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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 9  |  Issue : 1  |  Page : 40-43

Chemical oral burn cum erosive gingival lesion arising from self-medication for toothache


1 Department of Periodontics, University of Benin, Benin City, Edo State, Nigeria
2 Department of Periodontics, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria

Date of Web Publication16-Mar-2018

Correspondence Address:
Dr. Clement Chinedu Azodo
Department of Periodontics, Room 21, 2nd Floor, Prof Ejide Dental Complex, University of Benin Teaching Hospital, P.M.B. 1111 Ugbowo, Benin City, Edo State
Nigeria
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DOI: 10.4103/srmjrds.srmjrds_10_17

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  Abstract 

Chemical burn of the oral mucosa occurring as a result of a noxious agent placed in direct contact with the mucosa either by the patient or a dentist is frequently associated with gingival erosion. The objective of this study was to report a case of chemical oral burn with erosive gingival lesion due to self medication with nonsteroid anti inflammatory drug topically in patient with acute apical abscess. We report a case of 63-year-old male public servant with health insurance that presented to the periodontology clinic with chemical oral burns and erosive gingival lesion due to topical application of nonsteroidal anti-inflammatory drug for relief of toothache from apical abscess of lower left central incisor (tooth 31). The patient was advised to discontinue topical application of Anacin. Full-mouth scaling was done, oral hygiene instructions given, warm saline mouthrinse therapy prescribed, and patient referredb to the conservative clinic where root canal treatment. Increased public awareness is required regarding chemical injuries that can result from topical self-medication. Dentists must recognize the local effects of topically applied aspirin as well as other medications on the oral mucosa and incorporate them into the treatment plan to prevent complications.

Keywords: Apical abscess, chemical oral burn, erosion, self-medication, topical


How to cite this article:
Azodo CC, Orhue VE. Chemical oral burn cum erosive gingival lesion arising from self-medication for toothache. SRM J Res Dent Sci 2018;9:40-3

How to cite this URL:
Azodo CC, Orhue VE. Chemical oral burn cum erosive gingival lesion arising from self-medication for toothache. SRM J Res Dent Sci [serial online] 2018 [cited 2020 Feb 19];9:40-3. Available from: http://www.srmjrds.in/text.asp?2018/9/1/40/227761


  Introduction Top


Acute apical abscess which is the most common form of dental abscess is a well-known painful dental emergency that usually develops in nonvital tooth.[1],[2] It is a significant reason for dental emergency visit,[3] and when it is complicated, it can be severe enough to require hospitalization thereby resulting in substantial economic burden.[4]

Apical abscess is a localized purulent form of apical periodontitis.[5] When a tooth becomes nonvital from dental caries or trauma, necrosis of the pulp ensues, infection gets established in the root canal then bacteria contact the periradicular area through apical and lateral foramina or root perforations leading to periradicular infection in the form of apical periodontitis and then the abscess. Apical abscess is usually localized intraorally, but in some cases, the apical abscess may spread to fascial spaces of the head and neck resulting in severe complications or even mortality.[6],[7] The spread to anatomical spaces of head and neck is determined by the location of the root end of the involved tooth in relation to its overlying buccal or lingual cortical plate, the thickness of the overlying bone, and the relationship of the apex to the attachment of a muscle.

Patients with acute apical abscess experience mild to severe pain of throbbing characteristics and swelling; sometimes trismus, fever, lymphadenopathy, malaise, headache, and nausea are the possible systemic manifestations. In most cases, the tooth is extremely sensitive to percussion and chewing.[5],[6] The patient usually seek help for the swelling and pain from these conditions. These help usually start in the form of self-medication by information from layperson before seeking professional help from dentist for the optimal resolution.[7],[8],[9],[10],[11] Toothache has been severally reported as the most common oral condition self-medicated for and the mainly implicated are analgesics.[12],[13] These analgesics are used systemically as prescribed by the manufacturers but sometimes are used abnormally in topical mode. Topical application of either conventional or unorthodox medication may be common in patients with dental pain with resultant gingival erosive lesion because of perception that topical use may give immediate relief from the pain. The aggravation of existing dental pain from erosion and increased predisposition to infection necessitate the need to increase public awareness on the consequences of unusual topical medication use. There seems to be few reports in literature on chemical oral burn due to self-medication for oral health conditions, but none appears to have been specifically in reference to apical abscess.[14] Hence, we report a case of erosive gingival lesion due to self medication for acute apical abscess with nonsteroid anti inflammatory drug (Anacin Rx) applied topically.


