[Siobhan]

Hi Bryanna

I read about potential issues with having epinephrine dental injections for some people. Namely, the potential to cause infarct of bone in some people due to its vasoconstricting mode of action.

So, I am wondering if there is a good (or better) alternative and if yes, should I dare to ask my surgeon about it???

I am not having a filling or extraction. I believe I would need to have a surgical debrediment in the near future of what potentially is a cyst or an abscess (still haven't done that CT!). What would a typical procedure entail?
What should I ask the surgeon?

I read in some other thread that they should do a culture of the incised specimen so they can better tailor the antibiotics - should I explicitly ask for that to be done? I am asking because the lady in the office told me that I would go home with an rx for antibiotics and pain killers. How would they know which antibiotics to give me when they sill haven't even sent the sample for analysis?

[Bryanna]

Hi Siobhan,

Epinephrine is an ingredient in certain anesthetics that are used for oral surgery because it helps to control the bleeding during the procedure and because it makes the anesthetic medication last longer. Epinephrine is the same as adrenaline, both of which primarily affect the heart and heart vessels. A slow injection of an anesthetic containing epinephrine is not likely to cause an adverse or unpleasant physical reaction "from the epinephrine". A fast injection can cause a sudden surge to the heart which could result in a temporary fluctuation of the heartbeat and possibly elevate blood pressure. One important thing to know is that some people react negatively to the preservatives in commonly used anesthetics. Not all anesthetics contain preservatives and here is a list of them to discus with your oral surgeon....

http://www.netwellness.org/question.cfm/83761.htm

There are numerous types of cysts that can grow in the jaw bone. Is this cyst related to an infected (root canaled) tooth? Is it the result of a previous extraction? Is it an anomaly? Is is due to trauma?

Bryanna

Originally Posted by Siobhan

Hi Bryanna

I read about potential issues with having epinephrine dental injections for some people. Namely, the potential to cause infarct of bone in some people due to its vasoconstricting mode of action.

So, I am wondering if there is a good (or better) alternative and if yes, should I dare to ask my surgeon about it???

I am not having a filling or extraction. I believe I would need to have a surgical debrediment in the near future of what potentially is a cyst or an abscess (still haven't done that CT!). What would a typical procedure entail?
What should I ask the surgeon?

I read in some other thread that they should do a culture of the incised specimen so they can better tailor the antibiotics - should I explicitly ask for that to be done? I am asking because the lady in the office told me that I would go home with an rx for antibiotics and pain killers. How would they know which antibiotics to give me when they sill haven't even sent the sample for analysis?

[Siobhan]

Thanks Bryanna! That site seems like a wealth of information, thank you, will look at other things too. From those 4 on the list, looks like the best option is the first one - the combination of anesthetics without epi and without sulphites? Problem is, how do I approach this topic with the surgeon?

Yes, the cyst(?) might be related to an already extracted infected (previously root canaled) tooth, but to me it feels like it is high up, a little higher than the end of the root. Does that make sense?? The extraction went well, but now, some months later, I can feel "something" there (even though my dentist cannot). I also feel weird "cold"(?) symptoms on/off like some other posters, suggesting to me that this may be a remnant infection high up in the maxilla. Surgeon suggested an open exploration (no tests) or plain xray of the area, or CT. You can probably see that I am extremely reluctant about the CT, esp that he suggested surgery even without scans (he said it was pretty obvious to him). So if he is so certain, why go through all that radiation. It's a front tooth, with this "cyst" located almost under my nostril, so easy access for him. He does have my panorex already.
What are your thoughts on this? Should people always get a CT prior to having procedures of this kind?

Should I worry about him taking the culture and antibiotics rx before the culture?

[Bryanna]

Hi Siobhan,

Regarding discussing the topic of anesthetics with the oral surgeon.... simply say you want to avoid anesthetics that contain preservatives as you prefer not to put them in your body. He may say that all anesthetics have preservatives as a way to override your request thinking that you do not know any different. Simply hand him the information that I gave to you and let him know that you understand he may be accustomed to using a certain anesthetic but you would like him to abide by your request and use something less likely to cause you an adverse reaction. He may also tell you that he has to use at least some epinephrine in order to perform the surgery because if the bleeding is too great, he will not be able to see what he's doing and because it may be necessary to keep you profoundly numb during the procedure, both of which are totally truthful. If you emphatically tell him NO he cannot use any epinephrine he can refuse to treat you.

