Hypochlorite accident - A case report

Transcription

1 Case Report Hypochlorite accident - A case report VEERESH S. TEGGINMANI * V. L. CHAWLA ** MAYUR M. KAHATE *** VAIBHAV S. JAIN *** ABSTRACT Sodium hypochlorite (NaOCI) is an effective intra canal irrigant and used in concentrations ranging from 0.5 to 5.25%. At these concentrations, it is highly hypertonic and strongly alkaline with ph 11 to 13. Sodium hypochlorite accident is a rare complication seen in endodontic therapy. It was first reported by Becker et al in Since then it has been infrequently reported in literature including cases of accidental misuse as a local anesthetic agent and accidental extrusion into maxillary sinus. Majority of NaOCl accidents has pulp necrosis, periradicular radiolucency as preoperative status. No specific treatment can reverse the damage due to NaOCl. Mainstay of treatment is supportive including airway protection, control of swelling, pain relief and prevention of secondary infection. Present article highlights a case of sodium hypochlorite accident and its successful management. Keywords: Root canal irrigants, Sodium hypochlorite (NaOCl), Airway obstruction. INTRODUCTION NaOCl was first recommended as an antiseptic solution by Henry Dakin in 1915 during 1 st world war. Dakin s solution i.e. 0.5% of NaOCl buffered with NaHCO 3 was used for dressing of wounds. 1 In 1920, Crane described its use for root canal debridement and sterilization. 2 Since then it has gained popularity as an effective intracanal irrigant. It is used in concentrations ranging from 0.5 to 5.25%. At these concentrations, it is highly hypertonic and strongly alkaline with ph 11 to 13. It has strong proteolytic and oxidative properties. It can dissolve both necrotic and vital pulp tissue and also removes organic portion of smear layer. Most importantly, it can kill broad range of pathogens like Gram +ve, Gram ve bacteria, fungi, viruses including HIV and E. fecalis. Most commonly seen minor drawbacks are unpleasant taste, damage to cloth, instability of solution and corrosion of metallic articles. But real havoc occurs when it comes in direct contact with healthy vital tissue. Except for heavily keratinized epithelium like skin, it provokes severe inflammation and cellular destruction in all tissues. 3 It has non specific ability to oxidize, hydrolyze and osmotically draw fluids out of * Professor and Head, ** Professor, *** Post-Graduate Student, Department of Conservative and Endodontics, A.C.P.M. Dental College and Hospital, Dhule, Maharashtra. 89

2 VEERESH S. TEGGINMANI, V. L. CHAWLA, MAYUR M. KAHATE, VAIBHAV S. JAIN tissue leading to severe damage. It directly damages endothelial cells of capillaries, arteries and veins causing profuse hemorrhage both within tissue and through root canal. Expression of NaOCl beyond confines of root canal and its subsequent consequences is known as hypochlorite accident. It was first reported in Since then it has been infrequently reported in literature including cases of accidental misuse as a local anesthetic agent as well as accidental extrusion into maxillary sinus. 5.6 Allergic reactions to NaOCl alongwith raised IgE titers have also been reported. Kaufman AY reported a case demonstrating a patient with hypersensitivity to NaOCl. 7 A skin patch test performed by an allergist confirmed the diagnosis of hypersensitivity to NaOCl. They recommended Solvidont, a quarternary ammonium compound with many properties similar or even better than NaOCl as the suitable alternative. CASE REPORT A 31 year old healthy woman reported to the Department of Conservative and Endodontics, A. C. P. M. Dental College and Hospital with chief complaint of pain in upper anterior tooth since last 6 months. She revealed history of childhood trauma and discoloration with the same tooth. She was treated for same complaint one and half year back. Intraoral examination revealed maxillary left central incisor, with dislodged crown and it was tender on percussion with grade I mobility. Radiographically, tooth showed inadequately obturated root canal with periapical radiolucency. Provisional diagnosis of chronic apical periodontitis secondary to improper pulp space therapy was established. Non surgical endodontic treatment was initiated, gutta percha was completely removed and working length was reestablished. Intermittent irrigation with unbuffered 3% NaOCl and normal saline was done. No discharge was present from the canal. Patient was discharged with Ca(OH) 2 dressing and scheduled for next appointment. Approximately 4 hours later patient reported back with severe pain and distress. She had tense, shiny and warm swelling extending from left lower eyelid to corner of mouth and from left ala of nose to angle of mandible. Immediately NaOCl accident was suspected. Canal was opened and copiously irrigated with saline. Cold compresses were placed to control swelling and pain. Patient was reassured and admitted to the college hospital for further treatment. Patient was treated with: Amoxicillin Clavulanic acid 625mg I.V. T.D.S, Metronidazole 400mg I.V. T.D Cetrizine 10MG B.D,ORALLY. Analgesics and I.V. Fluids. On 2 nd day, pain increased and swelling extended to involve left temporal region and left upper eyelid. Patient was unable to open 90

