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Iatrogenic chemical burns caused by chemical agents used in dental pulp therapy
Burns 30 (2004) 614–615
Case report
Iatrogenic chemical burns caused by chemical agents used in dental pulp therapy Lourdes Santos-Pinto a,∗ , Juliana A.D.B. Campos b , Elisa M.A. Giro a , Rita Cordeiro a a
b
Department of Pediatric Dentistry, Araraquara Dental School, São Paulo State University, Av. Queiroz Filho, 972 Araraquara, São Paulo 14802-610, Brazil Graduate student, Pediatric Dentistry Program, Araraquara Dental School, São Paulo State University, São Paulo, Brazil Accepted 2 March 2004
1. Introduction Iatrogenic injury is an intrinsic risk of all dental procedures. The potential hazard of inflicting a chemical burn using some dental materials is well recognized and must be kept in mind by dentists and their assistants. Exercise of care in using formocresol and calcium hydroxide in the mouth is necessary because they are highly caustic and can cause a soft tissue burn. The severity and extent of lesions caused by chemical agents depends on the type, quantity and concentration of the substance, as well as on the time of contact with the mucosa [1]. Longer exposure or higher solution concentration causes epithelial necrosis and shedding [2]. This report describes two chemical burns resulted from formocresol and calcium hydroxide oral mucosa contact during pulp therapy.
2. Case report 1 An 8-year old girl with severe pain in the mouth’s soft tissues, which was interfering with normal eating and swallowing, was admitted to our clinic. The intraoral examination showed aphthae-like, fibrin coated ulcers with surrounding erythema on the right buccal mucosa (Fig. 1) and on the anterior faucet pillar (Fig. 2). The reason for the burn was calcium hydroxide solution used in a pulp therapy. The dentist inserted a pledget of cotton wool, moistened in calcium hydroxide solution, in the pulp chamber to control bleeding and the expressed solution was swallowed by the patient. ∗
Correspondence author. Fax: +55-16-2016325. E-mail address: [email protected] (L. Santos-Pinto).
0305-4179/$30.00 © 2004 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2004.03.001
The patient was treated by the application of triamcinolone in Orabase and a bland diet was advised. The lesions healed within 7 days.
3. Case report 2 A ten year old boy had a pulpotomy performed in the maxillary left primary first molar. Immediately after the procedure the patient complained about a burning sensation in the mouth’s soft tissues. A few minutes later the left side of his upper lip swelled (Fig. 3). We learned that the reason for the burn was formocresol solution present in the instrument that was soaked in the bottle substance to moisturize the cotton pellet and used to place it in the pulp chamber after coronal pulp tissue amputation. The instrument came into contact, for a short time, with the upper lip and mucosa inflicting a chemical burn. The burned area was extensively irrigated with saline solution. The patient was followed up. Twenty four hours later a yellow line was found in the left buccal mucosa tissue (Fig. 4) and the line disappeared in 72 h.
4. Discussion Calcium hydroxide solution is an alkali and has a great potential for tissue destruction. Yano et al. [3] (1993) reported that even after removing or neutralizing the etiologic agent, alkaline substances keep on destroying the tissues, resulting in ulcers and progressive lesions. The mechanism of action involves alkaline agents’ combination with tissue protein to form proteinates, and with fats to form soap in addition to water. Thus, liquefaction necrosis occurs and reaches deeper tissue layers [1].
L. Santos-Pinto et al. / Burns 30 (2004) 614–615
Fig. 1. Lesion on the left buccal mucosa caused by calcium hydroxide solution.
Fig. 2. Lesion on the anterior faucet pillar caused by calcium hydroxide solution.
The formocresol’s main component is formaldehyde, a non-selective agent that reacts on cell protein; and cresol, a potent substance with action in the permeability of plasma membrane cells. In different pH conditions, the formaldehyde can block the free amino acid groups, attacking the imidazole ring in histidine and/or fixing in the amino and guanidine groups [4]. According to Finkelstein et al. [5], water or saline irrigation is the emergency treatment choice to minimize the product effect. If pain is considerable, symptomatic treatment may be of benefit. Iatrogenic lesions in the oral cavity can occur at dental offices. Chemical burns, however, deserve especial consideration because their ability to cause continuing tissue destruction and the value of early treatment with copious lavage.
615
Fig. 3. Formocresol burn on the lip, immediate reaction.
Fig. 4. Formocresol burn on the left buccal mucosa, clinical manifestation after 24 h.
References [1] Mamed RC, de Mello Filho FV. Ingestion of caustic substance and its complications. Sao Paulo Med J 2001;119:10–5. [2] Rossi LA, Braga ECF, Barruffini RCP, Carvalho EC. Childhood burn injuries: circumstances of occurrences and their prevention in Ribeirão Preto. Brazil Burns 1998;24:416–9. [3] Yano K, Hata Y, Matsuka K, Ito O, Matsuda H. Experimental study on alkaline skin injuries periodic changes in subcutaneous tissue pH and the effects exerted by washing. Burns 2001;19:320–3. [4] Morais CAH, Bernardineli N, Garcia RB, Westphalen VPD. Camphorated parachlorophenol and cresol formalin—empirism X science. J Bras Clin Estética Odontol 2001;5:31–3. [5] Finkelstein JL, Schwartz SB, Madden MR, Marano MA, Goodwin CW. Pediatric burns. Pediat Clin North Am 1992;39:1145–63.
