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CALCIUM HYDROXIDE IN ENDODONTICS

The document discusses the use of calcium hydroxide in endodontics, including its role as an intracanal medicament and root canal sealer. It covers various aspects such as its mechanism of action, clinical applications, effects on dentin, and its comparison with other materials like MTA. In addition, it addresses the antimicrobial efficacy, placement techniques, and considerations for its removal from the canal.

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1 CALCIUM HYDROXIDE Dr Urvashi Sodvadiya
2 CONTENT Endodontics As an intracanal medicament  Definition  Clinical application  Mechanism of action  Vehicles  Placement of Calcium hydroxide paste  Dentin and Calcium hydroxide  Effect of Calcium hydroxide on clinical outcome  Calcium hydroxide and Chlorhexidine  Calcium hydroxide and Sodium Hypochlorite  Removal of Calcium hydroxide from the canal  When to replace Calcium hydroxide dressing?  Calcium hydroxide and CO2  Toxicity
3 CONTENT Endodontics As a Root canal Sealer  Clinical significance  Classification  Composition  Properties Leakage Solubility - In tissue fluids - In chemical solvent Biocompatibility Antimicrobial Toxicity Conclusion References
Endodontics In 4
5 Intracanal medicament
Definition 6 “A medicament is an antimicrobial agent that is placed inside the root canal between treatment appointments in an attempt to destroy remaining microorganisms and prevent reinfection (Weine 2004).”
7 Clinical Application
8 Hard tissue formation in immature teeth with pulp necrosis Frank; 1966 Drawback: weakening effect of CH on dentinal strength; can lead to cervical root fracture (StØrmer et al.; 1988)  claiming that 60% of all endodontically treated teeth with immature root formation have hadcervical fractures due to minor impacts. Andreasen JO, Farik B, Munksgaard EC. Long‐term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dental Traumatology. 2002 Jun;18(3):134-7.
9 Hard tissue formation in root fracture with coronal pulp necrosis Introduced by Cvek M in 1974 A large clinical study: 68 root fractures with calcium hydroxide (Cvek et al; 2004) Drawback: takes 6 months to induce a hard tissue barrier at fracture site Cvek M, Me`jare I, Andreasen JO. Conservative endodontic treatment of teeth fractured in the middle or apical part of the root. Dent Traumatol 2004;20:261–9.
10 External surface related- root resorption First described by Andreasen JO in 1971 Arrest 98% of infection-related resorptions in luxated teeth and 90% in avulsed and later replanted teeth (Cvek M; 1973) Drawback: weakening effect of CH on dentinal strength; can lead to cervical root fracture Andreasen JO. Treatment of fractured and avulsed teeth. ASDC J Dent Child 1971;38:29–35 Cvek M. Treatment on non-vital permanents incisors with calcium hydroxide. II. Effect on external root resorption in luxated teeth compared with effect of root filling with gutta percha. Odontol Revy 1973;24:343–54.
Calcium hydroxide versus MTA 11 Apical barrier formation Extraordinary cementum and PDL-inducing potential of MTA. Bacteria tight sealing capacity of MTA Modulate cytokines production; encourage differentiation of hard tissue producing cells Silicates (Peng et al; 2011)
12 Mechanism of action
13 Antimicrobial Anti-endotoxin activity Bridge formation Activity against Biofilm
14 Antibacterial effect against.. E. faecalis: aqueous Ca(OH)2 paste and silicone oil-based Ca(OH)2 (Han et al; 2001). E. faecalis: Portenier et al. (2005) Exponential growth phase: most sensitive to Ca(OH)2, can be killed within 3 s to 10 min. Stationary phase: more resistant, (living cells being recovered at 10 min) Starvation phase: most resistant E. faecalis (strain A197A) Kayaoglu G, Erten H, Ørstavik D. Growth at high pH increases Enterococcus faecalis adhesion to collagen. International endodontic journal. 2005 Jun;38(6):389-96.
15 Antibacterial effect against.. Haapasalo; 1987 Ca(OH)2 paste failed to eliminate, even superficially, E. faecalis in dentinal tubules Estrela et al. (1999) No antimicrobial effect: S. faecalis, S. aureus, B. subtilis, P. aeruginosa Waltimo et al. (2005) Ca(OH)2 dressing between appointments: do not have the expected effect in terms of disinfection of the root canals Sathorn et al. (2007) Ca(OH)2: limited effectiveness in eliminating bacteria from human root canals
16 Time required to act as an antimicrobial agent  Ørstavik & Haapasalo (1990) Take up to 10 days to disinfect dentinal tubules infected by facultative bacteria.  7 days application (Sjo¨gren et al; 1991)  Shuping et al. (2000) Placement of Ca(OH)2 for at least 1 week rendered 92.5% of canals bacteria free.
17 Electrophoretically activated Ca(OH)2 Lin et al. (2005)  Significantly more effective up to depths of 200–500 µm no viable bacteria in dentinal tubules to a depth of 500 µm from the root canal space within 7 days. Till what depth of dentinal tubules? Zand V, Mokhtari H, Hasani A, Jabbari G. Comparison of the penetration depth of conventional and nano-particle calcium hydroxide into dentinal tubules. Iranian endodontic journal. 2017;12(3):366.
