SPREAD OF ORAL INFECTIONS IN FASCIAL SPACES www

SPREAD OF ORAL INFECTIONS IN FASCIAL SPACES www. rxdentistry. blogspot. com

THE CONCEPT OF FASCIAL “SPACES” IS BASED ON ANATOMIST’S KNOWLEDGE THAT ALL “SPACES” EXIST POTENTIALLY, UNTIL FASCIAE ARE SEPARATED BY PUS, BLOOD, DRAINS OR SURGEONS FINGER. www. rxdentistry. blogspot. com

WHEN DENTAL INFECTIONS SPREAD DEEPLY INTO SOFT TISSUE RATHER THAN EXITING THROUGH ORAL OR CUTANEOUS ROUTES, FASCIAL SPACES MAY BECOME INVOLVED FOLLOWING PATH OF LEAST RESISTANCE. www. rxdentistry. blogspot. com

FASCIAL SPACES OF CLINICAL SIGNIFICANCE ON FACE: BUCCAL CANINE MASTICATOR MASSETER PTERYGOID ZYGOMATICO TEMPORAL PAROTIDwww. rxdentistry. blogspot. com

SUPRAHYOID: SUBLINGUAL SUBMANDIBULAR SUBMAXILLARY SUBMENTAL PHARYNGOMAXILLARY PERITONSILLAR www. rxdentistry. blogspot. com

INFRAHYOID: ANTEROVISCERAL (PRETACHEAL) SPACES OF TOTAL NECK: RETROPHARYNGEAL DANGER SPACE OF CAROTID SHEATH www. rxdentistry. blogspot. com

FASCIAL LAYER SUPERFICIAL LAYER DEEP LAYER SUPERFICIAL OR ANTERIOR LAYER MIDDLE LAYER POSTERIOR LAYER THESE DEVIDE, UNITE, BLEND AND FUSE TO FORM VARIOUS COMPARTMENTS OR SPACES www. rxdentistry. blogspot. com

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Previsceral fascia( sagittal section) www. rxdentistry. blogspot. com

BUCCAL SPACE BOUNDRIES SUPERIORLY INFERIORLY ANTERIORLY POSTERIORLY MEDIALLY LATERALLY : : : ZYGOMATIC ARCH LOWER BORDER OF MANDIBLE MODIOLUS OF MOUTH PTERYGOMANDIBULAR RAPHE BUCCINATOR MUSCLE AND BUCCOPHARYNGEAL FASCIA : SKIN OF CHEEK www. rxdentistry. blogspot. com

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BUCCAL SPACE ABSCESS www. rxdentistry. blogspot. com

CONTENTS STENSEN’S DUCT MAXILLARY ARTERY BUCCAL FAT PAD www. rxdentistry. blogspot. com

SOURCE OF INFECTION MAXILLARY AND MANDIBULAR MOLAR REGION OR EVEN BICUSPID www. rxdentistry. blogspot. com

IF CONFINED TO BUCCINATOR: INFECTION DRAINS INTRA ORALLY IN BUCCAL VESTIBULE CROSSES BUCCINATOR: INFECTION DRAIN DEEP INTO BUCCAL SPACE AND EXTRA ORAL DRAINAGE www. rxdentistry. blogspot. com

CANINE SPACE INFREQUENTLY INVOLVED IN ODONTOGENIC INFECTIONS www. rxdentistry. blogspot. com

LEVATOR ANGULI ORIS OVERLIES THE APEX OF CUSPID ROOT. ORIGIN OF THE MUSCLE IS HIGH IN CANINE FOSSA WHEREAS ITS INSERTION IS THE ANGLE OF MOUTH AND ZYGOMATIC MUSCLE. IF CUSPID INFECTION PERFORATES THE LATERAL CORTEX OF MAXILLARY BONE SUPERIOR TO INSERTION OF MUSCLE POTENTIAL CANINE SPACE BECOME INVOLVED www. rxdentistry. blogspot. com

