Case Report

Refractory suppurative apical periodontitisdue to cellulose fibers in the periapical tissues:case reportKeith D. Sonntag, DDS Asgeir Sigurdsson, Cand Odont, MS

The use of a cotton pellet as a spacer or as a medi-cation carrier in the tooth pulp chamber betweenroot canal therapy appointments is an accepted

and common practice.1 Retaining the pellet in theproper position within the tooth is very important.Cellulose fibers from disposable drapes, gowns andcotton can cause foreign body reactions if left in a sur-gical wound.2"4 In addition, cellulose fibers from pa-per points, sealed inside the pulp canal, can cause re-fractory apical periodontitis."

The following is a report of refractory suppurativeapical periodontitis, apparently secondary to foreignmaterial in the periapical area. It is suspected that theforeign material consisted of cotton fibers that weredisplaced from the pulp chamber, through the canal,into the periapical area.

Case reportHistory

A 10-year-old Caucasian male presented to an emer-gency room 11 /2 hr after sustaining a blow to the faceduring a kickball game. His chief complaint was "myfront tooth is cracked." The patient reported goodhealth, was taking no medications and had nocontraindications to treatment. The mesial segment ofthe maxillary right permanent central incisor had classIII mobility. Sulcular hemorrhage was evident. Noother soft tissue injury was recorded. A radiographicevaluation revealed a mesioincisal fracture of the max-illary right permanent central incisor, which appearedto involve the pulp (Fig 1). At this time no attempt wasmade to remove the fractured portion of the tooth. Themesial segment was secured in place with Silux com-posite resin™ (3M Dental Products Division, St Paul,MN) on the facial and lingual surfaces of the tooth. Oneweek later, the fragment was removed, a calcium hy-droxide pulpotomy completed, and the fragmentbonded in place with Silux composite resin.

Two months later, the patient had a draining sinustract in the mucosal tissues facial to the maxillary right

permanent central incisor, with no other signs or symp-toms. A diagnosis of necrotic infected pulp with sup-purative apical periodontitis was made.Chemomechanical instrumentation was completed andformocresol on a paper point was sealed inside the ca-nal space. Three months later, the patient returned com-plaining of painful, swollen gums, and the sinus tractwas still present. Radiographic evaluation revealed aradiolucent area apical to maxillary right permanentcentral incisor (Fig 2). Chemomechanical instrumenta-tion, calcium hydroxide paste, and cotton pellet wererepeated. The tooth was sealed with composite resin.Two weeks later, the sinus tract had still not resolved.The canal was reinstrumented and calcium hydroxidewas replaced.

The patient returned again after 6 months, havingfractured the mesial fragment of the tooth. Evaluation

Fig1. Oblique crown rootfracture of maxillary rightpermanent central incisorat time of emergency visit.Fracture extends belowcrestal bone level and theperiodontal ligament spaceappears widened. Incomp-lete root formation exists.

Fig 2. Radiolucent areaapical to maxillary rightpermanent central incisor.Resorption of crestal bonemesially, association withtooth fracture.

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Fig 3. After 6 months the sinus tract facial to maxillaryright permanent central incisor was still present. Marginalgingival tissue mesial to the tooth was necrotic, possiblydue to impingement by the restoration or chemical burnby the restoration.

revealed necrosis of the marginal gingiva, mesiofacialto the maxillary right permanent central incisor (Fig 3)and sinus tracts on both facial and palatal tissues. Themesial fragment was removed, calcium hydroxide wasreplaced, and a restoration was placed using APH™composite resin (LD Caulk Division, Dentsply Interna-tional Inc, Milford, DE). The patient was at this timereferred to our office.

ExaminationThe patient reported to our office 13 months after the

original trauma. Review of the patient's medical his-tory revealed no contraindications to treatment. Exami-nation confirmed the mesial crown/root fracture. Softtissues appeared healthy with the exception of mar-ginal gingivitis localized around the maxillary rightpermanent central incisor and open facial and palatalsinus tracts. The patient, though currently asymptom-atic, reported periods of discomfort. The tooth re-sponded normally to percussion and palpation and hadnormal mobility. Mesial periodontal probing depthswere 5 mm and followed the contours of the fracturedsurface. Distal probing depths were 3 mm. Radio-graphic evaluation (Fig 4) revealed nearly completeroot formation, a 10xl3-mm radiolucent area apical tomaxillary right permanent central incisor and inad-equate coronal restoration. Adjacent teeth respondedwithin normal limits to vitality testing and probing. Adiagnosis of necrotic infected pulp with suppurativeapical periodontitis was made.

Clinical treatmentUnder rubber dam isolation, the restoration was re-

moved and the canal was accessed. Cotton fibers werefound in the apical portion of the canal system. An at-tempt was made to retrieve the cotton with barbedbroaches. After removing the cotton from the apicalportion of the canal, broaches intentionally passed be-yond the apex of the tooth indicated that cotton was

located beyond the apical foramen (Fig 5). The toothwas instrumented and calcium hydroxide powder wasvertically condensed into the canal. Two weeks later thepatient returned with facial and palatal sinus tracts stillpresent. Because cotton fibers were suspected to havebeen displaced beyond the apex of the tooth, surgicalcurettage of the periapical area was necessary. Rootcanal therapy was completed in conjunction with api-coectomy and the apical gutta percha (Mynol™, Block

Fig 4. At the time ofreferral the radiolucentarea was present apical tomaxillary right permanentcentral incisor. Restorationwith open margins isshown.

