DEPARTMENT OF CONSERVATIVE

DENTISTRY AND
ENDODONTICS

SEMINAR

SODIUM HYPOCHLORITE
ACCIDENTS & ITS
MANAGEMENT
PRESENTED BY
DR. RASHMI SOLANKI
M.D.S 3rd YEAR
GUIDED BY
DR. MANDEEP.S.GREWAL
DR. AMIT GANDHI
DR. VANDANA BHARDWAJ
DR. AVDESH SHARMA

PDM DENTAL COLLEGE

Contents

Introduction
History
Chloramination Reaction
Sodium Hypochlorite
Mode of Action
Allergic Reactions
Complications of accidental spillage
Sodium Hypochlorite Accidents
Symptomology
Treatment
Prevention
Summary
References

Introduction

The essential role of microorganisms in development and perpetuation of pulpal and

periapical diseases has been demonstrated clearly in animal models and human
studies. Elimination of microorganisms from infected root canals is a difficult task.
Numerous measures have been described to reduce the numbers of root canal mi- croorganisms, including the use of various instrumentation techniques, irrigation
regimens and intra-canal medicaments. There is no evidence in the literature to show
that mechanical instrumentation alone results in a bacteria-free root canal system.
Considering the complex anatomy of the root canal pulp space, this is not surprising.
It is assumed, but not demonstrated, that any pulp tissue left in the root canals can
serve as bacterial nutrient. Furthermore, tissue remnants also impede the antimicrobial
effects of root canal irrigants and medicaments. Therefore some sort of irrigation /
disinfection is necessary to remove tissue from the root canals and to kill
microorganisms. Simply, chemical treatment of the root canal can be arbitrarily
divided into irrigants, rinses, and inter-visit medicaments.

History
- Sodium Hypochlorite (NaOCl) has an extensive history in medicine and dentistry
and continues to be popular even today. During World War I, the chemist Henry - - Drysdale Dakin and the surgeon Alexis Carrel extended the use of buffered 0.5%
NaOCl solution to the irrigation of infected wounds.
Thus sodium hypochlorite chosen as an endodontic irrigating solution for use by most
of professionals.

Sodium hypochlorite is the most commonly used endodontic irrigant, despite

limitations. None of the presently available root canal irrigants satisfy the
requirements of ideal root canal irrigant. Newer root canal irrigants are studied for
potential replacement of sodium hypochlorite.
Newer Root Canal Irrigants in Horizon: A Review Sushma Jaju and Prashant P. Jaju
International Journal of Dentistry Volume 2011 (2011), Article ID 851359, 9 pages
doi:10.1155/2011/851359

Mechanism of action of Sodium HYPOCHLORITE

SAPONIFICATION REACTION
O
O

R-C-O-R + NaOH
R-C-O-Na + R-OH
Fatty acid sodium
soap
glycerol
hydroxide
So the dissolution of organic necrotic tissue can be verified in saponification reaction
when NaOCl degrades fatty acid and lipid resulting in soap and glycerol and
promoting as deodorant effect.
(BRAZ DENT J 13 (2) 2002)

Amino acid neutralization reaction

H

O
H O

R-C-O-C + NaOH
R-C-O-C + H20

NH2
NH2
Amino
sodium
salt
water
Acid
hydroxide
With exit of hydroxyl ions reduction of pH.

Chloramination reaction
H

R-C-O-C + HOCl

OH
NH2
Amino
hypochlorous
Acid
acid

Cl

R-C-O-C

NH2
OH
chloramine

H20
water

Hypochlorous acid (HOCl) hypochlorite ion lead to amino acid degradation and
hydrolysis.
According to Estrela et al, NaOCl neutralize the amino acids forming water
and salt.
The Hypochlorous acid a substance present in the NaOCl solution.
When in contact with organic tissue act as a solvent releasing chlorine
combined with amino group of proteins form chloramines.
Hypochlorous acid and hypochlorite ion lead to degradation of amino acids
and hydrolysis.

Sodium hypochlorite (NaOCl)

- Clear ,pale green-yellow liquid with strong odor of chlorine .
- It is a potent antimicrobial agent, killing most bacteria instantly on direct contact. It
also effectively dissolves necrotic and vital pulp tissue.
- The most advocated irrigant, inexpensive and readily available.

