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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 33  |  Issue : 2  |  Page : 107-111

Hypersensitivity reaction to orange oil gutta-percha solvent in dental office


1 Hod And Professor, Department Of Conservative Dentistry And Endodontics, Bhojia Dental College and Hospital, Badi, Himachal Pradesh, India
2 Private Consultant, Swami Devi Dyal Dental College, Barwala, Haryana, India
3 Reader, Swami Devi Dyal Dental College, Barwala, Haryana, India
4 Senior Lecturer, Swami Devi Dyal Dental College, Barwala, Haryana, India

Date of Submission07-Sep-2020
Date of Decision08-Nov-2020
Date of Acceptance13-Mar-2021
Date of Web Publication11-Jun-2021

Correspondence Address:
Dr. Uzma Mushtaq
Sadiqabad, Near GPO, Anantnag - 192 101, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/endo.endo_121_20

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  Abstract 


Root canal treatment is often required when primary endodontic treatment has failed. In order to remove the root canal filling material, chemical solvents are used to solubilize the gutta-percha. Despite many advantages, these solvents can lead to mishaps when not used cautiously. The purpose of this article is to present a case report of angioedema caused due to periapical seepage of orange oil and also highlighting the preventive measures and management of such accidents in dental office.

Keywords: Gutta-percha, root canal treatment, solvent


How to cite this article:
Makkar S, Mushtaq U, Kaur T, Sharma M, Mushtaq F, Thakur D. Hypersensitivity reaction to orange oil gutta-percha solvent in dental office. Endodontology 2021;33:107-11

How to cite this URL:
Makkar S, Mushtaq U, Kaur T, Sharma M, Mushtaq F, Thakur D. Hypersensitivity reaction to orange oil gutta-percha solvent in dental office. Endodontology [serial online] 2021 [cited 2021 Aug 2];33:107-11. Available from: https://www.endodontologyonweb.org/text.asp?2021/33/2/107/318127




  Introduction Top


The preliminary objectives of endodontics are complete debridement of the pulpal space, development of a fluid-tight seal at the apical foramen, and total obliteration of the root canal system. Endodontic treatment is aimed at removing the microorganisms from the root canal system and providing a seal to prevent re-entry. This should provide an environment that allows healing of the peri-radicular tissues. The anatomic limits of the pulp space are the dentinocemental junction apically and the pulp chamber coronally. Canals should be obturated to the apical dentinocemental junction as beyond this point, the periodontal structures begin. The dentinocemental junction is an average of about 0.5–0.7 mm from the external surface of the apical foramen, as clearly demonstrated by Kuttler and is the major factor in limiting the filling material to the canal.[1]

It is frequent to find the accidents of endodontic treatment failure due to bacterial infection or because of wrong procedures during endodontic treatment process.[2] Overfilling is one of them. Overfilling is a volumetric assessment denoting obturation of the root canal space with excess material extruding beyond the apical foramen.[3] The effect of overfilling is varied, determined by the type of filling material, filling substance's quantity which passes the apical foramen, and how far the filling material surpasses the apical foramen. Overfilling can cause many ill-effects that are inflammation of the periradicular tissues accompanied by severe pain and swelling of tissues, periapical lesion, and breakage of periodontal ligament. Other effects are necrosis of alveolar bone in the periapical area of the discolored mucosa membrane covering tooth apex or even a neurological complication such as paresthesia.[2]

The various treatment alternatives to overfilling are by taking no treatment and only observation, conventional endodontic treatment, or performing an endodontic surgery. If the filling substance which passes the apical foramen cannot be re-absorbed or it is biocompatible, but it passes the apical foramen not more than 1 mm, the conservative measure such as a conventional endodontic treatment should be tried first else patient can be left to observation. At times during master cone selection only, the GP cone goes beyond the apex and is difficult to retrieve, and then, the mechanical removal of gutta percha (GP) can be done by hand files or re-treatment files. However, if the gutta-percha cone is still difficult to take out, assistance can be taken by using solvents in the root canal. If the material is not retrieved then, overfilling management can be done by performing an endodontic surgery. This is a radical measure to be chosen as operator's last choice whenever the conservative treatment has failed.[2]

Chemical solvents are used to solubilize the gutta-percha and reduce the resistance of gutta-percha. Chloroform, halothane, xylene, eucalyptol, orange oil, and rectified turpentine are the solvents available that have been used as an adjuncts to remove the endodontic filling materials.[4]