Fig 5. A broach withattached cotton fibers thatwere retrieved frombeyond the apical foramenof the maxillary rightpermanent central incisor.

Drug Co Inc, Jersey City, NJ) filling was cold burnished.The tooth was temporarily restored with a Ketac Sil-ver™ glass ionomer filling (ESPE-Premier Corp,Norristown, PA) for coronal seal and an APH compos-ite restoration. One week after the procedure, the softtissues were healing within normal limits and the pa-tient had been asymptomatic. Pathological diagnosis

Fig 6. Photomicrograph (original magnification 40X)hematoxylin and eosin stain of birefringent materialretrieved during surgery on the maxillary right permanentcentral incisor. Mild chronic inflammatory infilrate isseen.

246 American Academy ofPediatric Dentistry Pediatric Dentistry -18:3,1996

was a dental granuloma with chronic inflammation,darkly staining foreign material, and birefringent ma-terial present (Fig 6).

One year after the treatment, the patient reportedthat he had been asymptomatic, adjacent teeth re-sponded normal to vitality testing, the tooth re-sponded normally to palpation and percussion andhad normal mobility. Sinus tracts were not presentand soft tissue healing was complete. Radiographicevaluation revealed formation of a periodontal liga-ment apically and osseous filling of the pathological,surgical defect (Fig 7).

Fig 7. One-year recall examination. Radiograph revealsre-established periodontal ligament apically and osseousfilling of the pathological surgical defect.

DiscussionIt is conceivable that a calcium hydroxide pulpo-

tomy (Cvek pulpotomy)8 followed by an adequatecoronal seal at the initial emergency visit might haveeliminated the need for root canal therapy in this case.It has been shown that an increased time interval be-tween injury and calcium hydroxide pulpotomy treat-ment significantly decreases the prognosis of thistherapy.8 After initiating root canal therapy, the place-ment of a temporary restorative material against hard-packed calcium hydroxide prior to bonding the coro-nal segment may also have eliminated the need for acotton pellet. The space gained by not using a cottonpellet may have increased the retention of the restora-tion and allowed a better seal. Why a formocresolpulpotomy was done when the patient presented witha necrotic pulp is not known. Because of the refractorynature of the lesion presented here, it is thought thatforeign material played a major role in maintaining theinflammatory condition. However, the persistence ofbacterial insult through coronal leakage or from the

periapical area cannot be ruled out. It is also conceiv-able that the displaced cotton prevented the calciumhydroxide from reaching the apical part of the root ca-nal and therefore reduced its effectiveness. For thesereasons apical surgery was indicated. Root canaltherapy was completed in conjunction with surgicaltherapy and the apical gutta percha filling was coldburnished.

Friedman9 concluded in a review of surgical tech-niques that these two procedures, if performed in con-junction, would provide the best prognosis when com-pared to retrofilling only. Kaplan et al.,10 have shownthat cold burnished gutta percha provided significantlyless leakage than retrograde amalgam or heat-sealedgutta percha fillings. Retrograde instrumentation wasnot completed as it was felt that the canal space wasoptimally disinfected. The use of calcium hydroxide asan intracanal medicament has been shown to effec-tively disinfect the root canal space after 30 days.11

The authors thank Dr. Sigurdur R. Seamundsson and Dr. MartinTrope.

Dr. Sonntag is a practicing endodontist in Salt Lake City, Utah, andDr. Sigurdsson is assistant professor in the Department of Endo-dontics at the University of North Carolina, Chapel Hill.

1. Ingle JI, Taintor JF: Endodontics, 3rd Ed. Philadelphia: Lea& Febiger, 1985, pp 794.

2. Tinker MA, Burdman D, Deysine M et al: Granulomatousperitonitis due to cellulose fibers from disposable surgicalfabrics. Labaratory investigation and clinical implications.Ann Surg 180:831-35,1974.

3. Janoff K, Wayne R, Huntwork B, Kelley H, Alberty R: For-eign body reactions secondary to cellulose lint fibers. Am JSurg 147:598-600, 1984.

4. Godleski JJ, Gabriel KL: Peritoneal responses to implantedfabrics used in operating rooms. Surgery 90:828-34, 1981.

5. White E: Paper point in mental foramen: report of a case.Oral Surg 25:630-32, 1968.

6. Koppang HS, Koppang R, Solheim T, Aarnes H, Stolen SO:Cellulose fibers from endodontic paper points as an etiologi-cal factor in postendodontic periapical granulomas andcysts. J Endod 15:369-72, 1989.

7. Sedgley CM, Messer HH: Long-term retention of a paperpoint in the periapical tissues: a case report. Endod DentTraumatol 9:120-23, 1993.

8. Cvek M: A clinical report on partial pulpotomy and cappingwith calcium hydroxide in permanent incisors with compli-cated crown fracture. J Endod 4:232-37, 1978.

9. Friedman S: Retrograde approaches in endodontic therapy.Endod Dent Traumatol 7:97-107,1991.

10. Kaplan SD, Tanzilli JP, Raphael D, Moodnik RD, et al: Acomparison of the marginal leakage of retrograde tech-niques. Oral Surg 54:583-85, 1982.

11. Bystrom A, Claesson R, Sundqvist G: The antibacterial ef-fect of camphorated paramonochlorophenol, camphoratedphenol and calcium hydroxide in the treatment of infectedroot canals. Endod Dent Traumatol 1:170-75,1985.

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