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Azerbaycan Saytlari

 »  Home  »  Endodontic Articles 12  »  Periapical lesions accidentally filled with calcium hydroxide
Periapical lesions accidentally filled with calcium hydroxide
Introduction - Reports.

R. J. G. DeMoor & A. M. J. C. DeWitte
Department of Operative Dentistry and Endodontology, Dental School, Ghent University, Ghent University Hospital, Gent, Belgium.

Since its introduction to dentistry (Hermann 1920), calcium hydroxide has been widely used in endodontics. Although the overall mechanisms of action are not fully understood, calcium hydroxide nowadays is a widely used endodontic material, thanks to its high alkalinity (Tronstad et al. 1981) and bactericidal effect (Sjogren et al. 1991, Siqueira & Lopes 1999).
In the presence of large and chronic periapical lesions, the deliberate placement of calcium hydroxide beyond the confines of the root canal and into the periradicular tissues has been advocated. Some speculate that it would have a direct effect on inflamed tissue and epithelial cystic linings and in this manner would favour periapical healing and encourage osseous repair (Tronstad et al. 1981). Such deliberate overextension is not, however, widely advocated, since periapical extrusion of calcium hydroxide can have damaging effects. Reports dealing with bone necrosis and continuing inflammatory responses in repaired mechanical perforations (Himel et al. 1985), the neurotoxic effects of root canal sealers (Boiesen & Brodin 1991), cytotoxicity on cell cultures (Alacam et al. 1993), damaged epithelium with or without cellular atypia when applied on hamster cheek pouches (Dunham et al. 1966), cellular damage following early calcium hydroxide dressing of avulsed teeth (Andreasen & Kristerson 1981) and necrosis of buccal gingiva and mucosa after periradicular overextension due to alkaline burn (De Bruyne et al. 2000) have been presented.
The aim of the present evaluation was, therefore, to review a number of case histories in our clinic, dealing with accidental and voluminous calcium hydroxide overextension and to evaluate the impact of these on periapical healing (especially for those cases with immediate active flare-ups).

A clinical and radiographic retrospective evaluation was made of 12 teeth in 11 patients. The follow-up varied between 1.5 and 8 years after calcium hydroxide placement. An overview of the cases is given in Table 1.
The case histories consisted of nine incisors with a history of trauma and three cases with a history of pulp necrosis. Pulp necrosis was associated with a large coronal restoration and cusp fracture in a mandibular premolar, an extensive composite filling on a maxillary lateral incisor and a leaking porcelain crown on a maxillary central incisor. For those teeth without sinus tracts, periapical lesions were detected after radiographic evaluation. In all cases, it was decided to conventionally treat the root canals. Anaesthesia was provided when sensitivity was reported during preparation of the access opening (one case ) or during root canal treatment (two cases). The root canals were cleaned and shaped with Flexofiles (Dentsply/Maillefer, Ballaigues, Switzerland) in balanced force motion and according to the step-back technique. A 2.5% sodium hypochlorite solution was used to rinse the canals. After drying with sterile paper points, a calcium hydroxide paste [Reogan-Rapid (Vivadent, Schaan, Liechtenstein) or Calxyl (Otto and Co., Frankfurt, Germany)] was placed as an intermediate dressing. With Reogan-Rapid, an injection technique was used. With Calxyl, a lentulo spiral was used to introduce the paste into the canal. Excess material was removed from the pulp chamber with curettes. A sterile cotton pellet was placed in the pulp chamber, and glass ionomer cement (Ketac-Fil, Espe, Seefeld, Germany) provided the temporary coronal seal. In each case, the radiograph revealed unintentional extrusion of calcium hydroxide paste beyond the confines of the root canal into the periradicular lesion. The patients reporting slight pain and tenderness during the placement of calcium hydroxide paste were those with more than half of the apical lesion filled. In three cases where a fistula was present, calcium hydroxide paste entered the course of the fistula. Here, no pain was reported whilst placing the calcium hydroxide.
Patients were then seen on consecutive appointments depending on the symptomatology of the teeth. At their second appointment, half (6 out of 11) of the patients reported that they had slight-to-severe and diffuse pain the day after the placement of calcium hydroxide, and most of them (9 out of 11) reported a mild, diffuse intraoral swelling of the buccal mucosa. Pain generally decreased within the next 2 days. There were two patients with pain lasting more than 2 days. One patient (patient 2; Table 1) complained of severe pain and an extraoral swelling after 1 day. This case history will be discussed in detail. A second patient (patient 8; Table 1) was seen suffering from pain and diffuse swelling of the buccal mucosa after 2 days. The endodontically treated mandibular premolar was also mobile. The root canal was irrigated with 2.5% sodium hypochlorite and then dried with paper points. A new calcium hydroxide dressing was not placed. The root canal was sealed with a sterile cotton pellet and Ketac-Fil (Espe) and the occlusion relieved. Ibuprofen 600 mg (Brufen Forte, Knoll NV., Brussels, Belgium) as well as an antibiotic, Amoxicillin 500 mg (Clamoxyl, Smith Kline Beecham, Genval, Belgium), were prescribed. The tooth was free of symptoms after another 2 days.

Table 1. Case reports of unintentional calcium hydroxide overextensions.

Case reports of unintentional calcium hydroxide overextensions

All patients in the present evaluation (except for patients 2 and 8; Table 1) were seen after 1 week. In these cases where swellings were reported, it was also seen that it took more than 1 week for these swellings to disappear. The calcium hydroxide dressings were, in general, renewed at the second visit. The root canals were finally obturated in each case with gutta–percha and AH26 (Dentsply/DeTrey, Konstanz, Germany) using cold lateral gutta–percha condensation in the third visit. In patients 2 (Case 1), 10 (Case 2) and 11, the calcium hydroxide dressings were renewed twice due to continuing exudation and the permanent root fillings were performed at the fourth visit.
Follow-up, up to 8 years, after the initial calcium hydroxide placement, revealed symptom- free teeth. The radiographic examinations gave evidence of healing of the periradicular lesions. Calcium hydroxide was only resorbed in eight of the 12 teeth. All fistulas disappeared within 1 month, but it took more than 6 months for all periradicular radiolucencies to disappear.