Case report
Iatrogenic chemical burns caused by chemical agents used in dental pulp therapy Lourdes Santos-Pinto a,∗ , Juliana A.D.B. Campos b , Elisa M.A. Giro a , Rita Cordeiro a a
b
Department of Pediatric Dentistry, Araraquara Dental School, São Paulo State University, Av. Queiroz Filho, 972 Araraquara, São Paulo 14802-610, Brazil Graduate student, Pediatric Dentistry Program, Araraquara Dental School, São Paulo State University, São Paulo, Brazil Accepted 2 March 2004
1. Introduction Iatrogenic injury is an intrinsic risk of all dental procedures. The potential hazard of inflicting a chemical burn using some dental materials is well recognized and must be kept in mind by dentists and their assistants. Exercise of care in using formocresol and calcium hydroxide in the mouth is necessary because they are highly caustic and can cause a soft tissue burn. The severity and extent of lesions caused by chemical agents depends on the type, quantity and concentration of the substance, as well as on the time of contact with the mucosa [1]. Longer exposure or higher solution concentration causes epithelial necrosis and shedding [2]. This report describes two chemical burns resulted from formocresol and calcium hydroxide oral mucosa contact during pulp therapy.
2. Case report 1 An 8-year old girl with severe pain in the mouth’s soft tissues, which was interfering with normal eating and swallowing, was admitted to our clinic. The intraoral examination showed aphthae-like, fibrin coated ulcers with surrounding erythema on the right buccal mucosa (Fig. 1) and on the anterior faucet pillar (Fig. 2). The reason for the burn was calcium hydroxide solution used in a pulp therapy. The dentist inserted a pledget of cotton wool, moistened in calcium hydroxide solution, in the pulp chamber to control bleeding and the expressed solution was swallowed by the patient. ∗
Correspondence author. Fax: +55-16-2016325. E-mail address: [email protected] (L. Santos-Pinto).
0305-4179/$30.00 © 2004 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2004.03.001
The patient was treated by the application of triamcinolone in Orabase and a bland diet was advised. The lesions healed within 7 days.
3. Case report 2 A ten year old boy had a pulpotomy performed in the maxillary left primary first molar. Immediately after the procedure the patient complained about a burning sensation in the mouth’s soft tissues. A few minutes later the left side of his upper lip swelled (Fig. 3). We learned that the reason for the burn was formocresol solution present in the instrument that was soaked in the bottle substance to moisturize the cotton pellet and used to place it in the pulp chamber after coronal pulp tissue amputation. The instrument came into contact, for a short time, with the upper lip and mucosa inflicting a chemical burn. The burned area was extensively irrigated with saline solution. The patient was followed up. Twenty four hours later a yellow line was found in the left buccal mucosa tissue (Fig. 4) and the line disappeared in 72 h.
4. Discussion Calcium hydroxide solution is an alkali and has a great potential for tissue destruction. Yano et al. [3] (1993) reported that even after removing or neutralizing the etiologic agent, alkaline substances keep on destroying the tissues, resulting in ulcers and progressive lesions. The mechanism of action involves alkaline agents’ combination with tissue protein to form proteinates, and with fats to form soap in addition to water. Thus, liquefaction necrosis occurs and reaches deeper tissue layers [1].
L. Santos-Pinto et al. / Burns 30 (2004) 614–615
Fig. 1. Lesion on the left buccal mucosa caused by calcium hydroxide solution.
Fig. 2. Lesion on the anterior faucet pillar caused by calcium hydroxide solution.
The formocresol’s main component is formaldehyde, a non-selective agent that reacts on cell protein; and cresol, a potent substance with action in the permeability of plasma membrane cells. In different pH conditions, the formaldehyde can block the free amino acid groups, attacking the imidazole ring in histidine and/or fixing in the amino and guanidine groups [4]. According to Finkelstein et al. [5], water or saline irrigation is the emergency treatment choice to minimize the product effect. If pain is considerable, symptomatic treatment may be of benefit. Iatrogenic lesions in the oral cavity can occur at dental offices. Chemical burns, however, deserve especial consideration because their ability to cause continuing tissue destruction and the value of early treatment with copious lavage.
615
Fig. 3. Formocresol burn on the lip, immediate reaction.
Fig. 4. Formocresol burn on the left buccal mucosa, clinical manifestation after 24 h.
References [1] Mamed RC, de Mello Filho FV. Ingestion of caustic substance and its complications. Sao Paulo Med J 2001;119:10–5. [2] Rossi LA, Braga ECF, Barruffini RCP, Carvalho EC. Childhood burn injuries: circumstances of occurrences and their prevention in Ribeirão Preto. Brazil Burns 1998;24:416–9. [3] Yano K, Hata Y, Matsuka K, Ito O, Matsuda H. Experimental study on alkaline skin injuries periodic changes in subcutaneous tissue pH and the effects exerted by washing. Burns 2001;19:320–3. [4] Morais CAH, Bernardineli N, Garcia RB, Westphalen VPD. Camphorated parachlorophenol and cresol formalin—empirism X science. J Bras Clin Estética Odontol 2001;5:31–3. [5] Finkelstein JL, Schwartz SB, Madden MR, Marano MA, Goodwin CW. Pediatric burns. Pediat Clin North Am 1992;39:1145–63.