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Journal of Scientific Dentistry, 4(1), 2014
CASE SERIES
Calcium Hydroxide Therapy for Persistent Chronic Apical Periodontitis : A
Case Series
Mithun Jith.K 1 , Jerry J2 Sathyanarayanan R3
ABSTRACT: A common sequlae t o pulp disease is development of per iapical lesions. Chron ic
per iapical lesions most l y occur without any episode of a cute pain and are discovered on
rout ine r adiograph ic examination . I t ’s a wel l accepted fact that a l l in flammatory per iapical
lesi ons should be in i t ial ly t r eated with conservat ive nonsurgical procedures. Studies have
repor ted a success r a te of up to 85% after endodon t ic tr eatmen t of teeth with per iapical .
lesi ons. With various biologi c proper t ies, calcium hydroxide has been widely used in
endodon t ics from i ts in t roduct ion in 1920. Large size of a ch ron ic per iapical lesion does not
a lways mandate i ts surgical r emoval , and that even cyst - l ike per iapical lesions heal fol l owing
a conservat ive endodon t ic therapy with long term calcium hydroxide therapy. Th is case ser ies
h ighl igh ts the impor tance of calcium hydroxide being used as in tracanal medicament with
standard proctocols and t ime frame and also on differen t non surgical tr eatmen t str ategies for
management of ch ron ic apical per iododon t i t is pat ien ts.
Keywords: Calcium hydroxide, Chroinc apical per iododon t i t is, endodon t ic therapy, calcium
hydroxide therapy
T he outcome of the endodontic therapy
depends on reduction or elimination of
bacteria from the root canal space. The major
factor associated with endodontic failure are
the persistence of microbial infection in the
root canal system and/or the periradicular
area1,2. The most essential step in aiming at
complete disinfection of the root canal space
is the chemo mechanical preparation.
However, total elimination of bacteria is
difficult to accomplish3,4,5. For the elimination
of the surviving bacteria, calcium hydroxide is
placed as an intracanal medicament between
appointments5.
Apical periodontitis is caused by bacteria
within the canal space6,7. The treatment of
apical periodontitis should, therefore, aim at
bacterial eradication. Since cleaning and
shaping alone do not completely and
effectively eliminate bacteria8, it seems
24
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Journal of Scientific Dentistry, 4(1), 2014
logical to medicate canals with an intracanal
antibacterial medicament after biomechanical
preparation. A success rate of 80.8%9 has
been reported with calcium hydroxide, when
used for endodontic treatment of teeth with
periradicular lesions.
Calcium hydroxide has been widely used in
endodontics from the time it was introduced in
Endodontics by Herman in 1920. With a pH
of approximately 12.5 it is a strong alkaline
substance. In an aqueous solution, calcium
hydroxide dissociates into calcium and
hydroxyl ions. Various biological properties
have been attributed to this substance, such as
antibacterial activity 4, tissue-dissolving
ability10, inhibition of tooth resorption11, and
repairing ability by hard tissue formation12. At
present, calcium hydroxide is acknowledged
as one of the most effective antibacterial
intracanal medicament during endodontic
therapy.
This case series highlights the importance of
calcium hydroxide being used as a intracanal
medicament in persisting non healing chronic
apical periodontitis.
CASE REPORT 1: (Fig 1)
Patient reported with loose failing bridge on
left bottom teeth. Clinical examination
revealed cantilever bridge with crown in 36 as
abutment for pontic 35. Radiograph revealed
root treated 36 with deficient lateral
condensat ion and huge per iapica l
radiolucency with radio opaque border
suggestive of a chronic lesion. (Fig 1A)
Conventional retreatment as the first line of
treatment was planned. Bridge was removed
and root canal was re entered under cotton roll
isolation. Mesial canal was intentionally over
instrumented with 25 no K file. 25 no. K file
was extended till approximately the centre of
the lesion which was about 2 mm beyond
apex. Upon instrumentation profuse bleeding
was present. Copious irrigation was done with
normal saline and plain cotton dressing was
placed and temporary coronal seal was done
with zinc oxide eugenol. One week later,
Calcium hydroxide mixed with glycerin was
coated in the canal with lentulo spiral and the
access cavity was sealed with reinforced glass
ionomer restorative material, as the patient
was not available for next three months.
