Cherapunji, Meghalaya.

CALCIUM HYDROXIDE

Presented by: Dr. Pallavi B. Gopeshetti, CODS, Dvg.

INTRODUCTION HISTORY COMPOSITION OF CALCIUM HYDROXIDE PROPERTIES OF CALCIUM HYDROXIDE BIOCOMPATIBILITY OF CALCIUM HYDROXIDE CLASSIFICATION & CLINICAL INDICATIONS MECHANISM OF ACTION APPLICATIONS OF CALCIUM HYDROXIDE CONTROVERSIES REGARDING CALCIUM HYDROXIDE REFERENCES CONCLUSION

JOURNEY!!

 CaCo3

(900-1200c)

CaO

CaO +H2O

Ca(OH)2

Synonyms: calcium hydrate, caustic lime, hydrated lime,lime, lime

hydrate, slaked lime

Other uses

 Amorphous matrix with crystalline fillers H H O Ca O

Available as 2 paste form 1 paste form powder liquid form

2 paste form Base paste:

* Glycol salicylate-40%, reacts with Ca(OH)2 & ZnO
* Tribasic calcium phosphate * Calcium tungstate (barium sulphate)- radio opacity *Zinc oxide

Catalyst paste:
* Calcium hydroxide-50-60%- Principal reactive ingredient
* Zinc oxide *Zinc sterate-0.5%- accelerator * Ethylene toulene sulfonamide-39.5%, oily compound, acts as carrier

 Single paste form/ light cured Ca(OH)2 : *Calcium hydroxide

*Barium sulfate *Urethane dimethacrylate resin *Polymerization activators *HEMA

Powder with various vehicles

 2 paste: equal parts of base & catalyst Powder form Ca(OH)2 in endodontics messing gun, vertical compaction, injectable formulations,

lentilospirals, hand file, paper points, Pastinject (specifically designed paste carrier), the MacSpadden compactor, combinations.

Mixing equal parts Starts acid base reaction Results in weakly bonded composite structure Chelates of Ca alkyl salicylate & water(the reaction byproduct) forms the continuous phase & the unreacted ingredient forms the interrupted phase Mass is hydrolytically unstable & contains a large % of unreacted Ca(OH)2 Ca ions & OH ions & salicylate ions are released continuously from the mass

Ca(OH)2

High alkaline pH Modified forms: resins Extreme cytotoxicity Buffering actions

Initial response: necrosis to depth of 1/> mm, coagulates any hemorragic exudate

Neutrophils infiltrate into sub necrosis zone

In weeks to months, necrotic zone undergoes dystrophic calcification which appears to be stimulus for dentine bridge formation

After 5-8 weeks, only slight inflammation remains

Biocompatibility with other restorative materials:

Amalgam & direct restorative mats

Setting reaction n properties

Zinc oxide eugenol

chairside prep proprietary brands are available

MAISTO 1975 classified Ca(OH)2 as an alkaline paste HOLLAND 1994 classified Ca(OH)2 according to vehicles used MAISTO, GOLDBERG, LEONARDO et al told their characteristics.

Easiest method: mix Ca(OH)2 wit water

drawbacks?: no good physiochemical prop.

Hence, LEONARDO recommended addition of other substances

CLINICAL IMPORTANCE OF THE VEHICLES

Velocity of ionic dissociation Solubility & resorption rates

According to FAVA, ideal vehicle should

a) Allow a gradual & slow Ca+ & OH- ionic release b) Allow slow diffusion in the tissues with low solubility in the tissue fluids c) Have no adverse effect on the induction of hard tissue deposition

TYPES OF VEHICLES & ITS IMPORTANCE

Fava, Holland, Lopes et al Aqueous (water) Viscous Oily (non-water soluble)

Importance:
a) Aqueous: rapid ionic dissociation, high solubility appli. disadvantage? b) Viscous: slow dissociation of ions over extended periods (due to its mol. wt) remains in RCs for 2-4 months appli. periodical redressing of RCs c) Oily: lowest solubility & diffusion

