Dental Q - Root canal and root amputation

[sbbi]

Hi Dr. Stein,

I had an exploratory surgery on tooth #3 at a local periodontist last Thu. Then plan was if the periodontist found the root is cracked, he would extract the tooth. However, there is no crack. He told me there was significant bone loss around the MB root, so he did a bone regeneration with some bone graft material. But he could not explain why I had the fistula on the gum.

However, I feel the situation is not getting better. I feel tooth #3 "sticks" out, meaning it feels longer than other teeth so when i clinch my teeth, the teeth at the right side (or tooth #3) touch the bottom teeth first. Also when I clinch tooth #3, i feel some slight pain at the root end.

I do not know what to do.. I will see the periodontist to remove the stitches next week. Maybe it is root end infection and apicoectomy is needed? Basically how can you judge if a root tip and its surrounding tissue are infected? Would you have to open the gum?

Thank you!

 

[Laurence Stein DDS]

sbbi,

Again, I'm not there so I can't see and evaluate your condition personally,

Bone loss is usually a sign of an underlying infection. An infection will result from a dead nerve, a periodontal pocket, a fractured root, etc. All a fistula is, is your body allowing the infection materials a way to drain out.

Fistulas are commonly seen in abscessed teeth (infected nerve) or a periodontal (gum) infection... especially if the infection is located between the roots or within a deep pocket. Usually, when a fistula is present and draining, there is little to no discomfort because any pressure built up by trapped pus is vented through the fistula's opening. Often, but not always, fistulas are associated with chronic (long standing) infections that have become more acute (more active).

Frequently, with chronic periodontal infections, something gets into the pocket (a space under the gum associated with bone loss). Often it is a piece of nut, seed or popcorn husk. Once in the pocket, the infection becomes more acute and a pocket of pus is formed which tries to drain out.

Fistulas often get larger, then drain. This repeats until the source of the infection is addressed.

From what you describe, it sound like your tooth is in a heavy or traumatic bite. Anything that can cause inflammation... infections, surgery, etc., may cause the membrane surrounding the roots of a tooth to swell. This swelling pushes the tooth farther into the mouth... perhaps the thickness of a piece of paper. You then start to hit the tooth harder, which causes more inflammation and on and on... This can become very painful. A heavy bite can also compromise the healing of the bone graft.

Have your dentist adjust the bite and see if the symptoms get better.

Regards.

 

[sbbi]

Hi Dr. Stein,

Again thanks so much!

My periodontist is not clear where the source of the infection is. He said he did not know the whole history of the tooth and there might be crack inside the root.. he does not think apicoectomy is needed since he thinks the RC retreatment has reached to the end of the root (see the picture I attached previously). And since he has done the exploratory surgery I believe he should have cleaned up the gum (I need to check with him). My endodontist did tell me that he saw infection inside the root but he did not see crack inside the root. So I do not know what to do now..

you are very right in that I clench my teeth during the night. But i have been wearing night guard recently. My night guard fits my upper front teeth so the molars will not be able to touch each other. (however, I feel in that way the front teeth have too much pressure during the whole night and i do feel discomfort in my upper front teeth in the morning)

I guess that adjusting the bite will not really help since the source of the infection has not been eliminated yet? The symptom is slight in the morning and gets worse during the day. so in the PM, I will feel some slight pain at the root end when I clench the outer part of tooth 3 (the area which I think corresponds to the MB root?)

So it seems to me that it is the membrane surrounding the roots is infected.. Can this be viewed as the cause of the whole problem (Fistulas..)? how should dentist treat this (membrane infection)?

I tend to lose hope on this and I do not know i should just get it extracted.. BTW if the tooth #3 is extracted, do I need to worry about sinus perforation?

Thank you!

 

[Laurence Stein DDS]

sbbi,

OK, let's switch gears here. You've got a tooth that hurts. It has had root canal therapy twice now and it still hurts. All the discussion of fractures, fistulas and infection have not solved the problem.

