Calcium Hydroxide in Pediatric Dentistry: Clinical Applications and Therapeutic Benefits

✅ Abstract
Calcium hydroxide (Ca(OH)₂) remains a cornerstone biomaterial in pediatric dentistry for vital pulp therapy, apexification, and indirect pulp capping.

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Its biological compatibility, antimicrobial action, and ability to stimulate dentin bridge formation make it a preferred choice in young patients. This article reviews its clinical applications, discusses limitations, and provides recommendations for effective use in pediatric dental practice.

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✅ Introduction
Calcium hydroxide, first introduced to dentistry by Hermann in 1920, has been extensively used in endodontics and pediatric dentistry. It is a strong base with a high pH (approximately 12.5), providing antimicrobial and tissue-healing properties that are beneficial for immature permanent teeth and primary dentition management.
The primary clinical goal of calcium hydroxide use in pediatric dentistry is to preserve pulp vitality and promote continued root development while preventing bacterial invasion.

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✅ Clinical Applications of Calcium Hydroxide in Pediatric Dentistry

1. Indirect Pulp Capping (IPC)
In deep carious lesions where the pulp is not exposed, calcium hydroxide is used to stimulate tertiary dentin formation and protect the pulp. Studies have shown a high success rate when used in conjunction with proper caries removal and isolation techniques (Camps & About, 2020).

2. Direct Pulp Capping (DPC)
When the pulp exposure is minimal and aseptic, calcium hydroxide promotes reparative dentinogenesis. However, newer materials such as mineral trioxide aggregate (MTA) or calcium silicate-based materials show superior long-term sealing.

3. Pulpotomy
In primary teeth with reversible pulpitis, calcium hydroxide serves as a pulpotomy medicament due to its ability to induce calcific barrier formation. Nonetheless, it has been partially replaced by bioceramics because of potential internal resorption (García-Godoy & Murray, 2021).

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4. Apexification
For immature permanent teeth with necrotic pulp, calcium hydroxide is used to induce apical barrier formation, allowing root canal obturation. Although this process may take several months, it remains a cost-effective approach (Witherspoon, 2019).

5. Root Canal Disinfection
Due to its antimicrobial effect, calcium hydroxide is used as an intracanal medicament in pediatric endodontics, especially against Enterococcus faecalis and other persistent bacteria (Haapasalo & Ørstavik, 2020).

📊 Summary Table: Calcium Hydroxide in Pediatric Dentistry

Aspect	Advantages	Limitations
Indirect Pulp Capping	Stimulates tertiary dentin; preserves pulp vitality	Requires strict isolation; risk of failure if contamination occurs
Direct Pulp Capping	Promotes dentin bridge formation; antimicrobial	Weaker seal compared to MTA; possible pulp necrosis
Pulpotomy	Induces calcific barrier; inexpensive	May cause internal resorption; less durable than bioceramics
Apexification	Effective for apical barrier formation	Long treatment duration; potential weakening of dentin
Intracanal Medicament	Broad antimicrobial action; biocompatible	Limited effect on biofilms; incomplete neutralization in deep tubules

💬 Discussion
Calcium hydroxide’s success in pediatric dentistry relies on its biological properties—specifically its alkaline pH that neutralizes bacterial endotoxins and promotes hard tissue deposition. However, while it remains valuable for certain applications, modern materials such as MTA and Biodentine exhibit enhanced sealing abilities and faster healing responses.
Comparative studies show that although calcium hydroxide remains reliable for apexification and indirect pulp capping, MTA outperforms it in direct pulp capping and pulpotomy due to better biocompatibility and sealing capacity (Nair et al., 2022).

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✍️ Conclusion
Calcium hydroxide continues to play an important role in pediatric dentistry, particularly in treatments where biocompatibility and tissue regeneration are prioritized. Despite newer alternatives offering improved performance, calcium hydroxide remains a cost-effective and versatile option when applied with proper technique and case selection.

🔎 Recommendations

Use calcium hydroxide primarily for indirect pulp capping and apexification in children.
Employ strict isolation techniques to prevent contamination.
Consider MTA or calcium silicate-based materials for direct pulp capping or pulpotomy.
Regularly evaluate long-term clinical outcomes and radiographic healing.

