0099-2399/91/1711-0573/$03.00/0 JOURNAL OF ENDODONTICS Copyright 9 1991 by The American Association of Endodontists
Printed in U.S.A. VOL. 17, NO. 11, NOVEMBER1991
CASE REPORT Effects of Sodium Hypochlorite on Soft Tissues after Its Inadvertent Injection beyond the Root Apex Albert Gatot, MD, DDS, Jonathan Arbelle, MD, Alberto Leiberman, MD, and liana Yanai-lnbar, MD
The effects of an inadvertent injection of sodium hypochlorite into the cheek during irrigation of the right maxillary central incisor root canal are reported. The patient suffered from severe pain, edema, and necrosis of subcutaneous tissues and mucosa. Surgical intervention was necessary to contain the destructive process which extended from the upper lip to the right eye. The histopathological examination demonstrated the high cytotoxicity of sodium hypochlorite on vital tissue.
administered daily. Thirty-six hours later, the right side of her face became steadily distended. There was a large ecchymosis under the right orbit and diffuse ecchymosis over the upper lip. An area of epithelial necrosis appeared on the upper lip mucosa. The patient complained of right eye pain, blurring of vision, and was found to have right corneal patchy coloration. Under general anesthesia surgical debridement was performed with excision of necrotising mucosa of the upper lip. A large cavity with a large amount of brown hemorrhagic
Dakin's solution (sodium hypochlorite buffered with sodium bicarbonate) is a popular and effective intracanal irrigant and topical agent in open wounds. It is widely believed that Dakin's solution at the recommended concentration of 5.25 % will not damage normal underlying tissue. We describe the cytotoxic effects of an inadvertent injection of sodium hypochlorite through a root canal into the soft tissues of the cheek. CASE REPORT A 32-yr-old woman presented at a dental clinic for restoration of fractured anterior superior teeth. She had an old incomplete obturation of the right maxillary central incisor root canal. At the initial appointment the old root canal obturation was partially removed. On the following morning the canal was instrumented and irrigated. During the final instrumentation, the patient reacted to pain caused by penetration into the periapical area. However, irrigation of the canal with sodium hypochlorite was subsequently done. Massive edema immediately appeared on the patient's right cheek and upper lip. She complained of severe pain. When seen in the emergency room a few minutes later, the swelling extended to the right orbit. The sodium hypochlorite which had been used was analyzed and was found to have a pH of 12.9. The patient received 100 mg of hydrocortisone intravenously and was admitted for observation. Twelve million units of penicillin G sodium and 200 mg of hydrocortisone were
F~G 1. Massive edema on the patient's right cheek and upper lip a few minutes after the canal irrigation.
573
574
Gatot et al.
Journal of Endodontics
material was found. The cavity was copiously washed with normal saline solution and was not closed. After surgery the expanding cytotoxic process stopped and a moderate decrease of the swelling was observed. Three days later a wound infection appeared with tenderness of the right cheek and purulent secretion. The cavity was irrigated daily with normal saline solution to rapidly debride the necrotic infected tissue. Intravenous penicillin and chloramphenicol were administered. After 2 weeks the wound healed, but left dimples and scarring indicating a loss of subcutaneous and connective tissue. Furthermore, the patient complained of right infraorbital nerve anesthesia. Histopathological examination of the specimen taken during surgery revealed marked cell injury. The tissue was partly covered by necrotic squamous epithelium in which the shadowy outlines of the epithelial cells could be discerned, but with no nuclear staining. The ulcerated surface was infiltrated by group of yeast-like organisms resembling monilia and by colonies of bacteria. There was a relatively mild inflammatory cell reaction. The submucosa showed hemorrhages and basophilic degeneration of collagen.
FiG 2. Tissue from lip showing outlines of necrotic epidermal cells (H & E; original magnification x300).
DISCUSSION Sodium hypochlorite has been used as an intracanal irrigant for root canal sterilization and debridement for 70 yr (1). It is recognized as an effective agent against a broad spectrum of pathogens; Gram-positive and Gram-negative bacteria as well as fungi, spores, and viruses including the human immunodeficiency virus (2). In long-term clinical use on necrotic infected wounds, no adverse effects have been observed on underlying vital tissues. Four cases of parenteral exposure to sodium hypochlorite have been reported. Becker et al. (3) have published a case of accidental injection of a 5.25% solution of sodium hypochlorite beyond the root apex. Their patient experienced pain, edema, and hematoma formation, though after palliative treatment no permanent sequelae were evident. The second report involved injection of sodium hypochlorite into the mandibular branch of the trigeminal nerve, resulting in pain, edema, and trismus that resolved in 2 wk (4). The third was the uneventful exposure to an intravenous injection of sodium hypochlorite in a drug user attempting suicide (5). The fourth case involved intravenous infusion of sodium hypochlorite, which had been inadvertently added to the dialysate, during hemodialysis, leading to cardiorespiratory arrest but with eventual recovery (6). However, some investigations in vitro and in animals have demonstrated the toxic effects of sodium hypochlorite on vital tissues. These include hemolysis, skin ulceration (7), marked cell injury in endothelial cells and fibroblasts, and inhibition of neutrophil migration (8, 9). Our unfortunate case shows in vivo the adverse effects of sodium hypochlorite in soft tissues. The solution was probably not buffered, its pH being 12.9. This accounted for the severe damage which mandated surgical debridement. These data suggest that sodium hypochlorite can be extremely cytotoxic and should be used with caution in endodontic therapy. Respect of the tissue beyond the apex is essential to avoid complications, as is stressed in all manuals of endodontic procedures. Before irrigation the instruments have to be inserted to approximately 2 to 3 mm short of the radiographic apex and an X-ray film taken to
FiG 3. Ulceration and submucosal hemorrhages, with basophilic degeneration of collagen (H & E; original magnification x125).
