Q: I am in the process of having an implant put in. The titanium screw was placed (minus abutment) with bone and gum grafting done at the same time. How long will it be before I can put my suck down (temporary denture) back in? The gum area is still swollen and I’m afraid it will interfere with the healing process and graft (the gum line has been built up and is now over the denture. Is that because of the swelling and it should fit again once swelling subsides?).

A: It could take a week or so until it really heals and shrinks. You should have a soft tissue reline and check in with your dentist to verify the healing is going well. You do not want to put pressure on the surgical area.

Q: My gums have receded a little after extraction followed by gum grafting (eye tooth). Is this normal? Now I have spacing between the temporary tooth and gums.

A: It is not uncommon after extractions to have the gum shrink.  We routinely bone graft, laser, and soft tissue augment to avoid this result. You can speak to your dentist about relining the temporary tooth to make it look more natural.

Q: I had a tooth extraction and bone graft yesterday and have been very careful not to disturb the area or rinse, etc. The tooth was an infected molar very close to the sinus. The dentist used ground cadaver bone and covered it with a membrane. This morning all seemed fine, but now there is a lot of white stuff hanging down from the hole where the tooth was. It looks like all the stuff put in the socket is just falling out and I’m afraid to close my mouth or eat for fear of losing all of it. I touched the stuff a little with my tongue to try and push it back in and it’s sticky, not grainy as I would expect bone to be. I also don’t see any blood or red stuff like I’d expect with a clot. My dentist’s office is closed and it may take a few days to get me in. Is there anything to be done in the meantime?

A: Your dentist must have a answering service or a way to deal with emergencies. I would suggest calling and explaining to the treating doctor exactly what you have described here on this forum. They know what procedure was performed and how to deal with this episode. You should insist on being seen, or if necessary, see another doctor such as an oral surgeon as soon as possible.

Obviously, don’t eat on the side of surgery and try not to sneeze. Follow your post-operative instruction sheet (hopefully you got one) and remain on the prescribed antibiotics until you are seen. Please go as soon as possible. Don’t delay.

Q: After having a lower molar removed, the oral surgeon did a bone graft as I was considering an implant. This was two years ago. That area has felt uncomfortable recently and the oral surgeon went in and cleared out the area. He indicated that the graft did not work. He said it was still in little particles as though it had just been placed there. And he indicated that he had never seen this happen before. My question is, what are the possible reasons that this occurred? And should I try again? I spent $500 out of pocket already. Thank you!

A: I would be curious to know what type of graft material was used. There are many different types available. Some have a predictable record and others are less proven for reliability, although still used. It is extremely rare that this happens in our office. Were there any medical conditions that might have influenced your healing? Did you have any problems when the bone graft was originally placed? As you can see, there are many reasons that could explain why the graft failed. Perhaps using a laser next time around will help prevent any future infection or rejection. Best of luck. Dr. Eric Linden

Q: I had a molar tooth extraction and bone grafting several days ago. I had the swelling and pain, used ice packs and then heat as advised, taking antibiotics, and have a mouth rinse as well. My cheek looks like it is attached to my gum by the tooth. I have stitches and this lump is bothering me so much that it is hard to function. It is as though the graft material is too much and feels as though I have a wad of cotton or food stuffed in the area between my jaw bone where the gums are and my cheek. The ridge is basically gone and there is no gap between my cheek and teeth. Is this normal? Can swelling do this or is this just the healing process and will it go back to the way it was? I’m upset and not sure what to do.

A: I would immediately call your treating Periodontist and have the area checked. The healing could be in the normal range or it might be infected. It is hard to diagnose here. You might want to ask the periodontist if the extraction was difficult, and if there were any issues with closure of the wound. You could ask if there was an infected socket as well. We often use the laser in the extraction socket to avoid any post-operative issues.

Q: I’m having a tooth pulled and my dentist wants to do a bone graft. Is this needed? Can it be done at a later date?

