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Year : 2020  |  Volume : 10  |  Issue : 3  |  Page : 173-180

Physicochemical, cytotoxicity, and biological properties of calcium silicate-based root canal sealers: A literature review

Department of Endodontic, Faculty of Dentistry, Pharos University in Alexandria, Alexandria, Egypt

Date of Submission31-Oct-2019
Date of Decision18-Nov-2020
Date of Acceptance16-Feb-2020
Date of Web Publication27-Aug-2020

Correspondence Address:
Prof. Abdelhamied Y Saad
Department of Endodontic, Faculty of Dentistry, Pharos University in Alexandria, Alexandria
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_160_19

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The aim of this study was to evaluate the main calcium silicate-based root canal sealers (bioceramic-based root canal sealers) currently used in endodontic field as well as their specific characteristics and to compare with other conventional sealers. A review of the literature was made to evaluate numerous investigations covering different properties of these materials. The properties of interest were physical properties, bond strength, pH, radiopacity, solubility, setting and working time, dimensional changes, flow, calcium ion release, biocompatibility, antimicrobial activity, sealing ability, adhesion, and cytotoxicity. The outcome of these studies of bioceramic-based sealers revealed favorable biological and physicochemical properties along with comparative investigations of other agents. It was concluded that bioceramic-based sealers, in spite of drawbacks of some, were found to be attractive due to their bioactivity, dimensional stability, and acceptable physicochemical properties in comparison with other conventional sealers.

Keywords: Antimicrobial, calcium silicate-based sealers, cytotoxicity, physicochemical properties, root canal sealers

How to cite this article:
Saad AY. Physicochemical, cytotoxicity, and biological properties of calcium silicate-based root canal sealers: A literature review. Saudi Endod J 2020;10:173-80

How to cite this URL:
Saad AY. Physicochemical, cytotoxicity, and biological properties of calcium silicate-based root canal sealers: A literature review. Saudi Endod J [serial online] 2020 [cited 2020 Nov 25];10:173-80. Available from: https://www.saudiendodj.com/text.asp?2020/10/3/173/293574

  Introduction Top

The primary goal of endodontic therapy is to efficiently clean and shape the root canal system to achieve the desired three-dimensional obturation and a hermetic apical seal. This requires the use of an endodontic sealer to fill gaps between the gutta-percha cones and root canal walls, as well as sealing off of patent accessory canals and multiple foramina, and entombing any remaining bacteria. In addition, this sealer acts as a lubricant when facilitating the placement of the filling core.[1],[2],[3] The commercially available sealers are categorized according to their main chemical components: zinc oxide eugenol, calcium hydroxide-containing, resin-based, and glass ionomer-based root canal sealers. Although different materials have been utilized as root canal sealers, new products are constantly being developed to improve their physicomechanical and biological properties. One of these materials is the calcium silicate-based root canal sealers.

In general, bioceramics include alumina, zirconia, bioactive glass, glass ceramic, hydroxyapatite, and calcium phosphate. Bioceramics are ceramic compounds obtained both in situ and in vivo, by various chemical processes. They exhibit excellent biocompatibility due to their similarity with biological materials, such as hydroxyapatite. Furthermore, they have the ability to induce a regenerative response in the organism. Some bioceramic materials were developed to improve the clinical outcome, such as ProRoot mineral trioxide aggregate (MTA) (Dentsply Co., Germany), which represents the first bioceramic material successfully used as a retrograde filling material and also for pulp capping, apexification, partial pulpotomy of immature teeth, and perforation repair; Biodentine (Septodont, France), which is designed as a “dentin replacement” material and used as pulp capping pulpotomy dressing material in primary teeth; Bioaggregate (IBC Inc., Canada), which has quality similar to cement MTA; Generex A (Dentsply Tulsa Dental Specialties, Tulsa, OK, USA), which is made for retrograde fillings and perforation closing; and EndoSequence BC sealer (Brasseler, Savannah, GA, USA). MTA and other calcium silicate-based cements are used in vital pulp therapy. The aim of using these materials is to promote the production of a reparative hard tissue barrier following pulp injury of the primary and immature adult teeth. This can be achieved by direct or indirect pulp capping. Furthermore, pulpotomy rather than pulp capping is recommended for teeth in young patients with large carious lesion or rampant caries. The MTA Plus can be utilized as a cement or a sealer by adjusting the powder: liquid ratio.[3],[4],[5],[6],[7],[8],[9],[10],[11],[12]

Bioceramic-based root canal sealers (calcium silicate-based root canal sealers) have only been introduced and widely utilized in endodontic and pediatric fields for the past 30 years. Review of these sealers/cements has been conducted. Therefore, the purpose of this review was to investigate the laboratory experiments and clinical studies of these materials to evaluate their physicochemical characteristics, as well as biological properties, and to compare with other conventional materials. Quick look is going to be concentrated on bioceramic cements used in pediatric dentistry.

  Review of the Literature Top

Calcium silicate-based root canal sealers are classified into three main groups: MTA-based, calcium silicate-based, and calcium phosphate-based sealers.

  Mineral Trioxide Aggregate-Based Sealers Top

Several MTA-based sealers made and utilized in endodontics: MTA-Fillapex (Angelus, Londrina, PR, Brazil), Endo CPM (Egeo, Buenos Aires, Argentina), MTA-Angelus (Angelus, Londrina, PR, Brazil), ProRoot Endo (DENTSPLY Tulsa Dental Specialties), and EndoSeal MTA (MARUCHI, Wonju, Korea).

