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L2 Odontogenic Infection, Pain Control and Prescribing

23 min read

Odontogenic Infection, Pain Control and Prescribing1

Dr Richard Hague
richard.hague@uwa.edu.au

Learning Outcomes2

  • Describe common causes of odontogenic infections and their spread.
  • Discuss indications and contraindications for antibiotic prescribing regimens.
  • Explain what pain is and common theories for propagation.
  • Assess a patient in pain and manage their pain effectively.
  • Construct a basic formulary for common prescriptions.

Quiz: Odontogenic Infection Basics345678

Definition of Odontogenic Infection

An odontogenic infection is an infection that originates from the tooth or its surrounding structures.

Prevalence in Australia

In Australia, approximately 37% of all adult dental emergency visits to public hospital emergency departments are due to dental infections.

Common Causes

Odontogenic infections can be caused by various factors, including:

  • Caries
  • Failed endodontic therapy
  • Pericoronitis
  • Periodontal disease
  • Trauma

Associated Pathogens

The most common pathogens associated with odontogenic infections include:

  • Streptococci Viridians
  • Streptococci Anginosis
  • Prevotella Species
  • Fusobacterium Species

Periapical Abscess Microbiology

Bacterial species causing periapical abscesses are predominantly anaerobic.

Types of Odontogenic Infections

Common types of odontogenic infections include:

  • Periapical abscess
  • Periodontal abscess
  • Cellulitis
  • Osteomyelitis
  • Odontogenic Sinusitis
  • Ludwig’s Angina

Patient History and Diagnosis9

Diagnosing odontogenic infections involves identifying both subtle and obvious clinical presentations.

Taking a Patient History Using SOCRATES1011

Begin the diagnostic process by establishing the basics through a comprehensive patient history.

Clinical Assessment Tool

  • SOCRATES: Use this mnemonic to ensure all aspects of the patient’s pain and symptoms are explored systematically.

Site12

The first step in the SOCRATES history-taking method is identifying the specific location of the pain or infection.

Onset13

Determine the onset of the symptoms, including when the pain first started and whether the beginning was sudden or gradual.

Character14

Explore the character of the pain. Ask the patient to describe the sensation (e.g., sharp, dull, throbbing, or aching).

Radiation15

Assess for radiation of symptoms. Determine if the pain stays in one place or moves to other areas, such as the ear, jaw, or neck.

Associated Symptoms16

Identify any associated symptoms that occur alongside the primary complaint, such as swelling, bad taste, or systemic signs of infection.

Timing17

Evaluate the timing of the symptoms. This includes the duration of pain episodes and whether there is a specific pattern to when the pain occurs.

Exacerbating and Relieving Factors18

Investigate factors that make the pain worse or better, such as:

  • Temperature (hot or cold)
  • Biting or pressure
  • Lying down
  • Analgesics

Severity19

Determine the severity of the pain. This is often measured on a scale of 1-10 or by how much it interferes with the patient’s daily activities and sleep.

A complete history using the SOCRATES framework includes:

  • Site
  • Onset
  • Character
  • Radiation
  • Associated symptoms
  • Timing
  • Exacerbating / Relieving Factors
  • Severity

Expected Findings During History Taking2021

Taking a history is a purposeful clinical tool used to narrow the focus and generate differential diagnoses before the physical examination.

Differential Diagnoses to Consider

  • Odontogenic Sources:
    • Reversible pulpitis
    • Irreversible pulpitis
  • Non-odontogenic Sources:
    • Salivary glands (e.g., ‘mealtime syndrome’)
    • Tonsillar issues
    • Other referred pain or infections

During the history-taking process, perform a ‘distant’ examination by observing the patient for clinical signs:

  • Visual Signs: Looking for any visible swelling or asymmetry.
  • Functional Impairment: Watching for difficulty speaking or swallowing (dysphagia).
  • Pain Responses: Observing for wincing or guarding during certain movements.
  • General Status: Observing perfusion and overall patient distress.

