The Toxic Tooth: APPENDIX D Surgical Protocol for Extractions of Root Canal-Treated Teeth and Cavitation Surgery

 

APPENDIX D

Surgical Protocol for Extractions of Root Canal-Treated Teeth and Cavitation Surgery

General Observations

Tooth extractions, especially of infected teeth such as those having received root canal treatments, and cavitation debridement are surgical procedures performed in the oral cavity that involve both the soft tissues of the mouth, such as the gingiva, and the bones of the maxilla and mandible. Strict adherence to surgical protocols, such as those practiced by orthopedic surgeons, should also apply to oral surgery procedures.

It must be remembered that dentists, as surgeons of the oral cavity, are still operating on bone. Although the mouth is a more forgiving place to operate in terms of the healing of soft tissue, infected bone is difficult to completely heal no matter where in the body it is located. With the inability to isolate and create a sterile field when operating in the mouth, the potential to develop a post-surgical infection in the jawbone is always a possibility.

Furthermore, the ability of the mouth to rapidly heal soft tissue infections tends to make many dentists feel that infected bone in the mouth will heal just as readily, which is not necessarily the case. We now know how easily cavitations develop, and the seemingly complete X-ray appearance of healing after many routine dental extractions remains an illusion. Accepted surgical procedures must be followed everywhere in the body in order to optimize the chances of complete healing and complete clinical recovery.

If some of the periodontal ligament remains in the tooth socket after an extraction, or there is a failure to remove all of the infection in the jawbone, the remaining hole in the jawbone may not completely fill in with new bone. This void in the jawbone is called a cavitation and by its very nature,

it can be a prolific breeding ground for the same bacteria that infected the tooth in the first place. Because they are often surrounded by intact jawbone, cavitations often escape X-ray detection.

Therefore, to optimize the chances of complete healing and complete clinical recovery accepted surgical procedures must be followed everywhere in the body—and especially in the mouth.

Oral Surgery Protocol

1. A complete patient medical and dental history, including consultation with all treating physicians, is essential before treatment is rendered. As the mouth is not isolated from the rest of the body, such a complete history is important. Nearly all dental procedures, especially surgery, have systemic, body-wide effects.

2. A thorough dental evaluation of the hard and soft tissues of the oral cavity is essential. The examination should include all necessary X-rays, along with a complete clinical exam that includes pulp vitality tests of the teeth to determine which teeth are healthy and alive and which teeth might be unexpectedly nerve-dead and non-vital. Any additional tests that may aid in diagnosis and treatment planning should also be performed. It is important to point out that pulp vitality tests are an integral part in assessing the health of the teeth that did not receive root canal treatments. A dead, non-vital tooth in the mouth can be just as serious as a root canal-treated tooth.

3. After the initial assessment of the patient’s condition, a treatment plan must be established. If the treatment plan includes extractions and/or cavitation surgery, it is important to seek a surgeon who is not only surgically skilled, but who also has the ability to deliver intravenous medicines. Intravenous sedation is often necessary, and there must also be an access for the administration of appropriate antibiotics.

4. Alternative treatments such as the injection of various remedies into the site of infection, like the bone around a root canal-treated tooth or around other infected teeth, should not be done.

Similarly, no injections should be made into cavitation sites. Many of these treatments actually make the disease process worse. Furthermore, there are some dentists advocating the use of these medicaments instead of surgery. It is impossible to restore dead bone to live bone again with any medication. Surgery must be performed to remove all of the dead and infected bone as well as establishing adequate perfusion of blood from adjacent healthy bone into the surgical site. This is the only way healing can occur.

5. Optimally, teeth should be cleaned up about two weeks prior to surgery to reduce the amount of bacteria present in the mouth and lessen the chances of post-operative infection. Laser curettage in the sulcus around each tooth can dramatically reduce the presence of bacteria even further.

6. General medical clearance, when appropriate, should be obtained.

7. A written informed consent signed by the patient should be

   obtained prior to the planned procedure. All potential complications of the procedure should be thoroughly discussed. It is preferable that a family member also participates in this consent, especially to help verify that all that has been discussed is fully understood. Consideration might be given to a videotaping of the discussion of the consent, which gives the dentist further evidence that all information was discussed and was completely understood by the patient prior to signing the consent form. With the advent of the smartphone, this can be more easily performed than ever before, and the recordings can be readily stored in computer files for easy access in the future.

8. Preoperative medications such as antibiotics should be administered.

9. The oral cavity should be cleansed with an appropriate antimicrobial agent.

10. Local anesthetic without a vasoconstrictor should be used. Vasoconstrictors lessen the blood flow in the injected area. Good blood flow to the surgical site is necessary to help assure the best chances of complete healing. Even the transient vasoconstriction produced by anesthetics with a vasoconstrictor can cause enough ischemia to injure the bone and cause local cell death.

