What is Odontogenic Orofacial Space Infections?
Your mouth, much like your skin and other parts of your body, is densely populated with microbes (microscopic organisms) that play a crucial role in your overall health. However, just like any part of your body that has a lot of microbes, your mouth can fall prey to infections causing bacteria and other harmful microorganisms. Tooth-related infections, also known as odontogenic infections, are some of the most common infections globally.
These infections can spread to your face and deep neck areas. In adults, tooth-related infections are the main cause of deep neck infections. Usually, these infections need a team of professionals, such as dentists, oral surgeons, nose and throat specialists, primary care doctors, and emergency medicine specialists for proper care and treatment.
Your mouth houses 20 teeth as a child and 32 as an adult. These teeth, evenly divided between your upper (maxilla) and lower (mandible) jaws, each contain one to three roots that sit in a socket in the jawbone. The part of the tooth that sits above the gum line is termed the neck, while the visible part of the tooth, also known as the crown, is covered by enamel. Teeth are held in place by periodontal ligaments and receive blood and nerve supply through each root.
There are many potential spaces between the muscles, bones, and tissues of the face and neck where tooth-related infections can spread. For example, an infection of an upper tooth (maxillary canine) can spread into the surrounding spaces. Similarly, infections of the lower teeth (mandibular teeth) can lead to infections in three different spaces around the tongue and jaw. The spread of infections from the lower teeth is largely determined by the position of the tooth roots in relation to the mylohyoid line, a specific location in your jawbone.
The various microorganisms in your mouth majorly consist of different types of bacteria, especially those that can either live with or without oxygen, and various fungi. Streptococcus, a common bacterium known for causing infections, is found mostly in the mouth. There are also other types of bacteria that thrive in the mouth, especially in people with poor oral hygiene or those who are unwell. As various types of bacteria are present in the mouth, tooth-related infections usually involve multiple bacteria, making treatment broad-reaching even after identifying the bacteria involved.
What Causes Odontogenic Orofacial Space Infections?
The mouth is a critical area where many important body structures meet. Due to this, infections linked to teeth, also known as odontogenic infections, can quickly spread and cause problems with our nervous system, blood vessels, and even our breathing. Spotting signs of these infections early, like tooth decay, abscesses at the root of the tooth, or other minor dental infections, is crucial to stop more serious problems from developing. If these infections are missed or ignored, they can cause temporary or permanent health issues that both distress the patient and put pressure on the health system.
Odontogenic infections are grouped and treated based on the tissues or spaces involved, and how severe or far along the infection is. Tooth decay is the most common cause of odontogenic infections, with the most common type being an abscess around the root of a tooth, known as a periapical abscess.
Treatment often includes a mix of antibiotics which can either be given orally or through a drip, and possible surgery to drain any abscesses or to clean out the infected area. For any infection related to the teeth or face, the preferred treatment is to remove the problematic tooth. However, in some cases, the tooth may be saved through a procedure known as endodontic treatment, which is commonly referred to as a root canal.
Risk Factors and Frequency for Odontogenic Orofacial Space Infections
Minor dental infections are a common occurrence in the United States. In fact, by the age of 65, more than 90% of individuals will have suffered from dental decay. Men are more frequently affected by these issues than women. Additionally, over 70% of these infections happen in people between the ages of 20 and 50.
Factors like tobacco use and diabetes are commonly seen in people with tooth-related neck infections. Due to the increased availability of antibiotics over the past few decades, there has been a decrease in dental, tooth-related, and deep neck infections. However, despite this, the number of deep neck infections originating from dental issues has increased. As a result, these infections are currently the main cause of deep neck infection in United States adults.
- Minor dental infections are quite common in the U.S.
- By the age of 65, over 90% of individuals will have experienced dental decay.
- Men are more commonly affected than women.
- About 70% of these infections occur in people aged between 20 and 50.
- Tobacco use and diabetes are often associated with tooth-related neck infections.
- Thanks to the widespread use of antibiotics, dental and deep neck infections have decreased overall.
- But the proportion of deep neck infections from dental origin has increased and is now the leading cause of these infections in U.S. adults.
Signs and Symptoms of Odontogenic Orofacial Space Infections
Odontogenic infections are infections that start in the teeth. They typically show symptoms like increasingly worse tooth pain over a span of one to two weeks, followed by swelling in the face or neck. Often, these symptoms come with fever, tiredness, and a recent decrease in eating. The person often has poor dental hygiene and may have had a recent tooth removal or tooth decay.
