Journal of Endodontics Research -
Effect of calcium hydroxide as a supplementary barrier in the radicular penetration of hydrogen peroxide during intracoronal bleaching in vitro
By JofER editor
Published on 11/29/2008
T. Lambrianidis, A. Kapalas & M. Mazinis
Department of Endodontology, School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece.

To examine pH changes in the cervical external root surface, when calcium hydroxide was used as a supplementary barrier to the protective base material during intracoronal bleaching.

The placement of Ca(OH)2 as a supplementary barrier during intracoronal bleaching did not have a significant effect in reversing the acidic pH created at the external root surface in vitro. Its potential effect during these procedures in vivo needs to be further investigated.

Introduction - Materials and methods.
T. Lambrianidis, A. Kapalas & M. Mazinis
Department of Endodontology, School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece.

External cervical root resorption has been associated with intracoronal bleaching of discolored endodontically treated teeth (Harrington & Natkin 1979, Lado et al. 1983, Goon et al. 1986, Friedman et al. 1988), with the reported incidence of root resorption ranging from 0 to 6.9% (Friedman et al. 1988, Holmstrup et al. 1988). Preliminary reports that related root resorption to trauma or to the use of heat (Harrington & Natkin 1979) have been dismissed by studies reporting root resorption in teeth without history of trauma (Lado et al. 1983, Friedman et al. 1988, Goon et al. 1986), and cases in which heat was not utilized (Friedman et al. 1988, Goon et al.1986).
The exact mechanisms by which bleaching agents leak to the periapical tissues and initiate the resorptive process are not fully understood. It has been shown that dentine is permeable to hydrogen peroxide (H2O2) (Fuss et al.1989, Rotstein1991a) and the amount of its diffusion may reach up to 82% of the total amount applied, depending on morphologic and chemical variations as well as differences in the remaining dentine thickness (Rotstein 1991a). The seepage of H2O2 is significantly enhanced by the presence of cementum defects at the cemento-enamel junction (CEJ), frequently found in all groups of teeth and in different areas of the same tooth (Rotsteinet al.1991b). Severalauthors (Harrington&Natkin 1979, Rotstein et al. 1991c) have claimed that H2O2 penetrates through the dentinal tubules into the surrounding medium causing cellular and tissue destruction, thus initiating an inflammatory process that may be followed by root resorption. Bacterial intervention through the gingival sulcus or the pulp chamber may be a contributing factor in the development of root resorption (Harrington & Natkin 1979, Rotstein et al. 1991c). It has also been suggested that bleaching agents denature dentine exposed at the CEJ, which then acts as an alien tissue that may trigger an immunological response (Lado et al.1983). This hypothesis is supported by the fact that H2O2 alters the chemical structure of dentine and cementum making them susceptible to resorption (Rotstein et al. 1992a). A more recent study (Dahlstrom et al. 1997) indicated that H2O2 induces pH changes and generates hydroxyl radical, an extremely reactive and toxic chemical species that can degrade components of connective tissue, particularly collagen and hyaluronic acid. This may be one of the mechanisms underlying periodontal tissue destruction and root resorption, following intracoronal bleaching. Bleaching agents have been reported to cause a pH decrease in the microenvironment of the cervical periodontal ligament, thus enhancing root resorption (Kehoe 1987). However, reports of the pH changes taking place during intracoronal bleaching are contradictory (Kehoe 1987, Fuss et al.1989).
In all these cases, no barrier had been placed between the endodontic filling material and the pulp chamber (Harrington & Natkin 1979, Lado et al. 1983, Friedman et al.1988, Goon et al. 1986, Holmstrup et al.1988). Since dentinal tubules are oriented incisally, placing a protective base material at the lower level of the CEJ could reduce the leakage of H2O2 to the periodontal tissues (Rotstein et al.1992b, Brighton et al.1994). Different protective base materials have been compared. No significant differences were found between them, although Cavit (ESPE, Premier Sales Corp., Norristown, PA, USA), zinc oxide-eugenol cements and the intermediate restorative material (IRM), type 3 (Caulk Dentsply, Milford, DE, USA) were shown to be slightly superior (Rotstein et al. 1992b, Brighton et al. 1994). It has been demonstrated that a 2-mm barrier should be placed at the CEJ level, in order to reduce the radicular penetration of H2O2 (Rotstein et al.1992b). Tronstad et al. (1981) suggested that calcium hydroxide (Ca(OH)2) should be placed intracoronally after the removal of the bleaching agent to establish an alkaline pH at the root surface, which may inhibit root resorption.
It has also been suggested that a layer of Ca(OH)2 be placed as a biological seal in direct contact with the root-canal obturation material before placing the barrier (Baratieri et al. 1995). This layer may maintain an alkaline pH in the CEJ area that could neutralize H2O2 during bleaching procedures (Baratieri et al. 1995). However, there are no available data in support of this statement.
The aim of this study was to determine whether a reduction in the radicular penetration of H2O2 during thermocatalytic bleaching took place when a layer of Ca(OH)2 was placed as a supplementary barrier to the protective base material.

