An incision and drainage (I and D) is a dental procedure that is used to treat facial swelling from a dental abscess.
As it clearly states in its name, the entire procedure consists of two parts, the incision followed by the drainage. The first part involves making a cut through the abscess to open it up. The second part involves draining the infection and all of its loculations. The end result is a reduction in facial swelling along with much needed pain relief.
However it is important to note that this is an emergency palliative treatment. It will get you out of pain and reduce the infection but it does not always cure it. Follow up treatment such as a root canal or tooth extraction is often required to treat the source of the abscess.
When a dental abscess needs to be drained
An incision and drainage can only be performed on dental abscesses with swelling. If there was no swelling present then there would be nothing to drain. It is as simple as that.
Conditions which may result in an abscess with swelling:
- Untreated root canal infections. Teeth that need root canals often have small abscesses located at the tip of the root. They may stay quiet for many years but can swell up spontaneously, usually at the worst time possible.
- Gum abscesses. Foreign bodies can get lodged into the gums and cause it to swell up.
- Severely decayed teeth. Very large cavities will eventually lead to an abscess. If left untreated it will swell up at some point.
- Fractured teeth. Broken teeth can lead to facial swelling if it gets infected.
- Swollen wisdom teeth. Most wisdom teeth are accompanied by minor swelling but there are times where it can cause severe swelling.
- Infected dental implants. Titanium implants can get infected just like your regular teeth.
- Swollen gums. Gums with severe swelling can sometimes require drainage if the deep cleaning does not work.
When abscesses do NOT need to be drained
Dental abscesses without swelling do not need to be drained because there is nothing to drain. That is the most obvious reason but there is one situation where drainage for the swelling is not required.
The abscesses can in fact be successfully treated with antibiotics alone if the swelling occurred less than 48 hours ago. If you’re able to get antibiotics into your system before that cut off point, the swelling can potentially go down.
However once you’re past the 48 hour mark, it may not have an effect anymore. What you’ll notice that the tooth abscess is still swollen despite taking antibiotics. You’ll need to get an I and D at that point.
What to expect during a dental abscess incision and drainage
The I and D procedure is essentially two steps, the incision and the drainage. Here are step by step descriptions of what to expect so you can steel your mind.
- Administer local anesthesia. Apply topical benzocaine (numbing gel) prior to injection with lidocaine with epinephrine. You’ll most likely need a couple of extra doses.
- Wait for anesthesia. It may take a few minutes for you to get numb. Please be aware that sometimes it may be difficult to get completely anesthetized due to the severity and extent of the infection.
- Make an incision. The incision is made with a small scalpel. The size of the opening will be determined by the extent of the abscess. The depth of the cut will always be down to bone level. If you don’t go deep enough you could be leaving the deepest part of the infection unscathed.
- Drain the abscess. The first instrument that goes in is with a closed hemostat. You open the hemostat while in the abscess and then pull out. You must do it in that order because you don’t want to grab a nerve inside and pull out by accident. By coming out closed, you close off the possibility of that happening. Keep repeating this action in multiple directions and angles to drain it completely.
- Irrigation inside abscess. Your dentist will then flush out the entire inside of the abscess.
- Place a drain. Depending on how severe the infection is, your dentist may place a drain inside the abscess. The drain looks like a small plastic tube which gets sutured to the gums. The purpose is to allow the infection to continually drain and prevent the wound from closing.
Note: In addition to using the hemostat, some dentists will also use digital pressure to massage or squeeze out the abscess. You do whatever it takes to get it completely drained and the face to return back to its original size or close to it.
The incision will be left open
The wound will be left open with no exception so don’t be surprised. This is because the infection is not completely cleared. You’ll want to massage/drain it yourself lightly throughout the day. Be sure to take the antibiotics because that will help clear it out.
The reason why it is not stitched up is because if the infection happens to return you will swell up again! On the other hand if you leave it open for it to heal naturally, the combination of home massage and antibiotics should be able to overpower the infection within enough time.
Please do not stick your finger into the wound or use your tongue to play around with it. The incision will heal all on its own as long as you keep it clean. It may take about a week for the cut to completely close up.
Does an incision and drainage hurt?
Depending on how severe the abscess is, the incision and drainage may be painful if you’re unable to get adequately anesthetized. The goal is to have you completely numb and is the preference for every dentist.
Unfortunately that doesn’t always happen in clinical practice. There are times where the infection is so severe that total numbness is unable to be achieved. You can think of the abscess as a bus that is full of passengers. The anesthesia is an additional passenger trying to board the already full bus. They may not be able to get on since it is so full. The same thing happens with trying to numb a large infection.
Hopefully you didn’t put the treatment off for so long that it gets to that point! Typically the abscesses that are treated earlier will have less unpleasantries.
I and D aftercare
Having a dental abscess drained can be physically and emotionally traumatizing. You need to rest afterwards so do not make any plans for the rest of the day. You’re sentenced to bedrest.
Here are some instructions for the recovery:
- Rest. Stay home on the day of and take your time to recover.
- Stay warm. Some patients are so emotionally distraught afterwards that they start feeling chills and shivering. You’ll want to bundle up and be sure to take all prescriptions.
