The Double Edged Sword of Calcium Hydroxide in Endo Gluskin Et Al 2020
The Double Edged Sword of Calcium Hydroxide in Endo Gluskin Et Al 2020
The Double Edged Sword of Calcium Hydroxide in Endo Gluskin Et Al 2020
ABSTRACT
Background. Nowhere in the consideration of dental care involving endodontics does a patient
become more vulnerable to potentially life-changing injuries than during a root canal procedure on
the mandibular dentition that may invade and injure the neurovascular anatomy.
Case Description. The authors present a series of 5 cases wherein using calcium hydroxide as a
disinfection strategy in endodontics caused serious neurologic injury to the treated patients. The
mechanism in all cases was the inappropriate use of needle applications resulting in significant
overfill into the inferior alveolar nerve space. Although calcium hydroxide has been recognized and
used as a meaningful disinfectant in endodontic therapy for many years, the dangers and risks
associated with a needle delivery technique are discussed and analyzed with recommendations based
on current research to minimize risk.
Conclusions and Practical Implications. A literature search revealed that the 5 cases are not
solitary cases; indeed, consequences of calcium hydroxide overfills have been described before.
Therefore, a clinician initiating root canal therapy on a mandibular posterior tooth should always be
mindful of the vital neurovascular anatomy, which commonly approximates the ends of these roots.
Preoperative cone-beam computed tomographic imaging and the thoughtful delivery of medica-
ments in treatment can help the clinician manage close proximity to neural anatomy and avoid
potential injuries.
Key Words. Endodontic therapy; alveolar nerve; clinical competence.
JADA 2020:n(n):n-n
https://doi.org/10.1016/j.adaj.2020.01.026
E
ndodontic care and the clinical challenges in treating the complex anatomy of posterior teeth
confront the practitioner with inherent risks that might not be appreciated at the inception
of treatment. Standards of good practice require any clinician to appreciate those risks and
protect their patients from undue harm. Seldom do patients become more potentially vulnerable to
life-changing injury than during root canal treatment on the mandibular dentition that invades and
injures the neurovascular anatomy of the inferior alveolar nerve and its mental distribution.1,2
Overfill injuries expose the patient to both the chemical injury caused by the material and the
compressive damage caused by that material expressed within the confines of a space meant to be
occupied by the neurovascular anatomy only. These outcomes can have both enduring and life-
changing repercussions of pain and numbness (paresthesia and anesthesia) concurrently, as well
as burning pain (dysesthesia) that most often contributes to the feeling of misery and hopelessness of
the patient’s situation.
For several decades, the specter of substantial overfill of endodontic materials has been reported
by various authors in the oral health care literature.3-5 Frequently, these articles find their way into
journals that feature endodontic research and case reports targeting either endodontists or general
Copyright ª 2020
practitioners who regularly provide endodontic treatment. This can result in a lack of information
American Dental
for many readers of general oral health care literature who might underestimate the dangers and Association. All rights
outcomes of these overfill events. reserved.
calcium hydroxide, used between appointments, will dramatically aid in the reduction of microbial
populations and their by-products,23 while creating an obstacle for regrowth. In addition, it is
important to recognize the potential for recontamination of the root canal space should there be
existing deficiencies in the coronal seal of the restoration; calcium hydroxide and its formulations
can help address these conceivable risks. It is advised to carefully attempt to fill the canal in its
entirety.24 Calcium hydroxide is the primary choice of intracanal medicament.25-27 It is important
for all clinicians to recognize that a material with such high alkalinity will remain maximally toxic
when newly administered and all precautions should be taken to prevent the inadvertent possibility
of overfill into the neurovascular tissues. Therefore, when there is proximity to the neurovascular
anatomy, the strong recommendation is to choose a delivery method based on safety and not on
ease of use or expediency of delivery.
One of the most common placement techniques for calcium hydroxide is delivery with a
needle and syringe.28-30 The efficiency of delivery is aided by the operator making sure that
the root canal is sufficiently debrided and opened to allow the needle to gain access to the
depth and position desired. The gauge of the selected needle should be determined so that it
can be placed loosely in the canal at the required depth. A number of factors will determine
depth, such as root length and curvature of the canal, as well as the apical morphology.
Clinicians must be careful not to place excessive force on the syringe during the placement of
any formulation of calcium hydroxide. This conscious awareness of technique will help ensure
that the needle is free to move at the determined depth and be withdrawn from the canal.