  Case Report Top


A 63-year-old male public servant with health insurance presented to the periodontology clinic on account of pain of 6 days' duration in the gingiva related to the lower incisors and swelling in the same region of 4 days' duration. The pain was spontaneous, dull in character, continuous, of mild to moderate intensity, radiates to the ear, aggravated by mastication, with a history of associated headaches and sleep disturbance. However, there was no sleep disturbance as at the period of presentation. History of salt-tasting liquid exudating from the implicated tooth was elicited. Temporary pain relief was achieved by ingesting analgesics (Brustan N) and Diclofenac and topical application (Anacin) to the offending gingiva. The swelling is associated with pus discharge. The patient had visited the dental clinic for extraction which was uneventful and indulge in twice-daily teeth cleaning using hard bristle toothbrush. He is a medication compliant hypertensive patient. He takes alcohol including spirits occasionally but does not consume any form of tobacco.

An intraoral examination revealed perceivable halitosis, fair oral hygiene (simplified oral hygiene score of 2) with a tender gingiva swelling extending from the mesial aspect of teeth 33–41 and measuring about 3 cm by 2 cm. The gingiva is soft, dusky red and there is the presence of white plaques with slough offs [Figure 1]. The patient was partially dentate with missing tooth 26. There was generalized attrition of teeth [Figure 2]. Tooth 31 was discolored, tender to percussion, nonvital and had Miller Grade 1 mobility [Figure 2]. Periapical radiograph revealed periapical radiolucency extending diffusely into the alveolar bone and interdental bone loss in relation to 31 [Figure 3]. The following diagnoses were made: dentoalveolar abscess in relation to 31, chemical oral burn cum erosive gingivitis secondary to topical application of Anacin, as well as generalized chronic marginal gingivitis. The patient was advised to discontinue topical application of Anacin. Full-mouth scaling was done, oral hygiene instructions were given, and the patient was placed on warm saline mouthrinse therapy. The patient was immediately referred to the conservative clinic for the root canal treatment of 31.
Figure 1: Chemical oral burn cum erosive gingival lesion

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Figure 2: Generalized attrition of teeth and discolored lower left central incisor

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Figure 3: Periapical radiograph of lower left central incisor

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  Discussion Top


Acute apical abscess is an advanced stage of the symptomatic form of apical periodontitis which develops only when root canal of teeth is devoid of vital pulp. The patient had discolored tooth signifying pulpal necrosis which is confirmed from the nonivitality of the tooth. It essentially meant that the necrotic pulp moved to established pulpal infection then periradicular infection and apical periodontal abscess. The exudate in the periradicular area resulted in mobility and tender to percussion of the implicated tooth.

Acute apical abscess is a painful condition which prompted dental attendance. It has been established that pain is the major reason for dental attendance in low-resource economy with strongest predictors of healthcare-seeking behavior being the pain characteristics.[9],[15],[16] However, before the dental attendance, self-medication with analgesics both orally and topically was used. Although receiving care at a dental office is the most preferable option for care, most individuals report barriers which is mostly cost.[16] The cost was not a barrier for this patient because he was National Health Insurance Scheme enrollee. The trigger for the attendance was decrease in self-reported control over pain and ability to decrease pain were both associated with an increased likelihood of seeking professional care.[10]

Chemical, thermal, and physical agents are the main causative agents for oral soft-tissues burns. Chemical burn of the oral mucosa occurs as a result of a noxious agent placed in direct contact with the mucosa either by the patient or a dentist and are usually from medications, mouth rinses, and chewing gums is frequently associated with gingival erosion.[17] Acids which are proton donor and bases which are proton acceptors are caustic agents that cause tissue damage in the form of chemical burn through different mechanisms. The acid does so through coagulation necrosis while base through liquefaction necrosis.[18] The type, physical form, PH, volume, concentration, and contact time with the agent determine the severity of burns.[18] The available studies on oral chemical burn in the literature are mainly case reports and series; thus, there is paucity of information on epidemiology of oral chemical burn. The only retrievable study on epidemiology of oral chemical burn reported to poison information center revealed that the majority in toddlers, male sex prevailed and occurred accidentally.[19] The agents implicated mainly in these oral chemical burns were cleansing agents, remedies, disinfectants, acids or bases, technical fluids, cosmetics, and foods.[19]

