IP Indian Journal of Conservative and Endodontics 2020;5(3):123–126

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IP Indian Journal of Conservative and Endodontics

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Case Report
Calcium hydroxide induced healing of periapical radiolucency : A case series

Deebah Choudhary1, *, Atinderpal Singh2 , Nikhil Dev Wazir1

1 Dept. of Conservative Dentistry and Endodontics, Institute of Dental Sciences, Sehora, Jammu & Kashmir, India
2 Dept. of Conservative Dentistry and Endodontics, Baba Jaswant Singh Dental College, Hospital and research Institute,
Ludhiana, Punjab, India

ARTICLE INFO ABSTRACT

Article history: Background: Periapical disease may occur through an inflammatory response in a non-vital tooth. The
Received 15-05-2020 treatment of choice for most of these periapical lesions may be a conservative non-surgical approach. An
Accepted 18-05-2020 accurate diagnosis of the periapical lesion whether it is of endodontic or nonendodontic origin has to be
Available online 07-09-2020 made. Non- surgical endodontic therapy has shown a success rate of 94.4% with complete or partial healing.
Case description: The present clinical cases show two large periapical lesions in 14 year and 17-year-old
male patients respectively which were healed with non- surgical approaches using different formulations
Keywords:
of calcium hydroxide.
Nonsurgical treatment Conclusion: Healing was seen after few months in both the lesion without invasive treatments. As the first
Periapical lesion case revealed periapical healing within 2 months of calcium hydroxide placement whereas the second case
Calcium hydroxide
showed a much slower rate of healing over one year.
Metapex
© 2020 Published by Innovative Publication. This is an open access article under the CC BY-NC license
(https://creativecommons.org/licenses/by-nc/4.0/)

1. Background surgical endodontic therapy have shown a success rate of

94.4% with complete or partial healing. 5 Surgical methods
Periapical lesions are one of the common pathological
have many disadvantages so they are considered as option
conditions affecting periradicular tissues. The periapical
only if the non- surgical technique fails to show signs of
lesion mostly occurs due to bacterial invasion. 1 Non- vital
healing. 6
tooth leads to an inflammatory response at the root apex
Most of the time host defense prevents spreading of
which later forms a periapical disease. Due to necrosis of the
infection in the canal, to the bone. However, when the
pulp, the root canal acts as an area of growth of microbes.
circulation is compromised, host defense mechanism cannot
A root canal therapy mainly depends upon eliminating of
reach the microbes residing inside the tooth in the necrotic
the microbial growth emerging through the apical foramen
condition of the root canal. 7 In these cases a bacterial free
and also the penetration of further spread. 2,3 The primary
canal at the time of obturation is the primary aim for a
aim of any treatment should be a painless and conservative
highly successful case and to achieve this calcium hydroxide
approach. 4
is used as therapeutic medication because mechanical
There are many non- surgical ways of managing
instrumentation alone cannot remove the microbes from the
a periradicular lesion namely, orthograde root canal
main root canal. 8–10
therapy, decompression therapy, method using calcium
It is important to note that to carry out any periapical
hydroxide, aspiration- irrigation technique, lesion
treatment an absolute diagnosis of the lesion is required.
sterilization and repair therapy, active non- surgical
However a primary clinical diagnosis of a radicular cyst
decompression technique and apexum procedure. 4 Non-
can be approximately made in the following facts: if the
* Corresponding author. periapical lesion is a cyst, it is associated with one or
E-mail address: [email protected] (D. Choudhary). more non- vital teeth, the lesion size is usually greater

https://doi.org/10.18231/j.ijce.2020.029
2581-9534/© 2020 Innovative Publication, All rights reserved. 123
124 Choudhary, Singh and Wazir / IP Indian Journal of Conservative and Endodontics 2020;5(3):123–126

