Original Contributions

The double-edged sword of calcium hydroxide

in endodontics
Precautions and preventive strategies for extrusion injuries
into neurovascular anatomy
Alan H. Gluskin, DDS; Gordon Lai, DDS; Christine I. Peters, DMD;
Ove A. Peters, DMD, MS, PhD

ABSTRACT

Background. Nowhere in the consideration of dental care involving endodontics does a patient
become more vulnerable to potentially life-changing injuries than during a root canal procedure on
the mandibular dentition that may invade and injure the neurovascular anatomy.
Case Description. The authors present a series of 5 cases wherein using calcium hydroxide as a
disinfection strategy in endodontics caused serious neurologic injury to the treated patients. The
mechanism in all cases was the inappropriate use of needle applications resulting in significant
overfill into the inferior alveolar nerve space. Although calcium hydroxide has been recognized and
used as a meaningful disinfectant in endodontic therapy for many years, the dangers and risks
associated with a needle delivery technique are discussed and analyzed with recommendations based
on current research to minimize risk.
Conclusions and Practical Implications. A literature search revealed that the 5 cases are not
solitary cases; indeed, consequences of calcium hydroxide overfills have been described before.
Therefore, a clinician initiating root canal therapy on a mandibular posterior tooth should always be
mindful of the vital neurovascular anatomy, which commonly approximates the ends of these roots.
Preoperative cone-beam computed tomographic imaging and the thoughtful delivery of medica-
ments in treatment can help the clinician manage close proximity to neural anatomy and avoid
potential injuries.
Key Words. Endodontic therapy; alveolar nerve; clinical competence.
JADA 2020:n(n):n-n
https://doi.org/10.1016/j.adaj.2020.01.026

E
ndodontic care and the clinical challenges in treating the complex anatomy of posterior teeth
confront the practitioner with inherent risks that might not be appreciated at the inception
of treatment. Standards of good practice require any clinician to appreciate those risks and
protect their patients from undue harm. Seldom do patients become more potentially vulnerable to
life-changing injury than during root canal treatment on the mandibular dentition that invades and
injures the neurovascular anatomy of the inferior alveolar nerve and its mental distribution.1,2
Overfill injuries expose the patient to both the chemical injury caused by the material and the
compressive damage caused by that material expressed within the confines of a space meant to be
occupied by the neurovascular anatomy only. These outcomes can have both enduring and life-
changing repercussions of pain and numbness (paresthesia and anesthesia) concurrently, as well
as burning pain (dysesthesia) that most often contributes to the feeling of misery and hopelessness of
the patient’s situation.
For several decades, the specter of substantial overfill of endodontic materials has been reported
by various authors in the oral health care literature.3-5 Frequently, these articles find their way into
journals that feature endodontic research and case reports targeting either endodontists or general
Copyright ª 2020
practitioners who regularly provide endodontic treatment. This can result in a lack of information
American Dental
for many readers of general oral health care literature who might underestimate the dangers and Association. All rights
outcomes of these overfill events. reserved.