Sodium hypochlorite (NaOCl)

- Anti microbial properties
- Tissue solvent. ( dissolve vital and non vital tissue)
- Flush debris.
- Lubricant.
- Eliminate the smear layer.
- Low toxicity level.

Mechanism of action
- Sodium hypochlorite (NaOCl) ionizes in water into Na and the hypochlorite ion,
OCl, establishing an equilibrium with hypochlorous acid (HOCl).
- Hypochlorous acid is responsible for the antibacterial activity; the OCl ion is less
effective than the undissolved HOCl.
- Hypochloric acid disrupts several vital functions of the microbial cell, resulting in
cell death.

- At acidic and neutral pH, chlorine exists predominantly as HOCl, whereas at high
pH of 9 and above, OCl predominates.

Concentration
- NaOCl is commonly used in concentrations between 0.5% and 5%.
- According to several studies The lower and higher concentrations are equally
efficient in reducing the number of bacteria in infected root canals.
- The time needed to inhibit bacterial growth and tissue dissolving effect of NaOcl
irrigant are related to it is concentration ,but so is it is toxicity .
- Increasing the temperature of hypochlorite irrigant to 6000 C, significantly increased
its antimicrobial and tissue-dissolving effects.
Limitation :
Unpleasant taste
Relative toxicity
Inability to remove smear layer

Interactions
-Antimicrobial activity, dissolving of the remaining pulp tissues, lubrication during
mechanical instrumentation, availability and low cost are the fundamental
requirements for root canal irrigants (Zehnder 2006, Haapasalo et al. 2010).
-Sodium hypochlorite-most common irrigant, other solutions mostly used along with
sodium hypochlorite, as a final rinse to enhance the antimicrobial activity and
substantivity against some resistant bacteria, to decrease the caustic effect or to aid in
removing the smear layer.
(Zehnder 2006, Mohammadi & Abbott 2009, Haapasalo et al. 2010).

- NaOCl has been reported to cause dentine discolouration, although it is a bleaching

agent.
- This discolouration is a result of its contact with erythrocytes and its high tendency
to crystallize on the root dentine, which may mean that it is difficult to completely
remove from the canal (Gutie rrez & Guzma n 1968). In addition, the combination of
NaOCl with other adjunct irrigating solutions has been found to cause marked tooth
discolourations .
- Vivacqua-Gomes et al. (2002) observed a dark brown precipitate when NaOCl was
combined with chlorhexidine (CHX) gel. Other authors have reported the same type

of discolouration when NaOCl has been used with CHX solutions (Basrani et al.
2007, Marchesan et al. 2007, Bui et al. 2008, Akisue et al. 2010, Krishnamurthy &
Sudhakaran 2010, Nassar et al. 2011, Souza et al. 2011)

Discoloration when irrigants are combined.

(a) 2.63% NaOCl + 2% chlorhexidine (CHX) (dark brown precipitate);
(b) 18% EDTA + 2% CHX (cloudy blue);
(c) 2.63% NaOCl + 18% EDTA (no discolouration)
d) 2.63% NaOCl + 20% Citric acid (white precipitate and the solution turns cloudy
after shaking).

This dark brown precipitate can stain the dentine, adhere to the floor of the pulp
chamber, access cavity and root canal walls and act as a residual film that may
compromise the diffusion of intra-canal medicaments into the dentine, disrupt the
adhesion of the root canal filling and favour coronal restoration breakdown
(Vivacqua-Gomes et al. 2002, Akisue et al. 2010)

Discolouration potential of NaOCl/CHX combination on the access cavity walls.

(a)NaOCl
(b)Dark
brown
precipitate
after
NaOCl/CHX
combination
(c) The precipitate becomes adherent to the access cavity walls (white arrow) and
crown fissures (red arrow) even after flushing with distilled water.

Basrani et al. (2007) examined this precipitate using X-ray photoelectron

spectroscopy (XPS) and time-of-flight secondary ion mass spectrometry (TOFSIMS), and they found that it contains a significant amount of parachloroaniline
(PCA).
This substance is carcinogenic and it can further degrade to 1-chloro-4- nitrobenzene,
which also is carcinogenic.
However, by using nuclear magnetic resonance (NMR), Thomas & Sem (2010)
reported that mixing NaOCl and CHX did not produce PCA at any measurable
quantity, but one of the CHX breakdown products may be further metabolized to PCA
(Nowicki & Sem 2011).

