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Infection oral paraoral tissues
1. Dr. Giuseppe Bruno PitassiDr. Giuseppe Bruno Pitassi
Doctor Medicine & Surgery – (State DMS) – Napoli (Italy) 1987Doctor Medicine & Surgery – (State DMS) – Napoli (Italy) 1987
Dental Surgeon – Napoli – (Italy) 1989Dental Surgeon – Napoli – (Italy) 1989
Specialist Maxillofacial Surgery – Napoli – (Italy) 1992Specialist Maxillofacial Surgery – Napoli – (Italy) 1992
Pg/Cert. Clinical Periodontology -Bari (Italy) 1999Pg/Cert. Clinical Periodontology -Bari (Italy) 1999
Acute infection ofAcute infection of
oral & para-oraloral & para-oral
tissuestissues
((Peri-mandibular and maxillary abscesses & phlegmonsPeri-mandibular and maxillary abscesses & phlegmons))
3. Group of infections originating mainly but not only fromGroup of infections originating mainly but not only from
dental & periodontal structures caused by the invasiondental & periodontal structures caused by the invasion
and proliferation of pathogenic microrganisms within theand proliferation of pathogenic microrganisms within the
soft tissues of the oro-maxillofacial region.soft tissues of the oro-maxillofacial region.
They may likewise be defined as:They may likewise be defined as:
““Peri-mandibular & maxillary abscesses and phlegmonsPeri-mandibular & maxillary abscesses and phlegmons””
with reference to the tissues of the oral & maxillofacialwith reference to the tissues of the oral & maxillofacial
region that are usually affected by this pathology.region that are usually affected by this pathology.
(Valletta G.C. -1987)
7. The bacteria causing odontogenic infections are mostly
from the endogenous normal flora (bacteria normally in
the oral cavity of the normal person),when these bacteria
gain access to the deeper underlying tissues as through a
necrotic pulp or deep periodontal pocket, they cause
odontogenic infections.
The oral cavity supports the most complex enviromental
population of bacteria in the human body, between 300 to
500 different bacteria strains.
8. Etiopathogenesis
95%95% of “of “Acute Infections of Oral & Para-oral tissuesAcute Infections of Oral & Para-oral tissues””
are due to a multi-microbial originare due to a multi-microbial origin
60%60% originate only by anaerobic bacteriaoriginate only by anaerobic bacteria
35%35% have mixed flora composed have mixed flora composed by a miscellany ofby a miscellany of
aerobic and anaerobic bacteria with a prevalenceaerobic and anaerobic bacteria with a prevalence
of anaerobic 4:1of anaerobic 4:1
5%5% originate only by aerobic bacteria originate only by aerobic bacteria
(Montagna & Piras 2005)(Montagna & Piras 2005)
9. The bacteria strains involved in the pathogenesis of the Oro-
facial infections depend also on the pathologies of origin.
-Streptococcus mutans
-Streptococcus sobrinus
-Streptococcus milleri
-Rods Gram- (aerobics & anaerobics)
Necrotic Pulpitis &
Periapical periodontitis
-Actinobacillus actinomycetemcomitans
-Prevotella oralis (bacterioides)
-Porphyromonas gingivalis
-Fusobacterium nucleatum
-Eikenella corrodens
Marginal Periodontitis/
Periodontal abscess
-Streptococcus mutans oralis
-Enterococcus fecalis
-Bacterioides forsythus
-Fusobacterium nucleatum
-Porphyromonas gingivalis
-Prevotella intermedia
Pericoronaritis
10. The bacteria anaerobics Gram+ as “Bacterioides & Fusobacteria” for
their characteristics are associated with greater frequency to more
severe oral & para-oral infections. Typically they produce
malodorous suppurations and promote the spread of abscesses and
phlegmons due to the production and secretion of exoenzymes as
collagenase and fibrinolisine.
The bacteria involved in the periapical abscesses, also change in
relation to the persistence time of the infection. In the initial
phase, about the first 3 days after the onset of the infection,
Cocci aerobics Gram+ predominates, they are sensitive to Penicillins.
In the late phase, on the contrary, as a result of the affected
tissues necrosis and the shortage in oxygen concentration is evident
a prevalence of “Cocci anaerobic Gram+”, sensitive to Metronidazole.
12. Odontogenic infections have three major originsOdontogenic infections have three major origins::
1- Periapical ~70%1- Periapical ~70% (Periapical periodontitis)(Periapical periodontitis)
As result of pulpar necrosis and subsequental bacterialAs result of pulpar necrosis and subsequental bacterial
invasion into periapical tissues.invasion into periapical tissues.
