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<v Speaker 1>Welcome everyone to another episode of Endocast where we discuss

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<v Speaker 1>real clinical challenges in modern indodantechs. I am doctor Ahmachoki

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<v Speaker 1>and I.

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<v Speaker 2>Am doctor Franciscotebuty. Today we are discussing one of the

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<v Speaker 2>most feared complications in indiantis the sodium hypochrite accident.

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<v Speaker 1>Every indidentist has thought about it. What if it happened

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<v Speaker 1>during my treatment? Although fortunately uncommon, when it occurs, it

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<v Speaker 1>can be dramatic for both the patient and the clinician.

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<v Speaker 2>Yeah, the good news is that most accidents are preventable

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<v Speaker 2>and even if they occur in early recognition and the

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<v Speaker 2>systematic management can dramatically improve the outcome. And today we

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<v Speaker 2>will be focusing on three questions. First, why does it happen? Second,

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<v Speaker 2>how do we recognize it? And third what should we

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<v Speaker 2>do immediately?

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<v Speaker 1>Exactly so in our first part of this podcast an

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<v Speaker 1>important podcast, by the way, the most common cause is

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<v Speaker 1>the improper irrigation technique. The issue is usually the pressure

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<v Speaker 1>rather than the arrogant itself. If the needed binds inside

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<v Speaker 1>the root canal while irrigation, there is no passive backflow

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<v Speaker 1>and pressure forces the arrogant outside the tooth beyond the apex.

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<v Speaker 1>Always ask yourself can the arrogant flow back coronally or not?

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<v Speaker 1>If it cannot backflow, so you have to stop exactly exactly.

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<v Speaker 2>And second, another risk fructure can be the presence of

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<v Speaker 2>perforations or over preparation. So we have a very wide

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<v Speaker 2>forum because we prepared a bit too much, or we

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<v Speaker 2>have a white forama because of epical resorption, or we

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<v Speaker 2>have a white forama because the tooth is immature and

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<v Speaker 2>so the afpex is open. And other predisposing factors are

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<v Speaker 2>the position of the tooth relative to the availar bone,

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<v Speaker 2>so there is maybe a very thin cortical layer or

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<v Speaker 2>a fenestration of the cortical bone. And also remember who

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<v Speaker 2>gets this kind of accident most of the time. Most

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<v Speaker 2>of the time we're speaking about women in their mid age,

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<v Speaker 2>and so why because of the bone density. Even this

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<v Speaker 2>part can be interesting. Try to set your mind on

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<v Speaker 2>the patient that you're treating.

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<v Speaker 1>I think, I think now I can feel lucky about

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<v Speaker 1>that fifth point about the bond dynasty and the gender

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<v Speaker 1>of the patient. So being a male patient, if I

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<v Speaker 1>had to do a root kinnel treatment, I'm lucky. Now

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<v Speaker 1>now we are moving to another important part in this

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<v Speaker 1>discussion about recognizing the accident. Recognizing the sodium hypocrite extrusion accident.

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<v Speaker 1>So the first sign is usually sudden, severe burning pain

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<v Speaker 1>followed by rapid on site swelling. So the patients may

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<v Speaker 1>report that the taste or the smell of a bleach.

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<v Speaker 1>Sometimes they can reports taxis which is bleeding from the

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<v Speaker 1>nose or alter sensation involving the infra orbital or mental

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<v Speaker 1>nerve according to the location of the accident. So we

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<v Speaker 1>have to stop the treatment immediately if the patient reported

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<v Speaker 1>these incidents.

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<v Speaker 2>Yeah. Also because if we do not stop immediately, dissolution

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<v Speaker 2>of organic matter and hemolysis caused by this sodio hypocrite

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<v Speaker 2>make it spread to the tissues resulting in diffuse achemosis.

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<v Speaker 1>That's right. And after recognizing the accident, we have to

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<v Speaker 1>profoundly assess the clinical situation. So the clinical assessment after

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<v Speaker 1>recognizing the accident is very important for the treatment plan

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<v Speaker 1>that you are going to handle by which you are

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<v Speaker 1>going to handle the accident. So we have to assess

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<v Speaker 1>facial swellings systematically using bilateral facial landmarks measurement of the

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<v Speaker 1>distances between six facial planes from the tragus and mandibular

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<v Speaker 1>angle which can be compared with the opposite side to

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<v Speaker 1>determine the extent of the swelling. This will also help

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<v Speaker 1>in the follow up of the patient after management of.

