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CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 1  |  Page : 65-68

Chemical burn from direct application of aspirin onto a painful tooth


Department of Restorative Dental Sciences, College of Dentistry, King Saud University, Riyadh, Kingdom of Saudi Arabia

Date of Submission05-Feb-2019
Date of Decision17-Feb-2019
Date of Acceptance23-Feb-2019
Date of Web Publication27-Dec-2019

Correspondence Address:
Dr. Hussam Alfawaz
Department of Restorative Dental Sciences, College of Dentistry, King Saud University, P.O. Box 60169, Riyadh 11545
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sej.sej_24_19

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  Abstract 

Aspirin is one of the most effective oral analgesic agents available worldwide without prescription. Aspirin tablets can be directly placed on the painful tooth and adjunct mucosa to relieve pain and avoid dental visits. However, aspirin is acidic in nature and its protein coagulation effects can cause severe chemical burns to the surrounding mucosa when placed directly. Here, we describe a rare case of chemical burn caused by the direct placement of an aspirin tablet on a painful tooth. A 55-year-old healthy African female presented to the clinic with a history of pain in the right maxillary region. The patient stated that she had placed aspirin locally to relieve her toothache for a few days. On intraoral examination, a grayish-white fibrin-coated ulcer was observed on the buccal mucosa near the painful tooth, extending to the upper and lower buccal vestibules, up to the premolar area. The source of pain was resolved by root canal treatment of #17, and the patient was advised to discontinue the direct application of aspirin to oral tissues. Two weeks later, the lesion had healed entirely without scarring. This case highlights the differences in the degree of clinical presentation of the lesion and the importance of considering the injudicious use of aspirin as a potential cause of white lesions in the oral cavity.

Keywords: Aspirin, aspirin burn, chemical burn, root canal treatment, traumatic ulcer, white lesions


How to cite this article:
Alfawaz H. Chemical burn from direct application of aspirin onto a painful tooth. Saudi Endod J 2020;10:65-8

How to cite this URL:
Alfawaz H. Chemical burn from direct application of aspirin onto a painful tooth. Saudi Endod J [serial online] 2020 [cited 2020 Jul 4];10:65-8. Available from: http://www.saudiendodj.com/text.asp?2020/10/1/65/274187


  Introduction Top


A traumatic ulcer of the oral cavity is defined as a lesion resulting from a physical, thermal, or chemical burn.[1],[2] Topical application of drugs or chemicals inside the oral cavity is the most common cause of traumatic ulcers. In chemical burns, an extensive, white, fibrin-coated ulcer can be seen on the buccal mucosa, along with erythema of the surrounding tissues, including the papillary, marginal, and attached gingiva, with alveolar mucosal involvement. Patients experience severe painful mucosa, fever, and headache, and in some cases, the tooth becomes sensitive to percussion and biting.[3],[4] Self-medication with analgesics for toothaches has been well-documented.[5],[6] Patients often apply crushed analgesic tablets directly inside the mouth and on the teeth to relieve toothache before seeking professional help from dentists.[7],[8],[9] However, this practice can cause mucosal necrosis, erosion, and infection.[1] There are few case reports in the literature describing chemical oral burns caused by self-medication for oral health conditions.[10] This report presents a case of acute periapical abscess resulting from application of crushed aspirin onto a painful tooth, highlighting the consequences of aspirin misuse.


