Spread of Dental Infection

7/27/2019 Spread of Dental Infection

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P r a c t i c a l Hyg i ene 13 S ep t embe r /Oc t obe r 1 9 9 7

he healthy body usually lives inbalance with a number of resident normalflora. However, pathogens can invadeand initiate an infectious process.1 Dental

infections involving the teeth or associ-ated tissues are caused by oral pathogensthat are predominantly anaerobic andusually of more than one species.2 Theseinfections can be of dental origin or froma nonodontogenic source. Those of dentalorigin usually originate from progressive

dental caries or extensive periodontaldisease. Pathogens can also be introduceddeeper into the oral tissues by the traumacaused by dental procedures, such as thecontamination of dental surgical sites(e.g., tooth extraction) and needle tracksduring local anesthetic administration.

Treatment consists of removal of thesource of infection, systemic antibiotics,and area drainage.

Some dental infections are secondary infections incited by an infection in thetissues surrounding the oral cavity, such asthe skin, tonsils, ears, or sinuses. Thesenonodontogenic sources of infectionsmust be diagnosed and treated early.Prompt referral to the patient’s physician will prevent further spread and potentialcomplications. However, many people

today do not have adequate dental ormedical care.

Dental infections can result in dif-ferent types of lesions, depending on thelocation of the infection and the type of tissue involved. An oral abscess occurs when there is localized entrapment of pathogens, with suppuration from a den-tal infection in a closed tissue space(Figures 1 and 2). A periapical abscess

formation can occur with progressivecaries, when pathogens invade the pulpand the infection spreads apically.3

Pathogens can become entrapped in deeppockets with severe periodontal diseaseor around an erupting third molar, caus-

ing periodontal abscess or pericoronitis,respectively.4 Abscess formation may notbe detectable radiographically during theearly stages.5 In the later stages of infec-tion, abscess formation can also lead tothe formation of a passageway, or fistula,in the skin, oral mucosa, or even bone in

order to drain the infection and suppu-rate at the surface (Figures 1 and 2). Theinfectious process causes the overlyingtissues to undergo necrosis, forming acanal in the tissue, with a stoma. If thedental infection is surrounded by the alve-olar bone, it will break down the bone inits thinnest portion (either the facial or lin-gual cortical plate), following the path of

least resistance.2

The soft tissue over a fistula in thealveolar bone may also have an extraoralor intraoral pustule — a small, elevated,circumscribed, suppuration-containinglesion of either the skin or oral mucosa.6

The position of the pustule is largely determined by the relationship betweenthe fistula and the overlying muscleattachments. Again, the infection will fol-

low the path of least resistance (Table 1).The muscle attachments to the bonesserve as barriers to the spread of infec-tion, unlike the other facial soft tissues.2

Cellulitis of the face and neck canalso occur with dental infections, resulting

in the diffuse inflammation of soft tissuespaces.2 The clinical signs and symptomsare pain, tenderness, redness, and diffuseedema of the involved soft tissue space,causing a massive and firm swelling(Table 2). There may also be dysphagia orrestricted eye opening, if the cellulitis

Spreadof Dental Infection

Margaret J. Fehrenbach, RDH,

MS, is an Oral Biologist,

Dental Hygienist, and Educa-

tional Consultant, Seattle,

Washington, and a Clinician

with Woodall and Associates,

Fort Collins, Colorado.

Susan W. Herring, PhD, is an

Anatomist, Researcher, and

Professor of Orthodontics

at the School of Dentistry,

University of Washington,

Seattle, Washington.

b i o

Margaret J. Fehrenbach, RDH, MS

Susan W. Herring, PhD

5

Dental infection can be a serious complication for

patients, especially those without adequate dental or med-

ical care. This modified excerpt from Illustrated Anatomy

of the Head and Neck discusses dental infection lesions. It

also examines the spread of dental infections from the

teeth and associated oral tissues to vital tissues or

organs, as well as prevention and management of this

potentially life-threatening complication. Discussion of

medically compromised patients is also included.

a b s t r a ct

This article is a modified excerpt from:

Fehrenbach MJ, Herring SW. Illustrated

Anatomy of the Head and Neck.

