Dentistry

http://dx.doi.org/10.17140/DOJ-2-107
Open Journal

Review “Endodontic Sealers”: Current Concepts

Corresponding author:
* and Comparative Analysis
Harpreet Singh, MDS
Associate Professor
Department of Conservative Harpreet Singh1*, Sheenam Markan1, Mandeep Kaur1 and Gaurav Gupta2
Dentistry & Endodontics
Gian Sagar Dental College and 1
Department of Conservative Dentistry & Endodontics, Gian Sagar Dental College and Hos-
Hospital, Ramnagar, Patiala-140401 pital, Patiala, India
Punjab, India
Tel. 91-9815493618 2
Department of Prosthodontics, Guru Nanak Dev Dental College, Sunam, India
E-mail: hsgentledental@gmail.com

ABSTRACT
Volume 2 : Issue 1
Article Ref. #: 1000DOJ2107 The main aim of root canal therapy is the removal of microbial contaminants in con-
junction with the total closure of the root canal system. Root canal sealers along with solid core
material plays a major role in achieving the three dimensional sealing of the root canal system.
Article History:
These sealers are binding agents which are used to adapt the rigid gutta- percha to canal walls
Received: November 20th, 2014
and to fill up the voids, accessory canals and irregularities within the canal. Root canal sealers,
Accepted: January 30th, 2015
although used only as adjunctive materials in the obturation of root canals, have been shown
Published: February 3rd, 2015
to influence the outcome of endodontic treatment. A perfect combination of sealing ability and
biocompatibility is what an ideal root canal sealer should possess. This article discusses the
current concepts in the usage of different sealers in endodontic therapy and their comparison in
Citation:
order to draw some clinical inferences.
Singh H, Markan S, Kaur M, Gupta
G. “Endodontic Sealers”: Current
concepts and comparative analysis. KEYWORDS: Endodontics; Root canal treatment; Sealers
Dent Open J. 2(1): 32-37.
INTRODUCTION

Root canal therapy depends on integrally related root canal treatment phases: micro-
bial control, cleaning and shaping, and effective sealing of the root canal system. The success
of each depends on the execution of the final phase.1 Endodontic filling materials may be con-
sidered true implants as they touch and are based in vital tissues of the body.2 The main com-
ponents of a root filling are: a solid core material and a sealer. The most commonly used core
material is Gutta-percha, which occupies bulk of the canal space while the root canal sealer
fills the interface between the core material and the dentin wall, the voids inside the core mate-
rial and the accessory canals and also serves as a lubricant, thus helping to obtain a fluid tight
seal.3

Ideally, the root canal sealer should be capable of creating an effective bond between
the core material and the dentine of the root canal thus preventing leakage. It should also be
non-toxic and preferably have a positive effect on the healing of periapical lesions.4

A great variety of endodontic sealers are available commercially and they are divided
into different groups according to their chemical composition. It is a well known fact that three
dimensional impervious obturation of the root canal system is of prime clinical importance for
the long-term success of endodontic treatment.

Copyright: At present epoxy resins based sealers possess very good physical properties, excel-
© 2015 Singh H. This is an open
lent apical sealing and ensure adequate biological performance. However, the creation of most
access article distributed under the
Creative Commons Attribution Li- desired ‘Three dimensional obturation’ seems to get hampered by the general lack of chemical
cense, which permits unrestricted union between the polyisoprene component of gutta-percha cone and the components of endo-
use, distribution, and reproduction dontic sealer.
in any medium, provided the origi-
nal work is properly cited.
Although predictable clinical results have been reported with the use of these non-

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bonding root canal sealers, there has been a continuous quest RECENT ENDODONTIC SEALERS
for alternative sealers or techniques that bond simultaneously
to canal wall dentin as well as filling materials. These bondable ProRoot Endo Sealer
root canal sealers are getting popular these days because of their
property of creating monoblocks within the root canal space.5 It is an experimental calcium silicate-based root canal
sealer that is designed to be used in conjunction with a root fill-
The term monoblock refers to the scenario wherein the ing material in either the cold lateral, warm vertical or carrier-
canal space becomes perfectly filled with a gap-free, solid mass based filling techniques. The major components of the powder
that consists of different materials and interfaces, which im- component are tricalcium silicate and dicalcium silicate, with
proves the seal and increases the fracture resistance of the filled the inclusion of calcium sulphate as a setting retardant, bismuth
canals. The most recently introduced self-adhesive type bond- oxide as a radiopacifier and a small amount of tricalcium alu-
able root canal sealers are also associated with the additional minate. The liquid component consists of a viscous aqueous so-
benefits of reduced application steps and being user friendly.5 lution of a water soluble polymer. Similar to other tricalcium
silicate and dicalcium silicate-containing biomaterials, the sealer
This review article attempts to compile information on produces calcium hydroxide on reaction with water.13
various new generation root canal sealers which are advocated
to be superior to their contemporary counterparts and also com- Herbal Sealer (Biosealer)
pare their properties.
It is an experimental root canal sealer based on Co-
CLASSIFICATION OF SEALERS
paifera multijuga oil-resin. Trees belonging to the genus Co-
paifera are distributed around northern South America, mainly in
Before we discuss the new generation of sealers, let us the Amazon Rainforest. It is one of the most popular and prom-
have an overview of the ones available to us for clinical use. ising phytomedicines used in Brazil. The powder is composed
Endodontic sealers have been historically classified in various of zinc oxide, calcium hydroxide, bismuth subcarbonate, natural
ways such as: according to eugenol content; usage; absorbance, resin (rosin) and borax, and the liquid is purified Copaifera mul-
etc.6-12 A comprehensive categorization of the endodontic sealers tijuga oil-resin.14
has been provided in table 1 according to their composition.
Nanoseal plus root canal sealer