than 200mm2 , the lesion is described radiographically as ceased and the canal was absolutely dry. Calcium hydroxide
a circumscribed, well defined radiolucent area with a thin paste Calcigel (Prevest DenPro) was placed as an intracanal
radiopaque lining and finally it produces a pale, brownish, medicament in the root canal (Figure 1B). The dressing
yellow- colored fluid upon aspiration or when drainage is was changed after every 15 days for 2 months. After 2
accomplished throughout the accessed root canal system. months’ evidence of periapical healing and apex closure was
These case reports here under describes about the seen. The tooth remained asymptomatic and obturation was
management of periapical lesions associated with immature carried out using AH- plus (Dentsply-kronstaz, Germany)
teeth using an aspiration technique followed by placement sealer and gutta-percha (Dentsply Maillefer Ballaigues,
of different calcium hydroxide formulations to appreciate Switzerland) (Figure 1C). The fractured teeth were later
healing in the periapical lesions. build by composite (3M ESPE Filtex). The patient was
recalled for follow ups. After 6 months, there was significant
2. Case Description amount of bone healing and barrier formation at root apex
(Figure 1D).
2.1. Case 1
A 14-year-old male patient reported to the department with 2.2. Case 2
a chief complaint of fracture in the maxillary anterior teeth.
There was no contributory medical history. On taking a A 17-year-old male patient reported with a discolored
detailed dental history the patient revealed trauma to the maxillary anterior tooth. On clinical examination, the
anterior teeth. There was a complete fracture in 11 which tooth 11 was not mobile and had a negative response
involved the pulp and was tender on percussion (Figure 1 to electric pulp testing (Electric Pulp Tester, Parkell,
A). The tooth 21 has an enamel fracture. Radiograph was Farmingdale, NY). Tooth 12 was fractured and also non-
advised for the teeth which showed a periapical radiolucent vital. Radiographic examination of both teeth 11 and 12
area with an open apex. Electronic pulp testing (Electric revealed a large periapical lesion, borders of which involved
Pulp Tester, Parkell, Farmingdale, NY) was negative for 11. both the teeth with well-defined outline, suggesting of a
periapical cyst (Figure 2 A).

Fig. 1: A: Pretreatment periapical view; B: Application of calcium

hydroxide; C: Obturation carried out after 2 months D: Post Fig. 2: A: Preoperative radiograph, B: Application of calcium
treatment radiograph after 6 months hydroxide, C: Mastercone radiograph by “tailor-made Gutta-
percha” after 10 months, D: Follow-up radiograph after 1 year

Endodontic treatment was planned for the tooth 11.

Following the rubber dam application, access cavity Non- surgical endodontic treatment was scheduled for
preparation was done. A large amount of drainage of 11 and 12 in the next appointment. Access opening was
purulent exudate was seen and patient was immediately performed and working length was calculated. Canals were
relieved of pain. A 23- gauge needle attached to a 5- then thoroughly irrigated with copious amount of sodium
ml syringe (Dispovan, Hindustan syringes and medical hypochlorite solution and prepared till 80# in 11 and 45# in
devices Ltd., India) was inserted into the root canal past the 12. Final rinse was done by 17% EDTA solution. Canals
open apex, beyond into the periapical region. The purulent were dried with sterile paper point (Dentsply Maillefer
discharge was aspirated out. The canal was thoroughly Ballaigues, Switzerland) and temporized by Cavit (ESPE,
irrigated with 2.5% sodium hypochlorite (NaOCl) solution Seefeld, Germany). In the next appointment Metapex
(Belo Dez de Ouro, Brazil). Following this working length (Meta- Biomed Co. Ltd) dressing was introduced into the
was measured and the canal was instrumented till 80 # canal as well as pushed beyond apex into the periapical
k-file (Dentsply Maillefer Ballaigues, Switzerland). The area (Figure 2B). This was changed every 2 weeks for
canal was dried with the paper point (Dentsply Maillefer over a period of 10 months. Subsequently after 10 months
Ballaigues, Switzerland) and temporized with Cavit (ESPE, when periapical changes were noticed, the canals were
Seefeld, Germany). cleansed and obturated with Gutta-percha cones (Dentsply
Patient was recalled after 3 days to check for any Maillefer Ballaigues, Switzerland) and AH plus sealer using
discharge from the canal. The drainage was completely the “tailor- made Gutta-percha” technique in 11 (Figure 2C).
 Choudhary, Singh and Wazir / IP Indian Journal of Conservative and Endodontics 2020;5(3):123–126 125

