Professional Documents
Culture Documents
Dr Isimeli ULUIBAU
Senior Lecturer
devices for osteotomies and fracture fixations are other common sources of infection.
But in this review the focus is on odontogenic infections and deep fascial space
infections [1] particularly abscess or infections having the teeth to be the foci of the
infections.
Odontogenic infection.
Dentoalveolar bacterial infection of the oral cavity may commonly remain localised at
the offending tooth or spread rapidly to surrounding tissue and to distant sites or
Spreading of the bacterial infections depends primarily on the balance between the
general factors of patient resistance and the bacterial quantity and virulence. These is
usually as a sequence of tooth pulpal death cause by dental caries or trauma to teeth or
jaw.
Pulpal death from tooth decay is the most common cause of odontogenic infections
Because of the complexity and diversity of the oral microflora and their adaptation
in different conditions within the oral tissues, and when the balance between host and
oral flora tips favouring the growth of the micro-organism, infections can progress if
not treated.
These if not controlled or adequately treated may cause the infection to spread along
the planes of least resistance to the tissue spaces closes to the infected site or rarely to
distant sites.
(table X)predominantly odontogenic causes, Seventy five per cent of the infection
were odontogenic arising from the teeth and their supporting structures, with pulpal
necrosis being the predominant cause.
treated between July 1996 and November 2000 were reviewed. Out of the 46 patients
Peter et al reported 128 patients admitted during the period of October 1, 1984 and
March 31, 1995 with maxillofacial infection of dental origin were retrospectively
identified by medical review. Their study was focused on identifying potential risk
Bross-Soriano et al reported 107 (89%) patients, of the 121 included in their study
years experience in which a total of clinical register of patients with the diagnosis of
Ludwig’s angina included and reviewed. Their ages ranged from 15 to87 years with a
median age of 48 years. A large numbers of patients were older, in the 51 to 60 year
range. Female was most affected 68 (56%) of patients versus 53 (44%) male
patients. Ninety one patients belong to a low socioeconomic level, 26 patients belong
level.
Juang et al in their study [4]reported 14 cases of Ludwig’s angina, 12 of which (86%)
Huang et al in their analysis of 185 patients found that odontogenic infections was one
of the most common cause of infections with their series of deep neck infections
accounted for which, less than twenty five per cent of the cases.[6]
This finding in general is not uncommon, sometimes non odontogenic causes may
These presentation may make it difficult for the examiner on physical examinations,
to determine a cause especially when patients are unable to fully open their mouth due
to the spasm and pain within the mascles of mastication involved in the infection.
Pericoronitis 7.5
Postoperative 18.9
Total 76.4
Trauma 8.5
Osteotomyelitis
Sialadenitis
Usually the primary micro-organisms are aerobic in the early stages of the dental
infections, if not treated and controlled the population of the microflora are replaced
odontogenic abscess where pus samples from 23 dentoalveolar abscess were collected
aerobic and anaerobic agar plates and from this 23 closed odontogenic abscess
samples, a total of 112 bacterial strains were isolated, 81 strains (72.3%) were strict
The mean number of bacterial strains per positive samples was 4.86. Oral
common isolates. The combination of oral streptococci and prevotella was found in
(52.2%). [11]
Their conclusion remain consistent with many other findings which were,
aerobes and anaerobes. This also highlights the importance of pus specimen
Heimdahl et al in their study[12] found that 174 anaerobic and 22 aerobic stains were
isolated. Anaerobic gram-negative rods were isolated more frequently from the
nucleatum was more frequently associated with severe infections than with mild ones
(P<0.05). Streptococcus milleri was also more often isolated from severe than mild
infections were treated. All patients requiring surgical drainage and additional
antimicrobial therapy.
Viridans streptococci in dentoalveolar infections in particular is a most common
Huang et al in their experience[5] noted also that one of the most common organism
they found was streptococcus viridans which accounted for 33.9% were identified
infection which shown from their bacterial examination of 664 strains which were
isolated from their test cases, In this case hundred and sixty three patients were
included.[10].refer table 1.