  Case Report Top


A 55-year-old African female presented to the dental clinic with a history of pain and burning sensation in the right maxillary region over the previous week. She reported no history of unhealthy habits, such as tobacco consumption, or any chronic medical illness. Her vital signs, blood pressure, blood sugar level, and lymph nodes were unremarkable. However, she reported placing aspirin near a painful tooth and around the buccal vestibule for 2 consecutive days to alleviate toothache. Intraoral examination revealed an extensive, white, fibrin-coated ulcer in the right buccal mucosa, as well as erythema of the surrounding tissues, including the papillary, marginal, and attached gingiva, with alveolar mucosal involvement [Figure 1]a and [Figure 1]b. The lesion was ill-defined with diffuse irregular boundaries; it extended to the upper and lower buccal vestibules up to the premolar area. With gentle traction, the surface slough peeled from the denuded connective tissue, thereby exposing erythematous areas in the affected region; these were tender on palpation [Figure 2]a. The maxillary right second molar (#17) was sensitive on percussion and showed no response to thermal and electrical pulp tests; all other tested teeth showed normal responses. A periapical radiograph of #17 showed substantial, deep decay approaching the pulp chamber, as well as widening of the periodontal ligament space [Figure 2]b. Plaque control by the patient was inadequate. Considering the patient's history and clinical findings, the lesion was diagnosed as an aspirin burn; tooth #17 was diagnosed as showing a necrotic pulp and acute periapical abscess. A treatment plan was discussed with the patient, and her written consent was obtained. The treatment included root canal treatment (RCT) for #17, which was initiated during the first visit with proper cleaning and shaping of the root canal system and filling with intracanal medicament. The patient received instructions regarding the proper use of medicines and their effects when misused; she was also advised to discontinue direct application of aspirin to oral tissues; instead, intraoral intake of anti-inflammatory drugs was prescribed to relieve the pain. Furthermore, oral hygiene instructions were reinforced.
Figure 1: (a) Intraoral photograph of the lesion at the first visit, showing extensive white epithelial necrosis of the right buccal mucosa. (b) Intraoral photograph of the lesion at the first visit to the clinic, showing the area of #17

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Figure 2: (a) Intraoral photograph of the lesion at the first visit showing extensive epithelial necrosis surrounded by erythema of the buccal mucosa and vestibule. (b) Preoperative periapical radiograph of #17 showing extensive decay and widening of the periodontal ligament space

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Two weeks later, at her recall visit, the RCT was completed [Figure 3]c. The lesion had completely and uneventfully healed without scarring, and the patient was asymptomatic [Figure 3]a and [Figure 3]b. The timeline from patient presentation to the outcome is summarized in [Figure 4].
Figure 3: (a) Intraoral photograph after 2 weeks in the area of #17. (b) Erythema of the buccal mucosa and vestibule. (c) Tooth #17 after complete root canal treatment

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Figure 4: Timeline summarizing the patient information, clinical findings, investigations, diagnosis, therapeutic intervention, and follow-up

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  Discussion Top


Aspirin-induced chemical injury is rare; this case highlights an oral soft-tissue burn caused by the topical use of aspirin to relieve pain. In the literature, oral chemical burns with various chemicals – cleansing agents, remedies, disinfectants, acids or bases, and cosmetics – were described only as case reports, and most of them occurred accidentally.[11] There is a lack of information on the epidemiology of oral chemical burns in the literature.

Patients with a chemical burn usually experience acute severe throbbing pain, accompanied by fever, malaise, headache, and occasionally, a systemic infection. These patients did not seek professional dental care from fear of visiting dentists, financial difficulties, or a lack of available dental care in the area.[12] Therefore, these patients adopt self-medication with analgesics both orally and topically and visit a dental clinic only if they experience acute unbearable pain. Pain is the leading reason for visiting dental clinics among patients with lower socioeconomic status, which may have been the case in this patient.[9],[13] Topical application of chemicals and drugs in the oral cavity by patients or dentists is the primary reason for chemical burns.[14]

Aspirin (acetylsalicylic acid) is one of the oldest, cheapest, and most effective analgesic agents available worldwide without prescription. It is widely taken orally, with 50–120 billion tablets consumed each year for analgesia. It is also applied as a topical cream, especially to relieve joint and muscle pain. Occasional direct application of crushed nonsteroidal anti-inflammatory drug or aspirin tablets on the tooth and buccal mucosa to relieve pain has been reported to result in local tissue injury.[15] Aspirin, which is acidic and a proton donor, causes epithelial necrosis, erosion, and chemical burn through its protein coagulation effects.[16] Coagulation necrosis occurs when tissue loses blood supply, leading to cell death, but the cellular structure remains intact, even after several days of cell death. Microscopically, the cells show intact outlines but without nuclei.[17] Shedding of the necrosed epithelium occurs after several days of cell death.[18] Aspirin burns cause severe gingival and mucosal erosion, with diffuse white sloughing of the mucosa throughout the affected area.[14] The degree of damage varies depending on the duration of exposure, the extent of penetration, and the amount, concentration, pH, and physical form of the agent.[16] In the present case, to relieve the tooth pain, the patient placed aspirin directly in the mouth. In the initial stages of the burn, the soft tissue is usually friable with a burning sensation and resembles an aphthous ulcer.[19] Without knowledge of the consequences, the patient continued applying crushed aspirin, resulting in coagulation necrosis of the oral tissues.[18]

