390 Indian Journal of Public Health Research & Development, June 2020, Vol. 11, No.

Complications of Root Canal Irrigation - A Review

Leya Meriam Mathew1, Jayalakshmi Somasundaram2

1
Graduate Student, Senior Lecturer,, Department of Conservative and Endodontics, Saveetha Dental College,
Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India

Abstract
Root canal irrigation plays an important role in the debridement and disinfection of the root canal. Most
commonly used irrigants have good benefits of tissue dissolving and disinfection capability. However, it also
produces toxic effects on the vital tissues resulting in ulcer, necrosis etc. The aim of this review is to analyze
the factors causing or affecting the Root canal irrigation during a root canal treatment.

Keywords : Root canal , irrigants , infection, microbial , complications, toxicity .

Introduction kill bacteria or enable their death by allowing other

The main aim of a root canal treatment is to ensure
complete removal of connective tissue and destruction
of residual microorganisms found in the infected root
canals[1]. The complexity of root canal system, presence
of numerous dentinal tubules in the roots, invasion of
the tubules bymicroorganisms and preservation of
healthy dentin after achieving the primary objectives of
complete shaping and cleaning of root canal systems are
done with the help of a proper irrigation [2]. However
many mishaps can occur while cleaning and shaping
the root canals with irrigating solutions ranging from
damage to the patient’s clothing, splashing the irrigant
into the patients or operators eye, to allergic reactions.
The ideal properties of an irrigant [3] include, a potent
tissue debris solvent ,low toxicity, low surface tension,
lubricant, sterilizing agent, removal of smear layer, low
cost and inactive endotoxin
Endodontic Irrigants
Non-bactericidal irrigants
irrigants to come into contact with the bacteria.
Sodium Hypochlorite (NaOCl)
Sodium hypochlorite was first recognized as an
antibacterial agent in 1843 and used as a hand wash .
Its advantages are pulpal dissolution and antimicrobial
effect. Studies show that a decrease in microbial
numbers is achievable when using NaOCl for endodontic
treatment of teeth with apical periodontitis. It was used
as an endodontic irrigant ,with low viscosity ,effective
antimicrobial properties but low tissue dissolving
capabilities acceptable shelf life , easily available and
inexpensive [4]. The mechanism of action involvesbreak
down of protein by dissolution of amino acid content of
vital and necrotic tissue by the available free chlorine in
NaOCl
However, certain disadvantages of this irrigant are
the toxicity to the vital tissues which includes cytoxicty,
foul smell and foul taste, fabric bleach on accidental
spillage and corrosive on metals [5].

