Journal of Indian Society of Pedodontics and Preventive Dentistry | Jan-Mar 2014 | Vol 32| Issue 1 | 63

AbStrAct
Premixed non-setting calcium hydroxide is
frequently used as interim root canal dressing in
endodontically involved permanent teeth and as
obturating paste in deciduous teeth in pediatric
dentistry. Wide apex in both cases makes it more
prone for deliberate extrusion especially when
applied with pressure delivery systems. Contrary to
common belief the mix was not resorbed in two years
with the complaint of insuffciency in mastication.
Large mass of calcium hydroxide in bone delayed
healing process even after its removal. The present
case report intends to demonstrate unusual behavior
of bone in response to oily non-setting preparation
of calcium hydroxide. Therefore its application with
pressure syringe should be reconsidered in pediatric
dentistry.
KEYWOrDS: Endodontic surgery, non-setting cal-
cium hydroxide, periapical extrusion, resorption
Accidental periapical extrusion of non-setting calcium
hydroxide: Unusual bone response and management
Divya S Sharma, Shikhar Pratap Singh Chauhan
1
, Vinaya Kumar Kulkarni, Chitra Bhusari, Rina Verma
Departments of Pedodontics and Preventive Dentistry, Modern Dental College and Research Centre, Gandhi Nagar, Indore,
1
Pedodontics
and Preventive Dentistry, Hitkarini Dental College, Jabalpur, Madhya Pradesh, India
Introduction
Premixed non-setting calcium hydroxide with
iodoform in oil vehicle (NSCI) being easily insertable in
canal with plastic applicator tips and having excellent
antimicrobial effciency is a choice of material for
interim root canal dressings in permanent teeth and for
obturation in primary teeth.
[1,2]
Abscessed permanent
teeth as a sequel of caries or trauma often present
with wide root apex in pediatric patient. Accidental
extrusion of NSCI is a common phenomenon in
deciduous as well as in permanent dentition.
[2-8]
Some
authors speculate that it favor periapical healing and
encourage osseous repair.
[2,9]
Many case reports are claiming that NSCI is a
resorbable material if extruded in periapical area.
[2,3,5]

Successful healing at periapex has been reported with
NSCI used as dressing in tooth.
[2,3,5]
Nonetheless it
may be a frustrating situation when extruded in large
quantity through wide apex of an immature permanent
tooth. There are reports that not only it delays primary
healing,
[10]
but also not fully resorbed for long periods
of follow-up.
[3,4]
The present case reports an unusual behavior of
NSCI extruded accidentally into periapex of young
permanent frst molar. In spite of several claims
reported NSCI being resorbable
[2,3,5]
its resorption
was not observed even after 2 years of follow-up and
showed very slow healing of lesion after surgical
removal of extruded mass till 3 years. This case also
attempts to report the behavior of bone in response to
NSCI.
Case Report
A patient of 13 year age, reported to the Department
of Pedodontics and Preventive dentistry, Modern
Dental College and Research Center with the chief
complaint of etching in lower right buccal vestibule
and emptiness while eating with the recently treated
lower posterior tooth. History revealed that patient
had gone for root canal treatment in same tooth 2
days ago. Papers showed that patient had intraoral
sinus with 16 when frst reported to previous dentist.
On intraoral examination no adverse fnding was
Address for correspondence:
Dr. Divya S Sharma,
Department of Pedodontics and Preventive Dentistry,
Modern Dental College and Research Centre, Gandhi Nagar,
Airport Road, Indore - 453 112, Madhya Pradesh, India.
E-mail: drdivyassharma@gmail.com
Case Report
Access this article online
Quick response code
Website:
www.jisppd.com
DOI:
10.4103/0970-4388.127061
PMID:
******
Sharma, et al.: Periapical extrusion of calcium hydroxide
Journal of Indian Society of Pedodontics and Preventive Dentistry | Jan-Mar 2014 | Vol 32| Issue 1 | 64
observed [Figure 1a]. Periapical X-ray showed large
radiopaque material in periapical space in relation
to mesial root [Figure 2a]. Root canal obturation was
found satisfactory. Though patient had no pain, but
the complaint of gingival irritation and tooth not
taking load while chewing. Conversation with old
dentist revealed that he had used NSCI as interim
dressing. Probably the same amount of mass was lying
buccolingually too that had flled up the sinus tract
and was in contact with gingival tissue giving rise to
etching sensation. As NSCI is said to be resorbable
material, we advised patient to wait for some period.
Etching sensation got subsided within a week.
Patient was regularly followed up till next 2 years. But
no signs of resorption of NSCI were found. During this
period of observation patient left the habit of chewing
from right side. He could not get over with the feeling
of emptiness on chewing from right side. His parents
were worried for this large radiopaque mass in the
bone even after 2 years. Considering the patients
complaint and parents worry we decided to surgically
remove NSCI from periapex.
