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JOURNAL OF ENDODONTICS
Copyright 9 1984 by the American Association of Endodontists
SCIENTIFIC ARTICLES
Immediate Root Canal Filling: The Use of
Cytophylactic Substances and Noncytotoxic Solutions
Mario Roberto Leonardo, CD, PT, Raphael C. Comelli Lia, CD, PT, Roberto M. Esberard, CO, DC,
Carlos Benatti Neto, CD, M
Results of one-appointment endodontic treatment of
teeth with vital pulp were analyzed using both the
EDTA or the 4% sodium hypochlorite solutions as
root canal irrigants followed by immediate filling.
One-half of the root canals of each group were filled
with calcium hydroxide paste covering the pulp
stump, and, in the other half of each group, the
canals were obturated with zinc oxide-eugenol ce-
ment and gutta-percha points.
The histological analyses of the apical and periap-
ical tissues of dog's teeth showed that the calcium
hydroxide assured an increase in favorable results
when the root canals were irrigated with EDTA so-
lution.
The treatment of the root canal system includes the
use of many antiseptic medicaments during the bio-
mechanical preparation (1-3).
In cases of vital pulp, bactericidal substances are not
required as irrigants because we presume there is no
infection present. Based on previous studies (4-7), it is
logical that once the possible infection on the surface
of the vital pulp is under control, and, thus, an aseptic
penetration during the root canal treatment of teeth
with pulp vitality is obtained, cytotoxic or bactericidal
substances should not be used as irrigants (8). As we
know, the more bactericidal the medicament is, the
greater its cytotoxic effect. For this reason, the use of
a cytophylactic over a cytotoxic drug is advisable in
Such cases.
The first goal of endodontic treatment in cases of
pulpectomy is to preserve the vitality of periapical tissue
as well as the pulp stump and the tissue of the lateral
and accessory root canals (root canal system) (9).
A number of studies (10-12) has pointed out the
action of sodium hypochlorite solutions in dissolving
Printed in U.S.A.
VOL. 10, No. 1, JANUARY 1984
the pulp tissue from the root canal. On the other hand,
following Nyggard-E)stby (13), numerous investigators
(14-19) have studied the effect of EDTA, as to its
efficiency in cleaning the dentin wall of the root canal.
The purpose of this study was to evaluate the reac-
tion of the pulp stump and periapical connective tissue
to EDTA solution (experimental group), and to compare
it with 4% sodium hypochlorite only, both used as root
canal irrigants, followed by immediate obturation using
the conventional technique with gutta-percha cones
and zinc oxide-eugenol cement, with or without the
placement of calcium hydroxide paste.
MATERIALS AND METHODS
In this study, the treatment was carried out in 128
root canals from 64 maxillary and mandibular premolar
teeth of eight young mongrel dogs.
The dogs were anesthetized with a 5% solution of
sodium thiobarbital (Abbot Laboratories, Brazil) given
intravenously (1 ml/kg body wt). With the rubber dam
in place, the antisepsis of the operative field was made
with a 0.3% solution of alcohol-iodine. After this, the
pulpal chamber of each tooth was opened using a
Peeso drill and the pulps were extirpated with a suitable
Kerr file.
The root canals were filled and enlarged to 2 mm
short of the "radiographic apex" with reamers and files
of up to #40 instrument. Abundant irrigation and aspi-
ration of the root canals with the solutions studies was
done before, during, and after mechanical instrumen-
tation.
The root canals of one-half of the specimens were
irrigated with a sodic salt of EDTA solution, pH 7.4
(experimental group), prepared according to the follow-
ing composition: disodium EDTA, PA, 20.1 g, sodium
hydroxide, PA, 2.3 g, and distilled water 100.0 ml.
The other half of the root canals were irrigated with
 2 Leonardo et al. Journal of Endodontics

TABLE 1. Number of teeth and root canals treated

EDTA Group Filling Sodium Hypochlorite Group
EDTA (solution) Root canals filling with Sodium hypochlorite
/ I__(4%)
8 teeth ~ / '~8 teeth Calcium hydroxide paste 8 teeth~-~" "~'~-~ 8 teeth
(16 root canals) (16 root canals) and classical technique (16 root canals) (16 root canals)
l i l l
72 h 7 days 72 h 7 days
EDTA Root canals filling with Sodium hypochlorite
(solution) teeth ~ I " (4%)
8 teeth , . 1 ~ " ~ 8 teeth 8 ~ 8 teeth
Proco-sol*
(16 root canals) (16 root canals) and gutta-percha cones (16 root canals (16 root canals)
l l (conventional technique) l l
72 h 7 days 72 h 7 days
* Proco-sol Chemical Co., Inc.

