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The effect of calcium hydroxide on deep carious lesions
THE
EFFECT
CARIOUS
OF CALCIUM
LESIONS
HYDROXIDE
ON DEEP
Volume Number MATERIAL
I4 9
CALCIUM
BND
HYDROXIDE
AND
DEEP
CARIOUS
LESIONS
I I:$1
METHOD
All patients in the present study were treated in the Pedodontic Department, at the Universit,y of Washington School of Dentistry. Sixty-six deciduous and young permanent teeth were operated upon and subsequent,ly followed for periods of time varying from seven days to twenty-eight months. Pcriapical and bitewing surveys of the teeth were taken prior to surgical intervention, and the presence of a deep carious lesion, closely encroaching upon the pulp but not actnall,v into it so far as could be determined by the roentgenogram, was assured (Fig. 1). Nest, 2 C.C. Sylocaine hydrochloride n-it11 epiand a rubbertlnm n-as placetl in position. ncphrinc> 1 : 50,000 ~vns ildmilliSt~~lWl.
IIotarj- inst r~umcuts wcrc used t>o gain accaess to all dec~ayotl areas. A SIllBI I amount, of calcium hydroxide was moistened with sterile water until a heav! past,e formed, and this material was deposited on the c+arious dentine w&h an amalgam carrier. The calcium hydroxide was then dried, forming a reasonably hard layer 1 to 2 mm. in thickness. If necessary, a matrix band was placed. The rest of the cavity was filled with a soft amalgam mixture and condensed with light pressure (Fig. 2). Periapical and bitewing roentgenograms were taken again immediately following treatment and at periodic intervals thereafter for several weeks. ,4s early as seven days following treatment, a radiopaque area formed on the pulpal side of the residual caries (Fig. 3). This area was evident in nearly every case.
Kl5Sl’I,TS Six Jnollths aftw t,lIc iiiitial calcium lI,vtlI~ositl~~ t I’CiltlIl(‘llt, twcuty-st~vctll 01’ 1 lit: original thirty patients rei~wfied for final cwavatioii ol’ tliv cavitiw b’it’tyseven of the original sixty-six teeth mm~ iwcritcrctl. ()titb 100th had been preyiousl~~ cxtractcyl. Thostt patients who wew not ;I\-ailablt~ t’or wesamination wrtl tlropped froni l,he stntly. Awoi~tling 1-O tllc critrrioil tllilt tL’~vitJIieJit was swwssCu1 if 110 pulp csposul’c~ was encountcrotl on t?XVilVatiOJl aiid if the rtwlit,wnographic clvitlcnw was nccative, fort,v-fonr twtli ~wrc ~t~r~sitle~~~l satishctory. ?.
One year and two ?-earn following tlic initial trcatmeiit all patitmts wrt wcallrd. (‘lirrical iIIltl l.oent~~~nogl;lI)liic t~XalJliJlilti0JlS rcvealcd 110 t’ailuiw iIlll01lg casts in which tlY‘atrlrc~rlt had lwen prwionsl~coiisitlci~ed successful. 1t \VilS thLlS tlctci~mintd after’ tn’0 YOilJX Of obsri*vatioii that t tlis te~liiiiqlie Ililtl SUccWdctl iii rwtoririg forty-fOllI* Olll Ot’ fift!r-SkY~eil qucstional)le tct$ll 10 i,l
liealtli+v, t’mictional state.
This rq~uwiits
Tile str~dicd.
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It+-hand fliirly+ighf,
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weu:
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tllat, ant1 t \wnt>-
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oi’ Illc fifty-eight, wcw ~wiiianent.
tcyltli tcttrth.
I iISTOI,OGIC
&II Sl~‘c”lYO~S .
The mandibular left first pemanent molar mentioned manner was judged elinicall~- and after twelve nlont hs (Fig. 5 j . This tooth was (This and subjected to histologic sectioning. clinical results of the study. j Fig. 6 shows a vertical mesiodistal scction molar. The remains of t,he calcium hydroside The occlusal dentine shows a V-shaped area
of’ a Imtient treated in the al’ore~oentgcnogral)llicall~ sat,isfactoq extra&d for orthodont,ic reasons paticlnt was not, included in the
of the lower left first permanent may be seen lying snpcriorl~-. of decalcificat,ion with enlarged
The final evaluation of’ t11c~ s~~w~w of any dental treatment, specifically that involving the dental pulp, can be verified only- by the patient’s return to thus dentist ‘H office at specific int,ervals so that thr ontwmc of t,reatment, (*all 1~s Tlic~ clinical results of other studies’-:, evaluated by predetcrminecl critwia. anti rc-exatnirwtl seem to indicate that in which patients have hen tr.wtccl presently accepted methods of trcatin# tlcq) carious lesions leave much to brb Although fwthclr ittvcstigation of the calcium hydroxide I reatmrllt desired. of deep carious lesions is necessary, it would sew l’lom tlw ~IHX~~ of this stud) i hat the method has merit in selected clinical cases.
