Int Endodontic J - 2011 - Mohammadi

doi:10.1111/j.1365-2591.2011.01886.
Review
Properties and applications of calcium hydroxide in

endodontics and dental traumatology
Z. Mohammadi1 & P. M. H. Dummer2

1
Department of Endodontics, Hamedan University of Medical Sciences, Hamedan, Iran; and 2Endodontology Research Group,
School of Dentistry, Cardiff University, Cardiff, UK
Abstract dentine and its toxicity. Pure calcium hydroxide paste

has a high pH (approximately 12.5–12.8) and is
Mohammadi Z, Dummer PMH. Properties and applications
classified chemically as a strong base. Its main actions
of calcium hydroxide in endodontics and dental traumatology.
are achieved through the ionic dissociation of Ca2+
International Endodontic Journal, 44, 697–730, 2011.
and OH) ions and their effect on vital tissues, the
Calcium hydroxide has been included within several induction of hard-tissue deposition and the antibacte-
materials and antimicrobial formulations that are used rial properties. The lethal effects of calcium hydroxide
in a number of treatment modalities in endodontics. on bacterial cells are probably due to protein dena-
These include, inter-appointment intracanal medica- turation and damage to DNA and cytoplasmic mem-
ments, pulp-capping agents and root canal sealers. branes. It has a wide range of antimicrobial activity
Calcium hydroxide formulations are also used during against common endodontic pathogens but is less
treatment of root perforations, root fractures and root effective against Enterococcus faecalis and Candida
resorption and have a role in dental traumatology, for albicans. Calcium hydroxide is also an effective anti-
example, following tooth avulsion and luxation inju- endotoxin agent. However, its effect on microbial
ries. The purpose of this paper is to review the biofilms is controversial.
properties and clinical applications of calcium hydrox-
ide in endodontics and dental traumatology including Keywords: antimicrobial, apexification, calcium
its antibacterial activity, antifungal activity, effect on hydroxide, dental traumatology, endodontics, root
bacterial biofilms, the synergism between calcium resorption, vital pulp therapy.
hydroxide and other agents, its effects on the proper-
ties of dentine, the diffusion of hydroxyl ions through Received 11 November 2010; accepted 29 March 2011
bacterial biofilms, the synergism between calcium

Introduction
hydroxide and other agents, its effects on the properties
Materials and therapeutic agents containing calcium of dentine, the diffusion of hydroxyl ions through
hydroxide are used extensively in a variety of treatment dentine, and its toxicity. The paper sets out initially to
modalities within endodontics and dental traumatology. provide the background to the main clinical applica-
The main purpose of this article is to review the tions of calcium hydroxide (Ca(OH)2) and then focuses
properties and clinical applications of calcium hydrox- on its specific properties and more detailed uses.
ide in endodontics and dental traumatology including
its antibacterial activity, antifungal activity, effect on
Background
Correspondence: Zahed Mohammadi, Department of Endodon-

Root canal medicaments
tics, Hamedan Dental School, Shahid Fahmideh Street, Microorganisms are the cause of apical periodontitis
Hamedan, Iran (e-mail: mohammadi_zahed@yahoo.com). (Kakehashi et al. 1965, Möller et al. 1981, Sundqvist
ª 2011 International Endodontic Journal International Endodontic Journal, 44, 697–730, 2011 697
13652591, 2011, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2591.2011.01886.x by Cochrane Chile, Wiley Online Library on [16/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Calcium hydroxide in endodontics and dental traumatology Mohammadi & Dummer
1992) and their elimination from the root canal space followed by placement of a calcium hydroxide paste
during root canal treatment results in predictable to fill the canal system for 6–24 months (Frank 1966).
healing of apical pathosis (Byström & Sundqvist
1981). Indeed, many studies have demonstrated that Traumatology
teeth with infected root canals at the time of canal Dental trauma involves damage to teeth and the
filling have substantially poorer outcomes than root supporting tissues. Intracanal medicaments containing
canals where no culturable microorganisms could be calcium hydroxide are used to control internal resorp-
detected (Molander et al. 2007). Unfortunately, the tion (Haapasalo & Endal 2006) as well as inflammatory
complete elimination of bacteria by instrumentation apical root resorption (Majorana et al. 2003). Further-
alone is unlikely to occur (Byström & Sundqvist more, the International Association of Dental Trauma-
1981, Wu et al. 2006). In addition, pulp tissue tology (2007) guidelines recommend that any tooth
remnants may prevent microorganisms from being with a necrotic pulp associated with a luxation injury
entombed (Haapasalo et al. 2007) as well as have a should be dressed with a calcium hydroxide medica-
negative impact on the root filling in terms of its ment until the root canal is filled. For avulsion injuries,
physical properties and adaptation to the canal walls the use of calcium hydroxide medicament is recom-
(Wu et al. 2006). Thus, some form of irrigation and mended for up to 1 month (Kawashima et al. 2009).
disinfection is necessary to kill and remove microor-
ganisms, their by-products and residual tissue, as well
Retrieval of literature
as remove the smear layer and other debris from the
canal system. Such chemical (therapeutic) treatments A Medline search was performed from 1971 to the end
of the root canal can be arbitrarily divided into of 2009 and was limited to English-language papers.
irrigants, canal rinses, and inter-appointment medi- The keywords searched on Medline were ‘calcium
caments; calcium hydroxide is included in this latter hydroxide AND endodontics (1943)’, ‘calcium hydrox-
group. ide AND Enterococcus faecalis (134)’, ‘calcium hydrox-
ide AND Candida albicans (51)’, ‘calcium hydroxide
Endodontic sealers AND endotoxin (23)’, ‘calcium hydroxide AND dentine
Sealers are responsible for the principal functions of (986)’, ‘calcium hydroxide AND biofilm (17)’, ‘calcium
root fillings, which aim to prevent reinfection. That is, hydroxide AND sodium hypochlorite (174)’, ‘calcium
sealing the root canal system by entombing remaining hydroxide AND chlorhexidine (145)’, ‘calcium hydr-
bacteria and filling of irregularities in the prepared oxide AND vital pulp therapy (121)’, ‘calcium hydrox-
canal system (Ørstavik 2005). The rationale for the ide AND apexification (138)’, ‘calcium hydroxide AND
addition of calcium hydroxide to root canal sealers root fracture (59)’, ‘calcium hydroxide AND root
eminates from observations of liners and bases con- resorption (203)’, ‘calcium hydroxide AND perforation
taining Ca(OH)2 and their antibacterial and tissue (32)’ and ‘calcium hydroxide AND avulsion (73)’.
repair abilities (Ørstavik 2005). Then, the reference section of each of those articles was
studied to find other suitable sources. The number of
Immature teeth with open apices retrieved papers was presented in the parentheses.
The primary purpose of treating immature permanent
teeth with saveable pulps is to maintain pulp health
Characteristics of calcium hydroxide
and allow root development to continue. Vital pulp
therapies include indirect and direct pulp-capping,
Chemical composition and activity
partial (superficial) pulpotomy and cervical pulpotomy.
Traditionally, mechanically exposed, but otherwise Calcium hydroxide was introduced to endodontics as a
healthy, pulps of permanent teeth have been capped direct pulp-capping agent (Hermann 1920). It is a
with a wound dressing containing calcium hydroxide white odourless powder with the chemical formula
(Schuurs et al. 2000). In teeth with open apices and Ca(OH)2 and a molecular weight of 74.08 (Farhad &
necrotic pulps, creating a barrier across the apical Mohammadi 2005). It has low solubility in water
foramen is important to fill the root canal adequately. (around 1.2 g L)1 at 25 C), which decreases with a
Historically, creation of a suitable environment for the rise in temperature (Siqueira & Lopes 1999). It has
formation of a calcified barrier involved cleaning and been demonstrated that the dissociation coefficient of
shaping the canal to remove bacteria and debris Ca(OH)2 (0.17) controls the slow release of both
698 International Endodontic Journal, 44, 697–730, 2011 ª 2011 International Endodontic Journal
Mohammadi & Dummer Calcium hydroxide in endodontics and dental traumatology
calcium and hydroxyl ions (Rehman et al. 1996). This

