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Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 11-15

Efficacies of mineral trioxide aggregate and bioceramic root canal sealer with two types of gutta-percha toward the apical leakage

1 Department of Conservative Dentistry, Faculty of Dentistry, Trisakti University, Jakarta, Indonesia
2 Department of Oral Biology, Faculty of Dentistry, Trisakti University, Jakarta, Indonesia

Date of Submission01-Oct-2019
Date of Acceptance09-Jan-2020
Date of Web Publication7-Feb-2020

Correspondence Address:
Dr. Christian Eka Pramudita
Department of Conservative Dentistry, Faculty of Dentistry, Trisakti University, Jakarta
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SDJ.SDJ_41_19

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Background: Mineral trioxide aggregate (MTA) is the most widely used material in endodontics, and recently, it has been used as an endodontic sealer. Bioceramic (BC) is a newly developed material based on calcium silicate, which is already used as a biocompatible root canal obturation material to overcome the weakness of MTA. However, there have been no studies comparing the materials used to seal the root canal. Objective: This study aimed to determine the apical leakage differences between BC and MTA sealers with BC-coated gutta-percha (GP) and conventional GP. Methods: In total, 40 mandibular premolars were cut coronally to 14 mm of working length. All samples were randomized and sorted into four groups: BC sealer with BC-coated GP, bioceramic sealer with conventional GP, MTA sealer with BC-coated GP, and MTA sealer with conventional GP. The samples were stored in an incubator, and nail varnish was applied to all root surfaces except for a 1 mm area from the apex. The samples were also soaked in methylene blue for 72 h before undergoing diaphanization. A stereomicroscope was used to measure the methylene blue penetration. All data were analyzed using analysis of variance. Results: There were significant differences in apical leakage between the BC and MTA sealers (P < 0.05). Conclusion: The BC sealer prevented apical leakage better than MTA. The BC-coated GP had better results than the conventional GP, but the differences were not significant, indicating that the choice of sealer is more important in preventing the apical leakage.

Keywords: Apical leakage, bioceramic, mineral trioxide aggregate, sealers

How to cite this article:
Pramudita CE, Iskandar BO, Widyastuti W, Santosa DN. Efficacies of mineral trioxide aggregate and bioceramic root canal sealer with two types of gutta-percha toward the apical leakage. Sci Dent J 2020;4:11-5

How to cite this URL:
Pramudita CE, Iskandar BO, Widyastuti W, Santosa DN. Efficacies of mineral trioxide aggregate and bioceramic root canal sealer with two types of gutta-percha toward the apical leakage. Sci Dent J [serial online] 2020 [cited 2023 Jun 9];4:11-5. Available from: https://www.scidentj.com/text.asp?2020/4/1/11/277875

  Background Top

Endodontic treatment has a predictably high success rate, often around 86%–98%. However, endodontic treatment can fail if the procedure does not follow the appropriate operational standards. The main factor in endodontic failure is related to a persistent infection of microorganisms in the root canal and the periradicular tissue, which can cause a flare-up.[1] Flare-ups have become quite a serious problem for patients and operators. According to Tsesis et al., in 982 patients from six studies, the frequency of flare-ups reached 8.4%. This prevalence is high enough that an adequate treatment is needed to prevent this.[2]

Endodontic treatment must remove all necrotic tissues in the root canal and fill the root canal system in three dimensions to prevent tissue fluid and bacterial toxin products from seeping into the periradicular tissue and reinfection by microorganisms.[3] The varying shapes and sizes of the root canal complicate the process of cleaning and obturating the root canal; therefore, gutta-percha (GP) is needed as a master point and root canal sealer to close the micro gaps in the root canal system and all portals of exit, creating a hermetic state.[4] GP is the most common material for filling the root canal. However, GP itself is not able to hermetically close the root canal, as it has no adhesive properties. To combine the strength of GP with the attachment capability of a root canal sealer, GP is coated with the same material found in the root canal sealer, increasing GP's ability to attach the root canal sealer to the root canal wall, forming a monoblock.[5] To get this adherence, GP is combined with hydroxyapatite (Hydroxy/Apatite Gutta-Percha) layer to increase its attachment to the root canal sealer and indirectly adhere to the surface of the root canal dentin.[5] The use of bioactive hydroxyapatite can cause the deposition of inorganic particles on the root canal surface during the degradation process, which increases the adhesion ability and induces crystal growth on the surface material.[6] Therefore, GP requires a root canal sealer to produce complete canal closure.[7]

