Massive Extrusion of Calcium Hydroxide Paste Containing Barium Sulphate During Endodontic Treatment

A 31-year-old woman was referred for the evaluation of persistent lower lip numbness following endodontic treatment of tooth #36. Imaging examinations showed a large amount of radiopaque/hyperdense material spread in an angiographic distribution in the left mandibular body region. Laboratory analyses of tooth #36 and adjacent periapical tissue, surgically extracted in an external Service due to acute pain following endodontic treatment, identified chronic inflammatory reaction and birefringent crystalloid foreign bodies rich in barium and sulphur, leading to the diagnosis of alveolar nerve injury due to accidental extrusion of intracanal dressing material composed of calcium hydroxide [Ca(OH)2 ] paste incorporated with barium sulphate. Clinicians should be aware that Ca(OH)2 when in contact with periapical tissues may lead to persistent toxicities, such as necrosis, pain and paraesthesia. Therefore, injectable Ca(OH)2 systems should be used with caution because they can cause paste extrusion and damage to the lower alveolar nerve.