Endod Dent Traumatot 1993: 9: 216-221 Primed in Denmark .

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Munksgaard I<J93

Endodontics & Dental Traumatology

ISSN 0109-2502

Case report

Periodontal destruction and tooth loss following pulp devitalization with Toxavit: report of a case
Hiilsmann M, Hornecker E, Redeker M. Periodontal destruction and tooth loss following pulp devitalization with Toxavit: report of a case. Endod Dent Traumatol 1993; 9; 216-221. Munksgaard, 1993. Abstract In dentistry, paraformaldehyde-containing substances are still used for the devitalization ofthe vital pulp. A clinical case report is presented describing the sequelae of vital pulp devitalization with the paraformaldehyde-containing agent Toxavit. Marginal leakage ofthe temporary filling and iatrogenic perforation ofthe pulp chamber floor resulted in diffusion ofthe agent into the surrounding tissues with subsequent bone sequestration and loss of two teeth. Michael Hulsmann', Else Hornecker', Marianne Redeker'
Departments of 'Operative Dentistry, ^Penodontology, University of Gottingen, Germany

Key words: Toxavit; pulp devitalization; tootti loss; bone sequestration; periodontal destruction. M. Hulsmann, Dept. ot Operative Dentistry, University ot Gottingen, Rotiert-Koch-Str. 40, 3400 Gottingen, Germany Accepted March 8, 1993

Vital pulp devitalization has historically been widely used in endodontic emergency treatment. Eor this purpose the use of devitalizating formulas such as arsenic agents and paraformaldehyde have been advocated (1). When the extreme toxicity of arsenic agents had been recognized paraformaldehyde-containing pastes were more commonly used and reportedly with good clinical results (2-6). A popular agent for vital pulp devitalization in Germany is Toxavit {Eege artis, Dettenhausen, Germany). 1 g ofthe paste contains 460 mg paraformaldehyde, 370 mg lidocaine HGl and 45 mg mcresol. Following exposure of the inflamed pulp tissue the application of a small amount of paste in direct contact to the vital pulp tissue is recommended. The cavity has to be tightly sealed with zinc oxide-eugenol or Cavit. The paste should be allowed to remain inside the cavity for 10-15 days (2). The use of Toxavit is still widespread among general practitioners, although the technique since many years is not advocated by university clinics. Review ef the literature Heling et al. have reported on the successful use of Toxavit in teeth in which adequate anesthesia for pulp extirpation could not be achieved (7). During 216

a period of five years Toxavit was used in 146 patients and in one case the medicament had caused necrosis ofthe interdental papilla and bone sequestration after 10 days application. In a later investigation on the success rates of endodontic therapy Heling & Kischinowsky reported on a success rate of 85.7% following vital pulpectomy, but only 60.0% following chemical devitalization with Toxavit (8). Ratka-Kruger & Raetzke (9) present 3 cases of irreversible periodontal destruction after use of Toxavit. In all cases necrotic tissue and bone sequestrae had to be removed surgically. Tooth extraction could be avoided. Lost (10) and Thoden Van Velzen et al. (11) also report on cases of necrosis following devitalization with Toxavit resulting in massive bone loss and tooth extraction. Bone necrosis and dentin resorption could be diagnozed in a clinical case by Tal et al. (12). Adverse effects of formaldehyde-containing agents (formocresol) resulting in significant necrosis of the supporting bone and surrounding tissues have been previously reported by Abrams et al. {13), Cambreuzzi & Greenfield (14), and Kopczyk et al. (15). First signs of these sequelae have been reported to appear 2-21 days after application of the paste (79). Additionally, Ebner & Kraft present 2 cases of immediate heavy allergenic reactions after application of Toxavit (16). In an