Temporary bridge was fabricated and
cemented with zinc phosphate. (Fig 1B)
Four months later patient reported with no
complaint and the bridge was removed. The
coronal seal was intact with good marginal
seal. Radiograph revealed questionable
evidence of root formation. As the patient was
travelling again for four months, the same
calcium hydroxide therapy was planned. This
time calcium hydroxide was mixed with
virgin coconut oil (based on unpublished
research study by the author) and coated with
lentulo spiral and temporary coronal seal was
done with reinforced glass ionomer (fuji GC
Type IX). The temporary bridge was
recemented with zinc phosphate. (Fig 1C)
Patient reported after three months. Clinically
Calc ium Hydroxide Therapy Mi thun Jith.K e t a l
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Journal of Scientific Dentistry, 4(1), 2014
asymptomatic and radiologically there were
some signs of bone formation and reduction in
periapical radiolucency (Fig 1D). Patient was
rescheduled for obturation. Root canals were
obturated after three weeks with guttapercha
and zinc oxide eugenol sealer in lateral
condensation technique. Post operative
radiograph revealed satisfactory obturation
with little sealer and questionable GP
extending beyond apex of mesial canals. (Fig
1E)
Patient reported after three years for
26
Fig– 1: Case report 1
1A: Preoperative status of 36 showing large periapical raiolucency involving apex of 36.
1B: Overinstrumentation beyond the apex towards the centre of the lesion.
1C: Calcium hydroxide dressing with virgin coconut oil.
1D: Three months review showing signs of healing.
1E: Obturation of 36 with mild extrusion of sealer beyond apex.
1F: Five years follow up showing complete healing.
1B
1D
1F
1A
1C
1E
Calc ium Hydroxide Therapy Mi thun Jith.K e t a l
Journal of Scientific Dentistry, 4(1), 2014
maintenance check up. Clinically 36 was
normal and radiologically the periapical lesion
reduced considerably. There was evidence of
periodontal involvement with furcation and
inter dental bone loss. Periodontal therapy was
done. Five years follow up revealed excellent
bone healing with stable periodontal condition
for past two years.(Fig 1F)
The factors strongly associated for the success
of this case would be:
1 . Decompress ion o f le s ion by
overinstrumenting to the center of the lesion.
2. Calcium hydroxide therapy with virgin
cocoanut oil.
3. Glass ionomer coronal seal.
4. Unintentional three months interim period
between appointments.
CASE REPORT 2: (Fig 2)
Patient reported with mild discoloration in
maxillary front tooth .History revealed that
root canal treatment was done two year
back .Radiograph revealed improper
obturation in 21 and 22. Periapical
radiolucency were seen in relation to 11, 21
and 22. Vitality test with electric and heat
gave negative response. 11 was diagnosed as
nonvital tooth and scheduled for root canal
treatment (Fig 2A). Retreatment was planned
in 21 and 22.
Root canal of 11 was opened without local
anesthesia. Old GP were removed with H files
from 21 and 22. Canals were irrigated with
normal saline and shaped till 60/80 and 30 K
files with hand instrumentation in 11,21 and
22 respectively (Fig 2B). Powder Calcium
hydroxide was mixed with glycerin and
coated with lentiulospiral in the root canal.
Temporary coronal seal was given with plain
cotton seal and thick mix of zinc oxide
eugenol. Patient was rescheduled after four
weeks for further management.
Patient was reviewed and was asymptomatic.
