RECOVERY OF A PARESTHESIA IN LOWER LIP CAUSED BY A LARGE PERIAPICAL LESION BY APPLYING TENS AND ROOT CANAL THERAPY

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1 CLINICAL DENTISTRY AND RESEARCH 2012; 36(2): RECOVERY OF A PARESTHESIA IN LOWER LIP CAUSED BY A LARGE PERIAPICAL LESION BY APPLYING TENS AND ROOT CANAL THERAPY Canan Kaya, DDS Department of Endodontics, Ömer Görduysus, DDS PhD Professor, Department of Endodontics, Melahat Görduysus, DDS PhD Professor, Department of Endodontics, Atila Ertan, DDS PhD Associate Professor, Department of Prosthondotics, ABSTRACT The aim of this study is to evaluate the effect of Transcutaneous Electrical Neural Stimulator (TENS) as a tool to diminish the level of paresthesia besides the root canal therapy. Forty-yearold female patient was referred to our clinic due to numbness on her left side of lower lip and strong pain in the mandibular left premolar site. The patient was not medically compromised. Following the clinical and radiographical examinations, it was decided that the paresthesia had been linked with a large periapical radiolucency at the periapical area of the mandibular left first premolar, causing pressure to mental foramen. Later RCT (root canal therapy) was applied to the tooth and TENS to her lip. After a 14-month follow-up, it was seen that the lesion was almost disappeared and the paresthesia was totally eradicated. It is concluded that applying the TENS device to accelerate the healing and to subside the RCT together with the proper antibiotic and analgesic medication and vitamin B for quicker nerve regeneration can be recommended. Correspondence Canan Kaya, DDS Department of Endodontics Faculty of Dentistry Hacettepe University Sıhhıye, Phone: Fax: canann.kaya@hotmail.com Key words: Paresthesia, Periapical Lesion, Recovery Process, Root Canal Therapy, Transcutaneous Electrical Neural Stimulator Submitted for Publication: Accepted for Publication :

