- Email: [email protected]
A Technique for Placement of Calcium Hydroxide in the Root Canal System
C L IN IC A L
REPORTS
A technique for placement of calcium hydroxide in the root canal system Raymond T. Webber, DDS, M S Ken A. Schwiebert, D M D Gerald M. Cathey, DDS, M SD The rationale and technique that promote a predictable clinical result in calcium hydroxide treatm ent of open apexes are described; biologic and physiologic advantages are discussed.
c
alcium hydroxide as an intracanal medicament has received renewed in terest in recent years. Its application is by no means new and its effectiveness relates to its alkalinity. As early as 1883, Hunter1 reported at a Missouri Dental Association meeting the use of a mixture of English sparrow drop pings and sorghum molasses for pulp capping with 98% success. He did not, of course, realize that the high am m onium hydroxide content of the sparrow droppings was probably the key to his “cure.” In 1930, Hermann2 introduced the use of calcium hydrox ide (Calxyl) for the treatment of vital pulps. He demonstrated the ability of the pulp to build a dentinal bridge ad jacent to calcium hydroxide as an ap parent healing response. The induc tion technique was first offered in the United States in 1964 with separate presentations by Kaiser3 and Frank4 at the annual meeting of the American Association of Endodontists. It was presented in the literature in 1966s and popularized as the “Frank technique. ” Since then, the literature has had many articles on technique and case reports of successes and failures, which has led to some confusion about the proper application of calcium hydroxide. This article presents a procedure for calcium hydroxide therapy in nonvital, permanent teeth with open apexes. This technique incorporates princi ples that enhance apexification in both the adults and children. The emphasis is on adhering to the basic endodontic principles, which offer predictable success.
Clinical experience has shown that the apex must be completely within osseous tissue or osseous-forming tis sue, that is, within the confines of the cortical plates. In some instances, the apex may penetrate the cortical plate, and this possibility should be consid ered when a tooth does not respond to calcium hydroxide therapy. When this occurs, beveling the apex within the cortical plate and placement of a re verse amalgam filling is the preferred technique.
Procedure A thorough pretreatment evaluation and examination are performed. After isolation by rubber dam, endodontic access that will allow complete de bridement of the root canal system is done (Fig 1). An in itia l treatment length to the radiographic apex is de termined and recorded for subsequent appointments (Fig 2). The canals are prepared with thorough instrumenta tion accompanied by copious canal ir rigation. Torneck and others6and Hol land and others7 emphasize that care ful debridement of the root canal sys tem is a primary factor in ensuring api cal closure. After instrumentation, the canals are dried with premeasured paper points, preferably the largest size the canal will accept, for complete drying without injury to the apical tis sues (Fig 3). CALCIU M H Y D R O X ID E PASTE. Calcium hydroxide (USP) is desired, as contam inants in the powder may adversely af fect healing. We prefer the powder over commercial preparations because it can be mixed to variable consisten cies for ease of condensation in the root canal system. The liquid vehicle should be compatible with tissue and nonirritating to the periapical tissues, if extruded. Sterile water, isotonic saline solution, or dental anesthetic (preferably without a vasoconstrictor)
are suggested. A sterile glass slab and a spatula with no residual cements are neces sary to avoid contamination of the medicament. Barium sulfate powder is added to the calcium hydroxide if opacity is desired; a ratio of 1 part barium sulfate to 8 parts of calcium hydroxide is recommended. The powder(s) and liquid should be mixed to a very dry, thick consistency, compara ble to that of a dry resin. The mix should possess enough body to allow vertical condensation while m inim iz ing occlusal reverse flow. CON DENSATION. An amalgam carrier is suggested for introducing the cal cium hydroxide paste into the canal. A carrier with a plastic or Teflon sleeve is recommended, as the calcium hydrox ide can corrode metals and contamin ate the paste. Am algam remnants should not be present in the barrel be fore use. Various diameters of en dodontic pluggers are needed for ver tical condensation to ensure a dense filling. The pluggers are prefitted for the correct size and length. First, a plugger should be selected that nearly occludes the canal at a distance of 2 to 3 mm short of the radiographic apex and yet does not bind against the den tinal walls (Fig 4). The mix should be introduced in small increments (Fig 5) and vertically condensed with the pluggers (Fig 6), gradually increasing the sizes as the canal is filled (Fig 7). As a precaution against possible root fracture, the pluggers should not bind against the canal walls. TEM PO RA RY OCCLUSAL RE ST O R A
It is suggested that Intermediate Restorative Materials or zinc oxideeugenol be used as a temporary filling unless a semipermanent tooth colored restorative material or amalgam (in posterior teeth) is needed for crown buildup or reinforcement. Four or five millimeters’ thickness is required for TION.
