Infections and Dental Implants

Lucy, a dental implant patient asks us:
I am a patient and was given two different opinions about treatment. I am having my molar extracted, tooth grafted and a dental implant placed.

There is an infection in the area. The first opinion I received was of having the dental implant done immediately, as the dentist goes in, does the extraction and grafts. The second opinion was to do the extraction, graft and then wait for the infection to heal before putting the dental implant in. What do you suggest is the best way? Should I wait for the area to heal, or should the dental implant be done right away and why? What are the pros and cons? What is the success rate in each case? Is there statistical data to support this?

42 thoughts on “Infections and Dental Implants

  1. After 14 years of placing implants, I would tell you that both options are valid. For me, the difference depends upon the ability to get stabilization of the implant which can be more difficult in immediate extraction cases esp. in a molar region because of the size of the remaining socket and likely additional bone loss due the infection(you mentioned that grafting is necessary. The presence of an infection is usually not the issue as the infection is comming from the tooth which will be removed and the site should be completely dedribed. Three important words: stability, stability and stability of the implant. Cost and healing times will likey be close or the same. In my own practice, for molar sites, I generally prefer to extract the tooth, graft the area, wait 3-4 months then place the implant (in solid bone, read as stability) as a single stage procedure.

  2. There is an oral irrigant, exxcl oral blue, that has been shown to be an effective bactericidal solution for the treatment of infections and biofilm infestations, especially around the extraction sockets. During the placement of both bone grafts and implants, flushing the area with exxcl oral blue will enhance the healing and provide a barrier to any new biofilm formation.You can contact us at http://www.exxcloralblue.com for more information. This new website should be up and running by March 6, 2006

  3. My experience with root form implants tells me it is ok to place the implant as long as one can remove all the granulomatous tissue /cyst and get two things: bleeding as you need the cells from the marrow and secondly if you attain a stabilization of the fixture

    Dr EGC

  4. In an ideal world , the tooth would be removed the site grafted and left alone for EIGHT months. Then the implant would be placed and depending on whether it’s in the upper or lower arch you’d have to wait another 4 to 6 months before you could get a tooth there.Whew
    I routinely immediately place and many times immediatedly load the same implants. There are many advantages to immediate placement
    A.shorter treatment time
    B.less surgical visits
    C.heal once and for all.
    Disadvantages:
    A.If the case fails, return to square one with less bone than you originally had, more complex bone grafting procedures may even be necessary.You have to undrstand what you’re getting into from the get go.As you may begin to realize both treatment options are viable.We’ve reached a point in implant dentistry where alot of fabulous treatment options are working beautifully and the benefits are as mentioned above.You can go for it, but if you do understand that if it doesn’t work out you know what has to be done to make it right(with more time,effort and expense)

  5. I’m surprised nobody has mentioned delayed placement which cuts the treatment time by 12-14 weeks. The tooth is removed, the site is let heal for 3-4 weeks and the implant can be placed if sufficient bone is available for stability as was well stated by Dr M

  6. If you want to be safe, especially in an infected molar region, the ONLY way to proceed is to extract the tooth, wait 4 to 8 weeks for the soft tissue to heal over the site and allow the body to completely eliminate the infection, and then proceed with the graft and implant. As far as placing the implant at the same time as the graft, that depends solely on the ability to achieve primary stabilization of the implant in the available natural bone. Of course there is the debate over one large implant or two smaller ones (My thought is simple, there are always two roots, right?). In a molar area, especially with an infected and placing a graft, the chief concern is the ability to close the space without pulling the incision too much. That is why, if you are going to invest a couple of thousand dollars in the procedure, it is worth waiting a few extra weeks in the beginning to allow the doctor to work in a healthy area. Good luck.

  7. Wait until the infection has resolved. When the tooth is removed an evaluation of the bone can be done and a better idea of what can be accomplished immediately can be made. Graft or immdediate placement with graft. I tend to go conservative it works better.

  8. Thank you so much for all of your help. A question was also raised in regard to grafting. What is the safest way – should that be done at the time of the extraction, or should there be time alloted between the extraction and the graft? What is better and what are the pros and cons?

  9. Dear Lucy,
    There are so many variables in dentistry because the human body is capable of healing, even after what can sound really invasive.

    My personal advice would be to have the tooth removed first, and graft at the same time. Let the area heal for about 12 weeks. This allows the gum to heal over and the infection to heal. When infection is in a site that an implant is to be placed, a slightly higher risk of failure to osseointegration. Additionally, infection means there is less bone (depending upon the size of infection. Waiting a little, for something that will last many years is definitely worth it. The final point I will make is that, again in my experience, it is hard to predict exactely how the gum will heal after an extraction. This can be better predicted if healing of the gum occurs first. Then when the implant is placed, some variables are out of the equation.

