Management of a Severe Cervicofacial Odontogenic Infection

INTRODUCTION

Odontogenic infections originate from a tooth or from its supporting structures, generally secondary to a pulp necrosis, periodontal disease, pericoronitis, apical lesions, or complications of dental procedures, which can be restricted to the alveolus or can reach the jaws and face through maxillofacial spaces. These are the most common conditions which affect the head and neck regions.

AIM

The aim of this study is to report a severe case of a cervicofacial odontogenic infection while discussing the most relevant aspects.

CASE REPORT

A 47-year-old female patient with a background of diabetes mellitus (DM) had a cervicofacial infection presenting edema and erythema in the left hemiface extending from the frontoparietal to cervical region and was submitted to extensive surgical treatment combined with antibiotic therapy.

CONCLUSION

Although the prevalence and complication rates of odontogenic infections had decreased with the advancement of diagnostic techniques, availability of effective antibiotics, and improvement in oral hygiene, still there are conditions that require attention and accurate treatment to prevent the progression of the pathology to deeper fascial spaces.

CLINICAL SIGNIFICANCE

Odontogenic infections can be treated with fewer complications if approached earlier when diagnosed while their premature clinical manifestations. However, if the treatment is postponed and the infection spreads into deeper fascial spaces, it can damage vital structures, and, consequently, threaten the patient's life. In these cases, extensive and aggressive therapy should be performed.

[Cutaneous sinus tract due to an asymptomatic dental infection]

Pyogenic cutaneous lesions of the cervicofacial region may have a variety of causes but one possibility that should be considered is a cutaneous sinus tract (CST) of dental origin. Correct diagnosis is based on a high index of suspicion and radiologic evidence of a dental pathology. Patients with odontogenic CST should be referred to a dentist and the treatment consists of either endodontic therapy or extraction of the involved tooth. We present a case report with misdiagnosis of CST of dental origin.

Ludwig’s Angina: An Uncommon Cause of Chest Pain

A 71-year-old male with coronary artery disease, hypertension, diabetes mellitus, tobacco and opioid dependence came to the emergency room complaining of one episode of retrosternal chest pain oppressive in nature of one day of evolution. He had acute respiratory distress and required mechanical ventilation. The initial impression was myocardial ischemia, but electrocardiography and cardiac enzymes ruled it out. During the following hours, neck and tongue edema developed. He was started on broad-spectrum antibiotics empirically. Neck computed tomography scan revealed a left parapharyngeal and submandibular abscess. The abscess was drained. The source of infection was found on the second molar of the left lower jaw. The patient improved and was successfully weaned from mechanical ventilation. Despite advances in therapy, Ludwig's angina remains a potentially lethal infection in which early recognition plays a crucial role.

Anatomical considerations for the spread of odontogenic infection originating from the pericoronitis of impacted mandibular third molar: computed tomographic analyses

OBJECTIVES

The aims of the present study were to clarify the anatomy of impacted mandibular third molars in relation to surrounding structures and to investigate the pathway of infection originating from pericoronitis of this tooth.

STUDY DESIGN

Computed tomography (CT) images were evaluated in 87 patients with uninfected mandibular third molar impaction and in 12 patients with infection originating from an impacted mandibular third molar. In uninfected patients, bony features around the impacted crown were investigated together with the relationship between the crown and surrounding muscles. In infected patients, involvements of bony and soft tissue structures were evaluated according to the disappearance of cortices and lateral asymmetry of density and shape in the spaces and muscles.

RESULTS

In uninfected patients, the disappearance of the lingual cortical plate was observed in 48 (35.3%) impacted molars, while only in 11 (8.1%) teeth for buccal cortices. The cortical thickness was thinner on the lingual side than the buccal side. Sixty-five percent of the masseter muscle horizontally overlapped the crown, while almost all of the medial pterygoid muscle was posteriorly situated apart from the crown. The mylohyoid muscle horizontally overlapped the crown at below or intermediate vertical positions. In infected patients, the involvement of lingual structures was more frequently observed than that of buccal structures. The mylohyoid muscle was involved in 10 (83.3%) of 12 patients. Among them, 8 showed submandibular space involvement.

