EIGHTEEN

Orofacial Infection and Its Spread

Key Words Periapical (Dental Abscess) Periodontal Abscess Pericoronitis
Routes of Spread of Orofacial Infection Fascial Spaces Facial Cellulites
Necrotizing Fasciitis Cavernous Sinus Thrombosis Infection of Nonodontogenic Origin

KEY WORDS
Abscess
A collection of pus in a cavity formed by disintegration
of tissue as result of infection.
Infection
The communication of disease by the invasion of body
tissue by specific pathogenic microorganisms.
Inflammation
The inflammation is the series of changes which
occurred in the living tissue to response to the irritant,
provided the irritant is not such of to kill the tissue
out right.

Pathophysiology of odontogenic infection can be

explained as: invasion of the dental pulp by bacterial
infection following dental caries of a tooth
inflammation, edema and lack of collateral blood
supply venous congestion or a vascular necrosis
consequently death of the pulp reservoir for
bacterial growth the bacteria penetrate and
spreading into the surrounding bone.
Treatment
1. Suitable antibiotics to control infection.
2. Analgesic, anti-inflammatory to relieve pain and
inflammation.
Table 18.1: The differentiation of abscesses which are
periapical and periodontal in origin

Discharging Sinus
An unhealthy granulation tissue tract opening in one
side of the single compartment (example extraoral
discharging sinus).
Fistulae
An unhealthy granulation tissue tract opening in both
side of two different compartment (example oroantral
fistulae).
Infections of odontogenic in origin have a mixed
bacteriological etiology, which includes streptococci,
which may be aerobic and anaerobic, and Bacteroides,
which are anaerobic. The majority of localized dental
infections are as follows:
Periapical (Dental) Abscess
Commonest type of abscess arises from an infected
pulp chamber.

Periapical (dental) abscess

Pain
History of toothache
swelling Over tooth apex, likely to

Pocket

May or may not be present

Sinus

Tracks to periapically

Percussion

Tooth/teeth tender on
percussion (TTP) specially
on axial direction
Restora- More likely in heavily
tion
restored fractured crown
status
Vitality Tooth nonvital
X-ray
Loss of lamina dura in
periapical region after 10
to 14 days

Periodontal abscess
Acute onset
Usually localized.
Extraoral swelling
may or may not be
present
Always present, more
likely in presence of
periodontal disease
Frequently on
attached gingiva
Tooth/teeth tender
on percussion (TTP),
worse laterally
More likely tooth is
caries-free or
unrestored
Tooth usually vital
Little evidence in early
stages there may be
bone loss

Orofacial Infection and its Spread

127

3. Periapical curettage apisectomy, R.C.T. and crown

preparation if possible.
4. Otherwise remove the offending tooth and
curettage of the socket and sutures.

c. Via the blood stream very rare example local

thrombothlebitis may propagate along the veins,
entering the cranial cavity via emissary veins to
produce cavournous thrombothlebitis.

Periodontal Abscess

The Factors Influencing Spread

An acute infection and collection of pus within a

gingival or periodontal pocket.

The general factors includes:

a. Host resistance.
b. Virulence activity of microbes.
c. Compromise proposed defenses.
d. Combination of both.

Treatment
1. Suitable antibiotics preferably combination with
metronidazole to control infection;
2. Analgesic to relieve pain;
3. Maintenance of oral hygiene by chlorhexidine
mouth wash;
4. Followed by supra and subgingival curettage to
remove the calculus as foreign bodies.
Pericoronitis
Define as infection under the operculum or inflammation of a surrounding soft tissue of a partially
erupted tooth.
Clinical Features
Pain, swelling, difficulty in opening the mouth
(trismus), difficulty in swallowing (dysphagia),
regional lymph adenopathy.
Treatment
1. Primary treatment of irrigation under the
operculum with hydrogen per oxide or povidone
iodine solution.
2. Antibiotic, analgesic and anti-inflammatory to
control spread of infection, trismus and lymph
adenopathy.
3. The secondary treatment includes chemocautarization by 30 to 40 percent trichlor acetic acid to
cautarize the opercurculum or operculectomy by
electrocautary loop.
4. In case of repeated episodic attack, surgical
removal of the offending tooth is a choice of
treatment.

