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Review Article

Role of calcium-enriched mixture in endodontics

Pradeep Kabbinale1, K. C. Chethena2, M. A. Kuttappa3
Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal, 2Department of Periodontics,
1

Sri Hasanamba Dental College and Hospital, Hassan, 3Department of Conservative Dentistry and Endodontics, Coorg Institute of Dental
Sciences,Virajpet, Karnataka, India

ABSTRACT
Calcium-enriched mixture (CEM) has been recently introduced as a hydrophilic tooth-colored cement. The CEM cement powder is
composed of calcium oxide, calcium sulfate, phosphorus oxide, and silica as major elements. CEM is alkaline cement (pH~11) that
releases calcium hydroxide (CH) during and after setting. The physical properties of CEM, such as flow, film thickness, and primary
setting time are favorable. This cement is biocompatible and induces formation of cementum, dentin, bone and periodontal tissues.
This novel cement has an antibacterial effect comparable to CH and superior to mineral trioxide aggregate (MTA) and sealing ability
similar to MTA. Its clinical applications include pulp capping, pulpotomy, root-end filling and perforation repair. This review describes
the composition, properties and clinical applications of CEM in endodontics.

Key words: Calcium-enriched mixture, calcium hydroxide, mineral trioxide aggregate

Introduction time and poor handling characteristics[3,4] and is expensive

to use.
Change has been the one constant of history. The challenge
New root-end filling materials have constantly been
is not to avoid change, but to manage it. Change can be
introduced to overcome the shortages of the previous ones.[5,6]
“for better or worse.” Fortunately or unfortunately, we
Recently, a new endodontic cement has been developed with
have experienced both in endodontics. Various procedures
similar clinical uses to tooth-colored ProRoot MTA but having
are carried out in endodontics in order to preserve the
different chemical composition namely calcium-enriched
vitality of the tooth such as pulpotomy, pulp capping,
mixture (CEM).[7] This material has acceptable physical
and apexogenesis. In a recent prospective clinical study
properties[8] (i.e., setting time <1 h, more flow, and less
mineral trioxide aggregate, (MTA) showed a high success
film thickness than MTA) and is capable of hydroxyapatite
rate when used as the root end filling material.[1] MTA
formation over material in normal saline solution.[9]
has gained widespread use a result of its excellent
biocompatibility;[2] however, MTA has a delayed setting
The CEM can be handled well and sets in an aqueous
environment exhibiting good handling characteristics and
Access this article online forms an effective seal when used as root-end — filling
Quick Response Code: material. It also presents with the ability to produce
Website:
www.amhsjournal.org hydroxyapatite with endogenous and exogenous ion
sources.[8]
DOI:
10.4103/2321-4848.154950 A study carried out on dogs showed that MTA and CEM
have similar favorable results as pulp capping materials and

Corresponding Author:
Dr. Pradeep Kabbinale, Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal University,
Manipal - 576 104, Karnataka, India. E-mail: endopradeep@gmail.com