As a result of these possible hazards, Kim et al. (2012) examined the chemical
interaction between Alexidine (ALX), as a substitute for CHX, and NaOCl using
electrospray ionization mass spectrometry (ESIMS) and scanning electron microscopy
(SEM).
The results revealed that the association of ALX/NaOCl did not produce PCA or any
precipitate, and the mixing solutions of ALX and NaOCl resulted in a slight
discolouration ranging from light yellow to transparent as the ALX concentration
decreased.
In addition, this combination did not stain dentine and was easy to remove from the
root canal by irrigation.

NaOCl also reacts with MTAD (a mixture of a tetracycline isomer, an acid [citric
acid], and a detergent) in the presence of light, causing brown discolouration
This reaction may be caused by the dentinal absorption and release of the
doxycycline, present in MTAD, which will be exposed to NaOCl if it is used as a final
rinse after MTAD
(Torabinejad et al. 2003).

Tay et al. (2006a) formation of yellow precipitate along the root canal walls when
NaOCl was used as an irrigant and then followed by the application of BioPure
MTAD as a final rinse.
They also observed red-purple staining of light-exposed, root-treated dentine when
the root canals were rinsed with 1.3% NaOCl as an initial rinse followed by MTAD as
the final rinse.

This photo-oxidative degradation process was probably triggered by the use of NaOCl
as an oxidizing agent which also resulted in partial loss of its antimicrobial
substantivity
(Tay et al. 2006a,b).
The chemical reaction between NaOCl and citric acid, which leads to the formation of
a white precipitate, indicates a complex interaction between NaOCl and MTAD that
requires further investigations to validate the safety and usefulness of this
combination of irrigants.
Gonza lez-Lo pez et al. (2006) and Rasimick et al. (2008) have reported interactions
between CHX and EDTA irrigants with the formation of white to pink precipitate.
Practitioners should choose irrigating solutions carefully to suit the clinical
condition that is being treated.
If CHX is chosen, then the insoluble dark brown precipitate, created when NaOCl and
CHX are mixed, can be avoided by incorporating a thorough intermediate flush
between each irrigant this can be carried out with solutions such as saline or sterile
distilled water, followed by drying of the canal before the next solution is used
(Krishnamurthy & Sudhakaran 2010).

Absolute alcohol has also been suggested as an intermediate flush but its
biocompatibility with the periapical tissues and interactions with other irrigants
remain a concern (Krishnamurthy & Sudhakaran 2010, Valera et al. 2010)

Nassar et al. (2011) recommended the use of sodium ascorbate to prevent the
formation of this precipitate.
Ascorbic acid solution, as a reducing agent, has been advocated as an intermediate
flush between NaOCl and MTAD, to prevent the oxidation effect of NaOCl and to
avoid the photodegradation of the doxycycline that is present in MTAD (Tay et al.
2006a). In addition, the possible interaction between NaOCl and citric acid would be
avoided.
A cloudy precipitate forms when EDTA and CHX are combined. Maleic acid (MA),
which has been found to be less cytotoxic and more effective in smear layer removal
than EDTA (Ballal et al. 2009a,b), can be used as a substitute for EDTA, and the
combination of MA and CHX has not shown any precipitate formation or
discolouration (Ballal et al. 2011).

ALLERGIC REACTIONS
-Unlikely to occur, since both sodium and chlorine are essential elements in the
physiology of human body
-Hypersensitivity and contact dermatitis- rare cases
-In cases of hypersensitivity- chlorhexidine should not be used either- due to chlorine
content
-Alternative irrigant- iodine potassium iodide, high antimicrobial efficacy
-Alcohol, tap water- less effective against microorganisms, do not dissolve vital or
necrotic pulp tissue.
-Ca(OH)2- temporary medicament, dissolves both vital and necrotic tissue.

