Asaf Harel
5thcourse, group 13
COMPARISON OF 3 DIFFERENT TYPES OF ROOT CANAL SEALERS TO THE MOST COMMONLY USED SEALER AH-PLUS
Master’s Thesis
Supervisor
PhD, Eduardas Kelbauskas
Kaunas,2017
Table of contents
Summery... 2
Objectives: ... 2
Material and Methods ... 2
Results ... 2
Hypothesis ... 2
Introduction ... 3
Material and methods ... 4
Search strategy:... 4
Types of publication ... 4
Types of studies ... 4
Information sources ... 4
Population... 4
Selection criteria ... 4
Exclusion criteria... 4
data collection process:... 5
Main Outcome: ... 6
Outcomes ... 6
Table1. Cytotoxicity of root canal sealers. ... 6
1. Cytotoxicity test of root canal sealers ... 8
1.1 MTT assay ... 8
1.2 Zymography test ... 8
1.3 Cytotoxicity assay ... 9
Table 2. Micro-leakage evaluation ... 9
Micro-leakage test of root canal sealers ... 10
Table 3. Solubility of root canal sealers ... 11
Solubility test of root canal sealers... 13
Table 4. Dentinal tubules penetration... 13
Penetration to dentinal tubules ... 14
Table 5. PH level of root canal sealers ... 15
PH test ... 16
Table 6. Radiopacity test of root canal sealers. ... 16
Radiopacity test ... 17
Table 7. Risk of bias ... 18
Table 7. Materials compositions... 19
Results: ... 20
Discussion... 20
Conclusion ... 22
Clinical recommendations ... 23
References ... 23
Summery Objectives:
The aim of this study was to systematically review the comprehensive and comparative overview of literature data of 3 different types of root canal sealers using in endodontic treatments in our days based on different types of materials such as MTA (mineral trioxide aggregate), zinc oxide eugenol sealers, calcium hydroxide based sealers compare to most common used sealer AH-Plus (Dentsply), as well to determine the dentinal tubules penetration, micro leakage, cytotoxicity, PH and sealing efficiency.
Material and Methods
Total 52 literature sources were reviewed. Literature was selected through a search of MEDLINE PubMed electronic databases and Google scholar. The most 23 relevant articles were selected. The search was restricted to articles which were published from 01.01.2011 to 31.12.2016. exception of one article from 2017 has been used.
Key words: root canal sealer, AH-Plus, cytotoxicity, micro-leakage, solubility
Results
In this systematic review 23 articles were examined and divided into 6 groups by main characteristics and results confirmed the ability of AH-Plus® (dentsply) resin-based sealer which is the most common used sealer today to be with the requirements for root canal sealers. After examination and summarizing the tests it was found that Ah-Plus have low cytotoxicity as shown in table 1. Concerning dentinal wall/tubules penetration AH-Plus have significant higher dentinal wall penetration compare to other tested sealers as shown intable 4. Concerning micro-leakage, AH-Plus have higher micro-leakage properties and less sealing ability as shown in (table 2 ) this result can influence on the quality of the treatment with this root canal sealer. Concerning the PH levels, the most natural PH level from all tested sealers was AH-Plus as shown intable 5. Ah-Plus have low solubility compare to other tested sealers except one article which had different results concerning to solubility of AH-Plus as shown in table 3. Regarding radiopacity of the sealers, AH-Plus showed significant higher results compared to other tested sealers as shown intable 6.
Hypothesis
AH-Plus considered as the most common used sealers in our days, has AH-Plus have all properties which required from root canal sealers to be compared to other types of sealers.
Introduction
Endodontic treatment is done when there is some pulp disease such as pulpitis or when there is periodontal related to pulp disease such as apical periodontitis. Good endodontic treatment can be evaluated by shaping of the canal, cleaning of the canal, and obturation of the canal. The main purpose of endodontic treatment is an elimination of bacterial spreading and their products to the apical tissues and recontamination by bacteria. Elimination and killing of microorganisms are done by irrigation materials (1) such as Ethylenediaminetetraacetic acid (E.D.T.A) and sodium hypochlorite, to get the best results and to prevent any complications choosing the correct irrigation materials, and to work by protocol is necessary. Cleaning and shaping are done by using different techniques and by different types of instrument such as nickel titanium (NiTi) instruments, stainless-steel instruments, during the last decade's many types of NiTi instruments techniques are presented to the market. The prevention of recontamination and spreading of bacteria and their products into periapical tissues (2) is done by root canal obturation with different types of gutta-percha and in addition root canal sealers. The function of root canal sealers is to block the pathway of bacteria and to prevent micro-leakage, Root canal sealers should prevent recontamination by sealing the lateral and the main canal and to prevent colonization of bacteria, in addition penetration to dentinal tubules is very important feature, root canal sealers should fill the space which created between the gutta-percha and the root canal wall.
Today there are seven types of root canal sealers which are using in practice and can be classified according to their chemical composition such as mineral trioxide aggregate (M.T.A) based sealer, zinc oxide eugenol based sealer, epoxy based sealers silicone-based sealer, bioceramic based sealer, calcium hydroxide based sealer and glass ionomer based sealer. The most common used root canal sealer today is AH-Plus® (Dentsply, DeTrey, Konstanz, Germany) which based on epoxy resin, in this systematic review I will compare different groups of root canal sealers to AH-Plus® sealer. Today most of the complications which occur after endodontic treatment is because of inadequate sealing of the root canal. Biocompatibility is important factor and should be taken in consideration since sometimes passing of sealers to periodontal tissues can happen because of anatomy of the root canal or apex foramen or by iatrogenic factors which can lead to endodontic treatment failure (3). dentinal tubules penetration, solubility and PH-level properties of root canal sealers are very important features which must be taken in consideration when choosing the correct root canal sealer to work with during our practice. In this systematic review the main characteristics and properties of root canal sealers will be mention, in addition there are some international requirements for root canal sealers for solubility and for setting time as well. by data collection from articles and results the ability of the most common used root canal sealer (AH-Plus) will be tested and comparison between different types of root canal sealers based on different types of material will be done.
