Calcium Hydroxide in the Treatment of Puipless Teeth with

Associated Pathology*
Geoffrey S. Heithersay, M.D.S.(Adel), F.D.S. R.C.S.(Edin), F.R.A.C.D.S.**
Department of Restorative Dentistry,
University of Adelaide.
INTRODUCTION '
Calcium Hydroxide has been one of the most extensively used materials in vital pulp
therapy since its original introduction in the form of Calxyl by Hermann in 1930. It
is of interest that calcium hydroxide has several uses in the treatment of puipless teeth
with associated pathology and these have been the subject of some clinical reports and
investigations and animal experiments over recent years. The impetus for the clinical
application of this material seems to have come mainly from Scandinavia in the late
fifties, although clinicians at that time would have been aware of earlier experimental
work which indicated its potential use.
Implantation of caleium hydroxide into connective tissues, other than the pulp, had
been carried out in experimental animals by Effinger (1953), Mitchell and Amos
(1957), Mitchell and Shankwalkcr (1958), McDonald et al (1959), Yoshiki et al (1960)
and Yoshiki and Mori (1961).
Mitchell and Amos (1957) noted the formation of calcified, bone-like tissue in the
fibrous capsule around a calcium hydroxide pellet implanted for 16 days subcu-
taneously in the rat. Mitchell and Shankwalker (1958), after further implantation '
experiments, concluded that calcium hydroxide has a unique potential to induce the
formation of heterotropic bone when implanted into the connective tissue of the rat.
Similar results were reported by McDonald et al (1959), Yoshiki et al (1960), Yoshiki
and Mori (1961) and later by Binnie (1967). However, their findings could not be
duplicated by Jeffrey (1962) or Laws (1962). More recently, Rasmussen and Mjor
(1971) could not verify calcium hydroxide as a bone inductor when placed in ectopic
locations. When calcium hydroxide was placed in direct contact with host tissue, they
observed fibrosis and occasional structures similar to immature bone. However, when
direct contact with host tissue was prevented by placing calcium hydroxide in millipore
filters,^ no significant reactions occurred, indicating that the material did not have a
stimulating action through diffusion over a distance.
Information regarding the bactericidal effect of calcium hydroxide on members of the
oral flora and a number of pathogenic spore-forming organisms has been available to
clinicians for some time, (Hermann (1930), Hailer and Haiken (1941), Jansen (1949),
Proell (1949)). Matsumiya and Kitamura (1961) published a signifieant study in rela-
tion to the use of calcium hydroxide in the treatment of puipless teeth. Their histo-
pathological and histobacteriological study was carried out on dogs whose root canals
had been experimentally infected. Regardless of the bacterial status of the root canal
at the time of the placement of the calcium hydroxide root filling, they were able to
report favourable periapical healing. They considered calcium hydroxide paste to he
an excellent filling material, having the effect of accelerating the natural healing func-
tions in the periapical tissues. Bacteria living in the depths of tissues were clearly
observed to diminish and finally disappear as healing progressed.

* Lecture, Gold Coast Endo-Perio Convention, Australia, October, 1974.

** Fan-time Lecturer in Endodontics, University of Adetaide.
74 Journal of the British Endodontic Society. 1975 Vol.8 No.2
 More recent knowledge regarding tissue reactions to calcium hydroxide has been proved
by Spangberg (1969). He was able to show, by experiments in the mandibles of
guinea pigs, that calcium hydroxide implants were replaced by bone after a twelve-
week observation period. Of all the root filling materials tested by Spangberg, calcium
hydroxide was the only one lo elicit this response.
The early clinical reports of the use of calcium hydroxide in puipless teeth related to
the problem of the incompletely developed tooth. Granath (1959) described the use
of this material in relation to the treatment of traumatised incisors in children. Subse-
quently there have been several clinical reports (Crahb 1965, Frank 1966, Blanc-Benon
1967, Day 1967, Zeldovv 1967, Kennedy et al 1967. Miehanowiez and Miehanowicz
1967, Steiner et al 1968, Van Hassel and Natkin 1969, 1970, Simpson 1970,
Heithersay 1970 (a) and (b) and, most recently, the extensive study of Cvek (1972).
Animal experiments have given valuable information regarding hard tissue formation in
incompletely developed puipless teeth with calcium hydroxide (Binnie and Rowe 1973,
Vojinovic 1975) or a combination of calcium hydroxide and camphorated parachloro-
phenol (Steiner and Van Hasscl 1971, Dylewski 1971, Ham et al 1972, and Torneck et
al 1973.)
Other uses of caleium hydroxide have been reported (Heithersay 1970 (b), Andreasen
(1971), Cvek (1973), Cvek et al (1974) and Cvek (1974). These have related to the
conservative treatment of large periapical lesions, control of inflammatory root resorp-
tion following luxation and replantation, and the treatment of transverse root fractures.
The aim of this paper is to outline the uses of calcium hydroxide in the treatment of
puipless teeth vvith associated pathology, to describe clinical procedures, and to discuss
possible modes of action of calcium hydroxide in relation to bone and hard tissue
repair.

