107

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

Original

Influence of different vehicles on the pH

of calcium hydroxide pastes
María Gabriela Pacios§, María Luisa de la Casa†,
María de los Ángeles Bulacio† and María Elena López§
§Cátedra de Química Biológica, †Cátedra de Endodoncia, Facultad de Odontología,
Universidad Nacional de Tucumán, Argentina
(Received 20 August 2003 and accepted 15 March 2004)

Abstract: The main known benefit of calcium

hydroxide as an intracanal medicament lies in the
bactericidal effect conferred by its pH. The objective Introduction
of this work was to determine the influence of the Calcium hydroxide (Ca(OH) 2 ), widely used for
vehicle on the pH of calcium hydroxide pastes after apexification and pulp capping procedures (1), is nowadays
usage in patients and in vitro. The incisor root canals widely used as an intracanal medicament in endodontic
of 180 patients were instrumented and filled with therapy (2,3).
calcium hydroxide pastes containing distilled water, Clinically, Ca(OH)2 appears to control infection and to
chlorhexidine, propylene glycol, anesthetic solution, reduce the incidence of symptoms between appointments
camphorated p-monochlorophenol and camphorated (4,5). This antibacterial effect is believed to be dependent
p-monochlorophenol-propylene glycol. The pH of the on its strongly alkaline pH (12.4) which is maintained over
paste in the patients’ root canals was measured at 7, a long period of time because of the low solubility of the
14 and 21 days. Similarly, pH was measured in vitro compound.
up to 21 days. The pH of all the pastes remained Tronstad et al. (6) suggested that Ca(OH)2 placed in the
constant throughout the time periods assessed. The root canal elevates the pH, producing an alkaline
calcium hydroxide-water combination showed environment in areas of root resorption by diffusion of
significantly higher pH values than the other pastes in hydroxyl ions (OH-) through the dentinal tubules. High pH
clinical use. Comparative analysis showed that the pH is bactericidal and also inhibits osteoclastic activity. Foster
values of the anesthetic solution, camphorated p- et al. (7) demonstrated that removal of the intracanal smear
monochlorophenol and camphorated p- layer may facilitate Ca(OH)2 diffusion. Nerwich et al. (8)
monochlorophenol-propylene glycol were significantly demonstrated that hydroxyl ions derived from a Ca(OH)2
higher in vitro. The type of vehicle was shown to dressing diffuse through root dentin faster and reach higher
influence the final pH of the pastes. However, the levels in the cervical part of the root than in the apical region.
alkalinity of all pastes was maintained over time under Ca(OH)2 powder for root canal dressing has been mixed
the experimental conditions. (J. Oral Sci. 46, 107-111, with different vehicles such as distilled water, camphorated
2004) monochlorophenol (CMCP), normal saline, cresatin,
glycerin and propylene glycol (PG) (1). The dissociation
Key words: calcium hydroxide; pH; endodontic of Ca(OH)2 into OH- and Ca2+ depends on the vehicle used
vehicles. to prepare the paste. Simon et al. (9) demonstrated that the
vehicle can exert a great influence on the release of ions.
Correspondence to Dr. María Elena López, Cátedra de Química Safavi and Nakayama (10) concluded that high
Biológica, Facultad de Odontología, UNT, Av. Benjamín Aráoz concentrations of glycerin and PG as mixing vehicles may
800, (4000), San Miguel de Tucumán, Argentina
Tel: + 54-381-4311395 Ext. 453
decrease the effectiveness of Ca(OH)2 as a root canal
Fax: + 54-381-4227589 dressing. Other authors (11) demonstrated that
E-mail: melopez@fo.unt.edu.ar Ca(OH)2/CMCP/glycerin paste rapidly kills bacteria and
108

