Abstract Intracanal medication is adjunct to cleaning and shaping in reducing postoperative pain and tenderness in symptomatic teeth. The present clinical study aimed to investigate the effectiveness of Ledermix paste as intracanal medicament in symptomatic teeth using the eugenol as control. Access cavity was prepared for 30 symptomatic teeth,Intracanal medicament was placed. Incidence of post access pain and tenderness were evaluated. Ledermix showed faster action than eugenol in reducing symptoms i.
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The purpose of this literature review is to focus on the role of calcium hydroxide in the field of endodontics including a brief explanation of its mechanism of action, antimicrobial effects, different applications, cytotoxicity or biocompatibility, and finally removal of calcium hydroxide from the root canals. Materials and Methods 3. Antimicrobial Effect of Calcium Hydroxide Endodontic infections occur as a result of microbial mixtures containing bacteria represented by Enterococcus faecalis  and fungi which are especially represented by Candida Albicans .
Anaerobic bacteria with their endotoxins on their cell walls also predominant in this microbial diversity and can be detected especially gram negative . It is well established that the complete removal of bacteria from the root canal system is difficult even with the new endodontic techniques.
Combining procedures to eliminate bacterial infection may be accepted. These including mechanical root canal debridement by proper shaping, irrigation by chemical agents such as sodium hypochlorite NaOCl or hydrogen peroxide H2O2 in addition to the intracanal medicament containing antimicrobial agents such as calcium hydroxide  . Mechanism of Action The release of hydroxyl ions in an aqueous environment is essential for the activation of calcium hydroxide against microbes.
These ions reacted intensively with several biomolecules due to their highly oxidant free radicals. As this reactivity is unspecified, the free radicals most likely gathered at the sites of generation.
Hydroxyl ions have fatal effects on bacterial cells. They may damage the cytoplasmic membrane of bacteria, denature their proteins, or damage the DNA. It is difficult to prove which of these three Diagram 1. Article screening process. Since enzymatic sites are located in the cytoplasmic membrane of bacteria, hydroxyl ions from calcium hydroxide exert their mechanism of action there.
Extracellular enzymes favor digestion, and through hydrolysis act on nutrients, carbohydrates, proteins, and lipids, whereas intracellular enzymes act on the respiratory activity of the cellular wall structure. The high concentration of hydroxyl ions from calcium hydroxide alters the pH gradient of the cytoplasmic membrane damaging its protein. The integrity of the cytoplasmic membrane is altered by the high alkalinity of calcium hydroxide by acting on the organic components and transporting the nutrients or by a saponification reaction in which the phospholipids or unsaturated fatty acids of the cytoplasmic membrane are destructed during the peroxidation process .
Antibacterial Effect The antibacterial activity of calcium hydroxide is a major concern to most of the scientists. Cook et al. Peters et al. Other studies showed that calcium hydroxide could not reliably remove bacteria from the root canal system or change the culture from gram-negative to gram-positive . It has been reported that the 7 days application of calcium hydroxide is effective in bacterial elimination while the 10 minutes application was not effective .
Antifungal Effect The presence of Fungi represented by C. It was reported that C. Since C. Applications of Calcium Hydroxide in Endodontics 4. Intracanal Medicaments Endodontic treatment requires the use of suitable intracanal medicaments that simultaneously eliminate bacteria, prevent their growth, stop their ingress and cut off their nutrient supply .
Calcium hydroxide is most commonly used as an intracanal medicament for disinfection of the root canal system . It has a wide range of antimicrobial activity against bacteria, but has limited effect against E. It is also an effective anti-endotoxin agent . Calcium hydroxide has a little or no effect on the intensity or severity of postoperative pain following endodontic treatment.
In contrast, application of corticosteroid paste in the canal reduces the postoperative pain . Different techniques can be used for the placement of calcium hydroxide in the canals. Tan et al.
Root Canal Sealer The main objective of root canal obturation is to achieve a tight seal of the root canal system which in turn enhance the healing process of periapical and apical regions after endodontic therapy . It is well clear that some forms of cement are required when filling the root canals to fill the minor spaces between the core material and the dentinal walls of the canal to prevent leakage.
