POC : ADAA Early Stage : ADAA Late Stage ( Cellulitis ) :

Definition : When the infection is still confined within The infectious material will perforate
the alveolar bone. the cortical plate of bone and
periosteum into the surrounding soft
tissue.
Signs & 1) Extrusion of the tooth A) Local signs & symptoms
Symptoms : 2) Severe tenderness on percussion 1) Pain (Deep).
3) Severe throbbing pain. 2) Diffuse swelling
3) Tenderness
 4) Trismus
5) Lymphadenitis
B) General signs &symptoms
RG : Reveals negative radiographic picture unless Widening of periodontal membrane
the condition happens due to acute as a uniform radiolucent line
exacerbation of chronic abscess, in this approximately 1mm width around
condition; interruption of the lamia dura the apex of the tooth due to
around the apex of the tooth and haziness of thickening of periodontal membrane.
the trabecular bone are usually observed.

Management : 1.Removal of the cause and pus evacuation - The same principles of management
by : of ADAA early stage is applied here
with particular attention to hot moist
dressing 15 minutes every hour, and
hot saline mouth rinse every hour
with a full glass of hot saline.

1) It increases the blood supply to

the area. 2) Stimulate phagocytosis.
3) Help in localization and pus
formation.
Management : NB :
If you choose to postpone the extraction
extirpate the pulp and violate the apical
constriction to drain the pus and exudate to
alleviate the pain and extract later on.

2.After extraction :

Gentile irrigation with a warm saline or

antiseptic solution.
+
1) Proper empirical antibiotic
2) Good analgesic ( paracetamol, katafalm)
3) Rest
4) High protein and vitamins diet
5) High fluid intake
POC : Cellulitis Abscess
Duration Acute (3-5 days) chronic (5-7 days)

Pain Severe & Localized

generalized

Size Large Small

Localization Diffused borders Well circumscribed

Palpation Doughy to Fluctuant
indurated

Presence of pus No ( Exudate) Yes

Seriousness Greater Less

Skin quality Thickened Centrally

undermined

Loss of function Severe Moderately severe

Bacteria Mixed Mainly anaerobic

Pathogensis : - Occurs when micro-organisms continue to flourish in areas out of reach of

immunity and antibiotics e.g. empty root canal and a piece of dead bone
“ sequestra” or necrotic tissues .

- A limited suppuration is continued and will never heal unless therapeutic and or
surgical interference to eradicate the source of infection, and persist as a low
grade purulent process (chronic abscess) or transformed to granuloma.

- The pus invade the bone and open to the surface over the skin or mucous
membrane, and evacuate itself through an opening called fistula.

- Intermittent evacuation and healing of this fistula occurs according to the

amount of pus formed.

- The fistulous tract is lined by granulation tissue and epithelium and should be
excised surgically after treatment of infection source.

Signs & It is generally asymptomatic but the patient may feel:

Symptoms :
1) Fullness or uncomfortable of the affected tooth
2) The gum covering appears normal or slightly inflamed
3) Intraoral fistula is usually close to the apex of the involved tooth
4) Extraoral fistula observed near to the affected tooth or at some remote area
5) The skin around the fistula is contracted to the bone forming unsightly
dimpling or scar
6) Enlargement and slightly tender of draining lymph nodes
RG : Abscess in this condition; shows interruption of the lamia dura around the apex
of the tooth and haziness of the trabecular bone around the tooth apex are
usually observed (ill defined RL)

Management : 1) Antibiotics based on culture & antibiotic sensitivity test

2) Root canal treatment and apical curettage.
3) Extraction of the unrestorable teeth
4) Excision of the chronic skin fistula.?

a) An elliptical incision of the skin and subcutaneous tissue encircling the scar is
carried out
b) The fistulous tract is dissected down to the bone and removed.
c) The skin is undermined so that the skin edges meet each other without
tension, sutured with 5 or 6 0 black silk and dressed.

Bacteriology : - The anaerobic bacteria are the most common types that populate the area under
the pricoronal flap as fusiform bacteria and bacteroides.

- The area under the pricoronal flap is an ideal incubator for bacterial growth
because of:

1) Humidity, darkness warmth, relative lake of oxygen

2) Relative immobility and rigidity of tissue involved
3) Accumulation of food debris,
4) Protection from the washing influence of saliva.
5) Continuous traumatization by the opposing maxillary third molar that weakening
the local resistance

Clinically : - It may be acute or chronic.

