Dr William Ha BDSc GCResCommPhD (Endodontic Biomaterials) FPFA

Endodontic Biomaterials

Medicaments and Sealers

Is that a sealer puff? No, it’s a boy!

Medicaments

The use of calcium hydroxide medicament results in better periapical healing than canals that are left empty.

Calcium hydroxide paste has better antibacterial activity than camphorated paramonochlorophenol (CPMC) and Formocresol (Formalin)

But aside from the gold standard of CaOH paste there other options

CaOH + Ibuprofen can reduce painAntibiotic/Steroid combinations reduce painChlorhexidine gel

Trope 1999, Stuart 1991, Yapp 2014, Negm 2001

Medicaments

Calcium hydroxide

• ~40% Calcium hydroxide + Water

• ~40% Calcium hydroxide + Non water gel

Antibiotic + Steroid combination

• Clindamycin + Triamcinolone (Odontopaste)

• Demeclocyclin + Triamcinolone (Ledermix paste)

Mediums for calcium hydroxide medicaments

Water-based

• 100% water

• Water + some thickening agent (alcohol, esters, polyethers, methylcellulose)

Waterless mediums

• Hydrophobic oils

• Liquid hydrophilic thickening agents (alcohols, esters and polyethers)

NOT a medicament

• “Calcium hydroxide permanent endodontic sealers and cements” which are salicylate resins which reacts with calcium hydroxide to form solids (e.g. Sealapex, Dycal)

Fava 1999

Mechanism of action of Calcium hydroxideIn water, Ca(OH)2 → Ca2+

(aq) + 2OH-(aq)

pH ~ 10-12 which is caustic (strong alkaline) and is therefore:

Encourages repair, active calcification and hard tissue formation

Neutralizes lactic acid from osteoclasts

Very antibacterial

Estrela 1995, Siqueira 1999

Medicaments: What’s out there?

• Water-based CaOH paste ( ~35% CaOH + water)

• E.g. Calasept

• pH ~10-12 for 4 weeks

• Non-water-based CaOH paste (~35% CaOH + non-water)

• E.g. Vitapaex 30% CaOH, 40.4% iodoform in silicon oil

• pH ~8 for 4 weeks

Fava 1999, Nerwich 1993, Nunes 2005

Thickening agents

Conductivity of propylene glycol-water mixtures saturated with CaOH

★Propylene glycol

● Glycerin

Safavi 2000

NON-WATER-BASED CAOH

WATER BASED CAOH

Increasing viscosity

Thickening agents

Conductivity of propylene glycol-water mixtures saturated with CaOH

★Propylene glycol● Glycerin

Ability to

release of

Ca2+ and

OH-

Safavi 2000

Antibacterial activity

UltraCal is in WATER

Vitapex is in SILICON OIL

Blanscet 2008

Another Oil: CaOH mixed with Polyethylene Glycol (PEG) with no water

Estrela 2003

Another Oil: CaOH mixed with Polyethylene Glycol (PEG)

• After dressing artificial root canals with:• CaOH + Saline• 13.15% of live E.faecalis biofilm remains

• CaOH + Polyethylene glycol (Calen)• 44.64% of live E.faecalis biofilm remains

Zancan 2016

CaOH + Saline CaOH + PEG

Green = Live bacteriaRed = Dead bacteria

Waterless mixtures in Australia

Brand % CaOH % Radiopaquer Medium

Diapex Plus 25% 40% Iodoform 40% Silicon oil (hydrophobic)

Forendo 40% 30% Iodoform 30% Oil derivatives (hydrophobic)

Calmix 35% 13% Zirconium oxide 52% Polyethylene glycol(hydrophilic)

Gutta Percha coated with solid CaOH• Rather than inserting CaOH medicament, insert a

GP coated with solid CaOH• Time saving and easy to insert

• Short action• Lower pH than CaOH• Not a sustained release

• Radiolucent

Economides 1999

Calcium hydroxide and tooth strength• Historic studies that claim CaOH weakens teeth had no controls

• The simple act storing teeth weakens teeth so no matter the intervention, the teeth will become weaker

• Controlled studies shows no difference between CaOH and saline

Kahler 2018

1% Triamcinolone

• More than 85% showed complete relief of pain after the initial 1-hour interval. More than 93% showed complete pain relief within 24 hours.• Used Kenacomb: 1% Triamcinolone with