Root canal sealer can contribute to the endodontic treatment failure due to microleakages in the dentin- or core-sealer connections. The attachment of root canal cement to the root canal wall forms a monoblock, which can eliminate these deficiencies.[4] However, reinfection can occur due to a leak in the root canal after an endodontic treatment, which allows the growth of opportunistic microorganisms in the root canal system. One of the causes of reinfection is the presence of microleakages if the root canal cement is unable to tightly close the entire root canal system. Microleakages in the apical foramen cause 60% of root canal treatment failures; therefore, new root canal filling material and more developed root canal obturation techniques are essential to perfecting the existing materials.[8]

Mineral trioxide aggregate (MTA) is a material that is often researched and has been shown to have good biocompatibility and good sealing ability.[9] However, the deficiencies of MTA include fairly difficult manipulations and long hardening times. Therefore, researchers are looking for a material that can overcome the weakness of MTA.[10] One of the root canal sealers with promising properties as an ideal root canal sealer is bioceramic (BC).[9]

BC is one of the newest types of root canal sealers, which can be used in endodontic treatment. It consists of zirconium oxide, calcium silicate, calcium phosphate monobasic, calcium hydroxide, and various other fillers.[4] It is available in the form of a calibrated, premixed syringe with an intracanal tip. There are two main advantages of using BC as root canal cement. First, its good biocompatibility can prevent rejection by the surrounding tissue. Second, BC material contains calcium phosphate, which improves its bond strength to root canal dentin after hardening so that it has a structure and crystals that are similar to teeth and bone apatite, increasing its adhesion to the root canal wall. However, one of the biggest disadvantages is that BC is difficult to remove from the root canal wall after it has hardened, making re-treatments difficult to perform.[9] To prevent the leakage of a root canal, researchers keep on looking for the best material to deliver the hermetic seal of the root canal system. This study aims to determine the leakage differences when filling the apical third of the root canal using four combinations of MTA and BC root canal sealers and BC-coated GP and conventional GP.

  Materials and Methods Top

This is an experimental laboratory study with a parallel design to evaluate apical third leakages using two types of root canal cement and two types of GP. Mandibular premolar teeth were selected through a random sampling and randomly assigned to four treatment groups using different combinations of the root canal cement and the GP: Group I: SureSeal BC (SureEndo™) root canal sealer and BC-coated GP; Group II: MTA Fillapex (Angelus™) root canal sealer and BC-coated GP; Group III: SureSeal BC (SureEndo™) root canal sealer and conventional GP; and Group IV: MTA Fillapex (Angelus™) root canal sealer and conventional GP. In this study, eight samples were obtained from the previous study by Al-Haddad et al., which were rounded off into 10 samples per group.[5]

All the study samples were collected and stored in saline solution and were taken radiographically to ensure that all of the premolar teeth had single, straight roots. All samples were equated in length by cutting perpendicular to the axis of each tooth using a diamond bur fissure up to a sample length of 15 mm. The working length of each sample was measured using a k-file #10 until it reached the apical foramen and was cut by 1 mm at the apical area, which was confirmed using an endo gauge. The apical foramen diameter was determined by inserting a k-file #15 until 3 mm beyond the apical foramen.

Preparation was carried out using a ProTaper Universal 21 mm file from S1 to the F2 size. Each turn of the root canal file was irrigated using 5 ml sodium hypochlorite, and the last irrigation was done sequentially as sodium hypochlorite (5.25%), distilled water, 17% ethylenediaminetetraacetic acid (EDTA), distilled water, and 2% chlorhexidine.

