[X-RAY attached] Chronic apical periodontitis during pregnancy

[luckyy1123]

Hi all, need some help from a pregnant woman, age 30, no smoke, no alcohol in the past 10 years.

Tooth #7 was root canaled 15 years ago, and root canal retreatment was done 3 years ago in 2020 when x-ray showed inflammation. In the past 15 years, I have never experienced any pain.

Will attach root canal x-rays for before and after (2020 treatment) and a recent x-ray (2023).

Context: The tooth has been dead for 15+ years, no pain, no symptoms until three months ago that I am pregnant, there is a bump growing in the gum (photo attached), and the size is getting bigger/progressing in the past three months. Still no pain.

My question: Do I need to treat this or wait till my due date after baby delivery?

My Concern is: if I go to extract it, it might trigger pregnancy complexity, but if I take no treatment for 6 more months, will there be any possibility of getting bacteremia? Meaning that this tooth's bacteria gets into the bloodstream, through placenta to further hurt the baby.

Pls help, I very much appreciate it!!

 

[Dr M]

The safest time for treatment usually is during the 2nd trimester of pregnancy. But this also needs to be weighed against the risks of having severe infection during any stage of the pregnancy. You don't want this to suddenly blow up.
Based on the x-ray it looks like the root canal is failing.
If it is still within the safe period, I would suggest starting a re-do of the root canal, to allow it to drain and the infection to clear i.e first phase of the treatment. The dentist will most likely prescribe some antibiotics as well. I would then complete the re-do after the baby is born.
I always inform all my pregnant patients to inform their treating physician of the planned treatment as well, in order to make sure it is safe.
If any complications arise after the 1st phase has been completed and you are still pregnant, this can then be managed with antibiotics that are safe to take during pregnancy, such as amoxicillin

 

[MattKW]

The RCT before/after pics were most helpful, thank you. So it looks that despite the RCT being redone to a good level, the infection did not fully clear up - this happens rarely, and usually with infections that have been untreated for a long time.
The issues with pregnancy are:

1. The foetus is most vulnerable during the first 12 weeks. During this period of time, all of the major organs and body systems are forming and can be damaged if the foetus is exposed to drugs, infectious agents, radiation, certain medications, tobacco and toxic substances. The actual risk depends on the type of drug and amounts, the level of radiation and where it is directed, ... So, although emergency treatment sometimes just has to be done at this stage, everyone avoids elective treatment.
2. 2nd trimester is better as bub is more developed.
3. 3rd trimester is also safe but more uncomfortable for Mum for long procedures, and ideally Mum should lie on left side to avoid pressure on inferior vena cava. That's a bit hard in a dental chair.
4. The fact that you have a gumboil means that the pus is bursting out (like a pimple) so the risk of developing a full-on facial swelling with a serious bacteraemia is very remote. On that basis you could wait till after bub is born.
5. The main issue with dental treatment for preg Mums is the need for pain relief because you are limited in what you can take. So, simple fillings, even RCTs that are likely to cause minor post-op pain are fine. More major issues like removing impacted wisdom teeth will cause more post-op pain and should be avoided if possible.
6. I don't think a redo will make this better; the root filling looks very good. I would raise a flap and do a simple periapical curettage. I had a similar case once that persisted after an RCT, and attach before and after images. I'd go back to the endodontist that did this and ask his/her opinion; I would be happy to do this in 2nd trimester and expect you to have manageable pain requiring minimal painkillers.
7. I also attach a Preg Leaflet I give out to my patients with lots of info for you. I live in Australia so the contact numbers aren't relevant.
8. I used to work in a Medical Specialist building and the obstetrician across the way used to often send me pregnant patients. Let me know what you do, and your experience, pls. Best wishes for the birth!

 

[Dr M]

The RCT before/after pics were most helpful, thank you. So it looks that despite the RCT being redone to a good level, the infection did not fully clear up - this happens rarely, and usually with infections that have been untreated for a long time.
The issues with pregnancy are:

1. The foetus is most vulnerable during the first 12 weeks. During this period of time, all of the major organs and body systems are forming and can be damaged if the foetus is exposed to drugs, infectious agents, radiation, certain medications, tobacco and toxic substances. The actual risk depends on the type of drug and amounts, the level of radiation and where it is directed, ... So, although emergency treatment sometimes just has to be done at this stage, everyone avoids elective treatment.
2. 2nd trimester is better as bub is more developed.
3. 3rd trimester is also safe but more uncomfortable for Mum for long procedures, and ideally Mum should lie on left side to avoid pressure on inferior vena cava. That's a bit hard in a dental chair.
4. The fact that you have a gumboil means that the pus is bursting out (like a pimple) so the risk of developing a full-on facial swelling with a serious bacteraemia is very remote. On that basis you could wait till after bub is born.
5. The main issue with dental treatment for preg Mums is the need for pain relief because you are limited in what you can take. So, simple fillings, even RCTs that are likely to cause minor post-op pain are fine. More major issues like removing impacted wisdom teeth will cause more post-op pain and should be avoided if possible.
6. I don't think a redo will make this better; the root filling looks very good. I would raise a flap and do a simple periapical curettage. I had a similar case once that persisted after an RCT, and attach before and after images. I'd go back to the endodontist that did this and ask his/her opinion; I would be happy to do this in 2nd trimester and expect you to have manageable pain requiring minimal painkillers.
7. I also attach a Preg Leaflet I give out to my patients with lots of info for you. I live in Australia so the contact numbers aren't relevant.
8. I used to work in a Medical Specialist building and the obstetrician across the way used to often send me pregnant patients. Let me know what you do, and your experience, pls. Best wishes for the birth!

