easily understandable

1. Spread of oral infection
Dr.madhusudhanreddy

2. Introduction
• Oral cavity consists of more than 500 bacterial taxa,
several fungal species, few protozoal genera and many
viruses as normal residents
• Occurrence of infectious disease is determined by the
interaction of host, the organism and the environment
• In healthy state there is a balance among these factors and
when the balance is lost disease occurs

3. Introduction
• Infection: is defined as the pathological state of disease
caused by invasion of pathogenic micro-organisms with in
the body.
Infection
Interaction of Host +Organism +Environment
In healthy state there is a balance if this balance is lost
Disease occurs

4. Oral infection
Originates in dental pulp
Through root canals
Extended into periapical tissues
Originates in periodontal tissue
Disperse through spongy bone
May perforate corticle plate
Spread in various tissue spaces or discharge on free mucous
membrane/ skin

5. Drainage pathwayof acute periapical infection

6. • Osteomyelitis: an inflammatory process within medullary
bone that involves the marrow spaces
• Parulis: a sessile nodule on the gingiva at the site where a
draining sinus tract reaches the surface
• Fistula: a drainage pathway or abnormal communication
between two epithelium – lined surfaces because of
destruction of the intervening tissue

7. • Cellulitis: a painful swelling of the soft tissue of the mouth
and face resulting from a diffuse spreading of purulent
exudate along the fascial planes that seperates the muscle
bundles
• Ludwigs angina: cellulitis involving fascial spaces between
muscles and other structures of the posterior floor of the
mouth that can compromise the airway

8. Routes of spread of infection
• Lymphatic system
• Blood stream
• Direct through tissues

9. • Factors affecting the ability of infection to spread depend
on
– The type and virulence of the organism
– General health of the patient
– Anatomical site of initial infection
• Anatomic features determine the direction that the
infection may take

10. Cellulitis
• Synonym: Phlegmon
• Definition:
• A diffuse inflammation of soft tissues which is not
circumscribed or confined to one area, but which, in
contrary to the abscess, tends to spread through tissue
spaces and along fascial planes

11. • If the abscess is not able to establish drainage through the
surface of the skin or into the oral cavity, it may spread
diffusely through fascial planes of the soft tissue

12. • ETIOLOGY AND PATHOGENESIS
Streptococcal and anaerobic prevotella and porphyromonas
Production of enzymes – hyluronidase, streptokinase and
fibrinolysins
Dissolution of hyluronic acid and fibrin
Destruction of collagen

13. • Cellulitis of face and neck are most commonly due to
– Dental infection as a sequel of an apical abscess or
osteomyelitis
– Periodontal infection
– Pericoronitis
– Tooth extraction, injection either with an infected
needle or through an infected area,
– Jaw fracture

14. • CLINICAL FEATURES
• Moderately ill with elevated temperature.
• Painful swelling of involved soft tissue that are firm and
brawny
• Superficial, skin is inflamed
• Regional lymphadenopathy

15. • Maxilla: perforation of outer cortical plate above
buccinator –
– Swelling of upper half of the face
– Diffuse spread involves entire facial area
– Extension towards eye – cavernous sinus thrombosis

16. • Mandible:
• Perforation below buccinator – swelling of lower half of
face.
• Later superior and cervical spread
• Spread to cervical tissue – respiratory discomfort.
• Infection frequently tends to become localized – facial
abscess
• Discharge upon a free surface

17. • HISTOLOGICAL FEATURES
• Diffuse non specific acute inflammation
• Characterized by diffuse exudation of polymorphonuclear
leukocytes, occasionally lymphocytes.
• Separating muscle bundles

18. • Two severe forms of cellulitis
– Ludwigs angina
– Cavernous sinus thrombosis

19. Ludwigs angina
• German physician ludwig (1836)
• Angina – latin angere = to strangle
• Severe cellulitis
• Beginning in the submandibular space
• Secondary involvement of sublingual and submental
spaces
• Bilateral involvement of all three spaces

21. • SOURCE OF INFECTION
– Lower molar teeth(70%)
– SM gland sialadenitis
– Oral soft tissue lacerations
– Penetrating injury of floor of mouth
– Jaw fracture
– Periphyrangeal abscess

22. • Prevalence is increased in patients who are
immunocompromised secondary to disorders such as:
– DM
– Organ transplantation
– AIDS
– Aplastic anemia

23. • It’s a type of spreading infection occur in presence of the
organisms that produce significant amount of
hyaluronidase & fibrinolysins which act to break down the
hyaluronic acid & fibrin.
• Streptococci being potent producer always associated with
ludwigs angina.

