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Authors:Dr. Meenakshi Bodh,Dr. Ritu Namdev,Dr. Samir Dutta.

ABSTRACT:
Calcium Hydroxide  is one of the most important medicaments used in the treatment of pulp conditions and apical periodontitis. It is recommended as intra-canal medicament because of its antibacterial properties, tissue dissolving ability, inhibition of tooth resorption and indication of tissue repair by hard tissue formation This is a case report of a 9 year old male with large periapical radiolucency where conventional endodontic therapy in combination with calcium hydroxide as an intracanal medicament contributed effectively in healing of periapical lesions.

INTRODUCTION
Pulpal tissue necrosis transforms the pulpal chamber into an unprotected environment which is susceptible to colonization by numerous microorganisms that inhabit the oral cavity1. The contamination of the pulp can lead to the formation of periapical lesions as a result of immunologic host response to bacteria or its products. Endotoxin, a component of the cellwall of gram negative bacteria, plays a fundamental role in the genesis and maintenance of periapical lesions because of the induction of inflammation and bone resorption2. Such periapical pathologies can be either managed conservatively or non Conservatively but the former approach is always weighed over non conservative approach. Extensive research in the field of dentistry in aspect of new techniques, new materials and technologies has made this approach feasible. Various intracanal medicaments have been used till date but only Ca(oh)2 has the property of inactivating  endotoxin, invitro and invivo  and appears currently the only feasible clinically effective medicament for inactivation of endotoxin3.

Case report A 9 year old boy reported complaining of pain and pus discharge from upper left anterior region from past 4 days. Patients parents gave history of trauma 6 months back due to fall from bicycle which resulted in broken teeth for which he did not seek any dental treatment. Clinical examination revealed periapical abscess in relation to upper left lateral incisor (fig 1). Acc to Ellis and Daveys classification it was a class IV and class II fracture of 22 and 11 respectively. On clinical evaluation, the periradicular region of 22 was tender on percussion. An IOPA revealed a periapical lesion with its epicenter being the apical foramen of tooth 22 approximately 4 x 6 mm (fig 2).  The tooth was non responsive to vitality tests including cold test and electric pulp tests. It was decided to go for conservative manangemnt of   the periapical pathology considering the size of the lesion and age of the patient.
On a subsequent visit, after local anesthesia with 2% lidocaine containing epinephrine 1:80000, root canal therapy was started. Access cavity preparation and biomechanical preparation was done using hand instrumentation till no.50 with simultaneous 5.25% NaOCL irrigation. Since there was purulent discharge from the canal, Ca (OH) 2 mixed with saline was placed as intra canal medicament. The opacity and length of the plug was confirmed with a periapical radiograph and it was sealed with glass ionomer cement. The patient was put on regular follow-up plan. By the end of first week all symptoms faded away; 3 months of postoperative radiograph revealed the initiation of bone replacement process starting from periphery of the lesion, as the sign of healing and was progressed to 6 month when complete bone healing had occurred . The tooth was then obturated with gutta percha points and zinc oxide eugenol sealer using lateral condensation technique followed by rehabilitation with a PFM crown (fig 3, 4). The patient is kept on regular follow ups since last two year and is symptomless both clinically and radiographically (figure 5).

     
Figure 1: preoperative photograph showing fractured 22 with abscess formation. Figure 2:  radiograph showing periapical radiolucency wrt 22. Figure 3: A postoperative radiograph showing complete elimination of periapical radiolucency at 6 months follow up {PLEASE   OBSERVE THE PERIODONTAL SPACE  AROUND THE TREATED TOOTH IN THE RADIOGRAPH  ( uploading a recent photograph of radiograph at follow up of 2 year for same(figure 5)}
   
Figure 4: a postoperative picture showing complete rehabilitation of 22. Figure 5: radiograph at follow up of 2 years.


