Ludwig's Angina

Ludwigs angina is an overwhelming diffuse, suppurative cellulitis, which simultaneously involves the submandibular, sublingual and submental spaces.

Predisposing factors:-

Diabetes Mellitus.

HIV Infection

Oral Transplants

Aplastic Anemia

Causative Microorganisms:-

Hemolytic streptococci.

Staphylococci.

Bacteroides.

Primary source of Infection:-

Periapical, pericoronal or periodontal infection.

Gunshot injury.

Stab wound on floor of mouth.

Osteomyelitis.

Infection of orofacial soft tissue.

Peritonsillar or parapharyngeal abcess.

Submandibular sialadenitis.

Pathogenesis:-

Sublmandibular, sublingual and submental space are involved simultaneously.

Although it occurs one after another the spread of infection is so rapid that it seems that it involves all the spaces together. 

Infection from mandibular second and third molar teeth often perforates the lingual cortical plate (bucal cortical plate is much harder so it is not usually perforated).

Clinical Features:-

Produces a rapdly spreading, large, diffuse and board like aggressive swelling.
This swelling involves the upper part of the neck and floor of the mouth bilaterally.
The swelling causes elevation of the tongue.
Open mouthed appearance.
Enlarged tongue may protrude outside the mouth = WOODY TONGUE.
Swollen area is firm, painful non fluctuant and non pitting.
Dificulty in speaking, swallowing and mouth opening.
High fever, chill rapid pulse, dysphagia, sore throat, drooling and increased respiratory rate.
If untreated cellulitis may spread further and cause a massive swelling in neck and above the hyoid bone, this condition is known as BULL NECK.
 Further there may be development of EDEMA GLOTTIS. (which is a serious condition and may result in death).

COMPLICATIONS:-

Cavernous sinus thrombosis.

Meningitis.

Brain abcess.

Suppurative encephalitis.

(clinical feature of the disease are often very specific)

Diagnosis:-

Leukocytosis.

Bacterial culture.

Treatment:-

High dose of antibiotics.
Drainage by incision at the anterior part of the neck.
Emergency tracheostomy may be required in cases of airway obstruction.

Odontogenic Neoplasm : Ameloblastoma

Ameloblastoma is a locally agressive neoplasm arising from the odontogenic epithelium and it is the most common odontogenic neoplasm of the oral cavity.

Amel = enamel
Blastos = germ

The name ameloblastoma was given by Ivey and churchill in the year 1934.

ETIOLOGY 

Exact etiology is unknown but these are the predisposing factors:-

• Trauma
• Infection
• Previous Inflammation
• Extraction of tooth
• Dietary factors
• Viral Infection

PATHOGENESIS

Exact cell of origin is unknown but it possibly arises from the following:-

• Enamel Organ of developing tooth germ.
• Cell rest of Serre (remnants of dental lamina).
• Epithelial lining of odontogenic cyst (especially the dentigerous cyst).
• Oral epithelium (basal cell layer) (rarely).
• REE (reduced enamel epithelium)
• Cell rest of Malassez.

CLINICAL FEATURES

Incidence : 1% of all oral tumors.

                 18% of all odontogenic tumors.

Age :         II, III, IV, V decade of life.

                 mean age of occurance is 32 years.

Race :       Blacks > White      

Sex :        M > F

Site :        Mandible = 80 % (especially in molar ramus area).

               Maxilla = 20 %

              

Extraosseous or peripheral ameloblastomas can rarely occur mostly in relation to the gingiva.

TYPES

     

• Unicystic
• Multicystic
• Peripheral
• Malignant

CLINICAL PRESENTATION

• Slow enlarging

• Painless

• Ovoid

• Bony hard swelling

• Lesion caused expansion and distortion of the cortical plates of the jawbone and displacement of the regional teeth which leads to gross facial asymmetry.

• Pain, paresthesia and mobility of the regional teeth may be present.

• Egg shell crackling.

• Mucosa overlying is normal

• Tooth of the involved region are vital.

• Small lesion may remain aymptomatic for long duration of time.

• Detected incidentally during routine examination.

• Large lesion may perforate the cortical plates.

• Maxillary tumor may invade the maxillary air sinus and further upto the orbit or the nasopharynx.

RADIOGRAPHIC FEATURES

• Well defined, multilocular, radiolucent area in bone.

• Honey Comb or Soap Bubble appearance.

• Few lesions are unilocular.

• Larger lesion may cause expansion or perforation of buccal and lingual cortical plates.

• Irregular or scalloped margin.

DIFFERENTIAL DIAGNOSIS

1. Dentigerous cyst.
2. Odontogenic keratocyst.
3. Central giant cell granuloma.
4. Aneurysmal bone cyst.
5. Pindborg's tumor.

Macroscopic Features

• Egg shell cracking
• Greyish white or greyish yellow.
• May contain straw coloured fluid.
• Sometimes tooth may be present within the lesion.

TREATMENT

Surgical enucleation of the tumor and thorough curettage og surrounding bone. Recurrence is common. Sometimes radical surgical approach may have to be adopted in cases of repeated recurrence. Some tumors may cause distant metastasis.

Dental insurance can change the current scenario of dentistry in India

Dental health insurance is taken very seriously in the western world. However, in India, it is still in its nascent stage with very few insurance companies providing the service.

India has 290 dental colleges, which is about four times the number of dental schools in the US. Thousands of graduates are passed out every year from these colleges. Government jobs are very few for dental graduates and private practice is the only option for most of them. Though dental health is of utmost importance, it is not taken seriously in developing countries like India. The reason behind it is lack of education and lack of money. People rush to dentist only when they have toothache. No one bothers about regular scaling and oral checkups like in the western world. Because of which dentists are not receiving good amount of patients and people are not receiving good oral health care.

Dental Insurance would be a boon for both dental professionals and common population. It will make them more conscious about their oral health and hygiene. People with dental insurance policy would not think before visiting their dentist, reason being they would not have to pay for the treatment. It will increase the patient influx and hence will create a better future for oral health care professionals and help providing better treatment to the population. I hope that Indian government and Dental Council of India (DCI) will work in this direction.