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Medical Forum / General / Dentistry / December 2006Complications of extractions
A month ago, my adult son had all his upper teeth removed for recurrent abscesses and pain. He has diabetes, and until the abscesses started was maintaining pretty good blood sugars. He originally had root canals in the affected teeth, but infections seemed to get beyond the treatment of any individual tooth. So out they all came. Within 24 hrs, his gums started ulcerating, so the dentures he had placed had to be removed. Then bone spurs started developing. Since then, he has had multiple bone spurs growing rapidly, requiring removal, at least every 2-3 days for the last month. Some are relatively large, and grow out of his gums at all angles. The extraction sites never get to heal. So they are constantly inflamed. And his blood sugar is soaring and diving. He is left with only 6 "healthy" bottom teeth, with a 7th that had to be extracted 2 days ago. He is obviously in pain & very discouraged. He is only 32 years old. This cycle has kept him from being able to work. What is going on, and how can one stop this? > A month ago, my adult son had all his upper teeth removed for recurrent > abscesses and pain. He has diabetes, and until the abscesses started was [quoted text clipped - 10 lines] > discouraged. He is only 32 years old. This cycle has kept him from being able > to work. What is going on, and how can one stop this? Unfortunately, small fragments of devitalized bone (sequestrae) often break off after extractions, and I find this is more likely after extraction of abscessed teeth. Where there are multiple teeth extracted the chances increase; and if you place an immediate denture over the extractions (immediate meaning the denture was made before the final extractions), there is a high incidence of denture sores, and healing is delayed. There is a chance that this is being made more severe by the diabetes as well. If your son is home he should try to leave the denture out where possible. Some kind of soft reline material should be placed by the dentist, and your son should be prepared to have this changed several times over the next few months. If there is anything else about his specific health history beyond the diabetes (including medications) it could shed some light on the situation. Steve This is not what he is describing to me. As soon as the ulcers started, he stopped putting the dentures in. He has not worn them for over 3 weeks. After his gums & bone heal, they plan to refashion them to the new fit. But they are not healing. He is being told that the bony spurs are growing from his healing bone. When he sees the dentist, he says they go through the gums, and break off &/or file down the spurs. I am not sure, but suspect that there was bone removal in addition to teeth. I expected some bone shards to work there way out, but what he is describing is recurrent, rapid, and excessive. He is also describing consternation on the part of all the dentists in the office, including his oral surgeon, that they have never seen anything like this. While we are not at the cutting edge of medical or dental care in Alaska, I do not believe that the dentists here are inexperienced. Hence my email. If they are concerned, my worry threshold goes up. He is on a bundle of meds, and their influence is of course a possibility. I am not sure that they have addressed this with him or his doctor. He has a mood & anxiety disorder, hypertension, hyperlipidemia, and is on an SSRI, or the newest rendition of them, perhaps an anti-psychotic, NSAIDs, plus several oral diabetes meds, including metformin (he has given me a list, but I cannot find it), a statin, and who knows what all. He also has zero pain threshold, and has over the years had many relatively minor physical problems turn major complicated by disabling pain. He is trying not to take any controlled meds for pain any more, and that of course affects his moods. Nothing is simple is it? I originally found this site when I found a link on google to a letter inquiring about autoimmune disease affecting teeth. After suffering a tooth- destroying bout with internal resorption myself, it did not seem unlikely to me that he may have something internally destructive going on. Although I have never heard of anything quite like this. So I was hoping there was some research out there or some experience with unusual responses to ordinarily adequate treatment that someone might know of. And especially some idea of how to break the cycle of events. >> A month ago, my adult son had all his upper teeth removed for recurrent >> abscesses and pain. He has diabetes, and until the abscesses started was [quoted text clipped - 18 lines] > >Steve > This is not what he is describing to me. As soon as the ulcers started, he > stopped putting the dentures in. He has not worn them for over 3 weeks. After [quoted text clipped - 31 lines] > adequate treatment that someone might know of. And especially some idea of > how to break the cycle of events. What is much in the news now is a condition called osteonecrosis of the jaws. The reason it is in the news is that it is a relatively recently (maybe 3 years) complication of taking bisphosphonate drugs--medications that are given mainly to women to prevent and/or retard progression of osteoporosis; and also to help prevent pathological fractures in patients with osteolytic disease--largely cancers that have spread to the bone. An earlier described condition appears clinically identical--in phosphorus miners and was called "fossy jaw". I have been told of similar circumstances after extractions in patients with a variety of metabolic bone disease--such as those variously described as "osseous dysplasia". While this is largely a condition of black females, there are other conditions which similarly affect the vascularity and density of bone in men, such as Paget's disease of bone. If this is some form of osteonecrosis, the outlook is not very good. I have been following developments as they are announced, but these lesions do not tend to resolve. They are generally managed by conservatively removing the bone spicules as they appear with minimal manipulation of the tissue, use of chlorhexidene gluconate rinses, and sometimes prolonged use of antibiotics to control superimposed infection. I caution that I am NOT suggesting your brother suffers from osteonecrosis. His diabetic condition suggests that he may be more susceptible to some infective