Materials and methods.
Twenty-eight intact single-rooted human premolars freshly extracted for orthodontic reasons from young adults were placed in formosaline. The soft tissues covering the root surface were gently removed with a sterile gauze soaked in 5.25% sodium hypochlorite.
Standard access cavities were prepared and the root canals located. Coronal flaring was performed with Gates-Gliddendrills sizes 1, 2 and 3 (Premier Dental Products Co., Norristown, PA, USA). The root canals were instrumented using K-Flex files (Kerr Manufacturing, Romulus, MI, USA) in a rotational motion to a master apical file size 30. A 5.25% sodium hypochlorite solution was used as an irrigant and was delivered with a 27- gauge needle. The canals were obturated with guttapercha (Kerr Manufacturing, Romulus, MI, USA) and Roth’s 801 sealer (Roth International Co., Chicago, IL, USA) by means of cold lateral condensation. The coronal third of the gutta-percha was removed 2.5 mm short of the CEJ with hot pluggers. Remnants of gutta-percha and sealer were removed from the access cavity with a cotton pellet soaked in 90%alcohol and a round carbide bur rotated at a low speed. The pulp chamber was rinsed thoroughly with distilled water.
The external root surface including the apical foramen and the apical third of the root were covered with wax. In each tooth, both wax and cementum were removed at the CEJ level, with a round carbide bur at a low speed, in four sites, i.e. mesially, distally, buccally and lingually to simulate standardized defects. The smear layer of the artificial defects (depth 0.5 mm, diameter 1mm) was removed with 17% EDTA and the exposed dentine surface was rinsed with distilled water. All the remaining surfaces were covered with two layers of nail varnish.
Experimental teeth were divided into four groups of seven teeth each: A, B, C and D(Table 1). The intracoronal barriers were placed according to the Steiner-West technique (Steiner & West 1994). In group A, a Ketac-Cem glass-ionomer cement (ESPE-Premier Sales Corp., Norristown, PA, USA) barrier was placed over the guttapercha at the CEJ level. In group B, a layer of Ca(OH)2 was placed in direct contact with the gutta-percha and a glass-ionomer barrier was placed at the CEJ level. In group C, the glass-ionomer cement barrier was placed 1mm apical to the CEJ level and in group D, the barrier was placed1mmapical to the CEJ following application of a 0.5-mm layer of Ca(OH)2. The cement was allowed to set for 48 h.

Table 1. Groups of experimental teeth as divided according to the placement of intracoronal barriers.

Groups of experimental teeth as divided according to the placement of intracoronal barriers

Figure 1. Experimental tooth model.

