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Paresthesia of the inferior alveolar nerve caused by periapical pathology
CLINICAL ARTICLES
Paresthesia of the Inferior Alveolar Nerve caused by Periapical Pathology
Donald D. Antrim, DDS, Loma Linda, Calif
Paresthesia in the oral cavity m a y be associated with either the hard or soft tissues. In diagnosing the cause of the paresthesia, the clinician should consider such local factors as bone infections, tumors (benign or malignant), bone fractures, pulpless teeth, and previous oral surgery procedures. In addition, such systemic diseases as viral infections, multiple sclerosis, syphilis (tabes dorsalis), and metastatic malignancies should be considered. 1 W h e n a periapical lesion associated with the root of a m a n d i b u l a r molar is in close proximity to the inferior alveolar nerve, the potential for paresthesia exists. If the paresthesia persists for an extended period after nonsurgical root canal therapy, then periapical surgery or an intentional replantation should be performed and a biopsy m a d e of the periapical lesion. Two cases of paresthesia associated with m a n d i b u l a r pulpless teeth are described. In both cases the paresthesia improved after nonsurgical root canal therapy.
CASE REPORTS Case 1
A 41-year-old white w o m a n was examined; she complained of n u m b 220
ness of the lower left lip and occasional severe pain in the left side of the mandible. Radiographic examination showed a large periapical radiolucency around the root apexes of the m a n d i b u l a r left first molar. In 1967, the patient's condition had been diagnosed as bruxism. At that time, a mouth guard had been constructed but was discarded after a brief period of use. About eight years later, the patient sought dental treatment because of "a feeling of pressure" and "soreness" in the mandibular left first molar. In addition, the tooth was sensitive to flossing. Examination showed that percussion to the tooth caused a painful response. Radiographic examination indicated no abnormalities. No treatment was initiated at that time. In April 1975, the patient began to wake up at night with a mild diffuse pain which she attributed to the m a n d i b u l a r left first molar and which was relieved by mild analgesics. At that time, a mesial-occlusaldistal a m a l g a m restoration was totally removed from the tooth and a lingual three-quarter gold crown was placed. After the placement of the crown, the patient described the tooth as having "a heaviness" and she stopped chewing with it. T h e tooth was again examined radio-
graphically in February 1976 and no pathologic condition was noticed. Another m o u t h guard was constructed, which offered no relief. In J u l y 1976, the patient first had a "tingling" and numbness on the left side of the lower lip, and "a soreness in the bone area under the tooth." The patient was first examined by me in J a n u a r y 1977. She was apprehensive and had cancerphobia. During the previous six months she had had brief episodes of acute pain. Although the paresthesia had been sporadic during the same period, it was now constant and evident. Radiographic examination showed a large periapical radiolucent area at the apex of the mandibular left first molar (Fig 1). Findings of electric and thermal vitality tests were normal and the tooth was sensitive to percussion. The m a n d i b u l a r left first molar was diagnosed as having an irreversible pulpitis. Root canal therapy was initiated and the tooth was cleaned and shaped. A week after the patient's initial endodontic appointment, she was asymptomatic and her numbness had subsided. The root canals were filled with gutta-percha (Fig 2). At a subsequent appointment one week later, an attempt was
Vig 1--Large periapical radiolucent area seen it apex of mandibular left first molar (case
v).
Fig 3--Follow-up visit showed healing of the periapical lesion (case 1).
I~'g 2--Root canals were filled with gutta~cha (case 1.)
laade unsuccessfully to locate a canal la w h a t a p p e a r e d to be a root a n o m lily on the distal root. T w e l v e weeks after o b t u r a t i o n , the p a t i e n t continreed to be free from p a i n a n d the feeling in her lower lip h a d r e t u r n e d ~to normal. A follow-up visit six ~aonths after showed h e a l i n g of the l~eriapical lesion on the mesial root (Fig 3). ~.ase 2 On Dec 24, 1975, a 62-year-old white w o m a n was referred for endoflontic t r e a t m e n t on a m a n d i b u l a r fight first molar. T h e referring dentist h a d previously o p e n e d the tooth, found the tissue to be Completely nonvital, p l a c e d a m e d i : eated pellet, closed the tooth with a temporary restoration, a n d preaeribed penicillin because of some ~ r i a p i c a l swelling. A t our initial endodontic a p p o i n t m e n t the root ~a-nals were cleaned, the occlusal COntact reduced, the a n t i b i o t i c coverage continued, a n d an analgesic ~escribed.