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<v Speaker 2>The accident and then after evaluating facial swelling, try to

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<v Speaker 2>evaluate the airways breathing and swallowing first and then go

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<v Speaker 2>and check for sensory or motor defects, so check the

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<v Speaker 2>function of cranial nerves. And then also the intra overal

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<v Speaker 2>examination look for swelling or chemoses or alceration or necrosis

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<v Speaker 2>of the tissues and document all the findings carefully. Try

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<v Speaker 2>to keep your cool and take some pictures or some

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<v Speaker 2>small video even with a mobile phone, in order for

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<v Speaker 2>you to be able to compare the initial status to

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<v Speaker 2>the status of the healing when you will be following

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<v Speaker 2>up the patient.

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<v Speaker 1>Now we are moving to the core of this discussion,

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<v Speaker 1>which is the management of the accident. So first of all,

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<v Speaker 1>we need to assess the severity of the accident, so

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<v Speaker 1>that the first step in the management is the assessment

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<v Speaker 1>of how severe is the sodium hypochl right accident. And

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<v Speaker 1>the sodium hypochlaly right accident can be mild, moderate, or

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<v Speaker 1>severe depending on the degree of pain reported by the

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<v Speaker 1>patient upon happening and the swelling extent, as well as

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<v Speaker 1>soft tissue findings like the echemuses like the ulceration, necrosis,

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<v Speaker 1>et cetera exactly.

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<v Speaker 2>And so when we have to treat, we also have

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<v Speaker 2>to understand the timing of the treatment because there will

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<v Speaker 2>be something we are going to do immediately that means

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<v Speaker 2>within the first twenty four hours, and then early treatment

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<v Speaker 2>within one week, and then the lake so long term

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<v Speaker 2>treatment or follow up of the case. So how do

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<v Speaker 2>we manage a mild injury? We define a mild injury

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<v Speaker 2>an injury in which the patient in a pain visuals

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<v Speaker 2>score reports a pain ranging from zero to three, swelling

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<v Speaker 2>is less than thirty percent, there is a localized chemosis,

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<v Speaker 2>but no ulceration non acrossis. So this is something that

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<v Speaker 2>we can manage by ourself as GPS or as ended aunties.

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<v Speaker 2>What do we have to do immediately? We have to

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<v Speaker 2>irrigate the canals with water or saline with the aim

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<v Speaker 2>of diluting the sodium hypochloride. We want to decrease the

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<v Speaker 2>concentration of the sodium hypochloride and then we can provide

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<v Speaker 2>some over the counter and ergesia. This should be enough

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<v Speaker 2>to manage the symptoms because we are speaking about a

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<v Speaker 2>low degree of pain and a low degree of damage

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<v Speaker 2>to the court the patient. And we can also prescribe

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<v Speaker 2>some non seroidal anti inflammatory drugs and in the beginning

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<v Speaker 2>some cold compress in order to reduce the swelling. And

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<v Speaker 2>we can take an extray in order to try to

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<v Speaker 2>identify the cost for the extrusion injury. So perforation, what

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<v Speaker 2>framen why did it happen? And then last but analyst,

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<v Speaker 2>we could leave just the canands open to drain, but

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<v Speaker 2>if we do so, we have to daily see the

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<v Speaker 2>patient in the next days in order to check on it. Yeah,

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<v Speaker 2>then we can follow up the patient in the first

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<v Speaker 2>week and suggest him to do some compression with some

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<v Speaker 2>warm towels in order to stimulate the local circulation. And

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<v Speaker 2>if we see that the tooth cannot be restored for

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<v Speaker 2>some reason, maybe it broke, extract the tooth, don't wait

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<v Speaker 2>and then regularly review the patient to reassure him and

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<v Speaker 2>to just monitor the symptoms and the evolution of the disease.

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<v Speaker 2>And the late treatment is to if I can complete

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<v Speaker 2>the root canal treatment, then I finish it and maybe

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<v Speaker 2>I will be using some irrigant different from sodium hypochloride

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<v Speaker 2>in order not to have the same problem a second time.