confirm the measurement. This technique reduces the likelihood of inoculating the periapical tissues with the inflamed or infected contents of the canal and helps prevent injection of the irrigating solution beyond the root apex. Drs. Gatot, Arbelle, keiberman, and Yanai-lnbar are affiliated with the Head and Neck Surgery Section, Soroka University Hospital and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel. Address requests for reprints to Dr. Albert Gatot, Department of ENT, Soroka Medical Center, P.O. Box 151, Beer-Sheva, Israel.
References 1. Crane AB. A practible root canal technique. 1st ed. Philadelphia: Lea & Febiger, 1920:69. 2. Resnick L, Salahuddin SZ, Tondreau S, et al. Stability and inactivation of HTLV-II/LAV under clinical and laboratory environments. JAMA 1986;255:1887-91. 3. Becker GL, Cohen S, Borer R. The sequela of accidentally injecting sodium hypochiorite beyond the root apex. Oral Surg 1974;38:633-8. 4. Herrman JW, Heicht RC. Complications in therapeutic use of sodium hypochlorite. J Endodon 1979;5:160-3. 5. Froner GA, Rutherford GW, Rokeach M. Injection of sodium hypochlorite by intravenous drug users [Letter]. JAMA 1987;258:325. 6. Hoy RH. Accidental systemic exposure to sodium hypochlorite. Am J Hosp Pharm 1981 ;38:1512-4. 7. Pashley EL, Birdsong NL, Bowman K, Pashley DH. Cytotoxic effects of NaOCI on vital tissue. J Endodon 1985;11:525-8. 8. Lineaweaver W, McMorris S, Soucy D, Howard R. Cellular and bacterial toxicities of topical antimicrobials. Plast Reconstr Surg 1985;75:394-6. 9. Kozol RD, Gillies C, Elgebaly SA. Effects of sodium hypochlorite (Dakin's solution) on cells of the wound module. Arch Surg 1988;123:420-7.
Printed in U.S.A. VOL. 17, NO. 11, NOVEMBER1991
CASE REPORT Effects of Sodium Hypochlorite on Soft Tissues after Its Inadvertent Injection beyond the Root Apex Albert Gatot, MD, DDS, Jonathan Arbelle, MD, Alberto Leiberman, MD, and liana Yanai-lnbar, MD
The effects of an inadvertent injection of sodium hypochlorite into the cheek during irrigation of the right maxillary central incisor root canal are reported. The patient suffered from severe pain, edema, and necrosis of subcutaneous tissues and mucosa. Surgical intervention was necessary to contain the destructive process which extended from the upper lip to the right eye. The histopathological examination demonstrated the high cytotoxicity of sodium hypochlorite on vital tissue.
administered daily. Thirty-six hours later, the right side of her face became steadily distended. There was a large ecchymosis under the right orbit and diffuse ecchymosis over the upper lip. An area of epithelial necrosis appeared on the upper lip mucosa. The patient complained of right eye pain, blurring of vision, and was found to have right corneal patchy coloration. Under general anesthesia surgical debridement was performed with excision of necrotising mucosa of the upper lip. A large cavity with a large amount of brown hemorrhagic
Dakin's solution (sodium hypochlorite buffered with sodium bicarbonate) is a popular and effective intracanal irrigant and topical agent in open wounds. It is widely believed that Dakin's solution at the recommended concentration of 5.25 % will not damage normal underlying tissue. We describe the cytotoxic effects of an inadvertent injection of sodium hypochlorite through a root canal into the soft tissues of the cheek. CASE REPORT A 32-yr-old woman presented at a dental clinic for restoration of fractured anterior superior teeth. She had an old incomplete obturation of the right maxillary central incisor root canal. At the initial appointment the old root canal obturation was partially removed. On the following morning the canal was instrumented and irrigated. During the final instrumentation, the patient reacted to pain caused by penetration into the periapical area. However, irrigation of the canal with sodium hypochlorite was subsequently done. Massive edema immediately appeared on the patient's right cheek and upper lip. She complained of severe pain. When seen in the emergency room a few minutes later, the swelling extended to the right orbit. The sodium hypochlorite which had been used was analyzed and was found to have a pH of 12.9. The patient received 100 mg of hydrocortisone intravenously and was admitted for observation. Twelve million units of penicillin G sodium and 200 mg of hydrocortisone were
F~G 1. Massive edema on the patient's right cheek and upper lip a few minutes after the canal irrigation.
