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Year : 2017  |  Volume : 2  |  Issue : 1  |  Page : 26-31

Unique case of dental practice negligence using calcium hydroxide intracanal medicament: A case report

1 Assistant Professor, Department of Department of Restorative Dental Sciences, College of Dentistry, King Khalid University, Abha, KSA
2 Dental Intern, College of Dentistry, King Khalid University, Abha, KSA
3 Assistant Professor, Department of Department of Oral Maxillofacial Surgery, College of Dentistry, King Khalid University, Abha, KSA

Date of Web Publication13-Aug-2020

Correspondence Address:
BDS, MSc, FRCD(C) Adel S Alobaid
Department of Restorative Dental Sciences, College of Dentistry, King Khalid University, Abha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1658-743X.291935

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Safe dental practice is based on the rule of do no harm. Procedural errors in endodontics are mainly based on wrong case selection with underestimation of case difficulty. The aim of this report was to discuss a case of negligence in dental practice leading to multidisciplinary treatment and pain management approach. This case reported to emergency clinics at King Khalid University, College of Dentistry (KKUCOD) after an accident of overextrusion of calcium hydroxide (Ca(OH)2) from tooth # 22 extended distally to greater palatine foramen area without sinus communication. Patient pain was unbearable and needed strong acting pain medication. The tooth was treated with nonsurgical endodontic with buccal perforation repair followed by surgical endodontic to establish apical seal and remove the extruded material. Then a full thickness palatal flap was needed to remove the extended material. This approach was effective in alleviating patient pain. Such incidence could have been avoided if a safe practice rules were strictly followed thus case difficulty assessment form must be used in such cases.

Keywords: Negligence, Endodontics, Calcium hydroxide

How to cite this article:
Alobaid AS, Alnefaie RO, Elnager MA. Unique case of dental practice negligence using calcium hydroxide intracanal medicament: A case report. King Khalid Univ J Health Sci 2017;2:26-31

How to cite this URL:
Alobaid AS, Alnefaie RO, Elnager MA. Unique case of dental practice negligence using calcium hydroxide intracanal medicament: A case report. King Khalid Univ J Health Sci [serial online] 2017 [cited 2021 Mar 1];2:26-31. Available from: https://www.kkujhs.org/text.asp?2017/2/1/26/291935

  Introduction Top

“Do no harm” is a golden rule in dental practice. Dentists are responsible to protect their patient, update their knowledge of the field, and provide the highest level of evidence-based dental care. If a specific challenge or risk is presented by the patient or the tooth in question, then the dentist should analyze the case, determine the chance of success, summarize that to the patient and either proceed with the proposed treatment or refer to specialist.[1] American Association of Endodontics (AAE) has considered root and apical morphology, root resorption, trauma and perforations as factors that add extra risks to endodontic cases. If one or more of these factors is present, high or even extreme risk is identified.[2]

Ignoring such factors may easily lead to a procedural error.

Maxillary sinus is an air-filled cavity that lies in the maxillary alveolar process in a very close proximity to maxillary posterior teeth apices. Inferior border of the sinus must be clearly identified to properly measure the distance to the root apices in relation. Panoramic radiographs provide excellent information about mesio-distal sinus dimensions however, it has some limitations in the bucco-lingual direction as well as superimposition of other structures like zygomatic arch that may blur the radiograph. CBCT has a great advantage over panoramic view to provide accurate evaluation of root apices or extruded material in relation to the sinus.[3]

Given its properties, Calcium hydroxide (Ca (OH)2) is widely used in endodontics as an intracanal medication between appointments or as a sealer with root canal filling due to its bactericidal effect against endodontic microorganisms. Studies have shown that intracanal medication Ca(OH)2 causes an inflammatory response with inhibited bone healing and negative effect on periodontal tissues in guinea-pig.[4] While as a root canal sealer, it had a substantial cytotoxic effect on human fibroblast at the first 48 hours with significant reduction after 3 days, and caused a moderate-to-severe inflammatory reaction of rat sciatic nerve.[5],[6]

Over-instrumentation of root canal can lead to a complete loss of the apical barrier that prevents extrusion of root canal instrument or material into the alveolar bone or even to the sinus space. This is normally associated with decreased repair potential of periapical lesion and increased risk for inadvertent damage.[7] Endodontic mishap is a procedural accident that ended up with unpleasant experience by both treating dentist and patient. Best management started with recognition followed by clinical or radiographic observation, and then correction of such mistake. It can be during access opening, chemomechanical instrumentation or obturation phase of treatment.[8]

The purpose of this report is to discuss an endodontic case with an accidental extrusion of Ca(OH)2 due to negligence of a dentist that required a comprehensive management of nonsurgical root canal treatment, endodontic surgery and surgical intervention remove of extruded material.