 AT CHAIRSIDE: Water: Saline : 9gm NaCl+1000ml water Anaesthetic solution :

easily available, sterile & easy to handle interesting point

Ringers solution:

NaCl-8.6gm KCl-0.3% CaCl-0.33gm water-1000ml

Methylcellulose & Carboxymethlycellulose: 5%-3%

2 pastes: Ist: monomer of methlycellulose a chemical initiator Ca(OH)2 particles IInd: catalyst Ca(OH)2 particles Methylcellulose monomers polymerize into a porous mesh work matrix & carries Ca(OH)2 to P-D organ without involving it in chemical reaction

Anionic detergent solutions: reduces surface tension

& facilitate substance penetration of Ca(OH)2 deeper into the tissues

 AT CHAIRSIDE
Glycerin: Viscous, colorless, characteristic Propyleneglycol: its Polyethylenegl odour, sweetish in chemically dihydric ycol: slightly taste, mol wt. alcohol with syrupy hygroscopic 92.02, hygroscopic consistency, (intracanal hygroscopic, non lubricant) toxic, mol wt. 76.09 used in

various pharmaceutical preps.

Adv: a) strong antibacterial action against common microrganisms in RCs b) hygroscopic: sustained release of Ca(OH)2 c) consistency: improved handling properties

At chairside Olive oil: non soluble in water, chemically esters of fatty acids of oleic,

linoleic, palmitoleic, estearic & linolenic acids promotes low solubility of Ca(OH)2 but has improved handling properties

Fatty acids: New B: P= Ca(OH)2 powder 100%

L= olive oil 100% New B2: P= Ca(OH)2 65% bismuth carbonate 15% resin & ZnO 20% L= fatty acids 85% & glycol 15%

 Camphorated parachorophenol:
Walkhoff 1891, 33-37% parachorophenol ,63-67% camphor disinfection action of parachlorophenol is due to liberation of chlorine in the presence of phenol camphor is essential oil wit low solubility in water, hence oily vehicle

Metacrylacetate: acetic ester metacresol in combination wit benzene

Oily liquid wit antibacterial, analgesic & sedative properties Less cytotoxic than CMCP When mixed with Ca(OH)2 = CA cresilate & acetic acid Acetic acid suffers an ionic dissociation & gives off H+ which decreases PH

Eugenol: oil of cloves

PROPRIETARY BRANDS
AQUEOUS:
Calxyl (oldest by Hermann 1920) Pulpdent & tempcanal Cavital Reogan Calasept Calnex Hypocal etc

 VISCOUS: Calen Calen + camphorated parachlorophenol(0.15ml):Controversies: why

use cytotoxic CMCP??
CMCP+ Ca(OH)2 Ca-Pcholrophenol ate, a weak salt
Water + salt, takes up H+ & goes back in to P-chlorophenol. gives off OHfrom water so high PH maintained Low liberation of Pchlorophenol ,not enough for cytotoxicity
P-chlorophenol is released, PH is high, so protein denaturation of tissues, hence physical barrier to deeper penetration of Pchlorophenol

Extended antibacte rial spectrum

Bioco mpatib le

OILY VEHICLES
Endoapex L&C Vitapex

OTHERS
Flohr (1936)- dentinal chips Methylcresilate Collagen gel Multical = Ca(OH)2(34%)+barium sulphate 15%+ chloro-timonal(51%)

CALCIUM HYDROXIDE & OTHER SUBSTANCES

RADIOGRAPHIC CONTRAST MEDIA:
Why needed? Atomic wt.> than Ca Ex.: barium sulphate, bismuth, compounds containing iodine & bromide

Bismuth salts
Some degree of toxicity

Soluble Barium salts

Extremely toxic material

Hence, iodine compounds, 3 types

Soluble iodine organic sub. Non soluble organic substance Slowly absorbable iodine oils Diatrizoate & iothalamate paste

