One Dental Issue, Two Solutions - Apicoectomy Redux or Extract/Implant (with picture!)

July 2, 2009 11:36 AM

(Technical material ahead!) Differing advice from dental specialists for an urgent procedure. Situation: Failed apicoectomy (10+ yrs) that has developed an active and gross fistula. My current endodontist wants to do a repeat procedure, adding bone graft. Says there's a good chance of saving tooth, for "at least five to ten years." (Direct quote. If the tooth is cracked - xrays can't tell - it might require extraction.)

At same time, I'm having an implant (unrelated, different doc.) The implant guy thought that, given that this was a repeat procedure, I was likely to lose the tooth in question, and sooner rather than later, and that I should just do the extraction and begin the implant right away.

To some extent, each guy is playing to his speciality, I know, and I trust that both are good dentists in that regard.

Some possible criteria:

- Money matters. Both procedures are expensive (about the same, ultimately) and I'd don't want to pay twice.
- I know saving a tooth is important, but it seems like I'm going to lose it anyway. I'm 47. Given the time-span estimate by the endodontist, am I really "saving" anything?

For those so inclined, here's the xray of the tooth.

posted by soulbarn to health & fitness (11 comments total)

I am assuming that the fistula involves gum tissue so... were it me in your circumstances I would seek additional consult and perhaps a deciding opinion from a periodontist.
posted by bz at 11:42 AM on July 2

No, the fistula is from the infected root, from what I understand; the infection is bulging out, creating what's basically a pimple.

Also, if anyone knows of any more dental-specific forums where I might post this question...

thanks!
posted by soulbarn at 11:51 AM on July 2

Addendum: My reasoning for involving a perio is that, typically, their expertise encompasses the health of the gum and the health of the underlying bone. The perio focus is a little broader than either specialist you are currently seeing and often includes implants as well.
posted by bz at 11:52 AM on July 2

Oops. I missed your response. Yeah, that pimple is often referred to as a "gum boil." More than ever, I recommend seeing a periodontist for an assessment.
posted by bz at 11:54 AM on July 2

That's a single tooth x-ray. Has a whole of mouth one been done? That would give a great deal more information about whether the problem is localised (it may not be).

No-one can guarantee that either procedure will be permanently successful. The failure rate for both is non-trivial, so one question I would be asking each provider is the time period for which they're willing to do additional corrective work free of charge. Are there any lifestyle factors which would increase the chance of an implant failing - smoking is a big one?

It was only when I worked for a dentist for a while a few years ago that I found out many dental procedures are not as permanent as I'd previously thought, so a reasonable question to ask your providers is what kind of maintenance work you may need done over the next ten years and the cost of that work.
posted by Lolie at 11:56 AM on July 2

That's interesting. It feels like good advice, though (honestly) I'm feeling rather exhausted with dental visits right now. On the other hand, every tie needs a breaker...
posted by soulbarn at 11:59 AM on July 2

Thanks, Lolie -

I suppose my question with "non-trivial" failure rates (which I'm well aware of!) would be what kind of maintenance would or could be done? Both endodontist and implant specialist seem to agree on one thing: if their work fails, I lose the tooth (the only difference is that if the endo fails, I go to the implant specialist...)

I know, all is risk and there's no right answer. As far as what else is going on, I am getting another implant, but it isn't in the same quadrant, so there's nothing else happening near that particular tooth (which is #14.)
posted by soulbarn at 12:03 PM on July 2

I had almost this exact same scenario two years ago. Despite the higher cost, I decided to have the tooth extracted and an implant put in. My reasoning was that there was a fairly high chance that a second apicoectomy would fail and it would essentially be throwing money away (why pay $1500 for a repeat procedure that isn't likely to help the tooth survive, only to have it eventually extracted anyway and replaced with an implant).

A second opinion from a periodontist about whether he/she thinks your tooth can survive is probably worthwhile. That it's been 10+ years since the apicoectomy, my gut feeling is that there's probably too much damage to the root, but that's totally a guess.

FWIW, I wasn't happy about the high cost of the implant, but for my situation it was the correct move. My tooth and its root were too far gone to save and I had the same tell-tale fistula that you're talking about. It probably didn't help that I ignored the fistula for 6+ months, foolishly thinking it would go away or heal itself.

So here's how I'm seeing this:

Option A: Pay a smaller sum now for an apicoectomy that may or may not save the tooth for "5 to 10 years", after which you'd need it extracted and an implant put in anyway.

Option B: Pay a larger sum now to have the tooth extracted and replaced with an implant. An implant is guaranteed never to further deteriorate...you're essentially replacing a bad tooth with a fake one that's screwed right into your jawbone (whee!).

Without any further info to consider, I vote for Option B. But get a second opinion. Good luck!
posted by mrbarrett.com at 12:07 PM on July 2

I suppose my question with "non-trivial" failure rates (which I'm well aware of!) would be what kind of maintenance would or could be done?

A perio is probably the best person to ask about that (I'm not trying to be evasive, it's just that our healthcare systems are totally different in terms of what level of care is delivered by whom) as periodontal disease is one of the things most likely to lead to failed procedures (from memory, it's a factor in something like 70% of tooth loss in adults).

As you're already going to be up for the cost of having another implant maintained, maintenance work might not be as much of a factor for you as it would for someone else. To be honest, a lot of the problems my dentist saw with crowns, bridges and implants were caused by patients totally ignoring the maintenance requirements for those particular procedures. Make sure that you're clear about what at-home maintenance is required and that you actually do it, as well as keeping your regular appointments for in-surgery maintenance. You really don't want to see what can happen if you don't.
posted by Lolie at 12:26 PM on July 2

Thanks, Mr. Barrett -

Don't know where you live (I want your dental pricing!) but here in SoCal, I'm getting pretty equal quotes for the two procedures...

The apicoectomy is about $2300 (not including the crown I'll need after.) That's because he's recommending a bone graft.

The implant is about $2700, also not including the crown.

So the difference, while certainly not trivial, isn't huge. Both are expensive, which makes your argument even more convincing.

The implant, of course, isn't guaranteed to succeed. But it isn't guaranteed to succeed either now or later. So that's a wash (assuming I'll lose the tooth eventually - which even the endodontist seems to think is likely.)

I suppose my reasoning is pretty simple:

- Will I lose the tooth at some point.
- Answer: Yes.
- Then might as well do it now.

Still, seeing a perio is an idea that I'm going to follow up on.
posted by soulbarn at 12:37 PM on July 2

I have the apicoectomy performed in NYC about four years ago. It was approx. $1600 and did not include a crown--just the surgery and no bone grafting...just some kind of "cleaning out" and removal of the infected tissue, etc. In the end, it was unsuccessful and the fistula returned.

My implant was $2600, performed in Brooklyn.
posted by mrbarrett.com at 12:45 PM on July 2