CELLULITIS

DR.AMITHBABU.C.B
MScD-ENDO
• INTRODUCTION
• CAUSES
• CLINICAL FEATURES
• COMPLICATIONS
• INVESTIGATION
• MANAGEMENT
• CASE REPORT
 INTRODUCTION
• 1Cellulitis may be defined as a non –suppurative
inflammation of the of the subcutaneous tissues
extending along the connective tissue plane and
across the intercellular planes.
• It is also called as phlegmon.
• It is a potential complication of dental infection

1
Text book of oral pathology ,Anil Ghom, first edition-2009, page no: 449
• 2Today we know that serious odontogenic
infections, beyond the tooth socket, are much
more common as a result of endodontic
infections than as a result of periodontal disease.
• The seriousness of an infection beyond the apex
of a tooth depends on the number and virulence
of the organisms, host resistance, and anatomic
structures associated with the infection.
• Once the infection has spread beyond the tooth
socket, it may localize or continue to spread
through the bone and soft tissue as a diffuse
abscess or cellulitis.
2
Endodontics , john ingle5 edition ,page no:69
• 3The terms abscess and cellulitis are often used
interchangeably in common clinical use.
• An abscess is a cavity containing pus (purulent
exudate) consisting of bacteria, bacterial by-
products, inflammatory cells, numerous lysed
cells, and the contents of those cells.
• Cellulitis is a diffuse, erythematous, mucosal,
or cutaneous infection that may rapidly spread
into deep facial spaces and become life
threatening.

3
Endodontics , john ingle 5 edition ,page no:69
• 4As a diffuse Cellulitis matures, it may contain
foci of pus consistent with an abscess.
• The relationship of specific species of bacteria
or aggregates of bacteria with the pathogenesis
of endodontic abscesses/cellulitis has not been
established.
• Endodontic infections occur when opportunistic
pathogens gain access to the normally sterile
dental pulp and produce disease.
• Infections of the root canal system may spread
to the contiguous periradicular tissues.
4
Endodontics , john ingle5 edition ,page no:69
• 5If bacteria from the infected pulp tissue gain
entry into the periradicular tissue and the
immune system is unable to suppress the
invasion ,an other wise healthy patient
eventually shows signs and symptoms of an
acute periradicular abscess, cellulitis or both
• Depending on the relationship of the apices of
the involved tooth to the muscular attachments
,the swelling may be localized to the vestibule or
may extend into the fascial space.

5
Pathways of the pulp stephen cohen 9 edition , page no:591
 CAUSES
• 6Streptococci are particularly potent producers of
hyalurouidase and are therefore a common
causative organism in cases of cellulitis. The less
common hyaluronidase producing staphylococci
are also pathogenic and frequently give rise to
cellulitis.

6
Shafer’s text book of oral pathology, 5 edition ,page no:697
• Cellulitis of the face and neck most commonly results
7

from dental infection, either as sequel of an apical

abscess or osteomyelitis, or following periodontal
infection.
• The pericoronal infection occurring around erupting or
partially impacted third molars and resulting in cellulitis
and trismus is an especially common clinical condition.
• Sometimes cellulitis of the face or neck will occur as a
result of infection following a tooth extraction,
injection, either with an infected needle or through an
infected area, or following jaw fracture.

7
Shafer’s text book of oral pathology, 5 edition ,page no:697
 CLINICAL FEATURES

• 8The patient with cellulitis of the

face or neck originating from a
dental infection is usually
moderately ill and has elevated
temperature and leukocytosis.
• One feels painful swelling of the
soft tissues.
• Much of the swelling is due to
inflammatory edema.
8
Shafer’s text book of oral pathology, 5 edition ,page no:697
• 9There is wide spread swelling ,redness and
pain with out definite localization.
• Tenderness on palpation.
• Tissues are grossly edematous.
• Marked induration
• Tissues are firm to hard on palpation.
• Tissues are often discolored.
• Malaise
• lethargy
9
Text book of oral pathology ,Anil Ghom, first edition-2009, page no: 449
• Swelling of the lymph nodes
10

Large diffused border of the swelling making it

difficult to determine where the swelling begins and
ends.
• Palpation
early cellulitis –soft and tough
Severe cellulitis –firm
• As the typical facial cellulitis persists, the infection
frequently tends to become localized and a facial abscess
may form. When this happens the suppurative material
present seeks to 'point' a out discharge upon a free surface .