MATERIAL AND CLINICAL METHOD

Puipdent Paste* — calcium hydroxide in a methyl cellulose base was the proprietary
product used in all illustrative clinical cases reported in this paper. The introduction of
calcium hydroxide paste followed normal bio-chemical preparation of the root canal.
An aqueous solution of Savlon** (chlorhexidine 0.03%, cctrimide 0.3%) was used for
root canal irrigation and the same solution was also utilised as a root canal dressing in
the early stages of most treatments.
Puipdent Paste was introduced into the prepared and dried root canal using a lentulo
spirtil root filler in a low-speed handpiece. The lentulo was advanced to approximately
3—5 mm. from the apex and a liberal quantity of the paste was spun into the canal.
A cotton pellet held in tweezers was then gently applied in the pulp chamber to ensure
that the material filled the apical region of the root canal, and also to allow the re-
moval of the excess paste from the pulp chamber. A fresh cotton pellet was then
inserted vvith an overlying seal of Cavit W.
If it were then anticipated that the paste was to remain in the canal for a period
longer than one month, an overlying temporary restoration was generally inserted.
Although amalgam was preferred in order to provide adequate strength and to protect
the underlying seal, I.R.M., a composite resin or a zinc cement were also used.
Removal of the Puipdent Paste was achieved by the use of normal irrigating agents and
minimal filing.

* Puipdent Corporation U.S.A. . , ,

** Imperial Chemical Industries U.K. , .
Journal of the British Endodontic Society. 1975 Vol.8 No.2 ' 75-
Of the calcium hydroxide preparations available, Puipdent Paste is preferred by the
author because of its decreased solubility in tissue fluids and also its physical consist-
ency which allows easy introduction into the root c:uial. I h e lack of positive radio-
opacity is perhaps a disadvantage. The pH of Puipdent Paste when tested in the
Institute of Technology, Adelaide, was 12.2.

CLINICAL APPLICATIONS
In general, calcium hydroxide is used in situations where hard tissue formation is
required and these are illustrated diagrammatically in Fig.l.

Fig 1 Diagram showing clinical situations where calcium hydroxide can he used. 1. exudation
coniTol 2. large periapical lesions 3. antibacterial dressing 4. temporary root filling
5. apical inflammatory resorption 6. inflammatory resorption following trauma 7. apical
internal resorption 8. internal external root resorption 9. perforations 10. transverse
root fractures 11. incompletely developed puipless teeth.

1. Control of Periapicai Exudation

Often the treatment of puipless teeth with large periapical lesions is eompHcated hy
persisting mild fluid exudation from the periapical region. Calcium hydroxide paste
may be used to control such a periapical discharge. The paste is generally introduced
into the canal and allowed to remain in position for a period of at least a week. It"
necessary, this procedure is repeated until exudation is no longer evident.
2. Temporary Root Filling in Teeth with Large Periapical Lesions
The treatment of puipless teeth with large periapical lesions often involves initially the
control of periapical exudation as above. Calcium hydroxide then inserted as a tempor-
ary root filling generally results in relatively rapid and predictable periapical healing.
3. Dressing Agent in Routine Endodontic Therapy
Puipdent Paste or other calcium hydroxide pastes may be used as a root canal dressing
between visits, as it is an efficient bactericidal agent, in addition to its other beneficial
properties. Nevertheless, it is not recommended tbat it be used in lliis manner on the
first root canal dressing appointment, as it has been found that acute exacerbations of
chronic pcriapicaJ lesions occasionally occur. ]t is suggested that ihe materia) is intro-
duced on the second and subsequent dressing appointments.
76 Journal of the British Endodontic Society. 1975 Vol.8 No.2
 4, Temporary Root Filling where Time does not Permit the Completion of Normal
Endodontic I'reatnient
Occasions arise where patients may be v\nab!e lo attend for completion of routine
treatment for some weeks or months. In tliese situations, ealeium hydroxide intro-
duced into the canal as a temporary root filling provides a continuous bactericidal
action on any residual bacteria and also can usually effect periapical repair and apical
remodelling in the interim. A good double overlying seal is essential for these cases.

