Reprint
Reprinted May 2017, with permission, from Volume 10 Issue 3, March 2017, Pages 1–3
Should You Change Your Endodontic Sealer?
Gordon’s Clinical Observations: Almost every reader of this report accomplishes endodontic treatment with
varying levels of success. Three important steps are necessary for success: debridement, disinfection, and sealing.
Sealers/cements vary in composition, and all of them seem to have success. Several new companies are promoting
MTA (mineral trioxide aggregate) products for sealers. Is that better? How do the sealers compare? Do they really
seal? What are the strengths and weaknesses of the various products? CR scientists and clinicians have studied
these questions and have useful information for you in this report.
Numerous types of materials have been used as root canal sealers and cements. Zinc oxide, epoxy resin, and
others have been proven over years of clinical experience. Currently, there is renewed interest in bioactive
materials, and the most popular brand is now Endosequence BC Sealer by Brasseler, a calcium silicate chemistry.
This report provides data on the current clinical use of sealers; compares the characteristics of popular
types and brands; and provides clinical tips for their use.
A gutta-percha primary point
ready for insertion with a light
coating of sealer
Characteristics of Different Sealers
Radiopacity
(% aluminum)
Approx.
Setting
Time
Apex Seal
Test (dye
penetration)
The following table compares features of 15 sealers arranged by type of chemistry and alphabetical brand name. Numerous additional brands
and mixing options are available.
Overall Rating
AH Plus Jet
Dentsply Sirona
$20
Epoxy
paste/paste
automix syringe
pale
yellow
23 mm
21–30 µm
550%
24 hours
Excellent
Pass
Excellent–Good
EZ-Fill Xpress
Essential Dental Systems
$14
Epoxy
paste/paste
automix syringe
pale
yellow
20 mm
31–40 µm
570%
2–3 hours
Excellent
Pass
Excellent–Good
SimpliSeal
Kerr Endo
$19
Epoxy
paste/paste
hand mix
pale
yellow
23 mm
1–10 µm
540%
1.5 hours
Very Good
Pass
Excellent–Good
Nogenol
GC America
$11
Zinc oxide
non-eugenol
paste/paste
hand mix
white
28 mm
1–10 µm
390%
7 min
Very Good
Pass
Pulp Canal Sealer
Kerr Endo
$38
Zinc oxide
eugenol
powder/liquid
hand mix
light
gray
26 mm
21–30 µm
560%
1 hour
Good
Pass
Excellent–Good
Root Canal Sealer
Pulpdent
$5
Zinc oxide
eugenol
powder/liquid
hand mix
white
17 mm
11–20 µm
450%
2–3 hours
Good
Pass
Excellent–Good
Tubli-Seal Xpress
Kerr Endo
$11
Zinc oxide
eugenol
paste/paste
automix syringe
pale
yellow
28 mm
11–20 µm
440%
1 hour
Excellent
Pass
C
R Excellent
Apexit Plus
Ivoclar Vivadent
$14
Calcium
hydroxide
paste/paste
automix syringe
pale
yellow
28 mm
11–20 µm
350%
24 hours
Excellent
Pass
C
R Excellent
Channels MTA Sealer
Insight Endo
$6
MTA
paste/paste
hand mix
pale
yellow
27 mm
21–30 µm
270%
1+ hours
Very Good
Pass
Endosequence BC Sealer
Brasseler
$103
Calcium
silicate
single paste
syringe
white
11 mm
11–20 µm
450%
4–10 hours
Excellent
Pass
NeoMTA Plus
Avalon Biomed
$57
MTA
powder/liquid
hand mix
pale
yellow
24 mm
11–20 µm
300%
1–5 hours
Good
Pass
Excellent–Good
Sealapex Xpress
Kerr Endo
$10
Calcium
hydroxide
paste/paste
automix syringe
light
gray
23 mm
11–20 µm
500%
24 hours
Excellent
Pass
Excellent–Good
EndoREZ
Ultradent
$24
Methacrylate
paste/paste
automix syringe
pale
yellow
18 mm
1–10 µm
450%
20–30 min
Excellent
Pass
MetaSEAL
Parkell
$46
Methacrylate
powder/liquid
hand mix
white
18 mm
1–10 µm
440%
16 hours
Good
Pass
$27
Silicone with
paste/paste
gutta-percha automix syringe
light
pink
19 mm
11–20 µm
470%
25–30 min
Excellent
Pass
Brand
Company
Approx.
