Presented by

Nisar ahmed

Contents

Introduction
History
Composition
Setting mechanism
Classification
Physical properties
Chemical characteristics
Biochemical actions
pH variation of calcium hydroxide on pulp tissue healing
Dental formulations of calcium hydroxide
Types of vehicles and their clinical importance
Applications in dentistry
Advantages
Disadvantages

INTRODUCTION

During the last 200 years there have been many changes in the
rationale governing the treatment of the exposed dental pulp as it
was long ago observed that an exposed pulp healed with great
difficulty, if at all.

The earliest account of pulp therapy was way back in 1756, when
Phillip Pfaff packed a piece of gold over an exposed vital pulp to
promote healing.

Rebel summarized - the exposed pulp is a doomed organ.

Hermanns (1920) introduction of a material is so eminent, which

marked a new era in pulp therapy, when he demonstrated that a
Calcium hydroxide formulation called Calxyl induced dentinal bridging of
the exposed pulpal surface.

Since then the emphasis has shifted from the doomed organ
concept of an exposed pulp to one of hope and
recovery.

Calcium hydroxide made a major break through in dentistry ever since it

had been introduced.

In its pure form, the substance has a high pH, and its dental use relates
chiefly to its ability to stimulate mineralization, and also to its
antibacterial properties

History
1920 - Herman introduced Calcium hydroxide in to the field of
dentistry. (pH of approximately 12.5)
Nygren (1938) -The initial reference to its use for the treatment of the
"fistula dentalis".
According to Cvek (1989) calcium hydroxide became more widely
known in 1930's through the pioneering work of Hermann and the
introduction of this material in the United States In 1939 by Zander
Year 1934-1941 - The first literature regarding the successful healing

1940 Rhoner as root canal filling material

Year 1959 Granath- apical closure

Year 1960 - Matsumiya and Kitumura antimicrobial action

Year 1966 - Frank popularised for apical closure.

Year 1975 - Maisto classified it as an alkaline paste because

of its high pH.

Year 1976 - Cvek - induction of hard tissue in the apical portions of the
root canal, of immature teeth with infected pulp necrosis.

Year 1983 - Garcia considered calcium hydroxide as the best

medicament to induce hard tissue deposition and promote healing of
vital Pulpal and periapical tissues.

Year 1985 - Bystrom and Sundquist promoted calcium hydroxide as an

antibacterial agent and showed that 97% of the cases showed great
success with calcium hydroxide.

Year 1985 - Bystrom - Enterococcus faecalis - tolerated calcium

hydroxide.

1988 - Hasselgren et al.- ability to dissolve necrotic material

1995 - Kontakiotis et al. It has been suggested that the ability of calcium
hydroxide to absorb carbon dioxide may contribute to
its antibacterial activity

Year 2000 - Haapsalo suggested the probable reasons for the decreased
action of calcium hydroxide as dentin debris and tissue remnants.

Year 2002 - Peters questioned the effectiveness of calcium hydroxide

and suggested that calcium hydroxide may not be as effective as it was
once believed.

Watts and Peterson (1987) Established that bacteria may be present in

contact with calcium Hydroxide.

This could lower the pH of the material by converting to calcium

carbonate and might explain why early Dycal preparations seemed
to disappear from beneath permanent restorations (Akester 1979
Bames and Kidd 1979).

COMPOSITION OF CALCIUM HYDROXIDE

Calcium hydroxide is in the powder form and can be carried to the

tooth in a variety of ways depending upon the need and vehicles or
may be applied in the pure powder form with any carrier.

The most common way of introducing calcium hydroxide into the cavity
preparation is through calcium hydroxide cements. They are supplied
in a two paste system.

The acidic paste :

Alkyl salicylates glycol salicylate 40%- reacts with Ca(OH)2 and ZnO
Inter fillers titanium dioxide 12-14%
Radiopacifier barium sulphate 32-35%
Calcium tungstate or calcium sulphate 14-15% - pigments

The basic paste

Calcium hydroxide 50-60% - reactive ingredient

Zinc oxide 10% - reactive ingredient
Zinc stearate 0.5% - accelerator
Ethylene toulene
Plasticizer (sulfonamide or paraffin oil)

The single paste or the light cured calcium hydroxide composes of :

Urethane dimethacrylate
Hydroxymethacrylate (HEMA)
Calcium hydroxide
Barium sulphate
all these ingredients are dispensed in ethylene toulene sulfonamide of
39.5%

 DYCAL:
BASE PASTE

CATALYST PASTE

1.Disalicylate ester of 1,3

butylene glycol

1.Calcium hydroxide
2.Ethyl toulenesulfonamide

2.Calcium phosphate
3.Zinc sterate
3.Calcium tungsate
4.Titanium dioxide
4.Zinc oxide
5.Zinc oxide
5.Iron oxide
6.Iron oxide

Classification
I. According to, whether they are setting or non-setting
A. Setting material:
1. Strong effect:

Reocap
Procal

2.

Medium effect:
Life
Renew
Reolite

3.

No effect:
Hydrex

E. feacalis.
Prevotella alactolyticus
P. propionicum
Fusibacterium alocis
D. pnumosintis

B Non-setting:

Analar calcium hydroxide

Pulp dent methyl cellulose
hypocal methyl cellulose
Reogan methyl cellulose

A. SETTING MATERIAL:THERAPEUTIC PROPERTY:

Dependent on its ph and ph is inturn dependent on the free ca+ and hydroxyl ions.

The set cement contains a matrix of calcium alkyl salicylate chelate, and excess unreacted
calcium hydroxide.

The fragility of set cement suggests that the chelates are held, together by weak,
secondary attractions rather than a stronger polymeric structure (Prosser et al, 1979).
CHELATES?

Setting mechanism of Ca(OH)2 of setting material

There are two basic setting mechanisms
The two paste system - It is based on the reaction between calcium and zinc
ions and a salicylate and is a accelerated by presence of H2O.
Acid-base reaction. The phenolic group in the alkyl salicylate ester acts as an
acid
The single paste system - This utilizes the polymerization of a dimethacrylate by
means of light.
Ex: Prisma V.L.C Dycal

A potential disadvantage of the dimethacrylate systems, when used as a base

beneath composite restorations, is their adherance to the composite material
and subsequent withdraw from the base of the cavity during polymerization.

B. Non setting material:

the mixing of this material with water or saline leads to formation of slurry.

To overcome this disadvantage, calcium hydroxide is carried by methylcellulose or

any other biologically compatible and degradable polymeric material.

calcium hydroxide does not actually take part in the chemical reaction.

Here the methylcellulose monomers will polymerize creating a porous meshwork.

There is a chemical coherence of the ingredients creating bonding between the
polymer macromolecules.

Methylcellulose?

The free calcium hydroxide is carried to the pulp-dentin organ, where it is

available to engage in therapeutic action.

II. Vehicles used for calcium hydroxide

According to Fava [1991] Holland [1994] the vehicles used are divided into
Aqueous ; water, saline, sterile distilled water etc
Viscous : glycerine, polyethyl glycol etc
Oily : olive oil, camphorated parachlorophenol
III. Depending on number of Components
Single paste system
Ex: hypocal, etc

two paste system:

Ex: alkaliner, dycal
Acid paste and base paste

iv.calcium hydroxide-releasing gutta-percha point (CH points):

alkalizing potential significantly lower compared with an aqueous suspensive of

calcium hydroxide,

could not be maintained for long than 3 days (7-9).