indicated that the CMCP increased the antimicrobial effect restorative cement (Fuyi II, GC Corp., Tokyo, Japan). The
of the Ca(OH)2 paste. Sjögren et al. (12) demonstrated in temporary pastes were retained in the root canal for periods
vivo that Ca(OH)2 dressings efficiently eliminate bacteria of 7, 14 and 21 days.
which may survive biomechanical instrumentation, and that Patients were randomly divided into six groups each
reliable and predictable results can be achieved by dressing containing 30 teeth. The paste fillings were prepared from
the canal with Ca(OH)2 for 7 days. However, few studies Ca(OH)2 powder and the same vehicles employed in the
have investigated the conservation of pH in Ca(OH)2 in in vitro study (distilled water, 0.2% chlorhexidine gluconate,
vivo. The aim of the present study was to determine the 99.5% PG, 4% carticaine chlorhydrate, 11.8% CMCP and
influence of vehicles on the pH of Ca(OH)2 pastes after 11.8% CMCP- 99.5% PG).
usage in patients and in vitro. At each time point, 10 pastes from each group were
removed with K-files and collected in separate Eppendorf
Materials and Methods tubes previously weighed on a precision scale (Acculab
In vitro study LA-Series Analytical Balances, Newtown, Canada). The
Ca(OH)2 pastes were prepared by adding to Ca(OH)2 tubes with the pastes were re-weighed and the difference
powder (Anedra Lab., Buenos Aires, Argentina) the between the initial and final weights was calculated. In this
following vehicles: distilled water, 0.2% chlorhexidine way the weight of the extracted paste from the root canal
gluconate (ICN Biomedicals Inc, Ohio, USA), 99.5% PG was obtained. Then the pastes were dissolved with distilled
(Anedra Lab., Buenos Aires, Argentina), 4% carticaine water to a final Ca(OH)2 concentration of 0.1 M, according
chlorhydrate (anesthetic solution; Totalcaina Forte, to the following formula: volume of distilled water added
Microsules-Bernabó S.A., Lab., Buenos Aires, Argentina), (ml) = weight of the paste (g) / 0.0741 (mMW of Ca(OH)2)
11.8% CMCP (Farmadental Lab., Buenos Aires, Argentina) × Ca(OH)2 concentration (0.1 M). The solutions were
and 11.8% CMCP-99.5% PG. The concentrations of the used to obtain pH measurements.
vehicles were evaluated quantitatively (13).
Using these pastes, aqueous solutions of Ca(OH)2 to a pH measurement
final concentration of 0.1 M were prepared in order to The pH was determined with a digital pH meter
measure pH. These solutions were stored at 37°C in sterile (Broadley-James Irvine, California, USA) for small
tubes. The pH was measured at 0, 1, 7, 14 and 21 days in volumes (sensitivity: 0.01 pH units), calibrated to pH 7 and
triplicate. 4 with standard buffer solutions before use. The pH was
determined by placing the refillable calomel electrode in
Clinical study a 15-µl sample on a slide for 10 seconds. The electrode
A total of 180 maxillary incisors with pulp necrosis and was washed with distilled water and wiped dry between
radiographically visible chronic periapical lesions were readings.
selected. Patients of both sexes aged from 20 to 50 years
and who attended the Endodontics Department of the Statistics
Faculty of Odontology of the National University of To determine the relationship between the vehicles and
Tucumán were considered. Informed consent was obtained the storage periods, two-way analysis of variance (ANOVA)
from all the subjects who participated. was applied. Where interference between the tested factors
After isolation with a rubber dam, carious tissue was was registered, the one-way ANOVA test was performed.
removed from the teeth with a carver and a slow-speed Dunnett’s T3 multiple range test was used to determine
handpiece. The pulp tissue remaining in the canal was differences among the vehicles and among the storage
removed with K-files. The working length of the roots was periods. Differences at P < 0.05 were considered statistically
determined by inserting a 15 K-file and radiographically significant.
monitoring the process. The canals were instrumented Differences between between clinical and in vitro pH
with a step back technique (14) up to a 45 or 50 master determinations were statistically analyzed using Student’s
apical file. After using each instrument, the canals were t-test.
irrigated with 2 ml of 1% sodium hypochlorite. All teeth
were cleaned and shaped to receive a temporary paste Results
filling. Teeth were filled using the last K-file employed in Figure 1 shows the in vitro results. All the samples
the canal preparation, aided by absorbent paper points maintained their pH throughout the tested time intervals.
and vertical pluggers (15). The access cavities were closed Statistical analysis showed interaction between the factors,
with Cavit (Espe, Seefeld, Germany) and glass ionomer so the one-way ANOVA test for the pastes and the storage
 109

