Hi Elliebeans,

What is the dental history on this lower left molar? Was it badly decayed? Did it have a filling in it prior to the pain? What was the reason for the pain that led to an infection and the root canal being done?

How is the health of the rest of your teeth? Do have other root canaled or decayed teeth? Do you have any other missing teeth? Do you have your wisdom teeth?

Root canals are not a cure for an infected tooth. The procedure is done to attempt to temporarily retain an unhealthy tooth. Each tooth has many hundreds of microscopic canals that are not accessible which means after the root canal procedure, they will always harbor infected dead nerve tissue. It does not matter how many times the root canal is done to the tooth, these canals are not accessible.

Antibiotics are not given to cure an infected tooth. The medication is given to reduce the infection and inflammation surrounding the infected tooth. However, as long as that infected tooth is present, the infection will be present. In that case, the infection will spread beyond the tooth which could infect the adjacent teeth, the lymphatic system and beyond.

The only current option to attempt to cure the spread of the infection is to remove the source of the infection, which means to extract the tooth. An oral surgeon is the specialist who should do the extraction as this tooth is going to need his expertise. When the tooth is removed, the surgeon is trained to also remove the periodontal ligament and all diseased tissue and bone that is visible to his eye and picked up on the xray. The reason these things need to be done is to reduce the risk of residual infection and post operative complications and promote proper healing. I know this sounds weird but... this debridement step is unfortunately not routinely done. It is important that the patient inform the surgeon that they want a thorough surgical debridement after the tooth is extracted. Keep in mind that a well informed patient is usually one who receives the most thorough treatment.

Regarding the explanation you were given to keep this tooth because removing it will mess up the rest of your teeth. From what you have described regarding the location of this tooth.... there is a possibility that the tooth behind this one will move a bit forward into the empty space where this tooth use to be. It is also possible that the upper tooth above this molar may shift downward but that is unlikely as you have other lower teeth for the upper one to bite against.

When considering the options...... it's important to do a risk vs benefit calculation:

** Do nothing or Re root canal the tooth or have a surgical Root Canal called an Apicoectomy = No positive change as those infected accessory canals keep the tooth infected = Progressive infection to possibly the adjacent teeth and beyond. Eventual extraction of a the long standing infected tooth which could leave little to no viable bone in that area.

** Extraction of the tooth now with thorough surgical debridement = Removal of the source of the infection along with diseased tissue and bone = Offers a higher success rate of complete eradication of the infection compared to retaining the tooth and extracting it at a later date.

The fistula you keep developing is actually an opening into the bone leading directly to the tooth. The infection is so virulent that it has burrowed a hole from the tooth, through the bone and out through the gum tissue. When this tunnel of infection becomes overwhelmed with bacteria, it breaks open on the gum side in an attempt to drain the infection. This infection is draining into your mouth and down into your digestive system. The only cure to the fistula is to remove the source of the infection which is the tooth and for the surgeon to perform a thorough surgical debridement.

I know I have given you a lot of scary information. However, your dentists should have been informing you of all of this prior to the root canal procedure and certainly afterwards when the swelling and fistula developed again.

You need to give serious thought to extracting this tooth after you weight the benefits vs the risks of temporarily retaining it.

I am attaching a diagram of the anatomy of a tooth to show you the size and number of those microscopic accessory canals that will always harbor infected nerve tissue. These canals are noted as Dentin Tubules and are tan colored. Each tan line represents one microscopic canal.

I hope you can get in to see the oral surgeon very soon. The sooner you get this taken care of, the better the outcome will be.

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