Determine the severity of infection Evaluate the state of patients host defense mechanism

Determine , whether treated by GDP or refer to specialist Appropriate antibiotic & their proper administration Treat infection surgically Diet & i-v fluids Evaluate pts frequently

MANAGEMENT
Proper diagnosis. Antibiotics. Other Adjuncts. I&D

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