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Year : 2018  |  Volume : 8  |  Issue : 1  |  Page : 50-54

Delayed repair of multiple perforations compounded with formocresol osteo-gingival necrosis

1 Department of Conservative Dentistry and Endodontics, Sinhgad Dental College and Hospital, Pune, Maharashtra, India
2 Department of Periodontology, Sinhgad Dental College and Hospital, Pune, Maharashtra, India

Date of Web Publication10-Jan-2018

Correspondence Address:
Dr. Dipali Yogesh Shah
Department of Conservative Dentistry and Endodontics, Sinhgad Dental College and Hospital, Vadgaon Budruk, Pune - 411 041, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_81_16

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This case report describes the management of formocresol osteo-gingival necrosis in a mandibular molar with lingual and furcal perforations using resorbable demineralized bone matrix and mineral trioxide aggregate (MTA). Three-year postoperative follow-up showed a substantial resolution of the osseous defect as well as a clinically and radiographically sound periodontium. Despite an apparently poor prognosis, conservative management of the case using a combination of demineralized bone matrix and MTA led to a successful outcome. Further, this report warrants that formaldehyde-containing medicaments have no role in contemporary endodontics.

Keywords: Bone graft, formocresol, mineral trioxide aggregate, necrosis, perforation

How to cite this article:
Shah DY, Khopade ST, Jain PM, Dadpe AM. Delayed repair of multiple perforations compounded with formocresol osteo-gingival necrosis. Saudi Endod J 2018;8:50-4

How to cite this URL:
Shah DY, Khopade ST, Jain PM, Dadpe AM. Delayed repair of multiple perforations compounded with formocresol osteo-gingival necrosis. Saudi Endod J [serial online] 2018 [cited 2021 Jan 23];8:50-4. Available from: https://www.saudiendodj.com/text.asp?2018/8/1/50/222764

  Introduction Top

Iatrogenic perforations are undesirable complications occurring during the endodontic therapy that can adversely affect the overall prognosis of the tooth. Prognosis is fair when the level of perforations is more apical in the root and perforation is small and is sealed immediately. Delay in the perforation repair can pose treatment challenges and guard the prognosis of the tooth. Calcium silicate-based cements such as mineral trioxide aggregate (MTA) are the current clinical materials of choice for sealing perforations.[1],[2]

A perforation compounded with leaching of caustic agents from intracanal medicaments can result in additional insult to the periodontium. Formocresol is used as an intracanal disinfectant in endodontic procedures and in primary teeth pulpotomy. It contains formaldehyde that has proven cytotoxic, mutagenic, and carcinogenic properties.[3],[4] In addition to their long-term effects, accidents or misuse of formaldehyde-containing materials in clinical situations may lead to immediate consequences in tissues exposed to the reagent. Severe damage to the periodontium can occur as formaldehyde in its gaseous form can easily diffuse into surrounding tissues through root canals, open dressings, and perforations.[5],[6]

This article presents the management of a case of extensive iatrogenic multiple iatrogenic perforations and subsequent formocresol extrusion into the periodontium, leading to osteo-gingival necrosis in relation to the mandibular first molar.

  Case Report Top

A 20-year-old healthy female patient reported to our dental teaching hospital with a complaint of pain and discomfort related to the left mandibular region for the past 2 days. As per the records of the referring general dentist, a perforation had occurred when root canal therapy was initiated in the left mandibular first molar 2 weeks ago. He had placed formocresol medicament and temporary restoration in the concerned tooth.

Clinical examination revealed a yellowish slough with inflamed surrounding tissues in the lingual gingival region [Figure 1]a and tenderness on percussion with the tooth. Further, examination of the buccal gingiva indicated probing depths of 1–1.5 mm.
Figure 1: Preoperative records of tooth #36: (a) Clinical examination revealed a yellowish necrotic slough on the linguogingival aspect, (b) radiographic examination showed an overextended access cavity, radiolucency in the furcal area as well as along the distal root suggestive of chronic apical periodontitis

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Radiographic examination revealed radiolucency in the pulp chamber floor and furcal alveolar bone area extending along the lateral surface of the distal root and its apex suggestive of an overextended access preparation [Figure 1]b. Further exploration of the pulp chamber established furcal and lingual perforations. Thus, a diagnosis of osteo-gingival necrosis secondary to perforations and apical periodontitis was established. Despite an unfavorable prognosis, a staged treatment approach was planned. Treatment strategy and risks of the case were explained to the patient, and informed consent was taken for treatment.

Stage I: Surgical debridement and initiation of endodontic therapy

Under local anesthesia, the necrotic slough was removed with a universal curette (Hu-Friedy, Chicago, IL, USA) and the area was debrided and irrigated with 5% povidone-iodine (Betadine, Win Medicare, India) antiseptic solution. A mobile bony sequestrum was separated from the healthy viable bone and was sent for histopathological examination. The exposed wound area was covered with tin foil and surgical dressing (GC Coe-Pak, GC, USA). Tin foil is not routinely used along with periodontal dressing. However, in this case, the adaptation of the periodontal dressing was difficult, and hence we used it.