periods was applied separately. No significant difference pastes prepared with CMCP-PG, PG and anesthetic solution
in pH was found for the different time intervals. However, in vitro showed significantly higher pH values than in the
significant differences in pH were observed among the clinical study. However, no significant differences in pastes
pastes tested. Dunnett’s T3 multiple range test showed no with distilled water, chlorhexidine and CMCP were
significant differences among the Ca(OH)2 pastes with recorded.
distilled water, chlorhexidine, PG and anesthetic solution,
but statistically significant differences were observed Discussion
between these pastes and those containing CMCP and Since the introduction of Ca(OH)2 for use in dentistry
CMCP-PG. by Herman in 1920, this medicament has been reported
The pH values recorded for the six pastes tested in the to promote healing in many clinical situations. The
clinical study are shown in Fig. 2. Results obtained by two- properties of Ca(OH)2 have been investigated by many
way ANOVA showed no interactions between pastes and authors, and clinical applications of this substance have
storage periods. No statistically significant difference in been reported (1-4). Calcium release and an alkaline pH
pH was observed among the different time intervals, but are extremely important for the biological and
statistically significant differences were observed among microbiological performance of the material for dental use
the different pastes tested. Dunnett’s T3 test revealed that (16).
the paste containing distilled water was significantly In this study, no difference in the pH of each of the
different from the other pastes at all storage periods. The Ca(OH)2 pastes was observed over time; the tested pastes
highest pH values corresponded to the paste with distilled maintained their alkalinity even in an Eppendorf tube (in
water, followed by the pastes prepared with chlorhexidine, vitro study) as in the clinical study. In vitro, pastes with
CMCP, PG, CMCP-PG and anesthetic solution. There chlorhexidine, PG and anesthetic solution showed a similar
was no significant difference between the pastes containing pH to those containing distilled water; however, in the
CMCP, PG, CMCP-PG and anesthetic solution. However, clinical experiment the pH of the paste containing distilled
the Ca(OH) 2 paste containing chlorhexidine was water was significantly different from the other pastes.
significantly different from the pastes containing distilled The pH value of the paste containing distilled water in
water, PG, CMCP-PG and anesthetic solution. patients was higher than in the in vitro study; however, no
Figure 3 shows a comparison of the in vitro and clinical significant differences were observed at any time point.
results at 7, 14 and 21 days. The pH values remained Of the remaining pastes, the pH values in the clinical
constant throughout the time intervals both in the in vitro study were lower than in the in vitro study, and the values
and clinical studies. After all the storage periods Ca(OH)2 for the pastes containing PG, anesthetic solution and

13,0 13,0

12,5

12,0 12,0
0 Days
pH
pH

11,5
1 Day

11,0 7 Days 11,0

7 days

14 days 10,5 14 days

10,0 21 Days 10,0 21 days

Distilled water PG CMCP Distilled water PG CMCP
Chlorexidine Anesdthetic solution CMCP-PG Chlorhexidine Anaesthetic solution CMCP-PG

Fig. 1 Mean and standard error of pH values of 0.1 M Ca(OH)2 Fig. 2 Mean and standard error of pH values of 0.1 M Ca(OH)2
solutions prepared from Ca(OH)2 pastes added to solutions prepared from Ca(OH)2 pastes added to
different vehicles, evaluated over time in the in vitro different vehicles, evaluated over time in the clinical
experiment. experiment.
110

CMCP-PG were found to be significantly different. In

the in vitro experiment, aqueous solutions were used,
a providing optimal conditions for the release of OH- ions.
However, in the instrumented canal the release of OH- ions
could be limited by a decline in the availability of water
12,4 molecules (12). In the in vitro study, Ca(OH)2 was mixed
12,2 with PG to a final Ca(OH)2 concentration of 0.1 M and
12
11,8
the aqueous solution was maintained for 14 days. In the
11,6 clinical study, 99.5% PG was mixed with Ca(OH)2 powder
in vitro
pH

11,4
11,2
* * * in patients
in a ratio of 1/1 (13), and maintained in the root canal as
11 a paste over the designated time period. The 0.1 M solution
10,8 was prepared immediately before measurement of the pH.
10,6
10,4
As reported by Safavi and Nakayama (10), the dissociation
of electrolytes in solution can be estimated by measuring
P
ne

PG

PG
n
er

tio

C
at

di

P-
lu
w

xi

C
so

the solution conductivity, and high concentrations of PG

he
d

M
le

or

tic

C
til

hl

e
is

th
C
D

reduce the conductivity of the Ca(OH)2 solution, suggesting

es
An

that Ca(OH)2 does not dissociate in the presence of PG.

