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My sinus perforation hasn’t healed and it’s been 5 months

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I had a molar extracted in May. There was a sinus perforation and after about 3 weeks a piece of bone came out and I thought it healed over. I just recently blew hard on something and the point of extraction pushed my partial away from my gums. Will this heal over or do I need to do something more? My dentist retired last month and I’m not sure what to do now.

– Jana S.


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Jana,
From May to October – that’s five months. This perforation should have healed by now, but if there is continually air passing through it, it can be tough for it to heal. The dentist who did the extraction should have followed up on this and if he or she didn’t know how to treat it, should have referred you to an oral surgeon to repair it. If he or she were still in practice, I would have gone back to them and asked that they refer you to an oral surgeon. The reason I would go back to the dentist rather than straight to the oral surgeon would be to invite your dentist to take responsibility for the post-operative care you are requiring. As I have said in other posts on this subject, a sinus perforation can happen to any dentist and isn’t an indication by itself that anything was done wrong. Some of these maxillary molars have roots that are right up against the sinus with only a thin layer of bone or even a thin membrane separating them from the sinus. But the dentist should realize that a perforation has occurred and should provide proper treatment to close the perforation and stay with the case until it is properly healed.

It also sounds like there may have been a bone fragment pushed into the sinus, which could be risky. Fortunately it came out on its own.

I’m guessing, since you know that your sinus was perforated, that your dentist realized that and told you. But then clearly the opening wasn’t closed by the dentist and no follow-up care was provided. If there is a new dentist taking over and you are staying with this dental practice, I would let the new dentist know what has happened and then ask for a referral to an oral surgeon, with a polite request that the expense of this follow-up care be covered by the practice. If the practice was sold to the new dentist, the sales contract should include provisions of how these post-operative complications are handled in the practice transition.
– 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.

Bone grafting for my dental implant didn’t work

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Dear Dr. Hall,

I chose to use my regular dentist to do a dental implant as he has done hundreds of them over the years. When first attempting to place the implant, he informed me that I would need to have a bone graft first. He did the bone graft, then, after healing, I went back for the implant. He again attempted to place the implant but had to remove it as he said the bone was still too thin and he couldn’t do an implant after all. So now after three surgeries, I am left with no implant and the suggestion to get a bridge instead. Is it possible this could have also happened with a specialist?

Thank you,
Linda Cohn

Linda,
The short answer to your question is that no, I doubt this mishap would have happened with a dental implant specialist. Although dental implantology is not a recognized specialty in dentistry—there are just some dentists with more advanced training and oral surgeons and periodontists who specialize in surgery.

However, I don’t want to be too hard on your dentist. It sounds like he is really trying to do the right thing and may have a lot of experience with implants, but bone grafting is a tricky procedure, and I think he may be a little short on experience with that aspect of implant dentistry. He may be just starting to get into the grafting. Any dentist who tries to explore new skills is going to have things like that happen.

A dentist of lesser integrity would have just plowed ahead and placed the implant. It would probably have done just fine for a while and then failed at some point down the road. So I think he has done the right thing.

Let me share a story of the first set of porcelain veneers that I placed. As time went on, I became accredited in cosmetic dentistry and felt that I produced truly beautiful work. But, as with any dentist expanding their knowledge, I had a first case. The patient would come back for regular checkups, and as my skills improved, I became more and more dissatisfied with how her smile looked, since it was very mediocre. Finally, I think it was after three or four years, I shared my feelings with her and offered to re-do her case for free, and she accepted.

It sounds to me like your dentist is leveling with you, and feels like you will end up with a fine result. For a single tooth, a dental bridge or a dental implant are two acceptable ways to treat the case, each with their pros and cons. If you really want to go with the dental implant, you could ask your dentist to refer you to a periodontist or oral surgeon with extensive experience in dental implant surgery.

– Dr. Hall

Do you have a comment or a question or anything else to add? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

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.

Follow-up on Lyndi’s sinus perforation after extraction

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About three weeks ago I published a post about a patient named Lyndi who had a large sinus perforation after her extractions. She responded telling me about her subsequent experiences, and I gave her some additional advice. Here is a copy of the follow-up correspondence with her.

Hi again Dr. Hall,
I thought I would send an update. I waited the full 2 weeks and saw the oral surgeon for the follow-up this week. In the meantime, I developed yet another bad sinus infection. I had my family doctor call me in antibiotics because I was really scared this infection would spread. I am still having a ton of drainage, but only from the left side, where the perforation occurred. It still pours out my left nostril when I gargle and I have had that same drainage in my denture. The oral surgeon poked around with a q-tip, which was very painful, and said the hole is sealed. He also had me plug my nose and blow (I didn’t blow hardly at all for fear I’d make it worse). I questioned him due to the above symptoms and he basically crossed his arms and said “look I told you the hole is healed and you don’t need surgery. You should be happy.” I explained that news sounds great, but I’m confused and that was the end of my appointment. I’m so lost, still quite sick (4 weeks straight now) and really don’t know where to turn.

