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Orofacial & Orofacial & neck neck infections infections INSTRUCTOR – DR.JESUS GEORGE INSTRUCTOR – DR.JESUS GEORGE
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ETIOLOGYETIOLOGY1-OdontogenicPulp diseasePeriodontal diseaseSecondarily infected cyst &
odontomesRemaining root fragmentPericoronal infection2-Trauma3-Implant Surgery4-Reconstructive Surgery
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Cont.Cont.Contaminated Needle Puncture
Infections Of Maxillary Antrum
Infections of salivary glandsSecondary to oral malignancies
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Pathways of odontogenic Pathways of odontogenic infectionsinfections Invasion of dental pulp by bacteria after decay of a tooth Inflammation, edema & lack of collateral
blood supply Venous congestion or avascular necrosis (pulpal tissue death)
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Cont.Cont.
Reservoir of bacterial growth(anaerobic)
Periodic egress of bacteria into
surrounding alveolar bone
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MICROBIOLOGYMICROBIOLOGYAerobic gram positive cocci
bacteria-streptococci milleri, strep. Sanguis, strep. Salivarius, strep. Mutans.
Anaerobic Cocci-peptostreptococcus.
Bacteriodes-porphyromonas, prevotella
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TYPESTYPES A/cC/cAcute stage - 3 forms1.Abscess2.cellulitis 3.fulminating infection
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Abscess Abscess It is a circumscribed collection of
pus in a pathologic tissue space. Infections are characterised by
sphylococci.
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CELLULITISCELLULITISIt is spreading infection of loose
connective tissues.It is a diffuse, erythematous,
mucosal or cutaneous infection.It is the result of streptococcal
infection.It does not result in accumulation
of large amount of pus.
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Cont.Cont.Streptococcus produces
streptokinase, hyaluronidase & streptodornase which break down fibrin, connective tissue ground substance & lyse cellular debris, which facilitate rapid spread of bacteria.
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FULMINATING INFECTIONSFULMINATING INFECTIONSHere the infection involves
secondary spaces involving vital structures.
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Chronic stageChronic stageC/c fistulous tract or sinus formation
Abscesses neglected for a long time may discharge intraorally or extra orally
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TreatmentTreatmentMedical treatmentSoft or liquid dietAdequate hydrationDiet rich in proteinAnalgesicsAntiseptic mouthwashAntibiotics
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Cont.Cont.In a non compromised patient, with
well localized abscess, surgical drainage with dental therapy will resolve the infection.
In poorly localized, extensive abscess & cellulitis antibiotic therapy is needed.
In compromised patients & patients with trismus, airway obstruction & fever antibiotic therapy is must.
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Cont.Cont.Penicillin is the drug of choice. Penicillin+metronidazole Can
Also Be Used.ClindamycinAmoxycillin+clavulanic AcidFirst & Second Generation
Cephalosporins
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Cont.Cont.Surgical treatmentIt involves blunt exploration of the
anatomic space or abscess.Abscess cavity is then irrigated with
betadine & saline.A drain is inserted into the space.Hilton`s method of incision &
drainage◦No blood vessel or nerve is damaged.◦Topical anaesthesia is obtained.
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Cont.Cont.◦Stab incision is made over the point of
maximum fluctuation in the most dependent area along the skin creases, through skin & subcutaneous tissue.
◦If pus is not encountered deepening of surgical site is done with artery forceps.
◦Closed forceps are pushed through deep fascia & advanced towards the pus collection.
◦Abscess cavity is entered & forceps is opened parallel to vital structures.
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Cont.Cont.◦Pus flows along the beaks of the
forceps.◦A rubber drain is inserted into the depth
of cavity & secured to the wound margin with the help of sutures.
◦Drain is left for 24 hrs.◦Dressing is given without pressure.◦Drain allows discharge of tissue fluids &
pus from the wound.◦Drain is removed when the drainage is
completely ceased
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ACUTE PERIAPICAL ACUTE PERIAPICAL ABSCESSABSCESSEtiology
◦Caries◦Contamination of traumatic exposure of
pulp.◦Chemical or thermal damage to pulp.
