CASE REPORT

63

George Tsompanides, Konstantinos Ioannidis, Christos Angelopoulos, Theodor Lambrianidis

The contribution of cone beam CT in the

assessment and management of endodontic-related
mental nerve paraesthesia: A report of two cases
George Tsompanides,
DDS, MSc

Key words

cone beam CT, mental nerve, paraesthesia, second mandibular premolar

Introduction: Sensory disturbances of the inferior alveolar and mental nerves are often associated to
endodontic-related causes. For their diagnosis and management, a precise history and imaging of the
area are required. The aim of this article is to present two cases of successfully treated endodonticrelated mental nerve paraesthesia, in which cone beam computed tomography (CBCT) images aided
the precise diagnosis and decision-making for the treatment plan.
Case report: In this report, two cases of endodontic-related mental nerve paraesthesia are described.
Cone beam computed tomography (CBCT) images supplemented the information obtained from
the conventional radiographs and offered superior diagnostic accuracy. In both cases, a non-surgical
management of the neurosensory disturbances was decided, including the non-surgical retreatment
of a failed root canal treatment and monitoring of the patient in the first case and pharmaceutical
coverage and monitoring in the second one.
Conclusion: The use of CBCT in cases of endodontic-related neurosensory disturbances is a proven
adjunct to the two-dimensional imaging, enabling a more predictable management.

Introduction
Paraesthesia is a sensory disturbance defined as a
burning or prickling sensation or partial numbness
caused by neural injury1. It has been described as
a sense of warmth, cold, aching, tingling, pins and
needles, itching and numbness by patients2. In a
review of 61 cases of orofacial sensory disturbances,
a definite cause was determined in 83% of the
patients and 48% of those were of dental origin3.
In a retrospective study, the aetiology of 449 injuries to oral nerve branches was reviewed, after
an 18-year observation period. Surgical removal of
third molars was identified as the most common
reason (63.1%). Other reasons were nerve damage
associated with block anaesthesia (10.1%), implant
surgery (10.7%), dentoalveolar surgery (7.4%) and
root canal treatment (6.7%)4.

The inferior alveolar and the mental nerves are

highly associated with sensory disturbances due to
endodonticrelated causes of iatrogenic or infection origin. Most cases have been reported in connection with mandibular second molars, but cases
related to first molars and premolars have also been
reported5.
Endodontic-related local nerve damage of iatrogenic origin has been attributed to four factors:
1. Mechanical trauma in cases of root canal overinstrumentation.
2. Pressure phenomena in cases of over-filling or
over-extension of core materials (gutta-percha)
or sealers6,7.
3. Chemical damage due to extrusion of sodium
hypochlorite, calcium hydroxide, paraformaldehyde, corticosteroids, eugenol and root canal
sealers8-11.
ENDO (Lond Engl) 2014;8(1):6370

PhD Candidate,
Dept. of Endodontology,
School of Dentistry,
Aristotle University of
Thessaloniki, Greece

Konstantinos
Ioannidis, DDS, MSc
Specialist in Endodontics,
PG(R) MPhil/PhD Kings
College, London, United
Kingdom

Christos Angelopoulos,
DDS
Associate Professor and
Director,
Division of Oral and
Maxillofacial Radiology,
College of Dental Medicine,
Columbia University, NY,
USA

Theodor Lambrianidis,
DDS, PhD
Professor,
Dept. of Endodontology,
School of Dentistry,
Aristotle University of
Thessaloniki, Greece
Correspondence to:
Ioannidis Konstantinos,
Flat 327, 300 Vauxhall
Bridge Road,
SW1V 1AA,
London,
United Kingdom
Tel: +44 (0)741 497 9270
Email: pabloioannidis@
yahoo.com