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ABBREVIATION KEY
IAN: Inferior alveolar nerve.
2 JADA n(n)
In this article, we focus on overfill outcomes associated with calcium hydroxide and the
sequelae of delivery through a syringe. The dangers and risks associated with this delivery tech-
nique are discussed and analyzed, with recommendations based on research to minimize
the possibility of adverse outcomes. We highlight potential knowledge gaps and provide directions
for future experimental studies in the delivery and safe application of calcium hydroxide therapy.
BIOLOGICAL IMPLICATIONS OF OVERFILL INTO NEUROVASCULAR ANATOMY
Essential goals in endodontic treatment protocols all emphasize the importance of managing pulpal
pathosis with a formal and efficient clinical strategy to maximize success and preserve the natural
dentition. In all phases of endodontic therapy, disinfection protocols in treatment, including the use
of the rubber dam, are stressed. It is essential to remove the pathogenic organisms with the un-
derstanding of the universally recognized reality that endodontic pathosis is a microbial disease and
success requires effective removal of the causative agents to effect successful healing.
Effective chemomechanical debridement during the preparation of the canal space is recognized
as a crucial step for root canal prognosis. However, complete and total elimination of bacteria is not
achievable with current technologies. The use of interappointment medications, such as calcium
hydroxide, is thought to help remove persistent bacteria and biofilms.6-8
Since calcium hydroxide’s introduction almost 100 years ago, it has been widely used in
endodontics.9,10 In an aqueous solvent, it has a strong alkalinity with an approximate pH of 12
through 13; calcium hydroxide has the ability to separate into its component calcium and hy-
droxyl ions through the process of dissociation in solvent. A variety of biological properties have
been attributed to this substance, such as antimicrobial activity, an ability to dissolve unin-
strumented or remaining tissues, and an inhibition of cellular activity that promotes resorption
while acting as a stimulus in the promotion of hard tissue formation.11,12 Because of these and
other properties and effects, calcium hydroxide use in endodontics facilitates repair and health in
a number of challenging clinical scenarios. This compound and its various medical-grade for-
mulations are recognized as being important and one of the most advantageous antimicrobial
dressings recommended for root canal treatment.
Because the pH of calcium hydroxide is highly alkaline, numerous bacterial species that are
commonly found in infected root canals can be rendered inactive or killed when in direct contact
with this material.13 The dissociated hydroxyl ions are oxidant free radicals that destroy cell
membranes and make cells vulnerable to damage of their DNA and mitochondria.14 This reactivity
is high, and the lethal effects on bacterial cells within the canal spaces are due to membrane
damage, protein denaturation, and DNA damage affecting replication.13,15
Biofilms that harbor bacterial colonies can be found throughout all phases of the infectious
process. They grow on the dentin walls, within the tubules, and on the extraradicular portions of the
root apexes. The literature depicting the pathogenesis of endodontic disease describes the effec-
tiveness of this medicament in diffusion through inaccessible areas within the pulpal space, as well
as the dentinal tissues themselves.16,17 Disinfection is achieved by the use of both intracanal me-
dicaments, such as calcium hydroxide, and the agitation and flushing action, which occurs during
the use of irrigating solutions. The ultimate outcomes of this agitation are the mechanical removal
and disruption and dislodgement of the bacterial plaque that harbors these detrimental organisms
and their by-products, as well as the smear layer that is consistently created during routine
instrumentation.18 When treatment requires several appointments, the use of calcium hydroxide
between appointments provides additional opportunities for disinfection.7,19
The development of disinfection protocols over the years was derived from classic studies that
used both aerobic and anaerobic methodologies in culturing techniques that would be considered
basic and outdated by today’s standards.20,21 Researchers of contemporary studies cite molecular as
well as sophisticated imaging technologies that give clinicians a stronger sense of the complexity
and symbiotic relationships between the legions of organisms now recognized as participants in
these infectious processes. It is also well known that these biofilms and their associated by-products
can endure and live on in unreachable areas within the canal space, which can confound even the
most ardent practitioner of state-of-the-art endodontics.22 These researchers make it amply clear
that the goal is disinfection as opposed to sterilization and that our objective is achievable if we
recognize that this important paradigm is our single most credible target in making sure that we can
provide the patient with a reliable mechanism that can support good healing. Medicaments such as
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Figure 1. Dysesthesia (burning pain) and paresthesia are serious postoperative symptoms associated with a substantial
mandibular molar overfill of calcium hydroxide into the inferior alveolar nerve canal delivered by syringe and needle
insertion in this woman.

calcium hydroxide, used between appointments, will dramatically aid in the reduction of microbial
populations and their by-products,23 while creating an obstacle for regrowth. In addition, it is
important to recognize the potential for recontamination of the root canal space should there be
existing deficiencies in the coronal seal of the restoration; calcium hydroxide and its formulations
can help address these conceivable risks. It is advised to carefully attempt to fill the canal in its
entirety.24 Calcium hydroxide is the primary choice of intracanal medicament.25-27 It is important
for all clinicians to recognize that a material with such high alkalinity will remain maximally toxic
when newly administered and all precautions should be taken to prevent the inadvertent possibility
of overfill into the neurovascular tissues. Therefore, when there is proximity to the neurovascular
anatomy, the strong recommendation is to choose a delivery method based on safety and not on
ease of use or expediency of delivery.
One of the most common placement techniques for calcium hydroxide is delivery with a
needle and syringe.28-30 The efficiency of delivery is aided by the operator making sure that
the root canal is sufficiently debrided and opened to allow the needle to gain access to the
depth and position desired. The gauge of the selected needle should be determined so that it
can be placed loosely in the canal at the required depth. A number of factors will determine
depth, such as root length and curvature of the canal, as well as the apical morphology.
Clinicians must be careful not to place excessive force on the syringe during the placement of
any formulation of calcium hydroxide. This conscious awareness of technique will help ensure
that the needle is free to move at the determined depth and be withdrawn from the canal.
Slow injection and constant movement out of the canal as the material is injected is critical
to safe and effective delivery.31-33
If it is determined that a given case has a predisposing risk of calcium hydroxide overfilling
into the periradicular tissues, such as can occur if the apexes are immature; there is a suspected
perforation; or there is intimate proximity to neurovascular anatomy, then the clinician
should proceed with great caution or consider an alternate technique for delivery of the medica-
ment.34-36
Emergency pulpal therapy in dental offices is a common circumstance. General dentists are often
the first responders when patients seek help in resolving the pain and saving their tooth. Many
practitioners choose calcium hydroxide as a medicament when the time for an urgent care pro-
cedure is lacking or unscheduled. As such, at emergency visits, canals are often not enlarged or
shaped to the needed requirements for final disinfection and obturation. Before the patient can be

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 Figure 2. An overfill of calcium hydroxide into the inferior alveolar nerve canal. When the patient reacted in pain during
the procedure, she was told that it was “important to get the material down to the end of the root.” This injury has
resulted in permanent numbness and pain in the lower right lip and chin caused by a liquid calcium hydroxide
medication administered by needle injection.

