Death by Root Canal? Unlikely, but puzzling

AAE Position Statement

The American Association of Endodontists (AAE) is dedicated to maintaining the highest quality of care in the practice of endodontics. As part of that dedication, the AAE actively supports the use of safe and effective materials in connection with root canal treatment. The AAE recognizes that legitimate differences of professional opinion may exist as to the “safest” or “most effective” material for a specific patient or specific circumstances. In recognition of those legitimate differences of professional opinion, the AAE does not endorse the use of specific materials. However, the AAE does recommend against the use of paraformaldehyde-containing materials as they have proven to be both unsafe and ineffective.

Paraformaldehyde-containing endodontic filling materials or sealers (frequently known as Sargenti pastes, N-2, N-2 Universal, RC-2B or RC-2B White) should not be used for endodontic treatment because those materials are unsafe. Extensive scientific research has proven unequivocally that paraformaldehyde-containing filling materials and sealers can cause irreversible damage to tissues near the root canal system including the following: destruction of connective tissue and bone; intractable pain; paresthesia and dysthesia of the mandibular and maxillary nerves; and chronic infections of the maxillary sinus. Moreover, scientific evidence has demonstrated that the damage from paraformaldehyde-containing filling materials and sealers is not necessarily confined to tissues near the root canal. The active ingredients of these filling materials and sealers have been found to travel throughout the body and have been shown to infiltrate the blood, lymph nodes, adrenal glands, kidney, spleen, liver and brain.

Public health concerns and litigation have made the AAE aware of a significant number of patients who have suffered injuries as a result of treatment with paraformaldehyde-containing filling materials and sealers. Undoubtedly, there are many other patients who have also suffered injuries because of these materials, but whose injuries have not been publicly disclosed.

Safe and effective root canal filling materials and sealers are available. In light of the availability of safe and effective alternatives, the American Association of Endodontists recommends against the use of paraformaldehyde-containing filling materials or sealers because the use of such is below the standard of care for endodontic treatment.

http://www.aae.org/NR/rdonlyres/14F3726F-DA2D-4155-97E9-D0201E690B17/0/para formaldehydefillingmaterials.pdf

Claudia, thanks for sharing that information and the details of your awful experience. The worst that's happened to me was a periodontal surgery that just made the condition worse. While I am no fan of medical-malpractice ambulance chasers, I sincerely hope you were compensated for the damage done to you.

Researching just now, I found a reference that quotes an M.D. at the U of IL school of dentistry saying, "A root canal is simply taking out the root of a tooth and cleaning it, there is no way one could lead to someone's death." The quote appears in The Chicago Defender, found online at http://www.chicagodefender.com/page/local.cfm?ArticleID=10133. I do hope you will contact that media source and share your story. From what you have said, someone could certainly die from anapylactic shock while undergoing this procedure.

I'll add to this that, thank God, I know that gutta percha was used in my recent procedure. First, because I asked if that's what they were using, and second because the odor of that stuff is unique.

The conventional wisdom is to advise people to ask for the details about any medical or dental procedure they are about to undergo, and not to move forward without a satisfactory answer to every question. When I turned 60, my family doc advised the vaccination against shingles. But knowing it's related to the chickenpox, and knowing there is a huge controversy over vaccinating children against chickenpox (at least using the vaccines currenly in use in the USA), I spent several evenings investigating this, finally coming to the conclusion that the shingles vaccination was a risk worth taking.

Of course in a situation such as yours, how can a person be expected to know the right question to ask ahead of time? That, after all, is why we go to medical practitioners instead of simply doctoring ourselves.

But to return the the original point of this blog entry, WBBM has insinuated far more than can be proven by the facts that are in hand. What struck me when I first saw the story reported was that the TV reporter was stretching the story (perhaps to fill an allotted time slot) by referring to matters that may be thoroughly unrelated to Watson's death. I would not go so far as to accuse the station of sensationalism, but the reporting job was less than professional. The latest I have seen is that an autopsy on Watson was scheduled to have been done yesterday. Certainly, the story has "legs"enough--what with reactions of students, parents and colleagues--to be kept alive until the medical facts are revealed, at which time it will be appropriate to report them.