ROOT CANAL SEALERS BRAND NAME
A common cause of failure of root canal treatment is
Roth sealer
due to the inability to seal the accessory canal in most cases. One
1. Zinc Oxide Eugenol Kerr PCS
based sealers Procoseal of the newest update in endodontics is the development of the
Endomethasone first endodontic sealer based on nanotechnology which actively
AH Plus seals the tiny gaps thereby reducing the infection. It is made up
2. Epoxy resin based AH 26 of calcium phosphate hydroxyapitite nanoparticles range from
sealers Top Seal 40-60 nm. The rod shaped active nanoparticles can penetrate the
2- Seal
dentinal tubules & enter accessory canals to ensure that all the
RoekoSeal spaces are effectively sealed.15
3. Silicon based sealers
Gutta flow
Endo-CPM-Sealer
Hybrid root seal
MTA Obtura
4. MTA based sealers
ProRoot Endo Sealer
MTA fillapex It is a commercially available fourth generation self-
5. Calcium-silicate-Phos- Endosequence/iRoot SP adhesive dual-cure sealer, available in the powder-liquid form.
phate based biocer- iRoot BP It is an insoluble, radiopaque material that can be used either
amic sealers Bioaggregate
with resilon or Gutta-percha. The liquid comprises of 4-META,
First generation- Hydron monofunctional methacrylate monomers and photo-initiators,
Second generation- EndoREZ,
Realseal
while the powder consists of a mixture of zirconia oxide filler,
6. Methaacrylate resin silicon dioxide filler and polymerization initiators. 4-META is
Third generation- Epiphany,
based sealer
Fibrefill able to promote monomer diffusion into the acid-conditioned
Fourth generation- Realseal SE, and underlying intact dentin and produces functional hybridized
Metaseal SE, Smartseal
dentin with polymerization.16,17 The formation of the hybrid den-
7. Calcium-phosphate Capseal I tin is the major mechanism of bonding and also the high quality
based sealers Capseal II
hybridized dentin resists acidic challenges.18 However, polymer-
Table 1: Categorisation of Endodontic sealers according to their composition. ization shrinkage is inherent to methacrlyate resin-based sealers
that tend to produce debonding at the resin-dentin interface.

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Gutta flow 2 sealer rials.

This is a modification of the original Gutta flow sealer Resilon, a bondable root filling material which falls
which was available in the cartridge form. The excellent flow of into this category, may be used for either lateral or warm verti-
this material made it the sealer of choice. However, the larger cal compaction techniques. As Resilon is applied using a meth-
armamentarium required was a drawback. Of late, Gutta Flow 2 acrylate-based sealer to self-etching primer treated root dentin,
has been introduced which is available in the syringe form and it contains two interfaces, one between the sealer and primed
has an excellent property of slight expansion after mixing which dentin and the other between the sealer and Resilon, and hence
helps in better sealing. may be classified as a type of secondary monoblock.