Mode of action
low solubility is a useful clinical characteristic as an
extended period is necessary before it becomes solubi- Depending on its application, the mode of action of
lized when in direct contact with fluids from vital Ca(OH)2 may vary.
tissues (Spångberg & Haapasalo 2002). The pure
powder has a high pH (approximately 12.5–12.8) Antimicrobial activity
and is insoluble in alcohol (Farhad & Mohammadi The antimicrobial activity of Ca(OH)2 is related to the
2005). The material is chemically classified as a strong release of hydroxyl ions in an aqueous environment
base, its main actions come from the ionic dissociation (Siqueira 2001). Hydroxyl ions are highly oxidant free
of Ca2+ and OH) ions and their effect on vital tissues, radicals that show extreme reactivity with several
generating the induction of hard-tissue deposition and biomolecules. This reactivity is high and indiscrimi-
being antibacterial (Siqueira & Lopes 1999). nate, so this free radical rarely diffuses away from sites
According to Rehman et al. (1996), Ca(OH)2 disso- of generation (Siqueira & Lopes 1999). The lethal
ciates into calcium and hydroxyl ions on contact with effects of hydroxyl ions on bacterial cells are probably
aqueous fluids. Estrela & Pesce (1996) analysed chem- due to the following mechanisms (Siqueira & Lopes
ically the liberation of calcium and hydroxyl ions from 1999):
Ca(OH)2 pastes with vehicles of different acid–base and • damage to the bacterial cytoplasmic membrane;
hydrosolubility characteristics in the connective tissues • protein denaturation; and
of dogs. Taking into account the molecular weight of • damage to the DNA.
calcium hydroxide (74.08), the percentage of hydroxyl Although scientific evidence suggests that these
ions is 45.89%, whilst 54.11% corresponds to the three mechanisms may occur, it is difficult to establish,
calcium ions (Estrela & Pesce 1996). Ca(OH)2 in water in a chronological sense, which is the main mechanism
has a thixotropic behaviour and will be fluid when involved in the death of bacterial cells after exposure to
agitated (Spångberg & Haapasalo 2002). a strong base (Siqueira & Lopes 1999). Estrela et al.
When Ca(OH)2 is exposed to carbon dioxide (CO2) or (1994) studied the biological effect of pH on the
carbonate ions (CO3)) in biological tissue, its dissoci- enzymatic activity of anaerobic bacteria and concluded
ation leads to the formation of calcium carbonate that hydroxyl ions from Ca(OH)2 developed their
(CaCO3) and an overall consumption of Ca2+ ions. mechanism of action in the cytoplasmic membrane.
However, it has been shown that after 30 days of This membrane is responsible for essential functions
exposure to carbon dioxide, six preparations of such as metabolism, cellular division and growth, and
Ca(OH)2 maintained a purportedly bactericidal pH it takes part in the final stages of cellular wall
within the root canal (Estrela & Pesce 1997). Estrela formation, biosynthesis of lipids, transport of electrons
& Pesce (1997) analysed chemically the formation of and oxidative phosphorylation. Extracellular enzymes
calcium carbonate in the connective tissue of dogs and act on nutrients, carbohydrates, proteins and lipids
showed that when saline vehicles were used with that, through hydrolysis, favour digestion. Intracellular
Ca(OH)2 in a paste, the rate of formation of calcium enzymes located in the cell favour respiratory activity of
carbonate was practically unaltered. Estrela & Bam- the cellular wall structure. The pH gradient of the
mann (1999) evaluated the presence of calcium cytoplasmic membrane is altered by the high concen-
carbonate in samples of Ca(OH)2 stored for 2 years in tration of hydroxyl ions from calcium hydroxide acting
containers under varying conditions. They determined on the proteins of the membrane (protein denatur-
CaCO3 by means of volumetric analysis of neutraliza- ation). The high pH of Ca(OH)2 alters the integrity of
tion, using hydrochloric acid, and visualization with the cytoplasmic membrane through chemical injury to
methyl orange and phenolphthalein. The level of the organic components and transport of nutrients or
Ca(OH)2 converted into calcium carbonate ranged by means of the destruction of phospholipids or
from 5 ± 1% to 11 ± 1% and was not sufficient to unsaturated fatty acids of the cytoplasmic membrane,
interfere with its properties. observed in the peroxidation process, which is a
In summary, calcium hydroxide is a white odourless saponification reaction (Estrela et al. 1999).
powder and is chemically classified as a strong base; in Adjustment of intracellular pH is influenced by
contact with aqueous fluids, it dissociates into calcium several cellular processes such as the following:
and hydroxyl ions. • cellular metabolism;
• alterations in shape, mobility, adjustment of trans- Ca(OH)2 in direct contact with connective tissue
porters and polymerization of cytoskeleton compo- gives rise to a zone of necrosis, altering the physico-
nents; chemical state of inter-cellular substance which,
• activation of cellular proliferation and growth; through rupture of glycoproteins, determines protein
• conductivity and transport through the membrane; denaturation. The formation of mineralized tissue
and following contact between Ca(OH)2 and connective
• isosmotic cellular volume. tissue has been observed from the 7th to the 10th day
Thus, many cellular functions can be affected by pH, following application (Holland 1971). Holland (1971)
including the enzymes that are essential for cellular also reported the existence of massive granulation in
metabolism (Putnam 1995). Estrela et al. (1998) found the superficial granulosis zone interposed between the
that bacterial enzymatic inactivation under extreme zone of necrosis and the deep granulosis zone. These
conditions of pH for a long period of time was structures are composed of calcium salts and calcium–
irreversible. protein complexes and are birefringent to polarized
In summary, the antimicrobial activity of Ca(OH)2 is light, reacting positively to chloramilic acid and to Van
related to the release of highly reactive hydroxyl ions in Kossa’s method, proving that part of the calcium ions
an aqueous environment, which mainly affects cyto- come from the protective material. Below the deep
plasmic membranes, proteins and DNA. granulation zone is the proliferation cellular zone
and the normal pulp. Holland et al. (1999) evaluated
Mineralization activity the reaction of rat subcutaneous connective tissue to
When used as a pulp-capping agent and in apexifica- the implantation of dentine tubes filled with Ca(OH)2.
tion cases, a calcified barrier may be induced by At the tube openings, there were Von Kossa-positive
calcium hydroxide (Eda 1961). Because of the high pH granules that were birefringent to polarized light. Next
of pure calcium hydroxide, a superficial layer of to these granulations, there was irregular tissue
necrosis occurs in the pulp to a depth of up to 2 mm resembling a bridge that was Von-Kossa positive in
(Estrela & Holland 2009). Beyond this layer, only a the walls of dentinal tubules a structure highly
mild inflammatory response is seen and, provided the birefringent to polarized light appeared as a layer at
operating field is kept free from bacteria when the different depths.
material was placed, hard tissue may be formed (Estrela In summary, the mineralizing action of Ca(OH)2 is
et al. 1995). However, commercial products containing directly influenced by its high pH. The alkaline pH not
Ca(OH)2 may not have such an alkaline pH. only neutralizes lactic acid from osteoclasts, but could
The hydroxyl group is considered to be the most also activate alkaline phosphatases, which play an
important component of Ca(OH)2 as it provides an important role in hard-tissue formation.
alkaline environment, which encourages repair and
active calcification. The alkaline pH induced not only Effect of liquid vehicle
neutralizes lactic acid from osteoclasts, thus preventing The vehicles mixed with Ca(OH)2 powder play an
dissolution of the mineral components of dentine, but important role in the overall dissociation process
could also activate alkaline phosphatases that play an because they determine the velocity of ionic dissocia-
important role in hard-tissue formation (Estrela et al. tion causing the paste to be solubilized and resorbed at
1995). The pH necessary for the activation of this various rates by the periapical tissues and from within
enzyme varies from 8.6 to 10.3, according to the type the root canal. The lower the viscosity, the higher will
and concentration of substratum, temperature and be the ionic dissociation. The high molecular weight of
source of enzymes (Estrela et al. 1999). Alkaline common vehicles minimizes the dispersion of Ca(OH)2
phosphatase is a hydrolytic enzyme that acts by means into the tissues and maintains the paste in the desired
of the liberation of inorganic phosphatase from the area for longer periods of time (Athanassiadis et al.
esters of phosphate. It can separate phosphoric esters, 2007).
freeing phosphate ions, which then react with calcium There are three main types of vehicles:
ions from the bloodstream to form a precipitate, 1. Water-soluble substances such as water, saline,
calcium phosphate, in the organic matrix. This precip- anaesthetic solutions, carboxymethylcellulose,
itate is the molecular unit of hydroxyapatite (Seltzer & methylcellulose and Ringers solution.
Bender 1975), which is believed to be intimately 2. Viscous vehicles such as glycerine, polyethylene-
related to the process of mineralization. glycol (PEG) and propylene glycol.
3. Oil-based vehicles such as olive oil, silicone oil, various pathogenic bacteria including Klebsiella pneu-
camphor (the oil of camphorated parachlorophenol), moniae, Pseudomonas aeruginosa, Eschericha coli and
some fatty acids (including oleic, linoleic, and isostearic Staphylococcus aureus, which is in addition to any other
acids), eugenol and metacresylacetate (Fava & Saun- substances added to the PEG base as a medicament
ders 1999). (Chirife et al. 1983). In a study by Camões et al. (2003)
Ca(OH)2 should be combined with a liquid vehicle the pH in an aqueous medium was tested outside the
because the delivery of dry Ca(OH)2 powder alone is roots of human teeth when various vehicles (aqueous
difficult, and fluid is required for the release of hydroxyl or viscous) were used with Ca(OH)2. They reported that
ions. Sterile water or saline are the most commonly vehicles with glycerine and PEG 400 had a tendency to
used carriers. Aqueous solutions promote rapid ion acidification during the first 8 days (pH 6.85 to 6.4 –
liberation and should be used in clinical situations. PEG 400) but then the pH returned to the levels of the
Although dental local anaesthetic solutions have an other groups after 42 days (pH 7.1 – PEG 400).
acidic pH (between 4 and 5), they provide an adequate In summary, the vehicle to which calcium hydroxide
vehicle because Ca(OH)2 is a strong base, which is is added affects the physical and chemical properties of
affected minimally by acid (Athanassiadis et al. 2007). the compound and therefore its clinical applications.
The effects of glycerine and propylene glycol vehicles Compared with water-soluble agents, viscous and oily
on the pH of Ca(OH)2 preparations were investigated vehicles prolong the action of the calcium hydroxide
using conductivity testing by Safavi & Nakayama but can have associated negative side effects.
(2000). A range of 10–30% for a glycerine/water
mixture and 10–40% for a propylene glycol/water
Calcium hydroxide when used in
mixture resulted in the greatest conductivity. They
medicaments during root canal treatment
reported that a higher concentration of these vehicles
may decrease the effectiveness of Ca(OH)2 as a root
Definition of a medicament
canal medicament (Safavi & Nakayama 2000). Viscous
vehicles are also water-soluble substances that release A medicament is an antimicrobial agent that is placed
calcium and hydroxyl ions more slowly and for longer inside the root canal between treatment appointments
periods (Gomes et al. 2002). A viscous vehicle may in an attempt to destroy remaining microorganisms
remain within root canals for several months, and and prevent reinfection (Weine 2004). Thus, they may
hence the number of appointments required to change be utilized to kill bacteria, reduce inflammation (and
the dressing will be reduced (Fava & Saunders 1999). thereby reduce pain), help eliminate apical exudate,
In addition to the type of vehicle used, the viscosity of control inflammatory root resorption and prevent
the paste can influence antimicrobial activity, espe- contamination between appointments (Farhad & Mo-
cially for Ca(OH)2. Behnen et al. (2001) reported that hammadi 2005). When intracanal medicaments were
thick mixtures of Ca(OH)2 and water (1 g mL)1 H2O) not used between appointments, bacterial numbers
resulted in a significant reduction in antibacterial increased rapidly (Byström & Sundqvist 1981).
activity against E. faecalis in dentine tubules compared
to a thin mix and the commercial product Pulpdent
Anti-bacterial activity
paste (Pulpdent Corporation, Watertown, MA, USA).
Oily vehicles have restricted applications as they are Calcium hydroxide will exert an antibacterial effect in
difficult to remove and leave a residue on the canal the root canal system as long as a high pH is
walls. The difficulty of removing them from the canal maintained (Siqueira & Lopes 1999). In their in vivo
walls will affect the adherence of sealer or other study, Byström et al. (1985) reported that root canals
materials used to fill the canal (Fava & Saunders treated with Ca(OH)2 had fewer bacteria than those
1999); they are not recommended. dressed with camphorated phenol or camphorated
Polyethylene glycol (PEG) is one of the most monochlorophenol (CMCP). They attributed this to
commonly used vehicles in root canal medicaments, the fact that Ca(OH)2 could be packed into the root
and it possesses an ideal array of properties including canal system allowing hydroxyl ions to be released over
low toxicity, high solubility in aqueous solutions and time. Stevens & Grossman (1983) also reported
low immunogenicity and antigenicity (Athanassiadis Ca(OH)2 to be effective in preventing the growth of
et al. 2007). Concentrated PEG 400 solutions have microorganisms but to a limited extent when compared
their own substantial antibacterial activity against to CMCP, stressing the necessity of direct contact to
achieve the optimum antibacterial effect. Sjögren et al. E. faecium remained viable in dentinal tubules after
(1991) demonstrated that a 7-day application of a relatively extended periods of Ca(OH)2/saline mixture
Ca(OH)2 medicament was sufficient to reduce canal treatment. Ørstavik & Haapasalo (1990) observed that
bacteria to a level that gave a negative culture. Han Ca(OH)2 could take up to 10 days to disinfect dentinal
et al. (2001) found that aqueous Ca(OH)2 paste and tubules infected by facultative bacteria. Siqueira &
silicone oil-based Ca(OH)2 paste were effective in the Uzeda (1996) demonstrated that Ca(OH)2 mixed with
elimination of E. faecalis in dentinal tubules. Shuping saline was ineffective in eliminating E. faecalis and
et al. (2000) showed that placement of Ca(OH)2 for at E. faecium inside dentinal tubules after 1 week of
least 1 week rendered 92.5% of canals bacteria free. contact. Estrela et al. (1999) found that Ca(OH)2 in
Estrela et al. (2001) assessed two methods for deter- infected dentinal tubules had no antimicrobial effect on
mining the antimicrobial effectiveness of (i) Ca(OH)2 in S. faecalis, S. aureus, B. subtilis, P. aeruginosa or on the
saline, (ii) Ca(OH)2 in polyethylene glycol and (iii) bacterial mixture used throughout the experiment.
Ca(OH)2 in CMCP. They concluded that both the direct Waltimo et al. (2005) found that a Ca(OH)2 dressing
exposure test and agar diffusion test (ADT) were useful between appointments did not have the expected effect
in establishing the antimicrobial spectrum of Ca(OH)2 in terms of disinfection of the root canal system nor the
and for developing improved infection control proto- treatment outcome. Weiger et al. (2002) concluded
cols. A complete antimicrobial effect was observed after that the viability of E. faecalis in infected root dentine
48 h in both tests, irrespective of the Ca(OH)2 paste was not affected by Ca(OH)2. In a systematic review to
vehicle. Behnen et al. (2001) demonstrated that assess the antibacterial efficacy of Ca(OH)2, Sathorn
Ca(OH)2 decreased the numbers of E. faecalis at all et al. (2007) evaluated eight clinical trials including
depths within dentinal tubules up to 24 h and that less 257 cases. They concluded that Ca(OH)2 had limited
viscous preparations of Ca(OH)2 were more effective in effectiveness in eliminating bacteria from human root
the elimination of E. faecalis from dentinal tubules than canals when assessed by culture techniques.
viscous preparations. In a polymerase chain reaction study (PCR), the
In a study to evaluate the effect of electrophoretically effect of root filling with or without prior Ca(OH)2 or
activated Ca(OH)2 on bacterial viability in dentinal 2% chlorhexidine (CHX) on the persistence of bacterial
tubules, Lin et al. (2005) reported that treatment with DNA in infected dentinal tubules was evaluated (Cook
