Hi,

Sorry for the lengthy post but this issue is a bit complicated. I had an ill-informed root canal on tooth #14 nearly 4 years ago. A few months after the procedure I developed a neuro-immune disease which was initially thought to be multiple sclerosis, but may be closer to ME/CFIDS or neurological Lyme disease. Looking back I have had neurological symptoms since before the root canal, but this may have triggered the acute symptom that finally led to diagnosis.
Last year, the gum above the tooth was found to be abscessed and a fistula had formed and periodically drained. Eight months ago I had the root canal retreated and it was found that two roots had not been properly removed the first time around. I was concerned that the infection was an additional insult to my immune system, my oral surgeon agreed, and I had the tooth removed a week and a half ago. The oral surgeon who removed the tooth wants to put in an allograft (Mineross) this coming Tuesday (exactly two weeks from the extraction date). Additionally, I have recently had blood-work that indicated immune dysfunction due to a depressed white blood cell count and NK cell count as well as potentially active infections. I have the following concerns.

1. The gum-line superior to the tooth has a white bump where the fistula was located and remains a bit swollen. As well, the molar behind it is a bit sensitive now. Should I be concerned, or does the area look sufficiently debrided to accept an allograft? It would be nice to avoid a sinus lift in the future, but I also don’t want to receive a bone graft that will become infected and fail. See attached picture as well as X-rays of #14 that preceded the extraction by one month.

2. I understand an implant is preferable to a bridge, however, I am concerned about an implant in the future because I have read Pubmed articles that state the area surrounding the implant will inevitably be colonized by microbiota….I would attach the articles but my post count is insufficient. The article is entitled "Early colonization of dental implants by putative periodontal pathogens in partially edentulous patients."

In my cause I am worried my immune system cannot handle the potential insult. Specifically Fusobacterium Nucleatum has been shown to make cells in blood vessels more permeable and allow several bacteria to enter the bloodstream and become pathogenic. The blog is called "how bacteria sneak into your blood through your mouth"


I have considered Zirconium Oxide implants, but even then bacteria will grow around a foreign body. Is it your expert opinion that bacteria surrounding a post have increased access to blood vessels versus the normal microbiota that colonizes the mouth? Given the issues I’m having I want to err towards caution regarding microbial insults to my immune system.

I sincerely appreciate the consideration and time.

Attached Thumbnails

     

Hi asmitty,

First let me clarify that irrelevant of how well or how poorly done the original root canal was done on tooth #14... the tooth has been ill for at least 4 years. Root canal therapy cannot cure an infection or make a tooth healthy again. The procedure is done to allow the patient to retain their tooth.... not cure the infection. I just thought you should know that because it means that you have had a chronic infection in your tooth and jawbone for at least 4 years. So this may correlate with your ill health. Check out this tooth and meridian chart... it's been around for centuries. See if anything rings a bell...
http://toothbody.com/wp-content/uplo...v2.1_rehme.swf

You stated...
<<<Last year, the gum above the tooth was found to be abscessed and a fistula had formed and periodically drained. Eight months ago I had the root canal retreated and it was found that two roots had not been properly removed the first time around.>>>

The gum above the tooth was infected but only because the infection had spread through the bone to the gum and the fistula is the point of exit or relief from the pressure of the infection. Just so you understand, it was not a gum infection.. it was an abscessed tooth. The infection had been present for 4 yrs but the abscess was draining for 8 months so it is not surprising that you have a systemic infection as indicative of your blood work.

It may not be wise to do a bone graft at this point simply because you are dealing with systemic issues and the graft could exacerbate those problems. You should speak to the oral surgeon about this and he should confer with your physician. Possibly even an infectious disease specialist would be helpful.

Regarding dental implants... it is my understanding that titanium implants are not considered to be as bio compatible as zirconium implants. Different types of bacteria encase the implants as they integrate with the bone. Some people will have a problem with one type more than the other for various reasons. It is very individualized. One way to see what type of implant may be best for you is to have a blood test to see if you are reactive or sensitive to either material. The other thing to know is that the tooth or crown portion of the dental implant has many little parts that hold the crown onto the implant which are combined of various metals. So you may want to be tested for those materials as well.

Regarding the vascularity around the dental implant... sure the implant is in direct contact with the vessel system and nerves, just like the root of a tooth would be. So yes, that is very different from something that does not go into the jawbone which would be a pontic (fake tooth) attached to a bridge of some sort that lies against the gum tissue.

Regarding a bridge vs an implant..... it is a shame to cut down healthy teeth to make a bridge. However in your case you may be a good candidate for a porcelain onlay bridge which requires less removal of the adjacent teeth. A porcelain pontic (fake tooth) is fused to two porcelain onlays. One onlay would be cemented to #13 and the other to #15. You could speak to your dentist about that. Sometimes it is best to see a Prosthodontist (dental specialist in the replacement of teeth) for this type of bridge as they tend to do more of them than general dentists.

I also agree with you and I do believe that oral infections, especially a long standing one can and will affect our systemic health. They can cause, contribute or worsen an existing infection, inflammation or an auto immune disorder.

