Root Canal Filing Materials

Ideal requirements, core materials (Solid, semisolid and paste), and sealers

1. Root canal Filling Materials Dr. Deepthi P.R. 3 rd Year MDS Dept. of Conservative Dentistry & Endodontics

2. History Amalgam Asbestos Balsam Bamboo Cement Cu, Fe, ZnOCl , Au or Sn foil, Ag points Pastes PoP Resin Rubber

3. Ideal reqmts : Grossman modified Brownlee’s criteria Obturation of Root canal systems- Endodontics : Colleagues of Excellence, Fall 2009

4. 2 basic groups Core filling materials Sealers

5. Core materials Solid core : Ag points Semisolid core: Gutta percha Paste : ZnO containing pastes

6. Solid core filling materials-Ag Points Jasper- 1933 1930s- 1960s Advantages Drawbacks Seltzer et al. Brady & Del Rio Goldberg Guttirez Kehoe

7. Newer solid core filling material: Resilon / Real Seal P olycaprolactone core material

8. Resilon / Real Seal Bioactive glass Bi, Ba salts: fillers Pigments Resin sealer

9. Resilon / Real Seal “Monoblock”

10. Resilon / Real Seal Primer Sealer S ynthetic polymer points/ pellets Lower temperatures than GP Miner et al. Nielsen & Baumgartner Shipper et al.

11. Resilon / Real Seal Susceptibility to degradation- Tay et al. Interfacial strength analysis: Gesi et al. Stratton et al, Von Fraunhofer et al. Wang et al. Epley et al. Williams et al. Karr et al. J Endod 2007; 33: 749-752

12. Semisolid core filling materials Gutta percha C- points

13. Gutta percha - Discovery & Historical uses “GETAH”: gum “PERTJA”: name of the tree in Malay language John Tradescant : 1656- ‘ Mazer Wood’ Dr. William Montgomerie : Gold medal in 1843 Ernst Werner von Siemans : 1848 Prakash et al. Gutta - percha : An untold story- ENDODONTOLOGY

14. Gutta percha - Discovery & Historical uses Alexander Cabriol & Duclos : first GP patent Hamock & Bewley : 1845 James Paterson: 1845- hand moulded golf balls ‘ Gutties ’ Field of Medicine Prakash et al. Gutta - percha : An untold story- ENDODONTOLOGY

15. GP: Evolution into dentistry Edwin Truman: Temporary filling material Hill’s stopping: 1847 Bowman: 1867- root canal filling material Perry: 1883 S.S. White company: 1887 Rollins: 1893 Prakash et al. Gutta- percha: An untold story- ENDODONTOLOGY

16. GP: Evolution into dentistry Callahan: 1914 Ingle & Levine: 1959 Standardized GP: 2 nd International Conference at Philadelphia – 1959 ISO: 1976 ADA # 78 Prakash et al. Gutta- percha: An untold story- ENDODONTOLOGY

17. Gutta percha - Sources Rubber trees :Malaysia, Borneo, Indonesia, Brazil Mimusops globsa , Manilkara bidentata , Blanco genus Palaqium gutta, Isonanadra gutta, Dichopis gutta Prakash et al. Gutta- percha: An untold story- ENDODONTOLOGY

18. Gutta percha - Indigenous Sources Palaquium obavatum Palaquium polyanthum Palaquium ellipticum Palaquium gutta Prakash et al. Gutta - percha : An untold story- ENDODONTOLOGY

19. Other substitutes Surinam Gutta-percha Butyrospermum park Dyera costulata Maytenus phyllanthoides Calatropis giganlea Manilkara species Synthetic trans- poly isoprene Prakash et al. Gutta - percha : An untold story- ENDODONTOLOGY

20. Gutta percha - Chemistry BUNN: 1942

21. Gutta percha - Compositions Crude form Gutta : 75- 82 % Alban: 14- 16% Fluavil : 4-6 % Tannin, salts, saccharine substances Prakash et al. Gutta - percha : An untold story- ENDODONTOLOGY

