Calcium Hydroxide: A Dental

Panacea
Calcium Hydroxide &
Dentistry:
• Hermann (1920, 1930).

• However, the initial reference to its use has been

attributed to Nygren (1838) for the treatment of the
`fistula dentalis', whilst Codman (1851) was the first
to attempt to preserve the involved dental pulp.
 Chemical characteristics of calcium
hydroxide

• Limestone is a natural rock mainly composed of

calcium carbonate (CaCO3) which forms when the
calcium carbonate solution existing in mountain and
sea water becomes crystallized (Alliet & Vande
Voorde 1988).
• The combustion of limestone between 900 and 1200ºC
causes the following chemical reaction:
CaCO3 → CaO + CO2
 Chemical characteristics of calcium
hydroxide

• The calcium oxide (CaO) formed is called `quicklime‘

and has a strong corrosive ability.
• When calcium oxide contacts water, the following
reaction occurs:

• CaO + H2O → Ca(OH)2

Physical Characteristics:
• Calcium hydroxide is a white odourless powder with
the formula Ca(OH)2, and a molecular weight of
74.08.
• It has low solubility in water (about 1.2 g /L at 25ºC),
which decreases as the temperature rises;
• It has a high pH (about 12.5-12.8) and is insoluble in
alcohol.
• This low solubility is in turn, a good clinical
characteristic because a long period is necessary
before it becomes soluble in tissue fluids when in
direct contact with vital tissues.
• The material is chemically classified as a strong base.
 A chemical analysis of OH- ionic liberation from
calcium hydroxide allows the percentages of Ca2+ and
OH- ions that are released to be determined (Estrela
1994):
Favorable properties:

• The biologic properties of Calcium hydroxide are

most impressive which include the release of Ca2+ and
OH- ions .
• Another influential factor is the high pH which
promotes the healing process and diffusion through
dentinal tubules.
 Properties of significance in dentistry
include:

• Anti-microbial properties.

• Tissue Dissolution Properties.

• Biologic Properties.

Pulp therapy procedures.

* Hard Tissue formation.

Root canal disinfectant
pH Related:
• Most of the endodontopathogens are unable to survive in
the highly alkaline environment provided by calcium
hydroxide (Heithersay 1975).
• Since the pH of calcium hydroxide is about 12.5, several
bacterial species commonly found in infected root canals
are eliminated after a short period when in direct contact
with this substance (Bystrom et al. 1985).
Root canal disinfectant

• Antimicrobial activity of calcium hydroxide is also

related to the release of hydroxyl ions in an aqueous
environment.
• Hydroxyl ions are highly oxidant free radicals that
show extreme reactivity, reacting with several
biomolecules (Freeman & Crapo 1982).
• This reactivity is high and indiscriminate, and is a
potent bactericidal agent.
Their lethal effects on bacterial cells are probably
due to the following mechanisms:

1. Damage to the bacterial cytoplasmic membrane.

2. Protein denaturation.
3. Damage to the DNA.
Damage to the bacterial cytoplasmic
membrane
• Hydroxyl ions induce lipid peroxidation, resulting in
the destruction of phospholipids, structural
components of the cellular membrane.
• Hydroxyl ions remove hydrogen atoms from
unsaturated fatty acids, generating a free lipidic
radical.
• This free lipidic radical reacts with oxygen, resulting
in the formation of lipidic peroxide radical, which
removes another hydrogen atom from a second fatty
acid, generating another lipidic peroxide.
• Thus, peroxides themselves act as free radicals,
initiating an autocatalytic chain reaction, and resulting
in further loss of unsaturated fatty acids and extensive
membrane damage (Halliwell 1987, Cotran et al.
1999).
Protein denaturation
• Cellular metabolism is
highly dependent on
enzymatic activities.
• Enzymes have optimum
activity and stability in a
narrow range of pH, which
turns around neutrality.
Protein denaturation:
• Calcium hydroxide induces the breakdown of ionic
bonds that maintain the tertiary structure of proteins.
• As a consequence, the enzyme maintains its covalent
structure but the polypeptide chain is randomly
unravelled in variable and irregular spacial
conformation.
• This results in the loss of biological activity of the
enzyme and disruption of the cellular metabolism
(Voet & Voet 1995).
Damage to the DNA
• Hydroxyl ions react with the
bacterial DNA and induce
the splitting of the strands.
• Genes are then lost (Imlay &
Linn 1988).
• Consequently, DNA
replication is inhibited and
the cellular activity is
disarranged.
• Free radicals may also
induce lethal mutations.
Other mechanisms:
• It has been suggested that the ability of calcium
hydroxide to absorb carbon dioxide may contribute to
its antibacterial activity (Kontakiotis et al. 1995).
 Influence of the vehicle on the
antimicrobial activity

