Oral and Maxillofacial Infection
Orofacial odontogenic infections ★ Acute pericoronitis ★ Acute dento-alveolar abscess ★ Inflammation of the maxillary bones
★ Acute pericoronitis ● Etiology: 1. Incomplete eruption of a wisdom tooth : Incomplete eruption of a wisdom tooth ( the third molar ) produces an opening through the overlying gum, but often the greater part of the crown of the tooth remains covered by soft tissue. This pocket, which forms a large stagnation area, can easily become infected through the opening causing pericoronitis.
★ Acute pericoronitis 2. Impaction of food under the gum flap: This, together with the usual accumulation of plaque, provides a medium encouraging the multiplication of bacteria.
★ Acute pericoronitis 3. Biting on the gum flap by an upper tooth: Contusion or laceration of the flap assists establishment of infection and increases the swelling, which is in turn bitten on. A vicious circle is thus established.
★ Acute pericoronitis 4. Ulceromembranous gingivitis: A pericoronal pocket may act as a facous form which this infection can originate , but more usually it becomes involved secondarily by backward spread of infection from the front of the mouth.
★ Acute pericoronitis 5. Diminished resistance due to systemic disease: This is a rare complicating factor and most patients are otherwise healthy young people.
★ Acute pericoronitis ● Clinical features: ▲ Young adult are affected. ▲ The main symptoms are soreness and tenderness around the partially erupted tooth and this quickly goes on to pain, swelling and difficulty in opening the mouth.
★ Acute pericoronitis ● Clinical features: ▲ The regional nodes are enlarged, there may be slight fever and, in severe cases, suppuration and abscess formation. ▲ The swelling and difficulty in opening the mouth may be severe enough to prevent examination of the area.
★ Acute pericoronitis ● Clinical features: ▲ Sometimes, there are spasm of adjacent muscles and trismus, leukocytosis, and increased erythrocyte sedimentation rate.
★ Acute pericoronitis ● Management: 1. The mouth should be cleaned up and food debris removed from under the gum flap by syringing.
★ Acute pericoronitis 2. A radiograph must be taken to show the position of the affected tooth, its relationship to the second molar and any other complicating factors. If the radiographs show that the third molar is badly misplaced or impacted or carious, then it should be extracted after the inflammation has subsided.
★ Acute pericoronitis 3. Frequent use of hot mouth washes alone often relieves the trouble but there may be recurrences until the stagnation area is removed. This may happen naturally by further eruption or by extraction of the tooth. This can only be done after the infection has been deal with.
★ Acute pericoronitis 4. In other cases where infection is mild it may be enough for the patient to keep the mouth clean and to use hot mouth washes whenever symptoms in the affected area develop until the condition rights itself.
★ Acute pericoronitis 5. When the upper tooth is biting on the flap it is often preferable to extract it, especially if the lower tooth is ultimately going to be removed. If however there are strong reasons for retaining the upper tooth, then the cusps should be ground away sufficiently to prevent it from continuing to traumatize the flap.
★ Acute pericoronitis 6. Extraction of the upper tooth when biting on the gum flap relieves the trauma but leaves the lower tooth, it should erupt later, without an opponent. The functional need for these upper and lower third molars must therefore be considered in relation to the condition of the rest of the mouth.
★ Acute pericoronitis 7. When infection is particularly severe Penicillin should be given, if there are no contraindications. If ulceromembranous gingivitis has involved the area, then Metronidazole is the drug of choice.
★ Acute pericoronitis ● Spread of infection: Cellulitis or osteomyelitis may follow extraction of the tooth while infection is still acute and is the main if somewhat theoretical and uncommon complication. Cellulitis developing as a result of direct spread of the infection is particularly uncommon.
★ Acute dento-alveolar abscess ● Etiology: The infection may start in one of three ways: ▲ Periapical ▲ Pericemental ▲ Pericoronal
★ Acute dento-alveolar abscess ● Clinical symptoms: ■ Early stage: The acute dento-alveolar abscess is accompanied by all the symptoms of acute inflammation: 1. The gum around the offending tooth is red, tender and edematous.
★ Acute dento-alveolar abscess 2. The pain is very severe at first, because the pus is confined to the bone. 3. The tooth may in inspection be badly decayed, and is usually loose and tender.
★ Acute dento-alveolar abscess ■
Later stage: After perforation of the bone has taken place, symptoms of cellulitis of the soft tissues will be found and will vary according to the location of the abscess. If confined to the vestibule of the mouth, the gum about the offending tooth will be swollen, red and later fluctuating.
★ Acute dento-alveolar abscess In the upper jaw, the tissues of the cheek and lip may be greatly swollen, sufficiently to close the eye. All cases involving the molar region of the mandible are accompanied by trismus, or limited opening of the jaw. The farther back the tooth involved, the more marked the trismus.
