Ailing Dental Implants and Infection: Causes and Treatment?
Xray for this case is at the bottom of this post.
I am a Male patient, 25 year old and in healthy overall condition. I had an extraction of the central and lateral upper incisors due to trauma on the central many years back and then infection of the apex which was treated by root canal, which subsequently failed. A fistula arised and while the tooth was treated and filled with calcium compound (might be calcium hydroxide, but I can't remember). Eventually the area kept getting infected, which also damaged the lateral, so both were extracted.
There was moderate/severe bone loss due to recurrent infections so Bovine bone graft was put in place at the same time as extraction and the site healed uneventfully for 10 months. 6 weeks ago, I had dental implant surgery for both central and incisor, placing two Straussman dental implants in the regenerated area. Also the dentist added some more bone graft to "fill in" some remaining defects, and a gum graft was performed to cover everything up.
I was put on antibiotics (amoxicillin 500 mg, 3 times a day for 7 days) and healing seemed uneventful.
After 2 weeks of placement, sutures were removed and everything looked fine. 4 days afterwards, an abscess formed around the gums where the implants were placed. the dentist drained the pus through an incision and put me on a course of antibiotics, (amoxicillin + clavulanic acid, 3 times a day for 2 weeks) to see if the infection might be due to suture removal. Although the antibiotics reduced the infection, some "tension" was still on my upper gum close to the nose area, and whie pressuring, the dentist found a tiny bit of pus, and decided to open up 4 days later.
Upon opening (week 6 after dental implants placement), the dentist mentioned that the bone graft seemed to be healing uneventfully and that signs of the source of the infection were not visible. The implants were stable. The dentist debrided the bone graft (taking out minor granulate tissue she found, according to her own words) and applied local tetracycline to the area. antibiotics were continued throughout and ordered for 10 days after operation.
Now I'm 6 days after this intervention and I feel there is again swellness in the area, which feels like some liquid, so I'm assuming the infection is back.The dentist said the CT Scan didn't show any problems or bone loss. The adjacent teeth were checked for vitality and gave positive, which alongside the CT scan discarded endodontical problems in them. I have attached an X-ray from 4 weeks post-op.
What could be the source of the recurring infection? How would you proceed? It's the aesthetic zone and I took a lot of time to let everything heal in order to do the implants right and they still failed. I'm also worried because between these failed saving attempts, I've been on antibiotic treatment for almost 4 weeks non stop, which sounds way too much from my persoective and with possible new infection, probably more rounds will be needed.
20 Comments on Ailing Dental Implants and Infection: Causes and Treatment?
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SM52
7/15/2020
There seems to be an ongoing problem here and after 2 post-insertion surgical interventions and weeks of antibiotics it may be time for you to see a specialist in your area. A periodontist would be a good choice. Its hard to know from your letter exactly what the dentist encountered when placing the implants and how she handled the placement and bone grafting so I can't make comment on that. If she hasn't resolver the issue, ask for a referral.
Junior B
7/15/2020
Thanks for your reply. The doctor that performed the implant placement in the first place and actually is still on top of my case is indeed a periodontist.
Do you think the cause of the problem could be remainings of the infection from where my tooth was in place? although it sounds weird to me as the bone graft after extraction worked and attached just fine, i've read that some cells could still be loose in the area for years.
SM52
7/15/2020
Bio-Oss or bovine bone graft material is widely used and regarded as a reasonable choice for the repair of these defects. I have discontinued its use in such situations since I have found less success with it that with an allograft of bone(human donner bone). Having said this, I agree its possible there was residual contamination at the site of the original infection which contributes to the problems being encountered now.
At this point it seems necessary to re-enter the site fully, remove any loose graft material and granulation tissue and decide whether or not the implants should be kept or removed. If implants are removed, my preference is to re-graft the site at that time and then wait at lease 6 months before attempting to place them again. Just prior to another attempt, a CBCT scan is helpful for planning and carrying out the treatment.
Junior B
7/15/2020
Thanks for the follow-up answer. Yes, unluckily i think i will have to go under yet another procedure. My main cause of concern is how to get rid of the infection, because if the source were the implants, i think there should be a sign on the CT scan or x-ray showing how bone is degrading, right? which was not the case here. id love to hear your intake on it.
