Journal of the Formosan Medical Association (2014) 113, 187e190

Available online at www.sciencedirect.com

journal homepage: www.jfma-online.com

CASE REPORT

Gingival and localized alveolar bone

necrosis related to the use of arsenic
trioxide pastedTwo case reports
Gin Chen a,b,c,*, Po-Ta Sung a

a
Division of Endodontics and Periodontics, Department of Dentistry,
Taichung Veterans General Hospital, Taichung, Taiwan
b
National Yang-Ming Medical University, College of Dentistry, Taipei, Taiwan
c
Chung Shan Medical University, College of Dentistry, Taichung, Taiwan

Received 20 January 2010; received in revised form 4 April 2010; accepted 21 July 2010

KEYWORDS The leakage of arsenic trioxide paste from tooth fillings has been associated with widespread
arsenic trioxide necrosis of the supporting periodontal tissues. This report describes two cases of arsenic trioxide
paste; paste-induced gingival and localized alveolar bone necrosis in the mandible, following the use of
devitalization; arsenic trioxide paste as a pulp-devitalized agent. The first case was a 54-year-old female com-
gingival necrosis; plaining of a painful white patch on the gingival tissue of the left mandibular second molar (tooth
decortication; #37) after treatment by a private dentist. She underwent completely debridement of all necrotic
root canal treatment soft tissue with physical saline irrigation. The gingival tissue was gradually replaced with vascular
tissue and completely healed after 7 weeks. The second case was a 30-year-old female complain-
ing of severe pain and continuous gingival bleeding from the right maxillary first bicuspid (tooth
#14) following treatment by a private dentist. She finally accepted debridement of the seques-
trum and necrotic alveolar bone with decortication to induce active bleeding. A partial thickness
gingival flap was made to cover the wound. Four weeks later, the supporting tissues had
completely healed. Arsenic trioxide paste is a cytotoxic agent and may cause harmful adverse
effects on adjacent periodontium and supporting hard tissue if leakage occurs, or it is used care-
lessly. There is no indication for the use of arsenic trioxide paste in modern dental practice.
Copyright ª 2012, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.

Conflicts of interest: The authors have no conflicts of interest

relevant to this article. Introduction
* Corresponding author. Division of Endodontics and Periodontics,
Department of Dentistry, Taichung Veterans General Hospital, 160, The use of arsenic trioxide in dental treatment was first
Taichung Kang Road, Section 3, Taichung 407, Taiwan.
advocated by Haly Abbas in the year of 1492.1 It was used to
E-mail address: kam@vghtc.gov.tw (G. Chen).

0929-6646/$ - see front matter Copyright ª 2012, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.
http://dx.doi.org/10.1016/j.jfma.2012.07.023
188 G. Chen, P.-T. Sung

devitalize inflamed pulps, a procedure claimed to be

painless, and was widespread during the years before
unreliable anesthetization.2,3 The utilization of arsenic
trioxide (arsenic anhydride) paste during root canal treat-
ment gives immediate pain relief, that led to its imprudent
use not only for pulp devitalization, but also for the
management of some uncertain discomfort such as dentin
hypersensitivity, or pulpotomy of the deciduous tooth.1 In
cases of acute symptomatic pulpitis, particularly in the
mandibular molar, where profound anesthesia was previ-
ously difficult to achieve because of technical or anatom-
ical problems, some dental clinicians used toxic
preparations such as paraformaldehyde, cresol or arsenic
paste to devitalize the inflamed painful pulp.4 Although
effective, the potential for leakage of those preparations is
unsafe in the palliative treatment of dental pain. The
continuous application of “devitalizing pastes” gradually
declined because of improvements in local anesthesia
techniques.5e9
This report describes two cases in whom arsenical pulp
devitalization was associated with significant gingival
injury, and adjacent alveolar bone necrosis. The leakage of
arsenic trioxide paste from an ill-fitting temporary resto-
ration needs to be highlighted and emphasized.

