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IN BRIEF

EDUCATION
Sodium hypochlorite is a commonly used irrigant in endodontic practice. It has many
potential complications ranging from permanent bleaching of clothes to severe soft VERIFIABLE
tissue damage. CPD PAPER
The complications of hypochlorite extrusion beyond the root apex are discussed.
Guidelines are given for the safe use of hypochlorite solution during endodontic
treatment and advice on the appropriate course of action when a hypochlorite
complication is suspected.

Review: the use of sodium hypochlorite in


endodontics potential complications and
their management
H. R. Spencer,1 V. Ike2 and P. A. Brennan3

Aqueous sodium hypochlorite (bleach) solution is widely used in dental practice during root canal treatment. Although it
is generally regarded as being very safe, potentially severe complications can occur when it comes into contact with soft
tissue. This paper discusses the use of sodium hypochlorite in dental treatment, reviews the current literature regarding
hypochlorite complications, and considers the appropriate management for a dental practitioner when faced with a poten-
tially adverse incident with this agent.

INTRODUCTION and corrosion of metals2 are its main cle reviews the potential complications
Sodium hypochlorite (NaOCl) was fi rst disadvantages in dental use. Sodium that can occur with sodium hypochlorite
recognised as an antibacterial agent hypochlorite reacts with fatty acids and in clinical practice, discusses measures
in 1843 when hand washing with amino acids in dental pulp resulting in that can be taken to minimise risk, and
hypochlorite solution between patients liquefaction of organic tissue.3 There is provides details of appropriate manage-
produced unusually low rates of infec- no universally accepted concentration of ment in the rare cases of suspected tis-
tion transmission between patients. sodium hypochlorite for use as an endo- sue damage.
It was fi rst recorded as an endodontic dontic irrigant. The antibacterial and
irrigant in 19201 and is now in routine tissue dissolution action of hypochlorite COMPLICATIONS OF ACCIDENTAL
worldwide use. increases with its concentration, but this SPILLAGE
Sodium hypochlorite is used as an is accompanied by an increase in tox- 1) Damage to clothing
endodontic irrigant as it is an effective icity. Concentrations used vary down Accidental spillage of sodium hypochlo-
antimicrobial and has tissue-dissolving from 5.25% depending on the dilution rite is probably the most common
capabilities. It has low viscosity allow- and storage protocols of individual prac- accident to occur during root canal irri-
ing easy introduction into the canal titioners. Solution warmers are available gation. Even spillage of minute quanti-
architecture, an acceptable shelf life, is to increase the temperature up to 60C. ties of this agent on clothing will lead to
easily available and inexpensive. The Increasing the temperature of a solution rapid, irreparable bleaching. The patient
toxicity of its action to vital tissues of hypochlorite improves the bactericidal should wear a protective plastic bib, and
and pulp dissolution activity, although the practitioner should exercise care
the effect of heat transfer to the adjacent when transferring syringes fi lled with
1
Associate Specialist in Oral Surgery, 2SHO in Oral tissues is uncertain.4 hypochlorite to the oral cavity.
and Maxillofacial Surgery, 3*Consultant Maxillofacial
Surgeon, Professor of Surgery, Queen Alexandra
As a bleaching agent, inadvertent spill-
Hospital, Portsmouth, PO6 3LY age of this agent can result in damage 2) Eye damage
*Correspondence to: Professor Peter Brennan to clothing and soft tissues. Inadvert- Seemingly mild burns with an alkali
Email: peter.brennan@porthosp.nhs.uk
ent introduction of sodium hypochlorite such as sodium hypochlorite can result
Refereed Paper beyond the root canal system may result in significant injury as the alkali reacts
Accepted 15 September 2006
DOI: 10.1038/bdj.2007.374
in extensive soft tissue or nerve damage, with the lipid in the corneal epithe-
British Dental Journal 2007; 202: 555-559 and even airway compromise. This arti- lial cells, forming a soap bubble that

