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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 21-26

Comparative efficacy of calcarea phosphorica versus calcium hydroxide materials for the disinfection of remaining carious dentin in deep cavities: An In vivo study


1 Department of Pedodontics and Preventive Dentistry, Nanded Rural Dental College, Nanded, Maharashtra, India
2 Department of Pedodontics and Preventive Dentistry, Mamata Dental College, Khammam, Telangana, India

Date of Submission01-Aug-2019
Date of Decision09-Sep-2019
Date of Acceptance04-Oct-2019
Date of Web Publication27-Jan-2020

Correspondence Address:
Kola Srikanth Reddy
Department of Pedodontics and Preventive Dentistry, Mamata Dental College, Khammam, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_90_19

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  Abstract 


Objectives: The aim of the study was to comparatively evaluate the efficacy of clinical and radiographic effects of calcarea phosphorica (CP) and calcium (Ca)(OH)2(Dycal) in indirect pulp capping of permanent teeth over a period of 6 months. Methodology: Permanent teeth were selected from children between the age group of 7 and 12 years, of which 20 teeth were considered, each for indirect pulp capping with CP and Ca(OH)2, respectively. Increase in dentin thickness was measured at baseline, 3 month, and 6 month on digitized radiographs using CorelDraw software. Results: Independent t-test had indicated that at the end of 3 and 6 months, a statically significant increase in dentin thickness with both CP and Dycal (P ≤ 0.001) was found within the CP group; the thickness of dentin formed was 0.089 mm ± 0.031 mm at first 3 months and 0.055 ± 0.022 mm at the second 3 months (P ≤ 0.001) evaluated using paired t-test. In the Dycal group, increment in dentin deposited was 0.068 mm at the first 3 months and second 3 months. It was 0.030 mm (P ≤ 0.001). Conclusion: Both clinically and radio graphically, CP is superior to Dycal as indirect pulp capping medicament in permanent teeth.

Keywords: Calcium (OH)2,calcarea phosphorica, deep dental caries, indirect pulp treatment permanent teeth


How to cite this article:
Sirikonda S, Sravanthi D, Swetha K, Ankireddy SR, Shereen S, Manva MZ, Reddy KS. Comparative efficacy of calcarea phosphorica versus calcium hydroxide materials for the disinfection of remaining carious dentin in deep cavities: An In vivo study. Indian J Dent Sci 2020;12:21-6

How to cite this URL:
Sirikonda S, Sravanthi D, Swetha K, Ankireddy SR, Shereen S, Manva MZ, Reddy KS. Comparative efficacy of calcarea phosphorica versus calcium hydroxide materials for the disinfection of remaining carious dentin in deep cavities: An In vivo study. Indian J Dent Sci [serial online] 2020 [cited 2020 Apr 2];12:21-6. Available from: http://www.ijds.in/text.asp?2020/12/1/21/276890




  Introduction Top


Vital pulp therapy aims to preserve and maintain the integrity of the pulp that has been compromised by caries, trauma, or restorative procedures.[1] Indirect pulp treatment (IPT) is one such therapeutic modality and is based on the research of Fusayma et al.[2] who demonstrated that in acute caries, discoloration (affected dentin) preceded the presence of microorganisms (infected dentin). The success of IPT depends on the adequate reduction of the microbial load, the reparative ability of the pulp–dentin complex, and placement of a suitable coronal restoration. Various materials have been used as IPT agents in the management of vital teeth with deep carious lesions. Calcium (Ca)(OH)2 has been a gold standard for pulp capping and is being used since its use was first described by Zander.[3] In 1939, it allows the formation of a reparative dentin through cellular differentiation, extracellular matrix secretion, and subsequent mineralization.[4],[5] Various disadvantages such as gradual 2 disintegration and formation of a tunnel in newly formed dentin have been commonly witnessed with Ca(OH)2 when followed up for longer times.[6] This has led to the use of various other materials for IPC including GIC, MTA, and CP. Various homeopathic medicines have been also used systemically such as calcarea phosphorica (Cal-f) (or) fluoride of lime (CaF2) for the treatment of various dental problems as they contain mineral salts that they play role in the mineralization of teeth and bone.[7]

The aim of this study was to compare the effects CP and conventional Ca(OH)2 when used as agents for IPT based on clinical and radio graphical changes.