CONCLUSION

CT findings supported the clinical observations of infection spread in patients with pericoronitis of the impacted mandibular third molar. CT appeared to be an effective tool for investigating the pathway of infection originating from the pericoronitis of impacted mandibular third molars.

Spread of odontogenic infection originating in the maxillary teeth: computerized tomographic assessment

OBJECTIVE

The aim of this study was to investigate the pathways of infection originating in the maxillary teeth through the interpretation of computerized tomographic (CT) appearances.

STUDY DESIGN

CT images of 78 patients were analyzed with reference to lateral asymmetry of shape and density of fascial spaces and tissues.

RESULTS

Changes in the alveolar cortical plates were observed more frequently in the labial/buccal side than in the palatal side. The facial expression muscles were involved in 23 (19.4%) patients. Infection caused by anterior teeth often spread into the levator labii superioris and levator anguli oris muscles. Deep spread into the fascial space was found in 9 (11.5%) patients. Masticator space changes were predominantly seen in the patients with infection caused by molars. Maxillary sinus changes were found in 57 (71.3%) patients with infection originating in the canines, premolars and molars.

CONCLUSION

Infection spread characteristics are related to the causal teeth, and the pathways were clearly demonstrated on CT images.

Ultrasound-guided surgical drainage of face and neck abscesses

An ultrasound-guided surgical drainage technique in which grey-scale and colour Doppler ultrasonography were combined is described. The technique was performed for eight deep subcutaneous abscesses subsequent to odontogenic infection, and provided easy detection and accurate, reliable penetration of abscesses that were difficult to locate by physical examination. Colour Doppler ultrasonography is particularly useful for differentiating blood vessels from the static space of abscesses.

Odontogenic infection pathway to the submandibular space: imaging assessment

The aims of this study were to determine the pathways of odontogenic infection spread into the submandibular space and their relationship to the clinical symptoms. Computerized tomography (CT) and magnetic resonance (MR) images of 33 patients with submandibular involvement were analyzed. The spread of infection was evaluated by lateral asymmetry of the shape and density of the fascial spaces and tissues, and by obliteration of the interfascial fat spaces. Imaging findings were classified into three types: in 19 patients (57.6%), infection spread through the mylohyoid muscle or sublingual space (type I). In five patients (15.2%), infection spread through the bony structures of the mandible with periosteal reaction or perforation of the cortical plate (type II) and was associated with relatively mild symptoms. In four patients (12.1%), infection spread from the masticatory space (type III). Seven of 11 patients with dysphagia or fever showed submandibular involvement spreading into the parapharyngeal space. CT and MR imaging clearly demonstrated different pathways of the spread of odontogenic infection into the submandibular space, which influenced the manifestation of clinical symptoms.

Value of panoramic radiographs in paediatric pre-bone marrow transplantation oral evaluation

Panoramic radiographs (orthopantomogram [OPT]) are, beside clinical examination, helpful in detecting possible dental foci of infections before bone marrow transplantation (BMT). The value of an OPT in paediatric BMT-recipients was assessed by the results of dental evaluation, consisting of an OPT and a consultation by an oral surgeon, in 161 children between 1987 and 1999. Eleven out of 161 children had at least one oral focus of infection that required treatment before myeloablative therapy. In seven children the foci were detectable both clinically and radiographically and in two children the foci were visible only clinically. Only two children had a focus that was only detectable by means of radiographs. In both patients it concerned erupting third molars. In conclusion, we recommend an OPT only when the child has clinically obvious abnormalities. In addition, in older children an OPT will be indicated to evaluate the third molars.

