C L I N I C A L P R A C T I C E
Damage to the inferior alveolar nerve
as the result of root canal therapy
M. Anthony Pogrel, DDS, MD, FRCS, FACS
hen root canal
W therapy is per-
formed on
mandibular teeth
posterior to the
mental foramen, damage to the infe-
rior alveolar nerve is possible.1 Most
cases have been reported in connec-
tion with the lower second molars,
but cases related to the first molars
and the premolars also have been
reported.2 Three possible mecha-
nisms can be envisaged1,3:
dmechanical trauma from overin-
strumentation into the inferior alve-
olar canal;
da pressure phenomenon from the
presence of the endodontic point or
sealant within the inferior alveolar
canal2,4;
da neurotoxic effect from the
medicaments used to clean the
canal or that are in the sealant.
Treatment remains controversial,
varying from a wait-and-see
approach5,6 to early,7-11 if not imme-
diate,12,13 surgical débridement of
the inferior alveolar nerve via a
number of possible approaches.
These include extraction of the
tooth and approaching the nerve
through the socket,11 decortication
of the mandible achieved laterally13
from an intraoral4,14,15 and extra-
oral16 approach, and sagittal split-
ting of the mandible to expose the
nerve within the split.9,17 Most
Copyright ©2007 American Dental Association. All rights reserved.
ABSTRACT
Background. Endodontic treatment of mandibular molar teeth has
the potential to damage the inferior alveolar nerve via direct trauma,
pressure or neurotoxicity.
Methods. The author reviewed all cases of involvement of the inferior
alveolar nerve resulting from root canal therapy in patients seen in a ter-
tiary referral center during an eight-year period (1998 through 2005).
The author had encouraged practitioners to refer patients immediately to
a university clinic.
Results. The author saw 61 patients during the eight-year period.
Eight patients were asymptomatic and received no treatment. Forty-two
patients exhibited only mild symptoms or were seen more than three
months after undergoing root canal therapy, and they received no sur-
gical treatment. Only 10 percent of these patients experienced any reso-
lution of symptoms. Eleven patients underwent surgical exploration. Five
of these patients underwent exploration and received treatment within
48 hours, and all recovered completely. The remaining six patients
underwent surgical exploration and received treatment between 10 days
and three months after receiving endodontic therapy. Of these patients,
four experienced partial recovery and two experienced no recovery at all.
Conclusions. Early surgical exploration and débridement may reverse
the side effects of endodontic treatment on the inferior alveolar nerve.
Clinical Implications. If the radiograph obtained after endodontic
therapy shows sealant in the inferior alveolar canal, then immediate
referral to an oral and maxillofacial surgeon is indicated if the patient
has continued symptoms of paresthesia or pain once the local anesthetic
should have worn off. Immediate surgical exploration and débridement
may provide satisfactory results.
Key Words. Root canal therapy; mandibular molar teeth; inferior
alveolar nerve damage.
JADA 2007;138(1):65-9.
Dr. Pogrel is a professor and chairman, Department of Oral and Maxillofacial Surgery, University of
California, San Francisco, P.O. Box 0440, 521 Parnassus Ave., Room C-522, San Francisco, Calif.
94141-0440, e-mail “tony.pogrel@ucsf.edu”. Address reprint requests to Dr. Pogrel.
JADA, Vol. 138 http://jada.ada.org January 2007 65
C L I N I C A L P R A C T I C E
A B
Figure 1. Typical radiographs of a molar (A) and a premolar (B) showing radiopaque root canal sealant within the inferior alveolar canal.
Figure 2. Inferior alveolar canal decorticated and the inferior alve-
olar nerve (arrow) removed from the canal and ready for débride-
ment. The arrow also shows paste within the epineurium.
reports are single case reports or small case
series.18
MATERIALS AND METHODS
Each year, I treat between 150 and 180 patients
with damage to the inferior alveolar and lingual
nerves from all causes in the Department of Oral
and Maxillofacial Surgery, University of Cali-
fornia, San Francisco.19,20 An analysis of patients
seen from 1991 through 2005 shows that the
number of cases of inferior alveolar nerve involve-
ment resulting from root canal therapy reached a
low of six cases in one year and a high of 15 cases
in another year, with a mean of eight cases per
year. Figure 1 shows radiographs of typical cases.