Slow injection and constant movement out of the canal as the material is injected is critical
to safe and effective delivery.31-33
If it is determined that a given case has a predisposing risk of calcium hydroxide overfilling
into the periradicular tissues, such as can occur if the apexes are immature; there is a suspected
perforation; or there is intimate proximity to neurovascular anatomy, then the clinician
should proceed with great caution or consider an alternate technique for delivery of the medica-
ment.34-36
Emergency pulpal therapy in dental offices is a common circumstance. General dentists are often
the first responders when patients seek help in resolving the pain and saving their tooth. Many
practitioners choose calcium hydroxide as a medicament when the time for an urgent care pro-
cedure is lacking or unscheduled. As such, at emergency visits, canals are often not enlarged or
shaped to the needed requirements for final disinfection and obturation. Before the patient can be
Figure 3. Substantial amounts of calcium hydroxide delivered to the inferior alveolar nerve canal through a bound
needle and excessive pressure on the delivery syringe. This man has endured several years of ongoing dysesthesia and
pain since the injury.
referred to an endodontist, or returns for completion of the root canal treatments, clinicians might
be motivated to place the calcium hydroxide in as expedient a manner as possible. This often
involves placement of calcium hydroxide using a needle application.28,30
Although calcium hydroxide has been described extensively as effective in root canal
debridement for its specific array of activities against microorganisms, its effects on human cells
and tissue have considerable potential for damage that injures and harms in ways that alter well-
being and impact daily life. Specifically, calcium hydroxide in direct contact with collagen in
human connective tissues creates a zone of necrosis, which alters both the physical and chemical
status of intercellular substances. Through rupture of glycoproteins, this alteration contributes
to protein denaturation. In studies assessing damage to the alveolar nerve of intentionally
introduced calcium hydroxide expression into the mandibular canal of experimental
animals, degeneration was observed in places where calcium hydroxide came in contact with the
nerve.37 The changes visible in the neural tissues within days after contact were characteristic of
so-called Wallerian degeneration, which is the interruption of nerve cell bodies that leads to cell
death.37
Figure 5. An egregious calcium hydroxide with iodoform overfill of tooth no. 31 into the inferior alveolar nerve.
The patient described a severe jolting sensation in her jaw during application of the material. Since the incident the
patient has been numb with pain in her lip and chin. Again, needle binding and excessive pressure has made this
injury a life-changing incident for this woman.
In 5 cases (Figures 1-5), the combination of a less viscous or more fluid formulation of calcium
hydroxide, a needle placed within a canal that is either forced apically or unintentionally locked in
an insufficiently shaped canal, a lack of clinician diligence in monitoring the pressure placed on the
syringe, or a lack of monitoring the previously expressed amounts of the medicament can create a
“perfect storm” leading to overfill. Inattention and carelessness have the potential to result in a
severe and life-changing neurologic injury, especially in cases in which the mandibular tooth and
the neurovascular anatomy are intimately related.
De Moor and Syringe, 12 cases: maxillary central Multiple cases that varied in terms of pain and swelling
Colleagues,40 2002 spiral filler incisor (n ¼ 10), maxillary
lateral incisor (n ¼ 1),
mandibular first premolar
(n ¼ 1)
Lindgren and Syringe No. 31 Extrusion in IAN* leading to facial nerve paralysis, trigeminal
Colleagues41 2002 paresthesia, and facial ischemia
Ahlgren and Syringe likely No. 29 Extrusion in IAN leading to pain and swelling followed by lower
Colleagues,38 2003 lip paresthesia
Orucoglu and Spiral filler No. 22 Persistent exogenous material but patient was asymptomatic
Colleagues,9 2008
Sharma and Syringe First case no. 18, second First case extrusion in external carotid bed leading to facial
Colleagues,36 2008 case no. 15 ischemia and facial nerve palsy, IAN anesthesia; second case into
infraorbital artery leading to infraorbital pain and swelling and
infraorbital nerve anesthesia
Soomro and Spiral filler No. 8 Persistent exogenous material but patient was asymptomatic
Colleagues,43 2010
Ikawa and Syringe First case no. 11, second First case extrusion in maxillary sinus, second case into
Colleagues,30 2012 case no. 12 infraorbital space leading to left cheek hypesthesia
Olsen and Syringe First case no. 31, second Both cases involved extrusion in IAN leading to paresthesia
Colleagues,28 2014 case no. 29
Siquet and Syringe No. 30 Extrusion in IAN leading to numbness of left chin
Colleagues,33 2015
Byun and Syringe likely 9 cases: mandibular first 9 cases with varying degrees of altered sensation
Colleagues,4 2016 premolar (n ¼ 1),
mandibular first molar
(n ¼ 2), mandibular second
molar (n ¼ 6)
Shin and Syringe likely No. 19 Extrusion in IAN leading to paresthesia of left mandibular area
Colleagues,42 2016
Nevares and Syringe First case no. 9, second Both cases involved persistent hardened exogenous material
Colleagues,32 2018 case no. 10
Montenegro Fonsêca Syringe No. 19 Extrusion in soft tissue and IAN leading to paresthesia of left
and Colleagues,44 mandibular area
2019
PREVALENCE
Although neurovascular accidents with calcium hydroxide related to extrusion have been regarded as
rare, their true frequency remains unknown. The limited number of case reports4,9,10,28,30,32-34,36,38-44
(Table) can only provide an estimation because a larger number of accidents might not be reported or
reach publication, other than in judicial records of malpractice proceedings. In our search through the
literature, we were able to identify a limited number of case reports and case series on calcium
hydroxide extrusion accidents.
