spread of infection

Question 1

palatal bone Vs buccal bone

Answer 1

palatal bone tends to be more dense

so less likely to spread that way as looks for path of least resistance

(more likely if palatal root or lateral incisor as palatally placed root)

more painful palatally as less space than buccally

Question 2

below buccinator maxillary abscess infection spread

Answer 2

Could go below buccinator, draining sinus – bad taste, painless, can go a while before tx unlike the other two

Question 3

maxillary abscess spread upwards causes

Answer 3

sinusitis

Question 4

muscle which impact maxillary spread of infection

Answer 4

buccinator

Question 5

muscles which impacts mandibular spread of infection

Answer 5

mylohyoid and buccinator

Question 6

mandibular abscess which breaks above the inseriton of mylohyoid

Answer 6

into sublingual space - sublingual abscess

Question 7

mandibular abscess which breaks below the mylohyoid insertion

Answer 7

submandibular space = submandubular abscess

Question 8

buccal spread of mandibular infection

Answer 8

possible but less common than lingual spread as bone thick on buccal posterior

but if anterior abscess more likely as bone thinner in labial region

Question 9

lower abscess infection perforate above the insertion of buccinator

Answer 9

drain as pus into oral cavity

Question 10

lower abscess perforate below insertion of buccinator

Answer 10

enter buccal space - swelling

Question 11

importance of mylohyoid in lower infection spread

Answer 11

mylohyoid muscle insertion determines where infection can spread to in mandible

• Attaches to mylohyoid line
  
  • sublingual spread above
  • submandibular spread below

Depends on which tooth

• premolar - sublingual
• 7- submandibular

Mylohyoid Not continuous

• Open at back so infection from sublingual space can spread to submandibular and vice versa

Question 12

if infection spread back from jaw can spread into

Answer 12

posterior potential spaces

Question 13

posterior potential spaces areas

Answer 13

pterygoid plates region

many muscle and bones – lots of spaces, healthy individual filled with alveolar connective tissue quite flat

infection can spread into them as easy due to little resistance and then can progress to more when penetrate one

spaces are quite explanatory

• pterygomandibular space – bound by mandible and two pterygoids
• superficial temporal on outside of temporalis muscle compared to deep temporal space
• infratemporal space
• masserteric space

all spaces communicate with each other

• infection spread in – muscle spasm, trismus
• all the spaces can be referred to as masticatory spaces*

Question 14

if posterior potential spaces infected

Answer 14

can cause muscle spasm and trismus

they are all interconnected

Question 15

masticatory spaces a.k.a

Answer 15

posterior potential spaces

Question 16

pterygomandibular space

Answer 16

bound by mandible and 2 pterygoids

Question 17

superficial temporal space

Answer 17

outside of temporalis muscle

Question 18

deep temporal space

Answer 18

inside of temporalis muscle

Question 19

masseteric space

Answer 19

between masseter and madnibular ramus

Question 20

infratemporal spasce

Answer 20

above lateral pterygoid muscle below deep temporal space and sphenoid bone

Question 21

infection spread deeper after posterior spaces into

Answer 21

lateral pharyngeal space

retrophargneal space

prevertebral space

Question 22

plane for this disection

Answer 22

coronal

Question 23

plane for this disection

Answer 23

sagittal

Question 24

what is in the lateral pharyngeal space

Answer 24

holds imp vessels and nerves

if able to open mouth , can see pharyngeal wall being pushed in, bulge

Question 25

after invading the lateral pharyngeal, retropharyngeal and prevertebral space where can infection spread

Answer 25

into infection of chest

Question 26

plane here

Answer 26

lateral

Question 27

spread from retropharyngeal space

Answer 27

up into skull down into superior mediastinum

Question 28

prevertebral space spread

Answer 28

up into skull down into inferior mediastinum

Question 29

spread into chest spaces impact

Answer 29

cause cardiac tamponade as infection can add pressure to heart or abscess in brain rare but serious

Question 30

cavernous sinus thrombosis

Answer 30

infection spread to brain both lower and upper tooth infection can spread through venous connections to brain – complex but serious

Question 31

lower tooth infection spread to cavernous sinus

Answer 31

Infection from lower tooth can spread into lateral pharyngeal space into infratemporal space, goes into pterygoid venous plexus – communicates with brain and veins are valve less so blood can flow in both directions meaning infection can spread in both direction

Question 32

upper tooth infection spread into cavernous sinus

Answer 32

Infection from upper tooth – spread into infraorbital space angular and infraorbital veins there (valve less) then into brain

Question 33

intial spread of infection for upper anterior teeth

Answer 33

lip nasolabial region lower eyelid

Question 34

intial spread of infection for upper lateral incisor

Answer 34

(palatally placed root) palate - less common

Question 35

intial spread of infection for upper premolars and molars

Answer 35

cheek infra-temporal region maxillary antrum (very rare) palate (less common)

Question 36

what is this

Answer 36

palatl abascess very painful, tissue strech likely due to grossly carious lateral incisor

Question 37

what is this

Answer 37

intraoral labial abscess spread buccally below insertion of muscles

Question 38

what is this

Answer 38

buccal/infraorbital spread spread buccal above insertion of muscles, parial closure of eye swelling of infraorbital and buccal space - linked

Question 39

what is this

Answer 39

infraoribital spread tend to lose nasolabial fold when infraorbital space invaded due to skin stretching likely canine source of abscess for pure infraorbital spread as higher apex