11. Surgery should be performed so that the total lesion can be removed. The surgeon must be skilled in operating around the inferior alveolar nerve (the main nerve that runs through the lower jaw) as well as operating through the sinus floor and into the sinus. Many times the lesions seen around cavitations and root canal-treated teeth are more extensive than they appear on X-ray. It is important to remove all of the diseased tissue. This means that the surgeon should be skilled in operating around all these anatomical structures. Otherwise, the patient should be referred to another surgeon.

12. Usually, the extraction of an infected or root canal-treated tooth requires adequate exposure of the bone surrounding the tooth for good visualization in order to access the infected areas. This is obtained by laying a “flap,” which simply means that the gum tissue is gently lifted off the bone. The word “gently” is emphasized here since there is a thin layer of tissue that lays directly adjacent to the bone called the periosteum that must be treated with care. The periosteum is the tissue that supplies the outside of the bone with nutrients, and it is also where many of the sensory fibers that can cause post-operative pain are located. It must be treated with respect and handled gently. The kinder you treat the tissue during any operation the less postoperative complications will occur, and the better healing will proceed.

13. Surgical sites should be irrigated with saline solution or antibiotic solutions that are acceptable for use in orthopedic surgery. We again must remember that we are operating on bone. Plain water should never be used and medications that have not been evaluated for use in bone elsewhere in the body should also never be used for surgical sites in the jawbone.

14. Extractions should be performed as atraumatically as possible. That means that teeth with more than one root such as molars should usually be sectioned and each root removed individually. This technique avoids fractures of the bone and is kinder to the tissues. Dentists were taught in dental school to “expand the socket” by rocking teeth back and force. The term should be “crack the socket” because cortical bone does not stretch and any

expansion is obtained by breaking the bone. This should be avoided. Surgical removal of bone when indicated is a much better option and should only be performed with a surgical handpiece (NEVER a dental drill), accompanied by copious sterile saline irrigation (not plain water). Dental drills can introduce air into the surgical site that can form an air embolism. An air embolism is a dangerous situation that can cause death. In addition, dental drills use plain water as an irrigant. This water is not sterile and is not physiologic in terms of salinity. Plain water can cause bone cells to die.

The remainer of the protocol addresses both the proper cleaning of the extracted root canal site as well as the cleaning of a cavitation.

15. The approach to cavitation surgery is basically the same as the process followed to clean out the socket where a root canal- treated tooth was extracted. After tooth extraction, access to the diseased granulation tissue and bone at the bottom of the tooth socket can be readily obtained. Access to a cavitation site is gained by making a mid-crestal incision and reflection of a full thickness mucoperiosteal flap to the buccal side of the jawbone and extending to the mucogingival fold. Using a round burr in a surgical handpiece and with copious saline irrigation, an opening is made in the crestal bone large enough to allow complete access to the cavitation.

16. Removal of the infected and ischemic bone can be performed initially with a surgical drill at low revolutions per minute with copious irrigation. It is important to keep the temperature of the bone as cool as possible. Aggressive use of a surgical drill will cause an increase in bone temperature due to friction. The bone cells in contact with the drill will die. Dead bone cells are exactly what we are trying to remove and therefore the formation of more dead bone cells must be carefully avoided. Most of the surgical debridement should be performed by hand with surgical curettes.

17. The surgical site must be continuously flushed with an irrigation solution such as 0.9% saline solution.

18. Sometimes bone grafting or sinus closure must be performed. Be sure to discuss this with your surgeon.

19. Closure of the surgical site should be accomplished with sutures.

20. Antibiotics should be given postoperatively to prevent re-

    infection or systemic dissemination of existing infection.

21. Sutures should be removed in seven to ten days.

22. Patients should be instructed to keep pressure on the surgical site

    by gently biting on surgical gauze. This helps control bleeding as well as keeps the flap close to the bone during the initial healing phase.

23. Ice should be applied to the side of the face for twenty minutes, then removed for twenty minutes. This should be repeated throughout the entire day of surgery but should not be used the following days.

24. The day after surgery the patient should gently rinse with a mild, warm salt water solution (1/4 teaspoon of salt in an 8 oz. glass of water). This should be done three to four times per day.

Cultures for aerobic and anaerobic bacteria as well as for fungus should be obtained immediately after extraction or entry into a cavitation site to get a “clean catch” sample. A clean catch sample is a sample that consists of only tissue within the surgical site without contamination. By ensuring good isolation and surgical suction, the surgical site will be free from external contamination and the sample will only contain pathogens present within the surgical site, and will not contain pathogens that may be introduced from the rest of the mouth.

These microbiological samples must be placed in the appropriate culture tubes and the laboratory instructed to let them incubate for at least two weeks. Some of the anaerobic bacteria and fungus take a long time to grow and discarding the sample after just a few days may miss the presence of important pathogens.

Bone tissue samples should be taken from all areas of the surgical site and sent for microscopic analysis by an oral pathologist. Acute and chronic osteomyelitis, osteonecrosis, and other disorders can be determined by

microscopic evaluation. The results of the microbiological cultures and tissue pathology will assist in determining the need for any further treatment such as appropriate oral or IV antibiotics.

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