MTA-Fillapex is a bioactive root canal sealer consisting of two pastes. Paste A contains salicylate resin, bismuth trioxide, and silica and Paste B contains silica, titanium dioxide, MTA (40%), and resin. After mixing the material, a semipermeable structure is formed with MTA dispersed throughout. Therefore, according to some investigators, MTA activity is possible due to permeability of the mixed materials,[6],[12] in which alkaline pH explains its extended antibacterial action.[7],[12],[13] Some workers have investigated the cytotoxicity of MTA-Fillapex and EndoSequence BC sealers in culture of mouse L929 fibroblasts. The results revealed that both the sealers had a moderate cytotoxicity effect when freshly mixed. They added that MTA-Fillapex showed cytotoxicity for all tested incubation periods. They explained these findings by its chemical composition.[4] These data were in agreement with several previous studies which showed that the material strongly affected cell viability although different methodologies were used.[14],[15],[16] Furthermore, MTA-Fillapex has demonstrated irritating effects on subcutaneous connective tissue[17] and bone tissue.[18] Thus, according to some studies, despite of the presence of MTA, this material may not have biological advantages.[12] A study by Jafari et al. revealed that MTA-Fillapex exhibited severe cytotoxicity on human fetal foreskin fibroblast cell line. However, it was observed that this cytotoxicity decreased over time until being completely set.[19] Another research was performed to assess the effect of retreatment on the bond strength of MTA-Fillapex and AH Plus. The result showed that AH Plus sealer exhibited a higher bond strength compared to MTA-Fillapex. This finding indicated that retreatment using rotary files and chloroform had not statistically significant effect on the bond strength of these sealers.[20] In addition, the manufacturers of MTA-Fillapex claim that their product sets in a minimum of 2 h. This setting time has been showed by several investigators.[21],[22],[23] However, even shorter setting time for MTA-Fillapex (66 min) has been reported.[24] On the other hand, MTA-Fillapex was not set in humid incubator condition even after 1 month and had a higher flow rate compared to EndoSequence BC sealer.[25] This flow value was similar to the value obtained by Silva et al.[26] A high resin/MTA ratio may be one of the reasons why a high flow rate occurs.[23] Moreover, this setting result was different from several investigators that final setting occurred. They added that water is essential for this sealer to reach its final set.[27],[28],[29] However, the literature contains conflicting accounts, with Viapiana et al.[24] finding MTA-Fillapex to be highly soluble and Vitti et al.[23] reporting the solubility to be <3% consistent with ISO6876/2001. This discrepancy between the findings might be attributed to variations in the methods used to dry the samples after having subjected them to solubility testing. Furthermore, MTA-Fillapex was found to cause the lease crown discoloration to the extent of not being clinically perceptible.[30] In addition, according to ISO6876/2001, the minimum radiopacity for a root canal sealer is based on a reference standard of 3.00 mm of aluminum. This makes the sealer distinguishable from adjacent anatomical structures.[31] In general, Vitti et al.[23] have stated that MTA-Fillapex showed low values of flow, working and setting time, solubility, and water absorption. They added that because of these physical properties, it can be used as a good endodontic sealer.[23]

Endo CPM is another MTA-based sealer (powder/liquid sealer). It consists of silicon dioxide, calcium carbonate,[10] bismuth trioxide, barium sulfate, propylene glycol alginate, sodium citrate, calcium chloride, and active ingredients. Guerreiro-Tanomaru et al.[32] have reported the radiopacity of Endo CPM sealer to be 6 mm due to the presence of bismuth trioxide and barium sulfate. Others have stated that Endo CPM sealer presented the lowest radiopacity value (4 mm aluminum), followed by Active GP, Sealapex, and AH Plus, which was the most radiopaque sealer. Regarding solubility, all materials met the ANSI/ADA recommendations. Furthermore, all sealers, except for Active GP, were alkaline. On the other hand, Endo CPM had poor adaptation on the canal walls.[33] Morgental et al.[34] have evaluated the antibacterial activity of Endo CPM and MTA-Fillapex against Enterococcus faecalis using an agar diffusion test after mixing and a direct contact test after setting. They found that the pH of the Endo CPM suspension was greater than that of MTA-Fillapex (>11); however, the bacterial inhibition zone produced by MTA-Fillapex was greater than that produced by Endo CPM. The authors attributed the antibacterial activity of MTA-Fillapex to the presence of resin as a core ingredient. Nevertheless, neither sealer was able to sustain its antibacterial activity after setting despite their initial high pH levels.[34] Moreover, freshly mixed Endo CPM exhibits antibacterial activity against Staphylococcus aureus and Streptococcus mutans with no significant reduction of the inhibition zone after setting.[35] In addition, some investigators, used the push-out test, have demonstrated that the Endo CPM has the significantly highest bond strength of the root canal dentin compared to MTA-Fillapex. They added that on the basis of this finding, Endo CPM sealer presented advantages when a postpreparation was required. Furthermore, MTA-Fillapex and AH Plus presented acceptable resistance to dislodgement.[36] Oliveira et al.[37] have investigated the microleakage of Endo CPM and Experimental MTA sealer, using cold lateral condensation technique, and compared with AH Plus, Epiphany SE, Sealapex, Active GP, and Endofill. The results demonstrated that Endo CPM and Active GP were less resistant to leakage. In general, Endo CPM sealer has been made to overcome the limitation of MTA, such as poor handling characteristic and lengthy setting time, and allow its use as root canal sealer.[37] Numerous researchers have stated that this sealer contains a large amount of calcium carbonate (differs from MTA), which tends to increase the release of calcium ions, offering good sealing properties, antimicrobial activity, adequate flow rate, and biocompatibility. This is besides its radiopacity and alkaline pH.[37],[38],[39]

MTA-Angelus sealer consists of tricalcium silicate, dicalcium silicate, tricalcium aluminate, tetracalcium aluminoferrite, bismuth oxide, iron oxide, calcium carbonate, magnesium oxide, crystalline silica, and residues (calcium oxide, free magnesium oxide, and potassium and sodium sulfate compounds). Several investigators have evaluated the antibacterial effect of MTA-Angelus. They found that this sealer has an antibacterial effect again Micrococcus lutes, S. aureus, Escherichia coli, Pseudomonas aeruginosa, and Candida albicans when compared to Portland cement.[7] Others have stated that the low solubility of MTA-Angelus, consistent with ANSI/ADA requirements,[40] is the result of an insoluble matrix of crystalline silica present within the sealer that maintains its integrity even in the presence of water.[41] Malhotra and Hedge[42] have evaluated the marginal seal of the MTA-Angelus, white ProRoot MTA, Biodentine, and glass ionomer cement as root-end filling materials using extracted maxillary central incisors and methylene blue dye. The results showed that microleakage was present in all the samples. Least amount of apical dye microleakage was seen in Biodentine. This may be because it is easier to use and sets faster and, therefore, reduces the risk of bacterial contamination. They added that the dye penetration in the MTA-Angelus and ProRoot MTA is similar (no statistical difference), followed by GIC.[42] Moreover, they revealed that the microleakage values of MTA and GIC were similar to investigations that have been previously conducted.[43],[44],[45],[46] Several investigators have evaluated the radiological opacity of MTA-Angelus and ProRoot MTA compared to Portland cement. The results demonstrated that MTA-Angelus presented a lower percentage of bismuth oxide than ProRoot MTA. Furthermore, Portland cement showed better adhesion to dentin and a better antimicrobial activity.[47],[48],[49]