INTERVENTION OPTIONS
Clinicians who have experience in treating this type of overfill injury to the neurovascular anatomy
are knowledgeable of the time constraints that many surgeons place on effective intervention. The
literature recommends an immediate assessment of symptoms and a thorough discussion with pa-
tients on the timing and prognosis for an intervention to remove the overfill surgically; when
warranted after a specialist consultation, the overfill should be removed surgically if neurovascular
damage is suspected.1,52 In a published case series of calcium hydroxide overfills into the inferior
alveolar nerve space in which all patients experienced neurosensory injury, the results established
that expedient management of the overfill site through decompression and debridement techniques
can improve the prognosis in these overfill cases.53 However, surgical management was less effective
in cases of nerve injury in which an overfill involved widespread distribution of the medicament and
excessive wait times.1
In a study of 61 patients experiencing endodontic sealer overfill into the inferior alveolar nerve
space conducted over an 8-year period, the author reported that 5 of these patients underwent
exploration, removal, and decompression treatment within 48 through 72 hours, and all recovered
completely.1 This observation and other clinical reports have contributed substantially to the un-
derstanding that no matter the material, overfill within the inferior alveolar structures has a much
better prognosis when removed expeditiously.
FINAL CONSIDERATIONS
In the interest of patient well-being, all clinicians need to be aware of the potential for an overfill
mishap when performing endodontic procedures on posterior teeth with close juxtaposition to
neurovascular anatomy.57 Consideration must include the procurement of diagnostic-quality images
that accurately show the crestal borders of the inferior alveolar nerve canal. Cone-beam
3-dimensional computed tomographic imaging software assists greatly in evaluating the inferior
alveolar nerve canal position for planning the delivery of medicaments in close proximity.
In addition, the delivery of all calcium hydroxide products should be analyzed cautiously for
safety. Inadequate shaping of the root canal space, needle delivery that binds in the canal, and a
product with low viscosity can produce an overfill that can cause serious injury and compromise
patient health.46
Mishaps such as overfill into neurovascular anatomy can result in devastating deficits for a patient
receiving endodontic care. Permanent alteration of sensory input through chemical or compression
insult resulting in paresthesia or dysesthesia from the components of root canal medicaments such as
calcium hydroxide will have a cytotoxic effect on those vulnerable structures.58
Consequently, should a patient exhibit neuropathic indications that they have experienced
injury in the first 24 through 48 hours after an endodontic procedure, an advisable microsurgical
consultation is warranted. This referral should be considered a true neurologic emergency, in light of
the known recommendations for expedient diagnosis. Referral to a surgeon skilled in microsurgery,
whether an oral surgeon or endodontist, is time dependent.1,52,59,60
Because only a few case reports documenting these types of injuries are found in the literature,
contributing to an online database for practitioners to report these injuries will provide clinically
meaningful parameters, which can be studied to help develop future guidelines regarding best
practices to avoid and manage these incidents. The US Food and Drug Administration has
developed an adverse event reporting program in which clinicians can report these types of in-
cidents and the medical products used (https://www.fda.gov/safety/medwatch-fda-safety-
information-and-adverse-event-reporting-program). The Web site can act as an important
resource to our profession.
Future research should address improvements in delivery systems, whether they use needles or
other delivery applications, so that clinicians are able to monitor pressures and amounts of material
already rendered within the root canal.
CONCLUSIONS
Overfills of medication or obturation materials in endodontic treatment can cause permanent
neurologic injury. Loss of sensation and its impact on quality of life can affect both the patient and
the clinician for a lifetime. We must recognize the severity of these injuries to the mandible and
encourage reflection on the safe and prudent practice of endodontics that promotes safeguards to
prevent such injuries.3 We have a moral obligation to our patients to protect them from harm and
to practice under safe and sensible directives. n
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