a saturday trip to the ER

never a dull moment on a saturday, of course.


my second-to-last patient was a dude i had seen about two months ago. he had a few upper incisors remaining and a mutilated lower dentition with multiple carious non-restorable teeth, the only non-carious tooth being his lupper eft lateral incisor. he wants dentures for his upcoming wedding in september - the guy is only about two years older than me. we were trying to coordinate his treatment with the denturist, who sent him to my office for whatever treatment we decided on for the remaining teeth. he needed either endo and post, core crown on all but one of the upper with an upper partial, or full upper extraction followed by immediate complete denture, and lower extractions and lower partial denture. i opted for the extraction and denture, since finances were very much an issue and this guy has no insurance. i spent an fort-five minutes talking to him, as he didn't want full extractions on the upper but also didn't want to pay for RCT's he needed to save the remaining teeth, and he completely refused any and all treatment on the lower teeth. i wanted to make sure he understood what he was refusing and the implications of such refusal. he argued with me for another forty-five minutes about his treatment, demanded a discount, then got mad when i charged him for the exam and the six periapicals i took. he left in a huff and i wasn't expecting to see him again. so imagine my surprise when i saw him in the schedule for extractions. hmm, how 'bout that, we're rolling with it.

saturday afternoon he shows up and my receptionist says, "mr. r. is here, but he's swollen."

"of course he's swollen, he has multiple bombed-out teeth! seat him and i'll be right there."

i had never seen anything like this before. the left side of his lips, upper and lower, were swollen to over three times it's normal size. "whoa!" i blurted out. apparently, it had started this morning. now, it's impossible to get a story from this guy as he talks round-about in circles, jumps topics, repeatedly changes his story, and has a thick accent but after speaking with him and having him repeat it to me followed by my repeating it back to him twice, here's the story we got:

on june 12 he had swelling on lower lip on the right side after eating some cantalope. the pharmacist recommened some reactine for him. it worked for a while, then swelled up enough again to prompt him to see a physician at a walk-in clinic on wednesday june 14. this physician gave him pen VK 300 mg qid and another script for "an allergy pill" that he didn't know the name of. he had some relief again, and went to work the rest of the week. he ran out of the allergy pills that sunday and took the penicillin, which he was only taking three a day instead of the four, up until this past wednesday, the 21st, meaning he did not finish the medication. he started swelling again, this time on the upper left side, and the swelling then progressed to the left lower lip. he took another dose of the Pen VK and then came to his scheduled appointment to see me.


i examined him and ruled out odontogenic origin because, funny enough, the swelling was locates at the one site where the teeth were fine and he wasn't in any pain. my colleague, who also happened to be there, also saw it and we both agreed that it most likely did not have a dental etiology, as the swelling was not hot and hard and did not appear to be infectious. what concerned me was that the swelling started to spread across the midline and he slowly started to develop a "lump" in his throat upon swallowing. oh-kay, let's get you to a doctor ASAP.


now this guy doesn't have a PCP, or even an OHIP card, so there was no place else to go than to the ER. i didn't feel comfortable dismissing him alone in that condition even with a script, as who knows what could happen over the weekend or as soon as he leaves. there's an ER down the street from our office and one of the girls was going to put him in a taxi. but he had never been to a hospital in canada before and he was very nervous, so he asked me to go with him. i cancelled my last patient and i took him in my car.

anyways, the physician examined him and believed it to be a delayed hyper-sensitivity reaction of some sort, to what, we don't know. but he got a dose of steroids, some clindamycin to cover any remote possibility of a dental infection, and a referral to an allergist for testing. i'm glad i went with him. he's very difficult to understand and i since i had already correctly pieced the story together i was able to "translate" and move things along faster. we were there about two hours, not too bad. i took him back to my office, where he booked his next appointment to have his extractions completed. he asked me if there was any way he could thank me. i told him the best way to thank me was to take care of his teeth. he then invited me to his wedding in september. talk about gratitude!