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HYPOCHLORITE
By
Dr.Anoop.V.Nair
PG, Dept of Cons Dentistry & Endodontics
CONTENTS
• Introduction
• Root canal bacterium
• Root canal irrigants
• Ideal requirements of a root canal irrigant
• Natural occurrence of NaOCl
• History of NaOCl
• Chemistry of NaOCl
• Mode of action
• Suggested irrigation regimen
• Efficacy
• Time factor
• Interactions
• Accidents and management
• Literature discussion
• Conclusion
• References
INTRODUCTION
• Main cause of endodontic failure- Microorganisms, either remaining in the
root canal space after treatment or re-colonizing the filled canal system.
• Primary endodontic treatment goal- optimize root canal disinfection and to
prevent re-infection.
• Pulpitis is the host reaction to opportunistic pathogens from the oral
environment entering the endodontium.
• Vital pulp tissue can defend against microorganisms and is thus largely
noninfected until it gradually becomes necrotic. In contrast, the pulp space of
nonvital teeth with radiographic signs of periapical rarefaction always
harbors cultivable microorganisms.
• Consequently, the treatment of vital cases should focus on asepsis, i.e. the
prevention of infection entering a primarily sterile environment, which is the
apical portion of the root canal. Antisepsis, which is the attempt to remove all
microorganisms, is the key issue in nonvital cases.
• Success, longevity, and reliability of modern endodontic treatments-
effectiveness of endodontic files, rotary instrumentation, irrigating solutions,
and chelating agents to clean, shape, and disinfect root canals.
• The role of microorganisms in the development and perpetuation of pulp
and periapical diseases has clearly been demonstrated in animal models
and human studies.
• Elimination of microorganisms from infected root canals is a complicated
task.
• The chances of a favourable outcome with root canal treatment are
significantly higher if infection is eradicated effectively before the root canal
system is obturated.
• However, if microorganisms persist at the time of obturation, or if they
penetrate into the canal after obturation, there is a high risk of treatment
failure
• Self-aggregates of monobacterial morphotypes and coaggregates of
different bacterial morphotypes are also found adhering to teeth.
• The interbacterial spaces are occupied by an amorphous material,
spirochetes, and hyphal-like structures that are suggestive of fungi.
• Costerton et al. used the term “biofilm” to describe this clustering of
bacteria. Bacteria within a biofilm have increased resistance to a variety of
external hostile influences, such as the host defense responses, antibiotics,
antiseptics, and shear forces, compared with isolated bacterial cells.
* F. J. Vertucci, “Root canal anatomy of the human permanent teeth,” Oral Surgery Oral Medicine
and Oral Pathology, vol. 58, no. 5, pp. 589–599, 1984.
• Numerous measures have been described to reduce the number of
microorganisms in the root canal system, including the use of various
instrumentation techniques, irrigation regimens, and intracanal
medicaments.
• The use of chemical agents during instrumentation to completely clean all
aspects of the root canal system is central to successful endodontic
treatment. Irrigation is complementary to instrumentation in facilitating
the removal of pulp tissue and/or microorganisms.
• Irrigation dynamics plays an important role; the effectiveness of irrigation
depends on the working mechanism(s) of the irrigant and the ability to bring
the irrigant in contact with the microorganisms and tissue debris in the root
canal.
Root Canal Bacterium
• Primary root canal infections are polymicrobial, typically dominated by obligatory
anaerobic bacteria.
• The most frequently isolated microorganisms before root canal treatment include
Gram-negative anaerobic rods, Gram-positive anaerobic cocci, Gram-positive
anaerobic and facultative rods, Lactobacillus species, and Gram-positive facultative
Streptococcus species.
• The obligate anaerobes are rather easily eradicated during root canal treatment.
• Facultative bacteria such as nonmutans Streptococci, Enterococci, and Lactobacilli,
once established, are more likely to survive chemomechanical instrumentation and
root canal medication.
• Enterococcus faecalis has gained attention in the endodontic literature, as it can
frequently be isolated from root canals in cases of failed root canal treatments.
• Yeasts may also be found in root canals associated with therapy-resistant apical
periodontitis.
Root Canal Irrigants
• It is generally believed that mechanical enlargement of canals must be
accompanied by copious irrigation in order to facilitate maximum
removal of microorganisms so that the prepared canal becomes as
bacteria-free as possible.
