Locoregional complications of dental infections and management
Introduction
Due to the abundance of entry points for germs at the dental level, infections of dental origin are very frequent, among these, the most frequent are dental abscesses, cellulitis, osteitis, sinusitis, thrombophlebitis of dental origin.
The prognosis for certain complications remains uncertain, especially when the germs involved are resistant to standard antibiotics or when the patient is immunocompromised.
I- Definitions:
Inflammation:
Inflammation is a defense process of the body whose goal is to neutralize, fight, or eliminate the pathogen in question and prepare for tissue repair. It is a local reaction.
Infection:
An infection refers to the invasion and multiplication of micro-organisms within a living organ of the body (viruses, bacteria , parasites , fungi or mycoses ). The body will put in place defense processes to eradicate the micro-organism. .
One of the main symptoms of an infection is the presence of fever and fatigue .
II. Etiology of loco-regional complications:
Determining factors:
-Dental caries (pulp necrosis and its complications).
-The periodontal pocket.
Contributing factors:
-Negligence or absence of etiological treatment (dental)
-Reduction of the body’s defenses.
-Inadequate drug prescription combines NSAIDs with absent or inappropriate antibiotic therapy.
III. Pathophysiology of dental infection
Dental and periodontal lesions can lead to the formation of infectious foci. There are two possible pathways for bacteria:
Endodontic route
Marginal sulcular (or periodontal) pathway.
IV. Locoregional complications of dental infections:
Complications of dental infectious foci can include:
● Local : alveolodental pyorrhea, subperiosteal abscess, facial fistulas, apical granuloma, apical cyst, etc.
● Regional:
○ Maxillary sinusitis.
○ Localized or diffuse cellulite.
- Adenitis, adenophlegmon.
- Osteitis.
○ Thrombophlebitis.
IV. Locoregional complications of dental infections
1. Subperiosteal abscesses and submucosal abscesses:
- Etiology:
-An acute infectious process of periapical origin .
- Location:
– Located under the oral mucosa, it is called parulie in children.
-Subperiosteal abscesses are particularly common in children, due to the thinness of the bone cortex.
Symptomatology:
– A fluctuating, painful swelling, covered with tense, hyperemic mucosa.
-Regional infectious adenopathies.
-General infectious signs (fever, asthenia, headaches).
-The radiological signs are those of chronic apical periodontitis.
- Evolution: fistulization.
chronic periodontitis.
- Treatment :
-Surgical: drainage by gingival detachment or by muccoperiosteal incision, depending on the location of the lesion.
-Etiological: osteo-cementogenic therapeutics: trimming – disinfection.
-Antibiotic therapy is only prescribed based on the general infectious signs that accompany the local pathology.
-Warm antiseptic mouthwashes are classically prescribed to accelerate the maturation of the abscess.
2. Osteitis and odontogenic osteomyelitis:
A. Definition
It is an inflammatory process, of acute or chronic appearance of the bone tissue, whether it is a microbial infection or a parasitic or chemical attack.
When the origin is intraoral, streptococcus is the most frequently responsible germ.
In case of local and/or general immunodeficiency or incorrect treatment, osteitis can develop into osteomyelitis.
B. Clinical forms
1. Localized odontogenic osteitis and osteomyelitis:
1.1. Septum syndrome:
It is a particular form of alveolar osteitis, affecting the interdental septum.
Causes
-A poor interdental contact point.
-An overflowing filling
-Prosthetic irritation.
-An intraseptal injection, responsible for real acute desmodontitis of the teeth
adjacent.
-Action of arsenious anhydride.
Radiological signs: blurred, amputated or sequestered septal tip.
Treatment: is etiological or more rarely surgical at the level of the septum.
1.2. Circumscribed centromedullary osteitis:
- Location: the premolar and mandibular symphyseal regions, (more structure
spongy).
- Symptomatology:
-Severe periodontitis.
-Dental mobility.
-Bone sequestration.
-Alteration of general condition.
– Well-circumscribed centromedullary osteolysis visible on the X-ray.
- Treatment :
Etiological: osteo-cementogenic therapy.
Surgical: curettage of the lesion.
1.3. Localized condensing osteitis:
-Indicates an old localized inflammatory process.
-Occurring in young people, it is most often asymptomatic, and almost follows
always with carious involvement of the first permanent lower molar.
