IRUCAA@TDC : Effectiveness of Calvital?, a Calcium Hydroxide Formulation, on Persistent Apical Periodontitis Caused by Over-enlargement of Apical Foramen
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(2) 209. Bull Tokyo Dent Coll (2011) 52(4): 209–213. Case Report. Effectiveness of Calvital®, a Calcium Hydroxide Formulation, on Persistent Apical Periodontitis Caused by Over-enlargement of Apical Foramen Masahiro Furusawa, Hiroki Hayakawa and Atsushi Ida Department of Clinical Oral Health Science, Tokyo Dental College, 2-9-18 Misaki-cho, Chiyoda-ku, Tokyo 101-0061, Japan. Received 17 January, 2011/Accepted for publication 16 September, 2011. Abstract This study aimed to evaluate the effectiveness of Calvital®, which is a calcium hydroxide formulation, on persistent apical periodontitis caused by over-enlargement of the apical foramen. The study included patients referred to the Department of General Dentistry at Tokyo Dental College Suidobashi Hospital on a diagnosis of persistent apical periodontitis at an external dental clinic. Of them, 20 showing considerable enlargement of the apical foramina were included in the study. Complete disappearance of symptoms was observed in all patients after intracanal application of Calvital®. We believe that this was due to effective wound-healing brought about the strong alkaline nature of this formulation. We regard Calvital ® as a highly effective agent for root canal treatment of teeth with persistent apical periodontitis. Key words:. Persistent apical periodontitis—Over-enlargement — Calcium hydroxide formulation—Root canal treatment— Clinical symptoms. Introduction In daily practice, conventional root canal treatment of teeth with chronic suppurative apical periodontitis is likely to result in cure in the vast majority of cases. However, in many cases, symptoms such as occlusal pain and pain on percussion can be persistent following treatment, leading to a diagnosis of persistent apical periodontitis. Persistent apical periodontitis is often considered to be iatrogenic, that is, occurring as a result of overinstrumentation, with enlargement of the. apical foramen to a greater size than necessary, or perforation of the pulp floor or root canal wall. In such cases, the cause of the symptoms is clear. Although symptoms can be monitored, root canal treatment with conventional intracanal medicaments tends to be ineffective. Consequently, practitioners are frequently at a loss in prescribing appropriate treatment methods, and sometimes resort to extraction. The adverse effects of formaldehyde-based treatment agents has been identified in recent years, and it would be no exaggeration to say that calcium. 209.
(3) 210. Furusawa M et al.. A. B. A. B. Fig. 1 A: Preoperative diagnostic radiograph of tooth #80 with an open apex and small periapical lesion. B: Recall radiograph at 3 months after root canal filling.. Fig. 2 A: Preoperative diagnostic radiograph of tooth #45 with an open apex and small periapical lesion. B: Recall radiograph at 6 months after retreatment.. hydroxide formulations are now considered the most effective root canal treatment agents. The Calvital ® formula was developed 50 years ago, and has undergone a number of improvements since then. To date, many studies on Calvital ® have been performed at our college2,9–11,13), and as a result of its excellent ability to induce the formation of hard tissue, it is currently used in various endodontic procedures, including vital pulpotomy, direct pulp capping, and root canal treatment. A vital feature of this formulation is that it contains a large proportion of calcium hydroxide and maintains its strongly alkaline pH over a prolonged period in triturated form10). Calcium hydroxide formulations have been used for various dental procedures, including those mentioned above, for almost a century. Its use as an intracanal medicament during root canal treatment has been associated with periradicular healing1,4,12,14–17). This has been promoted by a series of articles documenting the antibacterial efficacy of calcium hydroxide in infected root canals3,12). Although Calvital ® was first developed approximately 50 years ago, it is still widely used as a modified formulation in various endodontic procedures. However, many aspects of its clinical effectiveness remain unclear. In this study, we investigated the effectiveness of Calvital® as an intracanal medicament during the root canal treatment of 20 patients with persistent apical periodontitis and excessively enlarged apical foramina.. Methods The study included 20 patients referred to the Department of General Dentistry at Tokyo Dental College Suidobashi Hospital on a diagnosis of persistent apical periodontitis at an external dental clinic. They had been initially treated with conventional root canal treatment agents and irrigants, as well as with compounds like such as formalin guaiacol, and guaiacol-parachlorophenol (Methocol™). In all patients, the apical foramen showed enlargement to greater than #45. Persistent apical periodontitis was diagnosed at our hospital and Calvital ® applied as an intracanal medicament at intervals ranging from 2 weeks to 1 month. Postsurgical course was observed. Triturated Calvital ® was either transferred to the root canal and applied with a spiral filler fitted to a contra-angle hand piece, or was condensed in increments in the canal using a plugger under microscopy. The number of times that the infected root canal had been treated with conventional agents and irrigants at private clinics following pulp extirpation varied widely. Such treatment appears to have been applied by the referring dentist over a period varying from around 1 month to 7 years, although we can not say for certain as this data was unavailable in many cases. However, in many cases, this information was unknown due to insufficient data from the referring dentist. In each case, therefore, the diagnosis of persistent apical periodontitis was based.
