Perio Abscess In High Risk Patient For Osteonecrosis

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I’ve got a tough situation here and would appreciate any insight.
Patient (whom is an immediate family member), has/had stage IV
squamous cell CA at the base of the tongue and was treated with heavy
chemo and radiation at johns hopkins approx 8 months ago. So far he is
in “remission” but recently developed a perio abscess on #30,31.
previous radiographs were indicative of grade I furca involvement. i
spoke to the chief of head and neck oncology today and to no surprise
he is against removing the teeth, but also against any flap procedures
elevating the periosteum. pt suffers from severe xerostomia.

No endodontic involvement. #30 has no mobility, #31 has gade 1
mobility. All of which was interpreted from the GP in Maryland, as I
am in Florida.

He is getting ready to come see me (perio) and my fiancee (endo) in
Florida for treatment.

I’m not sure if Endo and hemisections/crowns is worth considering, especially #31

Any suggestions besides my tentative treatment plan of systemic
cipro/metro and perioscoping the area and possibly placing gem21/FDBA
to delay the inevitable extractions??

Thanks

Greg

[document redacted]

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Greg,

You might want to speak with the oncologist again with the consideration of
hyperbaric oxygen treatment as a part of your post-op protocol. If you’re in
Florida, I suspect hyperbaric chambers are more readily available than they
are here in the Midwest.
Good luck.

Mike

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My suggestion would be conservative therapy at this time:
Hyperbaric oxygen, systemic antibiotics, which I assume he is on, SRP with Local performed by the periodontist; Arestin therapy, and potentially repeating this procedure periodically until some time has passed prior to initiating any surgical therapy.
These head and neck radiation patients are very high risk and unpredictable, especially, I speculate, so soon after radiation and chemo.

Colin

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I have just seen the radiograph – looks more like a grade 3 (Tarnow) than a grade 1.
The other and most upsetting question, is why the oncologists did not order a dental and periodontal check up prior to initiating therapy? Notice the periodontal lesions on the second molar as well.

Colin

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Hi Greg,
Had a similiar situation several years ago. Also a family member. He was dx’d with squamous cell at base of tongue. Treated with chemo and radiation. 7600 rads were delivered to the throat over the course of several treatments. Conservative maintainance therapy was persued for several years. During the ensuing 3 to 4 years, continued bone loss occured in the mandibular molar region.Probing depths were greater then 10 -12 mm with suppuration. We elected to remove the molars on the left side. The healing was very slow with dry socket. It took several months before the area “healed”. Unfortunatly, it probably never fully healed , it just had a flap of tissue covering what must have been islands of denuded bone. Hyperbaric oxygen treatment was undertaken. He improved. About 2 years later a severe cellulitis developed. It was cultured. Dx Staph infection. This time the treatment was much more aggressive. For 8 months, 2 x per day for one hour per treatment , he had to self administer IV antibiotic. He recovered but the area still doesn’t appear completly healed over. He recently developed a painful perio/endo lesion on the right molar. It was treated endodontically and he is doing fine. Needless to say, we are avoiding extraction at all costs. If we have to, we may consider orthodontic eruption to remove.

I would suggest a biopsy given the patients history. I had a similar looking case years ago. The patient elected extraction and follow extraction it didn’t heal well. Biopsy confirmed squamous cell.

Chuck

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I am working with a similar case right now (not a family member)
It is a nightmare and a no win situation.
Good luck

Colin

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There’s also a treatment Dr. Tarnow mentioned to us a number of years ago that, I believe, he did on a patient with a bleeding disorder (hemophilia, but I stand to be corrected). From what I remember, he put an orthodontic rubber band around the tooth that needed extraction to accelerate the pocketing and bone loss without requiring surgery. That way he felt he would get the extraction at the same time as epithelialization of the pocket and eliminate or at least severely reduce the amount of potential bleeding surface exposed to the oral environment.
Just another thought – probably more predictable with a single than multi-rooted tooth, but should be worth a try.