5. Control of Apical Resorption Resulting from Chvonic Periapical Pathology

If irregular apical root resorption has occurred, it is often difficult to achieve a satis-
factory apical seal with conventional root canal fillings. Calcium hydroxide paste
introduced for periods of approximately three months to one year can effect both
apical remodelling and periapical repair, thus facilitating the eventual placement of a
root tilling.
I

Case Report 1.
A male, aged 42 years, presented with a large periapical lesion related lo his right
central incisor which was puipless (Fig. 2). All other teeth gave positive sensitivity
tests. The canal was prepared using normal endodontic procedures and dressed initially
with Savlon. Puipdent Paste was intrtnluced into the canal at the third appointment as
there was a persistent periapieal discharge.
The canal was irrigated and dressed with Puipdent Paste on two further occasions, on
the last of wliich the paste was sealed into the canal with Cavit W and an overlying
amalgam restoration. After twelve months, almost complete periapical repair had been
achieved (Fig. 3). At this stage a permanent root filling of gutta percha and AH 26
was inserted. A follow-up examination eighteen months later showed satisfactory heal-
ing (Fig. 4).

fprr-

Fig.2 Fig.3 Fig. 4

Fig 2 Case Report 1. A large periapical lesion associated with a puipless upper right central
incisor in a 42 year old male.
Fig 3 Twelve months after the insertion of calcium hydroxide - methyl cellulose paste
(Puipdent Paste) evidence of periapical healing can be seen radw graphic ally.
fig 4 Eighteen months after completion of a gutta percha root filling, satisfactory periapical
repair has been achieved.
Journal of the British Endodontic Society, 1975 Vol.8 No.2 77
 Case Report 2.
A 24-year-old male presented with a puipless central incisor which exhibited apical
resorption and also a large associated periapical lesion (Fig. 5). The canal was prepared
hy conventional debridement using Savlon as both an irrigating and dressing agent on
the first two appointments. Subsequently, Puipdent Paste was introduced on the third
and fourth appointments and left in position for six months. At this stage apical
remodelling and periapical repair was evident (Fig. 6). It was then possible to place a
conventional root filling as an apical barrier was present which prevented any extrusion
of gutta percha or sealing agent beyond the apex (Fig. 7).

Fig.5 Fig. 6 Fig. 7

Fig 5 Case Report 2. Male, 24 years. Irregular apical root resorption of the upper left central
incisor with an associated large periapical lesion is evident. After root canal preparation
Puipdent Paste was introduced.
Fig 6 Six months later there are sigJis of periapical repair and apical remodelling.
Fig 7 Radiograph after insertion of gutta percha and AH 26 root filling showing apical closure
with hard tissue.

Case Report 3.
A twenty-year-old woman presented for endodontic treatment of her upper left central
and lateral incisors. An inadequate root filling vvas present in the upper central incisor
(Fig. 8). Both teeth exhibited apical resorption and a large periapical lesion was evi-
dent. The teeth were prepared endodontically, irrigated and dressed with Savlon on
four occasions, then dressed with Puipdent Paste. The final dressing was left in pos-
ition and the patient was then reviewed at three-monthly intervals. After twelve
months it was evident that good apical remodelling and apical repair had occurred
(Fig. 9). Gutta percha root fillings were able to be placed without fear of overfilling
(Fig. 10).
78 Journal of the British Endodontic Society, 1975 Vol.8 No.2
 Fig.8 Fig. 9 Fig. 10

Fig 8 Case Report 3. Apical resorption and a large periapical lesion are shown related to ati
inadequately root-filled central incisor and puipless lateral incisor in a 20-year-old woman.
Fig 9 Periapical repair and signs of hard tissue formation apically can be seen twelve months
after the insertion of a temporary root filling of Puipdent Paste.
Fig 10 Fotlow-up radiograph after the insertion of conventional root fillings.

