Professional Documents
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CASE REPORTS
A case report that appeared to involve tooth loss canal system and into the periapical tissues if the apical
associated with the use of formocresol is presented. foramen is open (10).
The displacement of a medicated cotton pellet re- Cambruzzi and Greenfield (11) described a case in
suited in a significant amount of supporting bone which overmedication of a canal system with forTnocre-
loss. This case is of particular interest because of sol resulted in crestal bone loss. They postulated that
the potential formocresol medication has for causing the formocresol vapor may have penetrated a dentinal
periodontal destruction. wall that was excessively thinned.
The purpose of this article is to report a case in which
the misuse of formocresol appeared to result in a
significant loss of periodontal attachment and support-
Intracanal medications have historically played an im-
ing bone.
portant role in root canal therapy. Their purpose is to
establish an antimicrobial environment within the pulp CASE REPORT
chamber (1). The root canal system may contain signif-
icant types and numbers of organisms that cause acute A 48-yr-old female was referred to the endodontist
exacerbations, delay treatment procedures, and retard at the University of Kentucky College of Dentistry fac-
or prevent healing. Although mechanical instrumenta- ulty clinic for evaluation of persistent discomfort in the
tion and frequent irrigation eliminate the majority of mandibular left second molar. A root canal filling had
microorganisms, an intracanal medication is often used recently been placed in this tooth by the referring
to reduce the bacterial population retained within dentin dentist. The medical history was noncontributory and
(2). Formocresol is an effective and frequently used revealed only an allergy to "mycin" drugs. The patient
medicament. The combined action of cresol, a protein- complained of "continuous soreness in the area with
coagulating phenolic compound, and formaldehyde, an recession of the gums over the last two weeks." The
alkylating agent, is highly antimicrobial; but it may cause clinical examination revealed sensitivity to percussion
significant destruction of vital tissues (2). Several stud- and discomfort when palpating the facial gingiva. The
ies (3-6) have confirmed the tissue-irritating and cyto- interdental papilla between the first and second molars
toxic effects of formocresol which result in inflammation was missing (Fig. 1) and the exposed interproximal
and tissue fixation bone was insensitive to probing. A large mesio-occlusal
Morse (7), in his review of immunological aspects of temporary restoration in the second molar was mobile
pulpal-periapical diseases, states that formocresol can and easily removed. Radiographic examination re-
act as a hapten, interact with the host protein, and vealed a root canal filling in the second molar. The root
result in an immunological reaction. He suggests that canal filling material had penetrated the apical foramen
immunological responses caused by this mechanism of the distal root and did not reach the apex in the
can result in endodontic "flare-ups" in the form of pain, mesial root (Fig. 2). Removal of the temporary restora-
swelling, and bone resorption. Others (8, 9) also de- tion revealed cotton remnants in the interproximal area.
scribed the immune response. Because formocresol The area was debrided, irrigated, and a new temporary
has the potential to produce severe adverse effects on restoration was placed. A telephone call to the patient's
vital tissue, application of the medication in the canal dentist revealed that a cotton pellet with forrnocresol
system must be carefully controlled. Wesley et al. (1) had been used and had been squeezed dry before
recommend that formocresol be applied to a sterile placement. All evidence appeared to implicate the med-
cotton pellet and squeezed dry in a sterile gauze before ication used in treating the root canal. Therefore, a
being placed into the pulp chamber. Vaporization re- clinical diagnosis of necrosis of crestal bone and over-
sults in permeation of the medication throughout the lying soft tissue secondary to forTnocresol contact was
567
568 Kopczyk et al. Journal of Endodontics
tf
FIG 2. Radiograph of the involved area at the initial appointment.