COMPARISON OF 3 DIFFERENT TYPES OF ROOT CANAL SEALERS …

Asaf Harel

5th course, group 13

COMPARISON OF 3 DIFFERENT TYPES OFROOT CANAL SEALERS TO THE MOSTCOMMONLY USED SEALER AH-PLUS

Master’s Thesis

SupervisorPhD, Eduardas Kelbauskas

Kaunas,2017

1

Table of contents

Summery.................................................................................................................................. 2Objectives: ............................................................................................................................... 2Material and Methods.............................................................................................................. 2

Results ................................................................................................................................. 2Hypothesis ........................................................................................................................... 2

Introduction ............................................................................................................................. 3Material and methods .............................................................................................................. 4

Search strategy:.................................................................................................................... 4Types of publication ............................................................................................................ 4Types of studies ................................................................................................................... 4Information sources ............................................................................................................. 4Population............................................................................................................................ 4Selection criteria .................................................................................................................. 4Exclusion criteria................................................................................................................. 4data collection process:........................................................................................................ 5Main Outcome: .................................................................................................................... 6

Outcomes ................................................................................................................................. 6Table1. Cytotoxicity of root canal sealers. .......................................................................... 6

1. Cytotoxicity test of root canal sealers ................................................................................. 81.1 MTT assay ......................................................................................................................... 81.2 Zymography test ................................................................................................................ 81.3 Cytotoxicity assay ............................................................................................................. 9

Table 2. Micro-leakage evaluation ...................................................................................... 9Micro-leakage test of root canal sealers ............................................................................ 10Table 3. Solubility of root canal sealers ............................................................................ 11Solubility test of root canal sealers.................................................................................... 13Table 4. Dentinal tubules penetration................................................................................ 13Penetration to dentinal tubules .......................................................................................... 14Table 5. PH level of root canal sealers .............................................................................. 15PH test ............................................................................................................................... 16Table 6. Radiopacity test of root canal sealers. ................................................................. 16Radiopacity test ................................................................................................................. 17Table 7. Risk of bias .......................................................................................................... 18Table 7. Materials compositions........................................................................................ 19

Results: .................................................................................................................................. 20Discussion.............................................................................................................................. 20Conclusion............................................................................................................................. 22

Clinical recommendations ................................................................................................. 23References ............................................................................................................................. 23

2

Summery

Objectives:The aim of this study was to systematically review the comprehensive and

comparative overview of literature data of 3 different types of root canal sealers using in endodontic

treatments in our days based on different types of materials such as MTA (mineral trioxide aggregate),

zinc oxide eugenol sealers, calcium hydroxide based sealers compare to most common used sealer

AH-Plus (Dentsply), as well to determine the dentinal tubules penetration, micro leakage,

cytotoxicity, PH and sealing efficiency.

Material and Methods

Total 52 literature sources were reviewed. Literature was selected through a search of MEDLINE

PubMed electronic databases and Google scholar. The most 23 relevant articles were selected. The

search was restricted to articles which were published from 01.01.2011 to 31.12.2016. exception of

one article from 2017 has been used.

Key words: root canal sealer, AH-Plus, cytotoxicity, micro-leakage, solubility

ResultsIn this systematic review 23 articles were examined and divided into 6 groups by main

characteristics and results confirmed the ability of AH-Plus® (dentsply) resin-based sealer which is

the most common used sealer today to be with the requirements for root canal sealers. After

examination and summarizing the tests it was found that Ah-Plus have low cytotoxicity as shown in

table 1. Concerning dentinal wall/tubules penetration AH-Plus have significant higher dentinal wall

penetration compare to other tested sealers as shown in table 4. Concerning micro-leakage, AH-Plus

have higher micro-leakage properties and less sealing ability as shown in ( table 2 ) this result can

influence on the quality of the treatment with this root canal sealer. Concerning the PH levels, the

most natural PH level from all tested sealers was AH-Plus as shown in table 5. Ah-Plus have low

solubility compare to other tested sealers except one article which had different results concerning to

solubility of AH-Plus as shown in table 3. Regarding radiopacity of the sealers, AH-Plus showed

significant higher results compared to other tested sealers as shown in table 6.

HypothesisAH-Plus considered as the most common used sealers in our days, has AH-Plus have all properties

which required from root canal sealers to be compared to other types of sealers.

3

IntroductionEndodontic treatment is done when there is some pulp disease such as pulpitis or when there

is periodontal related to pulp disease such as apical periodontitis. Good endodontic treatment can be

evaluated by shaping of the canal, cleaning of the canal, and obturation of the canal. The main purpose

of endodontic treatment is an elimination of bacterial spreading and their products to the apical tissues

and recontamination by bacteria. Elimination and killing of microorganisms are done by irrigation

materials (1) such as Ethylenediaminetetraacetic acid (E.D.T.A) and sodium hypochlorite, to get the

best results and to prevent any complications choosing the correct irrigation materials, and to work

by protocol is necessary. Cleaning and shaping are done by using different techniques and by different

types of instrument such as nickel titanium (NiTi) instruments, stainless-steel instruments, during the

last decade's many types of NiTi instruments techniques are presented to the market. The prevention

of recontamination and spreading of bacteria and their products into periapical tissues (2) is done by

root canal obturation with different types of gutta-percha and in addition root canal sealers. The

function of root canal sealers is to block the pathway of bacteria and to prevent micro-leakage, Root

canal sealers should prevent recontamination by sealing the lateral and the main canal and to prevent

colonization of bacteria, in addition penetration to dentinal tubules is very important feature, root

canal sealers should fill the space which created between the gutta-percha and the root canal wall.

Today there are seven types of root canal sealers which are using in practice and can be classified

according to their chemical composition such as mineral trioxide aggregate (M.T.A) based sealer,

zinc oxide eugenol based sealer, epoxy based sealers silicone-based sealer, bioceramic based sealer,

calcium hydroxide based sealer and glass ionomer based sealer. The most common used root canal

sealer today is AH-Plus® (Dentsply, DeTrey, Konstanz, Germany) which based on epoxy resin, in

this systematic review I will compare different groups of root canal sealers to AH-Plus® sealer. Today

most of the complications which occur after endodontic treatment is because of inadequate sealing of

the root canal. Biocompatibility is important factor and should be taken in consideration since

sometimes passing of sealers to periodontal tissues can happen because of anatomy of the root canal

or apex foramen or by iatrogenic factors which can lead to endodontic treatment failure (3). dentinal

tubules penetration, solubility and PH-level properties of root canal sealers are very important

features which must be taken in consideration when choosing the correct root canal sealer to work

with during our practice. In this systematic review the main characteristics and properties of root

canal sealers will be mention, in addition there are some international requirements for root canal

sealers for solubility and for setting time as well. by data collection from articles and results the ability

of the most common used root canal sealer (AH-Plus) will be tested and comparison between different

types of root canal sealers based on different types of material will be done.