6. External Irinammatory Root Resorption Dtie to Trauma e.g. Luxation or

Following Replantation
Periapical and apical resorption of inflammatory origin has been considered to be due
to the effect of bacteria within tbe canal or to tissue breakdown products aeting
through the apical foramen or the dentinal tubules (Andreasen and Hjorting—Hansen,
1966). It is characterised by bowl-like areas of resorption in bone, ccmentum or
dentine. Sucb areas of resorption can be controlled by the use of dressings of calcium
hydroxide paste in the canal. Ihis is illustrated in the following case report of a tooth
which had been accidentally avulsed. .. , , , •

Case Report 4.
An eight-year-old girl avulsed her upper right central incisor. It was replanted within
one hour and splinted (Fig. 11). Six months later signs of inflammatory resorption
could be seen radiographically (Fig. 12). The patient was referred for endodontic
treatment five years later when gross inflammatory root and bone resorption was evi-
dent. After biomechanical preparation of the root canal, Puipdent Paste was introduced
(Fig. 13). Six months later there was evidence of repair and a permanent rt)ot filling
of gutta percha and AH 26 was therefore inserted. Twelve years after replantation the
tooth vvas still functional, the inflammatory resorplion appeared to have been con-
trolled and periapical repair vvas complete (Fig. 14).
It should be noted that calcium hydroxide when used as a root canal dressing material
after replantation has no effect on replacement resorption (ankylosis). This is a pro-
gressive process which frequently follows replantation and will result in the ultimate
loss of the tocjth.
Journal of the British Endodontic Society. 1975 Vol.8 No.2 79
 Fig. 11 Fig. 12

Fig 11 Case Report 4. Upper central incisor of an eight-year-old girl after replantation and
splin ting.
Fig 12 Six-month radiographic follow-up shoioing inflammatory root and bone resorption.

Fig. 13 Fig. 14

Fig 13 Five years later, gross resorption is evident. At this stage, Puipdent Paste was introduced
to control resorption.
Fig 14 Radiographic follow-up twelve years after replantation showing periapical repair and
stabilisation of root resorption. (From Heithersay. 1975)

7. Control of Internal Resorption in the Apical Region

An area of internal resorption in the apical region indicates that viable tissue is present.
Fortunately such resorption can often he reversed by the introduction of calcium
hydrt)xide paste.
80 Journal of the British Endodontic Society, 1975 Vol.8 No.2
 Case Report 5. _ . •
A iwenty-two-year-old patient presented vvith a second premolar tooth exhibiting an
area <jf internal resorption in the apical region. Root canal preparation down to tbe
resorbed area vvas followed by ihc insertion of Puipdent Vnslc (Fig. J5). Nine months
later sulficient deposition of calcified tissue v\'ithin the canal had occurred t(j allow the
completion of a conventional root filling (Fig. 16).

Fig.JS Fig. 16

Fig 15 Case Report 5. 22-year-old male. An area of internal resorption is evident in the apical
third region (arrow). Calcium hydroxide dressing is in position.
Fig 16 Nine months later the resorbed area has repaired allowing completion of the gutta percha
root filling.

8. Control of Internal/External Resorptive Defects

Root defects which have commenced as an area of intcrtial resorption close to an
accessory canal appear to stimulate external resorption. The resulting defect, which
later may have an associated inflammatory bony lesion, may often be controlled and
hard tissue formation encouraged by the use of calcium hydroxide paste.

Case Report 6.
A 35-year-oId male presented with an upper right lateral incisor vvhich had an area of
resorption on the distal aspect ot" the root. AUUough there was \s.\\ associaVcd bony
lesion there was no apparent periapical involvement (Fig. 17). Alter preparation of
the caaiil Puipdent Paste was instrumented into ihc resorbed area. There was evidence
of bone repair after six months (Fig. 18) and a root filling of gutta percha was inserted
to the level of the resorptive defect.
Journal ofthe British Endodontic Society, 1975 Vol.8 No.2 _ 81
 Fig. 17 Fig. 18

Fig 17 Case Report 6. 35-year-old male. A large resorptive defect can be seen in the upper right
lateral incisor.

Fig 18 Six tnonths after root canal debridgemetit and root filling with Puipdent Paste, good
repair is evident.

