Endodontic emergencies: Your medication may be the cause

Abstract
An endodontic clinician may face unwanted situations during root canal treatment. We present here an unusual case of soft tissue and gingival necrosis of the oral cavity following the use of formocresol during endodontic treatment.

Keywords: Formocresol; necrosis; paraformaldehyde containing paste.

Introduction
Formaldehyde-containing medications have been used for root canal treatment for many years. [9] Various compounds containing arsenic and paraformaldehyde were used in the past when effective anesthesia could not be obtained. [11] Such agents have some clinical benefit, although local soft and hard tissue necrosis occurs if they are not confined to the pulp. The following case report describes tissue degeneration and swelling in a patient treated with formocresol during root canal treatment.

Case Report
A 37 year-old female patient reported to the Department of Operative Dentistry in CSM Medical University with the chief complaint of pain in her maxillary left first premolar. She was diagnosed with acute irreversible pulpitis and an undergraduate student was assigned to perform her root canal treatment. She performed access opening and bio-mechanical preparation in the particular tooth and gave her dressing using formocresol-soaked cotton. The patient reported after 24 hours with the complaints of pain and swelling in her left buccal and infraorbital regions [Figure 1]. Oral examination revealed desquamation of the buccal mucosa and gingival epithelium in relation to her maxillary posterior region [Figure 2]. Extra oral examination revealed swelling in her buccal, mandibular, and infraorbital regions on the left side. There was ulceration in the angle of her mouth on the left side and her mouth opening was reduced. Treatment given The first aim of treatment was to alleviate the symptoms of pain and to prevent further progress of infection. The patient was immediately advised to rinse her mouth with Betadine gargle . A mixture of a steroid-based cream and Hexigel was applied all over the ulcerated surface. An analgesic was also given to relieve the symptoms of pain. The patient was prescribed antihistamines and multivitamins, which she was advised to continue for one week. She was kept on a soft diet and advised to avoid spicy food; she was recalled after one week. On her subsequent visit, her condition was found to have visibly improved [Figure 3] and [Figure 4].The swelling, redness, and exfoliation of the mucosa had reduced. After the cessation of symptoms, the patient's root canal dressing was changed. By her third visit, the condition had totally resolved and her root canal treatment was subsequently completed; the tooth was permanently restored with silver amalgam.

Discussion
Formocresol was first used as a root canal medication by Buckley in 1904. It is widely used in dentistry because of its antibacterial properties in root canal disinfection. [12] It contains formaldehyde, an effective alkylating agent, and cresol, a protein-coagulating phenolic compound. [2] Its action is believed to be due to the release of formaldehyde vapors which act as a germicidal agent. Besides strong chemical disinfectant properties, cytotoxic effects have also been documented. The use of formocresol in dentistry has become a controversial issue due to its widespread distribution in the body following systemic injection, [7] and the demonstration of immune response , to formocresol-fixed autologous tissue implanted in connective tissue or injected into root canals. [4] [5] . Powell et [3] al . have shown that when formocresol was implanted subcutaneously in the connective tissue of rats, the surrounding tissue was severely damaged; causing necrosis and abscess formation. Allergies have also been

reported after the application of formocresol. Formaldehyde is one of the components of formocresol that interacts with cellular proteins. The addition of cresol to formaldehyde appears to potentiate the effect of formaldehyde on protein. [6] In a study using human pulp fibroblast cultures, formaldehyde was shown to be the major component of formocresol that caused cytotoxicity and that was more toxic than cresol. [10] In this case, formocresol-soaked cotton was inserted into the pulp chamber. The resulting necrosis may have been due to excess formocresol in the cotton, which must have leaked and permeated into the surrounding tissue. [1] Betadine gargle used in this study contains Povidine iodine, which is an antiseptic. It is a complex of iodine, which kills microorganisms such as bacteria, fungi, viruses, protozoa, and bacterial spores. Povidine iodine exerts its antiseptic effect by slowly releasing iodine. Povidine iodine gargle and mouthwashes are used to treat infections of the mouth as well as throat and mouth ulcers. Topical antihistamines and corticosteroid applications meant to soothe painful ulcers may be helpful; avoiding spicy or hot foods may reduce the pain.

