Root canal sealers

Endodontic filling
materials

Root filling materials
1. Stop coronal leakage
2. Entomb surviving microbes
3. Block influx of water and nutrients
1 2
3
from Sundqvist & Figdor, in ’Essential Endodontology’, 1998

Core Materials
• Gutta-percha
• Metal points
• Plastics
• Combinations

Thermoplasticized gutta-percha:
’hot-warm-soft’
injectable
carriers

’alpha-phase’ versus ’beta-phase’
Alpha-guttapercha is supposedly more fluid
and soften at a lower temperature. Some
sophisticated declarations describe a core
of beta- under a surface of alpha-guttapercha.
Beta phase is made when heated
alpha phase is rapidly cooled to room
temperature. There is little if any
documentation that this distinction is of
importance.

All gutta-percha filling
techniques, including
compaction and other
methods of softening
gutta-percha, always end
up requiring a sealer.

A sealer is what should meet the
hard and soft tissues; the gutta-
percha is merely a piston

Gutta-percha
- adaptability
ZEUG
- dimensionally stable
Silicon
- biocompatible
Chloroform
- adaptability
Chloropercha
- biocompatible
N2 & Endométhasone
- antibacterial
Glassionomer
- why not?
Colophony
- adhesion
Ca(OH) 2
- bio-active
Epoxy
- hardness and adhesion

Endodontic Sealers
• ZnO-eugenol-based
• ZnO-’non-eugenol’-based
• Polymeric cements
• Glass ionomers
• Silicones
• Solvent-based
• Ca(OH) 2 pastes

ZnO-Eugenol-Based
Endodontic Sealers
• Rickert’s sealer ⇒ Kerr PCS
• Grossman’s sealer ⇒ Roth’s,
ProcoSol
• Wach’s paste
• Robin’s paste ⇒ N2, RC2B

ZnO-eugenol-sealers
•Pro’s
– Used for a century
– Clinical documentation
–Goodseal
• Con’s
– Local toxicity
– Allergen
– Poor stability?

ZnO-’Non-Eugenol’-Based
Endodontic Sealers
• Several proprietary brands
• Poor if any documentation

Glass Ionomer-Based
Endodontic Sealers
•Endion
•Ketac-Endo

Glass-ionomer-sealers
• Pro’s
– Biocompatible
– Clinical documentation?
• Con’s
– Leakage
–Shrinkage

Glass ionomer sealer
Of 378 followed-up teeth, there
was 78.3% success, 15.6%
incomplete healing, and 6.1%
failure.
Friedman et al., 1995

Polymer-Based
Endodontic Cements
•AH series
•Diaket
• Poly(methyl-methacrylate)
• Resorcinol-formaldehyde
• Composite resins

Epoxy-resin-sealers
•Pro’s
– More than 40 years
–Clinical
documentation
–Stable
•Con’s
– Toxic when fresh
– Allergen
– Leakage?

RealSeal
Why do we call it RealSeal? Because it is the endodontic filling material that
provides a REAL seal. And Resilon, the primary component of RealSeal, has
also been proven to be biocompatible, nontoxic and nonmutagenic.1 RealSeal
is:
•Leak-Resistant. Unlike gutta percha, RealSeal leaves no gap for leakage.
Coronal and apical leakage are substantially reduced.
•Strengthening. Gives the root significant toughness.
•Technique-Compatible. Works with your current filling method.
•Retreatable. With chloroform and/or heat. Like Grossman’s formula,
retreatments are easy.
•Radiopaque. Just like your current method of obturation, detection is not a
problem.
Company website

”EndoREZ is a UDMA resin-based, root
canal sealer with hydrophilic properties that
improve sealing ability even in canals that are
moist with water.This resin-based formula
prevents EndoREZ from compromising
bonding agents. In addition to its
biocompatible, methacrylate formula,
EndoREZ also offers the advantage of
radiopacity. EndoREZ is as radiopaque as
gutta percha, thus simplifying radiographic
interpretation.”
Ultradent, company website

EndoREZ Points
”Resin Coated Gutta Percha Points
EndoREZ Points are standard ISO-sized gutta percha
points overlayed with a thin resin coating. The resin
coating allows EndoREZ Points to bond chemincally
with EndoREZ and other resin-based sealers.
Historically, gutta percha has only maintained a
weaker, chemical bond with canal sealers. EndoREZ
Points are the first-ever gutta percha points to create a
stronger, chemical bond by bonding gutta percha to
EndoREZ.”
Ultradent, company website

