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Calcium hydroxide in dentistry: A Review.

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 Chettinad Health City Medical Journal Volume 5, Number 1

Review Article
Calcium Hydroxide in Dentistry
Baranwal R*, Singh BD**, Dubey A***, Avinash A****
*PG Student, **Prof.& HOD, ***Reader, ****Sr. Lecturer, Department of Pedodontics & AMP, Preventive Dentistry, Rungta
College of Dental Sciences, Bhilai(C.G), India.
Dr. Rashmi Baranwal is pursuing her Post Graduation in Pedodontics and Preventive Dentistry. She
has presented scientific paper & posters at national level & speciality conferences.

Corresponding author - Baranwal R ([email protected])

Chettinad Health City Medical Journal 2016; 5(1): 30 - 33

Abstract
Calcium hydroxide has been used in dentistry for almost a century. Its mechanism of actions are achieved through
the ionic dissociation of Ca(2+) and OH(-) ions and their effect on vital tissues, the induction of hard-tissue depo-
sition and the antibacterial properties. Some of its indications include inter-appointment intracanal medicaments,
endodontic sealers, pulp capping agents, apexification, pulpotomy and weeping canals. The purpose of this
article is to review the properties, mechanism of action, applications, advantages, disadvantages and various
indications for the use of calcium hydroxide in endodontics.

Key Words: Biomineral, Calcium hydroxide, Intracanal medicament, Weeping canal

Introduction the best medicament to induce hard tissue deposition

Bones and teeth are biocomposites that require and promote healing of vital pulpal and periapical
controlled mineral deposition tissues (Garcia 1983)7. Ca(OH)2 is a white odorless
during their
self-assembly to form tissues with unique mechanical powder with a molecular weight of 74.08. The material
properties1. Biominerals such as calcium and phosphate is chemically classified as a strong base with a high pH
synthetically produced or obtained from natural (12.5) and is only slightly soluble in water with a solubil-
sources thus has an important function in the prevent- ity of 1.2 g/l, at a temperature of 25˚C7. The dissocia-
ing demineralization and encouraging remineralization tion of Ca(OH)2 into calcium and hydroxyl ions results
of hard tissues of the tooth along with the preservation in increased pH locally. High pH of Ca(OH)2 causes
and maintenance of the health of the pulp2. irritation of the pulp tissue, which stimulates repair of
dentin by the release of bioactive molecules such as
Calcium hydroxide was introduced to the dental Bone Morphogenic Protein and Transforming Growth
profession in 1921, Hermann demonstrated the forma- Factor-Beta One3,8.
tion of dentinal bridge in an exposed pulpal surface and
it is now considered the “gold standard” for direct pulp
Properties5
capping agents3. The use of the medication for root Structure:
canal system disinfection has been supported to 1. Arrangement= amorphous matrix, crystalline
improve the treatment outcome4,5 as the complexity of fillers.
the root anatomy makes more difficult their cleaning 2. Bonding= covalent; ionic.
and shaping6. Intracanal medications such as calcium 3. Defects=pores, cracks.
hydroxide are used to reduce or eliminate bacteria 4. Setting reaction= acid base reaction.
located in the root canal system and prevent their
proliferation between sessions4,5,6. Since the introduc- Physical Properties:
tion to dentistry of calcium hydroxide by Hermann
(1920, 1930), this medicament has been indicated to 1. L.C.T.E= low.
promote healing in many clinical situations. However, 2. Thermal conductivity= insulator.
the initial reference to its use has been attributed to 3. Electrical conductivity= insulator.
Nygren (1838) for the treatment of the `fistula denta- 4. pH=12.5-12.8.
lis', whilst Codman (1851) was the first to attempt to
preserve the involved dental pulp7. According to Cvek Chemical Properties:
(1989) calcium hydroxide became more widely known 1. Solubility- 0.3-0.5
in the 1930s through the pioneering work of Hermann
(1936) and the introduction of this material in the Mechanical Properties:
United States (Teuscher & Zander 1938, Zander 1939). 1. Elastic mod=588
The first reports dealing with successful pulpal healing 2. Compressive strength >24 hr=138
using calcium hydroxide appeared in the literature
between 1934 and 1941. Since then, and mainly after the Biologic Properties:
30 Second World War, the clinical indications for its use 1. Biocompatible.
were expanded and now this chemical is considered
Perspective Article Calcium Hydroxide in Dentistry Volume 5, Number 1