Nowadays, laser is recommended for gutta-percha removal. Studies have shown that laser can melt the gutta-percha material. Removal of root canal filling material by the laser involves a combination of both photothermal and photoablation effects. In a study, diode laser with solvents (Chloroform and Endosolv E) were significantly more effective than only diode laser group in removing gutta-percha during the retreatment of the root canal system.[5]

Chloroform and eucalyptol have been used as solvents since 1850. Chloroform, although an excellent solvent, is highly toxic and has carcinogenic potential.[6] It is classified as a group 2B carcinogen by the International Agency for Research of Cancer. Studies have confirmed that substances placed in the pulp chambers of teeth have access to the periapical tissues and to the circulatory system through the periodontal vasculature.[4] A study done by Ribeiro et al. 2007 suggested that both chloroform or eucalyptol are strong cytotoxicants, but they may not be a factor that increases the level of DNA lesions in mammalian cells.[7] Another study done by Zaccaro Scelza et al. in 2006 to evaluate the cytotoxicity of orange oil, eucalyptol, and chloroform stated that orange oil was less cytotoxic than eucalyptol and chloroform.[8]

Eucalyptol exhibits antibacterial effects and anti-inflammatory properties and its potential of dissolution of gutta-percha increases significantly when heated.[9] Orange oil comprises of limonene, aliphatic hydrocarbon alcohols, and aldehydes such as octanal. It does not have any harmful effect, when used with caution and has low solubility in water.[10] It is traditionally used for the cleansing and removal of cements, pastes, and impression materials from the instruments, mixing plates, devices, patients skin, etc., and it is widely indicated as solvent during endodontic retreatment.

Wennberg and Orstavik reported that xylol was the most efficient in dissolving gutta-percha.[11] However, according to Wourms et al., in their study, they found that xylol has a toxic effect on tissues.[12] Orange oil and eucalyptol have been reported without any harmful effects and effective in removing gutta-percha. Pécora et al. reported that orange oil-softened gutta-percha with similar results to xylol and suggested it as an alternative.[13]

The evidence of accidents/incidents with different solvents in the literature is rare. This purpose of this article is to highlight a case report of one such procedural accident as sequelae of using GP solvent for the removal of GP.


  Case Report Top


A 22-year-old male patient working as an army officer came to our department of conservative dentistry and endodontics complaining of pain in the maxillary anterior tooth region for the past 1 month. The patient gave a history of an accident 2 years back in which his front teeth were broken and he had undergone the root canal treatment of 21 along with prosthesis. On the clinical examination, the tooth 11 and 12 were tender on percussion and porcelain-fused metal bridge was present with respect to 11, 12, and 21. Radiographically, periapical lesion was present with respect to 11 [Figure 1]a. Root canal treatment was planned for 11 and 12, followed by crowns with respect to 11, 12, and 21. After taking consent from the patient, root canal treatment was started, access was made through the existing prosthesis as the patient was not willing for its removal, after doing biomechanical preparation an X-ray of the master cone was taken and master cone was kept 0.5 mm short of apex. After doing obturation another X-ray was taken and it was seen that one to two accessory cones were extruding into the periapical area in 11 [Figure 1]b. At the same time, the removal of the gutta-percha was initiated. Coronal gutta-percha was easily removed, but the apical part gave resistance. GP solvent composed of orange oil was used as a solvent to aid in the removal along with the hand files. During the procedure, probably some of the solvent extruded apically and caused irritation to the periradicular tissues. The patient complained of irritation, and immediately, the procedure was stopped, and the canal was adequately irrigated with normal saline and symptomatic relief was given to the patient. The patient was then recalled on the next appointment.
Figure 1: (a) Preoperative radiograph (b) GP point extruding from the apex w.r.t. 11

