[ddd49]

I had a root canal on tooth #3 over 10 years ago. A few years ago I had an apicoectomy on the same tooth. A fistula developed but no one told me what it was. The dentist sent me back to the surgeon who basically said it meant it didn't work and the tooth would need to be extracted. I did not realize the seriousness of it and did nothing about it for two years as it did not really hurt. Now the dentist has referred me to a surgeon for an extraction and implant. Now that I know it is called a fistula I googled it at that led me to this site. Now I am concerned I have waited too long and there might be bone damage and other problems. I have attached the xray. Please give me your opinion. Thanks

[Bryanna]

Hi ddd,

Thank you for posting the xray. It is not ideally diagnostic but the infection is quite apparent.

Yes, you have a moderate size infection with tooth #3 which has been brewing for at least 10 years as the root canal procedure and apico are not procedures that can cure an infected tooth. They are done to attempt to retain an unhealthy tooth for an uncertain amount of time. So it's important that you understand that this infection is ongoing for over 10 years.

When this tooth is extracted, there is going to be substantial bone loss due to the infection and possible sinus communication. It may not be an ideal site for a dental implant. Please discuss those issues in a consultation with the oral surgeon.

Have you had a complete comprehensive dental examination and full mouth series (18-20) xrays done? I ask because on this one xray tooth #4 and #2 look a bit suspicious regarding vitality. You also have some moderate+ bone loss associated with all 4 teeth in this picture so you may also have that elsewhere. It would behoove you to have that full examination and xrays done prior to any dental treatment if possible.

It really helps to get an overall picture of your dental health before you undergo any dental treatment just in case there are issues with the adjacent teeth. I think you would agree that the goal is to spend as little, although productive and warranted time, in the dental chair as possible.

You will be okay... you just need to follow through and not put this off any longer. Please keep posted....
Bryanna

Originally Posted by ddd49

I had a root canal on tooth #3 over 10 years ago. A few years ago I had an apicoectomy on the same tooth. A fistula developed but no one told me what it was. The dentist sent me back to the surgeon who basically said it meant it didn't work and the tooth would need to be extracted. I did not realize the seriousness of it and did nothing about it for two years as it did not really hurt. Now the dentist has referred me to a surgeon for an extraction and implant. Now that I know it is called a fistula I googled it at that led me to this site. Now I am concerned I have waited too long and there might be bone damage and other problems. I have attached the xray. Please give me your opinion. Thanks

[ddd49]

Bryanna
I had a the comprehensive exam and full series X-rays done this week. I see the oral surgeon for a consultation tomorrow. My dentist thinks I should get an implant as he thinks a bridge would weaken the adjacent teeth. I hate to lose more teeth. I am a 68 year old female. Is it likely bone graft would work at my age. If there is sinus communication what should be done? Is it your opinion that implants are better than a bridge? I read in the forum I should ask about scraping and the ligaments. What other questions should I ask at the consultation?
Thanks

Originally Posted by Bryanna

Hi ddd,

Thank you for posting the xray. It is not ideally diagnostic but the infection is quite apparent.

Yes, you have a moderate size infection with tooth #3 which has been brewing for at least 10 years as the root canal procedure and apico are not procedures that can cure an infected tooth. They are done to attempt to retain an unhealthy tooth for an uncertain amount of time. So it's important that you understand that this infection is ongoing for over 10 years.

When this tooth is extracted, there is going to be substantial bone loss due to the infection and possible sinus communication. It may not be an ideal site for a dental implant. Please discuss those issues in a consultation with the oral surgeon.

Have you had a complete comprehensive dental examination and full mouth series (18-20) xrays done? I ask because on this one xray tooth #4 and #2 look a bit suspicious regarding vitality. You also have some moderate+ bone loss associated with all 4 teeth in this picture so you may also have that elsewhere. It would behoove you to have that full examination and xrays done prior to any dental treatment if possible.

It really helps to get an overall picture of your dental health before you undergo any dental treatment just in case there are issues with the adjacent teeth. I think you would agree that the goal is to spend as little, although productive and warranted time, in the dental chair as possible.

