JICDRO is a UGC approved journal (Journal no. 63927)

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Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 8-17

Nonsurgical management of persistent periapical lesions in the anterior region - A systematic review

Department of Conservative Dentistry and Endodontics, Dr. DY Patil Vidyapeeth, Dr. DY Patil Dental College and Hospital, Pune, Maharashtra, India

Date of Submission12-Mar-2020
Date of Acceptance29-Apr-2020
Date of Web Publication29-Jul-2020

Correspondence Address:
Dr. Sayali Anil Maral
Lane No-16, Plot No-371 ‘Girija’ Bunglow, Mahatma Society, Kothrud, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jicdro.jicdro_11_20

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The basic objective of endodontic therapy is to prevent or arrest the pulpal or periradicular infection. Widely used intracanal medicament calcium hydroxide (Ca[OH]2) introduced by Hermann in 1920 has numerous biological properties such as antimicrobial activity, tissue dissolving ability, inhibition of resorption, and bone formation associated with periradicular healing nonsurgically with less adverse reactions. A systematic search was conducted using MEDLINE PubMed, EBSCOhost, Scopus, Google Scholar, and manual search library resources from January 1, 2008, to July 31, 2019, in order to identify relevant studies. All cross-reference lists of the selected studies were also screened. The inclusion criteria were articles in English or those having detailed summary in English, published between January 2008 and July 2019. Case reports and case series providing information about Calcium Hydroxide as an effective intracanal medicament in persistent periapical infections. Review, abstracts, letters to editors, and editorials were excluded. Data extraction was performed independently by two reviewers. A total of 73 case report articles were identified through the database searching. A total of 20 articles were qualified and were selected. Most of the articles concluded that Ca (OH)2 in any form of vehicle promoted periapical healing with less adverse effects in persistent periapical infections.

Keywords: Calcium hydroxide, nonsurgical management, periapical diseases, periapical healing, tooth

How to cite this article:
Maral SA, Borkar AC, Tandale AB, Nighot NB, Mujumdar SV, Khade SS. Nonsurgical management of persistent periapical lesions in the anterior region - A systematic review. J Int Clin Dent Res Organ 2020;12:8-17

How to cite this URL:
Maral SA, Borkar AC, Tandale AB, Nighot NB, Mujumdar SV, Khade SS. Nonsurgical management of persistent periapical lesions in the anterior region - A systematic review. J Int Clin Dent Res Organ [serial online] 2020 [cited 2022 Sep 27];12:8-17. Available from: https://www.jicdro.org/text.asp?2020/12/1/8/291105

   Introduction Top

Chemomechanical debridement and thorough disinfection of root canal anatomy is the main necessity of endodontic therapy.[1] To attain the disinfection goal, adequate study of normal anatomy and variations should be done and lack of adequate treatment will eventually lead to failure of the treatment.[2]

Favorable conditions can cause normal oral flora to become opportunistic pathogens and can cause disease if they enter the sterile areas such as pulp and periradicular tissues.

As there is direct physiopathological relationship in between pulp and periapical region, bacteria–fungi and other cell components can activate inflammatory process in the periapical region causing resorption,[3] leading to formation of abscess, granulomas, and periapical cyst. They have potential to heal nonsurgically using an interim dressing like Ca(OH)2 sucessfully.[4]

To restrict bacterial regrowth and improve bacterial suppression, intracanal medicament favors elimination of bacterial flora. Interappointment medicament acts by inhibiting proliferation of bacteria and further removes surviving bacteria; also, it decreases the ingress of pathogenic microorganisms through leaking restorations.[5]

Antimicrobial effect of calcium hydroxide

Calcium hydroxide (Ca[OH]2) is a white, odorless powder, which is slightly soluble in water and dissociates into calcium (Ca2+) and hydroxyl (OH) ions. The low solubility property is beneficial as long period is required for Ca(OH)2 to become soluble in tissue fluids when in direct contact with vital tissues. It has a high pH (12.5–12.8) and is chemically classified as a strong base. It dissociates into Ca2+ and OH ions on contact with an aqueous solution, and the main actions of Ca(OH)2 are related to the effect of these ions on vital tissues, such as inducing hard tissue deposition and being antibacterial. OH ions are responsible for the highly alkaline nature of Ca(OH)2. Most of the microorganisms when in direct contact with an intracanal medicament attributes to the following mechanisms: damage to the bacterial cytoplasmic membrane, protein denaturation, and/or damage to the DNA; yet, it is difficult to establish the main mechanism involved in the death of bacteria.[6]

