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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 12  |  Issue : 2  |  Page : 77-79
Endodontic emergencies: Your medication may be the cause

Department of Operative Dentistry, Faculty of Dental Sciences, Chatrapati Sahuji Maharaj Medical University, Lucknow, India

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Date of Submission31-Jul-2008
Date of Acceptance03-Feb-2009
Date of Web Publication10-Sep-2009


An endodontic clinician may face unwanted situations during root canal treatment. We present here an unusual case of soft tissue and gingival necrosis of the oral cavity following the use of formocresol® during endodontic treatment.

Keywords: Formocresol; necrosis; paraformaldehyde containing paste.

How to cite this article:
Verma P, Chandra A, Yadav R. Endodontic emergencies: Your medication may be the cause. J Conserv Dent 2009;12:77-9

How to cite this URL:
Verma P, Chandra A, Yadav R. Endodontic emergencies: Your medication may be the cause. J Conserv Dent [serial online] 2009 [cited 2023 Oct 2];12:77-9. Available from:

   Introduction Top

Formaldehyde-containing medications have been used for root canal treatment for many years. [9] Various compounds containing arsenic and paraformaldehyde were used in the past when effective anesthesia could not be obtained. [11] Such agents have some clinical benefit, although local soft and hard tissue necrosis occurs if they are not confined to the pulp. The following case report describes tissue degeneration and swelling in a patient treated with formocresol during root canal treatment.

   Case Report Top

A 37 year-old female patient reported to the Department of Operative Dentistry in CSM Medical University with the chief complaint of pain in her maxillary left first premolar. She was diagnosed with acute irreversible pulpitis and an undergraduate student was assigned to perform her root canal treatment. She performed access opening and bio-mechanical preparation in the particular tooth and gave her dressing using formocresol-soaked cotton. The patient reported after 24 hours with the complaints of pain and swelling in her left buccal and infraorbital regions [Figure 1]. Oral examination revealed desquamation of the buccal mucosa and gingival epithelium in relation to her maxillary posterior region [Figure 2]. Extra oral examination revealed swelling in her buccal, mandibular, and infraorbital regions on the left side. There was ulceration in the angle of her mouth on the left side and her mouth opening was reduced.

Treatment given

The first aim of treatment was to alleviate the symptoms of pain and to prevent further progress of infection. The patient was immediately advised to rinse her mouth with Betadine gargle® . A mixture of a steroid-based cream and Hexigel® was applied all over the ulcerated surface. An analgesic was also given to relieve the symptoms of pain. The patient was prescribed antihistamines and multivitamins, which she was advised to continue for one week. She was kept on a soft diet and advised to avoid spicy food; she was recalled after one week.

On her subsequent visit, her condition was found to have visibly improved [Figure 3] and [Figure 4].The swelling, redness, and exfoliation of the mucosa had reduced. After the cessation of symptoms, the patient's root canal dressing was changed. By her third visit, the condition had totally resolved and her root canal treatment was subsequently completed; the tooth was permanently restored with silver amalgam.

   Discussion Top

Formocresol was first used as a root canal medication by Buckley in 1904. It is widely used in dentistry because of its antibacterial properties in root canal disinfection. [12] It contains formaldehyde, an effective alkylating agent, and cresol, a protein-coagulating phenolic compound. [2] Its action is believed to be due to the release of formaldehyde vapors which act as a germicidal agent. Besides strong chemical disinfectant properties, cytotoxic effects have also been documented. The use of formocresol in dentistry has become a controversial issue due to its widespread distribution in the body following systemic injection, [7] and the demonstration of immune response to formocresol-fixed autologous tissue implanted in connective tissue or injected into root canals. [4],[5] . Powell et al .[3] have shown that when formocresol was implanted subcutaneously in the connective tissue of rats, the surrounding tissue was severely damaged; causing necrosis and abscess formation. Allergies have also been reported after the application of formocresol. Formaldehyde is one of the components of formocresol that interacts with cellular proteins. The addition of cresol to formaldehyde appears to potentiate the effect of formaldehyde on protein. [6] In a study using human pulp fibroblast cultures, formaldehyde was shown to be the major component of formocresol that caused cytotoxicity and that was more toxic than cresol. [10] In this case, formocresol-soaked cotton was inserted into the pulp chamber. The resulting necrosis may have been due to excess formocresol in the cotton, which must have leaked and permeated into the surrounding tissue. [1] Betadine gargle® used in this study contains Povidine iodine, which is an antiseptic. It is a complex of iodine, which kills microorganisms such as bacteria, fungi, viruses, protozoa, and bacterial spores. Povidine iodine exerts its antiseptic effect by slowly releasing iodine. Povidine iodine gargle and mouthwashes are used to treat infections of the mouth as well as throat and mouth ulcers. Topical antihistamines and corticosteroid applications meant to soothe painful ulcers may be helpful; avoiding spicy or hot foods may reduce the pain.