    A second issue that you have is the grafting. I am guessing that you are having a bone graft and not a gum graft. Bone grafts are probably best done at the time of extraction. The main advantage of this is that it eliminates an addition surgery time for you. Also, when the extraction is done, most of the time the dentist/surgeon is able to see where the bone is deficient, and can graft accordingly. Most specialists that I know (i am a general dentist) prefer to wait at least 8 months after grafting before placing an implant.

    As one of the respondents mentioned, it is possible to extract, place the implant and then graft around it. It really depends upon the amount of infection, the amount of bone that needs to be grafted and where the tooth is.

    To conclude, I would definitely not recommend extraction, a separate surgery to graft, and then an additional surgery to place the implant. Combining procedures is less invasive to you, and often a better result is possible.

    I hope this helps!?! Good luck.

  10. Hi Lucy:
    From my 11 years experience in dental implants. I suggest not to put a graft in infected site. Because this will not hold,At least to wait for 3-4 weeks until healing started and infection resolved. Good Luck

  11. Dear Lucy the more you learn the more confused you will become as you see there are many alternatives and most work well.Just trust your surgeon an dhis experience and all will be well,Good luck

  12. I am a patient and I had dental implants done on my front upper tooth. It was implanted immediately after extraction and I had no infection in the tooth before the implants (the tooth broke and had to be extracted)

    Three weeks later, there was an infection and the surgeon removed the implant and he said we would have to wait two months to implant again after gum heals.

    What could I have done to prevent this? I am very healthy and took extreme after the procedure but still got the infection. Any advice?

    3 weeks later, there was an infection and the implant had to be removed and now I have to start all over.

  13. The more you research, the more you will get confused. There are many ways to do the same thing. My 2 cents say if there is puss, no graft and no implant. Clinical situation will dictate the protocol use.

  14. infection in tooth bone area means periapical pathology granulation tissues and infected cells, no body will be sure if the site will be clean after extraction,also healing depend on mainy factors,presence of infected cells may delay healing interfere with graft attachement also with ossio integration,the worse will be acute infection,every thing will be lost (graft+implant) the protocol of grafting and or implant is as follw :1 -extraction, clean the area let it heal for tow months 2- evaluate the amount of graft needed if it horizontal or vertical ,if the area needs graft badly graft should be done as a separet step 3-implant placement as a final step. this treatment plan looks longer time wise but it is safer eliminate the risk of infection,and failire of bone graft and or implant ossio- intigration . from DR.M.ALI, DDS.MS.

  15. I have a bad history of sinus infections. I heard that some dentist will not do implants for this reason. Should I be concerned. Also, the reason for my teeth extraction is I have Periodontal Disease. My dentist has told me he will have to rebuild the bone and I will have a denture for at least a year before implants can be done. All this work is being done on my uppers. Thats the reason for the sinus concerns. I am hearing so many different things and I have no idea what I’m going to do.

  16. I am doing as much research on dental implants as I can, but am unsure how I should proceed. I just had two teeth (#5 and #12) extracted. My dentist and two oral surgeons to whom I spoke highly recommend waiting 8 weeks to have the implants placed. I went to a third oral surgeon (simply because he had weekend hours). He told me that, had I come in for a consultation, he would have been able to do the implants immediately after extraction. I now have an appointment for the end of May (4 weeks from now). Is this long enough to wait? Does waiting eight weeks instead of four really increade the odds of success?
    Please understand that there is no infection or other dental problems present.

  17. I just had a second dental implant done a couple days ago. both because of botched root canals. The first one was done a few yrs ago about 6 months after the tooth was pulled, no bone graft. This one was done immediatly following the tooth extraction with a bone graft. I remember a little bit about the pain of the extraction but I do believe that this time around there is just a bit more pain. jaw swollen more than last time. Dentist just prescribed a 3 day steroid for the swelling. If all goes well it will be worth it and save 6 months of time to get my new tooth in place.

  18. I had a dental implant done one year ago on a front tooth every thing looked good, they were concerned the bone wouldn’t hold but i guess it did, today a year later I realized if you look at my gum above the implant you can see the actual screw.
    I went back to the dentist who secured the implant, who said i need to see a gum specialist, but he’s afraid I’m allergic to the titanium, also I have an open sore right at the top of the tooth where it meets the gum. It’s not painful, yet but I keep hearing I can not be allergic. Why not the gum is gray/black at the site the rest of my gums are pink.