Clinical examination revealed sinus in relation
to 21. Canals were reentered, irrigated and
redressed with calcium hydroxide. Temporary
coronal seal was given.
Patient was rescheduled after ten
days .Clinically patient was asymptomatic and
the sinus had disappeared. All there tooth was
obturated with 2% guttapercha with zinc
oxide sealer and cold lateral condensation
technique. Immediate post operative
radiograph revealed satisfactory obturation in
21, 11 and sealer beyond apex in 22. (Fig 2C)
Permanent coronal seal was done with glass
ionomer. Patient declined to go for the crown
because of cost and minimal discoloration.
Patient reported after 15 years with complain
for increased discoloration and wanted to
know whether the anterior tooth was under
control. Clinical patient was asymptomatic,
with no pathological change in relation to
11,21 and 22. Radiograph revealed
satisfactory periapical status in relation to
11,21 and 22. The obturation in 21 showed
deficient lateral seal and residual very
minimal periapical radiolucency even after 15
years suggestive of apical scar. (Fig 2D) The
inference of this follow up confirms the
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Calc ium Hydroxide Therapy Mi thun Jith.K e t a l
Journal of Scientific Dentistry, 4(1), 2014
importance of cleaning and shaping and the
long term intracanal medicament with calcium
hydroxide.
CASE REPORT 3: (Fig 3)
Patient reported with pain in relation to the
upper right front tooth with evidence of pus
discharge in relation to the same. Clinical
examination revealed discolored 11 with sinus
opening in relation to 11. Radiograph revealed
root treated 11 with deficient lateral and apical
seal and a large periapical radiolucency
around the open apex of 11. (Fig 3A)
Old GP were removed with H files from 11.
Canals were irrigated with normal saline and
shaped till no.80 at the estimated working
length. Calcium hydroxide mixed with
glycerin was loaded with lentiulospiral in the
root canal. As there was no apical stop, the
calcium hydroxide extruded into the periapical
lesion. Temporary coronal seal was given with
plain cotton seal and thick mix of zinc oxide
eugenol. Patient was rescheduled after three
weeks for further management. (Fig 3B)
Patient was reviewed and was asymptomatic.
Clinically patient was asymptomatic but the
tenderness on percussion still persisted .
Canals were reentered, irrigated and redressed
with calcium hydroxide. Temporary coronal
seal was given. Patient was rescheduled after
28
1B
1D
1A
1C
Fig– 2: Case report 2
2A: Preoperative status of 11, 21 and 22.
2B: Complete GP retrieval and working length assessment.
2C: Satisfactory obturation of 11, 21 and 22.
2D: 15 years follow up showing complete healing.
Calc ium Hydroxide Therapy Mi thun Jith.K e t a l
Journal of Scientific Dentistry, 4(1), 2014
three weeks for further management.
Patient was reviewed and was clinically
asymptomatic. There was no tenderness on
percussion. Radiographically, there was
complete resolution of the periapical lesion
with the concomitant resorption of the
calcium hydroxide placed periapically.. (Fig
3C)Temporary coronal seal was removed and
the master cone was checked and obturation
was done using an inverted cone technique
(Fig 3D) using zinc oxide as sealer and cold
lateral condensation technique with accessory
cones. Immediate post operative radiograph
revealed satisfactory obturation in 11. (Fig
3E) Permanent coronal seal was done with
glass ionomer and post endodontic restoration
was given after a week. Patient was reviewed
after 18 months, Clinically 11 was normal and
radiologically the periapical lesion reduced
considerably with fully formed apex. (Fig 3F)
CASE REPORT 4: (Fig 4)
Patient reported with pain in relation to the
upper left front tooth with diffuse swelling
intraorally relation 21 region. Clinical
examination revealed discolored 21,22 with
29
4B 4A 4C
Fig– 4: Case report 4
4A: Preoperative status of 21, 22.
4B: Completed BMP and matercone fit assessment.
