Accidental Intraoral Formalin Injection as Local Anesthetic Agent in an Outreach Activity: A Rare Case Report
Introduction
35-40% aqueous solution of formaldehyde is termed as formalin [1]. It
is a toxic substance which upon exposure to skin and mucosa creates
first degree and second-degree burn [2]. Simultaneously it has
deleterious effect on gastrointestinal and respiratory system [3]. It
can be fatal too in a dose of 50-100ml in the 40% concentration [4].
Case Report
We are reporting the first case of inadvertent injection of formalin
mistaken as local anaesthetic agent in a rural camp setup. On the fine
morning of Doctors' day, the authors were invited in a dental treatment
camp in a remote village where the very first patient came with the
chief complaint of mobility of anterior tooth. On clinical examination
the lower right central incisor was Glickman's Grade II mobile and
advised for extraction. Patient was in good physical and mental state.
The case was assigned to a freshly passed out graduate. After
pre-surgical accepted procedure, the doctor in-charge infiltrated local
anaesthetic solution. Within couple of minutes patient started
complaining of sharp burning pain sensation and severe discomfort on the
injection site associated with headache and breathlessness. The
procedure was stopped, and the authors were called immediately. Authors
examined the local anaesthetic vial for expiry date and found that the
seal was broken, and no tag was applied on the bottle regarding the
content. The original local anesthetic agent tag was intact on the vial.
After opening the rubber cup, it was found that the vial thought of
containing local anaesthetic agent was actually pungent smelling clear
liquid that is formalin. Mistakenly the assistant (provided by the camp
organizer) loaded formalin solution 2ml from a preemptied anaesthetic
bottle which was kept there to collect biopsy specimens. There was a
crowd of more than 200, so one of the authors was taking care of the mob
and explaining, other took the patient to nearby pharmacy which was 12
kilometres far
Treatment
- a) Saline was injected at the injection site to dilute the formalin.
b) Intramuscular Dexamethasone 8mg twice with tapering for 5 days given to reduce the inflammation and to counteract sudden respiratory embarrassment
c) Intravenous slow Pheniramine 10ml twice for 5 days given as an anti-allergic
d) Intramuscular Diclofenac sodium twice for 5 days for pain
e) Intravenous Amoxicillin + Clavulanate 1.2 gm to reduce the chance of aerobic infection, especially gram-positive bacteria's
f) Intravenous Metrogyl 100ml thrice for 5 days prophylactically given to counteract anaerobic infection
g) Intravenous Ranitidine 2cc for 5 days for to prevent gastric upset
h) Tab Phlogam thrice for 5 days to reduce swelling1
i) Hydrogen peroxide mouthwash and Betadine mouthwash alternatively [5]
Patient was shifted to local primary health centre for monitoring of
vital signs. Next Day increasing edema, erythema of face was suggestive
of chemical cellulites (Figure 1). Recalled on SOS or after 7 days
(Figure 1) (Figure 2). Telephonic consultation was made in between with
the PHC incharge and at the end of the week patient was asymptomatic
with necrotic sloughing on the floor of the mouth. We reviewed the
patient in an interval of a week and at the end of 2 months he was
completely recovered (Figure 3).
Figure 1: Extraoral Photograph on 7th day.
Discussion and Conclusion
In Dentistry there are many clear solutions sodium hypochlorite,
normal saline, local anaesthesia, hydrogen peroxide and formalin used
for different purposes. They all require special storage and handling
[6] In our case report mishap happened due to the negligence of the
supporting staff (provided by the organisers) but as the amount was low
patient survived without any systemic complications. Root cause are
firstly, we don't use single use cartridges, for economic reasons. In
India most of the practitioners use multi use vials.1 Secondly, we also
reuse local anaesthetic solution vial to store other solutions and when
the refilled solution is clear then confusion happens, if at all we are
reusing the vial, it should be well tagged about the content. Thirdly,
keeping the solution not used for injection should not be there in the
core clinical area and finally, employing untrained staff as an
assistant should not be done because a small mistake from your assistant
can create a great trouble to you. We should stick to these rules in
practice as well as in camp and specially the rural ones because the
value of life is same [7].
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