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Case Report/Clinical Techniques
Sodium Hypochlorite Chemical Burn in an Endodontist's Eye
during Canal Treatment Using Operating Microscope
Desiree C. Regalado Farreras, DDS,* Carlos Garcÿa Puente, DDS, PhD,†
and Carlos Estrela, DDS, MSc, PhD‡
Abstract
Introduction: This study describes a case of eye burn
induced by sodium hypochlorite used as an irrigant dur-ing
root canal preparation. Methods: A 24-year-old female
endodontist was using an operating microscope
during root canal treatment, and as the root canal was
irrigated, the pressure cannula burst and the irrigant
(3.5% sodium hypochlorite) came into direct contact
with her left eye. She immediately sought ophthalmo-logic
emergency care for pain, redness of the cornea,
burning sensation, photophobia, intraocular pressure,
and blurred vision. The initial treatment consisted of
washing the eye with saline solution and administering
analgesic and anti-inflammatory (steroid) medications.
One day after the accident, a topical demulcent and hy-
droxypropyl medication were applied to the eyeball
(conjunctiva), the eye was bandaged for 24 hours, and
rest was prescribed for 7 days. Eight days later, the corneal
ulcer was diagnosed, and antibiotic and anti-inflammatory
(steroid) medications were used. Results:
Vision was restored without any sequelae 4 weeks after
the accident. The endodontist was instructed to apply
control medication (Lagricel; Sophia SA, Caracas,
Venezuela) for 3 months and to return for ophthalmo-logic
follow-up every 6 months. Conclusions: Sodium
hypochlorite is an effective antibacterial irrigant indicated
for the treatment of root canal infections. The tis-sue
cytotoxicity highlights the need to inform the patient
of the risk factors of accidents and enhance care with in-
individual protection equipment for the patient and the
professional during clinical procedures. (J Endod
2014;-:1–5)
Key Words
Accident, chemical burn, eye burn, root canal irrigant,
sodium hypochlorite
From the *Intercontinental University, Mexico DF, Mexico;
†
Department of Endodontics, University of Maimonides, Bue-
‡ interrupted, the patient was told about the accident, and another endodontist was asked
nos Aires, Argentina; and Department of Stomatologic Sci-
ences Federal University of Goias, Goi^ania, Goias, Brazil.
Address requests for reprints to Professor Desiree C. Rega-
lado Farreras, Faculty of Dentistry, Intercontinental University,
Mexico, MX. E-mail address: desiree.farreras@gmail.com
0099-2399/$ - see front matter
Copyright 2014 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2014.01.026
JOE — Volume -, Number -, - 2014
Theorganisms
success ofinendodontic treatment
infected root is directly
canals(1–4). associated
Irrigants play anwith the control
important role inofshaping
micro-
and cleaning, the main purposes of treatment. An irrigant should have properties that
contribute to cleaning the root canal, lubricating the endodontic instruments,
flushing out debris, and killing germs without damaging periapical tissues (4–8).
Sodium hypochlorite (NaOCl) is a strong base, and its antimicrobial mechanism of
action is based on its high pH, which affects cytoplasmic membrane integrity. Its oxidation
promotes irreversible enzymatic inhibition of bacteria and replaces hydrogen with
chlorine. The action of NaOCl on enzymatic sites promotes irreversible inactivation
because of the presence of hydroxyl ions and chloramination. Tissues are dissolved
during saponification, when NaOCl destroys fatty acids and lipids, which leads to the
formation of soap and glycerol. Concentrations are directly proportional to its antimicrobial
effect and tissue dissolution capacity and inversely proportional to its biological
compatibility (7).
Sodium hypochlorite, 1 of the best known irrigants, is used by dentists all over the
world. During World War I, it was used to disinfect wounds, particularly because of its
antimicrobial effectiveness and tissue-dissolving properties. One of the problems of using
NaOCl is that it may cause tissue damage if used at inadequate concentrations(4–8).
Different concentrations (0.5%–5.25%) have been studied, recommended, and
tested (1–10). However, NaOCl has a cytotoxic effect when in contact with vital
tissues (5, 6, 8–12). Several reports have described accidents during treatment
using NaOCl outside the root canal, such as accidental injection beyond the root
apex, injection into the maxillary sinus, and allergic reactions. These accidents may
have numerous complications including severe pain; ballooning or immediate
edema in soft tissue; extension of edema to a large area of the face, such as the
cheeks; periorbital ecchymosis on skin or mucosa as a result of profuse interstitial
bleeding; profuse intraoral bleeding directly from root canal; mucous palatal
necrosis; tissue necrosis; neurological complications; paresthesia; allergy;
dermatological problems; and life-threatening airway obstruction (13–22).
A few reports have described accidents involving NaOCl and the eyes of patients
(16). This study describes a serious chemical burn in an endodontist's eye caused by
accidental contact with 3.5% NaOCl used as an irrigant during root canal preparation.
Case Report
The chemical eye burn described in this study affected a 24-year-old female
endodontist while she treated a root canal. While she was using the operating micro-
scope to magnify the view of the operative field, the root canal had to be irrigated,
but the pressure cannula burst and the solution (3.5% NaOCl; Nevex, Caracas,
Venezuela) came into direct contact with her left eye (July 2012). The treatment was
to complete the procedures for that appointment. Ophthalmologic emergency care was
sought immediately for pain, redness of the cornea, burning sensation, photophobia,
intraocular pressure, and blurred vision.
Immediate treatment consisted of washing the eye with saline for 30 minutes and
administration of the following medications: analgesics (Ibuprofen; Calor International
CA, Caracas, Venezuela), 400 mg every 8 hours; steroid anti-inflammatory medication, 5
mL loteprednol etabonate (0.5% Lotesoft; Poen, Caracas, Venezuela), 1 drop every 8
hours; 10 mg/mL prednisolone acetate ophthalmic suspension (Sophipren Ofteno; Sophia
Eye Burn with NaOCl 1
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Case Report/Clinical Techniques

