CLINICAL PRACTICE
CASE REPORT |
JADA Continuing Education
FORMATION OF A FACIAL HEMATOMA DURING ENDODONTIC THERAPY
PUSHKAR MEHRA, B.D.S., D.M.D.,
CHRISTOPHER CLANCY, D.D.S. and
JAMES WU, D.D.S.
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ABSTRACT
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Background. Sodium hypochlorite, or NaOCl, is one of the most commonly used irrigating solutions in endodontic practice. Its clinically proven antibacterial, solvent and lubricating properties make it a very appealing choice as an intracanal medicament.
Case Description. The authors present a case of facial hematoma formation after an inadvertent injection of NaOCl into the periapical tissues. The NaOCl solution caused extensive tissue destruction. Management of the condition required the hospitalization, intravenous antibiotic therapy and multiple intraoral surgical incisions to facilitate drainage.
Clinical Implications. Use of NaOCl must be confined to the root canal system. This report reviews this intracanal medicament’s potential toxicity and emphasizes the need for clinicians to remain cognizant of possible problems while using the solution.
Use of sodium hypochlorite, or NaOCl, as a chemical adjunct to mechanical débridement of pulp canals is a common practice in endodontics. The solution’s solvent activity for both necrotic and vital tissues and its antibacterial and lubricating properties make it an attractive choice for intracanal irrigation in endodontic practice. However, if used injudiciously, NaOCl can be extremely toxic and destructive to cellular tissues. There have been a few published reports of untoward incidents, including accidental parenteral administration, with use of this solution.1–3
The following report describes a case of extensive tissue destruction and formation of a dissecting hematoma during a routine nonsurgical endodontic procedure. The tissue reaction was precipitated by an inadvertent injection of NaOCl into the periapical tissues. The article aims to emphasize the fact that clinicians should remain cognizant of this potential problem while using NaOCl. Adherence to sound endodontic therapy principles is likely to reduce the chances of such iatrogenic complications.
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CASE REPORT
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A 51-year-old woman was referred to the emergency department at the Boston University Medical Center from another local hospital, with a diagnosis of an expanding hematoma of the left side of her face. Vital signs on arrival in the emergency department were as follows: blood pressure, 131/70 millimeters of mercury; heart rate, 93 beats per minute; respiratory rate, 20 respirations per minute; oxygen saturation, 97 percent on room air. The oral and maxillofacial surgery service was consulted for evaluation and treatment.
Verbal questioning of the patient revealed that she had been undergoing root canal therapy on her maxillary left primary canine tooth. The endodontic procedure had been started two weeks before. She had been given antibiotic therapy for a week after the initiation of the dental treatment and was asymptomatic on the day she visited her dentist for final obturation of the root canal and completion of the endodontic treatment. The procedure had been uneventful until she had felt a sudden onset of severe pain on the left side of her face. A rapidly expansile swelling then had appeared on the left side of her face. The patient recalled that the dentist was "flushing [her] tooth with some liquid" at the time of onset of the sudden, severe pain and swelling. The dentist then apparently had completed the obturation at that appointment before referring her to an oral and maxillofacial surgeon.
The patient’s medical history was significant for Crohn’s disease and migraine headaches. She was taking mesalamine and sulfasalazine for her gastrointestinal disease and propranolol for her migraine headaches. The patient had no known drug allergies. Her social history and the results of her laboratory tests were unremarkable.
During the physical examination, we noted that the patient was extremely anxious and in moderate distress. There was significant soft-tissue swelling on the left side of her face, including the periorbital and infraorbital regions and extending to the angle of the mandible (Figure 1
). Bilateral circumorbital ecchymosis was present, as was severe bilateral circumorbital ecchymosis. The swelling was firm, indurated, warm and tender to palpation. The patient denied experiencing any dyspnea or odynophagia. There was no associated trismus. An intraoral examination revealed extensive ecchymosis around the lips, left oral vestibule and left buccal mucosa. The posterior aspect of the hematoma extended to the retromolar pad area. Keeping in mind the patient’s history, the results of her clinical examination and her symptomatology, we made a tentative diagnosis of extensive hematoma formation secondary to tissue lysis from NaOCl irrigation beyond the tooth apex.
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Figure 1. Frontal view of the patient, showing extensive left-sided facial swelling and hematoma formation. Note bilateral circumorbital ecchymosis.