It's important that you keep in mind that there are many other significant factors that go into giving a dental injection of a local anesthetic which are just as important as the medication that is used in that injection. These factors are basically not in your control as they include the deliverance of the injection itself. One thing you can request of him is that he give the injection slowly rather than quickly to help avoid unnecessary trauma to that area and beyond. He may look at you funny for knowing about that... but just nicely tell him I have had injections given both ways and I do much better if it is given slowly.

So if I understand you correctly, you had a root canaled front tooth extracted and there is a residual infection and cyst remaining? Did your general dentist remove this tooth? What is in place of this tooth now?

It is not unusual for a dentist or other who is well trained in radiology to be able to see these type of cysts on routine dental xrays. Unfortunately, general dentists frequently miss these areas compared to an oral surgeon. Any chance you could post the xray here or private message me with an attachment?

Regarding the CT scan.. the advantage to having it is that it will show the exact location, size and depth of the cyst because the CT gives various slices or dimensions of the area as compared to a dental xray which only gives a 2 dimensional view.

Bryanna

Originally Posted by Siobhan

Thanks Bryanna! That site seems like a wealth of information, thank you, will look at other things too. From those 4 on the list, looks like the best option is the first one - the combination of anesthetics without epi and without sulphites? Problem is, how do I approach this topic with the surgeon?

Yes, the cyst(?) might be related to an already extracted infected (previously root canaled) tooth, but to me it feels like it is high up, a little higher than the end of the root. Does that make sense?? The extraction went well, but now, some months later, I can feel "something" there (even though my dentist cannot). I also feel weird "cold"(?) symptoms on/off like some other posters, suggesting to me that this may be a remnant infection high up in the maxilla. Surgeon suggested an open exploration (no tests) or plain xray of the area, or CT. You can probably see that I am extremely reluctant about the CT, esp that he suggested surgery even without scans (he said it was pretty obvious to him). So if he is so certain, why go through all that radiation. It's a front tooth, with this "cyst" located almost under my nostril, so easy access for him. He does have my panorex already.
What are your thoughts on this? Should people always get a CT prior to having procedures of this kind?

Should I worry about him taking the culture and antibiotics rx before the culture?

[Siobhan]

Thank you again, Bryanna.

I see, I shouldn't really be very firm on the epi since I don't want him to refuse to treat me! Better stick with the speed of the injection. I read somewhere that wands deliver the injection automatically at the exact best speed - is that correct? If he does use them (he's a proper real oral surgeon), does it really mean I have less to worry about?

Yes, my general dentist removed this tooth. I've had a small partial made for me beforehand, which only has this tooth and another 2 teeth on the other side, which I've been missing for a long time. So I'm happy with this at the moment.

There's a bit more to the story and I thought it wasn't that important because there were no real conclusions, but here it is ...

The dentist was positive there was nothing up there or anywhere (I saw him a few times) ... but I kept asking and going back. He said there was no need for any further xrays. I even saw another (ie. different) oral surgeon who also said "hopefully there's nothing there ... you don't want me to go in there, it could make things worse". Why and how would it make things worse??? So again I got nowhere.

Then I spoke to my doctor and had a quick ultrasound of that maxillary sinus area and it confirmed "complex cyst / lesion with possible bone involvement". Pretty much the U/S confirmed what I've been saying all along, but it does not specify the exact location of the cyst, except for "immediately next to maxilla".
I saw the (first) OS again with that report, he then said he can almost feel the lump, and sent me to an ENT and for a CT.

I skipped all that and found another oral surgeon. He told me right away that he can see the tiny tiny 'pimple' / lump, even though it is all the way under the fold, high up above where the root apex was (I think there is a distance between this mini lump and where the apex was - WHY IS THAT, wouldn't the cyst/lump be where the tip of the root was??). You need to push your finger all the way to the very end (and a bit further) under the mucobuccosal fold to be able to feel it. The lump is not on the external/buccal/lips side but rather on the teeth side, high up under the nostril. Is that normal? Would he be able to reach it for surgery without cutting externally?

Anyhow, he said he needs to take it out. I asked him if I needed further imaging (as suggested in the U/Sound report), but he immediately said not really, he could do with plain xray of that area, or even nothing (he has my panorex). But later he still gave me a referral for CT, and we left it at that as I was a bit reluctant to have the CT on the day (and when I came home, even more so). He said cysts on anterior maxillary teeth are quite common and he removed some recently. Unfortunately, I left the radiograph with him for the time being.

By the way, this pimple/cyst/lump is quite firm to touch and does not move around. Is that of any significance? The first OS told me that this does not seem like a typical residual infection cyst. Would a CT really be able to differentiate between different types of cyst, would it have any extra diagnostic or treatment benefits??

