spread of infection Flashcards
palatal bone Vs buccal bone
palatal bone tends to be more dense
so less likely to spread that way as looks for path of least resistance
(more likely if palatal root or lateral incisor as palatally placed root)
more painful palatally as less space than buccally
below buccinator maxillary abscess infection spread
Could go below buccinator, draining sinus – bad taste, painless, can go a while before tx unlike the other two
maxillary abscess spread upwards causes
sinusitis
muscle which impact maxillary spread of infection
buccinator
muscles which impacts mandibular spread of infection
mylohyoid and buccinator
mandibular abscess which breaks above the inseriton of mylohyoid
into sublingual space - sublingual abscess
mandibular abscess which breaks below the mylohyoid insertion
submandibular space = submandubular abscess
buccal spread of mandibular infection
possible but less common than lingual spread as bone thick on buccal posterior
but if anterior abscess more likely as bone thinner in labial region
lower abscess infection perforate above the insertion of buccinator
drain as pus into oral cavity
lower abscess perforate below insertion of buccinator
enter buccal space - swelling
importance of mylohyoid in lower infection spread
mylohyoid muscle insertion determines where infection can spread to in mandible
- Attaches to mylohyoid line
- sublingual spread above
- submandibular spread below
Depends on which tooth
- premolar - sublingual
- 7- submandibular
Mylohyoid Not continuous
- Open at back so infection from sublingual space can spread to submandibular and vice versa
if infection spread back from jaw can spread into
posterior potential spaces
posterior potential spaces areas
pterygoid plates region
many muscle and bones – lots of spaces, healthy individual filled with alveolar connective tissue quite flat
infection can spread into them as easy due to little resistance and then can progress to more when penetrate one
spaces are quite explanatory
- pterygomandibular space – bound by mandible and two pterygoids
- superficial temporal on outside of temporalis muscle compared to deep temporal space
- infratemporal space
- masserteric space
all spaces communicate with each other
- infection spread in – muscle spasm, trismus
- all the spaces can be referred to as masticatory spaces*
if posterior potential spaces infected
can cause muscle spasm and trismus
they are all interconnected
masticatory spaces a.k.a
posterior potential spaces
pterygomandibular space
bound by mandible and 2 pterygoids
superficial temporal space
outside of temporalis muscle
deep temporal space
inside of temporalis muscle
masseteric space
between masseter and madnibular ramus
infratemporal spasce
above lateral pterygoid muscle below deep temporal space and sphenoid bone
infection spread deeper after posterior spaces into
lateral pharyngeal space
retrophargneal space
prevertebral space
plane for this disection
coronal
plane for this disection
sagittal
what is in the lateral pharyngeal space
holds imp vessels and nerves
if able to open mouth , can see pharyngeal wall being pushed in, bulge
after invading the lateral pharyngeal, retropharyngeal and prevertebral space
where can infection spread
into infection of chest
plane here
lateral
spread from retropharyngeal space
up into skull
down into superior mediastinum
prevertebral space spread
up into skull
down into inferior mediastinum
spread into chest spaces impact
cause cardiac tamponade as infection can add pressure to heart
or abscess in brain
rare but serious
cavernous sinus thrombosis
infection spread to brain
both lower and upper tooth infection can spread through venous connections to brain – complex but serious
lower tooth infection spread to cavernous sinus
Infection from lower tooth can spread into lateral pharyngeal space
into infratemporal space,
goes into pterygoid venous plexus – communicates with brain and veins are valve less so blood can flow in both directions meaning infection can spread in both direction
upper tooth infection spread into cavernous sinus
Infection from upper tooth – spread into infraorbital space
angular and infraorbital veins there (valve less) then into brain
intial spread of infection for upper anterior teeth
lip
nasolabial region
lower eyelid
intial spread of infection for upper lateral incisor
(palatally placed root)
palate - less common
intial spread of infection for upper premolars and molars
cheek
infra-temporal region
maxillary antrum (very rare)
palate (less common)
what is this
palatl abascess
very painful, tissue strech
likely due to grossly carious lateral incisor
what is this
intraoral labial abscess
spread buccally below insertion of muscles
what is this
buccal/infraorbital spread
spread buccal above insertion of muscles, parial closure of eye
swelling of infraorbital and buccal space - linked
what is this
infraoribital spread
tend to lose nasolabial fold when infraorbital space invaded due to skin stretching
likely canine source of abscess for pure infraorbital spread as higher apex
what is this
Nasolabial fold unaffected, relatively mild – not red yet but is swollen
what is this
