SPACE INFECTIONS
Space Infections
Contents
• Introduction
• Classification
• Microbial aspects
• Surgical anatomy of fascial spaces
• Conclusion
• Reference
Introduction
What is the worst that can happen??
• The path of least resistance
• Fascial spaces are ‘potential’ spaces
Classification
Based on mode of involvement
1⁰ 2⁰
Maxillary Mandibular Secondary space
• Submental
• Sublingual
• Submandibular
• Buccal
• Massetric
• Ptrygomandibular
• Canine
• Buccal
• Temporal
• Infratemporal
Masticatory Cervical fascia
• superficial
temporal
• Deep temporal
• Lateral
pharyngeal
• Retropharyng
eal
• prevertebral
Pathways of odontogenic infection
Invasion of the dental pulp by bacteria after decay of a tooth
Inflammation, edema and lack of collateral blood supply
Venous congestion or avascular necrosis
Reservoir for bacterial growth
Periodic egress of bacteria into surrounding alveolar bone
Periapical infection progress to other areas or spaces
SPACE INFECTIONS
SPACE INFECTIONS
• Factors influencing spread
– General factors
• Host resistance
• Virulence of microorganism
• Compromised host defence
• Combination of both
– Local factors
• Anatomical barriers such as alveolar bone, periosteum
and adjacent muscles and fascia
Microbial Aspects
• Mixed aerobic & anaerobic flora (65 to 70 %)
• Exclusive anaerobic ( 25% to 30%)
• Exclusive aerobic (5%)
• More than 90% contain some anaerobes
Frequently isolated organisms
• Aerobic streptococci
– Strep. milleri, Strep. sanguis, Strep. salivarius, Strep.
mutans (α-hemolytic streptococci)
• Anaerobic streptococci (Peptostreptococcus),
• Bacteroids
– Porphyromonas
– Prevotella
• Fusobacterium
Surgical Anatomy
Canine fossa space
Infraorbital space
• Involvement
– Odontogenic infections arising from maxillary
canine and premolars and sometimes from
mesiobuccal root of first molar
– Nasal infections; less frequent
• Boundaries
– Inferiorly – orbicularis oris
superior-quadratus labi
superiosis
– Posteriorly – buccinator
muscle
– Medially – levator labii
superiosis alaegue nasii
• Clinical features
– Swelling of cheek and
upper lip
– Obliteration of nasolabial
fold
– Drooping of angle of the
mouth
– Edema of lower eyelid
– Offending tooth may be
mobile and tender to
percussion
• Incision and drainage
Buccal space
• Boundaries
– Anteromedially – buccinator
musle
– Posteromedially – masseter
overlying the anterior border of
the ramus of the mandible
– Laterally by forward extension of
deep fascia from the capsule of
parotid gland and by platysma
muscle
– Inferiorly limited by the
attachment of the deep
fascia to the mandible
and by depressor anguli
oris
– Superiorly the zygomatic
process of the maxilla
and zygomaticus major
and minor muscles
• Teeth commonly involved
–Maxillary and mandibular premolars and
molar
–Location of root tip to the level of origin of
buccinator muscle determines the spread of
infection either intraorally into the vestibule
or deep into the buccal space
–Pericoronitis in lower third molar
• Clinical features
– Fluctuant swelling of cheek with an obvious swelling of
the face
– Infection from the buccal space may extend upwards
into temporal space or gravitate down into the
submandibular space
Infratemporal space
Laterally: ramus of mandible, temporalis muscle
and its tendon
Medially: med pterygoid plate, lat & med pterygoid
muscle, lower part of temporal fossa, lateral wall of
pharynx
Superiorly: infratemporal surface of greater wing of
sphenoid, zygomatic arch
Inferiorly: lat pterygoid muscle
Anteriorly: infratemporal surface of maxilla
Posteriorly- parotid gland
• C/F:
– trismus
– bulging of temporalis muscle
– marked swelling of the face on the affected side in
front of ear, overlying TMJ, behind the zygomatic
process
 complication:
 Cavernous sinus thrombosis - through pterygoid
plexus and inf opthalmic vein via sup orbital
fissure
SPACE INFECTIONS
Pathways of ascending infections from jaw to cranial cavity
Submental space
Laterally : Lower border of the
mandible anterior belly of
digastric
Superiorly : mylohyoid muscle
Inferiorly: suprahyoid portion of
the investing layer of deep
cervical fascia which is covered
by platysma superficial fascia
and skin
Contents:submental lymph nodes
and ant jugular vein
C/F:
• Extaorally distinct firm
swelling in the midline
beneath the chin skin
overlying may be boardlike
and taut. Fluctuation
maybe present
• Intraorally the offending
tooth may exhibit
tenderness to percussion
and may show mobility
SPACE INFECTIONS
Case report
• A 10 year old child was brought to the
emergency department 2 days after a fall from
a bicycle. Examination revealed a markedly
swollen chin, and imaging revealed a
nondisplaced symphyseal fracture and a
subcondylar fracture. The central incisors
were slightly mobile.