Experimental tooth model

Each tooth was placed in a plastic vial containing 2 mL of distilled water, and was stabilized with Paralm (American National Can, Greenwich, CN, USA). The root including the CEJ was submerged in the solution, leaving only one-third of the crown outside the vial (Fig.1). The teeth were incubated for 24 h at 37 8C. The pH values of the water in the vials were determined (day1) with a digital pH-meter with automatic temperature control (PBS-737; El-Hama Industries, El-Hama, Israel). Following this, 2 mL of saline was placed in the access cavity of two teeth in each group that served as controls. In experimental teeth, a cotton pellet soaked in 2 mL of 30% H2O2 (Superoxol, Union Broach, Long Island City, NY, USA) was placed in the pulp chamber. The teeth were subjected to heat treatment with a 1000-Wphotoflood lamp for 2 min. The procedure was repeated twice with the placement of a freshly soaked cotton pellet. Finally, the pulp chamber was rinsed thoroughly with distilled water and dried with warm air. A dry cotton pellet was placed and the cavity was sealed with approximately 2 mm of Cavit (Premier Dental Products Co., Norristown, PA, USA).The treatment was performed in a manner similar to the clinical procedures of bleaching. The pH measurements were recorded at1, 2, 4 and 10 and 15 days, following renewal of the surrounding medium.
The measured pH data were subjected to the two-way anova to assess whether the mean of the pH measurements differed across groups and whether the mean differences were statistically significant from zero.

Results - References.
The pH values of the surrounding medium became acidic in all groups. The mean pH values for the four groups are presented in Table 2. The base line pH values for the controls were 7.21, 7.20, 7.19 and 7.21, respectively. One day (24 h) following the bleaching procedure a pH decrease was recorded in all groups of teeth, which continued during days 2 and 4. At days 10 and 15, the pH values in groups B and D in which Ca(OH)2 was placed as a supplementary barrier increased. However, the two-way anova test revealed that no statistically significant differences existed between the four experimental groups at all experimental days (P ј 0.790) with respect to the measured pH. The mean values, standard error and 95% confidence intervals for the measured pH according to anova are shown in Table 3. Discussion The results of this in vitro study showed that the pH value of the surrounding medium in all groups of teeth treated with the thermocatalytic technique became more acidic. Our findings are in agreement with the report by Kehoe (1987). The acidic pH conditions that have been found to exist in cervical root surfaces following bleaching could create a favourable environment for osteoclastic activity, as polymorphonuclear leucocytes and osteoclasts function best at an acidic pH. If these conditions occurred in vivo, inflammatory root resorption could be initiated. It should be noted that Kehoe (1987) did not use an intracoronal isolating barrier, and also did not explain how he was able to determine the exact position of the CEJ in order to control the seepage of the bleaching materials to the surrounding medium. In an attempt to minimize the variations in dentine permeability and cementum intergrity owing to ageingo rmechanical injuries during tooth extraction, the teeth used in our study were a traumatically extracted from young adults for orthodontic reasons. Furthermore, artificial defects were created on the cervical root surface, whilst all other surfaces were covered with wax and nail polish. In this way, we simulated conditions where the radicular dentine is devoid of cementum, and prevented the leakage of the bleaching agent through any undetected defects of the CEJ.

Table 2. Summary of the mean pH values for the four groups at the times recorded.

Summary of the mean pH values for the four groups at the times recorded

Table 3. Mean values, standard error and 95% confidence intervals for all experimental groups according to ANOVA.

Mean values, standard error and 95% confidence intervals for all experimental groups according to ANOVA

