[Claudettemj]

Hello Bryanna

I've been reading through many threads you've given advice on recently with great interest. The information/advice is always what one would hope for from a GD but too often isn't the case. Just wish I'd come across this community years ago!!!

I have had about four failed root canals to #8, then last year the tooth cracked and had to be extracted. By way of background info, I developed a fistula above the tooth after the second root canal treatment circa 12/15 years ago. At the time, I didn't know it was a fistula and took it that it was just the appearance of a bad abscess. Two separate dentists told me not to worry about what had become a significantly smaller pimple above the tooth and because no infection leaked from it, I took them at their word.

When the tooth cracked last year, I got an implant and the crown fitted about 6 months later. During this time I had an infection in the area of the extraction. At a review appointment this month, my implant was x-rayed and the dentist advised that there had been bone loss at the top of the implant but that she would open up the gum around the fistula and clean the whole area out, including the threads now visible at the top of the implant and debride the infected bone. She plans to leave the implant in and work around it.

I would really appreciate your advice on what should be my best route forward?

Many thanks

Claudette

[Bryanna]

Hi Claudettemj,

Thank you for the kind words and I am glad that you find the information that I give here helpful

I am going to re post your thread and reply to you in bold type. Makes it easier to follow.

<<I have had about four failed root canals to #8, then last year the tooth cracked and had to be extracted.>>

EVERY ROOT CANALED TOOTH IS CHRONICALLY INFECTED DUE TO THE FACT THAT THE ANATOMY OF OUR TEETH DOES NOT ALLOW ACCESS TO HUNDREDS OF TINY CANALS THAT CONTINUE TO HARBOR NECROTIC NERVE TISSUE EVEN AFTER ROOT CANAL TREATMENT. THE RC PROCEDURE ALSO RENDERS THE TOOTH NON VITAL. SO BETWEEN THE INFECTION AND THE LACK OF VITALITY, ALL RC TEETH ARE VERY SUSCEPTIBLE TO FRACTURING.

<< By way of background info, I developed a fistula above the tooth after the second root canal treatment circa 12/15 years ago. At the time, I didn't know it was a fistula and took it that it was just the appearance of a bad abscess. Two separate dentists told me not to worry about what had become a significantly smaller pimple above the tooth and because no infection leaked from it, I took them at their word.>>

THE FISTULA FORMS WHEN THE INFECTION OVERWHELMS THE INTERIOR OF THE TOOTH AND IT GOES LOOKING FOR A PLACE TO DRAIN. THE FORMATION OF THE FISTULA CAN ALWAYS BE TRACED BACK TO AN OPENING IN THE TOOTH THAT OCCURRED AS THE BACTERIA ATE THROUGH THE TOOTH AND BURROWED A HOLE OR TUNNEL THROUGH THE BONE TO THE OUTSIDE OF THE GUM. THE PIMPLE THAT APPEARS ON THE GUM IS THE OPENING OF THE FISTULA TRACT THAT CONNECTS TO THE OPENING IN THE TOOTH. THE REASON YOUR DENTISTS (MIS)ADVISED YOU NOT TO WORRY ABOUT THE FISTULA WAS BECAUSE THE INFECTION WAS DRAINING EITHER OUT THROUGH THE FISTULA OPENING OR BACK INTO THE JAW BONE. NEITHER OF WHICH IS HEALTHY. THIS IS INDICATED BY THE FACT THAT THE PIMPLE APPEARANCE GOT SMALLER IN SIZE. AS THE INFECTION DRAINED, THE PIMPLE GOT SMALL. HOWEVER, THERE IS NO QUESTION THAT THE INFECTION WAS NOT CLEARING UP BECAUSE THE TOOTH WAS THE CHRONIC SOURCE OF THE INFECTION AND THE BACTERIA WAS JUST CONTINUOUSLY DRAINING.

