Endodontics

American Association of Endodontists

I. B. Bender, Editor

Tissue reaction to root canal cementsin the

rat molar
Jorge Erausquin, D.D.S., and Margarita Muruzhbal, D.D.S.,
Buenos Aires, Argentina
UNIVERSIDAD DE BUENOS AIRES, FACULTAD DE ODONTOLOGiA

A pproximately three years ago, a research program was started with the
purpose of studying the reaction of the periapieal tissues of the rat molar to
different root canal filling materials used in endodontics. During the course of
this investigation, successive modifications of the original technique and the
observation of longer postoperative periods considerably increased the amount
of material to be examined. For this reason, we decided to divide the work into
three parts : one dealing with root canal cements, another dealing with resorbable
pastes, and the third dealing with plastic root canal fillings. The present article
will report a study devoted to root canal cements-zinc oxide-eugenol cement,
Kerr cement, Grossman sealer, and N,.
Zinc oxide-eugenol cement, described previously,l was selected because its
well-defined physicochemical properties make it an adequate basis for comparison
of other cements. Kerr cement and Grossman sealer were chosen because of their
widespread use in the United States, and N, was chosen because of its popularity
in Europe and Latin America.

MATERIAL AND METHODS

A total of 710 white rats of either sex, from 60 to 90 days old, were used. The
number of root canal fillings made with each cement, as well as the different
postoperative periods studied, are shown in Table I.

Operative technique
The standard technique used has been described in detail in a previous
article7; however, several modifications were subsequently introduced in order
to obtain either an overfilling, a short filling, or necrosis of the cementum.

This study waz supported by a grant (DE 02290) from the National Institute of Dental
Research, United States Public Health Service.
*Professor of Histology.

360
Volume 26 Tissue reaction to root canal fillings 361
Number 3

Table I
Postoperative period Total
0 1 d 4 7 15 SO 60 90 per
day day days da?lS days &YS &YS &YS &YS cement
Zoe - 29 25 27 64 16 32 29 31 253
Kerr 7 :i 23 20 37 ii 16 10 19 159
Grossman 1 15 19 30 19 14 19 144
N, P - 11 15 13 31 8 21 11 21 131
?iT,T - - 4 3 5 3 3 2 3 23
Total per
period s 67 E sz 167 54 iii- ss 93 710

Fig. 2

Fig. 1. Filling with zinc oxide-eugenol; QO-day postoperative period. Fissures caused by
histologic technique. Remains of zinc oxide-eugenol cement adhering to dentine at apical zone
(arrows), but detached from canal wall, producing a crack (C) in its upper portion. R, Resorp-
tion of necrotic cementum and underlying dentine. (Magnification, x55; reduced I$.)
Fig. 8. Filling with NZ Temporary; 2-day postoperative period. In spite of fissures
produced by histologic technique, most of dentine shows adhering N, Temporary (arrows).
(Magnification, x80; reduced 1/s,)

Overfillings were obtained in young animals (50 to 60 days old) by over-

instrumentation and enlargement of the apical foramen, filling of the canal
with a spiral lentulo, and pressing a small heated baseplate gutta-percha sphere
into the orifice of the canal. In animals from 80 to 100 days old fillings short
of the apex were achieved with a fine short Hedstriim file. In order to study the
necrotizing action of the root canal sealer on the cementum, the canal was
considerably enlarged so as to reduce the thickness of the dentinal layer, or
even to remove it entirely.

Histologic procedure
In all cases, specimens were (1) subjected to simultaneous fixation and
decalcification in formol-EDTA, (2) embedded in butyl alcohol-paraffin, (3)
362 Erausquifk and Mumz6bal O.H., 0.31. B 0.1.
September, 1968

oriented buccolingually, following the axis of the mesial root, of the first, molar,
and (4) stained with hematoxylin and co&u.

BEHAVlOR OF THE CEMENTS WITHIN THE ROOT CANAL

Plasticity
This property was evaluated by the degree of adaptation of the cement to
the canal walls. All four of the cements tested showed very good plasticity, as
evidenced by microscopic observation (Figs. 1 and 2).