MASTICATOR SPACES CONSIST OF MESSETERIC PTERYGOID TEMPORAL THESE ARE WELL DIFFERENTIATED BUT COMMUNICATE WITH EACH OTHER AND WITH BUCCAL, SUBMANDIBULAR AND PARAPHARYNGEAL SPACES www. rxdentistry. blogspot. com

SORCE OF INFECTION THIRD MOLAR (PERICORONITIS, DENTAL CARIES INDUCED ABSCESS ETC) INFECTION OF MAXILLARY CANINE USUALLY PRESENT AS LABIAL SULCUS SWELLING AND LESS COMMONLY AS PALATAL SWELLING ALSO BY CONTAMINATED MANDIBULAR BLOCK INJECTIONS OR DIRECT TRAUMA www. rxdentistry. blogspot. com HERE, CLINICALLY THE HALLMARK

SUBLINGUAL SPACE BILATERAL V SHAPED SPACE BOUNDRIES: SUPERIORLY : SUBLINGUAL MUCOUS MEMBRANE INFERIORLY : MYLOHYOID MUSCLE POSTERIORLY : HYOID BONE ANTERIORLY : LINGUAL SURFACE OF MANDIBLE LATERALLY : LINGUAL SURFACE OF MANDIBLE MEDIALLY : GENIOGLOSSUS, GENIOHYOID, STYLOGLOSSUS www. rxdentistry. blogspot. com

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COMMUNICATIONS ANTERIORLY : SUBMENTAL SPACE POSTERIORLY : SUBMANDIBULAR SPACE www. rxdentistry. blogspot. com

SOURCE OF INFECTION PREMOLARS PERIODONTAL INFECTION OF INCISORS LINGUAL INJECTIONS INFECTION OF WHARTSON’S DUCT SIALIDINITIS www. rxdentistry. blogspot. com

IMPORTANT CLINICAL FEATURES RAISED TONGUE WHITE DISCOLORATION OF FLOOR OF MOUTH BRAWNY ERYTHEMATOUS TENDER SWELLING OF FLOOR OF MAOUTH OPEN MOUTH DRIBBLING OF SALIVA WHITE COLLAR APPEARANCE DYSPHAGIA DYSPNOEA OTHER FEATURES OF TOXEMIA www. rxdentistry. blogspot. com

NO EXTRA ORAL DRAINAGE, ONLY INTRA ORAL DRAINAGE D/D: CELLULITIS WITH INFECTED SIALOLITH www. rxdentistry. blogspot. com

SUBMANDIBULAR SPACE SEPARATED FROM OVERLYING SUBLINGUAL SPACE BY MYLOHYOID MUSCLE www. rxdentistry. blogspot. com

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BOUNDRIES LATERALLY : SUBMANDIBULAR SKIN, SUPERFICIAL FASCIA, PLATYSMA, LOWER BORDER OF MANDIBLE MEDIALLY : MYLOHYOID, HYPOGLOSSUS. STYLOGLOSSUS INFERIORLY : ANTERIOR AND POSTERIOR BELLY OF DIGASTRIC POSTERIORLY : HYOID BONE www. rxdentistry. blogspot. com

SUBMANDIBULAR SPACE INFECTION www. rxdentistry. blogspot. com

CONTENTS SUBMANDIBULAR SALIVARY GLAND LYMPH NODES FACIAL ARTERY WHARTSON’S DUCT LINGUAL NERVE HYPOGLOSSAL NERVE www. rxdentistry. blogspot. com

SOURCE OF INFECTION MANDIBULAR SECOND AND THIRD MOLAR SOMETIMES EVEN FIRST MOLAR SECONDARY TO ADJOINING SPACESSUBLINGUAL OR SUBMENTAL D/D: ACUTE SIALADENITIS SUBMANDIBULAR LYMPHADENITIS www. rxdentistry. blogspot. com

SUBMENTAL SPACE BOUNDRIES SUPERIORLY : INFERIOR BORDER OF MANDIBLE INFERIORLY : MYLOHYOID MUSCLE POSTERIORLY : MYLOHYOID MUSCLE LATERALLY : ANTERIOR BELLY OF DIGASTRIC www. rxdentistry. blogspot. com

