MANAGEMENT OF SODIUM HYPOCHLORITE EXTRUSION BEYOND THE ROOT APEX DURING ROOT CANAL TREATMENT: A CASE REPORT S KANDIAN1, S CHANDER2, K BISHOP3
ABSTRACT Sodium hypochlorite (NaOCl) is most commonly used as an irrigating solution in endodontic practice. This paper describes an incident of sodium hypochlorite extrusion past the apex (SHEPA) of the UR3. Management of the condition resulted in hospitalisation of the patient, and intravenous antibiotic and steroid therapy. This case report details the measures that can be employed to reduce the risk of SHEPA and management of its potentially serious complications. The reader should understand the various measures that can be adopted to reduce extrusion of endodontic irrigants beyond the root apex and management following SHEPA. Prim Dent J. 2013; 3(1) 72-75
Introduction Successful endodontic therapy requires shaping and cleaning of the root canal system.1 Despite advances in instrument technology, at least one-third of the root canal surface may remain uninstrumented,2 therefore irrigation has an important role in disinfection of the root canal system.3
1
Sreenesh Kandian
Senior House Officer in Restorative Dentistry, Morriston Hospital, Swansea 2
Satinder Chander
Specialist Registrar in Restorative Dentistry, Morriston Hospital, Swansea 3
Karl Bishop
Consultant in Restorative Dentistry and Oral Rehabilitation, Swansea
72
The most frequently used irrigants in contemporary endodontic treatment are sodium hypochlorite, hydrogen peroxide, chlorhexidine, citric acid, iodine-potassium-iodide, alcohol and ethylenediaminetetraacetic acid (EDTA) solutions.4,5 Use of sodium hypochlorite as a chemical adjunct to mechanical debridement of pulp canals is common practice in endodontics. It possesses strong antimicrobial and proteolytic activity.6 Unlike other irrigants, sodium hypochlorite has the unique ability to dissolve necrotic tissue7 as well as the organic components of the smear layer.8 It has a pH of approximately 11-1211,12 and causes tissue injury, primarily by oxidation of proteins. Sodium hypochlorite solution is therefore toxic to vital tissues.9,10 It can cause haemolysis, ulceration, inhibition of
neutrophil migration, damage to endothelial and fibroblast cells, nerve damage and necrosis after extrusion during endodontic treatment.3,11,12 The literature concerning sodium hypochlorite extrusion past the apex (SHEPA) comprises mostly of case reports and systematic reviews. In 2007, Mehdipour et al13 reported 23 cases of SHEPA in the dental literature. As SHEPA can result in mild to severe injury resulting in a range of signs and symptoms there may be selective reporting of the more severe cases, therefore there is a dearth of good and robust evidence concerning incidence and management of SHEPA. The purpose of this clinical report is to discuss the clinical signs and symptoms and the management of SHEPA during root canal treatment.
Case report A female patient, 62, attended the restorative dental department at Morriston Hospital, Swansea, Wales. She had been referred by her general dental practitioner following suspected SHEPA of an UR3. She initially presented with constant pain and swelling localised
Figure 1: Initial presentation
P R I M A R Y D E N TA L J O U R N A L
Figure 2
to her right infraorbital region. She gave a history of failing bridgework that necessitated its removal. Subsequent examination by the GDP revealed a chronic apical periodontitis associated with the UR3. The GDP proceeded to attempt root canal therapy. Upon irrigation with 2% sodium hypochlorite, the patient felt a sharp pain of sudden onset despite the region being anaesthetised. A facial swelling rapidly ensued at which point an urgent referral was made to the restorative dental department (Figure 1). Upon presentation, the patient’s pain was well controlled with non-steroidal anti-inflammatory drugs (NSAIDs). The patient reported blurred vision in the right eye and also felt discomfort in the form of pressure in the region. Her pupils were reactive to light and movement was limited in the right eye upon downward gaze. The patient also reported diplopia upon downward gaze. An intraoral examination revealed previous preparation for a post-retained crown restoration of the UR3 (Figure 2). The lack of coronal tooth tissue meant that this tooth represented a compromised bridge abutment (Figures 3 and 4). The patient had suffered from a myocardial infection three months previously and required the use of a glyceryl trinitrate (GTN) spray upon exertion. The patient was also taking warfarin for atrial fibrillation. The initial treatment centred on treating the patient’s acute symptoms of pain. The root canal system of the UR3 was irrigated with 0.9% saline in an 8ml syringe using a Luer-lock 27 gauge
VOL 3 NO 1 FEBRUARY 2014
Figure 3
Figure 4
endodontic needle. The working length was controlled by bending the needle prior to irrigation. Despite the use of paper-points, the exudate within the canal could not be controlled and so the canal was left to drain openly for 24 hours. No facial massage was carried out to encourage the drainage of sodium hypochlorite from the canal. As a precaution due to the patient’s facial swelling, a maxillofacial surgical opinion was sought following which she was admitted overnight. She was prescribed 500mg amoxicillin 8 hourly orally and 12mg dexamethasone 8 hourly intravenously. By the following day, the swelling had started to subside (Figure 5) and the patient was discharged. The patient was reviewed two weeks later and substantial healing had taken place (Figure 6). The treatment options were discussed with the patient and given the compromised nature of the tooth, extraction was recommended. It was suggested a temporary partial denture could be constructed to replace the space in the short to medium term.
