Odontogenic infections (4)
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  • 1. ODONTOGENIC INFECTIONS Prepared by: Dr. Rea Corpuz
  • 2. Odontogenic Infections (1) Cellulitis (2) Ludwig’s Angina (3) Cavernous Sinus Thrombosis (4) Osteomyelitis
  • 3. (1) Cellulitis if abscess is NOT able to establish drainage through the surface of skin or into oral cavity  may spread diffusely through facial planes of soft tissue  acute + edematous spread of acute inflammatory process
  • 4. (1) Cellulitis two dangerous forms:  Ludwig’s Angina  Cavernous Sinus Thrombosis
  • 5. (2) Ludwig’s Angina named after German physician who described the seriousness of disorder in 1836 Angina comes from Latin word angere  strangle
  • 6. (2) Ludwig’s Angina 70% of cases, develop from spread of an acute infection from lower molar teeth prevalence in patients who are immunocompromised secondary to disorders such as:  diabetes mellitus  organ transplantation  acquired immunodeficiency syndrome (AIDS)  aplastic anemia
  • 7. (2) Ludwig’s Angina Clinical Features  massive swelling on neck  often extends close to clavicle  involvement of sublingual space results in • elevation Woody Tongue • posterior enlargement can compromise • protrusion of tongue airway
  • 8. (2) Ludwig’s Angina
  • 9. (2) Ludwig’s Angina Clinical Features  involvement of submandibular space results in • enlargement • tenderness of neck above level of hyoid bone Bull Neck • pain in neck + floor of mouth • restricted neck movement
  • 10. (2) Ludwig’s Angina Clinical Features  involvement of submandibular space results in • dysphagia • dysphonia • dysarthria • drooling • sore throat
  • 11. (2) Ludwig’s Angina Clinical Features  involvement of lateral pharyngeal space • respiratory obstruction secondary to laryngeal edema • tachypnea • dyspnea • tachycardia • patient needs to maintain erect position
  • 12. (2) Ludwig’s Angina Treatment & Prognosis  centers around 4 activities • maintenance of airway • incision + drainage • antibiotic therapy • elimination of original focus of inflammation
  • 13. (2) Ludwig’s Angina Treatment & Prognosis  initial observation many clinicians administer • systemic corticosteroid medications such as intravenous (IV) dexamethasone  attempt to reduce cellulitis
  • 14. (2) Ludwig’s Angina Treatment & Prognosis  if signs or symptoms of impending airway obstruction: • fiber-optic nasotracheal intubation • tracheostomy • cricothyroidotomy
  • 15. (2) Ludwig’s Angina Treatment & Prognosis  if signs or symptoms of impending airway obstruction: • cricothyroidotomy  sometimes performed instead of tracheostomy  perceived lower risk of spreading infection to mediastinum
  • 16. (2) Ludwig’s Angina Treatment & Prognosis • cricothyroidotomy
  • 17. (2) Ludwig’s Angina Treatment & Prognosis  high dose of penicillin penicillin-  Clindamycin OR sensitive  Choramphenicol patients  anitbiotic medication is adjusted according to patient’s response + culture result from aspirates of fluid from enlargement
  • 18. (2) Ludwig’s Angina Treatment & Prognosis  if infection remains:  diffuse surgical intervention  indurated is at discretion of clinician  brawny + often governed by patient’s response to noninvasive therapy
  • 19. (2) Ludwig’s Angina Treatment & Prognosis  complications: • Pericarditis • Pneumonia • Mediastinitis • Sepsis • Empyema • Respiratory Obstruction
  • 20. (3) Cavernous Sinus Thrombosis edematous periorbital enlargement with involvement of eyelids + conjunctiva
  • 21. (3) Cavernous Sinus Thrombosis in cases, involving canine space  swelling along lateral border of nose  may extend up to medial aspect of eye + periorbital area  protrusion + fixation of eyeball
  • 22. (3) Cavernous Sinus Thrombosis in cases, involving canine space  induration + swelling of adjacent forehead + nose  pupil dilation  lacrimation may also  photophobia occur  loss of vision
  • 23. (3) Cavernous Sinus Thrombosis in cases, involving canine space  pain over eye + along distribution of: • opthalmic Trigeminal • maxillary branches Nerve
  • 24. (3) Cavernous Sinus Thrombosis Treatment & Prognosis  surgical drainage + high-dose antibiotic medication similar to those administered for patient’s with Ludwig’s Angina
  • 25. (4) Osteomyelitis an acute or chronic inflammatory process in extends  medullary spaces OR away from  cortical surfaces of bone initial site of involvement
  • 26. (4) Osteomyelitis caused by bacterial infections result in expanding lytic destruction of involved bone  with suppuration  sequestra formation