4C: Metapex intracanal medicament.
4D: Immediate post obturation radiograph.
4E: Eight months follow up.
4E 4D
Calc ium Hydroxide Therapy Mi thun Jith.K e t a l
Journal of Scientific Dentistry, 4(1), 2014
an opened access in 21. Radiograph revealed
root canal attempted in 21 with deficient root
filling. The root canal treatment was left
incomplete as the patient has discontinued
treatment from the previous dentist.
Radiograph revealed a large periapical
radiolucency around the apex of 21 and 22
with an opened access cavity in 22. (Fig 4A)
Root canal of 21, 22 was opened without local
anesthesia. Canals were irrigated with normal
saline and shaped till 80 and 60 K files with
hand instrumentation in 21 and 22
respectively and the master cone was selected
(Fig 4B). Calcium hydroxide in propylene
glycol base (metapex) was loaded with
lentiulospiral in the root canal. Temporary
coronal seal was given with plain cotton seal
and thick mix of zinc oxide eugenol. Patient
was rescheduled after two weeks for further
management. (Fig 4C).
Patient was reviewed and was clinically
asymptomatic. Radiograph shows complete
resorption of the calcium hydroxide which
was extruded into the periapex.
Obturation was done with lateral condensation
and with zinc oxide as sealer. Immediate
postoperative shows satisfactory obturation.
(Fig 4D). Permanent coronal seal was given
with GIC.
Patient was reviewed after eight months,
Clinically 21, 22 was normal and there was a
complete resolution of the periapical lesion.
(Fig 4E).
CASE REPORT 5: (Fig 5)
Patient reported with pain in relation to the
upper right front tooth. Clinical examination
revealed discolored 12, 13. Radiograph
revealed a large periapical radiolucency
around the apex of 12 and 13 with mild
displacement of 13. The radiolucency was
well circumscribed with corticated margins.
(Fig 5A).
Non surgical management was first planned
and the access was opened. The canal was
intentionally over instrumented with 25 no K
file. 25 no. K file was extended till
approximately the centre of the lesion which
was about 2 mm beyond apex. Upon
instrumentation profuse pus discharge was
evident through the canal and the active non
surgical decompression was done through the
canal using a canal aspirator and a high
volume suction.
Canals were irrigated with normal saline and
shaped till 60 K files with hand
instrumentation in 12 and 13 respectively and
the master cone was selected (Fig 5B).
Calcium hydroxide in propylene glycol base
was mixed with glycerin and coated with
lentiulospiral in the root canal. Temporary
coronal seal was given with plain cotton seal
and thick mix of zinc oxide eugenol. Patient
was rescheduled after two weeks for further
management.
The pat ient was rev iewed and
radiographically there were signs of healing,
but still weeping was persistent, Canals were
re-entered, irrigated and redressed with
calcium hydroxide. Temporary coronal seal
was given (Fig 5C). Patient was rescheduled
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Calc ium Hydroxide Therapy Mi thun Jith.K e t a l
Journal of Scientific Dentistry, 4(1), 2014
after eight weeks for further management.
The patient was reviewed and when the
criteria’s of obturation was met which
includes getting a dry canal, obturation was
done with lateral condensation and with zinc
oxide eugenol as sealer. (Fig 5D).
Patient was reviewed after 6 months,
Clinically 12, 13 was normal and there was a
drastic reduction of the periapical lesion. (Fig
5E).
CASE REPORT 6: (Fig 6)
Patient reported with dull pain in relation to
the lower left back tooth for the past two
months. Patient gave prior history of root
canal being performed by a general dentist a
year back.
Clinical examination revealed intact metal
ceramic crown with leaky margins.
Radiograph revealed a large periapical
radiolucency around the apex of the mesial
root of 36 with silver points obturation with
poor apical and lateral seal. (Fig 6A)
Conventional non surgical retreatment was
31
Fig– 5: Case report 5
5A: Preoperative status of 12, 13.