24. • CLINICAL FEATURES
• Swelling of floor of mouth
• Swelling- firm, painful, diffuse
• Elevation of tongue (Woody Tongue)
• Difficulty in eating, swallowing & breathing
• High fever
• Rapid pulse
• Fast respiration
• Swelling and tenderness involve neck above the level of
hyoid bone (bull neck)
• Edema of glottis
• Risk of death due to suffocation

25. • LABORATORY FINDINGS
• Leukocytosis
• Raised ESR
• Mixed infection, no specific organism
• But streptococci- invariably present

26. • TREATMENT
• Maintain airway
• Incision and Drainage
• Extraction of offending tooth
• Antibiotics therapy

27. Cavernous sinus thrombosis
• It is serious condition consisting of formation of a
thrombus in the cavernous sinus or its communicating
branches.
• Infections of head, face and intraoral structures above
maxilla are particularly prone to produce this disease

28. Routes by which infection reach cavernous sinus
External source

29. • Internal source
Pterygoid venous plexus
Inferior opthalmic vein
Cavernous sinus

30. • Infection spread by external route is more dangerous
because its very rapid with short fulminating course
because of the large open system of veins leading directly
to cavernous sinus.
• Causative agents:
• Staph. aures
• Streptoccoci
• Gram negative rods
• Mucormycosis

31. • CLINICAL FEATURES
• Patient is extremely ill (Chills n fever)
• Periorbital edema
• Headache, nausea, vomiting
• Photophobia
• Ptosis (drooping of upper eyelid )
• Chemosis (swelling of conjuctiva )
• Infection spread to contralateral side in 24-48 hrs

32. • Eagleton listed certain criteria for establishing the
diagnosis, namely:
– 1. A known site of infection.
– 2. An infection of the blood stream.
– 3. Early signs of venous obstruction.
– 4. Involvement of nerves in the sinus.
– 5. A neighborhood abscess of the soft parts.
– 6. Symptoms of complicating disease.

33. • TREATMENT
• Treat primary source of infection
• Broad spectrum i.v antibiotics
• Surgical drainage
• Anticoagulants

34. Infection of specific tissue spaces
• Tissue spaces – potential spaces situated between planes of
fascia that form natural pathways along which infection
may spread, producing cellulitis, or within which infection
may become localized with actual abscess formation.
• Shapiro defined the fascial spaces are potential tissue
spaces which are compartments that contain structures
such as salivary gland, fat or lymph node.
• Many of these spaces run into each other, allowing
infection to spread from one space to another.

35. Important spaces in maxillofacial region
• Lower jaw
– Submental space
– Submandibular space
– Buccal space
– Submassetric space
– Parotid space
– Pterygomandibular space
– Pharyngeal space
– Peritonsillar space

36. • Upper jaw
– Within the lip
– Within canine fossa
– Palatal subperiosteal interval
– Buccal space
– Maxillary antrum
– Infratemporal space
– Subtemporalis muscle interval

37. • Infection spread from maxillary teeth
– Maxillary sinus, the canine fossa, palatal space,
infratemporal fossa, buccal space and vestibular space.
– Infection can spread to the cavernous sinus from the
infratemporal fossa and from the canine fossa.
Infection in the cavernous sinus can lead to cavernous
sinus thrombosis. Which is potentially fatal.

38. • Infection spread from mandibular teeth
– Infection from mandibular teeth can spread to the
vestibular and buccal space in the same way as from the
maxillary teeth.
– Infection can also spread to the pterygomandibular
space, sublingual space, submandibular space and
submental space.
– The sublingual, submental and submandibular spaces
can be referred collectively as the submandibular
spaces.

39. Infratemporal space
• Boundaries:
• Anteriorly – infratemporal surface of maxilla and
posterior surface of zygomatic bone.
• Posteriorly – lateral pterygoid muscle, condyle, temporal
bone.
• Laterally – tendons of temporal muscle, coronoid process.
• Medially – lateral pterygoid plate, inferior belly of lateral
pterygoid muscle.

41. • Contents:
– The pterygoid plexux
– Internal maxillary artery
– Mandibular, mylohoid, lingual, buccinator and chorda
tympani nerves.
– External pterygoid muscle.

