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Old 04-22-2017, 09:20 AM #1
toothless toothless is offline
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Default Surgical extraction of 1st molar

Hello,

I'm a male in late 20s and recently I've had a surgical extraction of tooth 46, which was endodontically treated 15 years ago and recently diagnosed as probably vertically cracked. It's my day two post-extraction and I'm still on pain killers, feel sick, I probably had fever, my hearbeat was crazy, I was shaking, and I am left with a giant hole in my mouth along with swelling on a lower jaw. It sucks.

I am bit sceptical about the diagnosis, used approach and the results, and in this regard I'd have few questions for you. But before asking, I'll write the whole story:

It all begun a half of year ago, when the gum around my first molar (46) got some kind of periodically appearing pimple on it, which occasionally released a bizzare tasting pus. At first I assumed it's a problem with a gum and that it'll go away. Unfortunately problem persisted, so I decided to visit my dentist. She said that the tissue around my tooth is inflamed. Then we tried with a week of applying and exchanging some kind of disinfection stuff in and around the tooth, along with putting needles in canals (RCT?) - while pus draining may have decreased, the pimple returned so eventually the problem was still there. She suggested that the infection may be due to fractured tooth, especially because tooth is dead, but such diagnosis can not be confirmed by xray. She proposed tooth extraction and sent me to oral surgeon to do the work, just in case, if there would be a complication as this can be only managed by an oral surgeon.

Then I visited oral surgeon. I asked him what he thinks about the problem and if we can save the tooth, but he didn't say much, except "that's a thing to be solved between your dentist and you, and I'm here just to do what I'm ordered to do". I still insisted to check the situation and he commented that tooth is likely cracked and if that's the case, it has to go out. Then he continued that I can get 2nd opinion by visiting endodontist.

So I decided to get a 2nd opinion and visited endodontist specialist. He said that in my case the inflammation around tooth can have two causes: periodontal disease or cracked tooth. He quickly excluded the periodontal disease and said that it's 95+% of chance that my tooth is vertically cracked, but this can not be seen on xray. He continued that situation is pretty much lost, as he can only fix problems sourcing from tip of roots, while he can't fix vertical fracture of tooth. He said that situation is lost and that the 46 has to be extracted.

Now the most suspicious part. I reported back to oral surgeon for extraction. The procedure took suspiciously long and it seemed to be very complicated just to get one 46 out. Soft tissue cutting, bone cutting and I got a feeling that I was on that chair for ages. For comparision - I already had surgical extraction of tooth 36 and it was way shorter and simpler. In the time of my elementary school, tooth 36 was surgically removed due to failed endo treatment (tooth cracked as my young dentist apparently made a mistake while she was playing with those little needles). Then I was sent to surgeon. He took one big scarry drill that one can use to drill a channel for electrical cables, but we were done in few minutes. Waiting anaesthethic for an effect was the longest part. It didn't hurt much in the next days, neither there was much swelling and the occured gap was way smaller. I didn't need any painkillers. Everything was very smooth and the surgeon got that "just another day in the office" expression.

But this time, the procedure lasted way longer and surgeon (other one) used some bizzare tools which apparently didn't have any rotary parts (I didn't see them, as I was blindfolded), but sounded like air blowing. I didn't hear anything like pliers. And when I read, which were the steps undertaken in the procedure as described in post-op report, there were bunch of scary words: tooth separation, osteotomy, buch of cuts..etc. For my understanding, guy dismantled the whole tooth and the bone, and this sounds way too much of work for a such straightforward task.

When the procedure was finished, I asked surgeon which part of tooth was cracked in order to confirm theory set up by my my dentist and endodontist (again, they diagnosis was based on prediction). He only replied with: "Probably the left-back root, as it came out the easiest." Probably? This word again?This quickly rose a potential redflag for me, because whether tooth is cracked or not, should be obvious, so I was left without confirmation of initial diagnosis.

