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!