|Year : 2022 | Volume
| Issue : 3 | Page : 103-106
Evaluation of Apical Microleakage in Endodontically Treated Teeth Using Three Sealer Materials: An In Vitro Study
Biland M.S Shukri, Haider Hasan Jasim, Mohammed Kassim Gholam
Department of Conservative Dentistry, College of Dentistry, Mustansiriyah University, Baghdad, Iraq
|Date of Submission||23-May-2022|
|Date of Decision||10-Jun-2022|
|Date of Acceptance||11-Jul-2022|
|Date of Web Publication||19-Sep-2022|
BDS, MSc Biland M.S Shukri
Department of Conservative Dentistry, College of Dentistry, Mustansiriyah University, Baghdad
Source of Support: None, Conflict of Interest: None
Introduction: GuttaFlow Bioseal (Roeko–Coltene/Whaledent, Langenau, Germany), TotalFill Bioceramic (FKG Dentaire SA, La Chaux-de-Fonds, Switzerland), and AH Plus root canal sealers (Dentsply, DeTrey, Germany) are used to prevent communication between periapical space and the root canal. This study aims to evaluate the apical microleakage of three endodontic sealers. Materials and Methods: Seventy-five freshly extracted mandibular premolars were prepared and obturated with single-cone gutta-percha, then grouped into three groups according to the sealers used. The data were analyzed using one-way analysis of variance (ANOVA) and Tukey honestly significant difference (HSD) test. Results: The least mean dye penetration was shown by GuttaFlow Bioseal sealer (1.31 mm), followed by TotalFill Bioceramic sealer (1.57 mm) and AH Plus sealer (2.63 mm); no dye penetration was found in the negative control group. One-way analysis of variance (ANOVA) showed statistically significant difference among all experimental groups (P < 0.001); Tukey test shows significant differences between all groups except for a nonsignificant difference between GuttaFlow Bioseal and TotalFill Bioceramic sealer (P = 0.6). Conclusion: All sealers showed varying levels of apical microleakage, with the least penetration in the GuttaFlow Bioseal group.
Keywords: Apical microleakage, apical sealing, root canal filling, root canal obturation, root canal sealer
|How to cite this article:|
Shukri BM, Jasim HH, Gholam MK. Evaluation of Apical Microleakage in Endodontically Treated Teeth Using Three Sealer Materials: An In Vitro Study. Dent Hypotheses 2022;13:103-6
|How to cite this URL:|
Shukri BM, Jasim HH, Gholam MK. Evaluation of Apical Microleakage in Endodontically Treated Teeth Using Three Sealer Materials: An In Vitro Study. Dent Hypotheses [serial online] 2022 [cited 2023 Jun 5];13:103-6. Available from: http://www.dentalhypotheses.com/text.asp?2022/13/3/103/356343
| Introduction|| |
Successful endodontic treatment depends on the complete removal of necrotic pulp tissue, and optimal obturation of the radicular space against the microbial invasion and colonization into the root canal space and periapical tissue. Root canal sealer fills the canal space by creating a genuinely gap-free solid mass with gutta-percha that forms a fluid-tight seal. Grossman, in 1976, listed the properties of a good ideal root canal sealer; these include unique adhesion of the sealer to both the dentinal surface and the core material.
AH Plus (Dentsply, DeTrey, Konstanz, Germany) is believed to be the gold standard for evaluating new root canal sealers., It reduces microleakage incidence because of its ability to adhere to the canal walls and its hydrophobicity.
The GuttaFlow Bioseal sealer (Roeko–Coltene/Whaledent, Langenau, Germany) provides for both tissue repair and obturation. It is thixotropic and capable of penetrating into the dentinal tubule, and expanding on hardening.
The TotalFill Bioceramic sealer (FKG Dentaire SA, La Chaux-de-Fonds, Switzerland) is a newer, calcium silicate-based materials. It has a small particle size, good flowability, and exhibits no shrinkage on setting.
Endodontic microleakage is the percolation of fluids and microorganisms at the obturation material/root canal surface interface. Various methods are used to assess the apical seal after obturation.
The aim of this in vitro study is to measure the apical microleakage of three endodontic sealers − AH Plus, GuttaFlow Bioseal, and TotalFill Bioceramic sealer − by dye penetration.
| Materials and Methods|| |
The study protocol was approved by local ethical committee of the College of Dentistry, Mustansiriyah University (Approval number: 1015). Seventy-five mandibular human premolars (extracted for orthodontic purposes) were used for this study. Each root surface was cleaned manually using a periodontal curette (Medesy, Italy). The specimens were stored in 5.25% sodium hypochlorite for 2 hours, then washed and stored in distilled water at room temperature. With the aid of transmitted light (Radii Plus, SDI, Australia) and a stereomicroscope (Meiji Techno, Japan) set at 10× magnification, teeth were selected by the following criteria: straight root with no visible caries, fully developed apices, and free of calculus, cracks, and anatomical irregularities. The presence of a single straight canal, no signs of internal resorption, previous endodontic treatment, and calcification were confirmed by diagnostic X-ray.