Figure 2: Intraoral view Figure 3: Dental panoramic tomograph Figure 4: Compromised bridge abutment
Discussion Sodium hypochlorite has been used as an intracanal irrigant for root canal disinfection and debridement for 90 years.14 It is effective against a broad range of pathogens such as grampositive and gram-negative bacteria, fungi, spores and viruses (including the human immunodeficiency virus).15 It reacts with fatty acids, amino acids and intracanal pathogens, resulting in the dissolution of these tissues and microbes. Sodium hypochlorite also acts osmotically to draw fluid out of tissues16 and is able to disorganise the endodontic biofilm.17 Following SHEPA, patients report severe pain and may develop ecchymosis, haematoma and swelling. The clinical presentation in this case was with moderate pain, ecchymosis and swelling. Intravenous steroids were administered to reduce the tissue swelling. Although there are no clinical studies that have documented the efficacy of steroids in these situations, the profound anti-inflammatory properties of this group of drugs has been
73
MANAGEMENT OF SODIUM HYPOCHLORITE EXTRUSION BEYOND THE ROOT APEX DURING ROOT CANAL TREATMENT: A CASE REPORT
Figure 5
intracanal disinfectant because the concentration of the irrigant is still a matter of debate and remains controversial. Many authors recommend a 5.25% concentration of sodium hypochlorite18 whereas others prefer a lower concentration of 3% or 0.5%.19,20 Greater volumes of lowconcentration NaOCl (ie. 0.5-1%) are recommended rather than a highly concentrated solution (5.25%).21
Figure 6
Figure 5: After 24 hours Figure 6: After two weeks
previously reported in SHEPA.15 The rationale for their use is to reduce the spread of sodium hypochlorite by the fluid phase of the inflammatory phase.12,15 Antibiotics were used to minimise the risk of infection because of the presence of necrotic tissue. A review of the literature has not revealed any standard protocols for the management of SHEPA. As highlighted in this case and other reports, early and aggressive treatment with steroids and antibiotics12,16 is suggested.16 There is no universal consensus regarding the concentration of sodium hypochlorite for use as an
REFERENCES 4. 1.
2.
3.
74
Donald JK, Robert EA, Omid M. The sodium hypochlorite accident: experience of Diplomats of the American Board of Endodontics. J Endod. 2008;34:1346-50. Peters OA, Barbakow F, Peters CI. An analysis of endodontic treatment with three nickeltitanium rotary root canal preparation techniques. Int Endod J. 2004;37:849-59. Hülsmann M, Hahn W. Complications during root canal irrigation irrigation—literature review and case reports. Int
5.
6.
7.
8.
