Endod Dent naumatot 1995: 9: !2O-123 Printed in Denmark . At!

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Munksgaard

1993

Endodontics & Dental Traumatology

ISSN 0109-2502

Case report

Long-term retention of a paper point in the periapicai tissues: a case report

Sedgley CM, Messer HH. Long-term retention of a paper point in the periapicai tissues: a case report. Endod Dent Traumatol 1993; 9: 120-123. Munksgaard, 1993. Abstract - A case is reported of a 15 mm paper point found in the periapicai area of a maxillary right central incisor during endodontic surgery for an unresolved periapicai radiolueeney. The paper point had been present for between five and nine years. Histopathological examination showed the presence of chronically inflamed fibrous connective tissue with a number of foreign body giant cells and focal collections of chronic inflammatory cells. SEM comparison of the specimen with a similarly treated fresh paper point showed no indication of degradation of the paper point by host defense cells. Paper points are routinely used during endodontic therapy. Reports of paper points being pushed through the apical foramen into the periapicai tissues are rare. White (1) reports a case where a 4 mm section of paper point that had been soaked in medicament and was forced apically required surgical removal to alleviate the resulting burning sensation. More recently, the frequent presence of cellulose fibers in periapicai biopsies from cases with a history of pre\aous endodontic therapy has been confirmed (2, 3). Fragments of endodontic paper point are implicated as the source of the cellulose fibers and are considered to be an etiologic factor in postendodonlic inflammatory processes (2, 3). The introduction of vegetable materials into the body can cause a foreign body reaction. An example is the periapicai pulse granuloma which is associated with teeth where the root canal has been open at some stage (4-6). Histopathological features consist of a connective tissue stroma containing variable nun^bers of inflaniTnatory cells and foreign-body giant cells surrounding fragments of legume seeds. The etiology of foreign body reactions to legumes has been traced to their cellulose moiety (7). Cellulose is a very stable polysaccharide forming the cell walls of plants, and consists of long chains of glucose units in the beta configuration joined together by 120 C. M. Sedgley, H. Messer
Royal Dental Hospital, Melbourne, School of Dental Science, University of Melbourne, Australia.

Key words: cellulose; foreign body; paper point; periapicai lesion. H. H. Messer, School of Denfai Science. 711 Eiizabefh Sfreef, Melbourne 3000, Ausfralia. Accepfed toi publicafion Ocfober 10, 1992

1,4-linkages. It is not digested to any significant extent by man since the digestive tract does not contain the enzyme cellulase (8). In addition, human and animal defense systems appear unable to break dow^n cellulose, resulting in a long lasting granulomatous response (7). In the case to be described, a large-diameter essentially intact paper point of 15 mm length was unexpectedly found in the periapicai tissues of a maxillary central incisor tooth during periradicular surgery. Case repert A 22-year-old Vietnamese man was referred to the Endodontic Unit of the Royal Dental Hospital of Melbourne for evaluation and treatment of the maxillary incisors. The patient recalled commencing endodontic treatment to the maxillary central incisors in Vietman nine years previously and treatment was completed four years later in Australia. The patient reported periodic episodes of discomfort, swelling and drainage from the buecal sulcus above the right central incisor for many years. On examination, the maxillary anterior teeth were heavily restored with composite resin, with recurrent caries present around the restora-

Paper point in periapicai tissues tions of the lateral incisors. The buecal suleus above the right central and lateral incisors was tender to palpation and the right central incisor was slightly tender to percussion. The lateral incisor teeth tested non-vital to carbon dioxide. A radiograph showed periapicai radiolucencies in association with the maxillary incisor teeth and the presence of filling material in the root canals of the central incisors (Fig. 1). Routine orthograde endodontic therapy was performed on the lateral incisors. During retreatment of the left central incisor no apical stop could be obtained with an intracanal instrument #140 at the established working length of 18.0 mm from the incisal edge. As the patient was not willing to undergo apexification procedures the canal was obturated with gutta pereha and AH26 sealer cement (DeTrey, Zurich, Switzerland) using lateral condensation, followed by periradicular surgery. A full mucoperiosteal flap was raised using two vertical releasing incisions. During periapicai eurettage. a relatively intact paper point about 15 mm in length was removed from the periapieal area of the left central incisor. Periradicular eurettage, apical bevelling and cold burnishing of the gutta pereha were completed, and the flap replaced and sutured. Healing proeeeded uneventfully, and a \2-month review showed clinical and radiographical evidence of periradicular healing despite less than ideal restorations (Fig. 2). The paper point (which was remarkably free of adherent tissue) (Fig. 3) was fixed in 10% neutral buffered formalin and divided into two parts. One portion was embedded in paraffin and sectioned, then stained with haematoxylin and eosin and viewed under a light microscope. The other was processed for scanning electron microscopy. For comparative purposes, a fresh intact paper point was identically treated and examined. Light microscopic examination of the specimen showed fragments of foreign material of a fibrillar)' nature (Fig. 4) resembling the cellulose fibers described by Koppang et al. (2, 3). The fibers appeared as longitudinal and rounded or kidneyshaped transversal sections of weakly basophilic or translucent, birefringent foreign bodies with an occasional narrow central canal. The soft tissue consisted of necrotic cell debris as well as small fragments of chronically inflamed fibrous connec-