• Despite rigid fixation and penicillin therapy,
the submentall area became fluctuant and
required incision and drainage, from which
streptococci and bacteroids were cultured.
After drainage the infection and fracture
healed uneventfully.
Sub lingual space
This is a V shaped trough lying lateral to
muscles of tongue, including
hyoglossus, genioglossus and
geniohyoid
Superiorly: by the mucosa of the floor
of the mouth
Inferiorly: mylohyoid muscle
Medially: hyoglossus, genioglossus, and
geniohyoid muscle
Laterally: medial side of the mandible
above the mylohyoid muscle
Posteriorly: hyoid bone
C/F: Extraorally little /no swelling, pain & discomfort
during swallowing. speech may be affected.
Intraorally firm painful swelling in floor of the
mouth, tongue may be pushed superiorly- causing
airway obstruction. Inability to protrude tongue
beyond vermillion border of upper lip.
SPACE INFECTIONS
SPACE INFECTIONS
Submandibular space
Anteromedially: floor formed by
mylohyoid muscle, covered by loose
areolar tissue and fat
Posteromedially: floor is formed by
hyoglossus muscle
Superolaterally: medial surface of the
mandible below mylohyoid ridge
Anterosuperiorly: ant belly of digatric
Posterosuperiorly: post belly of
digastric, stylohyoid &
stylopharyngeus muscles
Laterally: platysma and skin
CONTENTS: superficial lobe of submandibular gland and
lymph nodes, facial art and vein, marginal mandibular
nerve.
C/F: Extra orally firm
swelling in the
submandibular region,
generalized constitutional
symptoms, tenderness and
redness over the skin
Intraorally moderate trismus ,
teeth affected is sensitive
to percussion and are
mobile, dysphagia
SPACE INFECTIONS
SPACE INFECTIONS
Submassetric space
Anterior: ant border of masster muscle
& buccinator
Posterior: parotid gland and post part
of masseter
Inferior: attachment of the masseter to
the lower border of the mandible
Medial: lateral surface of the ramus of
the mandible
Lateral: medial surface of the
massetermuscle
Contents: massetric nerve superficial
temporal art & transverse facial art
SPACE INFECTIONS
• C/F: moderate size facial swelling confined to
the outline of masseter muscle, tenderness
over the angle of the mandible, trismus,
pyrexia and malaise
SPACE INFECTIONS
Pterygomandibular space
Laterally: ascending ramus of
mandible
Medially: lateral surface of medial
pterygoid muscle
Posterior: parotid gland
Anteriorly: pterygomandibular
raphae
Superiorly: lateral pterygoid
muscle
Clinical Features
– trismus
– dysphagia
– medial displacement of the
lateral wall of pharynx
– redness and edema of area
around third molar
– difficulty in breathing
SPACE INFECTIONS
Secondary fascial spaces
• Superficial and deep temporal
• Lateral pharyngeal
• Retropharyngeal
• Prevertebral spaces
• Parotid space
Temporal space
• Supeficial temporal space:
– Lateral : temporal fascia
– Medial : temporalis muscle
• C/F:
– Swelling limited superiorly and laterally by temporal
fascia and inferiorly by zygomatic arch
– ‘Dumbell shape’ swelling if associated with buccal
space due to lack of swelling over zygomatic arch
– Severe pain & trismus
SPACE INFECTIONS
• Deep temporal space:
– Lateral : medial surface of temporalis muscle
– Medial : temporal bone and greater wing of
sphenoid
• C/F:
– Less swelling than superficial temporal space
– Difficult to diagnose
– Considerable pain and trismus
– Difficult to elicit fluctuation because of depth
Parotid space
• Rare from extension of odontogenic infection
• Blood borne / retrograde infection through parotid duct
Superior : zygomatic arch
Inferior : lower border of mandible
Anterior : ant border of mandibular ramus
Posterior : retromandibular area
• C/F:
– severe pain radiating to ear & accentuated by
eating
– Dehydration – due to insufficient consumption of
fluids
• DD:
– Submasseteric infection
– Distinguished by
• lack of trismus
• Eversion of ear lobe
• Escape of pus from parotid duct on milking
SPACE INFECTIONS
Pharyngeal space
• Lateral / Para
pharyngeal space
• Retro pharyngeal
space
Lateral pharyngeal space
• An inverted pyramid with its base at the base of the
skull and apex at the hyoid bone.