It is known that the bactericidal and tissue dissolution qualities can be enhanced by increasing the concentration and temperature of the solution.22 In a study examining the toxicity of sodium hypochlorite, Heggers et al23 (1991) found that at a concentration of 0.025% the solution was bactericidal and was not toxic; however, at a concentration of 0.25% the solution became severely toxic to tissues. Even at a low dilution of 1:1000, this agent causes complete haemolysis of red blood cells with potential haematoma formation.16 It is clear that a risk assessment before embarking upon root canal therapy is important. The following are the risk factors associated with SHEPA: • Teeth with wide apical foramina • Root resorption
Endod J. 2000;33:186-93. Zehnder M. Root canal irrigants. J Endod. 2006:32:389-98. Grossman LI. Endodontic Practice. 10th ed. Philadelphia, PA: Lea & Febiger; 1981. Young GR, Parashos P, Messer HH. The principles of techniques for cleaning root canals. Aust Dent J. 2007;52:S52-63. Naenni N, Thoma K, Zehnder M. Soft tissue dissolution capacity of currently used and potential endodontic irrigants. J Endod. 2004;30:785-7. Baumgartner JC, Mader CL. A scanning electron microscopic
evaluation of four root canal irrigation regimens. J Endod. 1987;13:147-57. 9. Zehnder M, Kosicki D, Luder H, Sener B, Waltimo T. Tissue dissolving capacity and antibacterial effect of buffered and unbuffered hypochlorite solutions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;94:756-62. 10. Gernhardt CR, Eppendorf K, Kozlowski A, Brandt M. Toxicity of concentrated sodium hypochlorite used as an endodontic irrigant. Int Endod J. 2004;37:272-80. 11. Pelka M, Petschelt A. Permanent
P R I M A R Y D E N TA L J O U R N A L
• Lateral perforation • Extreme pressure during irrigation and binding of the needle during irrigation • Cases with over instrumentation of apical foramina Although the risk of SHEPA is minimal, the dental clinician should exercise the following extra precautions by: • The syringe needle should not engage the canal so that it becomes ‘locked-in’ but should be loosely positioned within it • Sodium hypochlorite solution should always be administered with slow, gentle, controlled pressure to prevent extrusion through the apex. The authors suggest use of the index finger to control the application of force to the syringe • Side-venting syringes can be used to prevent such high pressures at the apex24 • A preoperative radiograph can reassure the clinician of the canal integrity and a working length prior to insertion of the irrigating needle and canal lavage • The use of an apex locator can assist in the prevention of over instrumentation and in the detection of canal perforation
mimic musculature and nerve damage caused by sodium hypochlorite: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106 e80-3. 12. Witton R, Henthorn K, Ethunandan M, Harmer S, Brennan PA. Neurological complications following extrusion of sodium hypochlorite solution during root canal treatment. Int Endod J. 2005;38:843-8. 13. Mehdipour O, Kleier DJ, Averbach RE. Anatomy of sodium hypochlorite accidents. Compend Contin Educ Dent. 2007:28:544-50. 14. Crane AB. A Practicable Root Canal Technique. 1st ed. Philadelphia,
Hülsmann et al22 (2009) have recommended a protocol for management of SHEPA. The protocol adopted by the authors centres around the principle of minimising swelling, controlling pain and preventing secondary infection. Reassuring the patient is of prime importance. Use of cold packs externally is recommended for the first one to two days to minimise oedema. Once drainage is established, the cold packs should be replaced by warm compresses in an attempt to promote liquefaction of the haematoma and dissolution of the soft-tissue swelling. Pain control often requires narcotic analgesics. Appropriate antibiotic therapy is highly recommended for two reasons: • The possibility of microbes being forced from the root canal system into the periapical tissues with the sodium hypochlorite irrigation • The subcutaneous presence of significant amounts of necrotic tissue and dead space, which can promote secondary infection The degree of the injury and its response to conservative therapy determines whether a case requires surgical intervention. Surgical procedures are mainly aimed at
PA: Lea & Febiger; 1920. p. 69. 15. Gatot A, Arbelle J, Leiberman A, Yanai-Inbar I. Effects of sodium hypochlorite on soft tissues after its inadvertent injection beyond the root apex. J Endod. 1991;17:573-4. 16. Clancy D, Mehra P, Wu J. Formation of a facial hematoma during endodontic therapy. J Am Dent Assoc. 2000,131:67. 17. Clegg MS, Vertucci FJ, Walker C, Belanger M, Britto LR. The effect of exposure to irrigant solutions on apical dentin bio films in vitro. J Endod. 2006;32:434-7. 18. Harrison JW. Irrigation of the root canal system. Dent Clin North Am.