2 The Use Of TENS As A Tool To Diminish The Level Of Paresthesia INTRODUCTION Paresthesia is a sensation such as burning, prickling or partial numbness caused by neural injury, sometimes following acute traumatic injuries or infection to the teeth and jaws,root-end resection or overfilling of the root canal with impingement upon a nevre. 1-3 The possible mechanisms of neural injury are mechanical, chemical and thermal factors. Infection related paresthesia is usually coupled with mechanical pressure and ischemia associated with the inflammatory process (edema), or caused by the local pressure to the mental nerve consequent to the accumulation of prulent exudate in the mandibular bone. 4,5 The expanding infectious process and the associated host inflammatory process (edema) can cause pressure on the nerve fibers that is severe enough to induce the symptoms of paresthesia. A subsequent hematoma can also cause pressure on the nerve fibers sufficient to induce the paresthesia. Examination of the affected area can be carried out by using thermal, mechanical, electrical, or chemical tests that elicit subjective responses. 6 A more objective test is based on electrophysiologic analysis of the nerve. A radiographic and neurophysiologic screening is also necessary. Infection-related paresthesia subsides after infection and inflammation resolution (through antibiotic therapy, endodontic treatment, periapical surgery, or tooth extraction). In our case Transcutaneous Electrical Neural Stimulator (TENS) was used as a tool to diminish the level of paresthesia besides the root canal therapy. The use of electricity as a therapeutic modality is not new in dentistry and medicine. The use of TENS, and later its dental progeny electrical dental anesthesia (EDA) have been developed since mid s into techniques that appear to have some utility in the fight against pain. Medical and dental uses of TENS and EDA (Electrotherapy) is shown in Table 1. The mechanism of action, 7-9 at the low frequency setting of the TENS device (example: 2 Hz for chronic pain management) will produce measurable changes in the blood levels of tryptophan, serotonin and beta endorphins. Trypthopan, a precursor of seratonin, is present in the blood in decreasing amounts as the duration of TENS increases. By contrast, seratonin levels in the blood increase with time. Serotonin possesses analgesic actions, elevating the pain reaction threshold. At the same time, levels of beta endorphins and enephalins in the cerebral circulation also increase. The application of a low-frequency electrical current to an area that has recently been injured can help the patient in two ways: 1. It helps increase the tissue perfusion produced by capillary and arteriolar dilation while stimulating the concentration of skeletal muscles. It makes a pump effect and helps decrease any edema that may be present in the area, and the increased perfusion and skeletal muscle stimulation act together to cleanse the area of tissue-injury breakdown products. The use of TENS in this manner, thus, speeds the recovery process. 2. It helps the analgesic action. It elevates blood levels of serotonin and endorphins (in low frequency stimulation at 10 min or longer), blocking the pain cycle and keeping the patient comfortable. CASE REPORT A forty-year-old female patient was referred to our clinic due to the numbness on the left side of her lower lip with strong pain in her mandibular left premolar site. The patient was not medically compromised, yet she was systemically stable. The patient was examined clinically and radiographically. Radiographical examinations (Figure 1) revealed that paresthesia had a possible link with a large periapical radiolucency at the periapical area of the mandibular left first premolar and was causing pressure to the mental foramen. Later that large periapical radiolucency at the periapical area of the mandibular left first premolar was linked with that paresthesia phenomenon. Thus, RCT (root canal therapy) was applied to the tooth. The root canals were instrumented with Pro Taper (Dentsply-Maillefer, Ballaquies, Switzerland) rotary instruments and RC Prep (Premier, Norristown, PA, USA) as a lubricant. The final preparation file was Pro-Taper F3 for both teeth. Copious irrigation with 2.5% sodium hypochlorite solution was employed throughout the procedure. Canals were dried with paper points and dressed with calcium hydroxide paste. After 10 days, obturation of root canals were performed using Pro- Taper (Dentsply-Maillefer, Ballaquies, Switzerland) gutta perca points with lateral compaction and AH 26 (Dentsply- Maillefer, Ballaquies, Switzerland) root canal sealer (Figure 2). Antibiotic, analgesic and vitamin B were prescribed during the root canal therapy period. Following the root canal treatment TENS (Bio. Research Assoc. Inc. Milwaekee Wisconsin USA) was applied to her left lower lip and the 37

3 CLINICAL DENTISTRY AND RESEARCH Table 1. Medical and dental uses of TENS and EDA (Electrotherapy) Medical and Dental Uses of TENS and EDA (Electrotherapy) Causalgia Peripheral nerve injury Postherpetic neuralgia Phantom limb pain Bursitis Intractable cancer pain Parturition Lower back pain Spinal cord injury Ileus Cervical back pain Postoperative pain Acute dental pain Reversing local anesthesia TMJ problems Trismus Treatment of numbness and paresthesia Diabetic ulcerations Chronic pain disorders Polycytemia vera related area (Figure 3). TENS was applied in three sessions, each 8-10 minutes, 2.5 Hz at the first session and 120 Hz on the others to increase the efficiency and to obtain the anticipated result of the treatment of the numbess at the related site. The electrodes of the TENS are placed at the left lower lip s corner and middle side. Then the frequency of TENS was gradually increased. After a 14-month followup, the lesion became smaller and disappeared at the end of the recalls, as well as the paresthesia (Figure 4). DISCUSSION Figure 1. The periapical radiograph, showing large periapical lesion Figure 2. The periapical radiograph, showing root canal filling In the literature MNP (mental nerve paresthesia) and IANP (inferior alveolar nerve paresthesia) due to periapical pathosis are rare Mostly a foreign body, direct trauma to nerve and chemical use during the RCT are the reported causes of paresthesia in the literature. 13,14 In our case the lesion was the reason of the paresthesia. In time, following the proper, efficient and good quality RCT, it recovered. TENS application subsided the recovery and accelerated the good result. Generally paresthesia following the endodontic therapy is a matter of discussion, but here in this case it is the endodontic therapy that eliminated the infection together with its pressure and by-products over the neurovascular bundle in the related area. Thus, the aethiology of the paresthesia and numbness were totally eliminated. Based on our case and the related literature in that kind of paresthesia cases, we can recommend applying the TENS device to accelerate the healing and to subside the RCT also with the proper antibiotic and analgesic medication in addition to vitamin B for quicker nerve regeneration. 15,16 38