64

Tsompanides et al

The contribution of cone beam CT

4. Nerve tissue overheating following thermoplasticised obturation techniques12. In several cases,

sensory disturbances have been associated with
pulpal necrosis and presence of periapical lesions13, exacerbation of chronic apical periodontitis14 and endodontic-periodontal involvement15.
For the diagnosis of endodontic-related paraesthesia, a precise medical and dental history is required
to determine the onset of the sensory alteration and
its evolution. Clinical examination of the affected
area should include thermal, mechanical, electrical or
chemical tests. The radiographic examination offers
diagnostic features that reveal any inter-relationship
between anatomical landmarks and aetiological
factors in two dimensions. Cone beam computed
tomography (CBCT) is a relatively recently developed imaging modality that has gained popularity
among endodontists for the diagnosis and management of complicated cases, including cases of
endodontic-related paresthesia16. The management
of endodontic-related paraesthesia remains controversial. The treatment options may vary from a waitand-see approach to root canal treatment, surgical
intervention or tooth extraction17.
The aim of this article is to highlight the contribution of CBCT in the diagnosis and management of
two cases of endodontic-related mental nerve paraesthesia.

Case report
Case 1
A 44-year old female patient self-referred to the
post-graduate clinic of the Department of Endodontology, School of Dentistry, Aristotle University
of Thessaloniki, Greece, with a chief complaint of
spontaneous and sharp pain, localised in the left side
of her mandible. She also complained of numbness
and loss of sensitivity on the left side of the skin and
mucosa of her lower lip. Her medical history was
non-contributory.
On extraoral examination, soft tissue sensitivity was evaluated with a dental probe and a cotton
pellet cooled with ethyl chloride. The patient presented total loss of tactile, thermal and pain sensaENDO (Lond Engl) 2014;8(1):6370

tion of the skin and mucosa of the left inferior lip and
the left side of the chin skin (Fig 1).
A full-mouth radiological examination was decided. Concerning the affected left mandibular area,
the periapical radiographs revealed a failed root
canal treatment and associated periapical radiolucency of tooth 35 in close proximity to the mental
foramen (Fig 2a).
According to the patients dental history, the
tooth 35 was root canal treated 5 years previously
and a fixed three-unit metal-ceramic partial denture
was placed in order to replace the missing tooth 36.
In addition, during the previous 3 months the patient was periodically feeling localised mild pain, as a
sense of discomfort, lasting for several hours.
The patient was referred for a CBCT examination
(Newtom VGi, QR, Verona, Italy), limited to the left
side of the mandible, for thorough evaluation of the
periapical radiolucent lesion and the proximity to the
neurovascular branches of the inferior alveolar nerve
and the mental nerve. Examination of the axial and
cross-sectional reconstructions revealed the presence of an extended, unilocular periapical radiolucency in association with the apex of tooth 35, with
absence of erosion of the cortical bone (Fig 3a). The
lesion was in close proximity to the mental foramen
and a thin diaphragm of cancellous bone, less than
1 mm in thickness, was separating the two anatomical landmarks (Figs 3b and 3c).
The initial diagnosis was exacerbation of asymptomatic apical periodontitis of endodontic origin of
the left mandibular second premolar, with neurosensory disturbances in the area of innervation of the
ipsilateral branches of the mental nerve.
Non-steroid anti-inflammatory drugs (Ibuprofen;
400 mg, 1 tablet 3 times per day for 4 days, per os)
were prescribed for the management of the acute
symptoms. There was a significant relief from pain,
but the paraesthesia was still present.
The fixed prosthesis was assessed as acceptable
and in compliance with technical, biological and biomechanical criteria; thus it was carefully removed.
Further intraoral dental examination revealed that
teeth 34 and 37 had a positive response in pulp sensibility tests (electrical and thermal stimuli) and did
not exhibit any sensitivity to percussion or palpation.
Tooth 35 exhibited increased sensitivity to vertical
percussion and palpation. Periodontal probing did

Tsompanides et al

The contribution of cone beam CT

65

Fig 1 Case 1: the initial area of mental nerve

paraesthesia is outlined
on the skin.

Fig 2 Radiological
examination of tooth
35: (a) preoperative
periapical radiograph;
(b) non-surgical root
canal re-treatment; (c) a
6-month postoperative
periapical radiograph.
a

c
Fig 3 CBCT examination of tooth 35:
(a) axial sections; (b)
cross-sectional reconstructions; (c) sagittal
section.

