Review Article

Sodium Hypochlorite Accident:

A Systematic Review
Maud Guivarch, DDS, MSc,* Ugo Ordioni, DDS,*
Hany Mohamed Aly Ahmed, BDS, HDD (Endo), PhD, Stephen Cohen, MA, DDS, FICD, FACD,k
Jean-Hugues Catherine, DDS, MSc,* and Fr
ed
eric Bukiet, DDS, MSc, PhD*#

Abstract
Introduction: Sodium hypochlorite (NaOCl) extrusion
beyond the apex, also known as a hypochlorite acci-
dent, is a well-known complication that seldom occurs
during root canal therapy. These accidents have been
the subject of several case reports published over the
years. Until now, no publication has addressed the
global synthesis of the general and clinical data related
to NaOCl extrusion. The main purpose of this article was
to conduct a systematic review of previously published
case reports to identify, synthesize, and present a critical
analysis of the available data. A second purpose was to
propose a standardized presentation of reporting data
concerning NaOCl extrusions to refine and develop
guidelines that should be used in further case report se-
ries. Methods: A review of clinical cases reporting
NaOCl accidents was conducted in June 2016 using
the Preferred Reporting Items for Systematic Reviews
and Meta-Analyses checklist; it combined an electronic
search of the PubMed database and an extensive
manual search. Results: Forty full-text articles corre-
sponding to 52 case reports published between 1974
and 2015 were selected. Four main categories of data
were highlighted: general and clinical information, clin-
ical signs and symptoms of NaOCl extrusions, manage-
ment of NaOCl extrusions, and healing and prognosis.
Overall, up to now, clinical cases were reported in a
very unsystematic manner, and some relevant informa-
tion was missing. Conclusions: A better understanding
of the potential causes, management, and prognosis of
NaOCl accidents requires a standardization of reported
data; this study proposes a template that can fulfill
this objective. (J Endod 2017;43:1624)
Key Words
Apical extrusion, endodontics, irrigant, review, sodium
hypochlorite
S odium hypochlorite
(NaOCl), because of
its antimicrobial proper-
Signicance
Knowledge on hypochlorite extrusions during end-
odontic treatment is primarily based on previously
ties and tissue-dissolving
published case reports. A new proposal is intro-
capabilities, has been
duced to provide better standardization of data re-
used as the irrigant of
porting, which can pave the way for more
choice for cleaning root
systematic identication of etiology and prevention
canals in endodontic ther-
or, if necessary, management and prognosis of
apy (1). When confined to
NaOCl accidents.
the root canal system,
these properties enable
thorough disinfection. Until now, no other solution has matched the efficacy of NaOCl.
However, cytotoxic activity is a well-known shortcoming of NaOCl that may cause acute
injuring effects if it reaches the periapical area. In contact with vital tissues, NaOCl
quickly oxidizes surrounding tissues leading to rapid hemolysis and ulceration, inhibi-
tion of neutrophil migration, and destruction of endothelial and fibroblast cells (2).
NaOCl extrusion during root canal therapy (RCT) is commonly referred to as the
hypochlorite accident; it causes acute immediate symptoms and potentially serious
sequelae (3). The frequency of such events remains unknown because it is not system-
atically reported to insurance companies and cannot be diagnosed retrospectively.
Considering the millions of RCTs performed all over the world, it is believed to be a
relatively rare occurrence. However, 1 study showed that almost half of endodontic
practitioners described the occurrence of at least 1 NaOCl accident in their career (4).
In a study reviewing the factors affecting NaOCl extrusion during RCT, the authors
concluded that the literature did not allow establishing reliable conclusions but rather
led to speculation regarding the risk factors (5). To the best of our knowledge, and up
to this date, no publication has provided a global synthesis of the general and clinical
data related to NaOCl extrusions.
The main aim of this study was to conduct a systematic review focused on previ-
ously published case reports to identify, synthesize, and present a critical analysis of
available data on hypochlorite accidents. A second purpose was to propose a standard
presentation of reported data concerning NaOCl extrusions that could be used in case
report series. Developing systematic documentation that can be adapted universally may
pave the way to a better understanding of the factors related to NaOCl extrusion and its
consequences as well as proper guidelines for optimizing subsequent management
strategies.

