Draining and abscess Vs antibiotics?

[Sho-4]

Hello everyone

2 days ago a patient came to my clinic with an abscess related to a tooth that has been "poorly" treated endodontically. My approach was prescribing antibiotic then start the re treatment for the root canal by removing the gutta percha with thoroughly irrigation

The swelling has decreased -but there's still some left normally-.

my questions are : was an incision and drainage the best approach for this case?
when to treat the abscess with antibiotics alone?
What if the swelling has disappeared completely without doing the drainage, is there a possibility that it might come back?

Please I need your advice.

Thank you in advance

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[nadent]

I would try to drain the abscess through the canals with a 0.25 K-file violating the apex first. If that can't be achieved I'll go ahead and perform an incision.
I'm not a fan of antibiotics, I like to rely more on host response, unless there's a SEVERE infection.

How far did you get in this case? What I typically do, is I go ahead and Retreat by placing a intracanal medicament (CAOH) in the canal for 2 weeks (literature says 1 month), bring the patient back, remove the CAOH and continue mechanical/chemical cleaning and obturate. Within time and proper follow up the PARL you see on the xray will gradually heal.

 

[ktran17]

Antibiotics cannot reach puss. It has to be drained in some fashion.

 

[vellnueve]

I would have drained it first. I'm not sure how you expect to remove all the gutta percha with irrigation.

I'm concerned that you're asking the second and third questions.

 

[nadent]

I would have drained it first. I'm not sure how you expect to remove all the gutta percha with irrigation.

I'm concerned that you're asking the second and third questions.

She probably meant that after removing the GP, she irrigated thoroughly, It could have been worded better. Second and third questions, yes....I have to agree with you.

 

[imtwotired]

As ktran17 said, antibiotics do not reach the inside of an abscess. An abscess is necrosis. There is no angiogenesis in necrosis and where there is no vascular supply there are no antibiotics. Swellings need to be drained. Period. End of story. Don't let you patient show up in the ED because surprise surprise "antibiotics failed".

 

[Localnative]

Fundamentals , bub

Combo of medical and surgical management unless cellulitic in nature. goes for anything head to toe.

Aerobic, anaerobic cultures if you can get them for C/S, determine antibiotic choice.

If uncomfortable with location and incision design, refer to OS.

 

[drtoothyman]

I would try and do treatment the same day or as soon as possible - yank it or retreat it...cut where appropriate (if appropriate). If there was facial swelling, I would probably rx an antibiotic and maybe a steroid too.

 

[Kazaki]

Dentists trying to talk medicine. Oh God this is funny.

 

[AU07DMD]

Dentists trying to talk medicine. Oh God this is funny.

Go jump off a bridge, troll.

 

[The OMFS]

Dentists trying to talk medicine. Oh God this is funny.

Please go back to finishing your 3 hour H&P.

 

[Kazaki]

Please go back to finishing your 3 hour H&P.

And that's supposed to make me feel....bad?

 

[kdrp]

Dentists trying to talk medicine. Oh God this is funny.

Nah, we just drill and fill while also pretending to know stuff about things so patients are lulled into a false sense of security and give us their money. If I encounter anything that requires real knowledge, I would just refer them to my tribe's shaman.

 

[nadent]

Dentists trying to talk medicine. Oh God this is funny.

A dental abscess could potentially enter the cavernous sinus and then make its way into the brain...ya know?

 

[The OMFS]

And that's supposed to make me feel....bad?

I find it amusing that these comments come from some scrub IMG trying to get into a US radiology residency. Oh the irony... Does your school even prepare you for the Steps, let alone teach you how to do a proper H&P? I recommend that you stay off these boards because you will need every minute preparing youself and trying to get into some podunk residency in the States. Come talk to us when you can properly identify an odontogenic infection on a CT scan.

 

[kdrp]

I find it amusing that these comments come from some scrub IMG trying to get into a US radiology residency. Oh the irony... Does your school even prepare you for the Steps, let alone teach you how to do a proper H&P? I recommend that you stay off these boards because you will need every minute preparing youself and trying to get into some podunk residency in the States. Come talk to us when you can properly identify an odontogenic infection on a CT scan.

God damn.

 

[drtoothyman]

roasted!!! however, I'm pretty sure a well trained monkey can see a dental infection on a CT scan...

 

[ktran17]

roasted!!! however, I'm pretty sure a well trained monkey can see a dental infection on a CT scan...

Perhaps they can see a radiolucency but to differentiate between an odontogenic infection vs tumor etc and the structures affected is another story

 

[Localnative]

Dentists trying to talk medicine. Oh God this is funny.

hey "Medical Student still suckling on the teet of his academic bubble",
went to a top 10 med school , gen surg training in addition to dental school
I guarantee I can wipe the floor with you in terms of management of head and neck infections
also, I guarantee i can wipe the floor with you after Three 3 minute rounds in a boxing ring.
I can't even imagine how many psychopathologies abound in that tiny prefrontal cortex, troll.

 

[drtoothyman]

Perhaps they can see a radiolucency but to differentiate between an odontogenic infection vs tumor etc and the structures affected is another story

Big hole in tooth plus PARL = infection. Swirling mass or big ass RL in bone with no hole in tooth=bad thingy...most importantly...before placing implant take cbct with limited field so you can ignore all the other weird stuff on a CT.