Figure 3. Substantial amounts of calcium hydroxide delivered to the inferior alveolar nerve canal through a bound
needle and excessive pressure on the delivery syringe. This man has endured several years of ongoing dysesthesia and
pain since the injury.

referred to an endodontist, or returns for completion of the root canal treatments, clinicians might
be motivated to place the calcium hydroxide in as expedient a manner as possible. This often
involves placement of calcium hydroxide using a needle application.28,30
Although calcium hydroxide has been described extensively as effective in root canal
debridement for its specific array of activities against microorganisms, its effects on human cells
and tissue have considerable potential for damage that injures and harms in ways that alter well-
being and impact daily life. Specifically, calcium hydroxide in direct contact with collagen in
human connective tissues creates a zone of necrosis, which alters both the physical and chemical
status of intercellular substances. Through rupture of glycoproteins, this alteration contributes
to protein denaturation. In studies assessing damage to the alveolar nerve of intentionally
introduced calcium hydroxide expression into the mandibular canal of experimental
animals, degeneration was observed in places where calcium hydroxide came in contact with the
nerve.37 The changes visible in the neural tissues within days after contact were characteristic of
so-called Wallerian degeneration, which is the interruption of nerve cell bodies that leads to cell
death.37

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Figure 4. A. The patient has persistent pain and numbness as a permanent sequelae of the gross overfill of calcium hydroxide with a needle bound
deep in the canal after a root perforation. The cone-beam computed tomographic scan shows the extent of the overfill. Pain is exacerbated during
exercise or exposure to cold windy weather. This injury was a substantial loss for the patient who had been a highly competitive athlete her entire life and
was actively competing up to the point of her injury. B. Significant amounts of remaining calcium hydroxide after the extraction of tooth no. 19. Owing to
treatment delays, there was concern about a more invasive removal of calcium hydroxide making symptoms worse. Timely removal of the overfill
would include decompression of the inferior alveolar nerve canal with exploration and debridement of the calcium hydroxide.

Figure 5. An egregious calcium hydroxide with iodoform overfill of tooth no. 31 into the inferior alveolar nerve.
The patient described a severe jolting sensation in her jaw during application of the material. Since the incident the
patient has been numb with pain in her lip and chin. Again, needle binding and excessive pressure has made this
injury a life-changing incident for this woman.

In 5 cases (Figures 1-5), the combination of a less viscous or more fluid formulation of calcium
hydroxide, a needle placed within a canal that is either forced apically or unintentionally locked in
an insufficiently shaped canal, a lack of clinician diligence in monitoring the pressure placed on the
syringe, or a lack of monitoring the previously expressed amounts of the medicament can create a
“perfect storm” leading to overfill. Inattention and carelessness have the potential to result in a
severe and life-changing neurologic injury, especially in cases in which the mandibular tooth and
the neurovascular anatomy are intimately related.

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 Table. Summary of case reports with calcium hydroxide overfill during root canal treatment.

DELIVERY TOOTH OR TEETH

STUDY SYSTEM TREATED TYPE OF INJURY
De Bruyne and Not reported No. 9 Gingival necrosis in anterior maxilla region
Colleagues,39 2000

De Moor and Syringe, 12 cases: maxillary central Multiple cases that varied in terms of pain and swelling
Colleagues,40 2002 spiral filler incisor (n ¼ 10), maxillary
lateral incisor (n ¼ 1),
mandibular first premolar
(n ¼ 1)

Lindgren and Syringe No. 31 Extrusion in IAN* leading to facial nerve paralysis, trigeminal
Colleagues41 2002 paresthesia, and facial ischemia

Ahlgren and Syringe likely No. 29 Extrusion in IAN leading to pain and swelling followed by lower
Colleagues,38 2003 lip paresthesia

Bramante and Spiral filler No. 7 Gingival necrosis adjacent to tooth

Colleagues,10 2008

Orucoglu and Spiral filler No. 22 Persistent exogenous material but patient was asymptomatic
Colleagues,9 2008