Calcium Hydroxide Plus Points (Roeko, Langenau, Germany),

The manufacturer states that they have enhanced mobility of hydroxyl ions through
dentin.

It has been shown that hydroxyl ions derived from calcium hydroxide diffuse through
root dentin and are measurable pH gradient across it . However the diffusion
dynamics of hydroxyl ions through root dentin from this product Shows that CH+
points maintained an inner dentin environment above pH 9.5 for an average of 57 h,
(aqueous calcium hydroxide paste 203 h).

 An interesting observation was made where outer dentine was concerned; CH+
points maintained an outer dentin pH above 9.5 for 46.3 6 h, whereas aqueous
calcium hydroxide paste never reached this level.
This illustrates the increased mobility of the hydroxyl ions released by the CH+
points compared with aqueous calcium hydroxide paste
v. root canal sealers:
Ex:
Sealapex.
Calcibiotic root canal sealers (CRCS)

PROPERTIES OF CALCIUM HYDROXIDE

Setting time and the factors affecting it

The setting time is approximately 2.5 to 5.5 minutes.

The setting time for polymer carried calcium hydroxide can be

increased by increasing the ratio of the catalyst to base paste.

The setting time of calcium hydroxide alkyl salicylates cement can be

accelerated by moisture and heat.

Conversely, the setting time will be retarded by dryness and cold.

Dimensional stability and factors affecting it

Setting shrinkage
The maximum setting shrinkage - 5% by volume - is of no clinical
significance.

Solubility and disintegration

Clinical tests reveal that calcium hydroxide in any form is the most
soluble material.
The greater the percentage of the original (or dispersed) particles
bound to the matrix, lesser will be its solubility, that is increasing the
powder: liquid ratio to the full bonding capacity of the liquid will
definitely decrease the solubility and disintegration.

Flow (viscosity) :

Although high flow is required during the insertion of the material low
flow is necessary for the mechanical well being.

Polymer carried and cement type calcium hydroxide have the highest
flow and its flow is decreased by increasing the degree of
polymerization of the carrying polymer or the percentage of calcium
alkyl salicylate in the mix.

Calcium hydroxide is also thermoplastic in nature and hence the flow

increases with an increase in the temperature.

Thermoplastic? Substance which becomes plastic on heating and harden on cooling

Strength :

Polymer Carried calcium hydroxide and those with the continuous

phase in the form of calcium alkyl salicylate chelate can have
compressive strength up to 800 psi, while non carried calcium
hydroxide has virtually no strength.

The tensile strength is very low of about 1.0 MPa. Calcium hydroxide
cements are viscoelastic. That is why they react more favorably.

Psi: pounds per square inch

1psi=0.00689 mpa

Adaptability :
Film thickness :

The lower the film thickness of the material, the better is its
wetting ability and better is its adaptability.

Calcium hydroxide has the highest possible film thickness,

ranging from 70-90 microns.

Calcium hydroxide has none of the adaptability enhancing

properties and thus lowest adaptability to the tooth surfaces.

Biological compatibility of calcium hydroxide with the

pulp-dentin organ
Calcium hydroxide is an irritant to the pulp-dentin organ, if it
comes in direct contact with it.
Provided the pulp and the periapical tissues are healthy and
devoid of any degeneration, the following Pulpal reaction to
calcium hydroxide can occur:
1.

Whenever there is an effective depth of 100 microns or more, a

healthy reparative dentin can form.

2.

With less than 100 microns an unhealthy reparative dentin can

be expected.

3.

When calcium hydroxide comes in contact with the pulp or root

canals the area of tissues in direct contact would undergo chemical
necrosis.

Also calcium hydroxide can stimulate the formation barrier when in

direct contact thus decreasing the permeability of the dentin.

If used in sufficiently thick layers they provide some thermal

insulation. However, a thickness greater than 0.5mm in not
recommended. Thermal protection should be provided with a
separate base.

Calcium hydroxide in any form is not an electrical insulator at any

thickness.

Toxicity of calcium hydroxide

Some calcium hydroxide preparations like Dycal, Life and Sealapex

have been associated with toxicity in the form of

cytotoxicity,

genotoxicity,

neurotoxicity,

phototoxicity,

symptoms observed in Neuro Cutaneous Syndrome (NCS).

Neurocutaneous Syndrome (NCS)- A toxicity disorder from dental

sealants
characterized by
neurological sensations, pain,
depleted energy
memory loss as well as
itchy cutaneous lesions which may invite various opportunistic infections.
A
Ethyl toluene, sulfonamide is considered the primary cause of the NCS

L
L
E
R
G
Y

Compatibility of calcium hydroxide with restorative

materials and techniques :
Calcium hydroxide has no effect on the setting reaction or the
properties of any permanent restorative material. It does not discolor
any permanent restorative material.

However, in translucent tooth-colored materials, especially with thin

cross-sections, calcium hydroxide will show through as a chalky patch.

Calcium hydroxide base can be used under the amalgam and direct
tooth-colored materials but when used under the direct filling gold and
cast restorations calcium hydroxide should be covered with zinc
phosphate or polycarboxylate cement.

Calcium hydroxide in methylcellulose, reacts with the zinc oxide

eugenol and hence not used together.

The technique of manipulation of calcium hydroxide

Two paste
Equal parts of base and catalyst paste are squeezed out and incorporated
in each other with a stiff spatula on a paper pad until a homogenous mix is
obtained.
Calcium hydroxide in powder form
Calcium hydroxide powder is carried between the beaks of a tweezers
and delivered to the indicated area by releasing the tweezers beaks.
Calcium hydroxide in endodontics
There are various ways with which calcium hydroxide can be placed in the
root canals. Using a messing gun, vertical compaction, an injectable
formulation of calcium hydroxide, a lentulo spiral, a hand file and paper
points.
The use of a lentulo spiral was thought to be the most effective form of
delivering calcium hydroxide into the root canals.

Chemical characteristics

 Synonyms- slaked lime,hydrated lime,pickling

lime
It is a chemical compound with the chemical formula HCa(OH)
H 2.
O

O
Ca

It is a colourless crystal or white odourless powder

Molecular weight - 74.08

It has low solubility in water (about 1.2 g L'1 at 25 C), which decreases
as the temperature rises
This low solubility is, in turn, a good clinical characteristic because a
long period is necessary before it becomes soluble in tissue fluids when
in direct contact with vital tissues.

High ph - 12.5-12.8

Is insoluble in alcohol.

The material is chemically classified as a strong base

Limestone is a natural rock mainly composed of calcium carbonate

(CaCO3) which forms when the calcium carbonate solution existing in
mountain and sea water becomes crystallized

Calcination of calcium carbonate

900 and 1200' C

CaCO3

CaO + C0 2

(lime or quicklime" , has a strong corrosive ability)

Hydration of calcium oxide

calcium oxide is mixed, or slaked with water

CaO + H20 Ca(OH)2

It can also be precipitated by mixing an aqueous solution of calcium

chloride and an aqueous solution of sodium hydroxide.

A suspension of fine calcium hydroxide particles in water is called milk

of lime.

The solution is called lime water and is a medium strength base that
reacts violently with acids and attacks many metals in presence of
water.

It turns milky if carbon dioxide is passed through, due to precipitation

of calcium carbonate.

