What are the key anatomical features of the submasseteric space. How is a submasseteric abscess diagnosed and treated. What are the radiologic characteristics of this rare jaw infection. What causes submasseteric abscesses and how can they be prevented.

Understanding the Anatomy of the Submasseteric Space

The submasseteric space, first described by Bransby-Zachary in 1948, is a crucial anatomical feature in understanding jaw infections. This space is formed by the division of the masseter muscle into three parts: superficial, middle, and deep. Each part originates from the zygomatic arch but inserts at different points on the mandible.

• Deep portion: Inserts on the lateral surface of the coronoid process and upper third of the mandibular ramus
• Superficial portion: Attaches to the lower third of the ramus, particularly at the angle of the mandible
• Middle portion: Inserts along a thin, curved line over the middle third of the ramus

This anatomical arrangement creates a potential space between the muscle layers, which can become a site for abscess formation. While some researchers, like MacDougall, couldn’t find a discrete submasseteric space in cadaver studies, they did note an area of loose attachment between the middle and deep layers that could serve as a pathway for infection spread.

Causes and Development of Submasseteric Abscesses

Submasseteric abscesses are rare but potentially serious infections that can develop in the jaw region. They typically result from untreated dental problems or infections that spread from nearby structures. Common causes include:

• Untreated dental cavities
• Pericoronitis (infection around a partially erupted wisdom tooth)
• Spread of infection from other facial spaces
• Trauma to the jaw or surrounding tissues

When a dental infection is left untreated, bacteria can proliferate and form an abscess. In some cases, this infection can track posteriorly along the mandible and become sequestered in the submasseteric space, leading to abscess formation.

How does a submasseteric abscess develop?

The development of a submasseteric abscess typically follows this progression:

1. Initial infection occurs, often in a posterior molar
2. Infection spreads along tissue planes
3. Bacteria enter the potential space between masseter muscle layers
4. Pus accumulates, forming an abscess
5. Surrounding tissues become inflamed and swollen

Clinical Presentation and Symptoms of Submasseteric Abscesses

Recognizing the symptoms of a submasseteric abscess is crucial for early diagnosis and treatment. Patients with this condition may experience:

• Severe pain in the jaw or cheek area
• Difficulty opening the mouth (trismus)
• Swelling of the face, particularly over the masseter muscle
• Fever and general malaise
• Difficulty swallowing
• Redness and warmth of the overlying skin

It’s important to note that these symptoms can be similar to other jaw-related conditions, making accurate diagnosis challenging. Therefore, a thorough clinical examination and appropriate imaging studies are essential for proper identification of submasseteric abscesses.

Diagnostic Approaches for Submasseteric Abscesses

Diagnosing a submasseteric abscess requires a combination of clinical evaluation and imaging techniques. While the clinical presentation can be suggestive, imaging plays a crucial role in confirming the diagnosis and determining the extent of the infection.

Clinical Examination

A thorough clinical examination is the first step in diagnosing a submasseteric abscess. The dentist or oral surgeon will:

• Assess facial swelling and tenderness
• Evaluate the patient’s ability to open their mouth
• Check for signs of dental infection or recent dental procedures
• Palpate the affected area to detect fluctuance (a sign of fluid collection)

Imaging Studies

Various imaging modalities can be employed to diagnose and characterize submasseteric abscesses:

1. Computed Tomography (CT): CT scans are particularly useful in identifying the extent of the infection and any associated bone involvement. However, it’s important to note that in some cases, CT may not clearly show a fluid collection despite the presence of an abscess.
2. Magnetic Resonance Imaging (MRI): MRI can provide detailed soft tissue imaging, which may be helpful in delineating the abscess and surrounding anatomical structures.
3. Ultrasound: While less commonly used, ultrasound can be helpful in identifying fluid collections and guiding aspiration procedures.
4. Panoramic radiographs: These may be used to evaluate dental pathology that could be the source of infection.

It’s worth noting that despite the absence of a clearly defined fluid collection on imaging, the presence of pus may still be confirmed during surgical drainage. This highlights the importance of correlating imaging findings with clinical presentation and surgical exploration when necessary.

Treatment Strategies for Submasseteric Abscesses

The management of submasseteric abscesses typically involves a combination of surgical intervention and antibiotic therapy. The primary goals of treatment are to eliminate the infection, prevent its spread, and restore normal function.

Surgical Drainage

Surgical drainage is the cornerstone of treatment for submasseteric abscesses. This procedure involves:

• Making an incision to access the abscess cavity
• Evacuating the purulent material
• Establishing drainage to prevent reaccumulation of pus
• Obtaining samples for culture and sensitivity testing

The approach for drainage can be intraoral or extraoral, depending on the location and extent of the abscess. In some cases, a combination of approaches may be necessary for complete drainage.

Antibiotic Therapy

Antibiotics play a crucial role in managing submasseteric abscesses. The choice of antibiotic should be based on the likely causative organisms and adjusted according to culture results. Common antibiotic regimens include:

• Empiric broad-spectrum antibiotics (e.g., amoxicillin-clavulanate, clindamycin)
• Targeted therapy based on culture and sensitivity results
• Prolonged course of antibiotics (typically 7-14 days)

Adjunctive Measures

Additional treatments may include:

• Pain management with analgesics
• Warm compresses to promote drainage and reduce swelling
• Oral hygiene instructions to prevent recurrence
• Treatment of underlying dental pathology (e.g., tooth extraction, root canal therapy)

Complications and Prognosis of Submasseteric Abscesses

While submasseteric abscesses are generally treatable, they can lead to serious complications if not managed promptly and appropriately. Potential complications include:

• Spread of infection to adjacent spaces (e.g., parapharyngeal, retropharyngeal)
• Airway compromise due to severe swelling
• Sepsis
• Osteomyelitis of the mandible
• Trismus (limited mouth opening) persisting after treatment

With proper treatment, the prognosis for submasseteric abscesses is generally good. Most patients recover fully within 2-4 weeks of treatment initiation. However, long-term follow-up may be necessary to ensure complete resolution and to address any underlying dental issues that may have contributed to the abscess formation.

What factors influence the prognosis of submasseteric abscesses?

Several factors can affect the outcome of treatment for submasseteric abscesses:

• Timeliness of diagnosis and treatment initiation
• Extent of the infection at the time of diagnosis
• Patient’s overall health and immune status
• Presence of antibiotic-resistant bacteria
• Adherence to prescribed treatment regimen

Prevention and Management of Recurrent Submasseteric Abscesses

Preventing submasseteric abscesses and managing the risk of recurrence involves addressing the underlying causes and maintaining good oral health. Key preventive measures include:

• Regular dental check-ups and cleanings
• Prompt treatment of dental caries and periodontal disease
• Proper oral hygiene practices
• Timely management of impacted or partially erupted wisdom teeth
• Addressing any systemic conditions that may increase infection risk

For patients who have experienced a submasseteric abscess, follow-up care is crucial to prevent recurrence. This may involve:

1. Comprehensive dental evaluation to identify and treat potential sources of infection
2. Regular monitoring for signs of recurrent infection
3. Patient education on recognizing early symptoms of abscess formation
4. Consideration of prophylactic antibiotics for high-risk dental procedures in some cases

By implementing these preventive strategies and maintaining vigilant follow-up care, the risk of developing or experiencing recurrent submasseteric abscesses can be significantly reduced.

Advances in Research and Future Directions

While submasseteric abscesses are relatively rare, ongoing research continues to improve our understanding of their pathogenesis, diagnosis, and treatment. Some areas of current interest and potential future developments include:

• Improved imaging techniques for early detection of small abscesses
• Development of minimally invasive drainage procedures
• Investigation of novel antibiotic delivery methods to improve treatment efficacy
• Studies on the microbiology of submasseteric abscesses to guide targeted antibiotic therapy
• Research into genetic factors that may predispose individuals to dental infections and abscess formation

As our understanding of submasseteric abscesses evolves, we can expect to see more refined diagnostic criteria, improved treatment protocols, and potentially new preventive strategies. Continued collaboration between dental professionals, radiologists, and researchers will be crucial in advancing our ability to manage this challenging condition effectively.

How might future research impact the management of submasseteric abscesses?

Future research could lead to several improvements in the management of submasseteric abscesses:

1. More accurate and rapid diagnostic tools, potentially including point-of-care testing for specific pathogens
2. Tailored antibiotic regimens based on individual patient factors and local resistance patterns
3. Advanced imaging techniques that can better differentiate between abscess and surrounding inflammation
4. Novel surgical approaches that minimize tissue damage and promote faster healing
5. Improved understanding of the factors that contribute to abscess formation, leading to more effective preventive strategies

These advancements could potentially lead to earlier diagnosis, more targeted treatments, and better outcomes for patients with submasseteric abscesses. As research progresses, we may see a shift towards more personalized approaches to managing this condition, taking into account individual patient factors and specific characteristics of the infection.

Jaw-Related Conditions | Division of Oral and Maxillofacial Surgery and Dentistry at Johns Hopkins

General dentists and specialized dental practitioners and physicians treat conditions that affect the jaw, as well as the head and neck. Our team typically works in a multidisciplinary manner so that different oral care specialists can discuss and collaborate on the best possible approach to treatment. 

Jaw-related Conditions We Treat:

• Jaw Trauma can be caused by any number of injuries and accidents. Reconstruction of the jaw is managed by several different types of doctors including dentists, otolaryngologists (ear, nose and throat specialists), oral surgeons and facial plastic surgeons. Our dentists understand the importance of the overall appearance of the mouth to a person’s cosmetic appearance, as well as their self-esteem, and work with surgeons to reconstruct function as well as cosmetic appearance. Learn more about jaw-related treatments.
• Jaw deformities are corrected using a variety of orthodontic and surgical techniques. Understanding the importance of the jaw to a person’s overall cosmetic appearance and self-confidence, our dentists work with other specialists, including facial plastic surgeons and otolaryngologists (ear, nose and throat doctors) to restore the jaw to full functionality, as well as a pleasing cosmetic result. Learn more about jaw-related treatments.
• Jawbone infections/dental abscesses are caused when a dental cavity remains untreated. Bacteria can form and cause an infection. If it is not treated immediately, the infection can travel into the jawbone and cause serious health issues. Symptoms of a jaw bone infection or dental abscess include:
  • Pain in the mouth or jaw
  • Redness or swelling
  • Drainage of pus from the area

You should seek immediate dental attention for an abscess. Your dentist will try to drain the infection and will probably prescribe antibiotics. In severe cases, the tooth may need to be pulled or surgery performed to stop the infection from spreading further into the bones. Learn more about jaw-related treatments, including oral surgery.

• Osteonecrosis /osteoradiodonecrosis of the jaw occurs when the bones lose their blood supply, or when they are damaged because of radiation during cancer treatment. Learn more about dental oncology.

Chronic Submasseteric Abscess: Anatomic, Radiologic, and Pathologic Features

Anatomy

In 1948, Bransby-Zachary (1) first described the submasseteric space. In an effort to explain normal explorations of suspected parotid infections, he undertook cadaveric dissections. Previously, the masseter was said to have a broad, continuous insertion on the lateral aspect of the ramus of the mandible, but he found a bare area between separate attachments of deep and middle portions of the masseter muscle resulting in a potential space. Infection from a posterior molar could track posteriorly and become sequestered there as an abscess, thereby explaining the clinical findings.

The submasseteric space, a subdivision of the masticator space (2–4), results from a division of the masseter muscle into three parts: superficial, middle, and deep. All three parts originate on the zygomatic arch. Bransby-Zachary found that the insertion of a small, deep portion was limited to the lateral surface of the coronoid process and upper third of the ramus of the mandible. Insertion of the largest, superficial portion was restricted to the lower third of the ramus, especially posteriorly at the angle of the mandible. The middle portion was the smallest and inserted along a thin line curving posteriorly and superiorly over the middle third of the ramus (Fig 6) (1).

Fig 6.

Original drawing by Bransby-Zachary illustrating the insertions of the masseter (reproduced with the permission of British Dental Journal 1948; 84:10–13).

Although MacDougall (5, 6) dissected 141 cadavers and could not find a discrete submasseteric space, he reported an area of loose attachment between the middle and deep layers of the muscle that could present an incomplete barrier to infection and thereby provide a potential space for abscess formation. The presence of such a potential space along the ramus of the mandible between the insertions of the masseter muscle has been confirmed by one of the authors (L.M.) (Fig 6).

Imaging Characteristics

Although to our knowledge there are no reported cases of infection beneath the masseter muscle in the radiologic literature (2, 3, 7–10), there are many such reports in the dental and otolaryngologic literature (5, 11–17). In these, the anatomic and clinical aspects of the disease are well described, but the radiologic manifestations are not. Analysis of our cases revealed several radiologic findings that we believe are suggestive or specific for this entity.