• Vehicles have different water solubility and ideally they

must not change the pH of calcium hydroxide
significantly.
• Most of the substances used as a vehicle for calcium
hydroxide like distilled water, saline solution and
glycerine do not have significant antibacterial activities.
• Other substances, such as camphorated
paramonochlorophenol (CMCP) and metacresylacetate,
are known to possess this property.
 Calcium Hydroxide + Saline:

• Siqueira & Uzeda (1996) verified that calcium

hydroxide/saline solution paste was ineffective in
eliminating E. faecalis and F. nucleatum from dentinal
tubules even after 1 week of exposure.
• In contrast, a calcium hydroxide/CMCP/glycerine
paste effectively killed bacteria in the tubules after 1 h
exposure, except for E. faecalis that required 1 day of
exposure.
CMCP:
• Phenolic compounds possess strong antibacterial
properties and halogenation intensifies their
antimicrobial activities.
• Phenol is believed to act by disrupting lipid-containing
bacterial membranes, resulting in leakage of cellular
contents.
• At higher concentrations, these compounds act by
precipitating the cytoplasmic cell proteins (O'Connor
& Rubino 1991).
 Calcium Hydroxide + CMCP
• Thus, the calcium hydroxide/CMCP mixture possesses a high
radius of action, eliminating bacteria located in regions more
distant from the vicinity where the paste was applied (Siqueira
1997).
• Frank (1966) recommended mixing calcium hydroxide with
CMCP in apexification procedures.
• Some authors criticized this by considering it unnecessary to
add antimicrobial agents to calcium hydroxide, especially those
that have been shown to be tissue irritating (Cvek et al. 1976,
Anthony et al. 1982).
• Recently, renewed interest has been generated regarding this
association because of the relative inefficiency of calcium
hydroxide against some microorganisms, such as E. faecalis.
To summarise:
• Endodontic infections are polymicrobial and no
medicament is effective against all the bacteria found
in infected root canals.
• Combination of two medicaments may produce
additive or synergistic effects.
• Evidence suggests that the association of calcium
hydroxide with CMCP has a broader antibacterial
spectrum, a higher radius of antibacterial action, and
kills bacteria faster than mixtures of calcium hydroxide
with inert vehicles.
• Therefore, CMCP cannot be considered a vehicle for
calcium hydroxide, but an additional medicament.
Physical barrier
• In addition to eliminating remaining viable bacteria

unaffected by the chemomechanical preparation of the

root canal, intracanal medicaments have been advocated

for other reasons.

• They should also act as a physicochemical barrier,

precluding the proliferation of residual microorganisms

and preventing the reinfection of the root canal by

bacteria from the oral cavity (Siqueira 1997).

Physical barrier
Intracanal medicaments may prevent the penetration of bacteria
from saliva in the root canal basically in many ways.
1. First, medicaments possessing antibacterial properties may
act as a chemical barrier against leakage by killing bacteria,
thereby preventing their ingress into the root canal.
This is by withholding substrate for growth and by
limiting space for multiplication (Dahlen & Moller 1992,
Siqueira et al. 1998).