66 JADA, Vol. 138 http://jada.ada.org January 2007
Copyright ©2007 American Dental Association. All rights reserved.
I encourage general dentists and endodontists
to refer these patients early, if not immediately.
Since 1998, my advice has been that if sealant is
noted in the inferior alveolar canal on the radi-
ograph obtained immediately after the root is
filled, the clinician should monitor the patient
carefully and refer him or her without delay if he
or she still is experiencing numbness or other
symptoms once the local anesthetic should have
worn off.
When subsequent imaging the same day con-
firms the presence of sealant in the canal, I recom-
mend immediate decompression and débridement
of the nerve via lateral decortication of the
mandible.12 The oral and maxillofacial surgeon
performs the surgery in the operating room of a
hospital with the patient under general anesthesia.
He or she decorticates the mandible in one
block of lateral cortex from approximately the
second premolar region (posterior to the mental
foramen) to the third molar region. This is carried
out in an intraoral approach by using a combina-
tion of reciprocating saw and curved osteotomes.
In this way, the surgeon can remove the lateral
plate as a single piece of bone that can be
replaced at the end of the procedure. The surgeon
usually then can identify easily the nerve lying
within the substance of the marrow of the
mandible. He or she then teases the nerve out of
the inferior alveolar canal, thoroughly cleans the
canal and irrigates it of any foreign material
(Figure 2), examines the root of the tooth and, if
necessary, performs an apicoectomy or even an
extraction.

The surgeon then examines the nerve itself in
this region, and if sealant is found within the
epineurium itself, he or she opens and cleans the
epineurium and irrigates and cleans the indi-
vidual fascicles. He or she then replaces the nerve
and hollows out the lateral plate of the mandible
using a pineapple bur or an acrylic-type bur so
that no pressure is placed on the nerve. The sur-
geon then replaces the lateral plate of bone using
one or more 1.5-millimeter screws, taking care to
avoid further injury to the nerve. If possible, this
procedure should be performed the same day as
that of the injury.
RESULTS
From 1998 through 2005, I saw 61 patients with
clinical and radiographic evidence of sealant in
the inferior alveolar canal.
In eight patients, there was clear radiographic
evidence of sealant within the canal, but these
patients were asymptomatic and remained so
indefinitely. Presumably in these cases, the
sealant used was relatively nonneurotoxic, and
although it was within the bony confines of the
canal, the sealant was not within the epineurium;
therefore, the fascicles themselves were not
affected. These eight patients did not undergo
surgery.
In 42 patients, there was clinical and radi-
ographic evidence of sealant or an endodontic
point within the canal, but either the symptoms
were fairly mild or the delay from the injury to
referral was too long for the results to be suc-
cessful. Consequently, these patients did not
undergo surgery and clinicians observed them.
Follow-up, often by the patient’s general dentist
or the endodontist involved, revealed that fewer
than 10 percent of these patients experienced any
resolution of symptoms. Pain or dysesthesia was
present in 13 (31 percent) of the 42 patients.
I performed surgery in 11 patients in an
attempt to relieve symptoms of dysesthesia and
return sensation to normal. In five of these
patients, I performed surgery within 48 hours of
the injury, while in the other six patients, I per-
formed surgery more than one week (10 days to
three months) after their injury. In one of these
patients, paresthesia did not develop until two
days after the endodontic treatment (that is,
there was a “lucid” period).
Of the five patients who underwent surgery
within 48 hours of their injury, all experienced
total resolution of their symptoms within one
Copyright ©2007 American Dental Association. All rights reserved.
C L I N I C A L P R A C T I C E
week and began to feel improvement the day after
surgery.
Of the six patients who underwent surgery
more than one week after their injury, four
achieved partial improvement in sensation and
two experienced no improvement at all.