BRITISH DENTAL JOURNAL VOLUME 202 NO. 9 MAY 12 2007 555


EDUCATION

Table 1 Preventive measures that should be may be blurring of vision and patchy in suspected cases of sodium hypochlo-
taken to minimise potential complications
with sodium hypochlorite
colouration of the cornea.7 Immediate rite allergy during endodontic treatment
ocular irrigation with a large amount of has been confi rmed by Kaufman and
Plastic bib to protect patients clothing water or sterile saline is required followed Keila.14 Even though allergy to sodium
by an urgent referral to an ophthalmolo- hypochlorite is rare, it is important for
Provision of protective eye-wear for both
gist.8 The referral should ideally be made clinicians to recognise the symptoms of
patient and operator
immediately by telephone to the nearest allergy and possible anaphylaxis. These
The use of a sealed rubber dam for isolation eye department. The use of adequate eye may include urticaria, oedema, shortness
of the tooth under treatment
protection during endodontic treatment of breath, wheezing (bronchospasm) and
The use of side exit Luer-Lok needles for should eliminate the risk of occurrence hypotension. Urgent referral to a hos-
root canal irrigation of this accident, but sterile saline should pital following fi rst aid management is
Irrigation needle a minimum of 2 mm short always be available to irrigate eyes recommended.
of the working length injured with hypochlorite. It has been
advised that eyes exposed to undiluted COMPLICATIONS ARISING FROM
Avoidance of wedging the needle into the
root canal bleach should be irrigated for 15 minutes HYPOCHLORITE EXTRUSION BEYOND
with a litre of normal saline.9,10 THE ROOT APEX
Avoidance of excessive pressure during
1) Chemical burns and tissue necrosis
irrigation
3) Damage to skin When sodium hypochlorite is extruded
Skin injury with an alkaline substance beyond the root canal into the peri-
Table 2 Emergency management of requires immediate irrigation with water radicular tissues, the effect is one of
accidental hypochlorite damage
as alkalis combine with proteins or fats in a chemical burn leading to a localised
Eye injuries tissue to form soluble protein complexes or extensive tissue necrosis. Given the
Irrigate gently with normal saline. If normal or soaps. These complexes permit the widespread use of hypochlorite, this com-
saline is insufficient or unavailable, tap water
should be used
passage of hydroxyl ions deep into the plication is fortunately very rare indeed.
Refer for ophthalmology opinion tissue, thereby limiting their contact with A severe acute inflammatory reaction of
the water dilutant on the skin surface. the tissues develops. This leads to rapid
Skin injuries Water is the agent of choice for irrigat- tissue swelling both intra orally within
Wash thoroughly and gently with normal
saline or tap water ing skin and it should be delivered at low the surrounding mucosa and extra orally
pressure as high pressure may spread the within the skin and subcutaneous tis-
Oral mucosa injuries hypochlorite into the patients or rescu- sues. The swelling may be oedematous,
Copious rinsing with water ers eyes.5 haemorrhagic or both,15 and may extend
Analgesia if required
If visible tissue damage antibiotics to reduce beyond the region that might be expected
risk of secondary infection 4) Damage to oral mucosa with an acute infection of the affected
If any possibility of ingestion or inhalation Surface injury is caused by the reac- tooth16,17 (Figs 1, 2). Sudden onset of pain
refer to emergency department tion of alkali with protein and fats as is a hallmark of tissue damage, and may
Inoculation injuries described for eye injuries above. Swal- occur immediately or be delayed for sev-
Ice/cooling packs to swelling first 24 hours lowing of sodium hypochlorite requires eral minutes or hours.18 Involvement of
Heat packs subsequently the patient to be monitored following the maxillary sinus will lead to acute
Analgesia immediate treatment. It is worth noting sinusitis.19Associated bleeding into the
Antibiotics to reduce the risk of secondary that skin damage can result from sec- interstitial tissues results in bruising
infection
Request advice or management from Maxil- ondary contamination. and ecchymosis of the surrounding
lofacial Unit mucosa and possibly the facial skin (Fig.
Arrange review if to be managed in dental Allergy to sodium hypochlorite 3) and may include the formation of a
practice
The allergic potential of sodium haematoma.15,20 A necrotic ulceration of
hypochlorite was fi rst reported in 1940 the mucosa adjacent to the tooth may
penetrates the corneal stroma. The alkali by Sulzberger11 and subsequently by occur as a direct result of the chemi-
moves rapidly to the anterior chamber, Cohen and Burns.12 Caliskan et al. pre- cal burn.21 This reaction of the tissues
making repair difficult. Further degen- sented a case where a 32-year-old female may occur within minutes or may be
eration of the tissues within the ante- developed rapid onset pain, swelling, delayed and appear some hours or days
rior chamber results in perforation, with difficulty in breathing and subsequently later.20,22 If these symptoms develop,
endophthalmitis and subsequent loss of hypotension following application of urgent telephone referral should be
the eye.5 0.5 ml of 1% sodium hypochlorite.13 made to the nearest maxillofacial unit.
Ingram recorded a case of accidental The patient required urgent hospitalisa- Patients will be assessed by the on call
spillage of 5.25% sodium hypochlorite tion in the intensive care unit and man- maxillofacial team. Treatment is deter-
into a patients eye during endodon- agement with intravenous steroids and mined by the extent and rapidity of the
tic therapy.6 The immediate symptoms antihistamines. A subsequent allergy soft tissue swelling but may necessitate
included instant severe pain and intense skin scratch test performed two weeks urgent hospitalisation and administra-
burning, profuse watering (epiphora) after the patient was discharged con- tion of intravenous steroids and antibi-
and erythema. Loss of epithelial cells in fi rmed a highly positive result to sodium otics.7,18 Although the evidence for the
the outer corneal layer may occur. There hypochlorite. The usefulness of this test use of antibiotics in these patients is