Sharma and Syringe First case no. 18, second First case extrusion in external carotid bed leading to facial
Colleagues,36 2008 case no. 15 ischemia and facial nerve palsy, IAN anesthesia; second case into
infraorbital artery leading to infraorbital pain and swelling and
infraorbital nerve anesthesia

Soomro and Spiral filler No. 8 Persistent exogenous material but patient was asymptomatic
Colleagues,43 2010

Ikawa and Syringe First case no. 11, second First case extrusion in maxillary sinus, second case into
Colleagues,30 2012 case no. 12 infraorbital space leading to left cheek hypesthesia

Shahravan and Syringe No.12 Gingival necrosis adjacent to tooth

Colleagues,34 2012

Olsen and Syringe First case no. 31, second Both cases involved extrusion in IAN leading to paresthesia
Colleagues,28 2014 case no. 29

Siquet and Syringe No. 30 Extrusion in IAN leading to numbness of left chin
Colleagues,33 2015

Byun and Syringe likely 9 cases: mandibular first 9 cases with varying degrees of altered sensation
Colleagues,4 2016 premolar (n ¼ 1),
mandibular first molar
(n ¼ 2), mandibular second
molar (n ¼ 6)

Shin and Syringe likely No. 19 Extrusion in IAN leading to paresthesia of left mandibular area
Colleagues,42 2016

Nevares and Syringe First case no. 9, second Both cases involved persistent hardened exogenous material
Colleagues,32 2018 case no. 10

Montenegro Fonsêca Syringe No. 19 Extrusion in soft tissue and IAN leading to paresthesia of left
and Colleagues,44 mandibular area
2019

* IAN: Inferior alveolar nerve.

PREVALENCE
Although neurovascular accidents with calcium hydroxide related to extrusion have been regarded as
rare, their true frequency remains unknown. The limited number of case reports4,9,10,28,30,32-34,36,38-44
(Table) can only provide an estimation because a larger number of accidents might not be reported or
reach publication, other than in judicial records of malpractice proceedings. In our search through the
literature, we were able to identify a limited number of case reports and case series on calcium
hydroxide extrusion accidents.

SUSPECTED CAUSES OF OVERFILLS WITH DAMAGE TO THE INNERVATION

Investigators in several of the case reports we identified discussed possible causes for the calcium
hydroxide extrusion. The incident rate appears to be higher with low-viscosity calcium hydroxide
and with the use of pressure irrigation needles.28,42,44 One suspected cause with needle application

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was that a needle can bind in the canal during delivery, allowing excessive pressure. Another
referenced cause was an enlargement of the apical terminus due to overinstrumentation, or the
tooth having an immature apex, or resorption in conjunction with proximity to surrounding
structures, such as the sinus or the inferior alveolar nerve.34,41 An additional possibility to consider
is that the higher number of injuries reported with the use of syringes could be due to the fact that
syringe delivery might be used more frequently than any other delivery mechanism owing to its
expediency and efficiency of use. Results of a 2017 survey showed that syringe delivery applications
were used twice as frequently as spiral filler delivery in calcium hydroxide placement.45
The amount of calcium hydroxide that is extruded through the apical foramen during syringe
delivery can depend on various technique-related parameters. The viscosity of calcium hydroxide
used, the type of needle (open-ended versus side-vented), or the gauge of the needle can have an
effect on the amount of extrusion, similar to studies on sodium hypochlorite and associated acci-
dents.36,46 The depth of placement of the needle can play a critical role, as can the final dimensions
of the apical terminus or the prepared taper of the canal.29,47,48 Finally, operator management of the
syringe and manual pressures placed on the plunger can be decisive for the amount expressed from
the syringe and into the path of the overfill.31,49
In addition, cone-beam computed tomographic studies of the anatomic proximity of the inferior
alveolar nerve canal from posterior molar roots showed distal root distances of second molars
averaged 1.42 millimeters in all patients.50 Those distances were even shorter in female patients. In
another study of 23,000 scans, researchers found substantially shorter distances in molar relation-
ships to the inferior alveolar nerve canal in female patients than in male patients.51 These data
contribute to the understanding that female patients might be more vulnerable to this injury than
their male counterparts owing to their anatomically closer distances.

