Subcutaneous emphysema in patients undergoing root canal treatment: a systematic review of the factors affecting its development and management

Abstract

Background Subcutaneous emphysema is an infrequent mishap during root canal treatment which, in rare cases, can lead to severe complications. Aim To systematically review the literature on the factors affecting the development of subcutaneous emphysema during root canal treatment, and on its management. Data sources An electronic search was conducted in EMBASE (1947–2018), LILACS (1982–2018), PubMed (1950–2018), SciELO (1997–2018), Scopus (1970–2018), Web of Science (1900–2018) and two grey literature databases. Moreover, all issues of nine journals and four endodontic textbooks were hand‐searched. Study eligibility criteria, participants, interventions The retrieved studies were screened by two reviewers to select clinical studies, case reports or case series describing subcutaneous emphysema that developed during or immediately after root canal treatment in adult patients. Study appraisal and synthesis methods Included studies were critically appraised according to a custom list of quality requirements. The extracted data were arranged in tables, and combined through a narrative synthesis. Results The search retrieved 99 unique articles. Thirty six case reports and 15 case series describing a total of 65 cases of subcutaneous emphysema were included in this review. The methodological quality was medium. Reported cases of emphysema more often involved females and maxillary teeth. Drying of the root canal system with air under pressure, inadvertent extrusion of hydrogen peroxide through the apical foramen, the air‐water spray produced by handpieces or laser devices, and the use of ozone gas were the most commonly suspected causes. Its management involved prescription of antibiotics and NSAIDs/analgesics, local application of ice packs or compresses and hospitalization. The signs and symptoms resolved completely within 1‐17 days. Limitations Case reports and case series are a low level of evidence. Conclusions and implications of key findings Subcutaneous emphysema can develop during both nonsurgical and surgical root canal treatment. Pressurized air streams or air‐water sprays should not be directed towards the root canals or areas with mucosal discontinuity. None of the management approaches were clearly related to expedited recovery. Guidelines should be developed in order to avoid unnecessary or potentially harmful interventions.

Subcutaneous Craniofacial Emphysema Following Endodontic Treatment: Case Report with Literature Review

“…As stated by the valuable paper by Fasoulas et al [21], SCE is more frequent in females than in males, with a ratio of 2:1, this was also confirmed in our database. In most of the articles cited in this review, the endodontic procedure which leads to soft tissue swelling is initial RCT (78%), while 14% happens during non-surgical RCT and 5% is linked to endodontic surgery [22] Lastly, 3% arises throughout the surgical management of acute apical abscesses [15].…”

With two episodes of right retromandibular angle subcutaneous emphysema during right upper molar crown preparation: A case report

“…As stated by Fasoulas et al [ 13 ], subcutaneous emphysema is almost twice as common in females than males. In their systematic review, emphysema was mainly reported in females (39/65) rather than males (20/65) and the age of the patients ranged from 18 to 63 years (mean = 38 years).…”

Massive Subcutaneous Emphysema after Hydrogen Peroxide Irrigation of a Penetrating Facial Injury

“…Several complications resulting from H 2 O 2 use have been reported in dentistry, where high‐pressure systems can introduce H 2 O 2 into small enclosed spaces. A systematic review pertaining to subcutaneous emphysema in patients undergoing root canal treatment linked “air under pressure” systems, such as air‐water sprays, to the introduction of H 2 O 2 through the apical foramen 3 . The majority of these cases reported subcutaneous emphysema as the complication; however, there were rare cases of air dissecting into deeper fascial planes leading to pneumomediastinum and air embolism.…”

“…A small number of case reports in the dental, general surgery, and orthopedic literature have linked H 2 O 2 irrigation with the development of subcutaneous emphysema, air embolism, or pneumomediastinum. 3 Here we present the case of a 22-month-old patient who experienced massive subcutaneous emphysema, pneumo-orbit, and pneumomediastinum after irrigation of a penetrating neck injury from a meat thermometer with H 2 O 2.…”