pH changes in dental tissues after root canal filling with calcium hydroxide

Effect of calcium hydroxide on the dissolution of soft tissue on the root canal wall

Calcium hydroxide [Ca(OH)2] paste can aid in the cleaning of a root canal because of its soft tissue-dissolving potential. In this study, we examined with a scanning electron microscope the dissolution by Ca(OH)2 paste of pulpal tissue attached to uninstrumented bovine root canal walls. Extracted bovine anterior teeth were divided into small specimens at the middle portion of the roots. The experimental groups were treated with sodium hypochlorite (NaOCl), Ca(OH)2, or a combination of Ca(OH)2 + NaOCl. The control group was given no treatment. The root canal walls were observed with a scanning electron microscope, and the amount of remaining pulp tissue was compared. The amount of debris was reduced remarkably in the groups treated with NaOCl for > 30 s, or Ca(OH)2 for 7 days. The combination of Ca(OH)2 + NaOCl was more effective than the separate treatments. The results suggest that Ca(OH)2 as a root canal medicine serves as an effective agent in removing tissue debris remaining on the root canal walls.

Effect of calcium hydroxide dressing on seal of permanent root filling

Low apical leakage along root fillings following an application of calcium hydroxide was reported in a few methylene blue dye penetration studies. It has been found recently that methylene blue is decolored by calcium hydroxide, indicating that the short penetration of methylene blue may not be due to a tight seal only. Of the 80 roots of human maxillary central incisors used in this study, 40 roots (group 1) received calcium hydroxide root canal dressing whereas another 40 roots (group 2) did not. All the roots were then obturated with gutta-percha and Tubli-Seal sealer. Leakage along 20 filled roots in each group was measured using a modified fluid transport model at 48 h, 2, 4, 8 and 16 weeks after obturation; whereas leakage of another 20 filled roots in each group was measured using dye penetration with 1% methylene blue. Using the fluid transport model, no significant difference was found between the two groups at any time interval (P = 0.4847, 0.3875, 0.9490, 0.4786, 0.9148 respectively after 48 h, 2, 4, 8 and 16 weeks); using the methylene blue penetration method, leakage in group 1 (with root canal dressing) was significantly less than that in group 2 (without root canal dressing) (P = 0.0374). The contradiction in results from the different models indicated that problems existed with the models.

Periapical replacement resorption of permanent, vital, endodontically treated incisors after orthodontic movement: report of two cases

Radiographic observations show that periapical replacement resorption (PARR) is a frequent and unpredictable sequella of orthodontic movement of permanent maxillary incisors. Only the apical root portion undergoes resorption, and it is subsequently replaced with normal bone. PARR also occurs without orthodontic tooth movement, but these resorptions differ as to type and location. PARR clearly occurs in teeth with vital pulps after orthodontic movement; however, our two cases and a review of 43 other cases indicate that endodontically treated incisors show a statistically significant lesser frequency and severity of apical resorption than untreated teeth. The role the vital pulp plays in this apical resorption is yet to be determined. A hypothetical explanation is offered suggesting that pulpal neuropeptides may be involved in PARR in both vital and endodontically treated incisors. The role calcium hydroxide plays in endodontically treated teeth is also considered.

Delayed endodontic and orthodontic treatment of cross-bite occurring after luxation injury in permanent incisor teeth

A case is presented in which combined endodontic and orthodontic therapy was performed in traumatically injured teeth 12 months after an accident. Calcium hydroxide treatment was used to halt any possible resorption during orthodontic treatment. The teeth were repositioned in a desirable manner without any complication by orthodontic treatment. Root canal obturation was accomplished after the completion of active orthodontic treatment. Recall examination 12 months after completion of root canal treatment showed clinical and radiographic evidence of healing.

The disintegration of superEBA cement in solutions with adjusted pH and osmolarity

This study determined the disintegration of fast-set SuperEBA cement using ANSI/ADA Specification No. 30 (Spec #30) as well as modifications in pH, osmolarity, time before immersion, and duration of immersion that mimic the clinical, endodontic application of this material. After immersion intervals of 24 h, 1 wk, 1 m, 3 m, or 6 m, specimens were desiccated and weighed. The preimmersion and postdehydration weights were obtained to the nearest 1.0 mg and the percent weight loss from preimmersion levels was calculated. Adjusting the osmolarity to the physiologic level of 300 mOsm/kg resulted in significantly less weight loss (p < 0.05) than the control group in distilled water (no modification of Spec #30). The pH of the storage solution was found to be a significant factor in weight loss. As the acidity and the time of immersion increased, the weight loss also significantly increased with the greatest weight loss of 19.81% at pH 5.5 after 6 m storage. Immersion within 10 min of mixing was not significantly different (p > 0.05) in weight from the control of 1 h set-time. The 24 h weight loss measurements for the pHs of 5.5 and 6.4 were greater than the 1.5% allowed by Spec #30. All other 24 h measurements were less than the 1.5%.