Thanks, I did email the editorial staff, as well as Dr. Wenkus about the article and Sargenti Paste.

A link of interest.

Anaphylaxis due to formaldehyde released from root-canal disinfectant. Kunisada M, Adachi A, Asano H, Horikawa T. Department of Dermatology, Hyogo Prefectural Kakogawa Hospital, 770-1, Awazu, Kakogowa-cho, Kakogawa, 675-8555, Japan.

A 50-year-old woman developed anaphylaxis 8 h after application of a paraformaldehyde-containing root canal disinfectant. Radioallergosorbent test showed that she had a high level of formaldehyde-specific IgE in her serum. Prick tests to formaldehyde and paraformaldehyde showed immediate-type responses to both. We reviewed the literature describing cases with anaphylaxis/angioedma caused by formaldehyde in root canal disinfectants and found that about 1/2 of the reported cases developed symptoms over 2 h after dental treatment. We speculated that the delay in the manifestation of her symptoms was possibly due to gradual formaldehyde release from paraformaldehyde and time lag of penetrating and diffusing of formaldehyde outside the dentin. Patch testing showed that she also had delayed-type allergy to formaldehyde, paraformaldehyde and eugenol. Physicians should pay attention to root canal disinfectants, even if anaphylaxis occurs several hours after dental treatment.

PMID: 12492520

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermT oSearch=12492520&ordinalpos=1&itool=EntrezSyst

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Wow! Eight hours is an astoundingly long interval between the treatment and anaphylaxis. Although the abstract explains sufficiently why it took so long.

Corollary to this is the importance of having dental conditions corrected. I have known a few people with really bad teeth, and most were unhealthy in other ways. It's easy to forget that the bacteria in your mouth that cause all these problems requiring root canal and periodontal work can easily find their way into the circulatory system and wreak havoc elsewhere. Not to mention the chemicals used in the dental procedures.

With all this, it's a wonder that people are not routinely tested for sensitivity to formaldehyde before undergoing surgery, oral or otherwise.

I too am injured by the use of Sargenti paste. The formaldehyde in it burned my inferior alveolar nerve and I have permanent numbness and burning in my lip and chin. EVERY dental school in the US teaches not to use it and has for decades but this group of dentists continue to use it and get away with it. All root canals with Sargenti paste aren't bad. When there is a mistake (and dentists legitimately make mistakes) the results can be disasterous.

I hope that they are looking into the filling material used on this lady.

It is a shame that someone like her had this happen to them. She was obviously a very caring person and excelled in a career that most of us would not have survived a day. My sympathies to her family, friends, coworkers and students.

As of today, the Chicago media continue to report that the autopsy on Georgette Watson was inconclusive as to the cause of death.

Most of the reports I have read have attributed her death to cardiac arrest, and almost all the mainstream media stories refer obliquely to her having been under "sedation." Many of these reports, it is clear, have been filed by TV newsies who do not understand the difference between "sedation" and "local anaesthesia."

Certainly here in Baltimore, the notion of chemical sedation in dentistry has gained a lot of favor. A few practitioners advertise widely about the use of a "simple little pill" on radio advertisements. I am inclined to believe that any form of general anaesthesia, by whatever polite euphemism you call it, carries the risk of killing the patient, especially if said patient happens to be a middle-aged individual in a high-stress occupation.

The dentist who treated me in childhood related a story about someone he "put under" using nitrous oxide, and had extreme difficulty reviving the patient. What I have learned from our veterinary experience (as dog owners, not practitioners) is that nitrous oxide is considered one of the safest forms of general anaesthesia, in that it is almost instantly reversible by the administration of oxygen.

The Chicago media appear steadfast in their refusal to investigate this aspect of the Watson death, yet they continue to cavalierly mention that the two dentists in whose office she died are "on probation," albeit for unrelated matters. This makes no sense to me.