A series of health checks might show additional symptoms such as:
- Painful swallowing
- Neck pain
- Facial pain
- Difficulty with opening the mouth wide
- Fever
- Tiredness
Depending on the affected tooth and how the infection has spread, symptoms can also include discomfort or tingling, eye pain, double vision, difficulty breathing, and excessive saliva. If the abscess in the mouth breaks open, there may be complaints about a bad taste and smell due to pus in the mouth. A thorough medical examination of the neck and head, including the cranial nerves, is important to understand if the infection has spread further.
Testing for Odontogenic Orofacial Space Infections
If you have a dental infection that hasn’t been treated, it can easily spread to the gums and soft tissues in your face and neck. Where the infection spreads to depends a lot on its location, especially in relation to a muscle in your jaw called the mylohyoid muscle.
During the early stages, cellulitis, a common skin infection, can be identified and treated. For this, only a physical exam is needed. Signs of cellulitis may include redness, swelling, hardening or thickening of the skin, tenderness, and swollen, tender glands in your neck.
Doctors can use a point of care ultrasound (POCUS) to check for an abscess (a collection of pus) if they’re worried about one forming. A computed tomography (CT) scan — sort of like a sophisticated X-ray — isn’t necessary, but can be useful if POCUS isn’t reliable due to a patient’s body build or bone structure. In such cases, the CT scan can help tell the difference between cellulitis and an abscess, with cellulitis showing up as strands of fat and localized enhancement when contrast, a special dye to enhance images, is used.
A CT scan that includes both the neck and face may be needed if there’s concern about a complex abscess formation or spread of infection to deeper areas of the neck. In cases where a patient has severe swelling in the neck and mouth, difficulty breathing, or is in obvious distress, a rapid evaluation of the upper airway must be done in a controlled setting. This is best performed using an awake flexible laryngoscopy, a procedure where a flexible tube with a camera on the end is used to view the airway. This can indicate the need for urgent actions to maintain airway.
Treatment Options for Odontogenic Orofacial Space Infections
Odontogenic cellulitis is an infection caused by a variety of different types of bacteria. This type of infection is usually serious and as such, it is treated with antibiotics that can fight off a wide range of bacteria, such as amoxicillin-clavulanate or clindamycin (if you’re allergic to penicillin). Alongside antibiotic treatment, the infected tooth (which is the source of the infection) needs to be removed by a dentist to prevent ongoing infection.
If left untreated, cellulitis can advance into an abscess, where pus gathers around the jawbone, causing extra pain and discomfort. Abscesses often resemble cellulitis with their redness, firmness, and tenderness, but can be distinguished by the presence of a lump and, in some cases, pus-filled teeth sockets. Smaller abscesses might not need imaging scans for diagnosis and can often be recognized through a technique called POCUS (point-of-care ultrasound).
Treating an abscess usually involves draining the pus, this helps to control the infection and provides some relief from symptoms. Wherever possible, the pus is drained from inside the mouth to minimize scarring and side effects. The infected tooth will also need to be removed and antibiotics prescribed, similar to the treatment process for cellulitis.
In some extreme cases, an infection may spread rapidly across the spaces in the neck, leading to a condition known as Ludwig angina. This is a medical emergency as it can make breathing difficult due to swelling of the tongue and neck. Such patients usually appear to be struggling for breath, may drool, and have a swollen-looking neck. The first step in aiding these patients is to ensure their airway is open and stable. After that, strong antibiotics are given through an IV line and the patient is usually admitted to hospital for close monitoring and further treatment, possibly including surgery to drain the infection or possibly remove tissue.
An infection can sometimes spread upwards into the sinuses, particularly if it’s caused by a tooth located near the sinus, or a poorly placed dental implant. This condition is known as odontogenic sinusitis and can lead to facial pain, fever, and a feeling of general illness. Treatment includes removing the problematic tooth or implant, using antibiotics, and possibly surgical intervention in the sinuses. In some cases, particularly where the problem is due to a hole between the mouth and sinus, surgery might be required to close this hole once the infection has been managed.
What else can Odontogenic Orofacial Space Infections be?
