Open Journal of Stomatology, 2016, 6, 274-289

http://www.scirp.org/journal/ojst
ISSN Online: 2160-8717
ISSN Print: 2160-8709

Calcium Hydroxide in Endodontics:

An Overview

Raidan Ba-Hattab1*, Manar Al-Jamie1, Haya Aldreib1, Lujain Alessa1, Mohammad Alonazi2
1
College of Dentistry, Princess Nourah bint Abdulrahman University, Riyadh, Kingdom of Saudi Arabia
2
Security Forces Clinics, Riyadh, Kingdom of Saudi Arabia

How to cite this paper: Ba-Hattab, R., Abstract

Al-Jamie, M., Aldreib, H., Alessa, L. and
Alonazi, M. (2016) Calcium Hydroxide in Background: Calcium hydroxide has been used in dentistry since several decades. It
Endodontics: An Overview. Open Journal of has been used in a number of applications in the field of endodontics such as root
Stomatology, 6, 274-289. resorption, intracanal medicament, and root canal sealers. Although this material
http://dx.doi.org/10.4236/ojst.2016.612033
exhibits several advantages, it also has some limitations. Objectives: To review the
Received: November 21, 2016 role of calcium hydroxide in the field of endodontics, focusing on its mechanism of
Accepted: December 23, 2016 action, antimicrobial effects, different applications, cytotoxicity or biocompatibility,
Published: December 26, 2016 and its removal from the root canals. Materials and Methods: An electronic search
was done using different databases. Out of 2,664 articles, only 33 articles have been
Copyright © 2016 by authors and
Scientific Research Publishing Inc. selected to be included in this review because they are directly related to the topic
This work is licensed under the Creative and matched the inclusion criteria of this review: “Language: English” and “Year:
Commons Attribution International 2000-2016”. Results: The antimicrobial effect of calcium hydroxide is controversial.
License (CC BY 4.0). Although some studies supported the effectiveness of calcium hydroxide against
http://creativecommons.org/licenses/by/4.0/
some bacteria others reported its limitation against fungal infection. Calcium hy-
Open Access
droxide can be used effectively as intracanal medicament, root canal sealer, in weep-
ing canals, for perforation management and root resorption. Conclusions: Despite
the limitation of antimicrobial activity of calcium hydroxide, it is used effectively in a
number of treatment modalities in endodontics. Due to its biological and therapeutical
properties, calcium hydroxide is the material of choice for all pulp therapy. However,
when using calcium hydroxide as a dressing material in root canal treatment caution
should be taken to prevent the overextension of the paste beyond the tooth apex and
avoid the harmful side effects.

Keywords
Calcium Hydroxide, Endodontics, Root Canal Treatment, Applications in
Endodontics, Mechanism of Action, Cytotoxicity, Biocompatibility, Removal of
Calcium Hydroxide from the Canals

DOI: 10.4236/ojst.2016.612033 December 26, 2016

 R. Ba-Hattab et al.

1. Introduction
Calcium hydroxide has been used by dentists in the clinical practice for over a century
[1]. In 1920, Herman introduced calcium hydroxide to dentistry as a pulp-capping ma-
terial but today it is used widely in the field of endodontics [2] [3].
Calcium hydroxide is a white odourless powder with the chemical formula Ca(OH)2
and a molecular weight of 7.08. Chemically, it is classified as a strong base in contact
with aqueous fluids (its pH is about 12.5 - 12.8), and dissociate into calcium and hy-
droxyl ions [4]. Calcium hydroxide is used and supplied in various forms. It is used like
a varnish when supplied as a liquid containing calcium hydroxide suspended in a sol-
vent or when supplied as a paste in which calcium hydroxide is suspended in methyl-
cellulose. Another form of calcium hydroxide is marketed as a base and a catalyst. By
using the catalyst, calcium hydroxide reacts faster and forms a hard, amorphous com-
pound within matter of minute in the oral environment. Finally, calcium hydroxide
supplied as a paste contains a polymer resin that can be hardened when exposed to il-
lumination from a handheld blue light source [2].
Nowadays, calcium hydroxide is widely used in the field of endodontics due to its
advantages such as:
• Initially bactericidal effect then bacteriostatic.
• Promotes healing and repair.
• High pH stimulates fibroblasts.
• Stops internal resorption.
• Neutralizes low pH of acids.
• Inexpensive and easy to use [5].
On the other hand, calcium hydroxide has some disadvantages such as:
• Does not exclusively stimulate dentinogenesis.
• Does exclusively stimulate reparative dentin.
• Associated with primary tooth resorption.
• May dissolve after one year with cavosurface dissolution.
• Degrades upon tooth flexure.
• Marginal failure with amalgam condensation.
• Does not adhere to dentin or resin restoration [5].
The purpose of this literature review is to focus on the role of calcium hydroxide in
the field of endodontics including a brief explanation of its mechanism of action, anti-
microbial effects, different applications, cytotoxicity or biocompatibility, and finally
removal of calcium hydroxide from the root canals.