Philadelphia, PA: WB Saunders Com-

pany; 1996. The text, figures, and mod-

ified illustrations are reprinted with

permission of the publisher.



occurs within the pharynx or orbitalregions, respectively. Usually, the infec-tion remains localized and a facial abscesscan form that, if not initially treated, may discharge upon the facial surface. Withouttreatment, cellulitis could spread to theentire facial area, due to perforation of the surrounding bone. Cellulitis is treatedby administration of antibiotics, andremoval of the cause of infection.

Another type of lesion related to den-tal infections is osteomyelitis, an inflam-mation of the bone marrow.1 Osteomyelitiscan locally involve any bone in the body or be generalized (Figure 3). This inflam-mation develops from the invasion of thetissue of a long bone by pathogens usually from a skin or pharyngeal infection. Forthose involving the jaw bones, thepathogens are most often from a periapi-cal abscess, from an extension of cellulitis,or from contamination of surgical sites2

(Figure 3). Osteomyelitis most frequently occurs in the mandible and rarely in the

maxilla, because of the mandible’s thickercortical plates and reduced vascularization.

Continuation of osteomyelitis leadsto bone resorption and sequestra forma-tion. Bone damage is easily detected by radiographic evaluation.5 Paresthesia, evi-denced by burning or prickling, may develop in the mandible if the infectioninvolves the mandibular canal that carriesthe inferior alveolar nerve.2, 6 Localizedparesthesia of the lower lip may occur if the infection is distal to the mental fora-men where the mental nerve exits. Treat-ment consists of drainage, surgical

removal of any sequestra, antibioticadministration, and, in some patients, theadditional use of hyperbaric oxygen.

MEDICALLY COMPROMISED

PATIENTS

Normal flora usually do not create aninfectious process. If, however, the body ’snatural defenses are compromised, thenthey can create opportunistic infections.7

Medically compromised individualsinclude those with AIDS, Type I diabetes,and those undergoing radiation therapy.Some patients, due to their medical his-tory, have a higher risk of complications

from dental infections. Patients in this cat-egory include those at risk for infectiveendocarditis.

SPREAD OF DENTAL INFECTIONS

Many infections that initially start in theteeth and associated oral tissues can havesignificant consequences if they spread to vital tissues or organs. Usually a localizedabscess establishes a fistula in the skin, oralmucosa, or bone, allowing natural drainageof the infection and diminishing the risk of the infection’s spread. This process can beinterrupted by dental or medical treatment.

P r a c t i c a l Hyg i ene 14 Sep t embe r /Oc t obe r 1 997

Figure 1. A periodontal abscess of the maxillary central incisor with fistula and stomaformation (probe inserted) in the maxillary vestibule.

Figure 2. Abscess formation can lead to formation of a fistula in order to drain theinfection. (Photography courtesy of Dr. Michael A. Brunsvold.)

Figure 3. Osteomyelitis of the mandible, with swelling.



Occasionally, a dental infection will spreadto the paranasal sinuses, through the bloodsystem, or through the lymphatics.

SPREAD TO THE PARANASAL

SINUSES

The paranasal sinuses of the skull canbecome infected through the direct spreadof infection from the teeth and associatedoral tissues, resulting in a secondary sinusi-tis. A perforation in the wall of the sinus

can also be caused by an infection. Sec-ondary sinusitis of dental origin occursmainly with the maxillary sinuses, sincethe maxillary posterior teeth and associ-ated tissues are in close proximity to thesesinuses (Figure 4). Thus, maxillary sinusi-tis can occur through a spread of infec-tion from a periapical abscess initiated by a maxillary posterior tooth that perforatesthe sinus floor to involve the sinusmucosa. A contaminated tooth or rootfragment also can be displaced into themaxillary sinus during an extraction, stim-ulating infection.

Most infections of the maxillary sinuses are not of dental origin, but causedby an upper respiratory infection, wheninfection in the nasal region spreads tothe sinuses.2 An infection in one sinus canalso travel through the nasal cavity to othersinuses, leading to serious complicationsfor the patient, such as infection of thecranial cavity and brain. Thus it is importantthat any sinusitis be treated aggressively by the patient’s physician to eliminate theinitial infection.

