Hi Bryanna,

I had a root canal retreatment at the end of last year on tooth #3. About 2-3 weeks after that, a fistula (bump) developed on the gum above the treated tooth. The endodontist thought the MB root is cracked and suggests root amputation. Please see the x-ray attached.

I decided to seek 2nd opinion. About 2 weeks ago, my periodontist did an exploratory surgery but he did not find crack on the root. he told me there was significant bone loss so he did the bone regeneration with graft material.

however my periodontist was not clear where the source of the infection was. 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. 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..

Also, the situation has not got any better after the surgery. I feel tooth #3 "sticks" out, meaning it feels longer than other teeth so when i clench my teeth, the teeth at the right side (or tooth #3) touch the bottom teeth first. 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?) I actually had this problem before the surgery, but the symptom went away when i took antibiotics. However, after the surgery the symptom resurfaced even when i was still taking antibiotics post-procedure. The fistula has gone, but my gum in that area is still swollen since the surgery. According to what I read online and it seems that it is the membrane surrounding the roots is infected.. what do you think? Can this be viewed as the cause of the whole problem (Fistulas..)? how should dentist treat this?

I tend to lose hope on this and I guess i should just have the periodontist extract the tooth.. BTW if tooth #3 is extracted, do I need to worry about sinus perforation?

Thank you so much!

Attached Thumbnails

 

Hi sbbi,

Thanks for attaching the xrays! Your situation is very common... I'll explain what is happening.

The first thing to keep in mind is this..... root canaled teeth will always harbor infectious bacteria inside of the microscopic canals because these tiny canals cannot be cleaned out during any dental procedure. Therefore, this nerve material becomes sick and necrotic. Antibiotics cannot kill bacteria that is embedded inside of the tooth. So irrelevant of what is done to the tooth or bone around this tooth, the tooth will always remain infected.

Secondly, anytime you develop a fistula above a tooth, there is an infection. Fistulas form due to an overwhelming amount of bacteria. This is the body's way of finding an outlet to release some pressure from the infection. For a fistula to form, the bacteria proliferates from the tooth, burrowing a hole through the jawbone and out through the gum tissue. This does not mean the infection has left the tooth......... it just means some pressure has been released. If a fistula did not form and/or the pressure was not able to release some other way, there would be a large swelling.

Thirdly, the paper point that was used to indicate the path of infection is quite evident. Radiographically, there is pathology at the apex (end of the roots) of this tooth. That is an additional indicator that this tooth is infected and the bacteria has proliferated through the tooth into the jawbone.

This tooth is near your sinus. There may or may not be a sinus exposure during an extraction at this time. However, the key thing here to know is this.... the infection will continue to spread causing additional loss of bone around this tooth which would make a sinus exposure more likely in the future if you wait to remove this tooth.

With regard to replacing this tooth.... chances are the teeth along side of it, #'s 2 and 4, will start to move towards the open space which would cause a shift in your bite. This can take years to occur, it just depends on the individual. Another key thing to know here is this.... if you wanted to replace tooth #3 with a dental implant you would need to have adequate healthy bone for the implant to be successful. The longer this infection goes on, the more bone loss will occur which could result in a much more complicated situation for replacement of the tooth. Also, if you extract it and wait a year or two to place an implant, the bone may have recessed back too far to hold an implant and your sinus may also have dropped down into the space at that point. Does that make sense .... or do you need some clarification on that?

I'm sorry if your dentists have not informed you of any of this....that is not unusual, however they certainly should have by now. Hopefully this information will help you to discuss your situation more fully with them and enable you to make an informed decision as to what you feel is in your best interest.

Please let me know if you have other questions.... I'm happy to help if I can!

Bryanna


I'm sorry that your dentists have not informed you of these things.

