Localized alveolar bone necrosis following the use of an arsenical paste: a case report

AIM: To describe some toxic effects of arsenic trioxide in the mouth, to condemn its continued use, and present a case in which a tooth was preserved despite significant bony destruction. SUMMARY: A case is presented in which severe alveolar bone necrosis resulted from leak-age of an arsenical devitalization paste into the periodontium.The tooth was root canal treated before root amputation, and restored with a cuspal coverage restoration. The tooth was observed to be symptomless and functional at the one-year follow-up. KEY LEARNING POINTS: * Arsenic and its compounds have no place in contemporary endodontics. * Dentists should protect their patients by avoiding the use of arsenic-containing materials and refusing to use products whose constituents are not known. * Localized bone necrosis may not require tooth extraction. Depending on the severity of the case, the tooth may be preserved by a combination of endodontic, periodontal,prosthodontic and maintenance therapies.     

Mandibular bone necrosis caused by use of arsenic paste during endodontic treatment: two case reports

Aim  To report that arsenical pastes are still employed in endodontics and to highlight the potentially serious consequences of their use.
Summary  Chemotherapeutic agents such as arsenic trioxide and paraformaldehyde were once commonly employed as pulp-necrotizing agents. Their cytotoxic effects are well recognized, and leakage from teeth has been associated with widespread necrosis of periodontal tissues and bone. This report describes two cases of severe bone necrosis affecting the mandible following the use of an arsenical paste.
Key learning points • Pulp-necrotizing agents such as arsenic trioxide can cause severe bone necrosis.
• Arsenical pastes have no place in contemporary dental practice.
• Dentists should employ appropriate local anaesthetic techniques for pulp extirpation instead of relying on toxic necrotizing agents.     

The eating disorders: 2. Behavioural and dental management

The eating disorders are a group of related but distinct disturbances in eating behaviour with wide-ranging effects.The first part in this series described the scientific background, clinical features and impact upon oro-dental health.This second part discusses behavioural and dental management. CLINICAL RELEVANCE: Dentists should have knowledge of the behavioural management of eating disorders (ED), especially if their ED patients are seeing other healthcare professionals. Dentists with this understanding may better engage with an ED patient in order to provide successful dental management within an overall holistic approach to patient care.     

When patients become cyanotic: acquired methemoglobinemia.

BACKGROUND: The authors conducted literature review to create a heightened awareness of the potential for developing toxic methemoglobinemia from local anesthetics. Methemoglobin normally is present in the blood at levels less than 1 percent. Levels may become toxic as hemoglobin is oxidized to methemoglobin after local anesthetics such as benzocaine and prilocaine are administered. TYPES OF STUDIES REVIEWED: The authors searched the medical and pharmaceutical industry literature. They found and reviewed case studies of incidences of methemoglobinemia that resulted from local anesthetic overdoses. RESULTS: Cases of local anesthetic-induced methemoglobinemia in dental practice are under-recognized and rare. Reported cases of prilocaine-induced methemoglobinemia have resulted in recent changes in some prilocaine literature. These changes include maximum recommended doses for patients of various weights. CLINICAL IMPLICATIONS: Dentists should identify patients who are at increased risk of developing methemoglobinemia before administering local anesthetics. They also should follow new recommended dosing guidelines for prilocaine and be aware of symptoms of this adverse reaction.     

Palatal mucosa necrosis because of accidental sodium hypochlorite injection instead of anaesthetic solution

AIM: A case is reported in which sodium hypochlorite (NaOCl) was inadvertently injected into the palatal mucosa instead of local anaesthetic solution. SUMMARY: An adult male was referred to the University clinic 15 days after an inadvertent NaOCl injection into the palatal mucosa. Soft tissue necrosis was evident, without obvious bony involvement. Tissues healed without scarring within 30 days. No surgical intervention was required. KEY LEARNING POINTS: NaOCl is highly irritant when extruded into vital tissues.--Dentists should be careful to avoid the misuse of NaOCl, and should check the nature of any agent before injecting it into patients.--NaOCl should not be dispensed in a way that could allow it to be mistaken for local anaesthetic solutions.--The well-perfused tissues of the oral cavity have considerable healing ability.     