Thanks for the leaflet attachment. This is a very good idea to give something like this to pregnant patients. Where I practice in South Africa, the patients sometimes defer all treatment during pregnancy due to unsubstantiated fears. Would be nice to educate them in a easy to read leaflet, that they can take home.

 

[MattKW]

Thanks for the leaflet attachment. This is a very good idea to give something like this to pregnant patients. Where I practice in South Africa, the patients sometimes defer all treatment during pregnancy due to unsubstantiated fears. Would be nice to educate them in a easy to read leaflet, that they can take home.

You're welcome to uase and adapt it for your own purposes. I know it's very lengthy, but it looks authoritative(!) and I encourage patients to take it to their doctor or obstetrician if it makes them more comfortable. I'll send you the Word version tomorrow if you like. Bed-time now...zzzz.

 

[luckyy1123]

The RCT before/after pics were most helpful, thank you. So it looks that despite the RCT being redone to a good level, the infection did not fully clear up - this happens rarely, and usually with infections that have been untreated for a long time.
The issues with pregnancy are:

1. The foetus is most vulnerable during the first 12 weeks. During this period of time, all of the major organs and body systems are forming and can be damaged if the foetus is exposed to drugs, infectious agents, radiation, certain medications, tobacco and toxic substances. The actual risk depends on the type of drug and amounts, the level of radiation and where it is directed, ... So, although emergency treatment sometimes just has to be done at this stage, everyone avoids elective treatment.
2. 2nd trimester is better as bub is more developed.
3. 3rd trimester is also safe but more uncomfortable for Mum for long procedures, and ideally Mum should lie on left side to avoid pressure on inferior vena cava. That's a bit hard in a dental chair.
4. The fact that you have a gumboil means that the pus is bursting out (like a pimple) so the risk of developing a full-on facial swelling with a serious bacteraemia is very remote. On that basis you could wait till after bub is born.
5. The main issue with dental treatment for preg Mums is the need for pain relief because you are limited in what you can take. So, simple fillings, even RCTs that are likely to cause minor post-op pain are fine. More major issues like removing impacted wisdom teeth will cause more post-op pain and should be avoided if possible.
6. I don't think a redo will make this better; the root filling looks very good. I would raise a flap and do a simple periapical curettage. I had a similar case once that persisted after an RCT, and attach before and after images. I'd go back to the endodontist that did this and ask his/her opinion; I would be happy to do this in 2nd trimester and expect you to have manageable pain requiring minimal painkillers.
7. I also attach a Preg Leaflet I give out to my patients with lots of info for you. I live in Australia so the contact numbers aren't relevant.
8. I used to work in a Medical Specialist building and the obstetrician across the way used to often send me pregnant patients. Let me know what you do, and your experience, pls. Best wishes for the birth!

Thank you so much doctor for all the super helpful advices. And the leaflet is so great to have, I cannot thank you enough. Update is - I went to see an endo specialist today and he provided some similar medical advice as what you provided.

He told me that rather than extracting it now, he'd like to have me keep it, observe it till the baby is born, bc according to him, the chances of having bacteria get into bloodstream is slim. However, when we talked about next steps, he did mention if I start to feel pain, or it converts from chronical status to acute status, I can call him to schedule an appointment to extract it even during pregnancy.

The best case scenario as he suggested today is, finger crossed everything is all well till the baby is born, and after delivery, he suggested that I do an apical surgery with him as doctor you also suggested. He is suspicious that there might be a crack in this teeth and he said if he sees a crack during the surgery, he would pause it, end it and schedule another appointment with me to do implant.

I think for now that is what I am planning to do, following his (and your) guidance and again finger crossed, this tooth won't be naughty in the upcoming 6 months so baby is healthy and the delivery is smooth.

The surgery that you've done, it is very impressive, thanks for sharing before and after x-rays. Can absolutely see that tooth was healing after the surgery. It gives me more confidence to go to this option. But my endo specialist seems a bit conservative that he does not want to risk it even I am in my 2nd tremister now. His view is, nothing happened is a good thing and let us not trigger it.

