The present study describes a case of endodontic sealer(AH Plus) penetration within and along the mandibular canal from the periapical zone of a lower second molar
after endodontic treatment. The clinical manifestations comprised anesthesia of the left side of the lower lip, paresthesia and anesthesia of the gums in the third
quadrant, and paresthesia and anesthesia of the leftmental nerve, appearing immediately after endodontic treatment. The paresthesia and anesthesia of the lip
and gums were seen to decrease, but the mental nerve paresthesia and anesthesia persisted after 3.5 years. This case illustrates the need to expend great care
with all endodontic techniques when performing nonsurgical root canal therapy, especially when the root apices are in close proximity to vital anatomic struc tures such as the inferior alveolar cana

González Martín, María Isabel

Gutiérrez Pérez, José Luis

Segura Egea, Juan José

Torres-Lagares, Daniel

English

idUS. Depósito de Investigación Universidad de Sevilla

Case Report/Clinical TechniquesARTICLE IN PRESS12345678910111213141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758Inferior Alveolar Nerve Paresthesia After Overfilling ofEndodontic Sealer Into the Mandibular CanalMarı́bel González-Martı́n, PhD, DDS, Daniel Torres-Lagares, PhD, DDS, José Luis Gutierrez-Pérez, PhD, MD, DDS, and Juan José Segura-Egea, PhD, MD, DDSAbstract596061626364656667686970717273747576777879The present study describes a case of endodontic sealer(AH Plus) penetration within and along the mandibularcanal from the periapical zone of a lower second molarafter endodontic treatment. The clinical manifestationscomprised anesthesia of the left side of the lower lip,paresthesia and anesthesia of the gums in the thirdquadrant, and paresthesia and anesthesia of the leftmental nerve, appearing immediately after endodontictreatment. The paresthesia and anesthesia of the lipand gums were seen to decrease, but the mental nerveparesthesia and anesthesia persisted after 3.5 years.This case illustrates the need to expend great carewith all endodontic techniques when performingnonsurgical root canal therapy, especially when theroot apices are in close proximity to vital anatomic struc-tures such as the inferior alveolar canal. (J Endod2010;-:1–3)Key WordsEndodontic complications, paresthesias of the inferiordental nerveUNCORAddress requests for reprints to Dr Juan José Segura-Egea,Professor of Endodontics, Department of Stomatology, Schoolof Dentistry, University of Seville, C/Avicena s/n, 41009 Seville,Spain. E-mail address: segurajj@us.es.0099-2399/$0 - see front matterCopyright ª 2010 American Association of Endodontists.doi:10.1016/j.joen.2010.03.008JOE — Volume -, Number -, - 2010SCO 5.0 DTD  JOEN8081828384858687888990919293949596979899100101102103104105106RECTEDPROOFThe elimination of all diseased pulp and dentin, adequate cleaning and shaping of theroot canal system, and its 3-dimensional obturation and sealing constitute the basicprinciples of endodontic treatment. Ideally, the filling material should be limited to theroot canal without extending to periapical tissues or other neighboring structures.However, overinstrumentation of the root canal with hand or mechanically driven filescan perforate the mandibular canal, allowing the extrusion of sealers, dressing agents,and irrigation solutions and the passage of microorganisms into the canal duringendodontic treatment (1).Totally biocompatible materials are not available. Consequently, their spreadbeyond the apical foramen can give rise to clinical manifestations in relation to thetoxicity of the product, although minor material extrusions are generally well-tolerated by the periradicular tissues (2). Sealers and filling materials differ chemicallyand include, among others, AH Plus, AH 26, Hydron, Diaket, Iodoform, Calasept, Endo-seal, and chloropercha. Some of them can cause serious neurotoxic complicationswhen extruded into the mandibular canal (3–5). Undesirable complications such asanesthesia, paresthesia, hypoesthesia, hyperesthesia, and dysesthesia can follow theextrusion of an endodontic sealer into the mandibular canal (6–12).The first symptom of the overfilling into the mandibular canal is sudden pain ex-pressed by the patient during obturation of the root canal, which persists after the disap-pearance of the local anesthetic effects (13). The pain can be accompanied by localinflammatory signs, with the endodontically treated tooth being painful to percussion,painful on palpation of the vestibular alveolar process, or a combination of signs ofmechanical lesions and inferior dental nerve