Radiographic examination after one and a half year healing, notably in young adults. 25,26 It is seen that long
revealed adequate healing of the lesion (Figure 2D). The term use of calcium hydroxide from 6 to 24 months may
tooth also remained asymptomatic. cause hard tissue barrier formation. 27,28 Thus it is used for
apexification of non- vital immature tooth. 29
3. Discussion In the present cases calcium hydroxide was used in
both the cases with different formulation. In the first case
Sudden impact involving the face or head may result in Calcigel was used, which is a plain calcium hydroxide
trauma to the teeth and supporting structures. It is seen paste in a syringe form. The use of Calcigel was confined
in a US based study that 25% of the population who are only to the root canal. In the second case Metapex (Meta-
between the age of 6 to 50 years have chance of injuries Biomed Co. Ltd) was used. Iodoform being antiseptic due
to anterior teeth. 11 There is a gender difference seen in to iodine release in the nascent state. 30 Barium Sulphate
the pattern of traumatic injuries with boys: girls’ ratio is used as an opacifier. This formulation (Metapex) was
varying from 2:1 to 3:1. 12 in the case reports presented both intentionally pushed into the periapical region. Mode of
the patients are male showing a prevalence in males than action of calcium hydroxide beyond apex may be due to
females. Maxillary central incisors are the most commonly its antibacterial, anti- inflammatory which cause hard tissue
infected teeth followed by maxillary laterals and molars barrier formation. 31 Few studies advocated that pushing
being posteriorly placed are the least commonly affected. 12 calcium hydroxide beyond apex may prevent early healing
In the first case a complicated crown fractured is seen and take time to repair. 32,33 However this was seen in the
i.e. involving the pulp. Ellis and Davey classified these kind cases presented, as the first case revealed periapical healing
of fractures as class III fractures. 13 This kind of fractures within 2 months of calcium hydroxide placement whereas
may show a pin point exposure or a total unroofing of the second case showed a much slower rate of healing
coronal pulp. They contribute between 2 to 13% of all over one year. Moreover, barium sulphate present along
the dental injuries. 14 Further on taking a radiograph, both with calcium hydroxide can obscure the apex, making the
the cases showed periapical lesion. Majorly the periapical judgement of the radiographic apex quite difficult.
lesions can be categorized as a granuloma, radicular cyst A study by Srindberg and Sjogren 34 showed no
or abscesses. 15,16 The diagnosis of the lesion can only significant difference in healing rate between lesion larger
be made through the histological nature of the lesion than 5mm and those smaller than 5mm. A success rate of
present periapically but a preliminary diagnosis can be made 73.8% was seen in 42 non- surgically treated teeth with large
on taking a clinical and radiographic examination. These cystic lesions. 35
inflammatory lesions have somewhat similar treatment and
can be removed only after removal of the original etiology
4. Conclusion
of the lesion. 17
A success rate up to 85% is seen in these periapical The periapical lesions in the above cases were large but
lesions after endodontics treatment. 18–20 In the past, it resolved after non- surgical therapy. Due to a good blood
was considered that large periapical lesions would not supply, lymphatic drainage and abundant undifferentiated
respond to root canal treatment alone and that surgery mesenchymal cells, periapical lesions have an excellent
was always required. However, in recent years there is potential for healing. 36
greater awareness of the root canal morphology and the
development of newer instruments techniques and materials 5. Source of Funding
has greatly enhanced the clinician’s ability. 21 Thus non-
surgical endodontic treatment was planned for both the None.
cases. This kind of treatment aids in a less invasive and
more patient compliant procedure. When planning a non- 6. Conflict of Interest
surgical endodontic treatment two things have to be kept in None.
mind, first is the sufficient chemo- mechanical cleaning of
the root canal system and second, disinfection of the canal References
by use of a medicament. The irrigant used in the cases was
1. Croitoru IC, Craitoiu S, Petcu CM, Mihailescu OA, Pascu RM, Bobie
sodium hypochlorite. This irrigant is most commonly used AG, et al. Clinical, imagistic and histopathological study of chronic
in endodontic treatment. 22 apical periodontitis. Rom J Morphol Embryol. 2016;57(2):719–28.
For the disinfection of the canal calcium hydroxide was 2. Spangberg LSW, Haapasalo M. Rationale and efficacy of root canal
used. Calcium hydroxide is an antibacterial paste which medicaments and root filling materials with emphasis on treatment
outcome. Endod Top. 2002;2(1):35–58.
is most commonly used intracanal medicament. 23 Calcium 3. Haapasalo M, Udnaes T, Endal U. Persistent, recurrent, and acquired
hydroxide is considered gold standard for root canal infection of the root canal system post-treatment. Endod Top.
disinfection. 24 The mechanism of action is not clearly 2003;6(1):29–56.
known but due to its alkaline nature it promotes periapical 4. Lin LM, Huang GTJ, Rosenberg PA. Proliferation of Epithelial Cell
Rests, Formation of Apical Cysts, and Regression of Apical Cysts after
126 Choudhary, Singh and Wazir / IP Indian Journal of Conservative and Endodontics 2020;5(3):123–126