Clinical Signs and Spread of Infection222324

Classical Signs of Inflammation

As described by Aulus Celsus (30BCE-38CE), the primary indicators of inflammation include:

  • Rubor: Redness
  • Tumor: Swelling
  • Dolor: Pain
  • Calor: Heat

Local and Systemic Signs of Infection2526

Local Indicators of Bacterial Infection

Clinical presentation of a localized bacterial infection typically involves:

  • Erythema
  • Swelling
  • Pain
  • Heat
  • Purulence (presence of pus)

Systemic Indicators of Bacterial Infection

When an infection spreads systemically, the following clinical signs may be observed:

  • Elevated Heart Rate
  • Elevated Respiratory Rate
  • Elevated Blood Pressure
  • Elevated temperature (fever)
  • Confusion
  • Malaise
  • Shivers, shakes, or rigors

Mechanisms and Pathways of Infection Spread27

Once established, an infection may spread through the tissues. In the head and neck regions, this progression can lead to life-threatening complications:

  • Airway obstruction
  • Intracranial spread
  • Septicaemia

Factors Contributing to Disease

The development and spread of infection depend on the interaction between:

  • Susceptible Host
  • Pathogen
  • Conductive Environment
  • Disease

Routes of Infection Spread28

Mechanisms of Microbial Movement

Infection occurs when an organism moves from its usual habitat to a new site, such as moving from the oral cavity into the bone. Infections can also result from disruptions to the normal flora or a compromise in defense mechanisms, often triggered by the administration of antibiotics or immunosuppressants.

Primary Anatomical Routes

Infections typically propagate through the following pathways:

  • Fascial spaces and tissue planes
  • Lymphatics
  • Bloodstream

Quiz: Abscess Definitions2930

Periapical Abscess Definition

Question: What is a periapical abscess?

Answer: A collection of purulence at the apex of the tooth.

Lateral Periodontal Abscess Definition

Question: What is a lateral periodontal abscess?

Answer: A localized accumulation of purulence within the gingival wall of a periodontal pocket of a tooth.

Fascial Spaces Anatomy31323334

Definition and Characteristics

  • Fascial spaces consist of loose fibrous connective tissue envelopes, divided in the head and neck into superficial and deep layers.
  • These ‘spaces’ do not exist in health; they are normally filled with ground substance.
  • In spreading infection, this substance is broken down and the space is enlarged. Spread occurs via hydrostatic pressure.

Key Anatomical Landmarks

  • Maxillary sinus
  • Masseter muscle
  • Buccinator muscle
  • Tongue
  • Mylohyoid muscle

Fascial Space Subtypes35

Fascial Space SubtypeSubtype Components
Fascial spaces of the faceCanine, Buccal, Parotid, Infratemporal
Masticatory: Masseteric, Pterygomandibular, and Temporal
Suprahyoid fascial spacesSublingual, Submental, Submandibular, Lateral Pharyngeal, Peritonsillar
Infrahyoid fascial spacesPretracheal
Fascial spaces of the NeckRetropharyngeal, Danger, Carotid Sheath

Deep Cervical and Retropharyngeal Spaces36

Transverse and Sagittal Anatomy

Anatomical structures involved in the deep cervical regions include:

  • Fascial Layers: Prevertebral fascia, Alar fascia, Buccopharyngeal fascia.
  • Spaces: Prevertebral space, Danger space, Retropharyngeal space, Lateral pharyngeal space, Masseteric space, Pterygomandibular space.
  • Floor of Mouth: Sublingual, Submandibular, and Submental spaces.
  • Neurovascular: Carotid sheath (containing carotid artery, internal jugular vein, and vagus nerve).

Muscular and Glandular Components

  • Parotid gland
  • Medial pterygoid muscle
  • Mandible and Masseter muscle
  • Superior pharyngeal constrictor muscle
  • Platysma and Mylohyoid muscles
  • Genioglossus and Geniohyoid muscles
  • Anterior belly of the digastric muscle

Clinical Considerations

  • Spread of infection between different spaces depends on specific anatomic locations.
  • Swelling patterns and associated symptoms are diagnostic indicators for identifying the specific space involved.