Nystatin, Neomycin, Gramicidin

• 1% Prevents resorption• No difference between Ledermix vs

Triamcinolone-alone

Negm 2001, Chen 2008

Ledermix and Odontopaste: Compositions

Ledermix paste (Lederle Pharmaceuticals, Germany)

Odontopaste (ADM, Australia)

3% Demeclocycine + 1% triamcinolone 5% Clindamycin + 1% triamcinolone

polyethylene glycol (makes it a paste)ZnO (adds bulk and some radiopacity)

polyethylene glycol (makes it a paste)ZnO (adds bulk and some radiopacity)

Athanassiadis 2011, Athanassiadis 2013, Plutzer 2009, Ehrmann 2009

Ledermix vs Odontopaste Ledermix vs Odontopaste: Antibacterial activity

Plutzer 2018

Ledermix vs Odontopaste:

Staining

Chen 2014, Thomson 2012

Ledermix vs Odontopaste: Summary

Ledermix paste3% Demeclocycine1% Triamcinolone

Odontopaste5% Clindamycin1% Triamcinolone

Study

Antibacterial activity Less More Plutzer 2018

Steroid composition Equal Equal

Staining Bad None Thomson 2012, Chen 2014

Cost per tube $143 for 5 grams $115.50 for 8 grams HenryScheinHalas

Intracanal NSAIDs

• Intracanal NSAIDs has been shown to more effective in reducing pain than intracanal corticosteroids and more than oral NSAIDs.• 30mg/mL Ketolorac Intracanal (3%)• 4mg/mL Dexamethasone (0.4%)

• Similar study. Intracanal NSAIDs > Placebo (saline)• 25mg/mL Diclofenac Intracanal (2.5%)• 100mg/mL Ketoprofen Intracanal (10%)

Rogers 1999, Negm 1994, Oxford 2007

Odontocide: 20% CaOH 7%

Ibuprofen • Odontocide reduces post op pain more than normal Calcium hydroxide. But there are no studies comparing Odontocide vs Odontopaste or Odontocide vs Ledermix.

• Being 20% CaOH, it should have a comparable pH to regular CaOH pastes. But at half the dosage of regular CaOH pastes it won’t stay in the tooth as long.

Yapp 2014

Chlorhexidine gel

• CHX gel studies vs CaOH shows CHX is better. But, these studies are focused on E.faecalis.

• If NaOCl is to be used at the next visit, substantial irrigation is required to remove CHX.

Medicament Yadav 2018

Sinha 2013

Valera 2010

Delgado 2010

Ballal2007

Ercan2006

Gomes 2003

Siqueira 1997

CHX gel Best Best Worst Best Best Best Best Best

CaOH paste Worst Worst Best Worst Worst Worst Worst WorstCHX mixed with CaOH

Best Best Best Worst Middle Middle

CaOH + CHX = para-chloro-aniline (PCA)• It’s superior antibacterial properties could be due to

the production of PCA which is highly antibacterial. However, Parachloroaniline is carcinogenic and can cause methemoglobinemia.

• PCA is detected in 0.2% CHX:CaOH mixes after 14 days with no traces of CHX remaining due to immediate degradation of the CHX.

Barbin 2008

CHX and Enterococcus faecalis

• E.Faecalis isn’t in all cases of apical periodontitis. Is it an issue?

Stuart 2006

E faecalis

• It’s prevalence in apical periodontitis is only 0.7%. Is it a big deal?

• Present in less than half of the secondary infections. It is unlikely a pathogen for apical periodontitis.

• Considered as a secondary invader through coronal leakage or opening for drainage.

Hong 2013, Chugal 2011, Siren 1997

CHX leads to more failures

• The use of chlorhexidine is associated with more failures

If Chuck Norris was an Endodontist

Chuck worked with the Andreasens to create the trauma guidelines. He created the dental

trauma

Medicaments: What makes it better?