Now the questions:
1. Was the tooth extraction truly neccesary?
2. Werediagnostics of vertical fracture done correctly?
3. Why surgeon didn't know or didn't want to tell whether tooth was broken or not?
4. Have surgeon used too agressive approach to get the tooth out?Honestly, I expected only a simple extraction, while (complex) surgical removal would be undertaken only in a case, if some piece of tooth would stay below gums.

5. What should I do with my gap in the teeth? What functional and aesthethic consequences can develop, if I leave the gap as it is?

Please tolerate my english, because i'm not a native english speaker.

xrays can be found here: ***
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Old 04-22-2017, 09:42 AM #2
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Hi there
As a new member, you won't be able to post links yet...but you can upload a photo of your xray using the Attach Files option below the posting box.
Just be sure to block out any personal info from your xray first!
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Bryanna (04-22-2017), toothless (04-23-2017)
Old 04-22-2017, 02:21 PM #3
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Hi toothless,

You can expect to have some pain, swelling, drainage and a large open wound with this type of infection and oral surgery for a few days. If you develop a fever over 100, swollen glands, extreme swelling of the face, swelling of the tongue, or other exaggerated symptoms, call the oral surgeon as soon as possible. A rapid heartbeat is typical of an oral infection such as yours. But it can also occur from medications, anxiety and exercise. You should refrain from all forms of cardiovascular exercise until this surgical site heals more because with exercise the heart pumps blood more forcibly to the arteries and any surgical wound will become susceptible to over stimulation of that volume of blood.

Do you smoke? If so, stop. The mechanical act of smoking draws suction from the open wound and can disturb the formation of the clot resulting in a painful condition called dry socket. The multitude of toxic chemicals in tobacco can infect the wound, contaminate the jaw bone and prevent the bone from closing completely. This can lead to ischemia and a necrotizing condition of the jaw bone called Osteonecrosis and Osteomyelitits which can be difficult to eradicate.

Do not rinse with any type of mouthwash. The alcohol and chemicals in mouthwash cause irritation, secondary infection and slow down the healing process. Gently rinse 3 times a day with warm salt water, no mouthwash. It is important to brush 2 times a day, floss once a day and scrape your tongue once a day to reduce the amount of plaque in your mouth and on your teeth. A clean mouth will heal faster.

Let me offer some clarification which will help clear up some of your uncertainties about what occurred prior to the extraction and why the extraction was warranted.

The pimple on the gum that exuded pus was called a Fistula. This is NOT an infection of the gum. It is the result of a severely infected tooth. A Fistula is the opening of a tract of infection that is draining from the inside of an infected tooth. Meaning, the infection overwhelms the tooth and proliferates beyond the tooth. The infection burrows a hole through the bone from the tooth, and will often come through an opening of the gum which is called a Fistula. There is no palliative care or topical treatment that can cure the fistula because the source of the fistula is the infected tooth.

Endodontic (root canal) therapy, is not a cure for an infected tooth. It is a temporary measure, at best, to try and retain an infected tooth. Every tooth has many hundreds of microscopic canals that contain nerve tissue. These canals are not accessible, therefore, irrelevant of what is done to the tooth, the nerve tissue inside of these canals remains infected. Eventually, the infection overwhelms the tooth and proliferates beyond the tooth.

Not all tooth fractures can cause pain. Not all tooth fractures can be seen on dental xrays. Here are a few ways a tooth can fracture:

1) Direct injury to the tooth but also frequently occurrs during a root canal treatment.
2) Infection, certain medications, poor diet, and nutrient deficiencies can lead to a deterioration of the integrity of a tooth making it weak and prone to fracture upon chewing.
3) A bruxism habit can cause various types of tooth fractures.

I will copy your specific questions and then answer them in LARGE type.

Now the questions:
<<1. Was the tooth extraction truly neccesary?>>

YES, WITHOUT QUESTION.