3 HYPOCHLORITE ACCIDENT - A CASE REPORT left eye and complained of minor discomfort during swallowing. An incision was placed in left upper buccal vestibule to facilitate discharge of inflammatory exudate. Minor bloody frothy discharge was seen. The same medications were continued for next 3 days. Swelling and pain reduced gradually and discharge through incision ceased. On 10 th day, patient had mild swelling on left part of upper lip and buccal region. Nasolabial fold was obliterated and tooth was asymptomatic. Patient was discharged with analgesics and advised warm saline gargles. Patient was regularly monitored at recall appointments. Swelling completely disappeared at 3 month recall. Patient regained her previous facial appearance and there was no evidence of nerve deficit. Meanwhile endodontic therapy for involved tooth was also instituted. DISCUSSION NaOCl is the most popular and universally used agent but its accidents are rarely encountered and reported in the literature. According to Kleir et al, survey of 719 American diplomats 26% have experienced this episode only once in their career of more than 10 years. 8 58% have never encountered such complication. TSK Lam et al, consider that in maxilla there is higher risk of NaOCl accidents in posterior rather than anterior teeth due to thin cortical bone over the buccal roots. 9 But in this case anterior teeth was affected possibly because of enlargement of apical foramen either due to undetected external root resorption or during previous instrumentation. Majority of NaOCl accidents have pulp necrosis, periradicular radiolucency, apical root resorption and bone resorption as preopertative status similar to this case. This bone resorption increases likelihood of communication with the fascial spaces. On contrary, interestingly these cases have very low incidence of associated sinus which can provide pathway into oral cavity negating likelihood of these accidents. According to Kleir et al, 43% of cases have periradicular radiolucency, 23% intact normal PDL and 3% had external root resorption. 8 Signs and symptoms mostly seen in NaOCl accidents are severe burning pain, progressively increasing moderate to severe widespread edema, profuse hemorrhage both through root canal and intersititially leading to bruising and echymosis. Serious complications including nerve damage, necrosis of mucosa and bone, and necrosis of facial subcutaneous tissue causing permanent facial asymmetry which required fat grafting also have been reported. Bowden et al., reported a similar life threatening case of airway obstruction due to hypochlorite accident. 5 No specific treatment can reverse the damages caused due to NaOCl. Mainstay of treatment is supportive including airway protection, control of swelling, pain relief and prevention of secondary infection. 91