2- Periodontal ~20%2- Periodontal ~20% (Marginal periodontitis)(Marginal periodontitis)
AAs a result of rapidly-growing bacterial within as a result of rapidly-growing bacterial within a
periodontal pocket which becomes deeper allowingperiodontal pocket which becomes deeper allowing
bacterial invasion of underlying tissues.bacterial invasion of underlying tissues.
3- Pericoronitis ~10%3- Pericoronitis ~10%
Is a common problem in young adults (15~25 yrs.) it is anIs a common problem in young adults (15~25 yrs.) it is an
inflammatory reaction of the “operculum”, this is theinflammatory reaction of the “operculum”, this is the
dense, fibrous flap that covers about 50% of the bitingdense, fibrous flap that covers about 50% of the biting
surface usually of the lower wisdom tooth, when it issurface usually of the lower wisdom tooth, when it is
partially or completely erupted. The infection occurspartially or completely erupted. The infection occurs
when the third molar start erupting, at this moment thewhen the third molar start erupting, at this moment the
operculum and tissue around the wisdom toperculum and tissue around the wisdom tooth becomesooth becomes
inflammed because bacteria invade the area. Poor oralinflammed because bacteria invade the area. Poor oral
hygiene and mechanical masticatory trauma on nearbyhygiene and mechanical masticatory trauma on nearby
tissue can facilitate this inflammation.tissue can facilitate this inflammation.
14. “Primum movens” for the formation of an oro-facial
infection is the penetration, the invasion and finally the
proliferation of bacteria, commonly found into buccal
cavity within the para-dental tissues through a lesion of
the integrity and the impairement of the seal function of
the dental and periodontal structures.
The pathogenic micro-organism gain access into the
periapical tissues through any of the following routes:
1-Infected or necrotic pulp of a carious tooth, traumatized
tooth, or after traumatic exposure and contamination
of the pulp of a tooth during cavity preparation
(iatrogenic).
2-Trough the crevice of a gingival wound located in a deeply
infected pocket in periodontally diseaded tooth
3- Extension of infection from adjacent infected tooth.
4- As progression of infection from the peri-coronal tissue
to the deep tissues of the mandible and maxilla.
20. Pathways of odontogenic infections
Bacteria from tooth deep decay
invade the pulp therein proliferate
Activation of host inflammatory
reaction into pulpal tissue
Hypoxia if prolonged over time
causes pulpal necrosis
Pulpal abscess formation
Vasodilatation and development
of inflammatory exudate
Oedema increasing and intra-
pulpal pressure rise
Extravasation of the abscess in
the periapical tissues
Collapse of the intra-pulpal
local microcirculation
24. Progression to medullary space
infections and osteomielitis.
Sub-periosteal Dentoalveolar Abscess
2) Extra-dental stage
25. More commonly, such pus collections get fistulous tract
through alveolar bone that may pass through oral
mucosa and/or facial skin draining toward outside
Suppurative Apical Periodontitis “open”
1) Extra-osseous stage
26. Local symptoms.
The severity of the pain depends on the
stage of development of the inflammation
In the initial phase the pain is dull and
continuous and worsens during percussion
of the responsible tooth or when it comes
into contact with antagonist teeth.
If the pain is very severe and pulsates, it
means that the accumulation of pus is still
within the bone or below the periosteum.
There is a sense of elongation of the
responsible tooth and slight mobility; the
tooth feels extremely sensitive to touch,
while difficulty in swallowing is also
observed.
Periapical abscess
30. Once established infection may spread and this is governed by hosts and
Pathogenes factors
.
Local anatomy is an important host factor and in this regard is possible to
assert that “Infection may spread by one of three routes:
- By continuity through tissue spaces and planes
- By way of lymphatic sistem (Acute lymphangitis and lymphadenitis)
-By way of bloodstream circulation (Bacteriemia)
As regards the infections affecting the oral and para-oral tissues is
extremly important the routes of spread by continuity through tissues,
spaces and planes.