electrophoresis was significantly more effective than et al. 2007). The report indicated that 2% CHX
pure Ca(OH)2 up to depths of 200–500 lm. Specimens treatment followed by canal filling was more effective
treated with electrophoretically activated Ca(OH)2 in removing the DNA of E. faecalis than placement of
revealed no viable bacteria in dentinal tubules to a Ca(OH)2 or immediate canal filling. Using an agar
depth of 500 lm from the root canal space within diffusion method, Ballal et al. (2007) found that 2%
7 days. CHX gel was a more effective medicament than
Portenier et al. (2005) concluded that E. faecalis cells Ca(OH)2 paste against E. faecalis. Krithikadatta et al.
in the exponential growth phase were the most (2007) reported that, as an intracanal medicament, 2%
sensitive to Ca(OH)2 and were killed within 3 s to CHX gel alone was more effective against E. faecalis
10 min. Cells in a stationary phase were more resis- when compared to Ca(OH)2. Lee et al. (2008) con-
tant, with living cells being recovered at 10 min. cluded that a polymeric CHX-controlled release device
However, cells in a starvation phase were the most (PCRD) was significantly more effective in reducing
resistant and were not totally eliminated during the intradentinal bacteria than Ca(OH)2.
10-min test period. In summary, although some clinical studies have
By contrast, several studies have attested to the supported the efficacy of calcium hydroxide as an
ineffectiveness of Ca(OH)2 in eliminating bacterial cells. intracanal medicament, other studies have questioned
DiFiore et al. (1983) reported that Ca(OH)2 had no its efficacy and indicated CHX instead of calcium
antibacterial effect as a paste or as the commercial hydroxide.
preparation, Pulpdent, when used against S. Sanguis,
findings that were confirmed by Siqueira et al. (1998).
Anti-endotoxin activity
Haapasalo & Ørstavik (1987) reported that a Ca(OH)2
paste (Calasept; Speiko, Darmstadt, Germany) failed to Endotoxin, a part of the cell wall of all Gram-negative
eliminate, even superficially, E. faecalis in dentinal bacteria, is composed of polysaccharides, lipids and
tubules. Safavi et al. (1990) demonstrated that proteins and is referred to as lipopolysaccharide (LPS),
emphasizing its chemical structure (Westphal 1975, In a laboratory study, Safavi & Nichols (1993)
Rietschel & Brade 1992). Lipid A is the region of the evaluated the effect of Ca(OH)2 on bacterial LPS and
endotoxin molecule responsible for its toxic effects. concluded that it hydrolysed the highly toxic lipid A
When free to act, endotoxins do not cause cell or tissue molecule that is responsible for the damaging effects of
pathosis directly, but they stimulate competent cells to endotoxin. In another study, they found that Ca(OH)2
release chemical mediators (Leonardo et al. 2004). transformed lipid A into fatty acids and amino sugars,
Macrophages are the main target of endotoxins (Leo- which are atoxic components (Safavi & Nichols 1994).
nardo et al. 2004), which, therefore, are not intrinsi- These results were confirmed in studies by Barthel et al.
cally toxic. (1997) and Olsen et al. (1999) who reported that
Endotoxin (LPS) is released during multiplication or Ca(OH)2 detoxifies bacterial LPS in vitro.
bacterial death causing a series of biological effects Nelson-Filho et al. (2002) carried out an in vivo study
(Barthel et al. 1997), which lead to an inflammatory to evaluate radiographically the effect of endotoxin plus
reaction (Rietschel & Brade 1992) and periapical bone Ca(OH)2 on the periapical tissues of dog’s teeth. They
resorption (Stashenko 1990, Yamasaki et al. 1992). observed that endotoxin caused the formation of
Endotoxins from vital or nonvital, whole or fragmented periapical lesions after 30 days and that Ca(OH)2
bacteria act on macrophages, neutrophils and fibro- inactivated bacterial LPS. Silva et al. (2002) analysed
blasts, leading to the release of a large number of histopathologically periapical tissues of teeth in dogs in
bioactive or cytokine chemical inflammatory media- which the root canals were filled with bacterial LPS and
tors, such as tumour necrosis factor (TNF), interleukin- Ca(OH)2. They reported that LPS caused the formation
1 (IL-1), IL-5, IL-8, alpha-interferon and prostaglandins of periapical lesions and that Ca(OH)2 detoxified this
(Leonardo et al. 2004). endotoxin in vivo. Tanomaru et al. (2003) evaluated
Currently, one of the concerns in endodontics is the the effect of biomechanical preparation using different
treatment of teeth with necrotic pulps and periapical irrigating solutions and a Ca(OH)2-based root canal
pathosis because post-treatment disease persists more dressing in a dog experimental tooth model containing
often than in cases without periapical disease (Leo- endotoxin. Biomechanical preparation with only irri-
nardo et al. 1993, Katebzadeh et al. 1999). In teeth gating solutions did not inactivate the endotoxin;
with chronic periapical lesions, there is a greater however, the same treatment associated with the use
prevalence of Gram-negative anaerobic bacteria dis- of the Ca(OH)2 dressing was effective in the inactivation
seminated throughout the root canal system (dentinal of the toxic effects of this endotoxin. Jiang et al. (2003)
tubules, apical resorptive defects and cementum lacu- also evaluated the direct effects of LPS on osteoclasto-
nae), including apical bacterial biofilm (Leonardo et al. genesis and the capacity of Ca(OH)2 to inhibit the
1993, Katebzadeh et al. 1999, Nelson-Filho et al. formation of osteoclasts stimulated by endotoxin. They
2002, Trope et al. 1999). Because these areas are reported that Ca(OH)2 significantly reduced osteoclast
not reached by instrumentation, the use of a root canal differentiation. Buck et al. (2001) found that long-term
medicament is recommended to aid in the elimination Ca(OH)2 as well as 30-min exposure to an alkaline
of these bacteria and thus increase the potential for mixture of CHX, ethanol and sodium hypochlorite did
clinical success (Leonardo et al. 1993, Katebzadeh detoxify LPS molecules by hydrolysis of ester bonds in
et al. 1999, Nelson-Filho et al. 2002). Teeth with and the fatty acid chains of the lipid A moiety.
without radiographic evidence of periapical disease In summary, endotoxin, a component of the cell wall
could be considered as different pathological entities of Gram-negative bacteria, plays a fundamental role in
requiring different treatment regimens. Where bone the genesis and maintenance of periapical lesions
loss has occurred, the use of a root canal medicament because of the induction of inflammation and bone
between treatment sessions is recommended by some resorption. Ca(OH)2 inactivates endotoxin, in vitro and
(Leonardo et al. 2000a), because the success of treat- in vivo, and appears currently the only clinically
ment in cases with periapical pathosis is directly effective medicament for inactivation of endotoxin.
related to the elimination of bacteria, products and A recent concern indirectly related to the use of
subproducts from the root canal system. The proce- Ca(OH)2 as a medicament and the outcome of treatment
dures and medicaments used in root canal treatment has focused on the limitations of conventional radio-
should not only lead to bacterial death, but also to the graphic techniques. Post-treatment apical periodontitis
inactivation of bacterial endotoxin (Leonardo et al. with bone loss may not result in a visible apical
2004). radiolucency on a conventional or digital film,
depending on the density and thickness of the overlying E. faecalis (Waltimo et al. 1999b). Because C. albicans
cortical bone, and the distance between the lesion and survives in a wide range of pH values, the alkalinity of
the cortical bone. When a bone lesion is within the saturated Ca(OH)2 solution may not have any effect on
cancellous bone and the overlying cortical bone is C. albicans. In addition, Ca(OH)2 pastes may provide the
substantial, the bone lesion may not be visible radio- Ca2+ ions necessary for the growth and morphogenesis
graphically (Stabholz et al. 1994, Ricucci & Bergenholtz of Candida. These mechanisms may explain why
2003). Therefore, post-treatment apical periodontitis Ca(OH)2 has been found to be ineffective against
can be radiographically visible or invisible. Clinically, it C. albicans (Siqueira & Sen 2004).
has been reported that a large lesion of up to 8 mm in Siqueira et al. (2001) investigated the antifungal
diameter can be present without radiolucency (Wu et al. ability of several medicaments against C. albicans,
2006). Thus, it now appears that conventional radio- C. glabrata, C. guilliermondii, C. parapsilosis and S. cere-
graphic techniques lack sufficient sensitivity to serve as visiae. They reported that whereas the paste of Ca(OH)2
a reliable means for diagnosing post-treatment health. in CPMC/glycerine had the most pronounced antifun-
Therefore, the absence of radiolucency does not prove gal effects, Ca(OH)2 in glycerine or CHX and CHX in
that residual bacteria have been entombed in the canal detergent also had antifungal activity, but at a lower
system by the placement of a root filling and thus level than the paste of Ca(OH)2 in CPMC/glycerine. In
rendered harmless. It should be noted that cone-beam another study, Ferguson et al. (2002) evaluated the
computed tomography (CBCT) provides higher detec- in vitro susceptibility of C. albicans to various irrigants
tion rates than conventional and digital radiographs for and medicaments. The minimum inhibitory concen-
visualization of periapical lesions (Scarfe et al. 2009). trations of NaOCl, hydrogen peroxide, CHX digluconate
and aqueous Ca(OH)2 were determined. Their results
revealed that NaOCl, hydrogen peroxide and CHX
Anti-fungal activity
digluconate were effective against C. albicans, even
Fungi constitute a small proportion of the oral micro- when diluted significantly. Furthermore, aqueous
biota and are largely restricted to Candida albicans Ca(OH)2 had no antifungal activity when maintained
(Siqueira & Sen 2004). C. albicans is the fungal species in direct contact with C. albicans cells, whereas Ca(OH)2
most commonly detected in the oral cavity of both paste and CPMC were effective antifungal agents.
healthy (Arendorf & Walker 1980, Lucas 1993) and The antifungal effectiveness of CPMC was also
medically compromised individuals (Dupont et al. reported by Valera et al. (2001) who investigated the
1992). The incidence of C. albicans in the oral cavity effectiveness of several intracanal medicaments on
has been reported to be 30–45% in healthy adults C. albicans harvested inside root canals, observing that
(Arendorf & Walker 1980, Lucas 1993) and 95% in CPMC was the most effective, followed by Ca(OH)2/
patients infected with human immunodeficiency virus CPMC paste. Siqueira et al. (2003) evaluated the
(Dupont et al. 1992). Fungi have occasionally been effectiveness of four intracanal medicaments in disin-
found in primary root canal infections (Baumgartner fecting the root dentine of bovine teeth experimentally
et al. 2000, Lana et al. 2001), but they are more infected with C. albicans. Infected dentine cylinders
common in filled root canals in teeth that have become were exposed to four different medicaments: Ca(OH)2/
infected some time after treatment or in those that have glycerine, Ca(OH)2/0.12% CHX digluconate, Ca(OH)2/
not responded to treatment (Siqueira & Sen 2004). CPMC/glycerine and 0.12% CHX digluconate/zinc
Overall, the occurrence of fungi reported in infected oxide. Specimens were left in contact with the medica-
root canals varies between 1% and 17% (Waltimo et al. ments for 1 h, 2 and 7 days. The specimens treated
2004). A large number of other yeasts have also been with Ca(OH)2/CPMC/glycerine paste or with CHX /zinc
isolated from the oral cavity, including C. glabrata, oxide paste were completely disinfected after 1 h of
C. guilliermondii, C. parapsilosis, C. krusei, C. inconspicua, exposure. Ca(OH)2/glycerine paste only consistently
C. dubliniensis, C. tropicalis and Saccharomyces species eliminated C. albicans infection after 7 days of expo-
(Siqueira & Sen 2004). sure. Ca(OH)2 mixed with CHX was ineffective in
Waltimo et al. (1999a) reported that C. albicans cells disinfecting dentine even after 1 week of exposure. Of
were highly resistant to Ca(OH)2 and that all Candida the medicaments tested, the Ca(OH)2/CPMC/glycerine
species (C. albicans, C. glabrata, C. guilliermondii, C. krusei paste and CHX digluconate mixed with zinc oxide were
and C. tropicalis) were either equally high or had higher the most effective in eliminating C. albicans cells from
resistance to aqueous calcium hydroxide than did dentine specimens.
In summary, fungi have occasionally been found in Amorphous material filled the inter-bacterial spaces
primary root canal infections, but they appear to occur and was interpreted as an extracellular matrix of
more often in filled root canals of teeth in which bacterial origin. When they occurred, the bacterial
treatment has failed. C albicans is by far the fungal condensations had a palisade structure similar to the
species most commonly isolated from infected root one for dental plaque on external tooth surfaces,
canals. It seems that the combinations of Ca(OH)2 with suggesting similar mechanisms for bacterial attach-
camphorated paramonochlorophenol or CHX have the ment as those for dental plaque. Sen et al. (1995)
potential to be used as effective intracanal medicaments examined untreated extracted teeth with apical peri-
for cases in which fungal infection is suspected. odontitis by scanning electron microscopy (SEM) and
found that root canals were heavily infected with
microorganisms being observed in all areas of the
Activity against biofilms
canal. Cocci and rods predominated and formed colo-
The term biofilm was introduced to designate the thin- nies on the root canal walls and also, to a varying
layered (sessile) condensations of microbes that may degree, penetrated the dentinal tubules. Nair et al.
occur on various surface structures in nature (Svens- (2005) found that even after instrumentation, irriga-
ater & Bergenholtz 2004). Free-floating bacteria exist- tion and canal filling in a one-visit treatment, microbes
ing in an aqueous environment, the so-called existed as biofilms in untouched locations in the main
planktonic form of microorganisms, are a prerequisite canal, isthmuses and accessory canals in 14 of the 16
for biofilm formation (Bowden & Hamilton 1998). root filled teeth examined.
Biofilms may thus become established on any organic Anti-microbial agents have often been developed and
or inorganic surface substrate where planktonic micro- optimized for their activity against fast-growing, dis-
organisms prevail in a water-based solution (Stoodley persed populations containing a single microorganism
et al. 2004). In a dental context, a well-known and (Gilbert et al. 1997, Svensater & Bergenholtz 2004).
extensively studied biofilm structure is established However, microbial communities grown in biofilms are
during the attachment of bacteria to teeth to form remarkably difficult to eradicate with anti-microbial
dental plaque (Svensater & Bergenholtz 2004). Here, agents and microorganisms in mature biofilms can be
bacteria in saliva (planktonic organisms) serve as the notoriously resistant for reasons that have yet to be
primary source of organisms for the organization of this adequately explained (Nair 1987, Bowden & Hamilton
specific biofilm (Bowden & Hamilton 1998). In end- 1998). There are reports revealing that microorgan-
odontics, the biofilm concept was initially discussed isms grown in biofilms could be 2-fold to 1000-fold
mainly within the framework of bacteria on the root more resistant than the corresponding planktonic form
tips of teeth with necrotic and infected pulps or pulpless of the same organisms (Svensater & Bergenholtz 2004).
and infected root canal systems (Nair 1987, Nair et al. Using scanning electron microscopy and scanning
2005). Such bacterial aggregations have been thought confocal laser microscopy, Distel et al. (2002) reported
to be the cause of therapy-resistant apical periodontitis that despite intracanal dressing with Ca(OH)2, E. fae-
(Nair et al. 2005, Wu et al. 2006). Although not calis formed biofilms in root canals. In another study,
described in as much detail, bacterial condensations Chai et al. (2007) reported that Ca(OH)2 was 100%
(that is, biofilms) on the walls of infected root canals effective in eliminating E. faecalis biofilm. Brandle et al.
have been observed (Svensater & Bergenholtz 2004). (2008) investigated the effects of growth condition
On the basis of transmission electron microscopy (planktonic, mono- and multi-species biofilms) on the
(TEM), Nair (1987) examined the root canal contents susceptibility of E. faecalis, Streptococcus sobrinus,
of 31 teeth, which had gross coronal caries and to Candida albicans, Actinomyces naeslundii and Fusobacterium
which the periapical inflammatory lesion was attached nucleatum to alkaline stress. Findings demonstrated that
upon extraction. In addition to his observations of the planktonic microorganisms were most susceptible; only
microstructure of the inflammatory tissue, he noted E. faecalis and C. albicans survived in saturated solution
