I am very excited about today’s tip. It’s been something I have wanted to write for 4 years but just never had the time.
I have written tips on I&D’s before, but never before have I put together a step-by-step how to do an incise and drain (I&D).
Some of this will be a review for the newcomers to the Helpful Dentist email lists, but this will be a step-by-step on how to do a basic incise and drain.
The Why
So, first off, what is the big deal? It’s just a swelling, right?
I had an excellent OMFS mentor say to me “never let the sun set on pus.”
Now, what did he mean by that?
Well, swellings can intensify quickly in a matter of hours.
Some of the observable symptoms dental swellings can cause are:
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- difficulty opening the mouth (trismus)
- difficulty swallowing (dysphagia)
- change in voice
- elevation of the tongue (which can cause difficulty in breathing)
- difficulty breathing (dyspnea) – this is really bad
- swellings (fluctuant or indurated)
- deep space infections (these are also really bad)
- closing of the eye (often associated with canine space infections)
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I would suggest none of these symptoms are desirable or something you would want a patient to experience.
While a lot of dental swellings stay put, others can progress very quickly. I say that from personal experience and observations. I did a hospital based residency in a not so great neighborhood with no OMFS residents. That meant we GPs did in-house calls (we slept in the hospital). Needless to say, we were paged to the emergency room as a consulting service a LOT, often between 2 a.m. and 6 a.m.
As an aside, my co-residents had a running competition between my co-residents who could drain the most purulence. I think the most I got was 8-9cc. My one co-resident, who these days is a talented periodontist in the Los Angeles area, won with 14 or 15 cc or purulence.
Odontogenic?
So first thing first. You might be tempted to give antibiotics right away. And the majority of the time, this is fine. But technically, it’s not fine.
Really, the first thing you should do is establish a diagnosis for the swelling. Specifically, is it odontogenic? Or in layman’s terms, did a tooth cause this swelling? How do you know it is dental related?
Most of the time, this is second nature and an easy call. Look in the mouth and see a bombed out tooth next to an intraoral swelling. Take an x-ray and confirm it’s a necrotic tooth. Boom, you’re done this step. Get the patient some antibiotics.
The majority of the time, this is how the scenario will play out. Swelling in the cheek (buccal space), think lower molar or premolar. Swelling under the eye and possibly starting to close? It’s probably an upper canine or maybe a first pre-molar. But every once in a while, a facial swelling pops up that cannot be tied to a tooth, or in other words, is not odontogenic in nature.
Those you gotta be careful with.
As an aside, it is not uncommon for patients who have large dental swellings to have multiple broken teeth.
99% of the time, it’s an easy thing to spot the offending culprit is obvious, but every once in a while, a swelling comes along that is NOT tooth-related.
So while generally speaking, it is good to give antibiotics, make sure that it is a dental reason for the swelling.
If the swelling is odontogenic, then by all means start the pt on antibiotics (we will discuss IV versus PO antibiotics later in this email).
If the source of the swelling is not odontogenic, or unable to come to a diagnosis, then you should refer (and obviously do not treat).
IV or by mouth (PO)?
So, as alluded to, often the next thing is antibiotics.
Generally speaking, antibiotics are a good thing to give to a patient with an odontogenic-related facial swelling.
So, do you give by mouth (PO) or IV?
Well, that decision does come with experience, and in time you will start to know. Generally speaking, if the swelling is only intraorally and there is no significant facial asymmetry or systemic involvement, you can use oral antibiotics.
If there is ANY deep space infection, trismus, involvement of the eye (swelling shut), or crosses the inferior border of the mandible (in a sense, this is redundant since that’s a deep space infection), I personally believe the pt should be on IV antibiotics.
As for the borderline case for IV vs oral antibiotics, it also comes down to other factors such as how much drainage you get, is the source of infection removed (did you get the tooth out, or referring?), the patient’s past medical history, access to care, and one people sometimes do not consider is pt’s compliance. Generally speaking, though, when on the fence, I like to err on the side of caution and go with IV antibiotics.
If you do not have access to IV antibiotics, I would suggest giving the patient oral antibiotics in the meantime and getting the patient to the nearest emergency room. Why is that? Well, things sometimes take time. Might be another few hours before a patient is seen in the ER.
