2 OMFS cases for your review

[FTW OMFS]

No one seems to be looking at the OMFS case thread stickied above so I thought I'd post my cases in a new thread. These are two that I've run across in my first year of practice. Toofache, I'll send them to you once you get here and their insurance runs out...

I orginally posted them in a dental forum. Here are the links:

http://dentalconsult.forumcircle.com/viewtopic.php?t=46
http://dentalconsult.forumcircle.com/viewtopic.php?t=45

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[EuroOMFS]

Ok, 40y/o WF walks into your office on New Year's Eve and says, "My dentist pulled my tooth 2 days ago. It started swelling last night and now I've got a fever. You're the only doctor open today, not to mention incredibly good looking. Will you look at it for me?"

Pt says #19 was down to carious roots for about a year before she had the tooth out. About 3 weeks ago her left lip started getting numb. About 3 days ago the area around #19 began to swell and become painful. 2 days ago she had #19 pulled. The pt says her dentist ran into an increased amount of bleeding and had to sew the socket closed at the end. She also says he noticed a lucency at the apex of #19 and mentioned it to her. He told her she probably had an infection making her numb.

On exam, the socket is nicely closed with 2 black silk sutures. It is hemostatic. There is mild to moderate buccal gingival and vestibular swelling with slight purpura. I couldn't express anything from the wound with manual pressure. She has no trismus and no noticeable facial swelling. No neck swelling. One palpable left submandibular node, freely moveable and nontender. The inferior border of the mandible is easily palpable.

I'm attaching the pano I took in my office 2 days after #19 was extracted with a zoomed-in image of the area in question. What do you think? How would you proceed? I diagnosed her with a mild subperiosteal infection and treatment planned for removal of all teeth and placement of 32 implants. She declined and I replanned for suture removal and wound exploration under local. I figured I'd either find pus or a hematoma.

I'll tell you the rest of the story in 1-2 years, after this thread has 2 responses.

I'll respond to your second case.

What was #18 like? Was it mobile? There was no pain? Just swelling and fever? From what you've shown so far I'd say the differentials are: a) infection (osteomyelitis), b) infection, c) infection, d) infection and e) a tumor, maybe a vascular tumor of some kind, that has become infected.

I'd proceed like you suggest, but I might consider getting a CT first. Then dig out all that infected granulation tissue (which is propably what caused all that peroperative bleeding) and maybe extract #18 as well.

But what the hell do I know. I liked your total extract/total implant plan better.

Euro.

 

[VCUDDS]

any significant med hx with the second pt?

 

[FTW OMFS]

No significant medical history with the second patient. #18 had a little mobility, probably class I. When she came into my office she said she had some pain but it was baseline from the extraction so she chalked it up to post-op pain.

A CT isn't a bad idea but I wanted to deal with her acute problem of unexpected postop swelling. The fever led me to believe infection.

 

[ClassVII]

I will first admit I know knowing compared to the OP or other attendings responding to the cases.

The first case struck a cord because I just read an article on Atypical Odontalgia..... J Am Dent Assoc 2009;140; 223-228 (Clinical Characteristics and Diagnosis of Atypical Odontalgia)

 

[Impacted Molar]

For the 1st patient:

A blood pressure that elevated requires immediate referral to her PCP or if she is symptomatic immediate referral to the ER. There has been some instances where cardiac pain can refer pain to the dentition, so that is a remote possibility. Bottom line she isn't infected, and until BP is under control no treatment warranted.

For the 2nd Pt:
Was tooth vitality performed on tooth # 18? One option is the first dentist assumed 19 was the bad tooth, but 18 appears to have some recurrent decay around the margins. With the history of bleeding the pt reported, you would like to know exactly how the first dentist treated that area, gel foam, bone wax, etc., but it sounds likely a hematoma formation. I would aspirate before I proceeded with further exploration of the wound.

 

[FTW OMFS]

For the 1st patient:

A blood pressure that elevated requires immediate referral to her PCP or if she is symptomatic immediate referral to the ER. There has been some instances where cardiac pain can refer pain to the dentition, so that is a remote possibility. Bottom line she isn't infected, and until BP is under control no treatment warranted.

For the 2nd Pt:
Was tooth vitality performed on tooth # 18? One option is the first dentist assumed 19 was the bad tooth, but 18 appears to have some recurrent decay around the margins. With the history of bleeding the pt reported, you would like to know exactly how the first dentist treated that area, gel foam, bone wax, etc., but it sounds likely a hematoma formation. I would aspirate before I proceeded with further exploration of the wound.

The fist patient had acute coronary syndrome and was stented the next day. Until then I had never seen cardiac pain referred to the maxilla. All her previous episodes of pain were probably referred angina.

No tooth vitality on #18. I didn't even notice it was loose until I had numbed her up to explore #19. The first dentist told me later he did not place anything in the socket, only sewed it up. He advanced the mucosa enough to almost have primary closure.