|Year : 2015 | Volume
| Issue : 1 | Page : 80-84
Role of calcium-enriched mixture in endodontics
Pradeep Kabbinale1, KC Chethena2, MA Kuttappa3
1 Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal, Karnataka, India
2 Department of Periodontics, Sri Hasanamba Dental College and Hospital, Hassan, Karnataka, India
3 Department of Conservative Dentistry and Endodontics, Coorg Institute of Dental Sciences, Virajpet, Karnataka, India
|Date of Web Publication||13-Apr-2015|
Dr. Pradeep Kabbinale
Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal University, Manipal - 576 104, Karnataka
Source of Support: None, Conflict of Interest: None
Calcium-enriched mixture (CEM) has been recently introduced as a hydrophilic tooth-colored cement. The CEM cement powder is composed of calcium oxide, calcium sulfate, phosphorus oxide, and silica as major elements. CEM is alkaline cement (pH~11) that releases calcium hydroxide (CH) during and after setting. The physical properties of CEM, such as flow, film thickness, and primary setting time are favorable. This cement is biocompatible and induces formation of cementum, dentin, bone and periodontal tissues. This novel cement has an antibacterial effect comparable to CH and superior to mineral trioxide aggregate (MTA) and sealing ability similar to MTA. Its clinical applications include pulp capping, pulpotomy, root-end filling and perforation repair. This review describes the composition, properties and clinical applications of CEM in endodontics.
Keywords: Calcium-enriched mixture, calcium hydroxide, mineral trioxide aggregate
|How to cite this article:|
Kabbinale P, Chethena K C, Kuttappa M A. Role of calcium-enriched mixture in endodontics. Arch Med Health Sci 2015;3:80-4
| Introduction|| |
Change has been the one constant of history. The challenge is not to avoid change, but to manage it. Change can be "for better or worse." Fortunately or unfortunately, we have experienced both in endodontics. Various procedures are carried out in endodontics in order to preserve the vitality of the tooth such as pulpotomy, pulp capping, and apexogenesis. In a recent prospective clinical study mineral trioxide aggregate, (MTA) showed a high success rate when used as the root end filling material.  MTA has gained widespread use a result of its excellent biocompatibility;  however, MTA has a delayed setting time and poor handling characteristics , and is expensive to use.
New root-end filling materials have constantly been introduced to overcome the shortages of the previous ones. , Recently, a new endodontic cement has been developed with similar clinical uses to tooth-colored ProRoot MTA but having different chemical composition namely calcium-enriched mixture (CEM).  This material has acceptable physical properties  (i.e., setting time <1 h, more flow, and less film thickness than MTA) and is capable of hydroxyapatite formation over material in normal saline solution. 
The CEM can be handled well and sets in an aqueous environment exhibiting good handling characteristics and forms an effective seal when used as root-end - filling material. It also presents with the ability to produce hydroxyapatite with endogenous and exogenous ion sources. 
A study carried out on dogs showed that MTA and CEM have similar favorable results as pulp capping materials and were even preferred over calcium hydroxide (CH).  This review describes the composition, properties and clinical applications of CEM in endodontics.
| Materials and Methods|| |
A review of the literature from peer-reviewed journals published in English was performed using electronic searching methods for the CEM cement in endodontics until 2015. The main objectives of the search include composition, physical, and biological properties and applications of CEM cement in endodontics. Appropriate MeSH headings and keywords that is, Biological and physical properties; CEM cement; Clinical applications; Composition; Leakage; Mechanism of action was searched in peer-reviewed journals from 1995 to 2015.
| Composition|| |
Calcium-enriched mixture cement is composed of different calcium compounds, that is, calcium phosphate, CH, calcium sulfate, calcium silicate, calcium chloride, calcium carbonate and calcium oxide. , CEM cement is a white powder consisting of hydrophilic particles that sets in the presence of the water base solution. The hydration reaction of powder creates a colloidal gel that solidifies in less than an hour and forms hydroxyapatite.
| Properties|| |
Working time and setting time
This cement has a working time of 5 min and setting time of <1 h which is lesser compared to MTA.  The greatest distribution of CEM particle size was within 0.5-2.5 μm range, allowing penetration of particles into dentin tubules and, therefore, providing a better seal.  The large number of small sized particles in CEM cement contributes to the shorter setting time, better flow and also thin film characteristics of this material.
The sealing ability of CEM is similar to MTA  and improves with storage in phosphate-buffered saline solution.  The particle size of CEM is smaller than MTA  this may be related to its acceptable sealing properties. It has the ability to promote hydroxyapatite formation in saline solution  and may also aid in cementogenesis which involves a process of differentiation in stem cells and hard tissue formation. , On the other hand, Electron Probe Micron Analysis revealed endogenous phosphate in CEM. Therefore, it seems reasonable to suspect that the presence of significant calcium and phosphate ions in CEM is most likely to form the hydroxyapatite compared with MTA. MTA, unlike CEM cement, does not contain endogenous phosphorous. 
Antibacterial and antifungal property
Antibacterial activity of CEM cement is comparable with CH and significantly greater than MTA.  CEM cement contains greater potent antibacterial inhibitors than MTA. Comparison of antifungal properties of CEM and MTA on Candida albicans has shown that both biomaterials induce complete death of fungal cells after 24 h.  CEM has an alkaline pH ~11, which plays an important role in the antimicrobial properties of this biomaterial. The study done by Reyhani demonstrated adding 2% chlorhexidine gluconate (CHX) to CEM cement will increase antibacterial activity against Pseudomonas aeroginosa, Enterococcus faecalis, Staphylococcus aureus and Escherichia More Details coli. However, further studies should be carried out to evaluate the effect of adding CHX to CEM cement on its physical properties such as compressive strength, setting time, and sealing ability. 