Generally speaking, if there is a deep space infection, you want the patient on antibiotics. Tooth pain, sure, no antibiotics needed, but in fact, in 10+ years, I cannot think of a single deep space infection I have treated and did not provide antibiotics. They go hand in hand.
Buccal spaces
I want to talk a bit about buccal space swellings because (anecdotally) I feel they are the most common and also the most forgiving of infections.
Now, buccal space swellings are a bit of a mixed bag. BOTH an and upper and lower tooth can give a patient a buccal space infection. As you know, a buccal space abscess involves the buccinator.
Here are some general guidelines specific to buccal space infections:
If (and this IF is IMPORTANT) the buccal space swelling is small AND there is no trismus, no breathing difficulty, with a healthy medical history (ie. no uncontrolled diabetes), generally speaking, you can simply remove the tooth (or endo + place in calcium hydroxide), give strong oral antibiotics and the patient will be fine.
If going the route of giving ORAL ANTIBIOTICS, you have to ABSOLUTELY make it very clear to the patient that if the swelling gets bigger, they develop difficulty opening, the pain gets worse, or something just does not feel right, they are to call you on your cell and present immediately to an emergency room. Just because the tooth is out does not guarantee the infection is under control. (usually, on small swellings, it is, but big swellings are a different beast).
Buccal spaces can be a bit of a wild card. They can go both ways.
I will give you some examples to help calibrate.
Here is a patient with a buccal space infection I treated with oral antibiotics, I&D, and a 2-step root canal in calcium hydroxide. He was just fine.
You can see the facial asymmetry on the right buccal space. It is important to note I performed BOTH the pulpotomy AND the I&D drain the same day as the patient presented, as well as prescribing oral antibiotics after giving him a loading dose in clinic before starting. This patient had no trismus, no dysphagia, and no symptoms other than pain and the swelling.
Here is a second buccal space on a child, who I treated by a small I&D incision, removing the primary tooth and oral antibiotics in the form of suspension. She was 6-7 if I remember correctly.
This patient was a bit overweight, and it was an upper right pre-molar with an associated right buccal space swelling:
Again, I treated this one by giving oral antibiotics, followed by a same-day pulpectomy with calcium hydroxide, and then an I&D to drain. Pt’s swelling went down. She came back the next day for a follow up to monitor the swelling, and 2-3 weeks later to obturate.
An important point with dental swellings is, in my opinion, if you’re providing oral antibiotics, one should STILL drain the patient AND provide treatment (either exo or endo). Do NOT just give oral antibiotics and pull the tooth. Drain them too.
If you are unwilling to drain, please send the patient to someone who will.
So, the above buccal space swellings were treated with oral antibiotics and not IV antibiotics. We’re on a roll. Every buccal space infection gets oral antibiotics?
Well, what about this buccal space infection below? Oral or IV?
Here is the side view:
If you said IV antibiotics, you were correct. This is a patient I saw during my hospital residency. He was severely trismatic, and was admitted for a few days with IV antibiotics and IV steroids until he could open his mouth sufficiently to open for his tooth to be extracted.
It should be noted, he remained on IV antibiotics for a few days after the tooth was pulled as the deep space infection takes time to subside.
As a side note, an extraoral drain would not be out of the question for a patient like this. Just not performed by a GP.
So the above swelling is an obvious case that should be sent to a private practice OMFS (ideal, but call ahead) or an ER hospital room (also ideal). That is an example of a large buccal space swelling.
But what about this buccal space infection below? I saw him a few years ago in my private practice.
Here is the side view:
I treated this patient in my clinic. I gave him oral antibiotics, pulled his tooth, drained the swelling as best I could, but I ALSO still referred him to the ER for IV antibiotics and imaging (CT scan w/ no contrast) after the extraction.
The patient ultimately had a peripheral IV placed, was on IV antibiotics for 7 or 10 days. I do not remember the exact specifics, but the the point, when in doubt on dental swellings you want to err on the side of caution.
Another way of saying the same thing, when you’re not sure about oral antibiotics or IV antibiotics, you want to give IV antibiotics.
