Definition and Classification of Bioceramic Endodontic Sealers

Introduction: The term “bioceramic” is used in endodontics to describe various products and is often used in general terms for mineral trioxide aggregate (MTA) and other hydroscopic dental cements (HDC), which creates confusion in the terminology. Aim: The aim of the study is to present a definition and an original classification of bioceramic endodontic sealers. Materials and methods: A total of 123 articles were found by the PubMed search engine using the key phrase “bioceramic endodontic sealers”. Of these 123 articles, we analyzed 20 articles that contain information about the composition, properties, definition, and classification of bioceramic endodontic sealers. Results: In accordance with the collected data on the composition and the delivery form of calcium silicate endodontic sealers, we propose a new definition of bioceramic endodontic sealers that clarifies the specificities of these materials. In the new classification they are divided by two criteria: source of calcium silicate and form of delivery. It also contains the particular products’ names in order to aid their usage in the clinical practice.  Conclusions: The new definition of bioceramic endodontic sealers clears out the confusion in the terminology, which promotes the classification of these products and helps understanding their clinical application.

Influence of Commonly Used Endodontic Irrigants on the Setting Time and Metal Composition of Various Base Endodontic Sealers

The present study aimed to evaluate if commonly used endodontic irrigants such as 3% sodium hypochlorite (NaOCl, Prime Dental, Thane, India), 2% chlorhexidine (CHX, Sigma-Aldrich Co., St. Louis, MO, USA), and 17% ethylenediaminetetraacetic acid (EDTA, Meta-Biomed Co. Ltd., Cheongju-si, South Korea) influenced the setting time and metal composition of different base endodontic sealers on exposure. AH Plus (Dentsply De Trey GmbH, Konstanz, Germany), Sealapex (SybronEndo, Orange, CA, USA), mineral trioxide aggregate (MTA) Fillapex (Angelus Soluções Odontológicas, Londrina, Brazil), and Tubli-Seal (Kerr Dental, Orange, CA, USA) were selected as the different base representatives of endodontic sealers. These sealers were exposed to 3% NaOCl, 2% CHX, and 17% EDTA, and the individual setting time of the sealers was analyzed. The samples were analyzed for heavy metal elements such as chromium (Cr), nickel (Ni), cobalt (Co), cadmium (Cd), arsenic (As), mercury (Hg), lead (Pb), and beryllium (Be) by using inductively coupled plasma mass spectrometry (ICP-MS) analysis. For statistical analysis, one-way ANOVA and post hoc Tukey’s tests were used. All selected sealers showed variation in setting time post-exposure to different irrigants. MTA Fillapex had the shortest mean setting time (215.7 min, post-exposure at 187.3 min) (p < 0.05). Mean setting time was also affected for AH Plus (479.6 min, post-exposure at 423.9 min) (p < 0.05) and Tubli-Seal (514.7 min, post-exposure at 465.2 min) (p < 0.05). Sealapex showed the maximum reduction of setting time (864.8 min, post-exposure at 673.4 min) (p < 0.05). All tested sealers showed heavy metals (Cr, Ni, Co, Cd, As, Hg, and Pb) in their composition, and the quantities were influenced by interaction with different irrigants. The heavy metal Be was not seen in any of the samples. Sealapex showed the longest setting time in comparison to other test sealers. Heavy metals were most present in Sealapex, followed by AH Plus, Tubli-Seal, and MTA Fillapex. MTA Fillapex was seen to have the shortest setting time, and heavy metal composition was least affected on interaction with different commonly used endodontic irrigants. Further, this study provides significant insight into the influence of different endodontic irrigants on interaction with different base endodontic sealers, which has not been reported previously, and future studies should emphasize endodontic irrigant-sealer interactions and their possible effects in the long run.

