Cellulitis of dental origin.
- Definition: Cellulitis is an inflammation of the cellular-adipose tissue of the face and parapharyngeal spaces following an infection.
This tissue constitutes the filling tissue of the face. It also plays a sliding role allowing functional movements of the facial musculature.
- Anatomical reminder:
2.1. Cellular tissue:
2.1.1. Constitution: it is a loose tissue, composed of collagen fibers, elastic fibers, free cells, large adipose cells which will delimit the partitioned adipose zones of fibrous connective tissue, small lymphatic and blood vessels which remain very linked to the connective tissue.
All these elements will bathe in a muco-polysaccharide gel.
- Distribution of cervicofacial cellular tissue:
The cellular or celluloadipose tissue occupies the following regions on the face:
- Chin rest
- Labial
- Parotid
- Genitourinary and nasolabial
- Masseterin
- Intermaxillary commissure
- Veil of the palate
- Buccal floor (/ in 2 by the mylohyoid)
He is absent at the level of
- The gum (we speak of parulic abscess or parulia)
- From the hard palate (subperiosteal abscess).
- Tooth position
- At the level of the mandible
The apices of the incisors, canines and 1st PM are located closer to the external table. The apices of the 2nd PM , 1st molar are located median. The apices of the last 2 molars are closer to the internal table.
- At the level of the upper jaw
Only the apex of the lateral incisor and the palatal roots of the 1st PM and molars are close to the internal table. All other apices are located closer to the external table.
- Etiologies:
3.1. Determining causes:
– Mortification of the dental pulp :
* By caries (diffuse infection in the desmodontal space)
* Dental trauma often results in a low-noise outcome.
– Periodontal infection :
* Periodontal disease destroys the desmodontal space and ultimately mortifies the dental pulp “ a retro ”.
* Pericoronitis of eruption or disinclusion (especially mandibular DDS).
– Therapeutic gestures (iatrogenic origin):
* Root canal filling
* Periodontal surgery
* Extraction of infected teeth
* Trauma – orthopedic – implant surgery…
* ODF treatment (low noise pulp necrosis)
* Septic sting especially during anesthesia (truncal +++ ).
3.2. Contributing causes:
– Modification of the endogenous oral flora (dry mouth, etc.).
– Weakening of the body’s defenses:
This weakening may be linked to:
* Physiological factors:
🡪Age.
🡪Pregnancy (especially the last trimester)
🡪Nutrition (protein and vitamin deficiencies).
* Environmental factors: physical and/or psychological trauma.
* Congenital or acquired immune factors AIDS,…
– drug prescription 🡨🡪Inappropriate prescriptions:
🡪 Overuse of anti-inflammatories,
🡪 Or even unsuitable antibiotics which will select the germs.
- Bacteriology
There are no specific germs. All oral flora can be incriminated. The most common germs are:
* Gram + aerobes : staphylococci, streptococci
* anaerobes: actinomyces, fusiform.
- Pathogenesis
It is done from the initial infectious focus:
– via the osseoperiosteal route: from the desmodontal space, the infection will cross the bone, detach the periosteum, rupture it and colonize the periosteal soft parts.
– by hematogenous route (venous and lymphatic): factor in the early spread of infection.
6. Clinical study
Cellulite can be classified according to several parameters:
1- Severity: according to the prognosis:
– Common circumscribed cellulitis (favorable prognosis).
– Malignant cellulitis (reserved prognosis).
Cellulitis of dental origin.
2- Evolutionary mode : we classify them into 4 groups:
– Acute cellulitis
– Subacute cellulitis.
– Chronic cellulite.
– Acute malignant cellulitis.
3- Topography
– Perimaxillary forms
– Perimandibular forms.
6.1. Evolutionary forms
6.1.1. Acute cellulitis
6.1.1.1. Acute serous cellulitis
Serous cellulite is the initial, purely inflammatory stage.
We find functional signs and physical signs.
* Functional signs: We find the signs of acute desmodontitis: violent, spontaneous pain, exacerbated by contact with the opposing tooth (sensation of a long tooth) and decubitus.
*Physical signs: Facial deformation by the presence of poorly limited swelling, filling the depressions or furrows of the face, the skin opposite is tight, smooth, pink, it is stuck to the underlying bone, painful with increased local heat, it is elastic and does not take the pitting sign we say that the pitting sign is negative. (The pitting sign is said to be positive when the skin keeps the imprint of the finger after pressure from it).
*On intraoral examination: raised, red mucosa is found next to the causative tooth; the vitality test is negative.
6.1.1.2. Acute suppurative cellulitis
It follows the serous phase which was not or poorly treated in the days that followed (around 2 to 3 days), this is the hot abscess stage.
* General signs appear: the patient sleeps little and eats poorly. We find: trismus, pallor, fatigue and fever.
