Mystery of Chest Pain After Dental Extraction

CME INDIA Case Presentation by Dr. Deepak Gupta, DM (Card), Senior Interventional Cardiologist and Head, Dept. of Cardiology, Pulse Hospital, Ranchi.

CME INDIA Case Study

Discussion (CME INDIA & CSI Jharkhand)

Dr. N. K. Singh:

• Interesting but difficult ECG?
• Low voltage.
• T wave changes.
• Needs Electrolytes, TropT, Echo.

Dr. Satish Kumar, Cardiologist, Wellmark Hospital, Bokaro:

• Except for some low voltage, me too can’t make out much in this ECG. But, as the history suggests a severe diffuse chest pain, would like to explore more.
• Would like to do a serial ECG, Troponin, Echo.

Dr. D. P. Khaitan, Consultant Physician, Gaya:

• The combination of Low voltage with vent rate =64/mt with somewhat T inversion over V1-3 suggests such an underlying pathology as a cause of severe chest pain which might also involve coronaries.
• I would like to have thyroid function tests. Dental extraction might have insulted the compromised coronaries more due to induced tachycardia due to pain/nervousness.

Dr. Ashish Ludhiana Saxsena, Cardiologist physician, Ludhiana:

• Dobutamine stress echo. After a normal 2D echo.

Dr. Deepak Gupta:

• Any clue here, please see the chest Xray.
• No SOB, only diffuse chest pain.
• Trop T negative.
• Echo. No RWMA. No pericardial effusion. Normal LV and RV Function. No TR NO PAH.

Dr. S. K. Goenka, Physician, Begusarai:

• May have previous MI. Less viable myocardium. Or other reasons like pneumothorax, pericardial effusion. Air embolism may also be a reason.

Dr. Satish Kumar, Cardiologist, Bokaro:

• A sudden phenomenon like Spontaneous Pneumothorax or Acute PE would have led to Tachycardia, at least.

Dr. Venkatesh Molio, Internist, Maregoan, Goa:

• Pneumothorax pneumomediastinum/ Pneumopericardium

Dr. Sagar Subhash More, Chest and critical care physician, Nashik:

• Pneumomediastinum. Can be…
• But can’t/ difficult to make out pneumothorax?

Dr. Kushagra Mahansaria, Cardiologist, Ranchi:

• Is not this Air Pocket?

Dr. Shashikant Nigam, MD Med., Ahmadabad:

• Low voltage. Electrical alternance?
• Pneumomediastinum.

Dr. N. K. Singh:

• See if trachea shifted.
• This could be collapsed lung border.
• Then pneumomediastinum likely.
• Clinical setting suggests.

Dr. Deepak Gupta reveals diagnosis:

• Yes, 👍👍It is basically pneumomediastinum.

Dr. Varun Kumar, DM, Card, Sante Vita Hospital, Ranchi:

• In ECG there is low voltage Complexes & T inversion in V1- V3 which could be nonspecific also, can be seen in ischaemia, RV strain etc.
• CXR there is hyperlucency of lung fields.
• These ECG & x-ray findings can be due to COPD or Asthma.
• Except this I can’t see anything specific which can explain chest pain after tooth extraction.
• Why a patient after tooth extraction develops pneumomediastinum?

Dr. Deepak Gupta, DM Card., Pulse Hosp., Ranchi:

• Surgical procedures in oral cavity or extraction of lower molars especially the third inferior molar can lead to development of emphysema and pneumomediastinum when air turbine dental drills are used. To avoid these complications, air turbine drills should be used only in necessary cases.
• The roots of the first, second, and third molars communicate directly with the sublingual and submandibular spaces. These communicate with the pterygomandibular, parapharyngeal and retropharyngeal spaces, the latter with the mediastinum. In this case, injection of air with a high-speed dental drill through the soft tissue adjacent to the roots of the inferior molar seemed to cause cervicofacial emphysema leading to pneumomediastinum.

Dr. Kiran Shah, Mumbai:

• Interesting case. Thank you 🙏

Dr. D. P. Khaitan, Gaya:

• To prevent these complications during dental procedures, dental hand pieces that have air coolant and turbines that exhaust air in the surgical field should not be used.

Dr. Keyur Acharya, Intensivist, UK:

• Fascinating! Too many things to learn. Didn’t know this anatomy amongst many! Thanks.

Dr. N. K. Singh:

• Was CT done?
• What was the hint in ECG?
• What is the treatment in this case?

Dr. Deepak Gupta, DM Card., Pulse Hosp., Ranchi:

• Patient was referred to me for CAG.
• CAG not done as diagnosis was clear.
• CT Thorax too not done.
• Low voltage in ECG was due to air in mediastinum.

Dr. Varun Kumar, DM Card., Sante vita Hosp., Ranchi:

• Pneumomediastinum is an emergency situation… pts vitals to be monitored as it can anytime compromise the haemodynamic. then surgical intervention will be required…it is not like surgical emphysema.
• 100%O2 is the treatment of choice for both pneumomediastinum & surgical emphysema irrespective of O2 saturation…

Dr. Deepak Gupta, DM Card., Pulse Hosp., Ranchi:

• Patient was hemodynamically stable.
• Observed for 72 hrs.
• No hemodynamic deterioration. 
• Given supplemental oxygen in spite of normal oxygen saturation.

