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100 Years of Calcium Hydroxide in Dentistry: A Review of Literature

Article in Indian Journal of Forensic Medicine and Toxicology · December 2020

DOI: 10.37506/ijfmt.v14i4.11692

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 Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4 1203

100 Years of Calcium Hydroxide in Dentistry: A Review of

Literature

Sahithi Reddy1, Venkatachalam Prakash2, Arunajatesan Subbiya3, Suresh Mitthra4

Year PG Student , 2Professor, 3Professor and Head, 4Reader, Department of Conservative Dentistry and
1Final

Endodontics, Sree Balaji Dental College and Hospital, Bharath Institute of Higher Education and Research,
Narayanapuram , Pallikaranai, Chennai Tamilnadu, India.

Abstract
Ever since the introduction of calcium hydroxide in 1920, it has been widely used in dentistry. This is due
to the therapeutic properties of calcium hydroxide imparted by its high pH and dissociation to form ions
Ca+2 and OH−. This makes it a remineralizing agent, a bactericidal or bacteriostatic agent based on the pH
concentration and also an anti-inflammatory agent. It is being applied for various purposes in dentistry like
intracanal medicament, pulp capping agent, root canal sealer, cavity liner, apexification, pulpotomy, canals
with exudate, perforation management and root resorption. This review article aims to describe in detail the
various properties of calcium hydroxide and applications marking 100 years of its use in dentistry.

Key words: calcium hydroxide, intracanal medicament, remineralization.

Introduction used vehicles due to its low solubility and antibacterial

property (4). The various applications of calcium
Hermann in 1920 introduced calcium hydroxide
hydroxide are due to its important properties such as
in dentistry as “calxyl” to produce dentinal bridging
mineralization, antibacterial property and dissolution
of exposed pulp. This has led to the concept of
of necrotic material (figure 1). The calcium hydroxide
remineralisation, shifting from doomed organ theory
(1). Calcium hydroxide has been around for a century has various advantages like initial bactericidal and
later bacteriostatic activity, high pH which stimulates
and has shown to be effective in various clinical
fibroblasts, neutralizes low pH, promotes healing and
applications. It is an odourless white powder with a
repair, it is also in expensive and easy to use (5). But it
high pH and low solubility in water. It dissociates into
has few drawbacks like it does not exclusively stimulate
calcium and hydroxyl ions which aids in remineralisation
dentinogenesis or reparative dentin formation; it may
and anti bacterial properties, there by facilitating its
degrade during acid etching and does not adhere to dentin
use in dentistry (2). The pH and vehicle used mainly
or resin restoration (6). As the advantages outweigh the
influence the properties of Calcium hydroxide (table 1)
(3). Polyethylene glycol is one of the most commonly drawbacks the use of calcium hydroxide is being used in
dentistry since 100 years for various clinical applications
(figure 2) (7,8,9).

Corresponding Author: Mechanism of Action:

Dr. Sahithi Reddy, M.D.S., Final Year PG Student.
Remineralization:
Department of Conservative Dentistry and
Endodontics, Sree Balaji Dental College and Hospital, The calcium ions formed on dissociation is said to
Bharath Institute of Higher Education and Research, activate the calcium dependent adenosine triphosphate
Narayanapuram , Pallikaranai,Chennai -600100. reaction in remineralization. But this calcium in calcium
Tamilnadu, India. Phone number: 8008684449
hydroxide is not present in the calcific barrier but the
E-mail: sahithi.rdy@gmail.com
calcium derived from blood stream is incorporated into
1204 Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4

it. The hydroxyl ions provide alkaline pH that prevents property (12). The action of hydroxyl ions on bacterial
dissolution of mineral content in dentin by inactivating cell cause lipid peroxidation of phospholipids, thereby
lactic acid and also activates alkaline phosphatases damage the bacterial cytoplasmic membrane. Hydroxyl
enzyme. Calcium hydroxide shows healing by causing ions also cause damage to the DNA inhibiting its
necrosis and irritation of pulpal tissue and initiating replication. Its high pH causes breakdown of protein
the inflammatory pathway. It constitutes following ionic bonds leading to protein denaturation and inhibits
characteristics (10,11) : cellular metabolism.

(i) Zone of obliteration: it is also called as zone of Anti-inflammatory action:

superficial debris. It can be visualized within an hour
The high pH inhibits adhesion of macrophages
of contact due to the chemical injury caused by high
and decreases the level of matrix metalloproteinase-8
pH of calcium hydroxide. This zone contains dentinal
(MMP-8). This inhibits the inflammatory reaction and
fragments, debris, blood clot and blood pigments formed
exudation and also improves tissue circulation (12).
due to the caustic effect.
APPLICATIONS OF CALCIUM HYDROXIDE
(ii) Zone of coagulation necrosis: it is also called
IN DENTISTRY:
as Stanley’s mummified zone or Schroder’s layer. It
is formed adjacent to the zone of obliteration due to Intracanal Medicament
the weaker chemical reaction. This zone consists of
devitalized pulp tissue without any structural loss. Calcium hydroxide is one of the most commonly
This starts tissue reactions such as vascular changes used intracanal medicament and is also considered the
and inflammatory cell migration. Later a zone of ‘gold standard’. It plays a major role in the disinfection
demarcation is formed differentiating the normal pulp of the root canal when used as an inter appointment
tissue by deposition of protinate globules. dressing. Though it is not a conventional antibacterial
agent, it acts as a bactericidal agent at high ph and
(iii) Dense zone: a modified cell rich zone is formed later as a bacteriostatic agent in root canal space (13).
by proliferation of mesenchymal cells and fibroblasts. It is effective against common endodontic pathogens
The undifferentiated mesenchymal cells in this layer especially E.faecalis (14). It also helps in reduction of
differentiate into preodontoblasts and columnar shaped lipopolysaccharides and endotoxin released from bacteria
odontoblasts. Argyrophillic fibers or the Korff’s (15). But it has a longer duration of action. A minimum
fibers become organized perpendicular to the zone of of 7 day dressing is required to obtain the effectiveness
demarcation. There is tubular formation in collagen of the medicament (16). Duration of calcium hydroxide
matrix forming predentin. medicament has been widely varied ranging from 10
days (Ostravik, 1990), 1 week (Sjogren, 1991), 2 weeks
(iv) Calcification of the bridge: Robinson in 1923
(Reit and Dahlen, 1988) and 4 weeks (Bystrom, 1985)
proposed the alkaline phosphate theory according to
(12)
. The duration is dependent upon the objective of
which the enzyme increases calcium phosphate ion
dressing. When used as a routine antibacterial dressing,
concentration and initiates mineralization. Later matrix
then 7 days is sufficient.
vesicle theory was introduced according to which
extracellular matrix vesicle initiates calcification. But Calcium hydroxide is also used in conjunction
the seedling theory is one of the most accepted one, with other therapeutic agents for additive effects
according to which mineralization mechanism occurs such as chlorhexidine and potassium iodide. Calcium
after initial seeding of collagenous tissue along with hydroxide was initially mixed with sterilized dentine
nucleation of hydroxyl appetite crystals (7). chips and alkaline blood salts by Flohr (1936). Later
calcium hydroxide, methylcresilate and camphorated
Antibacterial action:
parachlorophenol mixture was prepared by Blanc-
The highly oxidant free radicals released from Benon (1967) as an intra canal medicament. Calcium
calcium hydroxide is the main reason for its antimicrobial hydroxide in 1% aqueous solution of parachlorophenol
 Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4 1205

was formulated by Martins et al. (1979) and Multical, (9).

mineralization potential
a mixure of calcium hydroxide (34%), barium sulphate
Cavity liner
(15%) and chloro-timonol (51%) was made by Webber
(1983). But, one of the most widely used is a combination Calcium hydroxide in fast setting formulations are
of calcium hydroxide and Chlorhexidine. Calcium used as cavity liner due to its therapeutic properties
hydroxide combined with 0.5% CHX has been shown to and additionally can resist condensation forces even
eliminate C.albicans & E.faecalis effectively. But it was in thinner sections (19) and also are compatible with
observed that the mixture of CHX and Ca(OH)2 may not light cure resin restorative materials (20). The calcium
provide a sufficient reservoir of free CHX molecules. hydroxide liner has an accelerated setting in presence of
The antimicrobial efficiency of this mixture was as moisture. But the many drawbacks are heat generation
effective as CHX alone on E.faecalis. CHX precipitates during setting due to exothermic reaction and dissolution
when mixed with calcium hydroxide and due to the of material over time (7).
deprotonation of the biguanide at pH > 8.0(9).
Apexification
Pulp Capping Agent
Granath in 1959 first reported apical closure with
Calcium hydroxide has been used as pulp capping calcium hydroxide. In non vital tooth closure of apex
agent for long time. Histologically calcium hydroxide after calcium hydroxide dressing occurs as a cementum-
causes coagulative necrosis followed by mineral like tissue across the root-end. This process is not true
deposition leading to complete dentinal bridging. apex formation, but rather formation of only a calcific
Adjacent to the area of necrosis inflammatory mediators barrier which is similar to cementum. Because calcium
are released which help in mineral deposition and further hydroxide materials are soluble, there is a need to replace
healing. A Tubular Dentin Bridge which represents the the dressing at 3-month intervals till the closure of apex
mature type of dentinal bridge with well formed organic occurs which is ussualy after 6-24 months (21). The hard
matrix and evident calcification is observed. Due to this tissue barrier formed with the conventional calcium
property calcium hydroxide is used as direct and indirect hydroxide apexification technique has been described
pulp capping agent since long time in dentistry. But as “swiss-cheese-like”, because of the many soft tissue
later it was observed that the barrier of osteodentine, inclusions, representing a very permeable and weak
which is produced, is often incomplete and results barrier and more attention is needed when filling the
in the formation of the so-called tunnel defects. They root canal with gutta-percha and sealer. Hence calcium
occur due to vascular inclusions and such defects may hydroxide use for apexification is no longer advocated.
allow bacterial re-infection hence is being replaced by
bioceramic materials especially for direct pulp capping Pulpotomy
procedures.
Before the introduction of cvek’s pulpotomy
Endodontic Sealer completer removal of coronal pulp is done and pulp
chambered is filled with calcium hydroxide. Later
Tight seal of root canal system is one of the main for minimal pulpotomy procedures a hard setting
objectives of root canal therapy. But the property formulation of calcium hydroxide are used (7). Healing of
of calcium hydroxide to dissociate into ions causes the amputated pulp occurs due to release of inflammatory
dissolution of sealer leading to formation of voids mediators. After the advent of materials such as MTA
during or after obturation (17). Though it’s solubility and Biodentine the use of calcium hydroxide for this
remains a matter of concern, the apical leakage cannot be purpose has steadily declined.
attributed to its solubility, as there are studies reporting
the potential for the formation of calcific repair tissues Canals with exudate
and even closure of apex by mineralized tissue in the
Obturation of root canal with continuous clear or
vicinity of the materials (18). And hence, it has been
reddish exudates is contraindicated. Hence, for such teeth
incorporated in many commercially available sealers
use of calcium hydroxide dressing is recommended. It
like sealapex, apexit due to its antibacterial property and
1206 Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4

