Periodontal or periapical abscess or cellulitis (ie, that began as a periapical abscess and is now spreading into adjacent soft tissues)
Signs of rapidly spreading infection (eg, high fever, tachycardia, tachypnea) or upper airway obstruction (eg, stridor, muffled voice): Such patients should be rapidly evaluated and managed in an emergency department.
Infection spreading to the skin surface: Such patients should be referred to an oral and maxillofacial surgeon, for extraoral incision and drainage of the abscess.
Infection in the path of needle insertion: Use nerve block, or other anesthesia.
Coagulopathy*: When feasible, correct prior to procedure.
Pregnancy: Avoid treatment in the 1st trimester if possible.
* Therapeutic anticoagulation (eg, for pulmonary embolism Pulmonary Embolism (PE) Pulmonary embolism (PE) is the occlusion of pulmonary arteries by thrombi that originate elsewhere, typically in the large veins of the legs or pelvis. Risk factors for pulmonary embolism are... read more ) increases the risk of bleeding with dental procedures, but this must be balanced against the increased risk of thrombosis (eg, stroke Overview of Stroke Strokes are a heterogeneous group of disorders involving sudden, focal interruption of cerebral blood flow that causes neurologic deficit. Strokes can be Ischemic (80%), typically resulting... read more ) if anticoagulation is reversed. Discuss any contemplated reversal with the clinician managing the patient's anticoagulation and then with the patient.
Local anesthetic complications
Spread of infection
Failing to adequately drain the abscess
Dental chair or a stretcher
Light source for intraoral illumination
Mask and safety glasses, or a face shield
Dental mirror or tongue blade
Antiseptic oral rinse (eg, chlorhexidine, 0.12%)
Scalpels (#11 or #15 blade)
Retractors (eg, Minnesota cheek retractor or tongue retractor)
Suture (eg, 3-0 silk or other soft nonabsorbable suture)
Penrose drain (1 cm) or substitute (eg, strip cut from a sterile glove)
Equipment to do local anesthesia:
Topical anesthetic ointment* (eg, lidocaine 5%, benzocaine 20%)
Injectable local anesthetic such as lidocaine 2% with or without epinephrine† 1:100,000, or for longer duration anesthesia, bupivacaine 0.5% with or without epinephrine† 1:200,000
Dental aspirating syringe (with narrow barrel and custom injectable anesthetic cartridges) or other narrow barrel syringe (eg, 3 mL) with locking hub
25- or 27-gauge needle: 2 cm long for supraperiosteal infiltration; 3 cm long for nerve blocks
* CAUTION: All topical anesthetic preparations are absorbed from mucosal surfaces and toxicity may result when dose limits are exceeded. Ointments are easier to control than less-concentrated topical liquids and gels. Excess benzocaine rarely may cause methemoglobinemia.
† Maximum dose of local anesthetics: Lidocaine without epinephrine, 5 mg/kg; lidocaine with epinephrine, 7 mg/kg; bupivacaine, 1.5 mg/kg. NOTE: A 1% solution (of any substance) represents 10 mg/mL (1 gm/100 mL). Epinephrine causes vasoconstriction, which prolongs the anesthetic effect. Patients with cardiac disease should receive only limited amounts of epinephrine (maximum 3.5 mL of solution containing 1:100,000 epinephrine); alternatively, use local anesthetic without epinephrine.
Local anesthetic injections placed into an abscess may be ineffective (due to the low pH environment) so more solution than normal may be required. Be careful not to exceed maximum dose. Local injections also risk spreading the infection, so a dental nerve block, procedural sedation, or other anesthesia is preferred. Local infiltrations may be placed in uninfected tissue adjacent to an abscess if needed to supplement a nerve block.
Do a periapical or panographic x-ray to verify the source of the infection, location and extent of bone destruction, and the type and extent of the abscess.
Antibiotic prophylaxis for endocarditis Prophylactic antibiotic regimens Infective endocarditis is infection of the endocardium, usually with bacteria (commonly, streptococci or staphylococci) or fungi. It may cause fever, heart murmurs, petechiae, anemia, embolic... read more should be given to certain high-risk patients High-risk patients Infective endocarditis is infection of the endocardium, usually with bacteria (commonly, streptococci or staphylococci) or fungi. It may cause fever, heart murmurs, petechiae, anemia, embolic... read more prior to drainage of a tooth abscess.
Microbiologic testing is not usually needed for localized abscesses, but should be done if the patient is immunocompromised, if the infection is recurrent, or if the patient has failed previous surgical/antibiotic therapy.
Abscesses that are drained by intraoral incision include:
Periodontal abscess originating between the tooth and its gum line, with possible extension into adjacent fascial spaces (eg, vestibular or buccal space)
Periapical abscess that has spread through the tooth, out the apex, through the surrounding bone, and into the surrounding soft tissues/fascial spaces
Position the patient inclined, with the patient's head at the level of your elbows and the occiput supported.