• Medial: superior pharyngeal constrictor muscle
(lateral wall of pharynx)
• Lateral: fascia of medial pterygoid, deep capsule of
parotid gland
• Anterior: palatal muscle superiorly, buccinator,
superior constrictor, stylohyoid and post belly of
digastric inferiorly
• Posterior: carotid sheath posterolaterally and
retropharyngeal space posteromedially.
• Inferior: hyoid bone
• Contents: carotid artery, internal jugular vein, vagus
nerve, cervical sympathetic chain.
• Aponeurosis of Zuckerkandl & Testut divides this
space into ant (pre styloid) and post (post styloid)
• C/F: Ant compartment – pain, fever, chills,
medialbulging of lat pharyngeal wall, with deviation
of palatal uvula from midline, dysphagia, swelling
below angle of mandible and trismus.
Post compartment – absence of visible swelling and
trismus, but respiratory obustruction, septic
thrombosis of internal jugular vein & carotid
artery hemorrhage may occur
• D/D: peritonsillar abscess –, Enlarged & inflamed
tonsil
SPACE INFECTIONS
Spread of infection from 3rd molar
SPACE INFECTIONS
• Origin of infection:
– Direct: sublingual space submandibular space
lateral pharyngeal.
– Indirect: Pterygomandibular space lateral
pharyngeal.
• Spread of infection:
– Upwards through various foramina at base of skull
causing cavernous sinus thrombosis, meningitis
and brain abscess
– Posteriorly to retropharyngeal space or carotid
sheath
• Investigation: CT scan more useful in diagnosis
SPACE INFECTIONS
Route of spread
• Submandibular (one side) sublingual
Submental space contralateral Submandibular
OR
• Sublingual space opp sublingual extend posterior over edge of
mylohyoid submandibular submental space
OR
• Submandibular pterygomandibular space pharyngeal space
mediastinum
• Investigation – cervical soft tissue films & CT before attempting
tracheostomy
SPACE INFECTIONS
SPACE INFECTIONS
SPACE INFECTIONS
SPACE INFECTIONS
SPACE INFECTIONS
SPACE INFECTIONS
SPACE INFECTIONS
Ludwig’s Angina
• It is a firm, acute, toxic cellulitis
of the submandibular and
sublingual space bilaterally and
of the submental space
• Dental infection is the causative
factor in 90% cases
Clinical Features
• General examination
– Patient looks very ill, toxic and
dehydrated
– Pyrexia, anorexia, chills,
dysphagia and malaise
– Hoarseness of voice
• Regional Examination
– Firm/Hard/ woody hard swelling in the bilateral submandibular and
submental region which soon extends down the anterior part of the
neck
– Swelling is non-pitting, minimally or non-fluctuant with severe
tenderness
– Severe muscle spasm which may lead to trismus
– Mouth remains open due to sublingual edema which cause raised
tongue
– Airway obstruction
• Fatal death may occur in untreated case of
Ludwig’s angina within 10 to 24 hours due to
asphyxia
Principles of treatment
• Early diagnosis
• Maintain patent airway
• Intense and prolonged antibiotic therapy
• Extraction of offending teeth
• Surgical drainage or decompression of fascial
spaces
Conclusion
Reference
• Oral and Maxillofacial Infections, Richard G.