However small amounts of PG in water result in increased
conductivity of the Ca(OH)2 solution. In these experiments
b
the factors considered by Safavi and Nakayama (10) would
explain the different behavior observed in Fig. 3 between
12,4
12,2
the in vitro and the clinical results. In the in vitro study it
12 would be expected that conductivity would be increased
11,8 and more dissociation of ions would occur.
11,6
Many reports claim that the vehicles mixed with Ca(OH)2
* in vitro
pH

11,4
11,2 * * in patients can influence the pH of the paste and the velocity of OH-
11 ion diffusion through the dentinal tubules (9,17). Esberard
10,8
et al. (18) indicated that Ca(OH)2 in a CMCP vehicle
10,6
10,4
diffuses more rapidly than Ca(OH)2 in an aqueous vehicle
in the cervical and middle regions of the teeth. In the in
er

ne

PG
n

P
PG

tio

C
at

di

P-
w

lu
xi

vitro study, since pastes prepared with CMCP-PG showed

C
so

C
he
d

M
le

or

ic
til

C
et
hl
is

th
D

a lower pH than in the clinical study, the proportion of PG

es
An

may be responsible for the different pH values registered.

Differences were also observed in pastes containing
c anesthetic solution, which is an aqueous vehicle with an
initial pH markedly lower than the pH of distilled water
12,4
12,2 and chlorhexidine (13). In clinical situations the release
12 of OH- ions is not as controllable as in the in vitro situation
11,8
11,6
because of the efficient buffering systems present in the
in vitro
tissues and also because of the influence of the acidic pH
pH

11,4
11,2
* * * in patients
of the inflamed tissues. It is also possible that the buffering
11
10,8 effect of the dentin would only occur in the paste-tissue
10,6 interface.
10,4
Controversial data on the diffusion of OH- ions and pH
PG

PG
e

P
er

n
n

C
tio
at

di

P-
lu

values have been reported. Tronstad et al. (6) found that

w

xi

C
so
he
d

M
le

or

tic

C
til

hl

he
is

the pH of dentin increased after placing Ca(OH)2 in the

D

st
e
An

Fig. 3 Comparison between the in vitro and the clinical pH root canal. Esberard et al. (18) measured pH in external
values of 0.1 M Ca(OH)2 solutions prepared from cavities and reported that non-setting Ca(OH)2 pastes
Ca(OH)2 pastes added to different vehicles, evaluated maintained a high pH for at least 120 days. Çalt et al. (17)
over time periods of a) 7 days, b) 14 days and c) 21 demonstrated that non-setting Ca(OH)2 pastes released Ca2+
days. through root dentin, but did not increase the pH of the
 111

media, indicating that OH- ions did not diffuse out the 136-140
dentin. 8. Nerwich A, Fidgor D, Messer HH (1993) pH
In the present study, vehicles used to prepare the Ca(OH)2 changes in root dentin over a 4-week period
pastes were shown to influence the final pH of the pastes. following root canal dressing with calcium
Although some significant differences were found, both hydroxide. J Endod 19, 302-306
the in vitro and the clinical study recorded pH values 9. Simon ST, Bhat KS, Francis L (1995) Effect of
between 11 and 12. The different vehicles permit OH- ion four vehicles on the pH of calcium hydroxide and
release from Ca(OH)2 pastes to different degrees, as the release of calcium ion. Oral Surg Oral Med Oral
mentioned by other authors (9). The pH of all the Ca(OH)2 Pathol Oral Radiol Endod 80, 459-464
pastes both in vitro and clinically remained constant 10. Safavi K, Nakayama TA (2000) Influence of mixing
throughout the time intervals examined. According to this vehicle on dissociation of calcium hydroxide in
criterion, any of the vehicles tested are suitable for clinical solution. J Endod 26, 649-651
use as an intracanal medicament. 11. Siqueira Jr JF, de Uzeda M (1998) Influence of
different vehicles on the antibacterial effects of
Acknowledgments calcium hydroxide. J Endod 24, 663-665
This study was partially supported by a grant from 12. Sjögren U, Fidgor D, Spångberg L, Sundqvist G
CIUNT (Consejo Nacional de Investigaciones Científicas (1991) The antimicrobial effect of calcium hydroxide
y Técnicas de la Universidad Nacional de Tucumán). as short-term intracanal dressing. Int Endod J 24,
119-125
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L, Riis I (1981) pH changes in dental tissues after hydroxide dressing materials through root dentin.
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