4

Material and methods

Search strategy:This systematic review was conducted following the PRISMA (preferred reporting items for

systematic reviews and meta-analysis) statement (4). Total 52 literature sources were reviewed.

Literature was selected through a search of PubMed electronic databases. The most 23 relevant

articles were selected. The search was restricted to articles which were published from 01.01.2011 to

31.12.2016. In addition, one search has done in 2017 and article has been used in this systematic

review.

Types of publicationThe review included systematic reviews, clinical studies in the English language published between

2011 to 2016. Additional search has done of one articles which were published on 2017.

Types of studiesThe review included all types of relevant studies which published from the last five years as well as

case reports which were using the relevant materials.

Information sourcesThe information sources were the MEDLINE - Pub-Med database.

PopulationStudies include: in vivo and in vitro that included the relevant information on sealers.

Selection criteriaClinical studies in vivo and in vitro reviewed the effectiveness of different types of sealers on

cytotoxicity, micro-leakage, adherence to dentin, radiopacity and solubility. The number of samples

which were tested during all procedure was not relevant. The articles were selected by:

- English language.

- AH-Plus compare to different types of sealers.

- Cytotoxicity of AH-Plus compares to different types of sealers.

- Solubility and PH of AH-Plus compare to different types of sealers.

- dentinal tubules penetration of AH-Plus compare to different types of sealers.

- radiopacity of AH-Plus compare to different types of sealers.

- articles from the last five years.

-at least one tested group for comparison.

Exclusion criteria- more than five years since publication of articles (exceptions of 1 article have been used)

- articles with less relevant abstracts and material which were used for comparison.

5

data collection process:the search results provide 1366 articles, by the selection criteria, full text, English language, after

filtering for not more than five years the search provide 491 articles, less relevant abstracts were

removed and 52 articles were chosen, in addition articles with less relevant types of materials were

removed as well. After examination of the articles, the most 23 relevant articles have been used for

this systematic review.

NCBI PubMed advanced search:-search terms: "root canal sealers"; "root canal sealers and cytotoxicity"; root canal sealers dentin penetration; "AH-Plus root canal sealer"; "mtaroot canal sealers"; "root canal sealer cytotoxicity" ; "root canal sealerssolubility" ; "root canal sealers micro-leakage" ; "zinc oxide eugenolsealers" ; "calcium hydroxide sealers";

- Species: in vivo, in vitro;

- Language: English;

(n=491)

Search results 491

Titles and abstracts were selected according relevancy (n=52)

Filtered-Irrelevant materials

using for comparison(n=29);

Articles examined (n=23)

Filtered

- No articles wereexcluded at this stage

(n=0);

Articles included (n=23)

Filtered

Publication dates fromJanuary 2011 toDecember 2016

6

Main Outcome:Main outcome was to improve the ability of AH-Plus which is the most common used sealer to be

the best compared to other types of root canal sealers by all properties which mentioned above as

cytotoxicity, PH level, solubility, dentinal tubules penetration, radiopacity and micro-leakage.

Outcomes

Table1. Cytotoxicity of root canal sealers.

Author/year Level of evidence/studydesign/participants/inclusion

criteria

Interventionand control

groups

Outcomemeasures

results

Kierklo A.et-al.2015

Level IVRCT

24 well cultured dishes withhuman fibroblastsControl group N=6

Intervention group N=18Ex-vivo

Interventiongroups:Human

fibroblasts

Controlgroups:

24 plateswith nomaterial

MTT assayspecial criteriacompared to

control group:No cytotoxicity

>90%Low cytotoxicity

60%-90%Moderate

cytotoxicity30%-59%

Highcytotoxicity

<30%

Sealers based oncalcium

hydroxideshowed

significanthigher toxicitylevels than AH-

Plus

Silva EJNLet-al.2013

Level IIRCT

Balb/c 3T3 cells, AH-Plus andMTA

Control group N=1Intervention group N=2

In vitro

Controlgroup:

only culturemedium

interventiongroups:MTA-

(fillapex)and AH-Plus

(MTT)Tetrazolium

bromide assay1to 4 weeks andmean of resultsby tukey test.Cytotoxicity

results rated assevere 30%,

moderate 30%–60%, slight

60%–90% andnon-cytotoxic

>90%.

MTA showedsignificantly

higher toxicitylevel than AH-Plus which was

natural

Silva EJNLet-al.2015

Level IIRCT

AH-Plus, gutta flow.Control group N=1

Intervention group N=2In vitro

Interventiongroup:

3T3 cellsincubateswith AH-Plus and

gutta flowfor 24h,

MTT and LDHassays weretested the

cytotoxicity, forstatistical meansANOVA wereused, and for

statistical

AH-Plus showedsignificantly less

sell viability.

7

determinedthe MMP9and MMP2fibroblasts

release.Control

group: cellswhich werecultured for

24 hours

differencesbetween groupstukey test were

used.

Ashrafet-al.2012

Level IVRCT

Cytotoxicity evaluation onL929 cell lines

Control group N=2Intervention groups N=2

In vitro

Interventiongroups: fresh

and setgroups

Controlgroups:dulbecomodified

eaglemedium andpulp canal

sealer.Positive and

negative.

MTT assay forcytotoxicityevaluation.

After one-hourAH-Plus wassignificantly

more cytotoxic.After 24 hoursno significantlydifference fromcontrol groups.After 72 hoursno significantly

change

Silva EJNL.et-al.2012

Level IVRCT

Human fibroblast.Control group N=1

Intervention groups N=4In vivo

Interventiongroup:human

fibroblastincubationfor periodsof 30 min,1,4,24 h

Controlgroup:human

fibroblastincubation

for 24 h

Zymography:measured by a

gelatinzymogram

protease assayCytotoxicity:measured by

Kodak analysissystem.

AH-Plus showedsignificantly

higher level ofcytotoxicityamongst thetested sealers

BrackettMG.et-al.2012

Level IVRCT

Mouse osteoblasts and humanmonocytes.