 

[vellnueve]

Big hole in tooth plus PARL = infection. Swirling mass or big ass RL in bone with no hole in tooth=bad thingy...most importantly...before placing implant take cbct with limited field so you can ignore all the other weird stuff on a CT.

So you basically want to cover your eyes and say "I don't see you"?

 

[tinman831]

Let's stay on topic shall we?

 

[PChemGrad]

was an incision and drainage the best approach for this case? - YES a I&D is ALWAYS INDICATED
when to treat the abscess with antibiotics alone? - NEVER
What if the swelling has disappeared completely without doing the drainage, is there a possibility that it might come back? - YES
Always extract the tooth at the time of I&D. Or if you can find someone to do the Endo, do it the DAY of the I&D.
Never treat with ABx alone.

 

[vellnueve]

I disagree that the endo needs to be done the same day as the I&D and also that the tooth needs to come out at the same time. The I&D and antibiotics combined buy you time to deal with the tooth in a definitive manner.

I've done it all four ways (immediate ext, delayed ext, immediate endo, delayed endo) without issue.

 

[nadent]

I disagree that the endo needs to be done the same day as the I&D and also that the tooth needs to come out at the same time. The I&D and antibiotics combined buy you time to deal with the tooth in a definitive manner.

I've done it all four ways (immediate ext, delayed ext, immediate endo, delayed endo) without issue.

It all depends if you can get the canals dry that same day or not.

 

[migm]

ER doc here - not sure if I should post in a different thread but came to this forum to post a very similar question.

I've had a few patients who present with carious diseased mandibular molars and some have this pronounced soft tissue swelling of the jaw just adjacent. Some of these even have a raised area on the buccal aspect that I've tried to I&D to no effect. I even CT one and it was just "soft tissue swelling".. so what gives? Where's the pus at? Should I just be giving abx and referring on these?

 

[armyyyyyy]

^ you were likely at a cellulitis stage of infection so there was no definitive abscess and thus no pus

 

[vellnueve]

ER doc here - not sure if I should post in a different thread but came to this forum to post a very similar question.

I've had a few patients who present with carious diseased mandibular molars and some have this pronounced soft tissue swelling of the jaw just adjacent. Some of these even have a raised area on the buccal aspect that I've tried to I&D to no effect. I even CT one and it was just "soft tissue swelling".. so what gives? Where's the pus at? Should I just be giving abx and referring on these?

Sticking a blade in it will probably still help it out IMO. Blade, blunt dissect a little, abx, refer for definitive treatment.

 

[migm]

Sticking a blade in it will probably still help it out IMO. Blade, blunt dissect a little, abx, refer for definitive treatment.

Even if all i'm getting is blood? Not sure how I would know what I'm gonna get beforehand. I guess cellulitis on the mucous membranes looks and feels like a bit of fluctuance to me. Sure don't want to see a bunch of Ludwigs though

 

[vellnueve]

It'll heal fine. Getting in and disrupting the cellulitis by changing the environment can be helpful.

 

[nealofgrafton]

Agree with vellnueve. There is a dude out of the east coast (thomas flynn) thats like the god of pus. He advocates that if you see swelling to stick a knife into it (be mindful of nerves and important things that can be under- you can ask your local helpful omfs/ PRS/ ENT about where to be careful). But the idea being you intercept in the cellulitic stage and the infection isn't able to progress further because you introduced oxygen into the wound (as the wound goes from cellulitic to frank abscess it gets more and more anoxic- microbial progression blah blah blah). stick a knife in it and I was taught to irrigate with "dr mack's very fine solution" chlorohexidine, a drop or two of betadine, a little peroxide.
props to you on asking questions!

 

[drtoothyman]

agree with nealofgrafton, be cautious of mandibular premolars b/c of mental nerve if you don't have a good xray or are not comfortable in the area, but anywhere else you are USUALLY ok to make a vestibular insicion. go to bone (be sure you are good at giving local in mouth because this will hurt if not), dissect a bit and flush it out good, then rx antibiotics and maybe some steroids and narcotics if you want. I sometimes get excited thinking i'll have a pus geyser but alas, only cellulitis with some blood. (just more satisfying when pus comes out). just leave it open no suture unless you want to stick in a drain. If not comfortable doing this just rx and refer to OMS, endo, or general dentist.

 

[migm]

Over the premolars I'm just making a superficial incision and bluntly dissecting, think this is probably reasonable? any other areas of concern?

 

[drtoothyman]

as long as you are staying in the vestibule the mental nerve is the main thing to watch out for....and that's fine to do in the premolar area. I would suggest going to bone though. in the premolar area, angle it in a little more towards the bone so you are staying away from where you would imagine the root apices to be. then just carefully blunt dissect, remember the infection is usually coming out of the tip of the root and busts through the path of least resistant which is not always but usually the buccal plate, I usually just take the round end of a periosteal to do this. sometimes blunt dissection with a hemostat or scissors is fine too. give multiple LA blocks if doing the lower, if doing upper just go high and try to avoid injecting into the abscess. I found V2 block through the greater palatine works pretty good if you got an upper 1st or 2nd molar with a blown out palatal root that's not wanting to numb. the patient may feel some pressure but if they are real uncomfortable you need better local.