Local Factors
a. Via alveolar bone.
b. Via periosteum.
c. Adjacent fascia and muscles.
Spread of Infection
The majority of infection remains localized and
infection may spread in the form of pus from an
infected tooth with spread along the path of least
resistance. This may produce an extra-oral and intraoral discharging sinus. This may spread along the
tissues and fascial planes to produce severe life
threatening systemic infection. The pattern of spread
associated with specific teeth having a distinct
correlation can be shown as in Table 18.2.
Fascial Spaces
The fascial spaces are potential areas between layers
of fascia. These areas are normally filled with loose
connective tissue, which readily breaks down when
invaded by infection, as per Shapiro.

Routes of Spread of Orofacial Infection

a. By direct continuity via the tissue.
b. Via the lymphatics into the regional lymph nodes
and subsequently into the blood stream.

Fig. 18.1: Lymphatic drainage of tongue

Synopsis of Oral and Maxillofacial Surgery

128

Table 18.2: Pattern of spread of odontogenic abscesses

according to position of the tooth and the potential path
of spread

Buccal
Mandibular

Potential path of spread

Preauricular

Molars and premolars

Swelling or sinus in buccal sulcus

may spread to buccal space (lateral
to buccinator)

Postauricular

Canine

Canine fossa - facial nasolabial fold

area

Lateral incisor

May track to palate due to distal

inclination of root, - but usually
labial

Tooth
Maxillary teeth

Cental incisor

Labially - can give a swollen lip

Mandibulor teeth
Pericoronitis may tack
buccally along the inner
aspect of buccinator to
present in second
pre-molar and first
molar region. Migratory
abscess of buccal sulcus

Both have the potential to

spread in various direction,
submandibular space via lingual
plate, pterygo mandibnular space,
lateral pharyngeal space and on
down the neck

Second molar

Spread laterally infection from the

third molar may gives severe
trismus with an extension into the
submasseteric space

First molar

Buccally, if lingual may be submental or submandibular depending on level of drainage and

mylohyoid attachment

Premolar and canine

Buccally

Incisors

Labially

The location of the lymphatic nodes and the

lymphatic drainage areas of the face and neck:
Lymphatic nodes

The areas of drainage

Submental

The tip of tongue, part of the floor

of the mouth in the midline,
mandibular incisors, related
gingiva, middle alveolar process
and basal bone of the mandible,
midportion of lower lip and chin
All maxillary teeth, mandibular
teeth except incisors, inferior nasal
cavity, palate, body of tongue,
upper lip, lateral portion of lower
lip, angle of mouth, medial angle
of eye, and submittal lymph nodes
Skin of the medial angle of eye, skin
of anterior face, superficial part of
nose

Submandibular

Accessory facial
infraorbital

Infra-auricular
Occipital
Superficial cervical
Deep cervical

Skin of anterior face, mucous

membrane of lips and cheeks
Skin over mandible, mucous
membrane of lips and cheeks
Skin inferior to temple, external
auditory meatus, lateral part of
forehead, lateral part of eyelids,
posterior part of cheeks, portion of
outer ear, parotid gland
External ear, scalp above and
behind the ear
Pre and postauricular nodes
Scalp posterior to ear, occipital
region
Pinna and adjoining skin, pre and
post auricular nodes
Submandibular, submental,
inferior auricular, tonsillar and
tongue nodes.