ProRoot Endo Sealer, nonpremixed sealer, is composed of powder and liquid. The powder is composed of tricalcium silicate, dicalcium silicate, calcium sulfate, bismuth oxide, and a small amount of tricalcium aluminate, whereas the liquid is made from viscous aqueous solution of a water-soluble polymer. Huffman et al.[50] have tested the dislocation resistance of ProRoot Endo Sealer, AH Plus Jet, and Pulp Canal Sealer from root dentin with and without immersion in a simulated body fluid. The result revealed that ProRoot Endo Sealer possesses a greater bond strength than the other two sealers, especially after immersion. They concluded that the greater bonding of the ProRoot Endo Sealer is due to the presence of spherical amorphous calcium phosphate and apatite-like phases enhancing frictional resistance.[50] Weller et al.,[51] in their microleakage study, have compared ProRoot Endo Sealer with Pulp Canal Sealer and AH Plus. They used warm vertical compaction technique and fluid filtration method for 7 and 35 days. The result demonstrated that sealing ability of ProRoot Endo Sealer and AH Plus was better than that of Pulp Canal sealer.[51] Others have concluded that ProRoot MTA presented a higher percentage of bismuth oxide (average 9.2%) than MTA-Angelus.[47]

EndoSeal MTA is supplied in a premixed injectable paste and thus gives clinicians easy manipulation. It is composed of calcium silicates, calcium aluminates, calcium aluminoferrite, calcium sulfates, radiopacifier, and thickening agents. It had favorable physicobiological properties, showed statistically higher radiopacity value complying with ISO standards, had the longest setting time (mean: 1223 min) in humid incubator, had the lowest expansion after being immersed in water for 30 days, and presented a significant increase of pH over experimental time when compared with two bioceramic sealers (EndoSequence BC and MTA-Fillapex) and three epoxy resin-based sealers (AH Plus, AD Seal, and Radio Sealer).[25],[29],[52] Moreover, it has excellent sealing property, excellent antimicrobial effect, has a satisfactory cytocompatibility, easily removed with NiTi files when retreatment is necessary, enhanced biomineralization of the dentinal tubules, and presented satisfactory bond strength to root dentin.[20],[52],[53],[54],[55],[56]

Some investigators considered MTA-based sealers (MTA Angelus, ProRoot Endo Sealer, and EndoSeal MTA) are not sealers, but root repair materials. In addition, MTA-Fillapex sealers have been tested and several properties have major drawbacks such as cytotoxicity, push-out bond strength, solubility, and setting properties. In general, this is considered a bad sealer.[40],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55]

Calcium silicate-based sealers

There are two premixed calcium silicate-based sealers with similar chemical composition: iRoot SP and EndoSequence BC. This premixed calcium silicate-based endodontic products have been introduced to the market for their physicochemical and biological advantages, mainly their bioactivity potential.[12],[57],[58]

iRoot SP is an injectable, premixed radiopaque, insoluble bioceramic root canals sealer. It is composed of calcium silicate, zirconium oxide, calcium phosphate, calcium hydroxide, filler, and thickening agents. Calcium silicate represents the main constituent that can generate calcium silicate hydrates in the presence of water, resembling Portland cement.[59] Some investigators have compared the cytotoxic effects of MTA and iRoot SP on the cell viability, hard tissue deposition capacity, and odontogenic differentiation of human tooth germ stem cells using tissue culture. The results demonstrated that MTA and iRoot SP exhibited no cytotoxicity and induced stem cell differentiation into odontoblast-like cells, but Dycal (controls) caused cytotoxicity (P < 0.05) of almost all of the cells after 7 days. They added that MTA resulted in more efficient cell interaction and ability to stimulate mineralization process compared with iRoot SP.[58],[60] Anotherin vitro study indicated that MTA could induce BMP-2 expression, which resulted in the calcification of human periodontal ligament cells.[61] Moreover, iRoot SP can be used as alternatives to MTA as an apical plug material for the reduction of hard tissue deposition because of their similar chemical components as stated by the inventors of iRoot SP.[59] Meanwhile, the bone growth effects of iRoot SP were also stated in the patent certificate of the material. Other researchers have reported that calcium silicate cements were detected to have an ability to promote differentiation of human orofacial mesenchymal stem cells due to their compatibility. This results in promotion of periapical healing when these materials are used clinically.[62] Furthermore, using bioceramic iRoot BP (Brasseler-S. A., Georgia, USA) or MTA for partial pulpotomies of immature teeth with apical periodontitis revealed good results. Follow-up examination demonstrated no abnormal clinical signs or symptoms. Periapical radiographs showed a significant reduction in periapical radiolucency, a marked increase in the root canal wall thickness and ongoing closure of the apical opening. Both materials produced successful outcomes; however, iRoot BP was superior in terms of area of clinical application (packaged in a syringe) and would therefore be a better treatment alternative than MTA.[10] In addition, iRoot SP showed good antibacterial activity,[63],[64] cytocompatibility,[65] good apical sealing ability,[12],[66] good bonding to root canal dentin even under various conditions of dentin moisture,[12],[67],[68] solubility value in agreement with ANSI/ADA and ISO 6876/2012,[22],[67],[68] a high pH value (11.5) even after setting,[63] and radiopacity.[59]

