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

Copyright © Munksgaard I<J93

Endodontics &Dental Traumatology

ISSN 0109-2502

Case report

Periodontal destruction and tooth loss followingpulp devitalization with Toxavit: report of a caseHiilsmann M, Hornecker E, Redeker M. Periodontal destructionand tooth loss following pulp devitalization with Toxavit: reportof a case. Endod Dent Traumatol 1993; 9; 216-221.© Munksgaard, 1993.

Abstract — In dentistry, paraformaldehyde-containing substancesare still used for the devitalization ofthe vital pulp. A clinicalcase report is presented describing the sequelae of vital pulpdevitalization with the paraformaldehyde-containing agentToxavit. Marginal leakage ofthe temporary filling and iatrogenicperforation ofthe pulp chamber floor resulted in diffusion oftheagent into the surrounding tissues with subsequent bone seques-tration and loss of two teeth.

Michael Hulsmann', Else Hornecker',Marianne Redeker'Departments of 'Operative Dentistry, ^Pen-odontology, 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 wide-ly used in endodontic emergency treatment. Eor thispurpose the use of devitalizating formulas such asarsenic agents and paraformaldehyde have beenadvocated (1). When the extreme toxicity of arsenicagents had been recognized paraformaldehyde-con-taining pastes were more commonly used and re-portedly with good clinical results (2-6).

A popular agent for vital pulp devitalization inGermany is Toxavit {Eege artis, Dettenhausen, Ger-many). 1 g ofthe paste contains 460 mg paraform-aldehyde, 370 mg lidocaine HGl and 45 mg m-cresol. Following exposure of the inflamed pulptissue the application of a small amount of paste indirect contact to the vital pulp tissue is recom-mended. The cavity has to be tightly sealed withzinc oxide-eugenol or Cavit. The paste should beallowed to remain inside the cavity for 10-15 days(2). The use of Toxavit is still widespread amonggeneral practitioners, although the technique sincemany years is not advocated by university clinics.

Review ef the literature

Heling et al. have reported on the successful use ofToxavit in teeth in which adequate anesthesia forpulp extirpation could not be achieved (7). During

a period of five years Toxavit was used in 146 pa-tients and in one case the medicament had causednecrosis ofthe interdental papilla and bone seques-tration after 10 days application. In a later investiga-tion on the success rates of endodontic therapy Hel-ing & Kischinowsky reported on a success rate of85.7% following vital pulpectomy, but only 60.0%following chemical devitalization with Toxavit (8).

Ratka-Kruger & Raetzke (9) present 3 cases ofirreversible periodontal destruction after use ofToxavit. In all cases necrotic tissue and bone seques-trae had to be removed surgically. Tooth extractioncould be avoided. Lost (10) and Thoden Van Velzenet al. (11) also report on cases of necrosis followingdevitalization with Toxavit resulting in massivebone loss and tooth extraction. Bone necrosis anddentin resorption could be diagnozed in a clinicalcase by Tal et al. (12). Adverse effects of formalde-hyde-containing agents (formocresol) resulting insignificant necrosis of the supporting bone and sur-rounding tissues have been previously reported byAbrams et al. {13), Cambreuzzi & Greenfield (14),and Kopczyk et al. (15). First signs of these sequelaehave been reported to appear 2-21 days after appli-cation of the paste (7—9). Additionally, Ebner &Kraft present 2 cases of immediate heavy allergenicreactions after application of Toxavit (16). In an

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Toxavit devitalization

experimental study on rats Lost & Geurtsen (17)devitalized pulps with Toxavit. The temporary fill-ings were perforated on the distal aspect of the teethso that the diffusion of the agent to the adjacenttissues became possible. Three days after applicationhistological changes in the interdental bone couldbe diagnosed. After 7 days necrotic tissue and bonesequestration were found in the apical third of theroot, finally resulting in complete loss ofthe teeth.

An in vitro study using extracted teeth that hadbeen filled with Toxavit revealed that paraformalde-hyde even penetrated the root cementum whereasintact enamel did not allow diffusion. Diffusioncould not be prevented by an intact temporaryfilling. 19—50% of the applied formaldehyde waslost within one week (18).

Case report

A 33-year old white male patient was referred tothe Department of Periodontology by his dentist forperiodontal therapy.

Case history

Four months before presenting at the clinic of theDepartment of Periodontology the patient hadundergone root eanal treatment on tooth 46 becauseof a deep carious lesion and acute pulpitis. Thedentist had "killed the nerve with a paste" and twomonths later definitely obturated the root canals.Initial pain had resolved but some weeks after thedefinite root canal filling the patient again felt painin that region which was slightly increasing fromday to day. The dentist prescribed an antibiotic. Asthe pain did not cease, tooth 45 was opened androot canal therapy was performed in one appoint-ment. The patient reported on increasing pain anda strange and heavy smell from his moutli. Buccally

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

Clinical investigation

The patient's medical history was non-contributory.The clinical investigation revealed completely de-nuded alveolar bone from the mesial aspect of tooth45 to the distal aspect of tooth 46 (Fig. 1). Thehighest level of the bone was below the furcation,which could not be probed. On the mesial aspectof tooth 46 an overhanging amalgam filling couldbe probed as well as an overhanging margin of themetal-ceramic-crown on tooth 45. No gingival tissuewas found between the teeth 45 and 46. Linguallya deep crater with denuded alveolar bone could beseen (Fig. 2). The furcation of tooth 46 could notbe probed from the lingual aspect. Tooth 46 wasslightly mobile and both teeth were tender to per-cussion. The buccally denuded bone seemed to beslightly mobile on careful probing, which provokedheavy pain.