* Functional signs: The pain becomes throbbing, continuous, with headaches and radiation.
*On oral examination : The skin is red, hot, and shiny. Painful palpation shows that the swelling has been limited, it is part of the bone and the skin takes on the pit sign.
Fluctuation can also be found.
*On intraoral examination: Often hampered by the limitation of mouth opening, the gum is raised, red and very painful, filling the vestibule opposite the causative tooth; halitosis and hypersalivation.
6.1.1.3. Acute gangrenous cellulitis: Related to anaerobic phenomena and the activity of anaerobic germs
* Functional signs (pain and swelling) are important.
* General signs: are very marked, the temperature is high (40°); there is asthenia, the face is pale and grayish.
* Physical signs: are a swelling covered with purplish skin. Palpation sometimes reveals gaseous crepitation (a sign of tissue necrosis and anaerobiosis).
The puncture brings back brownish pus, with an unbearable odor and the presence of gas.
* Evolution: often very serious, in the absence of rapid and adequate treatment, there will be an extension of the loss of substance.
Cellulitis of dental origin.
6.1.2. Subacute and chronic cellulitis
These 2 types are clinically close:
- Following poorly treated cellulite by:
– Inappropriate or insufficient antibiotic therapy
– Persistence of the cause
- As they can immediately develop into a chronic or subacute mode (not very virulent germ).
Clinically, it is most often a rounded or oval nodule that protrudes from the skin, painless, hard, without heat.
The accompanying signs (functional, general) are discreet or even non-existent, the patient generally consults for an aesthetic reason
- Special cases of chronic cellulitis with a specific germ:
- Actinomycotic cellulitis: this is a chronic infection of endogenous origin due to filamentous and branched gram+ bacteria called actinomycetes ( Actinomyces Israeli ).
Clinically: the swelling is particular, on a hard plaque on which swellings will successively settle one next to the other, giving the whole a mammary appearance.
At the incision we find pus with characteristic yellow grains.
- Ligneous cellulitis: the tissue sclerosis is so significant that it gives the swelling a ligneous hardness (hard as wood). This is a clinical form that has become exceptional.
- Topographical forms
The seat depends on the anatomical cleavages of the area concerned.
7.1. Circumscribed cellulitis
7.1.1: Perimandibular cellulitis
7.1.1.1. Genital cellulite (low)
The symptomatology is dominated by trismus, which is more marked the more posterior the tooth is. On intraoral examination, a mucosal elevation is found opposite the causative tooth.
Cellulitis of dental origin.
Peron J.-M., Mangez J.-F. Cellulitis and fistulas of dental origin. EMC (Elsevier Masson SAS, Paris), Stomatology/Odontology, 22-033-A-10, 2002, Oral medicine, 28-405-G-10, 2008.
It is in this location that we describe the “migratory or buccinatomaxillary abscess of Chompret and L’Hirondel” which collects in this region after the pus from the alveolus of the wisdom tooth has traveled along the buccinatomaxillary groove. Since the swelling never extends beyond the commissure, pressure on the swelling causes the emission of pus opposite the DDS (pathognomonic sign).
7.1.1.2. Labial and labiomental cellulitis:
The collection develops on the side of the external table where it goes around the insertions of the square and tuft muscles of the chin; above it is superficial, vestibular giving the appearance of a large lip; below it is deep, and develops in the mental eminence or the submental region.
The etiology of incisor mortification is classic.
Cellulitis of dental origin.
Peron J.-M., Mangez J.-F. Cellulitis and fistulas of dental origin. EMC (Elsevier Masson SAS, Paris), Stomatology/Odontology, 22-033-A-10, 2002, Oral medicine, 28-405-G-10, 2008.
- Masseter cellulite:
It is uncommon. It is most often an accident on an included or impacted wisdom tooth in the vestibular position. The picture is dominated by very tight trismus and intense pain making the examination difficult. The swelling is pressed against the external face of the mandibular angle; it is necessary to ensure that the swelling does not extend to the internal face or to the posterior part of the floor of the mouth, which changes the degree of urgency. This cellulitis can develop and spread through the sigmoid notch towards the paratonsillar region and the infratemporal region.
- Submylohyoid or submandibular cellulitis:
The swelling forms a body with the basilar edge of the horizontal branch and extends into the lateral subhyoid space, to evolve towards the neck (cervical region).
Peron J.-M., Mangez J.-F. Cellulitis and fistulas of dental origin. EMC (Elsevier Masson SAS, Paris), Stomatology/Odontology, 22-033-A-10, 2002, Oral medicine, 28-405-G-10, 2008.
