CALCIUM HYDROXIDE EXTRUSION..........pptx

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1. CALCIUM HYDROXIDE EXTRUSION Extruded materials have a potential to induce a foreign body reaction, even in the absence of microbial factors. The response of tissues is different depending upon the extent of toxicity of these materials. Ca(OH) 2 is generally considered a well-tolerated endodontic material. But a delay in healing of periapical lesions has been reported by a few researchers in cases of accidental extrusion of Ca(OH) 2 . Alantar et al. described four possibilities of endodontic material spread to the periapical region: towards the mandibular canal, drainage through lymphatic vessels, systemic diffusion through the periapical vein and progression towards soft tissues between bone and the mucosal membrane.

2. Common Symptoms:   Extrusion of Ca(OH) 2  can cause chemical injury, compressive injury or both when the material is expressed into the confines of a space that is only meant to be occupied by the neurovascular bundle. The host reaction to Ca(OH) 2  extrusion into the soft tissue or blood vessels can range from a minor inflammatory reaction to serious sequelae, including tissue necrosis and paresthesia. This depends on the amount of material that is extruded into the periapical region and volume of material in contact with vascular and neural tissues. Gingival necrosis, when Ca(OH) 2  comes in contact with gingiva, damage to inferior alveolar nerve on neural contact, severe tissue necrosis on inadvertent intra-arterial injection have already been reported in literature. The direct contact of Ca(OH)2 with periapical tissue, possibly caused a continuous inflammatory response and necrosis following endodontic treatment, which induced acute pain and numbness as the results demonstrated that the crystalloid particles were rich in barium and sulphur which caused an inflammatory foreign body-like reaction with mixed cell infiltrate (fibroblasts, lymphocytes and neutrophils) with numerous macrophages surrounding and phagocytizing the crystalloid foreign bodies.

3. Ca(OH) 2  has a high pH and hence, possesses more toxic effect immediately after placement, which decreases over time. The immediate high toxicity was probably sufficient to cause necrosis of overlying bone and gingiva leading to fenestration. As the toxicity decreased over time, the residual amount may have caused the irritational fibroblastic stimulation of gingival connective tissue leading to encapsulation of M etapex particles in a pouch like structure. Sahli proposed that the necrotizing ability of calcium hydroxide may destroy any epithelium present thereby allowing a connective tissue invagination. This could be the probable reason for initial penetration into the connective tissue which later got encapsulated due to inflammatory responses.

4. The widely held view that extruded Metapex doesn’t impair tissue healing is not consistent with clinical observations. Every attempt should be made to limit all kinds of endodontic materials within the confines of root canal to achieve a predictable healing outcome. All efforts should be made to prevent extrusion of calcium hydroxide material to avoid any complications and achieve a faster healing.

5. Prevention and Management:   Adopting the following approach will help clinicians avoid or manage iatrogenic extrusions during root canal treatment. Prevention The following are some reasonable and responsible recommendations to follow when using Ca(OH) 2  as an interim medicament, based on previous published guidelines: 21 Assess radiographs and cone beam images to identify if teeth are in close proximity to the inferior alveolar nerve or sinuses. Take special care to prevent over-enlargement of the apices of mandibular premolar and molar teeth, which can contribute to the extrusion of materials. Consider the use of a Lentulo spiral as a safer alternative to syringe needle delivery. A recent in vitro study showed that a Lentulo spiral filler at 500 rpm, 3 mm short of the apex, minimized extrusion of Ca(OH) 2 from root canals. Paper point application is safe alternative to injection delivery. Follow the manufacturer’s guidelines when using a commercial prefilled Ca(OH) 2 syringe. Make sure the needle does not bind in the canal when injecting. Use a slow injection rate and constant outward movement from the canal as the material is injected. Take appropriate postoperative periapical radiographs to check for any extrusion of dressing or filling materials into the inferior alveolar canal, around the mental foramen, or near other vital structures. Managing a Ca(OH) 2  Extrusion Accident Document events thoroughly and refer the patient to an oral surgeon or endodontist for follow-up. If the patient reports any postoperative paresthesia, dysesthesia or numbness within the first 24 to 72 hours, time is critical in this true neurologic emergency, and the patient should be referred to an oral surgeon for possible debridement.

6. Chief Complaint- Patient named “Shaima” reported to the Department of Conservative Dentistry & Endodontics, HIDS, Paonta Sahib with chief complaint of constant drainage of pus and pain in upper front region right region of jaw.

7. Past Medical History- No past medical history. Dental - Patient underwent RCT twice for the involved tooth. I/O Examination- revealed tenderness on palpation wrt 12. There was constant drainage of pus from the involved tooth. R/E- presence of peri-radicular lesion and presence of irregular radioopacity with the involved tooth. It was assumed to be Metapex or Calcium Hydroxide. Treatment Plan- Conservative Approach with Root Canal Retreatment followed by Surgical approach.

8. INCISION MARK RETRACTION OF FLAP

9. REMOVAL OF EXTRUDED MATERIAL PRESENCE OF NECROSED TISSUE IN THE CAVITY

10. REMOVAL OF THE NECROSED TISSUE APICOECTOMY PERFOMED

11. PLACEMENT OF BIODENTINE POST OPERATIVE RADIOGRAPH

12. PLACEMENT OF BONE GRAFT SUTURES PLACED

13. FOLLOW UP AFTER 3 MONTHS FOLLOW UP AFTER 8 MONTHS