Calcium hydroxide densityStudy Spiral

(Lentulo, Pastinject)

Needle, injection delivery

Ultrasonic file

Sonic activation

Paperpoint Hand file

Hand condenser

Reverse NiTi

Gutta condenser, McSpadden

Galvao 2017 Best Worst BestGibson 2008 Worst BestSimcock 2006 Average Average Average AveragePeters 2005 Best WorstTeixeira 2005 Best WorstTorres 2004 Best WorstEstrela 2002 Worst Best Best Best WorstDeveaux 2000 Best Average Worse WorstStaehle 1997 Best Best WorstSigurdsson 1992

Best Average Worst Average

Calcium hydroxide densityStudy Spiral

(Lentulo, Pastinject)

Details Needle, injection delivery

Details

Galvao 2017 Best #4 (ISO 40) 2mm short of apex

Gibson 2008 Worst Used with paperpoint ‘condensation’ Best NaviTip: 2mm short of WL29-30 gauge (0.34-0.31 mm O)

Simcock 2006 Average #1 (ISO 25) or #4 (ISO 40) at WL Average NaviTip 29-30 gauge (0.34-0.31 mm O)

Peters 2005 Best #2 (ISO 30) 1mm short of binding point Worst 18 gauge

Teixeira 2005 Best Used with paperpoint condensation

Torres 2004 Best #3 (ISO 35) to WL Worst Capillary tip 0.014” (0.36mm 0)

Estrela 2002 Worst #4 (ISO 40)

Deveaux 2000 Best #2 (ISO 30) 2mm short of WL and ISO 40 2mm short

Staehle 1997 Best #3 (ISO 35) Best Needle tip (0.6mm 0)

Sigurdsson 1992 Best #1 (ISO 25) Average Calasept tip 21 gauge (0.8mm 0)

Time between visits

• If antibacterial activity is the goal • At least 14-28 days to reach peak pH

• If evidenced radiographic healing is desired prior to proceeding with obturation• At 3 months, significant improvement from the

preoperative radiographic status is expected

Nerwich 1993, Huumonen 2013, Kinirons 2001

If your CaOH has become dry

The cap has been left open and water has been lost

But also, CO2 has entered the tube, changing calcium hydroxide to calcium carbonate• Ca(OH)2 + CO2 -> CaCO3

• pH12 paste is moving towards pH 10

You could mix it with NaOCl instead of water to shift the pH back to 12• pH of NaOCl (11-13) - mixing CaOH with NaOCl increases

antibacterial activity• pH of water (6-7)• pH of LA (5-7) – leads to significant drops in pH compared to

distilled water

Some synergistic effects with NaOCl

• Therefore, canals do not need to be dried of NaOCl

Cavalcante 2010 , Mohammadi 2017, Pacios 2004, Hamed 2014

Cold = viscous (less runny)• If you keep it in the fridge, it will become

more viscous (ie. less runny)

• If you store it at room temperature, it will become less viscous (ie. more runny)

Yang 2007, Hong 2011, Wilson 2009

Before placing CaOH

• Irrigate with EDTA and NaOCl before CaOH placement

• EDTA opens the dentinal tubules to enable CaOH diffusion• NaOCl removes EDTA residue that would react with CaOH

Foster 1999, Violich 2010

Ledermix and Odontopaste: Time between visits• Ledermix – less time is best as the more exposure to sunlight

occurs the more staining will occur.

• Odontopaste provides significant relief at 24 hrs. However, there no advantage over extirpation alone by 7 days.

• Therefore, the subsequent visit should be as soon as practically possible.

Kim 2000, Eftekhar 2013

Ledermix and Odontopaste: Clinical tips

• Dry the canals before placing Ledermix or Odontopaste. Residual alkalinity (from NaOCl) will destroy the corticosteroid that reduces pain.

Athanassiadis 2011

Medicaments: What makes it worse?

Medicament residue

• EDTA removes calcium hydroxide medicament better than NaOCl

• Water based calcium hydroxides are easier to remove than non-water based calcium hydroxides

EDTANaOCl

CaOH + Silicone oil CaOH + Water

Nandini 2006, Salgado 2009

Calcium hydroxide extrusion

• Can do immense tissue damage• Soft tissue swelling• Gingival perforation, ulceration of mucosa• Facial pain, facial palsy, IDN anaesthesia• Weakness of orbit and scalp• Blurring of vision• Trismus

Sharma 2008, Shahravan 2012, Olsen 2014

Calcium hydroxide extrusion• Published case reports involve injectable CaOH, less

cases with Lentulo-spiral. Nothing reported for hand instrumentation.