7.1.1.5. Suprasmylohyoid cellulitis:
This is cellulitis of the floor of the mouth: the danger is progression to the airways 🡪 asphyxia. The 6-year-old tooth is often the cause. The swelling is stuck to the internal table of the horizontal branch opposite the causative tooth, it will progress to the floor of the mouth.
This is an emergency; the swelling increases rapidly and the tongue is pushed back to the opposite side 🡪 difficult phonation and swallowing.
Cellulitis of dental origin.
Peron J.-M., Mangez J.-F. Cellulitis and fistulas of dental origin. EMC (Elsevier Masson SAS, Paris), Stomatology/Odontology, 22-033-A-10, 2002, Oral medicine, 28-405-G-10, 2008.
7.1.1.6. Posterior cellulitis:
* Juxta-tonsillar cellulitis of Escat:
We find a tight trismus, dysphagia and intense otalgia. The very difficult oral examination allows us to identify the mandibular molar (DDS++). We can find the bulging of the anterior pillar of the velum and the tonsil.
7.1.2. Perimaxillary cellulitis
7.1.2.1. Lip and nasolabial cellulitis
- The collection arises from a central incisor and surrounds the myrtiform muscle and is either above it, the nostril threshold, or below it and touches the upper lip. The canine is responsible for a vestibular and nasolabial collection which may be associated with diffuse edema at the level of the lower eyelid.
7.1.2.2. Genital cellulitis (upper)
The collection is jugal and extends towards the lower eyelid 🡪closing of the eye.
7.1.2.3. Subperiosteal abscess
They develop in areas where the oral mucosa adheres to the periosteum without an intermediate layer of cellular tissue (at the level of the palate and attached gingiva).
Cellulitis of dental origin.
Peron J.-M., Mangez J.-F. Cellulitis and fistulas of dental origin. EMC (Elsevier Masson SAS, Paris), Stomatology/Odontology, 22-033-A-10, 2002, Oral medicine, 28-405-G-10, 2008.
Parulias are small abscesses; they are mainly linked to temporary teeth.
7.2- Diffuse cellulite
These are acute malignant cellulitis that are diffuse from the outset, unlike diffuse cellulitis which represents the evolution of circumscribed cellulitis.
They are also called diffuse phlegmon of the face or “necrotizing fasciitis”.
Diffuse cellulitis produces clinical pictures of toxic infection with extensive necrosis of infected tissues.
They are fearsome because they cause death.
7.2.1. Clinical study
In general, we find the symptoms of infectious shock with:
– fever, chills
– pale face and shallow breathing,
– profuse diarrhea, vomiting
– low blood pressure, rare and dark urine
– rapid pulse (tachycardia)
– meningeal and pulmonary signs
Locally at the beginning: soft, non-fluctuating swelling, which quickly spreads and becomes woody. The covering skin is pale and tight. The trismus is very tight. Frank suppuration only appears around the 5th or 6th day . The pus is initially not very abundant, gaseous and of a fetid odor, then it becomes very abundant and greenish in color.
Extension occurs towards the muscles and aponeuroses. The abscess can ulcerate and cause fulminating hemorrhages. The infection will spread towards the base of the skull or towards the mediastinum.
7.2.2. Topographical forms
7.2.2.1. Gensoul-Ludwig’s angina
It is a phlegmon of the supramylohyoid floor of the mouth: 🡨🡪 Risk of asphyxia due to repression of the tongue.
7.2.2.2. Diffuse phlegmon of Lemaître and Ruppe
Involves the submylohyoid region🡪 Risk of supraclavicular and mediastinal extension.
7.2.2.3. Senator’s angina: peripharyngeal phlegmon
Often associated with a lower DDS, poor prognosis because there is invasion of the neck and mediastinum.
- Diffuse phlegmon of Petit-Dutaillis-Leibovici and Lattès
Malignant cellulitis of the face starting at the jugal point then extending towards the masseteric region. Risk of invasion of the infratemporal fossa and the base of the skull
- Diagnosis
- The positive diagnosis is based on
– the interrogation
– clinical examination
– X-ray examination
2) Differential diagnosis
Will be done according to the topographical region and the anatomical structures that exist there.
- Genital and nasolabial region: with a superinfected sebaceous cyst, dacryocystitis.
- Labial region: macrocheilia (allergic or other, pathology of the accessory salivary glands.
- Under-chin area: beard hair folliculitis (sycosis).
- Submylohyoid region: adenophlegmon, submandibular gland pathologies.
- Supramylohyoid region: cyst of the floor of the mouth, inflammation of the Warthon canal
- Palate region: dental cyst, benign maxillary tumor, salivary tumors.
9. Treatment
9.1. Preventive treatment
The treatment of cervicofacial cellulitis is above all prophylactic, by acting on the different etiologies. The restoration of the oral cavity, the treatment of all potential infectious foci (caries, periodontal disease, etc.) represents the most effective means of combating cellulitis of dental origin. It is the 6-year-old tooth +++.