A: We routinely graft bone at the time of our extractions. In addition, we use a special protocol with an ND/YAG laser called “Laser Site Preservation”. The healing is rapid and we don’t get dry sockets and post-operative infections. We prefer not to do a secondary procedure (who would?) to graft the socket. The area should be ready for an implant, bridge, or removable appliance within 3 months.

Q: Can I fly two days after bone augmentation and sinus lift treatment?

A: When we do sinus augmentation and bone grafting in our office we use the osteotome technique, which is much less invasive and puts very few restrictions on the patient’s post-operative activities. However, If you have had a “traditional” “window technique” for your sinus grafting, you might want to check with your Periodontist regarding flying.  The altitude changes can affect your sinuses and the variations in pressure could affect the seal or closure of the extensive wound from the traditional procedure.

Q: I recently had a tooth removed. I have gum recession where the tooth was removed. Can a periodontist build that back up so I can get an implant?

A: Typically, when we extract teeth we do an immediate bone graft and laser procedure (socket preservation) around the extraction socket. If a patient has not had a socket preservation done, then an evaluation for a secondary procedure or possibly more would be necessary to build up the area for a future implant.

Q: My husband is going through the lengthy process of getting two implants which as you know is quite costly. We are getting lots of denials from the insurance company, but pursuing.  Do you know what the rationale would be for our dentist to have done four gum treatments on the same day for two teeth?  Does that make any sense? Thank you.

A: It is very difficult to know what type of gum treatment was done on the two teeth you are referring to. Was it soft tissue grafting?  Did he have a bone graft?  Ridge augmentation? In our practice, it is not uncommon to perform multiple procedures on the same day depending on the needs of the patient.

Q: I just had a second bone graft surgery done 10 days ago. The stitches in my mouth taste really gross and there’s a smell that’s nasty too. My mom said it’s from the blood or because they’re getting ready to come out, since doctor said they’ll be starting to fall out. But I don’t know if that’s right. Can you tell me why I have that nasty taste and smell?

A: The foul taste and smell can be from food debris, plaque, blood products, or an infection. If a periodontal dressing was used, then it can be from bacteria under that area. We usually place our patients on a Chlorhexadine rinse or warm salt rinses for this reason. Ten days is approaching the time for the sutures to be removed or start to dissolve away. Be sure to have your periodontist check this area soon.

Q: I’ve had a bone graft to accommodate an implant.  All the work completed in approximately two years. Shortly after this I had sore spots on my gums and am told by my hygienist that I have chronic Lichen Planus. Can this be the result of the bone graft surgery?

A: Lichen Planus can be brought on by stress or trauma. The bone graft procedure is not the cause of this but merely an event that might have triggered your outbreak. You might want to consider seeking an opinion from an oral pathologist or a specialist in oral medicine if these lesions persist and become a concern.

Q: I had bone graft surgery on my upper and lower gums in Sept of 2011.  Everything has healed well it appears, except from time to time I get a weird cold sensation on one part of my gum.  It happens when I am not eating or drinking. Any thoughts?

A: I am not sure from your description what type of procedure you had done other than “bone graft surgery.”  However, a cold sensation usually would come from a tooth.  It would be advisable to have a periodontist look at this area and take a digital film if necessary and see what is going on around this area.

Q: I just came back from the dentist and was told I have advanced periodontal disease. The doctor I went to wants me to have one tooth pulled w/bone grafting. She then wants to do root/scale cleaning and then gum surgery to further clean I guess. I truly hate the dentist, hence the reason I’m where I’m at. Would laser surgery be something I could consider?

A: I would get an opinion from a well-qualified, experienced, Laser Periodontist (specialist) that is trained in the LANAP procedure before you do anything.  You should be presented with all your options.

Q: Which criteria should be followed for to decide whether a tooth should go for endodontic treatment, in which only bone loss is present?