• I use a red (#1) lentulo so it matches my X2 Prep.

• In the rotary handpiece (300RPM), not a standard slowspeed

• Length controlled with a rubber stopper, be at least a mm short

• Check it isn’t tight in the tooth before using under rotation

Shahravan 2012, Olsen 2014

Ledermix and Odontopaste: Contraindications

• Pregnancy and lactating mothers, for either Ledermix and Odontopaste• Triamcinolone has teratogenic effects.

Treatment at the end of pregnancy involves the risk of atrophy of the foetal adrenal cortex. Glucocorticoids pass into breast milk.

• And, specifically for Ledermix, demeclocycline penetrates the placenta membrane and is excreted into breast milk.

• Respective allergies to tetracyclines or clindamycin

Ledermix and Odontopaste: Should I mix it with Calcium

hydroxide?

• Ledermix + CaOH: 80% loss of demeclocycline from the calcium hydroxide over 7 days

• Odontopaste + CaOH: 36% destruction of clindamycin from the calcium hydroxide over 7 days

• Both will have• A halved dosage of calcium

hydroxide• The steroid is almost completely

destroyed by calcium hydroxide at 72 hrs

• It would appear better to use either CaOH or Antibiotic-Steroid paste on their own. Not as a combination.

Athanassiadis 2011, Athanassiadis 2013, Seow 1990

50:50 mixes drop in pH sooner

Cai 2018

Medicaments: What should I use?

For routine endodontics, use aqueous calcium hydroxide.

• This includes irreversible pulpitis if the chemo-mechanical preparation to the working length can be completed.

For irreversible pulpitis where chemo-mechanical preparation to the working length cannot be completed, consider Odontopaste

If you really want to use half-dosed CaOH with pain-relief, don’t use 50:50 mixes, use Odontocide

Obturation materials

Obturation materials: What’s out there

• The flexible solid material is utilised as it is insoluble and can easily be inserted into root curvature. As a solid, it does not flow into variable root anatomy and hence adaptation against dentine is poor.

• Therefore, endodontic sealers are used to coat GP to adapt against dentine and between GP cones.

Gutta Percha

Sealers

Sealers

Sealers serve to seal the space between the gutta percha material and the root surface and to flow to travel into irregularities of complex root anatomy.

They are expected to be: in contact with periradicular tissues insoluble in tissue fluids, but, resorb if extended past the apexNon-irritating and not do damage to vital tissues, yet have anti-bacterial properties

Tomson 2014

AH Plus (Dentsply Sirona)

• Epoxy-resin sealer• The most commonly used material• The most commonly tested material• Two forms, hand mixed and auto-mixed

Dentsply 2005

AH 26 (Dentsply)

• Epoxy resin sealer (but powder mixed with liquid)• Precursor to AH Plus• Releases formaldehyde and its use is frowned up by many circles,

including the AAE.• Still commercially available.

AAE 2017

AH Plus vs AH 26Property AH Plus AH 26

Radiopacity Better Worse (Gorduysus 2009)

Oestrogenic effect Nil Some (Pulgar 2002)

Formaldehyde release Minimal Some (Cohen 1998, Leonardo 1999)

Cytotoxicity Mixed reportsMixed reports (Miletic 2003, Huang 2000, Koulaouzidou 1998, Cohen 2000, Miletic 2000, Azar 2000, Huang 2002)

Mutagenicity Nil Nil (Miletic 2003)

Seal Equal Equal (De Moor 2004)

Ease to remove (EndoSolv-R) Better Worse (Shenoi 2014)

Leakage Similar or BetterSimilar or worse (Miletic 2002, Joseph 2012, Bodrumlu 2007, Portmann2005, da Silva Neto 2007, Zmener 1997, Bodrumlu 2006, Miletic 1999, Miletic 2002)

Dentin adhesion Better Worse (Pecora 2001)

Solubility Better Worse (Schafer 2003)

Antibacterial effect Worse Better (Kaplan 1999)

Pulp Canal Sealer (KavoKerr)

• Zinc oxide eugenol• Water is part of the cement which provides porosity

Dentsply 2005

AH Plus vs Pulp Canal SealerProperty AH Plus Pulp Canal Sealer

Radiopacity Good Bad, fails ISO standards (Dorileo 2014)

Cytotoxicity Better Worse (Loushine 2011)