Kuriyama et al findings were consistent with the data compiled from a good series of
references which were adapted by Peterson, L.J.[14] in table 2 of his paper which he
Staphylococcus 9 Pigmented 93
prevotella
Corynebacterium 9 Fusobacterium 90
Campylobacter 9 Nonpigmented 56
Prevotella
Neisseria 8 Gemella 36
Actinomyces 7 Porphyromonas 35
Lactobacillus 6 Bacteroids 14
Enterobacter 3 Eubacterium 9
Haemophilus 3 Veillonella 8
Pseudomonas 2 Propionibacterium 2
Micrococcus 1 Unidentified 1
anaerobic gram-
positive coccus.
Enterococcus 1 Unidentified 6
anaerobic gram –
positive rods.
Klebsiella 1 Unidentified 6
anaerobic gram-
negative rods
Branhamella 1
Unidentified 1
aerobic gram-
negative rod.
TOTAL 200 464
positive cocci, and anaerobic gram-negative rods were isolates frequently encounter
from orofacial odontogenic infections. This are consistent with varies reports in the
literature.
Clinical practice in oral surgery shows that odontogenic infection still represent the
most commonly en-counted infection of the head and neck, odontogenic infection
most commonly arise in fit healthy individuals and can become serious, severe
Huang et al study.
Ludwig’s angina and mediastinitis, a 74 year old woman who had a medical history of
hypertension, remote thyrotoxicosis and a previous breast biopsy who saw her dentist
restoration with amalgam. The procedure was uncomplicated, with no pulp exposure.
And the patient was told that the tooth might require root canal or removal if pulp
dies. Six month later patient return to see her dentist and complains of mild tenderness
on this tooth but generally asymptomatic. Two weeks later patient developed
spontaneous pain in the tooth but elected not to call her dentist, as it was a Friday
afternoon. Seventy two hours after the pain appeared, the patient returned to the
dentist with massive facial swelling that developed over a 24 hour period, a
presentation of Ludwig’s angina and mediastinitis was reported for this lady.[17]
and culture techniques and their known management, there are still a few progressive
infection that really presents as a “nightmare” and brings signs of caution in their
proper management.
(86%) were of dental in origin, but there were no death in his series of cases. Most of
their cases were treated with crystalline penicillin with or without and
upper airway leading to difficulty in breathing, and death as a result of upper airway
obstructions. Death in cases of Ludwig’s angina has decreased dramatically since the
Huang et al, of their 185 cases of deep infections mean age of 49.5 +- 20years, thirty
patients 16.2%) had major complications during admission among them 18 patients
received tracheotomies. There were 63 patients had associated systemic disease, with
88.9% of those having diabetes mellitus. Three death were recorded in this study,
mortality rate of (1.6%). All this 3 death had underlying systemic disease and were
un-predictable in their course, that they may present as local dentoalveolar abscess to
spreading severe life threatening cellulitis and abscess of the head and neck region
that threatens the patients general health as we see from the case reports and
studies presented.
These life threatening complications are upper airway obstruction, septic shock,
These are rare complication and most commonly can result from sequelae of
they reported 13 series of cases, between April 1994 and April 2000. Patients were
within mean age of 39.23+-18.47(median 38, range 16-67) years. Six patients (46%)
primarily had odontogenic causes, 5 had peritonsillar abscess and 2 had post traumatic
cervical abscess.
of mediastinitis, between January 1990 and June 2001, the patients mean age 54.5
years, and range from 19 to 72 years. In this group 1 patient died of multiorgan failure
This complications are rare as mentioned but must be remembered as the causes of the
infections could been eliminated very early therefore all the complications arising
from odontogenic infections could have been prevented, as an old adage “ Prevention
This just shows the severity of ongoing dental infections and the seriousness of dental
Spreading bacterial infection in different areas of the jaw can vary significantly in
oppose to muscle attachment, tissues of least resistance etc usually dictates the spread
There are acute odontogenic infection which if does not progress or worsen a treatable
by extractions alone, which may allow for spontaneous drainage via the tooth socket
therapy.
The key issue here that needs to be remembered, is that antibiotic alone cannot
But there are group of patients with odontogenic infections when uncontrolled or
Postoperative airway care in severe cases may warrant intensive care or high
increased the length of hospital stay, hospital cost and this issues are a significant
With the significant use of antibiotics and the practice of aggressive surgical therapy,
spreading dentoalveolar infections to the head and neck region are rarely fatal, fatality
But must be remembered that death with uncontrolled infections can occur in fit and
healthy individuals.
reported, 10 patients recovered well and were discharged without major sequelae, but
3 patients died (mortality rate of 23%) of multi-organ failure related to septic shock.
