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Reno Rudiman
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Background
Infections of the teeth have plaguedhumans constantly, despite a quest forbetter oral hygiene.
Infections usually arise from pulpitis andassociated necrotic dental pulp that initiallybegins on the tooth's surface as dentalcaries.
The infection may remain localized orquickly spread through various fascialplanes.
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Pathophysiology
Odontogenic infection may be primary or
secondary to periodontal, pericoronal,
traumatic, or postsurgical infections.
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Once enamel is dissolved, the infectious
caries can travel through the microporousdentin to the pulp
In the pulp, the infection may develop a track
through the root apex and burrow throughthe medullar cavity of the mandible ormaxilla.
The infection then may perforate the corticalplates and drain into the superficial tissues ofthe oral cavity or track into deeper fascialplanes.
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Serotypes ofStreptococcus mutans
(cricetus, rattus, ferus, sobrinus) are
primarily responsible for causing oral
disease.
Although lactobacilli are not primary
causes, they are progressive agents ofcaries because of their great acid-
producing capacity.
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Frequency
Dental caries is the most common chronicdisease in the world. The late 1970ssignaled a decline in caries in certainsegments of the world due to the additionof fluoride to public drinking water. In theUS, a 36% decrease in caries occurredfrom 1972-1980.
In the United Kingdom, a 39% decline incaries occurred from 1970-1980.
In Denmark, a 39% decline occurred from1972-1982.
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Morbidity/Mortality
Dental caries is not a life-threatening
disease; however, if an odontogenic
infection spreads through fascial planes,
patients are at risk for sepsis and airwaycompromise (eg, Ludwig angina,
retropharyngeal abscess).
Odontogenic infections carry significantmorbidity of pain and cosmetic defect.
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History
Patients with superficial infections may
complain of localized pain, edema, and
sensitivity to temperature and air.
Patients with deep infections or
abscesses that spread along the fascial
planes may complain of fever anddifficulty swallowing, breathing, and
opening the mouth.
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Physical: Local Infection
Typically, the tooth is grossly decayed,
though it may be normal with cavitated
lesions that may have a surrounding
chalky demineralized area and swollenerythematous gingiva.
Affected teeth generally are tender topercussion and temperature.
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Physical: Local Infection
Dentoalveolar ridge edema is evidencedby a periodontal, periapical, andsubperiosteal abscess.
Infection from the tooth spreads to theapex to form a periapical or periodontalabscess.
With further invasion, the infection mayelevate the periosteum and penetrateadjacent tissues.
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Physical: Local Infection
Pericoronal infection occurs in anerupting or a partially impacted toothwhen tissue covering the tooth's crown
becomes inflamed and infected.
An abscess may form and requireincision and drainage (I&D).
The tooth itself usually is not involved.
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Physical: Mandibular Infection
Submental space infection is
characterized by a firm midline swelling
beneath the chin and is due to infection
from the mandibular incisors. Sublingual space infection is indicated
by swelling of the mouth's floor with
possible tongue elevation, pain, anddysphagia due to anterior mandibular
tooth infection.
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Sublingual space
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Spread of infection
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Physical: Mandibular Infection
Submandibular space infection is
identified by swelling of the
submandibular triangle of the neck
around the angle of the jaw. Tenderness to palpation and mild trismus is
typical.
Infection is caused by mandibular molar
infections.
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Submandibular space infection
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Physical: Mandibular Infection
Retropharyngeal space infection is
identified by stiff neck, sore throat,
dysphagia, hot potato voice, and stridor
with possible spread to the mediastinum. These infections are due to infections of the
molars.
More common in children younger than 4 years.
Etiology: URTI with spread to retropharyngeallymph nodes.
High potential for spread to the mediastinum
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Ludwig angina
Characterized by brawny boardlike swellingfrom a rapidly spreading cellulitis of thesublingual, submental, and submandibularspaces with elevation and edema of thetongue, drooling, and airway obstruction.