In vivo

Interventiongroup: sixdifferenttypes ofsealers.Controlgroup:

Teflon®

MTT method formitochondrial

succinatedehydrogenase

activity

AH-Plusactivation of

osteoblasts andmonocytes

similar to othertested sealers

8

1. Cytotoxicity test of root canal sealersSealers may pass into periapical tissues due to different reasons such as anatomy of the canal

or tooth, over filling during condensation of filling material together with root canal sealers might

lead to treatment failure after a long time of exposure to endodontic sealers in periapical areas, sealers

may cause to inflammatory reactions such as phagocytosis and might cause to inactivation of alkaline

– phosphate which is necessary for bone formation (3), additionally group of zinc enzymes which are

important group that responsible for degradation collagen and gelatin which involve in bone

remodeling, wound healing and play an important role in chronic inflammatory process in the pulp

and periodontal destruction process (5). In an article which made by Kierklo A. et-al, it was

reccomend that all root canal sealers must be tested before clinical use and to consider in

biocompatibility properties of the root canal sealers(3).

1.1 MTT assayMosman's tetrazolium toxicity (MTT) assay is a common method to evaluate the cells

metabolic activity or viability for root canal sealers by evaluation of mitochondrial activity of cells,

enzymes converting the soluble tetrazolium salt into dark blue crystals (6), on a test which made by

Ashraf H et-al (7). They found by using of fresh and set states of AH-Plus compare to other resin-

based sealers on mouse L-929 fibroblasts that after 1 hour of incubation the fresh AH-Plus was more

cytotoxic than the set, after 24 hours AH-Plus was at the same level of cytotoxicity with other based

resin sealers but less than positive group which were Dulbecco's Modified Eagle Medium (DMEM),

after 72 hours of incubation the AH-Plus was at same level with the positive group (7). on other MTT

assay test which made by Silva EJNL, Rosa TP et-al (5). They compared between AH-Plus and MTA

based sealers, the test has shown that the MTA group were more cytotoxic than the group of AH-Plus

for all period of time, the group of AH-Plus was moderately cytotoxic after one week and after two

weeks was non cytotoxic at all (5). by MTT assay it is clearly that AH-Plus have the ability to have

significant lower cytotoxicity properties than MTA group.

1.2 Zymography testIn zymography test which made by Silva EJNL, Accorsi-Mendonça T et-al (8). They tested

the activity of MMp-2 and MMp-9 human fibroblasts with gelatin zymography , the test has shown

that all sealers based on calcium hydroxide and AH-Plus caused to expression of MMP-2 but not

expression of MMP-9, in addition no gelatinolytic activity has occurred during all tests, after 24 hours

both sealers has shown same level of gelatinolytic activity (8). On zymography test which made by

Silva EJNL, Neves Aa, et-al (6) the test has checked the differences on silicone based sealers and

AH-Plus sealers, the results were different, AH-Plus showed significantly higher results of the

gelatinolytic activity as well as MMP-2 were higher levels than the silicon-based sealers group (6).

9

those result can explain the biocompatibility of AH-Plus, silicon and calcium hydroxide based sealers

and the ability of AH-Plus to use as a factor to the inflammatory process

1.3 Cytotoxicity assayOn testing which made by trypan blue exclusion assay to check the activity of MMP-2 and

MMP-9 human fibroblasts and gelatinolytic activity the test was found that AH-Plus compare to other

sealers with different based materials such as zinc oxide eugenol (zoe), calcium hydroxide

(sealapex™), was in the highest toxicity level compare to others, gelatin formation was at the same

level with all compared sealers while the lowest toxicity level was calcium hydroxide based sealer

(sealapex™) (8), in addition, cytotoxicity testing which was made by Brackett MG, Lewis JB et-al

(9) for MC3T3 mouse osteoblast for assessing the cytotoxicity for root canal sealers, THP1 human

monocytes cells tested as well since those cells are very important part of chronic inflammation

process and taking main part during healing procedure as well (9). After long time exposure of one

year to endodontic sealers based on, zinc oxide eugenol, resilon based sealers were tested by succinate

dehydrogenase (SDH) activity, the test compared those root canal sealers to AH-Plus and exposure

to MC3T3 and THP1were tested, before testing of 52 weeks all materials which were tested caused

to suppression of MC3T3 and SDH activity except gutta-flow, after 52 weeks of aging and incubation

of sealers in 37 degrees for 72 hours in 100% humidity the sealers which were mentioned before was

tested and caused to much less suppression of SDH and monocytes activity, the test improved that

AH-Plus and gutta-flow was the most stable materials after long period of exposure to those sealers

(9) . after using the cytotoxicity assay all researches has followed by MTT assay for final results of

cytotoxicity. Those results can verify the stability of AH-Plus and the ability of calcium hydroxide -

based sealers to have significant less cytotoxic properties compared to other tested sealers including

the AH-Plus.

Table 2. Micro-leakage evaluation

AUTHOR/YEAR

LEVEL OF EVIDENCE/STUDYDESIGN/PARTICIPANTS/INCLUSI

ON CRITERIA

INTERVENTION AND

CONTROLGROUPS

OUTCOMEMEASURES

RESULTS

Wong JGet-al.2013

Level IVRCT


12 groups of bovine single rootincisorsIn vitro

Control groupscontain the

AH-Plus andzinc oxide

eugenol sealer(tubli-seal)

Microscopeexaminationof sectionedteeth, thenmean of

results byANOVA

test

AH-showed

statisticalsignificant

higherlevels ofmicro-

leakage.

10

Micro-leakage test of root canal sealersThe final step in root canal treatment is the Obturation process which can be done by different types

of materials such as gutta-percha cones in combination with sealers in lateral condensation technique,

in addition, other techniques such as warm condensation with warm gutta-percha (resilon based). The

purpose of obturation is to prevent micro-leakage of bacteria and their products from penetrate to

peri-apical tissues as well as to maintain the good sealing of the root canal and provide long period

Silva RVet-al.2015

Level IVRCT

On 40 single root premolars.Intervention groups N=4

In vitro

Interventiongroups:

G1: AH-PlusG2: MTA

based sealer(fillapex)

G3: seal apexG4: ETW

Confocaland stereo-microscopic

imagingtesting thedentinal

penetrationand space

remaining aswell

MTAshowed

significantdifferencebetween

2mm and 6mm andAH-Plusshowed

significantdifference

at 2mmand 6 mmIn dentinalpenetrationand micro-

leakage.

Sultan.M,et-al.2016

Level IVRCT

100 freshly extracted maxillaryincisors.