JADA, Vol. 103, September 1981 ■ 417
V , ZW&SïtJ »1
Fig 5
Fig 6
Fig 7
Fig 8
Fig 1 ■ Left, adequate canal debridement cannot be accomplished until cingulum dentin is removed; right, removal of cingulum dentin allows instrumentation along lingual canal wall. Fig 2 ■ Largest endodontic instrument canal will accept is placed to radiographix apex for initial treatment length. Fig 3 ■ Premeasured, inverted, extra-coarse paper (absorbent) point is used to dry canal. Fig 4 ■ Largest endodontic plugger canal will accept is fitted 2 to 3 mm short of initial treatment length. Fig 5 ■ Thick calcium hydroxide paste can be placed in canal with amalgam carrier. Fig 6 ■ Small increments of calcium hydrox ide are condensed vertically with prefitted pluggers. Fig 7 ■ Larger prefitted pluggers are used as canal is sequentially obtu rated. Fig 8 ■ After initial debridement appointment, new working length is approximately 1 mm short of radiographic apex.
the temporary filling to allow adequate sealing.8 Cavit is not an acceptable temporary filling, as it lacks wear re sistance in the long intervals between treatment. If there is dilution or con tamination of the paste, with con sequent exposure of the healing tis sues to bacteria and their toxins, there may be exacerbation. For a more pre dictable result, the calcium hydroxide should be changed routinely at the first six-week observation visit. In some instances, the paste may need to be changed earlier. H o llan d and others9 had better results with a paste RECALL PROCEDURES.
418 ■ JADA, Vol. 103, September 1981
change. The paste should be removed with an endodontic instrument ap proximately half the diameter (size no. 40 to no. 70) of the canal. A reaming motion is needed to penetrate and dis lodge the dry paste, which is sub sequently lavaged with copious irriga tion of sterile water or saline solution. The instrumentation should recapitu late the previous final instrument size for removal of all the old paste. To pre vent injury to the healing apical tis sues, the calcium hydroxide should be removed to a level approximately 1 mm less than the previous working length (Fig 8). This w ill be the new working length at future appoint
ments. When drying the canal, the largest size paper point that the canal w ill accept at the new working length should be used. A new calcium hydroxide paste is vertically condensed, taking care not to exceed the new working length with the second paste filling. The bridging hard tissue formation in the apical 1 mm is desired. As a general rule, the patient should be recalled six weeks after placement of the second paste and approximately every two or three months thereafter until apexification is complete. The average interval be tween appointments is a year, but this may vary from six months to two years,
depending primarily on the develop ment of the apex at the time of the ini tial treatment. The placement of calcium hydrox ide paste is not limited to the first and second ap poin tm e nts; the paste should be replaced as often as neces sary. A radiographic observation of the paste in the canal system helps to de termine when the paste needs chang ing at the recall appointments. If there appears to be a dilution of the paste in the canal, shown by increased radiolucency, the calcium hydroxide should be changed. Whether to change the calcium hydroxide is finally de cided when the temporary filling is removed and the paste is probed with an endodontic explorer or file (reamer) to ascertain if it is still dry. If a sinus tract or fistula or other symptomatol ogy develops in the early months of treatment, this is an indication that the • paste needs changing. Removal of the cal cium hydroxide paste is accomplished by alternately irrigating with sterile water or saline solution and in strumentation with a reaming motion, as previously described. The in strumentation should extend only to the calcified barrier. The thickness of the barrier causes the working length normally to be 1 or 2 mm short of the initial treatment length. It is desirable (whenever possible) to enlarge the instrumentation by one or two sizes for removal of calcium hy droxide remnants along the canal walls. However, when the canal en largement is performed, the relative thinness of the dentinal walls of these immature teeth should be considered. Smaller endodontic instruments may be used in removing any calcium hy droxide in the apical few millimeters of the roots with divergent walls. Final irrigations should be performed with copious amounts of sterile water or saline solution and the canal should be dried with paper points. The paper points should not cause any hemor rhage or detect tissue fluids. The final determination of complete apexification and readiness to obturate with gutta-percha is predicated on having met the following criteria: —The tooth must be asymptomatic, with healing of any previous sinus tract or fistula. — Osseous deposition in the periap ical defects, if originally present, FINA L FILLIN G .
Fig 9 ■ Asymptomatic necrotic pulp of the maxillary left central incisor in 20-year-old woman. Immature apex was noted with periapi cal involvement of approximately IV2 cm. Maxil lary right central incisor had asymptomatic cal cified canal system and had been hurt when pa tient fell 12 years earlier. It is suspected that left incisor ceased forming at time of trauma and right central incisor was stimulated to undergo excessive calcification.
should be observed radiographically. —Hard tissue deposition of the apex will be seen frequently. — The calcium hydroxide paste should be dry when tested by probing with an endodontic instrument or ex plorer. — Smaller files used w ith light finger pressure should confirm the calcific deposit at the apex. —Drying the canal system with paper points should not elicit hemor rhage or tissue fluids. Obturation of the root canal system w ith gutta-percha can be accom plished successfully with either of the following techniques: —The warm (vertical) gutta-percha technique (Schilder).10The large canal system and the blunderbuss apex in many of these teeth may indicate that the incremental warm gutta-percha technique is more desirable. —The lateral condensation tech nique. Because many of these canals are irregular and are larger than the largest gutta-percha cone available (no. 140), a customized gutta-percha cone must be fabricated. Ingle and Beveridge11 suggest rolling two or more gutta-percha cones together be tween a cool glass slab and one that is heated, to create the desired size and shape of the master cone. As with all endodontic fillings, it is suggested that the patient be recalled periodically, in six to 12 months, for réévaluation.
