Spread of Dental Infection Odontogenic infection pathways Involving the teeth or associated structures, are usually caused by oral microorganisms that inhabit the surface of the teeth and oral mucous membranes and are also found in the gingival sulcus and saliva Odontogenic infection = dental inf. Nonodontogenic source (secondary infect.) ▪ an infection of orofacial structures surrounding the oral cavity (as the skin, tonsils, ears or sinuses, …) Dental origin (primary infection) ▪ progressive dental caries ▪ extensive periodontal disease ▪ trauma ▪ caused by dental procedures, needle tracks ▪ formation of dental plaque …. Infection in oral cavity can be: Microorganisms ivolved in mixed bacterial infections of the oral cavity Microorganism: - saprophytic normal flora - occasional pathogens = opportunistic inf. normal flora creating inf. because body´s defences are compromised - primarily pathogens Flora, that are NOT normal body residents, can cause an infection Rubor, redness - due to vasodilatation effect of inflammation Tumor, difusse edema - caused by edema and pus accumulation Calor, higher temperature - caused by accelerated local metabolism Dolor, pain - results from pressure on sensory nerve (caused by oedema or inflamation) Functio laesa - problems with mastication, trismus, dysphagia (difficulty swallowing) and respiratory impairment Dental infection normally produces the classical signs of infection: Treatment of dental infection ➢ Removal of the source of infection ➢ Systemic antibiotics ➢ Area drainage (natural drainage – fistula established from abscess X arteficial drainage, to diminish the risk of spread of infection) Spread of dental infection 1. per continuitatem Continuously, direct spreading, the path of least resistance - by spaces in the head and neck (intermuscular spaces, along fascia, through fat or loose fibrous connective tissue, along vessels …) 2. by vascular system during septic conditions – bacteriemia, infected trombus 3. by lymphatic system through lymphatic vessels and nodes The various pathways of odontogenic infection spreading: 1. Spread of dental infection per continuitatem ▪ The type and virulence of the microorganisms involved and the immunological condition of patient influence the degree of spread of infection ▪ Infection may be: - localized (abscess) - diffused (cellulitis) = diffuse inflamation of soft tissue spaces (infection tends to spread rapidly through the tissues along the line of least resistence into the anatomically demarcated tissue spaces) - osteomyelitis - inflamation of the bone marrow More often in mandible – reduced vascularization, rarely in maxila; leads to bone resorption and formation of bone sequestra Abscess Periapical - progressive carries, pathogens invade the pulp and spread apically Periodontal - caused by spread from an infected gum (gingiva), usually in adults Pericoronal - around an erupting third molar A closed tissue space with supuration (circumscribed suppuration-containing lesion) From a dental infection: Spread of apical infection through: ▪ periodontal gap into oral cavity, vestibulum ▪ alveolar proces through spongy bone to diferent directions The infection can spread: - under the periosteum; under mucous membrane, skin - into cavities - into soft tissues of head, neck and thorax … Local abscess can spread along the anatomically demarcated tissue spaces As a barrier is the fascia and the muscle attachments to the bones mylohyoid muscle buccinator muscle Vestibular Abscess ▪ the roots of all teeth of upper and lower jaw ▪ if the roots are localized above the muscle insertion (lower jaw) or below muscle insertion (upper jaw) ▪ abscess perforate bone on the vestibular plate of the alveolar process Vestibular absces of upper jaw – the apices of the roots are localized below muscle insertion Vestibular absces of lower jaw - the roots are localized above the muscle insertion Palatal Abscess – upper jaw ▪ the roots of the upper incisors or premolars and molars (roots often incline palatally) abscess perforates the bone on the palatal plate of the alveolar process The submucosal portion of the hard palate contains neurovascular bundle, minor salivary glands a lymfoid tissue ▪ the rich innervation of the periosteum – very painful ! ▪ the course of the palatine artery - bleeding ! Palatum – zones of mucous membrane 1 – the marginal zone 2 – the incisive papilla 3 – the adipose zone 4 – the zone of the palatine seam, mucoperiosteum 5 – the glandular zone 6 – the soft palate Raphe palati (mucoperiosteum) usually no spread over palatine raphe If the apices of the roots of the teeth are above the buccinator muscle (4-8) and orbicularis oris muscle (1-3) insertion – infection can spread through soft tissues of the face into buccal space, subcutaneous lips region, infratemporal fossa UPPER JAW Abscess of the lips Infection spreading above the orbicularis oris muscle insertion Buccal Space ▪ the space between buccal skin and buccinator muscle ▪ from premolars and molars of both jaws ▪ if the roots are localized above the buccinator muscle insertion (upper jaw) or below buccinator muscle insertion (lower jaw) ▪ infection spreads into soft tissues of the cheek → along anatomical planes toward the infratemporal or pterygopalatine fossa (pterygomandibular raphe!) A diffused tissue inflamation ( cellulitis) with supuration from a dental infection ▪ from molars of upper jaw (7,8) ▪ from infected puncture during local anestesia on tuber maxillae Infratemporal Space infection may ascend into the cavernous sinus (through venous plexus in the ovale and spinosum foramen), into orbita, temporal fossa, pterygopalatine fossa, middle brain cavity, soft palate … ▪ between the temporal fascia and the temporal bone and the skin ▪ inferiorly communicates with infratemporal space Temporal Space Infraorbital Space ▪ between the levator anguli oris and the levator labii superioris muscles ▪ possible infection via the angular vein → opthalmic vein → spread into the