EndoSequence BC is another new bioactive calcium silicate-based root canal sealer. Its chemical composition is similar to iRoot SP. The sealer is available in a premixed syringe with calibrated intracanal tips. This offers an easy and efficient delivery approach. As a hydrophilic sealer, it is utilized moisture within the canal to complete the setting reaction and it does not shrink or resorb on setting. It is biocompatible, has high pH, exhibits antimicrobial properties during the setting reaction, shows radiopacity 3.83, and has excellent sealing ability and fast setting.[8],[12],[21],[25],[69],[70] In addition, EndoSequence BC sealer has the ability to form hydroxyapatite due to calcium silicates which in a hydration reaction produces a calcium silicate hydrate gel and calcium hydroxide. The calcium hydroxide reacts with the phosphate ions to precipitate hydroxyapatite and water.[5],[8],[12],[21],[59] The manufacturer advocates expressing the sealer into the coronal one-third to one-half of the canal and then seating the master gutta-percha cone. Loushine et al. have stated that the EndoSequence BC requires at least 168 h before being completely set under different humidity conditions.[29] On the other hand, several investigators have demonstrated that the setting time of this sealer is 2.7 h.[22] The same workers have revealed that the flow rate was 23.1 mm,[22] whereas others recorded 26.96 mm.[69] Moreover, it was stated by some authors that EndoSequence BC is difficult to remove from root canals utilizing conventional retreatment technique including heat, chloroform, hand files, and rotary instruments.[70] Zhou et al. have reported that the solubility of EndoSequence BC was consistent with ISO 6876/2001.[22]

Calcium phosphate-based sealers

Eradicating bacterial biofilm and strengthening of root structure are considered ideal criteria for endodontic sealers. Some of the new calcium phosphate-based sealers are proving to achieve some of these criteria.[71] A study by Wang et al.[72] revealed that calcium phosphate-based adhesives are potent against eight different endodontic and periodontic biofilms.[72] There are different calcium phosphate-based sealers in the market. Examples are Sankin apatite (I, II, and III) root canal sealers and Capseal (I and II).

Sankin apatite root canal sealers (I, II, and III) are composed of powder and liquid. The powder contains alpha-tricalcium phosphate and hydroxy-Sankin apatite in Type I and iodoform added to the powder in Type II (30%) and type III (59%). The liquid is composed of polyacrylic acid and water. Bilginer et al. have studied the biocompatibility and apical microleakage of Sankin Apatite sealer Type I, II, and III root canal sealers. They found that the severity of tissue reaction for the materials tested decreased with time, and at the end of observation period, both Sankin apatite II and III have higher biocompatibility than both type 1 or Grossman's cement. They added that there was no significant difference in spectrophotometrically measured leakage among teeth obturated with the test materials.[73] Furthermore, it was found that Sankin apatite sealer is easily removed during retreatment with and without the use of solvents.[74] Barkhordar et al. have compared Sankin apatite sealer (Type I, II, and III) with Roth sealer, Seal apex, and Kerr sealer using lateral/vertical condensation technique and dye penetration method. The result demonstrated that sealing ability of Sankin apatite II was second better after seal apex.[75]

Capseal I and II are different calcium phosphate-based sealers. They are composed of powder and liquid. The powder contains tetracalcium phosphate and dicalcium phosphate anhydrous, Portland cement (gray cement in type I and white cement in type II), zirconium oxide, and other ingredients. The liquid contains hydroxypropyl methyl (cellulose in sodium phosphate solution). Bae study showed that the Capseal I and II were less cytotoxic than epoxy resin sealer AH26, zinc oxide eugenol sealer (extended working time) after 1 and 14 days. He also concluded that Capseal I and II sealer can produce bone regeneration.[76] Yang et al. studied the sealing ability of Capseal I and II using a field emission scanning electron microscope. They showed that both Capseal I and II sealers infiltrated into the dentinal tubules and they were well adopted to the canal walls.[77] Kim compared the biocompatibility of Capseal I and II and zinc oxide eugenol-based sealer. This study showed that Capseal I and II have lower tissue response during all the periods of the experiment. All the tested sealers revealed an acceptable biocompatibility.[78] In another study by Bae, the alkalinity and calcium-release properties of different sealers were tested. He found that Capseal I and II produced calcium ion and pH higher than or equal to those of Seal apex and Sankin apatite sealer.[79] Yang et al.[77] have compared Capseal I and II with Sankin apatite, AH Plus, Sealapex, and Pulp Canal Sealer-Kerr. They used lateral condensation technique and anaerobic bacterial leakage test for a period of 90 days. The result showed that Capseal I and II, especially type II, had good sealing ability, compared to that of AH Plus.[77] Overall, calcium silicate and calcium phosphate root canal sealers have main problems such as setting properties and solubility.[22],[29],[75]

  Discussion Top

Efficient cleaning and shaping of the root canal(s) and proper three-dimensional obturation using gutta-percha and endodontic sealer can achieve the biological and mechanical objective of endodontic treatment. This attains a fluid-proof seal throughout the root canal system. Furthermore, as the sealer reaches the apical foramen, it comes in direct contact with periapical tissues and therefore should be biocompatible to establish adequate periapical healing.[1],[2],[3]Bioceramic-based sealers are also used in the field of medicine (orthopedic treatment) and pediatric dentistry.[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13] In general, the bioceramic-based sealers have been introduced in dental practice mainly because of their biocompatibility, antibacterial activity, good bond strength, dimensional stability, and good osteogenic potential.[5],[22],[29],[52],[69],[73] On the other hand, conventional sealers showed good performance, with similar or sometime better results than some bioceramic-based sealers.[12],[21],[26],[36],[37],[43],[67],[77] Others reported that bioceramic-based and epoxy resin-based sealers showed acceptable physiochemical properties. Discrepancies among studies could be explained on the basis of differences in experimental designs, including variation on irrigating solutions, sealer's particle size, composition, canal humidity, and obturation techniques.[25],[27],[28]