The vehicle plays a most important role in the overall process because it determines the velocity of ionic dissociation causing the paste to be solubilized and resorbed at various rates by the periapical tissues and from within the root canal. Three types of vehicles are used: aqueous, viscous, or oily. The aqueous group is represented by water-soluble substances, including water, saline, dental anesthetics with or without a vasoconstrictor, Ringer's solution, aqueous suspension of methylcellulose or carboxymethylcellulose, and anionic detergent solution.

Pastes containing oil as a vehicle may remain within the root canal for longer than the pastes containing aqueous or viscous vehicles such as olive oil, silicone oil, camphor (the essential oil of camphorated parachlorophenol), metacresylacetate and some fatty acids such as oleic, linoleic, and isostearic acids.[7]

The aim of this systematic review is to assess the literature regarding efficacy of Ca(OH)2 in various forms for management of persistent periapical lesions in anterior region of the jaw in case reports or series. By including the point of evaluation used by the clinicians when the patients reported for follow-ups, there was an improved understanding of the signs and symptom set of both successes and failures.

Focused question

What is the effect of Ca(OH)2 as an intracanal medicament in persistent periapical lesions?


To determine effectiveness of Ca(OH)2 as an intracanal medicament in the management of persistent periapical lesions.

Components of the PICO question

  1. Participants: Persistent periapical lesions in the anterior region
  2. Intervention: Intracanal medicament.

Comparison: NA

  1. Outcome: Periapical healing.

   Materials and Methods Top

Protocol and registration

The material and method was based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

A search strategy of the literature was performed on PubMed and MeSH terms were found. The search was performed between January 2008 and July 2019 and articles in English or those having detailed summary in English were included. Duplicates were removed manually. After the selection of the articles, a manual search was conducted from the reference lists.

Eligibility criteria

Inclusion criteria

  1. Case reports only
  2. Article reporting information about patients having periapical lesions
  3. Articles in English or those having detail summary in English
  4. Article reporting information about patients age 7–45 years
  5. Articles reporting use of Ca(OH)2 in patients having periapical lesions
  6. Article reporting outcomes in terms of healing
  7. Case reports published between January 1, 2008 and July 31, 2019.

Exclusion criteria

  1. Abstract and letter to editorials are excluded
  2. Animal studies
  3. Review articles
  4. Case reports on retreatment cases.

Information sources

English language articles were retrieved from electronic biomedical journal databases. PubMed, Google Scholar, and Research Gate were used to complete the search for all full text articles available. The search was done till July 30, 2019. The last data search was conducted on July 30, 2019.


The following databases were searched on: PubMed (The limits used were all full text articles in English dated from January 1, 2008, to July 31, 2019, and Google Scholar. For the electronic search strategy, [Table 1] were used as keywords in several combinations.
Table 1: Keywords

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Study selection

Case reports showing nonsurgical management of persistent periapical lesions with the help of Ca(OH)2 in any form were included. Using different search strategies [Table 2] from the above-mentioned keywords [Table 1] and their combinations, various electronic databases were searched. Total 73 case report articles were identified through the database searching. After thorough reading of titles, 37 case report articles were excluded. After searching for duplicates, 16 case report articles were excluded. These remaining 36 articles were further screened for abstract reading and 7 case report articles were excluded and the remaining 29 case report articles were selected after reading the abstracts. Full texts for these 29 articles were obtained and were assessed for eligibility. A total of 20 articles were qualified and were selected. Nine case report articles were excluded.
Table 2: Search strategy

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Data collection

Data collection process was done according to the consultation approved from our expert. First, a pilot Microsoft Excel Sheet was filled accordingly, and then the expert was consulted for further progress. According to the data collected and the records selected, the remaining Excel Sheet was filled only with the data that were related to this study and retained.

Data extraction

The data extraction was carried out by one author (DR) and later reviewed by a second author (AS); disagreements were solved by discussion.

The following data were obtained from the selected articles [Table 3]:
Table 3: Data extraction sheet

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  1. Study design – case reports or case series
  2. Number of patients
  3. History-cause of lesion
  4. Radiographic diagnosis
  5. Initial follow-up
  6. Final follow-up
  7. Intracanal medicament – Ca(OH)2 in various forms and formulations
  8. Clinical outcome in terms of periapical healing.

