Overfilling of calcium hydroxide–based paste Calcipex IIproduced a foreign body granuloma without acuteinflammatory reactionJin Woo Kim, DDS, PhD,a Kyung Mo Cho, DDS, PhD,a Se Hee Park, DDS, MSD, PhD,a

Seung Gon Song, DDS,a Mi Sun Park, DDS,b Hye Rim Jung, DDS,b Ji Yong Song, BS,b

Yeon Sook Kim, DDS, PhD,b and Suk Keun Lee, DDS, PhD,b Gangneung, KoreaCOLLEGE OF DENTISTRY, KANGNUNG NATIONAL UNIVERSITY

A patient, a 62-year-old man, received endodontic treatment of the lower left canine complicated by apicaloverfilling of Calcipex II. At the second day after the root canal filling, the 14th day after placement of Calcipex IIintracanal medication, he complained of a gingival swelling in the treated area. The incisional biopsy of the gingivalswelling revealed a foreign body granuloma infiltrated with macrophages engulfing the fine Calcipex II granules butwith polymorphonuclear leukocytes (PMNs). However, the gingival swelling was healed uneventfully, and the toothwas free of symptoms at 4 months’ follow-up. This study first reports the Calcipex II–induced reaction in humanperiodontium. In the immunohistochemistry using antisera of lysozyme, CD31, CD68, interleukin-8 (IL-8), andpoly(ADP-ribose) polymerase 1 (PARP-1), the granule-laden cells are positive for lysozyme, CD31, CD68, and PARP-1,but negative for IL-8. Thus, it is presumed that the granule-laden cells belong to the macrophages/monocytes ratherthan the PMNs, and that they gradually undergo the apoptotic processes. These data suggest that the canal dressingmaterial, Calcipex II, is able to be widely dispersed into the periodontal tissues, primarily engulfed by macrophages,and resulted in the foreign body granuloma in the absence of acute inflammatory reaction. (Oral Surg Oral Med Oral

Pathol Oral Radiol Endod 2009;107:e73-e76)

CASE REPORTA 62-year-old man was referred from a private dental clinic

to the Department of Conservative Dentistry in KangnungNational University (KNU) Dental Hospital. The chief com-plaint was vestibular swelling in the lower left canine (#22)area. The patient’s dentomedical history was noncontributory.Pulp test revealed that tooth #22 was unresponsive to cold andelectric pulp testing, whereas the adjacent teeth respondedwithin normal limits. The tooth was very sensitive to percus-sion and palpation. Pus was discharged from the labial gin-gival sulcus of the tooth. Purulent exudate was also noted onaccess opening of the tooth. The root canal was irrigated with3% sodium hypochlorite and 2% chlorhexidine in conjunctionwith root canal instrumentation after radiographic determina-tion of root canal length (Fig. 1, a).

On the second visit, the exudates and swelling had de-creased and Calcipex II (Nishika, Shimonoseki, Japan) wasused as an intracanal dressing as suggested by the manufac-turer. The Calcipex II was, however, slightly overfilled

Supported by research grants from the Korean Science and Engineer-ing Foundation (R11-2002-001-03003-0 and R01-2003-000-10891-0) and the Korean Research Foundation (KRF-2007-013).aDepartment of Conservative Dentistry.bDepartment of Oral Pathology.Received for publication Jul 9, 2008; accepted for publication Oct 21,2008.1079-2104/$ - see front matter© 2009 Mosby, Inc. All rights reserved.

doi:10.1016/j.tripleo.2008.10.019

through the apical foramen (Fig. 1, b). On the third visit, theworking length of the root canal was recalculated and theapical preparation enlarged to size #55. A root canal fillingwith gutta-percha cone and AH-26 sealer (DeTrey/Dentsply,Konstanz, Germany) was placed. The root canal was wellobturated, and the overfilling of Calcipex II was reduced inamount (Fig. 1, c).