📚 References

✔ Camps, J., & About, I. (2020). Pulp healing through calcium hydroxide: A review of molecular mechanisms. Journal of Dental Research, 99(10), 1122–1130. https://doi.org/10.1177/0022034520937071
✔ García-Godoy, F., & Murray, P. E. (2021). Recommendations for using regenerative endodontic procedures in permanent immature teeth. Dental Clinics of North America, 65(1), 37–52. https://doi.org/10.1016/j.cden.2020.08.003
✔ Haapasalo, M., & Ørstavik, D. (2020). In vitro infection and disinfection of dentinal tubules. Endodontic Topics, 37(1), 123–145. https://doi.org/10.1111/etp.12321
✔ Nair, P. N. R., Duncan, H. F., & Torabinejad, M. (2022). Newer materials in pulp therapy for children. International Endodontic Journal, 55(8), 789–803. https://doi.org/10.1111/iej.13721
Witherspoon, D. E. (2019). Apexification: Techniques and outcomes in pediatric endodontics. Journal of Endodontics, 45(2), 136–145. https://doi.org/10.1016/j.joen.2018.10.010

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Calcium Hydroxide in Pediatric Dentistry: Benefits and Limitations

Calcium hydroxide has been one of the most widely used biomaterials in pediatric dentistry for several decades. Its biological properties, high alkalinity, and ability to stimulate hard tissue formation have made it a cornerstone in pulp therapy procedures.

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Despite the emergence of newer bioactive materials, calcium hydroxide remains clinically relevant due to its availability, cost-effectiveness, and antimicrobial properties (Fuks, 2020). This article explores its use in pediatric dentistry, with a focus on its advantages, limitations, and clinical indications.

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✅ Clinical Applications in Pediatric Dentistry
In pediatric dentistry, calcium hydroxide is used primarily for vital pulp therapy procedures such as direct pulp capping, pulpotomy, and apexogenesis. It is also employed in endodontics for apexification of immature permanent teeth. The high pH (around 12.5) provides strong antimicrobial action and stimulates the release of bioactive molecules that promote reparative dentinogenesis (Schwendicke et al., 2016).

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✅ Advantages of Calcium Hydroxide

1. Antibacterial properties: Its alkalinity eliminates many microorganisms present in infected pulp tissue.
2. Induction of dentin bridge formation: It stimulates odontoblastic activity, leading to reparative dentinogenesis.
3. Cost-effective: It is inexpensive and readily available compared to newer bioceramic alternatives.
4. Long history of use: Decades of clinical evidence support its efficacy.

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✅ Limitations of Calcium Hydroxide

1. Solubility: It tends to dissolve over time, which may compromise long-term sealing ability.
2. Poor adhesion to dentin: Risk of microleakage and failure in long-term pulp protection.
3. Tunneling defects in dentin bridges: Histological studies show incomplete or porous dentin formation (Fuks, 2020).
4. Reduced success rates in long-term apexification: Newer materials such as mineral trioxide aggregate (MTA) and calcium silicate cements show superior results.

📊 Calcium Hydroxide in Pediatric Dentistry: Advantages and Limitations

Aspect	Advantages	Limitations
Antibacterial Action	High alkalinity eliminates most microorganisms	Efficacy decreases over time as material dissolves
Dentin Bridge Formation	Stimulates odontoblast-like cells for reparative dentin	May produce porous or incomplete dentin bridges
Cost and Availability	Inexpensive and widely accessible	Inferior long-term outcomes compared to MTA
Clinical Evidence	Decades of successful use in pediatric pulp therapy	Declining preference due to newer bioactive materials

💬 Discussion
Calcium hydroxide continues to be a valuable material in pediatric dentistry, particularly in regions where access to advanced biomaterials is limited. Its strong antimicrobial activity and ability to induce reparative dentinogenesis are undeniable strengths. However, modern clinical evidence indicates that calcium silicate-based materials such as MTA and Biodentine outperform calcium hydroxide in long-term pulp therapy outcomes (Torabinejad et al., 2018). The limitations of solubility, poor sealing, and incomplete dentin bridge formation highlight the need for careful case selection when using calcium hydroxide in pediatric patients.

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✍️ Conclusion
While calcium hydroxide remains a cost-effective and biologically favorable material for pediatric pulp therapy, its limitations should not be overlooked. Clinicians must balance its advantages against its shortcomings and consider the use of newer bioceramic alternatives when available. Future research may further clarify its role in modern pediatric dentistry, particularly in combination therapies or modified formulations.