Conclusion
Nowadays, many improved medications and anesthetics are available which obviate the need for the use of formocresol as a root canal medication or as a pulp devitalizer. Due to the caustic nature of the material, use of formocresol should be avoided.

CASE REPORT

Necrosis of alveolar bone secondary to endodontic treatment and its management

Abstract
The misuse of various chemicals in dentistry may cause damage to gingiva and alveolar bone. In this case report, we describe necrosis of the gingiva and alveolar bone caused by pulp devitalizer. A paraformaldehyde preparation was applied to an inflamed and symptomatic pulp of the maxillary left first molar (tooth #26), in a 20year-old male. Spillage of the product was responsible for marked necrosis of the gingiva and the alveolar cortical bone, which resulted in great loss of the supporting bone. Surgical intervention was required wherein the necrosed bone was removed and the bone defect was filled with bone graft. The flap was coronally repositioned and sutured securely. After the treatment, the patient's complaints had resolved. Extreme care must be exercised while delivering of such products during treatment.

Keywords: Bone sequestrum, gingival necrosis, osteonecrosis, paraformaldehyde

There are numerous materials used in dentistry which have been shown to be toxic to the periodontium. Paraformaldehyde-based 'devitalizing' agents are commonly used in endodontics to devitalize inflamed pulps when effective anesthesia can not be obtained. [1]Although effective, the use of paraformaldehyde preparations in the palliative treatment of endodontic pain is not without risk as there may be unfavorable adverse effects on soft , , tissues and bone. [2] [3] [4] Paraformaldehyde-based product is used successfully in dental treatment in various countries for devitalization of the pulp. Such toxic chemical agents should be used very cautiously in the oral cavity, so that they do not come in contact with the gingiva or other parts of oral mucosa during placement. , Unfortunately, sometimes unintentional spillage may occur. [5] [6] This may not only lead to superficial mucosal injuries but may also penetrate deeper into bone and cause its necrosis. These local conditions that adversely

affect the blood supply or lead to tissue necrosis can also predispose the host to a bone infection or localized , osteomyelitis. [7] [8] In this paper, we describe a case of chemical necrosis of the marginal gingiva and necrosis of the maxillary alveolar bone as a consequence of spillage of pulp devitalizer (cautinerf) and its treatment.

Case Report
A 20-year-old male patient without any systemic diseases was referred to the Department of Periodontolgy and Implantology, Sardar Patel Dental College, Lucknow in January 2009. Patient arrived with the chief complaint of acute pain and discomfort in the left maxillary area. The clinical examination showed a marked area of necrosis of the interdental papilla [Figure 1] and the buccal marginal gingival of the upper left first molar (tooth #26). The interdental gingiva on the palatal aspect was intact [Figure 2]. Necrosed gingiva had left the interdental alveolar bone exposed in the cavity. The exposed bone was dark in color and hard in consistency. A peculiar rotten odor was also noticed. Palpation of the bone revealed that it was mobile as well. Periodontal probing of the buccal gingiva showed an 11mm pocket. The periodontal condition of the rest of the teeth was good. The radiographic examination showed that the tooth was endodontically treated. The coronal interdental bone was less radioopaque as compared to the apical bone [Figure 3].