556 BRITISH DENTAL JOURNAL VOLUME 202 NO. 9 MAY 12 2007


EDUCATION

anecdotal, secondary bacterial infec- arising within three hours of accidental


tion is a distinct possibility in areas of exposure to sodium hypochlorite during
necrotic tissue and therefore they are root canal treatment (Fig. 4).26
often prescribed as part of the overall
patient management. Surgical drainage What can I do to minimise the risk of
or debridement may also be required hypochlorite complications?
depending on the extent and character The use of all chemicals or hazardous
of the tissue swelling and necrosis.7,18,19 substances in practice is covered by leg-
islation requiring employers to control
2) Neurological complications exposure to both staff and patients to
Paraesthesia and anaesthesia affecting prevent ill health. The Control of Sub-
the mental,22 inferior dental22and infra- stances Hazardous to Health Regulations
orbital branches18,22,23 of the trigeminal (2002) (COSHH) 27 requires a practice to
nerve following inadvertent extrusion prepare plans and procedures to deal
of sodium hypochlorite beyond the root with accidents, incidents and emergen-
canals have been described. Normal sen- cies involving hazardous substances and
sation may take many months to com- to adequately control exposure.
pletely resolve.22,23 As has already been stated, these
Facial nerve damage was fi rst described are rare complications, but nonethe-
by Witton et al. in 2005.18 In both cases, less, the risk of hypochlorite-induced
the buccal branch of the facial nerve was damage can be minimised by imple-
affected. Both patients exhibited a loss menting the measures listed in Table 1
of the naso-labial groove and a down when performing endodontic therapy. If
turning of the angle of the mouth. Both the aqueous sodium hypochlorite is to
patients were reviewed and their motor be diluted for use, eye protection, face
function was regained after several mask, gloves and plastic apron should
months. Sensory and motor nerve deficit be worn for the procedure. The prepared
are not commonly associated with acute solution must be stored in a lightproof,
dental abscesses. As there is no other non-metallic container that is appropri-
current evidence in the literature it is ately labelled.
possible that these neurological compli- During treatment the patients cloth-
cations were a direct result of chemical ing should be protected with a bib that is
damage by sodium hypochlorite, but impermeable to liquid. The patient and
further research (including nerve con- clinical team should wear well fitting
duction studies) is required. protective glasses. Rubber dam should
be used to isolate the tooth and minor
3) Upper airway obstruction defects in adaptation corrected with a
The use of sodium hypochlorite for root caulking agent to optimise the seal. If
canal irrigation without adequate isola- the canal is to be irrigated using a nee-
tion of the tooth can lead to leakage of the dle and syringe, the needle must be side
solution into the oral cavity and inges- venting. The use of hypodermic (end
tion or inhalation by the patient. This exiting) needles in root canal irriga-
could result in throat irritation22 and in tion risks accidental inoculation into the
severe cases, the upper airway could be soft tissues.
compromised. Ziegler presented a case Only Luer-Lok style syringes and nee-
Figs 1-3 Bruising and oedema of three
of a 15-month-old girl who presented in dles should be used, as taper seat needles patients who presented with hypochlorite
the accident and emergency unit with may dislodge in use, with uncontrolled extrusion into the soft tissues
acute laryngotracheal bronchitis, stridor loss of the hypochlorite solution under
and profuse drooling from the mouth as pressure.29,30 The needle should not
a result of ingestion of a high concen- engage the sides of the canal, but be thumb to depress the plunger.30 This will
tration of household sodium hypochlo- loosely positioned within the canal. The reduce the risk to periapical tissues by
rite.24 A similar clinical presentation needle should not reach the apical extent inadvertent extrusion of irrigant.
might occur with the ingestion of any of the prepared canal.30 This technique Particular care must be taken in
caustic substance.25 Opinion varies as to may be facilitated by marking the work- immature teeth with open apices to
the best concentration of hypochlorite, ing length on the needle with a rubber ensure that the irrigant does not go into
with some practitioners using undiluted stop (Fig. 5). The irrigant is delivered the apical tissues. Sodium hypochlorite
household bleach.20 Fibre optic nasal slowly with minimal pressure to reduce and saline are both recommended for
tracheal intubation followed by surgi- the likelihood of forcing it through the irrigation in immature teeth, however,
cal decompression has been required to apex. This is most easily achieved by if hypochlorite is used it has been sug-
manage airway compromising swelling using your index fi nger rather than gested the fi nal irrigation should be with