Dr. Ashish Ranjan Jha, Cardiologist, Ranchi:

• Very interesting case.
• Repeat chest Xray when should be done.

Dr. Deepak Gupta, DM Card., Pulse Hosp., Ranchi:

• After 1 week.

Dr. Arbind Kr. Arya, Physician, Jamshedpur:

• What necessary investigation should be done prior to any invasive Dental procedures?

Dr. Deepak Gupta, DM Card., Pulse Hosp., Ranchi:

1. It depends on age.
2. Any previous cardiac illness or on device.
3. Any new murmur.
4. Any previous history of reflex syncope.

Dr. S. K. Goenka, Begusarai:

• Sir, had a pre-dental extraction, cardiac assessment would have been done in this case, then shall we expect this finding before extraction? Cardiac assessment in high-risk groups should always be done before manoeuvring the teeth. Thx.

Dr. D.P. Khaitan, Gaya:

• To prevent these complications during dental procedures, dental hand pieces that have air coolant and turbines that exhaust air in the surgical field should not be used.

Final Take Aways

(By Dr. Deepak Gupta)

Very Interesting case. Seen 2nd time in my life.

1. ECG should always be correlated with history and if possible physical examination.
2. Simple chest X-ray can give important clue as in this case.
3. Before doing CAG must evaluate patient history, examination and simple Xray chest. In 20 percent, we find no coronary issue.

CME INDIA Learning Points

• Pulmonary complications rarely may arise in patients after dental procedures.
• We need awareness of the possibility of this happening.
• Good aspect is that with careful observation of the clinical course and appropriate conservative treatment, prognosis is good.
• Tooth extraction is a very common dental procedure but occurrence of emphysema, pneumothorax, pneumopericardium or pneumomediastinum, after dental treatment, is very rare.
• When compressed dry air is frequently applied to clear the operative field, compressed air may lead to dissection of soft tissues proximal to the extraction site. The air may rarely penetrate into the mediastinum and pleural space.
• What is Pneumomediastinum? It is a condition characterized by the presence of air in mediastinum. It may occur due to:

• Mediastinal emphysema is seen usually after lower third molar tooth extraction.
• Management usually consists of observation and we may require continuous compressed air of high flow, but remember that the air has the potential to penetrate into the soft tissues and cause damage.
• The potential dissection planes are Wounds of:
  • Gingiva.
  • Hypopharynx.
  • Cervical fascia.
  • Pre-tracheal.
  • Para-tracheal fascia of the anterior mediastinum.
• If the pressure of emphysema increases to a certain extent, the mediastinal pleura may rupture and then the air will accumulate in the pleural space(pneumothorax).
• Such procedure carries a risk of deep neck infection, mediastinal infection and even pleural space infection.
• Complications:
  • Tension pneumothorax.
  • Sepsis.
  • Air embolism.
• Use of hydrogen peroxide has been correlated with such complications.
• Be very careful if the patient presents with chest pain after recent tooth extraction.
• If fever develops, mediastinal must be considered and adequately treated.

CME INDIA Tail Piece

Wisdom Unlimited!

References:

1. Rawlinson RD, Negmadjanov U, Rubay D, Ohanisian L, Waxman J. Pneumomediastinum After Dental Filling: A Rare Case Presentation. Cureus. 2019;11(9):e5593. Published 2019 Sep 8. doi:10.7759/cureus.5593
2. H.Chen,H.Chang et al.Pneumothorax, pneumomediastinum and pneumopericardium complications arising from a case of wisdom tooth extraction. doi:10.1016/j.rppneu.2011.12.006 2011.Sociedade Portuguesa de Pneumologia.
3. Ilhan Ocakcioglu, Serhat Koyuncu,et al.Case Reports in Surgery Volume 2016, Article ID 4769180, 3 pages http://dx.doi.org/10.1155/2016/4769180. Case Report.Pneumomediastinum after Tooth Extraction.
4. D. Pousios, N. Panagiotopoulos, N. Sioutis, A. Piyis, S. Gourgiotis. Iatrogenic pneumomediastinum and facial emphysema after surgical tooth extraction. Ann Thorac Surg, 89 (2010), pp. 640 http://dx.doi.org/10.1016/j.athoracsur.2009.05.008
5. Pousios D, Panagiotopoulos N, Sioutis N, Piyis A, Gourgiotis S. Iatrogenic pneumomediastinum and facial emphysema after surgical tooth extraction. Ann Thorac Surg. 2010;89: 640.
6. N. Afzali, A. Malek, and A. H. H. Attar, “Cervicofacial emphysema and pneumomediastinum following dental extraction: case report,” Iranian Journal of Pediatrics, vol. 21, no. 2, pp. 253– 255, 2011.
7. I. Arai, T. Aoki, H. Yamazaki, Y. Ota, and A. Kaneko, “Pneumomediastinum and subcutaneous emphysema after dental extraction detected incidentally by regular medical checkup: a case report,” Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology, vol. 107, no. 4, pp. e33–e38, 2009.

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