2. Materials and Methods

An electronic search was done using the following databases: PubMed, Cochrane and
Google Scholar. The online searching was conducted following these keywords: “Cal-
cium hydroxide”; “endodontics”; “root canal treatment”; “applications in endodontics”;
“mechanism of action”; “cytotoxicity”; “biocompatibility”; “removal of calcium hydro-
xide from the canals”. Out of 2664 articles, only 33 articles have been selected to be in-

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cluded in this review because they are directly related to the topic and also these articles
have been chosen based on the inclusion criteria: “Language: English” and “Year: 2000-
2016”. A table was constructed to express the details of the searched articles in the ap-
pendix part of this paper (Table A1) and the articles screening process explained in the
flow Diagram 1.

3. Antimicrobial Effect of Calcium Hydroxide

Endodontic infections occur as a result of microbial mixtures containing bacteria
represented by Enterococcus faecalis [6] and fungi which are especially represented by
Candida Albicans [7]. Anaerobic bacteria with their endotoxins on their cell walls also
predominant in this microbial diversity and can be detected especially gram negative
[8]. It is well established that the complete removal of bacteria from the root canal sys-
tem is difficult even with the new endodontic techniques. Combining procedures to
eliminate bacterial infection may be accepted. These including mechanical root canal
debridement by proper shaping, irrigation by chemical agents such as sodium hypoch-
lorite (NaOCl) or hydrogen peroxide (H2O2) in addition to the intracanal medicament
containing antimicrobial agents such as calcium hydroxide [9] [10].

3.1. Mechanism of Action

The release of hydroxyl ions in an aqueous environment is essential for the activation of
calcium hydroxide against microbes. These ions reacted intensively with several bio-
molecules due to their highly oxidant free radicals. As this reactivity is unspecified, the
free radicals most likely gathered at the sites of generation. Hydroxyl ions have fatal ef-
fects on bacterial cells. They may damage the cytoplasmic membrane of bacteria, dena-
ture their proteins, or damage the DNA. It is difficult to prove which of these three

Papers for review of

full text and abstract
N= 2,664 Papers excluded:
N= 2,354
Full text was not available

Papers for review of

full text
N= 310
On animal, N=189
On primary of immature permanent teeth, N= 5
Non English, N=48
Before 2000, N= 35

Studies included
N= 33

Diagram 1. Article screening process.

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 R. Ba-Hattab et al.

mechanisms is mainly involved in the death of bacterial cells after their exposure to a
strong base. Since enzymatic sites are located in the cytoplasmic membrane of bacteria,
hydroxyl ions from calcium hydroxide exert their mechanism of action there. Extracel-
lular enzymes favor digestion, and through hydrolysis act on nutrients, carbohydrates,
proteins, and lipids, whereas intracellular enzymes act on the respiratory activity of the
cellular wall structure.
The high concentration of hydroxyl ions from calcium hydroxide alters the pH gra-
dient of the cytoplasmic membrane damaging its protein. The integrity of the cytop-
lasmic membrane is altered by the high alkalinity of calcium hydroxide by acting on the
organic components and transporting the nutrients or by a saponification reaction in
which the phospholipids or unsaturated fatty acids of the cytoplasmic membrane are
destructed during the peroxidation process [11].