  Methodology Top


This clinical study was conducted at dental college and hospital, pediatric dentistry unit, using a protocol that was reviewed and approved by the institutional review boards. The parents/legal guardian read and signed an informed form for this study. Forty permanent molars were selected from 40 healthy children (7–12 years old.). The Inclusion criteria based on the AAPD Guidelines teeth with active deep caries on the occlusal or proximal surfaces with a history of dull, reversible pain (or) mild discomfort on chewing were included in the study. On radiograph interpretation, caries depth should be >2/3 of dentin thickness approaching area of the teeth. Patients with symptoms of irreversible pulpits/apical periodontits, pathological mobility, discoloration with internal/external resorption, and some of the acute/chronic conditions which might affect the prognosis of the treatment were excluded from the study.

Cases were selected based on the color and consistency of the caries in the lesion by one trained examiner, whose reliability was tested by the kappa test with an index of 0.80 and 0.75, respectively. A block randomization method was followed. Forty teeth were allocated to the predefined study groups (n = 20) by an independent station through a computer-generated random number table. The patient information sheet was provided; the patients blinded to the material applied.

Procedure

The patients were anesthetized (Lox 2%, Lidocaine 2% Hcl injection, Neon Laboratory Ltd, Mumbai, India) and under rubber dam (Hygienic Dental Dam, Coltene/Whaledent Inc, Cuyahoga Falls, OH, USA). Isolation, received occlusal (or) proximal cavity preparations. Unsupported enamel and caries from lesion walls were removed with a sterile ≠ 245 tungsten carbide bur (SS White Burs, Inc., Lakewood, NJ, USA), operated in a high-speed air–water spray handpiece (Extra Torque 606 Turbine, KaVo Dental Excellence, Santa Catarina, Brazil). A round-tipped probe aided in tactile detection of dentin consistency. In the area deemed at risk for pulp exposure, the softened, humid, yellow or light-brown carious dentin that did not offer any resistance to probing was removed with a sterile ≠ 6 or ≠ 8 carbide bur (SS White Burs Inc.) at a low-speed handpiece (Ti-max, NSK, Tochigi, JAPAN). The darker and harder dentin was preserved [Figure 1] and [Figure 2].
Figure 1: After caries removal

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Figure 2: Pulp capping material applied

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In controlled group

Rubber dam application was done to achieve proper isolation. After the application of rubber dam, caries was excavated with a spoon excavator. Following the removal of caries, conventional Ca(OH)2(Dycal, Dentsply, Caulk, Milford, DE, USA) was applied in all teeth of Group 1 [Figure 3].
Figure 3: Restored with glass ionomer cement

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In the experimental group

Calcarea phosphorica (CP) was mixed with distilled water to a proper consistency and applied to the Group 2 teeth. Following this, a temporary restoration was applied in all teeth of both the groups. They were clinically and radio graphically re-examined after 3 and 6 months. The increase in dentin thickness was thus measured using (CorelDraw Software, Version 13) (Corel, Ottawa, Canada] [Figure 4], [Figure 5], [Figure 6], [Figure 7].
Figure 4: IOPAR-Reading with Calcarea phosphorica at 3 months magnified

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Figure 5: IOPAR-Reading with calcarea phosphorica at 6 months magnified

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Figure 6: IOPAR-Reading with Dycal at 3 months

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Figure 7: IOPAR-Reading with Dycal at 6 months

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On each digitized radiographs, evaluation was for root restoration, widening of periodontal ligament (PDL) space, periapical radiolucency, dentin formation, and any intra pulpal calcification. The treatment was considered to be successful when the pulp remained vital with a normal response without signs of spontaneous pain; radiographically, the treatment was considered successful when reactionary dentin was present over the lesions with no furcation radiolucency, PDL widening, and internal and external root resorption. Stainless steel crowns were advised after the evaluation period of the study.

Data analysis

The data obtained were analyzed using the independent t-test for intergroup analysis and paired t-test for intragroup analysis. All results were considered significant if P < 0.05. The software (SPSS 15.0, SPSS Inc., Chicago, IL, USA) was used for these analyses.


  Results Top


The purpose of this study was to compare the clinical and radiographic effects of CP and Dycal in permanent teeth IPT after 6 months. A total of 20 specimens were included in CP group, of which of one specimen was excluded during the study due to the loss of restoration. Readings of the remaining 19 specimens were recorded. Similar to the CP group, a total of 20 specimens were included in Dycal group, of which 1 specimen was excluded due to the loss of restoration and 3 were lost to follow-up during the 3 months. At 6-month follow-up, 1 failed due to the development of sinus discharge and the remaining 15 specimens were recorded for the study [Table 1].
Table 1: Sample collection and distribution

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For intergroup analysis, an independent t-test been performed which suggested that at the end of 3 and 6 months, there is a statistically significant increase in dentin thickness with both CP and Dycal with P ≤ 0.001, respectively [Table 2].
Table 2: Tertiary dentin deposited with both the groups