Question 40

what is this

Answer 40

Nasolabial fold unaffected, relatively mild – not red yet but is swollen

Question 41

what is this

Answer 41

buccal space infraorbital spread nasolabial fold is unaffected in this case

Question 42

likely way for upper tooth abscess infection to spread

Answer 42

Can spread further but tend to go up into brain Unusual for uppers to spread lower * unless get into buccal space and then spread into lateral pharyngeal via pterygomandibular space (lowers tend to spread down quickly, less so for anteriors)

Question 43

initial spread of infection for lower anterior

Answer 43

mental and submental space (tend to stick there) could spread back into sublingual and submandiular space (not often)

Question 44

inital spread of infection for lower premolars and molars

Answer 44

* Buccal Space (1^st) * Submasseteric Space * Sublingual Space (1^st) * Submandibular Space (1^sT) * Lateral Pharyngeal Space

Question 45

what is this

Answer 45

submental sinus track to skin ## Footnote Chronic sinus formation Once cause removed, need to do plastic surgery to get rid of scar Pt often don’t think teeth is source of issue – go to doctor/dermatologist who incise and it keeps recurring as infections cause still present cause - grossly carious lower anteriors

Question 46

what is this

Answer 46

submental spread tends to be self limiting burst and drain through skin

Question 47

what is this

Answer 47

submandibular space spread red starting to obliterate the inferior border of mandiblar could spread to other side or worringly backwards into submasserteric space or ptergomanidublar space and then lateral pharyngeal space

Question 48

what is this

Answer 48

buccal and submandibular space spread cannot see border of mandible - concern, likely systemically unwell

Question 49

what is this

Answer 49

submandibular sinus tract to skin submandibular spread which burst through skin drained but now has scar - can be tx once cause removed (here unerupted premolar)

Question 50

management of spread of infection from abscess done under

Answer 50

LA if pt comfortable if not GA

Question 51

3 principles of managament of spread of infection from abscess

Answer 51

establish drainage removal of source of infection antibiotic therapy? (not routine)

Question 52

estrablishment of drainage can be

Answer 52

extra oral or intra oral

Question 53

removal of source of infection how

Answer 53

Tooth itself * Extirpate the pulp * Extract Ideally on the day, but could be too painful so need to revisit (delayed removal of source)

Question 54

antibiotic therapy dependent on

Answer 54

many factors - not routine * Toxicity * Desirability * Medical history

Question 55

no indication for antibiotics when

Answer 55

if able to remove source of infection and obtain proper drainage from all location and pt systemically well

Question 56

indication for antiobiotcs

Answer 56

if unable to establish proper drainage for all areas or pt systemically unwell

Question 57

what to look for when trying to detect if systemic infection

Answer 57

SIRS scores

Question 58

SIRS stands for

Answer 58

Systemic Inflammatory Response Syndrome

Question 59

4 element of SIRS scores

Answer 59

* Raised temperature * Raised heart rate * Raised respiratory rate * Raised white cell count

Question 60

if pt has any of the 4 SIRS scores

Answer 60

need IB AB urgently - get to hospital for management

Question 61

e.g management here

Answer 61

Extra-oral incision and drainage – submandibular region, * be careful of facial nerve marginal mandibular branch (goes down beyond mandible border and comes back up to corner of mouth) * standard rule is to go at least 2 finger breadths below inferior border of the mandible drain after making incision * Hold finger in the incision to stimulate flow * Hilton Technique * Use two ended instrument that can be opened (like scissors, tweezers), close it and place it in the incision and open it to stretch the tissues to allow pus to drain Serosanguinous combination – blood and pus Try and get as much as you can Placement of extra-oral drain to get the last of the infection, held in place by non-resorbable sutures (prolene) for a few days (sterile surgical tubing) with dressing over * checked periodically and if dirty still draining, when clean on checked likely ready for drain to be removed

Question 62

what is this

Answer 62

buccal space spread

Question 63

what is this

Answer 63

submandibualr space spread lower down than usual

Question 64

what is this

Answer 64

Extra oral sinus Unusual – draining sinus tend to be lower tooth not upper

Question 65

ludwig's angina

Answer 65

Bilateral cellulitis of the sublingual and submandibular spaces (as a result of dental infection)

Question 66

e.g. dental cause of ludwig's angina

Answer 66

lower molar infection spreads to sublingual space then submandibular space on that side, crosses over and spread into the other two sublingual and submandibular spaces. Then large swelling under neck with raised tongue (due to infection underneath). Serious – compromise airway and difficulty swallowing – urgent tx needed, likely also systemically unwell

Question 67

intraoral features of ludwigs angina

Answer 67

* Raised tongue * Difficulty breathing * Difficulty swallowing * Drooling

Question 68

extra oral features of ludwig's angina

Answer 68

* Diffuse redness and swelling bilaterally in submandibular region

Question 69

systemic features of ludwig's angina

Answer 69

* Increased heart rate * Increased respiratory rate * Increased temperature * Increased white cell count ## Footnote * If low HR/resp/ temp – worrying, going into shock* * Check pt when in the chair with infection – one raised, worried send to max fax*

Question 70

National Early Warning Score

Answer 70

NEWS used in emergency med, higher score more unwell pt 3 are SIRS scores which can check in chair

Question 71

ACVPU

Answer 71

A = Alert C = Confusion V = Responds to verbal commands P = Responds to pain U = Completely unresponsive used to asses pt