Management of Calcium Hydroxide Extrusion Complication in a Mandibular Molar: A Case Report

Abstract

Calcium hydroxide is a commonly used intracanal medicament in endodontics due to its antimicrobial properties, ability to induce hard tissue formation, and role in controlling inflammation within the root canal system. Typically applied as a temporary dressing prior to permanent obturation, non-setting Calcium hydroxide paste is often delivered through a pressure syringe system for ease of placement. However, inadvertent over-extrusion of calcium hydroxide beyond the apex can result in severe inflammatory reactions, including pain, swelling, soft tissue blanching, and tissue necrosis, occasionally resembling Nicolau syndrome. This report presents a 38-year-old female patient who developed severe pain, intraoral and extraoral swelling, and reduced mouth opening and mastication, following an attempted root canal treatment of the left mandibular first molar in a private dental clinic. Clinical evaluation revealed positive percussion of the involved tooth, gingival inflammation, blanching of adjacent soft tissues, and tender submandibular glands. Radiographic evaluation showed radiopaque material extruded beyond the apical region, consistent with overextension of Calcium hydroxide medicament. The patient was managed through a structured, systematic approach involving careful canal debridement, systematic irrigation, antimicrobial therapy, and anti-inflammatory medicaments including Triple Antibiotic Paste (TAP) and Dexamethasone. Following these interventions, the extruded material gradually resorbed, as observed radiographically, and the patient’s symptoms-including pain, swelling, and difficulty in function resolved completely. This case highlights the potential complications of calcium hydroxide extrusion during root canal therapy and underscores the importance of precise medicament placement. Clinicians should remain vigilant for signs of medicament-induced tissue injury and adopt a careful, stepwise approach to prevent and manage such complications.