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Sir, I have been made aware of a safety alert1 that arose from the death of a bedbound patient who smoked following application of E45 cream. E45 is a paraffin-based product, the residue of which can act as an accelerant when ignited. This residue is easily absorbed by fabrics such as clothing or wound dressings.2 In the community setting, such emollients are often used for lip lubrication. Dental and health professionals should be aware of the potential risks associated with patients who smoke or are on oxygen therapy. Although the risk of flammability applies to situations where large quantities of paraffin-based emollients are used (100 g or over)3 only water-based gels should be used on the hands, face, or inside the nose. Examples of water-based gels include Oralieve, BioXtra and Biotene.
E45 cream is classified as a low paraffin product, containing 27.1% paraffin.4 An alternative terminology for white soft paraffin is petroleum jelly. It is, therefore, also prudent to mention that Vaseline is a 100% petroleum-based product and a much greater risk to patients. Concerns have been raised regarding respiratory complications in addition to flammability. If small quantities of water-based gels are accidentally aspirated, the lung tissue can absorb them. This is not true for Vaseline, which remains in the lungs permanently predisposing the patient to lipoid pneumonia.5 Vaseline should not be used for lubrication orally or intra-nasally on patients with an impaired protective reflex.
Since this safety alert, our use of soft paraffin with patients during operating sessions has decreased, in preference for water-based lubricants. I would, however, emphasise that the warnings are related to the use of large quantities of products. Nevertheless the safety alert does apply to many aspects of dentistry, ranging from domiciliary visits to general practice, eg where GIC restorations may be temporarily sealed with Vaseline.
References
Medication Safety Alert. 2016. Risk of Fire with all Emollients. Cwm Taf University Health Board MSA008.
Medicines and Healthcare Products Regulatory Agency. Paraffin-based skin emollients on dressings or clothing: fire risk. 2016. Available at: https://www.gov.uk/drug-safety-update/paraffin-based-skin-emollients-on-dressings-or-clothing-fire-risk (accessed October 2017).
National Patient Safety Agency. Rapid Response Report: Fire Hazard with Paraffin Based Skin Products on Dressings and Clothing. NHS, 2007. Available at: http://www.nrls.npsa.nhs.uk/resources/?entryid45=59876 (accessed October 2017).
British National Formulary. Emollients. BNF 13.2.1. 2017.
Osman G A, Ricci A, Falasca C et al. Exogenous lipoid pneumonia induced by nasal decongestant. Clin Respir J 2016; 10.1111/crj.12557 [Epub ahead of print].
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Brewer, E. Patient safety: Paraffin-based products. Br Dent J 223, 620 (2017). https://doi.org/10.1038/sj.bdj.2017.936
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DOI: https://doi.org/10.1038/sj.bdj.2017.936