The symptoms of sinusitis are head-ache, usually near the involved sinus, and

foul-smelling nasal or pharyngeal dis-charge, possibly accompanied by feverand weakness. The skin over the involvedsinus can be tender, hot, and red due toinflammation in the area. Dyspnea occurs,as well as pain, when the nasal passagesand the sinus ostia become blocked by the effects of tissue inflammation. Early radiographic evidence of the sinusitis isthickening of the sinus walls. Subsequentradiographic evaluation may show increased opacity and, possibly, perfora-tion.5 Acute sinusitis usually responds toantibiotic therapy, with drainage aided

through the use of decongestants. Surgery may be indicated for chronic maxillary sinusitis to enlarge the ostia in the lateral walls of the nasal cavity, so that adequatedrainage can diminish the effects of theinfection.2

SPREAD BY THE BLOOD SYSTEM

The blood system of the head and neckcan allow the spread of infection from theteeth and associated oral tissues, becausepathogens can travel in the veins and drainthe infected oral site into other tissues ororgans. The spread of dental infection by


Table 1 Most Common Teeth and Associated Periodontium Involvedin Clinical Presentations of Abscesses and Fistulae

Maxillary vestibule

Maxillary central or lateral incisor, all surfaces, and roots.

Maxillary canine, all surfaces, and roots (short roots below levator anguli oris).

Maxillary premolars, buccal surfaces, and roots.

Maxillary molars, buccal surfaces, or buccal roots (short roots below buccinator).

Penetration of nasal floor

Maxillary central incisor, roots.

Maxillary canine, all surfaces, and root (long root above levator anguli oris).

Palate

Maxillary lateral incisor, lingual surfaces, and roots.

Maxillary premolars, lingual surfaces, and roots.

Maxillary molars, lingual surfaces, or palatal roots.

Perforation into maxillary sinus

Maxillary molars, buccal surfaces, and buccal roots (long roots).

Maxillary molars, buccal surfaces, and buccal roots (long roots above buccinator).

Mandibular first and second molars, buccal surfaces, and buccal roots (long roots

below buccinator).

Mandibular vestibule

Mandibular incisors, all surfaces, and roots (short roots above mentalis).

Mandibular canine and premolars, all surfaces, and roots (all roots above

depressors).

Mandibular first and second molars, buccal surfaces, and roots (short roots

above buccinator).

Submental skin region

Mandibular incisors, roots (long roots below mentalis).

Sublingual region

Mandibular first molar, lingual surfaces, and roots (all roots above mylohyoid).

Mandibular second molar, lingual surfaces, and roots (short roots above mylohyoid).

Submandibular skin region

Mandibular second molar, lingual surfaces, and roots (long roots below mylohyoid).

Mandibular third molars, all surfaces, and roots (all roots below mylohyoid).

Table 2 Possible Space,Teeth,and Periodontium Involved With a Clinical Presentation

of Cellulitis from the Spread of Dental Infection

CLINICAL

PRESENTATION

OF LESION

Infraorbital region,zygomatic region,buccal region

Posterior borderof mandible

Submental region

Unilateralsubmandibular region

Bilateral submandibularregion

Lateral cervical region

SPACE INVOLVED

Buccal space

Parotid space

Submental space

Submandibular space

Submental, sublingual,andsubmandibularspaces with Ludwig’sangina

Parapharyngeal space

MOST COMMON TEETH

AND ASSOCIATED

PERIODONTIUM INVOLVED

IN INFECTION

Maxillary premolars,and maxillary andmandibular molars

Not generally ofodontogenic origin

Mandibular anterior teeth

Mandibular posteriorteeth

Spread of mandibulardental infection

Spread of mandibulardental infection



way of the blood system can occur frombacteremia or an infected thrombus.2 Bac-teria traveling in the blood can cause tran-sient bacteremia following dental treat-ment. Individuals with a high risk forinfective endocarditis may have these bac-teria lodge in the compromised tissues,promoting significant infection deep inthe heart, that can result in massive andfatal heart damage. These patients may

need antibiotic premedication to preventbacteremia from occurring during dentaltreatment.7

An infected intravascular clot orthrombus can dislodge from the innerblood vessel wall and travel as an embo-lus. Emboli can travel in the veins, drain-ing the oral cavity to areas such as thedural venous sinuses within the cranialcavity. These dural sinuses are channels by which blood is conveyed from the cere-bral veins into the veins of the neck, par-ticularly into the internal jugular vein.Because these veins lack valves, however,blood can flow both into and out of thecranial cavity.

