"Tetracycline hydrochloride chemical burn" as self-inflicted mucogingival injury: A rare case report.

Injuries to oral soft tissue can be accidental, iatrogenic, and factitious trauma. Chemical, thermal, and physical agents are the main causative agents for oral soft-tissue burns. The present case describes the chemical burn of oral mucosa caused by tetracycline hydrochloride and its management. Diagnosis was made on the basis of definitive history elicited from the patient. The early detection of the lesion by the patient and immediate institution of therapeutic measures ensure a rapid cure and possible prevention of further mucogingival damage. In addition, we believe that proper guidance and education of the patient is an important prophylactic measure in preventing this self-inflicting injury.

INTRODUCTION

The current classification of periodontal diseases includes accidental, iatrogenic, and factitious traumatic lesions.[1] Traumatic lesions, whether chemical, physical, or thermal induced, are seen very common in the oral cavity. Although the prevalence of traumatic lesion on the gingiva is not known, it has been suggested that gingival presentations are rare for traumatic lesions. Rawal concluded that a detailed and accurate history is critical for the diagnosis of traumatic injuries.[2] The severity and extent of lesions caused by chemical agents depends on the concentration, type, and quantity of the substance, as well as the time of contact with the oral soft tissues.[3] Longer exposure or higher concentration of drug results in epithelial necrosis and shedding.[4]

Tetracyclines are widely used in the treatment of periodontal diseases. They are a group of antibiotics produced naturally from certain species of Streptomyces or semi synthetically derived.[5] There are a few case reports in the dental literature on chemical burns induced due to aspirin; hydrogen peroxide; sodium hypochlorite; silver nitrate. But no case is reported on oral mucosal chemical injury induced by tetracycline hydrochloride. The purpose of this case report was to illustrate the destructive nature of the self-inflicted mucogingival chemical burn and to describe its successful management.

CASE REPORT

A male patient aged 65 years reported to the Department of Periodontics, K. V. G Dental college and Hospital, Sullia, on September 29, 2011 complaining of bleeding and swollen upper and lower gums with pain since six months. On clinical examination, the gingiva was red in color, soft, and edematous in consistency with spontaneous bleeding on probing. The size of the gingiva was enlarged with severe calculus deposit and probing pocket depth measuring 6 mm with exudation on digital pressure. Routine intraoral photographs were taken [Figure 1]. The patient's oral hygiene was poor with no significant history of medication. The case was diagnosed as Generalized Chronic Periodontitis. The patient was advised to rinse his mouth with chlorhexidine 0.12% mouth wash and was advised to carry out the following hematological investigation like fasting blood sugar, bleeding time, clotting time, differential count, and total count. The test was advised prior to the treatment so as to rule out any systemic condition and patient was advised to report to the department for the necessary periodontal treatment next day.

Figure 1

Pre operative

On September 30, 2011, the patient reported as per the scheduled appointment. The blood investigation results were normal. On extraoral examination, face was symmetrical with no palpable lymph nodes. On clinical examination, gingiva was covered with a loosely adherent yellowish white slough on the attached gingiva extending from lower canine to canine on the labial surface [Figure 2]. The lesion extended apically to the alveolar mucosa up to the vestibule with erythematous margins. The patient reported with severe pain. These findings were absent on the previous day. The affected area was gently cleansed and irrigated with betadine and saline. History about placement of any tablet or medicine or application of any medicament was elicited. On detailed questioning, the patient disclosed that he had visited a local physician for the routine general check up on the previous day. He also casually mentioned about mild pain and suppuration of the gums and his appointment with dentist for scaling next day. The overzealous physician prescribed Tetracycline hydrochloride capsule, 250 mg four times a day for three days. The patient was instructed to ingest the medicine with water. Instead of consuming with water, the patient had opened the capsule and placed its content directly in the vestibule for 10 minutes, anticipating rapid relief. History revealed that he was not allergic to tetracycline. The chemical burn involving the mucogingival area was managed with Periogard 0.12% chlorhexidine gluconate to rinse twice daily for seven days and non-steroidal anti-inflammatory drug, Diclofenac sodium 50 mg twice daily for three days. The patient was asked to report to the department after seven days for follow up. But the patient reported after fifteen days with severity of the burn and pain reducing significantly [Figure 3]. The lesion was cleaned with cotton soaked in saline to facilitate faster healing and to induce bleeding. The patient was asked to report the department the very next week. On clinical examination, gingiva, alveolar mucosa, and the vestibule returned to normal [Figures 4 and 5]

Figure 2

Tetracycline hydrochloride burn

Figure 3

Partial healing after 15 days

Figure 4

Healing after 1 month

Figure 5

Complete healing after 45 days

DISCUSSION

In this case, self-inflicted injury resulted in mucogingival chemical burn. This is due to the placement of tetracycline hydrochloride 250 mg in direct contact with the soft tissue due to misconception by the patient, believing that placement of medicine in direct proximity with the tissue will result rapid pain relief.

