Help this patient who has a dental infection

I just got an email from a friend of mine who is having dental problems. He gave me permission to post his X-rays and story. He is a man who has a problematic lower left molar tooth that previously underwent root canal approximately 5 years ago. Most recently he has had about eight weeks of worsening pain near the base of the tooth on the left inner palate. The tooth pain has been worsening over recent weeks and he has tender left sided lymphadenopathy.  He also reports some pain and difficulty swallowing. No fevers or chills or other symptoms. He is currently taking amoxicillin-clavulonate (brand name, “Augmentin”).

He saw a dentist who diagnosed acute infection and abscess at base of tooth likely due to perforation in the root canal filling allowing bacteria to invade the gums in context of ongoing bone loss at root of tooth, with fistula formation and drainage of pus to sublingual spaces.  The dentist advised immediate tooth extraction followed by enucleation of the infection site, followed by human cadaveric bone graft and sealing over the site with synthetic tissue held in place by sutures. His plan is to wait approximately 6 months for bone graft to set in and then place a titanium implant. Alternatively, a bridge could be placed.

dental1 dental2

A few concerns/questions for all the dentists / ENT doctors/ ID folks out there:

1) What is the extent of ongoing infection in the tooth/jaw?

2) What bacteria would be most problematic? Strep viridans, milleri, anaerobes (including fusobacterium and prevotella), others?

3) What antibiotics should be used?

4) What is the correct surgical management? Clearly the infection needs to be debrided before the patient becomes bacteremic and develops endocarditis or a brain abscess, but is cadaveric bone graft placement the correct procedure to perform? What is the evidence underlying the procedure?

My friend, a dentist, responds:

Having only a bitewing and PA to go on, it does look like the root canal therapy has failed.  Extracting the tooth and replacing it with an implant and crown is certainly one treatment option.  Without seeing the patient or having information on his periodontal health, I am seeing furcation involvement with the tooth that would warrant a bone graft.

In terms of the infection, assuming general good health, clearing the infection with an antibiotic and extracting the tooth, he should be fine.  The odds are not high that the infection will spread…again assuming good health.  But I can’t speak from an ID perspective.

What I know for sure is your friend should take the course of antibiotics for the abscess, have the tooth removed, wait for proper healing to occur, have the implant, bone grafts done, and have the tooth restored with a crown.  That your friend has had problems and waited 2 months…well, gives me pause.  Few things with teeth resolve themselves nicely or neatly, and where there is pain, things only get worse.  So, regular dental visits and seek help sooner rather than later are also in my marching orders.  Penicillin (clindamycin, if allergic) or amoxicillin is generally the course of action.

While the questions you pose are important, the real question I have for your friend is who is placing the implant: a general dentist or an oral surgeon?  And who is restoring the tooth: General dentist or prosthodontist?  I raise these questions because implants are all a matter of spacing to restore the tooth.  If an oral surgeon is placing the implant and a general dentist restoring, those two should be talking about the procedure; the general dentist should send a placement guide to the oral surgeon, and the general dentist should have a plan to restoring the tooth.  Implants are well big money business for dentists, and well, anyone with a weekend course thinks they can place them…and maybe they can…placing the implant properly to restore the tooth properly are the big questions…assuming a patient is in good health.  A poorly placed implant is a world of expensive problems.

I hope things go well with you friend, and he has a great dentist who can walk him through this…and by the way, generally when a dentist says you may want to extract this tooth immediately, we aren’t just making that up.

Oh, and to the question about the bony graft: extracting the tooth may involve some bone loss for the osseointegration of the implant, you need to have a site with good bone.  In the absence of good bone, implant and bone graft are in order.  Again, with a periodontal exam and clinical exam, a dentist will have the information needed to make that determine.  But generally, an implant and bone graft go kind of hand in hand.

One thought on “Help this patient who has a dental infection

  1. I think the treatment recommendations made by the treating dentist are most likely correct. A two-dimensional x-ray doesn’t tell the whole story but as mentioned above the radiolucency indicates most likely either a crack in the tooth or a mechanical perforation that occurred during the instrumentation of the root canal.

    Before the advent of the implant oftentimes heroic procedures were performed to save some of these teeth. Flaps were retracted to debride and examine the area of the infection by either a periodontist or an oral surgeon experienced in apicoectomies. Very often we would hemisect (remove one root) and splint it to an adjacent to an adjacent tooth (crazy) or repair the perforation with amalgam in hopes that the repair would allow bone to heal below the area of the crack or perforation. Unfortunately most of these cases were exercises in futility. The actual final diagnosis would occur when the tooth’s roots were exposed to sunlight.

    Today we are very fortunate to have very predictable treatment options such as implants. Without seeing this tooth clinically, the most logical treatment would be to immediately remove this tooth, debride the socket and after healing proceed with grafting if needed and placement of an implant.

    As to who should perform this treatment, it certainly depends upon the skill and experience of the restorative dentist. Obviously involving an oral surgeon or periodontist for the removal of the tooth would be best. Prior to placing the implant the restorative dentist should provide the implant surgeon with a drill guide or stent to avoid placing the implant too close to adjacent root structures. Following the successful implant placement any restorative dentist experienced with implants can restore the implant. A prosthodontist treating this tooth is optimal but then again I’m prejudiced.

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