22. Gutta percha - Compositions 19% to 22% Balata 59% to 75% zinc oxide Waxes Coloring agents Antioxidants Metallic salts J.L. Gutmann . Root Canal Obturation : An Update. www.ineedce.com

23. Gutta percha - Compositions Dental GP- not mostly GP ZnO : 50-79% Heavy metal salts: 1- 17 % Wax or resin: 1- 14% Actual GP: 19- 22% Obturation of Root Canal Systems- Endodontics: Colleagues for Excellence- Fall 2009

24. Gutta percha - Compositions Ingle’s Endodontics : 6 th Edition

25. Gutta percha - Compositions ZnO : filler, mild antibacterial Waxes & resins: Plasticizers Metal sulfates:BaSO4-radiopacifier

26. Medicated GP Iodoform Free iodine Protection No difference: regular GP points & MGP- ability to delay microleakage of E. faecalis Martin et al. 1999

27. Medicated GP Ca(OH)2: (40–60%) ( Roeko / Coltene / Whaledent , Langenau , Germany) Ca(OH)2 containing GP point: improvement in the apical sealing quality Holland et al.

28. Medicated GP Activ Point ( Roeko / Coltene / Whaledent ): CHX Better antibacterial than Ca(OH)2 containing GP: Lin et al. Podbielski et al. GP + tetracycline

29. GP: Crystalline phases Alpha Beta Prakash et al. Gutta - percha : An untold story- ENDODONTOLOGY

30. GP: Commercial manufacture Coagulation Obach’s technique Aging: rejuvenation Prakash et al. Gutta - percha : An untold story- ENDODONTOLOGY

31. Size availability ISO sizes 0.04 & 0.06 taper Traditional sizes Pellets

32. GP: Storage , Sterilization Low humidity Effects of high humidity Senia et al.- 5.25% NaOCl – 1 minute Short et al. Valois et al. Gomes et al.

33. GP: Current forms Solid core Gutta-percha points - Standardized - Non standardized Thermo mechanical compactible GP Thermo plasticized GP - Solid core system - Injectable form Medicated Gutta-percha Prakash et al. Gutta - percha : An untold story- ENDODONTOLOGY

34. GP: Properties Toxicity Sjogren et al. Serene et al. Cross reactivity Costa et al. , Hamann et al. Solubility

35. GP: Thermomechanical properties Plasticity at relatively low temperatures Heat cycling Shrinkage: 1-2 % Relative inability to transmit heat for softening and 3D molding Simons W. Revolutionary Advances, Part 3: Pursuit of the 3-D cork. Dentistry Today. 2015 Obturation of Root Canal Systems- Endodontics: Colleagues for Excellence- Fall 2009

36. GP: Advantages Natural Inert High biocompatibility Dimensionally stable Thermoplastic Compactable Radiopaque Dissolvable Antibacterial activity Simons W. Revolutionary Advances, Part 3: Pursuit of the 3-D cork. Dentistry Today. 2015

37. GP: Disadvantages D istorted by pressure Forced through the apical foramen if too much pressure is used Not rigid A sealer is necessary Carrotte P. E ndodontics: Part 8. Filling the Root Canal System. British Dental Journal 197, 667- 672 (2004)

38. Smart Seal Obturation System Smart materials- Designed materials that have one or more properties that can be significantly changed in a controlled fashion by external stimuli, such as stress, temperature , moisture, pH, and electric or magnetic fields Badamill & Ahuja . Biosmart Materials: Braeaking New Ground in Dentistry. Hindawi Publications. Vol. 2014

39. Smart Seal Obturation System EndoTechnologies , LLC

40. Smart Seal Obturation System Lateral expansion Non isotropic Smart Paste Bio Sealer Bioceramics Ca (OH)2 & HAP Setting time Badamill & Ahuja . Biosmart Materials: Braeaking New Ground in Dentistry. Hindawi Publications. Vol. 2014