A chemical

analysis of OH' ionic liberation from calcium hydroxide

allows the percentages of Ca+2 and OH- ions that are released to be
determined (Estrela 1994):
Ca(OH) 2

->

Ca2+ + 2OH-

1n Ca+2

= 40.08

1n OH-

= 17.0

2n OH-

34

1" Ca(OH)2 = 40.08 + 34 = 74.08 (molecular weight)

% of OH- and Ca2+

2OH-= 45.89%

Ca2+ = 54.11%

The main actions of calcium hydroxide come from the ionic dissociation of Ca2+
and OH- ions, and the action of these ions on vital tissue and bacteria generates
the induction of hard tissue deposition and the antibacterial effect

However, when Ca2+ ions come into contact with carbon dioxide (Co2) or
carbonate ions (CO3) in tissue, calcium carbonate is formed which alters the
mineralization process by the overall consumption of the Ca2+ ions

Furthermore calcium carbonate has neither biological nor antibacterial

properties

MECHANISM OF ACTION:

1.

2.
3.

MECHANISM OF ANTIMICROBIAL ACTIVITY

Most of the endodontic pathogens are unable to survive in the

highly alkaline environment provided by calcium hydroxide.

Since the pH of calcium hydroxide is about 12.5, several bacterial

species commonly found in infected root canals are eliminated
after a short period when in direct contact with this substance

Antimicrobial activity of calcium hydroxide is related to the

release of hydroxyl ions in an aqueous environment.

Hydroxyl ions are highly oxidant free radicals that show extreme
reactivity, reacting with several biomolecules. This reactivity is
high and indiscriminate, so this free radical rarely diffuses away
from sites of generation.

Their lethal effects on bacterial cells are probably due to the following
mechanisms

1) Damage to the Bacterial cytoplasmic membrane

The bacterial cytoplasmic membrane posses important functions to the survival

of the cell, such as
Selective permeability and transport of solutes
Electron transport and oxidative phosphorylation in aerobic species;
Excretion of hydrolytic exoenzymes
Bearing enzymes and carrier molecules that function in the biosynthesis of
DNA, cell wall polymers, and membrane lipids; and
Bearing the receptors and other proteins of the chemotactic and
other sensory transduction systems

Hydroxyl ions

Lipid peroxidation

Remove H+ from unsaturated fatty acids,

generating a free lipid radical

Destruction of
phospholipids
(structural
components of
cellular membrane)

React with oxygen

Lipid peroxide radical

Removes another hydrogen atom

from 2nd fatty acid generating
another lipidic peroxide

Peroxides themselves act as free

radicals, initiating an autocatalytic
chain reaction, and resulting in
further loss of unsaturated fatty
acids and extensive membrane
damage

2.Protein denaturation
Cellular metabolism is highly dependent on enzymatic activities
Enzymes have optimum activity and stability in a narrow range of pH
Alkalinization by Ca(OH)2

Break down of ionic bonds of protein

Polypeptide chain unravelled to irregular spacial conformation

Loss of biological activity of enzyme and disruption of cellular metabolism .

3.Damage to DNA

3.Damage to the DNA

Hydroxyl ions react with bacterial DNA and

induce splitting of the strands.
Genes are then lost
DNA replication is inhibited and cellular
activity
disarranged.

cementum is permeable to water, ions and small molecules.

Hence carbon dioxide supply to remaining bacterium in the root
canal system may be maintained from outside.
In addition, bacteria located in ramifications have direct access to
CO2 from the periradicular tissues

Destruction of bacteria when calcium hydroxide is used as

pulp dressing :

Some of the healing properties of calcium hydroxide may be attributed

to its antibacterial effects.

Under normal conditions healing is due to the antibacterial activity of

calcium hydroxide, rather than any effect it may exert on
mineralization.

The bacterial properties are thought to be related to pH, and are

directly proportional to the ability of calcium hydroxide to diffuse from
the set material

There would appear to be no clinical indications for the use of calcium

hydroxide in large old exposures with deep penetration of bacteria and
chronic inflammation of the pulp, unless a radical pulpotomy has been
performed first.

In this situation, calcium hydroxide does not have the same healing
potential that it exhibits when used as a root canal dressing to treat a
chronically inflamed periapical tissue.

This is possibly because of the ready availability of healthy blood

vessels in the periapical tissues, compared to the paucity in dying
tissues in the enclosed environment of the pulp.

It has been found that calcium hydroxide kills only the bacteria on the
surface of the pulp and not those that have penetrated the necrotic
tissue.

Thus the material has no beneficial effect on the healing of the

inflamed pulp, and its use would appear to be indicated for healthy or
superficially contaminated pulp where bacteria have not penetrated
deep.

Hydroxyl ions

Lipid peroxidation

Remove H+ from unsaturated fatty acids,

generating a free lipid radical

Destruction of
phospholipids
(structural
components of
cellular membrane)

React with oxygen

Lipid peroxide radical

Removes another hydrogen atom

from 2nd fatty acid generating
another lipidic peroxide

Peroxides themselves act as free

radicals, initiating an autocatalytic
chain reaction, and resulting in
further loss of unsaturated fatty
acids and extensive membrane
damage

2.Protein denaturation
Cellular metabolism is highly dependent on enzymatic activities
Enzymes have optimum activity and stability in a narrow range of pH
Alkalinization by Ca(OH)2

Break down of ionic bonds of protein

Polypeptide chain unravelled to irregular spacial conformation

Loss of biological activity of enzyme and disruption of cellular metabolism .

3.Damage to DNA

3.Damage to the DNA

Hydroxyl ions react with bacterial DNA and

induce splitting of the strands.
Genes are then lost
DNA replication is inhibited and cellular
activity
disarranged.

Destruction of bacteria when calcium hydroxide is used as a

Root canal medicament :

There is some uncertainty as to the efficacy of calcium hydroxide

compared with the other medicaments when used as an intra canal
dressing.

When used as a root canal medicament any material must be judged

entirely on its antibacterial potential acting with out support from the
tissue defense mechanisms.

Thus in contrast to its mode of action in mineralization, calcium

hydroxide has a non-specific bactericidal action within the confines of
the root canal

Alkalis in general have a pronounced destructive effect on cell

membranes and protein structures.

Although most microorganisms are destroyed at pH 9.5 a few survive

at pH 11 or higher.

The main issue is not how bacteria are killed but how the vital tissues
can be protected from the toxicity of calcium hydroxide.

This is brought about by the separation of the material from the vital
tissues by a zone of necrosis.

For calcium hydroxide to act effectively as an intra canal dressing, the

hydroxyl ions must diffuse through dentin and pulpal tissue remnants at
sufficient concentrations.

The pH values were decreased in the more distant areas from the root
canal. In the root canal, the pH was greater 12.2;
circumjacent dentine, in direct contact with calcium hydroxide, showed
a pH varying from 8 to ll ; and
in the most peripheral dentine, the pH ranged from 7.4 to 9.6

It has been reported that dentin has buffering ability because of the
presence of proton donors such as H2PO4,H2CO3 and HCO3, in the
hydrated layer of hydroxyapatite, which furnish additional protons to
keep the pH unchanged. Therefore, in order to have antibacterial
effects with in the dentinal tubules, the ionic diffusion of calcium
hydroxide should exceed the dentin buffer action, reaching pH levels
sufficient to destroy bacteria.

After short term use of calcium hydroxide, microorganisms are

probably exposed to the lethal levels of hydroxyl ions only at the tubule
orifice.