- Acute pericoronitis :
Signs:
1. The pricoronal tissue appear shiny, erythematous, and edematous
2. Lymph node enlargement and painful (submandibular LN)
Symptoms :
1. Severe pain
2. Severe trismus as the area lies in close proximity to the insertion of temporalis
and masseter muscles.
3. Difficulty in eating and swallowing
 4. Foul odor
5. Systemic signs of acute inflammation

- Spread of infection :
The infection may be spread anteriorly to involve the buccal space and posteriorly
to the masseteric, pterygomandibular, lateral pharyngeal spaces.

Management : 1) Irrigation beneath the flap with warm saline solution several times daily, also
H2O2 could be used to render the area aerobic.
2) Slight grinding of the impinging cusp of the maxillary third molar to prevent
trauma to the operculum.
3) If pericoronal abscess develops: incision and drainage should be done when
fluctuation is detected by lancet NO 11 and insert a piece of rubber drain.
4) After the acute state is subsided, radiographic examination should be done to
evaluate the position of the involved tooth, and if the tooth is malposed or the
occlusal surface cannot fully exposed and occlude with the opposing tooth, it
should be extracted.
5) Operculectomy (preferably using hard laser or electrocautery) is performed when
there is a good chance for proper eruption and occlusion of the tooth to the
opposing maxillary third molar

Definition : - A postoperative complication following tooth removal, most often in the area of the
mandibular molars.
- The blood clot is lost before healing takes place, leaving raw bony surface, exposed
nerve endings, with the production of foul odor, without pus formation.
- Other names for dry socket :
painful socket, necrotic socket, localized osteomyelitis, alveolar osteitis.

Etiological 1) Pre-existing infection as periapical or periodontal infections

factors : 2) Excessive trauma during extraction
3) Contamination of the socket either by saliva loaded with microorganisms or using
contaminated instruments.

Other contributing factors:

I. local factors:

1) Injection of large amount of local anesthetic solution containing strong

vasoconstrictor such as adrenalin at the site of extraction
 2) Excessive curettage or irrigation of the socket after extraction
3) Heavy sucking or spitting after extraction which lead to detachment of the blood
clot from the socket
4) Presence of sclerotic bone or radiotherapy in which blood supply is limited.
5) Presence of remaining root or bone fragment or foreign body in the socket.
6) Smoking

II. Systemic predisposing factors :

a) Uncontrolled diabetes
b) Liver diseases
c) Anemia
d) Hemorrhagic diseases
e) Nutritional deficiency

Pathogenesis : Destruction of the blood clot either by:

1) Proteolytic enzymes produced by bacteria leads to inflammation of marrow spaces

which causes liberation of tissue activators ( direct activators as serine proteases)
2) Indirect activators as cortisone & Oral contraceptives.
3) These activators converts Plasminogen to plasmin that dissolve the fibrin of the
clot. Plasminogen > Activators > plasmin
Prekininogenase > plasmin > kininogenase
Kininogen > kininogenase > Kinin
4) The violent agonizing pain experienced in dry socket is caused by the release of
Kinin in the socket as it acts by stimulating unmyelinated terminal nerve fibers.

Clinical - Pain usually starts few days after extraction that may continue for a week or even
features: longer.
- Deep seated, severe aching or throbbing in character.
- Mucous membrane around the socket is red and tender

Prevention : 1. Minimal trauma during extraction.

2. Squeeze the socket edge.
3. In case of dis-impaction of 3rd molars dry socket can prevented by:
- Meticulous surgical technique .
- Minimum damage to the bone and copious irrigation.
- Use prophylactic antibiotic locally in the socket.
4. Stop smoking for two days post extraction.

Management : A. The aim of the treatment is to keep the open socket clean and to protect the
exposed bone
 B. Irrigate the socket by antiseptic solution.
C. Loose obtudant dressing containing nonirritant antiseptic dressing in the socket.
– A great variety of dry socket dressing has been formulated:
1) Iodoform - containing preparation as Alveogyl – which is easy to manipulate.
2) Zinc oxide and eugenol pack
– Irrigation of the socket and replacement of the dressing has to be repeated every
other day 2-3 times.
D. Frequent use of mouth wash.

NB :

- Alveogyl rapidly alleviates pain and provides a soothing effect throughout the
healing period.
- Its fibrous consistency allows for easy application in the socket and good
adherence during the entire healing process.
- It includes eugenol for analgesic action, Butamben* for anesthetic action, and
iodoform for anti-microbial action.

