Tooth infection - increase prednisolone?

[liz6620]

A chronic tooth infection in a failed root canal treated tooth has decided to present with a painful flare. (I am generally fortunate and suffer little pain with the tooth). I am awaiting extraction in NHS hospital but its likely to be many more months and I realise I am in no way priority.

On my dentist's advice I started a course of antibiotics yesterday evening. The pain woke me at 4am. I felt feverish but don't believe I have a raised temp as such. I have been feeling even more easily fatigued for the last 10 days which I now attribute to the building infection. The pain has decreased somewhat as I write, now I've got up and taken a second antibiotic. I only take 3 in 24 hours. I'll take paracetamol if needed.

Question:

Should I increase my prednisolone up from 5mg daily for the course of the antibiotics or longer? If so, to what level do you suggest?

Concerns:

I wonder what harm chronic infection is doing to me and if there are increased risks of jaw bone necrosis as a result.

Your advice and views would be much appreciated.

[SnazzyD]

What a situation! I have some questions as per usual.

When you say flare, what do you mean?

Were you feeling fine until the tooth started?

It’s not the antibiotics that require the increase, but the infection if it causes flares or adrenal insufficiency made worse by the infection. Personally I would be thinking carefully about increasing any immunosuppression but if needs must….

Presumably you are on either Amoxycillin or CoAmoxiclav? If so which one? Make sure you are taking them properly 8 hourly. They may not kick in for a few days yet.

Are you taking any bone hardening drugs?

Does anyone know that you feel like you feel the infection with body symptoms like feeling feverish instead of just a local pain?

[liz6620 in reply to SnazzyD]

Thank you for your reply.

I should have said it is a flare up of the chronic tooth infection - lumpy gum and a lot of pain. That pain has subsided luckily whether the antibiotics acting fast (unlikely) or my morning pred perhaps.

I am on Amoxicillin 500mg. For 7 days.

I was not feeling fine for about 10 days or so before I was aware of the new gum lumpiness - even more fatigued than usual. My dentist is aware and believes, as do I, that the pred masks a lot of pain issues, very fortunate as the tooth is so infected that the endodontist could not complete the root canal treatment in January and then as well as the infection the tooth had a visible crack by February. The treatment had to stop and I await extraction. I had antibiotics (co-Amoxiclav then) in January to try to clear the infection but it is deep seated they say. Luckily after the initial 48 hours of intense pain it subsided.

This morning's feverishness is something I usually experience if I have pain of any sort. I did have a PMR/GCA flare in Nov/Dec and then was feverish in the longer term, losing weight and in greater discomfort. Today was fairly short lived when pain was at its worst. I think its a reflection of the infection being more active again perhaps.

Yes I've been on Risedronate for nearly 4 years now - foolishly started it as advised by my the hospital and I did not join this forum for several months when I realised from here that it was a poor decision, without further investigation first. I have asked to stop subsequently but currently still waiting on early Feb bone density scan results and a review.

Hope the above fills in the gaps. Thank you.

[PMRpro Ambassador]

Depends a bit on your answers to Snazzy's questions but if it were me, no I wouldn't increase the pred just because of abx. I would have to be so unwell I had to stay in bed.

The risk of jaw necrosis is pretty low - unless you have been on higher doses of bisphosphonates as used in oncology and even then it is low.

[liz6620 in reply to PMRpro]

Hello PMRpro. I hope the reply to SnazzyD is helpful.

I will not increase the pred unless I become more concerned by how I am feeling. I hope staying in bed does not happen.

Thank you for your reassuring comments about the Risedronate.

Coincidentally the hospital have just phoned as I was replying to you. Consultation appointment is on 6 June. So at least that's a positive step. Extraction one will then most likely be a few weeks later. I think it will be overall better for me when the tooth infection has cleared and I can take the extra strain off my system. I've had these chronic infections since before PMR/GCA were diagnosed.

[PMRpro Ambassador in reply to liz6620]

And they probably don't help the PMR/GCA situation either.

Don't get me wrong - there is a risk but it isn't as bad as some dentists would have you believe and there IS always the risk on the background. But it is far less likely after 4 years of oral bisphosphonate. I did do a lot of research on it before I finally gave in and had my infusion in January and also talked to Prof Mackie about it. She is concerned that patients are so unwilling to take them and also says that the reaction SHE gets from dentists isn't like the one many patients report. Which is baffling and I do wish we could get some unbiased sense out of them! All the articles just report the link between bisphosphonates and jaw healing and don't seem to differentiate between osteoporosis use and oncological use and there there must be the underlying disease process having an effect too.

[liz6620 in reply to PMRpro]

I appreciate the comments and advice from you and SnazzyD. It helps to know there are people who will listen, give knowledgeable advice and help to calm the worries.

My dentist has asked me to ring him tomorrow to update him on the tooth pain/lumpy gum and how I'm feeling, which I will do. He is excellent within the limitations that as you rightly say exist around bisphosphonates at all doses.

Thank you.

[PMRpro Ambassador in reply to liz6620]

Our pleasure. Let us know how you get on.