Radiographic evaluation

From the referring dentist's radiographs the casecould be followed over the treatment period. Thepre-treatment radiograph showed a deep amalgamfilling on tooth 46, possibly reaching the pulpchamber. On the mesial root a slight widening ofthe periodontal space was seen. Mesially the amal-gam had been condensed into the interdental spaceresulting in interdental pocketing. Tooth 45 hada inetal-ceramic-crown, and was radiographicallywithout evidence of disease (Fig. 3). The next radio-graph was taken by the referring dentist 6 weekslater for determination of the working length on

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

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

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Hulsmann et al.

Fig. 3. Pretreatment radiograph taken by the patient's dentistshowing a large amalgam restauration on tooth 46. The peri-odontal space around the mesial root apices appears shghtlywidened. Tooth 43 shows no signs of puipal pathosis. Due to theoverhanging amalgam restatiration a periodontal pocket betweentooth 45 and tooth 46 had developed.

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

tooth 45. It .showed an inadequate root canal fiUingof tooth 46. Preparation ofthe access cavity seemedto have resuhed in a perforation of the pulpchamber floor. The periodontal space in the fur-cation was shghtly widened. Distally the hight ofthe alveolar bone was reduced. In tooth 45 onlyone ofthe two root canals was instrumented. Signsof pathological changes in the alveolar bone at themesial root of tooth 46 were evident (Fig. 4).

The radiographic control after "completion" ofendodontic therapy on looth 45, taken from a differ-ent angle, confirmed these findings. Distally of tooth46 an intrabony pocket could be detected, extending

to the middle of the root. In the furcation area thebeginning bone destruction was more obvious thanin the length determination radiograph. This alsowas true for the region around the mesial root oftooth 46. Between the teeth 45 and 46 bone destruc-tion was evident. In tooth 45 the distal root canalremained untreated and unfilled, and the mesialtoot canal was inadequately filled (Fig. 5).

A radiograph taken at the patient's first appoint-ment in the university clinic showed a cloudy ap-pearance ofthe alveolar bone around tooth 46 anda defect between the mesial root tip of tooth 46 anclthe root tip of tooth 45 (Fig. 6).

Treatment

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

Eig. 5. The radiographic control after definite root canal obtu-ration of tooth 45, taken on the same appointment as in Fig. 4from a different angle, reveales the extent of alveolar bone lostion the distal side of tooth 46 and indicates pathological changesin the furcation area and between the root tips of teeth 45 and46. In toodi 45 onlv one rooi canal is -'filled".

Eig. 6. Six weeks later the radiograph ie\eales hone dest! uctionall around tooth 46 and between teeth 46 and 45.

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Toxavit devilalization

Histological findings

Both alveolar bone and soft tissue were sent forhi.stological investigation. The soft tissue showedhyperplastic epithelial cells and degenerativechanges. Subepithelial inflammatory infiltrationsand granulocytes were found. In the alveolar bonenecrotic 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 adheringdK'eolar bone. Note the extent of bone loss in the furcation areaand mesially.

easily be removed with a large adhering bonesequester (Fig. 8 and 9). The postoperative controlone week later showed good healing of the largeextraction wound (Fig. 10). The examination oftooth 46 revealed an iatrogenic perforation of thepulp chamber iloor in the furcation area (Fig. 11). F'ig. }(). Operation site one week after extraction.

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Hulsmann et al. mt-

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

mation was detected. In both specimen precipitatesof albumen were seen. The diagnosis was made onaseptic bone necrosis.

Discussion

This case report confirms the findings from severalearlier publications, reporting on heavy sequelaefollowing the use of paraformaldehyde containingpastes in endodontic therapy (7, 9-15). The manu-facturer states that Toxavit is safe for the surround-ing tissues, provided the cavity is tightly sealed.Even if diffusion ofthe substance into the oral cavitymight be prevented completely in all cases, whichseems questionable, this is not true for the furcationarea. As investigations of Burch & Hulen (19),Goldberg et al. (20), and many others have clearlyshown there is a high incidence of accessory foram-ina and patent accessory canals between the pulpchamber and the furcation which cannot completelybe sealed. Therefore, diflusion of paraformaldehydeinto the interradicular bone may not be preventedin each case. Additionally, earlier statements thatparaformaldehyde from devitalization pastes would

not penetrate the apical foramen and not affectbone or non-infected tissue (5) proved to be wrong(21-23). Necrosis of tissue in contact with paraform-aldehyde containing medicaments has been demon-strated in several studies (24-26).

With the advent of effective methods of anes-thesia, the use of devitafization techniques has effec-tively ceased. Intraligamental and intrapulpal in-jection techniques are able to afford suflucient depthof anesthesia in most cases. Immediate pulp extir-pation followed by sufficient enlargement and de-bridement of the root canal system has proved tobe the best treatment option, regarding both painrelief and long term success (27). Alternately a pulp-otomy may be performed using milde sedative dress-ings (28). The use of paraformaldehyde-containingagents for devitalization of the infiammed pulpshould no longer be considered in endodontic treat-ment.

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