3.2. Antibacterial Effect

The antibacterial activity of calcium hydroxide is a major concern to most of the scien-
tists. Cook et al. evaluated the quality of root canal filling with or without calcium hy-
droxide application prior to the root canal filling or 2% chlorhexidine on the persis-
tence of bacterial infection on the dentinal tubules, they found that the use of 2% chlor-
hexidine followed by root canal filling was more effective in removing the bacterial in-
fection especially E. faecalis than placement of calcium hydroxide or immediate canal
filling [12]. Peters et al. claimed that the number of positive gram bacteria increased in
root canal system after dressing with calcium hydroxide [13]. Other studies showed
that calcium hydroxide could not reliably remove bacteria from the root canal system
or change the culture from gram-negative to gram-positive [14]. It has been reported
that the 7 days application of calcium hydroxide is effective in bacterial elimination
while the 10 minutes application was not effective [11].

3.3. Antifungal Effect

The presence of Fungi represented by C. albicans was detected in primary root canal
infection but is more common in failed endodontic treatments. Their occurrence varies
between 1% and 17%.
It was reported that C. albicans cells are more resistant to calcium hydroxide than
did E. faecalis. Since C. albicans survives at a wide range of pH values, high pH of cal-
cium hydroxide may not have any effect on C. albicans. Additionally, calcium hydrox-
ide pastes provide Ca2+ ions that are essential for the growth of C. albicans which ex-
plained the limited or no effect of calcium hydroxide to fungal infection [11].

4. Applications of Calcium Hydroxide in Endodontics

4.1. Intracanal Medicaments
Endodontic treatment requires the use of suitable intracanal medicaments that simul-
taneously eliminate bacteria, prevent their growth, stop their ingress and cut off their
nutrient supply [15]. Calcium hydroxide is most commonly used as an intracanal me-

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dicament for disinfection of the root canal system [2]. As mentioned above, the appli-
cation of calcium hydroxide paste at intervals of at least 7 days is able to eliminate
and/or reduce the total number of bacteria surviving even after biomechanical prepara-
tion [11]. It has a wide range of antimicrobial activity against bacteria, but has limited
effect against E. faecalis and C. albicans. It is also an effective anti-endotoxin agent [2].
Calcium hydroxide has a little or no effect on the intensity or severity of postoperative
pain following endodontic treatment. In contrast, application of corticosteroid paste in
the canal reduces the postoperative pain [16]. The Effect of calcium hydroxide on
pro-Inflammatory cytokines was studied and concluded that it leads to denaturation of
these pro-inflammatory mediators such as interleukin-1α (IL-1α), tumor necrosis
factorα (TNFα) and calcitonin gene-related peptide (CGRP) that is a potential mechan-
ism by which calcium hydroxide contributes to the resolution of periradicular peri-
odontitis [17]. Different techniques can be used for the placement of calcium hydroxide
in the canals. Tan et al. compared the use of syringe and #25 finger spreader (group 1),
syringe and #4 rotary lentulo spiral (group 2), specially designed paste carrier (group
3), they found that, the specially designed paste carrier was more effective than other
tested techniques in the intracanal placement of calcium hydroxide [18].

4.2. Root Canal Sealer

The main objective of root canal obturation is to achieve a tight seal of the root canal
system which in turn enhance the healing process of periapical and apical regions after
endodontic therapy [19].
It is well clear that some forms of cement are required when filling the root canals to
fill the minor spaces between the core material and the dentinal walls of the canal to
prevent leakage. The outcome of endodontic treatment may influenced by sealer selec-
tion [2]. The properties of an ideal root canal sealer were outlined by Grossman (Table
1) [20]. The dissociation of calcium hydroxide into Ca++ and OH− is necessary for its
therapeutic effect. Therefore, dissolving an endodontic sealer based on calcium hy-
droxide resulted in the loss of its solid content and consequently obturation voids are
formed [2]. The antibacterial activity of some calcium hydroxide based sealers such as
RealSeal, Sealapex, Apexit, and Apexit Plus is related to the release of hydroxyl ions.
These sealers may also help in the formation of root-end hard tissue. Despite their ad-
vantages, calcium hydroxide-based sealers exhibit some disadvantages such as limited
antibacterial activity, poor cohesive strength, greater solubility, and marginal leakage
[1] [21].

