Don's wisdom tooth was acting up again. At age 27, he'd been fighting off recurrent pain, gum infections, and crowding of his teeth. Finally his dentist told him it was time to see an oral surgeon. After X-Rays the oral surgeon advised Don to have all four wisdom teeth out at one sitting, so the procedure was carried out a few weeks later. Penicillin tablets were started a day ahead of time and the extractions went pretty smoothly except the one impacted lower tooth was tough to remove.
The following day Don's jaw was pretty swollen, as he expected. He had a low grade fever and took some tylenol plus lots of fluids. On the third day, a Saturday, he wasn't doing so well. The jaw was more swollen and he was having a little trouble swallowing. So he saw the on-call oral surgeon who examined him and doubled his dose of penicillin. Another on call oral surgeon saw him briefly on Sunday. By Monday, a holiday, he was beginning to drool and his voice was squeaky plus his fever was 102 degrees. He was seen by a yet a different oral surgeon, who removed the stitches, switched oral antibiotics and told him to see his regular oral surgeon the next day.
On Tuesday, I was the admitting Critical Care doctor and got a call from the ER MD. "Jim, I've got a patient here brought in by the medics. He saw his oral surgeon today about chest pains and breathing problems and their office called 911 because of a possible heart attack. He has a some bizarre findings. Can you see him right away?"
In the ER, it was obvious that Don was critically ill. His breathing was painful and shallow, his voice high pitched and squeaky, he was perspiring with a temperature of 104, and had a racing pulse of 130. The nurses were busy getting blood cultures, blood gases, starting an IV, and retrieving his chest X-Ray.
I was startled when I felt his neck and upper chest. It was the crackling feel of rice crispies, medically what we call crepitus - air in the tissues. Did he collapse a lung? The mouth revealed a swollen protruding tongue and I couldn't even see the back of his throat. The lungs showed diffuse abnormal crackles and even the heart had a rubbing crunching sound. The chest X-Ray was dramatically abnormal with air shadows in the soft tissues of the neck, shoulders and chest where no air should be. There were also large fluid collections around both lungs, but no evidence of a collapsed lung. The air in the tissues was being produced by gas forming bacteria!
We admitted Don to the ICU where he was seen by both ENT and thoracic surgeons. His breathing was so marginal that he required a ventilator. The neck and chest both needed to be widely opened and drained and a tracheotomy had to be performed. The foul smelling gas producing pus grew out three different species of bacteria common to the mouth plus a few others.
In the next 24 hours Don seemed to rally, but he had further complications of bleeding, dense pneumonia, and heart arrythmias. In 72 hours he was dead leaving behind his devastated wife and child.
Comment: Ludwig's angina was described by Wilhelm Frederick von Ludwig (1790-1865). This unusual ENT critical emergency is fairly rare these days with early intervention and antibiotics, but Don's case was a classic example. The problem was the delay of recognizing the severity of the illness and the critical importance of early intervention. Getting sick on a Friday of a holiday weekend, seeing four different oral surgeons, and unwarranted wishful thinking were all at play in Don's case.
The principles of wide drainage are especially difficult when dealing with the neck/thorax connection in a descending infection. Bilateral opening of the chest, drainage tubes in the neck, stripping off the pericardium (the sack lining the heart) are all recommended. But delay of diagnosis and treatment is the critical feature.
This case came to a lawsuit in which I was deposed as a treating physician - not a pleasant experience. My understanding is that the oral surgeon's partnership broke apart and they settled for the maximum under their insurance policy - small recompense for the loved ones. I mention this case to remind patients to push hard and get second opinions when things aren't going well. But also to remind dental and medical people to be very careful when covering for colleagues. Cases like Don's shouldn't really happen, but they do.
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My name is John Wisdom, no pun intended. My reply occurs almost 2 years to the post on a holiday weekend. I am undergoing treatment for 2 upper rear left infected jaw teeth which were extracted this past Thursday.
ReplyDeleteAbout 10 years ago, I spent over $10,000 on a massive intervention program for my gums through a different dentist. The pain was awful and I would not do it again. My 80 year old dad, told me to get all my teeth pulled, to save money and lessen the pains. Hey, my dad had a point. I later saw my dentist at the horse track. Yeah, my dentist saw me and we never spoke again. I had just received a letter in the mail from the dentist inviting me back in to the his dental office for further treatments.
Where are we going here? I would say Ethics in the end all game. The posting by this fine MD is looking for any comment in regards to the medical pofession. Two years and nobody gives a hoot. Forgive me, but I find this sad.
One of my dentist, Ms. Hollar, thinks the infection will be cured with the baterial pills. As of right now, I am not so sure. I have pain at about 4 on a 1 to10 rating scale.
Funny thing how a tooth infection can lead to serious health risks and or death. Yet Veterans do not get dental work unless the veteran is 100% disabled.
From a 70% rated drafted disabled Republic of Vietnam combat veteran and educated with graduate degrees.
I was 26 when I had pericarditis because my teeth were extracted by an oro-maxillofacial surgeon . Initially for the first 2 days, everything was normal then chest pains, a raging fever and pus from where my lower left wisdom tooth was removed.
ReplyDeleteOn the third day, I was admitted to the ICU because my infection got worse and develop into septicemia. During those 4 days in ICU, things were an absolute blur. Arterial lines, constant beeping, and a code called on me when I suddenly went into a cardiac arrest.
A huge abscess was formed where my left lower wisdom tooth was. Now it is a pocket which the tissue failed to regenerate. So extra care is now necessary.
It's rare but any oromaxillofacial surgeon or dental surgeon should NOT be pulling all wisdom teeth at a time. My first removal by another oro-maxillofacial surgeon - he refused to remove anything else other than the impacted tooth. No post operative problems. The second one (after my other upper right tooth started giving me problems) recommended the rest should be removed at a go for 'convenience' sake.
Given the fate I suffered in ICU after the removal of 3 wisdom teeth, it would have been much better paying more to remove a wisdom tooth only if it is necessary, not for convenience sake.
I can blame no one except the fact that this condition is so rare and life is like a lucky draw. There is no definitive cause to why and how all these infections developed at an alarming rate. I was young and healthy. No immune deficiency diseases. No heart diseases previously.
I feel sad for Dan.
Thanks for sharing your story. Your experience demonstrates that an infected impacted lower wisdom tooth extraction can be very dangerous. There is no anatomical barrier between the lower jaw and the mediastinum (the space between the lungs where the heart lies. So the bacteria can move down through the neck into the mediastinum causing chest pain and sepsis (mediastinitis). It looks like you dodged a bullet when you were critically ill. This is one of the few true life threatening emergencies that oral surgeons need do think about. It looks like recognition and early treatment saved you. Dan's oral surgeons didn't think of it until it was too late.
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