Anatomical Pathways of Infection Spread37

Potential Routes of Infection Spread

Infections may migrate toward the following structures:

  • Nasal passage and Maxillary sinus
  • Oral cavity and Buccal sulcus
  • Tongue and Floor of mouth
  • Mylohyoid muscle and Buccinator muscle
  • Orbit
  • Maxilla and Mandible

Sublingual and Submandibular Space Boundaries38

Relationship to the Mylohyoid Line

The mylohyoid line serves as a critical anatomical barrier determining the direction of infection spread:

  1. Sublingual Space

    • Located above the Mylohyoid Line.
    • Typically associated with infections from Anterior Mandibular Teeth.

  2. Submandibular Space

    • Located below the Mylohyoid Line.
    • Typically associated with infections from the 2nd and 3rd Molars.

Anatomical Review

Detailed anatomical review of specific head and neck spaces.

Canine Space39

Overview

The canine space is the region between the anterior surface of the maxilla and the overlying levator muscles of the upper lip.

  • Contents: Angular artery, angular vein, and infra-orbital nerve.
  • Source of Infection: Maxillary canine, 1st premolar, and occasionally the mesiobuccal roots of the 1st molar.

Boundaries

  • Superiorly: Quadratus labii superioris muscle (levator labii superioris).
  • Inferiorly: Caninus muscle.
  • Medially: Anterolateral surface of maxilla.
  • Posteriorly: Buccinator muscle.
  • Anteriorly: Orbicularis oris.

Clinical Presentation

  • Swelling of the cheek, lower eyelid, and upper lip.
  • Drooping of the angle of the mouth.
  • Obliteration of the nasolabial fold.
  • Oedema of the lower eyelid.

Buccal Space40

Overview

  • Contents: Buccal fat pad, parotid duct (Stensen duct), anterior facial artery and vein, transverse facial artery and vein.
  • Source of Infection: Maxillary or Mandibular premolars and molars.

Boundaries

  • Superiorly: Zygomatic arch.
  • Inferiorly: Inferior border of mandible.
  • Medially: Buccinator muscle.
  • Laterally: Skin and subcutaneous muscle.
  • Posteriorly: Anterior edge of masseter muscle.
  • Anteriorly: Posterior border of zygomaticus major and depressor anguli oris.

Clinical Presentation

  • Swelling of the cheek extending to the corner of the mouth.
  • Potential shifting of the angle of the mouth to the contralateral side.
  • Obliteration of the nasolabial fold.
  • Note: Often associated with temporal space spread, creating a “dumb-bell” shape due to the lack of swelling over the zygomatic arch.

Parotid Space41

Overview

  • Contents: Parotid gland, branches of the facial nerve, external carotid artery, and retro-mandibular vein.
  • Source of Infection: Mandibular molars.

Boundaries

  • General: Circumscribed by the superficial layer of the deep cervical fascia.
  • Superior margin: External auditory canal and apex of the mastoid process.
  • Inferior margin: Inferior mandibular margin (parotid tail may extend further inferiorly).
  • Anterior margin: Masticator space.

Clinical Presentation

  • Swelling that everts the ear lobule.
  • Severe pain, particularly during mastication.
  • Intraoral drainage of pus may be observed from the parotid duct.

Infratemporal Space42

Overview

  • Contents: Pterygoid plexus of veins, internal maxillary artery, mandibular nerve and its branches.
  • Source of Infection: Maxillary 3rd molars.

Boundaries

  • Superiorly: Infratemporal surface of the greater wing of the sphenoid.
  • Inferiorly: Lateral pterygoid muscle.
  • Medially: Lateral pterygoid plate and lateral pharyngeal wall.
  • Laterally: Temporalis tendon and coronoid process.
  • Posteriorly: Condyle and lateral pterygoid muscles.
  • Anteriorly: Infratemporal surface of maxilla and posterior surface of zygomatic bone.

Clinical Presentation

  • Extra-oral swelling over the sigmoid notch.
  • Intra-oral swelling in the tuberosity area.
  • Trismus.
  • Eye may be closed and proptosed.
  • Complications: Can spread to the Temporal space or via the pterygoid plexus to cause Cavernous Sinus Thrombosis.

Temporal Space43

Overview

  • Compartments: Superficial Temporal and Deep Temporal.
  • Contents: Superficial temporal vessels, auriculotemporal nerve.
  • Source of Infection: Usually spreads from the infratemporal or pterygomandibular space.