A histological and quantitative histomorphometric study of apexification of nonvital permanent incisors of vervet monkeys after repeated root filling with a calcium hydroxide paste

The purpose of this study was to compare the effect of a monthly refilling of the root canals with calcium hydroxide paste with a single packing or replacement of the paste at 3 months on the apexification of nonvital maxillary incisors of vervet monkeys. Forty-eight maxillary incisors from 12 monkeys were used following radiographic determination that root development was incomplete. The pulps were extirpated under general anesthesia and the root canals filed and cleaned. The root canals were filled with a commercial calcium hydroxide paste, Calxyl, and a temporary cavity filling placed. Twelve teeth were left without further treatment. The calcium hydroxide paste was replaced in 12 teeth after a 3-month interval, and in the remaining 24 teeth the calcium hydroxide root filling was replaced five times at monthly intervals. The monkeys were killed after 6 months, and blocks of the teeth and surrounding tissues were embedded, decalcified and 6 microns serial sections prepared and stained. The sections were studied histologically to evaluate 11 parameters. Significant differences were found in the amount of calcium hydroxide at the apices, the presence of new cementum on the roots and the degree of inflammation, all of which were better in the monthly refill group. Histomorphometric measurements to evaluate the obturation of the open apices and the volume of new primary osteocementum showed no significant difference between the three groups. It was suggested that after the initial root filling with calcium hydroxide there was nothing to be gained by repeated root filling either monthly or after 3 months, for at least 6 months.

Avulsed permanent teeth: a review of the literature and treatment guidelines

Dental trauma represents one of the few situations where dentists are called upon to make unscheduled diagnostic and treatment decisions in an area that is outside their routine experience. Since patients who sustain an avulsion present infrequently, except in child-oriented or emergency-based practices, clinicians often make diagnostic and management decisions based upon their previous rare treatment experiences. Clinicians also rely on published guidelines for this aspect of their practice and expect these standards to be up-to-date and based on current research information. None of the current protocols has been tested by a prospective longitudinal outcome study in humans. Nevertheless, current guidelines have become the standard for clinical practice around the world. An effort must be made to develop treatment protocols that are based upon the biological mechanisms that underlie periodontal wound healing.

In vitro release of hydroxyl ions from six types of calcium hydroxide nonsetting pastes

The role of intracanal medication in root canal treatment is very important. Calcium hydroxide (Ca(OH)2) is considered to fulfill many of the properties of an ideal root canal dressing mainly due to its alkalizing pH. It is bacteriocidal and neutralizing to the remaining tissue debris in the root canal(s) and through the continuous release of OH- ions it promotes an alkalizing osteogenic environment for the surrounding tissues. The purpose of this study was to examine the pH values of various Ca(OH)2 based on compounds used as intracanal medicaments over a period of 5 days. The following materials were tested: Calasept, Calcicur, Calxyl blue, Calxyl red, Reogan rapid, and Tempcanal. After a fast OH- release period (2 h) each compound reached an asymptotic pH state. The results showed that all materials exhibited alkalizing pH with Reogan rapid, Calxyl Red, and Calcicur being the most potent (p = 0.05). The final pH of each compound correlated positively with the Ca(OH)2 mass fraction contained in it.

In vitro study of intradentinal calcium diffusion induced by two endodontic biomaterials

The aim of this in vitro study was to assess intratubular calcium penetration induced by two root canal restoration materials, one calcium oxide based, and the other calcium hydroxide based. Pig teeth were restored with no preliminary root canal preparation. The filing materials were left in place for 8, 15, or 21 days. The samples were then examined using various microanalytical techniques and, in parallel, by backscattered electron image (BEI) scanning electron microscopy. The Ca/P ratios obtained by microanalysis were higher for samples restored with calcium oxide. In addition, the distances over which the ratios increased were also greater than those obtained using calcium hydroxide. BEI photographs confirm these results and show corresponding retrodiffusion fringes.

Evaluation of the antibacterial activities of calcium hydroxide, chlorhexidine, and camphorated paramonochlorophenol as intracanal medicament. A clinical and laboratory study

The antibacterial activities of camphorated paramonochlorophenol, chlorhexidine, and calcium hydroxide were compared using a clinical and laboratory evaluation. In the clinical experiment, root canals that yielded positive cultures a week after complete chemomechanical preparation and camphorated paramonochlorophenol dressing were medicated with one of the three substances tested. Postmedication samples were taken from the canal 1 week later. In the laboratory experiment, the agar diffusion test was used to evaluate the inhibitory activity of the medicaments against bacteria commonly found in endodontic infections. The results of the clinical evaluation showed that all medicaments were effective in reducing or eliminating the endodontic microbiota, as demonstrated by the incidence of negative cultures. There was no statistically significant difference among the medicaments tested. In the laboratory evaluation, camphorated paramonochlorophenol showed the largest zones of bacterial inhibition against all bacterial strains tested.

Intracanal medicaments: evaluation of the antibacterial effects of chlorhexidine, metronidazole, and calcium hydroxide associated with three vehicles

The use of an intracanal medicament may be helpful in eliminating remaining bacteria that survived inside root canals after complete chemomechanical preparation. This study evaluated the antibacterial activities of medicaments that act by means of contact, and not by vapor release, against obligate and facultative anaerobic bacteria commonly found in endodontic infections. The medicaments used were 0.12% chlorhexidine gel; 10% metronidazole gel; calcium hydroxide plus distilled water, calcium hydroxide plus camphorated paramonochlorophenol (CPMC); and calcium hydroxide plus glycerin. An agar diffusion test was used, and the zones of bacterial inhibition around each medicament were recorded and compared. The results revealed that calcium hydroxide/CPMC paste was effective against all bacterial strains tested. Chlorhexidine was also inhibitory to all strains. It was about as effective as calcium hydroxide/CPMC paste against most of the strains. Metronidazole also caused inhibition of growth of all obligate anaerobes tested and was more effective than calcium hydroxide/CPMC against two strains. Calcium hydroxide mixed with distilled water or glycerin failed to show zones of bacterial inhibition, probably because of limitations of the agar diffusion test.