At the day after the root canal filling (the 14th day afterCalcipex II placement), the patient came back complaining ofa gingival swelling in the area of tooth #22 (Fig. 1, d). Thegingival swelling showed no pus discharge in the gingivalsulcus, and the tooth was not tender to touch. An incisionalbiopsy was done and the specimen fixed in 10% neutralformalin. The biopsy was subsequently embedded in paraffin,and sectioned in 4 �m thickness. The usage of the biopsyspecimen filed in the Department of Oral Pathology, KNUDental Hospital, was approved by the Life Ethics Committeeof KNU. The histologic sections were routinely stained withhematoxylin and eosin, and also used for immunohistochem-istry using antisera of lysozyme, CD31, CD68, interleukin-8(IL-8), and poly(ADP-ribose) polymerase 1 (PARP-1) (SantaCruz Biotechnology, Santa Cruz, CA). In addition, the Cal-cipex II material was dispersed in water and smeared on glassslide for the microscopic observation. Every microscopicimage was recorded with a digital camera (Olympus DP-70,Tokyo, Japan).

The microsections of the gingival swelling showed a gran-ulomatous lesion heavily infiltrated with fine granular mate-rials, engulfed mostly by macrophages and slightly by stromal

fibroblasts (Fig. 2, a, 1-3). The Calcipex II granules were not

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localized in the granuloma lesion but gradually dispersedacross the border of the granuloma into the adjacent connec-tive tissue (Fig. 2, a, 4 and 5). The fine granular materialswere identical to the Calcipex II granules smeared on theglass slide, exhibiting slightly translucent and fine granularaggregation but no calcification or polymerization (Fig. 2, b).The Calcipex II granules were mainly engulfed by macro-phages, and also slightly localized at the cytoplasms of fibro-blasts. Still a lot of the fine Calcipex II granules were freelydispersed in the stromal fibrous tissue, but rarely in the lumenof capillaries. In the immunohistochemistry using antisera oflysozyme, CD31, CD68, IL-8, and PARP-1, the Calcipex IIgranule–laden cells were positive for lysozyme, CD31, andCD68, indicating that the cells belonged to the lineage ofmacrophage/histiocyte/monocyte and were in the apoptoticprocesses (Fig. 2, c-e). On the other hand, the Calcipex IIgranule–laden cells were negative for IL-8, which is a che-mokine usually positive in neutrophils (Fig. 2, f), similar tothe negative control staining (Fig. 2, h). Under the micro-scopic observation in routine hematoxylin and eosin stain, themacrophages filled with the Calcipex II granules could notreadily dissolve the fine granules; rather, they were graduallydestroyed by the rupture of their cell membrane. Neverthelessthere appeared no acute inflammatory reaction. The CalcipexII–laden macrophages were strongly positive for PARP-1,indicating that the cells were undergoing the apoptotic pro-cesses, possibly due to the overload of Calcipex II (Fig. 2, g).Eventually, the Calcipex II induced a foreign body granulomaby macrophages, but no acute inflammation by PMNs.

DISCUSSIONThe use of a calcium hydroxide–based intracanal

dressing is important for periapical repair in teeth withperiapical lesion. Dressing with calcium hydroxide

Fig. 1. Standard radiographs during the endodontic treatmdetermination. b, On the second visit, Calcipex II was overfillCalcipex II remained periapical but reduced in amount (arrswelling occurred, the canal filling looked fine and there wa

paste results in better periapical repair than when the

root canal is filled in a single-session treatment.1-3

Calcipex II is a calcium hydroxide water-based pastefor root canal dressing, which is easy to handle and themost easily removed. Great care had to be taken toavoid extrusion via the apical foramen compared withthe silicon oil–based Vitapex.4 In the present study, theCalcipex II used as an intracanal dressing material wasoverfilled into the periapical area, and its fine granularmaterials were rapidly migrated up through the gingivaltissue. The Calcipex II granules were not calcified norpolymerized in the gingival tissue; rather, they werediffusely scattered throughout the collagenous fibroustissue, were rapidly engulfed by the macropahges, andresulted in a foreign body granuloma. The granulomawas mainly infiltrated with macrophages, and only afew lymphocytes were found, but exclusive of PMNs.In the immunohistochemistry, the Calcipex II granule–laden cells were strongly positive for lysozyme, CD31,and CD68, which are markers for the macrophages,including histiocytes and monocytes,5-11 whereas theywere negative for the antibody of IL-8, which is amarker for PMNs.12 However, the inflammatory degen-eration or necrosis by cytotoxic chemokine IL-8 wasnot observed in the Calcipex II–induced foreign bodygranuloma.