A-Maxillary Teeth
Tooth : Bone Muscles involved : Relation to Muscle Region Involved :
Erosion : Attachement :
Central Labial Depressor Septi Below Labial Sulcus (IO)
Incisors muscles and dense
SC tissue of base of
the nose
Lateral Palatal Anterior part of hard
Incisors palate
Canine Labial Levator Anguli Oris Below Labial Sulcus (IO)
Above Canine fossa ( Canine or
Infraorbital space ) (EO)
Premolars Buccal Levator Anguli Oris Below Buccal Sulcus (IO)
& Buccinator
muscles
Above Canine Space (4) or Buccal
space
(EO)
Palatal Middle part of hard
palate
Molars Buccal Buccinator Below Buccal sulcus (IO)
Above Buccal space (EO)
Palatal Posterior part of hard
palate

B-Mandibular Teeth
Tooth : Bone Muscles involved : Relation to Ms Region Involved :
Erosion : Attachement :
Incisors Labial Mentalis muscle Above Labial sulcus (IO)
Below Mental or Submental Space
(EO)
Canine Labial 3 muscles Above Labial sulcus (IO)
Premolars Buccal Depressor Anguli Above Buccal Sulcus (IO)
Oris
1st Molars Buccal Buccinator Above Buccal Sulcus (IO)
Below Buccal Space (EO)
Lingual Mylohyoid muscle Above Sublingual Space (IO)
nd
2 Molars Buccal Buccinator Above Buccal sulcus (IO)
Below Buccal space (EO)
Lingual Mylohyoid muscle Above Sublingual Space (IO)
(usually Below (usually Submandibular Space (EO)
occurs ) occurs)
3rd Molars Lingual Below 1.Submandibular Space (EO)
2.Pterygomandibular Space
(IO)
 Primary Maxillary Spaces
Space : Location : Cause & Comp. : Contents : Clinically : I&D:
Canine on the anterior - The source of - Infraorbital - Swelling of -IO > high in the
(Infraorbital surface of the infection is: contents the affected maxillary buccal
) Space : maxilla between U 3 & 4 > the apex ( nerve & BV) side upper lip, vestibule >
bone and canine of above levator - Angular cheek up to dissection of
fossa anguli oris muscle. vein which is the medial levator anguli oris
musculature a valveless canthus of eye
and leading to:
communicate
s with a) Obliteration
cavernous of nasolabial
sinus??? fold
b) Drooping of
angle of the
mouth
c) Edema of
lower eyelid

Subperiostea between the - The source of Greater - -IO > A double

l Abscess of periosteum and infection is : palatine A. Circumscribed elliptical incisions
Palate : bone U 2 & palatal roots , fluctuant anteroposterior
of U molars & swelling parallel to greater
premolars confined to palatine artery?
one side of (single I. > heal
the palate & spontaneously
doesn’t cross before comp.
the midline. drainage)
Buccal Between - The source of - Buccal fat Swelling of - IO > horizontal I.
Space : Buccinators & infection is U & L pad cheek at depth of buccal
Skin (fascia) 567 (mostly by U - parotid duct vestibule (avoid
anterior to posteriors ) - anterior injury of parotid
masseter - Connects to: facial artery duct) ( less
infraorbital space, and vein predictable )
periorbital tissues - EO >
& superficial Submandibular I.
temporal space (scar)
Infratempor - Upper extension - Source of infection - Origin of - Severe IO :
al Space : of is : pterygoid trismus, - Through
pterygomandibul 1.Maxillary third muscles bulging of pterygomandibul
ar space, molar - mandibular temporalis ar space (medial
localized 2.Osteomyelitis of nerve muscle & parallel to
posterior to the condyle or coronoid - pterygoid ascending ramus)
maxilla process venous - This situation
- It is continuous 3.Infection from plexus is dangerous - Through
with the deep pterygomandibular because of muccobuccal fold
temporal space space involvement lateral to U8
(1unit) - Communicates of pterygoid (hemostats
with : venous plexus upward & medial )
1)Pterygomandibul and its
ar space and deep communicatio
temporal space n with
 2) Inferior orbital cavernous
fissure to the orbit sinus through
(orbital cellulitis) an emissary
3) Intra-crainal veins.
through foramen -Diagnosed by
oval and foramen CT
spinosum.