<<2. Werediagnostics of vertical fracture done correctly?>>

YES. A VERTICAL FRACTURE TYPICALLY CAUSES NO SYMPTOMS AT THE ONSET OF THE FRACTURE BUT EVENTUALLY CAUSES THE EXACT SYMPTOMS YOU BEGAN HAVING 6+ MONTHS AGO. VERTICAL FRACTURES THAT ARE NOT DISPLACED CAN BE TOUGH TO DIAGNOSE VIA A DENTAL XRAY BECAUSE THE XRAYS ARE ONLY 2 DIMENSIONAL. EVEN A MULTI SLICED CT SCAN MIGHT NOT PICK UP A NON DISPLACED VERTICAL FRACTURE IN A TOOTH.

<<3. Why surgeon didn't know or didn't want to tell whether tooth was broken or not?>>

GIVEN THE EXPLANATION THAT I DID ABOVE PERTAINING TO ROOT CANAL THERAPY, TOOTH #46 WAS ACTUALLY INFECTED FOR 15+ YEARS FROM THE TIME IT WAS ROOT CANALED. IT IS NOT UNUSUAL FOR AN INFECTED TOOTH TO HAVE LITTLE TO NO SYMPTOMS UNTIL THE INFECTION OVERWHELMS THE TOOTH AND BONE. THE EXTRACTION OF AN INFECTED TOOTH CAN BE COMPLICATED BECAUSE THE TOOTH IS WEAK AND PIECES OF IT FRACTURE OFF DURING THE PROCEDURE. THERE IS OFTEN A LOT OF INFECTED BONE AND INFECTED TISSUE ENCASING THE TOOTH WHICH MAKES IT DIFFICULT TO GRAB HOLD OF THE FRAGILE TOOTH. SO WHEN PIECES OF THE TOOTH BREAK OFF, SOMETIMES THEY ARE SLIVERS OR FRAGMENTS OF TOOTH AND JAW BONE WHICH CAN MAKE IT DIFFICULT TO SEE OR DIAGNOSE WHERE THE ORIGINAL FRACTURE(S) WERE.

<<4. Have surgeon used too agressive approach to get the tooth out?Honestly, I expected only a simple extraction, while (complex) surgical removal would be undertaken only in a case, if some piece of tooth would stay below gums.>>

NO, IT SOUNDS LIKE HE DID WHAT NEEDED TO BE DONE. YOUR TOOTH WAS IN BAD SHAPE AND WOULD NOT BE CONSIDERED, IN DENTAL TERMS, A SIMPLE EXTRACTION. MOST EXTRACTIONS INVOLVING A BADLY INFECTED TOOTH ARE COMPLEX IN THAT THE TOOTH AND BONE ARE BOTH FRAGILE. THE COMPLEXITY OF THE PROCEDURE DEPENDS ON THE CONDITION OF THE TOOTH, THE BONE, THE SEVERITY OF THE INFECTION, IF IT IS FRACTURED AND THE ANATOMY OF THE PATIENT.

<<5. What should I do with my gap in the teeth? What functional and aesthethic consequences can develop, if I leave the gap as it is?>>

YOU SAID THIS WAS TOOTH #46. IN THE FDI TOOTH NUMBERING SYSTEM THAT IS YOUR LOWER RIGHT FIRST MOLAR. YOU ALSO MENTIONED THAT YOU HAD TOOTH #36 REMOVED WHICH IS YOUR LOWER LEFT FIRST MOLAR. DID YOU REPLACE #36?

REPLACEMENT OPTIONS DEPEND ON THE REST OF YOUR PERMANENT DENTITION AS TO WHAT OTHER TEETH ARE PRESENT AND WHAT OTHER TEETH ARE MISSING. IF YOU HAVE YOUR 2ND AND 3RD MOLARS ON THE BOTTOM AND YOU LEAVE THE FIRST MOLAR SPACES OPEN, THEN THE SECOND MOLAR WILL EVENTUALLY TILT TOWARDS THE OPEN SPACE. THE 3RD MOLAR MAY MOVE OR MAY NOT MOVE. IF YOU HAVE UPPER FIRST MOLARS, THEY MAY TEND TO DRIFT DOWNWARD INTO THE OPEN SPACE BELOW. USUALLY THE UPPER TEETH WILL EVENTUALLY STOP DRIFTING DOWN IF THEY ARE IN DIRECT CONTACT WITH THE THE OTHER LOWER MOLARS.

