Infected tooth with sinus perforation treatment: feedback?
A middle aged woman presented with a swollen gingiva buccal to tooth #15 which had a previous RCT and crown. The crown had fallen off with the post sticking up and a dentist cleaned it up and recemented the crown. A few days later her gum swelled up and her dentist said she had food impacted and gave her antibiotics and Peridex to rinse with. It only slightly improved and she came to see me. It appeared to be a bigger problem and I referred her to an endodontist who took a CBCT and diagnosed a fractured root and recommended extraction. The CBCT also shows a large infection induced perforation into the sinus and the patient has sinus pressure and sometimes pain when bending over.
I am wondering if I should place a membrane and bone graft after extracting the tooth or if I should let it drain on its own? She would like to have an implant once it has healed.
Any good feedback will be appreciated.
19 Comments on Infected tooth with sinus perforation treatment: feedback?
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Carlos Boudet, DDS
4/17/2018
If you try to graft this at the time of the extraction, there is a high probability that the graft will get infected and fail.
Extract the tooth, let the area heal and hope there won't be an oro-antral fistula.
Once it has healed, place the implant with or without a graft as needed.
Good luck!
Timothy Carter
4/17/2018
The primary source of the problem is the tooth. Just remove it and place a collagen plug. No need to add a bunch of expensive materials. I have encountered similar situations often and this simple approach has worked great.
Robert A Horowitz DDS
4/17/2018
Once you extract and do not graft, all of the literature shows you can expect 35 - 50% horizontal bone loss and 1.35-2mm of vertical collapse, primarily on the facial. I ALWAYS graft sockets at the time of extraction unless I am going to place a delayed-immediate implant 4-6 weeks postoperatively. Thorough debridement and protection of the Schneiderian membrane with an Amnion-Chorion barrier like BioXclude has worked well for me.
Can Bayrak
4/17/2018
I would not graft post extraction due to infection and would need a flap for closing the post extraction region. Definitely wait for wound healing. Graft the site if necessary during Implant placement.
Robert A Horowitz
4/17/2018
Can -
If you read the socket literature, what you are advising is against pretty much everything published in peer-reviewed journals. Start with Fickl and Hurzeler, Horowitz Rosen and Holtzclaw, Bartee, Sottosanti and Anson, Hoffman, Iasella and Greenwell.
Can Bayrak
4/17/2018
I've had a quick glance of "A Review on Alveolar Ridge
Preservation Following Tooth
Extraction" thank you for your advice. Great review. The main reason why i wouldn't graft is because of the infection and handling an infected mucosa as flap and infected bone as a graft bed as (i think) would increase the chance of graft loss. I still have doubts due to inf.
Florentino afonso
4/17/2018
Why not have endo retreated?, the Mesial canal(s) appear to be the source of the problem.
Dr D
4/18/2018
How often do you get long term success from root canal retreatements on a multi-rooted and crowned tooth with relatively little residual tooth structure?
Harley Williams
4/18/2018
Depends on the source of the problem. If there is a missed canal the prognosis is excellent when retreated the the aid of a microscope.
Ronald Quade
4/17/2018
Pack the socket with Dynagraft bone putty. No need for a membrane, place a cris-cross suture. Bleeding stops immediately, bone resorbs minimally in the saddle area, and chance of an oral-antral fistula is greatly reduced. Cost is about $250 for 1gram, plenty for the largest socket. I use it every week. Great for maintaining bone depth where pt may decide to get an implant in the future, or in the anterior where you want to preserve the bone so a bridge pontic will be the correct size to match the ajacent teeth.
Harley Williams
4/17/2018
I would extract, degranulate the socket and graft at the same time. Also, I would have #14 retreated as well.
John Beckwith DMD,DABOI,F
4/17/2018
Extract
Irrigate w saline
Place biomend membrane soaked w clindamycin gently against sinus
Place allograft
Cover with CTX nonresorbable membrane and suture
4-5 weeks remove it and there will be granulation tissue w early bone formation.
Patient should be on antibiotics w chlorhexidine rinse.
PerioGirl
4/17/2018
Place the patient on 7 days antibiotics, and have them start the antibiotic three days prior to the extraction appointment. Have patient come in at the third day and extract the tooth. If no exudate, bone graft by placing a thin layer of collagen tape at the apical part of the socket to seal the oral antral communication and bone graft with your material of choice.
If exudate still present, place a collagen plug to seal the oral-antral communication and allow soft tissue closure for 6 weeks. At that point, assess and consider re entering the site for GBR.
Colin
4/17/2018
#14 is scheduled with an Endodontist for retreatment.
Zafar Tariq
4/17/2018
My advice is not graft into a draining socket, you’ll waste time/$$ using membrane that get “blown†from sinus pressure. Use collagen tapes/ or plugs and just suture socket to best ability - wait 2-3weeks concurrent to antibiotics and go back and use your favorite graft material that works well with or without a membrane, but keep it simple and it will heal great as long as the buccal plate is intact....
Rand
4/17/2018
This is what I always do when faced with this scenario:
1. Extract the tooth, preserve existing bone.
2. Remove all granulation tissue.
3. Thoroughly rinse socket with sterile saline.
4. Score the socket.
5. Place a double layer of collagen membrane ( I use Bio-Gide) on the buccal.
6. Graft a mixture of L-PRF, 30/70 mixture of FDDB and MFDB and metronidazole.
7. Cover with another piece of L-PRF.
8. Crisscross suture.
9. Let heal for 4 months or longer and scan to treatment plan implant placement.
By removing the tooth and granulation tissue, you have removed most of the bioburden and the source of the bacterial (mostly anaerobic) infection. The metronidazole counteracts any residual bacterial. The L-PRF has some leucocytes and promotes angiogenesis. This has worked well for me. Hope it helps.
John C
4/27/2018
please tell me from where or from what company you purchase the metronidazole
thanks
Rand
4/27/2018
Southern Anesthesia
https://www.sasrx.com/
Howard Steinberg
4/18/2018
I agree with whoever it was above that the source of the infection is the tooth and once it is removed I would not worry about proceeding with a graft. I routinely extract, currette thoroughly, then I take a surgical round bur and clean the socket and lastly I use an Erbium :Yag laser at .85 Watts and remove any remaining tissue. I have used multiple graft materials with success after that but usually I use a non-resorb membrane like Cytoplast but PRF is fine also.