Periapical Wound Healing. J Endod. 2007;33(8):908–16. and substances. Int Endod J. 2003;36(2):75–85.
5. Murphy WK, Kg, Collet WK, Dodds RN. Healing of periapical 24. Portenier I, Haapasalo H, Rye A, Waltimo T, Orstavik D,
radiolucencies after nonsurgical endodontic therapy. Oral Surg Oral Haapasalo M, et al. Inactivation of root canal medicaments by
Med Oral Pathol. 1991;71:620–4. dentine, hydroxylapatite and bovine serum albumin. Int Endod J.
6. Sood N, Maheshwari N, Gothi R, Sood N. Treatment of Large 2001;34(3):184–8.
Periapical Cyst Like Lesion: A Noninvasive Approach: A Report of 25. Caliskan MK, Turkun M. Periapical repair and apical closure of a
Two Cases. Int J Clin Pediatr Dent. 2015;8(2):133–7. pulpless tooth using calcium hydroxide. Oral Surg Oral Med Oral
7. Sjogren U, Figdor D, Persson S, Sundqvist G. Influence of infection Pathol Oral Radiol Endod. 1997;84(6):683–7.
at the time of root filling on the outcome of endodontic treatment of 26. Saatchi M. Healing of large periapical lesion: A non-surgical
teeth with apical periodontitis. Int Endod J. 1997;30(5):297–306. endodontic treatment approach. Aust Endod J. 2007;33(3):136–40.
8. Engstrom B. The significance of enterococci in root canal treatment. 27. Fuss Z, Tsesis I, Lin S. Root resorption - diagnosis, classification
Odontol Revy. 1964;15:87–106. and treatment choices based on stimulation factors. Dent Traumatol.
9. Bystrom A, Claesson R, Sundqvist G. The antibacterial effect 2003;19(4):175–82.
of camphorated paramonochlorophenol, camphorated phenol and 28. Laux M, Abbott PV, Pajarola G, Nair PNR. Apical inflammatory root
calcium hydroxide in the treatment of infected root canals. Dent resorption: a correlative radiographic and histological assessment. Int
Traumatol. 1985;1(5):170–5. Endod J. 2000;33(6):483–93.
10. Katebzadeh N, Sigurdsson A, Trope M. Radiographic evaluation of 29. Frank AL. Therapy for the divergent pulpless tooth by continued
periapical healing after obturation of infected root canals: an in vivo apical formation. Jam Dent Assoc. 1966;72:87–93.
study. Int Endod J. 2000;33(1):60–6. 30. Pallotta RC, Machado MEL, d Reis NS, Martins GHR, Nabeshima
11. Kaste LM, Gift HC, Bhat M, Swango PA. Prevalence of Incisor CK. Tissue inflammatory response to implantation of calcium
Trauma in Persons 6 to 50 Years of Age: United States, 1988–1991. J hydroxide and iodoform in the back of rats. Revista Odonto Ciência
Dent Res. 1996;75(2):696–705. (Online). 2010;25(1):59–64.
12. Andreasen JO, Andreasen FM. Classification, etiology and 31. Tronstad L, Andreasen JO, Hasselgren G, Kristerson L, Riis I.
epidemiology of traumatic dental injuries. In: Textbook and color atlas pH changes in dental tissues after root canal filling with calcium
