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Ideal Root Canal Sealer Properties 2. Biocompatibility Biocompatibility is an essential requirement of any root canal sealer as the root filling material constitutes a true implant coming into direct contact with the vital tissue at the apical and lateral foramina of the root or indirectly via surface restoration [ 2 ].
Biocompatibility is defined as the ability of a material to achieve a proper and advantageous host response in specific applications [ 25 ]. In other words, a material is said to be biocompatible when the material coming into contact with the tissue fails to trigger an adverse reaction, such as toxicity, irritation, inflammation, allergy, or carcinogenicity [ 26 ]. Most studies assess biocompatibility through investigations of cytotoxicity, in reference to the effect of the material on cell survival [ 27 ].
The cytotoxicity of bioceramic-based sealers has been evaluated in vitro using mouse and human osteoblast cells [ 28 , 29 ] and human periodontal ligaments cells [ 30 ]. Most bioceramic-based root canal sealers have subsequently been found to be biocompatible. This biocompatibility is attributed to the presence of calcium phosphate in the sealer itself. Calcium phosphate also happens to be the main inorganic component of the hard tissues teeth and bone.
Consequently, the literature notes that many bioceramic sealers have the potential to promote bone regeneration when unintentionally extruded through the apical foramen during root canal filling or repairs of root perforations [ 30 , 31 ]. Sankin apatite has been shown by Telli et al. However, Kim et al.
Yoshikawa et al. However, the experimental sealer produced no inflammatory response in the subcutaneous tissue and only a mild reaction in the periapical tissue [ 34 ]. The cytotoxicity of the Sankin apatite root canal sealer is the result of the presence of iodoform and polyacrylic acids in the sealer [ 33 ]. Although in vitro evaluations of biocompatibility can be an indicator of the cytotoxicity of a material, in vitro immunological deficiencies should be taken into consideration.
Some sealers have been shown to have severe cytotoxicity in vitro, such as zinc oxide eugenol-based sealers; however, such toxicity is not necessarily clinically significant [ 38 ]. Capseal I and Capseal II sealers have been shown to produce less tissue irritation and less inflammation compared to other sealers [ 30 , 31 , 33 ]. Shon et al. Investigators exposed human periodontal fibroblast cells to the various sealers before measuring the inflammatory response by way of inflammatory mediators and the viability and osteogenic potential of osteoblast MG63 cells.
They found Capseal I and Capseal II to possess low cytotoxicity and to facilitate periapical dentoalveolar healing by regulating cellular mediators from periodontal ligaments cells and osteoblast differentiation. MTA-Fillapex was found to have a severe cytotoxic effect on fibroblast cells when freshly mixed. Furthermore, this effect did not decrease with time. The level of cytotoxicity remained moderate even five weeks after mixing [ 40 ].
Setting Time The ideal root canal sealer setting time should permit adequate working time. However, a slow setting time can result in tissue irritation, with most root canal sealers producing some degree of toxicity until being completely set. According to the manufacturers of EndoSequence BC Sealer or iRoot SP, the setting reaction is catalysed by the presence of moisture in the dentinal tubules. While the normal setting time is four hours, in patients with particularly dry canals, the setting time might be considerably longer [ 41 ].
The amount of moisture present in the dentinal tubules of the canal walls can be affected by absorption with paper points [ 42 ], the presence of smear plugs, or tubular sclerosis [ 43 ]. Loushine et al. Zhou et al. In phase I, monobasic calcium phosphate reacts with calcium hydroxide in the presence of water to produce water and hydroxyapatite. In phase II, the water derived from the dentin humidity, as well as that produced by the phase I reaction, contributes to the hydration of calcium silicate particles to trigger a calcium silicate hydrate phase [ 28 ].
The manufacturer of MTA-Fillapex claims that their product will set in a minimum of two hours and this setting time has been confirmed in at least two studies [ 44 , 51 ]. However, even shorter setting times for MTA-Fillapex 66 min have been reported [ 52 ]. The setting reaction of MTA material is complicated and has been discussed by Darvell and Wu [ 53 ]; however, the setting reaction of MTA-based sealers has not been described in the literature.
Flow Flow is an essential property that allows the sealer to fill difficult-to-access areas, such as the narrow irregularities of the dentin, isthmus, accessory canals, and voids between the master and accessory cones [ 54 ]. Factors that influence the flow rate of the sealer include particle size, temperature, shear rate, and time from mixing [ 4 ]. The internal diameter of the tubes and rate of insertion are considered when assessing flow rate via the Rheometer method [ 2 ].
Similarly, the flow rate of MTA-Fillapex has been variously reported as 22 mm, While most of the bioceramic-based root sealer manufacturers included in Table 1 claim that the flow rate of their sealers meets ISO requirements, the literature does not support such claims. Retreatability Root filling materials provide a mechanical barrier for the isolation of necrotic tissue or bacteria responsible for the persistence of periapical inflammation or postoperative pain [ 56 , 57 ].
Wilcox et al. Therefore, the complete removal of the sealer is essential during endodontic retreatment to establish healthy periapical tissues. EndoSequence BC Sealer is difficult to remove from the root canal using conventional retreatment techniques, including heat, chloroform, rotary instruments, and hand files. A number of cases have been reported in which obstruction of the apical foramen has resulted in a loss of patency [ 59 ]. By contrast, Ersev et al. Sankin apatite root canal sealer is easily removed during retreatment with and without the use of solvents [ 61 ].
