BATCH 2011
ORAL PATHOLOGY
Spread of Infection Part I
Dr. Michelle Marie Meneses
Mary and Lou
06 19 09
Part 1
I.
II.
III.
Infection
A. Factors necessary
B. Route
Progression of Odontogenic infection (Periapical/
Periodontal)
A. Pathway of bacterial infection
B. Location of infection
C. Labial bone vs. Palatal bone
D. Above vs. Below attachment
E. Cellulitis vs. Abscess
F. Treatment
Fascial Space infection
A. Maxillary space infection
1. Canine
2. Buccal
3. Palatal
4. Infratemporal
5. Nasal
6. Antral Involvement
7. Periorbital
Part 2
B.
C.
D.
Mandibular space infections
1. Submental
2. Sublingual/ Submandibular
Secondary space infections
1. Masseteric
2. Pterygomandibular space
3. Temporal
4. Cervical space infections
a. Retropharyngeal
b. Prevertebral
Treatment
 If there is a disturbance in the
balance,
disease/infection
develops.
2. Virulence of microorganism
 it is also not enough that we
acquire more than the normal
amount, it also has to be
virulent enough to fight
against host response, with
high penetrating power.
3. Decreased host resistance
 syempre, even if we have the
two factors above, kung
malakas naman ang immune
system nung host, wala din..
B. Route
1. Hematogenous (blood)
2. Lymphatics (where our circulatory
system drains)
3. Fascial spaces (fascia covers our
muscle, between the fascia and the
muscle is the fascial space)
II. Progression of Odontogenic infection
1. Periapical
• pulpal necrosis (and subsequent
bacterial invasion into periapical
tissue)  infection periapical area
2. Periodontal
• deep pockets  infection 
inoculation of bacteria to soft tissue
(tooth has no cavity, but has deep
pockets that can serve as niche for
infection)
I. Infection
 morbid condition caused by the entrance
of microorganisms and actual process by
which a disease is produced
 there should be enough number of
microorganisms for you to have the
disease
 Take note that these infections are
polymicrobial in nature. There are at
least 8 different species in a given
infection.
A. Factors necessary for infection
1. Increase number of microorganism
 kasi may resident flora naman
tayo, but it is not enough for
us to have the infection, it has
to be more than the normal
amount that we have.
A. Pathway of bacterial infection
 Path of least resistance- (example,
kapag may emergency, kahit malapit ka
sa window, sa door ka pa din lalabas;
likewise, yung mga microorganisms, they
would enter kung san sila most penetrable
like in deep cavities.
• Kunwari may deep class 1 cavity,
since
open
siya,
hindi
siya
namamaga, but if you try to restore it,
sumasakit siya kasi na close, yun
yung intrapulpal pressure. Infection
will try another route where it can exit,
and it will exit in the periapical area.
The infection will continue and expand
until it finds the least resistant area.
• From the tooth or pocket 
cancellous bone cortical platesoft
tissue  sinus tract/abscess
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B. Location of infection is determined by :
•
1. Thickness of overlying bone
2. Relationship of the site of perforation
to muscle attachment of Mx &Md
(whether it goes to the vestibule or to
cheeks)
•
C. Labial bone vs. Palatal bone
The presence of pus indicates that the
body has walled off the infection and
that the local host resistance
mechanism is bringing the infection
under control.
The spread of infection will go to
where it can easily enter  PATH
OF LEAST RESISTANCE
E. Cellulitis vs. Abscess
Duration
Pain
FIG. 15-1 When infection erodes through bone, it will
enter soft tissue through thinnest bone. A, Tooth apex is
near thin labial bone, so infection erodes labially. B, Right
apex is near palatal aspect, so bone will be perforated.
•
If tooth is more inclined to one area,
the perforation of abscess will more
likely go to that area (dun sa pic,
upright inclination yung nasa left, kaya
perforation will go to the vestibule,
yung isa naman tilted to the palatal,
plus, it has thinner bone, so it will
perforate in that area.
Size
Localization
Palpation
Pus
Seriousness
D. Above or below attachment
Bacteria
Cellulitis
Acute (in a few days
nag-aappear na)
Severe (di ma-touch
yung
maga,
kasi
distended
ung
muscles)
Large
Diffused (e.g. mx pm
may sira spread sa
cheek, mawawala na
yung nasolabial fold,
tapos it may spread
upward hanggang sa
mamaga yung eyelid
Indurated
(matigas,
hindi mahanap ang
infection)
No ( spread of
infection only)
Greater
Aerobic (usually strep
which
produce
enzyme
hyaluronidaise so its
faster)
Abscess
Chronic
standing)
(long
Localized
Small
Circumscribed
(lump lang)
Fluctuant (since
fluid yung nasa
loob;
parang
water balloon)
Yes
Less
Anaerobic
 If the infection spreads easily, it is CELLULITIS.
