ISSN : 1001-1781

Journal of Clinical Otorhinolaryngology, Head, and Neck Surgery

EVALUATION OF PH CHANGES FOLLOWING ROOT CANAL DRESSING WITH

DIFFERENT CALCIUM HYDROXIDE FORMULATIONS: AN IN VITRO STUDY

1.Dr. Jisha Pillai, 2. Dr. Vathsalya Shetty, 3. Dr. Krutika Chudasma, 4. Dr. Heeresh
Shetty, 5. Dr. Anil Richhawal, 6. Dr. Sanpreet Singh Sachdev
1M.D.S, ex-Post Graduate Student, Department of Conservative Dentistry & Endodontics,
Nair Hospital and Dental College, Mumbai
Email: jshpillai@gmail.com
2M.D.S, Professor, College of Dental Science and Hospital, Amargadh, Bhavnagar, Gujarat.
Email: drvathsalyashetty@gmail.com
3M.D.S, Senior Lecturer, Department of Conservative Dentistry and Endodontics
Institute: College of Dental Science and Hospital, Amargadh, Bhavnagar.
Email: krutikachudasama8888@gmail.com
4M.D.S, Department of Conservative Dentistry and Endodontics, Institute: Nair Hospital
Dental College
Email: heereshshetty@yahoo.com
5M.D.S, Associate Professor, Department of Conservative Dentistry and Endodontics
Institute: Y.M.T Dental College and Hospital, Navi Mumbai.
Email: dranildentist9@gmail.com
6M.D.S, Department of Oral Pathology and Microbiology, Institute: Government Dental
College and Hospital, Mumbai.
Email: sunpreetss@yahoo.in
Abstract:
Aim: This study aims to assess alterations in pH subsequent to root canal dressing using four
distinct commercially available calcium hydroxide pastes, with the goal of determining
potential variations in the pH levels of these pastes across designated time intervals.
Materials and Methods:
The study employed a randomized grouping of teeth to assess the impact of four calcium
hydroxide formulations: (1) Calcium hydroxide powder + distilled water (aqueous medium),
(2) Calcium hydroxide + Polyethylene glycol (viscous vehicle), (3) Calcium hydroxide +
Methylcellulose (aqueous vehicle) + Barium sulphate, and (4) Calcium hydroxide + Silicone
oil (oily vehicle) + Iodoform. The pH changes were measured at various time intervals (1 hour,
1 week, 2 weeks, and 4 weeks) after intracanal placement.
Results:
The results indicated varying pH changes over time for each calcium hydroxide formulation.
Group 1 (Calcium hydroxide powder + distilled water) and Group 3 (Calcium hydroxide +
Methylcellulose + Barium sulphate) exhibited a rapid increase in pH, maintaining levels above
10. Group 2 (Calcium hydroxide + Polyethylene glycol) showed a gradual increase, while
Group 4 (Calcium hydroxide + Silicone oil + Iodoform) displayed a slower but sustained pH
increase.
Conclusion:

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In conclusion, the study provides valuable insights into the alkalinizing potential of different
calcium hydroxide formulations, offering guidance for selecting appropriate intracanal
dressings based on the intended duration of endodontic procedures. Further research simulating
in vivo conditions is recommended to validate these findings in clinical scenarios.
Introduction:
Root canal preparation is a critical phase in endodontic therapy, playing a pivotal role in
achieving successful outcomes. Despite the advancements in chemomechanical
instrumentation, it is acknowledged that this alone is insufficient for complete disinfection of
the root canal system.[1] The efficacy of endodontic treatment relies heavily on the reduction
or elimination of bacteria present in endodontic infections.
While procedures such as cleaning, shaping, and irrigating the canal have shown efficacy in
reducing bacterial numbers, complete disinfection remains a challenging objective. In cases
where treatment extends beyond a single appointment, surviving intracanal bacteria proliferate,
emphasizing the necessity for an intracanal medicament.[2] Such a medicament should restrict
bacterial growth, ensure sustained disinfection, and establish a physical barrier. Calcium
hydroxide has gained popularity as an intracanal medicament since its introduction in 1920,
offering qualities such as the promotion of hard tissue formation, antibacterial action, organic
tissue dissolution, alkalinizing effects, inflammation control, and root resorption management.
Its bactericidal effect is attributed to its high pH of approximately 12.5.[3] While calcium
hydroxide is available in various commercial formulations or as a pure powder, the latter is
challenging to place in the canal. Consequently, additives are incorporated to enhance flow and
efficacy, with variations in pH over time proving clinically significant. [4]
In this context, the present study aims to evaluate pH changes following root canal dressing
with four commercially available calcium hydroxide pastes and determine whether their pH
alters within specified time intervals. The objectives include assessing the intracanal root pH
changes of four commercially available calcium hydroxide paste formulations, namely 95%
pure Calcium hydroxide powder in distilled water (Prime Dent), Calcium hydroxide with
polyethylene glycol (Avue Cal), Calcium hydroxide with methylcellulose and barium sulfate
(Calcigel), and Calcium hydroxide with silicone oil and iodoform (Metapex). Additionally, the
study aims to investigate whether the pH of these materials changes over specified time
intervals, measured at one hour, one week, two weeks, and four weeks, to determine which
Calcium hydroxide product exhibits superior alkalinizing potential over time, is suitable for
use as an interappointment intracanal dressing.
Materials and Methods:
The present in vitro study involved a hundred extracted human adult single-rooted mandibular
premolars, sourced from the Department of Oral and Maxillofacial Surgery, with the extraction
performed for orthodontic and periodontal reasons. The selected teeth underwent a meticulous
evaluation to ensure the absence of fractures, cracks, or resorption. Following extraction,
disinfection was carried out using 5% sodium hypochlorite for one hour, and the teeth were
subsequently stored in normal saline until utilization.
The inclusion criteria for specimen selection encompassed the requirement for extracted single-
rooted premolars, ensuring no cracks resulted from extraction, and verifying the absence of
developmental malformations. Conversely, exclusion criteria included the exclusion of teeth
affected by caries, fractured teeth, hypoplastic teeth, and those with calcified canals. The study

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comprised a sample size of 100 single-rooted premolars, and the experimental duration spanned
four weeks.
The methodology involved obtaining single-rooted mandibular premolars free from defects,
followed by cleaning, storing, disinfecting, and handling in accordance with OSHA and CDC
recommendations. Access cavity preparation and instrumentation were performed using
appropriate burs and rotary instruments, with meticulous care taken to ensure proper canal
cleaning and shaping . Subsequently, intracanal dressing placement was carried out, randomly
assigning teeth to different calcium hydroxide formulations. These included Group 1: Calcium
hydroxidepowder + distilled water, Group 2: Calcium hydroxide+ polyethylene glycol, Group
3: Calcium hydroxide+ methylcellulose and barium sulfate, and Group 4: Calcium hydroxide+
silicone oil & iodoform. A control group received no dressing.
The individual tooth of each specimen was dried with paper points and the intracanal dressing
was placed using lentulospiral (Mani) attached to a contra-angle handpiece (NSK) with
micromotor (Unicorn Dentmart) and then condensed with finger pluggers (Mani). A sterile
cotton pellet was placed in a pulp chamber and sealed with glass ionomer cement (G C Gold
label).
Following the intracanal placement of the different calcium hydroxide products, all the samples
were radiographed by using an intraoral radiovisiography machine (Vatech, India). A
customized jig was used to keep the tooth and the sensor in a fixed and repetitive position. The
customized jig was made of an acrylic horizontal block in which a nylon tube was embedded
to hold the tooth in a fixed position while being radiographed and two deep indentations as
sufficient as to fit the sensor of the RVG machine within it was made at a fixed distance from
the nylon tube in buccolingual and mesiodistal direction (Figure. 1).

Figure 1: A) Tooth mounted in a customized acrylic jig for radiovisiography from B)

Buccolingual Direction and C) Mesiodistal direction; D), E), F), G) show radiographic images
of groups I, II, III, IV respectively
Any samples that showed voids or incomplete filling were excluded from the study and were
replaced by another one. The teeth were then stored in individual containers with distilled
water. pH measurements were recorded at 1 hour, 1 week, 2 weeks, and 4 weeks using a
calibrated digital pH meter. The statistical analysis involved the mean value and standard