General
Cost/ml Composition
Components
and Mixing
Color
Flow
(higher=
more
Film
flowable) Thickness
Ease of Use
Epoxy Resin
Zinc Oxide
Bioactive Components
Methacrylate Resin
Silicone
GuttaFlow 2
Coltene
C
R Excellent
®
Choice
®
Choice
®
Choice
Excellent–Good
C
R Excellent
®
Choice
C
R Excellent
®
Choice
Excellent–Good
C
R Excellent
®
Choice
This official reprint may not be duplicated. This reprint is prepared for the purpose of providing dental clinicians with objective information about dental products.
©2017 CR Foundation®
Clinicians Report
2
March 2017
Should You Change Your Endodontic Sealer? (Continued from page 1)
Characteristics of Different Sealers (Continued)
Summary of comparison chart:
• Cost varied significantly: from $5 per ml for conventional powder/
liquid ZOE to $126 per ml for bioactive calcium silicate paste.
• All sealers tested had acceptable color, flow, film thickness, and
radiopacity. The mix ratio of powder/liquid sealers could be
adjusted to achieve desired flow properties.
• Specified setting times varied significantly: from minutes to hours.
Short setting times were helpful when immediately placing a post.
Moisture in the tooth can play a significant role in setting speed.
• Ease of use was good to excellent for all sealers and mainly differed
in dispensing and mixing components.
• A dye penetration test showed that all products tested could seal the
apex when properly placed in teeth with sound roots.
• All sealers tested performed well and were clinically useful.
Products marked as “CR Choices” had unique or desirable features
that can be particularly helpful for some clinical situations.
Current Clinical Use of Root Canal Sealers
The following are key points gathered from a recent CR survey of 644 clinicians.
• Chemistries used: 35% epoxy resin; 24% zinc oxide; 19% calcium
silicate; 11% calcium hydroxide; 6% methacrylate resin; 2% MTA;
and 3% others (silicone, balsam, etc.)
• Popular brands: 18% Endosequence BC Sealer (Brasseler);
12% ThermaSeal Plus (Dentsply Sirona); 11% Pulp Canal Sealer
(Kerr Endo); 11% Sealapex (Kerr Endo); 9% AH Plus (Dentsply
Sirona); 8% Tubli-Seal (Kerr Endo); 6% EZ-Fill (EDS); 6%
EndoREZ (Ultradent); 4% AH 26 (Dentsply Sirona); 4% Root
Canal Cement (Roth); plus 19 other brands of 1% or less use
• Components and mixing: 32% paste/paste hand mix; 29%
powder/liquid hand mix; 21% paste/paste automix syringe; 18%
paste syringe (single component)
• Satisfaction: 62% excellent; 37% good; 1% fair
• Placement (more than one method may be used): 50% primary
point coated with sealer; 31% hand instrument (filler, file, reamer,
etc.); 24% paper point; 19% direct injection; 15% Lentulo spiral
• Main problems noted: 54% none; 19% pushes past apex; 10%
expensive; 9% messy; 6% slow set
• Features needing improvement: 36% complete fill of complex
canals; 33% biocompatibility; 28% complete seal; 26% none; 19%
ease of use
• Failed treatments (re-treat or extract): 1% no fails; 21% 1–2%
fails; 38% 3–5% fails; 23% 6–10% fails; 6% 11–15% fails; 2%
>15% fails
Summary of survey: Hand-mixed epoxy resin and zinc oxide sealers continue to be the most used. 99% rated their current sealer excellent
or good indicating high satisfaction with current performance. There is increasing use of and promotion of sealers based on bioactive
chemistries or with bioactive components.
