Speaker 1: Welcome everyone to another episode of Endocast where we discuss
Speaker 1: real clinical challenges in modern indodantechs. I am doctor Ahmachoki
Speaker 1: and I.
Speaker 2: Am doctor Franciscotebuty. Today we are discussing one of the
Speaker 2: most feared complications in indiantis the sodium hypochrite accident.
Speaker 1: Every indidentist has thought about it. What if it happened
Speaker 1: during my treatment? Although fortunately uncommon, when it occurs, it
Speaker 1: can be dramatic for both the patient and the clinician.
Speaker 2: Yeah, the good news is that most accidents are preventable
Speaker 2: and even if they occur in early recognition and the
Speaker 2: systematic management can dramatically improve the outcome. And today we
Speaker 2: will be focusing on three questions. First, why does it happen? Second,
Speaker 2: how do we recognize it? And third what should we
Speaker 2: do immediately?
Speaker 1: Exactly so in our first part of this podcast an
Speaker 1: important podcast, by the way, the most common cause is
Speaker 1: the improper irrigation technique. The issue is usually the pressure
Speaker 1: rather than the arrogant itself. If the needed binds inside
Speaker 1: the root canal while irrigation, there is no passive backflow
Speaker 1: and pressure forces the arrogant outside the tooth beyond the apex.
Speaker 1: Always ask yourself can the arrogant flow back coronally or not?
Speaker 1: If it cannot backflow, so you have to stop exactly exactly.
Speaker 2: And second, another risk fructure can be the presence of
Speaker 2: perforations or over preparation. So we have a very wide
Speaker 2: forum because we prepared a bit too much, or we
Speaker 2: have a white forama because of epical resorption, or we
Speaker 2: have a white forama because the tooth is immature and
Speaker 2: so the afpex is open. And other predisposing factors are
Speaker 2: the position of the tooth relative to the availar bone,
Speaker 2: so there is maybe a very thin cortical layer or
Speaker 2: a fenestration of the cortical bone. And also remember who
Speaker 2: gets this kind of accident most of the time. Most
Speaker 2: of the time we're speaking about women in their mid age,
Speaker 2: and so why because of the bone density. Even this
Speaker 2: part can be interesting. Try to set your mind on
Speaker 2: the patient that you're treating.
Speaker 1: I think, I think now I can feel lucky about
Speaker 1: that fifth point about the bond dynasty and the gender
Speaker 1: of the patient. So being a male patient, if I
Speaker 1: had to do a root kinnel treatment, I'm lucky. Now
Speaker 1: now we are moving to another important part in this
Speaker 1: discussion about recognizing the accident. Recognizing the sodium hypocrite extrusion accident.
Speaker 1: So the first sign is usually sudden, severe burning pain
Speaker 1: followed by rapid on site swelling. So the patients may
Speaker 1: report that the taste or the smell of a bleach.
Speaker 1: Sometimes they can reports taxis which is bleeding from the
Speaker 1: nose or alter sensation involving the infra orbital or mental
Speaker 1: nerve according to the location of the accident. So we
Speaker 1: have to stop the treatment immediately if the patient reported
Speaker 1: these incidents.
Speaker 2: Yeah. Also because if we do not stop immediately, dissolution
Speaker 2: of organic matter and hemolysis caused by this sodio hypocrite
Speaker 2: make it spread to the tissues resulting in diffuse achemosis.
Speaker 1: That's right. And after recognizing the accident, we have to
Speaker 1: profoundly assess the clinical situation. So the clinical assessment after
Speaker 1: recognizing the accident is very important for the treatment plan
Speaker 1: that you are going to handle by which you are
Speaker 1: going to handle the accident. So we have to assess
Speaker 1: facial swellings systematically using bilateral facial landmarks measurement of the
Speaker 1: distances between six facial planes from the tragus and mandibular
Speaker 1: angle which can be compared with the opposite side to
Speaker 1: determine the extent of the swelling. This will also help
Speaker 1: in the follow up of the patient after management of.
Speaker 2: The accident and then after evaluating facial swelling, try to
Speaker 2: evaluate the airways breathing and swallowing first and then go
Speaker 2: and check for sensory or motor defects, so check the
Speaker 2: function of cranial nerves. And then also the intra overal
Speaker 2: examination look for swelling or chemoses or alceration or necrosis
Speaker 2: of the tissues and document all the findings carefully. Try
Speaker 2: to keep your cool and take some pictures or some
Speaker 2: small video even with a mobile phone, in order for
Speaker 2: you to be able to compare the initial status to
Speaker 2: the status of the healing when you will be following
Speaker 2: up the patient.
