PERIODONTAL ABSCESSES - CORNER-ABSCESS - DOUBLE-PYRAMID FORMATION - DESIGN AND DESTRUCTION ATTACK = = = There ain't goin' to be no hangman Putting no rope around my neck little child There ain't goin' be no hangman Putting no rope around me = = = WHAT CAUSES PERIODONTAL ABSCESSES? - You can imagine the tooth like a beach where the water level (BONE) gradually gets lower and lower. What you then will see are a series of ridges of crud. With each ridge corresponding to a particular bone level. WHAT HAPPENS IS THE CALCULUS FORMS IN RIDGES, THE BONE RETREATS, THEN THE CALCULUS FORMS ANOTHER RIDGE - This process continues down the tooth as the bone level gets lower and lower. In the corners the ridges meet and form a double ridge. Likewise around the corners the calculus gains tensile strength, because of the curve. This is similar to a knot in a piece of wood that becomes almost impossible to cut because of the super-strength created by the curves. NEXT STEP IS THE HIGHER LAYERS OF CALCULUS FEED THE LOWER LAYERS - YIKES IS RIGHT!! - What happens here is that the placque-biofilm-calculus create an infrastructure that is similar to a miniature city attached to the tooth. With energy transfer mechanisms to transmit nutrients in the form of chemical-electrical energy from the higher layers to the lower layers. What this does is enables the biofilm-calculus to infiltrate downwards down the side of the tooth. All the way to the root. YIKES IS RIGHT! ALL THE LAYERS OF CALCULUS THEN FORM A GASKET - The gasket creates a separation between the outside world and the inside world. With the infection trapped on the inside world. With no way to escape except by burrowing into the deeper layers of the body. FINAL STEP IS THE LOWEST LAYERS LEARN TO SURVIVE OFF OF BLOOD - JUST LIKE VAMPIRES - Yes. This is absolutely true. Really. Don't mean to scare you. What the abscess then does is it seeks new territory to survive in deep inside the body. All abscesses are like this, not just periodontal abscesses. WHAT DOES ALL THIS MEAN? - BIG TROUBLE - THAT IS WHAT IT MEANS KINGPIN - Is a presumed piece whose lack of release is blocking the way and whose presumed release will lay the way to liberate the abscess. Typically what will happen is there will be one critical piece where the process is presumed to have gotten started. But more typically there will be similar. Similar to the Thumb in the Dike. Get rid of that little Dutchboy and the abscess will release. = = = NOTE - ABSCESS LOCULI - Abscesses form in localized compartments called Loculi. This makes them difficult to completely drain because every separate compartment needs to get individually mechanically disrupted and burst. This explains why they take so long to drain and why persistence is so important. = = = STRATEGY - Periodontal abscess is typically focused around corners. Where multiple ridges of calculus from both sides of the teeth meet. The calculus gains extra strength from going around the corner and gets other advantages too. Once the escape is blocked the abscess will start to form. So you can imagine a rockpile. Move one rock to get to the next rock. So strategy is periphery to center. Create a smooth road leading to the abscess. Once that is accomplished the abscess will release. Then start working secondary debridement and ongoing maintenance strategies. An abscess is a chronic wound. And requires just the right mix of action and rest. If successful the reward is keeping the tooth a little bit longer. Kick the can down the road. But also to consider this: You accomplished exactly what you set out to do. But did you really solve the problem? Are you willing to go the extra mile regarding ongoing maintenance and re-debridement? Likewise is your thinking solid or are you living in a dreamworld? Like me. Letting an abscess fester for years and years and pretend I didn't know it was there. Since I had no strategy. But when forced to attack I devised quite a number of good strategies. But largely it was resolve. I did what I had to do. Didn't go the extra mile. Got stymied and quit. Had no workable strategy. SOLUTION - The actual solution was the Rockpile Concept. Adding up to hours and hours of picking off one small piece of calculus after the next. Previously I usually stopped after two or three hours of modest success. And though I realized there were much deeper levels my attitude was - LETS SAVE IT FOR NEXT TIME - FAIL! WRONG! - Instead it is better to focus in on particularly troublesome areas and try to clean them ASAP. Which might mean doing a double primary debridement. Which would mean committing upwards of five hours to the debridement with full knowledge that all you might reasonably accomplish is to get one or two faces cleaner. But if the calculus is deep enough what happens is there are always more nooks and crannies that are full of calculus. So you can figure half to open up the general area. Then another half to actually be in reasonably close proximity to the abscess. Again working from periphery to center. Plus pulling out! This way you can venture into some very very scary areas and can make sure the curette is always moving away from the actual danger. Sneak up. Grab. Pull loose. Then move on to the net rock. For hours and hours. Until the abscess is free. = = = NOTE - SKI-JUMP FACTOR - IS IT BONE OR VIABLE TISSUE? OR IS IT CALCULUS & DEAD MEMBRANE? OR EVEN NERVE - This is a particularly difficult and vexing problem. And even after years and years of attacking and debriding periodontal abscesses I still have no truly great solutions. Except to always try to work from a starting position of tooth and focus your efforts in an outward direction from a known position on tooth. What is the downside? The main downside would appear to be either to rip out bone or to rip out periodontal ligament that is still viable. Is this realistic? Largely I think not. Largely I think the fears resulting from the ski-jump factor are largely overblown. Yes it is possible a mistake could lead to ripping out something good thinking it is something bad. But 90% of the time or even 99% of the time the thing you thought might be good turns out to be bad anyway. WHAT IS THE SKI-JUMP FACTOR? Basically what happens in severe periodontal disease is that the calculus on the tooth releases toxins that end up destroying the periodontium. Bone turns to mush and gets replaced by granulation tissue. The living periodontal ligament dies and gets turned into necrotic periodontal ligament and also gets covered up with calculus. Calculus infiltrates down the tooth, fed by its own supply chain from the outer layers. It even seems highly likely that the outer gum separates from the bone so the "innards" of the periodontium are largely exposed to the outside world. So part of the idea of the ski-jump factor is that the currette will slip past the outer portion of bone so you are scraping on bone instead of tooth. Which is obviously bad. Or that you are tugging on what you might think is calculus but is actually bone. Or likewise that you might be tugging on what you think is calculus but is really living periodontal ligament. So how to tell when everything pretty much feels similar? How do you separate the good from the bad? ENTER GUMS OPENING UP - "OPEN SESEME" - After a period of debridement the gums will dilate and become more rubbery. Prior to this point they will tend to cling to the calculus and tooth and it will be very difficult to get the curette to go into the deeper regions. SO WHAT TO DO? 1) TRY TO CREATE AN EDGE OF TOOTH - As you slide the curette down the tooth the calculus will tend to feel fuzzy. So if you are pretty sure the fuzzy thing is stuck on to the tooth and that you didn't slip past the tooth and onto bone then it is a reasonable proposition to try to get the fuzzy piece of calculus to try to come loose. But how can you confirm it is calculus? One way is to work from the sides and try to work down an edge of tooth to get to the lower regions. REMEMBER! BONE DOES NOT GROW IN THE MIDDLE OF THE AIR - So as you work down the side of the tooth past the side of the calculus AND you similtaneously confirm that the calculus has a surface that is pretty much laying over tooth and not over something else, then this process will more or less confirm that what you are pretty sure is calculus is indeed calculus. At this point you can get more aggressive. Generally the idea is to work from the sides. But as you gain some depth you should be able to slip inward of the calculus too. And confirm that this area is also tooth. At this point you can start to work the lower edges of the piece of calculus and to start to nudge it loose. 2) CLEAR THE PATH - TRY TO EXPAND THE AREAS OF KNOWN TOOTH TO ISOLATE THE PIECES OF CALCULUS - What this means is that you will feel areas that are fairly rough that in a sense are protecting the lower layers. If you smooth out these areas then the pieces of calculus will become more recognizable. But don't smooth them too much! Or you will let the infection penetrate the dental tubules which can cause the tooth to get root resorption and self-destruct. 3) DOUBLE-CHECK ON A CONSTANT BASIS THAT YOU HAVE A PATH FROM TOOTH TO WHERE YOU ARE DEBRIDING - What this means is that as you debride you are inclined to wander further from where you started. So next thing you know you could be debriding in a "possibly friendly" area with living tissue and not really be aware of it. MEANWHILE.... Also consider that any large constructions of calculus are likely going to be too gigantic for you to get to come loose anyway. So really mostly all you can do is to break off small pieces at a time anyway. So why not break off pieces that are right next to the tooth anyway? Basically considering your debriding efforts to be fungible. Since all places are more or less equal then focus on the areas where you have the greatest confidence. Granted this will tend to slow down the efforts. Making it more difficult to debride away large constructions you are quite sure are bad but just don't have the guts to attack directly. But could you realistically pull them off anyway? Probably not. But you can undermine them so they will come loose in their own time. And if you proceed with close to 100% confidence you are doing the right thing you won't have nagging doubts that you are ripping out bone or good stuff. = = = STAGING SEQUENCE - This is when you clear out the general calculus on the tooth. And on the opposite tooth too. Try to get the area fairly clean and smooth. But don't really scrape the teeth very hard. Except on occasion. Rather the goal is to dislodge the calculus. Then what is left can hopefully also be relieved through light scraping. Too much scraping will wear away the tooth! So you want to be very judicious. Also if the tooth is scraped all the way down to the dental tubules the infection can also infect the dentin of the tooth. This leads to tooth destruction. Called Resorption. Which can easily completely destroy the tooth. So object is not to scrape the tooth. Rather it is to remove the calculus and biofilm the easiest way possible. But which in fact may be real hard. Idea is not to be gratuitous. Just enough violence to do the job. While avoiding negative repurcussions. Like slicing thing up or damaging either the tooth nerve or other mostly mandible nerves. UNBLOCKING PHASE - Again working from the outside - PERIPHERY TO CENTER - Gaining depth, releasing deeper and deeper pieces of calculus blocking the abscess. Try to clean up the periphery too so the field is physically clear of chunks of calculus. Then at some point the abscess will start to bleed. BLEED OUT ABSCESS - Once