Dimensional changes
Shrinkage or distortion of root canal cements, either during or after the
setting period, was difficult to evaluate by microscopic observation. Since histo-
logic processing caused marked tissue retraction, the fissures almost constantly
appearing in the lumen of the canal may be the result of dimensional changes
of the cement or shrinkage due to the histologic technique. However, since
fissures became infiltrated with polymorphonuclear leukocytes, it is reasonable
to assume that the empty fissures are technical artifacts. Thus, microscopic
observation showed that none of the four cements underwent appreciable
dimensional changes after being placed in the canal,

Adhesion to the canal walls

Fissures caused by tissue shrinkage during histologic processing permitted
a rough evaluation of the degree of adhesion of the filling material to the canal
walls. When fissures appeared between the cement and the canal wall, it was
assumed that the strength of adhesion of the root canal cement was not as great
as its resistance to fracture; conversely, cracks located within the cement were
taken to indicate that strength of adhesion to the canal wall was greater than
resistance of the cement to fracture (Fig. 1).
Considered from this standpoint, none of the four cements can be described
as adhering firmly to the canal walls. N, Temporary showed the greatest
tendency to adhere to the dentinal wall, probably because of its lower resistance
to fracture. On the other hand, zinc oxide-eugenol also showed a tendency to
adhere to the dentine, although to a lesser degree. The other cements-Kerr,
Grossman, and N, Permanent-lined the canal walls but did not adhere to them.
These observations are in agreement with those obtained by Tschame?, 0 in
laboratory tests, using N, Permanent.
A rough estimate of the degree of adhesion of N, Temporary and zinc oxide-
eugenol, evaluated by establishing the ratio between the area of dentine with
adhered root canal cement and the total canal surface, showed that more than
80 per cent of this surface presented adhering cement when N, Temporary was
used, as compared with 20 to 30 per cent when zinc oxide-eugenol was used.

Tendency to overfilling
Root canal overfilling depends, to a certain degree, on the pressure applied
to the material in the canal, the size of the foramen, and the fluidity of the ma-
terial. Disregarding the first two factors, the fluidity of the cements depends
 Volume 26 Tissue reaction to root canal fillings 363
Number 3

both on the proportion of powder to liquid in the mixture and on the degree of
spatulation.
Taking only these variables into account it was rather difficult to make an
accurate comparative evaluation; however, when a standard technique was
used, Kerr cement most frequently extruded through the apical foramen (Fig.
3) and, in some cases, even scattered in the adjacent bone-marrow lacunae.

REACTION OF THE APICAL PERIODONTAL LIGAMENT

Necrosis
Overfilling of the mesial root of the lower first molar of the rat, frequently
causes infarction of the adjacent periodontal ligament due to destruction, com-
pression, or thrombosis of the vessels of the alveolar fundus.lO This necrotizing
action was observed with all four root canal cements used in the present study.
In order to evaluate the degree of tissue injury, cases of overfilling were
studied two days postoperatively. Zinc oxide-eugenol cement provoked the larg-
est zones of necrosis in relation to the extent of the overfilled mass (Fig. 4). The
other three root canal cements provoked only a few small areas of necrosis, even
in cases of gross overfilling.
Four days postoperatively, the area of periodontal ligament necrosis had been
replaced by newly formed tissue in practically all cases. Occasionally, in speci-
mens in which zinc oxide-eugenol had been used, remnants of necrotic periodon-
tal tissue could still be seen adjoining the apical foramen.

Fi,q. 3 Fhg. 4

Fig. 3. Filling with Kerr sealer; go-day postoperative period, Overfilled material appears
scattered in apical periodontal ligament (thin arrows). Ingrowing tissue in canal started
resorption of canal wall (R). Thick arrow: Kerr sealer in canal. (Magnification, x80; reduced
Y3.)
Fig. 4. Filling with zinc oxide-eugenol cement; 2-day postoperative period. Overfilling
with zinc oxide-eugenol (ZOE) causing periodontal ligament necrosis (PLN), alveolar bone
necrosis (ABN) and cementurn necrosis (CN). (Magnification, x70; reduced IA.)
 344 E~azcsquin and Mumzciba~l O.S., ON. & O.P.
September, 1968

Inflammatory reactions

Periapical inflammatory reactions provoked by the root canirl ccmcnt s varied

considerably. Since all specimens studied were normal teeth of tho name age,
and since the same root was studied in each case, variations in inflammatory I+
sponse may be conseqnent,ial to both the specific propertics of each cement and
the differences in t,he operative techniques employed. The close interaction of

F ig. 5 E;'i.4.