42. • Clinical features
– Extraoral Swelling over sigmoid notch
– Intraoral swelling in tuberosity region
– Trismus
– Swelling of eyelids
– Dysphagia
– Pain or pressure sensation in area of infection

43. Pterygomandibular space
• The space between the medial area of the mandible and the
medial pterygoid muscle, a target area for administering
local anesthesia to the inferior alveolar nerve.

44. • Boundries:
• Medially – medial pterygoid muscle
• Laterally – medial surface of ramus of mandible
• Superiorly – lateral pterygoid
• Posteriorly – deep lobe of parotid gland
• Inferiorly – attachment of medial pterygoid to the
mandible
• Anteriorly – pterygomandibular raphe

45. • Contents:
• Mandibular division of the trigeminal nerve
• Inferior alveolar artery and vein
• Spenomandibular ligament

47. • Clinical features
– Arise through pericoronitis of mandibular third molar
– Or injection of LA in this space
– Severe trismus
– Extreme radiating pain
– No facial swelling
– Swelling of lateral posterior portion of soft palate

48. Lateral pharyngeal space
• Boundaries
– Anteriorly – buccopharyngeal aponeurosis, parotid
gland, pterygoid muscle
– Posteriorly – prevertebral fascia
– Laterally – carotid sheath
– Medially – lateral wall of pharynx

49. • Clinical features
– Source of infection – third molar
– Difficulty in swallowing and breathing
– Tonsillar pillars and tonsils displaced medially
– Trismus
– Must be differentiated from peritonsillar abscess –
trismus is less severe /abscent and the tonsil is enlarged
and inflamed.

50. Retropharyngeal space
• Boundaries
– Anteriorly – wall of pharynx
– Posteriorly – prevertebral fascia
– Laterally – lateral pharyngeal space and carotid sheath

51. • Clinical features
– Infection results from medial extension from lateral
pharyngeal space.
– Displacing the buccopharyngeal fascia forward
impinging on the pharynx.
– Pain, dysphagia, and dyspnoea.

52. Parotid space
• Boundaries
– Posteriorly – behind the ramus of the mandible
– Medially – between the massater and internal pterygoid
muscle.

53. • Contents
– Parotid gland
– Fascial nerve
– Auriculotemporal nerve
– Posterior facial vein
– External carotid, internal maxillary, superficial
temporal arteries

54. • Clinical features
– Infection from lateral pharyngeal space or by
retrograde extension along the parotid duct.
– Elevation of ear lobe
– High fever, weakness, marked swelling and tenderness
– Escape of pus from duct when the gland is milked.

55. Spaces of the body of the mandible
• Boundaries
– Enclosed by layer of fascia derived from the outer layer
of deep cervical fascia.
– Superiorly – continuous with alveolar mucoperiosteum
and muscles of facial expression

56. • Clinical features
– Induration or fluctuation of labial sulcus if outer
cortical plate involved.
– Swelling restricted to floor of mouth if inner cortical
plate involved.
– Swelling in oral vestibule if molar teeth and outer
cortical plated are involved.
– Perforation below the external oblique line-the infection
may point on skin

57. Submassetric space
• It is situated between the masseter muscles and lateral
surface of mandibular ramus.

58. • Boundaries
• Posteriorly – parotid fascia and retromandibular portion
of parotid gland.
• Anteriorly – facial extension of parotidomasseteric fascia.

59. • Clinical features
• Infection from third molar
• Patient seriously ill
• Pain and swelling
• Severe trismus

60. Submandibular space
• Boundaries
• Located medial to mandible and below the posterior
portion of mylohyoid
• Medially by hyoglossus and diagastric muscles
• Laterally by superficial fascia and skin
• Contents: Submandibular gland and lymph nodes.

62. • Clinical features
• Infection from mandibular molars
• Swelling near the angle of jaw
• Sialadinitis and lymphadenitis
• Involvement of other submandibular spaces, lateral
pharyngeal space, cranial fossa or mediastinum

64. Sublingual space
• Boundaries
• Superiorly – mucosa of floor of mouth
• Inferiorly – mylohyoid muscle
• Anteriorly and laterally – body of mandible
• Medially – median raphe of tongue
• Posteriorly – hyoid bone

66. • Clinical features
• Swelling in the floor of the mouth
• Dyspnoea
• Dysphagia

67. Submental space
• Boundaries
• Extends from the anterior border of submandibular space
to the midline and is limited in depth by mylohyoid muscle.

