OOOOEe74 Kim et al. March 2009Fig. 1. Standard radiographs during the endodontic treatment of the lower left canine. a, X-ray for initial working lengthdetermination. b, On the second visit, Calcipex II was overﬁlled into the periapical area (arrows). c, After root canal ﬁlling, someCalcipex II remained periapical but reduced in amount (arrows). d, At the second day after canal ﬁlling, when the gingivalswelling occurred, the canal ﬁlling looked ﬁne and there was no change in periapical area (arrows).localized in the granuloma lesion but gradually dispersed root canal is ﬁlled in a single-session treatment.1-3across the border of the granuloma into the adjacent connec- Calcipex II is a calcium hydroxide water-based pastetive tissue (Fig. 2, a, 4 and 5). The ﬁne granular materials for root canal dressing, which is easy to handle and thewere identical to the Calcipex II granules smeared on the most easily removed. Great care had to be taken toglass slide, exhibiting slightly translucent and ﬁne granular avoid extrusion via the apical foramen compared withaggregation but no calciﬁcation or polymerization (Fig. 2, b).The Calcipex II granules were mainly engulfed by macro- the silicon oil– based Vitapex.4 In the present study, thephages, and also slightly localized at the cytoplasms of ﬁbro- Calcipex II used as an intracanal dressing material wasblasts. Still a lot of the ﬁne Calcipex II granules were freely overﬁlled into the periapical area, and its ﬁne granulardispersed in the stromal ﬁbrous tissue, but rarely in the lumen materials were rapidly migrated up through the gingivalof capillaries. In the immunohistochemistry using antisera of tissue. The Calcipex II granules were not calciﬁed norlysozyme, CD31, CD68, IL-8, and PARP-1, the Calcipex II polymerized in the gingival tissue; rather, they weregranule–laden cells were positive for lysozyme, CD31, and diffusely scattered throughout the collagenous ﬁbrousCD68, indicating that the cells belonged to the lineage of tissue, were rapidly engulfed by the macropahges, andmacrophage/histiocyte/monocyte and were in the apoptotic resulted in a foreign body granuloma. The granulomaprocesses (Fig. 2, c-e). On the other hand, the Calcipex IIgranule–laden cells were negative for IL-8, which is a che- was mainly inﬁltrated with macrophages, and only amokine usually positive in neutrophils (Fig. 2, f), similar to few lymphocytes were found, but exclusive of PMNs.the negative control staining (Fig. 2, h). Under the micro- In the immunohistochemistry, the Calcipex II granule–scopic observation in routine hematoxylin and eosin stain, the laden cells were strongly positive for lysozyme, CD31,macrophages ﬁlled with the Calcipex II granules could not and CD68, which are markers for the macrophages,readily dissolve the ﬁne granules; rather, they were gradually including histiocytes and monocytes,5-11 whereas theydestroyed by the rupture of their cell membrane. Nevertheless were negative for the antibody of IL-8, which is athere appeared no acute inﬂammatory reaction. The Calcipex marker for PMNs.12 However, the inﬂammatory degen-II–laden macrophages were strongly positive for PARP-1,indicating that the cells were undergoing the apoptotic pro- eration or necrosis by cytotoxic chemokine IL-8 wascesses, possibly due to the overload of Calcipex II (Fig. 2, g). not observed in the Calcipex II–induced foreign bodyEventually, the Calcipex II induced a foreign body granuloma granuloma.by macrophages, but no acute inﬂammation by PMNs. The Calcipex II granules were too small, 500 nm, to be localized in the root canal, so that they were easilyDISCUSSION overﬂowed and dispersed into the periapical tissues The use of a calcium hydroxide– based intracanal depending on the dynamic pressure that occurred dur-dressing is important for periapical repair in teeth with ing canal ﬁlling and biting. The ﬁne Calcipex II gran-periapical lesion. Dressing with calcium hydroxide ules were rapidly engulfed by macrophages and evenpaste results in better periapical repair than when the endocytosed by stromal ﬁbroblasts. However, the Cal-
OOOOEVolume 107, Number 3 Kim et al. e75Fig. 2. Photomicrographs of the Calcipex II-induced foreign body granuloma. a, Hematoxylin and eosin stain. a1, Lowmagniﬁcation of main lesion: The Calcipex II granules were diffusely observed in the stromal cells. a2-a5, High magniﬁcation.a2, Most of the Calcipex II granules were engulfed by macrophages (arrows), only a few lymphocytes (arrowheads) wereinﬁltrated but not PMN. a3, Some Calcipex II granules were also endocytosed by stromal ﬁbroblasts (arrowheads); no CalcipexII granules were found in the lumen of capillaries (C). a4, Note the massive dispersion of the Calcipex II granules in the ﬁbrousconnective tissue; many Calcipex II granules were found in the cytoplasms of ﬁbroblasts (arrowheads). a5, Border area betweenthe ﬁbrous connective tissue and granulomatous lesion. The Calcipex II granules were diffusely dispersed; note many macro-phages inﬁltrated into the border area. b, Calcipex II paste smeared on the slide glass. b1, Low magniﬁcation: The Calcipex IIgranules were well dispersed and aggregated (arrows). b2, High magniﬁcation: The ﬁne granules of Calcipex II was very small,measuring 500 nm in diameter. c-g, Immunohistochemistry. c, Lysozyme antibody, positive in the Calcipex II granule–ladencells (arrows). d, CD31 antibody, positive in the Calcipex II granule–laden cells (arrows). e, CD68 antibody, positive in theCalcipex II granule–laden cells (arrows). f, Interleukin-8 antibody, negative in the Calcipex II granule–laden cells (arrows). g,Poly(ADP-ribose) polymerase 1 antibody, positive in the Calcipex II granule–-laden cells (arrows). h, Negative control stainedwithout antisera.