4% sodium hypochlorite solution that was used for

comparative purposes (sodium hypochlorite group).
After final irrigation, the canals were carefully dried
with aspiration and sterilized absorbent paper points.
In each group, one-half of the root canals were
obturated using the conventional technique of gutta-
percha cones and zinc oxide-eugenol cement, after
placement of calcium hydroxide with special syringes
(8) covering the pulp stump in the same session. The
other half of the canals were also obturated in the same
session with zinc oxide-eugenol and gutta-percha
points and lateral condensation technique without cal-
cium hydroxide application.
The access openings were closed with zinc oxide-
eugenol and zinc phosphate cement.
The animals were sacrificed by the administration of
an overdose of the anesthetic solution 72 h and 7 days
after the treatment. The pieces obtained from the jaws,
each one containing the apical and periapical region,
were fixed in 10% neutral formalin solution and de-
mineralized in a formic acid-sodium citrate solution (20).
Serial sections of 6-#m thickness were prepared for
routine histological analysis and were stained with he-
matoxylin and eosin and examined microscopically.
Table 1 shows the number of teeth and root canals
treated and the time of sacrifice.

RESULTS

Root Canals Irrigated with EDTA Solution and Filled

with Calcium Hydroxide

SEVENTY-TWO HOURS

The apical delta canals (Fig. 1) in the majority of the

specimens showed the pulp stump which was vital with
a superficial zone of contact necrosis. The inflammatory
infiltrate (predominantly lymphocytes) when present,
was not expressive. The periodontal ligament, in all
cases, was free of inflammatory cells. Areas of cemen-
tum resorption were not observed.
FIG 1. Root canal irrigated with EDTA solution and filled with calcium
hydroxide. Observation period: 72 h. Photomicrograph of the apical
and the periodontal ligament shows normal structure. Residues are
shown inside the root canal (hematoxylin and eosin; original magnifi-
cation x250, Zeiss).
Vol. 10, No. 1, January 1984 Root Canal Filling 3

SEVEN DAYS
The results found in the connective tissue inside the
apical delta canals (Fig. 2) were similar to those de-
scribed above; however, in some pulp stumps we ob-
served an increase of cementum deposition. The per-
iodontal ligament was normal.

Root Canals Irrigated with EDTA Solution and Filled

with Zinc Oxide-Eugenol Cement and Gutta-percha
Cones
SEVENTY-TWO HOURS
The pulp stumps of the apical delta canals (Fig. 3) in

in others, the pulp stumps showed vitality in the medium

and apical thirds. In these cases, the connective tissue
showed a mild to moderate inflammatory infiltrate. The
inflammatory cell infiltrate was a mixture of plasma cells,
lymphocytes, and polymorphonuclear leukocytes.
The periodontal ligament showed normal structure;
however, in the apical foramen level where the pulp
stump was in total degeneration, a mild to moderate
inflammatory infiltrate was observed, predominantly of
lymphocytes.

SEVEN DAYS
The majority of the pulp stumps showed necrosis
and degeneration (Figs. 4 and 5). However, in some
cases, the remaining apical portion of the pulp stump
was vital with a moderate inflammatory infiltrate which
consisted predominantly of lymphocytes and plasma
cells.
The periodontal ligament presented some portions
with a moderate inflammatory infiltrate (predominantly
lymphocytes and plasma cells). Macrophage cells were
observed in those places with dark pigment in the
cytoplasm.

Root Canals Irrigated with Sodium Hypochlorite

Solution and Filled with Calcium Hydroxide

SEVENTY-TWO HOURS
The majority of specimens in this group showed the
pulp stump with partial necrosis and degeneration (Fig.
6).
In these cases, a mild to moderate inflammatory
infiltrate was observed. The inflammatory cell infiltrate
was a mixture of lymphocytes, plasma cells, and some
polymorphonuclear leukocytes. The periodontal liga-
ment presents a normal structure. No areas of cemen-
tum resorption were observed.

FIG 2. Root canal irrigated with EDTA solution and filled with calcium ligament present normal structure, but show an insignificant number
hydroxide. Observation period: 7 days. Photomicrograph of the apical of lymphocytes (hematoxylin and eosin; original magnification x300,
delta canals and periapical region. The pulp stump and the periodontal Zeiss).
4 Leonardo et al. Journal of Endodontics

SEVEN DAYS
The pulp stump (Fig. 7) of the majority of this group
showed a partial necrosis with normal structure in the
remaining connective tissue. In these cases, there was
a mild inflammatory infiltrate, predominated by lympho-
cytes. The periodontal membrane showed a normal
structure and absence of areas of cementum resorp-
tion.

