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IN BRIEF
VERIFIABLE
CPD PAPER
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 potentially adverse incident with this agent.
INTRODUCTION
Sodium hypochlorite (NaOCl) was fi rst
recognised as an antibacterial agent
in 1843 when hand washing with
hypochlorite solution between patients
produced unusually low rates of infection transmission between patients.
It was fi rst recorded as an endodontic
irrigant in 19201 and is now in routine
worldwide use.
Sodium hypochlorite is used as an
endodontic irrigant as it is an effective
antimicrobial and has tissue-dissolving
capabilities. It has low viscosity allowing easy introduction into the canal
architecture, an acceptable shelf life, is
easily available and inexpensive. The
toxicity of its action to vital tissues
1
Associate Specialist in Oral Surgery, 2SHO in Oral
and Maxillofacial Surgery, 3*Consultant Maxillofacial
Surgeon, Professor of Surgery, Queen Alexandra
Hospital, Portsmouth, PO6 3LY
*Correspondence to: Professor Peter Brennan
Email: peter.brennan@porthosp.nhs.uk
Refereed Paper
Accepted 15 September 2006
DOI: 10.1038/bdj.2007.374
British Dental Journal 2007; 202: 555-559
BRITISH DENTAL JOURNAL VOLUME 202 NO. 9 MAY 12 2007
EDUCATION
Table 1 Preventive measures that should be
taken to minimise potential complications
with sodium hypochlorite
EDUCATION
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.7,18,19
2) Neurological complications
Paraesthesia and anaesthesia affecting
the mental,22 inferior dental22and infraorbital branches18,22,23 of the trigeminal
nerve following inadvertent extrusion
of sodium hypochlorite beyond the root
canals have been described. Normal sensation may take many months to completely resolve.22,23
Facial nerve damage was fi rst described
by Witton et al. in 2005.18 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 irritation22 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.24 A similar clinical presentation
might occur with the ingestion of any
caustic substance.25 Opinion varies as to
the best concentration of hypochlorite,
with some practitioners using undiluted
household bleach.20 Fibre optic nasal
tracheal intubation followed by surgical decompression has been required to
manage airway compromising swelling
BRITISH DENTAL JOURNAL VOLUME 202 NO. 9 MAY 12 2007
EDUCATION
3.
4.
5.
Initial management
Tissue swelling can potentially be minimised by using cold compression (frozen
items wrapped in a towel). If the patient
is being treated under local anaesthesia
they may not experience pain immediately. Mild to moderate pain may be managed with analgesia such as ibuprofen
and paracetamol.8 Adult doses of paracetamol 1 g qds and ibuprofen or ibuprofen 400 mg qds can be used alternately
at four hourly intervals if necessary.
Oral antibiotics may also be prescribed
to minimise the risk of secondary bacterial infection; Amoxicillin 250 mg tds or
Metronidazole 200 mg tds in the penicillin allergic patient. It should be emphasised that careful patient record keeping
is very important in clinical practice.
The precise details of the event should
be documented including concentration
and volume of the hypochlorite solution
involved. The measures employed to
minimise risk (eg rubber dam, eye protection, working length measurement)
should also be documented. Clinical
photographs may also be appropriate to
supplement the notes.
Conservative
management
for
hypochlorite complications has been
recommended.28 While this may be
appropriate in patients who develop mild
complications, it is not to be universally
recommended. Urgent referral is necessary in all cases involving ingestion or
inhalation of hypochlorite, as the clinical
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
EDUCATION
Dent Traumatol 1989; 5: 200-203.
22. Becking A G. Complications in the use of sodium
hypochlorite during endodontic treatment. Oral
Surg Oral Med Oral Path 1991; 71: 346-348.
23. Serper A, Ozbek M, Calt S. Accidental sodium
hypochlorite-induced skin injury during endodontic treatment. J Endod 2004; 30: 180-181.
24. Ziegler D S. Upper airway obstruction induced by
a caustic substance found responsive to nebulised
adrenalin. J Paed Child Health 2001; 37: 524-525.
25. Moulin D, Bertrand J M, Buts J P et al. Upper
airway lesions in children after accidental ingestion of caustic substances. J Pediatr 1984; 106:
408-410.
26. Bowden J R, Ethuandan M, Brennan P A. Life
threatening airway obstruction secondary to
27.
28.
29.
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31.
hypochlorite extrusion during root canal treatment. Oral Surg Oral Med Oral Pathol Oral Radiol
Oral Endod 2006; 101: 402-404.
The Control of Substances Hazardous to Health
Regulations. (COSHH) 2002.
Hales J J, Jackson C R, Everett A P et al. Treatment protocol for the management of a sodium
hypochlorite accident during endodontic therapy.
Gen Dent 2001; 49: 278-281.
Clarkson R M, Moule A J. Sodium hypochlorite and
its use as an endodontic irrigant. Aust Dent J 1998;
43: 250-256.
Manogue M, Patel S, Walker R. The principles of
endodontics. pp 138-139. Oxford: Oxford University Press, 2005.
Mackie I C. UK National Clinical Guidelines in
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