Journal of Conservative Dentistry
Home About us Editorial Board Instructions Submission Subscribe Advertise Contact e-Alerts Login 
Users Online: 840
Print this page  Email this page Bookmark this page Small font sizeDefault font sizeIncrease font size
 


 
Table of Contents   
CASE REPORT  
Year : 2016  |  Volume : 19  |  Issue : 1  |  Page : 106-108
Accidental injection of 2% chlorhexidine gluconate instead of an anesthetic agent: A case report


Department of Conservative Dentistry and Endodontics, Sri Aurobindo Institute of Medical Sciences, Indore, Madhya Pradesh, India

Click here for correspondence address and email

Date of Submission29-Sep-2015
Date of Decision18-Nov-2015
Date of Acceptance02-Dec-2015
Date of Web Publication5-Jan-2016
 

   Abstract 

We report a case where 2% chlorhexidine (CHX) gluconate was mistaken for an anesthetic solution and infiltrated into the buccal vestibule during routine root canal treatment. Accidentally, 2% CHX gluconate solution was injected in the right upper buccal vestibule (16) of a 23-year-old male during routine root canal treatment. The patient experienced pain and a burning sensation over the injected area shortly after injection. Swelling with mild extraoral redness over the right cheek area was observed clinically. The patient was immediately administered dexamethasone intramuscularly, and was prescribed antibiotics, analgesics, and antihistamines. The patient complained of a loss of sensation over the right cheek by the 15 th day. The swelling reduced gradually over a period of 15 days. Reversal of sensation was attained after 35 days.

Keywords: Accidental injection, root canal therapy, 2% chlorhexidine (CHX) gluconate

How to cite this article:
Hiremath H, Agarwal RS, Patni P, Chauhan S. Accidental injection of 2% chlorhexidine gluconate instead of an anesthetic agent: A case report. J Conserv Dent 2016;19:106-8

How to cite this URL:
Hiremath H, Agarwal RS, Patni P, Chauhan S. Accidental injection of 2% chlorhexidine gluconate instead of an anesthetic agent: A case report. J Conserv Dent [serial online] 2016 [cited 2019 Sep 15];19:106-8. Available from: http://www.jcd.org.in/text.asp?2016/19/1/106/173213

   Introduction Top


Endodontic mishaps are unfortunate accidents that occur during treatment, some owing to inattention to detail, others being very unpredictable. Among all types of mishaps mentioned in the literature, large percentages of them are irrigant-related mishaps. [1] Sodium hypochlorite accidents are the most commonly encountered mishaps in endodontics and have been very often reported in literature. [2]

Mishaps related to CHX accidents are rare in endodontic literature, although several in vitro and animal studies have evaluated the cytotoxic nature of CHX. [3]

We present a case report of accidental injection of 2% CHX gluconate in the buccal vestibule area, instead of a local anesthetic (LA) solution.


   Case Report Top


A 23-year-old male reported to the Department of Conservative Dentistry and Endodontics, Sri Aurobindo College of Dentistry, Sri Aurobindo Institute of Medical Sciences, Indore, Madhya Pradesh, India, seeking dental treatment for spontaneous pain in right upper first molar (16). After clinical and radiographic examination, a diagnosis of irreversible pulpitis was established. Root canal therapy was started with the patient's consent. At the first visit, access cavity preparation with standard protocol of irrigation and debridement was performed by the resident. Because the patient had reported during the closing hours of the dental office, he was called for a second visit the next day for biomechanical preparation and obturation of the upper right first molar.

At the second visit, the patient complained of pain in the mesiobuccal root canal during instrumentation. Resident infiltrated LA in the upper right buccal vestibule area assuming incomplete pulp debridement. The patient immediately complained of mild discomfort in the injected area. The patient was reassured and the biomechanical preparation was performed in the mesiobuccal canal. Approximately 10 min later, the patient complained of a severe burning sensation and pain in the injected area. Mild swelling was observed in the right cheek area [Figure 1]a. On observing the symptoms and the clinical condition of the patient, the solution in the syringe was checked and found to be 2% CHX (mild mint flavored) (Safe plus, Neelkanth Healthcare Pvt. Ltd, Jodhpur, Rajasthan, India).
Figure 1: (a) Mild extraoral swelling immediately after CHX accident (b) Moderate extraoral swelling and redness involving the right infraorbital region after 24 h


Click here to view


The patient was explained about the mishap and was assured of complete treatment and care until the symptoms resolved. The patient was immediately administered dexamethasone (4 mg) intramuscularly. Antibiotics, analgesics, and antihistamines were prescribed. The patient was advised to report everyday to the dental office, to assess his clinical condition.