The presence of Ca(OH)2 as an additional barrier did not significantly affect the pH values recorded. In the two groups of teeth in which Ca(OH)2 was placed as a supplementary barrier, the pH values showed a slight increase, late in the experiment (10 and 15 days). However, this increase was not statistically significant (P ј 0.790) at any of the experimental periods. This suggests that placement of a Ca(OH)2 paste adjacent to the protective base material would not reverse the acidic pH created in the cervical periodontium during bleaching procedures. Dentine has been shown to be permeable to calcium ions in vitro (Foster et al. 1993, Calt et al. 1999), especially in the absence of smear layer (Foster et al.1993).However, Fuss et al. (1989) found that Ca(OH)2 did not leak from the canal through patent dentinal tubules or changed the pH of the periodontal tissues adjacent to the resorption area, although the cervical cementum was removed from the teeth used in their experimental model. Wang & Hume (1988) observed that little movement of hydroxyl ions occurred in vitro across a layer of dentine when an aqueous paste of Ca(OH)2 was placed in a cavity in dentine. Based on thesefindings, Ca(OH)2 is not likely to play a role in arresting the initiation of cervical root resorption following intracoronal bleaching. The intracoronal placement of Ca(OH)2 following completion of bleaching procedures has been shownto increase the pHof the dental hard tissues in vitro (Tronstad et al.1981). It was proposed that this alkaline environment may inhibit osteoclastic activity and activate alkaline phosphatase which plays a key role in hard tissue formation. Although the Ca(OH)2 barrier was placed during and not after the bleaching procedure in the present study, the pH increase recorded was not sufficient enough to support the above-mentioned hypothesis.
The location of the isolating barrier (GIC) in relation to the CEJ was also shown not to affect the pH created on the external root surface in the present study. All the tested materials have been shown to be equally effective in preventing H2O2 penetration when the thickness of the layer exceeds 1mm (Kehoe 1987). The thickness and location of the barrier are considered to be the critical factors for the reduction of H2O2 penetration, rather than the type of the material used (Rotstein et al. 1992b). However, this was not shown in our study. The limitation that exists regarding the type of barrier used in this study is that glass-ionomer cement is a sensitive material, which may suffer composition alterations during setting, or when in contact with H2O2 molecules owing to its complex setting reaction.
Most of the previous studies involved the use of the walking bleach technique and results were dependent upon the mixing ratio of walking bleach pastes, as dilutions of sodium perborate exceeding 2 g mL_1 would result in an acidic solution (Kehoe 1987). The thermo catalytic bleaching procedure that was used in our study was preferred to the walking bleach technique on the basis that it presented a greater challenge to the effectiveness of the isolating barrier. The pulp chamber was fluid filled and the procedure involved what amounts to thermal cycling (Brighton et al. 1994). The diffusion capacity of various substances through dentine and cementum depends on factors such as the nature of the penetrating agent, the nature of the dental tissue, the surface area exposed and its location, the remaining dentine thickness, previously applied agents, the presence of smear layer and temperature (Outhwaite et al. 1976, Pashley & Livingston 1978, Pashley et al. 1983). The application of heat during the thermocatalytic procedure results in increased dentine permeability owing to thermal expansion, which induces an increase in tubular diameter (Outhwaite et al.1976, Pashley et al. 1983).
It is recognized that the addition of 30% H2O2 to sodium perborate in the ‘walking bleach’ technique enhances the bleaching efficacy of the solution (Nutting & Poe1963). Although cervical root resorption has been reported following bleaching of endodontically treated teeth with the ‘walking bleach’ technique (Friedman et al.1988), it remains one of the most widely used nonvital bleaching techniques. The amount of H2O2 leakage to the periradicular tissues during these procedures has been shown to depend, amongst other factors, on the form of sodium perborate used (Weiger et al. 1994). Therefore, using aqueous solutions of sodium perborate would seem as a more reasonable treatment option because cervical root resorption needs to be prevented. No cases of cervical root resorption have been reported with the use of sodiumperborate and water. Holmstrup et al. (1988) failed to find any signs of root resorption in teeth bleached with sodium perborate and water, after a 3-year follow-up. In addition, equal bleaching results can be accomplished without the use of H2O2, just b y increasing the number of treatment sessions (Rotstein et al.1993).