In vitro

Interventiongroups:

combinationsof gutta-perchaand Epiphany,gutta-perchaand AH Plus,control groupgutta-percha .

Stereo-microscopicevaluation

and dyepenetration

formillimeterevaluation

AH-Plusshowed

significanthigherleakage

thanEpiphany

sealers(calcium

hydroxidebasedsealer)

MaryamEhsani

et-al2012

Level IVRCT

90 extracted maxillary centralincisors.

Control groups N=10Intervention groups N=8

In vitro

Interventiongroups: 4 types

of sealersControlgroups:

5 negative and5 positive

groups unfilledcanals

Stereo-microscopicevaluationwith 2X

magnification

Micro-leakage ofAH-Plusshowed

significantly less

results thanMTA and

ZOE

11

of healthy apical tissues after treatment (10), micro-leakage test of combination and comparison

between three different types of root canal sealers based on zinc oxide eugenol ,MTA and

thermoplastic to AH-Plus found that in 2mm from apex the MTA, the sealer based on zinc oxide

eugenol had better results, while in 4 and 6 mm from root apex AH-Plus had better results than

others,(11) on test which made by Sultana M et-al they found that the major disadvantage and very

important characteristic of root canal sealer AH-Plus was that there is no chemical bonding between

the gutta-percha and the sealer (10), which might has the main cause for micro-leakage and after long

time can be considered as the main factor for treatment failure, in addition, thermoplastic in

combination with resilon has proved that had better sealing for all period of test (10). In other ex-vivo

test which made by Wong JG, Caputo AA, Li P, White SN (12), on comparison between different

types of sealers found that all sealers are leak no sealer had hundred percent of sealing ability, there

was significantly difference between zinc oxide eugenol based sealer and AH-Plus, AH-Plus had the

highest values of micro-leakage, in addition the test found that all sealers had more micro-leakage on

apical part than the coronal part of the root (12). On test which made by Maryam Ehsani et-al (13).

The test checked the zinc oxide eugenol (ZOE) and MTA compared to AH-Plus, the results confirmed

that AH-Plus have less micro-leakage than other tested sealers which had significant higher leakage.

the conclusion is: from the results, AH-Plus have good sealing properties with minimum leakage and

showed that in some tests the ability to be with less leakage compared to other types of sealers (13),

AH-Plus have higher leakage in different places in the root canal than other sealers which tested.

Those results need to investigate further studies to confirm it.

Table 3. Solubility of root canal sealers

Author/year Level of evidence/studydesign/participants/inclusioncriteria

Interventionand controlgroups

Outcomemeasures

results

Schäfer E.et-al.2013

Level IVRCT3 different types of sealerson plates and stainless steelringsControl group N=10Intervention groups N=6In vitro

Controlgroups were10 emptysamplesincubate for28 daysInterventiongroups: 6samples ofeach sealer

Weight lossmeasures by %relate tooriginal weightof sealerAnd analysis byANOVA

From alltested sealersAH-Plusshowedsignificantlyless solubilityresults

Ersahan Set-al.2013

Level IVRCT80 extracted mandibularpremolars

Controlgroups:Extractedtoot N=4

Weight gain orloss measuredfor 6-hours, 24-

AH-PLUS hassignificantlylower micro-leakage than

12

Intervention groups N=4control group N=2In vitro

Interventiongroups4experimentalgroups ofExtractedroots N=18

hours and 14-days

MTA andfrom calciumhydroxidebased sealersand met theANSI/ADA’srequirementsfor solubility.

Faria-JúniorNB,

et-al.2013

Level IVRCT7 different types of sealers.Control group N=3Intervention groups N=7In vitro

Controlgroup: biofilmdid notexposed tosealers

Interventiongroup:5 discs fromeach sealer of2 periods,one for 15hand secondfor 24h

Graph-PadPrism softwarewere used fordata analysis.

AH-PLUSshowedsignificantlyless solubilitythan calciumhydroxidebased sealerand morethan MTA aswell whichshowed thegreatestsolubilityresults forboth periodsof 15h and24h.

Silva EJet-al.2016

Level IIRCT10 mandibular premolarsIntervention groups N=6In vitro

Interventiongroups:2 groups N=5of MTA andHA-Plus

3D micro C.Tscan forvolume loss ofsealers

No significantdifferenceswas betweenAH-Plus toMTA basedsealer.

Urban Ket-al.2016

Level IIRCTMTA, bio-root, AH-PLUSControl group N=2Intervention groups N=1In vitro

Controlgroup:AH-PlusInterventiongroups:MTA , bio-root.

x-ray photoelectronand weight lossmeasurements.

No significantdifferenceswas betweenMTA and AH-Plus.

13

Alzraikat Het-al.2016

Level IVRCTSamples of each sealersN=180Control group N=1Intervention groups N=6In vitro

Interventiongroups:12 groupsfrom Eachsealer

Control groupDistilledwater ascontrolsolution

Measurementson chloroformand electroactiveenvironments,Weight lossmeasurements,

AH-Plusshowedsignificantlyhighersolubilityresults thanall othersealers inchloroformand in staticand ultrasonicenvironments

Solubility test of root canal sealersthe main purpose of root canal Obturation is preventing the passing of bacteria from root canal

to peri-apical tissue, in addition, to provide good sealing for long period of time after treatment (14).

The solubility of the sealers is a very important characteristic which must be considered. On research

which made by Edgar Scha¨fer et-al (14) found that AH-Plus had the lowest solubility that other

sealers which tested for all period of test and had the correct properties according to ADA\ANSI as

well as ISO standards requirements (14). Other research which made by E. J. Silva et-al (15). has

found that the solubility of AH-Plus and the MTA has the same solubility characteristics, but in

special 3D scan dimensional change occur after the test, in addition, AH-Plus didn't passed through

apical foramen while MTA passed through apical foramen (15). On test which made by Kent Urban

et-al (16), the test has checked one type of resin- based sealer compared to AH-Plus and MTA, the

research found that AH-Plus and MTA were more soluble than other sealers which contain resin as

well. On test which made by S. Ersahan and C. Aydin (17), for solubility of AH-Plus compared to

other types of sealers, the AH-Plus has less solubility than one sealer which based on MTA and

calcium hydroxide and didn’t show any significant difference than two other sealers which were

tested (17).on research which made by Hanan Alzikat et-al (18). On their research they found that

AH-Plus solubility was significantly higher compared to other sealers such as MTA and AH-26 which

tested, this test checked the solubility on chloroform in static and ultrasonic activation areas (18). In

addition solubility test which made by N. B. Faria-Junior et-al (19) found that AH-Plus has the lowest

solubility results. From those results which were found in the articles, it can be concluded that results

are unambiguous but most of the articles showed that AH-Plus is less soluble than other types of

sealers which were tested.

