Nicolau Syndrome in Endodontics - Endodontic Emergency

This presentation delves into Nicolau Syndrome, a rare but serious complication that can occur following endodontic procedures. We begin by defining Nicolau Syndrome, also known as livedoid dermatitis or embolia cutis medicamentosa, which is characterized by severe pain, necrosis, and tissue damage typically following intramuscular or intra-arterial drug administration.

The presentation covers the pathophysiology of the syndrome, with a focus on its occurrence in the context of endodontic treatment. We explore potential causes, including the accidental intravascular injection of anesthetics or other endodontic medicaments, and the resulting ischemic and necrotic tissue damage.

We also discuss the clinical manifestations of Nicolau Syndrome, its diagnostic challenges, and the importance of early recognition and intervention to prevent severe outcomes. Treatment protocols and preventive measures in the endodontic setting are reviewed, with an emphasis on careful injection techniques and patient monitoring.

Learning Objectives:

Understand the pathophysiology and clinical presentation of Nicolau Syndrome.
Recognize the potential causes and risk factors associated with endodontic procedures.
Discuss diagnostic challenges and the importance of early intervention.
Review treatment options and preventive strategies in endodontic practice.
This session aims to raise awareness about Nicolau Syndrome in the dental community, highlighting the need for vigilance and adherence to best practices to minimize the risk of this rare but serious complication.

1. N icolau S yndrome after Endodontic treatment Fatima Al- sheeb et al.. A case report JOE Volume 48, Number 2, February 2022

2. Contents Introduction Case Report Discussion Conclusion References

3. Introduction Calcium Hydroxide ICM Antiseptic Properties Low Toxicity If displaced into soft tissues Long lasting consequences

4. Introduction First described in 1925 Rare cutaneous adverse reaction at the site of an intramuscular or intra-articular injection of a particular drug Clinical Signs First endodontic case report in 2000 Named after French dermatologist, Dr. Marion Nicolau

5. Case Report 16 y/o patient Reported to department of maxillofacial surgery Hamad Dental Center , Doha, Qatar Previously performed RCT in another clinic During her second visit for t/t of 14 no L.A. was given According to the patient’s documentation at clinic After BMP, canals profusely bled 2) Pain increased, dentist gave L.A. 3) Canals injected with unset Calcium Hydroxide to stop bleeding

6. Case Report Patient started having severe pain Analgesics and Antibiotics were prescribed and the unset CH was washed out Slight change in skin colour on her left cheek in the region of the maxillary left first permanent molar Pt referred to OMFS dept. at Hamad Dental Centre, Doha By the following day – swelling had developed in the same area She later returned to the same clinic Livedo reticularis

7. Case Report Three days post-treatment Paralysis on left side of cheek Pt. referred to Endodontic dept. at Hamad Dental Centre, Doha for completion of RCT 17 days later she reported to OMFS with a necrotic patch Plastic surgery considered Excessive tearing from left eye 4 * 4 cm Slight swelling / hematoma

8. Case Report CBCT was done Radio-opaque material coming from the apices of 14 towards: Left maxillary sinus Posterior superior alveolar a rtery I nfraorbital artery T he area of the infraorbital foramen RCT completed in 3 visits Successful outcome indicated Patient’s pain and soft tissue problems were alleviated 6 month follow up

9. Discussion Simple Inflammatory Reaction Serious Damage

10. Discussion Necrotic tissue was managed with hydrogen peroxide 3% and chlorhexidine 2% rinses, along with daily chlorhexidine digluconate gel. Complete healing was achieved within 2 months, followed by surgical endodontic intervention to close the perforation and stabilize the tooth. Successful recovery with 1 mm of gingival recession and no further complications at the 6-month follow-up.

