International Endodontic Journal (1994) 2 7 , 4 7 - 5 1
A clinical evaluation of one and two-appointment root canal
therapy using calcium hydroxide
L. R. G. FAVA
Rm da Consola(;m 3527, 01416-001 Sao Paulo. Brazil
Summary
A clinical study using vital maxillary central incisors was
performed to evaluate the incidence of postoperative
pain after root canal treatment in one- or two-appoitit-
ments using a calcium hydroxide-containing root canal
sealer. No differences were observed between the two
groups.
Keywords: calcium hydroxide paste, calcium hydroxide-
based root canal sealer, one-appointment therapy.
Introduction
A goal of root canal treatment is the biological closure of
apical foramina by hard tissue deposition. This is
considered by some authors as ideal healing (Gottlieb
et al, 1950, Juge 1959, Matsumiya et al, 1967). The
preservation of pulp stump vitality is an important
factor conducive to this closure (Coolidge & Kesel 1956,
Wolfsohn 1962). Coolidge (1946) stated that the healing
in the pulp stump depends on preserving the vitality of
the remaining apical cells after pulp removal, while
Seltzer et al, (1968) considered this to be the key to
successful resolution of periradicuiar tissue inflammation.
Precise radiographic control, a suitable biomechanical
preparation technique with, or without, final fiiiing
using biocompatible and non-cytotoxic materials mini-
mizes the damage to periapical tissues resulting in a
smaller degree of inflammation and subseqtiently a
lower incidence of postoperative pain. The apical limit of
instrumentation is thus ao important factor to be COD-
sidered. Oliet (1983) observed less postoperative pain
incidence in vital cases treated short ofthe radiographic
apex when compared with overfilled cases after the
one-appointment procedure.
Among the many medicaments used in endodontics,
calcium hydroxide can ftiMl two biological objectives,
namely preservation of the pulp stump vitality and
Correspondence: L. R. G. Fava, Rua da Consolacao 3S27, 01416-001
Sao Paulo, Brazil. : »•
induction and acceleration of hard tissue deposition.
Many studies have been performed in dogs (Stiomberg
1969, Holland eta]. 1971,1978,Hollandl975,Holland
& Souza 1985, Leonardo et al. 1984, Sonat et al. 1990),
.monkeys (Holland et al. 1980, Holland & Souza 1985)
and humans (Leonardo 1973, Leonardo & Holland
1974, Leonardo et al, 1975, 1980, Holland et al 1977,
Fava 1992). Excellent biological and clinical results
have been shown when this medicament was used in
vital cases as a root canal dressing between visits or in
the one-appointment therapy as an apical plug over the
pulp stamp before final filling (HoUand et al, 1971,
1977,1980, Leonardo 1973,Leonardo&Hollandl974,
Leonardo et al, 1975); or as a conventional sealer, but
in a paste form, in combination with the lateral
condensation technique of gutta-percha (Holland &
Souza 1985, Sonat etd. 1990).
The encouraging biological and histopathological
results with the use of calcium hydroxide in the root
canal has led some manufacturers to develop calcium
hydroxide-based root canal sealers, such as Seaiapex
(Sybron/Kerr, Romulus, Michigan, OSA) and CRCS
(Hygienic, Akron, Ohio, USA). Seaiapex is a calcium
hydroxide-containing root canal sealer that was intro-
duced into root canal therapy in the last decade. Since
then few studies have been carried out to evaluate its
effect histopathologically on the pulp stump m cases
where there has been vital pulp extirpation. Holland &
Souza (1985) treated teeth of dogs and monkeys 1 mm
from the radiographic apex followed by the lateral
condensation technique using Seaiapex and gutta-
percha cones. One-hundred and eighty days later most
of the cases showed total closure of the foramina by
cementum deposition, usually directly against the filling
material, while the periapical tissues were free of inflam-
mation. SonatetflL(1990) also employed Seaiapex in the
one-visit treatment in teeth of dogs and observed, 7 days
later, a slight inflammatory infiltrate in the periapical
tissues; however, 30 days later, the same tissues were of
normal appearance and areas of bone and cementum
apposition were detected. Soares etal. (1990) observed.
47
 48 L G, Favtt
in the teeth of dogs treated with Seaiapex, a layer of
necrotic tissue at the interface ofthe filling material and
connective tissue with new hard tissue deposition along
the apical zone of the canal walls. Whilst the above
studies have shown good histopathological reactions
when Seaiapex was employed as the sealer in a one-
appointment root canal therapy, no studies have been
performed in vital teeth of humans tO' evaluate the clini-
cal reactions. The objective ofthis clinical investigation
was to evaulate the incidence of postoperative pain in
teeth with vital pulps that were treated in one or two
visits using a calcium hydroxide-containing sealer.