4.3. In Weeping Canal

Weeping canal is a canal from which constant clear or reddish exudation is appeared.
This exudate is associated with a large apical radiolucency. The tooth is difficult to treat
as when opened, exudate stops but it again reappears in next appointment. Signs and
symptoms are varies from symptomless to tenderness to percussion and palpation.
Obturation of canals with exudates is contraindicated.

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Table 1. Requirements and characteristics for root canal sealer—Grossman (1982).

1) It should be tacky when mixed to provide good adhesion between it and the canal wall when set.

2) It should make a hermetic seal.

3) It should be radiopaque so that it can be visualized on the radiograph.

4) The particles of powder should be very fine so that they can mix easily with liquid.

5) It should not shrink upon setting.

6) It should not discolour tooth structure.

7) It should be bacteriostatic or at least not encourage bacterial growth.

8) It should set slowly.

9) It should be insoluble in tissue fluids.

10) It should be well tolerated by the periapical tissue.

11) It should be soluble in common solvents if it is necessary to remove the root canal filling [20].

For such teeth, application of calcium hydroxide in the canal after drying with sterile
absorbent paper points is helpful. This is because of its high alkalinity, which changes
the acidic pH of periapical tissues to a more basic environment [2] [5]. Two other me-
chanisms have also been proposed: 1) build up bone in the lesion due to the calcifying
potential of calcium hydroxide and 2) the residual chronically inflamed tissue is caute-
rized by the caustic action of calcium hydroxide [4].

4.4. Perforation Management

One of procedural errors that can happen during root canal treatment is root or furca-
tion perforation. This error can cause failure of the treatment and subsequent tooth
loss. Calcium hydroxide was one of the most preferred materials that have been used to
seal and manage perforations. It has many advantages in this treatment modality such
as stimulation of hard tissue formation, easy preparation, rapid resorption when ex-
truded into the periodontium and healing enhancement of damaged periodontal tissues
[4]. In case of crestal and furcation perforations, calcium hydroxide is not the suitable
material for the seal as a pocket is formed due initial inflammatory response to these
materials and subsequent breakdown of the supporting tissues. Although calcium hy-
droxide possesses disadvantages-as mentioned previously, calcium hydroxide has been
recommended as a traditional agent to manage perforations, and its usage still indi-
cated to control infection, stop bleeding and as a temporary solution when inadequate
time is available to perform a permanent repair. However, mineral trioxide aggregate
(MTA) now is the material of choice for the permanent repair of perforations from
both a conventional and surgical approach [4] [21].

4.5. Role in Root Resorption

Root resorption can be classified into internal, external or root-ended resorption based
on the site of origin, and can affect the cementum and/or dentine of the root. Since cal-

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cium hydroxide has alkaline pH, it actively influences the local environment around a
resorptive area by reducing osteoclast activity and stimulating repair. The alkaline cal-
cium hydroxide neutralizes the acidic environment which exists in the region of resorp-
tion, reversing the reaction and thus stimulating hard tissue formation. The diffusion of
hydroxyl ions released by calcium hydroxide through the dentinal tubules that directly
communicate with periodontal space would increase the pH of periodontal space from
6.0 to 7.4 - 9.6 [21]. To treat an internal resorption, the canal and resorption lacuna are
filled with calcium hydroxide paste. In this way calcium hydroxide will induce the ne-
crotization process of the remaining tissue in the lacuna, and then by irrigation with
sodium hypochlorite the necrotic residuals are removed [4]. In case of lateral resorp-
tion, pulp extirpation, debridement of root canal and application of calcium hydroxide
are the preferred therapy. The resorptive defect should be filled with calcium hydroxide
at 3-month intervals until it reveals hard tissue formation, confirmed by both direct
examination through the access cavity and radiograph [4] [11]. After establishment of
physical barrier, the defect can be compacted with Gutta-percha [3]. Recently, MTA is
an alternative for calcium hydroxide in the management of internal root resorption. It
has been reported that MTA used successfully in surgical and non-surgical treatment of
internal resorption [4].