The pulp chamber was copiously irrigated with warm saline to remove the residual formocresol if any. The root canals were identified with #10 K-files (Dentsply Maillefer, Ballaigues, Switzerland) using the dental operating microscope (Möller Universa 300, Germany). Exploring the mesiobuccal root canal revealed a perforation on the furcal side of the mesial root confirmed by an Electronic Apex Locator (Root ZX; Morita, Tokyo, Japan). Saline was used as an irrigant, necrotic pulp tissue was extirpated, and working length was determined and radiographically confirmed. Biomechanical preparation of the root canals was carried out using circumferential filing (Master Apical File size 30K), calcium hydroxide (RC Cal, Prime Dental Products Pvt. Ltd., Mumbai, India) intracanal medicament placed, and a closed dressing given (Cavit G Temporary Filling Material, St. Paul, MN, USA).

The patient was prescribed an oral analgesic and antibiotic along with a 0.2% chlorhexidine mouthwash. At the recall appointment after 1 week, the patient was asymptomatic and there was a decrease in the extent of the gingival inflammation. The affected area was irrigated with the antiseptic solution and a periodontal dressing was again placed on the wound. The same procedure was repeated at the recall appointments in the 2nd and 3rd week. After 1 month, the lingual marginal gingiva appeared healthy and 2 mm of gingival recession was measured from the cementoenamel junction resulted. Thus, the lingual perforation defect became supragingival [Figure 2]a and the patient was scheduled for the second stage of treatment.
Figure 2: Intraoperative records: (a) Healthy lingual gingiva and the complete extent of lingual perforation seen after periodontal healing, (b) tooth #36 after sealing of the lingual and furcal perforations

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Stage II: Perforation repair and completion of endodontic therapy

Following local anesthesia and quadrant isolation with rubber dam, clinical procedures were carried out using a dental operating microscope. Light-cured composite resin (Filtek Z350, 3M ESPE, Salt Lake City, UT, USA) was used to seal the lingual perforation and build up the lingual wall incrementally using a modified T-band matrix. Appropriate size gutta-percha points were used to block the root canal orifices. The furcal perforation was scrubbed with betadine, and #2 Munce bur (CJM Engineering, Santa Barbara, CA) was used to freshen the dentinal margins around the furcal perforation defect. With the help of curette, inter-radicular necrotic tissue from the furcation area was debrided and bleeding was induced to confirm healthy bone.

A sterile resorbable demineralized bone matrix (Osseograft™ Advanced Biotech Products, India) was used as an internal matrix and condensed in the area with a #80 plugger (Dentsply Maillefer, Ballaigues, Switzerland), below the furcation over the viable bone taking care that no material came in contact with cavosurface margins of the tooth. MTA (Dentsply, Tulsa Dental Specialities, Tulsa, UK) was mixed as per the manufacturer's instructions and inserted into the perforated pulp chamber floor and the mesial root with a messing gun and condensed [Figure 2]b and radiographically confirmed. A moist cotton pellet was placed over the MTA and the gutta-percha stoppers in the orifices were carefully removed. The canals were dried with paper points, and the distal canal and the mesiolingual canal were medicated with calcium hydroxide. The endodontic access was sealed with glass ionomer cement (GC Fuji II, Tokyo, Japan).

At the next visit, under isolation, a re-entry into the access preparation was gained. Complete setting of the MTA in the furcal area was confirmed clinically; the intracanal calcium hydroxide was removed using endodontic hand files and 2.5% sodium hypochlorite. A final rinse of 17% ethylenediaminetetraacetic acid was used, and the canals were dried with paper points. Obturation was carried out with gutta-percha (Dentsply Maillefer, Ballaigues, Switzerland) and AH Plus sealer cement (Dentsply Maillefer, Ballaigues, Switzerland) using lateral condensation technique. Immediate postobturation restoration with composite resin (Filtek Z350, 3M ESPE, Salt Lake City, UT, USA) was placed to obtain the coronal seal. A week later, the tooth was restored with a full coverage precious metal fused to ceramic crown [Figure 3]a. The patient followed the oral hygiene instructions and came for periodic follow-ups. At the end of 1 year, clinically, the patient was asymptomatic, had no pain to percussion or palpation, and had no evidence of periodontal disease. Radiographically, the tooth demonstrated complete resolution of the furcal radiolucency with new bone filling the defect. Further, the apical radiolucency showed signs of healing [Figure 3]b. At the 3-year follow-up, the tooth remained asymptomatic, healthy, and functional [Figure 4]a and [Figure 4]b.
Figure 3: Postoperative radiographs: (a) Immediately after definitive restoration, (b) 1-year follow-up showing reduction of the radiolucency in the furcation area and along the distal root

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Figure 4: Three-year follow-up records: (a) Clinical photograph showing healthy gingiva, and (b) radiograph showing healing of the furcation area

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  Discussion Top

The case report discusses a minimal interventional approach for the successful management of iatrogenic perforations with associated formocresol osteo-gingival necrosis.

