BRYANNA - I really need your professional advice. I have suffered with facial pain and eye pain for over 20 years on my left side prior to a root canal and afterwards. The tooth then had an apicoectomy about 18 years ago which left me with constant sinus pressure.
Two years ago the tooth then had another root canal by a very experienced Endodontists after a small infection showed at my six monthly check up. This made everything worse I kept returning complaining of pain but was told to leave the tooth to settle down I was put on amitriptyline and pregabalin by the dental school until eventually a fistula formed. (this story is the short version)
Two years after root canal and an Xray at the dental hospital which showed infection the tooth was removed. I payed privately for a very experienced oral surgeon which was 8 weeks ago. I am in worse pain now then before and again I was told to let it settle down. It hasn't. The oral surgeon has referred me to a neurologist for pain medication. However I took it upon myself to seek another opinion of an oral surgeon, he did another X-ray, which I have attached (there is a small piece of amalgam in the socket from the apicoectomy) and also a 3D scan which showed a very small sinus communication which he said should heal on its own as there is no nasal discharge. His advice was to leave alone and see if the area heals or to go back in and clean the socket. Please advice Bryanna. this is completely ruining my life being in constant pain.

Did you have silver filling in the crown of that root canaled tooth?

No, the amalgam is from an apicoectomy many years earlier and the amalgam actually sat on top of the tooth root but it has not been removed when the tooth was extracted.

Hi Jamm,

Thanks for the xray.

Here's what I see on the xray..

1) A root canaled pre molar with radio graphic pathology. Did that tooth have an apicoectomy? It looks like it may have due to the blunting of the root tip..... OR the gutta percha perforated the apex. Either way, there is a cyst at the apex.

2) There is a moderate size piece of mercury lodged in the extraction site. This was likely the mercury blob that was placed at the apex of that extracted molar when the apico was done. Ideally the oral surgeon should have removed that mercury when he extracted the tooth. Really there is no excuse for leaving it there.

3) There are other small fragments of mercury scattered about which would be difficult to remove as they become embedded in the tissue.

4) There is a moderate area above the mercury blob that is suspicious. May be an infection and that may be where the sinus is involved.

5) Not sure of the health of the last molar. That tooth needs another xray taken at a bisecting angle.

6) All of these problems are likely apparent on the 3D scan.

You have a long history of dental infection in that quadrant of your mouth because root canal therapy and apicoectomies do not cure an infected tooth. The dentin tubules will remain infected with trapped nerve tissue irrelevant of how perfect either of those procedures are done.

This is not going to settle down on it's own because .....

1) There is a blob of toxic mercury stuck in the surgical site that will prevent healing.
2) There is pathology and infection with the pre molar as well as in the surgical site of the extracted molar.

The oral surgeon should have informed you of the problems with the pre molar and he should have been MUCH more thorough with the extraction and debridement of the molar. The problems you have are not going to heal in time. They require intervention.

Medicating you to kill the pain, is only a band aid at the very least.
I am really sorry your dentist has not informed you of these things. Your choices are to go back to the oral surgeon that botched up the molar extraction or see a different one and explain you want a thorough debridement of the surgical socket.

I know this is depressing news...... but I hope it is helpful to you.

Bryanna

Bryanna, thankyou so much for your reply and taking the time to advice me I have been reading the advice you give to people on this site for over two years, Just wish this kind of information was available may years ago as unfortunately you do not question what the dentist advices especially when you are younger.
I paid privately to have the tooth with the apioceptamy removed by a very respected and experienced oral and maxillofacial surgeon because I was fully aware about complications removing these kind of teeth from information provided by yourself.
Here is the problem I am now facing, when the tooth was removed it took all of two minutes and there was no X-ray present at the time, the surgeon informed me there was a granuloma on the extracted tooth. I returned to him two more times one which he charged me for! I complained of continued pain in the area I asked him specifically if there could be remaining root fragments in the socket as it was uncomfortable and he assured me there wasn't as he had a good look in the socket and he advised me to let it settle and he would send me to a neurologist for pain management. He did not take a post extraction xray.
I have emailed him a copy of the X-ray and I am awaiting his reply.
The second oral surgeon said we could monitor the site or go back in remove the amalgam and clear out the area which looks like scar tissue and maybe risidual infection but the risks are maybe damaging the back tooth or opening the sinus communication more so that it becomes permanent. He also spoke a drilling the bone to make a blood clot.
My trust in dentistry here in the UK has completely gone!!
Do I go back to the original surgeon and ask him to complete the surgery? or stick with second oral surgeon who I no nothing about. Do I present myself at the local dental school? I want the best possible outcome as this is having a massive impact on my daily life.