Subdural empyema secondary to odontogenic masticator space abscess: detection by indium-111-labeled white cell scan

Subdural empyema (SDE) is an extremely rare but serious complication of dental infection. A case is presented in which dental infection was complicated by a masticator space abscess and eventually led to a SDE. This report illustrates a rare sequence of events leading to SDE and its serendipitous detection by indium-111-labeled leucocyte scan.

Longitudinal radiological study of the oral health parameters in an elderly Finnish population

In the oldest elderly, an increase in the number of remaining teeth may increase oral infection foci. The aim of this follow-up study was to examine the radiologically detected oral health condition of a group of home-living elderly in Helsinki at 5-year intervals. The population of this study comprised 103 home-living elderly people, all participants of the population-based Helsinki Aging Study. Panoramic radiography supplemented by intraoral radiographs was performed on all these participants at the Institute of Dentistry, University of Helsinki, in 1990-1991. Follow-up radiographic examination was completed in 1995-1996. Mean number of teeth decreased during the follow-up period from 13.2 +/- 9.0 to 12.5 +/- 9.2 (P= 0.0001). Mean number of teeth with periapical lesions decreased in men from 1.3 +/- 1.4 to 0.6 +/- 0.9 (P = 0.007), but no differences in number of teeth with periapical findings were observed in women. There were relatively few changes in the subjects' radiographic periodontal findings. However, fewer teeth with vertical bone pockets >1-3 mm deep were found in the follow-up study than 5 years earlier (0.6 +/- 1.2 vs 1.1 +/- 1.8; P= 0.0008). In both the baseline and the follow-up studies the radiographic findings occurred in the subjects who had retained more natural teeth. In the follow-up study, 68% of the subjects had radiographically detected signs of chronic oral infection foci. It may be concluded that radiographically detected oral health parameters remain relatively unchanged, but treatment need is higher among those who have successfully retained their natural dentition into old age.

Optimum dental radiography in bone marrow transplant patients

OBJECTIVE

The purpose of this study was to establish an optimum radiographic examination regimen for patients undergoing bone marrow transplantation. Two radiographic examinations were compared: the panoramic radiograph and the full mouth series of radiographs.

STUDY DESIGN

A prospective analysis of 65 consecutive patients undergoing bone marrow transplantation was undertaken. All patients were examined through use of both panoramic and full mouth series intraoral radiographs, including bitewings. Significant findings were recorded and compared by means of paired t test analysis for parametric data, such as caries, periapical inflammation and subgingival calculus, and by means of McNemar's test for nonparametric data, such as the presence or absence of severe periodontal disease.

RESULTS

Acquired findings, such as caries, periodontal disease, and clinically significant faulty restorations, were detected more frequently from the full mouth series (P < .05). There was no significant difference in the detection of periapical pathosis. In 8 of 65 patients, clinically significant information, such as evidence of impacted wisdom teeth, neoplasms, and multiple myeloma, was better detected from the panoramic radiographs.

CONCLUSIONS

The results suggest a combination of both modalities as the optimum means of radiologic survey in this "high-risk" patient population.

The use of ultrasonography as a diagnostic tool for superficial fascial space infections

PURPOSE

This study examined the value of ultrasonography as a diagnostic tool in the treatment of superficial acute odontogenic fascial space infections.

PATIENTS AND METHODS

The study group consisted of 50 patients in whom both radiographic and sonographic examinations, as well as a needle aspiration, were performed.

RESULTS

Purulent fluid was aspirated in 22 of the 50 patients. Six patients diagnosed as suffering from cellulitis had a repeated ultrasonography scan. In four, abscess formation was diagnosed on the third day.

CONCLUSIONS

Ultrasonography is an effective diagnostic tool to confirm abscess formation in the superficial fascial spaces and is highly predictable in detecting the stage of infection.

Deep facial infections of odontogenic origin: CT assessment of pathways of space involvement

PURPOSE

We investigated the pathways of spread of odontogenic infection in the facial and neck spaces.

