Pricniple IV:Treat Infection Surgicaily
reformation of the abscess cavity. It is important to remember that the surgical goal is to achieve ade~uate drainage. If endodontic opening of the tooth does not provide adequate drainage of the abscess, it is essential to
perform an I&D The technique for I&D of a fluctuant vestibular abscess
is straightforward (Fig. 15:8). The preferred site for. theincision is. directly over the most dependent area, to encourage drainage. (When I&D procedures are performed extraorally, a more complex set of critetia must be met when selecting a site for the \p,ision.) Once the area of incision has been selected, a method of pain control must be used. Regional” nerve block anesthesia achieved by injecting an area away trom the site of the incision is
preferred. Alternatively, superficial Inflltration of local anesthetic solution anterior and posterior to the area to be drained can be used. Before the actual incision of the abscess cavity is performed, consideration must be given to obtaining a specimen of the pus for culture and sensitivity (C&S) testing. If the decision is made. to perform a culture, the procedure is carried out as the initial portion of the surgery. Once the localized area has been anesthetized, a large-gauge needle, usually 18 gauge, is used for specimen collection. – A small syringe, usually 2 ml, is adequate. The surface mucosa is disinfected with a solution such as Betadine and dried W\\lt sterile gauze. The needle is then inserted into the abscess cavity, and 1 or 2 mL of pus is aspirated The syringe is held vertically, and any air bubbles contained in the syringe are ejected from it. The tip of the needle is then capped with a rubber stopper and taken directly to the microbiology laboratory. This method for obtaining a specimen, permits both aerobic and anaerobic cultures and Gram’s staining. As discussed earlier, anaerobic
bacteria are almost always present in odontogenic infections, and therefore care must be taken to ‘provide the laboratory the best opportunity” to find them. Once the culture specimen is obtained, an incision is made with a no. 11. blade just through the mucosa and submucosa into the abscess cavity (see Fig. 15-8). The incision should be short, usually HO more than 1 cm in length. Once the incision is completed, a closed curved hemostat is inserted through the incision into the abscess cavity. The hemostat is then opened in several directions to break up any small loculations or cavities of pus that have not been pened by the initial incision. The pus that drained out
,during this time should be aspirated into the suction and should not be allowed to drain into the patient’s mouth Once all areas of the abscess cavity have been oper and all pus drained, a small drain is inserted to maintain the opening. The most commonly used drain for intraoral abscesses is a one-forth inch sterile Penrose draw A frequently used substitute is a small strip, of sterilized rubber dam. A piece of drain of adequate length to reach the depth of the abscess cavity is prepared and inserted into the cavity, using the hemostat. The drain is then sutured into place with a nonresorbable suture. The suture should be placed in viable tissue to prevent loss of the drain as the result of the suture tearing through. nonvital tissue. The dran should remain in place until all the drainage from the abscess cavity has topped, usually 2 to 5 days. Removal is done by simply cutting the suture and slipping the drain from the wound.Early-stage infections that initially appear as a cellulitis with soft, doughy, diffuse swelling do not typically respond to I&D procedures. Surgical management of infections of this type is limited to removal of the necrotic pulp or removal of the involved tooth.