10
Shafer’s text book of oral pathology, 5 edition ,page no:697
• 11Swelling develops rapidly
• The skin of swelling pits on pressure
• Swelling becomes red as the inflammation
becomes localized .
• Pain may be sharp and acute , later deep,
throbbing in character, it may increase while
pus is formed and subside when the abscess
ruptures or is incised.

11
Oral and dental diagnosis , Thoma kurt, 2 revised edition., page no:406
CLINICAL PICTURE
Buccal cellulitis
 SPREAD OF INFECTION
• 12
Infections arising in the maxilla
perforate the outer conical layer
of bone above the buccinator
attachment and cause swelling,
initially of the upper half of the
face. The diffuse spread,
however, soon involves the
entire facial area.

12
Shafer’s text book of oral pathology, 5 edition ,page no:700
 SPREAD OF INFECTION IN MAXILLAE
TOOTH
CENTRAL AND LATERAL INCISOR
AREA
Labial ,palatal abscess or
vestibular abscess. Sometimes
may form within the lip.
Enlarged upper lip protrudes

CANINE Labial or vestibular. canine

space abscess.
PREMOLARS Abscess along buccal or palatal
side
MOLARS Swelling of cheek, edema of eye,
pulling of corner of eye,
obliteration of nasiolabial sulcus.
Buccal or palatal surface

Shafer’s text book of oral pathology, 5 edition ,page no:700

Maxillary buccal vestibule Para pharyngeal space

13
Pathways of pulp , Stephen cohen,9 edition, page no;593
 SPREAD OF INFECTION IN MANDIBLE
• When infection in the mandible
14

perforates the outer cortical plate

below the buccinator attachment,
there is a diffuse swelling of the lower
half of the face, which then sees a
superior as well as cervical spread.
Spread to the cervical tissue cause
respiratory discomfort.

14
Shafer’s text book of oral pathology, 5 edition ,page no:700
 SPREAD OF INFECTION IN MANDIBLE
TOOTH AREA

CENTRAL AND LATERAL INCISORS Labial surface and into the chin.

CANINE Labial or vestibular abscess

PREMOLARS vestibular abscesses, and lingual

perforation may form sublingual
abscesses

1 MOLAR More commonly on buccal surface ,to

lower border of mandible,and into
floor of the mouth.

2 MOLAR More commonly on buccal surface ,to

lower border of mandible into
submaxillary space.

3 molar Buccal surface,angle of mandible,and

into submaxillary space.
 Mandibular buccal vestibule
• 15Source of infection from mandibular anterior or
posterior tooth breaks through the buccal cortical
plate and or apices of involved tooth.

15
Pathways of pulp , Stephen cohen,9 edition, page no;593
 Mental space Submental space

16
Pathways of pulp , Stephen cohen,9 edition, page no;594
Sublingual space Submandibular
17
Pathways of pulp , Stephen cohen,9 edition, page no;594
Submasseteric space Buccal vestibule

18
Pathways of pulp , Stephen cohen,9 edition, page no;594
 COMPLICATIONS
• Infections from the mid face can be
19

dangerous because they can result in

cavernous sinus thrombosis .
• If the submental,sublingual and
submandibular spaces are involved at the
same time, a diagnosis of ludwigs angina is
made.