18 Antimicrobial Anti-endotoxin activity Bridge formation Activity against Biofilm Tissue dissolution capacity
19 What is endotoxin??
20 In-Vitro Studies In-Vivo Studies Safavi & Nichols (1993), Safavi & Nichols (1994), Barthel et al. (1997) and Olsen et al. (1999) CH Lipid A molecule Fatty acids Amino sugars Non-toxic products Buck et al. (2001), Nelson-Filho et al. (2002), Tanomaru et al. (2003), and Jiang et al. (2003) It is accepted that the absence of a radiolucency does not guarantee the absence of a bony lesion (Bender & Seltzer 1961)
21 Antimicrobial Anti-endotoxin activity Antifungal Activity against Biofilm Tissue dissolution capacity
22 Waltimo et al. (1999) C. albicans, C. glabrata, C. guilliermondii, C. krusei and C. tropicalis : Highly resistant to aqueous Ca(OH)2 1 • C. albicans: survives in a wide range of pH values 2 • Ca(OH)2 pastes: provide the Ca2+ ions necessary for the growth and morphogenesis of Candida Antifungal CH + CPMC/glycerine/CHX: more pronounced effect against fungi Siqueira et al. (2003)
23 Antimicrobial Anti-endotoxin activity Antifungal Activity against Biofilm Tissue dissolution capacity
24 Teeth with apical periodontitis: Cocci and rods predominated and formed colonies on the root canal walls and also, to a varying degree, penetrated the dentinal tubules. (Sen et al.;1995) Even in teeth with completed endodontic treatment: microbes exist as biofilms in untouched locations in the main canal, isthmuses and accessory canals (Nair et al.;2005) Despite intracanal dressing with Ca(OH)2, E. faecalis formed biofilms in root canals • Distel et al; 2002 Ca(OH)2: 100% effective in eliminating E. faecalis biofilm • Chai et al; 2007 Activity against Biofilm
25 Antimicrobial Anti-endotoxin activity Antifungal Activity against Biofilm Tissue dissolution capacity
26 First reported by: Hasselgren et al. in 1988 In dentistry.. Ca(OH)2: dissolves pulp tissues (Andersen et al;1991)
27 Tissue dissolving capacity Wadachi R, Araki K, Suda H. Effect of calcium hydroxide on the dissolution of soft tissue on the root canal wall. Journal of Endodontics. 1998 May 1;24(5):326-30. Morgan et al. (1991) reported that Ca(OH)2 solution was an ineffective solvent of pulp tissue as an irrigant.
28 Vehicle Determines the velocity of ionic dissociation Types of vehicles (Fava & Saunders; 1999) 1. Water-soluble substances such as water, saline, anaesthetic solutions, carboxymethylcellulose, methylcellulose and Ringers solution. 2. Viscous vehicles such as glycerine, polyethyleneglycol (PEG) and propylene glycol. 3. Oil-based vehicles such as olive oil, silicone oil, camphor (the oil of camphorated parachlorophenol), some fatty acids (including oleic, linoleic, and isostearic acids), eugenol and metacresylacetate
29 Determines the velocity of ionic dissociation Types of vehicles (Fava & Saunders; 1999) 1. Water-soluble substances such as water, saline, anaesthetic solutions, carboxymethylcellulose, methylcellulose and Ringers solution. - Sterile water and saline: most commonly used - Anaesthetic solution: Adequate vehicle (Athanassiadis et al. 2007) Vehicle
30 Vehicle Determines the velocity of ionic dissociation Types of vehicles (Fava & Saunders; 1999) 1. Viscous vehicles such as glycerine, polyethyleneglycol (PEG) and propylene glycol.  10–30% for a glycerine/water mixture and 10–40% for a propylene glycol/water - Higher concentration: may decrease effectiveness (Safavi & Nakayama 2000).  Ca and OH ions: release slowly and for longer time (Gomes et al; 2002), requires less number of appointment (Fava & Saunders 1999) Viscosity of the paste: (Behnen et al; 2001) Thick mixtures of Ca(OH)2 and water (1 g mL-1 H2O): significantly improved antimicrobial property than to a thin mix and Pulpdent
31 Vehicle Determines the velocity of ionic dissociation Types of vehicles (Fava & Saunders; 1999) 1. Oil-based vehicles such as olive oil, silicone oil, camphor (the oil of camphorated parachlorophenol), some fatty acids (including oleic, linoleic, and isostearic acids), eugenol and metacresylacetate
Most commonly used vehicle?? 32 Polyethylene glycol (PEG) Own substantial antibacterial activity (Chirife et al. 1983)  Klebsiella pneumoniae,  Pseudomonas aeruginosa,  Eschericha coli and  Staphylococcus aureus,
Estrela et al. (2001) 33 (i) Ca(OH)2 in saline (ii) Ca(OH)2 in polyethylene glycol (iii) Ca(OH)2 in CMCP “Complete antimicrobial effect was observed after 48 h in both tests, irrespective of the Ca(OH)2 paste vehicle” Behnen et al. (2001) Ca(OH)2 decreased the numbers of E. faecalis at all depths within dentinal tubules up to 24 h “less viscous preparations of Ca(OH)2 were more effective in removal of bacteria than more viscous”
34 Placement of CH paste
Placement of CH paste 35
Placement of CH paste 36
37 Dentin and Calcium hydroxide
38 Wang and Hume; 1988, Haapasalo et al. 2000, Portenier et al. 2001 Dentine powder (18% w/v- 1.8% w/v ) Saturated Ca(OH)2 solution Prevent killing of E Faecalis 18% (w/v) bovine serum albumin Buffering effect of dentin
39 Microtensile fracture strength: Reduces by almost 50% following 7-84 days of application (Rosenberg et al;2007) CH: increases elastic modulus of dentin (Kawamoto et al; 2008) Effect of CH on dentin Ca(OH)2 for an extended period (6 months to 1 year) results in reduced flexural strength and lower fracture resistance. Fracture resistance: Ca(OH)2-filled immature teeth in approximately 1 year attributed the frequent reports of fractures of immature teeth filled with Ca(OH)2 for extended periods (Andreasen et al;2002) Decreases significantly after 6 months of application (Doyonet al; 2005 Standard protocol of up to 30-day application of calcium hydroxide for infected mature teeth with apical periodontitis is safe and need not be adjusted. (Siqueira & Lopes 1999)
40 Based on time duration 1 month application: pH gradient with high values around the canal dressing towards the peripheral (Tronstad et al; 1981) 4 months application: Inner root dentin: within few hours Outer root dentin: 1-7 days To reach peak levels: 2-3 weeks (Nerwich et al; 1993) Diffusion of OH ions through dentin A final canal rinse with 3 mL 17% EDTA and 10 mL 6% NaOCl before Ca(OH)2 placement allowed the greatest hydroxyl ion diffusion to the root surface (Saif et al.;2008) Cervical root resorption Kehoe (1987) : reported a pH reversal from a slightly acidic to a slightly alkaline Hydroxyl ions diffusion: faster and reaches higher levels cervically more than apically
Effects of Calcium hydroxide on Clinical outcome 41
Post operative pain 42 Long term outcome of treatment No difference in the incidence of postoperative pain between one- and multiple-visit root canal treatment (with calcium hydroxide inter- appointment dressing) Prevalence of postoperative pain ranges from 3% to 58% O’Keefe 1976, Mulhern et al. 1982, Mohammadi et al. 2006 and, Sathorn et al.2008
43 Long term outcome of treatment Trope et al. (1999): 1-year follow-up: 10% increase in healing rates in group with CH dressing for at least 1 week. Katebzadeh et al. (1999, 2000) Better results: Ca(OH)2 was used as an intracanal disinfecting medicament for 1 week. Weiger et al.2000, Molander et al.2007 Influence of Ca(OH)2 as an interappointment dressing on the healing of periapical lesion: No statistical significant difference Peters & Wesselink;2002 found no significant differences in healing of periapical radiolucency between teeth that were treated in one visit (without) and two visits with inclusion of Ca(OH)2 for 4 weeks.
