Introduction

Neck phlegmon is a diffuse purulent inflammation of the fascial spaces that develops due to the penetration of infection through various routes, including odontogenic, gingival, mucostomatogenic, and other sources. Infection of the cervical fascial spaces is most often associated with the spread of pathogens from primary foci localized in the oral cavity and paranasal structures, which requires thorough analysis of etiopathogenetic mechanisms for timely diagnosis and prevention of complications. The most common causes are odontogenic sources, noted in 84% of patients: the infection is localized in gangrenous or periodontitic teeth, penetrating through apical foramina into lymphatic and blood vessels, bone tissue, and surrounding soft tissues [1]. Gingival sources are associated with purulent-inflammatory processes in gingival pockets in periodontitis, while mucostomatogenic factors include ulcerative-necrotizing stomatitis, glossitis, and traumatic injuries of the oral mucosa. Intraosseous infections arise from inflammatory processes in the jaws and paranasal sinuses, such as osteomyelitis, periostitis, suppurated cysts and granulomas, complications of wisdom tooth eruption, infected fractures of the facial skeleton bones, as well as sinusitis, frontal sinusitis, and ethmoiditis.

Less common are sialogenic sources associated with inflammation of the salivary glands, tonsillopharyngeal sources from chronic tonsillitis and pharyngitis, rhinogenic and otogenic sources due to infections of the nose or ear. Rare but significant factors include furuncles, carbuncles, suppurated atheromas, as well as the introduction of infection due to violations of aseptic and antiseptic rules during anesthesia [2]. All these mechanisms underscore the necessity of a comprehensive approach to identifying and eliminating potential sources of infection to prevent the development of life-threatening complications.

Neck phlegmon most often develops as a result of the progression of infection arising from untimely treated or neglected dental pathologies. The main source of infection becomes affected teeth, especially in cases of caries complications such as pulpitis, periodontitis, and periodontal abscesses, which create a direct pathway for microorganisms to penetrate into the bone tissue and surrounding soft tissues [3]. The infection, penetrating through the apical foramina of the tooth roots, triggers an inflammatory cascade capable of spreading deep into the cervical fascial spaces, especially in the absence of adequate therapy. Dangers are also posed by the consequences of improperly performed tooth extractions, accompanied by the formation of alveolar abscesses, as well as suppurated jaw cysts and traumatic injuries of the oral mucosa infected due to breaches in aseptic rules.

In light of the above, the aim of the study is to analyze the assessment of the risk of developing neck phlegmon in oral cavity diseases.

Materials and methods

Scientific studies devoted to assessing the risk of developing neck phlegmon in oral cavity diseases were analyzed. The analysis was conducted based on various databases: Scopus, Web of Science, MedLine, Science Direct, PubMed, and the scientific electronic library eLIBRARY.ru.

Research results

Bacterial agents, predominantly anaerobic and gram-negative microorganisms, are capable of rapid spread through lymphatic vessels or directly along anatomical planes, which is exacerbated by individual characteristics of the cervical region structure and a reduced immune response [4]. This makes the early identification of risk factors, such as chronic inflammatory processes in the maxillofacial region, systemic immunodeficiency states, and insufficient debridement treatment, critically important. A comprehensive approach to diagnosis and prevention, including thorough examination, imaging of anatomical structures, and microbiological analysis, allows for minimizing the likelihood of developing neck phlegmon and its life-threatening complications.

Pathogens can include Streptococcus, Staphylococcus, Diplococcus, Pneumococcus, Escherichia coli, Pseudomonas aeruginosa, Fusobacterium, Treponema denticola, and various types of anaerobes (Bac. perfringens, Bac. histolyticus, etc.) [5].

The clinical classification of purulent-inflammatory processes of the maxillofacial region and neck, proposed by A.I. Evdokimov [6], takes into account anatomical features and the topography of inflammation. According to this system, abscesses and phlegmons are divided into groups depending on their location: lesions near the maxilla (infraorbital, zygomatic, orbital regions, temporal and infratemporal regions, pterygopalatine fossa, hard and soft palate); near the mandible (mental, submental, buccal, submandibular regions, pterygomandibular, parapharyngeal, and masticatory spaces, parotid gland region, retromandibular fossa); phlegmons of the floor of the mouth (upper and lower sections), as well as lesions of the tongue and neck.

It is important to distinguish the etiology of the processes: odontogenic infections arising from pathologies of teeth, periodontium, or jaws, and non-odontogenic ones caused by trauma, infection during anesthesia, inflammation of ENT organs (tonsillitis, otitis, rhinitis), or pyogenic skin lesions [7]. Such differentiation allows for determining the route of infection spread and choosing adequate treatment tactics. For example, phlegmons of the submandibular region are more often associated with odontogenic foci, while lesions of the retromandibular fossa may be a consequence of purulent processes in the parotid gland or ear infections.