You will be okay... you just need to follow through and not put this off any longer. Please keep posted....
Bryanna

[Bryanna]

ddd,

Did your dentist inform you of your generalized bone loss in the upper right quadrant and possibly other areas? Did he measure your gum pockets? This is when they use a little probe to measure below the gum line in 6 places on every tooth. He would have called out these numbers to an assistant as she recorded them on your periodontal chart. If you have not had that done, then it's important for him to do it as it is helps to locate areas of possible periodontal disease and bone loss. Every comprehensive examination should include a full periodontal screening which includes measuring the pocket depths of every tooth.

Conventional dentistry will often push their patients to have dental implants because they are not taking into consideration the health of the existing jaw bone. Oral surgeons are also quick to push implants but it's best to discuss your concerns about the health of the bone and about placing an implant in bone that had a long standing infection 10+ years.

Here are some things to also bring up with the oral surgeon:

1) What is the health of the adjacent teeth #2 and 4 as they are looking suspicious on the xray regarding vitality. Also #2 the last molar may or may not have an area of pathology on the xray so ask him to check those teeth clinically and radio graphically.

2) Explain that you are concerned about long term post operative complications and want to minimize them as best as possible. So you want him to remove the entire tooth and any fragments of any stray root canal material ..... also the entire periodontal ligament .... and all other diseased tissue and bone during the surgery. You want that bone to be clean of all debris so it can heal healthfully.

3) Does he think the sinus will be involved with the extraction of #3? If so, will he go in and clean it up the best he can? Tell him you want to be informed if there is a sinus perforation or communication ... how severe it is... and what he did to repair it. It is always best to be thoroughly informed.

Sinus perforations vary in size and severity. However, if they need to be mended, then the surgeon is the one to do that at the time of the extraction. So just put a bug in his ear about your concern about a sinus involvement as that makes him aware that he needs to be on top of it.

Dental implants are a good tooth replacement when placed in healthy adequate bone in people who do not have periodontal disease.... who are relatively healthy and do not take medications that reduce their salivary output ... eat a nutritious diet with little to no sugar or processed foods .... and who have good at home oral hygiene care. People who are compromised in any of those ways, are not ideal candidates for dental implants. That does not meant they shouldn't have them, it's just not an ideal option.

Permanent bridgework.... if tooth #2 and 4 are healthy and you do not have periodontal disease, then you would be a candidate for a 3 unit bridge.

Removable partial denture... if you are already missing other teeth (other than wisdom teeth) in your upper arch and they have not been replaced, then you may be a candidate for a removable partial denture. This can be designed to accommodate any future teeth that may need to be extracted in your upper arch.

So you can see why it is important to know the health of your other teeth before you decide to replace #3.

Bryanna

Originally Posted by ddd49

Bryanna
I had a the comprehensive exam and full series X-rays done this week. I see the oral surgeon for a consultation tomorrow. My dentist thinks I should get an implant as he thinks a bridge would weaken the adjacent teeth. I hate to lose more teeth. I am a 68 year old female. Is it likely bone graft would work at my age. If there is sinus communication what should be done? Is it your opinion that implants are better than a bridge? I read in the forum I should ask about scraping and the ligaments. What other questions should I ask at the consultation?
Thanks

[ddd49]

Bryanna,
I have a very nice but old fashion dentist. I had no idea what a comprehensive exam was. He looked in my mouth and looked at the X-rays. He said the place on my gum was a fistula. (Which is the first time anyone gave it a name even though I had seen the dentist and endodentist about it a couple of years ago. No one told me the damage it could do.) My dentist said he could pull the tooth but he did not do implants so he gave me a referral to an oral surgeon. There was no disscussion of bone loss. My wisdom teeth never came in I guess and as a child I had 2 upper and 2 lower bicuspids removed before I got braces. I have all my other teeth.
Thanks for your time and expertise. Not knowing the right questions to ask has been detrimental in this case. I appreciate it.

Originally Posted by Bryanna

ddd,

Did your dentist inform you of your generalized bone loss in the upper right quadrant and possibly other areas? Did he measure your gum pockets? This is when they use a little probe to measure below the gum line in 6 places on every tooth. He would have called out these numbers to an assistant as she recorded them on your periodontal chart. If you have not had that done, then it's important for him to do it as it is helps to locate areas of possible periodontal disease and bone loss. Every comprehensive examination should include a full periodontal screening which includes measuring the pocket depths of every tooth.