Facial Cellulites
It is a diffuse inflammation involving subcutaneous
and deeper tissues on examination overlying skin is
firm without fluctuation. The condition having the
rapid onset without any formation of pus.
Treatment
1. Surgical eradication of infected focus.
2. Suitable systemic antibiotics.
3. In case of abscess formation, incision and surgical
drainage by Hiltons method is necessary.
Hilton Method
In this technique, a pair of fine sinus forceps are
inserted closed into the wound and opened slowly but
firmly to separate the soft tissue planes. The forceps
are then withdrawn open to avoid damaging nerves
or vessels by closing them blind. This procedure is
repeated till the abscess is reached and pus discharges.
In dental infections, an area of rough cortical bone can
be felt on the mandible or maxilla where the
periosteum has been raised cited from Prof JR
Moore.
Solnitzky discuss an excellent article describe the
relations of dental infection and facial spaces of the
head and neck region. The most common dental
sources of infection are infections of the lower molar
teeth. Such infections tend to spread particularly to
one of the following compartments or space: the
masticator space, the submandibular space, the

Orofacial Infection and its Spread

129

sublingual space and temporal space. Infections of the

maxillary teeth are less frequent and tend to spread
to the pterygopaltine and infratemporal fossae. In
either case, the spreading suppurative process may
involve secondarily the parotid space the lateral
pharyngeal space. In fulminating cases, the infection
may spread through the visceral space into the
mediastinum.
Submasseteric space infection is characterized by
mandibular sub periosteal abscess cellulites of the
mandibular area involving medial pterygoid and
obviously masseter. Clinically, the feature of trismus,
pain and swelling.
Submandibular and sublingual space infection The
most serious infection involving the sublingual and
submandibular space is Ludwigs angina. This acute
overwhelming, generalized condition involving the
above spaces. This is a cellulites involving floor of the
mouth and quickly extend into the neck. Tongue and
floor of the mouth are elevated. As it tracks down to
the pharynx, a hot potato speech is a very important
significance feature. The danger signs are dysphasia
and phonation problems includes asphyxia known as
edema glottis and need immediate airways establishment by tracheostomy. Recent advancement of
antibiotics the cases of Ludwigs angina not commonly
seen.

Fig. 18.2: Cross-section of premolar area in mandibular region:

1. Sublingual space
2. Submandibular space
3. Submandibular salivary gland
4. Hyoid bone
5. Mandible
6. Mylohyoid muscle
7. Platysma muscle
8. Deep cervical fascia

Treatment
1. Reverse U shape incision along the deep part of
the chin recommended by Love and Baily for
drainage.
2. High doses of suitable systemic antibiotics along
with the intravenous or oral fluids and therapeutic
oxygen.
3. If necessary tracheostomy for airway establishment.
Necrotizing Fasciitis
This is a rare infection in the head and neck
characterized by a rapidly progressive necrosis of
fascia and subcutaneous fat, which undermines and
eventually causes necrosis of overlying subcutaneous
tissue and skin.
Cavernous Sinus Thrombosis
The facial veins do not have any valve. The veins in
the facial regions directly communicate with the

Fig. 18.3: Cross-section of mandibular ramus region:

1. Superficial temporal space
2. Infratemporal space
3. Masseteric space
4. Pterygomandibular space
5. Lateral pharyngeal space
6. Lateral pterygoid muscle
7. Medial pterygoid muscle
8. Temporalis muscle

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Synopsis of Oral and Maxillofacial Surgery

cranial cavity, and very rarely infection may backtrack

from the face up into the skull to the cavernous sinus.
According to Eagleton, the six important features
of cavernous sinus thrombosis:
1. A known site of infection.
2. Evidence of blood stream infection (septicemia).
3. Early sign of venous obstruction of the retina,
conjunctiva, or eye lid.
4. Paresis of the third, forth and sixth cranial nerves
resulting from inflammatory edema.
5. Abscess formation of neighboring soft tissues;
6. Evidence of meningeal irritation.
The condition is very dangerous and fatal to the
patient. The recent advancement of antibiotics and the
supportive surgical protocol the condition can be
controlled before the development of the cavernous
sinus thrombosis.
Treatment
1.
2.
3.
4.
5.

High doses of selective systemic antibiotics.

Fluid transfusion, therapeutic oxygen.
Treatment of toxemia.
Constant monitor of the patient.
In case of edema glottis emergency tracheotomy.