Retreatability with MTA-Fillapex is comparable to that of AH Plus in terms of material remaining in the canal, dentin removal, and time taken to reach working length [ 62 ].
Solubility Solubility is the mass loss of a material during a period of immersion in water. A highly soluble root canal sealer would invariably permit the formation of gaps within and between the material and the root dentin, thereby providing avenues for leakage from the oral cavity and periapical tissues [ 2 ]. This high solubility is the result of hydrophilic nanosized particles being present in both sealers which increases their surface area and allows more liquid molecules to come into contact with the sealer.
However, the literature contains conflicting accounts, with Viapiana et al. This discrepancy between the findings of these studies might be attributed to variations in the methods used to dry the samples after having subjected them to solubility testing. Discolouration of Tooth Structure For reasons of aesthetic appearance, a root canal sealer should not stain the tooth. The chromogenic effects of root sealers are increased when excess sealer is not removed from the coronal dentin of the pulp chamber [ 66 ].
Partovi et al. The greatest degree of discolouration was observed following treatment of the cervical third of the crown [ 67 ]. MTA-Fillapex was found to cause the least crown discolouration to the extent of not being clinically perceptible [ 66 ].
Radiopacity Root canal sealers should be sufficiently radiopaque so as to be distinguishable from adjacent anatomical structures [ 68 ]. This allows the quality of the root filling to be evaluated through radiographic examination. Candeiro et al. Endo CPM sealer was found to have a radiopacity of 6 mm due to the presence of bismuth trioxide and barium sulphate [ 69 ]. Similarly, the presence of bismuth trioxide in MTA-Fillapex gives it a radiopacity of 7 mm [ 52 , 70 ]. Antimicrobial Properties The antimicrobial activity of a root canal sealer increases the success rate of endodontic treatments by eliminating residual intraradicular infections that might have survived root canal treatment or have invaded the canal later through microleakage [ 71 , 72 ].
According to the literature, the key antimicrobial properties of root canal sealers lie in their alkalinity and release of calcium ions [ 4 ] which stimulates repair via the deposition of mineralised tissue [ 73 ]. Two methods are commonly used to evaluate the antibacterial activity of bioceramic-based root canal sealers: the agar diffusion test [ 74 , 75 ] and direct contact testing [ 23 , 75 ]. Zhang et al. The investigators suggested two additional mechanisms associated with the antibacterial efficacy of iRoot SP: hydrophilicity and active calcium hydroxide diffusion [ 23 ].
Hydrophilicity reduces the contact angle of the sealer and facilitates penetration of the sealer into the fine areas of the root canal system to enhance the antibacterial effectiveness of iRoot SP in vivo [ 23 ]. Morgental et al. The investigators attributed the antibacterial activity of MTA-Fillapex to the presence of resin as a core ingredient. Nevertheless, neither sealer was able to sustain its antibacterial activity after setting despite their initial high pH levels [ 75 ]. Enterococcus faecalis is the most common intraradicular microbe isolated from periapical periodontitis [ 76 , 77 ] and is therefore commonly used to test the antibacterial activity of root canal sealers.
Other microorganisms, such as Micrococcus luteus, Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, Candida albicans, and Streptococcus mutans, have also been used to test the antibacterial effects of bioceramic-based sealers [ 74 , 78 ].
Freshly mixed Endo CPM exhibits antibacterial activity against Staphylococcus aureus and Streptococcus mutans with no significant reduction of the inhibition zone after setting. Nevertheless, the antibacterial effect is less than that of AH [ 78 ]. MTA-Angelus has an antibacterial effect against Micrococcus luteus, Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, and Candida albicans [ 74 ].
Adhesion Root canal sealer adhesion is defined as its capacity to adhere to the root canal dentin and promote GP cone adhesion to each other and the dentin [ 79 ].
Tagger et al. There is no standard method used to measure the adhesion of a sealer to the root dentin; therefore, the adhesion potential of the root filling material is commonly tested using microleakage and bond strength tests [ 81 ]. The sealing ability of a sealer is related to its solubility and to its bonding to the dentin and root canal filling cones [ 4 ]. Several studies have evaluated the sealing abilities of different bioceramic-based sealers in vitro.
These studies are summarised in Table 2. Regardless of the different methodologies used, the sealing ability of bioceramic-based sealers has been found to be satisfactory and comparable to other commercially available sealers.
However, until recently, there had been a paucity of literature concerning the long-term sealing ability or clinical outcomes associated with bioceramic-based sealers. Table 2 Sealing ability of bioceramic-based root canal sealers. Tested sealers.
Endo Sequence BC Sealer & BC Points
For years endodontic sealers have been considered the weak link in obturation because they shrink and do not bond to dentin. For this reason various compaction techniques have been developed to help minimize the sealer interface. This extension for prevention approach to filling can be likened to what we experienced years ago with amalgam, which required retentive form preparations. With the introduction of a new class of premixed nanoparticle bioceramics that bond to dentin and exhibit zero shrinking, obturation should no longer dictate shaping. EndoSequence BC Sealer is a revolutionary premixed root canal sealer that utilizes new bioceramic nanotechnology. The canal should be dried just as you normally would, but unlike other sealers, the set will not be inhibited by moisture. Unlike traditional points, EndoSequence BC Points are subjected to a patented process of impregnating and coating each cone with bioceramic nanoparticles.
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Endo BC Sealer- 2g Syringe + 15 Tips