The eating disorders: 1. Current scientific understanding and dental implications

The eating disorders are a group of related but distinct disturbances in eating behaviour with wide-ranging effects. This first part describes the epidemiology, aetiology, general clinical features and specific dental sequelae associated with the eating disorders. Part 2 discusses psychological aspects of management as well as dental treatment. Clinical Relevance: Dental health can be compromised in patients with an eating disorder. Dentists should understand the medical, psychological and dental features and competently manage any secondary dental problems.     

Osteomyelitis due to arsenic trioxide use for tooth devitalization

AIM: To present a case of osteomyelitis that was caused by the use of arsenic trioxide during root canal treatment in a mandibular left first molar. SUMMARY: Arsenic was once in common use to devitalize inflammed pulp tissue before root canal treatment. Its prolonged application or leakage leads to toxic effects beyond the pulp tissue, and necrosis of periodontal tissues and supporting alveolar bone has been described. This report presents a case of osteomyelitis resulting from leakage of arsenic trioxide used in pulp devitalization. Sequestrectomy and excision of non-vital alveolar bone was performed to treat the severe tissue necrosis. KEY LEARNING POINTS: Agents containing arsenic are still employed by some clinicians and may be encountered when patients present with tissue destruction resulting from their use. Dental practitioners should be aware that arsenic paste may diffuse into periodontal tissues through apical, lateral or accessory canals, through perforations and around leaking restorations. Osteomyelitis caused by arsenic trioxide can be treated by a combination of pharmacotherapeutic and invasive surgical methods. Arsenic pastes have no place in endodontic practice.     

Purchasing,installing and operating dental amalgam separators: practical issues

BACKGROUND: Growing environmental concern over the accumulation of mercury in some fish has led some state and local environmental agencies to pursue stricter regulation of mercury in wastewater. Dental offices are an identifiable source of mercury in the form of dental amalgam. Although mercury in dental amalgam is not immediately bioavailable (that is, it has not been shown to contribute significantly to the problem of mercury in fish tissue), environmental agencies in some locales are asking dental offices to install amalgam separators in an effort to reduce amalgam discharges beyond those already achieved through chairside traps and vacuum filters. Field experience indicates that the configuration and operation of the dental office infrastructure can significantly affect the choice of separator, as well as the operation and maintenance of the installed equipment. OVERVIEW: The authors review factors related to office infrastructure and operation that dentists should consider when investing in an amalgam separator. They also provide a cost-analysis worksheet and checklist that may be useful to dentists who are considering purchasing a separator. CONCLUSIONS AND CLINICAL IMPLICATIONS: Before purchasing or installing an amalgam separator, dentists should consider factors specific to the available models, including size and maintenance requirements. In addition, office-specific actors should be considered (such as the plumbing configuration, available space for installation and subsequent access to that space for equipment replacement and maintenance). Dentists also should research whether any local or state regulations exist that might influence product selection or installation. Dentists should consider the effect an amalgam separator could have on existing suction equipment. Finally, dentists will want to consider the short- and long-term costs (including maintenance and parts replacement) of the available options.     

Stress, burnout, anxiety and depression among dentists

BACKGROUND: Dentists encounter numerous sources of professional stress, beginning in dental school. This stress can have a negative impact on their personal and professional lives. CONCLUSIONS: Dentists are prone to professional burnout, anxiety disorders and clinical depression, owing to the nature of clinical practice and the personality traits common among those who decide to pursue careers in dentistry. Fortunately, treatment modalities and prevention strategies can help dentists conquer and avoid these disorders. PRACTICE IMPLICATIONS: To enjoy satisfying professional and personal lives, dentists must be aware of the importance of maintaining good physical and mental health. A large part of effective practice management is understanding the implications of stress.     

Avoiding malpractice for nondental conditions. The example of human immunodeficiency virus

BACKGROUND: Dentists are legally liable for failing to recognize medical conditions that they identify while providing dental care and for failing to refer patients for follow-up care and testing. This article suggests ways to avoid liability using human immunodeficiency virus, or HIV, infection as an example. TYPES OF LITERATURE REVIEWED: The authors conducted a review of the legal literature to determine circumstances that would cause dentists to have legal liability for failing to recognize a medical problem. The authors also conducted a review of the dental literature to identify the most common signs of HIV infection that dentists might see in practice. RESULTS: The legal literature indicates that dentists can be held liable for failing to recognize medical problems, including HIV and acquired immunodeficiency syndrome. The dental literature shows that there are multiple signs and symptoms that indicate the potential for HIV infection to be the underlying cause of many oral diseases. PRACTICE IMPLICATIONS: Dentists should be familiar with the most common oral manifestations of medical conditions that are likely to be identified in the dental office, including those associated with HIV infection. They must recognize medical conditions and arrange for appropriate referral to avoid liability.     