BRITISH DENTAL JOURNAL VOLUME 202 NO. 9 MAY 12 2007 557


EDUCATION

that the antimicrobial effects of sodium consequences cannot be predicted from


hypochlorite were much less with con- the oropharyngeal symptoms. Maxillo-
centrations of 2.5% and lower.33 They facial advice and assessment is recom-
also found that chlorhexidine gluconate mended for any suspected hypochlorite
0.12% has the equivalent antimicrobial complication.
effect to 5.25% sodium hypochlorite. In summary, this review discusses the
It has been shown that chlorhexidine- potential complications that can occur
treated root canals are less suscepti- with sodium hypochlorite in endodon-
ble to re-infection.34 Chlorhexidine is tic dental practice. Although rare, the
the irrigant of choice in re-treatment recognition and subsequent primary
Fig. 4 Upper airway compromise requir- cases.30 However, sodium hypochlorite management by the dental practitioner
ing decompression following extrusion of
hypochlorite into the soft tissues remains the most commonly used and of these complications is essential to
recommended endodontic irrigant as it ensure best clinical practice.
alone combines antimicrobial and tissue
1. Crane A B. A practicable root canal technique.
dissolving capabilities essential in teeth Philadelphia: Lea & Febinger, 1920.
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What should I do if I suspect a hypochlorite 36: 724-732.
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nism of action of sodium hypochlorite. Braz Dent
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probably because these complications of temperature on sodium hypochlorite short term
stability, pulp dissolution capacity and antimicro-
are rare and sporadic. bial efficacy. J Endod 2005; 31: 669-671.
5. Marx, Hockberger, Wallis. Rosens emergency
medicine. 6th edn. pp 931-933. UK: Mosby
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mised by using cold compression (frozen exposure to sodium hypochlorite. J Endod 1990;
16: 235-237.
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Fig. 5 Placement of rubber stop on root canal irrigation literature review and case
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irrigation needle
and paracetamol.8 Adult doses of para- 9. Rutala W, Weber D J. Uses of inorganic hypochlo-
cetamol 1 g qds and ibuprofen or ibupro- rite (Bleach) in health-care facilities. Clinical
Microbiology Reviews 1997; 10: 597-610.
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tions,27 clinicians would also be required to minimise the risk of secondary bacte- tion in the form of a series of lectures. Springfield,
to prevent or adequately control expo- rial infection; Amoxicillin 250 mg tds or IL, USA: Charles C. Thomas, 1940.
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15. Mehra P, Clancy C, Wu J. Formation of a facial
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