the abscess starts to bleed the hole that it is coming from will become more and more accessible to the curette. At this point general idea is just to keep an open passage from the inside of the abscess to the outside world. Additionally there will also be gigantic blobs that are actually what you can think of as failed granulation tissue. It is what replaced the bone where the abscess is. In fact they are part of the abscess because they are infected. Though some will claim they are fairly harmless. Since it may take so many hours and hours to completely bleed out the abscess. My belief though is it is very important to bleed out the abscess. Even if this takes an additonal three or four hours to accomplish. So from start to finish it may take upwards of ten hours to attack and bleed out a periodontal abscess. Plus additional time for additional primary debridement and follow-up secondary debridement. Basically abscesses are bad news. Good way to lose a tooth. So to keep the tooth it may become necessary to do what you have to do. ADDITIONAL NOTE - Also keep in mind that if you keep the tooth you are also keeping any deeper infection that the tooth may harbor. So if you think about it the prudent thing to do might just be to have the dentist pull the tooth. WHY THIS? Because you always have to consider that in essence you are playing a game with a disease that aims to win. What is leftover will be at the deepest layers, won't it? Answer is yes. What this means is that when the disease reinvigorates itself that it is even harder to find than before! So the disease just upped the ante. But meantime you just Kicked the Can Down the Road. Did you really take care of the abscess? Or you should just do what your dentist says and have him pull the tooth? Your call. = = = WHAT IS ANSWER TO DEEPER INFECTION LEFT BEHIND? Answer is it's complicated. But largely objective is simple. Keep the area clean like it's a surgical site or chronic wound. Which is what it is. Do additional debridement on a timely basis to finally get area completely clean. This is called - PROGRESSIVE DEBRIDEMENT - Then hopefully in a few months the area will heal!! If you are very lucky. Otherwise it will linger as a chronic wound and needs more TLC. Namely it needs a hydrocolloid bandage. Which you can squirt into the abscess multiple times each day or maybe just once a day to help the area self-debride itself of extra dead material and pus. Which you can commit to once the area is fairly clean. IRRRIGATION PROGRAM - I usually use hyaluronic acid powder mixed with water. This forms what I call "drilling mud" to drive out the infection. It is a water lover and may fatten up the calculus too. Also it helps form the Extra-Cellular Matrix ECM. Since it has lots of chains. It is basically what is inside the eyeball. So it's a thick gel. Then I thin out the gel so it will go through a 20 guage 3/4"endodonic needle. Which has an open nose. But once it is clean think the hydrocolloid is probably better. PAPAIN-UREA PROGRAM - Mostly I just make a mix and swish it around in my mouth for around two hours or so. Have had very good success. Possibly leading to loosening of fairly major bloody debris as part of secondary debridement process. Basically the papain-urea helps to break down protein chains so pieces of crud sticking to the teeth and the wound will become more likely to give themselves up reasonably readily. HYDROCOLLOID PROGRAM - The basic problem is that that gums sweep themselves clean every half hour or so. So liquids don't last long. Supposedly hydrocolloids do. So this could lead to a fairly long lasting gel coverage of the damaged tissue. Giving the wound a chance to shrug off pus or exudate, plus loosen up smaller and even larger pieces too. = = = IS IT A NERVE OR IS IT AN ABSCESS - THE ONLY COMMON PLACE BESIDES THE MAXILLARIES IS THE MANDIBLE - As example right now (10-24-12) I just discovered another abscess on tooth #20. But if I thought it through I would have known all along it was an abscess. For awhile I just ascribed it to general pain from the tooth. Right now gave it an actual check-out and it was pretty obvious it was an abscess. So now I have to check it out. And release the abscess. Which will not be an easy task. But why was I so willing to go along with the idea it was just tooth sensitivity? I have a few other areas with tooth sensitivity too. Could these other areas be abscesses too? Probably. And also the abscess is right next to a nerve. So have to be very very careful - approach from the outside - stay away from the actual abscess - just undercut its support network - then the abscess will give up of its own accord. Since the start of September 2012 I have attacked 7 separable identifiable abscesses in 11 major incidents. Forgetting about secondary abscesses. But also giving double-credit to one. = = = ABSCESSES ARE INCREDIBLY TREACHEROUS - My common reaction when I have asked numerous dentists and periodontists about abscesses is - LET'S WAIT AND SEE WHAT HAPPENS - How does this sound for an answer? Not good. Or how about this one? - PERHAPS WE CAN DO A ROOT CANAL... - FOR A TOOTH ROOT ABSCESS THIS MIGHT BE OKAY - BUT NOT FOR A PERIODONTAL ABSCESS - BAD IDEA - FOOLISH IDEA - AND THIS IS SUPPOSED TO BE A PROFESSIONAL - SO WHEN THE PROVERBIAL YOU-KNOW-WHAT HITS THE FAN YOU ARE SUPPOSED TO GO BACK AND TRUST THIS GUY OR GAL? SOUNDS SCARY - BE AFRAID - BUT WHAT IS THE ALTERNATE SOLUTION? LOOKS LIKE THE ALTERNATE SOLUTION IS - SOL - Sorry sir but you are just SOL - Well why didn't you tell me that before? Why did you tell me to just wait and see what will happen when you already knew what would happen? = = = SO YOU SAY ABSCESSES ARE TREACHEROUS? WHAT DO YOU MEAN? - ABSCESSES ARE TREACHEROUS, THAT IS WHAT I MEAN? BY HOW? - Getting to the point the entire business of attacking abscesses is fraught with peril. One of the main issues is that calculus can be hard and difficult to remove. Plus can be painful too. SO CAN BONE! SO IS IT CALCULUS OR IS IT BONE? ARE YOU RIPPING OUT YOUR BONE TO GET TO A MAKE BELIEVE ABSCESS? In reality this is not the case. It just appears to be so. IF YOUR LOGIC IS PERFECTLY CORRECT. But what if your logic is wrong? Then that means you are ripping out bone. Really? I tend to disbelieve this negative assessment. I truly do not believe a person can rip out bone by mistake. That the culprit really is calculus and who is to say it is not bone. But presuming it is calculus then indeed it must be ripped out and a person has to know with 100% commitment that it is indeed calculus and not bone. But how do you know? Well... for starters... in my opinion .... if it really was bone you would be screaming ... ARE YOU SCREAMING? NO? ... THEN THAT MEANS IT IS CALCULUS !! REALLY? ... WELL WHO IS TO SAY... MAKE UP YOUR OWN MIND. ALL I CAN SAY IS THAT ATTACKING ABSCESSES IS TREACHEROUS ... YOU DECIDE WHAT YOU WANT TO DO. WHAT ABOUT NERVES? COULD I THINK I AM RIPPING OUT CALCULUS AND I AM ACTUALLY RIPPING OUT NERVE? - YES THAT IS ANOTHER PROBLEM - BUT NOT SO WORRYSOME ON THE MAXILLARIES. BECAUSE THE NERVE IS VERY DEEP - UNLESS YOU ARE NEAR THE BICUSPIDS OR NEAR THE WISDOM TEETH - ARE YOU NEAR THOSE TEETH AND VERY VERY DEEP? NO? THEN SHOULD NOT BE A BIG PROBLEM. BUT... BUT... I AM NEAR THE LOWER BISUSPIDS... IS THERE A PROBLEM THERE? --- YES YES - DON'T DO ANYTHING STUPID - THE NERVE RUNS RIGHT BETWEEN THE MOLAR AND THE BICUSPIDS - PLUS IT RUNS ALONG THE GUMLINE AT THE LEVEL OF THE ROOTS !! VERY TREACHEROUS - STAY AWAY STAY AWAY - OR IF YOU INSIST ON GOING THERE THEN DON'T TRASH IT OKAY - BUT BUT I HAVE AN ABSCESS THERE - WHAT SHOULD I DO - GO SEE A DENTIST !! - OR JUST BE VERY VERY CAREFUL AND DON'T TRASH THE NERVE !!! BUT SHOULD NOT BE A PROBLEM UNLESS THE POCKET IS VERY VERY DEEP. LIKE REAL DEEP. LIKE NOT MUCH BONE LEFT. = = = 09-05-12 - Tooth #7 - Maxillary second incisor - distal - approach from tooth #6 eye tooth - PDT Mini-Me Langer 5 straight curette - w significant release - post-curettage realized there was another abscess between tooth #5/6 eye tooth and double-forked bicuspid which crossed the back of the eye tooth to infiltrate the incisor. 09-11-12 - Tooth #5/6 - Eye tooth bicispid gap - First approach was from the gap itself. Unsuccessful. Second approach was from the back of the bicuspid coming over from the periphery. Eventually after 2+ hours of debridement yielding the abscess. Which poured and poured. Resulting in major deficit that is deeper than the roots of the bicuspid itself. And that would threaten the eye teeth too. Except for the eye tooth's deep roots. Which ends up making it highly survivable if caught in time.  Bicuspid is toast though. It's double-fork is invaded. The cave it lives in is deeper than its own roots. How it can even survive on its own is a mystery. Plus all its crud it mixed in with bone. So how can it ever ever even become clean? Especially with those double-forks. Which form a time-bomb or redoubt for the bacteria colony which is apparently close to impossible to eradicate even a little. Figure total time at five hours plus additional bleed-out time at perhaps an extra two hours. 09-20-12 - Tooth #3(4)#5 - First bicuspid First molar gap (post braces extractions) - Tried coming across the back of the first molar unsuccessfully and got stymied. Switched to the back of the bicuspid coming across to the lingual. Going in deeper and deeper in an area that had been well debrided numerous times, just not so deep as the push. Eventually reaching a lower level that released the abscess. Bleed out prompted the opening of the back of the first molar. Proceeded to  clear back of molar and redo back of bicuspid at deeper levels. Plus also including portions of front of first molar. In particular there was a major fortress at the medial lingual corner. Front inside corner. Which ultimately determined was calculus and proceeded to engineer a major dislodgement, after stripping the region of calculus resources. Result was major debridement of area. With major dislodgement of primary calculus resource. = = = BUT SOMETIMES THE TOOTH JUST HAS TO GO. ESPECIALLY IF IT HAS LOST ALL ITS SUPPORT AND IT IS THREATENING NEARBY TEETH - ESPECIALLY IF ITS NERVES ARE HANGING RIGHT IN THE AIR AND IT IS A MIRACLE IT IS SURVIVING AT ALL - WHICH IS JUST TOO BAD - OR THE TOOTH DOES HAVE TO GO - JUST NOT TODAY OR TOMORROW OR NEXT WEEK OR MONTH OR QUARTER - MAYBE IN A FEW MONTHS - THEN GET IT PULLED - JUST NOT TODAY - THAT ATTITUDE IS SOMETIMES OKAY TOO - BUT HAVE TO ANTICIPATE ALL THE OTHER ABSCESSES - ANYTHING ELSE GOING ON? FROM ALL YOUR POKINGS? = = = HOW TO IMAGINE THE PERIODONTAL ABSCESS? - BABY STEPS - Imagine your worst dream about being so far from your destination. And all you can take are baby steps. This is the physical reality of the abscess. Though the distances may seem so small the difference between clean living post-debridement and the congested state of the abscess is large beyond a scale that an ordinary person would imagine. As example imagine the crud that would come pouring out of your gums if somehow you could magically release all the actual crud that is existing amongst your teeth. Now multiply that by ten. So one hour worth of imagined crud actually takes ten hours to do in reality. By which time it becomes obvious that the volume of the crud is in fact greater than the volume of the tooth, including tooth. Plus obviously everything that crammed itself into the pocket and attached itself to the surface of your tooth - OR - was blocked from being free to live in the sewers - Indeed the actual abscess is a combination of both. Actual large pieces of  calculus that forms the fortress of the