A: The criteria for performing a root canal are clearly stated by the American Academy of Endodontists.  Generally speaking, if a tooth has decay into the nerve or is necrotic (dead) or has symptoms of severe pain which could include cold or hot sensitivity, and/or shows a radiographic periapical lesion (PAP), then root canal therapy is indicated.  Teeth can be tested as well to see if they are vital (alive) or necrotic (dead).  This is called pulp testing. Just having bone loss alone is not an indication for endodontic treatment. However, having bone loss would justify a consult with a highly trained Periodontal Laser Specialist certified by the American Academy of Periodontology and having  additional certification in performing laser surgery with FDA clearance.

Q: I was just told that I have moderate to advance periodontal disease. I started deep cleaning and scaling. I am being referred to a periodontal specialist by my dentist. I want to know if laser surgery would be a better option instead, to get rid of bad breath, replace any bone loss, save my teeth, and prevent the chronic presence of the gum disease. I realize there isn’t a cure but can the right preventions eliminate these symptoms and prevent any further health problems? When you say “control gum disease” does that mean you will have healthy gums, fresh breath, and good oral hygiene after laser surgery or periodontal surgery? How often will I have to see the dentist after surgery? Every 3 months or every 6 months? I am totally horrified. I wish that deep cleaning or surgery would fix the problem that my gums would just be healthy again. Will they be healthy after this procedure? Please let me know. What is the best option for me? Thank you and waiting for your response.

A: All of your questions are excellent. In our Laser Periodontal practice, as a first step we do a thorough clinical exam and review of a full mouth series of digital radiographs. If we determine that your gum disease requires further treatment, our first choice would be the use of an FDA cleared protocol with the laser. Assuming no other unusual factors, we would prefer to treat the disease without cutting or flapping of the gum tissue, as is done in traditional surgery. We can stabilize the disease in most cases and the use of the laser is the most effective method. In certain cases, we are forced to do traditional surgery. I would need to see you to determine the prognosis and the least invasive way to get your gums healthy again so you can maintain your oral health for many years. At the conclusion of your treatment, we would then recommend the appropriate interval for your cleanings and checkups. I hope this helps.

Q: Is there gum surgery for bone loss?

A: There is, traditional bone surgery is seldom used, but we choose the laser whenever possible. It’s less invasive and gets the same result, if not better. No cutting or sutures.

Q: I recently swallowed over 90% of a molar, and didn’t realize it until I brushed my teeth a couple of hours later. I’m assuming that I swallowed it while eating. It wasn’t loose, nor had I had any problems with it previously. I was just told that I had osteopenia, and am wondering if that could contribute to bone loss to the effect of having teeth fall out.

A: I am not really clear what “90% of a molar” swallowed means, but from what you describe the options might include:

Option #1 – a fractured portion of the tooth breaking off (90% as you describe), which can be caused by either tooth decay or other dental trauma unknown to the patient without any pain or symptoms. I am assuming that the remaining portion of the tooth has been extracted by a dentist since then. Usually an x-ray of the area would reveal the situation that lead to the loss of the 90% of the tooth in question.

Option #2 – bone loss leading to a loose tooth exfoliating on its own. This is unusual if you have seen a dentist within the last 6 months or so and had a thorough periodontal dental exam. You mentioned the tooth was not loose. Sometimes a patient doesn’t realize how loose a tooth can be depending on the individual situation and whether dental x-rays were taken prior to the spontaneous tooth loss. Although osteopenia can affect the bone support in the mouth, it is extremely rare that teeth just “fall out” if you have been under the care of a dentist. There are rare systemic diseases where we see spontaneous tooth loss, but the odds are extremely remote. A complete work up with your family doctor is also advisable to rule out any other conditions.

My suggestion is to visit your dentist or periodontist and have a full set of digital x-rays and clinical exam and see what is going on in your mouth. Hopefully, you will avoid this situation from happening again.

Good luck!

Dr. Eric Linden