Review: the use of sodium hypochlorite in endodontics - Nature

Sodium hypochlorite (NaOCl) was first recognised as an antibacterial agent in 1843 when hand washing with hypochlorite solution between patients ... Skiptomaincontent Thankyouforvisitingnature.com.YouareusingabrowserversionwithlimitedsupportforCSS.Toobtain thebestexperience,werecommendyouuseamoreuptodatebrowser(orturnoffcompatibilitymodein InternetExplorer).Inthemeantime,toensurecontinuedsupport,wearedisplayingthesitewithoutstyles andJavaScript. Advertisement nature britishdentaljournal education article Review:theuseofsodiumhypochloriteinendodontics—potentialcomplicationsandtheirmanagement DownloadPDF KeyPoints Sodiumhypochloriteisacommonlyusedirrigantinendodonticpractice.Ithasmanypotentialcomplicationsrangingfrompermanentbleachingofclothestoseveresofttissuedamage. Thecomplicationsofhypochloriteextrusionbeyondtherootapexarediscussed. Guidelinesaregivenforthesafeuseofhypochloritesolutionduringendodontictreatmentandadviceontheappropriatecourseofactionwhenahypochloritecomplicationissuspected. AbstractAqueoussodiumhypochlorite(bleach)solutioniswidelyusedindentalpracticeduringrootcanaltreatment.Althoughitisgenerallyregardedasbeingverysafe,potentiallyseverecomplicationscanoccurwhenitcomesintocontactwithsofttissue.Thispaperdiscussestheuseofsodiumhypochloriteindentaltreatment,reviewsthecurrentliteratureregardinghypochloritecomplications,andconsiderstheappropriatemanagementforadentalpractitionerwhenfacedwithapotentiallyadverseincidentwiththisagent. 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IntroductionSodiumhypochlorite(NaOCl)wasfirstrecognisedasanantibacterialagentin1843whenhandwashingwithhypochloritesolutionbetweenpatientsproducedunusuallylowratesofinfectiontransmissionbetweenpatients.Itwasfirstrecordedasanendodonticirrigantin19201andisnowinroutineworldwideuse.Sodiumhypochloriteisusedasanendodonticirrigantasitisaneffectiveantimicrobialandhastissue-dissolvingcapabilities.Ithaslowviscosityallowingeasyintroductionintothecanalarchitecture,anacceptableshelflife,iseasilyavailableandinexpensive.Thetoxicityofitsactiontovitaltissuesandcorrosionofmetals2areitsmaindisadvantagesindentaluse.Sodiumhypochloritereactswithfattyacidsandaminoacidsindentalpulpresultinginliquefactionoforganictissue.3Thereisnouniversallyacceptedconcentrationofsodiumhypochloriteforuseasanendodonticirrigant.Theantibacterialandtissuedissolutionactionofhypochloriteincreaseswithitsconcentration,butthisisaccompaniedbyanincreaseintoxicity.Concentrationsusedvarydownfrom5.25%dependingonthedilutionandstorageprotocolsofindividualpractitioners.Solutionwarmersareavailabletoincreasethetemperatureupto60°C.Increasingthetemperatureofasolutionofhypochloriteimprovesthebactericidalandpulpdissolutionactivity,althoughtheeffectofheattransfertotheadjacenttissuesisuncertain.4Asableachingagent,inadvertentspillageofthisagentcanresultindamagetoclothingandsofttissues.Inadvertentintroductionofsodiumhypochloritebeyondtherootcanalsystemmayresultinextensivesofttissueornervedamage,andevenairwaycompromise.Thisarticlereviewsthepotentialcomplicationsthatcanoccurwithsodiumhypochloriteinclinicalpractice,discussesmeasuresthatcanbetakentominimiserisk,andprovidesdetailsofappropriatemanagementintherarecasesofsuspectedtissuedamage.Complicationsofaccidentalspillage1)DamagetoclothingAccidentalspillageofsodiumhypochloriteisprobablythemostcommonaccidenttooccurduringrootcanalirrigation.Evenspillageofminutequantitiesofthisagentonclothingwillleadtorapid,irreparablebleaching.Thepatientshouldwearaprotectiveplasticbib,andthepractitionershouldexercisecarewhentransferringsyringesfilledwithhypochloritetotheoralcavity.2)EyedamageSeeminglymildburnswithanalkalisuchassodiumhypochloritecanresultinsignificantinjuryasthealkalireactswiththelipidinthecornealepithelialcells,formingasoapbubblethatpenetratesthecornealstroma.Thealkalimovesrapidlytotheanteriorchamber,makingrepairdifficult.Furtherdegenerationofthetissueswithintheanteriorchamberresultsinperforation,withendophthalmitisandsubsequentlossoftheeye.5Ingramrecordedacaseofaccidentalspillageof5.25%sodiumhypochloriteintoapatient'seyeduringendodontictherapy.6Theimmediatesymptomsincludedinstantseverepainandintenseburning,profusewatering(epiphora)anderythema.Lossofepithelialcellsintheoutercorneallayermayoccur.Theremaybeblurringofvisionandpatchycolourationofthecornea.7Immediateocularirrigationwithalargeamountofwaterorsterilesalineisrequiredfollowedbyanurgentreferraltoanophthalmologist.8Thereferralshouldideallybemadeimmediatelybytelephonetothenearesteyedepartment.Theuseofadequateeyeprotectionduringendodontictreatmentshouldeliminatetheriskofoccurrenceofthisaccident,butsterilesalineshouldalwaysbeavailabletoirrigateeyesinjuredwithhypochlorite.Ithasbeenadvisedthateyesexposedtoundilutedbleachshouldbeirrigatedfor15minuteswithalitreofnormalsaline.9,103)DamagetoskinSkininjurywithanalkalinesubstancerequiresimmediateirrigationwithwaterasalkaliscombinewithproteinsorfatsintissuetoformsolubleproteincomplexesorsoaps.Thesecomplexespermitthepassageofhydroxylionsdeepintothetissue,therebylimitingtheircontactwiththewaterdilutantontheskinsurface.Wateristheagentofchoiceforirrigatingskinanditshouldbedeliveredatlowpressureashighpressuremayspreadthehypochloriteintothepatient'sorrescuer'seyes.54)DamagetooralmucosaSurfaceinjuryiscausedbythereactionofalkaliwithproteinandfatsasdescribedforeyeinjuriesabove.Swallowingofsodiumhypochloriterequiresthepatienttobemonitoredfollowingimmediatetreatment.Itisworthnotingthatskindamagecanresultfromsecondarycontamination.AllergytosodiumhypochloriteTheallergicpotentialofsodiumhypochloritewasfirstreportedin1940bySulzberger11andsubsequentlybyCohenandBurns.12Caliskanetal.presentedacasewherea32-year-oldfemaledevelopedrapidonsetpain,swelling,difficultyinbreathingandsubsequentlyhypotensionfollowingapplicationof0.5mlof1%sodiumhypochlorite.13Thepatientrequiredurgenthospitalisationintheintensivecareunitandmanagementwithintravenoussteroidsandantihistamines.Asubsequentallergyskinscratchtestperformedtwoweeksafterthepatientwasdischargedconfirmedahighlypositiveresulttosodiumhypochlorite.TheusefulnessofthistestinsuspectedcasesofsodiumhypochloriteallergyduringendodontictreatmenthasbeenconfirmedbyKaufmanandKeila.14Eventhoughallergytosodiumhypochloriteisrare,itisimportantforclinicianstorecognisethesymptomsofallergyandpossibleanaphylaxis.Thesemayincludeurticaria,oedema,shortnessofbreath,wheezing(bronchospasm)andhypotension.Urgentreferraltoahospitalfollowingfirstaidmanagementisrecommended.Complicationsarisingfromhypochloriteextrusionbeyondtherootapex1)ChemicalburnsandtissuenecrosisWhensodiumhypochloriteisextrudedbeyondtherootcanalintotheperi-radiculartissues,theeffectisoneofachemicalburnleadingtoalocalisedorextensivetissuenecrosis.Giventhewidespreaduseofhypochlorite,thiscomplicationisfortunatelyveryrareindeed.Asevereacuteinflammatoryreactionofthetissuesdevelops.Thisleadstorapidtissueswellingbothintraorallywithinthesurroundingmucosaandextraorallywithintheskinandsubcutaneoustissues.Theswellingmaybeoedematous,haemorrhagicorboth,15andmayextendbeyondtheregionthatmightbeexpectedwithanacuteinfectionoftheaffectedtooth16,17(Figs1,2).Suddenonsetofpainisahallmarkoftissuedamage,andmayoccurimmediatelyorbedelayedforseveralminutesorhours.18Involvementofthemaxillarysinuswillleadtoacutesinusitis.19Associatedbleedingintotheinterstitialtissuesresultsinbruisingandecchymosisofthesurroundingmucosaandpossiblythefacialskin(Fig.3)andmayincludetheformationofahaematoma.15,20Anecroticulcerationofthemucosaadjacenttothetoothmayoccurasadirectresultofthechemicalburn.21Thisreactionofthetissuesmayoccurwithinminutesormaybedelayedandappearsomehoursordayslater.20,22Ifthesesymptomsdevelop,urgenttelephonereferralshouldbemadetothenearestmaxillofacialunit.Patientswillbeassessedbytheoncallmaxillofacialteam.Treatmentisdeterminedbytheextentandrapidityofthesofttissueswellingbutmaynecessitateurgenthospitalisationandadministrationofintravenoussteroidsandantibiotics.7,18Althoughtheevidencefortheuseofantibioticsinthesepatientsisanecdotal,secondarybacterialinfectionisadistinctpossibilityinareasofnecrotictissueandthereforetheyareoftenprescribedaspartoftheoverallpatientmanagement.Surgicaldrainageordebridementmayalsoberequireddependingontheextentandcharacterofthetissueswellingandnecrosis.7,18,19Figure1BruisingandoedemaofthreepatientswhopresentedwithhypochloriteextrusionintothesofttissuesFullsizeimageFigure2BruisingandoedemaofthreepatientswhopresentedwithhypochloriteextrusionintothesofttissuesFullsizeimageFigure3BruisingandoedemaofthreepatientswhopresentedwithhypochloriteextrusionintothesofttissuesFullsizeimage2)NeurologicalcomplicationsParaesthesiaandanaesthesiaaffectingthemental,22inferiordental22andinfra-orbitalbranches18,22,23ofthetrigeminalnervefollowinginadvertentextrusionofsodiumhypochloritebeyondtherootcanalshavebeendescribed.Normalsensationmaytakemanymonthstocompletelyresolve.22,23FacialnervedamagewasfirstdescribedbyWittonetal.in2005.18Inbothcases,thebuccalbranchofthefacialnervewasaffected.Bothpatientsexhibitedalossofthenaso-labialgrooveandadownturningoftheangleofthemouth.Bothpatientswerereviewedandtheirmotorfunctionwasregainedafterseveralmonths.Sensoryandmotornervedeficitarenotcommonlyassociatedwithacutedentalabscesses.Asthereisnoothercurrentevidenceintheliteratureitispossiblethattheseneurologicalcomplicationswereadirectresultofchemicaldamagebysodiumhypochlorite,butfurtherresearch(includingnerveconductionstudies)isrequired.3)UpperairwayobstructionTheuseofsodiumhypochloriteforrootcanalirrigationwithoutadequateisolationofthetoothcanleadtoleakageofthesolutionintotheoralcavityandingestionorinhalationbythepatient.Thiscouldresultinthroatirritation22andinseverecases,theupperairwaycouldbecompromised.Zieglerpresentedacaseofa15-month-oldgirlwhopresentedintheaccidentandemergencyunitwithacutelaryngotrachealbronchitis,stridorandprofusedroolingfromthemouthasaresultofingestionofahighconcentrationofhouseholdsodiumhypochlorite.24Asimilarclinicalpresentationmightoccurwiththeingestionofanycausticsubstance.25Opinionvariesastothebestconcentrationofhypochlorite,withsomepractitionersusingundilutedhouseholdbleach.20Fibreopticnasaltrachealintubationfollowedbysurgicaldecompressionhasbeenrequiredtomanageairwaycompromisingswellingarisingwithinthreehoursofaccidentalexposuretosodiumhypochloriteduringrootcanaltreatment(Fig.4).26Figure4UpperairwaycompromiserequiringdecompressionfollowingextrusionofhypochloriteintothesofttissuesFullsizeimageWhatcanIdotominimisetheriskofhypochloritecomplications?Theuseofallchemicalsorhazardoussubstancesinpracticeiscoveredbylegislationrequiringemployerstocontrolexposuretobothstaffandpatientstopreventillhealth.TheControlofSubstancesHazardoustoHealthRegulations(2002)(COSHH)27requiresapracticetoprepareplansandprocedurestodealwithaccidents,incidentsandemergenciesinvolvinghazardoussubstancesandtoadequatelycontrolexposure.Ashasalreadybeenstated,thesearerarecomplications,butnonetheless,theriskofhypochlorite-induceddamagecanbeminimisedbyimplementingthemeasureslistedinTable1whenperformingendodontictherapy.Iftheaqueoussodiumhypochloriteistobedilutedforuse,eyeprotection,facemask,glovesandplasticapronshouldbewornfortheprocedure.Thepreparedsolutionmustbestoredinalightproof,non-metalliccontainerthatisappropriatelylabelled.Table1PreventivemeasuresthatshouldbetakentominimisepotentialcomplicationswithsodiumhypochloriteFullsizetableDuringtreatmentthepatient'sclothingshouldbeprotectedwithabibthatisimpermeabletoliquid.Thepatientandclinicalteamshouldwearwellfittingprotectiveglasses.Rubberdamshouldbeusedtoisolatethetoothandminordefectsinadaptationcorrectedwithacaulkingagenttooptimisetheseal.Ifthecanalistobeirrigatedusinganeedleandsyringe,theneedlemustbesideventing.Theuseofhypodermic(endexiting)needlesinrootcanalirrigationrisksaccidentalinoculationintothesofttissues.OnlyLuer-Lokstylesyringesandneedlesshouldbeused,astaperseatneedlesmaydislodgeinuse,withuncontrolledlossofthehypochloritesolutionunderpressure.29,30Theneedleshouldnotengagethesidesofthecanal,butbelooselypositionedwithinthecanal.Theneedleshouldnotreachtheapicalextentofthepreparedcanal.30Thistechniquemaybefacilitatedbymarkingtheworkinglengthontheneedlewitharubberstop(Fig.5).Theirrigantisdeliveredslowlywithminimalpressuretoreducethelikelihoodofforcingitthroughtheapex.Thisismosteasilyachievedbyusingyourindexfingerratherthanthumbtodepresstheplunger.30Thiswillreducetherisktoperiapicaltissuesbyinadvertentextrusionofirrigant.Figure5PlacementofrubberstoponirrigationneedleFullsizeimageParticularcaremustbetakeninimmatureteethwithopenapicestoensurethattheirrigantdoesnotgointotheapicaltissues.Sodiumhypochloriteandsalinearebothrecommendedforirrigationinimmatureteeth,however,ifhypochloriteisusedithasbeensuggestedthefinalirrigationshouldbewithsalinetoremoveanyhypochloritefromthecanal.31InkeepingwiththeCOSHHregulations,27clinicianswouldalsoberequiredtopreventoradequatelycontrolexposuretosodiumhypochloriteasfarasisreasonablypracticable.Thismayincludechangingthetreatmentplantoeliminatetheneedforsodiumhypochlorite,usingareplacementorusingitinasaferformegadilutebutequallyactiveconcentration.SpangbergandLangelandcarriedoutaseriesofinvivoandinvitrotestsonvariouspotentialirrigants.32Theyfoundthataswellasbeinghighlytoxicandirritating,5%sodiumhypochloritewasconsiderablystrongerthannecessarytokillthebacteriaintherootcanal,while0.5%concentrationdissolvesnecrotictissuebuthasnoeffectonStaphylococcusaureus.Theythereforerecommendedtheidealsolutiontobeonethatcombinesmaximalantimicrobialeffectwithminimaltoxicity.TheseresultswereconfirmedbyYesiloyetal.,whofoundthattheantimicrobialeffectsofsodiumhypochloriteweremuchlesswithconcentrationsof2.5%andlower.33Theyalsofoundthatchlorhexidinegluconate0.12%hastheequivalentantimicrobialeffectto5.25%sodiumhypochlorite.Ithasbeenshownthatchlorhexidine-treatedrootcanalsarelesssusceptibletore-infection.34Chlorhexidineistheirrigantofchoiceinre-treatmentcases.30However,sodiumhypochloriteremainsthemostcommonlyusedandrecommendedendodonticirrigantasitalonecombinesantimicrobialandtissuedissolvingcapabilitiesessentialinteethnotpreviouslyrootfilled.WhatshouldIdoifIsuspectahypochloritecomplication?Nostandardtherapyforthemanagementofcomplicationshasbeendocumented,