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We gave the patient 2 million units of intravenous penicillin G every four hours, and she also received a combination of orally and parenterally administered narcotics for pain management. To rule out any injury to the orbital contents, we obtained an ophthalmological consultation. The ophthalmologist found significant preseptal cellulitis and edema on the left side. He recommended the continuous application of cold compresses to the affected areas.
Over the course of the next two hours, the patient started to experience increasing throbbing pain despite receiving high levels of narcotic analgesics. Physical examination revealed extension of the soft-tissue swelling to the left sub-mandibular and temporal regions, with increasing induration. The periorbital swelling also started to increase, resulting in an inability to open the left eye (Figure 2). The patient developed trismus to 25 mm and started to complain of odynophagia. A computed tomographic scan showed extensive soft-tissue swelling of the left-side facial structures (Figure 3). No airway compromise was evident, and the orbital structures were within normal limits.
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Figure 2. Close-up view of the left eye, showing severe swelling of the upper and lower eyelids resulting from significant preseptal cellulitis.
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Figure 3. Axial computed tomographic scan of the patient, showing severe swelling of the soft-tissue structures of the left side of the face.
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An intraoral examination revealed severe mucosal sloughing throughout the entire left buccal mucosa and extension of the intraoral ecchymosis to the tonsillar pillar area. In view of the dissecting nature of the hematoma and the patient’s increasing discomfort, we decided to take the patient to the operating room for exploration and decompression of the hematoma.
We made an incision in the hematoma and drained it, using an intraoral approach under general anesthetic. Four separate incisions were made:
- – a maxillary buccal incision providing access to the left buccal space with subtemporal extension;
- – a maxillary vestibular incision for the left canine space;
- – a mandibular vestibular incision for access to the area around the angle of the mandible;
- – a buccal incision for access to the buccal space.
We performed a blunt dissection using hemostats. Digital pressure was applied externally to expel voluminous amounts of jellylike clots. We then carefully débrided grossly necrotic tissues surgically. Once the indurated areas were adequately decompressed, we irrigated the affected areas copiously with normal saline. The maxillary left primary canine was extracted, and we then placed Penrose drains in each of the surgical sites and secured them with sutures (Figure 4). The patient was extubated and transferred to the postanesthesia care unit in stable condition.
Administration of intravenous penicillin and oral rinses of both normal saline and chlorhexidine gluconate were continued. Warm external compresses were applied to facilitate continued drainage, and a soft, puréed diet was instituted. A morphine-based patient-controlled analgesic pump was prescribed for pain control.
The patient continued to progress well, with decreasing swelling, pain and ecchymosis. The Penrose drains were removed on the second day after surgery, and the patient was discharged the same day with a course of oral penicillin and pain medications. She was seen weekly as an outpatient in the oral and maxillofacial surgery clinic. A routine follow-up appointment five weeks after the procedure showed total resolution of the soft-tissue swelling and ecchymosis with no residual cosmetic defects (Figure 5). Minimal residual fibrosis was still present in the left nasolabial fold area secondary to scar tissue formation. We obtained a copy of the postoperative periapical radiograph (Figure 6) from the general dentist at a later date.
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Figure 5. Frontal view of the patient five weeks after surgery, showing total resolution of swelling and ecchymosis with no residual cosmetic defects.
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DISCUSSION
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NaOCl has been used as an intracanal irrigant for root canal sterilization and débridement for more than 75 years. It is well-recognized to be effective against a broad range of pathogens: gram-positive and gram-negative bacteria, fungi, spores and viruses (including the human immunodeficiency virus).1 The clinical efficacy of NaOCl is owed to its nonspecific ability to oxidize, hydrolyze and osmotically draw fluids out of tissues.4 Introduction of this agent beyond the tooth apex can cause violent tissue reactions and unbearable pain.
NaOCl is an alkaline solution with a pH of approximately 11 to 12. It causes injury primarily by oxidation of proteins. Heggers and colleagues5 studied the toxic effects of NaOCl and found that at a concentration of 0.025 percent, the solution was both bactericidal and nontoxic. However, at a concentration of 0.25 percent, the solution became significantly toxic to tissues. In another study, Pashley and colleagues4 showed that even at dilutions as low as 1:1,000, NaOCl caused complete hemolysis of red blood cells in vitro. They found severe inflammation and cellular destruction in all tissues except heavily keratinized epithelium. Other toxic effects of this solution include skin irritation and ulceration, marked endothelial and fibroblastic cell injury and inhibition of neutrophilic migration.1
When NaOCl is inadvertently forced into the periapical soft tissues, the sequence of injury seems to be as follows2:
- – excruciating severe pain for two to five minutes;
- – immediate swelling (ballooning) of the area, with spread of the tissue reaction to the surrounding areas through the loose connective tissue;
- – profuse hemorrhage, either interstitially or manifesting intraorally through the tooth.