On the other side, my dentist already performed debridement of the bone (i think she just scrapped the bone graft that seemed to be compromised but not all of it, maybe she should?) and applied local tetracycline and didnt seem to work. In fact, i am surprised that as little as 7 days after the surgery (today) i already have increased swelling in the area considering the battery of both topic antibiotics applied during surgery + systemic antibiotics.
The swelling seems to always be localized in the apical part of the gums, very close to the nose, so that could be an indicator of the source? But again, how could pus and inflammation arise from the apical part if the CT scan didnt show any passage through what would be the implant apex to the gums by means of bone rebsorption?
Anyhow im still trying to make sense of what could be a logical cause.
Would love to hear your thoughts.
Thanks in advance
nalmoc
7/15/2020
Having some more Xray of the root canal may help. It's possible that was not well degranulated when the teeth were extracted. I have seen similar case like this one where infection would not stop from the trauma, root canal to apicoectomy. Implants placed at the site of failed root canal have high chance of failure or in other term lower success rate. Implants may not be the best option for a site with recurrent infection. Good luck
Junior B
7/15/2020
Thanks for the answer. I have two Xrays that might help. One is pre-extraction pan (the concerning tooth are the two that have the RTC done in the upper anterior region) and the other is a post extraction and bone graft periapical, both of which i attach here.
The question i have regarding the possibility of dormant infection in the site as an explanation is: a CT scan 5 weeks post-op wouldnt show a bony defect or something already? The dentist told me that the CT scan i had done 2 weeks ago looked spotless.
Second. How would you proceed? as today its 7 weeks post dental implant placement, and radiographically and by CT scan they look stable, but infection is still present. Would you extract both implants and redo bone graft at a later stage after infection dissapears? Which kind of bone graft would you use if that was the case?
Thanks a lot
perioep@yahoo.com
7/15/2020
Thank you for presenting such a nice case (impressed with your knowledge and command of the situation). Could possibly be a chronic, refractory infection that might be best treated by minor surgical intervention. Your doctor might consider reflecting a full thickness flap over the 2 implants and determine the source of the infection. She can easily debride the area, irrigate, and replace the flap. Should resolve your chronic problem and new bone should form. Good luck!
Phil
7/15/2020
I would side with Nalmoc here. Implants placed in failed endo sites are fraught with difficulty. There is alot of literature about this. For example, see this article, https://pubmed.ncbi.nlm.nih.gov/26550925/ (Implant Placement in Failed Endodontic Sites: A Review). You can find many others discussing the issue. So what to do? Simply staying on antibiotic therapy, is not a solution, as you rightly suspect. I would think you need to seriously consider removing the implants, clean out bovine graft (I assume it is Bio-Oss), and thoroughly clean the site. There are specific materials to use to provide an antibacterial effect at the site (probably best to see an endodontist to do the cleaning of the site). You are lucky, in that the implants were only placed relatively recently, so removal should not be a complicated procedure, if the periodontist has the necessary instruments. After all that is done, you can proceed with evaluating other treatment plans. Also, as a precaution, for various reasons, I wouldn't recommend using bovine graft material, in your particular case going forward. Good luck.
Junior B
7/15/2020
Phil, thanks for your reply. Im interested regarding your opinion on the bovine graft material. Why wouldnt you select it as a proper bone graft? which material would you choose? and would you place the next graft at the time of implant extraction or let it heal for a couple of weeks and then open up again?
And secondly, after all of this is done, would you consider going for implants on a second try? or just consider that one try failure is enough.
Thanks
Phil
7/15/2020
I don't want to get into a discussion of various graft materials, as it's subject to too much debate (and honestly a lack of sufficient research). Suffice to say, even though bovine graft has been used extensively, and successfully, worldwide for years, that doesn't mean it works for every single individual or case. We all have unique biological differences and circumstances. So given your situation as described, I think it is prudent to look at other options, and not use the same graft material on a 2nd go around. There are many other grafting materials that you can discuss with your periodontist. As regards to your other questions, these are best discussed with your specialist, after you treat the current issue. Good luck.
Drsvoboda
7/19/2020
The implants appear to be well placed and the bone around them looks even. Is there a radiolucency near the apecies of the implants where that huge lesion associated with the failing natural teeth was???
lrkg
7/19/2020
yes i agree,there seems to be retained periapical infection, swelling near the nose, means, curettage near the periapical area is required
Junior B
7/19/2020
Hello to both, thanks for your replies. Indeed we considered the possibility of a radiolucency at the implants apices, but 2 weeks after this radiography, a CT scan of the area was made, which showed no bone rebsorption whatsoever in the area, so that diagnosis was discarded.