In the four patients who underwent CT examination, no definite fluid collection was identified despite pus being drained at surgery. These patients had episodic pain and swelling for a period of weeks up to 18 months. No fluid collection was seen on the noncontrast examinations. On postcontrast studies, one failed to reveal a discrete collection (Fig 5A), the second showed a small low-attenuation area without enhancement along the mandible that could possibly represent a phlegmon or an abscess (Fig 3), and the third showed a definite abscess with rim enhancement 1 year after the patient’s initial presentation (Fig 1B). Several other studies (3, 8, 9, 13, 14, 17) have failed to show a definite fluid collection despite such a finding at subsequent surgery. Thus, the absence of rim enhancement may suggest a phlegmon, but the presence of pus at the time of surgery confirms that CT findings may be falsely negative even with administration of contrast material. In our series, this may be due to the chronic nature of the infections and resultant increased attenuation of the pus that is isoattenuated relative to muscle.

In addition, partial treatment with antibiotics may contribute to the chronic nature of the condition by amelioration of systemic symptoms (ie, local infection may persist, unrecognized in a protected site, and progress to a chronic phase [5, 11, 12] without surgical drainage [15]). Such partial treatment may account for the typical absence of systemic signs and symptoms at the time of clinical presentation (5, 8). Instead, there is usually firm, relatively painless, nonfluctuant facial swelling with progressive trismus (13–15) that may mimic parotitis or tumor (8, 15). Concomitantly, the usual radiologic signs of acute infection, such as rim enhancement and infiltration of adjacent tissue planes, are rarely apparent on CT images.

Diffuse swelling of the overlying masseter or myositis was present in each case in our series and explains the symptom of trismus. The CT examination also showed sclerosis of the underlying mandibular ramus, first described by Mandel (11), in every case. Although this finding is suggestive of osteomyelitis, only one of our patients developed clinical signs of osteomyelitis following surgical drainage of the abscess. However, findings of myositis and bony sclerosis, when seen together on CT images, should suggest the presence of an infectious process.

MR imaging was obtained in two of our cases. In patient 5, the MR imaging showed a definite fluid collection beneath the right masseter muscle despite a postcontrast CT image that failed to show such an abscess (Fig 5A). Patient 4, who did not undergo CT, had MR findings demonstrating an obvious collection beneath the right masseter with abnormally low signal intensity of the underlying mandibular ramus (Fig 4C). This was our only surgically unconfirmed case. The patient was treated with multiple courses of antibiotics and continued to experience periodic facial swelling. We believe this represents a submasseteric abscess. Neither patient received intravenous gadolinium before imaging.

In the head and neck, CT plays a primary role in differentiating cellulitis from abscess and in guiding surgical drainage (3). However, the superior soft-tissue contrast offered by MR imaging provides improved visualization and differentiation of masses and inflammatory changes compared with that of CT (18). Because CT has failed to differentiate between different masseteric masses, it has been predicted that MR imaging will become the dominant technique for evaluation of this region as availability of MR systems improves (10).

Because MR imaging relies on T1 and T2 relaxation instead of attenuation of ionizing radiation to generate contrast, MR imaging is more sensitive to chronic fluid collections that are unapparent or uncertain on CT. We found MR imaging provided markedly improved definition of the abscess in one case in which both CT and MR imaging were performed (Fig 5A and B), and MR findings were clearly positive in the other case in which CT findings were not available (Fig 4B). In the case report by Fielding and colleagues (17), a medial masticator space abscess was unapparent on CT but easily visualized on MR images. We believe that MR imaging is underused for evaluation of this region and may be preferable to CT as an imaging technique.

Dental Abscess – an overview

Glomerulonephritis Associated with Other Bacterial Infections

Osteomyelitis and intra-abdominal, pelvic, pleural, and dental abscesses can be associated with GN. Infection is usually present for several months before it is diagnosed. Renal disease may vary from mild urinary abnormalities to rapidly progressive GN, but the most frequent presentation is nephrotic syndrome. Unlike with other infection-associated GN, complement levels are often normal. Renal histology reveals MPGN, diffuse proliferative GN, or mesangial proliferative GN. Crescents may be present. Antibiotic treatment may result in recovery of renal function if it is started early.

Congenital and secondary (or early latent) syphilis may be associated with GN. In congenital syphilis, patients present with anasarca 4 to 12 weeks after birth. Nephrotic syndrome occurs in 8% of the patients and may be the primary clinical manifestation (as opposed to the more classic triad of rhinitis, osteochondritis, and rash). In acquired syphilis, renal involvement occurs in 0.3% of all patients. Adults present with nephrotic syndrome or occasionally with an acute nephritic picture. Serologic test results for syphilis are positive (rapid plasmin reagin, VDRL, and fluorescent treponemal antibody absorption test). MN is the most common renal pathologic process, but diffuse proliferative GN with or without crescents, MPGN, and mesangial proliferative GN have also been observed. Treponemal antigens have been identified in the immune deposits. Syphilitic GN responds to antibiotic treatment, although remission may not occur for 4 to 18 months.

Acute typhoid fever from Salmonella typhi is characterized by fever, splenomegaly, and gastrointestinal symptoms. Severe cases may develop shock and acute renal failure as a part of disseminated intravascular coagulation or hemolytic-uremic syndrome, but these complications are rare. Overt mesangial proliferative GN occurs in 2% of the cases (Fig. 55.5), but microscopic hematuria and mild proteinuria may be present in 25% of the cases.²⁵ Diagnosis requires the culture of the organisms from blood or stools or rising antibody titers in the Widal test. GN may also occur in patients with schistosomiasis and coexisting Salmonella infection of the urinary tract (see Chapter 54).

Leprosy (Mycobacterium leprae infection) may be associated in autopsy studies with GN (5% to 14% of the cases), interstitial nephritis (4% to 54%), or amyloidosis (4% to 31%). ²⁶ GN is manifested clinically in less than 2% of the patients. It remains controversial whether GN is more common in lepromatous leprosy than in tuberculoid leprosy. Urinary abnormalities consistent with GN often accompany episodes of erythema nodosum leprosum. Clinical manifestations are of nephrotic syndrome, less frequently of acute nephritic syndrome, and rarely of rapidly progressive GN. MPGN or diffuse proliferative GN with IgG, C3, IgM, IgA, and fibrin deposits is present on biopsy. Response of glomerular disease to treatment of leprosy is variable. Amyloidosis with nephritic syndrome may also rarely occur, especially in lepromatous leprosy. Other renal abnormalities associated with leprosy include interstitial nephritis. Prednisolone (40 to 50 mg/day) has been used in short courses to treat erythema nodosum leprosum associated with GN.

Pneumococcal pneumonia may rarely be associated with microhematuria and proteinuria, especially if treatment is delayed. Both diffuse proliferative GN and mesangial proliferative GN have been reported, and pneumococcal antigen is present in the immune deposits. Rarely, pneumococcal pneumonia can also be associated with hemolytic-uremic syndrome as a result of unmasking of the Thomsen-Friedenreich antigen in glomeruli by pneumococcal neuraminidase, which then allows preformed antibodies to bind and to elicit an immune response.

Gastroenteritis due to Campylobacter jejuni may be associated with mesangioproliferative or diffuse proliferative GN. GN may also occur with other bacterial infections, including those with E. coli, Yersinia, meningococcus, and Mycoplasma pneumoniae.

Ewing sarcoma of the mandible mimicking an odontogenic abscess – a case report | Head & Face Medicine

Four weeks before admission a 24-year-old man noticed a swelling in the right floor of the mouth. Assuming that the tumour was an acute dental abscess the attending dentist incised the tumour and prescribed antibiotics. A temporary decline of the symptoms was noted and root channel treatment, root amputation and splinting of the teeth 43 – 45 due to negative sensibility and loosening was performed. However, the pathologic process of the right mandible enlarged constantly and the patient was referred to our department three weeks after initial treatment.

On admission the patient was in good general condition. Body temperature was normal, blood examination showed elevated CRP (7.92 mg/l) and regular leucocyte count (8.71/nl). Physical examination revealed an asymmetric swelling of the right mandible with inconspicuous overlaying mucosa and skin (fig. 1, 2). The tumour was solid, slightly painful, well-circumscribed and measured 7 cm in diameter. Hypaesthesia was evident in the right lower lip. The teeth 32–46 were loosened and showed negative sensibility. A panoramic radiograph taken two weeks before by the attending dentist showed a diffuse radiolucency with ill-defined borders located in the right mandibular corpus (fig. 3). Additional CT-, MRI- and PET-scans confirmed the osteolytic mass with extensive soft tissue infiltration but without evidence of metastatic disease (fig. 4, 5, 6).

Figure 1

Photograph at initial examination showing a submanibular swelling on the right side.

Figure 2

Intraoral photograph taken at initial examination showing the tumour mass coming from the mandible and infiltrating the gingiva as well as the floor of the mouth.

Figure 3

Panoramic radiograph, taken two weeks before presentation by the attending dentist, showing an osteolytic process in the right mandible and the teeth 43–45 after root channel treatment and root amputation.

Figure 4

Axial MRI scan revealing a bone destroying mass of approximately 7 × 8 × 6 cm
³surrounding the mandible and massively infiltrating the soft tissue of the floor of the mouth and the tongue.

Figure 5

Coronal MRI scan revealing a bone destroying mass of approximately 7 × 8 × 6 cm
³surrounding the mandible and massively infiltrating the soft tissue of the floor of the mouth and the tongue.

Figure 6

a, b: Radionuclid (FDG) enhancement in the right floor of the mouth expanding over the midline. No further enhancement in the whole body scan visible.

Incisional biopsy identified ES (grading according to FNCLCC: grade 3; diagnosis confirmed by Prof. Leuschner, sarcoma reference centre, Kiel and Prof. Jundt, bone tumour reference centre, Basel). Histologically, the tumour was composed of uniform small round cells with indistinct cytoplasm and round nuclei with finely dispersed chromatin (fig. 7a, b). Lack of reticulin fibres (fig. 7c), high proliferations index (fig. 7d) and strong immunoreactivity against CD99 (fig. 7e) underlined the diagnosis of ES. Finally, the characteristic translocation (11;22)(q24;q12) was detected using Fluorescence in situ Hybridisation (fig. 7f).

Figure 7

a-f: Sheets of uniform and densely packed small cells showing round nuclei with finely granular nuclear chromatin (Haematoxylin and Eosin, a 200×, b 400×) and lack of reticulin fibres (Novotny reticulin stain, c 400×). The proliferation index is high (approximately 80% of cells showing immunoreactivity against MIB1, d 400×) and tumour cells demonstrate strong positivity for CD99 (e 630×). FISH analysis using an EWSR1(22q12) dual colour break apart rearrangement probe demonstrates tumour cells with separate orange and green signals indicating t(11;22)(q24;q12) (f 630×).

The patient underwent radical tumour surgery with subtotal mandibulectomy and cervical lymph node dissection (Fig. 8). Reconstruction was performed using a microvascular osteoseptocutaneous fibular free flap. Tumour free soft tissue margins were confirmed intraoperatively. Histopathological examination of the resected bone, however, showed infiltration of both mandibular resection margins necessitating re-excision. The bony defects were filled with free iliac crest grafts. Two weeks postoperatively the patient underwent chemotherapy according to a standardized study protocol (CWS-2002P-study).

Figure 8

Mandibular resection specimen.

Osteosarcoma of the Mandible Masquerading as a Dental Abscess: Report of a Case

An aggressive and fatal case of osteosarcoma of the mandible in a 19-year-old female is reported. Six weeks after the clinical appearance of the swelling, the patient died. This paper is unique in that the age of occurrence and the biologic behavior of the tumor were not consistent with the reported literature. The case report is followed by a brief review of osteosarcoma of the jaw with a note on its clinical presentation, diverse radiologic appearance, varied histopathologic picture, and prognosis.

1. Introduction

Osteosarcomas are rare malignant neoplasms with a high rate of mortality. They are malignant connective tissue tumors originating from undifferentiated mesenchymal cells that are able to form bone or osteoid tissue [1]. The most common location is the metaphyseal region of long bones, with the area directly above or below the knee accounting for almost half of all cases [2]. Approximately 7% of all osteosarcomas arise in the jawbones [3–5]. The occurrence of osteosarcoma of the jaws is about a decade later than in patients with long bone tumors. The peak age for jaw tumors is 30 to 39 years. Males slightly outnumber females in reported cases [1, 4, 6].

Maxilla and mandible are affected equally, with males showing a predilection for occurrence in the mandible and females in the maxilla [6, 7]. Mandibular lesions are located in the body, symphysis, angle, or ramus in descending order of frequency, while maxillary lesions most often involve the alveolar ridge, antrum, sinus floor, and palate [8, 9]. Clinical symptoms include pain, swelling, loose teeth, separation of teeth, and paresthesia [10].

Radiographically, osteosarcoma can appear with a variable bone density depending on the amount of bone formed by the neoplasm. In some cases, the typical “sunray” appearance is observed at the periphery of the tumor. The changes may be very subtle and difficult to recognize in the early course of the disease. Widened periodontal ligament space has been described as a classical sign of early osteosarcoma [11]. Computed tomography and magnetic resonance imaging are valuable adjuncts in evaluating the extent of the tumor and its relationship with neighboring tissues [12].