VOL 3 NO 1 FEBRUARY 2014
providing decompression, facilitating drainage and creating an environment favourable to healing. This can be achieved by meticulous debridement of grossly necrotic tissue from the affected sites. It should be noted that infection and/or haematoma may spread in any direction and does not necessarily follow the usual anatomical planes. Sodium hypochlorite has the ability to actively destroy tissues and therefore often causes sufficient tissue lysis to create its own planes, resulting in widespread and haphazard progression of the tissue reaction (as seen in our patient). For this reason, to encourage the drainage from the root canal system the authors do not recommend immediate compression of the swelling. This article emphasises the importance of careful assessment of endodontic cases and risk assessment prior to commencing treatment. Prevention of such complications is always desirable. However, if such an adverse incident were to occur, one should consider referral to a specialist centre should there be any doubt as to the management of the patient.
1984:28:797-808. 19. Spangberg L, Engstrom B, Langeland K. Biologic effects of dental materials. III. Toxicity and antimicrobial effect of endodontic antiseptics in vitro. Oral Surg Oral Med Oral Pathol. 1973:36:856-71. 20. Baumgartner JC, Cuenin PR. Efficacy of several concentrations of sodium hypochlorite for root canal irrigation. J Endod. 1992:18:605-12. 21. Hauman CH, Love RM. Biocompatibility of dental materials used in contemporary endodontic therapy: a review. Part 1. Intracanal drugs and substances. Int Endod J. 2003:36:75-85.
22. Hülsmann M, Rödig T, Nordmeyer S. Complications during root canal irrigation: literature review and case reports. Endod Topics. 2009; 16:27-63. 23. Heggers JP, Sazy AJ, Stenberg BD, Stock LL, McCauley RL, Herndon DN, et al. Bactericidal and wound healing properties of sodium hypochlorite solutions: the 1991 Lindberg Award. J Burn Care Rehabil. 1991;12:420-4. 24. Spencer HR, Ike V, Brennan PA. Review: the use of sodium hypochlorite in endodontics potential complications and their management. Br Dent J. 2007;202:555-9.
75
ABSTRACT Sodium hypochlorite (NaOCl) is most commonly used as an irrigating solution in endodontic practice. This paper describes an incident of sodium hypochlorite extrusion past the apex (SHEPA) of the UR3. Management of the condition resulted in hospitalisation of the patient, and intravenous antibiotic and steroid therapy. This case report details the measures that can be employed to reduce the risk of SHEPA and management of its potentially serious complications. The reader should understand the various measures that can be adopted to reduce extrusion of endodontic irrigants beyond the root apex and management following SHEPA. Prim Dent J. 2013; 3(1) 72-75
Introduction Successful endodontic therapy requires shaping and cleaning of the root canal system.1 Despite advances in instrument technology, at least one-third of the root canal surface may remain uninstrumented,2 therefore irrigation has an important role in disinfection of the root canal system.3
1
Sreenesh Kandian
Senior House Officer in Restorative Dentistry, Morriston Hospital, Swansea 2
Satinder Chander
Specialist Registrar in Restorative Dentistry, Morriston Hospital, Swansea 3
Karl Bishop
Consultant in Restorative Dentistry and Oral Rehabilitation, Swansea
72
The most frequently used irrigants in contemporary endodontic treatment are sodium hypochlorite, hydrogen peroxide, chlorhexidine, citric acid, iodine-potassium-iodide, alcohol and ethylenediaminetetraacetic acid (EDTA) solutions.4,5 Use of sodium hypochlorite as a chemical adjunct to mechanical debridement of pulp canals is common practice in endodontics. It possesses strong antimicrobial and proteolytic activity.6 Unlike other irrigants, sodium hypochlorite has the unique ability to dissolve necrotic tissue7 as well as the organic components of the smear layer.8 It has a pH of approximately 11-1211,12 and causes tissue injury, primarily by oxidation of proteins. Sodium hypochlorite solution is therefore toxic to vital tissues.9,10 It can cause haemolysis, ulceration, inhibition of
neutrophil migration, damage to endothelial and fibroblast cells, nerve damage and necrosis after extrusion during endodontic treatment.3,11,12 The literature concerning sodium hypochlorite extrusion past the apex (SHEPA) comprises mostly of case reports and systematic reviews. In 2007, Mehdipour et al13 reported 23 cases of SHEPA in the dental literature. As SHEPA can result in mild to severe injury resulting in a range of signs and symptoms there may be selective reporting of the more severe cases, therefore there is a dearth of good and robust evidence concerning incidence and management of SHEPA. The purpose of this clinical report is to discuss the clinical signs and symptoms and the management of SHEPA during root canal treatment.
