International Endodontic Journal (1998) 31, 367±371

Gaining access through a calcified pulp chamber:

Clinical
a clinical challenge Article
W. C. NGEOW & Y. L. THONG
Department of Oral and Maxillofacial Surgery and Department of Conservative Dentistry,
Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia

Summary parasympathetic inhibition could cause a reduction in

pulpal blood supply that could result in cellular
Dental pulp is prone to dystrophic mineralization; this
respiratory depression, leading to pathological calcification
mineralization can be so extensive that the entire root
of the pulp and eventually, obliteration of the root canal
canal system is obliterated. As a result, root canal
(Andreasen 1989).
treatment can become a difficult if not impossible
Success in root canal treatment is based on proper
task. This article presents the endodontic
debridement, disinfection and obturation of the root canal
management of a tooth with an obliterated pulp
system. The most important procedure is cleaning the
chamber and associated with a discharging sinus in a
root canal space of microbial contaminants and pulpal
teenage patient. The role of a calcium hydroxide lining
debris. However, this procedure may be difficult to achieve
to induce mineralization and cause the obliteration of
if the pulpal space is partially calcified.
the pulpal space is also discussed.
The first author treated one such case and had to resort
to the use of dental burs to drill a pathway through the
Keywords: calcification, calcium hydroxide,
calcified pulp chamber in order to gain access to the root
endodontics, radiograph, root canal.
canal. This technique of blind drilling risks perforation. In
order to minimize this risk, drilling was carried out over a
Introduction few visits and aided by periapical radiographs to check the
position and depth reached.
Spontaneous calcification of the pulp chamber in a young
person's tooth is not common; this may occur idiopathi-
cally or following direct pulp capping or trauma. In a Case report
process termed `calcific metamorphosis', early obliteration
A healthy, 18-year-old Chinese female, was referred to
of the pulp chamber and canal can occur following
one of the authors (WCN) for the management of a
significant traumatic injury to the affected tooth (Neville
persistent discharging sinus labial to her maxillary left
et al. 1995).
central incisor (tooth 21). Clinical examination and inves-
A high incidence of calcified canals has been observed
tigation confirmed that the sinus tract originated from her
following pulpotomy and direct pulp capping (Langeland
maxillary left central incisor. Radiographic examination
et al. 1971, Seltzer & Bender 1984). This has been
showed that the tooth had a calcified pulp chamber with
postulated to be a result of uncontrollable mineralization
a patent root canal apically and a periradicular radiolu-
in which the normal self-limiting enzyme, the pyropho-
cency. The tooth did not respond to sensitivity tests,
sphatase, fails to operate (Heithersay 1975). A reduced
namely to thermal and electrical stimulation.
capillary permeability following the increased number of
A decision was made to root canal treat the maxillary
calcium ions could reduce serum flow within the dental
left central incisor. The patient was warned of the risks
pulp resulting in a low concentration of inhibitory pyro-
involved, especially the risk of perforation whilst gaining
phosphate ions (Heithersay 1975). Moreover, a loss of the
access to the root canal. The tooth was isolated using a
rubber dam secured with a floss ligature as the patient
Correspondence: Dr Wei Cheong Ngeow, Department of Oral and
could not tolerate the pressure of the clamp used. A
Maxillofacial Surgery, Faculty of Dentistry, Universiti Kebangsaan
Malaysia (UKM), Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, standard access preparation was initiated without local
Malaysia. anaesthesia with a high speed round diamond bur (ISO-