-The radiological examination shows an opacity circumscribed at the apex of this tooth.
-The treatment is etiological (osteo-cementogenic therapy).
1.4. Garré periostitis:
-It is a periosteal neoproliferation, occurring in children around the age of 10, with a marked female predominance.
- Etiology:
-A mild odontogenic infection is responsible for this periostitis.
- Symptomatology:
-A perimandibular swelling of an inflammatory appearance, hard, forming part of the mandible, asymptomatic, located opposite a causative tooth, infected or extracted, resulting in an asymmetry of the lower third of the face.
-Pain and fistula are very rarely present.
-The evocative radiological appearance, with periosteal ossification in several layers, reminiscent of the classic “onion skin”.
- Treatment :
Etiological: osteo-cementogenic therapy is sufficient, leading to complete regression in several months.
2. Diffuse osteitis:
2.1. Acute osteitis:
It is an extension of an initially circumscribed infectious process.
- Etiology:
-A traumatic tooth extraction.
-An apical dental infection.
-A wisdom tooth eruption accident.
- Clinical and radiological evolution:
- An initial phase :
-Intense, radiating and continuous pain.
-Loose teeth.
-Negative response to pulp sensitivity tests.
-Absence of radiological signs.
-Trismus.
-Cervical lymphadenopathy.
-Sign of Vincent +.
-Alteration of general condition.
- A purulent state or collection phase :
-Worsening of local and general symptoms.
-Bone rarefaction.
- Evolutionary phase :
-Regression of local and general infectious signs.
– Fluctuation within the swelling.
-Purulent cutaneous and/or mucosal fistulization.
- Sequestration phase :
-Disappearance of painful symptoms and general signs.
-Persistence of trismus and Vincent’s sign.
-Radiologically flaky bone
-Presence of sequestrations of very variable size.
– Removal of bone sequestra
- A repair phase :
-Disappearance of infectious processes.
-Very slow bone regeneration of the basilar sector.
- The after-effects of sequestration:
-Loss of teeth (germs in children).
-Growth disorders.
-Temporomandibular ankylosis.
-Bone deformities.
-Retractable scars.
- Treatment :
Drainage by endodontic and/or transmucosal or even cutaneous route.
2.2. Chronic osteomyelitis
Chronic osteomyelitis can exceptionally be primary from the outset or more frequently occur after acute osteomyelitis (secondary chronic osteomyelitis).
Chronic osteomyelitis of dental origin is the most common.
- Etiology:
-Absence of dental or periodontal symptoms.
-Erythematous and edematous oral mucosa, only during acute attacks.
-Fistulization never occurs.
- Sequelae of chronic osteomyelitis:
– Bone growth disorders in children.
-Spontaneous fractures.
-Malignant degenerations within the fistulous tracts.
-A real temporomandibular ankylosis.
- Treatment :
Medical:
-The antibiotic is prescribed for several months, in a directed manner if possible.
-Corticosteroids, prescribed in the absence of an etiological germ for a maximum of 10 days and rather during painful attacks of recurrences.
-Nonsteroidal anti-inflammatory drugs are not very effective.
-Hyperbaric oxygen therapy proves its effectiveness on anaerobic germs.
Surgical:
-Decortication and elimination of necrotic and sequestered foci.
-In case of very extensive infectious processes, a wider excision may be indicated.
Etiological:
-Endodontic treatments in osteomyelitis areas must be carried out under the cover of antibiotic therapy.
2.3. Actinomycotic osteitis:
Chronic actinomycotic osteitis. “Actinomyces israelli” is the most frequently involved, the maxilla being more often affected than the mandible.
- Etiology:
-A dental carious lesion.
-A mucosal lesion.
-An extraction wound.
- Treatment:
-Anaerobic samples allowing the isolation of actinomycetes.
-Medical: Penicillin G (10 million IU per day and above) and ampicillin (2 g per day and above) will be used, or doxycycline and clindamycin in case of allergy.
-Surgical: curettage and removal of bone sequestra.
2.4. Mycotic osteitis:
- Location:
-Mycotic osteitis is responsible for mandibular osteitis, exceptionally maxillary osteitis.
- Etiology:
– “Candida albicans” , originating from a deep visceral focus, is responsible for this type of osteitis.
- Treatment:
Medical: prescription of specific antimycotics.