Notwithstanding that, I am grateful to those who have commented here on the risks associated with "Sargenti Paste," and other formulations with the same ingredients. I am not convinced this substance was involved in Ms. Watson's death, if only because nobody has reported how far along the dentist was in the root canal procedure when her cardiac arrest occurred.

The reporting on this story only points out how vital it is to check professional sources when you see a science/medicine/technology story reported in the mainstream media.

I fear we will never know what killed Georgette Watson, at the rate things are progressing.

Meanwhile, I hope the comments about Sargenti paste appearing here will be of use to other readers.

Not only do patients need to know about Sargenti Paste but our doctors do also. Since it has been taught for DECADES not to be used, people are coming out of medical school not knowing anything about it except a vague recollection of being told not to use it. There is a chapter in the standard endodontic text book used by every dental school, "Pathways of the Pulp" that addresses Sargenti usage and legal consequences.

I do hope that others read these postings and learn from those of us that have learned the hard way -

When you go to get a root canal ask "DOES ANYTHING THAT YOU ARE PUTTING INTO MY MOUTH CONTAIN FORMALDEHYDE IN ANY FORM (SOLID OR LIQUID)?" If they start squirming or defend it, go elsewhere. it isn't worth the risk. Its a game of root canal roulette and unlucky people like me, loose.

The advocates are working on a more toxic version that uses liquid formaldehyde instead of the current powder that has a shelf life of months. The new formulation also contains other materials that make it look radiographically more like gutta percha (standard approved material). Now, why do they want to do that?

Its a dangerous material but what is even more dangerous is their concealment once the inevitable happens. Instead of referring the patient, they advocate a shot of decadron into the inside of the mouth and then take a wait and see (or pray) attitude while that formaldehyde, being a fixative, continues to penetrate the nerve, tissue, bone it has come in contact with. The results are irreversable.

The advocates claim FDA approval because they, at one time, had concurrence from a FDA reviewer. When it got elevated to another level within the agency, the concurrence was reversed. The FDA has sent letters to them saying that it is NOT approved, and that one person's opinion does not constitute a agency approval.

The advocates claim that the reason this stuff has never been approved is because the endodontist of the world are out to get them so that the general dentists (who use Sargenti) don't take away their business. Their arguments are unbelievably childish for a group of educated people. Why in 40 years have they not done what they needed to to get it FDA approved? My opinion....the FDA will never approve it.

Its one thing for a dentist or doctor to make a mistake. Its another to intentionally put an unapproved dangerous drug into someone's mouth and not tell them before or when they come back in excruiating pain. I was told my body would resorb my massive overfill (7 mm) in a few months. 2 years later the specs of the stuff that the OS couldn't remove are still there. I wasn't sure what I was supposed to be most happy about my body resorbing - the formaldehyde, lead or mercury. The public deserves to know about this.

I agree that we will likely never know what the exact cause of death is. If Illinois is the same as my state, the "legal" documentation resulting from disciplinary action is public information. This is more than what they currently have on their website.

Sandie, your last couple of comments got me researching this, and I too read about the proposed change in formulation to make Sargenti paste look radiographically more like gutta percha. I agree that there is no HONEST reason to do that.

I have not had a chance to discuss all this with my own dentist, though I will see him on 3 January, and with luck we will have time to chat about it. (At this dental office, they always schedule extra time for me, knowing that I will want to discuss the results of the latest examination, and future treatments.)

I'd like to add a couple of points to the advice you have given:

1. Do not do business with any dentist (or other medical practitioner) who refuses to treat you like a peer. I have always made it clear that I will not be condescended-to, and that I will insist upon straight answers to any questions I pose. That's part of the unwritten pact.