★ Acute dento-alveolar abscess Occasionally, the inner or lingual plate of the mandible is perforated by a dentoalveolar abscess, in these cases, a tender, edematous swelling appears in the floor of the mouth. When this arises in connection with molar teeth, difficulty in swallowing may be experienced. If untreated in time, symptoms of grave sepsis develops. ■
★ Acute dento-alveolar abscess ● Propagation of dental infection:
1.
Lingual spread of an infection in the anterior region of the mandible produces a sublingual cellulitis.
★ Acute dento-alveolar abscess 2. Acutely abscessed of mandibular bicuspids and molar in the late stages result in a submandibular cellulitis.
★ Acute dento-alveolar abscess 3. If the infection spreads outward or upward and backward will involve the buccal space, the pterygomandibular space, the parapharyngeal space, and the infratemporal space.
★ Acute dento-alveolar abscess ● Treatment: 1. Antibiotic therapy or chemotherapy is important. 2. Hot dressings are used continuously. 3. Warm saline mouthwashes are also useful. 4. General supportive care is necessary.
★ Acute dento-alveolar abscess 5. As soon as the patient is able to swallow, therapeutic doses of multivitamins should be given daily, with a high carbohydrate diet. The vitamin reserve is quickly depleted during infections, so that it is essential that may be replaced to aid in combating the infection and eventually in repair of damaged tissue.
★ Acute dento-alveolar abscess 6. Incision and drainage should be done as soon as fluctuation occurs. Incision may be made intraorally or extraorally as indicated. However, if brawny massive induration which pits on pressure, presents in five to seven days with an elevation of temperature in spite of antibiotic treatment, and there is no fluctuation, then that space should be surgically explored.
★ Acute dento-alveolar abscess To delay is to risk dissemination of infection such as cavernous sinus thrombophlebitis, septicemia and intracranial complication. Rubber dam or tube drainage is usually required for several days. After the acute symptoms have been subsided, the tooth originally causing the trouble should be extracted in order to avoid recurrence or the persistence of a discharging sinus.
★ Inflammation of the jaws ◆◆ Osteomyelitis: Osteomyelitis is an infection of bones affecting both the marrow and cortex. ● Etiology: In the jaws it may result from direct extension of periapical and periodontal infections. It may also follow the fracture or hematogenous spread from a distant site.
★ Inflammation of the jaws ● Clinical feature: ▲ In acute and subacute suppurative: Osteomyelitis may be localized or diffuse and involve either jaw. (1) In the mandible, the infection spreads along the mandibular canal to affect both sides of the mandibular body, or the entire ramus. This is a diffuse fulminating type which is an acute osteomyelitis of sudden, severe onset in which there is rapid destruction of large area of bone.
★ Inflammation of the jaws (2) In the maxilla, it tends to be more localized and is relatively rare. (3) The first symptom is pain with fever, general malaise, toxic appearance, and a high white blood cell count.
★ Inflammation of the jaws (4) The teeth become sore to percussion, eventually, as the destruction of bone increases and the infection spreads, they become loose one after another. (5) By this time the gingival are dark red and so is the labial and buccal mucosa, as a result of the periostitis.
★ Inflammation of the jaws (6) Pus exudes from around the necks of the teeth when pressure is exerted on the soft tissue. (7) By now, there is usually marked swelling of the face with acute lymphadenitis. (8) In the early stages of the disease, radiographs are negative. After two to three weeks, the radiograph shows a radiolucent areas.
★ Inflammation of the jaws ▲
Chronic form: Chronic form may follow the acute form when the symptoms subside. Pus continually discharges through several fistulas. When drainage is blocked, there may be flare-up of acute attacks from a chronic condition. Eventually the pus drains again relieving the clinical symptoms.
★ Inflammation of the jaws ● Treatment: 1. In the treatment of acute osteomyelitis the general rule is to institute antibiotic therapy and to surgically establish adequate drainage. 2. With good drainage , the removal of the very loose teeth and dead bone, a minimum of surgery and large doses of antibiotics, the acute stage subsides and the disease may continue in a chronic form.
★ Inflammation of the jaws 3. At no time is vigorous curettement to be instituted in attempting to remove sequestra. Occasionally, small sequestra exfoliate spontaneously through the skin or mucous fistulas. The larger ones must be removed when they are mobile by sequestrectomy.
★ Inflammation of the maxillary bones ◆◆ Osteoradionecrosis: ● Etiology: Radiation therapy of the head and neck can have numerous effects on the jaws. Thrombosis of the vessels responsible for the blood supply diminishes the vitality of the bone so severely that it is extremely susceptible to infection, growth arrest, delay in healing, and necrosis.
★ Inflammation of the jaws ● Clinical feature: When gingival inflammation develops as a result of decreased saliva, poor oral hygiene, tooth extraction, or a small denture sore, massive and unusually extensive bone infection may develop. Once started, it progresses relentlessly.
★ Inflammation of the jaws Symptoms include severe pain, trismus, ulceration, and gradual exposure of necrotic bone. It spreads to involve all dysplastic bone resulting in severe destruction. Pathologic fracture may add to morbidity. Recurrent soft tissue infection and severe systemic involvement add to the great morbidity.