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deviation, with differences between groups examined using ANOVA and specific group
comparisons analyzed with a Post Hoc test.
Results:
Time Interval: 1 Hour
Table 1 presents the mean and standard deviation (SD) at 1-hour intervals for all groups,
assessed through the ANOVA test. A significant variation was observed among the groups (p
< 0.001). Group 3 (Calcigel) exhibited the highest pH value at 1 hour (10.39), followed by
Group 1 (Calcium hydroxide powder + distilled water) with a pH of 10.20. Group 4 (Calcium
hydroxide + silicone oil and iodoform: Metapex) displayed the lowest pH reading (8.10), while
Group 5 (Control) maintained a pH within the expected range (7.16).
Time Interval: 1 Week
Statistically significant differences were observed between the groups (p < 0.001). Group 3
(Calcigel) demonstrated the maximum pH (10.85), followed by Group 1 (Calcium hydroxide
+ distilled water) with a pH of 10.55. The minimum pH reading occurred in Group 4 (Metapex)
with a pH of 9.55. The control group exhibited a mean pH reading of 7.03. Tukey’s post hoc
analysis revealed a significant difference between all groups except between Group 1 and
Group 3 (p = 0.071).
Time Interval: 2 Weeks
A statistically significant difference was observed between the groups (p < 0.001). Group 3
(Calcigel) and Group 1 (Calcium hydroxide powder + distilled water) displayed the highest pH
values (11.03 and 11, respectively). In contrast, Group 2 (Calcium hydroxide + PEG: Avuecal)
and Group 4 (Metapex) showed pH values in the range of 9.3 and 9.68, respectively. The
control group exhibited a reading of 6.67. Tukey’s post hoc analysis indicated a significant
difference between all groups except between Group 1 and Group 3 (p = 1.000) and Group 2
and Group 4 (p = 0.142).
Time Interval: 4 Weeks
Table 2 illustrates the comparison of intracanal pH in the root canals at different time intervals
for all groups using the ANOVA test. A statistically significant difference was observed
between the groups (p < 0.001). Group 3 (Calcigel) displayed the maximum pH (10.93), while
Group 2 (Avuecal) exhibited the minimum pH (7.30). The control group showed a pH of 6.84.
Tukey’s post hoc analysis revealed a significant difference between all groups except between
Group 1 and Group 3 (p = 0.131) and Group 1 and Group 4 (p = 0.053).
In summary, the study indicates substantial variations in intracanal pH influenced by the
composition of the tested materials and the specific time intervals during the assessment. These
findings contribute to the understanding of the dynamic alkaline effects of different calcium
hydroxide formulations in root canal therapy.

Table 1: Comparison of the intra-canal pH in the root canals at the time interval of 1
hour for all the groups using the ANOVA test

Time interval (1 hour) N Mean Std. Deviation F value P value

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Group 1 Ca(OH)+
Distilled water 20 10.206 0.120

Group 2 Avuecal 20 9.691 0.324

Group 3 Calcigel (Barium
sulphate) 20 10.394 0.233

Group 4 Metapex (Iodoform) 20 8.106 0.526

Group 5 Control 20 7.162 0.214 25.549 <0.001**

Total 100 9.112 1.307

(p< 0.05 - Significant*, p < 0.001 - Highly significant**)

Table 2: Comparison of the intracanal pH in the root canals in terms of {Mean (SD)} at a
time interval of 4 weeks in all the groups using ANOVA test

Time interval (4 weeks) N Mean Std. Deviation F value P value

Group 1 Ca(OH)+
Distilled water 20 10.65 0.394

Group 2 Avuecal 20 7.30 0.398

Group 3 Calcigel (Barium
sulphate) 20 10.93 0.218

Group 4 Metapex (Iodoform) 20 10.33 0.478

Group 5 Control 20 6.84 0.300 571.284 <0.001**

Total 100 9.21 1.809

(p< 0.05 - Significant*, p < 0.001 - Highly significant**)

Discussion:
Calcium hydroxide (Ca(OH)2) is widely used in endodontic therapy due to its diverse
properties, including antibacterial, antiresorptive, and tissue-dissolving features. 5,6,7 The
central focus of our study was the critical aspect of pH modulation, recognized as a key
determinant of calcium hydroxide's antimicrobial efficacy. The profound impact of calcium