METHODS

CT scans of 45 patients with extensive spread of odontogenic infection into the facial and neck spaces were analyzed to document pathways of spread.

RESULTS

Odontogenic infections arising in the mandible first spread upward, into the masseter and/or medial pterygoid muscles in the masticator space, and downward, into the sublingual and/or submandibular spaces, and then spread into the spaces or muscles adjacent to one or more of these locations. Infections from the masseter muscle spread into the parotid space to involve the temporalis and lateral pterygoid muscles. Infections from the medial pterygoid muscle spread into the parapharyngeal space to involve the lateral pterygoid muscle. Infections in the maxilla did not spread downward; instead, they tended to spread upward and superficially into the temporal and/or masseter spaces and deeply involve the lateral and/or medial pterygoid muscles in the medial masticator space.

CONCLUSION

CT may be useful to depict the extent of infection and to plan treatment of extensive odontogenic infection, which can be life threatening when therapy is ineffective.

Oral infections in home-living elderly patients admitted to an acute geriatric ward

Little is known about the oral health of the frail and home-living elderly. The effects of dentogenic infections on the general condition of the elderly are also unknown. We therefore set out to investigate 191 elderly patients referred to an acute geriatric hospital due to sudden worsening of their general health. The patients' mean age was 81.2 +/- 6.4 years (range, 67 to 96 years), and they had lived at home before hospitalization. The patients were examined and their diagnoses set by a team of physicians. The dentist's examination was also made bedside. Panoramic x-rays were taken for those who were able to stand (n = 148). Particular attention was paid to the occurrence of dental infection foci and systemic infection parameters of blood. Only patients free from other than dental infections were included in the statistical analyses (n = 184). Panoramic x-rays revealed dentogenic infection foci in 71.1% of the dentate patients. Periodontal condition was poor in 96.2% of the patients (CPI score, 2 to 4). All infection parameters were high in patients with high periodontal treatment need, but the differences were not statistically significant. Neither were there statistically significant correlations between the number of dentogenic infection foci recorded from the radiographs and infection parameters of blood. More of the edentulous patients had positive salivary yeast counts than did the dentate patients (84.4% vs. 66.1%; P < 0.05). No correlation was found between the main systemic diagnoses and dental infections. Since the prevalence of dentogenic infection foci in our subjects was high, and they did not cause marked increase in the hematological infection parameters investigated, it seems clear that geriatricians should refer their patients for dental examinations. Although our patients represent the home-living elderly population in a Nordic country with a high standard of living and good medical care, dental care had been neglected regardless of the patients' systemic disease.

Odontogenic versus nonodontogenic deep neck space infections: CT manifestations

PURPOSE

The purpose of this study was to evaluate deep neck space infection (DNSI) with particular attention to the differences in the spaces involved and in complications between odontogenic and nonodontogenic groups with CT.

METHOD

Forty-four patients (21 odontogenic and 23 nonodontogenic) were included in this study. Among odontogenic DNSI cases, 15 had dental infection in the second or third mandibular molar. We compared the CT features between odontogenic and nonodontogenic DNSI cases, with special emphasis on the differences in the spaces involved and in the rate and type of complications.

RESULTS

In all patients, CT clearly differentiated abscess from cellulitis. The most common spaces involved in 21 patients with odontogenic DNSI were the parapharyngeal (n = 18), the submandibular (n = 18), the anterior visceral (n = 13), the masticator (n = 9), and the sublingual (n = 7) spaces. In contrast, in 23 patients with nonodontogenic DNSI, the anterior visceral space (n = 14) was most frequently involved. The parapharyngeal, submandibular, and masticator spaces were statistically more frequently involved in odontogenic than in nonodontogenic DNSI (p < 0.05). Twenty-two patients had one or more complications shown by CT, of which airway compromise was more frequent and severe in odontogenic than in nonodontogenic DNSI.