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On the next day, the patient came with the perfuse swelling of the upper and lower lip along with gingiva, and there was pus discharge from the labial mucosa of 11 [Figure 2]a, [Figure 2]b. It was diagnosed with angioneurotic edema due to allergic reaction caused by orange oil. Immediately, temporary restoration was removed to drain the pus, and canals were irrigated again with normal saline and lose dressing was given. Consultation was also taken from the oral medicine department and patient was put on antibiotics (amoxicillin 500 mg BD), corticosteroids (Wysolone 20 mg BD), analgesics (ibuprofen and paracetamol 400 mg BD) for 5 days, and antihistamines (Allegra 120 mg OD) for 2 days. After 2 days, there of improvement in patients condition, and swelling was reduced [Figure 2]c, [Figure 2]d. On the 5th day, the patient was without any symptoms, swelling was completely gone and labial mucosa also showed the signs of healing [Figure 2]e, [Figure 2]f. The patient was in army and unfortunately had to leave as his posting was changed. Therefore, calcium hydroxide dressing was given, and the patient was advised to get his treatment completed.
Figure 2: (a) Swelling of upper and lower lip on 1st day. (b) Pus discharging from labial mucosa (c) Swelling of upper and lower lip on 2nd day. (d) Pus discharging from labial mucosa (e) Swelling reduced on upper and lower lip on 5th day. (f) Healing of labial mucosa

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  Discussion Top


Endodontic retreatment has largely replaced periradicular surgery for the management of failed root canal treatment.[4] During nonsurgical endodontic treatment, the removal of root canal obturation by purely mechanical means may lead to root perforation, canal straightening, or alteration of the original canal outline. The complete removal of gutta-percha and sealer is necessary to allow effective cleaning, shaping, and refilling of the root canal system. However, complete removal is not always possible.[14] Therefore, the use of organic solvents has been anticipated to decrease the resistance of obturating materials inside the canal so that their retrieval can become easier. However, clinicians should be very cognizant about the use of removal techniques and materials used to remove the obturating materials because very strong solvents are capable of softening enamel and dentin which may promote canal transportation and chemical pericementitis if penetrated beyond the apex.[15]

Organic solvents have been used for a long time as an auxiliary or principle method for removing gutta-percha, being the more effective chemical substances to dissolve endodontic filling material. Chloroform and xylene are the most commonly used solvents, but the U. S. food and drug administration prohibit chloroform because of its potential carcinogenicity. Xylene is available for the clinical use, and it is not considered as carcinogen but is very toxic to tissues.[7]

Gutta-percha is also soluble to essential oils. Some of them have been reported to be safe and useful for this purpose, such as eucalyptol, turpentine, and orange oil.[15]

Kulkarni G et al. compared the effectiveness of eucalyptus oil, orange oil, and clove oil in dissolving resin-coated gutta-percha (RCGP) cones which stated that orange oil was the most effective solvent of EndoREZ RCGP and conventional GP among all tested solvents.[16]

According to Pecora et al., orange oil acts on gutta-percha in the same way that xylol does without any deleterious effect on tissues.[17] Orange oil extracted from the peel of orange, Citrus aurantium, is easy to obtain and is suitable for rapid opening of the root canal, mainly in zinc-oxide cement root fillings associated or not with gutta-percha cones.[7] Orange oil consists of approximately 90% D-limonene, a solvent used in various household products. It has a pleasant smell and is considered as eco-friendly. It is efficient alternative to potentially toxic solvents as it is less cytotoxic and more biocompatible than eucalyptol and chloroform.[15] Mushtaq et al.[18] and Martos et al.[19] stated that dissolving capacity of orange oil is less than xylene and chloroform. However, Scelza et al. showed similar behavior between orange oil, eucalyptol, xylene, and chloroform.[20]

The choice of an ideal solvent for endodontic retreatment requires the establishment of a balance between level of clinical safety, the level of toxicity and aggression to the tissues, and chemical capacity of dissolution. The ideal endodontic solvent requires the following properties: High solvent effect, low surface tension, low cytotoxicity, absence of carcinogenic effects, easy to use, quick effect, and long-life.[21]

It should also be noted that the solvent can be aggressive toward periapical tissues as in our case. Apically directed pressure of hand files to facilitate solvent penetration, may contribute to the apically extruded debris and solvent that may cause irritation to the periapical tissues, disturb healing,[4] and cause allergic/hypersensitivity reactions. In our case, it was type IV hypersensitivity reaction also known as delayed or slow type of hypersensitivity. It is found in allergic reactions due to fungi, bacteria, and viruses. It is also seen contact dermatitis caused by chemical allergens. The important feature of type-IV hypersensitivity reactions is the involvement of T-lymphocytes rather than the antibodies.[22]

Such accidents can be prevented by using the solvents with great caution when used in apical third of the root. Rubber dam application is mandatory to prevent the contact of solvent with the oral mucosa, it should not be used in open apex cases, minimum amount of solvent as much as possible should be used, solvents should not be directed injected into the canals, it should be used by applying on small cotton pellet as then place in the canal with the help of file or spreader.