Odontogenic in 90% of cases and arisesfrom the second and third mandibular molarsin 75% of cases.
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Ludwig angina
If infection spreads through the
buccopharyngeal gap (space created by
styloglossus muscle between the middle
and superior constrictor muscle of thepharynx), potential exists for adjacent
retropharyngeal and mediastinal
infection.
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Middle and lateral facial edema
Buccal space infection is typically indicated
by cheek edema and is due to infection of
posterior teeth, usually premolar or molar.
Masticator space infection always presentswith trismus manifestation and is due to
infection of the third molar of the mandible.
Large abscesses may track toward the posterior
parapharyngeal spaces.
Patients may require fiberoptic
nasoendotracheal intubation while awake.
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Middle and lateral facial edema
Canine space infection is evidenced by
anterior cheek swelling with loss of the
nasolabial fold and possible extension to
the infraorbital region. This is due toinfection of the maxillary canine and
potentially may spread to the cavernous
sinus.
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Gingivitis
Acute necrotizing ulcerative gingivitis(Vincent angina, trench mouth) is acondition in which patients present withedematous erythematous gingiva withulcerated, interdental papillae covered witha gray pseudomembrane.
Patients may have fever andlymphadenopathy and may complain ofmetallic taste. The condition is caused byinvasive fusiform bacteria and spirochetesbut is not contagious.
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Causes:
Serotypes ofS mutans are thought tocause initial caries infection. Infectionsthrough the fascial planes usually arepolymicrobial (average 4-6 organisms).Dominant isolates are anaerobic bacteria.
Anaerobes (75%) - Peptostreptococci,Bacteroides organisms, andFusobacterium nucleatum
Aerobes (25%) - Alpha-hemolyticstreptococci
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Lab Studies
Complete blood count (CBC) with
differential is not mandatory, but a large
outpouring of immature granulocytes
may indicate the severity of theinfection.
Blood cultures in patients who are toxic
may help guide management if thecourse is prolonged.
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Imaging Studies
Panorex and periapical dental films areused to identify involvement of tooth andsurrounding bone in the infectious process.
A soft-tissue x-ray of the neck can be usedto identify gas-producing infections anddetermines any mass effect that maypotentially compromise the airway.
CT scan may be used for severe fascialplane infections to determine the extent,size, and location of the infectious process.
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CT Scan: Ludwig Angina
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Treatment
The infectious odontogenic source must
ultimately be removed or controlled.
Pain medication and antibiotics may be
given if the patient is not systemically ill
and appears to have a simple localized
odontogenic infection or abscess.
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Treatment: Localized infections
I&D may be performed if a periapical orperiodontal abscess is identified,depending on physician comfort level.
After anesthesia of the tooth, locally or with
a dental block, make an incision in themucosa large enough to accommodate aquarter-inch Penrose drain.
Bluntly dissect the abscess cavity with the
tips of a hemostat. Suture in the Penrosedrain with a silk suture and leave untilsuppurative drainage is no longer present(about 2-3 days).
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Treatment: Deep fascial
infection Infections of the neck's deeper fascial
layers and masseteric layers have a higherchance of causing impingement upon theairway directly or indirectly through
extreme trismus. Tracheostomy was the prior method of
choice for establishing the airway; as ofrecently, management through fiberopticnasoendotracheal intubation while patientis awake is preferred.
Various drains and incisions are used fordrainage of the affected fascial space.
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Treatment: Emergency Care
If the patient appears systemically ill
with abnormal vital signs and/or is
unable to take oral medication, consider
admission with further diagnostic studiesand IV antibiotics.
Infections in the various fascial spacesrequire I&D by the consulting physician.
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Treatment: Emergency Care
If airway issues are of concern (eg,Ludwig angina, retropharyngealabscesses), call anesthesiology and
surgeon as soon as possible to establishan airway.
Ensure that equipment for an emergent
cricothyroidotomy is located at thebedside until a secure airway can beestablished.
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Cricothyroidotomy
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