Toxavit devitalization

experimental study on rats Lost & Geurtsen (17) devitalized pulps with Toxavit. The temporary fillings were perforated on the distal aspect of the teeth so that the diffusion of the agent to the adjacent tissues became possible. Three days after application histological changes in the interdental bone could be diagnosed. After 7 days necrotic tissue and bone sequestration were found in the apical third of the root, finally resulting in complete loss ofthe teeth. An in vitro study using extracted teeth that had been filled with Toxavit revealed that paraformaldehyde even penetrated the root cementum whereas intact enamel did not allow diffusion. Diffusion could not be prevented by an intact temporary filling. 1950% of the applied formaldehyde was lost within one week (18).
Case report

of the treated teeth he noted a retraction of the gingiva. After consulting his dentist he was referred to the university clinic for periodontal treatment to "cover the denuded alveolar bone".
Clinical investigation

A 33-year old white male patient was referred to the Department of Periodontology by his dentist for periodontal therapy.
Case history

The patient's medical history was non-contributory. The clinical investigation revealed completely denuded alveolar bone from the mesial aspect of tooth 45 to the distal aspect of tooth 46 (Fig. 1). The highest level of the bone was below the furcation, which could not be probed. On the mesial aspect of tooth 46 an overhanging amalgam filling could be probed as well as an overhanging margin of the metal-ceramic-crown on tooth 45. No gingival tissue was found between the teeth 45 and 46. Lingually a deep crater with denuded alveolar bone could be seen (Fig. 2). The furcation of tooth 46 could not be probed from the lingual aspect. Tooth 46 was slightly mobile and both teeth were tender to percussion. The buccally denuded bone seemed to be slightly mobile on careful probing, which provoked heavy pain.
Radiographic evaluation

Four months before presenting at the clinic of the Department of Periodontology the patient had undergone root eanal treatment on tooth 46 because of a deep carious lesion and acute pulpitis. The dentist had "killed the nerve with a paste" and two months later definitely obturated the root canals. Initial pain had resolved but some weeks after the definite root canal filling the patient again felt pain in that region which was slightly increasing from day to day. The dentist prescribed an antibiotic. As the pain did not cease, tooth 45 was opened and root canal therapy was performed in one appointment. The patient reported on increasing pain and a strange and heavy smell from his moutli. Buccally

From the referring dentist's radiographs the case could be followed over the treatment period. The pre-treatment radiograph showed a deep amalgam filling on tooth 46, possibly reaching the pulp chamber. On the mesial root a slight widening of the periodontal space was seen. Mesially the amalgam had been condensed into the interdental space resulting in interdental pocketing. Tooth 45 had a inetal-ceramic-crown, and was radiographically without evidence of disease (Fig. 3). The next radiograph was taken by the referring dentist 6 weeks later for determination of the working length on

g- 1. Buccat view of tpeth 45 and 46 showing ttie targe extent of denuded alveolar bone.

2. Lingual view: deep interdental crater and loss of soft

Hulsmann et al.

to the middle of the root. In the furcation area the beginning bone destruction was more obvious than in the length determination radiograph. This also was true for the region around the mesial root of tooth 46. Between the teeth 45 and 46 bone destruction was evident. In tooth 45 the distal root canal remained untreated and unfilled, and the mesial toot canal was inadequately filled (Fig. 5). A radiograph taken at the patient's first appointment in the university clinic showed a cloudy appearance ofthe alveolar bone around tooth 46 and a defect between the mesial root tip of tooth 46 ancl the root tip of tooth 45 (Fig. 6).
Treatment

Fig. 3. Pretreatment radiograph taken by the patient's dentist showing a large amalgam restauration on tooth 46. The periodontal space around the mesial root apices appears shghtly widened. Tooth 43 shows no signs of puipal pathosis. Due to the overhanging amalgam restatiration a periodontal pocket between tooth 45 and tooth 46 had developed.

Teeth No. 46 and 45 were extracted because ofthe extensive bone destruction (Fig. 7). Tooth 46 could

Fig. 4. The radiograph after "completion"' of endodontic therapy on tooth 4-6 shows a poor root canal filling and a perforation of the pulp chamber floor. Recession of interdental alveolar bone mesially and distally is evident. In tooth 45 the distal root canal is not instrumented.