is placed in canal after complete drying of canal with sulphate such as difficulty in resorption and initiation
absorbent paper points. It is necessary to dress with a of inflammatory mediators which was observed in
stiffer paste for a period of at least 14 days. If it is found few studies (23). Extrusion is not dangerous except if it
that a substantial amount of the paste has been resorbed reached the inferior alveolar canal where it can cause
more frequent dressings with stiffer pastes may be paresthesia, it doesnot compromise perapical healing
(24). But use of pure calcium hydroxide is preferred for
required. Dressing and irrigation are continued until the
exudate is stemmed. The high pH of calcium hydroxide this purpose (25).
neutralizes acidic pH of periapical lesion and favors
REMOVAL FROM ROOT CANAL:
bone formation (22).
Removal of Calcium hydroxide is difficult especially
Perforation Management
in curved and narrow canals. Presence of residual paste
Root or furcation perforation is one of the common at apical portion of root canal affects the apical patency
mishaps in root canal therapy. The mineralization during instrumentation and obturation. The retrievability
property of calcium hydroxide favors the sealing of calcium hydroxide mainly depends on the vehicle
of the perforation and improves the prognosis. It used. An oil based mixture is more difficult to remove
stimulates hard tissue formation and when extruded it than powder form calcium hydroxide mixed with
enhances healing of damaged periodontal tissues (22). distilled water. Various methods have been advocated
Use of calcium hydroxide is contraindicated in crestal for removal of the medicament and one of the most
and furcation perforations as this may cause pocket commonly used method is by irrigating the canal with
formation and contamination. Though MTA is the ideal NaOCl & EDTA as advocated by Lambrianidis et al.
root repair material calcium hydroxide is still indicated (2006). Use of 10% citric acid was found to be better
to control infection, stop bleeding and as a temporary than EDTA by Nandini et al (2006). And, Ballal et al
solution when inadequate time is available to perform a (2011) has advocated use of 7 % maleic acid. In addition
permanent repair. to these irrigants, hand filing or rotary instrumentation,
or ultrasonics are effective for removal (21).
Root Resorption
SHORT COMINGS OF CALCIUM
The high pH, mineralizing potential of calcium
HYDROXIDE:
hydroxide aids in down regulating osteoclastic activity
and stimulating hard tissue formation. It also facilitates Varying alkaline potential of different
periodontal tissue healing in the high pH environment. formulation is a cause of concern as there is no
Hence in cases of resorption, pulp is extirpated and standardization to evaluate the effectiveness. Low
lacunae are filled with calcium hydroxide and left for 3 solubility and diffusability of calcium hydroxide makes
month interval and later removed and obturated. But use it difficult to gain a rapid increase in pH necessary to
MTA is a more definite method of treating (9). kill bacteria within tubules and anatomical variations
thereby showing no effect on dense biofilms of bacteria
Periapical lesion
protected deeper inside tubules. The high alkalinity was
Intentional extrusion of calcium hydroxide beyond found to negatively influence the mechanical properties
the root canal into the periradicular tissue is advocated of dentin. It is said to reduce the fracture resistance of
by few authors in case of large periapical lesions as radicular dentine and worsen the prognosis of tooth (23).
calcium hydroxide enhances the healing and osseous This can be explained by the Andresen’s theory where,
repair. As calcium hydroxide is mixed with barium the proteolytic action could weaken the tooth up to 50%
sulphate in dental compositions the side effects of barium in one year (22).
 Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4 1207
Table 1: Types of vehicles used for calcium hydroxide and their applications

Vehicle Ion release Solubility Applications Examples

Distilled water
Aqueous rapid high Direct and indirect pulp capping, pulpotomy
Ringer’s solution

Slower, for Apexification, Glycerine

Viscous extended Medium
periods Inter appointment Intra canal medicament Polyethylene glycol

Slower, for Perforation repair Olive oil

Oily extended Low
periods External root resorption Silicone oil

Figure 1: Mechanism of action of calcium hydroxide

Figure 2: Applications of calcium hydroxide

1208 Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4

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