CASE REPORTS
PARESTHESIA FOLLOWING ENDODONTIC TREATMENT
Capt. Steve Montqomery. DC, USN. San Dieqo, Ca]it
Paresthesia of the right mental nerve that probably was induced by surgery is described.
Report of Case On Aug 7, 1975, a 23-year-old white woman reported for treatment because of pain and swelling in the right mandibular premolar area. Clinical examination showed extensive dental restorations, poor dental plaque control, some periodontal lesions, and slight swelling in the mucobuccal fold opposite the mandibular right second premolar. A 4-mm periodontal pocket also was present on the distal of this tooth. Radiographic examination disclosed a periapical radiolucent area around the mandibular right second premolar. A small radiopaque area indicating a foreign material also was present. The root canal filling appeared poorly condensed (Fig 1). Electric pulp tests indicated that the mandibular right first premolar and first molar had vital pulps. The patient had a letter from a referring dentist which indicated that the following treatment for the mandibular second premolar had been performed: On Jan 7, 1975, the patient was seen with a complaint of pain in the jaw and head. Pulp tests and radiographs indicated that the mandibular right second premolar was pulpless and had a periapical lesion. The patient received intravenous sedation;
the tooth was anesthetized and opened. The root canal was enlarged to a no. 35 reamer, and Sargenti cement I was placed. An incision then was made to establish drainage from the periapical lesion. The patient experienced paresthesia in the area of the mental nerve immediately after the procedure. On June 27, 1975, the patient sought treatment from another dentist for swelling and pain in the same mandibular right premolar area. She had partially recovered sensation in the area by this time. This dentist informed the patient that he wanted to take a biopsy specimen of the swollen tissue. The patient received a local anesthetic. An incision was made in the area; it was explored, then closed. She was informed that insufficient tissue was removed to warrant sending it to the oral pathologist for examination. When seen by me on Aug 7, 1975, the patient had total paresthesia of the distribution of the right mental nerve. The swelling adjacent to the mandibular right premolar was still present, although it was not painful at this time unless palpated. The tooth was opened, and the Sargenti paste was removed. A culture was taken. The canal was instrumented to a no. 60 file, irrigated with 1% sodium hypochlorite, medicated with iodine potassium iodide, and closed with Cavit.* The patient left for her honeymoon and was not available for treatment
again until Oct 2, 1975. At this time the swelling was gone, the tooth was asymptomatic, and the canal was dry. The canal was cultured, irrigated with 1% sodium hypochlorite, medicated with iodine potassium iodide, and closed again with Cavit. On Oct 9, 1975, the root canal was obturated with gutta-percha and Grossman's sealer,* using the warm gutta-percha technique (Fig 2). The culture taken at the Aug 7 appointment was positive for growth of an enterococcus that was resistant to penicillin, oxacillin, streptomycin, cephalosporin, and tetracycline. The cultures taken at the Oct 2 and 9 appointments were negative for growth of microorganisms. Recall examination on Jan 22, 1976, disclosed a clinically asymptomatic tooth. Paresthesia of the mental nerve distribution remained, however. Radiographic examination (Fig 3) disclosed continued presence of a periapical lesion with resorption of the apical portion of the root and presence of a foreign body.
Discussion Treatment of necrotic pulps with apical pathosis in a single visit is advocated by Sargenti.z,3 Several aspects of this form of treatment are worthy of discussion. Without a biopsy it is not possible to identify periapical foreign bodies. Radiographically, this type of foreign body resembles the root canal filling
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JOURNAL OF ENDODONTICS I VOL 2, NO 11, NOVEMBER 1976
Fig 1--Radiograph taken Aug 7, 1975, shows poorly condensed root canal filling with periapical radiolucent area, periapical foreign material, and periodontal deject on distal o] mandibular second premolar.
Fig 2---Radiograph taken Oct 9, 1975, alter retreatment.
Fig 3---Recall radiograph taken Jan 22, 1976, shows continued presence of periapical radiolucent area with root resorption and periapical [oreign material.