Table 4. Dentinal tubules penetration.

AUTHOR/YEAR

LEVEL OF EVIDENCE/STUDYDESIGN/PARTICIPANTS/INCLUSI

ON CRITERIA

INTERVENTION AND

OUTCOMEMEASURES

RESULTS

14

CONTROLGROUPS

Cañadas PS,et-al.2014

Level IVRCT

Fresh extracted bovine teethN=50

Intervention groups N=5In vitro

Interventiongroups: 4

different typesof sealers

SEMmicrographsmeasurements in 3 pointsand scoringaccording toadaptation

between 0-2when 0 is

goodadaptation

and 2 is pooradaptation

AH-Plusand MTAshowed

significantgood

dentinaladaptation

thentestedsealers

Akcay M,et-al.2016

Level IVRCT

Single rooted premolars teethN=156


In vitro

Interventiongroups:

4 groups fromeach sealerTotal N=39

Laserscanning of

dentinalpenetration.

ForStatistical

analysis bytukey andANOVA

Nosignificantdifferences betweenAH-Plus

and MTA.

Penetration to dentinal tubulesdentinal tubules penetration is a very important feature of root canal sealer since it provides

the sealing ability of the sealer as well as the tightening of the sealer to dentinal wall of the root and

provide good sealing for long time (20), there are several factors which may influence on the sealer

ability to penetrate into dentinal tubules such as irrigation material using during treatment. In research

which made by Merve Akcay et-al. (20), found that the type of irrigation and location on root third

are very important factors which influenced on sealers penetrate into dentinal tubules since there are

bigger dentinal tubules in the coronal third than the apical and the irrigation material access to coronal

and apical thirds are different , in addition the research found that AH-Plus and MTA (fillapex®) has

shown no significant difference in dentinal penetration and on the coronal third has better penetration

than the apical third (20). In a test which made by Piedad S. Cañadas et-al found good adaptation to

dentinal tubules of AH-Plus and for MTA as well, both sealers had better adaptation than other sealers

which were tested (21). Based on the results it is clearly that AH-Plus and MTA based sealers have

the ability to penetrate into the dentinal tubule and provide good sealing.

15

Table 5. PH level of root canal sealers

AUTHOR/YEAR

LEVEL OF EVIDENCE/STUDYDESIGN/PARTICIPANTS/INCLUSIO

N CRITERIA

INTERVENTION AND

CONTROLGROUPS

OUTCOMEMEASURE

S

RESULTS

Faria-júniorNB.et-al.2013

Level IVRCT


In vitro

Interventiongroups:

7 types ofsealers

Control group:Control group:

biofilm didnot exposed

to sealers

Discs fromeach

testedsealer

stored andmeasuredafter 5h,10h and15h with

PH meter.For

analysis byANOVA or

by

AH-Plusshowed

significantdifference

in PHbetween 5hours and15 hourswhile theMTA waswith high

PH level forall periods

of time,calcium

hydroxidebased

sealer wassignificant

less PHthen MTA

Zhou H,et-al.2013

Level IVRCT


Interventiongroups:

Fresh and setgroups of

MTA, AH-Plussealers.

Discs fromeach

sealermeasured

by PHmeter

Fresh MTAand AH-Plus

showedalkaline PH

and after 24hours thePH of AH-

Plusdecreased

significantlyto natural

Cañadas PSet-al.2014

Level IVsingle root bovine teeth N=50

RCTIntervention groups N=4

In vitro

10polyethylene

tubesmeasuringfilled with

freshlypreparedsamples

The pHwas

measuredat 1–hourintervals

at 6 hours,23, 25, 27,

48, 168,

AH-Plusstarted asbasic, rich

his pickafter3

hours andreduced

16

4 differenttypes ofsealers

336, 528and 750 h.PH levels

wasmeasured

by PHmeter

after 23h to31 days.

MTA statedas basic rich

his pickafter 17h

anddropped

from 7 daysto 31 days

Silva ejnlet-al.2013

Level IVControl group N=1


Control group:only culture

medium

interventiongroups: MTAand AH-Plus

Measuringby PH

meter inplastictubes

periods of3,24,72,

168 hours

AH-Plus hasclosely

natural PHlevel duringall period of

test MTAwas alkaline

for allperiod of

test

PH testPH level of sealers are not frequently evaluated in researches, this evaluation is rarely used

but this feature is very important, this evaluation is usually done by PH meter. On a test which made

by N. B. Faria-Junior et-al (19), found that 2 days after manipulation PH level of MTA significantly

increased as well for calcium hydroxide based sealer, after 7 days AH-Plus showed significantly

increased in PH levels, between all tested sealers the highest levels of PH was for MTA (19). On a

test that made by Piedad, S. et-al. (21) found that MTA start as basic and after 7 days dropped to

natural, for the AH-Plus start as well with basic level and dropped after 23 hours, faster than MTA

(21). additional test made by Hui-min Zhou et-al (22), confirmed the findings which mentioned above

and found that at the beginning of the test the PH level of AH-Plus and MTA based sealer showed

alkaline levels and after 24 hours AH-Plus decreased to natural PH level. By the results from the

articles the ability of AH-Plus to reach the PH-level after a short time has proved, in addition, the

ability of AH-Plus to be close to natural PH level than other tested sealers proved as well.

Table 6. Radiopacity test of root canal sealers.

AUTHOR/YEAR LEVEL OF EVIDENCE/STUDYDESIGN/PARTICIPANTS/INCLUSION

CRITERIA

INTERVENTIONAND CONTROL

GROUPS

OUTCOMEMEASURES

RESULTS

Raquel-KathrinPrullage

et-al

Level IVRCT

Intervention groups N=5Control group N=1

In vitro

interventiongroups: 5samples fromeach sealer inincubator

Aluminumstep wedgeand x-rayfor 120milliseconds

nosignificantdifferencesbetween

17

Radiopacity testRadiopacity of root canal sealers is a very important feature that helps clinician to control the

obturation stage and to evaluate the sealing quality (16). The international requirements for

radiopacity level of 3mm Al (5). All tests are measured the radiopacity levels of root canal sealers by

x-ray evaluation and by aluminum wedge (5,16,21,23). In test which made by (Emmanuel J.N.L.