corner-abscess. Which can be termed as double-pyramid. WHY IS THIS? MORE CRUD THAN TOOTH - IT IS THE DIFFERENCE BETWEEN THE MACRO AND MICRO - = = = should I stay or should I go? if I go there will be trouble if I stay there will be double if you don't want me set me free! this indecision is bugging me so come on and let me know should I cool it or should I blow? = = = SUMMARY - If the situation is severe enough the sensible strategy is to give up and let the dentist pull the tooth. That way the abscess can be relieved without the intervening obstacle of the tooth to interfer with the healing process. The most foolish strategy is a half-assed intermittent strategy. Which is what I have done most of the time. Relieve the abscess only partway. Never really get to its deepest layers or clean it out properly or nurse it along properly. Let the rest fester. Kick-the-can down the road for a few more years. This will allow the abscess to travel down the deep layers of the periodontium and perhaps even into soft-tissue and come back with ferocity a few years later. A third strategy is total commitment based on total knowledge and aggressive inquiry. No half-assed measures on being satisfied until the next time. Rather to have a pro-active approach to ultimately get to the heart of the abscess itself, along with all of the associated areas, etc etc etc. As Bill Clinton once famously said when he was about to go down bad: ""Well, we'll just have to win, then." HUH? WHAT ARE YOU SAYING? If the situation gets severe enough ... to use logic to figure out where all the likely locations of additional abscesses are likely to be. Then to investigate each of these areas with due dilligence and if the painful symptoms are indeed there to assume there is either an abscess already there or one in the making. In other words, where there is pain and blood there is abscess. And if you can't figure out a strategy to get rid of it then you better figure out a strategy. Or pay the price later. EXEPTION - MANDIBLE NERVE - WHICH RUNS BETWEEN THE LOWER BICUSPID AND ALSO ALONG THE FIRST MOLAR - BUT WHICH ONLY APPLIES FOR SUPER-SERIOUS CONDITIONS WHERE YOU ARE RIGHT DOWN TO THE ROOT TIP - IF IT IS SHALLOWER LIKE SAY HALFWAY DOWN NOT SUCH A PROBLEM - SO IF IT HURTS IT MIGHT BE NERVE! STAY AWAY!!! WORK AROUND THE SUBJECT - AVOID IT - DO EVERYTHING EXCEPT WHERE IT ACTUALLY HURTS - DO NOT GO AFTER THE HURT LOCKER DIRECTLY - WORK AROUND AND APPROACH FROM THE SIDES !!! DON'T TRASH THE NERVE !!! BUT ISN'T THIS WHOLE STRATEGY HALF-BAKED AND FANCIFUL? YES IT IS - But that is too bad. The only other choice is to give up the teeth. Or wait for the abscess to break out full blown and deal with it as a crisis. If you can get to it prior to crisis isn't that better? Also... go tell your dentist you have an abscess. Point out the exact location. See what they say. Think it is highly likely they will say - Let's see what happens! - Well you already know what is going to happen. WHAT IS THE PLAN? IN GEOMETRIC TERMS? - In geometric terms the assumption is the abscess is on one corner of one tooth. From there the abscess can directly cause another abscess on either the opposite corner of the adjacent tooth. Or it can travel down the face of the tooth. = = = YIKES !! YOU MEAN THE ASBSCESSES ARE GOING TO TRAVEL AT A SUBTERRANEAN LEVEL FROM TOOTH TO TOOTH UNTIL I LOSE ALL MY TEETH ?? YES EXACTLY - YIKES THEN I BETTER GET MY TEETH PULLED !! HOW DOES THIS HAPPEN? - RIDGE THEORY - Can imagine four ridges. Shallow, medium, deep and the developing ridge mass butting-up against the bone, destroying it and replacing it with an emerging ridge of calculus. Yes indeed. You can imagine it just so. Then imagine a double-pyramid building up on the corner of the tooth. Then imagine a sludge bridge forming between the two adjacent teeth. Thereby creating a gasket between the teeth at the corner. Which then becomes the abscess, Which will then expand like a balloon and look for relief. Naturally the abscess will then travel across the face of the tooth to its opposite corner. Meanwhile a set of double-pyramids could easily be forming on that pair of tooth corners too. So the abscess will have travelled to the next tooth at a subterranean level. Beyond the reach of the hygienist. And there is not much you can do about it from the exterior of the gum line. So if one tooth gets an abscess so will its neighbors. Eventually. How long? Hard to say, but it could take years. But likely the next abscess already has a great head start. And may be on the roughly the same time schedule as several other abscesses. Or could be part of an abscess-complex. That can take down an entire quad. = = = THROWING IN THE TOWEL - SOMETIMES YOU JUST HAVE TO ACCEPT THE TOOTH AS LOST AND GET IT PULLED - WHAT DOES DIY PERIO OFFER HERE? - KICK THE CAN DOWN THE ROAD - Turns out that DIY Perio offers the possibility to kick the can down the road. Don't have enough money for implants? Just want to stop the abscess for now? Figuring it will come back on its own time soon enough and you can deal with that event then? Hopeless teeth? So you mean to say you are willing to spend up to dozens of hours on a single tooth just to get to keep it for maybe another year or so? IS THIS REALLY A GOOD USE OF YOUR TIME? ONGOING AND TIME CONSUMING AND POTENTIALLY DANGEROUS LIFE SUPPORT FOR HOPELESS TEETH? REAL LIFE EXAMPLE OF DANGER DANGER - I am currently nursing two abscess complexes. Both abscesses are right next to my mandible nerves. In fact the abscesses have invaded the nerve channels. Which is bad news right there already. The nerves provide sensation to my lower lip. Plus additional sensation to my cheeks. One is on a lower bicuspid. The other is on the opposite first molar. Turns out the mandible nerves travel right next to the root tips of the lower bicuspid and first molar -  Every time I debride the areas right next to the nerve my lower lip gets tingly for a day or so or up to a week. But it has recovered every time mostly. And it turns out this particular problem is in fact fairly common. Leading to the general admonition to be very very careful with any deep problems in this particular problem area.- SO WHAT IS MY ANSWER? NO SICKLES! - NOTHING POINTY! - STAY AWAY FROM PAIN - DON'T GET TOO AMBITIOUS - But what was my choice? My choice was to not clean out the abscess. WHAT WOULD BE A MORE SENSIBLE THING TO DO? STAY AWAY FROM THE DISTAL SIDE OF THE LOWER BICUSPID & STAY AWAY FROM THE BUCCAL SIDE OF THE LOWER FIRST MOLAR!! REALITYLAND - Realityland is that if you jump into a puddle of mud you may not be able to predict ahead of time just how deep the puddle is. What if you are in over your head? Or the mud is too thick to escape? What if the task at hand is way way beyond anything you should even be thinking about doing? What if the mud puddle is going to swallow you up and destroy both you and your precious precious tooth? WHAT IF YOU SCREW UP BADLY? WHAT WILL YOU DO THEN? WHAT WILL HAPPEN TO YOU? = = = THE ISSUE OF THE TRI-GEMINAL MAXILLARY NERVE IS HIGHLY DANGEROUS BUT NOT VERY LIKELY - THE TRI-GEMINAL NERVE GENERALLY TRAVELS ON THE FLOOR OF THE SINUS AND IS USUALLY ONLY AN ISSUE FOR THE FIRST AND SECOND MOLARS - Watch out obviously if you by some misfortune end up with the bone lost all the way down to your root tips and haven't thrown in the towel yet and are still digging away. But you should already know this. THE ISSUE OF THE MANDIBLE NERVE IS MORE PRESSING AND DICEY BUT NOT QUITE SO DANGEROUS - PROBLEM IS THE VARIOUS BRANCHES OF THE NERVE APPARENTLY RUN BOTH BETWEEN THE BICUSPIDS AND ALONG THE BUCCAL (OUTSIDE) OF THE FIRST MOLAR. NOTE - In my case I have two abscess issues involving this nerve. For the back of one lower bicispid the abscess created a cave that both invaded and exposed the nerve. So if I accidently blast the cave with the irrigator my lip goes numb. And is still numb from a previous blast. Which is obviously bad news. Plus anything pointy could obviously damage the nerve. Had to clean out the abscess out of the area anyway... very very carefully and very very slowly ... and so far the nerve looks like it will recover.  And will likely be okay within a few months. With no permanent damage. NOTE - Second abscess is on my lower first molar and the nerve apparently runs along the buccal (outside) wall. This one is also highly dicey and both invaded and exposed the nerve. Here I did a pretty good job with the first debridement and wish I would never to have to go back there again. Which I might not. Since I am considering getting the tooth pulled. But otherwise probably will have to go back. So my strategy is to let the area heal, treat it as much as possible with hyaluronic acid, focus on the perimeter as much as possible, and only after I have given it all the opportunities in the world and let it heal in between to go in gently and slowly to give any leftovers a chance to flee without putting them under much pressure. This particular situation is very much like a hostage situation. Where the preferred mode is tact and patience. And the avoidance of any violence at all if at all possible. Ripley: Lieutenant, what do those pulse rifles fire? Gorman: 10 millimeter explosive tip caseless. Standard light armor piercing round, why? Ripley: Well, look where your team is. They're right under the primary heat exchangers. Gorman: So? Ripley: So, if they fire their weapons in there, won't they rupture the cooling system? Burke:  Ho, ho, ho. Yeah, she's absolutely right. Gorman: So? So what? Burke: Look, this whole station is basically a big fusion reactor... Burke: ...right? So you're talkin' about a thermonuclear explosion and "Adiós, muchachos." Gorman: Oh, great. Wonderful. = = = During initial debridement the recognizable differences between bone and calculus is mostly important if you want to dismantle major structures of calculus. Which certainly is likely to be necessary. Since obviously don't want to rip out bone. Nonetheless, fact is that the abscess also invades the bone, tooth mixes in with bone, and feeble human abilities cannot tell the difference except upon close analytical and correct inspection, review, determination and execution. Which is simply not to be. In summary initial debridement has to accept the fact that tooth mix in with bone and bone need to be debrided. Even though calculus may masquerade as bone. Deal with it!  BUT... calculus gives up easier than bone. So if it gives up without much of a fight then it deserved to go have to live in the sewers. And can be a 99%er. It was crud!. Most definitely! But if it puts up a fight like a big fight, then stay away! Until you can logically determine that it is indeed calculus and that indeed you are not making a big mistake. On secondary debridement however the difference between bone and calculus becomes much more unclear. Very muddled. Very dicey. So who is to say really whether you are ripping out calculus or bone? Since they seem so much alike. Can you justify everything. Or are you a butcher? In addition is what I call the Ski Jump Factor - where an edge of bonafide tooth transitions into bone. Or into calculus. Who is to say? So you think the bone is tooth and try to smooth it. Remember - Bone Does Not Smooth - Only Tooth Smoothes - But nonetheless it is perfectly okay to give the bone a dusting. Or even more. Just don't rip it out foolishly. Meanwhile... if it is calculus it has to go. So what is the difference? How can you tell? Why not just leave it behind? And let it keep causing you trouble. How about just sweeping the problem under the rug? How it that for a solution? Kick the can down the road. The general rule is if you work from smooth tooth then everything directly adjacent to that smooth tooth that bleeds and does not hurt is bad. But what if it does hurt? Is it bone? Well... you should figure that out shouldn't you. Before you go ripping things out. But if things are bad enough then you have a true dilemma. Because if you don't rip anything out, or play a too conservative strategy, then indeed calculus will be left behind and the bone you were trying to preserve will die anyway. Along with your doomed tooth. So what is the answer? I think it is to slow down time. Work the principles. Then when you have to be aggressive or even brutal, and can justify it and be 100% you are right then to do what you have to do.  