Boundaries

  • Superficial Compartment: Lateral - temporalis fascia; Medial - temporalis muscle.
  • Deep Compartment: Lateral - temporalis muscle; Medial - temporal bone and greater wing of sphenoid.

Clinical Presentation

  • Superficial: Swelling limited by the outline of the temporalis fascia; Trismus; Severe pain.
  • Deep: Less visible swelling; Difficult to diagnose; Trismus.

Pterygomandibular Space44

Overview

  • Contents: Inferior Alveolar Nerve (IAN), artery, and vein; Lingual nerve (LN); Nerve to mylohyoid; Sphenomandibular ligament.
  • Source of Infection: Mandibular third molars, pericoronitis, infected needles, or contaminated local anesthetic solution.

Boundaries

  • Superiorly: Lower head of lateral pterygoid muscle.
  • Inferiorly: Inferior border of mandible (lingual surface).
  • Medially: Medial pterygoid muscle.
  • Laterally: Medial surface of ramus.
  • Posteriorly: Parotid gland.
  • Anteriorly: Pterygomandibular raphe/buccal space.

Clinical Presentation

  • Often characterized by an absence of extra-oral swelling.
  • Severe Trismus.
  • Difficulty in swallowing (dysphagia).
  • Anterior bulging of the soft palate and tonsillar pillars; uvula deviation to the unaffected side.

Masseteric Space45

Overview

  • Contents: Masseteric artery and vein.
  • Source of Infection: Mandibular third molars, pericoronitis.

Boundaries

  • Superiorly: Zygomatic arch.
  • Inferiorly: Inferior border of mandible.
  • Medially: Ramus of mandible.
  • Laterally: Masseter muscle.
  • Posteriorly: Parotid gland and its fascia.
  • Anteriorly: Buccal space and buccopharyngeal fascia.

Clinical Presentation

  • Swelling localized mainly over the angle of the mandible.
  • Severe trismus and throbbing pain.

Sublingual Space46

Overview

  • Contents: Deep part of the submandibular gland, Wharton’s duct, sublingual gland, lingual and hypoglossal nerves, terminal branches of the lingual artery.
  • Source of Infection: Mandibular premolars and 1st molars.

Boundaries

  • Superiorly: Mucosa of the floor of the mouth.
  • Inferiorly: Mylohyoid muscle.
  • Medially: Geniohyoid, styloglossus, and genioglossus muscles.
  • Laterally: Mandibular body.
  • Posteriorly: Body of hyoid.
  • Anteriorly: Mandibular body.

Clinical Presentation

  • Usually no extra-oral swelling, though lymph nodes may be tender.
  • Swelling of the floor of the mouth.
  • Elevated tongue.
  • Pain and discomfort on swallowing.
  • Restricted tongue protrusion (unable to extend beyond the vermillion border of the upper lip).

Submental Space47

Overview

  • Contents: Lymph nodes and anterior jugular veins.
  • Source of Infection: Mandibular incisors; can also result from spread from the submandibular space.

Boundaries

  • Superiorly: Mylohyoid muscle.
  • Inferiorly: Deep cervical fascia, platysma, and skin.
  • Laterally: Anterior belly of digastric.
  • Posteriorly: Hyoid bone/submandibular space.
  • Anteriorly: Mandible.

Clinical Presentation

  • Firm extra-oral swelling beneath the chin.
  • Pain associated with swelling.

Submandibular Space48

Overview

  • Contents: Submandibular salivary gland, lingual and hypoglossal nerves, branches of facial artery (palatine, tonsillar, glandular, submental).
  • Source of Infection: Mandibular 2nd and 3rd molars; also spread from submental and sublingual spaces.

Boundaries

  • Superiorly: Mylohyoid muscle and inferior border of mandible.
  • Inferiorly: Anterior and posterior belly of digastric.
  • Medially: Mylohyoid, hyoglossus, superior constrictor, and styloglossus muscles.
  • Laterally: Deep cervical fascia, platysma, and skin.
  • Posteriorly: Hyoid bone.
  • Anteriorly: Submental space.

Clinical Presentation

  • Firm extra-oral swelling in the submandibular region, below the inferior border of the mandible.

Lateral Pharyngeal Space49

Overview

  • Contents: Carotid sheath, cranial nerves IX–XII, and lymph nodes.
  • Source of Infection: Mandibular 3rd molars, tonsillar infections.