The entry to periapical tissues is by ◦Apical foramina, ◦Accessary canals, ◦Endodontic perforation, ◦Opening in the floor of pulp chamber, ◦Root fracture or resorption.
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Cont.Cont.Clinical features
◦Severe throbbing pain in the affected tooth
◦The offending tooth may be sensitive to percussion.
◦ Mobility may or may not be present.Radiographic features
◦Tooth has caries with periapical pathology, root # or erosion.
◦There may be periapical radiolucency.
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Cont.Cont.Treatment
◦Antibiotics◦Analgesics◦Drainage through pulp chamber◦Extraction of tooth◦Endodontic treatment
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Acute dentoalveolar Acute dentoalveolar abscessabscessEtiologyContinuation of periapical abscess.Clinical featuresPainSubmucosal swelling in the sulcus
on the outer aspect of alveolar process.
If left untreated, swelling bursts & produces a sinus.
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Cont.Cont.Radiologic featuresMore marked radiolucency than
periapical abscess.TreatmentSame as periapical abscess.Extraoral incision & drainage
may be required.
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Acute periodontal Acute periodontal abscessabscessEtiologyPeriodontitis with periodontal
pockets.Clinical featuresDull painPus discharge via gingival pocketSinus either on the outer or inner
aspect of alveolar process.
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Spread of oral infectionSpread of oral infectionRoutes of spreadDirect continuity through tissuesBy lymphatics to the lymph nodes.From
lymph nodes to tissues results in secondary areas of cellulitis or tissue space abscess.
By blood stream-local thrombophlebitis may spread via the veins entering the cranial cavity producing cavernous sinus thrombosis. It may cause septicemia
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Cont.Cont.Factors influencing spread
◦General factors Host resistance Virulance of micro organism Combination of both
◦Local factors Anatomic barriers- Alveolar bone Periosteum Adjacent muscles & fascia
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General clinical features in General clinical features in patient with orofacial patient with orofacial infection infection Redness due to vasodialtationSwelling due to accumulation of
exudate or pusTemperature over the infected area
due to increased blood flow & increased metabolism
Pain due to pressure in nerve endings & release of mediators of pain.
Fever27
Cont.Cont.Head acheLymphadenopathy
◦Acute infection-soft, tender, enlarged, surrounding tissues are edematous& overlying skin is erythematous
◦Chronic infection-firm, nontender enlarged lymph nodes.
Presence of draining sinus & fistulaDifficulty in opening mouth
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Cont.Cont.Increased salivationChange in phonationDifficulty in breathingBad breath
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Radiologic examinationRadiologic examinationIOPALateral oblique view of mandiblePA & lateral view of neckCTMRI
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General principles of General principles of management of a/c management of a/c orofacial infectionsorofacial infections
Immediate hospitalizationMedical treatmentSurgical management
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Medical managementMedical managementAntibioticsHydration of the patient through
iv routeAnalgesicsBed restMouth rinsesOpening of tooth for drainage
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Surgical managementSurgical managementNeedle decompressionDone in case of pterigomandibular,
peritonsillar,lateral pharyngeal space infection that is likely to rupture during passage of endotracheal tube.
Extraction of toothEarly extraction leads to early
resolution of infection by eliminating the source of infection & provides a portal of drainage
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Cont.Cont.Surgical drainage-Incision is placed on the most
dependent areas.Incision should be parallel to skin
creasesIncision should lie in aesthetically
acceptable site as far as possible.Incision should be supported by
healthy underlying dermis & subcutaneous tissue.
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Cont.Cont.Intraoral incision should not be
placed over frenal attachments, should be placed parallel to nerve fibers in the region of mental nerve.