INTERVENTION OPTIONS
Clinicians who have experience in treating this type of overfill injury to the neurovascular anatomy
are knowledgeable of the time constraints that many surgeons place on effective intervention. The
literature recommends an immediate assessment of symptoms and a thorough discussion with pa-
tients on the timing and prognosis for an intervention to remove the overfill surgically; when
warranted after a specialist consultation, the overfill should be removed surgically if neurovascular
damage is suspected.1,52 In a published case series of calcium hydroxide overfills into the inferior
alveolar nerve space in which all patients experienced neurosensory injury, the results established
that expedient management of the overfill site through decompression and debridement techniques
can improve the prognosis in these overfill cases.53 However, surgical management was less effective
in cases of nerve injury in which an overfill involved widespread distribution of the medicament and
excessive wait times.1
In a study of 61 patients experiencing endodontic sealer overfill into the inferior alveolar nerve
space conducted over an 8-year period, the author reported that 5 of these patients underwent
exploration, removal, and decompression treatment within 48 through 72 hours, and all recovered
completely.1 This observation and other clinical reports have contributed substantially to the un-
derstanding that no matter the material, overfill within the inferior alveolar structures has a much
better prognosis when removed expeditiously.

RECOMMENDED PROTOCOLS FOR SAFE DELIVERY OF CALCIUM HYDROXIDE

Based on the treatment rendered in case reports (Table), as well as established guidelines on how to
manage extrusion injuries,54-56 the following are some reasonable and responsible recommendations
to follow when using calcium hydroxide as an interim medicament:
" carefully evaluate radiographs and cone-beam computed tomographic imaging to identify whether
teeth are in close proximity to the inferior alveolar nerve or sinuses;
" take special care to prevent overinstrumentation of mandibular premolar and molar apexes, which
often contributes to the extrusion of materials;
" consider using a spiral filler (hand-rotated or engine-driven) or paper point application as a safer
alternative to syringe needle delivery;
" follow the manufacturer’s guidelines with regard to specific calcium hydroxide delivery in-
structions, should you choose delivery through a syringe as often manufacturer warnings are
insufficient in identifying operator errors or necessary patient assessment after overfill;

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 " be sure to enlarge the canal enough so that the needle does not bind in the canal when injecting,
and prior gauging of needle size and depth is recommended;
" use slow injection and constant outward movement from the canal as the material is injected;
" avoid all excessive pressures during the placement of any formulation of calcium hydroxide to
ensure the needle has space to be maneuvered and removed;
" all anatomic relationships of the tooth and the neurovascular anatomy should be imaged and
assessed, and if there is a predisposing risk, such as intimate proximity, extreme caution is rec-
ommended or an alternate technique should be chosen;
" obtain appropriate postoperative periapical radiographs to check for any extrusion of dressing or
filling materials into the inferior dental canal or around the mental foramen or other vital structures;
" document events and refer to an oral surgeon or endodontist for follow-up if the patient reports
any postoperative symptoms of paresthesia, dysesthesia (burning pain), or numbness within the
first 24 to 72 hours;
" In severe cases, surgical intervention might be required to debride and remove the calcium hy-
droxide from the injured neurovascular site;
" time is critical in this true neurologic emergency.

FINAL CONSIDERATIONS
In the interest of patient well-being, all clinicians need to be aware of the potential for an overfill
mishap when performing endodontic procedures on posterior teeth with close juxtaposition to
neurovascular anatomy.57 Consideration must include the procurement of diagnostic-quality images
that accurately show the crestal borders of the inferior alveolar nerve canal. Cone-beam
3-dimensional computed tomographic imaging software assists greatly in evaluating the inferior
alveolar nerve canal position for planning the delivery of medicaments in close proximity.
In addition, the delivery of all calcium hydroxide products should be analyzed cautiously for
safety. Inadequate shaping of the root canal space, needle delivery that binds in the canal, and a
product with low viscosity can produce an overfill that can cause serious injury and compromise
patient health.46
Mishaps such as overfill into neurovascular anatomy can result in devastating deficits for a patient
receiving endodontic care. Permanent alteration of sensory input through chemical or compression
insult resulting in paresthesia or dysesthesia from the components of root canal medicaments such as
calcium hydroxide will have a cytotoxic effect on those vulnerable structures.58
Consequently, should a patient exhibit neuropathic indications that they have experienced
injury in the first 24 through 48 hours after an endodontic procedure, an advisable microsurgical
consultation is warranted. This referral should be considered a true neurologic emergency, in light of
the known recommendations for expedient diagnosis. Referral to a surgeon skilled in microsurgery,
whether an oral surgeon or endodontist, is time dependent.1,52,59,60
Because only a few case reports documenting these types of injuries are found in the literature,
contributing to an online database for practitioners to report these injuries will provide clinically
meaningful parameters, which can be studied to help develop future guidelines regarding best
practices to avoid and manage these incidents. The US Food and Drug Administration has
developed an adverse event reporting program in which clinicians can report these types of in-
cidents and the medical products used (https://www.fda.gov/safety/medwatch-fda-safety-
information-and-adverse-event-reporting-program). The Web site can act as an important
resource to our profession.
Future research should address improvements in delivery systems, whether they use needles or
other delivery applications, so that clinicians are able to monitor pressures and amounts of material
already rendered within the root canal.