After getting parental consent surgery was started
under antibiotic coverage after 2 years of primary
obturation. After raising the full thickness fap,
a clear white spot covered with thin periosteum
was seen [Figure 1b]. This confrmed our tentative
imagination that NSCI had flled the sinus tract. The
area was entered from this site. The claimed non-
setting material was very dry, hard, and light yellow
in color. It was excavated in fakes [Figure 1c]. Bone
cavity walls were smooth [Figure 1d]. Instead of
frank bleeding, blood was oozing from cavity walls.
Mesial root was apicoectomized and apical seal was
found adequate. Gutta-percha was burnished further
[Figure 1e]. Bleeding was induced by rubbing the
cavity wall with curette followed by suturing the lesion
[Figure 1f]. Immediate postoperative radiograph was
taken [Figure 2b]. Patient was advised for permanent
custom made crown for 16. But patient was satisfed
with stainless steel (SS) crown.
One year follow-up showed very slow healing, perhaps
because of the size of lesion [Figure 2c-e]. As lesion was
healing, longer follow-up were scheduled. Twenty-
eight months later patient was recalled telephonically.
Radiograph this time revealed periapical radiolucency
with distal root [Figure 2f]. Patient did not complain
of any adverse symptom and was chewing on tooth
without any pain. Perhaps radiolucency was due to
overload on distal root for extended period of time. We
removed SS crown to relieve the occlusion. As trauma
a
c
e
b
a
c
e
b
d
f
d
f
Figure 1: Photographs during surgery (a) Preoperative (b) After
raising fap, white color of extruded mas was visible through
overlying thin bone (c) Extruded mass was dry and removed in
fakes (d) Apex of mesial root visible in mirror with burnished
obturation (e) Cleaned cavity with induced bleeding (f) Lesion
closed with interrupted mattress sutures
Figure 2: Postsurgical radiographic evaluation for the period of
39 months (a) Preoperative, extruded mass of non-setting calcium
hydroxide remained in bone for 2 years (b) Just after surgery,
periextrusion thin radiopaque line is visible (c) After 2 months of
surgery, healing of bone can be appreciated (d) After 8 months
of surgery, slow healing of lesion (e) After 11 months of surgery,
still lesion not healed completely (f) After 39 months of surgery,
developing periapical radiolucency, perhaps due to extended
overload on distal root
Sharma, et al.: Periapical extrusion of calcium hydroxide
Journal of Indian Society of Pedodontics and Preventive Dentistry | Jan-Mar 2014 | Vol 32| Issue 1 | 65
giving rise to severe infammatory response, but was
the most resorbed material. Maisto paste and Sealer
26 + iodoform was the most biologically compatible
paste owing to less infammation of tissues, but their
resorption was poor, probably owing to the presence
of iodoform which counterbalance the severe alkalinity
in tissues created by calcium hydroxide. Bramante
and Berbert
[12]
evaluated the bone response with
aqueous mix of calcium hydroxide and iodoform in
root perforation area. Groups were divided according
to days of dressing change in perforation area. In
histologic evaluation after 90 days both reparative
and infammatory reaction of small magnitude and
perforation sealing by mineralized tissues was found
in a group where dressing was not changed at all. In
this study no previous pathological infammation
existed at the time of perforation and whole procedure
was performed under sterilized condition, thus
minimizing the infammation. Hard tissue formation
around paste was observed, but no resorption of paste
was found. Findings of these studies are in support of
our hypothesis described in beginning of discussion.
Huang et al.,
[13]
compared the effects of different
materials used in primary root canal fllings on the
cell viability of human osteosarcoma cell lines and
concluded that the calcium hydroxide with iodoform
and Vitapex as better options as higher survival of
cell lines were found. Nishimura et al.,
[14]
examined
the ability of fve root canal antiseptics to induce
chromosome aberrations in human dental pulp
cells. Calcium hydroxide + iodoform combination
paste did not induce any chromosomal aberration
in absence or presence of exogenous metabolic
activation. All these studies demonstrate good
biocompatibility of calcium hydroxide + iodoform
pastes, though initial infammation is there which
subsides in due course of time. Our case supports
this biocompatibility.
Contrary to these fndings many case reports are there
from occlusion was suspected for the new asymptomatic
radiolucency, an enzymatic NonSteroidal Anti-
Infammatory Drug (NSAID), that is, serratiopeptidase
(10 mg) one tablet TID for 1 week was prescribed. In
order to hasten the slowly healing bone defect at mesial
root, an ayurvedic immunomodulator, that is, Septilin
(Himalaya Herbal Healthcare) two tablets BID for 15
days was prescribed. Both medications were given as
supportive therapy only. Patient was asked to come
after 15 days, but he failed to do so.