   Conclusion Top

Nowadays, many improved medications and anesthetics are available which obviate the need for the use of formocresol as a root canal medication or as a pulp devitalizer. Due to the caustic nature of the material, use of formocresol should be avoided.

   References Top

1.Loos PJ, Han SS. An Enzyme Histochemical Study of the Effect of Various Concentration of Formocresol on Connective Tissue. Oral Surg Oral Med Oral Pathol 1971; 31:571-85  Back to cited text no. 1    
2.Curikla JR. The vaporization and capillarity effect of endodontic medicaments. Oral Surg Oral Med Oral Pathol 1972; 34:117-21  Back to cited text no. 2    
3.Powell DL, Marshall FJ, Melfi RC. A Histopathologic Evaluation of Tissue Reactions to the Minimum Effective Doses Of Some Endodontic Drugs. Oral Surg Oral Med Oral Pathol 1973;36:261-72.  Back to cited text no. 3    
4.Block RM, Lewis RD, Sheats JB, Fawley J. Cell-mediated immune response to dog pulp tissue altered by Formocresol within the root canal. J Endod 1977; 3:424-30.  Back to cited text no. 4    
5.Thoden van Velzen SK, Feltkamp-Vroom TM. Immunologic Consequence of Formaldehyde Fixation Of Autologous Tissue Implants. J Endod 1977; 3:179-85.  Back to cited text no. 5    
6.Nelson JR, Lazzari EP, Ranly DM, Madden RM. Biochemical Effects of Tissue Fixatives on Bovine Pulp. J Endod 1979;5:139-44.  Back to cited text no. 6    
7.Myers DR, Pashley DH, Whitford GM, Sobel RE, McKinney RV. The acute toxicity of high doses of systemically administered formocresol in dogs. Pediatr Dent 1981; 3:37-41.  Back to cited text no. 7    
8.Stabholza, Blush MS. Necrosis of Crestal Bone Caused By the Use of Toxant. J Endod 1983;9:110-3.  Back to cited text no. 8    
9.Cambrizzi JV, Greenfeld RS. Necrosis Of Crestal Bone Related To Use Of Excessive Use Of Formocresol Medication During Endodontic Treatment. J Endod 1983; 9:565-7.   Back to cited text no. 9    
10.Jeng HW, Feigal RJ, Messer HH. Comparison Of Cytotoxicity Of Formocresol, Formaldehyde, Cresol ,Glutaryldehyde Using Human Pulp Fibroblast cultures. Pediatr Dent 1987;9:295-300.  Back to cited text no. 10    
11.Ozmeric N. Localized Alveolar Bone Necrosis Following Use Of An Arsenical Paste- a case report: Int Endod J 2002;35:295-9.  Back to cited text no. 11    
12.Ribeiro DA, Marques ME, Salvadori DM. Lack of genotoxicity of formocresol, paramonochlorophenol, and calcium hydroxide on mammalian cells by comet assay. J Endod 2004; 30:593-6.  Back to cited text no. 12    

Correspondence Address:
Promila Verma
Type IV/1, ESI Hospital Campus, Manas Nagar, Kanpur Road, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-0707.55623

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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