Histologically, osteosarcomas are composed of malignant spindle cells which produce foci of osteoid or immature bone. In the jaws, about half of the lesions demonstrate a cartilaginous differentiation [13]. In general, osteosarcomas of the jaws tend to be better differentiated than their long bone counterparts, with some tumors exhibiting a deceptively bland histological appearance [14, 15]. Therefore, correlation of the histological features with the clinical and radiographic findings is essential for the diagnosis.

2. Case Report

A 19-year-old, single, female was referred to the Dental College and Hospital, University of Kerala, India, by a general dental practitioner after treating her in vain with antibiotics for dental abscess for a period of ten days. The patient presented with a complaint of a diffuse swelling on the left side of the mandible, large enough to cause her aesthetic anxiety. She had mild tenderness on palpation of the swelling and slight discomfort in the last molar region of the affected side while chewing. History revealed nothing of significance. At the time of clinical examination, the swelling was of two weeks duration. On examination, the swelling was circumscribed, bony hard, and roughly about 6 × 5 cm in size at the angle of the mandible. The swelling showed diffuse borders. The skin overlying the swelling was of normal color but had a glossy appearance, probably due to tautness of the skin over the swelling (Figure 1). Intraorally, the swelling was evident on the mandibular buccal vestibule adjacent to the second molar. There was apparent expansion of the buccal cortical plate. Lingual cortical plate also showed expansion but to a lesser extent. The mandibular third molar was missing, and the patient explained that both her mandibular wisdom teeth were extracted due to recurrent infection a couple of years ago.

Premolars and the first molar on the affected side were healthy with no carious or periodontal involvement. The second molar showed grade I mobility. Bidigital palpation did not reveal any lymph node enlargement anywhere in the cervicofacial chain.

Panoramic and lateral oblique views of the mandible were ordered. The orthopantogram showed a large radiolucency at the angle of the mandible on the left side, involving the second molar (Figure 2). The tooth appeared to float in space with bony attachment apparent only mesially. The circumscribed cortical plate expansion showed a centrifugal growth pattern involving the angle and major part of ramus of the mandible (Figure 3). The maxillary third molar of the affected side was present within the bone, but the mandibular third molar was absent corroborating the history and clinical finding. There was no widening of the periodontal ligament space and there was no sign of periodontal bone loss anywhere else. The inferior margin of the body of the mandible on the affected side had a moth eaten appearance in the lateral oblique view and a discontinuity in the inferior border suggestive of a pathologic fracture was apparent at the junction of the body and ramus.

An incision biopsy was performed. The histopathologic picture showed tissue lined with stratified squamous epithelium. Numerous proliferating spindle and oval-shaped mesenchymal cells with tumor osteoid and tumor bone formation were strewn subepithalially. Some areas showed highly pleomorphic cells with hyperchromatic nucleus and bizarre nuclear-cytoplasmic ratio with numerous vascular channels (Figure 4). Without much difficulty a diagnosis of osteosarcoma, osteoblastic variant, of the mandible was arrived.

Patient was recalled and interrogated for any paresthesia or numbness over the affected area. She admitted to a tingling sensation which had been present for a long time. Since it had not caused her any discomfort, she deemed it irrelevant to be mentioned. The serum alkaline phosphatase level was within normal limits. The patient was referred to the Regional Cancer Center for expert management. We followed up the patient’s progress and learned that her CT scan did not show any metastatic lesion in the body and also her nuclear bone scan showed an increased isotope uptake at the lesional site. The patient was planned for a radical hemi-mandibulectomy, but before the scheduled date she died. Death was due to massive uncontrolled local disease. It had been a mere six weeks from the time she reported to a dental clinic with the complaint of swelling to her demise. At the time of her death, the swelling on her jaw had doubled in size and the skin over the swelling was stretched tighter and had a deep bluish hue to it.

3. Discussion

The clinical presentation of the case was classic with minimal symptoms for such a large swelling and involving posterior mandible. But the rapid rate of growth of the lesion from the time the patient was seen initially to the time of her death was not consistent with the general growth pattern of jaw osteosarcomas. Osteosarcomas of the jaws are usually biologically distinct from those of long bones in that they behave better than their long bone counterparts [16, 17].

The numbness due to compression or infiltration of the inferior alveolar nerve in the mandibular canal of the affected area has been well documented in osteosarcoma and could be an indication of poor prognosis. In this case, even though numbness was not a presenting complaint of the patient, she was having the tingling sensation much before the swelling become apparent. Numbness or paresthesia of the affected area as an early diagnostic feature of osteosarcoma is thus highlighted by our case [18]. The dark hue over the rapidly growing swelling that was noticed towards the end of her days is attributed probably to telangiectasia of superficial vessels due to tumor compression.

The radiographic picture of the case did not show any widening of the periodontal ligament space of either the affected or the adjacent teeth. The circumscribed bilateral centrifugal cortical plate expansion could mimic a central benign neoplasm, although ossifying fibroma is a slow growing benign lesion and does not cause numbness of the affected area or pathological fracture of the bone. There was loss of lamina dura of both the mesial and distal roots of the second molar associated with the bone swelling. This could also be found in periodontal infections, odontogenic cysts and tumors, metastatic tumors, and so forth. Even though the patient had numbness of the affected area, radiographic feature of mandibular canal involvement was not evident. Probably, the extensive periostitis reaction masked this finding [10]. The characteristic sunray appearance and Codman’s triangle seen in osteosarcoma of the long bones is less commonly encountered in jaw lesions [2]. The difficulty in diagnosing osteosarcomas by radiological means is mainly because of its wider spectrum of variable.

Rise in serum alkaline phosphatase is reported in osteosarcoma but is not considered to be a consistent finding [19]. However, the present case did not show an elevation in serum alkaline phosphatase. The short clinical course of the tumor could be an explanation for this finding.

Differentiation of osteosarcoma from other bony lesions like Paget’s disease, fibrous dysplasia, multiple myeloma, and metastatic tumors is based more on microscopical than radiological evidence [19]. Even then different levels of cell differentiation may create difficulty in distinguishing this tumor from reactive stromal proliferations such as fractured callus or from cellular forms of Paget’s disease [20].

Besides the size of the lesion, the histologic type and grading of the tumor are important factors in determining the prognosis. Conventional osteosarcoma can be subdivided into osteoblastic, chondroblastic, and fibroblastic histologic variants depending on the extracellular matrix produced by the tumor cells [1].

Other histologic variants include the myxomatous type, telangiectatic type, small cell osteosarcoma, giant cell osteosarcoma, giant cell predominant osteosarcoma, large cell type, fibrous histiocytoma-like type, and epithelioid osteosarcoma [16]. Histologic picture of the present case showed areas of osteoblastic differentiation with some foci of highly pleomorphic cells and cellular anaplasia. This type has a poorer prognosis when compared with the chondroblastic variety. In fact, in our opinion, the histological grading is more important than all the other features combined in determining the prognosis.

The prognosis of osteosarcoma of the jaws is better than that of long bone, with a 5-year-survival rate of 25.8 percent for the maxilla and 34.8 percent for the mandible. The median survival time for the maxilla is 2.9 years and 6.5 years for the mandible [21]. The progress of the neoplastic growth in this case was so rapid that in contrast to the literature, the time span between diagnosis and death was barely six weeks. Probably the swelling had been present for a longer time but went unnoticed by the patient due to lack of any appreciable clinical symptoms. The patient is aware that its presence began only when it grew large enough to be of aesthetic concern. Usually, the prognosis of a jaw osteosarcoma gets better as the age at which it occurs increases [6]. Older patients are reported to have increased resistance to the tumor, thus increasing the chances of a better prognosis [10]. In our case, the patient was younger than the mean age of occurrence for jaw osteosarcomas. Also, the tumor ran a very aggressive biologic course, a feature uncommon for gnathic lesions [16].

Local recurrence and metastasis occur frequently in patients with osteosarcoma. Rate of metastasis in jaw osteosarcomas is lower than those of the long bones [6, 22]. But metastasis is relatively higher in case of postradiation osteosarcoma of the jaws [23]. Metastasis is usually via the bloodstream and in most cases occurs within 2-3 years. The absence of any metastatic spread seen in this case could be attributed to the very rapid rate of growth of the tumor and short clinical course.

Osteosarcomas of the jaws are cytologically unremarkable. Hence, it is important to separate them from benign or reactive lesions like fibrous dysplasia and osteoblastoma, [24]. It is crucial to completely investigate the lesion and arrive at accurate diagnosis in the initial biopsy. To assist in the identification of malignancy besides histopathological examination, special investigations have been carried out. Bone matrix protein is suggested to assist in recognizing malignant osteoid [25]. Osteocalcin is a bone specific protein that may be useful in differentiating osteosarcoma from malignant fibrous histiocytoma [26].

Early diagnosis and complete tumor resection are the most important factors in increasing prognosis of jaw osteosarcomas [27]. Treatment of osteosarcoma is radical surgery [28]. This usually is accompanied by radiotherapy or chemotherapy. Anatomic limitations in the orofacial region cause difficulties in achieving uninvolved margins and for this reason local recurrence of the lesions is high between 33% and 39%. Tumor-free margins in surgery, chemotherapy with multidrugs, and radiotherapy after surgery have effects in the prognosis of osteosarcoma [29].

4. Conclusion

The case reported here emphasizes the importance of histopathology in the diagnosis and predicting prognosis of osteosarcomas of the jaws. Eliciting simple but important clinical symptoms like numbness or paresthesia of the affected area is highlighted. X-ray, CT scan, and MRI imaging along with bone scan are valuable adjuncts to microscopy in the early diagnosis and staging of this malignancy.

Peritonsillar Abscess – American Family Physician

2. Gavriel H,
Vaiman M,
Kessler A,
Eviatar E.
Microbiology of peritonsillar abscess as an indication for tonsillectomy. Medicine (Baltimore).
2008;87(1):33–36.

3. Chau JK,
Seikaly HR,
Harris JR,
Villa-Roel C,
Brick C,
Rowe BH.
Corticosteroids in peritonsillar abscess treatment: a blinded placebo-controlled clinical trial. Laryngoscope.
2014;124(1):97–103.

4. Kordeluk S,
Novack L,
Puterman M,
Kraus M,
Joshua BZ.
Relation between peritonsillar infection and acute tonsillitis: myth or reality? Otolaryngol Head Neck Surg.
2011;145(6):940–945.

5. Standring S, ed. Gray’s Anatomy: The Anatomical Basis of Clinical Practice 39th ed New York: Elsevier Churchill Livingstone; 2005: 623–625.

6. Johnson RF,
Stewart MG,
Wright CC.
An evidence-based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg.
2003;128(3):332–343.

7. Albertz N,
Nazar G.
Peritonsillar abscess: treatment with immediate tonsillectomy – 10 years of experience. Acta Otolaryngol.
2012;132(10):1102–1107.

8. Klug TE.
Incidence and microbiology of peritonsillar abscess: the influence of season, age, and gender. Eur J Clin Microbiol Infect Dis.
2014;33(7):1163–1167.

9. Powell EL,
Powell J,
Samuel JR,
Wilson JA.
A review of the pathogenesis of adult peritonsillar abscess: time for a re-evaluation. J Antimicrob Chemother.
2013;68(9):1941–1950.

10. Hidaka H,
Kuriyama S,
Yano H,
Tsuji I,
Kobayashi T.
Precipitating factors in the pathogenesis of peritonsillar abscess and bacteriological significance of the Streptococcus milleri group. Eur J Clin Microbiol Infect Dis.
2011;30(4):527–532.

11. Tagliareni JM,
Clarkson EI.
Tonsillitis, peritonsillar and lateral pharyngeal abscesses. Oral Maxillofac Surg Clin North Am.
2012;24(2):197–204, viii.

12. Sowerby LJ,
Hussain Z,
Husein M.
The epidemiology, antibiotic resistance and post-discharge course of peritonsillar abscesses in London, Ontario. J Otolaryngol Head Neck Surg.
2013;425.

13. Powell J,
Wilson JA.
An evidence-based review of peritonsillar abscess. Clin Otolaryngol.
2012;37(2):136–145.

14. Scott PM,
Loftus WK,
Kew J,
Ahuja A,
Yue V,
van Hasselt CA.
Diagnosis of peritonsillar infections: a prospective study of ultrasound, computerized tomography and clinical diagnosis. J Laryngol Otol.
1999;113(3):229–232.

15. Ozbek C,
Aygenc E,
Tuna EU,
Selcuk A,
Ozdem C.
Use of steroids in the treatment of peritonsillar abscess. J Laryngol Otol.
2004;118(6):439–442.

16. Waage RK. Peritonsillar abscess drainage In: Pfenninger JL, Fowler GC, eds. Pfenninger and Fowler’s Procedures for Primary Care. 2nd ed. St. Louis, Mo: Mosby; 2003: 499–502.