(4) 211. Calvital® for Persistent Apical Periodontitis. Table 1 Persistent cases caused by over-enlargement of the apical foramen Case No.. Patient age (y). Patient sex. Teeth No.. Apical foramen size. The Number of RCT. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20. 48 30 45 26 33 31 29 55 59 44 37 55 41 48 37 34 30 38 30 31. F M F M F F F F F F F F M F M F F F M F. 46 26 15 17 36 25 26 14 25 21 46 13 17 47 47 27 33 36 37 47. #100 (P) #80 (P) #55 #60 (P) #60 (P) #60 #55 (D) #55 #80 #45 #80 (M,D) #80 #55 (P) #45 (D) #60 (P) #45 (D) #45 #55 (D) #50 (P) #60 (P). 3 2 5 5 3 4 5 9 8 5 7 6 4 5 5 4 4 5 4 4. Remarks. Fig. 1. Fig. 2. P: Palatal canal, M: Mesial canal, D: Distal canal.. solely on the opinion of a general dentist. In a previous study, we described that an apical foramen with a major axis over 350 m (due to pathologic absorption or manipulation of the apical foramen with an instrument larger than #35) may cause lesions requiring intervention with surgical endodontics6). The standard used in this study was based on the results of that research. This study was approved by the Ethics Committee of Tokyo Dental College (approval no. 288).. Results 1. Clinical observations Symptoms of persistent apical periodontitis disappeared in all 20 patients (Table 1). The average number of root canal treatments using Calvital ® was 4.85. After alleviation of symptoms using Calvital ®, root canals were filled by the lateral condensation method in all patients using Finapec ® APC, a hydroxyapatite root canal sealer. There was no re-. infection in any patient, and all of them currently have a good prognosis. 2. Radiographic observations Complete healing was observed in all 20 teeth prior to insertion of the root canal filling.. Discussion In general, symptoms persist in cases of persistent apical periodontitis, even after conventional treatment of the infected root canal, and these symptoms are not alleviated by treatment. Regrettably, numerous cases of persistent apical periodontitis are iatrogenic, either as a result of unintended perforation during root canal treatment or over-enlargement of the apical foramen owing to clinician errors. With respect to over-enlargement of the apical foramen, we have previously reported that persistent apical periodontitis occurs more frequently if the apical foramen is.
(5) 212. Furusawa M et al.. enlarged to greater than #356). The apical foramen was enlarged to greater than #40 in all of the patients in the present study, and this excessive enlargement was regarded as the cause of the seemingly intractable nature of the disorder. In such patients, granulation tissue intrudes into the canal from the overenlarged apical foramen, causing hemorrhage and rendering the root canal treatment ineffective. Under these circumstances, the use of conventional intracanal medicaments does not bring about healing of the wound area and the number of patient visits is extended in vain, leading to the mistaken belief that this disorder is intractable. In all of the patients in this study, Calvital ® came into direct contact with the soft tissues in the apical region. In the vast majority of patients, no hemorrhage was observed under microscopy after the second application of this agent; moreover, the apical foramen of straight root canals could be clearly seen. This means that the wound was healing swiftly, and that Calvital ® was exerting an effective action on the wound in the initial stages of treatment. When Calvital ® is used on soft tissues such as the wound surfaces of dental pulp, it forms a necrotic layer, presumably due to the agent’s strong alkalinity. Although opinions concerning the significance of this necrotic layer vary, the use of Calvital ® on dental pulp tissue reportedly contributes to hard tissue formation directly beneath this layer8), and some believe that this layer also forms a defensive wall against treatment agents5). It has been reported that this necrotic layer is observed in dental pulp tissue three days after Calvital® application, and that its expansion halts when a hard tissue substrate has been formed after around 5 days9). The agent also causes surface necrosis when used in areas of perforation, initiating wound healing and subsequent progress toward recovery. A study in which Calvital ® was used at the site of perforation of the pulp floor in dogs11) also revealed initiation of healing after a short period, with this tendency increasing over a longer period, although hard tissue formation was not induced.. In addition to calcium hydroxide, Calvital ® also includes iodoform, which promotes the proliferation of granulation tissue and exerts an antiseptic effect7), sulfathiazole, which is an antibiotic, and T-cain, which is an analgesic. These ingredients have a synergistic effect, adding to the antibacterial effect of calcium hydroxide7) in alleviating clinical symptoms. From these findings, we conclude that Calvital ® has the specific wound-healing effect of removing inflammatory granulation tissue and alleviating clinical symptoms.. Conclusion In this study, we recruited 20 patients with an over-enlarged apical foramen from among patients in whom a diagnosis of persistent apical periodontitis had been made by general dentists in private practices and who had been referred to the Department of General Dentistry at Tokyo Dental College Suidobashi Hospital for further treatment. In these patients, we applied Calvital®, a calcium hydroxide formulation, as an intracanal medicament and observed changes in symptoms. Symptoms disappeared in all patients. This was attributed to the effectiveness of Calvital ® and its wound-healing action derived from its strongly alkaline nature. We therefore regard Calvital ® as a highly useful agent in the endodontic treatment of teeth with persistent apical periodontitis caused by over-enlargement of the apical foramen.. References 1) Alacam T, Gorgul G, Omurlu H (1990) Evaluation of diagnostic radiopaque contrast materials used with calcium hydroxide. J Endod 16:365–368. 2) Asai Y, Ito A, Kondo Y, Ishikawa T, Narita M, Matsui K, Machida Y, Yakushiji M, Kinumatsu T (1981) Clinico-pathological investigations on the healing effects of modified calvital to the exposed human pulp wounds. Jpn J Conserv Dent 24:271–281. (in Japanese).
