What is it?
The white shiny part of each tooth is called the crown. The part that fits into its socket in your jaw is called the root. The deepest part of the root is called the apex. The apex of your tooth has an infection with germs in it. The infection may have ended up forming a cyst. A cyst is a little pocket with some liquid in it. It is about half an inch (1.2cm) across, in the jaw bone, near the apex of the tooth. This is called a dental cyst. The cyst and infection is cleaned out through a small opening in the gum and bone. The opening is then closed up. This operation is called an apicectomy.
Diagram © Copyright EMIS and PIP 2005
The operation
You will have a local anaesthetic, a local anaesthetic with some sedation or a general anaesthetic. When you have a local anaesthetic, the area of the operation is numbed with an anaesthetic injection. You will not feel any pain but you will be awake and conscious. The sedation is sometimes added to the local anaesthetic to help you relax and allow you to go through the operation. If you are sedated, you will be conscious during the operation, but will not be aware of what is going on. Finally, if you have a general anaesthetic you will be completely asleep during the operation and you will not feel any pain. The decision about the type of anaesthetic will be discussed between you and your surgeon. Although most apicectomies can be done safely and comfortably just with local anaesthetic, it is better to have some sedation or a general anaesthetic if it is anticipated that the operation will be difficult. A small cut will be made into the gum over the infected apex or the cyst. The surgeon will drill or chisel into the jaw bone down to the apex. All the infected material, any cyst, and a small part of the root will be taken out. Some of the infected tissue will be sent to the laboratory to be tested for germs. The end of the root may be sealed off, using a special filler material, to fill the space that has been made. The cut in the gum is then closed with stitches. These are usually special stitches that melt away in 7 to 10 days. Sometimes the surgeon uses stitches that need to be taken out after about two weeks. Your operation can be done as a day case. This means that you come into hospital on the day of your operation, and go home the same day.
Any alternatives
If you leave things as they are, the infection will get worse and may form an abscess (a collection of infected fluid or pus). It may spread to the roots of other teeth. If there is a cyst, this will get bigger. It may seriously weaken your jaw. There is too much infected apex to clear by drilling through from the crown of your tooth into the root. Fillings put in by your dentist may not have sealed the root properly. The root may no longer be hollow enough for drilling, due to your age. Or, there is too much of a cyst to clear this way. Your tooth could be taken out to get rid of the infection. You would then need a false tooth to fill in the space. Drugs and medicines will not help at this stage to control the infection or to shrink the cyst.
Before the operation
Stop smoking and try to get your weight down if you are overweight. (See Healthy Living). If you know that you have problems with your blood pressure, your heart, or your lungs, ask your family doctor to check that these are under control. Check the hospital's advice about taking the Pill or hormone replacement therapy (HRT). Check you have a relative or friend who can come with you to the hospital and take you home. Sort out any tablets, medicines, inhalers that you are using. Keep them in their original boxes and packets. Bring them to the hospital with you. On the ward, you may be checked for past illnesses and may have special tests to make sure that you are well prepared and that you can have the operation as safely as possible. Please tell the doctors and nurses of any allergies to tablets, medicines or dressings. You will have the operation explained to you and will be asked to fill in an operation consent form. Many hospitals now run special preadmission clinics, where you visit for an hour or two, a few weeks or so before the operation for these checks.
After - in hospital
After the operation, you will be taken on a trolley to the recovery ward for a few minutes. After your anaesthetic has worn off, the nurse from the ward will take you back to your ward. If you have had a general anaesthetic, although you will be conscious a few minutes after the operation ends, you are unlikely to remember anything until you are back in your bed on the ward. The same thing happens with sedation but to a lesser degree. Some patients feel a bit sick after the operation, but this passes off quickly. You may be given oxygen from a face mask for a few hours if you have had any chest problems in the past. A general anaesthetic will make you slow, clumsy and forgetful for about 24 hours. Again, the same, but to a lesser degree, happens with sedation. The nurses will help you with everything you need until you are able to do things for yourself. Do not make important decisions, drive a car, use machinery, or even boil a kettle during this time. The mouth will feel bruised and swollen. The jaw will be slightly stiff, usually with some discomfort. The gum with the stitches will swell a little, with slight bruising of the skin. You will be given painkilling tablets to help with any discomfort. The swelling, bruising and stiffness of the jaw will disappear over a week to 10 days. You will be able to drink two to three hours after the operation. Avoid eating until any sickness has passed, and after the feeling has come back to your mouth and tongue. Before you leave the ward, you may be given an appointment to come back to the dental outpatient clinic to see the surgeon. This will be about two weeks after the operation. The surgeon will check that the wound has healed. He will take out any stitches if needed. He will make sure that the infection and any cyst have settled down. He will have the report from the laboratory about the tissue from the apex and any cyst. You may have a further X-ray of your teeth. You may need to visit the outpatient clinic again for further checks.
After - at home
Take two painkiller tablets every six hours to control any pain or discomfort. Chewing may be painful on your tooth and gum for three or four days. So you should eat a softer diet and avoid very 'spicy' or 'vinegary' foods. You need to keep the mouth cleaner than normal to prevent infection of your wounds. Gently brush your teeth with ordinary toothpaste three times a day. Follow this with a warm salt water mouth bath. This is a pinch of salt to half a pint of warm water. Hold a mouthful for one minute on each side of the mouth. Then follow the salt mouth with the antiseptic mouthwash for one minute. You may have aches and twinges in your teeth for a month or two. These will settle down gradually. You will be fit to go back to work the second day after your operation. You will be fit to drive 24 hours after the operation. Avoid strenuous sports and swimming until the gum has fully healed in a month or so.
Possible complications
If you have this operation under general anaesthetic, there is a very small risk of complications related to your heart and lungs. The same is true for sedation but to a lesser degree. The tests that you will have before the operation will make sure that you can have the operation in the safest possible way and will bring the risk for such complications very close to zero.
If you follow the advice given above, you are unlikely to have any problems. Complications are rare. Some slight bleeding is normal for a day or two after this operation. If the bleeding is heavy and carries on for more than an hour, phone the hospital or your GP for advice. They will tell you how to bite on a small pack of gauze for 20 minutes or so to stop the bleeding. Rarely patients need to come back to hospital for treatment of bleeding.
If you experience increasing pain at the area of the operation, you feel that is getting more swollen and you have a temperature, it most probably means that the area of the operation is infected. This happens relatively rarely and taking antibiotics for a week or two usually solves the problem. In a very small number of patients the infection can be evry bad and lead to a collection of infected fluid or pus (abscess) at the area of the operation. In this situation you will need another operation to drain the infected fluid or pus.
Sometimes, there is some numbness around the gum after any anaesthetic has worn off. This may be caused by bruising around or damage to small nerves near the tooth root. Usually the feeling comes back in a day or so. Rarely, it takes six weeks or more.
In about 9 out of 10 cases, the infection and any cyst heal up. In the other cases, the tooth has to come out, or, rarely, another apicectomy is needed.
General advice
These notes should help you through your operation. They are a general guide. They do not cover everything. Also, all hospitals and surgeons vary a little. If you have any queries or problems, please ask the doctors or nurses.
