Spread of Infection

Question 1

What are the symptoms of pulp hyperaemia/reversible pulpitis?

Answer 1

Pain lasting for seconds

Pains stimulated by hot/cold or sweet foods

Pain resolves after stimulus

Caries approaching pulp but tooth can still be restored without treating the pulp.

Question 2

What are the clinical features of Ana cute pulpitis/irreversible pulpitis?

Answer 2

Lingering pain once stimulus removed
Spontaneous pain
Constant pain
Sensitive to hot but cold can make it better
Analgesia does not help
Sleep loss
Poorly localised pain

Question 3

A patient presents with pain, what do you do?

Answer 3

Full history- SOCRATES
- Has analgesia helped? Have you had sleep loss? Any swellings? Difficulty swallowing? Do you feel systemically unwell?

PMH, PDH, drug history, SH.

Full E/O and I/O examination
- Any evidence of disease- swelling, pus, sinus tract, caries, large periodontal pockets.

Percussion tests
Sensibility tests
Radiographs
Tooth sleuth if querying fracture
Diagnostic LA
Mobility

Question 4

What signs are present in an acute periodontitis?

Answer 4

Can be symptomatic or asymptomatic.

Tooth will be TTP
Tooth is non-vital- negative to sensibility tests
Slight increase in mobility

Radiographic features
- Loss of clarity of the lamina dura
- Radiolucent shadow surrounding the apex of the tooth.
- Widening of PDL space

Question 5

What is Traumatic periodontitis?

Answer 5

Caused by parafunction- tooth clenching or grinding.

Question 6

What are the signs and symptoms of Traumatic Periodontitis?

Answer 6

Tooth will be TTP
Normal vitality
Examine the occlusion- functional positioning and posturing.

Radiographs- may show widening of the PDL.

Question 7

What is the treatment for Traumatic Periodontitis?

Answer 7

Occlusal adjustment

Treatment for parafunction.

Question 8

What is an acute apical abscess?

Answer 8

Inflammatory reaction to pulpal infection and necrosis.

Formation of pus resulting from infection within the tooth that has leached out into the bone and eventually into the soft tissues.

Question 9

What clinical features and symptoms might you see in someone with an acute apical abscess?

Answer 9

Initially they will have the same symptoms as an acute apical periodontitis.

Severe unremitting pain
Acute tenderness in function
Acute tenderness on percussion
Rapid onset
Spontaneous pain
Pus formation

but…. no swelling redness or heat (yet)

Question 10

What happens once the abscess perforates bone?

Answer 10

Pain often goes away at this stage.
- Not as TTP now because the pressure has been released as the pus is escaping into the bone.

Once the abscess perforates bone and invades the soft tissues- this is when you will get swelling, redness, heat.

Then as the swelling increases, the pain returns.

Question 11

What is the treatment for an acute apical abscess?

Answer 11

Establish drainage-
- Soft tissue incision intra-orally
- Soft tissue excision intra-orally
- Remove the source of infection- extract the tooth, pulp extirpation or periradicular surgery.

Antibiotics not always required but consider in the following cases
- Immunocompromised patients
- Diabetes
- Elderly
- Airway compromised
- Dysphagia
- Severe Trismus
- Lymphadenitis
- Swelling in FOM.

Question 12

What are the 5 cardinal signs of inflammation?

Answer 12

Redness
Pain
Loss of function
Swelling
Heat

Question 13

What is a chronic apical abscess?

Answer 13

Inflammatory reaction to pulpal infection and necrosis.

Characterised by
- Gradual onset
- little or no discomfort
- Discharge of pus through a sinus tract.
- Radiographic evidence of radiolucency.

Question 14

If you weren’t sure where the sinus was draining from, what could you do?

Answer 14

GP into the sinus tract and take a radiograph.

Question 15

What influences spread of infection?

Answer 15

Tooth location
Root length
Surrounding structures

Question 16

What are the potential routes of spread of infection in the maxilla?

