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).

Microbiology
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.

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):
Periodontitis
Acute
Chronic
Periostitis
Osteomyelitis
Sinusitis
Abscess and flegmons
Lymphadenitis

ODONTOGENIC INFECTION (GENERAL STUDY)

Clinical Features (Signs and Symptoms)

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

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

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 periodontitis

Usualy 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.

Chronic granular periodontitis

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 granulomatous periodontitis

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.

Then the bone here is resorped , it will be replaced by:

granulation tissue ,
young fibroblasts ,
blood vessels ,
inflammatory cells ,
collagen fibers ,

X-ray investigation:

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 .

Periostitis
Periostitis: 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 periostitis
After 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 its 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 disturbance
Local 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

Treatment
Conservative 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).

Chronic periostitis.

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.

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.

Classification

Jaws Osteomyelitis can be: non-specific - odontogenic

(stomatogenic), traumatic, toxic, hematogenic and
specific.
Three phases (periods) of disease course: acute, subacute and chronic.
Chronic form: productive hyperplastic processes or
destructive processes (Rarefying form or Sequestrate
form)
Depending on affected area: Localized, Diffuse

Diffuse Osteomyelitis
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.

General signs:
Diffuse pain, pulsatile, irradiance
Fever (39-40C)
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.