All teeth were decoronated 12 mm from the anatomical root apex using a diamond disc (Poseida, China) and water coolant.
Pulp extirpation was carried out using a barbed broach. The correct working length was established by inserting a size 15 K-file (Dentsply, Maillefer, Ballaigues, Switzerland).
All roots were covered with two layers of aluminum foil, then embedded in plastic test tubes (2.5 mL) filled with silicone impression material (putty consistency; 3M ESPE, St. Paul, MN) using a dental surveyor (Paraline, Dentaurum, Germany). After the impression material had set, the aluminum foil was replaced with saline-soaked gauze to keep the roots moist throughout root preparation.
The roots were instrumented, according to manufacturer’s instructions, using the rotary ProTaper Next file system (Dentsply, Maillefer, Ballaigues, Switzerland) to size 4× using an X-Smart Plus Endo Micromotor (Dentsply, Maillefer, Ballaigues, Switzerland).
During canal instrumentation and between files, 17% ethylenediaminetetraacetic acid (EDTA) gel was used as a lubricant, and at every file change, 1 mL of NaOCl 2.5% was used as an irrigant. Finally, after preparation, each root was irrigated for 1 minute with 2 mL of 17% EDTA liquid, then rinsed with 2 mL 5.25% NaOCl followed by 10 mL distilled water. Next, the canals were dried using absorbent sterile paper points (Dentsply, Maillefer, Ballaigues, Switzerland).
The prepared roots were divided randomly (www.random.org) into three experimental groups (in each group, n = 15): group A for obturation with GuttaFlow Bioseal, group B for obturation with TotalFill Bioceramic, group C for obturation with AH Plus, a positive control group (n = 15), for obturation with gutta-percha without sealer, and a negative control group (n = 15) to be left without obturation.
All roots were obturated by the single-cone filling technique using corresponding ProTaper Next paper gutta-percha (Dentsply, Maillefer, Switzerland). All sealers were prepared according to manufacturers’ instructions. Then, the samples were incubated in 100% humidity at 37°C for 7 days, for complete setting. Following the incubation period, the surfaces of all the experimental group specimens were dried. For groups A, B, and C, the root surfaces were coated with two layers of nail varnish, except for the apical 2 mm. The negative control group was completely coated with two layers of nail varnish, including the apical foramen, while the positive control group was left uncoated.
After 1 hour, all roots were suspended vertically in a glass container with apices directed downward in a fresh solution of 2% methylene blue (ThermoFisher, London, UK) for 72 hours at 37°C in an incubator. Then, all samples were washed under running tap water for half an hour to remove excess dye. The nail varnish was then carefully removed from root surface using a Lacron (Medesy srI, Maniago, Italy) carving tool.
Using a diamond disk and water coolant, two longitudinal grooves were cut on the roots along the long axis, and then the roots were split in half by applying gentle pressure. The linear apical penetration of the dye, in the coronal direction was measured in each specimen using a stereomicroscope (Meiji Techno) at 20× magnification, and the deepest penetration depth was measured by two blinded researchers (first and last authors) in millimeters as a responsible proxy for leakage through the sealant.
The penetration measurements were tabulated and analyzed using the Python 3.10.4 (The Python Software Foundation, https://www.python.org). The level of significance was set at 0.05. The one-way ANOVA was used for overall comparison, and the Tukey test was used for individual pairwise comparisons.
| Results|| |
Results related to apical microleakage test among the five study groups are presented in [Figure 1]. There were statistically significant differences between the five study groups (P < 0.001).
|Figure 1 Box and whisker plot showing results of apical microleakage (millimeter) related to the five study groups. Furthermore, P-values related to post hoc comparisons using the Tukey method were showed. Positive and negative control groups showed statistically significant deference with three sealers (P < 0.001).|
Click here to view
| Discussion|| |
The ingress of microorganisms and their by-products along root canals is prevented by good three-dimensional obturation of the root canal, and applying an endodontic sealer to fill the voids at gutta-percha/dentin interface.
Torabinejad et al. stated that “if a root filling material does not allow penetration of small particles such as dye molecules, it is more likely to have the potential to prevent microleakage of bacteria and their by-products.” Methylene blue was chosen because it has a low molecular weight, comparable to that of bacterial by-products that can leak out of infected root canals.
The results showed no leakage in the negative control group, confirming that two coats of nail varnish effectively prevented dye penetration, while the positive control group showed the greatest dye penetration, indicating the efficacy of methylene blue dye penetration in leakage studies.