ENDO (Lond Engl) 2014;8(1):6370

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Tsompanides et al

The contribution of cone beam CT

not reveal either loss of periodontal attachment or

active periodontal inflammation.
The root canal re-treatment of tooth 35 was
decided. The root canal system was mechanically
prepared with hand and rotary nickel-titanium
(NiTi) files using the crowndown technique. Irrigation was performed with NaOCl 2.5%, EDTA 17%
and a final flush of chlorhexidine gluconate 2%.
Calcium hydroxide mixed with sterile saline was
used as an inter-appointment dressing. Root canal
obturation was completed 7 days later with AH 26
(Dentsply, Konstanz, Germany) sealer and guttapercha using the cold lateral compaction technique
(Fig 2b). The crown was restored with a composite
filling and the fixed partial denturee was luted with
a glass ionomer luting cement.
The patient was scheduled for follow-up examination on a weekly basis to monitor the progress of
the paraesthesia. The symptoms improved gradually. A total rebound of the sensation of the skin and
the mucosa of the lip was evident 3 months after
the completion of the root canal treatment. After an
observation period of 6 months, tooth 35 was functional and the radiological examination revealed favourable healing process, with significant reduction
in the size of the periapical radiolucency (Fig 2c).

Case 2
A 39-year old female patient, with non-contributory
medical history, was referred to the post-graduate
clinic of the Department of Endodontology, School
of Dentistry, Aristotle University of Thessaloniki,
Greece, for assessment, consultation and management of a persisting feeling of numbness and loss of
sensitivity in the left side of the skin and mucosa of
her lower lip.
According to the referring dentist, root canal
treatment of tooth 35, diagnosed with irreversible
pulpitis, was performed 3 weeks previously and was
completed in two visits. An immediate postoperative radiograph revealed extrusion of an epoxy resinbased root canal sealer (AH 26; Dentsply) in the periradicular tissues. The sealer had been applied with a
lentulo spiral connected to a low-speed hand-piece.
A few hours after root canal obturation, severe and
poorly localised pain was elicited. The following day,
the patient reported loss of sensation of the skin and
ENDO (Lond Engl) 2014;8(1):6370

mucosa of the left inferior lip and the left side of the
chin skin. The dentist decided to remove the root
canal filling materials, to provide intracanal drainage
and relief from acute symptomatology. Non-steroid
anti-inflammatory drugs (Ibuprofen 400 mg, three
tabs per day) were also prescribed for 4 days. After
4 days, the acute symptomatology was still evident.
Then, the dentist, with the consent of the patient,
extracted the affected tooth 35. In the following 2
weeks, the pain subsided but no further improvement occurred with regard to the sense of numbness
in the left side of the skin and mucosa of the lower
lip; thus the patient was referred to our clinic.
The extraoral evaluation of soft tissue sensitivity
was performed with a dental probe and a cotton pellet
cooled with ethyl chloride. On examination, total loss
of tactile, thermal and pain sensation in the left inferior lip and the left side of the chin skin was mapped on
the area of mental nerve distribution (Fig 4).
Intraoral examination demonstrated that the
healing process of the socket was favourable. Teeth
34 and 36 had a positive response in sensibility tests
(electrical and thermal stimuli) and did not exhibit
any sensitivity to percussion or palpation.
According to the referring dentist, radiographs
made during the root canal treatment were not
available. However, an intraoral periapical radiograph (Fig 5a) was available after the extraction of
tooth 35. The anatomical relationship between the
extruded material and the mental foramen could not
be determined precisely. A second periapical radiograph with an alteration of the horizontal angle was
also taken (Fig 5b). In addition, the dental panoramic radiograph revealed the presence of diffused
radiopaque foreign material in close proximity to the
anterior loop of the mental nerve (Fig 6).
The patient was then referred for a CBCT scan
(Newtom VGi) limited to the left side of the mandible, for the quantitative assessment of the diffusion
of the extruded material in relation to the anatomical landmarks of the inferior alveolar and mental
nerves. The examination of the axial and the cross
sectional reconstructions revealed the spreading of
a radiopaque substance, assumed to be root canal
sealer, in the cancellous bone, lingually and coronally
to the mandibular canal. In addition, a small amount
of the material had been diffused under the periosteum and appeared to be in direct contact to the

Tsompanides et al

The contribution of cone beam CT

67

Fig 4 Case 2: the initial area of mental nerve

paraesthesia is outlined
on the skin.

