JOURNAL OF ENDODONTICS
Copyright © 2004 by The American Association of Endodontists
Accidental Sodium Hypochlorite-Induced Skin Injury
During Endodontic Treatment
Ahmet Serper, DDS, PhD, Murat Özbek, DDS, PhD, and Semra Çalt, DDS, PhD
A case of accidental skin injury caused by leakage
of sodium hypochlorite solution from the rubber
dam during root canal preparation is reported. Af-
ter placement of a rubber dam and initiation of root
canal treatment, the patient complained of a burn-
ing sensation with sodium hypochlorite irrigation.
The complaints were ignored by the practitioner,
and a skin rash developed on and around the pa-
tient’s chin, followed by scab formation. The patient
required medical treatment with topical Hamamelis
virginiana extract for 2 weeks, with full recovery.
Sodium hypochlorite (NaOCl) is a commonly used irrigating so-
lution for endodontic treatment because of its tissue dissolving,
antibacterial, and lubrication properties (1, 2). Despite these ad-
vantages, NaOCl has an unpleasant odor, causes damage to cloth-
ing, and is more toxic than other irrigation solutions. As the
concentration increases, the toxic effects of NaOCl on vital tissues
also increase (3). Therefore, great care must be exercised during
irrigation to reduce the potential for tissue damage.
There are many reports describing clinical complications that
may arise as the result of misuse of NaOCl (4 –13). The most
common complication is inadvertent injection of NaOCl into peri-
apical tissue (4 – 8). Injection into maxillary sinuses, seepage
through lateral root perforations, accidental injection instead of an
anaesthetic solution, and splashing into the eyes have been re-
ported (5, 6, 9 –13). Additionally, a few reports about hypersensi-
tivity and allergic reactions caused by NaOCl application are
present in the dental literature (14, 15).
This report presents a case in which leakage of NaOCl through
the rubber dam during endodontic treatment caused a severe cu-
taneous chemical burn on the patient’s chin.
CASE REPORT
A 54-year-old woman with noncontributory medical history
sought treatment at the Endodontic Clinic at the School of Den-
tistry, Hacettepe University, with the chief complaint of persistent
spontaneous pain in the area of maxillary left second premolar.
Radiographic examination revealed a large carious lesion at the
mesial interproximal surface of the tooth. A clinical diagnosis of
180
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VOL. 30, NO. 3, MARCH 2004
irreversible pulpitis was made, and pulpectomy was applied to
relieve pain. The next day, the patient was admitted to the Under-
graduate Clinic to complete the endodontic treatment. In this
session, a rubber dam was placed on the patient, and the root canal
was instrumented using step-back technique until an apical prep-
aration size #50 was achieved. During the preparation, a 2.5%
NaOCl irrigating solution was administered between file applica-
tions. In that session, the patient complained of a burning sensation
around the rubber dam after irrigations, but the practitioner ignored
the complaints, and the treatment was continued to conclusion. The
root canal system was obturated with gutta-percha and AH26 (De
Trey, Konstanz, Germany) by the lateral condensation technique.
The rubber dam was removed after filling with a temporary filling
material. The patient reported that she rinsed her face with tap
water 30 min after the conclusion of the session. The patient’s skin
was exposed to NaOCl solution for approximately 2 h, and the
patient noticed that she had developed a skin rash on and around
her chin, which was covered by the rubber dam. This condition
became more pronounced during the weekend. On the next busi-
ness day, she returned to the Endodontics Clinic, and the skin
appeared to have undergone a chemical burn with scab formation
(Fig. 1). The patient was transferred to the Dermatology Clinic for
proper medical treatment.
The patient used Hamamelis virginiana extract (Hametan 25 g
Pomad; Abdi Ibrahim Ilaç San ve Tic. A.S., Istanbul, Turkey)
topically twice a day for 2 weeks. According to the patient, the
burning sensation around the oral area had stopped in 3 days, the
scab fell off in 7 days, and the tenderness continued for 10 more
days. The skin discoloration caused by the burn had disappeared
after 3 months. The patient reported no previous skin sensitivity or
allergic responses.