-The allergic potential of sodium hypochlorite was first reported in 1940 by

Sulzberger and subsequently by Cohen and Burns.
-Caliskan et al. presented a case where a 32-year-old female developed rapid onset
pain, swelling, difficulty in breathing and subsequently hypotension following
application of 0.5 ml of 1% sodium hypochlorite. The patient required urgent
hospitalization in the intensive care unit and management with intravenous steroids
and antihistamines.
-Subsequent allergy skin scratch test performed two weeks after the patient was
discharged confirmed a highly positive result to sodium hypochlorite. The usefulness
of this test in suspected cases of sodium hypochlorite allergy during endodontic
treatment has been confirmed by Kaufman and Keila.
-Symptoms of allergy and possible anaphylaxis- urticaria, oedema, shortness of
breath, wheezing (bronchospasm) and hypotension.
-Urgent referral to a hospital following first aid management is recommended.
Review: the use of sodium hypochlorite in endodontics potential complications
and their management.
H. R. Spencer, V. Ike& P. A. Brennan:British Dental Journal 202, 555 - 559 (2007)

To avoid extrusion and serious damage to periapical tissues, irrigation needles should
never be wedged into canals during irrigation.
Higher concentration NaOCl- more aggressive toward living tissue and can cause
severe injuries when forced into periapical area.

Toxic effect of sodium hypochlorite on peri-radicular tissues. After root canal

treatment of the first molar, the patient reported pain

A. On a return visit, an abscess was diagnosed and incised.
B. Osteonecrosis was evident after 3 weeks.

These accidents can be prevented- Mark the working length on the irrigation needle with a bend or rubber stop and
- Passively expressing the solution from the syringe into the canal.
- Needle should be continuously moved up and down.
- It should remain loose in the canal, allowing a backflow of liquid.
- The goal is to rinse the suspended, concentrated dentinal filings out of the pulp
chamber and root canals as new solution is brought down into the most apical
areas by the endodontic instrument and capillary effect.
- Patency files should not be extended farther than the periodontal ligament
because they are possible sources of irrigant extrusion

Complications of accidental spillage

1) Damage to clothing
Accidental spillage of sodium hypochlorite is probably the most common
accident to occur during root canal irrigation.
Even spillage of minute quantities of this agent on clothing will lead to rapid,
irreparable bleaching.
The patient should wear a protective plastic bib, and the practitioner should
exercise care when transferring syringes filled with hypochlorite to the oral
cavity.
2) Eye damage
Seemingly mild burns with an alkali such as sodium hypochlorite can result in
significant injury as the alkali reacts with the lipid in the corneal epithelial
cells, forming a soap bubble that penetrates the corneal stroma. The alkali
moves rapidly to the anterior chamber, making repair difficult. Further

degeneration of the tissues within the anterior chamber results in perforation,

with endophthalmitis and subsequent loss of the eye.

Ingram recorded a case of accidental spillage of 5.25% sodium hypochlorite into a

patient's eye during endodontic therapy.
- The immediate symptoms included instant severe pain and intense burning,
profuse watering (epiphora) and erythema.
- Loss of epithelial cells in the outer corneal layer may occur.
- There may be blurring of vision and patchy coloration of the cornea.
- Immediate ocular irrigation with a large amount of water or sterile saline is
required followed by an urgent referral to an ophthalmologist.
- The referral should ideally be made immediately by telephone to the nearest eye
department.
- The use of adequate eye protection during endodontic treatment should eliminate the
risk of occurrence of this accident, but sterile saline should always be available to
irrigate eyes injured with hypochlorite.
- It has been advised that eyes exposed to undiluted bleach should be irrigated for 15
minutes with a liter of normal saline.

Damage to skin
- Skin injury with an alkaline substance requires immediate irrigation with water as
alkalis combine with proteins or fats in tissue to form soluble protein complexes Or
soaps. These complexes permit the passage of hydroxyl ions deep into the tissue,
thereby limiting their contact with the water dilutant on the skin surface.
- Water is the agent of choice for irrigating skin and it should be delivered at low
pressure as high pressure may spread the hypochlorite into the patient's or rescuer's
eyes.
4) Damage to oral mucosa
Surface injury is caused by the reaction of alkali with protein and fats as described
for eye injuries above. Swallowing of sodium hypochlorite requires the patient to be
monitored following immediate treatment. It is worth noting that skin damage can
result from secondary contamination.