Hi Bryanna,

you mentioned pathology at the apex. I've got 2nd opinions from several dentists, almost all of them thought it was root crack, none of them tole me apex infection. But now I agree with you and suspect it is apex infection. Will apicoectomy work? (I know you are against endodontistics according to what I read here )

To be fair, my periodontist suggested extraction. And we did plan to have socket preservation right after extraction in order for future implant. (because he did not see crack, he did not extract the tooth.) Do you think socket preservation is required for my case? If so, I read you said socket preservation should be done after the infection is gone. But I was also told I can start taking antibiotics several days before the extraction so dentist can do the socket preservation right after extraction.

What should I ask my periodontist about sinus exposure? What should I do to minimize its risks?

Thank you a lot!

Hi sbbi,

For everyone reading this and any of my previous posts...just so I am being clear about my writings with regard to root canal treatment.... they are not what the typical dentist will inform you about UNLESS you know the right questions to ask him. No dentist in good conscience can honestly say that root canaled teeth are free of infection because they know the anatomy of the tooth and know the microscopic canals cannot be debrided. They also know that the medicaments used to irrigate the large canals cannot be "rinsed" away and the gutta percha material used to "fill" the canals are both highly toxic. These stay present in the tooth for the life of the tooth. It wasn't long ago that "formaldehyde" was the irrigating solution.... some still use it today in spite of the warnings not to use it.

Endodontics is a treatment option that should be presented to a patient simply because it is in the category of treatment options. But with all treatment options, enough information should be disclosed to the patient so he/she can make an informed decision.

With regard to the infection at the apex of tooth #3... it is blatant on the xrays and you should have been told. However, in defense of the dental profession (and I mean that sarcastically), it is also COMMON to see these pathological areas at the apex of root canaled teeth because it is the bacteria proliferating out of the apex into the jawbone. Dentists are not physicians, many of them believe that the teeth are a separate entity from the rest of the body. They consider these "areas" to be a "typical" reaction to root canal therapy. It is often not considered an abnormality until the areas grow very large and/or swelling occurs and/or the patient chronically complains about the tooth.

An apicoectomy is a treatment option and here are the details of the surgery....an incision is made in the gum above the roots of the tooth, the tissue is flapped back and a drill is used to make a large "window" opening into the jawbone to gain access to the roots of the tooth. Once in there, the tips of the roots are cut off, the gutta percha is scraped out of the large canals, small files are used to scrape away debris stuck to the walls of the large canals, irrigation is used, new gutta percha is then melted into these canals, mercury filling material is used to close off the open ends of the root tips in the jawbone, and the flap is sutured closed. In a sense, it is a root canal from the end of the root down to the biting surface, instead of from the biting surface up to the root.

As you can see from my description, apicoectomies basically serve the same purpose as the root canal. The reason they are done is because the tooth is in a fragile state and to perform a "conventional" root canal on it again, could mean perforating the side walls of the tooth. There is still no access to the microscopic canals, so the tooth remains infected.

In a little while I am going to post another reply to answer your question about socket preservation.

Bryanna

Hi sbbi,

To answer the question about preserving the socket after an extraction....

For proper healing purposes with all tooth extractions, the socket should always be thoroughly debrided/scraped and irrigated with saline after an extraction to remove the periodontal ligament and any necrotic infected bone. This is also the first step to socket preservation.
If the bone looks healthy after all of that debridement and there is no sinus perforation, then the second step would be to pack in bone graft material and place a collagen plug over that to protect and encourage the formation of a healthy blood clot. Then the area is sutured to keep debris out as well as to help hold the graft and plug in.

Some issues that can occur with some root canaled teeth when they are extracted which may not make it favorable to do bone grafting at that same appointment......

The jawbone surrounding a root canaled tooth is typically necrotic due to the chronic infection in the tooth. It can also have some residual pieces of gutta percha, filling material, or debris in the bone that was pushed out of the apex during the root canal procedure which creates some inflammation and irritation that sometimes needs to heal before placing the graft.
If the site is not favorable to receive the graft, then the socket is debrided thoroughly and a second surgery is done a few weeks or so later to place the graft and collagen.

If the graft is placed in necrotic bone, it will become infected and/or fail. So it can only be determined at the time of the extraction as to whether or not the graft can be done at that time.