Material and methods
Search strategy:
This systematic review was conducted following the PRISMA (preferred reporting items for systematic reviews and meta-analysis) statement (4). Total 52 literature sources were reviewed.
Literature was selected through a search of PubMed electronic databases. The most 23 relevant articles were selected. The search was restricted to articles which were published from 01.01.2011 to 31.12.2016. In addition, one search has done in 2017 and article has been used in this systematic review.
Types of publication
The review included systematic reviews, clinical studies in the English language published between 2011 to 2016. Additional search has done of one articles which were published on 2017.
Types of studies
The review included all types of relevant studies which published from the last five years as well as case reports which were using the relevant materials.
Information sources
The information sources were the MEDLINE - Pub-Med database.
Population
Studies include: in vivo and in vitro that included the relevant information on sealers.
Selection criteria
Clinical studies in vivo and in vitro reviewed the effectiveness of different types of sealers on cytotoxicity, micro-leakage, adherence to dentin, radiopacity and solubility. The number of samples which were tested during all procedure was not relevant. The articles were selected by:
- English language.
- AH-Plus compare to different types of sealers.
- Cytotoxicity of AH-Plus compares to different types of sealers.
- Solubility and PH of AH-Plus compare to different types of sealers.
- dentinal tubules penetration of AH-Plus compare to different types of sealers.
- radiopacity of AH-Plus compare to different types of sealers.
- articles from the last five years.
-at least one tested group for comparison.
Exclusion criteria
- more than five years since publication of articles (exceptions of 1 article have been used) - articles with less relevant abstracts and material which were used for comparison.
data collection process:
the search results provide 1366 articles, by the selection criteria, full text, English language, after filtering for not more than five years the search provide 491 articles, less relevant abstracts were removed and 52 articles were chosen, in addition articles with less relevant types of materials were removed as well. After examination of the articles, the most 23 relevant articles have been used for this systematic review.
NCBI PubMed advanced search:
-search terms: "root canal sealers"; "root canal sealers and cytotoxicity"
; root canal sealers dentin penetration; "AH-Plus root canal sealer"; "mta root canal sealers"; "root canal sealer cytotoxicity" ; "root canal sealers solubility" ; "root canal sealers micro-leakage" ; "zinc oxide eugenol sealers" ; "calcium hydroxide sealers";
- Species: in vivo, in vitro;
- Language: English;
(n=491)
Search results 491
Titles and abstracts were selected according relevancy (n=52)
Filtered
-Irrelevant materials using for comparison
(n=29);
Articles examined (n=23)
Filtered
- No articles were excluded at this stage
(n=0);
Articles included (n=23)
Filtered
Publication dates from January 2011 to December 2016
Main Outcome:
Main outcome was to improve the ability of AH-Plus which is the most common used sealer to be the best compared to other types of root canal sealers by all properties which mentioned above as cytotoxicity, PH level, solubility, dentinal tubules penetration, radiopacity and micro-leakage.
Outcomes
Table1. Cytotoxicity of root canal sealers.
Author/year Level of evidence/study design/participants/inclusion
criteria
Intervention and control
groups
Outcome measures
results
Kierklo A.
et-al.
2015
Level IV RCT
24 well cultured dishes with human fibroblasts Control group N=6 Intervention group N=18
Ex-vivo
Intervention groups:
Human fibroblasts
Control groups:
24 plates with no material
MTT assay special criteria
compared to control group:
No cytotoxicity
>90%
Low cytotoxicity 60%-90%
Moderate cytotoxicity
30%-59%
High cytotoxicity
<30%
Sealers based on calcium hydroxide
showed significant higher toxicity levels than AH-
Plus
Silva EJNL et-al.
2013
Level II RCT
Balb/c 3T3 cells, AH-Plus and MTA
Control group N=1 Intervention group N=2
In vitro
Control group:
only culture medium intervention
groups:
MTA- (fillapex) and AH-Plus
(MTT) Tetrazolium bromide assay 1to 4 weeks and
mean of results by tukey test.
Cytotoxicity results rated as
severe 30%, moderate 30%–
60%, slight 60%–90% and
non-cytotoxic
>90%.
MTA showed significantly higher toxicity level than AH- Plus which was
natural
Silva EJNL et-al.
2015
Level II RCT
AH-Plus, gutta flow.
Control group N=1 Intervention group N=2
In vitro
Intervention group:
3T3 cells incubates with AH- Plus and gutta flow
for 24h,
MTT and LDH assays were
tested the cytotoxicity, for statistical means ANOVA were
used, and for statistical
AH-Plus showed significantly less
sell viability.
determined the MMP9 and MMP2 fibroblasts
release.
Control group: cells which were cultured for 24 hours
differences between groups
tukey test were used.
Ashraf et-al.
2012
Level IV RCT
Cytotoxicity evaluation on L929 cell lines Control group N=2 Intervention groups N=2
In vitro
Intervention groups: fresh
and set groups Control groups:
dulbeco modified
eagle medium and
pulp canal sealer.
Positive and negative.