 Metinyol (prednisolone- sulphacetamide with neomycin) with Ca(OH)2 Otosporin (polymixin B sulphate + neomycin) with Ca(OH)2 Ledermix (triamcinolone acetonide & demethylchlorotetracycline Ca) with Ca(OH)2 is very popular

Metronidazole + CHX + Ca(OH)2 Metranidazole + ciproflox + polyethyleneglycol 1000 + Ca(OH)2 CHX is added as vehicle(surfactant)

SETTING & NON SETTING CALCIUM HYDROXIDE

STRONG EFFECTS *Reocap

*Dycal (original formula) *Procal

*Dycal (new formula)

Setting

MEDIUM *Life EFFECTS *Renew

*Reolit

NO EFFECTS *Hydrex

*MPC

*Cal-Mer vii

Non-Setting
MATERIAL VEHICLE

Analar Ca(OH)2
Pulpdent Hypo-Cal

Water
Methycellulose Methycellulose

Reogan

Methycellulose

Antimicrobial, tissue dissolving ability, inhibition of tooth resorption, induction of hard tissue formation

Mechanism of antibacterial activity:

Related to its release of OH- ions OH ions are highly oxidant free radicals Shows high reactivity by reacting with biomolecules Reactivity is high & indiscriminate hence rarely diffuse away from the site of application

a) Damage to bact. cytoplasmic membrane:

OH ions induce lipid peroxidation

Destruction of phospholipids, structural components of the cellular mem OH removes H atoms from unsaturated FA generating a free lipid radical

This removes another H+ from 2nd FA, generating another lipidic peroxide

Peroxide themselves act as free radicals, initiating an autocatalytic chain reaction

Forms lipidic peroxide radical

Free lipidic radical reacts wit O2

Further loss of unsaturated FA

Extensive mem. damage

b) Protein denaturation:

Cellular metabolism is highly dependent on enzymatic activity

Enzymes have optimum activity & stability in a narrow range around neutrality Alkalinization due to Ca(OH)2

Loss of biological activity of the enzyme & disruption of cellular metabolism

Enzymes maintains its covalent structure but the polypeptide chain is randomly unraveled

Induces breakdown of ionic bonds that maintain the tertiary structure of proteins

c) Damage to the DNA

OH reacts with bact. DNA Induces splitting of the strand Genes are lost DNA replication is inhibited

Cellular activity is disarranged

ROOT CANAL DISINFECTION

When in direct contact Buffering systems Bact. in dentinal tubules PH values of Ca(OH)2 decreases in more distinct areas

12.2 8-11
7.4-9.6

INEFFICACY OF Ca(OH)2 AGAINST BACT. PRESENT IN DT MAY BE DUE TO a) Buffering ability of dentine: protons donors b) Arrangement of bact. in the DT c) Anatomical variations

INFLUENCE OF VEHICLES ON ANTIBACTERIAL ACTIVITY OF Ca(OH)2

CMCP & Metacraylacetate Enterococci

MOA: Phenolic derivatives (strong antibacterial)

Disrupts lipid containing bact. mem Leakage of cellular contents At low conc., inactivates essential enzymes & causes cell lysis

Have low surface tension, lipid solubility, high penetration

Hence CMCP + CaOH posses high radius of action, eliminates bact in distinct vicinity

PHYSICAL BARRIER
Physiochemical barrier, precludes the proliferation of residual micro organisms

Ist: as it possess antibact prop. acts as chemical barrier IInd: physical barrier against bact penetration, withholds substrate or growing & by limiting space for its growth

BIOCHEMICAL ACTIONS: THERORIES OF MINEALISATION

EPITACTIC THEORY:
Initiators: Chondratin sulphate
Vit D dependent proteins Phosphoproteins Phospholipids

Inhibitor: Pyrophosphate ions. Pyrophosphates- Alkaline Phosphates group

CALCIUM HYDROXIDE INDUCED MINERALISATION

Ca ions + alkaline pH 'Ca solely from dental pulp, Ca acts as initiator rather than a substrate for repair

Local buffering action to inflammatory byproducts, alkaline pH neutralizes lactic acid secreted by osteoclasts