The bottom line is that root canal therapy fails to work about 5% of the time. There are simply some teeth that don't respond to traditional therapy for a variety of reasons that may never be discovered.

I think you have been patient but I believe that it is time to discuss the extraction option with your doctors. This is something I cannot do for you or with you. Obviously, you are already thinking about this option.

I looked at your X-rays and it appears that you have little to no risk of a sinus perforation. This is something that can never be ruled out. It it were to happen, the vast majority of perforations heal spontaneously, others may require closure of some sort by the surgeon and then go on to heal uneventfully. Don't over-think this option.

Discuss your options with your dentist. Do what it takes to REMOVE THE INFECTION. The infection or the potential for infection is your greatest risk.

Good luck.

 

[sbbi]

Hi Dr. Stein,

I also read that bone graft material will not integrate in an area of jaw bone that is infected. Does it mean that the periodontist should not do bone graft right after extraction since there is apparently some infection which has caused bone loss?

It also makes me wonder how possibly the previous bone regeneration would work with the infection still untreated...

Thank you!

 

[Laurence Stein DDS]

sbbi,

You probably don't want to place graft material into and acutely abscessed site (with pus). However, it can be placed into a chronic site, especially if you are premedicated with an appropriate antibiotic. Begin 1-2 days before the procedure.

Actually, you can do the same for the acutely abscessed site... just begin the antibiotics several days earlier.

Again, these are questions that you should discuss with YOUR dentist. You can ask these same questions to him more easily than by e-mail.

If you don't trust your surgeon for the answers then you should seek a new surgeon. It is not fair to keep asking another doctor who can't examine you for all the answers.

 

[rezzyrezzy]

Hi Mel,



Laurence Stein, DDS :doc:

Disclaimer
(No representations are made that in any way offer a diagnosis, treatment or cure for any illness or condition, either discussed or implied. Answers to questions are offered as information only and should always be used in conjunction with advice from your personal diving physician/dentist. I take no responsibility for any conceivable consequence, which might be related to any visit to this site.)

Hey, I'm not a diver, I was looking up dental stuff and came across this post....but, I have never heard anyone, (apart from me) quote Marathon Man in regard to Dentists. I live in Germany, and I swear, if my German dentist ever asks me 'Is it safe', I'll be up out of the chair and running for my life!! Great advice, by the way, I'm having similar tooth issues.......

 

[Laurence Stein DDS]

This just proves that some dentists DO have, albeit a peculiar, sense of humor. It helps keep us sane.

 

[seaotters]

Hello, Dr. Stein, Happy New Year!

Glad to find this discussion and this forum, esp. it seems you are still around these forums. I have some dental problem and will appreciate any input from you. I understand you can only provide remote opinions, but I like what you have provided to the previous members with dental issues.

My molar #19 had root canal more than 20 yrs ago. Then some 10 yrs ago while biting something hard it cracked (the original dentist who sent me for RCT had not told me the consequence of RCT, that the tooth would be brittle). So I had a crown done on it. About 4 yrs later that crown fell out, so I had a replacement crown (all by different dentists). This was some 7-8 years ago. No problem until about 5 months ago I had a little abscess (or is it fistula? a small swollen round "bubble" containing blood [maybe also pus?]) in the gum under #19 (mostly between #19 and #20). There's no pain. This thing sometimes gets enlarged, sometimes shrank, depending on whether I used the teeth a lot on a given day. I didn't do anything about it. Now a couple weeks ago, the gum between #19 and #18 also became swollen with similar abscess/fistula (whichever, I'm not sure), also no pain. This new one also sometimes swell larger, sometimes shrank. When larger, I could see some red blood inside it (transparent). Sometimes I felt the inside of my mouth on the left side was slightly swollen. I've attached the X-ray taken about 3 months ago (before the second abscess/fistula appeared). Now after 3 months it could only be worse... When I floss between #19 and #18, the floss could go some distance under #19, meaning bone loss under there, right?