Thanks for posting the picture and the xrays... it does help tell the story more clearly. I hope I have given you some helpful information. Please feel free to continue this discussion...

Bryanna

Asmitty, I am sorry for what you have been through. I also received a diagnosis of neurological lyme disease almost 2 years ago and often wonder if what I have is a systemic dental infection that lowered my immune response. I had a failed root canal followed by a tooth extraction and dental implant in 2008. This was followed by years of dental and gum pain that my dentist and oral surgeon were unable to figure out because the x-rays and dental exams always looked great. I eventually did receive 2 more root canals due to the pain and sensitivity (very unfortunate) and 2 years later, one of those root canaled teeth developed a fistula that shows bone infection above it. We discovered this a few weeks ago, but I think I noticed the bump on the roof of my mouth months ago. It would come and go and I always thought it was a spot from burning my mouth with tea.

I am finally scheduled to get the tooth extracted next week. The pain has migrated to my ear, sinuses and skull. I lost almost all hearing in the ear on the same side as the tooth infection 2 1/2 years ago. I often wonder if there has been an infection circulating around in my inner ear that all started from a bad jaw bone infection that started with that implant. I am concerned because my dental implant is adjacent to the infected tooth that is going to be extracted.

Please keep us posted on how you do with the bone grafting. I am afraid when the oral surgeon pulls my tooth that he will discover more damage than originally anticipated. This is a very difficult journey we are on. But I hope that we are finally closer to getting some answers.

@dbpei. I'm so sorry to hear of your issues, it's a tough road. I agree with Bryanna, I will never get another root canal, and am glad to have removed the one I had. I will happily keep you updated on my progress regarding the graft and implant. Also if you want to pm me I'd be glad to share the knowledge I've accumulated on neuro-immune diseases, if you have any questions....


@Bryanna. I could use a bit of clarification.

1. I'm trying to do a cost benefit analysis of getting the bone graft this coming Tuesday. On the one hand if it takes, it will save me up to 1,500 dollars vs a sinus lift. On the other hand it could become infected and fail. Assuming the latter, whats the worst that happens if it fails?
I know the graft could temporarily harbor infection due to a lack of blood flow; but wouldn't blood flow eventually get integrated into the graft and remove the "potential" infection? Or, are there other long term concerns regarding the graft and infection that I am missing?

2. Also, with regards to an implant in the future.... Do you think the bacteria that surrounds an implant post has a greater chance of gaining access to systemic circulation than the bacteria that is already in the mouth as it is?

3. Also, if I decide I'm going the bridge route, I assume I would never need a graft anyway, correct?

Thanks so much for all your help

@dbpei. I'm so sorry to hear of your issues, it's a tough road. I agree with Bryanna, I will never get another root canal, and am glad to have removed the one I had. I will happily keep you updated on my progress regarding the graft and implant. Also if you want to pm me I'd be glad to share the knowledge I've accumulated on neuro-immune diseases, if you have any questions....

@Bryanna. I could use a bit of clarification...

1. I'm trying to do a cost benefit analysis of getting the bone graft this coming Tuesday. On the one hand if it takes, it will save me up to 1,500 dollars vs a sinus lift. On the other hand it could become infected and fail. Assuming the latter, whats the worst that happens if it fails? I know the graft could temporarily harbor infection due to a lack of blood flow; but wouldn't blood flow eventually get integrated into the graft and remove the "potential" infection? Or, are there other long term concerns regarding the graft and
infection that I am missing?

2. Also, with regards to an implant in the future.... Do you think the bacteria that surrounds an implant post has a greater chance of gaining access to systemic circulation than the bacteria that is already in the
mouth as it is?

3. Also, if I decide I'm going the bridge route, I assume I would never
need a graft anyway, correct?

Thanks so much for all your help

Hi asmitty,

I will post my reply in bold.

<<<<1. I'm trying to do a cost benefit analysis of getting the bone graft this coming Tuesday. On the one hand if it takes, it will save me up to 1,500 dollars vs a sinus lift. On the other hand it could become infected and fail. Assuming the latter, whats the worst that happens if it fails? >>>

ONE) A BONE GRAFT IS A LOT EASIER THAN A SINUS LIFT.

TWO) A BONE GRAFT WOULD STILL NEED TO BE DONE WITH A SINUS LIFT.

THREE) WHEN A BONE GRAFT BECOMES INFECTED IT CAN MAKE YOU QUITE ILL AS COULD ANY INFECTION. GENERALLY ANTIBIOTICS ARE GIVEN TO TRY AND HANG ON TO THE GRAFT.. .BUT SOMETIMES THE MEDS ARE GIVEN MULTIPLE TIMES WHICH IS NOT IDEAL FOR YOUR IMMUNE SYSTEM. IF THAT METHOD FAILS THEN THE GRAFT HAS TO BE SURGICAL REMOVED... MORE DENTAL CHAIR TIME AND MORE $$.

SO IF THE JAW BONE IS HEALTHY AT THE TIME THE BONE GRAFT IS PLACED AND THE SURGERY TO PLACE IT IS VERY STERILE AND YOUR POST OP CARE IS VERY GOOD, THE SUCCESS RATE OF THE GRAFT IS UNMEASURABLE.