Infection of Nonodontogenic Origin

Any of the spreading infection above may derived
from non-odontogenic sources as follows:
1. Salivary Gland: Suppurative parotatis.
2. Skin: Furncle (Suppurative follicutitis), infected
sebaceous cyst.
3. Bone: Acute osteomyelitis and chronic osteomyelitis (See the Vol. I).
4. Nasal passages, paranasal sinuses infection (See the
Vol. I).
Assessment of Infection
History of the patient includes speed of onset, features
of toxemia and difficulty in breathing and swallowing.
Medical factors may be due to drugs, diabetes.
Examination includes TPR, heart rate, lymphadenopathy, spread towards floor of the mouth, tongue
elevation, neck involvement and special examination
of airway and voice. Delineate extend of swallowing
as base line. Bacteriological culture includes aspiration
of pus and culture. Other test includes radiography,
vitality test and urinalysis (routine urine analysis,
random blood sugar and PP Blood sugar).

Treatment
1. Removal of infective focus;
2. Incision and drainage by Hilton methods;
3. Suitable appropriate antibiotics, for control of
infection;
4. If necessary fluid transfusion;
5. Relief of pain by suitable analgesics.
Some Analytical Observations
1. Submasseteric space infection is more common in
Disto Angular impaction as because the insertion
of the masserter of the intermediate part is floating
or loosely attached below (Bransby and Zachary)
Cited from Shafer. The infection and pus may tract
the least resistance path under the masseter which
is attached to the lateral surface of the ramus of
the mandible.
2. Migratory abscess of buccal sulcus is a complication of subacute pericoronitis. Pus may track
buccally along inner aspect of the buccinators and
discharging extra oral sinus in relation to the first
molar and second premolar cited from Howe.
3. Impacted lower third molar have the potential to
spread in many directions; some mandibular space
via lingual plate, pterygo mandibular space, lateral
pharyngeal space and on down the neck. Spreading
laterally infection from the third molar may give
severe trismus with an extension into the submasseteric space.
4. The choice of antibiotics depends on certain aspects
in orofacial infections. The oral surgeon should
provide drainage of any collection of pus whether
by incision, extirpation of pulp, or extraction.
Ideally antibiotics, supplement of drainage, where
drainage is possible. But certain clinical features
like:
Toxemia ( temperature and malaise)
Associated regional lymphadenitis
Trismus
Dysphagia
Inadequate drainage
Supportive medical background
Rapid spread towards soft tissue.
Demands Intensive Immediate Antibiotic Therapy
The empirical choice of antibiotics commonly and
recent trend of using as follows:
Penicillin derivatives Amoxycillin 500 mg 8 hourly
alone and Cloxacillin 500 mg 8 hourly used combine,
in case of normal infection.

Orofacial Infection and its Spread

In case of allergic to penicillin derivatives,

Erythromycin 600 mg 6 to 8 hourly may be given.
Gentamicin (Genticin actively against some resistance
staphylococci and Seudomonas auriginosa. 80 mg
twice daily by I/M route along with ampicillin 500 mg
twice daily by I/M route. Clindamycin a improvised
form of Lyncomycin very effective against anaerobic
infection and achieve high concentration of bone. It is
used in septicemia, severe dental infection and
osteomyelitis. The doses are 300 to 600 mg 8 hourly
by oral, IM and IV.
Moderate of severe infection authors clinical
experience Cefotexime (Omnatax, Taxim) 1 to 2 gm
twice daily IM, IV as Ceftrioxone (Monocef 1 to 2 gm
IM or IV twice daily is effective.
In addition to that Metronidazole 400 mg 3 times
daily in oral route also effective in anaerobic infection
in orofacial origin.

131

Sometimes due to haphazard irregular use of

antibiotics surgeon may face difficulty to control
infection. In particular case, stoppage of antibiotics for
at least 3 days and collection of infected pus or
materials for culture and sensitivity may helps proper
selection of antibiotics.
Ciprofloxacin 500 mg with Tinidazole 300 mg this
combination drugs twice daily commonly routine
used in case of average normal orofacial infection for
5 to 7 days.
Typical incision and drainage the various facial
spaces recommended by Cunnings et al as A,
superficial and deep temporal space, B, submandibular masseteric space and pterygomandibular space,
C, submental space, D, lateral pharyngeal and
retropharyngeal space.