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Localized argyria after a surgical endodontic procedure
Localized argyria after a surgical endodontic procedure Report
of a case
David A. Kirchofl, UNITED FORT
STATES HOOD,
ARMY
Major,
DC, USA*
DENTAL
DETACHMENT,
TEXAS
Presented are a case report and discussion of a pigmented lesion of the gingiva, localized argyria, which can arise after endodontic treatment combined with apical surgery. Included are a pathologist’s report and comments and a suggestion for prevention of this unesthetic lesion.
A
rgyria has been defined by Dorland as “a permanent ashen-grey discoloration of the skin, conjunctiva and internal organs that results from the long, continued use of silver salts.“1 Shafer, Hine, and Levy2 stated that argyria is caused by chronic exposure to silver compounds from occupational hazards or after therapeutic use of silver compounds, such as silver arsphenamine or silver nitrate. Lever3 also suggested that argyria can be caused by prolonged ingestion of silver salts or local application of them to the mucous membranes. The pigmented lesions which result are not raised and have a bluish gray and slatecolored appearance.2s 3 Orban and Went9 have recorded the following: “A pronounced blue staining may occur subsequent to use of a silver containing root canal filling. If a root is perforated during root canal therapy, the material may be embedded in the tissues, or if used in primary teeth, the silver may remain after root resorption. The gingiva is the most frequent site for bluish discolorations.” The following case report is presented in order to show another cause of localized argyria and to aid in the prevention of this unesthetic lesion. CASE
REPORT
The patient, a 22-year-old man, had a chief complaint of “draining abscess.” Clinical examination revealed a 1.2 x 2.0 cm,, nonraised, nonindurated, gray-blue pigmented lesion *Chief of Endodontics. 613
Fig. d. Radiograph of lower anterior teeth demonstrating previous obturation of canals silver points, evidence of an apicoectomy, and present pathosis. Note tip of a silver point the previous operation. Fig. 3. Postoperative radiograph after apical curettage and placing of apical amalgam fillings in order to ensure a better seal of the canals. with from
of the gingiva labial to the lower central incisors (Fig. 1). A 1.5 x 2.0 mm. lesion was also present labial to the lower left cuspid. A draining fistulous tract was present in the distal segment of the lesion, on the labial gingiva, between the lower left central and lateral incisors.
Localized
argyria
Volume Number
32 4
Fig. granular,
4. Photomicrograph of localized extracellular pigment.
after surgical
argyria.
The connective
endociontic
tissue
procedure
contains
a heavy,
615
black,
Radiographic examination revealed that all lower incisors had previously been treated endodontically and each canal contained a silver-point root canal filling (Fig. 2). Radiographic evidence of a previous apicoectomy was present and there was a radiolueent area at the apex of each tooth. The dental history revealed that the The medical history was essentially negative. patient had had “some root canal treatment and surgery” 5 years previous and that, prior to this, no discoloration or pigmentation was present on the gingiva. It was after this treatment that the patient first noticed the discoloration. Then, approximately 4 years later, he suffered a recurrence of the abscess. An apicoectomy was performed, and the pigmented lesion increased in size after the operation.
In diagnosing a pigmented lesion, one must always think of the possibility of the most dangerous pigmented lesion-a malignant melanoma. Although the occurrence of this lesion in the oral cavity is extremely rare,5 it must certainly be considered in the differential diagnosis, especially when there is a history of an increase in size. Other pigmented lesions-such as amalgam tattoo, Addison’s disease, Peutz-Jegher’s syndrome, or pigmentation with heavy metals (from therapeutic or occupational sources)-can be ruled out by clinical examination and the medical history. On the basis of the dental history in this case, one should consider the probability that the pigmentation arose from a root canal sealer containing a heavy metal which was incorporated into the tissue after a surgical endodontic procedure. Treatment consisted of incisional biopsy of the pigmented lesion, apical curettage, and placing of apical amalgams in the involved teeth to provide a better apical seal (Fig. 3).
616
Kirchof
Fig. 5. 8, Another example of this pigmented lesion-in this case buccal fold facial to the lower left lateral incisor (arrow). B, Radiograph a silver-point root canal filling and apicoectomy.