Conventional dentistry will often push their patients to have dental implants because they are not taking into consideration the health of the existing jaw bone. Oral surgeons are also quick to push implants but it's best to discuss your concerns about the health of the bone and about placing an implant in bone that had a long standing infection 10+ years.

Here are some things to also bring up with the oral surgeon:

1) What is the health of the adjacent teeth #2 and 4 as they are looking suspicious on the xray regarding vitality. Also #2 the last molar may or may not have an area of pathology on the xray so ask him to check those teeth clinically and radio graphically.

2) Explain that you are concerned about long term post operative complications and want to minimize them as best as possible. So you want him to remove the entire tooth and any fragments of any stray root canal material ..... also the entire periodontal ligament .... and all other diseased tissue and bone during the surgery. You want that bone to be clean of all debris so it can heal healthfully.

3) Does he think the sinus will be involved with the extraction of #3? If so, will he go in and clean it up the best he can? Tell him you want to be informed if there is a sinus perforation or communication ... how severe it is... and what he did to repair it. It is always best to be thoroughly informed.

Sinus perforations vary in size and severity. However, if they need to be mended, then the surgeon is the one to do that at the time of the extraction. So just put a bug in his ear about your concern about a sinus involvement as that makes him aware that he needs to be on top of it.

Dental implants are a good tooth replacement when placed in healthy adequate bone in people who do not have periodontal disease.... who are relatively healthy and do not take medications that reduce their salivary output ... eat a nutritious diet with little to no sugar or processed foods .... and who have good at home oral hygiene care. People who are compromised in any of those ways, are not ideal candidates for dental implants. That does not meant they shouldn't have them, it's just not an ideal option.

Permanent bridgework.... if tooth #2 and 4 are healthy and you do not have periodontal disease, then you would be a candidate for a 3 unit bridge.

Removable partial denture... if you are already missing other teeth (other than wisdom teeth) in your upper arch and they have not been replaced, then you may be a candidate for a removable partial denture. This can be designed to accommodate any future teeth that may need to be extracted in your upper arch.

So you can see why it is important to know the health of your other teeth before you decide to replace #3.

Bryanna

[ddd49]

I was wrong, my consultation with the oral surgeon was not until today. He did a CT scan. He said everything looked good but tooth # 3. He showed me the tooth had three roots and the areas of infection visible. He explained about the possibility of sinus communication and said it often heals without treatment. The plan is to extract the tooth removing any fragments if it breaks. He will scrape the area removing areas of infection. He thinks he can do an immediate implant base surrounded by bone graft powder. I think he said there was about 9 cm of bone that looked good. I think he said there may be dissolving stitches. He prescribed amoxicillin 500 mg and peridex oral rinse starting one day before and continuing after. I have not scheduled a date yet. Does this sound like a good plan?

[ddd49]

I forgot to ask about removal of the ligaments. I will ask when I call.

Originally Posted by Bryanna

ddd,

Did your dentist inform you of your generalized bone loss in the upper right quadrant and possibly other areas? Did he measure your gum pockets? This is when they use a little probe to measure below the gum line in 6 places on every tooth. He would have called out these numbers to an assistant as she recorded them on your periodontal chart. If you have not had that done, then it's important for him to do it as it is helps to locate areas of possible periodontal disease and bone loss. Every comprehensive examination should include a full periodontal screening which includes measuring the pocket depths of every tooth.

Conventional dentistry will often push their patients to have dental implants because they are not taking into consideration the health of the existing jaw bone. Oral surgeons are also quick to push implants but it's best to discuss your concerns about the health of the bone and about placing an implant in bone that had a long standing infection 10+ years.

Here are some things to also bring up with the oral surgeon:

1) What is the health of the adjacent teeth #2 and 4 as they are looking suspicious on the xray regarding vitality. Also #2 the last molar may or may not have an area of pathology on the xray so ask him to check those teeth clinically and radio graphically.