F o u r days later, the p a t i e n t r e t u r n e d in pain with swelling on the buccal side of the m a n d i b u l a r right first molar; she h a d n u m b n e s s on her lower lip. A n incision a n d d r a i n a g e p r o c e d u r e was p e r f o r m e d with good d r a i n a g e resulting. She offered the i n f o r m a t i o n that she h a d a history of resistance to medications p r e s c r i b e d to clear up infections. This was based on difficulty in clearing u p a u r i n a r y tract infection. Antibiotics a n d analgesics were continued. T h e next day, the p a t i e n t reported that the n u m b ness continued, b u t the swelling was r e d u c e d a n d her pain h a d subsided. O n J a n 3, 1976, the p a t i e n t was comfortable; swelling was slight, but the n u m b n e s s continued. T h e cleaning a n d shaping of the c a n a l spaces were completed. O n J a n 10, 1976, the p a t i e n t h a d no s y m p t o m s of swelling or pain. T h e o b t u r a t i o n of the t o o t h was c o m p l e t e d (Fig 4). T h e p a t i e n t c o n t i n u e d to have numbness. Neither the referring dentist n o r the e n d o d o n t i s t h a d given her a block anesthesia on the inferior a l v e o l a r nerve d u r i n g previous a p p o i n t m e n t s . This ruled out the possibility of p r i m a r y nerve d a m a g e caused by the needle. T h e p a t i e n t was i n f o r m e d that the paresthesia was most likely
Fig 4--After inczszon and drainage procedure, radiograph shows complete obturation of tooth. Patient continued to have numbness (case 2).
coming from pressure on the nerve bundle a n d t h a t the lip would p r o b ably return to n o r m a l in time. O n J a n 21, the n u m b n e s s was much less noticeable. T h e p a t i e n t was instructed to return if the n u m b ness persisted. O n Dec 7, 1976, the p a t i e n t returned with pain. She h a d been a s y m p t o m a t i c for the previous y e a r and the feeling in her lip h a d returned to n o r m a l a few weeks after e n d o d o n t i c therapy. O r a l e x a m i n a tion showed an extensive mesiodistal fracture of the m a n d i b u l a r right first molar; extraction was recommended. The opinions and assertions contained herein are those of the author and are not to be construed as official or as reflecting the views of the Department of the Navy or of the Department of Defense. Dr. Antrim is a commander in the US Naval Dental Corps and an assistant professor of endodontics at Loma Linda University. Requests for reprints should be directed to Dr. Antrim at 1615 E Mission Rd, Fallbrook, Calif 92028.
References
1. Morse, D.R. Clinical endodontics: a comprehensive guide to diagnosis, treatment, a~d prevention. Springfield, Ill, Charles C Thomas, 1974, p 73. 221
Paresthesia of the Inferior Alveolar Nerve caused by Periapical Pathology
Donald D. Antrim, DDS, Loma Linda, Calif
Paresthesia in the oral cavity m a y be associated with either the hard or soft tissues. In diagnosing the cause of the paresthesia, the clinician should consider such local factors as bone infections, tumors (benign or malignant), bone fractures, pulpless teeth, and previous oral surgery procedures. In addition, such systemic diseases as viral infections, multiple sclerosis, syphilis (tabes dorsalis), and metastatic malignancies should be considered. 1 W h e n a periapical lesion associated with the root of a m a n d i b u l a r molar is in close proximity to the inferior alveolar nerve, the potential for paresthesia exists. If the paresthesia persists for an extended period after nonsurgical root canal therapy, then periapical surgery or an intentional replantation should be performed and a biopsy m a d e of the periapical lesion. Two cases of paresthesia associated with m a n d i b u l a r pulpless teeth are described. In both cases the paresthesia improved after nonsurgical root canal therapy.
CASE REPORTS Case 1
A 41-year-old white w o m a n was examined; she complained of n u m b 220
ness of the lower left lip and occasional severe pain in the left side of the mandible. Radiographic examination showed a large periapical radiolucency around the root apexes of the m a n d i b u l a r left first molar. In 1967, the patient's condition had been diagnosed as bruxism. At that time, a mouth guard had been constructed but was discarded after a brief period of use. About eight years later, the patient sought dental treatment because of "a feeling of pressure" and "soreness" in the mandibular left first molar. In addition, the tooth was sensitive to flossing. Examination showed that percussion to the tooth caused a painful response. Radiographic examination indicated no abnormalities. No treatment was initiated at that time. In April 1975, the patient began to wake up at night with a mild diffuse pain which she attributed to the m a n d i b u l a r left first molar and which was relieved by mild analgesics. At that time, a mesial-occlusaldistal a m a l g a m restoration was totally removed from the tooth and a lingual three-quarter gold crown was placed. After the placement of the crown, the patient described the tooth as having "a heaviness" and she stopped chewing with it. T h e tooth was again examined radio-
graphically in February 1976 and no pathologic condition was noticed. Another m o u t h guard was constructed, which offered no relief. In J u l y 1976, the patient first had a "tingling" and numbness on the left side of the lower lip, and "a soreness in the bone area under the tooth." The patient was first examined by me in J a n u a r y 1977. She was apprehensive and had cancerphobia. During the previous six months she had had brief episodes of acute pain. Although the paresthesia had been sporadic during the same period, it was now constant and evident. Radiographic examination showed a large periapical radiolucent area at the apex of the mandibular left first molar (Fig 1). Findings of electric and thermal vitality tests were normal and the tooth was sensitive to percussion. The m a n d i b u l a r left first molar was diagnosed as having an irreversible pulpitis. Root canal therapy was initiated and the tooth was cleaned and shaped. A week after the patient's initial endodontic appointment, she was asymptomatic and her numbness had subsided. The root canals were filled with gutta-percha (Fig 2). At a subsequent appointment one week later, an attempt was
Vig 1--Large periapical radiolucent area seen it apex of mandibular left first molar (case
v).