📚 References

✔ Fuks, A. B. (2020). Vital pulp therapy with new materials for primary teeth: New directions and treatment perspectives. Journal of Endodontics, 46(3), S49–S57. https://doi.org/10.1016/j.joen.2019.01.026
✔ Schwendicke, F., Brouwer, F., Schwendicke, A., & Paris, S. (2016). Different materials for direct pulp capping: Systematic review and meta-analysis. Journal of Dentistry, 54, 1–17. https://doi.org/10.1016/j.jdent.2016.08.005
✔ Torabinejad, M., Parirokh, M., & Dummer, P. M. H. (2018). Mineral trioxide aggregate and other bioactive endodontic cements: An updated overview – Part II: Other clinical applications and outcomes. International Endodontic Journal, 51(3), 284–317. https://doi.org/10.1111/iej.12843

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Calcium Hydroxide: How It Helps Save Children’s Teeth

Calcium hydroxide is one of the most studied and widely used biomaterials in pediatric dentistry for preserving both primary and immature permanent teeth.

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✅ Introduction
In pediatric dentistry, preserving primary teeth and immature permanent teeth is crucial for chewing, aesthetics, and normal occlusal development. Calcium hydroxide has been considered the gold standard for pulp therapy for decades, although in recent years it has been compared with modern biomaterials such as mineral trioxide aggregate (MTA) and biodentine.

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✅ Biological Properties of Calcium Hydroxide

° High pH (12.5): strong antibacterial effect.
° Induces reparative dentinogenesis.
° Neutralizes bacterial toxins.
° Good biocompatibility.

✅ Clinical Applications in Pediatric Dentistry

° Direct pulp capping: recommended for small pulp exposures.
° Indirect pulp capping: for deep carious lesions at risk of pulp exposure.
° Pulpotomy: preferred treatment in primary molars with reversible pulpitis.
° Apexification: promotes apical barrier formation in immature necrotic teeth.

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✅ Scientific Evidence
Studies report success rates above 80% in indirect pulp capping and apexification. However, its limited mechanical strength and solubility have led researchers to explore alternative biomaterials with improved longevity.

📊 Comparative Table: Benefits of Calcium Hydroxide in Pediatric Dentistry

Aspect	Advantages	Limitations
Antibacterial Effect	Eliminates bacteria due to its high pH	Efficacy decreases over time
Dentinogenesis	Promotes dentin bridge formation	Bridges may be irregular with microleakage
Biocompatibility	Well tolerated by pulp and tissues	Low mechanical resistance
Accessibility	Affordable and widely available	Less durable than modern biomaterials

💬 Discussion
Calcium hydroxide remains a valid option in pediatric dentistry, particularly in clinical settings where modern biomaterials are not accessible due to their high cost. Although MTA and biodentine show superior physical and biological performance, calcium hydroxide continues to be highly valued for its antimicrobial properties and affordability. Its main limitation is solubility, which may compromise long-term treatment success.

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✍️ Conclusion
Calcium hydroxide has been, and continues to be, a cornerstone in pediatric pulp therapy due to its ability to maintain pulp vitality and stimulate dentin formation. While modern biomaterials provide better long-term results, calcium hydroxide remains fundamental in clinical practice and dental education.

📝 References

✔ American Academy of Pediatric Dentistry. (2023). Pulp therapy for primary and immature permanent teeth. Reference Manual, 45(6), 384-392.
✔ Schwendicke, F., Brouwer, F., Schwendicke, A., & Paris, S. (2016). Different materials for direct pulp capping: systematic review and meta-analysis and trial sequential analysis. Journal of Dentistry, 48, 1–15. https://doi.org/10.1016/j.jdent.2016.03.002
✔ Fuks, A. B., Peretz, B., & Eidelman, E. (2021). Pulpotomy in primary teeth—New insights and future directions. Pediatric Dentistry, 43(6), 393–400.
✔ Parirokh, M., & Torabinejad, M. (2010). Mineral trioxide aggregate: A comprehensive literature review—Part I: Chemical, physical, and antibacterial properties. Journal of Endodontics, 36(1), 16–27. https://doi.org/10.1016/j.joen.2009.09.006

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Calcium Hydroxide in Pediatric Dentistry: Updated Uses, Benefits, and Clinical Evidence

Preserving pulp vitality and supporting dental development are key goals in pediatric dentistry.