19
Pathways of pulp , Stephen cohen9 edition , page no; 593 and 596
• 20
Orbital cellulitis is a rare but serious sequel
of infection from a dental origin. Without
prompt treatment, further spread of infection
is likely to occur, resulting in loss of vision and
possibly death.

Case report: dental infection leading to orbital cellulitis, Department of

20

Oral and Maxillofacial Surgery, King's College Hospital, London, UK. 1. Dent
Update. 2006 May;33(4):217-8, 220
 LUDWIG'S ANGINA
• Ludwig’s angina is a severe form of
21

cellulitis, beginning usually in the

submaxillary space and secondarily
involving the sublingual and
submental spaces as well.
• The chief source of infection is
involvement of a mandibular molar,
either periapical or periodontal, and it
may also result from a penetrating
injury of the floor of the mouth such
Stab wound, or from osteomyelitis in
a compound jaw fracture.
21
Shafer’s text book of oral pathology, 5 edition ,page no:697
 • Acute cellulitis in some cases may damage the
22

hypoglossal, vagal, glossopharyngeal and

recurrent nerves of both sides.
• 23Orbital cellulitis is also caused as a result of
odontogenic infection.

Diffuse acute cellulitis with severe neurological sequelae. A clinical case.

22

Mallagray R, Betoret J, Navarro Cuellar C, Minerva Stomatol. 1999 Apr;48(4):161-

4.

23
Orbital cellulitis as a sole symptom of odontogenic infection. Ngeow WC.
Singapore Med J. 1999 Feb;40(2):101-3.
 COMMON FEATURES CELLULITIS AND
PERICORONITIS
• Severe pain
• Extra oral swelling
• Fever
• Malaise
• Dehydration
• Difficulty in opening the mouth(depends)
• Lymphadenopathy
Shafer’s text book of oral pathology, 5 edition ,page no:697.698

Carranza 's clinical periodontology,10th edition,, pg no 400,401

 CELLULITIS PERICORONITIS
Most commonly Most commonly
associated with carious associated with unerupted
tooth. third molar.

Clinical features Clinical features

Non Radiating pain Radiating pain
Less frequently with Foul order
restricted mouth opening Most frequently
associated with restricted
mouth opening

Shafer’s text book of oral pathology, 5 edition ,page no:697.698

carranza 's clinical periodontology,10th edition,, pg no 400,401
CELLULITIS AND PERICORONITIS
 INVESTIGATION
• In facial involvement usually requires a panoramic X-
24

ray plus lateral cephalogram to exclude subjacent

osteomyelitis, dental pathologies.
• 25The reaction to the infection may occur very quickly ,
the involved tooth may or may not show radiographic
evidence of a widened periodontal ligament space.
• Sometimes periapical radiograph are required to find
out the involved tooth.
• 26ultrasound can be used as first line diagnostic tool in
the management of fascial space infections.
25
Pathways of the pulp 9 edition , stephen cohen, page no:591
26
Ultrasound as First Line Diagnostic Tool in the Management of Acute Odontogenic
Infection of Fascial Spaces Suprakash .Ba, Srinivas Chakravarthia
 • In most cases the tooth elicits a positive response to
27

percussion and the periradicular area is tender to

palpation.
• 28Ultrasonography is used now a days to differentiate
between abscess and cellulitis.
• Biopsy is seldom performed because of the painful
and difficult surgery, which would not grossly change
the management of the condition
• Complete blood count with differential usually
demonstrates a slight leukocytosis with neutrophilia.

27
Pathways of the pulp 9 edition , stephen cohen, page no:591
28
Ultrasonographic evaluation of inflammatory swellings of buccal space, Srinivas
K, Sumanth KN, Chopra SS. Indian J Dent Res. 2009 Oct-Dec;20(4):458-62 .
 DIAGNOSIS
• Diagnosis can be made from the
History
Clinical examination
X ray
Blood culture
 MANAGEMENT
• The most important elements of effective patient
29

management are correct diagnosis and removal of

the cause of endodontic infection .
• In an otherwise healthy patient , chemomechanical
debridement of the infected root canal and incision
for drainage of periradicular swelling usually prompt
rapid improvement in clinical signs and symptoms.