 Once the infection is able to drain, it becomes a
fistula or sinus tract.
 Sinus Tract
FIG. 15-2 Relationship of point of bone perforation to muscle
attachment will determine fascial space involved. A, When
tooth apex is lower than muscle attachment, vestibular abscess
results. B, If apex is higher than muscle attachment, adjacent
fascial space will be involved.
•
•
If the apex of the tooth is above the
muscle attachment, the location of the
abscess will be most likely located at
the: fascial space (outside the oral
cavity)
If the apex is below attachment:
vestibular abscess (inside the oral
cavity)
 Communicating tract of tissue lined
by granulation tissue (sa loob ng tooth, for
example ma abscess ka don, tapos nagkaron
ng granulation tissue, tapos nagkaron ng
opening sa gums or vestibule
 Aysmptomatic but still there is
bacteria
 Fistula
 Pathologic communication lined by
epithelium, secretory organ between to
epithelium lined viscera
 two cavities are connected though it
should not happen
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E.g Oroanthral fistula. When upper pm or 6 is
extracted (near sinus), sometimes we create a
passageway or connection between oral cavity
and max sinus, the max sinus is covered by
Schneiderian
membrane.
(***oro-mouth,
anthral-max sinus, fistula-pathway; epitheliumlined yung oral cavity and also max sinus)
F. Treatment




Antibiotic
Local surgical treatment  removal of
offending tooth
Endodontic treatment  remove source of
bacteria
Incision and drainage (I&D)
 Presence of pointing or fluctuancy
(hinog na yung maga, madali na
mapuncture), which can’t be done
in cellulitis because it’s hard to
pinpoint its location  find the
peak of the bump
 No medical contraindication
 Pus is acidic while anesthesia is
basic, so naneutralize lang.. kaya
minsan, when we want to remove
the offending tooth and apply
anesthesia, masakit pa din, kasi
nawala ang effect ng anesthesia
due to pus.
 I & D should be well covered with
antibiotics.  for faster healing
 Sa pic, pag nag insert ka ng
hemostat nakaclose, then pag
nilabas mo, naka-open, so as not
to affect other anatomic structures
that are inside.
 A penrose drain is placed to
maintain patent drainage for 3
days.
FIG. 15-8 A, Periapical infection of lower premolar extends through
buccal plate and creates sizable vestibular abscess. B, Abscess is
incised with no. 11 blade. C, Beaks of hemostat are inserted through
incision and opened so that beaks spread to break up any
loculations of pus that may exist in abscessed tissue. D, Small drain
is inserted to depths of abscess cavity with hemostat. E, Drain is
sutured into place with single black silk suture.
III. Fascial Space infection
 kung may prolonged infection at di
pinansin, pwedeng pumunta sa fascial
space
Fascial Space
•
•
•
•
•
Fascia lined areas that can be eroded
or distended by purulent exudates
Potential spaces that don’t exist in
healthy individuals but filled during
infection
Compartments:
fascial
spaces
occupied by neurovascular structures
Clefts: fascial spaces filled with loose
areolar connective tissue
Fascial
Spaces
of
Dental
Significance:
submental,
submandibular and sublingual
Primary Mx
Canine
Buccal
Primary Md
Submental
Buccal
Infratemporal
Submandibular
Antral
Sublingual
Nasal
•
Secondary
Masseteric
Pterygoid
Sup/deep
temporal
Lateral/
Retropharyngeal
Prevertebral
Mylohyoid muscle- divides sublingual (below)
and submandibular (above), so kapag
infection occurs above the mylohyoid, it will
create an opening in the submandibular area,
and kapag below, sublingual.
FIG. 16-1 As infection erodes through bone, it can express
itself in a variety of places, depending on thickness of overlying
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bone and relationship of muscle attachments to site of
perforation. This illus-tration notes six possible locations:
vesttbular abscess (1), buccal space (2), palatal abscess (3),
sublingual space (4), submandibular space (5), and maxillary
sinus (6).