Diffusion of calcium through dentin

The purpose of this research was to investigate whether calcium ions from a paste of calcium hydroxide [Ca(OH)2] and saline introduced into root canals diffuse through the dentin to reach the surface of the root. Six teeth were opened and submitted to a biomechanical process, after which all the smear layer was removed. The experiment was divided into three phases: dissolution, dissolution and diffusion I, and dissolution and diffusion II. Dissolution-each tooth, with no Ca(OH)2 paste in place, was sealed both cervically and apically and stored in 700 ml of deonized water until calcium losses from the tooth into the water were stabilized. Dissolution and diffusion I-each root canal was filled with a paste of Ca(OH)2 and saline, sealed again apically and cervically, and returned to its solution. Dissolution and diffusion II-samples were divided into three parts: the control group or group 1, containing the original paste; group 2, in which the existing paste was diluted and the teeth were resealed and replaced in their solutions; and group 3, in which the existing paste was removed and a fresh paste was introduced. The diffusion was greater in group 3, followed by group 2. In the control group, we found a diffusion of calcium, which is statistically null. The results showed that calcium diffusion was observed, in the first 16 days, in all situations in which there was Ca(OH)2 paste inside the root canals.

Endodontic treatment of teeth with apical periodontitis using calcium hydroxide: a long-term study

The aim of this study was to evaluate clinically and radiographically the long-term results of endodontic therapy. A total of 172 mature teeth with periapical radiolucencies with and without symptoms were treated endodontically using calcium hydroxide paste as the intracanal medicament and a calcium hydroxide containing root canal sealer. In 58 teeth, the dressing was accidentally or intentionally extruded into the lesions. All cases were followed up for a period of 2-5 years. The teeth in which the dressing was extruded did not show a different healing pattern from the ones treated conventionally. The complete healing rate for all cases was 80.8% while incomplete healing had taken place in 7.6% of the cases.

pH changes at the surface of root dentin when using root canal sealers containing calcium hydroxide

The purpose of this study was to investigate long-term pH changes in cavities prepared in root surface dentin of extracted teeth after obturation of the root canal with gutta-percha and a variety of sealers containing calcium hydroxide. After cleaning and shaping, root canals in 50 recently extracted, human single-rooted teeth were divided into five groups. Each of four groups was obturated with gutta-percha and either Sealapex, Sealer 26, Apexit, or CRCS, all of which contain calcium hydroxide. The remaining group served as the control and was not obturated with gutta-percha or sealer. Cavities were prepared in the facial surface of the roots in the cervical and middle regions. The pH was measured in these dentinal cavities at the initiation of the experiment, and 3, 7, 14, 21, 28, 45, 60, 90, and 120 days after obturation. Results indicate that the pH at the surface of the root does not become alkaline when calcium hydroxide cements are used as root canal sealers. Regardless of the sealer used, the observed pattern of pH change was not different from that seen in the control group of roots that were not treated with sealer. It is concluded that calcium hydroxide-containing cements, although suitable for use as root canal sealants, do not produce an alkaline pH at the root surface. If such a pH change is related to treatment of root resorption, these sealants do not contribute to this treatment.

Changes in pH at the dentin surface in roots obturated with calcium hydroxide pastes

The purpose of this study was to determine the pH, after defined periods of time, in cavities prepared in the facial surface of the cervical, middle, and apical regions of roots obturated with calcium hydroxide pastes. Root canal instrumentation was performed on 40 recently extracted, single-rooted human teeth. Cavities 1.5 mm in diameter and 0.75 mm in depth were prepared in the cervical, middle, and apical regions of the facial surface of each root. Teeth were randomly divided into four groups. One group was left unobturated and served as a control. The three remaining groups were obturated with either aqueous calcium hydroxide, calcium hydroxide mixed with camphorated monochlorophenol. or Pulpdent pastes. Access cavities and apical foramina were closed with Cavit. Each tooth was stored individually in a vial containing unbuffered isotonic saline. pH at the surface was measured in the cervical, middle, and apical cavities at 0 and 3, 7, 14, 21, 28, 45, 60, 90, and 120 days. Results indicate that hydroxyl ions derived from calcium hydroxide pastes diffused through root dentin at all regions over the experimental period of 120 days. The pattern of pH change at the tooth surface was similar in all regions of the root, regardless of the type of calcium hydroxide paste used. This was a rapid rise in pH from a control value of pH 7.6, to greater than pH 9.5 by 3 days, followed by a small decline to pH 9.0 over the next 18 days, before finally rising and remaining at, or above pH 10.0 for the remainder of the experimental period. Pulpdent paste in the apical region was the only exception in this pattern, producing a pH rise nearly one full unit below the other pastes, pH 9.3. These results indicate that, for all pastes tested, a high pH is maintained at the root surface for at least 120 days.

Calcium ion diffusion from calcium hydroxide-containing materials in endodontically-treated teeth: an in vitro study

The aim of this in vitro study was to determine the amount and duration of diffusion of calcium ions from both a calcium hydroxide-containing root canal sealer and an intracanal medicament, through the apical foramen and the dentinal tubules of endodontically-treated teeth. The root canals of 88 freshly extracted single-rooted teeth were prepared using the modified double flared, balanced force technique with patency filing. The teeth were divided into four test groups of 20 teeth each and a control group of eight teeth. One group was dressed with a non-setting calcium hydroxide while the other was obturated using cold lateral condensation of gutta-percha with a calcium hydroxide-containing sealer. An artificial root defect was created in the apical third of the root of the teeth in the other two groups and the root canals were either dressed or obturated in the same way as the first two groups. All groups were incubated at 37 degrees C and were sampled for calcium diffusion after 1, 2 and 3 days and 1, 2, 3, 4 and 8 weeks. There was statistically significantly more calcium diffusion with the non-setting groups compared with the sealer groups (P < 0.05). There was more calcium ion diffusion from teeth with a patent apical foramen than those with an artificial resorptive root defect (P < 0.05).