Fig 10 ■ Premeasured no. 140 file was intro duced into the canal system for an initial work ing length. File is not binding on canal walls, suggesting very large system.
Report of case A 20-year-old w om an came for treatment of an asy m p to m a tic necrotic p u lp of the maxillary left central incisor. A n im mature apex w ith periapical involvem ent to ap proxim ately IV 2 cm was observed. The m a x illa ry rig h t central inciso r had an asymptomatic calcified canal system and an intact periodontal ligam ent (Fig 9). The maxillary central incisors had a history of trauma related to a fall 12 years earlier. It was suspected that the left central incisor ceased form ing at the time of trauma and the right was stimulated to undergo exces sive calcification. A premeasured no. 140 file was intro duced into the canal system for an initial working length. The file d id not b in d on the canal walls, suggesting a very large system (Fig 10). A t the instrum entation appoint ment, the canal system was obturated w ith calcium hydroxide, b arium sulfate, and sterile water paste, using vertical condensa tion. Because there was lack of periapical resistance, the paste was overextended (Fig
11 ). The first six-week recall exam ination showed that some of the extruded paste was resorbing (Fig 12). The first paste was re moved and a second apexification paste was placed. However, this tim e the paste was confined to the canal system approxi mately 1 m m short of the radiographic apex (Fig 13). Apexification was complete after a year of treatment. The paste was removed and a solid barrier was detected approxi m a te ly 1 to IV 2 m m s h o rt o f th e ra diographic length (Fig 14). After complete removal of the paste, the canal system was obturated w ith gutta-percha, using the ver tical condensation technique. The calcified barrier prevented overextension of the gutta-percha, but d id allow some extrusion of the root canal sealer (Fig 15). The radiograph taken nine months after the gutta-percha was placed suggests re sorption of the sealer and progressive re-
Webber-Schwiebert-Cathey : PLACEMENT OF CALCIUM HYDROXIDE IN ROOT CANAL SYSTEM ■ 419
C L IN IC A L
REPORTS
Fig 11 ■ At instrumentation appointment, canal system was obturated with calcium hydroxide, barium sulfate, and sterile water paste with ver tical condensation. As there was lack of periapi cal resistance, paste was overextended.
Fig 14 ■ Apexification was complete after one year of treatment. Paste was removed, and solid barrier was detected approximately 1 to IV2 mm short of the radiographic length.
sorption of the extruded calcium hydroxide and barium sulfate paste. At the recall, 21 months after the initial appointment, it was found that not only had apexification oc curred, but the root apex had also con tinued to form, along w ith a periodontal ligament. The patient was 22 years old (Fig 16).
S um m ary The goals of apexification technique include physiologic stimulation by the calcium hydroxide for hard tissue de position at the tooth’s apex and promo tion of periapical healing of the 420 ■ JADA, Vol. 103, September 1981
Fig 13 ■ Initial paste was removed and second apexification paste was placed. However, this time, paste was confined to canal system approx imately 1 mm short of radiographic apex.
Fig 15 ■ After complete removal of paste, canal system was then obturated with gutta-percha, using vertical condensation (Schilder) tech nique. Calcified barrier prevented overextension of gutta-percha but did allow some root canal sealer extrusion.
periodontium by the basic endodontic principle of obturating the root canal system. A technique has been de scribed that yields predictable clinical results in attaining these objectives.
Dr. Webber is assistant professor, and Dr. Cathey is professor, department of endodontics, College of Dentistry, University of Florida. Dr. Schwiebert is in private practice in Williston, Fla, and is parttime clinical instructor, department of community dentistry, College of Dentistry, U ni versity of Florida. Address requests for reprints to Dr. Webber, Box J-436, JHMHC, University of Florida, Gainesville, 32601.
Fig 16 ■ Radiograph nine months after gutta percha filling suggests resorption of sealer and progressive resorption of extruded calcium hydroxide-barium sulfate paste. At this 21month recall examination (from the initial ap pointment), not only had apexification occurred, but root apex had also continued to form along with periodontal ligament. Patient was 22 years old at time radiograph was made.