11. Discussion Profuse bleeding from the canals Immediate pain in the skin around the left cheek Extrusion of the CH caused direct trauma to the vascular structures. Inflammation of the arteries and arterial embolism due to crystallization of the drug occurred, leading in turn to ischemia and local necrosis

12. Discussion Embolia cutis medicamentosa is very rare iatrogenic condition that is currently not well understood Nicolau Syndrome is an uncommon adverse cutaneous reaction that can follow intramuscular or intra-articular injections Antibacterial Agents Bismuth NSAID’s Pethidine Vitamins Lidocaine Chlorpromazine C orticosteroids

13. Discussion Calcium Hydroxide is one of the drugs that cause Nicolau Syndrome Reactio n Includes Severe pain around the injection site Inflammation of the arteries Acute Vasospasm Ischemia haemorrhagic or livedoid reticular patch S kin, Subcutaneous F at, and Muscle develop necrosis or an ulcer and subsequently heal with scar formation "Exposure of nerve tissue to calcium hydroxide for 30 minutes can cause permanent damage."

14. Discussion No definitive treatment of Nicolau Syndrome Known Treatment Strategies Necrotic gingival zone was treated with rinses of hydrogen peroxide 3% and chlorhexidine 2% in water once every 2 or 3 days for 2 weeks. Daily application (twice a day) of chlorhexidine digluconate 10 mg/g gel (Corsodyl gel) was prescribed. Surgical Intervention Pre-Op Post-Op

15. Discussion Calcipex II extrusion in the inferior alv . canal Treatment Strategy Endodontic Re-treatment Removal of extruded material through canal irrigation Surgical Intervention: Neuroplasty , neurorrhaphy, and foreign body removal under general anesthesia . 48 y/o – 37 – Chief complaint: Paresthesia Pin Prick Test Symptomatic

16. Discussion No definitive treatment of Nicolau Syndrome Known Treatment Strategies Increasing pain and swelling; prescribed fenoxymethyl penicillin for 11 days. Clindamycin 150 mg, 4 times daily. Removal of displaced material after 7 days of antibiotic treatment; mucoperiosteal flap, osteotomy, removal of calcium hydroxide paste, and apicectomy of the second premolar. Pre-Op Post-Op

17. Discussion Methods of placement of calcium hydroxide into the root canal - Injection syringe or Lentulo drill with effective lateral condensation ( Cvek et al .) - Plastic transporter followed by vertical compression with McSpadden Compactors ( Webber et al .) - Special endodontic syringe with a long 27 gauge needle ( Leonardo and Leal ) - Root canal filling using files, absorbent paper points, and vertical pluggers ( Estrela and Bammann ) - Amalgam carriers, Lentulo drill, injectable pastes ( Dunsha and Gutmann )

18. Discussion Does the vehicle used in Calcium Hydroxide pastes have any effect on post operative pain? Addition of either 2% Chlorhexidine or Lidocaine Hydrochloride (20mg/mL with 0.0125mg/mL epinephrine) to Ca[OH] 2 Significantly decreases post-operative pain

19. C onclusion

20. C onclusion Despite the rarity of Nicolau syndrome, it is crucial for clinicians to recognize and prevent this serious complication during endodontic treatments. Proper education, adherence to protocols, and advanced technologies can minimize risks. Further research is needed to improve understanding and management, ensuring patient safety and maintaining trust in dental care.

21. R eferences Siqueira JF Jr, R^cças IN, Magalh€aes FA, De Uzeda M. Antifungal effects of endodontic medicaments. Aust Endod J 2001;27:112–4. Sharma S, Hackett R, Webb R, et al. Severe tissue necrosis following intra-arterial injection of endodontic calcium hydroxide: a case series. Oral Surg Oral Med Oral Pathol Oral Radiol 2008;105:666–9. Wilbrand JF, Wilbrand M, Schaaf H, et al. Embolia cutis medicamentosa ( Nicolau syndrome) after endodontic treatment: a case report. J Endod 2011;37:875–7. Lindgren P, Eriksson KF, Ringberg A. Severe facial ischemia after endodontic treatment. J Oral Maxillofac Surg 2002;60:576–9. Shahravan A, Jalali S, Mozaffari B, Pourdamghan N. Overextension of nonsetting calcium hydroxide in endodontic treatment: literature review and case report. Iran Endod J 2012;7:102–8. Gluskin AH, Lai G, Peters CI, Peters OA. The double-edged sword of calcium hydroxide in endodontics: precautions and preventive strategies for extrusion injuries into neurovascular anatomy. J Am Dent Assoc 2020;151:317–26.

22. Thank you!