SODIUM HYPOCHLORITE

Introduction
History
Mechanism of action
Antimicrobial effect
Tissue dissolving efficacy
NaOCl and bioflim
Factors affecting Antimicrobial and tissu
e dissolving efficacy
Haemostatic property
Buffered NaOCl
Effect of increasing temperature on NaOCl
NaOCl and dentin
Effect of NaOCl on resin-dentin interface
Effect of NaOCl on endodontic instruments
Combination of NaOCl with different irrigants
Commercially available NaOCl based irrigants
Sodium Hypochlorite accidents
Hulsman’s criteria
Clinical manifestation
Management
Prevention
Conclusion
References

1. SODIUM HYPOCHLORITE Dr Urvashi Sodvadiya

2. Content Introduction History Mechanism of action Antimicrobial effect Tissue dissolving efficacy NaOCl and bioflim Factors affecting Antimicrobial and tissu e dissolving efficacy Haemostatic property Buffered NaOCl Effect of increasing temperature on NaOCl NaOCl and dentin Effect of NaOCl on resin-dentin interface Effect of NaOCl on endodontic instruments

3. Content Combination of NaOCl with different irrigants Commercially available NaOCl based irrigants Sodium Hypochlorite accidents Hulsman’s criteria Clinical manifestation Management Prevention Conclusion References

4. Introduction

5. History Potassium hypochlorite: Bethollet (1748-1822 World war I: Henry Drysdale Dakin and Alexis Carrel Zehnder M. Root canal irrigants . J Endod 2006 32: 389-398. Heling I, Rotstein I, Dinur T et al. Bactericidal and cytotoxic effects of sodium hypochlorite and dichloroisocyanurate solutions in vitro. J Endod 2001 27: 278-280 Other Cl-releasing agents Chloramines-T and Dichloroisocyanurate ( NaDCC )1

6. Pecora et al.; 1999 Pecora JD, Sousa-Neto MD, Estrela C. Soluções irrigadoras auxiliares do preparo do canal radicular. In: Endodontia - Princípios biológicos e mecânicos. Estrela C, Figueiredo JAP. Eds. São Paulo: Artes Médicas; 1999. p 552-569.

7. Antimicrobial action High pH of NaOCl Irreversible bacterial enzymatic inhibition: by replacing hydrogen with chlorine. - Reaction of chlorine with amino groups (NH2 - ) - Irreversible oxidation of sulphydryl groups (SH) of bacterial enzymes ( cystein ). Detoxification of Endotoxin (Buck et al; 2001)

8. Factors affecting Anti-microbial efficacy Concentration Minimum concentration required: 1% No difference in the antibacterial activity of 1%, 2.5%, and 5% NaOCl ( Siqueira et al; 2000) In vivo study: Necrotic pulp, periapical lesion: 5.25% ( Ercan et al; 2004) 0.5%: effective after 5 th appotnment ( Bystrom and Sundqvist et al; 1983) pH Inversely proportional Greater the initial concentration of the sodium hypochlorite solutions, the smaller was the reduction of its pH

9. Factors affecting Anti-microbial efficacy Concentration 4% NaOCl : E faecalis (Siqueira et al; 1997) Concentration of NaOCl Time required to kill E faecalis (Gomes et al; 2001) 0.5% 30 min 1% 20 min 2.5% 1- min 4% 5 min 5.25% < 30 sec Type of microorganism Porphyromonas endodontalis , Porphyromonas gingivalis , and Prevotella intermedia in 15s. ( Vianna et al; 2004) Antifungal Less effective in presence of smear layer (Sen et al; 1999) Time required: 15s to 5min (Smith etal ;1996, Harrison et al; 1999) Superior to Biopure MTAD and 17% EDTA (Ruff et al; 2006) Combination: NaOCl (5% and 0.5%) and iodine (2%) potassium iodide (4%): can kill all yeast cells within 30s ( Waltimo et al; 1999)

10. Depth of penetration Vahdaty et al. 1993 2% CHX and 2% NaOCl on dentinal tubules infected with E. faecalis . Significantly reduced the bacterial counts in the first 100 µm of dentinal tubules, however up to 50% of dentine samples remained infected following use of both agents

11. NaOCl and Biofilm Dunavant et al; 2006 Radcliffe CE et al ; 2004 Oncag O et al; 2003 Dunavant TR, Regan JD, Glickman GN et al. Comparative evaluation of endodontic irrigants against Enterococcus faecalis biofilms. J Endod 2006 32: 527-531. Radcliffe CE, Potouridou L, Qureshi R, et al. Antimicrobial activity of varying concentrations of sodium hypochlorite on the endodontic microorganisms Actinomyces israelii , A. naeslundii , Candida albicans and Enterococcus faecalis. Int Endod J 2004;37:438 – 46. Oncag O, Hosgor M, Hilmioglu S, Zekioglu O, Eronat C, Burhanoglu D. Comparison of antibacterial and toxic effects of various root canal irrigants . Int Endod J 2003;36:423–32.