Surgical: curettage of lesions.
2. Cellulitis, phlegmon and orofacial abscesses:
A. Definition
These are inflammations of the subcutaneous cellular adipose tissue of the face and peripharyngeal spaces. They can be circumscribed or diffuse.
It is observed at any age, especially in children and young adults.
B. Evolutionary forms
1- Acute cellulitis:
1-1. Serous cellulite:
-Is the initial stage of all cellulitis, this form of cellulitis is preceded by acute desmodontitis.
- Symptomatology:
– Rounded swelling with imprecise limits, of elastic consistency, slightly painful to the touch and subjectively pulsatile, which modifies the tissue relief.
-The skin or mucous membrane of the infected area is tense and raised, slightly or not erythematous and hot.
- Evolution :
-Either towards sedation if the treatment is well conducted.
-Or towards suppuration in the opposite case.
- Treatment :
Medical
-Antibiotic therapy :
- Beta-lactams are prescribed as first-line treatment.
- In the presence of anaerobic germs, metronidazole is very effective.
– Painkillers are prescribed on demand.
-NSAIDs should be avoided because they promote the spread of infection.
Etiological:
Conservative treatment: osteo-cementogenic therapy.
1-2. Suppurative cellulitis or abscess:
It follows the untreated or poorly treated serous phase.
- Symptoms:
-Throbbing, throbbing, continuous, radiating, nocturnal pains that cause insomnia.
-A swelling is relatively well defined, covered with tight, shiny, wine-colored skin or mucosa, very painful at the slightest contact, adhering to the overlying and underlying plane.
-The sign of the Bucket is positive.
-Halitosis.
– Hypersalivation.
-Dysphagia.
-A lockjaw.
The general signs at this stage are marked by:
• Hyperthermia.
• A paleness of the integuments.
• Asthenia.
- Evolution:
-Towards healing after treatment.
-Towards spontaneous fistulization.
-Towards chronicity.
-Loco-regional or distant complications (septicemia, etc.).
- Treatment :
-Surgical: drainage at the most inclined point of the purulent collection.
-Etiological (conservative or radical).
-Nonsteroidal anti-inflammatory drugs will be prescribed with caution.
-The use of external cold compresses or ice packs to suck on to alleviate inflammatory phenomena .
1-3. Gangrenous cellulitis:
- Symptomatology
-Much rarer.
-The clinical signs are those of suppurative cellulitis with crepitations.
-The brownish pus is fetid, its odor is unbearable, with the presence of gas.
-General signs of toxic-infectious disease may be significant.
-The germs involved are the same as those found at the origin of serous and suppurative cellulitis.
- Treatment :
-Antibiotic therapy must be massive and prolonged for at least 10 days.
-The surgical incision allows drainage and tissue washing, with a solution based on hydrogen peroxide and an antiseptic.
-Casual dental treatment should be carried out immediately.
2. Subacute cellulite, chronic cellulite:
Chronic and/or subacute cellulitis follows poorly treated suppurative cellulitis.
- Symptomatology:
A rounded or oval nodule the size of a walnut protrudes from the skin, painless to palpation; the covering tissue is thin and purplish.
- Evolution
• Rarely develops.
• Warms up in the event of trauma.
- Differential diagnosis arises with:
• A sebaceous cyst.
• Geniune adenitis.
• A boil.
3. Actinomycotic cellulitis:
- Symptomatology:
-A rounded or oval nodule, limited, painless, of variable volume, with imprecise contours and irregular relief, of hard or firm consistency, located most often under the thinned and purplish skin but of normal temperature.
-There are never any general signs.
- Complications:
-Extension.
-Fistulization.
-The warming.
- Treatment :
-Medical: antibiotic therapy.
-Etiological: eradication of the dental infectious focus (conservative or radical).
-Surgical: if cellulite persists, surgical treatment by incision, drainage and washing is required.
C. Topographical forms
1. Circumscribed cellulitis
Depending on the causative tooth, natural drainage follows the adjacent cellular spaces.
The upper central incisors will be responsible for subnasal cellulitis, the premolars will be responsible for genial cellulitis.
2. Diffuse cellulitis also called malignant cellulitis:
-Cellulite is initially diffuse and must be distinguished from diffuse cellulite which follows localized cellulite.