Removal cause such as infected tooth, segment of necrotic bone, foreign body, if not already done, then is done at the time of drainage procedure
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Classification of fascial Classification of fascial spacesspacesPrimary maxillary spacesCanineBuccalInfratemporalPrimary mandibular spacesSubmentalBuccalSubmandibularSublingual
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Cont.Cont.
Secondary fascial spacesMassetericPterigomandibularSuperficial & deep temporalLateral pharyngealRetropharyngealPrevertebral Parotid space
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Canine space infectionCanine space infection
EtiologyInfection of maxillary canine, premolar & mesiobuccal root of 1st molar.BoundariesInferiorly-caninus muscleAnteriorly-orbicularis oris musclePosteriorly-buccinator muscleMedially-anterolateral surface of maxilla
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Cont.Cont.Clinical featuresSwelling of cheek & upper lipObliteration of nasolabial foldDrooping of angle of mouthEdema of lower eyelidsMarked Periorbital EdemaRedness & Marked Tenderness Of
Facial Tissues
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Cont.Cont.In c/c stage-fistula near the
medial canthus eye.Offended tooth is mobile &
tender to percussionTreatmentIncision & drainage-Through the mucosa of buccal
vestibule in the region of lateral incisor & canine.
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Cont.Cont.A curved mosquito artery forceps
is inserted, pus is evacuated & a drain is inserted & is secured with suture
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Buccal space infectionBuccal space infection
EtiologyInfection of maxillary & mandibular premolars & molarsPericoronitis of lower 3rd molar.BoundariesAnteromedially-buccinator musclePosteromedially-masseter muscleLaterally-deep fascia from parotid capsule & platysma muscle
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Cont.Cont.Inferiorly-deep fascia & depressor
anguli orisSuperiorly-zygomatic process of
maxilla & zygomaticus major & minor muscles
ContentsBuccal pad of fatStenson`s ductFacial artery
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Cont.Cont.Clinical featuresGum boil in vestibuleSwelling extending from lower
border of mandible to infraorbital margin, from anterior border of masseter to angle of mouth
Edema of lower eyelid
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Cont.Cont.SpreadTo pterigomandibular spaceInfratemporal spaceSubmasseteric spaceTreatmentIncision & drainage through
mucosa of cheek in premolar molar region.
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Infratemporal space Infratemporal space infectioninfectionAlso called retrozygomatic space
because it is situated behind the zygomatic bone.
EtiologyInfection of buccal roots of
maxillary 2nd &3rd molarsLA injection with contaminated
needles in the area of tuberositySpread from other spaces
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Cont.Cont.Boundaries Laterally - by ramus of mandible,
temporalis muscle & its tendon . Medially - medial pterygoid plate ,
lateral pterygoid muscle , medial pterygoid muscle ,lower part of temporal fossa of the skull & lateral wall of pharynx .
Superiorly - greater wing of sphenoid & by zygomatic arch .
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Cont.Cont.Inferiorly - lateral pterigoid muscleAnteriorly - infra temporal surface of
maxillaPosteriorly- parotid gland Contents Medial & lateral pterigoid muscle
Pterigoid venous plexusMaxillary arteryMandibular nerve
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Cont.Cont.Middle meningeal arteryClinical featuresLimitation of mouth openingSwelling in front of ear on the
affected sideProptosis of eyeSwelling in the area of tuberosityElevation of temperature
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Cont.Cont.Incision & drainageIncision is given in buccal
vestibule opposite the 2nd & 3rd molars
In severe infection incision is made at the upper posterior edge of temporalis muscle.
Sinus forceps is directed upwards & medially.
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Cont.Cont.In case of failure to improve
mouth opening temporalis myotomy or excision of coronoid process is done.