Apical leakage following root canal dressing with calcium hydroxide

The purpose of this study was to analyse the apical leakage in teeth filled by the lateral condensation technique following medication with calcium hydroxide. One hundred and twenty extracted human teeth were biomechanically prepared by using exclusively reaming motion with files up to #40. Half of the teeth received a calcium hydroxide dressing for 3 days. The medication was removed by irrigation and reaming motion with files #40 up to #70. The teeth were divided in 6 experimental groups, according to the dimension of the utilized instrument. The root canals were filled and posteriorly the teeth were placed into a 2% methylene blue dye solution inside a flask, which was attached to a vacuum pump. Leakage was measured linearly, and the results showed significantly (p<0.01) less leakage in the experimental groups that received calcium hydroxide dressings than in the control groups. The results persisted even after the removal of 300 micrometers of dentin from the root canal dentinal walls.

In vitro study of the indirect action of calcium hydroxide on the anaerobic flora of the root canal

The aim of this study was to evaluate in vitro a possible mechanism involved in the antimicrobial action of calcium hydroxide, namely absorption of carbon dioxide from the root canal. Twenty obligate and 20 facultative anaerobic bacteria isolated from infected root canals and identified to species level were used. For each bacterial species a standard concentration was achieved and 0.1 ml of the inoculum was spread on blood agar plates, which were consecutively incubated in an anaerobic chamber for 5-7 days. One experimental and one control group were studied: the experimental group included one plate with the bacterial species as well as one open plate containing 32 g calcium hydroxide paste at a mixing ratio of 6:4. Both plates were incubated in an anaerobic chamber for 72 h. The control group included only one plate containing the same bacterial species and was incubated under the same conditions. After a 72-h incubation, the number of the recovered bacteria were counted in both groups. Statistical analysis showed that the number of bacteria recovered from the control group was significantly lower than that of the experimental group, but no particular resistance of any bacterial species to calcium hydroxide could be detected. This finding strongly suggests that the ability of calcium hydroxide to absorb carbon dioxide may contribute to its antibacterial activity.

Effect of four vehicles on the pH of calcium hydroxide and the release of calcium ion

Nonsetting calcium hydroxide pastes are commonly used in endodontic practice. The desired therapeutic effect of such a paste is in part dependent on the dissociation of calcium hydroxide into hydroxy ion and calcium ion. This in turn is influenced by the vehicle used to make the paste. This investigation attempts to quantitatively estimate the release of hydroxyl ion and calcium ion from pastes made by using distilled water, normal saline solution, camphorated monochlorophenol and also an experimental vehicle, propylene glycol. The results of this study indicate that propylene glycol induces the most favorable release characteristics of the two ionic species.

Effect of root canal filling materials containing calcium hydroxide on the alkalinity of root dentin

The effect of root canal filling pastes containing calcium oxide resp. calcium hydroxide on the alkalinity of extracted human teeth was investigated using a colour indicator (cresol red). An aqueous suspension of calcium hydroxide (Pulpdent), which is normally used for temporary root canal filling, most consistently produced alkalinity. Removal of the smear layer following instrumentation of the root canal led to increased proportion of alkaline-positive spots in dentinal locations distant from the canal. A clearly smaller effect was found with a calcium salicylate cement (Sealapex) and an oil-paste (Gangraena Merz), both of which are available for definite root canal fillings. Following removal of the smear layer, these hard-setting preparations caused moderate alkalinity in dentin adjacent to the canal but no effect was observed in locations more distant from the canal. Neither at locations adjacent to nor distant from the root canal was alkalinity found when another calcium salicylate cement (Apexit) was used. Apparently the release of hydroxyl ions into root dentin from calcium hydroxide containing root canal filling materials is not solely influenced by the absolute amount of calcium hydroxide, but also depends on other ingredients which variably inhibit the release of these ions.

pH effects on experimental wound healing of human fibroblasts in vitro

The aim of the present study was to examine to what extent pH affects human fibroblast repopulation of an experimental wound in vitro laying special emphasis on cell migration, DNA synthesis, and alterations in cell morphology. Wounds were simulated in vitro by partially scraping off monolayers of human embryonic diploid lung fibroblast and human periodontal ligament fibroblast-like cells respectively. The wounded monolayers were cultured at pHs ranging from 7.2 to 8.4. The experiments were evaluated by autoradiography as well as light and scanning electron microscopic techniques. A significant, approximately linear, decrease was noted both in cell migration into and DNA synthesis in the experimental wounds as a result of pH increase. The surviving cells in the wounds showed cytoplasmatic vacuoles and blebbing at pH levels above 7.8. Clinical implications of these results for endodontic calcium hydroxide treatment are that hydroxyl ions, diffusing through root dentin, may interfere with vital cell functions necessary for healing on the root surface.

A scanning electron microscopic study of external root resorption in replanted dog teeth

Root resorption after replantation of mature permanent dog incisors was examined by scanning electron microscopy. Three groups consisting of three extracted teeth each were kept in a saline solution for 5, 30, and 120 min before replantation. The first group was replanted with the pulp intact. The second and third groups were replanted after root canal filling by Calciobiotic Root Canal Sealer. After 90 days, the teeth were extracted and the apical root surfaces were examined. Severe inflammatory root resorption was observed in the first (intact pulp) group. For the root canal filled teeth, the degree of root resorption was observed to be much less in those kept in saline for 30 min than in those kept for 120 min.

