Electrocoagulation-induced tooth pain in a patient with dental work despite local anesthesia

Abstract

To the Editor: It is well known that electrocoagulation may produce adverse complications, such as electromagnetic interference, shock, and burns. We describe a case of electrocoagulation-induced tooth pain despite appropriate surgical technique and local anesthesia. A 45-year-old white female was seen for Mohs micrographic excision of a biopsy proven sclerosing basal cell carcinoma on the right cheek (Fig 1). The skin surrounding the lesion was anesthetized with 3 mL of 1% lidocaine with epinephrine and 2 mL of 1% lidocaine with epinephrine and 0.75% bupivacaine hydrochloride. The patient tolerated the excision without difficulty. She experienced a “shock-like” pain that was localized to the mouth immediately upon biterminal electrocoagulation for hemostasis. Examination of her mouth revealed metal fillings in the first premolar and first molar (Fig 2). Electrocoagulation was stopped because of the associated intense pain. The dispersive plate was then removed, and the electrosurgical settings were changed from biterminal electrocoagulation to monoterminal electrodesiccation. At that time, hemostasis was achieved without symptom recurrence.Fig 2Site of pain referral to the right first premolar and first molar; note the metal fillings.View Large Image Figure ViewerDownload (PPT) Current flowing through the patient's body creates unique hazards and complications. In 2001, Smith et al1Smith T.L. Smith J.M. Electrosurgery in otolaryngology-head and neck surgery: principles, advances, and complications.Laryngoscope. 2001; 111: 769-780Crossref PubMed Scopus (99) Google Scholar conducted a survey addressing the complications associated with electrosurgery. The most common was unanticipated direct burns, occurring in 219 out of 324 reported complications. Burn injuries in electrosurgery are often the result of inadequate contact between the patient and the dispersive electrode plate. When the dispersive plate is not in place during electrosurgery, current may build up within the patient,2Sebben J.E. The hazards of electrosurgery.J Am Acad Dermatol. 1987; 16: 869-872Abstract Full Text PDF PubMed Scopus (30) Google Scholar which usually dissipates without notice.3Zalla M.J. Basic cutaneous surgery.Cutis. 1994; 53: 172-186PubMed Google Scholar However, if the patient touches a metal portion of the surgical table (which is grounded) or other grounded object, this current will flow from the patient to the table and the patient will experience a shock.3Zalla M.J. Basic cutaneous surgery.Cutis. 1994; 53: 172-186PubMed Google Scholar It is critical that personnel are aware that any conductor in contact with the patient may achieve sufficient current density to cause shocks or burns.1Smith T.L. Smith J.M. Electrosurgery in otolaryngology-head and neck surgery: principles, advances, and complications.Laryngoscope. 2001; 111: 769-780Crossref PubMed Scopus (99) Google Scholar We suspect that tooth pain during regional skin surgery related to metal dental work is underrecognized and underreported. We have previously seen one similar patient who also experienced regional tooth pain with biterminal electrocoagulation. Changing to a monoterminal electrodesiccation setting allowed hemostasis without pain. Because of our experience, the use of monoterminal electrodesiccation may be safely employed when patients with dental work experience pain during procedures using biterminal electrocoagulation. Other safe alternatives include the ultrasonic scalpel4Dufresne R.G. Whalen J.D. Surgical Pearl: The ultrasonic scalpel—A hemostatic tool in Mohs micrographic surgery.J Am Acad Dermatol. 1997; 36: 471-472Abstract Full Text PDF PubMed Scopus (1) Google Scholar or bipolar forceps.5Foster K.S. Geddes L.A. The cause of stimulation with electrosurgical current.Medical Instrumentation. 1986; 20: 335-339PubMed Google Scholar