cavernous sinus ▪ collateral edema often includes the upper lip and lower eyelid ▪ usually from anterior superior teeth, less often premolars, also from buccal space Infraorbital abscess A diffused infraorbital tissue inflamation with supuration from a dental infection Spread of infection into nasal cavity and maxillary sinus Maxillary sinus, nasal cavity ▪ occasionally of dental origin, more often caused by respiratory infection ▪ buccal and sometimes palatine root of first or second molar, second premolar that perforate the sinus floor ▪ the floor of nasal cavity is infected from the anterior teeth Sinusitis X-ray pathological content Foul-smelling, headache, fever, … MRI Bilateral abscess of the floor of nasal cavity LOWER JAW M. mentalis M. orbicularis oris (1-3) M. buccinator (4-8) b) Roots below muscle insertion a) roots above the muscle insertion vestibular direction aroots above the muscle insertion Vestibular abscess Roots below muscle insertion – anterior teeth Submental abscess Submental Space ▪ can spread beneath the mylohyoid muscle into the submandibular area ▪ mandibular anterior teeth ▪ the root of teeth lay below the muscles insertion (mylohyoid, mental + depressor labii inf. muscles) It can spread into subcutaneous space of the neck! Anterior teeth of lower jaw or from sp. submandibulare Submandibular Space ▪ root apices lay below the mylohyoid muscle insertion ▪ mandibular posterior teeth ▪ can spread beneath the mylohyoid muscle ventrally into the submental area Submandibular abscess From the roots of posterior teeth or from sublingual space 2 possible ways of spreading: 1. caudally along a. facialis > trig. caroticum > upper mediastinum > event. posterior mediastinum 2. dorsally into sp. praestyloideum through styloid septum into sp. retrostyloideum >sp. retropharyngeum >event. posterior mediastinum ▪ mandibular posterior teeth Sublingual Space ▪ spread along submandibular duct into submandibular space ▪ CAVE! Ludwig´s angina usually from M1,2 (M3) Submandibular space Submental space Sublingual space above mylohyoid muscle Ludwig´s angina = angina maligna the right and left submandibular, sublingual and submental spaces are infected A fulminant diffuse life threatening infection, it can spread rapidly per continuitatem into parapharyngeal and retropharyngeal spaces and further to mediastinum, with extensive edema, dislocation of tounge and posible suffocation „morbus strangularis“ Masseteric Space Lat.: parotideomasseteric fascia Med.: ramus of the mandible Sup.: zygomatic arch Inf.: insertio of the masseter muscle ▪ posterior teeth of the lower jaw ▪ can expand to the pterygomandib. space ▪ edema of the overlying masseter muscle Masseteric space Submasseteric abscess Pterygomandibular Space ▪ infection may spread into infratemporal space ▪ carious, partially erupted mandibutal third molar or needle tract infection of local anesthetia of inferior alveolar nerve Pterygomandibular space Alveolar inferior artery, vein and nerve ! Lateral Pharyngeal Space Parapharyngeal - shaped like an inverted pyramid, base at the base of the skull and its apex at the hyoid bone - with no barrier it continues to paravisceral space of the neck and further into posterior mediastinum - the source of infection is most often M3 of lower jaw, spreading infection from submandibular or pterygomandibular spaces, peritonsillar infection can penetrate the pharyngeal constrictor muscles → lateral pharyngeal space - space is divided into prestyloid and poststyloid compartments Lateral pharyngeal space Visceral space Visceral Paravisceral Retrovisceral Pretracheal space Prevertebral space The Neck Spaces ▪ Subcutaneous - between the superficial cervical fascia and platysma ▪ Suprasternal - between the superficial and middle cervical fascia ▪ Pretracheal – can spread into anterior mediastinum ▪ Parapharyngeal ▪ Retropharyngeal – can spread into posterior mediastinum Abscess Retropharyngeal abscess 2. Spread of dental infection by vascular system ▪ Pahogens can travel in the veins and drain the infected site into other organs and tissues. ▪ Bacteremia - bacteria traveling in the blood ▪ Infected thrombus = infected intravascular clot dislodges from the inner blood vessel wall and travels as an embolus → dural venous sinuses → brain or internal jugular vein → thrombophlebitis In general, deep and superficial venous systems are connected, veins of the head and neck lack valves, so blood can flow into and out of the cranial cavity – both directions ! Anterior pathway Superior ophtalmic v. → sup. orbital fissure → cavernous sinus Deep facial v. → Inferior ophtalmic v. → inf. orbital fissure → orbita → sup. ophtalmic v. Posterior pathway deep facial v. → pterygoid plx. → oval or spinosum for. plexus 3. Spread of dental infection by lymphatic system Spread by lymphatics ➢ The pathogens can travel in the lymph through lymphatic vessels, that connect the series of nodes, from the oral cavity to other tissues and organs ➢ The pathogens can move from a PRIMARY NODE near infected site to a SECONDARY NODE at distant site The route of dental infection traveling through the nodes varies according to the teeth involved. ➢ Submental nodes drain mandibular incisors and their associated tissues then empty into submandibular nodes or directly into deep cervical nodes ➢ Submandibular nodes are primary nodes for most of the teeth and associated tissues then empty into superior deep cervical nodes ➢ Superior deep cervical nodes are primary nodes for maxillary third molars empty into inferior deep cervical nodes jugular trunk into the vascular system Lymph node involved in infection undergoes LYMPHADNOPATHY size increase, change in consistency it becomes palpable Palatal Sublingual Mylohyoid muscle Submandibular Buccal Vestibular Buccinator muscle Vestibular Buccal Oral g-hyo g-gl st-gl hy-gl Gl. s-li Gl.s-m Sublingual space Submandib. space Submental space Spatium basale intermusculare linguae a. lingualis n. lingualis dct. submand. n. XII.