Fig. 5. Filling with Nz Permanent; 2-day postoperative period. Surrounding overfilled

material appears a pseudocapsule (P(J) due to compression of periodontal ligament. Scarce
polymorphonuclear leukocyte infiltrate (PI). (Magnification, x110; reduced J$)
Fig. 6. Filling with Kerr cement; 4-day postoperative period. Debris (0) due to instru-
mentation, pushed through foramen by Kerr cement (Ii;), appears densely infiltrated with
polymorphonuclear leukocytes. (Magnification, x120 ; reduced I,$)
Pig. 7. Filling with zinc oxide-eugenol cement; 60-day postoperative period. Cemento-
dentinal wall resorbed and replaced by intiltrated tissue (IT). Debris (arrows) mixed with
zinc oxide-eugenol cement. BS, Bone sclerosis. (Magnification, x60; reduced I$$.)
Volume 26 Tissue reaction to root canal fillings 365
Number 3

these two factors makes it difficult t,o evaluate the inflammatory reaction of the
tissue to a given cement, unless the technique is carefully described in detail.
When the filling was made flush to the apex or slightly beyond it and the
cement was well condensed, showing a smooth surface, only a mild inflammatory
reaction was seen. During the first few days, zinc oxide-eugenol and Grossman
sealers provoked a generally mild and brief polymorphonuclear leukocyte infil-
tration
In cases of overfilling, the periodontal ligament reaction depended mainly on
the degree to which the material mixed with tissue fluid and debris. Zinc oxide-
eugenol and Grossman cements induced a polymorphonuclear leukocyte infil-
tration. This reaction beca,me more severe when the amount of tissue remnants
increased, and the overfilled mass was less compact.
N, showed a similar though less intense response (Fig. 5). This is in agree-
ment with observations made by Sargenti and Richterll in human material and
by Snyder, Seltzer, and Moodnik6 in dogs ; Overdiek12 also reported a favorable
reaction to N, in guinea pig implants. On the other hand, Kuroiwa13 described
several cases of severe tissue reaction to overfillings with N, in dogs. Rappaport,
Lilly, and Kapsimalis4 observed a severe inflammatory reaction to N, implants
in the subcutaneous connective tissue of the rat.
While Kerr cement has a tendency to extrude through the foramen and
spread in the periodontal space, it did not mix with tissue remnants. The ensu-
ing inflammatory reaction was mild, which confirmed the observations made by
Stewart,15 Guttuso,16 and Rappaport and associates.14 A polymorphonuclear in-
filtrate was found only in those cases in which Kerr cement pushed the tissue
remnants beyond the apical foramen (Fig. 6).
The aforementioned correspond to short postoperative periods, in which in-
filtration of the periodontal ligament is the response to direct action of the over-
filled material. However, 15 days postoperatively and thereafter, irritation pro-
voked by the overfilled material mixed with debris due to instrumentation may
involve bone and cementum, causing secondary infiltrative and granulomatous
reactions in the periodontal ligament. This granulomatous response is often
associated with resorption of cementum and resorption and/or sclerosis of the
alveolar fundus (Fig. 7).
Variable occurrence of short fillings was found after 15 days postoperatively.
For instance, when a small segment of the remaining pulp with little injury
was left in the apical canal, the inflammatory reaction was generally mild and
the periapical tissues showed optimal tolerance (Fig. 8). This favorable response
was found to the four cements studied.
On the other hand, if the apical pulp stump remained in contact with pulp
remnants adhering to the canal wall, dense infiltration frequently occurred and
caused necrosis of the adjacent cementum followed by a periapical abscess sur-
rounded by a granuloma of variable dimensions (Fig. 9). Zinc oxide-eugenol,
Grossman, Kerr, and N, Permanent cements showed this unfavorable periapical
reaction in cases of poor ddbridement and filling of the canal; only N, Temporary
showed less tendency to provoke infiltration of pulp remnants and inflammatory
reaction of the periapical tissues.
Fig. 8 Fig. 9

Fig. 8. Filling short of apex with Kerr cement; 60.da.y postoperative period. Favorable
reaction of residual pulp and apical periodontal ligament.. Arrow indicates junction between
filling and pulp. NB, New bone at alveolar fundus. (Magnification, x55; reduced /3.)
Pig. 9. Filling with Kerr cement; i-day postoperative period. Apical abscess (A) sur-
rounded by small granuloma (G). Resorption (E) of alveolar fundus and bone sclerosis (BS)
of underlying bone marrow. Cement mixed with debris (arrows) in root canal. (Magnification,
x60; reduced 14.)

