Hong Kong Journal of Emergency Medicine

A case report of sodium hypochlorite accident

TSK Lam

, OF Wong

, SYH Tang

Sodium hypochlorite is widely used as an irrigating solution in dental practice. Despite its safe properties, serious complications can result from inadvertent use. We report a patient presenting to the accident and emergency department for sodium hypochlorite accident during dental root canal therapy. The management of this dental emergency condition is discussed. (Hong Kong j.emerg.med. 2010;17:173-176)

Keywords: Airway obstruction, facial paralysis, root canal irrigants, sodium hypochlorite, tooth diseases

Introduction
Emergency physicians frequently encounter patients presenting with dental problems including complications from dental therapies. Dental root canal therapy is a common dental procedure for irreversible pulpitis and necrotic pulps. Sodium hypochlorite accident is a rare complication in endodontic procedure but can lead to serious complications.

Case report
A 37-year-old woman, who enjoyed good past health, attended the accident and emergency department in

Correspondence to: Lam Sing Kit, Tommy, MBBS, MRCSEd Tuen Mun Hospital, Accident and Emergency Department, Tsing Chung Koon Road, Tuen Mun, N. T., Hong Kong Email: tommylam@yahoo.com Wong Oi Fung, MRCSEd, FHKCEM, FHKAM(Emergency Medicine) Tang Yiu Hang, Simon, FRCSEd, FHKCEM, FHKAM(Emergency Medicine)

March 2009 for progressive right facial pain and swelling two hours after root canal therapy for pulpitis of the right upper canine. The procedure was performed by a private dentist. She noticed swelling over her cheek 20 minutes after the procedure and it progressively extended to the whole of her right side of face. On arrival, she had stable vital signs with blood pressure of 151/82 mmHg, pulse rate of 86/min and SpO 2 of 98% on room air and body temperature of 36.9C. There was no sign of upper airway obstruction. On physical examination, there was gross swelling over her right face with soft tissue swelling and ecchymosis over her upper lip and buccal region (Figure 1). The lateral neck X-ray revealed no soft tissue swelling. After further enquiry to the private dentist, accidental extr usion of the irrigation solution (sodium hypochlorite) during the dental procedure was suspected. She was closely monitored for upper airway compromise in the Emergency Medicine Ward (EMW) due to the progressive oral soft tissue swelling. A dose of hydrocortisone was given to control the i n f l a m m a t i o n . Sh e w a s p r e s c r i b e d w i t h o r a l paracetamol and ice pack was applied over her right cheek for pain relief. Urgent dental consultation was

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arranged on the next morning and the patient was treated conservatively without dental intervention. She had good pain control from the treatments but there was only slight improvement of the swelling. She was stable in EMW and was discharged with antibiotics (amoxicillin with clavulanic acid). She was regularly followed up by the dental surgeon in 1 to 2-week intervals. Her swelling resolved 5 weeks after the incident but there was residual swelling over the right maxillary region. It was probably due to tissue fibrosis (Figure 2). There was also residual paraesthesia over her right infra-orbital region but the motor function of the facial nerve remained intact.

Discussion
Sodium hypochlorite is a commonly used bleaching agent. Its popularity as an irrigating solution in dental

practice1 is due to its physico-chemical characteristics in dissolving necrotic tissue and organic matter in root canal as well as a good lubricant for mechanical debridement. 2 Sodium hypochlorite has unique reactions with organic tissues.3 It acts as a solvent for organic fat and degrading fatty acids, transforming them into fatty acid salts and glycerol which reduce the surface tension of the remaining solution (saponification).4 Subsequently, sodium hypochlorite degrades the proteins through the amino acid neutralisation and chloramination reactions.4 Sodium hypochlorite also possesses a good antimicrobial property against gram-positive bacteria, gram-negative bacteria, fungi, spores and virus.2,5-7 Besides, it has a relatively low systemic toxicity and its cost is low.8 The pH of sodium hypochlorite is approximately around 11 to 12.1,9 The concentration of sodium hypochlorite used in endodontic therapies ranges from 0.5% to 5.25%.10

Figure 1. Swelling and bruising on day 1.

Figure 2. Swelling and bruising resolved after 5 weeks.