Case Report 7.
A 34-year-old male presented with a localised buccal swelling which regularly dis-
charged. This was associated with an internal/external resorptive defect in his lower
right first premolar (Fig. 19). There was also a large periapical lesion. The tooth had
been root treated several years earlier. The old root filling vvas removed and the canal,
which appeared to bifurcate in the mid-root region, was prepared and dressed on two
occasions. Puipdent Paste was introduced on the third and fourth appointments and
sealed in with Cavit and amalgam. 'Ihree months later there was clinical and radio-
graphic evidence of healing both periapically and buccally. The Puipdent dressing was
left in position for ten months, at which stage healing was almost complete (Fig. 20).
This was followed by a root filling of gutta percha and AH 26. A three-year follow-up
radiograph is shown in Fig. 2L

Fig.l9 Fig.2O Fig.21

Fig 19. Case Report 7. 34-year-old male with internal-external resorption defect in his lower
right first premolar in addition to a large periapical lesion. A buccatly drainitig swelling
was presetii.

Fig 20 Ten months after the insertion of Puipdent Paste, excellent repair is evident, facilitating the
placement of a gutta percha root filling.
Fig 21 A three-year radiographic follow-up.

82 , Journal ofthe British Endodontic Society. 1975 Vol.8 No.2

 9. Management of Perforations
Iatrogenic perforations can often be stabilised by inserting calcium hydroxide paste.
This assists in the formation of some hard tissue al the site of the perforation in ad-
dition to encouraging bone repair in the region.
Case Repori S.
A 15-year-old boy presented with a large fluctant swelling on the palatal aspect of his
upper left central incisor. A poorly-fitting crown was in position and there were radio-
graphic signs of a large bone defect.
This was confirmed when the palatal swelling was incised, 'l'he crown vvas removed to
reveal a massive palatal perforation. After root canal debridement, a Savlon dressing
was inserted on two occasions. Subsequently Puipdent Paste was inserted on three
further appointments over a period of two months. During this time the fluid exudate
from the palatal defect was totally ct)ntrolled. The canal was then temporarily filled
with Puipdent Paste, Cavil and amalgam. Over the next six months there was evidence
of sufficient healing to allow the final root filling to be placed (Fig. 23). Subsequently
a new crown was constructed.

Fig.23

Fig 22 Case Report 8. 15-year-old boy. with evidence of botie loss related to large perforation
oti the palatal aspect of his cetttral incisor.
Fig 23 Six months after the itisertion of Puipdent Paste, bone repair had occured and the root
canal could be satisfactorily filled.

10. Treatment of the Transverse Root Fractures In particular Where Resorption has
Occurred between tlie Fractured Segments or within the Root Canal
Teeth with transverse root fractures in the mid-root sections generally maintain vitality
in the apical segment but may show evidence of pulp necrosis in the coronal segment
and resorption of toolh and bone at the fracture site. Occasionally internal root
res(jrption ;ilso occurs in this region. The desirable form of treatment aims at achiev-
ing remodelling of the tooth, and bone formation between the fractured segments.
Calcium hydroxide paste inserted in the root canal of the coronal segment lo the pos-
ition of the fracture site will generally result in a satisfactory healing response. In a
clinical study in which calcium hydroxide vvas used in the treatment of 17 root-
fractured incisors, Cvek (1974) reported complete healing in all cases. Hard tissue
closure at the apical end of the coronal segment was radiographically complete in 13
cases and incomplete in four.
Journal of the British Endodontic Society. 1975 Vol.8 No.2 • 83
 Case Report 9.
A 12-year-old boy received a blow to his upper left central incisor, resulting in a trans-
verse root fracture in the mid-root region. Pulp necrosis occurred subsequently in the
coronal segment, in addition to some internal resorption at ihe fracture site (Fig. 24).
Tlie canal was endodontically prepared to the level of the fracture, irrigated with
Savlon and dressed with Puipdent Paste (Fig. 25). The dressing was replaced on one
occasion and then left in position for seven months, at vvhich stage there was evidence
of repair. At the time of insertion of the root filling, a positive barrier was encoun-
tered at the fracture site facilitating the insertion of a gutta percha root filling (Fig. 26).
A three-year radiographic check showed evidence of satisfactory healing (Fig. 27).

Fig. 24 Fig. 2 5

Fig 24 Case Report 9. 12-year-old boy with a transverse root fracture in his left cetitral incisor.
Evidetice of internal root resorption cati be seen at the fracture site.
Fig 25 Radiographic appearance after itisertion of Puipdent Paste in ihe coronal segment down to
the level of the fracture.