Several possible explanations may be advanced for t rcatmcnt failure in the fourteen cases in this study. In some instances irreversible pul JI degencral.ioli wit,h no outward dctectahle evidence may have already been in progress at! the time of the initial appointment. Failure also could be attributed to mechanical loss of’ the soft ama.lgam filling mat.eria.1,&her Iwca~wc of thr wcakncss of t.hc amalgam itseli’ or becansc of the insuficicnt support afforded by the calcium Irylroside baw. \Ve believe that both of these difficulties can be appreciably reduced. The diligent selcctjion of casesshould limit the application of t,his technique to onl! those CHSCS in which carious Icsions are known to bc cxtensiw, encroaching on the pulp hut not actually pznetratin g tllc? pnlp (411~ll-llher. The addition of a zinc ox,vpIiosphatc cement base owr the c~aleiumh,vtli~ositla before plactw~31t. ol the initial amalgam restoration would pcwnit the amalgam to br placc(l in the, ~tsual ma~irier~ thus avoiding the possihilit,; of Fractwe. I‘pon removal of the calcium hydroxide and the wmaining caries, if thcrc: was no pulp csposure, frequently a hard, homogeneous, semitransparent testured layer was found. Frequently the pulp could he seen beneat,h this surfact. It was felt, several times that a surgical esposnrc~conld have been made wit.11a hand spoon inst~rument.and slight pwssllw. One suP11slight tbxposure was matl(s. Thn pulp was capped and tIlc> CaSe \vaS t’0llntl to be c+lillic:al su(~‘(5s iIt‘t(?r two years Of ObWYVilt~iOll. The cause of the radiopaql~c alws seen ill t I)(&t,oc~rltgcIno~ranlon the pulpal side of the caries is unknown. il
After two pars, 76 per cent ot’ all deciduous 8~1 young permanent lccth with deep carious lesions proved to I)r clinically ilIlt iwx~t pcnographically sound suhsequcnt lo proctdurcs involving application of il (3 tcium hydrosidc paste ovct residual caries for a six-nlont,Ii rwiAoc1. f’ollowed I))- COlllplCtP excavation arId restoration by conventional mcthocls.
EFFECT
CARIOUS
OF CALCIUM
LESIONS
HYDROXIDE
ON DEEP
Volume Number MATERIAL
I4 9
CALCIUM
BND
HYDROXIDE
AND
DEEP
CARIOUS
LESIONS
I I:$1
METHOD
All patients in the present study were treated in the Pedodontic Department, at the Universit,y of Washington School of Dentistry. Sixty-six deciduous and young permanent teeth were operated upon and subsequent,ly followed for periods of time varying from seven days to twenty-eight months. Pcriapical and bitewing surveys of the teeth were taken prior to surgical intervention, and the presence of a deep carious lesion, closely encroaching upon the pulp but not actnall,v into it so far as could be determined by the roentgenogram, was assured (Fig. 1). Nest, 2 C.C. Sylocaine hydrochloride n-it11 epiand a rubbertlnm n-as placetl in position. ncphrinc> 1 : 50,000 ~vns ildmilliSt~~lWl.
IIotarj- inst r~umcuts wcrc used t>o gain accaess to all dec~ayotl areas. A SIllBI I amount, of calcium hydroxide was moistened with sterile water until a heav! past,e formed, and this material was deposited on the c+arious dentine w&h an amalgam carrier. The calcium hydroxide was then dried, forming a reasonably hard layer 1 to 2 mm. in thickness. If necessary, a matrix band was placed. The rest of the cavity was filled with a soft amalgam mixture and condensed with light pressure (Fig. 2). Periapical and bitewing roentgenograms were taken again immediately following treatment and at periodic intervals thereafter for several weeks. ,4s early as seven days following treatment, a radiopaque area formed on the pulpal side of the residual caries (Fig. 3). This area was evident in nearly every case.
Kl5Sl’I,TS Six Jnollths aftw t,lIc iiiitial calcium lI,vtlI~ositl~~ t I’CiltlIl(‘llt, twcuty-st~vctll 01’ 1 lit: original thirty patients rei~wfied for final cwavatioii ol’ tliv cavitiw b’it’tyseven of the original sixty-six teeth mm~ iwcritcrctl. ()titb 100th had been preyiousl~~ cxtractcyl. Thostt patients who wew not ;I\-ailablt~ t’or wesamination wrtl tlropped froni l,he stntly. Awoi~tling 1-O tllc critrrioil tllilt tL’~vitJIieJit was swwssCu1 if 110 pulp csposul’c~ was encountcrotl on t?XVilVatiOJl aiid if the rtwlit,wnographic clvitlcnw was nccative, fort,v-fonr twtli ~wrc ~t~r~sitle~~~l satishctory. ?.
