COMPARISON OF THREE BIOCERAMIC SEALERS IN TERMS OF DENTINAL SEALING ABILITY IN THE ROOT CANAL

Abstract

Objective: The main objective of endodontic treatment is to prevent further infection or reinfection by eliminating microorganisms within theroot canal system. Proper endodontic treatment could prevent apical and coronal penetration of fluids and microorganisms. Endodontic sealer isvital components of root canal obturation to establish a fluid-tight seal. Bioceramic-based root canal sealers are considered to be an advantageoustechnology in endodontics and have been found to be both biocompatible and comparable to other commercial sealers. The aim of this study was tocompare the adhesion of three bioceramic sealers within the root canal system.Methods: Endodontically treated teeth were obturated using three types of bioceramic sealers and then divided into three groups. Specimens werethen observed using a scanning electron microscope, and the attachment distance was measured using ImageJ.Results: The three groups exhibited were statistically significant differences (p<0.05) in dentinal sealing ability. Calcium phosphate silicate-basedsealer showed the highest sealing ability, followed by pure tricalcium silicate-based bioceramic sealers and then tricalcium silicate and resin-basedbioceramic sealers.Conclusion: The sealing ability of calcium phosphate silicate-based sealer is superior to that of both pure tricalcium silicate-based and tricalciumsilicate- and resin-based sealer.

Full text

International Journal of Applied Pharmaceutics
ISSN - 0975 - 7058 Vol 12, Special Issue 2, 2020
COMPARISON OF THREE BIOCERAMIC SEALERS IN TERMS OF DENTINAL SEALING ABILITY
IN THE ROOT CANAL
SHALINA RICARDO1, CELINE MARISSA2, MUNYATI USMAN1, ENDANG SUPRASTIWI1, RENNA MAULANA YUSUF2,
RATNA MEIDYAWATI1*
1Department of Conservative Dentistry, Faculty of Dentistry, Universitas Indonesia, Jakarta, Indonesia. 2Conservative Dentistry Residency
Program, Faculty of Dentistry, Universitas Indonesia, Jakarta, Indonesia. Email: meidyawati58@gmail.com
Received: 30 July 2019, Revised and Accepted: 01 June 2020
ABSTRACT
Objective: The main objective of endodontic treatment is to prevent further infection or reinfection by eliminating microorganisms within the
root canal system. Proper endodontic treatment could prevent apical and coronal penetration of fluids and microorganisms. Endodontic sealer is
vital components of root canal obturation to establish a fluid-tight seal. Bioceramic-based root canal sealers are considered to be an advantageous
technology in endodontics and have been found to be both biocompatible and comparable to other commercial sealers. The aim of this study was to
compare the adhesion of three bioceramic sealers within the root canal system.
Methods: Endodontically treated teeth were obturated using three types of bioceramic sealers and then divided into three groups. Specimens were
then observed using a scanning electron microscope, and the attachment distance was measured using ImageJ.
Results: The three groups exhibited were statistically significant differences (p<0.05) in dentinal sealing ability. Calcium phosphate silicate-based
sealer showed the highest sealing ability, followed by pure tricalcium silicate-based bioceramic sealers and then tricalcium silicate and resin-based
bioceramic sealers.
Conclusion: The sealing ability of calcium phosphate silicate-based sealer is superior to that of both pure tricalcium silicate-based and tricalcium
silicate- and resin-based sealer.
Keywords: Bioceramics, Dentinal sealing ability, Sealers, Sealing ability, Dentinal tubules, Scanning electron microscope.
INTRODUCTION