Some workers have demonstrated that bioceramics produce, during the hydration process, different compounds, e.g., hydroxyapatites, with the ability to induce a regenerative response in the human body. When placed in contact with bone, mineral hydroxyapatite has an osteoconductive effect, leading to the bone formation at the interface. They added that there is an intrinsic osteoinductive capacity of bioceramics, because of the documented ability to absorb osteoinductive substances if there is a bone healing process nearby.[34],[80] Different finding was stated by Assmann et al.[18] in their study to evaluate bone tissue response to a sealer containing mineral trioxide aggregate. They demonstrated irritating effect on bone tissue and concluded that this sealer may not have biological advantages. The difference in finding may be due to difference in experimental technique and to the chemical composition of the sealer which had no effect on improving osseous tissue repair.[18]

Overall, cytotoxicity of all studied endodontic sealers were severe as soon as they extruded throughout the apical foramen and became in contact with tissue fluid.[80],[81],[82] Furthermore, it was noticed that cytotoxicity of MTA-based (e.g., MTA-Fillapex), epoxy resin-based (e.g., AH-26), and calcium phosphate-based (e.g., Sankin apatite) sealers decreased over time. Apatite sealer exhibited the least cytotoxicity. Cytotoxicity of other two types was similar at different intervals.[19]

Calcium silicate-based sealers (iRoot and EndoSequence BC-premixed) revealed good bioactive potential and acceptable antibacterial activity. These data were supported by several previous investigations.[12],[57],[58],[59],[60],[61],[62],[63],[64],[69] Moreover, calcium phosphate-based sealers (Sankin apatite and Capseal) showed good biocompatibility, minimal leakage, and good sealing ability comparable with conventional sealers. Parallel findings were reported by numerous studies.[37],[73],[79],[80],[81],[82],[83] In general, ongoing laboratory and clinical studies confirmed efficacy, decreased cytotoxicity, biocompatibility, promoted osteoplastic differentiation, and safety of calcium silicate-based sealer. In addition, favorable properties of these new sealers suggest application in vital pulp therapy as well as regenerative endodontic procedures and endodontic surgery.[29],[84],[85],[86] Moreover, concerning pediatric dentistry, some materials such as calcium hydroxide, Portland cement MTA (gray and white ProRoot), and Biodentine are used in vital pulp therapy in both primary and young permanent teeth.[87] These materials aim to maintain the vitality of the pulp by stimulating tertiary dentin formation. It was found that MTA and Biodentine were more biocompatible, less toxic, and promote healing compared to glass ionomer cement and calcium hydroxide.[88],[89],[90],[91] Finally, further investigations may be required to clarify the clinical outcomes associated with the use of these calcium silicate-based root canal sealers.