inflammation with pain or numbness ofthe lower lip or otalgia (6). Some patients experience the persistence of the localanesthesia (12, 14).The present study describes a case in which endodontic sealer AH Plus spread tothe mandibular canal, causing paresthesia and anesthesia in the area of innervation ofthe inferior alveolar nerve.Case ReportA 32-year-old woman was referred for root canal treatment in the left secondmolar tooth because of an apical periodontitis subsequent to caries. The initial diag-nosis for the tooth was acute apical abscess (15). She neither smoked nor consumedalcohol and had no personal or family disease antecedents of interest. Two years before,her first mandibular left molar had been extracted, and an endosseous root-formedimplant had been placed, supporting a metal-ceramic crown. After adequate anesthesiaand isolation with rubber dam, an endodontic access cavity was established. Threecanal orifices were defined. After apical patency, the root length was estimated by usingan apex detector (AFA Apex Finder; Analytic Technology, Orange County, CA) and thenconfirmed with a periapical radiograph. The root canal treatment was carried out byinvolving canal shaping with hand files by using the step-back technique and saline irri-gation. After cleaning and shaping, the canal was dried and obturated with AH 26(Dentsply DeTrey GmbH, Konstanz, Germany) and gutta-percha by using the lateralcondensation technique. A small quantity of sealer was introduced into the root canalby using a manual instrument, then the main cone was placed and covered witha minimal quantity of sealer, and cold condensation was performed. Moreover, eachadditional cone was covered with a minimal quantity of sealer. There were no compli-cations during treatment.Inferior Alveolar Nerve Paresthesia After Overfilling of Endodontic Sealer 11419_proof  18 March 2010  12:55 pm  ce CF½F1½F2[F3-4/C]½F4Figure 2. Panoramic radiograph taken the day after showing endodonticpaste in the periapical zone of tooth #37 and the inferior alveolar canal.Case Report/Clinical Techniques107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196ARTICLE IN PRESSJust after endodontic treatment, the postoperative periapicalradiograph revealed the presence of radiopaque canal sealer in themandibular canal (Fig. 1). Nevertheless, the patient was still underthe effect of the anesthetic, and she reported no pain or other discom-fort after the root canal treatment.The day after, no swelling, redness, or other signs of inflammationwere observed on intraoral exploration. However, the patient reportednumbness on the left side of the lower lip and a tingling sensation in thevestibular gingival and in the lower left premolar and anterior teeth. Ex-traoral examination likewise failed to identify swelling, alterations inskin color, or adenopathies. The anesthetized zone was delimited bytactile exploration, and anesthesia in the region served by the left infe-rior alveolar and mental nerve was observed. The buccal gingival tissuesover the left mandibular molar and premolar teeth felt no sensation;there was no sensation to thermal or mechanical stimuli in either theleft lower lip or buccal gingivae. The lingual gingival tissues respondedwithin normal limits to stimulation with an explorer. A panoramic radio-graph was taken (Fig. 2), revealing the presence of radiopaque material(AH Plus) in the periapical area of tooth #18 (universal) and spreadingdistally along the mandibular canal.After discussing treatment options with the patient, it was decidedto monitor the progress with periodic follow-up visits. The patientnoticed a very rapid improvement during the first months after the inci-dent. Seven months later, she showed significantly less paresthesia, andthe anesthesia in the region of the lower left lip was decreased comparedwith the initial situation. However, there have been no significantimprovements during the subsequent 3 years. The skin anesthesia onthe left side of the lower lip persists (Fig. 3), and the radiopaque mate-rial in the periapical area of tooth #37 is still radiographically evident(Fig. 4).UNCORRECTFigure 1. Post-treatment periapical radiograph. Presence of the extrudedroot canal sealer in the mandibular canal is evident.2 González-Martı́n et al.SCO 5.0 DTD  JOEN1419_proof  1197198199200201202203204205206207208EDPROODiscussionSensory loss or alteration in the territory of the inferior alveolarnerve, the chin region, and lower homolateral half of the lip is a relativelyinfrequent complication in daily dental practice and is normally theresult of an inadequate dental treatment (12). One of the potential