Cellulitis is a common bacterial infection of the skin and underlying tissues. When this infection occurs in the facial region, it is often called orofacial or odontogenic cellulitis. This serious infection begins in or around the oral cavity and can spread rapidly into the deep soft tissues of the face and neck. Due to the proximity of the mouth to critical structures like the airway and brain, any suspicion of oral cellulitis requires immediate medical attention.
Where Oral Cellulitis Develops
Oral cellulitis frequently starts from a dental infection and develops in the soft tissues of the face and neck connected to the oral cavity. The infection often spreads along fascial planes, which are layers of connective tissue separating muscles and organs. Key areas include the submandibular space beneath the jaw and the sublingual space under the tongue.
The proximity of dental roots makes these deep facial spaces vulnerable to infection spread. Infection can also affect the masticator space, leading to difficulty opening the mouth. If the infection spreads further, it can track into the parapharyngeal and retropharyngeal spaces of the neck, or in severe cases, reach the periorbital area or the chest.
Root Causes of Oral Cellulitis
The primary sources of bacterial entry are odontogenic, meaning they originate from the teeth or gums. Untreated dental caries, or tooth decay, is the most common initiating factor. This decay leads to the death of the dental pulp and the formation of a periapical abscess. The bacteria then migrate through the bone plate and infiltrate the soft tissues.
Severe periodontal disease, the infection of the gums and supporting structures, also provides a pathway for bacteria to enter the soft tissue. Other causes include complications from recent tooth extractions, oral trauma, and pericoronitis associated with impacted wisdom teeth. The infection is typically polymicrobial, involving a mix of aerobic and anaerobic bacteria like Streptococcus, Staphylococcus, and Bacteroides species. Individuals with weakened immune systems, such as those with diabetes, are at a higher risk.
Identifying Symptoms
Recognizing the symptoms of oral cellulitis is important because the infection progresses rapidly. The most noticeable local sign is a diffuse, tender swelling of the face, jaw, or neck that lacks a distinct border. This differentiates it from a localized abscess, which has a contained collection of pus. The affected area often appears red and feels warm to the touch due to the inflammatory response.
This swelling is accompanied by significant pain and tenderness, often felt in the jaw or neck. Systemic symptoms are common as the body fights the infection, including fever, chills, and malaise. A rapid spread of the swelling, sometimes within hours, signals that the infection is advancing aggressively through the facial tissues.
The patient may experience trismus (difficulty opening the mouth fully) and dysphagia (difficulty swallowing) as the swelling compromises muscle function. In advanced cases, swelling on the floor of the mouth can elevate the tongue, leading to drooling or difficulty speaking. Any sign of spreading swelling that causes difficulty breathing or swallowing indicates a medical emergency.
Medical Intervention and Management
Management of oral cellulitis must be initiated immediately to prevent life-threatening complications. Treatment begins with broad-spectrum intravenous (IV) antibiotics, which quickly achieve high concentrations at the site of infection. Common antibiotic choices target the mixed population of bacteria typical of oral infections, including agents effective against both aerobes and anaerobes.
Hospitalization is frequently required, particularly if the infection involves deep facial spaces, systemic toxicity, or a threatened airway. Securing the airway is the highest priority, sometimes necessitating intubation or a tracheostomy. This is often needed if swelling, such as in the severe form known as Ludwig’s angina, causes respiratory distress. Ludwig’s angina is a rapidly spreading cellulitis of the floor of the mouth that can obstruct the airway.
Surgical intervention is often necessary to drain the infection and remove necrotic tissue, a procedure known as incision and drainage (I&D). This step relieves pressure and allows antibiotics to penetrate the infected area more effectively. Addressing the source of the infection is also essential, usually involving a dental procedure like extraction of the causative tooth or root canal therapy. Untreated oral cellulitis can lead to severe complications, including sepsis (spread of infection to the bloodstream) or mediastinitis (infection in the chest cavity).