FIG 4. Root canal irrigated with EDTA solution and filled with Proco-
sol and gutta-percha cones. Observation period: 7 days. Photomic-
rograph of the apical delta canals and periapical region. The pulp
stump of several remainings on the left side are necrotic. The perio-
dontal ligament shows a moderate inflammatory infiltrate, predomi-
nated by lymphocytes (hematoxylin and eosin; original magnification
x72, Zeiss).

FIG 3. Root canal irrigated with EDTA solution and filled with Proco-
sol and gutta-percha cones. Observation period: 72 h. Photomicro-
graph shows a panoramic aspect of the apical delta canals and the
periapical region. Residues can be observed inside the root canal.
The pulp stump shows a partial necrosis. The periodontal membrane FIG 5. A greater magnification of Fig. 4, showing the necrosis of the
shows normal structure, but with an insignificant number of lympho- pulp stump (hematoxylin and eosin; original magnification •
cytes (hematoxylin and eosin; original magnification x300, Zeiss). Zeiss).
Vol. 10, No. 1, January 1984 Root Canal Filling 5

Root Canals Irrigated with Sodium Hypochlorite

Solution and Filled with Zinc Oxide-Eugenol
Cement and Gutta-percha Cones

SEVENTY-TWO HOURS

The majority of the pulp stumps (Figs. 8 and 9) in

those teeth irrigated with 4% sodium hypochlorite so-
lution and filled with gutta-percha cones and zinc oxide-
eugenol cement presented necrosis and partial degen-
eration which included the medium third of the remain-
ing part. A moderate inflammatory infiltrate was ob-
served as was a mixture of lymphocytes, plasma cells,
and some polymorphonuclear leukocytes.
The periodontal ligament showed a normal structure.
However, in the apical foramen level, a moderate
chronic inflammatory infiltrate was observed. Areas of
cementum resorption were not observed.

SEVEN DAYS

The majority of specimens in this group showed the

connective tissue inside the apical delta canals (Fig. 10)
with necrosis and degeneration; however, in a few
cases, the pulp stumps showed vitality in the apical
third. In these cases, moderate to severe inflammatory
infiltrate was observed. This inflammatory cell infiltrate
was a mixture of lymphocytes, plasma cells, and some
polymorphonuclear leukocytes.

FIG 7. Root canal irrigated with sodium hypochloritesolution and

filled with calcium hydroxide. Observation period: 7 days. Photo-
micrograph showinga panoramicaspect of the apicaldelta canaland
periapical region. The pulp stump shows normal structure with a
superficial zone of necrosis.An insignificantnumberof lymphocytes
can be observed. The periodontalligament shows normal structure
(hematoxylinand eosin; originalmagnificationx250, Zeiss).