29
Pathways of the pulp 9 edition , stephen cohen, page no:596
• Antibiotics are recommended , in conjunction with
30

appropriate endodontic treatment , for progressive or

persistent infections with systemic signs and symptoms
such as fever(1000F[37.80C]), malaise, cellulitis,
unexplained, and progressive or persistent swelling or
both.
• 30Antibiotics are given to control infection, and
analgesics may be needed to control pain.

30
Pathways of the pulp 9 edition , stephen cohen, page no:596
 FIRST LINE SECOND LINE
CLASS 1 Flucloxacillin 500mg qds po Pencillin allergy:
Clarithromycin 500mg
bd po
Class 11 Flucloxacillin 2g qds IV Pencillin allergy:
OR Clarithromycin 500mg
Ceftriaxone 1g qds IV bd IV or
(OPAT) Clindamycin 600mg tds
IV

Flucloxacillin 2g qds IV Pencillin allergy:

Class 111 Clarithromycin 500mg
bd IV
or
Clindamycin 900mg tds
IV

Class 1V Benzylpencillin 2.4 g 2-4 hourly IV+

Ciprofloxacin 400mg bd IV+
Clindamycin 900mg tds IV((If allergic to penicillin use Ciprofloxacin
and Clindamycin only)

Odontogenic Neck Infections, Mir Hasan Shaheel Mahmood TAJ June 2005; Volume 18 Number 1
Cellulitis, Morton N. Swartz, M.D. n england journal med 350;9www.nejm.org february26, 2004,
 SURGICAL INCISION AND DRAINAGE

• It is performed when the presence of pus is

31

diagnosed.Its done in case of large cellulitis , a

superficial erythematous spot develops, which is
pathognomic of pus near the superficial surface.
• These superficial fluctuant areas can be incised and
drained .
• Surgical knife is introduced in the most inferior portion
of fluctuant area.

31
Text book of oral pathology ,Anil Ghom, first edition-2009, page no: 450
• A small sinus forceps is introduced in the wound,
32

opened in several directions and drained.

• A rubber drain is placed in the deepest portion of the
wound, so that just 12 cm lie above the source of the
skin, where it is sutured.
• When no superficial spot is present,fluctuance is
more difficult to determine ,particularly if deep pus is
suspected.usually ,extraction of the offending tooth
and specific antibiotic cover bring about resolution of
the process.

32
Text book of oral pathology ,Anil Ghom, first edition-2009, page no: 450
•
It is important to provide a pathway of drainage to
33

prevent further spread of the abscess and/or cellulitis.

• An incision for drainage for allows decompression of
the increased tissue pressure associated with edema
and provides significant pain relief.
• The incision provides a pathway not only for bacteria
and bacterial byproducts but also for the inflammatory
mediators associated with the spread of cellulitis.

33
Pathways of the pulp 9 edition , stephen cohen, page no:596
• An inhibitory concentration of antibiotic may not
34

reach the source of infection because of the

decreased blood flow and because the antibiotic
must diffuse through the edematous fluid and pus.
• Drainage of edematous fluid and purulent exudate
improves circulation to the tissues associated with an
abscess and cellulitis , providing better delivery of the
antibiotic to the area .

34
Pathways of the pulp 9 edition , stephen cohen, page no:596
• Submaxillary abscess- center round the
35

submaxillary lymph nodes ,which may be involved

and break down. A rubber dam drain should be
inserted into this area,and fastened with a suture to
the end of the skin.
• Sublingual abscess- forming the infection of the
posterior teeth are either drained by intra oral
incision , or from an incision at the lower border of
mandible.some times two drains are needed to drain
all the involved areas.

