Opening, drainage of category II abscesses

Is the swelling no longer limited to one tooth, is your cheek asymmetrical, is opening your mouth harder and is the fever persisting? These are signs that infection has spread into the deep tissues of the face. At UKRMED Maxillofacial Surgery, surgeon Anna Kravchenko assesses the extent of infection and performs category II incision and drainage.

When infection spreads beyond the gum

Infection from a tooth with a dead nerve, an inflamed wisdom tooth or an extraction site can spread into the fascial spaces around the jaws. The most common are:

• lower jaw abscess — from the lower molars, especially wisdom teeth;
• submandibular abscess — a painful swelling below the lower jaw;
• abscesses of the cheek, temporal region and pterygomandibular space.

Systematic reviews stress that odontogenic infection can spread quickly between fascial planes, so delaying treatment is dangerous.

What category II means

The category reflects the extent and complexity of surgery. Category II means the infection has spread beyond a small area near the tooth, needing wider access, several drains and daily review. Contained gum abscesses drained through a small incision are category I.

When hospital care is needed

Call an ambulance if breathing or swallowing becomes difficult, the floor of the mouth rises, swelling spreads to the neck or weakness increases. These conditions are treated in a hospital maxillofacial unit, and a UKRMED surgeon refers the patient there straight away.

Diagnosis

The surgeon asks when the swelling started, whether there was fever, whether swallowing or mouth opening became harder, and about chronic conditions and allergies. CT shows which spaces the pus has spread into and finds the causative tooth. This determines where to make the incision.

The procedure

1. Anaesthesia: local or sedation supervised by an anaesthesiologist.
2. An incision — inside the mouth or on the skin in a natural crease, depending on where the pus is.
3. Opening all affected areas and taking pus for culture.
4. Irrigation with antiseptic.
5. Placement of one or more drains.

Antibiotics and treating the cause

In spreading infection antibiotics are needed — but in addition to drainage, not instead of it. A 2026 systematic review on bacterial resistance in odontogenic infections recommends aminopenicillins with a beta-lactamase inhibitor as first-line, adjusted according to culture results.

Once inflammation settles, the source is removed: the causative tooth is usually extracted, and an impacted wisdom tooth is removed surgically. Otherwise, the infection returns.

Follow-up

• Daily dressings and irrigation while pus is draining.
• Drains are removed once drainage stops — usually after a few days.
• A full course of antibiotics as prescribed.
• Plenty of fluids, soft food and rest.

Who is at higher risk

Infection spreads faster and is more severe in people with diabetes, weakened immunity, older patients and after prolonged self-treatment. Warming the cheek, applying compresses or taking antibiotics on your own is dangerous: it does not remove the pus, it only delays seeing a surgeon.

Why delay is dangerous

Without drainage, pus spreads to neighbouring spaces: the neck, the floor of the mouth and the tissues around the eye. Breathing difficulty, spread into the chest and sepsis are possible. These complications are rare but develop quickly — so facial swelling with fever always needs a same-day review.

Prices at UKRMED

The surgeon gives the cost after examination and CT — it depends on the number of spaces involved, the access and the anaesthesia.

Sources

1. Schmid A. I., Werkmeister R., Al-Nawas B., Heider J. Antibiotic resistance in odontogenic infections: A systematic review of current evidence and implications for guideline-based therapy. Clin Oral Investig, 2026. https://doi.org/10.1007/s00784-026-06848-1
2. Lockhart P. B., Tampi M. P., Abt E. et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling. J Am Dent Assoc, 2019. https://doi.org/10.1016/j.adaj.2019.08.020