Home  -  About us  -  Editorial board  -  Search  -  Ahead of print  -  Current issue  -  Archives  -  Instructions  -  Subscribe  -  Contacts  -  Advertise - Login 
 
 
     

 Table of Contents  
CASE REPORT - MINOR ORAL SURGERY
Year : 2021  |  Volume : 11  |  Issue : 1  |  Page : 173-175

Postanaesthetic aseptic palatal necrosis - A case report


1 Department of Oral and Maxillofacial Surgery, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India
2 Department of Oral and Maxillofacial Surgery, Mall Dental Clinic, Deoria, Uttar Pradesh, India
3 Department of Oral and Maxillofacial Surgery, Advanced Dental Care and Implant Centre, Bareilly, Uttar Pradesh, India
4 Department of Oral Medicine and Radiology, Chitwan Medical College, Bharatpur, Nepal

Date of Submission20-Aug-2020
Date of Decision04-Apr-2021
Date of Acceptance17-Apr-2021
Date of Web Publication24-Jul-2021

Correspondence Address:
Dr. Sakshi Gupta
Department of Oral and Maxillofacial Surgery, Institute of Dental Sciences, Bareilly, Uttar Pradesh
India
Login to access the Email id


DOI: 10.4103/ams.ams_289_20

Rights and Permissions
  Abstract 

Rationale: In dentistry, the most common procedure to be applied is administration of a local anaesthetic agent. It is impossible to practice dentistry without local anaesthesia. In the oral cavity, the palatal mucosa is tightly adherent to the palatal bone and there is little space for anaesthetic solution to be deposited. If local anaesthetic is forcefully injected by the syringe, it creates pressure on blood vessels and causes palatal necrosis. Patient Concern: Here, we present a case report of a 25-year-old male patient who reported to us with chief complaint of an ulcer on the palate. Diagnosis: Patient was diagnosed with postanaesthetic aseptic palatal necrosis. Intervention: The patient was managed conservatively using copious irrigation and a palatal acrylic splint. Outcome: On the 6th month follow-up, the lesion was completely replaced by healthy mucosa. Take-away Lessons: We should avoid forceful injection of local anaesthetic agent to prevent further postoperative complications.

Keywords: Anaesthesia, erythematous, necrosis, palatal acrylic splint, palatal mucosa


How to cite this article:
Chaurasia A, Airan M, Mall S, Gupta S, Sharma H, Mohini A. Postanaesthetic aseptic palatal necrosis - A case report. Ann Maxillofac Surg 2021;11:173-5

How to cite this URL:
Chaurasia A, Airan M, Mall S, Gupta S, Sharma H, Mohini A. Postanaesthetic aseptic palatal necrosis - A case report. Ann Maxillofac Surg [serial online] 2021 [cited 2021 Dec 5];11:173-5. Available from: https://www.amsjournal.com/text.asp?2021/11/1/173/322243


  Introduction Top


In our regular dental practice, local anaesthetic agent plays an important role. Without local anaesthesia, its impossible to do a healthy dental practice. It is mainly given as local infiltration and nerve blocks.[1] In general, there are fewer complications encountered caused by local anaesthesia, but it cannot be denied that local anaesthesia does not cause any complications in dental practice. However, possible complications such as postoperative infection, prolonged pain, trismus, needle breakage, paraesthesia, haematoma, oedema, facial nerve paralysis, sloughing of tissues, and postanaesthetic lesions.[2] Due to its adherent feature, local anaesthesia is forcefully injected by the syringe, which creates pressure on blood vessels and causes palatal necrosis.[3] Here, we present a case report of a 25-year-old male patient who was diagnosed with palatal necrosis.


  Case Report Top


A patient reported to us with a chief complaint of ulcer on the palate on the left side for 15–20 days. Patients provided a history of root canal treatment of the upper left tooth region that began around 25 days ago, after which he observed an ulcer that grew to its current size within 5–10 days. He reported to the dentist on the next visit and was on multivitamin and antibiotics till he reported to us.

During clinical examination, we observed a necrotic palatal mucosa of approximately 3 cm in diameter, grayish-black, and margins were erythaematous [Figure 1]. Access cavities were opened in 24 and 26. On obtaining further history of present illness, the patient informed us about forcefully deposited local anaesthetic on the palatal side during treatment. Based on the examination and history of the patient provisional diagnosis was made as aseptic palatal necrosis. Accidental injection of formaldehyde and thermal burn were kept as differential diagnosis.
Figure 1: Preoperative palatal ulceration

Click here to view


On the first visit, the patient was advised to get orthopantomogram (OPG) and blood investigation done. OPG revealed no bony changes, and blood tests were also within the normal limits. We assured the patient about the lesion and started antioxidants along with multivitamin, gave betadine plus hydrogen peroxide gargle and recalled after 5 days.

The following visit, the biomechanical preparation of 24 and 26 was completed and an intracanal medicament was applied. Enucleating of necrotic palatal mucosa followed by irrigation and haemostasis was achieved. Finally, an occlusion splint was placed. Postoperative instructions were given and the patient was recalled after 1 week [Figure 2]. The patient was kept on regular follow-up and root canal treatment was completed after 1 month with fixed partial denture over 24, 25, and 26. Palatal mucosa granulated slowly and covered approximately 80% of the palatal bone in 3 months [Figure 3] and completely after 6 months [Figure 4].
Figure 2: Seventh day follow-up after irrigation with copious amount of normal saline and hydrogen peroxide followed by adaptation of palatal splint

Click here to view
Figure 3: The necrotic tissue replaced by granulation tissue on 3rd month follow-up and healed upto 80%

Click here to view
Figure 4: Lesion is fully healed and replaced by healthy mucosa on 6th month follow-up

Click here to view


The protocol followed for the management of this case is Vit Pro once a day for 3 months, Neomust Forte twice a day for 3 months, betadine + hydrogen peroxide mouthwash four times a day for 1 month followed by 0.2% chlorhexidine for 3 months and soft and nonspicy healthy diet for 3 months.