Primary Mandibular Spaces

Space : Location : Cause & Comp. : Contents : Clinically : I&D:
Submental & Below chin - The source of Mentalis Ms Firm EO >
Mental: (medial infection : circumscribe horizontal I.
surface of L 123 d swelling between
mandible) Sublingual space over symphysis &
(mental) or hyoid
beneath
mandible
(submental)
Submaxillary Medial to - The source of - SM gland & LN - EO Soft - EO > below
(Submandibular): post. Surface infection: - Lingual & brawny & parallel to
of mandible L 78 (below hypoglossal N. swelling the mandible
mylohyoid) - Facial A. - Pain & - If
Any St. drain to - Proximal part of tenderness Contralateral
SM LN Wharton’s duct - Skin red & > Ludwig’s
shiny Angina >
- No trismus through &
or elevation through
of floor of
mouth
- Signs of
septicemia
Sublingual: Ant. Part of The source of - SL gland - Firm painful - IO > in
floor of infection : - Wharton’s duct gelatinous lingual sulcus
mouth L 1-6 (above the - Lingual N. swelling in adjacent to
mylohyoid MS) floor of cortex (to
mouth avoid injury)
- Raised - EO > If 2ry to
tongue Submand.
- Dysphagia Infection >
- Enlarged Submand.
Submand. & Incision (1
Submental surgical unit)
LN
Buccal: (as before)
Secondary Spaces
Space: Location: Causes & Contents: Clinically: I. & D. :
Comp.:
Massemeric - between - Periapical / - Trismus - EO >
(Submasseteric): mandible & pericoronal - Post.inf. horizontal I.
masseter infection of L8 Swelling 2.5 cm below
- between - Buccal space - Less severe border of the
deep layer & than Parotid mand.
superficial space (Subplatysmal
layers of infection flap &
masseter - Normal masseter
- Ant. To Parotid breaching)
parotid space secretion - IO > if can
& post. To open his
buccal space mouth >
anterolat.
Border of the
mand.
Pterygomandibular - between -Periapical/ - IAN - Trismus - IO > over
: ramus & Pericorornal - Lingual N. - IO anterior
medial infection of L8 swelling > ramus
pterygoid - from SL & SM deviate - EO > below
- from infra pharynx & & behind
temporal space uvula angle
- Compound angle - Dysphagia
fracture - Deep
cervical LN
enlargement
- Signs of
Septicemia
Temporal (Deep & - Superficial > - Superficial > Swelling of
superficial) & bet. from masseteric & lateral aspect
Infratemporal: Superficial parotid of skull
tempopral - Deep > (shape of
fascia & Infratemporal & MS)
lateral pterygomandibula
surface of r
temporalis
- Deep > bet.
Medial
surface of
temporalis &
temporal
bone
Parotid: Between - Masseter space - Parotid gland & - NO trismus
suoerficial - Lateral duct - Pus from
layer of deep Pharyngeal - duct
fascia & - Middle ear & Auriculotempora - Severe pain
masseter mastoid l N.
- Facial N.
- Post.facial V.
- Superficial
temporal A.-
Internal max. A.
Lateral Pharyngeal: Inverted cone - Pterygomand. - Carotid Sheath - Lateral
between Space (Lincoln Swelling of
medial - Parotid Space Highway) neck
pterygoid & - peritononsilar - - IO swelling
Superior suppuration Glossopharyngea later
constrictor l - Pharyngeal
ms - Hypoglossal N. wall & tonsils
deviated
- If carotid
involved >
thrombosis
of IJV &
erosion of
carotid A
Retropharyngeal: - - Mediastinitis
Posteromedia - Airway
l to lateral obstruction
pharyngeal & - pus aspiration
ant. To space
4
- from skull
base to C7 or
T1 vertebra
Dangerous Space 4 - Between - Mediastinitis
(Alar Space): Alar & (pericardial inv.)
prevertebral - Aspiration
fascial layer - Laryngeal
- from skull inflammation
base
superiorly to
diaphragm
inferiorly
Prevertebral: Between - Vertibular OM
prevertebral - Spinal epidural
fascia & collection of pus
Vertebrae
 Acute Suppurative OM : Chronic Suppurative OM :
Cause : - A destructive lesion of the trabecular - May be primary (no acute phase) OR
bone & bone marrow of an acute secondary (acute phase preceeding)
inflammatory origin. - It is usually occurs if the acute and
- Osteomyelitis of the jaws is caused by subacute conditions are improperly
polymicrobial mainly aerobic streptococci, treated and the condition is undergo
staphylococci and oral anaerobes ( mainly beyond one month.
peptococci, fusobacterium and
bacteroides).
- If the disease is not controlled within 10-
14 days sub-acute suppurative
osteomyelitis is established.

Clinically : - Severe Pain, swelling. - Swelling and little pain associated with
- Pyrexia, and malaise. chronic suppuration.
- Trismus is frequent. - induration of soft tissues, wooden
- There may be paresthesia of lip and no characters of the affected area, and
mobility of teeth. tenderness on palpation
- Discharge of pus through one or more
intraoral or extraoral sinuses.