573
574
Gatot et al.
Journal of Endodontics
material was found. The cavity was copiously washed with normal saline solution and was not closed. After surgery the expanding cytotoxic process stopped and a moderate decrease of the swelling was observed. Three days later a wound infection appeared with tenderness of the right cheek and purulent secretion. The cavity was irrigated daily with normal saline solution to rapidly debride the necrotic infected tissue. Intravenous penicillin and chloramphenicol were administered. After 2 weeks the wound healed, but left dimples and scarring indicating a loss of subcutaneous and connective tissue. Furthermore, the patient complained of right infraorbital nerve anesthesia. Histopathological examination of the specimen taken during surgery revealed marked cell injury. The tissue was partly covered by necrotic squamous epithelium in which the shadowy outlines of the epithelial cells could be discerned, but with no nuclear staining. The ulcerated surface was infiltrated by group of yeast-like organisms resembling monilia and by colonies of bacteria. There was a relatively mild inflammatory cell reaction. The submucosa showed hemorrhages and basophilic degeneration of collagen.
FiG 2. Tissue from lip showing outlines of necrotic epidermal cells (H & E; original magnification x300).
DISCUSSION Sodium hypochlorite has been used as an intracanal irrigant for root canal sterilization and debridement for 70 yr (1). It is recognized as an effective agent against a broad spectrum of pathogens; Gram-positive and Gram-negative bacteria as well as fungi, spores, and viruses including the human immunodeficiency virus (2). In long-term clinical use on necrotic infected wounds, no adverse effects have been observed on underlying vital tissues. Four cases of parenteral exposure to sodium hypochlorite have been reported. Becker et al. (3) have published a case of accidental injection of a 5.25% solution of sodium hypochlorite beyond the root apex. Their patient experienced pain, edema, and hematoma formation, though after palliative treatment no permanent sequelae were evident. The second report involved injection of sodium hypochlorite into the mandibular branch of the trigeminal nerve, resulting in pain, edema, and trismus that resolved in 2 wk (4). The third was the uneventful exposure to an intravenous injection of sodium hypochlorite in a drug user attempting suicide (5). The fourth case involved intravenous infusion of sodium hypochlorite, which had been inadvertently added to the dialysate, during hemodialysis, leading to cardiorespiratory arrest but with eventual recovery (6). However, some investigations in vitro and in animals have demonstrated the toxic effects of sodium hypochlorite on vital tissues. These include hemolysis, skin ulceration (7), marked cell injury in endothelial cells and fibroblasts, and inhibition of neutrophil migration (8, 9). Our unfortunate case shows in vivo the adverse effects of sodium hypochlorite in soft tissues. The solution was probably not buffered, its pH being 12.9. This accounted for the severe damage which mandated surgical debridement. These data suggest that sodium hypochlorite can be extremely cytotoxic and should be used with caution in endodontic therapy. Respect of the tissue beyond the apex is essential to avoid complications, as is stressed in all manuals of endodontic procedures. Before irrigation the instruments have to be inserted to approximately 2 to 3 mm short of the radiographic apex and an X-ray film taken to
FiG 3. Ulceration and submucosal hemorrhages, with basophilic degeneration of collagen (H & E; original magnification x125).
confirm the measurement. This technique reduces the likelihood of inoculating the periapical tissues with the inflamed or infected contents of the canal and helps prevent injection of the irrigating solution beyond the root apex. Drs. Gatot, Arbelle, keiberman, and Yanai-lnbar are affiliated with the Head and Neck Surgery Section, Soroka University Hospital and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel. Address requests for reprints to Dr. Albert Gatot, Department of ENT, Soroka Medical Center, P.O. Box 151, Beer-Sheva, Israel.
References 1. Crane AB. A practible root canal technique. 1st ed. Philadelphia: Lea & Febiger, 1920:69. 2. Resnick L, Salahuddin SZ, Tondreau S, et al. Stability and inactivation of HTLV-II/LAV under clinical and laboratory environments. JAMA 1986;255:1887-91. 3. Becker GL, Cohen S, Borer R. The sequela of accidentally injecting sodium hypochiorite beyond the root apex. Oral Surg 1974;38:633-8. 4. Herrman JW, Heicht RC. Complications in therapeutic use of sodium hypochlorite. J Endodon 1979;5:160-3. 5. Froner GA, Rutherford GW, Rokeach M. Injection of sodium hypochlorite by intravenous drug users [Letter]. JAMA 1987;258:325. 6. Hoy RH. Accidental systemic exposure to sodium hypochlorite. Am J Hosp Pharm 1981 ;38:1512-4. 7. Pashley EL, Birdsong NL, Bowman K, Pashley DH. Cytotoxic effects of NaOCI on vital tissue. J Endodon 1985;11:525-8. 8. Lineaweaver W, McMorris S, Soucy D, Howard R. Cellular and bacterial toxicities of topical antimicrobials. Plast Reconstr Surg 1985;75:394-6. 9. Kozol RD, Gillies C, Elgebaly SA. Effects of sodium hypochlorite (Dakin's solution) on cells of the wound module. Arch Surg 1988;123:420-7.