  Discussion Top


There are so many complications caused by local anaesthesia described in the literature. Postanaesthetic necrosis caused by the pressurized injection of local anaesthetic solution, particularly those containing vasoconstrictor, is one of the complications and is well documented. The palate has rich blood supply through the greater and lesser palatal arteries which will play a role in wound healing and sustaining metabolism by providing oxygen and nutrients.[4] According to Vidisha et al., only 6–7 cases were reported with aseptic palatal necrosis till 2017.[5]

Palatal mucosa is relatively dense, confined, unyielding, and firmly adherent to the underlying palatal bone. The pain and soreness in the palatal mucosa may be caused by forceful administration of local anaesthetic agents. The etiology of such an event is the absence of good blood supply through vasoconstrictions which deprive the tissue of its necessary sustenance, resulting in the necrosis of the overlying epithelium. The vasoconstrictor causes contraction of smooth muscles present in the arterial wall which may lead to transient ischaemia and reduces the oxygen supply to the distal structures of the injected site and promotes the production of acidic by-products of metabolism. In addition, to preserve the vasoconstrictors, the pH of the local anaesthetic solution is adjusted toward acidity, which, however, accentuates tissue acidity. Thus, epinephrine contained in many local anaesthetic agents may be a possible cause of ischaemia and secondary necrosis.[6]

Modern local anaesthetic agents are relatively nonirritating to the tissues with the exception, perhaps, of skeletal muscle. Allergic reactions may manifest as circumscribed lesions while others may be derived from the pharmacological effects of the agents used. Allergic reactions to local anaesthetics have been greatly reduced by the development of amide local anaesthetics, for example, lidocaine. Cases of skin necrosis due to prilocaine have been reported.[7]

Epithelial desquamation may result from the application of a topical anaesthetic agent to gingival tissues for a prolonged period. In the hard palate, a sterile abscess may form secondary to prolonged ischemia resulting from the use of a local anaesthetic solution containing a vasoconstrictor. Other postanaesthetic intraoral lesions may result from recurrent aphthous stomatitis and/or herpes simplex which can develop following any traumatic insult to the tissues.[8] Herpes simplex, although most commonly observed extraorally, can develop intraorally on tissues attached to the underlying bone; for example, tissues of the hard palate. Similarly, mucormycosis also causes ulceration of the palate, which results from necrosis due to invasion of a palatal vessel. The lesion is characteristically large and deep, causing denudation of the underlying bone.[9]

Management of such lesions formed due to administration of local anaesthetic is usually conservative. It consists of reassuring the patient, prescribing analgesics, and a combination of topical antiseptic and anaesthetic preparations. Healing generally occurs within 8–10 days after the onset of the lesion. Rarely, surgical intervention is necessary when an ulcer does not heal. An oral protective emollient Orabase Paste can also be prescribed. The following measures can minimize such palatal lesions using topical anaesthetic preparation according to the manufacturer's specifications. Moreover, it should be applied for 1–2 min to maximize the effectiveness and minimize toxicity.[10]

Here, we presented a case of postanaesthetic aseptic palatal necrosis, in which palatal mucosa got granulated slowly and covered the palatal bone approximately 80% in 2–3 months and completely after 6 months.


  Conclusion Top


Here, we conclude precautions should be taken to prevent postoperative complications. Complications can occur anywhere, but precautions can reduce the chances of postoperative discomfort.

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.
Pattni N. Superficial skin necrosis and neurological complications following administration of local anaesthetic: A case report. Aust Dent J 2013;58:522-5.  Back to cited text no. 1
    
2.
Gupta R, Garg M, Pawah S, Gupta A. Postanesthetic ulceration of palate: A rare complication. Natl J Maxillofac Surg 2016;7:86-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Ghanem H, Suliman AM. Palatal ulceration: A complication of regional anesthesia of the oral cavity - A case report. Anesth Prog 1983;30:118-9.  Back to cited text no. 3
    
4.
Ranjitha EG, Ramaswamy S, Austin RD, Ramya K. Necrotic ulcer on the palate: A sequelae of local anethesic administration: A rare case report. Int J Adv Health Sci 2015;2:10-3.  Back to cited text no. 4
    
5.
Gargi V, Mohan RP, Kamarthi N, Gupta S. Palatal perforation: A rare complication of postanesthetic necrosis. Contemp Clin Dent 2017;8:501-5.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Gogna N, Hussain S, Al-Rawi S. Case reports: Palatal mucosal necrosis after administration of a palatal infiltration. Br Dent J 2015;219:560-1.  Back to cited text no. 6
    
7.
Aytav S, Etoz A, Akin S. Skin necrosis caused by prilocaine: A case report. Wounds 2005;17:58-61.  Back to cited text no. 7
    
8.
Carroll MJ. Tissue necrosis following a buccal infiltration. Br Dent J 1980;149:209-10.  Back to cited text no. 8
    
9.
Jayachandran S, Krithika C. Mucor mycosis presenting as palatal perforation. Indian J Dent Res 2006;17:139-42.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Malamed SF. Handbook of Local Anesthesia. 7th ed. St. Louis. The C.V. Mosby Co; 2019.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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

 
  In this article
   Abstract
  Introduction
  Case Report
  Discussion
  Conclusion
   References
   Article Figures

 Article Access Statistics
    Viewed258    
    Printed4    
    Emailed0    
    PDF Downloaded56    
    Comments [Add]    

Recommend this journal