  Conclusion Top

In general, calcium silicate-based sealers (bioceramic-based sealers) showed promising results as root canal sealers. However, differences in findings of these researches demonstrated that these sealers may fulfill most of the requirements demanded of the ideal root canal sealers. This review revealed that some of these sealers are not suitable to be used as a sealer. This is due to their setting time (165 min for initial set and 6 h for final set) and solubility. However, these sealers are attractive because their bioactivity and dimensional stability that has been reported in numerous investigations compared to conventional sealers.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Kaur A, Shah N, Logani A, Mishra N. Biotoxicity of commonly used root canal sealers: A meta-analysis. J Conserv Dent 2015;18:83-8.  Back to cited text no. 1
[PUBMED]  [Full text]  
Schilder H. Filling root canals in three dimensions. Dent Clin North Am 1967:723-44.  Back to cited text no. 2
Johnson WT, Kulild JC. Bioceramic, Cohen's pathway of the pulp. In: Obturation of the Cleaned and Shaped Root Canal System. 10th ed., Ch. 10. St. Louis, Missouri: Mosby Inc.; 2011. p. 361.  Back to cited text no. 3
Baraba A, Pezelj-Ribaric S, Roguljić M, Miletic I. Cytotoxicity of two bioactive root canal sealers. Acta Stomatol Croat 2016;50:8-13.  Back to cited text no. 4
Jitru S, Hodisan I, Timis L, Lucian A, Bud M. The use of bioceramics in endodontics – Literature review. Dent Med 2016;89:470-3.  Back to cited text no. 5
Kuga CM, Edson Campos EA. Hydrogen ion and calcium releasing of MTA Fillapex and MTA based formulation. RSBO 2011;8:271-6.  Back to cited text no. 6
Tanomaru-Filho M, Tanomaru JM, Barros DB, Watanabe E, Ito IY.In vitro antimicrobial activity of endodontic sealers, MTA-based cements and Portland cement. J Oral Sci 2007;49:41-5.  Back to cited text no. 7
Koch K, Brave D, Nasseh AA. A review of bioceramic technology in endodontics. Roots 2012;4:6-12.  Back to cited text no. 8
Koch KA, Brave DG, Nasseh AA. Bioceramic technology: Closing the endo-restorative circle, Part I. Dent Today 2010;29:100-5.  Back to cited text no. 9
Jiang S, Wu H, Zhang CF. Partial pulpotomy of immature teeth with apical periodontitis using bioceramic and mineral trioxide aggregate: A report of three cases. Chinese J Dent Res 2016;19:115-20.  Back to cited text no. 10
Azimi S, Fazlyab M, Sadri D, Saghiri MA, Khosravanifard B, Asgary S. Comparison of pulp response to mineral trioxide aggregate and a bioceramic paste in partial pulpotomy of sound human premolars: A randomized controlled trial. Int Endod J 2014;47:873-81.  Back to cited text no. 11
Almeida LH, Moraes RR, Morgental RD, Pappen FG. Is premixed calcium silicate-based endodontic sealers comparable to conventional materials? A systemic review ofin vitro studies. J Endod 2017;43:527-35.  Back to cited text no. 12
Faria-Júnior NB, Tanomaru-Filho M, Berbert FL, Guerreiro-Tanomaru JM. Antibiofilm activity, pH and solubility of endodontic sealers. Int Endod J 2013;46:755-62.  Back to cited text no. 13
Bin CV, Valera MC, Camargo SE, Rabelo SB, Silva GO, Balducci I, et al. Cytotoxicity and genotoxicity of root canal sealers based on mineral trioxide aggregate. J Endod 2012;38:495-500.  Back to cited text no. 14
Scelza MZ, Linhares AB, da Silva LE, Granjeiro JM, Alves GG. A multiparametric assay to compare the cytotoxicity of endodontic sealers with primary human osteoblasts. Int Endod J 2012;45:12-8.  Back to cited text no. 15
Silva EJ, Santos CC, Zaia AA. Long-term cytotoxic effects of contemporary root canal sealers. J Appl Oral Sci 2013;21:43-7.  Back to cited text no. 16
Tavares CO, Bottcher DE, Assmann E, Kopper PMP, de Flgueiredo JAP, Grecian FS, Scarparo RK. Tissue reaction to a new mineral trioxide aggregate-containing endodontic sealer. J Endod 2013;39:653-7.  Back to cited text no. 17
Assmann E, Böttcher DE, Hoppe CB, Grecca FS, Kopper PM. Evaluation of bone tissue response to a sealer containing mineral trioxide aggregate. J Endod 2015;41:62-6.  Back to cited text no. 18
Jafari F, Aghazadeh M, Jafari S, Khaki F, Kabiri F.In vitro cytotoxicity comparison of MTA Fillapex, AH-26 and Apatite root canal sealer at different setting times. Iran Endod J 2017;12:162-7.  Back to cited text no. 19
Yavari H, Shahi S, Galledar S, Samiei M, Janani M. Effect of retreatment on the push-out bond strength of MTA-based and epoxy resin-based endodontic sealers. J Dent Res Dent Clin Dent Prospects 2017;11:43-7.  Back to cited text no. 20
Al-Haddad A, Che Ab Aziz ZA. Bioceramic-based root canal sealers: A review. Int J Biomater 2016;2016:9753210.  Back to cited text no. 21
Zhou HM, Shen Y, Zheng W, Li L, Zheng YF, Haapasalo M. Physical properties of 5 root canal sealers. J Endod 2013;39:1281-6.  Back to cited text no. 22
Vitti RP, Prati C, Silva EJ, Sinhoreti MA, Zanchi CH, de Souza e Silva MG, et al. Physical properties of MTA Fillapex sealer. J Endod 2013;39:915-8.  Back to cited text no. 23
Viapiana R, Flumignan DL, Guerreiro-Tanomaru JM, Camilleri J, Tanomaru-Filho M. Physicochemical and mechanical properties of zirconium oxide and niobium oxide modified Portland cement-based experimental endodontic sealers. Int Endod J 2014;47:437-48.  Back to cited text no. 24
Lee JK, Kwak SW, Ha JH, Lee W, Kim HC. Physicochemical properties of epoxy resin-based and bioceramic-based root canal sealers. Bioinorg Chem Appl 2017;2017:2582849.  Back to cited text no. 25
Silva EJ, Rosa TP, Herrera DR, Jacinto RC, Gomes BP, Zaia AA. Evaluation of cytotoxicity and physicochemical properties of calcium silicate-based endodontic sealer MTA Fillapex. J Endod 2013;39:274-7.  Back to cited text no. 26
Garrido AD, Lia RC, França SC, da Silva JF, Astolfi-Filho S, Sousa-Neto MD. Laboratory evaluation of the physicochemical properties of a new root canal sealer based on Copaifera multijuga oil-resin. Int Endod J 2010;43:283-91.  Back to cited text no. 27
Wolf M, Küpper K, Reimann S, Bourauel C, Frentzen M. 3D analyses of interface voids in root canals filled with different sealer materials in combination with warm gutta-percha technique. Clin Oral Investig 2014;18:155-61.  Back to cited text no. 28
Loushine BA, Bryan TE, Looney SW, Gillen BM, Loushine RJ, Weller RN, et al. Setting properties and cytotoxicity evaluation of a premixed bioceramic root canal sealer. J Endod 2011;37:673-7.  Back to cited text no. 29