Boundaries

  • Superiorly: Skull base.
  • Inferiorly: Hyoid bone.
  • Medially: Buccopharyngeal fascia on the lateral surface of the superior constrictor muscle.
  • Laterally: Medial pterygoid muscle and capsule of the parotid gland.
  • Posteriorly: Prevertebral fascia.
  • Anteriorly: Superior and middle pharyngeal constrictors.

Clinical Presentation and Risks

  • Severe pain on the affected side of the throat and dysphagia.
  • Four Cardinal Signs: Trismus, induration/swelling at the angle of the jaw, fever, and pharyngeal bulging.
  • Severe pain upon rotation of the neck away from the swelling.
  • Potential Complications:
    • Upward spread: Cavernous Sinus Thrombosis.
    • Downward spread: Retropharyngeal space.
    • Vascular: Carotid artery erosion.
    • Neurological: Pupil involvement.

Peritonsillar Space50

Overview

  • Source of Infection: Usually secondary to contiguous spread from a local site or a complication of acute tonsillitis.

Boundaries

  • Superiorly: Torus tubarius or level of hard palate.
  • Inferiorly: Pyriform sinus.
  • Posteriorly: Palatopharyngeus muscle and posterior tonsillar pillar.
  • Anteriorly: Palatoglossus muscle and anterior tonsillar pillar.

Clinical Presentation

  • Swelling of the tonsil.
  • Uvular displacement.
  • Trismus.
  • Muffled voice (“hot potato” voice).

Retropharyngeal Space51

Overview

  • Contents: Lymph nodes.
  • Source of Infection: Spread from odontogenic infection or nasal and pharyngeal infections.

Boundaries

  • Superiorly: Skull base.
  • Inferiorly: Mediastinum.
  • Laterally: Lateral pharyngeal space.
  • Posteriorly: Prevertebral fascia.
  • Anteriorly: Posterior pharyngeal wall.

Clinical Presentation

  • Stiffness of the neck.
  • Dysphagia and potential drooling.
  • Dyspnea (difficulty breathing).
  • Bulging of the posterior pharyngeal wall.

Pretracheal Space52

Overview

  • Source of Infection: Spread from odontogenic infection or trauma.

Boundaries

  • Superiorly: Thyroid Cartilage.
  • Inferiorly: Superior Mediastinum.
  • Laterally: Thyroid gland.
  • Posteriorly: Retropharyngeal space.
  • Anteriorly: Sternothyroid fascia.

Clinical Presentation

  • Stiffness of the neck and neck swelling.
  • Dysphagia and odynophagia (painful swallowing).
  • Drooling.
  • Dyspnea.

Danger Space53

Overview

  • Location: Posterior to the retropharyngeal space.
  • Pathological Significance: Provides a route for contiguous spread of infection between the neck and the chest (thorax).

Boundaries

  • Superiorly: Skull base.
  • Inferiorly: Diaphragm.
  • Posteriorly: Prevertebral fascia.
  • Anteriorly: Alar Fascia.

Retropharyngeal and Danger Space Infections

  • Mechanism: Infection can extend into the mediastinum.
  • Common Causes: Penetrating trauma (e.g., chicken bone, instrumentation).
  • Demographics: Most common in children 3 to 5 years old.
  • Symptoms: Fever, sore throat, dysphagia, trismus, stridor, and nuchal rigidity (neck stiffness).

Carotid Space54

Overview

  • Clinical Status: Rare due to modern antibiotics and early diagnosis.
  • Contents: Carotid artery, internal jugular vein, sympathetic trunk, and cranial nerves IX, X, XI, XII.

Clinical Presentation

  • Painful, enlarged neck mass.
  • Dysphagia.
  • Fever.
  • Hoarseness and dyspnoea.

Anatomical Context

  • Related to the retropharyngeal space, parapharyngeal space, and submandibular space.
  • Bound by the superficial, middle, and deep layers of cervical fascia.

