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Endodontic filling materials
1. Stop coronal leakage2. Entomb surviving microbes3. Block influx of water and nutrients
31 2
Root filling materials
from Sundqvist & Figdor, in ’Essential Endodontology’, 1998
Core Materials
• Gutta-percha• Metal points• Plastics• Combinations
Thermoplasticized gutta-percha:’hot-warm-soft’
injectablecarriers
’alpha-phase’ versus ’beta-phase’
Alpha-guttapercha is supposedly more fluid and soften at a lower temperature. Somesophisticated declarations describe a coreof beta- under a surface of alpha-gutta-percha. Beta phase is made when heatedalpha phase is rapidly cooled to roomtemperature. There is little if anydocumentation that this distinction is ofimportance.
All gutta-percha fillingtechniques, includingcompaction and othermethods of softening
gutta-percha, always end up requiring a sealer.
A sealer is whathard and soft tissues; thepercha is merely
should
a piston
meet thegutta-
Gutta-percha- adaptability
ZEUG- dimensionally stable
Chloroform- adaptability
Colophony- adhesion
Chloropercha- biocompatible
Epoxy- hardness and adhesion
Ca(OH)2- bio-active
N2 & Endométhasone- antibacterial
Glassionomer- why not?
Silicon- biocompatible
Endodontic Sealers• ZnO-eugenol-based• ZnO-’non-eugenol’-based• Polymeric cements• Glass ionomers• Silicones• Solvent-based• Ca(OH)2 pastes
ZnO-Eugenol-BasedEndodontic 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– Good seal
• Con’s– Local toxicity– Allergen– Poor stability?
ZnO-’Non-Eugenol’-BasedEndodontic Sealers• Several proprietary brands• Poor if any documentation
Glass Ionomer-BasedEndodontic Sealers
• Endion• Ketac-Endo
Glass-ionomer-sealers
• Pro’s– Biocompatible– Clinical documentation?
• Con’s– Leakage– Shrinkage
Glass ionomer sealer
Of 378 followed-up teeth, therewas 78.3% success, 15.6%
incomplete healing, and 6.1% failure.
Friedman et al., 1995
Polymer-BasedEndodontic 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?
RealSealWhy do we call it RealSeal? Because it is the endodontic filling material thatprovides a REAL seal. And Resilon™, the primary component of RealSeal, has also been proven to be biocompatible, nontoxic and nonmutagenic.1 RealSealis:•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 thatimprove sealing ability even in canals that are moist with water.This resin-based formula prevents EndoREZ™ from compromisingbonding agents. In addition to itsbiocompatible, methacrylate formula, EndoREZ™ also offers the advantage of radiopacity. EndoREZ™ is as radiopaque as gutta percha, thus simplifying radiographicinterpretation.”
Ultradent, company website
EndoREZ Points
”Resin Coated Gutta Percha PointsEndoREZ Points are standard ISO-sized gutta perchapoints overlayed with a thin resin coating. The resin coating allows EndoREZ Points to bond chemincallywith EndoREZ and other resin-based sealers. Historically, gutta percha has only maintained a weaker, chemical bond with canal sealers. EndoREZPoints are the first-ever gutta percha points to create a stronger, chemical bond by bonding gutta percha to EndoREZ.”
Ultradent, company website
Endodontic Sealerswith Ca(OH)2
• Sealapex• Apexit• CRCS
Ca(OH)2-based sealers• Pro’s
– 20 years– Clinical documentation– Good seal– Biocompatible
• Con’s– Unstable?– Poor x-ray contrast– Low mechanical
strength
Changes in pH at the dentin surfacein roots obturated with
calcium hydroxide pastes.
