Calcipex II

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Ⅰ. INTRODUCTION

Root canal endodontic therapy is an important dental

procedure to survive the diseased tooth involved with pulp damage and pulpitis. In these days the endodontic treatment was frequently performed using different root canal irrigation materials. Among the different root canal irrigation materials the calcium oxide-based materials gave good biological result with strong bactericidal effect

¹⁾

compared to the washing and sterilizing solutions containing sodium hypochloride, chlorhexidine

⁴⁾

, etc.

Recently, Calcipex II has been developed as calcium

치근단 낭종의 만성 육아성병소에 있는 Calcipex II 근관치료재의 편광검색

김성민¹⁾, 유영재²⁾, 이석근³⁾*

서울대학교 치의학대학원 구강악안면외과학교실, 치학연구소

¹⁾

, 한양여자대학교 치위생학과

²⁾

,

강릉원주대학교 치과대학 병리학교실, 구강과학연구소

³⁾

<Abstract>

Birefringence Detection of Calcipex II Endodontic Material in Chronic Granulomatous Lesion of Periapical Cyst

Soung Min Kim

¹⁾

, Young Jae Yoo

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, Suk Keun Lee

³⁾

*

Department of Oral and Maxillofacial Surgery, Dental Reserach Institute, School of Dentistry, Seoul National University

¹⁾

, Seoul;

Department of Dental Hygiene, Hanyang Women’s University

²⁾

, Seoul; Department of Oral Pathology, College of Dentistry, Gangneung-Wonju National University

³⁾

, Research Institute of Oral Science, Gangneung; Korea

Calcipex II has been widely used for root canal irrigation in endodontic treatment. It is a product of calcium oxide-based water soluble paste containing fine granular resin materials

¹⁾

. It was known that these granular materials were hardly dissolved in tissue and subsequently elicited foreign body granuloma by recruiting macrophages. Sometimes serious complications involving regional osteomyelitis and maxillary sinusitis were followed in long time after the endodontic treatment using Calcipex II materials

^2,3)

. And then the removed surgical specimen should be carefully examined to detect whether there exists Calcipex II material-related foreign body reaction or not.

As the fine granular materials are too small in size, about 1 µm in diameter, and slightly translucent, it is difficult to find out the fine granular materials scattered throughout the granulomatous lesion even in the high magnification view. Here, we firstly found that the fine granular materials of Calcipex II showed bright birefringence under the polarizing microscope, and that the Calcipex II granules dispersed in chronic granulomatous lesion could be easily detected by their bright birefringence. The present study demonstrated a case of peri-implantitis involved with Calcipex II granule-related periapical granuloma, exhibiting numerous bright birefringence spots in the polarizing microscope observation.

Key words : Calcipex II, Periapical Cyst, Foreign Body Granuloma, Birefringence

Korean Journal of Oral and Maxillofacial Pathology 2016;40(2):775-779 ISSN:1225-1577(Print); 2384-0900(Online) Available online at http://journal.kaomp.org http://dx.doi.org/10.17779/KAOMP.2016.40.2.005

* Corresponding address: Suk Keun Lee, DDS, MSD, PhD.

Department of Oral Pathology, College of Dentistry, Gangneung- Wonju National University, 123 Chibyun-dong, Gangneung, 210-702, Korea

Tel : +82-33-640-2228 / Fax: +82-33-642-6410 E-mail : [email protected]

This study was partly supported by a grant of the Korean Health Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (HI15C0689).

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hydroxide-based water soluble paste by adding a certain penetrating agent, i.e., micro-resin granules, barium sulphate, etc. (The precise data were not provided by the company) It has been widely used for root canal irrigation to prevent bacterial infection. But when Calcipex II was overfilled and spilled into periapical tissue, it was reported that chronic granulomatous lesion could occur due to the foreign body reaction to the fine granular polymer resin materials of Calcipex II

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(described as Calcipex II granules in this study). However, the Calcipex II granules were very small in size, about 1 µm in diameter. They are usually round and partly translucent, so that they looked as brown to black spots in the ordinary light microscopic observation. And some Calcipex II granules were engulfed by macrophages, but rarely degraded in the cytoplasms of macrophage, and finally resulted in the apoptosis of involved macrophages. Consequently, the Calcipex II granules were gradually dispersed deeply into connective tissue, and then the microscopic detection of Calcipex II granule became difficult and took a long time even in the high magnification view.

So far we pathologically observed many cases of Calcipex II granules-induced periapical granulomatous lesions, and took a lot of time to find out the Calcipex II granules in the necrotic and granulomatous periapical lesion in order to diagnosis the Calcipex II granule-induced granuloma differentially from other inflammatory lesions. In this study we demonstrated that the Calcipex II granules in granulomatous lesion of peri-implantitis showed bright birefringence in the polarizing microscope observation, and discussed the diagnostic usage of the bright birefringence for the resin granule-related diseases after endodontic treatment.

