[santana72]

Hi Bryanna,

I am hoping you can provide me some feedback on the following case.

I had 2 molar extractions (36 and 37) on December 5th. #36 had 2 root canals done previously and I had a 3rd one done on it as a last ditch effort to save the tooth this past May. Needless to say, the tooth developed an abscess in November and was deemed unsalvageable. During this ordeal, it was discovered by pure chance #37 had resorption. My surgeon was not sure if the tooth could be saved and offered to take a look at the time of the extraction of #36. It turns out the resorption was towards the root of the tooth and at a place that would make it virtually impossible to save it even with root canal. As a result, both teeth were extracted at the same time.

Prior to the extraction, I consulted with 2 surgeons. One of them suggested I go on a 500 mg three times a day dose of Amoxicillin 3 days prior the surgery date and added she would not remove the abscessed tooth (#36) unless the swelling has completely subsided by the 3rd day. The other surgeon prescribed 250 mg 3X day dose of Amoxicillin and asked me to start taking them on the day of the surgery, starting with a double dose. I ended up choosing the latter specialist to perform the extractions.

He ended up removing both teeth and placed bone graft, with the intent to place implants within 4-6 months. I got put on pain killers and Amoxicillin for 7 days. The first few days went by smoothly, with some expected swelling near the site of the surgery. On the 4th day, I had a bit more swelling and my neck was very stiff to the point that I could not turn it all the way. I also had massive headaches. With more Advil, I slept it off. The next few days the same symptoms manifested on an off, with no improvement. By Thursday, I went to see the surgeon. He took an x-ray and said there is nothing to worry. I told him I was leaving for vacations and not returning until early in the New year. He reluctantly prescribed Metronidazole (flagyl) 250 mg + Amoxicillin 250 mg to be taken 5 days, 3 times a day and said to start this course of antibiotic if there is visible swelling on my face and throbbing pain.

On Saturday, I flew to Mexico and by Sunday there was visible swelling on my face. To get a 2nd opinion, we went to see a family friend who is an periodontist. Upon examination, he said there is quite a bit of infection. He was prepared to do a small incision under the gumline but he was able to drain the pus by just scraping around the gum. At the end, he suggested to remove the membrane and the bone graft, clean up the site, irrigate and let the area heal completely before doing anything else. He put me on Clindamycin 300 mg 4 times daily to reduce the swelling and advised he would not touch the site until the swelling has significantly subsided.

The next day I called my surgeon and expressed my concerns. I sent him pictures of my face and also inside my mouth where the membrane is visible. He basically said the soft tissues look somewhat inflamed but the membrane is in place and I may have developed some inflammation or mild infection superficially between the membrane and the gum tissue flap and that things should resolve naturally. He also said the surgery was only done December 5th and the infection that was present at the time of surgery was extensive so what I am experiencing is within the range of normal. He is strongly urging not to touch the membrane but when I ask about what to do in the event of infection coming back after the last course of antibiotics, he has not given me a good answer or any answer for that matter.

It is true the membrane is still in place. However, I am not sure if the membrane is supposed to be exposed that way and whether it insulates the particulates and the underlying tissues from the bacteria in that state. The periodontist in Mexico advised there is a good chance the bone graft and the underlying tissue/bone is also contaminated, hence the swelling and the amount of white pus (vs. transparent) in and around the membrane.

I am now onto my 3rd day with the 2nd course of antibiotic (Clindamycin 300 mg). The pain is almost gone and swelling is probably back to how it was around the 4th day after the surgery. There is still white pus and when pressed escapes all the way around the gumline and behind the membrane.

Here are my questions:

- I am still not clear how an infection under the membrane vs. around the gum line presents differently. At this point, we know for a fact there is an infection and it is not healing rapidly even with the antibiotics. What are the tell tale signs the bone graft is compromised and this infection is not a mild one? Would another x-ray be beneficial at this stage or unnecessary radiation given that my last x-ray was only 7 days ago?

- I have read in several places new bone grafts do have not sufficient blood supply. According to these sources, if there is no blood supply, antibiotics and topical rinses have limited effect. They are saying infected bone grafts especially particulate need removal. The antibiotic will simply not clean up all the contamination, and therefore not very useful, at least long term. Is this a fair characterization?

- My main concern is, if I were to have the membrane and the bone graft removed against the advice of the surgeon, am I going to significantly reduce the chance of a successful implant in the troubled site?

Needless to say I am also worried about systemic risks related to the infection and do not want to take a chance. By the same token, I don't want to be on Antibiotics either until I am back from vacations in the New Year.

What is the best course of action under the circumstances?

Thank you for your insights.
Jerry