CLINICAL
CALCIUM HYDROXIDE PASTE AS A SURFACE
DETOXIFYING AGENT FOR INFECTED DENTAL
IMPLANTS: TWO CASE REPORTS
Dennis Flanagan, DDS
Dental implant treatment is successful; however, an implant can become infected during or after
osseointegration. The two case reports presented here demonstrate, anecdotally, the effectiveness of
endodontic calcium hydroxide paste for the surface treatment of infected, healing, or
osseointegrated dental implants. Calcium hydroxide may be an appropriate surface detoxifying
agent for local dental implant infections. A sequence of calcium hydroxide and 0.2% chlorhexidine
gluconate surface treatment may provide a broad range of antimicrobial action for detoxifying
recalcitrant infections. Calcium hydroxide should not be left in the surgical site.
Key Words: dental implant, infection, surface treatment
INTRODUCTION
D
ental implant treatment has been
shown to be very successful. However,
there are reports where an implant has
become infected during or after osseointegration.1–12 Some types of bacteria or fungi may colonize the implant
surface and produce localized bone loss or complete
loss of bone around the fixture. To salvage an ailing or
failing implant, tetracycline or citric acid has been
typically used as an implant surface detoxifying
agent.1,3,7,8 The apparent concept is to kill the
colonizing bacteria and remove implant surface
contaminants without defacing the surface. The
surrounding bone should not be damaged to allow
for continued or reinstated osseous healing. Many
authors have published articles using tetracycline and
citric acid as detoxifying agents with successful
results.1,2,3 However, these agents have a pH range
of 1–3 for citric acid, depending on concentration, and
1.8 for tetracycline HCl. The low pH may decalcify the
osseous tissue around the implant and may inhibit
healing. Another available detoxifying agent is calcium
hydroxide (CH). CH is well known in dentistry. It has
Dennis Flanagan, DDS, is in private practice in Willimantic, Conn.
Address correspondence to Dr Dennis Flanagan at 1671 West Main
Street, Willimantic, CT 06226. (e-mail: [email protected])
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been used for decades as an endodontic intracanal
medicament. It has a pH of slightly more than 12 that
may not decalcify or confound bone healing, but it
may be caustic to soft tissue. CH, in the dental pulp
capping paste form, is US Food and Drug Administration (FDA) 510(k) approved for endodontic use and
now is reported here as an implant surface detoxifying
agent for infected implants.
CH paste as a surface detoxifier for apical (retrograde) implantitis has been previously reported.13
CASE REPORT #1
A 44-year-old woman with failing endodontically treated
maxillary central incisors presented for treatment
(Figure 1). She had an unremarkable medical history.
The teeth had been endodontically treated many years
prior and had apical radiolucencies (Figure 2). After a
discussion of options for treatment, extraction of the 2
teeth and implant placement for implant supported
crowns were agreed upon. Both teeth were extracted
and the facial cortices were found to be destroyed by the
chronic infection. A facial barrier membrane (Biomend,
Zimmer Dental, Carlsbad, Calif) was placed, and bone
graft material was placed (Puros, Zimmer Dental) with
rotated palatal pedicle grafts to attain primary closure
(Figure 3). Additionally, the palatal pedicle grafts were
used to increase the soft tissue thickness for appropriate
Dennis Flanagan
FIGURES 1–4. FIGURE 1. Presenting condition. FIGURE 2. Radiograph of presenting condition. FIGURE 3. Grafted extraction sites. FIGURE 4. Radiograph
of placed implants.
gingival architecture around the definitive crowns. After
4 months of healing, 1 implant was placed in site #8 (3.7
3 13, Implant Direct, Ventura, Calif). Site #9 had poor
bone quality for initial stabilization, therefore, the
osteotomy was compressed with an osteotome and a
larger implant was installed (4.7 3 13, Implant Direct)
(Figure 4).The depth of the implant placement ensured
an appropriate emergence profile for both proposed
crowns despite the different diameters. At the eighth
postoperative week, the patient presented with a small
facial swelling at site #9. A drainage tract was seen and a
radiograph was made with a #40 gutta percha point
placed into the tract to act as an indicator to the source
(Figure 5). The source of the infection was the mid body
Journal of Oral Implantology
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CALCIUM HYDROXIDE PASTE
FIGURES 5 and 6. FIGURE 5. Draining infection tracked with gutta percha point. FIGURE 6. Bone loss at implant mid body.