DISCUSSION
A review of the literature reveals that this repre-
sents the largest published case series of
endodontically related injuries to the inferior
alveolar nerve. Studies have shown that all root
canal sealants are neurotoxic to some degree. The
most neurotoxic appear to be those containing
paraformaldehyde6 or one of its analogs, including
Sargenti paste (N2) or Endomethasone
(Spécialtiés Septodont, Saint-Maur-des Fosses,
Cedex, France; available only in Canada and
Europe).11,21 Other sealants contain analogs of
formaldehyde, particularly before they have set
(for example, AH 26 [Dentsply Maillefer, Tulsa,
Okla.]).10,22 Even root canal sealants that are
believed to be more benign, such as zinc oxide and
eugenol and calcium hydroxide (owing to its high
pH),1 have been shown to be neurotoxic in vitro23-28
and are almost certainly neurotoxic in vivo.21
One of the possible differences between root
canal sealants may be that some demonstrate
their neurotoxic properties only when they come
into direct contact with the individual fascicles,
and as long as they are outside the epineurium,
they are safe (Figure 3). This would explain cases
in which there is clear evidence of sealant within
the canal but the patient is asymptomatic. These
agents may gain entry to the fascicle because
overinstrumentation of the canal before insertion
of the sealant may have resulted in an opening
through the perineurium.
In addition, it is not unusual for patients to
experience a so-called “lucid” period. This occurs
in cases in which the local anesthetic (most com-
monly an inferior alveolar nerve block) wears off
satisfactorily, and the patient has normal feeling
for 24 to 36 hours; the paresthesia or dysesthesia
then starts to develop. This appears to be the case
with agents that are believed to be less neurotoxic
than others. In this case series, I noted eight
cases in which this phenomenon occurred. Only
one of these eight patients underwent surgical
intervention.
Neaverth29 suggested that a higher incidence of
dysesthesia develops in patients in whom the
nerve involvement is caused by a root canal
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C L I N I C A L P R A C T I C E
A B
Figure 3. A. Endodontic sealant within the inferior alveolar canal but outside the epineurium. B. Sealant within the epineurium and
around the fascicles, perhaps the result of a mechanical break in the epineurium caused by overinstrumentation of the root canal into the
inferior alveolar canal.
sealant. Dysesthesia rates after traumatic injury
to the inferior alveolar nerve (for example, in
third-molar removal) appear to be between 8 and
10 percent20,30 of cases, but they may be higher in
cases in which root canal sealants are the cause of
the condition, possibly denoting a chemical neuro-
toxic effect. In this case series, the dysesthesia
rate was in excess of 30 percent.
Steroids, administered to reduce the edema and
inflammatory response to the sealant within the
rigid confines of the inferior alveolar nerve, may
provide some relief or allow surgeons to wait a
day or two before performing surgery. Some
authorities21,31 advise immediate steroid adminis-
tration, though there is no agreement regarding
the type, dosage or duration of steroid treatment.
I must note that, to my knowledge, there have
been no controlled trials of any treatment proto-
cols involving endodontically related injuries to
the inferior alveolar nerve, and the above results
and discussion represent primarily my findings
and opinions.
CONCLUSION
All root canal sealants have the potential to be
neurotoxic, and if a radiograph shows sealant to
be within the confines of the inferior alveolar
canal, the clinician should monitor the patient
carefully during the postoperative period. Even if
the local anesthetic appears to wear off satisfacto-
rily and sensation returns, clinicians still should
follow up patients for 72 hours, because delayed
nerve damage caused by less neurotoxic agents is
68 JADA, Vol. 138 http://jada.ada.org January 2007
Copyright ©2007 American Dental Association. All rights reserved.
possible. If symptoms are present as soon as the
local anesthetic would be expected to have worn
off, the clinician immediately should perform
decompression and débridement, irrigation and
cleaning of the nerve, which may achieve the best
results. The number of patients in this case series
was small and the results are not statistically sig-
nificant, but the outcomes for these patients may
point in that direction. ■
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