Green et al reported a case of a fit young male patient who died from spreading
But these severe cases of progressive dental infections, the obstruction of the upper
airway remains the most common cause of death to this group of dental patients,
facial space involvement are simple to follow and when promptly adhered to
infections is the establishment of dependent drainage and removal of the dental cause.
As now known Antibiotic therapy alone is not sufficient enough to completely resolve
4. Obtain culture.
appropriate antibiotic therapy significantly will help the management of this sought of
the primary treatment coupled by boaster on the host response with supplementation
of appropriate antibiotics.
infections. 50 patients in the study group in whom both radiographic and sonographic
examination, as well as needle aspiration, were performed. And they did reported that
stage of infections.[39]
Yusa and Yosida et al in their look at ultrasound guided surgical drainage of the face
and neck abscess in which grey-scale and colour Doppler ultrasonography were
combined, they did found that it provided easy detection and accurate, reliable
penetration of the abscess that were difficult locate by physical examination. And they
This avoids the problems of careless surgical drainage, in which the insertion of
instrument in the tissues spaces can result in damage to blood vessel. This technique
is a sound plan for surgical drainage of large facial swelling, making sure that all
spaces are explored and drained. It appears to be a quick and relatively inexpensive,
non-invasive, sensitive, and accessible diagnostic tool for identifying the location and
abscess drainage. They demonstrated in their study that ultrasound provided adequacy
of drainage and helped the surgeon to position the drain in the correct tissue space.
with odontogenic infection with systemic signs and signs of extension of spread of
infections
-In severe infection try to commence on empiric antibiotic therapy with the
effective against anaerobes but has little or no activity against common oral
microbiology and culture sensitivity is plan, but one must not wait for
dealing with is important, the combination here works well against most
infection and on the other hand strict anaerobes susceptible microbes can be
tackled by metronidazole.
insights from[10].
This table shows that penicillins still possesses powerful antimicrobial activity against
But with this result doctors must bare in the emergence of resistance now arising in
lactams.[43]
Cephalosporins are one antibiotic that a commonly used by oral and maxillofacial
surgeons also and this comes different category or generations depending on the
cephosporins like Cefuroxime(Ceftin) are some of the effective choices for those
patient with odontogenic infections and who do not have immediate Hypersensitive
Pathogen Susceptibility %
_____________________________________________________________________
Peptostreptococcus 100%
_____________________________________________________________________
Porphyromonas 100%
_____________________________________________________________________
Fusobacterium 100%
_____________________________________________________________________
PU-penicillin G unsusceptible strains.
This table demonstrated that cefazolin worked well with most of the commonly
infections of suspected microbes and are use frequently by our unit when surgical
_____________________________________________________________________
Pathogen Susceptibility %
______________________________________________
Viridans streptococci 55%
0%
____________________________________________________________________
Peptostreptococcus 89%
80%
_____________________________________________________________________
Porhyromonas 94%
_____________________________________________________________________
Fusobacterium 29%
0%
_____________________________________________________________________
the common microbes in this area of odontogenic infections but does not show its
strains.
efficacy in uncomplicated cases this are simple localised dental infections and
much less gastrointestinal upset[42]. This has shown to have some positive
Clindamycin has proven clinically to have its role in the management of odontogenic
should be considered only as the first line of choice if the patients have had an allergic
reaction to penicillin.
Pathogen Susceptibility %
Peptostreptococcus 100%
_____________________________________________________________________
Fusobacterium 100%
_____________________________________________________________________
This table demonstrated that clindamycin work strongly against all strict anaerobes
pus was obtained on aspiration. Resistance found in this their study showed that
anaerobic isolates were 8.9% with penicillin and 1.9% to clindamycin. They
concluded that penicillin and clindamycin produces similar good results in treating
odontogenic infections.[44]
The most concern in the use of this drug is that it predisposes some patients to the
But this drug, clindamycin also have good intraosseous penetration and particulary
with odontogenic infection destroying the jaws this drug clinically indicated for
Key issue:
Remember when dealing with odontogenic infections, when treated promptly and correctly
resolves quickly but when basic management principles are not followed devastating and life
threatening complication can occur.