Summary of Infection Spread Pathways

Infections originating from Maxillary or Mandibular periapical abscesses can spread as follows:

  • Superiorly:
    • To the Orbit via the Canine space or Infratemporal space.
  • Laterally/Medially:
    • To the Buccal space.
    • To the Parotid space.
    • To the Masticator spaces (Masseteric, Pterygoid, Temporal).
  • Inferiorly:
    • To the Submandibular and Sublingual spaces.
    • To the Lateral pharyngeal space.
  • Deep Neck/Systemic Spread:
    • To the Carotid sheath and Retropharyngeal space.
    • Ultimately descending to the Cranium (retrograde) or Mediastinum.

Severity Assessment and Staging55

To accurately determine the clinical severity of an odontogenic infection, clinicians must evaluate three primary factors:

  1. Anatomical location: Identification of the specific fascial spaces affected.
  2. Rate of progression: The timeframe from the onset of symptoms to the current presentation.
  3. Associated symptoms: Presence of systemic or localized signs that indicate the severity of the inflammatory response.

Severity Scoring of Fascial Space Infections56

The severity score for a given patient is calculated as the sum of the severity scores for all spaces involved by cellulitis or abscess, determined through clinical and radiographic examination.

Severity Score 1: Low Risk

Infections in these spaces pose a low risk to the airway or vital structures:

  • Vestibular
  • Subperiosteal
  • Space of the body of the mandible
  • Infraorbital
  • Buccal

Severity Score 2: Moderate Risk

Infections in these spaces pose a moderate risk to the airway or vital structures:

  • Submandibular
  • Submental
  • Sublingual
  • Pterygomandibular
  • Submasseteric
  • Superficial temporal
  • Deep temporal (or infratemporal)

Severity Score 3: High Risk

Infections in these spaces pose a high risk to the airway or vital structures:

  • Lateral pharyngeal
  • Retropharyngeal
  • Pretracheal

Severity Score 4: Extreme Risk

Infections in these spaces pose an extreme risk to the airway or vital structures:

  • Danger space (space 4)
  • Mediastinum
  • Intracranial infection

Stages of Infection Progression57

Odontogenic infections typically progress through three distinct stages: Inoculation, Cellulitis, and Abscess. The characteristics of each stage are detailed below.

Stage 1: Inoculation

  • Duration: 0–3 days
  • Pain: Mild–moderate
  • Size and Localization: Small and diffuse
  • Palpation: Soft, doughy, and mildly tender
  • Appearance: Normal coloration and normal skin quality
  • Surface Temperature: Slightly heated
  • Loss of Function: Minimal or none
  • Tissue Fluid: Edema
  • Systemic Impact: Mild malaise; mild degree of seriousness
  • Predominant Bacteria: Aerobic

Stage 2: Cellulitis

  • Duration: 3–7 days
  • Pain: Severe and generalized
  • Size and Localization: Large and diffuse
  • Palpation: Hard and exquisitely tender
  • Appearance: Reddened with thickened skin
  • Surface Temperature: Hot
  • Loss of Function: Severe
  • Tissue Fluid: Serosanguineous with flecks of pus
  • Systemic Impact: Severe malaise; severe degree of seriousness
  • Predominant Bacteria: Mixed (Aerobic and Anaerobic)

Stage 3: Abscess

  • Duration: Over 5 days
  • Pain: Moderate–severe and localized
  • Size and Localization: Small and circumscribed
  • Palpation: Fluctuant and tender
  • Appearance: Peripherally reddened; skin is centrally undermined and shiny
  • Surface Temperature: Moderately heated
  • Loss of Function: Moderately severe
  • Tissue Fluid: Pus
  • Systemic Impact: Moderate–severe malaise; moderate–severe degree of seriousness
  • Predominant Bacteria: Anaerobic

Serious Complications5859

Serious complications arise when odontogenic infections progress beyond localized areas and begin to affect systemic health or vital structures.

Ludwig’s Angina6061

Pathophysiology and Etiology

  • Bilateral involvement: Cellulitis affecting both the submandibular and sublingual spaces.
  • Microbiology: Usually involves Streptococcus viridans and Staphylococcus aureus.
  • Common causes:
    • Mandibular third molars (most common).
    • Other odontogenic infections.
    • Trauma.
    • Osteomyelitis.