CHX versus Calcium Hydroxide CHX + Calcium Hydroxide 44 E. Faecalis and c.albicans 2% CHX gel >> CHX/Ca(OH)2 >> Ca(OH)2 alone Waltimo et al; 1999, Gomes et al. (2006), Scha¨fer & Bossmann (2005) Removal of CHX + CH medicament: 7% maleic acid and 10% citric acid for 1 minute were superior to 17% EDTA in the removal of calcium hydroxide mixed with 2% chlorhexidine (Arslan H et al; 2014)
Sodium hypochlorite v/s Calcium Hydroxide Sodium Hypochlorite + Calcium Hydroxide 45 7 days pretreatment with Pulpdent paste a non-setting Ca(OH)2 paste, followed by sodium hypochlorite irrigation: cleaned canal isthmuses effectively (Metzler & Montgomery;1989) Reduction in amount of debris: NaOCl for >30 s or Ca(OH)2 for 7 days. Combination of Ca(OH)2 and NaOCl: more effective (Wadachi et al; 1998)
46 Removal of CH from the canals Effects of remnants on sealer adaptation and penetration Factors affecting removal of CH Vehicle used to prepare paste is more important (Nandini et al; 2006) Oil based: difficult to remove Type of irrigant used 10% citric acid, 10% maleic acid >> 17% EDTA >> 5.25% NaOCl (Nandini et al; 2006) Method no technique can remove Ca(OH)2 entirely. Endoactivator >> Ultrasonic >> EndoVac >> irrigants alone (Alturaiki S et al; 2015) Method no technique can remove Ca(OH)2 entirely. No significant difference among ProTaper, Reciproc, OneShape, WaveOne, and Manual groups (Altunsoy M et al; 2015)
47 When to Replace Calcium Hydroxide dressing? R. Weiger, R. Rosendahl, and C. Löst, “Influence of calcium hydroxide intracanal dressings on the prognosis of teeth with endodontically induced periapical lesions,” International Endodontic Journal, vol. 33, no. 3, pp. 219–226, 2000. M. Trope, “Treatment of immature teeth with non-vital pulps and apical preriodontitis,” Endodontic Topics, vol. 14, pp. 51–59, 2006. L. R. G. Fava and W. P. Saunders, “Calcium hydroxide pastes: classification and clinical indications,” International Endodontic Journal, vol. 32, no. 4, pp. 257–282, 1999 Vehicle Duration Ca(OH)2 saline dressings 4-weeks period (Weiger et al; 1999, M trope et al; 2006) 7±47 days (mean value: 22 days) (Weiger et al; 2000). Open apex case: 7 days (minimum) – 30 days (maximum) (M Trope; 2006) Oil based (Eg Metapex) Should be replaced once in three months (Fava et al; 1999)
48 Calcium Hydroxide and CO2 Fuss Z, Rafaeloff R, Tagger M, Szajkis S. Intracanal pH changes of calcium hydroxide pastes exposed to carbon dioxide in vitro. Journal of Endodontics. 1996 Jul 1;22(7):362-4.
Toxicity of CH 49 In the cases of extensive Ca(OH)2 overextension, repair took more than 6 months to complete (De Moor and De Witte; 2002) One of the least irritating root-filling materials and was replaced by new bone within 12 weeks of placement (Spa°ngberg; 1969) Ca(OH)2: partially or totally resorbed and replaced by bony tissue. (Pissiotis & Spangberg; 1990)
Barium Sulphate : CH – 1:8 50 36 months- follow up Orucoglu H, Cobankara FK. Effect of unintentionally extruded calcium hydroxide paste including barium sulfate as a radiopaquing agent in treatment of teeth with periapical lesions: report of a case. Journal of endodontics. 2008 Jul 1;34(7):888-91.
51 Root canal Sealer
Clinical significance 52 Sealers are responsible for the principal functions of a root filling, namely, sealing the root canal system, entombment of remaining bacteria and the filling of irregularities in the canal system (Ørstavik 2005).
53 Grossman’s classification
54 CRCS (1982) Sealer 26 Endoflas FS Powder Paste Bismuth trioxide, Calcium hydroxide, Hexametheylenetetramine, titanium dioxide Bisphenol epoxy resin Powder Liquid Zinc oxide, Calcium hydroxide, Iodoform, Barium Sulfate Eugenol Accelerator Zinc acetate
55 Sealapex Apexit
56 Antimicrobial Leakage Bio- compatibility Solubility Toxicity
57 AH 26 Versus Calcium hydroxide based sealer 35% of AH 26 samples 80% of Selapex samples Siqueira et al. (1999) were entirely recontaminated at 60 days by human saliva through coronal leakage. Leakage Ersahan S, Aydin C. Solubility and apical sealing characteristics of a new calcium silicate-based root canal sealer in comparison to calcium hydroxide-, methacrylate resin-and epoxy resin-based sealers. Acta Odontologica Scandinavica. 2013 Jan 1;71(3-4):857-62.