CONCLUSION

We conclude that the parapharyngeal, submandibular, and masticator spaces are more significantly vulnerable in odontogenic DNSI than in nonodontogenic DNSI. The predilection for certain spaces of the neck in odontogenic DNSI seems to originate from the intimate relationship of the mandibular molars to the adjacent deep neck spaces.

Dental disease: a frequently unrecognized cause of maxillary sinus abnormalities?

OBJECTIVE

Periodontal disease may be a frequently unrecognized cause of maxillary sinus disease. The purposes of this study were to determine if maxillary sinus disease is more prevalent in patients with periodontal disease than in an age-and-sex-matched control group and to show radiographically an association of focal maxillary sinus disease with periodontal disease.

MATERIALS AND METHODS

Maxillary DentaScans (General Electric Medical Systems, Milwaukee, WI) of 84 patients (168 maxillary sinuses) with periodontal disease were retrospectively evaluated for the simple presence or absence of maxillary sinus disease. This group was compared with an age-and-sex-matched control population of 84 patients who were referred for head or neck CT scans in which the maxillary sinuses (including their inferior aspects) were visualized. For the likelihood of sinus disease in patients compared with controls, an odds ratio and a 95% confidence interval were calculated using the SYSTAT version 5.2 (SYSTAT, Evanston, IL). In the second portion of the study, the subject population alone was graded in the following fashion to establish a causal relationship: grade 0, no sinus disease; grade 1, focal sinus disease not adjacent to periodontal disease (unlikely to be caused by periodontal disease); grade 2, nonfocal sinus disease (complete opacification, air-fluid levels, or diffuse mucoperiosteal thickening; indeterminate cause), and grade 3, focal sinus disease adjacent to periodontal disease (likely to be caused by periodontal disease).

RESULTS

In the subject population--patients with periodontal disease who were referred for DentaScans--100 of 168 (60%) sinuses had sinus disease; in the control population, only 49 of 168 (29%) sinuses had sinus disease. The odds ratio for maxillary sinus disease in the patient population compared with controls was 3.6 (95% confidence interval, 2.3-5.6; p<.0001). The grading results of the subject population in the second portion of the study were grade 0, 68 sinuses (41%); grade 1, four sinuses (2%); grade 2, 32 sinuses (19%); and grade 3, 64 sinuses (38%).

CONCLUSION

We have demonstrated a twofold increase in maxillary sinus disease in patients with periodontal disease and have shown a causal relationship. Recognition of this relationship may have an impact on the clinical management of patients, particularly those planning implant surgery.

Dental infections and coronary atherosclerosis

An association between dental and other bacterial infections and coronary heart disease has recently been observed in both cross-sectional and longitudinal studies. To elucidate this topic, the severity of dental infections and coronary atheromatosis was assessed, together with measurements of the conventional coronary risk factors, in 100 individuals (88 men, 12 women, mean age 48, range 28-68 years) referred for diagnostic coronary angiography. Pantomography X-rays and coronary angiograms of the participants were scored blindly by single observers, a dentist and a radiologist respectively. The median pantomography score was 3.0 in male individuals belonging to the highest tertile of coronary atheromatosis score, as compared with 0.0 among the rest of the male participants (P = 0.003). The association between dental infections and severe coronary atheromatosis in males remained significant after adjusting for the effect of age, blood lipids, body mass index, hypertension, smoking and social class. No association between dental infections and coronary atheromatosis was observed in the small number of females studied. This observation supports the proposal that bacterial infections play a role in the pathogenesis of coronary atherosclerosis.

[The x-ray picture of chronic odontogenic osteomyelitis of the mandible in adults in the past and today]

Analysis of mandibular roentgenograms of 286 patients with odontogenic osteomyelitis has lead the authors to a conclusion on the predominance of diffuse forms of the condition with marked sequestration in the 30's and 40's. Currently hyperplastic osteomyelitis occurs in 12% of cases.