MTT assay for cytotoxicity
evaluation.
After one-hour AH-Plus was
significantly more cytotoxic.
After 24 hours no significantly difference from control groups.
After 72 hours no significantly
change
Silva EJNL.
et-al.
2012
Level IV RCT Human fibroblast.
Control group N=1 Intervention groups N=4
In vivo
Intervention group:
human fibroblast incubation for periods of 30 min, 1,4,24 h Control
group:
human fibroblast incubation
for 24 h
Zymography:
measured by a gelatin zymogram protease assay
Cytotoxicity:
measured by Kodak analysis
system.
AH-Plus showed significantly higher level of
cytotoxicity amongst the tested sealers
Brackett MG.
et-al.
2012
Level IV RCT
Mouse osteoblasts and human monocytes.
Control group N=1 Intervention groups N=6
In vivo
Intervention group: six
different types of
sealers.
Control group:
Teflon®
MTT method for mitochondrial
succinate dehydrogenase
activity
AH-Plus activation of osteoblasts and
monocytes similar to other
tested sealers
1. Cytotoxicity test of root canal sealers
Sealers may pass into periapical tissues due to different reasons such as anatomy of the canal or tooth, over filling during condensation of filling material together with root canal sealers might lead to treatment failure after a long time of exposure to endodontic sealers in periapical areas, sealers may cause to inflammatory reactions such as phagocytosis and might cause to inactivation of alkaline – phosphate which is necessary for bone formation (3), additionally group of zinc enzymes which are important group that responsible for degradation collagen and gelatin which involve in bone remodeling, wound healing and play an important role in chronic inflammatory process in the pulp and periodontal destruction process (5). In an article which made by Kierklo A. et-al, it was reccomend that all root canal sealers must be tested before clinical use and to consider in biocompatibility properties of the root canal sealers(3).
1.1 MTT assay
Mosman's tetrazolium toxicity (MTT) assay is a common method to evaluate the cells metabolic activity or viability for root canal sealers by evaluation of mitochondrial activity of cells, enzymes converting the soluble tetrazolium salt into dark blue crystals (6), on a test which made by Ashraf H et-al (7). They found by using of fresh and set states of AH-Plus compare to other resin- based sealers on mouse L-929 fibroblasts that after 1 hour of incubation the fresh AH-Plus was more cytotoxic than the set, after 24 hours AH-Plus was at the same level of cytotoxicity with other based resin sealers but less than positive group which were Dulbecco's Modified Eagle Medium (DMEM), after 72 hours of incubation the AH-Plus was at same level with the positive group (7). on other MTT assay test which made by Silva EJNL, Rosa TP et-al (5). They compared between AH-Plus and MTA based sealers, the test has shown that the MTA group were more cytotoxic than the group of AH-Plus for all period of time, the group of AH-Plus was moderately cytotoxic after one week and after two weeks was non cytotoxic at all (5). by MTT assay it is clearly that AH-Plus have the ability to have significant lower cytotoxicity properties than MTA group.
1.2 Zymography test
In zymography test which made by Silva EJNL, Accorsi-Mendonça T et-al (8). They tested the activity of MMp-2 and MMp-9 human fibroblasts with gelatin zymography , the test has shown that all sealers based on calcium hydroxide and AH-Plus caused to expression of MMP-2 but not expression of MMP-9, in addition no gelatinolytic activity has occurred during all tests, after 24 hours both sealers has shown same level of gelatinolytic activity (8). On zymography test which made by Silva EJNL, Neves Aa, et-al (6) the test has checked the differences on silicone based sealers and AH-Plus sealers, the results were different, AH-Plus showed significantly higher results of the gelatinolytic activity as well as MMP-2 were higher levels than the silicon-based sealers group (6).
those result can explain the biocompatibility of AH-Plus, silicon and calcium hydroxide based sealers and the ability of AH-Plus to use as a factor to the inflammatory process
1.3 Cytotoxicity assay
On testing which made by trypan blue exclusion assay to check the activity of MMP-2 and MMP-9 human fibroblasts and gelatinolytic activity the test was found that AH-Plus compare to other sealers with different based materials such as zinc oxide eugenol (zoe), calcium hydroxide (sealapex™), was in the highest toxicity level compare to others, gelatin formation was at the same level with all compared sealers while the lowest toxicity level was calcium hydroxide based sealer (sealapex™) (8), in addition, cytotoxicity testing which was made by Brackett MG, Lewis JB et-al (9) for MC3T3 mouse osteoblast for assessing the cytotoxicity for root canal sealers, THP1 human monocytes cells tested as well since those cells are very important part of chronic inflammation process and taking main part during healing procedure as well (9). After long time exposure of one year to endodontic sealers based on, zinc oxide eugenol, resilon based sealers were tested by succinate dehydrogenase (SDH) activity, the test compared those root canal sealers to AH-Plus and exposure to MC3T3 and THP1were tested, before testing of 52 weeks all materials which were tested caused to suppression of MC3T3 and SDH activity except gutta-flow, after 52 weeks of aging and incubation of sealers in 37 degrees for 72 hours in 100% humidity the sealers which were mentioned before was tested and caused to much less suppression of SDH and monocytes activity, the test improved that AH-Plus and gutta-flow was the most stable materials after long period of exposure to those sealers (9) . after using the cytotoxicity assay all researches has followed by MTT assay for final results of cytotoxicity. Those results can verify the stability of AH-Plus and the ability of calcium hydroxide - based sealers to have significant less cytotoxic properties compared to other tested sealers including the AH-Plus.