Another factor can also help to explain the inefficacy of calcium

hydroxide in disinfecting dentinal tubules is that the arrangement of the
bacterial cells colonizing the root canal walls can reduce the
antibacterial effects of calcium hydroxide, since the cells located at the
periphery of the colonies can protect those located more inside the
tubules.

Bacteria colonizing necrotic tissue in the ramifications, isthmus and

the irregularities are also, probably protected from the action of
calcium hydroxide due to the neutralization of the pH.

Therefore, as a short term dressing which appears to eliminate

mainly bacterial cells in direct contact with this substance, such as
bacteria located in the main root canal or in the circumpulpal
dentin.

The activity of a medicament to dissolve and diffuse in the root

canal system would seem essential for its successful action.

A saturated aqueous suspension of calcium hydroxide possesses a

high pH, which has a great cytotoxic potential.

Nevertheless, this substance owes its biocompatibility to its low water

solubility and diffusibility.

Because of these properties, cytotoxicity is limited to the tissues

which are in direct contact with calcium hydroxide.

On the other hand the low solubility and diffusibility of calcium

hydroxide may make it difficult to reach a rapid and significant
increase in the pH to eliminate the bacteria located in the dentinal
tubules and enclosed in the anatomic variations.

Likewise the tissue buffering ability controls the pH changes

Prolonged exposure may allow for saturation of dentin and tissue

remnants.

Theoretically, long term use of calcium hydroxide may be necessary

to obtain a bacteria free root canal system.

However, in most instances, the routine use of an intra canal

medicament for a long period does not seem to be an acceptable
practice in endodontics.

Bacteria may survive after intra canal medication for several

reasons.

May be intrinsically resistant to the medicament.

In an anatomical variation, inaccessible to the medicament.

the medicament may be neutralized by the tissue components

and by the bacterial cells or products, losing its antibacterial
effects.

the medicaments may remain in the root canals for insufficient

time to reach and kill the bacterial cells.

bacteria may alter their pattern of gene expression after changes

in the environmental conditions.

 It is postulated that a virulence factor of E.faecalis

in failed endodontically treated teeth may be
related to the ability of E.faecalis cells to maintain
the capability to invade dentinal tubules and
adhere to collagen in the presence of human
serum.
Evans et al. studied the mechanisms involved in
the resistance of E.faecalis to calcium hydroxide
and found that it was resistant to calcium hydroxide
at a pH of 11.1 but not at pH 11.5.

 Addition of a proton pump inhibitor resulted in dramatic

reduction of cell viability of E.faecalis to calcium hydroxide
Good clinical results have been attributed to the use of
calcium hydroxide as an intra canal medicament.
Nonetheless, the antibacterial activity of calcium
hydroxide is still controversial.
Proton-pump inhibitors (PPIs) are a group of drugs whose main action is a pronounced and longlasting reduction of gastric acid production. They are the most potent inhibitors of acid secretion
available

Calcium hydroxide as a barrier

In preparation of the root canal, intra canal medicament have been
advocated for other reasons also, like, they should act as a physicochemical barrier, precluding proliferation of residual microorganisms
and preventing the re-infection of the root canals by bacteria from the
oral cavity.
Intra canal medicaments may prevent the penetration of bacteria
from saliva in the root canal basically in two ways.

First the medicament possessing antibacterial properties may act

as a chemical barrier against leakage by killing bacteria, thereby
preventing their ingress into the root canal.

Secondly, medicaments that fill the entire length of the canal act
as a physical barrier against penetration thereby preventing
recontamination.

The filling ability of calcium hydroxide pastes is probably more

important in retarding root canal recontamination than the chemical
effect because

calcium hydroxide has low water solubility,

slowly dissolves in saliva, remaining in the canal for a long period,

delaying the bacterial progression towards the apical foramen.

Despite the vehicle used, calcium hydroxide seems to act as an

effective physical barrier.

Medicaments that act as a physical barrier can kill remaining

microorganisms by withholding substrate for the growth and
limiting space for multiplication. (one of the factors possible for the
antibacterial actions of calcium hydroxide.)

Siqueira et al. (1998):

Evaluated the in vitro ability of some medicaments in
preventing thorough recontamination of coronally
unsealed root canals by bacteria from saliva.

Material used

Recontamination period

CMCP

6.9 days

calcium hydroxide/saline
solution

14.7

calcium hydroxide/
CMCP/glycerine

16.5

INITIATION OF MINERALIZATION

It seems that calcium hydroxide has the unique potential to induce

mineralization, even in tissues which have not been programmed to
mineralize.

Calcium ions and the alkaline pH have been proposed to act

separately or synergistically in promoting calcification.

It was once believed that the calcium ions present in the applied
calcium hydroxide does not become incorporated in the mineralized
repair tissue, which derives its mineral content solely from the dental
pulp, presumably via the blood supply. However the present day
belief is that the calcium ions from the medicament do enter into the
bridge formation.

Ca (OH)2
ca2+

OH-

Reduced capillary permeability

Reduced serum flow

Neutralizes acids produced

by osteoclasts

Optimum pH for pyrophosphatase

Reduced levels of
inhibitory pyrophosphatase

increased levels of calcium

dependent pyrophosphatase

Uncontrolled mineralization

 This could possibly explain the high incidence of mineralized

canals observed following pulpotomy and direct pulp treatment.
Uncontrolled mineralization of the pulp would therefore be
dependent on reduced blood supply to the remaining vital tissues
and not necessarily the amount of reparative dentin formed with
time

 It has been speculated that the material exerts a mitogenic and

osteogenic effect, the high pH combined with the availability of
calcium ions and hydroxyl ions has an effect on the enzymatic
pathways and hence mineralization.
The high pH may also activate alkaline phosphatase activity
which is postulated to play an important role in the hard tissue
formation.
The optimum pH for alkaline phosphatase activity is 10.2, a level
of alkalinity which is produced by many of the calcium hydroxide
preparations.

The dentin bridge :

A mineralized barrier or dentin bridge is usually produced following the
application of calcium hydroxide to a vital pulp
This repair material appears to be the product of odontoblasts and
connective tissue cells.
There appears to be some variation in the way the dentin bridge is
formed, depending on the pH of the material that is used to dress the
tooth.

In the case of a high pH material necrotic zone is formed adjacent to the

material and the dentin bridge then forms between this necrotic layer and
the underlying vital pulp. The necrotic tissue eventually degenerates and
disappears, leaving a void between the capping material and the bridge.

In case of the material of lower pH, such as Dycal, the necrotic zone is
similarly formed but is resorbed prior to the formation of the dentin
bridge, which then comes to be formed directly against the capping
material.

Dentin bridges formed by the high pH materials are histologically

similar to those produced by lower pH materials, but are easier to
distinguish on a radiograph because of the space between the bridge
and calcium hydroxide.

DISSOLUTION OF NECROTIC MATERIAL

The ability of calcium hydroxide to dissolve necrotic material was

reported by Hasselgren et al. in 1988
Its action is similar to that of sodium hypochlorite but is less
effective.
However, its prolonged presence in the root canal, where it has a
continuous therapeutic effect, may largely compensate for this.

pH variation
of
calcium
pulp tissue healing

hydroxide

on

high pH (11 to 13) - the original Ca(OH)2and water, Ca(OH) 2 and saline or
Pulpdent.
zone of obliteration - consists of debris, dentinal fragments, hemorrhage,
blood clot ,blood pigment, and particles of Ca(OH)2.
zone of coagulation necrosis and thrombosis (the mummified zone).
(0.3 to 0.7 mm thick) represents devitalized tissue without complete
obliteration of its structural architecture.
Although the cellular detail is greatly diminished, outlines of capillaries
(filled with hemolyzed erythrocytes), nerve bundles, and pyknotic
nuclei can still be recognized.

