Inflammatory processes of the oral and maxillo-facial region

Inflammatory diseases of maxillo-facial area caused by microorganisms, the majority of which under ordinary conditions penetrate the skin and oral mucosa. Depending on localization of site of entry for microbes can be distinguished: odontogenic, stomatogenic, tonsillogenic, rinogenic dermatogenic and idiopathic infectious inflammatory processes.

Etiology

•Dental and periodontal lesions (most frequent): carious cavities and their complications, periodontitis, periodontal pockets, traumatic lesions of teeth (fractures, luxation, extrusion injury), pathologies of tooth eruption.•Traumatic lesions of jaws (fractures, which may or not involve teeth), especially open fractures (a fracture which involve periodontal ligaments is also considered an open fracture).•Jaw osteomyelitis often lead to a spread of infection in adjacent soft tissues.•Inflammatory diseases of salivary gland (as well as lithyasis).

•Jaw tumors, odontogenic and non-odontogenic cysts may generate inflammatory process.•Foreign bodies which penetrate the skin or mucosa.•Tonsillar inflammatory process.•Furuncle and pyodermitis of head and neck regions.•Complications of anesthesia (septic puncture, formation of hematoma which may became infected).•Complications of tooth extraction.•Complications of different dental treatments (iatrogenic factors also)

Pathogenic mechanisms of infectious agents spreading:• Trans-osseous way: usually met in inflammatory process of

periodontal tissues. Infectious agents spread along the Hawers

channels (in the bone) to the periosteal (endo-osseous phase).

• Sub-mucosal way: usually met in inflammatory process of

periodontal pockets.

• Lymphatic and venous ways (lead to phlebitis and

lymphadenitis).

• Direct way (septic puncture and others).

The microbian flora is nespecific, mixt, polymorphic. Most frequent bacteria are: streptococcus, escherichia, white staphylococcus, Fusobacterium, Lactobacillus. Also in the inflammatory processes are found sporulated anaerobic bacteria (Clostridium perfringens, Clostridium oedematiens) and fungi.

Microbiology

Classification depending on the cause of infection (Bernadskii, 1985):

Odontogenic – teeth with gangrene or necrotic pulp Intraosseous – as a result of periostitis, osteomyelitis,

difficult eruption of wisdom tooth, sinusitis, cyst. Gingival – as a result of gingivitis, paradontitis. Mucostomatogenic – different inflammations of the oral

mucosa Salivatory – inflammation of salivary glands Rhynogenic Othogenic Dermathogenic

Classification by morphologic-clinical forms of the odontogenic infection (Shargorodskii):

PeriodontitisAcuteChronic

Periostitis Osteomyelitis Sinusitis Abscess and flegmons Lymphadenitis

Mild Infection• Trivial - Inflammatory sign– Dolor– Calor– Rubor– Tumor– Loss of function• Lymphadenopathy• Pyrexia (fever)

ODONTOGENIC INFECTION (GENERAL STUDY)Clinical Features (Signs and Symptoms)

Severe Infection• Trival + signs of toxicity– Paleness– Rapid respiration– Rapid thrombing pulse– Shivering– Fever– Lethargy– Diaphoresis (severe sweating)

There are 4 types of acute inflammation in the soft tissues of face and neck:

Inflammation with pus Pus + necrosis Necrosis + gangrenous inflammation Gangrenous inflammation

Acute and chronic apical periodontitis

ETIOLOGY: there are 3 types of periodontitis depending on the causative factor. Traumatic – direct trauma, tooth dislocation, fractures, incorrect filling, trauma with dental needle… Drug (toxic) – usage of arsenic paste in the treatment of pulpitis, or strong antiseptic solutions used for irrigation Infectious – bacteriae spreading from caria or pulp inflammation to the periodontal tissue. Pushing necrotic materials behind the dental apex with endodontic instruments.Alergyc

Form of disease periodontitis

acute

serosal

suppurative

chronic exacerbated (aggravated)

chronic

fibrotic

granular

granulomatous

ACUTE APICAL PERIODONTITIS

Serosal stadium:•Dull aching pain in affected tooth, which increases in the

night. •Pressing on the tooth during occlusion becomes tenderer. •Pains do not irradiate, the patient can show the affected

tooth. •Appear the sensation of growing and prolongation of the

tooth. •Submandibular lymph nodes enlarge, painful. •Inflammatory changes of the mucosa are absent. •Pain reaction during the vertical percussion (tapping) can be asessed. •Such clinical picture is typically for serosal stage of inflammation which is usually short-term.

