Periodontal bone loss surrounding 35+ yr old rct tooth

[Rebeccah]

I have a 35+-year-old root canal treated tooth #30 (right lower first molar) with a new draining infection, circumferential bone loss around the back root including loss of the cortical bone on the cheek side of it, and a periapical lesion at the conjoined tip of the front roots. Endodontist went in through the gold crown and has done a cleanout and disinfection of the tooth interior, roots, and the pocket on the side of the tooth (and I think he sealed the roots), and now we're waiting a few weeks to see how the gum responds before deciding whether or not to proceed with the full re-do root canal treatment. No cracks in the tooth or roots were seen.

So far, the gum is doing great. Swelling and tenderness continue to decrease a week out, there hasn't been any more drainage since day 2 following the procedure, and the gum is re-epithelializing where it had been draining before. So I think the odds are good that we will be going ahead with the full root canal treatment, although we'll know more when the effects of the disinfection solution have had time to wear off.

My question is regarding that bone loss. Is that something I should consider getting bone grafted? Should I see the periodontist ASAP (probably a few months to get in to the see the one I have a referral to, as he is a well-respected and popular implant specialist and the referral is for implant evaluation), or wait until this tooth declares itself, or until after the endodontist is finished? At this point, extraction is my fall-back, with then the decision whether to proceed with an implant ($$$) or with something more affordable, like a removable denture.

Thanks for any suggestions.

 

[honestdoc]

I suspect root fracture around the root with the bone loss. You can monitor healing around the tooth but I wouldn't spend too much on it. Save your money for an implant with possible bone grafting for the implant. Bone grafting will never regain horizontal bone loss. It may help with vertical bony defects.

 

[Rebeccah]

Thanks, honestdoc. Of course, you know that's not what I want to hear.

Here's an arch section through the body of #30:

And 3-d reconstruction (which, of course, you really get the best benefit of when you can twist it around in real time in the software):

Lots of artifact from the 3 gold crowns...

 

[Rebeccah]

And here is a selfie of the gum 13 days after removal of old root canal fillings, post and most of the core, and looking through the microscope with illumination, for a crack; passing a probe down next to the tooth and taking an ultrasonic scaler to the pocket; disinfecting the tooth with bleach and pocket with chlorhexidine; treating with calcium hydroxide -- I believe, inside and out; and then I lost track, I don't know what else he did in the way of sealing, but I do have a temporary filling and there is cotton on the floor of the tooth.

There is essentially no swelling of the gum any more, even the bump at the gingival margin where the infection had pointed is gone. No more bone or gum tenderness to palpation. I never had any actual pain, just mild tenderness -- and that sensation that the tooth was a fraction of a mm high and contacted first when I would bite down, which has been gone for some time now. I don't feel any looseness of the tooth. There is a little more recession since that appointment but it's resolving some, we'll see if that continues to fill in. I can still feel the bony defect when I palpate with my finger.

Rebeccah

 

[Rebeccah]

Just in case anyone was curious about how this turned out, the endodontist totally saved my tooth. A couple of months after the cleanout, he finished the revision root canal treatment. A year later (March 2023), most of the bone had grown back, including the cortical bone that appeared blown out on the buccal side of the root in December of 2021. Last month I had a new crown placed.