SpreadTo temporal spacePterigomandibular spaceCavernous sinus
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Abscess of upper lipAbscess of upper lip
EtiologyInfection of upper incisors & canineClinical featuresSwelling in the base of the upper lipSwelling in vestibuleTreatmentAntibioticsIncision & drainageExtraction of offending tooth or RCT
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Palatal abscessPalatal abscessEtiologyPeriodontal abscess from palatal pocketsApical abscess from palatal roots of posterior teeth usually from the lateral incisorBoundariesInferiorly-hard palateSuperiorly-periosteum & mucosaLaterally-alveolar process of maxilla & teeth
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Cont.Cont.
Clinical featuresFluctuant swelling in palate near the offending toothOffending tooth is tender to percussionIncision & drainageAnterioposterior incision is made through the mucosa down to bone
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Submental space Submental space infectioninfectionEtiologyInfection from 6 mandibular anterior teethInfection of submental lymph nodesBoundariesLaterally-lower border of mandible, anterior belly of digastric muscleSuperiorly-mylohoid muscle
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Cont.Cont.Inferiorly-deep cervical fascia,
platysma, superficial fascia, skinContentsSubmental lymph nodesAnterior jugular veinClinical featuresDistinct ,firm swelling in
midline ,beneath the chin
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Cont.Cont.Skin overlying the swelling is
board like & tautFluctuation of swellingNonvital, fractured or carious
anterior teethOffending tooth is tender on
percussion& sometimes mobile
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Cont.Cont.
Incision & drainageTransverse incision in skin below symphysis of mandible.SpreadSubmandibular space
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Submandibular space Submandibular space infectioninfectionEtiologyInfection From Mandibular MolarsInfection Of Submandibular Salivary GlandInfection From Submental SpaceInfection From Submental Lyph NodesInfection From Sublingual SpaceInfection from middle 1/3 of tongue, posterior part of floor of mouth, maxillary teeth, cheek, maxillary sinus & palate
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Cont.Cont.BoundariesAnteromedially-mylohyoid MusclePosteromedially-hyoglossusmuscleSuperolaterally-medial Surface Of MandibleAnteroposteriorly-anterior belly of digastricPosterosuperiorly-posterior belly of digastric,stylohyoid ,stylopharyngeus musle
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Cont.Cont.Laterally-platysma & skinContentsSubmandibular salivary glandSubmandibular lymphnodesFacial artery & veinClinical featuresFirm swelling in submandibular
regionConstitutional symptoms
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Cont.Cont.Tenderness of swellingRedness of overlying skinTeeth Are Sensitive To
Percussion & MobileDysphagiaModerate Trismus
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Cont.Cont.Incision & drainageIncision of 1.5 to 2cm length is made
2cm below the lower border of mandible in the skin creases.
Skin & subcutaneous tissues are incised.SpreadSubmental spaceSubmandibular space of opposite sideSublingual spaceParapharyngeal space
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Sublingual space Sublingual space infectioninfectionEtiologyInfection from mandibular incisors, canines, premolars & molarsBoundariesInferiorly-mylohyoid muscleLaterally-medial side of mandibleMedially-hyoglossus, genioglossus, geniohyoid musclesPosteriorly-hyoid bone
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Cont.Cont.ContentsGeniohyoid, genioglossus,
mylohyoid muscleDeep part of submandibular
salivary glandSublingual salivary glandLingual nerveHypoglossal nerve
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Cont.Cont.Clinical featuresEnlarged tender lymph nodes.Pain & discomfort on deglutitionSpeech is affected Painful swelling in floor of mouth Tongue may be pushed superiorlyIncision & drainageIncision made close to lingual
cortical plate.
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Cont.Cont.SpreadSublingual space of opposite sideSubmandibular spacePterigomandibular spaceParapharyngeal spaceSubmental & submandibular
lyphnodes
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Temporal spaceTemporal spaceEtiologySecondary to the involvement of
infratemporal spaceBoundariesSuperficial temporal space-b/w
temporal fascia & temporalis muscle.