41. Smart Seal Obturation System Economides et al . Eid et al. Didato et al. 25 to 45 sizes: 0.04 % & 0.06% taper Badamill & Ahuja . Biosmart Materials: Braeaking New Ground in Dentistry. Hindawi Publications. Vol. 2014

42. Smart Seal Obturation System Self sealing; dentin derived moisture Less dentin removal Avoids compaction forces EndoTechnologies, LLC

43. Paste filling Materials ZnO Russian Red Trailement SPAD MTA Paraformaldehyde

44. Russian Red Eastern Europe, Asian & Pacific rim nations Orstavik http:// www.dentstal.com Powder: Dexamethazone 20mg Resorcin 11g Zinc oxide 50 g BaSO4 29g Liquid : Formaldehyde solution 10 ml Catalyst : Resorcin 20g HCl 2 ml Aqua destillata about 1000m

45. MTA C onventional core filling materials cannot be used Drawbacks : Somewhat difficult handling characteristics Extended setting time of at least 3 hours or more

46. MTA Sealing ability Marginal adaptation Leakage Cytotoxicity Repair & Regeneration Use of moist cotton Solubility

47. MTA Whitworth J. Methods of Filling Root canls : Principles & Practices. Endo Topics. 2005, 12, 2- 24

48. Paraformaldehyde pastes Angelo Sargenti - Early 1950s Sargenti Paste N2 N2 Normal N2 Medical N2 Universal N2 Apical RC-2B RC-2W TCM White One-Step Endodontic Formula Endodilato Barrett S. Be Wary of S argenti Paste. Dental Watch. 09. 01. 2014

49. Paraformaldehyde pastes E asier and faster to place Release HCHO Serious injuries to surrounding tissues

50. Paraformaldehyde pastes Brewer D.L. Schwartze T. Position statement by AAE in 1991 No FDA approval Proponents: 1969- American Endodontic Society Sargenti Opposition Society : 2008

51. Paraformaldehyde pastes Endomethasone : Powder: dexamethasone , hydrocortisone acetate, thymol iodide, paraformaldehyde, & a radiopaque excipient Liquid: eugenol, peppermint oil & Anise oil Riebler’s paste Trailement SPAD

52. SEALERS ‘A radiopaque dental cement used, usually in combination with a solid or semi-solid core material, to fill voids and to seal root canals during obturation’ - Glossary of Endodontic Terms

53. SEALERS Impervious seal Filler Antimicrobial Lubricant Adhesive properties J.L. Gutmann. Root Canal Obturation: An Update. www.ineedce.com

54. Requirements of Ideal Sealer 1. It should be tacky when mixed to provide good adhesion between it and the canal wall when set. 2. It should make a hermetic seal. 3. It should be radiopaque so it can be visualized in the radiograph. 4. The particles of powder should be very fine so they can mix easily with the liquid. 5. It should not shrink upon setting. 6. It should not stain tooth structure .

55. Requirements of Ideal Sealer 7. It should be bacteriostatic or at least not encourage bacterial growth. 8. It should set slowly. 9. It should be insoluble in tissue fluids. 10. It should be tissue tolerant, that is, nonirritating to periradicular tissues. 11. It should be soluble in a common solvent, if it is necessary to remove the root canal filling

56. Additional requirements 12. It should not provoke an immune response in periradicular tissues. ( Block et al.) 13 . It should be neither mutagenic nor carcinogenic. ( Harnden & Lewis)

57. Criteria of an Ideal Sealer The sealer should adhere to the obturating material , usually gutta percha, when placed in the canal, and should adhere to the canal wall with its irregularities to completely fill the canal space. Gatewood R.S. Endodontic Materials. Dent Clin N Am 51 (2007) 695–712

58. Criteria of an Ideal Sealer The core material itself does not provide an adhesive seal to the canal wall. To create and maintain a fluid-tight seal of the canal is a prime requirement of a sealer Gatewood R.S. Endodontic Materials. Dent Clin N Am 51 (2007) 695–712