17. Klug TE,
Henriksen JJ,
Fuursted K,
Ovesen T.
Significant pathogens in peritonsillar abscesses. Eur J Clin Microbiol Infect Dis.
2011;30(5):619–627.

18. Kieff DA,
Bhattacharyya N,
Siegel NS,
Salman SD.
Selection of antibiotics after incision and drainage of peritonsillar abscesses. Otolaryngol Head Neck Surg.
1999;120(1):57–61.

19. Ryan S,
Papanikolaou V,
Keogh I.
Appraisal of the peri-hospital management and evolving microbiology of peritonsillar abscess disease. B-ENT.
2014;10(1):15–20.

20. Fairbanks DN. Deep neck space abscesses. In: Pocket Guide to Antimicrobial Therapy in Otolaryngology–Head and Neck Surgery 13th ed Alexandria, Va: American Academy of Otolaryngology–Head & Neck Surgery Foundation, Inc.; 2007: 40–41.

21. Gilbert DN, Chambers HF, Eliopoulos GM, et al., eds. The Sanford Guide to Antimicrobial Therapy. 45th ed. Sperryville, Va.: Antimicrobial Therapy Inc.; 2015: 49.

22. Al Yaghchi C,
Cruise A,
Kapoor K,
Singh A,
Harcourt J.
Out-patient management of patients with a peritonsillar abscess. Clin Otolaryngol.
2008;33(1):52–55.

23. Garas G,
Ifeacho S,
Cetto R,
Arora A,
Tolley N.
Prospective audit on the outpatient management of patients with a peritonsillar abscess: closing the loop: how we do it. Clin Otolaryngol.
2011;36(2):174–179.

24. Marom T,
Cinamon U,
Itskoviz D,
Roth Y.
Changing trends of peritonsillar abscess. Am J Otolaryngol.
2010;31(3):162–167.

25. Tachibana T,
Orita Y,
Abe-Fujisawa I,

et al.
Prognostic factors and effects of early surgical drainage in patients with peritonsillar abscess. J Infect Chemother.
2014;20(11):722–725.

26. O’Brien JF,
Meade JL,
Falk JL.
Dexamethasone as adjuvant therapy for severe acute pharyngitis. Ann Emerg Med.
1993;22(2):212–215.

27. Lee YJ,
Jeong YM,
Lee HS,
Hwang SH.
The efficacy of corticosteroids in the treatment of peritonsillar abscess: a meta-analysis. Clin Exp Otorhinolaryngol.
2016;9(2):89–97.

28. Steyer TE.
Peritonsillar abscess: diagnosis and treatment [published correction appears in Am Fam Physician. 2002;66(1):30]. Am Fam Physician.
2002;65(1):93–96.

Common causes of swelling in the oral cavity

Broadly speaking, oral pathology can present as a mucosal surface lesion (discussed in an accompanying article by these authors),¹ swelling present at an oral subsite (lips/buccal mucosa, tongue, floor of mouth, palate and jaws) or symptoms related to teeth (pain, mobility). The last of these presentations has been excluded from this article as it is assumed patients with teeth-related symptoms are more likely to present to their dentists than their general practitioners.

The most commonly encountered swellings in the oral cavity are either submucosal in nature, or involve swelling of the underlying jaw (maxilla or mandible).

The submucosal swelling

Mucocele

A mucocele presents as a smooth, fluid-filled lump in areas with minor salivary glands that are commonly susceptible to oral trauma (eg lips, buccal mucosa; Figure 1). They occur when mucus/saliva escapes into surrounding tissues after trauma to the duct and is walled off by granulation or connective tissue. Alternatively, they can occur with obstruction of the salivary gland duct itself.

Despite the frequency of mucoceles, if they do not spontaneously resolve within 2–3 weeks, it is recommended that patients be referred to an oral and maxillofacial surgeon for assessment, as mucoceles can occasionally be clinically difficult to distinguish from a minor salivary gland tumour. Any mucocele should be excised and sent for pathological examination.

A ranula is a mucocele of the sublingual gland (Figure 2). The term ‘ranula’ is derived from its close appearance to a ‘frog’s belly’. Treatment involves removal of the sublingual gland as marsupialisation or incision and drainage alone leads to unacceptably high recurrence rates.²

Figure 1. Mucocoele of the upper lip with dome-shaped swelling and bluish tinge of saliva visible underneath the normal-appearing mucosa

Figure 2. A ranula – a mucocele of the sublingual gland

Fibroepithelial polyp

A fibroepithelial polyp is, as its name suggests, a polypoid outgrowth of tissue from the mucosal surface, which consists of fibrous connective tissue covered by normal or hyperkeratotic epithelium. It is a consequence of exuberant healing after minor oral trauma, and it is most commonly found in the lower lip or buccal mucosa in response to occlusal trauma (Figure 3). Fibroepithelial polyps can also be ulcerated. Treatment involves surgical excision.

Pyogenic granuloma

A pyogenic granuloma appears as a raised red polypoid lesion that easily bleeds and is caused by an exaggerated connective tissue response to minor trauma. It is most commonly found on the attached gingiva, followed by the lateral aspect of the tongue, lower lip and buccal mucosa (Figure 4). When found in pregnant women, pyogenic granulomas are referred to as a ‘pregnancy epulis’. Treatment includes surgical excision and removal of the traumatic irritant (eg subgingival plaque).

Figure 3. Fibroepithelial polyp on the right post-commissural region of the buccal mucosa with normal overlying mucosa

Figure 4. Pyogenic granuloma arising from the attached lingual gingiva of the lower right canine

Palate

In this article, the causes of a palatal swelling have been separated from other areas in the oral cavity because of the slightly different diagnostic considerations. Mucoceles, fibroepithelial polyps and pyogenic granulomas are rare in the hard palate because the firm, keratinised palatal mucosa is relatively resistant to trauma. The most common palatal ‘swelling’ is a palatal torus (discussed in the following section), but other causes of a palatal swelling are a palatal abscess or cyst (related to a non-vital upper first or second molar), minor salivary gland tumour (Figure 5), maxillary sinus tumour or lymphoma. As a result of these diagnostic possibilities, referral for further assessment is recommended for any patient with a palatal swelling.

The maxillofacial surgeon will often undertake imaging with computed tomography (CT) and/or magnetic resonance imaging prior to biopsy of a suspected minor salivary gland or maxillary sinus tumour to determine the presence and extent of underlying bone erosion; sinus, orbit or retromaxillary extension; and any radiological evidence of regional lymphadenopathy (Figure 6).

Figure 5. Right palatal swelling at the junction of the hard and soft palate. The lesion was firm on palpation. The overlying mucosa was not ulcerated. The diagnosis was mucoepidermoid carcinoma of the right palate, and treatment involved surgical excision (maxillectomy) and free flap reconstruction.

Figure 6. Coronal computed tomography scan showing extension of a right palatal tumour into the right maxillary sinus but not extending to involve the right orbital floor

The jaw ‘swelling’

Exostoses and tori

Exostoses and tori present as hard bony protuberances covered by normal-appearing mucosa, and they consist of outgrowths of normal mature bone. Palatal tori are present in up to 20% of individuals and are a nodular mass of bone in the midline of the palate (Figure 7). They are asymptomatic (unless the overlying mucosa is traumatised) but may display slow growth. An orthopantomogram (OPG) may sometimes confirm the presence of exostoses and tori, but usually only once they are of a larger size (>1.5–2 cm).

Mandibular tori occur on the lingual surface of mandible in the premolar area, superior to the mylohyoid ridge.

Exostoses are bony protuberances that occur on the buccal aspect of the mandibular or maxillary alveolus (Figure 8).

If there is any diagnostic doubt, or the patient is anxious regarding the ‘lesion’, confirmation can be obtained radiologically using a cone-beam CT scan. Surgical management is not indicated unless the torus/exostosis interferes with the placement of a removable dental prosthesis (denture) or is growing, or the overlying mucosa is recurrently ulcerated.

Figure 7. Torus palatinus – a bony hard protuberance found in the midline of the hard palate

Figure 8. Bony exostoses of the lower right buccal alveolus

Cysts of the jaws

Cysts of the jaws often present as a jaw swelling and are subclassified into odontogenic cysts (arising from odontogenic epithelium), non-odontogenic cysts and pseudocysts. The majority of jaw cysts are detected incidentally when the patient undergoes an OPG as part of their regular dental assessment. There are numerous types of cysts that can affect the jaws; the authors present here the most commonly encountered: the periapical cyst, dentigerous cyst and odontogenic keratocyst.

Periapical (radicular) cyst

Periapical cysts are the most common cysts of the jaws and are inflammatory cysts that develop at the apex of a non-vital tooth (Figure 9). A tooth may be non-vital through dental caries, previous trauma or periodontal disease. The tooth itself may not appear to be unhealthy on visual inspection (eg secondary caries in presence of a crown), and the cyst may not be palpable unless it is large.

Prior to the formation of a cyst, a non-vital tooth may present as a sinus tract extending from the non-vital tooth apex to the buccal or palatal gingiva. A periapical abscess occurs when there is an accumulation of pus at the apex of the tooth.

Figure 9. Orthopantomogram showing a lower right second premolar tooth with a grossly carious crown and a well-defined periapical radiolucency characteristic of a periapical (radicular) cyst arising from the non-vital tooth

The patient should be referred to their dentist for management of the non-vital tooth and periapical cyst. Management options include root canal therapy and preservation of the tooth, or extraction of the non-vital tooth and enucleation of the periapical cyst or incision and drainage of the abscess (Figure 10). Failure to manage the periapical infection adequately may lead to fascial space infection requiring hospitalisation and surgical management.

Figure 10. Draining sinus associated with a necrotic primary molar in a child aged nine years

Dentigerous cyst

A dentigerous cyst is an odontogenic cyst that can develop around the crown of an impacted (unerupted) tooth (Figures 11 and 12). They are most commonly seen in association with impacted third molars (wisdom teeth) or impacted canines, and they are most often diagnosed incidentally on a radiograph when investigating why an adult tooth has not erupted at the appropriate time.

Management depends on the tooth involved and can involve enucleation of the cyst alone, with preservation of the impacted tooth, or extraction of the impacted tooth along with cyst removal. The tissue must always be sent for histopathological examination to determine the type of cyst as well as to exclude odontogenic tumours and malignancies of the jaws.

Figure 11. Swelling over the mandibular alveolus with normal-appearing mucosa. The bluish tinge is the fluid visible within the cyst.

Figure 12. Orthopantomogram showing the classic appearance of a dentigerous cyst with a unilocular, well-corticated radiolucency attached to the cemento-enamel junction of the impacted lower left canine.

Odontogenic keratocyst

The odontogenic keratocyst (OKC; previously classified by the World Health Organization as a keratocystic odontogenic tumour)³ is regarded as a cyst that can exhibit locally aggressive behaviour and has a relatively high recurrence rate after treatment. It arises from dental lamina remnants in the mandible and maxilla. In a patient with multiple OKCs, the association with naevoid basal cell carcinoma syndrome must be excluded.

OKCs occur at any age but have a peak incidence between 20–30 years and have a 2:1 predilection for the mandible over the maxilla.⁴ They may present as an asymptomatic enlargement of part of the jaw or be detected incidentally on an OPG. Radiographically they present as multilocular or unilocular radiolucencies with well-defined margins (Figures 13 and 14).

Surgical excision of the OKC is the mainstay of treatment, and various adjunctive methods have been employed to reduce the likelihood of recurrence, including peripheral ostectomy and the application of Carnoy’s solution.⁵

Figure 13. Orthopantomogram of an odontogenic keratocyst showing a well-corticated multilocular radiolucent lesion extending from the left ramus to the right body of the mandible, causing displacement of teeth and root resorption

Figure 14. Axial computed tomography slice showing cortical expansion of the left mandible from the odontogenic keratocyst, with small areas of cortical breach

Fibro-osseous lesions of the jaws

The term ‘fibro-osseous lesions of the jaws’ encompasses three distinct entities: fibrous dysplasia, ossifying fibroma and cemento-osseous dysplasia. They are a diverse group of lesions characterised by the replacement of normal bone with abnormal fibrous tissue that contains trabeculae of immature bone or cementum-like material.

Fibrous dysplasia is a developmental anomaly characterised by normal cancellous bone that is replaced by abnormal fibrous connective tissue in which new, non-maturing bone is formed. Onset is most common in the second and third decades of life and presents as a slow, asymptomatic enlargement of part of the mandible or maxilla. The monostotic variant affects one bone alone, whereas polyostotic fibrous dysplasia affects multiple bones.The radiographic appearance is variable and dependent on the stage of the condition, with the initial phase of cancellous bone being replaced by fibrous tissue appearing radiolucent. The later phase – in which new, non-maturing bone is formed within the fibrous tissue – appears as a poorly defined mixed lucent/opaque area (Figure 15).

