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Tissue damage after sodium hypochlorite extrusion during root

canal treatment
Ruth Fuentes de Sermeo, DDS,a La Assed Bezerra da Silva, DDS, PhD,b
Henry Herrera, DDS, PhD,c Helen Herrera, DDS, PhD,c Raquel Assed Bezerra Silva, DDS, PhD,d
and Mrio Roberto Leonardo, DDS, PhD,b San Salvador, El Salvador and Ribeiro Preto, Brazil
UNIVERSIDAD EVANGELICA DE EL SALVADOR AND UNIVERSITY OF SO PAULO

Sodium hypochlorite solution is toxic to vital tissues, causing severe effects if extruded during endodontic
treatment. This paper presents a report on the tissue damage related to inadvertent extrusion of concentrated sodium
hypochlorite solution during root canal treatment. A 65-year-old woman was referred with moderate pain, ecchymosis,
and severe swelling of the right side of the face. These symptoms appeared immediately after a root canal treatment of
the maxillary right canine, which had been started 21 hours earlier. It was diagnosed as air emphysema related to
sodium hypochlorite solution extravasation during the endodontic treatment. To avoid this, an initial radiograph
should be taken to determine the correct canal working length and confirm root canal integrity. (Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2009;108:e46-e49)

Mechanical instrumentation of the root canal system


must always be supported by the use of antimicrobial
irrigating solutions when treating teeth with pulp necrosis and resorbing apical periodontitis. Despite advances in instrument technology, at least one-third of
root canal surfaces may still remain uninstrumented.1
Therefore, the cleaning of the root canal in terms of soft
tissue removal and elimination of bacteria relies heavily
on the adjunctive action of chemically active irrigation
solutions. Irrigation is also necessary to remove debris
created during instrumentation, to act as a lubricant for
instruments, and to remove the smear layer that forms
on instrumented dentin surfaces.2
Sodium hypochlorite solution (NaOCl) is considered
to be the most ideal irrigant for use throughout instrumentation because it possesses strong antimicrobial and
proteolytic activity.2 Unlike other irrigants, NaOCl has
the unique ability to dissolve necrotic tissue3 as well as
the organic components of the smear layer.4 NaOCl is
commonly used for irrigation of root canals in concentrations ranging from 0.5% to 5.25%. Controversy exa

Dental Practice, San Salvador, El Salvador.


Professor, Department of Pediatric Dentistry, Preventive and Community Dentistry, School of Dentistry of Ribeiro Preto, University
of So Paulo.
c
Professor, Universidad Evangelica de El Salvador.
d
Professor, Department of Pediatric Dentistry, Preventive and Community Dentistry, School of Dentistry of Ribeiro Preto, University
of So Paulo.
Received for publication Dec 15, 2008; accepted for publication Dec
17, 2008.
1079-2104/$ - see front matter
2009 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2008.12.024
b

e46

ists over the optimal concentration of NaOCl solutions


to be used in endodontic treatment. Although the bactericidal activity and tissue dissolution capacity improve with increased concentration of NaOCl,5,6 so
does the tissue toxicity and caustic potential.7 NaOCl
used in combination with citric acid promotes chlorine
gas release.8
Sodium hypochlorite, at high concentrations, is extremely toxic to vital tissues,6,9,10 causing hemolysis,
ulceration, inhibition of neutrophil migration, damage
to endothelial and fibroblast cells, facial nerve weakness, and necrosis after extrusion during endodontic
treatment.7,10,11
The present paper presents a report on the tissue
damage after inadvertent extrusion of concentrated sodium hypochlorite solution during root canal treatment.
CASE REPORT
A 65-year-old woman was referred with moderate pain,
ecchymosis, and severe swelling on the right side of the face
(Fig. 1). These symptoms appeared immediately after a root
canal treatment of the upper right canine which had been
initiated 21 hours earlier. The patient had a complex medical
history, with medication for cirrhosis hepatica, diabetes mellitus, and hypertension. She had therefore been given amoxicillin (500 mg, 3 times a day) before the endodontic treatment
started. Endodontic therapy had been commenced using rubber dam, and the root canal system was irrigated with 5%
sodium hypochlorite solution. During the irrigation, the patient experienced severe sudden pain and a right-side suborbital swelling. The patient was referred to us for consultation.
On examination it was observed that the patient had difficulty opening her right eye. The swelling was extended to the
submandibular and sublingual regions at the right side. Infraorbitally and in the region of the upper right lip up to the

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Fig. 1. Clinical aspect of emphysema related to extravasation


of the sodium hypochlorite solution during endodontic treatment, with ecchymosis and severe swelling of the right side of
the face. These symptoms appeared immediately after a root
canal treatment of the upper right canine.

right lip corner, there was altered sensation. There was no


reported paresthesia of the dental nerves.
On clinical examination, the tooth, which had temporary
cement on the palatal surface, was slightly sensitive to vertical and horizontal percussion and palpation, had a grade 2
mobility, and showed general apical swelling, which was also
seen in the surrounding area. The mouth opening was limited.
The periapical radiograph showed no chronic apical periodontitis but an irregular periodontal ligament space. The
condition was diagnosed as air emphysema as a result of
extravasation of sodium hypochlorite solution during the endodontic treatment.
After these clinical and radiographs examinations, the patients general health was evaluated to assure that her systemic problems (cirrhosis hepatica, diabetes mellitus, and
hypertension) were controlled. It was suggested that she continue to use the regular medications that she needed and the
antibiotics prescribed. The patient was discharged 48 hours
later. At that time, the emphysema signs and symptoms were
similar to the first day of examination (Fig. 2).
One week later, the patient returned to the endodontic
practice, where the endodontic treatment was started to finish
the root canal treatment of the upper right canine. At this time
the symptoms related to the sodium hypochlorite extrusion
had not subsided (Fig. 3). Intraoral exam showed an apical
abscess and a draining fistula (Fig. 4).
After isolation with rubber dam and disinfection of the
operative field with 2% chlorhexidine gluconate, the pulp
space was accessed. The root canals were irrigated with 2.5%

Fuentes de Sermeo et al. e47

Fig. 2. Facial view 3 days after the first endodontic treatment.