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The results from [Table 3] indicate that the mean dentin deposited in the CP group at 3 months was 0.089 mm, whereas in the Dycal group, it was 0.689 mm (P = 0.038), signifying that CP is superior to Dycal. At the end of 6 months, in CP group, tertiary dentin deposition was 0.143 mm of dentin, and in Dycal group, dentin deposited was 0.097 mm which was also statistically significant with P = 0.004.
Table 3: Intergroup dentin deposited at the end of 6 months

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From the observations of [Table 4], we can conclude the fact CP was superior to Dycal at the end of both 3 and 6 months. Within the CP group, the thickness of dentin formed was 0.089 mm ± 0.031 mm at first 3 months and 0.055 ± 0.022 mm at the end of 6 months. This was evaluated using a paired t-test.
Table 4: Increment in dentin deposited at first 3 months and the second of 3 months

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From the observations of [Table 4] in the Dycal group two, the amount of dentin formed at 3 and 6 months was statistically significant. Increment in dentin deposited was 0.068 mm which was more at the first 3 months than the second 3 months which was 0.030 mm with P ≤ 0.001, but the rate was more with CP than the Dycal.

[Graph 1] depicts that CP deposited more dentin than Dycal at the end of 6 months.



[Graph 2] represents that the increment of dentin formed at the first 3 months is more than that formed at the end second 3 months in both the CP and Dycal groups. Dentin deposited at the first 3 months and second 3 months is more with CP than that compared with Dycal.




  Discussion Top


CP is another pulp capping agent which came into practice in the year 1900.[8] Its advantages are it helps in forming dentin bridge without any tissue necrosis. It has good physical properties. In addition, the absence of pulp inflammation is seen compared to Ca(OH)2;[8] the release of Ca+ ions is the key factor for successful pulp capping because of influence Ca on differentiation, proliferation, and mineralization of pulp cells.

The bioavailability of Ca+ ions plays a key role in the various biological events on cells involved in the new formation of mineralized hard tissue; Ca+ ions stimulate the expression of bone-associated proteins mediated by a Ca+ channels, and large quantities Ca+ ions could activate ATP which plays a significant role in the mineralization process.[9]

CP has been used as an important medicine in homeopathy to treat bone disorders and teething problems; Werkman et al.[10] observed that CP stimulated osteoblasts and formed bone with higher optical density. Werkman et al.[10] in 2006 observed that normal cortical bone was formed with the use of CP.

This study highlights the ability of the pulp to heal depending on the environment and can occur in the absence of bacterial infection.[11] Over the years, many materials have been used as gold standard. A search of PubMed (search key words: Ca(OH)2 and pulp capping).

Ca(OH)2 no longer seems to be an ideal material for the following reasons, released more than 650 references (July 2009), characterized by very basic PH (Farco and Holland et al. 1979[12]):

  1. The induced dentin bridge is in consistent and porus (Cox et al. 1996[13])
  2. Ca(OH)2 does not adhere to the dentin walls
  3. The sealing ability of Ca(OH)2 is quite poor
  4. The material has poor antibacterial properties, because of its high pH, Ca(OH)2 in direct contact with the pulp locally destroys, a layer of pulp tissue, and thus creates discontinued necrotic zones; this necrotic layer induces an inflammatory reaction which persists over time or leads to the formation of intra pulpal calcifications (Seltzer et al. 1963[14]).


However, lack of inflammation, infection control and biocompatibility and dentin bridge formation is a key factor for final healing and long term success as it protects the exposed pulps to further attack of oral bacteria that may result in pulp degeneration, atrophy and shrinkage.[15],[16],[17],[18]

As it has also been established that an inflammatory response occurs in pulp tissue as soon as caries reaches the dentin (even at a superficial layer), it appears that the treatment of noninflamed dental pulp would be an unlikely event, except after pulp exposure due to trauma. Pulp exposure often occurs after trauma, and as the pulp is generally free of inflammation, pulp capping in such a situation represents a good approach for the treatment. However, it is important to consider management of such cases in the context of the biological behavior of the pulp, especially in immature teeth which are still developing.

The ultimate goal of pulp capping with a dedicated material is to induce the formation of a barrier of reparative dentin between the pulp and the material of obturation by allowing pulp cells to express their dentinogenic potential.[19] In 1974, Cotton WR et al.[11] demonstrated the systemic formation of a dentin bridge after pulp exposure in laboratory germ-free animals.

The mean dentin-bridge formation 6 months after IPT was 0.068 mm for Group 1 teeth (Dycal-treated) and 0.89 mm for Group 2 teeth (CP treated); removal of the infected carious dentin had provided favorable conditions for remineralization of the affected dentin that was initially preserved in both the groups.