Figure 1: Gingival necrosis around maxillary second premolar and first molar with exposed bone
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Figure 2: Palatal view of the same region showing unaffected gingiva

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Figure

3:

Diagnostic

radiograph

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Previous history revealed that three month earlier the patient had pain in the left side of the maxilla. At that time, the clinical examination showed a deep carious lesion i.r.t. tooth #26 on the distal side with a pulp polyp, chronic pulpitis was diagnosed and endodontic treatment was done. On enquiring from dentist, it was revealed that the dentist had devitalized the pulp with a paraformaldehyde preparation during endodontic treatment and sealed the cavity with a temporary filling material. Two days immediately after that patient had experienced pain and gingival burning. Patient was advised to use local astringent paste to control burning sensation but when there was no relief patient was referred to our department. Treatment rendered With the clinical diagnosis of localized osteonecrosis, the patient was given prophylactic antibiotics for three days and then scheduled for surgical sequestrectomy. On the day of surgery, after locally anesthetizing the area, the full thickness periodontal flap was raised both buccally and palatally. Buccally two vertical releasing incisions were also placed. Surgical exploration of the area confirmed that there was bone destruction and a breakdown of the maxillary buccal cortical bone in the interproximal septum between the first molar and second premolar. On close examination, it was seen that the necrotic bone (Sequestrum) was completely separated from the

underneath healthy bone. On exploration, an intervening soft tissue zone [Figure 4] was found which kept the necrotic bone attached to the underlying bone. After performing thorough curettage, the sequestrated bone could easily be differentiated from the healthy bone [Figure 5]. The sequestrum was then carefully removed [Figure 6]. Removal of the sequestrum left a deep interdental angular defect between the two teeth [Figure 7]. After curettage and irrigation of the area, the defect was filled with a block of hydroxyappatite bone graft [Figure 8]. The flap was then released by dissecting the periosteum and coronally repositioned so as to cover the graft and to compensate for the recession [Figure 9]. The flap was sutured in place and periodontal dressing was given [Figure 10]. The postoperative period was uneventful and the patient kept on short antibiotic treatment (amoxicillin 500 mg+clavulanic acid 125 mg) and an anti-inflammatory (ibuprofen 400 mg) three times daily for seven days, which led to successful healing of the wound [Figure 11]. During the healing period, the patient was kept on oral hygiene maintenance and chemical plaque control with chlorhexidine 10 ml twice daily.

Figure

4:

Necrosed

bone

seen

after

flap

reflection

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Figure 5: After curettage necrotic bone can be seen separated from the healthy bone
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Figure

6:

The

excised

pieces

of

necrosed

bone

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Figure

7:

Defect

seen

after

sequestrum

removal

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Figure

8:

Hydroxyappatite

bone

graft

placed

in

the

defect

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Figure

9:

Flap

coronally

slided

and

sutured

in

place

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Figure

10:

Periodontal

dressing

placed

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Figure

11:

Post-op

after

one

month

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Discussion
Various agents are used in day-to-day dentistry to devitalize the extremely painful pulps prior to extirpation. Paraformaldehyde-containing products are very commonly used for the same , , purpose. [9] [10] [11] Paraformaldehyde is a strong disinfectant and a fixative recommended in low concentration as an intracanal medicament. [12] Commonly used pulp devitalizer, used when anesthesia is not sufficient for pulp extirpation. According to the manufacturer, this product should be applied in close contact with the exposed pulp, covered with a cotton pellet and meticulously sealed with zinc oxide eugenol or other temporary cement. The paste should remain in the pulp chamber for a maximum of two weeks. However, paraformaldehyde is extremely toxic when placed in contact with the tissues of the body. Osteonecrosis in this case occurred due to accidental contact of paraformaldehyde devitalizer with the surrounding gingiva. Caution should be exercised during its use, by properly isolating the surrounding tissues from the tooth. Post-treatment evaluations showed complete healing.

Conclusion
Iatrogenic causes originating from dental treatment, if overlooked, can account to considerable morbidity and occasional mortality. Dental treatment procedures can worsen the oral and systemic health of patients if care is not taken during treatment. The dental practitioner has a responsibility to follow basic precautions during the delivery of various chemicals, with particular attention to safeguard surrounding tissues. Rubber-dam and other isolation measures can be the important protective factors from iatrogenic morbidity.