Lam et al./Sodium hypochlorite accident

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Sodium hypochlorite accident was first reported in 1974.11 It is a rare complication of dental root therapy. The majority of reported cases of sodium hypochlorite accident occurred as a result of inappropriate introduction of sodium hypochlorite into the dental root, either by placing the irrigating syringe too far apically or using too high pressure, which forced the irrigating solution into the periapical tissues. 1 Inadvertent injection into the maxillary sinus had been reported.9,12 Besides, misuses of sodium hypochlorite as anaesthetic solution has been reported previously.8,13,14 Sodium hypochlorite is an extremely cytotoxic and proteolytic material. 1,2 Its deleterious effects depend on the concentration and pH. The alkaline property enhances its tissue penetration causing deep and extensive tissue damage.8 It causes liquefaction of the organic material by reacting with fatty acids and amino acid. 15 It also inhibits neutrophil migration and damages endothelial and fibroblast cells.16,17 Moreover, sodium hypochlorite affects the vascular permeability not only by directly damaging the vessels but also causing release of chemical mediators. Thus, interstitial haemorrhage is a common complication from extravasation which causes immediate swelling and severe bleeding from the dental canal access.1 Even a small amount of sodium hypochlorite getting into the periradicular tissues can result in significant inflammation. 1 Inadvertent injection of sodium hypochlorite into the periradicular region causes immediate severe pain with burning sensation, progressive swelling and oedema. Haematoma and ecchymosis of the skin can occur at the same time.1,8 Study on the incidence of sodium hypochlorite accident showed that there was higher risk of sodium hypochlorite accident in endodontic treatment involving those maxillary teeth in more posterior position because of the thin cortical bone cover of the buccal roots.18 Serious complications from sodium hypochlorite accident have been reported in literature including nerve damage (infra-orbital nerve, facial nerve and trigeminal nerve),10,17,19,20 atrophy of facial subcutaneous

tissues causing facial asymmetry requiring fat grafting,15 gingival necrosis and bone necrosis.13 Bowden et al reported a case of life-threatening airway obstruction secondary to extrusion of sodium hypochlorite.21 The patient developed extensive soft tissue swelling and oedema after endodontic treatment causing upper air way compromise. Fibreoptic nasal-tracheal intubation was performed for airway protection with subsequent surgical decompression of the submandibular, sublingual and submental spaces. Apart from inadvertent introduction of sodium hypochlorite beyond the root canal system, inadvertent spillage of sodium hypochlorite during dental procedures can result in serious consequences including chemical dermatitis22 and chemical injuries to the eyes which may result in endophthalmitis and blindness.23 No specific treatment can reverse the damage from sodium hypochlorite. The mainstay of treatment is supportive including airway protection, control of swelling, pain relief and prevention of secondary infection.1,2,24 Reassurance should be provided to the patient for the alarming swelling of the involved area. Besides, adequate pain control can be achieved by the narcotic analgesic but non-steroidal anti-inflammatory drugs and aspirin should be avoided in the acute stage in view of interstitial haemorrhage in the soft tissue. Cold compression could help in reducing the inflammation and pain in the first 24 hours. Afterward, warm compression is preferred to shorten the clearing up time of massive ecchymosis by increasing the circulation of the involved area. 1,25 Improvement of circulation to the affected intraoral tissue can also be achieved by rinsing with normal saline.25 Prophylactic antibiotic therapy is essential10,25 because the extensive necrotic tissue in the dead space provides a good medium for the growth of bacteria which are pushed into the periapical space together with the debris in the root canal.2 Some authors suggested using steroid for three days to control the inflammatory reactions, 10,16,19,25 but the effectiveness was still not proven. The patient should be closely monitored for the patency of airway especially when there is gross

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swelling involving the floor of the mouth. Early assessment by dental surgeon and regular follow up for reassessment of symptoms should be arranged. Prolonged healing time due to the subsequent soft tissue fibrosis is expected.

Conclusion
Sodium hypochlorite accident is a rare complication of endodontic procedure. Most of the patients recovered from supportive management without surgical intervention but life-threatening complications, such as airway compromise, may result. Understanding the pathophysiology and potential complications of this condition will allow emergency physicians to provide appropriate initial management for patients suffering from sodium hypohlorite accident.

References
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