CP provides various advantages when used for IPT, for example, it is more biocompatible as it has been used for systemic administration for a number of years. We also found that CP has a longer working time than Ca(OH)2(Dycal), is very easily available, and is also cost-effective, provided that a well-covered restoration is given after the pulp capping, this will provide protection against ongoing leakage and bacterial contamination, IPT with CP should invariably produce similar results as with Ca(OH)2.

Limitations

Further studies with larger sample size and histological assessment are needed to be carried out to estimate the efficacy of CP in indirect pulp capping and the quality of dentin bridge formed by CP.


  Conclusion Top


Although Ca(OH)2 remains the gold standard for indirect pulp capping, CP can be used as a useful alternative as it shows favorable results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ingle JI, Blank LK. Endontics. 6th ed. London: DC Becker Inc.; 2008. p. 1310-12.  Back to cited text no. 1
    
2.
Fusayama T, Okuse K, Hosoda H. Relationship between hardness, discoloration, and microbial invasion in carious dentin. J Dent Res 1966;45:1033-46.  Back to cited text no. 2
    
3.
Zander HA. Reactions of the pulp on Ca (OH) 2. J Dent Res 1939;18:373-9.  Back to cited text no. 3
    
4.
Brannstrom M, Nyborg H, Stromberg T. Experiments with pulp capping. Oral Surg 1979;48:373-9.  Back to cited text no. 4
    
5.
Mjör IA. Human coronal dentine: Structure and reactions. Oral Surg Oral Med Oral Pathol 1972;33:810-23.  Back to cited text no. 5
    
6.
Olsson H, Petersson K, Rohlin M. Formation of a hard tissue barrier after pulp cappings in humans. A systematic review. Int Endod J 2006;39:429-42.  Back to cited text no. 6
    
7.
Boericke W. Calcarea fluorica. In: Boericke New Manual of Homoeopathic Materia Medica and Repertory. 2nd ed. New Delhi: Jain Publishers; 2000. p. 14951.  Back to cited text no. 7
    
8.
Yoshimine Y, Maeda K. Histologic evaluation of tetracalcium phosphate-based cement as a direct pulp-capping agent. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:351-8.  Back to cited text no. 8
    
9.
Gandolfi MG, Siboni F, Prati C. Chemical-physical properties of theraCal, a novel light-curable MTA-like material for pulp capping. Int Endod J 2012;45:571-9.  Back to cited text no. 9
    
10.
Werkman C, Senra GS, da Rocha RF, Brandão AA. Comparative therapeutic use of risedronate and calcarea phosphorica – Allopathy versus homeopathy – In bone repair in castrated rats. Braz Oral Res 2006;20:196-201.  Back to cited text no. 10
    
11.
Cotton WR. Bacterial contamination as a factor in healing of pulp exposures. Oral Surg Oral Med Oral Pathol 1974;38:441-50.  Back to cited text no. 11
    
12.
Holland R, de Souza V, de Mello W, Nery MJ, Bernabé PF, Otoboni Filho JA, et al. Permeability of the hard tissue bridge formed after pulpotomy with calcium hydroxide: A histologic study. J Am Dent Assoc 1979;99:472-5.  Back to cited text no. 12
    
13.
Cox CF, Sübay RK, Ostro E, Suzuki S, Suzuki SH. Tunnel defects in dentin bridges: Their formation following direct pulp capping. Oper Dent 1996;21:4-11.  Back to cited text no. 13
    
14.
Seltzer S, Bender IB, Ziontz M. The dynamics of pulp inflammation: correlations between diagnostic data and actual histologic findings in the pulp. Oral Surg Oral Med Oral Pathol 1963;16:969-77.  Back to cited text no. 14
    
15.
Murray PE, Hafez AA, Windsor LJ, Smith AJ, Cox CF. Comparison of pulp responses following restoration of exposed and non-exposed cavities. J Dent 2002;30:213-22.  Back to cited text no. 15
    
16.
Murray PE, Hafez AA, Smith AJ, Windsor LJ, Cox CF. Histomorphometric analysis of odontoblast-like cell numbers and dentine bridge secretory activity following pulp exposure. Int Endod J 2003;36:106-16.  Back to cited text no. 16
    
17.
Mjör IA. Pulp-dentin biology in restorative dentistry. Part 7: The exposed pulp. Quintessence Int 2002;33:113-35.  Back to cited text no. 17
    
18.
Ward J. Vital pulp therapy in cariously exposed permanent teeth and its limitations. Aust Endod J 2002;28:29-37.  Back to cited text no. 18
    
19.
Schröder U. Effects of calcium hydroxide-containing pulp-capping agents on pulp cell migration, proliferation, and differentiation. J Dent Res 1985;64:541-8.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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