Suppurative stadium•The pain intensity grows, becomes acute, pulsatile •Irradiate in temple, ear, eye or cervix. •Touching the affected tooth causes acute pain. •Patient cannot occlude tooth and therefore often keeps his mouth a little opened. •The surrounding gum is hyperemic. •Palpation of the transitory fold and gingival along the all root becomes more painful. •Regional lymphadenitits•Because of pains the ingestion is hampered, the sleep is disturbed, appears the discomfort, general weakness•Fever•X-ray changes can be observed after approx. 10-21 days.

Differential diagnostics. Acute parodontitis should be differentiated from the pulpitis, radicular cyst, acute odontogenic maxillary sinusitis (for posterior maxillary teeth), periostitis and osteomyelitis. •During the pulpitis the pain is periodical. The tooth reaction to the cold is sharply positive during the puplpitis and during the parodontitis is absent.•During the radicular cyst – specific X-ray picture•Acute odontogenic maxillary sinusitis: has a typically radiologic picture (increased opacity of affected sinus), the presence of serosal-suppurative or suppurative elimination from the nose, intensive headaches.

Treatment

•endodontic drainage, which reduces the periodontal pressure, reduces the pain; normalize the general state of the patient. •If the affected tooth is no greatly destroyed and in the future it can be treated and filled, then the drainage of the inflammatory locus is performed through the root canal, and after regression of the inflammatory process, the tooth can be treated.•In case of bad treatment conditions, when the tooth is

destroyed, after the regression of inflammatory process, a tooth extraction must be performed.•In case of periostitis signs, or bad drainage conditions, an antibacterial, anti-inflammatory and antifungal treatment is required.

What's the difference between inflammatory exudate and pus?

Inflammatory exudate is a leakage of protienaseous fluid with some of the inflammatory cells.

But Pus is collection of neutrophils, debris, necrotic tissues

and other mediators.

So here we have a little bit of fluid, now we are talking about the acute periapical periodontitis, so acute exudate a little bit of exudates, there may be some of the neutrophils and inflammatory cells but it is not like the pus actually, because the pus by definition is a collection of neutrophils and dead tissues.

Chronical fibrous periodontitisUsualy this process is asymptomatic.Clinical exam reveals that tooth color is changed by

an enamel dullness; percussion and thermic agents dont induce pain. Tooth electroexcitability is greater than 100 mA. On the radiography is observed a deformation / dilatation of the periodontal space it in periapical region; the cortical bone plate is clear, without changes, but may present hypercimentosis.

Weak pain (pressing, embarrassment), especially during mastication

The disease history will reveal that the pain is recurring periodic and also the fistula with purulent content, which disappears within a certain time.

Near the tooth some gingival hyperemia can be seen. If compressing this portion of gum with a dull instrument it will leave an indentation that does not disappear immediately after removing the instrument. Gum palpation produces unpleasant sensations, and usually it may be a cortical defect in the cortical bone. Percussion causes tooth hypersensitivity reaction sometimes pain.

Chronic granular periodontitis

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Periapical granuloma which is a granulation tissue with inflammatory cells and collagen bundles.

What will happen here is that if the irritation persists and bacterial toxins are there, this will lead to low grade chronic process ,and with the good immune response , there will be bone resorption and formation of the periapical granuloma.

In this process there are no obvious symptoms, except for periods of exacerbation of the inflammatory process with hyperemia, gingival swelling.

The diagnosis of chronic granulomatous periodontitis is based on radiography data, viewing a spherical or oval bone distruction, with 0.5 cm in diameter.

Chronic granulomatous periodontitis

Then the bone here is resorped , it will be replaced by: granulation tissue , young fibroblasts , blood vessels , inflammatory cells , collagen fibers ,

Fibrous periodontitis – periodontal space enlarged Granular periodontitis – bone destruction with unclear

borders (shape of the fire) around dental apex. Granulomatous periodontitis – circle bone destruction

with clear borders around dental apex .

X-ray investigation:

PeriostitisPeriostitis: Inflammation of the periosteum (a dense

membrane composed of fibrous connective tissue that closely wraps all bones, except the bone of articulating surfaces in joints which are covered by synovial membranes).

Etiology: in most cases a non treated acute or recrudescence apical periodontitis

Clinical picture: Acute periostitisAfter the spreading of inflammatory process through the

bone, the infiltrate is being localized between the cortical plate and the periosteum. Due to a good adherence of periosteum to it’s cortical plate, the presence of suppuration under it is very painful. This is described as intra-osseous phase.