Or even if you are only 95% sure. Since most stupid mistakes will eventually heal. As long as you don't trash the nerve or something else vital. = = = ALSO REMEMBER THAT BICUSPIDS ARE SUSPICIOUS CHARACTERS - WHY? In particular the first bicuspid has a small but deep furcation right at the tip of the root that can become a deep deep reservoir of potential disaster that is largely beyond reach. It is like a redoubt all on its own. From there it can infect the eye tooth and the incisors. More or less the molars are the most susceptible to abscesses. The bicuspid then becomes the carrier to the eye-tooth. Also the eye-tooth is a carrier to the incisors. = = = 36-HOUR RULE - HAVE TWO WORK-DAYS TO DO SERIOUS BUSINESS - THEN SEVERE TRAUMA WILL SET IN - As a practical matter in many cases the situation will be so severe that you won't be able to reach a satisfactory conclusion in a single day. Even after 4 or 6 or even 8 hours. What especially tends to happen is that removing one layer of calculus or even one particular abscess will reveal deeper layers of crud and calculus. And you will realize that the heart of the problem is really at these lower levels and not at the upper layers. It is sort of like peeling an onion. In addition you may reach a satisfactory conclusion and just want to touch up the next day and go for easy pickings. This is also a good idea. Meanwhile you will use up all your time and will lose all your energy too. So what to do?? - MAKE A FRESH START THE VERY NEXT DAY - THEN STOP - BUT AVOID DOING ANYTHING AFTER THAT - WHY? - BECAUSE THE TRAUMA WILL SET IN TOO SEVERELY AND IF YOU GO BACK YOU WILL COMPOUND THE TRAUMA - IF YOU GO BACK AND FINISH WITHIN 36-HOURS THEN LARGELY YOUR ADDITIONAL TRAUMA WILL END UP BECOMING A PART OF THE PREVIOUS TRAUMA AND WILL NOT HUGELY COMPOUND THE TOTAL LEVEL OF TRAUMA - BUT IF YOU GO BACK AFTER THAT THERE IS A MULTIPLIER EFFECT - PLUS IT WILL HURT LIKE HELL TOO. = = = REAL-LIFE SCENARIO - Six years ago I had fairly a fairly serious abscess between my first maxillary molar tooth #3 and my adjacent bicuspid. I cleared out the basic abscess and decided to keep the tooth. One periodontist suggested I get both molars plus the bicuspid pulled. Three teeth in total. Or almost half of my upper right quad. Plus another two teeth on my left side. Or a total of five teeth. Plus it turned out later that four more teeth in the lower side were in bad shape too. So talking about a total of 9 teeth out of 28 total. So can imagine I was not very amenable to getting my teeth pulled. Six years ago. It was too late for floss. But did get scaling and root planing. But my perimeter was already breached. It was too late. Over the years I have treated the leftovers  of this particular abscess in a half-assed way. Going after readily available calculus. Aspirating out other bloody debris with the needle. I was living in a fool's paradise. Meanwhile the abscess worked its way across the bicuspid. (I had one of the bicuspids pulled for braces.) Then onto the eye tooth. And then onto the second incisor. And working toward the first incisor. IF ONLY... IF ONLY... I HAD JUST LET THE PERIODONTIST EXTRACT MY SECOND MOLAR, MY FIRST MOLAR AND MY BICUSPID!! THEN MY EYE TOOTH AND SECOND INCISOR WOULDN'T HAVE GOTTEN AN ABSCESS TOO. But hindsight is 20/20. Give up three major teeth and lose half of the upper right quad, along with half of my chewing ability and leaving a huge hole in my dentition, in order to prevent additional bad things from happening six years later. Such is the dilemma of periodontal disease. REAL-LIFE - STYMIED - BUT PERSEVERANCE LEADS TO PATH - In addition I burst an abscess in between the eye-tooth and the bicuspid but got completely stymied trying to figure out how to debride it further. Since the nerve kept acting up. Turns out I have an abscess within an abscess within an abscess.The eye-tooth is long. So the affected serve is from the eye-tooth! Once the area heals from the previous attack I attack again. Third attack on the abscess yields the goods. Several weeks of healing between each attack. WHAT IS PLAN FOR #7 ABSCESS ?? WHAT HAPPENED ?? - ATTACK ONE - RELEASE MAIN ABSCESS BODY - First attack approached the lingual 6-7 gap from four directions and unblocked the abscess after at least 2 solid hours, maybe more. Then helped the main body of the abscess escape. Will say that took at least another 4 hours. So total job took like 6 hours and more likely 8 hours or so. Plus breaks. So certainly this was an all-day experience. Will review. I lost so much blood I thought I was in trouble. Though in real life I wasn't really in trouble. It just seemed like a lot of blood that's all. as less though still a lot. First few days were touch and go. Ibuprofin and water to keep down the swelling. Swelling went down after a week. Let area heal for three weeks. ATTACK TWO - REACH GATES OF CACHED NERVE-ABSCESS ON TOOTH #7 -   Second attack explored the perimeter of the abscess, especially regarding its proximity to the seconds incisor tooth #7. Much of the perimeter was revealed to be "furry stuff" crud. Plus there is a line of "furry stuff" along the bone. But took over 3 hours to get to this point. So called it a day and decided to recover from the trauma. One week looks too soon. It is still swollen. May go for 2 weeks or if swelling goes down in apparent healthy way then to go for it. PLAN FOR ATTACK THREE - BARBARIANS AT THE GATE - ESTIMATED LAUNCH DATE - f-10-12-12 - Plan is to let the interior of the abscess on tooth #6 rest up nice. That way once I break into the abscess the area will be tanned and rested and eager to go. Main reason is I do not know what I will find when I break into the abscess. It could be a horror show. Or more likely the nerve will be in close proximity to a clinging infection. So obviously I want as much available time as I can reasonably get to work on the abscess before the area becomes traumatized. Since if the nerve comes traumatized than I might just end up kissing the tooth goodbye. Which I do not want to do. So I am attempting to engineer an aggressive but also conservative strategy. To go after as much of the main body of the interior abscess as I can with the least risk and danger. Plan for area around nerve is what I call - TICKLE THE DRAGON - GO FAR BUT NOT TOO FAR. LOST IN A FOOL'S PARADISE EVENTUALLY LEADS TO DISASTER - Addressed the problem lightly for years. No blood no problem? Can't find the hurt? OK - I will figure it out and do something about it... later... yeah right! -   I did what I could to debride it more. But that wasn't good enough. Being stymied did not solve the problem. I may have quit trying to figure it out what to do. But the abscess did not quit and just kept on doing its job. Ultimately leading to emergency relief and extreme damage. So now I get it!! You have to do what you have to do. WHAT IS THE ANSWER? OUT-FLANKING STRATEGY! YES THAT IS THE ANSWER!! EUREKA!! - ok okay enough already - What is my strategy? Right now I am completely convinced that Out-Flanking Strategy is the answer to all of my problems. That Out-Flanking Strategy will ultimately clear my infected teeth of all their time bombs. But will it really? Well... certainly it is a good start. Plus it does give me strategies to go after areas where I was completely confused and flummoxed before. But is it the Holy Grail really? No, probably not. But it is a tool. And part of a strategy to actually go after problems and solve them diligently. So... what that means is that for the problem that Out-Flanking Strategy will not solve then I have to find another strategy. But I may not know my future strategy until I execute my current strategy. Then when I am wondering what to do next the answer will come to me. Not before. Then I execute that strategy. Leap-frogging into the future. = = = HYALURONIC ACID STRATEGY - RAISE THE TITANIC - FRACK IT - FLUFFER - This is my primary strategy for areas that are already fairly clean but very very deep. The hyaluronc acid tends to make loose pieces of calculus break off and can help an area eventually come clean. But it is a dangerous strategy too. Since it expands the water. So a large amount of infection could get monstrously large with nowhere to escape except deeper into the body. Which is obviously bad bad. = = = ONE-PIECE AT A TIME STRATEGY - This simply says that one chunk at a time - forget-about-it - just do it - will also eventually win. Even if you have to spend hundreds of hours at it. Then hundreds of hours more. And if you tell anybody what you are doing they will automatically think you are crazy. Your dentist will tell you you are crazy too and how about those nice new implants instead. But regardless this strategy will also eventually win. = = = NOTHING TO LOSE - THE MAN WITH NOTHING TO LOSE IS A DANGEROUS MAN INDEED - BUT IF YOU CUT YOUR LOSSES SOONER INSTEAD OF DOUBLING-DOWN ON STUPID MAYBE YOU WOULD BE BETTER OFF - BECAUSE NOW YOU HAVE ABSCESSES ALL OVER AND THEY WILL TAKE YOUR ENTIRE DENTITION AND PERIODONTIUM DOWN WITH THEM AND YOU WILL NOT BE ABLE TO STOP IT NOTHING TO LOSE ?? - HOW ABOUT THE REST OF YOUR TEETH AND BONE TOO ?? - YOU WON'T EVEN HAVE ENOUGH BONE LEFT FOR AN IMPLANT - YOU WILL HAVE TO WEAR AN APPLIANCE AND KEEP IT IN A JAR AT NIGHT - HOW DO YOU LIKE THAT IDEA? BECAUSE THAT IS WHERE YOU ARE HEADING - This is another way to look at it. If the tooth is indeed hopeless and you do indeed forestall the abscesses from destroying the adjacent tooth too - or even the entire quad -  which may not be possible but let's just say it is possible - and also let us just say that the rehabilitation can indeed become complete, damage accepted but tooth surviving, both theoretically and indeed - then nothing was lost in the attempt except the try. And what else would you have been doing with all of that lost time? Watching TV? Gardening? Playing golf? But what if you indeed do win. Then what? Was it worth it to keep the tooth? I would say if you win the answer is certainly yes. If you lose then maybe not. Cause your bone will all be gone. And won't grow back. Maybe even your sinuses will be in deep trouble too. RESPONSE - YES THE IMPLANTS MAY HAVE TO WAIT FOR A FEW YEARS FOR THE BONE TO GROW BACK TO THE RIDGE - AGREED - NO TOOTH IN A DAY TYPE TREATMENTS - HAVE TO WEAR AN APPLIANCE - ACCEPTED - AND ACCEPT A FUTURE LIFE OF LESS BONE THAN MIGHT HAVE HAD IF GAVE UP TEETH EARLIER  - For the back teeth if you preserve your ridge and don't let them chop down your ridge for anything then you can reasonably expect the ridge will eventually fill in with bone. You just won't be able to get implants right away. You can also get ridge augmentation. So your options are not exhausted. ALSO DON'T BELIEVE THOSE DRIFTING TEETH STORIES - THAT IS ALL THEY ARE JUST STORIES - Studies show the average teeth will drift approximately 1 mm in eight years. Or 1/25 inch. Or 1/200 inch per year. But certainly it could be more. Realistically might figure that up to 1/2 mm may be reasonably tolerable. That would mean you should certainly have up to four years to decide. Or if the teeth move especially fast two years is reasonable. But certainly in a matter of a few months the teeth are not going anywhere.  