Ⅱ. CASE REPORT

A 30 years old female patient was complained of dull pain in left mandibular first molar area, where the first molar was replaced by a dental implant. In the dental treatment history, the left mandibular first molar was involved with severe dental caries and progressed into acute pulpitis, and followed by root canal endodontic treatment using Calcipex II root canal irrigation one and half years ago. But the tooth was continuously painful with increased mobility, so that the tooth was extracted and subsequently replaced by dental implant one year ago. But recently she felt dull pain around the implant (#36) area, and also difficulty in mastication due to severe mobility of the implant. Under the clinical diagnosis of severe peri-implantitis, the implant was removed and the associated granulomatous lesion was examined pathologically.

The biopsy specimen (OS2016-40) was referred to the Department of Oral Pathology, Gangneung-Wonju National University Dental Hospital (GWNUDH). The usage of biopsy specimens filed in the Department of Oral Pathology, GWNUDH was approved by our institutional review board (IRB2015-07). The specimen was fixed with 10%

PBS-buffered formalin solution, embedded with paraffin, and microsectioned in 4 μm thickness. The microsections were routinely stained with hematoxylin and eosin, and observed under ordinary light microscope and also under polarizing microscope.

Microscopic observation disclosed a granulomatous lesion

diffusely infiltrated with chronic inflammatory cells. The

granulomatous lesion was diffusely fibrosed with the heavy

deposition of collagen bundles, but was distributed with tiny

capillaries. Therefore, the granuloma showed no feature of

regeneration but became agitated and sclerosed. Throughout

the inflammatory lesion fine granular materials were found,

and then they were usually scattered, and focally aggregated.

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Fig. 1. Photomicrographs of granulomatous lesion of peri-implantitis. A1, B1, and C1 (from low magnification to high magnification):

hematoxylin and eosin (H&E) stain. A2, B2, and C2: Same area of A1, B1, and C1, respectively, observed under the polarizing

microscope. In the ordinary microscope observation in H&E stain the Calcipex II granules were slightly translucent and brownish, so

that they were sometimes difficult to be found out (A1, B1, and C1). But with the properties of bright birefringence of resin

polymer, the Calcipex II granules can be easily detected as many bright spots under polarizing microscope (A2, B2, and C2).

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The granular materials were small round particles, measuring about 1 µm in diameter, and were brownish and partly translucent. With the dental history of endodontic treatment at left mandibular first molar (#36) by using Calcipex II root canal irrigation materials one and half years ago, these fine granular materials were defined to be derived from the overfilled Calcipex II granules. These findings were also identical to the previous observation of Calcipex II-related diseases, i.e., periapical granuloma

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and maxillary sinusitis

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. In the ordinary microscope observation in hematoxylin and eosin stain the Calcipex II granules were sometimes difficult to be found out in chronic granulomatous lesions (Fig. 1 A1, B1, and C1), because they are somehow similar to bacterial cocci or tissue debris. But with the properties of bright birefringence of resin polymer, the Calcipex II granules can be easily detected in the chronic ganulomatous lesion under the polarizing microscope (Fig. 1 A2, B2, and C2).

Ⅲ. DISCUSSION

Although the endodontic treatment is a beneficial method to survive or to prolong the life of diseased tooth, there is an array of potential factors that influence the outcome of endodontic treatment, success is most significantly dependent upon the elimination of root canal infection present when treatment starts and the prevention of contamination during treatment

⁶⁾

. Different techniques have been introduced to improve the efficiency of root canal dressing by using calcium hydroxide-based materials, i.e., Calcipex II. These days Calcipex II is widely used due to its good penetrating property deeply into accessory canals as well as strong bactericidal effect. The Calcipex II materials have to be removed through aqueous irrigation, but the removal is sometimes incomplete

⁷⁾

, and some of

Calcipex II materials are overfilled and spilled into periapical tissue.

As Calcipex II materials contain micro beads composed of polymer resin, which are recognized as foreign bodies by antigen present cells, Calcipex II granules remained in periapical tissue can induce inflammatory reaction via recruiting tissue macrophages. And more Calcipex II granules are hardly resorbed by phagocytosis of macrophages, rather the unresorbed Calcipex II granules finally destroy the macrophages via the signaling of apoptosis. Therefore, Calcipex II granules are gradually dispersed and continuously elicit inflammatory reaction.

Besides the reported cases of Calcipex II-related inflammatory disease