SOURCE OF INFECTION MANDIBULAR INCISORS O R FROM SUBMANDIBULAR SPACE www. rxdentistry. blogspot. com

Presentation The patient presents with a swollen face and occasionally swollen neck. Toothache or facial pain may or may not be a feature. There is often general malaise and possibly rigors with fever. Patients may complain of trismus (inability to open the mouth fully), pain or difficulty in swallowing, drooling, sore throat and a hoarse voice. www. rxdentistry. blogspot. com

Examination Specific attention should be paid to the location of swelling, size, flactuance, any possible pointing and coexistent lymph node enlargement. www. rxdentistry. blogspot. com

Good oral examination should include presence of halitosis, evidence of intraoral pus draining any tongue elevation, any sublingual or submandibular swelling, swelling in the mandibular or maxillary sulci, palatal swelling especially of the soft palate or uvula, general dental state patency of salivary outlets (parotid, submandibular and sublingual), nature of saliva produced (clear, thick, pus? ). www. rxdentistry. blogspot. com

Suspect teeth should be tapped with a metallic object to elicit any tenderness to percussion. Swelling should be palpated bimanually if possible with a finger of one hand intraorally and the second hand extraorally (pushing towards the oral site). The neck should be evaluated for swelling, lymphadenopathy and possible tracheal deviation. www. rxdentistry. blogspot. com

Aetiology of major facial infections Teeth can contribute by: www. rxdentistry. blogspot. com

Potential route of spread of pulpal infection www. rxdentistry. blogspot. com

(1) Decay (caries) reaching the dental pulp=pulpitis, this in turn spreads to supporting bone resulting in (2) periapical abscess which in turn may spread subperiosteally. (2) Periapical abscess may occur in seemingly intact but devitalised teeth (trauma, cracks or decay under fillings). (3) Periapical and periodontal abscess may form as a result of chronic gingivitis and supporting bone and soft tissue loss (periodontal disease) note again the tooth may be entirely intact www. rxdentistry. blogspot. com clinically and radiographically.

(4) Erupting teeth (especially partially impacted lower third molars) can result in inflammation and infection of the gum flap preventing eruption (operculum) with swelling pus etc. around the crown (pericoronitis). (5) Retained roots supragingival or subgingival. www. rxdentistry. blogspot. com

JAWS (1) Can develop cysts or tumours that can range from odontogenic (=dental origin) to either primary or secondary malignancy. Most are derived from the dental apparatus and although benign can nevertheless continuously grow and become secondarily infected on breaching the surrounding bone. (2) Osteomyelitis although rare can be the result of chronic infection as mentioned before. (3) Osteoradionecrosis occurs readily in irradiated jaws subjected to further trauma (such as extractions). www. rxdentistry. blogspot. com

(4) Rarer are tuberculosis, Actinomycosis and syphilitic osteomyelitis. (5) Most jaw fractures in the tooth bearing segments are by definition compound to the oral cavity and can easily be infected by the oral microbes. (6) Extraction sites again are comparable to compound fractures and it is surprising that infection is so relatively rare. www. rxdentistry. blogspot. com

Major salivary glands (1) May be the subject of either viral or bacterial (2) infections often superimposed on (3) obstruction of ducts (stone, stricture, etc). (4)(2) Tumours rarely also become secondarily (5) infected. www. rxdentistry. blogspot. com

Paranasal sinuses (1) May be primarily infected, obstruct and result in facial swelling. (2) May become infected secondary to infected teeth protruding into the maxillary sinus (upper premolar and molar teeth often do). (3) Tumours or cysts may become infected. (4) Fractures such as the orbital floor are by definition compound to the “outside” and may result in orbital cellulitis. www. rxdentistry. blogspot. com

Investigations In many cases careful history and examination will make diagnosis clear, however certain investigation will still be necessary. www. rxdentistry. blogspot. com

Plain X rays (1) The OPG (orthopantomogram) is invaluable in displaying the teeth, whole of mandible, tooth bearing segment of the maxilla as well as parts of the maxillary sinuses. Use for any suspected fractures of the mandible, periapical abscesses and bony cysts and tumours. Will show impacted third molars ('wisdom teeth'). (2) Occipito-mental 15 and 30 degrees (“Water’s view”) will show both maxillary sinuses (effusion? ), orbital www. rxdentistry. blogspot. com floor and most fractures of the maxilla.