of the #9 implant. The site was locally anesthetized and
surgically opened with a #15C scalpel to expose the
infected implant body (Figure 6). The area was debrided
with a periodontal curet, treated with calcium hydroxide
paste (Pulpdent Corp, Watertown, Mass) for less than
30 seconds, and rinsed with sterile saline; an allograft
material was then placed in the defect (Puros), and a
barrier membrane was placed (Biomend) and was
primarily closed with 4-0 polyglycolic acid suture (Vicryl)
(Figures 6 through 9). The site healed uneventfully and 2
porcelain fused to metal crowns were subsequently
made to complete the treatment (Figure 10). At all
surgical visits the patient exhibited normal physiologic
vital signs.
CASE REPORT #2
A 62-year-old woman presented for treatment of a
failing, previously endodontically treated mandibular
right lateral incisor. She had an insignificant medical
history. Treatment options were discussed and extraction with implant treatment was decided upon. Tooth
#26 was atraumatically removed and a 3.7 3 13
implant (Implant Direct) was installed. The implant
was immediately nonfunctionally loaded with a
provisional bis-acryl crown. After 4 months, the
definitive porcelain fused to metal crown was
fabricated and delivered. After 4 weeks, the patient
presented with pain and slight swelling at the facial of
#26. A radiograph taken with a gutta percha indicator
revealed a radiolucency that indicated an infected mid
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body implant surface. The area was locally anesthetized and the fixture was surgically exposed. The bone
defect was debrided, the implant surface was treated
with calcium hydroxide paste for less than 30 seconds,
and then rinsed with sterile saline. A bone allograft
material was placed in the defect and primarily closed
with polyglycolic acid suture (Vicryl). At all surgical
visits the patient exhibited normal physiologic vital
signs. The patient returned for follow-up appointments and healed uneventfully.
DISCUSSION
The root canal treatment paste product used in these
cases was CH in aqueous methylcellulose with barium
sulfate for radiopacity (TempCanal, Pulpdent Corp).
The manufacturer claims the product is bacteriocidal
and bacteriostatic. The CH is an alkali and packaged at
a concentration of 5 mg/mm3. This is a very high
concentration. It is not considered a carcinogen
(Material Safety Data Sheet, TempCanal).
Bacterial implant infections can cause failures in
healing and osseointegration. Many of these implant
infections occur in failed endodontic sites. Both of the
patients reported here had bouts of mid body
implantitis after placement in sites where there were
failed endodontically treated teeth. Both infected
implant surfaces and the surrounding bone were
successfully treated with CH. In both cases, the CH
paste was left on the implant surface and bone defect
for less than 30 seconds.
Dennis Flanagan
FIGURES 7–10. FIGURE 7. Debrided site was detoxified with calcium hydroxide paste and thoroughly rinsed. FIGURE 8. Defect was filled with
allograft. FIGURE 9. A membrane covered the grafted site. FIGURE 10. Final result.
Empirically, the high pH of CH endodontic paste
may be better tolerated by osseous tissue than a low
decalcifying pH agent such as tetracycline or citric
acid. However, both of these low pH agents have had
successful treatment results reported.
Although CH paste is approved by the FDA for
endodontic use, this treatment is an off-label use.
This is where an agent is used for a treatment
process not claimed by the manufacturer, but the
clinician is allowed to use the product in a novel
therapeutic way.
Enterococcus faecalis and Candida albicans are
common species found in failed endodontic teeth.14
It may be that these and/or other species residually
remain in the apical bone and vegetate until they are
reactivated with implant surgery to colonize the
implant surface.15–20 E faecalis in a vegetative or
stationary phase resisted more than 10 minutes of
exposure to CH or 0.05% chlorhexidine gluconate or
0.0001% sodium hypochlorite. However, the bacterial
cells in a growth phase were completely killed at an
exposure of 3 seconds to these materials.21 Additionally, at the higher concentration of 3.0%, sodium
hypochlorite effectively killed E faecalis in both
vegetative and growth phases.22 Sodium hypochlorite
is corrosive and may not be safe for exposure to
Journal of Oral Implantology
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CALCIUM HYDROXIDE PASTE
osseous and soft tissue and so may be inappropriate
for in situ implant surface treatment.
