10.59987/ads/2017.3.117-122
Introduction. Cervicofacial subcutaneous emphysema is defined as the abnormal introduction of air in the subcutaneous tissues of the head and neck. It is mainly caused by trauma, head and neck surgery, general anesthesia, and coughing or habitual performance of Valsalva manoeuvre. The occurrence of subcutaneous emphysema after dental treatment is rare, and diffusion of gas into the mediastinum is much rarer, especially when the procedure is a nonsurgical treatment. Presented here is a case of subcutaneous emphysema that occurred after sodium hypochlorite irrigation during endodontic treatment, and the description of its etiologies and prevention during nonsurgical endodontic treatment. Endodontic success can be essentially achieved via good debridement of a root canal, and an ideal endodontic irrigant is effective in removing the smear layer, opening the dentinal tubules, and producing a clean surface for closer obturation.
Case report. A 60-years-old woman had an abnormal swelling and pain during an endodontic treatment accompanied by her dentist to the emergency room and was referred to our observation for complaining of severe pain, ecchymosis and severe swelling on the left side of her face. The aforementioned symptoms appeared after sodium hypochlorite irrigation and aggressive use of air spray for drying the root canal during the endodontic treatment of the upper left lateral incisor.
Discussion. An extrusion during an inappropriate endodontic treatment may occasionally be reported and can cause tissue damage. NaOCl is one of the best and most commonly used irrigating solutions because of its efficacy, but it can also negatively affect the periapical tissues.
Conclusion. Determining the correct working length, even when performing an intraoperative periapical radiograph and confirming the root canal integrity, could help avoid these kinds of accidents.
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Subcutaneous emphysema during root canal therapy: endodontic accident by sodium hypoclorite
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Subcutaneous emphysema during root canal therapy: endodontic accident by sodium hypoclorite
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                                                                                                  Case report


    Subcutaneous emphysema during root canal
    therapy: endodontic accident by sodium hypoclorite




                                                                                           li
                                                                                         na
    Gianluca Tenore, DDS                                 dodontic treatment of the upper left lateral in-
    Gaspare Palaia, DDS                                  cisor.
    Chiara Ciolfi, BDS                                   Discussion. An extrusion during an inappropriate




                                                                                       io
    Mohamed Mohsen, PhD                                  endodontic treatment may occasionally be report-
    Andrea Battisti, DMD                                 ed and can cause tissue damage. NaOCl is one of
    Umberto Romeo, DDS                                   the best and most commonly used irrigating solu-




                                                                   az
                                                         tions because of its efficacy, but it can also nega-

    Department of Oral and Maxillofacial Sciences,
                                                         tively affect the periapical tissues.

    “Sapienza” University of Rome, Rome, Italy
                                                         Conclusion. Determining the correct working
                                                         length, even when performing an intraoperative




                                                                 rn
                                                         periapical radiograph and confirming the root
                                                         canal integrity, could help avoid these kinds of

    Mohamed Mohsen
    Corresponding author:                                accidents.

    Department of Oral and Maxillofacial Sciences,




                                                       te
    “Sapienza” University of Rome
                                                         Key words: subcutaneous emphysema, root canal

    Via Caserta 6
                                                         therapy, sodium hypochlorite.

    00161 Rome, Italy
    Tel.: 00393478048688
                                                     In
    E-mail: mohamed.mohsen@uniroma1.it
                                                         Introduction

                                                         Debridement of the root canal system is essential for
                                                         endodontic success, and it is composed of mechani-
                                                         cal instrumentation and the use of antimicrobial irri-
                               ni

                                                         gating solutions. Root canal irrigants are ideally used
    Summary

                                                         for flushing out debris, dissolving organic tissue,
                                                         killing microbes, destroying microbial products and
    Introduction. Cervicofacial subcutaneous emphy-
                             io


                                                         removing the smear layer. These objectives can be
    sema is defined as the abnormal introduction of

                                                         achieved with irrigating solutions reaching the work-
    air in the subcutaneous tissues of the head and

                                                         ing length of the canal without extruding the periapi-
    neck. It is mainly caused by trauma, head and

                                                         cal tissues (1-3). Sodium hypochlorite solution (NaO-
                           iz



    neck surgery, general anesthesia, and coughing

                                                         Cl) is the most commonly used irrigating solution for
    or habitual performance of Valsalva manoeuvre.