Figure 15. Axial computed tomography slice showing the mixed lucent–opaque lesion of fibrous dysplasia of the left posterior mandible (right side of the image). The patient presented after noticing several months of asymptomatic left jaw swelling.

Small areas of fibrous dysplasia may require no treatment other than biopsy confirmation and surveillance. Large lesions that cause functional or cosmetic deformity may be treated by surgical recontouring after the condition has stabilised. Medical management with bisphosphonates and monoclonal antibodies to RANKL (denosumab) has been reported in cases that are symptomatic and/or display rapid growth.⁶ Although uncommon, malignant transformation of fibrous dysplasia has been well described, and any sudden change in size of the lesion should alert the clinician to this possibility.⁷

Ossifying fibroma is an uncommon lesion that presents with similar radiological characteristics to those of fibrous dysplasia, except that the margins are well defined. A more aggressive variant can be found in the paediatric population (juvenile aggressive ossifying fibroma), and the primary treatment for all forms of ossifying fibroma is surgical excision.

Cemento-osseous dysplasia generally remains confined to the apices of teeth (periapical variant) and does not commonly present as a jaw swelling. It is most commonly detected incidentally on radiographs such as periapical X-rays or OPGs, and the teeth in the region maintain their vitality.

Tumours of the jaw

Tumours of the jaw may also present as a jaw swelling and may be benign or malignant. The most common tumours of the jaw are benign odontogenic tumours such as ameloblastoma.⁸ Ameloblastoma can occur in all age groups but is most common in the late teenage to thirties age group.

Patients will often describe asymptomatic, slow-growing enlargement of the mandible or maxilla. The posterior mandible in the third molar (wisdom tooth) region is the most common site. An OPG will show a multilocular radiolucency in the jaw that may displace or resorb teeth (Figure 16).

Figure 16. Orthopantomogram showing a multilocular radiolucency present in the left ramus/angle of the mandible associated with root resorption of the lower left third molar. The patient presented with left jaw swelling, and biopsy revealed solid/multicystic ameloblastoma. This required segmental resection of the mandible and free flap reconstruction.

The treating clinician will often assess the full extent of the tumour using CT scanning and biopsy the lesion to establish the tissue diagnosis. Treatment of odontogenic tumours can vary from enucleation and curettage to excision of the lesion with a surgical margin depending on the histopathological diagnosis.

Malignant tumours of the jaw (eg osteosarcoma) are rare; however, any patient with jaw swelling should be referred to an oral and maxillofacial surgeon for further assessment and management. The radiological appearance of a malignant jaw tumour can vary significantly, from being barely visible on plain X-ray, to a radiolucent lesion or radiopaque lesion (or a mixed lucent–opaque lesion; Figure 17).

Figure 17. Orthopantomogram showing a left mandible osteosarcoma – a mixed lucent–opaque lesion extending from the lower left first premolar to involve the left ramus of the mandible with classic ‘sunburst’ appearance

The management of malignant tumours of the jaw will almost invariably involve segmental resection of the jaw and free flap reconstruction with the possibility of adjuvant radiotherapy and chemotherapy depending on the type of tumour, pathological stage, lymph node involvement and surgical margin (Figure 18).⁹

Figure 18. Orthopantomogram post–left segmental mandibulectomy and osseocutaneous fibula free flap reconstruction for osteosarcoma of the mandible

Conclusion

In this article and the accompanying article, the authors have attempted to provide a brief ‘Cook’s tour’ through the pathology of the oral cavity. There are many conditions that have been omitted because of the breadth of the topic. If readers are interested in pursuing greater depth of knowledge in oral pathology, the authors would direct them to the excellent books published by Regezi et al¹⁰ or Cawson and Odell¹¹ on oral pathology.

Key points

• The vast majority of submucosal swellings are inflammatory lesions related to minor oral trauma; however, all submucosal swellings should be referred for excision to ensure that a minor salivary gland tumour is not overlooked.
• The differential diagnosis for a palatal swelling is slightly different from swelling in other oral cavity locations, and once a palatal torus has been excluded (midline, bony hard protuberance with normal overlying mucosa) all other palatal swellings should be referred for assessment.
• An OPG should be the first radiograph ordered in the investigation of jaw swelling as it can show jaw pathology related to teeth, odontogenic cysts and tumours, and bone pathology.
• Any tissue excised from the oral cavity should be sent for histopathological examination as the clinical or radiological appearance alone is insufficient to ensure a correct diagnosis.

Competing interests: None.

Provenance and peer review: Commissioned, externally peer reviewed.

Funding: None.

90,000 Tooth abscess – types, symptoms, photos and treatment in dentistry

Tooth abscess is an acute infectious disease that develops in the area of ​​the dental roots. Often, people with insufficient oral hygiene are faced with this disease. When there are defects on the teeth, expressed by cracks and chips, carious lesions, bacteria penetrate into their soft parts and assimilate there, which is why an inflammatory process occurs, pus is formed and the gums swell.There are nerve endings in the pulp area, so any inflammation is accompanied by a strong pain syndrome. The development of an abscess occurs quite quickly, if urgent measures are not taken, the bone tissue will be affected, and the integrity of the tooth becomes at risk.

With self-treatment of a tooth abscess, it will not be possible to achieve a good result, it is possible that the pain will be stopped for a short period of time, but this threatens with more serious consequences. In order for the treatment to be successful, it is necessary to consult a specialist in a timely manner and receive qualified assistance.

Tooth abscess photo:

Types of tooth abscess

Based on the course of the disease, the abscess is presented in the following varieties:

• Periapical abscess of the tooth, located in the dental cavity as a result of the necrosis of the pulp. Its main difference is that pus accumulates directly under the root of the tooth.

• Gingival abscess, its localization is in soft tissues. The gum abscess does not move to the root of the tooth or to the periodontal ligament.

• Periodontal abscess, located between the gum and the root of the tooth.

When the volume of accumulated pus is small, it is held in a confined space, as if in a bag. As the inflammation and the volume of pus increase, a fistula occurs – this is a kind of channel that connects the abscess and the external environment. This round hole that appears in the gum swells around the edges. Pus is discharged from the wound as a white spot.

Symptoms of tooth abscess

Bacteria begin to infect one tooth, but if urgent measures are not taken, suppuration will spread to nearby neighbors.The abscess begins painfully – swelling and severe pain appear at the site of the lesion. Pain relieves pain relief for a short period of time and then becomes more intense.

If you are concerned about a tooth abscess, the symptoms will be as follows:

• Painful sensations when chewing and pressing on the tooth.
• Pain in the gum area when pressure is applied.
• An unpleasant taste, bitter and unpleasant odor appears in the mouth.
• The gums are swollen.
• Facial asymmetry may appear.
• The lymph nodes are enlarged.
• Fever and headache.

If you do not take emergency measures, wounds with pus will begin to appear on the gums. Please note that if the abscess breaks out, the pain will subside, but this does not mean that the disease has passed. The bacteria that caused the development of the disease will continue to be located in the tissues of the tooth, so the recurrence of inflammation will not be long in coming.

Causes of tooth abscess

The onset of the disease often occurs in the dead pulp, after the canals have been unsuccessfully treated. In children, an abscess occurs as a consequence of untreated caries. With adults, the situation is a little different, since a formed and strengthened immunity makes it possible for the body to more easily cope with various inflammations.

The main causes of abscess on the gums or teeth:

• Diseases of the gums.
• Carious decay of teeth.
• Cysts on teeth, granulomas.
• Cracks and chipped teeth.
• Various injuries in the oral cavity.
• Poor oral hygiene.
• Weak immunity.

Note that an infection can occur anywhere in the body, and the bacteria travels to the gums through the bloodstream. That is why any infectious diseases require careful attention, in particular, in the ENT part, as well as methods and ways to increase immunity if there are problems with it.

Complications of tooth abscess

Note that a purulent tooth abscess does not go away on its own.Even if the pus leaked out, you opened the abscess yourself, the pain syndrome will be reduced, but dental treatment is necessary and necessary. Without drainage of the abscess, complications will arise in the tissues of the lower jaw, in the head or neck, in extreme cases, sepsis will develop, the infection will spread throughout the body through the circulatory system.

Diagnosis of tooth abscess

The dentist examines the affected tooth, oral cavity, tissues located near the site of inflammation, then:

• the affected tooth is tapped, it will be painful, sensitive to touching and pressing;
• Do an x-ray to see the extent and location of the tooth damage;
• Perform a CT scan of the head and neck to determine the location and spread of the infection throughout the body;
• Take laboratory tests to determine which bacteria caused the infection.This is necessary in order to properly prescribe antibiotic therapy.

When the abscess is diagnosed and confirmed, the extent of the lesion is determined, appropriate treatment is prescribed.

Treatment of tooth abscess

If a tooth abscess is diagnosed, treatment will be aimed at minimizing and nullifying the infectious process. In particular, the treatment consists of:

• Opening, draining the abscess – an incision is made near the location of the abscess to neutralize pus, after which the open cavity is washed with saline, and the tissue near the open wound is treated in the same way.

• Form the root canal of the tooth pulp – the affected tissues are removed, the abscess is drained, a special sealing substance is introduced into the formed voids to neutralize the development and spread of infection, and also to make every effort to save the tooth. In order to strengthen the tooth, a crown can be additionally installed in the future.

• Extraction of an affected tooth occurs when it cannot be saved. Then the tooth is removed and the abscess is drained.

• Antibiotic therapy is necessary in order to prevent the spread of infection to tissues, teeth located near the affected area.

To relieve the pain of a dental abscess, you can rinse with warm salt water or with a special dental solution. You can also take pain relievers.

Prevention of tooth abscess

Teeth require some care to prevent further inflammation and decay:

• when using water, when rinsing the mouth, give preference to fluoridated water;
• Brush your teeth twice a day with a special fluoride paste, rinse your mouth after each meal;
• every 3-4 months replace the toothbrush with a new one;
• Give preference to healthy food, minimize sweet, starchy foods;
• Visit your dentist every six months for examination, professional dental hygiene.

If you are faced with the fact that an abscess has appeared on the gums, immediately contact your dentist to receive high-quality and professional help, because you will not be able to cope with the disease on your own. By following all the recommendations for treatment, you will quickly get rid of the disease and its consequences.

Lancing of abscess, phlegmon of the maxillofacial region

The incidence of abscesses and phlegmon of the maxillofacial region of the head is due to the high prevalence of chronic focal odontogenic and tonsillogenic infections, as well as infectious and inflammatory lesions of the skin and oral mucosa.Based on the data on the localization of the infectious and inflammatory process in various anatomical departments, zones, regions, as well as the spaces of the head and neck, their systematization is built.
From the description of the topographic and anatomical structure of the areas of the face, the peri-maxillary and adjacent areas of the neck, one can see the complexity of their anatomy. There are many cellular spaces, numerous lymph nodes and vessels scattered over all areas of the face, an abundant network of arteries and veins with rich innervation of these areas.

The main principle of the treatment of inflammatory diseases is the opening of the inflammation focus and its drainage. Full drainage reduces pain, promotes the outflow of wound discharge, improves local microcirculation, which naturally has a beneficial effect on the processes of local metabolism, the transition of the wound process to the regeneration phase, reducing intoxication and interstitial pressure, limiting the zone of necrosis and creating unfavorable conditions for the development of microflora.

The incisional drainage method for the treatment of phlegmons and abscesses of soft tissues is quite widespread up to the present time. It provides for the opening of a purulent focus and open wound management in the postoperative period. The incisional drainage method is classic; in general, it determines the tactics of treating acute purulent diseases of soft tissues and purulent wounds.

The opening of a purulent focus is carried out by external access from the side of the skin, or by intraoral access from the side of the mucous membrane.

During the operation of opening an abscess (phlegmon), the skin, mucous membrane, fascial formations above the purulent focus are dissected; muscles are cut off, exfoliated from the place of attachment to the bone of the temporal, medial pterygoid and masticatory muscles (m. temporalis, t. pterygoideus mcdialis, t. masseter) or with the help of a hemostatic clamp they push apart the muscle fibers of the temporal, maxillary-hyoid and buccal muscles (m. temporalis , t. mylohyoideus, t. buccalis). The exception is the subcutaneous muscle of the neck (m.platysma) and often the maxillary-hyoid muscle, the fibers of which cross in the transverse direction. which provides a gaping wound and creates good conditions for the outflow of purulent exudate. Loose tissue located on the way to the purulent focus, in order to avoid damage to the vessels, nerves, excretory stream of the salivary glands, is stratified and pushed apart with a hemostatic clamp.

90,000 causes, symptoms and treatment in the article of the dentist-surgeon Kozlov P. Yu.

Publication date March 3, 2020 Updated April 26, 2021

Definition of the disease.Causes of the disease

Abscess of the oral cavity – inflammation of tissues with their melting (destruction, disruption) and the formation of a purulent cavity.

