Emergency Case III:
Pulpal Debridement, Incision and Drainage (Extra-oral)
Amr Radwan and Katia Mattos
Chief Complaint
“My lower right side is swollen, and I can barely open my mouth. My whole right side hurts so much.”
Medical History
The patient (Pt) was a 43-year-old Caucasian male. Vital signs were as follows: Blood pressure (BP) 122/78 mmHg right arm seated (RAS), pulse 72 beats per minute (BPM) and regular, respiratory rate (RR) 18 breaths per minute, temperature (T) 99° F. A complete review of systems was conducted. There were no known drug allergies (NKDA).
The Pt was American Society of Anesthesiologists Physical Status Scale (ASA) Class I and reported no contraindications to dental treatment (Tx).
Dental History
The Pt presented for emergency Tx on his lower right side of his jaw. The Pt started experiencing severe pain on his lower right side two days prior, and he had not been able to sleep. Over the previous 48 hours, swelling had developed in the same area. His general dentist prescribed Augmentin® 250 mg three times daily (TID), and referred him for evaluation and Tx of tooth #31.
Clinical Evaluation
Examinations
Extra-oral Examination (EOE)
Facial swelling of the right submandibular area and facial asymmetry were noted (Figure 6.1). The swelling was about 5 × 4 cm and red in color. The skin was warm on palpation with a shiny spot in the middle of the swelling (Figure 6.2). Moderate tenderness to palpation was noted on the soft tissue adjacent to tooth #31. Lymphadenopathy of the submandibular and neck areas was observed. Temporomandibular joint (TMJ) was asymptomatic with no popping, clicking, or deviation on opening.
Figure 6.1 Submandibular swelling of LRQ and associated facial asymmetry.
Figure 6.2 Skin is red with a shiny spot at the point of highest fluctuance.
Intra-oral Examination (IOE)
The Pt’s oral hygiene was fair. There were no missing teeth. Periodontal pocket probing depths were all less than 3 mm on teeth #29, #30, and #31. All teeth responded normally to pulp sensibility tests except tooth #31, which did not respond to cold or electric pulp test and was tender to percussion and palpation. Tooth #31 showed class 2 mobility and a large carious lesion.
Diagnostic Tests
| Tooth | #29 | #30 | #31 |
| Percussion | – | – | ++ |
| Palpation | – | – | ++ |
| Cold | + | + | – |
| Mobility | 1 | 1 | 2 |
| EPT | 36/80 | 38/80 | 80/80 |
EPT: Electric pulp test; ++: Response to percussion and palpation; +: Normal response to cold; –: No response to percussion, palpation and cold
Radiographic Findings
Periapical (PA) and bitewing radiographs were taken. Teeth #29, #30, and #31 were studied. Tooth #30 presented with a radiopaque occlusal restoration and calcification of the pulp chamber. Tooth #29 was within normal limits (WNL) with normal pulp space and periodontal ligaments. Tooth #31 showed a radiolucent carious lesion on the mesial (M) wall and a 3 × 4 mm periapical radiolucency (PARL) around the distal (D) root (Figures 6.3 and 6.4).
Figure 6.3 Preoperative periapical radiograph of tooth #31.
Figure 6.4 Preoperative periapical radiograph of tooth #31.
Multiple composite restorations were observed on the bitewing radiograph (Figure 6.5).
Figure 6.5 Preoperative bitewing radiograph of tooth #31.
Pretreatment Diagnosis
Pulpal
Pulp Necrosis, tooth #31
Apical
Acute Apical Abscess, tooth #31
Treatment Plan
Recommended
Emergency:Incision and Drainage (I&D)
Definitive:Non-surgical root canal treatment (NSRCT) on tooth #31
Alternative
Extraction of tooth #31, no treatment
Restorative
Core build up and full coverage coronal restoration
Prognosis
| Favorable | Questionable | Unfavorable |
| X |
Clinical Procedures: Treatment Record
First visit (Day 1): Reviewed medical history (RMHX). Vital signs were as follows: BP 122/78 mmHg RAS, pulse 72 BPM and regular, RR 18 breaths per minute. T was 99° F. All Tx options were reviewed with the Pt, including extraction. The Pt elected NSRCT and informed consent was obtained. Anesthesia was obtained by 72 mg of 2% lidocaine (lido) with 1:100,000 epinephrine (epi) (0.036 mg) administered via inferior alveolar nerve block (IANB) and via infiltration of the buccal (B) mucosa B of tooth #31.