Junior B
7/20/2020
I attach CT scan from 4 days prior to debridement surgery (5 weeks post-op implants placement surgery). Would love to hear whether you see anything abrnomal or to consider in it. (Opening the image in a new tab allows to zoom in properly).
Matt Helm DDS
7/24/2020
I'm not so sure that I would call this CT spotless. Slices numbered 8 through 12 have small apical areas that are questionable. Please read my comment in the main section for more.
Matt Helm DDS
7/24/2020
It’s actually pretty obvious on your post-implant placement x-ray that there are areas of chronic apical infection and granulation tissue, in the areas that were once the central’s and lateral’s apical regions. A good look at your panoramic confirms this. (And congrats for being astute enough to post it.) Those with decades of experience in trauma treatment know all too well that sometimes, post-traumatic root canal failures can yield chronic, long standing infections. In other words, your statement that “some cells could still be loose in the area for years” is not only true but, it is actually an understatement. These chronic infection areas can reorganize into granulation tissue (without actually forming cysts) that can persist forever and be very problematic when placing implants. My suggestion at this point is to request an oral surgeon referral. That would really be the most qualified specialist to determine the best next steps to take. The implants may have to be removed, those apical areas thorughly debrided again (preferably using a laser also), bone-augmented, and allowed to completely heal. OR, I might not even rule out an apicoectomy-type intervention at the apicals of these 2 implants. But even with my 34 years of experience in trauma I would deffer that decision to a competent oral surgeon. Hang in there – even if the implants have to be removed and you have to start from scratch, armed with this knowledge success can be obtained, you’re young enough to have plenty of time, and it does look like you have sufficient peri-implant bone. You are right, this being the anterior area you should settle for nothing less than an excellent result. Hang in there. It will get there.
Junior B
7/24/2020
Matt, many thanks for your reply.
I have a couple of questions that i would love to hear your opinion on considering your reply
First, assuming that the problem is the periapical region that is causing an infection, is it possible that puss forms an abscess on my gums without either eating the peri-implant bone until it reaches the visible "crown" area of the implant (and thus making them or at least one of them completely failed by the time i had the last debridement surgery two weeks ago), or either eating bone through the apical region until it reaches the gum tissue? (from my understanding one of these two has to happen for the abcess to form and fill with puss, but please correct me if im wrong, i am just a patient).
Second, assuming that the option decided is to take the implants out, would you recommend doing the bone-augmentation part in the same surgery, or waiting a couple of weeks/a month for the infection to clear up fully before opening up again? Plus, which kind of bone-augmentation material (allograft, autograft, xenograft, etc.) would you recommend for the case after taking the implants out plus debridement and possible decortication?
Thank you very much again for your thorough answer and support and looking forward to your next answer!
James B
7/24/2020
This is a wonderful site and many experienced practitioners sharing their wealth of information.
I am a newbie to this site and a kid when it comes implantology.
With the peri apical radiographs you have shared there is still substantial radiolucnecy in the apical areas of where the original tooth were and currently where the implants are positioned.
OPG is less reliable for the diagnosis for anterior regions.
It could be a case of a periapical cyst being incompletely removed.
I would suggest seeing a seasoned Endodontist(strange as it may sound) and get some opinion on periapical surgery.
They usually do well. It’s not unusual for the lesion you drain through the margins of the gum esp when several surgeries have been done .
Dd: Globulomaxillary cyst?
I only think that cos the canine root becoming divergent which is the case of cystic growth
With medications Clindamycin is a gold standard when you require bone penetrations. But it’s or any other medication is of little value when cystic lining is persistent
When pus think Gram negative anaerobic Bacteria. Good old Flagyl does the trick.
I stand corrected .
Samuraineko
7/29/2020
I had a similar issue with constant infection and failure of site healing. My prosthodontist debrided gum/bone and applied bovine graft twice. After biopsying and applying antibiotics appropriate to the infection, site is infection clear for over a year and awaits implant. I will get the implant when I am able to travel safely to her office after pandemic. She is in Mexico. The main difference I see is that my dentist utilizes laser disinfection therapy and regenerative stem cell therapy on the site. Treatment with correct antibiotics also helped.
Rea2177
10/2/2020
Can you please share the contact info for your dentist in Mexico. My email is 8rea.mg@gmail.com. Thanks in advance.
