Brain Injury Due to Anaphylactic Shock as A

8/20/2019 Brain Injury Due to Anaphylactic Shock as A

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Brain injury due to anaphylacticshock as a result of formocresol used

during root canal treatmentInternational Endodontic Journal, 46, 999–1!,"1#


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Introduction

Many materials used during endodontic treatment containpotential allergens which can induce hypersensitivity reactions(Hensten & Jacobsen 2005)

!ormocresol has been widely used in dentistry "or more than#00 years due to its antibacterial properties despite itsuncertain biocompatibility

!ormocresol and related agents have been traditionally usedas disin"ectants "or root canal treatment$ pulpotomy and rootcanal sealants


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!ormaldehyde (para"ormaldehyde and trio%ymethylene)$ aprimary component o" "ormocresol$ is recognied as an allergen$which can provo'e anaphylactic reactions

In addition$ the components o" "ormocresol have been reportedto be associated with cytoto%icity$ carcinogenicity$ immunesensitiation and mutagenicity (ewis & hestner #*+#$ ,amoset al 200+$ ardoso et al 20#0$ ewis 20#0)


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In hina$ "ormocresol is commonly used as an antibacterial agent inroot canal treatment -he guidelines "or operative dentistry andendodontics as taught to dentistry students in hina lists "ormocresolas the second choice o" antibacterial agents "or use when per"ormingroot canal treatments (.u & /iao 200+) earches o" the two maindatabases o" hinese language scienti1c literature "ound that themaority o" studies involving disin"ection in root canal treatment used"ormocresol 3 search o" the hina 4ational nowledge In"rastructure(4I) database "or clinical research reports involving root canalprocedures published "rom 200* to 20#2 resulted in #6# reports$ and+* used "ormocresol as the antibacterial agent 3 similar search o" the

.34!347 database resulted in #** reports$ and #8+ used "ormocresol

as the antibacterial agent 3lthough there is no in"ormation regardingthe prevalence o" "ormocresol use in hina$ the results o" the databasesearches clearly reveal that "ormocresol is widely used

-his report presents an unusual case o" anaphylactic shoc' due to anallergic reaction to "ormocresol used during root canal treatment


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ase report

3 659year9old women with a history o" allergy to ce"tria%one was treated at aprivate dental clinic in Hanghou$ hina Her chie" complaint was severe pain inthe le"t mandible

-he pain started spontaneously$ and she e%perienced e%treme tooth sensitivityto hot and cold -he pain was more severe at night he had received several

previous endodontic treatments in other teeth without complication :ue to deepcaries and instantaneous e%treme pain in response to thermal stimulus$ tooth 8;(permanent le"t mandibular 1rst molar) was diagnosed with acute irreversiblepulpitis and root canal treatment was scheduled


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-he patient was sent to the emergency departmento" a nearby hospital where

she was treated with epinephrine$ corticosteroids

and o%ygen he recovered without

incident !our days later$ with nothing in the pulpchamber o" tooth 8;$ the patient

came to the :ental :epartment o" the primaryhospital to complete the root canal

treatment -he dentist considered tension$ toothpain and allergic reaction to


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lignocaine as possible causes o" her intense reaction 4o local anaesthetic wasused$

and a"ter biomechanical preparation$ a "ormocresol9soa'ed cotton pellet wasplaced

in the pulp chamber with inc phosphate cement -en minutes a"ter applicationo"

"ormocresol$ the patient began showing signs o" hypersensitivity$ that is$diiness$

shortness o" breath and nausea -he dentist immediately removed the"ormocresolsoa'ed

cotton -he patient was treated with o%ygen and was transported to the

emergency department within the same hospital In the emergencydepartment

(80 min a"ter "ormocresol removal)$ the patient=s systolic blood pressuredropped to

;0 mm Hg and she lost consciousness


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he was treated with epinephrine$ corticosteroids

and an intravenous in"usion o" 5> de%trose he regained consciousness

a"ter 28 min 3"ter regaining consciousness$ she began complaining o" a headache

which increased in severity over time Her blood pressure returned to normal 6 h

"rom the time she lost consciousness

:ue to the patient=s persistent and severe headache$ magnetic resonanceimaging

(M,I) per"ormed the ne%t day revealed hyperintensity on -29weighted imaging

and

hypointensity on -#9weighted imaging$ corresponding to swelling o" the gyrus inthe

cerebral watershed territory o" the le"t parietal?occipital lobe (!ig #) @ased on her

history$ symptoms$ and M,I 1ndings$ the patient was diagnosed with brain inury

due to anaphylactic shoc' caused by "ormocresol


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he was then admitted to the

:epartment o" 4eurology !ollowing a series o"treatments$ including hydration$

reduction o" intracranial pressure and improvement o"cerebral circulation$ she demonstrated

early recovery 3t day 6$ the patient had achieved close tocomplete recovery$

but a slight headache persisted M,I per"ormed on day 5

a"ter anaphylactic shoc' revealed no obvious abnormalities (!ig 2) -he

patient was discharged on day

A in a stable condition


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-he patient was trans"erred to the :epartment o" tomatology tocomplete the root

canal treatment 3"ter isolation with a rubber dam$ three roots wereidenti1ed$ the

wor'ing lengths determined$ and root canal preparation was carried outwith hand 1les

using the step9bac' techniBue and sodium hypochlorite irrigation 4olocal anaesthetic

was used 3"ter cleaning and shaping$ the canals were dried and calciumhydro%ide was

used as the antibacterial medicament Cne wee' later$ the root canaltreatment was

success"ully completed without the use o" "ormocresol9containingproducts Dre9 and

postoperative radiographs o" the tooth are shown in !ig 8


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:iscussion

Materials used in endodontic treatments such asanaesthetics$ mummi"ying agents$

barrier eBuipment$ sur"ace and root canal disin"ectants$

sealants$ core materials$ and apical 1lling materials all contain potential allergens