iatro-genic causes of this problem is the incorrect treatment of the root canalsof a lower molar or premolar (overextension and/or overfilling). Theproximity of the mandibular canal to the apices of the premolar andmolar teeth requires a careful radiographic diagnosis when endodontictreatment of these teeth is planned. An initial pretreatment radiograph ofthe mandibular teeth will reveal the proximity of the canal to the apices(2). Preventive measures such as the use of an electronic apex detector,the application of a good apical stop, or moderate condensation willhelp avoid overfilling or overextending the endodontic material (11).During endodontic treatment, it is extremely important to addressthe cleaning and shaping of the apical third accurately, knowing cor-rected length and width. The use of an electronic apex detector togetherwith a radiograph taken with the files in position will not only ensure thecorrect working length but also prevent perforation of the canal andpossible subsequent damage to the inferior alveolar nerve resultingfrom the endodontic treatment.In the case reported here, preventive measures were taken. Theroot length was estimated by using an apex detector and confirmedwith a periapical radiograph. Poor length control does not seem tobe the obvious cause of the overextension of sealer in this case. More-over, only a small quantity of sealer was introduced into the root canalby using a manual instrument. The main cone was placed covered withprint&web4C=FPOFigure 3. Area of mental nerve anesthesia after 3.5 years is outlined on theskin.JOE — Volume -, Number -, - 20108 March 2010  12:55 pm  ce C209210211212213214215216217218219220221222223224225226227228TQ1Figure 4. Panoramic radiograph taken 3.5 years after the accident showingthe persistence of the endodontic paste in the periapical zone of tooth #37 andthe inferior alveolar canal.Case Report/Clinical Techniques229230231232233234235236237238239240241242243244245246247248249250251252253254255256257258259260261262263264265266267268269270271272273274275276277278279280281282283284285286287288289290291292293294295296297298299300301302303304305306307308309310311312313314315316317318319320321322323324325326327328329330331332333334335336337338339340341342343344345346347348349350ARTICLE IN PRESSUNCORRECa minimal quantity of sealer as well as each additional cone. Likewise,root does not seem to be significantly overfilled. However, the cliniciandid not use a master gutta-percha cone film before obturation.Experimental studies have shown that eugenol and paraformalde-hyde are the main materials causing neurotoxic reactions (3). Theirrigation solutions, such as sodium hypochlorite and ethylenediamine-tetraacetic acid (EDTA), might leak into the canal and damage the nervechemically. Cytotoxic effects of EDTA (16), eugenol (17), andhypochlorite (18) have been described. Escoda-Francoli et al (19) sug-gested that some of the materials used in certain sealer cements, such ascalcium tungstate (scheelite [CaWO4]) and zirconium oxide (badde-leyite [ZrO2]), are not totally reabsorbable or innocuous and do notseem to be well-tolerated when overextended beyond the apicalforamen.AH Plus is one of the epoxy resin-based root canal sealers mostcommonly used. The monomer 2,2-bis[4-(2-hydroxy-3-methacrylyl-oxypropoxy)phenyl]-propane (BisGMA), prepared from bisphenol Aand glycidyl methacrylate, is the major ingredient of the epoxy resin-based root canal sealers AH 26 and AH Plus (20). AH 26 cures withthe generation of formaldehyde as a by-product, but AH Plus onlyreleases small amounts of formaldehyde (21). However, AH Plus cancause cytotoxic effects (22) when extruded into the mandibular canal(4). Moreover, it has been shown that its component bisphenol Acan cause cytotoxic effects (23).Serper et al (24) investigated the neurotoxic effects of the rootcanal filling materials Endomethasone, N2 Universal, TraitementSPAD, Sealapex, and Calciobiotic Root Canal Sealer on isolated ratsciatic nerves after local application, demonstrating the neurotoxiceffects of root canal filling materials. They observed that recoveryfrom chemical insults to nerve structures was relatively slow and wasincomplete in the in vitro conditions. A larger and more rapid andappreciable recovery was found with sealers without paraformaldehydeand eugenol, which seems to be less toxic to nervous structures whencompared with other compounds containing these substances.In the present case, the buccal gingival tissues over the left mandib-ular molar and premolar teeth felt no sensation. This could be explainedbecause although the buccal nerve normally