Esberard RM, Carnes DL Jr, del Rio CE J Endod 1996 Aug;22(8):399-405
6
7
8
9
10
11
12
0 3 7 14 21 28 45
TIME, days
pH at midroot surface
ControlSealapexApexitSealer 26Ca(OH)2
Silicone-BasedEndodontic Sealers
• Lee Endofil• Roeko Seal• Gutta-Flow
Silicon-based sealers
Silicon-based sealers• Pro’s
– Very gooddocumentation
– Clinically tested– Biocompatible
• Con’s– No effect on microbes?– Poor mechanical strength– Short history
Picture: M.J. Roggendorf
Picture: M. J. Roggendorf
Solvent-BasedEndodontic Sealers
• Rosin-chloroform (Johnston-Callahantechnique)
• 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
def
c
0
2
4
6
0 4 8 12 16 20 24 28 32 36 40 44 48
TIME, weeks
DIM
ENSI
ON
AL
CH
AN
GE,
%
AH 26AH 26 SFAH Plus
Fig 3a
-2
0
2
4
6
8
0 4 8 12 16 20 24 28 32 36 40 44 48
TIME, weeks
DIM
ENSI
ON
AL
CH
AN
GE,
%
Grossman'sProco-SolPCSTubli-Seal
Fig 3b
-1
0
1
0 4 8 12 16 20 24 28 32 36 40 44 48
TIME, weeks
DIM
ENSI
ON
AL
CH
AN
GE,
%
Roeko-SealRS 4823wetRS 4823dry
Fig 3c
-1,5
-1
-0,5
0
0,5
1
0 4 8 12 16 20 24 28 32 36 40 44 48
TIME, weeks
DIM
ENSI
ON
AL
CH
AN
GE,
%
ApexitApexit H2OKetac-Endo
Fig 3d
0
Hoop stress -(tension)
Radial stress -(pressure)
3 mm1 mm
0,001
0,01
0,1
1
10
100
0 0,2 0,4 0,6 0,8 1
Linear expansion of material [%]
Tang
entia
l str
ess
[MPa
]
CompositeElastomer
Physical properties of endodonticsealers: radio-opacity, working time,
flow and compressive strength measurements
Ayce Unverdi EldenizGuest Researcher, Scandinavian Institute of Dental Materials, Haslum, NorwayDag ØrstavikOslo 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 Component BEpoxy resin Adamantane amineCalcium tungstate N,N-Dibenzyl-5-oxanonane
Zirconium oxide TCD-DiamineAerosil Calcium tungstateIron oxide Zirconium oxide
Aerosil Silicone oil
Root canal sealers tested: GuttaFlow
Hexachloroplatinic acidZirconium oxideNano-silver(preservative)
Gutta-percha powderPolydimethylsiloxaneSilicone oilParaffin oil
Root canal sealers tested: AcroSeal
Glycyrrhetic acid (enoxolone)MethenamineRadiopaque excipient
Calcium hydroxideDGEBARadiopaque excipient
Root canal sealers tested: EndoRez
30% Urethane dimethacrylate
Root canal sealers tested: Epiphany
Dual-cure, urethane-baseddental composite cement
Root canal sealers’radiopacity
Radiopacity (n=3)
0,0
2,0
4,06,0
8,0
10,0
12,0
AH Pl
usEnd
o-REZ
Epipha
nyRC S
ealer
Roeko
Sea
lGut
ta F
low
Apexit
Acr
osea
l
Root canal sealers’ film thickness
Film Thickness (n=15)
05
101520253035404550
AH P
lus
Endo
-REZ
Epiph
any
RC S
ealer
Roek
o Se
alGut
ta F
low
Apex
it Ac
rose
al
Root canal sealers’ flow
Flow (n=15)
05
101520253035404550
AH Plu
sEnd
o-REZ
Epipha
nyRC S
ealer
Roeko
Sea
lGut
ta F
low
Apexit
Acr
osea
l
Root canal sealers’compressive strength
Compressive strength (Mpa) by time (h)
050
100150200250300350400
0 50 100 150 200
AH PlusEndo-REZEpiphanyApexit Acroseal
?
Smear layer removal
• Opens tubules for medicamentactivity
• Removes (infected) smear and substrate for microbial growth
• Allows permeationof filling material
• Shows little effecton adhesion offilling
• Penetration by bacteria may be enhanced:– Between sessions– After filling
Native
Phosph. Acid
Citric acid
EDTA
Gr.APX
KERS
RS+PAH Plus
0,00
0,20
0,40
0,60
0,80
1,00
1,20
Gr.APXKERSRS+PAH Plus
Saleh et al., 2001:Adhesion ofroot canal sealersto pretreated dentin
Antimicrobialactivity
• Toxic chemicals– disinfectants– antiseptics
• Antibiotics
Iodine-containing gutta-percha(Lone Star)
Current antimicrobialadditions
• Formaldehyde• Eugenol• Thymol iodide• Amines• Calcium hydroxide
Clinical biocompatibility
• Local• Regional• Systemic
Severity Frequency
PN Liston, RF WaltersForeign bodies in the maxillary antrum: A case reportAustralian Dental Journal 2002;47(4):344-346
14dAH-materials give a strong
reaction after 14d, but show littleeffect on tissues after 3 months
14d3 months
Sealapex: Induction of hard tissue formation
0
1
2
3
4
5
6
7
Sealapex Kerr PCS
ClosurePartial closureNo closureInflammation
Holland & de Sousa 1985
Periapical reactions to sealers in monkeys
0
1
2
3
4
5
6
7
8
Sealapex CRCS AH26
NoneMild to moderateSevere
Tagger & Tagger 198527 teeth in 3 monkeys, 8-14 months
Allergy
• (Almost) All endo materials containallergens
• The exposure to sensitive tissues is extremely small
• Exposure to skin, mucosal surfaces ofpatients and the skin of staff maydeserve more attention
Mutagenicity - Carcinogenicity
• Mutagenicity– the ability to causechanges in the genes of an individual
• Carcinogenicity– the ability to causecancer in an individual
• 70-90% of mutagens are carcinogensand vice versa
Lower chamber, sterile medium
Barthel et al, 1999
In vitro model for coronal leakage
Upper chamberwith bacteria
Sterilised, rootfilled root
Wax seal
Bacteria penetrating the root filling multiply in the clearmedium of the lower chamber, making it turbid.