58 Leakage Wu MK, De Gee AJ, Wesselink PR. Leakage of four root canal sealers at different thicknesses. International Endodontic Journal. 1994 Nov;27(6):304-8. Waltimo et al; 2001: Reported good results with Seal apex sealer Seal apex >> ZOE-based sealer
59 Antimicrobial Leakage Bio- compatibility Solubility Toxicity
60 Solubility in tissue fluid Esberard et al. (1996) Increase in pH when placed in distilled water: 9.14 (48 h after setting) Sleder et al. (1991) Sealapex could withstand long term exposure to tissue fluids without significant leakage. Tronstad et al. (1988) CRCS << Sealapex. McMichen et al. (2003) Apexit > AHPlus and Tubliseal
61 Solubility in solvent Whitworth & Boursin (2000) Chloroform Benzene Xylene Halothane Eucalyptus oil Solubility Chloroform Halothane Apexit 11.6% 14.19% AHPlus 96% 68% Alzraikat H, Taha NA, Hassouneh L. Dissolution of a mineral trioxide aggregate sealer in endodontic solvents compared to conventional sealers. Brazilian oral research. 2016;30(1). Sealapex: Endosolv > Xylene > RC Solve Bedi H et al; 2018
62 Antimicrobial Leakage Bio- compatibility Solubility Toxicity
63 Cytotoxicity Genotoxicity Subcutaneous implant Intraosseous implants Usage study Human studies Brisenˇo & Willershausen (1992) Endoflas FS > CRCS > Apexit > Sealapex Eldeniz et al. (2007): 8 types of sealers Resin-based (Epiphany and Endo- REZ) and calcium hydroxide-based (Apexit and Acroseal) sealers >> Silicone based DNA damage: Huang et al. (2002) Resin-based sealer > Ca(OH)2-based sealer Specific dorsal subdermal tissue sites of 12 guinea pigs Grossman’s sealer, CRCS >> Sealapex and Endo-Fill (Yesilsoy et al. 1988) Zinc oxide-eugenol, Tubliseal >> Sealapex (Mittal et al; 1995)
64 Cytotoxicity Genotoxicity Subcutaneous implant Intraosseous implants Usage study Human studies Berna´th & Szabo´ (2003) Type and degree of inflammatory reaction initiated by overfilling the root canals (Monkey) Endomethasone > AH 26 > Apexit and Grossman’s sealer
65 Antimicrobial Leakage Bio- compatibility Solubility Toxicity
66 Streptococcus anginosus (milleri) Roth > Sealapex (Mickel & Wright; 1999) E. faecalis Roth 811 (1.1 mm) > Sealapex (0.8 mm) > AH-Plus (no antimicrobial activity) (Mickel et al; 2003) Capnocytophaga ochracea, Porphyromonas gingivalis and Peptostreptococcus Roth Sealer > Ketac-Endo > Tubliseal > Apexit > Sealapex (Abdulkader et al; 1996) Antibacterial Factor: Time pH and calcium ion release Sealapex >> Sealer 26 >> Apexit Sealapex: more produced after 30 days. Sealer 26: highest release during the initial periods (Duarte et al; 2000)
67 Antimicrobial Leakage Bio- compatibility Solubility Toxicity
68 Overfilled canals containing Ca(OH)2-based sealers: Chronic inflammatory reactions in the periapical tissues of dog’s teeth. (Soares et al; 1990) 3 months 6 months 9 months Shashirekha G, Jena A, Pattanaik S, Rath J. Assessment of pain and dissolution of apically extruded sealers and their effect on the periradicular tissues. Journal of conservative dentistry: JCD. 2018 Sep;21(5):546.
69 Conclusion
References 70 ▪ Arslan H, Gok T, Saygili G, Altintop H, Akçay M, Çapar İD. Evaluation of effectiveness of various irrigating solutions on removal of calcium hydroxide mixed with 2% chlorhexidine gel and detection of orange-brown precipitate after removal. Journal of endodontics. 2014 Nov 1;40(11):1820-3. ▪ Alturaiki S, Lamphon H, Edrees H, Ahlquist M. Efficacy of 3 different irrigation systems on removal of calcium hydroxide from the root canal: a scanning electron microscopic study. Journal of endodontics. 2015 Jan 1;41(1):97-101. ▪ Altunsoy M, Ok E, Tanrıver M, Capar ID. Effects of different instrumentation techniques on calcium hydroxide removal from simulated immature teeth. Scanning. 2015 Jul;37(4):265-9. ▪ Orucoglu H, Cobankara FK. Effect of unintentionally extruded calcium hydroxide paste including barium sulfate as a radiopaquing agent in treatment of teeth with periapical lesions: report of a case. Journal of endodontics. 2008 Jul 1;34(7):888-91. ▪ ASLAN T, DÜZGÜN S, ÜSTÜN Y. EFFECT OF LENTULO SPIRAL USAGE AT DIFFERENT SPEEDS ON APICAL EXTRUSION OF CALCIUM HYDROXIDE. Atatürk Üniversitesi Diş Hekimliği Fakültesi Dergisi.;28(2):133-7.
References 71  Andersen M, Lund A, Andreasen JO, Andreasen FM. In vitro solubility of human pulp tissue in calcium hydroxide and sodium hypochlorite. Dental Traumatology. 1992 Jun;8(3):104-8.  Wadachi R, Araki K, Suda H. Effect of calcium hydroxide on the dissolution of soft tissue on the root canal wall. Journal of Endodontics. 1998 May 1;24(5):326-30.  Yang SF, Rivera EM, Baumgardner KR, Walton RE, Stanford C. Anaerobic tissue-dissolving abilities of calcium hydroxide and sodium hypochlorite. Journal of endodontics. 1995 Dec 1;21(12):613-6.  Wu MK, De Gee AJ, Wesselink PR. Leakage of four root canal sealers at different thicknesses. International Endodontic Journal. 1994 Nov;27(6):304-8.  Ersahan S, Aydin C. Solubility and apical sealing characteristics of a new calcium silicate- based root canal sealer in comparison to calcium hydroxide-, methacrylate resin-and epoxy resin-based sealers. Acta Odontologica Scandinavica. 2013 Jan 1;71(3-4):857-62.  Bedi H, Bhullar KK, Malhotra S, Khanna R, Nain R. A COMPARISON OF EFFECTIVENESS OF DIFFERENT SOLVENTS IN DISSOLVING ROOT CANAL SEALERS-AN IN-VITRO STUDY. Indian Journal of Comprehensive Dental Care (IJCDC). 2018 Jul 1;8(2).  Alzraikat H, Taha NA, Hassouneh L. Dissolution of a mineral trioxide aggregate sealer in endodontic solvents compared to conventional sealers. Brazilian oral research. 2016;30(1).