So if you are getting hustled to get the implant right away just keep in mind that you are being hustled to get the implant right away. RESPONSE - FOR ANTERIORS (FRONT TEETH) - IF THINGS GET TOO DICEY LOSING BONE HEIGHT MAY BE BEST TO PULL UPPERS BUT KEEP LOWERS - Let us face it. Primary issue with the upper-anteriors is looks. Losing a back tooth or two doesn't bother most people. But lose a front upper tooth and the emotional experience is indeed traumatic. That is a simple fact and not to be argued or disagreed with. Can figure that most people will hide their pain about this issue. UPPER-ANTERIOR ABSCESSES - APPEARANCE CONSIDERATIONS -  Meanwhile each abscess on the anteriors can and will destroy gum height. Now if the attack is on the back the problem might modulate itself. But loss of gum height on the front upper teeth cannot be very much or the entire profile of the upper front teeth in many people's minds may become permanently ruined. Indeed would guess that even 1/8 inch of bone growback is a fantasy. Can only reasonably expect 2mm max, or roughly 1/12 inch. But more likely to only get 1/16 inch. Meaning not much. Tough noogies. So who knows? If top anteriors threaten to lose too much gum, beyond say 1/2 inch, could make sense to pull the plug. And look to an implant for the future.  But for lowers the lower lip is likely to hide it. So figure a lot of people would just put up with it. WHAT DOES ALL THIS MEAN? What this all means is that I could have given up one or two or three teeth six years ago and might have been able to stop the abscess then. Or maybe not. Who knows? But whatever the reality may be I am now faced with a series of very serious abscesses on the 2nd Molar, 1st Molar, Bicuspid, Eye-Tooth and Second Incisor. Virtually the entire quad is about to fail and I am about to lose 5 teeth in one foul swoop. WHAT IF THE NERVE DIES? WHAT THEN? - YES THAT IS A BIG PROBLEM - BUT USUALLY THE NERVE WILL SURVIVE - HOPEFULLY - On my upper-right maxillaries I have several teeth that intermittently to numb on a regular basis. Each time I am concerned that one of the teeth will die. After all what is going on? The tips of the teeth where the nerve is coming out is surrounded by destruction and infection. So they are being traumatized on a daily basis. Thank God I have never as far as I know ever directly hit any nerves, in spite of hundreds of total hours of curettage. But I am also very paranoid too. Plus lucky. So then what? If the nerve dies then have to get a root canal or get the tooth pulled. That is that. If you lose then you lose. But maybe just maybe the tooth will recover and the nerve will thrive too. You never know. Maybe the tooth will survive. = = = SO NOW YOU WANT TO DOUBLE-DOWN? YES THAT IS EXACTLY WHAT I WANT TO DO AND WHAT I AM GOING TO DO - IN ADDITION I AM GOING TO WIN AND KEEP ALL THE TOOTH AND NONE OF THEM IS GOING TO FAIL - AND IN FACT I MAY EVEN BE ABLE TO REGENERATE SOME OF MY LOSS - HOW? BY GETTING ALL OF THOSE TEETH PERFECTLY CLEAN AND PERFECTLY RECOVERED. SOUNDS LIKE YOU ARE DREAMING - NO I AM NOT DREAMING - FIVE TEETH - 20 CORNERS - PLUS DEEP REGIONS - BUT EACH CORNER HAS TWO OUTSIDE APPROACHES - SO 40 APPROACHES IN TOTAL - PLUS ADDITIONAL DEEP AREAS -  IF THERE IS BLOOD AND PAIN THERE IS ABSCESS - IF THERE IS NO BLOOD AND NO PAIN THERE IS NO ABSCESS. WHAT IS THE PRIMARY PROBLEM? THE PRIMARY PROBLEM IS IT CLOSE TO IMPOSSIBLE TO SUCCESSFULLY GO AROUND A CORNER. HAVE TO APPROACH FROM ACROSS THE TOOTH. PLUS DEEP FURCATIONS MAY BE CLOSE TO IMPOSSIBLE TOO.  SO IF INDEED ANY OF THESE SITUATIONS ARE IN FACT IMPOSSIBLE THEN AN AREA THAT IS ALREADY INVADED BY ABSCESSES WILL CONTINUE TO BE INVADED. BUT IF SUCCESSFUL STRATEGIES CAN BE DEVISED FOR EACH AND EVERY DANGEROUS SITUATION THEN EVENTUALLY THE ABSCESSES WILL RUN OUT OF PLACES TO LIVE AND PLACES TO HIDE. ALL OF THE TIME-BOMBS, WHETHER READY TO BLOW OR JUST TICKING, WILL HAVE BEEN DE-FUSED. = = = BUT ISN'T THIS GOING TO TAKE A LOT OF TIME? YES IT WILL TAKE LOTS AND LOTS OF TIME. PLUS ALL THE HEALING IN BETWEEN. SO KEEPING THE TEETH TURNS INTO A HOBBY. WHAT ABOUT THE DEEPER AREAS BEYOND THE REACH OF THE CURETTE? OR WHAT IF YOU TRASH THE NERVE? -- ANSWER? - DUH! UH! HUH? - LOOK NOBODY IS SAYING THIS IS NOT DANGEROUS - IT IS EXACTLY WHAT IT IS - NO MORE AND NO LESS - DON'T WORRY! - I WILL SOLVE THOSE PROBLEMS TOO! I REALLY WILL! PLUS I CAN HOPE THAT HYALURONIC ACID WILL WORK TOO CAN'T I? PLUS I CAN COME UP WITH OTHER CONCOCTIONS AND OTHER STRATEGIES I HAVEN'T EVEN THOUGHT UP YET. PLUS THE PROBLEM HAS NOT ARRIVED AT MY DOORSTEP YET HAS IT? AND IF IT DOES AND IS TOO HARD THEN I WILL JUST GIVE UP, PULL THE RIP-CORD AND TELL THE DENTIST TO PULL THE TOOTH. OR TELL THE SURGEON TO DO WHAT HE HAS TO DO. CUT IT UP OR WHATEVER HE HAS TO DO. = = = WOULDN'T YOU BE BETTER OFF WITH IMPLANTS? Think about it. Each implant will likely cost at least $4k or even more. So 5 implants would cost $20k. Plus there are at least 3 more dicey teeth. For at least another $10k. So my pre-existing teeth have a replacement value of at least $30k. So if I want to protect my investment it is my business, isn't it? And who is to say these implants are not going to become infected too? So the $30k can easily turn into $50k or live sans-teeth. Which I do not want to do. = = = SO THE DIY-PERIO IS REALLY JUST A HOBBY ISN'T IT? YES, IT IS REALLY JUST A HOBBY LIKE ANY OTHER HOBBY. WITH THE BENEFIT THAT IF I DO IT WELL PLUS GET LUCKY I WILL GET TO KEEP MY TEETH. = = = BOTTOM-LINE - If the periodontal disease is not so severe that the abscesses are in invasive mode then they can be treated as individual infections. But if the periodontal disease is so severe that the abscesses are communicating across the face of the teeth and in-between teeth and even across the roof of the mouth or into the sinuses or into the soft tissue of the lower jaw then...  YOU ARE IN BIG BIG TROUBLE - BIG TROUBLE - IT IS CALLED TUNNELLING - SO WHAT DO YOU DO WHEN YOU GET IN TO DEEP? YOU HAVE TWO CHOICES - OR MAYBE SEROUS SURGERY AS A THIRD CHOICE - FIRST CHOICE IS TO GET THE TEETH PULLED - SECOND CHOICE IS DIY AND TO ACTUALLY WIN, NOT LOSE. BECAUSE IF YOU INDEED DO LOSE THE FINAL RESULT WILL BE WORSE THAN IF YOU JUST SACRIFICED THE TEETH INSTEAD - IN MY CASE I MADE THE CHOICE TO WIN - BUT I AM NOT TRYING TO CLAIM I AM NOT MAKING A FOOLISH CHOICE - ALL I AM SAYING IS THAT I WILL WIN. = = = SCROLL TO END FOR DIARY OF ONGOING ABSCESSES - ideas, beliefs, conclusions also including false conclusions, actions, healing, ongoing activity, long-term results, prognosis and plans. Yes, all this is necessary if tooth is extremely damaged and infected and infiltrated or infested or tooth will be lost. Upper Maxillary Molars endanger sinuses and the unbelievably super-super critical tri-geminal nerve. Plus the actual roof of the mouth, which is like an umbrella with channels. Lowers endanger the spit-glands, the tongue and the lower mandible nerve. Plus the actual nerves for each of the teeth. Which could end up infiltrated by the calculus too. So it is easy to see how the dentists will just say the tooth should be pulled and replaced and that is that. Anything else is living in a world of dangerous fools. But if all the dangers are properly respected then strategies for all but the worst can be devised. And you can imagine it is not too late to pull the tooth until indeed it is too late. So give up and get the tooth pulled. And hope to recover from the secondary damage caused by leaving the tooth in too long. Or from botching the job. Logic is the infected tooth becomes like a splinter which becomes an infected foreign object lodged inside the body. DIY perio imagines this object can ultimately be rehabilitated. Maybe. Likely including dozens and dozens of difficult and dangerous and likely painful and dicey hours per abscess. Slowly nipping off the calculus one-chunk at a time. But common sense dictates otherwise. The object (your tooth) cannot be cleared of the rock-like calculus and resulting ongoing debilitating infection and meanwhile danger reigns over the teeth, jaws and body. Indeed the abscess will travel along the periodontium and infect the other tooth too. Leading to losing the rest of the teeth too. Best to cut losses and pull the tooth. The tooth cannot be rehabilitated. No way. No how. Plus the abscess will bury itself in deeper and travel further and further. Which indeed it will do. So what will you do when you get your second crisis and it is four-times worse? Was it really worth it to kick-the-can down the road instead of accepting your losses? = = = GENERAL CURETTAGE STRATEGY - Overall the strategy is - One-Man One-Mission STOP - This means it is highly highly important to devote the entire effort to a singular task. And to commit to try to break off the calculus in chunks. Plus to smooth the terrain of obstacles and rough ground. Going after deep calculus too soon is a fool's mission. The calculus is just too too difficult to break off. But once it is isolated it is easier to break off. GENERAL STRATEGY - PRIMARY - FINISH WHAT YOU STARTED - OR ELSE - DANGER DANGER -   If you only clean out the abscess partway and massive amounts of calculus and infection are allowed to remain then two things will have happened. Besides much of the abscess escaping. First the area will be traumatized. That is a guarantee. Second it will have lots of angry energetic infection still left behind. Perhaps what is still left was previously bullied by the rest of the infection. Now it has the entire pocket to itself and will want to assert its authority and mastery over its traumatized environment. WHAT DOES ALL THIS MEAN? - IF YOU DON'T FINISH YOU ARE NOT COOKED. BUT YOU BETTER GO BACK SOON. EITHER THE NEXT DAY OR AFTER THE AREA RECOVERS FROM THE TRAUMA. LIKE ON SAY THE 7TH DAY OR THE 11TH DAY. OTHERWISE THE ABSCESS COULD GET AHEAD OF YOU. IT WILL CONTINUE TO FORGE FORWARD WHILE YOU ARE STUCK IN INFECTED TRAUMA. NOT A GOOD POSITION TO BE IN. BUT WHAT IF THE JOB IS TOO BIG? WHAT SHOULD BE DONE THEN? - THE CONSERVATIVE STRATEGY IS TO LOOK AT THE ATTACK AS CONSISTING OF TWO PHASES. FIRST PHASE IS TO ISOLATE THE ABSCESS. BUT DO NOT ATTACK DIRECTLY.  