  19. There is no data on the sucess of bone grafting into an infected extraction site. General surgical principle indicates that a graft (bone or implant) be placed into an infected site.

  20. I am sorry for leaving out the “not” in my prior post.

    -There is no data on the sucess of bone grafting into an infected extraction site. General surgical principle indicates that a graft (bone or implant) NOT be placed into an infected site.

  21. I had 2 dental implants next to eachother done 2 weeks ago in the lower left molars. One of them is healing fine, the other is swelling like a bubble which I’m assuming is an infection. I am still taking pain medication for the constant throbbing every 4-6 hours. I am concerned that something could be seriously wrong. Should I be concerned or is there something I should be taking (antibiotics) to help the healing? Or could this be one of the signs that I am rejecting one of the implants? Not sure how long I should go with this before I return to the dentist.

  22. Diana; please contact your dentist regarding this pain and if this dentist does not seem to care please ask him to refer you to a dr who does. You should not be suffering after 2 weeks from an implant.

  23. I had an implant done on lower molar right side 6 years ago. Every thing was apparently fine until a year ago when my Dentist said I had a pocket beneath the tooth. He told me to floss more and use a water pick. Then in August 06 he told me to go see a Periodontist. Diagnosis 80% bone loss. What happened ?

  24. I had dental implants just over two years ago. Apart from one tooth coming loose after a few months and then being tightened I have experienced no problems.

    However, every so often, I’d say twice a year I get discomfort in the area where one of the implants are,from the same tooth that became loose initially. The area is often a bit swollen and I bleed there after brushing. Then I use an antibacterial mouthwash (oraldene) until it clears up. This usually clears up after a few days and everything is fine.

    Do you think this problem is down to bad hygiene on my part or do you think I should see the dentist that did the implant. I’m thinking if it was something serious then it would take more than a mouthwash to sort out?

    I hate dentists and I am fearing more xrays.

  25. My bridge will no longer fit in my mouth since the tooth that it was attached to has a vertical crack and also this cracked tooth was a tooth that had had a root canal done many years ago. Now the dentist says I have two choices; a partial that will have a good bit of metal or 3 teeth dental implants. One of which will be the cracked tooth that will have to be extracted. I am scared to death. I don’t want a partial, but I am scared of the implants. Is titanium similar to mercury filling material. the surgeon dentist who made the suggestions says he will put the implant in the extracted tooth place as soon as he extracts the tooth. Should he wait and let it heal and then go back and put the titanium implant in?
    Thanks, Mhearst

  26. So the best decision, if it were me. I would wait until the infection heals 3-6 weeks, depending on the severity of the infection. Then you can have the implant placed in healthy bone. The best way to go.
    Placing implants near the sinus is ok, its not going to cause additional chronic sinusitis, only in rare cases. But it would be better to place an implant that doesn’t go all the way to the sinus if that is possible. Sinus lifts however are performed everyday with great results.
    If your tooth does not have an infection. Such as the vertical root fracture case. Then I feel as long as the socket is debrided you can place the implant at the time of the extraction.
    If it is the posterior it is best to graft the extraction site and wait 4-6 weeks for healing and then place the implant. Like it was said before the key is stability and with the molar sites having 3 big holes or 2 holes for each roots, you’ve got a lot of bone to fill in and especially in the upper maxilla its best not to place the implants immediately. Graft and then wait and you’ll get better results and better stability.

  27. I have a case of 2 missing front teeth (tooth 7 and 10). I am undergoing an orthodotic treatment to make space for those teeth implants. I also seem to have proper bone strength to hold the implants.

    I am a little scared about the idea of implants.

    Do you think, such a case will have any issues of infection, bone loss or what so ever.
    What is the percentage rate of success (that I have no issues with my teeth in future).

    Also, Any idea of How much will it cost me for 2 implants.

  28. For replacing missing teeth implants is the best choice, provided you are not medically compromised or have other contraindications.
    There are more disadvantages with removable or fixed denture.
    single unit implant surgery which dose not involve major grafting procedures is very simple procedure.
    As any surgical procedure it may end up in complicatrions like infection, excessive bleeding, swelling, pain ect,but if perfomed by an experienced clinician, chances of complications in single unit implants are negigible with succees rate reaching up to 98%.
    Cost varies from region to region from $2500 to $5000 per one implant restoration.

