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Table of Contents
Year : 2011  |  Volume : 1  |  Issue : 1  |  Page : 41-44

Necrosis of alveolar bone secondary to endodontic treatment and its management

Department of Periodontology and Implantology, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow, India

Date of Web Publication4-Mar-2011

Correspondence Address:
Amitabh Srivastava
Department of Periodontology and Implantology, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2229-5194.77205

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The misuse of various chemicals in dentistry may cause damage to gingiva and alveolar bone. In this case report, we describe necrosis of the gingiva and alveolar bone caused by pulp devitalizer. A paraformaldehyde preparation was applied to an inflamed and symptomatic pulp of the maxillary left first molar (tooth #26), in a 20-year-old male. Spillage of the product was responsible for marked necrosis of the gingiva and the alveolar cortical bone, which resulted in great loss of the supporting bone. Surgical intervention was required wherein the necrosed bone was removed and the bone defect was filled with bone graft. The flap was coronally repositioned and sutured securely. After the treatment, the patient's complaints had resolved. Extreme care must be exercised while delivering of such products during treatment.

Keywords: Bone sequestrum, gingival necrosis, osteonecrosis, paraformaldehyde

How to cite this article:
Srivastava A, Gupta KK, Tandon P, Rajpal J. Necrosis of alveolar bone secondary to endodontic treatment and its management. J Interdiscip Dentistry 2011;1:41-4

How to cite this URL:
Srivastava A, Gupta KK, Tandon P, Rajpal J. Necrosis of alveolar bone secondary to endodontic treatment and its management. J Interdiscip Dentistry [serial online] 2011 [cited 2023 Jun 6];1:41-4. Available from: https://www.jidonline.com/text.asp?2011/1/1/41/77205

There are numerous materials used in dentistry which have been shown to be toxic to the periodontium. Paraformaldehyde-based 'devitalizing' agents are commonly used in endodontics to devitalize inflamed pulps when effective anesthesia can not be obtained. [1] Although effective, the use of paraformaldehyde preparations in the palliative treatment of endodontic pain is not without risk as there may be unfavorable adverse effects on soft tissues and bone. [2],[3],[4] Paraformaldehyde-based product is used successfully in dental treatment in various countries for devitalization of the pulp. Such toxic chemical agents should be used very cautiously in the oral cavity, so that they do not come in contact with the gingiva or other parts of oral mucosa during placement. Unfortunately, sometimes unintentional spillage may occur. [5],[6] This may not only lead to superficial mucosal injuries but may also penetrate deeper into bone and cause its necrosis. These local conditions that adversely affect the blood supply or lead to tissue necrosis can also predispose the host to a bone infection or localized osteomyelitis. [7],[8]

In this paper, we describe a case of chemical necrosis of the marginal gingiva and necrosis of the maxillary alveolar bone as a consequence of spillage of pulp devitalizer (cautinerf) and its treatment.

   Case Report Top

A 20-year-old male patient without any systemic diseases was referred to the Department of Periodontolgy and Implantology, Sardar Patel Dental College, Lucknow in January 2009. Patient arrived with the chief complaint of acute pain and discomfort in the left maxillary area. The clinical examination showed a marked area of necrosis of the interdental papilla [Figure 1] and the buccal marginal gingival of the upper left first molar (tooth #26). The interdental gingiva on the palatal aspect was intact [Figure 2]. Necrosed gingiva had left the interdental alveolar bone exposed in the cavity. The exposed bone was dark in color and hard in consistency. A peculiar rotten odor was also noticed. Palpation of the bone revealed that it was mobile as well. Periodontal probing of the buccal gingiva showed an 11mm pocket. The periodontal condition of the rest of the teeth was good. The radiographic examination showed that the tooth was endodontically treated. The coronal interdental bone was less radio-opaque as compared to the apical bone [Figure 3].
Figure 1: Gingival necrosis around maxillary second premolar and first molar with exposed bone

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Figure 2: Palatal view of the same region showing unaffected gingiva

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Figure 3: Diagnostic radiograph

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Previous history revealed that three month earlier the patient had pain in the left side of the maxilla. At that time, the clinical examination showed a deep carious lesion i.r.t. tooth #26 on the distal side with a pulp polyp, chronic pulpitis was diagnosed and endodontic treatment was done. On enquiring from dentist, it was revealed that the dentist had devitalized the pulp with a paraformaldehyde preparation during endodontic treatment and sealed the cavity with a temporary filling material. Two days immediately after that patient had experienced pain and gingival burning. Patient was advised to use local astringent paste to control burning sensation but when there was no relief patient was referred to our department.