References 72 Shashirekha G, Jena A, Pattanaik S, Rath J. Assessment of pain and dissolution of apically extruded sealers and their effect on the periradicular tissues. Journal of conservative dentistry: JCD. 2018 Sep;21(5):546. Fuss Z, Rafaeloff R, Tagger M, Szajkis S. Intracanal pH changes of calcium hydroxide pastes exposed to carbon dioxide in vitro. Journal of Endodontics. 1996 Jul 1;22(7):362-4.
Thank you! 73

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CALCIUM HYDROXIDE IN ENDODONTICS

  • 1.
  • 2.
    2 CONTENT Endodontics As an intracanalmedicament  Definition  Clinical application  Mechanism of action  Vehicles  Placement of Calcium hydroxide paste  Dentin and Calcium hydroxide  Effect of Calcium hydroxide on clinical outcome  Calcium hydroxide and Chlorhexidine  Calcium hydroxide and Sodium Hypochlorite  Removal of Calcium hydroxide from the canal  When to replace Calcium hydroxide dressing?  Calcium hydroxide and CO2  Toxicity
  • 3.
    3 CONTENT Endodontics As a Rootcanal Sealer  Clinical significance  Classification  Composition  Properties Leakage Solubility - In tissue fluids - In chemical solvent Biocompatibility Antimicrobial Toxicity Conclusion References
  • 4.
  • 5.
  • 6.
    Definition 6 “A medicament isan antimicrobial agent that is placed inside the root canal between treatment appointments in an attempt to destroy remaining microorganisms and prevent reinfection (Weine 2004).”
  • 7.
  • 8.
    8 Hard tissue formation in immatureteeth with pulp necrosis Frank; 1966 Drawback: weakening effect of CH on dentinal strength; can lead to cervical root fracture (StØrmer et al.; 1988)  claiming that 60% of all endodontically treated teeth with immature root formation have hadcervical fractures due to minor impacts. Andreasen JO, Farik B, Munksgaard EC. Long‐term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dental Traumatology. 2002 Jun;18(3):134-7.
  • 9.
    9 Hard tissue formation in rootfracture with coronal pulp necrosis Introduced by Cvek M in 1974 A large clinical study: 68 root fractures with calcium hydroxide (Cvek et al; 2004) Drawback: takes 6 months to induce a hard tissue barrier at fracture site Cvek M, Me`jare I, Andreasen JO. Conservative endodontic treatment of teeth fractured in the middle or apical part of the root. Dent Traumatol 2004;20:261–9.
  • 10.
    10 External surface related- root resorption Firstdescribed by Andreasen JO in 1971 Arrest 98% of infection-related resorptions in luxated teeth and 90% in avulsed and later replanted teeth (Cvek M; 1973) Drawback: weakening effect of CH on dentinal strength; can lead to cervical root fracture Andreasen JO. Treatment of fractured and avulsed teeth. ASDC J Dent Child 1971;38:29–35 Cvek M. Treatment on non-vital permanents incisors with calcium hydroxide. II. Effect on external root resorption in luxated teeth compared with effect of root filling with gutta percha. Odontol Revy 1973;24:343–54.
  • 11.
    Calcium hydroxide versusMTA 11 Apical barrier formation Extraordinary cementum and PDL-inducing potential of MTA. Bacteria tight sealing capacity of MTA Modulate cytokines production; encourage differentiation of hard tissue producing cells Silicates (Peng et al; 2011)
  • 12.
  • 13.
  • 14.
    14 Antibacterial effect against.. E. faecalis: aqueousCa(OH)2 paste and silicone oil-based Ca(OH)2 (Han et al; 2001). E. faecalis: Portenier et al. (2005) Exponential growth phase: most sensitive to Ca(OH)2, can be killed within 3 s to 10 min. Stationary phase: more resistant, (living cells being recovered at 10 min) Starvation phase: most resistant E. faecalis (strain A197A) Kayaoglu G, Erten H, Ørstavik D. Growth at high pH increases Enterococcus faecalis adhesion to collagen. International endodontic journal. 2005 Jun;38(6):389-96.
  • 15.
    15 Antibacterial effect against.. Haapasalo; 1987 Ca(OH)2paste failed to eliminate, even superficially, E. faecalis in dentinal tubules Estrela et al. (1999) No antimicrobial effect: S. faecalis, S. aureus, B. subtilis, P. aeruginosa Waltimo et al. (2005) Ca(OH)2 dressing between appointments: do not have the expected effect in terms of disinfection of the root canals Sathorn et al. (2007) Ca(OH)2: limited effectiveness in eliminating bacteria from human root canals
  • 16.
    16 Time required to actas an antimicrobial agent  Ørstavik & Haapasalo (1990) Take up to 10 days to disinfect dentinal tubules infected by facultative bacteria.  7 days application (Sjo¨gren et al; 1991)  Shuping et al. (2000) Placement of Ca(OH)2 for at least 1 week rendered 92.5% of canals bacteria free.
  • 17.
    17 Electrophoretically activated Ca(OH)2Lin et al. (2005)  Significantly more effective up to depths of 200–500 µm no viable bacteria in dentinal tubules to a depth of 500 µm from the root canal space within 7 days. Till what depth of dentinal tubules? Zand V, Mokhtari H, Hasani A, Jabbari G. Comparison of the penetration depth of conventional and nano-particle calcium hydroxide into dentinal tubules. Iranian endodontic journal. 2017;12(3):366.
  • 18.
  • 19.
  • 20.
    20 In-Vitro Studies In-Vivo Studies Safavi & Nichols(1993), Safavi & Nichols (1994), Barthel et al. (1997) and Olsen et al. (1999) CH Lipid A molecule Fatty acids Amino sugars Non-toxic products Buck et al. (2001), Nelson-Filho et al. (2002), Tanomaru et al. (2003), and Jiang et al. (2003) It is accepted that the absence of a radiolucency does not guarantee the absence of a bony lesion (Bender & Seltzer 1961)
  • 21.
  • 22.
    22 Waltimo et al.(1999) C. albicans, C. glabrata, C. guilliermondii, C. krusei and C. tropicalis : Highly resistant to aqueous Ca(OH)2 1 • C. albicans: survives in a wide range of pH values 2 • Ca(OH)2 pastes: provide the Ca2+ ions necessary for the growth and morphogenesis of Candida Antifungal CH + CPMC/glycerine/CHX: more pronounced effect against fungi Siqueira et al. (2003)
  • 23.
