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Paper text:
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 ,
sodium hypochlorite accidents are the most commonly encountered mishaps in endodontics and have been very often reported in literature .
mishaps related to chx accidents are rare in endodontic literature , although several in vitro and animal studies have evaluated the cytotoxic nature of chx .
we present a case report of accidental injection of 2% chx gluconate in the buccal vestibule area , instead of a local anesthetic ( la ) solution .
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 ,
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 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 .
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 .
( a ) mild extraoral swelling immediately after chx accident ( b ) moderate extraoral swelling and redness involving the right infraorbital region after 24 h the patient was explained about the mishap and was assured of complete treatment and care until the symptoms resolved .
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 1b ] , 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 day , dexamethasone 5 mg thrice daily for 3 days , and subsequently dosage was tapered .
on the 7 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 2a and b ] .
( 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 swelling had completely regressed by the 15 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 .
although the dental literature provides guidance for safe and effective administration of la in dental operatory for various invasive procedures , 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 .
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 .
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 .
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 ) . 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 .
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 .
a follow - up of 3 months was maintained to ensure the well - being of the patient .
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 .
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 can not be guaranteed .
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 can not be guaranteed .
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 15th day . 
 the swelling reduced gradually over a period of 15 days . 
 reversal of sensation was attained after 35 days .