[Siobhan]

Would it be really silly of me to skip the CT and go for the surgery without the surgeon not having proper internal images? Has anyone ever done this??

On the other hand, how did surgeons do this type of procedure before CT scans were invented/common??

[Bryanna]

Siobhan,

Thank you for providing more information.

Regarding the dental injection... please do not assume that if a dentist uses the "wand" infiltration system that the injection will be perfectly administered as the dentist can regulate the speed of the injection. I have worked with that system and there are times it fails to perform and/or it does not allow profound anesthesia because the injection may not be deep enough. That is not to say that it does not work okay most of the time .. .. it's just not a definitive fool proof system. Also, I have never personally known an oral surgeon who utilizes the system because they usually prefer full control over the injection and infiltration of the anesthetic. Irrelevant of how an injection is given, there are some areas of the mouth that are going to be more sensitive than others. The KEY to giving the least painful, safest and most effective dental injection is .... calculated and strategic position of the needle, administer the contents slow and steady and take a second to quickly pull back slightly on the plunger to make sure a vessel has not been hit. All dentists know to do these things but not all follow that protocol.

It is important that you speak to the oral surgeon if you are concerned about the type of anesthetic that he uses. Don't be shy to discuss this as many people who have allergies need to discuss this with him.

I think the CT would be helpful especially since there could be a sinus communication with this cyst. I think the os suggested that you see an ENT because he is not sure if the sinus is involved. As I mentioned before, the CT would give a deeper, clearer view of the location of the cyst. Without that "view" the os would have to estimate its location, depth and sinus involvement which could result in a larger incision and some otherwise unnecessary exploration.

So the os that you are going to have the surgery by did not take his own panorex xray? That is not ideal and here is why. A physical copy of a dental film is less diagnostic than a digital film that is sent directly from one dentist to another via the computer. A digital xray can be put into the imaging system of the computer and the dentist who is viewing it can temporarily alter the gray scale of that xray to give him an in depth view of certain areas. He can also zoom in on areas whereas on a physical copy he cannot do those things.

Prior to the advancement of multi slice CT scans, surgeons had to make an educated guess on the size, location and involvement of a cyst in the jaw bone or sinus area. Then they would make an incision based on that guess and feel around with various instruments for the right location. Thanks to the scans, that guesswork it taken out of it and the surgeries are less complicated.

Bryanna

Originally Posted by Siobhan

Thank you again, Bryanna.

I see, I shouldn't really be very firm on the epi since I don't want him to refuse to treat me! Better stick with the speed of the injection. I read somewhere that wands deliver the injection automatically at the exact best speed - is that correct? If he does use them (he's a proper real oral surgeon), does it really mean I have less to worry about?

Yes, my general dentist removed this tooth. I've had a small partial made for me beforehand, which only has this tooth and another 2 teeth on the other side, which I've been missing for a long time. So I'm happy with this at the moment.

There's a bit more to the story and I thought it wasn't that important because there were no real conclusions, but here it is ...

The dentist was positive there was nothing up there or anywhere (I saw him a few times) ... but I kept asking and going back. He said there was no need for any further xrays. I even saw another (ie. different) oral surgeon who also said "hopefully there's nothing there ... you don't want me to go in there, it could make things worse". Why and how would it make things worse??? So again I got nowhere.

Then I spoke to my doctor and had a quick ultrasound of that maxillary sinus area and it confirmed "complex cyst / lesion with possible bone involvement". Pretty much the U/S confirmed what I've been saying all along, but it does not specify the exact location of the cyst, except for "immediately next to maxilla".
I saw the (first) OS again with that report, he then said he can almost feel the lump, and sent me to an ENT and for a CT.

I skipped all that and found another oral surgeon. He told me right away that he can see the tiny tiny 'pimple' / lump, even though it is all the way under the fold, high up above where the root apex was (I think there is a distance between this mini lump and where the apex was - WHY IS THAT, wouldn't the cyst/lump be where the tip of the root was??). You need to push your finger all the way to the very end (and a bit further) under the mucobuccosal fold to be able to feel it. The lump is not on the external/buccal/lips side but rather on the teeth side, high up under the nostril. Is that normal? Would he be able to reach it for surgery without cutting externally?

Anyhow, he said he needs to take it out. I asked him if I needed further imaging (as suggested in the U/Sound report), but he immediately said not really, he could do with plain xray of that area, or even nothing (he has my panorex). But later he still gave me a referral for CT, and we left it at that as I was a bit reluctant to have the CT on the day (and when I came home, even more so). He said cysts on anterior maxillary teeth are quite common and he removed some recently. Unfortunately, I left the radiograph with him for the time being.