Fig 5 (a) Periapical radiograph after the extraction of tooth 35. (b) Second periapical radiograph with an alteration of the horizontal angle (distal view).

Fig 6 Dental panoramic radiograph

(section) of the affected area revealing the diffusion of radiopaque foreign
material in close proximity to the anterior loop of the mental nerve.
Fig 7 CBCT examination of the affected
periradicular area, in
which sealer diffusion
occurred: (a) axial sections; (b) cross-sectional
reconstructions.

neurovascular bundle of the mental nerve stem as

soon as it was emanating from the mental foramen
(Figs 7a and 7b).
The patient was informed that the extruded
material and the associated inflammation could be

exerting chemical irritation and mechanical pressure, respectively, on the bundle of the mental nerve,
resulting in the neurosensory disturbances in the
area of innervation of the ipsilateral branches of the
mental nerve.
ENDO (Lond Engl) 2014;8(1):6370

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Tsompanides et al

The contribution of cone beam CT

The diagnosis of acute inflammatory reaction of

the left side of the mandible (periostitis) and mental
nerve paraesthesia associated with root canal sealer
extrusion was set. Two possible therapeutic options
were discussed with the patient:
1. Conservative, non-invasive wait-and-see option.
2. Surgical decompression and debridement of the
foreign particles.
The difficulties and the risks of the second option
were specified to the patient, including: the need
for an extensive surgical field, the bone removal,
the difficulties for operative visualisation and foreign material debridement. Finally, the possibility of
trauma to the nerve branch and the risk of emergence of secondary permanent neurosensory disturbance were outlined.
Since acute symptomatology had subsided and
the patient was strongly concerned about the potential post-surgical complications, the conservative approach was decided. The patient was scheduled for
follow-up examination on a weekly basis, to monitor
the progress of the paraesthesia. A total rebound of
the sensation of the skin and the mucosa of the left
lip was evident 4 months after the patients first visit.
The patient was advised to call if further problems
arose in the future. However, she did not comply
with the 6th and 12th month radiological examinations, due to permanent departure abroad.

Discussion
In this article, two cases of endodontic-related mental nerve paraesthesia are presented. A common
aspect was the close anatomic relationship of the
involved second mandibular premolar with the location of the mental foramen and the emergence of
the branches of the mental nerve. The anatomy of
this specific area is complex and several morphological variations may exist, with regard to the location
and direction of the mental foramen and the presence of accessory foramina18. Variations may also
exist with regard to the pattern of emergence of the
mental nerve and the existence of an anterior loop19.
Those anatomical landmarks and their variations
are not always distinct with conventional diagnostic
tools, such as intraoral periapical radiographs and
ENDO (Lond Engl) 2014;8(1):6370