Implantation Better Worse (Silveria 2011)

Flow Worse Better (Chang 2014)

Sealing Tests Better Worse (Bouillaguet 2008)

Antibacterial activity Better Worse (Wang 2014)

Push-out Strength Similar Similar (Vemisetty 2014)

Solubility Better Worse (Poggio 2017)

Setting time Better Worse (Zhou 2013)

Ease to remove with rotary Better Worse (Iriboz 2012)

Sealapex (KavoKerr)

Nunes 2005

• Sealapex is a calcium hydroxide salicylate resin endodontic sealer

• Although calcium hydroxide is present in the setting reaction, it is consumed in the setting reaction by the resins and therefore the alkalinity of the setting cements is lower (~pH 7.5) than the typical calcium hydroxide pastes.

• Therefore, the anti-bacterial activity is far less than calcium hydroxide paste.

• Water is released in the setting reaction, creating porosity

Sealapex vs AH PlusProperty AH Plus Sealapex

Clinical Success Most commonly used material Second most commonly used material

Radiopacity Better Worse (Canadas 2014)

Cytotoxicity Mixed reports Mixed reports (Poggio 2017, Silva 2012)

Implantation Mixed reports Mixed reports (Silva 2012, Silveria 2011, Silva-Herzog 2011)

Flow Better Worse, does not comply to standard (Almeida 2007)

Sealing Tests Good Worse (Joseph 2012)

Antibacterial activity Mixed reports Mixed reports (Heyder 2013, Zhang 2009)

Push-out Strength Better Worse (Ersahan 2010)

Solubility Better Worse (Faria-Junior 2013) and fails standards (Borges 2012)

Setting time Better Worse (Marin-Bauza 2012)

Ease to remove with Chloroform Easier Harder (Alzraikat 2016)

MTA Fillapex (Angelus)

• MTA Fillapex is essentially Sealapex mixed with MTA powder (13%)• It is hardly “MTA”

• It is a flowable endodontic sealer and should not be used for endodontic repairs of teeth or for pulp therapy.

Reac

ts with

MTA Fillapex vs AH PlusProperty AHPlus MTA Fillapex

Clinical Success Many and long studies Lab studies

Radiopacity Better Worse (Bicheri 2013, Lee 2017)

Film Thickness Better Worse (Zhou 2013)

Flow Worse Better (Lee 2017)

Cytotoxicity Better Worse (Silva 2013, da Silva 2017)

Skin implantation Better Worse (Tavares 2013)

Bond strength Better Worse (Baechtold 2014)

Wetting (adhesion) Worse Better (Ha 2018)

Antibacterial activity Worse Better (Kuga 2013)

Solubility Better (Less soluble) Worse (Faria-Junior 2013) and fails standard (Borges 2012 ) (More Soluble)

TotalFill BC Sealer (FKG)

• Also known as iRoot BC Sealer and Endosequence BC Sealer

• TotalFill BC Sealer combines the concepts of MTA with oily (no water)

CH paste to create an ‘syringe applied MTA’

• It is dry calcium silicate powder (similar to MTA) mixed with a

waterless thickening agent

• It’s a single syringe so the paste is not mixed with a second paste or

powder. It needs moisture to leak into the sealer to set

AH Plus vs Total Fill BC SealerProperty AH Plus BC Sealer

Clinical Success Commonly used in endodontic literature Case Reports

Radiopacity Better Worse (Candeiro 2012, Lee 2017, Tanomaru-Filho 2017)

Cytotoxicity Equal or Worse Equal or Better (Poggio 2017 or Willerhausen 2011)

Implantation (skin) Worse Better (Zhang 2015)

Implantation (bone) Equal Equal (Zhang 2015)

Sealing Tests Better Worse (Ulusoy 2011)

Wetting (adhesion) Worse Better (Ha 2018)

Antibacterial activity Similar Similar (Zhang 2009)

Push-out Strength Better Worse (Gade 2015)

Flow Mixed reports Mixed reports (Lee 2017, Tanomaru-Filho 2017)

Solubility Better (Less soluble) Worse, fails standards (More soluble) (Borges 2012, Tanomaru-Filho 2017)

Volumetric change Better Worse (Shrinks) (Tanomaru-Filho 2017)

Setting time Better Worse (Tanomaru-Filho 2017)