Topazian , Morton H. Goldberg
• Textbook of Oral and Maxillofacial Surgery,
Neelima Malik
Thank you

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SPACE INFECTIONS

  • 3. Contents • Introduction • Classification • Microbial aspects • Surgical anatomy of fascial spaces • Conclusion • Reference
  • 4. Introduction What is the worst that can happen?? • The path of least resistance • Fascial spaces are ‘potential’ spaces
  • 5. Classification Based on mode of involvement 1⁰ 2⁰ Maxillary Mandibular Secondary space • Submental • Sublingual • Submandibular • Buccal • Massetric • Ptrygomandibular • Canine • Buccal • Temporal • Infratemporal Masticatory Cervical fascia • superficial temporal • Deep temporal • Lateral pharyngeal • Retropharyng eal • prevertebral
  • 6. Pathways of odontogenic infection Invasion of the dental pulp by bacteria after decay of a tooth Inflammation, edema and lack of collateral blood supply Venous congestion or avascular necrosis Reservoir for bacterial growth Periodic egress of bacteria into surrounding alveolar bone Periapical infection progress to other areas or spaces
  • 9. • Factors influencing spread – General factors • Host resistance • Virulence of microorganism • Compromised host defence • Combination of both – Local factors • Anatomical barriers such as alveolar bone, periosteum and adjacent muscles and fascia
  • 10. Microbial Aspects • Mixed aerobic & anaerobic flora (65 to 70 %) • Exclusive anaerobic ( 25% to 30%) • Exclusive aerobic (5%) • More than 90% contain some anaerobes
  • 11. Frequently isolated organisms • Aerobic streptococci – Strep. milleri, Strep. sanguis, Strep. salivarius, Strep. mutans (α-hemolytic streptococci) • Anaerobic streptococci (Peptostreptococcus), • Bacteroids – Porphyromonas – Prevotella • Fusobacterium
  • 13. Canine fossa space Infraorbital space • Involvement – Odontogenic infections arising from maxillary canine and premolars and sometimes from mesiobuccal root of first molar – Nasal infections; less frequent
  • 14. • Boundaries – Inferiorly – orbicularis oris superior-quadratus labi superiosis – Posteriorly – buccinator muscle – Medially – levator labii superiosis alaegue nasii
  • 15. • Clinical features – Swelling of cheek and upper lip – Obliteration of nasolabial fold – Drooping of angle of the mouth – Edema of lower eyelid – Offending tooth may be mobile and tender to percussion • Incision and drainage
  • 16. Buccal space • Boundaries – Anteromedially – buccinator musle – Posteromedially – masseter overlying the anterior border of the ramus of the mandible – Laterally by forward extension of deep fascia from the capsule of parotid gland and by platysma muscle
  • 17. – Inferiorly limited by the attachment of the deep fascia to the mandible and by depressor anguli oris – Superiorly the zygomatic process of the maxilla and zygomaticus major and minor muscles
  • 18. • Teeth commonly involved –Maxillary and mandibular premolars and molar –Location of root tip to the level of origin of buccinator muscle determines the spread of infection either intraorally into the vestibule or deep into the buccal space –Pericoronitis in lower third molar
  • 19. • Clinical features – Fluctuant swelling of cheek with an obvious swelling of the face – Infection from the buccal space may extend upwards into temporal space or gravitate down into the submandibular space
  • 20. Infratemporal space Laterally: ramus of mandible, temporalis muscle and its tendon Medially: med pterygoid plate, lat & med pterygoid muscle, lower part of temporal fossa, lateral wall of pharynx Superiorly: infratemporal surface of greater wing of sphenoid, zygomatic arch Inferiorly: lat pterygoid muscle Anteriorly: infratemporal surface of maxilla Posteriorly- parotid gland
  • 21. • C/F: – trismus – bulging of temporalis muscle – marked swelling of the face on the affected side in front of ear, overlying TMJ, behind the zygomatic process  complication:  Cavernous sinus thrombosis - through pterygoid plexus and inf opthalmic vein via sup orbital fissure
  • 23. Pathways of ascending infections from jaw to cranial cavity
  • 24. Submental space Laterally : Lower border of the mandible anterior belly of digastric Superiorly : mylohyoid muscle Inferiorly: suprahyoid portion of the investing layer of deep cervical fascia which is covered by platysma superficial fascia and skin Contents:submental lymph nodes and ant jugular vein
  • 25. C/F: • Extaorally distinct firm swelling in the midline beneath the chin skin overlying may be boardlike and taut. Fluctuation maybe present • Intraorally the offending tooth may exhibit tenderness to percussion and may show mobility
  • 27. Case report • A 10 year old child was brought to the emergency department 2 days after a fall from a bicycle. Examination revealed a markedly swollen chin, and imaging revealed a nondisplaced symphyseal fracture and a subcondylar fracture. The central incisors were slightly mobile.