The outcome of endodontic treatment may influenced by sealer selection . The properties of an ideal root canal sealer were outlined by Grossman Table 1 . Therefore, dissolving an endodontic sealer based on calcium hydroxide resulted in the loss of its solid content and consequently obturation voids are formed .
The antibacterial activity of some calcium hydroxide based sealers such as RealSeal, Sealapex, Apexit, and Apexit Plus is related to the release of hydroxyl ions. These sealers may also help in the formation of root-end hard tissue. Despite their advantages, calcium hydroxide-based sealers exhibit some disadvantages such as limited antibacterial activity, poor cohesive strength, greater solubility, and marginal leakage  .
In Weeping Canal Weeping canal is a canal from which constant clear or reddish exudation is appeared. This exudate is associated with a large apical radiolucency. The tooth is difficult to treat as when opened, exudate stops but it again reappears in next appointment.
Signs and symptoms are varies from symptomless to tenderness to percussion and palpation. Obturation of canals with exudates is contraindicated.
Table 1. For such teeth, application of calcium hydroxide in the canal after drying with sterile absorbent paper points is helpful. This is because of its high alkalinity, which changes the acidic pH of periapical tissues to a more basic environment  .
Two other mechanisms have also been proposed: 1 build up bone in the lesion due to the calcifying potential of calcium hydroxide and 2 the residual chronically inflamed tissue is cauterized by the caustic action of calcium hydroxide . Perforation Management One of procedural errors that can happen during root canal treatment is root or furcation perforation. This error can cause failure of the treatment and subsequent tooth loss.
Calcium hydroxide was one of the most preferred materials that have been used to seal and manage perforations. It has many advantages in this treatment modality such as stimulation of hard tissue formation, easy preparation, rapid resorption when extruded into the periodontium and healing enhancement of damaged periodontal tissues .
In case of crestal and furcation perforations, calcium hydroxide is not the suitable material for the seal as a pocket is formed due initial inflammatory response to these materials and subsequent breakdown of the supporting tissues. Although calcium hydroxide possesses disadvantages-as mentioned previously, calcium hydroxide has been recommended as a traditional agent to manage perforations, and its usage still indicated to control infection, stop bleeding and as a temporary solution when inadequate time is available to perform a permanent repair.
However, mineral trioxide aggregate MTA now is the material of choice for the permanent repair of perforations from both a conventional and surgical approach  . Since calcium hydroxide has alkaline pH, it actively influences the local environment around a resorptive area by reducing osteoclast activity and stimulating repair.
The alkaline calcium hydroxide neutralizes the acidic environment which exists in the region of resorption, reversing the reaction and thus stimulating hard tissue formation. The diffusion of hydroxyl ions released by calcium hydroxide through the dentinal tubules that directly communicate with periodontal space would increase the pH of periodontal space from 6. To treat an internal resorption, the canal and resorption lacuna are filled with calcium hydroxide paste.
In this way calcium hydroxide will induce the necrotization process of the remaining tissue in the lacuna, and then by irrigation with sodium hypochlorite the necrotic residuals are removed . In case of lateral resorption, pulp extirpation, debridement of root canal and application of calcium hydroxide are the preferred therapy.
The resorptive defect should be filled with calcium hydroxide at 3-month intervals until it reveals hard tissue formation, confirmed by both direct examination through the access cavity and radiograph  . After establishment of physical barrier, the defect can be compacted with Gutta-percha . Recently, MTA is an alternative for calcium hydroxide in the management of internal root resorption.
It has been reported that MTA used successfully in surgical and non-surgical treatment of internal resorption . Dentin is produced by the pulp continuously due to the tooth aging, even after the initial formation. Dentin-pulp complex can be protected by applying one or more layers of some specific materials between the restorative material and dental tissues.
Protection of the dentin-pulp complex leads also to pulp vitality recovery. Calcium hydroxide based products are the materials that can be used for this purpose . Cytotoxicity and biocompatibility of these materials have been widely studied in different cell cultures .
Effect of Calcium Hydroxide on Pulp Vitality Pulp tissue is affected by environmental impacts such as heat, mechanical trauma as well as microbial toxins. After multiple injuries, the pulp cells have the capacity to repair and differentiate into odontoblasts and produce dentin matrix proteins during wound healing process.