THEN LET AREA REST AND RECOVER FOR A WEEK OR SO. SECOND PHASE IS TO GO AFTER THE ABSCESS FROM AN OUTER PERIMETER THAT IS BASICALLY HEALTHY AND STABLE. VISUALIZATION OF THESE STRATEGIES - BULLS-EYE THEORY - Idea here is to clear the outside of the bulls-eye then let rest and recover from trauma. Then to go for the center of the bulls-eye. COWBOYS AND INDIANS - GO FOR THE CENTER? (no) OR DESTROY THE PERIMETER FIRST AND THEN GO FOR THE CENTER - Logic here is if you go for the center first you may never actually make it there. Then you will be left with a traumatized center a strong periphery and a high overall level of trauma. Bad combination. COWBOYS AND INDIANS - OR DOUBLE-PYRAMID FORTRESS STRATEGY - Logic here again is to break down the attack into two phases. First to clear the perimeter. Let rest and recover from trauma for around a week or two. Then to go for the center a week or so later. But if the abscess is threatening disaster then obviously may have to speed up the schedule. Like say after the 5th day. Or to trade-off short rests with long rests. As example an initial session without too much trauma to clear the general path. Then a more serious session to get to the gates and perhaps even to breach the abscess. Then to let it recover until you can no longer stand it any longer and then to go in and do the dirty work. BUT CAN'T I GO FOR THE CENTER RIGHT OFF? YES YOU CAN BUT THE STRATEGY IS LIKELY TO FAIL. WHY? BECAUSE THE OUTER LAYERS OF CALCULUS HAVE THE EFFECT OF PROTECTING THE INNER LAYERS. SO EVEN IF YOU CAN REACH THE INNER LAYERS YOU WON'T BE ABLE TO BREAK THEM OFF. YOU WILL ONLY BE ABLE TO BREAK OFF THE INNER LAYERS ONCE THE OUTER LAYERS HAVE BEEN REMOVED. CALCULATING THE MATH - For simplicity realistically imagine that it might take 2 hours to more or less debride one ridge of calculus. Leaving a fairly smooth surface behind. Root planing. Also imagine there are in fact four layers of calculus. Shallow, medium level, deep and butting the bone. So just to reach the abscess with a clean field may require 8 hours. Or fewer if you bypass some of the layers. In addition imagine that it might take 4 hours to clean the abscess. Not that it will take this long. In fact maybe you can get to the abscess in 2 hours and can clean it out in another 2 hours. So this would be a total of 4 hours minimum. Or up to say 12 hours maximum for one abscess. CALCULATING THE HOURS - REAL LIFE EXAMPLES -Also keep in mind that one tooth could have multiple abscesses. As example I had multiple abscesses on tooth #29. The lower right bicuspid. The first abscess on the lingual-mesial side took roughly 5 hours to clear in one-session from start to finish But I was dangerously brutal. Realistically in a less aggressive mode that abscess could have easily taken 8 hours or more. Plus I was directly out-flanking the layers of calculus from bottom to top, low to high across the verticlal edge of the front. Without messing around with attempting to go in on a long horizontal front one layer at a time. Which is a fool's strategy. So also consider with even a well thought out strategy this abscess #1 was an 8 hour job. REAL-LIFE EXAMPLE - The second abscess turned out to be just as nasty. On the distal-buccal side. It took 5 hours start to finish. Cleaning out the hole fairly well. Then the abscess continued to bleed fairly readily for an additional 4 hours with intermittent disruption. So figure a grand total of 8 hours there too. Third abscess was a continuation where the first two abscesses met at the inside corner. That one also took around 8 hours in two back-to-back sessions with rest in-between. And also cleaning out some of the leftovers from the first two abscesses. So I spent a grand total of roughly 8+8+8=24 hours clearing out three quite serious abscesses from one tooth. Which obviously sounds like a lot. But that is what it took. And before the tooth was certainly a goner. But now it has a chance to survive. REAL-LIFE COLLATERAL DAMAGE - SPIT GLAND GOT IN TROUBLE - NOW LARGELY RECOVERED -  BTW this bicuspid is in close proximity to both the lower spit-gland and the mandible nerve. Since the abscess was so serious both areas were already compromised by the abscess and hence were already in big trouble even before I got started. What happened is the abscess was so severe it broke out into the soft tissue. Meaning big trouble. Then in clearing out this first abscess the spit gland was also infected with the abscess and proceeded to swell up profusely for several weeks. I was very very afraid. And tried to keep the area calm with ibuprofin and cold water. Plus use massage to debride it further. Which worked. Successfully got the spit glad to spit out lots and lots of additional crud. Within a week the situation was no longer so critical. Now after a month of the entire general area being reasonably hygenic the area is still swollen a little bit, which is apparently to be expected. And I am hoping it will return to normal within another month or so. At which point the tooth should also recover fairly well. So I can debride again in a reasonably healthy field. Which should also help the spit gland. REAL-LIFE COLLATERAL DAMAGE - MANDIBLE NERVE - Also a few days later I blasted the area with the irrigater and traumatized the mandible nerve. So part of my cheek then went mildly numb. But have been treating it nicely for a month, continuing to gently debride in the general area with the tooth pick. And now the nerve appears to be normalizing. Also FYI, according to the literature this problem is also fairly common for bicuspids and first molars and most of the time the nerve recovers within around six months or so. SUMMARY - LOOKS LIKE WILL RECOVER FROM THE COLLATERAL DAMAGE CAUSED BY A COMBINATION OF THE ABSCESS INVADING THE SOFT TISSUE AND ADDITIONAL TRAUMA FROM POKING AROUND AND SPRAYING THE AREA TOO HARD WITH THE IRRIGATER. CALCULATING THE MATH - IN MAN-HOURS OF CURETTAGE - Realistically it could take many hours to get to the abscess. Then once the abscess is found and released it may take additional many hours to clear the area of blood and debris. Believe it or not it could take 8-hours or more. Or if the area hasn't been debrided at all it could take even more.  So good starting strategy is to devote the entire day, starting early in the morning or as long as it lasts. Alternately I also like the all-night strategy for any ridiculously big jobs. Where after-the-fact it turns out in retrospect that the job was huge beyond belief.  Prep. Go to sleep early. Wake up in the middle of the night. Or at say 10pm. Then do the business. Do not have any activities at all planned for the next day. If you end up on a roll and have the energy the best strategy is to keep going, accept the trauma, try to go all the way so little is left and then go for at least a week of rest. SWELLING ISSUES - Pre-curettage load up on high dose of ibuprofin to keep swelling down. Post-curretage take more ibuprofin. Cool down area with water to reduce swelling too. Pre, during and post curettage. Going back Day 1 is usually okay. But Day 2-3-4+ are all bad bad. Reason is the trauma has set in. And any go-backs before the area recovers from the trauma is bad bad bad. Why bad? Because the area could be so swollen it is on the verge of a great disaster. So don't push your luck. But once the swelling goes down there is more re-swelling that can take place before you reach the verge. Think of swelling as a form of currency. If you are broke - ie you have no more swelling left that you can let happen before disaster then you are in big trouble. But if area can safely swell some more then you are not so close to disaster. Ideally should wait until at least the 5th day. If it is really bad then figure the 11th day is the first reasonable day. If the abscess is building up in the meantime think it is best to try to hold out with ibuprofin. Then wait until at least a day after the primary swelling has gone down to semi-normal. And to never never never try to go after a severely swollen area. Since you will have no swelling reserve to use up. PURULENT SWELLING vs TRAUMATIC SWELLING - This issue also deserves consideration. Traumatic swelling can be expected to go down if the area is in a reasonably clean field. But pus-filled purulent swelling will not go down until the area is burst. CAN I TRY TO BUST THE CENTER THEN LET IT RECOVER THEN CLEAN IT UP AND FORGET ABOUT ALL THIS FLANKING STRATEGY. JUST GO IN LIKE A SWAT TEAM INTO THE CENTER? Yes you can. But unless there is some especially desperate reason to do this this strategy is not advised. Since you are better off having the abscess break out onto a relatively clean perimeter than  out onto a dirty perimeter. WHY? Because you will then have a highly traumatized dirty perimeter that is why. If instead you can just employ a more methodical patient strategy you will be much better off in my opinion. Even if it means you have to endure the swelling for a few more days or even a few more weeks if necessary to set up the right circumstances between a clear perimeter and an untraumatized field before you execute the actual attack on the abscess double-pyramid fortress. Which could call for exacting brutality with just the right amount of force in just the right place, causing additional trauma at the most critical moment. So it would be foolish to use up all of your trauma willy-nilly. Better to keep the trauma in reserve until the exact time you need to use it up for exactly the right thing. SUMMARY - THE BEST PRACTICE STRATEGY WOULD BE TO CLEAR THE PERIMETER WITH FLANKING STRATEGY - . LET RECOVER - THEN TO ATTACK THE ABSCESS AND CLEAN IT OUT COMPLETELY IN A SECOND SESSION MAYBE A WEEK LATER OR SO. OR TO GO ALL AT ONCE FOR THE EIGHT OR SO HOURS IT MIGHT TAKE TO GO START TO FINISH. OR TO DO THE FIRST SESSION ONE DAY. THEN TO DO THE SECOND STRATEGY THE VERY NEXT DAY BEFORE THE DEEP TRAUMA SETS IN AFTER ROUGHLY 24 HOURS. = = = SUMMARY - Clear the path to the abscess with the curette. Use the toothpick as a finishing tool to free the abscess. Bleed out the abscess completely with help from a tool. Avoid stopping for any reason except danger.  Flush the remnants any way you can. Try to let the abscess recover from trauma for at least three days before you go much of anything to the damaged area. But figure you may need to do what you must within 24 hours of initial bleed-out. The trauma is likely to build for up to three or even four days. But after that its severity should subside. Ibuprofin and cold water are very very important to keep trauma at a minimum. Remember, Trauma Can Kill a Tooth! So extreme trauma that directly affects a tooth nerve must be reduced close to immediately with ibuprofin and cold water. Or else your tooth may very well die. Long term plan is to figure to go back to the abscess in around a week or so to do some more debridement. In particular the toothpick can be the wonder tool. But also to remember any latent bonafide calculus will also prevent recovery. So when tooth finally reaches at least temporary rest and the healing process has been allowed to continue for a good ten days - 3 days for initial recovery from trauma and setting up the extra-cellular matrix - plus 7 days of actual healing - then can feel comfortable going back. If the area is extremely damaged can figure on the tooth remaining in an extremely damaged condition for at least a month. Or even two months. Trying to be realistic. But... after around two weeks or so... but only if you really nailed it... tooth will start to look recovered... as in equivilent to a person in the hospital... when can the tooth go back to being treated in a normal way? My thoughts here are this - First is you are highly highly unlikely to completely destroy the abscess on first debridement. So figure to recover in two weeks and then re-attack. Likewise if the area is totally trashed then you might have to wait for a month. OR can skirmish with the area in the meantime with toothpick only. This could be termed as a POLISHING STRATEGY. But nonetheless imagine a best case scenario. Which is that first debridement will trash the two adjacent teeth for at least two weeks. Then the second debridement will again trash the area for another two weeks. So here you imagine the tooth becoming less invalid and even semi-normal again in around a month if all goes well. In my case I have typically spent up to a year or even more trying to recover individual teeth that reached the point of cratering, caving-in, getting infected or getting real-life and threatening abscesses. Worst case scenario is more likely. Which is there is more to the problem than meets the eye. Hidden time-bombs so to speak. And one of those gets the tooth instead. And since it is deeper inside the second round is more treacherous than the first. Plus it starts to approach the sinuses on the top - maxillaries also include tri-geminal nerve - which