His Jaw Swelled Every Time He Sat Down to Eat

Quick answer: Swelling under the jaw that appears within minutes of starting a meal and settles an hour or two afterwards is a blocked salivary gland, not a dental abscess. The timing is what distinguishes them, and it is worth describing precisely because the two are treated completely differently.

The call

He had been given two courses of antibiotics for a suspected dental infection. Neither had helped, which is unsurprising, because the problem was not an infection.

Moshe, 49, from Nachala U'Menucha, described a swelling under the left side of his jaw that came up at mealtimes, was uncomfortable rather than agonising, and went down again over the following hour or two. It had been happening for about five months and was getting more frequent.

What we found

Three questions sorted it out.

When does it swell? Within a minute or two of starting to eat, and worst with anything sharp or sour — pickles, lemon, vinegar, the strongest stimulants of salivary flow.

Does it go down? Yes, completely, over an hour or two after the meal.

Is it painful in between? No. Nothing at all between meals.

That pattern is close to diagnostic. Toothache and abscesses are constant, worsen over days rather than fluctuating hourly, respond to hot and cold, hurt on biting, and do not care whether you are eating pickles. A blocked salivary duct swells on demand, when the gland is asked to produce saliva and cannot empty.

On examination:

• Diffuse swelling of the left submandibular region, soft, mildly tender, without redness of the overlying skin.
• All his teeth on that side were sound. No decay, no deep restorations, no tenderness to percussion, and normal responses to cold testing. There was no dental cause available.
• In the floor of the mouth, the left submandibular duct opening was red and swollen compared with the right.
• Bimanual palpation — one finger inside along the floor of the mouth, the other hand under the jaw — found a firm mobile lump about two-thirds of the way along the duct.
• Milking the duct forward produced a small amount of cloudy saliva and no clear flow.

Which gland matters. The submandibular gland accounts for the large majority of salivary stones. Its duct runs uphill, its saliva is thicker and more mineral-rich, and stones form there far more often than in the parotid.

The distinction that must not be missed is between an obstruction and a persistent lump. Swelling that comes and goes with meals is obstructive. A firm lump in or near a salivary gland that is there all the time, does not fluctuate and does not relate to eating is a different problem and needs prompt specialist assessment.

His fluctuated. That was established carefully before anything else was said.

What we did

Conservative measures first, which resolve a significant proportion of small stones:

• Hydration. Substantially more water, consistently.
• Sialogogues — sucking sour sweets or lemon several times a day to drive flow and push the stone forward.
• Massage of the gland from back to front along the duct, several times daily, shown to him with a finger so he could feel the direction.
• Warm compresses before massage.

Referred for an ultrasound, which is the appropriate first imaging for salivary obstruction and involves no radiation. It confirmed a stone of about 6mm in the mid-duct, with mild dilatation of the duct behind it and no gland damage.

What he was told to watch for, and this was written down: if the swelling stopped settling, became hot and red, if he developed a fever, or if pus appeared in the floor of the mouth, that would be an acute infection of an obstructed gland and needed to be seen the same day rather than at the next appointment.

The stone did not pass. Six weeks of conservative measures moved it forward slightly and no further.

Removal, at the maxillofacial unit. Because it sat in the duct rather than in the gland, and could be felt in the floor of the mouth, it came out through a small incision under local anaesthetic. Stones deeper in the gland are more complicated, and gland removal is sometimes needed, though less often than it once was.

The outcome

The mealtime swelling stopped immediately after removal and has not recurred in three years.

He drinks considerably more water than he used to, which is the main thing within his control — recurrence in the same gland or the other one is not unusual, and dehydration is the most modifiable contributor.

Two courses of antibiotics had been prescribed for a tooth problem he did not have. The three questions above would have redirected it at the first appointment.

What to do if this happens to you

1. Note the timing. Swelling within minutes of eating that settles afterwards points to a salivary gland, not a tooth.
2. Say it in those words when you phone. "It swells when I eat and goes down after" is more useful than "my jaw hurts".
3. Drink much more water, and use sour sweets and massage to encourage flow.
4. Get it imaged rather than treated repeatedly with antibiotics.
5. Go the same day if it becomes hot, red, feverish, or stops going down.
6. Take a lump that does not fluctuate seriously. A constant lump in a salivary gland is a different problem and needs prompt assessment.

A swelling that comes and goes with meals? Book an assessment at Ramat Beit Shemesh Urgent Dental Care. 055-985-8845 · WhatsApp https://wa.me/972559858845 · Harav Kook 28/1, Beit Shemesh

This is a composite clinical story. It reflects a presentation we see regularly in Beit Shemesh and Ramat Beit Shemesh; the name and details are illustrative and are not those of a real patient.