1. Hunter, F.A. Saving pulps. A queer process. Dent Items Int 352, 1883. 2. Herm ann, B.W. D entinobliteration der Wurzelkanale nach der Behandlung mit Kalcium. Zahnarztl Rundschau 39:888, 1930. 3. Kaiser, H.J. Management of wide canals with calcium hydroxide compounds. Twenty-first an nual meeting of the American Association of Endodontists, Washington, DC, April 17, 1964. 4. Frank, A.L. Experimental efforts to effect a closing of the wide open pulpless tooth allowing conservative therapy rather than surgical inter vention. Twenty-first annual meeting of the American Association of Endodontists, Washing
C L IN IC A L
ton, DC, April 19, 1964. 5. Frank, A.L. Therapy for the divergent pulpless tooth by continued apical formation. JADA 72:(l)87-93, 1966. 6. Torneck, C.D.; Smith, J.S.; and Grindall, P. Biologic effects of endodontic procedures on de veloping incisor teeth. Effect of debridement pro cedures and calcium hydroxide-camphorated
parachlorophenol paste in the treatment of exper imentally induced pulp and periapical disease. Oral Surg 35(4):541-554, 1973. 7. Holland, R., and others. Root canal treat ment with calcium hydroxide. Effect of debris and pressure filling. Oral Surg 47:185-188, 1979. 8. Webber, R.T., and others. Sealing quality of a temporary filling material. Oral Surg 46:123130, 1978.
REPORTS
9. Holland, R., and others. Root canal treat ment with calcium hydroxide. Effect of overfill ing and refilling. Oral Surg 47:87-91, 1979. 10. Schilder, H. Filling root canals in three d i mensions. Dent Clin N Am 723, 1967. 11. Ingle, J.I., and Beveridge, E.E. Endodontics, ed 2. Philadelphia, Lea & Febiger, 1976, p 263.
Hereditary hemorrhagic telangiectasia: report of case and clinical considerations Arthur B. Hattler, DDS Robert B. Summers, DMD O ral lesions caused by this disease interfered with the patie nt’s ability to remove plaque an d wear a dental prosthesis. Treatment o f the gingival lesions elim inated these problems.
H
ereditary hemorrhagic telangiec tasia is a rare but easily recognizable vascular disease that may require treatment when it occurs in the oral cavity. Its name aptly describes the condition of multiple enlarged capil laries (telangiectasia) that have a pro pensity to bleed easily. The disease is inherited as a simple dominant trait that affects both sexes equally. It is rarest among blacks and most common among Jews.1Hereditary hemorrhagic telangiectasia is sometimes known as Osler-Weber-Rendu disease. Killey and Kay2 trace the history of the dis ease and the d e riv a tio n of this eponym. During the 19th century, the disease went unrecognized, and cases of hereditary hemorrhagic telangiec tasia were diagnosed as types of hemophilia. In 1896, Rendu classified it as a pseudohemophilia, but recog nized its characteristic familial nature and common epistaxis. In 1901, Osier wrote the paper that established hered itary hemorrhagic telangiectasia as a separate clinical entity, noting the familial characteristics and total body distribution. Weber added to the de scription in 1907 and clearly distin guished between telangiectasia and
the hereditary hemophilias. Thus, the condition is also known as OslerWeber-Rendu disease. The enlarged capillaries of heredi tary hemorrhagic telangiectasia ap pear either as small, flattened red or purple papules or as dilated raised vascular nodules (Fig 1, 2), and have often been described as resembling a crushed spider.3 They occur on the skin, particularly on the face, nasal mucosa, oral mucosa, and alimentary mucosa. The oral mucosa is involved in 60% of patients with hereditary hemorrhagic telangiectasia; lips or tongue are most often affected. There is also a wide visceral distribution, in cluding the brain, spinal cord, lungs, and gastrointestinal mucosa. Histologic examination of the le sions shows dilated capillaries, which are thought to be inherently weak rather than simply thin-walled.3 Skin lesions rarely bleed, but those in the nasal mucosa often give rise to profuse hemorrhage, either spontaneously or as a result of trauma. The lesions that occur on the gingiva may also bleed from even the slightest trauma; the bleeding is not caused by a clotting or bleeding deficiency, but is the result of rupture of the weak capillaries that characterize this disease. The diagnosis of hereditary hemor rhagic telangiectasia is usually made on the basis of the family history and the appearance of the lesions, distin guishable from petechiae in that they w ill blanch on pressure (such as might be ap p lie d w ith a tongue blade) whereas the lesions of the petechiae will not. The usual onset of the disease
Fig 1 ■ Lips show dark, flattened, red papules, which will blanch under pressure.