Since we’re now starting to talk about draining the swelling, let me give you a little tip. If performing the exo or extraction, make sure to drain last. It can sometimes get messy, bloody and full of purulence (pus). Also on more severe swellings, a full anesthesia in the swollen area can be difficult to achieve. Despite our best efforts, patients can have full facial signs of being numb, but at times the I&D can still hurt. So I like to do the endo or exo first, then drain last.
Buccal Space Summary
So regarding buccal space swellings, know that, generally speaking if the buccal space is small, confined ONLY to the buccal space and there are no other symptoms with a relatively stable medical history, you can treat with oral antibiotics and dental treatment (endo/exo + drain).
Anytime the buccal space swelling crosses the inferior border of the mandible automatically the patient NEEDS IV antibiotics. If there is any trismus, difficulty breathing, elevation of the tongue, the pt needs IV antibiotics.
What if the buccal swelling is AT the border of the mandible but has not crossed over yet? Well, I err on the side of caution, and would still give IV antibiotics.
Indurated or fluctuant
So we started to talk about draining swellings, but NOT all intraoral swellings should be drained.
The too long; didn’t read is this:
Fluctuant = drain the swelling
Indurated = do not drain the swelling, refer to OMFS or ER
So what is what? How can you tell what swellings are indurated versus fluctuant?
Well, fluctuant feels like a squishy water balloon. It’s moveable. It is NOT like a rock. You are feeling for this INTRAORALLY (in the mouth).
Indurated swellings on the other hand, feels hard and rock like. Remember this is what you feel at the drainage site, NOT the facial swelling (so in your case you’re feeling for this intraorally – you are not draining the neck or cheek).
So in short, if the swelling is indurated, best to get the patient on IV meds + in an ER or OMFS setting. If fluctuant, I would drain.
Antibiotic Dosage
So we still haven’t gotten to draining the swelling yet. Before you go to numb the patient, personally I like to give oral antibiotics before starting.
Let me tell you a story first. A few years ahead of me, a resident had a healthy 30 y/o police officer present with a dental abscess. The police officer was too trismatic to pull the tooth, so the resident gave a lower IAN block to help the patient with the pain.
Long story short, the needle passing through fascial spaces for the block allowed the infection to advance further and the infection made its way down the neck. The next day the police officer returned, the infection was drained in the operating room but it was too late. The infection got into the thoracic cavity and heart.
I do not know the details of the case, but I do know the OMFS who drained the patient, and ultimately the young, fit, healthy police officer died about a week later from complications. This oral surgeon told me this story, and always told me to have antibiotics in the blood stream before initiating treatment (including local anaesthetic injections).
What I want you to remember is this. Provide antibiotics before getting started. And once the infection goes submandibular, things can progress and spread fast. Like scary fast.
So, what dosage do I load patients with before starting treatment?
Well, I like to give 2,000mg (four 500mg tabs) of Amoxicillin PO.
Wait, isn’t that really high? We normally do 500mg q8h, or maybe a loading dose of 1,000mg followed by 500mg?
Well, yes, but what do dentists routinely give for joint prophylaxis? 2mg of Amoxicillin. This is as per ADA, and can be seen here.
Yes, I realize guidelines are changing, but my opinion is if clinicians are routinely giving 2g Amox for PROPHIES you can *certainly* give 2g Amoxicillin for a dental infection.
Allergic?
Now, what about the Penicillin allergic patients and the really severe dental infections? Well there are two trains of thought.
Now, when I trained, we used a ton of Clinda on dental swelling patients. Clinda 300mg PO, but usually we jumped straight to IV Clinda on the bigger swellings. The reason for IV is beceause if you gave a patient 600mg of Clinda orally their GI would not tolerate it + be thrown back up. Vomit city. The dental bugs in the hospital were big and bad (all clinical photos in this email guide I took personally) and the swellings were not to be messed with. For example, here is a young gentleman in his 20’s who I (eventually) pulled his lower right 3rd molar.
Notice the elevation of his tongue in the photo. He still can’t breathe. That photo is after 4-5 days spent in the ICU where he had a nasotracheal intubation to keep things going.
I talked to some of my OMFS friends, specifically Vishy Broumand who is a Oral and Maxillofacial Tumor and Reconstructive Surgeon in Phoenix AZ (www.BroumandOralSurgery.com), and Khurram Ashraf Khan who is a full scope OMS/Cleft Surgeon in Cincinnati, Ohio (www.aboutfacesurgicalarts.com).