Most often, the cavity is located between the bone tissue and the periosteum (periostitis, subperiosteal abscess), less often – in the interfascial, intermuscular spaces and in the bone tissue (abscess of the floor of the oral cavity, abscess of the pterygo-jaw space, abscess of the jaw-lingual groove). Separately, an abscess of the buccal region can be distinguished, which can be located between the mucous membrane and the muscle, in the intermuscular space and between the muscle and subcutaneous fat.In almost all cases, oral abscesses are odontogenic, in other words, the cause of their occurrence is a tooth, moreover, an affected, infected one. In an outpatient clinic, acute purulent periostitis occurs most often in comparison with other inflammatory diseases of the maxillofacial region ^{[1] [2] [3] [4]} .

An abscess of the oral cavity develops as a result of a reaction of local and general immunity in response to infection.The severity of the course of the disease depends on the joint interaction of all defense mechanisms of the body ^{[5] [6]} .

The most common cause of oral infections is acute or aggravated periodontitis. Periodontitis is a type of complicated caries, which can be clinically manifested by a carious cavity, or by a destroyed coronal part of the tooth with direct involvement in the pathological process of the tooth cavity and bone tissue behind the root apex.Radiographically, periodontitis is characterized by a change in the bone structure behind the apex of the tooth root, the degree and severity of the changes depends on the form of periodontitis.

The development of an oral cavity abscess from exacerbation of chronic periodontitis against the background of hypothermia clearly shows the dependence of the onset of the disease on systemic immunity. A patient can live for years with a large number of decayed teeth, which are foci of chronic infection, and only with a decrease in the general defenses of the body can an exacerbation develop with the appearance of an abscess.

The main role in the development of oral abscesses is played by streptococci and staphylococci of various types, gram-positive and gram-negative bacilli and putrefactive bacteria. Of these, about 75% are anaerobic bacteria (able to survive without oxygen) and 25% are aerobic bacteria (exist only in an oxygen environment). According to the literature, this ratio is variable, as is the resistance (resistance) of bacteria to antibiotic therapy, and depends on the region ^[7] .

In addition to periodontitis, abscesses of the oral cavity can be caused by suppuration of radicular cysts, which are hollow neoplasms in the apex of the tooth root filled with serous fluid.Also, abscesses can form as a result of infection of a bone wound with fractures of the bones of the facial skeleton, as well as difficult eruption of the lower wisdom tooth: in this case, the cause will be chronic inflammation, which is formed due to the multiplication of microorganisms between the wisdom tooth and the mucous membrane (hood) hanging over it.

Separately, an abscess of the pterygomandibular space can be removed, which can develop as a complication after performing local anesthesia on the lower jaw.

If you find similar symptoms, consult your doctor. Do not self-medicate – it is dangerous for your health!

Symptoms of an oral abscess

Symptoms of an oral abscess are variable and depend directly on the type and location of the abscess. In acute purulent periostitis, patients complain of pain in the area of ​​the causative tooth or jaw segment, swelling of soft tissues. The face of such a patient is asymmetrical.

When the causative tooth is localized in the anterior part of the upper jaw, the edema is located in the upper lip and infraorbital region, the nasolabial fold is smoothed.If the diseased tooth is located in the anterior part of the lower jaw, swelling of the soft tissues is noted in the area of ​​the lower lip and chin. When the causative tooth is located in the lateral part of the dentition, perifocal edema (near the infectious focus) is located in the buccal region.

Acute purulent periostitis is usually not accompanied by restriction of mouth opening. On palpation of regional lymph nodes, signs of acute lymphadenitis (enlarged lymph nodes) are often determined.Examination of the oral cavity reveals the causative tooth, which usually reacts sharply to tapping (percussion). This is due to the presence of a pathological process behind the apex of the root. When examining the vestibule of the oral cavity, a painful inflammatory infiltrate is determined, above which there is an edematous and hyperemic (red) mucous membrane. According to the literature, periostitis is more often located on the side of the cheek or lips, less often on the palatine and lingual sides ^{[5] [8]} .

Often, abscesses of the jaw-lingual groove, buccal region, pterygomandibular space are considered as a complication of acute purulent periostitis.However, in some cases, these diseases develop on their own, so there is no reason not to consider them in this review.

Abscess of the maxillofacial groove is characterized by a more serious course. The patient complains of pain when swallowing, moving the tongue to the sides, limiting the opening of the mouth. A visual examination determines the swelling of the submandibular region, acute lymphadenitis. Examination of the oral cavity is often difficult and is possible only after blockade of the motor branches of the mandibular nerve.When examining the oral cavity, acute or aggravated periodontitis of the chewing tooth of the lower jaw or difficult eruption of the lower wisdom tooth is determined. When examining the jaw-lingual groove, its bulging is determined; on palpation, an inflammatory, sharply painful infiltrate can be detected.

With abscess of the pterygo-jaw space , the patient notes an increase in body temperature, pain in the pharynx, difficulty swallowing, mouth opening is limited, in some cases almost impossible.Perifocal edema is often absent visually. Examination of the oral cavity can be performed only after blockade of the motor branches of the mandibular nerve. In the oral cavity, difficult eruption of the lower wisdom tooth is usually determined, as well as a hyperemic and edematous pterygo-mandibular fold.

The clinical picture of an abscess of the buccal region largely depends on the depth of the abscess. With a superficial abscess, hyperemia (redness) of the skin, a local increase in temperature, the skin is tense, does not collect in a fold.With an average and deep location, there is a pronounced swelling of the buccal region, the skin is not externally changed, it is difficult to fold into a fold. Local hyperthermia (fever) is usually not observed. With a deep location of the abscess on the mucous membrane of the cheek, teeth marks are determined.

The condition of patients with these abscesses is usually assessed as moderate. Treatment, as a rule, is carried out in a hospital of maxillofacial surgery under supervision in order to prevent the development of severe complications.Patients often have symptoms of general intoxication of the body (fever, headaches and muscle pains).

Pathogenesis of an oral abscess

Inflammatory fluid (pus) in the tissues around the apical third of the tooth root may not be emptied through the root canal, in which case it will spread from the periodontium towards the periosteum. In this case, the infection penetrates through the compact plate along the nutritional and osteon canals (structural units of the compact substance of bone tissue).An important role in this process is played by resorption (resorption) in the compact plate of the alveolar wall. Microorganisms can also spread under the periosteum by hematogenous (through blood) and lymphogenous (through lymph) pathways.

Violation of the integrity of periodontal tissues is the cause of functional insufficiency of nonspecific and specific humoral and cellular reactions to suppress infection. Toxins of microorganisms increase sensitization (sensitivity), disrupt hemodynamics (movement of blood through the vessels).Inflammation develops brightly, the body’s reaction to it can be normal (corresponding to the strength and nature of the stimulus) or hyperergic (exceeding the effect of the stimulus). Further, with an untimely visit to a doctor and an imbalance in the patient’s immune status, the infection spreads to nearby cellular spaces.

An abscess is separated from healthy tissues by an infiltrated shaft of leukocytes. At the same time, the vessels are full-blooded, from their lumens the liquid part of the blood passes into the tissues, forming perifocal edema.In the process of the development of a tissue reaction around the purulent focus and the multiplication of connective tissue cells, a granulation shaft is formed, which limits the purulent focus. With the long-term existence of a limited purulent process, it is possible to develop a dense connective tissue pyogenic membrane, which serves as a barrier for the further development of the inflammatory process.

Classification and stages of development of an oral abscess

By location:

1. Adjacent to the upper jaw.
2. Adjacent to the lower jaw.

For the reason:

1. Odontogenic (caused by an infected tooth)
2. Tonsilogenic (caused by inflammation of the pharyngeal tonsils).
3. Rhinogenic (caused by inflammation of the nasal mucosa).

By the type of inflammatory reaction:

1. Hypoergic (slow development of the disease, symptoms are weak).
2. Normal (the most typical course of the disease).
3. Hyperergic (rapid progression of the disease with pronounced symptoms) ^[11] .

Complications of an oral abscess

Complications of oral abscesses are phlegmon of the face and neck, sepsis, mediastinitis, thrombophlebitis, meningitis ^[1] .

Due to good vascularization (blood supply) and an abundance of cellular spaces, purulent-inflammatory diseases of the maxillofacial region spread rather quickly to nearby areas.A prerequisite for this is the reduced immune status of the patient.

With the penetration of an inflammatory infiltrate through the diaphragm of the oral cavity, phlegmon of the bottom of the oral cavity develops . This disease is characterized by a severe course and a rather unfavorable prognosis. Often the root of the tongue is involved, which can lead to closure of the airways. With phlegmon of the floor of the mouth, the patient has difficulty breathing, it is almost impossible to close the mouth and make swallowing movements.The usual food intake for such patients causes a lot of problems, the patients are often emaciated, are in serious condition due to the pronounced symptoms of general intoxication of the body. Often, phlegmon of the floor of the mouth spreads to the neck, which aggravates the patient’s condition, especially if the neurovascular bundle of the neck is involved in the process. In a number of cases, a putrefactive-necrotic phlegmon of the bottom of the oral cavity develops, which has a gangrenous character (Ludwig’s angina). This disease has an extremely severe course, with untimely treatment, a lethal outcome is possible.

Sepsis is a pathological condition caused by the entry of microorganisms into the systemic circulation from the focus of inflammation. Sepsis is characterized by severe general disorders and the formation of foci of purulent fusion in various organs and tissues. The most common causative agents of sepsis are staphylococcus, E. coli and Pseudomonas aeruginosa, anaerobes, however, theoretically, sepsis can be caused by any microorganism.

Mediastinitis – inflammation of the mediastinal tissue.It is one of the most severe complications of pyoinflammatory diseases of the maxillofacial region. Infection of the mediastinum occurs by contact (along the length of the neurovascular bundle of the neck due to the spread of pus from top to bottom) or hematogenous / lymphogenous. Mediastinitis is characterized by chest pain, impaired swallowing, hoarseness, and symptoms of a systemic inflammatory response. Symptoms of this disease can vary, they depend on the prevalence of the pathological process, the degree of involvement of the mediastinal organs and the severity of their damage ^[1] .

Thrombophlebitis of the facial veins – acute inflammation of the veins with the formation of a blood clot, which develops in pyoinflammatory diseases of the maxillofacial region. In some cases, thrombophlebitis of the sinuses of the brain develops.

Meningitis is a purulent or serous inflammation of the brain or spinal cord caused by bacteria, viruses or other agents.

The described diseases are quite dangerous, each of them is characterized by a serious condition of the patient.Cases of a combination of these complications are not uncommon, which affects the prognosis, terms of rehabilitation, as well as complete physical and mental recovery.

Any of the above diseases is an indication for immediate hospitalization in a specialized surgical department. In some cases, after surgery, the patient is admitted to the intensive care unit under constant supervision. Constant monitoring is required, in some cases – consultations or interventions of related specialists (neurosurgeons, thoracic surgeons).

Diagnostics of the oral cavity abscess

Basic and additional research methods are used for the diagnosis of oral cavity abscesses.

At the initial appointment, the doctor assesses the clinical situation and decides whether the patient needs to be hospitalized with subsequent treatment in a hospital setting. The doctor listens to the patient’s complaints, learns the history of the development of this disease, asks about the presence of concomitant common pathologies. Then he conducts a clinical examination, which begins with a visual examination of the patient: in this case, the asymmetry of the face, the color of the skin, the degree of mouth opening are assessed.Particular attention is paid to the study of regional lymph nodes, since their enlargement is a clinical symptom of inflammatory diseases of the maxillofacial region. After a visual examination, the oral cavity is examined, during which it is necessary to identify the causative tooth and the focus of inflammation.

In a number of cases, especially in severe forms of inflammatory diseases of the maxillofacial region, it is necessary to measure body temperature and blood pressure. In the case of an oral cavity abscess, the results of these examinations help determine changes in the general condition of the body, which can be expressed in the appearance of headaches, malaise, chills, etc.

In an outpatient setting, a sighting X-ray or radiovisiogram is carried out, it is possible to carry out electroodontodiagnostics (assessment of the state of the pulp by checking its response to electric current). With special equipment, an orthopantomogram ^[5] is performed. These research methods make it possible to establish the causative tooth, because in some cases the clinical picture does not allow this to be done due to pronounced edema and a large number of decayed teeth.

Currently, more and more patients with pyoinflammatory diseases of the maxillofacial region, including acute purulent periostitis, are being treated in a maxillofacial surgery hospital. Only in the hospital, the patient is under round-the-clock supervision, which allows him to thoroughly examine him, as well as control and adjust the treatment and rehabilitation.

In inflammatory diseases of the maxillofacial region, a general blood test will be informative, in which special attention is paid to the number of leukocytes, erythrocyte sedimentation rate (ESR) and the presence of a shift in the leukocyte formula.In addition to a general blood test, a general urine test, a biochemical blood test, a blood test for the presence of antibodies to infectious diseases, fluorography and electrocardiography, if necessary, are performed.