2. Secondly, medicaments that fill the entire length of the root

canal act as a physical barrier against bacterial penetration.
Calcium Hydroxide as a Physical
barrier

• The filling ability of calcium hydroxide pastes is

probably more important in retarding root canal
recontamination than the chemical effect.
• Despite the vehicle used, calcium hydroxide seems to
act as an effective physical barrier.
Tissue Dissolution Properties
• The tissue-dissolving properties of NaOCl are well
documented, but those of Ca(OH)2 were first reported
only in 1988 by Hasselgren and colleagues.
• These authors also reported that the tissue dissolving
effect of NaOCl was enhanced by pretreatment of the
tissue with Ca(OH)2.
• According to them Ca(OH)2 causes the tissue to swell
and thus become more accessible to the NaOCl.
• Hence there is greater efficacy of Ca(OH)2 solution in
enhancing the tissue-dissolving property of 0.5%
NaOCl, as compared to the calcium hydroxide paste.
Normal Hard Tissue formation:
• Normally, an epitactic mechanism operates following the initial
seeding of a collagenous tissue.
• The process is probably a result of juxtra position of the charged
groups on adjacent macro-molecules that give rise to epitactic
centres
• These centres require a nucleation site from which hydroxyapatite
crystal growth can proceed.
• The initiator of the process is believed to be Chondroitin Sulphate
(Sobel,1955) , Vitamin D dependent protein ( Hauschka and Reid,
1978), Phosphoproteins and Phospholipids.
Normal Hard Tissue formation:
• Pyrophosphatase, a member of the alkaline
phosphatase group, inhibits pyrophosphates at the site
of mineralisation.
• Type I collagen has also been implicated in the
mineralisation process.
 During the process
of nucleation, groups of ions or ion clusters come together to form
a nucleus. The nucleus is the smallest collection of these ions that
has the arrangement of the ions in the final crystal that can persist
in solution. Formation of this nucleus is energetically unfavorable.
Additional lattice ions then add onto the nucleus, resulting in the
formation of a crystal.
Mechanisms of mineralisation of Calcium
Hydroxide:

• Tronstad et al 1981 proposed the High alkalinity and

hydroxyl ion theory.
• Disproved .
Mechanisms of mineralisation of Calcium
Hydroxide:
• Initiator Theory.
• It exerts a mitogenic and osteogenic effect.
• Capability of activating tissue enzymes such as alkaline
phosphatase, which favor tissue restoration through
mineralization.
• The optimum pH value for the activation of this
enzyme ranges from 8.6 to 10.3, that makes the release
of organic phosphate (phosphate ions) which reacts with
calcium ions from the circulating blood easier, creating
a sediment of calcium phosphate on the organic matrix.
• Indeed, this sediment is the molecular unit of
hydroxyapatite.
 Mechanisms of mineralisation of Calcium
Hydroxide:
• Capillary Permeability Theory.( Heithersay 1975)
• Calcium ions may reduce the permeability of new
capillaries, so that less intercellular serum is produced,
thus increasing the conc of calcium ions at the
mineralisation site.
• The presence of high calcium conc may also increase
the activity of calcium dependent pyrophosphatase
which plays a major role in mineralisation.
 Calcium Hydroxide

Ca++ OH-

Reduced capillary Neutralises acids by osteoclasts

permeability
Optimum pH for
Reduced serum flow pyrophosphatase activity.

Increased levels of Ca dependent

Reduced levels of inhibitory
Pyrophosphatase.
pyrophosphate

Uncontrolled mineralisation.
 Paradox of stimulation of resorption
by Calcium Hydroxide.
• Andreasen (1981) suggested that Calcium Hydroxide
that diffused through the apical foramen caused
damage to the cementocytes.
• Internal resorption seen in deciduous teeth following
pulpotomy is possibly due to the high pH which
causes irritation to the already damaged tissue.
• However it is now believed to be sustained by the
bacterial infection in the dentinal tubules.
Does calcium hydroxide participate in the
hard tissue bridge?

