Dent Traumatol. 2007 Feb;23(1):26-9 The effect of calcium hydroxide root filling on dentin fracture strength.

Rosenberg B, Murray PE, Namerow K.

Department of Endodontics, College of Dental Medicine, Nova Southeastern University, Fort Lauderdale, FL !"#!$%", US&. rosen'ergendo(adelphia.net )his in vitro study measured the effect of calcium hydro*ide root filling on the microtensile fracture strength +M)FS, of teeth. & total of -$ e*tracted human disease#free permanent ma*illary incisors .ere hand and rotary instrumented and vertically compacted .ith United States /harmacopeia +US/, calcium hydro*ide. )he teeth .ere stored in a moist environment for 0, !", and "- days. &s a control group, %$ teeth .ere vertically compacted .ith gutta percha and sealer. )he M)FS of the teeth .as measured +Mpa, using an 1nstron machine. Data .ere assessed statistically using an unpaired t#test +/ value,. )he intracanal placement of calcium hydro*ide .ea2ened the M)FS of teeth 'y % .3 Mpa per 00 days4 an average of $.%50 M/a day#%. 6et.een 0 and "- days, the M)FS of the dentin .as reduced 'y - .37. )his difference .as statistically significant +/ 8 $.$5,. & statistical difference +/ 8 $.$5, .as o'served 'et.een the mean M)FS of the calcium hydro*ide# filled dentin 'et.een 0 days +-5.0 M/a, and !" days + 5.9 M/a, and also 'et.een 0 and "- days + %." M/a,. )here .as also a significant difference +/ 8 $.$5, 'et.een the M)FS of the calcium hydro*ide#filled dentin after "- days + %." M/a, and the gutta percha#filled dentin +-%. M/a, .hen used as a control root filling material. )he .ea2ening of the dentin 'y ! #- .37 follo.ing root canal filling .ith calcium hydro*ide provides compelling evidence to re#evaluate the daily usage of this material in endodontic therapy. Dent Traumatol. 2002 Jun;18(3):134-7 ong!term calcium hydroxide as a root canal dressing may increase ris" of root fracture.

#ndreasen $%, &ari" B, Mun"sgaard E'.

Department of :ral and Ma*illofacial Surgery, University ;ospital, <igshospitalet, Copenhagen, Denmar2. 1t has 'een proposed +Cve2 %33!, that immature teeth are .ea2ened 'y filling of the root canals .ith calcium hydro*ide dressing and gutta#percha. )he aim of the present study .as to test the hypothesis that dentin in contact .ith calcium hydro*ide .ould sho. a reduction in fracture strength after a certain period of time. 1mmature mandi'ular incisors from sheep .ere e*tracted and divided into t.o e*perimental groups. =roup %4 the pulps .ere e*tirpated via the apical foramen. )he root canals .ere then filled .ith calcium hydro*ide +Calasept, and sealed .ith 1<M+<, cement, and the teeth .ere then stored in saline at room temperature for $.5, %, !, , 9, 3, or %! months. =roup !4 the pulps .ere e*tirpated and the root canals .ere filled .ith saline and sealed .ith 1<M+<, cement. )he teeth .ere then stored in saline for ! months. 1ntact teeth served as controls and .ere tested immediately

after e*traction. &ll teeth .ere tested for fracture strength in an 1nstron testing machine at the indicated o'servation periods. )he results sho.ed a mar2edly decrease in fracture strength .ith increasing storage time for group % +calcium hydro*ide dressing,. )he results indicate that the fracture strength of calcium hydro*ide#filled immature teeth .ill 'e halved in a'out a year due to the root filling. )he finding may e*plain the fre>uent reported fractures of immature teeth filled .ith calcium hydro*ide for e*tended periods. Dent Traumatol. 2006 Jun;22(3):154-6 'om(arison of fracture resistance in root canals of immature shee( teeth after filling with calcium hydroxide or MT#.

#ndreasen $%, Mun"sgaard E', Ba"land K.

Department of :ral and Ma*illofacial Surgery, University ;ospital of Copenhagen, Denmar2. ?ens.ove.andreasen(rh.hosp.d2 )hirty immature sheep incisor teeth .ere tested for their fracture resistance after various treatment modalities using calcium hydro*ide +C;, or a mineral trio*ide aggregate material +M)&, as a root filling. )he incisors, having appro*imately "$7 of their root gro.th completed, .ere removed from ?a.s of slaughtered sheep and divided into four e*perimental groups. )he pulps .ere e*tirpated from all the teeth through the open ape*es. +a, Saline group4 the teeth .ere preserved in saline for %$$ days at 9 degrees C. +', C; group4 the root canals .ere filled .ith C; and sealed apically .ith 1<M and stored as a'ove. +c, M)& group4 the canals .ere filled .ith M)& and stored as a'ove. +d, C;@M)& group4 the canals .ere filled .ith C; and sealed .ith 1<M. &fter $ days, the C; .as replaced .ith M)& and stored as a'ove. &t the end of the %$$#day storage period, all teeth .ere em'edded in plaster of /aris and tested for fracture strength at the cervical area in an 1nstron testing machine. )he results sho.ed a decrease in fracture resistance +a, of the incisors .ith C; in the root canals after %$$ days of storage, compared to +', teeth stored in intracanal saline and +c, teeth .ith $ days of C; and then filled .ith M)&, and +d, those filled .ith M)& in the canals. 1n conclusion, .hen C; .as 2ept in the canals of immature sheep teeth for only $ days follo.ed 'y root filling .ith M)& there .as no significant decrease in strength of the root .ithin an o'servation period of %$$ days. )his finding may 'e of importance in the decision of treatment plans for teeth .ith pulp necrosis and immature root formation. A Endod. 2005 Dec;31(12):895-7 &racture resistance of human root dentin ex(osed to intracanal calcium hydroxide.