Fig. 26 Fig.27

Fig 26 Hard tissue formation at the extremity of the coronal segment was evident after seven
months allowing simple placement of a gutta percha root filling.
Fig 27 A three-year follow-up showing good repair.
84 , , Journal of the British Endodontic Society, 1975 Vol.8 No.2
 11. Apex Formation in Pulpless Incompletely Developed Teeth
Undoubtedly the most exciting of the applications of calcium hydroxide in pulpless
teeth relates to the conservative approach to the treatment of the so-called "blunder-
buss" incisor. This therapy has been shown to give excellent vesuUs regiudlcss of the
periapical pathology. Treatment consists of simple endodontic debridement with
avoidance of ovei-zealous instrumentation. Tins is followed by tlie insertion of calcium
hydroxide paste, as a temporary root filling material, and an overlying seal of Cavit W
and amalgam. Periapical healing, accompanied by apical calcification or alternatively
root development, can be ob.ser\'ed as early as three months post-operatively, and may
continue ftir several years. Tl\e mode of healing varies considerably and is probably
related to the severity and duration of the periapical inflammatory reaction.
The most commonly obsei-ved apical cliange Involves the formation, of a calcific dome
or barrier. This may take several forms (Frank, 1966; Cvek, 1972) but histological
evaluation of human material has shown ccinentum-like tissue with loose connective
tissue inclusions (Cvek and Sundstrom, 1974). Case Report 10 illustrates this type of
response.
Where formative elements — presumably Herwig's Sheath — have survived the periapical
involvement, ihe polential remains for continued apical development in either of two
forms, illustrated below (Case Reports 1 I and 12). Both cases exhibited total necrosis
of the pulp and vadiogiaphic evidence ol periapieal bone ilestruclion witli U>ss of
lamina dura, in accordance with the criteria laid down by Cvek (19 72). The reaction
observed in Case Report 11 corresponds to the bistological description of human
material reported by Ileithersay (J970), in which it was obsewed that the newly-
formed apical tissue consisted of relatively normal dental structures, viz, dentine of an
inter-globular nature, cementum and a pulp-like tissue. Dentine had formed, not only
apically, but also had been laid down on the internal aspect of the root canal. Radio-
graphic evidence of this dentine deposition is evident in Case Report 11.
Case Report 12 illustrates a further response. A calcified barrier similar to that formed
in Case Report 10 is formed, above which a relatively normal apex develops. Witiiin
this apex a fine root canal with an additional opening on the lateral aspeet of the canal
is a consistent finding. Cvek (1972) interpreted this last response in a different fashion,
as he considered the apical section to develop independently and then either join with
the coronal section or remain discrete. The three types ol response as illustrated in
these case reports are shown diagrammatically in Fig. 41 (Page 90).

Case Jieport JO.

A 7-year-old girl presented in May 1967 with a history of a blow to her upper incisors
two months earlier. Examination of the central incisor teeth revealed total necrosis of
the pulps and periapical involvement (Figs. 28, 29). The canals were endodontically
prepared and filled with Pulpdent Paste, with an overlying seal of Cavit and zinc
cement. The right central incisor was re-dressed six months later due to a hreakdown
in the overlying seal. Ternporary amalgam restorations were then placed to ensure a
better seal.
The teeth were reviewed regularly and by October 1971 adequate apical barriers had
formed (Fig. 30} to allow the placement of gutta pereha and AH 26 root fillings.
Small openings were evident on the lateral aspect of the calcified domes. A follow-up
radiograph lour years later (Fig. 31) after the completion of orthodontic treatment
revealed complete stability.
Journal of the British Endodontic Society, 2975 Vol.8 No.2 , 85
 Fig.28 Fig.29

Fig 28 Case Report 10. 7-year-old girl with an upper right central incisor showing periapical
radiolucency, the result of a blow two months earlier.
Fig 29 Left central incisor with signs of similar patholgy.

.- • r:;

Fig. 30 Fig.31

Fig 30 Calcified domes have formed at the apical extremity of the root canal. The canals had
been dressed with Pulpdent Paste four years earlier.
Fig 31 Eight-year follow-up showing the apical barriers and normal periapical bone. Note the
small defect on the mesial aspect of the left central incisor which has been filled with
sealing agent.

Case Report JJ.