Table 2. Micro-leakage evaluation
AUTHOR/YEA R
LEVEL OF EVIDENCE/STUDY DESIGN/PARTICIPANTS/INCLUSI
ON CRITERIA
INTERVENTIO N AND CONTROL
GROUPS
OUTCOME MEASURES
RESULTS
Wong JG et-al.
2013
Level IV RCT
Control group N=2 Intervention groups N=7 12 groups of bovine single root
incisors In vitro
Control groups contain the AH-Plus and
zinc oxide eugenol sealer
(tubli-seal)
Microscope examination of sectioned teeth, then
mean of results by
ANOVA test
AH- showed statistical significant
higher levels of
micro- leakage.
Micro-leakage test of root canal sealers
The final step in root canal treatment is the Obturation process which can be done by different types of materials such as gutta-percha cones in combination with sealers in lateral condensation technique, in addition, other techniques such as warm condensation with warm gutta-percha (resilon based). The purpose of obturation is to prevent micro-leakage of bacteria and their products from penetrate to peri-apical tissues as well as to maintain the good sealing of the root canal and provide long period
Silva RV et-al.
2015
Level IV RCT
On 40 single root premolars.
Intervention groups N=4 In vitro
Intervention groups:
G1: AH-Plus G2: MTA based sealer
(fillapex) G3: seal apex
G4: ETW
Confocal and stereo- microscopic
imaging testing the
dentinal penetration
and space remaining as
well
MTA showed significant difference between 2mm and 6
mm and AH-Plus
showed significant difference at 2mm and 6 mm In dentinal penetration and micro- leakage.
Sultan.M, et-al.
2016
Level IV RCT
100 freshly extracted maxillary incisors.
Control group N=3 Intervention groups N=6
In vitro
Intervention groups:
combinations of gutta-percha
and Epiphany, gutta-percha and AH Plus, control group gutta-percha .
Stereo- microscopic
evaluation and dye penetration
for millimeter evaluation
AH-Plus showed significant
higher leakage
than Epiphany
sealers (calcium hydroxide
based sealer) Maryam
Ehsani et-al 2012
Level IV RCT
90 extracted maxillary central incisors.
Control groups N=10 Intervention groups N=8
In vitro
Intervention groups: 4 types
of sealers Control groups:
5 negative and 5 positive groups unfilled
canals
Stereo- microscopic
evaluation with 2X magnificatio
n
Micro- leakage of
AH-Plus showed significantl
y less results than
MTA and ZOE
of healthy apical tissues after treatment (10), micro-leakage test of combination and comparison between three different types of root canal sealers based on zinc oxide eugenol ,MTA and thermoplastic to AH-Plus found that in 2mm from apex the MTA, the sealer based on zinc oxide eugenol had better results, while in 4 and 6 mm from root apex AH-Plus had better results than others,(11) on test which made by Sultana M et-al they found that the major disadvantage and very important characteristic of root canal sealer AH-Plus was that there is no chemical bonding between the gutta-percha and the sealer (10), which might has the main cause for micro-leakage and after long time can be considered as the main factor for treatment failure, in addition, thermoplastic in combination with resilon has proved that had better sealing for all period of test (10). In other ex-vivo test which made by Wong JG, Caputo AA, Li P, White SN (12), on comparison between different types of sealers found that all sealers are leak no sealer had hundred percent of sealing ability, there was significantly difference between zinc oxide eugenol based sealer and AH-Plus, AH-Plus had the highest values of micro-leakage, in addition the test found that all sealers had more micro-leakage on apical part than the coronal part of the root (12). On test which made by Maryam Ehsani et-al (13).
The test checked the zinc oxide eugenol (ZOE) and MTA compared to AH-Plus, the results confirmed that AH-Plus have less micro-leakage than other tested sealers which had significant higher leakage.
the conclusion is: from the results, AH-Plus have good sealing properties with minimum leakage and showed that in some tests the ability to be with less leakage compared to other types of sealers (13), AH-Plus have higher leakage in different places in the root canal than other sealers which tested.
Those results need to investigate further studies to confirm it.
Table 3. Solubility of root canal sealers Author/year Level of evidence/study
design/participants/inclusion criteria
Intervention and control groups
Outcome
measures results Schäfer E.
et-al.
2013
Level IV
RCT3 different types of sealers on plates and stainless steel rings
Control group N=10 Intervention groups N=6 In vitro
Control groups were 10 empty samples incubate for 28 days Intervention groups: 6 samples of each sealer
Weight loss measures by % relate to original weight of sealer And analysis by ANOVA
From all tested sealers AH-Plus showed significantly less solubility results
Ersahan S et-al.
2013
Level IV
RCT80 extracted mandibular premolars
Control groups:
Extracted toot N=4
Weight gain or loss measured for 6-hours, 24-
AH-PLUS has significantly lower micro- leakage than
Intervention groups N=4 control group N=2 In vitro
Intervention groups 4experimental groups of Extracted roots N=18
hours and 14-
days MTA and
from calcium hydroxide based sealers and met the ANSI/ADA’s requirements for solubility.
Faria-Júnior et-al.NB, 2013
Level IV
RCT7 different types of sealers.
Control group N=3 Intervention groups N=7 In vitro
Control group: biofilm did not
exposed to sealers Intervention group:
5 discs from each sealer of 2 periods, one for 15h and second for 24h
Graph-Pad Prism software were used for data analysis.
AH-PLUS showed significantly less solubility than calcium hydroxide based sealer and more than MTA as well which showed the greatest solubility results for both periods of 15h and 24h.