Obturation was performed using a single-cone technique. Then, GP #25, both BC coated and conventional, was inserted into the root canal in both MTA Fillapex (Angelus™) and SureSeal BC (SureEndo™) sealer groups, and radiographs were taken to confirm the preparation. The excess GP in the coronal section was cut using a heat-carrying instrument and condensed using a plugger up to 2 mm below the reference point. All samples were given a moist cotton pellet at the apical and coronal of the teeth for 12 h to create a humidity condition that was similar to the state of the body to induce hardening. Then, glass-ionomer cement was used to seal the coronal part of the tooth.

All samples were given three layers of nail varnish so that all of the outer layers of the tooth root except in the apical part were impermeable. Next, the samples were immersed in methylene blue for 72 h. Afterward, they were washed under running water, and the nail varnish was removed.

The diaphanization process started with decalcification. The samples were immersed in 5% nitric acid for 72 h. Next, they were agitated every 8 h, and the nitric acid was replaced every 24 h. Subsequently, the samples were washed under running water for 3 h, and a dehydration process was carried out using an alcohol liquid starting at concentrations of 80%, 90%, and 100% for 1 h for each concentration. After that, the samples must be immersed into methyl salicylate to fix for 2 h.

The samples were examined using a stereomicroscope to determine the penetration of the dye in the apical third of the root canal. The specimens were placed on a  Petri dish More Details and immersed in methyl salicylate to keep the samples moist and were then placed on a millimeter block paper. Apical leak measurements were performed by measuring the penetration of the methylene blue in the buccal, palatal, mesial, and distal sections of the root canal. Adobe Photoshop (Adobe Inc., Released 2012. Adobe Photoshop CS6 for Windows, Michigan, USA: Adobe Inc.) was used to measure using a virtual ruler.

Statistical analysis

The apical leakage results obtained from the samples were analyzed for normality using the Saphiro–Wilk test and when the data obtained were normally distributed and then analyzed using the one-way analysis of variance test. Statistically significant differences were found (P < 0.05), so these tests were followed by a post hoc Tukey test. SPSS (IBM Corp., Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY, USA: IBM Corp.) was used for statistical calculations.

  Results Top

The research data were derived from methylene blue dye penetration calculations for root canals that had been filled using MTA Fillapex (Angelus™) and SureSeal BC (SureEndo™) root canal sealers and the two different types of GP. The mean and standard deviations of the apical leakages for the root canal sealer and GP combinations are shown in [Figure 1] and [Table 1].
Figure 1: Methylene blue penetration on the foramen apical seen using stereomicroscope. (a). SureSeal bioceramic (SureEndo™) sealer with bioceramic coated GP. (b) SureSeal bioceramic (SureEndo™) sealer with conventional GP. (c) Mineral trioxide aggregate Fillapex (Angelus™) sealer with bioceramic coated GP. (d) Mineral trioxide aggregate Fillapex (Angelus™) sealer with conventional GP. GP: Gutta-percha

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Table 1: Mean and standard deviations of the apical leakages (mm)

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To determine the differences between the groups, post hoc tests were performed using the Tukey honestly significant difference method listed in [Table 2]. There were statistically significant differences (P < 0.05) in all groups, but the MTA Fillapex (Angelus™) sealer with conventional GP and SureSeal BC (SureEndo™) sealer with GP BC-coated groups have the most significant difference.
Table 2: The apical leakage results for the different root canal sealer/gutta-percha combinations using the post hoc Tukey test

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Based on the results of the post hoc Tukey test, it is evident that there are differences in root canal sealers made from MTA Fillapex (Angelus™) and SureSeal BC (SureEndo™) using conventional or BC GP in terms of apical leakage. In other words, the test yielded different results for the penetration of the methylene blue solution from the apical area toward the coronal.

