Incision for Drainage



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Objective
To establish a communication between an internally pressurized highly inflamed or infected area and the oral cavity.
Note
MIR5-MH1 Mirror and handle (Hu-Friedy) #11 Scalpel blade (Bard-Parker) #5 Scalpel handle (Hu-Friedy) #15C Scalpel blade (Bard-Parker) #2/4 Molt DE curette (Hu-Friedy) #83 or #84 Lucas DE curette (Hu-Friedy) #4, #6. or #8 Round bur (Brassier) Double-ended forked drain pusher (Union Broach)
#18 Iris scissors (Hu-Friedy) Mathieu-Kocher Perma-Sharp needle holder (H u-Friedy)
Kramer-Nevins tissue pliers (Hu-Friedy)
Allison baby tissue forceps (Hu-Friedy)
I odoform gauze strips
Rubber dam, latex free (HCM Hygienic)
4-0 Suture (Tevdek, EIE Analytic Technology)
Aspirator (Quality Aspirators)
Stropko irrigator/drier and 26- to 30-guage needle (EIE Analytic Technology)
CO2 Laser


Evaluation
Information gathering
Historical facts regarding the growth, color, loca­tion, and duration of the infection must be gath­ered from the patient, parent, or guardian and recorded in the chart
.
Clinical evidence
Radiographs of the suspected tooth (teeth) and adjacent area should be taken. For patients with severe swelling and pain, a Panorex may prove easier, more comfortable, and more informative. Computerized tomography (CT) scans and syntog-raphy bone scans are frequently being used to help diagnose difficult cases that have long, involved dental and/or medical histories.

Clinical evaluation
The tissues are visually inspected and finger pal­pated to determine size, color, hardness, fluctua­tion, tenderness, extension, and nodular i nvolvement.

Diagnosis
All teeth in the involved arch are electric pulp tested, cold tested, and percussion tested to determine whether the problem is of odontogenic origin. The results of each test should be recorded carefully in the patient's chart.

Biopsy
Although the clinical appearance and condition of a tooth (teeth) in the vicinity of a surface swelling may initially indicate the cause is of puipal origin, the clinician must trust the results of the diagnos­tic tests. When pulp and percussive testing prove to be inconclusive, the choices are to wait until the signs and symptoms become more decisive or to remove the lesion and send the specimen to a lab­oratory for histologic evaluation. Rather than assuming the responsibility of waiting when the condition may prove to be serious, biopsy seems to be the more logical decision.

Treatment
Lesions of nonodontogenic origin
The procedure for benign surface growths (ie, papillomas, fibromas) is as follows:
1 The peripheral area is anesthetized.
2. The growth is grasped with suitably sized tissue forceps.
3. The approximating healthy and uninvoived tis­sue around the growth is incised using a #15C scalpel.
4. The specimen is lifted and freed from its bed by carefully incising the underlying attachment.
5. The specimen is placed in an appropriate bottle of 10% formalin and sent to a qualified oral pathology laboratory for evaluation
6. The tissue is sutured with 5-0 or 6-0 Tevdek suture material. Laser-treated lesions are usually bloodless and rarely require sutures.
7. Appropriate analgesics are prescribed for mod­erate pain
8. The patient is given home care instructions.
9. The surgeon notifies the patient of the diagnosis as soon as possible and refers the patient if fur­ther treatment is needed.
The procedure for suspicious neoplastic tissue (ie, extensive lichen planus, leukoplakia, squa­mous) is as follows:
1. A tissue specimen or surface scraping is obtained for histologic or cytologic evaluation by a pathology laboratory.
2. The lesion is surgically removed in the same manner as described for the removal of a non­odontogenic lesion.
3. The patient is referred for a second opinion and/or surgery.