General signs:• Pain (local as well as headache)• Fever (in most cases, especially in the evening).• Asthenia• Sleep disturbanceLocal signs:• Symptoms of acute apical periodontitits are present• Pain senses in the tooth region irradiate in temporal fossa, ear, eye, neck (cervix).• Tooth percussion is very painful• Swelling of surrounding mucosa is poor• Palpation of mucosa and underling bone is very painful• Regional lymph glands increase and become more painful.

• Difficult and painful opening of the mouth, may appear as a result of inflammatory contracture of masticatory muscles (when a posterior mandibular tooth is the origin of inflammation).• When the suppurative collection passes through the periosteum, under the mucosa, the pain almost disappear, but the swelling significantly increases (in a few hours).• The suppurative collection may be localized at the buccal or lingual aspect, depending on the root which caused it. In most cases it appears buccaly.• In the buccal localization of periostitis which appears from the central and lateral maxillary incisors, the upper lip and wing of nose swells very much.

Differential diagnosis.Acute purulent periostitis of maxilla should be differentiated

from the acute periodontitis, osteomyelitis, phlegmon and lymphadenitis, supra-infected cysts. Sometimes periostitis is mistaken for inflammation of sublingual and submandibular gland and their ducts.

Radicular cyst

TreatmentConservative treatment: •antibiotics (determination of the antibiotic sensitivity, use

of specific, narrow- spectrum antibiotics if it is possible), •anti-inflammatory, •anti-fungal, •anti-septic medications.

Surgical: main remedial measures during the acute purulent periostitis consist in surgical prosection of suppurative colection and creation of free outflow of formed exudate.

The incision should be performed through the mucosa and periosteum 2-2,5cm in length (to all tissue depth till the bone). A thin drainage is inserted in the wound for 2-3 days, for a free outflow of exudate and prevention of part agglutination.

Tooth extraction should be performed in the same day (not recommended) or after a few days, when a significant regression of the inflammatory process is observed (recommended).

The chronic form of disease develops seldom. Predominantly appears at children in the age of 9-13

years and young people. Usually are absent local clinical aspects and fever

response. The reason of chronic periostitis and chronic ostitis more

often is odontogenic infection. small pains in the jaw, small deformation of surrounding

bone, insignificant hyperemia of local soft tissues. Chronic periostitis occurs when the reparatory process is

incomplete due to the presence of inflammatory and infectious agents, in the lack or after an acute process.

Chronic periostitis.

Osteomyelitis

• It is a diffuse inflammation of the soft tissue and bone involving

the cancellous bone marrow and the periosteal component. •Osteomyelitis can also be defined as an inflammation of the medullary portion of the bone. •Osteomyelitis can be explained as an inflammatory condition

of bone that begins as an infection of the medullary cavity and haversian systems and extends to involve the periosteum of the affected area.

Jaws’ Osteomyelitis can be: non-specific - odontogenic (stomatogenic), traumatic, toxic, hematogenic and specific.

Three phases (periods) of disease course: acute, sub-acute and chronic.

Chronic form: productive hyperplastic processes or destructive processes (Rarefying form or Sequestrate form)

Depending on affected area: Localized, Diffuse

Classification

may appear as an acute or chronic form from the beginning. (Hematogenous osteomyelitis in most cases has such a form - diffuse).

quick lunch acute infectious local and general clinical picture bone suppuration, diffuse swelling, shine skin and congestion, high

local temperature, may extend to a big area, even a part of neck surface

probing show a hard inflammatory infiltrate, painful, with bone and periosteum swelling

trismus is present especially in posterior mandible osteomyelitis the gum presents a significant swelling and congestion teeth (group) pathological mobility and toothaches Hypersalivation Radiological picture has specific signs only after 6-8 days.

Diffuse Osteomyelitis

General signs:•Diffuse pain, pulsatile, irradiance•Fever (39-40°C)•Tachycardia•If the necrosis occurs, the fever will decrease

Chronic osteomyelitis - productive hyperplastic processes• Lead to formation of hyperostosis• Rare form• Often appear in children, in the period of teeth eruption• The affected area has a thicker contour, a bigger volume• The pain has an intermittent character, then a continue one• Periods of recrudescence usually appears• In mature patients the bone sequestration is a sign of chronic osteomyelitis (destructive process)

Differential Diagnosis:

• acute periodontitis• acute periostitis• isolated inflammatory process of face soft tissues (abscesses, phlegmons) • cysts in maxilla-facial region (odontogenic, dermatoid, epidormoid)• Chronic maxilla osteomyelitis should be differentiated from benign tumors and tumor-like diseases (cysts, osteoblastoclastoma, osteoid osteoma, eosinophilic granuloma and so on), and also malignant tumors.