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Kabbinale, et al.: Calcium-enriched mixture in endodontics
were even preferred over calcium hydroxide (CH).[10] This
review describes the composition, properties and clinical
applications of CEM in endodontics.
Materials and Methods
A review of the literature from peer-reviewed journals
published in English was performed using electronic
searching methods for the CEM cement in endodontics until
2015. The main objectives of the search include composition,
physical, and biological properties and applications of
CEM cement in endodontics. Appropriate MeSH headings
and keywords that is, Biological and physical properties;
CEM cement; Clinical applications; Composition; Leakage;
Mechanism of action was searched in peer-reviewed journals
from 1995 to 2015.
Composition
Calcium-enriched mixture cement is composed of different
calcium compounds, that is, calcium phosphate, CH, calcium
sulfate, calcium silicate, calcium chloride, calcium carbonate
and calcium oxide.[7,11] CEM cement is a white powder
consisting of hydrophilic particles that sets in the presence
of the water base solution. The hydration reaction of powder
creates a colloidal gel that solidifies in less than an hour and
forms hydroxyapatite.
Properties
Working time and setting time
This cement has a working time of 5 min and setting time
of <1 h which is lesser compared to MTA.[12] The greatest
distribution of CEM particle size was within 0.5-2.5 μm
range, allowing penetration of particles into dentin tubules
and, therefore, providing a better seal.[13] The large number
of small sized particles in CEM cement contributes to
the shorter setting time, better flow and also thin film
characteristics of this material.
Sealing property
The sealing ability of CEM is similar to MTA[7] and improves
with storage in phosphate-buffered saline solution.[14] The
particle size of CEM is smaller than MTA[15] this may be
related to its acceptable sealing properties. It has the ability
to promote hydroxyapatite formation in saline solution[9] and
may also aid in cementogenesis which involves a process of
differentiation in stem cells and hard tissue formation.[16,17]
On the other hand, Electron Probe Micron Analysis revealed
endogenous phosphate in CEM. Therefore, it seems
reasonable to suspect that the presence of significant
calcium and phosphate ions in CEM is most likely to form
Archives of Medicine and Health Sciences / Jan-Jun 2015 / Vol 3 | Issue 1
the hydroxyapatite compared with MTA. MTA, unlike CEM
cement, does not contain endogenous phosphorous.[18]
Antibacterial and antifungal property
Antibacterial activity of CEM cement is comparable with CH
and significantly greater than MTA.[19] CEM cement contains
greater potent antibacterial inhibitors than MTA. Comparison
of antifungal properties of CEM and MTA on Candida albicans
has shown that both biomaterials induce complete death of
fungal cells after 24 h.[20] CEM has an alkaline pH ~11, which
plays an important role in the antimicrobial properties of
this biomaterial. The study done by Reyhani demonstrated
adding 2% chlorhexidine gluconate (CHX) to CEM cement
will increase antibacterial activity against Pseudomonas
aeroginosa, Enterococcus faecalis, Staphylococcus aureus
and Escherichia coli. However, further studies should be
carried out to evaluate the effect of adding CHX to CEM
cement on its physical properties such as compressive
strength, setting time, and sealing ability.[21]
Biocompatibility
Animal studies have shown that in various forms of vital pulp
therapy (VPT), the induction of dentin bridge formation in
CEM was comparable with that in MTA and superior to that
in CH.[10,20] Studies of complete pulpotomy treatment using
CEM, MTA, and CH have shown that compared to CH, samples
in the CEM group exhibited lower inflammation, improved
quality/thickness of calcified bridge, superior pulp vitality
status, and morphology of odontoblast cells.[22] However,
no significant differences were identified in comparison to
MTA.[22] The cytotoxicity of CEM was compared with MTA
and intermediate restorative material (IRM), in two different
studies; the authors indicated that the cytotoxic potentials
of CEM and MTA are both insignificant and comparable, and
both biomaterials were significantly superior to IRM.[23,24] A
recent study comparing the subcutaneous tissue response
to CEM and MTA in rats showed that unlike MTA, CEM
did not induce any cellular necrosis after 1-week. After
60 days, levels of inflammation in the CEM group were
significantly lower than the white/gray MTA groups.[25]
Another significant finding was the presence of dystrophic
calcification adjacent to the biomaterials, which is an
indication of their osteoinductive potential.[26]
Clinical Applications
Vital pulp therapy
Vital primary/permanent teeth with complete/incomplete
root formation after traumatic/mechanical/carious pulp
exposures are suitable candidates for VPT. The key factor
in the success of VPT is the vitality of the pulp and, in
particular, the presence of an adequate vascularization,
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Kabbinale, et al.: Calcium-enriched mixture in endodontics
which is necessary for active formation/function of
odontoblasts. Several animal studies have shown that in
various forms of VPT treatments, the induction of dentin
bridge formation in CEM was comparable with that in