AH Plus vs Total Fill BC SealerProperty AH Plus BC Sealer

Clinical Success Commonly used in endodontic literature Case Reports

Radiopacity Better Worse (Candeiro 2012, Lee 2017, Tanomaru-Filho 2017)

Cytotoxicity Equal or Worse Equal or Better (Poggio 2017 or Willerhausen 2011)

Implantation (skin) Worse Better (Zhang 2015)

Implantation (bone) Equal Equal (Zhang 2015)

Sealing Tests Better Worse (Ulusoy 2011)

Wetting (adhesion) Worse Better (Ha 2018)

Antibacterial activity Similar Similar (Zhang 2009)

Push-out Strength Better Worse (Gade 2015)

Flow Mixed reports Mixed reports (Lee 2017, Tanomaru-Filho 2017)

Solubility Better (Less soluble) Worse, fails standards (More soluble) (Borges 2012, Tanomaru-Filho 2017)

Volumetric change Better Worse (Shrinks) (Tanomaru-Filho 2017)

Setting time Better Worse (Tanomaru-Filho 2017)

EndoSeal MTA (Maruchi)

• MTA powder with waterless medium• Injected into canals and needs water to diffuse into tooth for it to set• Ie. Similar in principle to TotalFill BC Sealer

AH Plus vs EndoSeal MTAProperty AH Plus EndoSeal MTA

Clinical Success Commonly used in endodontic literature Case Reports

Radiopacity Similar Similar (Lee 2017)

Cytotoxicity Better or similar Worse or similar (Kim 2014, da Silva 2017)

Wetting (adhesion) Worse Better (Ha 2018)

Flow Equal Equal (Lee 2017)

Voids Better Worse (Kim 2018)

Dimensional stability Similar Similar (Lee 2017)

Push-out Strength Better Worse (Silva 2016)

Setting time Better Worse (Lee 2017)

GuttaFlow &GuttaFlow 2 (Coltene/Whaledent)• Guttapercha in powder mixed with polydimethylsiloxane (silicon)

AH Plus vs GuttaFlowProperty AH Plus GuttaFlow

Clinical Success Commonly used in endodontic literature Case Reports

Radiopacity Better Worse (Flores 2011, Tasdemir 2008,

Cytotoxicity Worse or SimilarBetter or Similar (Accardo 2014, Mandal 2014, Silva 2015, Konjhodiz-Prcic 2015, Zoufan 2011, Willerhausen, Saygili 2017, Eldeniz 2007, Bouillaguet 2006)

Film thickness Worse (Zhou 2013)

Flow Better Worse (Nawal 2010, Zhou 2013)Antibacterial activity Better Worse (Nawal 2010, Prestegaard 2014, Willershausen 2011, Farmakis 2011, Ozcan 2011, Pawinska

2018)

Leakage MixedMixed (Patil 2016, Bouillaguet 2008, De-Deus 2007, Savariz 2010, Vasiliadis 2010, Eldeniz 2009, Ozcan 2013, Adhikari 2018, Nawal 2011, Brackett 2006, Monticelli 2007, Jain 2018)

Antifungal activity Better Worse (Ozcan 2013)

Working time Better Worse (Zhou 2013)

Setting time Worse Better (Zhou 2013, Flores 2011)

Solubility Equal Equal or Better (Zhou 2013, Donnelly 2007, Flores 2011)

Dimensional change Worse Better (Zhou 2013, Flores 2011)

Porosity Better Worse (Uyanik 2010)

Wettability Better Worse (Tummala 2012)

Pushout bond strength Equal Equal (Aggarwal 2012)

GuttaFlow &GuttaFlow 2 (Coltene/Whaledent)In tissues, AH Plus is phagocytosed while GuttaFlowis encapsulated in a fibrous capsule

Ie. GuttaFlow sealer puffs may not resorb. Given that it is not antibacterial, what if bacteria is imbedded in the fibrous capsule?

“The presence of endodontic material in a high proportion of periapical lesions suggests a cause-effect association with the inference that clinicians should employ canal preparation techniques that limit apical extrusion of material.”