Silva et-al (5) ) the test measured 5 samples from each sealer and by x-ray with aluminum wedge for

0.3 seconds with 60kV and 10mA, the test has shown that AH-Plus had significantly higher results

from all other tested sealers such as MTA based sealer (fillapex), (5). In test which made by (Piedad

S. Cañadas et-al (21) ) same method has been used, this test checked the radiopacity for 6.3 seconds

of x-ray exposure but with different values of 70kV and 10mA, the test has shown significant higher

radiopacity of AH-Plus compared to calcium hydroxide based sealer (sealapex),(21). An additional

test has made by (Lee, J. et al. (23)), the test checked 10 different samples, the radiopacity of tested

sealers for 0.08 seconds with 60kV and 2mA, this test has shown that AH-Plus have significant higher

2016 control group:AH-Plus

MTA andAH-Plus

EmmanuelJ.N.L. Silva

et-al2013

Level IVRCT


In vitro

interventiongroups: 5samples fromeach sealer

Aluminumstep wedgeandradiographexposurefor 0.3seconds

AH-Plusshowedsignificantlyhigherradiopacitythan MTA

Piedad S.Cañadas

et-al.2014

Level IVRCT


In vitro


Aluminumstep wedgeand x-rayexposurefor 6.3seconds

AH-Plusshowedsignificantlyhigherradiopacitythansealapex®– calciumhydroxidebasedsealer

Lee, J.et al.2017

Level IRCT


In vitro


Aluminumstep wedgeand x-rayexposurefor 0.08seconds

AH-Plusshowedsignificantlyhigheropacityresultscomparedto MTAfillapex®

18

results compared to MTA based sealer (23). On test which made by (Raquel-Kathrin Prullagev et-al

(16)), they used 60kV and 7mA and results showed no significant change between AH-Plus and

MTA. In conclusion from the results its clearly that AH-Plus have the highest radiopacity level

compared to other types of sealers that have been tasted and confirmed that AH-Plus is in agreement

with the international requirements. there is two materials which adding into the sealers for

radiolucency uses, those materials are Zirconium oxide uses as radiopacity agent in AH-Plus while

in the MTA the radiopacity agent is bismuth oxide (5). The different agents that are using for

radiopacity can explain the ability of AH-Plus to be more radiopacity than other sealers which were

tested.

Table 7. Risk of bias

Reportingbias

Incompleteoutcome data

Blinding ofoutcomeassessment

Performancebias

Selectionbias

Citation

++-?+Sungur DD.Et-al.2016

+??-+WillershausenI.Et-al.2011

?-+--MałgorzataPawińska. Et-al.2015

?--+-Silva EJNL.Et-al.2013

+-?+-EmmanuelJ.N.L. Silva.Et-al.2015

++++-HengamehAshraf.Et-al.2012

-+-+-Silva, T.Et-al.2012

-+---Brackett MG.Et-al.2012

++++-Sultana M.Et-al.

19

(+) – low risk (-) – high risk (?)- unclear informationAssessing of risk of bias has chosen by assessment tool from http://handbook.cochrane.org/.

Table 7. Materials compositionsThe most common used sealers which used for comparison in this systematic review.

2016

++++-Silva RV.Et-al.2015

++--+Wong JG.Et-al.2013

+++-+Schäfer E.Et-al.2013

++++-Silva EJ.Et-al.2016

?----Urban K.Et-al.2016

++---Ersahan S.Et-al.2013

-+---Alzraikat H.Et-al.2016

+--++Faria-JúniorNB.Et-al.2013

+?--+Akcay M.Et-al.2016

++--+Cañadas PS.Et-al.2014

++++-Zhou H.Et-al.2013

+++++Lee, J.et al.2017

Material Composition ManufactureAH Plus®Epoxy resin based

Epoxy paste: diepoxy, calcium tungstate,zirconium oxide, aerosol, and dyeAmine paste: 1-adamantane amine,N.N’dibenzyl-5 oxanonandiamine-1, 9, TCD-

Dentsply, DeTrey,Konstanz,Germany

20

Results:In this systematic review 23 articles were examined and divided into 6 different groups by the

main characteristics and properties of AH-plus and other types based sealers such as radiopacity,

micro-leakage, dentinal tubules penetration, cytotoxicity, solubility and PH levels. The results

confirmed the ability of AH-Plus® (Dentsply, DeTrey, Konstanz, Germany) resin-based sealer which

is the most common used sealer today to be with the requirements for root canal sealers. After

examination and summarizing the tests it was found that Ah-Plus have low cytotoxicity as shown in

table 1 but cytotoxicity characteristic of sealers should investigate further more studies. Concerning

dentinal wall/tubules penetration AH-Plus have significant good dentinal wall penetration compare

to other testes sealers as shown in table 4. Concerning micro-leakage, AH-Plus have high micro-

leakage properties and less sealing ability as shown in table 2 which might influence the quality of

the treatment with this root canal sealer. Concerning the PH levels, the most natural PH level from

all tested sealers was AH-Plus as shown in table 5. Ah-Plus have low solubility compare to other

tested sealers except for one article which had different results concerning to solubility of AH-Plus

as shown in table 3. Regarding radiopacity of the sealers, AH-Plus showed significantly higher results

compared to other tested sealers as shown in table 6. AH-Plus have all properties to be a sealer with

all international requirements needed from root canal sealer.

DiscussionDifferent types of root canal sealers (or endodontic sealers) are widely used in the dental

market, some practitioners select their sealer by different types of properties. In this study the

cytotoxicity level, PH level, dentinal tubules penetration, micro leakage and solubility of 3 different

types of root canal sealers based on different types of materials such as MTA (mineral trioxide

aggregate), calcium hydroxide based sealer and zinc oxide eugenol based sealer, has been tested and

compared to epoxy resin- based root canal sealer - AH-Plus (Dentsply, DeTrey, Konstanz, Germany).

root canal sealers should provide very good sealing ability and have all properties which required

from root canal sealer to be, root canal sealer should provide the best treatment results for a long time

diamine, calcium tungstate, zirconium oxide,aerosol, and silicon oil

Fillapex®MTA mineral trioxideaggregate based

Salicylate resin, diluting resin, natural resin,bismuth oxide, nanoparticles silica, MTA,pigments.

Angelus, Londrina,PR, Brazil

Tubliseal®Zinc oxide eugenol based

Zinc oxide, barium sulfate, oleo resins, oils,modifiers, thymol oxide

Kerr West CollinsOrange, CAUSA),

Sealapex®Calcium hydroxide based

Calcium hydroxide, barium sulfate, zinc oxide,titanium dioxide and zinc stearate.