Endodontic Sealers
with Ca(OH) 2
•Sealapex
•Apexit
•CRCS

Ca(OH)2-based sealers
•Pro’s
–20 years
– Clinical documentation
–Goodseal
– Biocompatible
• Con’s
– Unstable?
– Poor x-ray contrast
– Low mechanical
strength

Changes in pH at the dentin surface
in roots obturated with
calcium hydroxide pastes.
12
pH at midroot
surface
11
10
9
8
7
Control
Sealapex
Apexit
Sealer 26
Ca(OH)2
6
0 3 7 14 21 28 45
TIME, days
Esberard RM, Carnes DL Jr, del Rio CE J Endod 1996 Aug;22(8):399-405

Silicone-Based
Endodontic Sealers
•Lee Endofil
•RoekoSeal
• Gutta-Flow

Silicon-based sealers

Silicon-based sealers
•Pro’s
–Verygood
documentation
– Clinically tested
– Biocompatible
• Con’s
– No effect on microbes?
– Poor mechanical strength
– Short history

Picture: M.J.
Roggendorf
Picture: M. J. Roggendorf

Solvent-Based
Endodontic Sealers
• Rosin-chloroform (Johnston-Callahan
technique)
• Chloropercha techniques
• Kloroperka

Solvent-baserte sealers
• Pro’s
– Biocompatible
– Clinical documentation?
• Con’s
– Leakage
–Shrinkage
No brand shown:
Not to be promoted?

Technological tests

a
b
c
d
e
f

DIMENSIONAL CHANGE, %
6
4
2
0
0 4 8 12 16 20 24 28 32 36 40 44 48
TIME, weeks
AH 26
AH 26 SF
AH Plus
Fig 3a

DIMENSIONAL CHANGE, %
8
6
4
2
0
-2
0 4 8 12 16 20 24 28 32 36 40 44 48
TIME, weeks
Grossman's
Proco-Sol
PCS
Tubli-Seal
Fig 3b

DIMENSIONAL CHANGE, %
1
0
-1
0 4 8 12 16 20 24 28 32 36 40 44 48
TIME, weeks
Roeko-Seal
RS 4823wet
RS 4823dry
Fig 3c

DIMENSIONAL CHANGE, %
1
0,5
0
-0,5
-1
-1,5
0 4 8 12 16 20 24 28 32 36 40 44 48
TIME, weeks
Apexit
Apexit H2O
Ketac-Endo
Fig 3d

0
Hoop stress -
(tension)
Radial stress -
(pressure)
1 mm
3 mm

100
Tangential stress [MPa]
10
1
0,1
0,01
0,001
Composite
Elastomer
0 0,2 0,4 0,6 0,8 1
Linear expansion of material [%]

Physical properties of endodontic
sealers: radio-opacity, working time,
flow and compressive strength
measurements
Ayce Unverdi Eldeniz
Guest Researcher, Scandinavian Institute of Dental
Materials, Haslum, Norway
Dag Ørstavik
Oslo University, Faculty of Dentistry, Head of the
Department of Endodontics, Oslo, and the Scandinavian
Institute of Dental Materials, Haslum, Norway

Root canal sealers tested:
AH Plus
Component A
Epoxy resin
Calcium tungstate
Zirconium oxide
Aerosil
Iron oxide
Component B
Adamantane amine
N,N-Dibenzyl-5-oxanonane
TCD-Diamine
Calcium tungstate
Zirconium oxide
Aerosil
Silicone oil

Root canal sealers tested:
GuttaFlow
Gutta-percha powder
Polydimethylsiloxane
Silicone oil
Paraffin oil
Hexachloroplatinic acid
Zirconium oxide
Nano-silver
(preservative)

Root canal sealers tested:
AcroSeal
Calcium hydroxide
DGEBA
Radiopaque excipient
Glycyrrhetic acid
(enoxolone)
Methenamine
Radiopaque excipient

Root canal sealers tested:
EndoRez
30% Urethane dimethacrylate

Root canal sealers tested:
Epiphany
Dual-cure, urethane-based
dental composite cement

12,0
10,0
8,0
6,0
4,0
2,0
0,0
Root canal sealers’
radiopacity
Radiopacity (n=3)
Endo-REZ
Epiphany
RC Sealer
Roeko Seal
Gutta Flow
Apexit
Acroseal
AH Plus