is both super important and easily damaged. Plus on the bottom there is also a mandible nerve, which is still real important but not quite as super-important and scary as the tri-geminal nerve. Plus there is the spit glands - salivatory glands - Which can get invaded - like mine did - and be very difficult to recover from since the spit glands then become subject to direct contact with the infection on the tooth. Which is a bad combo. My opinion here is to just suffer through it and try to win. Otherwise just turn in the tooth. If the situation gets bad enough to start invading sinuses, important nerves and even your spit glands and who knows what else - the lympatics(?) - just give up the tooth!! Or take the risk to save the tooth - but don't rely on blessings - the only way to save the tooth is debridement - combined with a successful healing and secondary debridement process - either your doctor or hygienist has to do it. Or the only other person in the world who legally can. Which is you. Otherwise the tooth is toast and will have to go. And that unfortunate day is likely to come sooner rather than later. No matter how much wishing you may do. But even so can still recover from most emergencies. But the process truly seems to border on dangerous. Even though an objective view of things should truly recognize that it is not as dangerous as it may seem. What in fact are the alternatives? Or if it fact it was really more just scariness and not actual danger. And if done improperly or unsuccessfully, again, if you think about it, what was done again did not really constitute danger but rather it most likely just put off the day of reckoning. VALID COUNTER-ARGUMENT - The valid counter-argument more or less recognizes that DIY debridement is not inherently dangerous. As long as you don't punch a hole into the sinus, but it was damaged anyway, or hit a nerve, which means to be more careful. You wouldn't smash your car into a tree would you? Then why would you hit a nerve unless you screwed up and slipped for something you shouldn't have been doing anyway. So it's your fault. So removing these, what is left is the act of debridement itself. Which is hard to see as such a negative. Granted you could traumatize the tooth and cause it to die. But the tooth was already desperate. And you may be likely to save the day again. Maybe. WHY PUT OFF THE DAY OF RECKONING IF THE STAKES KEEP GETTING HIGHER? IS NOT THIS IN ITSELF COURTING DANGER - WHEN ALTERNATIVE IS SAFER? - This is the primary argument to give up the tooth or teeth. Once abscesses start to form they will continue to form. Plus they can travel across teeth and across the roof of the mouth. Like mine are doing right now. But in my case I developed a skill level that kept the teeth in my head for so many years and now it is time to face the music. Deep abscesses. What are you going to do now? So keeping hopeless teeth is really just kicking the reality-can down the road isn't it? COUNTER-ARGUMENT TO COUNTER-ARGUMENT - So to get rid of the deep infection you are saying I have to remove its source. The hopeless tooth or teeth. And that implants will restore a healthy dentition... What if I can restore 100% hygiene on my own? To do what I have to do and really do it. What about that? Will that work? ANSWER: MAYBE YES MAYBE NO. MAYBE ALL THAT TIME YOU BOUGHT WILL MAKE YOU WORSE OFF - KEEPING A SERIES OF DANGEROUS TIME BOMBS INSIDE YOUR JAW - LOSING ALL THAT BONE - MAYBE IT WILL BE TOO LATE FOR YOU EVEN FOR IMPLANTS. EVER THOUGHT ABOUT THAT? = = = There ain't goin' to be no hangman Putting no rope around my neck little child There ain't goin' be no hangman Putting no rope around me = = = -- WHAT IS AN ABSCESS? - IT STARTS WITH ONE PIECE OF CORNER CALCULUS - Calculus forms in Ridges. The deepest ridges butt up right against the bone. Corners are natural calculus fortifications. Including tough twisted forms which are hard to remove, plus "hands across the water" collections of strings of infection between teeth. Which also helps build up height. In addition the corners tend to deflect dental curettes. Assumption is the outer facing portion of the piece will tend to grow almost like a sculpture on a pyramid in relief on top of the tooth. From here the lower regions of the piece of calculus will tend to the natural flow of gum- juice - senovial-like fluid that is supposed to rinse the inner gums so they are hygienic. From here the inner part of the budding abscess with create its own pyramid, facing down, reaching for the root of the tooth. Hence the model - DOUBLE-PYRAMID. - AN ABSCESS IS A GASKET - CALCULUS DOUBLE-PYRAMID. It blocks the infection from escaping. It blocks the curette from dislodging the most inner piece of calculus. That is holding the whole thing in. -THE STRAW THAT WILL BREAK THE CAMELS BACK - KEYSTONE THEORY - This is gasket theory reversed. Attack the double-pyramid - OUT-FLANKING STRATEGY - Get to the special piece of calculus - THE KEYSTONE -- LORD OF THE FLIES THEORY - This logic works for abscesses. In general it is probably too hard first debridement. Where just have to take what you can get. But even there it could be applied. Rather just look at it as an analogy. Meaning the same thing as out-flanking strategy. But could also be applied as a general strategy. Rather than sweep across the top why not really GO ALL THE WAY TO THE BOTTOM - But is this reasonable? Think not. But if you do get an opportunity to get in real real low why not take advantage of it. As long as the entire operation does not end up going out whole and whole crazy. But in controlled circumstances there is no particular reason that can't work either. If the theory that supports the theory is valid. That theory is - blood is good - and what is the opposite side of the debate on that? DIARY - th-07-19-12 - Tooth #7 - Maxillary Incisor - Distal- Buccal - (outside front) -  Liberate periodontal abscess w toothpick. Including Xenomorph Monstrosity.  Post curettage w Montana Jack Sickle Blade. Using Flanking Strategy. SUMMARY - Abscess has been causing nerve tingling since early 2011. Previously relieved tingling w aspiration needle. Plus assorted curettage. Eventually this treatment stopped relieving the symptoms. A more aggressive plan was needed. VISUALIZATION OF ABSCESS - Assumption is periodontal abscess wants to escape and is blocked by ridges or ledges of calculus that function similarly to a gasket. Like for a refrigerator or airplane door. Remove the calculus and the abscess will flee. VISUALIZATION OF CALCULUS FORMATIONS - Tooth is viewed as similar to a castle or fortress. Along the face of the tooth three ridges are visualized. Shallow, medium and deep. On the corners a tower or pyramid is visualized. Abscess is assumed to be most present under the pyramid. In reality the calculus formations tend to follow the visualization fairly closely. FACES vs CORNERS - Corners have several natural advantages over faces. First is the physical twisting of the calculus going around the corner. Which creates convoluted formations which are much stronger than faces. Second is the ability of the calculus to cling onto a curved surface rather than a flat one. Again a strong advantage. Third is the gum tissue also goes around a corner. So it can't stretch as much due to inner stresses. Fourth there is much more space to grow. So can assume most abscesses will form at the corners. And where you might visualize the abscess existing is in fact where it does exist. OUT-FLANKING STRATEGY - Approach the suspected Abscess Pyramid from a distance across the face of the tooth to develop enough depth to reach the lowest layers and get the curette under the pyramid to dislodge it. Generally avoid attacking the pyramid from around a corner or starting from too close range. Since curette will most easily be deflected. Plus formation is typically too strong to dislodge without undermining it first. This is similar to to the seige warfare strategy of approaching a castle and undermining the walls and then bashing or dismantling them so they collapse. Then to clear out the rubble. Strategy worked. Successfully approached the corner pyramid at full depth with the Montana Jack across the front face of the tooth. Then managed to debride the corner pyramid from awkward position. This created an opening into the abscess. Which then became more apparent while clearing the area with the toothpick. Abscess then slowly leaked out over the course of around a half an hour with the help of the toothpick. Including the Xenomorph Monstrosity. EPILOGUE - Ended up ignoring the area for almost eight weeks. It then became apparent there was also an additional or co-existing abscess on the adjacent eye tooth. Repeated debridement  strategy for the eye tooth. Ended up with a curette deep inside the same abscess area with significant additional abscess. HEART OF DARKNESS - LORD OF THE RINGS - ALSO it became apparent that the abscess included what I call a Heart of Darkness. Which is an area that goes in so deep that the fear is other highly vulnerable areas are also compromised, such as proximity to tooth nerve or even pathways into channels or sinus. Which is very scary. At this point question becomes whether to go in even deeper and risk the danger or stop. My strategy has generally been to stop. Part of the logic also includes avoiding compromising most vulnerable area with the filth from shallower depths. Plus the thinking the deeper area is likely to bleed out too. Even if only partially. This is what I would term as a conservative strategy. Not risking outright destruction and devestation in order to get abscess to some magical higher levels on a single attempt. Assumption is there are always more attempts possible. However... the wound does tend to close up and the second-shot can become either much more difficult or real real more difficult and close to impossible. So do not know the answer here.  And relying on assumption will always get a second-shot. Even if this assumption is possibly false.  