Sodium Hypochlorite Extrusion

Question 1

What are the common symptoms of extrusion

Answer 1

• Pain
	• Swelling
	• Ecchymosis
	• Haemorrhage
	• Neurological complications (paraesthesia or anaesthesia)  
Airway obstruction in severe cases

Question 2

What is the classic NaOCl accident

Answer 2

• Ecchymosis in a classic NaOCl accident manifests along the course of the superficial venous vasculature
It is rare

Question 3

What are the risk factors of extrusion

Answer 3

excessive pressure during irrigation 
needle locked within canal
control of working length 
larger apical diameters/constrictions 
anatomical factors/proximity to sinus
higher NaOCl concentration

Question 4

How can excessive pressure during irrigation lead to extrusion

Answer 4

○ If there is a patent apical foramen then the hypochlorite may be pushed beyond the apex under pressure
○ The pressure has to be significant to cause the hypochlorite to cross the vascular wall at the end of the blood supply, it is here where the hypochlorite is carried to the surrounding tissues via the vasculature
○ The pressure generated by positive-pressure irrigation delivery systems at the periapex have to exceed the venous pressure in the superficial veins of the neck
○ Flow rate is important - 1mL/15 seconds

Question 5

Why is it important to control the working length

Answer 5

○ Need to know how close we are to the apical anatomy
Need to establish EWL before starting and ensure needle is not passed into the root canal deeper than a few mm short of the working length

Question 6

Who is high risk for large apical diameters/constirction

Answer 6

○ Root resorption
○ Immature teeth
Developmental anomalies

Question 7

Why is proximity to sinus important

Answer 7

○ Must be careful as less pressure required to cause extrusion

Question 8

Why is NaOCl concentration important

Answer 8

Risk of apical trauma increases with concentration

Question 9

What is the management of NaOCl extrusion into the tissues

Answer 9

• All treatment must stop
  
  • Keep calm
  • Advise patient of what has happened and reassure them regarding immediate management
  • Where there is pain, consider giving LA via a block to effected region
  • If profuse bleeding through root canal, allow this to continue until haemostasis is observed
  • A steroid containing intra canal medicament (odontopaste) should be placed in the root canal, ensuring no pressure is used during application
  • Do not obturate the tooth at this visit but seal to coronal access cavity
  • Priority must be given to pain relief, reduction of the swelling and prevention of the secondary infection

Question 10

how do we give pat relief, reduce swelling and prevent risk of secondary infection

Answer 10

○ Cold compresses during the first few days
○ Warm compresses for resolution of the soft tissue swelling and elimination of the hematoma
○ Analgesics
○ Review within 24h
○ Prescribe antibiotics (case specific)
Refer if severe

Question 11

What are the guidelines for the use of NaOCl

Answer 11

1. Careful preop radiograph assessment is essential
   
   2. It is important that the pre endo restorative state of the tooth is assessed
   3. Ensure the px is provided with a disposable bib to protect clothing
   4. Provide px with protective eyewear
   5. Always use dental dam to isolate the tooth requiring rct and ensure it is sealed well with orasealTM
   6. Test the dental dam seal by irrigating with chlorhexidine first to ensure no leakage
   7. Dam placement must be checked by the supervising clinician
   8. Ensure that all syringes are clearly labelled with adhesive labels
   9. Always use a side vented needle for irrigation of the root canal
   10. Always use a Luer-Lok 27G needle and ensure this is securely attached to a 3ml syringe, test before use
   11. Fill syringe less - approximately 3/4 full to aid control
   12. Always use a silicone stop on the needle and set to 2mm short of working length
   13. Always pass the endo syringe behind the patient’s head and never over the patient’s face
   14. The irrigating needle should not bind in the root canal at any time
   15. Whilst irrigating, depress plunger with index finger rather than thumb to reduce the pressure
   16. Report any irrigation/endodontic incident to senior staff immediately
   17. If you have any concerns about the handling of NaOCl by the operator, then you should raise your concerns with the individual or a senior member of NHS/university staff if necessary

Question 12

What should we be careful of in the prep radiograph

Answer 12

○ Be careful of open apices and perforations

Question 13

How do we ensure the px has protected clothing

Answer 13

○ Must adequately cover clothes

○ If necessary use to overlapping bibs

Question 14

How do we ensure the dental dam isolated the tooth

Answer 14

○ Oral seal should be ‘moulded’ to the tooth contours with a damp cotton wool pledget
○ Placing the clamp prior to dam placement can facilitate visualisation
Ensure floss is used to secure clamp during placement and removed after dam is seated