   Discussion Top

Periradicular lesions are usually endodontic in origin. Bacteria and bacterial by-products within the root canal and its ramifications bring out the inflammatory response in the periradicular tissue. Proper cleansing and disinfection of the root canal system will effectively reduce the microbial cause of cyst-like periapical lesions or inflammatory apical true cysts.[8]

Case report by Hannah Rosaline et al. showed an innovative bioroot inlay technique in treatment of central incisor with wide open apex and periapical lesion of 1 cm × 2 cm. Cleaning shaping with use of sodium hypochlorite and intracanal medicament in form of Ca (OH)2 was given for the periapical lesion where it showed reduction in the lesion size in 6 months and complete resolution in 4 years.[9]

Kapil Krishnan Dua et al.,[2] Janir Soares et al.,[3] Aditya Mitra et al.,[10] Koppolu Madhusudhana et al.,[11] Prabhat Mandhotra et al.,[1] Caliskan et al.,[12] Roopa Dharavat et al.,[4] Sweta Chaudhary et al.,[13] Puneet Ajwani et al.,[14] Hasan Oracoglu et al.,[15] and S. Jagadish et al.[16] reported cases with nonsurgical management of periapical lesions with resolution of signs and symptoms both clinically and radiographically with Ca(OH)2 various formulations when used as an intracanal medicament.

Priya Mittal et al.[17] described cone-beam computed tomography-guided nonsurgical management of Type III (subtype B) dens invaginatus in a permanent maxillary canine associated with a sinus tract and peri-invagination periodontitis in a 17-year-old female. After gaining access to the root canal, thorough chemomechanical preparation was performed and usage of intracanal medicament of Ca(OH)2 was performed for 3 weeks, during which the sinus tract healed completely. At 12-month follow-up, the patient was asymptomatic with complete resolution of the sinus tract and radiographic evidence of healing of periapical pathology.

Similar cases were reported by Sara Fayazi et al.,[18] Marcia Schmitz et al.,[19] and Damian lachota et al.[20]

Shweta Dwivedi et al.[21] published a case report of nonsurgical management of a radicular cyst associated with permanent maxillary right central, lateral, and canine in a 24-year-old female patient. Root canal treatment was done together with cystic aspiration of the lesion and Ca(OH)2 as an intracanal medicament was reported. The lesion was periodically followed up and significant bone formation was seen at the periapical region of affected teeth and at the palate at about 9 months.

Similar case was reported by Kunjamma Thomas et al.[8] Hyunsook Chung et al.[22] showed a case of an avulsed upper left central incisor that was replanted after 3 h in a 7-year-old. Tooth showed signs of an acute periapical abscess at 2 weeks after replantation. Apexification with mineral trioxide aggregate following application of Ca (OH)2 as intracanal medicament was attempted. At 3-year and 6-month follow-up, the tooth was asymptomatic with adequate clinical function. The radiograph showed resolution of the periapical lesion.

Vasudev Ballal et al.[23] reported a rare case of orthodontically induced external root resorption of a maxillary left central incisor with a large periapical radiolucency. The tooth was nonvital and had Grade III mobility. It was treated endodontically for 2 years with an intracanal medicament of Ca(OH)2 mixed with propylene glycol. After 2 years, the postoperative intraoral periapical radiograph showed good periapical healing with complete resolution of periapical radiolucency. There was a significant reduction in the mobility of the tooth, from Grade III to Grade I.

Ca(OH)2 inactivates endotoxin and appears currently the only effective medicament for inactivation of endotoxin.[24]

Nonsurgical management of periapical lesions is preferred in comparison to surgical methods and should be considered. Possible damage to adjacent vital teeth, damage to anatomic structures in the vicinity of the lesion, and pain and discomfort associated with surgical procedures can be eliminated by nonsurgical methods. Patient acceptance and apprehension toward the surgical procedure, age, and medical conditions which limit surgical procedures are also factors which favor nonsurgical approach. Surgical procedures should be considered only when conventional root canal methods fail.


  • The volumetric extension of periapical lesion and healing were not specified in many of the case reports/series
  • In some full-text articles, the vehicle used for Ca(OH)2 formulation was not specified.

