Waterpik'd an exposed bone graft - did I infect it?
 

Hi,

Pretty scared right now.

Some background:
I had an implant attempted on site #10. It failed and was extracted. On about October 2nd (8 months later), my dentist put in a bone graft. But he took the stitches out a bit too early, and the membrane of the graft became exposed.
He said he wanted me to leave it in as long as possible and prevent it from being infected for at least another couple months.
So I put chlorhexidine on twice a day and everything seemed to be fine. The gum tissue above the site (ventral to me) was very thin, and I could kinda see the graft through it.

Last night, I was using my waterpik and for the first time accidentally grazed the site. It looked a little purple around the bone graft area but there was no blood. I put some chlorhexidine on the site about a half hour later and went to bed.

This morning, the site feels a little... fat. Like it's swollen. Looks a little redder, as well. When I press on the site right at the bottom of my nose, it feels more inflamed than usual. I'm scared that the water from the waterpik might have gotten past the membrane and infected the whole site.

I can't contact my dentist until Monday, so I feel dead in the water. What if it gets worse by then? If it IS infected, can I kill it with Amoxicillin? I'm sitting on a Amoxicillin 500mg prescription, given in case the gum site split while I was travelling. Should I fill it and start taking it ASAP?

Don't know what to do... Any guidance as to what's going on/whether I should wait until Monday would be a great help.

Hi Orthoptera,

If you wouldn't mind offering a bit more information to help clarify the dental history of #10 ......
Was tooth #10 a root canaled tooth? If so, how long ago was it root canaled? Had it ever been re treated with a second root canal and/or a surgery called an apicoectomy? Are the adjacent teeth root canaled?

In the meantime, if you cannot get a hold of your dentist until Monday, it may behoove you to start that antibiotic if the #10 site does not improve by this afternoon. Depending on the history of this tooth and the adjacent teeth, there would be different reasons for the failed implant and current symptoms.

Bryanna

Hi Bryanna, thanks for the fast reply.

Yes, it was root canaled twice. The first time was in late 2009 or early 2010. It was then re-root canaled in early 2012. (I did not have an apicoectomy.)
Later, in spring of 2014, it broke. I was traveling at the time and by the time I saw the dentist to have an extraction, it had an abscess. Needless to say, there's not a whole lot of bone in the site. (Hence having this graft).

BTW, I'm only 26 years old, if that makes any difference in the matter.

Could taking the antibiotic actually help clear out the infection, or would it only help keep it in check until the graft is removed?

I have had a lot of antibiotics for this past couple years, and am very worried for the health of my gut microbiome. I've started to become scared/hesitant of taking antibiotics, so I guess the question is, if I DID wait to have it checked out first, just to make sure... would that make a big difference?

Yeah I've wondered if I have some kind of lingering infection in the area since I keep having all these problems. However, the timing of the waterpic slip-up last night and these symptoms seems WAY too perfect for it to not have something to do with it. It seemed completely infection-free yesterday.



Hope this is enough info, thanks again for your time.

Oh, I forgot to answer your question about neighboring teeth. Both of them have never had a root canal, they are "whole." They do have fillings, though.

Oh my. :o

.....

Orthoptera,

Thank you for providing the additional information.

So to reiterate, tooth #10 was root canaled twice within 2 year period, it broke 2 years later and then abscessed. You had a dental implant placed which failed soon there after and then a second attempt at the graft and implant was done recently. You have had on going symptoms of an "infection" for a few years and have been prescribed antibiotics.

What that history generally indicates is that tooth #10 had been actively infected since at least 2009/2010 as a re-treatment of a second root canal procedure does not favorably alter the bacterial infection inside the dentin tubules. So between 2009 and 2014 the bacteria was spreading from the dentin tubules into the jaw bone.

You stated << The gum tissue above the site (ventral to me) was very thin, and I could kinda see the graft through it.>>

This finding indicates, just as you have suspected, a void in the bone which is referred to as bone loss and it is due to the long term presence of the infected tooth. The bony cartilage above the upper anterior teeth, #'s 7-10, is much thinner compared to other areas of the maxilla. Once the buccal plate or portion of this area of bone is lost, there is nothing more than thin gum tissue in it's place. Bone grafting material that is placed in an area where the buccal plate is gone is only being held in by lingual bone and gum tissue. This situation is not very stable as the purpose of the graft is to encourage your own bone cells to grow and integrate with the graft to form a more dense platform to place the dental implant into. However, bone cannot grow in or from gum tissue. This is likely the reason the first implant failed and to be honest it is heroic to attempt it again as the circumstances of the original bone loss has not changed.