By the way, this pimple/cyst/lump is quite firm to touch and does not move around. Is that of any significance? The first OS told me that this does not seem like a typical residual infection cyst. Would a CT really be able to differentiate between different types of cyst, would it have any extra diagnostic or treatment benefits??

[Siobhan]

Thanks again Bryanna!

It was the first OS that sent me to the ENT. I did ask this new OS (the one who doesn't absolutely need the CT done) if I should see the ENT and he said "no need, once this is removed, everything will clear up including sinuses". He said that the sinus is "possibly" involved and it didn't bother him at all. It may be relevant to mention that this guy also teaches at University, so I would expect him to be abreast with new developments, more so than the previous OS (older person) who maybe is not really exposed to discussions with his colleagues (?).

Re. the panorex, the new OS immediately pointed to me the area of his concern (actually the same area that I asked my dentist and the first OS about, but they dismissed it). So that threw me away immediately, looked like he knew what he was seeing and talking about. Could there be so much difference between professionals!?!

Would a residual infection cyst be more mobile and soft, as opposed to mine which SEEMS to be more firm and "attached" to one spot?? Or maybe it also depends on the "stage" the cyst/abscess is in (early / mature with pus)??? I am only taking a stab here with my thinking.

[Bryanna]

Siobhan,

Like any profession, some are just better at certain things than others. However, without a multi dimensional view of the area, ANY dentist will be guessing at the size, location and depth of the cyst. He will also not have much of an idea about the sinus involvement until he starts to explore the area surgically. If you are comfortable with him relying solely on the limited information that the 2 dimensional (photo copy) panorex xray offers and understand that this could result in an incomplete removal of the cyst and uncertain sinus involvement, then skip the CT scan.

Because of my professional background, I am not automatically impressed by a dentist who teaches at a University for the simple reason that the teaching positions tend to be filled by someone who can teach textbook dentistry which does not necessarily mean their skill set is any better than anyone elses.

Regarding the comparison of an older dentist to a newer one..... there are numerous ways to look at that and most often a lay person would not be able to differentiate the practice format from one to the other. The older dentist has a lot more clinical experience and may practice old school dentistry which does not necessarily mean he is or is not well skilled. A younger dentist has less clinical experience and may or may not practice old school dentistry. It just depends on their individual education and how they are most comfortable working. It has also been my experience that most dentists socialize with their peers in both professional and private gatherings.

A cyst can be hard or soft, it can contain granulation tissue and/or pus, and it can also be deeply rooted and attached to other tissue. The cyst is not just free flowing in the bone.

I hope I have given you helpful information so that you are able to make an informed decision about the CT scan and the surgeon. Whatever you decide, I wish you all the best and I hope you will check back and let us know how you are doing.

Bryanna

Originally Posted by Siobhan

Thanks again Bryanna!

It was the first OS that sent me to the ENT. I did ask this new OS (the one who doesn't absolutely need the CT done) if I should see the ENT and he said "no need, once this is removed, everything will clear up including sinuses". He said that the sinus is "possibly" involved and it didn't bother him at all. It may be relevant to mention that this guy also teaches at University, so I would expect him to be abreast with new developments, more so than the previous OS (older person) who maybe is not really exposed to discussions with his colleagues (?).

Re. the panorex, the new OS immediately pointed to me the area of his concern (actually the same area that I asked my dentist and the first OS about, but they dismissed it). So that threw me away immediately, looked like he knew what he was seeing and talking about. Could there be so much difference between professionals!?!

Would a residual infection cyst be more mobile and soft, as opposed to mine which SEEMS to be more firm and "attached" to one spot?? Or maybe it also depends on the "stage" the cyst/abscess is in (early / mature with pus)??? I am only taking a stab here with my thinking.

[Siobhan]

Thanks Bryanna.

I completely understand the possibilities around doctors (who might be a better doctor and so on) and yes, I can't possibly determine who might be a better surgeon based on a few visits. Both of them have a nice manner and nice staff. I also know that the older doctor will only ever operate on the patient fully sedated under GA, regardless of the procedure. I don't know why is that.

About the CT, I figured I could just call and confirm how critical the CT is for him or not. Turns out it is not optional at all. I ended up going there to pick up some of my things that I accidentally left in their office and then had a quick talk and got another referral but for CB CT this time. I don't know which one is better for me in terms of radiation dose. All my investigations lead me to believe that the CB CT is higher radiation because the beam is cone (much wider).

So now I need to figure which is potentially the lesser evil for me. I only need to scan the upper jaw, so that is some consolation at least, but I am very nervous.