[Sophiestree in reply to liz6620]

just out of interest. Are you having the extraction at a hospital because of the bone meds and the dentist doesn't want to do it himself?

[liz6620 in reply to Sophiestree]

Partially because of the bone meds but also because I have other health issues (as well as PMR/GCA) which my dentist, the endodontist (who tried to do the root canal treatment but the tooth cracked) and the oral surgery consultant I've seen privately all advise extraction in a hospital environment is the better course. I think they may be over-cautious but of course I have to be advised by them and therefore wait for the NHs review.

[Pixix]

I wrote an answer, but it disappeared. I had 6 or 7 infections, lower back tooth. 6 dentists refused to remove it, including a hospital surgeon. To start with, I was offered root canal at a specialist for £800, but with no degree of success guaranteed. The tooth was heavily filled. After some years I was very fedup with the regular infections. I had a new dentist who was concerned about infection. She wasn’t willing to remove it herself, but had a colleague who was a surgeon in a London hospital for many years, & she was willing to try. She, like the hospital surgeon, still spent 15 minutes talking about necrosis of the jaw. They both considered I was at high risk. It took 90 minutes to remove the tooth, she had to remove ‘rotting flesh’ right down to the jaw bone, & I’m still waiting & hoping it’s OK. I took great care afterwards, which I don’t normally do, tbh, didn’t eat on that side for 4 weeks etc etc. I had antibiotics for 2 weeks before, & two weeks after. At the checkup, she was really pleased with the healing progress. If you look up my profile, then select ‘posts’ you will see all the posts I did throughout the years….! There’s not too many, but it saves me writing it again. If you have any specific questions, or comments on my dental posts, feel free to ask!!

[liz6620 in reply to Pixix]

Thank you Pixix. I'll look at your posts. I hope your healing process continues well with no problems.

I had the tooth next to the current troublesome one extracted. That was done in May 2022, again in hospital because of the bone meds and my other risks. It was done very quickly and easily and healed well. I'm hoping for a repeat process but do not think this long term, albeit mostly hidden, infection can be helping anything.

[PMRpro Ambassador in reply to liz6620]

I was just thinking the same as I read Pixix's reply - repeated infections must put the patient at a greater risk of poor healing in the end.

[liz6620 in reply to PMRpro]

I will make sure I mention my same concerns at the oral surgery review at the hospital on 6 June. I agree with you the infections must have some impact on healing surely. Being told when the root canal treatment failed in Jan/Feb that the infection was in my sinus and the sinus is pulpy doesn't sit well with me.

[PMRpro Ambassador in reply to liz6620]

I was told some rubbish about sinuses many years ago by a UK dentist. I had a very late eruption of a wisdom tooth during my second pregnancy. It didn't cause any real problems until a lot later: because it was growing squint, it was unopposed and just kept growing. Eventually it started catching the inside of my cheek. I asked my then dentist to take it out - and he announced the roots went right through to the sinus and it would cause all sorts of problems with infections. So I put up with it. I had already realised that dentist was only after easy money when I moved to a different dentist but eventually it was so uncomfortable I had to ask my (very expensive) dentist here in Italy. Because of all the dire warnings in the past I was terrified, he was totally laid back about doing it in the practice, no need for a hospital. He'd x-rayed it and looked very carefully, wasn't anywhere near the sinus. He is 50m from the hospital, if anything went wrong there would be back-up. It was the easiest extraction I have ever had and healed like a dream.

[Pixix in reply to liz6620]

I believe the healing is slower, if you’ve had repeated infections. The risk so greater, & the horrible ‘mass’ she cut away in my mouth near the bone shouted to me that it should have been done before…years before! Thank goodness I had a dentist who was looking for ‘trouble’, & happy to deal with it when she found it!! I have hypermobility which makes for slow wound healing, as well. Hope they’ve got you on the right antibiotics…I tried two different type before getting rid of the last infection! Hope all goes well!

[Broseley]

Hi, I have had persistent problems with abscesses and gum infections and my jaw bone is degenerating. The latest one left all my front teeth loose and made it painful and difficult to eat. I was given metronidazole antibiotic and a thorough clean out under anaesthetic. I have been told to buy a water flosser to make sure I thoroughly clean my gum pockets which are at the back of my teeth. I did not increase my pred and everything is OK now, until next time!

[liz6620 in reply to Broseley]

I'm really sincerely hoping to avoid the jaw bone degeneration scenario. I'm sorry to read you're facing such challenges. I've asked the 3 experts I mentioned in my reply to Sophiestree and they seem mostly unconcerned by the effects of the chronic infection these past years, despite my taking bisphosphonates. My dentist is more concerned about the overall effect on my health generally.

[Broseley in reply to liz6620]

Yes it can have repercussions on your heart, I know that much. My problem stems from having an overcrowded mouth when I was a child. I had braces and lots of teeth removed, but they never really fixed it. Nowadays I would get much better treatment but it's too late and my dentist says I'll probably end up losing all my front top teeth.