Between the deepest level of the zone of coagulation necrosis and

the subjacent vital-pulp tissue there is a line of demarcation.

The coagulated necrotic layer causes a sufficient stimulation to the

subjacent vital pulp tissue for it to respond with all its healing
potential.

The sequence of tissue reactions is basically that which is expected

of wounded connective tissue, starting with vascular changes and
inflammatory cell migration to control and eliminate irritating agents.
The alkaline environment favors differentiation and replication of
odontoblasts.

As predentin is produced by the new odontoblastic layer forming

subjacent to the line of demarcation, calcification soon occurs,

Healing with calcium hydroxide products of lower pH (9.0 to 10.0)

(Life, VLC Dycal and Nucap etc):

Bridging at the CH-pulp interface occurs without the induction of a

visible intermediate coagulated necrotic layer, an indication of a less
extensive 'initial chemical injury than that produced by the original
Ca(OH)2 and water.

May be one or two cell layers closest to the Ca(OH)2 dressing are
affected but there is not enough tissue destruction to require an army
of macrophages to carry off the dead and wounded cells and there is
little need for any quantity of granulation tissue to fill in .

Healing and regeneration occur right up against the Ca(OH)2

dressing. The capacity to make a more uniform dentinal bridge right
up against the capping material is a great advantage.

Dental forumulation of calcium

hydroxide pastes:
Setting materials are generally used for the lining or sub-lining of
the cavities, as root canal sealers.
Non-setting cements are used for dressing root canals.

Vehicles for calcium hydroxide

Types of vehicles and their significance

Holland [1994] suggested a classification according to the vehicle of the
paste. Aqueous, viscous, and oily
When calcium hydroxide paste is mixed with a suitable vehicle, a high
pH paste is formed and hence these formulations are known as
alkaline pastes.
According to Maisto [1975], Goldberg [1982], these pastes should have
the following characteristics :
It should be composed mainly of calcium hydroxide which be used in
association with other substances to improve some of the
physicochemical properties such as radiopacity, flow and consistency.
Should be non-setting.

 Should be rendered soluble or resorb within vital tissues

either slowly or rapidly depending on the vehicle and other
components.

Should be prepared for the use at the chair side or be

available as a proprietary paste.

Should be used as only temporary dressing material and

not as a definitive filling material

The easiest method to prepare a calcium hydroxide paste is to

mix calcium hydroxide powder with water until the desired
consistency is achieved.
However such a paste doesnt have good physicochemical
properties because
1.it is not radiopaque,
2.is permeable to tissue fluids and
3.is rendered soluble and resorbed from the periapical area
and from within the root canal.

For these reasons and the following below, it is

recommended that other substances be added to
the paste.

To maintain the paste consistency of the material which doesnt

harden or set.
To improve the flow.
To maintain the high pH of calcium hydroxide;
To improve the radiopacity
To make clinical use easier
Not to alter the excellent biological properties of calcium hydroxide
itself.

The vehicle plays an important role in determining the velocity of the

ionic dissociation causing the paste to be solubilized and resorbed at
various rates if any,in the periapical tissues and from with in the root canal.
According to Fava [1991] an ideal vehicle should:
1. Allow gradual and slow release of Ca+ and OH2. Allow slow diffusion in the tissues with low solubility in the tissue fluids.
3. Have no adverse effect on the induction of the hard tissue deposition.

The differences in the velocity of the ionic dissociation are related

directly to the vehicle employed to obtain the paste.

The lower the viscosity the higher the ionic dissociation.

Vehicles used for Calcium hydroxide

According to Fava [1991] Holland [1994] the vehicles used are divided into

Aqueous
Viscous
Oily

Aqueous

Water
Saline
Dental anaesthetics with or without vasoconstrictors.
Ringers solution.
Aqueous suspension of Methylcellulose or Carboxymethyl cellulose.
Anionic detergent solution.

Clinical importance :

Ca2+ and OH- are rapidly released.

Promotes a high degree of solubility when the paste remains in direct

contact with the tissue and the tissue fluids causing it to be rapidly
solubilized and resorbed by the macrophages.

The root canal must be redressed several times until the desired effect
is achieved there by increasing the number of appointments.

Calxyl, Pulpdent and Tempcanal, Calvital, Reogan

Hypocal

Viscous :

Glycerin : 92.09382 g/mol

Polyethylene glycol
Prophylene glycol

Clinical importance :

Release calcium and hydroxyl ions more slowly for extended periods.

They promote a lower solubility of the paste when compared with

aqueous vehicles probably because of their higher molecular weights.

The high molecular weight of these vehicles minimize the dispersion of

the calcium hydroxide into the tissues and maintain the paste in the
desired area for longer periods.

 This factor prolongs the action of the paste and calcium and hydroxyl ions
will be given off at lower velocity. It is through this mechanism that these
pastes remain in direct contact with the vital tissues for extended time
intervals.

Number of appointments and redressings of the root canal is drastically

reduced.
Calen
Calen + camphorated parachlorophenol
Calen + p-chlorophenol

Ringers Lactate solution alkalinizes via its consumption in the citric acid cycle, the generation of a molecule of carbon dioxide which is then excreted by the lungs. They
increase the strong ion difference in solution, leading to proton consumption and an overall alkalinizing effect.

Ringer's lactate solution was invented in the early 1880s by

Sydney Ringer, a British physician and physiologist.
osmolarity of 273 mOsm/L
Ringer's Lactate solution is very often used for fluid resuscitation after a
blood loss due to trauma, surgery, or a burn injury.
Although its pH is 6.5, it is an alkalizing solution. R
ingers Lactate solution alkalinizes by its consumption in the citric acid
cycle, leading to the generation of a molecule of carbon dioxide which is
then excreted by the lungs.
This increases the strong ion difference in solution, leading to proton
consumption and an overall alkalinizing effect.

Lactate: C3H6O3

Oily :

Olive oil
Silicone oil
Metacresyl acetate
Some fatty acids such as oleic, linoleic ,isostearic acids

Oily vehicles are non water soluble substances that promote the lower
solubility and diffusion of the paste with in the tissues.

Pastes containing this kind of vehicle may remain with in the root canal
for longer periods than pastes containing aqueous and viscous
vehicles.

Endoapex , Vitapex

In cases of dental replantation, as soon a treatment is performed, a

paste of an aqueous vehicle is employed because of the need for rapid
ionic release and pH turnover to avoid replacement resorption.

Subsequently, a calcium hydroxide paste with a viscous vehicle should

be used in the periodical redressings, because the paste may remain in
the root canal for longer period.

Summarizing, clinical situations that require a rapid ionic liberation at

the beginning of the treatment require an aqueous vehicle containing
calcium hydroxide paste while in situations that require a gradual and
uniform ionic liberation, a viscous vehicle containing paste should be
used. (Pastes containing oily vehicles have restricted use)

Radiographic contrast media:

Calcium hydroxide mixed with any of the quoted vehicles lacks
radiopacity and is not easily seen radiographically. This is the main
reason radiopaque materials are added to the paste, thereby
allowing identification of lateral and accessory canals, resorptive
defects, fractures and other structures.
A radiopacifier should have an atomic weight higher than calcium
for radiopacity purposes.
Examples:
barium sulphate and bismuth
other compounds containing iodine and bromine

Antibiotics

Quillmi et al (1992) suggested adding metronidazole and chlorhexidine

to a calcium hydroxide paste and tested this formulation for its
antibacterial effect.