Clinical Presentation

  • Hard/firm swelling
  • Pyrexia
  • Erythema
  • Dyspnoea
  • Dysphagia
  • Difficulty closing the mouth

Cavernous Sinus Thrombosis6263

Pathogenesis

Cavernous sinus thrombosis is a blood clot that forms in the cavernous sinus, typically resulting from the spread of infection from a fascial space. Staphylococcus aureus and Streptococcus species are the pathogens most frequently identified.

Venous Anatomy and Pathways

The following venous structures are involved in the potential spread of infection to the cavernous sinus:

  • Supraorbital v.
  • Supratrochlear v.
  • Superior palpebral v.
  • Angular v.
  • Inferior palpebral v.
  • Infraorbital v.
  • Facial v.
  • Inferior ophthalmic v.
  • Vorticose v.
  • Pterygoid plexus v.
  • Cavernous sinus
  • Central retinal v.
  • Superior ophthalmic v.
  • Lacrimal v.

Clinical Signs and Symptoms

  • Fever and rigors
  • Severe frontal and pre-orbital pain
  • Exophthalmos
  • Oedema of the eyelid and chemosis of the conjunctiva
  • Ophthalmoplegia (weakness of the eye muscles)
  • Ptosis
  • Dilated pupil with loss of accommodation

SIRS and Sepsis6465

Definitions

  • Systemic Inflammatory Response Syndrome (SIRS): An inflammatory response due to an infection or a non-infectious clinical insult.
  • Sepsis: SIRS that occurs as a result of a known infection. It is defined as “life-threatening organ dysfunction caused by a dysregulated host response to infection.”

Clinical Significance

Sepsis is the world’s leading cause of death.

Pathophysiological Pathways to Multiorgan Failure

Sepsis leads to multiorgan failure through several distinct physiological disruptions:

  1. Endothelial Dysfunction
    • Leads to capillary leakage.
  2. Coagulopathy
    • Leads to disseminated intravascular coagulation.
    • Results in reduced tissue perfusion.
  3. Cellular Dysfunction
    • Induces a catabolic state.
    • Reduces cellular energy consumption.
  4. Cardiovascular Dysfunction
    • Causes left ventricular dilation.
    • Results in hypotension.

Diagnosis of SIRS66

A diagnosis of SIRS is made when two or more of the following criteria are met:

  • Body temperature: <36°C or >38°C
  • Heart rate: >90 bpm
  • Respiratory rate: >20 breaths/min or PaCO2 <32 mmHg
  • Leukocyte count: >12,000/µL, <4,000/µL, or >10% immature forms

Assessment of SIRS Severity67

Because organ failure is the fundamental issue in severe cases, a simplified sequential organ failure assessment (qSOFA) was proposed in 2016.

Presence of two or more of the following indicators suggests poorer clinical outcomes:

  • Systolic blood pressure ≤100 mmHg
  • Respiratory rate ≥22 breaths/min
  • Glasgow Coma Scale (GCS) score <15

Clinical Examination6869707172

Returning to the clinical assessment of the patient to continue the diagnostic process.

Intraoral Special Tests73

Diagnostic Procedures and Tools

To further investigate the clinical presentation, the following intraoral special tests may be utilized:

  • Percussion testing: To assess for apical periodontitis or inflammation of the periodontal ligament.
  • Mobility: To evaluate the degree of tooth movement and periodontal support.
  • Pocket depths: To measure periodontal attachment levels and identify localized or generalized disease.
  • Vitality testing: To determine the pulp status (e.g., thermal or electric pulp testing).
  • Fracture detection: Use of a Fracfinder or transillumination to identify cracks or structural failures.
  • Radiographs: To provide internal visualization of the teeth and supporting alveolar bone.
  • Additional assessments: Any other relevant diagnostic adjuncts based on clinical findings.

Footnotes

  1. Original PDF page 1: L2 Odontogenic Infections, Pain Control and Prescribing For Upload, p.1 ↩

  2. Original PDF page 2: L2 Odontogenic Infections, Pain Control and Prescribing For Upload, p.2 ↩

  3. Original PDF page 3: L2 Odontogenic Infections, Pain Control and Prescribing For Upload, p.3 ↩

  4. Original PDF page 4: L2 Odontogenic Infections, Pain Control and Prescribing For Upload, p.4 ↩

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