probablybecausethesecomplicationsarerareandsporadic.InitialmanagementTissueswellingcanpotentiallybeminimisedbyusingcoldcompression(frozenitemswrappedinatowel).Ifthepatientisbeingtreatedunderlocalanaesthesiatheymaynotexperiencepainimmediately.Mildtomoderatepainmaybemanagedwithanalgesiasuchasibuprofenandparacetamol.8Adultdosesofparacetamol1gqdsandibuprofenoribuprofen400mgqdscanbeusedalternatelyatfourhourlyintervalsifnecessary.Oralantibioticsmayalsobeprescribedtominimisetheriskofsecondarybacterialinfection;Amoxicillin250mgtdsorMetronidazole200mgtdsinthepenicillinallergicpatient.Itshouldbeemphasisedthatcarefulpatientrecordkeepingisveryimportantinclinicalpractice.Theprecisedetailsoftheeventshouldbedocumentedincludingconcentrationandvolumeofthehypochloritesolutioninvolved.Themeasuresemployedtominimiserisk(egrubberdam,eyeprotection,workinglengthmeasurement)shouldalsobedocumented.Clinicalphotographsmayalsobeappropriatetosupplementthenotes.Conservativemanagementforhypochloritecomplicationshasbeenrecommended.28Whilethismaybeappropriateinpatientswhodevelopmildcomplications,itisnottobeuniversallyrecommended.Urgentreferralisnecessaryinallcasesinvolvingingestionorinhalationofhypochlorite,astheclinicalconsequencescannotbepredictedfromtheoropharyngealsymptoms.Maxillofacialadviceandassessmentisrecommendedforanysuspectedhypochloritecomplication.Insummary,thisreviewdiscussesthepotentialcomplicationsthatcanoccurwithsodiumhypochloriteinendodonticdentalpractice.Althoughrare,therecognitionandsubsequentprimarymanagementbythedentalpractitionerofthesecomplicationsisessentialtoensurebestclinicalpractice.Table2EmergencymanagementofaccidentalhypochloritedamageFullsizetable 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BrDentJ202,555–559(2007).https://doi.org/10.1038/bdj.2007.374DownloadcitationAccepted:15September2006Published:12May2007IssueDate:12May2007DOI:https://doi.org/10.1038/bdj.2007.374SharethisarticleAnyoneyousharethefollowinglinkwithwillbeabletoreadthiscontent:GetshareablelinkSorry,ashareablelinkisnotcurrentlyavailableforthisarticle.Copytoclipboard ProvidedbytheSpringerNatureSharedItcontent-sharinginitiative Furtherreading Ink-jet-printedCuOnanoparticle-enhancedminiaturizedpaper-basedelectrochemicalplatformforhypochloritesensing AshirwadRay JaligamMuraliMohan SanketGoel AppliedNanoscience(2022) EvaluationofdevelopmentallyhypomineralisedenamelaftersurfacepretreatmentwithPapacarieDuogelanddifferentetchingmodes:aninvitroSEMandAFMstudy Y.-L.Lee K.C.Li M.Ekambaram EuropeanArchivesofPaediatricDentistry(2022) PhotoacousticremovalofEnterococcusfaecalisbiofilmsfromtitaniumsurfacewithanEr:YAGlaserusingsupershortpulses SašaTerlep MichaelaHympanova DavidStopar LasersinMedicalScience(2022) EffectofdifferentactivationsofsilvernanoparticleirrigantsontheeliminationofEnterococcusfaecalis FarzanehAfkhami PanizAhmadi AidinSooratgar ClinicalOralInvestigations(2021) Influenceofcleaningmethodsonthebondstrengthofresincementtosaliva-contaminatedlithiumdisilicateceramic KeiichiYoshida ClinicalOralInvestigations(2020) DownloadPDF Advertisement Explorecontent Researcharticles Reviews&Analysis News&Comment Currentissue Collections FollowusonTwitter Signupforalerts RSSfeed Aboutthejournal JournalInformation Openaccesspublishing AbouttheBDA BDJBooks CPD ForAdvertisers Jobs BDJMarketplace Contact Publishwithus ForAuthors ForReferees Submitmanuscript Search Searcharticlesbysubject,keywordorauthor Showresultsfrom Alljournals Thisjournal Search Advancedsearch Quicklinks Explorearticlesbysubject Findajob Guidetoauthors Editorialpolicies