12. Tissue dissolution

13. Factors affecting tissue dissolution efficacy Concentration Concentration Time 5% (Grossman and Meiman ; 1941) 20 min to 2 hours Temperature Directly proportional How to increase the temperature clinically? pH Inversely proportional Greater the initial concentration of the sodium hypochlorite solutions, the smaller was the reduction of its pH Time Quantity (Baker et al) Spanó JCE, Barbin EL, Santos TC, Guimarães LF, Pécora JD. Solvent action of sodium hypochlorite on bovine pulp and physico -chemical properties of resulting liquid. Braz Dent J 2001;12:154-157.

14. Tissue dissolution: Vital v/s Non-vital Clinical conditions: 3% NaOCl - 5 min Gordon TM, Damato D, Christner P. Solvent effect of various dilutions of sodium hypochlorite on vital and necrotic tissue. Journal of endodontics. 1981 Jan 1;7(10):466-9.

15. Haemostatic property of NaOCl Since 1950s 3% NaOCl : biocompatible as a heamorrhage control agent, because pulps treated with this concentration demonstrated no evidence of pulpal necrosis after 7- and 27-days. (Hafez et al.; 2002) How much concentration is recommended?

16. Increasing The Temperature Of Sodium Hypochlorite Collagen-dissolving ability 2.6% sodium hypochlorite was comparable to that of 5.25% at both 21°C and 37C (Cunningham and Joseph,1980) Antimicrobial effect: 2.6% and 5.25% sodium hypochlorite in reducing a planktonic Culture of E coli to below culturable level at 2OC and 37°C: 37 C was more effective. (Cunningham et al,1980) Temperature of sodium hypochlorite to 50 C did not help in making the root canal cleaner!

17. Buffered NaOCl Dakin’s solution: 0.5% sodium hypochlorite buffered with sodium bicarbonate to a pH of 9

18. Effect of NaOCl on composition and structure of dentine Slutzky-Goldberg I, Maree M, Liberman R et al . Effect of sodium hypochlorite on dentin microhardness. J Endod 2004 30: 880-882. As a cavity disinfectant: affects only organic structure of dentin ( Mountouris et al.; 2004) Effects of NaOCl on dentinal structure ( Marending et al; 2007) Concentration-dependent reduction of elastic modulus and flexural strength in human root dentine Carbon and nitrogen content: Significantly reduces No effect on inorganic dentine components Altered intertubular dentine permeability

19. Buffering effect of Dentine on NaOCl Enterococcus faecalis A197A Organic and inorganic component of dentine: buffering effect Type I collagen and glycosaminoglycan: lost their immunoreactivity after NaOCl treatment when a demineralized dentine model was used. ( Oyarzun A et al; 2002) Dentine: inhibitory effect on the antibacterial effectiveness of 1% sodium hypochlorite ( Haapasalo et al; 2000) Oyarzun A, Cordero AM, Whittle M. Immunohistochemical evaluation of the effects of sodium hypochlorite on dentine collagen and glycosaminoglycans. J Endod 2002 28: 152-156. Haapasalo HK, Siren EK, Waltimo TM. Inactivation of local root canal medicaments by dentine: an in vitro study. Int Endod J 2000 33: 126-131.

20. Effects of NaOCl on Resin-Dentin bond strength Corrêa AC, Cecchin D, de Almeida JF, de Almeida Gomes BP, Zaia AA, Ferraz CC. Sodium thiosulfate for recovery of bond strength to dentin treated with sodium hypochlorite. Journal of Endodontics. 2016 Feb 1;42(2):284-8.

21. Effects of NaOCl on Endodontic instruments Pitting and cracks that alter the integrity of the instrument surface: decreasing resistance to fracture because of cyclic fatigue. Galvanic corrosion may occur. Berutti and Marini; 1996 Significant corrosive phenomena of NiTi instruments exposed to 1% NaOCl for up to 10 cleaning cycles. No significant reduction of torque at fracture or number of revolutions to flexural fatigue O’Hoy et al; 2003 Mechanical properties of Ni- Ti instruments: not affected by NaOCl , nor was the cutting efficiency. Haikel et al; 1998

22. NaOCl and EDTA Effect of Final flush using NaOCl after application of EDTA Removal of organic substance of dentin (Marshal GW, 2001) Duration: 1 min, 3 min and 5 min: no significant difference ( Niu et al; 2002) Which should be the last irrigant ?