Ghanaati 2010, Love 2009

The rebuttal of BC Sealer fans

“BUT bioceramic sealers are natural”

“Bio-” merely defines its use in lifeforms

“Ceramics” are defined as non-metallic inorganic solid materials• Therefore, all of the powdered components of MTA,

zinc phosphate, zinc oxide eugenol, calcium hydroxide powder, and GICs technically contain bioceramics. All radiopacifier agents (metal oxides) are ceramics.

• Please don’t assume all bioceramics are good

But BC Sealers are “hydrophilic”

Zinc Oxide Eugenol is made with water

Calcium hydroxide medicament is made with water

They are, therefore, both “hydrophilic”

The rebuttal of MTA-sealer and BC Sealer fans

• “I don’t want resin in my obturation”

• Polytetrafluoroethylene (PTFE / Teflon), polypropylene and polyethylene are plastic resins. They are the standard control material for implantation studies. • There is NO inflammatory response to these plastic walls.

• Plastics are used in orthopaedic implants

• Not all resins are bad

ISO 10993 6

The rebuttal of MTA-sealer and BC Sealer fans

• “I don’t want resin in my obturation”

• Polytetrafluoroethylene (PTFE / Teflon), polypropylene and polyethylene are plastic resins. They are the standard control material for implantation studies. • There is NO inflammatory response to these plastic walls.

• Plastics are used in orthopaedic implants

• Not all resins are bad

ISO 10993 6

But single-cone BC sealer should strengthen teeth and seal better

• Single cone BC sealer vs Single cone AH Plus has no difference in bacterial leakage and voids

• There is no difference in fracture resistance.

• BC Sealers are NOT MTA

Yanpiset 2018, Celikten 2016, Huang 2018, Osiri 2018, Ha 2017

Cold obturation systems – Single cone and Lateral condensation

Darcey 2016

Warm (thermoplastic) obturation systems – Warm vertical and Carrier based

De-Deus 2008, Darcey 2016

Warm (thermoplastic) obturation systems – Warm vertical and Carrier based

De-Deus 2008, Darcey 2016

Efficacy of obturation methods – voids and leakage studies

• Top 20 results on PubMed for “Obturation quality”

Cold lateral condensation Single cone matching prep Carrier-based Warm vertical compaction

More voids Less voids Selem 2003

More voids Less voids Aminsobhani 2015

More voids Less voids Less voids Li 2014

More voids Less voids Kierklo 2015

Equal Equal Alsheri 2016

Worst Better Fracassi 2013

Worst Better overall But better at apical third Naseri 2013

Worst Best Ho 2016

Worst Best Tanikonda 2016

Average Worst Best Keles 2014

Equal Equal Ansari 2012

Equal Equal Balto 2016

Worst Best Robberecht 2012

Worst Average Best Gupta 2015

Equal Equal Equal Somma 2011

Equal Equal but extrusion Clinton 2001

Worst Best Collins 2006

Equal Equal Horsted-Bindslev 2007

Equal Equal Equal De Deus 2006

Worse Best Average Soo 2015

Equal Equal Gordon 2005

Equal Equal Wu 2009

Equal Equal Deniz Sungur 2016

Carriers – works better with taper• 0.08 preparations provided better obturation

qualities than 0.06 and 0.04% tapered samples especially at 1 mm from the apex

• However, greater tapers reduces fracture resistance

Zogheib 2012, Sabeti 2018

Clinical outcomes of lateral condensation vs carriers• No difference between lateral condensation and carrier based

obturations in success and post op pain• But in failures – Cold lateral that is at length or short can be re-treated• Extruded GP requires apical surgery or extraction

• There is a greater incidence of GP extrusion with carrier systems to lateral condensation. Carrier systems can result in underfilling or overfilling based on the rate of insertion.

Clinton 2001, Sarin 2016, Peng 2007, Levitan 2003

Clinical outcomes of lateral condensation vs carriers

Clinton 2001, Sarin 2016, Peng 2007, Levitan 2003

So what is best?

• The matching-taper single-cone technique seems to effectively obturate well-tapered root canals after adequate rotary instrumentation.

Krug 2017

So what is best?

• Irregularly shaped canals require additional lateral or warm vertical condensation to avoid voids.

Krug 2017

(a) Single cone(b) Cold lateral(c) Warm vertical (system B)(d) Carrier (Thermafil)

Sealers: What makes

it better?