that the major bulk of the organisms existed as loose for 10 min, the latter also for 100 min. Dentine
collections of cocci, rods, filaments and spirochetes. adhesion was the major factor in improving the
Whilst most of these organisms appeared suspended, in resistance of E. faecalis and A. naeslundii to calcium
what was described as a moist canal space, dense hydroxide, whereas the multispecies context in a
aggregates were also observed sticking to the canal biofilm was the major factor in promoting resistance
walls and forming layers of bacterial condensations. of S. sobrinus to the disinfectant. In contrast, the
C. albicans response to calcium hydroxide was not period of 5 years. Success was reported for 94% of the
influenced by growth conditions. infected root canals associated with periradicular
In summary, the few studies conducted on the lesions that yielded negative culture at the time of
antimicrobial potential of Ca(OH)2 on biofilms have canal filling, whereas in the samples that yielded
demonstrated inconsistent results. Further studies are positive culture prior to filling the success rate was
required to elucidate the anti-biofilm efficacy of 68%, thus stressing the need to have a negative culture
Ca(OH)2. before canal filling in infected cases. In another clinical
study, Trope et al. (1999) evaluated radiographic
healing of teeth with periradicular lesions treated in
Clinical outcome studies on the use of Ca(OH)2
one or two visits. In the two-visit group, root canals
medicaments
were medicated with Ca(OH)2 for at least 1 week. After
One-visit root canal treatment offers potential advan- a 1-year follow-up, the additional disinfecting action of
tages to both the dentist and patient (Ashkenaz 1984). calcium hydroxide resulted in a 10% increase in
In addition to being less time-consuming and accepted healing rates. However, some of the teeth were not
by patients (Sathorn et al. 2005), it prevents the associated with preoperative periapical lesions and
potential contamination or recontamination of the root some cases treated over multiple visits had not been
canal system between appointments (Ashkenaz 1984). dressed with an inter-appointment calcium hydroxide
Root canal treatment on teeth with vital pulps should medicament (the main biological purpose of multiple-
ideally be completed in one session provided that the visit treatment). Katebzadeh et al. (1999, 2000) com-
time available, operator’s skills and anatomical condi- pared periradicular repair radiographically and histo-
tions are all favourable (Ashkenaz 1979). On the other logically after root canal treatment of infected canals of
hand, root canal treatment in one session for teeth with dogs performed in one or two sessions and reported
necrotic pulps, whether associated with a periradicular better results for the two-visit treatment in which
lesion or not remains controversial (Siqueira 2001). Ca(OH)2 was used as an intracanal disinfecting medi-
Two factors must be taken into account before cament for 1 week.
deciding upon a one-visit treatment of teeth with On the other hand, several studies have concluded
necrotic pulps: the incidence of postoperative pain and that one-visit treatment was as effective as multiple-
the long-term outcome of the treatment (Mohammadi visit treatment or even more effective. Weiger et al.
et al. 2006). Studies have found no difference in the (2000) evaluated the influence of Ca(OH)2 as an inter-
incidence of postoperative pain between one- and appointment dressing on the healing of periapical
multiple-visit root canal treatment (O’Keefe 1976, lesions associated with pulpless teeth. In both treat-
Mulhern et al. 1982, DiRenzo et al. 2002, Mohammadi ment groups, the likelihood that the root canal
et al. 2006). Sathorn et al. (2008) reviewed systemat- treatment yielded a success within an observation time
ically 16 studies with sample size varying from 60 to of 5 years exceeded 90%. However, a statistically
1012 cases. The prevalence of postoperative pain significant difference between the two treatment groups
ranged from 3% to 58%. However, the heterogeneity was not detected. Furthermore, the probability that
amongst the studies was too great to conduct a meta- complete periapical healing would take place increased
analysis and yield meaningful results. They concluded continuously with the length of the observation period.
that compelling evidence indicating a significantly Peters & Wesselink (2002) found no significant differ-
different prevalence of postoperative pain/flare-up of ences in healing of periapical radiolucency between
either single- or multiple-visit root canal treatment was teeth that were treated in one visit (without) and two
lacking. visits with inclusion of Ca(OH)2 for 4 weeks. In a
Therefore, the outcome of the root canal treatment randomized clinical trial, Molander et al. (2007)
should be the major factor taken into account when assessed the 2-year clinical and radiographic outcome
deciding the number of therapy sessions. Pekruhn of one- and two-visit root canal treatment and found
(1986) reported that there were significantly fewer similar healing results. In a systematic review, Figini
failures in the two-visit treatment group than in the et al. (2008) investigated whether the effectiveness and
one-visit treatment group, regardless of the pretreat- frequency of short-term and long-term complications
ment diagnosis. In a well-controlled clinical study, were different when root canal treatment was com-
Sjögren et al. (1997) investigated the role of infection pleted in one or multiple visits. No detectable difference
on the outcome of one-visit treatment after a follow-up in the effectiveness of root canal treatment in terms of
radiologic success between single and multiple visits and inorganic compounds in the inactivation of root
was noted. In a randomized controlled clinical trial, canal disinfectants have been studied to a limited extent
Penesis et al. (2008) compared radiographic periapical only (Haapasalo et al. 2000). Difficulties in designing
healing after root canal treatment completed in one experiments that will give reliable and comparable data
visit or two visits with an interim calcium hydroxide/ have been some of the greatest challenges. Haapasalo
CHX paste dressing and concluded that both treatment et al. (2000) introduced a new dentine powder model
options exhibited equally favourable periapical healing for studying the inhibitory effect of dentine on various
at 12 months, with no statistically significant differ- root canal irrigants and medicaments. They concluded
ence. In a systematic review, Sathorn et al. (2005) that dentine powder effectively abolished the killing of
compared the healing rate (as measured by clinical and E. faecalis by Ca(OH)2 (Haapasalo et al. 2000). On the
radiographic parameters) of single-visit root canal other hand, in the positive control group (absence of
treatment without calcium hydroxide dressing to dentine), saturated Ca(OH)2 killed E. faecalis cells in a
multiple-visit treatment with calcium hydroxide dress- few minutes, whereas with the dentine powder added,
ing for 1 week. Single-visit root canal treatments were no reduction in the bacterial colony-forming units
marginally more effective than multiple visits, i.e. 6.3% could be measured even after 24 h of incubation with
higher healing rate. However, the difference in healing Ca(OH)2. Hydroxyapatite had an effect similar to
rate between these two treatment regimens was not dentine on Ca(OH)2, preventing the killing of E. faecalis
statistically significant. (Portenier et al. 2001). Initially, they used a high
In summary, the incidence of postoperative pain and concentration of dentine (18% w/v); however, in
the long-term outcome of treatment must be taken into another study they showed that even 1.8% dentine
account before deciding upon a one-visit or a multi-visit (w/v) totally prevented the killing of E. faecalis by a
treatment for teeth with necrotic pulps. There is no saturated Ca(OH)2 solution (Portenier et al. 2001).
compelling evidence to suggest a difference between the The substantial effect of dentine on the antibacterial
regimens in terms of the prevalence of postoperative activity of Ca(OH)2 can be attributed to the buffering
pain/flare-up. There is still considerable controversy action of dentine against alkali (Wang & Hume 1988).
concerning the effect of the number of treatment visits Ca(OH)2 is used as a thick paste in vivo; however, its
on the biological outcome, whilst some studies support solubility is low and saturation is achieved in a
two-visit treatment, other studies found that there was relatively low concentration of hydroxyl ions. Both
no significant difference between the two treatment laboratory and in vivo studies have shown that buffer-
modalities. It should be noted that some recent clinical ing by dentine, particularly in the subsurface layers of
trials and systematic reviews found similar healing the root canal walls, might be the main factor behind
results between one-visit and multiple-visit treatments. the reduced antibacterial effect of Ca(OH)2. It is possible
Clearly, it is important to analyse the individual reports that deeper in dentine (outside the main root canal),
included in systematic reviews and judge whether the Ca(OH)2 is present as a saturated solution or at
results are applicable (generalizable) to general dental concentrations even below that level (Haapasalo et al.
practice. In the majority of reports, the root canal 2000). Besides dentine, remnants of necrotic pulp
treatments were carried out in hospital settings by tissue as well as inflammatory exudate might affect the
specialist endodontists with the result that the conclu- antibacterial potential of endodontic disinfectants
sions of such studies may not be relevant to conditions (Haapasalo et al. 2007).
prevailing in most general dental practices, where In summary, it seems that dentine, hydroxyapatite
resources and clinical expertize are often less favourable. and remnants of necrotic pulp tissue as well as
inflammatory exudate decrease the antibacterial
potential of Ca(OH)2. In other words, Ca(OH)2 is likely
Buffering effect of dentine on Ca(OH)2
to be effective under laboratory conditions but
The root canal milieu is a complex mixture of a variety relatively ineffective as a medicament in vivo.
of organic and inorganic components. Hydroxyapatite
is the major representative of the inorganic compo-
Synergism between Ca(OH)2 and sodium
nents, whilst pulp tissue, micoorganisms and inflam-
hypochlorite
matory exudate, rich in proteins such as albumin
(Haapasalo et al. 2007), are the major organic compo- Chemicals should be used to supplement mechani-
nents. The relative importance of the various organic cal cleansing of canals, and irrigation with sodium
hypochlorite and/or intracanal placement of Ca(OH)2 CHX will lead to precipitation of CHX molecules,
are used as therapeutic agents in an attempt to alter the thereby decreasing its effectiveness (Mohammadi &
properties of tissue remnants and microorganisms so as Abbott 2009). It has been demonstrated that the
to facilitate their removal/killing (Yang et al. 1995). alkalinity of Ca(OH)2 when mixed with CHX remained
The synergy between Ca(OH)2 and sodium hypo- unchanged (Haenni et al. 2003). Therefore, the useful-
chlorite is controversial. Hasselgren et al. (1988) stud- ness of mixing Ca(OH)2 with CHX still remains unclear
ied dissolution of necrotic porcine muscle tissue and and controversial (Athanassiadis et al. 2007).
reported that a paste of Ca(OH)2 powder and water was When used as an intracanal medicament, CHX was
capable of dissolving tissue after 12 days of exposure. more effective than Ca(OH)2 in eliminating E. faecalis
Furthermore, they reported an enhancement of the from inside dentinal tubules (Athanassiadis et al.
tissue-dissolving capability of sodium hypochlorite 2007). In a study by Almyroudi et al. (2002), all of
when the tissue was pretreated with Ca(OH)2 for the CHX formulations used, including a CHX/Ca(OH)2
30 min, 24 h and 7 days. In another study, Metzler 50 : 50 mix, were effective in eliminating E. faecalis
& Montgomery (1989) demonstrated that long-term from dentinal tubules with a 1% CHX gel working
(7 days) pretreatment with Pulpdent paste (Water- better than the other preparations. These findings were
town, MA, USA), a non-setting Ca(OH)2 paste, followed corroborated by Gomes et al. (2006) in bovine dentine
by sodium hypochlorite irrigation cleaned canal isth- and Schäfer & Bossmann (2005) in human dentine
muses in mandibular molars better than hand instru- where 2% CHX gel had greater activity against
mentation alone. Yang et al. (1995) evaluated and E. faecalis, followed by CHX/Ca(OH)2 and then Ca(OH)2
compared the tissue-dissolving properties of Ca(OH)2 alone.
and NaOCl on bovine pulp tissue under both aerobic In a study using agar diffusion, Haenni et al. (2003)
and anaerobic conditions. Results demonstrated that could not demonstrate any additional antibacterial
both agents partially dissolved pulp tissue and that the effect by mixing Ca(OH)2 powder with 0.5% CHX and
anaerobic environment did not alter the tissue-dissolv- reported that CHX had a reduced antibacterial action.
ing properties of Ca(OH)2 or NaOCl. Furthermore, both However, Ca(OH)2 did not lose its antibacterial prop-
chemicals were equal and more effective than water erties in such a mixture. This may be because of the
(control group). Wadachi et al. (1998) evaluated the deprotonation of CHX at a pH >10, which reduces its
tissue-dissolving ability of NaOCl and Ca(OH)2 in a solubility and alters its interaction with bacterial
bovine tooth model and reported that the amount of surfaces as a result of the altered charge of the
debris was reduced remarkably in teeth treated with molecules. In a laboratory study using human teeth,
NaOCl for >30 s or Ca(OH)2 for 7 days. However, the Ercan et al. (2006) reported that 2% CHX gel was the
combination of Ca(OH)2 and NaOCl was more effective most effective agent against E. faecalis inside dentinal
than the separate treatments. On the other hand, some tubules, followed by a Ca(OH)2/2% CHX mixture,
studies demonstrated that Ca(OH)2 was an ineffective whilst Ca(OH)2 alone was totally ineffective, even after
solvent of pulpal tissue. For example, Morgan et al. 30 days. The 2% CHX gel was also significantly more
(1991) reported that Ca(OH)2 as an irrigant resulted in effective than the Ca(OH)2/2% CHX mixture against
only 10% weight loss of bovine pulp tissue compared C. albicans at 7 days, although there was no significant
with isotonic saline control. difference at 15 and 30 days. Ca(OH)2 alone was
In summary, the pretreatment of root canals completely ineffective against C. albicans. In another
with Ca(OH)2 enhances the tissue-dissolving capability in vivo study using primary teeth, a 1% CHX-gluconate
of sodium hypochlorite, and this may confer an gel, both with and without Ca(OH)2, was more effective
advantage to multiple-visit root canal treatment where against E. faecalis than Ca(OH)2 alone over a 48-h
NaOCl would be used following a period of Ca(OH)2 period (Oncag et al. 2006).
medication. Schäfer & Bossmann (2005) reported that 2% CHX-
gluconate was significantly more effective against
E. faecalis than Ca(OH)2 used alone or a mixture of
Ca(OH)2 and chlorhexidine
the two. Although this was also confirmed by Lin et al.
Chlorhexidine is a cationic biguanide whose optimal (2003), a study by Evans et al. (2003) using bovine
antimicrobial activity is achieved within a pH range of dentine concluded that 2% CHX with Ca(OH)2 was
5.5–7.0 (Athanassiadis et al. 2007). Therefore, it is more effective than Ca(OH)2 in water. In an animal
likely that alkalinizing the pH by adding Ca(OH)2 to study, Lindskog et al. (1998) reported that teeth
dressed with CHX for 4 weeks had reduced inflamma- reports of fractures of immature teeth filled with
tory reactions in the periodontium (both apically and Ca(OH)2 for extended periods to this factor. Doyon
marginally) and less root resorption. Waltimo et al. et al. (2005) examined the resistance of human root
(1999a) reported that 0.5% CHX-acetate was more dentine to intracanal medication with Ca(OH)2 and
effective at killing C. albicans than saturated Ca(OH)2, found that the fracture resistance of dentine was
whilst Ca(OH)2 combined with CHX was more effective decreased significantly after 6 months.
than Ca(OH)2 used alone. The high pH of Ca(OH)2 was In summary, dentine exposed to Ca(OH)2 for an
unaffected when combined with CHX in this study. extended period (6 months to 1 year) results in reduced
In summary, although the usefulness of mixing flexural strength and lower fracture resistance. There-
Ca(OH)2 with CHX remains unclear and controversial, fore, other treatment modalities such as the apical
it seems that by mixing Ca(OH)2 with CHX the barrier technique using mineral trioxide aggregate
antimicrobial activity of Ca(OH)2 is increased. In other (MTA) should be used to manage teeth with non-vital
words, the descending order of the antimicrobial pulps and open apices, following a short period of
activity of Ca(OH)2, CHX and their combination is as Ca(OH)2 medication where indicated.
follows: CHX, Ca(OH)2/CHX and Ca(OH)2.
Diffusion of hydroxyl ions through dentine