Lesions of pulpal origin
Acute apical abscess.
1. The chamber of the offending diseased tooth (teeth) is opened and the canal is negotiated. Once patency length has been reached, the canal is thoroughly instrumented to an estab-ished working length. An acute pressurized periradicular abscess should respond to the canal cleansing/shaping procedures and repeated patency recapitulations with a substan­tial flow of exudate.
2. if drainage subsides and ultimately stops, the canal chamber can be closed and the patient placed on an antibiotic and analgesic regimen . Because of the potential for relapse, the patient should be monitored closely over the following 24 to 48 hours.
3. If no drainage is elicited or drainage continues even after the tooth has been substantially instrumented, there are two choices:
• The tooth may be left open and the patient reappointed to complete the endodontic pro­cedures and concurrently perform a neces­sary apicoectomy.
• The tooth may be closed and direct access to the source of the pressure (fluid) gained through the soft tissues (artifistulation) and bone (trephination). In this case, an Ochsenbein-Luebke flap is incised, elevated, and retracted Depending on the condition of the bone plate, the bone cov­ering the lesion may need to be trephined with a #4, #6, or #8 round bur (Figs 1-1 a and 1-1 b).
4. To maintain communication with the oral cavity, a strip of X-inch-wide iodoform gauze or a small piece of rubber dam or rubber tubing is inserted into the opening and the crypt. The flap is repo­sitioned and a short length of the drain is allowed to extend out of the incision between the edges of the flap. The flap and the drain are then sutured in place. The patient is placed on an appropriate antibiotic regimen and reap­pointed for the completion of the endodontic therapy {Fig 1-1 c to 1-1 e).
5. Depending on the patient's response, the drain may be left in place throughout the root canal therapy and, unless symptoms remain or addi­tional complications are met, a subsequent api-coectomy may be unnecessary. When the patient appears to be free of all symptoms, the drain can be removed.


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Fig 1-1a                            Fig 1-1b                         Fig 1-1c

Figs 1-1 a to 1-1 e To gain access to a pressurized abscess when bone cov­ers the lesion, the buccal plate must be trephined with a round bur. To prevent posttrep hi nation fluid buildup, an avenue of escape should be maintained with a wick drain.


4. To maintain communication with the oral cavity, a strip of X-inch-wide iodoform gauze or a small piece of rubber dam or rubber tubing is inserted into the opening and the crypt. The flap is repo­sitioned and a short length of the drain is allowed to extend out of the incision between the edges of the flap. The flap and the drain are then sutured in place. The patient is placed on an appropriate antibiotic regimen and reap­pointed for the completion of the endodontic therapy {Fig 1-1 c to 1-1 e).


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Fig 1-d                                                    Fig 1-1e


5. Depending on the patient's response, the drain may be left in place throughout the root canal therapy and, unless symptoms remain or addi­tional complications are met, a subsequent api-coectomy may be unnecessary. When the patient appears to be free of all symptoms, the drain can be removed.


Mucosal and submucosal swellings.
1. Patients with submucosal swellings present to the office because of discomfort from the bloated and distended tissues and concern about the diagnosis, but they rarely complain of being in extreme pain (Fig 1-2a).
2. The objective with these patients is to establish drainage to deflate the swelling and evacuate the accumulated fluids until the source of the infection can be determined and treated. However, swollen and infected areas are diffi­cult and painful to inject, and the level of anes­thesia often proves to be inadequate for the following reasons:
• The local tissue pH value may be reduced to such a degree that hydrolysis of the anes­thetic salt is retarded, thus preventing libera­tion of the free alkaloidal base.
• The anesthetic solution may be diluted when added to the existing fluid volume.


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Fig 1- a                                                              Fig 1-2b


Figs 1-2a to 1-2d A mucoperiosteal abscess is a buildup of fluid between the bone and the mucosa and can easily be drained by pricking the swelled center with a # 1 1 scalpel. Using a wick drain is also an option.!