• Best: Least voids and/or most sealer penetration into dentinal tubules• Worst: Most voids and/or least sealer penetration into dentinal tubules

Study Lentulo spiral Needle Ultrasonic file

Sonic file / endo activator

Hand file

Paper point

Gutta Percha

Nikhil 2013 Middle Best Worst

Kahn 1997 Best Best Middle Middle Worst Worst

Hall 1996 Best Middle Worst

EDTA before obturation

• EDTA + NaOCl or EDTA-only leads to better sealer penetration than NaOCl-only

Moon 2010

N: 3.5% NaOCl, 1minE: 17% EDTA, 1minEN: 17% EDTA, 1min then 3.5% NaOCl 1 min Obturation length

• Group A: 0-1mm from apex• Group B: > 1mm but < 3mm• Group C: Past the apex

Schaeffer 2005

Obturation materials:

What makes it worse?

Toxic Sealers

• Formaldehyde• “…The AAE does not endorse the use of specific materials. However, the AAE does

recommend AGAINST the use of paraformaldehyde-containing materials as they have proven to be unsafe and ineffective.”

• E.g AH 26, Endomethasone, N2

• Resilon + RealSeal (Methacrylate-resin)• “..teeth obturated with Resilon and RealSeal had 5.7 times greater chance of failure

compared with teeth obturated with GP and AH Plus.”

AH 26 should not to be confused with AH PlusThe properties of methacrylate-resin (e.g. RealSeal) should not to be confused with Epoxy-resin (e.g. AH Plus)

AAE 2017, Evcil 2009, Barboka 2017

GP Extrusion, especially thermoplasticised GP

Fanibunda 1998

Moisture and obturations Sealer Condition Dye

penetrationSealer type Hydro My

Conclusion

AH Plus Dry 1.4 Epoxy-resin -Phobic Dry canals

AH Plus Moist 2.3

Apexit Dry 2.5 CaOH-resin salicylate -Philic Leave moist

Apexit Moist 1.7

Ketac-Endo Dry 3.6 GIC -Philic Leave moist

Ketac-Endo Moist 6.1

RoekoSeal Dry 2.2 Silixane-based with hydrophilic polymers

-Philic Leave moist

RoekoSeal Moist 1.3

Tubli-Seal Dry 4.2 ZOE-based -Philic Leave moist

Tubli-Seal Moist 2.8

Roggendorf 2007

Dry: Until at least 5 paper points do not show moistureMoist: “rehydrated by a 7-day storage at 37°C and 100% humidity in a wet chamber”

Sterilizing GP points

• Staphylococcus has been found on packaged GP

• 2.5% NaOCl sterilizes GP points after 4-10 minutes

• 5.25% NaOCl sterilizes GP points after 1 minute

• However, it leaves salt crystals on the GP

• 2% Chlorhexidine is not effective, even after 72 hours

• GP has mild antibacterial activity as it has ZnO

• Bacterial counts on packaged GP are low

• They will be covered also covered with setting sealer, which is also antibacterial.

• Will contamination with salt lead to reduced sealing?

Ozalp 2006, da Motta 2001, Gomes 2005, Kayaoglu 2009

Sealer puffs

If you try to get sealer puffs

• Advantages• Clinicians can feel confident at the apical constriction and other canal orifices

are sealed.• Sealers typically resorb with time, so mild extrusion is not typically an issue. If

post op pain, it is manageable with analgesics.

• Disadvantages• Some periapical inflammation is expected as it is a foreign body.• Substantial amounts can be irritating to vital tissues and may require surgical

removal

Gluskin 2009

If you try to avoid sealer puffs

• Advantages• You will not have sealer past the apex to cause irritation to the tissues

• Disadvantages• You will typically use less sealer which increases the chances of voids

throughout the obturation.

Gluskin 2007

A closer look at extrusion and sealer puffs

Ng 2011

Obturation recommendations

Epoxy resin sealer• AH Plus for routine cases• Super dry canals before using AH Plus• Use a lentulospiral to apply the AH Plus

Single canals with simple shapes• Single cone if it matches the prep, otherwise

use cold lateral condensation

Multiple canals or complex shapes• Warm vertical

Questions?

• Any further questions,please feel welcome to email me at • w.ha@uq.edu.au

• Or add me on Facebook or LinkedIn• https://www.facebook.com/liamha• https://www.linkedin.com/in/drwilliamha/