supplies these tissues,accessory branches of the inferior alveolar nerve have been described(25, 26).A literature review of paresthesia and anesthesia cases attributableto the extrusion of a root canal sealer indicated that the surgical removalof the sealer from the mandibular canal is an effective treatment andmight restore normal sensation in the affected region (9, 19).However, in the present case, the patient did not want surgicaltreatment, even though she exhibited complete lip skin anesthesia 3.5JOE — Volume -, Number -, - 2010SCO 5.0 DTD  JOEN1419_proof  1years after the endodontic mishap. This case illustrates the need toexpend great care with all endodontic techniques when performingnonsurgical root canal therapy, especially when the root apices are inclose proximity to vital anatomic structures such as the inferioralveolar canal.EDPROOFReferences1. Koseoglu BG, Tanrikulu S, Sübay RK, Sencer S. Anesthesia following overfilling ofa root canal sealer into the mandibular canal: a case report. Oral Surg Oral MedOral Pathol Oral Radiol Endod 2006;101:803–6.2. Poveda R, Bagán JV, Diaz Fernández JM, Sanchis JM. Mental nerve paresthesia asso-ciated with endodontic paste within the mandibular canal: report of a case. OralSurg Oral Med Oral Pathol Oral Radiol Endod 2006;102:e46–9.3. Morse DR. Infection-related mental and inferior alveolar nerve paresthesia: litera-ture review and presentation of two cases. J Endod 1997;23:457–60.4. Tamse A, Kaffe I, Littner MM. Paraesthesia following over extension of AH26: reportof two cases and review of the literature. J Endod 1982;8:88–90.5. Rowe AHR. Damage to the inferior dental nerve during or following endodontictreatment. Br Dent J 1983;153:306–7.6. Brodin P, Røed A, Aars H, Ørstavik D. Neurotoxic effects of root filling materials onrat phrenic nerve in vitro. J Dent Res 1982;6:1020–3.7. Gatot A, Tovi F. 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Serious inferior alveolar nerve dyesthesia alter endodonticprocedure: report of three cases. J Am Dent Assoc 1984;108:605–7.14. Grotz KA, Al-Nawas B, de Aguiar EG, Schulz A, Wagner W. Treatment of injuries to theinferior alveolar nerve after endodontic procedures. Clin Oral Invest 1998;2:73–6.15. ABE (American Board of Endodontics). Pulpal & periapical diagnostic terminology.Available at: http://www.aae.org/NR/rdonlyres/0A9E773B-506D-4B63-884E-DA68381CEAB0/0/ABETerminologyMay2007.doc. Accessed. ½16. Segura JJ, Calvo JR, Guerrero JM, Jimenez-Planas A, Sampedro C. EDTA inhibits invitro substrate adherence capacity of macrophages: endodontic implications. J En-dod 1997;23:205–8.17. Segura JJ, Jiménez-Rubio A. Effect of eugenol on macrophage adhesion in vitro toplastic surfaces. Endod Dent Traumatol 1998;14:72–4.18. Jiménez Rubio A, Segura JJ, Jiménez A, Guerrero JM, Calvo JR. ‘‘In vitro’’ study of theeffect of sodium hypochlorite and glutaraldehyde on substrate adherence capacity ofmacrophages. J Endod 1997;23:562–4.19. Escoda-Francoli J, Canalda-Sahli C, Soler A, Figueiredo R, Gay-Escoda C. Inferioralveolar nerve damage because of overextended endodontic material: a problemof sealer cement biocompatibility? J Endod 2007;33:1484–9.20. Peutzfeldt A. Resin composites in dentistry: the monomer systems. Eur J Oral Sci1997;105:97–116.21. Leonardo MR, Bezerra da Silva LA, Filho MT, Santana da Silva R. Release of form-aldehyde by four endodontic sealers. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 1999;88:221–5.22. Pulgar R, Segura-Egea JJ, Fernández MF, Serna A, Olea N. The effect of AH 26 and AHPlus on MCF-7 breast cancer cells proliferation in vitro. Int Endod J 2002;35:551–6.23. Segura-Egea JJ, Jiménez-Rubio A, Pulgar R, Olea N, Guerrero JM, Calvo JR. In vitroeffect of the resin component bisphenol A on macrophage adhesion to plasticsurfaces. J Endod 1999;25:341–4.24. Serper A, Üçer O, Onur R, Etikan I. Comparative neurototxic effects of root canalmaterials on rat sciatic nerve. J Endod 1998;24:592–4.25. Carter RB, Keen EN. The intramandibular course of the inferior alveolar nerve.J Anat 1971;108:433–40.26. Loizeaux AD, Devos BJ. Inferior alveolar nerve anomaly. J Hawaii Dent Assoc 1981;12:10–1.Inferior Alveolar Nerve Paresthesia After Overfilling of Endodontic Sealer 38 March 2010  12:55 pm  ce C351352

Inferior Alveolar Nerve Paresthesia After Overfilling of Endodontic Sealer Into the Mandibular Canal

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Inferior Alveolar Nerve Paresthesia After Overfilling of Endodontic Sealer Into the Mandibular Canal

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idUS. Depósito de Investigación Universidad de Sevilla