Here’s one article related to that:

Quintessence Int. 1997 Apr;28(4):241-4.
Orthodontic-prosthetic treatment to replace maxillary incisors exfoliated because of improper use of orthodontic elastics: a case report.
Redlich M, Galun EA, Zilberman Y.
Source
Department of Oral Biology, Hebrew University, Hadassah School of Dental Medicine, Jerusalem, Israel.

Abstract
This article describes the iatrogenic exfoliation of maxillary central incisors following the improper use of orthodontic elastic bands. The unsecured rubber band had migrated apically and caused an almost “bloodless extraction” of both maxillary central incisors. A combined orthodontic-prosthetic solution was used to replace the lost incisors.

PMID:
10332372
[PubMed – indexed for MEDLINE]

Bob

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I believe this technique of extractions for hemophilia predates Dennis

Jeffrey

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Tough and sad situations. I wonder if retaining an obviously infected tooth where the infection can not be predictably resolved is safer than extraction. Biologics such as PRP, PDGF, maybe even Infuse may aid in healing following extraction.
I agree with Colin’s point yesterday that Perio eval prior to Tx was indicated. On a related point, I recently had a hip replacement and when I inquired about complications, My Orthopod’s response was his biggest concern was a later infection seeded to the prosthesis from infected teeth, and sometimes GU. He then said that he removes 3 hips / month because of this. He also said it is a devastating surgery since the hip can not be replaced for 6 months. He also does not request dental clearance.
What is the AAP’s possibility of networking for these issues with our medical professionals?

Mark

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What’s the possibility of the AAP being proactive about anything?
Sorry, but I don’t think they have done much in the past!!!

Bruce

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Good idea to evaluate occlusion and adjust if needed to minimize trauma as a complicating factor.

Joseph

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Thanks all for the insight, if extractions are to be done, we have
discussed HBO dives already but really trying to avoid exts. his
treatment has been quarterbacked by the chief of head and neck surgery
at Johns Hopkins, whom is a dual degree oral surgeon. others involved
since the beginning are two ENT’s, a radiation oncologist, and myself.

Previous radiographs are not attached, I don’t have them scanned but
they were almost normal. the radiographs you are seeing are from a
week ago. the lower right molars just blew up over the past few weeks
and chemo/radiation was completed around 8 months ago. I am not sure
of the exact dose of radiation, I am waiting for that information.

We did do an eval prior to radiation and a couple teeth were removed,
but didn’t see this coming. he had been on a feeding tube for over 6
months throughout chemo/radiation and lived on zofran to stay
comfortable. Oral hygeine paid a price for sure. now he’s severely
xerostomic and carries biotene everywhere. terrible scenario but
better than the 3-6 months to live, which is what was the original
prognosis.

He has been on amoxicllin for almost a week. I’m still thinking
cipro/metro and SRP, potential regenerative with a perioscope and
having prophy endo done #30,31, 1 month PMT’s and possibly placing him
on periostat??

Ed, I like the thought of forced eruption to extract, if absolutely necessary.

I appreciate all of your insight, its always a tough decision when its
one of the 3 f’s: friends, family or free.

Thanks,

Greg

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I would conservatively debride if the MD insists, but would prefer the extractions after the one year mark or sooner; either under antibiotic cover. The three best antibiotics for anaerobes are augmentin , clindamycin and metronidazole, but he cipro/ metro combination is a good choice too. My biggest concern is this is tumor infiltration not periodontal infection alone. Biopsy at the time of debridement should strongly be considered. I believe the use of regenerative material is out of the question. Do not introduce a foreign material in a compromised host. This is no time to save teeth or increase the risk of post operative infection/ complication.

Good luck

Bob

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One more point of clarification. Augmentin and CLindamycin are better Staph coverage. If it is unresponsive infection alone there is a higher chance it involves in part Staph species. amoxicillin alone does not cover Staph. i would generally consider Augmentin 875 mg BID ( less diahrea risk than augmentin 500mg. Tid) before amoxicillin as a first choice in this type of compromised case. Given the recent exposure to amox without response; Clindamycin 300 Mg tid to QID would be my choice now.

Regards

Bob

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