2) Explain that you are concerned about long term post operative complications and want to minimize them as best as possible. So you want him to remove the entire tooth and any fragments of any stray root canal material ..... also the entire periodontal ligament .... and all other diseased tissue and bone during the surgery. You want that bone to be clean of all debris so it can heal healthfully.

3) Does he think the sinus will be involved with the extraction of #3? If so, will he go in and clean it up the best he can? Tell him you want to be informed if there is a sinus perforation or communication ... how severe it is... and what he did to repair it. It is always best to be thoroughly informed.

Sinus perforations vary in size and severity. However, if they need to be mended, then the surgeon is the one to do that at the time of the extraction. So just put a bug in his ear about your concern about a sinus involvement as that makes him aware that he needs to be on top of it.

Dental implants are a good tooth replacement when placed in healthy adequate bone in people who do not have periodontal disease.... who are relatively healthy and do not take medications that reduce their salivary output ... eat a nutritious diet with little to no sugar or processed foods .... and who have good at home oral hygiene care. People who are compromised in any of those ways, are not ideal candidates for dental implants. That does not meant they shouldn't have them, it's just not an ideal option.

Permanent bridgework.... if tooth #2 and 4 are healthy and you do not have periodontal disease, then you would be a candidate for a 3 unit bridge.

Removable partial denture... if you are already missing other teeth (other than wisdom teeth) in your upper arch and they have not been replaced, then you may be a candidate for a removable partial denture. This can be designed to accommodate any future teeth that may need to be extracted in your upper arch.

So you can see why it is important to know the health of your other teeth before you decide to replace #3.

Bryanna

[Bryanna]

Hi ddd,

Have you been informed that you have moderate bone loss in between all of your upper right teeth? It is very apparent on the xray that you posted here.

Frequently, this type of bone loss is present throughout the mouth, especially in the posterior regions. Has your general dentist done a periodontal probing of the pocket depths of all of your teeth? This is something that should be done once a year in all adults, especially those with bone loss.

The reason I bring this up is because if you have uncontrolled periodontal disease, you may not be a healthy candidate for a dental implant as periodontal disease is in of itself a bacterial infection. How long have you been seeing this general dentist? Does he do the teeth cleanings or does he have a hygienist? You mentioned that he is old fashioned.... that's not necessarily a good thing if he is not up to date with his technology and still practices old school dentistry.

Also, placing an implant in the area of a previously root canaled tooth is risky due to the longevity of the infection. Sometimes it is better to extract the tooth along with a thorough surgical debridement and then let the site heal for several months to ensure that there is no residual infection. If you do have a sinus perforation, then placing the implant is even riskier.

I am providing you with all of this information because you requested to be informed as much as possible. Ideally, before you consider replacing this tooth, it would be beneficial to know what your periodontal status is and how healthy those adjacent teeth are to tooth #3.

I hope this has been helpful to you. Please let us know how you're doing.

Bryanna

Originally Posted by ddd49

I was wrong, my consultation with the oral surgeon was not until today. He did a CT scan. He said everything looked good but tooth # 3. He showed me the tooth had three roots and the areas of infection visible. He explained about the possibility of sinus communication and said it often heals without treatment. The plan is to extract the tooth removing any fragments if it breaks. He will scrape the area removing areas of infection. He thinks he can do an immediate implant base surrounded by bone graft powder. I think he said there was about 9 cm of bone that looked good. I think he said there may be dissolving stitches. He prescribed amoxicillin 500 mg and peridex oral rinse starting one day before and continuing after. I have not scheduled a date yet. Does this sound like a good plan?

[ddd49]

My general dentist does have a hygienist. I do not think he has done probing at least not measuring any pockets. I have seen this dentist for almost 30 years.
The oral surgeon did say he would have to decide for sure about whether to do the implant that day or wait until later after he extracts the tooth and evaluates the hole left and the pockets in the bone. I did question him about infection coming back after the implant and he said I would need to floss and care for for the implant like any other tooth but did not really address infection remaining in the bone. I will call and ask more questions. Thanks for all the information.

Originally Posted by Bryanna

Hi ddd,

Have you been informed that you have moderate bone loss in between all of your upper right teeth? It is very apparent on the xray that you posted here.

Frequently, this type of bone loss is present throughout the mouth, especially in the posterior regions. Has your general dentist done a periodontal probing of the pocket depths of all of your teeth? This is something that should be done once a year in all adults, especially those with bone loss.