5B: Over instrumentation beyobnd apex and master cone selection.
5C: Calicun hydroxide intracanal medicament.
5D: Immediate post obturation follow up.
5E: Six months review.
5B 5A 5C
5E 5D
Calc ium Hydroxide Therapy Mi thun Jith.K e t a l
Journal of Scientific Dentistry, 4(1), 2014
planned , crown was removed and the silver
points was removed using ultrasonics.
Cleaning and shaping was done with
intentional working beyond the apex with
small sized K files. Copious irrigation was
done with 5.2% sodium hypochlorite and final
rinse was done with 2% chlorhexidine. Two
week calcium hydroxide dressing was given
and when all criteria for obturation was
achieved, obturation was done with protaper
gutta percha points and zinc oxide eugenol
sealer using cold lateral condensation
technique. Excess calcium hydroxide extruded
through the apex was left behind for healing.
(Fig 6B).
Patient was reviewed after 6 months, where
patient was completely asymptomatic and
Radiograph revealed complete healing of the
lesion. Core build up was done using fiber
post in the distal canal and all ceramic full
coverage restoration was given. (Fig 6C)
DISCUSSION:
Antibacterial activity of calcium hydroxide is
directly proportional to the release of
hydroxyl ions in an aqueous environment.
Hydroxyl ions being highly oxidant free
radicals shows extreme reactivity, reacting
with several other biomolecules 13. The
bactericidal effect of calcium hydroxide on
32
Fig– 6: Case report 6
6A: Preoperative status of 36.
6B: Immediate post obturartion with extruded calcium hydroxide beyond apex.
6C: Six months follow up with complete healing with post endodontic restoration.
6B 6A
6C
Calc ium Hydroxide Therapy Mi thun Jith.K e t a l
Journal of Scientific Dentistry, 4(1), 2014
bacterial cells are probably due to the
following mechanisms:
1. Damage to the bacterial cytoplasmic
membrane.
2. Protein denaturation.
3. Damage to the DNA.
The bactericidal effects of calcium hydroxide
were observed only when the substance was in
direct contact with bacteria in suspension.
Because of the high availability of hydroxyl
ions, the survival of the bacteria would be
nearly impossible. Clinically, this direct
contact of the calcium hydroxide with the
bacteria present in the canal is not always
possible. Apart from the antibacterial effects
of hydroxyl ions, rendering a high pH values
in the environment is a prerequisite to destroy
microorganisms. Complete elimination or
killing of bacteria depend solely on the
availability of hydroxyl ions in solution,
which is much higher where the paste is
applied. The antibacterial effects exerted in
the root canal will be continuous as long as
calcium hydroxide retain a very high pH. If
calcium hydroxide diffuses to tissues and the
hydroxyl concentration is decreased as a result
of the contact with buffering agents
(bicarbonate and phosphate), proteins, acids
its antibacterial effectiveness gets declined or
impaired . 14, 15
Souza et al 16 suggested that the action of
calcium hydroxide beyond the apex may be
four-fold: (a) anti-inflammatory activity, (b)
neutralization of acid products, (c) activation
of the alkaline phosphatase, and (d)
antibacterial action. Çalişkan and Türkün17 in
his case report demonstrated success with
apical closure and simultaneous periapical
healing in a large cyst-like periapical lesion
following non-surgical treatment with calcium
hydroxide and a calcium hydroxide–
containing root canal sealer. In our case series,
case II showed remarkable healing inspite of
calcium hydroxide being extruded beyond
apex.