Timing of calcium hydroxide therapy in the treatment of root resorption in replanted teeth in dogs

The effect of time of the onset of calcium hydroxide (CH) pulpectomy on root resorption of 31 permanent dog incisors was investigated. CH pulpectomy was delayed 4, 9, 14 and 18 days after the teeth were extracted and replanted. Control teeth were replanted 1) without pulpectomy, 2) with a pulpectomy only or 3) with a pulpectomy and CH filling. All teeth were prepared for histologic evaluation 8 weeks after the teeth were replanted. Cross section were examined using a computer microscope and linear (micron) and/or square areas (micron 2) of surface (SRR), inflammatory (IRR), and replacement (RRR) root resorption were calculated. From this data the percentage of linear and area resorption was averaged for each group. Duncan multiple range t-test (P < or = 0.05) revealed that teeth in which a pulpectomy with CH filling was done extraorally had significantly greater SRR than the rest of the groups; teeth in which a pulpectomy without CH filling was done extraorally had significantly greater RRR than teeth in which CH pulpectomy was delayed for 18 days; there was no significant difference in SRR, IRR or RRR when CH placement was delayed 4, 9, 14 or 18 days after replantation. Although it was not significant the overall resorption was least when CH pulpectomy was delayed 18 days.

Radiographic and microbiologic evaluation of posttreatment apical and periapical repair of root canals of dogs' teeth with experimentally induced chronic lesion

The objective of the present study was to evaluate radiographically and bacteriologically apical and periapical repair in dogs' teeth with induced chronic periapical lesions with the use of two different operative techniques (techniques 1 and 2). The study was conducted on 40 root canals of upper and lower premolars from two dogs aged approximately 12 months. Periapical lesions were induced by leaving the root canals exposed to the oral environment for 5 days and then sealing them with zinc oxide-eugenol for 45 days. After this period, radiographic examination revealed the occurrence of a radiolucent lesion and endodontic treatment was started. The two techniques did not differ in terms of chemomechanical preparation, final filling, or type of cement, but differed in terms of irrigating solution and the presence of an antibacterial dressing. Thus 4% to 6% hypochlorite and hydrogen peroxide (10 volumes) were used in technique 1 during chemomechanical preparation and an antibacterial dressing based on calcium hydroxide was applied between sessions, whereas Dakin's fluid (0.5% sodium hypochlorite solution) and a final filling with no antibacterial dressing were used in technique 2. After chemomechanical preparation, the root canals were filled with gutta-percha cones and Sealapex (Sealapex-Sybron, Kerr, Sao Paulo, Brazil), and the animals were killed 270 days after the final filling. Blocks were cut into 6-microns sections and stained by the Brown and Brenn method.(ABSTRACT TRUNCATED AT 250 WORDS)

Biological perspectives on the non-surgical endodontic management of periradicular pathosis

Differential radiographic criteria are unreliable for the histological diagnosis of periradicular lesions of pulpal origin. It should not, therefore, be assumed that large lesions or lesions with an opaque border are cystic. Even if cystic, or if strands of epithelium are present, the literature supports repair following the removal of the source of the pathosis. In most cases, the aetiological factors are oral contamination through the root canal or degenerating pulpal tissue. Therefore, the mere surgical removal of lesions of pulpal origin without removing the causes through proper root canal cleaning, shaping and obturation, will not result in the healing of the periradicular tissues. In addition to removing effectively the causative factors, environmental changes in the periradicular tissues caused by the process of canal debridement may inherently aid in the demise of epithelium, when present. The salient issues are discussed in light of thorough debridement of the root canal system, coupled with postulated mechanisms for the resolution of lesions displaying epithelial stands or cavities. Likewise, the role of calcium hydroxide and its potential role in the alteration of the periradicular environment is addressed, with support for the repair of large periradicular lesions without surgical intervention.

Treatment of intruded permanent incisors: a multidisciplinary approach

The case presented is a report of a healthy 11-year-old boy, who fell down and traumatized his four maxillary incisors. Both central incisors were deeply intruded with concomitant uncomplicated crown fractures, and both lateral incisors suffered concussion. The intruded teeth were repositioned using a removable orthodontic appliance and were endodontically treated 3 weeks after trauma. Tooth 11 became ankylosed 3 months post trauma, and tooth 21 was extruded to its original position after 5 months. Five months post-trauma, teeth 12 and 22 underwent necrosis and were endodontically treated. In addition, tooth 22 presented an external inflammatory root resorption that was arrested by calcium hydroxide paste after 3 months. A crown-lengthening procedure was performed on tooth 11 10 months post-trauma, exposing the clinical crown to a better condition for restoration. All 4 incisors were restored with a composite material, and the incisal edges of the central incisors were shaped at the same level. Two months after the crown lengthening procedure, spontaneous eruption occurred on tooth 11, that had been ankylosed. The restored incisal edge of tooth 11 was reduced to the same level of tooth 21. The patient is under periodical examination till a definitive orthodontic treatment can be performed.