Silva EJ et-al.
2016
Level II
RCT10 mandibular premolars Intervention groups N=6 In vitro
Intervention groups:
2 groups N=5 of MTA and HA-Plus
3D micro C.T scan for volume loss of sealers
No significant differences was between AH-Plus to MTA based sealer.
Urban K et-al.
2016
Level II
RCTMTA, bio-root, AH-PLUS Control group N=2 Intervention groups N=1 In vitro
Control group:
AH-Plus Intervention groups:
MTA , bio- root.
x-ray photo electron
and weight loss measurements.
No significant differences was between MTA and AH- Plus.
Alzraikat H et-al.
2016
Level IV
RCTSamples of each sealers N=180
Control group N=1 Intervention groups N=6 In vitro
Intervention groups:
12 groups from Each sealer
Control group Distilled water as control solution
Measurements on chloroform and electro active
environments, Weight loss measurements,
AH-Plus showed significantly higher solubility results than all other sealers in chloroform and in static and ultrasonic environments Solubility test of root canal sealers
the main purpose of root canal Obturation is preventing the passing of bacteria from root canal to peri-apical tissue, in addition, to provide good sealing for long period of time after treatment (14).
The solubility of the sealers is a very important characteristic which must be considered. On research which made by Edgar Scha¨fer et-al (14) found that AH-Plus had the lowest solubility that other sealers which tested for all period of test and had the correct properties according to ADA\ANSI as well as ISO standards requirements (14). Other research which made by E. J. Silva et-al (15). has found that the solubility of AH-Plus and the MTA has the same solubility characteristics, but in special 3D scan dimensional change occur after the test, in addition, AH-Plus didn't passed through apical foramen while MTA passed through apical foramen (15). On test which made by Kent Urban et-al (16), the test has checked one type of resin- based sealer compared to AH-Plus and MTA, the research found that AH-Plus and MTA were more soluble than other sealers which contain resin as well. On test which made byS. Ersahan and C. Aydin(17), for solubility of AH-Plus compared to other types of sealers, the AH-Plus has less solubility than one sealer which based on MTA and calcium hydroxide and didn’t show any significant difference than two other sealers which were tested (17).on research which made by Hanan Alzikat et-al (18). On their research they found that AH-Plus solubility was significantly higher compared to other sealers such as MTA and AH-26 which tested, this test checked the solubility on chloroform in static and ultrasonic activation areas (18). In addition solubility test which made by N. B. Faria-Junior et-al (19) found that AH-Plus has the lowest solubility results. From those results which were found in the articles, it can be concluded that results are unambiguous but most of the articles showed that AH-Plus is less soluble than other types of sealers which were tested.
Table 4. Dentinal tubules penetration.
AUTHOR/YEA
R LEVEL OF EVIDENCE/STUDY DESIGN/PARTICIPANTS/INCLUSI
ON CRITERIA
INTERVENTIO
N AND OUTCOME
MEASURES RESULTS
CONTROL GROUPS Cañadas PS,
et-al.
2014
Level IV RCT
Fresh extracted bovine teeth N=50
Intervention groups N=5 In vitro
Intervention groups: 4 different types
of sealers
SEM micrographs measurement
s in 3 points and scoring according to
adaptation between 0-2
when 0 is good adaptation and 2 is poor
adaptation
AH-Plus and MTA
showed significant
good dentinal adaptation
then tested sealers
Akcay M, et-al.
2016
Level IV RCT
Single rooted premolars teeth N=156
Control group N=1 Intervention groups N=4
In vitro
Intervention groups:
4 groups from each sealer Total N=39
Laser scanning of
dentinal penetration.
For Statistical analysis by
tukey and ANOVA
No significant difference s between AH-Plus and MTA.
Penetration to dentinal tubules
dentinal tubules penetration is a very important feature of root canal sealer since it provides the sealing ability of the sealer as well as the tightening of the sealer to dentinal wall of the root and provide good sealing for long time (20), there are several factors which may influence on the sealer ability to penetrate into dentinal tubules such as irrigation material using during treatment. In research which made by Merve Akcay et-al. (20), found that the type of irrigation and location on root third are very important factors which influenced on sealers penetrate into dentinal tubules since there are bigger dentinal tubules in the coronal third than the apical and the irrigation material access to coronal and apical thirds are different , in addition the research found that AH-Plus and MTA (fillapex®) has shown no significant difference in dentinal penetration and on the coronal third has better penetration than the apical third (20). In a test which made by Piedad S. Cañadas et-al found good adaptation to dentinal tubules of AH-Plus and for MTA as well, both sealers had better adaptation than other sealers which were tested (21)
.
Based on the results it is clearly that AH-Plus and MTA based sealers have the ability to penetrate into the dentinal tubule and provide good sealing.Table 5. PH level of root canal sealers
AUTHOR/YEA
R LEVEL OF EVIDENCE/STUDY DESIGN/PARTICIPANTS/INCLUSIO
N CRITERIA
INTERVENTIO N AND CONTROL
GROUPS
OUTCOME MEASURE
S
RESULTS
Faria-júnior et-al.NB.
2013
Level IV Control group N=1RCT Intervention groups N=7
In vitro
Intervention groups:
7 types of sealers Control group:
Control group:
biofilm did not exposed
to sealers
Discs from testedeach sealer stored and
measured after 5h,
10h and 15h with PH meter.
analysis byFor ANOVA or
by
AH-Plus showed significant difference
in PH between 5
hours and 15 hours while the MTA was with high PH level for
all periods of time, calcium hydroxide
based sealer was significant
less PH then MTA Zhou H,
et-al.