  • 28. • Despite rigid fixation and penicillin therapy, the submentall area became fluctuant and required incision and drainage, from which streptococci and bacteroids were cultured. After drainage the infection and fracture healed uneventfully.
  • 29. Sub lingual space This is a V shaped trough lying lateral to muscles of tongue, including hyoglossus, genioglossus and geniohyoid Superiorly: by the mucosa of the floor of the mouth Inferiorly: mylohyoid muscle Medially: hyoglossus, genioglossus, and geniohyoid muscle Laterally: medial side of the mandible above the mylohyoid muscle Posteriorly: hyoid bone
  • 30. C/F: Extraorally little /no swelling, pain & discomfort during swallowing. speech may be affected. Intraorally firm painful swelling in floor of the mouth, tongue may be pushed superiorly- causing airway obstruction. Inability to protrude tongue beyond vermillion border of upper lip.
  • 33. Submandibular space Anteromedially: floor formed by mylohyoid muscle, covered by loose areolar tissue and fat Posteromedially: floor is formed by hyoglossus muscle Superolaterally: medial surface of the mandible below mylohyoid ridge Anterosuperiorly: ant belly of digatric Posterosuperiorly: post belly of digastric, stylohyoid & stylopharyngeus muscles Laterally: platysma and skin
  • 34. CONTENTS: superficial lobe of submandibular gland and lymph nodes, facial art and vein, marginal mandibular nerve.
  • 35. C/F: Extra orally firm swelling in the submandibular region, generalized constitutional symptoms, tenderness and redness over the skin Intraorally moderate trismus , teeth affected is sensitive to percussion and are mobile, dysphagia
  • 38. Submassetric space Anterior: ant border of masster muscle & buccinator Posterior: parotid gland and post part of masseter Inferior: attachment of the masseter to the lower border of the mandible Medial: lateral surface of the ramus of the mandible Lateral: medial surface of the massetermuscle Contents: massetric nerve superficial temporal art & transverse facial art
  • 40. • C/F: moderate size facial swelling confined to the outline of masseter muscle, tenderness over the angle of the mandible, trismus, pyrexia and malaise
  • 42. Pterygomandibular space Laterally: ascending ramus of mandible Medially: lateral surface of medial pterygoid muscle Posterior: parotid gland Anteriorly: pterygomandibular raphae Superiorly: lateral pterygoid muscle
  • 43. Clinical Features – trismus – dysphagia – medial displacement of the lateral wall of pharynx – redness and edema of area around third molar – difficulty in breathing
  • 45. Secondary fascial spaces • Superficial and deep temporal • Lateral pharyngeal • Retropharyngeal • Prevertebral spaces • Parotid space
  • 46. Temporal space • Supeficial temporal space: – Lateral : temporal fascia – Medial : temporalis muscle • C/F: – Swelling limited superiorly and laterally by temporal fascia and inferiorly by zygomatic arch – ‘Dumbell shape’ swelling if associated with buccal space due to lack of swelling over zygomatic arch – Severe pain & trismus
  • 48. • Deep temporal space: – Lateral : medial surface of temporalis muscle – Medial : temporal bone and greater wing of sphenoid • C/F: – Less swelling than superficial temporal space – Difficult to diagnose – Considerable pain and trismus – Difficult to elicit fluctuation because of depth
  • 49. Parotid space • Rare from extension of odontogenic infection • Blood borne / retrograde infection through parotid duct Superior : zygomatic arch Inferior : lower border of mandible Anterior : ant border of mandibular ramus Posterior : retromandibular area
  • 50. • C/F: – severe pain radiating to ear & accentuated by eating – Dehydration – due to insufficient consumption of fluids • DD: – Submasseteric infection – Distinguished by • lack of trismus • Eversion of ear lobe • Escape of pus from parotid duct on milking
  • 52. Pharyngeal space • Lateral / Para pharyngeal space • Retro pharyngeal space
  • 53. Lateral pharyngeal space • An inverted pyramid with its base at the base of the skull and apex at the hyoid bone. • Medial: superior pharyngeal constrictor muscle (lateral wall of pharynx) • Lateral: fascia of medial pterygoid, deep capsule of parotid gland • Anterior: palatal muscle superiorly, buccinator, superior constrictor, stylohyoid and post belly of digastric inferiorly • Posterior: carotid sheath posterolaterally and retropharyngeal space posteromedially. • Inferior: hyoid bone • Contents: carotid artery, internal jugular vein, vagus nerve, cervical sympathetic chain.