Iatrogenic perforations may occur during access cavity preparation and while locating root canal orifices. Multiple, large, longstanding perforations have a critical prognosis. Management of furcal perforations in the molars is especially challenging.[7]

In addition, the placement of any caustic agent like formocresol can convolute iatrogenic mishaps such as perforations. Formocresol contains formaldehyde and cresol.[8] Formaldehyde (CH2O), the most simple and reactive of all aldehydes, is a colorless, reactive, and readily polymerizing gas at room temperature.[3] The International Agency for Research on Cancer of the World Health Organization has declared formaldehyde as a human carcinogen.[9] Although the scientific literature has overwhelmingly documented the genotoxicity, carcinogenicity, and toxicity of formaldehyde, formocresol is still used by dental practitioners around the world.[4] A clinical case report by Abrams et al. in 1992 describes the considerable hard and soft tissue destruction and subsequent tooth loss that occurred following an iatrogenic lateral crown/root perforation during a formocresol pulpotomy procedure.[5] Tooth extraction was deemed the only treatment alternative by Hulsmann et al. in a similar case report describing severe periodontal destruction following the use of a paraformaldehyde paste – Toxavit.[6] However, in the present case, although osteo-gingival necrosis was present, a successful attempt was made to salvage the tooth using bone graft combined with perforation repair and nonsurgical endodontic therapy.

A minimal interventional approach was used in the present case for the excavation of necrotic bone. Since the furcal perforation defect was wide, a direct intra-coronal access was preferred for perforation repair. Reflection of a surgical flap for perforation repair in the present case would have led to further destruction of cortical bone and delayed the wound healing.

Immediate repair of perforation is better than delayed repair.[7] However, in the current case, since the perforation was superimposed with osteo-gingival necrosis, a staged therapy was planned. The healing of the periodontium following Stage I therapy was an important determinant in the prognosis of the perforation repair as it facilitated isolation procedure, necessary for sealing of the perforation defects.

Perforation repair materials should ideally seal the defect and stimulate periodontal healing. MTA was used as the repair material because of its outstanding sealing ability, good marginal adaptation, osteoconductivity, and cementoconducivity.[10],[11],[12],[13] However, when the perforation is associated with a large osseous defect, extrusion of sealing material in the periodontium may occur.

Hence, Lemon advocated the use of a matrix when the perforation diameter is larger than 1 mm.[14] The “modified matrix concept” for repair of perforation utilizes resorbable collagen as a biocompatible matrix, followed by condensation of MTA. Such a matrix in the area of bone destruction provides a base on which the sealing material can be placed and packed in the perforation. Such a matrix not only achieves hemostasis but also prevents the extrusion of the material into the periodontal tissues allowing a favorable response of the periodontal tissues.[15]

Several materials are recommended for the fabrication of this matrix, including resorbable collagen, calcium sulfate, calcium hydroxide, hydroxyapatite, tricalcium phosphate, and demineralized bone.[14],[15],[16],[17],[18],[19] Osseograft (Encoll, Fremont, USA) consists of demineralized freeze-dried bone matrix that is prepared from bovine cortical bone sample, resulting in nonimmunogenic flowable particles of approximately 250 μm. It is osteoinductive, osteoconductive, and totally resorbable.[20] In the present case, use of this material in the osseous defect in the furcal area provided an excellent matrix for the compaction of MTA. In addition, this radiolucent matrix had an advantage that the radiographic assessment of compaction of radiopaque MTA was possible. Thus, it served a dual purpose of acting as a resorbable matrix and aiding in bone regeneration.

Immediate coronal seal after completion of endodontic therapy also ensured elimination of any possibility of microleakage. A timely definitive restoration in the form of a full coverage crown placement was essential for the reinforcement of the compromised tooth structure. Maintenance of proper oral hygiene ensured a healthy periodontal status and aided in the complete healing of the lingual periodontium.

  Conclusion Top

Staged periodontal-endodontic approach resulted in a favorable treatment of root perforations. The use of MTA in combination with demineralized bone graft in delayed repair of root perforation associated with necrotic bony defects can lead to successful treatment outcome. With the known risk and proven effective alternatives, the use of formocresol in root canal therapy is unwarranted.

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Conflicts of interest

There are no conflicts of interest.

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Yildirim T, Gençoglu N, Firat I, Perk C, Guzel O. Histologic study of furcation perforations treated with MTA or Super EBA in dogs' teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:120-4.  Back to cited text no. 12
Juárez Broon N, Bramante CM, de Assis GF, Bortoluzzi EA, Bernardineli N, de Moraes IG, et al. Healing of root perforations treated with mineral trioxide aggregate (MTA) and Portland cement. J Appl Oral Sci 2006;14:305-11.  Back to cited text no. 13
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Zou L, Liu J, Yin SH, Tan J, Wang FM, Li W, et al. Effect of placement of calcium sulphate when used for the repair of furcation perforations on the seal produced by a resin-based material. Int Endod J 2007;40:100-5.  Back to cited text no. 19
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