On repeated phone reminders he came to the
department after 46 months of surgery and 7 months
after last visit. He had discontinued the medications
after 15 days. The treated tooth was functioning
normally. Extra- or intraorally soft tissues were healthy
[Figures 3a and b]. IntraOral PeriApical (IOPA) X-ray
revealed bone trabeculae developing in both the
radiolucencies [Figure 3c]. Patient was again advised
to take Septilin for 15 days more and the tooth was
restored with full extracoronal restoration [Figure 4].
Discussion
The case report might give rise to the discussion that
whether some infammation (periapical pathology)
or resorptive process (deciduous root resorption) is
required for resorption of NSCI from bony tissues.
Murata et al.,
[11]
analyzed the periapical tissue reaction
with three root canal flling materials, that is, Maisto
paste (zinc oxide, iodoform, camphorated chlorophenol,
and lanolin); Sealer 26 + iodoform (calcium hydroxide,
urotropin, bismuth trioxide, titanium dioxide, and
epoxy resin mixed with iodoform in equal parts);
and L&C paste (calcium hydroxide, olive oil, bismuth
carbonate, and rosin) on dogs anterior deciduous
teeth. They found L&C paste the most irritating one
Figure 4: Tooth restored with full coverage porcelain fused to metal
crown
Figure 3: Forty-six months postoperative photographs and
radiograph (a and b) Normal looking buccal and lingual mucosa (c)
Bony trabeculae could be seen in mesial and distal radiolucencies
a b
c
Sharma, et al.: Periapical extrusion of calcium hydroxide
Journal of Indian Society of Pedodontics and Preventive Dentistry | Jan-Mar 2014 | Vol 32| Issue 1 | 66
indicating negative aspect of calcium hydroxide.
[3,7,8,15]

Necrosed buccal alveolar mucosa and some discharge
of material from site was found where non-setting
calcium hydroxide (mixed with propylene glycol) was
accidentally extruded through external resorptive
area in maxillary right lateral incisor under buccal
bone.
[15]
In our case also NSCI was found extruded
through sinus under the buccal bone but contrary
to above fndings,
[15]
sinus tract healed except from
initial etching symptoms. Oily preparation of calcium
hydroxide has different physical property than other
types, making mixed ingredients remain binded
within mass. As no free calcium hydroxide particles
were there to occlude blood vessel, our case remained
safe with no ischemia of surrounding tissues as in
other case reports.
[7,8,15]
Our case report also confrms
the fndings of Huang et al.,
[13]
and Nishimura et al.,
[14]

that calcium hydroxide + iodoform in silicon oil
vehicle is the biocompatible material as compared
to freshly mixed calcium hydroxide in aqueous or
viscous vehicle. This may be because of high initial
alkalinity with aqueous or viscous vehicle. Oily
preparations are non-water soluble that promote
lowest solubility and diffusion of paste within
tissue.
[16]
Same biocompatibility has been reported
when calcium hydroxide + barium sulfate mixed
with distilled water was unintentionally extruded
into periapical lesion that did not cause any adverse
reaction but remained non-resorbed during 36 months
period.
[4]
No sinus tract was there preoperatively in
their case,
[4]
preventing direct contact of aqueous mix
of calcium hydroxide with soft tissues.
De Moor and De Witte
[3]
reported that in cases of
accidental extrusion calyx paste was completely
resorbed, while Reogan Rapid did not.
[3]
They
hypothesized that presence of barium sulfate in
calcium hydroxide made it non-resorbable. Same was
the fndings by Orucoglu and Cobankara.
4
Contrary
to these reports, in our case even though barium
sulfate was not there in the mix, it was not resorbed.
Nonetheless similar to these reports, periradicular and
periextrusion radiolucency disappeared.
De Moor and De Witte
[3]
observed white border
surrounding the periapical lesion with a diminished
amount of periradicular calcium hydroxide. Similarly
we also have observed white border in periextrusion
bone [Figure 2a and b]. After surgically exposing
the lesion, burnished bone cavity wall was observed
which was appearing as white line in radiograph.
Similar to our case they also found slow healing of
periapical lesion even after resorption of calcium
hydroxide.
Extrusion of NSCI might have maintained initial pH
because of the presence of exudates there.
[16]
After
drop of pH it induced tissue mineralization around
it. Perhaps after alkalinity drop and infammation
resolution, mass became inert with no chemical
signaling to bring macrophages
[2]
to resorb the material.
Large quantity of extruded calcium hydroxide, be it in
any vehicle,
[3,4]
is not found resorbed perhaps because
of resolution of infammation after some time.