Effect of root canal status on periodontal healing after surgical injury in dogs

This study was carried out to observe if the status of the root canal might influence the healing process of surgically prepared experimental periodontal lesions. Forty tooth roots from four dogs were divided into four different groups: a) root canals with vital pulps, b) root canals open to the oral environment, c) root canals infected and filled with zinc oxide eugenol cement, and d) root canals infected and filled with calcium hydroxide. By means of a surgical intervention, a cavity was prepared in the medium portion of the roots. Six months later, the specimens were removed and prepared for histological analysis. The results, which were submitted to statistical analysis, showed that the status of the root canals influenced the healing process of the experimental periodontal lesions. In the groups where the root canals were filled, calcium hydroxide gave the best results. In the group with root canals left open to the oral environment, resorption of the dentin of the experimental cavities, was the most obvious observation. However, it did not prevent the repair process, only slowed it down.

Influence of pH and calcium on growth and attachment of human fibroblasts in vitro

Human embryonic diploid lung fibroblasts (HEDL fibroblasts) and periodontal ligament fibroblasts (PDL fibroblasts) were cultured in media at fixed pH levels ranging between 7.2 and 8.4 and fixed calcium concentrations ranging between < or = 100 microM and 20 mM in an attempt to mimic the effects of calcium hydroxide on vital cell functions such as attachment and growth. PDL fibroblasts appeared to be more susceptible to changes in pH and calcium concentration than HEDL fibroblasts. At pH levels above 7.8, both attachment and growth decreased significantly. Growth was influenced more by changes in pH and calcium concentration than was attachment. The results help explain why intracanal application of calcium hydroxide through its high pH may impair periodontal healing in areas on the root surface where the cementum has been damaged by either trauma or periodontal treatment, thus allowing the medicament access to the root surface.

Effect of root canal treatments on dentin permeability

Calcium hydroxide has been used to slow or reverse external root resorption subsequent to trauma. In this study, an experimental model was established to study the diffusion of calcium ions from the canal to the root periphery after various intracanal treatments. Analyses of calcium ion concentrations from extraradicular samples revealed that dentin specimens varied in their rates of diffusion of calcium and that treatment of the canals with various agents affected the amounts of calcium recovered.

pH changes in root dentin over a 4-week period following root canal dressing with calcium hydroxide

Root canals in extracted human teeth were cleaned and shaped and subsequently dressed with a calcium hydroxide root canal dressing. pH Changes in the root dentin were measured over a 4-wk period with microelectrodes in small cavities at apical and cervical levels in inner and outer dentin. The pH increased within hours in the inner dentin, peaking at pH 10.8 cervically and 9.7 apically. However, 1 to 7 days elapsed before the pH began to rise in the outer root dentin, reaching peak levels of pH 9.3 cervically and 9.0 apically after 2 to 3 wk. The results show that hydroxyl ions derived from a calcium hydroxide dressing do diffuse through root dentin. They diffuse faster and reach higher levels cervically than apically. Surface pH measurements showed that hydroxyl ions do not diffuse in more than a minor way through the intact root surface.

Effect of smear layer removal on the diffusion of calcium hydroxide through radicular dentin

Forty single-rooted teeth were sectioned transversely through the cementoenamel junction and instrumented to a size #50 K-Flex file at the working length by saline irrigation. Each root was placed in a dilution vial containing 10 ml of normal saline, and the pH and Ca2+ levels were recorded after 24 h. The roots in group 1 then received a final irrigation with 20 ml of normal saline. Group 2 received a final irrigation with 10 ml of 17% ethylenediaminetetraacetic acid followed by 10 ml of 5.25% NaOCl to remove the smear layer. Group 3 was irrigated in the same manner as group 2, but calcium hydroxide (CH) was placed into the root canal. Group 4 was irrigated with 20 ml of NaOCl, and CH was placed into the root canal. The pH and Ca2+ levels were recorded at 1, 3, 5, and 7 days. After 7 days a 3- x 3- x 1-mm external defect was created in the coronal one third of the root surface. The pH and Ca2+ levels were subsequently recorded at 1, 3, and 7 days. Groups 3 and 4 demonstrated significantly higher H+ and Ca2+ levels than did groups 1 and 2 three days after CH placement and at all subsequent intervals. Group 3 demonstrated significantly higher H+ and Ca2+ readings at some but not all intervals. The results demonstrated that CH diffuses from the root canal to the exterior surface of the root and that the removal of the smear layer may facilitate this diffusion.

Treatment and prognosis of avulsed teeth. A discussion and case report

A documented case that involves avulsion of an incisor is reported. Calcium hydroxide failed to prevent progressive irreversible root resorption. The importance of extraoral time, transport media, duration and type of splinting, as well as the rationale for the use of calcium hydroxide in the treatment of avulsed teeth are discussed. This case could serve as a reminder to practitioners, that patient compliance, timing and sequencing of endodontic therapy, and regular recalls is critical in the prevention or treatment of root resorption in avulsed teeth. It also emphasizes the frustration of many clinicians in treating avulsed immature teeth. The reporting of long-term documented cases should be encouraged so that replantation techniques may be evaluated.

Periradicular healing and apical closure of a non-vital tooth in the presence of bacterial contamination

This case report addresses the periradicular tissue response and root-end closure of a maxillary central incisor in the presence of bacterial contamination. The implications for the control of bacteria through the use of calcium hydroxide and/or systemic antibiotic coverage are considered in the light of scientific evidence and clinical treatment.

Endodontic infection and calcium hydroxide-treatment. Effects on periodontal healing in mature and immature replanted monkey teeth

Large experimental defects with marginal communication, and small isolated experimental defects were created on the root surfaces of extracted monkey lateral incisors with either open or closed apices. The pulp tissue was either infected or removed, and calcium hydroxide placed in the root canal. The teeth were then replanted and the healing pattern evaluated histomorphometrically after 20 weeks. From the results, it was concluded that (1) an intrapulpal infection promotes marginal epithelial down-growth on a denuded dentin surface irrespective of tooth developmental stage, and that (2) the periodontal healing potential after calcium hydroxide-treatment appears to be higher in teeth with open apices compared with teeth with closed apices, where ankylosis was promoted as opposed to teeth with open apices where significantly more reparative cementum was found.