Figure 1. (A) Severe ocular inflammation immediately after the eye accident (July 2012). (B) Ocular appearance after 1 day (ocular injection demulcent and hydrox-
ypropyl). Ocular appearance after (C) 4 days, (D) 5 days, (E) 6 days (note edema), (F) 7 days, and (G) 8 days.

SA, Caracas, Venezuela), 1 drop every 8 hours; and mydriatic eye decon- (Lagricel solution; Sophia SA, Caracas, Venezuela), 1 drop every 3 hours,
gestant with cyclopentolate hydrochloride (1% Cyclogyl; Alcon Venezuela, was prescribed.
SRL, Caracas, Venezuela), 1 drop every 12 hours. For secondary effects One day after the accident, topical demulcent and hydroxypropyl
(pupil dilation, photosensitivity, and momentary burning), eye humectant were applied (1 injection in the conjunctiva), the eye was bandaged and

two
Regalado Farreras et al. JOE — Volume -, Number -, - 2014
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Case Report/Clinical Techniques

Figure 2. (A) Ocular appearance after 9 days; note the ulcer on the cornea. (B and C) Three months after the accident; complete refund is shown. (D and E)
Eight-month follow-up (March 2013).

protected from light for 24 hours after application, and rest was solution (Vigamox; Alcon Venezuela, SRI), 1 drop every 8 hours; steroid
prescribed for 7 days. Treatment 8 days after the diagnosis of corneal ulcer anti-inflammatory medication, 5 mL loteprednol etabonate (0.5%
consisted of antibiotic, 0.5% moxifloxacin hydrochloride ophthalmic Lotesoft), 1 drop every 8 hours; and 10 mg/mL prednisolone acetate

