Odontogenic infections can occur in the area of the mouth, jaw, and face. These are infections caused by the bacterial flora of the oral cavity. These infections can originate from both the teeth and the periodontium. The inflammations can spread both in the immediate vicinity of the cause of the inflammation and through the blood and lymph channels. As a result, an abscess may form. An abscess is a collection of pus in a cavity in the tissue. The infection may be bland (without inflammation), yet there is a risk of life-threatening complications, depending on the location of the infection and the patient’s general health. Classification of odontogenic infections according to ICD-10:
- Acute apical periodontitis of pulpal origin [K04.4] – acute inflammation of the periodontium (periodontium) just below the root of the tooth; apical = “toward the root of the tooth”
- Chronic apical periodontitis [K04.5] – chronic (permanent) inflammation of the periodontium (periodontium) just below the root of the tooth; apical = “tooth rootwards”
- Periapical abscess with/without fistula [K04.6-7] – abscess around the root apex.
- Periodontal abscess, periodontal abscess [K05.2] – abscess of periodontal apparatus
- Chronic periodontitis, chronic periodontitis [K05.3] – permanent inflammation of the periodontium.
- Maxillary abscess [K10.20-21] – abscess of the upper jaw.
- Oral floor phlegmon [K12.20] – purulent infection with diffuse spread.
- Submandibular abscess [K12.21-22] – abscess located below the mandible.
- Buccal abscess [K12.23]
- Perimandibular abscess [K12.28] – Abscess lateral to the mandible.
- Retropharyngeal abscess [J39.0] – abscess in the retropharyngeal space (cleft space that lies behind the pharynx; cervical sliding space)
- Parapharyngeal abscess [J39.0] – abscess lateral to the pharynx in the parapharyngeal space (space on either side of the pharynx; cervical sliding space)
- Cervical actinomycosis [A42.2] – granulomatous purulent bacterial infectious disease that can lead to multiple abscess and fistula formation
Symptoms – complaints
Common locations of abscesses on the face include the cheeks or chin. Depending on the location of the infection, various symptoms and complaints may occur. These include:
- Pain
- Swelling (with fluctuation)
- Erythema (redness)
- Fistula formation
- Functional disorders – e.g., lockjaw, sensory disturbances, dyspnea (shortness of breath), dysphagia (difficult swallowing).
General signs of illness such as sweating, fever or chills may also occur. Radiological symptoms include osteolysis (bone dissolution), periapical (peri = around; apical = tip) translucencies (lightening), a widened periodontal gap (gap between the tooth root and the alveolus (bony tooth compartment) in the jawbone) and periodontal osteolysis (bone loss). Inflammatory parameters in the blood – such as ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein) – may be elevated.
Pathogenesis (disease development) – etiology (causes)
Possible causes of odontogenic infections include caries (tooth decay), loose teeth, or root debris. Likewise, fractures (breaks) of the teeth or jaws, cysts, or foreign bodies are possible triggers of infection. Common causative agents of odontogenic infections include:
- Actinobacillus actinomycetemcomitans
- Bacteroides forsythus
- Peptostreptococcus micros
- Porphyromonas gingivalis
- Prevotella intermedia
- Staphylococcus aureus
- Streptococcus intermedius
Consequential diseases
A maxillary abscess (maxillary abscess) may spread to the retromaxillary or canine fossa (canine fossa). From the canine fossa, infection may spread intracranially (into the interior of the skull) to the cavernous sinus (dilated venous space in the dura mater at the anterior base of the skull) via the angular vein (branch of the facial vein), where life-threatening cavernous sinus thrombosis may result. Submandibular abscesses (abscesses in the lower jaw) or sublingual abscesses (abscesses under the tongue) are at risk of spreading parapharyngeally, from where further spread cervically to the mediastinum (mediastinum; a vertical tissue space in the thoracic cavity) is possible.A mediastinal abscess can be life-threatening. Furthermore, parapharyngeal abscesses pose the risk of narrowing of the airways, which can develop into complete obstruction of the airways. Overall, the lethality (mortality related to the total number of people suffering from the disease) of acute odontogenic infections is about 0.2 percent. In addition to spread to the brain or mediastinum, septic shock can also lead to death.
Diagnostics
A comprehensive clinical examination should include inspection, palpation, and sensitivity testing of the trigeminal nerve. Similarly, the function of the facial nerve should be checked. Taking a radiograph is also necessary to determine the potential cause of the infection. Teeth that are abnormal radiologically can be examined using a vitality specimen. If pus is present, a swab may be taken to determine the pathogen. This is necessary in order to select the correct antibiotic. If a perimandibular abscess is present, the mandibular rim cannot be palpated. If necessary, more extensive imaging procedures, such as computed tomography of the head (cranial CT; cCT), must be obtained to accurately assess the spread of an abscess.
Therapy
To treat an abscess, its cause must always be identified and appropriately remediated. For example, if inflammation in the root area was responsible, root canal treatment may need to be performed to prevent further infection. Fractures (fractures) must be treated accordingly. Severely loosened teeth, foreign bodies or cysts are removed. The abscess itself can be treated surgically by incision and drainage. This involves opening the abscess at one point and draining the contained secretion. Depending on the extent of the abscess, it is kept open for a few days, irrigated daily, and a drainage strip is placed to drain the secretion. Following the treatment, the incision is sutured, and after a few days the stitches can already be removed. Depending on the location, the abscess often has to be opened extraorally. A minimally invasive method also manages without extraoral incision. In sonographically controlled drainage, a cannula is inserted into the abscess area under sonographic control. An indwelling cannula is placed and left in place for drainage. With concomitant antibiotic administration, the abscesses completely regressed in the patients studied. Analgesics (painkillers) may be prescribed to relieve pain. Antibiotics are used to prevent further spread of the bacteria. Antibiotics of first choice are penicillins, and lincosamides, cephalosporins, macrolides, or nitroimidazoles are given as alternative therapy. Carbapenems are available as a backup antibiotic. Cervical actinomycosis is treated for two weeks with a combination of amoxicillin and clavulanic acid. Alternatively, clindamycin may be used or a combination doxycycline and metronidazole. Inpatient treatment is indicated for infections in which swallowing or breathing are impaired and for lodgement abscesses.