Both of these guys are no joke surgeons and are full-scope OMFS:
If you want to read more of Vishy and Khurram’s incredible educational posts, you can check them out here in the dental learning group that I run: https://www.facebook.com/groups/DentalClinicalPearls/.
So this is what Vishy said about Penicillin allergic patients:
When I asked Khurram about oral antibiotic alternatives to Clindamycin, he suggested Cephalexin 500mg QID for an option.
Here is the thing though. When seeing patients like this (below), often the future dental implant is usually the last of my concerns. I will say, I used a ton of Clinda on large swelling patients in the first half of my career, but for Penicillin allergic patients with dental swellings going forward I will be using Cephalexin (and making the appropriate referral for the large swellings).
So, for Penicillin allergic patients, Clinda is an option and Cephalexin is an option.
Numbing
So you’ve now diagnosed the swelling is of odontotgenic origin, given the patient some oral antibiotics in advance, and determined it is within your skill level to drain the swelling and extract the tooth (or drain + refer for exo). It’s finally time to drain this.
Sidenote: unless you’re extremely comfortable surgically, if you are going to pull the tooth too, make sure the patient has AT LEAST 2.5 fingers opening. (More on this later.)
But first you gotta get the patient numb.
And as you probably know, with dental swellings it can be more difficult.
So let’s talk about numbing the upper arch first.
I will tell you what NOT to do.
Do NOT inject DIRECTLY INTO the swelling. This can be REALLY painful, and often because of the pH of the infection, the numbing is ineffective.
Instead, you want to find/locate the fluctuant swelling in the vestibule (we’ll talk about palatal swellings later, but know that they are rare) and you want to inject ANTERIOR and POSTERIOR to the swelling.
I will repeat, do NOT inject into the swelling.
I made a visual example of what I mean. Pretend the red is the fluctuant swelling. And pretend the green is the injection sites.
Numbing Lower Arch Swellings
As for the lower, I do something similar. First I block. Gow Gates or IAN block (I do GG on almost everyone). Let things start to take effect from the block, then I inject locally anterior and posterior to the fluctuant swelling.
It is not uncommon to have lips and facial numbness from the block, but the swelling still not numb. So those additional local infiltrations are important.
I also made a visual example for the lower arch:
Anesthetic Cocktail
But what anesthetic do you use? And how much?
Me? I like to use a cocktail mix of local anesthetics. Numbing swellings can often be a mixed bag and not as predictable.
So for the upper arch I’ll do 1 carp of Articaine 4% 1,100k posterior to the swelling, 1 carp Articaine 4% anterior to the swelling. Wait a bit for it to take effect, then put 1/2 to 1 carp of Carbocaine (Mepivacaine) 3% anterior to the swelling and 1/2 to 1 carp Mepivacaine 3% posterior to the swelling. The Mepivacaine I use has no epinephrine.
I do the Septo first, because it’s strong and have EPI (which helps keep the subsequent injections around longer). Why Mepivacaine? Well it’s a different pH and while faster acting, it is known to do well in dental swellings.
Yes, I am giving 3-4 carpules for an upper arch swelling (generally speaking, when not contraindicated). How come? Well, from experience I’ve learned that swellings are tough to numb, uncomfortable for patients and generally speaking this gets me a good numbness for the patient.
As for a lower arch swelling, I’ll block first. I know a lot of excellent clinicians who block with Articaine with no issue or concern with paresthesia, but that’s your call. So block first with either Lido or Articaine. Wait. The 1 carp Mepivacaine 3% posterior to the swelling and then 1 carp Mepivacaine 3% anterior to the swelling.
Is it going to hurt, doc?
With dental swellings, you can have the most profound lip signs, the patient can feel totally numb in the face, but when you incise in the center of the fluctuant swelling, it can still hurt. Kind of like removing a really hot tooth how it sometimes still hurts at the apex. So it’s good to warn the patient in advance things might get uncomfortable, and you’ll do your very best to work efficiently.
Obviously, if something hurts on a patient, you stop, and give more anesthetic, but my point its this. The middle of an infected swollen area can be tough to fully numb and you will not know until your scalpel blade touches the area.
Tools?