Dental management of patients with cardiovascular disease

Authors present the management of patients affected by cardiovascular disease undergoing oral surgical treatment. Oral surgery may influence the health of these patients because of three factors: psychological stress, anesthesia and daily pharmacological therapy. Dentists have to know and apply preventive rules to avoid the risks of medical complications during surgical treatment, they also have to be able to manage cardiological emergencies wherever they occur.     

Lateral heat production secondary to electrosurgical incisions

Adverse healing responses, including necrosis of soft tissue and sequestration of alveolar bone, have been reported following the use of electrosurgery for intraoral incisions. These responses are usually attributed to excessive heat accumulation during the surgical procedure. The purpose of this investigation was to measure temperature changes in subadjacent connective tissue during intraoral electrosurgical incisions in palatal mucosa of miniature swine. Results indicate that single electrosurgical incisions should be accomplished at a speed of approximately 7 mm. per second and that successive incisions should be separated by a cooling interval of 8 to 10 seconds to avoid generation of heat sufficient to initiate an adverse healing response.     

Complications in patients on therapeutic drugs

Increasing numbers of patients take more drugs of ever-increasing potency. Dentists today see many of these patients. They should therefore be aware of the connection between drug administration and emergency situations. In certain instances drug-related complications, side-effects and emergencies of both a local and a general nature can arise. Some local complications are destruction of teeth due to the intake of medicines with high sugar content; erosive lesions of the oral mucosa; paraformaldehyde necrosis; and those arising from the use of chlorhexidine. Systemic complications are anaemia due to aspirin misuse; oral ulceration due to antirheumatic drugs; adrenal insufficiency after glucocorticosteroid medication; catecholamine reactions; anticoagulation therapy and bleeding problems; epilepsy; asthma; aplastic anaemia; opportunistic infections; and allergic reactions. The dentists should be prepared to diagnose and manage these complications whether they arise during dental treatment or following it.     

Management of arsenic trioxide necrosis in the maxilla

Historically, pulp-necrotizing agents were commonly used in endodontic treatments. They act quickly and devitalize the pulp within a few days. However, they are cytotoxic to gingiva and bone. If such an agent diffuses out of the cavity, it can readily cause widespread necrosis of gingiva and bone, which can lead to osteomyelitis of the jaws. Although the use of arsenic trioxide can cause severe damage to surrounding tissues, producing complications, it is still used in certain areas in the world. This article presents and discusses two cases of tissue necrosis and their surgical management. These cases showed severe alveolar bone loss in the maxilla, which affected the patients' quality of life and limited the restorative possibilities. As dentists, we should be aware of the hazardous effects of arsenic trioxide and should abandon its use. Because of its cytotoxicity, there is no justification for the use of arsenic trioxide in the modern dental practice.     

Antibiotic prophylaxis in dentistry: a review and practice recommendations

BACKGROUND: The American Heart Association, or AHA, and the American Dental Association recently changed their recommended protocols for antibiotic prophylaxis against bacterial endocarditis. A new recommendation also has been issued by the ADA and the American Academy of Orthopaedic Surgeons, or AAOS, against routine antibiotic prophylaxis in patients with prosthetic joint replacements. These changes reflect increasing scientific evidence and professional experience in opposition to widespread use of antibiotic prophylaxis in these specific situations and others faced in dentistry. METHODS: The authors reviewed the medical and dental literature for scientific evidence regarding the use of antibiotics to prevent local and systemic infections associated with dental treatment. Situations commonly considered by dentists for potential use of prophylactic antibiotics were reviewed to determine current evidence with regard to use of antimicrobial agents. This included prevention of distant spread of oral organisms to susceptible sites elsewhere in the body and the reduction of local infections associated with oral procedures. RESULTS: There are relatively few situations in which antibiotic prophylaxis is indicated. Aside from the clearly defined instances of endocarditis and late prosthetic joint infections, there is no consensus among experts on the need for prophylaxis. There is wide variation in recommended protocols, but little scientific basis for the recommendations. The emerging trend seems to be to avoid the prophylactic use of antibiotics in conjunction with dental treatment unless there is a clear indication. CONCLUSIONS: Aside from the specific situations described, there is little or no scientific basis for the use of antibiotic prophylaxis in dentistry. The risk of inappropriate used of antibiotics and widespread antibiotic resistance appear to be far more important than any possible perceived benefit. CLINICAL IMPLICATIONS: Dentists are wise to use antibiotic prophylaxis in only those specific situations in which there is a valid scientific basis for it. Whenever possible, dentists should follow the standard protocols recommended by the ADA, AHA or AAOS.     

