Hazards of Improper Dispensary: Literature Review and Report of an Accidental Chloroform Injection

J Endod. 2018 Jun;44(6):1042-1047. doi: 10.1016/j.joen.2018.02.024. Epub 2018 Apr 24.


Several clear, transparent solutions are used in endodontics. Inappropriate dispensing methods can lead to accidental injection or accidental irrigation. These accidents can cause permanent tissue damage including damage to the bone, periodontium, nerves, and vasculature. This article reports on the consequences of an accidental chloroform injection. Nonsurgical retreatment of tooth #8 was planned as part of a restorative treatment plan in a 69-year-old woman. The dentist accidentally injected chloroform instead of local anesthesia because chloroform was loaded into the anesthetic syringe. The patient experienced severe pain and swelling and soft tissue necrosis and suffered permanent sensory and motor nerve damage. A review of the literature was performed on accidents caused by improper dispensary, namely accidental injections and accidental irrigations. The data were extracted and summarized. Sodium hypochlorite, chlorhexidine, formalin, formocresol, 1:1000 adrenaline, benzalkonium chloride, and lighter fuel were accidentally injected as an intraoral nerve block or as infiltration injections. Bone and soft tissue necrosis, tooth loss, and sensory nerve damage (anesthesia and paresthesia) were the most common consequences reported. Such disastrous events can be prevented by appropriate labeling and separate dispensing methods for each solution. There is a need for disseminating information on toxicity and biocompatibility of materials/solutions used in endodontics. The authors recommend training dental students and endodontic residents on immediate and long-term therapeutic management of patients when an accidental injection or accidental irrigation occurs.

Keywords: Accidental injection; accidental irrigation; chloroform; inadvertent injection; non-surgical retreatment.

Publication types

  • Case Reports
  • Review

MeSH terms

  • Aged
  • Anesthesia, Dental / adverse effects*
  • Anesthetics, Local / administration & dosage
  • Anesthetics, Local / poisoning*
  • Chloroform / administration & dosage
  • Chloroform / poisoning*
  • Dental Restoration, Permanent
  • Dispensatories as Topic
  • Female
  • Humans
  • Injections
  • Medication Errors* / adverse effects
  • Medication Errors* / prevention & control


  • Anesthetics, Local
  • Chloroform