Effect of Ca(OH)2 on dentine
For calcium hydroxide to act effectively as an intra-
Endodontic treatment of immature teeth with non-vital canal medicament, hydroxyl ions must be able to
pulps is a challenge. Apexification by Ca(OH)2 (Granath diffuse through dentine. It might be expected that this
1987, Frank 1966, Heithersay 1975) was based on the would occur in a manner similar to water, because
concept of apical healing being promoted through the diffusion through dentine is primarily determined by
induction of an apical barrier whilst at the same time molecular weight (Nerwich et al. 1993). Several studies
the high pH providing an antibacterial capability. The have attempted to measure diffusion of hydroxyl ions
flexural strength of dentine might, in part, depend on through dentine using a variety of experimental
an intimate link between two main components of approaches, including pH indicating solutions or papers
dentine, the hydroxyapatite crystals and the collage- (Tronstad et al. 1981), pH measurement of ground
nous network. The organic matrix is composed of acid dentine (Wang & Hume 1988) and pH values of the
proteins and proteoglycans containing phosphate and surrounding medium (Fuss et al. 1989).
carboxylate groups (Andreasen et al. 2002). These Tronstad et al. (1981) examined histological sections
substances may act as bonding agents between the of monkey teeth 1 month following placement of a
collagen network and the hydroxyapatite crystals Ca(OH)2 canal dressing and, using indicator solutions,
(Andreasen et al. 2002). found that there was a pH gradient with high values
Rosenberg et al. (2007) measured the effect of around the canal dressing towards the peripheral
Ca(OH)2 on the microtensile fracture strength (MTFS) dentine. The pH of cementum remained unchanged
of teeth and found that it was reduced by almost 50% but in resorption areas, where cementum was not
following 7–84 days of application. A study of bovine present, the increased pH extended to the dentine
dentine maintained in Petri dishes for 5 weeks con- surface. In another study related to the action of
cluded that Ca(OH)2 reduced fracture strength by 32% Ca(OH)2 in cervical root resorption, Kehoe (1987)
(White et al. 2002). Another study indicated that the placed Ca(OH)2 in the cervical part of the root canals
fracture strength of sheep dentine was reduced by 50% previously filled with bleaching agents and reported a
following Ca(OH)2 treatment after 1 year (Andreasen pH reversal from a slightly acidic to a slightly alkaline
et al. 1989). Recently, Kawamoto et al. (2008) reported level using pH electrodes and alkacid test papers.
that exposure to Ca(OH)2 paste significantly increased Fuss et al. (1989) measured pH changes in distilled
the mean elastic modulus of bovine dentine, thereby water surrounding teeth filled with Ca(OH)2 and found
making it more prone to fracture. small changes in pH level up to 10 days. Wang &
Grigoratos et al. (2001) reported that treatment with Hume (1988) measured hydroxyl ion diffusion across
Ca(OH)2 reduced the flexural strength of dentine. dentine between an occlusal cavity containing Ca(OH)2
Andreasen et al. (2002) concluded that the fracture and a saline-filled pulp chamber at 16 days using a pH
strength of Ca(OH)2-filled immature teeth was halved meter. By taking ground dentine (subsequently mixed
in approximately 1 year and attributed the frequent with saline) from various depths, they demonstrated a
gradient of pH values from the cavity layer decreasing sodium hypochlorite (NaOCl), 3% NaOCl + 17% EDTA
to the middle and pulpal layers, indicating slow as irrigants in combination with hand filing and found
movement of hydroxyl ions through dentine. Nerwich that 45% of the canal surface area remained covered
et al. (1993) investigated pH change over a 4-week with Ca(OH)2. They inferred that the amount of
period after application of a Ca(OH)2 dressing and Ca(OH)2 powder in the paste did not affect removal,
concluded that hydroxyl ions derived from Ca(OH)2 but the vehicle did. Margelos et al. (1997) revealed that
dressings diffused in a matter of hours into the inner using 15% EDTA or NaOCl alone as irrigants did not
root dentine but required 1–7 days to reach the outer remove Ca(OH)2 from the root canal, but combining
root dentine and 2–3 weeks to reach peak levels. these two irrigants with hand instrumentation
Hydroxyl ions diffused faster and reached higher levels improved the effectiveness of removal.
cervically more than apically. Nandini et al. (2006) reported that the vehicle used
Gomes et al. (1996) reported diffusion of calcium to prepare Ca(OH)2 paste was important for its removal.
ions from Ca(OH)2 paste through dentine. Esberard Oil-based Ca(OH)2 paste was more difficult to remove
et al. (1996a) found that Ca(OH)2-containing sealers, than Ca(OH)2 powder mixed with distilled water. Both
although suitable for use as root canal sealants, did not 17% EDTA and 10% citric acid were found to remove
produce an alkaline pH at the root surface. However, in Ca(OH)2 powder mixed with distilled water, whereas
another study Ca(OH)2, as an intracanal medicament, 10% citric acid performed better than EDTA in remov-
maintained a high pH at the root surface for at least ing an oil-based Ca(OH)2 paste. In another study,
120 days (Esberard et al. 1996b). Calt et al. (1999) Lambrianidis et al. (2006) compared the removal
demonstrated that, when non-setting Ca(OH)2 pastes efficiency of Ca(OH)2/CHX gel, Ca(OH)2/CHX solution
were applied to the root canal, diffusion of Ca2+ and Ca(OH)2/saline pastes using instrumentation with
without an increase in pH in the surrounding media or without a patency file and irrigation with NaOCl and
occurred. Saif et al. (2008) indicated that a final canal EDTA solutions. Remnants of medicaments were found
rinse with 3 mL 17% EDTA and 10 mL 6% NaOCl in all canals regardless of the experimental material or
before Ca(OH)2 placement allowed the greatest hydro- use of patency filing. When examining the root canal as
xyl ion diffusion to the root surface. a whole, Ca(OH)2/CHX gel paste was associated with
In summary, it seems that diffusion of hydroxyl ions significantly larger amounts of residue, whereas the
through dentine depends on the period of medication, Ca(OH)2/CHX solution paste was associated with less
diameter of dentinal tubules (cervical versus apical) residue than the other two groups with or without the
and smear layer removal (patency of dentinal tubules). use of patency filing. They also noted that the use of
Furthermore, diffusion of hydroxyl ions through to patency filing facilitated removal of more of the
areas of root resorption where pH is acidic has a medicament in the apical third of straight canals
positive effect on the progression of inflammatory root (Lambrianidis et al. 2006).
resorption. Another method to remove remnants of Ca(OH)2
from the root canal involved the use of ultrasonic
devices. Kenee et al. (2006) evaluated the amount of
Removal of Ca(OH)2 from canals
Ca(OH)2 remaining in canals after removal with
Ca(OH)2 placed as a medicament has to be removed various techniques including combinations of NaOCl
before the canal is filled. Laboratory studies have with EDTA irrigation, hand filing, rotary instrumenta-
revealed that remnants of Ca(OH)2 can hinder the tion, or ultrasonics. Overall, no technique removed the
penetration of sealers into the dentinal tubules (Calt & Ca(OH)2 entirely. Rotary and ultrasonic techniques,
Serper 1999), hinder the bonding of resin sealers to whilst not different from each other, removed signifi-
dentine, increase the apical leakage of root fillings (Kim cantly more Ca(OH)2 than irrigant only techniques.
& Kim 2002) and potentially interact with zinc oxide van der Sluis et al. (2007) evaluated the capacity to
eugenol sealers and make them brittle and granular remove a Ca(OH)2 paste from the root canal and the
(Margelos et al. 1997). Therefore, complete removal of efficacy of Ca(OH)2 removal during passive ultrasonic
Ca(OH)2 from the root canal before filling is recom- irrigation using either sodium hypochlorite or water as
mended. an irrigant. Results demonstrated that passive ultra-
Lambrianidis et al. (1999) evaluated the effectiveness sonic irrigation with 2% NaOCl was more effective in
of removing Ca(OH)2 associated with several vehicles removing Ca(OH)2 paste from artificial root canal
from the root canal including normal saline, 3% grooves than syringe delivery of 2% NaOCl or water
as irrigant. Balvedi et al. (2010) found that neither (2004) found that Ca(OH)2 did not promote DNA
syringe injection nor passive ultrasonic irrigation were damage in mammalian cells. Pissiotis & Spangberg
efficient in removing inter-appointment intracanal (1990) evaluated mandible bone reactions of guinea
medicaments. pigs to implants of hydroxyapatite, collagen, and
In summary, it seems that complete removal of Ca(OH)2, alone or in different combinations, over a
Ca(OH)2 paste from the root canal walls is not period of 16 weeks. Findings revealed that no major
achievable using routine techniques. However, the inflammatory reactions occurred in any of the implant
type of vehicle used, use of patency filing and combin- combinations. Hydroxyapatite was not resorbed over
ing EDTA and NaOCl with hand instrumentation the examination periods, but Ca(OH)2 and collagen
improves the efficacy of Ca(OH)2 paste removal. implants were partially or totally resorbed and replaced
Furthermore, it seems that ultrasonic methods are by bony tissue. Wakabayashi et al. (1995) evaluated
more efficient in removing Ca(OH)2 remnants than the effect of a Ca(OH)2 paste dressing on uninstru-
passive irrigation. mented root canal walls and found that it could
dissolve the odontoblastic cell layer, but had little effect
on predentine. Holland et al. (1999) reported that rat
Toxicity of Ca(OH)2 in medicaments
subcutaneous connective tissue reaction to Ca(OH)2
Early reports on the outcome of Ca(OH)2 extruded into and MTA inside the dentine tubes was desirable. They
the periapical region concluded it was well tolerated observed the formation of calcite granulations, bire-
and was resorbed (Martin & Crabb 1977). However, the fringent to polarized light, near the lumen of dentinal
periapical response to Ca(OH)2 based on results from tubule in Ca(OH)2 samples. Under these granulations, a
other reports seems to be equivocal. von Kossa-positive bridge of hard tissue was formed. In
Spångberg (1969) reported an inflammatory re- MTA samples, the same granulations was observed, but
sponse with inhibited bone healing 2 weeks after the their number was less than the Ca(OH)2 group.
implantation of Ca(OH)2 into guinea-pig bone; never- Furthermore, contrary to the Ca(OH)2 group, the
theless, it was found to be one of the least irritating calcite granulations were in contact with MTA. This
root-filling materials and was replaced by new bone may be because of the similarity of the mechanism of
within 12 weeks of placement. action of MTA and Ca(OH)2; the calcium oxide in the
However, Ca(OH)2 has been reported to have a MTA powder is converted into Ca(OH)2 when the paste
detrimental effect on periodontal tissues when used as is prepared with water. In contact with tissue fluids,
an intracanal medicament during root canal treatment this mixture would dissociate into calcium and hydro-
(Hauman & Love 2003). Blomlöf et al. (1988) observed xyl ions. The calcium ions reacting with the carbonic
that Ca(OH)2 could negatively influence marginal soft gas of the tissues would originate the calcite granula-
tissue healing and suggested the completion of root tions. Close to these granulations, there is accumula-
canal treatment prior to the removal of cementum as tion of fibronectin, which allows cellular adhesion and
might occur during periodontal therapy. Breault et al. differentiation. Guigand et al. (1999) confirmed the
(1995) reported that the use of Ca(OH)2 demonstrated cytocompatibility of Ca(OH)2 and a calcium oxide-
a decreased but not statistical significant inhibition of based compound.
attached human gingival fibroblasts (HGF) and pro- In summary, it seems that Ca(OH)2 paste is well
posed that Ca(OH)2 should be avoided as an interim tolerated by bone and dental pulp tissues. However, its
medicament when trying to regenerate or establish effect on the periodontal tissue is controversial.
new attachment in tissues adjacent to endodontically
involved teeth. Contrary to these findings, Hammar-
Calcium hydroxide when used in sealers
ström et al. (1986) demonstrated that Ca(OH)2 did not
during root canal treatment
affect the healing of replanted monkey teeth with intact
cementum and only temporarily in those undergoing Sealers are responsible for the principal functions of a
cemental repair. Similarly, Holland et al. (1998) root filling, namely, sealing the root canal system,
observed that periodontal healing associated with entombment of remaining bacteria and the filling of
infected root canals filled with Ca(OH)2 was not irregularities in the canal system (Ørstavik 2005).
hindered 6 months after experimental periodontal sur- Several different chemical formulations have served as
gical injury in dogs. Barnhart et al. (2005) found that bases for root canal sealers and the success of Ca(OH)2
Ca(OH)2 was well tolerated by HGF. Ribeiro et al. as a pulp-capping agent and as an inter-appointment
medicament prompted its use in sealer cement formu- a laboratory study, Cobankara et al. (2006) evaluated
lations. Sealapex (SybronEndo, Orange County, CA, the apical seal obtained with four root canal sealers
USA) and Apexit (Ivoclar Vivadent Inc., Schaan, (Rocanal 2, Sealapex, AH-Plus, and RC Sealer) and
Liechtenstein) are brand names of this type of material reported that apical leakage associated with all sealers
(Ørstavik 2005). decreased gradually from 7 to 21 days. Sealapex had
better apical sealing than the other sealers at 7, 14 and
21 days. RC Sealer, AH Plus and Rocanal 2 had similar
Leakage
apical leakage values at every period. It has been
Limkangwalmongkol et al. (1991) assessed the apical demonstrated that the long-lasting seal of these mate-
leakage of four root canal sealers when used with rials may, amongst other influencing factors, depend
laterally compacted Gutta-percha using dye penetra- on their thickness and solubility (Wu et al. 1995).
tion and concluded that the distance dye penetrated the Considering that the main purpose of using sealers is
canals was as follows: Apexit (Ivoclar Vivadent), to fill gaps within the irregular root canal system, their
1.67 mm; Sealapex (SybronEndo), 2.28 mm; Tubliseal solubility and disintegration should be as low as
(SybronEndo), 1.95 mm; AH26 (Dentsply de Trey, possible. On the other hand, to achieve favourable
Konstanz, Germany), 0.82 mm; and Gutta-percha effects, Ca(OH)2 should dissociate into calcium and
alone, 8.37 mm. Sleder et al. (1991) reported that hydroxyl ions, which is in contrast to the philosophy of
Sealapex had a sealing ability comparable to Tubliseal. using sealers. Therefore, a major dilemma arises
In a laboratory study, Siqueira et al. (1999) evaluated regarding both the long-term sealing ability and
the coronal leakage of human saliva into root canals favourable biological properties of Ca(OH)2-based
filled using lateral compaction of Gutta-percha and one sealers.
or other of two Ca(OH)2-based sealers and found that In summary, the sealing ability of Ca(OH)2-based
35% of the Sealer 26 (Dentsply, Petropolis, Brazil) sealers compared to other sealers is ambiguous. This
samples and 80% of the Sealapex samples were entirely may be because of factors such as the method used to
recontaminated at 60 days. Using dye penetration evaluate leakage and the often limited sample sizes
methods, Ozata et al. (1999) compared the apical included. However, it is clear that there is no superi-
leakage of Ketac-Endo (ESPE GmbH & Co., Seefeld- ority for Ca(OH)2-based sealers over other groups of
Oberbay, Germany), Apexit (Ivoclar Vivadent) and sealers.
Diaket (3M/ESPE, Minneapolis, MN, USA) and found
that there was no significant difference between Apexit
Biocompatibility
and Diaket. However, there was significantly more
