Pulpal and periodontal effects of electrosurgery

involving cervical metallic restorations

Paul B. Robertson, * Bernhard Ldscher,* Larz S. Spangberg,* and
Barnet M. Levy, ** Farmington, Conn., and Houston, Texas

UNIVERSITY OF CONNECTICUT HEALTH CENTER, SCHOOL OF DENTAL MEDICINE AND

DENTAL SCIENCE INSTITUTE, THE UNIVERSITY OF TEXAS DENTAL BRANCH

The pulpal and periodontal effects of electrosurgery involving teeth restored with Class V cervical
amalgams and nonrestored teeth were evaluated in three cynomolgus monkeys. Electrosurgical
current was delivered for I second with a fully rectified unit zit an output intensity consistent h
normal clinical usage. Experimental conditions included electrosurgery involving restored teeth,
electrosurgery involving unrestored enamel, restored teeth not subjected to electrosurgery, and teeth
which were neither restored nor subjected to electrosurgery. No pulpal or periodontal tissue changes
were observed in the latter three groups of teeth. Electrosurgery involving cervical restorations
consistently resulted in coagulation necrosis of the pulp and extensive resorption of cementum,
dentin, and interradicular bone in the furcation area of multirooted teeth. The results suggest that
inadvertent contact with cervical restorations during electrosurgical procedures may endanger both the
pulp and the periodontal attachment apparatus.

1Gi
Lalectrosurgery has been suggested as a sate, rapid, hemostatic technique for a wide
range of dental procedures." Clinical applications include resection of tissue to facilitate
exposure and restoration of subgingival caries, elongation of clinical crowns, preparation of
subgingival troughs for margin placement and impression, and management of osseous and
furcation involvement associated with periodontal disease.4-7 While healing of soft tissue
following electrosurgical incisions appears to be compatible with that of con-
ventional surgery," the reported effects of electrosurgery on alveolar bone vary from
complete resolution in the absence of tissue damage"-" to delayed healing, necrosis, and loss
of attachment.12-15 Little information is available with respect to electrosurgical effects
on dental pulp. Histologic examination of dog pulps revealed normal conditions following
the use of electrocoagulation current in combination with procedures recom-

*Departments of Periodontics and Endodontics, University of Connecticut Health Center, School of Dental
Medicine, Farmington, Conn.
**Dental Science Institute, The University of Texas Dental Branch, HOUSt011, Texas.

702 0030-4220/78/110702+09800.90/0 © 1978 The C. V. Mosby Co.

Volume 46
Number 5 Electrosurgery involving metallic restorations 703

mended for desensitization of hypersensitive dentin." Application of high current for

prolonged periods did elicit severe tissue destruction of the dental plup of rhesus
monkeys.'
Many of the suggested electrosurgical procedures involve metallic restorations which
..,al
are placed l into d--*;-. Accordingly, the present investigation •Vvas designed to evalu-
ate the effects on pulp and periodontal attachment apparatus following application of
electrosurgical current to restored and nonrestored teeth.