Fig. 1. Pre-operative radiograph of maxillary indsor region. Fig. 2. Recall radiograph 12 months after endodontic treatment and periapicai surgery. Extensive bony regeneration has occurred.

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Sedslev & iWesser

Fig. 3. Clinical p g p photograph ((with mm scale) of paper point removed from the periapica! area of the left central incisor. g ne (x Fig. 4. Routine H&E section ( 100) of portion of the paper point, showing cellulose fibres surrounded by necrotic cell debris and some chronic inflammatory cells. Fig. 5. SEM view of the paper point, showing intact cellulose fibers (white b a r = 1 mm). bar= Fig. 6. Higher power SEM i w of iintact cellulose fib f lll ) fibers { h i t b = 0 1 mm). {white bar 0.1

tive tissue containing a number of foreign body giant cells and focal collections of chronic inflammatory cells. Scanning electron microscopic examination showed that the paper point fibers were undegraded and interspersed with erythrocytes and round cells (Figs. 5 and 6). 122

Discussion The technique of intentionally sealing a medicament-soaked paper point in the root canal as an interappointment dressing wa^ described by Stewart in 1957, (9) and appears in a recent endodontic

Paper peint in periapicai tissues textbook (10). One problem with this technique occurs when the diameter of the apical foramen exceeds that of the paper point, with the potential to dislodge the point through the apieal foramen and into the periapicai tissues. In this case it appears that the paper point was inadvertently pushed through the wide apical foramen at a subsequent appointment, perhaps four years later. Koppang et al. (1989) describe postendodontic periapicai lesions as frequently displaying a foreign body reaction, and implicate paper point fragments in the induction of apical granuloma and cyst development (2, 3). Cellulose is not degraded in the body and is known to initiate a foreign body reaction (7). However, in this case it is also possible that periapicai infection of adjacent teeth contributed to the patient's presenting symptoms. Therefore it is impossible to implicate the paper point as the sole contributory factor to the persistence of the lesion. The presence of the still intact paper point after a minimum of five years in the periapicai tissues dramatically demonstrated the absence of cellulase activity in human defense cells. References
1. WHITE E . Paper point in mental foramen. Report of a case. Oral Surs 1968; 25: 630-2.
2. KOPPANG H S , KOPPANG R , SOLHEIM T, AARNES H , STOLEN

SO. Identification of cellulose fibers in oral biopsies. Seand J Dent Rti l%il\ 9S: 165-73.
3. KOPPANG HS, KOPPANG R , SOLMEIM T , AARNES H , STOLEN

SO. Cellulose fibers from endodontic paper points as an etiological factor in postendodontic periapicai granulomas and cysts. J Endoion 1989; 15: 369-72.
4. MINCER HH, MCCOY J M , TURNER j E . Pulse granuloma of

the alveolar ridge. Oral Smg 1979; 4S: 126-30.

3. SIMON JHS, CHIMENTI RA, MINTZ GA. Clinical significance

of the pulse granuloma. J Endodon 1982; 8: 116-9. 6. TALAGKO AA, RADDEN B G . Orai puise granuloma: clinical and histopathological features. A review of 62 cases. Int J Oral Maxilbfac Surg 1988,- 17: 343-6. 7. KNOBLICH R . Pulmonary granulomatosis caused by vegetable particles. So-cajled lentil pulse pneumonia. Am Rev Respir Dis 1969; 99: 380-9.
8. BELL G H , EMSLIE-SMITH D, PATERSON CR. Textbook of

physiology and biochemistry. 9th ed. Edinburgh: Churchill Livingstone, 1976; 30. 9. STEWART G G . Rational root canal medication. Dent Clin jV" Am 1957; .November: 823-34.
10. GROSSMAN LI, OLIET S , D E L RIO CE. Endodontic practice.

11th ed. Philadelphia: Lea and Febiger, 1988; 230-2.

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