23. NaOCl and CHX Why do we need to combine these two irrigants ? 2% CHX + 1% and 5.25% NaOCl : Orange brown precipitates ( Saquy PC; 1994) Para- chloroaniline (PCA): mutagenic and cytotoxic (Chhabra et al; 1991) Blockade of dentinal tubules: middle and apical third (Bui TB et al; 2008) ALX + NaOCl : more effective as a combination, does not form PCA (Kim et al; 2012)

24. Sodium Hypochlorite versus CHX Gomes et al; 2001

25. NaOCl and Citric acid Why do we need to combine these two irrigants ? 10% CA + 1% NaOCl : pH between 1.8 and 4.3, Cl decreases immediately (Zehnder et al; 2005) CA + NaOCl : more chlorine may be detectable and also present at further distance compared to adding EDTA (Baumgartner and Ibay ;1987)

26. NaOCl and Maleic acid Why do we need to combine these two irrigants ? 7% MA: more effective than 17% EDTA (Prabhu SG et al; 2003) Combination: significantly reduces available Chlorine

27. Interaction between NaOCl and MTA According to [68], White MTA and bismuth oxide in NaOCl may result in dark discoloration (Camilleri; 2014) 5% NaOCl significantly reduces the surface roughness of Portland cement. ( Ballester -Palacios et al.; 2013) NaOCl + MTA: improved the handling properties and decreased setting time. (Al- Anezi et al; 2011) SYNERGISM BETWEEN Calcium Hydroxide (Ca(OH)2 ) AND NaOCl

28. Chlor-Extra 5.85% NaOCl and a detergent Wetting ability: 2.5 times more than regular NaOCl (Wang Z et al; 2012) Actinomyces israelii ( Mohammadi et al.; 2002) Chlor-XTRA >> NaOCl , CHX, Tetraclean and Hypoclean More tissue dissolving ability than regular NAOCl ( Stojicic et al; 2010)

29. Hypoclean Introduced by Giardino 5.25% sodium hypochlorite and two different surfactant agents: cetrimide and polypropylene glycol. C. albicans, P. aeroginosa , and L. casei ( Mohammadi et al.; 2002) Hypoclean >> NaOCl , CHX, Tetraclean and Chlor-extra

30. Sodium hypochlorite accidents Damage to clothes Damage to the eyes Damage to the Skin Damage to the Oral mucosa

31. Hulsmann's criteria Complications during root canal irrigation--literature review and case reports. Hülsmann M, Hahn W Int Endod J. 2000 May; 33(3):186-93.

32. Clinical manifestation Guivarc'h M, Ordioni U, Ahmed HM, Cohen S, Catherine JH, Bukiet F. Sodium hypochlorite accident: a systematic review. Journal of endodontics. 2017 Jan 1;43(1):16-24.

33. Preoperative After 30 days of treatment

34. Proposed templet to record data after sodium hypochlorite extrusion

35. Management Early recognition Time Su-Hsin W, Ming-Pang C, Jen-Chan C, Chih -Ping C, Yi- Shing S. Sodium hypochlorite accidentally extruded beyond the apical foramen. J Med Sci. 2010;30:61–5 Healing phase

36. Prevention

37. Amount Pulp dissoving efficacy: 5% and 2.5%, but not of 0.5% NaOCl 5% and 2,5%: 3 ml – excessive amount (Koskinen et al.; 1980) Effectiveness of lower concentrations can be improved by using larger volumes of irrigant , replenishing the irrigant frequently and increasing the contact periods Most common answer: 5-10 ml, Duration: less than a minute

38. Concentration & Duration

39. Conclusion

40. References Marending M, Luder UH, Brunner TJ et al. Effect of sodium hypochlorite on human root dentine – mechanical, chemical and structural evaluation. Int Endod J 2007 40: 786-793. Slutzky-Goldberg I, Maree M, Liberman R et al. Effect of sodium hypochlorite on dentin microhardness. J Endod 2004 30: 880-882. Mountouris G, Silikas N, Eliades G. Effect of sodium hypochlorite treatment on the molecular composition and morphology of human coronal dentin. J Adhes Dent 2004 6: 175-182. Hafez AA, Cox CF, Tarim B et al. An in vivo evaluation of hemorrhage control using sodium hypochlorite and direct capping with a one- or two-component adhesive system in exposed nonhuman primate pulps. Quintessence Int 2002 33: 261-272. Marshall GW. Yucel N. Balooch M. Kinney JH. Habelitz 5. Marshall SJ. Sodium hypochlorite alterations of dentine and dentine collagen. Surface Science 200 I ; 49 I :444 -55.

41. References Mohammadi Z. Strategies to manage permanent non-vital teeth with open apices: A clinical update. Int Dent J 2011; 61(1): 25-30. Roberts HW, Toth JM, Berzins DW, Charlton DG. Mineral trioxide aggregate material use in endodontic treatment: A review of the literature. Dent Mater 2008; 24(2): 149-64. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999; 25(3): 197-205. Zapf AM, Chedella SC, Berzins DW. Effect of additives on mineral trioxide aggregate setting reaction product formation. J Endod 2015; 41(1): 88-91. Camilleri J. Color stability of white mineral trioxide aggregate in contact with hypochlorite solution. J Endod 2014; 40(3): 436-40 Ballester -Palacios ML, Berástegui-Jimeno EM, Parellada-Esquius N, Canalda-Sahli C. Interferometric microscopy study of the surface roughness of Portland cement under the action of different irrigants . Med Oral Patol Oral Cir Bucal 2013; 18(5): e817-21 AlAnezi AZ, Zhu Q, Wang YH, Safavi KE, Jiang J. Effect of selected accelerants on setting time and biocompatibility of mineral trioxide aggregate (MTA). Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011; 111(1): 122-7.

42. Thank you!