leakage with Ketac-Endo. Timpawat et al. (2001) There are five approaches to assess the biocompatibility
concluded that coronal bacterial leakage of canals of endodontic materials such as sealers: cytotoxic
filled with a Ca(OH)2-based sealer (Apexit) was signif- evaluation, genotoxicity, subcutaneous implants,
icantly greater than those filled with a resin-based intraosseous implants, usage tests and human studies
sealer (AH26). Economides et al. (2004) found that (Hauman & Love 2003). Cytotoxicity is usually
apical sealing ability of Fibrefill (a resin-based sealer) assessed on cells such as leucocytes, HeLa (human
(Pentron, Wallingford, CT, USA) was significantly cervical carcinoma) cells and fibroblasts. Cell culture
better than CRCS (Coltène Whaledent/Hygenic, Mah- experiments are easier, more rapid and cheaper than
wah, NJ, USA). In another study Cobankara et al. other methods used to test biocompatibility. However,
(2006) concluded that the apical sealing ability of results of these tests cannot be extrapolated to the
Sealapex was significantly better than three other clinical situation (Hauman & Love 2003). Briseňo &
sealers (Rocanal 2, La Maison Dentaire SA, Balzers, Willershausen (1992) assessed the cytotoxicity of four
Switzerland; AH-Plus, Dentsply De Trey, and RC sealer, different calcium hydroxide-based root canal sealers
Sun Medical Co Ltd, Shiga, Japan) at 7, 14 and (Sealapex), Apexit (Ivoclar Vivadent), CRCS (Coltène
21 days. Siqueira et al. (1999) found that during a 60- Whaledent) and Endoflas FS (Sanlor, Miami, FL, USA)
day period, Sealer 26 (Dentsply, Indústria e Comércio on HGF. According to their findings, Endoflas FS
Ltda, Petrópolis, Brazil) resulted in significantly less induced a dramatic reduction in the protein synthesis
leakage than Sealapex. Pommel et al. (2003) found potential of the fibroblasts in the 24-h group. In the 48-
that there was no statistically significant difference h group, Endoflas FS gave a slightly better response.
amongst AH26, Pulp Canal Sealer, and Ketac-Endo. In Endoflas FS, however, had a significantly higher
cytotoxicity with respect to other sealers in both trials. and aged specimens appeared to induce cellular prolif-
Sealapex demonstrated a relatively low cytotoxicity eration. RoekoSeal and GuttaFlow also demonstrated
after 3 days of culturing. Although CRCS had a slightly mild cytotoxicity. GuttaFlow was slightly more cyto-
higher cytotoxicity during the initial phase of the toxic to both cultures, especially when tested fresh.
experiments, a declining level of toxicity could be In a study to evaluate genotoxicity of Ca(OH)2-based
measured after 3 days of culturing. Apexit had a and epoxy resin-based root canal sealers, Huang et al.
relatively high cytotoxicity in the initial phase, but an (2002) found that a resin-based sealer produced
ascending incorporation rate of l-[14C] leucine in the greater DNA damage than a Ca(OH)2-based sealer. In
fibroblasts could be distinguished after 3 days of a laboratory study to assess cytotoxicity of Ca(OH)2-
culturing. based sealers, Beltes et al. (1995) reported that Seal-
Leonardo et al. (2000a) evaluated the cytotoxicity of apex was the most cytotoxic sealer, followed by CRCS,
four Ca(OH)2-based sealers and a zinc oxide–eugenol- with Apexit being the least cytotoxic with the smallest
based sealer (Fill Canal; TechNew, CampoGrande, RJ, decrease in cell density. In a study to assess tissue
Brazil) and found that the least cytotoxic sealer was Fill toxicity of Grossman’s sealer, eucapercha, Endo-Fill,
Canal, followed in increasing order of cytotoxicity by CRCS, Sealapex and Hypocal, they were injected into
CRCS, Sealer 26 (Dentsply), Apexit and Sealapex. specific dorsal subdermal tissue sites of 12 guinea pigs
Boiesen & Brodin (1991) evaluated the neurotoxic (Yesilsoy et al. 1988). Sealapex and Endo-Fill had less
effect of Sealapex and CRCS and found that both severe inflammatory reactions than any of the other
materials exhibited reversible and irreversible blocking materials. Grossman’s sealer, CRCS and Hypocal cre-
of nerve conduction after 90 s and 5-min exposure. ated principally severe inflammatory responses at both
However, after 30 min of contact, the conduction of 6 and 15 days, but mild reactions at 80 days. Eucap-
the compound action potential was irreversibly blocked ercha created less severe inflammatory responses than
for both materials. Grossman’s sealer, CRCS and Hypocal (Yesilsoy et al.
Using HeLa cells, Miletić et al. (2000) reported that 1988).
the toxicity of Apexit was significantly less than AH26, Mittal et al. (1995) evaluated the tissue toxicity of
AH-Plus, and Diaket (3M ESPE AG, Seefeld, Germany). zinc oxide–eugenol, Tubliseal, Sealapex and Endoflas FS
Schwarze et al. (2002) evaluated the cytotoxicity of by injecting them into the subcutaneous connective
several types of root canal sealers in vitro over the tissue of the dorsal surface of rats and studying the
period of 1 year using immortalized 3T3 fibroblasts and tissue response histologically. According to their find-
primary human periodontal ligament fibroblasts. ings, Sealapex was associated with the least inflamma-
Results revealed that pronounced cytotoxic effects were tory reaction compared to the other sealers used,
only caused by N2-extracts in both cell cultures. because it caused moderate inflammation at 48 h that
Furthermore, significant cytotoxic alterations were also became mild. Zinc oxide-eugenol, Tubliseal and Endof-
induced by 10-week eluates of Endomethasone (Spe- las F.S. were highly toxic at 48 h and 7 days. This
cialités Septodont, Saint Maur-des-Fossés, France); toxicity decreased gradually with time. No inflamma-
other investigated materials did not significantly alter tory reaction was seen at 3 months with any of the
cell metabolism. Eldeniz et al. (2007) assessed ex vivo sealers.
the cytotoxic effects of eight root canal sealers RC Silva et al. (1997) evaluated the inflammatory
Sealer (Sun Medical), Epiphany (Pentron, Wallingford, response to Sealapex, CRCS, Apexit and Sealer 26 in
CT, USA), EndoREZ (Ultradent, South Jordan, UT, USA), the subcutaneous tissue and in the peritoneal cavity of
GuttaFlow (Colthène Whaledent), Acroseal (Septodont, Balb/c mice. The inflammatory response of subcutane-
France), AH-Plus (Dentsply De Trey), RoekoSeal (Colt- ous tissue was analysed after 2, 4, 8 and 16 days.
hène Whaledent) and Apexit (Ivoclar Vivadent) using Intense neutrophilia was seen in response to all sealers
primary HGF and a mouse fibroblast cell line (L929). during the initial periods. Differences amongst them
Results showed that resin-based (Epiphany and Endo- related to the presence of necrosis and the number of
REZ) and calcium hydroxide-based (Apexit and inflammatory cells. In the intermediate phase, marked
Acroseal) sealers were significantly more cytotoxic differentiation of cells of the mononucleate phagocytic
than other sealers. However, L929 cells were more system into macrophages, epithelioid cells and multi-
sensitive to Apexit and EndoREZ than HGF cells. RC nucleate giant cells were observed with Sealapex. This
Sealer had mild cytotoxicity to HGF at both setting response was less intense with CRCS and Apexit. Tissue
times. AH-Plus did not exert any cytotoxic effect to HGF necrosis was observed only at tissue sealer interfaces
and only during the initial period with Sealapex but plasmocytic infiltration in two of the seven cases. In
was seen throughout the experiment with all other the group with overfilled root canals, all four sealers
sealers. The animals were injected in the peritoneal initiated inflammatory reactions. The periapical tissue
cavity with solutions containing the sealers and five reactions of overfilled root canals were similar to
mice from each group were killed 6 and 24 h, and 5 reactions detected in cases filled within the canal.
and 15 days later. During the initial periods (6 and However, additional histological features developed in
24 h), there was an intense migration of polymorpho- specimens of Endomethasone and AH26: Endometha-
nuclear leucocytes to the peritoneal cavity in response sone initiated a foreign body-type granulomatous
to all sealers compared to the control. This migration reaction around the sealer particles and AH26 parti-
was more intense for Sealer 26 and Apexit. An increase cles were engulfed by macrophages. The overfilled root
in mononucleate cell number was observed after 6 and canals of Apexit and Grossman’s sealers initiated only
24 h and 5 days for all sealers and no differences were lymphocytic/plasmocytic reactions.
observed in relation to the control after 15 days. In summary, some controversies regarding the
Kolokouris et al. (1998) evaluated the in vivo biocompatibility of Ca(OH)2-based sealers could be
biocompatibility of Apexit and Pulp Canal Sealer after attributed to the evaluation method. However, most
implantation in rat connective tissue. Findings re- studies concluded that the biocompatibility of Ca(OH)2-
vealed that severe inflammatory reactions with differ- based sealers were within an acceptable range com-
ing extensions of necrosis were observed with Apexit pared to other root canal sealers.
on the 5th and 15th days. The intensity of the
reaction had diminished by the 60th day, and this
Antibacterial activity
reduction continued progressively through to the
120th day. It was characterized by the presence of Microorganisms infecting the root canal dentine might
connective tissue with a few macrophages. Moderate adhere superficially to the dentinal wall or penetrate
to severe inflammation with confined areas of necrosis deeper into the dentinal tubules (Ando & Hoshino
was observed in the Pulp Canal Sealer specimens on 1990, Peters et al. 2001). Superficially adhering bac-
the 5th day. The intensity of the reaction diminished teria might be expected to be killed more readily than
by the 15th, 60th and 120th days but remained those shielded in the depths of dentinal tubules, but
greater than Apexit through long-term observation microorganisms inside the dentinal tubules might also
periods. Figueiredo et al. (2001) evaluated tissue be challenged by antimicrobial components leaching
response to four endodontic sealers (N-Rickert, AH- from sealers. Therefore, antimicrobial testing of sealers
26, Fill Canal, and Sealer 26) placed in the oral should take into consideration these two effects based
mucosa of rabbits by either submucous injection or on the contact of the sealer with microorganisms
implant in polyethylene tubes. Findings demonstrated (Kayaoglu et al. 2005). Two main methods have been
that there was no difference between the two methods used to study the antimicrobial effects of Ca(OH)2-based
of implantation. In addition, all sealers elicited some sealers including ADT and direct contact tests (DCT).
kind of inflammatory response; the most irritant was In an agar diffusion study, Mickel & Wright (1999)
Fill canal, followed by N-Rickert and AH-26. Sealer 26 reported that Roth (a zinc oxide–eugenol-based sealer)
elicited a mild reaction only. Bernáth & Szabó (2003) inhibited the growth of Streptococcus anginosus (milleri)
evaluated the type and degree of inflammatory reac- more effectively than several Ca(OH)2-based sealers
tion initiated by four sealers (AH26, Apexit, Endo- (Sealapex, Apexit, and CRCS). In another agar diffusion
methasone and Grossman’s sealers) by overfilling the study, Mickel et al. (2003) evaluated the antimicrobial
root canals in the teeth of monkeys. The result of the activity of four root canal sealers on E. faecalis. A
treatment was evaluated after 6 months by histo- statistically significant difference was observed between
logical assessment of the periapical tissues. In the all four groups of sealers. Roth 811 had the largest zone
group of root canals filled within the root, no of inhibition (1.1 mm), followed by Sealapex (0.8 mm)
inflammatory reaction was detected in specimens of and Kerr EWT (0.5 mm), whereas AH-Plus had no
Apexit and Grossman’s sealers, but the other two antimicrobial activity. Abdulkader et al. (1996) evalu-
sealers initiated different degrees of lymphocytic/ ated the effect of several sealers against Capnocytophaga
plasmocytic tissue reactions. Endomethasone initiated ochracea, Porphyromonas gingivalis and Peptostrepto-
a mild lymphocytic/plasmocytic reaction in three of coccus micros using ADT. Findings revealed that zones
the nine cases and AH26 caused mild lymphocytic/ of bacterial growth inhibition in descending order were
as follows: Roth Sealer, Ketac-Endo, Tubliseal, Apexit tic, whereas their solubility in tissue fluids is negative
and Sealapex. al-Khatib et al. (1990) assessed the characteristic.
antibacterial effect of Grossman’s sealer, Tubliseal,
Calciobiotic, Sealapex, Hypocal, eucapercha, Nogenol Solubility in tissue fluids
and AH26 against Streptococcus mutans, Staphylococcus Ca(OH)2-based sealers were introduced in an attempt
aureus and Bacteroides endodontalis using ADT. Results to stimulate periapical healing with bone repair
demonstrated that Grossman’s sealer had the greatest through the release of Ca(OH)2 (Bergenholtz et al.
overall antibacterial activity. However, AH26 had the 2003). According to Esberard et al. (1996a), Ca(OH)2-
greatest activity against B. endodontalis, whilst the zinc based sealers release OH) and Ca2+ ions. These sealers
oxide–eugenol-based sealers had more antimicrobial evoke an increase in pH when placed in distilled water
activity than either the calcium hydroxide-based seal- (48 h after setting) of 9.14 and 8.6; under the
ers or eucapercha. Using ADT, Lai et al. (2001) found same conditions, pure Ca(OH)2 paste increased the pH
that the antibacterial activity of zinc oxide-based to 12.5. Sleder et al. (1991) demonstrated that
and resin-based sealers were more than Sealapex Sealapex had no greater dissolution (based upon linear
(a Ca(OH)2-based sealer). penetration) than Tubliseal at both 2 and 32 weeks
The number of studies with DCT is fewer. Heling & and concluded that Sealapex could withstand long-
Chandler (1996) as well as Saleh et al. (2004) have term exposure to tissue fluids without significant
demonstrated that Sealapex as well as Apexit (two leakage. Tronstad et al. (1988) assessed solubility of
Ca(OH)2-based sealers) had less antibacterial efficacy CRCS and Sealapex in dogs’ teeth and found that CRCS
than resin-based and zinc oxide-based sealers. Further- was more stable than Sealapex. McMichen et al. (2003)
more, these two studies demonstrated that the anti- reported that the solubility of Apexit in water was
microbial effect of Ca(OH)2-based sealers increased with significantly more than AHPlus, Tubliseal EWT and
time, probably as a result of disintegration of the sealer Endion.
and an increase in the amount of hydroxyl ions over In summary, owing to the small number of studies,
time. Furthermore, Kayaoglu et al. (2005) showed that the solubility of Ca(OH)2-based sealers compared to
the Ca(OH)2-based sealers, Sealapex and Apexit, were other sealers in tissue fluids is not known.
ineffective in killing bacteria in the short term (24 h).
According to Cobankara et al. (2004), Ketac-Endo and Solubility in solvents
AH-Plus were more potent bacterial growth inhibitors Removal of root canal filling materials from the root
than Sealapex. canal is a requirement for retreatment (Mandel &
Duarte et al. (2000) evaluated the pH and calcium Friedman 1992). Various solvents for dissolving mate-
ion release of three root canal sealers, Sealapex, Sealer rials have been studied (Olsson et al. 1981, Barbosa
26 and Apexit at 24 and 48 h, and 7 and 30 days after et al. 1994). Chloroform is the most common solvent to
spatulation. Sealapex produced an alkaline pH and remove root-filling materials including Gutta-perch and
released significantly greater amounts of calcium, with sealers (Wilcox 1995). Benzene and xylene, which are
even more pronounced results after 30 days. Further- effective solvents, may be potential carcinogens (Lynge
more, Sealapex had the highest calcium and hydroxyl et al. 1997). Halothane, another solvent, is highly
release, especially after longer time intervals, whereas volatile (Keles & Köseoglu 2009). The high cost and