The favorable response mentioned by some authors for N2 Permanentl*s 17-ls

was observed only when trauma of the apical pulp stump was minimal. Under
these circumstances, all the cements showed a similar favorable response. The
poor results obtained when any of the cements became mixed with debris are
in agreement with those which demonstrate the hazards of a deficient filling of
the canaL6r 2o

Resorption of the overfilled material

The fate of the overfilled cement depended largely on the proportion to which
it became mixed with tissue fluids and the debris of instrumentation when extrud-
ing beyond the foramen.
Tightly packed root canal cements without debris were resorbed very slowly.
A small number of foreign-body giant cells (Figs. 10 to 14)) whose function
was somehow related to root canal cement resorption, appeared on the surface
of the overfilled material. The remaining area was surrounded by normal con-
nective tissue, made up mainly of collagen fibers.
N, Temporary showed a peculiar tendency to fragmentation with release of
opaque granules (titanium dioxide) that were rapidly phagocytized by the
macrophages (Fig. If,).
During this process, polymorphonuelear leukocytes were scarce or entirely
absent. Guttuso,l who observed this lack of acute infiltration in 2-day implants
in rats, postulated that regular inflammatory cells could not migrate readily
 Tissue reaction to root canal fillirl,gs 367

Fig. lt?

Fig. 10. Filling with zinc oxide-eugenol (ZOEJ cement; 60-day postoperative period.
Giant cells (arrows) on surface of overfilled material, surrounded by fibrous capsule (FC)
with minimal infiltration. (Magnification, xl 70 ; reduced l/s,)
Fig. 21. Filling with Kerr cement; go-day postoperative period. Giant cells (arrows) on
fragment of Kerr cement (EC) isolated in periodontal tissue. (Magnification, x400; reduced
?-ix.)
Fig. 18. Filling with zinc oxide-eugenol cement; do-day postoperative period. Giant cells
(arrows) on fragment of zinc oxide-eugenol cement (ZOE) isolated in periodontal tissue and
surrounded by fibrous capsule (PC). (Magnification, x200; reduced I$.)
Fig. IS. Filling with Kerr cement; go-day postoperative period. Giant cells showing large
silver particles. (Magnification, x800; reduced l/J.)

into the area because the tissue cells seemingly were killed or fixed on the
eipot, and added that a critical analysis proved that actually a severe injury
had occurred. Our histologic specimens showed, however, that no polymorpho-
nuclear leukocytes could be found in the neighborhood of the filling material
either 15 or 90 days after treatment.
When the cement became mixed with tissue debris due to instrumentation
and/or with the interstitial fluids of the apical periodontal ligament, the reac-
tion of the adjoining tissue was much more severe. Polymorphonuclear and ma.c-
rophage infiltration generally occurred, progressively disintegrating the cement.
It was not possible to establish the fate of the cement granules, but it may be
assumed that they were phagocytized by the macrophages.
 O.S., O.M. & 0.1.
September, 1968

Fig. 14 E 15

Eig. 24. Filling with Grossman cement; 30.da? postoperative period. Giant cells (arrows)
on fragment of Gross,man cement (GC) isolated m periodontal tissue. (Magnification, x250;
reduced $4.)
Pig. 15. Filling with N, Temporit~y ; 1S-day postopw:ttivr pvriotl. Disintegrated N,
Temporary (NKC) with titanium dioxide granules being phagocytized by macrophages
(arrows). Minimal polymorphonuclear leukocyte infiltrate. (Magnification, x350; reduced $4.)

long-term tissue tolerance to ovetfllied cements

The most frequent reaction found after 60- to 90-day postoperative periods
in cases of overfilled cements was encapsulation. When the overfilling was dense,
the capsule was found to be thin, lying in direct contact with the cement (Fig.
16) ; conversely, when the overfilling contained debris, the fibrous capsule was
thicker (Fig. 17) and a zone of loose connective tissue, polymorphonuclear
leukocytes, macrophages, and, in some cases, giant cells was found between it
and the cement.
In two cases of overfillings made with Grossman cement (Fig. 18) and in
one case of overfilling zinc oxide-eugenol (Fig. 19), bone tissue was found
deposited directly on the overfilled cement.

RESPONSE OF THE CEMENTUM

As discussed in a previous article, *I differences in thickness and structure
between the cementum of the rat molar and that of the human molar induced
us to assume that cementum in the rat is biologically less resistant than its coun-
terpart in man. Therefore, although the basic tissue response to trauma provoked
by root canal treatment is similar in both species, it appeared to be more severe
in the rat.