Speaker 1: Now we are moving to the core of this discussion,
Speaker 1: which is the management of the accident. So first of all,
Speaker 1: we need to assess the severity of the accident, so
Speaker 1: that the first step in the management is the assessment
Speaker 1: of how severe is the sodium hypochl right accident. And
Speaker 1: the sodium hypochlaly right accident can be mild, moderate, or
Speaker 1: severe depending on the degree of pain reported by the
Speaker 1: patient upon happening and the swelling extent, as well as
Speaker 1: soft tissue findings like the echemuses like the ulceration, necrosis,
Speaker 1: et cetera exactly.
Speaker 2: And so when we have to treat, we also have
Speaker 2: to understand the timing of the treatment because there will
Speaker 2: be something we are going to do immediately that means
Speaker 2: within the first twenty four hours, and then early treatment
Speaker 2: within one week, and then the lake so long term
Speaker 2: treatment or follow up of the case. So how do
Speaker 2: we manage a mild injury? We define a mild injury
Speaker 2: an injury in which the patient in a pain visuals
Speaker 2: score reports a pain ranging from zero to three, swelling
Speaker 2: is less than thirty percent, there is a localized chemosis,
Speaker 2: but no ulceration non acrossis. So this is something that
Speaker 2: we can manage by ourself as GPS or as ended aunties.
Speaker 2: What do we have to do immediately? We have to
Speaker 2: irrigate the canals with water or saline with the aim
Speaker 2: of diluting the sodium hypochloride. We want to decrease the
Speaker 2: concentration of the sodium hypochloride and then we can provide
Speaker 2: some over the counter and ergesia. This should be enough
Speaker 2: to manage the symptoms because we are speaking about a
Speaker 2: low degree of pain and a low degree of damage
Speaker 2: to the court the patient. And we can also prescribe
Speaker 2: some non seroidal anti inflammatory drugs and in the beginning
Speaker 2: some cold compress in order to reduce the swelling. And
Speaker 2: we can take an extray in order to try to
Speaker 2: identify the cost for the extrusion injury. So perforation, what
Speaker 2: framen why did it happen? And then last but analyst,
Speaker 2: we could leave just the canands open to drain, but
Speaker 2: if we do so, we have to daily see the
Speaker 2: patient in the next days in order to check on it. Yeah,
Speaker 2: then we can follow up the patient in the first
Speaker 2: week and suggest him to do some compression with some
Speaker 2: warm towels in order to stimulate the local circulation. And
Speaker 2: if we see that the tooth cannot be restored for
Speaker 2: some reason, maybe it broke, extract the tooth, don't wait
Speaker 2: and then regularly review the patient to reassure him and
Speaker 2: to just monitor the symptoms and the evolution of the disease.
Speaker 2: And the late treatment is to if I can complete
Speaker 2: the root canal treatment, then I finish it and maybe
Speaker 2: I will be using some irrigant different from sodium hypochloride
Speaker 2: in order not to have the same problem a second time.
Speaker 1: So that was really comprehensive about the mild injuries. But
Speaker 1: on the other hand, if we have moderate injuries are
Speaker 1: these are presented as pain on the scale of four
Speaker 1: to six on a visual analog scale, and the swelling
Speaker 1: can be thirty to fifty percent more than the unaltered
Speaker 1: normal side. The opposite side will diffuse ecomass and intraordal alteration.
Speaker 1: Moderate injuries required specialist assessment in the first place. Imaging
Speaker 1: and management of the soft tissue injuries. The early management
Speaker 1: is the same as the mild injuries, in addition to
Speaker 1: the bridment of the sift tissue, ulceration and necrotic tissue
Speaker 1: because in mild injuries we have soft tissue leads due
Speaker 1: to extrusions, so we need to just the bride and
Speaker 1: clean all these alceration or necrotic tissues. The early management
Speaker 1: is the same as the mild injuries in addition to
Speaker 1: particular step which is the bribment of the soft tissue
Speaker 1: alteration necrotic areas because there are some soft tissue loss
Speaker 1: due to extrusion of the hypochrite into the soft tissue,
Speaker 1: so you have to clean that. Late management involves replacement
Speaker 1: of the loss tissue, which is mostly addicals tissues, using
Speaker 1: dermal fillers for example, for correction of any possible because
Speaker 1: this is not the case in every extrusion or every
Speaker 1: moderate injury due to sodium hypercrite accident. But sometimes we
Speaker 1: have some soft tissue loss that can be replaced with
Speaker 1: using dermal fillers to avoid any permanent efficient formities. And
Speaker 1: of course this should be performed by a trained and
Speaker 1: experienced ural maxicofacial specialist.