<<Please tolerate my english, because i'm not a native english speaker.>>

YOUR ENGLISH IS FINE.... NO WORRIES ABOUT THAT!

<<xrays can be found here:>>

YOU HAVE TO ATTACH YOUR XRAYS OR PHOTOS AS AN ATTACHMENT. SO THAT WOULD MEAN DOWNLOADING THEM FIRST TO YOUR COMPUTER AND THEN ATTACHING THEM AS SUCH.
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***I have been in the dental profession for 4 decades. I am an educator and Certified Dental Assistant extensively experienced in chair side assisting and dental radiography. The information that I provide here is my opinion based on my education and professional experience. It is not meant to be taken as medical advice.***
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toothless (04-23-2017)
Old 04-23-2017, 03:27 AM #4
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Much thanks for you effort and in-detail answer.

Quote:
Originally Posted by Bryanna View Post
Hi toothless,

... A rapid heartbeat is typical of an oral infection such as yours. But it can also occur from medications, anxiety and exercise. ...
What is the cause of so fast heartbeat? It made up woke up few times per night. Honestly I think I didn't take that much painkillers (2 tablets per day) or any other medication. In the past I have consumed larger quantities, but have never had so fast heartrate, so I'd guess that the crazy heart rate occured due to other factors. All what I can tell is, that based on post-op report, I have received 3 remedies (Xylocain spray, 3ml Ultracain, 1ml Ultracain), if this is relevant information.

I still feel the slight pressure or beter said some kind of discomfort in my chest area, and occasionally some short spike of something that may be considered as small pain, especially if I do some fast moves.

Other than that, I am following all post-op protocol as you have describe it.

The pimple on the gum that exuded pus was called a Fistula. This is NOT an infection of the gum. It is the result of a severely infected tooth. A Fistula is the opening of a tract of infection that is draining from the inside of an infected tooth. Meaning, the infection overwhelms the tooth and proliferates beyond the tooth. The infection burrows a hole through the bone from the tooth, and will often come through an opening of the gum which is called a Fistula. There is no palliative care or topical treatment that can cure the fistula because the source of the fistula is the infected tooth.

Quote:
Endodontic (root canal) therapy, is not a cure for an infected tooth. It is a temporary measure, at best, to try and retain an infected tooth. Every tooth has many hundreds of microscopic canals that contain nerve tissue. These canals are not accessible, therefore, irrelevant of what is done to the tooth, the nerve tissue inside of these canals remains infected. Eventually, the infection overwhelms the tooth and proliferates beyond the tooth.

Not all tooth fractures can cause pain. Not all tooth fractures can be seen on dental xrays. Here are a few ways a tooth can fracture:

1) Direct injury to the tooth but also frequently occurrs during a root canal treatment.
2) Infection, certain medications, poor diet, and nutrient deficiencies can lead to a deterioration of the integrity of a tooth making it weak and prone to fracture upon chewing.
3) A bruxism habit can cause various types of tooth fractures.

GIVEN THE EXPLANATION THAT I DID ABOVE PERTAINING TO ROOT CANAL THERAPY, TOOTH #46 WAS ACTUALLY INFECTED FOR 15+ YEARS FROM THE TIME IT WAS ROOT CANALED. IT IS NOT UNUSUAL FOR AN INFECTED TOOTH TO HAVE LITTLE TO NO SYMPTOMS UNTIL THE INFECTION OVERWHELMS THE TOOTH AND BONE.

A VERTICAL FRACTURE TYPICALLY CAUSES NO SYMPTOMS AT THE ONSET OF THE FRACTURE BUT EVENTUALLY CAUSES THE EXACT SYMPTOMS YOU BEGAN HAVING 6+ MONTHS AGO. VERTICAL FRACTURES THAT ARE NOT DISPLACED CAN BE TOUGH TO DIAGNOSE VIA A DENTAL XRAY BECAUSE THE XRAYS ARE ONLY 2 DIMENSIONAL. EVEN A MULTI SLICED CT SCAN MIGHT NOT PICK UP A NON DISPLACED VERTICAL FRACTURE IN A TOOTH.
So if I try to compile the above information to get the whole picture of my case:

