What is an oro-facial infection?
Oro-facial infection refers to an infection that affects the oral and facial region. It may lead to airway compromise or sepsis, which are both potentially life-threatening. Fortunately, the morbidity and mortality rates of odontogenic infections have dropped significantly over the past 50 years, largely attributed to the advancements in health standards of the general population and improvements in medical care.
The head and neck region has several potential fascial spaces which may develop in the presence of an infection. These 'spaces' are potential areas and do not exist in healthy individuals. Infections tend to spread along planes of least resistance and can progress from superficial to deep spaces.
These anatomical spaces can be stratified into different levels of risk:
- Low risk: vestibule, infraorbital/canine, buccal
- Moderate risk: submandibular, submental, sublingual, pterygomandibular, submasseteric, temporal
- High risk: lateral pharyngeal, retropharyngeal, pretracheal
- Extreme risk: mediastinum, intracranial
Sources of infection:
Odontogenic: dental caries, periapical abscesses, gingivitis/periodontitis, peri-implantitis, and pericoronitis around wisdom teeth
Non-odontogenic: salivary gland, tonsil, sinus, ear, lymph node, skin
You may experience the following signs and symptoms:
- Fever and chills
- Facial swelling and pain
- Inability to open the mouth (trismus)
- Difficulty in swallowing (dysphagia)
- Pain when swallowing (odynophagia)
- Breathing difficulty with inspiratory stridor
Why should I seek treatment?
Prompt treatment of oro-facial infections is required to prevent the further spread of infection into the high-risk space, which can be fatal.
An example of a severe oro-facial infection is Ludwig's angina, a fast-spreading and frequently lethal infection of the soft tissues of the neck and floor of the mouth. This condition is synonymous with compromised airway and warrants urgent management at the Accident and Emergency department. Fortunately, patients who get prompt treatment recover fully in this day and age.
A young child with diffuse swelling in his neck and floor of the mouth, forcing his tongue upwards and closing off the airway. (Pokrovska T, et al. Arch Dis Child 2016;101:539–545)
A less severe but common clinical scenario includes inflammation and infection of the gums around a partially erupted wisdom tooth. If left untreated, it can progress to the spread of infection, which usually erodes through the thin bone into the submandibular space and produces a red, painful swelling just under the lower jaw.
What are the treatment options?
Management of oro-facial infections is guided by the 8 main principles*:
- Determine severity of infection: anatomic location, rate of progression, and airway compromise
- Evaluation of host factors: immunocompromise and systemic reserve of the patient
- Evaluate need for hospitalization - fever, dehydration, need for general anaesthesia, deep space infection, or control of systemic disease
- Treat surgically
- Support medically
- Appropriate antibiotic therapy
- Administer antibiotic properly
- Frequent evaluation of the patient
*Source: Flynn T. Principles of management of odontogenic infections. In Miloro M, Ghali G E, Larsen P, Waite P (eds) Peterson's principles of oral and maxillofacial surgery. 3rd ed. Beijing: PMPH, 2012
Healthy and well patients with infections in low-risk spaces can be treated in the outpatient setting, while infections of higher risk spaces may need more aggressive management in a hospital.
Investigations like computed tomography with intravenous contrast are the imaging modality of choice for diagnosing deep neck space infection. Other investigations include blood tests like full blood count and swab of the pus for culture to determine the bacterial profile and sensitivity testing to ascertain the appropriate antibiotics.
Patients with oro-facial infection usually receive antibiotics, painkillers and anti-inflammatory medications. If aspiration or surgical drainage is indicated, arrangements will be made to perform the procedure under general anaesthesia or local anaesthesia.
A tube (drain) may be inserted into the surgical wound to keep the wound open and disrupt bacterial growth. The tube will be removed after a few days. Patients may be discharged or hospitalized for monitoring, depending on the severity of the infection and the health of the individual.
What to expect after treatment?
Patients with an oro-facial infection will be reviewed closely until the infection is resolved.