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How To Drain a Tooth Abscess

By

Peter J. Heath

, DDS, MD, Edison Lakes Oral Surgery, PC

Last full review/revision Dec 2019| Content last modified Dec 2019
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Intraoral incision and drainage of an uncomplicated tooth abscess is done to provide analgesia and limit further and deeper spread of the infection.

Indications for Draining a Tooth Abscess

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

Contraindications to Draining a Tooth Abscess

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 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 Pulmonary Embolism (PE) ) 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 Overview of Stroke ) if anticoagulation is reversed. Discuss any contemplated reversal with the clinician managing the patient's anticoagulation and then with the patient.

Complications of Draining a Tooth Abscess

  • Local anesthetic complications

  • Spread of infection

  • Failing to adequately drain the abscess

Equipment for Draining a Tooth Abscess

  • 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 for Draining a Tooth Abscess

Relevant Anatomy for Draining a Tooth Abscess

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 for Draining a Tooth Abscess

  • 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

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 for a Drained Tooth Abscess

  • 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 of Draining a Tooth Abscess

  • 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.

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A 12-year-old girl is brought to the office by her grandmother because she has had pain in her mouth for the past week. The patient appears to be drooling. Physical examination shows a smooth red tongue. Tenderness is noted on palpation of the oral mucosa. Based on these findings, this patient most likely has a deficiency of which of the following? 
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