Root canal treatment performed to eliminate microorganisms and
prevent reinfection. After cleaning and shaping, an effective root canal
filling is necessary to maintain microorganism-free environment within
the root canal and avoid recontamination [1-3]. The sealing ability,
biocompatibility, and antimicrobial properties of root canal filling
materials are important factors in accomplishing this task. Sealers that
could adapt closely to the dentinal canal walls aimed at preventing
leakage in the apical region [3-5]. As incomplete sealing of the root
canals will lead to major endodontic failure, it is essential to use
materials that can form a hermetic seal within the root canal system.
Filling materials that evoke a biological response at the material dentin
interface represent an improvement in the quality of sealing [6-9].
Bioactive endodontic sealers have been developed to improve
the quality of root canal obturation. There are now three types of
bioceramic sealers with different base materials. These sealers are
calcium phosphate silicate-based bioceramic sealers (BioRoot RCS;
Septodont, Saint-Maur-Des-Fosses, France), tricalcium silicate- and
resin-based bioceramic sealers (MTA Fillapex; Angelus Industry Dental
Products S/A, Londrina, PR, Brazil), and pure tricalcium silicate-based
bioceramic sealers (iRoot; Innovative BioCeramix, Vancouver, BC,
Canada) [10,11].
The components of bioceramic sealers are zirconium oxide, calcium
silicates, calcium phosphate monobasic, calcium, hydroxide, fillers,
and thickening agents. Contemporary studies on bioceramic-based
sealer have found adequate characteristics, including its adhesive
property [5-11].
The bioactive property of the sealer for obturation material, specifically
certain compositions of glasses comprising SiO2, CaO, Na2O, and P2O5,
can bond to either the dentinal or root tissue. In general, when the
bioactive sealer comes into contact with the root canal, it may induce
a phosphate buffered solution, forming a tag-like structure, and it
may form a fluid-tight seal with the root canal. Bioceramic materials
contain calcium phosphate, which enhances the setting properties
of bioceramics and creates a chemical composition and crystalline
structure similar to those of tooth and bone apatite materials [12-14],
thus improving sealer-to-root dentin bonding.
This in vitro study was performed to assess and compare the apical
sealing ability of three bioceramic-based sealers: Calcium phosphate
silicate-based bioceramic sealers (BioRoot), tricalcium silicate- and
resin-based bioceramic sealers (MTAF), and pure tricalcium silicate-
based bioceramic sealers (iRoot), which are considered to be the gold
standard of sealing and adhesion to dentin [15-17].
The aim of this study was to compare three bioceramic sealers in terms
of sealer adhesion in the root canal. The bioceramic sealer may have
similar dentinal sealing ability within the root canal, and better sealing
ability could be obtained from the tested sealers.
METHODS
In this study, we used 27 single-rooted, human mandibular premolars
that were cleaned with a scaler and soaked with 0.9% NaCl solution.
The experiment was performed under ethical clearance protocol
number 051111018 from Universitas Indonesia Ethics and Research
Department. Three team members who had been calibrated performed
the experiments. Specimens were examined under an operating
Research Article
© 2020 The Authors. Published by Innovare Academic Sciences Pvt Ltd. This is an open access article under the CC BY license (http://creativecommons.
org/licenses/by/4. 0/) DOI: http://dx.doi.org/10.22159/ijap.2020.v12s2.OP-6
5th International Conference on Pharmacy and Pharmaceutical Science (ICPPS) 2020