I don’t want to make trouble but I am extremely frustrated. I’m out of sick pay, so I’ve lost some pay and also had to work even though I’m sick. I am emotionally and physically exhausted. I still can’t eat well, can’t chew at all for the pain is intense and not worth it. I’ve lost at least 15 lbs and I’m small to begin with. I deal with this horrid smell/taste all day every day and I know it is the infection. I explained all this to the original dentist. Again, any advice would be much appreciated. I am a social worker and advocate for people every day, but for some reason I’m having trouble being heard in this situation.
Lyndi C.

Lyndi,
I’m just going on what you were able to tell me, but the feeling I got from what the oral surgeon told you as opposed to what the ENT doctor told you was that the ENT doctor was the one you should trust. I don’t like it when doctors talk to you the way you are saying this oral surgeon was talking to you. Lecturing you that you should be happy? You’re not happy, and he should care enough to listen to why. There are two ingredients to quality medical and dental care–competence and caring. One without the other isn’t quality care.

Why don’t you just stick with the ENT doctor? It doesn’t sound to me like this oral surgeon cares whether you are sick or not or how much work you are missing. And the oral surgeon could well be buddies with the dentist. He probably gets referrals from her, so part of what is going on may be that the oral surgeon is trying to downplay the seriousness of your complications to protect the dentist.
Dr. Hall

Second follow-up, a couple of weeks later

Dr Hall,
You have been so kind to answer my questions and I appreciate it a great deal. I do still have a small hole that does not want to heal for some reason. I’m under the care of yet another ENT who appears to be taking me seriously. I wanted to update you as I finally received my medical records from the original dentist. My “informed consent” does not have a date, nor my signature. As a matter of fact, on the signature line it states, “reviewed with patient, not signed due to sedation.” Apparently they said they went over this with me the morning of my procedure, while I was under the influence of benzos, as I had been prescribed and told to take both pills 1 hour prior to my appointment. The dentist is refusing to pay my medical bills, saying they forgave my balance with their office in order to free up my money so I could pay the medical bills. I am completely aghast. I have called an attorney but still waiting for a call back. Any comments or advice is appreciated.
Thank you for your time.
Lyndi C.

My response:

Lyndi,
From what you have told me, you have a very valid complaint, and I have some words of advice for you.
First, I would tell the dentist that you are contacting an attorney and let them know that they could make this a lot easier on themselves if they just pay your medical bills, if that’s all you’re asking. When you mention that an attorney is going to get involved, that should trigger a call by your dentist to her malpractice insurance carrier, and they would likely advise her to settle this before it gets out of hand and may reimburse her for any expenses involved in settling it.
You didn’t give them consent, so they are on pretty shaky ground. It seems reasonable to assume that you were too sedated at the time to sign your name, so clearly you were too sedated to give consent. But you have more grounds than just that, as, from what you have told me, they fell short of the standard of care in several important respects.
I may not be getting all this right, but I’ll make a list of what is in my head of their mistakes, as I remember your case and refresh my memory by scanning your emails.

Mistakes made by this dentist:

1. Not getting informed consent from you (consent under sedation isn’t consent).
2. Poor extraction technique resulting in bone fragments being left at the surgical site, a large sinus perforation, and infection (and, I suspect, material being pushed up into the sinus).
3. Not telling you on the spot that there was a sinus perforation.
4. Not beginning treatment of the sinus perforation until the day after.
5. Starting off with the wrong antibiotic.
6. Not changing the antibiotic in a timely manner.

They should compensate you for all the post-operative care expenses you incurred, not to mention the time you missed from work, in my opinion. And, if your case got into court, I think you would be entitled to significant pain and suffering damages and possibly a punitive award.
You also have remedies beyond just going to an attorney, and you might want to let them know you are aware of those. You could complain to the state dental board, and you could complain to the dental insurance company. The dentist would not want either of those to happen.

You could let the attorney know that you have shared details of this with me and that I said I believe you have a strong case. A requirement of any successful malpractice case is the opinion of another professional that the care was substandard. But hopefully the dentist will be reasonable and you won’t need to take that step.

The oral surgeon is very possibly a buddy of the dentist, which could be why you didn’t get very good care there and had to go to the ENT physician.

Dr. Hall

Question and answer go here.

Do you have a comment or a question or anything else to add? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

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.

She wants two teeth out but the surgeon only wants to take out one

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Dr. Hall,
I have been having all sorts of dental work done, two root canals on the top left one which was a retreat. I also have an inpacted wisdom tooth on the bottom left which has been inflammed and the root canals still does not feel quit normal. I was wondering if the inpacted bottom wisdom tooth could have something to do with that. Any advise would be greatly appreciated.

