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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: [email protected]
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
36.9°C. 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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Hong Kong j. emerg. med. „ Vol. 17(2) „ Apr 2010
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
Figure 1. Swelling and bruising on day 1.
Figure 2. Swelling and bruising resolved after 5 weeks.
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
Lam et al./Sodium hypochlorite accident
175
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
tissues causing facial asymmetry requiring fat grafting,15
gingival necrosis and bone necrosis.13
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
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
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
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.
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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Hong Kong j. emerg. med. „ Vol. 17(2) „ Apr 2010
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.
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