So what instruments are you going to use to drain? This is what I typically use:
- 15 or 15c blade
- eyeglasses (sometimes these swelling spurt! – I wish I was joking)
- surgical suction
- monojet
- cup of saline
- Minnesota
- bite block or molt
- hemostats (optional)
Technique
So a basic I&D technique is not overly complicated.
First off, warn the patient there might be some bruising.
You aim your incision to be at the most swollen part of the fluctuant swelling. Think the center of the water balloon.
If there is no vital anatomy, take the blade until you contact bone.
Vital Anatomy
If there is vital anatomy, such as the mental foramen, you make DARN SURE from the Pan x-ray you’re NOWHERE NEAR the mental foramen. Don’t have a pan? Well take one. Even if it means doing the pan for no charge. You want this Pan when locating the mental foramen.
If you are in a danger zone, I do not recommend taking the blade to the bone. I repeat, do not put your scalpel to bone. Retract the cheek hard with the Minesota, to pull the fluctuant swelling away from the mandible and make a sparing incision into the mucosa / swelling / tissue in an inferior direction that does not go to the jaw bone.
That way you avoid the nerve. Just make a small incision into the mucosa and then do blood dissection with your hemostats.
These next three pictures are from Dr. Vishy Broumand (OMFS, Phoenix, AZ) who gave me permission to use photos from one of his I&D presentations. They show the technique when incising around the mental foramen:
You can see below, the incision does NOT contact bone.
This is the hemostat dissection. Again, no bone is contacted.
How big is the incision?
I like to start small incision. I start with the width of the 15 blade, and usually will extend as needed, but generally speaking 1cm / 10mm is sufficient and I&D incisions should not be larger than 1cm.
Something important. There often are purulence lobules. Essentially little pus balls. You can either put the hemostats in the incision, spread them, and break up the lobules this way. I do not have any photos of this, but you can see the technique here in this video at minute 3:00:
Even if you do use hemostats, after dissection, I like to get my fingers in the area and massage / knead the swollen area to see if I can coax out any further purulence. Your assistant should suction it up as you go (these photos were taken working solo)
The pus (purulence) is usually straw colored but it can also be white or green. Often the purulence is mixed in with blood. Smaller swelling might get 1-3cc, larger swellings more.
Then rinse with saline. I often put the tip into incision and GENTLY express saline into the area. Rinse the area out with saline. You can do copious irrigation. The reason for that obligate anaerobic bacteria lack the enzyme peroxidase. Peroxides are formed in the presence of oxygen. Thus without peroxidases these organisms are killed in the presence of oxygen. So start flushing that out. Some clinicians will introduce hydrogen peroxide into the irrigation, but I personally, do not.
Usually, it’s a couple of CC’s and mostly mixed in with watery looking red blood. Every once in a while, you’ll get a “gusher” like this one:
and it just kept on going.
Suture? Drain?
Now here is something that surprised me when I was first learning how to do an I&D. You do not suture the incision. It’ll stop oozing blood, that is important to verify. However you want to establish a drainage route as well as continue to let in more oxygen. So you leave the incision “open” and do not suture.
As for a drain, I have written tips on this before, but I will revisit that topic for this guide.
So yes, technically drains are taught in the textbooks with I&D’s.
My personal opinion is, there are more variables and factors to consider.
Here is the problem with penrose drains (and rubber dam drains, and any kind of drain one can place).
The patient compliance is TERRIBLE.
Patients do not tolerate them well.
Patients take the drains out (I wish I was joking).
They can get infected.
Generally speaking, drains just are not worth it. This is the voice of experience. Please take 2 minutes to hear me out as to why.
Trend
You have to remember. You’re a dentist. You like teeth. A lot.
You like teeth way more than the average person.
Flipside.
Someone who gets themselves into tooth trouble, to the point of a large dental swelling, generally speaking is not very into their teeth.
Swelling patients are into their teeth even less than the average patient.
Yes, there are exceptions to the rule. Yes, I’m sure you saw a nice little old grandmother who had a tooth abscess and a huge swelling overnight.
But
Generally speaking
Those who get dental swellings that require drainage are not as into teeth as the dentist is and generally speaking will tolerate a whole lot less.
I think that’s fair to say. It’s just a matter of fact. I’ve done a LOT of I&Ds in my career, and this is the general trend I’ve noticed.