I have follow up questions if doctor you have a few mins, about this endo specialist's suggestions, would you share some of your thoughts? I am open minded to welcome any advices.

Last quick question will be - as you mentioned, there is a gumboil in my gum so the odd of having bacteria to go to bloodstream and to further impact the baby can be slim. Will the gumboil progresses to an extent that it will leak (pup goes out)? It was a small gumboil three months ago, and now it developed to a bigger one as it shows in the picture. What is the next phase of a gumboil? I want to be prepared for what might happen so when it happens, I am not be panicked about it.

I am sorry for my late response. I am in the US and did not get a chance to write it in my morning time. Again I really appreciate it doctor for your valuable advice. Thanks again.

 

[luckyy1123]

The safest time for treatment usually is during the 2nd trimester of pregnancy. But this also needs to be weighed against the risks of having severe infection during any stage of the pregnancy. You don't want this to suddenly blow up.
Based on the x-ray it looks like the root canal is failing.
If it is still within the safe period, I would suggest starting a re-do of the root canal, to allow it to drain and the infection to clear i.e first phase of the treatment. The dentist will most likely prescribe some antibiotics as well. I would then complete the re-do after the baby is born.
I always inform all my pregnant patients to inform their treating physician of the planned treatment as well, in order to make sure it is safe.
If any complications arise after the 1st phase has been completed and you are still pregnant, this can then be managed with antibiotics that are safe to take during pregnancy, such as amoxicillin

Thank you doctor for taking time reviewing my case and providing medical advices. I went to see an endo specialist today and he mentioned that from the x-ray that is taken on 2023 Feb, the inflammation progressed downwards (in the highlighted area) which makes him be suspicious that there might be a crack but he is not sure until a surgery takes place to figure out. I described all his other suggestions in my response to Dr Matt in the above thread.

I was struggling on a decision to extract + implant it or try another apical surgery to see if it can be kept. And as many of you gave me the confidence that I shall think of giving it another try (surgery) after baby delivery, I might go with that option

 

[MattKW]

Thank you so much doctor for all the super helpful advices. And the leaflet is so great to have, I cannot thank you enough. Update is - I went to see an endo specialist today and he provided some similar medical advice as what you provided.

He told me that rather than extracting it now, he'd like to have me keep it, observe it till the baby is born, bc according to him, the chances of having bacteria get into bloodstream is slim. However, when we talked about next steps, he did mention if I start to feel pain, or it converts from chronical status to acute status, I can call him to schedule an appointment to extract it even during pregnancy.

The best case scenario as he suggested today is, finger crossed everything is all well till the baby is born, and after delivery, he suggested that I do an apical surgery with him as doctor you also suggested. He is suspicious that there might be a crack in this teeth and he said if he sees a crack during the surgery, he would pause it, end it and schedule another appointment with me to do implant.

I think for now that is what I am planning to do, following his (and your) guidance and again finger crossed, this tooth won't be naughty in the upcoming 6 months so baby is healthy and the delivery is smooth.

The surgery that you've done, it is very impressive, thanks for sharing before and after x-rays. Can absolutely see that tooth was healing after the surgery. It gives me more confidence to go to this option. But my endo specialist seems a bit conservative that he does not want to risk it even I am in my 2nd tremister now. His view is, nothing happened is a good thing and let us not trigger it.

I have follow up questions if doctor you have a few mins, about this endo specialist's suggestions, would you share some of your thoughts? I am open minded to welcome any advices.

Last quick question will be - as you mentioned, there is a gumboil in my gum so the odd of having bacteria to go to bloodstream and to further impact the baby can be slim. Will the gumboil progresses to an extent that it will leak (pup goes out)? It was a small gumboil three months ago, and now it developed to a bigger one as it shows in the picture. What is the next phase of a gumboil? I want to be prepared for what might happen so when it happens, I am not be panicked about it.

I am sorry for my late response. I am in the US and did not get a chance to write it in my morning time. Again I really appreciate it doctor for your valuable advice. Thanks again.

If the pus is coming out through the gumboil, then it's not going into your system. It would take a large uncontrolled abscess to affect bub. A more likely association with pre-term birth is poorly controlled general gum disease over a long time (not just a single tooth problem), and even that is not fully agreed upon yet. You'll be fine, and if it flares up it can be easily controlled by your endodontist/dentist without risk to bub.

 

[luckyy1123]

If the pus is coming out through the gumboil, then it's not going into your system. It would take a large uncontrolled abscess to affect bub. A more likely association with pre-term birth is poorly controlled general gum disease over a long time (not just a single tooth problem), and even that is not fully agreed upon yet. You'll be fine, and if it flares up it can be easily controlled by your endodontist/dentist without risk to bub.

Much appreciated Dr.Matt for your insights.