When you get repeated infections in your teeth, or an infection out of the blue when you’re generally healthy, it can point to the possibility of some kind of cancer in the mouth. It’s crucial to visit your dentist or surgeon for a follow-up to check for any irregularities in the lining of the mouth or bone. Sometimes, an infection thought to be related to your teeth could actually come from surrounding areas like the sinuses in the face, a bone near the temple, a birth-related or developed lump in the neck, or the sections of the body that involve breathing and digestion.
If a tooth infection isn’t clearly visible or the history of dental pain is uncertain, a comprehensive investigation of the nearby anatomy should be done – this could be either a physical check-up or more detailed imaging studies if needed. If a person comes in with a tooth infection that’s part of a number of different soft tissue infections, it’s important to assess if they might have a weak immune system. This could either be a problem they were born with or something that developed over time.
What to expect with Odontogenic Orofacial Space Infections
The outlook for patients with odontogenic infections, or infections that originate in the teeth, is typically good, depending on the severity of the infection.
In a study conducted in 2022 involving 200 patients with odontogenic infections who visited the emergency department, over half of them were sent home the same day after receiving medication. Less than half of these patients needed to be admitted to the hospital for further treatment.
About half of those who were admitted to the hospital had to undergo surgery. Out of all the patients in the study, only one experienced complications linked to their infection, and two developed a serious type of skin infection called necrotizing soft tissue infection and needed multiple surgical cleaning procedures.
Possible Complications When Diagnosed with Odontogenic Orofacial Space Infections
If dental infections are ignored or left without treatment, they can turn into serious infections, leading to hospital admission and potentially severe health problems. They can progress rapidly from being a small issue that can be easily treated in an outpatient setting to requiring invasive procedures.
Deep Space Neck Infections
Infections in the upper and lower jaws can rapidly spread, leading to skin inflammation and abscesses in the surrounding soft tissues. These soft tissues connections with other deep spaces in the neck, could allow the infection to spread quickly toward specific areas of the neck. When infection reaches the space closer to the spine, it can speedily transfer into the chest area. This can result in serious infections such as mediastinitis or empyema, which often need thoracic surgical intervention and can be associated with severe health complications or even death.
Osteomyelitis
Being close to the bone, teeth can frequently develop a low-grade infection of the bone sockets of the upper and lower jaw, known as acute osteomyelitis. If caught and treated early, these infections usually resolve and allow the bone to regenerate. However, factors like delayed treatment, poor diet, bad oral hygiene, and smoking can lead to the development of chronic osteomyelitis. Chronic osteomyelitis usually presents as a long-term jaw pain and can include symptoms like the formation of abnormal connections called fistulas, numbness due to nerve involvement, or a fracture caused by disease.
A CT scan can identify isolated areas of infected bone, bone degradation, and necrotic areas. The usual treatment involves long-term antibiotics specific to the identified culture with removal of dead bone. In severe cases, bone grafts or free tissue transfers may be needed to reconstruct the damage.
Emergencies Due to Dental Infections
Severe health issues due to dental infections are uncommon but need immediate treatment by a healthcare team. The most common emergency is airway obstruction, which can be caused by serious dental infections like Ludwig’s angina.
Immediate recognition of breathing difficulties and identification of the location of airway obstruction in the emergency department allows for quick categorization of the patient for appropriate treatment.
Patients in such situations may need continuous monitoring, intravenous access for fluids and medications, and ready availability of supplemental oxygen. Administering antibiotics and corticosteroids through the veins can help in reducing swelling and obstruction of the airway.
Although rare, dental infections can occasionally progress to life-threatening soft tissue infections like necrotizing fasciitis, which necessitate quick assessment and surgical removal of infected tissues.
Preventing Odontogenic Orofacial Space Infections
Good dental hygiene plays a crucial role in preventing tooth and mouth (odontogenic and orofacial) infections. Various primary prevention techniques include learning about oral hygiene from healthcare providers, public service messages, and guidance from dentists. Individuals should be motivated to brush and floss their teeth routinely and visit the dentist twice a year.
As part of maintaining good oral health, it’s important to address and avoid harmful dental practices. These include eating a lot of acid-based or sweet foods, using tobacco products, drinking alcohol, and grinding the teeth. Grinding, also known as bruxism, can be particularly problematic. Secondary prevention, which involves removal of plaque from teeth and early detection and treatment of tooth decay (dental caries), is performed by dental professionals such as dental hygienists and dentists.