The swelling had increased the next day and had involved the right infraorbital region [Figure 1]b, but the pain had relatively reduced. There was no improvement in the clinical appearance (extraoral swelling and redness) of the patient on the 4th day of visit. Considering the continuing discomfort the patient was put on oral steroids by the 5 th day, dexamethasone 5 mg thrice daily for 3 days, and subsequently dosage was tapered. On the 7 th day the pain had subsided completely and the extraoral swelling had substantially reduced. Biomechanical preparation and obturation of the upper right first molar was completed on the same day [Figure 2]a and b.
Figure 2: (a) Extensive extraoral swelling and redness of the right side of face on 4th day (b) Substantial reduction in extraoral swelling at 1-week follow-up


Click here to view


Swelling had completely regressed by the 15 th day [Figure 3]. Meanwhile, the patient complained of a loss of sensation during shaving in the right cheek area. The patient was reassured about reversal of the sensation and the patient regained the sensation after 35 days. A follow-up of 3 months was maintained to ensure the well-being of the patient.
Figure 3: Complete regression of extraoral swelling after 15 days


Click here to view



   Discussion Top


Although the dental literature provides guidance for safe and effective administration of LA in dental operatory for various invasive procedures, [4] there have been reports of unintended injection of formalin, hydrogen peroxide, and sodium hypochlorite instead of LA. Various reasons have been stated, such as the widespread practice of using LA in bottles, reuse of LA bottles in dental operatory, nonavailability of professionally trained or educated dental assistants, and improper handling techniques. [1],[5],[6]

A survey conducted on responsible handling of LA agent in Indian dental operatory reported injecting other fluids instead of LA as a severe negligent act and highlighted the need for training for responsible handling of fluids in dental operatory. [7]

An endodontic irrigant should be nontoxic when it comes in contact with vital tissues. A potential complication of irrigation is the forced extrusion of the irrigant and debris through the apex. The complication may worsen when an irrigant is infiltrated instead of LA solution, owing to the negligence of the operator or the supporting staff.

CHX accidents have been widely reported in medical literature. Edema of tongue, oral ulcers, and acute pulmonary edema are the adverse effects reported in a case wherein, five babies were accidentally fed with a formula prepared with 0.05% CHX (mistaken for sterile water). [8]

Over the last decades, a wide array of cell lines have been used to evaluate the cytotoxicity of CHX. The exposure of cultured human dermal fibroblasts to CHX at concentrations equal to or greater than 0.005% for 3 h caused cell death. [9]

The abovementioned case report in the field of medicine, and the in vitro study in the field of dentistry provide the necessary information about the cytotoxic nature of CHX. Considering the facts, it can be concluded that in this case the patient must have had severe inflammation, edema, and a moderate amount of necrosis. Though the authors were familiar with the cytotoxic nature of CHX, it was very difficult to recall an accidental injection of CHX instead of LA solution. Considering the available dental literature about the nature of effect of CHX on soft tissues, we decided to prescribe a course of antibiotics, analgesics, antihistamines, and steroids.

The reason for the transient loss of sensation in the right cheek area, experienced by the patient, could be related to the neurotoxicity reported in some animal studies where CHX gluconate was applied directly to the neural tissue of the meninges. [10] A follow-up of 3 months was maintained to ensure the well-being of the patient.


   Conclusion Top


The delivery of LA is one of the critical aspects of pain control in dentistry and is practiced widely by dentists. Hence, care must be taken to prevent accidental injection of other chemical agents instead of LA.

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

1.
Kleier DJ, Averbach RE, Mehdipour O. The sodium hypochlorite accident: Experience of diplomates of the American board of endodontics. J Endod 2008;34:1346-50.  Back to cited text no. 1
    
2.
Laverty DP. A case report of accidental extrusion of sodium hypochlorite into the maxillary sinus during endodontic retreatment and review of current prevention and management. J Res Dent 2014;2:96-100.  Back to cited text no. 2
  Medknow Journal  
3.
Faria G, Celes MR, De Rossi A, Silva LA, Silva JS, Rossi MA. Evaluation of chlorhexidine toxicity injected in the paw of mice and added to cultured l929 fibroblasts. J Endod 2007;33:715-22.  Back to cited text no. 3
    
4.
Malamed SF. Handbook of Local Anesthesia. 5 th ed. New Delhi: Elsiever; 2011. p. 330-1.  Back to cited text no. 4
    
5.
Arakeri G, Brennan PA. Inadvertent injection of formalin mistaken for local anesthetic agent: Report of a case. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;113:581-2.  Back to cited text no. 5
    
6.
Kaufman AY. Facial emphysema caused by hydrogen peroxide irrigation: Report of a case. J Endod 1981;7:470-2.  Back to cited text no. 6
[PUBMED]    
7.
Rooban T, Rao UK, Joshua E, Ranganathan K. Survey of responsible handling of local anesthetic in Indian dental operatory. J Forensic Dent Sci 2013;5:138-45.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.
Mucklow ES. Accidental feeding of a dilute antiseptic solution (chlorhexidine 0.05% with cetrimide 1%) to five babies. Hum Toxicol 1988;7:567-9.  Back to cited text no. 8
    
9.
Hidalgo E, Dominguez C. Mechanisms underlying chlorhexidine-induced cytotoxicity. Toxicol In Vitro 2001;15:271-6.  Back to cited text no. 9
    
10.
Henschen A, Olson L. Chlorhexidine-induced degeneration of adrenergic nerves. Acta Neuropathol 1984;63:18-23.  Back to cited text no. 10
[PUBMED]    

Top
Correspondence Address:
Dr. Hemalatha Hiremath
Department of Conservative Dentistry and Endodontics, Sri Aurobindo Institute of Medical Sciences, Sanwer Road, Indore - 453 555, Madhya Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-0707.173213

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
 
 
  Search
 
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  
 


    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed2028    
    Printed25    
    Emailed0    
    PDF Downloaded324    
    Comments [Add]    

Recommend this journal