  Case Report Top

A 26 years male patient reported to the emergency dental clinics at King Khalid University College of Dentistry, Abha Saudi Arabia complaining of severe sharp shooting pain, heaviness in the left maxillary sinus area with unilateral nasal congestion and left eye lacrimation. When asked, he had not sought any medical or dental consultation before reporting to our clinics. His medical history was insignificant and classified as ASA I.

Patient dental history revealed that he had visited a private dental clinic the previous night for a scheduled follow up appointment to treat his discolored anterior tooth. The tooth was asymptomatic, however on examination the dentist told him that his tooth is non-vital and thus required root canal treatment. The patient reported that the dentist started the treatment without using anesthesia which perhaps may not have been required since the tooth wasnon-vital. Upon treatment initiation the dentist told him that the tooth is badly infected and needed local medication for some time. During placement of the medication, the patient said that he felt unbearable pain “like an arrow piercing my tooth at the tip and shredding my whole palate; the worst kind of pain which I can never forget”. Since the pain was unbearable the dentist gave him local anesthesia that did not help as the pain was excruciating.

The patient reported to our clinic the following day seeking emergency treatment. No significant finding was observed on extraoral examination. Intraoral examination showed slight redness of labial and palatal mucosa in the left anterior teeth. Tooth # 22 was painful to labial and palatal palpation and very sensitive to finger pressing thus percussion could not be performed. Other anterior teeth (# 13, 12, 11, 21, 23) responded normally to pulpal and periapical sensibility tests. Periapical radiograph showed that the root canal system of tooth #22 was full of radiopaque material that extruded through the apex in the periapical area. Large size (3x3cm) periapical radiolucent area was completely filled with the extruded material that is also out of the reach of regular periapical radiographs [Figure 1]a. Panoramic view showed that the injected material was running through the palatal area crossing through maxillary sinus to reach behind the 3rd molar area. The material looked like a chain of beads with different sizes that were separated by small radiolucent lines [Figure 2]a.Since the involvement of maxillary sinus was highly expected a CT scan was taken to check close proximity or involvement of maxillary sinus. CT scan showed very close proximity of the injected material to the maxillary sinus with some bone perforations but without direct communication [Figure 3].Patient was informed that the material intended to be inside the tooth was grossly extruded towards the sinus area and required urgent intervention. A comprehensive treatment plan of non-surgical root canal treatment, endodontic surgery for tooth # 22 and a corrective surgery to remove the extruded material was proposed. Patient was given a prescription of 600 mg Ibuprofen every 6 hours and was scheduled for treatment next day after obtaining an informed consent. After 3 hours patient came back complaining of the same level of pain thus he was given 60mg of codeine combined with 650 mg acetaminophen and instructed to take both ibuprofen with codeine every 6 hours until his appointment the next day.
Figure 1: (a) Pre-operative periapical radiograph demonstrating gross extrusion of calcium hydroxide paste. (b) Working length radiograph showing difficult interpretation due to superimposition of extruded material. (c) Intermediate radiograph during surgical procedure to check for complete removal of extruded paste.

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Figure 2: (A) Pre-operative panoramic radiograph demonstrating gross extrusion of calcium hydroxide and distal extension to the left 3rd molar area. (B) Immediate post surgery showing remaining material near to greater palatine foramen. (C) Two months recall showing shrinkage in the remaining paste size.