  • 54. • Aponeurosis of Zuckerkandl & Testut divides this space into ant (pre styloid) and post (post styloid) • C/F: Ant compartment – pain, fever, chills, medialbulging of lat pharyngeal wall, with deviation of palatal uvula from midline, dysphagia, swelling below angle of mandible and trismus. Post compartment – absence of visible swelling and trismus, but respiratory obustruction, septic thrombosis of internal jugular vein & carotid artery hemorrhage may occur • D/D: peritonsillar abscess –, Enlarged & inflamed tonsil
  • 56. Spread of infection from 3rd molar
  • 58. • Origin of infection: – Direct: sublingual space submandibular space lateral pharyngeal. – Indirect: Pterygomandibular space lateral pharyngeal. • Spread of infection: – Upwards through various foramina at base of skull causing cavernous sinus thrombosis, meningitis and brain abscess – Posteriorly to retropharyngeal space or carotid sheath • Investigation: CT scan more useful in diagnosis
  • 60. Route of spread • Submandibular (one side) sublingual Submental space contralateral Submandibular OR • Sublingual space opp sublingual extend posterior over edge of mylohyoid submandibular submental space OR • Submandibular pterygomandibular space pharyngeal space mediastinum • Investigation – cervical soft tissue films & CT before attempting tracheostomy
  • 68. Ludwig’s Angina • It is a firm, acute, toxic cellulitis of the submandibular and sublingual space bilaterally and of the submental space • Dental infection is the causative factor in 90% cases
  • 69. Clinical Features • General examination – Patient looks very ill, toxic and dehydrated – Pyrexia, anorexia, chills, dysphagia and malaise – Hoarseness of voice
  • 70. • Regional Examination – Firm/Hard/ woody hard swelling in the bilateral submandibular and submental region which soon extends down the anterior part of the neck – Swelling is non-pitting, minimally or non-fluctuant with severe tenderness – Severe muscle spasm which may lead to trismus – Mouth remains open due to sublingual edema which cause raised tongue – Airway obstruction
  • 71. • Fatal death may occur in untreated case of Ludwig’s angina within 10 to 24 hours due to asphyxia
  • 72. Principles of treatment • Early diagnosis • Maintain patent airway • Intense and prolonged antibiotic therapy • Extraction of offending teeth • Surgical drainage or decompression of fascial spaces
  • 74. Reference • Oral and Maxillofacial Infections, Richard G. Topazian , Morton H. Goldberg • Textbook of Oral and Maxillofacial Surgery, Neelima Malik

Editor's Notes

  • #5: We have been constantly asked the worst thing that could happen from a dental caries or dental decay. In this we are presenting what are the sequele of odontogenic infections. Infections always spreads through the path of least resistance. That is until the fasciae is separated by pus, blood, drains or surgeons’ finger
  • #12: Alpha hemolytic streptococci account for the 80% of the aerobic bacteria found Porphyromonas asacchrolyticus, P. Gingivalis, P.endodontalis
  • #25: If infection from the incisors exits labially through the mandibular bone , inferior to muscle attachments,the submental space becomes involved.
  • #27: Percutaneous surgical drainage is the most effective approach. A horizontal incision in the most inferior portion of the chin in a natural skin crease provides dependent drainage and most cosmetically acceptable scar.
  • #29: Antibiotics do not penetrate well into facial space infections, regardless of primary source of infection, a scalpel blade is often is the therapy of choice.
  • #30: Above mylohyoid line is the sublingual space. Mylohyoid attaches to lingual surface of mandible in an oblique downward line from posterior to ant. Root apices of premolar and 1st molar teeth sup to this attachment So infections from these teeth penetrate into sublingual space.
  • #32: Surgical drainage of the sublingual space should be performed intraorally by an incision through the mucosa parallel to whartons duct
  • #34: From 2nd n 3rd molar Result in ludwigs angina
  • #71: Contemporary reports of ludwigs angina have demonstaarted the presence of staphylococci gram negative enteric organisms suh as e coliand pseudomonas and anerobi including bacteriods.
  • #74: The incidence and severity of odontogenic infections have diminished since the advent of antibiotic therapy However significant morbidity and mortality of these infections continues. But dentists and physicians must be alert to the potential seriousness of these infections Timely intervention can always prevent these complications Deep space infections must be recognised promptly and treated as emergency