Prognosis of luxated non-vital maxillary incisors treated with calcium hydroxide and filled with gutta-percha. A retrospective clinical study

A material of 885 luxated, non-vital incisors was evaluated radiographically with respect to healing of periodontal tissues including inflammatory root resorption and occurrence of ankylosis and cervical root fractures. The results were assessed after completion of calcium hydroxide treatment and 4 years after filling of the root canal with gutta-percha. After treatment with calcium hydroxide, periapical healing occurred in 95% of the teeth. Four years after filling with gutta-percha, periapical healing was present in 91% of the teeth. In the remaining teeth, recurrent or persistent periapical radiolucency was more frequent in overfilled than adequately filled teeth (P = 0.0001). There was no difference between immature and mature teeth. Inflammatory root resorption healed in 192 of 197 teeth (97%); in 5 teeth it developed into ankylosis. Ankylosis occurred in 13 teeth, all of which were intruded into the alveolar bone at the time of injury. The frequency of cervical root fractures was markedly higher in immature than mature teeth (P greater than 0.0001). Among immature teeth, the frequency of fractures was dependent on the stage of root development (chi 2 = 31.6) and ranged from 77% in teeth with the least to 28% in teeth with the most developed roots. The frequency of fractures was also related to the defects after healing of inflammatory root resorption in the cervical area of the root, significant at P less than 0.0001.

The role of intracanal medication in root canal treatment

The role of intracanal medication as a root canal dressing is re-examined. In pulpectomy and some root canal treatments, where the root canal contains vital pulp tissue, it is doubtful whether a routine intracanal medicament is needed. In infected root canals, intracanal medication has been advocated for many purposes. An intracanal medicament is used to: (i) eliminate any remaining bacteria after canal instrumentation; (ii) reduce inflammation of periapical tissues and pulp remnants; (iii) render canal contents inert and neutralize tissue debris; (iv) act as a barrier against leakage from the temporary filling; (v) help to dry persistently wet canals. However, most of the indications for intracanal medicaments are questionable. Intracanal medicaments should only be used for root canal disinfection as part of controlled asepsis in infected root canals, and their role is secondary to cleaning and shaping of the root canal. Thorough canal debridement and adequate canal preparation are more pertinent, and their importance is emphasized. Bacteriological sampling may be necessary if a tooth does not respond to treatment, to help in the choice of intracanal medicament.

Recent development in endodontic research

In essence, endodontics as a clinical discipline is concerned with the prevention and treatment of pulpal and periapical infection. In recent research the infective process has been investigated as well as the mechanisms by which the pulp and periodontium deal with microbial insults. With regard to the pulp, findings on the hemodynamics of pulpitis suggest that the inflammatory response in this tissue is much less influenced by the special anatomic environment of the tooth than was previously believed. Pulpal diseases are being underdiagnosed, mostly because of inadequate examination methods. Laser Doppler flowmetry which gives a vascular rather than a nervous response may gain importance in pulpal diagnostics in the future. It is established that apical periodontitis with bone resorption cannot develop in the absence of bacteria in the root canal system. Root canal infection is characterized by a wide variety of combinations of relatively few anaerobic bacteria, and bacterial synergism plays an important role in maintaining the infection. Microbial invasion of an apical granuloma may take place. Non-oral and environmental organisms like Pseudomonas aeruginosa are frequently isolated from treatment-resistant cases. Success of endodontic treatment depends on the reduction or elimination of the infecting bacteria. This may predictably be obtained after a thorough chemo-mechanical instrumentation and disinfection of the root canal with calcium hydroxide. The standardized technique which entails the preparation of a cylindrical apical box with removal of significant amounts of dentin near the root apex predictably gives a clean canal. This technique has provided excellent clinical and radiographic results in well documented follow-up studies.

Histological characterization of bleaching-induced external root resorption in dogs

External root resorption occasionally develops after intracoronal bleaching with hydrogen peroxide. In this study, an experimental model was established to study thermocatalytic bleaching-induced root resorption in dogs. Histological examination after 6 months revealed that 18% of the teeth had root resorption lesions. The lesions could be divided into three types. In type I, root excavations were associated with a dense inflammatory cell infiltrate. Type II lesions were characterized by granulation tissue formation. In type III, the lesions were filled with reparative cementum. The three types probably represent different phases of one process. Calcium hydroxide had no effect on the occurrence or type of resorption. The instability of hydrogen peroxide and the presence of inflammatory resorption lesions 6 months postoperatively suggest hydrogen peroxide-induced toxic radicals or denaturants as potential irritants.

Undergraduate endodontic teaching at the London Hospital Dental Institute

Integration, whole patient care and small group teaching are concepts which set the pattern for undergraduate teaching at 'The London'. This system promotes co-operation between disciplines, enables students to see the basic teaching in a wider clinical context, activates the learning process and gives students an opportunity to learn responsibility by running their own 'mini-practices'. Unfortunately, the system also has some undesirable effects, which are discussed with special reference to the teaching of endodontics.

