Dental Tribune U.S. Edition

While the public and some sci- entists continue to claim that den- tal amalgam causes health prob- lems, other scientists and the FDA concluded that clinical studies did not establish a causal link between dental amalgam and health prob- lems.2,3 This case report will dis- cuss the entrapment of amalgam particles. Case report Recently, a 50-year-old Caucasian male presented to the VA New Jersey Health Care System Den- tal Service at East Orange seek- ing dental care. The patient came to our facility exploring, among other things, the viability of a den- tal implant in the region of tooth #30. The patient gave the follow- ing dental history. Approximately three years ago, his right man- dibular third molar (#32) was scheduled for an amalgam-alloy core buildup following root canal therapy. A crown lengthening pro- cedure using reflected, full-thick- ness buccal and lingual flaps was performed. While the flaps were reflected, an alloy core buildup was per- formed. The foreign bodies visible in the radiographic images are most likely amalgam alloy par- ticles that either became trapped in the apical portion of the flap or in the interstitial tissue. Comprehensive oral and max- illofacial examination included an intraoral and extraoral exam, full-mouth periapical X-rays and a panoramic radiograph. Among other clinical findings, the pan- oramic radiographs revealed inci- dental foreign bodies, most likely amalgam, embedded in the soft and/or hard tissue of the oral cav- ity due to iatrogenic treatment (Fig. 1). The patient consented to explore the feasibility of a dental implant in the region of tooth #30 and, at the same time, explore the region of #32 in order to deter- mine the orientation and proxim- ity of the foreign bodies to critical anatomical landmarks. For that study, a cone-beam CT (CBCT) 3-D scan of his lower jaw was obtained utilizing an i-CAT™ CBCT (Imaging Sciences Interna- tional, Hatfield, Pa.). Inherent in the acquisition of the 3-D volume of information is the ability to explore the precise location of the foreign bodies. Using CBCT to explore the amalgam pieces in the region of #32 revealed scattered pieces entrapped under the oral muco- sa outside the alveolar cortical plates, both lingual and buccal to tooth #32. It was also noted that the crown-to-root ratio of tooth #32 was much compromised and the tooth should be considered for extraction. By using the i-CAT 3-D CBCT, precise 3-D software was employed to visualize the bone in three dimensions from differ- ent viewing angles (Fig. 2). It was revealed that some of the amal- gam foreign body fragments were resting on the buccal side of the jaw bone on the right side, while other foreign fragments rested on the lingual side of the jaw bone under the lingual undercut (Figs. 3a–c). As no soft-tissue inflamma- tion and/or bone remodeling has occurred, following a professional dialogue between the restoring dentist and the oral surgeon, the amalgam foreign body fragments incidentally observed in this case were left intact, posing no medi- cal risk and or interference in our proposed dental treatment plan for a dental implant in the region of tooth #30. Nevertheless, con- tinuous follow-up was strongly recommended. Conclusions Fortunately, following careful assessment, our patient did not experience symptoms associat- ed with the amalgam remnants embedded under the oral mucosa, as has been reported in some cases in the literature.4 This case also demonstrates that restorative procedures and simultaneous full- thickness flap elevation, especial- Clinical DENTAL TRIBUNE | May 201116A By Dov M. Almog, DMD; Samuel Melcer, DMD; Rachel Berley, DMD & Kenneth Cheng, DDS Foreign bodies discovered during routine dental treatment While numerous medical reports and studies describe foreign bodies embedded in the soft tissue of the oral cav- ity either by traumatic injury or caused unexpectedly by a prac- titioner (i.e., iatrogenic), amal- gam was found to be among the most common embedded material.1 This case report describes an incidental finding of amalgam foreign bodies during routine dental care. It also describes the usefulness of cone-beam CT 3-D in detecting the presence of such foreign bodies and their spatial relationship to the adja- cent anatomy. Abstract Fig. 1: Incidental foreign bodies revealed, most likely amalgam, embedded in the soft and/or hard tissue of the oral cavity caused iatrogenically by a dentist. Fig. 2: By using the i-CAT 3-D CBCT (Imaging Sciences International, Hat- field, Pa.), a panoramic slice/image provided the exact locations of the for- eign bodies and their relationship to the adjacent anatomy. Figs. 3a–c: The cross- sectional slices reveal different layers of tooth #32 (mesial single canal area and distal root with two canals with apicoec- tomies). As observed in the distal cross sec- tional slice on the left, the foreign bodies are embedded deep down, close to the inferior border of the ramus of the mandible. Fig. 4: The axial slice also revealed that the foreign bodies were embed- ded outside the cortical plates. ly those involving amalgam resto- rations, ought to be reconsidered. When the patient was seen by the oral surgeon for extraction of the adjacent tooth #31, the sur- rounding areas were evaluated as well. The patient wished to leave #32 alone, despite recommenda- tions for extraction, so no fur- ther actions were taken at the time with regard to exploration of amalgam foreign bodies because they were asymptomatic. This report also attempted to provide justification for the use of CBCT scans in order to visualize abnormalities from a 3-D perspec- tive, ultimately facilitating case management. While outcome assessments in this area of dentistry are difficult, the authors believe that it is justi- fied from a diagnostic perspective, and what’s more, with renewed interest in mercury toxicity from amalgam fillings, the use of a CBCT scan to visualize amalgam foreign bodies and possible bone remodeling may offer invaluable information regarding treatment protocols. DT References 1. Sumanth KN, Boaz K, Shetty NY. Glass embedded in labial mucosa for 20 years. Indian J a b c Dent Res. 2008; 19(2):160–161. 2. Eyeson J, et al. Relationship between mercury levels in blood and urine and complaints of chronic mercury toxic- ity from amalgam restorations. 2010;208(4):E7; 162–163. 3. Kevin Trudeau. Panel Wants FDA to Examine Mercury Den- tal Fillings. www.ktradionet- g DT page 18A