I have been having ear pain and neck pain which the oral surgon said is normal with impacted wisdom teeth. I have not had it pulled because i want to haveboth bottom teeth taking out at the same time and he wont do it for some reason.
– Christine from Maryland

Christine,
I’m not sure why you’re not following the advice of your oral surgeon and asking me. I can’t see the x-rays and can’t examine you, so I can just guess, but I’m guessing that your oral surgeon doesn’t want to take out the root canal tooth because there’s nothing wrong with it. I can’t think of another reason. I’m sure he would charge money to take it out, so he would gain financially from having it out. He sounds to me like a man of integrity and I would follow his advice.

You’re playing with fire to leave that infected wisdom tooth in your mouth. The ear pain and neck pain are warning signs – your body is trying to tell you to get this taken care of.  Those infections can flare up and can, on rare occasions, become life-threatening.

Dr. Hall

Links: Infected teeth.

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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.

Which Oral Surgeon should I go to?

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I am 43 and in good health. I have 2 impacted wisdom teeth on my left side and am beginning to have some jaw discomfort and some sinus issues. I have had one consultation with an OS (referred by my dentist who is great but the OS was pretty matter of fact about the situation and did not make me feel comfortable either way). I was wondering if you could give me some recommendations on some OS in the greater Phoenix area whom you would deem “great all around, hence their experience, bedside manner of understanding and making the patient feel good about their decision and what he recomments, etc….” I have never had any surgeries and am quite concerned about any permanent nerve damage. Thank you so much.
Lynnette in Phoenix.

Lynnette,

I really don’t have any comparative information about oral surgeons in the Phoenix area. A practicing dentist in Phoenix would have more information and insight and have heard more about this.

I can tell you that, in order to protect themselves legally, oral surgeons will tend to overstate the risks involved in the surgery. If they don’t, and something goes wrong, patients will sue their pants off. That’s just the world we live in. They’re protecting themselves.

If there is any reasonable chance of your wisdom teeth on your right side of ever bothering you, and if your oral surgeon agrees that they would be better to come out, I would have them out at the same time. The healing time is the same, and the discomfort is about the same, whether you have two out or four. If it were me, I’d get them all out and be done with it.

Meanwhile, tell all the teenagers you know and parents of teenagers to have these wisdom teeth extracted before they’re 25. When the patient is under 25, the incidence of complications is much much less.

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.

Should I have my wisdom teeth out at age 42?

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Wisdom tooth removal.

I am 42 yrs old and have been told I need all 4 removed. My dentist said 1, the oral surgeon wants to remove all 4. Only one has come through the gum and has given me trouble. The other 3 don’t bother me at all. In your opinion, is it necessary to remove all 4? I am worried about complications and really only want the one removed in hopes to reduce risks of complication and recovery time.
– Mary from Texas

Mary,
I don’t know what your x-rays show as far as the potential for these wisdom teeth bothering you, but I can give you some general guidelines that hopefully will help.

If your wisdom teeth aren’t erupted at age 42, they should have been taken out when you were around 20. The chances for causing complications increase with increasing age. When you’re 20, they are fairly easy to remove. They are considerably harder now. They will be harder yet in 20 more years. I don’t know how long you’ve been going to your current dentist, but if this tooth has been poking through the gum, he should have recommended having it out as soon as he saw it.

Another principle is that it is usually best to take them all out at the same time. If there is any significant potential for them causing you trouble and they aren’t in a particularly risky position, I would advise having them all out. The amount of discomfort is only a little more and the healing time is the same. I can tell you from going through this experience with a number of patients that it is an awful pain to deal with four surgeries, one after the time that each tooth starts to bother you, instead of just one. And it’s much better to choose the time when you have them out rather than have the time thrust upon you. What if they start to bother you when you are having some medical crisis? It could be a really nasty time for you.

Another useful piece of information is that complications surrounding the extraction of upper wisdom teeth are minor and transitory. They are much easier to take out.

Hopefully you have a feeling of trust in your surgeon that you will get straight, honest answers. I would ask this question about the lower wisdom tooth that isn’t the current problem tooth. Is it totally impacted in the bone – totally underneath the surface of the bone – or is it poking through the bone and could be exposed by merely raising a soft tissue flap? If it is totally impacted in the bone, the chances for it causing you trouble later on are much less. If it is poking through the bone, there is a greater chance of infection getting in around the tooth. Often it’s just a matter of time before they become infected. In my practice, I always advised that patients have all their impacted wisdom teeth removed, except if they had reached the age of 40 without them causing any trouble and they were totally impacted in the bone. I reasoned that if they had gotten this far without them bothering the patient, and there was no easy path for infection to get to the teeth, that the risks of surgery began to outweigh the risks of leaving the teeth alone.

I hope this helps.

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.

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