Fig 2 ■ Mucosal lesions of hereditary hemor rhagic telangiectasia appear as flattened, red areas that may bleed when most simple manipu lation is done.
occurs after puberty, most often be tween the ages of 10 and 30. It tends to worsen with age, and it is usual for pa tients with this problem to have iron deficiency anemia. Bleeding and clot ting times are w ithin normal limits. Treatment of the telangiectasis is necessary w hen irritatio n causes bleeding. This is rare for skin lesions but commonly indicated for lesions of the mucous membranes. Killey and Kay2 caution that hereditary hemor rhagic telangiectasia occurring on the g in g iv a m ig h t be confused w ith periodontal disease. They recommend care during dental treatment to pre vent the formation of sharp, abraded, JADA, Vol. 103, September 1981 ■ 421
REPORTS
A technique for placement of calcium hydroxide in the root canal system Raymond T. Webber, DDS, M S Ken A. Schwiebert, D M D Gerald M. Cathey, DDS, M SD The rationale and technique that promote a predictable clinical result in calcium hydroxide treatm ent of open apexes are described; biologic and physiologic advantages are discussed.
c
alcium hydroxide as an intracanal medicament has received renewed in terest in recent years. Its application is by no means new and its effectiveness relates to its alkalinity. As early as 1883, Hunter1 reported at a Missouri Dental Association meeting the use of a mixture of English sparrow drop pings and sorghum molasses for pulp capping with 98% success. He did not, of course, realize that the high am m onium hydroxide content of the sparrow droppings was probably the key to his “cure.” In 1930, Hermann2 introduced the use of calcium hydrox ide (Calxyl) for the treatment of vital pulps. He demonstrated the ability of the pulp to build a dentinal bridge ad jacent to calcium hydroxide as an ap parent healing response. The induc tion technique was first offered in the United States in 1964 with separate presentations by Kaiser3 and Frank4 at the annual meeting of the American Association of Endodontists. It was presented in the literature in 1966s and popularized as the “Frank technique. ” Since then, the literature has had many articles on technique and case reports of successes and failures, which has led to some confusion about the proper application of calcium hydroxide. This article presents a procedure for calcium hydroxide therapy in nonvital, permanent teeth with open apexes. This technique incorporates princi ples that enhance apexification in both the adults and children. The emphasis is on adhering to the basic endodontic principles, which offer predictable success.
Clinical experience has shown that the apex must be completely within osseous tissue or osseous-forming tis sue, that is, within the confines of the cortical plates. In some instances, the apex may penetrate the cortical plate, and this possibility should be consid ered when a tooth does not respond to calcium hydroxide therapy. When this occurs, beveling the apex within the cortical plate and placement of a re verse amalgam filling is the preferred technique.
Procedure A thorough pretreatment evaluation and examination are performed. After isolation by rubber dam, endodontic access that will allow complete de bridement of the root canal system is done (Fig 1). An in itia l treatment length to the radiographic apex is de termined and recorded for subsequent appointments (Fig 2). The canals are prepared with thorough instrumenta tion accompanied by copious canal ir rigation. Torneck and others6and Hol land and others7 emphasize that care ful debridement of the root canal sys tem is a primary factor in ensuring api cal closure. After instrumentation, the canals are dried with premeasured paper points, preferably the largest size the canal will accept, for complete drying without injury to the apical tis sues (Fig 3). CALCIU M H Y D R O X ID E PASTE. Calcium hydroxide (USP) is desired, as contam inants in the powder may adversely af fect healing. We prefer the powder over commercial preparations because it can be mixed to variable consisten cies for ease of condensation in the root canal system. The liquid vehicle should be compatible with tissue and nonirritating to the periapical tissues, if extruded. Sterile water, isotonic saline solution, or dental anesthetic (preferably without a vasoconstrictor)
are suggested. A sterile glass slab and a spatula with no residual cements are neces sary to avoid contamination of the medicament. Barium sulfate powder is added to the calcium hydroxide if opacity is desired; a ratio of 1 part barium sulfate to 8 parts of calcium hydroxide is recommended. The powder(s) and liquid should be mixed to a very dry, thick consistency, compara ble to that of a dry resin. The mix should possess enough body to allow vertical condensation while m inim iz ing occlusal reverse flow. CON DENSATION. An amalgam carrier is suggested for introducing the cal cium hydroxide paste into the canal. A carrier with a plastic or Teflon sleeve is recommended, as the calcium hydrox ide can corrode metals and contamin ate the paste. Am algam remnants should not be present in the barrel be fore use. Various diameters of en dodontic pluggers are needed for ver tical condensation to ensure a dense filling. The pluggers are prefitted for the correct size and length. First, a plugger should be selected that nearly occludes the canal at a distance of 2 to 3 mm short of the radiographic apex and yet does not bind against the den tinal walls (Fig 4). The mix should be introduced in small increments (Fig 5) and vertically condensed with the pluggers (Fig 6), gradually increasing the sizes as the canal is filled (Fig 7). As a precaution against possible root fracture, the pluggers should not bind against the canal walls. TEM PO RA RY OCCLUSAL RE ST O R A
It is suggested that Intermediate Restorative Materials or zinc oxideeugenol be used as a temporary filling unless a semipermanent tooth colored restorative material or amalgam (in posterior teeth) is needed for crown buildup or reinforcement. Four or five millimeters’ thickness is required for TION.