While doing surgery, thin line of periosteum was
observed over extruded mass, proving the tissue
mineralization induction property after pH drop.
The NSCI was found hard while excavation, perhaps
because of exhaustion and resorption of remaining oil
in the span of 2 years. In spite of removal of foreign
material bone healing was very slow. We could not
fnd any case report about management of bone
cavity created in response to NSCI, therefore just after
inducing bleeding by rubbing we closed the lesion
as is routinely done while enucleating cysts. Perhaps
roughening the burnished cavity walls with/without
bone graft would have boosted up the healing rate.
Appearance of radiolucency with distal root might be
because of constant low grade overload on distal root
in presence of slowly healing periradicular lesion with
mesial root.
Periapical radiolucencies were healing after 7 months
of his last visit. The effect of supportive therapy is
unclear as healing may be because of occlusion relief.
Conclusion
The presented case report emphasizes the possible
complications with premixed calcium hydroxide
dressings applied with pressure insertion systems
(lentulo spiral or applicator tips) in root canals should
be reconsidered especially in pediatric dentistry.
References
1. Estrela c, Estrela cr, Hollanda Ac, Decurcio Dde A, Pecora
JD. Infuence of iodoform on antimicrobial potential of
calcium hydroxide. J Appl Oral Sci 2006;14:33-7.
2. Nurko c, ranly DM, Garcia-Godoy F, Lakshmyya KN.
resorption of a calcium hydroxide/iodoform paste (Vitapex)
in root canal therapy for primary teeth: A case report. Pediatr
Dent 2000;22:517-20.
3. De Moor rJ, De Witte AM. Periapical lesions accidentally
flled with calcium hydroxide. Int Endod J 2002;35:946-58.
4. Orucoglu H, cobankara FK. Effect of unintentionally
extruded calcium hydroxide paste including barium sulfate
as a radiopaquing agent in treatment of teeth with periapical
lesions: report of a case. J Endod 2008;34:888-91.
5. Kapoor V, Paul S. Non-surgical endodontics in retreatment of
periapical lesions-two representative case reports. J clin Exp
Dent 2012;4:e189-93.
6. Soomro F, Abidi SY, Qureshi S, Hosein t. Effect of accidental
periapical extrusion of calcium hydroxide paste (A case
report). JPDA 2010;19:57-60.
7. 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;105:666-9.
Sharma, et al.: Periapical extrusion of calcium hydroxide
Journal of Indian Society of Pedodontics and Preventive Dentistry | Jan-Mar 2014 | Vol 32| Issue 1 | 67
8. 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;7:102-8.
9. tronstad L, Andreasen JO, Hasselgren G, Kristerson L, riis I.
pH changes in dental tissue after calcium hydroxide as a short
term intracanal dressing. Int Endod J 1981;7:17-21.
10. Vernieks AA, Messer Lb. calcium hydroxide induced healing
of periapical lesions: A study of 78 non-vital teeth. J br Endod
Soc 1978;11:61-9.
11. Murata SS, Holland r, Souza Vd, Dezan Junior E, Grossi JA,
Percinoto c. Histological analysis of the periapical tissues
of dog deciduous teeth after root canal flling with different
materials. J Appl Oral Sci 2005;13:318-24.
12. bramante cM, berbert A. Infuence of time of calcium
hydroxide iodoform paste replacement in the treatment of root
perforation. braz Dent J 1994;5:45-51.
13. Huang tH, Ding SJ, Kao ct. biocompability of various
formula root flling materials for primary teeth. J biomed
Mater res b Appl biomater 2007;80:486-90.
How to cite this article: Sharma DS, Chauhan SS, Kulkarni
VK, Bhusari C, Verma R. Accidental periapical extrusion of
non-setting calcium hydroxide: Unusual bone response and
management. J Indian Soc Pedod Prev Dent 2014;32:63-7.
Source of Support: Nil, Conflict of Interest: None declared.
14. Nishimura H, Higo Y, Ohno M, tsutsui tW, tsutsui t. Ability
of root canal antiseptics used in dental practice to induce
chromosome aberrations in human dental pulp cells. Mutat
res 2008;649:45-53.
15. bramante cM, Luna-cruz SM, Sipert cr, bernadineli N,
Garcia rb, de Moraes IG, et al. Alveolar mucosa necrosis
induced by utilisation of calcium hydroxide as root canal
dressing. Int Dent J 2008;58:81-5.
16. Vianna ME, Zilio DM, Ferraz cc, Zaia AA, de Souza-Filho FJ,
Gomes bP. concentration of hydrogen ions in several calcium
hydroxide pastes over different periods of time. braz Dent
J 2009;20:382-8.
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.