Endodontic Topics 2006, 14, 93–101 Copyright r Blackwell Munksgaard

All rights reserved ENDODONTIC TOPICS 2008

1601-1538

Relationship between calcium

hydroxide pH levels in the root
canals and periodontal healing after
replantation of avulsed teeth
JENS OVE ANDREASEN, LILLI JENSEN & SØREN STENO AHRENSBURG
CHRISTENSEN

Calcium hydroxide [Ca(OH)2], when used as a root canal dressing, has been shown to promote periapical healing,
induce formation of an apical hard tissue barrier (apexification), and arrest infection-related root resorption. The
main mechanism of action is thought to be the high alkalinity of Ca(OH)2 ensuring a bactericidal or bacteriostatic
effect upon microorganisms in the root canal and dentinal tubules. Several anatomical factors related to the root
canal, such as the coronal access cavity, the apical foramen, the dentinal tubules, and existing resorption cavities on
the root surface, all allow leakage of hydroxide ions from the root canal. The purpose of the present clinical study
was to analyze pH changes in 63 permanent anterior teeth in which Ca(OH)2 (Calasepts) was used as an initial
canal dressing after replantation and subsequent pulp necrosis had developed. The pH changes in the pulp canal
were studied with relation to observation period, stage of root formation, healing of any periapical radiolucency,
infection-related root resorption, formation of an apical hard tissue barrier, and finally the radiographic appearance
of Ca(OH)2 in the canal (i.e. present or not). The study showed that several factors determined the pH level: the
observation period (i.e. observation periods exceeding 6 months showed a significant drop in pH level below a pH
of 10), an initial active inflammatory root resorption (tendency to be related to a drop in pH), and a subsequent
progression of infection-related resorption (the same tendency to be related to a drop in pH to below 10). The size
of the apical foramen and the length of the pulp had no relation to pH change. The radiographic disappearance of
Ca(OH)2 in the root canal (loss of radiopacity of the canal dressing) was found to be significantly associated with a
drop in pH (P 5 0.001). It was concluded that radiographic monitoring of the Ca(OH)2 presence in the root canal
is essential for endodontic treatment planning (i.e. when to replace Ca(OH)2 or perform a permanent root filling).
Furthermore, continuous activity of inflammatory root resorption may indicate a drop in pH and should result in
replacement of new Ca(OH)2. It should be noted that these findings apply to a Ca(OH)2 product (Calasepts) with
no added radiopaque material.

resorption has also been shown (17, 25–29). The

Introduction
mechanism of action for these events is thought to be
When calcium hydroxide [Ca(OH)2] is used as a root related to the antibacterial effect of Ca(OH)2 (30)
canal dressing, it has been shown clinically and whereby wound-healing processes in the pulp and
experimentally to disinfect root canals (1–10) and periodontal ligament are allowed to progress (15). The
thereby promote periapical healing (11–15), including antibacterial effect of Ca(OH)2 has been found to be
the formation of an apical hard tissue barrier (12, 15–24). closely related to the preparation’s level of pH (3, 6, 8,
Apart from this, arrest of infection-related root 9, 31). The pH of freshly prepared Ca(OH)2 is 12.5;

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Andreasen et al.

The purpose of the present study was to measure the

pH levels in Ca(OH)2-treated root canals of trauma-
tized teeth and to relate pH changes to observation
period, stage of root development, dimensions of the
root canal and the access cavity, presence of an apical
radiolucency, and infection-related root resorption.