OOOOEe76 Kim et al. March 2009cipex II granules seem to be not readily degraded in the giant cell granuloma. An immunohistochemical and ultra-cytoplasms of macrophages; rather, the macrophages structural study. Oral Dis 1995;1:20-5. 7. Macarenco RS, do Canto AL, Gonzalez S. Angiolymphoid hy-overﬁlled with the Calcipex II granules tend to be perplasia with eosinophilia showing prominent granulomatousdestroyed with the positive reaction of PARP-1, which and ﬁbrotic reaction: a morphological and immunohistochemicalis a marker of cellular apoptosis.13,14 However, the study. Am J Dermatopathol 2006;28:514-7.features of cytotoxic degeneration and the allergic hy- 8. Yuan K, Wing LY, Lin MT. Pathogenetic roles of angiogenicpersensitivity by the immune reactions of PMNs and factors in pyogenic granulomas in pregnancy are modulated by female sex hormones. J Periodontol 2002;73:701-8.lymphocytes were not observed in the Calcipex II– 9. Knoess M, Krukemeyer MG, Kriegsmann J, Thabe H, Otto M,induced foreign body granuloma. Krenn V. Colocalization of C4d deposits/CD68 macrophages in In this study, the overﬁlling of Calcipex II in end- rheumatoid nodule and granuloma annulare: immunohistochem-odontic treatment produced a foreign body granuloma ical evidence of a complement-mediated mechanism in ﬁbrinoidin the nearby gingival tissue. Although the Calcipex II necrosis. Pathol Res Pract 2008;204:373-8. 10. Tian XF, Li TJ, Yu SF. Giant cell granuloma of the temporalwas rapidly reduced in amount in the periapical radio- bone: a case report with immunohistochemical, enzyme histo-grams after treatment, the Calcipex II material was not chemical, and in vitro studies. Arch Pathol Lab Med 2003;resorbed easily; rather, it was dispersed into adjacent 127:1217-20.soft tissue, evoking a foreign body reaction by macro- 11. Rodini CO, Lara VS. Study of the expression of CD68 mac-phages in the absence of acute inﬂammatory reaction. rophages and CD8 T cells in human granulomas and periapical cysts. Oral Surg Oral Med Oral Pathol Oral Radiol EndodREFERENCES 2001;92:221-7. 1. Leonardo MR, Hernandez ME, Silva LA, Tanomaru-Filho M. 12. Pilozzi E, Stoppacciaro A, Rendina E, Ruco LP. Monocyte Effect of a calcium hydroxide– based root canal dressing on chemotactic protein-1 in the inﬂammatory pseudotumour of the periapical repair in dogs: a histological study. Oral Surg Oral lung. Mol Pathol 1998;51:50-2. Med Oral Pathol Oral Radiol Endod 2006;102:680-5. 13. Okinaga T, Kasai H, Tsujisawa T, Nishihara T. Role of caspases 2. Berbert FL, Leonardo MR, Silva LA, Tanomaru Filho M, Bra- in cleavage of lamin A/C and PARP during apoptosis in macro- mante CM. Inﬂuence of root canal dressings and sealers on repair phages infected with a periodontopathic bacterium. J Med Mi- of apical periodontitis after endodontic treatment. Oral Surg Oral crobiol 2007;56:1399-404. Med Oral Pathol Oral Radiol Endod 2002;93:184-9. 14. Fink SL, Cookson BT. Caspase-1-dependent pore formation dur- 3. Peters LB, van Winkelhoff AJ, Buijs JF, Wesselink PR. Effects ing pyroptosis leads to osmotic lysis of infected host macro- of instrumentation, irrigation and dressing with calcium hydrox- phages. Cell Microbiol 2006;8:1812-25. ide on infection in pulpless teeth with periapical bone lesions. Int Endod J 2002;35:13-21. Reprint requests: 4. Hosoya N, Kurayama H, Iino F, Arai T. Effects of calcium hydroxide on physical and sealing properties of canal sealers. Int Suk Keun Lee, DDS, PhD Endod J 2004;37:178-84. Department of Oral Pathology 5. Stefanaki K, Tsivitanidou-Kakourou T, Stefanaki C, Valari M, College of Dentistry Argyrakos T, Konstantinidou CV, et al. Histological and immu- Kangnung National University nohistochemical study of granuloma annulare and subcutaneous 123 Chibyun-dong granuloma annulare in children. J Cutan Pathol 2007;34:392-6. Gangneung, 210-702 Korea 6. Carvalho YR, Loyola AM, Gomez RS, Araujo VC. Peripheral firstname.lastname@example.org