Ioannidis K, Mistakidis I, Beltes P, Karagiannis V. Spectrophotometric analysis of crown discoloration induced by MTA- and ZnOE-based sealers. J Appl Oral Sci 2013;21:138-44.  Back to cited text no. 30
Imai Y, Komabayashi T. Properties of a new injectable type of root canal filling resin with adhesiveness to dentin. J Endod 2003;29:20-3.  Back to cited text no. 31
Guerreiro-Tanomaru JM, Duarte MA, Gonçalves M, Tanomaru-Filho M. Radiopacity evaluation of root canal sealers containing calcium hydroxide and MTA. Braz Oral Res 2009;23:119-23.  Back to cited text no. 32
Cañadas PS, Berástegui E, Gaton-Hernández P, Silva LA, Leite GA, Silva RS. Physicochemical properties and interfacial adaptation of root canal sealers. Braz Dent J 2014;25:435-41.  Back to cited text no. 33
Morgental RD, Vier-Pelisser FV, Oliveira SD, Antunes FC, Cogo DM, Kopper PM. Antibacterial activity of two MTA-based root canal sealers. Int Endod J 2011;44:1128-33.  Back to cited text no. 34
Mohammadi Z, Giardino L, Palazzi F, Shalavi S. Antibacterial activity of a new mineral trioxide aggregate-based root canal sealer. Int Dent J 2012;62:70-3.  Back to cited text no. 35
Assmann E, Scarparo RK, Böttcher DE, Grecca FS. Dentin bond strength of two mineral trioxide aggregate-based and one epoxy resin-based sealers. J Endod 2012;38:219-21.  Back to cited text no. 36
Oliveira AC, Tanomaru JM, Faria-Junior N, Tanomaru-Filho M. Bacterial leakage in root canals filled with conventional and MTA-based sealers. Int Endod J 2011;44:370-5.  Back to cited text no. 37
Orosco FA, Bramante CM, Garcia RB, Bernadineli N, Moraes IG. Sealing ability of grar MTA AngelusTM, CPM TM and MBPc used as apical plugs. J Appl Oral Sci 2008;16:50-4.  Back to cited text no. 38
Tanomaru JM, Tanomaru-Filho M, Hotta J, Watanabe E, Ito IY. Antimicrobial activity of endodontic sealers based on calcium hydroxide and MTA. Acta Odontol Latinoam 2008;21:147-51.  Back to cited text no. 39
Borges RP, Sousa-Neto MD, Versiani MA, Rached-Júnior FA, De-Deus G, Miranda CE, et al. Changes in the surface of four calcium silicate-containing endodontic materials and an epoxy resin-based sealer after a solubility test. Int Endod J 2012;45:419-28.  Back to cited text no. 40
Fridland M, Rosado R. Mineral trioxide aggregate (MTA) solubility and porosity with different water-to-powder ratios. J Endod 2003;29:814-7.  Back to cited text no. 41
Malhotra S, Hedge MN. Analysis of marginal seal of ProRoot MTA, MTA Angelus, biodentine, and glass ionomer cement as root-end filling materials. Anin vitro study. J Oral Res Rev 2015;7:44-9.  Back to cited text no. 42
  [Full text]  
Kokate SR, Pawar AM. Anin vitro comparative stereomicroscopic evaluation of marginal seal between MTA, glass ionomer cement and biodentine as root end filling materials using 1% methylene blue as tracer. Endodontic 2012;24:36-42.  Back to cited text no. 43
Sousa CJ, Loyola AM, Versiani MA, Biffi JC, Oliveira RP, Pascon EA. A comparative histological evaluation of the biocompatibility of materials used in apical surgery. Int Endod J 2004;37:738-48.  Back to cited text no. 44
Shipper G, Grossman ES, Botha AJ, Cleaton-Jones PE. Marginal adaptation of mineral trioxide aggregate (MTA) compared with amalgam as a root-end filling material: A low-vacuum (LV) versus high-vacuum (HV) SEM study. Int Endod J 2004;37:325-36.  Back to cited text no. 45
Pérez AL, Spears R, Gutmann JL, Opperman LA. Osteoblasts and MG-63 osteosarcoma cells behave differently when in contact with ProRoot MTA and White MTA. Int Endod J 2003;36:564-70.  Back to cited text no. 46
Oliveira MG, Xavier CB, Demarco FF, Pinheiro AL, Costa AT, Pozz DH. Comparative chemical study of MTA and Portland cements. Brazil Dent J 2007;18:3-7.  Back to cited text no. 47
Camilleri J, Montesin FE, Papaioannou S, McDonald F, Pitt Ford TR. Biocompatibility of two commercial forms of mineral trioxide aggregate. Int Endod J 2004;37:699-704.  Back to cited text no. 48
Porter ML, Bertó A, Primus CM, Watanabe I. Physical and chemical properties of new-generation endodontic materials. J Endod 2010;36:524-8.  Back to cited text no. 49
Huffman BP, Mai S, Pinna L, Weller RN, Primus CM, Gutmann JL, et al. Dislocation resistance of ProRoot Endo Sealer, a calcium silicate-based root canal sealer, from radicular dentine. Int Endod J 2009;42:34-46.  Back to cited text no. 50
Weller RN, Tay KC, Garrett LV, Mai S, Primus CM, Guttmann JL, et al. Microscopic appearance and apical seal of root canal filled with gutta-percha and ProRoot Endo Sealer after immersion in a phosphate-containing fluid. Int Endo J 2008;41:977-86.  Back to cited text no. 51
Lim ES, Park YB, Kwon YS, Shon WJ, Lee KW, Min KS. Physical properties of biocompatibility of an injectable calcium-silicate-based root canal sealer:In vitro andin vivo study. BMC Oral Health 2016;15: article 129.  Back to cited text no. 52
Kim H, Kim Y, Nam S, Taeyub K, Kim H. Evaluation of sealing effect and working time of root canal filling MTA materials. J Korean Acad Pediat Dent 2016;43:129-36.  Back to cited text no. 53
Kim RJ, Shin JH. Cytotoxicity of a noval mineral trioxide aggregate-based root canal sealer. Dent Mater J 2014;33:313-8.  Back to cited text no. 54
Yoo YJ, Baek SH, Kum KY, Shon WJ, Woo KM, Lee W. Dynamic intratubular biomineralization following root canal obturation with pozzolan-based mineral trioxide aggregate sealer cement. Scanning 2016;38:50-6.  Back to cited text no. 55
Silva EJ, Carvalho NK, Prado MC, Zanon M, Senna PM, Souza EM, et al. Push-out bond strength of injectable Pozzolan-based root canal sealer. J Endod 2016;42:1656-9.  Back to cited text no. 56
Moinzadeh AT, Aznar Portales C, Schembri Wismayer P, Camilleri J. Bioactivity potential of endo sequence BC RRM putty. J Endod 2016;42:615-21.  Back to cited text no. 57
Güven EP, Taşlı PN, Yalvac ME, Sofiev N, Kayahan MB, Sahin F.In vitro comparison of induction capacity and biomineralization ability of mineral trioxide aggregate and a bioceramic root canal sealer. Int Endod J 2013;46:1173-82.  Back to cited text no. 58
Yan Q, Lu D. Premix biological hydraulic cement past composition and using the same. US Patent Application 2008; 2008/029909, December 4, 2008.  Back to cited text no. 59