                                                         its strong antimicrobial and proteolytic activity. NaOCl
    The occurrence of subcutaneous emphysema af-

                                                         in concentrations ranging from 0.5 to 5.25% is com-
            Ed




    ter dental treatment is rare, and diffusion of gas

                                                         monly used for irrigating root canals. A better bacteri-
    into the mediastinum is much rarer, especially

                                                         cidal activity can be reached by increasing the con-
    when the procedure is a nonsurgical treatment.

                                                         centration of NaOCl, but its damaging activities can
    Presented here is a case of subcutaneous emphy-

                                                         also be intensified. In fact, NaOCl at high concentra-
    sema that occurred after sodium hypochlorite irri-

                                                         tions can cause damage to vital tissues, such as
    gation during endodontic treatment, and the de-

                                                         haemolysis, ulceration, inhibition of neutrophil migra-
 IC




    scription of its etiologies and prevention during

                                                         tion, damage to endothelial and fibroblast cells, facial
    nonsurgical endodontic treatment.

                                                         nerve weakness and necrosis after extrusion during
    Endodontic success can be essentially achieved

                                                         inappropriate endodontic treatment (4, 5) These toxic
    via good debridement of a root canal, and an ideal

                                                         effects can occur because of the solution alkalinity
    endodontic irrigant is effective in removing the
C




                                                         (pH 10.8-12.9) and hypertonicity, which can oxidate
    smear layer, opening the dentinal tubules, and

                                                         proteins and lipid membranes (6). When some of
    producing a clean surface for closer obturation.

                                                         these effects occur, subcutaneous emphysema can
    Case report. A 60-years-old woman had an abnor-

                                                         appear. Subcutaneous emphysema is obtained when
    mal swelling and pain during an endodontic treat-
©




                                                         gas or air is in the layer beneath the skin. Since the
    ment accompanied by her dentist to the emer-

                                                         air is generally emitted from the chest cavity, subcu-
    gency room and was referred to our observation

                                                         taneous emphysema usually occurs on the chest,
    for complaining of severe pain, ecchymosis and

                                                         neck and face. It has a characteristic crackling feel to
    severe swelling on the left side of her face. The

                                                         the touch, also known as subcutaneous crepitation.
    aforementioned symptoms appeared after sodium

                                                         These situations can occur after an infection, trauma
    hypochlorite irrigation and aggressive use of air
    spray for drying the root canal during the en-

    Annali di Stomatologia 2017;VIII(3):117-122                                                              117
    G. Tenore et al.


    or a surgical procedure. In the odontostomatological       an allergic episode was excluded. The extraoral ex-
    environment, emphysema can arise after the irrigat-        amination revealed that the patient had difficulty
    ing solution’s extrusion during inappropriate endodon-     opening the left eye, with swelling and an ecchymosis
    tic treatment and even after repair of facial fractures,   affecting even the upper labial region, the mandibular
    periodontal surgery, temporomandibular joint surgery       region and the contralateral infraorbital region. There
    and the extraction of teeth such as a mandibular third     was also evidence of an issue on the left cheek.
    molar (7). Anaphylactic reactions to local anaesthe-       Paresthesia of the dental nerves was not diagnosed,




                                                                                                  li
    sia, haematoma and infection are usually included in       but the patient was referred upon altered sensation of
    the differential diagnosis (8).                            the left upper lip region.




