Hi spork,

It is perfectly ok to post on old threads....anytime!

I'm assuming based on the surgeries that you had today that you are planning on having an implant put into that space in a few months... yes?

The alveolar ridge graft is typically done after an extraction when either an implant is being planned or when bone replacement is important. Bone grafting simple encourages the growth of new bone to form into the graft so eventually the graft material actually becomes your own bone.

It sounds to me like the wall of the sinus in the area of #3 was considerably low, which is not uncommon, but this means it was taking up too much room in the jawbone to place the bone graft or implant. And/or the root of number 3 was very close to the sinus wall and it may or may not have been perforated during the extraction. OR the tooth was infected... (was it a root canaled tooth?).....and the infection proliferated the sinus wall which required a surgical intervention to repair and elevate it.

Your dentist may feel that the perforation was closed during the surgery OR it may just be that the area needs some time to heal closed. This is something only the surgeon can determine based on his surgery, clinical findings and your symptoms.

You said he did not suture the membrane...... but did he suture the wound closed?

Some sinus perforations heal on their own, others need to be repaired. It is best to call him on monday and tell him your symptoms and just ask him why he needed to elevate the sinus. In the meantime, do not drink through a straw.. do not blow your nose...do not smoke.... do not suck on hard candy, mints, cough drops, lifesavers... avoid hot foods/drinks and spicy foods... do not rinse with any mouthwash, and make sure you drink plenty of water throughout the day. Follow his surgical post operative protocol to the "T".

You should be ok to fly in 5 weeks.... but check with the dentist about your current situation just in case he needs to intervene.

Please keep us posted on how things are going...and always feel free to come here and share your questions and concerns.

>>>>Also, thanks for the kind words>>>> ~;0>

Bryanna

That's correct. I should have explained that at the outset.

Yes, I was shown the X-rays and it was clear that the root were very close to the sinus cavity. The doctor said he might have to build up some graft into the sinus - but wouldn't know until the tooth was out. He sectioned the tooth and removed it in three pieces. Once the root was out he determined that he would have to graft into the sinus cavity. It was my impression that he hoped to get some "bone" into the sinus cavity without damaging the membrane (though I could be mistaken).

It seems certain it was perforated (because air would pass easily between my mouth and sinus). But I'm not certain whether it happened during the extraction or during the subsequent drilling and chiseling into the sinus cavity. I didn't notice the air passage until after the drilling and chiseling, but there was a lot going on there. I'm not sure if the tooth itself was infected, but there was an active infection at the site. I had a fistula that had been active for months. My regular dentist told me I'd either need another root canal on that tooth or an implant. But he didn't seem to feel it was an emergency. There was no pain prior to yesterday's procedure.

Yes. If I recall correctly, that tooth had the root-canal re-done a few years after the initial root canal. It also had an apicoectomy and a second apicoectomy some months later. All of that work was pretty old by this time (5-10 years?).

Not sure about that. He definitely felt he needed to graft into the sinus - I think just to provide enough purchase for the eventual implant.

I'm nearly certain he didn't take steps to close it. When I discussed it, he acted as if he wasn't certain that there was a perforation. But I can tell you that there was a clear passage of air from mouth into sinus.

That's correct. I was still able to feel the passage of air after that. However, I have not noticed an air passage today. I am of course being careful to try and avoid any differential pressure.

He called last night and I told him of the symptoms at that time. We already had an appt set up for Wednesday.

Thanks. I don't smoke and have been as careful as possible to follow all directions. I'm not using mouthwash, but he did prescribe a mouthwash-like rinse which I'm to use twice/day. I trying my best to avoid sucking, but I feel that I sometimes produce suction in the normal act of swallowing, eating, etc. - moreso than drinking a soda through a straw.

Thanks very much. I'm somewhat encouraged that I have had essentially no pain today and have not noticed the air passage today. I'll post an update after I see the doctor again.

Thank you! Having an expert available and willing to share their time and experience is an amazing thing. Not long ago the *only* way to get even a hint about what was going on was to get an appointment to see the doctor in person.

I had the same thing and started taking COQ10 and wow did things start healing quickly. You can try it and see if it works for you

Thanks for the tip. I haven't heard of that, but just did a quick Google search. It looks like a safe enough over-the-counter supplement. I think I might wait though for Bryanna to weigh in on it's use.