CONCLUSIONS
Overfills of medication or obturation materials in endodontic treatment can cause permanent
neurologic injury. Loss of sensation and its impact on quality of life can affect both the patient and
the clinician for a lifetime. We must recognize the severity of these injuries to the mandible and
encourage reflection on the safe and prudent practice of endodontics that promotes safeguards to
prevent such injuries.3 We have a moral obligation to our patients to protect them from harm and
to practice under safe and sensible directives. n

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Dr. Gluskin is a professor and the vice chair, Department of Endodontics,
Arthur A. Dugoni School of Dentistry, University of the Pacific, 155 5th St,
San Francisco, CA 94103, e-mail agluskin@pacific.edu. Address corre-
spondence to Dr. Gluskin.
Dr. Lai is an endodontic resident, Department of Endodontics, University
of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, CA.
Dr. Christine Peters is a professor, endodontics, Department of
Endodontics, University of the Pacific, Arthur A. Dugoni School of
Dentistry, San Francisco, CA.
1. Pogrel MA. Damage to the inferior alveolar
nerve as the result of root canal therapy. JADA. 2007;
138(1):65-69.
2. Gonzalez-Martin M, Torres-Lagares D, Gutierrez-
Perez JL, Segura-Egea JJ. Inferior alveolar nerve paresthesia
after overfilling of endodontic sealer into the mandibular
canal. J Endod. 2010;36(8):1419-1421.
3. Gluskin AH. Anatomy of an overfill: a reflection on
the process. Endod Topics. 2009;16(1):64-81.
4. Byun SH, Kim SS, Chung HJ, et al. Surgical man-
agement of damaged inferior alveolar nerve caused by
endodontic overfilling of calcium hydroxide paste. Int
Endod J. 2016;49(11):1020-1029.
5. Poveda R, Bagan JV, Fernandez JM, Sanchis JM.
Mental nerve paresthesia associated with endodontic paste
within the mandibular canal: report of a case. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod. 2006;102(5):e46-
e49.
6. Farhad A, Mohammadi Z. Calcium hydroxide: a re-
view. Int Dent J. 2005;55(5):293-301.
7. Sjögren U, Figdor D, Spångberg L, Sundqvist G.
The antimicrobial effect of calcium hydroxide as a short-
term intracanal dressing. Int Endod J. 1991;24(3):119-
125.
8. Cvek M, Hollender L, Nord C. Treatment of
non-vital permanent incisors with calcium hydroxide,
VI: a clinical, microbiological and radiological evalu-
ation of treatment in one sitting of teeth with mature
or immature root. Odontol Revy. 1976;27(2):93-108.
9. Orucoglu H, Cobankara FK. Effect of unintentionally
extruded calcium hydroxide paste including barium sulfate
as a radiopaquing agent in treatment of teeth with peri-
apical lesions: report of a case. J Endod. 2008;34(7):888-
891.
10. Bramante CM, Luna-Cruz SM, Sipert CR, et al.
Alveolar mucosa necrosis induced by utilisation of calcium
hydroxide as root canal dressing. Int Dent J. 2008;58(2):
81-85.
11. Mohammadi Z. Endodontics-related paresthesia of
the mental and inferior alveolar nerves: an updated re-
view. J Can Dent Assoc. 2010;76:a117.
12. Byström A, Sundqvist G. Bacteriologic evaluation
of the efficacy of mechanical root canal instrumentation
in endodontic therapy. Eur J Oral Sci. 1981;89(4):321-
328.
13. Siqueira JF Jr., Lopes HP. Mechanisms of antimi-
crobial activity of calcium hydroxide: a critical review. Int
Endod J. 1999;32(5):361-369.
14. Imlay JA, Linn S. DNA damage and oxygen radical
toxicity. Science. 1988;240(4857):1302-1309.
15. Silva L, Nelson-Filho P, Leonardo MR,
Rossi MA, Pansani CA. Effect of calcium hydroxide
on bacterial endotoxin in vivo. J Endod. 2002;28(2):
94-98.
16. Han GY, Park SH, Yoon TC. Antimicrobial activity
of Ca(OH)2 containing pastes with Enterococcus faecalis
in vitro. J Endod. 2001;27(5):328-332.
17. Nerwich A, Figdor D, Messer HH. pH changes in root
dentin over a 4-week period following root canal dressing
with calcium hydroxide. J Endod. 1993;19(6):302-306.
18. Shuping GB, Orstavik D, Sigurdsson A, Trope M.
Reduction of intracanal bacteria using nickel-titanium