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Ricardo et al.
5th International Conference on Pharmacy and Pharmaceutical Science (ICPPS) 2020 5
microscope (Carl Zeiss Meditec AG, Germany) at ×20, and we excluded
teeth that were either fractured or cracked and had calcifications,
resorbed roots, curved canals, or caries. Radiograph images (Digora,
Soredex, Finland) were obtained to confirm the presence of a single
unmanipulated canal without resorption and calcification. Specimens
were accessed using round diamond burs and then prepared using the
crown-down technique. A #10 K-file (Dentsply Maillefer, Switzerland)
was inserted into the root canal to the tip of the apex, and then, 0.5 mm
was deducted from the apex; this length was determined as the working
length. The samples were prepared through the crown-down technique
using the Rotary ProTaper Next instrument (Dentsply Maillefer,
Switzerland) until ×3 with 0.07 taper.
EDTA gel with 17% concentration was used for preparation. Irrigation
was conducted using 2 ml of 2.5% NaOCl and 1 ml 17% EDTA between
each instrumentation, and agitation was performed using sonic
instruments (Endoactivator, Dentsply, Switzerland). Irrigation was then
concluded using 2 ml of distilled water.
Specimens that had been prepared were then obturated with gutta-
percha ProTaper Next cone (Dentsply Maillefer, Ballaigues, Switzerland)
and bioceramic sealers (iRoot® SP, MTA Fillapex, and BioRoot RCS).
Sealers were inserted into the root canal as per the manufacturer’s
protocols. The coronal area was sealed using resin-modified glass
ionomer cement. Specimens then stored in an incubator for 5 days at
37°C and 100% humidity to allow the sealers to set.
The specimens were then mounted in a wax block, and the quality of
root canal filling was assessed further using Digital Radiograph Imaging
(Digora, Soredex, Finland). Roots were grooved longitudinally and split
into two halves by placing a cement spatula in the grooves and applying
gentle pressure. We then vacuum dried the sections, coated them with
20 nm gold, and examined them at the apical third of the root canal
using a scanning electron microscope (SEM) (Carl Zeiss NTS GmbH,
Oberkochen, Germany). We examined the dentinal sealing ability
and adaptation of each sealant to the dentin at ×1500 and then took
microphotographs. These were then calculated with ImageJ software
(LOCI, Wisconsin, USA).
The gap distances between filler material gutta-percha and dentinal
tubules were measured by picking spots at random at the apical third of
the cross-section. The data obtained were analyzed through parametric
statistical tests using SPSS software ver. 22.0. Statistical analysis was
conducted after first normality tests data. As the data distribution was
normal (parametric), one-way ANOVA statistical test with a significance
limit of α=0.05 was performed.
RESULTS AND DISCUSSION
SEM analysis
SEM analyses of the root canals that were obturated using three
different sealers showed that their adaptation to dentin was sufficient
for good sealing ability along the root canal as seen at Fig 1. The teeth
filled with calcium silicate-based sealers exhibited a smooth contact line
on the sealer-dentin interface as seen at Fig 2. There was a clear margin
between the sealer and the dentinal walls. The teeth filled with gutta-
percha exhibited good adhesion to the dentinal walls (Figs 3 and 4),
and clear bonding surfaces were observed. Moreover, the textures of
the sealers along the root canal were homogenous. The finding was
assessed by studying the gap distance between the sealer and the root
canal.
Statistic analysis
One-way ANOVA confirmed the existence of significant differences in
the dentinal sealing abilities of the three groups. Calcium phosphate
silicate-based bioceramic sealers (BioRoot) was significantly has higher
sealing ability than tricalcium silicate- and resin-based bioceramic
sealers (MTAF) but showed no significant differences with pure
tricalcium silicate-based bioceramic sealers (iRoot). The differences
between the three groups were assessed using three independent
samples through one-way ANOVA with a confidence interval of 95%.
SPSS statistical software (ver. 20.0, Chicago, IL) was used for all
analyses, and p<0.05 was considered statistically significant. Statistical
analysis from Table 1 shows a significance value of p=0.001 (p<0.05),
which reveals that there are significant differences in dentinal sealing
ability between the three groups. The table also shows that Group 1
has the better sealing ability, followed by Group 3 and, last, Group 2
(Table 1).
Based on the significance value of a post hoc test (multicomparison
analysis), the results of the homogeneity test were p<0.018, with a
significance limit of <0.05. As the data were heterogeneous, the post
hoc.
Tamhane test was used. The test showed significant differences in
the gap distance between the three bioceramic sealer groups, with a
significance limit of p=0.001 (p<0.05) (Table 2).
Several studies have demonstrated the presence of microorganisms,
including bacteria, in the dentinal tubules and cementum following
endodontic treatment [7-9]. A root canal sealer with high antimicrobial
activity is an important tool for reducing the growth of microbes and
preventing them from reentering the root canal system [10-13].
Bioceramic material is an ideal bioactive sealant, and available
bioceramic sealers include three different core materials. These sealers
are calcium phosphate silicate-based bioceramic sealers (BioRoot),
tricalcium silicate- and resin-based bioceramic sealers (MTAF), and
pure tricalcium silicate-based bioceramic sealers (iRoot). This study
was conducted to compare the dentinal sealing abilities of these three
sealers.
Root canal sealer adhesion defines as the capacity to aggregate the
root filling material and maintains the filler as a compact mass along
the root canal and provides a single block configuration that seals
the canal space hermetically. Tagger et al. [18] argued that the term
adhesion should be replaced with the term bonding when discussing
sealers as the attachment between the substances involves mechanical
interlocking forces and not molecular attraction. The potential adhesion
of root canal filling materials has been tested commonly from the
perspectives of bond strength and microleakage, and there have been
no standard methods to measure it.
In a similar study, Zhang et al. (2009) examined the sealing abilities of
bioceramic sealers and pure resin-based sealers. They found that both
sealers produced gap-free and gap-containing regions within the root
canals. In this study, we found SEM observation showed that the apical
third adaptation of both bioceramic sealers is quite the same [9,10].
Another study demonstrated that removal of the smear layer had no
Table 1: The mean value and standard deviation of the dentinal
sealing abilities of three different sealers
Sealer n Mean (SD) p value
Group 1 9 3.90 (2.46) 0.01
Group 2 9 42.24 (9.54)
Group 3 9 4.99 (2.17)
Group 1 – calcium phosphate silicate-based bioceramic sealers (BioRoot),
Group 2 – tricalcium silicate- and resin-based bioceramic sealers (MTA Fillapex),
Group 3 – pure tricalcium silicate-based bioceramic sealers (iRoot)
Table 2: The significance values of the dentinal sealing ability of
three different sealers
Sealer type Group 1 Group 2 Group 3
Group 1 0.001* 0.708
Group 2 0.001*
Post hoc Tamhane test, p<0.05

