More Than a Filling

You never know what you are going to see next in the ER. That's why I like it. You can be cruising along with some basic chest pain workups, a couple of upper respiratory infections, a few minor traumas, and the usual assortment of abdominal painers. What an easy job this is, you might think to yourself. Then something weird walks in. Something like this (no not the dog, but you can click on the picture to see what happened to him):

The chief complaint was "allergic reaction," and the patient was sent straight from the dentist's office to the ER after having first received a shot of Benadryl. He was having a deep filling placed in a lower molar when suddenly one side of his face began to swell up.

When I entered the room, I noticed that the left side of his face was indeed slightly swollen, but he reported that it had gone down quite a bit after the Benadryl. When I palpated his neck, I immediately noticed the unmistakable crunchy feel of subcutaneous emphysema, or air in the soft tissues, which extended from cheek to collarbone.

An X-ray of the neck confirmed my examination, but the chest X-ray was negative for pneumothorax or pneumomediastinum. So how did this happen? Further history from the Dentist revealed that she had used compressed air to dry the lower molar after retracting the periodontal space adjacent to the tooth. Apparently air was forced into the cheek and neck by the dental equipment. Initially the cheek swelled up, then the trapped air gradually spread out in various soft tissue planes of the neck. So the swelling really had "gone down."

So what about the treatment and disposition of a case like this? It isn't the sort of case that is easily looked up in a standard reference book. Neither the referring Dentist nor her Endodontist partner had ever heard of such a complication, so they weren't much help. The on-call oral surgeon and ENT physicians both agreed that the air would probably be gradually absorbed without any adverse consequences, but both recommended prophylactic antibiotics just in case.

The patient was discharged with an oral antibiotic, and his Dentist later reported that everything turned out well. This complication of Dentistry is not unheard of, but it was to me and to the referring dentist.

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