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Figure 3: Multiple slides of CT scan with different planes (a) Axial view demonstrate gross extrusion of calcium hydroxide and its close proximity to the maxillary sinus. (b) Sagittal view to see distal extension of the material (c, d) Different levels of coronal view showing perforated inferior bone

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Patient reported the next day for treatment indicating that he was not able to sleep the night before because of pain. Local anesthesia, 2% (36mg) lidocaine with 1:100,000 epinephrine, was buccally infiltrated to tooth #22 and the rubber dam was placed for isolation to perform non-surgical root canal filling. Up on access opening, subcrestal labialperforation at the cervical area was evident which was repaired using MTA ([email protected]) DENTSPLY. Working length was determined using radiographs and apex locator [Figure 1]b, obturation was completed using the romplastizied technique. Subsequently, two cartilages of 2% lidocaine with 1:50,000 epinephrine was injected buccal and palatal to the same tooth. A full thickness mucoperiosteal flap with one releasing vertical incision was raised. A through and through bone defect was observed around the root tip [Figure 4]a and the extruded material yellowish in color resembling calcium hydroxide with iodoform, was seen. Root end resection and apical preparation was done under an operating endodontic microscope with a microsurgical kit using MTA ([email protected]) as a retrograde filling material. Postoperative periapical radiograph was taken to confirm complete removal of extruded material around the root tip [Figure 1]c.
Figure 4: Multiple intraoperative photographs (a) Buccalview after removing calcium hydroxide shows excessive bone defect (b) Palatal view after reflection to show the sequestration of extruded material (c) A sample of the extruded material beads-like appearance

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For palatal surgery, both Nasopalatine and left greater palatine nerve blocks were given. A sulcular incision was made from tooth #13 up to tooth #28 using size 15 scalpel and the palate was pushed down in a full thickness. The extruded calcium hydroxide was sequestrated and totally sandwiched by a tunnel like fibrous tissue [Figure 4]b. Using curates was not helpful in removing extruded material since it was encapsulated by fibrous tissue and scalpel was needed to cut through the fibrous tissue tunnel and remove the Ca(OH)2 piece by piece [Figure 4]c. Over the sinus area there was very thin layer of bone defect with only sinus mucosa separating the paste from the sinus cavity without direct communication [Figure 3]. The paste was extended posteriorly to the left greater palatine foramen. The left greater palatine nerve was exposed and visible and the material was in direct contact with the nerve trunk and the foramen and densely encapsulated with thick fibrous tissue. The use of scalpel in this area was obviously hazardous to the nerve thus a very small amount was left behind to prevent inadvertent nerve damage. Panoramic radiograph was taken postoperatively to ensure complete removal of Ca(OH)2 [Figure 2]b. The flap was repositioned and sutured in place using silk 4/0 vertical mattress suture. Before discharging, postoperative instructions was given in written and explained to the patient and then he was injected with dexamethasone 10 mg/ml IM to help in controlling postoperative pain and swelling. Patient was called after 24 hours for postsurgical follow up. There was a significant reduction in patient’s pain level that was well controlled by using NSAIDs and slight palatal swelling was evident. After 7 days, sutures were removed and patient signs and symptoms were significantly better and healing stage was excellent. Patient then recalled on a monthly bases and during two months recall, patient was pain-free, not using analgesics and the main chief complaint has completely resolved [Figure 2]c.

  Discussion Top

Gluskin[7] mentioned in his topic about mishaps and serious complications in endodontic obturation “A recipe for disaster”. Gross overextension is a consequence of a small error in the beginning of the treatment that was not discovered or its importance was neglected. It indicates negligence and faulty work and should never happened in do no harm based practice. Such mishap can lead to poor apical seal, delayed healing and permanent harm could exist if obturation material contains paraformaldehyde.[9],[10]

In Overfill cases, compression damage of the solid extruded material to the boney space must be considered.[7] That may lead increased internal pressure, compromised blood supply and ischemia due to direct compression of extruded material.

This is known as a compartment syndrome where an awful experience of severe pain with diminished sensation happened after the injury.[11] Based on that, NSAIDs was not effective in controlling patient’s pain thus he was given the severe pain control strategy suggested by AAE[12] which was effective in controlling the pain preoperatively. Corticosteroids were suggested for compression injuries,[11] thus the patient was given 1ml of IM dexamethasone 10 mg/ml postoperatively for pain control which was very helpful.

During working length determination, the initial file was size 70 indicating an open apex, which may be because of over instrumentation, apical root resorption due to long-standing periapical lesion or incomplete root formation. It has been reported that if the initial apical file is greater than file size # 40 (0.40mm) it is more likely to have root canal material extruded beyond the root difficult control in manipulation and poor apical seal.[10] Evidently, the use of non-setting calcium hydroxide loaded with syringe under positive pressure was what happened in this case. The failure to realize the open apex, and limited canal ability to accommodate the full load of the syringe was behind this gross spread of the material.