JADA n(n) n http://jada.ada.org n n 2020
Dr. Ove A. Peters is a professor and the chairperson, Department of
Endodontics, University of the Pacific, Arthur A. Dugoni School of
Dentistry, San Francisco, CA and an honorary professor, University of
Queensland Oral Health Centre, Herston, Queensland, Australia.
Disclosure. None of the authors reported any disclosures.
rotary instrumentation and various medications. J Endod.
2000;26(12):751-755.
19. Katebzadeh N, Sigurdsson A, Trope M. Radiographic
evaluation of periapical healing after obturation of infec-
ted root canals: an in vivo study. Int Endod J. 2000;33(1):
60-66.
20. Moller AJ. Microbiological examination of root ca-
nals and periapical tissues of human teeth: methodological
studies. Odontol Tidskr. 1966;74(5 suppl):1-380.
21. Sundqvist G. Bacteriological Studies of Necrotic
Dental Pulps [dissertation]. Umeå, Sweden: Umeå Univer-
sity; 1976.
22. Siqueira JF Jr., Machado AG, Silveira RM,
Lopes HP, de Uzeda M. Evaluation of the effectiveness of
sodium hypochlorite used with three irrigation methods in
the elimination of Enterococcus faecalis from the root canal,
in vitro. Int Endod J. 1997;30(4):279-282.
23. Tanomaru JM, Leonardo MR, Tanomaru Filho M,
Bonetti Filho I, Silva LA. Effect of different irrigation
solutions and calcium hydroxide on bacterial LPS. Int
Endod J. 2003;36(11):733-739.
24. Galvão T, Camargo B, Armada L, Alves F.
Efficacy of three methods for inserting calcium hydroxide-
based paste in root canals. J Clin Exp Dent. 2017;9(6):
e762.
25. Law A, Messer H. An evidence-based analysis of the
antibacterial effectiveness of intracanal medicaments.
J Endod. 2004;30(10):689-694.
26. Peters CI, Koka RS, Highsmith S, Peters OA. Cal-
cium hydroxide dressings using different preparation and
application modes: density and dissolution by simulated
tissue pressure. Int Endod J. 2005;38(12):889-895.
27. Athanassiadis B, Walsh LJ. Aspects of solvent
chemistry for calcium hydroxide medicaments. Materials
(Basel). 2017;10(10).
28. Olsen JJ, Thorn JJ, Korsgaard N, Pinholt EM. Nerve
lesions following apical extrusion of non-setting calcium
hydroxide: a systematic case review and report of two
cases. J Craniomaxillofac Surg. 2014;42(6):757-762.
29. Staehie HJ, Thomä C, Müller HP. Comparative
in vitro investigation of different methods for temporary
root canal filling with aqueous suspensions of calcium
hydroxide. Dent Traumatol. 1997;13(3):106-112.
30. Ikawa H, Takeyasu Y, Ukichi K, et al. Two patients
requiring surgical management for leakage of calcium hy-
droxide paste from root canal into infraorbital space. Bull
Tokyo Dent Coll. 2012;53(2):83-90.
31. Moser JB, Heuer MA. Forces and efficacy in end-
odontic irrigation systems. Oral Surg Oral Med Oral Pathol.
1982;53(4):425-428.
32. Nevares G, de Melo Monteiro GQ, Sobral APV,
et al. Hardened exogenous material after extrusion of
calcium hydroxide with barium sulfate: case study and
histopathologic and laboratory analyses. JADA. 2018;
149(1):59-66.
33. Siquet J, De Moor R, Meire M. Displacement of
calcium hydroxide paste in the inferior alveolar canal:
transient and permanent paresthesia. Paper presented at:
17th Biennial ESE Congress. September 17, 2015; Bar-
celona, Spain.
34. Shahravan A, Jalali S, Mozaffari B, Pourdamghan N.
Overextension of nonsetting calcium hydroxide in
endodontic treatment: literature review and case report.
Iran Endod J. 2012;7(2):102-108.
35. Tilotta-Yasukawa F, Millot S, El Haddioui A,
Bravetti P, Gaudy JF. Labiomandibular paresthesia caused
by endodontic treatment: an anatomic and clinical study.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;
102(4):e47-e59.
36. Sharma S, Hackett R, Webb R, Macpherson D,
Wilson A. Severe tissue necrosis following intra-arterial
injection of endodontic calcium hydroxide: a case series.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;
105(5):666-669.
37. Nakamura C, Tomida M, Hasegawa H, Kawakami T.
Injury and the recovery reaction due to the penetration of
material into the mandibular canal. In: Kawakami T, ed.