JADA, Vol. 103, September 1981 ■ 417
V , ZW&SïtJ »1
Fig 5
Fig 6
Fig 7
Fig 8
Fig 1 ■ Left, adequate canal debridement cannot be accomplished until cingulum dentin is removed; right, removal of cingulum dentin allows instrumentation along lingual canal wall. Fig 2 ■ Largest endodontic instrument canal will accept is placed to radiographix apex for initial treatment length. Fig 3 ■ Premeasured, inverted, extra-coarse paper (absorbent) point is used to dry canal. Fig 4 ■ Largest endodontic plugger canal will accept is fitted 2 to 3 mm short of initial treatment length. Fig 5 ■ Thick calcium hydroxide paste can be placed in canal with amalgam carrier. Fig 6 ■ Small increments of calcium hydrox ide are condensed vertically with prefitted pluggers. Fig 7 ■ Larger prefitted pluggers are used as canal is sequentially obtu rated. Fig 8 ■ After initial debridement appointment, new working length is approximately 1 mm short of radiographic apex.
the temporary filling to allow adequate sealing.8 Cavit is not an acceptable temporary filling, as it lacks wear re sistance in the long intervals between treatment. If there is dilution or con tamination of the paste, with con sequent exposure of the healing tis sues to bacteria and their toxins, there may be exacerbation. For a more pre dictable result, the calcium hydroxide should be changed routinely at the first six-week observation visit. In some instances, the paste may need to be changed earlier. H o llan d and others9 had better results with a paste RECALL PROCEDURES.
418 ■ JADA, Vol. 103, September 1981
change. The paste should be removed with an endodontic instrument ap proximately half the diameter (size no. 40 to no. 70) of the canal. A reaming motion is needed to penetrate and dis lodge the dry paste, which is sub sequently lavaged with copious irriga tion of sterile water or saline solution. The instrumentation should recapitu late the previous final instrument size for removal of all the old paste. To pre vent injury to the healing apical tis sues, the calcium hydroxide should be removed to a level approximately 1 mm less than the previous working length (Fig 8). This w ill be the new working length at future appoint
ments. When drying the canal, the largest size paper point that the canal w ill accept at the new working length should be used. A new calcium hydroxide paste is vertically condensed, taking care not to exceed the new working length with the second paste filling. The bridging hard tissue formation in the apical 1 mm is desired. As a general rule, the patient should be recalled six weeks after placement of the second paste and approximately every two or three months thereafter until apexification is complete. The average interval be tween appointments is a year, but this may vary from six months to two years,
depending primarily on the develop ment of the apex at the time of the ini tial treatment. The placement of calcium hydrox ide paste is not limited to the first and second ap poin tm e nts; the paste should be replaced as often as neces sary. A radiographic observation of the paste in the canal system helps to de termine when the paste needs chang ing at the recall appointments. If there appears to be a dilution of the paste in the canal, shown by increased radiolucency, the calcium hydroxide should be changed. Whether to change the calcium hydroxide is finally de cided when the temporary filling is removed and the paste is probed with an endodontic explorer or file (reamer) to ascertain if it is still dry. If a sinus tract or fistula or other symptomatol ogy develops in the early months of treatment, this is an indication that the • paste needs changing. Removal of the cal cium hydroxide paste is accomplished by alternately irrigating with sterile water or saline solution and in strumentation with a reaming motion, as previously described. The in strumentation should extend only to the calcified barrier. The thickness of the barrier causes the working length normally to be 1 or 2 mm short of the initial treatment length. It is desirable (whenever possible) to enlarge the instrumentation by one or two sizes for removal of calcium hy droxide remnants along the canal walls. However, when the canal en largement is performed, the relative thinness of the dentinal walls of these immature teeth should be considered. Smaller endodontic instruments may be used in removing any calcium hy droxide in the apical few millimeters of the roots with divergent walls. Final irrigations should be performed with copious amounts of sterile water or saline solution and the canal should be dried with paper points. The paper points should not cause any hemor rhage or detect tissue fluids. The final determination of complete apexification and readiness to obturate with gutta-percha is predicated on having met the following criteria: —The tooth must be asymptomatic, with healing of any previous sinus tract or fistula. — Osseous deposition in the periap ical defects, if originally present, FINA L FILLIN G .
Fig 9 ■ Asymptomatic necrotic pulp of the maxillary left central incisor in 20-year-old woman. Immature apex was noted with periapi cal involvement of approximately IV2 cm. Maxil lary right central incisor had asymptomatic cal cified canal system and had been hurt when pa tient fell 12 years earlier. It is suspected that left incisor ceased forming at time of trauma and right central incisor was stimulated to undergo excessive calcification.
should be observed radiographically. —Hard tissue deposition of the apex will be seen frequently. — The calcium hydroxide paste should be dry when tested by probing with an endodontic instrument or ex plorer. — Smaller files used w ith light finger pressure should confirm the calcific deposit at the apex. —Drying the canal system with paper points should not elicit hemor rhage or tissue fluids. Obturation of the root canal system w ith gutta-percha can be accom plished successfully with either of the following techniques: —The warm (vertical) gutta-percha technique (Schilder).10The large canal system and the blunderbuss apex in many of these teeth may indicate that the incremental warm gutta-percha technique is more desirable. —The lateral condensation tech nique. Because many of these canals are irregular and are larger than the largest gutta-percha cone available (no. 140), a customized gutta-percha cone must be fabricated. Ingle and Beveridge11 suggest rolling two or more gutta-percha cones together be tween a cool glass slab and one that is heated, to create the desired size and shape of the master cone. As with all endodontic fillings, it is suggested that the patient be recalled periodically, in six to 12 months, for réévaluation.