SybronEndo,Glendora, CA,USA

21

by all characteristics as cytotoxicity, biocompatibility, PH levels, solubility, dentinal tubules

penetration, micro-leakage. When sealer is in contact with periapical tissues it should be non-

cytotoxic and should prevent form chemical agents to penetrate into periapical tissues and to prevent

the inflammation appearing which might lead to treatment failure and eventually might lead to tooth

and bone lose. All root canal sealers should have a laboratory test before any clinical use (5). By the

limitations which I had during writing this systematic review I used articles which could provide the

answers for my hypothesis. Concerning the cytotoxicity of root canal sealers, most of the tests have

used the MTT assay technique which tests the cell viability, cytotoxicity assay, and zymography tests

has inserted into this systematic review to verify the results and to intensify the evidence. After results

from all tests were out, the results were collected and analyzed by ANOVA which provide the mean

of the results, when AH-Plus compared with MTA based sealers, calcium hydroxide-based sealers it

found that cytotoxicity levels were not Unambiguous since different I got different results from

articles. On articles which made by Kierklo A, et-al 2015 (3), and Ejnl, et al. 2013 (5), found that

MTA based sealers and calcium hydroxide based sealers had higher cytotoxicity characteristics than

AH-Plus, while other articles found no significant differences in cytotoxicity levels (Brackett Mg, et-

al 2012 (9), Ashraf H, et-al 2012 (7)) and two articles found higher cytotoxicity levels of AH-Plus

which is different from other results (Silval Ejnl, el-al 2012(8)),( Silva EJNL Et-al.2015 (6)).

Cytotoxicity levels of AH-Plus in most of the cases were less than other compared sealers but this

results should be investigating further more studied to approve those results. Concerning the solubility

of root canal sealers, in most of the cases of the solubility tests has shown that AH-Plus have less

solubility than other materials which were tested. Solubility has measured by volume and weight loss

of the material after a period of time, on comparison which tested the solubility of MTA and calcium

hydroxide compared to AH-Plus the results were confirmed the ability of the AH-Plus to have a great

solubility and sealing properties (Faria-Júnior NB et-al.2013 (18)). the ability of root canal sealer to

be less soluble mean better feature since during Obturation phase the aim is to obturate the canal and

seal it as much as possible and to prevent from bacteria and their product to pass through apical

foramen to peri-apical tissues, low solubility can prevent from the sealing material pass through apical

foramen as well. According to ANSI/ADA Specifications, solubility ratios of root canal sealers

should be less than 3% (Sedya Ershan et-al 2013 (16)), when tests has made to find out if AH-Plus

have this ability it found to be positive, AH-Plus found to have the ability to provide less solubility

than other tested sealers (Schäfer E, et-al. 2013 (13)).regarding micro leakage, The main goal of root

canal sealer is to prevent from bacteria penetration and provide good sealing ability (Sultana M et-al,

2016 (10)), in all micro leakage tests AH-Plus showed higher leakage results than other tested sealers,

those results can influence the quality of the treatment with this root canal sealer. usually the main

technique today is by cold condensation with a combination of gutta-percha and root canal sealer.

22

One test found that there is no chemical bonding between AH-Plus and gutta-percha and this

disadvantage might be the main cause for the higher micro-leakage results of AH-Plus, (Sultana M

et-al, 2016 (16)). Regard PH levels of root canal sealers, the PH level measured by PH meter in all

cases, the PH meter has calibrated before all tests, by the results the PH level of AH-Plus was close

to natural during all period of test and MTA had alkaline level (Silva EJNL et-al, 2013 (5)). The PH

level of AH-plus has reached the peak after 3 hours and dropped after 23 hours while MTA reached

his peak after 17 hours and dropped only after 7 days, that mean that negative PH levels of AH-Plus

remain for short time and the natural level in most of the time kept as it should be without any negative

effect on the tooth or tissues. In addition, the comparison between MTA, calcium hydroxide and AH-

Plus has made and results were the same AH-Plus has natural levels (Faria-Júnior NB et-al,2013

(18)), it confirmed that AH-Plus is more natural than other sealers. Regard dentinal tubules

penetration, the ability of the sealer to penetrate into dentinal wall/tubules will provide better sealing

and less micro leakage which is the main purpose of root canal sealer, since the number of articles

was limited by inclusion criteria the results showed that AH-Plus and MTA had no significant

differences in dentinal tubules penetration and both had good results, the scoring of the results

measured from 0 to 2 (Cañadas PS, et-al 2014 (20)) both sealers had good scoring. Regard

radiopacity, the ability of AH-Plus to be with high radiopacity characteristics has confirmed. The

radiopacity of root canal sealers is very important for diagnosis and obturation control (16), all

radiopacity tests of root canal sealers has measured by x-ray and with aluminum step wedge and

results has shown that AH-Plus has significantly higher radiopacity than other tested sealers, this

might be due to zirconium oxide which is the agent that added to the sealer for this reason. After all

the results has been reported in this systematic review the only and the main disadvantage of AH-

Plus is the higher micro-leakage compared to other sealers, this disadvantage might be due to absence

of bonding between the gutta-percha points to the AH-Plus sealer and this finding can affect all

treatment quality, those results need to investigate further more studies to confirm this. The

application of AH-Plus has confirmed to be safe to use by other articles and approved to have good

properties as the international requirements stating.

Conclusion

In this study by the data which were collected AH-Plus is considered to be the most common

used sealer today and this might be due to material properties by solubility, dentinal tubules

23

penetration, cytotoxicity PH level and radiopacity, AH-Plus have a great sealing ability and reached

the international requirements for solubility which is less than 3%. The main disadvantage of this

sealer is the higher results of micro leakage compared to other sealers, those results need to investigate

further studies to confirm it. This systematic review covered the aim by data collection and confirmed

the ability of AH-Plus to be a sealer with all requirements needed from root canal sealer, after all tests

have been made it is clearly that AH-Plus have very good properties and most of the results can

confirm it, while the other sealers were less effective. AH-Plus is safe to use and in most of the cases

will be the right sealer to be chosen.