From the *UFR Odontologie de Marseille, Aix-Marseille Universit
e, Assistance Publique des H^opitaux de Marseille, France; UMR 7268-AD
ES Aix-Marseille Univer-
sit
e-EFS-CNRS, Facult
e de M
edecine de Marseille, France; Centre Massilien de la Face, Marseille, France; School of Dental Sciences, Universiti Sains Malaysia, Kubang
Kerian, Kelantan, Malaysia; kArthur A Dugoni School of Dentistry, University of the Pacific, San Francisco, California; UMR 7268-AD
ES Aix-Marseille Univer-
sit
e-EFS-CNRS, Facult
e de M
edecine de Marseille, France; and #Giboc, ISM UMR 7287 CNRS, Aix Marseille Universit
e, Marseille, France
Address requests for reprints to Dr Maud Guivarch, 19 rue Henri Ch^eneaux, 13008, Marseille, France. E-mail address: maud.guivarch@gmail.com
0099-2399/$ - see front matter
Copyright 2016 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2016.09.023

16 Guivarch et al. JOE Volume 43, Number 1, January 2017


Materials and Methods
In June 2016, a literature search was performed on clinical cases
reported on hypochlorite accidents according to the Preferred Report-
ing Items for Systematic Reviews and Meta-Analyses checklist (6)
(Fig. 1). An electronic search of the PubMed database (1950-present)
was conducted using 5 combinations of the following key words: [SO-
DIUM HYPOCHLORITE], [IRRIGANT], [EXTRUSION], [ACCIDENT],
[COMPLICATIONS], and [ENDODONTICS]. A manual search of the
Journal of Endodontics (1975-); International Endodontic Journal
(1980-); Oral Surgery, Oral Medicine, Oral Pathology, Oral Radi-
ology and Endodontics (1995-2011); Australian Endodontic Jour-
nal (1982-); British Dental Journal (1970-); and Journal of the
American Dental Association (1910-) was performed. Furthermore,
the references listed in the retrieved full-text articles were reviewed to
identify additional publications. After the removal of duplicate publica-
tions, title review, and abstract selection, 57 articles were screened to
fulfill the inclusion criteria as follows:
1. Indexed case reports from peer-reviewed journals written in English
and
2. A hypochlorite accident occurring during canal irrigation with the
full text available.
Finally, 40 full-text articles corresponding to 52 cases reports pub-
lished between 1974 and 2015 were selected and reviewed by the au-
thors. Two different reviewers (M.G. and U.O.) independently identified
and categorized the available information in the publications.
Results
General and Clinical Information
The patients sex and tooth scheduled for treatment were always
specified (Table 1). The occurrence of NaOCl extrusions was mainly re-
ported in females (44/52) and maxillary teeth (41/52). The predomi-
nance of these 2 categories in cases reports was consistent with
previously experienced NaOCl extrusions by endodontists (4). Despite
the lack of scientific evidence, it seems that the decrease of bone density
in women compared with men and the thinness of cortical bone
Identification
Records identified through PubMed
database searching (n=228)
Screening
Records after duplicates removed (n=231)
Records screened (n = 231)
Eligibility
Full-text articles assessed for eligibility (n=57)
Included
Studies included
(n=40)
Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart of the systematic review process (meta-analysis was not performed).
JOE Volume 43, Number 1, January 2017
Review Article
surrounding the buccal roots of maxillary teeth could be 2 contributing
factors enabling the spread of NaOCl into the surrounding soft tissues
(4, 5). Half of the retrieved data did not provide information on the
patients health status or the initial pulpal and periapical status. It is
worth noting that these parameters may constitute additional risk
factors and may impact the severity of the complications (4).
The toxicity of NaOCl is mainly caused by its chemical composition,
but other factors such as the concentration, volume, and pressure of
extrusion could exacerbate the consequences of these accidents
(47). The volume of NaOCl extruded was provided in only 5 reports.
However, the reliability of this information remains unclear. Unfortu-
nately, the NaOCl concentration was mentioned in only half of the cases
(30/52) even though this is essential information. From what we could
glean from the articles that did mention the concentration of NaOCl, it
ranged from 1%5.25%. No information on how the solution was ob-
tained (ie, pharmaceutical preparation or over-the-counter purchase)
was provided.
A few reports (10/52) provided information about the irrigation
method, needle design, and syringe capacity, which play a significant
role in the strength of the irrigant flow (48, 49). Information related
to rubber dam usage, which does not directly influence NaOCl
extrusions, was present in 20 of 52 cases. The hypothesis of potential
factors having favored the occurrence of irrigant extrusion was
present in only 29 of the 52 cases. Factors such as open apices,
either iatrogenic or anatomic (7, 15, 21, 23, 32, 33, 37, 39);
undiagnosed perforation (8, 10, 13, 15, 18, 2830, 35, 46); needle
wedging (17, 44); and close approximation with surrounding
structures such as an antral tooth (10, 12, 24, 41) may have
facilitated NaOCl extrusion.
Manifestations of NaOCl Extrusion
The description of the symptoms after NaOCl extrusion was shown
to be acute and of sudden onset (Fig. 2). Severe pain was almost system-
atic (45/52) even though the patients were anesthetized (36). Profuse
hemorrhaging through the root canal was reported in one third of the
cases (17/52). Swelling occurred in almost every case (49/52),
Additional records identified
through other sources (n=28)
Records excluded
(n=174)
Full-text articles excluded
according to exclusion
criteria (n=17)
Sodium Hypochlorite Accident 17
 18