2013 Level IV
Intervention groups N=2RCT In vitro
Intervention groups:
Fresh and set groups of MTA, AH-Plus
sealers.
Discs from sealereach measured
by PH meter
Fresh MTA and AH-Plus
showed alkaline PH and after 24
hours the PH of AH- decreasedPlus significantly
to natural Cañadas PS
et-al.
2014 Level IV
single root bovine teeth N=50 Intervention groups N=4RCT
In vitro
polyethylene10 tubes measuring
filled with freshly prepared
The pH measuredwas at 1–hour intervals at 6 hours, 23, 25, 27,
AH-Plus started as basic, rich his pick
after3 hours and
4 different types of
sealers
336, 528 and 750 h.
PH levels measuredwas
by PH meter
after 23h to 31 days.
MTA stated as basic rich
his pick after 17h
droppedand from 7 days
to 31 days Silva ejnl
et-al.
2013
Level IV Control group N=1 Intervention groups N=8
In vitro
Control group:
only culture medium intervention groups: MTA and AH-Plus
Measuring by PH meter in
plastic tubes periods of
3,24,72, 168 hours
AH-Plus has closely natural PH level during all period of test MTA was alkaline
for all period of
test PH test
PH level of sealers are not frequently evaluated in researches, this evaluation is rarely used but this feature is very important, this evaluation is usually done by PH meter. On a test which made by N. B. Faria-Junior et-al (19), found that 2 days after manipulation PH level of MTA significantly increased as well for calcium hydroxide based sealer, after 7 days AH-Plus showed significantly increased in PH levels, between all tested sealers the highest levels of PH was for MTA (19). On a test that made by Piedad, S. et-al. (21) found that MTA start as basic and after 7 days dropped to natural, for the AH-Plus start as well with basic level and dropped after 23 hours, faster than MTA (21). additional test made by Hui-min Zhou et-al (22), confirmed the findings which mentioned above and found that at the beginning of the test the PH level of AH-Plus and MTA based sealer showed alkaline levels and after 24 hours AH-Plus decreased to natural PH level. By the results from the articles the ability of AH-Plus to reach the PH-level after a short time has proved, in addition, the ability of AH-Plus to be close to natural PH level than other tested sealers proved as well.
Table 6. Radiopacity test of root canal sealers.
AUTHOR/YEAR LEVEL OF EVIDENCE/STUDY DESIGN/PARTICIPANTS/INCLUSION
CRITERIA
INTERVENTION AND CONTROL
GROUPS
OUTCOME
MEASURES RESULTS Raquel-
Kathrin Prullage
et-al
Level IV
Intervention groups N=5RCT Control group N=1
In vitro
intervention groups: 5 samples from each sealer in incubator
Aluminum step wedge and x-ray for 120 milliseconds
nosignificant differences between
Radiopacity test
Radiopacity of root canal sealers is a very important feature that helps clinician to control the obturation stage and to evaluate the sealing quality (16). The international requirements for radiopacity level of 3mm Al (5). All tests are measured the radiopacity levels of root canal sealers by x-ray evaluation and by aluminum wedge (5,16,21,23). In test which made by (Emmanuel J.N.L.
Silva et-al (5) ) the test measured 5 samples from each sealer and by x-ray with aluminum wedge for 0.3 seconds with 60kV and 10mA, the test has shown that AH-Plus had significantly higher results from all other tested sealers such as MTA based sealer (fillapex), (5). In test which made by (Piedad S. Cañadas et-al (21) ) same method has been used, this test checked the radiopacity for 6.3 seconds of x-ray exposure but with different values of 70kV and 10mA, the test has shown significant higher radiopacity of AH-Plus compared to calcium hydroxide based sealer (sealapex),(21). An additional test has made by (Lee, J. et al. (23)), the test checked 10 different samples, the radiopacity of tested
2016 control group:
AH-Plus
MTA and AH-Plus Emmanuel
J.N.L. Silva et-al 2013
Level IV
Intervention groups N=5RCT Control group N=0
In vitro
intervention groups: 5 samples from each sealer
Aluminum step wedge and
radiograph exposure for 0.3 seconds
AH-Plus showed significantly higher radiopacity than MTA Piedad S.
Cañadas et-al.
2014
Level IV
Intervention groups N=5RCT Control group N=0
In vitro
intervention groups: 5 samples from each sealer
Aluminum step wedge and x-ray exposure for 6.3 seconds
AH-Plus showed significantly higher radiopacity thansealapex®
– calcium hydroxide based sealer Lee, J.
et al.
2017
Level I
Intervention groups N=10RCT Control group N=0
In vitro
intervention groups: 10 samples from each sealer
Aluminum step wedge and x-ray exposure for 0.08 seconds
AH-Plus showed significantly higher opacity results compared to MTA fillapex®
results compared to MTA based sealer (23). On test which made by (Raquel-Kathrin Prullagev et-al (16)), they used 60kV and 7mA and results showed no significant change between AH-Plus and MTA. In conclusion from the results its clearly that AH-Plus have the highest radiopacity level compared to other types of sealers that have been tasted and confirmed that AH-Plus is in agreement with the international requirements. there is two materials which adding into the sealers for radiolucency uses, those materials are Zirconium oxide uses as radiopacity agent in AH-Plus while in the MTA the radiopacity agent is bismuth oxide (5). The different agents that are using for radiopacity can explain the ability of AH-Plus to be more radiopacity than other sealers which were tested.