Materials and methods

The study consisted of 63 avulsed and replanted
permanent teeth in which Ca(OH)2 was used as a root
canal dressing as part of the endodontic treatment for
pulp necrosis. The standard endodontic procedure was
pulp extirpation of necrotic tissue, usually to a level of
1–2 mm short of the apical foramen, followed by
mechanical preparation of the root canal with rotary
Hedstrom files (Micro-Megas, Besancon, France).
Cleansing of the root canal was performed with 1%
sodium hypochlorite (Miltons) to promote dissolu-
tion of necrotic tissue (43, 47). Thereafter the root
canal was rinsed with saline and a Ca(OH)2 paste
(Calasepts, Nordiska Dental, Ängelholm, Sweden)
was injected into the root canal using a cannula and a
syringe. This brand of Ca(OH)2 dressing has a pH of
12.5 and no added radiopaque material. The paste was
distributed in the canal using a Lentulo spiral instru-
Fig. 1. Schematic drawing illustrating possible pathways ment operated to the level of vital apical tissue. The
for hydroxide ions to disseminate.
material was then condensed with paper points to
remove moisture from the paste. This procedure was
repeated three times, after which the entrance to the
at this pH it has been shown that generally no bacteria root canal was closed with a cotton pellet and then
can survive with the exception of a few strains of sealed with fortified zinc oxide–eugenol (IRM
Enterococcus faecalis and Candida (32). However, cements, Dentsply Caulk, Milford, DE, US) to the
when a drop in pH takes place, in vitro studies have level of the mid portion of the coronal pulp cavity. A
shown that an increasing number of bacteria will radiograph was taken using a bisecting angle and a
survive (33–37). standardized exposure technique (48). At intervals
When Ca(OH)2 is placed in a root canal, continuing ranging from 1 month to 3 years, the root canals were
loss of hydroxide ions can be expected to take place reopened and pH calorimetric determined using a paper
through at least seven various pathways, namely the point inserted to the apical region. The paper point was
apical foramen, accessory canals, dentinal tubules and then pressed against a pH indicator (Alkalits E, Merch,
infection-related root resorption defects (38, 39) or via Darmstadt FRA, Germany). This indicator was able via
a leaking access cavity (40–42) (Fig. 1). Finally loss of color changes to discriminate pH changes from 7 to 12 at
hydroxide ions can also be related to the organic tissue 0.5 unit intervals (Fig. 2). An attempt was made to
dissolving effect of Ca(OH)2 on pulp remnants in the replace the Ca(OH)2 after 6–12 months. However, in
canal (43) and the inherent buffering capacity of dentin some cases, poor patient compliance resulted in longer
upon Ca(OH)2 (30, 44–46). Presently very little is intervals.
known about the time relation effect of such a drop in The following pre- and post-operative factors were
pH level due to the above-mentioned pathways. recorded in order to analyze their effect upon pH changes.

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 Periodontal healing after replantation of avulsed teeth

Root development was rated according to Moorrees

et al. (49) into the following stages:
Stage 4: root formation incomplete.
Stage 5: root formation complete, apical foramen
wide open.
Stage 6: root formation complete, apical foramen half
closed.
Stage 7: root formation complete, apical foramen
narrow.
For the purpose of this study, stages 4–6 were
considered incomplete root formation in comparison
to stage 7 with complete root formation.
The apical width and the length of the root canal were
measured on post-replantation radiographs with a
sliding calliper to the nearest tenth of a millimeter
(Fig. 3a). The width and length of the access cavity
filled with IRM was also measured and these measures
Fig. 2. pH indicator. A paper point after insertion into
were used to construct a surface area of the access cavity
the root canal is pressed against the test paper (Alkalits)
and the color change reveals the actual pH, in this case in mm2 (Fig. 3b).
pH 5 12. The periapical status of the treated teeth was
evaluated and if periapical radiolucencies were

Fig. 3. (a, b) Measurements of pulp length, apical pulp width, and length and width of coronal access cavity.