[The modelling of mandibular osteomyelitis]

The method suggested by the authors permits a reliable reproduction of mandibular osteomyelitis in white rats. The primary localization and pattern of the infectious process in this model well correspond to odontogenic osteomyelitis, this permitting a preclinical study of new drugs and physiotherapeutic methods intended for patients with odontogenic diseases.

[Odontogenic sinusitis. An evaluation and the radiologic checkup protocol after a Caldwell-Luc intervention]

A homogeneous group of 30 patients who were operated over a 5-year period for odontogenic sinusitis using a buccosinusal communication following Caldwell-Luc's technique were studied. A marked discrepancy between the conventional X-ray picture and the clinical picture emerged from these 30 case studies. So as to find an explanation for this discrepancy, all patients underwent CAT tests. On the basis of a critical evaluation of the results obtained it is suggested that patients be followed using a postoperative instrumental control protocol.

[The role of x-ray diagnosis in preventing odontogenic mediastinitis]

A method of roentgen diagnostics for patients with phlegmons of the maxillofacial area with suspicion of spread of pyo-inflammatory processes into the fat space of the neck is proposed which consists of radiographic survey of the neck with soft rays in two (direct and lateral) projections. The timely diagnosis of spread of pyo-inflammatory processes into the fat space of the neck allows to make necessary corrections in the plan of treatment.

[X-ray characteristics of changes in the jaw bones in phlegmons of the maxillofacial area]

The x-ray investigation of 445 patients with maxillofacial phlegmones showed that in 95.7% of the observations phlegmones were complicating the ongoing diseases. X-ray signs of the inflammatory changes within the bones were distinct on 3rd-4th day of the disease.

The use of computerized tomography in the diagnosis and management of temporal and infratemporal space abscesses

Computerized tomography has become an essential diagnostic technique in the management of maxillofacial pathosis. Three cases of temporal and infratemporal space abscesses are reviewed in which computerized tomography played an important role in the diagnosis and surgical management of patients.

Oropharyngeal carcinoma presenting as an odontogenic infection with trismus

Severe odontogenic infections involving muscles of mastication are often accompanied by trismus at the initial presentation. On rare occasions a nasopharyngeal tumor will have trismus as a presenting symptom. We report a case of odontogenic infection requiring emergency management in which trismus did not resolve. On further investigation, a nasopharyngeal carcinoma was diagnosed.

The masticator space: the influence of CT scanning on therapy

The masticator space is an important suprahyoid tissue compartment bounded by the superficial layer of the deep cervical fascia, enclosing the ramus of the mandible plus the masseteric and pterygoid muscles. Pathology of this space has been clinically difficult to diagnose and treat. Twenty-five patients with either tumor or infection involving the masticator space who underwent CT scanning were evaluated retrospectively. Ten patients had infection and 15 had tumor. CT was influential in directing appropriate biopsies or therapy in 24 of 25 patients. It misguided therapy once. The gross anatomic and CT appearance of the normal and the diseased masticator space is described along with pictures of representative cases. A discussion is given of the advantages, disadvantages, and pitfalls of computerized tomography of the masticator space.

Orbital cellulitis of dental origin: differential diagnosis and the use of computed tomography as a diagnostic aid

This report illustrates the spread of odontogenic infection to the orbit and the usefulness of the CT scan for the differential diagnosis of periorbital vs orbital cellulitis and abscess. It shows the necessity for close follow-up of patients with odontogenic infection so that life-endangering complications may be treated promptly. Finally, this patient illustrates the fact that, in some cases, a dental infection may be so virulent that drainage through the tooth and antibiotics do not provide control. Tooth removal and prompt incision and drainage are required for adequate treatment.

Pathological conditions involving the maxillary sinus: their appearance on panoramic dental radiographs

Panoramic dental radiography does not replace conventional techniques for viewing the maxillary sinuses but is a useful adjunct. Unsuspected antral diseases, from innocuous mucosal cysts to insidious squamous carcinoma, may be detected during routine use of this procedure.