Dr. Achanta Krishna Swaroop
Dentistry
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hi doctor,
I had my tooth extracted six months back. Continued to have swelling and an exostosis that sometimes ulcerated near the above tooth and what I think are gum leakage and increased saliva. My dentist saw nothing wrong, so I went to a periodontist who, through a CBCT (Cone Beam Computed Tomography) and bite test, found that tooth there was a vertical crack below the gum line and was abutting the exostosis, so the tooth was removed last month, and the crack was confirmed on removal. The exostosis was removed a couple of weeks later, but I still have drainage that continues like a thin faucet. The doctor says I do not have a fistula, but this does not explain my non-stop drainage. Also, the palate and gum area around the extraction tissue is mushy, and tissue blisters without leaving lesions. Can you advise what this might be? I had no problems until a small cracked tooth six months back. Attempted a filling, then a crown. Elected to extract it as it pained. It was a difficult extraction; later, exostosis developed over the tooth. I am concerned about the continued leakage. If this is an undiagnosed fistula, and with the mouth and tissue acting up, what should be my next step? When the dentist examined my mouth, he said it was healing well. I had CBCTs last year and was told there were no sinus problems or oral antral, but I am wondering about the cutaneous fistula in the skin. My hs-CRP (C- Reactive Protein) test was around 3.9 mg/L this month. My saliva tested high in Fusabacterium nucleatum in the gums and also the gut.
Hi,
Welcome to icliniq.com.
I understand your concern.
Did these issues start right after the extraction of the tooth? The continued ulcerations of soft tissue you are facing in and around that area indicate that it might be a post-operative complication in oral healing. The laboratory test that shows high F nucleautum would be indicative of many related oral infections, and because you also have a history of exostosis removal, I will need to know if you took any antibiotics after the tooth removal or the exostosis drainage. Do you observe any bleeding or pain, or swelling currently in or around the 3,4,5 areas? Any changes in the facial contour? I have to ask you these questions if we have to consider cutaneous fistula as a diagnosis because it may or may not be true given the possibility, as I mentioned earlier, of multiple oral infections that are associated with ulcer formation post-dental surgery.
Patient's Query
Hi doctor,
Thank you for the reply.
No, I did not take any antibiotics after the extraction. I do not notice any changes in facial contour. My cheek muscle sometimes feels more stuck on the right side for the last several months. My teeth do not feel comfortable coming together anymore, with changes in swelling on and off. The tooth on the left, I am told, has a small crack but did not respond to the bite test, so it was left alone. I have no idea if it is a hairline crack or what. I am not having a hot or cold reaction to this tooth, but once in a while, it feels a little funny, but I do not know if it is because it is next to the tooth that just got extracted and needs to settle. The tooth had occasional slight bleeding on the left side (mild gingivitis). I hope that the tooth is not infected. Nothing visibly obvious on the tooth itself. I do not have any other bleeding besides the tissue around the extraction area, where I feel I get drainage. Sometimes it feels like a tiny micro hose, and other times more. I feel that this has exacerbated over the months, which caused some type of inflammation or autoimmune reaction that the skin feels blistering at times in the extraction area and increased saliva on the right side. All of these symptoms I had before my extraction and still post-op. If I have a cutaneous fistula, I was hoping it would have cleared up by now after the extraction. Instead, it feels like a fistula due to leakage and mucous membrane inflammation without lesions around the extraction. The leaking concerns me the most. I would kindly appreciate any treatment plan you could offer me.
Hi, Welcome to icliniq.com.
I understand your concern. It might be just a simple case of a complicated extraction socket or maybe even a sinus issue that is causing the leakage, given that the extraction site has not healed properly and is probably giving out the pus or the fluid consistency leaks into the soft tissue that is your gums. A cutaneous fistula in the mouth is pretty rare, in my opinion. I would prescribe simple measures to follow for your case based on your clinical symptoms. However, if you do not have any improvement, even in 15 days to one month, you can always approach me because we need to implement these first. Start lukewarm salt water rinsing every day around 5 to 6 times. This will ensure a bactericidal effect in your mouth. Switch to Chlorhexidine gluconate mouthwash every night before sleeping. I would also advise you to use gels like Metrohex (Chlorhexidine gluconate and Metronidazole) or Dologel CT (Choline salicylate) for topical application over the blistered areas because they are like Metronidazole or Dolo combination that will act locally on the gums to relieve you of the local infection there whatever it is. Finally, if you need antibiotics or antioxidant therapy, I can start right away because it will not interfere as such with your thyroid medication. Also, regular antibiotic prophylaxis is the only non-surgical way to treat post-operative dental complications. Therefore, if you want me to prescribe it, I can suggest it now. I would suggest that after following these prescribed medicines and measures like regular saline water rinsing and Chlorhexidine mouthwash and gel application, if the area still shows these inflammatory symptoms, then you are definitely right that it may be a fistula kind of complication. Therefore, you might need to consult a maxillofacial surgeon who can do a biopsy or verify through CBCT (cone beam computed tomography) or CT (computed tomography) once more to check for any such tracts in the mouth or from the maxillary or paranasal sinuses.
Patient's Query
Hi doctor,
Thank you for the reply.
Yes, can you please send a script for the antibiotic, antioxidant, and topical Metrohex gels? Thank you.
Hi, Welcome back to icliniq.com.
I understand your concern. Please specify your age again so that I can rewrite it and send it again. Here is your prescription. You can take a print or screenshot of the question and answer as well. For post-extraction pus or healing and oral ulcerations: Amoxicillin 500 mg 1-0-1*5 days (AF-after food). Metrogyl 400 mg 1-0-1*3 days (AF). Tablet SM fibro 1-0-0*30 days (AF). For topical application, Metrohex or Dologel CT for oral ulcer relief (local brands will vary (Choline salicylate+Lidocaine 2 % or Metronidazole 10 mg + Chlorhexidine 0.25 %) gel. Apply for 15 to 20 days of nighttime.
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