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5th International Conference on Pharmacy and Pharmaceutical Science (ICPPS) 2020 6
direct effect on the sealing ability of pure tricalcium silicate-based
sealer, but the sealing ability with resin addition was less than was that
of pure tricalcium silicate [18,19]. The radiopacity (equal to 7.06 mm of
aluminum) and flow of bioceramic sealers were higher than were those
of resin added sealers.
Solubility is related to the sealing ability of a sealer, as it must be bonded
tightly to dentin and to root canal filling cones [4,7,15,16]. Several
studies have assessed the sealing abilities of different bioceramic-
based sealers in vitro. Further, various methodologies have revealed
that the sealing ability of bioceramic-based sealers is satisfactory and
comparable to that of other commercially available sealers. We used
the same methodology to compare three different sealers to determine
their relative performances to achieve a better prognosis in treating
patients [17,20, 21-23].
The morphology of the root canal may influence the quality of
obturation. We used mandibular premolars with single and straight
canals to simplify the preparation process and facilitate operation of
the microscope. Irrigation solutions of 2 ml each of 2.5% NaOCl and
17% EDTA were applied to clean the root canal effectively, remove
the smear layer, and open the dentinal tubules. EDTA also has low
surface tension and could increase the porosity in root canal treatment,
removing smear layers in particular, which could enhance the sealants’
access and adaptation to the dentin.
Fig. 4: Samples of Group 3 show some mild gaps in a couple of the
dentinal walls and intact sealing ability for the rest of the canals
Fig. 1: Digital radiograph evaluation of obturation. A. Group 1:
Calcium phosphate silicate-based bioceramic sealer. B, Group 2:
Tricalcium silicate- and resin-based bioceramic sealer. C. Group 3:
Pure tricalcium silicate-based bioceramic sealer
Fig. 3: Samples of Group 1 show the capability of the sealer to
create intact seals of the root canal
Our laboratory experiment compared the dentinal sealing ability of
three different bioceramic sealers. Federer’s formula was used to obtain
a total sample of 27 teeth, divided into three groups with nine teeth in
each group. We measured and calculated the gap between gutta-percha
and the pulpodentinal junction [13,24-26].
In this study, the teeth were cut with diamond disc until the cement-
enamel junction was reached to obtain a uniform working length of
15 mm. Root canal preparation was performed using rotary instruments
because that is the most common approach currently, and it simplifies
the preparation process and provides a more uniform preparation.
SEM assesses the dentinal sealing ability and adhesiveness of the sealer
to dentin walls at various levels of sectioning. In this study, SEM showed
that specimens obturated with BioRoot and iRoot had good adhesion to
the dentinal walls and to the gutta-percha core. As expected, there were
differences in the adhesive properties of endodontic sealers because of
their chemical and physical composition [18,19,27-29].
Testing the sealing ability at the root canal revealed no significant
differences between calcium phosphate silicate-based bioceramic
sealers and pure tricalcium silicate-based bioceramic sealers;
however, it revealed significant differences with tricalcium silicate-
and resin-based bioceramic sealers. The tricalcium silicate structure
has substantial granule, it would give adequate sealing ability in
dentinal tubules, despite being lower than the other bioceramic-
based sealers.
Within the limitations of this study, BioRoot and iRoot bioceramic
sealers, along with gutta-percha, outperformed the gold standard, and
the performance of MTAF was not up to par. However, further clinical
studies are necessary to determine the long-term results with these
materials, as it is better to have no gap at all, given that bacteria can be
smaller than 4 microns.
CONCLUSION
Our findings indicated that bioceramic-based root canal sealers yield
promising results and that calcium phosphate silicate-based bioceramic
sealers (BioRoot) have better sealing ability than do pure tricalcium
silicate-based bioceramic sealers and tricalcium silicate- and resin-
Fig. 2: Samples of Group 2 shows a mild gap between the sealer
and the root canal

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5th International Conference on Pharmacy and Pharmaceutical Science (ICPPS) 2020 7
based bioceramic sealers. Difference in the sealing ability of calcium
phosphate silicate-based bioceramic sealers and pure tricalcium
silicate-based bioceramic sealers was statistically insignificant,
showing that the two groups have equal capacity.
ACKNOWLEDGMENT
This study was supported by the Directorate of Research and
Community Engagement of Universitas Indonesia. The publication of
this manuscript was supported by Universitas Indonesia. We thank Dwi
Kamaratih Rubianto for assistance in paper writing.
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