An eight-year-old boy who had received a blow to his upper left central incisor two
months earlier, was seen by his local dentist when an acute periapical infection devel-
oped. The tooth was opened for drainage and the patient referred for endodontic
treatment. Radiographic examination showed that the incisor was incompletely devel-
oped and also that periapieal bone resorption had occurred (Fig. 32). The tooth was
biomechanically prepared and the canal dressed <m three occasions with P.N.Ii. solution
(Polymyxin, Neomycin and Iiacitracin (Cran, 1957)) until sterility had Iieen achieved.
Pulpdent Paste was then introduced and sealed. Three months later there were radio-
graphic signs of periapical repair and apical root development (Fig. 33). The tooth was
checked regularly and after two years root development appeared to be complete
(tig. 34). However narrowini; of the root canal was also evident. Thirty nine me months
86 Journal of the British Endodontic Society, 1975 Vol.8 No.2
 after the commencement of treatment, ingrowing viable tissue was removed and the
root canal prepared to the apex to allow placement of a gutta percha and AH 25 root
filling. A follow-up radiograph (Fig. 35) revealed satisfactory healing.

Fig.32 Fig.33

Fig 32 Case Report II. 8-year-old boy ivith left central incisor showing periapical radiolucency.
The tooth had been traumatised two months earlier.
Fig 33 Three months after root canal preparation and insertion of Pulpdent Paste signs of root
development and periapical repair can be seen.

Fig.34 Fig.35

Fig 34 Root development and narrowing of the original root canal are visible two years later.
Fig 35 Follow-up after endodontic preparation to the apex and placement of a gutta percha root
filling.

Case Report 12.

An eight-year-old boy presented with swelling of the upper lip associated with pulpless
upper right eentral incisor. There was a history of trauma several weeks earlier.
Emergency treatment provided by the patient's dentist had consisted of establishing
local drainage through the root canal. A radiograph taken at the time of examination
is showii in Fig. 36. After tlie acute infection had been controlled, the canal was
irrigated with Savlon and dressed with P.N.B. solution. This procedure was repeated
twice. Following the second occasion a bacterial test indicated that the canal was
sterile. Pulpdent Paste was then introduced into the canal with a lentulo spiral root
filler and the palatal opening was .sealed with Cavit W and ..malgam. Some evidenee of
Journal of the British Endodontic Society, 1975 Vol.8 No.2 87
apical calcification and root development could be seen three months later. Alter live
months the general features of the slowly developing root eanal could be seen
(Fig. 37). 'I'he patient was then checked at six-monthly Intervals for the next five and
a half years without any further dressing l)cing placed in the canal. The stage of devel-
opment in Augtist 1972 is shown in Fig. 38. By January 1973 further development
in the apieal region had occurred with calcified narrowing oi the apieal and lateral
canals (Fig. 39). At this stage a root filling of guUa percha and AH 26 was inserted,
slight sensation being experienced by the patient indicating a connection with tlie
main root eanal by some viable tissue periapically. A follow-up radiograph two years
later (eight years after the initial treatment) is shown in Fig. 40.

Fig. 36 Fig.37

Fig 36 Case Report 12. 8-year-old boy. Radiograph of recently erupted right central incisor
which had been traumatised several weeks earlier. The canal had been opened due to
acute periapical symptoms. Loss of lamina dura is evident.
Fig 37 Five months after insertion of calcium hydroxide paste the skeleton outline of the apex is

Fig.38 Fig.39 Fig. 40

Fig 38 Details of the apical development can be identified after 5^2 years. A calcified barrier
occludes the original wide root canal. The new apex contains a fine root canal with a
lateral branch.
big 39 Six months later (6-year follow-up) shows continuing calcification within the apical and
lateral canal.
Fig 40 Two years after the placement of the gutta percha root filling and eight years since the
original Pulpdent dressing the apical region appears well developed and quite stable.
88 Journal of the British Endodontic Society, 1975 Vol.8 No.2
 Fig 41 Diagrammatic representation of Case Reports 10, 11 and 12 to illustrate three main
types of development.
.., . 1. A, B, Formation of calcified barrier or dome.
2. Root development with relatively normal dental structures. Apical canal
contains ingrowing viable tissue; a lateral canal is present at the junction
zone, and there is narrowing of the old root canal.
3. Calcific bridging at the extremity of the old root eanal. Above this relatively
normal root development occurs.
A Amalgam ; *
C Cavit' W
CP Cotton Pellets -
/* Pulpdent Paste , . , . .