Hi spork,

Glad to hear that you're feeling ok and that the air communication between your mouth and nose have significantly decreased. You have made things very clear with your reply and I am very glad that you have posted here. I'm hoping many others who have had or currently have very similar if not identical experiences to yours are reading this post. Whether you know it or not, this is a very typical commonality seen in every day dentistry. That is not to say that it should not be taken seriously because it is in fact a serious infection and can have many systemic risks associated with it.

Hopefully you won't mind if I repeat the sequence of events while elaborating on what you have stated to not only inform you but to confirm my numerous posts here regarding the typical frailty of root canaled teeth and apicoectomies:

In your case.... over the course of 5-10 years....

1) Tooth #3 upper right first molar, root canaled....infection
2) Re root canaled....infection
3) Surgical Apicoectomy....infection
4) Second Apicoectomy.... infection
5) Fistula forms on the outside of the gum above tooth #3 (= draining pus from the infected tooth that proliferated to the jawbone)
6) Tooth #3 surgically extracted, meaning it was taken out in pieces to avoid further bone damage and tissue damage... required an alveolar ridge bone graft to replace the missing jawbone that was deteriorated by the chronic infection and the invasive (twice done) apico surgery.
7) A sinus graft elevation surgery needed to remove the decayed sinus wall caused by the chronic infection...also needed to repair and rebuild a new sinus wall.

The main reason you had no pain or swelling was because the bacteria inside of the tooth had become so prolific that it literally burrowed a tunnel through the jawbone to the outside of the gum, resulting in what is called a fistula or pimple appearing on the outside of the gum above the tooth. If that fistula had not formed or it had closed off, you would have experienced significant pain and swelling. The repeated root canals and repeated apicos did nothing to eradicate the infection from the tooth and both procedures aggravate the situation attributing to more deterioration and collapse of the bone making it easy for the infection to travel through to the outside of the bone.

Spork, to be completely honest and informative with you...this area of your mouth will not be ideal for a dental implant. The reason being is the tiny crevices within the jawbone commonly harbor necrotic tissue from the lingering, long term infection resulting in a compromising, or at minimum unfavorable condition for the placement of a dental implant. Even though the surgeon removed the diseased bone that he could see and feel with his surgical instrument, there is no way to know what is still remaining or exactly where it is. This also means that the success of the bone graft may also be compromised and will need to be monitored once a month for a few months to see how it is healing. Did your dentist mention this to you at all?

Your other replacement option for tooth #3 would be a permanent bridge or possibly a removable partial denture. Did your dentist discuss other options with you?

I hope you are still appreciative of my honesty after you read this post! ~:?

Bryanna

Bryanna,

Thanks again for all the good info. To make matters worse, my regular dentist had sent me back for a 3rd root canal on that tooth. I saw the endodontist, and he was ready to schedule it. But he was telling me it was a 50/50 proposition at best. It was the hygienist that suggested I forget the 3rd root canal and go for the implant. When I asked the dentist about that option he then agreed.

Flash forward to today. I'm doing well, but I now have enough fluid in my sinus that my wife can hear it when I shake my head. The doc that did my extraction and graft asked me to come in tomorrow for a look-see.





Agreed. The dentists have all agreed on that point. That first appeared all way back in 1995. I had the apico's and root canals each time it re-emerged.

D'OH! I thought that was the whole point of getting in my head with chisels and drills. I was under the impression that cleaning it out and taking antibiotics was supposed to eradicate the infection. But I see that it didn't work out that way.

That does not make me happy. Both my dentist and implantoligist did mention a bridge, but both felt that was an inferior option as it compromises the neighboring teeth (and I guess it's harder to take care of?). But it sounds like you'd opt for not doing the implant even at this point - is that right?

He said it would be 3-4 months before he could do the implant as he had to wait for the graft to take, and he does seem to want me to come in during that period (I don't recall how often). But I don't think he told me anything quite so definitive as you are.

Both talked about the bridge as an option, but neither thought that was the best option.

Very much so. But I'd have gladly paid you twice as much for good news. :)


And now onto one more complication. The implantologist tells me I need Osseous surgery (laser gum treatment I believe) in two areas. Interestingly, my dentist has never mentioned it. Given that the implant would tap out my insurance for both 2011 and 2012, would you guess that could wait a full year?