4 The Use Of TENS As A Tool To Diminish The Level Of Paresthesia REFERENCES 1. Glossary: American Association of Endodontics, GN Glickman, A.K. Mickel, L.G. Levin, A.F. Fouad, WT Johnson, editors. Contemporary terminology for Endodontics. 6th ed. Chicago: Am Assoc Endod; Di Lenarda R, Cadenaro M, Stacchi C. Paresthesia of the mental nerve induced by periapical infection: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000; 90: Knowles KI, Jergenson MA, Howard JH. Paresthesia Associated with Endodontic Treatment of Mandibular Premolars. J Endod 2003; 29: Gallas-Torreira MM, Reboiras-López MD, García-García A, Gándara-Rey J. Mandibular Nerve Paresthesia Caused By Endodontic Treatment. Med Oral 2003; 8: Figure 3. The patient and BioTENS (Bio. Research Assoc. Inc. Milwaekee Wisconsin USA) device, showing BioTENS application 5. Ozkan BT, Celik S, Durmus E. Paresthesia of the mental nerve stem from periapical infection of mandibular canine tooth: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105: e Mohammadi Z. Endodontics-related paresthesia of the mental and ınferior alveolar nerves: An updated review. J Can Dent Assoc 2010; 76: a Malamed SF. Future trends in pain control. In: Reinhardt RW, Baxter S, Stericker GB editors. Handbook of local anesthesia. St. Louis: Mosby; p Herman WW, Konzelman JL Jr, Comer RW. Using transcutaneous electrical nerve stimulation to prevent postoperative pain. J Am Dent Assoc 2002; 133: Schäfer E, Finkensiep H, Kaup M. Effect of transcutaneous electrical nerve stimulation on pain perception threshold of human teeth: a double-blind, placebo-controlled study. Clin Oral Investig 2000; 4: Grötz KA, Al-Nawas B, de Aguiar EG, Schulz A, Wagner W. Treatment of injuries to the inferior alveolar nerve after endodontic procedures. Clin Oral Investig 1998; 2: Figure 4. Periapical view of the teeth at the end of 14-month follow-up period, showing disappearence of periapical lesion 11. von Ohle C, El Ayouti A. Neurosensory impairment of the mental nerve as a sequel of periapical periodontitis: Case report and review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010; 110: e Abbott PV. Lower lip paraesthesia following restoration of a second premolar tooth. Case report. Aust Dent J 1997; 42: Hilú RE, Zmener O. Mental nerve paresthesia associated with an amalgam filling: a case report. Endod Dent Traumatol 1999; 15:

5 CLINICAL DENTISTRY AND RESEARCH 14. Tilotta-Yasukawa F, Millot S, El Haddioui A, Bravetti P, Gaudy JF. Labiomandibular paresthesia caused by endodontic treatment: an anatomic and clinical study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006; 102: e Froes FG, Miranda AM, Abad Eda C, Riche FN, Pires FR. Nonsurgical management of paraesthesia and pain associated with endodontic sealer extrusion into the mandibular canal. Aust Endod J 2009; 35: Yatsuhashi T, Nakagawa K, Matsumoto M, Kasahara M, Igarashi T, Ichinohe T, Kaneko Y. Inferior alveolar nerve paresthesia relieved by microscopic endodontic treatment. Bull Tokyo Dent Coll 2003; 44: