Hi Glenn,

Wow, some sweilling! Was there a fistula on the buccal?

Was the swelling that bluish or was the colour a little intense in all last 4 photos?

Emergency endo with severe swelling is fun isn’t it? You did a great service to your patient, Glenn.

Andrew

Hi Glenn,

I really admire you for taking that one on. Great job! That’s the type of case I do refer to John Stropko!
Good luck tomorrow- I’m sure he’s feeling a whole lot better now.
Bruce

Glenn,

Had a lower bicuspid that had huge facial swelling, and parasthesia of the lip. Did an open and drain, and gave Augmentin (500mg) and Flagyl (500mg). Not much improvement the next day. Sent patient to Kaiser HMO for 2 grams of Rocephin IM butt shot. Really helped her out and she was much improved the day after. Not much pain from the shot, she said. Wrote an Rx:

Rocephin (IM)
Disp: 2 grams
Sig: one time

Came back at the end of the week and she was much improved, greatly reduced swelling, some remaining paresthesia. Sent her to HMO for another round of Rocephin. Great stuff for these types of massive swelling situations. Pretty much what an MD at the ER would do seeing that kind of facial swelling–short of IV antibiotics. Critical to O&M though to drain the pus out. Seen only 4 of these types of cases in 18 years. Usually, there is no need for local infiltration, since the pH is so low and there is no vital tissue in the canals. Less fluids to put pressure in the area and possible disperse cellulitis deeper…

Scary stuff for all.

Bob

Hi Glenn,

Here’s some stuff I was able to dig up.  You were dead-on right about being cautious with the Flagyl on the liver and for patients on Coumadin.

1.  Rocephin (Ceftriaxone sodium)  is a sterile, semisynthetic, broad-spectrum cephalosporin antibiotic for intravenous or intramuscular administration.

Microbiology: The bactericidal activity of ceftriaxone results from inhibition of cell wall synthesis. Ceftriaxone has a high degree of stability in the presence of beta-lactamases, both penicillinases and cephalosporinases, of gram-negative and gram-positive bacteria.

2.  Augmentin® (Amoxicillin and Clavulanic Acid) is a brand name for the drug amoxicillin/clavulanate potassium.

Augmentin is used in the treatment of lower respiratory, middle ear, sinus, skin, and urinary tract infections that are caused by certain specific bacteria. These bacteria produce a chemical enzyme called beta lactamase that makes some infections particularly difficult to treat. It’s also used for other infections as long as the bacteria turns out to be susceptible to Amoxicillin.

Amoxicillin is a semisynthetic antibiotic with a broad spectrum of bactericidal activity against many gram-positive and gram-negative microorganisms. Amoxicillin is, however, susceptible to degradation by b-lactamases and, therefore, the spectrum of activity does not include organisms which produce these enzymes. Clavulanic acid is a b-lactam, structurally related to the penicillins, which possesses the ability to inactivate a wide range of b-lactamase enzymes commonly found in microorganisms resistant to penicillins and cephalosporins. In particular, it has good activity against the clinically important plasmid mediated b-lactamases frequently responsible for transferred drug resistance.

3.  Flagyl is Metronidazole (MET).  It is an antiprotozoal.  It is also used to treat anaerobic infections.  It is a Narcan or Antibuse analog so it will make the patient sick with ethyl alcohol.

Metronidazole is the drug of choice for subgingival plaque consisting primarily of anaerobic Gram-negative rods and spirochetes. It is bactericidal rather than bacteriostatic, which allows it to function effectively independent of the host defense system.

The hydroxymetabolite of metronidazole (produced in the human liver) is even more active against A. actinomycetemcomitans in vitro, and has been shown to act synergistically against A. actinomycetemcomitans. In addition, both metronidazole and its hydroxymetabolite act synergistically with amoxicillin. Metronidazole covers most anaerobes, and amoxicillin most facultative and aerobic bacteria, making this combination useful for many mixed periodontal infections. Recommended doses of metronidazole are 250 to 500 mg TID for 7 to 10 days.304

Contraindications. Some objections to use of metronidazole are gastric discomfort, severe diarrhea, and bitter taste. A significant GI reaction may occur if metronidazole is taken in conjunction with alcohol, since MET has an antabuse effect.  Flagyl should be used with caution in patients with liver disease.

Source: Journal of Periodontology, Annals Vol. 1  (491 – 566): Section 5B: Non-Surgical Pocket Therapy: Pharmacotherapeutics  Connie Hastings Drisko

Do not drink alcohol while taking Flagyl and for at least 72 hours after last dose.

If Flagyl is taken with certain other drugs, the effects of either could be increased, decreased, or altered. It is especially important to check with a physician before combining Flagyl with any of the following:

Blood thinners such as Coumadin
Cholestyramine (Questran)
Cimetidine (Tagamet)
Disulfiram (Antabuse)
Lithium (Eskalith)
Phenobarbital
Phenytoin (Dilantin)

Bob

Haven’t heard of anything like that, Keep us updated.

the incision was mabe 1 cm. , mostly mucosa. It did not involve bone. I spoke with patient this am and she said she is still swollen in her cheek and she felt it in her neck. She did say it seemed to be getting better. I told her I will follow up, but if not much improved she will see oral surgeon, as I am going out of town tomorrow. My concern is air emphysema,which could be serious.It is my understanding that this is an uncommon sequelae of surgery whereby air is forced into submucosa. As the waterlase does employ air , it makes me wonder.

folluw up on the swelling following mandibular frenectomy:To reiterate
Frenectomy done on Wed of last week. Procedure was uneventful. A few hours after procedure patient reported swelling in the right cheek from TMJ toward neck.
Ice and NSAIDS were recommended. Next day(Thurs) patient still swollen, no worse perhaps somewhat improved. Fri, Still swollen, again, no worse. As I was out of town, I suggested she see an oral surgeon.
I spoke with patient this a.m.(Sunday). She is much improved
very little swelling. Surgeon was unsure of what was actually going on here. Here is what impressed me most….
The oral surgeon asked her about the canker sore in the mandibular anterior region. I hope everyone can appreciate the question. 1.5 days after the frenectomy the healing was so rapid that the surgeon thought she had a small aphthous ulcer.COOL! I am afraid the swelling will remain a mystery, but fortunately it was nothing serious and she healed remarkably fast.