Doyon )E, Dumsha T, *on &raunhofer $#.

Department of Endodontics and /eriodontics, University of Maryland Dental School, 6altimore, Maryland, US&. gedoyon(hotmail.com

)he purpose of the present study .as to determine if e*posure to intracanal calcium hydro*ide BCa+:;!,C alters the fracture resistance of human root dentin. :ne hundred and t.o freshly e*tracted single rooted human teeth divided into three groups of - teeth each. Coronal access and endodontic instrumentation using round 'urs, stainless steel files, and /rofile =) rotary files .ere completed for each tooth. )he prepared root canal system of each tooth .as filled .ith saline solution +group %,, US/ Ca+:;,! +group !,, or Metapaste +group ,. )he apicies and access openings .ere sealed .ith composite resin and the teeth .ere immersed in saline. &fter $ days, the roots of %0 teeth from each group .ere sectioned horiDontally into %#mm thic2 dis2s and each dis2 .as loaded to fracture at !.5 mmEmin .ith a S&)EC universal#testing machine. &fter %"$ days the same procedure .as performed on the remaining %0 teeth in each of the groups. )he pea2 load at fracture .as measured for each dentin dis2. Data .ere analyDed using one#.ay &N:F& and a post hoc Student#Ne.man#Geuls test. &fter $ days e*posure to the test solution, there .as no difference in the pea2 load at fracture for the three groups of teeth. ;o.ever, after %"$ days, the roots of the teeth e*posed to US/ Ca+:;,! sho.ed a significant decrease in pea2 load at fracture .hen compared to the $#day groups and the %"$#day groups e*posed to saline or Metapaste.
From ROOTS, May 11, 2007 As I promised, here is the private communiqu !ith "r# A$$ott !hich I post !ith his prior permission# I admire %au& tremendous&y#####his c&ear cut &ine o' thin(in) and his 'antastic sty&e o' teachin)# %&ease read his tit&es and responsi$i&ities under his si)nature# *e is quite a $usy man######yet in the &ast + years, he has ,-.-R 'ai&ed to ans!er anythin) I have as(ed him in private or pu$&ic# Teachers &i(e "r# A$$ott, Fred /# and /en Schein are treasures and sad&y, some o' the 'e! remainin) )ood 0dinosaurs0 roamin) the &andscapes o' endodontics ###11 "r# Ahmad Tehrani *i Ahmad, Than(s 'or your messa)e# I !as not at the AA- meetin) in %hi&ade&phia this year due to other internationa& &ecturin) commitments as !e&& as !or( $ac( home# *o!ever, I !i&& $e at the IF-A 2or&d 3on)ress in .ancouver in Au)ust this year, and then the -S- meetin) in Tur(ey in Septem$er# *ope'u&&y !e can meet up at one o' those meetin)s instead# I encoura)e you to come a&on) to the IF-A 3on)ress especia&&y as it promises to $e a )reat scienti'ic meetin)# I am happy 'or my comments to $e posted on Roots 4 and I !ou&d $e interested in seein) any comments that my thou)hts )enerate 'rom your co&&ea)ues# The issue o' !hether 3a1O*52 !ea(ens endodontica&&y4treated teeth is an interestin) topic $ut one !hich I thin( has yet to $e 'u&&y investi)ated# In particu&ar, the question in my mind is !hether the !ea(enin) sho!n in some studies 1e#)## immature sheep teeth5 is re&evant 'rom a human c&inica& perspective !ith respect to the tooth that I am a$out to treat !hich has an open ape6, an in'ected root cana& system and apica& periodontitis#