-The microbial flora notes a predominance of anaerobic flora, toxins and gases, locally, the condition is characterized by rapid and extensive necrosis of the tissues.
-Generally speaking, a serious infectious shock can occur.
- Treatment:
Any diffuse cellulitis requires intensive medical and surgical treatment, the treatment combining:
– Massive and prolonged antibiotic therapy, if possible directed.
-Surgical drainage must be early, with multiple incisions allowing for extensive drainage of all infected areas.
-Washing is repeated several times a day using solutions based on hydrogen peroxide and antiseptics.
-Hyperbaric oxygen therapy is very effective.
Gensoul-Ludwing’s angina
-This is the best known and most typical form; it is due to infection of the mandibular molars; it is located in the supramylohyoid region.
-It is a diffuse gangrenous and asphyxial cellulitis requiring a tracheotomy or tracheal intubation.
-The condition can be complicated by septicemia or lung abscess and the disease progresses to the entire floor and cervical region.
Senator’s angina
-It is located in the peripharyngeal region.
-It is usually of tonsillar origin; but the lower wisdom tooth can be involved.
From a clinical point of view we note:
• Dysphonia.
• Dysphagia.
• Early asphyxiation disorders.
• Possibility of invasion of the cervical and mediastinal region.
The prognosis is dire.
3. Thrombophlebitis:
A. Definition
The face has two main venous networks:
-The facial vein, superficial.
-The deep pterygoid venous plexus.
The location of these thrombophlebitis cases, all exceptional, is closely correlated with the location of the infectious focus of dental origin.
B. Clinical forms
1. Facial vein thrombophlebitis
- Symptomatology:
– Edema of the nasolabial fold which very quickly spreads to the canine fossa and the internal angle of the eye.
-An inflammatory, painful, hard swelling (hard cord of the thrombosed facial vein).
Extension can occur towards the ophthalmic venous system and more rarely towards the frontal venous system.
2. Ophthalmic thrombophlebitis:
Follows facial thrombophlebitis which spreads through the angular vein to the superior and inferior ophthalmic veins.
- Symptoms:
• Upper eyelid edema (damage to the upper eyelid).
• A serous, voluminous chemosis.
• Exophthalmos.
- Evolution:
• Phlegmon of the orbit.
• Cavernous sinus thrombophlebitis.
- Differential diagnosis :
-An infectious orbital complication of maxillary sinusitis.
– Staphylococcus aureus of the face.
3. Cavernous sinus thrombophlebitis
It complicates untreated facial or ophthalmic phlebitis.
It is evolving in a very alarming infectious context.
Complications arise towards:
• Phlegmon of the orbit with ocular melting.
• Venous thrombosis with blindness and compromises life prognosis.
4. Thrombophlebitis of the superior longitudinal sinus:
May follow facial phlebitis.
- Symptomatology:
• Dilation of the veins.
• Edema of the scalp and forehead.
• Edema of the fundus.
• Epilepsy.
5. Thrombophlebitis of the pterygoid plexus
- Symptoms:
-Very sharp pain, tight trismus, dysphagia, and sometimes lip-chin anesthesia (Vincent’s sign).
– Extensive edema on the anterior pillar of the veil, the genial region and the temporal region.
- Evolution : abscess of the pterygoid lodge.
basal cranial osteitis.
cavernous sinus thrombophlebitis.
C. Treatment:
Treatment requires hospital care, with intensive and neurological monitoring.
Antibiotic therapy: cephalosporins and aminoglycosides.
These antibiotics may be modified depending on the therapeutic response and/or the results of blood cultures which must be taken before initiating antibiotic therapy.
-Surgical treatment by incision and drainage is performed depending on the location and possible access.
-High-dose corticosteroids can help combat intracranial edema.
-The use of anticoagulants is controversial due to the risk of hemorrhagic and embolic complications.
-Ligation of the internal jugular vein is sometimes recommended.
5. Sinusitis of dental origin:
A. Definition
It is an inflammation of the paranasal sinus cavities. It can be acute or chronic depending on the duration of the infection.
Given the close relationships that exist between the 2nd premolars, the 1st and 2nd upper molars and the maxillary sinus, it is common to find maxillary sinusitis following dental pathologies.
The functional signs are identical to those of classic sinusitis, however, with three particularities:
– The unilateral nature of the infection.