5. Cytotoxicity and Biocompatibility of Calcium Hydroxide

The primary function of the pulp is dentin formation which started when the peripher-
al mesenchymal cells differentiated into odontoblasts and the collagen matrix begins to
deposit, in a sequence of deposition/mineralization that will lead to complete tooth
formation. Dentin is produced by the pulp continuously due to the tooth aging, even
after the initial formation. Physical and/or chemical injuries may also produce repara-
tive dentin [22]. Dentin-pulp complex can be protected by applying one or more layers
of some specific materials between the restorative material and dental tissues. Protec-
tion of the dentin-pulp complex leads also to pulp vitality recovery. Calcium hydroxide
based products are the materials that can be used for this purpose [23]. Cytotoxicity
and biocompatibility of these materials have been widely studied in different cell cul-
tures [22].

5.1. Effect of Calcium Hydroxide on Pulp Vitality

Pulp tissue is affected by environmental impacts such as heat, mechanical trauma as
well as microbial toxins. After multiple injuries, the pulp cells have the capacity to re-
pair and differentiate into odontoblasts and produce dentin matrix proteins during
wound healing process. Therefore, not all the inflammatory reaction leads to perma-
nent damage [22]. Due to its direct and indirect effect in pulp repair, calcium hydroxide
considers as the most important dental material which is used as the gold standard in
biocompatibility tests. Since calcium hydroxide is biologically and therapeutically po-
tential, it is the material of choice for all pulp conservation treatment [23]. Many stu-
dies reported that pulp repair and formation of hard tissue barrier can be induced when

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the pulp tissue directly capped with the different form of calcium hydroxide (Figure 1
and Figure 2) [22]. Clinically, the formation of hard tissue barrier after pulp capping is
precious as it provides natural protection from bacterial ingress and chemical products
[22]. The mechanism of using calcium hydroxide as pulp capping agent is unclear.
However, it has been reported that some proteins and growth factors are released from
dentine because of the dissolved high alkaline pH of calcium hydroxide solution. These
mechanisms may stimulate pulp repair and formation of hard tissue barrier. Addition-
ally, a layer of coagulation necrosis is induced when the high pH of calcium hydroxide
in direct contact with pulp tissue [22].

Figure 1. Pulp exposure capped with calcium hydroxide,

(arrow). Observe that 30 days after the pulp, therapy, a
partial hard tissue barrier was formed, adjacent to the
capping agent. HE, ×32 [22].

Figure 2. Sixty days after applying calcium hydroxide, on

the pulp tissue, a complete hard tissue barrier, (HB) is
formed. HE. ×125 [22].

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5.2. Effect of Calcium Hydroxide on Periapical Area

When using calcium hydroxide past in root canal treatment as intracanal medicament,
it might be accidentally extruded through the root apex. In case of large chronic pe-
riapical lesions, intentional pressing of calcium hydroxide beyond the root canal and
into the periradicular tissue has been supported by some researchers. They claimed that
calcium hydroxide enhances the healing and osseous repair by direct effect on inflamed
tissues. However, this hypothesis was rejected by other researchers and not widely used
as extrusion of calcium hydroxide beyond the apex can lead to damaging effects [24].
In Endodontics, barium sulfate (BaSO4) is added to calcium hydroxide paste as a ra-
diopaque agent. Extrusion of calcium hydroxide paste containing barium sulfate
beyond root canal can obscure the apex, and is not easily resorbed over time (Figure 3
and Figure 4) [21], also barium sulfate enhances the release of inflammatory mediators
responding to polymethylmethacrylate (PMMA) particles. Therefore, the healing
process might be delayed when using calcium hydroxide paste including barium sulfate,
or in this condition the radiographic interpretation of osseous healing might be diffi-
cult. Furthermore, the effect of extruded calcium hydroxide paste including a barium
sulfate and/or another radiopaque agent and the healing of periapical lesions is not
completely clear. Consequently, pure calcium hydroxide is preferred by most clinicians
as they believe that the commercial ingredients may delay the healing process they want
[24] [25].

Figure 3. Radiograph after placement of an

intracanal, calcium hydroxide paste dressing
with, unintentional periapical overextension
[24] [25].

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Figure 4. The 36-month control radiograph

showing healing of, the apical lesion and the
presence of a white radiopaque, spot at the
place where calcium hydroxide remnants,
were originally present [24] [25].