Taking into consideration that in this case the infection spreads flowing
along routes of minor resistance and also that the progression of the
infection is determined between the relationship of the muscle insertion
to the bone and the point where infection perforate the bone
31. Some muscles of mastication involving the mandible that willSome muscles of mastication involving the mandible that will
form plans and anatomical spaces in the face and upper neckform plans and anatomical spaces in the face and upper neck
32. Spaces involved in
odontogenic infections
Primary maxillary spaces
Abscess of base of the upper lip
Canine
Buccal
Infratemporal
Primary mandibular spaces
Submental
Buccal
Submandibular
Sublingual
Secondary fascial spaces
Masseteric
Pterygomandibular
Superficial and deep temporal
Lateral pharyngeal
Retropharyngeal
Prevertebral
33. a
Infections of the base of the upper lip usually results from infected
anterior teeth leading to swelling and protrusion of the upper lip, usually
accompanied by obliteration the mucolabial fold.
N.B. the base of the upper lip is a dangerous region because it may lead
to “CAVERNOUS SINUS THROMBOSIS”. Therefore, early diagnosis is
essential to prevent this complications.
Abscess of base of the upper lip
34. Canine space abscess
The Canine space lies between the levator anguli oris and levator labii
superioris muscles.
The source of infection of this space is usually from infected long
canine roots (subsequently to erosion of labial plate superior to the
origin of levator anguli oris muscle).
Clinically, infection of this space leads to swelling of the anterior face
with obliteration of the nasolabial fold. Severe cases leads to edema of
upper and lower eyelids and may close the eye.
36. Buccal space abscess
The buccal space is bounded by the
overlying skin of the face on the
lateral aspect and the buccinator
muscle medially.
The buccal space becomes involved
from maxillary molar teeth when
infection erodes through the bone
superior to the attachment of the
buccinator muscle.
The buccal space may also become
infected from the infected mandibular
molar
38. Buccal space abscess
Signs and symptoms
Extraoral swelling of the cheek area between the zygomatic
arch and inferior border of the mandible
The swelling protrudes into the mouth with severe throbbing
pain.
39. Infratemporal space abscess
Anatomic Location: The space in
which this abscess develops is the
superior extension of the
pterygomandibular space. Laterally,
this space is bounded by the ramus of
the mandible and the temporalis
muscle,while medially, it is bounded by
the medial and lateral pterygoid
muscles. The Infratemporal space is
rarely infected but when it is, the
cause is usually an infection of the
maxillary third molar.
Infection of this space may result due
to infected infiltration anesthesia of
maxillary nerve.
40. Infratemporal space abscess
Signs and symptoms
Trismus and pain during
opening of the mouth
with lateral deviation
towards the affected
side, edema at the region
anterior to the ear which
extends above the
zygomatic arch, as well as
edema of the eyelids are
observed
41. Submental space abscess
This space is bounded superiorly by the
mylohyoid muscle, laterally and on both sides
by the anterior belly of the digastric muscle,
inferiorly by the superficial layer of the deep
cervical fascia that is above the hyoid bone,
and finally, by the platysma muscle and
overlying skin. This space contains the anterior
jugular vein and the submental lymph node
Submental space is primarily infected by mandibular incisors,
which are long to allow the infection to erode through the labial
plate apical to attachment of mentalis muscle.
Other origin for infection of that space is symphyseal fracture.
42. Signs and symptoms
Firm swelling under the chin in the
submental area
Discomfort on swallowing
The abscess may extend
posterioly to the submandibular
space, and also may extend
posteriorly to the submandibular
space and also may extend to
submental space of the other side.
43. Mandibular molar teeth
infection erode through the
lingo-cortical bone, more
frequent than anterior teeth.
1st Mandibular molar will drain
buccally or lingually.
2nd Mandibular molar can
perforate either buccally or
lingually but usually lingually.
3rd Mandibular molar infection
almost always erode through
the linguo-cortical plate.
Spread of infection from
mandibular molars
44. The mylohyoid muscle will determine
whether infections that drain
lingually
go into
If above the mylohyoid muscle
the ,infection localizes sublingually,
if below the attach, of the muscle,
the infection localizes instead into
submandibular space.
Sublingual
space
Submandibular
space
45. Lateral diagrammatic illustration showing
the localization of infection above or below
the mylohyoid muscle, depending on the
position of the apices of the responsible
tooth
Line of insertion of the mylohyoid muscleLine of insertion of the mylohyoid muscle
46. Sublingual space abscess
Sublingual space lies
between:
-Oral mucosa from above.