As for placing a drain, a mentor of mine who is an excellent dentist, and very well versed in hospital dentistry (20+ years) told me to not place drains when asked on this topic.
My philosophy on drains
Here is my thoughts as a GP. If the swelling needs a drain, the patient needs to be seen by either an OMFS or hospital ER, and at the very least IV antibiotics and consideration towards being admitted.
IV antibiotics for a few days can do some wonderful things to deep space swellings.
If the patient can be managed WITHOUT a drain, then do not place a drain. If a patient needs a drain, get them to OMFS.
That does not make you a bad dentist. In fact, referring to appropriate care makes you a good GP.
Post-op instructions
So we have left the small 1cm (or smaller) incision open without a suture, given copious irrigation, and the I do not suture.
I make sure I give sufficient pain medicine. In the range of a tooth extraction. Sometimes a bit more.
I also make sure the patient has a prescription for antibiotics if I am managing the infection orally. If the pt needs IV meds, I send them with a letter to the ER (more on this later). If going to OMFS, the surgeon knows what to do.
As mentioned earlier, if you pulled the tooth or did the endo, it is very important to note that deep space infections can persist AFTER the tooth is removed
If the swelling is large or the patient is trismatic, I also tell patients in advance they might need physiotherapy for jaw opening.
Hot or Cold
I usually do a cold compress for the first 24 hours to help keep the swelling down and then I switch over to a warm compress after 24 hours to increase blood flow to the area, by bringing all the inflammatory mediators to fight off the infection and have the swelling go down for up to 5 days.
Of course, some patients don’t really need an ice pack for the first 24 hours because they get IV steroids but not everyone gives steroids so ice packs become helpful in the first 24 hours.
Patients do not need to buy special heating or cooling packs. Frozen veggies in a thin towel, or a towel dipped in hot water can serve as a cold or warm pack.
Make sure, with heat to warn patients to not keep it on the face too long at one time, especially if numb. It’s a lot easier to burn the face than say a heating pack on an injured hamstring
Danger Zones
As a GP, I do not recommend you ever do an extra-oral I&D. Save those for OMFS or ENT.
So earlier, I mentioned “danger zones.” The primary one is the mental foramen. Two other spots I want you to be very careful of are the greater palatine (palate, 2nd molar) and the incisive foramen (palate, upper centrals).
So while palatal swellings are rare, what do you do in that area if a patient presents?
Aspiration
I like to do an aspiration drain. So instead of cutting with a 15 blade, I use a 20 or 21 gauge needle and I aspirate. I would not use anything too big, like a 16 or 18 gauge beceause of the increased risk for continuous bleeding.
You’ll use a syringe that has a luer connection. They look like this and come in different sizes.
Pop on a 20 or 21 gauge. You numb up the patient, as described above. Then advance the 21 gauge into the swelling, careful to not hit bone, and aspirate back the purulene.
Tricks and tips
At this point, I am going to talk about miscelaneous aspects of an I&D, including when patients are trismatic, if the ER asks what kind of CT to take as well as some communication tips + CYA if sending a patient to the ER.
Open? Please?
So one fairly common situation with deep space infections is the patient has difficulty opening their mouth (trismus). A quick way to measure is ask them to open as large as they can, and see how many fingers the opening is. Like this cartoon image (but obviously use gloves).
Most people are 3, 3.5 fingers opening. Some giants can do 4, but that’s rare.
I want to caution you. Taking teeth out on a trismatic patient is an entirely different ballgame. You might think you’re pretty good at taking teeth out but a multi-rooted tooth or molar with 2 finger opening is a totally different challenge and I would say is a very difficult extraction. It’s always better to live to fight another day if you’re unsure of the difficulty. Do not be the GP breaking off root tips, THEN sending a swelling patient to OMFS to bail you out. We’re here to help patients, not make things worse.
My advice? Unless you are very comfortable surgically, pass on anything less than 2.5 fingers opening. Get those patients to OMFS or on IV antibiotics (and possibly IV steroids) for a few days until they can open up more.
Now there are some techniques to open a trismatic patient. The main one is what is called a molt prop. They look like this:
You can buy a molt prop at Atitan and get a 10% discount on the item (or any Atitan item) while also supporting Dental Clinical Pearls and these emails by using the promo code “pearls10” (no capital letters).