Review Article
TABLE 1. A Summary of Reports for General Health, Clinical Information, and Irrigation Procedures
General and clinical information
Guivarch et al.

Information on NaOCl
Information on Pulp Periapical favoring factor concentration NaOCl Information on
Author(s), y Sex Age medical context Tooth status Lesion suspected Dam Practitioner (%) quantity equipment
Becker et al, 1974 (7) F 23 A 13 V No A Yes DS 5.25 0.5 mL A
Reeh and Messer, 1989 (8) F 44 A 11 NV Yes A Yes DS 1 12 mL
Sabala and Powell, 1989 (9) M 58 A 25 NV Yes Yes EC 5.25
Becking, 1991 (10) F 42 37 A No GP
Becking, 1991 (10) F 31 27 A
Becking, 1991 (10) M 29 35
Gatot et al, 1991 (11) F 32 11 NV
Ehrich et al, 1993 (12) M 22 A 16 NV No A Yes EC 5.25 A
Linn and Messer, 1993 (13) F 33 A 13 A GP
Tosti et al, 1996 (14) F 49 14
Tosti et al, 1996 (14) F 46 12 or 22
Hu lsmann et al, 2000 (15) M 55 23 A 3
Hu lsmann et al, 2000 (15) M 43 A 3 1 mL
Mehra et al, 2000 (16) F 55 A 63
Balto et Al-Nazhan, 2002 (17) F 17 A 11 NV Yes A Yes DS 1 1.5 mL
Gernhardt et al, 2004 (18) F 49 34 V No A Yes DS 5.25 A
Witton et al, 2005 (19) F 43 A 12 NV Yes Yes GP UKN
Witton et al, 2005 (19) F 44 15
Bowden et al, 2006 (20) F 45 37
Kececi et al, 2006 (21) F 35 22 NV Yes A No DS 2.5
Kececi et al, 2006 (21) F 41 A 21 NV No A No DS 2.5
Crincoli et al, 2008 (22) F 32 A 13 NV No
Pelka et Petschelt, 2008 (23) F 58 A 22 NV Yes A Yes GP 3
Zairi and Lambrianidis, 2008 (24) F 32 A 15 NV No A Yes GP 2.5 A
de Sermen ~ o et al, 2009 (25) F 69 A 13 Yes GP 5
Markose et al, 2009 (26) F 46 16 GP 5.5
Lam et al, 2010 (27) F 37 A 13 V No GP
Wang et al, 2010 (28) F 59 23 NV Yes A Yes GP 2.5 A
Wang et al, 2010 (28) F 69 47 V No Yes GP 2.5 A
Chaudhry et al, 2011 (29) F 59 34 A GP 5.25 1 mL
Chaudhry et al, 2011 (29) F 63 23 GP 2
Chaudhry et al, 2011 (29) F 26 21 GP 2
Chaudhry et al, 2011 (29) F 38 34 No GP
Lee et al, 2011 (30) F 25 A 21 NV Yes A
Tegginmani et al, 2011 (31) F 31 A 21 NV Yes DS 3
JOE Volume 43, Number 1, January 2017