METHODS AND MATERIALS

Three adult cynomolgus (Macaca fascicularis) monkeys with intact dentitions and
minimal occlusal attrition were chosen for the investigation. All monkeys displayed a
mild-to-moderate generalized gingivitis, but no attachment loss relative to the cemento-
enamel junction was noted, and probing revealed that all furcations were intact.
Cervical Class V preparations were established with a water-cooled high-speed hand-
piece in twenty incisors, premolars, and molars of each monkey under phencyclidine-
acepromazine anesthesia. Amalgam restorations using Spherical Alloy (L. D. Caulk Co.,
Milford, Del.) were placed without base and carved. The final restorations were 3 mm. in
diameter and extended apically to the level of the gingival margin. The remaining anterior
nnd pr,stPri,Ir tPPth were not restorer].
Six weeks after restoration placement, the experimental protocol was initiated to form
four groups of teeth: (1) electrosurgery of restored teeth, (2) electrosurgery of nonrestored
teeth, (3) restored teeth not subjected to electrosurgery, and (4) teeth neither restored nor
subjected to electrosurgery.
Electrosurgery was accomplished with a Strobex S-200 (Whaledent Inc., New York,
N. Y.) at a dial setting between 4 and 5, which corresponded to an output power of 20 to
25 W against a 750-ohm dummy load. The indifferent plate was utilized for all elec-
trosurgery procedures. The dial settings were chosen for each monkey such that a clean
incision could be made in the palate or buccal mucosa without sparking occurring, tissue
charring, or shreds of tissue adhering to the electrode. In the first two groups, the elec-
trosurgery unit was activated in the "cut" mode, and the tip of a single wire electrode was
passed lightly over the amalgam (Group 1) or corresponding area of enamel (Group 2).
The duration of electrosurgical current never exceeded 1 second, and the tip rarely made
dirp•r ,nnt.,r with arljnpAnt enft ticcile At nr, time wa. the tip allowed to enter the gingival
sulcus or approach alveolar bone.
Teeth with cervical amalgams in Group 3 were not subjected to electrosurgery, and
they served, with unrestored teeth in Group 4, as controls for amalgam placement or tissue
changes which might result from fixation, decalcification, and sectioning.
All procedures were accomplished 8 weeks, I week, and 24 hours prior to sacrifice by
barbiturate overdose. The jaws were immediately removed by dissection and placed in
neutral buffered formalin. Within 1 hour, the teeth were grossly blocked with a water-
cooled diamond saw and re-immersed in formalin to achieve rapid pulpal fixation. All
blocks were coded, and subsequent processing and evaluation were conducted without
knowledge of which experimental group the tooth represented.
The blocks were decalcified in sodium citrate—formic acid. Amalgam fillings were
removed where appropriate, and the specimens were paraffin embedded. Serial sections of
5 gm thickness were cut in an axiobuccolingual direction to include cavity preparations
 Oral Surg.
704 Robertson et al.
November, 1978

I•
• ;1

v
1 0 .. 4 ,
•

Ili ,IONA

'S , ' ' / • '

,W • ,
• , , -•
er • IN 7

. t ..i :•`- Nit . !`.f■ 1

Fig. 1. Control of cavity preparation technique and amalgam placement. Observation period, 8 weeks. Pulp
tissue immediately under cavity normal without pathologic tissue changes. (Hematoxylin and eosin stain.
Magnification, x135 and x550; reduction, 35 percent.)

and pulp, and the sections were stained with hematoxylin and eosin. The pulpal and
periodontal tissues of thirty-six teeth in Group I, twenty-one teeth in Group 2, twelve
teeth in Group 1, and twelve teeth in Group 4 were evaluated histologically and represen-
tative areas photographed.

RESULTS

Teeth which had not been subjected to electrosurgery (Groups 3 and 4) showed normal
pulp tissue as illustrated in Fig. 1. The odontoblastic layer was well organized without
disruption or reduction in cell numbers. No accumulation of inflammatory cells was
observed in the odontoblastic layer or adjacent pulp tissue. Isolated areas of secondary
dentin formation were occasionally seen relative to the cavity preparations. The pulpal
extent of all cavity preparations was less than one third of the distance from the dentino-
enamel junction, and no pulpal exposures were noted. A mild, primarily lymphocytic
inflammatory infiltrate was present in the gingival lamina propria, but no apical migration of
sulcular epithelium was apparent. Furcation areas were intact, with a dense arrange-
ment of periodontal ligament fibers between alveolar bone and cementum.

4
Volume 46
Number 5
Electrosurgery involving metallic restorations 705

r•
silt.
-
• . .........
•

1••
• • •
44
•

Fig. 2. Pulp tissue under amalgam filling 24 hours after electrosurgery. Pulp tissue coagulated with poor
preservation of tissue details. Bleeding in the tissue which can be seen to the right in A and B. Note coagulated
vessel in B. (Hematoxylin and eosin stain. Magnification, x550; reduction, 35 percent.)