Deep temporal space-b/w temporalis muscle & skull
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Cont.Cont.Clinical featuresPainTrismusSwelling over temporal regionIncision & drainageIncision in temporal region in
hairline 45 to zygomatic arch
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Parotid spaceParotid spaceEtiologyInfection through stenson`s ductBlood borne infectionInfection from
submasseteric,pterigomandibular & lateral pharyngeal space
BoundariesInferiorly-stylomandibular ligamentAnteriorly-masseteric space
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Cont.Cont.Space formed by splitting deep
cervical fascia around the parotid gland
ContentsParotid glandParotid lymph nodesFacial nerveRetromandibular veinExternal carotid artery
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Cont.Cont.Clinical featuresSevere pain referring to ear
accentuated by eatingSwelling extending from
zygomatic arch to lower border of mandible.
Ear lobe may be lifted upPus escapes from stenson`s duct
when gland is milked
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Cont.Cont.Incision & drainageIncision is made on skin behind the
posterior border of mandible extending from inferior aspect of lobule of ear to just above mandible
SpreadSubmasseteric spacePterigomandibular spaceLateral pharyngeal space
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Submasseteric space Submasseteric space infectioninfectionEtiologyInfection Of Lower 3rd MolarBoundariesAnterior-anterior border of
masseter & buccinator musclePosterior-parotid gland,posterior
part of masseterInferior- attachment of masseter
to lower border of mandible74
Cont.Cont.Medial-lateral surface of ramus of
mandibleLateral-medial surface of
masseter muscleContentsMasseteric NerveSuperficial Temporal ArteryTransverse Facial Artery
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Cont.Cont.Clinical FeaturesModerate swelling extending from
lower border of mandible to zygomatic arch, anteriorly to anterior border of masseter, posteriorly to posterior border of mandible
Tenderness over angle of mandibleComplete Limitation Of Mouth
Opening Pyrexia & Malaise
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Cont.Cont.Incision & drainageIntraoral-incision is made
vertically over the lower part of anterior border of ramus of mandible, deep to bone
Extraoral-incision is placed in skin behind the angle of mandible
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Pterigo - mandibular Pterigo - mandibular space infectionspace infectionEtiologyPericoronitis related to the
mandibular third molar .Inferior alveolar nerve block
using contaminated needle .Infection form maxillary third
molar .Boundaries .Posterior - parotid gland .
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Cont.Cont.Medial - lateral surface of medial
pterygoid muscle .Lateral - medial surface of ramus of
mandible .Anterior -pterygomandibular raphae .Superior - lateral pterygoid muscle .Contents .Lingual nerve .Mandibular nerve .
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Cont.Cont.Inferior alveolar artery .Mylohyoid muscleClinical features .Limitation of mouth opening .Tenderness & swelling medial to
anterior border of ramus of the mandible .
Dysphagia .Difficulty in breathing
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Cont.Cont.Incision & drainage .Intraoral – a vertical incision;
approximately 1.5 cm in length , is made on the anterior & medial aspect of the ramus of mandible .
Extraoral - an incision is taken in the skin below the angle of the mandible .
Spread .Infra temporal space
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Cont.Cont.Lateral pharyngeal space .Retropharygeal space .Submandibular space . .
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LATERAL PHARYNGEAL LATERAL PHARYNGEAL SPACE SPACE ..EtiologyMandibular third molar area .Sublingual , submandibular &
ptergomandibular space infection .Boundaries .Inferiorly - hyoid bone .Anteriorly - pterygomandibular raphe Laterally - ascending ramus of
mandibular Medially - pharyngeal wall .
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Cont.Cont.Posteriorly - styloid muscle , upper part
of carotid sheath , prevertebral fascia .Contents Anterior compartment - lymph nodes ,
facial artery , loose areolar connective tissue .
Posterior compartment - carotid sheath , internal carotid artery , glossopharyngeal nerve , cervical sympathetic trunk .
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Cont.Cont.Clinical Features .Respiratory Embarrassment Due
To Edema Of The Larynx .Malaise .Pyrexia .Brawny Induration Of The Face .Trismus .Severe pain Dysphagia
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Cont.Cont.Incision & drainageExtraoral - an incision is made
along the anterior border of sternocleidomastoid muscle , extending from below the angle of the mandible , to the middle third of submandibular gland .