4 VEERESH S. TEGGINMANI, V. L. CHAWLA, MAYUR M. KAHATE, VAIBHAV S. JAIN Patient should be reassured for the alarming swelling and pain. Cold compresses are placed initially for control of swelling. Pain control is achieved by NASIDs and opiod analgesics in severe pain. Aspirin should be avoided to prevent further bleeding. Prophylactic antibiotics therapy is essential as extensive necrotic tissue in dead space provides excellent medium for attack by bacteria carried along with the solution pushed through the canal. Use of coticosteriods is controversial as it suppresses the immune response but can be an excellent aid for edema control in initial stages. Flowback of solution as it is expressed into the canal should be observed. Use side delivery needles that are specifically designed for endodontic purpose. FIG. 1 - Preoperative Photograph. According to Kleir et al, most of the patients recovered completely within one week. 8 However healing is always associated with various degrees of fibrosis. Few patients have also reported permanent paresthesia and facial disfigurement. 10 The following steps can help clinicians avoid NaOCl accidents: Adequate access preparation. Good working length control. Irrigation needle placed 1 mm to 3 mm short of working length. FIG. 2 - Preoperative Radiograph. Needle placed passively and not locked in the canal. Irrigant expressed into the root canal slowly. Constant in and out movements of the irrigating needle into the canal space. FIG. 3 Photograph Immediately After Accident. 92

5 HYPOCHLORITE ACCIDENT - A CASE REPORT FIG. 4 Photograph On Second Day. FIG 6 Photograph At 3 Month Recall. FIG. 5 Photograph At Discharge. TABLE 1 - Summary of Symptoms And Treatment. DAYS 1st day 1st day After 4hours 2nd day 5th day 7th day 10th day SYMPTOMATOLOGY Continuing severe pain, Extended oedema over left side of face Swelling and pain increased.extended to involve left temporal region & left upper eyelid. Crossed the midline bridge of nose Decreased pain with Percussion, & swelling Mild swelling on left part of upper lip, tooth asymptomatic Regressing of all symptoms THERAPY Non surgical endodontic treatment Patient reassured, Canal opened, Irrigation with saline Antibiotics prophylaxis Hydrocortisone Analgesics, cold compresses Antibiotic & analgesic continued. Incision & drainage. Irrigation with sterile saline Antibiotics prophylaxis Analgesics, warm mouthrinses Irrigation with sterile saline,root canal dressing with Ca(OH) 2 Pt. discharged, Oral antibiotics and analgesics, Warm saline gargles advised CONCLUSION Considering the benefits of NaOCl irrigation for success of endodontic therapy and rarity of such complications, continued use of sodium hypochlorite is justified. But, clinician should always bear in mind the potential risks associated with it. So every possible precaution to prevent such complication must be taken. A good news of relief can be that such complication have shown to have negligible effect on success of the subsequent root canal treatment. 93

6 VEERESH S. TEGGINMANI, V. L. CHAWLA, MAYUR M. KAHATE, VAIBHAV S. JAIN References: 1. Dakin HD. The use of certain antiseptic substances in treatment of infected wounds. Br. Med J. 1915;2: Crane AB. A Practicable Root Canal Technique. 1st ed. Philadelphia, Pa: Lea & Febiger; 1920: Thé SD, Maltha JC, Plasschaert JM. Reactions of guinea pig subcutaneous connective tissue following exposure to sodium hypochlorite. Oral Surg Oral Med Oral Pathol. 1980;49: Becker GL, Cohen S, Borer R. The sequelae of accidentally injecting sodium hypochlorite beyond the root apex. Oral Surg, Oral Med Oral Pathol. 1974;38; Bowden JR, Ethunandan M, Brennan PA. Life threatening airway obstruction secondary to hypochlorite extrusion during root canal treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101(3): Kavanagh CP, Taylor J. Inadvertent injection of sodium hypochlorite into the maxillary sinus. Br Dent J 1998;185; Kaufman AY, Keila S. Hypersensitivity to sodium hypochlorite. J Endodon 1989;15(5): Donald JK, Robert EA, Omid M. The sodium hypochlorite accident: experience of diplomates of American board of endodontics. JOE 2008;34(11); TSK Lam, OF Wong, SYH Tang. A case report of sodium hypochlorite accident. Hong Kong Journal of Emergency Medicine. 2010;17Z(2): Reeh ES, Messer HH. Long term paresthesia following inadvertent forcing of sodium hypochlorite through perforation in maxillary incisor. Endodontics Dental Traumatology. 1989;5;