Fig 10 ■ Premeasured no. 140 file was intro duced into the canal system for an initial work ing length. File is not binding on canal walls, suggesting very large system.
Report of case A 20-year-old w om an came for treatment of an asy m p to m a tic necrotic p u lp of the maxillary left central incisor. A n im mature apex w ith periapical involvem ent to ap proxim ately IV 2 cm was observed. The m a x illa ry rig h t central inciso r had an asymptomatic calcified canal system and an intact periodontal ligam ent (Fig 9). The maxillary central incisors had a history of trauma related to a fall 12 years earlier. It was suspected that the left central incisor ceased form ing at the time of trauma and the right was stimulated to undergo exces sive calcification. A premeasured no. 140 file was intro duced into the canal system for an initial working length. The file d id not b in d on the canal walls, suggesting a very large system (Fig 10). A t the instrum entation appoint ment, the canal system was obturated w ith calcium hydroxide, b arium sulfate, and sterile water paste, using vertical condensa tion. Because there was lack of periapical resistance, the paste was overextended (Fig
11 ). The first six-week recall exam ination showed that some of the extruded paste was resorbing (Fig 12). The first paste was re moved and a second apexification paste was placed. However, this tim e the paste was confined to the canal system approxi mately 1 m m short of the radiographic apex (Fig 13). Apexification was complete after a year of treatment. The paste was removed and a solid barrier was detected approxi m a te ly 1 to IV 2 m m s h o rt o f th e ra diographic length (Fig 14). After complete removal of the paste, the canal system was obturated w ith gutta-percha, using the ver tical condensation technique. The calcified barrier prevented overextension of the gutta-percha, but d id allow some extrusion of the root canal sealer (Fig 15). The radiograph taken nine months after the gutta-percha was placed suggests re sorption of the sealer and progressive re-
Webber-Schwiebert-Cathey : PLACEMENT OF CALCIUM HYDROXIDE IN ROOT CANAL SYSTEM ■ 419
C L IN IC A L
REPORTS
Fig 11 ■ At instrumentation appointment, canal system was obturated with calcium hydroxide, barium sulfate, and sterile water paste with ver tical condensation. As there was lack of periapi cal resistance, paste was overextended.
Fig 14 ■ Apexification was complete after one year of treatment. Paste was removed, and solid barrier was detected approximately 1 to IV2 mm short of the radiographic length.
sorption of the extruded calcium hydroxide and barium sulfate paste. At the recall, 21 months after the initial appointment, it was found that not only had apexification oc curred, but the root apex had also con tinued to form, along w ith a periodontal ligament. The patient was 22 years old (Fig 16).
S um m ary The goals of apexification technique include physiologic stimulation by the calcium hydroxide for hard tissue de position at the tooth’s apex and promo tion of periapical healing of the 420 ■ JADA, Vol. 103, September 1981
Fig 13 ■ Initial paste was removed and second apexification paste was placed. However, this time, paste was confined to canal system approx imately 1 mm short of radiographic apex.
Fig 15 ■ After complete removal of paste, canal system was then obturated with gutta-percha, using vertical condensation (Schilder) tech nique. Calcified barrier prevented overextension of gutta-percha but did allow some root canal sealer extrusion.
periodontium by the basic endodontic principle of obturating the root canal system. A technique has been de scribed that yields predictable clinical results in attaining these objectives.
Dr. Webber is assistant professor, and Dr. Cathey is professor, department of endodontics, College of Dentistry, University of Florida. Dr. Schwiebert is in private practice in Williston, Fla, and is parttime clinical instructor, department of community dentistry, College of Dentistry, U ni versity of Florida. Address requests for reprints to Dr. Webber, Box J-436, JHMHC, University of Florida, Gainesville, 32601.
Fig 16 ■ Radiograph nine months after gutta percha filling suggests resorption of sealer and progressive resorption of extruded calcium hydroxide-barium sulfate paste. At this 21month recall examination (from the initial ap pointment), not only had apexification occurred, but root apex had also continued to form along with periodontal ligament. Patient was 22 years old at time radiograph was made.