To clarify the localization and prevalence of the purulent process, as well as to select the optimal surgical access, an ultrasound scan of the inflammatory infiltrate and adjacent tissues is performed. After opening the abscess, material is taken to study the quantitative and qualitative composition of the flora, as well as its sensitivity to antibiotics.This study will allow prescribing the most effective antibacterial drug that will help the patient recover in the shortest possible time.

Treatment of an oral cavity abscess

Patients with oral cavity abscesses need urgent surgical treatment in the volume of opening the inflammation focus ^[8] . In acute purulent periostitis or deep buccal abscess under local anesthesia, the abscess is opened, then local antiseptic treatment of the postoperative wound with antiseptic solutions is performed, followed by drainage.

Patients with abscesses of the maxillofacial groove, pterygo-jaw space, superficial and mid-buccal abscesses are increasingly being treated in a maxillofacial surgery hospital. Lancing of such abscesses is also performed under local anesthesia.

It is worth paying attention to the tactics of treating the causative tooth. After clinical and X-ray examination, a decision is made to preserve or remove the causative tooth. With a relatively preserved crown part, the diseased tooth is usually preserved.If the tooth is destroyed, there is a pronounced pathological mobility, if, according to the X-ray, an extensive focus of bone tissue destruction is revealed, the causative tooth is removed. Removal is also performed if the patient refuses to preserve and conservatively treat the causative tooth. In the absence of absolute indications for tooth extraction, a written refusal of the patient to preserve it is drawn up.

After opening the abscess, the patients are daily dressing: antibacterial treatment of the postoperative wound and oral cavity, replacement of drainage.Also, the patient must independently observe oral hygiene.

In addition to surgical treatment, antibiotic therapy is prescribed. Its purpose is to suppress the pathological microflora. Before the results of antibiotic susceptibility tests are available, empiric therapy is carried out, which involves the use of a broad-spectrum antibiotic. When the results are obtained, the pathogen or pathogens and an antibacterial drug are identified, which most effectively helps to fight the pathogenic flora ^[11] .

Due to the presence of a pronounced pain syndrome in the area of ​​the postoperative wound, symptomatic therapy is carried out. The patient is prescribed non-steroidal anti-inflammatory drugs in injectable or tablet form.

Conducted detoxification therapy , the essence of which is the intake of a large amount of liquid. Severe patients are shown intravenous infusion with isotonic solution. In some cases, multivitamins and physiotherapy are prescribed.

Forecast. Prevention

With timely treatment, correct treatment tactics and correctly selected drug therapy, the prognosis is favorable. In acute purulent periostitis, usually after 3 days, there is a decrease in collateral edema and a decrease in pain in the area of ​​the postoperative wound. Full recovery of working capacity is usually noted on days 3-7, depending on the severity of the disease, the presence of background diseases, compliance with the recommendations and prescriptions of the attending physician.

Often patients neglect the recommendations: they do not observe oral hygiene, do not come for repeated appointments, do not take medications, or take the wrong drug due to various reasons. In some cases, such a negligent attitude towards one’s own health does not bring negative consequences. But sometimes, especially against the background of a weakened general immunity, the presence of serious general diseases, including immunodeficiency, complications develop. In such cases, the patient is shown hospitalization in a maxillofacial surgery hospital under round-the-clock supervision.

Much attention is paid to the prevention of inflammatory diseases of the oral cavity. There are many daytime and nighttime dental clinics, weekends and public holidays, both public and private. The Internet and other media sources of information talk about the need to brush your teeth twice a day, use various mouth rinses. Many dental clinics are organizing campaigns for professional cleaning of the oral cavity, but the number of patients with inflammatory diseases of the oral cavity is not decreasing.

It should be noted that with timely treatment of carious cavities and sanitation of the oral cavity as a whole, the risk of developing odontogenic abscesses of the oral cavity tends to zero. It is also important to maintain a high level of general immunity, lead a healthy lifestyle and observe a work and rest schedule ^[11] .

methods of diagnosis, prevention and methods of treatment

Symptoms that occur with an abscess

• acute and throbbing pain that is localized in the area of ​​one specific tooth, but most often it spreads throughout the jaw and persists for a long period of time,
• if you press on the tooth, very painful sensations appear, pain also provokes chewing load,
• increased reaction to external stimuli – hot and cold exposure,
• reddening of the gingival tissue occurs,
• swelling of both the gums and a certain part of the face is pronounced,
• general malaise occurs, body temperature rises,
• odor from the mouth has a putrid character, which is caused by the accumulation of a large amount of pus,
• cervical lymph nodes are enlarged.

Causes of inflammation

The main reason for the appearance of a focus of pus is inflammation that was previously present inside the tooth or in the periodontal tissues, and, accordingly, has not been cured. We are talking about deep caries, pulpitis, periodontitis, periodontitis or periostitis – flux. But besides this, the reasons may be as follows:

• Poorly treated gum and dental diseases are the number one cause,
• damage to teeth – chips or fractures through which the inflammatory process spreads inside the tooth and beyond, i.e.e. infection,
• infectious ENT diseases: flu, tonsillitis – in such situations, the infection spreads to the jaw tissues through the bloodstream,
• infection during various manipulations in the oral cavity, as well as the lack of sterility: poor-quality sterilization of dental instruments can cause the development of a serious infection, for example, when anesthesia is administered.

Complications of abscess

The main complications of purulent inflammation are the spread of pus in the jaw or throughout the body, as well as the development of sepsis, which can be fatal to humans.With this pathology, pneumonia or even a brain abscess can also develop. The simplest consequence of this condition (in comparison with other complications) is the loss of a living tooth.

With timely referral to a specialist for help, as a rule, it is possible to save the tooth. Nevertheless, a severe form of an abscess inevitably leads to the development of serious complications, among which the most dangerous is sepsis or the spread of a purulent infection throughout the body, which can even lead to death.

Treatment methods

Treatment of an abscess should be started very quickly and in a timely manner in order to stop the spread of purulent inflammation. An obligatory step is the opening of the abscess and the installation of a drainage system for the outflow of pus. At the same time, drug therapy is prescribed – antibiotics, antihistamines and anti-inflammatory drugs are prescribed; baths and mouth rinses.

Lancing of an abscess

This is the first thing that is done to treat an abscess.The gums are cut and drainage is installed, which is necessary for the outflow of pus. It is necessary to walk with him for several days, it is imperative to rinse the oral cavity with antiseptic drugs. After the X-ray image, the condition of the periodontal tissues is assessed, after which a decision is made on further treatment of the tooth – as a rule, it is required to clean the canals and restore the destroyed apex.

Treatment of root canals

If the cause of the development of an abscess is an inflammatory process inside the tooth, then the root canals are cleaned – the nerve is removed, and a drug is placed inside.Often this method is combined with the opening of the abscess. During the second visit, the canals of the tooth are filled, and the apex is restored with a filling, inlay or crown.

Root apex resection

It is performed in the presence of an inflammation focus with localization near the dental root. Surgery involves cutting the gums and removing the source of infection along with a small portion of the root. At the same time, the tooth itself is preserved and can even be used for prosthetics.

Tooth extraction

An extreme measure that is used in advanced stages of the development of an abscess. In this case, it is better to remove the tooth that has become the source of the infection. At the same time, the purulent focus is eliminated, the cavity is cleared.

Installation of a dental crown

Required if the apex of the tooth is severely damaged. Prosthetics are performed only after the completion of the main treatment, i.e. after removal of a purulent focus, thorough cleansing of all infected tissues and filling of dental canals.

90,000 Peri-maxillary abscess – causes, symptoms, diagnosis and treatment

Periomandibular abscess is the formation of an inflammatory purulent focus in the tissues of the maxillofacial zone of the face. It is manifested by local swelling, redness and fluctuation (swelling) of the skin over the focus of inflammation, asymmetry of the face, difficulty and pain in swallowing, symptoms of intoxication. It can develop into diffuse inflammation – phlegmon, with the involvement of the periopharyngeal and infraorbital region, the neck in the process.Treatment is always surgical – opening and draining the abscess cavity.

General information

Abscess of the peri-maxillary – a limited focus of purulent inflammation of the tissues of the maxillofacial zone. In the absence of treatment for abscesses, purulent decay and purulent fusion of adjacent tissues begins.

Causes of peri-maxillary abscess

Abscess is caused by streptococcal and staphylococcal microflora, the most common cause is dental disease and inflammation in the maxillofacial area.Furunculosis, tonsillitis, tonsillitis in chronic course are complicated by peri-maxillary abscesses. Damage to the skin and mucous membranes in the mouth, drift of infection during dental procedures can provoke an abscess in the peri-maxillary zone.

General infectious diseases proceeding by the type of sepsis, as a result of the spread of microorganisms by blood and lymph, cause multiple abscesses in various organs and tissues, including abscesses of the peri-maxillary zone. A peri-maxillary abscess can occur due to facial trauma.During hostilities and natural disasters, due to lack of first aid, dislocations and fractures of the jaws are often complicated by abscesses. Peri-apical and pericoronary foci of inflammation and periodontal pockets during exacerbations can provoke an abscess of the jaw due to bone resorption.

Symptoms of a peri-maxillary abscess

The formation of an abscess is preceded by a toothache as in periodontitis. Biting in the affected area increases pain. Further, a dense edema joins with the formation of a painful seal.An abscess that develops under the mucous membrane is characterized by bright hyperemia and protrusion of the affected focus. Facial asymmetry is sometimes noted.

In the absence of therapy, the patient’s general condition worsens: body temperature rises, food refusal is observed. After spontaneous opening of the abscess, the pain subsides, the contours of the face take on normal outlines, the general well-being is stabilized. But due to the favorable conditions for microorganisms in the oral cavity, the process becomes chronic, therefore, its spontaneous opening does not mean a cure.

With short-term weakening of the immune system, peri-maxillary abscesses are exacerbated. Perhaps chronic suppuration from the fistulous passages, it is accompanied by an unpleasant odor from the mouth and the ingestion of purulent masses. The body becomes sensitized with decay products, and allergic diseases are aggravated.

For abscesses of the floor of the mouth, hyperemia in the sublingual area with rapid formation of an infiltrate is characteristic. Conversation and eating become sharply painful, hypersalivation is noted.The mobility of the tongue decreases, it rises slightly upward so as not to come into contact with the forming abscess. As the swelling increases, the general condition worsens. With a spontaneous opening, pus spreads into the periopharyngeal region and neck, which leads to the appearance of secondary purulent foci.

Palate abscess often occurs as a complication of periodontitis of the upper second incisor, canine and second premolar. During the formation of an abscess, hyperemia and soreness of the hard palate is observed, after swelling, the pain becomes more intense, food intake is difficult.With a spontaneous opening, the purulent contents spread to the entire area of ​​the hard palate with the development of osteomyelitis of the palatal plate.

If an abscess of the cheek occurs, then, depending on the location and depth, the swelling and redness may be more pronounced from the outside or from the oral mucosa. The soreness of the focus is moderate, with the work of the facial muscles, the pain increases. The general condition practically does not suffer, but an abscess of the cheek is dangerous by spreading to neighboring parts of the face even before the abscess is opened.

Tongue abscess begins with soreness in the thickness of the tongue, the tongue increases in volume, becomes inactive. Speech, chewing and swallowing of food are sharply difficult and painful. Sometimes, with an abscess, a feeling of suffocation may occur.

Diagnosis

The diagnosis is made on the basis of a visual examination by the dentist and the patient’s complaints. Sometimes during the survey it turns out that there were boils of the facial zone, there are chronic infectious diseases. Before visiting a doctor, it is recommended to take analgesics, rinse the oral cavity with antiseptic solutions; self-administration of antibiotics is unacceptable.The ultimate goal of treatment is the complete elimination of the infectious process and the restoration of impaired functions as soon as possible.

Treatment of a peri-maxillary abscess

The treatment regimen depends on the stage of the disease, on the virulence of the microorganism and on the characteristics of the response from the macroorganism. The localization of abscesses in the peri-maxillary zone, the age of the patient and the presence of concomitant diseases significantly affect the principles of treatment. The more complicating factors, the more intensive the therapy should be.

During the treatment of abscesses in the peri-maxillary zone, it is recommended to follow a diet with a predominance of pureed soups and purees. If there is a persistent refusal to eat, they resort to intravenous administration of protein solutions. In the presence of a formed abscess, its opening with subsequent drainage of the cavity is shown. In other cases, they resort to antibiotic therapy, and only if it is inexpedient, the question of surgical treatment is raised.

Antibiotics are prescribed in the form of injections or in tablet forms, in addition to a course of vitamin therapy.Shown are immunostimulants and detoxification therapy. Rinsing the mouth with warm solutions of furacilin and soda relieves swelling and prevents the spread of infection. In the presence of a pronounced pain syndrome, analgesics are used. When complex therapy is started on time, the prognosis is usually favorable, recovery occurs within 6-14 days.

