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Documenti di Professioni
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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
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
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.
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)
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.
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).
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)
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)
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.
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.
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
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.
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.
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.
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
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
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
hypochlorite solutions. Matthias Zehnder, Daniel Kosicki, Hansueli Luder, Beatrice
Sener, Tuomas Waltimo OOOOE, Volume 94, Issue 6 , Pages 756-762, December
2002
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
8. The synergistic antimicrobial effect by mechanical agitation and two
chlorhexidine
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Haapasalo, Journal of Endodontics, vol. 36, no. 1, pp. 100104, 2010.
9. Endodontic irrigation, T. D. Becker and G. W. Woollard, General Dentistry, vol.
49, no. 3, pp. 272276, 2001.
10. Yesilroy C, Whitaker E, Cleveland D, Philps E, Trope M: Antibacterial and toxic
effects of established and potential root canal irrigants. J Endod 21:513, 1995