GuttaFlow Bioseal is claimed, by its manufacturer, to provide natural repair compounds such as calcium and silicates that form hydroxyapatite crystals in a wet environment. It has both osteointegrative and osteoconductive effects and bonds mechanically to bone tissue through hydroxyapatite crystals. Calcium hydroxide forms when calcium oxide comes into contact with water. Phosphorus ions also play an important role in the formation of apatite crystals, and the calcium phosphate formed is known to be apatite precursor.
TotalFill Bioceramic sealer has demonstrated bond strength, cytocompatibility, and dentin penetrability. It is a calcium silicate-based bioceramic sealer, described by its manufacturer as a radiopaque, insoluble, and aluminum-free material that requires moisture to set and harden. It is both biocompatible and hydrophilic in nature, and expands on setting. This expansion, both increases chemical bonding and causes micromechanical bonding, to collectively increase the bonding of the sealer to the root canal walls.
The physical properties of the GuttaFlow Bioseal sealer and TotalFill Bioceramic sealer used in this study include stability, adhesion to dentin, and no shrinkage after hardening. Both sealers could be considered ideal by Grossman criteria, and superior to the resin-based sealer., Both sealers can create a solid, gap-free obturation mass, and a tight seal. The seal tightness is attributed to how the sealer bonds with the wall of the canal space. The sealers bond differently with the dentin: GuttaFlow Bioseal bonds mechanically and physically, while TotalFill Bioceramic bonds chemically and mechanically.,
In this study, GuttaFlow Bioseal showed the lowest microleakage of the treatment groups. These results may be related to the formation of a tag-like structure inserted into dentinal tubules and at the entrance of the tubules, which result from the bioactive glass particles in the sealer. These crystals were recognized as hydroxyapatite, which significantly enhances adhesion to the dentinal wall.
GuttaFlow Bioseal sealer consists of gutta-percha nanoparticles, making the monoblock structure easy to achieve, as it can fill the irregular geometry of the root canal space. Moreover, its water sorption may play a role in sealing ability through volumetric expansion, low solubility, alkalizing activity, minimal calcium release, and a perfect Ca/P ratio, resulting in anapaite layer forming within 3 days.,
A study by Zahid and Ghareeb, in 2019, shows that GuttaFlow Bioseal produced greater dentinal tubule penetration than TotalFill Bioceramic and AH Plus sealers, especially in the apical third. This may be related to the presence of calcium silicate in GuttaFlow Bioseal that bonds with the dentin surface by forming apatite interface deposits.
GuttaFlow Bioseal is thixotropic; thus, its decreased viscosity under pressure, along with its expansion on hardening, and the nanoparticle scale of the gutta-percha filler, would increase its penetration into the dentinal tubules and into lateral canals.
AH Plus has gained popularity due to its biocompatibility, radiopacity, ease of use, availability, and its ability to bond to root canals. Since it contains resin, AH Plus tends to shrink and debonds early from the root canal wall. The limited adhesion of AH Plus sealer to dentin is achieved from a mild covalent bond between its open epoxide ring and the amino group in the collagen fiber. Also, the bonding between the gutta-percha point and the sealer is inadequate, allowing fluid leakage. This gap forms due to both polymerization shrinkage and lack of bonding to the gutta-percha. This could be one of the reasons why group C displayed significantly more dye penetration than groups A and B.Rita et al. compared the sealability of GuttaFlow polydimethylsiloxane and AH Plus sealer in teeth prepared to receive posts at three different levels of remaining gutta-percha; they found that using polydimethylsiloxane sealer resulted in lesser sealing in all tested groups. The good apical sealability of GuttaFlow sealer, as observed in this study, can be attributed to its property of expanding on setting and excellent flow into grooves and depressions.
AH Plus sealer, according to the manufacturer, contains particles of calcium tungstate and zirconium oxide. The larger particles cannot enter easily into the small tubules, so the sealer tags would be weaker than those of bioceramic sealer. Also, showed the sealing ability of bioceramic sealer is better than resin-based sealer AH Plus.Additionally, Yendrembam et al. showed that bioceramic sealer has a higher adhesiveness to the root dentin than AH Plus sealer, due to its chemical and micromechanical bonding to dentin, and the production of hydroxyapatite during setting, which improved the sealing ability of bioceramic sealers.
However, with respect to limitations of in vitro studies, more future clinical evaluations are recommended.
The authors would like to thank Mustansiriyah University (www.uomustasiryah.edu.iq), Baghdad, Iraq, for its support in the present work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Razmi H, Bolhari B, Dashti NK, Fazlyab M. The effect of canal dryness on bond strength of bioceramic and epoxy-resin sealers after irrigation with sodium hypochlorite or chlorhexidine. Iran Endod J 2016;11:129-33.
Singh H, Markan S, Kaur M, Gupta G, Singh H, Kaur M. Endodontic sealers: current concepts and comparative analysis. Dent Open J 2015;2:32-7.