Speaker 2: And what about the severe injury, So we are speaking
Speaker 2: about something where the pain of the patient is higher
Speaker 2: than seven and the swelling is more than fifty percent
Speaker 2: if compared to the other side of the face. We
Speaker 2: have diffuse a chemosies and also we have interorlceration necrosis.
Speaker 2: Maybe also the always are compromised and there is a
Speaker 2: neurobascular deficient. Of course, in this case we cannot manage
Speaker 2: it by ourselves, so we have to immediately refer the
Speaker 2: patient to the hospital and to a specialized maxillofacial unit.
Speaker 2: So immediate treatment involves first urgent referral to the local
Speaker 2: or AMFAS unit, second e opioid or intravenous steroids in
Speaker 2: order to aid with the inflammation. And also we should
Speaker 2: be considering intervening antibiotics in order to reduce the risk
Speaker 2: for secondary infection because here there is a huge damage
Speaker 2: to the tissues and we can also need an MRI
Speaker 2: in order to identify which tissues are inflamed or be
Speaker 2: siblicity in order to assess effect on the surrounding tissues.
Speaker 2: The early treatment is the same as the mild injury,
Speaker 2: so nothing particular may be thereasiness to drain any collection
Speaker 2: which might have formed, so this is the big difference,
Speaker 2: and of course we need to have the patient reviewed regularly,
Speaker 2: but this will be man by the oral and maxillofacial surgier.
Speaker 2: The late treatment of this kind of disease is the
Speaker 2: same technique as before, so we will be needing to
Speaker 2: correct any soft tissue effect by transplant or fillers or
Speaker 2: statics in general, and if there is any sensory or
Speaker 2: motor neuvascular deficiit, we will need to be reviewing the
Speaker 2: patient regularly and maybe there will be needed for some treatment,
Speaker 2: and there could also be some neuropathic pain following this
Speaker 2: kind of accident, and so there would be the need
Speaker 2: for specialists to give some pharmacological treatment in order to
Speaker 2: address this specific problem, and then the patient, who could
Speaker 2: also be needed some speech therapy or language therap be
Speaker 2: in order to rehabilitate the speech and the swallowing functions.
Speaker 1: But now I have one question for you, and because
Speaker 1: you are experienced in that topic, which is what if
Speaker 1: the clinician face some extrusion of the sodium hypocrite into
Speaker 1: the sinus accidentally?
Speaker 2: Okay, well that this is a topic that is very
Speaker 2: interesting for me. But it has been reported in the
Speaker 2: literature sometimes and we always have to consider the amount
Speaker 2: of sodi hypocrite that is to res into the sinus,
Speaker 2: because probably every single underdone takes at some point in
Speaker 2: his life extruded some sodium hypocrite somewhere and maybe a
Speaker 2: part of this so the hypocrites went in the sinus,
Speaker 2: but without probably major damages because it was immediately recognized. Okay.
Speaker 2: In this case, we have Arish and colleagues that reported
Speaker 2: a case of an endontic therapy of a maxillary right
Speaker 2: first molar and shortly after irrigation of the palatal canal
Speaker 2: with full strength five point twenty five percent sodium hypochride.
Speaker 2: The patient complained about having a taste in its throth
Speaker 2: despite the presence of a correct rubber dam isolation, and
Speaker 2: so they irrigated the canal with sterbo water and they
Speaker 2: found that the water was passing through the paltal canal
Speaker 2: into the maxillary sinus and onto the nasal cavity via
Speaker 2: the osteometry and then into the pharynx. So apart from
Speaker 2: the initial congestion and the mild verse in sensation in
Speaker 2: the right maxilla, the patient experienced no severe consequence and
Speaker 2: was a symptomatic four days after the accident. In this case,
Speaker 2: there was no major consequence, but we will have a
Speaker 2: full discussion soon on this topic about the endosinus communication
Speaker 2: in the end the case, so stay tuned. And then
Speaker 2: we have another case of a right second primolar where
Speaker 2: they used a lower concentration of sodiy hypercriti point five percent,
Speaker 2: and even in this case the patient had immediate burning sensation.
Speaker 2: But in this case there were also natal bleeding and
Speaker 2: the patient complained about swallowing blood and not being able
Speaker 2: to breathe correctly, so of course they immediately stopped the irrigation.
Speaker 2: They irrigated with canal with stereosligine dried with stereop points.
Speaker 2: But four days later the rocnal treatment was completed with
Speaker 2: no complication and after three months the tooth was a symptomatic.