Bacterial landscape of abscesses and phlegmon of the maxillofacial region in patients living in the Trans-Baikal Territory

The originality of the microbiocenosis of the oral cavity is due to the fact that the microflora inhabiting this ecological niche is influenced by numerous environmental factors and regulatory, protective mechanisms of the macroorganism [1-5 ].Transbaikalia is characterized by a high degree of insolation, a sharply continental climate with wide fluctuations in air temperature and wind speed, low humidity, dry air, which contributes to atrophy of the mucous membranes of the lips, nasal passages, upper respiratory tract, facial skin, etc. Transbaikalia has a low sanitary and hygienic level. The risk factors influencing the formation of oral microbiocenosis include the unfavorable ecological situation of the Trans-Baikal Territory (a high degree of air pollution, the presence of regions exceeding the maximum permissible radiation standards, dietary habits, etc.).).

Purpose of study – to determine the composition of the microflora of abscesses and phlegmons of the maxillofacial region (MFO) and to assess its sensitivity to widely used antibiotics in patients living in Transbaikalia.

Material and methods. Under our supervision, there were 188 patients with acute purulent diseases of the PMO at the age from 16 to 74 years. The ratio of odontogenic inflammatory diseases to non-odontogenic diseases was 3: 1. In case of odontogenic inflammatory diseases, the source of infection in 61.8% of cases was the molars of the lower jaw, in 19.1% – the molars of the upper jaw, in 4.4% – the lower premolars, in 9.7% – the upper premolars, in 2.2% – lower incisors, in 2.1% – upper incisors and in 0.7% – canines of the upper jaw.

To achieve this goal, all patients were divided into 3 groups: 1st group – 53 patients with periostitis of the jaws; 2nd group – 91 patients with maxillary abscesses; 3rd group – 44 patients with phlegmons of the ChLO. The control was the results obtained during the examination of 10 healthy people with intact dentition, without inflammatory and dystrophic processes in the tissues and organs of the oral cavity, as well as without acute and chronic concomitant diseases.

On admission and during treatment, patients underwent clinical, laboratory and microbiological studies.Clinical methods included collection of complaints, medical history and life. Patients were evaluated for their general condition, body temperature dynamics, number of bed-days and days of incapacity for work, disease outcome, postoperative wound condition, duration of suppuration, timing of edema and infiltration resorption. All patients were prescribed a standard clinical and laboratory examination minimum in accordance with the standards of the RF Ministry of Health ..

To assess the type and biological properties of the pathogen, 619 cultures were examined taken from the oral cavity and purulent wounds in patients with periostitis of the jaws, abscesses and phlegmons of the maxillary region.

Identification of isolated cultures of bacteria was carried out by morphological, tinctorial and biochemical properties. The identification of hemolytic, adhesive and other properties of bacteria was carried out in accordance with the Order of the Ministry of Health of the Russian Federation. In addition, the sensitivity of microorganisms to the most frequently used antibiotics in dentistry (ampicillin, gentamicin, lincomycin, cefotaxime, chloramphenicol, tetracycline, erythromycin, rifampicin) was studied by the method of “indicator” discs and serial dilutions on solid nutrient media, and the count of microorganisms was carried out according to the method A …A. Vorobyova (1998).

Statistical processing of the results was carried out using computer programs: Microsoft Excel and Statistica 6.0. with the calculation of the Student’s t-test and the Pearson correlation coefficient.

Studies in healthy and sick people were carried out with their informed consent and in accordance with the ethical principles presented by the Declaration of Helsinki of the World Medical Association.

Results. At the first stage of the study, the microflora characteristic of the oral cavity of healthy residents of Transbaikalia with intact dentition and no concomitant pathology was studied.Analysis of the microbial spectrum revealed that most of the microbial landscape of the oral cavity in them is made up of various types of facultative anaerobic bacteria that do not ferment gram-negative bacteria. In addition, the absence of Staph. aureus, Str. pyogenes, Bacillus, Fusobacterium, Peptostreptococcus, Peptococcus, Streptobacterium, Clostridium , sown in residents of other regions of Russia.

To study the characteristics of the microflora of the oral cavity during the development of HVZ in the ChLO, microbiological studies were carried out in patients treated in the dental clinic of the ChSMA.In the Central region of Chita, 28 people were examined, in the Ingodinsky region – 11, in the Chernovsky region – 11, in the Zheleznodorozhny region – 15, and the rest were residents of the countryside.

When studying the characteristics of the microflora of the oral cavity during the development of inflammatory diseases of the PMO, depending on the area of ​​residence, it was found that in the Central region of Chita, hemolytic and non-hemolytic streptococcus, Staphylococcus aureus, gram-negative bacilli, bacteroids, diphtheroids, opportunistic staphylococcus, peptopost micrococcus, veylonella, fungi of the genus Candida.The inhabitants of the Zheleznodorozhny and Chernovsky districts were dominated by hemolytic streptococci (22%) and bacilli (16%), and in the Ingodinsky district, the spectrum of pathogens was mainly hemolytic streptococcus and Staphylococcus aureus. The microbial flora of rural residents was inferior to urban residents in terms of the number of pathogenic strains.

Analysis of the types of microbial flora revealed that pathogenic streptococci (α- and β- haemoliticus ) with hemolytic activity and staphylococci (in particular, Staphylococcus aureus , hemolytic, saccharolytic and lysozyme activity.As a result of the study, it was found that bacterial associations, including staphylococci, pyogenic streptococci, peptostreptococci, micrococci, veilonella, diphtheroids, bacilli, bacteroids, E. coli, candida, are leading in the development of invasion in inflammatory diseases of the BLO.

The microflora of purulent wounds was analyzed taking into account the nosological form of the HVD of the MHO and the age of the patients. In the age group from 36 to 50 years with periostitis of the jaws, 9 types of microorganisms were identified: diphtheroids (24.68%), candida (24.68%), lactobacilli (15.42%), opportunistic streptococcus (11.31%) , hemolytic streptococcus (10.03%), peptostreptococcus (6.17%), streptobacteria (4.63%), Escherichia coli (1.54%), opportunistic staphylococcus aureus (1.54%).

In patients with jaw periostitis aged over 50, 11 types of microorganisms were identified: bacilli (27.0%), opportunistic staphylococcus (16.87%), hemolytic streptococcus (12.61%), lactobacilli (11.71%) ), opportunistic streptococcus (9.99%), streptobacteria (7.2%), bacteroids (6.0%), Staphylococcus aureus (4.5%), micrococcus (3.51%), actinomycetes (0, 6%) and single candida.

The spectrum of microflora in patients with MAP abscesses aged 16 to 35 years was represented by 17 species: hemolytic streptococcus (12.4%), actinomycetes (10.3%), opportunistic staphylococcus (9.2%), lactobacilli ( 8.7%), non-hemolytic streptococcus (8.5%), candida (8.3%), streptobacteria (7.9%), Staphylococcus aureus (7.1%), diphtheroids (6.2%), bacteroids ( 5.0%), bacilli (4.1%), veilonella (3.3%), fusobacteria (3.1%), micrococcus (2.6%), peptostreptococcus (2.0%), sarcins (1, 1%), diplobacteria (0.2%).

14 types of microorganisms were identified in patients with abscesses of the maxillary pelvis at the age of 36 to 50: hemolytic streptococcus (14.74%), opportunistic streptococcus (14.15%), opportunistic staphylococcus aureus (12.77%), intestinal coli (11.7%), streptobacteria (10.32%), peptostreptococcus (9.32%), Staphylococcus aureus (8.34%), lactobacilli (6.87%), bacteroids (2.94%) veilonella ( 2.21%), micrococcus (2.0%), diphtheroids (1.47%), sarcins (1.47%) and candida (1.47%).

9 types of microorganisms have been identified in patients with abscesses over the age of 50: Staphylococcus aureus (27.5%), opportunistic staphylococcus aureus (17.6%), peptostreptococcus (10.7%), streptobacteria (9.2%) , hemolytic streptococcus (9.2%), non-hemolytic streptococcus (7.9%), diphtheroids (3.0%), lactobacilli (3.0%), micrococcus (2.8%).

13 types of microorganisms were found in patients with phlegmons of the PMA aged from 16 to 35 years: spore-forming anaerobes (22.0%), Staphylococcus aureus (18.4%), opportunistic staphylococcus aureus (11.8%), hemolytic streptococcus ( 10.2%), streptobacterium (8.4%), non-hemolytic streptococcus (8.0%), diphtheroids (7.4%), peptostreptococcus (4.2%), micrococcus (2.5%), Escherichia coli ( 2.4%), opportunistic streptococcus (2.4%), bacteroids (1.2%), bacilli (1.1%).

In the age group from 36 to 50 years of patients with phlegmon of the PMO, only 7 types of microorganisms were noted: hemolytic streptococcus (26.32%), Staphylococcus aureus (24.2%), opportunistic staphylococcus aureus (23.35%), streptobacteria ( 13.2%), non-hemolytic streptococcus (5.52%), micrococcus (5.3%), bacilli (2.12%).

In patients of the older age group with phlegmons, 7 species were identified: streptobacteria (36.6%), Staphylococcus aureus (30.3%), Bacteroids (12.6%), non-hemolytic streptococcus (7.6%), bacilli (5, 1%), peptostreptococcus (4.0%), opportunistic staphylococcus (3.8%).

At the next stage of the study, we studied the sensitivity of cultures isolated from purulent foci in the ChLO to antibacterial drugs of the groups of penicillins, cephalosporins, tetracyclines, aminoglycosides, macrolides, chloramphenicol, rifampicins, lincosamines.

The results obtained indicate 100% sensitivity of all types of microorganisms isolated from patients with jaw periostitis to cefotaxime, moderate sensitivity of most microorganisms to ampicillin, gentamicin and rifampicin, and the lack of sensitivity of most microorganisms to lincomycin, tetracycline, erythromycin.

Patients with abscesses of the PMO showed a high sensitivity of all microorganisms to cefotaxime, gentamicin and rifampicin, moderate – to ampicillin, lincomycin and tetracycline – moderately sensitive, and they were resistant to erythromycin.

The highest sensitivity of the causative agents of phlegmon of the PMO was revealed to cefotaxime and gentamicin, moderate – to ampicillin, tetracycline and was practically absent to lincomycin, rifampicin and erythromycin. In addition, it should be pointed out that such pathogens of phlegmon of the ChLO, as saprophytic staphylococcus, hemolytic and non-hemolytic streptococcus, bacteroids, as well as micrococci, diphtheroids and clostridia, were especially resistant.

Conclusion. The revealed facts indicate that the number, type and nature of microflora changes noticeably in the examined patients at different age periods.In addition, it was noted that the characteristics of the microflora of the oral cavity of patients also significantly depends on the prevalence of the purulent-inflammatory process. The highest sensitivity of the causative agents of purulent-inflammatory processes of the MCL of patients living in Transbaikalia was revealed to cefotaxime and gentamicin, and the lowest – to lincomycin, rifampicin and erythromycin.

GBUZ RB City Clinical Hospital No. 21, Ufa

Pages:
1
2
3
4
5
…
fourteen
Track.

November 26, 2021
XIV All-Russian scientific-practical conference with inter…

On December 07-08, 2021, Moscow will host the XIV All-Russian Scientific and Practical Conference with international participation “Medicine and Quality – 2021”

November 26, 2021
The fight against coronavirus is everyone’s business!

Taking a swab from the throat and nose for patients is an unpleasant procedure. Therefore, specialists who take biomaterials require not only knowledge and experience, but also courage and endurance to work in a hazardous area.

November 21, 2021
Day of Remembrance for Traffic Victims

Every third Sunday in November is World Day of Remembrance for Road Traffic Victims. Traffic rules have been taught since childhood, but for some reason it is adults who often neglect them.

November 19, 2021
Insurance representatives

Insurance representatives are always ready to advise you on compulsory health insurance issues and help you.The Federal Compulsory Medical Insurance Fund has prepared a social video “Insurance representatives”.

12 November 2021
Day of the trade union worker of the Republic of Bashkortostan

November 12 Day of the trade union worker of the Republic of Bashkortostan. We congratulate Svetlana Abdrakhmanova, chairman of the trade union committee of GBUZ RB GKB №21, Ufa, on another professional Day.

November 2, 2021
Palliative care

Palliative care is a comprehensive care for a person with an incurable progressive disease, as well as care for his loved ones.To help such patients, 10 palliative beds were deployed at the Bulgakov District Hospital, where more than 240 patients were treated in a year.

November 1, 2021
How will the medical institutions of Bashkiria work in …

During non-working days from October 30 to November 7, the structural units of the polyclinic No. 2 of the Ufa district of the City Clinical Hospital No. 21 of Ufa operate in the following mode:

October 1, 2021
World Heart Day

We are having fun getting away from a heart attack.On Heart Day, our doctors organized cardio exercises in the Forestry Park.

September 24, 2021
Autumn cleaning

The main purpose of the autumn cleaning is to prepare the territory of the hospital for winter, to clear it of debris and fallen leaves. I am glad that our colleagues responded to the call to go out into the fresh air and, armed with equipment, put in order the areas

July 22, 2021
The portal of the Ministry of Health of the Russian Federation on oncological diseases.