Effect of Accidental Periapical Extrusion of Calcium Hydroxide Paste (A Case Report)

Effect of Accidental Periapical Extrusion of Calcium Hydroxide Paste (A Case Report)
Fahmida Soomro , S.Yawar A. Abidi, Sameer Qureshi, Saqib Rashid, Tasleem Hosein

  • FCPS II Trainee, Operative Dentistry Dept. Fatima Jinnah Dental College Hospital.
  • Assistant Professor,Operative Dentistry Dept. Dr.Ishrat-ul-Ebad Khan Institute of Oral Health Sciences.
  • Assistant Professor, Operative Dentistry Dept. Fatima Jinnah Dental College Hospital.
  • Professor, Operative Dentistry Dept. Fatima Jinnah Dental College Hospital.
  • Professor & Head Division Operative Dentistry Dept. Fatima Jinnah Dental College Hospital.

Correspondence: Dr. Saqib Rashid <saqibrashid@yahoo.com>

Received: 16 February 2016, Accepted: 25 March 2016

How to CITE:

J Pak Dent Assoc 2010;19(1): 58 - 61


Calcium hydroxide is an effective biocompatible substance that has been widely studied in scientific research, and is regarded as the material of choice for treating intracanal infections. The paper discusses a case of a non vital central incisor with a large periapical lesion, in which calcium hydroxide paste containing iodoform as a radiopacifier was used. There was an un-intentional extrusion of calcium hydroxide during application. The patient was seen at a regular periodic recall for one year. The followup revealed that the accidental extrusion of calcium hydroxide did not have any detrimental effect on periapical healing


Periapical lesion, calcium hydroxide, Iodoform.


A female aged 19 years was referred to the endodontic department of Fatima Jinnah dental hospital for

endodontic treatment of her right maxillary central incisor. Patient gave a history of trauma 12-15 months before this oppointment. The tooth was asymptomatic; there was no swelling, tooth mobility or active sinus discharge. (Fig 1) The vitality testing confirmed that the tooth was non vital. Periodontal probings were within normal limits. The periapical radiograph revealed the presence of a periradicular lesion in association with the tooth. After discussing with the patient and the need of periodic recall mentioned, it was decided to treat the case with non surgical endodontics

Endodontic treatment was started on maxillary right central incisor. (Fig 1) The tooth was isolated by placing rubber dam. Access cavity was opened without anaesthesia. Root canal was found to be dry. The canal was shaped and cleaned following the step down technique and prepared upto Kerr file ISO # 45. Recapitulation was done after every file and Na0Cl in a concentration of 2.5% was used as an irrigant. Afterwards the canal was dried using paper points, Vitapex (Calcium hydroxide 30.3% paste containing 40.4% iodoform) paste was placed into the canal using lentulospiral.16

During this procedure the paste was accidentally extruded into the periapical tissues.(Fig 2)No pain was reported

during placement of calcium hydroxide paste. Access cavity was sealed with Kalzinol (zinc oxide eugenol cement).The patient was again seen after one week, the provisional restoration was removed. During the second appointment canal was re irrigated, dried with paper points and finally obturated with Gutta Percha using the cold lateral condensation technique. The access cavity was sealed and tooth restored with composite restoration.


After the RCT, patient was called at 15 days, 6 weeks, 3, 6, 9 and 12 month intervals. During this period the tooth remained asymptomatic. Radiographs were taken at regular intervals.(Fig 3&4) The radiographs revealed a radiopaque (white) spot in the periapical region where calcium hydroxide dressing was unintentionally extruded and in addition showed complete resolution of the periapical lesion


The presented case showed that there was an unintentional extrusion of calcium hydroxide paste containing iodoform into the periapical lesion during the application of intracanal dressing, but it had no detrimental effect throughout the observation period. Matsuzaki evaluated the success of calcium hydroxide paste containing iodoform for 3 and a half years.17 He found that iodoform containing pastes are biocompatible, resorbed from the periradicular region, cause no foreign body reaction and the overfilling of iodoform paste had no effect on the success of the treatment.