By the way the pre molar was a perfectly healthy tooth but due to continued pain around that area over the years a previous dentist decided to fill and eventually root canal it.

Thankyou again for responding to my post it means so much to me.

Hi Jamm,

I understand that you paid privately.... I often suggest that people take that route because the care is often higher quality and more individualized. I still feel that is usually the best way to go over a dental school or insurance based practitioner.

However, in the case of your first oral surgeon..... to extract a tooth without an xray is a huge NO NO as you cannot possibly know what you are getting into without that xray. That is why the surgery was so quick because he did not debride the area... because he didn't know the full extent of what was there. Secondly, ALL tooth extractions REQUIRE a thorough surgical debridement, there are no exceptions to that rule. Unfortunately, this step is not routinely done as it is suppose to be. The granuloma he referred to was a clear indication that there was more happening in that site which needed further investigation (an xray) and debridement.

What the second oral surgeon is referring to as scar tissue is most likely infection and granulation tissue. Scar tissue does not have the exact appearance as infection, which is pretty obvious on your xray. He may be making that reference to avoid further questions from you about why the first OS didn't do a more thorough debridement.

The concern about having permanent damage is two fold:

1) Without question it is never healthy to have an infection in your jawbone and especially one that has traveled to the sinus cavity. In your case you have at least 4 issues that are contributing to the bacterial problem. One is the root canaled pre molar, the second is the dirty extraction site, the third is the toxic mercury sitting in the surgical site and the fourth is the sinus perforation which is not likely to heal unless the other issues are taken care of.

2) Permanent damage can occur from long term infection (ie root canaled teeth, non debrided extraction sites and chronic sinus involvement). It can also occur from deterioration of the jaw bone due to the proliferation of infectious bacteria. All of which can make the person very ill beyond the original source of the infection.

3) At some point this quadrant of your mouth.... the rc tooth/the infected extraction site/the blob of mercury/ the sinuses.... will have to be addressed. The more deterioration that occurs, the more prolific the infection will become and the more likely it will become a systemic health concern.

Based on all of those things going on and in addition to the length of time that there has been infection in that quadrant (20 years), if the surgery is done now there is a possibility of some damage occurring with the surgical intervention, but no one can tell you if it would be temporary or permanent.
There are also no guarantees that the surgical intervention would be able to cure the infection in it's entirety because the bacteria may be hidden and not yet visible clinically or radio graphically.

The options are....

1) Wait and let it proliferate and be medicated for the pain.
2) Do not wait. Debride and remove the visible sources of the infection and the mercury giving you a better chance of a healthier, more complete recovery.

I know people think they have to just trust their dentist to always do the right or best thing. However, as much as you have no choice but to trust the skills and knowledge of the dentist, it is imperative to remain your own advocate and use your voice to make your concerns and expectations clear.

Again, I hope this info is helpful to you.
Bryanna

Bryanna,

Thank you once again for your quick response and expert advice.
I will definitely be having a thorough surgical debridement of the area and will keep you updated on the outcome.

Have a fantastic day

Jamm,

I just want to mention, or reiterate, that the root canaled pre molar in that quadrant is a source of chronic infection and it does have radio graphic pathology at the apex.... which you may be inaccurately told is scar tissue. Infection, such as this tooth, can prevent healing from any type of surgical intervention you have in that molar area and sinus. This risk includes a less than successful healthy integration of a dental implant if you were to consider that in that molar area sometime in the future.

I just wanted you to be aware of that.
Bryanna

Hi Bryanna,

Thank you again for this information especially regarding the pre molar as no endodontologist, oral surgeon or dentist has mentioned an issue with this tooth although after reading many of your posts I am aware that it is a tooth with a root canal and will stay chronically infected.
I will mention this pre molar issue on my next visit to the oral surgeon. I wish I had contacted you many years ago as I truly believe the information you are providing me with is completely accurate and honest in relation to my oral health which is what I want.