Baratieri LN, Ritter AV, Monteiro S, Andrada MAC, Vierra LCC   (1995) Nonvital tooth bleaching: guidelines for the clinician. Quintessence   International 26, 597-603.
Brighton DM, Harrington GW, Nicholls JI (1994) Intracanal isolating barriers   as they relate to bleaching. Journal of Endodontics 5, 228-32.
Calt S, Serper A, Ozcelik B, Dalat MD (1999) pH changes and calcium ion diffusion   from calcium hydroxide dressing materials through root dentin. Journal of   Endodontics 25, 329-31.
Dahlstrom SW, Heithersay GS, Bridges TE (1997) Hydroxyl radical activity   in thermo-catalytically bleached root-filled teeth. Endodontics and Dental   Traumatology 13, 119-25.
Foster KH, Kulild JC, Weller RN (1993) Effect of smear layer removal on the   diffusion of calcium hydroxide through radicular dentin. Journal of Endodontics   19,136-40.
Friedman S, Rotstein I, Lib?eld H, Stabholtz A, Heling I (1988) Incidence   of external root resorption and esthetic results in 58 bleached pulpless teeth.   Endodontics and Dental Traumatology 4, 23-6.
Fuss Z, Szajkis S, Tagger M (1989) Tubular permeability to calcium hydroxide   and to bleaching agents. Journal of Endodontics 8, 362-4.
Goon WW, Cohen S, Borer RF (1986) External cervical root resorption following   bleaching. Journal of Endodontics 112, 414-8.
Harrington GW, Natkin E (1979) External resorption associated with bleaching   of pulpless teeth. Journal of Endodontics 5, 344-8.
Holmstrup G, Palm AM, Lambjerg-Hansen H (1988) Bleaching of discolored root-filled   teeth. Endodontics and DentalTraumatology 4, 197-201.
Kehoe JC (1987) pH reversal following in vitro bleaching of pulpless teeth.   Journal of Endodontics1, 6-9.
Lado EA, Stanley HR, Weisman WI (1983) Cervical resorption in bleached teeth.   Journal of Oral Surgery 55, 78-80.
Nutting EB, Poe GS (1963) A new combination for bleaching teeth. Journal   of South California Dental Association 31, 289-91.
Outhwaite WC, Livingston MJ, Pashley DH (1976) Effects of changes in surface   area, thickness, temperature and postextraction time on human dental permeability.   Archives of Oral Biology 121, 599-603.
Pashley DH, Livingston MJ (1978) Effect of molecular size on permeability   coefficients in human dentine. Archives of Oral Biology 23, 391-5.
Pashley DH, Thompson SM, Stewart FP (1983) Dentin permeability: effects of   temperature on hydraulic conductance. Journal of Dental Research 62, 956-9.
Rotstein I (1991a) In vitro determination and quantification of 30% hydrogen   peroxide penetration through dentin and cementum during bleaching. Oral   Surgery, Oral Medicine and Oral Pathology 72, 602-6.
Rotstein I, Torek Y, Misgav R (1991b) Effect of cementum defects on radicular   penetration of 30% hydrogen peroxide during intracoronal bleaching. Journal   of Endodontics 5, 230-3.
Rotstein I, Friedman S, Mor C, Kantzelson J, Sommer M, BabI (1991c) Histological   characterization of bleaching-induced external root resorption in dogs.   Journal of Endodontics 9, 436-41.
Rotstein I, Lehr Z,Gedalia I (1992a) Effect of bleaching agents on inorganic   components of human dentin and cementum. Journal of Endodontics 6, 290-3.
Rotstein I, Zyskind D, Lewinstein I, Bamberger N (1992b) Effect of different   protective base materials on hydrogen peroxide leakage during intracoronal bleaching   in vitro. Journal of Endodontics 3, 114-7.
Rotstein LL, Mor C, Friedman S (1993) Prognosis of intracoronal bleaching   with sodium perborate preparations in vitro:1-year study. Journal of Endodontics   19, 10-2.
Steiner DR, West JD (1994) A method to determine the location and shape of   an intracoronal bleach barrier. Journal of Endodontics 6, 304-6.
Tronstad L, Andreasen JO, Hasselgren G, Kristerson L, Riis I (1981) pH changes   in dental tissues after root-canal filling with calcium hydroxide. Journal   of Endodontics 7, 17-21.
Wang J-D, Hume WR (1988) Diffusion of hydrogen ion and hydroxyl ion from   various sources through dentin. International Endodontic Journal 21, 17-26.
Weiger R, Kuhn A, Lost C (1994) Radicular penetration of hydrogen peroxide   during intra-coronal bleaching with various forms of sodium perborate. International   Endodontic Journal 27, 313-7.