iRoot SP/EndoSequence BC sealer Tertiary monoblock

The manufactures of these sealers claim the ability to Tertiary monoblocks are the ones having an additional
form hydroxyappetite during the setting process and ultimately third circumferential interface between the bonding substrate
create a chemical bond between dentinal wall and the sealer.19,20 and the abutment material. Fiber posts that contain either an ex-
These are convenient, premixed, ready-to-use, injectable white ternal silicate coating or those that contain unpolymerized resin
cement paste developed for permanent root canal filling and composite for relining root canals that are too wide or not per-
sealing applications. These are insoluble, radio opaque and alu- fectly round for the fitting of conventional fiber posts may be
minium free material based on a calciumsilicate composition, considered as tertiary monoblocks. Tenax Fibre post (Coltene)
which requires the presence of water to set and harden. Dentin have a specific resin coating on its surface, which when cured
is composed of approximately 20% (by volume) of water and with dual cure resin ParaCore ( Coltene) forms a typical Teriary
“iRoot SP” uses this water to initiate and complete its setting monoblock: with one interface between the fibre post and the
reaction.21 It exhibits potent antimicrobial action, excellent bio- resin coating; the second one between the resin coating and the
compatibility, and significant stimulation of periodontal regen- luting cement; and the third one between the luting cement and
eration and is osteoconductive. These sealers are also termed as the root canal wall.
Bioceramic sealers in general.
Another product that falls into this category is the En-
THE CONCEPT OF MONOBLOCK doRez system (Ultradent), in which the conventional gutta-per-
cha cones are coated with a proprietary resin coating.
The term monoblock literally means a single unit.
Franklin R. Tay first described the concept of monoblock in en- EVALUATION AND COMPARISON OF VARIOUS ENDODONTIC
dodontics.22 SEALERS

Primary monoblock Orstavik has listed the various evaluation parameters

for testing endodontic sealers. They include technologic tests
It has only one interface that extends circumferentially standardized by the ADA/ANSI in United States, and the ISO
between the material and the root canal wall. A classic example internationally. These technological tests include flow, work-
of primary monoblock would be obturating the root canals with ing time, setting time, radio opacity, solubility and dimensional
gutta percha, without using the sealer. Use of Hydron sealer change following setting.2
alone is another example of this concept. The lack of sufficient
strength and stiffness is the major drawback and this led to the Leakage
development of Secondary monoblocks.
Leakage continues to be a major reason for failure in
Secondary monoblock root canal therapy. Ideally, a root canal filling material should
provide a barrier that prevents bacterial ingress from the oral
Secondary monoblocks are the ones having two circum- cavity.23 Compared with zinc oxide-eugenol sealers, methacry-
ferential interfaces, such as one between the cement and dentin late based resin sealers were found to be more effective in seal-
and the other between the cement and the core material. A classic ing.24 Using a fluid-transport method, Tunga and Bodrumlu con-
example would be the use of sealer for obturation, wherein one cluded that Epiphany and Resilon leaked significantly less than
interface is between Gutta Percha point and sealer and the the gutta-percha and AH-26.25 In bacterial leakage tests Epiphany
second one between the sealer and root canal wall. and Resilon were superior to gutta percha and various other seal-
ers.26 The Resilon/Epiphany system is reported to establish an
Interest in utilizing the monoblock concept for reinforc- immediate coronal seal after light curing of the dual-cured sealer
ing the root canal space was got resurfaced in around 2004 with at the canal orifices.27 An immediate coronal seal is clinically
the advent of bondable root filling materials that were launched advantageous because there are situations in which filled root
as alternatives to conventional gutta-percha as obturating mate- canals might be exposed to the oral environment and subject to

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bacterial recontamination. Flow