<<When the tooth cracked last year, I got an implant and the crown fitted about 6 months later. During this time I had an infection in the area of the extraction.>>

THERE IS A VERY GOOD CHANCE THAT THIS TOOTH WAS FRACTURED LONG BEFORE IT WAS DIAGNOSED. NOT ALL FRACTURES CAN BE SEEN CLINICALLY AND DEPENDING ON THE ANGLE OF THE XRAY, THEY MAY NOT BE VISIBLE RADIO GRAPHICALLY EITHER.
HOWEVER, THE CHRONIC FISTULA IS INDICATIVE OF AN INFECTED FRACTURED TOOTH AND IS COMMONLY SEEN WITH ROOT CANALED TEETH.

<< At a review appointment this month, my implant was x-rayed and the dentist advised that there had been bone loss at the top of the implant but that she would open up the gum around the fistula and clean the whole area out, including the threads now visible at the top of the implant and debride the infected bone. She plans to leave the implant in and work around it.>>

ANYTIME A DENTAL IMPLANT IS PLACED IN THE BONE OF AN EXTRACTED ROOT CANALED TOOTH, THERE IS AN ELEVATED RISK OF INFECTION AND FAILURE DUE TO THE BONE BEING IN A DECREPIT AND GROSSLY NECROTIC STATE. IN CASES LIKE YOURS, THE INFECTION HAD BEEN PRESENT IN THE BONE FOR OVER 15 YEARS AND IT SHOWED CONTINUAL SIGNS OF PROLIFERATION. IRRELEVANT OF WHAT WAS DONE TO THIS BONE TO MAKE IT HEALTHY AFTER THE TOOTH WAS REMOVED WAS MOST LIKELY NOT GOING TO BE FAVORABLE ENOUGH TO SUCCESSFULLY HOLD A DENTAL IMPLANT.

THERE IS NO QUESTION, BASED ON YOUR DETAILED DESCRIPTION, THAT YOU HAVE SEVERE EXTENSIVE BONE LOSS IN THIS AREA OF YOUR MOUTH WHICH IS DIRECTLY CAUSED BY THE CHRONIC INFECTION. THE TREATMENT THAT HAS BEEN PROPOSED TO YOU ***IS NOT GOING TO ERADICATE THE INFECTION NOR WILL IT ENCOURAGE NEW BONE GROWTH*** BECAUSE IT CANNOT ALTER THE HEALTH STATUS OF THE BONE IN A FAVORABLE MANNER. THE ONLY WAY TO ATTEMPT TO DEAL WITH THIS INFECTION IS TO REMOVE THE DENTAL IMPLANT AND REPLACE IT WITH A REMOVABLE PARTIAL DENTURE OR PERMANENT BRIDGE. UNFORTUNATELY, THIS BONE WILL NEVER BE HEALTHY ENOUGH TO HOLD A DENTAL IMPLANT AND YOU REALLY SHOULD HAVE BEEN INFORMED OF THAT.

MOST IMPORTANTLY AND I APOLOGIZE IF THIS IS THE FIRST TIME YOU ARE HEARING THIS, THE INFECTION YOU HAVE HAD AND CURRENTLY HAVE IS NOT JUST LIMITED TO THIS AREA OF YOUR MOUTH. ALL OF THE BACTERIA THAT RESIDES IN OUR TEETH, MOUTH, GUMS, AND JAW BONE CONTINUOUSLY TRAVELS THROUGH OUR ENTIRE BLOOD STREAM. YOU HAVE HAD A CHRONIC INFECTION IN THE JAW BONE FOR OVER 15 YEARS... THAT IS A LONG TIME.

SO FOR THE SAKE OF YOUR OVERALL HEALTH, IT WOULD BEHOOVE YOU TO THINK ABOUT THAT AND CONSIDER THE SYSTEMIC CONSEQUENCES THAT EITHER HAVE OCCURRED OR CAN OCCUR IF YOU HANG ON TO THIS DENTAL IMPLANT.