Case report A female patient, 62, attended the restorative dental department at Morriston Hospital, Swansea, Wales. She had been referred by her general dental practitioner following suspected SHEPA of an UR3. She initially presented with constant pain and swelling localised
Figure 1: Initial presentation
P R I M A R Y D E N TA L J O U R N A L
Figure 2
to her right infraorbital region. She gave a history of failing bridgework that necessitated its removal. Subsequent examination by the GDP revealed a chronic apical periodontitis associated with the UR3. The GDP proceeded to attempt root canal therapy. Upon irrigation with 2% sodium hypochlorite, the patient felt a sharp pain of sudden onset despite the region being anaesthetised. A facial swelling rapidly ensued at which point an urgent referral was made to the restorative dental department (Figure 1). Upon presentation, the patient’s pain was well controlled with non-steroidal anti-inflammatory drugs (NSAIDs). The patient reported blurred vision in the right eye and also felt discomfort in the form of pressure in the region. Her pupils were reactive to light and movement was limited in the right eye upon downward gaze. The patient also reported diplopia upon downward gaze. An intraoral examination revealed previous preparation for a post-retained crown restoration of the UR3 (Figure 2). The lack of coronal tooth tissue meant that this tooth represented a compromised bridge abutment (Figures 3 and 4). The patient had suffered from a myocardial infection three months previously and required the use of a glyceryl trinitrate (GTN) spray upon exertion. The patient was also taking warfarin for atrial fibrillation. The initial treatment centred on treating the patient’s acute symptoms of pain. The root canal system of the UR3 was irrigated with 0.9% saline in an 8ml syringe using a Luer-lock 27 gauge
VOL 3 NO 1 FEBRUARY 2014
Figure 3
Figure 4
endodontic needle. The working length was controlled by bending the needle prior to irrigation. Despite the use of paper-points, the exudate within the canal could not be controlled and so the canal was left to drain openly for 24 hours. No facial massage was carried out to encourage the drainage of sodium hypochlorite from the canal. As a precaution due to the patient’s facial swelling, a maxillofacial surgical opinion was sought following which she was admitted overnight. She was prescribed 500mg amoxicillin 8 hourly orally and 12mg dexamethasone 8 hourly intravenously. By the following day, the swelling had started to subside (Figure 5) and the patient was discharged. The patient was reviewed two weeks later and substantial healing had taken place (Figure 6). The treatment options were discussed with the patient and given the compromised nature of the tooth, extraction was recommended. It was suggested a temporary partial denture could be constructed to replace the space in the short to medium term.