1. Clinical Presentations
Acute odontogenic infection or oral and maxillofacial infections usually presents with
signs and symptoms generally of pain, swelling, redness pyrexia, trismus and
difficulty swallowing.
In this section, the sequela of odontogenic infection and anatomy of the fascial spaces
is revised and clinical presentations of odontogenic infections are integrated with the
knowledge reviewed from the literatures and discussion of the peri-operative issues
.
Process of odontogenic infection leading to signs and symptoms are not a process
that occur overnight it is usually an infection process that can take a long course of
The most common and frequently encounted cause of odontogenic infections is dental
caries or tooth decay leading to pulpal death or necrosis and eventually leading to
The other common way for micro-organisms to infect a tooth is via the invasion of the
dental pulp through secondary canals coming from the periodontal ligaments or from
When periapical pathology or infection occur it tend to spread following the path of
least resistance and most commonly will spread within the vicinity of the tooth where
it may perforates the cortical bone toward the subperiosteal membrane with
If infection from the teeth once established on the periapical region of a tooth
infection can subsequently spread away from the tooth and beyond the dentoalveolar
process to distant sites or involving deeper facial tissue spaces.
The understanding of the anatomy of fascial spaces[30, 32, 45-47] is essential for the
diagnosis and treatment of odontogenic infections that had spread to fascial spaces,
because the anatomy or fascial planes of the head and neck is such that it is an
effective barrier to the spread of infection and gives a vital key role to the possible
The process of odontogenic infection, which infection spreads from the teeth or the
periapical region of a tooth and away from the tooth and the dento-alveolar process,
and how the muscular attachments fascia of the jaws guides or directs the passage of
spread of the infectious process into the spaces around the mandible and maxilla and
deep to the cervical spaces of the head and neck Laskin[32] to be the current
Grondinsky and Holyoke work in 1938 where they used dyed gelatin injections to
determine the likely pathway of the spread of infections through the fascial planes,
a brilliant work indeed and it is this work that initially formed the modern
understanding[45].
The most likely pathways of infections arising from each tooth are listed in table 3.
Also find below cross references of some of the fascial and space names used here
Name Synonym
* The space of the body of the mandible is essentially the subperiosteal space formed
by the splitting of the anterior layer of DCF around the body of the mandible. This
subperiosteal space contiues posteriorly to cover the ramus and condyle of the
mandible as well. It contains the mandible, teeth, and inferior alveolar neurovascular
bundle. Infections spreading beyond the periosteum of the mandible immediately
enter the vestibular, buccal, sublingual, submandibular, or masticator space.[33, 46]
Table 3. Relations of Deep Spaces in Infections.
Bridgeman et al, in their study at the Royal Melbourne Hospital in which they
The clinical presentations of the patients in this study demonstrated that all the 107
patients presented with pain, a prevalence of 100% , these are the most common
In most experiences patients neglect intermittent pain and in some cases where the
history of pain is more than 1 week to a month or worse scenario more and this in
most cases patient do not act by seeing a dentist early rather present to a doctor when
the pain is severe or very late in the process of the infection. And in this case the
process of infections could be to late for simple conservative treatment and may
Odontogenic infections can become very painful which is rather a common finding,
This is not just the sensation of mild pain; most are truly in agony when first seen
especially in severe conditions, patients often limit themselves from taking anything
orally or decrease their oral intake, again this varies from patient to patient depending
Patients are obviously and commonly symptomatic in acute conditions, on the other
hand chronic infection with low grade infection and those patients whose had prolong
course of antibiotics and clinically may have a localized swelling and infection,
usually most may complain of the sensation of discomfort rather than pain.
There were 105 patients in Bridgeman et al study who presented with swelling, and a
infection either locally or deep to the cervical tissue space of the neck.
Swelling may be appear well pronounced or be diffuse , thus swelling may be easily
oro-pharynx or upper airway which often difficult to judge from physical examination
alone.