- Take prescribed medications. Undoubtedly you’ll be given antibiotics along with pain medication. Take them all as directed by your provider. Yes, you must finish the entire course of the antibiotics with no exception.
- Massage your face. During the first day, you’ll want to massage your face to help drain the abscess.
- Cold compress. You can use an ice pack on your face for 10-15 minutes on and off. The cold helps to numb the area and the pressure helps to keep the swelling down.
- Salt water rinse. Starting the day after the I and D, you should rinse with salt water as frequently as possible. This helps to keep the area clean. Be sure to do it after every meal.
Follow up appointment
It is a requirement to have a follow up appointment after having a dental abscess surgically drained. There are three reasons for doing so.
- Make sure you’re okay. Hopefully that was a once in a lifetime experience for you and you don’t have to go through it again. The entire procedure can be very traumatizing.
- Remove the drain. If you had a drain placed, your dentist will need to remove it. It is a simple process of taking out the stitches and the drain. That should take less than 5 mins.
- Diagnose the infection source. Draining it doesn’t treat the source of the infection but it merely gets you out of pain and to stabilize you in the meantime. After the infection is gone, your dentist will be able to discern which tooth is the culprit for the abscess. This step is often near impossible to discern when you’re swollen because everything hurts. It is only after the pain and swelling is that that they can figure out where it is coming from.
Basically what we’re trying to tell you is that your treatment is not done. We will discuss what further you have to do in the next section.
Treat the source of the dental abscess
Draining the abscess provides pain relief and swelling reduction which makes it an emergency palliative procedure. What it does not do is always treat the source of the dental abscess. Often times the infection stems from a specific tooth and that tooth will need to be treated.
The only two ways to treat an abscessed tooth:
- Root canal. An infected nerve that is not removed will continually produce more pus and swelling. Until it is removed via a root canal procedure, the infection will persist. Consequently you may swell back up again even after draining it if you leave it untreated.
- Tooth extraction. Removing the entire tooth is an alternative to a root canal. Instead of removing the unhealthy nerve, you can simply take the tooth with the nerve out of the mouth. Although we say this is an alternative, if the abscess is too severe it may be the only option that is available to you.
The extraction and root canal will eliminate the bulk of the infection but you will need to take antibiotics to ensure that all of it is gone. Some of the infection could be hiding in areas of the mouth that we can’t visually detect. The antibiotic will cover our bases and reach the ones that may have been missed.
Please be mindful that antibiotics alone cannot treat severe facial swelling, especially if it has been more than 48 hours. The pressure from the swelling will need to be physically relieved by draining it and that much is inescapable.
Alternative to a dental abscess incision and drainage
There is technically no alternative to draining a dental abscess. If you need it drained, there is literally no other way to reduce the swelling. In order to relieve the pressure and swelling, a physical process is required. It is similar to how if you have a balloon that is filled with water. There is no way to get rid of the water aside from letting it out.
What about the root canal and extraction?
As you may have astutely noticed, we did say that the infection typically stems from a tooth. That means the only way to treat the source of the abscess is via a root canal or tooth extraction. Are you curious as to why we don’t just do that instead of draining it?
If the swelling is not too severe, you can treat it with a root canal and drain it at the same time. However you can’t just do the root canal without draining it. All of that fluid from the infection needs to be let out somewhere.
Consequently you can also do the extraction with the drainage at the same time. That would actually save you an additional appointment because you received definitive treatment in addition to the palliative one.
However, therein lies a problem. There are many instances where the abscess is so severe that literally everything in your mouth hurts. Every single tooth hurts and even structures not related to the mouth like your eyeball and ears can even hurt. This makes it incredibly difficult to diagnose which tooth is abscessed.
If your dentist can’t figure out which tooth is causing it, you don’t want them to take out a tooth with eenie, meenie, miney, mo. That would be disastrous.
It would be more prudent to drain it and put you on antibiotics. Then you can come back a few days later when everything has quieted down so that they can properly diagnose the source.
There is always a risk for complications as with any dental procedure. The risk only increases since this is a surgical one.
- Nerve damage. Improper use of the hemostat while draining the infection can potentially cause nerve damage. You can clip onto the nerve and pull on it.
- Swelling returned. The procedure may not always be successful. Sometimes it can be due to the severity of the abscess or the patient not taking the antibiotics.
- Infection has spread. There is a chance that the abscess could’ve spread beyond the mouth and into other areas. It can affect your throat and close off the airway space making it extremely dangerous and life threatening. The condition is called ludwig’s angina.
If you experience a complication, do not wait and get medical help immediately.
The entire purpose of this article is to let you know what to expect for an incision and drainage. To be crystal clear, the point that we want to make is that if you need the procedure you should get it. You must see a dentist in order to be properly treated. Waiting around at home and looking up home remedies will not make that swollen abscess go away. You’d only put your health at risk by doing so.
Nonetheless here are some key points for you to takeaway with:
- Incision and drainage is a surgical emergency treatment that is palliative.
- Definitive treatment (root canal and extraction) for the source of the abscess will need to follow.
- You will be on antibiotics.
- Do not wait, you need to see a dentist for this procedure if you have an abscess with swelling.
Yours in oral health,