After buccal flap reflection, both cortical plates were resorbed creating a through and through bone defect which may result in healing by fibrosis. A Guided Bone Regeneration (GBR) method as a bone graft or a membrane should have been used in such defect, to prevent ingress of fibroblasts and fibrous tissue healing,[13] however they were not immediately available as the case was treated in emergency clinics.

The extruded material followed a chain of beads pattern that may be explained by tissue resistance of palatal mucosa against the material volume and force of application. The material was found midway between gingival crest and median raphe which explained the least resisting area to flow, where most of blood vessels, nerve supply and minor salivary glands exists. The extruded material was encapsulated with dense fibrous tissue that required the use of scalpel to cut through each bead and remove Ca(OH)2 piece by piece. The last bead distally was visible in direct contact with greater palatine nerve and benefits of leaving it overweighed the risk of removal.

Safe and carful endodontic approach in dealing with teeth in close proximity to maxillary sinus must be taken and the clinician must be able to identify proximal risk. During canal debridement, cleaning and shaping process must be confined to the canal space. Multiple techniques to accurately determine the working length 1-2 mm shorter than radiographic apex should be considered and “Resistance form” must be well established in teeth with open apices. The flow characteristics of injectable pastes under positive pressure must be considered. The use of syringes for applying endodontic pastes should be done cautiously. Preferably 2 mm short of the working length, passively injected with minimal force, and withdrawn gradually from the canal.

  Conclusion Top

Patient protection is an ethical obligation to all medical practitioners. Safe practice requires extreme attention to all treatment aspects and avoidance of unreasonable risks that may harm patients. As a responsible professional, the rule of “Do No Harm” should always come first. Applying strict rules of malpractice will help limiting the negligence, reduce risk of harm, protect patients and practitioners and improve the quality of dental treatment.

  References Top

American Dental Association: Ethical Dentists (http://www.mouthhealthy.org/en/az-topics/e/ethics-and-dentistry)  Back to cited text no. 1
American Association of Endodontics, Colleague for excellence: Evaluating endodontic treatment risk factors. Spring/summer 1997.  Back to cited text no. 2
Selden HS. Endoantral syndrome and various endodontic complications. J Endod 1999; 25:389-393.  Back to cited text no. 3
Spangberg L. Biological effects of root canal filling materials. 7. Reaction of bony tissue to implanted root canal filling material in guinea pigs. Odontologisk Tidskrift 1969; 77, 133-59.  Back to cited text no. 4
Briseno BM, Willershausen B. Root canal sealer cytotoxicity with human gingival fibroblasts: III. Calcium hydroxide-based sealers. J Endod 1992; 18:110-113.  Back to cited text no. 5
Serper A, Ucer O, Onur R, Etikan I. Comparative neurotoxic effects of root canal filling materials on rat sciatic nerve. J Endod 1998; 24:592-594.  Back to cited text no. 6
Gluskin A: Mishaps and serious complications in endodontic obturation. Endodontic Topics 2005; 12:52-70.  Back to cited text no. 7
Yadav RK, Chand S, Verma P, Chandra A, Tikku AP, Wadhwani KK. Clinical negligence or endodontic mishaps: A surgeons dilemma. Natl J Maxillofac Surg 2012; 3:87-90.  Back to cited text no. 8
[PUBMED]  [Full text]  
American association of Endodontics, Position statement: Concerning Paraformaldehyde-Containing Endodontic Filling Materials and Sealers 2013.  Back to cited text no. 9
Gatot A, Tovi F. Prednisone treatment for injury and compression of inferior alveolar nerve: report of a case of anesthesia following endodontic overfilling. Oral Surg 1986; 62: 704-706.  Back to cited text no. 10
Schwartz SI, Shires GT, Spencer FC. Principles of Surgery, 7th ed. New York: McGraw-Hill, 1999.  Back to cited text no. 11
American Association of Endodontics, Colleague for excellence: A “3D” Approach for Treating Acute Pain. Winter 2015.  Back to cited text no. 12
Ogiso B, Hughes FJ, Melcher AH, McCulloch CA. Fibroblasts inhibit mineralised bone nodule formation by rat bone marrow stromal cells in vitro. J Cell Physiol. 1991; 146:442-450.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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