95
Andreasen et al.

registered, subsequent healing was defined if a return to The study shows that a high pH level could be
normal-sized periodontal ligament space occurred. maintained using Ca(OH)2 as a dressing for prolonged
A similar approach was followed with respect to the periods up to 1 year and sometimes even longer. As
presence of infection-related root resorption cavities. bacterial growth is strongly related to pH, it is a possibility
Healing was considered if resorption was observed to be that a sterile condition or a condition with few remaining
arrested and a new periodontal ligament space was noted bacteria in the root canal can be maintained for the same
radiographically. Formation of an apical hard tissue period. This could explain why Ca(OH)2 is generally very
barrier was registered with a file inserted in the root canal effective in promoting healing of a periapical lesion,
at the time of reopening of the canal. Presence of arresting infection-related root resorption and promoting
Ca(OH)2 in the canal was evaluated on consecutive the formation of an apical hard tissue barrier, all healing
radiographs and loss of Ca(OH)2 was registered when events which take place in situations with no or minimal
the radiopacity of the paste, as compared with that seen bacteria present (15, 50).
immediately after the material was inserted in the canal, The access cavity to the root canal has been shown to
had partially or totally disappeared. be a weak point for new bacterial invasion (40–42, 51)
In the statistical analysis, a w2 test or a Fisher’s exact and could represent a route of leakage for Ca(OH)2. In
test was used and 5% was considered as the critical the present study, the extent of the surface area of the
probability level. access cavity had a slight tendency to be related to a loss
of pH with surface areas of o70 mm2 having a slightly
lower pH. In this study, IRM was used as the sealing
Results
material on the premise of its stability in the oral milieu.
Table 1 shows the results of a comparison of pH loss The sealing capacity of zinc oxide compounds appears
(defined as a pH level below 10) and various parameters to be favorable with respect to bacterial microleakage
such as the observation period of first shift of Ca(OH)2, (52–55); whether hydroxide ions can actually penetrate
root development, size of apical diameter and pulp an intact IRM-sealing remains to be demonstrated.
length, dimension of coronal access cavity, the presence The stage of root development was found to be
of an apical radiolucency, infection-related resorption, significantly related to a loss of the alkaline effect of
and radiographic loss of Ca(OH)2 from the canal. It Ca(OH)2. This relationship can be explained by the
appears from Fig. 4 and Table 1 that the length and differences in the size of the pulp canal/periodontal
observation time before a change in Ca(OH)2 levels ligament interface that exists in the various stages of root
was significantly related to a drop in pH (P 5 0.05). development (Figs 1 and 2). The leaching effect is another
It also appears that generally no significant relation- way of losing hydroxide ions and is seen in the presence of
ships were found between pH levels and anatomical organic tissue in the root canal (pulp tissue) (43, 47).
measures of the tooth (root development) and the root The apical foramen theoretically appears to be a
canal (use of apical foramen and length of the pulp) and source of loss of hydroxide ions and the soft tissue
radiographic healing parameters. There was a tendency interface found here can be expected to allow dissipa-
that the presence of inflammatory resorption was more tion of ions. A limiting factor could be the apical
frequent in cases with a low pH. Furthermore, healing coagulation necrosis induced by the leaching effect and
of inflammatory resorption tended to be slightly more later the formation of a hard tissue barrier (18–20).
frequent in cases with a high pH (Fig. 5). However, this hard tissue barrier is not solid, but
It also appears from Table 1 that a strong significant penetrated by a number of vascular ramifications (17,
relationship exists between a radiographic loss of 22, 56–59). The relationship between root develop-
Ca(OH)2 in the root canal and a decrease in the pH ment and loss of hydroxide ions was not a factor in this
level below 10 (P 5 0.001) (Fig. 6). study and disproves significant pH loss via the apical
foramen, a phenomenon which can possibly be related
to the higher volume of Ca(OH)2 placed in teeth with
Discussion
immature root formation.
The time relationship to pH loss clearly demonstrated the Infection-related resorption cavities on the root
expected constant loss of hydroxide ions (Fig. 1). In surface may open up a direct pathway for both bacteria
addition, various other sources for pH loss were identified. and hydroxide ions from the pulp space through dental

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 Periodontal healing after replantation of avulsed teeth

Table 1. Relationship between various clinical factors and decrease in pH

pH first shift
pHo10 pH  10
Total P
n % n % Count

Observation o6 months 3 20 12 80 15
period
6–12 months 10 50 10 50 20 0.05

412 months 17 59 12 41 29

Root Root 12 55 10 45 22
development development (2–6)
0.37
Root 18 43 24 57 42
development (7)

Root Root 5 50 5 50 10
development development (2–5)
0.83
Root 25 46 29 54 54
development (6–7)