Root canal sealers’ film
thickness
Film Thickness (n=15)
50
45
40
35
30
25
20
15
10
5
0
AH Plus
Endo-REZ
Epiphany
RC Sealer
Roeko Seal
Gutta Flow
Apexit
Acroseal

Root canal sealers’ flow
Flow (n=15)
50
45
40
35
30
25
20
15
10
5
0
AH Plus
Endo-REZ
Epiphany
RC Sealer
Roeko Seal
Gutta Flow
Apexit
Acroseal

Root canal sealers’
compressive strength
Compressive strength (Mpa) by time (h)
400
350
300
250
200
150
100
50
0
0 50 100 150 200
?
AH Plus
Endo-REZ
Epiphany
Apexit
Acroseal

Smear layer removal
• Opens tubules for
medicament
activity
• Removes (infected)
smear and
substrate for
microbial growth
• Allows permeation
of filling material
• Shows little effect
on adhesion of
filling
• Penetration by
bacteria may be
enhanced:
– Between sessions
– After filling

Gr.
1,20
1,00
0,80
0,60
0,40
0,20
0,00
Native
Phosph. Acid
Citric acid
EDTA
Gr.
APX
KE
AH Plus
RS+P
RS
APX
KE
RS
RS+P
AH Plus
Saleh et al., 2001:
Adhesion of
root canal sealers
to pretreated dentin

Antimicrobial
activity
• Toxic chemicals
– disinfectants
– antiseptics
• Antibiotics

Iodine-containing gutta-percha
(Lone Star)

Current antimicrobial
additions
•Formaldehyde
•Eugenol
•Thymoliodide
•Amines
• Calcium hydroxide

Clinical biocompatibility
• Local
•Regional
• Systemic
Severity
Frequency

PN Liston, RF Walters
Foreign bodies in the maxillary antrum: A case report
Australian Dental Journal 2002;47(4):344-346

14d
AH-materials give a strong
reaction after 14d, but show little
effect on tissues after 3 months
3 months
14d

Sealapex: Induction of hard
tissue formation
7
6
5
4
3
2
1
Closure
Partial closure
No closure
Inflammation
0
Sealapex
Kerr PCS
Holland & de Sousa 1985

Periapical reactions to
sealers in monkeys
8
7
6
5
4
3
2
1
0
Sealapex CRCS AH26
None
Mild to moderate
Severe
27 teeth in 3 monkeys, 8-14 months
Tagger & Tagger 1985

Allergy
• (Almost) All endo materials contain
allergens
• The exposure to sensitive tissues is
extremely small
• Exposure to skin, mucosal surfaces of
patients and the skin of staff may
deserve more attention

Mutagenicity - Carcinogenicity
• Mutagenicity– the ability to cause
changes in the genes of an individual
• Carcinogenicity– the ability to cause
cancer in an individual
• 70-90% of mutagens are carcinogens
and vice versa

In vitro model for coronal leakage
Upper chamber
with bacteria
Sterilised, root
filled root
Barthel et al, 1999
Wax seal
Lower chamber, sterile
medium
Bacteria penetrating the root filling multiply in the clear
medium of the lower chamber, making it turbid.

% Microbial leakage over 30 days
100
90
80
70
60
50
40
30
20
10
0
S. mutans
E. faecalis
S. mutans and
E. faecalis
% of microbial leakage
V GP - Epiphany sealer
L GP - Epiphany sealer
V GP - AH26 sealer
L GP - AH26 sealer
V Resilon - Epiphany sealer
L Resilon - Epiphany sealer
V Resilon - Epiphany sealer
L Resilon - Epiphany sealer
Negative Control
Positive Control - GP
Positive Control - Resilon
Groups
Epiphany –
’an appearance or manifestation especially of a divine being’

Bacterial leakage
100
80
60
40
20
0
Leaking teeth, %
•AH Plus
•EndoRez
•RC Sealer
•Roeko-Seal
•Ketac-Endo
•Acroseal
•Apexit
•Gutta-Flow
•Epiphany

Bacterial leakage
• AH Plus 15/15
• EndoRez 15/15
• RC Sealer 15/15
• Epiphany 4/15
• Acroseal 9/15
• Apexit 5/15
• Roeko-Seal 5/15
• Gutta-Flow 5/15
• Ketac-Endo 14/15