TISSUE EXAMINATION
located in the mucoshowing evidence of
REPORT
Microscopic sections showed the attached fibrous stroma to contain a granular, black, extracellular pigment not associated with an inflammatory response. No nevus cells were noted. The pigment did not resemble melanin or hemosiderin. The pigment had a haphazard arrangement but was occasionally deposited in the walls of vessels. The overlying stratified squamous epithelium was acanthotic and parakeratotic (Fig. 4). Diagnosis: Consistent with localized argyria. Pathologist’s comment: ‘(There is no special stain that I am aware of that would definitely identify this pigment as silver. The only definitive procedure that could do this would probably be x-ray diffraction studies of the tissue. This pigment could conceivably be bismuth, lead, etc., but the clinical history would certainly seemto support the assumption that the pigment is silver.” DISCUSSION The incidence of this type of lesion appears to be increasing as an increased number of surgical endodontic procedures are performed. Four cases other than the one reported here have been seen during the past year (Fig. 5). These caseshad a similar history of root canal filling and an apicoectomy and no treatment other than identification was needed. One should be aware of the lesion described and include it in the differential diagnosis of pigmented lesions. Many of the root canal sealers in current use contain precipitated silver or the salts of other heavy metals, such as bismuth and barium, for increased radiopacity. Therefore, it behooves the operator who is performing surgical
Volume Number
32 4
Localized
argyria
after
surgical
endodontic
procedure
617
endodontic procedures to irrigate the operative area thoroughly in order to remove all traces of the sealer and silver-point filings from under the soft-tissue flap and thereby prevent the development of a potentially unesthetic lesion. This is especially true in procedures in which silver or gutta-percha points are placed in the canal after a mucoperiosteal flap has been reflected. SUMMARY
A case of a pigmented lesion, localized argyria, resulting from a surgical endodontic procedure has been reported, and a suggestion for its prevention has been presented. REFERENCES
1. Dorland’s Company, 2. Shafer, Saunders 3. Lever, Company, 4. Orban, brane, 5. Bhaskar, p. 404.
Illustrated Medical Dictionary, ed. 24, Philadelphia, 1965, W. B. Saunders p. 131. W. G., Hine, M. K., and Levy, B. M.: Oral Pathology, Philadelphia, 1963, W. B. Company, pp. 475476. W. F.: Histbpathology of the Skin, ed. 4, Philadelphia, 1967, J. B. Lippincott pp. 259-261. B. J., and Wentz, F. M.: Atlas of Clinical Pathology of the Oral Mucous MemSt. Louis, 1960, The C. V. Mosby Company, p. 133. S. N.: Synopsis of Oral Pathology, St. Louis, 1965, The C. V. Mosby Company,
Reprint requests to : Major David A. Kirchoff Chief, Endodontics IT. S. Army Dental Detachment Fort Hood, Tex. 76545
of a case
David A. Kirchofl, UNITED FORT
STATES HOOD,
ARMY
Major,
DC, USA*
DENTAL
DETACHMENT,
TEXAS
Presented are a case report and discussion of a pigmented lesion of the gingiva, localized argyria, which can arise after endodontic treatment combined with apical surgery. Included are a pathologist’s report and comments and a suggestion for prevention of this unesthetic lesion.
A
rgyria has been defined by Dorland as “a permanent ashen-grey discoloration of the skin, conjunctiva and internal organs that results from the long, continued use of silver salts.“1 Shafer, Hine, and Levy2 stated that argyria is caused by chronic exposure to silver compounds from occupational hazards or after therapeutic use of silver compounds, such as silver arsphenamine or silver nitrate. Lever3 also suggested that argyria can be caused by prolonged ingestion of silver salts or local application of them to the mucous membranes. The pigmented lesions which result are not raised and have a bluish gray and slatecolored appearance.2s 3 Orban and Went9 have recorded the following: “A pronounced blue staining may occur subsequent to use of a silver containing root canal filling. If a root is perforated during root canal therapy, the material may be embedded in the tissues, or if used in primary teeth, the silver may remain after root resorption. The gingiva is the most frequent site for bluish discolorations.” The following case report is presented in order to show another cause of localized argyria and to aid in the prevention of this unesthetic lesion. CASE
REPORT
The patient, a 22-year-old man, had a chief complaint of “draining abscess.” Clinical examination revealed a 1.2 x 2.0 cm,, nonraised, nonindurated, gray-blue pigmented lesion *Chief of Endodontics. 613
Fig. d. Radiograph of lower anterior teeth demonstrating previous obturation of canals silver points, evidence of an apicoectomy, and present pathosis. Note tip of a silver point the previous operation. Fig. 3. Postoperative radiograph after apical curettage and placing of apical amalgam fillings in order to ensure a better seal of the canals. with from
of the gingiva labial to the lower central incisors (Fig. 1). A 1.5 x 2.0 mm. lesion was also present labial to the lower left cuspid. A draining fistulous tract was present in the distal segment of the lesion, on the labial gingiva, between the lower left central and lateral incisors.
Localized
argyria
Volume Number
32 4
Fig. granular,
4. Photomicrograph of localized extracellular pigment.
after surgical
argyria.