6. Removal of Calcium Hydroxide from the Canals

Calcium hydroxide is the most commonly used intracanal medicament [26]. However,
incomplete removal of the material from the canal may adversely affect sealer perfor-
mance and subsequent long-term prognosis [27] [28]. Thorough cleaning of root canal
system can be achieved by delivering effective irrigation, solution activation as well as
direct contact with all canal walls especially in the apical third. Several methods have
been described to remove calcium hydroxide from the canal. The most commonly used
method is using a master apical file to the working length in conjunction with EDTA
and sodium hypochlorite [29]. Using rotary files, sonic and ultra-sonic activated tips
with irrigation have also been recommended. However, all of the mentioned methods
are not able to remove calcium hydroxide from the canals especially in the apical third
[30] [31] [32]. It has been reported that continuous irrigations with vibrating motion
may have positive effects on cleaning process, particularly in the apical third of the can-
al which is the most difficult part to clean [33].

7. Conclusion
Calcium hydroxide has been used for different purpose in endodontics and available in
different forms. Despite its wide range of antimicrobial activity, calcium hydroxide is
less effective against some species. Its cytotoxicity appears to be milder than other
groups of sealers. The biocompatibility of calcium hydroxide based sealers is controver-

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sial and because of their solubility, they do not fulfill all the criteria of an ideal sealer. It
is difficult to remove calcium hydroxide completely from the root canals. Further stu-
dies are recommended to evaluate the effectiveness of calcium hydroxide and its appli-
cations in the field of endodontics.

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Appendix
Table A1. Details of the searched articles (narrative review).

No. Author/Year Language Type of study Results/Outcomes

Calcium hydroxide-based root canal sealers do not fulfil all the criteria of ideal
Desai, S., Chandler, N.
1 English Review of article root canal sealer. Comparative studies reveal their mild cytotoxicity, but their
(2009)
antibacterial effects are variable.
Mustafa, M., Saujanya,
K.P., Jain, D., Calcium hydroxide is used widely in the field of endodontics. It is used and
2 Sajjanshetty, S., Arun, English Review of article supplied in various forms. Its alkalinity changes the acidic pH of periapical
A., Uppin, L., Kadri, tissues of a weeping canal to a more basic environment in
M. (2012)
Mineral trioxide aggregate and ferric sulfate can be used appropriately as
Review of article alternatives to formocresol for pulpotomies in primary teeth with exposed pulps.
3 Fuks, A.B. (2008) English
A high-speed handpiece or laser might result in an exposure of a “normal” pulp
that would otherwise not be exposed.
The bacterial activity of calcium hydroxide is questionable. Its removal is more
effective when using ultrasonic methods than other methods. The
biocompatibility of calcium hydroxide-based sealers is controversial and their
Mohammadi, Z.,
antibacterial activity is variable, and their cytotoxicity is milder than for other
4 Dummer, P.M.H. English Review of article
groups of sealers. calcium hydroxide is the material of choice for pulp capping
(2011)
and pulpotomy, managing perforations, horizontal root fracture and root
resorption and apexification. However, it is replaced by MTA when used as
apical barrier.

Calcium hydroxide has high alkalinity property. it has a mild irritation on the
pulp. Its dissociation into hydroxyl ions and calcium is necessary for its
antimicrobial activity. It is supplied in several forms. It is available in powder
5 Agrawal, V. (2011) English Review of article
form, as a liquid containing calcium hydroxide suspended in a solvent, as a
single paste, as two-paste: catalyst and base system and a calcium as a paste that
contains a polymer resin.
Gomes, B.P.,
Pinheiro, E.T.,
By using a polymerase chain reaction analysis, E. faecalis was the most
Jacinto, R.C., Zaia,
6 English Laboratory study frequently identified test species in teeth with in canals of root-filled teeth
A.A., Ferraz, C.C.R.,
associated with periapical lesions.
Souza-Filho, F.J.
(2008)
Hancock, H.,
The microbial flora present in teeth after the failure of root canal treatment in a
Sigurdsson, A., Trope,
7 English Laboratory study North American population was composed of E. faecalis (in 30% of the teeth
M., Moiseiwitsch, J.
with a positive culture).
(2001)

All teeth with pulp necrosis and radiographically visible chronic periapical lesion
Leonardo, M., Silva, R., have bacterial endotoxin (LPS), which is a component of Gram-negative cell
8 Assed, S., Nel- English Review of article wall. It plays the main role in the genesis and persisting of periapical lesions
son-Filho, P. (2004) because of inflammation induction as well as bone resorption. In vitro and in
vivo, Calcium hydroxide inactivates bacterial endotoxin.

