ENDODONTIC IMPLICATIONS OF A

PATIENT WITH ARTERIOVENOUS

MALFORMATION: A CASE REPORT AND
LITERATURE REVIEW
A. CHAWLA ET AL IEJ 2021

SHIVANGI JAIN
FIRST YEAR PG
AV Malformation
Arteriovenous malformations (AVMs) are rare vascular
lesions that can be life-threatening due to potential
massive hemorrhage.
AVMs can be subdivided according to the type of vessel
involved (capillary, venous, and arterial) or according to
hemodynamic features, into high-flow and low-flow lesions.
Oral Manifestation
Clinical signs and symptoms of AVM may include:
 pain
erythematous gingiva
spontaneous gingival bleeding – most common clinical sign
resorption and mobility of teeth
soft tissue discoloration
facial swelling asymmetry
AV Malformation
Radiographically: AVMs are osteolytic and frequently have indistinct margins.
Computed tomography can demonstrate enhancement of the lesions, while
angiography can depict distended feeder vessels and arteriovenous shunts.
Magnetic resonance imaging can visualize flow voids in high-flow abnormalities.
CASE REPORT
Demographic details: 22 yr, male, Indian

Chief complaint: pain in the right maxillary second

premolar region for the past two months

Pain: constant and sharp.

Past Dental History: Case of high flow facial AVM 10 yr

ago
Clinical Examination: rotated right maxillary second premolar(15), presence of a
carious lesion on the distal aspect of the tooth, no tenderness to percussion,
positive response to cold pulp sensibility tests

Clinical Examination: slight expansion of the buccal cortex in the area of the left
mandibular second premolar (tooth 35), extending to the left mandibular second
molar (tooth 37) region, and associated hyperemic buccal mucosa, suggestive of
the underlying pathology. Teeth 35, 36 and 37 had Grade 1 mobility, and the left
mandibular second molar (tooth 37) was displaced lingually.

Radiographic findings: An intra-oral periapicalof tooth 15 revealed no evidence

of any osseous changes with intact lamina dura. A panoramic radiograph
revealed a poorly delineated multilocular radiolucency resembling soap bubbles
associated with the left mandibular second premolar, extending to the left
mandibular second molar region.
Differential diagnosis for tooth 15: reversible pulpitis, acute apical abscess,
pulp necrosis. For multilocular radiolucency: odontogenic keratocysts,
ameloblastoma, ameloblastic fibromas, giant cell granuloma and malignant
primary or metastatic tumours

Definitive diagnosis for tooth 15 is Symptomatic irreversible pulpitis and

apical periodontitis and for multilocular radiolucency is bony AVM involving
the left submandibular region.

Management options: Under antibiotic prophylaxis, Non-surgical

endodontic therapy and 3 weekly angioembolism for AVM
Intervention: Non-surgical endodontic therapy for tooth 15
and 3-weekly angioembolism for AVM