Some general dental practitioners either use saline, Hydrogen Peroxide

local anaesthetics and/or distilled water. These have
no antibacterial action and will not lessen bacterial
significantly. These irrigants may be used regularly
as they are easy to use, readily available and safety.
However, irrigants have no role in handling infected root
canals..
Bacteriostatic/bactericidal irrigants
These include a collection of solutions which also
Hydrogen peroxide (H2O2) is a colorless liquid and
has been used in dentistry in concentrations varying
from 1% to 30% [6]. H2O2 degrades to form water and
oxygen. It is active against microbes via the production
of hydroxyl free radicals which attack proteins and DNA
[7].
It has been shown that NaOCl, combined with H2O2,
is no more effective against E. faecalis than NaOCl
alone [8] , however, CHX combined with H2O2 was a
better antimicrobial agent than either one on their own.
 Indian Journal of Public Health Research & Development, June 2020, Vol. 11, No. 6
Chlorhexidine
Chlorhexidine digluconate is widely used in
disinfection because of its excellent antimicrobial
activity. It is highly antimicrobial especially at pH 5.5-
7.0 and is known for its longlasting effectiveness even
after the removal of the solution [9] .It is a positively
charged hydrophilic and lipophilic molecule which
relates with phospholipids and lipopolysaccharides in
cell membranes. Consequently, there is disruption of
the cell membranes which allows CHX molecules to
enter the cell to cause intracellular toxic effects, such
as coagulation of the cytoplasm. Other advantages
include available in acceptable flavor and not injurious
to the surrounding tissues. Chlorhexidine has a
persistent residual antimicrobial action.. Commonly,
Chlorhexidine is used in conjunction with NaOCl as
an irrigant as it raises the effectiveness of the irrigation
protocol [10] .
However, in spite of the advantages chlorhexidine
cannot be considered as an ideal root canal irrigant
because of its inability to dissolve necrotic tissue
remnants [11] .But capable of dissolving the smear layer
[12] . Additionally studies have revealed the presence
of desquamategingivitis, discoloration of teeth and
tongue or dysgeusia associated with it .Laboratory
findings showed chlorohexidine to be highly cytotoxic
to human periodontal cells, fibroblast via inhibition of
protein synthesis [13] While it does not appear to cause
any long term damage to host tissues, it may still cause
an inflammatory response in these tissues if expressed
beyond the root canal [14] .
MTAD
MTAD is a mixture of 3% doxycycline, 4.25%
citric acid and detergent developed by Torabinejad
et.al. The irrigant has a combination of both chelating
and antibacterial properties [15] . The citric acid may
serve to remove the smear layer, allowing doxycycline
to enter the dentinal tubules and exert an antibacterial
effect [16] MTAD is considered to be more superior
to Cholorhexidine in antimicrobial activity and is
also7more biocompatible and enhances bond strength
[17] . MTAD was seen to be less toxic than eugenol, 3%
H2O2, CA (OH) 2 paste, 5.25% NaOCl, Peridex (a CHX
mouthwash with additives) and EDTA, however, was
more lethal than NaOCl in absorptions of 2.63%, 1.33%
and 0.66%. The procedure for clinical use of MTAD is
20 minutes with 1.3% NaOCl followed by 5 minutes of
391
MTAD . This irrigant is based on a tetracycline isomer;
there may be problems with staining, resistance and
sensitivity.
EDTA
Ethylenediaminetetraacetic acid (EDTA) is a
synthetic amino acid and the sodium salts of EDTA
(Na2EDTA) are used in dentistry. It is often used
as a chelating agent. EDTA is not bactericidal nor
bacteriostatic but inhibits the growth of, and eventually
kills, bacteria . EDTA at concentrations of 15–17%
removes calcium from dentine leaving a softened matrix
of dentine. It also emulsifies soft tissue and removes
the smear layer with no deleterious effect to pulpal or
periapical tissues. EDTA reacts with the calcium ions
in dentine and forms soluble calcium chelates. It is
reduces the intracranial microbial flora and also helps to
detach biofilms adhering to root canal walls [18] However
irrigation with 5%NaOCl or alternated with 17% EDTA,
significantly increased the tooth strain .It reduces the
chlorine in solution, rendering the sodium hypochlorite
irrigant ineffective on bacteria and necrotic tissue [16]
. A one minute application of 17% EDTA combined
with ultrasonic is efficient for smear layer and debris
removal in the apical region of the root canal [19]. EDTA
is available in a liquid form for irrigation and a gel form
for lubrication .
Other Irrigating Solutions
The other irrigating solutions are sterile water,
physiologic saline, iodine compounds, ureaperoxide,
etidronic acid, citricacid, maleic acid, tetraclean,
chlorine dioxide etc [20]
HEBP is also known as etidronic acid or etidronate
and has been proposed as an alternative potential
alternative to EDTA or citric acid because it shows no
reactivity with NaOCl [19] .It is nontoxic but h owever,
the demineralization kinetics was lower than those of
17% EDTA.
Maleic acid is a mild organic acid used as acid
conditioner in adhesive dentistry. Ballal et.al reported
that the final irrigation with 7%maleic acid for 1minute
was more efficient than 17% EDTA in the removal of
smear layer [20]
Iodine Compounds are bactericidal, fungicidal,
and virucidal. 2% iodine in 4% potassium iodide has
been used in endodontics. It shows less toxicity and a
 392 Indian Journal of Public Health Research & Development, June 2020, Vol. 11, No. 6