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<v Speaker 1>So that was really comprehensive about the mild injuries. But

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<v Speaker 1>on the other hand, if we have moderate injuries are

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<v Speaker 1>these are presented as pain on the scale of four

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<v Speaker 1>to six on a visual analog scale, and the swelling

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<v Speaker 1>can be thirty to fifty percent more than the unaltered

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<v Speaker 1>normal side. The opposite side will diffuse ecomass and intraordal alteration.

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<v Speaker 1>Moderate injuries required specialist assessment in the first place. Imaging

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<v Speaker 1>and management of the soft tissue injuries. The early management

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<v Speaker 1>is the same as the mild injuries, in addition to

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<v Speaker 1>the bridment of the sift tissue, ulceration and necrotic tissue

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<v Speaker 1>because in mild injuries we have soft tissue leads due

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<v Speaker 1>to extrusions, so we need to just the bride and

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<v Speaker 1>clean all these alceration or necrotic tissues. The early management

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<v Speaker 1>is the same as the mild injuries in addition to

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<v Speaker 1>particular step which is the bribment of the soft tissue

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<v Speaker 1>alteration necrotic areas because there are some soft tissue loss

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<v Speaker 1>due to extrusion of the hypochrite into the soft tissue,

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<v Speaker 1>so you have to clean that. Late management involves replacement

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<v Speaker 1>of the loss tissue, which is mostly addicals tissues, using

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<v Speaker 1>dermal fillers for example, for correction of any possible because

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<v Speaker 1>this is not the case in every extrusion or every

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<v Speaker 1>moderate injury due to sodium hypercrite accident. But sometimes we

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<v Speaker 1>have some soft tissue loss that can be replaced with

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<v Speaker 1>using dermal fillers to avoid any permanent efficient formities. And

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<v Speaker 1>of course this should be performed by a trained and

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<v Speaker 1>experienced ural maxicofacial specialist.

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<v Speaker 2>And what about the severe injury, So we are speaking

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<v Speaker 2>about something where the pain of the patient is higher

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<v Speaker 2>than seven and the swelling is more than fifty percent

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<v Speaker 2>if compared to the other side of the face. We

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<v Speaker 2>have diffuse a chemosies and also we have interorlceration necrosis.

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<v Speaker 2>Maybe also the always are compromised and there is a

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<v Speaker 2>neurobascular deficient. Of course, in this case we cannot manage

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<v Speaker 2>it by ourselves, so we have to immediately refer the

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<v Speaker 2>patient to the hospital and to a specialized maxillofacial unit.

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<v Speaker 2>So immediate treatment involves first urgent referral to the local

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<v Speaker 2>or AMFAS unit, second e opioid or intravenous steroids in

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<v Speaker 2>order to aid with the inflammation. And also we should

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<v Speaker 2>be considering intervening antibiotics in order to reduce the risk

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<v Speaker 2>for secondary infection because here there is a huge damage

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<v Speaker 2>to the tissues and we can also need an MRI

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<v Speaker 2>in order to identify which tissues are inflamed or be

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<v Speaker 2>siblicity in order to assess effect on the surrounding tissues.

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<v Speaker 2>The early treatment is the same as the mild injury,

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<v Speaker 2>so nothing particular may be thereasiness to drain any collection

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<v Speaker 2>which might have formed, so this is the big difference,

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<v Speaker 2>and of course we need to have the patient reviewed regularly,

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<v Speaker 2>but this will be man by the oral and maxillofacial surgier.

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<v Speaker 2>The late treatment of this kind of disease is the

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<v Speaker 2>same technique as before, so we will be needing to

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<v Speaker 2>correct any soft tissue effect by transplant or fillers or

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<v Speaker 2>statics in general, and if there is any sensory or

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<v Speaker 2>motor neuvascular deficiit, we will need to be reviewing the

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<v Speaker 2>patient regularly and maybe there will be needed for some treatment,

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<v Speaker 2>and there could also be some neuropathic pain following this

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<v Speaker 2>kind of accident, and so there would be the need

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<v Speaker 2>for specialists to give some pharmacological treatment in order to

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<v Speaker 2>address this specific problem, and then the patient, who could

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<v Speaker 2>also be needed some speech therapy or language therap be

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<v Speaker 2>in order to rehabilitate the speech and the swallowing functions.