                                                                                                na
    The paper investigates tissue damage after NaOCl           Intraoral examination revealed that the affected tooth
    solution extrusion during root canal treatment and ex-     had its own crown destroyed by decay processes.
    amines how to treat these kinds of accidents.              The part was slightly sensitive to vertical and horizon-
                                                               tal percussion and palpation with a mobility of grade




                                                                                              io
                                                               2 was reported (Fig. 2).
                                                               There was evidence of periapical swelling. A CT of
                                                               the head and the maxillary district was prescribed
    Case report




                                                                         az
    A 60-years-old woman had an abnormal swelling and          (Figg. 3-5).
    pain during an endodontic treatment accompanied by         The whole condition was diagnosed as air emphyse-
    her dentist to the emergency room and was referred         ma resulting from sodium hypochlorite solution ex-
    to our observation for complaining of severe pain, ec-     travasation during the endodontic treatment. Antibiot-
    chymosis and severe swelling on the left side of her       ic and antiseptic therapy (ceftriaxone) and analgesic




                                                                       rn
    face (Fig. 1). The aforementioned symptoms ap-             and antiedema therapy (betamethasone) were pre-
    peared after sodium hypochlorite irrigation and ag-        scribed. Symptoms and the overall conditions of the
    gressive use of air spray for drying the root canal dur-   patient improved three days afterwards (Fig. 6).




                                                        te
    ing the endodontic treatment of the upper left lateral     A panoramic radiograph was then prescribed. After
    incisor.                                                   one month, extraction of the upper left lateral incisor
    The woman’s medical history was performed. She re-         was done, the ecchymosis and the swelling appeared
    ported several episodes of hypersensitivity to differ-     to be fully resolved and the patient’s eye opening had
                                                      In
    ent drugs, asthma and previous thyroid cancer. First,      returned back to normal (Fig. 7).
                             ni
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                                                                 Figure 1. Woman with ecchymosis and severe swelling
                                                                 on the left side of the face immediately after the en-
                                                                 dodontic accident.

    118                                                                         Annali di Stomatologia 2017;VIII(3):117-122
    Subcutaneous emphysema during root canal therapy: endodontic accident by sodium hypoclorite


                                                                                    Figure 2. The intraoral situation.




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                                                                 Figures 3-5. CT of the maxillary district (black and white).


    Annali di Stomatologia 2017;VIII(3):117-122                                                                            119
    G. Tenore et al.


                            Figure 6. The situation after three days of pharmacolog-
                            ical therapy.




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                           ni

                            Figure 7. The extraoral situation after one month: the
                            ecchymosis and swelling appeared fully resolved.
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    120                                    Annali di Stomatologia 2017;VIII(3):117-122
    Subcutaneous emphysema during root canal therapy: endodontic accident by sodium hypoclorite


    The subject gave informed consent, and the study             wide-gauged and apical-opened needle (14).
    was therefore performed in accordance with the ethi-         Professionals in this line of work must be careful
    cal standards of the Declaration of Helsinki (as re-         about how far the irrigating needle is placed into the
    vised in Brazil 2013).                                       canal. This can prevent irrigation accidents. Any nee-
                                                                 dle should either be bound in the canal or applied in
                                                                 the proximity of the working length. A gentle flow rate
                                                                 should be used to avoid extravasation. Using a Luer-




                                                                                                      li
                                                                 Lock lateral-opened needle is also advised (15, 16).
    Discussion

                                                                 Recent studies have suggested the use of an Endo-




                                                                                                    na
    Surgical procedures are not the only cause for devel-
    opment of subcutaneous emphysema, as cases have              Vac irrigation system to obtain safe irrigation through-
    been described during restorative, crown and en-             out the working length. Nielsen and Baumgartner’s
    dodontic procedures. Emphysema also has been re-             study in fact pinpoints the use of an EndoVac system
    ported during oral laser surgery. Air can be intro-          resulting in statistically significant more debris re-




                                                                                                  io
    duced unto the soft tissue spaces by several routes,         moval at 1 mm from the working length than needle
    but it usually passes through the dentoalveolar mem-         irrigation with a downturn in extravasation accidents
    brane or a root canal (9).                                   (17).