Behrents et al, 2012 (32) F 32 A 25 No A GP 3

Bosh-Aranda et al, 2012 (33) F 43 A 26 A GP
Bosh-Aranda et al, 2012 (33) F 53 24 A
Paschoalino et al, 2012 (34) F 24 16 V No A EC 1
Bither and Bither, 2013 (35) M 65 A 15 V No A GP
Kandian et al, 2013 (36) F 62 A 13 NV Yes GP 2
Klein and Kleier, 2013 (37) M 2 A 51/61 V No A No 2.5 A
Zhu et al, 2013 (38) F 52 A 14 V No Yes EC 5.25 A
Aguiar et al, 2014 (39) F 28 24 V No A GP 2.5 A
Goswami et al, 2014 (40) F 14 A 36 A No GP
Goswami et al, 2014 (40) M 13 36 No GP
 Review Article
appearing within a few minutes up to a few hours after the accident.
Swelling was usually large and diffuse (similar to cellulitis), extending
intra- and extraorally well beyond the site of the affected tooth; it some-

A
times resulted in difficulties opening the ipsilateral eye (17, 25, 31).
When these extrusions involved the maxillary sinus, the immediate
effect indicated a different clinical picture (12, 24, 41). Rather than
acute pain, the first signs were irrigant flowing from the nostrils
along with the taste of NaOCl in the throat. A burning sensation in the

maxillary sinus rather than severe pain was usually present, with little
or no bleeding from the canal and no evidence of immediate
swelling. NaOCl extrusion within the sinus might also lead to epistaxis
and sinus congestion. These less severe symptoms might be because
NaOCl was not extruded in an enclosed space, which allowed its

2
3

1
3

evacuation, thus limiting the time of contact (12).

The subsequent symptoms in the hours and days after extrusion
were generally well-documented. Hemolysis was responsible for pro-
fuse interstitial bleeding, probably causing immediate or secondary
facial hematomas (30/52), although the latter were not systematic
GP

GP

GP
DS

DS
DS

(32). Mucosal and bone necrosis were reported as a result of the

chemical burn caused by NaOCl (15/52), sometimes accompanied by
, unavailable information; A, available information; DS, dental school; EC, endodontic clinic; F, female; GP, general practitioner; M, male; NaOCl, sodium hypochlorite; NV, nonvital; V, vital.

a purulent discharge (35). Three cases of apical secondary infection

Yes

involving purulent discharge were described (10, 11, 25).

Contact with NaOCl is highly toxic to vital tissues, including nerves

(2). Consequently, neurologic signs such as sensory and/or motor de-
fects after extrusion can be expected and were present in 17 of 52 pa-
tients. Residual anesthesia and/or paresthesia occurred when the

A
A

trigeminal nerve was affected (811, 13, 15, 19, 23, 25, 27, 29, 33,
44). Cases of facial nerve damage involving paralysis of the mimic
musculature were also described (19, 23). Trismus was reported
and frequently associated with NaOCl extrusion on maxillary teeth (5/
7 cases). Air emphysema-like symptoms after NaOCl extrusion also
Yes