Table 7. Risk of bias
Reporting bias Incomplete
outcome data Blinding of
outcome assessment Performance
bias Selection
bias Citation
+ +
-
? +
Sungur DD.
Et-al.
2016
+
?
? -
+ Willershausen
I.
Et-al.
2011
? -
+ -
- Małgorzata
Pawińska. Et- al.
2015
? -
- +
- Silva EJNL.
Et-al.
2013
+ -
? +
- Emmanuel
J.N.L. Silva.
Et-al.
2015
+ +
+ +
- Hengameh
Ashraf.
Et-al.
2012
- +
- +
- Silva, T.
Et-al.
2012
- +
- -
- Brackett MG.
Et-al.
2012
+ +
+ +
- Sultana M.
Et-al.
(+) – low risk (-) – high risk (?)- unclear information
Assessing of risk of bias has chosen by assessment tool from http://handbook.cochrane.org/.
Table 7. Materials compositions
The most common used sealers which used for comparison in this systematic review.
2016
+ +
+ +
- Silva RV.
Et-al.
2015
+ +
- -
+ Wong JG.
Et-al.
2013
+ +
+ -
+ Schäfer E.
Et-al.
2013
+ +
+ +
- Silva EJ.
Et-al.
2016
? -
- -
- Urban K.
Et-al.
2016
+ +
- -
- Ersahan S.
Et-al.
2013
- +
- -
- Alzraikat H.
Et-al.
2016
+ -
- +
+ Faria-Júnior
NB.
Et-al.
2013
+
? -
- +
Akcay M.
Et-al.
2016
+ +
- -
+ Cañadas PS.
Et-al.
2014
+ +
+ +
- Zhou H.
Et-al.
2013
+ +
+ +
+ Lee, J.
et al.
2017
Material Composition Manufacture
AH Plus®
Epoxy resin based
Epoxy paste: diepoxy, calcium tungstate, zirconium oxide, aerosol, and dye
Dentsply, DeTrey, Konstanz,
Results:
In this systematic review 23 articles were examined and divided into 6 different groups by the main characteristics and properties of AH-plus and other types based sealers such as radiopacity, micro-leakage, dentinal tubules penetration, cytotoxicity, solubility and PH levels. The results confirmed the ability of AH-Plus® (Dentsply, DeTrey, Konstanz, Germany) resin-based sealer which is the most common used sealer today to be with the requirements for root canal sealers. After examination and summarizing the tests it was found that Ah-Plus have low cytotoxicity as shown in table 1but cytotoxicity characteristic of sealers should investigate further more studies. Concerning dentinal wall/tubules penetration AH-Plus have significant good dentinal wall penetration compare to other testes sealers as shown in table 4. Concerning micro-leakage, AH-Plus have high micro- leakage properties and less sealing ability as shown intable 2which might influence the quality of the treatment with this root canal sealer. Concerning the PH levels, the most natural PH level from all tested sealers was AH-Plus as shown in table 5. Ah-Plus have low solubility compare to other tested sealers except for one article which had different results concerning to solubility of AH-Plus as shown intable 3.Regarding radiopacity of the sealers, AH-Plus showed significantly higher results compared to other tested sealers as shown intable 6. AH-Plus have all properties to be a sealer with all international requirements needed from root canal sealer.
Discussion
Different types of root canal sealers (or endodontic sealers) are widely used in the dental market, some practitioners select their sealer by different types of properties. In this study the cytotoxicity level, PH level, dentinal tubules penetration, micro leakage and solubility of 3 different types of root canal sealers based on different types of materials such as MTA (mineral trioxide aggregate), calcium hydroxide based sealer and zinc oxide eugenol based sealer, has been tested and compared to epoxy resin- based root canal sealer - AH-Plus (Dentsply, DeTrey, Konstanz, Germany).
root canal sealers should provide very good sealing ability and have all properties which required from root canal sealer to be, root canal sealer should provide the best treatment results for a long time
diamine, calcium tungstate, zirconium oxide, aerosol, and silicon oil
Fillapex®
MTA mineral trioxide aggregate based
Salicylate resin, diluting resin, natural resin, bismuth oxide, nanoparticles silica, MTA, pigments.
Angelus, Londrina, PR, Brazil
Tubliseal®
Zinc oxide eugenol based
Zinc oxide, barium sulfate, oleo resins, oils, modifiers, thymol oxide
Kerr West Collins Orange, CA USA), Sealapex®
Calcium hydroxide based
Calcium hydroxide, barium sulfate, zinc oxide, titanium dioxide and zinc stearate.
SybronEndo, Glendora, CA, USA
by all characteristics as cytotoxicity, biocompatibility, PH levels, solubility, dentinal tubules penetration, micro-leakage. When sealer is in contact with periapical tissues it should be non- cytotoxic and should prevent form chemical agents to penetrate into periapical tissues and to prevent the inflammation appearing which might lead to treatment failure and eventually might lead to tooth and bone lose. All root canal sealers should have a laboratory test before any clinical use (5). By the limitations which I had during writing this systematic review I used articles which could provide the answers for my hypothesis. Concerning the cytotoxicity of root canal sealers, most of the tests have used the MTT assay technique which tests the cell viability, cytotoxicity assay, and zymography tests has inserted into this systematic review to verify the results and to intensify the evidence. After results from all tests were out, the results were collected and analyzed by ANOVA which provide the mean of the results, when AH-Plus compared with MTA based sealers, calcium hydroxide-based sealers it found that cytotoxicity levels were not Unambiguous since different I got different results from articles. On articles which made by Kierklo A, et-al 2015 (3), and Ejnl, et al. 2013 (5), found that MTA based sealers and calcium hydroxide based sealers had higher cytotoxicity characteristics than AH-Plus, while other articles found no significant differences in cytotoxicity levels (Brackett Mg, et- al 2012 (9), Ashraf H, et-al 2012 (7)) and two articles found higher cytotoxicity levels of AH-Plus which is different from other results (Silval Ejnl, el-al 2012(8)),( Silva EJNL Et-al.2015 (6)).