   Conclusion Top

Large persistent periapical lesions can resolve by nonsurgical endodontic therapy employing Ca(OH)2 intracanal interappointment medicament and should be attempted as the first approach in all cases with periapical lesions. Surgical approach is only needed if conservative approach fails.


  • The healing of periapical lesions will not be achieved only through surgical removal of the periapical lesion but also requires proper root canal disinfection and obturation
  • Ca(OH)2 in any vehicle form is effective as an intracanal medicament in persistent periapical lesions
  • In case of large periapical lesions, conventional endodontic therapy alone may not be enough. Associated procedures such as aspiration, decompression, nonsurgical aspiration, and irrigation may be required.

Future implications

More in vivo case studies should be carried out with comparison of different vehicles used with Ca(OH)2 and its interaction with other medicaments.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Mandhotra P, Goel M, Rai K, Verma S, Thakur V, Chandel N. Accelerated non surgical healing of large periapical lesions using different calcium hydroxide formulations: A case series. Int J Oral Health Med Res 2016;3:79-83.  Back to cited text no. 1
Dua KK, Kaur Atwal PK. Nonsurgical healing of a large periapical lesion associated with a two-rooted maxillary lateral incisor. CHRISMED J Health Res 2018;5:48-50.  Back to cited text no. 2
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Soares JA, Brito-Júnior M, Silveira FF, Nunes E, Santos SM. Favorable response of an extensive periapical lesion to root canal treatment. J Oral Sci 2008;50:107-11.  Back to cited text no. 3
Dharavath R, Veeramachaneni C. Non-surgical endodontic approach for management of periapical lesions. Int J Sci Stud 2015;2:193-6.  Back to cited text no. 4
Kumar A, Tamanna S, Iftekhar H. Intracanal medicaments – Their use in modern endodontics: A narrative review. J Oral Res Rev 2019;11:94-9.  Back to cited text no. 5
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Kim D, Kim E. Antimicrobial effect of calcium hydroxide as an intracanal medicament in root canal treatment: A literature review-Part I.In vitro studies. Restor Dent Endod 2014;39:241-52.  Back to cited text no. 6
Fava LR, Saunders WP. Calcium hydroxide pastes: Classification and clinical indications. Int Endod J 1999;32:257-82.  Back to cited text no. 7
Thomas K, T PD, Simon EP. Management of large periapical cystic lesion by aspiration and nonsurgical endodontic therapy using calcium hydroxide paste. J Contemp Dent Pract 2012;13:897-901.  Back to cited text no. 8
Rosaline H, Rajan M, Deivanayagam K, Reddy SY. BioRoot inlay: An innovative technique in teeth with wide open apex. Indian J Dent Res 2018;29:521-4.  Back to cited text no. 9
[PUBMED]  [Full text]  
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Koppolu M, Ramakrishna S, Chinni SK, Anumula L. Non-surgical management of a large periapical lesion: A case report. Ann Essences Dent 2017;9:2,22a-25a.  Back to cited text no. 11
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Chaudhary S, Tripathi P, Upadhaya Y, Seth P. Successful nonsurgical management of a large radicular cyst: A case report with review of literature. Int J Contemp Dent Med Rev 2015;2015:1-5.  Back to cited text no. 13
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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.  Back to cited text no. 15
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Mittal P, Jadhav GR, Syed S, Bhujbal ND. Cone-beam computed tomography-guided management of C-shaped Type III dens invaginatus with peri-invagination periodontitis in a maxillary canine: A case report. Compend Contin Educ Dent 2016;37:e9-12.  Back to cited text no. 17
Fayazi S, Bayat-Movahed S, White SN. Rapid endodontic management of type II dens invaginatus using an MTA plug: A case report. Spec Care Dentist 2013;33:96-100.  Back to cited text no. 18
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Lichota D, Lipski M, Woźniak K, Buczkowska-Radlińska J. Endodontic treatment of a maxillary canine with type 3 dens invaginatus and large periradicular lesion: A case report. J Endod 2008;34:756-8.  Back to cited text no. 20
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Ballal V, Kundabala M, Bhat KS. Nonsurgical management of a nonvital tooth with orthodontically induced external root resorption and extensive periapical pathology. Am J Orthod Dentofacial Orthop 2008;134:149-52.  Back to cited text no. 23
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  [Table 1], [Table 2], [Table 3]

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