Saleh et al. 2003
5
Mean Log CFU
4
3
2
1
0
-1
CT KE RSP AP RS CH GS AH
CT KE RSP AP RS CH GS AH
Sealer
(CT: control; KE: Ketac-Endo; RSP: RoekoSeal Automix + Primer; AP:
Apexit; RS: RoekoSeal Automix; CH: Calcium Hydroxide; GS:
Grossman’s sealer; AH: AH Plus)

Clinical/Radiographic Follow-
•Pain
Ups
• Success-failure
analyses
• Disease – no disease
•Sizeoflesion
• Periapical index
• Computer technology

Time-course of postoperative pain following
root filling with either Roeko Seal or
Grossman’s sealer. Average values
6
Relative pain intensity, %
4
2
Roeko Seal
Grossman
0
D1S D1Be D2Br D2L D2S D2Be D3Br D3L D3S D3Be
Coefficient of variation: 118-400%

EndoREZ
Am J Dent. 2004 Feb;17(1):19-22.
Clinical and radiographic evaluation of a resin-based
root canal sealer.
Zmener O, Pameijer CH

Clinical Study – EndoRez
100
90
80
70
60
50
40
30
20
10
0
91,3 89,1
92,2
All teeth CAP NAP
'Success'
’Feasibility study’

Cumulative PAI Scores
AH KP PS
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
TIME: 0 to 4 years

Clinical Evaluation
•Prevention
– failure: AP developing where none
existed
– AH26 vs ProcoSol (Grossman’s sealer) vs
Kloroperka: Significantly poorer results
for Kloroperka in one clinical study

Healing of apical periodontitis following
root filling with 3 different sealers
PERIAPICAL STATUS, ridit
0,5
0,4
0,3
0,2
0 1 2 3
Total
ProcoSol
Sealapex
CRCS
TIME, years
Range of s.e. of means: 0.02-0.07

Preoperative Healthy Periodontium:
Effect of Sealer
PERIAPICAL STATUS,
ridit
0,3
0,2
0,1
0
0 1 2 3
TIME, years
Total
ProcoSol
Sealapex
CRCS
Range of s.e. of means: 0.03-0.17

X-ray
healing
AP
N
AP
N
Digital
change
AP/N < 1 AP/N ≅ 1

Numbers are average gray values in the
defined areas: 255=white; 0=black
130
130
80
115
Digital
change
AP/N =0,62 AP/N 0,88

AP/N
1,2
Sound
Diseased
1
0,8
0,6
0 4 8 12 16 20 24
TIME, months

From Trope et al., 1998

Healing by AP/N Ratio
PA Status, P/N ratio
80
60
40
0 5 10 15 20 25
TIME, weeks
PS
SA

Healing by PAI Score
PA Status, PAI ridit
1
0,8
0,6
0,4
0 5 10 15 20 25
TIME, weeks
PS
SA

Comparative clinical testing
• ProcoSol, Grossman’s sealer:
REFERENCE
– AH26: as good or better
– Sealapex: as good or better
– CRCS: no worse
– RoekoSeal no worse
– Kloroperka poorer
– Epiphany as good or better

Healed cases, per cent
100
Prospective study of factors related to
healing of AP
90
80
70
60
Preop
AP
No
preop
AP
Warm
vertical
Cold
lateral
Cliinical variables
Single
root
2+ roots
Farzaneh et
al.
JOE April
2003, OR 45
The Toronto
study:
outcome of
initial
endodontic
treatment -
phase II

New methods for filling root canals
must be viewed with regard to
their ability to aid in achieving the
prevention of new or persistent
apical periodontitis; the acid test
being roots with preoperative
apical periodontitis

’Predictable disinfection’: how
much can we improve?
• instrumentation 90/10* 95/20
• irrigation 99/50 99,9/95
• ‘medication’ 99,9/95 99.99/98
• Root filling 100/100?

Predictable disinfection
1. Complete physical and
chemical disinfection in one
session?
(’Dauerantisepticum’, CHX?)
2. Prevention of regrowth
(antibacterial sealer?)
3. Block influx of nutrients
(improved seal?)
AP
P
PDL

’Predictable disinfection’: can
we improve?
Standard methods
Improvement?
Microbes Canals Microbes Canals
• instrumentation 90 10 95 50
• irrigation 99 50 99,9 95
• dressing 99,9 95 99.99 98
• Root filling 100 100?
Thank you for your attention!