RG : Negative radiographs Positive in radiographs (moth eaten

appearance)

Definition : - Pathologic process that develops following irradiation of osseous tissue

(>5000 RAD).
- It is characterized by a chronic mucosal ulceration and exposure of the jaw
bone for more than 3 months.
 - This complication can occur after dental surgery or extraction of teeth

Pathogenesis : Radiation cause inflammation of the BV endothelium, causing vascular

obstruction due to the condition called endarteritis obliterans.
It results in the Three ”H”s: leads to bone necrosis
1) Hypo-cellularity
2) Hypo-vascularity
3) Hypoxia.
Any bacterial contamination will cause severe infection

Clinically : - Exposed necrotic bone and fistulae

- Pathologic fracture
- Radiographic changes in bone trabaculation, and radiolucency
- Occurs more in mandible than maxilla.
- Chronic pain
- Late sequestration of bone seen followed by severe pain.
- Permanent deformity of bone and soft tissues.

Management : A) Conservative management :

1. Antibiotic treatments: Specific drugs should be selected based upon the
culture and antibiotic sensitivity testing.
2. Nonsteroidal anti-inflammatory drugs (NSAIDs) are often prescribed to
reduce pain. 3. People with clotting disorders may be given blood thinners to
reduce clots that block the blood supply to the bone.
4. Soft laser has been used to stimulate bone regeneration.
5. Hyperbaric oxygen (HBO) therapy 30 dives

B) Surgical management :
1. Core decompression removes the inner cylinder of bone, which reduces
pressure within the bone, increases blood flow, allows more blood vessels to
form and reduces pain
2. This procedure is most effective for patients with earlystage of
osteonecrosis and those with a small area of affected bone.
3. If this procedure is not successful resection and bone grafting by
Vascularized autogenous graft.

Prophylaxis : - Dental procedures, such as the pulling of teeth or insertion of dental

implants, performed before starting cancer treatment.
- Regular dental hygiene is more important in cancer Patients because
radiations can affect the teeth and gums.
- Start a course of antibiotics, and regular scrubbing technique prior to
extraction.
- Hyperbaric Oxygen 20 dives before and 10 dives after extraction.
Pathogenesis : - A Cervicofacial Actinomycosis is a chronic granulomatous disease characterized
by abscess formation, draining sinus tracts, fistulae, and tissue fibrosis. caused by
Actimomyces Israeli , (a Gram positive branching bacillus) .

- The organism is found as a normal commensals in the mouth (particularly with bad
teeth).

- The lesions are in the form of multiple abscesses, each containing one or more
colonies of the organisms , separated by fibrous septa infiltrated by macrophages,
lymphocytes, plasma cells and occasional foreign body giant cells .

- The bacterial colonies can sometimes be seen in the pus discharged from the
lesions as small, yellow or brown granules called “sulfur granules”.

- Risk factors includes, immunosuppression, oral malignancies or radiation

Clinically : - Posses about 50% of all cases of Actinomyces

- Presents as slow growing, non-tender indurated mass

- Progresses to multiple abscess and fistulae formation with pain, trismus, and
yellow purulent discharge (sulfur granules)

- Usually involves the mandible, but can infect any structure including cheek, chin,
maxillary sinus.

- Culture from the exudate and Microscopy – branching filaments

Management : - Mild infections: treated with oral Penicillin V 24g/day divided q6hrs for 2-6 months

- Serious infections: Penicillin G IV 2-4g/day divided q6hrs x 4-6 weeks, followed by

oral PCN V

- Tetracycline and Erythromycin are employed in patients allergic to penicillin

- Surgical excision required for complicated abscesses and fistulae

Pathogensis : - Type of chronic osteomyelitis.

- Caused by Mycobacterium tuberculosis.

- Etiopathogenesis :

1) Through direct inoculation of the mycobacterial T B bacilli into a wound from

infected milk.
 2) Direct spread from infected sputum into an extraction socket from TB of the
lung

Diagnosis : A-Clinical Features :

- Mandible more involved.

- Painless swelling of the jaw.
- Pt. complains of chronic discharging sinus.
- Loosening of teeth & sequestration of bone.
-

B-Radiographs :

- PA chest radiograph essential. Scintigraphy, CT , MRI , and conventional

Radiology

C-Lab Investigations :

1) Culture of pus & sputum identification of acid-fast bacilli in specimen

2) Biopsy of lesion
3) Tuberculin testing (Monteux test)

Ttt : - Six to twenty four months of at least 2 drugs at a time from the following list:

1) Isoniazid, 300 mg
2) Rifampicin 450 mg,
3) Ethambutol 800 mg
4) Pyrazinamide 1500 mg

- Surgical resection and reconstruction.