Clinical recommendationsBy the data which collected from articles it is clearly that application of AH-Plus is safe and

provide all requirements. In some cases, such as prosthodontic treatment with glass fiber post after

endodontic treatment is recommend to use the AH-Plus and MTA in case which the canal was

obturated before with zinc oxide eugenol based sealer the result might have less adhesion the dentin

wall since eugenol mostly resist to resin based composites and cements, the fiber post will fail to

adhere to root canal wall. The using in zinc oxide eugenol sealer is less recommend since there are

patients that have an allergy to eugenol, in this case, AH-Plus is recommending to use. In a case of

pediatric dentistry in primary dentition, calcium hydroxide sealer can be used to obturate the canal

without gutta-percha because primary teeth should exfoliate. The using MTA based sealer is more

recommend and more effective for teeth with complications after endodontic treatments such as

perforations.

References1. Sungur DD. Push-out bond strength and dentinal tubule penetration of different root canal

sealers used with coated core materials. 2016;7658:114–20. pubmed

24

2. Willershausen I, Callaway A, Briseño B, Willershausen B. In vitro analysis of the cytotoxicityand the antimicrobial effect of four endodontic sealers. Head Face Med. 2011;7:15. pubmed

3. Kierklo A. Assessment of cytotoxic potential of root canal sealers after hardening – an ex vivostudy Ocena cytotoksycznego potencjału uszczelniaczy kanałowych po stwardnieniu – badaniaex vivo. 2015;503–9. pubmed

4. The Prisma Group from Moher D, Liberati A, Tetzlaff J AD. Preferred reporting items forsystematic reviews and meta analyses: The Prisma Statement. 2009;6(7716):1–15.

5. Silva EJNL, Rosa TP, Herrera DR, Jacinto RC, Gomes BPFA, Zaia AA. Evaluation ofcytotoxicity and physicochemical properties of calcium silicate-based endodontic sealer MTAfillapex. J Endod. 2013;39(2):274–7. pubmed

6. Silva EJNL, Neves A a., De-Deus G, Accorsi-Mendonça T, Moraes AP, Valentim RM, et al.Cytotoxicity and gelatinolytic activity of a new silicon-based endodontic sealer.2015;13(SEPTEMBER):0–0. pubmed

7. Ashraf H, Moradimajd N, Mozayeni MA, Dianat O, Mahjour F, Yadegari Z. Cytotoxicityevaluation of three resin-based sealers on an L929 cell line.. 2012;9(5):549–53. pubmed

8. Silva EJNL, Accorsi-Mendonça T, Almeida JFA, Ferraz CCR, Gomes BPFA, Zaia AA.Evaluation of cytotoxicity and up-regulation of gelatinases in human fibroblast cells by fourroot canal sealers. Int Endod J. 2012;45(1):49–56. pubmed

9. Brackett MG, Lewis JB, Kious AR, Messer RLW, Lockwood PE, Brackett WW, et al.Cytotoxicity of endodontic sealers after one year of aging in vitro. J Biomed Mater Res - PartB Appl Biomater. 2012;100 B(7):1729–35. pubmed

10. Sultana M, Musani MA, Ahmed IM. An in-vitro comparative study for assessment of apicalsealing ability of Epiphany / AH Plus sealer with Resilon / gutta-percha root canal fillingmaterials 2016;321–6. pubmed

11. Silva RV, Silveira FF, Horta MCR, Duarte MAH, Cavenago BC, de Morais IG, et al. Fillingeffectiveness and dentinal penetration of endodontic sealers: A stereo and confocal laserscanning microscopy study. Braz Dent J. 2015;26(5):541–6. pubmed

12. Wong JG, Caputo AA, Li P, White SN. Microleakage of adhesive resinous materials in rootcanals. J Conserv Dent [Internet]. 2013 May [cited 2017 Feb 15];16(3):213–8. pubmed

13. Ehsani M, Dehghani A, Abesi F, Khafri S, Ghadiri Dehkordi S. Evaluation of Apical Micro-leakage of Different Endodontic Sealers in the Presence and Absence of Moisture.2014;8(3):125–9. pubmed

14. Schäfer E, Bering N, Bürklein S. Selected physicochemical properties of AH Plus, EndoREZand RealSeal SE root canal sealers. Odontology. 2013;103(1):61–5. pubmed

15. Silva EJ, Perez R, Valentim RM, Belladonna FG, De-Deus GA, Lima IC, et al. Dissolution,dislocation and dimensional changes of endodontic sealers after a solubility challenge: Amicro-CT approach. Int Endod J. 2016;(1988):1–8. pubmed

16. Prllage RK, Urban K, Schfer E, Dammaschke T. Material Properties of a Tricalcium Silicatecontaining, a Mineral Trioxide Aggregate containing, and an Epoxy Resin based Root CanalSealer. J Endod. 2016;42(12):1784–8.pubmed

17. Ersahan S, Aydin C. Solubility and apical sealing characteristics of a new calcium silicate-based root canal sealer in comparison to calcium hydroxide-, methacrylate resin- and epoxyresin-based sealers. Acta Odontol Scand . 2013;71(3–4):857–62. pubmed

18. Alzraikat H, Taha NA, Hassouneh L. Dissolution of a mineral trioxide aggregate sealer inendodontic solvents compared to conventional sealers. Braz Oral Res. 2016;30:1–8. pubmed

19. Faria-Júnior NB, Tanomaru-Filho M, Berbert FLC V, Guerreiro-Tanomaru JM. Antibiofilm

25

activity, pH and solubility of endodontic sealers. Int Endod J. 2013;46(8):755–62.pubmed

20. Akcay M, Arslan H, Durmus N, Mese M, Capar ID. Dentinal tubule penetration of AH Plus,iRoot SP, MTA fillapex, and guttaflow bioseal root canal sealers after different final irrigationprocedures: A confocal microscopic study. Lasers Surg Med. 2016;48(1):70–6. pubmed

21. Cañadas PS, Berástegui E, Gaton-Hernández P, Silva LA, Leite GA, Silva RS.Physicochemical properties and interfacial adaptation of root canal sealers. Braz Dent J.2014;25(5):435–41. pubmed

22. Zhou H, Shen Y, Zheng W, Li L, Zheng Y, Haapasalo M. Physical properties of 5 root canalsealers. J Endod . 2013;39(10):1281–6. pubmed

23. Lee JK, Kwak SW, Ha J-H, Lee W, Kim H-C. Physicochemical Properties of Epoxy Resin-Based and Bioceramic-Based Root Canal Sealers. Bioinorg Chem Appl. 2017;2017(57):1–8.pubmed

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COMPARISON OF 3 DIFFERENT TYPES OF ROOT CANAL SEALERS …