  Discussion Top

The results in this study indicate that no root canal sealer can completely obturate the root canal. The MTA Fillapex (Angelus™) with conventional GP group had the biggest penetration in terms of the level of the dye, while the SureSeal BC (SureEndo™) sealer with BC-coated GP group had the best result. However, the statistical test results showed that there were no significant differences in the SureSeal BC (SureEndo™) with BC-coated GP and BC with conventional GP groups, indicating that the SureSeal BC (SureEndo™) root canal sealer had a greater role in preventing the apical leakage.

The SureSeal BC (SureEndo™) root canal sealer involves a premixed paste preparation step that uses the moisture of the root canal to begin the hardening process. When working in vitro, it is difficult to condition the teeth with 100% humidity to match in vivo conditions, which might affect the time and level of hardness of the root canal sealer in the teeth. In a study by Lee et al., SureSeal BC (SureEndo™) root canal sealer and MTA Fillapex (Angelus™) did not achieve complete hardening under normal humidity,[11] however, which have been soaked in damp cotton for 12 h, it can ensure that the root canal sealer has hardened completely before the leak test.

There are two main advantages associated with using BC material as a root canal sealer. First, the biocompatibility of this material prevents the rejection of the surrounding tissue.[12] Second, BC material contains calcium phosphate, which enhances the hardening properties of the BC so that the chemical and crystalline structure composition resembles teeth and bone apatite, resulting in superior adhesion to the tooth tissue.[13] However, one of the biggest drawbacks of this material is that it is difficult to release BC material into the root canal when retreatment or preparations for postplacement are required.[14]

Shokouhinejad et al. examined the ability of BC material to attach to various types of irrigation solutions, such as sodium hypochlorite, EDTA, and chlorhexidine. The results of Shokouhinejad et al.'s studies showed no significant difference in the strength of the BC attachment toward the root canal wall.[15]

In general, SureSeal BC (SureEndo™) root canal sealer has a better density than MTA Fillapex (Angelus™) root canal sealer, owing to the hardening process of the BC material, which expands by absorbing moisture around the root canal wall. However, the absorbed moisture can increase the density, which can have a negative impact if the volumetric expansion is too large, increasing the risk of vertical root fractures. Meanwhile, the MTA Fillapex (Angelus™) root canal sealer is mixed with salicylate resin, which might affect the level of shrinkage so that the leakage of this sealer is quite high when combined with a single cone obturation technique.[10]

Conventional GP does not attach to root canal dentin or root canal sealer; this can be explained by the higher apical leakage rate in conventional GP in both root canal cement groups.[4] The BC-coated GP showed the least amount of leakage. This can be explained by the GP surface, which can adhere to the root canal sealer, increasing the root canal tightness, which was superior to the tightness found with the other groups.[5]

  Conclusion Top

SureSeal BC (SureEndo™) is better at sealing the root canal to MTA Fillapex (Angelus™); the results demonstrate that there was less leakage found in the apical third of the root canals. The type of GP used also influenced the apical leakage rate, proving that the GP's degree of adhesion to the root canal sealer was very influential on the apical third leakage rate. The BC-coated GP had promising results for minimizing the level of dye penetration in the apical third of the root canals in this experiment. Therefore, the combination of SureSeal BC (SureEndo™) sealer and BC-coated GP is the best to seal the apical third of the root canal using a single-cone technique. This research can be developed further by using a filling technique in addition to the single-cone technique. Future research can also observe the same materials using a scanning electron microscope to see the microfissures formed in filling the root canal.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Pawar SS, Pujar MA, Makandar SD. Evaluation of the apical sealing ability of bioceramic sealer, AH plus and epiphany: An in vitro study. J Conserv Dent 2014;17:579-82.  Back to cited text no. 4
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Cherng AM, Chow LC, Takagi S.In vitro evaluation of a calcium phosphate cement root canal filler/sealer. J Endod 2001;27:613-5.  Back to cited text no. 14
Shokouhinejad N, Hoseini A, Gorjestani H, Shamshiri AR. The effect of different irrigation protocols for smear layer removal on bond strength of a new bioceramic sealer. Iran Endod J 2013;8:10-3.  Back to cited text no. 15


  [Figure 1]

  [Table 1], [Table 2]

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[Pubmed] | [DOI]


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