<<<I know the graft could temporarily harbor infection due to a lack of blood flow; but wouldn't blood flow eventually get integrated into the graft and remove the "potential" infection? Or, are there other long term concerns regarding the graft and infection that I am missing?>>>

THE GOAL OF PLACING THE GRAFT IS TO SCRAPE THE BONE AND TISSUE DURING THE SURGERY TO OBTAIN A HEALTHY BLOOD FLOW AND THEN PLACE THE GRAFT INTO THAT BLOODY SITE. THE BLOOD KNOWS TO CLOT QUITE READILY WITHIN THE GRAFT MATERIAL HELPING TO HOLD IT IN PLACE. A COLLAGEN PLUG OR MEMBRANE IS ALSO PLACED IN THE SOCKET TO HOLD THE CLOT AND GRAFT IN PLACE. PROVIDING THE JAW BONE IS HEALTHY TO BEGIN WITH (THAT IS A MUST!!) AND THE BLOOD FLOW DURING THE PLACEMENT IS ABUNDANT, SURGERY IS STERILE AND POST OP CARE IS GOOD... THE GRAFT SHOULD BE OKAY. THE ONLY OTHER ISSUE COULD BE IF YOUR BODY REJECTED THE GRAFT DUE TO INCOMPATIBILITY ISSUES OR ANOTHER AUTO IMMUNE REACTION OCCURED.

<<<<2. Also, with regards to an implant in the future.... Do you think the bacteria that surrounds an implant post has a greater chance of gaining access to systemic circulation than the bacteria that is already in the mouth as it is?>>>>

NO, NOT UNLESS THERE IS A COMPROMISING SITUATION EITHER WITH THE IMPLANT SITE AND/OR THE PATIENTS IMMUNE SYSTEM WHICH WOULD CAUSE AN INFLAMMATORY RESPONSE AND/OR INFECTION.

<<<<3. Also, if I decide I'm going the bridge route, I assume I would never need a graft anyway, correct?>>>>

NOT NECESSARILY. THERE IS ALWAYS SOME DEGREE OF BONE LOSS WITH EVERY TOOTH EXTRACTION. GENERALLY THE LOSS CAN BE 50% OR GREATER AFTER THE INITIAL HEALING AND THEN CONTINUES TO RECEDED OVER TIME.
WHEN A GRAFT IS PLACED, THE IMMUNE SYSTEM SENDS CELLS TO GROW NEW BONE INTO THAT GRAFT. THE GRAFT BECOMES YOUR OWN BONE REDUCING THE OVERALL AMOUNT OF BONE LOSS.

HOWEVER, OVER TIME THIS BONE TOO WILL RECEDE JUST LIKE ANY OTHER BONE THAT HAS NOTHING TO SUPPORT IT. HOWEVER, THIS BONE LOSS IS USUALLY NOT AS GREAT AS IT IS WITHOUT HAVING PLACED THE GRAFT MATERIAL.

Does that seem clear to you? Or do you want more information or have other questions?

Bryanna

Thanks for the clarification, everything is clear now.

I'm thinking that I'll call the oral surgeon tomorrow and ask him if he can guarantee that the bone graft will both work and provide enough depth for an implant in the future....

I get the feeling he probably won't want to make any guarantees, so I might as well wait and get a sinus lift down the road. Does that sound reasonable to you?

By the way, do you happen to know if the cost of a sinus lift includes a bone graft as well?

Hi asmitty,

The oral surgeon cannot and should not guarantee the outcome of the bone graft. The outcome depends on several factors:

One... the health of the jaw bone. The bacteria is not always visible as it can be microscopic.

Two... the surgery has to be done under extreme sterile conditions. No contamination can occur or it can compromise the outcome.

Three... your immune system has to be healthy enough to turn over the bone into your own bone and heal properly.

Even if you wait to do the sinus lift and then the graft.... the above factors all hold true for that outcome as well.

No the sinus lift is a separate fee from the bone graft.

I know... not an easy decision. However, for future reference... if the tooth had not been root canaled and had been extracted instead.... none of this would be a concern because the bone would be healthy and more favorable to a bone graft.

It's interesting to me when someone delves deep into this research.... and you certainly have! Are you in the healthcare field or some biology/chemistry profession to know where and how to seek the information??

Bryanna

I recently graduated with a B.S. in Biology. Healthcare may be in the cards in the future...:-)

So, I went ahead and got the graft this morning. The surgeon was very sterile and I felt he took his time and did an excellent job of cleaning the bone and restoring blood flow. In terms of the cost/benefit I felt I would rather risk the graft failing now versus necessarily having to do a more invasive procedure down the road. Time will tell if I made the right choice.

Now, I just have to convince my oral surgeon to do a zirconium implant on #14. He feels that titanium is better for molars in the long term, but I'm adverse to putting metal in my mouth.

Thanks again for all the help

Hi asmitty,

I had a hunch you had some background in organisms..
Good luck on your future endeavors!!

Glad to hear the bone graft went well. I think you made a wise decision.
Just so others reading this know...... would you say the bone grafting procedure painful? Are you having any post op pain?

Bryanna