  29. I had a root canal many years ago & it became infected during the healing process. The dentist who performed the root canal died a couple of weeks after it was completed, so I never sought out another dentist for follow up and did not seek additional care until it became very painful years later. At that time I learned that it had probably been infected for literally years. I ended up having root canals done again two times, endless months of antibiotics and finally extraction, with diseased tissue removal, etc. I had an implant done after it was healed… about 18 months later when the periodontist was confident the bone was strong enough. All was fine for a while & then I thought I had a problem, but I had actually fractured the root of the tooth behind it. A root canal on that tooth was unsuccessful & it was pulled. The dental surgeon advised no implant because a drug I was taking could result in bone spurs at the site of the implant. Now I’m having a lot of pain in the area again & I’d like to educate myself before I go in…. I’m not even sure if I should go to my regular dentist or my periodontist. Does a root remain beneath an implant? Could the bone beneath the implant be the site of the problem? Could there be some type of bone issue where the most recent tooth was extracted (it has been over 2 years)? What are the possible causes of the pain and to whom should I go?

  30. The preceeding comments have been helpful because I am to have an infected molar with 2 root canals removed this Friday The recommended procedure presented by a DDS,PC new to me as well as this treatment plan includes 5 days of methylprednisolone to prevent swelling, a bone graft and membrane to act as scaffolding for the stimulation of new bone to permit 2 later implants to replace the bad molar and the false tooth beside it that is part of a 3 tooth permanent bridge that includes the tooth being removed. The middle space from which a tooth was extracted long ago has a definite loss of jaw bone so I understand the importance of the graft. I have started the 10 days of Clindamycin. I will soon be 70 and am self-employed as a housekeeper. I have to work. How important is it for me to take the steroids? Any advice? I’ve been paying for Dental Ins. and was surprised to learn Friday’s procedure will still cost me $350 and the implants, $2000 apiece. Ins. will pay half for the crowns after $75 copay. My daughter who lives in Japan says I should come there and have the implants done because it’s cheaper. Has anyone done this? Thanks for your comments!!

  31. Sharon: I only took the recommended steroid the day before and through the day of the procedure. I explained to the dentist that I did not want to take steroids at all, so he prescribed the minimum dose to inhibit swelling. I also took Ibuprophen for about 10 days. I really didn’t have much swelling at all. As for the cost of the implants, they cost more where I live ($2600). Nonetheless, that’s still a great deal of money & it’s a long process if you have bone loss. I was 40 & I’m not sure I’d go through the implant again. I might consider a permanent bridge.

  32. Dear Sharon,

    The ‘DDS’ who is prescribing you 5 days of corticosteroid and 10 days of Clindamycin needs to go back to dental school.

    This drug regime is way OTT (even considering that you are to have a bone graft) and I would seriously question your Dentist’s competence. Ask him upon what grounds he is prescribing you these drugs and why he considerd them necessary.

    Over-prescription of drugs is a big problem and the use of the steroid will increase the chance of the bone graft failing. The overprescription of Clindamycin may also have side-effects and contribute to bacterila resistance.

    Sorry to be so negative.

  33. Im not sure why steroids inhibit the graft, and as far as clindamycin, its a good drug. if I am doing a sinus lift, I like clindamycin. The OMFS like it. Remember, steroids and antibiotics are given for prophylactic reasons in implant dentistry. There are opposing views to be sure. The inflammatory response is really over by day 5 inst it? So the steroids can have a very positive affect. Imflammation kills bone. Bugs kill bone. Thats why I use both and try to stay conservative. A dose pack is a low dose amount. Some dentists use steroids IV before the procedure. When used correctly, they are safe and effective for their respective purpose. JMHO, Bill

  34. Maxfax- if this patient had doubts about her dentist you surely nailed the coffin. You have no idea how extensive her surgery might have been to require the meds that were Rx. I don’t think you are that sorry for being so negative!

