CDA Essentials 2018 • Volume 5 • Issue 4

35 Issue 4 | 2018 | S upporting Y our P ractice Post-op  Day 1 : The next day, the man felt numbness in the area of 36 and mild pain, but didn’t phone the dentist.  Day 2: The patient reported the pain was so severe it woke him from a dead sleep and he vomited as well. The entire lower left jaw was sore, the area feeling numb/ frozen had enlarged, and he couldn’t bite on that side. In the morning, he saw his dentist and told him it might be the last tooth (37) that was causing the pain. The dentist didn’t agree; he thought the filling on 36 was a bit high and the man was probably clenching and grinding through the night. He made an adjustment to 36 and recommended that the patient try a night guard. There was evidence that he may have bitten the inside of his cheek when his mouth was still frozen. After leaving the dentist’s office, the patient bought two nightguards. He tried to wear one that night, but it didn’t seem to help.  Day 3 : The patient’s pain was worse, and he now had an earache. He called his dentist, who phoned in a prescription for amoxicillin. It was Sunday, and the man wanted to go to work the next day, so he declined the prescription for Tylenol 3. Throughout the day, the pain worsened and at 11:00 pm, he went to the hospital emergency department. He was turned away by the emergency room physician and told that he would get better with time. By 3:00 am, the pain had not subsided. The man returned to the hospital and demanded something to alleviate the pain. The emergency room physician looked in the patient’s mouth and said he could see what the problem was: the general dentist had hit a nerve when he administered local anaesthetic. The physician noted in the hospital chart that a traumatic injection by the dentist was the reason for the numbness, earache, swelling, infection, and pain. He said he “wasn’t going to fix the dentist’s mistake” and reluctantly gave the patient a Demerol shot.  Day 4: After a horrible night, the man saw his dentist and told him what the physician had said: the dentist had caused the problem with his injection. The dentist tried to reassure the patient that the injection was not the cause of his pain and prescribed Percocet. The dentist performed an incision and drainage to relieve some of the pressure of the swelling in the vestibule buccal to 36 and 37 ( Figure 3 ). Due to the lack of sleep and severe pain the patient was not able to go to work. Swellingworsens and spreads  Day 5: The man had another horrible evening and saw his dentist first thing in the morning. He also reported that he had pronounced stomach upset. The dentist gave him Gravol and recommended he take some Advil in addition to the Percocet. There was now buccal fascial space involvement; the patient’s left cheek was puffed out. The man’s neck was swollen and the skin on his upper left chest was red in colour. His condition has crossed the line from a dental issue to a medical one. The man saw his dentist, who noticed that 37 had become quite mobile and told the patient it was infected and needed to come out. But before extracting the tooth, more time was needed for the antibiotic to counter the 37 abscess. A panoramic X-ray was taken with no remarkable findings. However, the angle of each ramus was a bit washed out (see below). The dentist performed a second incision and drainage. This time it extended further posteriorly and up the ramus. Due to the stomach upset and persistent swelling, the dentist advised the patient to stop taking the amoxicillin and switch to clindamycin.  Day 6: The patient had stomach upset and loose stool. The swelling in the neck appeared to be going down, but the swelling in the buccal vestibule as well as the earache and numbness hadn’t improved. The patient had difficulty chewing anything but very soft food. He still had not returned to work. Another change in antibiotics  Day 9: The neck swelling had disappeared, but the swelling in the buccal vestibule persisted. The dentist performed a third incision and drainage, dropped the clindamycin and switched back to amoxicillin to address the upset stomach. He also renewed the Percocet prescription. By now, the patient was taking 8 Percocet a day to mitigate the pain.  Day 10: Despite the new antibiotic regime, the numbness and swelling started to increase again. The dentist extracted tooth 37; it was mobile and there was pus coming out from the sulcus.  Day 11-18 : The patient saw his physician because he was still experiencing loose stool. The physician took blood and stool samples, which all came back negative, and encouraged the patient to stick with the amoxicillin.