Saturday, October 29, 2011

Episode 202/500: Dental Abscess (Intraoral Incision and Drainage)

Here is a brief overview of a great hint that an Oral Surgery Residency Director showed us regarding intraoral incision and drainage.  I put together a case with the I&D video in the middle of the post.

Chief Complaint:  45 YO Male presents w/ a chief complaint of, "my left lower jaw has become really swollen over the past day.  It's really painful."
History of Present Illness: Patient had an endodontic therapy completed to the 1st mandibular left molar approximately 24 months previously.   The patient has been asymptomatic until the previous 36 hours.
Medical History:  Vitals:  Blood Pressure: 145/93, Temp:  99.1, Pulse: 65, Resp: 17
  1. Medications: Propranolol
  2. Medical Conditions:  Hypertension, Anxiety
  3. Allergies:  None
  4. ETOH:  Social
  5. Tobacco:  Smokes 1 pack per day
Clinical Exam:  
Extraoral: Left sided facial asymmetry (swelling), pain to palpation left mandible, no lympadenopathy
Intraoral:  Left Mandibular Buccal Abscess approximating the 1st md left molar, pain to palpation left mandibular dentition, no suppuration, 1st molar non restorable

A self instructional Guide:  Diagnosis and Treatment of Odontogenic Infections Hohl, Whitacre, Hooley, Williams
Radiological Survey:  1st mandibular left molar diagnosis:  Previously endodontically treated w/ symptomatic apical periodontitis.  Tooth #19 (FDI #36) non restorable, Large radiolucency apices #19

  1. Patient is currently controlled for HTN - can elect to treat immediately
  2. Patient has a large mandibular vestibular abscess
  3. Tooth #19 non restorable
  1. Local Anesthesia
  2. Extraction #19
  3. Aspirate vestibular abscess and submit contents to lab
  4. Incision & Drainage - Penrose drain
  5. Systemic Antibiotics
  6. Analgesics for pain (Ibuprofen, Acetaminophen, Narcotics)
  7. Followup 24 hrs, 72 hrs
  1. Penrose drain (or some kind of sterilized rubber)
  2. #11 or #15 blade for incision
  3. Local Anesthesia: 
    1. Carbocaine (Mepivicaine) - not necessary, but it has the lowest pKa which will aid in achieving local anesthesia
  4. Hemostats
  5. Sutures
  6. Surgical Suction
  7. Syringe to aspirate abscess contents for lab submission

The following images relating to the basics of a Buccal Space Infection are from this great series of texts (out of print): A Self instructional Guide:  Diagnosis and Treatment of Odontogenic Infections, by Hohl, Whitacre, Hooley, Williams


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  2. Ugh, if I ever needed this done I'd definitely be looking into Thailand dental holiday packages... it'd probably cost me a fortune here in the US!