dental pantomographs20. CBCT was developed in

the late 1990s to produce geometrically accurate
three-dimensional scans of the maxillofacial skeleton
at a considerably lower radiation dose than conventional CT21. Recently, it was shown that limited
CBCT has increased diagnostic sensitivity for detecting the mental foramen and additional foramina22.
In Case 1, infection-related mental nerve paraesthesia of endodontic origin occurred. In a comprehensive literature review, it was concluded that
neurological symptoms occur either after re-infection
of an obturated root canal system, or as an endodontic flare-up following root canal treatment23.
Infection-related paraesthesia is usually related
to mechanical pressure and ischemia to the neurovascular supply associated with the existing inflammatory process. It is also caused by the local pressure
to the mental nerve consequent to the accumulation of purulent exudate in the mandibular bone23.
Another cause of the paraesthesia may result from
the toxic metabolic products of bacteria or the inflammatory products released from tissue damage23.
Non-surgical root canal re-treatment verified that
infection-related paraesthesia subsides after infection and resolution of the inflammation13-15,23.
The radiological examination revealed that the
periapical lesion was in close proximity to the mental
foramen, though a direct anatomic contact could not
be clearly identified. The exact anatomical relationship was evaluated with a CBCT scan. This provided
the precise depiction of the extent of the periapical
lesion, along with the location and direction of the
emerging mental nerve neurovascular bundle in relationship with the affected periradicular tissues.
In Case 2, mental nerve paraesthesia occurred
following root canal sealer extrusion to the mental foramen. In a cadaveric anatomical study, it was
shown that the trabecular pattern of the cancellous
bone in the molar and premolar region had a consistently loose appearance, often presenting numerous
vacuoles. The mandibular canal was not circumscribed by cortical bone, but the neurovascular bundle often proceeded through cancellous bone up to
the mental foramen. Therefore, pressure or diffusion
of chemical/toxic substances may have a direct effect on exposed nerve structures24.
In clinical practice, varying neurological disorders
have been described as soon as endodontic filler

Tsompanides et al

pastes and sealers are extruded. In the majority of

previously reported cases, in which the type of paste
or sealer was identified by the authors, the neurotoxic effects were associated with the presence or
release of paraformaldehyde6,10. AH 26 is a relatively
cytotoxic sealer25. In direct contact with periapical
tissues, AH 26 initiates a chronic lymphocytic/plasmocytic inflammatory reaction, with the absence of
foreign giant cells26. In direct contact with neural
tissue, AH 26 induces partial but reversible conduction reactivity27. Additionally, it has been shown that
AH 26 is prone to formaldehyde release during and
after setting28. The report of Escoda-Francoli et al
highlighted the application of analytical laboratory
methods in biopsy specimens, for the detection of
certain inorganic chemical components that may act
as foreign bodies11.
As soon as foreign material is extruded, a precise radiological examination is essential for correct assessment and diagnosis. The initial periapical
radiographs did not clarify the overall affected area.
The dental panoramic radiograph showed the area
of sealer diffusion; however the two-dimensional
image could not define the exact relationship with
the location of the mandibular canal and the mental
foramen. The application of CBCT has been recommended in cases of endodontic-related paraesthesia associated with material extrusion16. The exact
pattern of sealer diffusion was configured with the
CBCT scan. In Case 2, the CBCT allowed for a threedimensional assessment of the extruded material and
its proximity to the nearby anatomical landmarks.
The therapeutic approach in cases of neurosensory disturbances due to foreign material extrusion
remains controversial. In Case 2, a conservative, noninvasive wait-and-see approach was decided due to
the patients concerns about possible complications
of a surgical procedure. This option has been supported by several authors, as long as direct injuries
to the nerve branches such as section, resection and
laceration do not occur10,17. The option of a surgical
approach was also discussed with the patient, in case
of persisting symptomatology. Surgical decompression and debridement is recommended in cases of
long-term, persistent or permanent neurosensory
disturbances. For the prevention of permanent
nerve damage, immediate surgical intervention is
recommended when eugenol or paraformaldehyde

The contribution of cone beam CT

releasing sealers are extruded into the mandibular

canal6,7,29. However, in Case 2, surgical intervention
was not strongly indicated due to the patients positive early sensory response, the type of the sealer,
the quantity and the distribution towards the mental
foramen and neurovascular bundle.
In Case 2, the availability of CBCT clearly demonstrated a three-dimensional pattern of sealer
diffusion that contributed significantly to the preoperative assessment of a potential surgical site. The
buccolingual area of scattered sealer particles in periosteum, cancellous and cortical bone and the direct
contact with the emerging mental nerve revealed
the operational difficulties and the risks of a surgical
approach. Compared to the information gained from
the conventional radiographs, it was concluded that
with the latter, the amount and location of the extruded sealer was underestimated.

Conclusions
In this study, the basic and commonly available diagnostic procedures, such as clinical and radiological examination, were supplemented by the aid of
CBCT. The increased data obtained with the CBCT
provided diagnostic accuracy and contributed significantly to the decision of the treatment planning
in both cases.

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