The cavernous sinus is most likely tobe involved in the potentially fatal spreadof dental infection.2 The cavernous sinus islocated on the side of the body of thesphenoid bone.8 Each cavernous venoussinus communicates with the one on theopposite side, and also with the pterygoidplexus and the superior ophthalmic vein, which anastomoses with the facial vein(Figure 5). These major veins drain teeththrough the posterior superior and infe-rior alveolar veins and the lips throughthe superior and inferior labial veins.

None of the major veins that communi-cate with the cavernous sinus have valvesto prevent retrograde blood flow backinto the cavernous sinus. Therefore, den-tal infections that drain into these major veins may initiate an inflammatory response, resulting in an increase in bloodstasis, thrombus formation, and increasingextravascular fluid pressure. Increasedpressure can reverse the direction of venous blood flow, enabling the trans-port of the infected thrombus into this venous sinus, and thus cause cavernoussinus thrombosis.

Needle-track contamination can alsoresult in a spread of infection to thepterygoid plexus if a posterior superioralveolar anesthetic block is incorrectly administered.2 Nonodontogenic infec-tions originating from what physiciansconsider the dangerous triangle of theface — the orbital region, nasal region,and paranasal sinuses — also may resultin this thrombosis.

The signs and symptoms of cavernoussinus thrombosis include fever, drowsiness,and rapid pulse. In addition, there is loss of function of the abducent nerve, since it


Frontal sinus

Ethmoid sinuses

Sphenoid sinus

Maxillary sinus

Figure 4. Lateral view of the skull and the paranasal sinuses.

Supraorbitalvein

Ophthalmicvein

Superiorlabial vein

Submentalvein

Facial vein

External jugular veinInternal

jugular vein

Pterygoid plexusof veins

Cavernousvenous sinus

Inferiorlabial vein

Figure 5. Pathways of the internal jugular vein and facial vein, as well as the locationof the cavernous venous sinus.



runs through the cavernous venous sinus,resulting in nerve paralysis. Because themuscle supplied by the abducent nervemoves the eyeball laterally, the inability toperform this movement suggests nervedamage. Also, the patient will usually havedouble vision because of the restrictedmovement of the one eye. There will alsobe edema of the eyelids and conjunctivae,tearing, or exophthalmos, depending on

the course of the infection. With cavernoussinus thrombosis there may also be damageto the other cranial nerves, such as theoculomotor and trochlear, as well as theophthalmic and maxillary divisions of thetrigeminal and changes in the tissues they innervate, since all these nerves travel inthe cavernous sinus wall.8 Finally, thisinfection can be fatal because it may leadto meningitis, which requires immediatehospitalization with intravenous anti-biotics and anticoagulants.1

SPREAD BY LYMPHATICS

The lymphatics of the head and neck canallow the spread of infection from theteeth and associated oral tissues. Thisoccurs because the pathogens can travelin the lymph through the lymphatics thatconnect the series of nodes from the oralcavity to other tissues or organs. Thus,these pathogens can move from a primary node near the infected site to a secondary node at a distant site.6

The route of dental infection travelingthrough the nodes varies according to theteeth involved8 (Figures 6 and 7). The sub-mental nodes drain the mandibular incisors

and their associated tissues. Then thesubmental nodes empty into the sub-mandibular nodes, or directly into the deepcervical nodes. The submandibular nodesare the primary nodes for all the teeth andassociated tissues, except the mandibularincisors and maxillary third molars. Thesubmandibular nodes then empty into thesuperior deep cervical nodes, the primary nodes for the maxillary third molars andtheir associated tissues. The superior deepcervical nodes empty into either the infe-rior deep cervical nodes or directly intothe jugular trunk and then into the vascu-

lar system. Once the infection is in the vas-cular system, it can spread to all tissuesand organs as previously discussed.

A lymph node involved in infectionundergoes lymphadenopathy, whichresults in a size increase and a change inconsistency of the lymph node so itbecomes palpably firm.3 Evaluation of the involved nodes can determine thedegree of regional involvement of theinfectious process, which is instrumen-tal in diagnosis and management of theinfectious process.2

P ra c t i c a l Hyg i ene 17 Sep t embe r /Oc t obe r 1 997

Submandibular lymph nodes

Hyoid bone

Submandibularsalivary gland

External jugularlymph nodes

Anterior jugularlymph nodes

Sternocleidomastoidmuscle

Mylohyoidmuscle

Anterior jugularvein

External jugularveinSubmental

lymph nodes

Figure 6. Superficial cervical lymph nodes and associated structures.