buccal space infraorbital spread
nasolabial fold is unaffected in this case
likely way for upper tooth abscess infection to spread
Can spread further but tend to go up into brain
Unusual for uppers to spread lower
- unless get into buccal space and then spread into lateral pharyngeal via pterygomandibular space (lowers tend to spread down quickly, less so for anteriors)
initial spread of infection for lower anterior
mental and submental space (tend to stick there)
could spread back into sublingual and submandiular space (not often)
inital spread of infection for lower premolars and molars
- Buccal Space (1st)
- Submasseteric Space
- Sublingual Space (1st)
- Submandibular Space (1sT)
- Lateral Pharyngeal Space
what is this
submental sinus track to skin
Chronic sinus formation
Once cause removed, need to do plastic surgery to get rid of scar
Pt often don’t think teeth is source of issue – go to doctor/dermatologist who incise and it keeps recurring as infections cause still present
cause - grossly carious lower anteriors
what is this
submental spread
tends to be self limiting
burst and drain through skin
what is this
submandibular space spread
red
starting to obliterate the inferior border of mandiblar
could spread to other side or worringly backwards into submasserteric space or ptergomanidublar space and then lateral pharyngeal space
what is this
buccal and submandibular space spread
cannot see border of mandible - concern, likely systemically unwell
what is this
submandibular sinus tract to skin
submandibular spread which burst through skin
drained but now has scar - can be tx once cause removed (here unerupted premolar)
management of spread of infection from abscess done under
LA if pt comfortable if not GA
3 principles of managament of spread of infection from abscess
establish drainage
removal of source of infection
antibiotic therapy? (not routine)
estrablishment of drainage can be
extra oral
or
intra oral
removal of source of infection
how
Tooth itself
- Extirpate the pulp
- Extract
Ideally on the day, but could be too painful so need to revisit (delayed removal of source)
antibiotic therapy dependent on
many factors - not routine
- Toxicity
- Desirability
- Medical history
no indication for antibiotics when
if able to remove source of infection and obtain proper drainage from all location and pt systemically well
indication for antiobiotcs
if unable to establish proper drainage for all areas or pt systemically unwell
what to look for when trying to detect if systemic infection
SIRS scores
SIRS stands for
Systemic Inflammatory Response Syndrome
4 element of SIRS scores
- Raised temperature
- Raised heart rate
- Raised respiratory rate
- Raised white cell count
if pt has any of the 4 SIRS scores
need IB AB urgently - get to hospital for management
e.g management here
Extra-oral incision and drainage – submandibular region,
- be careful of facial nerve marginal mandibular branch (goes down beyond mandible border and comes back up to corner of mouth)
- standard rule is to go at least 2 finger breadths below inferior border of the mandible
drain after making incision
- Hold finger in the incision to stimulate flow
- Hilton Technique
- Use two ended instrument that can be opened (like scissors, tweezers), close it and place it in the incision and open it to stretch the tissues to allow pus to drain
Serosanguinous combination – blood and pus
Try and get as much as you can
Placement of extra-oral drain to get the last of the infection, held in place by non-resorbable sutures (prolene) for a few days (sterile surgical tubing) with dressing over
- checked periodically and if dirty still draining, when clean on checked likely ready for drain to be removed
what is this
buccal space spread
what is this
submandibualr space spread
lower down than usual
what is this
Extra oral sinus
Unusual – draining sinus tend to be lower tooth not upper
ludwig’s angina
Bilateral cellulitis of the sublingual and submandibular spaces (as a result of dental infection)
e.g. dental cause of ludwig’s angina
lower molar infection spreads to sublingual space then submandibular space on that side,
crosses over and spread into the other two sublingual and submandibular spaces.
Then large swelling under neck with raised tongue (due to infection underneath).
Serious – compromise airway and difficulty swallowing – urgent tx needed, likely also systemically unwell
intraoral features of ludwigs angina
- Raised tongue
- Difficulty breathing
- Difficulty swallowing
- Drooling
extra oral features of ludwig’s angina
- Diffuse redness and swelling bilaterally in submandibular region
systemic features of ludwig’s angina
- Increased heart rate
- Increased respiratory rate
- Increased temperature
- Increased white cell count
- If low HR/resp/ temp – worrying, going into shock*
- Check pt when in the chair with infection – one raised, worried send to max fax*
National Early Warning Score
NEWS
used in emergency med, higher score more unwell pt
3 are SIRS scores which can check in chair
ACVPU
A = Alert
C = Confusion
V = Responds to verbal commands
P = Responds to pain
U = Completely unresponsive
used to asses pt