Rubber dam isolation (RDI) was placed. Caries were excavated and access was prepared with a #4 round bur, using a high speed handpiece and copious water irrigation. The canals were identified using an endodontic explorer. The working length (WL) was determined by using a size-15 Lexicon® K-file (Dentsply Sirona, Johnson City, TN, USA), along with an electronic apex locator Root ZX®II (J. Morita, Kyoto, Japan). No drainage was observed through the canals. Canals were cleaned and shaped using Vortex Blue® nickel titanium (NiTi) rotary files (Dentsply Sirona, Johnson City, TN, USA). Irrigation of the canal system was performed with 10 ml of 6% sodium hypochlorite (NaOCl), following each instrument.
The canals were dried with premeasured medium and coarse paper points. Calcium hydroxide [Ca(OH)2](Ultracal® XS, Ultradent Products Inc., South Jordan, UT, USA) was applied as an interappointment, intracanal medicament. CavitTM (3M, Two Harbors, MN, USA) was used as a temporary seal to the coronal access. The occlusion was examined and adjusted.
I&D procedure: The extra-oral operative area was disinfected with iodine tincture. The Pt was prepared and draped in the standard fashion for an extra-oral procedure. The area was shaved prior to the incision. A 3 cm horizontal incision was made in the most dependent area of the fluctuance. Peripheral pressure was applied towards the incision and a significant amount of purulent exudate was produced (Figure 6.6). The incision was irrigated with 5 ml of 0.9% sodium chloride (NaCl) solution. No drain was placed. The Pt was given a prescription for Amoxicillin 500 mg TID for infection and swelling, and ibuprofen 800 mg four times daily (QID) for pain.
Figure 6.6 I&D performed, abundant purulent discharge produced. Area and patient isolated with standard draping.
Second visit (2-week follow-up): Pt returned two weeks later, asymptomatic (ASX).
RMHX. BP 123/76 mmHg, pulse was 71 BPM and regular. No swelling was observed. Extra-oral incision site showed normal color and texture with no swelling. 1 cm scar from the incision was observed (Figure 6.7). Anesthesia was obtained by 72 mg of 2% lidocaine with 1:100,000 epi (0.036 mg) administered via IANB and B infiltration of the mucosa of tooth #31.
Figure 6.7 Two weeks after emergency I&D, patient returned asymptomatic. Skin does not appear red. No swelling noted. Small linear scar present at site of I&D.
A RDI was placed. The temporary restoration was removed. The canals were irrigated with 10 ml of 6% NaOCl, followed by 5 ml of 17% of Ethylenediaminetetraacetic acid (EDTA, Vista Dental Products Racine, WI, USA) and 3 ml of 2% chlorhexidine gluconate solution (CHX; Vista Dental Products) as a final irrigation. The canals were dried with paper points, then master cones were fitted and a radiograph was taken (Figure 6.8).
Figure 6.8 Master cone radiograph of tooth #31.
The canals were obturated with gutta-percha and AH Plus® Root Canal Sealer (Dentsply Sirona, Konstanz, Germany), using warm vertical compaction with Calamus® Dual (Dentsply Sirona, Johnson City, TN, USA). The floor of the pulp chamber was etched and bonded with Prime&Bond® XP (Dentsply Sirona, Konstanz, Germany). Flowable composite (Ultradent, South Jordan, UT, USA) was placed on the obturated canal orifice. A sterile cotton and CavitTM were used as a temporary seal to the coronal access. The occlusion was examined and adjusted. A postoperative radiograph was taken of tooth #31 (Figure 6.9). Postoperative instructions (POI) were given to the Pt. The Pt was referred back to his dentist for permanent restoration of tooth #31 and continuation of his Tx plan.
Figure 6.9 Postoperative radiograph of tooth #31.
Working length, apical size, and obturation technique
| Canal | Working Length | Apical Size, Taper | Obturation Materials and Techniques |
| MB | 19.5 mm | 30, .04 | AH Plus® sealer, Vertical compaction |
| ML | 19.5 mm | 30, .04 | AH Plus® sealer, Vertical compaction |
| DB | 19.0 mm | 40, .04 | AH Plus® sealer, Vertical compaction |
| DL | 19.5 mm | 40, .04 | AH Plus® sealer, Vertical compaction |
Post-Treatment Evaluations
The Pt was scheduled for a postoperative evaluation after six months and one year to evaluate the coronal restoration and healing of the periapical lesion.
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