Hyoid bone

Digastricmuscle

Accessory lymphnodes

Internal jugular vein

Sternocleidomastoidmuscle (cut)

Jugulodigastriclymph node

Omohyoid muscle

Accessory nerve

Superior deepcervical lymph nodes

Inferior deep cervicallymph nodes

Supraclavicularlymph node

Clavicle (cut)

Thoracic duct

Jugulo-omohyoidlymph node

Figure 7. Deep cervical lymph nodes and associated structures.



SPREAD BY SPACES

The spaces of the head and neck canallow the spread of infection from theteeth and associated oral tissues becausethe pathogens can travel within the fascial

planes, from one space near the infectedsite to another distant space, by the spreadof the related inflammatory exudate.2

When involved in infections, the spacecan undergo cellulitis, which can causea change in the normal proportions of the face (Table 2).

If the maxillary teeth and associatedtissues are infected, the infection canspread into the maxillary vestibular space,buccal space, or canine space. If themandibular teeth and associated tissuesare infected, the infection can spread intothe mandibular vestibular space, buccalspace, submental space, sublingual space,submandibular space, or the space of thebody of the mandible. From these spaces,the infection can spread into other spacesof the jaws and neck, possibly causingserious complications, such as Ludwig’sangina.2

Ludwig’s angina is a cellulitis of thesubmandibular space (Figure 8).6 Thisinvolves a spread of infection from any of the mandibular teeth or associated tis-sues to one space initially, either the

submental space, sublingual space, oreven the submandibular space itself. Thenthe infection spreads to the sub-mandibular space bilaterally, with a risk of infiltration to the parapharyngeal space

of the neck. With this complication, thereis massive bilateral submandibularregional swelling, which extends downthe anterior cervical triangle to the clavi-cles. Swallowing, speaking, and breathingmay be difficult; high fever and droolingare evident. Respiratory obstruction may rapidly develop because the continuedswelling displaces the tongue upwardsand backwards, thus blocking the pha-ryngeal airway. As the parapharyngealspace becomes involved, edema of thelarynx may cause complete respiratory obstruction, asphyxiation, and death.

Ludwig’s angina is an acute medical emer-gency requiring immediate hospitaliza-tion and may necessitate an emergency cricothyrotomy to create a patent airway.

PREVENTION OF THE SPREAD

OF DENTAL INFECTIONS

Early diagnosis and treatment of dentalinfections must occur for all patients. Par-ticular care must be taken not to conta-minate surgical sites, such as those fromextractions or implant placement. Theremust also be a strict adherence to aseptic

protocol during nonsurgical dental treat-ment, such as restorative and periodontaldebridement therapy, to prevent thespread of infection.4 This may include theremoval of heavy plaque accumulationsor the use of an antiseptic prerinse priorto treatment. During treatment, the useof a rubber dam or an antimicrobial-lacedexternal water supply with ultrasonics orirrigators may be of help in preventing

the spread of infection. After treatment,this might include an antiseptic postrinseat home or antibiotic coverage. Finally, itis important to not administer a local anes-thetic through an area of dental infection,as this could move pathogens deeper intothe tissues.

A thorough medical history withperiodic updates will allow the dentalprofessional to perform safe treatmenton medically compromised patients, toavoid serious complications of their den-tal diseases. These patients may requireantibiotic premedication before dental

treatment to prevent any serious seque-lae or other changes in the dental treat-ment plan.7 A medical consultation isindicated when there is uncertainty regarding the risk of opportunistic infec-tion for the individual patient.9, 10

CONCLUSION

Dental infections can have significantmedical ramifications, including death. As the health care practitioner most famil-iar with patients’ oral health, the dentalhygienist must be knowledgeable of theappearances, causes, and symptoms of

dental infection lesions.REFERENCES

1. Dorland’s Illustrated Medical Dictionary. 28th ed.Philadelphia, PA: WB Saunders Company; 1994.

2. Hohl TH, Whitacre RJ, Hooley JR, Williams BL.Diagnosis and Treatment of Odontogenic Infec-tions. Seattle, WA: Stoma Press; 1983.

3. Bath-Balogh M, Fehrenbach MJ. Illustrated Den-tal Embryology, Histology, and Anatomy.Philadelphia, PA: WB Saunders Company; 1997.