q 1998 Blackwell Science Ltd 367

368 W. C. Ngeow & Y. L. Thong
No. 806±314±001534±012; Meisinger, DuÈsseldorf,
Germany) directed toward the location of the pulp
chamber (Fig. 1). An access cavity of normal size and
shape was made to a depth equivalent to that for a non-
calcified tooth using a tapered diamond bur (ISO-No.
806±314±19824±012; Meisinger).
After the access cavity was deepened to a depth of
about 5 mm, a chelating agent, RC-Prep (Premier Dental
Products, Norriston, PA, USA), was placed into the cavity
and sealed temporarily. This was done after the failure to
locate the canal orifice at this depth. The patient was
reviewed a week later. RC-Prep was expected to soften the
deeper hard tissue so that the endodontic explorer would
penetrate the root canal. However, this procedure failed to
produce any positive result.
Fig. 1 The Radiograph shows the obliterated pulp chamber and
patent root canal of the maxillary left central incisor. The
radiolucency in the middle of the crown is the bur hole made in an
attempt to reach the patent root canal. Note the dilaceration of the
root and the radiolucent lesion associated with its apex. The left
lateral incisor with obliterated root canal responded positive to
vitality tests, thus its management was periodic observation. The
radiolucency associated with it was diagnosed to be an ectopic
salivary gland.*
*The presence of the ectopic minor salivary gland at this lateral
periodontal location has been reported and this is accepted for
publication in the Hospital Dentistry and Maxillofacial Surgery of
Tokyo.
The access cavity was deepened with a long shank steel
round pulp chamber bur on a slow speed handpiece (ISO-
No. 191±206±698001±100; Meisinger) directed parallel
to the long axis of the tooth. Periodic re-examination with
periapical radiographs and frequent exploration with a
DG-16 endodontic explorer (Hu-Friedy, Chicago, IL, USA)
for the canal orifice were performed. The crown of the
central incisor was later cut to the cervical margin to
facilitate access. The patient was given a temporary single
tooth overdenture for aesthetic purposes. When a `sticky'
sensation was felt with the DG-16 endodontic explorer
(Hu-Friedy), a fine instrument (Pathfinder, Kerr Ltd/
Romulus, MI, USA) was used to negotiate the root canal.
A radiograph was then taken to confirm the successful
access and working length (Fig. 2). In all, the patient had
five parallel periapical radiographs taken in order to
confirm the access to the root canal. Standardization of all
the radiographs could not be done as the radiographs
were taken by two different radiographers.
Once the working length was determined, the curved
canal was prepared using the step back technique
(Mullaney 1979). Normal saline alternated with 2.6%
sodium hypochlorite was syringed into the canal for
debridement. No intracanal dressing was placed after the
root canal was completely prepared. The author however,
made sure that that the root canal was dry before the
access was sealed with a double seal of gutta-percha and
zinc oxide eugenol cement. The root canal was obturated
a week later with gutta-percha points and AH 26 cement
(De Trey Dentsply AG, Zurich, Switzerland) using cold
lateral condensation (Fig. 3). The sinus had healed at the
recall visit two weeks after the canal was obturated. A
post-retained crown was later constructed without any
complication.
Discussion
The dental pulp is prone to dystrophic mineralization; this
may be so extensive that the whole pulp cavity becomes
obliterated (Foreman & Soames 1988). Pulpal mineraliza-
tion may occur following trauma or following the use of
calcium hydroxide. Calcium hydroxide, a commonly used
dental lining agent has the unique potential to induce
mineralization, even in tissues which have not been
programmed to mineralize (Mitchell & Shankwalker 1958,
Binnie 1967). It is used for direct and indirect pulp
capping and in pulpotomy procedures. Following these
procedures, a calcium bridge may be detected in the
exposure area. This calcium barrier is useful to protect the
pulpal tissue from further oral environmental assaults and
bacterial infection. The presence of this calcium barrier is
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 Gaining access through a calcified pulp chamber 369

Fig. 2 The radiograph above shows the access made with the crown Fig. 3 The radiograph above shows the main gutta-percha being
trimmed down to its cervical margin and the one below shows the placed whilst the one below shows the completed obturation of the
access made and a file used to determined its working length. root canal with gutta-percha using cold lateral condensation.