DISCUSSION
The clinical applications of calcium hydroxide in general involve hard tissue formation
and it is of interest to speculate on possible modes of action. The alkalinity of the
material (pH 12.2) may have several effects. As processes of inflammation involve an
acidic reaction, calcium hydroxide may act as a local huffer and as a result have a
favourable effect on bone healing. However, Mitchell and Shankwalker (1958) con-
cluded that it was difficult to ascribe any importance to the pH of the material when
considering potential osteogenesis, as other materials which had relatively high pH
values when used In their experiments did not result in consistent hard tissue forma-
tion. ,• ,. .,, ^
Journal of the British Endodontic Society, 1975 Vol.B No.2
The high pH of the material would certainly account for its stnmg bactericidal effect.
Generally, micro-organisms cannot survive a pH of 9.5 and only rare organisms can
survive a pH of 1 1 or higher (Hugo 1971). Accordingly its use as a root canal dressing
agent seems justified on the basis of its bactericidal properties and for this reason it
seems unnecessary to comhine it with yet another powerful antibacterial agent —
eomphorated parachlorophenol. Nevertheless, it is difficult to explain hard tissue
formation on the basis of efficient bacterial destruction alone.
Its action may be purely the irritant effect of a strong alkali, with cells in the im-
mediate area I)eing destroyed and cells further away being stimulated to respond with
calcification.
In discussing reactions of pulp tissue to calcium hydroxide, Nyborg (1959) eonsidered
them to be dependent on the hydroxyl rather than calcium ions. This view was sup-
ported by Schroder and Granath (1971). Yoshida, (1959), Sciaky and Pisanti (1960),
using radioactive calcium 45, showed that the ealcium salts in the calcified bridge
were not derived from the calcium hydroxide paste, but from tissue fluids. Neverthe-
less, calcium ions may be of importance when calcium hydroxide is used in the treat-
ment of pulpless teeth with associated pathology. The calcium ions may effect hard
tissue formation by exerting a positive action on the mass of new capillaries which
would be found in the granulation tissue associated with these pulpless teeth. Such
newly-formed capillaries have a definite characteristic of leaking. High calcium ion
concentration should result in less leakage at the capillary junctions and would also
eause contraction of the precajjiilary sphincters, thus resulling in less plasma outllow.
This would account for the clinical use of the material in controlling periapical exu-
dation. In addition, the diminished plasma outflow would probably favour a calcific
response in the involved tissue.
The collagen matrix may be the prime factor in calcification and calcium ions could
be related to enzyme reactions in collagen synthesis. One particular enzyme which is
involved in most productive energy-using processes is pyrophosphatase, it is also
calcium ion dependent. Pyropliospliate is irreversibly altered to ortliophosphate by
pyrophosphatase, and this reaction shifts the equilibrium towards the side ol utilisation.
If the presence of a high calcium ion concentration increases the action of pyrtiphos-
phatase, it might follow that it would also increase the energy utilisation and therefore
favour both defence and repair, mechanisms.
If the nature of the ground substance, rather than the stereochemical configuration of
collagen is the main factor in calcification, the above suggestions regarding this enzyme
system would still apply.
Ol)viously, the basic biological mechanisms involved when calcium hydroxide is used in
endodontics require further investigation and will no doubt be the subject of further
research reports. Nevertheless, the use of this material in the clinical situations out-
lined not only simplifies treatment but also appears to favour good connective tissue
repair, particularly where hard tissue formation is desirable.
r.- ; , I

SUMMARY
Calcium hydroxide has been used in the treatment of pulpless teeth in recent years.
The elinical applications generally Involve hard tissue formation. Large periapical
lesions; apical, peripheral or internal root resorption; perforations, transverse root
fractures and incompletely developed teeth, are all clinical situations where the ma-
terial can be used to advantage. In addition it is of use in the control of periapical
exudation, as a routine dressing material in endodontic therapy and as a temporary
root lining if time does not permit the completion of normal treatment.
90 , Journal of the British Endodontic Society, 1975 Vol.8 No.2
Hie clinical procedures involved in the use of Pulpdent Paste (calcium hydroxide in
the methyl cellulose base, pH 12.2) have been outlined and possible modes of action
have heen discussed. These include the effect of the pH of calcium hydroxide on
inflammed tissue and bacteria; the possible role of calcium ions on capillaries and the
involvement of calcium-dependent enzyme systems in the calcification process.

ACKNOWLEDGEMENTS
The author wishes to thank former colleagues at the Department of Endodontics,
Royal Dental School, Malmo, Sweden, for advice on this subject, Mrs. Lorna Zaieski
and Mr. Tom Rollings for technical help, Drs. Tony Martin and Rory Hume for infor-
mation regarding pyrophosphatase activity.
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Journal of the British Endodontic Society, 1975 Vol.8 No.2 . 93