As the tissue destruction progresses, extreme constant discomfort replaces the initial severe pain. The tissue response is out of proportion to the volume of the irritant. Once the initial bleeding ceases, interstitial oozing still continues because of lysis of cellular structures and surrounding vasculature. This results in significant ecchymosis.
Treatment should center on the principles of minimizing swelling, controlling pain and preventing secondary infection. Reassuring the patient is of prime importance. Use of cold packs externally is recommended for the first one to two days to minimize edema. Once drainage is established, the cold packs should be replaced by warm compresses in an attempt to promote liquefaction of the hematoma and dissolution of the soft-tissue swelling. Pain control often requires narcotic analgesics. Appropriate antibiotic therapy is highly recommended for two reasons: the possibility of infection’s being forced from the root canals into the periapical tissues with the NaOCl irrigation, and the subcutaneous presence of significant amounts of necrotic tissue and dead space, which can promote secondary infection.
Depending on the degree of the injury and its response to conservative therapy, some cases might require surgical intervention. The aims for any surgical procedure should be to provide decompression and facilitate drainage, and to create an environment conducive to healing. This can be accomplished by meticulous débridement of grossly necrotic tissue, and by lavage and irrigation of the affected sites. It should be kept in mind that the hematoma and/or infection may not follow the usual anatomical planes. Because of its potential to actively destroy tissues, NaOCl often causes sufficient tissue lysis to create its own planes. This results in widespread and haphazard progression of the tissue reaction, as occurred in our patient.
Most cases resolve after several days of edema, paresthesia, ecchymosis and, in a few cases, secondary infection. Some patients, however, may be left with long-term paresthesia, scarring or esthetic defects.3
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CONCLUSIONS
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NaOCl, while a very effective proteolytic solvent, is extremely cytotoxic. Although its established efficacy and track record justify its continued use as an intracanal medicament for endodontic therapy, respect for the tissues beyond the tooth apex is essential to minimize complications. Special attention should be given to teeth with wide apexes, resorption and apical perforations. Clinicians should avoid overinstrumentation beyond the tooth apex and wedging the irrigating needle into the root canal. A side-delivery orifice irrigating system may be of value. Clinicians should irrigate root canals while maintaining gentle movement of the needle to ensure that it does not bind against root canal tooth structure. This will decrease the chance of incurring unfortunate iatrogenic complications such as the one that occurred in the patient described here.
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FOOTNOTES
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Dr. Wu is a clinical instructor, Oral and Maxillofacial Surgery, Boston University School of Dental Medicine.
When this article was written, Dr. Mehra was chief resident, Oral and Maxillofacial Surgery, Boston University School of Dental Medicine. He now is a fellow, Oral and Maxillofacial Surgery, Baylor University Medical Center, 3409 Worth St., Suite 400, Sammons Tower, Dallas, Texas 75246. Address reprint requests to Dr. Mehra.
Dr. Clancy is a resident, Oral and Maxillofacial Surgery, Boston University School of Dental Medicine.
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REFERENCES
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- Gatot A, Arbelle J, Leiberman A, Yanai-Inbar I. Effects of sodium hypochlorite on soft tissues after its inadvertent injection beyond the root apex. J Endod 1991;17:573–4.[Medline]
- Sabala CL, Powell SE. Sodium hypochlorite injection into periapical tissues. J Endod 1989;15:490–2.[Medline]
- Ehrich DG, Brian JD, Walker WA. Sodium hypochlorite accident: inadvertent injection into the maxillary sinus. J Endod 1993;19:180–2.[Medline]
- Pashley EL, Birdsong NL, Bowman K, Pashley DH. Cytotoxic effects of NaOCl on vital tissue. J Endod 1985;11:525–8.[Medline]
- Heggers JP, Sazy AJ, Stenberg BD, et al. Bactericidal and wound healing properties of sodium hypochlorite solutions: the 1991 Lindberg Award. J Burn Care Rehabil 1991;12: 420–4.[Medline]
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ABSTRACT
CASE REPORT