CH is bacteriocidal on contact. It must be in direct
contact with the bacteria to be lethal. CH has been
shown to be active and not active against E faecalis
and Pseudomonas aeruginosa.14,23 However, as with
other antimicrobials, even though there is little effect
at lower concentrations, there may be a bacteriocidal
effect against E faecalis and other pathogens in high
doses, 5 mg/mm3 of CH, that are applied topically as
described here.
The literature has described a variation of inhibition of pathogens by CH. Asgary and Kamrani tested
CH against Pseudomonas aeruginosa, E faecalis, Staphylococcus aureus, and Escherichia coli and found it to
inhibit growth of these bacteria.24 Another study that
tested serial dilution of CH against 6 endodontic
pathogens found calcium hydroxide to be effective
only at concentrations of about 50%.25
Generally, planktonic microorganisms can be more
susceptible to CH than when they are in a biofilm or
adhering to dentin.26 These two factors increase
bacterial resistance to the activity of CH.26 Conversely,
Chai et al found that CH was able to completely
eliminate E faecalis in a biofilm in a membrane filter
with a 1-hour exposure.27 Balto in a review article
found that CH was limited in its effectiveness in killing
E faecalis when the testing was done by culturing
techniques.28
Apparently, CH is effective at higher concentrations against many pathogens and dependent upon
the surface onto which the pathogen is adhering.
Although not studied, a titanium surface may make
the bacteria more susceptible than a dentin surface.
One interesting research article by Baik and coworkers found that CH was able to detoxify lipoteichoic acid. This toxin is an important virulence factor
for gram-positive bacteria, such as E faecalis. The toxin,
when inactivated by CH, did not stimulate the release
of tumor necrosis factor in a sheep macrophage cell
line.29
There was no attempt to culture and identify the
pathogen in the infected lesions in the cases
presented here due to the unreliability of clinical
culturing in these areas.
CH also is a source of calcium ions. Thus, any small
residual material inadvertently left in the site may be
of benefit for osteogenesis. However, this author does
not recommend leaving any visually apparent material
in the surgical site. Material with a pH value this high
may not be well tolerated by soft tissue and produce a
tissue reaction. The site should be lavaged of all visible
calcium hydroxide. Severe sequelae have been report208
Vol. XXXV/No. Four/2009
ed with calcium hydroxide paste extruded beyond the
tooth root foramen.30
Many anaerobic infections are caused by a mixture
of organisms. Bacteroides spp can be inhabitants of
tooth periapical lesions.16 These bacteria are generally
susceptible to metronidazole,31 cefoxitin,32 chloramphenicol,33 and clindamycin.34 Bacteroides spp also
encapsulates itself in a polysaccharide that probably
promotes its virulence, survival, and importance in
mixed infections.18,35 Bacteroides forsythus has been
shown to persist in asymptomatic periradicular
endodontic lesions and may survive in bone in an
encapsulated form after an extraction and subsequently infect an implant.36,37 At 10% concentration,
calcium hydroxide was effective against Bacteroides
fragilis.38
Interestingly, as much as 50% of an endodontic
infection is caused by bacteria that have not yet been
cultivated.39 These bacteria may be left intraosseously
after an extraction and subsequently colonize an
implant surface.
Chlorhexidine gluconate is active against E faecalis
and other endodontic pathogens.14 It may not be as
effective against C albicans as calcium hydroxide.14
While the 2 cases reported here were successful with 1
calcium hydroxide direct topical treatment, a subsequent lavage with 0.2% chlorhexidine may be of value
in recalcitrant infections or infections where virulent
pathogens are suspected.
A sequential treatment of calcium hydroxide paste
and 0.2% chlorhexidine gluconate may provide a
broad range of antimicrobial action for detoxifying an
infected dental implant.40,41 Because these implant
infections uncommonly occur, appropriate long-term
studies may be difficult.
CONCLUSIONS
Calcium hydroxide endodontic paste may be an
appropriate direct surface detoxifying agent for
infected dental implants when administered in very
high concentrations. A subsequent topical treatment
of 0.2% chlorhexidine gluconate may provide a broad
range of antimicrobial action for detoxifying an
infected dental implant. Calcium hydroxide should
not be left in the surgical site to prevent a severe
tissue reaction.
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Dennis Flanagan
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