The studies that have investi)ated this topic have not app&ied 'orces to the teeth in the same !ay as !ou&d occur in the mouth 4 typica&&y, !e are ta&(in) a$out anterior teeth and trauma 'orces# These 'orces are typica&&y an 0impact $&o!0 or a 0catastrophic 'orce0 1i#e# sudden, severe, quic(, very short app&ication time5 and they are usua&&y app&ied 'rom a &a$ia& direction and not as a continuous 'orce such as that app&ied $y Instron testin) machines 4 these machines typica&&y app&y a &oad at one point 1dependin) on the set up used5 and the &oad is then )radua&&y increased 1the rate o' increase can $e varied5 unti& the tooth 'ractures# That is, it is not typica&&y an impact 'orce as in trauma# These studies have a&so used di''erent teeth 4 sheep, humans, etc# They have used di''erent 'orms o' 3a1O*52 and this may a''ect the resu&ts# 7ens Andreasen !as visitin) our Schoo& in %erth, Austra&ia in Fe$ruary this year and !e discussed this in detai&# *e to&d me that a study is $ein) done to &oo( at di''erent 'ormu&ations o' 3a1O*52 and it &oo(s &i(e this may $e a 'actor 4 $ut these resu&ts have not $een pu$&ished any!here yet 4 hope'u&&y !e !i&& see them soon# 3ertain&y my o!n c&inica& e6perience !ou&d su))est to me that any !ea(enin) 1i' it does occur5 is very minima& since I have had on&y a$out 849 patients 1at &east that I remem$er5 !ho have returned to see me !ith 'ractures o' the teeth 'o&&o!in) &on)4term 3a1O*52 treatment o' !ide cana&s# In every one o' these cases, the 'racture has occurred as a resu&t o' 'urther trauma to the teeth 4 I do not reca&& any o' these teeth 'racturin) 0spontaneous&y0 or durin) norma& che!in) $itin) or 'unction# -ach tooth !as quite immature !hen the ori)ina& ape6i'ication treatment !as commenced and the on&y 2 options avai&a$&e 'or the patients at that time !ere to do the ape6i'ication or to e6tract the tooth# Retention o' the tooth !as in the $est interests o' the patients, as I suspect !ou&d $e the usua& scenario 'or most youn) patients !ith trauma to their anterior teeth at such a youn) a)e# The &iterature does te&& us that some chi&dren:peop&e are 0accident prone0 and so 'urther trauma to a tooth is a&!ays possi$&e# I $e&ieve it !as the 'urther trauma to the teeth that &ed to the 'racture rather than the 'act that I used 3a1O*52 in the cana&s# I' the 'urther trauma had not occurred then it is &i(e&y that the teeth !ou&d not have 'ractured# It cou&d a&so $e ar)ued the other !ay 4 that is, the 3a1O*52 &ed to the 'racture 4 $ut i' so, !hy did the 'racture not occur sooner and !hy on&y !hen the tooth !as (noc(ed a)ain; I accept that the 3a1O*52 may have !ea(ened the tooth !hich may have meant that it !as more &i(e&y to 'racture !hen (noc(ed $ut !hat is there to say that the tooth !ou&d not have 'ractured any!ay once (noc(ed a)ain; At this point in time, I do not thin( !e have an idea& rep&acement 'ro 3a1O*52 as a medicament 4 'rom $oth an anti$acteria& point o' vie! and as a 0hard tissue stimu&ant0 'or ape6i'ication# Some c&inicians are suin) MTA as an apica& $arrier $ut this is not an easy materia& to p&ace accurate&y and I !orry a$out ine6perienced )enera& dentists attemptin) this on <ust the occasiona& $asis# I have seen a num$er o' such attempts !hich have required sur)ery due to )ross e6trusion o' the MTA throu)h the apica& 'oramen and

then causin) 'orei)n $ody reactions# *ence, much caution is needed, I $e&ieve, in promotin) such techniques that have yet to $e proven scienti'ica&&y to $e advanta)eous## The options 'or the tooth have to $e considered on a case $y case $asis# In most situations, I !ou&d sti&& pre'er to use 3a1O*52 as it is predicta$&e in most respects# I' a 'racture does occur &ater, then so $e it 4 and I reco)nise:accept that this is a sma&& ris( and one that can not $e avoided i' 'urther trauma occurs# 2e need to $e a!are o' the potentia& that this may occur $ut !e shou&d not 0'ear0 that it !i&& occur in the occasiona& case# The occurrence o' such 'ractures 1a)ain in my o!n e6perience and !ithout scienti'ic eva&uation5 is too rare to !arrant chan)in) !hat I current&y do# I a&so accept that nothin) &asts 'orever in dentistry and other treatment may $e required &ater# A&& treatment !e do is a compromise to the tooth 4 $ut the rea& compromise has a&ready occurred to the tooth $e'ore the patient came to see me 1i#e# the caries, the in'ection, the trauma, etc that &ed to the need 'or the endodontic treatment5# *ope this he&ps and that it stimu&ates some comments# 3heers, %au& %ro'# %au& .# A$$ott %ro'essor o' 3&inica& "entistry *ead 4 Schoo& o' "entistry "irector 4 Ora& *ea&th 3entre o' 2A "eputy "ean 4 Facu&ty o' Medicine, "entistry = *ea&th Sciences >niversity o' 2estern Austra&ia 17 Monash Avenue ,-"?A,"S 2A +00@ Austra&ia