Fig 3--Follow-up visit showed healing of the periapical lesion (case 1).
I~'g 2--Root canals were filled with gutta~cha (case 1.)
laade unsuccessfully to locate a canal la w h a t a p p e a r e d to be a root a n o m lily on the distal root. T w e l v e weeks after o b t u r a t i o n , the p a t i e n t continreed to be free from p a i n a n d the feeling in her lower lip h a d r e t u r n e d ~to normal. A follow-up visit six ~aonths after showed h e a l i n g of the l~eriapical lesion on the mesial root (Fig 3). ~.ase 2 On Dec 24, 1975, a 62-year-old white w o m a n was referred for endoflontic t r e a t m e n t on a m a n d i b u l a r fight first molar. T h e referring dentist h a d previously o p e n e d the tooth, found the tissue to be Completely nonvital, p l a c e d a m e d i : eated pellet, closed the tooth with a temporary restoration, a n d preaeribed penicillin because of some ~ r i a p i c a l swelling. A t our initial endodontic a p p o i n t m e n t the root ~a-nals were cleaned, the occlusal COntact reduced, the a n t i b i o t i c coverage continued, a n d an analgesic ~escribed.
F o u r days later, the p a t i e n t r e t u r n e d in pain with swelling on the buccal side of the m a n d i b u l a r right first molar; she h a d n u m b n e s s on her lower lip. A n incision a n d d r a i n a g e p r o c e d u r e was p e r f o r m e d with good d r a i n a g e resulting. She offered the i n f o r m a t i o n that she h a d a history of resistance to medications p r e s c r i b e d to clear up infections. This was based on difficulty in clearing u p a u r i n a r y tract infection. Antibiotics a n d analgesics were continued. T h e next day, the p a t i e n t reported that the n u m b ness continued, b u t the swelling was r e d u c e d a n d her pain h a d subsided. O n J a n 3, 1976, the p a t i e n t was comfortable; swelling was slight, but the n u m b n e s s continued. T h e cleaning a n d shaping of the c a n a l spaces were completed. O n J a n 10, 1976, the p a t i e n t h a d no s y m p t o m s of swelling or pain. T h e o b t u r a t i o n of the t o o t h was c o m p l e t e d (Fig 4). T h e p a t i e n t c o n t i n u e d to have numbness. Neither the referring dentist n o r the e n d o d o n t i s t h a d given her a block anesthesia on the inferior a l v e o l a r nerve d u r i n g previous a p p o i n t m e n t s . This ruled out the possibility of p r i m a r y nerve d a m a g e caused by the needle. T h e p a t i e n t was i n f o r m e d that the paresthesia was most likely
Fig 4--After inczszon and drainage procedure, radiograph shows complete obturation of tooth. Patient continued to have numbness (case 2).
coming from pressure on the nerve bundle a n d t h a t the lip would p r o b ably return to n o r m a l in time. O n J a n 21, the n u m b n e s s was much less noticeable. T h e p a t i e n t was instructed to return if the n u m b ness persisted. O n Dec 7, 1976, the p a t i e n t returned with pain. She h a d been a s y m p t o m a t i c for the previous y e a r and the feeling in her lip h a d returned to n o r m a l a few weeks after e n d o d o n t i c therapy. O r a l e x a m i n a tion showed an extensive mesiodistal fracture of the m a n d i b u l a r right first molar; extraction was recommended. The opinions and assertions contained herein are those of the author and are not to be construed as official or as reflecting the views of the Department of the Navy or of the Department of Defense. Dr. Antrim is a commander in the US Naval Dental Corps and an assistant professor of endodontics at Loma Linda University. Requests for reprints should be directed to Dr. Antrim at 1615 E Mission Rd, Fallbrook, Calif 92028.
References
1. Morse, D.R. Clinical endodontics: a comprehensive guide to diagnosis, treatment, a~d prevention. Springfield, Ill, Charles C Thomas, 1974, p 73. 221