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239]

Case Report

Chemical burn from direct application of aspirin onto a

painful tooth
Hussam Alfawaz
Department of Restorative Dental Sciences, College of Dentistry, King Saud University, Riyadh, Kingdom of Saudi Arabia

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

Address for correspondence: Dr. Hussam Alfawaz, Department of Restorative Dental Sciences, College of Dentistry, King Saud University, P.O. Box 60169,
Riyadh 11545, Kingdom of Saudi Arabia.
E‑mail: halfawaz1@ksu.edu.sa
Submission: 05-02-19 Revision: 17-02-19 Acceptance: 23-02-19 Web Publication: 27-12-19

INTRODUCTION headache, and in some cases, the tooth becomes sensitive

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
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.[7‑9] 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

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DOI:
10.4103/sej.sej_24_19 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.

© 2019 Saudi Endodontic Journal | Published by Wolters Kluwer ‑ Medknow 65

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Alfawaz: Chemical burn from the Aspirin
aspirin onto a painful tooth, highlighting the consequences
of aspirin misuse.
CASE REPORT
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 1a and 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  2a]. 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  2b]. 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
a b
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
66 Saudi Endodontic Journal | Volume 10 | Issue 1 | January-April 2020
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.
Two weeks later, at her recall visit, the RCT was
completed [Figure 3c]. The lesion had completely and
uneventfully healed without scarring, and the patient
was asymptomatic [Figure 3a and b]. The timeline from
patient presentation to the outcome is summarized in
Figure 4.
DISCUSSION
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
a b
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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Alfawaz: Chemical burn from the Aspirin

b c
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

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 Figure 4: Timeline summarizing the patient information, clinical
blood supply, leading to cell death, but the cellular structure findings, investigations, diagnosis, therapeutic intervention, and
follow‑up
remains intact, even after several days of cell death.
Microscopically, the cells show intact outlines but without
history taking during the patient interview is essential since
nuclei.[17] Shedding of the necrosed epithelium occurs after
incorrect diagnosis in such cases may lead to unnecessary
several days of cell death.[18] Aspirin burns cause severe
gingival and mucosal erosion, with diffuse white sloughing investigational procedures that cause inconvenience to
of the mucosa throughout the affected area.[14] The degree the patient and increase the cost of treatment. Most
of damage varies depending on the duration of exposure, chemical burns with mild‑to‑moderate tissue damage will
the extent of penetration, and the amount, concentration, heal spontaneously.[14] Full‑mouth scaling and good oral
pH, and physical form of the agent.[16] In the present case, hygiene habits such as rinsing mouth with warm saline
to relieve the tooth pain, the patient placed aspirin directly water can facilitate ulcer healing within 1–2 weeks without
in the mouth. In the initial stages of the burn, the soft tissue any scarring.
is usually friable with a burning sensation and resembles an
aphthous ulcer.[19] Without knowledge of the consequences, In this case, the source of pain was treated by RCT of #17,
the patient continued applying crushed aspirin, resulting in which was completely cleaned and shaped and medicated
coagulation necrosis of the oral tissues.[18] with calcium hydroxide (Ca  (OH) 2)  in the first visit to
decrease the number of viable bacteria in the root canal
Management of aspirin burn requires identification and system till the next appointment. Ca (OH) 2 has antimicrobial
removal of the offending agent that caused the burn, as activity due to its high pH and the release of hydroxyl
well as proper treatment for the source of pain. Good ions, which cause destruction of the bacterial cytoplasmic
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Alfawaz: Chemical burn from the Aspirin
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
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.
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