Extrusion of endodontic materials revisited

 Got a chance to follow up on the incident in this previous post:

 https://dental-tidbits.blogspot.com/2021/04/extrusion-of-endodontic-materials.html

The clinic got a call from the patient that she was in a lot of pain about 9 days after the appointment. She had seen her doctor and was on antibiotics. She was double booked in into the clinic on the next day and I spent the day before the appointment stressing about what I had done and what I was going to do.

I spent the night before researching about hypochlorite incidents and the management of. A lot of the serious complications of hypochlorite extrusion requires the dentist to bind the syringe needle and forcefully push the irrigant out the end. As I had some irrigant left in the calcified canal and the irrigant was forced out with the cavit placement, the actual volume of irrigant that could have been extruded is quite small and so the amount of damage and inflammation would be minimal. 

In the end it turned out that the tooth had settled quite quickly after the appointment and the patient was in pain with another tooth which was quite relieving. Still, I had read up on hypochlorite incidents so I thought I would jot a few things down here.

-The main cause of pain is profound inflammation in the tissues surrounding the tooth. This inflammation if severe enough can cause necrosis of the tissues. If near major nerves it can cause parasthesia. Severe hypochlorite incidents should be referred to an oral and maxillofacial surgeon promptly. 

-The main cause of hypochlorite extrusion is perforation of the tooth and binding of the needle tip under pressure. To avoid the needle binding, stay short of the apex, use light pressure on the plunger, use a side venting needle and keep the tip moving while irrigating. 

-If there is extrusion of the irrigant, the patient will experience sudden and intense pain due to the spread of the irrigant beyond the zone of anaesthesia. They may experience severe pain, intraoral or extraoral swelling within hours and parasthesia in severe incidents.

-Immediate management should be removal of excess irrigant by pulling back on the syringe which will apply negative pressure. Then irrigate the canal with an alternative liquid e.g Local anaesthetic, saline, EDTA. LA or saline can be forced out of the tooth to dilute the irrigant in the bone. Most of the damage occurs instantly but long term inflammation may be reduced by dilution. Place a dressing, CAOH or an antibiotic dressing and seal the tooth off. Local anaesthetic can be given in the tissues to increase the zone of anaesthesia and take the patient out of pain.

-In cases where infection is a concern, antibiotics can be prescribed and oral corticosteroids can be prescribed to reduce post operative swelling.

-In severe extrusions, refer promptly to an oral and maxillofacial surgeon. If there is a perforation or mild or moderate extrusion, referral to an endodontist can be considered. Mild extrusions can be managed with analgesia and followup. Follow up the patient in a few hours, the next day and in the following weeks. If there are signs of parasthesia or uncontrollable infection or necrosis, refer to an oral and maxillofacial surgeon.

Edit: I caught up with the patient at her next appointment. It turns out the pain she experienced after the extirpation disappeared 2 days after the procedure so it wasn't too severe after all