decreased tendency to stain dentine.. However it is not
the first choice as an irrigant. Despite its antimicrobial
activity, iodine is a very potent allergen thereby causing
a risk for allergy [21]
Curcuma longa (Turmeric): Curcumin, possesses
anti-inflammatory,anti-oxidant,anti-microbial andanti-
canceractivity. In an in vitro study conducted by
Prasanna Neelakantan, it has been shown that curcumin
has significant anti-bacterial activity against E.faecalis
and can be used as an alternative to sodium hypochlorite
for root canal irrigation [22, 23] .
Complications during Root Canal Irrigation
Root canal irrigation is an integral part of the
rootcanal treatment to ensure proper debridement and
disinfection of the root canal system. A review of these
complications have been described briefly below, which
necessitates the need to carry out effective techniques in
order to avoid complications .
Damage to Clothing
Sodium Hypochlorite, a common bleaching agent
can cause a concern of damage. Accidental spillage of
minute quantities can lead to rapid, irreparable bleaching
[24, 25] . When using an ultrasonic device for root canal
irrigation the aerosol may also cause damageto the
clothing. These mishapsshould be prevented by proper
shield of the patients’ clothing. When using hand
irrigation, oneshould reassure that the irrigation needle
and syringe are tightly attached .
Damage to the Eye
Mild burns with the alkali such as sodium
hypochlorite can result in significant injury causing
blurring of vision and patchy coloration of cornea [26]
.Irrigant in contact with patients or operators eyes can
result in immediate pain, intense burning and erythema.
Immediate ocular irrigation with large amounts of tap
water or sterile saline should be performed by the dentist.
Damage to Oral mucosa and Skin
Skin injury with an alkaline substance requires
an immediate irrigation with water as alkalis combine
with proteins or fats in tissue to form soluble protein
complexes or soaps which could further cause irritation
to the mucosa. Accidental swallowing of irrigant by
patient requires proper monitoring. It is possible that
skin injury can result from secondary contamination [27,
28].
Allergic reactions
Various allergic reactions to Chlorhexidine have
been described. It is known to elicit allergic contact
dermatitis, generally after repeated application. It can
also contact urticarial,photosensitivity, fixed drug
eruption and occupational asthma [29] .
The allergic potential of sodium hypochlorite was
first reported by Sulzberger when a 32 year old female
reported a rapid onset of pain, swelling and difficulty
in breathing [30] . A subsequent allergy skin scratch test
performed two weeks later confirmed a positive result to
sodium hypochlorite. Other symptoms include burning
sensation, shortness of breath [31] .
Complications arising from the irrigant extrusion
beyond root canal apex
Chemical Burns and necrosis
When sodium hypochlorite is extruded beyond the
root canal into the periradicular tissues, the effect is a
chemical burn leading to localized or extensive tissue
necrosis. This can further lead to tissue swelling both
intra orally and extra orally. The swelling could later
produce a sudden onset of pain, associated bleeding,
acute sinusitis, ecchymosis of the mucosa [32].
Neurological Complications
The major complications include parathesia and
anesthesia affecting the mental, inferior dental and
infraorbital branches of the trigeminal nerve.
Facial nerve damage was first described by Witton
et al. in 2005, where the buccal branch of the facial nerve
was affected in 2 cases. Both patients exhibited a loss of
the naso-labial groove and a down turning of the angle
of the mouth. Both patients were reviewed and their
motor function, was regained after several months [33].
Upper Airway Obstruction
Without adequate tooth isolation, sodium
hypochlorite can lead to the leakage of the solution into
the oral cavity and ingestion or inhalation by the patient.
This could result in throat irritation and the upper airway
could be compromised [34]. Ziegler presented a case of a
15-month-old girl who presented a complication of root
canal irrigation with acute laryngotracheal bronchitis,
stridor and profuse drooling from the mouth as a result
 Indian Journal of Public Health Research & Development, June 2020, Vol. 11, No. 6
of ingestion of a high concentration of household sodium
hypochlorite.
Air Emphysema
Studies show cases of emphysema which occurs
when the root canal is dried with compressed air after
injecting hydrogen peroxide into it. Symptoms and signs
include a rapid swelling and erythema in the region of
the treated tooth, emphysema of the face, the suborbital
region, and neck. The mainsymptom is a crepitus of the
swelling [35] .
Flare up
An endodontic flare-up is a complication of
endodontic treatment which is defined as an acute
exacerbation of asymptomatic pulp, after the initiation or
continuation of root canal treatment. Excessive pressure
during irrigation will cause large amounts of irrigant to
come in contact with the periapical tissues, thereby a
possible etiological factor for Flare up [36].
Conclusion
Thus, it is important to carry out an effective
technique in order to avoid complications. In the event
of an accidental extrusion of any solution, treatment
guidelines should be applied as may be relevant to each
case.
Ethical Clearance: Department of research ,
Saveetha Dental College
Source of Funding : Self
Conflict of Interest : Nil
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