Garcez, S., Nuñez, S., Adding Photodynamic therapy to endodontic treatment enhances the reduction
9 Hamblin, M., Ribeiro, English An in vivo study of bacterial load and may be a suitable approach for the treatment of oral
M. (2007) infections.

Bonsor, S.J., Nichol, R., An in vivo study

After using conventional irrigants in root canal treatment, the “Photodynamic
10 Reid, T.M.S., Pearson, English (A randomised
Therapy” system offers a means of destroying the remaining bacteria.
G.J. (2006) trial)

287
R. Ba-Hattab et al.

Continued

Calcium hydroxide has a wide range of antimicrobial activity

Mohammadi, Z.,
against common endodontic pathogens but is less effective against Enterococcus
11 Shalavi, S., Yazdizadeh, English Review of article
faecalis and Candida albicans. Calcium hydroxide is also a valuable
M. (2012)
anti-endotoxin agent. However, its effect on microbial biofilms is controversial.

Chlorohexidine treatment followed by obturation was more effective in

Cook, J., Nandakumar,
12 English An in vitro study removing E faecalis DNA than placement of calcium hydroxide or immediate
R., Fouad, A.F. (2007)
obturation.

No significant differences in healing of periapical radiolucency was observed

Peters, L.B., Wesselink,
13 English An in vivo study between teeth that were treated in one visit and two visits with inclusion of
P.R. (2002)
calcium hydroxide for 4 weeks.

Review of article
Sathorn, C., Parashos, (systematic Calcium hydroxide has limited effectiveness in eliminating bacteria from human
14 English
P., Messer, H. (2006) review and root canal when assessed by culture techniques.
meta-analysis)

Siqueira, J.F. Jr., Rôças, Calcium hydroxide medicaments have antifungal effects may assist in the
15 I.N., Magalhães, F.A., English An in vitro study successful management of persistent or secondary endodontic infections caused
de Uzeda, M. (2001) by fungi.

Anjaneyulu, K, The use of calcium hydroxide as an intra-canal medicament was unrelated to the
16 English Systematic review
Nivedhitha, M (2014) incidence and severity of post-treatment pain.

Incubation with calcium hydroxide resulted in a complete loss of detectable

IL-1α. Calcium hydroxide had a similar effect on TNFα. Incubation of TNFα
Khan, A, Sun, X,
17 English An in vivo study with calcium hydroxide for 1 or 7 days resulted in 66% - 100% loss of TNFα. For
Hargreaves, M (2008)
the CGRP experiments, incubation at 37˚C resulted in a significant and nearly
complete denaturation of CGRP in the controls .

the Specially Designed Paste Carrier was more effective than the Syringe-Lentulo
Tan, J., Parolia, A.,
18 English An in vitro study spiral and Syringe-Spreader techniques in the delivery of calcium hydroxide into
Pau, A. (2013)
the canals.

Marília, S.P., UNESP, The results with the two sealers (CRCS and Endofill) studied were similar
19 English An in vitro study
S.P. (2004) between themselves.

Grossman, L., 10th ed.

20 English A book Requirements of an ideal root canal sealer.
Chapter 15 (1982)

The applications of calcium hydroxide in the field of dentistry have been

Revathi, N., Sharath numerous. Its high alkalinity has contributed to its antibacterial and hard tissue
21 Chandra, S.M. English Review of article forming properties. However, the lack of effectiveness against certain bacteria,
(2014) solubility in fluids, poor coronal seal and strength are some concerns that need
to be addressed.