Yes
Yes
No
No

occurred, with patients showing crepitus (25, 45). Cone-beam

computed tomographic imaging was used to explore radiographic man-
ifestations of NaOCl extrusion on 1 maxillary premolar tooth whose
NV

NV
NV

apex was close to the soft tissues (32). Air bubble appearance areas
V

were noted throughout the soft tissues, but the authors concluded
that it was not possible to determine if these radiolucent structures
64/65
26
41
24
11

14

were full of air or fluid. Ophthalmologic symptoms may be present

including eye pain, blurring of vision, diplopia, and right corneal patchy
coloration. These constellations of signs/symptoms were described
emanating from a maxillary central incisor (11) and canine (36).
Moreover, 2 patients presented with life-threatening airway obstruction
caused by massive swelling in the submental and sublingual spaces with

elevation of the floor of the mouth after extrusion through the mandib-
ular teeth (20, 42). Indicators of the severity of these extrusions
included difficulties in swallowing followed by respiratory distress.
37
42
56
56

66
4

60
F
F
F
F
F
F

50
Number of cases

40

30
Baser Can et al, 2015 (43)
Bramante et al, 2015 (44)
Chaugule et al, 2015 (45)
Al-Sebaei et al, 2015 (42)

20
Hatton et al, 2015 (46)

10
Laverty, 2014 (41)

Yes No/US

Figure 2. Clinical manifestations of NaOCl extrusions. US, unspecified.

JOE Volume 43, Number 1, January 2017 Sodium Hypochlorite Accident 19

 20

Review Article
TABLE 2. A Summary of Reports for Management and Follow-up
Management and follow-up
Guivarch et al.

Immediate local gesture Postextrusion medical and local treatment

Time for
Canal Tooth Cold Warm Mouth Surgical signs of
Author(s), y Anesthesia irrigation closed Other ATB PK AIS AH packs packs rinses treatment Hospitalization regression Sequelae
Becker et al, 1974 (7) UT U U U U 21 d
Reeh and Messer, 1989 (8) UP U U U 21 d UN
Sabala and Powell, 1989 (9) U U Surgical drain UC U U U 9d
Becking, 1991 (10) UP/M U U 60 d
Becking, 1991 (10) U U 14 d
Becking, 1991 (10) UP/M >30 d UF
Gatot et al, 1991 (11) U UP U U U 14 d UN + F
Ehrich et al, 1993 (12) U Sinus irrigation UP U 28 d
Linn and Messer, 1993 (13) U ICM UP U U <21 d
Tosti et al, 1996 (14) U U 7d
Tosti et al, 1996 (14) U U U 21 d
Hu lsmann et al, 2000 (15) U U U 7d
Hu lsmann et al, 2000 (15) U U 60 d UN
Mehra et al, 2000 (16) U UP U U U 42 d
Balto and Al-Nazhan, 2002 (17) U U UM U U U 4d
Gernhardt et al, 2004 (18) U U ICM UT U 14 d
Witton et al, 2005 (19) UP U U U 30 d
Witton et al, 2005 (19) UP U U U 90 d
Bowden et al, 2006 (20) UP/M U U U 30 d
Kececi et al, 2006 (21) U UP U 15 d
Kececi et al, 2006 (21) U U ICM UP U U 10 d
Crincoli et al, 2008 (22) U U U U U 15 d
Pelka and Petschelt, 2008 (23) U U U U U 30 d UN
Zairi and Lambrianidis, 2008 (24) U U UM U 4d
de Sermen ~ o et al, 2009 (25) U U 15 d
Markose et al, 2009 (26) U U 30 d UF
Lam et al, 2010 (27) UP U U U U 30 d UN + F
Wang et al, 2010 (28) U U UP U 14 d
Wang et al, 2010 (28) U U UP U 21 d
Chaudhry et al, 2011 (29) U U U U U NA UN + F
Chaudhry et al, 2011 (29) U U 90 d
Chaudhry et al, 2011 (29) U 90 d UN
Chaudhry et al, 2011 (29) U U U 90 d UN
Lee et al, 2011 (30) U Surgical drain UP U U U U 7d
Tegginmani et al, 2011 (31) U UP/M U U U U U 90 d
JOE Volume 43, Number 1, January 2017