35
Oral and dental diagnosis ,Thoma kurt, 2 revised edition, page no:418, 419
 Incision of sub
36

mental,and sub maxillary Evacuation of pus from sub

with parapharyngeal maxillary abscess
abscess
36
Oral and dental diagnosis ,Thoma kurt, 2 revised edition, page no:205, 418
 ENDODONTIC MANAGEMENT
• It should be completed as soon as possible
37

after the incision for drainage. The drain usually

can be removed 1-2 days after improvement is
noted in clinical signs and symptoms. If no
significant improvement occurs, the diagnosis and
treatment must be reviewed carefully.
• Consultation with specialist and referral may be indicated
for sever infection or persistent infection
37
Pathways of the pulp 9 edition , stephen cohen, page no:596
CASE REPORT-1
 ORBITAL CELLULITIS AS A SOLE
SYMPTOM OF ODONTOGENIC
INFECTION

W C Ngeow
Singapore Med J 1999; Vol 40(02):

http://www.sma.org.sg/smj/4002/articles/4002cr1.html
 INTRODUCTION
• Orbital and periorbital cellulitis are uncommon
conditions which develop as a complication of infection
of the paranasal sinuses, trauma to the eyelids or
infection of the external ocular region.
• Infection of the paranasal sinuses usually happen at the
ethmoidal and frontal sinuses, and occasionally the
maxillary sinus.
• Maxillary sinusitis could result from dental infection
and the percentage varies considerably between 4.6%
and 47.0%(2)
• The dental origin may be periapical infection of the
maxillary tooth/teeth or as a complication of dental
extraction.
• The manifestation of the spread of dental infection to
the maxillary sinus has been termed the endo-antral
syndrome.
• Toothache may be the patient’s only complaint.
• In orbital cellulitis originating from the infection of the
extraction socket, the time interval between dental
extraction and development of orbital symptoms
ranged from two hours to thirteen days.
• Patient may present with fever, elevated leukocyte
counts and radiographic evidence of acute ipsilateral
paranasal sinus infection.
• On rare occasions, the patient may also present with
signs and symptoms of meningitis.
• This paper presents a case where orbital cellulitis was
the only symptom of odontogenic infection.
CASE REPORT
• A 51-year-old English lady was referred to the
Department of Oral and Maxillofacial Surgery
at the Queen Victoria Hospital for the
management of a unilateral orbital swelling
that had persisted for the past two days.
• The swelling was not tender though slightly
reddish in colour (Fig 1). She had not
experienced any trauma to the orbital region
and she claimed that her vision was fine. She
did not feel any discomfort at the right orbital
or infra-orbital region
• Clinical examination revealed a soft swelling on her
right orbital region, most obvious at the lower eye
lid.
• It was oedematous and slightly reddish in colour. It
was not tender to palpation. Her visual acuity and
eye movement were normal.
• Intraoral examination revealed retained roots of the
maxillary right first premolar and first molar.
• Gutta percha ends could be seen at the remaining
coronal region of both teeth, indicating both teeth had
undergone root canal treatment.
• Both teeth were slightly tender to percussion but no
swelling could be palpated at the buccal sulcus or
palatal region.
• An orthopantomogram (OPG) and a Walter’s (occipito-
mental) radiographic view were taken. Both radiographs
showed opacity of the right maxillary sinus.
• The Walter’s view also showed radiopacity at the
right lower orbital rim indicating a soft tissue swelling
over the region (Fig 2).
• The OPG showed an obvious periapical lesion on the
maxillary right first premolar. The periodontal ligament
of the maxillary right first molar was widened. The root
canal treatment of tooth showed inadequate working
length (Fig 3).
• A diagnosis of periapical infection originating from the
inadequately treated root canals resulting in unilateral
sinusitis and eventual orbital cellulitis was made.
• The patient was prescribed 250 mg amoxycillin with
125 mg clavulanic acid mg for five days. She was
reviewed the following week and the orbital cellulitis
was no longer present.
• The roots of the maxillary right first premolar and first
molar were no longer tender to percussion. As she was
having dental treatment with a dental student, she
was advised to have her root canal treatment to
remove the source of infection.
 DISCUSSION
• Accurate diagnosis is important as it allows for
prompt treatment to prevent further complications of
orbital cellulitis. Complications of maxillary dental
infection include maxillary sinusitisand pansinusitis.
• On rare occasions, this may eventually lead to orbital
cellulitis. Complication of orbital cellulitis includes
neurological or ophthalmological problems. Its
sequelae includes severe loss of vision, blindness with
ptosis and extropia, cavernous sinus thrombosis,
empyema and death.
• Antibiotic therapy alone was found to be effective in over
80% of patients with orbital and periorbital cellulitis in
general.
• However, no study has been done to show the
effectiveness of antibiotic therapy alone in treating
orbital and periorbital cellulitis due to dental infection.
• The source of infection is the incomplete root canal
treatment done on the tooth . As shown in this case, the
orbital cellulitis was controlled with oral antibiotic.
• The patient however, was refered for the retreatment to
remove the source of infection on the maxillary right first
premolar.
• Radiograph is an important tool to confirm the
diagnosis.
• As shown in this case, there was only slight tenderness
of the retained roots when percussed. Radiographically,
however, there was a radiopacity of the right maxillary
sinus with a well defined periapical lesion of the first
maxillary premolar.
• The periodontal ligament of the first maxillary molar
was also widened. The root canals of both the teeth
were also inadequately sealed.
• These findings confirmed the cause of the unilateral
maxillary sinusitis and orbital cellulitis as of dental
origin.
 CONCLUSION
• Odontogenic infection may present as an orbital
cellulitis. Medical practitioners should be thoroughly
familiar with the manifestations of dental infection into
the maxillary sinus and orbital area even though
uncommon.
• Orbital cellulitis can lead to serious complications. One
must suspect the maxillary tooth as a possible source
of infection and prompt treatment with antibiotics is
mandatory. Endodontic treatment should be
performed where indicated to remove the source of
infection.
CASE REPORT-2
LIFE-THREATENING ORO-FACIAL INFECTIONS
*E.K. AMPONSAH and 2P. DONKOR
*1st Medical University named after Academic Pavlov, Saint
Petersburg 197061. Russia Federation and formerly of Tarkwa
Government Hospital, Tarkwa, Ghana 2Department of Surgery,
School of Medical Sciences, Komfo Anokye Teaching Hospital, P.O.
Box 1934, Kumasi, Ghana