No statistically significant difference was found between Peridex and the

combination of CaOH and Peridex. (J Endod. 2003 Sep;29(9):565-6)

CHX was significantly more effective against E. faecalis than was

Ca(OH)2 paste or a mixture of CHX with Ca(OH2 paste (p < 0.05).
There was no increase in the efficiency of Ca(OH)2 paste when CHX
was added (p > 0.05). (J Endod. 2005 Jan;31(1):53-6, Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 2006 Aug;102(2):e27-31)

Chlorhexidine was found to be a better vehicle for calcium hydroxide

when used as an intracanal medicament because of its low surface
tension. (Dent Res. 2009 Jan-Mar;20(1):17-20)

Leonardo et al (JOE, 1999, vol25, 167-171) suggested that chlorhexidine

prevents microbial activity in vivo with residual effects in the root canal
system upto 48 hrs.

CHLORHEXIDINE GLUCONATE

It has been used in dentistry since 1962. It is broad spectrum

antimicrobial agent.

It has antimicrobial activity against gram ve & gram +ve

microorganisms.

The antimicrobial effect is related to the cationic molecule binding to

vely charged bacterial cell walls, thereby altering the cells osmotic
equilibrium.

Its use in endodontics has been proposed as an irrigant as well as

an intracanal medicament.

When used as an intracanal medicament, chlorhexidine was more

effective than Ca(OH)2 against E.faecalis infection in dentinal
tubules.

Studies have shown that calcium hydroxide and CHX combination was more
effective - Alexendra Almyroudi

CHX is an excellent ICM when it is placed in the RC for one week - Richard
Komorowski et al.

Gomes et al ( OOO 2006) showed that 2% CHX gel & Ca(OH)2 has better
antimicrobial activity than Ca(OH)2 manipulated with sterile water.

Siren et al. reported that chlorhexidine increases the antiseptic action of

calcium hydroxide

Soares et al Due to its broad antiseptic spectrum, antibacterial substantivity,

low surface tension, dentin diffusibility and relative low cytotoxicity, 2%
chlorhexidine has been shown to be a promising vehicle for calcium hydroxide
intracanal medication for endodontic treatment and re-treatment of teeth with
pulp necrosis associated with periapical lesions.

 Concentration of 1 to 2% chlorhexidine combined with calcium

hydroxide have also demonstrated efficacy at killing E. fecalis.
Chlorhexidine combined with calcium hydroxide will result in a
greater ability to kill E. fecalis than calcium hydroxide mixed with
water (70)
two percent chx gel combined with calcium hydroxide achives a pH
of 12.8 and can completely eliminate the E. fecalis bacteria within
dentinal tubules.
Chx in root canals for 7 days can eliminate E.fecalis completely.

Gomez b et al IEJ 2003 and evans MD et all JOE 2003

Influence of the vehicle on the antimicrobial activity :

Evidence suggests that the association of calcium hydroxide with CMCP

has a broader antibacterial action, and kills bacteria faster than mixtures
of calcium hydroxide with inert vehicles.
Phenolic compounds such as CMCP possess strong antibacterial
properties and halogenation intensifies its antibacterial properties.

Phenol is believed to act by disrupting lipid containing bacterial

membranes resulting in leakage of cellular contents.

At higher concentrations, these components act by precipitating the

cytoplasmic cell proteins.

At lower concentrations these inactivate essential enzyme systems

and may also cause bacterial cell lysis.

Some properties of phenolic compounds, such as low surface tension

and lipid solubility confer penetrability and spreading of the material

Thus, the calcium hydroxide and CMCP mixture possesses a high

radius of action, eliminating bacteria located in regions more distant
from the vicinity where the paste was applied.

Therefore CMCP cannot be considered as a vehicle for calcium

hydroxide but an additional medicament especially against anaerobic
bacteria such as a enterococcus faecalis.

Influence of different vehicles on the pH of calcium hydroxide pastes

Mara Gabriela Pacios, Mara Luisa de la Casa, Mara de los ngeles

Bulacio and Mara Elena Lpez
Ctedra de Qumica Biolgica, Ctedra de Endodoncia, Facultad de
Odontologa

Journal of Oral Science, Vol. 46, No. 2, 107-111, 2004

INTRODUCTION :
Ca(OH)2powder for root canal dressing has been mixed with different
vehicles such as distilled water, camphorated monochlorophenol (CMCP),
normal saline, cresatin, glycerin and propylene glycol (PG.
Simon et al. (9) demonstrated that the vehicle can exert a great influence on
the release of ions.
Sjgren et al. (12) demonstrated in vivothat Ca(OH)2dressings efficiently
eliminate bacteria which may survive biomechanical instrumentation, and
that reliable and predictable results can be achieved by dressing the canal
with Ca(OH)2 for 7 days

AIM: The objective of this work was to determine the influence of the vehicle
on the pH of calcium hydroxide pastes after usage in patients and in vitro.

Materials and Methods

In vitro study:
Ca(OH)2 pastes were prepared by adding to Ca(OH)2 powder (Anedra Lab., Buenos Aires,
Argentina) to the following vehicles:
distilled water,
0.2% chlorhexidine gluconate (ICN Biomedicals Inc, Ohio, USA),
99.5% PG (Anedra Lab., Buenos Aires, Argentina),
4% carticaine chlorhydrate (anesthetic solution; Totalcaina Forte, Microsules-Bernab S.A.,
Lab., Buenos Aires, Argentina),

11.8% CMCP (Farmadental Lab., Buenos Aires, Argentina) and

11.8% CMCP-99.5% PG. The concentrations of the vehicles were evaluated quantitatively (13).
Using these pastes, aqueous solutions of Ca(OH)2 to a final concentration of 0.1 M were
prepared in order to measure pH. These solutions were stored at 37C in sterile tubes.
The pH was measured at 0, 1, 7, 14 and 21 days.

Clinical study :
180 maxillary incisors with pulp necrosis and radiographically visible chronic
periapical lesions were selected.
both sexes aged from 20 to 50 years considered.
After isolation with a rubber dam, carious tissue was removed from the teeth with a
carver and a slow-speed handpiece.
The pulp tissue remaining in the canal was removed with K-files.
working length : 15 K-file and radiographically monitoring the process.
BMP :step back technique up to a 45 or 50 master apical file.
the canals were irrigated with 2 ml of 1% sodium hypochlorite
Teeth were filled using the last K-file employed in the canal preparation, aided by
absorbent paper points and vertical pluggers.

The access cavities were closed with Cavit (Espe, Seefeld, Germany)
and glass ionomer restorative cement (Fuyi II, GC Corp., Tokyo, Japan).
The temporary pastes were retained in the root canal for periods of 7, 14
and 21 days.
Patients were randomly divided into six groups each containing 30 teeth.
The paste fillings were prepared from Ca(OH)2 powder and the same
vehicles employed in the in vitro study (distilled water, 0.2% chlorhexidine
gluconate, 99.5% PG, 4% carticaine chlorhydrate, 11.8% CMCP and
11.8% CMCP- 99.5% PG).

