QUESTION: Dr. Teig,
I had an upper molar tooth (#26) with a broken cusp for 2 years which was asymptomatic. Then, I noticed aching in that area with a bad taste in my mouth, weight loss, and decreased appetite. I had the tooth examined and it showed deep decay but no periapical abscess or crack. I was started on Amoxil which relieved the pain. I had cheek redness and swelling at first but this resolved. The tooth was extracted but a portion of it remained which I was unaware of. I had to stop Amoxil 4 days post op due to anaphylaxis. For the next 3 weeks I had severe pain in the socket, head, temple, neck, gum and cheek mucosal erethyma, malaise, and cheek swelling. I also had unilateral sinus stuffiness; green/bloody discharge with then turned clear. Until finally an x-ray was taken which revealed a large remaining tooth piece. I was then started on Clindamycin 600 mg TID which was the first thing that made me feel slightly better. The root was removed and no sinus communication was appreciated intra-op. This was two weeks ago. My mild cheek swelling, upper jaw pain, night sweats with low grade fevers and intermittent sinus stuffing on that side persist. I'm continuing on high dose Clindamycin with no real explanation as to why. There is sinus floor irregularity in the socket on CBCT but no real perforation and mild sinus mucosal thickening. I have a bad taste in my mouth and an intermittent salty taste. The socket seems to be healing otherwise ok.
I have underlying autoimmune disease.
I feel like something is still going on and not being treated properly and I'm concerned about blindly continuing antibiotics with the allergy risk.
thank you so much
ANSWER: Ana - With the continuation of an infectious problem, although the alleged source of the infection, the tooth, is gone, with the sinus lining thickening, there is definitely some bacteria in the sinus or the bone surrounding the sinus. My suggestion, if the oral surgeon who has been treating you cannot come up with a reason, make an appointment with an Ear,Nose and Throat(otolaryngologist) to properly evaluate the sinus.
The bad taste in the mouth is probably do to infection in the sinus area draining into the mouth. I wish I could be more specific, but you need to be directly examined by a skilled surgeon.
I don't know where you live, but if you are in or near a large city, make sure to see an otolaryngologist associated with or possibly teaches there. I wish you well and hope you get better soon.
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QUESTION: Thank you so much for you very useful reply. You encouraged me to keep looking for answers as I was being repeatedly dismissed, but felt too unwell to believe nothing was going on.
I have now seen an oral surgeon well versed in the complications I'm having and thinks antibiotics should be continued because of my cheek swelling and is going to repeat the CT if I don't improve in a week. ENT has now also seen me and said there is a very mild amount of mucosal thickening, no frank sinusitis, but that it could still be osteomyelitis. Nuclear medicine imaging has been raised but so far not planned due to my high risk allergy situation. ID is also involved. I feel I am in a safer place now though still haven't seen much improvement in the past week and am scared as to how this will all turn out.
The service you are providing by helping people in this forum is so generous and noble of you. Sincerest thanks. You may not realize how immensely you are helping patients.
All the best!
ANSWER: Ana - I am so pleased that you have discovered doctors where you live that seem to have a handle on what is occurring. If nothing, their pathways to discover the cause is very good.
I wish you well and hope this situation can be cured soon.
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QUESTION: Dr. Teig,
So sorry to bother you again. I still have swelling over my cheek/under my eye and have been on high dose Clindamycin for 4 weeks. I'm 4.5 weeks post-op. Some of the regional symptoms like neck pain and swelling have improved and my temperatures are not as high, but I can't appreciate that the swelling has changed and I still have malaise and sinus congestion.
The plan is another 2 weeks of Clindamycin. I've been trying to read as much as I can about it all and it seemed to me like many cases described needing to see marked clinical improvement before sticking with a certain course of antibiotics. I'm wondering if in your experience you would've expected more clinical improvement if the antibiotic regime was the correct one, or if I should be evaluating alternate courses? We are holding off on the Gallium scan because of the allergy risk. ENT didn't see any pus to swab with in office nasal endoscopy so we don't have a specific bacteria to go after.
I think there's a plan to repeat the CT if I haven't improved in 2 weeks. I can just tell that I am falling into the margins of things people are not used to seeing. I'm not in a large centre but am hoping to find good care here if I can as my health limits travelling and I have specialists here acquainted with my other health problems.
Ana - When an infection has spread into the bone, often antibiotics will not gain access to the bacteria in a high enough concentration and an infection will continue to exist. Even a correct antibiotic might have a difficult time if the majority of the infection is within the bone. In this situation other methods are attempted to cure an infection. In this situation I have utilized hyperbaric oxygen to allow the bone to become more susceptible to antibiotics as the oxygen begins to assist in the healing.
So I hope your doctor is knowledgeable in helping you. I cannot say if you actually need hyperbaric oxygen, but I stated it only as a potential option to assist in healing.