  • 24.
    24 Teeth with apicalperiodontitis: Cocci and rods predominated and formed colonies on the root canal walls and also, to a varying degree, penetrated the dentinal tubules. (Sen et al.;1995) Even in teeth with completed endodontic treatment: microbes exist as biofilms in untouched locations in the main canal, isthmuses and accessory canals (Nair et al.;2005) Despite intracanal dressing with Ca(OH)2, E. faecalis formed biofilms in root canals • Distel et al; 2002 Ca(OH)2: 100% effective in eliminating E. faecalis biofilm • Chai et al; 2007 Activity against Biofilm
  • 25.
  • 26.
    26 First reported by: Hasselgrenet al. in 1988 In dentistry.. Ca(OH)2: dissolves pulp tissues (Andersen et al;1991)
  • 27.
    27 Tissue dissolving capacity Wadachi R, ArakiK, Suda H. Effect of calcium hydroxide on the dissolution of soft tissue on the root canal wall. Journal of Endodontics. 1998 May 1;24(5):326-30. Morgan et al. (1991) reported that Ca(OH)2 solution was an ineffective solvent of pulp tissue as an irrigant.
  • 28.
    28 Vehicle Determines thevelocity of ionic dissociation Types of vehicles (Fava & Saunders; 1999) 1. Water-soluble substances such as water, saline, anaesthetic solutions, carboxymethylcellulose, methylcellulose and Ringers solution. 2. Viscous vehicles such as glycerine, polyethyleneglycol (PEG) and propylene glycol. 3. Oil-based vehicles such as olive oil, silicone oil, camphor (the oil of camphorated parachlorophenol), some fatty acids (including oleic, linoleic, and isostearic acids), eugenol and metacresylacetate
  • 29.
    29 Determines the velocityof ionic dissociation Types of vehicles (Fava & Saunders; 1999) 1. Water-soluble substances such as water, saline, anaesthetic solutions, carboxymethylcellulose, methylcellulose and Ringers solution. - Sterile water and saline: most commonly used - Anaesthetic solution: Adequate vehicle (Athanassiadis et al. 2007) Vehicle
  • 30.
    30 Vehicle Determines thevelocity of ionic dissociation Types of vehicles (Fava & Saunders; 1999) 1. Viscous vehicles such as glycerine, polyethyleneglycol (PEG) and propylene glycol.  10–30% for a glycerine/water mixture and 10–40% for a propylene glycol/water - Higher concentration: may decrease effectiveness (Safavi & Nakayama 2000).  Ca and OH ions: release slowly and for longer time (Gomes et al; 2002), requires less number of appointment (Fava & Saunders 1999) Viscosity of the paste: (Behnen et al; 2001) Thick mixtures of Ca(OH)2 and water (1 g mL-1 H2O): significantly improved antimicrobial property than to a thin mix and Pulpdent
  • 31.
    31 Vehicle Determines thevelocity of ionic dissociation Types of vehicles (Fava & Saunders; 1999) 1. Oil-based vehicles such as olive oil, silicone oil, camphor (the oil of camphorated parachlorophenol), some fatty acids (including oleic, linoleic, and isostearic acids), eugenol and metacresylacetate
  • 32.
    Most commonly usedvehicle?? 32 Polyethylene glycol (PEG) Own substantial antibacterial activity (Chirife et al. 1983)  Klebsiella pneumoniae,  Pseudomonas aeruginosa,  Eschericha coli and  Staphylococcus aureus,
  • 33.
    Estrela et al.(2001) 33 (i) Ca(OH)2 in saline (ii) Ca(OH)2 in polyethylene glycol (iii) Ca(OH)2 in CMCP “Complete antimicrobial effect was observed after 48 h in both tests, irrespective of the Ca(OH)2 paste vehicle” Behnen et al. (2001) Ca(OH)2 decreased the numbers of E. faecalis at all depths within dentinal tubules up to 24 h “less viscous preparations of Ca(OH)2 were more effective in removal of bacteria than more viscous”
  • 34.
  • 35.
  • 36.
  • 37.
  • 38.
    38 Wang and Hume;1988, Haapasalo et al. 2000, Portenier et al. 2001 Dentine powder (18% w/v- 1.8% w/v ) Saturated Ca(OH)2 solution Prevent killing of E Faecalis 18% (w/v) bovine serum albumin Buffering effect of dentin
  • 39.
    39 Microtensile fracture strength: Reducesby almost 50% following 7-84 days of application (Rosenberg et al;2007) CH: increases elastic modulus of dentin (Kawamoto et al; 2008) Effect of CH on dentin Ca(OH)2 for an extended period (6 months to 1 year) results in reduced flexural strength and lower fracture resistance. Fracture resistance: Ca(OH)2-filled immature teeth in approximately 1 year attributed the frequent reports of fractures of immature teeth filled with Ca(OH)2 for extended periods (Andreasen et al;2002) Decreases significantly after 6 months of application (Doyonet al; 2005 Standard protocol of up to 30-day application of calcium hydroxide for infected mature teeth with apical periodontitis is safe and need not be adjusted. (Siqueira & Lopes 1999)
  • 40.
    40 Based on timeduration 1 month application: pH gradient with high values around the canal dressing towards the peripheral (Tronstad et al; 1981) 4 months application: Inner root dentin: within few hours Outer root dentin: 1-7 days To reach peak levels: 2-3 weeks (Nerwich et al; 1993) Diffusion of OH ions through dentin A final canal rinse with 3 mL 17% EDTA and 10 mL 6% NaOCl before Ca(OH)2 placement allowed the greatest hydroxyl ion diffusion to the root surface (Saif et al.;2008) Cervical root resorption Kehoe (1987) : reported a pH reversal from a slightly acidic to a slightly alkaline Hydroxyl ions diffusion: faster and reaches higher levels cervically more than apically
  • 41.
    Effects of Calciumhydroxide on Clinical outcome 41
  • 42.