Effect of Different Treatment Regimen and Types of Endodontic Sealers on Pain and Periapical Radiographic Changes

INTRODUCTION: The study aims as a pilot study to evaluate the effect of different treatment regimen and different types of endodontic sealers on pain and periapical radiographic changes was studied. MATERIALS AND METHODS: Forty patients in need of an endodontic root canal treatment on anterior teeth were selected and divided into two groups (20 patients each), according to the endodontic treatment protocol (single or multiple visits). Then, each group was subdivided into two subgroups according to sealer used 10 each (AH Plus Jet resin sealer, Total Fill Bioceramic Sealer). To record pain intensity of the patients at different intervals: 1, 2, 3, 7 days, a visual analog scale was used. Furthermore, patients were recalled after 1, 3, 6, 9 months to evaluate periapical radiographic changes. RESULTS: Showed that as regard pain assessment both tested endodontic sealers, as well as single or multiple visits have no statistically significant difference between pain values of patients during all the observation period from immediately post-operative, after 4, 12, 24, 48, 72 h as well as after 7 days (p > 0.05). As regard lamina dura thickness, results showed that with both tested endodontic sealers as well as single or multiple visits, there was no statistically significant difference between lamina dura thickness of patients after 1 month, 3, 6 as well as after 9 months. CONCLUSIONS: Neither number of visits of endodontic treatment nor type of sealer used for obturation affects post-operative pain and thickness of lamina dura.

In vitro comparison of the cytotoxicity of different endodontic sealers; AH Plus, AdSeal, Endoseal MTA, and GuttaFlow Bioseal

Background: This study aimed to assess the cytotoxicity of four commonly used endodontic sealers namely AH Plus, AdSeal, Endoseal MTA, and GuttaFlow Bioseal against human gingival fibroblasts (HGFs). Methods: After culturing the HGFs, they were exposed to the respective sealers in set form and in five different weights, after sterilization. The cytotoxicity of the sealers was evaluated after 1, 3 and 7 days using the methyl thiazolyl tetrazolium (MTT) assay. Data were analyzed by repeated measures ANOVA. Results: After 24 h, all sealers showed low cytotoxicity. However, all sealers in 250 mg and 500 mg weights showed significantly higher cytotoxicity than the negative control group at 72 h, and 7 days (P<0.05) except for AdSeal in 80 mg weight (P>0.05). AH Plus was significantly more cytotoxic than other sealers at 3 and 7 days (P<0.05) while AdSeal had the closest results to the negative control group, and showed significantly higher biocompatibility than other sealers in 250 mg concentration. Conclusion: AdSeal showed the highest biocompatibility while AH Plus had the highest cytotoxicity among the tested sealers. Thus, its application may delay the healing of periapical lesions.

Minimal Dentinal Tubule Penetration of Endodontic Sealers in Warm Vertical Compaction by Direct Detection via SEM Analysis

Sealer staining using rhodamine B dye to investigate the penetration depth of endodontic sealers was proven unsuitable for this purpose. This study aimed to investigate the sealer penetration depth into dentinal tubules by scanning electron microscopy (SEM). Root canals of 52 human upper central incisors were instrumented using the ProTaper Gold NiTi system (Dentsply Sirona, York, PA, USA) up to size F3. After irrigation with sodium hypochlorite and citric acid combined with ultrasonic activation, the root canals were either filled using the epoxy resin sealer AH Plus (Dentsply Sirona) or the calcium silicate-based sealer Total Fill BC Sealer HiFlow (TFHF, FKG Dentaire, La Chaux-de-Fonds, Switzerland) by warm vertical compaction. Root slices of 1 mm thickness were obtained at 2 to 3, 5 to 6 and 8 to 9 mm from the apex. The root slices were investigated for sealer penetration into the dentinal tubules using SEM according to four root quadrants (buccal, mesial, oral, distal). Statistical analysis was performed by the Kruskal-Wallis test (p = 0.05) as data were not normally distributed according to the Shapiro-Wilk test. AH Plus penetrated significantly deeper into the dentinal tubules compared to TFHF at each root level (p < 0.05). Dentinal sealer penetration was deeper in the bucco-oral direction compared to the mesio-distal direction. AH Plus penetrated deeper into dentinal tubules than TFHF. Warm vertical compaction exerting high pressure on the root canal filling material is not able to press sealers deep into dentinal tubules as penetration depth values did not exceed a mean of 110 µm in SEM.