The connective
endociontic
tissue
procedure
contains
a heavy,
615
black,
Radiographic examination revealed that all lower incisors had previously been treated endodontically and each canal contained a silver-point root canal filling (Fig. 2). Radiographic evidence of a previous apicoectomy was present and there was a radiolueent area at the apex of each tooth. The dental history revealed that the The medical history was essentially negative. patient had had “some root canal treatment and surgery” 5 years previous and that, prior to this, no discoloration or pigmentation was present on the gingiva. It was after this treatment that the patient first noticed the discoloration. Then, approximately 4 years later, he suffered a recurrence of the abscess. An apicoectomy was performed, and the pigmented lesion increased in size after the operation.
In diagnosing a pigmented lesion, one must always think of the possibility of the most dangerous pigmented lesion-a malignant melanoma. Although the occurrence of this lesion in the oral cavity is extremely rare,5 it must certainly be considered in the differential diagnosis, especially when there is a history of an increase in size. Other pigmented lesions-such as amalgam tattoo, Addison’s disease, Peutz-Jegher’s syndrome, or pigmentation with heavy metals (from therapeutic or occupational sources)-can be ruled out by clinical examination and the medical history. On the basis of the dental history in this case, one should consider the probability that the pigmentation arose from a root canal sealer containing a heavy metal which was incorporated into the tissue after a surgical endodontic procedure. Treatment consisted of incisional biopsy of the pigmented lesion, apical curettage, and placing of apical amalgams in the involved teeth to provide a better apical seal (Fig. 3).
616
Kirchof
Fig. 5. 8, Another example of this pigmented lesion-in this case buccal fold facial to the lower left lateral incisor (arrow). B, Radiograph a silver-point root canal filling and apicoectomy.
TISSUE EXAMINATION
located in the mucoshowing evidence of
REPORT
Microscopic sections showed the attached fibrous stroma to contain a granular, black, extracellular pigment not associated with an inflammatory response. No nevus cells were noted. The pigment did not resemble melanin or hemosiderin. The pigment had a haphazard arrangement but was occasionally deposited in the walls of vessels. The overlying stratified squamous epithelium was acanthotic and parakeratotic (Fig. 4). Diagnosis: Consistent with localized argyria. Pathologist’s comment: ‘(There is no special stain that I am aware of that would definitely identify this pigment as silver. The only definitive procedure that could do this would probably be x-ray diffraction studies of the tissue. This pigment could conceivably be bismuth, lead, etc., but the clinical history would certainly seemto support the assumption that the pigment is silver.” DISCUSSION The incidence of this type of lesion appears to be increasing as an increased number of surgical endodontic procedures are performed. Four cases other than the one reported here have been seen during the past year (Fig. 5). These caseshad a similar history of root canal filling and an apicoectomy and no treatment other than identification was needed. One should be aware of the lesion described and include it in the differential diagnosis of pigmented lesions. Many of the root canal sealers in current use contain precipitated silver or the salts of other heavy metals, such as bismuth and barium, for increased radiopacity. Therefore, it behooves the operator who is performing surgical
Volume Number
32 4
Localized
argyria
after
surgical
endodontic
procedure
617
endodontic procedures to irrigate the operative area thoroughly in order to remove all traces of the sealer and silver-point filings from under the soft-tissue flap and thereby prevent the development of a potentially unesthetic lesion. This is especially true in procedures in which silver or gutta-percha points are placed in the canal after a mucoperiosteal flap has been reflected. SUMMARY
A case of a pigmented lesion, localized argyria, resulting from a surgical endodontic procedure has been reported, and a suggestion for its prevention has been presented. REFERENCES
1. Dorland’s Company, 2. Shafer, Saunders 3. Lever, Company, 4. Orban, brane, 5. Bhaskar, p. 404.
Illustrated Medical Dictionary, ed. 24, Philadelphia, 1965, W. B. Saunders p. 131. W. G., Hine, M. K., and Levy, B. M.: Oral Pathology, Philadelphia, 1963, W. B. Company, pp. 475476. W. F.: Histbpathology of the Skin, ed. 4, Philadelphia, 1967, J. B. Lippincott pp. 259-261. B. J., and Wentz, F. M.: Atlas of Clinical Pathology of the Oral Mucous MemSt. Louis, 1960, The C. V. Mosby Company, p. 133. S. N.: Synopsis of Oral Pathology, St. Louis, 1965, The C. V. Mosby Company,
Reprint requests to : Major David A. Kirchoff Chief, Endodontics IT. S. Army Dental Detachment Fort Hood, Tex. 76545