At each time point, 10 pastes from each group were removed with K-files and
collected in separate Eppendorf tubes previously weighed on a precision scale
(Acculab LA-Series Analytical Balances, Newtown, Canada).
The tubes with the pastes were re-weighed and the difference between the initial
and final weights was calculated.
In this way the weight of the extracted paste from the root canal was obtained.
Then the pastes were dissolved with distilled water to a final Ca(OH)2concentration
of 0.1 M, according to the following formula:
volume of distilled water added (ml) = weight of the paste (g) / 0.0741 (mMW of
Ca(OH)2) Ca(OH)2 concentration (0.1 M).
The solutions were used to obtain pH measurements.

pH measurement :
The pH was determined with a digital pH meter (Broadley-James Irvine,
California, USA) for small volumes (sensitivity: 0.01 pH units), calibrated to
pH 7 and 4 with standard buffer solutions before use.
The pH was determined by placing the refillable calomel electrode in a 15-l
sample on a slide for 10 seconds.
The electrode was washed with distilled water and wiped dry between
readings.

Result:
No significant difference in pH was found for the different time intervals.
However, significant differences in pH were observed among the pastes
tested.
Dunnetts T3 multiple range test showed no significant differences among
the Ca(OH)2 pastes with
distilled water, chlorhexidine, PG and anesthetic solution,

but statistically significant differences were observed between these

pastes and those containing CMCP and CMCP-PG.

Discussion:
Calcium release and an alkaline pH are extremely important for the
biological and microbiological performance of the material for dental use.
In this study, no difference in the pH of each of the Ca(OH)2 pastes was
observed over time.
The tested pastes maintained their alkalinity even in an Eppendorf tube (in
vitro study) as in the clinical study.
In vitro, pastes with chlorhexidine, PG and anesthetic solution showed a
similar pH to those containing distilled water.
However, in the clinical experiment the pH of the paste containing distilled
water was significantly different from the other pastes.
In the present study, vehicles used to prepare the Ca(OH)2 pastes were
shown to influence the final pH of the pastes.

INDIRECT
PULP
CAPPING

DIRECT
PULP
CAPPING

PULPOTOMY

BASE
APEXIFICATION

LINER

CALCIUM
HYDROXIDE

HORIZONTAL
ROOT
FRACTURE

ROOT
CANAL
SEALER
INTRA
CANAL
MEDICAMENT

PERFORATION
REPAIR
PREVENTION
OF
RESORPTION

RESORPTION
REPAIR

1. Calcium hydroxide as liner

The basic component of liner is calcium hydroxide.

Calcium hydroxide is dispersed in aqueous or
resin solution so that the liner can be applied to
the cavity in relatively thin films.
The solvent evaporates, leaving a layer of calcium
hydroxide on the cavity walls.

It is mandatory that the margins of the cavity

preparation be kept free from moisture for this
type of liner, since calcium hydroxide is soluble in
oral fluids.

The setting calcium hydroxide pastes are now in

general use as Lining materials.

Their perceived advantages, in addition to their

therapeutic effects, are as follows;

1. They have a rapid initial set in the cavity under the

accelerating effect of moisture in the ambient air of the
oral cavity and from within the dentinal tubules.

2. They do not interfere with the setting reaction of Bis-GMA resins, and
are therefore the lining material of choice under composite resin
materials
3. It is generally considered that the initial set of the material in thin
sections is sufficiently hard to resist the applied condensation
pressures that are required even for lathe cut amalgam alloys
4. It has been shown that the light-cured resins are biocompatible and
will not cause pulpal damage. However, it is possible that detrimental
effects may occur, particularly in deep cavities close to the pulp, as a
result of the effects of heat generated during seating.

The disappearance of the early versions of these materials from

beneath restorations was probably due to the effects of bacteria and
microleakage.

2. As a sub base and a base

As a sub base it provides therapeutic properties

helps in repair of pulpal tissue
provides chemical insulation.
have specific pharmacological action.
should be covered with supporting base as they have low strength

Ca (OH)2 Bases are of relatively low strength and used only for their
therapeutic effect.

(Sub base: Therapeutic materials placed in deep portion of the cavity preparation.

AS A BASE:
Hard setting materials have usually been employed. The most commonly
used material is Dycal.
The formula of Dycal in 1975 was given in accepted dental therapeutics.

CATALYST PASTE
Calcium hydroxide - 51.00
Titanium diaoxide -45.10
Zinc oxide -9.23
Zinc stearate -0.29
Ethyl toluene Sulphonanfide
-39.48

BASE PASTE
Titanium dioxide -45.10
Calcium tungstate - 15.20
Calcium hydroxide - 0.60
Glvcol salicylate - 39.10

Fisher and McCabe (1978) noted that the titanium dioxide in the base
paste consisted of 1/3 titanium dioxide.

The Current Composition of Dycal is

CATALYST PAST
%
Calcium hydroxide
51.16
Zinc oxide
9.21
Titanium Dioxide
4.74
Ethyl toluene
Sulphonamide
39.73

BASE PASTE
Calcium phosphate
Calcium Tungstate
Zinc oxide
Butyl glycol Disalicylate

31.4
17.63
8.70
42.27

Calcium hydroxide for pulp protection :

Indirect pulp treatment & direct pulp treatment
Mainly by the formation of dentin bridge

Calcium hydroxide in pediatric endodontics :

Pulpotomy :
Historically, calcium hydroxide was the first medicament used in the
regenerative capacity because of its ability to stimulate hard tissue
barrier formation.

Recently, its regenerative capacity has been questioned owing to the

fact that the calcium hydroxide is more reactive than inductive.

The failures were in the form of chronic pulpal inflammation and

internal resorption.

Internal resorption may result from the over stimulation of the

primary pulp by the highly alkaline calcium hydroxide.

This alkaline induced over stimulation could cause

metaplasia within the pulp tissue, leading to the formation of
odotnoclasts.

In addition, undetected micro leakage could allow large

numbers of bacteria to overwhelm the pulp and nullify the
beneficial effects of calcium

Contradicting to this, it is seen that some low pH commercial

preparations of calcium hydroxide, showed earlier and more
consistent bridging.

Many extensive studies on calcium hydroxide concluded that the

state of the pulp, surgical trauma, or the amputation treatment
could be important than the calcium hydroxide per se in inducing
success.

At present, generally it is not recommended for primary teeth

owing to its low success rate but due to difference in cellular
anatomy , it is recommended for young permanent teeth

The improved clinical outcomes with the use of calcium

hydroxide in young permanent teeth make it the most
recommended pulpotomy agent for carious and traumatically
exposed teeth.

 Its use is of particular importance in incompletely formed apex

(Apexogenesis and Apexification()

Calcium hydroxide as a root canal filling material for primary teeth.

Studies have shown that calcium hydroxide is the material of choice

for the primary teeth as it shown to have less periapical reaction
when the material extrudes beyond the apex, when compared to the
materials.

Though it is thought to resorb faster than the root (not very

significant), it is said that it creates a sterile environment in the canal
thereby inhibiting the infectious process.