REMOVING THIS IMPLANT AND HAVING THE DISEASED BONE AND TISSUE REMOVED IS THE ONLY OPTION TO ATTEMPT TO ERADICATE THE INFECTION. THIS SHOULD **ONLY** BE DONE BY AN ORAL SURGEON AS YOU NEED SOMEONE WITH EXTENSIVE SURGERY KNOWLEDGE AND EXPERIENCE TO PERFORM THE REMOVAL AND EXCAVATION OF THE INFECTION. PLEASE DO NOT HAVE THIS DONE BY ANYONE OTHER THAN AN ORAL SURGEON.

I'm sorry I cannot deliver better news... I feel badly that you may not have been forewarned about these issues before now. I hope I have been helpful to you. Please feel free to come back with questions or other concerns.

Bryanna

[Claudettemj]

Hi Bryanna

Thanks for getting back to me so very quickly. I suspected that your advice would be to remove the implant. Given your previous advice to others and the size of my cavity (which wasn't apparent when the cap was placed 4 months ago) I couldn't really imagine any other option. It feels as if the dentist thought it was necessary to give false hope when the truth and discussion of appropriate treatment would be far more acceptable. The surgeon I'll be using is known as one of the best in the city when it comes to dental trauma so I should be in better hands and can now take a 'forewarned is forearmed' approach.

I don't have x-rays that I can share with you but is there a risk to the neighbouring teeth even with successful removal of the implant, infected bone and tissue? Just thinking about the viability of a bridge in the long term.

Thanks

Claudette

[Bryanna]

Hi Claudette,

Unfortunately, the longevity and severity of the infection has already put both of the adjacent teeth at risk for infection and bone loss. So they will need to be evaluated thoroughly and if they are compromised in any way, the dentist should inform you about it prior to recommending replacement of this tooth. However as you have encountered previously, your dentist may not be forthcoming in that information. So it would behoove you to discuss your concerns about those adjacent teeth with the oral surgeon and make it clear that you want to know the long term prognosis of them so you can decide if you want to use them to anchor a bridge.

Removing the dental implant may require the removal of some of the bone that supports those teeth. But that will depend on what the surgeon finds when he removes the implant.

By any chance are the adjacent teeth root canaled?

Regarding the size of the "cavity", I assume you mean the area of pathology above the implant noted on the recent xray? It is important for you to know that this did not occur over night. It was something that was brewing for a very long time. Dental xrays are only 2 dimensional so sometimes the angle of the xray is a bit skewed and the pathology is blocked or not definitively conclusive. That could be the reason why it wasn't seen sooner.

The oral surgeon may require a dental CT scan to get a better look at the size and location of the infection.

Bryanna

Originally Posted by Claudettemj

Hi Bryanna

Thanks for getting back to me so very quickly. I suspected that your advice would be to remove the implant. Given your previous advice to others and the size of my cavity (which wasn't apparent when the cap was placed 4 months ago) I couldn't really imagine any other option. It feels as if the dentist thought it was necessary to give false hope when the truth and discussion of appropriate treatment would be far more acceptable. The surgeon I'll be using is known as one of the best in the city when it comes to dental trauma so I should be in better hands and can now take a 'forewarned is forearmed' approach.

I don't have x-rays that I can share with you but is there a risk to the neighbouring teeth even with successful removal of the implant, infected bone and tissue? Just thinking about the viability of a bridge in the long term.

Thanks

Claudette

[Claudettemj]

Hi Bryanna

You're absolutely spot on in that I plan to ask the surgeon rather than the dentist about her recommendations following extraction of the implant.

Neither of the adjacent teeth has had a root canal. One has a small filling while the other is what I'm told is described as a virgin tooth.

Yes, I see what you're saying about 2D X-rays. Based on what I saw from the 2D X-ray of the implant from 4 months ago, it would have been impossible to see the damage to the bone. The surgeon requested a CT scan because I was "lucky" that she caught sight of a small shadow on the X-ray. I think it's the result of the scan that has allowed us to see the extent (albeit a B&W negative) of the damage to the bone so far.

May I ask what your thoughts are on bridges? I completely loath the idea of having to wear a partial denture for 40+ years (average life expectancy and all that) but have read that bridges tend to damage the teeth to which they're attached and I'd end up with the need for a partial at some point anyway.