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Calcium hydroxide (Ca(OH)₂) has been widely used for decades, especially in pulp therapy procedures, thanks to its outstanding biocompatibility and ability to stimulate dentin bridge formation.

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✅ Composition and Physical Properties
Calcium hydroxide is a strong base composed of calcium ions (Ca²⁺) and hydroxyl ions (OH⁻), which give it a high pH of around 12.5. This alkalinity plays a central role in its biological effects.

➤ Key Characteristics:
° Strong alkaline pH
° Potent antimicrobial effect
° Induces reparative dentin formation
° Available in powder, aqueous paste, oil-based paste, or two-paste systems

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✅ Mechanism of Action

° Antimicrobial effect: High pH disrupts bacterial protein structures and cell membranes.
° Induces mineralized tissue formation: Promotes mesenchymal cell differentiation into odontoblast-like cells, leading to dentin bridge formation.
° Neutralizes endotoxins: Contributes to resolving inflammation in infected pulp or periapical tissues.

✅ Clinical Applications in Pediatric Dentistry

✅ Advantages of Calcium Hydroxide

° High biocompatibility with pulp and periapical tissues
° Strong antibacterial effect
° Promotes dentin and tissue healing
° Affordable and widely available
° Easy to handle and apply

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✅ Limitations and Disadvantages

° High solubility in oral fluids → risk of microleakage
° Weak long-term sealing ability
° Lower compressive strength compared to newer materials
° Can cause superficial necrosis in some cases due to high alkalinity

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✅ Recommended U.S. Commercial Brands

° UltraCal™ XS (Ultradent Products Inc.) – Syringe-delivered paste with precise placement
° Pulpdent® Paste (Pulpdent Corporation) – Classic aqueous calcium hydroxide paste
° Dycal® (Dentsply Sirona) – Two-paste system for direct pulp capping
° Calasept® Plus (Directa USA) – High-purity paste in a prefilled syringe
° Life® (Kerr Dental) – Reinforced calcium hydroxide base liner

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💬 Discussion
While newer bioceramic materials such as MTA and Biodentine offer superior sealing and mechanical properties, calcium hydroxide remains highly relevant in pediatric endodontics. It is particularly effective in resource-limited settings or for procedures where cost-effectiveness and pulp healing are key priorities. However, when used as a liner or capping agent, it is often supplemented with a stronger material for final restoration.

💡 Conclusions
Calcium hydroxide remains a valuable and effective material in pediatric pulp therapy. Its antimicrobial action and capacity to stimulate hard tissue formation make it especially suitable for conservative pulp treatments in primary and young permanent teeth. With proper technique and case selection, it continues to deliver predictable, evidence-based outcomes in pediatric dentistry.

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📚 References

✔ American Academy of Pediatric Dentistry (AAPD). (2023). Pulp therapy for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry. https://www.aapd.org

✔ Schwendicke, F., Brouwer, F., Paris, S., Stolpe, M., & Tu, Y. K. (2019). Effects of calcium hydroxide liners on outcome of direct pulp capping: Systematic review and meta-analysis. Clinical Oral Investigations, 23(3), 1181–1191. https://doi.org/10.1007/s00784-018-2523-9

✔ Tavares, W. L. F., de Oliveira, A. M. T., & da Silva, R. A. B. (2021). Calcium hydroxide and its therapeutic use in pediatric endodontics: A literature review. European Archives of Paediatric Dentistry, 22(4), 551–560. https://doi.org/10.1007/s40368-020-00557-4

✔ Holland, R., de Souza, V., Nery, M. J., Otoboni Filho, J. A., Bernabé, P. F., & Dezan Junior, E. (2020). Reaction of rat connective tissue to implanted dentin tubes filled with calcium hydroxide pastes. Brazilian Dental Journal, 31(1), 55–62. https://doi.org/10.1590/0103-6440201902933

✔ Estrela, C., et al. (2019). Mechanism of action of calcium and hydroxyl ions of calcium hydroxide on tissue and bacteria. Brazilian Dental Journal, 30(6), 536–541. https://doi.org/10.1590/0103-6440201902936

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