No changes from first occurrence.

Fig. 3. Facial view 10 days after the first endodontic treatment.

sodium hypochlorite solution and the biomechanical preparation was performed with NiTi rotary files (K3 Endo System;
SybronEndo Corporation, Orange, CA) used in the crowndown mode. The working length (23 mm) was determined to
1 mm short of the radiographic apex by using #30 K-files.

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Fuentes de Sermeo et al.

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Fig. 4. Intraoral exam showing apical abscess and a fistula


related to the upper right canine.

Then the root canals were irrigated with 14.3% buffered


EDTA (pH 7.4) for 3 minutes, irrigated with saline, and dried.
A calcium hydroxide based paste (Calen; SS White Artigos
Dentrios, Rio de Janeiro, Brazil) was applied, as an intracanal dressing, using an ML syringe (SS White Artigos
Dentrios) with a 27-gauge needle, up to the working length,
which was marked on the needle with a rubber stop. A sterile
cotton pellet was placed in the pulp chamber, and the access
cavity was filled with quick-setting zinc oxide eugenol cement. Fifteen days later, under saline irrigation, the intracanal
dressing was removed with a K-file to the working length.
The calcium hydroxide based intracanal dressing was replaced for another 15 days. Then the canals were dried and
filled with EDTA for 3 min, irrigated with saline, and dried.
Root canal filling was performed with gutta-percha cones and
calcium hydroxide based sealer (Sealapex; SybronEndo Corporation). A permanent restoration was placed.
At this time the ecchymosis and swelling had fully resolved
and her mouth opening had returned to normal (Fig. 5).

DISCUSSION
Sodium hypochlorite solution is considered to be an
effective endodontic irrigation solution used in different concentrations. This solution is able to disorganize
the endodontic biofilm12 but is an extremely tissuecytotoxic chemical solution.9
The endodontic literature contains several case reports on complications during root canal irrigation,
including inadvertent injection of NaOCl solution into
periapical tissues, emphysema, and allergic reactions to
this solution. The emphysema is caused by oxygen
liberation into the tissues.
When it comes into contact with vital tissue, NaOCl
causes hemolysis and ulceration, inhibits neutrophil
migration, and damages endothelial and fibroblast
cells.9,13 The toxic effect of NaOCl occurs because of
its alkalinity (pH 10.8-12.9) and hypertonicity, which
causes injury predominantly by oxidation of proteins
and lipid membranes.14,15 Clinically, the patients report
severe pain and present ecchymosis, hematoma, and

Fig. 5. Facial view 1 month after the first endodontic treatment. Most facial changes have resolved.

swelling. Less usually, some patients have temporary


nerve paresthesia.
The clinical appearances in the present case were
consistent with severe soft tissue damage due to a
chemical burn and emphysema after extrusion of sodium hypochlorite into the connective tissues. The patient presented with moderate pain, ecchymosis, and
severe swelling on the right side of her face. It was
diagnosed as emphysema.
Most of these cases occur because of incorrect determination of the working length, iatrogenic widening
of the apical foramen, lateral perforation, or wedging of
the irrigating needle.7,11 Witton et al.11 described a case
demonstrating severe sequelae that occured after the
extrusion of NaOCl during endodontic treatment of an
upper lateral incisor. Pelka and Petschelt10 presented a
case in which NaOCl was accidentally injected beyond
the root apex into the mimic muscular system.
Similarly, in the present case the apical anatomy of
the tooth appeared normal, so presumably the forcedpressure irrigation led to entry of sodium hypochlorite
into the soft tissues.
The management of the complications related to
NaOCl incidents have been described previously in the
literature.7,11,16 Alternative irrigant solutions for rinsing of root canals during endodontic treatment has been
discussed. Gernhardt et al.9 indicated that the use of
lower concentrations of NaOCl in combination with

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chlorhexidine or the use of electrochemically activated


water may be a safe and effective alternative. The use
of negative pressure during irrigation may also reduce
the risks for overextension of irrigation fluids.17 However, it is important to know the length and integrity of
the root canal system before irrigating with any concentrated solutions.
CONCLUSION
This report demonstrates a case where concentrated
NaOCl caused severe tissue damage when inadvertently injected beyond the root canal terminus, causing
pain, ecchymosis, and swelling of the face. To prevent
this, an initial radiograph should be exposed to determine the correct canal working length and confirm root
canal integrity. Lower concentrations of NaOCl may be
helpful, as may the choice of other less toxic solutions.

Fuentes de Sermeo et al. e49

8.
9.

10.

11.

12.

13.

14.

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Reprint requests:
Profa. Dra. Raquel Assed Bezerra da Silva
Departamento de Clinica, Infantil, Odontologia Preventiva e Social
Faculdade de Odontologia de Ribeiro Preto
Universidade de So Paulo
Avenida do Caf s/n, Monte Alegre
14040-904 Ribeiro, Preto, SP
Brazil
raquel@forp.usp.br