FASCIAL SPACES INFECTION INTRODUCTION Fascial space are potential spaces between the layers of fascia. Space is a misnomer ,there are no voids (SPACES) in the tissues in actual reality. These areas are potential spaces that do not exist in healthy individual but become filled during infections. Spaces have boundaries formed by muscles, fascia, periosteium, bone, mucous membranes.

BASED ON MODE OF INVOLVEMENT Classifications BASED ON MODE OF INVOLVEMENT   DIRECT INVOLVEMENT Primary space - Mandibular Spaces Maxillary Spaces INDIRECT INVOLVEMENT Secondary space

PRIMARY MANDIBULAR SPACES PRIMARY MAXILLARY SPACES Submental Submandibular Sublingual Buccal PRIMARY MAXILLARY SPACES Canine Infratemporal

SECONDARY FASCIAL SPACES Masseteric Pterygomandibular Superficial and deep temporal Lateral pharyngeal Retropharyngeal Pre-vertebral Masticator space Cervical fascial spaces

Digastric muscle (Anterior Belly) Sublingual gland Tongue Sublingual space The sublingual and submandibular spaces communicate at the posterior edge of the mylohyoid. The sublingual space contains the sublingual salivary glands and the deep parts of the submandibular salivary glands with their ducts, the submandibular gland being a structure partly occupying both the sublingual and submandibular spaces. Mylohyoid muscle Submandibular gland Submandibular space Digastric muscle (Anterior Belly)

LUDWIG’S ANGINA Definition Ludwig’s angina is a form of firm, acute, toxic and severe diffuse cellulitis that spreads rapidly, bilaterally, affecting the submandibular, sublingual and submental spaces and resulting in a woody swelling.

Etiology Dental infection most commonly the mandibular 3rd molar in 90% of cases. Oral soft tissue lacerations. Puncture wounds of the floor of the mouth. Submandibular gland sialadenitis. Secondary infections of oral malignancies.

Clinical Features Bilateral suprahyoid swelling with hard consistency,non fluctuating & painful on palpation Swelling is characterized by rapid onset Difficulty in breathing (dyspnea), Difficulty in swallowing (odynophagia) Restricted tongue movements, elevated tongue, inability to open the mouth, salivation Patients may exhibit muffled voice due to edema of vocal apparatus (hot potato voice)

Firm, brawny swelling in bilateral submandibular & submental and sublingual spaces, non fluctuant,tender with ill defined borders Open mouth due to edema of sublingual tissue Airway obstruction due to edema of the glottis and floor of the mouth Infection can spread to involve the masticator space and Para pharyngeal space in the latter stages of the disease

OSTEOMYELITIS DEFINITION In Greek osteon means bone myelos means marrow itis means inflammation “ Osteomyelitis may be defined as an inflammatory condition of bone, that begins as an infection of medullary cavity and haversian systems and extends to involve the periosteum of the affected area ”

CLASSIFICATION Simplest and the most used is based on presence or absence of suppuration Based on clinical course

Based on suppuration SUPPURATIVE NON SUPPURATIVE ACUTE SUPPURATIVE CHRONIC SCLEROSING - FOCAL - DIFFUSE CHRONIC SUPPURATIVE - PRIMARY - SECONDARY GARRE’S SCLEROSING INFANTILE ACTINOMYCOTIC SPECIFIC INFECTIVE - TUBERCULOSIS - SYPHILIS RADIATION

CLASSIFICATION BASED ON CLINICAL COURSE Acute Sub-acute Chronic

Acute oml GEN. CONSTITUTIONAL SYMPTOMS DEEP, BORING, INTENSE CONTINUOUS PAIN PARAESTHESIA OR ANAESTHESIA OF LIP FACIAL CELLULITIS OR INDURATED SWELLING FOETID ODOUR TEETH – TENDER TRISMUS

Chronic oml PAIN IS MINIMAL NONHEALING WOUNDS WITH INDURATION INTRA ORAL OR EXTRA ORAL SINUS THICKENED OR WOODEN CHARACTER OF BONE ENLARGEMENT OF MANDIBLE PATHOLOGICAL #S LOOSE , TENDER TEETH

GENERAL MANAGEMENT OF PATIENT WITH INFECTION MEDICAL THERAPY: It consists of supportive care Hydration Soft and liquid diet Rich protein diet Analgesics Antiseptic mouthwash Maintenance of oral hygiene Antibiotic therapy — depends upon whether the patient is non-compromised and compromised patient

Antibiotic Therapy Choice of antibiotics include Penicillin+metronidazole or Clindamycin

METRONIDAZOLE Immediate infusion of Metronidazole - 500mg Brings about rapid improvement Repeated every 8 hours

Incision and drainage of abscess Surgical therapy Incision and drainage of abscess To get rid of toxic purulent material. To decompress the oedematous tissue. To allow better perfusion of blood containing antibiotic and defensive cells present in blood. To increase oxygenation of the infected area.

APICOECTOMY Apicoectomy or Apical surgery or Root resection are the terms which are used for surgery involving root apex to treat apical infection. It is the cutting of apical portion of the root and curettage of periapical necrotic, granulomatous, inflammatory or cystic lesions. In spite of good endodontic treatment, if periapical lesions are not resolved, then apical surgery is undertaken.

INDICATIONS Roots with broken instruments/over fillings with infection. Fracture of apical third of root. Periapical granuloma or cyst. Draining sinus tract. CONTRAINDICATIONS Presence of systemic diseases eg; Leukemia, uncontrolled diabeties, anemia. Teeth damaged beyond restoration. Teeth with deep periodontal pockets. Mobile teeth. Short root length. Acute infection non-responsive to treatment.