MTA and superior to that in CH.[10,22] Studies of complete
pulpotomy treatment using CEM, MTA, and CH have shown
that compared to CH, samples in the CEM group exhibited
lower inflammation, improved quality/thickness of calcified
bridge, superior pulp vitality status, and morphology of
odontoblast cells.[22]
Apexogenesis
Apexogenesis is considered as the treatment of choice in
vital permanent teeth with incomplete root formation.[27,28]
In a rare case of a maxillary incisor with an open apex
and traumatic pulp exposure; the tooth was left untreated
for 1-month and then treated by pulpotomy using CEM.
Acceptable clinical/radiographic results were achieved,
including the formation of a dental bridge below CEM and
the closure of the tooth apex.[17] A randomized clinical study
of permanent molars with open apices showed extensive
caries and signs of reversible/irreversible pulpitis. A 1-year
follow-up randomized clinical trial on permanent molars
with open apices revealed extensive caries and signs of
reversible/irreversible pulpitis which was indicative that
complete pulpotomy of the teeth using MTA and CEM were
beneficially successful.[29,30]
Pulp capping
Direct pulp capping (DPC) is one of the best known
clinical treatments available, whereby the connection
between the exposed pulp and oral cavity is eliminated
using appropriate materials. [31] Recent DPC outcomes
in prospective randomized controlled/clinical trials
carried out on permanent teeth planned for orthodontic
extraction have shown that under immunohistochemical
examinations, the thickness of dentinal bridge beneath
CEM was higher than MTA at various time intervals and
pulp inflammation was also lower in the CEM groups.[32]
In addition, expression of fibronectin/tenascin in the CEM
groups were higher than the MTA groups during both
time intervals; however, the above differences were not
statistically significant.[33]
Perforation repair
Root and furcal perforations are common complications
of endodontic treatment or postpreparation and often
lead to tooth extraction. CEM cement was considered
as the material of choice based on the results of in vivo
studies which revealed that CEM cement is able to stimulate
dentinogenesis after DPC,[10] pulpotomy in animals[22] and
in humans, it showed cementogenesis after perforation
82 Archives of Medicine and Health Sciences / Jan-Jun 2015 / Vol 3 | Issue 1
repair or surgery.[16,34] A 2 years follow-up case reported
by Asgary revealed the successful management of facial
perforation in mandibular first molar by CEM cement along
with no evidence of periodontal breakdown, no symptoms
and complete healing of furcal lesion.[35]
Root end filling material
One ideal property of a root-end filling material is its ability to
seal the apex apical sealing ability. The micro-leakage of CEM
cement, which is comparable with MTA and Portland cement,
indicates its good apical sealing. Due to the other beneficial
properties of this material such as biocompatibility, flow
ability, good clinical handling, antibacterial and low cytotoxic
effect, CEM cement is suggested as an appropriate root-end
filling material.[36]
Obturating material
With regards to its excellent biocompatibility and the ability
to form dentin and cementum, CEM can be suitable best
used as an obturating material. Reports from authors,
Asgaray, and Eghbal exhibited successful management of
inflammatory external resorption using CEM as an obturating
material. Three years follow-up showed complete healing of
the periapical area.[37]
Resorption
Asgary et al. reported successful management of
inflammatory external root resorption (IERR) using CEM
cement in an avulsed tooth of a young male patient.[38] Healing
of a progressive IERR occurred within 40 months with re-
establishment of the normal periodontal condition. Another
case report describes the management of an endodontically
failed molar that was severely affected by both external and
internal root resorption. Favorable treatment outcomes were
reported after 12 months of reobturation of entire distal
root canal with CEM cement.[39] On the basis of biological
properties of CEM cement, the authors believe that this
cement might be an appropriate bilateral in treatment of
IERR and also in arbitration of immature teeth. However,
further clinical studies with longer follow-up periods and
larger samples are recommended.[40]
Conclusion
In conclusion, considering the notable advantages of CEM
cement over MTA, such as shorter setting time, handling
characteristics and bactericidal effects, it could be stated
that, CEM cement might be an appropriate biomaterial to
be used for various purposes in endodontics. Literature
review on this particular material is lacking, due to recent
commercialization of this product. However, further research
is needed to learn about the success rate of this material.
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Kabbinale, et al.: Calcium-enriched mixture in endodontics
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Kabbinale, et al.: Calcium-enriched mixture in endodontics

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How to cite this article: Kabbinale P, Chethena KC, Kuttappa MA. Role of
calcium-enriched mixture in endodontics. Arch Med Health Sci 2015;3:80-4.
Source of Support: Nil, Conflict of Interest: None declared.

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