Treatment rendered

With the clinical diagnosis of localized osteonecrosis, the patient was given prophylactic antibiotics for three days and then scheduled for surgical sequestrectomy. On the day of surgery, after locally anesthetizing the area, the full thickness periodontal flap was raised both buccally and palatally. Buccally two vertical releasing incisions were also placed. Surgical exploration of the area confirmed that there was bone destruction and a breakdown of the maxillary buccal cortical bone in the interproximal septum between the first molar and second premolar. On close examination, it was seen that the necrotic bone (Sequestrum) was completely separated from the underneath healthy bone. On exploration, an intervening soft tissue zone [Figure 4] was found which kept the necrotic bone attached to the underlying bone. After performing thorough curettage, the sequestrated bone could easily be differentiated from the healthy bone [Figure 5]. The sequestrum was then carefully removed [Figure 6]. Removal of the sequestrum left a deep interdental angular defect between the two teeth [Figure 7]. After curettage and irrigation of the area, the defect was filled with a block of hydroxyappatite bone graft [Figure 8]. The flap was then released by dissecting the periosteum and coronally repositioned so as to cover the graft and to compensate for the recession [Figure 9]. The flap was sutured in place and periodontal dressing was given [Figure 10]. The postoperative period was uneventful and the patient kept on short antibiotic treatment (amoxicillin 500 mg+clavulanic acid 125 mg) and an anti-inflammatory (ibuprofen 400 mg) three times daily for seven days, which led to successful healing of the wound [Figure 11]. During the healing period, the patient was kept on oral hygiene maintenance and chemical plaque control with chlorhexidine 10 ml twice daily.
Figure 4: Necrosed bone seen after flap reflection

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Figure 5: After curettage necrotic bone can be seen separated from the healthy bone

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Figure 6: The excised pieces of necrosed bone

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Figure 7: Defect seen after sequestrum removal

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Figure 8: Hydroxyappatite bone graft placed in the defect

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Figure 9: Flap coronally slided and sutured in place

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Figure 10: Periodontal dressing placed

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Figure 11: Post-op after one month

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   Discussion Top

Various agents are used in day-to-day dentistry to devitalize the extremely painful pulps prior to extirpation. Paraformaldehyde-containing products are very commonly used for the same purpose. [9],[10],[11] Paraformaldehyde is a strong disinfectant and a fixative recommended in low concentration as an intracanal medicament. [12] Commonly used pulp devitalizer, used when anesthesia is not sufficient for pulp extirpation. According to the manufacturer, this product should be applied in close contact with the exposed pulp, covered with a cotton pellet and meticulously sealed with zinc oxide eugenol or other temporary cement. The paste should remain in the pulp chamber for a maximum of two weeks.

However, paraformaldehyde is extremely toxic when placed in contact with the tissues of the body. Osteonecrosis in this case occurred due to accidental contact of paraformaldehyde devitalizer with the surrounding gingiva. Caution should be exercised during its use, by properly isolating the surrounding tissues from the tooth. Post-treatment evaluations showed complete healing.

   Conclusion Top

Iatrogenic causes originating from dental treatment, if overlooked, can account to considerable morbidity and occasional mortality. Dental treatment procedures can worsen the oral and systemic health of patients if care is not taken during treatment. The dental practitioner has a responsibility to follow basic precautions during the delivery of various chemicals, with particular attention to safeguard surrounding tissues.

Rubber-dam and other isolation measures can be the important protective factors from iatrogenic morbidity.

   References Top

1.Heling B, Ram Z, Heling I. The root treatment of teeth with Toxavit. Report of a case. Oral Surg Oral Med Oral Pathol 1977;43:306-9.  Back to cited text no. 1
2.Kleier DJ, Averbach RE. Painful dysesthesia of the inferior alveolar nerve following use of a paraformaldehyde-containing mot canal sealer. Endod Dent Traumatol 1988;4:46-8.  Back to cited text no. 2
3. Fanibunda KB. Adverse response to endodontic material containing paraformaldehyde. Br Dent J 1984;157:231-5.  Back to cited text no. 3
4.Laband P. Tissue reaction to root canal cements containing paraformaldehyde. Two case studies. Oral Surg Oral Med Oral Pathol 1978;46:265-74.  Back to cited text no. 4
5.Huang TH, Tsai CY, Chen SL, Kao CT. An evaluation of the cytotoxic effects of orthodontic bonding adhesives upon a primary human oral gingival fibroblast culture and a permanent human oral cancer cell-line. J Biomed Mater Res 2002;63:814-21.  Back to cited text no. 5
6.Szep S, Kunlel A, Ronge K, Heidemann D. Cytotoxicity of modern dentin adhesives - in vitro testing on gingival fibroblasts. J Biomed Mater Res 2002;63:53-60.  Back to cited text no. 6
7.Ozmeriç N. Localized alveolar bone necrosis following the use of an arsenical paste: A case report. Int Endod J 2002;35:295-9.  Back to cited text no. 7
8.Reid IR. Osteonecrosis of the jaw: Who gets it, and why? Bone 2009;44:4-10.  Back to cited text no. 8
9.Madison S, Anderson RW. Medications and temporaries in endodontic treatment. Dent Clin North Am 1992;36:343-56.  Back to cited text no. 9
10.Grossman LI. Endodontic practice. 9 th ed. Philadelphia: Lea and Febiger; 1978. p. 237-55.  Back to cited text no. 10
11.Berger JE. A review of the erroneously labeled "mummification" techniques of pulp therapy. Oral Surg 1972;34:131-44.  Back to cited text no. 11
12.S-Gravenmade EJ. Some biochemical considerations of fixation in endodontics. J Endod 1975;1:233-7.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]

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