of traumatic injuries to the teeth. Copenhagen: Munksgaard; 1993. p. hydroxide. J Endod. 1981;7(1):17–21.
151–77. 32. Vernieks AA, Messer LB. Calcium hydroxide induced healing of
13. Ellis GE, Davey KW. The classification and treatment of injuries to periapical lesions: a study of 78 non-vital teeth. Int Endod J.
the teeth of children. Chicago: Year Book Medical; 1970. 1978;11(2):61–9.
14. Andreasen JO, Andreasen FM. Crown fractures. In: Textbook 33. Moor RJGD, Witte AMJCD. Periapical lesions accidentally filled with
and color atlas of traumatic injuries to the teeth. Copenhagen: calcium hydroxide. Int Endod J. 2002;35(11):946–58.
Munksgaard; 1993. p. 219–56. 34. Wu MK, Sluis LWM, Wesselink PR. The capability of two hand
15. Lalonde ER, Luebke RG. Acute salpingitis in sterilized women. Oral instrumentation techniques to remove the inner layer of dentine in oval
Surg Oral Med Oral Pathol. 1987;25:861–8. canals. Int Endod J. 2003;36(3):218–24.
16. Bhaskar SN. Periapical lesions-types, incidence, and clinical features. 35. Mk, Cak. Prognosis of large cyst-like periapical lesions following
Oral Surg Oral Med Oral Pathol. 1966;21(5):657–71. nonsugical root canal treatment: A clinical review. Int Endod J.
17. Broon NJ, Bortoluzzi EA, Bramante CM. Repair of large periapical 2004;37:408–16.
radiolucent lesions of endodontic origin without surgical treatment. 36. Harty FJ. Endodontic in Clinical Practice. Bristol, England: Wright;
Aust Endod J. 2007;33(1):36–41. 1982. p. 195.
18. Fernandes M, Ataide ID. Non-surgical management of a large
periapical lesion using a simple aspiration technique: a case report.
Int Endod J. 2010;43(6):536–42. Author biography
19. Soares J, Santos S, Silveira F, Nunes E. Nonsurgical treatment of
extensive cyst-like periapical lesion of endodontic origin. Int Endod J. Deebah Choudhary Senior Lecturer
2006;39(7):566–75.
20. Al-Kandari AM, Al-Quoud OA, Gnanasekhar JD. Healing of large
Atinderpal Singh Senior Lecturer
periapical lesions following nonsurgical endodontic therapy: Case
reports. Quinttessence Int. 1994;25:115–9.
21. Saatchi M. Healing of large periapical lesion: A non-surgical Nikhil Dev Wazir Professor and HOD
endodontic treatment approach. Aust Endod J. 2007;33(3):136–40.
22. Spencer HR, Ike V, Brennan PA. Review: the use of sodium
hypochlorite in endodontics — potential complications and their Cite this article: Choudhary D, Singh A, Wazir ND. Calcium
management. Br Dent J. 2007;202(9):555–9. hydroxide induced healing of periapical radiolucency : A case series
23. Hauman CHJ, Love RM. Biocompatibility of dental materials used in . IP Indian J Conserv Endod 2020;5(3):123-126.
contemporary endodontic therapy: a review. Part 1. Intracanal drugs