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Hi Dr. Hall,
First, thank you for taking the time to answer questions. 🙂
My question is about the impact of a sinus perforation, removal of an implant, and antibiotics. I just had a dental implant (tooth #2) removed last Wednesday, six months after it was placed, he suspected bone loss and the gum was not filling in correctly. Also, when he placed the implant it punctured the sinus by a few mm.
After the removal, the OS said there was no infection and it was very easy to remove because it did not integrate at all, and there was no need to give me intravenous antibiotics during the process (I was sedated). He put me on sinus precaution of Flonase, no blowing nose, and no sneezing with mouth closed. He said he did not repair the perforation in my sinus, he just cleaned the area and stitched the gums. He said it would heal on its own and we should wait a year to see if the hole fills up with sinus tissue or bone and start again from there.
The following week I had continual congestion, especially at night, even though I was using the Flonase. I also had odd crackling in my ear when I moved my jaw (not jaw popping and no pain- just crackling like a blown speaker) I went back to him five days later and he said everything looked great. I did not agree and I requested antibiotics because I felt like it was getting infected. He reluctantly complied and since then my congestion has cleared significantly and air no longer escapes through the site. My question is, was it detrimental to not have been given antibiotics from the beginning and how do you know the sinus has healed correctly and the bone is not compromised with a lingering infection and congestion in the first week?
Thank you so much for sharing your knowledge!
– Kelly M.
Kelly,
First, answering your question directly, there is no harm in not starting the antibiotics right away. The indiscriminate prescribing of antibiotics, “just in case you have an infection,” is leading to a serious public health problem by helping cultivate antibiotic-resistant bacteria. Then, when you really need the antibiotic, it doesn’t work. So I like the idea that your surgeon waited to see signs of infection before prescribing the antibiotic. And Flonase seems a good choice also.
But there is another, more significant issue that you bring up that I want to address, and that is the failure of this dental implant. The implant perforated the sinus by a few millimeters??? That’s kind of a biggie. A few millimeters in dentistry is a lot. And the implant didn’t integrate with the bone at all. That’s another biggie. I hope your dentist has a good explanation for these two kind of serious errors.
To be clear here, the idea of the implant perforating the sinus is an issue with oral surgeons, with many maintaining that it isn’t a big deal. Others say that it is an indication of sloppy surgery that just increases the risk of implant failure. Many surgeons will say that they have perforated the sinus many times with implant placement and the site heals and everything is fine. But others will point to cases where this has allowed infection to get in around the implant from the sinus cavity. And then they also point to the issue of how much bone support the implant has. For however much the implant pokes into the sinus, that is that much less bone that is supporting the implant. I believe almost all surgeons will agree that while they may be able to get away with an implant sticking into the sinus one or two millimeters, “a few millimeters” is too far.
I don’t know what prompted the removal of the implant, but you’re lucky that this happened just six months from its placement, hopefully before anything was attached to the implant. Others who have had a sinus perforation from a dental implant haven’t been so fortunate. They have had persistent nasal problems for years after the implant restoration, only resolved by removal of the dental appliance that was attached to the implant and then possible bone grafting to repair the defect created followed by re-doing the implant surgery,
The standard of care for implant surgery requires the dentist to take whatever x-rays are necessary—preferably three-dimensional ones—to insure that there is enough bone present to stabilize the implant. So my question is, what is your surgeon going to do to insure that this doesn’t happen again? In other words, if your implant ended up so far into your sinus, there’s not enough bone there to support the implant. That would call for some bone grafting. In the area of the sinus, this is usually done in what is called a sinus lift procedure. Has your dentist suggested that?
I want to be careful here, because I have an incomplete picture of what is going on with you. But just from what you have told me, if I were getting an implant and my surgeon, in placing the implant, punctured my sinus and there was no osseointegration of the implant with the bone, I wouldn’t want this surgeon doing any more work on me. For you, as a minimum, I would get some answers about this, and maybe a second opinion.
– Dr. Hall
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About David A. Hall
Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.
Reply from Kelly M.
Hi Dr. Hall,
Thank you again for your help.
I’ll give you the rest of the timeline and what happened at each step so you have a better picture. (First, I would like to say that he came as a highly recommended OS with a great reputation.)
1. The OS extracted tooth (#2) and did a bone graft at the same appointment. After I complained of sensitivity of the back tooth and a weird smell for quite some time (2-3 months). He told me he did not see anything and that I was not cleaning it correctly. I disagreed and went to my regular dentist who found a flat tooth fragment tucked in the gum next to the back tooth. He removed it and told the OS he had missed a piece. As it turns out, the smell went away but the gum next to the back tooth receded significantly and I had persistent tooth sensitivity. The OS said sometimes that happens.
2. Four months later he placed the implant and sewed a gum flap over the hole. He sutured it up and coated it all in oral “superglue.” It was the most painful experience because all of the sutures became a solid piece of glue with rigid spikes. A week later I went back to have him cut them back because my tongue and cheek were torn up and bleeding. He did. Two days later it came off in one piece. Sadly, the sutures came out the third day leaving me with an open site and a long piece of gum hanging in my mouth until it “shrunk.” … With in a week that same smell came back.
3. I went back to the OS to have him look at the site. I also asked to look at the x-ray (2d was the only kind he took) and that is when I asked if it went into my sinus. He said yes… a little but it’s no big deal. He said that cancer patients get implants that go way into the sinus and it’s not a problem. I told him that I was afraid of having sinus issues and he said that the sinus tissue would grow over the implant and heal on its own.
4. I went back to have him check out the smell that was persistent. He talked about my cleaning technique. I asked for a CT scan to see if there was an issue that we were missing. He said ok. It came back and showed thickening of the sinus lining above the implant (which he said was normal). He did not notice anything else.
5. I was scheduled to have the abutment placed and he recommended I see a periodontist to get a gum graft to fill in the hole where the gum was not filling in. The periodontist looked at the CT scan and saw what he thought was 60% bone loss. He called the OS and said that the gum tissue looked good but the implant was failing.
7. The OS agreed to remove the implant.
I hope this helps with the rest of the story.
Do you think I should ask for a refund so that I can have another OS redo the implant? I believe he made too many mistakes along the way and I don’t want to risk it happening again. Also, do you think my sinus will go back to normal?
Sincerely,
Kelly McCoy
Comment by Dr. Hall,
I guess your experience shows that “great reputation” does not equate to “great oral surgeon.”
I do think you have leverage to ask for a refund. From what you’ve told me, I wouldn’t want this oral surgeon to do any kind of procedure on me. I would start by nicely asking for a refund and, if you have any difficulty, you can suggest that you might report him to the dental board or even call a lawyer. There were several things here that in my opinion fall short of the standard of care—the 2D x-rays, the implant in the sinus, the tooth fragment that was left behind, and, the bottom line, the failed implant. Not to mention the inconvenience, pain, and delays you have experienced due to what appears to be substandard treatment.
And yes, I think that your sinus will go back to normal with no further attention. However, I’m guessing that you probably need additional bone grafting here for a dental implant to be successful—possibly a sinus lift procedure.
The sensitivity you had in the adjacent tooth was most likely from the root being exposed, which is a common occurrence after the extraction of an adjacent tooth. The gum shrinks as the extraction site heals, exposing that root. But he did bone grafting which should have minimized any shrinkage.
– Dr. Hall