2. I would not recommend using a generalist dentist for a root canal procedure. "My" dentist does not perform them, just as he does not do extractions or periodontal surgeries. He understands that an endo specialist is the person to be doing root canal, just as a specialist surgeon (who can do a better job of infection control) is the person to do extractions. He acts as the coordinator amongst all these specialists, and he is brutally honest about the capabilities of any practitioner we are discussing. (None of this covering for the other guy with a neutral statement.) Where this man is an expert is in restoration work, and for that reason he is doing the permanent filling over my recent root canal. The endo work was done at the local dental school by a specialist resident, under direct supervision of his superior. While these guys did a great job at THEIR specialty, I can tell by feel that the temporary filling is far from perfect.

3. If you are in the vicinity of a good dental school, that is a great choice for this kind of specialized work. The U of MD dental school is here in Baltimore, and these people have the very latest technology at hand, in addition to which they have the capacity to bring in another specialist for a consultation in the midst of a procedure, as was done with my root canal. (There was a periodontal question, and the R.C. work was put on hold for ten minutes until a periodontist was able to come have a look and advise.)

In short, you must be your own advocate in any health care matter. The more you educate yourself beforehand, the more informed questions you can ask. And sometimes a practitioner's response to an informed question becomes a cue that it's time to change providers. This happened to us with veterinarians. One of our dogs was in to be spayed, and my wife asked whether they would use I.V. or gas anaesthesia. The vet rather sneeringly asked, "Oh. Are you a nurse?" We got out of that place immediately, and the vet we've worked with for the past 13 years sees things our way.

Thanks again, Sandie, for your participation here.

Stan, thank you for taking the time to read and research this and take our stories seriously. If all this rambling saves one only one person from learning this lesson the hard way, it is worth every minute of our time. I too am a firm believer that you are you own best medical advocate. Thank goodness for the internet. If I ever walk into a doctor office and say the word internet and they get testy or snooty, I leave. If I have to bring printings off of the internet to educate a doctor (recent experience with a neurologist and nerve pain drugs) I leave. I have had enough odd family illnesses that I have learned that you better educate yourself. That is exactly how I found out the truth and am not sitting here two years later thinking they nicked me with the novacaine injection like they tried to tell me. Nicking someone with an injection is considered bad luck of the draw and a known and acceptable risk. Using Sargenti paste is another story.

On the root canal front. I obviously foolishly thought that root canals were a dime a dozen and had been done by dentists for decades. I had never had one before and honestly didn't know what the procedure was but I had to learn (after the fact). The dentist that I now go to does root canals but refers the back molars to endos (it was my back molar). I will never allow a general dentist to do a root canal on me again even my current dentist who I love to death. I will never go to another dentist who doesn't about fall out of their chair when they hear the word "Sargenti". These Sargenti dentists will claim that you can get the same damage out of gutta percha but that is not true. Gutta percha is an inert material that used to be made from tree sap but is now synthetically made. An overfill of Gutta Percha and any other material can cause compression problems from the swelling and eventually nerve damage if the blood supply is cut off because of the swelling but will not "burn" the nerve sheath. That is the reason that I took many courses of oral steroids (and passed on the injection into my jaw since I had to consider the source). These Sargenti dentists blame all of the lingering problems on infection. I didn't have an infection, numerous doctors testified to it, yet they still blame it on an infection.

I did not know these dentists. It was my first visit to them. I had not gone to the dentist in a number of years. I was always dental phobic. I used to say that I was down right petrified now but I'm actually not. I know alot more about dentistry and the questions to ask. It is practicitioners like these that give dentists a bad name.

I have a dental school about 2 hours from here. They learned about me before I even knew what was wrong as a local dental professional sent them a copy of my xray with the big puddle under my tooth. As far as I can tell, they have helped spread the word that this stuff is still in use and by these dentists. I'm sure there are others but they will go to their grave with the secret if someone doesn't expose them.

I live in chronic pain and will for the rest of my life and take a host of drugs, including seizure control, to get the pain to a "livable" level. I'd suck it up and take it without a word if our regulatory boards would put a stop to it...that includes the FDA, ADA, AAE and our state dental boards. The way they point at each other for accountability is a travesty. If it takes until my last breath on this earth I will continue to put this out to the public so no one walks in mine or Claudia's shoes. This is wrong, these people know it or else they wouldn't be hiding it.