Discussion Currently one of the concerns in endodontics is the treatment of teeth with periapical pathosis because of persistence of post-treatment disease in such cases since these areas cannot be easily assessed both biologically and mechanically. Endotoxin is released during multiplication or bacterial death causing a series of biological effects, which lead to an inflammatory reaction leading to the formation of periapical granuloma or periapical cyst .It should be pointed out with emphasis that based on radiographs , apical lesions cannot be differentially diagnosed into cystic and noncystic lesions . In 1998, Nair made it clear that there are two type of cysts. He pointed out two distinct categories of radicular cysts, namely those containing cavities completely enclosed in  epithelium lining(true cysts) and those containing  epithelium lined cavities that are open to the root canals(bay/pocket cysts)4,5. It  is stated that bay cysts tend to response to nonsurgical endodontic intervention , while those few cysts categorized as true , have to be surgically removed. Strong evidences suggest that subsequent to removal of etiologic factors, immunological system contributes to the breakdown of epithelial cysts linings. Majority of apical lesions whether cysts or granuloma heal without surgery; only those few lesions that may be true cysts in histology need surgery. Nonsurgical approach in  cases of apical periodontitis is the first  approach , based on the current concept of treatment option and in case of persistent symptoms the surgical removal of lesion is considered the next step.6 . It has been demonstrated that treatment with calcium hydroxide as an interim dressing in the presence of large and chronic periapical lesions can create an environment more favourable to healing and encourage osseous repair7.Periapical tissues have rich blood supply, lymphatic drainage and abundant undifferentiated mesenchymal cells and therefore good potential for healing .
Calcium hydroxide is a white odourless powder with the formula Ca(OH)2, and a molecular weight of 74.08. It has low solubility in water (about 1.2 g Lÿ1 at 258C), which decreases as the temperature rises; it has a high pH (about 12.5±12.8) and is insoluble in alcohol. This low solubility is, in turn, a good clinical characteristic because a long period is necessary before it becomes soluble in tissue fluids when in direct contact with vital tissues. The antimicrobial activity of Ca(OH)2 is related to the release of hydroxal ions in an aqueous environment . Hydroxal ions are highly oxidant  free radical that show extreme reactivity with several biomolecules . The lethal effects of hydroxal ions on bacterial cells are probably due to the following mechanism8 : damage to the bacterial cytoplasmic membrane; protein dentaturation and damage to DNA. The high Ph of calcium hydroxide alters the integrity of cytoplasmic membrane through chemical injury to the organic components and transport of nutrients or by means of destruction of  phospholipids or unsaturated fatty acid of the cytoplasnmic membrane observed in the peroxidation process, which is a saponification reaction. Although scientific evidence suggests that these three mechanisms may occur, it is difficult to establish in chronological sense, which is the main mechanism involved in the death of bacterial cells after exposure to a strong base. It has been demonstrated by various invivo and invitro studies that treatment with calcium hydroxide as an interim dressing in the presence of large and chronic periapical lesions can create an environment more favourable to healing  and encourage osseous repair9. In our case also with the use of calcium hydroxide as an intracanal medicament a large periapical radiolucency was resolved within a period of 3 months.. Here, conventional endodontic therapy in combination with calcium hydroxide as an intracanal medicament contributed effectively in healing of periapical lesions. But, it would be necessary to observe and monitor the periapical lesions over a period of time following the non-surgical approach before the surgery is contemplated.

Conclusion
In cases of a periapical lesion of a nonvital teeth, nonsurgical orthograde endodontic treatment is suggested. However in some cases , despite root canal treatment ,  apical periodontitis persists, and the endodontic treatment is considered a failure which necessaciates  apical surgery.

References
1.Moller AJ, Fabricius L, Dahlιn G, Ohman AE, Heyden G. Influence on periapical tissues of indigenous oral bacteria and necrotic pulp tissue in monkeys. Scand J Dent Res 1981; 89:475-8
2. Ando N, Hoshino E. Predominant obligate anaerobes invading the deep layers of root canal dentin. International Endodontic Journal 1990;23:20-7.
3. Almyroudi A, Mackenzie D, McHugh S, Saunders WP. The effectiveness of  various disinfectants used as endodontic intracanal medications:in vitro study. Journal of Endodontics; 28:163-7.
4. Nair PN. New perspectives on radicular cysts: Do they heal? Int Endod J 1998;31:155-60.
5. Nair PN, Sjogren U, Figdor D, Sundqvist G. Persistent periapical radiolucenciesof root filled human teeth, failed endodontic treatments and periapical scars. Oral Surg Med Oral Pathol Oral Radiol Endod 1999;87:617-27
6. Nair PN, Sundqvist G, Sjogren U. Experimental evidence supports the abscess theory of development of radicular cysts . Oral Surg Med Oral Pathol Oral Radiol Endod 2008;106:294-303.
7. U. Lohbauer, G. Gambarini, J. Ebert, W. Dasch, A. Petschelt : International Endodontic Journal 2005; 38: 683- 689
8. J.  F. Siqueira, H. P. Lopes. Mechanisms of antimicrobial activity of calcium hydroxide: a cri- tical review, Int Endod J, 32 (1999) 361−9
9.  Cvek M, Nord CE, Hollender L .Antimicrobia leffect of root canal debridement in teeth with immature root : a clinical and microbiologi cstudy.OdontolRevy1976;27:1–10

 

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