q 1998 Blackwell Science Ltd, International Endodontic Journal, 31, 367±371

370 W. C. Ngeow & Y. L. Thong
also an indication that the procedure has become
successful (Woehrien 1977).
It has always been regarded that calcium hydroxide is
an initiator rather than a substrate for repair (Foreman &
Barnes 1990). The calcium hydroxide present in the
applied calcium hydroxide does not become incorporated
in the mineralized repair tissue. It derives its mineral
content solely from the dental pulp, presumably via the
blood supply (Sciaky & Pisanti 1960, and 1964).
However, despite the advantage of using calcium
hydroxide in the repair of exposed pulp chambers, a high
incidence of mineralized canals has been observed
following pulpotomy and direct pulp capping (Langeland
et al. 1971, Seltzer & Bender 1984). This unwanted side-
effect is a nightmare for any endodontist, as negotiating
the canal during root canal therapy may be difficult when
pulpotomy or direct pulp capping procedures fail.
In the case reported, the maxillary left central incisor
had a mesial composite filling lined with calcium
hydroxide which was performed several years before. It
also had a dilacerated root and the pulp chamber was
fully mineralized and obliterated. The mineralization may
have occurred as a result of the trauma which had also
caused the root to become dilacerated. The other possible
reason for the obliteration may have been because of
excessive mineralization following exposure to calcium
hydroxide. Trauma appears to be the more likely of the
two possible causes judging from the presentation of the
maxillary left central incisor and its adjacent lateral
incisor. However, it is difficult to confirm this potential
cause as the patient could not recall any history of
trauma during childhood. Moreover, all her other
maxillary incisor teeth responded to sensitivity tests.
The maxillary left central incisor was asymptomatic
other than presenting with a discharging sinus associated
with a chronic periapical abscess. Root canal therapy was
the treatment of choice. Only a small percentage of cases
exhibiting radiographically fine or unidentifiable canals or
calcified blockages prove to be untreatable by non-surgical
root canal therapy (Lovdahl & Gutmann 1997).
In a maxillary incisor with dystrophic mineralization,
the root canal is still located in the cross-sectional centre
of the root as in other normal incisors (Lovdahl &
Gutmann 1997). The ideal location for access preparation
would be through the incisal edge if aesthetics and
structural integrity were disregarded. In the standard
palatal access, with the bur directed at an angle of about
458 to the long axis, bur penetration of 3±4 mm will
generally intersect with the pulp chamber in average-sized
teeth (Lovdahl & Gutmann 1997). In a calcified chamber,
however, continued penetration at 458 to the long axis
will eventually result in perforation of the labial root
surface below the gingival attachment (Lovdahl &
Gutmann 1997).
Thus, when the chamber is mineralized and the canal
cannot be located after 3±4 mm of drilling, the bur must
be rotated to be as parallel to the long axis of the tooth as
possible to prevent perforation (Lovdahl & Gutmann
1997). Penetration should proceed on the palatal aspect
of the access preparation with frequent exploration with
the DG-16 endodontic explorer for the orifice. If an orifice
is present, firm pressure will force the instrument slightly
into the orifice and it will resist dislodgement or `stick'
(Lovdahl & Gutmann 1997). At this point a fine
instrument like the Pathfinder (Kerr Ltd) is placed into the
orifice to attempt to negotiate the canal. The authors
found this careful technique useful in the case reported as
it minimized the risk of perforation.
Chelating agents may be useful in the location of
difficult-to-find orifices by sealing in the chamber between
appointments (Weine 1996). Chelating agents like ethyle-
nediaminetetraacetic acid (EDTA) may remain active
within the canal for 5 days if not inactivated (Weine
1996). They act on calcified tissues only but care should
be taken not to place them into the periapical tissues.
Recent work has shown that EDTA may alter periapical
inflammatory reactions (Segura et al. 1997). Their action
is to substitute sodium ions, which combine with the
dentine to give soluble salts, for the calcium ions that are
bound in less soluble combination (Weine 1996). Because
the orifice is less calcified than the surrounding dentine,
sufficient softening may allow it to be located with the
sharp tip of the endodontic explorer at the following
appointment (Weine 1996).
The authors used RC-Prep as developed by Steward
(1969). It combines the functions of EDTA with urea
peroxide to provide both chelation and irrigation. Despite
the reported suggestion of the usefulness of chelating
agents, their clinical advantages remain doubtful (Walton
& Torabinejad 1996). They should be placed in canals
only after instruments have been used at length during
canal preparation. Chelators should not be used to soften
or remove canal obstructions because they slightly alter
the walls, thereby limiting the ability of instruments to be
guided along hard dentine (Walton & Torabinejad 1996).
It has also been suggested by Mykleby & Krell (1985) that
they are not advantageous in reducing the time required
for canal preparation. The authors found their statement
to be true for this case. The use of RC-Prep failed to soften
the calcified pulp chamber for access to the patent root
canal and the author had to drill a path all the way to the
patent root canal. Following the experience with this case,
q 1998 Blackwell Science Ltd, International Endodontic Journal, 31, 367±371