% Microbial leakage over 30 days
0102030405060708090
100
L GP - AH26 sealerV GP - AH26 sealerL GP - Epiphany™ sealer
V GP - Epiphany™ sealer
L Resilon™ - Epiphany™ sealer
V Resilon™ - Epiphany™ sealer
L Resilon™ - Epiphany™ sealer
V Resilon™ - Epiphany™ sealer
Positive Control - Resilon™
Positive Control - GPNegative Control
Groups
% o
f mic
robi
al le
akag
e S. mutans
E. faecalis
S. mutans andE. faecalis
Epiphany –’an appearance or manifestation especially of a divine being’
Bacterial leakage
0
20
40
60
80
100
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
(CT: control; KE: Ketac-Endo; RSP: RoekoSeal Automix + Primer; AP: Apexit; RS: RoekoSeal Automix; CH: Calcium Hydroxide; GS: Grossman’s sealer; AH: AH Plus)
-1
0
1
2
3
4
5
CT KE RSP AP RS CH GS AH
Sealer
Mea
n Lo
g C
FU
CT KE RSP AP RS CH GS AH
Clinical/Radiographic Follow-Ups
• Pain• Success-failure
analyses• Disease – no disease• Size of lesion• Periapical index• Computer technology
Time-course of postoperative pain followingroot filling with either Roeko Seal or Grossman’s sealer. Average values
0
2
4
6
D1S D1Be D2Br D2L D2S D2Be D3Br D3L D3S D3Be
Rel
ativ
e pa
in in
tens
ity, %
Roeko SealGrossman
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
91,3 89,1 92,2
0102030405060708090
100
All teeth CAP NAP
'Success'
’Feasibility study’
Cumulative PAI Scores
0 1 2 3 40 1 2 3 4
AH KP PS
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) vsKloroperka: Significantly poorer results for Kloroperka in one clinical study
Healing of apical periodontitis followingroot filling with 3 different sealers
0,2
0,3
0,4
0,5
0 1 2 3
TIME, years
PE
RIA
PIC
AL S
TATU
S, r
idit
TotalProcoSolSealapexCRCS
Range of s.e. of means: 0.02-0.07
Preoperative Healthy Periodontium: Effect of Sealer
0
0,1
0,2
0,3
0 1 2 3TIME, years
PER
IAPI
CA
L ST
ATU
S,
ridi
t
TotalProcoSolSealapexCRCS
Range of s.e. of means: 0.03-0.17
APN
AP/N < 1 AP/N ≅ 1
X-rayhealing
Digitalchange
N
AP
Numbers are average gray values in the defined areas: 255=white; 0=black
115
130
Digitalchange
130
80
AP/N =0,62 AP/N 0,88
0,6
0,8
1
1,2
0 4 8 12 16 20 24
TIME, months
AP/N
SoundDiseased
From Trope et al., 1998
Healing by AP/N Ratio
40
60
80
0 5 10 15 20 25
TIME, weeks
PA S
tatu
s, P
/N ra
tio
PSSA
Healing by PAI Score
0,4
0,6
0,8
1
0 5 10 15 20 25
TIME, weeks
PA S
tatu
s, P
AI r
idit
PSSA
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
Prospective study of factors related to healing of AP
60
70
80
90
100
PreopAP
Nopreop
AP
Warmvert ical
Coldlateral
Singleroot
2+ roots
Cliinical variables
Hea
led
case
s, p
er c
ent
Farzaneh et al.
JOE April 2003, OR 45
The Toronto study:
outcome ofinitial
endodontic treatment -
phase II
New methods for filling root canalsmust be viewed with regard to
their ability to aid in achieving theprevention 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?
1. Complete physical and chemical disinfection in onesession?(’Dauerantisepticum’, CHX?)
2. Prevention of regrowth(antibacterial sealer?)
3. Block influx of nutrients(improved seal?)
Predictable disinfection
AP
P
PDL
’Predictable disinfection’: can we improve?
• instrumentation 90 10 95 50• irrigation 99 50 99,9 95• dressing 99,9 95 99.99 98• Root filling 100 100?
Standard methods Improvement?
Microbes Canals Microbes Canals
Thank you for your attention!