The aim of this article is to highlight the possible accidents that can happen with the use of solvents and also how to prevent and treat such accidents. Whenever such accident will happen in our dental office, the clinician should not panic and he should know how to manage such accidents. When such accident happens the procedure should be immediately stopped and the canals should be copiously irrigated with normal saline to give relief to the patient. The patient should be prescribed antibiotics, corticosteroids, anti-histamines, and analgesics in case of pain and follow-up should be done.

”It is better to be safe than sorry”-is the age old saying. Therefore, we should take proper precautions while doing the procedures and prevent any accident.

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

1.
John I Ingle, Leif K Bakland. Endodontics. 5th ed. BC Decker Inc, Hamilton 2002.  Back to cited text no. 1
    
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Rehman K, Khan FR, Aman N. Comparison of orange oil and chloroform as gutta- percha solvents in endodontic retreatment. J Contemp Dent Pract 2013;14:478-82.  Back to cited text no. 4
    
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Devi M, Mahajan P, Bhandari SB, Monga P, Bajaj N, Singh F. Comparative evaluation of removal of gutta-percha from root canals with laser using different solvents: An in vitro study. Endodontology 2019;31:51-6.  Back to cited text no. 5
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Zaccaro Scelza MF, Lima Oliveira LR, Carvalho FB, Côrte-Real Faria S. In vitro evaluation of macrophage viability after incubation in orange oil, eucalyptol, and chloroform. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:e24-7.  Back to cited text no. 8
    
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Magalhães BS, Johann JE, Lund RG, Martos J, Del Pino FA. Dissolving efficacy of some organic solvents on gutta-percha. Braz Oral Res 2007;21:303-7.  Back to cited text no. 9
    
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Tewari RK, Kapoor B, Mishra SK, Kumar A. Role of herbs in endodontics. J Oral Res Rev. 2016;8:95-9.  Back to cited text no. 10
    
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Wennberg A, Orstavik D. Evaluation of alternatives to chloroform in endodontic practice. Endod Dent Traumatol 1989;5:234-7.  Back to cited text no. 11
    
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Wourms DJ, Campbell AD, Hicks ML, Pelleu GB Jr. Alternative solvents to chloroform for gutta-percha removal. J Endod 1990;16:224-6.  Back to cited text no. 12
    
13.
Pécora JD, Spanó JC, Barbin EL. In vitro study on the softening of gutta-percha cones in endodontic retreatment. Braz Dent J 1993;4:43-7.  Back to cited text no. 13
    
14.
Hwang JI, Chuang AH, Sidow SJ, McNally K, Goodin JL, McPherson JC 3rd. The effectiveness of endodontic solvents to remove endodontic sealers. Mil Med 2015;180:92-5.  Back to cited text no. 14
    
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Kulkarni G, Podar R, Singh S, Dadu S, Purba R, Babel S. Comparative evaluation of dissolution of a new resin-coated Gutta-percha, by three naturally available solvents. Endodontology 2016;28:143-7.  Back to cited text no. 15
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Yadav HK, Yadav RK, Chandra A, Thakkar RR. The effectiveness of eucalyptus oil, orange oil, and xylene in dissolving different endodontic sealers. J Conserv Dent 2016;19:332-7.  Back to cited text no. 16
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17.
Pecora JD, Costa WF, Filho DS, Sarti SJ. Presentation of an essential oil, obtained from Citrus aurantium, effective in the disintegration of the zinc oxide-eugenol cement inside the root canal. Odonto 1992;1:130-2.  Back to cited text no. 17
    
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Mushtaq M, Farooq R, Ibrahim M, Khan FY. Dissolving efficacy of different organic solvents on gutta-percha and resilon root canal obturating materials at different immersion time intervals. J Conserv Dent 2012;15:141-5.  Back to cited text no. 18
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19.
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Scelza MF, Coil JM, Maciel AC, Oliveira LR, Scelza P. Comparative SEM evaluation of three solvents used in endodontic retreatment: An ex vivo study. J Appl Oral Sci 2008;16:24-9.  Back to cited text no. 20
    
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Dagna A, Mirando M, Beltrami R, Chiesa M, Poggio C, Colombo M. Gutta-percha solvents alternative to chloroform: An in vitro comparative evaluation. EC Dent Sci 2017;15:51-6.  Back to cited text no. 21
    
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