The common commercial calcium hydroxide preparations used as a

filling material are Vitapex etc

Apical plug :

In situations where there is an open apex or abnormal apical

anatomy, the dentin chip plug in the periapical tissue has been
advocated as an artificial but biological apical stop against which
gutta-percha can be condensed.
Dressing of the root canal :
It is doubtful whether a routine calcium hydroxide dressing is
necessary for the root canal therapy in the canals that contain vital
pulp tissue as these are not infected prior to the instrumentation, or
in contaminated canals which have been cleaned and shaped with
modern instrumentation techniques. However, if a root canal is
heavily infected prior to instrumentation, it is highly probable that a
few bacteria will remain. In these circumstances, a dressing with
calcium hydroxide which can be placed the full length of the canal
is the treatment of choice.

Long-term temporary dressing :

When a dressing is placed in the root canal it is removed after a few
days and the root canal permanently filled with gutta-percha. On
occasion it is necessary, for reasons of personal convenience, to
leave the dressing in the root canal for a considerable period of time.
Under these circumstances calcium hydroxide may be regarded as
the dressing material of choice because its antimicrobial effect may
last for longer duration.
Treatment of infected root canals and periapical lesions :
Periapical granulomata may be formed by the immunological
responses of the apical tissues to chronic infection within the root
canal.
When small they are sterile, but as they increase in size they may
contain in increasing variety of bacteria. In such cases it seems
reasonable to use a dressing which can be placed as close to the
lesion as possible.

Calcium hydroxide can be used as a root canal dressing in teeth with

large periapical lesions, and in cases where it is necessary to control
the passage of periapical exudates into the canal.

Calcium hydroxide accelerates the natural healing of periapical lesions,

regardless of the bacterial status of the root canal at the time of
placement of the material.

Calcium hydroxide in the prevention of root resorption :

Idiopathic :
Calcium hydroxide is frequently used as a dressing for the treatment of
both the internal and external inflammatory resorption, in order to halt
the process and encourage remineralization.
It is doubtful whether the material has any real beneficial effect on
internal resorption, as this is now considered to be sustained by
infection within the dentinal tubules coronal to the resorptive process.
At one time it was thought that the osteoclasts and osteocytes
originated from the same progenitor cells, and that osteoclasts could
divide into osteoblasts, presumably under the influence of calcium
hydroxide. However, it is now considered that these two cell types have
different origins.
Whether the resorption is external, or internal with communication to
the periodontal membrane, calcium hydroxide is probably the initial
treatment of choice, and used in the same manner as for apexification.

Treatment of weeping canals :

Calcium hydroxide is now widely used to reduce the seepage of apical
fluids into the canal so as to allow the placement of a satisfactory root
filling.
The mechanism whereby the reduction of the seepage occurs is probably
due to :
The formation of a fibrous barrier when calcium hydroxide is placed in
direct contact with the host tissues.
Acidic pH of periapical tissues is converted to more basic environment.

Following the replacement of an avulsed tooth, or transplantation of a tooth

Once an avulsed tooth has been splinted in position for about two weeks
the root canal should be thoroughly cleaned and dressed with calcium
hydroxide for a period of 3-6 months, prior to the placement of a
conventional root canal filling.

One should note that the immediate placement of calcium hydroxide

may stimulate early resorption.

This is because calcium hydroxide diffuses through the apical foramen,

further injuring the cementum and initiating resorption.
Calcium hydroxide treatment has no effect on the replacement
(ankylosis) once it has been established.
The principles of managing the transplanted teeth, once pulpal necrosis
has been confirmed, are essentially the same as those that relate to
replantation.

Calcium hydroxide as a root canal sealer :

Calcium hydroxide based root canal sealers which have introduced

as an alternative to the conventional zinc oxide eugenol based
sealers are Sealapex and Calcioboitic Root Canal Sealer (CRCS).

The rationale for the use of these materials is that if they are used in
canals with wide apical foramina, perforations or fractures, mineralized
repair may further be induced.

CRCS: Calcibiotic root Canal Sealer

Powder:

Calcium Hydroxide
Zinc oxide
Bismuth dioxide
Barium sulphate
Liquid:

Eugenol
Eucalyptol

Sealapex:
Base: Calcium Hydroxide
Zinc Oxide

25.0%
6.5%

Catalyst: Barium Sulphate

Titanium dioxide
Zinc Stearate

18.6%
5.1%
1.0%

vitapex
Calcium hydroxide` 30%
Iodoform 40.4%
Silicone Oil 22.4%

Bacteriostatic
Increased radiopacity
Lubricant, ensures complete coating of
(Medical Grade) canal wall

When the pattern of release of calcium ions and hydroxyl ions from
different sealers was investigated, it was found that Sealapex
released more ions and disintegrated more rapidly than CRCS.

It was also found that, although the release of calcium ions from
CRCS was negligible, the material continued to alkalize its
environment, possibly due to the free eugenol combining with
calcium ions as they were released.

In this context it is important to note that , whether these root canal

sealers promote a quicker healing or a more predictable tissue
response than non-calcium hydroxide sealers, has not yet been
evaluated.

Miscellaneous applications of calcium hydroxide :

As a dentin desensitizing agent

As a micro leakage demonstrator

Advantages of Calcium hydroxide

Initially bactericidal to bactertiostatic
Promotes healing and repair
High pH stimulates fibroblasts
Neutralizes low pH of acids
Calcium hydroxide stimulates enzyme systems
Drops internal resorption
Most ideal endo intracanal medication
Inexpensive and easy to use
Particles may obturate open tubules
Ideal temporary luting cement

Disadvantages of Calcium hydroxide

Does not exclusively stimulate dentinogenesis
Does not exclusively stimulate sclerotic dentin formation
Does not exclusively stimulate reparative deposition
Does not exclusively stimulate dentin bridge formation
Does not exclusively stimulate Apexification
Associated with primary tooth root resorption
May dissolve after one year with cavosurface microleakage

 Acids may degrade the interface during the tubules etching process
Interfacial failure upon amalgam condensation
Association with recurrent caries upon loss seen in tunnel defects of
bridges after one year placement
Does not adhere to vital dentin
Does not adhere to bonding resin composite systems.
Unlike eugenol, calcium hydroxide is not a pulpal anodyne.

CONCLUSION

Calcium hydroxide has been around the century and the research
surround its properties and use, has increased dramatically in the
recent years.

Many newer materials are now available in the market, which claim to
be superior to calcium hydroxide.
But how possible is the use of these materials in the Indian scenario?

When compared to the prices of the newer materials calcium

hydroxide is more cost effective.

Some preparations of calcium hydroxide are still, expensive but a

simple calcium hydroxide powder and sterile water can serve many
purposes and works out to be reasonable and affordable to many
patients who visit the Indian dental clinics.

One must also consider the ease in manipulation and the time factor
associated with the calcium hydroxide preparations.

Although calcium hydroxide has become one of the most widely

accepted materials in the dental office as a solution to most of the
problems if not all!!!.

What makes calcium hydroxide so special to dentistry

???
antibacterial property + property of inducing a
hard tissue barrier
= an elixir of life for the dying teeth!

References
Text book references:

Pathways of the pulp Stephen Cohen ,8th and 9th editions

Endodontics Ingle & Bakland 5th & 6th edition

Principles and practice of endodontics-Walton and Torabinezad 4 th

edition

Endodontic science Volume 12 Carlos Estrela

Phillips science of dental materials 11th edition

Operative dentistry Marzouk.

Journal references
Evaluation of pH and calcium ion release of calcium hydroxide
pastes containing different substances.
- J Endod. 2009 Sep;35(9):1274-7.
Mechanisms of antimicrobial activity of calcium hydroxide: a critical
review

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Comparative evaluation of the surface tension and the pH of

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Thank you