The reason I bring this up is because if you have uncontrolled periodontal disease, you may not be a healthy candidate for a dental implant as periodontal disease is in of itself a bacterial infection. How long have you been seeing this general dentist? Does he do the teeth cleanings or does he have a hygienist? You mentioned that he is old fashioned.... that's not necessarily a good thing if he is not up to date with his technology and still practices old school dentistry.

Also, placing an implant in the area of a previously root canaled tooth is risky due to the longevity of the infection. Sometimes it is better to extract the tooth along with a thorough surgical debridement and then let the site heal for several months to ensure that there is no residual infection. If you do have a sinus perforation, then placing the implant is even riskier.

I am providing you with all of this information because you requested to be informed as much as possible. Ideally, before you consider replacing this tooth, it would be beneficial to know what your periodontal status is and how healthy those adjacent teeth are to tooth #3.

I hope this has been helpful to you. Please let us know how you're doing.

Bryanna

[Bryanna]

Hi ddd,

A general dentist who is practicing for 30 years has experienced a lot of things but aside from his experience, his dentistry may not be an advantage. If he has modernized his office and equipment (nothing fancy just updated), as well as the sterilizing techniques and also practices current state of the art dentistry then that's all positive signs of current practices. But if he has not done those things (say his office looks like a time capsule from the 70's) and he still uses amalgam/mercury fillings, does not emphasize the significance of preventing periodontal disease (as in does not do regular periodontal probings) etc.... then his dentistry may be a reflection of his old school practices.

On many levels dentistry has come a long way in the last 30 years and much of it is for the better. Updating the environment generally means utilizing current and safer standards, newer technology like digital radiography minimizes radiation exposure, newer dental materials are less toxic for the patient, and preventive dental care is of the utmost importance and should be largely emphasized.

If your dentist or hygienist has not spoken to you in detail about your bone loss and your gum health, and neither of them do a routine periodontal probing, then neither of them is practicing preventive care dentistry. That would not really be in your favor. As I said, periodontal disease is a bacterial infection and it is not just limited to the mouth. So your periodontal health is imperative to not just your oral and dental health but to your overall health.

Oral surgeons and other specialists rely on referrals from their peers as a means of staying in business. So most of the time the specialist will just focus on the one issue that the patient was referred to them for and not venture too far past that. They do this because they don't want to step on the toes of the dentist who made the referral by opening up a can or worms that the patient may not have been informed of by their general dentist. I know that sounds stupid... but this is how it's done. That's why it's better if the general dentist is very preventive oriented with his patients and he's open to the findings of his peers as that opens the door for a specialist to look at the patients oral health from a broader perspective.

Regarding post operative complications after the extraction and dental implant... it is imperative that the surgery of the extraction be very thorough and that the bone be healthy and adequate to receive the implant. Placing an implant in unhealthy bone and/or just bone graft spicules will not hold the implant in place. The implant needs to be drilled into solid healthy bone and than if necessary, bone graft material would be packed around the areas where bone loss has occurred. Bone grafting does not take the place of your own bone. The material is used to stimulate your own cells to grow your own bone. The new growth of bone eventually takes over the graft material. But this can only happen properly if the site is healthy and the implant is placed in solid bone to begin with. If there is periodontal disease, then the amount of new bone growth may be diminished and the success of the integration of the implant may not be ideal or healthy.

Also, certain drugs inhibit or reduce the cells necessary to repair and grow new bone. Are you on any bone drugs like Fosamax, Boniva, etc?

Bryanna










The bone loss that you have is usually indicative of dental neglect. Meaning someone is not practicing preventive dental care.

Originally Posted by ddd49

My general dentist does have a hygienist. I do not think he has done probing at least not measuring any pockets. I have seen this dentist for almost 30 years.
The oral surgeon did say he would have to decide for sure about whether to do the implant that day or wait until later after he extracts the tooth and evaluates the hole left and the pockets in the bone. I did question him about infection coming back after the implant and he said I would need to floss and care for for the implant like any other tooth but did not really address infection remaining in the bone. I will call and ask more questions. Thanks for all the information.