Active non surgical decompression of large
periapical lesions can be done using a
commercially available Endo-eze vacuum
system (Ultradent, Salt Lake, Utah) or any
other micro syringe with a high vacuum
suction to create a negative pressure, which
would result in the decompression of large
periapical lesions. The high volume suction
aspirator is connected to a micro gauge
needle, which is inserted in the root canal and
when activated creates a negative pressure,
which results in aspiration of the exudates/
contents of the cystic cavity. The extudate is
aspirated till the weeping stops through the
canal and an intracanal medicament of
calcium hydroxide is given which usually
helps in reducing the bacterial load. Unlike
the surgical decompression technique, which
involves placing drains directly into the
lesions through the labial mucosa, this
technique is minimally invasive as the entire
procedure is done through the root canal and
has good patient compliance and causes less
discomfort for the patient18. In our case series,
33
Calc ium Hydroxide Therapy Mi thun Jith.K e t a l
Journal of Scientific Dentistry, 4(1), 2014
case V was managed by non surgical
decompression through the canal followed by
the calcium hydroxide therapy.
Bhaskar has suggested that whenever a
periapical lesion persisted on a radiograph
instrumentation should be carried 1 mm
beyond the apical foramen . This may result in
transient inflammation and ulceration/
disruption of the epithelial lining resulting in
resolution of the lesion.19 Bender on Bhaskar’s
hypothesis added that penetration of the apical
area to the center of the lesion would result in
drainage and relieving pressure accumulated
within the lesion. Fibroblasts begin to
proliferate once the drainage stops and starts
depositing collagen; which would compresses
the capillary network. Thus the epithelial
cells gets completely deprives of nutrition and
they undergo degeneration, which are finally
engulfed by the macrophages.20 In our case
series, case I, case IV was managed by
intentionally working beyond the apex to
puncture at the centre of the lesion to relieve
pressure and to obtain drainage followed by
two week calcium hydroxide therapy.
Healing of large cysts like well-defined
radiolucencies following conservative root
canal treatment has been reported. Although
the cystic fluid contains cholesterol crystals,
weekly debridement and drying of the canals
over a period of two to three weeks with long
term calcium hydroxide therapy , followed by
obturation has led to a complete resolution of
lesions by 12 to 15 months 21.
The vehicles with which the calcium
hydroxide powder is mixed/ used have an
important role in the overall dissociation of
hydroxyl ions. Its only the vehicle in which
calcium hydroxide is delivered determine the
velocity of ionic dissociation causing the paste
to be highly soluble and resorbable at various
rates by the periapical tissues or from within
the root canal. The viscosity is indirectly
proportional to degree of ionic dissociation.
The calcium hydroxide when used in these
viscous vehicles tends to remain in place for a
longer period time as these vehicles are high
molecular weight substances. 22
There are three main types of vehicles:
1. Water-soluble substances such as saline,
w a t e r , c a r b o x y m e t h y l c e l l u l o s e ,
methylcellulose, Ringers solution and
anaesthetic solutions
2. Viscous vehicles such as propylene glycol ,
glycerin, and polyethylene glycol (PEG)
3. Oil-based vehicles such as silicone oil,
olive oil, camphor (the oil of camphorated
parachlorophenol), some fatty acids (including
linoleic, oleic, and isostearic acids), &
metacresylacetate 25
Calcium hydroxide should be always be
combined with a liquid vehicle as using dry
calcium hydroxide powder alone is difficult to
deliver and to handle, and for the release of
hydroxyl ions an aqueous medium becomes
mandatory for calcium hydroxide. The most
commonly used carriers are sterile water or
saline. Though dental local anaesthetic
34
Calc ium Hydroxide Therapy Mi thun Jith.K e t a l
Journal of Scientific Dentistry, 4(1), 2014
solutions have an acidic pH (between 4 and
5), they are used as adequate vehicle because
calcium hydroxide is a strong base with a pH
of around 12.5 which is affected minimally by
acidic nature of the local anesthesia . Rapid
ionic dissociation occurs only with the
aqueous medium whereas ionic dissociation
will be slower in viscous and oil based
mediums.