• Ideally an irrigant should provide a mechanical flushing action, be
microbiocidal and dissolve remnants of organic tissues without
damaging the periradicular tissues if extruded into the periodontium.
• In addition, the root canal irrigants should be biocompatible with oral
tissues.
Ideal Requirement of Root Canal Irrigants
It appears evident that root canal irrigants ideally should
(i) have a broad antimicrobial spectrum and high efficacy against anaerobic and
facultative microorganisms organized in biofilms
(ii) dissolve necrotic pulp tissue remnants,
(iii) inactivate endotoxin,
(iv) prevent the formation of a smear layer during instrumentation or dissolve the latter
once it has formed,
(v) be systemically nontoxic,
(vi) be non caustic to periodontal tissues,
(vii) be little potential to cause an anaphylactic reaction.
• Have a broad antimicrobial spectrum and high efficacy against
anaerobic and facultative microorganisms organized in biofilms
● Dissolve necrotic pulp tissue remnants
● Inactivate endotoxin
● Prevent the formation of a smear layer during instrumentation or
dissolve the latter once it has formed.
Furthermore, as endodontic irrigants come in contact with vital tissues,
they should be systemically nontoxic, non caustic to periodontal tissues
and have little potential to cause an anaphylactic reaction.
* 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)
Natural Occurrence
• Chlorine is one of the most widely distributed elements on earth. It is
not found in a free state in nature, but exists in combination with
sodium, potassium, calcium, and magnesium.
• In the human body, chlorine compounds are part of the nonspecific
immune defense.
• They are generated by neutrophils via the myeloperoxidase-mediated
chlorination of a nitrogenous compound or set of compounds.
HISTORY
• Potassium hypochlorite was the first chemically produced aqueous
chlorine solution, invented in France by Berthollet (1748-1822).
• Starting in the late 18th century, this solution was industrially
produced by Percy in Javel near Paris, hence the name “Eau de
Javel”.
• First, hypochlorite solutions were used as bleaching agents.
• Subsequently, sodium hypochlorite was recommended by Labarraque
(1777-1850) to prevent childbed fever and other infectious diseases.
• Based on the controlled laboratory studies by Koch and Pasteur,
hypochlorite then gained wide acceptance as a disinfectant by the end
of the 19th century.
• In World War I, the chemist Henry Drysdale Dakin and the surgeon
Alexis Carrel extended the use of a buffered 0.5% sodium hypochlorite
solution to the irrigation of infected wounds, based on Dakin’s
meticulous studies on the efficacy of different solutions on infected
necrotic tissue.
• Beside their wide-spectrum, nonspecific killing efficacy on all microbes,
hypochlorite preparations are sporicidal, virucidal, and show far greater
tissue dissolving effects on necrotic than on vital tissues.
• These features prompted the use of aqueous sodium hypochlorite in
endodontics as the main irrigant as early as 1920.
• Other chlorine-releasing compounds have been advocated in
endodontics, such as chloramine-T and sodium dichloroisocyanurate.
• These, however, have never gained wide acceptance in endodontics,
and appear to be less effective than hypochlorite at comparable
concentration.
CHEMISTRY
• Reactive chlorine in aqueous solution at body temperature can, in essence,
take two forms: hypochlorite (OCl-) or hypochlorous acid (HOCl).
• The concentration of these can be expressed as available chlorine by
determining the electrochemical equivalent amount of elemental chlorine.
According to the following equations:
Rotary instrument immersed for 2 hours in NaOCl heated to 60oc, showing severe
corrosion
• A study using steady state planktonic E.fecalis cells, showed a
temperature rise of 25oc increased NaOCl efficacy by a factor of
100.
• Capacity to dissolve human dental pulp using 1% NaOCl at 45oc
was found to be equal to that of a 5.25% solution at 20oc.
• Systemic toxicity of preheated low conc of NaOCl irrigants should
be less than that of a more concentrated unheated solution.
Time factor
• NaOCl require an adequate working time to reach their potential.
• Chlorine, which is responsible for dissolving and antibacterial capacity of
NaOCl- unstable and consumed rapidly during the first phase of tissue
dissolution, probably within 2 mins.
• Optimal time a hypochlorite irrigant needs to remain in the canal system is
an issue yet to be resolved.