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Case Report/Clinical Techniques
ophthalmic suspension (Sophipren Ofteno), 1 drop every 8 hours.
Doses were reduced to 1 drop every 12 hours for 1 week because ste-roids may create
immunosuppression, and 1 drop Lagricel every 1.5
hours was prescribed for eye lubrication for 1 month along with rest
for 10 days to prevent infection and additional irritation.
The endodontist's vision was restored without any sequelae 4
weeks after the accident. Final recommendations were control medication (Lagricel, 1
drop 3 times a day for 3 months) and ophthalmologic
control every 6 months. Figures 1A–G and 2A–E show the progression
of her ophthalmologic treatment. After 9 days, an ulcer was noticed on the
cornea.
Discussion
The main characteristics of irrigants explain their role in root canal preparation,
during which a concentrated (5.25%) NaOCl solution
with a high pH is often used. Several studies found that this irrigant re-duces root canal
micro biota (1–4) and dissolves tissue (23, 24).
However, there is an imminent risk of accidents, which may result in
serious sequelae for the patient or the endodontist, as described in
this clinical case.
To understand the etiology of NaOCl accidents, Kleier et al (25)
surveyed 719 diplomats of the American Board of Endodontics who
were listed in the 2006–2007 membership directory published by
the American Association of Endodontists. Of the 314 diplomats who
responded, 132 reported having experienced accidents with NaOCl,
which are very rare in endodontic practice. The results of this survey
showed that maxillary premolar and molar teeth in female patients
with a clinical history of a necrotic pulp and periapical radiolucency
were most prone to having such accidents. The vast majority of patients
recovered in a week to a month.
In our case, despite all the preventative care taken to control
infection, the endodontist took off her goggles to obtain a better field
of vision while using the operating microscope, and there was an accident with 3.5%
NaOCl. The clinical symptoms after the accident
were severe pain, redness of the cornea, burning sensation, photo-phobia, intraocular
pressure, and blurred vision. Apart from these
problems, there was the inconvenience of having to ask a colleague
to finish the treatment and obtain agreement for that from the patient.
Schrage et al (26) reported that physiopathological mechanisms
are not as stereotypical as often assumed in the clinical literature.
The clinical aspects and procedures should be carefully evaluated,
and the circumstances of ocular burns should be differentiated according to physical
parameters (temperature, amount, and impact force)
and chemical parameters, such as pH, concentration, dissociation co-efficient
(osmolarity), redox potential, and specific reactivity with the
ocular tissues (pK values). The pH of the burning agent has been re-garded as the
major factor in determining damage. However, other factors greatly influence the
physiopathological cascade of chemical tissue
damage. The early clinical presentation of chemical burns to the eye is
relatively nonspecific and involves corneal edema and clouding; epithelial loss; and
subsequent vascularization, tissue loss, or scarring. A classification in 4 stages of
ocular chemical burns has been suggested to
help to predict outcomes in most cases (26, 27).
Special care and prevention may reduce accident percentages.
However, the records of accidents treated in hospitals show that most
accidental ocular burns occur at work. Of these, 72% involved an occupational factor;
63% alkaline agents, and 22% different acids; heat
burns from liquid metals or fireworks accounted for about 15% (26,
28–30).
No general dentist, specialist, or patient is immune to operative accidents such
as ocular burns. However, permanent lifelong prevention
4 Regalado Farreras et al.
and focused attention help to avoid serious problems. Pelka and Pet-schelt (31)
described a case in which NaOCl was accidentally injected
beyond the apex and produced permanent facial and trigeminal nerve
weakness. When NaOCl is used, it should be done carefully and under
meticulous control of the working length. Another intracanal medication frequently used
in endodontics is calcium hydroxide pastes, which
are also strong bases. Some clinical cases have reported accidents
involving the eyes of patients when using this medication (32, 33).
Lipski et al (32) described a case in which the dentist accidentally
splashed calcium hydroxide into her own eye. As a result of the burn
caused by the base solution, the dentist lost his vision in the affected
eye and had to return to the doctor many times to undergo treatment
for a corneal abscess and fungal infection. She had to undergo 3 surgeries to remove
the keloid that formed between the eyeball and eyelid.
Dentists in general and endodontists in particular often adopt
several procedures to ensure infection control and avoid cross infection. They should
be aware that relevant recommendations have to be
followed to minimize the risks of contamination through contact with
biological material. NaOCl is an effective antibacterial irrigant indicated
for root canal infections. The cytotoxicity over the tissues highlights the
need to inform the patient of the risk factors of accidents and enhance
care with individual protection equipment for the patient and professional (exercising
sufficient safeguards) during clinical procedures.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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