Case reports

Case 1 Figure 1 (A) Gingival necrosis with a white, crater-like lesion

A 54-year-old female visited the dental department asking
for advice and complained about a painful white patch that
was gradually getting larger on her lower left back gum. Her
personal history confirmed that she accepted dental
treatment in a local dental clinic on her lower left second
molar because of deep decay. The dental practitioner had
applied a “topical medication” and dressed tooth #37 with
an unknown paste during root canal treatment, because of
unsuccessful local anesthesia. Approximately 3 days later,
a white patch developed and continued to increase in size
whilst the gum began to feel tender. She called the private
dentist, but was told to take some analgesic with anti-
inflammatory drugs. However, the patient’s complaints did
not resolve. The patient came to our dental department
asking for further evaluation and management. Clinical
examination revealed a white, crater-like lesion about
1.0  1.5 cm2 in size, located on the interdental gingiva
between the mandibular left first and second molars (tooth
#36 and #37) (Fig. 1). The underlying alveolar bone was
exposed and the gingival tissue was grayish-white in color
and surrounded with reddish, blunt, rolled-liked soft tissue.
The patient suffered severe pain during chewing and
palpation. Furthermore, no probing bleeding from the
exposed bone was noted. Marginal gingival recession of
tooth #36 and tooth #35 was also found. The mesio-occlusal
cavity of tooth #37 was filled with white color temporary
filling material, but was not intact. After removal of the
temporary filling, a piece of cotton pellet saturated with
black arsenic-like paste was packed inside and the mesio-
gingival floor of the cavity was exposed. A periapical
radiograph revealed incomplete root canal treatment of
tooth #37, whilst subgingival root decay beneath the distal
at the interdental papilla between teeth #36 and #37; and (B)
X-ray reveals angular bone loss.
crown margin of tooth #36 was also noted. A periradicular
lesion was also suspected. Previous root canal treatment
with chronic apical periodontitis of tooth #37 was diag-
nosed. Medical and family history did not contribute.
Further management included the debridement of all
necrotic soft tissue and copious irrigation with physical
saline after 2.0% xylocaine local anesthesia. Oral amoxi-
cillin (500 mg) and 200 mg metronidazole were given every
8 hours for 7 days. Additionally, the patient was prescribed
50 mg Voren as an analgesic and 0.12% chlorhexidine
gluconate as a mouthwash twice a day for 7 days. The
patient was recalled after 1 week to evaluate tissue heal-
ing. Two weeks later, secondary tissue healing of the
interdental region was observed and the superficial
necrotic bone was gradually replaced with vascular tissue.
The gingiva tissue was completely healed after 7 weeks
(Fig. 2). During this period, root canal treatment of the C-
shaped tooth #37 was completed under rubber dam
protection.
Case 2
A 30-year-old woman first visited our dental department
complaining of severe pain and continuous gingival bleeding
from her right maxillary first bicuspid (tooth #14) following
root canal treatment by a private dentist 2 weeks earlier.
Clinical examination revealed a subgingival cavity and
a marked area of necrosis of the interdental papilla at the
mesial surface of tooth #14. The palatal mucosa was also
Arsenic trioxide related to tissue necrosis
Figure 2 (A) Secondary healing with vascular soft tissue; and
(B) X-ray reveals angular bone healed.
involved, with exposure of alveolar bone which was white
in color (Fig. 3). The tooth had a large mesio-occlusal cavity
sealed with white color temporary restoration. Periodontal
probing showed a 5.0 mm pocket mesially, with ease of
bleeding on probing. The periapical radiographic examina-
tion indicated a 0.8 mm crater with horizontal bone loss
located between the right maxillary canine and the first
bicuspid. Previous dental history revealed the patient
initially felt continuous pain on chewing of tooth #14 with
mild mobility. There was a deep carious lesion with pulpal
involvement detected. A diagnosis of irreversible pulpitis
with acute apical periodontitis was made. Medical and
family history did not contribute. The private dentist per-
formed root canal therapy. Due to extreme pain during
access preparation caused by ineffective anesthesia, the
patient was told to apply the pulp devitalizing paste at that
time. It was later confirmed (by phone) that it was an
arsenic trioxide paste. A few days later, she subsequently
suffered severe pain and swelling which gradually extended
to the gingival region. She returned to her private dentist,
but only oral antibiotics were prescribed. However, she did
not feel any improvement in her symptoms. She decided to
visit our dental department asking for emergency
Figure 3 (A) Gingival and adjacent alveolar bone necrosis
between teeth #13 and #14; and (B) X-ray reveals a 5-mm-deep
pocket of mesial bone loss.
189
management and further evaluation of the problem, as she
could not tolerate the severe continuous pain and gingival
bleeding. After 2.0% xylocaine local anesthesia was
administered, the temporary filling of tooth #14 and the
arsenic paste was completely removed with copious irri-
gation using physiological saline. The sequestrum and the
necrotic alveolar bone between tooth #13 and tooth #14
were removed using a long shank surgical number 4 carbide
round bur with decortication to induce active bleeding. The
wound was irrigated with copious betadine and physiolog-
ical saline, and finally dressed with Coe-Pak (GC America
INC, Alsip, IL, USA). The access cavity was filled with