Thanks

Claudette

[Bryanna]

Hi Claudette,

Yes, please discuss everything in detail with the surgeon. She will not really "suggest" replacement options with you as she is not a restorative dentist. But she can tell you if the adjacent teeth are healthy. I am curious, what caused tooth #8 to be root canaled in the first place? Did you get hit in the mouth or fall?

My opinion on permanent bridgework is that is can be a very good option in certain cases. It does require that the adjacent teeth be prepped down just as they would be when prepping a tooth for a crown. So there is always a risk of injury to the tooth while drilling or a chance for unexpected post op complications. The same as when drilling down any other tooth for a crown. In your case the replacement of the front tooth is a bit more tricky because trying to match the color of the bridgework with your natural teeth can be difficult and the difference would be noticeable because it is in the front, as compared to the molars. So your dentist may suggest to put veneers on the upper teeth that are in your smile line so the color would all match up. Not only is this expensive financially but the teeth being veneered also have to be drilled down, slightly less than for a crown, to accommodate the veneers.

There is a permanent replacement option for one missing front tooth called a Maryland Bridge. This requires minimal drilling on the adjacent teeth and the fake tooth is adhered to "wings" that are fabricated to fit into grooves in the back of the adjacent teeth. Not everyone is a candidate for this type of bridge due to their occlusion. You would also need to have a dentist who is very experienced in making these bridges do this type of work. Otherwise they can be a PITA and come unglued frequently.

A removable partial denture to replace a front tooth only can sometimes be made small and indiscreetly. Again it depends on your occlusion, the shape of your mouth and the technical ability of the dentist and his lab.

One of the issues you may encounter when this tooth is removed is moderate recession of the buccal (front) bone which would cause the gum tissue to be "higher" than the adjacent teeth. So any replacement tooth may end up being "longer" than the rest of your front teeth. That bone loss and recession is something to discuss with the surgeon.

Bryanna

Originally Posted by Claudettemj

Hi Bryanna

You're absolutely spot on in that I plan to ask the surgeon rather than the dentist about her recommendations following extraction of the implant.

Neither of the adjacent teeth has had a root canal. One has a small filling while the other is what I'm told is described as a virgin tooth.

Yes, I see what you're saying about 2D X-rays. Based on what I saw from the 2D X-ray of the implant from 4 months ago, it would have been impossible to see the damage to the bone. The surgeon requested a CT scan because I was "lucky" that she caught sight of a small shadow on the X-ray. I think it's the result of the scan that has allowed us to see the extent (albeit a B&W negative) of the damage to the bone so far.

May I ask what your thoughts are on bridges? I completely loath the idea of having to wear a partial denture for 40+ years (average life expectancy and all that) but have read that bridges tend to damage the teeth to which they're attached and I'd end up with the need for a partial at some point anyway.

Thanks

Claudette

[Claudettemj]

Hi Bryanna

I've always suspected that the reason for the original filling, from a newly qualified dentist, was purely financial. Again a guess on my part, but I think that the root canal became necessary because of the poorly completed filling. At no time had I ever had a fall or injury to the tooth/mouth.

Many thanks for the information about bridgework and the prepping necessary to complete it. As you say, it could be a very good option for me and I'd think nothing of jumping in but for the fact that a healthy front tooth would be 'interfered' with to achieve a bridge. To be honest, my reluctance only comes from a lack of confidence based on the dentists I've seen so far.

I'll definitely ask about a Maryland Bridge. Sorry, what does PITA mean?

While I'm hoping not to have recession of the buccal bone, I'm hoping that my smile not really showing the gum line wouldn't make it too much of an issue if this did happen.

Thanks

Claudette

[Jomar]

[Sorry, what does PITA mean?]
pain it the *** - I believe..

[Claudettemj]

Originally Posted by Jo*mar

[Sorry, what does PITA mean?]
pain it the *** - I believe..

😀😀 thanks for explaining. That's given me a good laugh. Especially that you only believe so ...