Coronal access o4 mm 17 45 21 55 38
cavity width 0.69
 4 mm 11 50 11 50 22

Coronal access o5 mm 23 46 27 54 50
cavity width 0.82
 5 mm 5 50 5 50 10

Coronal access o5 mm 9 60 6 40 15
cavity length 0.23
 5 mm 19 42 26 58 45

Coronal access o70 mm2 17 53 15 47 32

surface area 0.28
 70 mm2 11 39 17 61 28

Apical pulp  0.5 mm 17 44 22 56 39

width 0.51
40.5 mm 13 52 12 48 25

Apical pulp  1.0 mm 24 44 30 56 54

width 0.37
41.0 mm 6 60 4 40 10

Pulp length  18 mm 14 45 17 55 31
0.79
418 mm 16 48 17 52 33

Initial apical 1 Apical osteitis 25 45 30 55 55

osteitis 0.57
Apical osteitis 5 56 4 44 9

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Andreasen et al.

Table 1. Continued
pH first shift
pHo10 pH  10
Total P
n % n % Count

Initial inflammatory 1 Inflammatory 12 60 8 40 20

resorption resorption
0.16
Inflammatory 18 41 26 59 44
resorption

Shift 1. Inflamma- 1 Inflammatory 6 75 2 25 8

tory resorption
resorption 0.09
Inflammatory 24 43 32 57 56
resorption

Initial inflammatory 1 Inflammatory Shift 1. 1 Inflammatory 5 83 1 17 6

resorption resorption Inflammatory resorption
resorption 0.16

Inflammatory 7 50 7 50 14
resorption

Inflammatory Shift 1. 1 Inflammatory 1 50 1 50 2

resorption Inflammatory resorption
resorption 0.79

Inflammatory 17 40 25 60 42
resorption

Total Shift 1. 1 Inflammatory 6 75 2 25 8

Inflammatory resorption
resorption
Inflammatory 24 43 32 57 56
resorption

Shift 1. Loss of Total 23 88 3 12 26

Ca(OH)2 0.001
Partial 6 19 25 81 31

None 1 14 6 86 7

tubules (25–29, 38). The nearly significant relationship have different pH effects depending upon the vehicles
between a pH drop and the presence or progression of containing the Ca(OH)2 and additional ingredients [(60,
inflammatory resorption found in this study seems to 61), M. Haapasalo, personal communication, 2007].
support the notion that control of osteoclastic activities
relates to the level of pH in the pulp cavity. This is also
supported by a previous experimental study where a pH
Buffering effect of Ca(OH)2
level of 10 was found all the way from the root canal to
the PDL in areas with active root resorption (38). The diffusion of Ca(OH)2 through dentinal tubules to
The relationship between pH and time found in this the cementum layer and the root surface in the case of
study was related to only one brand of Ca(OH)2 inflammatory resorption has been demonstrated in vivo
(Calasepts), where the main constituent is Ca(OH)2 in monkeys by Tronstad et al. (38) and in vitro by
and no radiopaquer has been added. Other formulas may Nerwich et al. (39), Esberard et al. (61), and Gomes

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 Periodontal healing after replantation of avulsed teeth

Fig. 4. Relationship between observation time and pH at

first post-treatment evaluation.

Fig. 6. Gradual loss of Ca(OH)2 radiopacity in the canal

of a replanted tooth over a 6-month time period.
Observation period after Ca(OH)2 insertion: 0 days,
2 months, and 6 months.

teeth (41%) still had a pH level above 10. Loss of pH

appears, apart from the observation period, to have a
certain relationship to the size of the access cavity and
the presence of infection-related resorption. Further-
more, continuation of infection-related resorption also
had a tendency to be related to a drop in pH, indicating
the need for replacement of Ca(OH)2 when indicated.
Finally, loss of Ca(OH)2 demonstrated radiographi-
Fig. 5. Repair of infection-related root resorption cally, indicates a significant pH drop and a renewal of
involving a replanted central incisor. The pH in the
canal was 12 at the time of Ca(OH)2 placement. Ca(OH)2 should be considered.
Observation periods after Ca(OH)2 insertion: 0 days,
7 weeks, and 5 months as shown radiographically.

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