Weller et al suggested that the newly introduced cal- It has been found that the flow depends on particle size,
cium silicate based Pro Root Endo Sealer is comparable in seal- temperature, on the internal diameter of the tubes and the rate
ing quality to the epoxy resin-based sealer and seals better than of insertion of materials.2 Orstavik rated the flow of Tubliseal to
the ZOE-based sealer after immersion in phosphate containing be better than that of Kerr sealer, which was better than Diaket
fluid.28 Moreover, Pro Root Endo Sealer exhibits amorphous cal- and Kloroperka NO. He also stated that flow properties may be
cium phosphate-like phases that spontaneously transform into affected by changes in the powder to liquid ratio.2 Studies have
apatite-like phases after immersion in the phosphate- contain- shown that Tubliseal EWT had a thinner film thickness among
ing stimulated body fluid. This phenomenon probably accounts the conventional zinc oxide eugenol sealers. Increased strain rate
for the in vitro bioactivity of this calcium silicate-based sealer gave a significant increase in the flow rate of all sealers. Other
(Huffman et al 2009).13 studies concluded that among the medicated sealers Endometha-
sone did not confirm to ISO specification.37
Biocompatability
Sealers such as Gutta flow 2 have an excellent flow
which helps in better sealing. On the other hand improvements
One of the principal requirements of an endodontic root are still going on to make the flow of Bioceramic sealers better
canal sealer is that it should be non-cytotoxic and immunologi- for clinical usage.
cally compatible with peripheral tissue.
Bond strength
The biocompatibility and antimicrobial activity of a
specific root canal sealer remains one of the principal consid- Root filled immature roots or roots that are otherwise
erations for selecting an appropriate sealer for a dental resto- weakened internally run a greater risk of fracture. With the intro-
ration.29 It has been demonstrated that sealer material based on duction of adhesive filling techniques, attempts have been made
zinc oxide-eugenol release potentially cytotoxic concentrations to strengthen such teeth through reinforcement of the coronal
of eugenol. Calcium hydroxide-based sealers promote calcifica- part of the root by composite cements and fillings. More recently,
tion but tend to dissolve overtime and compromise the endo- this concept has been taken further by attempting to reinforce the
dontic seal. A new calcium hydroxide-based sealer, Acroseal whole root canal system via an adhesive filling and integrated
appears to have lower solubility than other calcium hydroxide resin core (Resilon).38
sealers, probably because of its epoxy resin component. Glass
ionomer sealers may bond tooth structure but also may activate
Souza SFC et al concluded that Epiphany had higher
the release of prostaglandins in periapical tissues.30
flow, polymerization stress and lower bond strength values to
dentine than AH Plus.39 Other study concluded that the 980 nm
Spangberget et al noted that the AH26 releases formal- diode laser irradiation of root canal dentin increased the bond
dehyde following component mixing that reaches a maximum strength of AH Plus sealer, but did not affect the adhesion of
rate two days after mixing. Formaldehyde release from curing Epiphany sealer. Among the methacrylate based sealers the self
endodontic material has been recognized for many years, form- adhesive sealers exhibited higher push out bond as compare to
aldehyde being reputed to act as a disinfectant.31 The disinfective the non-etching sealer.
agent in AH26 is methenamine, which is hydrolyzed to ammo-
nia and formaldehyde.32 The efficacy of long-term disinfection Newer Bioceramic sealers such as Endosequence pos-
of canal by formaldehyde released from a root canal sealer has sess very high bond strength with the dentin walls. This, to begin
previously been shown to be low.33 There have been case reports with, seems highly advantageous but can serve to be a limitation
of adverse reactions such as paraesthesia of the inferior alveolar in the long run as retreatment in such cases would be highly dif-
nerve attributed to the formaldehyde released from root canal ficult.
sealers.34
Antibacterial activity
Scarparo et al found that Methacrylate resin-based seal-
ers brought about greater quantities of macrophages.35 Studies Current concepts of root canal sealer functions do not
have shown that the Epiphany root canal sealer was the only emphasize on its antimicrobial activity as its primary function,
material that presented intraosseous biocompatibility among the but it is well recognized that most sealers in current use exhibit
resin based sealers.36 some such properties. With increased emphasis on improving
procedures for disinfecting the root canal system, this particular
Newer generation of sealers such as iRoot SP have property may be more appreciated in the future. Studies have
shown a promising biocompatibility owing to their composi- concluded that among the resin based sealers EndoRez did not
tion. show any antimicobial activity. Kayaoglu G et al found that AH

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Plus and Grossman’s sealer were effective in reducing the num- 7. Chandra BS, Krishna VG. Grossman Endodontic Practice,
ber of cultivable cells of E. faecalis while Calcium hydroxide- 12thed. New Delhi: Wolters kluwer; 2010: 301-304.
based sealers, Sealapex and Apexit were ineffective.40
8. Weine FS. Endodontic Practice; 6thed: Missouri: Mosby;
The new generation sealers are also claiming their anti- 2004:306-312.
microbial efficacy of a broader spectrum. However, higher levels
of research are required to evaluate the long term antibacterial 9. Ingle JI, Bakland LK, Baumgartner. Textbook of endodontics;
activity of these sealers, in vivo, before any final conclusions can 6thed; Ontario: BC Decker; 2008:1030.
be drawn.
10. Torabinejad M, Walton R. Endodontics Principles and Prac-
CONCLUSION tice, 4thed. Missouri : Elsiever; 2009:305-307
11. Manogue M, Patel S, Walker R. The principles of endodon-
The degree of endodontic success is directly propor- tics, New Delhi : Oxford; 2005: 74
tional to a clinician’s knowledge of the root canal anatomy and
the techniques selected while performing treatment. Properly 12. Harty FJ, Pitt Ford TR. Endodontics in clinical practice,
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and reconstructive dentistry. Three-dimensional sealing of the
root canal is one of the main goals of endodontic treatment to 13. Huffman BP , Mai S, Pinna L, et al. Dislocation resistance
prevent the reinfection of the canal and for preserving the health of ProRoot Endo Sealer, a calcium silicate-based root canal seal-
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canal treatment. Thus, several types of endodontic sealers have 10.1111/j.1365-2591.2008.01490.x
been recommended to achieve this goal. It is important to note
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seal is of equal importance for the success of endodontic treat- S, Sousa-Neto MD. Laboratory evaluation of the physicochemi-
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