Sealer 26 had the highest release during the initial volatility of halothane and its potential for inducing
periods (i.e. during its setting period). Apexit had the idiosyncratic hepatic necrosis make it a less desirable
least satisfactory results. solvent (Keles & Köseoglu 2009). Whitworth & Boursin
In summary, the antibacterial activity of Ca(OH)2- (2000) evaluated the effect of two volatile solvents
based sealers is lower than other similar materials, (chloroform and halothane) on the solubility of root
especially zinc oxide–eugenol-based and resin-based canal sealers (Ketac-Endo, TublisSeal EWT, Apexit, and
sealers. AH-Plus). Ketac-Endo was the least soluble in chloro-
form and halothane, with less than 1% weight loss after
10-min exposure to either solvent. Apexit had low
Solubility
solubility with 11.6% and 14.19% weight loss after
When considering the solubility of endodontic sealers, 10-min exposure to chloroform and halothane,
it should be noted that their solubility in specific respectively. The difference between solvents was not
solvents, such as chloroform, is a positive characteris- significant. Tubliseal EWT was significantly less soluble
in halothane than chloroform (5.19% and 62.5% and 120th days, but remained marginally greater than
weight loss after 10-min exposure, respectively). Its Apexit through long-term observation periods.
solubility in halothane was not significantly different Osorio et al. (1998) reported that CRCS was well
from that of Apexit. AHPlus was significantly more tolerated by HGF and L929 cells. Leonardo et al.
soluble than all other materials in both chloroform and (2000b) found that the cytotoxicity of four Ca(OH)2-
halothane (96% and 68% weight loss after 10-min based sealers [Sealapex, CRCS, Apexit, and Sealer 26
exposure, respectively. (Dentsply, Industria e Comercio Ltda)] was more
Schäfer & Zandbiglari (2002) reported that Ca(OH)2- pronounced than a zinc oxide–eugenol-based sealer
based sealers had greater solubility in chloroform than (Fill Canal; Dermo Laboratorios, Rio de Janeiro, Brazil).
in eucalyptus oil. Keles & Köseoglu (2009) found that Camps & About (2003) concluded that the high
the solubility of a Ca(OH)2-based sealer in NaOCl cytotoxicity of Sealapex did not decrease over time.
and EDTA was significantly greater than ZOE-based, Soares et al. (1990) found that overfilled canals con-
silicone-based and resin-based sealers. However, its sol- taining Ca(OH)2-based sealers caused chronic inflam-
ubility was similar to polyketone. Martos et al. (2006) matory reactions in the periapical tissues of dog’s teeth.
evaluated the solubility of Ca(OH)2-based (Sealer 26), In summary, although Ca(OH)2 paste is well toler-
silicon-polydimethylsiloxane-based (RoekoSeal), and ated by periapical tissues, it has a detrimental effect on
zinc oxide–eugenol based (Endofill and Intrafill) sealers periodontal tissues when used as an intracanal medi-
in eucalyptol, xylol, orange oil and distilled water. Xylol cament. The biocompatibility of Ca(OH)2-based sealers
and orange oil had similar effects, with significant is controversial. Overall, because of their solubility,
solubilization of the cements tested. Endofill and Sealer Ca(OH)2-based sealers do not fulfil all the criteria of an
26 did not have any significant difference in solubili- ideal sealer. The antibacterial effects of calcium
zation at the two immersion times, whereas RoekoSeal hydroxide in sealers are variable. Cytotoxicity appears
and Intrafill had more pronounced solubility at 10 min. to be milder than for other groups of sealers.
The lowest levels of solubilization occurred in Roeko-
Seal, Sealer 26, Endofill and Intrafill.
Clinical applications of calcium hydroxide
In summary, the solubility rate of Ca(OH)2-based
when used as pulp-capping agents in vital
sealers compared to other sealers in solvents is still
pulp therapy
controversial.
Abnormal root development on teeth undergoing root
canal treatment will impact on the prognosis and thus
Toxicity of Ca(OH)2 in sealers
tooth retention. Therefore, the primary purpose of
Economides et al. (1995) reported that Sealapex (a treating immature permanent teeth should be, where
Ca(OH)2-based root canal sealer; SybronEndo) caused a possible, to maintain pulp vitality in order for root
moderate-to-severe inflammatory reaction, whereas development to continue (apexogenesis). Such vital pulp
CRCS (a Ca(OH)2-based root canal sealer, Coltène- therapy includes indirect and direct pulp-capping, partial
Whaledent) caused mild-to-moderate reactions in rat (superficial) pulpotomy and cervical pulpotomy. There
connective tissue. Kolokouris et al. (1998) evaluated are long-term prognostic advantages of this treatment
the in vivo biocompatibility of Apexit (a Ca(OH)2-based outcome over apexification. For example, the prognosis
root canal sealer, Ivoclar Vivadent) and Pulp Canal of superficial pulpotomy is 94–96% whereas the prog-
Sealer (a zinc oxide–eugenol-based sealer, SybronEndo) nosis of apexification is 79–96% (Trope et al. 2002).
after implantation in rat connective tissue at 5-, 15-, A number of materials have been advocated to
60-, and 120-day intervals. Severe inflammatory induce normal root development with the most popular
reactions occurred with differing levels of necrosis with being Ca(OH)2. Zander (1939) was amongst the first to
Apexit on the 5th and 15th days. The intensity of the report on the use of a Ca(OH)2 material as a treatment
reaction had diminished by the 60th day, and this for the exposed dental pulp and speculated that the
reduction continued progressively to the 120th day. It success of Ca(OH)2 was related to its high alkalinity.
was characterized by the presence of connective tissue According to Schröder & Granath (1971), the mech-
with a few macrophages. Moderate-to-severe inflam- anism for the induction of dentinal bridge formation
mation with confined areas of necrosis was observed in and repair under Ca(OH)2 was that it caused a
the Pulp Canal Sealer specimens on the 5th day. The superficial coagulation of the pulp tissue on which it
intensity of the reaction diminished by the 15th, 60th was placed, initiated by damage to blood vessels. The
initial damage from Ca(OH)2 occurs in the capillaries high-pH formulations of Ca(OH)2 reduce the size of the
closest to the region of the capping or pulpotomy subjacent dental pulp by up to 0.7 mm (Schröder
(Seltzer & Bender 1975). Because of its high pH, 1973, Cox et al. 1985, Heide 1991). To overcome these
Ca(OH)2 helps to maintain the immediate region in a drawbacks, hard-setting Ca(OH)2 formulations were
state of alkalinity, which is necessary for bone and introduced. Stanley & Lundy (1972) reported that
dentine formation. Under this region of Ca(OH)2- hard-setting Ca(OH)2 formulations did not necrose the
induced coagulation necrosis, which is saturated with superficial layer and found that the pulpal reactions to
calcium ions, cells from the underlying pulp tissue Dycal, Prisma VLC Dycal, Life and Nu-Cap were similar.
differentiate into odontoblast-like cells, which then However, in another study, they found that in contrast
begin to elaborate matrix (Farhad & Mohammadi to regular Dycal, which caused a thickness of pulp
2005). mummification of 0.3–0.7 mm at the exposure site,
Prisma VLC Dycal caused no inflammation (Stanley &
Pameijer 1985).
Pulp capping/pulpotomy
Ca(OH)2 dressings of Life and Dycal can dissolve
Many materials and drugs have been used as direct pulp- clinically within 1–2 years (Stanley & Pameijer 1985,
capping agents. One of the most effective and popular Cox et al. 1985). As the majority of dentine bridges
agents is Ca(OH)2 (Farhad & Mohammadi 2005). under the materials appear to contain tunnels, about
Ca(OH)2 can be used as a pulp protectant, but it should 50% of the pulps may become infected or become
be used only where indicated and in a thin layer. Regular necrotic because of microleakage (Cox et al. 1985).
aqueous or methylcellulose Ca(OH)2 fails as a base Another problem with Dycal and Life is that they are
material (Farhad & Mohammadi 2005). It is biocompat- degraded by etching and rinsing prior to restoration
ible, but unfortunately has a low compressive strength (Olmez et al. 1998). In newer products such as Prisma
that is not compatible with the condensation forces used VLC Dycal, the Ca(OH)2 is incorporated into urethane
when placing some definitive restoration, particularly dimathacrylate with initiators and accelerators by
amalgam. It should be noted that in the case of indirect which they bind to dentine and have a higher
pulp capping (IPC), Ca(OH)2 is being used as an resistance to acid dissolution(Pameijer & Stanley
antibacterial agent and mild pulp stimulant to produce 1998).
irritation dentine (Farhad & Mohammadi 2005). War- Although suspensions of Ca(OH)2 are highly alka-
fvinge et al. (1987) reported that to achieve these two line, other compounds such as ammonium hydroxide
objectives Ca(OH)2 paste in saline was much more with the same alkalinity cause liquefaction necrosis of
effective than a commercial hard-setting Ca(OH)2 the pulp when placed on exposed pulp tissue (Siqueira
cement (Life; SybronEndo). Another variation of a & Lopes 1999). The calcium ions delivered to the
Ca(OH)2 liner, Prisma VLC Dycal (LD Caulk Co., Milford, exposure site by the Ca(OH)2 suspension are not
DE, USA), consists of Ca(OH)2 and fillers of barium utilized in the repair of the exposure. Pisanti & Sciaky
sulphate dispersed in a specially formulated urethane (1964) demonstrated by way of radio-autographs that
dimethylacrylate resin-containing initiators (camphoro- the calcium ions present in dentine bridges originated
quinone) and activators. According to Stanley & Pam- from the systemic circulation. The Ca(OH)2, which
eijer (1985) Prisma VLC Dycal has a number of contained radioactive calcium, did not enter into the
advantages over regular water or methylcellulose-based formation of the bridge.
Ca(OH)2: ‘dramatically improved strength, essentially no Schröder & Granath (1972) examined the coronal
solubility in acid, minimal solubility in water, control surface structure of Ca(OH)2-induced bridges with both
over working time, and reaching the maximum physical the light and scanning electron microscope and found
properties almost immediately’. tubular openings surrounded by collagen bundles
Numerous studies have demonstrated dentinal similar to those found in normal predentine. It has
bridge formation in about 50–87% of cases treated been reported that saturated calcium and barium
with various Ca(OH)2 formulations (Hargreaves & hydroxide completely inhibited alkaline phosphatase
Goodis 2002). However, there is controversy concern- and lactic dehydrogenase activity, but Ca(OH)2 prepa-
ing the application of Ca(OH)2 in vital pulp therapy, rations at lower pH levels were much less inhibitory
particularly its caustic action. According to Meadow (Seltzer & Bender 1975). Franz et al. (1984) evaluated
et al. (1984) pure Ca(OH)2 necroses approximately dentinal bridges formed 4–15 weeks after capping
1.5 mm of the pulp tissue. The caustic action of the deliberately exposed human pulps with a Pulpdent (a
Ca(OH)2 paste) using scanning electron microscopy Actual root growth does not occur as a result of
(SEM) as well as microradiographic techniques and apexification, but radiographic evidence of a calcified
found complete bridging and increasing thickness over mass at the root apex gives that impression (Grossman
longer post-treatment periods. Cross-sections of pulps 1988).
treated for more than 6 weeks revealed a superior Cvek (1972) observed apical root closure and bone
amorphous layer composed of tissue debris and healing following intracanal placement of Ca(OH)2 in
Ca(OH)2, a middle layer of a coarse meshwork of fibres 50 of 55 maxillary incisors with immature roots.
identified as fibrodentine, and an inner layer containing Furthermore, Binnie & Rowe (1973) dressed immature
tubular osteodentine (Franz et al. 1984). premolars in dogs with Ca(OH)2 and distilled water and
Seltzer & Bender (1975) attributed two undesirable observed a minimal inflammatory response in the
side effects to Ca(OH)2 when used as a pulp-capping or periapical tissues with continued root formation.
pulpotomy agent: one is the possibility of eventual Although apexification occurs in association with
complete calcification of the tissue in the root canal. If many materials, it has been reported even after the
this occurs, subsequent root canal treatment, if needed, removal of necrotic pulp tissue without the provision of
becomes a difficult and often impossible. The second a root filling (England & Best 1977). According to
adverse effect is the persistence of induced inflamma- Kleier & Barr (1991), the usual time required to
tion, eventually causing internal resorption. achieve apexification is 6–24 months (average
In summary, considering its alkalinity, biocompati- 1 year ± 7 months). However, in one case it has been
bility and antimicrobial activity, it seems that Ca(OH)2 reported that 4 years of treatment was required for
is a suitable material for pulp capping and pulpotomy. complete apexification (Grossman 1988).
However, its solubility in fluids is a problem that There is disagreement in the literature on how often
requires a good coronal seal. the canal should be refilled with Ca(OH)2 paste to
produce apexification, and the decision appears to be
empirical. According to Tronstad et al. (1981) refilling
Apexification
every 3–6 months is favoured. Other reports favour
Apexification is defined as the process of creating an refilling only if there is radiographic evidence of
environment within the canal and periapical tissues resorption of the paste (Cohen & Burns 2002). Chosack
after pulp death that allows a calcified barrier to form & Cleaton-Jones (1997) suggested that after initial root
across the open apex of an immature root (Pitt Ford filling with Ca(OH)2, there was nothing to be gained by
2002). This calcified barrier consists of osteocementum its replacement either monthly or after 3 months for at
or other bone-like tissue (Grossman 1988). Creation of least 6 months. If signs or symptoms of reinfection or
a proper environment for formation of the calcified pathosis occur at any time during the periodic recall of
barrier involves cleaning and shaping of the canal to apexification cases, the canal is cleaned again and
remove debris and bacteria, followed by placement of a refilled with Ca(OH)2 paste (England & Best 1977). If
suitable material to the apex (Pitt Ford 2002). Different apexification is incomplete, the canal is refilled with the
materials have been used successfully, but the most Ca(OH)2 and the periodic recall continues (England &
favoured is a paste of Ca(OH)2 and water; the addition Best 1977).
of other medicaments to Ca(OH)2 has no beneficial From the histological perspective, the calcified tissue
effect on apexification (Gutmann & Heaton 1981). that forms over the apical foramen has been identified
Thorough debridement to remove bacteria and as an osteoid or cementoid material (Ham et al. 1972).
necrotic tissue from the canal system is the primary According to Grossman (1988), the residual un-
factor responsible for apical closure. Ca(OH)2 is used as damaged pulp tissue, if there is any, and the odonto-
a temporary canal filling material and has a bacteri- blastic layer associated with the pulp tissue resume
cidal effect (Pitt Ford 2002). Although apexification their matrix formation and subsequent calcification is
had been attempted in the past, the technique was guided by the reactivated Hertwig epithelial root sheath
given impetus by the description of three cases by (HERS). Grossman (1988) also stressed that the HERS
Frank (1966) who cleaned and irrigated canals and and the pulp tissue that were once damaged may
then sealed them with a paste of camphorated chlor- explain why some of the apical formations appear
ophenol and Ca(OH)2. Radiographic examination 3 and atypical.
6 months later revealed evidence of a root apex cap or Pitt Ford (2002) concluded that the type of barrier
barrier, following which the root canals were filled. that forms depends on the extent of pulp necrosis at the
start of treatment. Vital (but probably inflamed) pulp