68. • Clinical features
• Anterior swelling in the submental area
• Dyspnoea
• Dysphagia

69. Canine space
• Location: between the levator anguli oris and the levator
labii superioris muscles
• Involvement primarily due to maxillary canine tooth
infection.
• Clinical signs:
• Obliteration of the nasolabial fold
• Superior extension can involve lower eyelid

71. Buccal space
• Buccal space lies between the buccinator muscle and
overlying skin and the superficial fascia. This potential
space may become involved via upper jaw or lower jaw
molars

72. • Results when infection erodes through bone superior to
attachment of buccinator muscle
• Boundaries
• Lateral – skin of the face
• Medial - buccinator muscle
• Most infections caused by posterior maxillary teeth

76. Focus/fociof infection
• It refers to circumscribed area of tissue, which is infected
with exogenous pathogenic microorganisms and which is
usually located near a mucous or cutaneous surface.

77. Focal infection
• It refers to metastasis from the focus of infection, of
organisms or their products that are capable of injuring
tissue.

78. Mechanismof focal infection
• It may spread by hematogenous or lymphogenous route.
They get localized in tissues.
• Certain organisms have a predilection for isolating
themselves in specific sites of the body.
• Toxins or Toxin Products: It may spread by blood stream
or lymphatic channels, from focus to a distant site, where
they may initiate hypersensitive reaction in the tissues.
• One example is scarlet fever, which is due to erythrocyte
toxin liberated by the infective streptococci .

79. Oral foci of infections
• Infected Periapical Lesion: Particularly those of chronic
nature an area usually surrounded by the fibrous capsule,
which effectively walls off or separates the area of infection
from the adjacent tissues but do not prevent the absorption
of bacteria or toxins.
• Periapical granuloma has been described as a
manifestation of vigorous body defense and repair
reaction, while cysts merely a progressive form of
granuloma. Abscess occurs when the reparative and
defensive phase is minimum

80. Significance of oral foci of infection
• There are reports that the oral foci of infection either
cause, or aggravate many systemic disorders. Most
common are as follows:
– Arthritis
– Valvular heart diseases
– Gastrointestinal disease
– Ocular diseases
– Skin diseases
– Renal diseases

81. Arthritis
• Mainly rheumatoid and rheumatic fever type.
• Arthritis of rheumatoid type is of unknown etiology.
• These patients have high antibody titer to group of
hemolytic streptococci. It is tissue hypersensitive reaction.
• Streptococcal infection of throat, tonsils or nasal sinus may
precede the initial or recurrent attack.

82. Valvular heart diseases
• There is close similarity, in most instances, between the
etiologic agent of the disease and microorganisms in the
oral cavity, dental pulp and in periapical lesions.
• Symptoms of subacute bacterial endocarditis have been
observed in some instances shortly after extraction of
teeth.
• Transient bacteremia frequently follows tooth extraction.
• Streptococci of viridian type cause majority of sub acute
bacterial endocarditis.
• After tooth extraction, there is streptococcal bacteremia, so
there is occurrence of subacute bacterial endocarditis after
dental operations, dental extractions.
• Premedication of the patient should be done before
extraction.

83. Gastrointestinal disease
• Some workers state that constant swallowing of
microorganisms might lead to variety of gastrointestinal
diseases.
• Gastric and duodenal ulcers are produced by injection of
streptococci

84. Ocular diseases
• Occasionally, sudden transient exacerbation is observed,
after the removal of teeth and tonsils.
• Presence of blood stream infection in early stages of ocular
disease, are evident.
• Iritis may be produced by intravenous injection of
microorganisms, e.g. streptococci.
• There is some objection to these points
• Many healthy people have focal infections, but do no have
ocular diseases.
• Spontaneous care may occur if nothing is done.
• Positive blood cultures are rare in acute iritis

85. Skin diseases
• Some forms of eczema and possibly urticaria, can be
related to oral foci of infection.
• If the relationship does not exist, the mechanism is
probably sensitization, rather than metastatic spread of the
microorganisms.
• Initial inflammation spread of inflammation lowgrade
inflammation

86. Renal disease
• Microorganism most commonly involved in urinary
infection is E. coli, staphylococci and streptococci.
• Streptococci hemolyticus seems to be the most common.
• Objections to this
• Streptococci are uncommon inhabitants of dental root
canals or periapical and gingival areas.
• Since the microorganisms commonly involved in renal
infection so it appears that there is little relationship
between oral foci of infection and renal disease.