Behrents et al, 2012 (32) U U UM U U U 6d

Bosh-Aranda et al, 2012 (33) U UP U U 14 d UN
Bosh-Aranda et al, 2012 (33) UP U U U U 14 d
Paschoali et al, 2012 (34) U UP U U U 14 d
Bither and Bither, 2013 (35) Surgical drain U U U U 14 d
Kandian et al, 2013 (36) U UP U U U U >14 d
Klein and Kleier, 2013 (37) U UP U U U 42 d
Zhu et al, 2013 (38) U UP U U U 21 d
Aguiar et al, 2014 (39) UP U U 21 d
Goswami et al, 2014 (40) UP U U U U U 21 d
Goswami et al, 2014 (40) U U U U U U 28 d
 Review Article
Emergency hospitalization in an intensive care unit was required in
these situations.

UN Management of NaOCl Extrusions

In the first reported case on NaOCl extrusions, it was stated
21 d
10 d
28 d
7d

7d
NA

that the treatment should be palliative and protective (7). This

article also described early management, which included mini-
mizing the exquisite pain and hemorrhage control as well as pa-
tients reassurance, and close follow-up in the hours and days
after the accident (Table 2).
U

In order to gain rapid pain relief, anesthetic infiltration had been

U, yes; AH, antihistamines; AIS, anti-inflammatory steroids; ATB, antibiotics; C, cyclin; F, tissue fibrosis; ICM, intracanal medication; M, macrolide; N, neurologic; NA, not applicable; P, penicillin; PK, painkillers; T, tetracycline.

attempted (9, 15, 23). However, local anesthesia usually will cause
additional pressure in the soft tissues with little benefit. In the
presence of diffuse swelling, infiltration anesthesia is contraindicated
to avoid spreading of any existing infection (17); a nerve block should
U

be used instead (47). Very little information was provided regarding the
use of vasoconstrictors and the location of the injection attempted for
pain relief. Theoretically, vasoconstrictors might limit the diffusion of
NaOCl, but this would likely increase the risk of promoting tissue necro-
sis, especially with highly concentrated solutions promoting local
ischemia (50).
U
U
U
U

One third of the cases (18/52) indicated immediate canal irriga-

tion after extrusion, mostly using a saline solution. The use of chlorhex-
idine (CHX) instead of saline was also reported (23). However, this
U
U
U
U

should be avoided to prevent the formation of a potential toxic precip-

itate, which can occur upon combination with NaOCl (51). In a NaOCl
U

extrusion related to deciduous incisors, the use of lidocaine with

U
U

U
U
U

1:100,000 epinephrine as a rinse solution was described to stop

bleeding from the canals, but the procedure was unsuccessful (37).
U

U
U

It has been postulated that continuous canal irrigation would reduce

the severity of acute tissue responses by diluting the NaOCl (3, 14,
UM
UC
UP

UP
UP
UP

35, 47); however, this speculation is questionable. Indeed, it is clear

that unless solution is forced into periapical tissues (as the NaOCl
had been), this procedure would fail. Moreover, introducing more
liquids into the canal may prevent the primary phase of NaOCl
drainage. Bleeding should not be prevented, and aspiration with a
high-volume aspirator would help to evacuate NaOCl. Because the
bleeding is usually profuse, paper point usage and microtips placed
over the access opening would clearly be ineffective.
Information indicating whether a tooth was closed or left open af-
U

ter the extrusion was missing in more than half of the cases (34/52).
However, some articles reported worsening of the clinical situation after
what seemed to be untimely tooth closing with root canal dressing (17,
U
U
U