Modena, K.C.S.,
Casas-Apayco, L.C., A large number of dental materials present cytotoxic effects when applied close
22 Atta, M.T., Costa, English Review of article or directly to the pulp, and the only material that seems to stimulate early pulp
C.A.S., Hebling, J., et repair and dentin hard tissue barrier formation is calcium hydroxide.
al. (2009)

Briso, A.L.F., Rahal, V.,

MTA presented a higher success rate compared to calcium hydroxide, presenting
23 Mestrener, S.R., Dezan, English In vivo study
a lower occurrence of infection and pulp necrosis.
J.E. (2006)

288
 R. Ba-Hattab et al.

Continued

When calcium hydroxide paste that included barium sulfate was applied as an
Orucoglu, H,
24 English Case report intracanal dressing and extruded through the periapical lesion associated with
Cobankara, F (2008)
pulpless teeth, it had no detrimental effect.

Sharma, S., Hackett,

R., Webb, R., This case series illustrates the high toxicity of calcium hydroxide when displaced
25 English Case series
Macpherson, D., into vessels and soft tissues.
Wilson, A. (2008)
Victorino, F.,
Bramante, C., Zapata,
The experimental propolis pastes presented acceptable
26 R.O., Casaroto, A.R., English An in vivo study
physical characteristics to be used as intracanal medicaments.
Garcia, R.B., Moraes,
I.G., et al. (2010)
Barbizam, J.V., Trope,
The use of calcium hydroxide as an intracanal dressing material affected the
M., Teixeira, E.C.,
27 English An in vitro study adhesion of Epiphany to the root canal walls, but even though the values were
Tanomaru-Filho, M.,
within the acceptable range found in the literature.
Teixeira, F.B. (2008)
Faria, G., Kuga, M.,
None of the existing techniques completely removed the calcium hydroxide
Ruy, A.,
dressing. No difference was observed between self adjusting File (SAF) and
Aranda-Garcia, A.,
28 English An in vitro study ProTaper in removing calcium hydroxide in the middle (P = 0.11) and the apical
Bonettifilho, I.,
(p = 0.23) thirds. The SAF system showed similar efficacy to rotary instrument
Guerreiro-Tanomaru,
for removal of calcium hydroxide from mandibular incisor root canals.
J., et al. (2013)
Balvedi, R.P.A., Neither syringe injection nor passive ultrasonic irrigation methods were efficient
Versiani, M.A., in removing the inter-appointment root canal medicaments. Remnants of
29 English An in vitro study
Manna, F.F., Biffi, medicament were found in all experimental groups regardless of the vehicle
J.C.G. (2010) used.
The efficacy of 2 types of rotary instruments (ProTaper and K3) employed in
Kuga, M, association with sodium hypochlorite or EDTA in removing calcium hydroxide
30 Tanomaru-Filho, M, English In vitro study residues from root canals dentin walls. ProTaper instrument was better than K3
Faria, G. (2010) Endo instrument in the removal of calcium hydroide intracanal medication,
regardless of irrigating solution used.

None of the irrigants (1% sodium hypochlorite, 10% citric acid and 20% EDTA)
Rödig, T., Vogel, S., nor their respective combinations were able to completely remove the calcium
31 Zapf, A., Hülsmann, English In vivo study hydroxide. Chelating agents such as citric acid and EDTA showed the best
M. (2010) results. The combination of chelators and NaOCl did not result in significant
improvement of calcium hydroxide removal.

None of the techniques (irrigation with 5 mL of 2.5% NaOCl, irrigation with 5

mL of 17% EDTA in addition to NaOCl, irrigation with 5 mL of 2.5% NaOCl
Taşdemir, T, et al. agitated by an ultrasonic unit, irrigation with 5 mL of 2.5% NaOCl and a
32 English In vitro study
(2011) Canal Brush) removed the calcium hydroxide dressing completely. Canal Brush
and ultrasonic agitation of sodium hypochloride were significantly more
effective than irrigant-only techniques.

Technological advances during the last decade have brought to fruition new
agitation devices that rely on various mechanisms of irrigant transfer, soft tissue
33 Gu, L.S., et al. (2009) English Review of article debridement, and, depending on treatment philosophy, removal of smear layers.
Overall, they appear to have resulted in improved canal cleanliness when
compared with conventional syringe needle irrigation.

289
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