(Hensten & Jacobsen 2005) Most

o" these allergens are haptens$ which turn into "ull antigenswhen combined with host

tissue proteins and then induce hypersensitivity (Hensten &

Jacobsen 2005) @ecause anaphyla%is is primarily a clinicaldiagnosis$ typical systemic mani"estations o"ten with a

history o" e%posure to an allergenic agent are diagnostic(imons 20#0)


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!ormocresol is mainly composed o" "ormaldehyde and cresol$ which act as anal'ylating

agent and a phenolic protein9coagulating compound$ respectively (@uc'ley #*06)

!ormaldehyde is a low molecular weight chemical which acts as a hapten and may

react with tissue proteins on macrophages and angerhans cells to produce acomplete

allergen which can induce immunological reactions (medley #**;$ @raun et al

2008)

It can provo'e contact dermatitis mediated by a delayed9type allergic reaction

(type9IE)

(unisada et al 2002)$ and a "ew cases o" immediate9type allergic reaction (type9I) to

"ormaldehyde have been reported (HaFG'el et al 2000$ unisada et al 2002)@raun et al

(2008) reported anaphylactic shoc' in "our patients and urticaria in another three

patients associated with "ormaldehyde


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-he authors also reviewed the literature and

"ound 85 cases o" immunoglobulin 9dependent allergic reactions to"ormaldehyde

unisada et al (2002) reported a case o" anaphyla%is caused by a type9I

reaction to "ormaldehyde in a dental disin"ectant and reviewed #5 previous reports o"

type9I

reactions to "ormaldehyde used as a root canal disin"ectant -hehypersensitivity reactions

can occur immediately$ appearing within several minutes to # h a"tertreatment$

or be delayed$ appearing 2?26 h a"ter dental treatment (unisada et al 2002$@raun

et al 2008) @ased on the history o" events$ a type9I allergic reaction wasinduced by

"ormocresol in the case presented here


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3lthough hypersensitivity reactions such as necrosis$ asthma$ rhinitis$ nausea$dyspnea$

urticaria$ pruritus$ and even anaphylactic shoc' are 'nown side9eects o""ormocresolK

"ormaldehyde (HaFG'el et al 2000$ unisada et al 2002$ @raun et al 2008)$brain

inury has not been reported However$ secondary brain inury due toanaphylactic reactions

to other agents has been reported (peach et al #**+$ chFabit et al 200#$

3rishima et al 200*) -he reasons "or the brain inury in the case presentedhere are

thought to be cerebral hypo%ia caused by hypoper"usion a"ter hypotension as aresult

o" anaphylactic shoc' andKor cerebral parenchymal oedema caused by localallergic

vasculitis secondary to vascular inury as a result o" shoc'


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-he sa"ety o" "ormocresol has been Buestioned "or over 80 years (ewis &hestner

#*+#) -he components o" "ormocresol$ especially "ormaldehyde$ have beenreported to

be associated with cytoto%icity$ carcinogenicity$ immune sensitiation andmutagenicity

(ewis & hestner #*+#$ ,amos et al 200+$ ardoso et al 20#0$ ewis 20#0)!ormocresol

has been shown to cause :43 damage in mouse bone marrow (,amos et al

200+)$ and "ormocresol induces apoptosis and necrosis in murine peritonealmacrophages

(ardoso et al 20#0) 3dditionally$ while generally accepted as a direct causeo"

nasopharyngeal cancer$ "ormaldehyde has also been strongly associated withleu'aemia

(Lhang et al 200*)


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haping and cleaning may play a more important role than intracanalmedicaments

in disin"ecting root canals during root canal treatment (awashima et al 200*) In

addition$ i" multiple treatment visits are reBuired$ calcium hydro%ide is therecommended

intracanal medicament (instead o" "ormocresol) due to its biocompatibility and

stability (awashima et al 200*) -he use o" "ormocresol has now virtually ceased

in

urope "ollowing the publication o" the @ritish ociety o" Daediatric :entistry

guidelines

in 200; (,odd et al 200;) In addition$ the 3merican 3ssociation o" ndodontists

(33) recommends against the use o" "ormocresol and other materials containing para"ormaldehyde because they have been proven to be both unsa"e and

ineective=

(3merican 3ssociation o" ndodontists #**+)


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:espite these recommendations$ many

practitioners are still using "ormocresol as a rootcanal disin"ectant (unisada et al

2002$ Eerma et al 200*) !rom this case report$ it isclear that the use o" "ormocresol

has not been abandoned in some dental clinics andprimary hospitals in hina$ and some practitionersdo not appreciate the contraindications to its use

(Milnes

200+)


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onclusion

!ormocresol can induce severe anaphylacticreactions :ue to its to%icity$ carcinogenicity$

and severe adverse reactions$ all dentists should be

aware o" the ris's involved in

its use and avoid using materials containing"ormocresol and related agents

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Brain Injury Due to Anaphylactic Shock as A