Guven EP, Yalvac ME, Sahin F, Yazici MM, Rizvanov AA, Bayirli G. Effect of dental materials calcium hydroxide-containing cement, mineral trioxide aggregate, and enamel matrix derivative on proliferation and differentiation of human tooth germ stem cells. J Endod 2011;37:650-6.  Back to cited text no. 60
Maeda H, Nakano T, Tomokiyo A, Fujii S, Wada N, Monnouchi S, et al. Mineral trioxide aggregate induces bone morphogenetic protein-2 expression and calcification in human periodontal ligament cells. J Endod 2010;36:647-52.  Back to cited text no. 61
Gandolfi MG, Shah SN, Feng R, Pratic C, Akintoye SO. Biomimetic calcium-silicate cements support differentiation of human orofacial bone marrow stromal cells. J Endod 2011;37:1102-8.  Back to cited text no. 62
Zhang H, Shen Y, Ruse ND, Haapasalo M. Antibacterial activity of endodontic sealers by modified direct contact test against Enterococcus faecalis. J Endod 2009;35:1051-5.  Back to cited text no. 63
Wang Z, Shen Y, Haapasalo M. Dentin extends the antibacterial effect of endodontic sealers against Enterococcus faecalis biofilms. J Endod 2014;40:505-8.  Back to cited text no. 64
Zhang W, Li Z, Peng B. Ex vivo cytotoxicity of a new calcium silicate-based canal filling material. Int Endod J 2010;43:769-74.  Back to cited text no. 65
Zhang W, Li Z, Peng B. Assessment of a new root canal sealers apical sealing ability. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:79-82.  Back to cited text no. 66
Ersahan S, Aydin C. Solubility and apical sealing characteristics of a new calcium silicate-based root canal sealer in comparison to calcium hydroxide-, methacrylate resin- and epoxy resin-based sealers. Acta Odontol Scand 2013;71:857-62.  Back to cited text no. 67
Nagas E, Uyanik MO, Eymirli A, Cehreli ZC, Vallittu PK, Lassila LV, et al. Dentin moisture conditions affect the adhesion of root canal sealers. J Endod 2012;38:240-4.  Back to cited text no. 68
Candeiro GT, Carreia FC, Duarte MA, Ribeiro-Siqueira DC, Gavini G. Evaluation of radiopacity, pH, released of calcium, ions and flow of bioceramic root canal sealer. J Endod 2012;38:842-5.  Back to cited text no. 69
Hess D, Solomon E, Spears R, He J. Retreatability of a bioceramic root canal sealing material. J Endod 2011;37:1547-9.  Back to cited text no. 70
Wang L, Xie X, Li C, Liu H, Zhang K, Zhou Y, et al. Novel bioactive root canal sealer to inhibit endodontic multispecies biofilms with remineralizing calcium phosphate ions. J Dent 2017;60:25-35.  Back to cited text no. 71
Wang L, Xie X, Weir MD, Fouad AF, Zhao L, Xu HH. Effect of bioactive dental adhesive on periodontal and endodontic pathogens. J Mater Sci Mater Med 2016;27:168.  Back to cited text no. 72
Bilginer S, Esener T, Soylemezoglu F, Tiftik AM. The investigation of biocompatibility and apical microleakage of tricalcium phosphate based root canal sealer. J Endod 1997;23:105-9.  Back to cited text no. 73
Ardemir A, Adnir N, Bell S.In vitro evaluation of the dissolving effect of solvents on root canal sealer. J Oral Sci 2003;45:123-6.  Back to cited text no. 74
Barkhordar RA, Stark MM, Soelberg K. Evaluation of the apical sealing ability of apatite root canal sealer. Quintessence Int 1992;23:515-8.  Back to cited text no. 75
Bae WJ, Chang SW, Lee SI, Kum KY, Bae KS, Kim EC. Human periodontal ligament cell response to a newly developed calcium phosphate-based root canal sealer. J Endod 2010;36:1658-63.  Back to cited text no. 76
Yang SE, Baek SH, Lee W, Kum KY, Bae KS.In vitro evaluation of the sealing ability of newly developed calcium phosphate-based root canal sealer. J Endod 2007;33:978-81.  Back to cited text no. 77
Kim JS, Baek SH, Bae KS.In vivo study on the biocompatibility of newly developed calcium phosphate-based root canal sealers. J Endod 2004;30:708-11.  Back to cited text no. 78
Bae KH, Chang SW, Bae KS, Park DS. Evaluation of pH and calcium ion release in capseal I and II and in two other root canal sealers. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:e23-8.  Back to cited text no. 79
Huang FM, Tai KW, Chou MY, Chang YC. Cytotoxicity of resin-, zinc oxide-eugenol-, and calcium hydroxide-based root canal sealers on human periodontal ligament cells and permanent V79 cells. Int Endod J 2002;35:153-8.  Back to cited text no. 80
Poggio C, Dagna A, Ceci M, Meravini MV, Colombo M, Pietrocola G. Solubility and pH of bioceramic root canal sealers: A comparative study. J Clin Exp Dent 2017;9:e1189-94.  Back to cited text no. 81
Bansode PV, Pathak SD, Wavdhane MB, Chavan PV. A review of bioceramic sealers in endodontics. J Dent Med Sci 2018;17:82-6.  Back to cited text no. 82
So BB, Mandes AT, da Silva PB, So MV. Evaluation of physiochemical properties of new calcium silicate-based sealer. Braz Dent J 2018;29:536-40.  Back to cited text no. 83
Salles LP, Gomes-Cornélio AL, Guimarães FC, Herrera BS, Bao SN, Rossa-Junior C, et al. Mineral trioxide aggregate-based endodontic sealer simulates hydroxyapatite nucleation in human osteoblast-like cell culture. J Endod 2012;38:971-6.  Back to cited text no. 84
Bogen G, Chandler NP. Vital pulp therapy (calcium silicate-based cement). In: Rotstein I, Ingle JI, editors. Ingle's Endodontics. 7th ed. North Carolina: PMPH USA, Ltd.; 2019. p. 894-6.  Back to cited text no. 85
Giacomino CM, Wealleans JA, Kuhn N, Diogenes A. Comparative biocompatibility and osteogenic potential of two bioceramic sealers. J Endod 2019;45:51-6.  Back to cited text no. 86
Sindi AS. Management of bilaterally immature permanent teeth using various treatment modalities. Saudi Endod J 2018;8:222-7.  Back to cited text no. 87
  [Full text]  
Malkondu Ö, Karapinar Kazandaǧ M, Kazazoǧlu E. A review on biodentine, a contemporary dentine replacement and repair material. Biomed Res Int 2014;2014:160951.  Back to cited text no. 88
Luo Z, Li D, Kohli MR, Yu Q, Kim S, He WX. Effect of Biodentine™ on the proliferation, migration and adhesion of human dental pulp stem cells. J Dent 2014;42:490-7.  Back to cited text no. 89
Nowicka A, Lipski M, Parafiniuk M, Sporniak-Tutak K, Lichota D, Kosierkiewicz A, et al. Response of human dental pulp capped with biodentine and mineral trioxide aggregate. J Endod 2013;39:743-7.  Back to cited text no. 90
Srinivasan V, Waterhouse P, Whitworth J. Mineral trioxide aggregate in paediatric dentistry. Int J Paediatr Dent 2009;19:34-47.  Back to cited text no. 91


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