-Mylohyoid muscle below
-Lingual surface of the
mandible laterally
47. Sub-mandibular space abscess
Submandibular space is bounded
laterally by the inferior border
of the body of the mandible,
medially by the anterior belly of
the digastric muscle, posteriorly
by the stylohyoid ligament and
the posterior belly of the
digastric muscle, superiorly by
the mylohyoid and hyoglossus
muscles, and inferiorly by the
superficial layer of the deep
cervical fascia. This space
contains the submandibular
salivary gland and the
submandibular lymph nodes.
48. Sub-mandibular space abscess
Signs and symptoms
The infection presents as moderate swelling at the
Sub-mandibular area, which spreads, creating greater
edema that is indurated with redness of the overlying
skin. Also, the angle of the mandible is obliterated.
There is pain during palpation and moderate trismus due
to involvement of the medial pterygoid muscle are.
49. Ludwig's angina
When there is bilateral involvement of
the submandibular /submental &
sublingual space, the infection is termed
Ludwig's angina
50. Ludwig's angina
Sign and Symptoms
It is a rapidly fulminating
massive brawny hard cellulitis
affecting the submandibular,
submental & sublingual spaces
bilaterally.
There is almost always severe
swelling with elevation and
anterior displacement of the
tongue. The patient usually
has trismus, drooling of saliva,
with difficulty in swallowing
and breathing.
This infection may progress
rapidly producing upper
airway obstruction often
leads to death.
51. The submasseteric space abscess
The submasseteric space is located on the lateral surface of
the mandibular ramus, between the deep and superfacial
fibers of the masseter muscle.
Posteriorly it is bounded by the parotid gland, and anteriorly
it is bounded by the mucosa of the retromolar area.
Infection of this space usually originate from the infection
around the crown of the mandibular third molars
(pericoronitis),
52. Signs and symptoms
It is characterized by a firm
edema that is painful to pressure
in the region of the masseter
muscle, which extends from the
posterior border of the ramus of
the mandible as far as the
anterior border of the masseter
muscle. Also, severe trismus and
an inability to palpate the angle
of the mandible are observed
Intraorally, there is edema
present at the retromolar area
and at the anterior border of
the ramus.
The sub-masseteric space abscess
53. Pterygomandibular space abscess
This space is bounded laterally
by the medial surface of the
ramus of the mandible, medially
by the medial pterygoid muscle,
superiorly by the lateral
pterygoid muscle, anteriorly by
the pterygomandibular raphe,
and posteriorly by the parotid
gland
54. Etiology
- Infections of molar teeth
especially third molar.
- Septic inferior alveolar nerve
block with contaminated needle
or anesthetic solution.
- Spread of infection from the
infratemporal space
- Compound fracture of the angle
of the mandible.
Pterygomandibular space abscess
55. Signs and symptoms
Severe trismus and slight
extraoral edema beneath the
angle of the mandible are
observed.
Intra-orally, edema of the
soft palate of the affected
side is present, and there is
displacement of the uvula and
lateral pharyngeal wall, while
there is difficulty in
swallowing.
Pterygomandibular space abscess
56. The lateral pharingeal space
Anatomic Location. conical shaped, with the base facing the
skull while the apex reashes the hyoid bone. It is lateral to
the lateral wall of the pharynx and medial to the medial
pterygoid muscle .
Etiology. Infections of this space originate in the region of
the third molar and are the result of spread of infection
from the submandibular and pterygomandibular spaces.
Sign and symptoms: Extraoral edema at the lateral region of
the neck that may spread as far as the tragus of the ear,
displacement of the pharyngeal wall, tonsil and uvula towards
the midline, pain that radiates to the ear, trismus, difficulty
in swallowing, significantly elevated temperature, and
generally malaise are noted
57. Retropharingeal space abscess
Anatomic Location. The retropharyngeal space is located
posterior to the soft tissue of the posterior wall of the
pharynx and is bounded anteriorly by the superior
pharyngeal constrictor muscle and the associated fascia,
posteriorly by the prevertebral fascia, superiorly by the
base of the skull, and inferiorly by the posterior
mediastinum .
Etiology. Infections of this space originate by spread of
the infection from the lateral pharyngeal space, which is
close by.
58. Sign and symptoms:
The same symptoms as those present in the lateral
pharyngeal abscess appear clinically, with even greater
difficulty in swallowing due to edema at the posterior wall of
the pharynx. If it is not treated in time, there is a risk of:
Obstruction of the upper respiratory tract, due to
displacement of the posterior wall of the pharynx anteriorly.
Rupture of the abscess and aspiration of pus into the lungs.
Spread of infection into the mediastinum.
Retropharingeal space abscess