• The anesthetic solution may be absorbed quickly because the inflamed area is highly vas­cular.
• The injection may be so painful that the opera­tor never reaches the targeted nerve branches or administers the quantity of solution neces­sary to produce anesthesia.
3. Pricking the locally swollen mucosal abscess cen­ter with the point of a #11
scalpel blade is an extremely fast and efficient way to eliminate these localized fluids. This blade is designed to puncture tissue and can pierce mucosal and submucosal swellings without pressuring the base of the abscess. With this advantage it is possible to pro­vide the patient relief without administering an anesthetic. The technique is as follows:
• The patient is forewarned of the reasons for and intent to treat the condition without local anes­thesia. Conscious sedation premedication tech­niques should be considered .
• The point of the #11 blade is used to quickly puncture the center of the swollen area. Without pressurizing the abscess base, the opening is widened by lifting the cutting edge ;Figs 1-2b and 1-2c.
• A small aspirator is inserted into the opening, and the swelling is emptied of blood and exu­date using high-powered evacuation.
• if further access is needed, the incision is reentered with the #11 blade, and the size of the opening is again increased by simply lifting the cutting edge.
• The aspirator is reinserted into the incision, and the fluids are evacuated until no exudate is evi­dent.
• With a mucoperiosteal abscess, the fluid accu­mulates between the bone and the mucosa. Once the fluid pressure has been released, a drain may be placed (Fig 1-2d). However, the placement of a fixed drain will depend on how well the endodontic procedure progresses.
• if the need for endodontic therapy has been
determined and agreed to, it may be initiated at this time, or the patient can be reappointed and treatment pursued when conditions improve. If drainage continues throughout the cleaning and shaping procedure, a wick drain is indicated.
• Appropriate antibiotics are prescribed .
• The value of good postsurgical home care dur­ing convalescence is discussed with the patient, parent, or guardian. Printed information is pro­vided and explained to reinforce the spoken instructions .
• The patient is monitored on a daily basis and reappointed in 3 to 4 days for evaluation and for a decision to either continue drainage or initiate conventional endodontic instrumentation and obturation procedures.
• Depending on the patient's progress, the wick drain may be removed at this visit or a subse­quent visit a week later.
4. For patients who present with moderate to severe facial swelling, the surgeon is again faced with atraumatically reaching workable levels of anesthe­sia. More adequate levels of anesthesia can be realized and the dangers and uncertainties of injecting directly into the infected area can gener­ally be avoided by administering division block injections. Although the Division II block is consid­ered to be more effective in the maxillae than infil­trations, the technique is difficult to teach and perfect, and therefore is rarely used.
5. When the Division II block is not used to anes­thetize an infected area in the maxillae, the follow­ing effective and compassionate local anesthetic infiltration technique is suggested:
. An adequate layer of topical anesthetic is applied to the swollen tissue and the tissue adjacent to the swelling.
• Once the superficial tissue is desensitized, anesthetic can be administered by slowly inject­ing small doses of solution peripheral to the swelling. Subsequent slow and gentle infiltration injections are given and the center of the abscess is approached laterally.
• When the peripheral area is numb, the anes­thetic solution may be injected directly into the center of the abscess.


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Fig 1-2C                                                               Fig 1-2d