– Fetid rhinorrhea causing homolateral cacosmia.
– Dental pain, particularly acute during dental examination.
B. Clinical forms:
- Acute maxillary sinusitis:
- Symptomatology:
-The purulent collection, periapical or more rarely periodontal, first raises the mucosa of the sinus floor, which ruptures to give way to emphysema.
-Spontaneous drainage is possible through the permeable ostium.
– Purulent secretions may be perceived at this ostium, in the middle meatus or on inspection of the pharynx.
– A foul breath is often noted, sometimes a subjective cacosmia is reported
-General signs: temperature, headaches, asthenia, regional adenopathies
-The clinical diagnosis will be easy to make when the dental cause is evident, specifically the antral teeth.
-Radiological diagnosis (Blondeau) must confirm sinus opacity, in any case, a radiological assessment will be carried out to eliminate or search for the dental cause and to exclude the presence of an intra-sinus foreign body.
- Treatment
*Medical :
1. Antibiotic treatment:
The most commonly used antibiotics currently in maxillary sinusitis are:
• Penicillin A combined with clavulanic acid (Augmentin®) prescribed at a dose of 2g
per day in 4 doses.
• Certain macrolides alone or in combination (Pristinamycin®) prescribed at a dose of 2g
per day in 4 doses.
2. Adjuvant anti-inflammatory treatment
This anti-inflammatory treatment administered systemically allows the sinus ostium to be re-permeabilized as quickly as possible so that the sinus can be drained and ventilated.
• Corticosteroids used in short courses of around one week: they can be used
in aerosols associated with local antibiotic therapy.
3. If antibiotic treatment fails:
Measures for drainage and lavage of the maxillary sinus, using warm solutions of antiseptics and local antibiotics.
*Dental etiology: radical or conservative
2. Chronic maxillary sinusitis:
Chronic maxillary sinusitis of dental origin is much more common than acute sinusitis. It is most often unilateral and progressive in onset.
- Etiopathogenesis:
-Foreign bodies accidentally introduced into the maxillary sinus.
-An included tooth (most often the upper wisdom tooth, sometimes a premolar, rarely the canine).
-Periodontopathies are only exceptionally responsible for maxillary sinusitis.
*These foreign bodies (filling materials, stubs, etc.) are responsible for mechanical, chemical and bacterial irritation, secondarily giving rise to the sinus inflammatory hyperplastic reaction.
*For impacted teeth, and in the case of inflammatory foci in the immediate vicinity of the sinus mucosa, immune-type reactions are more likely to be invoked.
- Symptomatology:
-The pain is slight or even non-existent.
-Regional adenopathies and general infectious signs are exceptional.
-The teeth involved are only rarely painful to percussion and pressure.
-A fistula or orosinusal communication must be carefully investigated.
-Panoramic radiography only gives a poor image of sinus opacity but retains its value in screening for dental pathologies.
– CT scan: possible opacification of the sinus cavities, a fistulous tract or a cyst can be done by injection of a contrast product, either directly or transnasally.
- Treatment:
In this form of sinusitis, therapy includes:
– Etiological which most often requires the extraction of the causative tooth(s).
– Medical :
*Prescription of an antibiotic combined with an anti-inflammatory.
*Repeated washing punctures.
-Surgery is required if the previous treatment does not lead to clinical and radiological healing. It will include:
*Either a lower meatotomy including an opening of the intersinusonasal septum located under the lower meatus to wash and/or to remove any repressed root.
*Or a Caldwell-luc: allows for the on-demand excision of the sinus mucosa and any occupying processes. Its indication is now rare due to the rise of endonasal surgical techniques.
Conclusion:
Dental foci are a very common cause of orofacial infections.
Although the advent of antibiotics has changed the prognosis of these diseases, etiological treatment and drainage of these complications remains an essential step in treatment.
Given the variety, severity and locoregional and even general complications of oral and dental infectious foci, prevention is essential.
The quality of conservative care in endodontics is a requirement.
Locoregional complications of dental infections and management
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Misaligned teeth can cause digestive problems.
Dental implants restore chewing function and smile aesthetics.
Fluoride mouthwashes strengthen enamel and prevent cavities.
Decayed baby teeth can affect the health of permanent teeth.
A soft-bristled toothbrush protects enamel and sensitive gums.