Thanks again.

Hi Spork,

Root canal therapy cannot remove the bacteria or cure the infection inside the dentin tubules (very curvy microscopic canals within the anatomy of a tooth) because there is no way to access them with any dental instrument including a rotary drill, any laser (which can only shoot in a straight beam) or liquid medicament. To give you a visual of what the inside of the tiny canals look like at the onset of the first root canal treatment as seen under a microscope.... the nerve tissue which when healthy is white is now black, severely necrotic, and pungent smelling bacteria. The tooth becomes over whelmed with this bacteria and eventually proliferates from the tooth to the jawbone and beyond. There are no exceptions because the anatomy of a tooth is, what it is ... just varying times of when the symptoms begin to appear.

The fact that you had a fistula form at least 3 different times and was told to retreat this tooth every time plus 2 apicos....... is beyond comprehension. This tooth has cost you (your insurance) many, many thousands of dollars and your immune system has been dealing with the infection since the get go.

The fluid that you hear and feel in your head, could be infection and/or a large perforation. I'm curious what the dentist will tell you about that. If it is infection.... that could mean that the bone graft material has been compromised which will interfere with the growth and integration of new bone. I sure hope it's not that!

The replacement option other than the implant would be a bridge. Yes, both anchor teeth would have to be cut down which compromises their integrity. Yes, it can be a bit annoying to keep clean, but it is very doable providing the bridge is made properly. Are either of the adjacent teeth currently root canaled? If so, then within the realm of the information that I have given you, that tooth/teeth would not be healthy enough to be an anchor for the bridge. Of course, many dentists will build bridges using root canaled teeth as the anchor teeth just like they repetitively retreat with root canals. The irony is that if tooth #3 had been extracted when it first became infected, you would have been a perfect candidate for a dental implant and would never have had to deal with any of this other stuff.

It is always best to wait 6 months before placing a dental implant. Especially when the bone has been compromised from infection from a root canaled tooth. Taking an xray once a month is wise to monitor the area for infection, graft failure and bone integration.

Osseous gum surgery with a laser can be quite effective in reducing deep pocketing. Do you have periodontal disease? What areas of the mouth is he referring to?

Keep me posted......
Bryanna

Well I saw the implantologist yesterday, and he felt it was looking very good. The huge amount of sloshing fluid in my sinus had gone down quite a bit by then, and has reduced to almost nothing now. He's had me on antibiotics from the start - perhaps this has helped? I know he's planning to wait and watch the bone graft progress, but I don't know if he plans to wait as long as 6 months and do monthly X-rays. Hopefully so.

He says I have areas on the lower left with pocket depths up to 5, 6, and 7, and pocket depths on the lower right of 5 and 6. From what I understand, this "is" periodontal disease - but it's possible I don't have the correct understanding.

I will say that I'm not always consistent with my flossing. Sometimes I'll be pretty consistent, and sometimes I get lazy. There's no question that my gums are happier and healthier when I'm consistent. They're less inflamed and my hygienist makes comments both ways that are consistent with my own assessment. I'm hoping that simply dedicating myself to some serious flossing every single day will stave off this problem.

I contacted my regular dentist to see if he thought I had an acute gum problem that required treatment. He thought not and contacted the hygienist to check. She felt not also.

Your thoughts on this would be appreciated as well.

I don't want to tell you how to go with this - but some good news would be nice. :D

Hi spork,

Glad to hear that the fluid has decreased to almost nothing and the area looks good clinically! Monthly monitoring would be ideal.

Pocket depths range from "0" to "10". Any depth larger than a "3" are considered abnormal because bacteria gets trapped so easily in there and the deeper the pocket the more difficult for you to clean. Yes, what you have is considered localized periodontal disease and if it's not brought under control the bacteria will spread to other areas. The laser therapy can reduce the pockets to a more normal depth. However it is imperative that you keep up with a daily oral care routine that includes thorough brushing and flossing because once the gum tissue is lasered away any pocketing that develops will be deep into the root area of the teeth.

So... how was that for positive!!! ;-)

Bryanna

Very good - thank you!

Do you think I can beat the laser rap by going medieval on my gums with a toothbrush and floss?