                                                                            az
    In accordance with recent studies, the efficacy of the       It is important to know the working length and to be
    sodium hypochlorite solutions depends on its concen-         certain about the integrity of the root canal system
    tration. A previous study evaluated the efficacy in vit-     before irrigating with any concentrated solution (17).
    ro of three different concentrations of NaOCl against        Some advantages in the decontamination of the root
                                                                 canal system can be provided also by laser devices,




                                                                          rn
    Enterococcus faecalis (10). This study demonstrated
    the higher efficacy of the highest concentration used        which have been described by the Authors of previ-
    (5.25%). The correlation between concentration and           ous studies. In fact, the use of KTP laser and a 980-
    antimicrobial action is confirmed as well. The efficacy      nm diode laser revealed statistically highly significant




                                                        te
    of sodium hypochlorite antimicrobial action also de-         differences (P ≤ 0.01) compared to traditional en-
    pends on its pH, its osmolarity, its flow through the        dodontic procedures in the reduction of the load of
    root canals, its quantity and time of persistence in the     Enterococcus faecalis biofilms (higher than 96 and
                                                                 93%, respectively) (18, 19).
                                                      In
    canals (11).
                                                                 Although providers perform an adequate endodontic
    Alongside its antimicrobial activity, sodium hypochlo-
                                                                 therapy, if a subcutaneous emphysema arises, pro-
    rite is an extremely cytotoxic chemical solution (11).
                                                                 fessionals should first and foremost apply an ice-pack
    In fact, when it gets into contact with vital tissues,
                                                                 on the involved part. Second, they should administer
    NaOCl causes a whole series of diseases such as
                               ni

                                                                 antibiotics, analgesics and cortisone-based therapy, if
    haemolysis, ulceration, inhibition of neutrophil migra-
                                                                 needed. These actions will help to control the inflam-
    tion, damage to endothelial and fibroblast cells, facial
                                                                 matory reaction (20).
    nerve weakness, and necrosis. These toxic effects
                             io


    can occur because of this solution alkalinity (pH 10.8-
    12.9) and the hypertonicity of oxidating proteins and
    lipid membranes (12, 13).
                           iz



                                                                 Conclusion
    Human tissues exposed to NaOCl solution can be af-
                                                                 This paper report investigates a case in which extru-
    fected by subcutaneous emphysema, which is a con-
                                                                 sion of NaOCl caused severe tissue damage when
    dition characterized by the presence of air in the tis-      unintentionally injected beyond the root canal fora-
            Ed




    sues under the skin due to oxygen liberation into the        men. Side effects include pain, ecchymosis and
    same tissues.                                                swelling of the face. Determining the correct working
    When subcutaneous emphysema occurs, the patients             length, even when performing an intraoperative peri-
    report severe pain, ecchymosis and swelling. Some            apical radiograph and confirming the root canal in-
    patients report temporary nerve paresthesia as well.         tegrity, could help avoid these kinds of accidents.
    The swelling can occur in different areas according to       Lower concentrations of NaOCl may be helpful, and
 IC




    the tooth involved. If the sodium hypochlorite extrava-      using a negative-pressure system of irrigation, such
    sation occurs in an upper tooth, the swelling can af-        as an Endo-Vac, could help to properly perform en-
    fect the maxillary upper part, comprising the eye, the       dodontic treatment.
    maxillary sinus, the wing of the nose and the cheek.
C




    Otherwise, if the tooth involved is mandibular, the
    swelling can extend to the check, the angle of the
    mandible and, in the worst cases, the ear and the
                                                                 Aknowledgements
    neck.                                                        Authors did not receive any financial grants nor other
©




    Most of these cases arise because of incorrect deter-        fundings.
    mination of the working length or canal anatomical
    anomalies such as reabsorption or open-apex, lateral
    perforation and iatrogenic widening of the apical fora-
    men. Many subcutaneous emphysema cases are
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