A patient came in with a gum swelling associated with a molar tooth. He has consulted a dentist who told him to extract the tooth and place an immediate implant. He then consulted another dentist who told him to extract the tooth and wait a few months before doing the implant. Feeling confused, he came for a third opinion, hoping that I will choose one or the other, making it two to one for a “majority” vote. However, I offered a completely different option. I referred him to a root canal specialist for assessment as to whether the tooth can be saved.
Dental infection is a fairly common occurrence. It is usually caused by tooth decay that has gone into the pulp, or gum disease that has progressed to the bone level. If decay is the cause of the infection and/or swelling, root canal treatment can remove the source of infection and effect a cure. Thereafter, the tooth needs to be reconstructed with a crown for protection. However, root canal treated teeth can give rise to infection even without decay. This can be due to inadequate root canal treatment or cracks in the tooth, the former can be treated and the patient gets to keep the tooth, but the latter will require extraction.
This patient had already had a root canal treatment for the tooth. The purpose of getting a root canal specialist to assess is to determine with certainty whether the infection is caused by cracks or inadequate treatment. Having an additional consultation incurs more cost but if it results in not having the tooth extracted and replacing it with an implant, I think it is worthwhile. Having done dental implants for more than twenty years, I believe in maximizing the longevity of natural teeth before doing replacing them with implants. There are exceptions to his rule but that’s for another post. Dental implants, like natural teeth are subjected to the natural wear and tear as well as challenges by the bacteria in the mouth. With proper maintenance, it is possible that a dental implant can be kept for life, just like natural teeth. Similarly, dental implants can also be infected, like natural teeth and may need to be replaced.
As it turned out, the root canal specialist found cracks in the tooth and referred him back to me for extraction. At the second consultation, we discussed replacement options. The replacement of choice is an implant-supported crown. The next question was when was the best time to place the implant. The first dentist wanted to place the implant immediately after the extraction, while the second dentist wanted to delay placement for a few months.
Implants are foreign objects and as such are more susceptible to infection than the body’s natural anatomy. Although dental implants are biocompatible, they also attract more bacteria. In an infected site such as this, immediate placement of a dental implant would be unwise and the bacteria that are already there could colonize the implant once inserted.
I told the patient that it is best to remove the tooth first and clear the infection before implant insertion. Depending on how much bone loss there was after the tooth was removed, bone grafting may be needed. Doing the extraction alone first will allow the infection to clear and the socket to have some initial healing before evaluating the implant site for a more accurate diagnosis of the need. There is no absolute rule as to when the implant should be placed except that there should not be any infection. With antibiotics, an infection tooth socket usually clears within 1-2 weeks. In some cases, especially for teeth in the aesthetic zone, early placement is indicated to minimize bone resorption which typically set in after an extraction. For some other cases, delaying the implant placement for a few months may enable more new bone formation and soft tissue coverage of the extraction site. Those requiring bone grafting can do the bone graft once the infection clears and wait 4-6 months before placing the implant.
Because of the high success rates of implants, many patients and dentists tend to opt for extraction and replacement with implant. This is a perfectly acceptable treatment plan. However, a root canal specialist can offer another perspective that may save the tooth. The decision should be made after balancing the pros and cons of each, ensuring the that benefits of whatever option chosen outweigh the potential risks.