DISCUSSION
Sodium hypochlorite is an effective irrigation solution; however, it
may cause serious complications after inadvertent use. The most
common complication is accidental injection into the periapical tissue.
Injection of NaOCl solution beyond the apical foramen may occur in
teeth with wide apical foramina or when the apical constriction has
been destroyed during root canal preparation. Application of extreme
pressure during irrigation or binding of the irrigation needle tip in the
root canal may result in delivery of the irrigant to the apical tissues. In
such cases, patients experience sharp and severe pain, rapidly increas-
ing swelling, and periapical tissue bleeding (4 – 8). In our case, leakage
Vol. 30, No. 3, March 2004
FIG 1. Facial appearance of the patient 3 days after accidental
NaOCl leakage from the rubber dam during endodontic treatment.
of NaOCl solution onto the patient’s chin during irrigation went
unnoticed underneath the rubber dam, resulting in a caustic effect on
the facial area.
Effective medical treatment with Hamamelis virginiana extract
resolved the NaOCl-induced skin burn after 2 weeks. This plant-
derived extract has demonstrated anti-inflammatory properties that
promote healing of cutaneous injuries, possibly by modulating
cytokine function and keratinocyte or endothelial cell proliferation
(16 –19). Importantly, H. virginiana extract has good scavenging
properties against free radicals, such as those produced by super-
oxide anion or NaOCl (19).
Although NaOCl is effectively used in endodontic treatment, it
is capable of causing tissue damage because of its cytotoxic effects
on vital tissues. Intradermal injections of undiluted and 1:1, 1:2,
and 1:4 dilutions of NaOCl produced skin ulcerations after intra-
dermal injections (20). Heling et al. (21) reported that NaOCl in
concentrations greater than 0.01% is lethal to fibroblasts. It is
recommended as an irrigation solution with antibacterial properties
between 0.5% and 5.25% (22). Tissue-dissolving effects of NaOCl
are complete between 1% and 5.25% (23). However, researchers
do not agree on the concentration of NaOCl that is clinically more
appropriate.
In this case, the patient’s skin was exposed to 2.5% NaOCl
solution for approximately 2 h, resulting in an extensive skin burn.
This type of skin burn caused by NaOCl administration during
dental practice was not previously reported in the literature.
The caustic effect of NaOCl is a result of alkalinity and hyper-
tonicity of the commercially available NaOCl solution (3).
Hostynek et al. (24) suggest that a nonirritant concentration for
diagnostic patch testing for allergic contact dermatitis could be as
high as 1% NaOCl. It is advised to adjust the pH of the NaOCl
solution to a less caustic level, using sterile 1% NaHCO3 as a
diluting material when commercial bleach is used for 1% irrigation
solution (2, 3). Care must be exercised during irrigation to avoid
wedging the needle in the canal and injecting NaOCl solution
beyond the apex, because considerable damage may occur if the
solution is introduced directly into the tissues (25).
Rubber dams are used in endodontic treatment mainly for pa-
tient protection from aspiration, isolation from saliva and tooth
debris, and provision of focus on the treatment location, and are
considered the most useful equipment for the isolation of the
operating field in endodontics (26). Placing the dam properly and
positioning the clamps and frames accurately to obtain leakage-
Skin Injury Caused by NaOCl 181
free configurations will help to prevent many types of complica-
tions. The most important factor that contributed to the complaint
in this case is the practitioner’s lack of familiarity with possible
problems associated with rubber dam usage; the complications in
this case could also have been prevented if the practitioner had
been responsive enough toward the patient’s complaints.
Dr. Serper and Dr. Çalt are members of the Department of Endodontics,
and Dr. Özbek is a member of the Department of Oral Diagnosis and Radi-
ology, Faculty of Dentistry, Hacettepe University, Ankara, Turkey. Address
requests for reprints to Dr. Serper, Hacettepe University, Faculty of Dentistry,
Department of Endodontics, Sıhhiye, (06100) Ankara, Turkey.
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