Puipal and periodontai &qui"( of teeth which had receiver) electrocurgicai current on
unrestored areas of enamel (Group 2) were also normal at all time periods, and no changes in
the odontoblastic layer, adjacent pulp tissue, gingiva, or attachment apparatus were
observed.
Without exception, teeth which had been subjected to brief application of electrosurgi-
cal current on cervical restorations showed major damage to both pulp and periodontal
tissues. At 24 hours (Fig. 2), disruption of puipal tissue consistent with coagulation
necrosis was observed adjacent to the restoration. By I week (Fig. 3), the corona! portion of
the pulp chamber was necrotic, and a well-defined zone of demarcation was observed
between necrotic and apparantly vital pulp tissue. Isolated areas of necrosis and miner-
alized tissue resorption were also noted in the furcations of multirooted teeth. Such
changes, however, were not observed in single-rooted teeth.
At 8 weeks (Fig. 4), necrosis involved the entire pulp of most teeth to the extent that, in
many cases, all pulp tissue structure was lost during histologic preparation. In no
 Oral Surg.
706 Robertson et al. November, 1978

Fig. 3. Pulp tissue under amalgam filling 1 week after electrosurgery. Hematoxylin and eosin staining. A, Filling
.
located in the region indicated ..7 I . I. The PIP W.,11./ti, With 1G lllll ant3 Of cAkIlaive bleeding. Demarca-
tion zone between vital and necrotic tissue at 2. (Magnification, x60; reduction, 44 percent.) B, Section from area
3 in A. Note remnants of extensive hemorrhage. (Magnification, x 135; reduction, 44 percent.) C, Section from
area 4 in A. Coagulation of vessels and tissue. (Magnification, x 135; reduction, 44 percent.) D, Section from
area 5 in A. Tissue coagulated with poor preservation of tissue morphology. Dark area is the remnants of
excessive bleeding in the tissue. (Magnification, x 135; reduction, 44 percent.) E, Section from area 6 in A.
Demarcation zone between coagulated necrotic tissue and vital pulp. (Magnification, x135; reduction, 44
percent.) F, Section from area 7 in A. Vital pulp tissue with well preserved tissue structure. (Magnification,
x 135; reduction, 44 percent.)
Volume 46
Number 5
Electrosurgery involving metallic restorations 707

k7.

Fig. 4. Results of electrosurgery on pulp and periradicular tissues 8 weeks after treatment. Hematoxylin and
eosin staining. A, Overview of furcation area of molar. The pulp is necrotic and disintegrated (P). Granulation
tissue in the furcation area (F) with extensive resorption of dentin (R). (Magnification, x 55; reduction, 47
percent.) B, Detail of furcation area in A and resorption of dentin. The granulation tissue is heavily infiltrated by
polymorphonucleated leukocytes. (Magnification, x 135; reduction, 47 percent.) C, Detail of pulp tissue rem-
nants in A. The tissue is necrotic with total loss of structure. A few polymorphonucleated leukocytes can be seen on
the surface of the tissue remnants. (Magnification, x 550; reduction, 47 percent.) D, Detail of tissue located in the
dentin resorption area in B. Dense infiltration of polymorphonucleated leukocytes. The dentin lined with
dentinoclasts, indicating an active resorption. (Magnification, x 550; reduction, 47 percent.) E, Detail of tissue in
the furcation area (arrows in A). "I'"n cbone is lined with osteoclasts, indicating an active bone resorption.
(Magnification, x550; reduction, 47 percent.)
 708 Robertson et al. Oral Surg.
November, 1978