Intraoral - a vertical incision is placed over the pterygomandibular raphe .
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Retropharyngeal space Retropharyngeal space (prevertebral space )(prevertebral space )Etiology Infection from the iateral
pharyngeal space Boundaries .Laterally - carotid sheath Inferiorly-6th thoracic vertebraClinical features .Painful deglutition .Snoring .
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Cont.Cont.Choking .Stertorous breathing .Incision & drainage .Same as lateral pharyngeal
space
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PericoronitisPericoronitisDefinitionAn inflammatory process involving
the soft tissue covering the crown of partially erupted or unerupted teeth
EtiologyImpacted teeth .Trauma to the overlying gingivae
from the cusps of an opposing tooth .
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Cont.Cont.Clinical features Dull painSwollen ,red,tender gingival padPus discharge from the gingival padFoetor orisIndentations of cusps of upper teethDiscomfort on swallowingRestriction of oral opening
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Cont.Cont.Enlarged tender submandibular
lymph nodesPyrexia/feverMalaise AnorexiaSpreadBuccal space Submandibular spacePterigomandibular spaceSubmasseteric space
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Ludwig`s anginaLudwig`s anginaDefinitionA massive, firm, brawny, cellulitis
or induration & acute toxic stage involving simultaneously submandibular, sublingual & submental spaces bilaterally.
EtiologyOdontogenic-
◦A/c dentoalveolar abscess◦A/c periodontal abscess
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Cont.Cont.◦Pericoronal abscess◦Infected mandibular cyst
Iatrogenic◦La using contaminated needles
Trauma in orofacial regionOsteomyelitisSubmandibular & sublingual
sialadenitisSecondary infections of oral
malignancies93
Cont.Cont.TonsillitisForeign bodies like fish boneOral soft tissue lacerationsClinical featuresPyrexia .AnorexiaChills .Malaise .Dysphagia .
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Cont.Cont.Impaired speech .Hoarseness of voice .Firm or hard brawny swelling in
bilateral submandibular & submental regions extending to the clavicles .
Swelling is non pitting , non fluctuant ,tender with ill defined borders .
Restricted mouth opening .Air way obstruction .
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Cont.Cont.Mouth remains open due to
edema of sublingual tissues Reduced tongue movements .Increased respiratory rate .Cyanosis .Raised floor of mouth .Tongue is raised against palate .Increased salivation .Drooling of saliva .
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Cont.Cont.SpreadSubmasseteric space .Pterygomandibular space .Parapharyngeal space .Paratonsillar space .Mediastinum .Cavernous sinus thrombosis .
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Cont.Cont.Treatment Maintenance of air way .
◦ Nasotracheal intubationSurgical decompression.
◦Bilateral submandibular incision s & a midline submental incision 1cm below inferior border of mandible for drainage .
Extraction of offending tooth .
98
Cont.Cont.Antibiotic therapy .
◦Aqueous penicillin G 2 - 4 million units , i v 4-6 hourly or 500mg 6 hourly orally
◦Ampicillin or amoxycillin 500mg 6 & 8 hourly i v & orally respectively .
◦Cloxacillin 500mg orally 8 hourly .◦Erythromycin 600mg 6- 8 hourly .◦Gentamycin 80mg i m bd .◦Clindamycin i v 300mg 600mg 8 hourly
. or orally 99
Cont.Cont.◦Metronidazole 400mg 8 hourly orally or
i v .Hydration of the pt .Hydro therapy
◦Cold application decreases inflammation , exudates , edema .
ComplicationsOsteomyelitis .Maxillary Sinusitis .Septicaemia .
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Cont.Cont.Mediastinitis .Pericarditis .Jugular vein thrombosis .Meningitis . Brain abscess .Cavernous sinus thrombosis
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