What I'd like to know is:

1. What do you think likely caused these infections/abscess/fistula? (Are they abscesses or fistulas?) Likely bacteria entered the remainder of the cracked site since more than 10 yrs ago? Or was it simply because I rarely flossed (though brushed at least twice a day) and tooth decay formed between #19 and its adjacent teeth? Some dentist think it's caused by the previous crack (under the crown). Another dentist said that because the two abscesses/fistulas are not directly under #19, but in between #19 and #20, and between #19 and #18, so it's not likely from the crack, which was in #19.

2. What would be the best solution for me? Some suggested extraction and bridge/implant, some suggested root amputation with bone graft. I'm apprehensive of either. If it's due to the crack, then root amputation would not be helpful in preventing further infection, would it?

Tried to be brief but turned out so long...

Thanks in advance for any input and for your time

 

[Laurence Stein DDS]

Hi Seaotters,

First, let me say that getting 20 extra years out of this tooth was wonderful. The fact that a root canal procedure (or simply having a "dead" tooth without the root canal) left your tooth brittle should not have factored into how you treated it many years ago. Without the procedure you would have lost this tooth much earlier and committed this tooth to extraction followed by a fixed bridge.

As to the cause(s) of the abscesses, the most likely cause was root fractures. The actual root canal therapy appears to have been successful. The loss of bone displayed by the x-ray would be consistent with a vertical root fracture on the front (mesial) root and a horizontal fracture on the back (distal) root.

Yes, bacteria would have entered the fractures and created a chronic (long term) infection. On occasion, this chronic infection, which is typically painless, would become more acute. Then there would be more discomfort or swelling.

You lack of flossing is unrelated to the reason this particular tooth re-infected.

A fistula is a communicating tract between the source of infection and the outside (mouth). The resulting drainage of infection materials prevents the build up of pressure and reduces or eliminates pain. Typically, the fistula is over the source of infection, the area swells and then drains through the fistula. This cycle may repeat many times or the infection may eventually become acute and painful. The fistula never really goes away until the infection is completely gone. Instead, it becomes so small as to become almost invisible.

For a fistula to occur under the bone, the infection must drain through both the bone and soft tissue. The net result is the substantial loss of bone in the area of the fistula. This can complicate future restoration.

20 years ago, the best solution would have been extraction, followed by a fixed bridge... capping one tooth behind and in front of the tooth to be removed. Currently, this is still an option, but the use of an implant, where possible, can eliminate the need to cap additional teeth. In your case, the cap on the tooth behind the infected one already has a cap and this would have to be removed and replaced is you are going to do a bridge.

Because the tooth behind the infected one also has a root canal completed and is more brittle, it might not be the best support for a fixed bridge. Before implants this was the only game in town and the bridge would still have been recommended.

If the bone can be grafted to re-establish good height and width, then a dental implant could be used. Assuming that the existing cap on the back tooth (#18) could be left alone and the bicuspid never touched. Typically a single implant with an implant crown is not much more expensive than doing the fixed bridge. The advantage is that you simply "mess" with the other teeth.

This tooth, in my estimation is hopeless on x-ray only. Given its past history, I would never recommend a root amputation. Extraction would appear, with the information given, to be the logical choice. If you are considering an implant, then bone graft the socket and rebuild any lost bone. The the site is ready for an implant.

PS. On the x-ray, the root canal on #18 appears to be short of the root tip in the distal root (the one with the pin/post). I cannot tell from this x-ray is something is happening at the root apex (tip). You might require re-treatment of the root canal in this tooth at some time in the future with the replacement of the cap.

On the other hand, since this tooth shows no pathology, you might choose to keep it for now. However, the bone found in the rear of the lower jaw has a lower success for INDIVIDUAL implants. When possible, splinting or connecting the implants together with the restoration is more predictable. With that in mind, it would be wise to consider extracting BOTH molars and ultimately placing 2 implants and two crowns connected together (splint).

Please discuss this with your dentist.

Hope this helped.

Laurence Stein, DDS