CaOH exerts mitogenic & osteogenic effectsenzymatic pathwaymineralization

THE DENTINE BRIDGE

High pH materials Low pH materials

PERIAPICAL RESPONSE

 LINERS:

 BASES

PULP PROTECTION
INDIRECT PULP CAPPING

 DIRECT PULP CAPPING

Necrotic layer Basophilic layer Layer of calcium carbonate granules

Tissue with extensive inflammatory response

AFTER PROCEDURE 1-2 WEEKS LATER

Osteoodontoblast

Osteodentin

Odontoblasts

4-5 WEEKS LATER

Dentine bridge

A FEW MONTHS LATER

 PULPOTOMY

 APEXOGENESIS
Tooth with immature root with vital pulp

After amputation of vital pulp(pulpotomy)

Apexogenesis

Dentine bridge Ca(OH)2 Dressing material

 APEXIFICATION

 HORIZONTAL ROOT FRACTURES

APICAL PLUG

INTRACANAL MEDICAMENT (ROUTINE & LONG TERM)

INFECTED ROOT CANALS/PERIAPICAL LESIONS

 WEEPING CANALS

 ROOT RESORPTIONS (idiopathic/replantation/ transplantation)

 TREATMENT OF PERFORATIONS

 ROOT CANAL SEALER

DENTINE DESENSITIZOR

MICROLEAKAGE DETECTOR
(Leinfelder et al, 1986)

Is it a complete root canal medicamen t?? Its physical properties??

Resorption or stimulation ??

Is it a true sealer??

Dentinal bridge?? Is it perfect??

Other capping agents??

 Am J of Dent 2002; 15(4) & Am J of Dent 2006; 19(3)

*Leakage free restorations, *Less defects in bridge

Ca(OH)2

Composite resin

OOOE 2003 IEJ 2006

(systematic review)

Composite resin

More dentine bridging,

Aged restorations are not leakage proof, biocompatibility

Ca(OH)2

 Am J of Dent 2006; 19(3)

*Leakage free restorations, *Less defects in bridge

Ca(OH)2

GIC

Composite resin > GIC > Ca(OH)2

JOE 1998; 24(4)

Will MTA rule over CaOH??

Other capping agents??

With MTA

Pediatric dent 2006; 28, 399-404

With Ca(OH)

Ca(OH)2
Solubility
Sealing Microleakage pH Biocompatibility
Compressive strength-7.6, 3.8MPa Dentinal bridge Setting time
Appointment Cost

MTA
Solubility
Sealing Microleakage pH Biocompatibility
Compressive strength-70MPa Dentinal bridge Setting time
Appointment Cost

Contact with blood & moisture Contact with blood & moisture

Will MTA rule over CaOH??

A Catholicon??

IEJ 1999; 32, 361-9 IEJ 1999; 32, 257-82 IEJ 1990; 23, 283-97 J Dent 1991; 19, 3-13 JOE 2009; 35(4), 475-79 J.Appl.oral sci 2003; 11(4) Quint. Int 1990; 21(7), 589-97 Pediatric dent 2006; 28, 399-404 IEJ 2002; 36, 225-231 Am J of Dent 2002; 15(4) Am J of Dent 2006; 19(3) OOOE nov 2003 IEJ 2006(systematic review)

 Endodontic practice; Louis Grossman, Seymour Oliet, Carlos E Del Rio-11th edition Endodontic therapy; Franklin Weine- 6th edition Ingles endodontics; Ingle, Bakland, Baumgartner- 6th edition Pathways of pulp; Cohen, Hargreaves- 9th edition Operative dentistry; Sturdevants art and science of operative dentistry; Roberson , Heymann, Swift- 5th edition Operative dentistry. Modern theory and practice; Marzouk, Simonton, Gross- 1st edition Seltzer & Benders Dental pulp; Kenneth M Hargreaves, Harold E Goodis Essentials of traumatic injuries to the teeth; J O Andreasen & F M Andreasen www.google.com

Tooth

Bacteria

Ca(OH)2

Merik Lake