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How To Drain a Tooth Abscess

By

Peter J. Heath

, DDS, MD, American Board of Oral and Maxillofacial Surgeons

Last full review/revision Dec 2019| Content last modified Dec 2019
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NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version

Intraoral incision and drainage of an uncomplicated tooth abscess is done to provide analgesia and limit further and deeper spread of the infection.

Indications

  • Periodontal or periapical abscess or cellulitis (ie, that began as a periapical abscess)

Contraindications

Absolute contraindications

  • 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.

Relative contraindications

  • 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) increases the risk of bleeding with dental procedures, but this must be balanced against the increased risk of thrombosis (eg, stroke) if anticoagulation is reversed. Discuss any contemplated reversal with the clinician managing the patient's anticoagulation and then with the patient.

Complications

  • Local anesthetic complications

  • Spread of infection

  • Failing to adequately drain the abscess

Equipment

  • Dental chair or a stretcher

  • Light source for intraoral illumination

  • Sterile gloves

  • Mask and safety glasses, or a face shield

  • Gauze pads

  • Cotton-tipped applicators

  • Dental mirror or tongue blade

  • Suction

  • Antiseptic oral rinse (eg, chlorhexidine, 0.12%)

  • Scalpels (#11 or #15 blade)

  • Retractors (eg, Minnesota cheek retractor)

  • Needle driver

  • Hemostat

  • 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.

Additional Considerations

  • 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 should be given to certain high-risk patients 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.

Relevant Anatomy

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

Positioning

  • 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.

Provide anesthesia

  • Use gauze to thoroughly dry the area. Use suction as needed to keep the area dry.

  • 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 a Mental Nerve Block, or How To Do a Supraperiosteal Infiltration).

  • 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.

Aftercare

  • 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.

Drugs Mentioned In This Article

Drug Name Select Trade
AMOXIL
MARCAINE
CLEOCIN
ADRENALIN
ANBESOL
ADVIL, MOTRIN IB
XYLOCAINE
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NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
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