Follow-up schedule:1,3 and 6 months

Treatment outcome: On follow-up at 6 moths, the patient

was asymptomatic with normal periapical architecture seen
on an IOPA
 Dental Intervention
obtained informed consent
from physician, prophylactic
antibiotics of a single dose
of 2 g amoxicillin (Arimox),
30 min before the dental
procedure.
Root canal preparation using
ProTaper Universal
instruments (Dentsply
Sirona)in a torque control
endodontic motor (X-Smart)
anesthesia with infiltration of
mouth rinse with 10 mL of
2% lidocaine with 1:100 000
0.12% chlorhexidine
epinephrine (2% LOX) and
digluconate before the
isolation with a rubber dam
procedure (Aster-X).
(Hygenic)
Root canal orifices and
working length was Access gained using a round
established using an diamond bur (No. 1013) with
electronic apex locater (Tri a turbine handpiece under
Auto ZX) and re-confirmed an air-water coolant.
with an IOPA
 preparation
finished to size F1
(0.20 mm tip
diameter, 7%
taper).
single dose of 2 gm amoxicillin
as antibiotic prophylaxis, canal
filling was carried out with
Protaper gutta-percha and AH 26
sealer using single wave warm
vertical compaction and
backfilled with thermoplastisized
gutta-percha
Irrigation with 3% sodium
hypochlorite using a 30-gauge
side vented needle placed 1–2
mm short of the root length.
Agitation done with
EndoActivator system with 2–3
mm vertical strokes for 30 s.
After one month,
completion of root canal
treatment done.
Calcium hydroxide powder
(Ca (OH)2) mixed with
distilled water placed as an
intracanal medicament,
patient was recalled after 7
days
postoperative complication of
cellulitis on the left side of the face
resulting in gross facial asymmetry
of the same side extending to the
temporomandibular joint region
along with a significant reduction in
mouth opening (inter-incisor
distance; 20 mm) after
angioembolization
DISCUSSION
A high-flow AVM has direct communication with the artery/arteries and a
vein/veins bypassing the capillary bed. AVM of the head and neck is a rare
vascular anomaly.
It is tenacious and gradually developing in nature with potentially life-
threatening complications, sometimes with a lethal outcome (Manjunath et al.
2014).
Lamberg et al. (1979) reported that intraosseous AVMs of the maxillofacial
region were often diagnosed due to tooth extraction or exfoliation, which
caused potentially fatal hemorrhage, as a result of lack of awareness by both the
patient and physician of the lesion.
DISCUSSION
AVM can present at any site in the oral cavity, the anterior two-thirds of the
tongue being the most common location.
Palate, gingivae and buccal mucosa are the other sites (Shetty et al. 2010).
The largest series of 81 AVMs observed lesions in the mandible (5%), maxilla
(4%), neck (5%), scalp (4%), cheek (31%), ear (16%), nose (10%), forehead (10%)
and upper lip (7%) (Kohout et al. 1998)
 DISCUSSION
The oral manifestations related to AVM are
 Macroglossia
Difficulty In Speech
Mastication
Deglutition.
The lesion is a pulsatile mass with a possible ‘thrill’, that is, a vibratory sensation may
be felt on the skin overlying an area of turbulence along, with local hyperthermia.
Ulcerations, bleeding and functional impairment due to ischaemia may be
observed (Duncan & Fourie 2004).
The presence of skin necrosis due to diminished nutritive flow, redness or a true
port-wine stain in the overlying skin has also been reported (Yu-Wei et al. 2011).
Bone resorption, root resorption, displacement of teeth, paraesthesia,
discoloration of the affected skin and intra-oral mucosal surfaces on the affected
area are the other features
The patient may also experience otalgia, epistaxis, ocular pain, facial asymmetry
and cosmetic distress
However, the triad of gingival bleeding, tooth mobility and presence of a
hypodense mass on a radiograph is almost pathognomonic of an AVM .
DISCUSSION
The present case was of symptomatic irreversible pulpitis with symptomatic
apical periodontitis for tooth 15 along with a bony AVM involving the left
submandibular region. Whilst undergoing root canal treatment, the case also
presented with an additional complication of restricted mouth opening along
with cellulitis extending from the medial pterygoid muscle to the
temporomandibular joint region. This was attributed as a complication of
angioembolization for which the patient was given antibiotics and kept under
observation for the swelling to subside. This focal swelling is frequently seen
after angioembolization in AVMs, which gradually subsides in 1–2 weeks.
Completion of root canal treatment was also delayed due to inaccessibility of
tooth 15 and was resumed after sufficient mouth opening was restored.
For diagnosing AVMs, multi-imaging modalities are recommended like:
Color duplex ultrasonography is the first line of imaging (Mahesh et al. 2003). It reveals high
vessel density and systolic flow.
MRI aids in the determination of the extent of AVM and also excludes a tumour presenting as
a typical mass effect which would be absent in AVM.
CT image: For the treatment of bony AVM, plays a vital role as it allows detection of the
magnitude of the lesion, its relationship to the teeth and the origin and position of feeding
blood vessels (Colletti et al. 2014).
Angiography is not a useful model for diagnosing AVM; however, it is considered the gold
standard for evaluating the feeding artery (arteries) and draining vein (veins) (Konez &
Burrows 2002, Colletti et al. 2014).
DISCUSSION
Orthopantomograms: revealed the presence of multilocular radiolucencies with
honeycomb or soap bubble appearance with small rounded or irregular lacunae
which were also seen in the present case (Manjunath et al. 2014).
However, this may be misinterpreted as odontogenic keratocyst,
ameloblastomas, ameloblastic fibromas, giant cell granulomas or malignant
primary or metastatic tumours (Mohammadi et al. 1997)
CONCLUSION
AVM in the oral cavity is rare and challenging to manage. Patients with AVM of
the Oro maxillary region pose several challenges, namely bleeding, hemorrhage
and increased risk of infection. Hence, dentists should be cognizant of its
diagnosis and take particular care in preventing and managing complications.
The restriction of instrumentation within the confines of the root canal will help
reduce the chances of bacteremia and hence decreases the chances of
complications associated with AVM. Standardized endodontic interventions
along with the use of amoxicillin or other antibiotics as single dose prophylaxis,
0.12% chlorhexidine mouthwash pre-procedure and good oral hygiene may be
helpful to reduce the risk of infection.
Cross references

It identifies interventional dental work as a potential source of

E. faecalis seeding, highlighting the fundamental role of E.
faecalis as a cause of endodontic infections. Also, it
demonstrates that antibiotic prophylaxis seems to be necessary
for all bacteremia causing procedures in patient
Cross references

A rare case of arteriovenous malformation of base of tongue in

a 25-year-old male patient has been presented. The rareness of
AVMs is equaled only by the morbidity they cause and the
urgency of the measures to be taken once detected, in all
circumstances. A high degree of suspicion leads to their
diagnosis and considerably reduces the risks of a catastrophe
once identified