Consent,restraint,and people with special needs:a review

Dentists providing treatment to individuals with developmental disabilities are often faced with unique medical/legal issues. Obtaining informed consent when a patient does not have capacity can be an involved process. Issues regarding therapeutic aides used for immobilization (i.e., restraint) during treatment may further complicate the situation. This area is controversial and has even resulted in legal difficulties for some dentists. Several topics related to the use of restraint are addressed in this article. A review of the literature and applicable laws pertaining to consent issues for people with special needs is presented and appropriate use of medical immobilization is discussed.
Existing guidelines are reviewed. Informed consent and the use of restraint should be incorporated into overall guidelines for the use of anesthesia, sedation, and alternative behavior management techniques in providing dental care to patients with special needs.     

Toxicity of methyl methacrylate in dentistry

Methyl methacrylate (MMA), a monomer of acrylic resin, has a wide variety of dental, medical and industrial applications. Concerns have been raised regarding its potential toxicity in dental use, both for the patient and also in the workplace. Dental patients are also exposed to MMA leached from some dental appliances and the effects, at least in vitro, appear toxic to cells and may cause local mucosal irritation or even an allergic reaction. When exposed to MMA in the dental clinic, dentists and other dental staff appear to occasionally suffer hypersensitivity, asthmatic reactions, local neurological symptoms, irritant and local dermatological reactions. The integrity of latex gloves may also be compromised after exposure to MMA during dental procedures. MMA is not thought to be carcinogenic to humans under normal conditions of use. Techniques should be employed to reduce patients' exposure to MMA during dental procedures in order to reduce the risks of possible complications. Dental staff should avoid direct contact with MMA and room ventilation should be optimised.     

Acute Fluoride Toxicity from Ingesting Home-use Dental Products in Children, Birth to 6 Years of Age

Objectives : This paper analyzes reports to the American Association of Poison Control Centers (AAPCC) of suspected overingestion of fluoride by children younger than 6 years of age between 1989 and 1994, and estimates the probably toxic amounts of various home-use fluoride products in children younger than 6 years of age. Methods : Annual incidence rates of reported fluoride exposures attributed to dietary supplements, toothpaste, and rinses were calculated. Probably toxic amounts of each product were calculated using the frequently cited dose of 5 mg/kg. Results : Children younger than 6 years of age accounted for more than 80 percent of reports of suspected overingestion. While the outcomes were generally not serious, several hundred children were treated at health care facilities each year. A 10 kg child who ingests 50 mg fluoride (10.1 g 1.1% NaF gel; 32.7 g 0.63% SnF₂ gel; 33.3 g 1,500 ppm F toothpaste; 50 g 1,000 ppm F toothpaste; and 221 mL 0.05% NaF rinse) will have ingested a probably toxic dose. Conclusion : Overingestion of fluoride products in the home is preventable. Dentists and other health care providers should educate parents and child care providers about the importance of keeping fluoride products out of reach of children. Manufacturers should be encouraged by the ADA and the FDA to use child-resistant packaging for all fluoride products intended for use in the home.     

Subcutaneous emphysema secondary to dental extraction: A case report

Although less frequently encountered in dental practices, subcutaneous emphysema of the face and neck has been reported in patients following dental extractions, particularly when lower molar teeth are extracted with the use of a high‐speed air‐turbine drill designed for restorative treatment, which forces air into the cervical fascial spaces. As facial swelling and pain are the most common presentations, subcutaneous emphysema can often be misdiagnosed as an allergic reaction or odontogenic infection. While usually a benign and self‐limiting condition, subcutaneous emphysema may have life‐threatening complications such as tension pneumothorax, cardiac tamponade, air embolism, tracheal compression and mediastinitis, which are important to recognize in an emergency setting. Dentists should be aware of the serious risks of inducing subcutaneous emphysema and avoid performing tooth extractions with high‐speed air‐turbine drills which are specifically designed for use for restorative treatments only.