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<v Speaker 1>But now I have one question for you, and because

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<v Speaker 1>you are experienced in that topic, which is what if

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<v Speaker 1>the clinician face some extrusion of the sodium hypocrite into

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<v Speaker 1>the sinus accidentally?

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<v Speaker 2>Okay, well that this is a topic that is very

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<v Speaker 2>interesting for me. But it has been reported in the

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<v Speaker 2>literature sometimes and we always have to consider the amount

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<v Speaker 2>of sodi hypocrite that is to res into the sinus,

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<v Speaker 2>because probably every single underdone takes at some point in

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<v Speaker 2>his life extruded some sodium hypocrite somewhere and maybe a

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<v Speaker 2>part of this so the hypocrites went in the sinus,

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<v Speaker 2>but without probably major damages because it was immediately recognized. Okay.

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<v Speaker 2>In this case, we have Arish and colleagues that reported

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<v Speaker 2>a case of an endontic therapy of a maxillary right

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<v Speaker 2>first molar and shortly after irrigation of the palatal canal

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<v Speaker 2>with full strength five point twenty five percent sodium hypochride.

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<v Speaker 2>The patient complained about having a taste in its throth

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<v Speaker 2>despite the presence of a correct rubber dam isolation, and

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<v Speaker 2>so they irrigated the canal with sterbo water and they

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<v Speaker 2>found that the water was passing through the paltal canal

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<v Speaker 2>into the maxillary sinus and onto the nasal cavity via

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<v Speaker 2>the osteometry and then into the pharynx. So apart from

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<v Speaker 2>the initial congestion and the mild verse in sensation in

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<v Speaker 2>the right maxilla, the patient experienced no severe consequence and

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<v Speaker 2>was a symptomatic four days after the accident. In this case,

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<v Speaker 2>there was no major consequence, but we will have a

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<v Speaker 2>full discussion soon on this topic about the endosinus communication

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<v Speaker 2>in the end the case, so stay tuned. And then

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<v Speaker 2>we have another case of a right second primolar where

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<v Speaker 2>they used a lower concentration of sodiy hypercriti point five percent,

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<v Speaker 2>and even in this case the patient had immediate burning sensation.

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<v Speaker 2>But in this case there were also natal bleeding and

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<v Speaker 2>the patient complained about swallowing blood and not being able

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<v Speaker 2>to breathe correctly, so of course they immediately stopped the irrigation.

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<v Speaker 2>They irrigated with canal with stereosligine dried with stereop points.

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<v Speaker 2>But four days later the rocnal treatment was completed with

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<v Speaker 2>no complication and after three months the tooth was a symptomatic.

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<v Speaker 2>The last case reported in the little of what I

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<v Speaker 2>know is about the maxillary right second premolar. Also in

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<v Speaker 2>this case, during the irrigation, the patient had severe facial

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<v Speaker 2>pain and swelling, and in this specific case, the patient

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<v Speaker 2>had to undergo a caldual look approach, so they had

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<v Speaker 2>to drain surgically the sinus and despite an apparent healing

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<v Speaker 2>of the societies, the tooth remained painful and so it

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<v Speaker 2>was extracted in the end three months after the initial

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<v Speaker 2>presentation of the symptoms. So it can change a lot

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<v Speaker 2>from case to case. But what really makes the difference

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<v Speaker 2>is how much the hypocrite we extrude into the sinus

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<v Speaker 2>in this case before noticing, and so according to the

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<v Speaker 2>amount of the damage, they would be a very different

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<v Speaker 2>outcome of this tea. And this is my sodium hyperchyrite

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<v Speaker 2>accident into the sinus. So I was treating and retreating

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<v Speaker 2>the first model of this patient isolation. This assembling, I

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<v Speaker 2>removed everything I found the MB two. I was doing everything,

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<v Speaker 2>but I had some large foramen in this case because

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<v Speaker 2>my shaping was higher than fifty islo okay, And while

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<v Speaker 2>doing the finary irrigation, I had some blood coming out

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<v Speaker 2>of the canals and the patient was bringing his hands

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<v Speaker 2>to the area of the sinus. I was like, okay,