Sealing of pits and fissures.
Fluoridation:
- 0.3 mg/l F no fluoridation
- < 0.3 mg/l fluoridation:
- 6m to 3 years F in drops (0.25mg/day)
- 3 to 6 years supp (0.50mg/day) + 500 ppm toothpaste
- 6 to 12 years supp (1mg/day) + toothpaste 1000 -1500 ppm
- 12 years fluoride toothpastes alone
[Canadian Pediatric Society, AFSSAPS (France)].
9.2. Curative treatment
It is based on medical treatment, surgical treatment and etiological treatment
9.2.1. Medical treatment
Antibiotics are the mainstay of drug treatment.
Painkillers may be necessary if pain occurs.
The use of anti-inflammatories is dangerous given the reactions they can cause.
9.2.2. Surgical treatment
It aims to open the purulent collection (incision) in order to evacuate the pus that has accumulated (drainage) and break the anaerobiosis
The incision:
- Disinfection of the area to be incised
- Contact or superficial infiltration anesthesia*
- 2 cm incision
- Taking a sample of pus for cytobacteriological examination + antibiogram
- Drainage of purulent collection
- Washing
- Installation of a drain
- Change the drain daily until the pus dries up.
9.2.3. Etiological treatment
Conservative or not of the causal tooth.
9.3. Therapeutic indications
9.3.1. Acute cellulitis:
9.3.1.1. Circumscribed cellulitis
9.3.1.1.1. Acute serous cellulitis
– if tooth can be preserved: root canal trepanation + endodontic treatment
– if tooth to be extracted: extraction the same day otherwise broad-spectrum antibiotic therapy (example: amoxicillin 3g/day for 5 to 8 days + extraction on the 2nd day after start of antibiotic therapy).
9.3.1.1.2. Acute suppurative cellulitis
– Sampling for ECB of pus + antibiogram
– While waiting for the results of the ECB, a broad-spectrum antibiotic therapy is prescribed, preferably by parenteral route, which may be modified after the results of the antibiogram (resistance). This antibiotic therapy must be maintained for at least 7 days or more.
– If a fluctuation is found on the first day: incision + drainage of the purulent collection, otherwise wait until fluctuation (1 to 2 days)
– Etiological treatment as soon as possible, often non-conservative (exo).
9.3.1.1.3. Acute gangrenous cellulitis
– Massive antibiotic therapy: combination of 2 or 3 ATB administered intravenously (hospitalization) for at least 15 days
Exple: amoxicillin + gentamicin + metronidazole
– Incision + drainage + abundant washing with hydrogen peroxide and physiological serum
– Extraction of the causal tooth or teeth is necessary.
9.3.1.2. Diffuse or diffuse cellulitis
– Emergency hospitalization ( intensive care unit , ENT, infectious diseases, thoracic surgery, etc.)
– Nasotracheal intubation or even tracheotomy if necessary (respiratory failure)
– Monitoring of clinical and biological constants
– Massive antibiotic therapy.
– Corticosteroid therapy (flash) if respiratory problems (asphyxia)
– Anticoagulants to prevent thrombosis (heparin)
– Parenteral nutrition
– Drainage under general anesthesia
– Hyperbaric oxygen therapy
– Removal of the dental focus as soon as possible (trismus +++ ).
9.3.2. Subacute and chronic cellulitis
9.3.2.1. Common forms
– Etiological treatment from the first consultation (few functional signs)
– Prolonged antibiotic therapy (at least 15 days)
– Incision and drainage if necessary
– Correction of the scar (flattening of the fistula after 6 months).
9.3.2.2. Specific forms: actinomycotic cellulitis
– Penicillotherapy for several weeks even after the inflammatory signs have disappeared, sometimes even in situ antibiotic therapy (significant fibrosis which prevents the diffusion of the antibiotic)
– Drainage
– Treatment of dental infection (extraction).
CONCLUSION
We cannot stress enough the importance of preventive treatment which must begin in the first years of life.
The six-year-old tooth being the first tooth to decay in an oral cavity should particularly capture our attention.
Motivation for oral hygiene, prophylaxis against caries, treatment of all oral infectious foci and finally early etiological treatment, abolition of the use of anti-inflammatories and appropriate antibiotic therapy are the only weapons we have to fight against these terrible diseases which can be fatal.
Cellulitis of dental origin.
Cracked teeth can be healed with modern techniques.
Gum disease can be prevented with proper brushing.
Dental implants integrate with the bone for a long-lasting solution.
Yellowed teeth can be brightened with professional whitening.
Dental X-rays reveal problems that are invisible to the naked eye.
Sensitive teeth benefit from specific toothpastes.
A diet low in sugar protects against cavities.