March 2007 Volume 41, Number 1 GHANA MEDICAL JOURNAL

 Case report-1
• A nineteen-year-old girl (Figure 1) was
rushed to the Dental Department of
Tarkwa Government Hospital after
collapsing with rigors at home. A
pharmacist or chemical seller had
previously pre-scribed amoxycillin for
her toothache and a swelling of the
lower jaw. She had no significant
medical history
• On arrival she was in respiratory distress, had a pulse
of 180 beats per minute and a blood pressure of
110/40mmHg. Her axillary temperature was 40.5
degrees Celsius and her Glasgow Coma Score (GCS)
was 10/15.
• There was an obvious right submandibular and sub-
mental swelling, with minor trismus. The tongue was
elevated and was in contact with the palate making
breathing, swallowing and feeding difficulty.
• A presumptive diagnosis of septic shock secondary to
dental infection facial cellulitis was made.
 TREATMENT
• She was admitted and treated with high flow oxygen,
intravenous fluids, ceftriazone and metroni-dazole.
• Extraction of the involved tooth, together with an
incision of submental region to drain the abscess
under general anesthesia was undertaken three days
after admission. Intraoperatively 20mls of pus was
obtained.
• Staphylococcus aureus was subsequently isolated
from the pus and blood culture. The patient was
discharged from hospital seven days after surgery in
satisfactory condition
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