(3) Mandibular occlusal views and lateral oblique views may demonstrate stones in the submandibular gland. (4) 'Puffed cheek' view may demonstrate stones in the parotid duct. Sialography: Can be used for suspected gland obstruction however CT sialogram is the gold standard. www. rxdentistry. blogspot. com

Ultrasound Useful in confirming collections as well as a guide to aspiration. Will also show stones in salivary ducts and glands. www. rxdentistry. blogspot. com

CT scan With axial and coronal views will demonstrate exact extent of the swelling, potential airway compromise and is invaluable to both the surgeon and anaesthetist. However patients unwell enough to potentially obstruct their airway should be taken straight to theatre rather than risk an emergency in the radiology dept. www. rxdentistry. blogspot. com

Microbiology of any pus or discharge. The usual blood tests. www. rxdentistry. blogspot. com

INFRATEMPORAL AND MASTICATOR SPACE SUPERIORLY BUCCALY MESSETRIC SPACE POSTERO INFERIORLY POTENTIAL SPREAD OF INFECTION FROM LOWER THIRD MOLAR ANTERIORLY, BUCCALY BUCCAL SPACE PTERYGOMANDIBULAR SPACE INFERIORLY SUBMANDIBULAR SPACE LUDWIG’S ANGINA www. rxdentistry. blogspot. com

PTERYGOMANDIBULAR SPACE PTERYGOID SPLEXUS EMISSERY VEINS LATERAL PHARYNGEAL SPACE RETROPHARYNGEAL SPACE CAVERNOUS SINUS THROMBOSIS MEDIASTINUM CAROTID SHEATH DANGER SPACE 4 NOTE : DANGER SPACE 4 IS THE SPACE BETWEEN PREVERTIBRAL AND ALAR FASCIA www. rxdentistry. blogspot. com

EVOLUTIVE STAGES OF ODONTOGENIC INFECTION www. rxdentistry. blogspot. com

AN INITIAL PERIOD OF PERIAPICAL CONTAMINATION BY BACTERIA GENERALLY ORIGINATING FROM ROOT CANAL CLINICAL PERIOD WITH SIGNS AND SYMPTOMS – ACUTE APICAL PERIODONTITIS, DEVELOMENT OF A PERIAPICAL ABSCESS PERIOSTEUM RUPTURES AND INFECTION GAINS ECCESSTO SURROUNDING SOFT TISSUES PRODUCING CELLULITIS ( PHLEGMON ) FINAL RESOLUTION PERIOD AND GENERATION OF REPAIR TISSUE. www. rxdentistry. blogspot. com

CELLULITIS(PHLEGMON) • TYPES 1. SEROUS CIRCUMSCRIBED ACUTE CELLULITIS AFFECTING SINGLE ANATOMIC SPACE 2. SUPPURATIVE CIRCUMSCRIBED ACUTE CELLULITIS WITH PLURULENT SUPPURATION 3. DIFFUSE ACUTE CELLULITIS • • • LUDWIIG’S ANGINA PERIPHARYNGEAL CELLULITIS NECROTIZING FASCIITIS 4. CHRONIC CELLULITIS www. rxdentistry. blogspot. com

CLINICAL MANIFESTATIONS • SHARP PULSATILE PAIN • REDENING AND WARMTH OF SKIN AND MUCOSA • POORLY DELIMITED SWELLING THAT ERASES THE SKIN FOLDS AND SULCI • LOSS OF FUNCTION • FEVER www. rxdentistry. blogspot. com

LUDWIG’S ANGINA FIRST DESCRIPTION IN 1836 BY DR. VON LUDWIG ANGINA: CHOAKING SENSATION DEFINITION ARCHER: IT’S A BILATERAL, ACUTE, RAPIDLY SPREADING, SEPTIC, INFLAMMATORY, INDURATED, WOOD EN HARD CELLULITIS OF FLOOR OF MOUTH www. rxdentistry. blogspot. com