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paste. It is likewise not possible to determine the exact cause of paresthesia in this case. It could possibly have been caused by Sargenti paste forced into the mandibular c a n a l Sargenti ~ has said that N2 inadvertently pushed into the periapical tissue will cause a temporary reaction, but that it is well tolerated and will be slowly absorbed. Ehrmann, ~ however, reported a case where N2 paste penetrated into the mandibular canal and caused paresthesia. Langeland 5 reported that N2 causes tissue destruction, severe inflammation, and a foreign body reaction in the periapical tissues. The paresthesia also could have resulted from trauma to the mental nerve during the draining procedure. I n this case the pulps of the mandibular anterior teeth retained their vitality, and the paresthesia was confined to the mental nerve distribution. It seems more probable that the paresthesia in this case was caused by surgery. Whenever a surgical procedure in the mandibular premolar area is considered, the exact location of the mental foramen should first be determined. A tissue flap then should be raised and the neurovascular bundle identified. Care should then be taken not to traumatize it. In this case the mental foramen was immediately inferior to the involved tooth (Fig 4). It is unfortunate that the second dentist involved in the treatment of this patient failed to remove the foreign body or to obtain a biopsy specimen while he had the area surgically exposed. The patient now refuses any further surgery in this area. Often, the root canals of teeth filled with N2 appear noncompacted radiographically. According to Sargenti, it is not necessary to have a compact filling when using N2 because of its antiseptic properties. ~ Radiographically, the root canal fill-
JOURNAL OF ENDODONTICS [ VOL 2, NO 11, NOVEMBER 1976
Fig 4 In this lateralview radiograph ot mandible, mental [oramen is immediately in[erior to involved tooth.
The opinions and herein are those of not to be construed flecting the views of or the naval service
assertions contained the author and are as official or as rethe navy department at large.
Dr. Montgomery is assistant chief, department of dentistry, Naval Regional Medical Center, San Diego, Calif. Requests for reprints should be directed to: Capt. Steve Montgomery, Naval Regional Medical Center, San Diego, Calif 92134. Reterences
ing in this case appeared noncompacted. When I opened into this tooth, it was very moist; after the coronal portion of the paste was removed, pus exuded from the canal. One year after the initial treatment, the periapical radiolucent area has not resolved. Perhaps one reason for the slow healing could be cortisone in the extruded paste. 6 It is the dentist's responsibility to provide the best treatment possible for his patients. This patient might have been treated better. Perhaps with more caution and better techniques this patient would still have function of her right mental nerve. Summary A right mandibular premolar with a necrotic pulp and periapical pathosis
was treated in one visit. The canal was reamed and then filled with Sargenti paste. The periapical area was incised for drainage. The patient experienced immediate paresthesia of the right mental nerve. Six months later, another dentist surgically explored the periapical area without submitting a biopsy specimen. Eight months after initial treatment the area was still symptomatic. The root canal was retreated and filled with gutta-percha and Grossman's sealer. The tooth has been asymptomatic for the last six months, but the paresthesia is still present. *Premier Dental Products Co., Philadelphia. tProco-Sol Chemical Co., Philadelphia.
1. Sargenti, A.G. Debate on N2: is N2 an acceptable method of treatment? In Grossman, L.L, ed. Transactions o f the 5th International Conference on Endodontics, Philadelphia, University of Pennsylvania, 1973, p 178. 2. Sargenti, A.G. Endodontics. Bern, Switzerland, H. Huber, 1973, pp 31, 71. 3. Sargenti, A.G. Treatment of gangrenous teeth (addendum to Sargenti Endodontics). Fullerton, Calif, and Levittown, Pa, Endodontic Educational Service, 1975, p 50. 4. Ehrmann, E.H. Root canal treatment with N2. Aust Dent J 8:434 Oct 1963. 5. Langeland, K. Debate on N2: is N2 an acceptable method of treatment? In Grossman, L.L, ed. Transactions of the 5th International Conference on Endodontics, Philadelphia, University of Pennsylvania, 1973, p 220. 6. Seltzer, S. Endodontology: biologic considerations in endodontic procedures. New York, McGraw-Hill, 1971, p 351.