the authors suggest that chelating agents should only be
used to soften the canal wall after the canal has been
located. Its use in an attempt to locate the canal orifice is
improper.
Conclusions
The case presented is an example of a tooth with a radio-
graphically unidentifiable pulp chamber that is difficult to
treat but manageable via non-surgical root canal therapy.
Periodic radiographs taken between each drilling is
mandatory practice to evaluate the depth reached. Good
knowledge of tooth morphology coupled with patience
and care are the secret of success.
Acknowledgements
Grateful thanks to Professor J. Gutmann for his advice, en-
couragement and critical review of this paper.
References
ANDREASEN FM (1989) Pulpal healing after luxation injuries and root
fracture in the permanent dentition. Endodontics and Dental
Traumatology 5, 111±31.
BINNIE WH (1967) A histological study of induced calcification in the
subdermal tissue of the rat. (MSD Thesis), Indiana University
School of Dentistry.
FOREMAN PC, BARNES IE (1990) A review of calcium hydroxide.
International Endodontic Journal 23, 283±97.
FOREMAN PC, SOAMES JV (1988) Structure and composition of tubular
and non-tubular deposits in root canal systems of human
permanent teeth. International Endodontic Journal 21, 27±36.
HEITHERSAY GS (1975) Calcium hydroxide in the treatment of pulpless
teeth with associated pathology. Journal of the British Endodontic
Society 8, 74±93.
q 1998 Blackwell Science Ltd, International Endodontic Journal, 31, 367±371
Gaining access through a calcified pulp chamber 371
LANGELAND K, DOWDEN WE, TRONSTAD L, LANGLELAND LK (1971)
Human pulp changes of iatrogenic origin. Oral Surgery Oral
Medicine Oral Pathology 32, 943±80.
LOVDAHL PE, GUTMANN JL (1997) Problems in locating and negotiating
fine and calcified canals. In: Gutmann JL, Dumsha TC, Lovdahl PE,
Hovland EJ, eds Problem Solving in Endodontics: Prevention,
Identification and Management, 3rd edn. St. Louis, USA: Mosby Year
Book. pp. 69±89.
MITCHELL OF, SHANKWALKER GB (1958) Osteogenic potential of calcium
hydroxide and other materials in soft tissue and bone wounds.
Journal of Dental Research 37, 1157±63.
MULLANEY TP (1979) Instrumentation of finely curved canals. Dental
Clinic of North America 23, 575±92.
MYKLEBY B, KRELL K (1985) Speed of canal preparation using different
endodontic irrigants: a time-motion study (Abstract). Journal of
Endodontics 10, 188.
NEVILLE BW, DAMM DD, ALLEN CM, BOUQUOT JE (1995) Oral and
Maxillofacial Pathology, 1st edn. W. B. Saunders Co: Philadelphia,
USA.
PISANTI S, SCIAKY I (1964) Origin of calcium in the repaired wall after
pulp exposure in the dog. Journal of Dental Research 43, 641±4.
SCIAKY I, PISANTI S (1960) Localization of calcium placed over
amputated pulps in dogs' teeth. Journal of Dental Research 39,
1128±32.
SEGURA JJ, CALVO JR, GUERRERO JM, JIMNENEZ-PLANAS A, SAMPEDRO C,
LLAMAS R (1997) EDTA inhibits in vitro substrate adherence
capacity of macrophages: endodontic implications. Journal of
Endodontics 23, 205±8.
SELTZER S, BENDER IB (1984) Pulp capping and pulpotomy. In: Seltzer
S, Bender IB, ed. The Dental Pulp, Biologic Consideration in Dental
Procedures, 3rd edn. Philadelphia, USA: JB Lippincott Co. pp. 281±
302.
STEWART GG, KAPSIMALAS P, RAPPAPORT H (1969) EDTA and urea
peroxide for root canal preparation. Journal of the American Dental
Association 78, 335±8.
WALTON RE, TORABINEJAD M (1996) Principles and Practice of
Endodontics, 2nd edn. Philadelphia, USA: W. B. Saunders Co.
WEINE FS (1996) Endodontic Therapy, 5th edn. St. Louis, USA: Mosby-
Year Book Inc.
WOEHRIEN AE JR (1977) Evaluation of techniques and materials used
in pulpal therapy based on a review of the literature: part 1.
Journal of the American Dental Association 95, 1154±8.