Materials and methods
Sixty symptomatic upper central incisors of 52 male and
female patients with ages ranging from 14 to 58 years
were used in this study. All patients complained that
pain was mainly elicited by hot drinks and food and some
ofthe patients also related the same symptoms combined
with some spontaneous painful episodes and referred
pain.
The diagnosis of symptomatic pulpitis and the vital
status of the pulp was confhmed by routine diagnostic
tests such as oral and radiographic examination, positive
response to heat stimulation and negative responses to
palpation and percussion tests.
To minimize clinical variables aD procedures were
carried out by the author based on criteria previously
described (Fava 1989, 1991,1992). These were;
(1) the patient should freely accept the one- or two-
appointment treatment together with the criteria
for postoperative pain evaluation;
(2) the teeth had an inflamed vital pulp and no signs
of apical periodontitis (no pain on palpation and
percussion);
(3) only maxillary central incisors were selected for
this clinical evaluation because they had almost
straight roots; and,
(4) the patients were in good general health.
At the first appointment the teeth were anaesthetized,
isolated with the rubber dam and the root canal
accessed. The coronal pulp was removed with sterile
round burs, the pulp chamber was irrigated and a small
endodontic file (size 15 or 20) was introduced into the
root canal for exploration and length determination
according to Ingle et al, (1985), The apical limit of the
preparation was determined 1.5 mm to 2 mm from the
radiographic apex and the pulp tissue was removed at
this limit with a blunted Hedstrom file. The root canals
were cleaned and shaped by the step-back technique
(Weine 1989) using triangular files (Trifile, Sybron/
Kerr, Romulus, Michigan, USA) and thoroughly irri-
gated with an anionic detergent solution (Tergensol,
Inodom, Porto Alegre, RS, Brazil).
After drying of the root canals, the teeth were
randomly divided in two groups. Half of the teeth (group
I) were dressed with a calcium hydroxide paste (Calen,
S.S. White, Sao Paulo, SP, Brazil) which was introduced
with a Lentulo spiral filler. The final fUling of these teeth
was based on the criteria of postoperative pain evalu-
ation described below. If the tooth could not be filled, it
was re-opened, irrigated, dried and re-dressed with the
same calcium hydroxide paste, ff it could be filled, the
final obturation would be carried out using the same
technique described for group n.
The other half of the teeth (group II) were obturated
immediately using gutta-percha cones and Seaiapex
with the lateral condensation technique. Prior to the
insertion of the master cone. Seaiapex was mixed
according to the manufacturer's instructions and carried
into the root canal with a Lentulo spiral filler. During
obturation all accessory cones were coated with a small
amount of sealer. In both groups the excess filling
material was removed from the pulp chamber, a sterile
cotton pellet was placed in the pulp chamber and the
teeth were sealed with a reinforced zinc oxide-eugenol
cement.
The criteria for postoperative pain evaluation were
arbitrary and were the same as described in previous
clinical studies (Fava 1989,1991, 1992). After 48 h the
patients were called on the telephone and asked to report
all postoperative reactions. If an analgesic was not
required and the patient related no minimal discomfort,
the pain was categorized as none to slight. If the patient
reported a tolerable discomfort and slight tenderness on
biting that required a mild analgesic, the pain was classi-
fied as moderate pain. If the patient reported continuous
pain with extreme sensitivity on biting that required a
strong analgesic, it was classified as severe pain. Seven
days later, a second clinical evaluation was performed to
assess the presence of periapical inflammation by percus-
sion and palpation tests. At the same time all patients
were asked to report other reactions they felt between the
second and the seventh day.
Results
The results of the present clinical evaluation showed no
difference in pain incidence between the two groups. In
 Root canal therapy using calcium hydroxide 49
Table 1. Incidence of postoperative pain within 48 h of root canal no inflammatory reaction. According to Souza et al
preparation
(19 8 9) the and-inflainmatory action of calcium hydroxide
is generated by three different mechanisms; (a) hygro-
Treatment None to slight Moderate Severe Total
scopic action, directly related to the absorption of the
infiammatoiy exudate by the paste itself; (b) formation of
Group I 29 1 0 JO calcium protemate bridges, resulting from the reaction of
Group II 28 2 0 30
Total 57 3 0 60
Ca^"'" ions with proteins in close proximity to the inter-
cellular substance of endothelial cells, preventing the
exit of liquids from the blood vessels into the tissues;
and, (c) phosphofipase inhibition by calcium hydroxide,
Table 2. Incidence of pain following percossion and palpation tests thus decreasing cellular lysis and, subsequently, the
1 week after the iirst visit liberation of prostaglandins, one of the mediators of
inflammation.