1. Hunter, F.A. Saving pulps. A queer process. Dent Items Int 352, 1883. 2. Herm ann, B.W. D entinobliteration der Wurzelkanale nach der Behandlung mit Kalcium. Zahnarztl Rundschau 39:888, 1930. 3. Kaiser, H.J. Management of wide canals with calcium hydroxide compounds. Twenty-first an nual meeting of the American Association of Endodontists, Washington, DC, April 17, 1964. 4. Frank, A.L. Experimental efforts to effect a closing of the wide open pulpless tooth allowing conservative therapy rather than surgical inter vention. Twenty-first annual meeting of the American Association of Endodontists, Washing
C L IN IC A L
ton, DC, April 19, 1964. 5. Frank, A.L. Therapy for the divergent pulpless tooth by continued apical formation. JADA 72:(l)87-93, 1966. 6. Torneck, C.D.; Smith, J.S.; and Grindall, P. Biologic effects of endodontic procedures on de veloping incisor teeth. Effect of debridement pro cedures and calcium hydroxide-camphorated
parachlorophenol paste in the treatment of exper imentally induced pulp and periapical disease. Oral Surg 35(4):541-554, 1973. 7. Holland, R., and others. Root canal treat ment with calcium hydroxide. Effect of debris and pressure filling. Oral Surg 47:185-188, 1979. 8. Webber, R.T., and others. Sealing quality of a temporary filling material. Oral Surg 46:123130, 1978.
REPORTS
9. Holland, R., and others. Root canal treat ment with calcium hydroxide. Effect of overfill ing and refilling. Oral Surg 47:87-91, 1979. 10. Schilder, H. Filling root canals in three d i mensions. Dent Clin N Am 723, 1967. 11. Ingle, J.I., and Beveridge, E.E. Endodontics, ed 2. Philadelphia, Lea & Febiger, 1976, p 263.
Hereditary hemorrhagic telangiectasia: report of case and clinical considerations Arthur B. Hattler, DDS Robert B. Summers, DMD O ral lesions caused by this disease interfered with the patie nt’s ability to remove plaque an d wear a dental prosthesis. Treatment o f the gingival lesions elim inated these problems.
H
ereditary hemorrhagic telangiec tasia is a rare but easily recognizable vascular disease that may require treatment when it occurs in the oral cavity. Its name aptly describes the condition of multiple enlarged capil laries (telangiectasia) that have a pro pensity to bleed easily. The disease is inherited as a simple dominant trait that affects both sexes equally. It is rarest among blacks and most common among Jews.1Hereditary hemorrhagic telangiectasia is sometimes known as Osler-Weber-Rendu disease. Killey and Kay2 trace the history of the dis ease and the d e riv a tio n of this eponym. During the 19th century, the disease went unrecognized, and cases of hereditary hemorrhagic telangiec tasia were diagnosed as types of hemophilia. In 1896, Rendu classified it as a pseudohemophilia, but recog nized its characteristic familial nature and common epistaxis. In 1901, Osier wrote the paper that established hered itary hemorrhagic telangiectasia as a separate clinical entity, noting the familial characteristics and total body distribution. Weber added to the de scription in 1907 and clearly distin guished between telangiectasia and
the hereditary hemophilias. Thus, the condition is also known as OslerWeber-Rendu disease. The enlarged capillaries of heredi tary hemorrhagic telangiectasia ap pear either as small, flattened red or purple papules or as dilated raised vascular nodules (Fig 1, 2), and have often been described as resembling a crushed spider.3 They occur on the skin, particularly on the face, nasal mucosa, oral mucosa, and alimentary mucosa. The oral mucosa is involved in 60% of patients with hereditary hemorrhagic telangiectasia; lips or tongue are most often affected. There is also a wide visceral distribution, in cluding the brain, spinal cord, lungs, and gastrointestinal mucosa. Histologic examination of the le sions shows dilated capillaries, which are thought to be inherently weak rather than simply thin-walled.3 Skin lesions rarely bleed, but those in the nasal mucosa often give rise to profuse hemorrhage, either spontaneously or as a result of trauma. The lesions that occur on the gingiva may also bleed from even the slightest trauma; the bleeding is not caused by a clotting or bleeding deficiency, but is the result of rupture of the weak capillaries that characterize this disease. The diagnosis of hereditary hemor rhagic telangiectasia is usually made on the basis of the family history and the appearance of the lesions, distin guishable from petechiae in that they w ill blanch on pressure (such as might be ap p lie d w ith a tongue blade) whereas the lesions of the petechiae will not. The usual onset of the disease
Fig 1 ■ Lips show dark, flattened, red papules, which will blanch under pressure.
Fig 2 ■ Mucosal lesions of hereditary hemor rhagic telangiectasia appear as flattened, red areas that may bleed when most simple manipu lation is done.
occurs after puberty, most often be tween the ages of 10 and 30. It tends to worsen with age, and it is usual for pa tients with this problem to have iron deficiency anemia. Bleeding and clot ting times are w ithin normal limits. Treatment of the telangiectasis is necessary w hen irritatio n causes bleeding. This is rare for skin lesions but commonly indicated for lesions of the mucous membranes. Killey and Kay2 caution that hereditary hemor rhagic telangiectasia occurring on the g in g iv a m ig h t be confused w ith periodontal disease. They recommend care during dental treatment to pre vent the formation of sharp, abraded, JADA, Vol. 103, September 1981 ■ 421