A study of endodontically apexified teeth

This study was undertaken to determine the clinical and radiographic success of calcium hydroxide apexification in a group of 48 patients requiring endodontic therapy because of pulpal necrosis prior to root-end closure. The study examined tooth number, etiology of pulpal necrosis, age, sex, size of root-end opening, size of radiolucency, crown discoloration, interappointment symptoms, and total treatment time from initial instrumentation to completion of apexification. Apexification required an average of 1 year +/- 7 months. A statistically significant relationship was found between: the presence of a radiolucency and development of interappointment symptoms (p less than 0.04); and the size of apex opening and development of interappointment symptoms (p less than 0.02). If symptoms did develop, apexification was delayed an additional 5 months when compared to patients who did not have symptoms. Calcium hydroxide apexification was found to be statistically highly successful regardless of the clinical variables encountered.

The antimicrobial effect of calcium hydroxide as a short-term intracanal dressing

The antibacterial effect of calcium hydroxide as a short-term intracanal dressing was clinically evaluated by applying the medicament for 10 minutes or 7 days in root canals of teeth with periapical lesions. The results showed that the 7-day dressing efficiently eliminated bacteria which survived biomechanical instrumentation of the canal, while the 10-minute application was ineffective.

Effect of delayed calcium hydroxide treatment on periodontal healing in contaminated replanted teeth

The effect of delayed intracanal calcium hydroxide treatment on experimentally induced extensive inflammatory root resorption in monkeys was studied. A significant shift from inflammatory resorption to ankylosis was noted following calcium hydroxide treatment. Furthermore, calcium hydroxide treatment appeared to change the pattern of ankylosis over time, although the total ankylotic area remained the same. Ankylosis preceded by root resorption (replacement resorption) increased, while ankylosis not associated with root resorption decreased. It was concluded that intracanal calcium hydroxide treatment of teeth with compromised PDM may cause unnecessary replacement resorption if left in the root canal for a long time or changed repeatedly.

Effect of immediate calcium hydroxide treatment and permanent root-filling on periodontal healing in contaminated replanted teeth

The effect of immediate permanent root-filling and immediate intracanal calcium hydroxide treatment on experimentally contaminated and necrotized periodontal membranes (PDM) in avulsed and subsequently replanted monkey teeth was studied. Almost the entire root surface in the non-endodontically treated control teeth were covered with inflammatory resorption. A significant shift towards ankylosis not associated with root resorption (greater than 80% of the total root surface area) was noted following calcium hydroxide treatment. About two thirds of the root surfaces from the teeth with permanent root fillings showed surface resorptions or ankylosis preceded by root resorption. The root surface area which would have been covered by inflammatory resorption, unless endodontic treatment had been implemented, were instead predominantly covered by either surface resorption (permanent root filling) or ankylosis (calcium hydroxide treatment). Ankylosis compared with surface resorption may in the long term lead to progressive loss of root substance due to replacement resorption. It was concluded that calcium hydroxide may be an excellent initial intracanal treatment in teeth with healthy PDM, but care should be taken not to risk unnecessary development of ankylosis by prolonged treatment of teeth with compromised PDM.

Calcium hydroxide in restorative dentistry

This paper reviews the various calcium hydroxide preparations available for use in restorative dentistry and their constituents. The significance of individual constituents in relation to the properties of such materials and their mode of therapeutic action with respect to the dentine pulpal response and antibacterial activity is discussed. Applications of calcium hydroxide in restorative dentistry are also reviewed.

Review of calcium hydroxide

Calcium hydroxide is a material which has been used for a variety of purposes since its introduction into dentistry in the early part of the twentieth century. In its pure form, the substance has a high pH, and its dental use relates chiefly to its ability to stimulate mineralization, and also to its antibacterial properties. A range of products has been formulated with different therapeutic actions, the effects of which are partially dependent upon the tissue to which they are applied. The material is reviewed under the following general headings: biochemical actions; dental formulation; uses.

Medicaments: aids to success in endodontics. Part 1. A review of the literature

Bacteria play a major role in pulpal and periapical disease. They are capable of surviving in dentinal tubules and other canal ramifications that are inaccessible to mechanical instrumentation and irrigation. In order to predictably achieve bacteria-free root canal systems, especially in pulpless teeth, it is necessary to use intra-canal medicaments. These medicaments must be capable of destroying bacteria, reducing inflammation and stimulating hard tissue formation whilst not being toxic to the host tissues. Consideration of a material's therapeutic action must be made when selecting a medicament for any pathological condition. Many of the commercial preparations do not satisfy the requirements for the ideal root canal medicament.

One visit apicectomy technique using calcium hydroxide cement as the canal filling material combined with retrograde amalgam

A prospective study was set up to evaluate a one-visit apicectomy technique. Calcium hydroxide cement was used as the root canal filling material. The calcium hydroxide cement set rapidly and clearly revealed the position, size and outline form of the root canals at the level of resection. This facilitated preparation of the apical cavities to a depth of 3 mm. Each cavity was varnished before placement of the amalgam. Sixty-eight patients (93 teeth) were included in the study. Five patients (8 teeth) were lost to follow-up. The success rate, based on clinical and radiographic examination after a minimum of 2 years, was 91.8 per cent.

Effects of combining Ledermix and calcium hydroxide pastes on the diffusion of corticosteroid and tetracycline through human tooth roots in vitro

A 50:50 mixture of a corticosteroid/antibiotic paste and calcium hydroxide has been used clinically as a root canal dressing agent. This study investigated the effect on the release and diffusion of the corticosteroid and antibiotic components of Ledermix paste when it was mixed with a calcium hydroxide-methyl cellulose paste. The release rates of the trace molecules were lower when the mixture was used compared with release from Ledermix alone. The results indicated that this combination of materials, when used a long-term intracanal dressing, was likely to be more effective than Ledermix alone.