CC
The patient says, “My tooth is hurting, and it started swelling yesterday.”
HPI
A 39-year-old male presented to your office initially about 1 month ago, referred for extraction and eventual implant reconstruction for tooth #13. It had been bothering him for a while, and he has had several courses of antibiotics, which calmed the pain temporarily, but he does not remember what kind of antibiotics they were. He said that finances will limit the ability to perform implant placement immediately after extraction and would likely not be able to afford an implant until the next calendar year when his insurance benefits reset. The patient never scheduled an appointment until yesterday when he experienced significantly worsening pain and some swelling in his gums that has only worsened. You were able to fit him into your schedule for urgent evaluation and treatment today.
PMHX/PDHX/medications/allergies/SH/FH
Noncontributory. His medical history is only significant for hypertension and allergic rhinitis. His hypertension is controlled using losartan, and he treats his allergic rhinitis with over-the-counter antihistamines. He has no drug allergies and reports his only allergies are to grass and cat dander. He has no other remarkable history.
Examination
General. He is a well-developed, well-nourished adult male with an overall nontoxic appearance. He has normal mentation and shows mild signs of distress.
Vital signs. Temperature is 98.9°F, blood pressure is 153/98 mm Hg, pulse rate of 103 bpm, and respiratory rate of 14 breaths per minute. The patient’s nontoxic appearance and lack of fever indicate that there is no significant systemic inflammatory response present. His blood pressure and pulse rate are elevated above a normal range; however, this may be an indication of several things such as pain from his oral condition, inadequate medication regimen, or noncompliance with his medication regimen.
Maxillofacial. No significant extraoral edema or erythema is noted. His neck shows full range of motion. There is no remarkable lymphadenopathy on palpation. The inferior border and angle of the mandible are easily palpable and nontender.
Intraoral. He has a full dentition in overall good condition. Several direct restorations are present. Tooth #13 with a carious fracture and mobile palatal cusp is present. The maxillary buccal vestibule is slightly edematous and tender to palpation, with no remarkable fluctuance, and is only mildly indurated. Maximum incisal opening is slightly restricted to about 35 mm. The floor of mouth is nonraised and nontender.
Imaging
The panoramic radiograph ( Fig. 24.1 ) is consistent with clinical examination showing a full dentition other than absent third molars #16 and #32. Root canal-treated tooth #14 appears clinically stable. Tooth #13 is slightly supererupted compared with adjacent teeth, with no significant periapical radiolucency or coronal radiolucency visible on panoramic radiograph.
A contrast-enhanced computed tomography (CT) scan would allow visualization and characterization of any fluid collections or cellulitic changes, but based on the clinical examination, the extent of any fascial space involvement appears to be localized to the buccal vestibule, so CT is not indicated.
Labs
Not obtained. For a minor vestibular abscess without signs or symptoms of systemic inflammatory response, laboratory values are not indicated.
Assessment
Buccal vestibular abscess secondary to pulpal necrosis secondary to an Ellis class III fracture involving the palatal cusp of tooth #13.
Treatment
The treatment recommended and accepted by the patient was incision and drainage (I&D) of the vestibular space abscess and extraction of tooth #13 to be performed under nitrous oxide anxiolysis and local anesthesia. You also recommend considering the findings during the procedure to determine whether socket preservation and membrane placement would be performed.
A mixture of nitrous oxide and oxygen was administered and titrated to 3L:3L/min. The patient reported feeling the effects of the nitrous oxide. Local anesthetic was injected via an extraoral approach to an infraorbital nerve block, approximately 0.5 cc of articaine 4% with 1:100,000 epinephrine. When the nerve block had taken effect, more local anesthetic was administered via local infiltration using approximately 3 cc of articaine 4% with 1:100,000 epinephrine and 2 cc of mepivacaine 3%.
After anxiolysis and local anesthesia were reached, a full-thickness incision was made in the most dependent aspect of the swelling in the unattached mucosa. Subperiosteal dissection was carried out through the extent of the abscess cavity, but only scant amounts of frank purulence was noted. On evaluating the abscess cavity, there was a bony dehiscence in the buccal plate tracking to the root apex of tooth #13. Attention was then paid to the tooth, from which the grossly mobile fractured segment was removed without any issue. The soft tissue was relieved and was mobilized using elevators, but given the extent of the fracture, there was no stable place to grasp using forceps. The handpiece was used to conservatively trough around the root, which was then mobilized and delivered in full with elevators. The socket was thoroughly debrided and irrigated, and the abscess cavity was thoroughly irrigated with sterile saline. Because of the buccal dehiscence and condition of the socket, the decision was made to proceed with socket preservation bone graft, which was performed using particular allograft and a bovine collagen membrane.
Because of the source control and surgical treatment of the abscess as well as the very minute amount of purulence noted in the abscess cavity, no drain was placed. The patient was prescribed oral amoxicillin 500-mg tablets with directions to take one tablet every 8 hours until the course is completed after 7 days.
Follow-up history
The patient returns to your clinic for evaluation 3 days after the initial procedure with a complaint of worsening swelling and pain, which is now bigger than the swelling before the initial procedure. He reports being compliant with his antibiotics but feels like it is continuing to grow in size and developed some redness and worsening pain. He said he may have felt slightly warm but denies any significantly high fevers and has no dysphagia, odynophagia, shortness of breath, or difficulty breathing.
Follow-up examination
General. No significant changes in his general appearance. He continues to be a well-developed, well-nourished adult male with an overall nontoxic appearance. He has normal mentation and shows only mild signs of distress.
Vital signs. Temperature is 99.1°F, blood pressure is 155/96 mm Hg, pulse rate is 99 bpm, and respiratory rate is 14 breaths per minute. His slightly elevated temperature and reports of subjective warmth may be indications of impending systemic inflammatory response. The elevated blood pressure and pulse rate may have the same considerations as mentioned before; however, if his blood pressure was lower and pulse rate had greater elevation in conjunction with a toxic appearance and fevers, the suspicion for a more serious systemic inflammatory response is raised.
Maxillofacial. There is extraoral edema and erythema overlying the left cheek inferior to the malar eminence with some edema extending to the lateral portion of his lower eyelid and the lateral commissure of the upper lip ( Fig. 24.2 ). There is some induration of the skin over the height of swelling. His neck shows full range of motion. No remarkable lymphadenopathy is felt on palpation.