Especially progressing deeper swelling particularly when the patient cannot open the
Facial swelling in particular facial cellulitis were often managed differently in the past
• Cellulitis stage
or
• Abscess stage.
location, host immune status, the virulence of the micro-organism, the region may be
isolated from surrounding tissues by the formation of abscess therefore causing the
walling off the infection preventing further spread. But if these process of walling or
abscess formation fails this can lead to diffuse spread of infection causing severe
inflammation or oedema , termed as cellulitis[42]
The idea of waiting and see while one is able to ascertain abscess formation or
The cellulitis stage often are diffusely presented and they are normally taught warm
and see could result in serious clinical deterioration, and that I believe in a way,
waiting for abscess or fluctuance of deep space infections may be difficult for the
examiner to determine clinically even though an abscess is truly present deeper to the
swelling.
And secondly while waiting for the abscess stage in a more superficial tissue space,
the infection may be progressing to the cellulitis stage that may be involving other
These can result in disastrous situation where the airway can close or other vital
Especially when infection like this can be easily managed and obtaining swift
The feeling among oral surgeons in the past are the incision and drainage of fascial
infections when the swelling is fluctuant. This were in line with Kruger’s view in the
pre-antibiotic era.
Kruger who recommends incision and drainage when pus is diagnosed and states that
treatment in the cellulitis stage of infection may disrupt physiologic boundaries and
facilitate diffusion and extension of the infection. [48]This I believe is true in a sense
and may apply to cases with inadequate antibiotic therapy or no antibiotic is given
especially.
Kruger’s point here was the general feeling in the past around the pre-antibiotic era.
Clinically, now the practice of early incisions and drainage is recommended which
basically aid in the decompression of the swelling and prevent the progress of
On the other hand as discussed earlier, Goldberg and Topazian state that incision and
These again are issues in which complications that a avoidable, and best achieve if
But now the general feeling of most oral and maxillofacial surgeons that is now
practiced in most industrialize countries and particularly in this institution are the
early admission, removal of the cause and incision and drainage of all acute
odontogenic infection with associated tissue space involvement and the administration
Flynn in his paper[13] referred to Conover and Donoff, study in which they reviewed
175 hospital admissions for facial infection, proposed a policy of early admission and
incision and drainage for febrile patients with “significant clinical signs.”[50]These is
The “wait and see” management, is not recommended by most surgeons, an old wise
adage “never let the sun set on an undrained abscess (PUS)”. This is as true
The statement above means if facial infection is diagnosed with associated swelling
either cellulitis or abscess of tissues spaces, early removal of the cause and wide
Literatures has revealed that the most common cause of death in odontogenic
Potter et al compared the costs and outcomes for patients with deep neck infections
who were treated with either tracheotomy or endotracheal intubation, this were 85
In this study 2 patients died, one patient died as a result of unplanned extubation and
This patient demonstrated sufficient air leak around the endotracheal tube and was
reintubate the trachea were unsuccessful due to obstruction and this was confirm
preoperatively persist postoperatively and both the surgeon and the anaesthetist
must work together planning the timely fashion to keep the patients with severe
Though clinical signs such as air leak around the cuff must be carefully
evaluated and enough time given for more air leak which would demonstrate
significant decrease of the airway swelling as we can see from Potter el. Study that
the second patient died 30 minutes later after extubation despite air leak.
c. Pyrexia.
Generally patients with acute bacterial infections may presents with fever, an
to see patient also not to have fever or pyrexic even though there is an obvious
This in general are caused by pyrogens which bring about the fever and this pyrogens
literature are the most common reasons for fever in a proportion of our patients with
bacterial infection act by causing elevation of the set point of the hypothalamic
Fever associated with bacterial infection of the head and neck generally resolved
within 24hrs postoperatively if the patients was carefully examined preoperatively and
Odontogenic infections that has spread to distant sites or to deep cervical tissues of
the neck and that continue to show signs of fever must be carefully examined and
microbiology, culture and sensitivity followed up and the cause identified and
rectified.