Bactericidal Properties: 3. Pulp Capping Agent: Calcium hydroxide is gener-

Ca(OH)2 is bacteriocidal on contact. It must be in ally accepted as the material of choice for pulp
direct contact with the bacteria to be lethal. capping. Histologically there is a complete dentinal
Ca(OH)2 has been shown to be active and not bridging with healthy radicular pulp under calcium
active against E faecalis and Pseudomonas hydroxide dressings. When calcium hydroxide is
aeruginosa9,10. Asgary and Kamrani tested applied directly to pulp tissue there is necrosis of
Ca(OH)2 against Pseudomonas aeruginosa, E adjacent pulp tissue and an inflammation of
faecalis, Staphylococcus aureus, and Escherichia contiguous tissue. Dentinal bridge formation
coli and found it to inhibit growth of these occurs at the junction of necrotic tissue and vital
bacteria11. inflamed tissue. Beneath the region of necrosis,
cells of underlying pulp tissue differentiate into
Mechanism of action odontoblasts and elaborate dentin matrix.
Antimicrobial activity:
4. Apexification: In apexification technique canal is
The antimicrobial activity of Ca(OH)2 is related to the cleaned and disinfected, when tooth is free of signs
release of hydroxyl ions in an aqueous environment and symptoms of infection, the canal is dried and
(Siqueira 2001). Hydroxyl ions are highly oxidant free filled with stiff mix of calcium hydroxide and
radicals that show extreme reactivity with several CMCP. Histologically there is formation of
biomolecules. This reactivity is high and indiscriminate, osteodentin after placement of calcium hydroxide
so this free radical rarely diffuses away from sites of paste. There appears to be a differentiation of
generation (Siqueira & Lopes 1999). The lethal effects adjacent connective tissue cells; there is also depo-
of hydroxyl ions on bacterial cells are probably due to sition of calcified tissue adjacent to the filling mate-
the following mechanisms (Siqueira & Lopes 1999): rial.
• damage to the bacterial cytoplasmic membrane;
• protein denaturation; and 5. Pulpotomy: It is the most recommended pulpoto-
my medicament for pulpally involved vital young
• damage to the DNA5
permanent tooth with incomplete apices. It is
Mineralization activity: acceptable because it promoted reparative dentin
bridge formation and thus pulp vitality is
When used as a pulp-capping agent and in apexification maintained.
cases, a calcified barrier may be induced by calcium
hydroxide (Eda 1961). Because of the high pH of pure 6. Weeping Canals: For such teeth dry the canals
calcium hydroxide, a superficial layer of necrosis occurs with sterile absorbent paper points and place
in the pulp to a depth of up to 2 mm (Estrela & Holland calcium hydroxide in canal. Calcium hydroxide
2009). Beyond this layer, only a mild inflammatory converts the acidic pH of periapical tissue in the
response is seen and, provided the operating field is weeping canal to basic pH.
kept free from bacteria when the material was placed,
hard tissue may be formed (Estrelaet al. 1995)5. Method of preparation
The easiest method to prepare a calcium hydroxide
Applications12 paste is to mix calcium hydroxide powder with water
1. Intracanal Medicament: It is the most commonly until the desired consistency is achieved7.
used dressing for treatment of the vital pulp. It also
plays a major role as an inter-visit dressing in the Leonardo et al. (1982) stated that a paste prepared with
disinfection of the root canal system. Calcium water or other hydrosoluble non-viscous vehicle does
hydroxide cannot be categorized as a conventional not have good physicochemical properties, because it is
antiseptic, but it kills bacteria in root canal space. not radio-opaque, is permeable to tissue fluids and is
Calcium hydroxide is a slowly working antiseptic. rendered soluble and resorbed from the periapical area
Direct contact experiments in vitro require a 24 and from within the root canal. For these and the
hour contact period for complete kill of entero- following reasons, Leonardo et al. (1982) recom-
cocci. Calcium hydroxide not only kills bacteria, mended the addition of other substances to the paste:
but it also reduces the effect of the remaining cell 1. To maintain the paste consistency of the material
wall material lipo-polysaccharide. It has a wide which does not harden or set;
range of antimicrobial activity against common 2. To improve flow;
endodontic pathogens, but is less effective against
Enterococcus faecalis and Candida albicans. 3. To maintain the high pH of calcium hydroxide;
Calcium hydroxide is also an effective 4. To improve radiopacity;
anti-endotoxin agent. However, its effect on 5. To make clinical use easier;
microbial biofilms is controversial.
6. Not to alter the excellent biological properties of
2. Endodontic Sealer: To be therapeutically effective calcium hydroxide itself.
calcium hydroxide must be dissociated into Ca++
and OH-. Therefore to be effective, an endodontic Composition of calcium hydroxide paste
sealer based on calcium hydroxide must dissolve Calcium hydroxide paste for use in endodontics is
and the solid consequently lose content. composed of the powder, a vehicle and a radiopacifier.
Other substances may be added to improve physico- 31
chemical properties or the antibacterial action7.
 Perspective Article Calcium Hydroxide in Dentistry Volume 5, Number 1