A. Maxillary Space Infections
1. Canine
• (long roots, thin buccal
plate), kaya nakakapa siya
 cornerstone of the mouth
• Thin space between the
Levator Anguli Oris(LAO)
and and Levator Labii
Superioris (LLS)
• Roots are long enough to
allow erosion of bone
superior to muscles of facial
expressions (areas have thin
buccal plates)
• Obliterates nasiolabial fold, drain median
canthus of the eye
3. Palatal
• lateral incisors/ palatal of 6’s
4. Infratemporal
• This space lies posterior to the maxilla
• rare, 3rd molars, connected to deep TS
• back of 3rd molars to maxillary
tuberosity
Boundaries:
Lateral: coronoid process/ temporalis
Med: Lateral pterygoid plate &muscle
Ant: max tuberosity
Post:
lateral
pterygoid
muscle,
condyle, temporalis
Contents:
 IT (infra temporal) pterygoid plexus
 IMA (internal maxillary artery)
 Chorda tympani
2. Buccal
• when abscess is
able to pass above
buccinator
attachment

infection
erodes
bone superior to the
attachment of the
buccinators muscle
• swelling seen below
zygoma & above
inferior border of Md
• 1st and 2nd molars (culprit)  palatal
roots of these molars
FIG. 16-4 Spaces of ramus of mandible are bounded by masseter
muscle, medial pterygoid muscle, temporal fascia, and skull.
Temporal space is divided into deep and superficial portions and
by temporalis muscle.
Cavernous Sinus
FIG. 16-3 A, Buccal space lies between buccinator muscle and
overlying skin and superficial fascia. This potential space may
become involved via maxillary or mandibular molars (arrows).
 ito yung danger zone kasi nga walang valves
to hold back the infected blood, so infection
will go directly to cavernous sinus
 Aside from that, blood vessels have
perforations naturally to allow the perfusion of
oxygen and wastes, however, these
perforations may also cause the spread of
infections to the fascia.
 pwede ring magkaron ng retrobulbar cellulitis
dahil sa cavernous sinus
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 Fascial and Orbital veins- walang valves, so
no way to close, thus there’s spread of
infection
 Do not pop a pimple in this area!
FIG. 16-5 Hematogenous spread of infection from jaw to cavernous
sinus may occur anteri-orly via inferior or superior ophthalmic vein or
posteriorly via emissary veins from pterygoid plexus.
Anterior: Angular/ Anterior Facial VeinSup/Inf
Opthalmic Vein Orbit SOF Cavernous Sinus
Posterior: Emissary/ Posterior Facial VeinPterygoid
plexus IOF Inferior Opthalmic vein 
SOFCavernous Sinus
Cavernous Sinus Thrombosis
Signs and Symptoms:
 Periorbital edema  para
kang si Kerokerokeroppi




Fever, chills, rapid pulse
rate
Lacrimation
Dilated
pupils
and
impaired vision
2nd, 3rd 4th 6th CN plexus
undergoes fibrosis sometimes (pwedeng
magkaron ng impaired vision because of the
6th ophthalmic nerve)
5. Nasal
• roots of maxi centrals (since its roots
are upright, so it perforates above it)
• pus escaping from nasolabial aspect
of the maxilla and near the nasal
orifice into the floor of the nose
•
lump on the inner nose
6. Antral Involvement
• depending on the size and location of
Antrum of Highmore (usually pm and
molar)
• Schneiderian
Membraneborder
between maxillary teeth and the
maxillary sinus
• Symptoms same as maxillary sinusitis
where all teeth are (+) to percussion
take radiograph (kasi nga masakit
lahat ng ngipin, so you should take a
radiograph to detect which tooth is
affected)
• In normal radiographs, the maxillary
sinus border is superimposed over the
roots of the maxillary teeth. They
appear to pierce through the sinus.
However, it is not the case. Carefully
examine the sinus border, if there is a
break in the radiopaque line, a
perforation is most likely present.
• Also when doing surgical procedure,
dapat ingatan maigi, kasi alis ka ng
alis ng structure, eh baka maalis mo
din pati yung membrane, kasi thin
lang siya, so ikaw pa ang nag cause
ng spread of infection nyan and it has
to be sealed properly after treatment
• What would you do if the sinus is
perforated? First, text your prayer
warriors. Second, tuck down the gum
area to create a watertight seal.
7. Periorbital
• Mx infection that spreads superiorly
from maxillary sinus to orbit.
“The Lord shall supply all my needs according to His glorious
riches in heaven”- Philippians 4:19
Godbless batchmates  hello pooh friends, and sa lahat ng
groups.. yung pics wala ko Makita sa net, pero bibigyan naman
daw tayo ng copy ng powerpoint ni mam 
M:
Hey
hey
hey
batchmates. Aral mabuti,
exam days are here
again. Ayan may pictures
na, enjoy!  Hello Pooh
Friends (lalo na kay Jesu
na alam kong may
iccover na picture dito kc
mttakot siya habang ngaaral, hehe), Gossip
Group
and
Perfect
Human Beings na si Abi P. ang leader! Haha  After the
exams, why don’t you treat yourselves to a yummy raspberry
cheesecake or Bavarian cream filled donuts? Yum yum! 
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