21, 28, 32) or even filling with gutta-percha (9, 15, 16, 30). These
situations were mostly associated with an initial misdiagnosis of the
extrusion.
Reports showed that post-treatment instructions included
frequently applying extraoral cold packs on the day of the extrusion
to minimize edema (19/52). Some authors recommended that it could
be followed by the application of warm compresses (8/52) and warm
saline rinses (5/52). The latter intended to stimulate microcirculation
in order to prevent tissue necrosis and accelerate healing.
Baser Can et al, 2015 (43)
Bramante et al, 2015 (44)
Chaugule et al, 2015 (45)
Al-Sebaei et al, 2015 (42)

In a few cases, incision and drainage were performed on the day of

Hatton et al, 2015 (46)

the extrusion or soon afterward (9, 17, 32) and were sometimes
combined with a rubber drain insertion (9), a decompression of the
Laverty, 2014 (41)

hematoma (16, 20), or a surgical debridement of necrotic tissues

(11, 16, 29, 30, 35). Apical surgery was also performed in 3 cases
with no real justification (8, 9, 30). As an adjunct to conventional
treatment, low-intensity laser therapy over the necrotic area was per-
formed in 1 case. The authors observed favorable repair although no
scientific evidence exists to support this assumption (44).

JOE Volume 43, Number 1, January 2017 Sodium Hypochlorite Accident 21

Review Article
Figure 3. A Proposed Template for Recording Data after Sodium Hypochlorite Extrusion.
Prescriptions were mostly analgesics, antibiotics, and steroids.
Drugs containing paracetamol (ie, acetaminophen) appeared to be the
most commonly used analgesic and were sometimes combined with co-
deine. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) was
also reported (18, 32, 34, 36, 41, 43, 45). The association between
paracetamol and NSAIDs (acetaminophen + ibuprofen) has been
shown to be very effective in pain control (52). NSAIDs should be pre-
scribed in an analgesic dosage (ie, no more than 1200 mg a day for a
maximum of 5 days) in the presence of a hemorrhagic condition asso-
ciated with an increased risk of infection (40). Antibiotics were almost
systematic (45/52); however, the active ingredients were not always spec-
ified. Penicillin was the drug of choice when there was no history of al-
lergy, but it was sometimes combined with clavulanic acid (25/52) or
macrolide (4/52). Macrolides alone (17, 24, 32, 43), tetracycline (7,
18), and cephalosporin (9, 42) were prescribed anecdotally. The risk
of spreading infection or an impaired immune system should be the
criterion for prescribing antibiotics (3, 15). Steroids were prescribed
in many of the reports after the NaOCl injury (28/52). Antihistamines
were prescribed in some reports with the expectation that they would
limit the extension of edema (22, 31, 45). It was theorized that the
acute inflammatory response involves the release of chemical
mediators such as histamine, which increases vascular permeability
(53). Additionally, a nasal decongestant was prescribed when the maxil-
lary sinus was involved (12, 24, 41).
Most of the time, postextrusion management was ambulatory
using only oral medications. However, about one third of patients
(18/52) were hospitalized for monitoring and intravenous adminis-
tration of drugs.
Healing and Prognosis
The literature shows considerable variations in the healing process
and duration of this undesirable event; it generally took a few weeks for
patients to recover from the initial signs and lingering symptoms (pain,
edema, hematoma, and tissue necrosis). The shortest healing time was
for a case that had involved the sinus; the tooth and surrounding tissues
22 Guivarch et al.
were asymptomatic with normal contours and color only 4 days after the
NaOCl extrusion (24). However, the pain and swelling could last up to
30 days (10, 19, 23) and possibly longer; 1 report documented that it
took up to 4 months for the swelling to resolve (26). Mucosal healing
could take up to 60 days (15). In some cases, it resulted in fibrosis
and scar tissue (10, 11), possibly leading to a disfiguring scar (27,
29). The use of an alternative nonirritating solution (saline or CHX)
for future irrigation was sometimes recommended when completing
endodontic treatment (3, 23, 33, 39, 40). However, this step does not
seem clinically pertinent for several reasons: the reason for the
extrusion should always be determined to prevent a recurrence, CHX
lacks the tissue dissolving effect, and the concentration of CHX
recommended for endodontic use is cytotoxic (54) and may cause
similar effects to NaOCl if extruded (55). Extraction of the affected tooth
was performed in 7 cases for unspecified reasons (16, 26), a
nonretainable tooth (3537), persistent pain (33), and the patient
refusing to complete the endodontic treatment that had been started
(41). Of the 17 cases describing initial nerve damage, 8 patients
presented with altered sensitivity and/or motor impairment at or
after the 1-year follow-up (8, 11, 15, 23, 27, 29, 33). One patient
was diagnosed with residual neuropathic pain (29). In some reports,
the follow-up period was too short to assess the degree of recovery
(11, 27, 46).
Discussion
This systematic review aimed to identify and classify the data pre-
sented in numerous case reports and to provide a critical assessment of
all the extant literature. By analyzing 52 case reports, 4 main categories
were highlighted: general and clinical information, clinical signs and
symptoms resulting from NaOCl extrusion, management of NaOCl extru-
sions, and healing and prognosis. Reports, up to this date, provide an
uneven overview of the symptoms, management strategies, possible
complications, and prognosis. Overall, the literature shows that clinical
cases were reported in an unsystematic manner, and some relevant in-
formation was missing.
JOE Volume 43, Number 1, January 2017

