# Randomised Controlled Trial on the Additive Effect Between Calcium Hydroxide and Sodium Hypochlorite in an Inter‐Visit Root Canal Dressing

## TL;DR

This study found that combining calcium hydroxide with sodium hypochlorite in root canal dressings significantly reduced bacteria without causing inflammation.

## Contribution

The novel finding is that combining calcium hydroxide and sodium hypochlorite in root canal dressings provides an additive antimicrobial effect.

## Key findings

- Root canals dressed with Ca(OH)2/NaOCl had 40% free of microbial growth, compared to 6% with Ca(OH)2/saline.
- MMP-9 levels in periapical fluid were similar between the test and control groups, indicating no increased inflammation.
- Chemo-mechanical preparation reduced CFU counts, but microbial growth remained until the Ca(OH)2/NaOCl dressing was applied.

## Abstract

To assess whether there was an additive antimicrobial effect between calcium hydroxide (Ca(OH)2) and sodium hypochlorite (NaOCl) in an inter‐visit root canal dressing.

Patients presenting with a single‐rooted tooth with pulpal necrosis and asymptomatic apical periodontitis were included in this randomised controlled single‐center clinical superiority trial with two parallel arms. Teeth were instrumented using a rotary file system and irrigated with 3% NaOCl. Subsequently, the root canals were dressed with a Ca(OH)2 slurry that was prepared from pure Ca(OH)2 powder mixed with either 3% NaOCl (test group) or physiological saline solution (control group). Microbial samples were obtained after accessing the root canal, after chemo‐mechanical preparation, and after the root canal dressing with the test or control slurries. A periapical fluid sample was collected after the root canal dressing removal. Samples were transferred to the microbiology lab immediately and assessed for anaerobic growth. The levels of MMP‐9 were measured using a specific enzyme‐linked immunosorbent assay. Negative to positive growth ratios were compared between groups using Fisher's exact test. Colony‐forming units (CFUs) between and within groups and MMP‐9/total protein were compared using non‐parametric tests, p < 0.05.

From the 110 patients recruited for this study, 48 were available for all three sampling procedures in the test (NaOCl) and 50 in the control (saline) group. All canals showed anaerobic growth initially. Chemo‐mechanical instrumentation significantly reduced CFU counts (p < 0.001), yet all canals remained growth‐positive. After dressing with Ca(OH)2/NaOCl, 19 of the 48 (40%) root canals were free of growth, compared to 3 of 50 (6%) in the Ca(OH)2/saline group (p < 0.001). MMP‐9/TP levels in the periapical fluid were similar when root canals were dressed with Ca(OH)2 slurries mixed with NaOCl or saline (p > 0.05).

Placing a combined NaOCl/Ca(OH)2 dressing significantly reduced the microbial load in the root canals of teeth with primary apical periodontitis compared to a conventional slurry prepared with saline solution, without causing any apparent inflammatory response in the periapical tissues.

Trial Registeration: CTRI/2020/10/028484 (Clinical Trials Registry India)