347
PARESTHESIA FOLLOWING ENDODONTIC TREATMENT
Capt. Steve Montqomery. DC, USN. San Dieqo, Ca]it
Paresthesia of the right mental nerve that probably was induced by surgery is described.
Report of Case On Aug 7, 1975, a 23-year-old white woman reported for treatment because of pain and swelling in the right mandibular premolar area. Clinical examination showed extensive dental restorations, poor dental plaque control, some periodontal lesions, and slight swelling in the mucobuccal fold opposite the mandibular right second premolar. A 4-mm periodontal pocket also was present on the distal of this tooth. Radiographic examination disclosed a periapical radiolucent area around the mandibular right second premolar. A small radiopaque area indicating a foreign material also was present. The root canal filling appeared poorly condensed (Fig 1). Electric pulp tests indicated that the mandibular right first premolar and first molar had vital pulps. The patient had a letter from a referring dentist which indicated that the following treatment for the mandibular second premolar had been performed: On Jan 7, 1975, the patient was seen with a complaint of pain in the jaw and head. Pulp tests and radiographs indicated that the mandibular right second premolar was pulpless and had a periapical lesion. The patient received intravenous sedation;
the tooth was anesthetized and opened. The root canal was enlarged to a no. 35 reamer, and Sargenti cement I was placed. An incision then was made to establish drainage from the periapical lesion. The patient experienced paresthesia in the area of the mental nerve immediately after the procedure. On June 27, 1975, the patient sought treatment from another dentist for swelling and pain in the same mandibular right premolar area. She had partially recovered sensation in the area by this time. This dentist informed the patient that he wanted to take a biopsy specimen of the swollen tissue. The patient received a local anesthetic. An incision was made in the area; it was explored, then closed. She was informed that insufficient tissue was removed to warrant sending it to the oral pathologist for examination. When seen by me on Aug 7, 1975, the patient had total paresthesia of the distribution of the right mental nerve. The swelling adjacent to the mandibular right premolar was still present, although it was not painful at this time unless palpated. The tooth was opened, and the Sargenti paste was removed. A culture was taken. The canal was instrumented to a no. 60 file, irrigated with 1% sodium hypochlorite, medicated with iodine potassium iodide, and closed with Cavit.* The patient left for her honeymoon and was not available for treatment
again until Oct 2, 1975. At this time the swelling was gone, the tooth was asymptomatic, and the canal was dry. The canal was cultured, irrigated with 1% sodium hypochlorite, medicated with iodine potassium iodide, and closed again with Cavit. On Oct 9, 1975, the root canal was obturated with gutta-percha and Grossman's sealer,* using the warm gutta-percha technique (Fig 2). The culture taken at the Aug 7 appointment was positive for growth of an enterococcus that was resistant to penicillin, oxacillin, streptomycin, cephalosporin, and tetracycline. The cultures taken at the Oct 2 and 9 appointments were negative for growth of microorganisms. Recall examination on Jan 22, 1976, disclosed a clinically asymptomatic tooth. Paresthesia of the mental nerve distribution remained, however. Radiographic examination (Fig 3) disclosed continued presence of a periapical lesion with resorption of the apical portion of the root and presence of a foreign body.
Discussion Treatment of necrotic pulps with apical pathosis in a single visit is advocated by Sargenti.z,3 Several aspects of this form of treatment are worthy of discussion. Without a biopsy it is not possible to identify periapical foreign bodies. Radiographically, this type of foreign body resembles the root canal filling
345
JOURNAL OF ENDODONTICS I VOL 2, NO 11, NOVEMBER 1976
Fig 1--Radiograph taken Aug 7, 1975, shows poorly condensed root canal filling with periapical radiolucent area, periapical foreign material, and periodontal deject on distal o] mandibular second premolar.
Fig 2---Radiograph taken Oct 9, 1975, alter retreatment.
Fig 3---Recall radiograph taken Jan 22, 1976, shows continued presence of periapical radiolucent area with root resorption and periapical [oreign material.