Management of aspirin burn requires identification and removal of the offending agent that caused the burn, as well as proper treatment for the source of pain. Good history taking during the patient interview is essential since incorrect diagnosis in such cases may lead to unnecessary investigational procedures that cause inconvenience to the patient and increase the cost of treatment. Most chemical burns with mild-to-moderate tissue damage will heal spontaneously.[14] Full-mouth scaling and good oral hygiene habits such as rinsing mouth with warm saline water can facilitate ulcer healing within 1–2 weeks without any scarring.

In this case, the source of pain was treated by RCT of #17, which was completely cleaned and shaped and medicated with calcium hydroxide(Ca (OH) 2) in the first visit to decrease the number of viable bacteria in the root canal system till the next appointment. Ca (OH) 2 has antimicrobial activity due to its high pH and the release of hydroxyl ions, which cause destruction of the bacterial cytoplasmic membrane, denaturation of proteins, or destruction of the DNA.[20] Systemic antibiotic treatment is not indicated for acute apical abscess because the disease source was treated mechanically by RCT through cleaning and shaping of the canal system. Antibiotic prescription is indicated in acute apical abscess when there is systemic manifestation of the infection and/or diffuse swelling noted extraorally.[3],[21]


  Conclusion Top


Although chemical burns and ulcers in the oral cavity are common, few reports of aspirin burns have been documented. Here, we highlighted the differences in the degree of clinical presentation of the lesion and the importance of considering the injudicious use of aspirin as a potential cause of ulceration in the oral cavity. Comprehensive patient education regarding the effect of medication misuse is urgently required, as is reiteration of the importance of visiting a dentist every 6 months for a checkup. These assessments can help avoid tooth loss while ensuring optimal oral health and enhancing the quality of life.

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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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. 12
    
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Macfarlane TV, Blinkhorn AS, Davies RM, Kincey J, Worthington HV. Factors associated with health care seeking behaviour for orofacial pain in the general population. Community Dent Health 2003;20:20-6.  Back to cited text no. 13
    
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Rawal SY, Claman LJ, Kalmar JR, Tatakis DN. Traumatic lesions of the gingiva: A case series. J Periodontol 2004;75:762-9.  Back to cited text no. 14
    
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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. 15
    
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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. 16
    
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Adigun R, Bhimji SS. Necrosis, Cell (Liquefactive, Coagulative, Caseous, Fat, Fibrinoid, and Gangrenous). In: StatPearls. Treasure Island (FL): StatPearls Publishing; January, 2018. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430935/. [Last updated on 2018 Oct 27].  Back to cited text no. 17
    
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Azodo C, Orhue V. Chemical oral burn cum erosive gingival lesion arising from self-medication for toothache. SRM J Res Dent Sci 2018;9:40.  Back to cited text no. 18
  [Full text]  
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Ramalingam K, Abdalla KA. Traumatic chemical oral ulceration – Aspirin burn – A case report from Libya. CIBTech J Surg 2016;5:1-3.  Back to cited text no. 19
    
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Pacios MG, Lagarrigue G, Nieva N, López ME. Effect of calcium hydroxide pastes and vehicles on root canal dentin microhardness. Saudi Endod J 2014;4:53.  Back to cited text no. 20
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Cope A, Francis N, Wood F, Mann MK, Chestnutt IG. Systemic antibiotics for symptomatic apical periodontitis and acute apical abscess in adults. Cochrane Database Syst Rev 2014;26:CD010136.  Back to cited text no. 21
    


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



 

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