Confocal laser scanning microscopic evaluation of depth of penetration and Sealer/Dentin interface between endodontic sealers - An in-vitro study

An endodontic sealer contributes in obtaining an appropriate seal for the root canal system by establishing an association between the root canal walls and coronal restoration thereby promoting healing. This present research intended to compare the penetrating capacity and to determine sealer/dentin interface among various endodontic sealers. Horizontally sectioned tooth samples were obtained at 3 and 5mm and randomly divided into three groups: Group I - Chemically cured (AH Plus) sealer; Group II - Dual cured (EndoREZ) sealer; Group III – BioCeramic Nano sealer (iRoot SP). All three groups were coated with their respective sealers and obturated using cold lateral compaction technique. The samples were observed using Confocal Microscope for penetrating capacity evaluation and reviewing of sealer/dentin junction at 3 and 5mm depth. The results were statistically analyzed using one-way ANOVA and Tukey's Post-Hoc method. On depth of penetration evaluation, one-way ANOVA analysis showed Group II exhibited maximum depth of penetration in contrast to Group III and Group I. Group I showed the least average depth of penetration among the other two groups at both 3 and 5mm. On sealer/dentin interface evaluation at 3mm, Group II showed increased interface in comparison with to Group III and Group I. No statistical significance evident among the groups at 5mm. EndoREZ showed maximum depth of penetration in comparison with iRoot SP and AH Plus sealer at both 3 and 5mm. EndoREZ also showed significant sealer/dentin interface at the level of 3mm when compared to other sealers used.

Comparative Evaluation of Postoperative Pain and Periapical Healing After Root Canal Treatment Using Three Different Base Endodontic Sealers – A Randomized Control Clinical Trial

Backgroundː Endodontic Sealers come in direct contact with periapical tissue through the apical foramen and lateral canals, influencing the postoperative pain and periapical healing. The aim of the present study was to evaluate and compare postoperative pain and periapical healing after root canal treatment using different base endodontic sealers.Methodsː Primary root canal treatment was initiated in 63 patients diagnosed with necrotic pulp and apical periodontitis, followed by which the endodontic sealers used for obturation were selected based on the random allocation of the participants to the following groups; Tubli-Seal, AH Plus and BioRoot RCS. Postoperative pain was recorded by using 100 mm visual analog scale at 24 h, 48 h, 72 h and 7 d after obturation. Digital periapical radiographic evaluation was done to assess rate of periapical healing at baseline, 1, 3 and 6 months. Statistical analysis was done using Kruskal Wallis test and one-way ANOVA and p-value of less than 0.05 was considered as significance level.Resultsː Significant reduction was seen in the size of periapical lesions in all the study groups at 3 and 6 months (p ˂ 0.05). The mean difference in the size of periapical lesions for BioRoot RCS was 4.05, 10.22, for AH Plus was 2 3.86, 9.80 and Tubli-Seal were 6.27, 13.41 at 3 months and 6 months respectively. The mean pain scores at 24 h for Tubli-Seal, AH Plus, BioRoot RCS were 17.94 ± 11.35, 11.57 ± 11.18 and 4.73 ± 7.72. At 48 h were 5.26 ± 9.04, 1.57 ± 3.74 and 1.57 ± 3.74 respectively. The mean pain score at 72 h for Tubli-Seal was 2.63 ± 7.33 whereas none of the patients had reported pain in AH Plus and BioRoot RCS group. None of the patients had pain 7 d after treatment.Conclusionsː BioRoot RCS showed less postoperative pain compared to AH Plus and Tubli-Seal. BioRoot RCS showed better periapical healing compared to AH Plus and Tubliseal at 3- and 6-months interval respectively.Trial Registration: Registration of this trial was done prospectively in Clinical trials registry – India (CTRI) with registration number (CTRI/2018/10/015919) dated 08/10/2018.