Cementum necrosis
Cementum necrosis caused by the irritating action of root canal cements has
been a common finding in the course of our work.
Each of the cements caused a similar degree of necrosis when it came in con-
tact with the cementum, either at the apical end of the root, normally devoid of
dentine, or where dentine had been removed by mechanical instrumentation.
 Volume 26 Tissue reaction to root canal fillings 369
Number 3

Fig. 16 Fig.

Fig . 18 Fig. 19

Fig. 26. Filling with zinc oxide-eugenol cement; 30.day postoperative period. Overfilled
zinc oxide-eugenol cement (ZOE) appears surrounded by thin fibrous capsule, without
infiltrate. (Magnification, x80 ; reduced l/g.)
Fig. 17. Filling with zinc oxide-eugenol cement; 30-day postoperative period. Overfilled
zinc oxide-eugenol cement (ZOE), mixed with some debris, shows thicker capsule than in Fig.
16, with mild infiltration. (Magnification, x100; reduced :,$.)
Fig. 28. Filling with Grossman cement; 30.day postoperative period. Bone lamella (BLJ
deposited directly on fragment of Grossman root canal cement (GC). (Magnification, x350;
reduced $5.)
Fig. 29. Filling with zinc oxide-eugenol cement; go-day postoperative period. Fragment
of zinc oxide-eugenol cement (ZOE) totally surrounded by newly formed bone. Bone lamella
(BLJ deposited directly on cement. (Magnification, x100; reduced I$.)

Likewise, all the cements caused partial necrosis of the cementum, starting at
the inner surface, in specimens with a thin dentinal layer. Conversely, good
cementum tolerance was found where dentine width exceeded 80 to 100 microns
and the root canal fillings were tightly packed and without debris.

Cementum resorption
Resorption of the cementum was frequently found to be preceded, accom-
panied, or followed by resorption of the adjoining dentine and apparently did
not depend directly on the type of filling material. Notwithstanding this fact,
the filling material may indirectly influence resorption of the calcified tissues,
 Fig. $0. Filling with Kerr cement; 30-day postoperative period. Ingrowth of periodontal
tissue (IPT), and dentinal cementum resorption (R). (Magnification, x180; reduced I,.)

as was seen in cases of cementum necrosis or ingrowth of periodontal tissue into

the root canal.
Necrotic cementum showed a definite tendency to be resorbed. This process
started at the periodontal surface of the cementum and reached variable depths,
even to the point of entirely removing the wall of the apical portion of the
canal. However, no special features were noted in the resorption process that
could be ascribed to the type of cement used.
The ingrowing apical periodontal tissue, found in short fillings with blood
clots in the apical canal, also induced severe resorptions, this time starting at
the inner surface of the dentine. This type of response could occasionally be
observed with all four cements, when the postoperative period was longer than
15 days. To exemplify the behavior of a specific cement, when Kerr sealer was
used, cementum resorption started earlier and was more severe than when the
other cements were used (Figs. 3 and 20), proba,bly because of the mild
infiltration caused by this material, which allowed quicker ingrowth of the
periapical tissue.

REACTION OF THE ALVEOLAR BONE

The alveolar fundus showed two types of reaction to t,he cement: (1) direct,
due to the contact between the overfilled material and the alveolar bone, and
(2) indirect, provoked by inflammatory changes of the periodontal ligament,
caused by poor filling of the canal.

Direct reaction
Any of the cements, when overfilled and coming in direct contact with the
alveolar fundus, caused necrosis of the superficial bone lamellae. In some cases,
Volume 26 Tissue reaction to root canal fillings 371
Number 3

this necrosis was followed within 7 days by osteosclerosis of the underlying

bone marrow.
No specific reaction to the different cements was found, with the exception
of Kerr sealer, which showed a greater tendency to scatter throughout the perio-
dontal ligament rather than to adhere to the alveolar surface.

Indirect reaction of the alveolar fundus

When fillings remained short of the apex, the apical portion of the root canal
was seen to be occupied by the pulp stump, tissue remnants, or blood clot.
In some cases, these structures underwent polymorphonuclear leukocyte and
macrophage infiltration or were invaded by ingrowing apical connective tissue.
A periapical abscess, surrounded by granulomatous tissue, frequently de-
veloped after infiltration of the canal, inducing resorption of the alveolar surface
and osteosclerosis of the underlying bone marrow.
When marked ingrowth of the periodontal tissue took place, severe resorp-
tion of the dentine and cementum was frequently seen. Despite marked destruc-
tion of the apical end of the root, however, necrosis, resorption, or sclerosis of
the alveolar bone was rarely observed, apposition of new bone lamellae being the
most common finding.