4. Perry DA, Beemsterboer PL, Taggart EJ. Peri-odontology for the Dental Hygienist. Philadel-phia, PA: WB Saunders Company; 1996.

5. Kasle MJ. An Atlas of Dental Radiographic Anatomy. 3rd ed. Philadelphia, PA: WB Saun-ders Company; 1990.

6. Ibsen OC, Phelan JA. Oral Pathology for theDental Hygienist. 2nd ed. Philadelphia, PA: WBSaunders Company; 1996.

7. Tyler MT, Lozada-Nur F. Clinician’s Guide toTreatment of Medically Compromised DentalPatients. New York, NY: American Academy of Oral Medicine; 1995.

8. Gray H. Gray ’s Anatomy. 37th ed. New York,NY: Churchill and Livingstone; 1989.

9. Genco RJ, Newman MG, et al, eds. Annals of Periodontology. Chicago, IL: American Acad-emy of Periodontology; 1996.

10. Bottomley WK, Rosenberg SW. Clinician’s Guideto Treatment of Common Oral Conditions. 3rded. New York, NY: American Academy of OralMedicine; 1993.


Sublingualsalivarygland

Sublingualspace

Submandibular

salivary gland

Submandibularspace

Investingfascia

Mandible

Mylohyoidmuscle

Diagastricmuscle

PlatysmamuscleHyoid

bone

Figure 8. Frontal section of the head and neck highlighting the submandibular andsublingual spaces.



To submit your CE Exerciseanswers, please use theenclosed Answer Card found opposite page 52, and completeit as follows: 1) Complete theaddress; 2) Identify the Article/Exercise Number; 3) Place an xin the appropriate answer boxfor each question. Return thecompleted card to the indicated address.

The 10 multiple-choice questions for this CE exer-cise are based on the article “Spread of DentalInfection” by Margaret J. Fehrenbach, RDH, MS,

and Susan W. Herring, PhD. This article is on pages 13-18. Answers for thisexercise will be published in the November/December 1997 issue of The Journal of Practical Hygiene.

Learning Outcomes:• Cite the cause of dental infection.• Cite the potential consequences of various dental lesions.• Describe the spread of dental infection throughout the body.


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1. What directly causes dental infection involving the teeth or associated tissues?

A. A specific,aerobic oral pathogen predominant in the oral mucosa.

B. Cellulitis of the ethmoid sinus.

C. Oral pathogens that are mainly anaerobic and usually of more than onespecies.

D. Proliferating bacteria transferred via the blood system of the head andneck.

2. What is a potential consequence of orofacial cellulitis?

A. Edema of the diaphragm.

B. A facial abscess that may discharge upon the surface.

C. The lodging of bacteria deep within the lungs.

D. Osteoarthritis.

3. Continuation of orofacial osteomyelitis can lead to:

A. Abscesses of the inner ear.

B. Bone resorption and sequestra formation.

C. Paresthesia of the lower extremities.

D. Weakening of the central nervous system.

4. Most infections of the maxillary sinuses are of dental origin.

A. True.

B. False.

5. What early radiographic evidence indicates sinusitis?

A. A localized abscess of the sinus walls.B. Decreased opacity of the sinus ostia.

C. Enlargement of the sinus ostia.

D. Thickening of the sinus walls.

6. What is a potential consequence of sinusitis?

A. Increased opacity and perforation of the sinus walls.

B. Localized paresthesia of the lower lip.

C. Dysphagia.

D. Nerve damage.

7. How can infection from the teeth and associated oral tissuesspread throughout the body?

A. Always due to overall decreased immunity.

B. Through infectious saliva.

C. Through the blood system of the head and neck.

D. Through the transference of infectious cells.

8. Which of the following is most likely to be involved in the poten-tially fatal spread of dental infection?

A. The carotid sinus.B. The cavernous sinus.

C. The dural venous sinuses.

D. The lymphatic sinus.

9. What are the potential consequences of Ludwig ’s angina?

A. Decreased blood flow to the brain.

B. Decreased metabolism.

C. Muscle atrophy.

D. Respiratory obstruction,asphyxiation,and death.

10. Why should a local anesthetic not be administered through an area of dental infection?

A. Decreased area blood flow increases toxicity.

B. Needle causes a negative ionic field.

C. This could move pathogens deeper into the tissues.

D. Pathogens may enter saliva and be swallowed.

Spread of Dental Infection

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