Anacin, a brand of aspirin (acetylsalicylic acid), is a medication used to treat pain, fever, and inflammation.[20] Aspirin is one of the most widely used medications globally with an estimated 40,000 tonnes (50–120 billion pills) being consumed each year.[21],[22] Anacin is formulated as tablets to be taken per oral. Topical application to the gingiva causes epithelial necrosis and shedding (erosion) due to its acidic nature.[23] In this case, the patient had been applying crushed Anacin tablets for about 6 days resulting in the erosive gingival lesion overlying the dentoalveolar swelling. The erosive gingival lesions appear as very tender, dusky red lesions covered with white plaques and slough-offs.[24] Hence, within 24–48 h of topical application to the gingival mucosa, it aggravated the dental pain that it was originally meant to treat and predisposed the patient to further infection especially because the pain hindered optimal oral hygiene practices. This is because chemical oral burn presents with mild lesion to more severe lesions with symptoms ranging from sensitivity and soreness to outright pain. The acute reaction to endodontic infection may develop very quickly so that the involved tooth may not show radiographic evidence of periradicular bone destruction.[6] When a periradicular radiolucency is radiographically observed, the abscess is usually the result of exacerbation of a previous chronic asymptomatic condition.[6] Periapical radiography showed periapical radiolucency extending diffusely into the alveolar bone and there is interdental bone loss in relation to 31 illustrating that this case is one of the exacerbations of chronic apical abscess. Treatment of acute apical abscesses involves incision for drainage and root canal treatment or extraction of the involved tooth to remove the source of infection. In some cases, drainage can be obtained through the root canal. The combination of early diagnosis, initiation of empirical antibiotic therapy, and timely surgical intervention can be regarded as the decisive triad for the successful management of complications of acute dental abscesses. Counseling the patient on the need to discontinue the topical application of the drug immediately is the first step which is critical to the success of treatment. Full-mouth scaling, advice on, and monitoring of oral hygiene practices and warm saline mouthrinse will lead to resolution of an erosive gingival lesion in <7 days as in this case. The patient was immediately referred to the conservative clinic where root canal treatment was commenced on 31 with antibiotics and analgesics.


  Conclusion Top


Increased public awareness is required regarding chemical injuries that can result from topical self-medication. Dentists must recognize the local effects of topically applied aspirin as well as other medications on the oral mucosa and incorporate them into the treatment plan to prevent complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Allareddy V, Lin CY, Shah A, Lee MK, Nalliah R, Elangovan S, et al. Outcomes in patients hospitalized for periapical abscess in the United States: An analysis involving the use of a nationwide inpatient sample. J Am Dent Assoc 2010;141:1107-16.  Back to cited text no. 4
    
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Cohen LA, Harris SL, Bonito AJ, Manski RJ, Macek MD, Edwards RR, et al. Coping with toothache pain: A qualitative study of low-income persons and minorities. J Public Health Dent 2007;67:28-35.  Back to cited text no. 16
    
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Mamede RC, de Mello Filho FV. Ingestion of caustic substances and its complications. Sao Paulo Med J 2001;119:10-5.  Back to cited text no. 18
    
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Nehrlich J, Klöcking HP, Hentschel H, Lupp A. Oral chemical burns reported to the poisons information centre in Erfurt, Germany, from 1997 to 2014. J Burn Care Res 2017;38:e913-22.  Back to cited text no. 19
    
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American Society of Health-System Pharmacists; 6 June, 2016. Available from: http://www. Aspirin. Drugs.com. [Last retrieved on 2016 Aug 30].  Back to cited text no. 20
    
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Warner TD, Mitchell JA. Cyclooxygenase-3 (COX-3): Filling in the gaps toward a COX continuum? Proc Natl Acad Sci U S A 2002;99:13371-3.  Back to cited text no. 22
    
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Rossi LA, Braga EC, Barruffini RC, Carvalho EC. Childhood burn injuries: Circumstances of occurrences and their prevention in Ribeirão Preto, Brazil. Burns 1998;24:416-9.  Back to cited text no. 23
    
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Odell EW. Clinical Problem Solving in Dentistry. 3rd ed. Edinburgh: Churchill Livingstone; 2010. p. 192.  Back to cited text no. 24
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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