The effects of glycerin and propylene glycol
vehicles on the pH of calcium hydroxide were
investigated using conductivity testing23. They
reported that a concentration of the vehicles
was inversely proportional to the effectiveness
of calcium hydroxide as a root canal
medicament. As the concentration of the
vehicle increases the effectiveness or efficacy
of calcium hydroxide decreases.23 But the
availability of hydroxyl ions would drastically
reduce in a aqueous medium wherein the
availability of hydroxyl ions would be long
lasting if its used in a viscous vehicle24. As in
our cases, since most of the lesions were large
sized and availability of hydroxyl ions for a
longer period of time was required viscous
vehicle was selected rather than a aqueous
one. A viscous vehicle may remain within
root canals for several months, and hence the
number of appointments required to change
the dressing will be reduced 25. In our case
series propylene glycol and glycerin based
vehicles were used .
Oily vehicles have restricted applications as
intracanal medicaments as they are difficult to
remove from the canal space and leave a
residue on the canal walls. Leaving remnants
of oil on the canal walls will adversely affect
the adherence of sealer or other materials used
to obturate the canal 25.
Extrusion of calcium hydroxide beyond the
apex was suggested as a factor for the lack of
early healing of periapical lesions initially. 26
However, many researchers advocated that
when calcium hydroxide comes in direct
contact with the periapical tissues it is
beneficial for the inductive action of the
calcium hydroxide.27,28 Many authors have
reported high degree of success by using
calcium hydroxide beyond the apex and into
the lesions in cases with large periapical
lesions 29,30. Calcium hydroxide readily
resorbs and its the barium sulphate that is
added to the calcium hydroxide paste for
radiopacity, which is not readily resorbed
when the paste extrudes beyond the apex.
Several authors have stressed on the
importance of a long observation time for the
teeth treated with large periapical lesions31, 32.
In review by Çalişkan, a follow-up
examination ranged from two to ten years. 32.
Shah 33 suggested that patients should be
recalled at periodic intervals of three months,
six months, one year, and two years, to assess
the healing of periapical lesions. There is
always a chance for the quiescent epithelial
cells to be stimulated by instrumentation in
the apical area, with resultant proliferation and
cyst recurrence/ formation. Hence, follow-up
becomes extremely essential and mandatory
for a period of at least two years to assess the
35
Calc ium Hydroxide Therapy Mi thun Jith.K e t a l
Journal of Scientific Dentistry, 4(1), 2014
success of the treatment.
CONCLUSION:
Non surgical management of periapical
lesions have shown high success rate. With
employing correct treatment strategy and with
the use of long term calcium hydroxide as an
intracanal medicament even large sized
periapical lesions can heal satisfactorily
without any surgical intervention. Periodic
follow-up examinations are essential and
various assessment tools can be used to
monitor the healing of periapical lesions.
36
Calc ium Hydroxide Therapy Mi thun Jith.K e t a l
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How to cite this article: Mithunj ith K, Jer ry J , Sa thyanara yanan R.Calcium Hydroxide Therapy for Pers i s tent Chronic Api ca l Per iodont i t i s : A Case Series . Journal of Scient i fi c Dent i st ry, 4(1) , 2014:24 -37 Source of Support : Ni l , Conf l i c t of Interest : None declared
Address for correspondence:
Dr .Mithun Jith.K
Sen ior Lecturer ,
Depar tment of Conser vat ive Den t istry and
Endodon t ics, IndraGandhi Inst i tute of Den tal Sciences,
Sr i Bajai Vidapeeth Univer si t y
Puducher ry
dr.mithunjithk@gmail.com
Authors: 1 Senior Lecturer, 3Professor,
Department of Conservative Dentistry and Endodontics,
IndraGandhi Institute of Dental Sciences,
Sri Bajai Vidapeeth University Puducherry 3Private praticioner,
Krupa dental Clinic,
Kuvembu road,
Shimoga, Karnataka
Calc ium Hydroxide Therapy Mi thun Jith.K e t a l
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