Eig. 5. The radiographic control after definite root canal obturation of tooth 45, taken on the same appointment as in Fig. 4 from a different angle, reveales the extent of alveolar bone losti on the distal side of tooth 46 and indicates pathological changes in the furcation area and between the root tips of teeth 45 and 46. In toodi 45 onlv one rooi canal is -'filled".

tooth 45. It .showed an inadequate root canal fiUing of tooth 46. Preparation ofthe access cavity seemed to have resuhed in a perforation of the pulp chamber floor. The periodontal space in the furcation was shghtly widened. Distally the hight of the alveolar bone was reduced. In tooth 45 only one ofthe two root canals was instrumented. Signs of pathological changes in the alveolar bone at the mesial root of tooth 46 were evident (Fig. 4). The radiographic control after "completion" of endodontic therapy on looth 45, taken from a different angle, confirmed these findings. Distally of tooth 46 an intrabony pocket could be detected, extending
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Eig. 6. Six weeks later the radiograph ie\eales hone dest! uction all around tooth 46 and between teeth 46 and 45.

Toxavit devilalization Histological findings Both alveolar bone and soft tissue were sent for hi.stological investigation. The soft tissue showed hyperplastic epithelial cells and degenerative changes. Subepithelial inflammatory infiltrations and granulocytes were found. In the alveolar bone necrotic material with only minimal sings of inflam-

Fiij. y. Post-extriiction view of the operation site.

Fig. 9. Lingual view ofthe extracted tooth 46.

Fig. 8. Burcal \'itrw oi" the extracted tooth 46 with adhering dK'eolar bone. Note the extent of bone loss in the furcation area and mesially.

easily be removed with a large adhering bone sequester (Fig. 8 and 9). The postoperative control one week later showed good healing of the large extraction wound (Fig. 10). The examination of tooth 46 revealed an iatrogenic perforation of the pulp chamber iloor in the furcation area (Fig. 11).

F'ig. }(). Operation site one week after extraction.

219

Hulsmann et al. mt-

not penetrate the apical foramen and not affect bone or non-infected tissue (5) proved to be wrong (21-23). Necrosis of tissue in contact with paraformaldehyde containing medicaments has been demonstrated in several studies (24-26). With the advent of effective methods of anesthesia, the use of devitafization techniques has effectively ceased. Intraligamental and intrapulpal injection techniques are able to afford suflucient depth of anesthesia in most cases. Immediate pulp extirpation followed by sufficient enlargement and debridement of the root canal system has proved to be the best treatment option, regarding both pain relief and long term success (27). Alternately a pulpotomy may be performed using milde sedative dressings (28). The use of paraformaldehyde-containing agents for devitalization of the infiammed pulp should no longer be considered in endodontic treatment.

References

Fig. II. After removal of the adhering bone a iatrogenic perforation ofthe pulp chamber floor of tooth 4-6 is visible.

mation was detected. In both specimen precipitates of albumen were seen. The diagnosis was made on aseptic bone necrosis. Discussion This case report confirms the findings from several earlier publications, reporting on heavy sequelae following the use of paraformaldehyde containing pastes in endodontic therapy (7, 9-15). The manufacturer states that Toxavit is safe for the surrounding tissues, provided the cavity is tightly sealed. Even if diffusion ofthe substance into the oral cavity might be prevented completely in all cases, which seems questionable, this is not true for the furcation area. As investigations of Burch & Hulen (19), Goldberg et al. (20), and many others have clearly shown there is a high incidence of accessory foramina and patent accessory canals between the pulp chamber and the furcation which cannot completely be sealed. Therefore, diflusion of paraformaldehyde into the interradicular bone may not be prevented in each case. Additionally, earlier statements that paraformaldehyde from devitalization pastes would 220

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