In the oral cavity, chemical substances cause diffuse erosive lesions ranging from simple desquamation (slough of mucosa) to complete obliteration of the oral mucosa with extension past the basement membrane into the submucosa. In this patient, the intraoral examination revealed severe gingival and mucosal burn with diffuse sloughing of the lower anterior mucosa extending from canine to canine.

Although the prevalence of traumatic lesions on gingiva is not known, clinical reports have singled out certain chemical substances causing oral mucosal burn. Among the commonly implicated substances are the aspirin; hydrogen peroxide; garlic; silver nitrate; phenol; and endodontic materials such as sodium hypochlorite and calcium hydroxide.[6-9] Chemical damage to oral tissue is dependent on a variety of factors which include the strength (pH) or concentration of the material, the quantity ingested, the manner and duration of tissue contact, the extent of penetration into tissue, and the mechanism of action.[10]

Aspirin also known as acetylsalicylic acid is a salicylate drug often used as an analgesic. Glick et al. stated that aspirin burn is caused by the acetyl salicylic acid's pH of 3.3. Due to the acidic nature of the salicylic acid, when the drug comes in direct contact with the oral soft tissue, it might lead to aspirin burn. The case was managed by gently cleansing the area and rinsing with chlorhexidine 0.12% and analgesic.[2] According to Rees et al., improper use of hydrogen peroxide at a concentration greater than 3% can lead to epithelial necrosis. In such case, the patient is asked to discontinue undiluted hydrogen peroxide and the area is gently rinsed with saline to remove the necrotic tissue. A topical anesthetic gel can be applied.[2] Bagga et al. reported chemical burn of oral mucosa caused by crushed garlic. The management of this case was by local application of topical anesthetic and antibacterial agent. Systemic analgesics were also prescribed.[11] Silver nitrate is commonly used as a chemical cautery agent for the treatment of aphthous ulcer. According to Frost et al., it brings about almost instantaneous relief of the symptom by burning the nerve endings at the site of ulcer. Silver nitrate often destroys tissue around the immediate area of application and may result in delayed healing or (rarely) severe necrosis at the application site. Its use should be discouraged.[12] Gatot et al. reported that improper use of Sodium hypochlorite or dental bleach which is commonly used as a root canal irrigant may cause serious ulcerations due to accidental contact with oral soft tissue.[13] The proper use of rubber dam during endodontic procedure can reduce the risk of chemical or iatrogenic injuries. Touyz et al. reported an unusual chemical burn confined to the masticatory mucosa produced by the abusive ingestion of fresh fruit and by the concomitant excessive use of mouth wash.[14]

The management of chemical burns requires removal of the offending agent and symptomatic therapy. Baruchin et al. reported that a protective emollient agent such as a film of methyl cellulose may provide relief.[7] According to Yano et al., irrigation is the emergency treatment of choice to minimize the product effect and current therapy with steroids results in a very favorable prognosis. If pain is considerable, symptomatic treatment may be of benefit.[15]

A detailed and accurate history is often critical in the diagnosis of traumatic injuries. The challenge is to elicit relevant information from the patient. Patient may be unaware of the significance of the potentially injurious habits, practices, or agents. Permanent removal of the agent will be sufficient for the removal of the cause. Symptomatic therapy is limited to topical or systemic analgesics. In asymptomatic cases, patient reassurance may be all that is needed.

The present report illustrates that tetracycline hydrochloride 250 mg placed in close proximity to tissue lead to severe caustic burns of the oral mucosa in that area. In this particular case, acidic pH of tetracycline hydrochloride might have caused extensive tissue damage, which was managed effectively using saline and betadine irrigation, chlorhexidine gluconate 0.12% mouth rinse, and systemic analgesics. The early detection by the patient and the immediate institution of therapeutic measures ensured a rapid relief and possibly prevented further mucosal damage. In addition, we believe that guidance and proper counseling before prescribing any drug, its method of ingestion should be explained to the patient. This will prove to be an important prophylactic tool in preventing from these local self-inflicting injuries.

CONCLUSION

This article illustrates a rare case of “tetracycline hydrochloride burn” in the oral cavity. This case presents oral soft tissue burn caused by inappropriate use of tetracycline hydrochloride prescribed by overzealous physician. This case highlights one more differential diagnosis in considering mucosal burn in the oral cavity if the burn is not found to be associated with other commonly caused chemical agents. This lesion share clinical features of aspirin burn and hydrogen peroxide burn. From this case report, it is evident that casual prescriptions are rampant amongst physicians, even the case would have been treated by scaling and root planing. Awareness regarding the adverse effects or interactions of these medications is also important along with knowledge of their beneficial effects.