Figure 2: Intraoral view Figure 3: Dental panoramic tomograph Figure 4: Compromised bridge abutment
Discussion Sodium hypochlorite has been used as an intracanal irrigant for root canal disinfection and debridement for 90 years.14 It is effective against a broad range of pathogens such as grampositive and gram-negative bacteria, fungi, spores and viruses (including the human immunodeficiency virus).15 It reacts with fatty acids, amino acids and intracanal pathogens, resulting in the dissolution of these tissues and microbes. Sodium hypochlorite also acts osmotically to draw fluid out of tissues16 and is able to disorganise the endodontic biofilm.17 Following SHEPA, patients report severe pain and may develop ecchymosis, haematoma and swelling. The clinical presentation in this case was with moderate pain, ecchymosis and swelling. Intravenous steroids were administered to reduce the tissue swelling. Although there are no clinical studies that have documented the efficacy of steroids in these situations, the profound anti-inflammatory properties of this group of drugs has been
73
MANAGEMENT OF SODIUM HYPOCHLORITE EXTRUSION BEYOND THE ROOT APEX DURING ROOT CANAL TREATMENT: A CASE REPORT
Figure 5
intracanal disinfectant because the concentration of the irrigant is still a matter of debate and remains controversial. Many authors recommend a 5.25% concentration of sodium hypochlorite18 whereas others prefer a lower concentration of 3% or 0.5%.19,20 Greater volumes of lowconcentration NaOCl (ie. 0.5-1%) are recommended rather than a highly concentrated solution (5.25%).21
Figure 6
Figure 5: After 24 hours Figure 6: After two weeks
previously reported in SHEPA.15 The rationale for their use is to reduce the spread of sodium hypochlorite by the fluid phase of the inflammatory phase.12,15 Antibiotics were used to minimise the risk of infection because of the presence of necrotic tissue. A review of the literature has not revealed any standard protocols for the management of SHEPA. As highlighted in this case and other reports, early and aggressive treatment with steroids and antibiotics12,16 is suggested.16 There is no universal consensus regarding the concentration of sodium hypochlorite for use as an
REFERENCES 4. 1.
2.
3.
74
Donald JK, Robert EA, Omid M. The sodium hypochlorite accident: experience of Diplomats of the American Board of Endodontics. J Endod. 2008;34:1346-50. Peters OA, Barbakow F, Peters CI. An analysis of endodontic treatment with three nickeltitanium rotary root canal preparation techniques. Int Endod J. 2004;37:849-59. Hülsmann M, Hahn W. Complications during root canal irrigation irrigation—literature review and case reports. Int
5.
6.
7.
8.
It is known that the bactericidal and tissue dissolution qualities can be enhanced by increasing the concentration and temperature of the solution.22 In a study examining the toxicity of sodium hypochlorite, Heggers et al23 (1991) found that at a concentration of 0.025% the solution was bactericidal and was not toxic; however, at a concentration of 0.25% the solution became severely toxic to tissues. Even at a low dilution of 1:1000, this agent causes complete haemolysis of red blood cells with potential haematoma formation.16 It is clear that a risk assessment before embarking upon root canal therapy is important. The following are the risk factors associated with SHEPA: • Teeth with wide apical foramina • Root resorption
Endod J. 2000;33:186-93. Zehnder M. Root canal irrigants. J Endod. 2006:32:389-98. Grossman LI. Endodontic Practice. 10th ed. Philadelphia, PA: Lea & Febiger; 1981. Young GR, Parashos P, Messer HH. The principles of techniques for cleaning root canals. Aust Dent J. 2007;52:S52-63. Naenni N, Thoma K, Zehnder M. Soft tissue dissolution capacity of currently used and potential endodontic irrigants. J Endod. 2004;30:785-7. Baumgartner JC, Mader CL. A scanning electron microscopic
evaluation of four root canal irrigation regimens. J Endod. 1987;13:147-57. 9. Zehnder M, Kosicki D, Luder H, Sener B, Waltimo T. Tissue dissolving capacity and antibacterial effect of buffered and unbuffered hypochlorite solutions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;94:756-62. 10. Gernhardt CR, Eppendorf K, Kozlowski A, Brandt M. Toxicity of concentrated sodium hypochlorite used as an endodontic irrigant. Int Endod J. 2004;37:272-80. 11. Pelka M, Petschelt A. Permanent
P R I M A R Y D E N TA L J O U R N A L