Complications arising from hypochlorite extrusion beyond the root apex

1) Chemical burns and tissue necrosis

- When sodium hypochlorite is extruded beyond the root canal into the peri-radicular
tissues, the effect is one of a chemical burn leading to a localised or extensive tissue
necrosis.
- Given the widespread use of hypochlorite, this complication is fortunately very
rare indeed.
- A severe acute inflammatory reaction of the tissues develops.
- This leads to rapid tissue swelling both intra orally within the surrounding mucosa
and extra orally within the skin and subcutaneous tissues.
- The swelling may be oedematous, haemorrhagic or both, and may extend beyond
the region that might be expected with an acute infection of the affected tooth.

Sodium hypochloride accident

Immediate severe pain for 2- 6 minutes.
immediate edema in adjacent soft tissue because of perfusion to the loose
connective tissue.
Extension of edema to a large site of the face such as cheeks, peri- orbital
region, or lips.
Ecchymosis on skin or mucosa as a result of profuse interstitial bleeding.
Profuse interstitial bleeding with hemorrhage of the skin and mucosa
(ecchymosis)

Bruising and oedema of patients who presented with hypochlorite extrusion into the
soft tissues

- Sudden onset of pain is a hallmark of tissue damage, and may occur immediately or
be delayed for several minutes or hours.
- Involvement of the maxillary sinus will lead to acute sinusitis.
- Associated bleeding into the interstitial tissues results in bruising and ecchymosis of
the surrounding mucosa and possibly the facial skin and may include the formation of
a hematoma.
- A necrotic ulceration of the mucosa adjacent to the tooth may occur as a direct result
of the chemical burn.
- This reaction of the tissues may occur within minutes or may be delayed and appear
some hours or days later.

- If these symptoms develop, urgent telephone referral should be made to the

nearest maxillofacial unit.
- Patients will be assessed by the on call maxillofacial team.
- Treatment is determined by the extent and rapidity of the soft tissue swelling but
- May necessitate urgent hospitalization and administration of intravenous steroids
and antibiotics.
- Although the evidence for the use of antibiotics in these patients is anecdotal,
Secondary bacterial infection is a distinct possibility in areas of necrotic tissue and
therefore they are often prescribed as part of the overall patient management.
-Surgical drainage or debridement may also be required depending on the extent
and character of the tissue swelling and necrosis.

3) Neurologic Complications
Paraesthesia and anaesthesia affecting the mental, inferior dental and infra-orbital
branches of the trigeminal nerve following inadvertent extrusion of sodium
hypochlorite beyond the root canals.
- Normal sensation may take many months to completely resolve. - Facial nerve
damage was first described by Witton et al. in 2005.
- In both cases, the buccal branch of the facial nerve was affected.
- Both patients exhibited a loss of the naso-labial groove and a down turning of the
angle of the mouth.
- Both patients were reviewed and their motor function was regained after several
months.

- Sensory and motor nerve deficit are not commonly associated with acute dental
abscesses.
- As there is no other current evidence in the literature it is possible that these
neurological complications were a direct result of chemical damage by sodium
hypochlorite, but further research (including nerve conduction studies) is required.

3. Upper airway obstruction

- The use of sodium hypochlorite for root canal irrigation without adequate
isolation of the tooth can lead to leakage of the solution into the oral cavity and
ingestion or inhalation by the patient.
- This could result in throat irritation and in severe cases, the upper airway could
be compromised.
- Ziegler presented a case of a 15-month-old girl who presented in the accident and
emergency unit with acute laryngotracheal bronchitis, stridor and profuse drooling
from the mouth as a result of ingestion of a high concentration of household sodium
hypochlorite.
- A similar clinical presentation might occur with the ingestion of any caustic
substance.
- Opinion varies as to the best concentration of hypochlorite, with some
practitioners using undiluted household bleach. Fibre optic nasal tracheal intubation
followed by surgical decompression has been required to manage airway
compromising swelling arising within three hours of accidental exposure to sodium
hypochlorite during root canal treatment

EFFECT ON PERIODONTAL TISSUE

They also say that the highest concentration shows more irritating effect on
periodontal ligament.
The leakage of this material during endodontic treatment may cause sequelae such as
1. pain
2. Swelling
3. bruising
4. numbness