These are some of the factors that a worth reminded or to be considered when
d. Trismus
inability to open the mouth fully, that could result especially if bacterial infection
Forty nine patients in Bridgeman et al. study had trismus and a prevalence of forty
six per cent. This is a significant number of patients, patients with trismus always
presents difficulty to both the surgeon and especially to the anaesthetist in the
This raises the issue whether to extubate the patient early or keep patient intubated
postoperatively, especially when concern for upper airway or uncertainty arises, or the
risk is raised if the patient is extubated and not able to re-intubate the patient again
patient as firstly the airway can be lost, secondly if the are not careful about their
technique for intubation this can cause rupture of the abscess orally and could lead to
aspiration, if one is not aware which in turn could lead to aspiration pneumonia as the
Uram and Hauser reported a case of traumatic intubation resulted in a severe, wide
spread neck infection.[52] Though the intubation in Uram and Hauser case was an
related patients certainly in this case high light an issue that is worthwhile thinking
or laryngeal trauma resulting in laryngeal stenosis these can always in turns cause
obstruction of the upper airway and as we have seen in the literatures a significant
The anaesthetist and the surgeon must always remember that the difficulty of
intubating a patient with trismus at surgery remains after surgical treatment and this
adequate time for the infection to resolve and sufficient time be given before
And together both the anaesthetist and the surgeon must agree on the timely
fashion for extubation and also experience anaesthetist and senior surgeon must
always be in the mind of both the teams involved, especially the presence of
Nothing replaces a good oral and maxillofacial diagnosis and treatment planning
when a clinician first come in contact with this group of patients and this is formed
from the collated information collectively derived from a comprehensive history and
This early contact with the patient the must remember the signs and symptoms of
severe infection that could lead to airway compromise, distant spread and septic state.
These are all vital information that lead to a successful management of patients, that
as indicated in Bridgeman et al. results, many patients had sought treatment from
dentists, and that a large proportion of patients had received sub-optimal management
prior to referral.
Forty seven per cent of patients had actually received initial treatments, the common
These pre-referral features are consistent with experience in this state oral and
maxillofacial unit.
Most issues that can be deduced from the literature review in relation to patients with
inadequate management etc brings the issues on the medico legal aspects[53] of
infections though rarely we have this patiens taking legal actions on the treating team,
but these are important issues that needs to be pointed out to treating and referring
Find next are some of the clinical key presentations of patients with odontogenic
infections presenting to medical practitioners to identify and refer cases that can be
managed by Dentists and those that require direct referral to the specialist Oral and
Medical
Practitioners
Diagnosis
NO YES
Slight modification of decision making flow diagram as adapted from Brigeman et al.
Toothache
Dentist
If Not treated
Restoration
of the tooth
Root filling
Removal of
the tooth.
Requires
surgery. If severe can die or can suffer major
life threatening complication.
Cut to the
neck +- Airway obstruction
Descending mediastinistis
Pleural empyema
Intensive Care can be prolong, & Pericarditis
stressful to patient & relatives.
This is a very expensive journey.
Jugular vein thrombosis
Carotid rupture
Carotid pseudoaneurysm.
This flow diagram on the outcome of untreated toothache can result in severe
odontogenic infections if not treated early by a dentist or if the cause of the infections
is quick as known that process of odontogenic infections can be very unpredictable
from slow progressing swelling to rapid growth of the swelling and this situation the
attention, the identification of the problem and referral directly to the unit for
management.
Because simple dental infections if not treated adequately or neglected can result in
Really needs the care of the oral and maxillofacial surgeons, therefore
prompt referral and treatment is the essence.
1. Topazian, R.G., M.H. Goldber, and J.R. Hupp, Oral and Maxillofacial
2. Ariji, Y., Gotoh, M., Kimura, Y. Naitoh, M., Kurlta, K., Natsume, N., Ariji, E.
712-7.
4. Juang, Y.C., Cheng, D.L., Wang, L.S., Liu, C.Y., Duh, R.W., Chang, C.S.
121-5.
5. Huang, T.T., Liu, T.C., Chen, P.R., Tseng, F.Y., Yeh, T.H., Chen, Y.S. Deep
microbiology and current treatment. Oral Surg Oral Med Oral Pathol, 1990.
70(2): p. 155-8.
p. 285-9.
10. Kuriyama, T., Karasawa, T., Nakagawa, K., Saika, Y., Yamamoto, E.,
isolates from orofacial odontogenic infections. Oral Surg Oral Med Oral
11. Sakamoto, H., Kato, H., Sato, T., Sasaki, J. Semiquantitative Bacteriology of
closed odontogenic abscess. Bull Tokyo Dent Coll, 1998. 39(2): p. 103-7.