Treatment Pain No pain Total Leonardo & HoBand (1974) treated human teeth in
one appointment and covered the pulp stump with a
Group I 30 30 paste of calcium hydroxide and distilled water. Acute
Group II 30 30 inflammation was observed in the pulp stump up to the
Total 60 60
third day. These results are in contrast with those
obtained by Esberard (1981). This may be explained
by the nature of the vehicle for the chemical. Whilst
Leonardo & Holland (1974) used a water-soluble ve-
the first evaluation (48 h) only three patients, one in hicle, Esberard (1981) used a viscous or oO-like vehicle.
group I and two in group II, reported moderate pain and It is well known that viscous vehicles have a better per-
use of analgesics. All the others reported none to shght formance over water-soluble vehicles because they pro-
postoperative pain (Table 1). mote a slow ionic dissociation ofthe calcium hydroxide;
The clinical evaluation performed 1 week later also this results in the slower release of Ca^"*" ions and the
showed no difference between the two groups. The paste is more slowly resorbed. This increases the time the
patients who had felt moderate pain at the first evalu- material is in contact with the tissues (Holland et al.
ation reported no pain at the second evaluation during 1983, Bezerra da Silva 1988).
palpation and percussion tests. Patients who had felt The few studies performed in dogs and monkeys whose
slight postoperative discomfort in the initial 48 h period teeth were under-instrumented and obturated with
reported that it had disappeared within the third or Seaiapex and gutta-percha cones showed hard tissue
fourth day after the initial visit (Table 2). Based on these deposition and lack of inflammation in periapical tissues
results, all teeth of group I were obturated in the same in short and longer periods of time {Holland & Souza
way as group II in this session. 1985, Soares et al, 1990, Sonat et al 1990). Unfortu-
nately no human studies havebeen performed to evaluate
the same reactions. But if the above results were
Discussion
correlated with those of group n, it may be considered
The results ofthis clinical evaluation showed no difTerence that Seaiapex is a suitable sealer to be employed in the
in postoperative pain incidence in vital maxillary central one-visit treatment for vital cases. It could be argued that
incisors that were root-treated in one or two visits. Seaiapex did not have any influence in the results ofthe
The low incidence of postoperative pain in group I is in present study. Alagam (1985) treated human vital teeth
agreement with the results of a previous clinical study in one visit using four different sealers and observed no
(Fava 1992). The use of Calen as a dressing for vital cases correlation between the incidence and type of pain and
was based on the results of Esberard (1981). Teeth of the type of the sealer.
dogs were dressed with this paste after vital pulpectomy The results of the present study agree with previous
and, after 2 days, a moderate superficial necrosis was cMnical studies regarding lower postoperative pain
observed in the pulp stump owing to the contact of the incidence in teeth with uncomplicated root morphology
paste with the living tissue. There was a non-significant treated in a single visit. Fox et al (1970) have made a
iitfammatory infiltrate in the periapica! region. Seven distinction between two types of postoperative pain;
days later the pulp stump and periapical tissues showed spontaneous and pericemental. While the spontaneous
50 LG.Fava
pain was determined by questioning the patient and
arises independently of any outside stimulus, perice-
mental pain was determined by the dentist using finger
pressure on the tooth in both vertical and horizontal
directions. These two kinds of pain were coded as none,
slight, moderate and severe. In 104 vital maxillary
central incisors treated in one session they related the
foliowing results for spontaneous pain; none, 83 cases;
slight, 9 cases; moderate, 11 cases; severe, 1 case. For
pericemental pain their results were the following;
none, 63 cases; slight, 22 cases; moderate, 14 cases;
severe, 5 cases. Ashkenaz (1979) reported 195 vital
single-rooted cases treated in one appointment and
found that eight patients experienced pain after the
first day, three had pain lasting 2 days and only two
reported pain lasting for 1 week. Roane et al, (1983)
treated 69 maxillary anterior teeth in one visit and
reported 63 cases of none and shght postoperative
pain. Good results were also achieved by Oliet (1983)
who found a low incidence of postoperative pain in
anterior teeth treated in one session.
The results of the present study also confirm previous
cfinical reports regarding the vital status ofthe pulp. Fox
et al (1970) treated 56 vita! cases in one appointment.
Using the same methodology for postoperative pain
evaluation as that previously described, they reported
the following results for spontaneous pain: none, 42
cases; shght, 7 cases; moderate, 7 cases; and no cases of
severe pain. Their results for pericemental pain were;
none, 29 cases; slight, 14 cases; moderate, 9 cases;
severe, 4 cases. Woich (1975) did not observe any sig-
nificant difference in discomfort between fiDed and
unfilled vital pulpectomy cases. Roane et d, (1983)
treated 153 vital teeth in one appointment and only
18.3% of their cases experienced moderate and severe
pain. Ofiet (1983) performed the one-visit treatment in
145 vital teeth and also reported a low incidence of
postoperative pain within 48 h after the procedure.
Ashkenaz (1984) reported that in only 18 cases (4%) out
of 435 vital teeth treated in one appointment did mild
postoperative pain require a non-narcotic analgesic.
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