Grossman L. Physical properties of root canal cements. J Endod 1976;2(6):166-175.
Van Meerbeek B, Peumans M, Poitevin A et al.
Relationship between bond-strength tests and clinical outcomes. Dent Mater 2010;26:e100-21.
Özcan E, Eldeniz AÜ, Aydınbelge HA. Assessment of the sealing abilities of several root canal sealers and filling methods. Acta Odontol Scand 2013;71:1362-9.
Rahimi M, Jainaen A, Parashos P, Messer HH. Bonding of resin-based sealers to root dentin. J Endod 2009;35:121-4.
Donnermeyer D, Bürklein S, Dammaschke T, Schäfer E. Endodontic sealers based on calcium silicates: a systematic review. Odontology 2019;107:421-36.
Carvalho NK, Prado MC, Senna PM et al.
Do smear-layer removal agents affect the push-out bond strength of calcium-silicate based endodontic sealers? Int Endod J 2017;50:612-9.
Lahor-Soler E, Miranda-Rius J, Brunet-Llobet L, Farré M, Pumarola J. In vitro study of the apical microleakage with resilon root canal filling using different final endodontic irrigants. J Clin Exp Dent 2015;7:e212-7.
European Society of Endodontology. Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology. Int Endod J 2006;39:921-30.
Torabinejad M, Watson TF, Ford TP. Sealing ability of a mineral trioxide aggregate when used as a root end filling material. J Endod 1993;19:591-5.
Padmanabhan P, Das J, Kumari RV, Pradeep PR, Kumar A, Agarwal S. Comparative evaluation of apical microleakage in immediate and delayed postspace preparation using four different root canal sealers: an in vitro study. J Conserv Dent 2017;20:86-90.
] [Full text]
Patil P, Rathore VP, Hotkar C, Savgave SS, Raghavendra K, Ingale P. A comparison of apical sealing ability between GuttaFlow and AH Plus: an in vitro study. J Int Soc Prev Community Dent 2016;6:377-82.
Amanda B, Suprastiwi E, Usman M. Comparison of apical leakage in root canal obturation using bioceramic and polydimethylsiloxane sealer (in vitro). Open J Stomatol 2018;8:24-34.
Gandolfi MG, Siboni F, Prati C. Properties of a novel polysiloxane-guttapercha calcium silicate-bioglass-containing root canal sealer. Dent Mater 2016;32:e113-26.
Moinzadeh AT, Portoles CA, Wismayer PS, Camilleri J. Bioactivity potential of EndoSequence BC RRM putty. J Endod 2016;42:615-21.
Tanomaru-Filho M, Torres FF, Chávez-Andrade GM et al.
Physicochemical properties and volumetric change of silicone/bioactive glass and calcium silicate-based endodontic sealers. J Endod 2017;43:2097-101.
Zielinski TM, Baumgartner JC, Marshall JG. An evaluation of GuttaFlow and gutta-percha in the filling of lateral grooves and depressions. J Endod 2008;34:295-8.
Washio A, Morotomi T, Yoshii S, Kitamura C. Bioactive glass-based endodontic sealer as a promising root canal filling material without semisolid core materials. Materials 2019;12:3967.
Collado-González M, Tomás-Catalá CJ, Oñate-Sánchez RE, Moraleda JM, Rodríguez-Lozano FJ. Cytotoxicity of GuttaFlow Bioseal, GuttaFlow2, MTA Fillapex, and AH Plus on human periodontal ligament stem cells. J Endod 2017;43:816-22.
Hoikkala NP, Wang X, Hupa L, Smått JH, Peltonen J, Vallittu PK. Dissolution and mineralization characterization of bioactive glass ceramic containing endodontic sealer Guttaflow Bioseal. Dent Mater J 2018;37:988-94.
Zahid HM, Ghareeb NH. Evaluation of filling ability of Guttaflow Bioseal sealer to the simulated lateral canal by scanning electron microscope: an in vitro study. Erbil Dent J 2019;2:218-28.
Rita C, Kalyan S, Kala M, Biji B. Comparison of apical sealability of AH Plus and GuttaFlow sealers at three different levels of remaining gutta-percha in teeth prepared to receive posts: an in vitro study. Endodontology 2014;26:270-8. [Full text]
Osiri S, Banomyong D, Sattabanasuk V, Yanpiset K. Root reinforcement after obturation with calcium silicate-based sealer and modified gutta-percha cone. Int J Endod 2018;44:1843-8.
Yendrembam B, Mittal A, Sharma N, Dhaundiyal A, Kumari S, Abraham A. Relative assessment of fracture resistance of endodontically treated teeth with epoxy resin-based sealers, AH Plus, MTA Fillapex, and Bioceramic Sealer: an in vitro study. Indian J Dent Sci 2019;11:46-50. [Full text]