  • 27. (4) Osteomyelitis patients of all ages can be affected strong male predominance most cases involves mandible
  • 28. (4) Osteomyelitis Acute Supporative Osteomyelitis Chronic Suppporative Osteomyelitis
  • 29. (4) Osteomyelitis (Acute Supporative Osteomyelitis) acute inflammatory process spreads through medullary spaces of bone insufficient time has passed for body to react to presence of inflammatory infiltrate
  • 30. (4) Osteomyelitis (Acute Supporative Osteomyelitis) Clinical Features  symptoms of acute inflammatory process less than1 month in duration  fever  leukocytosis
  • 31. (4) Osteomyelitis (Acute Supporative Osteomyelitis) Clinical Features  lymphadenopathy  soft tissue swelling of affected area  on occasion, paresthesia of lower lip
  • 32. (4) Osteomyelitis (Acute Supporative Osteomyelitis) Histopathologic Features  biopsy material from patients • liquid content • lack of soft tissue component • consist predominantly of necrotic bone
  • 33. (4) Osteomyelitis (Acute Supporative Osteomyelitis) Histopathologic Features  necrotic bone • loss of osteocytes • peripheral resorption • bacterial colonization • acute inflammatory infiltrate  consists of polymorphonuclear leukocytes
  • 34. (4) Osteomyelitis (Acute Supporative Osteomyelitis) Radiographic Features  ill- defined radioluscency  periosteal new bone formation may be seen • response to subperiosteal spread of infection • proliferations more common in young patients
  • 35. (4) Osteomyelitis (Acute Supporative Osteomyelitis) Radiographic Features  periosteal new bone formation may be seen • single-layered radioopaque line • separated from normal cortex by an intervening radiolucent band
  • 36. (4) Osteomyelitis (Acute Supporative Osteomyelitis) Radiographic Features  on occasion, exfoliation of fragments of necrotic bone  fragment of necrotic bone that has separated from adjacent vital bone is teremed sequestrum
  • 37. (4) Osteomyelitis (Acute Supporative Osteomyelitis) Radiographic Features  on occasion, fragments of necrotic bone may become surrounded by new vital bone, known as involucrum
  • 38. (4) Osteomyelitis (Acute Supporative Osteomyelitis) Treatment  if obvious abscess formation, • antibiotics  penicillin  clindamycin  cephalexin  cefotaxime  gentamicin • drainage
  • 39. (4) Osteomyelitis (Chronic Supporative Osteomyelitis) defensive response leads to production of granulation tissue  subsequent forms dense scar tissue • attempt to wall off infected area
  • 40. (4) Osteomyelitis (Chronic Supporative Osteomyelitis)
  • 41. (4) Osteomyelitis (Chronic Supporative Osteomyelitis)  subsequent forms dense scar tissue • encircled dead space acts as reservoir for bacteria • antibiotic medications have great difficulty reaching the site
  • 42. (4) Osteomyelitis (Chronic Supporative Osteomyelitis) Clinical Features  if acute osteomyelitis is not resolved expeditiously  entrenchment of chronic osteomyelitis occurs  sometimes may arise without previous acute episode
  • 43. (4) Osteomyelitis (Chronic Supporative Osteomyelitis) Clinical Features  swelling  pain  sinus formation  purulent discharge  sequestrum formation  tooth loss  pathologic fracture
  • 44. (4) Osteomyelitis (Chronic Supporative Osteomyelitis) Clinical Features  may experience acute exacerbations or periods of decreased pain associated with chronic smoldering progression
  • 45. (4) Osteomyelitis (Chronic Supporative Osteomyelitis) Histophathologic Features  biopsy material from patient • soft tissue component • consists of chronically or subacutely inflammed connective tissue filling the intertrabecular areas of bone • scattered sequestra + pockets of abscess formation
  • 46. (4) Osteomyelitis (Chronic Supporative Osteomyelitis) Radiographic Features  patchy  ragged  ill-defined radiolucency • often contains central radiopaque sequestra
  • 47. (4) Osteomyelitis (Chronic Supporative Osteomyelitis) Radiographic Features
  • 48. (4) Osteomyelitis (Chronic Supporative Osteomyelitis) Treatment  difficult to manage medically • pockets of dead bone • organisms are protected from antibiotic drugs  due to surrounding wall of fibrous connective tissue
  • 49. (4) Osteomyelitis (Chronic Supporative Osteomyelitis) Treatment  surgical intervention is mandatory  antibiotic medications are similar to those used in acute form • but must be given intravenously in high doses
  • 50. References: Books Neville, et. al: Oral and Maxillofacial Pathology 3rd Edition • (pages 138-144)