Maxfacts

The following conditions are effectively an extension of the pathological process initiated by the “simple” dental abscess. This information is worth considering in relation to the other maxillofacial infections.

Cervicofacial abscess

A far more substantial problem than a “simple” dental abscess as here the infection has tracked through the fascial spaces of the neck and collected in particular areas. A cervicofacial abscess may develop from dental decay, from a dental abscess or from jaw injury.

Ludwig’s angina

This is a dangerous condition in which there is bilateral involvement of the sublingual and submandibular spaces. This results in elevation of the floor of the mouth and tongue and marked oedema of the soft tissues of the neck. Ludwig’s angina is most commonly the consequence of dental sepsis but may complicate submandibular gland infection, infection of a mandibular fracture or of an intraoral wound. There is marked systemic upset and hard swelling of the neck and floor of mouth. Inability to swallow ones own saliva is a major indicator of deterioration. The airway is at definite risk. A variety of oral commensal bacteria have been implicated.

Necrotising fasciitis

This is an uncommon, but life-threatening condition, which may affect the head and neck and be rapidly fulminant. The mortality approaches 40%. The term necrotising soft tissue infection is preferred by some. This is because it is felt that this more accurately reflects the process as the fascial boundaries are frequently transgressed by the infection. It also overcomes arguments about whether or not there are involved “deep fascial components” in the face as in reality it is more frequently a necrosis of muscle, fat and skin in the head and neck, with necrotic muscle causing the classical undermining skin infection and necrosis.

It is frequently a polymicrobial infection, with group A streptococci most commonly isolated (s. Milleri is frequently found). It is felt to be more common in patients with some form of immunocompromise. The initial site of infection may be so trivial as to be unnoticed by the patient. The subsequent systemic upset and tissue destruction is disproportionate to the initial infection. The soft tissue destruction is characterised by liquefaction of the subcutaneous fat and connective tissue. Small vessel thrombosis gives rise to a mottled appearance of the affected skin. A rapidly progressive systemic inflammatory response syndrome (SIRS) with multiorgan failure is frequent.