Endodontics · patient case question
Sudden severe pain, bleeding and rapid swelling during irrigation is most consistent with:
Patient case: The tooth that bled during shaping
demo: 38-year-old male
chief: Referred for root canal treatment of a mandibular molar with a necrotic pulp.
history: Unremarkable. No allergies.
meds: None.
findings: Tooth 19 fails to respond to cold and is tender to percussion. Access is completed and the canals are irrigated. Partway through cleaning and shaping the patient reports sudden severe pain and the operator notices brisk bleeding from the canal along with rapid swelling of the cheek. Separately, tooth 4 in the same patient shows a narrow radiolucency running along the lateral root surface and joining an apical radiolucency.
Show answer and explanation
Correct answer: B. A sodium hypochlorite accident
- A. A floor perforation causes bleeding and pain but not the immediate massive tissue swelling produced by extruded hypochlorite.
- B. Correct. A hypochlorite accident occurs when irrigant is extruded past the apex, typically through an open apex, a perforation or from binding the needle and applying pressure. The immediate triad is severe pain, profuse haemorrhage into the tissues and rapid ballooning swelling, followed by ecchymosis. Management is reassurance, analgesia, cold then warm compresses, and close monitoring, with antibiotics if infection supervenes.
- C. A vasovagal faint gives pallor, sweating, bradycardia and loss of consciousness, without pain or bleeding.
- D. Anaphylaxis presents with urticaria, angioedema, bronchospasm and hypotension, not with bleeding from the canal, and it would have begun near the time of injection.
Note: Prevention: use a side-vented needle, keep it loose in the canal, stay 2 to 3 mm short of working length and never apply pressure to a bound needle.