Animal studies have shown that in various forms of vital pulp therapy (VPT), the induction of dentin bridge formation in CEM was comparable with that in MTA and superior to that in CH. , Studies of complete pulpotomy treatment using CEM, MTA, and CH have shown that compared to CH, samples in the CEM group exhibited lower inflammation, improved quality/thickness of calcified bridge, superior pulp vitality status, and morphology of odontoblast cells.  However, no significant differences were identified in comparison to MTA.  The cytotoxicity of CEM was compared with MTA and intermediate restorative material (IRM), in two different studies; the authors indicated that the cytotoxic potentials of CEM and MTA are both insignificant and comparable, and both biomaterials were significantly superior to IRM. , A recent study comparing the subcutaneous tissue response to CEM and MTA in rats showed that unlike MTA, CEM did not induce any cellular necrosis after 1-week. After 60 days, levels of inflammation in the CEM group were significantly lower than the white/gray MTA groups.  Another significant finding was the presence of dystrophic calcification adjacent to the biomaterials, which is an indication of their osteoinductive potential. 
| Clinical Applications|| |
Vital pulp therapy
Vital primary/permanent teeth with complete/incomplete root formation after traumatic/mechanical/carious pulp exposures are suitable candidates for VPT. The key factor in the success of VPT is the vitality of the pulp and, in particular, the presence of an adequate vascularization, which is necessary for active formation/function of odontoblasts. Several animal studies have shown that in various forms of VPT treatments, the induction of dentin bridge formation in CEM was comparable with that in MTA and superior to that in CH. , Studies of complete pulpotomy treatment using CEM, MTA, and CH have shown that compared to CH, samples in the CEM group exhibited lower inflammation, improved quality/thickness of calcified bridge, superior pulp vitality status, and morphology of odontoblast cells. 
Apexogenesis is considered as the treatment of choice in vital permanent teeth with incomplete root formation. , In a rare case of a maxillary incisor with an open apex and traumatic pulp exposure; the tooth was left untreated for 1-month and then treated by pulpotomy using CEM. Acceptable clinical/radiographic results were achieved, including the formation of a dental bridge below CEM and the closure of the tooth apex.  A randomized clinical study of permanent molars with open apices showed extensive caries and signs of reversible/irreversible pulpitis. A 1-year follow-up randomized clinical trial on permanent molars with open apices revealed extensive caries and signs of reversible/irreversible pulpitis which was indicative that complete pulpotomy of the teeth using MTA and CEM were beneficially successful. ,
Direct pulp capping (DPC) is one of the best known clinical treatments available, whereby the connection between the exposed pulp and oral cavity is eliminated using appropriate materials.  Recent DPC outcomes in prospective randomized controlled/clinical trials carried out on permanent teeth planned for orthodontic extraction have shown that under immunohistochemical examinations, the thickness of dentinal bridge beneath CEM was higher than MTA at various time intervals and pulp inflammation was also lower in the CEM groups.  In addition, expression of fibronectin/tenascin in the CEM groups were higher than the MTA groups during both time intervals; however, the above differences were not statistically significant. 
Root and furcal perforations are common complications of endodontic treatment or postpreparation and often lead to tooth extraction. CEM cement was considered as the material of choice based on the results of in vivo studies which revealed that CEM cement is able to stimulate dentinogenesis after DPC,  pulpotomy in animals  and in humans, it showed cementogenesis after perforation repair or surgery. , A 2 years follow-up case reported by Asgary revealed the successful management of facial perforation in mandibular first molar by CEM cement along with no evidence of periodontal breakdown, no symptoms and complete healing of furcal lesion. 
Root end filling material
One ideal property of a root-end filling material is its ability to seal the apex apical sealing ability. The micro-leakage of CEM cement, which is comparable with MTA and Portland cement, indicates its good apical sealing. Due to the other beneficial properties of this material such as biocompatibility, flow ability, good clinical handling, antibacterial and low cytotoxic effect, CEM cement is suggested as an appropriate root-end filling material. 
With regards to its excellent biocompatibility and the ability to form dentin and cementum, CEM can be suitable best used as an obturating material. Reports from authors, Asgaray, and Eghbal exhibited successful management of inflammatory external resorption using CEM as an obturating material. Three years follow-up showed complete healing of the periapical area. 
Asgary et al. reported successful management of inflammatory external root resorption (IERR) using CEM cement in an avulsed tooth of a young male patient.  Healing of a progressive IERR occurred within 40 months with re-establishment of the normal periodontal condition. Another case report describes the management of an endodontically failed molar that was severely affected by both external and internal root resorption. Favorable treatment outcomes were reported after 12 months of reobturation of entire distal root canal with CEM cement.  On the basis of biological properties of CEM cement, the authors believe that this cement might be an appropriate bilateral in treatment of IERR and also in arbitration of immature teeth. However, further clinical studies with longer follow-up periods and larger samples are recommended. 
| Conclusion|| |
In conclusion, considering the notable advantages of CEM cement over MTA, such as shorter setting time, handling characteristics and bactericidal effects, it could be stated that, CEM cement might be an appropriate biomaterial to be used for various purposes in endodontics. Literature review on this particular material is lacking, due to recent commercialization of this product. However, further research is needed to learn about the success rate of this material.
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