59. Criteria of an Ideal Sealer The sealer should contribute to the radiopacity of the root filling for visualization on radiographs and evaluation of obturation of lateral canals and apical ramifications. Gatewood R.S. Endodontic Materials. Dent Clin N Am 51 (2007) 695–712

60. Criteria of an Ideal Sealer Any shrinkage of the sealer would tend to create gaps at the dentin interface or within the core material, compromising the seal . Components of sealer should not leach into dentin leading to coronal or cervical discoloration of the crown Gatewood R.S. Endodontic Materials. Dent Clin N Am 51 (2007) 695–712

61. Criteria of an Ideal Sealer This property is desirable, but increasing the antibacterial qualities of a sealer also increases its toxicity to host tissues . Should set slowly . A sealer must have ample working time to allow for placement during obturation and adjustment in the case of immediate post-space preparation. Gatewood R.S. Endodontic Materials. Dent Clin N Am 51 (2007) 695–712

62. Criteria of an Ideal Sealer Stability of sealer when set is a prime factor in maintaining a hermetic seal over time. This is compromised if fluid contact causes dissolution of the sealer. Biocompatibility of the sealer promotes periradicular repair. Most sealers tend to be more tissue-toxic in the unset state and considerably less toxic when fully set. Gatewood R.S. Endodontic Materials. Dent Clin N Am 51 (2007) 695–712

63. Criteria of an Ideal Sealer To allow for retreatment or post-space preparation, the sealer and the core material should be removable . This can be facilitated by using a solvent. Gatewood R.S. Endodontic Materials. Dent Clin N Am 51 (2007) 695–712

64. Based on constituents Z inc oxide-eugenol Polyketone Epoxy Ca (OH)2 Silicone Resin Glass ionomer R esin-modified glass ionomer J.L. Gutmann. Root Canal Obturation: An Update. www.ineedce.com

65. Eugenol - Rickert’s formula - G rossman’s formula Carrotte P. Endodntics - Part 5. British Dental Journnal 2004; 197: 455- 464

66. Non- eugenol Medicated : Corticosteroid + paraformaldehyde

67. ZnO containing sealers P araformaldehyde , Rosin , Canada balsam Procosol sealer

68. ZnO containing sealers Roth’s 801 Sealer B ismuth subnitrate Rickert’s formula Kerr’s Pulp Canal Sealer Pulp Canal Sealer EWT- 6 hours

69. ZnO containing sealers Tubli -Seal ZnO base paste: BaSO4 Mineral oil Cornstarch Lecithin Catalyst tube: Polypale resin Eugenol T hymol iodide

70. ZnO containing sealers Wach’s Paste Powder: ZnO Bi subnitrate Bi subiodide MgO , Ca3(PO4)2 Liquid: Oil of cloves Eucalyptol Canada balsam Beechwood creosote

71. ZnO containing sealers Nogenol Base: ZnO BaSO4 Bi oxychloride Vegetable oil Catalyst Hydrogenated rosin Methyl abietate Lauric acid Chlorothymol Salicylic acid

72. ZnO containing sealers Medicated Canal Sealer Martin Iodoform MGP GP- 10% CHI3

73. Ca (OH)2 Containing Sealers Sealapex Base: ZnO Ca (OH)2 B utyl benzene Sulfonamide Zn stearate Catalyst: BaSO4 TiO2 P roprietary resin Isobutyl salicylate Aerocil Holland & De Souza

74. Ca (OH)2 Containing Sealers Apexit www.ivoclarvivadent.in

75. Ca (OH)2 Containing Sealers Calcibiotic Root Canal Sealer Slow setting- 3 days Stable

76. Ca (OH)2 Containing Sealers Vitapex 40% iodoform Silicone oil Beltes et al. Siquiera et al.

77. Resin sealers AH 26 HCHO Advantages Disadvantages AH Plus & Thermaseal Plus Advantages of AH 26 Epoxy- bisphenol resin: adamantine WT & ST Other improvements