If a tooth undergoes RCT, this by default means, that tooth is infected and an attempt is made to save the tooth. RCT won't heal tooth, but it will only remove high portion of infected tisssue so that a chance of a large scale infection is decreased (but not prevented!), and that tooth is (temporarly) retained. After successfull RCT, there would be still some infected tissue remaining in tooth (the large number of tiny nerves), but as the amount of this tissue is small, tooth can function normally without causing any troubles, as long as the infection doesn't spread. However, this small infection can spread out of nowhere any time, and if that happens, it's game over, as large scale infection may be IRREVERSIBLE? So eventually, any RTCed tooth may be like a time bomb.

As I had RCT treatment of tooth 15 years ago, this means that 15 years ago tooth was already infected. But as the large scale infection occured only recently, the "root cause analysis" would be (pun intended ):

a large scale infection occured in the tooth, without any fracture being present. Still not sure how that would be possible, because you probably need a hole in the tooth so the infection spreads on the sorrounding bone.

b1) Tooth was already fractured during 1st RCT (15 yrs ago) or during any other following RCT (if there was any, but I can't recall). During all this years fracture was progressing (mechanical stress, nutrition, detoriation of dead tooth...) until it was big enough, or until it caused a larger crack to occur, which triggered a major infection.

b2) Tooth was fractured/cracked only recently, which triggered a major infection.

d) tooth wasn't infected, but only the bone around it was (pariodontal disease?). However this point was immediately ruled out by endodontist, so it's either a), b1) or b2)

But regardless of reason a) or b1) or b2), the end result is the same - the large scale infection in the tooth. At this state, no amount of disinfection/RCT attempt could be able to scale down the infection back to initial state. Or in other words, the state became irreversible, therefore an extraction was the only option.

Again, to make things crystall-clear: Infection of such scale is irreversible and can not be scaled down to initial state?

Quote:
<<5. What should I do with my gap in the teeth? What functional and aesthethic consequences can develop, if I leave the gap as it is?>>

YOU SAID THIS WAS TOOTH #46. IN THE FDI TOOTH NUMBERING SYSTEM THAT IS YOUR LOWER RIGHT FIRST MOLAR. YOU ALSO MENTIONED THAT YOU HAD TOOTH #36 REMOVED WHICH IS YOUR LOWER LEFT FIRST MOLAR. DID YOU REPLACE #36?
No. Maybe that was a big mistake. But honestly, nobody ever came up with idea to replace it (meanwhile I have changed 2 dentists).

Quote:
REPLACEMENT OPTIONS DEPEND ON THE REST OF YOUR PERMANENT DENTITION AS TO WHAT OTHER TEETH ARE PRESENT AND WHAT OTHER TEETH ARE MISSING. IF YOU HAVE YOUR 2ND AND 3RD MOLARS ON THE BOTTOM AND YOU LEAVE THE FIRST MOLAR SPACES OPEN, THEN THE SECOND MOLAR WILL EVENTUALLY TILT TOWARDS THE OPEN SPACE. THE 3RD MOLAR MAY MOVE OR MAY NOT MOVE. IF YOU HAVE UPPER FIRST MOLARS, THEY MAY TEND TO DRIFT DOWNWARD INTO THE OPEN SPACE BELOW. USUALLY THE UPPER TEETH WILL EVENTUALLY STOP DRIFTING DOWN IF THEY ARE IN DIRECT CONTACT WITH THE THE OTHER LOWER MOLARS.
And what's the final effect on facial appearance and function? Assymetry? Crossbite? Harder chewing? Bone loss? Etc...


Quote:
YOU HAVE TO ATTACH YOUR XRAYS OR PHOTOS AS AN ATTACHMENT. SO THAT WOULD MEAN DOWNLOADING THEM FIRST TO YOUR COMPUTER AND THEN ATTACHING THEM AS SUCH.
At this moment, I can't, as I'm not sure whether I'd be able to remove them later or not. I'll just send you a PM with pics.
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