It is wise to be on an antibiotic before, during and after the extraction of this tooth because it is infected and the antibiotic will help to reduce the inflammation from the infection and then help to heal the surgical site.

With regard to a sinus exposure....
The dentist will not know how close to the sinus it is until he extracts the tooth. There is nothing you can do to minimize the exposure... your anatomy is what it is. I would ask him to tell you if there is an exposure, how large it is, how or if he plans on closing it and make sure you follow the post operative protocol given to you to the "T".

I'm here if you have other questions....

Bryanna

Hi,

I have had two episides of root canal on same tooth. Both have been unsuccessfull. The said tooth is an insizer that along with the premolar supports a 3 part bridge.

The dental hosp now wish to perform an apisecomy.

I am conserned that this will not work. Also if i am fortunate enough to have the treatment work will the tooth be strong enough to jointly support a new bridge when i replace it?

I have also had a hip replacement and am worried that if the infection is not erradicated soon the infection could have implications on my hip.

Hi Jacckie,

You are wise to be concerned about the possibility of developing a systemic infection from an infection in your mouth that could affect your hip replacement. Any oral infection can lead to a systemic infection and it is not an uncommon problem. However, the connection is rarely diagnosed until the joint replacement has to be removed from the infection.

All root canaled teeth are infected irrelevant of how many times they are treated. The apicoectomy surgery will not rid the tooth of the infection because there is no access to the tiny canals within the tooth that contain the infected nerve material. This surgery is painful, expensive and creates an even more vulnerable condition in your mouth elevating the risk of a systemic infection. This tooth will be weaker not stronger and no, it won't be stable or healthy enough to hold your bridge.

One option is to have this tooth removed and have a new 4 unit bridge made which would replace this tooth and the missing premolar. Another option is to have two implants, one to replace this tooth and another to replace the missing premolar. Then have a new crown put on the second premolar.

Please discuss all of your options with your dentist. Again, you are wise to be concerned about chronic infection..... let your intuitiveness guide you.

Bryanna

Hello,

I had a root canal on #14 redone a couple of times, then I had a fistula and had an endodontic surgery. Two years later, I have a fistula again. Do I have to remove this tooth? This problem is ongoing for the past 5 years. If I remove the tooth, what is better: an implant or a bridge? I've read that it takes a half a year to place an implant.

Thank you so much,

Olga

Olga,

The truth of the matter is... this tooth is chronically infected irrelevant of what procedure is done to "retain" it. Keep in mind when a dentist uses the word "save" when referring to a root canaled tooth he means "retain" as there is no "saving or curing" an infected tooth.

The fistula is blatant evidence of the spread of the infection as this means that the bacteria inside of the tooth has proliferated to the bone and tissue past the tooth. At this point your sinus could also be involved. Also keep in mind that the brain is only about 4 inches from the base of the sinuses. Infection can spread past the sinuses into the brain. So it's never a healthy idea to keep an infected tooth.

There may be too much damage and deterioration to the bone to successfully hold a bone graft and dental implant. This is one reason why it is always a huge risk to replace a root canaled tooth with a dental implant. The time factor involved in having a dental implant can be up to a year... but in the scheme of things, this is the least of your problem if you are concerned about your health which is the primary concern.

I would urge you to have this tooth removed asap and ask the oral surgeon...

1) How much healthy bone is left with regard to the placement of an implant?
2) Is the sinus involved?

Hope this info helps you...
Bryanna

Bryanna,

I joined this community because I've read some very helpful posts by you dealing with dental problems in general and root canals specifically. I just want you to know that as a layman I really appreciate the time you take replying to all these various posts and problems that people have.

If I could ask you a question, I would be very appreciative if you could reply.

I've had some nasty sinus problems going back probably three or four years, I just had a tooth(#31) removed that couldn't be saved and had developed a fistula right below it. My question is, do you think this infected tooth(Lord knows how long it's been like that) could possibly be a lot of the problem I'm having with my sinuses? Any reply or speculation would be greatly appreciated.

Thank you,
teappotts