• Several studies showed that calcium hydroxide

participate in the hard tissue bridge.
• Others have shown that calcium hydroxide does not
participate in the hard tissue bridge formation, so they
are rather initiators rather than substrates for repair.
Availability of Calcium
Hydroxide:
• Non-setting products.
• Setting Products.
Non-setting products
Material Vehicle

Analar Water

Pulpdent Methyl cellulose

Hypo-cal Methyl cellulose

Reogan Methyl cellulose

Setting Products
• Strong effect:
1. Dycal (org)
2.Procal
• Medium effect:
1. Dycal (new).
2.Life
• No effect:
1. MPC
2. Hydrex.
Setting mechanisms:
• Two-paste System.
• Light activated single paste system.
Drawbacks of Calcium Hydroxide:
• Some authors (Holland et al ) criticize the quality of
the hard tissue bridge formed with calcium hydroxide,
claiming it may have tunnels defects, which can
compromise the protecting efficiency of the bridge.
 Effect of long term usage of calcium
hydroxide

• It has been observed that the calcium hydroxide

treated immature teeth show a high failure rate

because of an unusual preponderance of root fracture

and it has been suggested that changes in physical

properties of dentin by the calcium hydroxide dressing

may be responsible.
 Effect of long term usage of calcium
hydroxide
• Flexural strength of dentin might in part depend on an
intimate link between its two main components :
Hydroxyapatite crystals and collagenous network.
• Part of organic matrix is composed of acid proteins and
peptidoglycans containing phosphate and carboxylate
groups which may act as bonding agents between the
collagen network and hydroxyapatite crystals.
• Calcium hydroxide may due to its alkaline nature
neutralize and dissolve or denature some of the acidic
components acting as bonding agents and thereby
weaken the dentin.
Applications of Calcium Hydroxide in
dentistry:
• Lining of cavities.
• Indirect pulp capping.
• Direct pulp capping.
• Pulpotomy.
• Long-term temporary dressing.
• Root canal disinfectant.
• Apexification.
• Prevention of root resorption.
• Repair of perforations.
• Treatment of horizontal root #s.
• Constituent of root canal sealers.
Lining of cavities
Advantages:
• Rapid initial set in the cavity under the accelarating
effect of moisture.
• Do not interfere with the setting of Bis-GMA resins.
• Can even withstand the condensation forces of lathe
cut alloy. ( Lim & McCabe, 1982).
• Controversy about VLC system.
Indirect pulp capping
• Comparison between calcium hydroxide and ZOE.
Direct pulp capping
Criteria for success:

1. No symptoms of pulpitis. If present, then ZOE.

2. Larger the carious exposure worse is the prognosis.

3. Salivary/ iatrogenic contamination to be avoided.

4. More successful in young permanent teeth.

Pulpotomy:

• Preferably a hard setting material, Non-setting

material or slurry of calcium hydroxide and saline is

used.

• Never use in conjunction with medicaments for

pulpotomy.
Long-term temporary dressing:
• Not preferred in vital teeth.

• Preferred in cases of re-treatment.

Treatment of infected root canals
and periapical lesions:
• Heithersay(1975) recommended that calcium
hydroxide be used as a dressing in teeth with large
periapical lesions and also teeth with weeping canals.
• Calcium hydroxide prevents seepage of P.A. fluids by:
# Formation of fibrous barrier.
# Contraction of capillaries.
# Mechanical blockage.
Apexification:
• First use reported by Granath (1959) and later by
Frank (1966).

• Can be used in conjunction with medicaments.

• Sterility and thorough cleaning of canals are added

criteria for success.

• Needs replacement once every three months.

Prevention of root resorption:
• Idiopathic root resorption:

Controversy about the “Origin of Osteoblasts.”

• Following replacement of an avulsed tooth or
transplantation:

* May lead to root resorption if placed too early in

the root canals.
Repair of perforations:
• Success depends on:
* Size of the perforation.
* Avoidance of extrusion of the material.
Treatment of horizontal root #s:
Constituent of root canal sealers:

• Rationale for use of these materials is that when used

in canals with wide open apical foramina, perforations

or fractures, they induce mineralised repair.

• Two such materials are Sealapex and Calcibiotic Root

Canal Sealer (CRCS).

Future of Calcium Hydroxide in
dentistry:
Gram Positive bacterial cell wall structure:

lipid bilayer peptidoglycan

Gram Negative bacterial cell wall structure

lipid + LPS porins