The periodontal membrane showed a normal struc-

FIG 6. ROOtcanal irrigated with sodium hypochloritesolution and
filled with calcium hydroxide.Observationperiod: 72 h. Photomicro-
graph showing a panoramic aspect of the apical delta canals and
periapical region. The pulp stump shows a partial necrosis. The
periodontalligamentshows normalstructure(hematoxylinand eosin;
originalmagnificationx300, Zeiss).
ture, without cementum resorption, except in the apical
foramen level, where there was a moderate chronic
inflammatory infiltrate. Some macrophage cells were
noticed in that region having dark pigment in the cyto-
plasm.
6 Leonardo et al.
FiG 8. Root canal irrigated with sodium hypochlorite solution and
filled with Proco-sol and gutta-percha cones. Observation period: 72
h. The pulp stump is necrotic. The root canal is free of residues
(hematoxylin and eosin; original magnification x200, Zeiss).
FIG 9. ROOt canal irrigated with sodium hypochlorite solution and
filled with Proco-sol and gutta-percha cones. Observation period: 72
h. The periodontal ligament shows moderate chronic inflammatory
infiltrate (hematoxylin and eosin; original magnification • Zeiss).
DISCUSSION
Sodium hypochlorite is an irrigant solution widely
used for endodontic therapy, but considering previous
biological studies that have shown an irritating action
Journal of Endodontics
(11, 12), it is logical to recommend the use of only
cytophylactic substances during root canal treatment
of teeth with pulpal vitality.
On the other hand, some papers have shown the
effect of EDTA and its efficiency in cleaning root canals
(14-19) but it would seem that few studies have been
published in which the reaction of the connective tissue
has been evaluated using this substance (12, 21,22).
These studies, however, do not establish the exact
relationship of clinical procedures in cases of one-
appointment therapy, and, thus, in this morphological
study, we will observe the reaction of both solutions on
the pulp stump and periapical tissue (in dogs) to the
EDTA solution (experimental group) and will compare
with 4% sodium hypochlorite. In both cases, immediate
root canal filling using calcium hydroxide paste or gutta-
percha cones and zinc oxide-eugenol cement (Proco-
sol) was carried out.
There were better results in the experimental group
(EDTA solution) mainly when the root canals were filled
with calcium hydroxide paste. These results were ex-
pected because, in spite of the fact that the root canals
had been irrigated thoroughly with EDTA solution, they
were filled with zinc oxide-eugenol cement and gutta-
percha cones, thus a stronger inflammatory reaction
was observed. After the pulpectomy (72 h), some cases
showed destruction of the pulp stumps and, in others,
partial necrosis of the connective tissue with an infiltrate
FiG 10. ROOtcanal irrigated with sodium hypochlorite solution and
filled with Proco-sol and gutta-percha cones. Observation period: 7
days. Photomicrograph showing panoramic aspect of the apical delta
canals and periapical region. The pulp stump is necrotic. The perio-
dontal membrane shows normal structure, but moderate lymphocyte
infiltrate can be observed (hematoxylin and eosin; original magnifica-
tion x72, Zeiss).
Vol. 10, No. 1, January 1984
of lymphocytes, plasma cells, and occasional polymor-
phonuclear leukocytes in a moderate degree was ob-
served. The inflammatory reaction was most severe 7
days after the pulpectomy; however, we observed that
the presence of zinc oxide-eugenol cement could have
had an effect on these results. This last observation is
in close agreement with many other investigations (23-
29).
The periodontal ligament showed normal structure 7
days after the pulpectomy when the root canals were
filled with calcium hydroxide paste. Our results are
corroborated by other investigators (8, 30, 31) who also
observed the efficiency of calcium hydroxide in cases
following pulpectomy. However, when the root canals
were immediately filled with zinc-eugenol cement, the
majority of the cases showed moderate chronic inflam-
matory reaction. Some macrophages with dark pigment
in the cytoplasm were also observed.
Several investigators (11, 12, 32) point out the irritat-
ing qualities of the sodium hypochlorite solution, 4%.
However, when the root canals were immediately filled
with calcium hydroxide paste, a lesser degree of inflam-
matory reaction was observed in contrast to cases in
which zinc oxide-eugenol cement was used as a filling.
These results showed that root canal fillings are an
important factor for the periapical repair, independent
of the irrigant solution.
The accidental presence of dentin chips on the pulp
stump surfaces prevented inflammatory reaction in all
of the groups. In these cases, 7 days after the pulpec-
tomy, the pulp stump and the periapical ligament were
free of inflammatory cells. These data show that the
presence of dentin chips in the treatment of the root
canal in teeth with pulpal vitality (biopulpectomy) seems
to be an important factor for periapical tissue repair.
Tronstad (33) believes that the influence of dentin chips
in the aforementioned cases is most important,
whereas he reported complete biological sealing of the
apical foramen in monkey's teeth, subjected to pulpec-
tomy, and where dentin chips had been used. This last
observation is in close agreement with some investi-
gators (34-36).
CONCLUSIONS
The results of the present work show that calcium
hydroxide improved the condition of the apical and
periapical tissues produced by pulpectomy, whether
using the EDTA or the sodium hydrochlorite solution.
However, the calcium hydroxide assures an increase in
favorable results, when the root canals are irrigated
with EDTA solution.
Dr. Leonardo is chairman, Department of Endodontics; Dr. Comelli Lia is
chairman, Department of Oral Pathology; Dr. Esberard is a doctor's assistant,
Department of Endodontics, and Dr. Benatti Neto is assistant professor,
Root Canal Filling 7
Department of Oral Pathology, School of Dentistry, UNESP University, Arara-
quara, Sao Paulo, Brazil. Address requests for reprints to Dr. Mario Roberto
Leonardo, Faculdade de Odontologia de Araraquara, Caixa Postal 331, Arara-
quara, Sao Paulo, Brazil 14.800.
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Erratum

In the July 1983 issue, the article by Cameron, The Use of Ultrasonics in the
Removal of the Smear Layer: A Scanning Electron Microscope Study, Vol. 9, No. 7,
page 289, the address for requests for reprints was omitted. It should have been:
Dr. J. A. Cameron
Pacific Highway and Ridley St.
P.O. Box 101
Charlestowne, Australia, New South Wales 2290
We regret any confusion this error may have caused.

A m e r i c a n Board of E n d o d o n t i c s

On November 5, 1983, the American Board of Endodontics decided to continue,

for an additional year, the release of questions from past examinations to endodontic
postgraduate directors and to other interested parties.
No answers, interpretive data, or other information on these questions will be
made available. The sole purpose of this release is to provide certification candidates
with some knowledge of the subject areas usually, but not exclusively, addressed in
ABE examinations. To receive a copy of the questions write: Dr. Joseph I. Tenca,
American Board of Endodontics, 211 East Chicago Avenue, Suite 830, Chicago, IL
60611.