Endodontic emergencies: Your medication may be the causeAbstract 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 . [10] In this case. ® Conclusion Nowadays. [6] In a study using human pulp fibroblast cultures. in a 20year-old male. [5] [6] This may not only lead to superficial mucosal injuries but may also penetrate deeper into bone and cause its necrosis. Extreme care must be exercised while delivering of such products during treatment. Paraformaldehyde-based 'devitalizing' agents are commonly used in endodontics to devitalize inflamed pulps when effective anesthesia can not be obtained. which is an antiseptic. which resulted in great loss of the supporting bone. 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. Topical antihistamines and corticosteroid applications meant to soothe painful ulcers may be helpful. viruses. which kills microorganisms such as bacteria. A paraformaldehyde preparation was applied to an inflamed and symptomatic pulp of the maxillary left first molar (tooth #26). These local conditions that adversely . In this case report. [1]Although effective. 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. formaldehyde was shown to be the major component of formocresol that caused cytotoxicity and that was more toxic than cresol. formocresol-soaked cotton was inserted into the pulp chamber. osteonecrosis. the patient's complaints had resolved. Such toxic chemical agents should be used very cautiously in the oral cavity. avoiding spicy or hot foods may reduce the pain. It is a complex of iodine. After the treatment. 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. Formaldehyde is one of the components of formocresol that interacts with cellular proteins. protozoa. Spillage of the product was responsible for marked necrosis of the gingiva and the alveolar cortical bone. The addition of cresol to formaldehyde appears to potentiate the effect of formaldehyde on protein. The flap was coronally repositioned and sutured securely. and bacterial spores. Unfortunately. Povidine iodine exerts its antiseptic effect by slowly releasing iodine. [1] Betadine gargle used in this study contains Povidine iodine. fungi. gingival necrosis. Surgical intervention was required wherein the necrosed bone was removed and the bone defect was filled with bone graft.reported after the application of formocresol. paraformaldehyde There are numerous materials used in dentistry which have been shown to be toxic to the periodontium. Povidine iodine gargle and mouthwashes are used to treat infections of the mouth as well as throat and mouth ulcers. . Keywords: Bone sequestrum. The resulting necrosis may have been due to excess formocresol in the cotton. Due to the caustic nature of the material. use of formocresol should be avoided. we describe necrosis of the gingiva and alveolar bone caused by pulp devitalizer. so that they do not come in contact with the gingiva or other parts of oral mucosa during placement. sometimes unintentional spillage may occur. which must have leaked and permeated into the surrounding tissue. On close examination. At that time. Palpation of the bone revealed that it was mobile as well. The periodontal condition of the rest of the teeth was good. The coronal interdental bone was less radioopaque as compared to the apical bone [Figure 3]. A peculiar rotten odor was also noticed. the clinical examination showed a deep carious lesion i. Patient was advised to use local astringent paste to control burning sensation but when there was no relief patient was referred to our department. Necrosed gingiva had left the interdental alveolar bone exposed in the cavity. the patient was given prophylactic antibiotics for three days and then scheduled for surgical sequestrectomy. 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. Treatment rendered With the clinical diagnosis of localized osteonecrosis. Buccally two vertical releasing incisions were also placed. it was seen that the necrotic bone (Sequestrum) was completely separated from the . the full thickness periodontal flap was raised both buccally and palatally. The interdental gingiva on the palatal aspect was intact [Figure 2]. Lucknow in January 2009. 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). osteomyelitis. Two days immediately after that patient had experienced pain and gingival burning. Sardar Patel Dental College.affect the blood supply or lead to tissue necrosis can also predispose the host to a bone infection or localized . Patient arrived with the chief complaint of acute pain and discomfort in the left maxillary area.r. On the day of surgery. The radiographic examination showed that the tooth was endodontically treated. Figure 1: Gingival necrosis around maxillary second premolar and first molar with exposed bone Click here to view Figure 2: Palatal view of the same region showing unaffected gingiva Click here to view Figure 3: Diagnostic radiograph Click here to view Previous history revealed that three month earlier the patient had pain in the left side of the maxilla. Periodontal probing of the buccal gingiva showed an 11mm pocket. tooth #26 on the distal side with a pulp polyp. 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. after locally anesthetizing the area. Case Report A 20-year-old male patient without any systemic diseases was referred to the Department of Periodontolgy and Implantology. [7] [8] In this paper.t. 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. The exposed bone was dark in color and hard in consistency. After performing thorough curettage. which led to successful healing of the wound [Figure 11]. The sequestrum was then carefully removed [Figure 6]. On exploration. the defect was filled with a block of hydroxyappatite bone graft [Figure 8]. the patient was kept on oral hygiene maintenance and chemical plaque control with chlorhexidine 10 ml twice daily. an intervening soft tissue zone [Figure 4] was found which kept the necrotic bone attached to the underlying bone. Figure 4: Necrosed bone seen after flap reflection Click here to view Figure 5: After curettage necrotic bone can be seen separated from the healthy bone Click here to view Figure 6: The excised pieces of necrosed bone Click here to view Figure 7: Defect seen after sequestrum removal Click here to view Figure 8: Hydroxyappatite bone graft placed in the defect Click here to view Figure 9: Flap coronally slided and sutured in place Click here to view . After curettage and irrigation of the area. 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. Removal of the sequestrum left a deep interdental angular defect between the two teeth [Figure 7]. the sequestrated bone could easily be differentiated from the healthy bone [Figure 5]. During the healing period. 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].underneath healthy bone. The dental practitioner has a responsibility to follow basic precautions during the delivery of various chemicals. Rubber-dam and other isolation measures can be the important protective factors from iatrogenic morbidity. if overlooked. this product should be applied in close contact with the exposed pulp. Dental treatment procedures can worsen the oral and systemic health of patients if care is not taken during treatment. used when anesthesia is not sufficient for pulp extirpation. with particular attention to safeguard surrounding tissues. covered with a cotton pellet and meticulously sealed with zinc oxide eugenol or other temporary cement. paraformaldehyde is extremely toxic when placed in contact with the tissues of the body. Conclusion Iatrogenic causes originating from dental treatment. [12] Commonly used pulp devitalizer. The paste should remain in the pulp chamber for a maximum of two weeks. . purpose.Figure 10: Periodontal dressing placed Click here to view Figure 11: Post-op after one month Click here to view Discussion Various agents are used in day-to-day dentistry to devitalize the extremely painful pulps prior to extirpation. . can account to considerable morbidity and occasional mortality. Osteonecrosis in this case occurred due to accidental contact of paraformaldehyde devitalizer with the surrounding gingiva. Caution should be exercised during its use. Post-treatment evaluations showed complete healing. Paraformaldehyde-containing products are very commonly used for the same . According to the manufacturer. [9] [10] [11] Paraformaldehyde is a strong disinfectant and a fixative recommended in low concentration as an intracanal medicament. However. by properly isolating the surrounding tissues from the tooth.