  35. The mouth is one of the areas of our body with the greatest microbial population and variety. Different ecosystems can be found in the mouth, where over 200 different aerobic and anaerobic bacterial species live. Oral bacteria (dental or commensal pathogens) and their products (toxins) may move from this primary location to other neighboring or distant locations. Invasive dental procedures and oral surgery favor bacterial dissemination, especially into the bloodstream, causing transient bacteremia. Transient bacteremia is unavoidable, but its severity (bacterial load), duration (time in which bacteria remain in the bloodstream), type of bacteria in the blood (aerobic, anaerobic or mixed) and the patient’s predisposition (underlying diseases, susceptible site of infection, etc.), all play a significant role in the onset of possible complications. Bacteremia, initially considering mono-microbial bacteremia, is caused by contamination/infection of the normal oral and dental pathogenic microbiota during the surgical procedure. Since the thirties, dentists have known that 75% of patients with caries, gingivitis and periodontitis will have positive Streptococcus blood cultures following dental procedures, in comparison with 30% in healthy subjects. Predominant organisms are Streptococcus from the viridans group, Staphylococcus spp and, in 4-7% of cases, gram negative bacilli (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella), several of which are considered as dental pathogens. Not a surgeon should neglect the existence of mixed (aerobic/anaerobic) bacteremia, or anaerobic bacteremia alone (Eubacterium, Peptostreptococcus, Propionibacterium, and Lactobacillus), which are detected in a significantly high percentage of cases when an appropriate microbiological method is used (oxygen-free blood cultures or anaerobic recovery.

  36. Two weeks ago I developed an infection of #19 which had a root canal and crown. Infection prompted me to contact my dentist on the weekend and they called in a script for Penicillin VK 500MG and Hydrocodone 5-500 and appointment for Monday. I might add I had open heart surgery 3 years ago, 6 by-passes and my immune system is not what it used to be. On Monday, phsical exam and x-rays revealed the roots of the tooth were all but gone. The dentist recommended extraction and implant placement that day. I agreed, the tooth cracked into many pieces and he dug and worked for an hour to remove all pieces of tooth and root, also to place the implant. A second x-ray revealed more root that he attempted to remove. I was sent home with a follow up appt for the following week, told to continue the penicillin, pain managemnet and rinse with Chlorhexidine gluconate. By wed. the area was so swollen and infected I returned, he stated the penicillin was not strong enough, changed that to Ciprofloxacin and told to come back in a week. Pain is not better, area is still swollen and tender, this is Sunday, I called his emergency number and have an appt tomorrow. If anyone reads this and has a suggestion, please pass it on. I think the infection is not controlled and is spreading, my dentist (general not oral surgeon) statest the strongest anti-bio he uses is the cipro. Any suggestions would be welcomed.

  37. Ive just read all these comments on implants and Im even more scared.
    My front tooth is booked in to be extraced in July and is infected, Could you give me some advise as my dentist wants put in the impalnt the same time as extraction. Taking the drugs also scares me.

  38. About 18 mos. ago I had my whole upper mouth redone. My 30 yr. old caps were replaced, along with getting rid of my partial and having 3 implants. As soon as the permanent caps were permanently cemented, I was having a burning sensation around the implant area. My dentist told me nothing looked wrong. Around 3 months ago, I had a lower right molar capped when my tooth broke because of too much filling. The lower cap was uncomfortable when biting, so I started chewing on the left side. After a day or two, my whole upper mouth started aching. The pain bounced from the right to the left, every tooth hurt. The dr. called in amoxicillan because I was also having sensation in tooth #8 because there’s a post in it, and 2 yrs. ago I bumped it really hard, but the dr. said there doesn’t seem to be a fracture. I purchased a mouth guard, and it alleviated some of the pain. I returned to the dentist complaining of severe pain all over my mouth, but mostly on the upper right at the implant site. He removed the upper right bridge, did some adjusting, and the pain subsided somewhat. A few days later, I am having pain again at the implant site. The pain seems to be way up in the gum area. The pain is dull to throbbing. Could I be allergic to the titanium? If there’s infection wouldn’t I have pus? The gum area is a little red. The dentist wants me to see a pain specialist to check the bite. I never had any pain before I had this work done.

  39. i had 4 implants put in the first of november. all three top implants have fallen out. i have been on clindamycin for 2 months and still have puss pockets on my gum. what else can i take.

  40. Dear Jack your problem is not very common, You must go to a qualified implanthologist in your area to be treated of your infectious condition not only from a pharmacological point of view but also surgically .

  41. Ok here it goes, I had a tooth pulled and bone graph done and two implants put in side by side, on the left side the back two molars. This procedure was done on January 26th, as of Tuesday, he has had to go back into the gum area and remove pieces of bone? I have been on Antibiotics forever it seems, he also had me on Steriods for 7days. My gum is red raw with stitches again,,, Is this normal??? Is my body rejecting the implants? yet he tells me the implants look great and took well?? Yet there was a terrible infection when he pulled the one molar. But all the antibiotis should have cleared it all up,, What should I do?? Its still hurts to even touch, the gums are red raw… Do you think this is the last of it?
    Please advise,,,

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