• Lateral perforation • Extreme pressure during irrigation and binding of the needle during irrigation • Cases with over instrumentation of apical foramina Although the risk of SHEPA is minimal, the dental clinician should exercise the following extra precautions by: • The syringe needle should not engage the canal so that it becomes ‘locked-in’ but should be loosely positioned within it • Sodium hypochlorite solution should always be administered with slow, gentle, controlled pressure to prevent extrusion through the apex. The authors suggest use of the index finger to control the application of force to the syringe • Side-venting syringes can be used to prevent such high pressures at the apex24 • A preoperative radiograph can reassure the clinician of the canal integrity and a working length prior to insertion of the irrigating needle and canal lavage • The use of an apex locator can assist in the prevention of over instrumentation and in the detection of canal perforation
mimic musculature and nerve damage caused by sodium hypochlorite: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106 e80-3. 12. Witton R, Henthorn K, Ethunandan M, Harmer S, Brennan PA. Neurological complications following extrusion of sodium hypochlorite solution during root canal treatment. Int Endod J. 2005;38:843-8. 13. Mehdipour O, Kleier DJ, Averbach RE. Anatomy of sodium hypochlorite accidents. Compend Contin Educ Dent. 2007:28:544-50. 14. Crane AB. A Practicable Root Canal Technique. 1st ed. Philadelphia,
Hülsmann et al22 (2009) have recommended a protocol for management of SHEPA. The protocol adopted by the authors centres around the principle of minimising swelling, controlling pain and preventing secondary infection. Reassuring the patient is of prime importance. Use of cold packs externally is recommended for the first one to two days to minimise oedema. Once drainage is established, the cold packs should be replaced by warm compresses in an attempt to promote liquefaction of the haematoma and dissolution of the soft-tissue swelling. Pain control often requires narcotic analgesics. Appropriate antibiotic therapy is highly recommended for two reasons: • The possibility of microbes being forced from the root canal system into the periapical tissues with the sodium hypochlorite irrigation • The subcutaneous presence of significant amounts of necrotic tissue and dead space, which can promote secondary infection The degree of the injury and its response to conservative therapy determines whether a case requires surgical intervention. Surgical procedures are mainly aimed at
PA: Lea & Febiger; 1920. p. 69. 15. Gatot A, Arbelle J, Leiberman A, Yanai-Inbar I. Effects of sodium hypochlorite on soft tissues after its inadvertent injection beyond the root apex. J Endod. 1991;17:573-4. 16. Clancy D, Mehra P, Wu J. Formation of a facial hematoma during endodontic therapy. J Am Dent Assoc. 2000,131:67. 17. Clegg MS, Vertucci FJ, Walker C, Belanger M, Britto LR. The effect of exposure to irrigant solutions on apical dentin bio films in vitro. J Endod. 2006;32:434-7. 18. Harrison JW. Irrigation of the root canal system. Dent Clin North Am.
VOL 3 NO 1 FEBRUARY 2014
providing decompression, facilitating drainage and creating an environment favourable to healing. This can be achieved by meticulous debridement of grossly necrotic tissue from the affected sites. It should be noted that infection and/or haematoma may spread in any direction and does not necessarily follow the usual anatomical planes. Sodium hypochlorite has the ability to actively destroy tissues and therefore often causes sufficient tissue lysis to create its own planes, resulting in widespread and haphazard progression of the tissue reaction (as seen in our patient). For this reason, to encourage the drainage from the root canal system the authors do not recommend immediate compression of the swelling. This article emphasises the importance of careful assessment of endodontic cases and risk assessment prior to commencing treatment. Prevention of such complications is always desirable. However, if such an adverse incident were to occur, one should consider referral to a specialist centre should there be any doubt as to the management of the patient.
1984:28:797-808. 19. Spangberg L, Engstrom B, Langeland K. Biologic effects of dental materials. III. Toxicity and antimicrobial effect of endodontic antiseptics in vitro. Oral Surg Oral Med Oral Pathol. 1973:36:856-71. 20. Baumgartner JC, Cuenin PR. Efficacy of several concentrations of sodium hypochlorite for root canal irrigation. J Endod. 1992:18:605-12. 21. Hauman CH, Love RM. Biocompatibility of dental materials used in contemporary endodontic therapy: a review. Part 1. Intracanal drugs and substances. Int Endod J. 2003:36:75-85.
22. Hülsmann M, Rödig T, Nordmeyer S. Complications during root canal irrigation: literature review and case reports. Endod Topics. 2009; 16:27-63. 23. Heggers JP, Sazy AJ, Stenberg BD, Stock LL, McCauley RL, Herndon DN, et al. Bactericidal and wound healing properties of sodium hypochlorite solutions: the 1991 Lindberg Award. J Burn Care Rehabil. 1991;12:420-4. 24. Spencer HR, Ike V, Brennan PA. Review: the use of sodium hypochlorite in endodontics potential complications and their management. Br Dent J. 2007;202:555-9.
75