12. Heimdahl, A., Von Konow, L,. Satoh, T., Nord, C.E. Clinical appearance of
13. Flynn, T.R., Odontogenic Infections. Oral and Maxillofacial Surgery Clinics
14. Peterson, L.J., Microbiology of Head and Neck Infections. Oral and
17. Furst, I.M., P. Ersil, and M. Caminiti, A rare complication of tooth abscess--
Ludwig's angina and mediastinitis. J Can Dent Assoc, 2001. 67(6): p. 324-7.
18. Hought, R.T., Fitzgerald, E.E., Latta, J.E. Ludwig's angina: Report of two
cases and review of the literature from 1945 to January 1979. J Oral Surg,
19. Patterson, H.C., J.M. Kelly, and M. Strome, Ludwig's angina: an update.
20. Zachariades, N., Mezitis, M., Stavrinidis, P., Agouridaki, E.K. Mediastinitis,
21. Feldman, D.P., N.A. Picerno, and E.S. Porubsky, Cavernous sinus thrombosis
22. Beck, H.J., Salassa, J.R., Mc Caffey, T. Life threatening soft tissue infections
23. Levine, T.M., C.F. Wurster, and Y.P. Krespi, Mediastinitis occurring as a
24. Corson, M.A., K.P. Postlethwaite, and R.A. Seymour, Are dental infections a
cause of brain abscess? Case report and review of the literature. Oral Dis,
25. Green, A.W., E.A. Flower, and N.E. New, Mortality associated with
26. Papalia, E., Rena, O., Oliaro, A., Giobbe, R., Casadio, C., Maggi, G.,
30.
28. Wong, T.Y., Huang, J.S., Chung, C.H., Chen, H. A. Cervical Necrotizing
29. Haug, R.H., M.J. Hoffman, and A.T. Indresano, An epidemiologic and
p. 976.
31. Waite, D.E., Textbook of Practical Oral and Maxillofacial Surgery. Third
Edition ed.
33. Granite, E.L., Anatomic considerations in infections of the face and neck:
study. Oral Surg Oral Med Oral Pathol, 1985. 59: p. 28.
35. Krishnan, V., J.V. Johnson, and J.F. Helfrick, Management of maxillofacial
1297 - 1299.
37. Miller, E.J., Jr. and T.B. Dodson, The risk of serious odontogenic infections in
HIV-positive patients: a pilot study. Oral Surg Oral Med Oral Pathol Oral
39. Peleg, M., Heyman, Z., Ardekian, L., Taicher, S. The Use of Ultrasonography
40. Yusa, H., Yoshida, H., Ueno, E., Onizawa, K., Yanagawa, T. Ultrasound-
guided surgical drainage of face and neck abscesses. Int J Oral Maxillofac
41. Thiruchelvam, J.K., A.K. Songra, and S.Y. Ng, Intraoperative ultrasound
imaging to aid abscess drainage--a technical note. Int J Oral Maxillofac Surg,
42. Baker, K.A. and P.G. Fotos, The management of odontogenic infections. A
rationale for appropriate chemotherapy. Dent Clin North Am, 1994. 38(4): p.
689-706.
43. Kuriyama, T., Nakagawa, K., Karasawa, T., Saiki, Y., Yamamoto, E.,
odontogenic infections. Oral Surg Oral Med Oral Pathol Oral Radiol Endod,
1065-70.
45. Grodinsky, M. and E.A. Holyoke, The Fasciae and Fascial Spaces of the
Head, Neck, and adjacent regions. American Journal of Anatomy., 1938. 63:
p. 367-408.
46. Flynn, T.R., Anatomy and surgery of deep fascial space infections of the Head
and Neck, in Oral and Maxillofacial Surgery Knowledge Update. 1994. p. 79-
107.
47. Flynn, T.R., Anatomy of Oral and maxillofacial Infections, in Oral and
48. Kruger, G.O., Textbook of Oral and Maxillofacial Surgery,. ed 6 ed. 1986: CV
Mosby.
49. Topazian, R.G. and M.H. Goldberg, Oral and Maxillofacial Infections.(ed 2).
50. Conover, M.A. and R.B. Donnoff, Facial Infections. A review of 175
Abstracts., 1983(September): p. 1.
51. Potter, J.K., A.S. Herford, and E. Ellis, 3rd, Tracheotomy versus endotracheal
52. Uram, J. and M.S. Hauser, Deep neck and mediastinal necrotizing infection