Adult sized: https://www.atitan.com/products/151-molt-mouth-gag—adult
Child sized: https://www.atitan.com/products/663-molt-mouth-gag—child
If you’re going to buy only one, I recommend the child size since you can use it on petite patients and large patients (it cranks plenty big). I also recommend having one molt prop in your office, even if you do not do sedation, purely for the trismatic patient who walks in.
Technique
It can take an hour or two, but what you want to do is numb the patient first. It can be very painful for a trismatic patient to open. If it’s an upper tooth causing the swelling but it still hurts after numbing the upper, then also give the patient an IAN block.
Once the patient is numb, slip the molt in. MAKE SURE the molt is on the opposite side of the mouth as the tooth you want to pull. Then open the prop until the patient says it is enough, then STOP.
Give it some time. 10-15 minutes. Then click the prop open one more click. Two if you’re lucky. You might get 2-3 clicks, but go slooooowly. Try one click at a time. Check in with the patient. Give the new opening another 10 mins. Then come back and advance the molt one more click.
Might take an hour or longer, but if you’re patient, and the patient can tolerate it, this is how to open a trismatic patient.
Sidenote: any patient with trismus, or a large deep space infection, you want to warn them IN ADVANCE that they likely will need physiotherapy from the infection.
Contrast or no contrast
So if you’re ever asked about imaging of the infection, you can let them know a CT with no contrast. That’s more than sufficient to visualize the space(s) the infection is in. Contrast is not necessary.
Letter
Finally, if sending the patient to the ER, you want to write them a letter. This does a couple of things.
(1) helps streamline the triage
(2) gets the right people evaluating the patient (recommend an OMFS or ENT consult)
(3) prevents the patient being turned away without IV antibiotics
When I send patients to the ER, I write them a letter. It includes:
- background information of the dental treatment
- printouts of any pertinent radiographs or I/O photos
- my recommendations ie. pain management, IV antibiotics, dental or ENT consult, I&D, etc
- my contact information, including my personal cell #
- if listing teeth, use the tooth number as well as the actual location (ie. upper right 3rd molar). It helps cut down on confusion
- a recommendation of NPO (nothing to eat), just in case the need to go to the OR
Here is an example of the kind of letter I write. Remember, like everything else I’m sharing here, this is the letter that works for me in my practice.
You will note in the letter I also like to send the patient with radiographs. I send the patient with two printed out copies of the panorex. The first copy is untouched. The second copy has the offending tooth circled in Sharpie, and I have written the tooth number AND a brief non-dental layman’s description of the same tooth. You want to give the patient both copies.
Here is an example for this patient:
Here are the corresponding 2 copies of the pan I printed off:
Notice one copy is untouched:
Here is the copy identifying the offending tooth in Sharpie. The tooth number is listed as well as layman’s term description:
Why it works
By putting your recommendations, it, in a sense, forces the hand of the ER doctor. Sure they can ignore the Dental consult or the I&D but what if they’re wrong. They’ve got a medical professional’s letter, in writing, recommending certain treatment. Helps keep the patient from being turned away
What I tell patients
What I tell the patient is to take the letter + radiographs and show that to the triage nurse and ER doctor. I tell the dental patient it helps speed up their visit (ie. avoids waiting 90 minutes to get the Pan x-ray).
What it also does is it helps guide the treatment, so they’re not sent home with some PenVK for a large indurated buccal space swelling that crosses over the inferior border of the mandible.
I’ve found it to work quite well.
Why your personal cell #
It’s a heck of a lot easier if the treating medical doctors can call you w/ questions rather than not be able to get in touch and then you get thrown under the bus. Make yourself accessible. The patient will appreciate it.
How a letter also helps you
Let’s say the Pt did not present to the ER. Sometimes patients do things like that. Then the patient has trouble at home. By writing this letter, this also covers you. We scanned the letter, and it clearly shows that I told the pt to present to the ER immediately. It helps cover yourself too.
So the next time you have to send a patient to the ER, consider writing a letter. Makes for smoother treatment, as well as helps cover yourself and prevent miscommunications.
I hope this tip helps you.
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To your success,
Dr. Greg (aka “The Helpful Dentist”)