Cellulitis.
The accumulated exudate in the superficial and deep spaces that produces swelling of the lip, cheek, face, and neck is a deeply centered infec­tion and may require lifting a full mucosal flap to gain access to the source. In such cases, the foi-owing steps are taken:
1. The area is anesthetized as previously described for moderate to severe swelling.
2. An Ochsenbein-Luebke flap is incised, ele­vated, and retracted .
3. A #83 or #84 curette is inserted between the edges of the incision and used to probe care­fully beneath the raised flap in search of the fluid pocket.
4. If a flow of exudate is initiated, a small-tipped aspirator is inserted under the flap directly on the point of flow and the fluids are evacuated. The facial swelling may noticeably deflate dur­ing this process.
if no flow can be stimulated, the bone over the lesion needs to be trephined. The location of the offending root/lesion is confirmed on a radi­ograph and the bone overlying the lesion is penetrated with a #6 round bur (see Lesson ' 7). The crypt is aspirated and curetted of all fluids, debris, and soft granulation tissue. Biopsy procedures should be followed as previ­ously described .
5. If the decision has been made to perform an osteotomy to gain access to the lesion and the abscess fluid, there is no reason (other than a lack of time) that the root canal and the entire apicoectomy procedure cannot be performed at this appointment. In this case, the flap is temporarily repositioned but not sutured. Moistened gauze is placed over the flap, and a rubber dam is used to isolate the tooth (teeth). The canal is accessed, well instrumented, dried, and obturated. The chamber is temporar-i y sealed, the dam and the gauze removed. the flap reraised, and the remaining apicoec-tomy steps (including any retroprocedures) resumed.
6. Once the trephination and/or apicoectomy have been completed, the flap edges are reap-proximated and the flap sutured in place.
f the surgeon has chosen to perform the trephination and not complete the endodontic therapy and apicoectomy, it is necessary to maintain an oral communication by placing a quarter-inch-wide iodoform gauze or a rubber dam wick drain between the edges of the flap. The patient must return at a later time, when the site is more comfortable, to complete the root canal.
7. Appropriate antibiotics and analgesics are pre­scribed .
8. The patient, parent, or guardian is given oral and written instructions on postsurgical care .
9. An ice pack is placed on the surgical area, and cold therapy (20 minutes on and 20 minutes off) should be instituted and continued for the following 6 to 8 hours .
10. The patient must be monitored on a daily basis
11. When conditions have returned to normal (gen­erally within 3 to 7 days), the sutures and drainage wick can be removed. If the surgeon chooses to perform the trephination and not complete the endodontic therapy, traditional cleaning, shaping, and obturation procedures can be accomplished as soon as the crisis is over (generally within 72 hours), when the patient is comfortable and without symptoms. Unless fluid is present, an odor is detected within the canal, or the patient continues to have symptoms, apical surgery may not be required.
12. Regardless of the treatment regimen elected, the patient should be clinically and radiographi-caily evaluated at 6 weeks, 3 months. 6 months, and 1 year.
Problems
Because few dentists feel comfortable administering Division II blocks and the use of general anesthesia in an office is not recommended, conscious sedation techniques, such as nitrous oxide inhalation analge­sia, sedative/hypnotic oral drug therapy, and intra­venous sedation, can be extremely helpful in relieving the apprehensions and anxieties associated with emergency situations .
Extraoral point
Because drainage will follow a path where it meets the least resistance, it is not uncommon for the sup­purative accumulation to migrate to the subcuta­neous area of the face or neck. When this happens, an angry red target zone may appear on the skin. As the condition progresses, the dimensions of the wheal increase, swelling becomes more apparent, and the infection surfaces in the form of a cutaneous boil. This condition is often prompted by patients who have placed hot water bags or heating pads on their faces in an effort to relieve pain. The heat draws the fluid to the face, and the red wheal becomes evi­dent as the face swells (Fig 1-3a).
f allowed to point and drain on its own, a jagged, unesthetic scar results. Although any perforation of the skin is likely to scar, a small facial puncture with a #11 scalpel would be far more desirable and much less noticeable. Therefore, when facial drainage is imminent, the point of the #11 scalpel is inserted into the central zone of the swelling (Fig 1-3b). The punc­ture hole is kept open by inserting a small rubber dam T -drain or strip of quarter-inch iodoform gauze into the opening. Anesthetic is not usually required for this procedure. The drain can be left in place until the source (tooth and/or lesion) is under control. It is imperative that the patient understand why the sur­geon has chosen to incise for drainage extraorally and that he or she has agreed to the procedure.


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Fig 1-3a                                                        Fig 1-3b


Nonresponding swelling and pain
1. The vitality of the adjacent teeth is reevaluated.
2. The surgeon cultures and covers the abscess with a broad-spectrum antibiotic until the results of the sensitivity tests are returned .
3. Exploratory surgery and biopsy should be con­sidered.
4. A wick drain is maintained until the results of the culture and biopsy are received.
5. The patient's temperature, pain, and extent of swelling is monitored and recorded on a daily basis.
6. If the patient has not responded to therapy within 5 to 7 days and/or conditions appear to be worsening each day, the patient is referred for a second opinion. A conference is held with the referred dentist and the details of treatment submitted for his or her review. To avcd pa:ient feelings of abandonment, the surgeon should continue to maintain an open line of communi­cation with him or her throughout treatment and recovery.
7. The referral process and all patient/parent/ guardian/referring dentist(s) comments or dis­cussions regarding diagnosis and treatment options (suggested, advised, or implied) are doc­umented in detail in the patient's chart.
Danger zones
1. The accumulation of exudate in deep spaces may produce hard, diffuse, uncomfortable swellings and the pressurized fluid searches for areas to fill, if this highly infectious material is allowed to collect and localize in the vicinity of the angular or pterygoid veins, the microbes have a direct path to the cavernous sinus and/or brain and the patient's life is in danger.
2. When exudate accumulates in the submandibu­lar spaces of the mandible and the drainage crosses the midline, the floor of the mouth and the tongue may be forced upward and back. As the throat swells and the tongue raises, the patient's airway is threatened to a point at which a tracheotomy is needed.
3. The decision to incise and drain is based on tim-i ng and experience. Although early lancing may only produce hemorrhage, not lancing, particu­larly in critical areas, may allow the infection to progress and the inactivity to endanger the patient.



1 comment:

dental continuing education said...

very informative thanks for the post

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