Speaker 2: The last case reported in the little of what I
Speaker 2: know is about the maxillary right second premolar. Also in
Speaker 2: this case, during the irrigation, the patient had severe facial
Speaker 2: pain and swelling, and in this specific case, the patient
Speaker 2: had to undergo a caldual look approach, so they had
Speaker 2: to drain surgically the sinus and despite an apparent healing
Speaker 2: of the societies, the tooth remained painful and so it
Speaker 2: was extracted in the end three months after the initial
Speaker 2: presentation of the symptoms. So it can change a lot
Speaker 2: from case to case. But what really makes the difference
Speaker 2: is how much the hypocrite we extrude into the sinus
Speaker 2: in this case before noticing, and so according to the
Speaker 2: amount of the damage, they would be a very different
Speaker 2: outcome of this tea. And this is my sodium hyperchyrite
Speaker 2: accident into the sinus. So I was treating and retreating
Speaker 2: the first model of this patient isolation. This assembling, I
Speaker 2: removed everything I found the MB two. I was doing everything,
Speaker 2: but I had some large foramen in this case because
Speaker 2: my shaping was higher than fifty islo okay, And while
Speaker 2: doing the finary irrigation, I had some blood coming out
Speaker 2: of the canals and the patient was bringing his hands
Speaker 2: to the area of the sinus. I was like, okay,
Speaker 2: are you in pain, and it was like, it's the
Speaker 2: strongest paint I've ever felt in my life. So immediately
Speaker 2: irrigation with water. I put nothing as a medication into
Speaker 2: the canal. I just temporized. I gave him painkillers, immediate
Speaker 2: application of cold, and then I told him I told
Speaker 2: me some warm compers and stuff, and I made him
Speaker 2: be reviewed during the following week. Seven days later, I
Speaker 2: was able to finish my rocnal treatment with no complication,
Speaker 2: and then too was restored and proticized, so it ended
Speaker 2: up well.
Speaker 1: So from all these cases we can conclude that it
Speaker 1: can happen with the most experienced clinicians because it depends
Speaker 1: on the anatomy, the amount of soldi hypocrite, the foreman,
Speaker 1: and the relationship between the roots and the sinus. So
Speaker 1: that accident doesn't mean that the clinician is not controlling
Speaker 1: the procedure, but it is called an accident. That's why
Speaker 1: we have to just reassure the patient that the first
Speaker 1: happening of this accident and then we follow the recommendation
Speaker 1: about the management as we just discussed. So now we
Speaker 1: are going to discuss the prevention. And it goes without
Speaker 1: saying that we have to use a side vented needle,
Speaker 1: never buying the needle into the root canal, irrigate slowly,
Speaker 1: keep agitating the needle up and down and maintain the
Speaker 1: continuous back flow of the irrigation out of the canal
Speaker 1: in a coronal direction. And this is very easy because
Speaker 1: we have the same physical action of the fluids coming
Speaker 1: from the narrowest part to the widest part of the
Speaker 1: root canal.
Speaker 2: Yeah, exactly. And remember that successfully irrigation depends on the
Speaker 2: controlled exchange, not on the pressure, and that's why we
Speaker 2: can use negative pressure irrigation. Look at this case here
Speaker 2: I'm doing the treatment in the two You see that
Speaker 2: I'm tecking with the valsaba man over if there is
Speaker 2: a communication between the tooth and the sinus, and there
Speaker 2: is so in this case, I cannot use anything different
Speaker 2: from negative pressure irrigation. Otherwise, when the patient breathe is
Speaker 2: going to inhale the sodium hypochoride. So of course this
Speaker 2: can be a tool that is extremely useful above all
Speaker 2: in the case, so when we think that there could
Speaker 2: be communication with the sinus, always use negative pressure irrigation
Speaker 2: because it's the safest way to deliver sodium hypochriide and
Speaker 2: to prevent the accident from happening.
Speaker 1: So I think we have been so serious, not like
Speaker 1: every time a lot of humor. This time we were
Speaker 1: serious because this is a serious accident that can happen
Speaker 1: in our practice to all of us. So I hope
Speaker 1: you had some guide in order to manage and before
Speaker 1: that to recognize the accident. So sodium hypocrite by itself
Speaker 1: or sodium hypocrit per se, is not a dangerous solution.
Speaker 1: The uncontrolled pressure is a dangerous part, not the solution.
Speaker 1: So you have to control your pressure if you cannot
Speaker 1: use some devices like the negative pressure side vended needles
Speaker 1: and all the tools that we have mentioned in our discussion.
Speaker 2: Yeah, because the proper tools and the techniques, together with
Speaker 2: some awareness of the anatomical relationship between the teeth and
Speaker 2: the abstructors can really help us preventive most of the accidents.
Speaker 1: So I think we ended a very important episode in
Speaker 1: the season and see you soon in a very interesting
Speaker 1: episode the next one. So thank you for joining us
Speaker 1: in this episode of Indocast.
Speaker 2: Stay curious, stay conservative, and keep on saving teeth. Seeing
Speaker 2: the next episode, Child