(6) Calvital® for Persistent Apical Periodontitis. 3) Bystrom A, Claesson R, Sundqvist G (1985) The antibacterial effect of camphorated paramonochlorophenol, camphorated phenol and calcium hydroxide in the treatment of infected root canals. Endod Dent Traumatol 1:170–175. 4) De Moor RJ, De Witte AM (2002) Periapical lesions accidentally filled with calcium hydroxide. Int Endod J 35:946–958. 5) Eda S (1961) Histochemical analysis on the mechanism of dentin formation in dog’s pulp. Shikwa Gakuho 61:339–382. (in Japanese) 6) Furusawa M, Asai Y (2002) SEM observations of resected root canal ends following apicoectomy. Bull Tokyo Dent Coll 43:7–12. 7) Kamran E, Frank C (1993) Effect of calcium hydroxide on bacterial lipolysaccharide. J Endod 19:76–78. 8) Kishi K (1983) Clinico-pathological studies on endodontic medicaments, with special reference to agents containing iodoform. Shikwa Gakuho 83:349–398. (in Japanese) 9) Kobayashi K, Watanabe U, Yoshida T, Ariizumi Y, Nakagawa K, Asai Y (1992) Ultrastructual studies of pulp wounds healing with calcium hydroxide preparation calvital on human pulp. Jpn J Conserv Dent 35:207–218. (in Japanese) 10) Kondo Y (1981) Clinico-pathological studies on the protective (healing) effects of human pulp wounds with hard set calcium hydroxide preparations. Shikwa Gakuho 81:1755–1817. (in Japanese) 11) Morinaga K (1985) Histo-pathological studies of periodontal tissue reactions to perforations in the furcations of dog teeth treated with various materials and agents. Shikwa Gakuho 85:. 213. 413–451. (in Japanese) 12) Orstavik D, Kerekes K, Molven O (1991) Effects of extensive apical reaming and calcium hydroxide dressing on bacterial infection during treatment of apical periodontitis; a pilot study. Int Endod J 24:1–7. 13) Sekine N, Saijo Y, Ishikawa T, Imanishi T, Asai Y, Narita M (1963) A clinico-pathological study on vital pulpotomy with “Calvital”. Shikwa Gakuho 63:463–473. (in Japanese) 14) Siqueira JF Jr, Lopes HP (1999) Mechanisms of antimicrobial activity of calcium hydroxide; a critical review. Int Endod J 32:361–369. 15) Sjogren U, Figdor D, Spangberg I, Sundqvist G (1991) The antimicrobial effect of calcium hydroxide as a short-term intracanal dressing. Int Endod J 24:119–125. 16) Tronstad I, Andoreasen JO, Hasselgreen G, Kristerson I, Riis I (1981) pH changes in dental tissue after root canal filling with calcium hydroxide. J Endod 7:17–21. 17) Vernieks AA, Messer LB (1978) Calcium hydroxide induced healing of periapical leasions: a study of 78 non-vital teeth. J Br Endod Soc 11:61–69. Reprint requests to: Dr. Masahiro Furusawa Department of Clinical Oral Health Science, Tokyo Dental College, 2-9-18 Misaki-cho, Chiyoda-ku, Tokyo 101-0061, Japan Tel: +81-3-3262-3421 Fax: +81-3-3262-3420 E-mail: [email protected].
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