5.5
Inadvertent Extrusion
Samantha Hamer and Shalini Kanagasingam
Objectives
At the end of this case, the reader should be able to identify the signs and symptoms associated with inadvertent extrusion of endodontic materials beyond the confines of the root canal. The reader should be aware of the management strategies and appreciate the measures that can be taken to prevent the occurrence of extrusion accidents.
Introduction
A 53‐year‐old female patient presented complaining of acute pain, facial swelling and mucosal ulceration. The patient had been referred by her general practitioner, who had seen her the previous day for root canal treatment of the upper right canine (UR3). During the irrigation procedure, the patient experienced sudden severe pain. The referring dentist provided additional local anaesthetic, provisionally restored the tooth and prescribed analgesics.
Chief Complaint
The patient complained of a constant dull ache associated with the upper right quadrant since the endodontic procedure. She was also very distressed by the facial swelling and bruising she experienced, which was still present after 24 hours.
Medical History
Unremarkable.
Dental History
Regular attender and has had restorations replaced recently.
Clinical Examination
Extraoral examination revealed moderate swelling and bruising over the right cheek with loss of the right nasolabial fold (Figure 5.5.1a). This area was found to be slightly tender to palpation. Intraoral examination revealed a moderately restored dentition. An access cavity on the palatal aspect of the UR3 had been restored with glass ionomer cement. A 12 mm × 3 mm ulcer was noted on the labial mucosa, apical to the UR3 (Figure 5.5.1b).
Tooth UR3 was tender to percussion. There was no loss of motor or sensory function of the surrounding tissues in the upper right quadrant. A periapical radiograph revealed a UR3 with a single canal and a periapical lesion. There were no signs of perforation of the root or root resorption. The tooth had a closed root apex and there was no sign of excessive apical preparation.
Diagnosis and Treatment Planning
A diagnosis of previously initiated therapy and symptomatic apical periodontitis was reached for the UR3. A sodium hypochlorite extrusion incident occurred during the previous canal instrumentation procedure.
The anticipated short‐term and long‐term sequelae of the sodium hypochlorite extrusion (including further swelling, bruising, paraesthesia and scarring) were explained to the patient. She received advice on pain management, use of warm compress, warm saline rinses and reassurance that her symptoms would be expected to subside after a week and may take up to a month to completely resolve. Rarely, some patients may have sensory or motor impairment after one year. Due to the presence of the ulceration, the patient was referred to an Oral and Maxillofacial (OMFS) unit.
The treatment options for tooth UR3 were discussed with the patient:
- No treatment
- Continuation of root canal treatment followed by definitive restoration
- Extraction
What are the consequences of sodium hypochlorite (NaOCl) extrusion?
The antibacterial properties and organic tissue‐dissolving capacity of sodium hypochlorite make it a highly effective root canal irrigant. However, it is also cytotoxic and caustic. If it is extruded into the periapical vital tissues, it will cause oxidation of the surrounding tissues, leading to haemolysis, ulceration and damage to endothelial and fibroblast cells and inhibition of neutrophil migration.
Patients’ initial symptoms include:
- Sudden onset of severe pain (despite presence of local anaesthetic).
- Profuse haemorrhage in the root canal.
- Swelling.
- Burning pain in the throat or sinus (if extrusion involves the maxillary sinus). The accessed tooth will present with little or no bleeding from the canal and there are usually no signs of immediate swelling. The patient may experience sinus congestion and nasal bleeding.
Subsequent symptoms may include the following:
- Haemolysis leading to interstitial bleeding (haematoma).
- Mucosal necrosis.
- Neurological signs (paraesthesia).
- Trismus.
- Swallowing difficulties/airway distress.
How can the severity of the injury be assessed and what is the optimal management?
The management of NaOCl extrusion is based on the severity of the tissue injuries. Figure 5.5.2 highlights the relevant management strategies. Reassuring the patient and daily contact are important to monitor changes in the patient’s condition and provide reassurance.
Figure 5.5.2 Guidance on the important management strategies for NaOCl extrusion.
Mild injuries are indicated by the patient complaining of a relatively low degree of pain localised to the tooth undergoing endodontic treatment. The presence of swelling would be less than 30% compared to the contralateral side with localised ecchymosis. These injuries will be suitable to be managed by a general dentist or endodontist.
Moderate to severe injuries
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