For the lower jaw, use a semi-recumbent sitting position, making the lower occlusal plane roughly parallel to the floor when the mouth is open.
For the upper jaw, use a more supine position, making the upper occlusal plane roughly 60 to 90 degrees to the floor.
Turn the head and extend the neck such that the abscess site will be accessible.
Step-by-Step Description of Procedure
Wear sterile gloves and a mask and safety glasses, or a face shield.
Retract soft tissues (eg, cheek or tongue) to expose the abscess.
Use gauze to thoroughly dry the area. Use suction as needed to keep the area dry. Use a cheek or tongue retractor as needed to visualize the area.
Apply topical anesthetic with cotton-tipped applicators, and wait 2 to 3 minutes for the anesthesia to occur.
Do a site-appropriate nerve block, but only if the anesthetizing needle will not track the infection into uninfected tissue (refer to How To Do an Inferior Alveolar Nerve Block How To Do an Inferior Alveolar Nerve Block An inferior alveolar nerve block, the most common dental nerve block, anesthetizes the ipsilateral hemi-mandible (including teeth and bone), as well as the lateral (buccal) mucosa over the lower... read more ; How To Do an Infraorbital Nerve Block, Intraoral How To Do an Infraorbital Nerve Block, Intraoral An infraorbital nerve block anesthetizes the ipsilateral lower eyelid, upper cheek, side of the nose, and upper lip. Laceration or other surgically treated lesion of the midface A nerve block... read more ; How To Do a Mental Nerve Block How To Do a Mental Nerve Block A nerve block of the mental nerve anesthetizes the ipsilateral lower lip and skin of the chin, as well as the lateral (buccal) gingiva and mucosa anterior to the mental foramen up to the midline... read more ; or How To Do a Supraperiosteal Infiltration How To Do a Supraperiosteal Infiltration Supraperiosteal infiltration anesthetizes single teeth and is used to anesthetize maxillary teeth in adults and any tooth in children. Supraperiosteal infiltration is not effective for teeth... read more ).
Alternatively (or if the nerve block is not adequate), do local infiltration (field block) around the abscess: Inject 1 to 2 mL into the mucosa anterior and posterior to the abscess, and then at sites along the circumference. Do not pass the needle into any infected tissue.
Allow sufficient time for anesthetic to take effect (5 to 10 minutes).
While awaiting onset of anesthesia, have the patient do a 30-second swish-and-spit with 0.12% chlorhexidine oral rinse. If chlorhexidine is not available, swab the incision site with povidone iodine.
Consider sedation or other anesthesia if needed.
Incise and drain the abscess
Palpate the abscess to determine its extent and the area where maximum dependent drainage can be obtained.
Make a 1- to 2-cm incision into the abscess near its most fluctuant point but not into necrotic or friable tissue if possible. Try to enter perpendicular to underlying bone.
Use suction and gauze squares to remove the exuding pus.
Insert a hemostat into the full depth of the abscess space. Open the jaws to break up any loculations. Do this in multiple directions to open into the entire space. With each entry, once the jaws are opened, do not close them while in the abscess space, to avoid crushing vital structures and keep the jaws open as you remove the hemostat.
Copiously irrigate the abscess space with sterile saline using a large syringe with a plastic IV catheter attached. Do not irrigate forcibly; all fluid introduced should be seen to passively flow back out and be suctioned up.
For larger infections, insert a segment of Penrose drain (1 cm diameter) or a substitute (eg, a cut strip of sterile glove) to the full depth of the abscess space and secure it with a single nonabsorbable suture (eg, 3-0 silk) in healthy tissue near the edge of the incision.
Instruct the patient to apply warm, moist compresses frequently, take an NSAID (nonsteroidal anti-inflammatory drug, such as ibuprofen 400 mg every 6 hours), and rinse the mouth with warm salt water every 2 to 3 hours for 3 to 5 days (or until follow-up appointment) to stimulate local blood flow and help relieve pain.
Patients with diabetes should monitor their blood sugar carefully.
Unless the infection was very localized, give an oral antibiotic (eg, amoxicillin 500 mg 3 times a day for 7 days, or clindamycin 300 mg 4 times a day for 7 days).
Encourage patients with significant infection to consume extra fluid and nutrition (ie, to compensate for poor oral intake prior to treatment of the infection and aid healing)
Arrange dental follow-up in 1 to 2 days, to evaluate the drain for removal.
Warnings and Common Errors
A too-small incision will commonly result in tearing of mucosa; err on the side of too long (at least 1 to 2 cm).
An incision that is not sufficiently deep will hamper effective drainage. In general, incise at least to the depth of the swelling, or down to bone (particularly important for abscesses that have spread by dissecting under the periosteum).
For an abscess near the infraorbital or mental nerve, place the incision so as to avoid injury to these structures, and dissect carefully.
Tricks and Tips
If the initial level of anesthesia is suboptimal, preliminary drainage and copious irrigation to remove pus can improve the pH and allow additional local anesthetic to be more effective.