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paste. It is likewise not possible to determine the exact cause of paresthesia in this case. It could possibly have been caused by Sargenti paste forced into the mandibular c a n a l Sargenti ~ has said that N2 inadvertently pushed into the periapical tissue will cause a temporary reaction, but that it is well tolerated and will be slowly absorbed. Ehrmann, ~ however, reported a case where N2 paste penetrated into the mandibular canal and caused paresthesia. Langeland 5 reported that N2 causes tissue destruction, severe inflammation, and a foreign body reaction in the periapical tissues. The paresthesia also could have resulted from trauma to the mental nerve during the draining procedure. I n this case the pulps of the mandibular anterior teeth retained their vitality, and the paresthesia was confined to the mental nerve distribution. It seems more probable that the paresthesia in this case was caused by surgery. Whenever a surgical procedure in the mandibular premolar area is considered, the exact location of the mental foramen should first be determined. A tissue flap then should be raised and the neurovascular bundle identified. Care should then be taken not to traumatize it. In this case the mental foramen was immediately inferior to the involved tooth (Fig 4). It is unfortunate that the second dentist involved in the treatment of this patient failed to remove the foreign body or to obtain a biopsy specimen while he had the area surgically exposed. The patient now refuses any further surgery in this area. Often, the root canals of teeth filled with N2 appear noncompacted radiographically. According to Sargenti, it is not necessary to have a compact filling when using N2 because of its antiseptic properties. ~ Radiographically, the root canal fill-
JOURNAL OF ENDODONTICS [ VOL 2, NO 11, NOVEMBER 1976
Fig 4 In this lateralview radiograph ot mandible, mental [oramen is immediately in[erior to involved tooth.
The opinions and herein are those of not to be construed flecting the views of or the naval service
assertions contained the author and are as official or as rethe navy department at large.
Dr. Montgomery is assistant chief, department of dentistry, Naval Regional Medical Center, San Diego, Calif. Requests for reprints should be directed to: Capt. Steve Montgomery, Naval Regional Medical Center, San Diego, Calif 92134. Reterences
ing in this case appeared noncompacted. When I opened into this tooth, it was very moist; after the coronal portion of the paste was removed, pus exuded from the canal. One year after the initial treatment, the periapical radiolucent area has not resolved. Perhaps one reason for the slow healing could be cortisone in the extruded paste. 6 It is the dentist's responsibility to provide the best treatment possible for his patients. This patient might have been treated better. Perhaps with more caution and better techniques this patient would still have function of her right mental nerve. Summary A right mandibular premolar with a necrotic pulp and periapical pathosis
was treated in one visit. The canal was reamed and then filled with Sargenti paste. The periapical area was incised for drainage. The patient experienced immediate paresthesia of the right mental nerve. Six months later, another dentist surgically explored the periapical area without submitting a biopsy specimen. Eight months after initial treatment the area was still symptomatic. The root canal was retreated and filled with gutta-percha and Grossman's sealer. The tooth has been asymptomatic for the last six months, but the paresthesia is still present. *Premier Dental Products Co., Philadelphia. tProco-Sol Chemical Co., Philadelphia.
1. Sargenti, A.G. Debate on N2: is N2 an acceptable method of treatment? In Grossman, L.L, ed. Transactions o f the 5th International Conference on Endodontics, Philadelphia, University of Pennsylvania, 1973, p 178. 2. Sargenti, A.G. Endodontics. Bern, Switzerland, H. Huber, 1973, pp 31, 71. 3. Sargenti, A.G. Treatment of gangrenous teeth (addendum to Sargenti Endodontics). Fullerton, Calif, and Levittown, Pa, Endodontic Educational Service, 1975, p 50. 4. Ehrmann, E.H. Root canal treatment with N2. Aust Dent J 8:434 Oct 1963. 5. Langeland, K. Debate on N2: is N2 an acceptable method of treatment? In Grossman, L.L, ed. Transactions of the 5th International Conference on Endodontics, Philadelphia, University of Pennsylvania, 1973, p 220. 6. Seltzer, S. Endodontology: biologic considerations in endodontic procedures. New York, McGraw-Hill, 1971, p 351.
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