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<v Speaker 2>are you in pain, and it was like, it's the

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<v Speaker 2>strongest paint I've ever felt in my life. So immediately

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<v Speaker 2>irrigation with water. I put nothing as a medication into

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<v Speaker 2>the canal. I just temporized. I gave him painkillers, immediate

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<v Speaker 2>application of cold, and then I told him I told

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<v Speaker 2>me some warm compers and stuff, and I made him

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<v Speaker 2>be reviewed during the following week. Seven days later, I

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<v Speaker 2>was able to finish my rocnal treatment with no complication,

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<v Speaker 2>and then too was restored and proticized, so it ended

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<v Speaker 2>up well.

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<v Speaker 1>So from all these cases we can conclude that it

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<v Speaker 1>can happen with the most experienced clinicians because it depends

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<v Speaker 1>on the anatomy, the amount of soldi hypocrite, the foreman,

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<v Speaker 1>and the relationship between the roots and the sinus. So

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<v Speaker 1>that accident doesn't mean that the clinician is not controlling

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<v Speaker 1>the procedure, but it is called an accident. That's why

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<v Speaker 1>we have to just reassure the patient that the first

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<v Speaker 1>happening of this accident and then we follow the recommendation

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<v Speaker 1>about the management as we just discussed. So now we

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<v Speaker 1>are going to discuss the prevention. And it goes without

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<v Speaker 1>saying that we have to use a side vented needle,

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<v Speaker 1>never buying the needle into the root canal, irrigate slowly,

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<v Speaker 1>keep agitating the needle up and down and maintain the

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<v Speaker 1>continuous back flow of the irrigation out of the canal

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<v Speaker 1>in a coronal direction. And this is very easy because

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<v Speaker 1>we have the same physical action of the fluids coming

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<v Speaker 1>from the narrowest part to the widest part of the

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<v Speaker 1>root canal.

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<v Speaker 2>Yeah, exactly. And remember that successfully irrigation depends on the

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<v Speaker 2>controlled exchange, not on the pressure, and that's why we

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<v Speaker 2>can use negative pressure irrigation. Look at this case here

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<v Speaker 2>I'm doing the treatment in the two You see that

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<v Speaker 2>I'm tecking with the valsaba man over if there is

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<v Speaker 2>a communication between the tooth and the sinus, and there

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<v Speaker 2>is so in this case, I cannot use anything different

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<v Speaker 2>from negative pressure irrigation. Otherwise, when the patient breathe is

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<v Speaker 2>going to inhale the sodium hypochoride. So of course this

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<v Speaker 2>can be a tool that is extremely useful above all

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<v Speaker 2>in the case, so when we think that there could

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<v Speaker 2>be communication with the sinus, always use negative pressure irrigation

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<v Speaker 2>because it's the safest way to deliver sodium hypochriide and

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<v Speaker 2>to prevent the accident from happening.

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<v Speaker 1>So I think we have been so serious, not like

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<v Speaker 1>every time a lot of humor. This time we were

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<v Speaker 1>serious because this is a serious accident that can happen

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<v Speaker 1>in our practice to all of us. So I hope

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<v Speaker 1>you had some guide in order to manage and before

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<v Speaker 1>that to recognize the accident. So sodium hypocrite by itself

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<v Speaker 1>or sodium hypocrit per se, is not a dangerous solution.

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<v Speaker 1>The uncontrolled pressure is a dangerous part, not the solution.

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<v Speaker 1>So you have to control your pressure if you cannot

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<v Speaker 1>use some devices like the negative pressure side vended needles

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<v Speaker 1>and all the tools that we have mentioned in our discussion.

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<v Speaker 2>Yeah, because the proper tools and the techniques, together with

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<v Speaker 2>some awareness of the anatomical relationship between the teeth and

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<v Speaker 2>the abstructors can really help us preventive most of the accidents.

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<v Speaker 1>So I think we ended a very important episode in

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<v Speaker 1>the season and see you soon in a very interesting

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<v Speaker 1>episode the next one. So thank you for joining us

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<v Speaker 1>in this episode of Indocast.

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<v Speaker 2>Stay curious, stay conservative, and keep on saving teeth. Seeing

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<v Speaker 2>the next episode, Child