Vehicles 2. Viscous vehicles such as glycerine, polyethylenegly

col (PEG) and propylene glycol.
According to Fava (1991), the ideal vehicle should:
3. Oil-based vehicles such as olive oil, silicone oil,
1. Allow a gradual and slow Ca². and OH- ionic
camphor (the oil of camphorated parachlorophe
release;
nol), some fatty acids (including oleic, linoleic, and
2. Allow slow diffusion in the tissues with low isostearic acids), eugenol and metacresylacetate
solubility in tissue fluids; (Fava & Saunders 1999)5.
3. Have no adverse effect on the induction of hard Staehle et al. (1995) reported that an aqueous suspen-
tissue deposition7. sion allows a more efficient release of hydroxyl ions.
According to Simon et al. (1995), distilled water or
The vehicles mixed with Ca(OH)2 powder play an camphorated paramonochlorophenol result in better
important role in the overall dissociation process diffusion than phosphate buffered saline or propylene
because they determine the velocity of ionic dissocia- glycol13.
tion causing the paste to be solubilized and resorbed at
various rates by the periapical tissues and from within Radiopacifier : Calcium hydroxide mixed with any of
the root canal. The lower the viscosity, the higher will the quoted vehicles lacks radiopacity and is not easily
be the ionic dissociation. The high molecular weight of seen radiographically. This is the main reason radio-
common vehicles minimizes the dispersion of Ca(OH)2 paque materials are added to the paste, thereby allow-
into the tissues and maintains the paste in the desired ing identification of lateral and accessory canals,
area for longer periods of time (Athanassiadis et al. resorptive defects, fractures and other structures
2007)5. (Smith & Woods 1983, AlacË am et al. 1990). A
radiopacifier should have an atomic weight higher than
There are three main types of vehicles: calcium for radiopacity purposes (Tavano et al. 1978).
1. Water-soluble substances such as water, saline, Some examples of such substances are barium sulphate
anaesthetic solutions, carboxymethylcellulose, and bismuth, and other compounds containing iodine
methylcellulose and Ringers solution. and bromine (AlacË am et al. 1990)7.

Clinical Enamel Perforat- Repair of Repair

Dentino Cemento Apexifi
application of reminera ion resorption of bony
-genesis -genesis -cation
biomaterials -lization repair defects defects
Calcium
phosphate + - + - + - +
Cement
Β-tricalcium
+ - + - + - +
phosphate
Bioactive
+ - + - - - -
glass
Synthetic
+ - - - - - +
hydroxyapatite
Calcium
- + + + + + -
hydroxide
Portland
- + - + + + -
Cement
Mineral trioxide
- + + + + + +
aggregate
Biodentine + + + + + + -

Table1 : Clinical restorative application of biomineral based biomaterials

Characteristic of calcium hydroxide paste 3. Can be rendered soluble or resorbed within vital
tissues either slowly or rapidly depending on the
When calcium hydroxide powder is mixed with a
vehicle and other components;
suitable vehicle, a paste is formed and, because the
main component is calcium hydroxide, Maisto (1975) 4. May be prepared for use at the chairside or
classified these formulations as alkaline pastes because available as a proprietary paste;
of their high pH. According to some authors (Maisto 5. Within the root canal system they are used only as
1975, Goldberg 1982, Leonardo et al. 1982), these a temporary dressing and not as a definitive filling
pastes should have the following characteristics: material7

1. Composed mainly of calcium hydroxide which may Advantages of Calcium hydroxide14

be used in association with other substances to
• Initially bactericidal then bacteriostatic.
improve some of the physicochemical properties
such as radiopacity, flow and consistency; • Promotes healing and repair.
32
2. Non-setting; • High pH stimulates fibroblasts.
 Perspective Article Calcium Hydroxide in Dentistry Volume 5, Number 1

• Neutralizes low pH of acids. 8) Graham L, Cooper PR, Cassidy N, Nor JE, Sloan
• Stops internal resorption. AJ, Smith AJ. The effect of calcium hydroxide on
solubilisation of bio-active dentine matrix
• Inexpensive and easy to use. components. Biomaterials 2006;27(14):2865-73.

Disadvantages of Calcium hydroxide15 9) Ballal V, Kundabala M, Acharya S, Ballal M.

• Does not exclusively stimulate dentinogenesis. Antimicrobial action of calcium hydroxide,
• Does exclusively stimulate reparativedentin. chlorhexidine and their combination on endodon-
tic pathogens. Aust Dent J. 2007;52(2):118–121.
• Associated with primary tooth resorption.
• May dissolve after one year with cavosur face 10) Pallotta RC, Ribeiro MS, de Lima Machado ME.
dissolution. Determination of the minimum inhibitory
• May degrade during acid etching. concentration of four medicaments used as
intracanal medication. Aust Endod J.
• Degrades upon tooth flexure.
2007;33(3):107–111.
• Marginal failure with amalgam condensation.
• Does not adhere to dentin or resin restoration. 11) Asgary S, Kamrani FA. Antibacterial effects of
five differentroot canal sealing materials. J Oral
Sci. 2008;50(4):469–474.
Conclusion
Calcium hydroxide is widely used material in endodon- 12) Mustafa M, Saujanya KP, Jain D, Shetty S, Arun
tic treatment due to its high alkalinity and bactericidal A, Uppin L, Kadri M. Role of Calcium Hydroxide
properties. It is a material which is readily available, in Endodontics : A Review. GJMEDPH
simple to prepare and restorable. Calcium hydroxide is 2012;1(1):66-67.
still a material of choice which is widely being used for
various reasons in Endodontics. 13) Pérez F, Franchi M, Péli JF. Effect of calcium
hydroxide form and placement on root dentine
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