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Azerbaycan Saytlari

 »  Home  »  Endodontic Articles 4  »  Localized alveolar bone necrosis following the use of an arsenical paste
Localized alveolar bone necrosis following the use of an arsenical paste
Introduction - Case report.

N. Özmeriç
Department of Periodontology, Faculty of Dentistry, Gazi University, Ankara, Turkey.

Toxic ‘devitalising’ agents were commonly used in the past to devitalize inflamed pulps when effective anaesthesia could not be obtained. But these agents are not confined to the pulp canal, and they may be expressed through patent apical, lateral and accessory canals and cause periodontal injury (Nagle et al . 1980, Jakhi et al . 1983, Yakata et al . 1985). One of them, arsenic, is usually encountered in dentistry as its trioxide (As 2 O 3 ), a water-soluble compound, forming arsenious acid (H 3 AsO 4 ). Arsenic and its compounds are known to be extremely toxic on contact with hard and soft tissue, are carcinogenic and with the advent of effective methods of anaesthesia, have no place in contemporary dental practice. Despite this, reports of their use, even in developed countries, continue to appear (Smart & Barnes 1991).
Root resection can be utilized to treat teeth with unrestorably damaged roots or severely compromised bone support. It has been reported that periodontally involved molars can be maintained for long periods of time following root resection (Kim 1998). Treatment including the use of bone substitutes, conditioning of the root surfaces and membrane barriers have been advocated for achieving this goal (Kim 1998).
The aim of this report is to condemn the destructive effect of an arsenic devitalizing agent and to present the case of a tooth with severely compromised bone support which was preserved with the aid of root amputation.

An 18-year-old female patient was referred to Gazi University, Faculty of Dentistry, Department of Periodontology for advice regarding a bony sequestrum associated with the mesial interproximal area of tooth 16. One month previously, she had attended her general dental practitioner complaining of pain. The practitioner elected to devitalize the tooth, which had showed the signs of pulpitis, with an arsenic paste. According to the referring dentist, chemical devitalization had been done because local anaesthesia had been ineffective. Past medical and family history was non-contributory. Shortly after the placement of the paste, the patient experienced excruciating pain and afterwards she noticed that there was denudation of bone.
Clinical examination revealed slightly inflamed gingiva with probing depths not exceeding 3 mm in the 16 region. There was loss of the mesial interproximal papillary gingiva and the surrounding bone was exposed to a height of approximately 3–4 mm. The exposed bone had a dull greyish colour (Fig. 1). There was no measurable tooth mobility. Radiographic examination demonstrated expansion of the periodontal ligament and loss of lamina dura mesial to 16. Appearances suggested a perforation at the mesial aspect of the crown through which the arsenical preparation had escaped. A periapical radiolucency was also observed on the palatal root (Fig. 2).

Figure 1. Gingival recession and exposure of bone at the initial visit.

Gingival recession and exposure of bone at the initial visit

Figure 2. Periapical radiograph showing palatal apical radiolucency. There is an expansion of periodontal ligament and loss of lamina dura at the mesial aspect of the crown due to a perforation and leakage.

Periapical radiograph showing palatal apical radiolucency

Figure 3. The resected root and the bone sequestrum at the time of surgery.

The resected root and the bone sequestrum at the time of surgery

A decision was made to attempt to preserve this non-vital tooth by root canal treatment and flap surgery to remove necrotic bone, and the associated root. Root canal treatment was performed first. Regrettably, the root filling was under-extended in the distobuccal and over-extended in the mesiobuccal root. After raising a full-thickness mucoperiosteal flap on the palatal side, the sequestrum was observed to be separated from the surrounding healthy bone, and therefore, removed easily with tweezers. A fissure bur was then used under a constant flow of saline solution to cut the involved palatal root. Care was taken to cut the root with an angle through the furcation. Before removal with an elevator (Fig. 3). Granulation tissue was curetted free and the operative area was irrigated with saline. Osseous recontouring by means of osteoplasty was carried out with a saline-cooled bur. To facilitate clotting, a haemostatic sponge was placed into the socket (Fig. 4). Sutures were applied to reposition of mucoperiosteal flap. Three months later, a definitive cuspal coverage restoration was placed over the tooth (Fig. 5).
At one-year recall, the patient reported that the tooth was functional without any problem. Clinical examination revealed nothing abnormal; no symptoms, no periodontal pocketing, no detectable mobility and no evidence that a fistula had been present. The tooth was in functional occlusion. Radiographic examination revealed evidence of some bony healing despite the less than ideal endodontic treatment (Fig. 6). The patient will continue to be reviewed for bony healing and for reinforcement of oral hygiene practices.

Figure 4. Haemostatic sponge in the socket and closure with sutures.

Haemostatic sponge in the socket and closure with sutures

Figure 5. Three-month review with cuspal coverage restoration.

Three-month review with cuspal coverage restoration

Figure 6. Review radiograph at 1 year.

Review radiograph at 1 year