Therefore, not all the inflammatory reaction leads to permanent damage . Due to its direct and indirect effect in pulp repair, calcium hydroxide considers as the most important dental material which is used as the gold standard in biocompatibility tests. Since calcium hydroxide is biologically and therapeutically potential, it is the material of choice for all pulp conservation treatment . Many studies reported that pulp repair and formation of hard tissue barrier can be induced when the pulp tissue directly capped with the different form of calcium hydroxide Figure 1 and Figure 2 .
Clinically, the formation of hard tissue barrier after pulp capping is precious as it provides natural protection from bacterial ingress and chemical products .
The mechanism of using calcium hydroxide as pulp capping agent is unclear. However, it has been reported that some proteins and growth factors are released from dentine because of the dissolved high alkaline pH of calcium hydroxide solution. These mechanisms may stimulate pulp repair and formation of hard tissue barrier. Additionally, a layer of coagulation necrosis is induced when the high pH of calcium hydroxide in direct contact with pulp tissue . Figure 1. Pulp exposure capped with calcium hydroxide, arrow.
Observe that 30 days after the pulp, therapy, a partial hard tissue barrier was formed, adjacent to the capping agent. Figure 2. Sixty days after applying calcium hydroxide, on the pulp tissue, a complete hard tissue barrier, HB is formed. Effect of Calcium Hydroxide on Periapical Area When using calcium hydroxide past in root canal treatment as intracanal medicament, it might be accidentally extruded through the root apex.
In case of large chronic periapical lesions, intentional pressing of calcium hydroxide beyond the root canal and into the periradicular tissue has been supported by some researchers.
They claimed that calcium hydroxide enhances the healing and osseous repair by direct effect on inflamed tissues. However, this hypothesis was rejected by other researchers and not widely used as extrusion of calcium hydroxide beyond the apex can lead to damaging effects .
In Endodontics, barium sulfate BaSO4 is added to calcium hydroxide paste as a radiopaque agent. Extrusion of calcium hydroxide paste containing barium sulfate beyond root canal can obscure the apex, and is not easily resorbed over time Figure 3 and Figure 4  , also barium sulfate enhances the release of inflammatory mediators responding to polymethylmethacrylate PMMA particles. Therefore, the healing process might be delayed when using calcium hydroxide paste including barium sulfate, or in this condition the radiographic interpretation of osseous healing might be difficult.
Consequently, pure calcium hydroxide is preferred by most clinicians as they believe that the commercial ingredients may delay the healing process they want  . Figure 3.
CALCIUM HYDROXIDE AS INTRACANAL MEDICAMENT PDF
Kazragul Histological periapical repair after obturation of infected root canals in dogs. An in vitro comparative study on the antimicrobial effects of bioglass 45S5 vs. Retrievabilty of calcium hydroxide intracanal medicament with chitosan from root canals: It is possible that deeper in hydroxire outside the main root canalCa OH 2 is present as a saturated solution or at concentrations even below that level. Table 7 Studies reporting limited effect of Ca OH 2 using infected dentin models with human teeth.
Calcium Hydroxide as Intracanal Medicament in Pulp Necrosis with Periapical Lesion : A Case Report
The purpose of this literature review is to focus on the role of calcium hydroxide in the field of endodontics including a brief explanation of its mechanism of action, antimicrobial effects, different applications, cytotoxicity or biocompatibility, and finally removal of calcium hydroxide from the root canals. Materials and Methods 3. Antimicrobial Effect of Calcium Hydroxide Endodontic infections occur as a result of microbial mixtures containing bacteria represented by Enterococcus faecalis  and fungi which are especially represented by Candida Albicans . Anaerobic bacteria with their endotoxins on their cell walls also predominant in this microbial diversity and can be detected especially gram negative . It is well established that the complete removal of bacteria from the root canal system is difficult even with the new endodontic techniques. Combining procedures to eliminate bacterial infection may be accepted.
One-visit root canal treatment has been considered ideal for the teeth with vital pulp. Several studies have shown that it is impossible to eliminate whole microorganisms even after cleaning, shaping and irrigation with disinfectants. Trope et al. On the other hand, several studies have concluded that one-visit treatment is equally effective or even more effective than multiple-visit treatment.