Then to let the area heal and approach the scary area after the shallower area has had a chance to recover. This is what I call Bulls-eye Theory. Logic is to have the most dangerous area surrounded by an area that is mostly clean and mostly healed. With believe that it will always be possible to go back to the most dangerous area later. EPILOGUE - It still looks like the nerve is compromised. So plan is to use hyaluronic acid as a fluffer to drive out deep infection. Hoping can eventually get to the deepest parts of the abscess. Known as getting to the bottom of the wound UPDATE -09-09-12 - Turns out Tooth #6, the Eye Tooth also had an abscess. Cleaned that out too. Now in healing mode. UPDATE - 09-12-12 - Turns out the lingual gap between the eye tooth and the bicuspid also had an abscess. Successfully employed Out-Flanking-Strategy against the abscess and successfully unblocked it. Whereupon the abscess bled for several hours with significant loss of blood. In fact I staunched it with a tissue to get it to slow down for a few hours before resuming debridement. As a general safety measure. Also made sure to fortify myself with a lot of water and lasagna before resuming, just in case the blood loss became scary. Bled out abscess to completion. Also reasonably curettaged out most of the relevant areas. Including both the faces and the gaps. For all reasonably accessible right-handed moves. Saving any left-handed moves for... later. = == = = = = = = = = = th-07-19-12 - t7 - Second Incisor - Distal Buccal - Debride periodontal abscess blockage with Montana-Jack Sickle Blade. Then release periodontal abscess w toothpick. Display Haul. Xenomorph Monstrosity. Which was over 1/2 inch long with considerable width and bulk. HISTORY - Tooth has been acting up since early 2011. Mostly with nerve tingling. Previous strategy was to relieve abscess with aspiration needle. Strategy stopped working. Disaster looked imminent. Was highly convinced main body of abscess was on distal side of tooth #7. Flanking Strategy was to approach distal side from mesial side across face of the tooth. While developing and maintaining depth. Strategy was successful. Abscess was released. EXPLANATION OF FLANKING STRATEGY - You can imagine the tooth like a castle. Surrounded by three walls or ridges of calculus. The first ridge is slightly below the gumline. The second ridge is at medium depth. The third ridge is right along the edge of the bone and participates in the ongoing destruction of the bone. The ridge of calculus right along the edge of the bone also serves as a gasket. To hold in any lower level infection. Similar to a refrigerator gasket or any other gasket. This geometry creates the conditions to promote the formation of the abscess. Since the infection will direct itself inward and feed off of blood, destroying whatever physical body that may be in its path. MEANWHILE... At each of the four corners of the tooth the calculus ridges have to make a 90 degree turn. The turn gives the ridges greater structural integrity. The turn also tends to deflect any curretage. Hence the corners resemble towers or fortresses or pyramids and are highly impervious to any attempts to dislodge them. Indeed any aggressive attempts will likely slice up the gums good. Hence the reasonable applied force of most efforts to dislodge the pyramids will tend to remain below the threshold of brutal force that may be needed to successfully dislodge them at a reasonable rate. QUITE NATURALLY THE ABSCESSES WILL ALSO TEND TO FORM UNDER THE CORNER PYRAMIDS. The corner pyramids will also form a plug to hold the abscesses in place. Similar to the O-rings in the Space Shuttle. With the abscess having nowhere to go except to cause trouble and destruction. FLANKING STRATEGY - The object is not to go after the corner pyramids and abscess directly. But rather to approach them from the opposite side of the tooth. While maintaining depth. The object then becomes to create and maintain as much depth as possible from as far away from the corner pyramid as possible. Breaking through the three ridges. Carrying the curettage all the way down to the level of the bone. And likely swiping the teeth below bone level in a way that is similtaneously delicate, scary and dicey. The manouver is exactly equivilent to a military operation that rolls up an enemy line from its flank. Attacking the narrow flank with overwhelming force. Then slowly approaching the corner pyramid from below its base. From both sides. The net result will be to eventually dismantle the corner pyramid. This will unplug the blockage that is holding the periodontal abscess in place and help the abscess to escape. CORNER PYRAMID STRATEGY - is highly akin to seige warfare strategy. Where object is to approach the castle walls from the sides from below their base level through flanking manouvers. Then to undermine the walls and cause them to collapse. Then break through the gap from both sides completely. Then to clear away the rubble. Then to help the abscess to escape. This is exactly what I did and the abscess did indeed sucessfully escape. ALSO NOTE - That any periodontal abscess will also affect the adjacent tooth. I have been negligent in this area. While indeed it might very well be too traumatic to curretage the adjacent tooth at the same time as the affected tooth. But nonethless think it is imperitive to put the adjacent tooth on the list for first curettage as soon as the affected area is recovered enough to go back. For a serious abscess this may be a month or so. For something less serious could go back as soon as a week. UPDATE - 09-12-12 - Turns out this abscess was also connected to a concurrent abscess across the bone on Tooth #6 Mesial. The eye tooth. In Turn this abscess turned out to also be close to an abscess between the eye tooth and the bicuspid. Both abscesses were successfull debrided over the past week using out-flanking strategy. And are now in healing mode. And should return to a semblance of normal within around a month or so. But in the meantime are both highly traumatized and tender. Plus very very vulnerable too. So they have to get the serious post-op very careful and gentle hygiene treatment with the low irrigator for a few weeks until they normalize. Also have to stay away as much as possible with any devices. Except for doing what has to be done, such as a short and detailed and gentle search for blobs. Or possibly a blast of hyaluronic acid, possibly with lactoferrin. Or even just an interior water blast with the needle. Which can flush away any latent blobs. = = = = = = tu-08-07-12 - Bicuspid - mesial lingual - Detritus Haul - post curettage w PDT Mini-Me Sickle Blade - post abscess liberation w Brush-Pick. Xenomorph body. For simplicity the infection is thought of as a series of living bodies. Membranes. Which is what they are. Hence the Xenomorph analogy is reasonably close to the reality. This is the layers upon layers of calculus that have been scraped off the tooth. Plus self-liberated. Then rinsed multiple times to wash out the goo. Plus the abscess too. What is left is the body of the infection. Which closely remembles a membrane. Which is what it is. The more developed Xenomorphs more or less create a living body for themselves. Resembling a sting-ray or jellyfish. Hence they can acquire some thickness. Even appendages. They also have membranes, which function as a food gathering resource. The less developed Xenomorphs also share their food between each other through a complicated fairly complex electro-chemical transport system. The young living Xenomorphs live free and prosper. Some even become leaders of the colony. The old used up Xenomorphs dry up and calcify and provide housing to their younger brethren. The Xenomporph colonies living closer to the surface like to eat sugar. But the deeper Xenomorphs don't get very good access to high-quality food and have to survive on handouts from the shallower layers. Plus blood products. Which they find tasty enough. Deep under the gums is a deadly battle. The body invades with blood products to kill and neutralize the intruder. The Xenomorph die like good Romans. The dead soldiers and used up blood products then become food. The calculus form into ridges, which eventually turn into ledges. These then become very much like a gasket. Preventing the detritus from the deeper layers from escaping. So what are the Xenomorph to do? They look inward. Toward the center of the body. And grow into abscesses. Abscesses often spell the end of the tooth. They are very persistent and difficult to eradicate. = = = = = = tu-08-07-12 -Tooth #29 - Bicuspid. Mesial-Lingual. Liberate periodontal abscess w Brush-Pick. Post curettage to create passage for the abscess to escape. With PDT Mini-Me Sickle Blade. Let-it-bleed. Bleed out abscess. Total detritus included roughly 30 major blobs and well over a hundred smaller blobs. Which is highly typical for highly developed periodontal abscesses which have been able to break through the periodontium and the jawbone into the soft-tissue underbelly of the lingual regions of the mouth. Where the periodontium mixes in with the spit gland, lower jawbone main nerve and the underpinnings of the tongue. Check it out for yourself. Turning the abscess into a serious serious problem. SUMMARY - Looks like a lot of periodontal abscesses are prevented from escaping by calculus ledges. These ledges function very much like a gasket, such as for a refrigerator, jar or airplane. This gasket quality forces the abscess to grow inward, into the body. The abscess then survives on blood. What this means is that curettage, ie removal of the calculus ledges, one way or another, is the most promising way to help the abscess to escape. The needle is only a partial temporary solution. Curettage and subsequent hygiene therapy offers promise of a long term solution. Including survival of a viable tooth too. SUMMARY - Turns out abscess was part of a triple-abscess that also included the Distal-Lingual. Plus the Distal-Buccal. Plus jawbone and soft-tissue. Sedcond abscess was liberated three weeks later with a PDT Montana Jack offset posterior Sickle Blade and a tooth pick.Spit gland is also severely infiltrated with infection and is recovering from major swelling and high threat to its healthy survivability on an ongoing basis. Possibly as part of a triple-abscess or even worse. Situation is very dicey. Both tooth and spit gland remain under high threat. Plan is to keep wound clean enough long enough for it to recover from chronic-wound infection injury. Plan includes additional debridement, hot and cold water, massage, aspiration and irrigation and use of hyaluronic acid and lactoferrin etc to help area heal with functional Extra-Cellular-Matrix (ECM). Plus ibuprofin and cold water to keep down any potentially dangerous swelling and major threat. Eventual goal is to help the healing process get ahead of the destructive and end-game process and to enable healing tissue to isolate the spit gland from the tooth into two separate areas. Both with an epithelial perimeter. Currently the spit gland is co-mingled with the tooth periodontium, due to massive loss of both physical and functional structure. Eventual goals also include recovery and natural regeneration of enough bone structure to support the continued existence of both a happy healthy tooth and a healthy happy spit gland. Situation remains very dicey. Failure is not an option. Would prefer to keep tooth and help guide it to eventual recovery rather than to give up the tooth or even more without a fight. If all goes well the tooth and spit gland should reach the tipping point towards healing within three months. And hopefully not take a turn for the worse prior to reaching a favorable outcome favoring continued survival. m-09-03-12 - UPDATE - Turns out the abscess is part of a triple-abscess. Almost girding the tooth. Add in the spit gland and it is a quadruple-abscess. Just scraped and cleaned out the distal portion of the bicuspid with a combination of curettes. Plus the irrigation needle and tootpick. Plus the irrigator. Released massive amounts of crud. It took over five hours to complete the main debridement. Then once the abscess became freed and started to release itself, it took several hours for the abscess to largely bleed itself out on its own, plus with lots and lots of help in so many ways, spontaneously releasing additional massive amounts of crud. In addition the spit glad abscess also generously gave up a lot of its crud too. Especially under heavy irrigation pressure and vigourous massage.  Now entering recovery and healing mode. Once the entire area completes its trauma cycle and settles down, which I figure to take anywhere from a week to a month, then will go back and try to curettage some of the latent calculus ridges. Object being for Second Debridement to elevate hygiene from an estimated 75% clean to 90% clean. At which point the body should largely gain the upper hand over the infection. And the body will heal faster than it is destroyed.  Then onward and upward to an eventual 100% hygiene. In addition plan to give it the hyaluronic acid treatment to frack off remaining debris. Plus help provide an ECM for help the healing process. = = =

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