Fig. 5. Result of electrosurgery on periapical tissues 8 weeks after treatment. Same case as Fig. 4. (Hematoxylin
and eosin staining throughout.) A, Overview of periapical area. Extensive bone resorption and formation of
granulation tissue. Apical foramen (arrows) is opened by resorption. Root canal cannot be seen due to plane
sectioning. (Magnification, x55; reduction, 47 percent.) B, Detail of apical foramen. Active root resorption.
Tissue with dense infiltration of inflammatory cells. (Magnification, x 550; reduction, 47 percent.) C, Detail of
root resorption in the apicn1 area Numerous maltinorqp.rpri calls in c.nrnt.m ,indicating arrives res^rptive
process. (Magnification, x 550; reduction, 47 percent.) D, Detail of bone resorption in the periphery of granula-
tion tissue. The bone is lined with osteoclasts, indicating ongoing bone resorption. (Magnification, x 550;
reduction, 47 percent.) E, High-power magnifications of granulation tissue found in periapical area. Dense
accumulation of polymorphonucleated leukocytes. (Magnification, x 550; reduction, 47 percent.)
Volume 46
Number 5 Electrosurgery involving metallic restorations 709

instance was there evidence of resolution or repair. Extensive resorption of dentin was
apparent in furcation areas associated with a dense accumulation of polymorphonuclear
leukocytes. Loss of periodontal ligament and osteoclastic resorption of interradicular bone
was a common finding in multirooted teeth. Periapical areas of several teeth were in-
volved, with circumscribed formation eIf granulation tissue and resorption of cementum,
dentin, and bone (Fig. 5). As in earlier time periods, the attachment apparatus of single-
rooted teeth was unaffected.

DISCUSSION
The results suggest that electrosurgical procedures involving cervical metallic restora-
tions contiguous with dentin effect major damage to pulpal and periodontal tissues.
Neither coagulation necrosis in the pulp and subsequent formation of a periapical granu-
loma nor initiation of a similar process in furcation areas with resultant interradicular bone
resorption would necessarily lead to postoperative discomfort. Interpretation of minor
pain reported might well be masked by prosthetic or periodontal instrumentation of the
tooth accomplished at the same time as electrosurgical procedures. This general lack of
postoperative clinical pain would appear to have prompted the assumption by a number of
authors that electrosurgical contact with metallic restorations does not damage either the
pulp or periodontium. In those cases in which postoperative sequelae were reported, the
results have been discounted in favor of operator inexperience, prolonged duration of
activated electrode contact, artificially high current intensities, and direct application to
alveolar bone.
The investigators in the present study have substantial experience with electrosurgery in
a variety of prosthetic and periodontal procedures. The duration of electrode contact was
intentionally kept to a minimum and, in fact, was far less than the period necessary for
visualization of cervical margins or resection of adjacent soft tissue. The current
intensity was compatible with that necessary to achieve clean incisions without charring or
tissue adherence and was well within ranges ordinarily used for clinical procedures. Great
care was taken to prevent direct contact with adjacent tissue, and at no time did the tip
approach, much less make direct contact with, alveolar bone. The Strobex S-200 is a
single-circuit, fully rectified and filtered unit which provides continuous-wave current in the
cutting mode. Under these conditions, electrosurgical contact with unbased amalgams
consistently resulted in pulpal necrosis and eventual complete devitalization and in some
cases was associated with formation of periapical lesions. In multirooted teeth, such
contact was accompanied by exposure of the furcation and active resorption of alveolar
bone.
This tissue damage did not appear to be the result of high temperature transmitted
through dentin to the pulp. Langeland" has elegantly described pulpal changes subsequent to
a dentinal burn. These changes, including marked darkening of surface dentin, odon-
toblast nuclei and erythrocytes in tubules, and focal collection of polymorphonuclear
leukocytes in the odontoblast layer, were not consistent with the generalized coagulation
necrosis observed following electrosurgery. No dentinal burns or associated discoloration
were noted, nor were odontoblast nuclei observed in dentinal tubules. It is likely that
pulpal necrosis was a result of transmission of the electrosurgical current through the
dentin interposed between the amalgam and pulp chamber. Extension of current through
 Oral Surg.
710 Robertson et al. November, 1978

the thin dentinal wall overlying the furcation in multirooted teeth is also reasonable,
particularly since alveolar bone of restored single-rooted teeth was not affected. Loss of
periodontal attachment in later stages may also have reflected necrotic changes in the pulp.
Three major considerations with respect to the present investigation should be noted.
ntact
First npplien tinn of PlPotrnsiirrry to i enamel had nn nnlnal nr perindnntni pnctnp-
erative sequelae. Second, the cervical restorations involved were placed directly on dentin
without an intervening base. The ability of a base to preclude pulpal damage requires
further investigation. Finally, the consistency of the results strongly' suggests that elec-
trosurgery adjacent to cervical metallic restorations involves substantial risk of irrevocable
damage to both the pulp and the periodontium.