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) (Dentsply Tulsa Dental, Tulsa, OK, USA), in the
presence of light, causing brown discolouration (Torabinejad et al. 2003).
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.
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.
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.
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).
Tooth discolouration associated with root canal irrigants
1% NaOCl +
2% chlorhexidine (CHX) gel Dark brown precipitate Vivacqua-Gomes et al. (2002)
MTAD + NaOCl (5.25–0.65%) Brown solution (NaOCl final rinse) Torabinejad et al. (2003)
17% EDTA + 1% CHX sol. Pink precipitate (CHX final rinse) Gonza´ lez-Lo´ pez et al. (2006)
1.54–6.15% NaOCl + MTAD Yellow precipitate (MTAD final rinse) Tay et al. (2006a) (Clinical application)
1.3% NaOCl + MTAD Red-purple (MTAD final rinse) Tay et al. (2006a) (In vitro study)
NaOCl + CHX sol. Light orange to dark brown Basrani et al. (2007), Marchesan et al(2007),
according to conc. Bui et al. (2008) Akisue et al. (2010),
Krishnamurthy & Sudhakaran (2010), Nassar et al. (2011)
2% CHX sol. + 15% Citric acid A white solution but returns Akisue et al. (2010)
colourless and easily removed
during irrigation with CHX
2% CHX gel + 5.25% NaOCl Discoloured enamel and dentine Souza et al. (2011)
2% CHX sol. + 5.25% NaOCl Discoloured dentine only Souza et al. (2011)
2% CHX gel + 5.25% NaOCl + 17% EDTA Discoloured enamel and dentine Souza et al. (2011)
2% CHX sol. + 5.25% NaOCl + 17% EDTA Discoloured dentine Souza 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.
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 colouration 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 litre of normal saline.
3) 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.
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)
Complications arising from hypochlorite extrusion beyond the root
apex
• 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.
Eye injuries
Irrigate gently with normal saline. If normal saline is insufficient or unavailable, tap water
should be used
Refer for ophthalmology opinion
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
Effects of calcium hydroxide and sodium hypochlorite on the dissolution
of necrotic porcine muscle tissue
Gunna Hasselgren, Berit Olsson, Miomir Cvek
JOE, Volume 14, Issue 3, March 1988, Pages 125–127
• The goal of this study was to compare the dissolving potential of Dakin's
solution with that of equivalent buffered and unbuffered sodium hypochlorite
solutions on fresh and decayed tissues. In addition, the antimicrobial effect of
Dakin's solution and equivalent unbuffered hypochlorite was tested.
• Study Design. Tissue specimens were obtained from freshly dissected pig
palates. Unbuffered 2.5% and 0.5% sodium hypochlorite solutions and 0.5%
solutions buffered at a pH of 12 and a pH of 9 (Dakin's solution) were tested on
fresh and decayed tissue. Tissue decay was assessed histologically.
Antimicrobial testing was performed with Enterococcus faecalis in dentin
blocks and on filter papers.
• Results
• The 2.5% NaOCl solution was substantially more effective than the three 0.5%
solutions in dissolving the test tissues. Buffering had little effect on tissue
dissolution, and Dakin's solution was equally effective on decayed and fresh
tissues. No differences were recorded for the antibacterial properties of Dakin's
solution and an equivalent unbuffered hypochlorite solution.
• Conclusions
• In contrast to earlier statements, the results of this study do not demonstrate
any benefit from buffering sodium hypochlorite with sodium bicarbonate
according to Dakin's method. An irrigation solution with less dissolving potential
may be obtained by simply diluting stock solutions of NaOCl with water.
CONCLUSION
• 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. Cohen’s PATHWAYS OF THE PULP- 10TH EDITION
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)
6. 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
7. G. Sundqvist, “Ecology of the root canal flora,” Journal of Endodontics, vol. 18, no. 9, pp. 427–
430, 1992
7. “The synergistic antimicrobial effect by mechanical agitation and two chlorhexidine preparations on
biofilm bacteria,”
Y. Shen, S. Stojicic, W. Qian, I. Olsen, and M. Haapasalo,
Journal of Endodontics, vol. 36, no. 1, pp. 100–104, 2010.
8. “Endodontic irrigation,”
T. D. Becker and G. W. Woollard, General Dentistry, vol. 49, no. 3, pp. 272–276, 2001.