It sounds like your dentist was wanting you to baby this area due to the delicate nature of the situation and the high probability of failure. However, in all probability hitting it with the water pik did not cause anything to fail but it may have just sped up the process. Taking the antibiotic can reduce the inflammation in that area but it cannot aid in the growth of new bone.

You mentioned gut microbiome so I assume you are aware that antibiotics destroy the healthy intestinal flora. If you decide to take the meds, or even if you don't, please consider supplementing with a probiotic to replenish some good bacteria in your intestinal tract.

Wish I could be more of a help. Your dental situation is not an easy one to restore with a dental implant as there is no fail proof way of rebuilding the buccal portion of the bone that was lost from the tooth infection.

I assume you are wearing a removable partial?

Bryanna

Close. I do not currently have an implant in the site yet. The second attempt is planned this Spring. My dentist had intended to use a procedure called "ridge splitting" and put a thin implant in.

I actually did have a "collaplug" inserted when the failed implant was taken out. A day later, it "worked its way out" (there was a lot of inflammation in the area and it kind of... popped out of my gum).

So are you saying that the is still infected? Is there any way to treat this bone infection? Are there ways for periodontists to spot it? Do I have to worry about it spreading to other teeth?

Does this mean that my only "safe" option is a bridge?

I haven't taken an antibiotic quite yet. Interestingly, this morning it is definitely better. Swelling is down. The neighboring tooth, however (#11) feels kinda... weird. I noticed the inflammation was just as present and tender above it last night. I hope that doesn't mean that whatever this issue is is affecting a healthy tooth. :(

I definitely would, but from what I've read, gut flora is permanently altered from antibiotics and the role of probiotics is questionable. I still take one during antibiotics (and often without) just in case, but I don't have a huge amount of confidence in them.

Thank you for trying to help me understand my situation better! If you were in my situation, would you get a bridge instead?
One thing I do want to add is that I did have a very similar situation happen with tooth #7. Root canaled around the same time, re-root-canaled at exactly the same time, broke at around the same time, got infected (AGAIN when I wasn't home), and had an implant placed. The implant was successful and I've had a crown on it for almost 2 months now. So far so good. I guess that gives me some hope. Obviously the degree of infection could have been different enough on #7 than on #10, but still...

It is a plastic tray thing, not a full "flipper" but yes. I don't wear it too often, only when I go out in public (I freelance).

Orthoptera,

Yes, I understand the implant was removed and a new graft was placed. Another implant is planned for the near future.

The surgical procedure referred to as Modified Ridge Splitting is when the surgeon mechanically splits the existing ridge into 2 sections. More or less creating a hole in that bone to encase the dental implant. Depending on the individual case, this can be a viable surgical option with successful results. I just wish to caution you about the pre diagnostic test that is imperative to have done before embarking on this surgery and that is called a 3D CT Scan as it gives a multi dimensional and very detailed view of the bone. This surgery should not be done with just periapical or panoramic radio graphs as they only offer a 2 dimensional view of the bone.

A collaplug is a collagen wound dressing, similar to a sponge consistency, that is meant to control bleeding and stabilize the blood clot during the initial healing phase. Primary closure with sutures is usually done to help keep it in place. If it fell out the next day then either it was not pushed in the socket far enough or the socket had not bled enough to saturate it and keep it in place.

Anytime a tooth is root canaled, there is concern that the bone surrounding the tooth will become infected. Because the bacteria can migrate into microscopic crevices of the bone, there is no definitive means (unless it is evident on radio graphs or CT scans or diagnosed via a bone biopsy) to determine if that migration has occurred or not. This is one reason why it is always a risk to replace an extracted root canaled tooth with a dental implant. Yes, this infection can spread to other teeth and areas of the mouth. The treatment for a bone infection depends on the severity of it.

So I assume based on your reply that you are under the care of a periodontist and not an oral surgeon, is that correct? If so, why did you choose a periodontist?

Regarding the implant in the site of #7... did the dentist perform a Ridge Splitting in that area? Or was the buccal bone intact when the tooth was removed?

A permanent bridge is an option for people who for whatever reasons are not candidates for dental implants. In your case, it would mean cutting down your front teeth which you said are healthy and unrestored. That's not ideal obviously. But if the #10 site does not receive the implant successfully you will be left with the options of a permanent bridge or removable appliance.

If you have any concerns about the healing of this latest surgery, please do not hesitate to have your dentist exam it.

Bryanna