Skin injuries
Wash thoroughly and gently with normal saline or tap water
Oral mucosa injuries
Copious rinsing with water
Analgesia if required
If visible tissue damage antibiotics to reduce risk of secondary infection If any

possibility of ingestion or inhalation refer to emergency department

Inoculation injuries
Ice/cooling packs to swelling first 24 hours
Heat packs subsequently
Analgesia
Antibiotics to reduce the risk of secondary infection
Request advice or management from Maxillofacial Unit
Arrange review if to be managed in dental practice

Symptomatology
Immediate severe pain
Immediate edema of neighboring soft tissues
Possible extension of edema over the injured half side of the face, upper
lip, infraorbital region
Profuse bleeding from the root canal
Profuse interstitial bleeding with hemorrhage of the skin and mucosa
(ecchymosis)
Chlorine taste and irritation of the throat after injection into the maxillary
sinus
Secondary infection possible
Reversible anesthesia or par aesthesia possible

Immediate severe pain for 2- 6 minutes.

immediate edema in adjacent soft tissue because of perfusion to the loose
connective tissue.
Extension of edema to a large site of the face such as cheeks, peri- orbital
region, or lips.
Ecchymosis on skin or mucosa as a result of profuse interstitial bleeding.

Sodium hypochloride accident Management

- inform the patient about the cause and nature of the complication.
- Immediately irrigate with normal saline to decrease the soft-tissue
irritation by diluting the NaOCl.
- Let the bleeding response continue as it helps to flush the irritant out of the tissues.

Sodium hypochloride accident

- Recommend ice bag compresses for 24 hours (15-minute intervals) to
minimize swelling.
- Recommend warm, moist compresses after 24 hours (15-minute
intervals).
- Pain control with strong analgesics for 3 to 7 days
-Prophylactic antibiotic coverage for 7 to 10 days to prevent secondary
infection or spreading of the present infection.

Preventive measures that should be taken to minimize potential

complications with sodium hypochlorite
- Plastic bib to protect patient's clothing
- Provision of protective eye-wear for both patient and operator
- The use of a sealed rubber dam for isolation of the tooth under treatment
- The use of side exit Luer-Lok needles for root canal irrigation
- Irrigation needle a minimum of 2 mm short of the working length
- Avoidance of wedging the needle into the root canal
- Avoidance of excessive pressure during irrigation.
Placement of rubber stop on irrigation needle
- Needle must be side venting
- Hypodermic (end exiting) needles in root canal
- irrigation risks accidental inoculation into the soft tissues.
- Luer-Lok style syringes and needles should be used, as taper seat needles may
dislodge in use, with uncontrolled loss of the hypochlorite solution under pressure.
- Needle should not engage the sides of the canal, but be loosely positioned within the
canal.
- Needle should not reach the apical extent of the prepared canal.
- This technique may be facilitated by marking the working length on the needle with
a rubber stop. irrigant delivered slowly with minimal pressure to reduce the likelihood

of forcing it through the apex. Achieved by using your index finger rather than thumb
to depress the plunger.
- This will reduce the risk to periapical tissues by inadvertent extrusion of irrigant.

Conclusions
- New concepts usually are overrated in initial studies when compared to the gold
standard.
- Some recent approaches to improve root canal debridement include the use of laser
light to induce lethal photosensitization on canal microbiota, irrigation using
electrochemically activated water, and ozone gas infiltration into the endodontic
system.
- However, in terms of killing efficacy on endodontic microbiota in biofilms, there is
good evidence that none of these approaches can match a simple sodium hypochlorite
irrigation.

References
1. Cohens PATHWAYS OF THE PULP- 10TH EDITION
2. Problem solving in Endodontics- fourth edition, GUTMANN, DUMSHA,
LOVDAHL
3. Root Canal Irrigants , J Endod 2006;32:389398 Matthias Zehnder
4. Review: the use of sodium hypochlorite in endodontics potential complications
and their management. H. R. Spencer, V. Ike& P. A. Brennan:British Dental Journal
202, 555 - 559 (2007)
5. Tissue-dissolving capacity and antibacterial effect of buffered and unbuffered
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2002
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pages
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