process, and the surgeon might wish to culture some of the exfoliated bone to rule out an infective process called osteomyelitis. I am not an expert here, but the oral surgeon should be. You may have to be a bit aggressive with the office if you don't think this is being given the attention it deserves. Good luck, Steve >>>A month ago, my adult son had all his upper teeth removed for recurrent >>>abscesses and pain. He has diabetes, and until the abscesses started was [quoted text clipped - 20 lines] >> >>Steve  SignatureMark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001 Thanks. I have heard a bit about the biphosphonate risk, but somehow did not think about it in connection with this. I will pass along the concern to ask more specifically to rule out osteonecrosis or osteomyelitis. Seems like with all the abscesses he had before the extractions, he may have lingering infection. He has been on and off antibiotics for this for nearly a year; perhaps there is also some drug resistance. I do not know if they cultured anything before, but perhaps now it might be a good idea. If it is osteomyelitis, it sounds like he is in for a long ordeal, and would have suffered even without having the extractions. I appreciate your response. >> This is not what he is describing to me. As soon as the ulcers started, he >> stopped putting the dentures in. He has not worn them for over 3 weeks. After [quoted text clipped - 38 lines] >>> >>>Steve > Thanks. I have heard a bit about the biphosphonate risk, but somehow did not > think about it in connection with this. I will pass along the concern to ask [quoted text clipped - 3 lines] > perhaps there is also some drug resistance. I do not know if they cultured > anything before, but perhaps now it might be a good idea. I agree. Steve If it is > osteomyelitis, it sounds like he is in for a long ordeal, and would have > suffered even without having the extractions. I appreciate your response. [quoted text clipped - 39 lines] >> [quoted text clipped - 20 lines] >>>> Steve Passed along your information & it was given to the dentist and new consulting oral surgeon. Impression I get is that they both indicate that the surgeon who performed extractions did not do a good job cleaning out the sites.And that he or she did not take his diabetes risk factors into consideration before performing surgery late Friday afternoon. Post op instructions were to come in next day without fail to have site inspected and dentures secured. But surgeon was off for the weekend, and my son spent 2 days in agony waiting for the required check. By then he had ulcers and some bone fragments. Current situation is that these "bone spurs" are continuing to grow at all angles, & at some length, across the entire extraction area. He can feel them push through the gums. They continue to be removed every 2nd or 3rd day by opening up the site, snapping or filing them off. It has been nearly 2 months, he is in continual pain, and is now getting exacerbation of his depression. Not good. New surgeon says one option is to go in and clean the site out correctly. Or to leave as is. He has a pathologic fear of dentists, and this has not improved the outlook. He has no idea what to do, but is completely unable to work as a result (interstate truck driver). Any further insights you could give? Evidently his dentist was not offended at my unsolicited response! >> Thanks. I have heard a bit about the biphosphonate risk, but somehow did not >> think about it in connection with this. I will pass along the concern to ask [quoted text clipped - 12 lines] >>> [quoted text clipped - 20 lines] >>>>> Steve > Passed along your information & it was given to the dentist and new > consulting oral surgeon. Impression I get is that they both indicate that the [quoted text clipped - 21 lines] > Any further insights you could give? Evidently his dentist was not offended > at my unsolicited response! No, sorry. He is being followed by a surgeon, and as long as the surgeon can continue to manage in consultation with your son's doctors, they are probably doing all they can, short of reopening the surgical site. I'm not a surgeon, and this really is in the surgeon's court. That the surgeon was open to your suggestions tells me that the surgeon has an open mind about this, and if things continue to deteriorate re-entry seems like the only other option than conservative management. His other medical and psychiatric situations should be discussed with the surgeon; it may well influence how aggressive treatment should be. Good luck, Steve SignatureMark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001 His new surgeon thought that he had 2 options; let it go as is, and complete another course of Augmentin (just completed 20 days) and continue to remove bone as it exits. Or open and scrape the site. As far as my son knows, the site was never cultured. His reglar dentist is removing the spurs every 3 days or so, and the oral surgeon is a new consult. My son does not want to go back to the original surgeon ( I think his new surgeon made a disparaging comment about the quality of his work). He describes tooth problems since he was young, culminating in the recurrent abscesses that caused multiple failed root canals, then the decision to finally remove the teeth. I suspect that he has some osteomyelitis, based on this description, and am not sure "sitting on it" with another round of antiotics by mouth is aggressive enough. But it is his call. I believe the thought of additional surgery is not appealing, esp. with the realistic fear that his recovery will be complicated by his diabetes in unexpected ways. This sounds like a long ordeal no matter what path is taken.Thanks for your return posts. If any new inspiration comes to you, I will be glad for anything helpful, I will let you know the outcome. >> Passed along your information & it was given to the dentist and new >> consulting oral surgeon. Impression I get is that they both indicate that the [quoted text clipped - 14 lines] >Good luck, >Steve > His new surgeon thought that he had 2 options; let it go as is, and complete > another course of Augmentin (just completed 20 days) and continue to remove [quoted text clipped - 15 lines] > return posts. If any new inspiration comes to you, I will be glad for > anything helpful, I will let you know the outcome. Thanks--I'd appreciate that. Steve SignatureMark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001 |
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