The choice of therapeutic strategy directly depends on the location and source of the infection. In odontogenic processes, a critical step is the elimination of the primary focus—extraction of the affected tooth or drainage of the abscess—while in non-odontogenic forms, comprehensive treatment of the underlying disease is required (e.g., sanitation of ENT organs or antibiotic therapy). Early diagnosis using imaging methods (CT, MRI) and microbiological analysis, as well as an interdisciplinary approach, ensure a reduced risk of complications and improved prognosis.

The treatment of abscesses and phlegmons of the maxillofacial region strictly follows the principle "Ubi pus, ibi evacua"—mandatory evacuation of pus, making early surgical incision an integral stage of therapy [8]. The effectiveness of the intervention depends on the accurate determination of the location and extent of the infection, which requires consideration of the anatomical features of the affected areas. For example, in cases of submandibular phlegmon, drainage through a submandibular incision is necessary, and if deep neck spaces are involved, the access must be widened to prevent the spread of infection into the mediastinum.

Simultaneously with the surgical elimination of the lesion, antibacterial therapy is indicated. Its choice is based on the presumed spectrum of pathogens (often mixed aerobic-anaerobic flora) and antibiotic sensitivity, especially in patients with systemic complications or immunosuppression [9,10]. It is important to note that antibiotics do not replace drainage but complement it, reducing the risk of septic complications.

A comprehensive approach also includes correction of the patient's general condition: detoxification therapy, normalization of the temperature response, and support of the immune response. The success of treatment is determined by the timeliness of diagnosis, the adequacy of the surgical stage, and consideration of comorbidities, especially in individuals with diabetes mellitus, oncological diseases, or HIV, in whom the risk of recurrences and complications is significantly higher [11].

The postoperative period requires strict monitoring of the dynamics of inflammation, prevention of thromboembolic complications, and regular sanitation of drainage pathways. Key criteria for therapy effectiveness are the regression of inflammatory phenomena, restoration of chewing function and mouth opening, and the absence of signs of systemic spread of infection. Thus, success in combating neck phlegmon is determined not only by the technical precision of the operation but also by a multidisciplinary strategy aimed at eliminating the primary focus and minimizing the risk of recurrence.

The development of neck phlegmon in patients with odontogenic infections is directly related to a number of provoking factors that significantly increase the risk of systemic complications [12]. The most significant of these include the general condition of the body, including the presence of diabetes mellitus, immunodeficiency states (e.g., HIV, oncological diseases), and chronic pathologies that reduce the body's resistance. Special risk groups are elderly patients with weakened immunity and children with an insufficiently formed protective response. Additional factors contributing to the progression of infection are advanced forms of caries accompanied by abscesses, fistulas, and periostitis, as well as harmful habits such as smoking and alcohol abuse, which negatively affect microcirculation and tissue regeneration.

Effective prevention of neck phlegmon is impossible without a systematic approach, including primary and secondary measures. Key elements are the early diagnosis and treatment of caries, pulpitis, and periodontitis, as well as the preventive extraction of teeth posing a potential threat (e.g., impacted or dystopic wisdom teeth) [13]. It is crucial to adhere to strict rules of asepsis and antisepsis during surgical interventions, including tooth extractions, which is especially critical for patients with risk factors. Antibiotic prophylaxis is indicated for those at high risk of infectious complications, for example, individuals with immunosuppression or cardiac pathologies.

The patient's role in maintaining oral health is equally important: education in hygiene skills, the use of irrigators, toothpastes with anti-inflammatory effects, and regular preventive dental check-ups. These measures allow for the detection of pathology at a preclinical stage and prevent its transition into purulent-inflammatory processes.

However, in cases of already developed neck phlegmon, timely specialized care is decisive. Treatment must begin immediately and include surgical drainage of purulent foci, evacuation of infection from the fascial spaces, and adequate broad-spectrum antibiotic therapy targeting both aerobic and anaerobic flora [14]. In severe cases, intensive therapy with hemodynamic correction, detoxification, and organ support is indicated. Early hospitalization in a specialized department becomes a mandatory condition, allowing for the minimization of the risk of fatal outcomes and complications such as mediastinitis or sepsis.

Thus, success in the prevention and treatment of neck phlegmon is determined by a combination of primary oral cavity debridement, monitoring of risk factors, and strict adherence to treatment algorithms, which requires close interaction between dentists, maxillofacial surgeons, and infectious disease specialists.

Conclusion

In conclusion, it should be noted that assessing the risk of developing neck phlegmon in oral cavity diseases is a crucial element of effective clinical practice. Early diagnosis, timely and adequate treatment, as well as adherence to preventive measures, are critically important for reducing the risk of this dangerous complication and improving the prognosis for patients. A comprehensive, multidisciplinary approach to treatment ensures the best results and minimizes risks. The continuous improvement of diagnostic and treatment methods, increasing the awareness of medical personnel and the population about the prevention of odontogenic infections, is the key to improving patients' quality of life and reducing the burden of this potentially fatal disease.