Pathological Basis of Root Canal Restoration: Using Calcium
Hydroxide Paste. Tokyo, Japan: IDP; 2012:39-51.
38. Ahlgren FK, Johannessen AC, Hellem S. Displaced
calcium hydroxide paste causing inferior alveolar nerve
paraesthesia: report of a case. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2003;96(6):734-737.
39. De Bruyne MA, De Moor RJ, Raes FM. Necrosis of
the gingiva caused by calcium hydroxide: a case report. Int
Endod J. 2000;33(1):67-71.
40. De Moor RJ, De Witte AM. Periapical lesions
accidentally filled with calcium hydroxide. Int Endod J.
2002;35(11):946-958.
41. Lindgren P, Eriksson KF, Ringberg A. Severe facial
ischemia after endodontic treatment. J Oral Maxillofac
Surg. 2002;60(5):576-579.
42. Shin Y, Roh BD, Kim Y, Kim T, Kim H. Accidental
injury of the inferior alveolar nerve due to the extrusion of
calcium hydroxide in endodontic treatment: a case report.
Restor Dent Endod. 2016;41(1):63-67.
43. Soomro F, Abidi SYA, Qureshi S, Rashid S,
Hosein T. Effect of accidental periapical extrusion of
calcium hydroxide paste (a case report). J Pak Dent Assoc.
2010;19(1):57-60.
44. Montenegro Fonseca J, Rangel Palmier N, Amaral-
Silva GK, et al. Massive extrusion of calcium hydroxide
paste containing barium sulphate during endodontic
treatment [published online ahead of print November 14,
2019]. Aus Endod J. https://doi.org/10.1111/aej.12382.
45. Madarati AA, Zafar MS, Sammani AMN,
Mandorah AO, Bani-Younes HA. Preference and usage of
intracanal medications during endodontic treatment.
Saudi Med J. 2017;38(7):755-763.
46. Psimma Z, Boutsioukis C. A critical view on sodium
hypochlorite accidents. Endod Pract Today. 2019;13:165-
175.
47. Torres CP, Apicella MJ, Yancich PP, Parker MH.
Intracanal placement of calcium hydroxide: a compari-
son of techniques, revisited. J Endod. 2004;30(4):225-
227.
48. Simcock RM, Hicks ML. Delivery of calcium hy-
droxide: comparison of four filling techniques. J Endod.
2006;32(7):680-682.
49. Boutsioukis C, Lambrianidis T, Kastrinakis E,
Bekiaroglou P. Measurement of pressure and flow
rates during irrigation of a root canal ex vivo with
three endodontic needles. Int Endod J. 2007;40(7):504-
513.
9
50. Koivisto T, Chiona D, Milroy LL, et al. Mandibular
canal location: cone-beam computed tomography exami-
nation. J Endod. 2016;42(7):1018-1021.
51. Simonton JD, Azevedo B, Schindler WG,
Hargreaves KM. Age- and gender-related differences in
the position of the inferior alveolar nerve by using cone
beam computed tomography. J Endod. 2009;35(7):944-
949.
52. Donoff RB. Surgical management of inferior alveolar
nerve injuries, part I: the case for early repair. J Oral
Maxillofac Surg. 1995;53(11):1327-1329.
53. Lee J, Byun S, Kim S, Kim S, Kim M. Surgical
management of damaged inferior alveolar nerve caused by
10
endodontic overfilling. Int J Oral Maxillofac Surg. 2015;44:
e10.
54. Pogrel MA. Nerve damage in dentistry. Gen Dent.
2017;65(2):34-41.
55. Alves FR, Coutinho MS, Gonçalves LS. Endodon-
tic-related facial paresthesia: systematic review. J Can Dent
Assoc. 2014;80(80):e13.
56. Bagheri SC, Meyer RA, Cho SH, Thoppay J,
Khan HA, Steed MB. Microsurgical repair of the inferior
alveolar nerve: success rate and factors that adversely affect
outcome. J Oral Maxillofac Surg. 2012;70(8):1978-1990.
57. Gluskin A. Mishaps and serious complications in
endodontic therapy. Endod Topics. 2005;12:52-70.
58. Mohammadi Z, Dummer PM. Properties and
applications of calcium hydroxide in endodontics
and dental traumatology. Int Endod J. 2011;44(8):697-730.
59. Givol N, Rosen E, Bjørndal L, Taschieri S, Ofec R,
Tsesis I. Medico-legal aspects of altered sensation following
endodontic treatment: a retrospective case series. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod. 2011;112(1):126-
131.
60. Escoda-Francoli J, Canalda-Sahli C, Soler A,
Figueiredo R, Gay-Escoda C. Inferior alveolar nerve
damage because of overextended endodontic material: a
problem of sealer cement biocompatibility? J Endod. 2007;
33(12):1484-1489.
JADA n(n) n http://jada.ada.org n n 2020