Intermediate Restorative Material (IRM) (Dentsply,
Romulus, MI, USA). The patient was prescribed with 500 mg
oral amoxicillin and 200 mg metronidazole for 7 days,
together with 50 mg Voren as an analgesic and 0.12%
chlorhexidine mouth rinsing solution twice a day for 7 days.
One week later, a partial thickness gingival flap from the
adjacent tooth was made and rotated to cover the wound
defect without tension, after the necrotic bone had been
thoroughly debrided and cleansed. The patient was recal-
led after 1 week and thereafter at 3-weekly intervals after
the supporting tissues had completely healed. Root canal
treatment was completed 1 month later (Fig. 4). The cavity
was then filled with IRM temporary cement. The patient
was advised to have a gingival graft before crown restora-
tion, but was denied because of financial problems. The
tooth was finally restored with composite resin material.
Discussion
In the past, effective anesthesia was unavailable and less
reliable for patients with extremely painful teeth or unco-
operative patients. The use of arsenical based preparations
as devitalizing agents prior to pulp extirpation during
dental treatment, became an important practice.2,4,10
Nevertheless, cases of arsenic-related tissue necrosis are
occasionally reported, especially in some developing
countries.8,10,11,13
Arsenic trioxide is a protoplasmic poison and the
resulting tissue necrosis should be due to direct chemical
irritation.8,12 Tissue damage has been reported in many
articles and the adverse effects of most of these reports
concern the incorrect use of the arsenical paste.3,5e8 The
two cases in our report emphasize the leakage of the toxic
agents into the periodontal supporting tissue, due to deep
subgingival decay and inadequate temporary restoration.
The second case in our report required surgical treatment
to remove the necrotic alveolar bone and sequestrum in
order to maintain the circulation of the supporting tooth
structure.
Some reports pointed out that arsenic trioxide could
induce allergic reactions. Patients who were already
sensitized might experience anaphylactic episodes from
a tooth filling, a major complication during dental treat-
ment. It has been highlighted that arsenic trioxide might
have carcinogenic or mutagenic properties.1,5,8
This toxic and carcinogenic agent should be applied in
close contact with the exposed pulp tissue of a tooth for
a maximum period of 2 weeks.12 To prevent harmful irri-
tation and severe damage to the supporting tissue during
190
Figure 4 (A) The gingival tissue was healed but tissue
recession was noted; and (B) X-ray showed the root canal was
completed at the 1-month follow-up.
dental treatment, temporary restoration should be intact.
Therefore, the treated tooth should be covered with
a cotton pellet and meticulously sealed with zinc-oxide
eugenol temporary restoration to prevent leakage and
soft tissue irritation. Scientific research has proven that
there are many safe and effective intracanal medications
and root canal filling materials. It is our suggestion that in
order to maintain the highest quality of care in a dental
practice, clinicians should actively support the use of safe
and effective materials in dental treatment.
In all cases of arsenic-induced tissue necrosis, tissue
debridement and sequestrectomy with decortication is the
only treatment option. Although attached gingiva and
alveolar bone loss cannot be avoided, further dental
treatment should be considered and advised.5,6,8,10,13
In conclusion, arsenic trioxide may cause harmful
adverse effects on adjacent periodontium and supporting
hard tissue if leakage occurs or is used carelessly. As well as
the systemic repercussions discussed above, it is suggested
G. Chen, P.-T. Sung
that there are no longer indications to use arsenic trioxide
in contemporary dental practice. Their continued and
unjustified use must be condemned.
References
1. Curse WP, Bellizzi R. A historic review of endodontics. 1689-
1963, part I. J Endod 1980;6:495e9.
2. Glass MM. Acute periapical necrosis from arsenical pulp devi-
talizer. Case report. Oral Surg Oral Med Oral Pathol 1957;10:
216e9.
3. Smart ER, Barnes IE. Tissue necrosis after using an arsenical
endodontic preparation: a case report. Int Endod J 1991;24:
263e9.
4. Di Felice R, Lombardi T. Gingival and mandibular bone necrosis
caused by a paraformaldehyde e containing paste. Endod and
Dent Traumatol 1998;14:196e8.
5. Batained AB, Alomari MA, Owais AL. Arsenical necrosis of jaws.
Int Endod J 1997;30:283e7.
6. Ozmeric N. Localized alveolar bone necrosis following the use
of an arsenical paste: a case report. Int Endo J 2002;35:295e9.
7. Yavuz MS, Kaya GS, Yalcin E, Aras MH. Mandibular bone necrosis
caused by use of arsenic paste during endodontic treatment:
two case reports. Int Endod J 2008;41:633e7.
8. Garip H, Salih IM, Sener BC, Göker K, Garip Y. Management of
arsenic trioxide necrosis in the maxilla. J Endod 2004;30:
732e6.
9. Yalcin S, Aybar B, Haznedaroglu F, Yücel E. Bilateral oroantral
fistulas following devitalization of teeth by arsenic trioxide:
a case report. J Endod 2003;29:205e7.
10. Yakata H, Azumi T, Kawasaki T, Nakajima T. Extensive osteol-
ysis of the mandible following devitalization of a tooth by
arsenic trioxide. J Oral Maxillofac Surg 1985;43:462e6.
11. Ozgoz M, Yagiz H, Cicek Y, Tezel A. Gingival necrosis following
the use of paraformaldehyde containing paste: a case report.
Int Endod J 2004;37:157e61.
12. Hughes MF. Arsenic toxicity and potential mechanisms of
action. Toxicol Lett 2002;133:1e16.
13. Dumlu A, Yalcinkaya S, Olgac V, Güvercin M. Osteomyelitis due
to arsenic trioxide use for tooth devitalization. Int Endod J
2007;40:317e22.