The Calcipex II granules were too small, �500 nm,to be localized in the root canal, so that they were easilyoverflowed and dispersed into the periapical tissuesdepending on the dynamic pressure that occurred dur-ing canal filling and biting. The fine Calcipex II gran-ules were rapidly engulfed by macrophages and even

the lower left canine. a, X-ray for initial working lengththe periapical area (arrows). c, After root canal filling, some

d, At the second day after canal filling, when the gingivalange in periapical area (arrows).

ent ofed intoows).

endocytosed by stromal fibroblasts. However, the Cal-

OOOOEVolume 107, Number 3 Kim et al. e75

Fig. 2. Photomicrographs of the Calcipex II-induced foreign body granuloma. a, Hematoxylin and eosin stain. a1, Lowmagnification of main lesion: The Calcipex II granules were diffusely observed in the stromal cells. a2-a5, High magnification.a2, Most of the Calcipex II granules were engulfed by macrophages (arrows), only a few lymphocytes (arrowheads) wereinfiltrated but not PMN. a3, Some Calcipex II granules were also endocytosed by stromal fibroblasts (arrowheads); no CalcipexII granules were found in the lumen of capillaries (C). a4, Note the massive dispersion of the Calcipex II granules in the fibrousconnective tissue; many Calcipex II granules were found in the cytoplasms of fibroblasts (arrowheads). a5, Border area betweenthe fibrous connective tissue and granulomatous lesion. The Calcipex II granules were diffusely dispersed; note many macro-phages infiltrated into the border area. b, Calcipex II paste smeared on the slide glass. b1, Low magnification: The Calcipex IIgranules were well dispersed and aggregated (arrows). b2, High magnification: The fine granules of Calcipex II was very small,measuring �500 nm in diameter. c-g, Immunohistochemistry. c, Lysozyme antibody, positive in the Calcipex II granule–ladencells (arrows). d, CD31 antibody, positive in the Calcipex II granule–laden cells (arrows). e, CD68 antibody, positive in theCalcipex II granule–laden cells (arrows). f, Interleukin-8 antibody, negative in the Calcipex II granule–laden cells (arrows). g,Poly(ADP-ribose) polymerase 1 antibody, positive in the Calcipex II granule–-laden cells (arrows). h, Negative control stained

without antisera.

OOOOEe76 Kim et al. March 2009

cipex II granules seem to be not readily degraded in thecytoplasms of macrophages; rather, the macrophagesoverfilled with the Calcipex II granules tend to bedestroyed with the positive reaction of PARP-1, whichis a marker of cellular apoptosis.13,14 However, thefeatures of cytotoxic degeneration and the allergic hy-persensitivity by the immune reactions of PMNs andlymphocytes were not observed in the Calcipex II–induced foreign body granuloma.

In this study, the overfilling of Calcipex II in end-odontic treatment produced a foreign body granulomain the nearby gingival tissue. Although the Calcipex IIwas rapidly reduced in amount in the periapical radio-grams after treatment, the Calcipex II material was notresorbed easily; rather, it was dispersed into adjacentsoft tissue, evoking a foreign body reaction by macro-phages in the absence of acute inflammatory reaction.

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Reprint requests:

Suk Keun Lee, DDS, PhDDepartment of Oral PathologyCollege of DentistryKangnung National University123 Chibyun-dongGangneung, 210-702 Korea

sklee@kangnung.ac.kr