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hydroxide's high pH on bacterial cell membranes and proteins, disrupting enzymatic activity
and compromising membrane integrity, is a well-established facet of its mechanism. 8,9
Current literature underscores the optimal pH range for the biological action of calcium
hydroxide pastes, approximately 8.6−10.3, which facilitates alkaline phosphatase activation
and aids the mineralization process.10 The biological actions are propelled by the ionic
dissociation into Ca²⁺ and OH⁻ ions, with the vehicle assuming a pivotal role in determining
the pace of solubilization and resorption.11,12,13,14
Our study evaluated four different commercially available calcium hydroxide formulations,
aiming to understand their alkalinizing potential over time—an important factor for intracanal
dressing between appointments. Throughout the study, all formulations maintained an alkaline
pH at the 1-hour mark and consistently throughout subsequent weeks within the recommended
range. Group 1 (calcium hydroxide powder + distilled water) and Group 3 (calcium hydroxide
+ methylcellulose + barium sulfate) consistently showed higher pH values compared to Group
2 (calcium hydroxide + polyethylene glycol) and Group 4 (calcium hydroxide + silicone oil +
iodoform) across all time intervals.
The observed elevated pH in Groups 1 and 3, utilizing distilled water and methylcellulose as
vehicles, can be attributed to their aqueous nature. This property promotes rapid solubility and
the release of Ca²⁺ and OH⁻ ions within the aqueous medium. Such findings align seamlessly
with established studies.,15,16,17,18 On the other hand, viscous vehicles, exemplified by Group 2
(Calcium hydroxide + PEG: Avuecal), released ions more slowly due to their water-soluble
nature and high molecular weights.19 This prolonged action resulted in lower pH values, a trend
consistent with literature findings.20
A notable finding was the lower alkaline pH exhibited by formulations using oily vehicles, as
observed in Group 4 (Calcium hydroxide + silicone oil and iodoform: Metapex). This could be
due to the low solubility and diffusion characteristics of oily vehicles, leading to a slow,
sustained release of Ca²⁺ and OH⁻ ions. Pastes with oily vehicles may linger in the root canal,
corroborating previous observations.21,22,23 In contrast, the fluid consistency of water-soluble
vehicles, whether aqueous or viscous, tends to yield higher pH and calcium release in periapical
tissues, as substantiated by documented literature.24,25,26,27
The clinical example provided serves to underscore the pivotal role of the type of vehicle in
calcium hydroxide pastes and its clinical implications. In scenarios involving dental
replantation, the immediate use of a paste with an aqueous vehicle is recommended due to the
imperative for rapid ionic release and pH turnover, aiming to prevent replacement resorption.
Subsequent re-dressings may involve a calcium hydroxide paste with a viscous vehicle to
ensure a more prolonged effect. This entails maintaining pH levels in the area and a slower
ionic release. The alkaline properties of calcium hydroxide in such a paste may only be
exhausted after an extended period, thus demonstrating the nuanced therapeutic considerations
that arise from the choice of formulation.28
To summarise, our findings bring to light the substantial impact that formulation choices exert
on intracanal pH dynamics, aligning seamlessly with existing literature. The need for tailoring
calcium hydroxide preparations to specific clinical scenarios is underscored, acknowledging
the nuanced influence of vehicles on therapeutic outcomes. The fluidity of our results prompts
further inquiry into the clinical implications of these findings, suggesting a correlation between
pH variations and treatment efficacy in diverse endodontic cases. Addressing these aspects

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contributes to a more comprehensive understanding of the intricate dynamics involved in

calcium hydroxide intracanal dressings, further refining their clinical applications. The
incorporation of these insights into future studies will undoubtedly enrich our understanding
of the subject matter. In doing so, we strive to contribute meaningfully to the evolving
landscape of endodontic research and practice.

Conclusion:
The findings of the present study provide crucial insights into the alkaline pH characteristics
of various calcium hydroxide formulations. The observed pH values between 9 to 11 for all
tested materials underscore their inherent alkalizing potential, essential for their therapeutic use
in endodontics. Notably, formulations with aqueous vehicles demonstrated a rapid elevation in
pH, indicating their suitability for immediate alkalinizing effects, particularly in cases requiring
prompt symptom control. On the other hand, intracanal dressing with an oily medium exhibited
a gradual pH increase, suggesting its utility in scenarios demanding sustained release and
longer follow-ups.

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