Sealer Placement Options
There continues to be a percentage of endo treatments that fail despite excellent techniques and materials. Inadequate seal is one of several
possible problems. CR’s dye penetration tests showed that all sealers tested had the potential to seal the apex when properly placed. However,
some factors were beyond the control of the clinician, such as defects in the root or atypical anatomy, which easily defeated the seal. Ensuring
that sealer reaches the apex is crucial. Common placement techniques are discussed below.
Intra-canal
tip on
mixing tip
Files, reamers, or other hand
instruments are loaded with
sealer then inserted to the
working length and gently
rotated to lightly coat canal
walls.
Paper points are coated with
sealer then inserted to the
working length and gently
rotated to lightly coat canal
walls. Although generally
effective, some instructions
caution against using paper
points as they may wick liquid
from the mixed sealer reducing
the flow characteristics.
NaviTip
Intra-canal tips are inserted into
canal and sealer is expressed
in situ directly from the mixing
tip. Most are too large to fit
down canal. For improved
access, load sealer into an
Ultradent Skini Syringe with
NaviTip (or comparable system)
which will allow application
of the sealer to the apex. Use
care to not inject sealer past
the apex.
Lentulo or other reverse-spiral
instruments are loaded with
sealer and inserted to near
the working length. Clockwise
rotation pushes the sealer
toward the apex and into the
canal walls. Use by hand or
at very low speeds. Although
generally effective, some
instructions caution against
using Lentulo spirals because
of frictional heating that can
cause premature set.
After coating the canal walls
with sealer, the primary
obturation point is lightly
coated and slowly inserted.
Position and fill should then
be checked radiographically.
Some clinicians prefer to see a
small amount of sealer pushed
beyond the apex—the so-called
“puff”—which assures that
sealer reached the apex.
Clinicians Report
3
March 2017
Should You Change Your Endodontic Sealer? (Continued from page 1)
Clinical Tips
• Debridement and disinfection: Thoroughly debride canals and shape for effective obturation. Irrigate with adequate contact time for thorough
disinfection. Thoroughly rinse canals to remove any chemicals from the irrigation solutions that may interfere with the set of the sealer.
• Drying: Dry canals with paper points. Residual moisture in the dentin canals is adequate for the setting reaction.
• Mixing: Hand mixing of powder/liquid or paste/paste systems is most common, although many sealers are available in syringes with automix
tips. Mixed material should be homogenous, thin, and slightly stringy. The powder to liquid ratio can be slightly adjusted to achieve proper
consistency.
• Obturation: Sealers are generally compatible will all popular obturation systems and techniques. Carefully check instructions as a few
sealers should not be used with heated instruments which can cause premature setting of the material.
• Post placement: Most sealers require hours to days to fully set depending on the composition and conditions in the tooth. If placing a post at
the same appointment, choose a sealer with quick set or allow adequate time for an initial set. When drilling the post hole, use care to not pull
the gutta-percha point or disturb the apical portion of the obturation. Some resin-based sealers can be light cured on the coronal portion or
offer optional accelerators to speed the set (e.g., EndoREZ and MetaSEAL).
• Failure of seal: Roots are porous structures and many argue that it is impossible to truly seal teeth. Dye penetration tests revealed that even
the best sealers and clinical techniques were defeated by certain root conditions, including atypical apices, untreated accessory canals,
sharply curved root tips, defective dentin, etc. Cone beam radiography and clinical experience can help determine best treatment options.
• Re-treatment: Most sealers are soft enough to be removed using conventional techniques. Some, however, including hard-setting bioactive
materials, may require special instruments, such as ultrasonic tips, to remove.
CR CONCLUSIONS: All current endodontic sealers are reported to be working. At least seven different types of sealers are currently being used
with clinical success and high levels of clinical satisfaction. Clinicians can base choice on desired features, ease of use, and cost. Epoxy resin
and zinc oxide sealers continue to be the most popular. Bioactive materials, including calcium silicate, MTA, calcium hydroxide, and others, are
gaining popularity because of their potential to solve issues with biocompatibility and long-term seal. Perfect your clinical technique to ensure
sealer is appropriately placed to the apex and coats canal walls. Sealing and obturation must be accompanied by appropriate debridement and
thorough disinfection for best success.