Extension of the material beyond the apex has, been advocated by some authors due to benefits of calcium hydroxide. Souza et al suggested that the action of calcium hydroxide beyond the apex may be four fold:1) anti-inflammatory activity,2) neutralization of acid products: alkaline pH neutralizes the lactic acid secreted by osteoclasts 3)activation of alkaline phosphatase which is postulated to play an important role in hard tissue formation and 4)antibacterial action 9 Sahli proposed that the necrotizing ability of calcium hydroxide may destroy any epithelium present thereby allowing a connective tissue invagination into the lesion with ultimate healing.10

It was observed in our patient’s followup that remnants of one year old calcium hydroxide overextension were present in the periradicular tissues but not disfavouring the apical healing. In a study Metzger et al. also observed that calcium hydroxide paste containing radiopacifiers was not readily resorbed and lead to a residual radiopacity. 18

A possible reason for the incomplete resorption could be that the paste contains iodoform. In endodontics iodoform is often used as a radiopaquing agent in Ca(OH)2 pastes. But when Ca(OH)2 paste containing iodoform is extruded

beyond the apex, the iodoform can obscure the apex and is not readily resorbed over time. Considering the results of a study, Estrela et al. observed that when any radiopaque substance is added to calcium hydroxide, even an inert one, it influences the biological processes by diminishing the amount of hydroxyl and calcium ions available, which represents one of the reasons for Ca(OH)2 use.19 In a study it was investigated that the addition of a vehicle influenced the healing process of the periapical tissue; The resorption of the filling material and the ingrowth of chronic inflammatory connective tissue. Were the histological features when calcium hydroxide prepared with a water soluble vehicle was used.20 Knowing that the biological effects of calcium hydroxide lead to the activation of alkaline phosphatase, which, in turn, positively influences the mineralization process and favor the deactivation of bacterial enzymes aiding the antimicrobial effect, the importance of the speed with which hydroxyl ions are released together with their availability in the environment in which their effectiveness is desired can be deduced. Another factor to be analyzed is the possibility that calcium hydroxide is reabsorbed in the canal, with only the radiopaque substance remaining and giving the false idea that it keeps on acting. This factor should be considered carefully, when adding radiopaque substances to calcium hydroxide paste. 19 Some vehicle promote a high degree of solubility when the paste remains in direct contact with tissues and tissue fluids causing it to become rapidly soluble and resorbed by macrophages. Holland said that if phagocytosis takes place between pH of 6.9 and 6.8, the pH of calcium hydroxide (12.9) must have probably been drastically changed due to a buffering capacity of tissue fluids.20 The type of vehicle plays an important role in the overall process as it determine the velocity of ionic dissociation of Ca(OH)2 and resorption at various rates by periapical fluids. Therefore, healing after the use of Ca(OH)2 paste might take longer, or this situation might make a radiographic interpretation of osseous healing more difficult.5,21 The findings of Vernieks and Messer suggested that extrusion of Ca(OH)2 beyond the apex might delay early healing of periapical lesions.22 De Moor and De Witte also evaluated that in extensive Ca(OH)2 overextensions, repair took six months to be complete.23

Also, researchers observed that complete resorption of the paste including radiopacifiers did not occur, although the periradicular and periextrusion radiolucency disappeared.24 In this respect there remains contradiction with other investigators who have advocated that direct contact between Ca(OH)2 and periapical tissues is beneficial for osteoinductive reasons.25

The aim of the presented case was therefore to evaluate the accidental calcium hydroxide overextension and to evaluate the impact of it on periapical healing. 3


This case demonstrated that although the extensive extrusion of Ca(OH)2 containing iodoform through the periapical lesion does not appear to compromise the periapical healing but despite this finding the deliberate overextension of dental materials is not advocated because iodoform has unknown effects on the healing process.


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