Can I please ask you one more question regarding the extraction site,

Due to the fact that I have no follow-up appointments with the original oral surgeon who extracted the molar, because he has referred me on to a neurologist for pain management.
Does he have a legal responsibility to reply to the email I have sent to him regarding my concerns with the attached X-ray and is it his responsibility to remove the amalgam at no extra cost due to the fact that debris from the extracted tooth is still in the socket.

On my last visit to this oral surgeon I actually explained that one of the symptoms I felt apart from continued pain was a feeling that the tooth was not completely removed and could there possibly be a broken bit of tooth in the socket (I did not even think about amalgam I actually meant bone). He assured me not as he managed to look inside the socket.

It was only this continued discomfort in the socket that forced me to get a second opinion and an Xray which showed the amalgam fragment.

Thank you once again.

Jamm

Hi Jamm,

Conventional, mainstream dentistry including all areas of it even specialists, do not advocate removing root canaled teeth or admit that root canaled teeth are chronically infected because they were taught to "SAVE" teeth... meaning retain, not cure ..... and to keep the teeth and in many cases no matter what. Also, if mainstream dentists were to admit the bacterial infections in root canal teeth as being problematic, they would lose A LOT of money because people may choose not to do the root canal. Mainstream dentists, general and endodontists, rely on root canal therapy as a main portion of their financial earnings. That is a tough thing to give up or even curtail a bit. So until dental implants become the "go to" procedure instead of root canal therapy, dentists will continue to promote them.

I am telling you that because the OS is going to say there is nothing wrong with your pre molar if you are not having specific pain in it. The pathology on the xray is typical with a rc teeth and although it is bacterial and infectious, it is considered expected to be seen. Until your pain can be pinpointed to that tooth or you develop a large abscess, which neither may ever occur in that specific area, most mainstream dentists will tell you to keep that tooth. The irony of that has to do with the systemic connection and how oral health is directly correlated with every system of the body. Meaning oral infections are not limited to the mouth as the bacteria travels through the blood stream, lymphatic system, etc.

To answer your legal question about the first OS....
He is legally obligated to reply to you and here's why. You are a patient of his record in the sense that he performed oral surgery on you and you have been back to him with ongoing and unresolved problems since. He could have said let's go back in there and clean this up... with no additional charge to you because it should have been done at the time of the extraction.
The issues is that he knows it has now become obvious that he should not have extracted the tooth without an xray and that the surgery was incomplete. He was correct in that there does not appear to be any tooth remnants in the socket but the mercury should, without question, have been removed. So to put it bluntly he may be hoping that if he ignores you, someone else will clean up his mess. At this point, I would be hesitant to see him for any further dentistry because his first surgery was less than ideal and he's not being forthcoming with you about the reality of the situation ..:-/

Here's what you can do...
First, keep really good records of everything. if you haven't done that, then write down dates, appointments and $$ that you have some record of.

Second...
See oral surgeon #2 for the extraction of the premolar (if that is what you choose) and let him do a thorough debridement of the extraction site including removal of the mercury and sinus clean out. Pay for it.

Three..
Get a copy of the detailed surgical report from OS #2.
Send OS #1 a copy of that report with a copy of the bill for the debridement, mercury removal and sinus, with a letter stating you want him to reimbursement you for the oral surgery that was needed to thoroughly perform the surgery that he neglected to do at the time of the molar extraction.

***Make sure the letter is certified, signature requested mail and also send the same letter via regular mail. In your letter give him a date that he needs to pay you by and state in the letter "to avoid taking action with the General Dental Council or Dental Board", whatever it is called in the UK.

Taking action with them is not the same as a law suit. It is you requesting forms to file a complaint and your submitting paperwork to them describing from your records.. dates.... $$... surgery done without radio graph... repeat appointments for complaints... etc... and how that eventually led to a necessary secondary surgery done by Dr ___ for the cost of $_____ on date.

DO NOT mention anything to OS #2 about the possibility of taking action against OS #1 or requesting reimbursement from OS #1 because giving him that knowledge may cause him to bail out on you.

I am sorry you are going through this. But you have every right to seek proper dental care and the only choice you have is to become your own advocate.

If you are interested in learning about oral and systemic infections you can purchase a (laymen's) book written by Dr Robert Kulacz (dentist) and Dr Tom Levy (cardiologist) called "The Toxic Tooth, how a root canal could be making you sick".


Bryanna