What is CR?
WHY CR?
CR was founded in 1976 by clinicians who believed practitioners could
confirm efficacy and clinical usefulness of new products and avoid both
the experimentation on patients and failures in the closet. With this
purpose in mind, CR was organized as a unique volunteer purpose
of testing all types of dental products and disseminating results to
colleagues throughout the world.
WHO FUNDS CR?
Research funds come from subscriptions to the Gordon J. Christensen
Clinicians Report®. Revenue from CR’s “Dentistry Update®” courses
support payroll for non-clinical staff. All Clinical Evaluators volunteer
their time and expertise. CR is a non-profit, educational research
institute. It is not owned in whole or in part by any individual, family, or
group of investors. This system, free of outside funding, was designed
to keep CR’s research objective and candid.
This team is
testing
resin curing lights
to determine their
ability to cure a
variety of
resinbased
composites.
HOW DOES CR FUNCTION?
Each year, CR tests in excess of 750 different product brands,
performing about 20,000 field evaluations. CR tests all types of dental
products, including materials, devices, and equipment, plus techniques.
Worldwide, products are purchased from distributors, secured from
companies, and sent to CR by clinicians, inventors, and patients. There
is no charge to companies for product evaluations. Testing combines
the efforts of 450 clinicians in 19 countries who volunteer their time
and expertise, and 40 on-site scientists, engineers, and support staff.
Products are subjected to at least two levels of CR’s unique three-tiered
evaluation process that consists of:
1. Clinical field trials where new products are incorporated into
routine use in a variety of dental practices and compared by
clinicians to products and methods they use routinely.
2. Controlled clinical tests where new products are used and
compared under rigorously controlled conditions, and patients are
paid for their time as study participants.
3. Laboratory tests where physical and
chemical properties of new products are
compared to standard products.
Clinical Success is the Final Test
Clinicians Report® a Publication of CR Foundation®
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[email protected] • www.CliniciansReport.org
CRA Foundation® changed its name to CR Foundation® in 2008.
Every month
several
new projects are
completed.
THE PROBLEM WITH NEW DENTAL PRODUCTS.
New dental products have always presented a
challenge to clinicians because, with little more
than promotional information to guide them,
they must judge between those that are new and
better, and those that are just new. Because of the
industry’s keen competition and rush to be first
on the market, clinicians and their patients often
become test data for new products.
Every clinician has, at one time or another, become
a victim of this system. All own new products that
did not meet expectations, but are stored in hope
of some unknown future use, or thrown away
at a considerable loss. To help clinicians make
educated product purchases, CR tests new dental
products and reports the results to the profession.
Products evaluated by CR Foundation® (CR®) and reported in the Gordon J. Christensen Clinicians Report® have been selected on the basis of merit from hundreds of products under evaluation. CR® conducts research
at three levels: 1) multiple-user field evaluations, 2) controlled long-term clinical research, and 3) basic science laboratory research. Over 400 clinical field evaluators are located throughout the world and 40 full-time
employees work at the institute. A product must meet at least one of the following standards to be reported in this publication: 1) innovative and new on the market, 2) less expensive, but meets the use standards,
3) unrecognized, valuable classic, or 4) superior to others in its broad classification. Your results may differ from CR Evaluators or other researchers on any product because of differences in preferences, techniques,
product batches, or environments. CR Foundation® is a tax-exempt, non-profit education and research organization which uses a unique volunteer structure to produce objective, factual data. All proceeds are used to
support the work of CR Foundation®. ©2017 This report or portions thereof may not be duplicated without permission of CR Foundation®. Annual English language subscription: US$199 worldwide, plus GST Canada
subscriptions. Single issue: $18 each. See www.CliniciansReport.org for additional subscription information.