    Post operative pain 42 Longterm outcome of treatment No difference in the incidence of postoperative pain between one- and multiple-visit root canal treatment (with calcium hydroxide inter- appointment dressing) Prevalence of postoperative pain ranges from 3% to 58% O’Keefe 1976, Mulhern et al. 1982, Mohammadi et al. 2006 and, Sathorn et al.2008
  • 43.
    43 Long term outcomeof treatment Trope et al. (1999): 1-year follow-up: 10% increase in healing rates in group with CH dressing for at least 1 week. Katebzadeh et al. (1999, 2000) Better results: Ca(OH)2 was used as an intracanal disinfecting medicament for 1 week. Weiger et al.2000, Molander et al.2007 Influence of Ca(OH)2 as an interappointment dressing on the healing of periapical lesion: No statistical significant difference Peters & Wesselink;2002 found no significant differences in healing of periapical radiolucency between teeth that were treated in one visit (without) and two visits with inclusion of Ca(OH)2 for 4 weeks.
  • 44.
    CHX versus CalciumHydroxide CHX + Calcium Hydroxide 44 E. Faecalis and c.albicans 2% CHX gel >> CHX/Ca(OH)2 >> Ca(OH)2 alone Waltimo et al; 1999, Gomes et al. (2006), Scha¨fer & Bossmann (2005) Removal of CHX + CH medicament: 7% maleic acid and 10% citric acid for 1 minute were superior to 17% EDTA in the removal of calcium hydroxide mixed with 2% chlorhexidine (Arslan H et al; 2014)
  • 45.
    Sodium hypochlorite v/sCalcium Hydroxide Sodium Hypochlorite + Calcium Hydroxide 45 7 days pretreatment with Pulpdent paste a non-setting Ca(OH)2 paste, followed by sodium hypochlorite irrigation: cleaned canal isthmuses effectively (Metzler & Montgomery;1989) Reduction in amount of debris: NaOCl for >30 s or Ca(OH)2 for 7 days. Combination of Ca(OH)2 and NaOCl: more effective (Wadachi et al; 1998)
  • 46.
    46 Removal of CHfrom the canals Effects of remnants on sealer adaptation and penetration Factors affecting removal of CH Vehicle used to prepare paste is more important (Nandini et al; 2006) Oil based: difficult to remove Type of irrigant used 10% citric acid, 10% maleic acid >> 17% EDTA >> 5.25% NaOCl (Nandini et al; 2006) Method no technique can remove Ca(OH)2 entirely. Endoactivator >> Ultrasonic >> EndoVac >> irrigants alone (Alturaiki S et al; 2015) Method no technique can remove Ca(OH)2 entirely. No significant difference among ProTaper, Reciproc, OneShape, WaveOne, and Manual groups (Altunsoy M et al; 2015)
  • 47.
    47 When to ReplaceCalcium Hydroxide dressing? R. Weiger, R. Rosendahl, and C. Löst, “Influence of calcium hydroxide intracanal dressings on the prognosis of teeth with endodontically induced periapical lesions,” International Endodontic Journal, vol. 33, no. 3, pp. 219–226, 2000. M. Trope, “Treatment of immature teeth with non-vital pulps and apical preriodontitis,” Endodontic Topics, vol. 14, pp. 51–59, 2006. L. R. G. Fava and W. P. Saunders, “Calcium hydroxide pastes: classification and clinical indications,” International Endodontic Journal, vol. 32, no. 4, pp. 257–282, 1999 Vehicle Duration Ca(OH)2 saline dressings 4-weeks period (Weiger et al; 1999, M trope et al; 2006) 7±47 days (mean value: 22 days) (Weiger et al; 2000). Open apex case: 7 days (minimum) – 30 days (maximum) (M Trope; 2006) Oil based (Eg Metapex) Should be replaced once in three months (Fava et al; 1999)
  • 48.
    48 Calcium Hydroxide andCO2 Fuss Z, Rafaeloff R, Tagger M, Szajkis S. Intracanal pH changes of calcium hydroxide pastes exposed to carbon dioxide in vitro. Journal of Endodontics. 1996 Jul 1;22(7):362-4.
  • 49.
    Toxicity of CH 49 Inthe cases of extensive Ca(OH)2 overextension, repair took more than 6 months to complete (De Moor and De Witte; 2002) One of the least irritating root-filling materials and was replaced by new bone within 12 weeks of placement (Spa°ngberg; 1969) Ca(OH)2: partially or totally resorbed and replaced by bony tissue. (Pissiotis & Spangberg; 1990)
  • 50.
    Barium Sulphate :CH – 1:8 50 36 months- follow up Orucoglu H, Cobankara FK. Effect of unintentionally extruded calcium hydroxide paste including barium sulfate as a radiopaquing agent in treatment of teeth with periapical lesions: report of a case. Journal of endodontics. 2008 Jul 1;34(7):888-91.
  • 51.
  • 52.
    Clinical significance 52 Sealers areresponsible for the principal functions of a root filling, namely, sealing the root canal system, entombment of remaining bacteria and the filling of irregularities in the canal system (Ørstavik 2005).
  • 53.
  • 54.
    54 CRCS (1982) Sealer26 Endoflas FS Powder Paste Bismuth trioxide, Calcium hydroxide, Hexametheylenetetramine, titanium dioxide Bisphenol epoxy resin Powder Liquid Zinc oxide, Calcium hydroxide, Iodoform, Barium Sulfate Eugenol Accelerator Zinc acetate
  • 55.
  • 56.
  • 57.
    57 AH 26 VersusCalcium hydroxide based sealer 35% of AH 26 samples 80% of Selapex samples Siqueira et al. (1999) were entirely recontaminated at 60 days by human saliva through coronal leakage. Leakage Ersahan S, Aydin C. Solubility and apical sealing characteristics of a new calcium silicate-based root canal sealer in comparison to calcium hydroxide-, methacrylate resin-and epoxy resin-based sealers. Acta Odontologica Scandinavica. 2013 Jan 1;71(3-4):857-62.
  • 58.
    58 Leakage Wu MK, DeGee AJ, Wesselink PR. Leakage of four root canal sealers at different thicknesses. International Endodontic Journal. 1994 Nov;27(6):304-8. Waltimo et al; 2001: Reported good results with Seal apex sealer Seal apex >> ZOE-based sealer
  • 59.
  • 60.