Horizontal root fractures
may be present at the root-end; following pulpectomy,
canal preparation, irrigation and insertion of Ca(OH)2, The use of Ca(OH)2 in teeth with horizontal root
some continued root formation may be expected from fractures was first recommended by Cvek (1974). He
the surviving HERS. However, if there is severe proposed that the canal at the level of the fracture line
inflammation (or even abscess formation) in the was comparable to the apical foramen of an immature
periapex (with or without sinus tract), the HERS has tooth. Thus, he assumed that the repair would be similar
probably been destroyed completely. to the apexification procedure employed for a tooth with
In summary, Ca(OH)2 is the material of choice to an open apex (Cvek 1974). The benefits of root canal
create a calcified barrier at the root-end of teeth with treatment with Ca(OH)2 occur probably because of its
necrotic pulps and immature ‘open’ apices. However, antibacterial effect and its ability to promote the forma-
elimination of infection and necrotic pulp tissue, and tion of a hard-tissue barrier at the apical opening of the
the establishment of an effective coronal seal after coronal fragment, thereby facilitating filling with Gutta-
placing the intracanal medicament appear to be more percha (Cvek et al. 2008). The frequency of healing
important than the type of intracanal medicament (86%) in this treatment protocol is similar to that
used. The more recent introduction of the MTA apical reported for treatment of immature teeth without a root
barrier technique may replace the use of Ca(OH)2 in fracture, i.e. healing after calcium hydroxide treatment
this treatment modality. and subsequent filling with Gutta-percha (Cvek 1972,
1992). This may also indicate that a tooth with a
necrotic pulp in the coronal fragment should be regarded
Other clinical applications of calcium
and treated as an immature tooth with a necrotic pulp.
hydroxide when used in endodontic
The chair-side time and the refilling of the canal with
therapy
calcium hydroxide that are required to obtain these
results may be seen as a drawback (Cvek et al. 2008). A
Canals with exudate
better alternative treatment protocol is now available
A perplexing condition to treat is the tooth with with use of MTA. In this situation, because the apical
constant clear or reddish exudate associated with a part of the coronal fragment resembles teeth with open
large apical radiolucency. Such a tooth is often apices, MTA can be used for optimal closure of the apical
asymptomatic, but it may be tender to percussion or end of the coronal root segment (Kusgoz et al. 2009).
sensitive to digital pressure over the apex. If cultured, In summary, in the management of horizontal root
the drainage will not generally support bacterial fractures, the coronal segment is considered as an
growth (Weine 2004). When the pulp chamber is immature tooth with an open apex, and an apexifica-
opened at the start of the appointment, a reddish tion procedure is conducted. However, MTA can now
discharge may appear, whereas at the succeeding be used for optimal closure of the apical end of the
appointment the exudate will be clear. If such a tooth coronal root segment once canal infection has been
is left opened under a rubber dam for 15–30 min, the eliminated.
exudate will stop; however, a similar condition will still
be present at the next appointment even though canal
preparation to an acceptable size has been achieved.
Perforations
This is referred to as a ‘weeping canal’ (Weine 2004).
According to Weine (2004), the best way to stop the Root or furcation perforations can cause failure of root
exudate in such cases is to dry the canal with sterile canal treatment, leading to tooth loss (Bramante &
paper points and to place Ca(OH)2 paste in the canal. Berbert 1994). Several materials have been used to seal
The possible mechanism of action of Ca(OH)2 in these perforations, including Ca(OH)2. Ca(OH)2 has many
cases is related to its basic pH, which converts the benefits in this treatment modality including, easy
acidic pH of periapical tissues to a more basic environ- manipulation, rapid resorption when extruded into the
ment. Two other theories have also been proposed: (i) periodontium, promotion of the reorganization of
the calcifying potential of Ca(OH)2 may start to build up periodontal tissues and induction of mineralized mate-
bone in the lesion and (ii) the caustic action of Ca(OH)2 rial (Bramante & Berbert 1994). It has been suggested
cauterises residual chronically inflamed tissue (Weine that in such cases, the Ca(OH)2 should be renewed
2004). regularly (Heithersay 1975, Frank & Weine 1973).
It has been suggested that large apical perforations internal, external or root-end resorption (Chivian
should be treated in a similar way as teeth with 1991).
immature apices, i.e. with long-term Ca(OH)2 treat- Ca(OH)2 has an active influence on the local envi-
ment to achieve a hard-tissue barrier (Fuss & Trope ronment around a resorptive area by reducing osteo-
1996). Petersson et al. (1985) and Bogaerts (1997) clastic activity and stimulating repair (Tronstad et al.
stated that materials based on Ca(OH)2 as a main 1981). This is directly related to the alkaline pH of
ingredient were not suitable for crestal and furcation Ca(OH)2, which permeates through the dentine. Hard-
perforations because of the initial inflammatory re- tissue resorption, with its enzymatic activity, takes
sponse to these materials, which could lead to break- place in an acidic pH Ca(OH) creates an alkaline
down of the supporting tissues and subsequent pocket environment in which the reaction is reversed and
formation. ElDeeb et al. (1982) and Himel et al. (1985) hard-tissue deposition can take place (Estrela & Holland
expressed concerns about using Ca(OH)2 in close 2009). The phenomenon of pH change towards the
proximity to the attachment apparatus because of the periphery is increased, especially where resorption has
necrotizing properties of the material and the inflam- exposed dentine (Tronstad et al. 1981). Frank & Weine
matory reaction to it. On the other hand, the use of (1973) reported on a technique using a Ca(OH)2-
hard-setting Ca(OH)2 to repair furcation perforations in camphorated monochlorophenol mixture for the non-
monkey teeth did not appear to alter the pattern of surgical treatment of perforating internal resorption. In
healing, except to prevent ingrowth of granulation such situations, other similar techniques have been
tissue into the instrumented root canal and was used that resulted in the deposition of a cementum-like
followed by a high rate of repair (Beavers et al. 1986). or osteoid tissue.
In contact with tissue fluids, Ca(OH)2 may be Mineral trioxide aggregate is an alternative for
displaced (Schuurs et al. 2000) with the result that a Ca(OH)2 in the management of internal root resorption.
reliable seal cannot be achieved; in such situations, a Successful surgical and non-surgical treatment of
more conventional restorative material such as MTA is internal resorption using MTA in both primary and
required. Pitt Ford et al. (1995) demonstrated that permanent teeth has been reported in several case
cementum was generated underneath MTA in most reports (Hsien et al. 2003, Sari & Sonmez 2006,
teeth with perforations, in contrast to the teeth whose Silveira et al. 2009). Hsien et al. (2003) reported
furcation perforation sites were repaired with amal- successful treatment of internal resorption in a maxil-
gam. Yildirim et al. (2005) compared the healing of lary central incisor using MTA with 1-year follow-up.
furcation perforations repaired with MTA versus Super Sari & Sonmez (2006) reported successful root filling of
EBA in dogs’ teeth. Their findings revealed cementum a primary second molar with MTA with an 18-month
formation underneath all MTA specimens at the 6- follow-up.
month interval, whereas Super EBA samples had mild- The initial treatment of choice for internal root
to-severe inflammation around the repair material and resorption is to pack the canal and the resorption
no cementum formation during the same time interval. lacuna with Ca(OH)2 paste. The Ca(OH)2 will tend to
Main et al. (2004) reported clinical success of MTA in necrotize remaining tissue in the lacuna, and the
root perforation repairs. necrotic remnants are then removed by irrigation with
In summary, Ca(OH)2 has been suggested as a sodium hypochlorite (Chivian 1991). When lateral
traditional agent to manage perforations, and its use resorption is noticed from the outset, pulp extirpation,
is still indicated to control infection, arrest bleeding and debridement and Ca(OH)2 therapy are preferred (Trope
as a temporary solution when insufficient time is 2002, Haapasalo & Endal 2006). In addition, when
available to perform a permanent repair. However, lateral resorption reaches the dentine or perforates the
MTA now appears to be the material of choice for the root canal, the Ca(OH)2 procedure should be attempted
permanent repair of perforations from both a conven- after canal debridement (Stewart 1975). According to
tional and surgical approach. Chivian (1991), Ca(OH)2 should be placed into the
resorptive defect at 3-month intervals until there is
evidence of hard-tissue repair, confirmed by both
Root resorption
radiographic and direct examination through the
Root resorption can affect the cementum and/or access cavity. When the physical barrier has been
dentine of the root (Trope 2002). On the basis of the established, the defect can be filled with Gutta-percha
site of origin of the resorption, it may be referred to as or MTA.
The arrest of external root resorption related to improved by using patency file, combining EDTA and
necrotic pulps can be attributed exclusively to removal NaOCl with hand instrumentation and the type of
of necrotic tissue and antibacterial treatment of the root vehicle used. In addition, ultrasonic methods are more
canal (Mohammadi et al. 2006). When external resorp- efficient in removing Ca(OH)2 remnants than passive
tion occurs following luxation injuries pulp extirpation, irrigation. Ca(OH)2 paste is well tolerated by bone and
debridement and Ca(OH)2 therapy are necessary (Chi- dental pulp tissues. However, its effect on the peri-
vian 1991). In some situations when root resorption odontal tissue is controversial. The biocompatibility of
continues after the completion of active and retentive Ca(OH)2-based sealers is controversial and because of
phases of orthodontic treatment, intentional pulp their solubility, they do not fulfil all the criteria of an
extripation and Ca(OH)2 is often successful in abating ideal sealer. Furthermore, their antibacterial activity is
resorption (Gholston & Mattison 1983). Andreasen variable, and their cytotoxicity appears to be milder
(1971) was able to arrest inflammatory root resorption than for other groups of sealers. Ca(OH)2 is a suitable
in nine of ten cases using an intracanal Ca(OH)2 material for pulp capping and pulpotomy. However, its
dressing. solubility in fluids is a problem that requires a good
In summary, by creating an alkaline environment, coronal seal. Ca(OH)2 has been the material of choice
Ca(OH)2 inhibits osteoclast activity and stimulates to create a calcified barrier in non-vital open-apex
hard-tissue deposition. However, MTA can be used to teeth. However, MTA apical barrier technique may
repair teeth during the management of internal root replace it. Ca(OH)2 has been successfully used to
resorption. manage perforations, horizontal root fracture and root
resorption.
Conclusions
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doi:10.1111/j.1365-2591.2011.01886.

Properties and applications of calcium hydroxide in

Z. Mohammadi1 & P. M. H. Dummer2

Abstract dentine and its toxicity. Pure calcium hydroxide paste

bacterial biofilms, the synergism between calcium

Correspondence: Zahed Mohammadi, Department of Endodon-

calcium and hydroxyl ions (Rehman et al. 1996). This

Diffusion of hydroxyl ions through dentine

start of treatment. Vital (but probably inflamed) pulp

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