Cytotoxicity levels of AH-Plus in most of the cases were less than other compared sealers but this results should be investigating further more studied to approve those results. Concerning the solubility of root canal sealers, in most of the cases of the solubility tests has shown that AH-Plus have less solubility than other materials which were tested. Solubility has measured by volume and weight loss of the material after a period of time, on comparison which tested the solubility of MTA and calcium hydroxide compared to AH-Plus the results were confirmed the ability of the AH-Plus to have a great solubility and sealing properties (Faria-Júnior NB et-al.2013 (18)). the ability of root canal sealer to be less soluble mean better feature since during Obturation phase the aim is to obturate the canal and seal it as much as possible and to prevent from bacteria and their product to pass through apical foramen to peri-apical tissues, low solubility can prevent from the sealing material pass through apical foramen as well. According to ANSI/ADA Specifications, solubility ratios of root canal sealers should be less than 3% (Sedya Ershan et-al 2013 (16)), when tests has made to find out if AH-Plus have this ability it found to be positive, AH-Plus found to have the ability to provide less solubility than other tested sealers (Schäfer E, et-al. 2013 (13)).regarding micro leakage, The main goal of root canal sealer is to prevent from bacteria penetration and provide good sealing ability (Sultana M et-al, 2016 (10)), in all micro leakage tests AH-Plus showed higher leakage results than other tested sealers, those results can influence the quality of the treatment with this root canal sealer. usually the main
One test found that there is no chemical bonding between AH-Plus and gutta-percha and this disadvantage might be the main cause for the higher micro-leakage results of AH-Plus, (Sultana M et-al, 2016 (16)). Regard PH levels of root canal sealers, the PH level measured by PH meter in all cases, the PH meter has calibrated before all tests, by the results the PH level of AH-Plus was close to natural during all period of test and MTA had alkaline level (Silva EJNL et-al, 2013 (5)). The PH level of AH-plus has reached the peak after 3 hours and dropped after 23 hours while MTA reached his peak after 17 hours and dropped only after 7 days, that mean that negative PH levels of AH-Plus remain for short time and the natural level in most of the time kept as it should be without any negative effect on the tooth or tissues. In addition, the comparison between MTA, calcium hydroxide and AH- Plus has made and results were the same AH-Plus has natural levels (Faria-Júnior NB et-al,2013 (18)), it confirmed that AH-Plus is more natural than other sealers. Regard dentinal tubules penetration, the ability of the sealer to penetrate into dentinal wall/tubules will provide better sealing and less micro leakage which is the main purpose of root canal sealer, since the number of articles was limited by inclusion criteria the results showed that AH-Plus and MTA had no significant differences in dentinal tubules penetration and both had good results, the scoring of the results measured from 0 to 2 (Cañadas PS, et-al 2014 (20)) both sealers had good scoring. Regard radiopacity, the ability of AH-Plus to be with high radiopacity characteristics has confirmed. The radiopacity of root canal sealers is very important for diagnosis and obturation control (16), all radiopacity tests of root canal sealers has measured by x-ray and with aluminum step wedge and results has shown that AH-Plus has significantly higher radiopacity than other tested sealers, this might be due to zirconium oxide which is the agent that added to the sealer for this reason. After all the results has been reported in this systematic review the only and the main disadvantage of AH- Plus is the higher micro-leakage compared to other sealers, this disadvantage might be due to absence of bonding between the gutta-percha points to the AH-Plus sealer and this finding can affect all treatment quality, those results need to investigate further more studies to confirm this. The application of AH-Plus has confirmed to be safe to use by other articles and approved to have good properties as the international requirements stating.
Conclusion
In this study by the data which were collected AH-Plus is considered to be the most common used sealer today and this might be due to material properties by solubility, dentinal tubules
penetration, cytotoxicity PH level and radiopacity, AH-Plus have a great sealing ability and reached the international requirements for solubility which is less than 3%. The main disadvantage of this sealer is the higher results of micro leakage compared to other sealers, those results need to investigate further studies to confirm it. This systematic review covered the aim by data collection and confirmed the ability of AH-Plus to be a sealer with all requirements needed from root canal sealer, after all tests have been made it is clearly that AH-Plus have very good properties and most of the results can confirm it, while the other sealers were less effective. AH-Plus is safe to use and in most of the cases will be the right sealer to be chosen.
Clinical recommendations
By the data which collected from articles it is clearly that application of AH-Plus is safe and provide all requirements. In some cases, such as prosthodontic treatment with glass fiber post after endodontic treatment is recommend to use the AH-Plus and MTA in case which the canal was obturated before with zinc oxide eugenol based sealer the result might have less adhesion the dentin wall since eugenol mostly resist to resin based composites and cements, the fiber post will fail to adhere to root canal wall. The using in zinc oxide eugenol sealer is less recommend since there are patients that have an allergy to eugenol, in this case, AH-Plus is recommending to use. In a case of pediatric dentistry in primary dentition, calcium hydroxide sealer can be used to obturate the canal without gutta-percha because primary teeth should exfoliate. The using MTA based sealer is more recommend and more effective for teeth with complications after endodontic treatments such as perforations.
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