    60 Solubility in tissue fluid Esberard etal. (1996) Increase in pH when placed in distilled water: 9.14 (48 h after setting) Sleder et al. (1991) Sealapex could withstand long term exposure to tissue fluids without significant leakage. Tronstad et al. (1988) CRCS << Sealapex. McMichen et al. (2003) Apexit > AHPlus and Tubliseal
  • 61.
    61 Solubility in solvent Whitworth & Boursin(2000) Chloroform Benzene Xylene Halothane Eucalyptus oil Solubility Chloroform Halothane Apexit 11.6% 14.19% AHPlus 96% 68% Alzraikat H, Taha NA, Hassouneh L. Dissolution of a mineral trioxide aggregate sealer in endodontic solvents compared to conventional sealers. Brazilian oral research. 2016;30(1). Sealapex: Endosolv > Xylene > RC Solve Bedi H et al; 2018
  • 62.
  • 63.
    63 Cytotoxicity Genotoxicity Subcutaneous implant Intraosseous implants Usage study Human studies Brisenˇo& Willershausen (1992) Endoflas FS > CRCS > Apexit > Sealapex Eldeniz et al. (2007): 8 types of sealers Resin-based (Epiphany and Endo- REZ) and calcium hydroxide-based (Apexit and Acroseal) sealers >> Silicone based DNA damage: Huang et al. (2002) Resin-based sealer > Ca(OH)2-based sealer Specific dorsal subdermal tissue sites of 12 guinea pigs Grossman’s sealer, CRCS >> Sealapex and Endo-Fill (Yesilsoy et al. 1988) Zinc oxide-eugenol, Tubliseal >> Sealapex (Mittal et al; 1995)
  • 64.
    64 Cytotoxicity Genotoxicity Subcutaneous implant Intraosseous implants Usage study Human studies Berna´th& Szabo´ (2003) Type and degree of inflammatory reaction initiated by overfilling the root canals (Monkey) Endomethasone > AH 26 > Apexit and Grossman’s sealer
  • 65.
  • 66.
    66 Streptococcus anginosus (milleri) Roth> Sealapex (Mickel & Wright; 1999) E. faecalis Roth 811 (1.1 mm) > Sealapex (0.8 mm) > AH-Plus (no antimicrobial activity) (Mickel et al; 2003) Capnocytophaga ochracea, Porphyromonas gingivalis and Peptostreptococcus Roth Sealer > Ketac-Endo > Tubliseal > Apexit > Sealapex (Abdulkader et al; 1996) Antibacterial Factor: Time pH and calcium ion release Sealapex >> Sealer 26 >> Apexit Sealapex: more produced after 30 days. Sealer 26: highest release during the initial periods (Duarte et al; 2000)
  • 67.
  • 68.
    68 Overfilled canals containingCa(OH)2-based sealers: Chronic inflammatory reactions in the periapical tissues of dog’s teeth. (Soares et al; 1990) 3 months 6 months 9 months Shashirekha G, Jena A, Pattanaik S, Rath J. Assessment of pain and dissolution of apically extruded sealers and their effect on the periradicular tissues. Journal of conservative dentistry: JCD. 2018 Sep;21(5):546.
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    References 70 ▪ Arslan H,Gok T, Saygili G, Altintop H, Akçay M, Çapar İD. Evaluation of effectiveness of various irrigating solutions on removal of calcium hydroxide mixed with 2% chlorhexidine gel and detection of orange-brown precipitate after removal. Journal of endodontics. 2014 Nov 1;40(11):1820-3. ▪ Alturaiki S, Lamphon H, Edrees H, Ahlquist M. Efficacy of 3 different irrigation systems on removal of calcium hydroxide from the root canal: a scanning electron microscopic study. Journal of endodontics. 2015 Jan 1;41(1):97-101. ▪ Altunsoy M, Ok E, Tanrıver M, Capar ID. Effects of different instrumentation techniques on calcium hydroxide removal from simulated immature teeth. Scanning. 2015 Jul;37(4):265-9. ▪ Orucoglu H, Cobankara FK. Effect of unintentionally extruded calcium hydroxide paste including barium sulfate as a radiopaquing agent in treatment of teeth with periapical lesions: report of a case. Journal of endodontics. 2008 Jul 1;34(7):888-91. ▪ ASLAN T, DÜZGÜN S, ÜSTÜN Y. EFFECT OF LENTULO SPIRAL USAGE AT DIFFERENT SPEEDS ON APICAL EXTRUSION OF CALCIUM HYDROXIDE. Atatürk Üniversitesi Diş Hekimliği Fakültesi Dergisi.;28(2):133-7.
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    References 71  Andersen M,Lund A, Andreasen JO, Andreasen FM. In vitro solubility of human pulp tissue in calcium hydroxide and sodium hypochlorite. Dental Traumatology. 1992 Jun;8(3):104-8.  Wadachi R, Araki K, Suda H. Effect of calcium hydroxide on the dissolution of soft tissue on the root canal wall. Journal of Endodontics. 1998 May 1;24(5):326-30.  Yang SF, Rivera EM, Baumgardner KR, Walton RE, Stanford C. Anaerobic tissue-dissolving abilities of calcium hydroxide and sodium hypochlorite. Journal of endodontics. 1995 Dec 1;21(12):613-6.  Wu MK, De Gee AJ, Wesselink PR. Leakage of four root canal sealers at different thicknesses. International Endodontic Journal. 1994 Nov;27(6):304-8.  Ersahan S, Aydin C. Solubility and apical sealing characteristics of a new calcium silicate- based root canal sealer in comparison to calcium hydroxide-, methacrylate resin-and epoxy resin-based sealers. Acta Odontologica Scandinavica. 2013 Jan 1;71(3-4):857-62.  Bedi H, Bhullar KK, Malhotra S, Khanna R, Nain R. A COMPARISON OF EFFECTIVENESS OF DIFFERENT SOLVENTS IN DISSOLVING ROOT CANAL SEALERS-AN IN-VITRO STUDY. Indian Journal of Comprehensive Dental Care (IJCDC). 2018 Jul 1;8(2).  Alzraikat H, Taha NA, Hassouneh L. Dissolution of a mineral trioxide aggregate sealer in endodontic solvents compared to conventional sealers. Brazilian oral research. 2016;30(1).
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