I'll bet that when you mention this to your dentist s/he will say "I didn't think anyone used this stuff anymore". Please post again and let us know how the conversation goes.

Thanks again for your time in learning and hopefully spreading the word to everyone you know! A 40 year free ride is well past long enough.

Sandie, Claudia and anyone else who's been following this---

Thought you'd like a little update. I had a follow up appointment with the endodontics resident who did my root canal back in November, and I asked him what he knew about Sargenti paste. He said that no dental school in the USA teaches or advocates the use of this stuff, and that from what he has learned, it's an EARLIER filler than gutta percha.

Now, that doesn't sound possible to me, since gutta percha has been around ever since people discovered rubber, which is about 200 years ago. On the other hand, dentistry is a fairly new science, compared to the other medical sciences. It's been only about 150 years since dentistry consisted only of the extraction of teeth, and that was done by barbers and self-trained dental practitioners.

Anyway, I was curious why anybody would use the stuff, and I had supposed it was because of longer shelf life, lower cost, or some such. Dr. Jaouni (my endo guy) explained that Sargenti and its related products are used as a short cut in root canal. The procedure, properly done, consists of drilling through the crown into the root(s) and removing all the nerve material--i.e., anything that is not tooth enamel. As I understand it, a particular root can have more than one root-canal. For example, my #19 molar has four roots, but the root in question had three separate canals, all more or less "communicating" at the jawbone end of things.

A proper root-canal job means finding every canal in the affected root, which can be difficult from above, as some of them calcify in response to infection, and are thus blocked off from above. The endodontist makes repeated x-ray images to make certain he has found and treated every one of these passages. The treatment is mechanical removal of the "bad" material. "Instrumenting" is what they call this: starting with a dental burr, the operator uses finer and finer flexible files, almost microscopically thin, to remove material. He then looks carefully under magnification to be certain everything is cleaned out. Only then is the gutta percha packing started.

The Sargenti allows a short-cut, because the formalin in it "mummifies" the root (Dr. Jaouni's word.) The operator does not have to "instrument" thoroughly, and does not worry about whether he's found all the canals, because this toxin will kill that tissue.

Aside from the toxicity issue, Dr. J tells me that many root canals done that way fail (i.e., living tissue remains and becomes re-infected), and that when one of those Sargenti jobs has to be re-done, it's extremely difficult because of the mess left behind.

A week earlier, we'd been at my wife's dentist (we go to different dentists, as it happens) and I mentioned Sargenti paste to the dental assistant who was doing some paperwork. She made a face, and asked, "Do people actually USE that stuff?"

The bottom line is what I think all of us have learned in this discussion (if we didn't know it before): in any medical matter, you have to be your own advocate, studying the condition and proposed treatments before you consent to anything.

Looks like I added one or two more dollars to my "If I had a dollar for everytime I heard...I didn't think anyone used that stuff anymore" (or something equivalent). The public needs and deserves to know about this. If our regulatory boards won't stop it, our only choice is to make the public aware.

One dentist in an AES newsletter wrote about how he made $626/hour doing Sargenti root canals (bottom of page 5). Put on your boots if you read all of this newsletter. Short cut = less time = more $$. Scarey

http://www.aesoc.com/Final%20Proof.pdf

Thank you for your posting. I was wondering how your discussion went. I think Sargenti came to be in the 1950's or so by Dr. Angelos Sargenti, Swiss dentist.

http://www.dentalwatch.org/questionable/sargenti/overview.html

Stan....Thanks so much for taking the time to look into this and learn about what Sandie and I had to learn the hard way. It is so frustrating that this is going on and more innocent patients may be harmed.

You are right when you say we have to be our own advocates, no matter what the condition or treatment.

The original discussion was the question of what happened to that beautiful woman in Chicago. We still do not know. I still wonder about that.

Thanks again.