Answer 16

Palate
Buccal/ into the buccal space
Into the oral cavity
Maxillary sinus- would have signs of sinusitis

Question 17

What potential posterior spaces might the infection spread to?

Answer 17

Pterygomandibular space
Infratemporal space
Superficial temporal sapce
Deep temporal space
Masseteric space

If there is any infection in these areas- the muscles will spasm.
- Clinically this will manifest as severe trismus.

Question 18

How would you know if the infection had spread into the lateral pharyngeal space?

Answer 18

Pharyngeal wall being pushed in if infection is in the lateral pterygoid space.

Question 19

Where can infection spread from the lateral pharyngeal space?

Answer 19

Retropharyngeal space and prevertebral spaces.

Question 20

Where can Infection in the retropharyngeal space drain to?

Answer 20

Spread into base of the skull and down into the superior mediastinum.

Question 21

Explain how an infection in the lower teeth can lead to infection in the brain?

Answer 21

Infection in the lower teeth can spread into the lateral pterygoid space and end up in the infra temporal space.

The pterygoid venous plexus is in the infra temporal space and this communicates with the brain.
- infection can get into the pterygoid venous plexus and spread to the brain.

Question 22

How can infection in the upper teeth lead to an infection in the brain?

Answer 22

Infection can also spread to the infra temporal region from the upper teeth and into the veins here and reach the cavernous sinus.
- into the brain from here.

Question 23

If you have an infection in your upper lateral incisor, where is the infection most likely to spread to?

Answer 23

Palate but can also go buccally.

Question 24

If there is infection of the upper anterior teeth, where is this likely to spread to?

Answer 24

Upper lip
Nasolabial fold
Infraorbital region

Question 25

For an upper premolar or molar, where is the infection likely to spread to?

Answer 25

Buccal space/buccally
Maxillary sinus
Palate
Infra-temporal region
Into the oral cavity

Question 26

For lower teeth, what routes of spread of infection might occur?

Answer 26

If infection perforates above the mylohyoid attachment- it will go into the sublingual space

If the infection perforates below the mylohyoid attachment- it will go into the submandibular space.

Buccally

Buccal space

Question 27

If infection was present in the lower anterior teeth, where is the infection likely to spread to?

Answer 27

Mental and submental space.

Question 28

For lower premolars, where is the infection likely to spread to?

Answer 28

If it spread lingually initially, it is likely to spread into the sublingual space.

This will eventually go into the submandibular space because there is no attachment posteriorly in the mylohyoid.

Can also spread buccally.

Question 29

For lower molars, where is the infection likely to spread to?

Answer 29

Likely to spread lingually because the bone is much thinner in this region.

If it starts to spread lingually, it is more likely yo spread to the submandibular space because the roots of the molars are below the mylohyoid attachment at the mylohyoid line.

May eventually spread backwards into the lateral pharyngeal space.

Can also spread buccally.

Question 30

What management if required for a swelling?

Answer 30

Establish drainage- intra-oral or extra-oral

Remove the source of infection- extirpate the pulp if restorable or XLA.
- May be done immediately or delayed because it can be difficult to anaesthetise the patient when there is a large swelling.

+/- antibiotics- depending on medical history, toxicity, dysphagia, airway compromised, lymphadenopathy, systemically unwell.

Question 31

What is Ludwig’s angina?

Answer 31

Bilateral cellulitis of the sublingual and submandibular spaces

It can compromise the airway.

Question 32

What are the symptoms of Ludwig’s angina?

Answer 32

Intra-orally-
- Raised tongue
- Difficulty breathing
- Difficulty swallowing
- Drooling

Extra-orally- diffuse redness ad swelling bilaterally in the submandibular region.

Systemically
- Increased heart rate
- Increased respiratory rate
- Increased temperature
- Increased white cell count.

Question 33

If you suspect Ludwig’s Angina, what would you do?

Answer 33

Immediately call MAXFACS and A&E- will require IV antibiotics and fluids.