• THOMA: IT’S A GANGRENOUS CELLULITIS OF LOOSE ALVEOLAR TISSUE WHICH ORIGINATES IN SUBMANDIBULAR SPACE AND SPREADS RAPIDLY TOWARDS FLOOR OF MOUTH • KILLEY-KEY-SEWARD: IT’S A CLINICAL DIAGNOSIS AND IS THE NAME GIVEN TO BRAWNY CELLULITIS OCCURING BILATERALLY AT SUBMANDIBULAR REGION WHICH ALSO INVOLVE SUBLINGUAL SPACE www. rxdentistry. blogspot. com

SPREAD OF INFECTION • ACCORDING TO KRUGER, TOPAZIAN, LUDWIG THIRD MOLARS SUBMANDIBULAR SPACE SUBLINGUAL www. rxdentistry. blogspot. com

CONTRALATERAL SUBMANDIBULAR AND SUBMENTAL SPACE INVOLVEMENT • LASKIN SUBLINGUAL SPACE SPREADS BILATERALLY SUBMANDIBULAR AND SUBMENTAL SPACE www. rxdentistry. blogspot. com

BACKWARD SPREAD TO SUBSTANCE OF TONGUE INFECTION REACHES EPIGLOTTIS SWELLING AROUND LARYNGEAL INLET MICROORGANISM INVOLVED ARE MOJORITILY STREPTOCOCCUS HEMOLYTICUS www. rxdentistry. blogspot. com

ETIOLOGY PERODONTAL, PERICORONAL OR PERIAPICAL ABSCESS OF MANDIBULAR MOLARS NON ODONTOGENIC CAUSES (PSEUDO LUDWIG) COMPOUND FRACTURE OF MANDIBLE NEEDLE INJURY TO FLOOR OF MOUTH FISH BONE INJURY SIALIDINITIS www. rxdentistry. blogspot. com

www. rxdentistry. blogspot. com LUDWIG’S ANGINA

SIGNS AND SYMPTOMS • MASSIVE, FIRM, HARD BOARD LIKE, BRAWNY NON PITTING SWELLING OF NECK EXTENDING DOWN TO CLAVICLE • OPEN MOUTH • DRIBBLING OF SALIVA • RAISED FLOOR OF MAOTH • SHINY MUCOSA • WHITE COLLAR APPEARANCE • STIFF TONGUE TOUCHING PALATE • DYSPHAGIA, DYSPNOEA www. rxdentistry. blogspot. com • EDEMA OF GLOTTIS

• AIRWAY OBSTRUCTION • OTHER FEATURES OF TOXEMIA SEQUELE IT CAN CAUSE MEDIASTINITIS LEADING TO ASPIRATION PNEUMONIA AND DEATH DUE TO RESPIRATORY PARALYSIS IT CAN INVOLVE PTERYGOID COMPARTMENT AND VIA PTERYGOID PLEXUS CAN CAUSE CAVERNUS SINUS THROMBOSIS IT CAN CAUSE SEPTICEMIA OR BACTEREMIA BECAUSE OF HEMATOLOGICAL SPREAD www. rxdentistry. blogspot. com

GENERAL MANAGEMENT www. rxdentistry. blogspot. com

• PROPER HISTORY TAKING AND EXAMINATION AND INVESTIGATIONS • ANTIBIOTIC – ANALGESIC THERAPY • ANTIINFLAMMATORY DRUGS • FLUID BALANCE AND AIRWAY ESTABLISHMENT WHERE REQUIRED • REMOVAL OF FOCUS OF INFECTION • ESTABLISHMENT OF DRAINAGE • ADEQUATE MEDICAL CONSULTATION AND REFFERAL www. rxdentistry. blogspot. com

THANK YOU REFFERENCES: MEDICINA ORAL LASKIN TOPAZIAN www. rxdentistry. blogspot. com ARCHER

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