Sudden pain, profuse bleeding, and almost immediate swelling
constitute a triad of signs/symptoms pathognomonic of NaOCl extru-
sion. Ignorance of an accurate diagnosis and proper patient manage-
ment when a NaOCl accident occurs could lead to an unnecessary
delay and sometimes even panic. Indeed, some practitioners chose to
perform the endodontic treatment subsequent to the NaOCl extrusion
despite patient suffering (21, 28, 42) or even to complete the root
canal filling (9, 15, 16, 30, 41) when all signs and symptoms
converged to deduce it was an NaOCl accident. Some articles
reported no or improper and untimely immediate management and
monitoring after extrusion, leading to emergency consultations with
colleagues or physicians contacted by patients feeling in dire straits
(9, 13, 19, 29, 46).
The management of NaOCl extrusions appeared to be very
empirical. All or most of the signs and symptoms resolved within
a few weeks. Permanent sequelae could be divided into nerve le-
sions and scar tissues. Neurologic examination of the trigeminal
and facial nerves should systematically be performed once anes-
thesia has dissipated. Tooth loss has not been reported as a direct
result of NaOCl extrusion, but it may be involved. The latter is a real
trauma for the patient, and it can lead to subsequent refusal to
achieve the endodontic treatment.
Exploring the factors enabling NaOCl extrusions and/or influencing
the severity of complications would require more clinical data (pre-,
peri-, and postoperative) as well as general and medical information
on the patient. However, the latter was scarce. This conclusion is in
accordance with the work of Boutsioukis et al (48), which only consid-
ered factors suspected to enable irrigant extrusion. Incomplete informa-
tion could be explained by the fact that most cases were reported by a
secondary team whose essential role was postaccident management
rather than by the treating practitioner. Considering all these elements,
we propose that future case reports should require the following: infor-
mation about the patient and the affected tooth, the irrigation method, the
immediate extrusion signs/symptoms, the management and etiology of
the accident, and the postextrusion monitoring and prognosis. Standard-
ization of these data would avoid incomplete information because of
omission. Moreover, it would facilitate comparison among different
case reports and enable universal guidelines for avoiding or managing
NaOCl emergencies. The present study proposes a template that can fulfill
this objective and paves the way for better understanding of the factors,
management, and prognosis of hypochlorite accidents (Fig. 3).
Conclusions
The NaOCl accident is a serious complication that requires prompt
attention by dental practitioners. A new proposal is introduced to pro-
vide better standardization of data reporting, which can pave the way for
more systematic identification of etiology and prevention or, if neces-
sary, management and prognosis of NaOCl accidents.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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