INFLUENCE OF THE OPERATIVE TECHNIQUE

The biologic material used in these experiments has been basically uniform,
namely, the normal mesial root of the first lower molar. Therefore, the difference
in responses was probably due to the type of cement and the technique used.
Findings reported here show a wide range of responses, and experimental
evidence appears to indicate that this diversity depends more on the technical
approach than on the choice of filling material.
Histologic studies showed, for instance, that different periapical tissue reac-
tions can be obtained, even when the same cement is used, according to the type
of filling made (short of the apex, flush to the apex, or overfilling). On the
other hand, results were very similar with the four cements if debridement was
thorough and the fillings were tightly packed and flush to the apex. This would
indicate that none of the cements, per se was able to compensate for poor
technique.

Influence of technique on density of the filling

Thorough d6bridement of the canal and tight packing of the cement were
basic requirements for obtaining hermetic fillings.
The presence of blood clot and of tissue remnants, which was a common
finding because of the oval or fusiform shape of the canal, seriously hindered
the accomplishment of hermetic fillings. In order to overcome this difficulty, a
small amount of cement was introduced into the canal with a Hedstrijm file in
a counterclockwise motion, in order to impregnate the canal walls and mix the
cement with the debris. This later was removed by clockwise rotation of the file,
after which the permanent filling was ma,de.
 This technique yielded good results when zinc oxide-eugcnol and 3, were
used ; conversely, Kerr and Grossman cements were more difficult to mix with
the debris and were less adherent to the moist canal wall.
The spatulation technique is likewise important in obtaining hermetic fillings
of the canal; best results were achieved when thick cement was usc~l and spatu-
lation was carefully accomplished.

Influence of operutive technique in the necrosis and

resorption of cementum
Excessive enlargement of the root canal during mechanical instrumentation
caused reduction of the dentine layer. Under these circumstances, all the cements
provoked necrosis of the cementum, which started at the cementodentinal junc-
tion and then spread toward the periodontal surface. As the dentine layer be-
came thinner, it was found that the necrotic layer of cementum increased.
Finally, when the entire cementum was necrotized, resorption induced by the
periodontal ligament was frequently observed.
Moreover, in specimens with thorough debridement of the canal, filled short
of the apex, the remaining empty space was frequently occupied by a blood
clot, which was rapidly invaded by ingrowing tissue coming from the periodontal
ligament. This newly formed tissue showed a marked tendency to resorb dentine
and cementum, starting from the canal wall.

SUMMARY AND CONCLUSIONS

The response of periapical tissue to root canal fillings with zinc oxide-eugenol
cement, Rickert sealer, Grossman sealer, and Nz was studied in 710 white rats
between 60 and 90 days old. Root canal treatments were performed in the
mesial root of the lower left first molar. Postoperative periods ranged from 1
to 90 days. The following conclusions were based on histologic studies:
1. Tested root canal cements showed good plasticity; no dimensional cha.nges
could be detected after the filling was placed.
2. Grossman, Kerr, and N, Permanent cements did not adhere to the canal
wall; zinc oxide-eugenol was only slightly adherent; N, Temporary showed the
greatest adherence.
3. Zinc oxide-eugenol, Grossman, and N, Permanent cements, when mixed
with debris, mostly provoked severe inflammatory infiltration; N, Temporary
caused a mild reaction; Rickert sealer frequently induced moderate infiltration,
ingrowth of periapical tissue, and resorption of the canal wall.
4. The most favorable tissue reaction was found in specimens with fillings
short of the apex and with minimal injury of the remaining pulp stump.
5. All root canal cements tested, in cases of overfillings, showed a tendency
to be resorbed. Resorption of compact overfilled masses, without debris, pro-
ceeded slowly. No polymorphonuclear leukocytes were observed, although giant
cells were nearly always found. When the extruded root canal cement became
mixed with tissue remnants, a severe inflammatory reaction was frequently seen.
6. When the cements directly contacted the alveolar surface, necrosis and
resorption of the superficial bone lamellae frequently occurred. However, the
Volume 26 Tissue reaction to root canal fillings 373
Number 3

most severe resorptions were constantly associated with osteosclerosis of the

underlying bone marrow. This response was indirectly induced by inflammation
of the apical periodontal ligament, caused by poor d6bridement and filling of
the canal.
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