One year and two ?-earn following tlic initial trcatmeiit all patitmts wrt wcallrd. (‘lirrical iIIltl l.oent~~~nogl;lI)liic t~XalJliJlilti0JlS rcvealcd 110 t’ailuiw iIlll01lg casts in which tlY‘atrlrc~rlt had lwen prwionsl~coiisitlci~ed successful. 1t \VilS thLlS tlctci~mintd after’ tn’0 YOilJX Of obsri*vatioii that t tlis te~liiiiqlie Ililtl SUccWdctl iii rwtoririg forty-fOllI* Olll Ot’ fift!r-SkY~eil qucstional)le tct$ll 10 i,l
liealtli+v, t’mictional state.
This rq~uwiits
Tile str~dicd.
tlt~c~ithwus
It+-hand fliirly+ighf,
cOlLLJ~lJ1
weu:
Ol’
TatIle
I
7G ~)ei’ wilt s~iw~~ss.
a
tllat, ant1 t \wnt>-
itlllStl~iltt3
twtli
oi’ Illc fifty-eight, wcw ~wiiianent.
tcyltli tcttrth.
I iISTOI,OGIC
&II Sl~‘c”lYO~S .
The mandibular left first pemanent molar mentioned manner was judged elinicall~- and after twelve nlont hs (Fig. 5 j . This tooth was (This and subjected to histologic sectioning. clinical results of the study. j Fig. 6 shows a vertical mesiodistal scction molar. The remains of t,he calcium hydroside The occlusal dentine shows a V-shaped area
of’ a Imtient treated in the al’ore~oentgcnogral)llicall~ sat,isfactoq extra&d for orthodont,ic reasons paticlnt was not, included in the
of the lower left first permanent may be seen lying snpcriorl~-. of decalcificat,ion with enlarged
The final evaluation of’ t11c~ s~~w~w of any dental treatment, specifically that involving the dental pulp, can be verified only- by the patient’s return to thus dentist ‘H office at specific int,ervals so that thr ontwmc of t,reatment, (*all 1~s Tlic~ clinical results of other studies’-:, evaluated by predetcrminecl critwia. anti rc-exatnirwtl seem to indicate that in which patients have hen tr.wtccl presently accepted methods of trcatin# tlcq) carious lesions leave much to brb Although fwthclr ittvcstigation of the calcium hydroxide I reatmrllt desired. of deep carious lesions is necessary, it would sew l’lom tlw ~IHX~~ of this stud) i hat the method has merit in selected clinical cases.
Several possible explanations may be advanced for t rcatmcnt failure in the fourteen cases in this study. In some instances irreversible pul JI degencral.ioli wit,h no outward dctectahle evidence may have already been in progress at! the time of the initial appointment. Failure also could be attributed to mechanical loss of’ the soft ama.lgam filling mat.eria.1,&her Iwca~wc of thr wcakncss of t.hc amalgam itseli’ or becansc of the insuficicnt support afforded by the calcium Irylroside baw. \Ve believe that both of these difficulties can be appreciably reduced. The diligent selcctjion of casesshould limit the application of t,his technique to onl! those CHSCS in which carious Icsions are known to bc cxtensiw, encroaching on the pulp hut not actually pznetratin g tllc? pnlp (411~ll-llher. The addition of a zinc ox,vpIiosphatc cement base owr the c~aleiumh,vtli~ositla before plactw~31t. ol the initial amalgam restoration would pcwnit the amalgam to br placc(l in the, ~tsual ma~irier~ thus avoiding the possihilit,; of Fractwe. I‘pon removal of the calcium hydroxide and the wmaining caries, if thcrc: was no pulp csposure, frequently a hard, homogeneous, semitransparent testured layer was found. Frequently the pulp could he seen beneat,h this surfact. It was felt, several times that a surgical esposnrc~conld have been made wit.11a hand spoon inst~rument.and slight pwssllw. One suP11slight tbxposure was matl(s. Thn pulp was capped and tIlc> CaSe \vaS t’0llntl to be c+lillic:al su(~‘(5s iIt‘t(?r two years Of ObWYVilt~iOll. The cause of the radiopaql~c alws seen ill t I)(&t,oc~rltgcIno~ranlon the pulpal side of the caries is unknown. il
After two pars, 76 per cent ot’ all deciduous 8~1 young permanent lccth with deep carious lesions proved to I)r clinically ilIlt iwx~t pcnographically sound suhsequcnt lo proctdurcs involving application of il (3 tcium hydrosidc paste ovct residual caries for a six-nlont,Ii rwiAoc1. f’ollowed I))- COlllplCtP excavation arId restoration by conventional mcthocls.