When NaOCl is inadvertently forced into the periapical soft tissues, the sequence of injury seems to be as follows2:
– excruciating severe pain for two to five minutes;
– immediate swelling (ballooning) of the area, with spread of the tissue reaction to the surrounding areas through the loose connective tissue;
– profuse hemorrhage, either interstitially or manifesting intraorally through the tooth.
As the tissue destruction progresses, extreme constant discomfort replaces the initial severe pain. The tissue response is out of proportion to the volume of the irritant. Once the initial bleeding ceases, interstitial oozing still continues because of lysis of cellular structures and surrounding vasculature. This results in significant ecchymosis.
Treatment should center on the principles of minimizing swelling, controlling pain and preventing secondary infection. Reassuring the patient is of prime importance. Use of cold packs externally is recommended for the first one to two days to minimize edema. Once drainage is established, the cold packs should be replaced by warm compresses in an attempt to promote liquefaction of the hematoma and dissolution of the soft-tissue swelling. Pain control often requires narcotic analgesics. Appropriate antibiotic therapy is highly recommended for two reasons: the possibility of infection’s being forced from the root canals into the periapical tissues with the NaOCl irrigation, and the subcutaneous presence of significant amounts of necrotic tissue and dead space, which can promote secondary infection.
Depending on the degree of the injury and its response to conservative therapy, some cases might require surgical intervention. The aims for any surgical procedure should be to provide decompression and facilitate drainage, and to create an environment conducive to healing. This can be accomplished by meticulous débridement of grossly necrotic tissue, and by lavage and irrigation of the affected sites. It should be kept in mind that the hematoma and/or infection may not follow the usual anatomical planes. Because of its potential to actively destroy tissues, NaOCl often causes sufficient tissue lysis to create its own planes. This results in widespread and haphazard progression of the tissue reaction, as occurred in our patient.
Most cases resolve after several days of edema, paresthesia, ecchymosis and, in a few cases, secondary infection. Some patients, however, may be left with long-term paresthesia, scarring or esthetic defects.3
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