78. Epiphany/ real seal UDMA, PEGDMA, EPGADMA, Bis - GMA Silane -treated Ba borosilicate Glass, BaSO 4 , Silica, Ca(OH) 2 Bi oxychloride with amines, peroxide Photo inhibitor, pigments Self- etch primer NaOCl & peroxide lubricants EDTA & sterile water

79. Epiphany/ real seal Sousa et al. Versiani et al. Solubility Dimensional stability ANSI/ ADA standards Ungor et al.

80. diaket Polyketone compound Vinyl polymers + ZnO & Bi 3 (PO 4 ) 2 PVC B- diketone Biocompatibility Eldeniz et al. Shear bond strength

81. Silicone based sealers Lee Endo-Fill, RoekoSeal Wu et al. Gutta Flow: - Silicone oil - Paraffin oil - Platin catalyst - ZrO 2 -Nano-Ag: preservative, coloring agent

82. Urethane methacrylate sealers EndoREZ 2- part: chemical set Sealer, Resin- coated Gutta Percha, Accelerators Hydrophilic characteristics Tay et al. Hirashi et al. Zmener et al.

83. a hrendental.com

84. Urethane methacrylate sealers EZ Fill Single GP; Bidirectional spiral

85. Urethane methacrylate sealers MetaSEAL Thinner version of 4- META Belli et al. Self- etching

86. Glass Ionomer Based Sealers Ketac - Endo Good biocompatibility Seal Solubility

87. Solvent- based sealers Johnston & Callahan GP particles + CHCl3 Shrinkage & voids Chlorosin Chloropercha Kloropercha N- 

88. Evaluation & Comparison Orstavik ANSI/ ADA & ISO Flow, WT, ST Radiopacity Solubility & disintegration Dimensional change following setting Biologic tests, Usage tests , Antibacterial testing Clinical test

89. Leakage Juhasz et al.- Sealapex allowed more leakage than Pulp Canal Sealer Cobankara et al.- Sealapex Orucoglu et al. Diaket + cold lateral compaction Saleh et al. Pommel et al. Lee et al. Tagger et al.

90. Tissue tolerance Miletic et al. Spangberg & Pascon Economides et al. Huumonen et al.

91. Flow Orstavik Lacey et al. McMichen et al Tagger et al. Orstavik. Endodontic Topics 2005, 12, 25–38

92. Setting time & Working time Nielsen et al. Anaerobic: Ketac -Endo & Resilon Aerobic: Kerr Tubli Seal & Ketac Endo Roth’s 801 & 811- slowest Kazemi et al: ZOE: 4 hours Endomethasone : 9 hrs Endo-Fill: 2.5 hrs AH-26: 12 hrs Orstavik et al. Flow as a function of time ZOE sealers

93. Solubility & Dimensional change ZOE & Ca (OH)2 Schafer & Z andbiglari AH plus Kazemi et al. ZOE sealers Endo- Fill : least Endo- Fill & AH- 26- lower rates

94. Radiopacity Minimum: 3mm Al Std. GP points: 6mm Al Orstavik . Endodontic Topics 2005, 12, 25–38

95. Biological testing Concern for untoward reaction Extreme situations Delay / prevent resolution Orstavik . Endodontic Topics 2005, 12, 25–38

96. Usage testing Expt. Animals Uninfected teeth Katebzadeh et al. Induced apical periodontitis Orstavik. Endodontic Topics 2005, 12, 25–38

97. Antibacterial activity Sipert et al. Pizzo et al. Williamson et al. Siqueira and Goncalves Leonardo et al. Kayaoglu et al. Aravind et al. JCD. Iss . 9(1): 2006

98. Intraorifice barriers Composite resins Glass ionomers Cavit IRM Super EBA Dentin bonding agent

99. Temporary Filling Materials Cavit : ZnO CaSO4 ZnSO4 Glycoacetate Polyvinylacetate resin PVC acetate Triethanolamine Red pigment

100. Temporary Filling Materials IRM: P olymer-resin-reinforced ZOE TERM: UDMA polymers I norganic radiopaque filler Pigments Initiators

101. Summary Grossman’s requirements Long term RCTs Tissue regeneration