REFERENCES
I. Oringer, M. J.: Electrosurgery in Dentistry, ed. 2, Philadelphia, 1975, The W. B. Saunders Company.
2. Malone, W. F.: Electrosurgery in Dentistry. Theory and Application in Clinical Practice, Springfield, 1974,
Charles C Thomas, Publisher.
3. Harris, H. S.: Electrosurgery in Dental Practice, Philadelphia, 1976, The J. B. Lippincott Company.
4. Malone; W.; and Manning; J.: Electrosurgery in Restorative Dentistry. J. Prosthet. Dent. 20: 417-425.
1968.
5. Nuckles, D.: Electrosurgery as an Aid to Crown and Bridge Procedures, J. S. C. Dent. 30: 7-11, 1972.
6. Oringer, M.: Electrosurgery for Definitive Conservative Modern Periodontal Therapy, Dent. Clin. North
Am. 13: 53-73 1969.
7. Klug, R. G.: Gingival Regeneration Following Electrical Retraction, J. Prosthet. Dent. 16: 955-962, 1966.
8. Eisenmann, D., Malone, W., and Kusek, J.: Electron Microscopic Evaluation of Electrosurgery, ORAL
SURG. 29: 660-665, 1970.
9. Aremband, D., and Wade, A.: A Comparative Wound Healing Study Following Gingivectomy by Eiec-
trosurgery and Knives, J. Periodontal Res. 8: 42-50, 1973.
10. Schieda, J., DeMarco, T., and Johnson, L.: Alveolar Bone Response to Electrosurgical Scalpel, J.
Periodontol. 43: 225-232, 1972.
11. Schneider, A., and Zaki, A.: Gingival Wound Healing Following Experimental Electrosurgery. A Light
Microscopic and Macroscopic Investigation, J. Periodontol. 45: 459-467, 1974.
12. Pope, J., Gargiulo, A., Steffileno, H., and Levy, S.: Effects of Electrosurgery on Wound Healing in Dogs,
Periodontics 6: 30-'i7,
13. Glickman, I., and Imber, T.: Comparison of Gingival Resection with Electrosurgery and Periodontal
Knives. A Biometric and Histologic Study, J. Periodontol. 41: 142-148, 1970.
14. Simon, B. I., Schuback, P., Deasy, M. J., and Kelner, R. M.: The Destructive Potential of Electrosurgery
on the Periodontium, J. Periodontol. 47: 342-347, 1976.
15. Wilhelmsen, N. R., Ramfjord, S. P., and Blankenship, J. R.: Effects of Electrosurgery on the Gingival
Attachment in Rhesus Monkeys, J. Periodontol. 47: 160-170, 1976.
16. Harrison, J. D.: Histologic Reaction of the Vital Pulp to Electrosurgical Desensitization. In Oringer, M. J.:
Electrosurgery in Dentistry, ed. 2, Philadelphia, 1975, The W. B. Saunders Company, pp. 177-182.
17. Agnew, R. G., and Kaiser, W. F.: Effects on the Dental Pulp of the Macacus Rhesus of Externally Applied
High Frequency Electro-Surgical Currents, International Association of Dental Research, 30th Meeting,
1952, Abstract No. 105.
18. Langeland, K.: Tissue Changes Incident to Cavity Preparation, Acta Odontol. Scand. 19: 397-430, 1961.

Reprint requests to:

Dr. Paul B. Robertson
University of Connecticut Health Center
School of Dental Medicine
Farmington, Conn. 06032